Cranial Cruciate Ligament Disease in Dogs

Print/View PDF

Sign in to continue reading this article

Not registered? Create an account for free to read full articles on www.veterinaryteambrief.com.

To access full articles on www.veterinaryteambrief.com, please sign in below.

Busy? Sign in Faster. Sign into www.veterinaryteambrief.com with your social media account.

Figure 1 Proper hand positioning and technique for assessing cranial tibial thrust

Cranial cruciate ligament disease (CCLD) is caused by a gradual degeneration of the cranial cruciate ligament (CCL), which results in a partial or complete ligament tear. CCLD is the most commonly diagnosed disorder of the canine stifle joint1 and is the orthopedic disease most commonly treated surgically in practice.

Patients can present with a variety of signs; some are easily recognizable and easy to diagnose, while others are less obvious, making diagnosis more challenging.

The CCL serves 4 functions2:

  • Prevention of cranial tibial thrust (CTT)
  • Prevention of hyperextension of the stifle
  • Prevention of excessive internal rotation of the stifle
  • Proprioception

Tear or rupture of the ligament allows excessive movement in the stifle, causing lameness and pain. (See Table 1.)

Table1
Cranial Cruciate Ligament Signs
Typical HistoryClinical Signs
3-legged gaitSloppy sit
LimpingStifle effusion
Slow to rise (when bilateral)Pain on stifle palpation and manipulation (hyperextension)
Trouble climbing stairsTrouble climbing

 

CCLD occurs in dogs of all sizes at different ages. (See Table 2.) Dogs that are female, obese, or older are at higher risk for CCLD.3,4  A genetic link has been documented in the Newfoundland breed that may also be present in other breeds.5

Related Articles
Top 5 Tips for Postoperative At-Home Care
Top 5 Most Common Orthopedic Conditions in Dogs
Taking the Lead on Orthopedic Examinations

Table2
Breeds Commonly Affected by CCLD
BreedsAge Typically AffectedSigns

Large4,16,17

Labrador retriever

Newfoundland

Rottweiler

2-6 yearsWeight-bearing to non-weight-bearing lameness; pain on stifle hyperextension, palpable joint effusion, and stifle thickening

Small4,16,17

Bichon frise

West Highland white terrier

Yorkshire terrier

<8 yearsCan be associated with medial patellar luxation

Other16,17

Boxer

Mastiff

Pit bull terrier

<2 yearsDisease is often bilateral

 

Diagnosis

Physical examination should include gait observation and careful orthopedic examination, including stifle palpation and manipulation.

Simple presentations of CCLD include high-grade lameness (ie, toe-touching lameness to non-weight-bearing lameness) with obvious cranial drawer (CD) and CTT.6 Evaluation of CD signs and CTT, which are diagnostic tests for CCLD, should be performed during examination. (See Figure 1 & Cranial Drawer & Cranial Tibial Thrust Tests.) 

Cranial Drawer & Cranial Tibial Thrust Tests

Cranial drawer test

  • Place one hand on the distal femur with the thumb on the caudal aspect of the condyle and the index and middle fingers on the patella.
  • Place the thumb of the other hand on the fibular head and the index and middle fingers on the tibial tuberosity.
  • Slide the tibia cranial to the femur; if the tibia slides cranially, the CD is positive. 

Cranial tibial thrust test

  • Place one hand on the distal femur.
  • Firmly flex the hock (talocrural joint) with the other hand, while maintaining a static angle of the stifle.
  • With positive CTT, the tibia translates cranially (ie, thrusts) relative to the femur during flexion of the tarsus; with complete CCL tears, a CCLD diagnosis is straightforward. 

[ad override]

If ligament degeneration has been present for several months or longer, thickening of the medial aspect of the stifle joint, known as medial buttress, is likely present. This fibrous tissue forms to help stabilize the joint4 and can be palpated during orthopedic examination. All patients with CCLD will have pain on hyperextension of the stifle; in fact, this is likely the earliest finding on examination after the patient becomes lame.6 

Approximately half of patients with CCLD will also have a torn medial meniscus. During stifle range of motion, a meniscal click may be heard, and these patients are typically painful on hyperflexion of the stifle joint.6-10

Chronic partial tears are more difficult to diagnose, as many patients with partial tears have negative or mild CD signs and CTT because of periarticular fibrosis. These patients often have a history of chronic, lower-grade lameness. Some degree of medial buttress may be palpable on examination, and hyperextension will elicit pain.5 

Radiographs should be obtained in patients with suspected CCLD to aid in diagnosis, rule out other diseases, and plan for surgery. Sedation can aid in proper positioning. On radiographs, stifle joint effusion and osteophytosis of the patella, femur, and/or tibia can be seen.  

Treatment

Surgical treatment of CCLD results in faster healing time and the most favorable return to function.11,12 Many procedures have been developed to treat CCLD, including extracapsular lateral suture stabilization (ELSS) and osteotomy-based techniques such as tibial plateau leveling osteotomy (TPLO) and tibial tuberosity advancement (TTA). Board-certified surgeons currently perform TPLO and TTA more often than ELSS in both large- and small-breed dogs because osteotomy procedures are perceived to result in a more rapid return to full function.13 More recently, the literature has supported the superiority of TPLO over ELSS, with dogs returning to more normal function with TPLO as compared with ELSS.13-15 Currently, there is insufficient data comparing all available surgical techniques simultaneously to come to a strong scientific conclusion; hence, anecdotal clinical experience continues to play a major role in surgical technique selection. 
[ad override]

Most patients that receive appropriate postoperative care return to normal function within 3 to 6 months. Strict exercise restriction for 6 to 8 weeks is required following all surgeries to ensure proper healing without implant system failure. An E-collar is recommended while the incision is healing because stifle surgeries have a higher than average postoperative infection rate and patients tend to lick and chew their incisions.

Conclusion

It is imperative that clients whose dogs have CCLD understand the following:

  • Surgery is required to achieve the most optimal outcome.
  • Postoperative care rules must be followed to minimize complications and help ensure a successful outcome.
  • Full recovery takes months.
  • Even with surgery, varying degrees of arthritis will still be present.

CCLD is commonly diagnosed in a variety of breeds and can be successfully treated surgically, but client understanding and compliance is paramount to success.

1 Create a client information handout explaining the details of CCLD to ensure clients with pets experiencing this common condition receive a consistent message.

2 Evaluate all patients with hind-limb lameness for CCLD, and perform a complete orthopedic examination, including cranial drawer and cranial tibial thrust tests.

3 Take time to impress on clients the importance of CCLD postoperative care to achieve an optimal outcome for the patient.

References and author information Show
References
  1. Arnoczky SP. Pathomechanics of ligament and meniscal injuries. In: Bojrab MJ, ed. Disease Mechanisms in Small Animal Surgery. 2nd ed. Philadelphia, PA: Lea & Febiger; 1993:764-770. 
  2. Kowaleski P, Boudrieau RJ, Pozzi A. Stifle joint. In: Tobias KM, Johnston SA, eds. Veterinary Surgery Small Animal. St. Louis, MO: Saunders Elsevier; 2012:909-910.
  3. Adams P, Bolus R, Middleton S, Moores AP, Grierson J. Influence of signalment on developing cranial cruciate rupture in dogs in the UK. J Small Anim Pract. 2011;52(7):347-352. 
  4. Duval JM, Budsberg SC, Flo GL, Sammarco JL. Breed, sex, and body weight as risk factors for rupture of the cranial cruciate ligament in young dogs. J Am Vet Med Assoc. 1999;215(6):811-814. 
  5. Wilke VL, Zhang S, Evans RB, Conzemius MG, Rothschild MF. Identification of chromosomal regions associated with cranial cruciate ligament rupture in a population of Newfoundlands. Am J Vet Res. 2009;70(8):1013-1017.
  6. Kowaleski P, Boudrieau RJ, Pozzi A. Stifle joint. In: Tobias KM, Johnston SA, eds. Veterinary Surgery Small Animal. St. Louis, MO: Saunders Elsevier; 2012:918.
  7. Williams J, Tomlinson J, Constantinescu G. Diagnosing and treating meniscal injuries in the dog. Vet Med. 1994;89:42. 
  8. Ralphs SC, Whitney WO. Arthroscopic evaluation of menisci in dogs with cranial cruciate ligament injuries: 100 cases (1999 -2000). J Am Vet Med Assoc. 2002;221(11):1601-1604. 
  9. Casale SA, McCarthy RJ. Complications associated with lateral fabellotibial suture surgery for cranial cruciate ligament injury in dogs: 363 cases (1997- 2005). J Am Vet Med Assoc. 2009;234(2):229-235. 
  10. Dillon DE, Gordon-Evans WJ, Griffon DJ, Knap KM, Bubb CL, Evans RB. Risk factors and diagnostic accuracy of clinical findings for meniscal disease in dogs with cranial cruciate ligament disease. Vet Surg. 2014;43(4):446-450.
  11. Hart JL, May KD, Kieves NR, et al. Comparison of owner satisfaction between stifle joint orthoses and tibial plateau leveling osteotomy for the management of cranial cruciate ligament disease in dogs. J Am Vet Med Assoc. 2016;249(4):391-398.
  12. Wucherer KL, Conzemius MG, Evans R, Wilke VL. Short-term and long-term outcomes for overweight dogs with cranial cruciate ligament rupture treated surgically or nonsurgically. J Am Vet Med Assoc. 2013;242(10):1364-1372.
  13. Nelson SA, Krotscheck U, Rawlinson J, Todhunter RJ, Zhang Z, Mohammed H. Long-term functional outcome of tibial plateau leveling osteotomy versus extracapsular repair in a heterogeneous population of dogs. Vet Surg. 2013;42(1):38-50.
  14. Bergh MS, Sullivan C, Ferrell CL, Troy J, Budsberg SC. Systematic review of surgical treatments for cranial cruciate ligament disease in dogs. J Am Anim Hosp Assoc. 2014;50(5):315-321.
  15. Gordon-Evans WJ, Griffon DJ, Bubb C, Knap KM, Sullivan M, Evans RB. Comparison of lateral fabellar suture and tibial plateau leveling osteotomy techniques for treatment of dogs with cranial cruciate ligament disease. J Am Vet Med Assoc. 2013;243(5):675-680.
  16. Whitehair JG, Vasseur PB, Willits NH. Epidemiology of cranial cruciate ligament rupture in dogs. J Am Vet Med Assoc. 1993;203(7):1016-1019.
  17. Vasseur PB, Pool RR, Arnoczky SP, Lau RE. Correlative biomechanical and histologic study of the cranial cruciate ligament in dogs. Am J Vet Res. 1985;46(9):1842-1854.
Author

Karl C. Maritato

DVM, DACVS (Small Animal) MedVet Cincinnati and MedVet Dayton

Karl C. Maritato, DVM, DACVS (Small Animal), is a veterinary surgery specialist at MedVet Cincinnati and MedVet Dayton, Ohio. Although he performs all small animal surgeries, Dr. Maritato’s special interests are neurosurgery and orthopedics, particularly diseases of the stifle, angular limb deformities, and joint replacements. He lectures across the United States on a variety of surgical topics and has been featured on NBC 4 News in Columbus and ABC 9 News in Cincinnati. Dr. Maritato received his DVM from Ross University; he completed an internship at Louisiana Veterinary Referral Center in Mandeville and a residency at the Columbus MedVet Medical and Cancer Centers for Pets.

Material from Veterinary Team Brief may not be reproduced, distributed, or used in whole or in part without prior permission of Educational Concepts, LLC. For questions or inquiries please contact us.

Veterinary Team Brief delivers practical skills for team-based medicine—with clinical strategies for team training, peer-reviewed credibility, concise content, essential training modules, and easy-to-implement protocols. From the publisher of Clinician's Brief.