Madeleine Ovenden Canine Cruciate Ligament disease; A comparison of repair techniques to find the most appropriate method: Introduction:

I have chosen to investigate canine cruciate ligament disease, as cranial cruciate ligament disease is the most common cause of hind leg lameness in a dog. The stifle joint, which contains the cruciate ligaments, is also the most commonly diseased joint in a dog. I have also spent several weeks at Anderson Abercromby Orthopaedic Referrals, with cruciate ligament repair being performed almost every day. In my project I aim to recognise the anatomy and mechanics of the stifle joint first in order to fully understand changes that occur from cruciate ligament disease. Then I will look at methods of clinical examination and how to diagnose cruciate ligament disease. Finally my aim is to review some popular techniques (surgical and non surgical) to evaluate the most appropriate method. Anatomy and Mechanics of the Stifle: The stifle is a complex joint which joins together the femur and the head of the tibia. It is a condylar synovial joint with a number of different ligaments, connective tissue and muscles surrounding it. The ligaments in the stifle act as constraints of movement and contribute to femorotibial stability that allows movement. The cranial and caudal cruciate ligaments both arise from the femur and insert of the tibia. They are covered with synovial membrane, synovial vessels then lead to smaller vessels, which penetrate the ligaments and fuse with endoligamentous vessels to supply blood and innervation. However, the cranial cruciate ligament has a smaller blood supply and the cores of the cruciate ligaments are often poorly supplied making repair difficult. The table below shows the angle of normal movement in a healthy stifle (Anderson, J. 1994, p267): Plane of Movement:
Flexion/Extension Internal Rotation External Rotation

Angle:
110 (150 max) Minimal in extension. 20-45 in flexion. Minimal

Diagram of the Stifle taken from Dog Health Handbook Website

Madeleine Ovenden

The caudal cruciate ligament is broader and slightly longer than the cranial cruciate ligament. Both are composed of bundles of fibres, which are taut at different positions during movement. The cranial cruciate ligament, which is most commonly damaged in cruciate ligament disease, has two major bands: the cranio-medial and the caudo-lateral. The cranio-medial is taut in extension and flexion but the caudo-lateral relaxes during flexion.
BSAVA: Manual of small animal arthrology, pg. 269 Figure 3

Diagram 3 shows the importance of this in the diagnosis of partial tears of the cranial cruciate ligament. If the caudo-lateral band ruptures there is no instability but if the cranio-medial band ruptures then there is instability in flexion. Similarly to the cranial cruciate ligament, the caudal cruciate ligament in made up of two portions. The bigger cranial portion is taut in flexion and lax in extension. However, the caudal portion is taut in extension and lax in flexion.

The main function of the cruciate ligaments are that they act as constraints to stifle movement. The cranial cruciate ligament prevents cranial displacement of the tibia, which would cause the tibia to slip forward, as well as preventing the stifle from hyperextension. The caudal cruciate ligament oppositely prevents caudal displacement of the tibia, the tibia slipping backward. During flexion both ligaments twist on each other to limit excessive internal rotation of the tibia, this happens regularly when a dog is standing with the stifle angle at 130-140 and prevents the stifle from collapsing. Stopping the stifle from rotating also prevents varus or valgus movement where the limb is twisted inward or outwards. The cranial cruciate ligament also contains mechanoreceptors, which detect increased strain and can start contraction of the caudal thigh muscles and relaxation of the quadriceps muscles to protect the stifle and stabilise it. The lateral collateral ligament limits lateral or outward movement and is tight only in extension. The Medial collateral ligament limits medial or inward movement, it is tight in flexion and extension and also prevents external rotation of the tibia when it is flexed.

Madeleine Ovenden

The menisci are also important structures in the stifle; they are fibrocartilaginous structures that lie in between the surfaces of the femur and tibia. They function primarily as shock absorbers and lubricate the stifle joint. Nerves within the menisci also act to control joint movement by detecting pressures within the joint. The menisci have five ligamentous attachments as well as the medial collateral ligament being attached to the Anatomy of the menisci BSAVA: medial meniscus. The menisci move Canine and Feline musculoskeletal cranially during extension and caudally disorders pg. 359 Figure 22.11 during flexion. Due to the medial meniscus being attached to the medial collateral ligament and not attached to the femur, movement is limited and during weight bearing the medial meniscus becomes crushed between part of the femur and tibial plateau. This is thought to be the reason for common medial meniscus injury as the lateral meniscus is rarely involved. The menisci help femorotibial stability, load distribution and lubrication within the joint. Similar to the cruciate ligaments, the tips and peripheral areas of the menisci are vascularized but the central zone is poorly supplied making healing difficult following injury.

The mechanics of the stifle are important to cruciate ligament disease, as they explain the changes that take place after rupture of damage of the cruciate ligaments. During weight bearing and muscle contractions a number of forces are applied to the stifle. The gastrocnemius and the quadriceps muscles both exert a cranial or forward force on the tibia, that is opposed by the hamstrings and biceps femoris muscles exerting a caudal or backward force on the tibia. Other cranial forces act on the tibia because the tibial plateau is not perpendicular to the line joining the centre of motion of the stifle and the tarsus. This is called the cranial tibial thrust (Slocum and Devine, 1983, cited by Houlton et al. 2006 p357-8) but it is opposed by the cranial cruciate ligament, biceps femoris and hamstring muscles. Therefore, if the cranial cruciate ligament has ruptured, the tibia will move forward during weigh bearing. This has formed the basis of the tibial compression test, one of the tests for cruciate ligament rupture.

BSAVA Canine and Feline Musculoskeletal Disorders pg. 358 Figure 22.10

Madeleine Ovenden

Changes that occur from Cruciate Ligament Disease: Although often thought to be associated with trauma, according to the article Rupture of the Cranial Cruciate Ligament in Dogs Part 1 (Moore and Read, 1996 p226) only approximately 20% of complete and partial tears of the cranial cruciate ligament are associated with trauma. If trauma is involved it is often during sudden rotation when the stifle is in 20-50 of flexion, due to the two cruciates twisting on each other. Situations where this can occur could be suddenly turning on a weight-bearing limb. Alternatively if the stifle is hyperextended, the cranial cruciate ligament is the first structure to be damaged, this could happen if a dog is running and steps into a hole. Another trauma mechanism for cranial cruciate ligament rupture is when excessive force is placed on the joint e.g. when landing from a height so that the cranial tibial thrust produced exceeds the breaking strength of the cranial cruciate ligament. Finally, when ligaments are put under stress they deform and need time to return to their normal shape after weight bearing. If the cranial cruciate ligament is exposed to repetitive heavy weight bearing it can result in ligament failure and damage. The majority of cranial cruciate ligament ruptures seem to be associated with degenerative changes in the ligaments and stifle joint (Arnoczky, S.P. 1988 p76. Houlton et al. 2006 p358). These degenerative changes can include age as the tensile strength of the cranial cruciate ligament decreases with ageing as the collagen fibres and cellular elements degenerate. These changes to collagen fibres and cellular elements happen much earlier in larger breed dogs which explains why cranial cruciate ligament rupture is seen much earlier in life in large breed dogs when less than two years old. An in vitro study (Wingfield et al., 2000, cited by Houlton et al. 2006 p358) to support this showed that only half the load per unit body mass was required to cause rupture of the ligament in a Rottweiler compared with that in a greyhound. Reasons for degeneration are not fully understood but several other factors are thought to be involved, more commonly: obesity, lack of fitness, abnormal gait. There may be some form of immune mediated disease, vascular disease or other problems including patellar luxation and intercondylar notch deformity, which can weaken the cranial cruciate ligament. Finally if there is an increased tibial plateau angle in a stifle joint the cranial cruciate ligament is placed under more stress. Cruciate ligament disease or rupture can be seen in any breed of dog although many large and giant breed dogs are over-represented and strangely higher incidence of cruciate ligament disease has been reported in a number of papers for spayed females. Following cranial cruciate rupture a number of changes take place in the stifle joint, interestingly approximately 50% of dogs with cranial cruciate ligament rupture have meniscal injuries too (Bennett et al., 1998, cited by Houlton et al. 2006 p359). There is a lower incidence of meniscal injuries in small breed dogs and dogs with partial ligament rupture (Houlton et al. 2006 p359). After cranial cruciate rupture following trauma, acute onset severe pelvic limb lameness can be seen and if bilateral rupture takes place an arched back may be mistaken for spinal problems and difficulty from getting up and jumping may be present. In most cases the onset of lameness is gradual and stiffness after rest can be seen as well as not sitting symmetrically with the stifle flexed.

Madeleine Ovenden
Following cranial cruciate ligament damage degenerative changes take place in the joint as one of the primary joint restraints isnt working. Firstly the tibia will move cranially to the femur as the limb bears weight. Periarticular osteophyte formation is common and occurs when new bone forms around the stifle joint and is a feature of osteoarthritis. Capsular thickening of the stifle joint often occurs as the joint attempts to stabilise itself, this can however make diagnosis difficult. Muscle degeneration can also occur which weakens the stifle. Observations of the caudal cruciate ligament show that changes after rupture do not produce as severe changes, including far less prominent osteophyte formations and articular cartilage changes in the stifle. The caudal cruciate ligament is rarely ruptured alone as it is protected from extreme movements by other structures. If the caudal cruciate ligament were ruptured alone it would be seen in young, large breeds from severe trauma. The femoral attachment site of the ligament breaking off is often seen in patients. Clinical Examination and Diagnosis: During clinical examination a number of different things must be evaluated, firstly the gait of the dog should be analysed for the degree of lameness. If the rupture is acute and from trauma severe lameness can be seen with little weight bearing, unlike some degenerative ruptures where joint thickening can stabilise the joint to allow some weight bearing. Examination of the lumbosacral spine, posture and entire limb should be done to detect any other possible causes of lameness. Femoropatellar stability and quadriceps muscle atrophy are both features of degenerative cranial cruciate ligament disease so should be checked. Joint movement should next be tested, flexion and extension of the stifle may be limited and an audible click if present may be a sign of meniscal damage but absence of a click doesnt mean there is no meniscal damage. Joint instability can be tested by two methods, the cranial drawer test and the tibial compression test. These tests are best performed with the dog lying down and anaesthesia or sedation may be necessary if pain or anxiety make examination difficult.

The Cranial Drawer Test: Index finger placed on the patella and the thumb on the lateral fabella, with the other hand the index finger on the tibial crest and thumb on the head of the fibula. A cranial or forward force is applied to the tibia in full extension and in 30-60 of flexion to detect partial ruptures. If there is a complete rupture of the cranial cruciate ligament then an abnormal drawer motion is present during both extension and flexion. Partial rupture of the craniomedial band of the ligament can be seen if the cranial drawer motion is detected in a flexed position and the caudolateral band is relaxed in flexion. Rupture of only the caudolateral band is not easily diagnosed with the cranial drawer test as the craniomedial band remains taut in flexion and extension so prevents the abnormal drawer motion.

BSAVA Canine and Feline Musculoskeletal disorders pg. 360 Figure 22.12

Madeleine Ovenden
The dog may show pain when being examined and a comparison should be made with the other stifle joint to be aware of bilateral cruciate disease. The clinician should also be aware that Periarticular fibrosis and meniscal injury might prevent a cranial drawer motion. Tibial Compression Test: The stifle joint is flexed while one hand is placed over the tibial crest to feel for cranial movement of the tibia; this is mimicking the loading condition that generates the cranial tibial thrust. This may be less painful for the dog but not as sensitive for detecting partial ruptures. BSAVA Canine and Feline Musculoskeletal disorders pg.360 Figure 22.13

It has become common in examination to take radiographs of the stifle to eliminate any other causes of lameness e.g. bone abnormalities and the degree of osteoarthritis. Both the mediolateral view of the stifle and the caudocranial view should be taken; these are then used to calculate the tibial plateau angle. The method of measuring the tibial plateau angle is shown in the diagram below and is approximately 20-25 in dogs.
Positioning for the mediolateral view. BSAVA Canine and Feline Musculoskeletal Disorders. Figure 22.14, page 361. Positioning for the caudocranial view. BSAVA Canine and Feline Musculoskeletal Disorders. Figure 22.15, page 361.

The tibial plateau angle is calculated by firstly drawing a line that goes through the centre of the talus and the midpoint of the intercondylar eminences (A). Line B is then drawn through the cranial and caudal margins of the tibial plateau. Line C is then drawn perpendicularly to A and the angle is then measured as shown in the diagram. Often in radiographs Periarticular osteophytes can be seen but it is said that there is poor correlation between radiographic evidence of osteoarthritis and limb function (Houlton et al. 200 p361).

BSAVA Canine and Feline Musculoskeletal Disorders. Figure 22.17, page 362.

Madeleine Ovenden
Synovial fluid analysis can also provide evidence the degree of inflammation that can be associated with osteoarthritis. The majority of dogs with cranial cruciate ligament have white blood cell counts less than 5 x 10/l which is consistent with osteoarthritis (Houlton et al. 2006 p362). Fragments of menisci may also be found in the meniscal fluid but do not necessarily imply anything about the condition of the menisci. Arthroscopy may also be used to examine the cranial cruciate ligament and menisci but removal of the infrapatellar fat pad is necessary. Magnetic resonance imaging may also be used to detect meniscal injuries but it isnt very specific so may not detect small tears. Non-Surgical and Surgical Techniques: Non-surgical management is a possibility and is usually used if finance, equipment or expertise may not be available. It is advisable in dogs weighing less than 15 Kg or dogs with mild or intermittent lameness. It requires monitoring of the dogs weight, exercise and pain. Keeping the dogs weight down helps relieve the forces put on the joint and is better for the dogs health. Strict lead walking may be necessary and any jumping on and off things should be avoided. In some cases physiotherapy or Underwater treadmill at Lake hydrotherapy can be used to increase range of County Veterinary Specialists motion and strengthen the muscles around the used for physiotherapy post stifle joint to stabilise it. This can however be TPLO surgery expensive for the owner so is not usually done. The next step of treatment is appropriate pain management, which usually involves nonsteroidal anti-inflammatory drugs (NSAIDs) e.g. meloxicam. Several can be tested out to see the best results with the dog and then minimised to the lowest possible dose as the stifle becomes more stable in roughly 6-12 months. As with surgical treatment there is an onset of osteoarthritis, which cannot be avoided. Non-surgical management should be used for treatment of caudal cruciate ligament rupture, as changes that take place in the joint after rupture are minimal and gait returns to normal. Avulsion injuries where the ligament breaks off from the attachment site on the bone can be managed by surgical fixation of the bone fragment with a screw or wire. As mentioned earlier conservative management has shown good results with small dogs weighing less than 15 kg and is not advisable for larger dogs. Some reasons for continued lameness may include meniscal damage, partial cranial cruciate ligament rupture or joint sepsis. If this happens then surgical management may be necessary to stabilise the joint or to look at the state of the menisci. Other circumstances where surgery may not be the best option could be in older dogs with cranial cruciate ligament rupture and severe degenerative joint changes mean that prognosis following surgery is not promising. In these cases pain management with NSAIDs or analgesics will help as the joint may have been stabilised by joint changes.

Madeleine Ovenden
Surgical Techniques: All surgical options aim to remove any damaged tissue e.g. menisci (meniscectomy) or ligament, stabilise the joint, reduce the cranial tibial thrust and try to prevent any future osteoarthritis or meniscal damage. Surgical procedures to stabilise the joint can be split into intra-articular techniques, which try to replace the cruciate ligament, or extraarticular techniques, which stabilise the joint by altering other features. In all cases the joint should be opened by lateral or medial arthrotomy, any damaged ligament and any menisci should be removed and the joint irrigated with saline solution. If there are osteophytes, they can be removed with a sharp scalpel but the joint must be thoroughly washed again with saline to make sure nothing is left in the joint.

Some common intra-articular techniques include using autogenous grafts that are made from parts of the patellar tendon and fascia lata. One technique involves drilling holes in the femur and tibia and passing a strip of fascia lata through them then tying them taut to remove drawer motion. The positioning of the holes is very important to ensure the material doesnt weaken and break. These grafts undergo avascular necrosis when there is a lack of blood supply, which leads to death of bone tissue. However, after 12-14 weeks neovascularization takes place to form new blood vessels. They are weak during this period so when put under stress have a tendency to break. There is also a risk of injury to surrounding structures such as the peroneal nerve, popliteal artery and the caudal cruciate ligament if the graft isnt placed properly.

DeAngelis Suture. BSAVA Manual of Small Animal Arthrology. Figure 16, page 285.

Extra-articular techniques can include looping material around the lateral fabella and through a tunnel in the tibial crest, which is called the DeAngelis suture. Non-absorbable materials are used and self-locking knots or crimp clamps are used to secure the material. Prognosis after a DeAngelis suture shows good joint stability but after a few weeks a cranial draw returns usually from the suture breaking. Most of the long-term joint stability will come from Periarticular fibrosis not the suture. Another extraarticular technique is called Capsular Imbrication and involves multiple sutures in the lateral tissues of the stifle to stabilise the joint. The sutures are tightened with the limb in extension and the technique works well with small dogs. There are some risks with these techniques, including infection, as the material is foreign to the body and peroneal nerve injury.

Madeleine Ovenden
Surgeries to reduce the cranial tibial thrust are more complex but often have better success rates and are suitable for large dogs. The Tibial Plateau Levelling Osteotomy (TPLO) is one technique performed by making a crescent-shaped cut with a shaped saw back slightly from the patellar tendon into the tibia. The bone piece is then rotated roughly 5 depending on the dogs size etc. before securing it with a bone plate and screws. This technique is the most common technique employed at Anderson Abercromby veterinary referrals where I spent some time. The success rate is high if sterile techniques are used, blood supply is maintained well and proper techniques are used to secure the plate. Complication of TPLO surgeries can range from fractures of bone parts to sepsis or patellar tendon injury. TPLO surgery is also expensive costing over 2000 so may not be a viable option for every patient. The image on the left below depicts how rotating the bone piece helps to level the Tibial Plateau. The image on the right shows a radiograph of the bone piece being held into place with a bone plate and screws.

A diagram and radiograph of the TPLO surgery technique. Fitzpatrick Referrals website.

A Tibial Tuberosity Advancement (TTA) is another technique used to reduce the cranial tibial thrust, it is supposedly less invasive and initially the recovery will be quicker but after the first few

A diagram and radiograph of the TTA surgery technique. Fitzpatrick Referrals website.

Madeleine Ovenden
months will be similar to the TPLO. This technique should not be used on patients with a steep tibial plateau angle. The procedure starts by cutting the front part of the tibia bone off and moving it forward, a bone spacer is then placed between the fragment and the tibia. Plates and screws then hold the bone fragment in place and bone graft from the shoulder joint can be put in the gap to try and stimulate it to heal. The bone spacers, screws and plates are made from commercially pure titanium. Following TTA surgery there is a higher risk of meniscal injury than after TPLO surgery and risks of bone fragments fracturing and infection still remain.

Postoperative care and Prognosis: The prognosis following surgery depends on several factors including technique used, the age and physical condition of the patient. Postoperative rehabilitation plays a large role in good recovery after cruciate ligament surgery. As in non-surgical management hydrotherapy can be used postoperatively helps increase range of motion more than regular walking. Other physiotherapy exercises may be employed that can help weight bearing but for the first several weeks following surgery exercise should be restricted. Several appointments will follow surgery to check recovery is going well and there are no complications. Exercise regulations vary from each practice; however, at Anderson Abercromby where I completed my work experience lead walking is suggested from 10 days onwards for 5-10 minutes twice a day. This should be followed until X-rays at 6 weeks post op to check that the bone is healing nicely, if there are no problems exercise can be increased from there gradually. When assessing different techniques, radiographic assessment should not be used to try and correlate osteoarthritis, as there is little correlation between that and clinical function. If there are any incidents of increased lameness following cranial cruciate ligament repair surgery it may be down to a number of things. Firstly if there is a partial tear, increased lameness may suggest a complete tear in the ligament. Damage to the menisci, sepsis or damage to other ligaments may also occur. It must be noted that the progression of osteoarthritis post cranial cruciate ligament damage and repair may contribute to varying degrees of lameness in the patient. Prognosis following caudal cruciate ligament damage is usually good as most dogs recover without need for surgical management. If surgical management is necessary then extra-articular stabilisation and fixation of any bone fragments may be necessary, but usually give good outcomes. Conclusion: Canine cruciate ligament disease has a large part in small animal medicine and is constantly being scrutinised as to which technique produces the best results and prognosis. The resources I used to write my project came from a variety of sources; some were review articles, which tackled the idea of reviewing different techniques and others included manuals published by the British Small Animal Veterinary Association. All provided sound evidence that I was able to include in my project. However, after reviewing with my tutor and realising that as was unable to find or use data from my work placement I included a study by Vasseur that had been referenced in BSAVA Canine and Feline Musculoskeletal Disorders.

Madeleine Ovenden

I decided to investigate a study by P.B Vasseur in 1984, which studied 85 dogs following cranial cruciate ligament rupture to help provide some evidence that will in turn help me to review and conclude about treatment following cranial cruciate ligament rupture. The study appeared in Veterinary Surgery journal in 1984 but is referenced in some of the articles I have read that are more recent. The dogs in the study were on leash walking for 3 to 6 weeks, any weight loss was indicated and pain-relieving medication was administered if necessary. The degree of lameness was based on several different tests, so for a dog to be considered to be clinically normal they would need to show no lameness when weight bearing on the limb and a normal range of movement should be seen in the stifle. From this we can presume that clinically improved would involve the dog exercising normally and better than when it ruptured its cranial cruciate ligament. The categories for dogs less than 15kg of clinically normal and improved were evaluated after an average follow up period of 36.6 months; in contrast the same categories for dogs weighing over 15kg were evaluated after an average of 49.1 months. Lameness in dogs under 15kg, which were clinically worse showed lameness worsening over an average of 8.2 months and in dogs over 15kg the same category worsened over an average of 10.2 months. In both weight categories of dogs that were clinically worse, surgical replacement or management was performed.

The results are shown below: Weight: Clinically Normal 21 4 Degree of Lameness Clinically Improved 3 7 Clinically Worse 4 46 Total

Less than 15kg More than 15kg

28 57 85

From the study there is strong evidence that for small breed dogs less than 15 kg, nonsurgical management should be tried first. This should also be the case if lameness is not seen to be very bad and there are financial restrictions in place for the owner. From the table we can see that the two different weight categories show almost opposite results with the mode in less than 15 kg being clinically normal and in more than 15kg being clinically worse. As I mentioned earlier if lameness in dogs less than 15kg worsens or persists then surgical management should be performed to try and correct the problem. The percentages of clinically normal and improved for less than 15kg and more than 15kg are 86% and 19% respectively. Clearly highlighting the fact that dogs weighing more than 15kg are likely to get worse if surgical management is not undertaken. Larger breed dogs should undergo surgical management as the forces on the joint are much greater that in smaller dogs so the joint is unlikely to be able to recover without any surgery. There are several different approaches I have reviewed in surgical management, intra-articular and extra-articular techniques try to replace the function of the cranial cruciate ligament. This may help slightly but often findings show grafts breaking or becoming loose so that the femorotibial joint is still unstable. Personally I

Madeleine Ovenden
feel surgeries such as the TPLO or TTA that address the problem of the cranial tibial thrust are a more sensible option for patients. This is due to a number of reasons, the surgeries are likely to produce more permanent results e.g. screws and bone plates are less likely to come loose like a graft might and therefore once completed are less likely to need attention in the future. These surgeries that change the tibial plateau angle should also stop the tibia from slipping forward in the way that the cranial cruciate ligament would if it was intact.

Overall Review: After my research into the topic it has become clear to me that there is no one simple answer to my question. A problem I faced when completing my project is that the most appropriate method can change according to a number of things, whether the cranial cruciate ligament was ruptured by trauma or through degenerative changes. The size and breed of the dog as well as the age will also have a bearing on how to treat the injury. If there is meniscal damage, whether the tibial plateau angle in abnormal and whether non-surgical management has been unsuccessful. To help illustrate this point I included several flow diagrams, which I found in BSAVA Canine and Feline Musculoskeletal disorders that depict how the path of treatment changes with the circumstances. Another problem was that although there have been several review papers concerning cruciate ligament injury and repair, studies behind them have not produced concrete results as to which method is best and the most successful as a consequence of each patient with cruciate ligament disease having different a number of different factors.

Madeleine Ovenden

If asked how I would treat a patient with cruciate ligament disease, obviously a great number of factors need to be taken into account, and I feel the most important of these is size and weight. From what I have researched in my project I would probably employ surgical techniques when treating a patient and not opt for non-surgical as I feel they give a lower chance of successful recovery. When in the area of surgical techniques I

Madeleine Ovenden
would lean towards choosing a TPLO style technique as they accept that the cruciate ligament is gone and instead of trying to replace or mimic its function directly they look more at counteracting the changes that take place in the stifle after rupture. It is also the most commonly employed surgical method at Anderson Abercromby Veterinary Referrals where I completed work experience. From observing TPLO surgeries and seeing patients post-operatively usually at 6 weeks after surgery I feel it is quite a successful method with few complications in the practice that I have worked at and patients recovering well. What is certain is that there is no right technique and new techniques to tackle the problem of cruciate ligament disease in dogs are constantly being invented. More so we are still yet to find the perfect solution, as osteoarthritis and degeneration of the joint are unavoidable and sadly inevitable.

Madeleine Ovenden

Bibliography: Arnoczky, S.P., 1988. The Cruciate Ligaments: the Enigma of the Canine Stifle. Journal of Small Animal Practice, 29, pp.71-90. Collinson, R.W., 1994. BSAVA Manual of Small Animal Arthrology. British Small Animal Veterinary Association: Gloucestershire. Chapter 16 written by Anderson, J. John E.F. Houlton, James L. Cook, John F. Innes and Sorrel J. Langley-Hobbs (2006), BSAVA Manual of Canine and Feline Musculoskeletal Disorders. British Small Animal Veterinary Association: Gloucestershire. Moore, K.W. & Read, R.A., 1996. Rupture of the Cranial Cruciate Ligaments in Dogs Part 1. The Compendium Small Animal, 18 (3), pp.223-233. Moore, K.W. & Read, R.A., 1996. Rupture of the Cranial Cruciate Ligaments in Dogs. Part II. Diagnosis and Management. The Compendium Small Animal, 18 (4), pp.381-391.

Fitzpatrick Veterinary Referrals, [viewed 15.11.2012] Available from:

http://www.fitzpatrickreferrals.co.uk/our-services/surgery/conditions/cranialcruciate-ligament-injury. Dog Health Handbook, [viewed 15.11.2012] Available from http://www.dog-healthhandbook.com/dog-knee-injuries.html.