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Flashcards in Tendon and ligament disease - SA Deck (32)
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1

Name 2 types of tendon injury

- traumatic lacerations
- strains (breaking or dehisence of fibres, mechanically induced or result of weakening by degeneration)

2

Outline mm injury

similar to tendons, less commonly specifically diagnosed

3

Presentation - tendon/ mm injuries

- lameness (acute/ chronic)
- swelling (diffuse, painful, oedema if acute, organised and established if chronic)
- specific functional disability (e.g. unable to extend stifle)

4

Diagnosis - tendon/ mm injuries

- CS (dysfunction)
- radiograph (swelling, gap)
- ultrasound (gap, loss of linear orientation of fibres)

5

Pathophysiology of tendon repair

- fibroblasts and collagen fibres line up along line of action
- sheathed tendons have poorer blood supply and heal slower
- 6 weeks to regain 50% normal strength
- 1 year to regain average 80% normal strength

6

Tx - tendon injry

- rest
- specific support to protect tendon from loading (dressing, cast, trans-articular fixator)
- primary sx repair for lacerations (tendon sutures to manage load, direct contact of edges, suture of epi-tendon to promote healing)
- ultrasound to monitor

7

Name 2 suture patterns for tendon repair

- locking loop
- 3 loop pulley (creates loops around collagen fibres)
- appose tendon edges (3mm gap intereferes with tendon healing)
- non-absorbable prolene (takes long time to heal)

8

Degree of ligament injury/ sprain

- mild/ moderate / severe/ = first/ second/ third degree
- increasing levels of soft tissue damage, swelling, pain, lameness and instability

9

Ligamentous injury - PE

normal PE but especially ROM
- further tests: (radiography with stressed views, ultrasound, manipulate under anaesthesia)
- always check for ancillary damage

10

Tx - ligament injury

- rest, reduce swelling (drugs, cooling)
- external coaptation + support
- ligament repair
- internal ligament splintage
- attention to other structures
- arthrodesis
* degree of tx depends on instability, pain and healing potential*

11

What is arthrodesis?

- a salvage procedure
- joint fusion
- ROM of joint is permanently lost

12

Tx - long-term tx of ligament injury

- long aftercare periods - slow healing
- not always acceptable function (repair mechanics not perfect, extra-chronic capsular tissue, secondary OA)
- may require arthrodesis at second stage

13

How common is ligament disease in small animals?

Not very common except canine cranial cruciate ligament

14

Describe the cranial cruciate

runs from proximal and lateral femur to distal and medial tibia, the caudal cruciate runs in opposite direction.
- cranial cruciate is designed to resist the force that as the dog moves forward and thrust it weight forwards, the reactive force acts caudally and the stifle is vulnerable to this caudal force as the round profile of the femur can slip across the tibial plateau. If the CCL ruptures and the femur can move across the tibia, the menisci can become damaged

15

What is canine cruciate disease?

- normally related to degeneration
- can be acute (trauma or degenerative ligament giving way)
- associated with MPL (medial patella luxation)
- causes a debilitating cr-cd instability in the stifle
- 60% cases involve medial meniscus
- human CL injuries normally traumatic, canine CL injuries are usually the consequence of gradual degeneration of the ligament

16

Typical presentation - CCLR

- middle aged dogs (2-10yo)
- overweight, neutered
- medium to large breeds (labrador, rottweiler, spanial, bull breeds, not sighthounds such as greyhounds and lurchers)
- hx: typically insidious onset HL lame, may be bilateral, acute onset lameness can occur

17

PE - CCLR

- HL lame (ddx hip and LS dz)
- mm atrophy (quadriceps, hamstrings)
- stifle effusion
- medial buttress
- cr-cd stifle instability
- pain on manipulation, sit test

18

What is a medial buttress?

- sign of CCLR
- soft tissue thickening on medial aspect of joint (stifle)

19

Which two PE tests are needed for CCLR?

- cranial drawer
- tibial thrust

20

Describe the tibial thrust test

- test for CCLR (along with cranial drawer)
- push tarsus, puts tension in gastroc, this pushes tibia forwards, to elicit this, you need an almost complete CCLR (partial rupture may not elicit any movement at all)

21

What is the commonest reason for stifle OA?

CCL dz

22

What are the broad tx options for CCL dz?

- conservative (non-sx)
- sx tx

23

Outline conservative (non-surgical) tx of CCL dz

- INDICATIONS: minimal lame, low grade pain, weight

24

What are the sx options of CCL dz/

- ADVANTAGES: should improve joint stability, should speed up recovery, allows meniscal lesions to be tx
- RECOVERY: joint will never be 100% stable, DJD will always be present thus residual lameness, limb fxn can be very good but not 100%

25

What are the sx tx options for CCL dz?

- no option for direct repair of cruciate
1.) use an implant in a position analogous to the CCL. Restore joint stability (temporarily), allows fibrous tissue to stabilise stifle
2.) change the mechanics of stifle to negate the need for CCL support (e.g. TPLO, TTA, CWTO, TTO)
- any sx should involve inspection of meniscus and removal of damaged areas (do before sx, via an arthrotomy)

26

Define TPLO

- sx correction of CCLR
- Tibial Plateau Levelling Osteotomy = this changes the angle that the tibia meets the femur allowing the articular surfaces to bear more of the caudal shear force from tibial thrust

27

Define TTA

- sx correction of CCLR
- = Tibial Tuberosity Advancement
- the line of the patella tendon is advanced making it parallel to the line of force transfer across the joint. The tension in the tendon cancels out the compression across the joint negating the caudal movement of the femur

28

Define CWTO

= Closed Wedge Tibial Osteotomy
- sx correction of CCLR
- similar to TPLO but dorsal displacement of tibial tuberosity
- tendinitis
- cranial wedge
- makes tibial plateau flat
- lowering top of tibia, puts strain on patella tendon thus more prone to tendonitis

29

Define TTO

= Triple Tibial Osteotomy
- for sx correction of CCLR

30

What is the best sx procedure for CCLR?

- most of current options based on extracapsular suture or tibial osteotomy have a similar outcome at 12 wks post sx
- that said there are numerous claims for advantages relating to new procedures all the time