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Abstract
This study carried out on stifle joints of Sixty-five clinically healthy adult mongrel dogs of both sexes and aged from 1 - 3 years old. The CrCL of the right stifle joint of all animals were severed after lateral arthrotomy. The dogs were classified into three groups:
І- Group І (Control group): five dogs were used and the CrCL was severed after lateral stifle arthrotomy.
II- Group II (Extra-articular reconstruction): In this group 30 dogs were used. These dogs were classified into two groups (II A& II B) each of them contained15 dogs.
*Group II A (Modified Lateral Fabellar Suture): in this group, the nylon monofilament fishing line was used in the form of self locking knot beside square knot around the fabella. The fishing line was passed through the tibial crest drilled hole, after it was passed under the common patellar tendon. Fifteen dogs were divided equally into three subgroups (II A1, II A2 and II A3) according to the time of surgical correction of the ruptured CrCL as directly after its severance, 6 weeks and 12 weeks respectively.
*Group II B (Popliteal Tendon Transposition): in this group, the popliteal muscle was severed at tendomuscular junction. The tendon with its sesamoid bone were transposed with nylon suture No. 5 using Krackow suture and then passed through the tibial crest drilled hole. The suture in the medial side of the tibia was fixed by stainless steel endobutton. Fifteen dogs were divided equally into three subgroups (II B1, II B2 and II B3) according to the time of surgical correction of the ruptured CrCL as directly after its severance, 6 weeks and 12 weeks respectively.
III- Group III (Intra-articular reconstruction): In this group, 30 dogs were used. These dogs were classified into two groups (III A& III B) each of them 15 dogs.
*Group III A (Over-The-Top technique): in this group, the fascia lata autograft strip was used with lateral third of the common patellar tendon. The fascial strip was passed through the intercondylar space of the femur penetrating the caudal joint capsule. Fifteen dogs were divided equally into three subgroups (III A1, III A2 and III A3) according to the time of surgical correction of the ruptured CrCL as directly after its severance, 6 weeks and 12 weeks respectively.
*Group III B (Modified Achilles’ Tendon (SDF) Autograft): in this group, the superficial digital flexor tendon strip autograft of the ipsilateral limb was used. The SDF strip passed through the tibial and the femoral drilled tunnels. the drilled tunnels were isometric to the footprint of the CrCL. The tibial side graft was fixed with stainless steel endobutton. Fifteen dogs were divided equally into three subgroups (III B1, III B2 and III B3) according to the time of surgical correction of the ruptured CrCL as directly after its severance, 6 weeks and 12 weeks respectively.
The obtained results were classified into clinical, radiographic, clinicopathological, and histopathological findings. Dogs were examinated at (Zero time, One months, Two months, Three months and Six months) postoperatively.
Clinical finding:
During the first week after surgery, all operated limbs were suffered from severe degree of joint effusion, which gradually subsided till the 2nd month of surgery only the dogs of control group have a mild degree.
Post-operative management largely included of restriction exercise (house confinement with some leash walking) for the first four to six weeks followed by a slight increase in activity, then unrestricted activity after 8 to 10 weeks.
All dogs of the control group underwent apparent severe degree of lameness. The severity of lameness gradually worsened over several weeks to months until the end of the study. Periarticular thickening and Quadriceps atrophy were progressively increased from mild to severe degree at the end of the study.
In reconstruction groups, dogs progressively improvement in lameness, in which the degree of motion was good to excellent at the end of 6 months. Reconstructed stifles were found to have normal range of motion, no cranio-caudal or latero-medial instability, and markedly reduced internal rotation of the tibia on the femur. The group II was reached to the good and excellent degree of lameness earlier than that of the group III. Group II B, which reached to the good and excellent degree of lameness earlier than that of the group II A. Group III B was reached to the good and excellent degree of lameness earlier than that of the group III A. One case of the subgroup IIB1 was developed seroma over the stainless steel endobutton. The seroma was subsided after 2 months postoperatively. In one case from the subgroup III B1, the endobutton was removed surgically at 4th month after reconstruction. In this case, the dog was walked without lameness beside no evidence of joint instability. Periarticular thickening was progressively decreased from moderate to mild degree with exception of the subgroup III B1 after endobutton was removed; the degree of periarticular thickening was none. Quadriceps atrophy was none degree at 2nd and 3rd months after reconstruction surgery, but in group III quadriceps atrophy was mild degree till the end of the study at 6 months.
In 9 dogs all-over the study (13.84%), medial patellar luxation was developed after 2 months of 1st surgery, (one from the control group, two from the subgroup II A3, two from the subgroup II B3, two from the subgroup III A3, two from the subgroup III B3). These were due to bad habit of dogs, which lead to removal of stitches by their teeth. All cases of medial patellar luxation except the control group were corrected using reinforcement technique. Two cases of corrected medial patellar luxation were returned after one month from reconstruction (one from the subgroup III A3, one from the subgroup III B3). The septic arthritis became clinically apparent, causing the suture line in the retinaculum to break down and leading to medial patellar luxation.
Radiographic finding:
In control group, dogs at 3rd month after severing of the CrCL showed mild radiographic changes. Dogs at 6th months post-operation showed marked radiographic changes (showing peri and intra-articular osteophytes and bony sclerosis).
In all groups of reconstruction, most of dogs had no evidence of radiographic changes or periarticular osteophytes formation at any time after surgery. Two cases (one from subgroup III A3 and one from subgroup III B3) which medial patellar luxation was occurred after one month of reconstruction showed mild to moderate degree of radiographic changes. In one case from the subgroup III B1, after the endobutton was removed surgically at 4th month of reconstruction, there was no evidence of radiographical changes.
Clinicopathological finding:
In control group, the total leukocytic count was high in number all-over the period of the study. Indicating the chronic degenerative joint disease was developed.
In reconstruction groups, the total leukocytic count was high in the 1st and 2nd months post reconstruction, but the total leukocytic count was lowered in the 3rd and 6th months post reconstruction. Indicating the chronic degenerative joint disease was firstly developed and then subsided. Two cases of the subgroup III A3 and subgroup III B3 were complicated by medial patellar luxation, these cases had high total leuckocytic count.
In the differential leuckocytic count of all groups of this study, neutophil percent was not exceed than 36 % all-over the study period indicating that, the non-suppurative joint disease was developed except two cases of the septic arthritis from the subgroup III A3 and subgroup III B3.
Histopathological finding:
Grossly in the control group, one dog was weighting 13 Kg. Noticed that, growing of fibrous band at the site of the CrCL. The medial meniscus torn was severely damaged because of chronic instability (mostly after 6 months of severing of the CrCL). The cartilage fibrillation was progressed with time after resection of the CrCL. Peri-articular osteophytes was identifiable in cases that are more chronic.
In all reconstruction groups, minimal changes in the articular cartilage and no meniscal damage were noticed while mild degree showed in the group III A. In the group III B during the first few weeks after the tendon graft CrCL reconstruction, the intra-articular portion of the graft appeared at the earlier time very weak. After 2 months, the graft was increased in its strength. In groups III A and III B of intra-articular autograft, the autografts were viable and strong by time inside the operated stifle joints. In cases complicated by medial patellar luxation, the medial meniscus and articular surface were severely affected as a result of the development of the chronic degenerative disease. Tissue reaction around the endobutton was covering all around the endobutton.
Microscopically the popliteal sesamoid bone after 6 months of reconstruction surgery showed its remainants.
Conclusion
- Early surgical interference to reconstruct the severed CrCL obtained a better result than delayed interferences because the delayed interferences had higher joint changes and lower grad of joint motion than that of the early interferences.
- The Extra-articular techniques were preferable than Intra-articular techniques.
- The popliteal tendon transposition technique was the best technique than Modified lateral fabellar suture, Over–The-Tope and Modified Achilles’ tendon (SDF) autograft techniques.
- Modified Achilles’ tendon (SDF) autograft technique with the tibial side endobutton was preferable than the Over-The-Top Intra-articular technique.
- In Modified Achilles’ tendon (SDF) autograft technique, the removing of endobutton after 4 months postoperatively had good effect on the dog motion.