The cranial cruciate ligament (CCL) is a critical stabilizing structure in the canine stifle joint and rupture of this ligament is one of the most common orthopedic injuries in large breed dogs. The CCL (number 4 on diagram) counters the tendency of the tibia to move forward (tibial thrust). Unlike humans, dogs walk on their toes with their heel elevated off of the ground and their knee bent forward. These results in forces applied down through the femur to the tibial plateau which is sloped backwards. If the slope is too great the CCL is put under too much stress and can rupture, either partially or fully, resulting in lameness.
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For many years various techniques were devised to repair the CCL and stabilize the other structures around the stifle joint. While many have been successful, results have not always been satisfactory. The Tibial Plateau Levelling Osteotomy (TPLO) was devised by Dr. Barclay Slocum in 1993 and has grown in popularity in the last few years. Unlike traditional approaches to cruciate rupture, the TPLO does not rely on repair of the ligament but instead relies upon correcting the slope of the tibial plateau. This prevents the femur from sliding down the plateau and tibial thrust is eliminated. The technique involves a curved cut in the tibia and reattachment with a special plate after forward rotation thus reducing the angle of the tibial slope. The "drawer sign", the movement of the tibia in a cranial direction noted after cruciate rupture, is still present after the TPLO technique and is not a sign of failure. The TPLO was patented by Dr. Slocum and initially only available to those who were accredited to perform the procedure. This patent has expired leading to more widespread use of the technique but it does require specialized training and equipment.
Recovery from CCL Surgery
The recovery from CCL surgery is similar with all techniques but veterinarians can be notorious for failing to impress upon owners the importance of the recovery phase. While designing a rehabilitation program, remember the importance of nutrition following any kind of surgery. The goals of the rehabilitation program are:
1. Reduce swelling
2. Regain functional control of motion in hip, stifle and hock
3. Encourage early controlled weight bearing
4. Increase muscle strength to aid in joint stability
5. Prevent re-injury
During the rehabilitation the dog should not be allowed to jump onto or off of furniture, in or out of vehicles, run, play roughly, climb stairs, and precautions must be taken against slipping.
Ice the area for 10-15 minutes 2-3 times a day. For the first three days use only ice. After three days, heat can be alternated with ice but always start and end with ice.
Begin passive range of motion (ROM) exercises gently gliding the limb. This involves flexing and extending the hip, stifle and hock. Some muscle massage is also helpful.
Short, very controlled leash walks on a flat surface with good traction for five minutes 3-4 times a day.
Day 10 to Week 4
Continue ROM exercises and increase walks to 10 minutes but remain on flat ground with good traction.
Begin static weight bearing exercises for 3-5 seconds at a time. These include offering a treat from the opposite hip, lifting the sound leg, lifting the sound leg and the opposite front leg, and rocking forward, back, and side to side.
Increase leash walks to 15-20 minutes and add very small hills. Increase weight bearing exercises to 10 seconds and add chest raises.
Increase leash walks to 25 minutes and add moderate inclines. Lead the dog in figure eight patterns and add some low barriers to walk over. Swimming can be started.
Start to increase active exercises including walking in circles in both directions and climbing small staircases (5-6 stairs). Start slow jogging but always on a leash.
Each patient will progress at its own rate but pushing too hard or failing to properly supervise the dog may result in breakdown of the surgical repair or at the very least, increase the recovery time.
There are more and more veterinary nurses learning about physiotherapy and also many human physiotherapists taking an active interest in veterinary patients. It is important to remember that the success of the surgical repair is often determined by the post operative care.