Stifle Joint Conditions in Veterinary Medicine PDF

Conditions of the stifle Lecture plan Stifle joint- review of anatomy Clinical examination of stifle- review Diagnosis of stifle conditions Conditions of stifle-list • • • • Aetiology Clinical signs and Diagnosis Treatment Prognosis and after care Stifle joint –Cranial view Trochlea Caudal cruc...

Conditions of the stifle Lecture plan Stifle joint- review of anatomy Clinical examination of stifle- review Diagnosis of stifle conditions Conditions of stifle-list • • • • Aetiology Clinical signs and Diagnosis Treatment Prognosis and after care Stifle joint –Cranial view Trochlea Caudal cruciate Ligament (CaCL) Medial meniscus Medial collateral ligament Patellar ligament Tibia Lateral collateral ligament Cranial cruciate Ligament (CCL) Lateral meniscus Long Digital extensor tendon Fibula Patella Stifle joint–Lateral view Sesamoid Lateral meniscus Patella (position) Patellar ligament Lateral collateral ligament Fibula Long digital Extensor tendon Tibia Lecture plan Stifle joint- review of anatomy Clinical examination of stifle- review Diagnosis of stifle conditions Conditions of stifle-list • • • • Aetiology Clinical signs and Diagnosis Treatment Prognosis and after care Clinical exam of stifle-review Clinical exam of stifle- Clinical exam of stifle- Localisation: Don’t forget bilateral hip, hock and lumbosacral disease Toe-touching”-affected Toe-touching” “Toe-touching” -affected leg leg affected leg at Lecture plan Stifle joint- review of anatomy Clinical examination of stifle- review Diagnosis of stifle conditions Conditions of stifle-list • • • • Aetiology Clinical signs and Diagnosis Treatment Prognosis and after care Diagnosis Common History and clinical signs Radiography Arthrocenthesis Others Scintigraphy Ultrasound MRI Diagnosis-Radiography •Two views (CrCd and ML) of both stifles • Others- stressed and skyline, flex/ext, include tibia •ML- most useful and don’t forget trochlear ridges! • Views for TTA/TPLO TPLO views TTA views Diagnosis Lecture plan Stifle joint- review of anatomy Clinical examination of stifle- review Diagnosis of stifle conditions Conditions of stifle-list • • • • Aetiology Clinical signs and Diagnosis Treatment Prognosis and after care Conditions of stifle-list Developmental: • • • Osteochondrosis Growth disturbances e.g genu valgum Patella luxation Traumatic: • • Fractures of stifle region Ruptured ligaments (CCL, CaCL, Patella, Collaterals and multiple) Traumatic (cont’d): • Avulsions (Long digital extensor tendon, gastrocnemius, tibial tuberosity) Acquired: • • • • Cruciate disease OA Immune-mediated arthritis Neoplasia The Cranial Cruciate Ligament (CCL) Introduction: • Most common cause of hindlimb lameness in the dog • Important role in stifle joint stability (craniocaudal and internal/external rotation) • Aetiology- unknown and controversial • Treatment- v. controversial The Cranial Cruciate Ligament (CCL) Cr Macroscopically CCLs are comprised of functional bands: Cranial(cr) and Caudal (cd) IMPORTANT IF PARTIAL RUPTURE! Cd The Cranial Cruciate Ligament (CCL) Aetiology: • Trauma (least common) • “Disease” or degeneration in older dogs (+ minor trauma) or in predisposed breeds e.g. Labrador Retriever, Terrier breeds • Young large breed dogs e.g Great Dane, Bull Mastiff The Cranial Cruciate Ligament (CCL) Aetiology (2): • “Disease” related to: o increased collagen metabolism in CCLs of predisposed dog breeds o Increased joint laxity o Narrowed Intercondylar notches o Sloping angle of tibial plateau o Immune mediated disease Distal femoral intercondylar notch (ICN) containing the CaCL and CCL The Cranial Cruciate Ligament (CCL) Clinical signs: • Chronic/Acute onset hindlimb lameness • Leg carried flexed or “Toe Touching” • Stifle effusion- (patellar ligament-not pencil like) • Medial Buttress and OA-chronic • Tibial compression test/Cranial drawer test Partial tears Abnormal cranial drawer and tibial thrust tests The Cranial Cruciate Ligament (CCL) Diagnosis: § Clinical examination and history- very important § Radiography (ML and CrCd views) § Others§ Arthrocenthesis § MRI The Cranial Cruciate Ligament (CCL) Treatment: • Conservative: o Dogs < 15kg o Restricted exercise and analgesia for 6-8 weeks o 85% will have satisfactory function (Vasseur, 1984) o Recent studies- Wucherer 2013 o Cats??? • Surgical The Cranial Cruciate Ligament (CCL) Surgical Treatment: • Intracapsular (e.g Over the Top technique (OTT)) • Extracapsular (e.g Fabellotibial nylon sutures) • Periarticular (e.g Tibial Plateau levelling Osteotomy (TPLO) or Tibial tuberosity advancement (TTA) • Stifle arthroscopy All intracapsular and extracapsular techniques aim to mimic CCL action ? lateral/medial arthrotomy to expose/inspect joint The Cranial Cruciate Ligament (CCL) OTT Over the top (OTT) The Cranial Cruciate Ligament (CCL) DeAngelis or Lateral fabellotibial suture (LFTS) Common in first opinion practice But osteotomies increasing The Cranial Cruciate Ligament (CCL) Periarticular techniques e.g • Closing wedge or tibial plateau levelling osteotomy (TPLO) • tibial tuberosity advancment (TTA) or modified Macquet procedure The Cranial Cruciate Ligament (CCL) Prognosis: • OTT- Satisfactory outcomes in 80% but only 66% sound (Innes, 1998, 2000) • LFTS- Similar outcomes with 5 year follow–up (Innes, 1998, 2000) • TPLO- no long term subjective follow-up but early objective study suggests no difference (Conzemius, 2001) • Increasing evidence that osteotomies do better earlier (Gordon-Evans, 2014, Krotschek, 2016) The Cranial Cruciate Ligament (CCL) Aftercare • As before • Re-examine at 4-6 weeks/12 weeks • Progress x-rays for osteotomies at 8 weeks. • Complications: infection, menisci tears Meniscal injury • At surgery (always check!) or “late” meniscal injury • Mostly medial (25-50%) • Different classification of tears-“bucket-handle”, caudal pole- most common • May respond to conservative management for 4-6 weeks • Surgical removal if persistent lameness Patellar Luxation Aetiology: • Congenital/ Developmental or Traumatic • Medial>Lateral • Toy breeds/large breeds more common? • Cats- often asymptomatic • Due to developmental malalignment of quadriceps complex Patellar Luxation Grading degree of luxation (1-4) (Putnam, 1968): 1-Intermittent patellar luxation, reduction immediate 2-Frequent luxation, reduction not always immediate 3-Permanent luxation, reduction possible but reluxates 4-Permanent luxation but reduction not possible Patellar Luxation Diagnosis: • History and clinical signs • Radiography Patellar Luxation Treatment: Conservative: • if none or intermittent clinical signs • Restricted, controlled exercise and NSAIDs Surgical: § If recurrent clinical signs § Restore normal alignment of quadriceps mechanism by a combination of: Patellar Luxation Reinforcement of lateral retinaculum Release of medial retinaculum Patellar Luxation Deepening of trochlear groove Transposition of tibial tuberosity Wedge or block trochleoplasty Osteochondrosis Aetiology: • Not very common • Lateral/Medial femoral condyle (articular surface) • Breed predisposition (e.g. Labrador Retriever) • Male > Female • If “joint mouse” then OCD (Osteochondritis dissecans) Osteochondrosis Clinical signs: • Lameness from 5 months old • Bilateral crouching gait • Joint effusion and discomfort upon palpation Diagnosis: • History and clinical signs • Radiography (CrCd most usebut can see flattening on ML view) Osteochondrosis Osteochondral autologous transplantation “Syncart” Rupture of the Collateral ligaments Aetiology: • Alone or in combination with CCL rupture • Medial or Lateral Diagnosis: • Abnormal joint movement in medial or lateral direction • Stressed radiographs (take contralateral limb to check for normality) Rupture of lateral collateral ligament - note widening of lateral joint space Rupture of the Collateral ligaments Treatment: • Parapatellar approach to side affected • Primary repair of ligament and repair protected by screws and washers at insertion sites Multiple ligament injuries Aetiology • Uncommon injuries usually working dogs Diagnosis: • Careful clinical examination • Stress radiography Treatment: • Repair of CCL, collateral ligament(s), removal of damaged meniscus and joint capsule- good prognosis but don’t underestimate repair!! • TAESF Buster 5y.o Collie with stifle disruption Multiple ligament injuries in the cat Aetiology: • Usually in association with CCL rupture • Meniscal injuries Treatment: similar to dogs • Transarticular pin across stifle joint for 4 weeks • TAESF Fractures of stifle region Stifle Miscellaneous Stifle OA: • Common • Secondary to CCL rupture • Manage as for OA patient • TKR Stifle neoplasia: Remember sites around joint! Poor recovery in CCL case Summary §CCL disease/ rupture- Very importantknow how to manage §ALWAYS CHECK THE MENISCUS! §Others to note: Patellar luxation OA Osteosarcoma in giant breed dog The end- any questions?