ACL and CrCL (CCL) Extra Capsular Repair
Cranial Cruciate Ligament (CrCL or CCL) and Anterior Cruciate Ligament (ACL) Disease in Dogs
The stifle joint is the joint between the thigh bone (the femur) and the two lower leg bones (tibia and fibula). It is the quadruped equivalent of the knee in bipeds (i.e., humans).
A ligament is a band of connective or fibrous tissue that connects two bones, or cartilage, at a joint; the cranial cruciate ligament is the ligament that connects the thigh bone with the lower leg bone – it helps to stabilize the stifle joint. Cranial cruciate ligament disease , also referred to as the anterior cruciate ligament (ACL), is the sudden (acute) or progressive failure of the cranial cruciate ligament, which results in partial to complete instability of the stifle joint. Cranial cruciate rupture is the tearing of the cranial cruciate ligament; it is the most common cause of rear-leg lameness in dogs and a major cause of degenerative joint disease (progressive and permanent deterioration of joint cartilage) in the stifle joint; rupture may be partial or complete.
The possibility of a genetic link is unknown. An understanding of the role genetics might play may be important in increasing the likelihood of actively restraining stifle deficiencies and/or structural (conformation) abnormalities. What is currently known is that all breeds are susceptible. Specifically, the incidence of cranial cruciate ligament disease increases for Rottweilers and Labrador retrievers younger than four years of age, dogs older than five years of age, and in large-breed dogs from one to two years of age. The predominant gender this affects is the spayed female.
Symptoms and Types
The severity of this condition is related to the degree of rupture: whether it is a partial rupture, or a complete rupture. The manner of rupture is also indicative of the severity, based on whether it presented suddenly, or has been a long-term (chronic) degenerative condition. Degeneration is the decline or loss of function or structure. Sudden (acute) front ligament (cranial cruciate) rupture results in non-weight bearing lameness, and fluid build-up in the joint (known as joint effusion). The dog will hold the affected leg in a partial bent position (flexion) while standing. A subtle to marked intermittent lameness, that may last from weeks to months, is consistent with partial tears in the cruciate; tears that are degenerating and progressing to complete rupture. Normal activity resulting in sudden (acute) lameness would suggest degenerative rupture.
A decrease in muscle mass and weakening of muscles (known as muscle atrophy) in the rear leg – especially the quadriceps muscle group, would be an indication that the leg is not being used properly and the muscles are suffering as a result. Progressive and permanent deterioration of joint cartilage will result if the condition is left untreated, due to ongoing inflammation, and to conditions that will encourage the degeneration of the ligament and surrounding muscles.
The causes for cranial cruciate ligament disease are most frequently caused by repetitive micro-injury to the cranial cruciate ligament, that is, putting pressure on the ligament in the same way, repeatedly. This action causes slight stretching of the ligament each time, altering the structure, and eventually causing the ligament to tear. Symmetrical or structural abnormalities that occur in the formation, or growth process (conformation abnormalities) are also suspected in the majority of cases. If the bones that make up the stifle were abnormally formed, the cruciate ligament will be unduly stressed and traumatized. Obesity also plays a role in cruciate ligament disease, when it is present, as the weight increases the incidence of repetitious injury to the same part of the leg.
Some of the incidents which may bring about deterioration of the cruciate are injury to the stifle joint; a history of athletics, where repetitive movement can cause stress to the ligaments; a specific traumatic event, as from jumping badly, or any accident that causes the ligament to tear; a knee injury, such as dislocation of the kneecap (medically referred to as patellar luxation).
Your veterinarian will have several diagnostic procedures to follow when looking for the source of the injury. A diagnostic evaluation for cranial cruciate rupture will include a cranial drawer test, which involves specific manipulation to assess the status of the cruciate ligament.
- Dogs greater than 33 lbs (15 kg) should be treated with stabilization surgery; only 20 percent improve or are normal within six months with conservative medical management
- Following surgery, the use of ice packs and physical therapy (such as range-of-motion exercises, massage, and electrical muscle stimulation) are important for improvement
- Weight control is an important component for decreasing stress on the stifle joint
- Stabilization surgery is recommended for all dogs, as it speeds the rate of recovery, reduces joint degeneration, and enhances function
Living and Management
After the condition has been diagnosed and your pet has gone through the initial stage of treatment, management will depend on the particular method of treatment you and your veterinarian decided on. Most surgical techniques require two to four months of rehabilitation. If conformational abnormalities have been determined, it is wise to avoid breeding your pet to prevent passing along the gene. A second surgery may be required in 10 to 15 percent of cases, because of subsequent damage to the meniscus (a crescent-shaped cartilage located between the femur and tibia in the stifle). Regardless of surgical technique, the success rate generally is better than 85 percent.
Extra-Capsular Suture Stabilization (also called “Ex-Cap suture”, “lateral fabellar suture stabilization” and the “fishing line technique”) has been performed for many years. While there are many variations of this technique (different suture materials, ways to tie the suture, how to attach the suture to the bone etc.), the general concept of this procedure is to replace the function of a defective CrCL on the outside of the joint. This is usually accomplished by utilizing a strong suture placed along a similar orientation to the original cruciate ligament. The suture needs to stabilize the knee joint, while allowing normal knee movement, until organized scar tissue can form and assume the stabilizing role. The most common complications after this procedure involve failure of the suture and progressive development of arthritis. Suture failure tends to be more common in larger, active dogs; hence many surgeons reserve this technique for small breeds, older and/or inactive dogs. The main advantages of this technique include the lower cost and the lack of a bone cut (meaning that complications associated with the bone cut are not seen with this technique).