Comparison of Arthroscopy and Arthrotomy for Diagnosis of Medial Meniscal Pathology: An Ex Vivo Study

Objective— To evaluate the sensitivity and specificity of arthroscopy and arthrotomy for diagnosis of medial meniscal pathology and to evaluate the diagnostic value of medial meniscal probing. Study Design— Ex vivo study. Animals— Cadaveric canine stifle joints (n=30). Methods— Stifle joints were assigned to either a cranial cruciate ligament (CrCL) deficient or intact group. Within each stifle joint, no medial meniscal tear, a peripheral detachment, or 1 of 3 variants of vertical longitudinal tears of the medial meniscus were created. Each stifle joint had arthroscopy, craniomedial (CrMed), and caudomedial (CdMed) arthrotomy. Diagnoses were made by both observation and probing. Sensitivity, specificity, and correct classification rate (CCR) for diagnosing the state of the medial meniscus using both observation and probing with all diagnostic methods were calculated. Odds ratios were calculated to determine if probing increased diagnostic accuracy. Results— Arthroscopy with probing was the most sensitive and specific diagnostic method and had the highest CCR. For arthrotomy, CrMed was the most sensitive in CrCL‐deficient and CdMed the most sensitive in stable, CrCL‐intact stifle joints. For all methods, probing increased their diagnostic accuracy. Conclusions— Arthroscopy is the most accurate diagnostic method; however, probing the medial meniscus enhances the diagnostic accuracy of all methods. Clinical Relevance— Accurate diagnosis of medial meniscal pathology is ideally achieved by means of arthroscopy; however, if arthrotomy is chosen, CrMed should be selected in unstable and CdMed in stable stifle joints. Regardless, medial meniscal probing should be performed to increase diagnostic accuracy.     

Synovial T-cell lymphoma of the stifle in a dog

A 6-year-old, 43-kg, spayed female rottweiler was presented for a 1-month history of progressive, left hind-limb lameness. Upon physical examination, a cranial drawer sign and joint distention were present in the left stifle. Radiographically, the stifle had evidence of effusion, remodeling of the patella, and an enlarged popliteal lymph node. Marked synovial thickening and an intact cranial cruciate ligament were noted during surgery. Despite finding a nonspecific, mixed inflammatory response on joint fluid cytopathology, histopathology demonstrated T-cell lymphoma of the synovium. Lameness may be the sole presenting clinical sign in canine lymphoma.     

Cranial tibial thrust: a primary force in the canine stifle

A cranially directed force identified within the canine stifle joint was termed cranial tibial thrust. It was generated during weight bearing by tibial compression, of which the tarsal tendon of the biceps femoris is a major contributor, and by the slope of the tibial plateau, found to have a mean cranially directed inclination of 22.6 degrees. This force may be an important factor in cranial cruciate ligament rupture and in generation of cranial drawer sign.     

Cranial cruciate ligament injury in the dog: pathophysiology, diagnosis and treatment

Cranial cruciate ligament (CCL) disease in the dog is a multifactorial complex problem that requires a thorough understanding of the biomechanics of the stifle joint to be understood. Successful treatment of rupture of the CCL should be based on managing underlying anatomical and conformational abnormalities rather than attempting to eliminate the tibial cranial drawer sign. The cranial and caudal cruciate ligaments, the patella ligament and quadriceps mechanism, the medial and lateral collateral ligaments, the medial and lateral menisci and the joint capsule provide stability of the joint and load-sharing. The function of the stifle is also significantly influenced by the musculature of the pelvic limb. An active model of biomechanics of the stifle has been described that incorporates not only the ligamentous structures of the stifle but also the forces created by weight-bearing and the musculature of the pelvic limb. This model recognises a force called cranial tibial thrust, which occurs during weight-bearing, and causes compression of the femoral condyles against the tibial plateau. In middle-aged, large-breed dogs, forces acting on the CCL together with conformation-related mild hyperextension of the stifle and slightly increased tibial plateau slopes are suspected to cause progressive degeneration of the ligament. Palpation of craniolateral stifle laxity has become pathognomonic for CCL rupture; however, chronic periarticular fibrosis, a partial CCL rupture, and a tense patient, may make evaluation of instability of the stifle difficult. Surgical treatment is broadly separated into three groups: intracapsular, extracapsular, and tibial osteotomy techniques. Tibial osteotomy techniques do not serve to provide stability of the stifle but rather alter the geometry of the joint to eliminate cranial tibial thrust such that functional joint stability is achieved during weight-bearing. Visualisation of both menisci is a critical aspect of CCL surgery, irrespective of the technique being performed. Regardless of the surgical technique employed, approximately 85% of dogs show clinical improvement. However, many of these dogs will demonstrate intermittent pain or lameness. Post-operative management is an integral part of the treatment of CCL rupture, and significant benefits in limb function occur when formalised post-operative physiotherapy is performed.     

Preliminary study evaluating tests used to diagnose canine cranial cruciate ligament failure

O bjective : To estimate specificity, sensitivity, positive predictive value and negative predictive value of tests and signs used for the diagnosis of cranial cruciate ligament failure in dogs.
M ethods : One stifle in each of 42 dogs was examined: 25 "affected" and 17 "control" dogs. All dogs were subjected to the following tests when conscious: cranial drawer, tibial compression, patellar tendon palpation and palpation of the medial aspect of the joint. Under general anaesthesia, cranial drawer and tibial compression tests were repeated and a lateral stifle radiograph was taken to evaluate changes of the infrapatellar fat pad. The results were analysed using a 2×2 table method. Sensitivity, specificity, positive predictive value and negative predictive value were estimated.
R esults : The sensitivity of the cranial drawer and tibial compression tests was surprisingly low when performed on conscious patients but significantly better when performed under anaesthesia. Similarly, palpation of the medial aspect of the stifle joint cannot be considered a reliable indicator of cranial cruciate ligament injury. Patellar palpation and radiographic assessment showed excellent sensitivity, specificity, positive predictive value and negative predictive value.
C linical S ignificance : In the diagnosis of cranial cruciate ligament, it is essential that the clinician is aware of each test's features and limitations to reduce the risk of misdiagnosis.     

Evaluation of Experimental Transection and Partial Excision of the Caudal Cruciate Ligament in Dogs

The caudal cruciate ligament (CaCL) of one stifle joint in seven dogs was transected and a 2 to 4 mm section was removed. Six months after surgery, none of the dogs were lame. Thigh muscle circumference, stifle range of motion, and internal tibial rotation in the operated limb were not significantly different from the preoperative measurements or the contralateral, unoperated limb. A caudal drawer motion was consistently present in the stifle joints with a transected CaCL. A radiographic evaluation of the operated stifle joints did not reveal osteoarthritic changes; four of seven stifle joints had an irregular fat pad 6 months after surgery. Results of a joint fluid analysis revealed a slight increase in synovial cells within treated stifle joints; inflammatory cells were not observed. The only gross morphologic change in stifle joints with a severed ligament was enlarged knobby remnants of the CaCL. Articular cartilage defects or osteophytes were not observed. Results of a histologic examination of the CaCL remnants revealed synovial cellular capping and intraligamentous fibroplasia. Based on a limited number of dogs, it was concluded that isolated transection of the CaCL produced minimal clinical and pathologic changes in the stifle joint during a 6 month period.     

Evaluation of Fibular Head Transposition for Repair of Experimental Cranial Cruciate Ligament Injury in Dogs

Unilateral cranial cruciate ligament excision and fibular head transposition (FHT) were performed on 30 adult dogs. Vertical ground reaction forces were determined using force plate data before and after surgery. Cranial drawer motion, tibial rotation, and varus-valgus motion were measured at monthly intervals. Radiographic, gross, and histological examinations of the stifle joints that had been operated on were performed 3 weeks, 4 months, and 10 months after surgery. A scoring system was used to evaluate lameness, osteophyte formation, and meniscal damage. Rank correlation coefficients were calculated between variables tested in pairs. Cranial drawer motion and abnormal tibial rotation were present in all of the joints that had been operated on. Peak vertical force and associated impulse were not restored during the study time period. Meniscal damage was noted in 25% of the dogs at month 4 and in 50% of the dogs at month 10. Progressive gross and histological deterioration of the articular cartilage was observed in all joints. Positive correlations were noted between the degree of stifle joint instability and meniscal injury or radiographic changes. FHT did not control cranial drawer motion and rotational instability, was not successful in restoring limb function, and did not prevent joint degeneration, especially meniscal damage.     

Biomechanics of tibial plateau leveling of the canine cruciate-deficient stifle joint: a theoretical model

OBJECTIVE: To evaluate the effect of tibial plateau leveling on the biomechanics of the canine stifle. STUDY DESIGN: Analysis of a 3-dimensional (3-D) anatomically accurate theoretical model of the canine stifle. METHODS: A 3-D, 3-segment mathematical model of the normal canine stifle was modified to simulate the effect of rotation of the tibial plateau during tibial plateau leveling osteotomy (TPLO). The model examined the normal stifle, the stifle with a tibial plateau angle (TPA) of 0 degrees, and the stifle with a TPA of 5 degrees. Analysis of the models at 10 consecutive equally spaced positions during the stance phase yielded data such as ligament forces and joint reaction forces at each position. RESULTS: Rotation of the tibial plateau to a TPA of 0 degrees almost eliminates forces in the cranial cruciate ligament (CCL) throughout the stance phase. Rotation to a TPA of 5 degrees did not, however, substantially decrease the load in the CCL. Both procedures increased the load in the caudal cruciate ligament (CaCL). CONCLUSIONS: Cranial tibial thrust (CTT) is converted into caudal tibial thrust when the TPA is 0 degrees ; however, rotating the plateau to a TPA of 5 degrees does not eliminate the CTT. CLINICAL RELEVANCE: The TPLO procedure performed as currently recommended (rotating the tibial plateau to a TPA of 5 degrees) may not eliminate the CTT, but only reduce it. Both TPLO procedures evaluated here were found to increase the load in the CaCL.     

Multiple ligamentous injuries of the canine stifle joint: a study of 12 cases

Multiple ligamentous injuries of the canine stifle are uncommon. In this study, they affected mainly adult, male, working or sporting dogs and occurred secondary to severe trauma, or where chronic joint infection had weakened the supporting structures. Rupture of the cranial cruciate, caudal cruciate and lateral collateral ligaments was the most common injury observed and this occurred after catching the limb in a fence or gate. Reconstruction of the collateral and cranial cruciate ligaments, and careful repair of damaged menisci and joint capsule, was an effective method of treatment for medium- and large-size dogs. Reconstruction of the caudal cruciate ligament and postoperative limb support was not found to be essential. All dogs with subluxated stifles had good to excellent limb function with minimal loss of mid-thigh circumference or stifle joint range of motion at follow-up. Less favourable results were achieved where there was stifle joint luxation with extensive disruption to secondary joint restraints.     

Cemented Total Knee Replacement in 24 Dogs: Surgical Technique, Clinical Results, and Complications

Objective— To characterize the performance of cemented total knee replacement (TKR) in dogs.
Study Design— Preclinical research study.
Animals— Skeletally mature, male Hounds (25–30 kg; n=24) with no preexisting joint pathology.
Methods— Dogs had unilateral cemented TKR and were evaluated at 6, 12, 26, or 52 weeks (6 dogs/time point) by radiography, bone density analysis, visual gait assessment, and direct measurement of thigh circumference and stifle joint range of motion as indicators of functional recovery. At study end, the stability of the cemented tibial component was determined by destructive mechanical testing.
Results— Joint stability was excellent in 16 dogs (67%) and good in 8 dogs. None of the tibial components had evidence of migration or periprosthetic osteolysis whereas 1 femoral component was loose at 52 weeks. There was an early and significant decrease in tibial bone density, likely because of disuse of the operated limb. Dogs returned to full activity by 12 weeks. The tibial cement–bone interface maintained its strength over 52 weeks.
Conclusions— Cement provides stable fixation of the tibial component in canine TKR.
Clinical Relevance— Cemented TKR yields adequate clinical function and stifle joint excursion in the dog. Clinical studies are needed to determine the long-term fate of cemented TKR implants, to assess the influence of implant design on implant fixation and wear, and to obtain objective functional data.     

PARTIAL AVULSION OF THE ORIGIN OF THE CRANIAL CRUCIATE LIGAMENT IN A 4 YEAR-OLD DOG

A four year-old intact male Dalmatian was referred to the veterinary teaching hospital at Louisiana State University for acute, non-weight-bearing left hindlimb lameness of three weeks duration. Information supplied by the referring veterinarian indicated the lameness was first diagnosed and treated seven months previously, but recurred three weeks ago. External rotation of the left stifle, mild discomfort upon stifle flexion, mild to moderate muscle atrophy and palpable joint effusion were noted during physical examination. Slight cranial drawer movement with a soft end-point was discovered during manipulation of the left stifle. A triangular bone fragment and thickened, confluent intracapsular soft tissues were observed on radiographs of the stifle. Radiographically, moderate degenerative changes suggested chronicity. This report describes the clinical and radiographic findings of a rarely reported partial avulsion of the origin of the cranial cruciate ligament in a skeletally mature dog.     

A Novel Pin Distraction Device for Arthroscopic Assessment of the Medial Meniscus in Dogs

Objective— To describe an extra-articular joint distractor for meniscal examination and treatment during canine stifle arthroscopy.
Study Design— Case series.
Animals— Dogs ≥20 kg with suspected cranial cruciate ligament (CrCL) deficiency.
Methods— A custom designed linear side bar was constructed to allow invasive pin distraction of the stifle joint. Its design efficacy for distraction of the medial joint compartment, observation and probing of the medial meniscus, and value during meniscal surgery was evaluated by clinical use.
Results— Application of the stifle distractor medial to the stifle joint using 2 negative threaded pins was easily performed percutaneously without the need of power equipment; however, unintended intra-articular placement of 1 threaded pin occurred in 2 stifles, without appreciable consequence to joint function. Observation as well as thorough probing of the caudal horn of the medial meniscus, even in the presence of a prominent remnant of the CrCL or severe periarticular fibrosis, was possible. Partial meniscectomy was effectively performed as needed without apparent damage to the associated articular surfaces.
Conclusions— Distraction and translation of the medial compartment of the stifle joint using invasive pin distraction allowed observation and palpation of the caudal horn of the medial meniscus so that assessment and treatment were readily accomplished without apparent morbidity.
Clinical Relevance— With careful attention to accurate pin placement, invasive pin distraction of the medial compartment of the canine stifle joint may improve arthroscopic evaluation and treatment of meniscal pathology.     

Effects of surgical implants on high-field magnetic resonance images of the normal canine stifle

To determine the effect of surgical implants on the depiction of canine stifle anatomy in magnetic resonance (MR) images, three canine cadaver limbs were imaged at 1.5 T before and after tibial plateau leveling osteotomy (TPLO), tibial tuberosity advancement (TTA), and extra-capsular stabilization (ECS), respectively. Susceptibility artifacts associated with implants were identified in MR images as a signal void and/or signal misregistration, which obscured or distorted the anatomy. Using the preoperative images as a reference, articular structures of the stifle in postoperative images were graded using an ordinal scale to describe to what degree each anatomic structure could be evaluated for clinical purposes. The TPLO implant, which contains ferromagnetic stainless steel, produced marked susceptibility artifacts that obscured or distorted most stifle anatomy. The titanium alloy TTA implants and the stainless steel crimps used for ECS produced susceptibility artifacts that mainly affected the lateral aspect of the stifle, but allowed the cruciate ligaments and medial meniscus to be evaluated satisfactorily. Susceptibility artifact was significantly less marked in images obtained using turbo spin-echo (TSE) sequences than in sequences employing spectral fat saturation. Clinical MR imaging of canine stifles containing certain metallic implants is feasible using TSE sequences without fat saturation.     

USING MACHINE LEARNING TO CLASSIFY IMAGE FEATURES FROM CANINE PELVIC RADIOGRAPHS: EVALUATION OF PARTIAL LEAST SQUARES DISCRIMINANT ANALYSIS AND ARTIFICIAL NEURAL NETWORK MODELS

As the number of images per study increases in the field of veterinary radiology, there is a growing need for computer‐assisted diagnosis techniques. The purpose of this study was to evaluate two machine learning statistical models for automatically identifying image regions that contain the canine hip joint on ventrodorsal pelvis radiographs. A training set of images (120 of the hip and 80 from other regions) was used to train a linear partial least squares discriminant analysis (PLS‐DA) model and a nonlinear artificial neural network (ANN) model to classify hip images. Performance of the models was assessed using a separate test image set (36 containing hips and 20 from other areas). Partial least squares discriminant analysis model achieved a classification error, sensitivity, and specificity of 6.7%, 100%, and 89%, respectively. The corresponding values for the ANN model were 8.9%, 86%, and 100%. Findings indicated that statistical classification of veterinary images is feasible and has the potential for grouping and classifying images or image features, especially when a large number of well‐classified images are available for model training.     

Diagnosis and surgical repair of stifle luxation in a spur-thighed tortoise (Testudo graeca).

This report describes stifle luxation resultant from multiple ligamentous injuries in a spur-thighed tortoise (Testudo graeca). Despite an absence of obvious trauma in the case history, the tortoise presented with acute, unilateral hind limb lameness. Diagnosis of stifle luxation was based on cranial drawer motion, increased rotational joint instability. and radiographic findings. Joint stabilization was accomplished by a combination of cranial cruciate reconstruction using an autograft of lateral vastus muscle in an over-the-top procedure and lateral imbrication of the joint capsule. Postoperative management included restriction of limb movement for 6 wk and parenteral chondroprotective regime. Treatment was effective in restoring clinically normal function to the limb.     

Prevalence of cranial cruciate ligament rupture in a population of dogs with lameness previously attributed to hip dysplasia: 369 cases (1994-2003)

OBJECTIVE: To determine the prevalence of cranial cruciate ligament rupture (CCLR) in dogs with lameness previously attributed to canine hip dysplasia (CHD). DESIGN: Retrospective study. ANIMALS: 369 client-owned dogs. PROCEDURES: Hospital medical records from 1994 to 2003 were reviewed for dogs in which the referring veterinarian had diagnosed hip dysplasia or hip pain. Dogs were designated as having hind limb lameness because of partial or complete CCLR or CHD. RESULTS: 8% of dogs were sexually intact females, 43% were spayed females, 14% were sexually intact males, and 35% were castrated males. Mean age was 3.8 years (range, 3 months to 15 years). The most common breeds were the Labrador Retriever (21%), German Shepherd Dog (13%), and Golden Retriever (11%). The prevalence of CCLR as the cause of hind limb lameness was 32% (95% confidence interval, 27.2% to 36.8%). The distribution of CCLR among hind limbs was left (29%), right (28%), and bilateral (43%). Of 119 dogs with CCLR, 94% had concurrent radiographic signs of CHD, 92% had stifle joint effusion, and 81% had a cranial drawer sign. CONCLUSIONS AND CLINICAL RELEVANCE: On the basis of the high prevalence of CCLR in dogs referred for lameness because of CHD, it is important to exclude other sources of stifle joint disease before making recommendations for treatment of CHD.     

Ultrasonographic, computed tomographic and magnetic resonance imaging anatomy of the normal canine stifle joint

Ultrasonographic (US), magnetic resonance (MR) and computed tomographic (CT) images of normal canine stifle joints were obtained and compared with plastinated cross-sectional slices of cadaver specimens from the same dogs. The bony and articular structures were identified and correlated with the three diagnostic imaging modalities. These results provide an atlas of normal cross-sectional US, MR and CT anatomy of the canine stifle, which can be used for the interpretation of stifle images from any of these imaging modalities.     

ULTRASONOGRAPHIC ANATOMY OF THE NORMAL CANINE STIFLE

Ultrasonographic examination of the normal canine stifle joint was performed to characterize its normal anatomy. Stifles of four normal adult dogs were imaged in sagittal and transverse planes and each anatomic structure visualized was recorded. Normal anatomic structures consistently seen included the patellar tendon, medial and lateral menisci, the cranial cruciate ligament and femoral condyle cartilage. The caudal cruciate ligament was visualized in two dogs. Collateral ligaments and meniscal ligaments were not visualized. The dogs were then euthanized and each stifle was isolated. Following removal of superficial muscles and skin, each stifle was imaged in a water bath to definitively identify the structures that had previously been visualized on the live dogs. The ultrasonographic appearance of the isolated stifle specimens was similar to that found in live dogs. The results of this study indicate that ultrasound can be used to image the normal anatomy of the canine stifle. The echogenicity of the patellar ligament, cruciate ligaments, menisci and articular cartilage was similar to that previously reported in equine stifles and human knees.     

MAGNETIC RESONANCE ARTHROGRAPHY OF THE CANINE STIFLE JOINT TECHNIQUE AND APPLICATIONS IN ELEVEN MILITARY DOGS

The stifle joints of eleven military working dogs were evaluated using conventional magnetic resonance (MR) imaging and MR arthrography. A protocol optimizing MR imaging of the canine stifle joint is discussed, as well as potential uses for administration of intra-articular gadolinium. The technique for performing MR arthrography is described, and post-contrast image findings are reviewed. MR arthrography was performed by using an intra-articular injection of diluted gadolinium. Consistently good quality images were obtained, and no complications were clinically detected following MR arthrography. Cranial cruciate ligament abnormalities were seen in six dogs, meniscal abnormalities were visualized in nine menisci, and synovitis and medial ligament strain were seen in eight dogs. Surgical and post-mortem confirmation of these findings is discussed in seven dogs. Although MR arthrography adds an invasive procedure to conventional MR imaging, it can provide useful information on pathologic changes in the canine stifle joint.     

Custom total knee replacement in a dog with femoral condylar bone loss

Objective— To report surgical planning, technique, and outcome of custom total knee replacement (TKR) performed to manage a medial femoral condylar nonunion in a dog.
Study Design— Clinical case report.
Animal— A 3-year-old, 20 kg Karelian Bear Hound.
Methods— Computed tomographic scan of the left pelvic limb was used to build a stereolithography model of the distal portion of the femur. The model was used to create a custom augment to replace the missing medial femoral condyle and a custom stem for intramedullary condylar cemented fixation. The augment and stem were adapted to femoral and tibial components already available. The model was used to rehearse the surgery and then the custom prosthesis was implanted.
Results— Weight bearing returned 8 hours after surgery and improved thereafter. Joint alignment was normal and prosthetic joint motion was 60–165° postoperatively. The dog resumed moose hunting 3 months after surgery. Peak vertical force and impulse of the operated limb measured 17 months after surgery were 65% and 47% of the normal, contralateral limb.
Conclusion— Based on short-term follow-up, cemented canine TKR was successfully achieved for management of a severely abnormal stifle joint.
Clinical Relevance— With further refinement and development of commercially available prostheses, TKR should be possible for canine patients.