Download - Cruciate Sx
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Name the 2 cruciate ligaments and the direction they run in
• Cranial
– Runs in same direction as your hand in your pants pocket
– More cranial in the intercondylar space
– Runs cranially & medially as it courses distally to insert at the cranial intercondyloid area of the tibia
• Caudal
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What are the 3 functions of the CrCL
• 1. prevent cranial displacement of the tibia
• 2. limit internal tibial rotation
• 3. prevent stifle hyperextension
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What are the 2 distinct bands of the CrCL & their functions
• Craniomedial band
– Taut during flexion AND extension
• I.e. always working
– This rupture only drawer in flexion
• Caudolateral band
– Only taut in extension
– Rupture = no cranial drawer
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What causes CrCL rupture
• Excess stress on normal ligament
– Uncommon in dogs
• Normal stress on abnormal lig
– Most common form in dogs
– Degeneration occurs earlier & is more severe in larger breeds
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What might you find on PE - acute rupture
• Acute rupture
– Lameness
– Effusion
– Often not super painful
– Cranial drawer sign
• Complete rupture present in flex & extension
• Only craniomedial band = drawer in flex
• Only caudolateral = no cranial drawer
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What might you find on PE - chronic rupture
• Lamenss
• Muscle atripohy
• Periarticular fibrosis
• Joint effusion
• +/- crepitus
• Decreased ROM
• +/- cranial drawer
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What is the gold Dx test for cruciate rupture?
• Cranial drawer!
• Why is it commonly missed? – Diff to detect in conscious pt
– Need good technique
– Periarticualr fibrosis may limit cranial drawer
– Might only be partially ruptured (i.e. caudolateral band tear = no drawer)
– Absence doesn’t rule out cruciate disease!
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What can you see?
Displaced fat pad because joint effusion
Osteophyts on distal pole of patella
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What might you see on rads?
- Bone sclerosis
- Osteophytes on , distal pole of patella trochlear ridge, tibial plateau
- Look for avulsion fractures
- Joint effusion – displacement of fat pad
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What are some options for treating cruciate disease?
• Conservative – NO! continued instability – worsening!
• Sx – Passive joint stabilisation
• Extracapsular – Lateral fabello-tibial suture
• Intracapsuar – not used anymore
– Tibial osteotomy sx • TPLO ~4% late meniscal injury
• TTO ~4%
• TTA – 22-42% late meniscal injury!
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Describe skin incision for stifle joint exploration & cruciate sx
• Curvilinear skin incision centred at level of patella, on lateral aspect of stifle
• Extend from distal 1/3- ½ of femurs
• Down to a point just distal to tibial tuberosity
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Now what?
• Incise SQ tissue along same line of skin incision –
• Fascia lata & lateral reticulum are incised along similar line – approx 2-3mm caudal to patella lig, incise fascia 15mm lateral to patella lig (leave enough tissue between incison & patella to place sutures alter
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After incising fascia lata(remember that really
plasticcy kind of tissue that the biceps is attached to)
• Fascia lata is undermined & reflected caudally
– Beware: the peroneal nerve
• Proximally – need to dissect the loose fascia between the biceps & vastus lateralis and the facial attachment of the vastus to the femur
– In this way we can reflect biceps – expose and locate lateral fabella – before making capsule incision
– To expose the joint capsule
– Beware: avoid the caudal femoral a & v in this area
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Once the joint capsule is exposed
• Make a stab incision at the level of the patella
– Along the same line as the precious incisions
• Extend this incision in the capsule distally to level of the tibia – don’t damage the long digital extensor tendon
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So how to we maximise our visibility into the joint?
• Extend the joint, luxate patella medially then flex joint to hold patella out of the way
• Use gelpi retractor in soft tissue to aid exposure
• Retract infrapatella fat pad cranially with sharp pointed Senn retractor – ID sites of stifle distractors
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ID sites of stifle distractors
• Intracondylar fossa of the femur & the insertion site of the cr cruciate lig of the tibia
• When stifle distractors are openend the distal point will hook on intermeniscal lig behind the fat pad
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• ID origin & insertion of both long digital extensor tendon (lateral femoral condyle) and the lateral collateral lig
• ID Cr & Cau crucitae lig
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How to visualise the menisci?
• Put the stifle in cranial drawer –
• Use either
– Stifle joint distractor
– OR Homann retract with a Senn retractor
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Which meniscus is more likely to be damaged?
• Medial – because
– Firmly attached to tibial plasteau
– Lateral meniscus is only loosely attached – able to move out of the way
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How to place LFTS? – which muscles to retract/elevate?
• Reflect biceps femoris – caudally at level of patella – use sharp/blunt dissection
• Need to be able to visualise the lateral fabella
– (which is at the same level of the patella, in the origin if the lateral head of
the gastrocnemius)
• Elevate the cranial tibial muscle – from the prox lateral tibia
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Where do we drill the hole?
• Subperiosteally elevate cr tibial muscle from prox lateral tibia – allow placement of the hole
• Transversely through the prox tibia, at the level of the tibial tuberosity
• Use drill bit & Jacob's chuck/power drill
• Tunnel needs to be perpendicular to the bone (lateral to medial)
• Mark location of hole using a 18g needle
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Now we have a hole…?
• Pass cruciate needle around the lateral sesamoid – Beware trapping the peroneal n. – immediately caudal to fibula head!!! – Feed the needle cranioprox to caudal distally – Walk needle tip off the bone to stay as close as possible to the fabella – Once placed – tugging on suture should feel fabella moving (about 1mm)
• Place distal end of suture through the tunnel, then feed suture back behind the patella lig
– Tie/crimp it securely adjacent to the lateral part of femoral condyle – Tied in a neutral standing position – Place knot on laterla aspect of the stifle so you can suture biceps over the top
of it to hide the knot
– ***use 27 or 36kg nylon leader line
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closing
• Close the fascia lata with an interrupted pattern to achieve imbrication
– Caudal edge of fascia should imbricate over the top of the cranial edge – horizontal mattress sutures
– Close SQ and skin
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