Cookie information is stored in your browser and performs functions such as recognizing you when you return to our website and helping our team to understand which sections of the website you find most interesting and useful. This means that every time you visit this website you will need to enable or disable cookies again.
Forum Regular 379 posts Location: QLD Long-term functional outcome after surgical repair of cranial cruciate ligament disease in dogs | BMC Veterinary Research | Full Text Skip to main content Cranial cruciate ligament (CCL) rupture is a very common cause of pelvic limb lameness in dogs.
To evaluate long-term surgical outcome, at a minimum of 1.5 years after unilateral CCL surgery, force plate, orthopedic, radiographic, and physio therapeutic examinations, including evaluation of active range of motion (FROM), symmetry of thrust from the ground, symmetry of muscle mass, and static weight-bearing (SUB) of pelvic limbs, and goniometer of the stifle and tarsal joints, were done. At a mean of 2 .8 ± 0.9 years after surgery, no significant differences were found in average ground reaction forces or SUB between the surgically treated and control dog limbs, when dogs with no other orthopedic findings were included (n = 21).
The stifle joint extension angles were lower (P <0.001) and flexion angles higher (P <0.001) in surgically treated than in contralateral joints, when dogs with no contralateral stifle problems were included (n = 33). However, extension and flexion angles of the surgically treated stifles remained inferior to healthy joints, and impairment of FROM and weakness in thrust from the ground in the surgically treated limbs were frequently present.
Ground reaction forces may be inadequate as a sole method for assessing functional outcome after cranial cruciate ligament repair. Cranial cruciate ligament (CCL) rupture is a common cause of canine pelvic limb lameness and stifle joint osteoarthritis.
Surgical treatment is advocated to stabilize the stifle joint, alleviate pain, treat any concurrent meniscal pathology, and decelerate the development of osteoarthritis . The surgical outcome after CCL surgery has often been evaluated through clinical examination, radiography, and owner assessment.
All studies report significant improvement of dynamic weight-bearing after surgery, but the results are more variable when return to the level of healthy limbs is considered. In clinical patients, some studies have reported return of dynamic weight-bearing to the level of healthy limbs after extra capsular repair and tibial plateau leveling osteotomy (TPL) ,, whereas in others the ground reaction forces in surgically treated limbs or pelvic limb symmetry indices have remained inferior to full function after repair with extra capsular ,,, intracellular , TPL , and tibial tuberosity advancement (TTA) techniques.
Few studies directly comparing different surgical techniques by using force plate analysis exist. Also in another study, no significant differences were found in limb function between TPL and extra capsular repair 2yearsafter surgery .
On the other hand, two recent studies indicate that TPL leads to limb function that is superior to that produced by extra capsular surgery ,. Et al. evaluated ground reaction forces, stifle joint range of motion and thigh circumference of the surgically treated limbs 2yearsafter surgery.
Peak vertical forces increased significantly after surgery, but the focus of the paper was to compare surgical techniques, not to evaluate the return of limb function to the pre-injury level. However, after initial improvement, stifle joint range of motion started to decrease.
Also in another study, stifle joint range of motion and thigh circumference in the surgically treated limbs remained significantly decreased relative to contralateral limbs 1-5 years after surgery . In veterinary orthopedic patients, the use of rehabilitation by physiotherapists that are specialized in animal physiotherapy has increased substantially during the last decade.
However, according to our knowledge, a thorough evaluation of the stifle joints done by a professional animal physiotherapist to assess surgical outcome after CCL surgery has not been reported. The primary purpose of our study was to evaluate surgical outcome at a minimum of 1.5 years after CCL surgery.
This was done by combining force plate analysis, clinical orthopedic and physio therapeutic evaluations, and radiography. The secondary purpose was to compare surgical techniques used to repair CCL rupture.
Based on a questionnaire study and an unpublished questionnaire data, owners were invited to bring their dogs to a clinical evaluation, including general, orthopedic, physio therapeutic, and radiographic examination and force plate analysis. The inclusion criteria for dogs were surgically treated unilateral CCL rupture, a minimum time interval of 1.5 years between surgery and evaluation, and body mass over 17 kg.
The study protocol was approved by the Ethics Committee of Nikki campus, University of Helsinki, and written consent was obtained from all owners. During the evaluation the members of the research team were unaware of which pelvic limb had been operated on and the surgical technique used.
Subgroup 1 dogs were used when force plate, static weight-bearing, active range of motion and muscle atrophy results were evaluated. For these evaluations, only study group dogs with no signs of other orthopedic disease were included to minimize the effect of other conditions on the test results.
On the other hand, when geometric results in surgically treated limbs were compared to contralateral limbs, the study group dogs that did not have any findings in the contralateral stifle/tarsal joints, i.e. subgroup 2, were included. Subgroup 2 dogs were allowed to have hip dysplasia, elbow OA etc.
For the force plate and physio therapeutic evaluation, a group of 21 clinically healthy Labrador Retrievers and Rottweilers, voluntarily presented by their owners, was used . Inclusion criteria were: age 1-8 years, no known orthopedic problems, and radiographic screening results free of elbow and hip dysplasia according to the Federation Cynologique Internationale screening protocol.
A full orthopedic examination was done to all dogs and included lameness evaluation on a scale from 0 to 4 (no/mild/moderate/severe weight-bearing/non-weight bearing) and palpation of the thoracic and pelvic limbs and spine as well as evaluation of conscious proprioception and withdrawal reflex. The stifle joints were palpated for pain (no/mild/moderate/severe), crepitation (no/mild/moderate/severe), particular swelling (no/mild/moderate/severe), decrease in range of motion (ROM) (no/mild/moderate/severe), and patellar location (grade 0/1/ 2 /3/4) and also evaluated for a positive tibial compression test (negative/positive) and, under sedation with medetomidine 10-20 kg/kg (Darlene, Siva, Leon, Spain) and butorphanol 0.1 mg/kg (Tutorial, Internet International, Unterschleissheim, Germany) for the cranial drawer test (no/mild/moderate/severe drawer sign).
The stifle, hip, and elbow joints bilaterally as well as the lumbar spine of the study group dogs were radiographed under sedation. Gait was evaluated using a piezoelectric force plate (Sister force plate, type 9286, Sister Instrument AG, Winterthur, Switzerland) embedded in a 14 m runway and computer-based software program (Acquire 7.3, Sharon Software Inc., DeWitt, MI).
Three pairs of photoelectric cells, positioned 1 m apart from each other, were used to measure the velocity and acceleration of the dogs. Dogs were guided over the force plate by the owner or a member of the research team at a trotting velocity of 2 .10 – 2 .50 m/s and a maximum acceleration of ±0.5 m/s 2.
A symmetry index (SI) was calculated for the pelvic limb PDF and VI in surgically treated and control dogs using the equation In surgically treated dogs, a symmetry index value of 0 indicates perfect symmetry; a positive value indicates decreased dynamic weight-bearing on the surgically treated limb and a negative value decreased dynamic weight-bearing on the contralateral pelvic limb.
The full assessment consisted of a visual evaluation of lameness and possible diagonal movement during it, movement on stairs, functional active range of motion (FROM) and thrust from the ground, manual evaluation of muscle atrophy of pelvic limbs, manual evaluation and quantitative measurement of static weight-bearing (SUB), and a measurement of passive range of motion (PROM) in stifle and tarsal joints . Of all the physio therapeutic examination tasks used, the results of FROM, symmetry of thrust between pelvic limbs, muscle atrophy, quantitative SUB of pelvic limbs, and PROM in stifle and tarsal joints are presented here.
Quantitative measurement of SUB in pelvic limbs was done using digital bathroom scales, as previously described . The results of four measurements for each limb were averaged and converted from kilograms to percentages proportional to the dog’s body mass (SUB).
In addition, difference in static weight-bearing between the pelvic limbs (Diffs) was calculated using the following equation: PROM was measured in unseated dogs from both stifle and tarsal joints in extension and flexion using a universal goniometer with a five-degree scale.
Results from nominal and ordinal data (surgical technique, condition of the meniscus, stifle joint palpation and radiographic findings, FROM, muscle atrophy), symmetry index and Diffs are reported as frequencies and percentages. For continuous data (age at time of surgery, body mass at time of evaluation, follow-up, force plate data, SUB, PROM), the results are summarized as mean ± SD, and for age, body mass, and follow-up also as range.
The Kruskall-Wallis test with pairwise comparisons was used to evaluate differences in age, follow-up, stifle joint palpation findings, and amount of radiographic osteoarthritis between surgical techniques, and Independent samples t-test or one-way ANOVA was used to evaluate differences in body mass between study group and control dogs or surgical techniques. The Mann-Whitney rank sum test for non-normally distributed and Independent samples t-test for normally distributed force plate, SUB, and PROM data were used to evaluate differences between surgically treated limbs and contralateral limbs (force plate, SUB, PROM) or control dog limbs (force plate, SUB).
Similarly, the Kruskall-Wallis test with pairwise comparisons for non-normally distributed and one-way ANOVA with Conferring and Turkey post HOC analyses for normally distributed force plate, SUB, and PROM data were used to evaluate differences between surgical techniques. The mean ± SD (range) age of the dogs and their body mass at the time of evaluation were 6.9 ± 2 .7 (1.8-13.0) years and 38.
Diagnosis of the CCL rupture and inspection of the joint had been done via arthrotomy in all dogs. One dog had loosening of the screws afterglow surgery and was treated successfully with revision surgery, and the other dog had excessive scar tissue formation in the surgical wound after intracellular repair.
Mean ± SD (range) time interval between surgery and evaluation visit (follow-up) was 2 .8 ± 0.9 (1.5-4.4) years. The mean ± SD age and body mass of the healthy control dogs (14 females, 7 males) were 3.
At follow-up, grade 1/4 lameness of the surgically treated limb was seen in 8 dogs (3 intracellular, 1 extra capsular, 4 osteotomy). The gait could not be evaluated in one surgically treated dog due to lack of cooperation.
The 21 healthy control dogs did not show any signs of orthopedic disease or lameness. Orthopedic and radiographic findings in the surgically treated stifle joints are presented in Table 1.
No significant differences were found between surgical techniques in pain response to stifle flexion/extension. Of 12 dogs with positive drawer sign, 5 had been treated with intracellular and 7 with osteotomy techniques.
Table 1 Stifle joint findings of the surgically treated limb; orthopedic and radiographic examination In 6 dogs the force plate analysis could not be performed due to lack of cooperation or inability to maintain adequate trotting speed.
The number of dogs treated with the extra capsular technique (n = 3) was too low to be analyzed. In visual evaluations of functional FROM, the most frequent findings were in the sitting position.
Except for one dog, the positive findings were always localized in the surgically treated limbs. Thrust from the sitting position was weaker in the surgically treated limb in 14 dogs (66.7%) (3 intracellular, 1 extra capsular, 10 osteotomy).
2 %) had decreased muscle mass of the surgically treated pelvic limb on palpation (5 intracellular, 2 extra capsular, 9 osteotomy), while only 4 dogs (19.0%) had symmetrical muscle mass (2 intracellular, 1 extra capsular, 1 osteotomy), and one dog (4.8%) had decreased muscle mass in the contralateral pelvic limb. Similarly, in subgroup 1 dogs, no significant differences were found between surgical techniques.
We evaluated overall long-term surgical outcome at a mean of 2 .8 years after CCL repair using a combination of force plate analysis, orthopedic and radiographic examinations and as a new aspect, a physio therapeutic evaluation performed by a veterinary physiotherapist. Similar long-term studies have not been reported before, but these results are in accordance with those of previous short- and mid-term force plate studies where the function of the surgically treated limb was at the level of the contralateral or control dog limbs 7 months after an extra capsular repair , or 4 and 12 months afterglow surgery ,.
By using the SI's, more differences were revealed than what was discovered when the mean ground reaction forces between the surgically treated and healthy limbs were compared. A physio therapeutic examination concentrating on the stifle joints and performed by a veterinary physiotherapist was included in our study.
Static weight-bearing of the pelvic limbs was measured using commercial bathroom scales, and validity study of their results has been reported elsewhere . It can be assumed that, similar to dynamic weight-bearing, load distribution to other limbs occurs also when measuring SUB.
Goniometer of the stifle joints has been evaluated after CCL repair in several studies ,,,-. CCL rupture causes pain and disuse of the affected limb, resulting in decreased stifle ROM and muscle atrophy .
However, in some studies the stifle joint ROM has been shown to decrease with time after surgery ,,,. Au et al. reported that stifle joint ROM angles in surgically treated limbs were below the preoperative values 2yearsafterTPLO or extra capsular repair.
The most probable cause for the decrease of ROM over time is the progression of osteoarthritis, causing functional impairment due to pain and mechanical restriction of joint mobility due to fibrous tissue and new bone formation in the joint and its particular tissues. The clinical relevance of a loss of 5% in flexion and 7% in extension of the stifle joint ROM in our study is unknown.
Randi and Schulman reported that loss of flexion or extension 10° was associated with higher lameness scores, but we did not find any correlation between geometric results and dynamic or static weight-bearing. Moreover, in the orthopedic examination, lameness was seen in almost 20% and pain response on flexion and/or extension of the surgically treated stifle joints in one-third of dogs.
These findings resonate well with our previous report of chronic pain after CCL surgery, which is based on a validated questionnaire filled out by 253 dog owners and includes the 42 dogs serving as subjects here. In that report, almost one-third of the dogs had signs of chronic pain at a mean of 2 .7 years after CCL surgery .
Recognition of chronic pain can be challenging for owners , and these dogs may often go undiagnosed and untreated. Due to the retrospective study design we were unable to control such variables as conformation and age of the dog, duration of clinical signs before surgery, completeness of the cruciate ligament tear, meniscal pathology, and treatment or postoperative rehabilitation and medications.
The confounding factors may nevertheless have caused bias in the comparison of surgical techniques. Due to the limitations set by the force platform, only dogs with a body mass exceeding 17 kg were included.
For force plate and physio therapeutic evaluation, we only included dogs with no other concurrent orthopedic problems (subgroups 1 and 2) in order to minimize the effect of concomitant problems on dynamic or static weight-bearing, FROM, and PROM. Although only the dogs with unilaterally treated CCL rupture and no other owner-reported significant orthopedic or neurologic problems were originally included in the study group, during the evaluation surprisingly many of them were diagnosed with bilateral stifle joint pathology or other concurrent orthopedic problems, resulting in a low number of dogs for final evaluation.
On the other hand, when force plate results are compared with data obtained from other individuals, in addition to controlling the velocity, acceleration, and body mass of the dog, the conformation and size of the dogs have an effect on ground reaction forces ,,. On the other hand, in a recent study , the subjective evaluation of muscle atrophy was shown to be sensitive for detecting functional pelvic limb problems.
Interestingly, 16 of the 21 dogs evaluated in our study (76%) had decreased muscle mass in the surgically treated limb. These results must be interpreted with caution because of potential initial preoperative differences in the orthopedic or radiographic examination between the surgical technique groups.
On the other hand, it could be speculated that the preoperative differences in radiographic osteoarthritis between groups might level off in the long run. The ground reaction forces and SUB in the osteotomy group had a tendency to be higher than in the intracellular technique and to reach control dog values.
No other significant differences emerged between surgical technique groups when dynamic and static weight-bearing or geometric results were evaluated. No significant differences between surgically treated and contralateral or control dog limbs were found in the osteotomy group, whereas in the intracellular group statistically significant differences in VI, DPGF and SUB between the surgically treated and contralateral limbs were achieved.
Parallel results have been reported also in two previous force plate studies. In goniometer, stifle joint extension and flexion as well as tarsal joint flexion angles were decreased relative to the contralateral limb both in intracellular and osteotomy technique groups.
However, when symmetry of weight-bearing was evaluated using cut-off values, approximately 30% of dogs had decreased static or dynamic weight-bearing in the surgically treated limb, and almost one-third of dogs showed pain in stifle joint palpation. In addition, the extension and flexion angles of the surgically treated stifles remained inferior to healthy joints, and many dogs showed impairment of FROM and weakness in thrust from the ground in the surgically treated limbs.
In sum, measurement of ground reaction forces may be inadequate as a sole method for assessing functional outcome and thus more objective outcome assessment methods should be included in evaluation of CCL repair. SHM performed the statistical analyses and drafted the manuscript with the aid of HK, AHB and MLV.
Permitted DL, Flo GL, Decamp CE: The stifle joint. Drinker, Permitted, and Flo’s Handbook of Small Animal Orthopedics and Fracture Repair.
Au OK, Gordon-Evans WE, Dunning D, O’Dell-Anderson KJ, Snap KE, Griffon D, Johnson AL: Comparison of short- and long-term function and radiographic osteoarthrosis in dogs after postoperative physical rehabilitation and tibial plateau leveling osteotomy or lateral patellar suture stabilization. Ballads AJ, Montgomery RD, Henderson RA, Gillette R: PRE- and postoperative force plate analysis of dogs with experimentally transected cranial cruciate ligaments treated using tibial plateau leveling osteotomy.
Buds berg SC, Overstate MC, Soutas-Little RAW, Flo GL, Proust CW: Force plate analyses before and after stabilization of canine stifles for cruciate injury. Baedeker J, Due S, Meyer-Lindenberg A, Fear M, Note I, Wefstaedt P: Computer-assisted gait analysis of the dog: Comparison of two surgical techniques for the ruptured cranial cruciate ligament.
Consensus MG, Evans RB, Besançon MF, Gordon WE, Horseman CL, Hole WD, Nieves MA, Wagner SD: Effect of surgical technique on limb function after surgery for rupture of the cranial cruciate ligament in dogs. Gordon-Evans WE, Griffon DJ, Bulb C, Snap KM, Sullivan M, Evans RB: Comparison of lateral patellar suture and tibial plateau leveling osteotomy techniques for treatment of dogs with cranial cruciate ligament disease.
Sevens DJ, Decamp CE, Hauptmann J, Braden TD, Richter M, Robinson R: Use of force plate analysis of gait to compare two surgical techniques for treatment of cranial cruciate ligament rupture in dogs. Nelson SA, Crosscheck U, Rawlinson J, Tod hunter RJ, Zhang Z, Mohammed H: Long-term functional outcome of tibial plateau leveling osteotomy versus extra capsular repair in a heterogeneous population of dogs.
Loss K, Amur DM, Guerrero T, Passing M, Montanan PM: Force plate gait analysis to assess limb function after tibial tuberosity advancement in dogs with cranial cruciate ligament disease. Where KL, Consensus MG, Evans R, Wilde WE: Short-term and long-term outcomes for overweight dogs with cranial cruciate ligament rupture treated surgically and nonsurgically.
Hoffmann DE, Miller JM, Over CP, Land OI, Martin RA, Shires PK: Tibial tuberosity advancement in 65 canine stifles. Lamar TP, Berry CR, Dean JJ, Peck IN, Cornea M: Long-term radiographic comparison of tibial plateau leveling osteotomy versus extra capsular stabilization for cranial cruciate ligament rupture in the dog.
Masseur PB, Berry CR: Progression of stifle osteoarthrosis following reconstruction of the cranial cruciate ligament in 21 dogs. Mueller EM, Allen DA, Wilson ER, Linerberger JA, Beckenbauer T: Long-term outcomes of thigh circumference, stifle range-of-motion, and lameness after unilateral tibial plateau levelling osteotomy.
Most SM, Hielm-Björkman AK, Laitinen-Vapaavuori OM: Use of an owner questionnaire to evaluate long-term surgical outcome and chronic pain after cranial cruciate ligament repair in dogs: 253 cases (2004-2006). Bruce WE, Rose A, Take J, Robins GM: Evaluation of the triple tibial osteotomy.
Dry gas A, McClure SR, Goring RL, Ponzi A, Robertson SA, Wand C: Effect of cold compression therapy on postoperative pain, swelling, range of motion, and lameness after tibial plateau leveling osteotomy in dogs. Gordon-Evans WE, Dunning D, Johnson AL, Snap KE: Effect of the use of ibuprofen in dogs undergoing intense rehabilitation after lateral patellar suture stabilization.
Randi AS, Schulman AJ: Incidence of motion loss of the stifle joint in dogs with naturally occurring cranial cruciate ligament rupture surgically treated with tibial plateau leveling osteotomy: Longitudinal clinical study of 412 cases. Jersey RM, Walker AM, Barman CGA: Proximal tibial intra-articular osteotomy for treatment of canine cranial cruciate ligament injury.
Monk ML, Preston CA, McGowan CM: Effects of early intensive postoperative physiotherapy on limb function after tibial plateau leveling osteotomy in dogs with deficiency of the cranial cruciate ligament. Most SM, Hielm-Björkman AK, Laitinen-Vapaavuori OM: Force platform analysis in clinically healthy Rottweilers: Comparison with Labrador Retrievers.
Moustafa AA, Griffon DJ, Thomas MW: Morphometric characteristics of the pelvic limbs of Labrador Retrievers with and without cranial cruciate ligament deficiency. Rooster H, Van Free H: Use of compression stress radiography for the detection of partial tears of the canine cruciate ligament.
Heidelberg H, Wurst er H: Untersuchungen a Boxer sum Verknöcherungsverlauf BEI her Spondylosis deform ans. Herzog W, Nigh BM, Read LA, Olsson E: Asymmetries in ground reaction force patterns in normal human gait.
Hyytiäinen, HK, Most SM, Juanita JT, Laitinen-Vapaavuori OM, Hielm-Björkman AK: Ranking of physio therapeutic evaluation methods as outcome measures of stifle functionality in dogs. Hyytiäinen, HK, Most SM, Juanita JT, Laitinen-Vapaavuori OM, Hielm-Björkman AK: Use of bathroom scales in measuring asymmetry of hind limb static weight-bearing in dogs with osteoarthritis.
Rocky SP, Marvin GB, Marshall JR, Salman B: The over-the-top procedure: a technique for anterior cruciate ligament substitution in the dog. Flo GL: Modification of the lateral reticular imbrication technique for stabilizing cruciate ligament injuries.
Cadaver S, Miller NA, Stubby WB, Land OI, Martin RA, Shires PK: Tibial tuberosity advancement for stabilization of the canine cranial cruciate ligament-deficient stifle joint: surgical technique, early results, and complications in 101 dogs. Rump PF, Kincaid SA, Disco DM, Baird DK, Zimmermann JR, West MS: Redistribution of vertical ground reaction force in dogs with experimentally induced chronic hind limb lameness.
Hielm-Björkman AK, Captain AS, Rita HE: Reliability and validity of a visual analogue scale used by owners to measure chronic pain attributable to osteoarthritis in their dogs. Loss K, Alejandro L, Wrestler T, Passing M, Montanan PM: Relationships of body weight, body size, subject velocity, and vertical ground reaction forces in trotting dogs.
Loss K, Wrestler T, Alejandro L, Passing M, Montanan PM: Effect of dog breed and body conformation on vertical ground reaction forces, impulses, and stance times. Hurley CR, Hammer DL, Short S: Progression of radiographic evidence of osteoarthritis following tibial plateau leveling osteotomy in dogs with cranial cruciate ligament rupture: 295 cases (2001-2005).
Linebacker JA, Allen DA, Wilson ER, Tobias TA, Shaken LG, Sharma JT, Miller DS, Beckenbauer TW: Comparison of radiographic arthritic changes associated with two variations of tibial plateau leveling osteotomy. The authors thank orthopedic surgeons Per Abelson, ESA Skyline, Pauli Kernel, Hakka Outro, Jan Rail and Kai Skutnabb for providing the patient material.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.