1 14 BRITISH VETERINARY JOURNAL, 141, 2

THE CANINE STIFLE . II . TRAUMATIC

CONDITIONS

H . R . DENNY
Department of Veterinary Surgery, University of Bristol, Langford House, Langford,
Bristol BS18 7D U

Traumatic conditions of the stifle can be broadly divided into :

1 . Fractures .
2 . Ligament injuries .
3 . Muscle and tendon injuries .

FRACTURES
The specific fractures include :
1 . Supracondylar and condylar fractures of the femur .
2 . Patellar fractures .
3 . Fractures of the fabellae (see avulsion of the gastrocnemius muscle) .
4 . Fractures of the proximal epiphyses of the tibia .

Supracondylar and condylar fractures of the femur

Supracondylar fractures of the femur are common . The injury tends to be seen in pups
between three and 10 months old and typically trauma causes separation or fracture
separation of the distal femoral epiphysis. Open reduction is essential to prevent caudal
rotation of the femoral condyles and malunion . In puppies under six months old crossed
Kirschner wires are used for fixation (Sumner-Smith & Dingwall, 1973) (Fig . 1) . This
method should have minimal effect on longitudinal growth of the bone . Care should be
taken during reduction to protect the germinal cells of the growth plate by avoiding
leverage on the epiphyseal side of the fracture . In pups over seven months old, with
limited growth potential left, a single lag screw (Fig . 2) provides optimal stability (Knight,
1956 ; Hinko, 1974) . If this method is used in younger pups the screw should be removed
after three to four weeks to prevent premature closure of the distal femoral growth plate .
Fractures of a single condyle or both condyles of the distal femur (T fracture) are rare .
Lag screws either alone or in combination with Kirschner wires are generally used for
fixation (Fig . 3) .

Fractures of the patella and injuries to the straight patellar ligament

(Denny, 1975 ; Betts & Walker, 1975)
Fracture of the patella is rare . The fracture may be transverse, longitudinal or
comminuted . Fracture of the patella and avulsion or rupture of the straight patellar
ligament cause inability to extend the stifle . AP and lateral radiographs of the stifle will
confirm the diagnosis. A skyline view of the trochlea and patella is also useful to
demonstrate fragments in comminuted fractures . In transverse fractures fixation is
achieved with a wire suture and a tension band wire placed over the anterior aspect of the
patella (Fig . 4) . A lag screw is used for longitudinal fractures . Patella transplantation has


THE CANINE STIFLE Il ;

been successfully undertaken experimentally in dogs (Vaughan & Formston, 1973) and
this procedure can provide a solution for the animal with a severely comminuted fracture
of the patella when reconstruction is not practicable (Fig . 5) .
A repair of a rupture of the straight patellar ligament or a reattachment in the case of
avulsion will be subjected to considerable tension by the pull of the quadriceps muscles .
The muscle pull can be counteracted by placing a tension band wire (18 or 20 gauge)
between the patella and the tibial crest (Fig . 6) (Brinker, Piermattei & Flo, 1983) .

a) b) a) b)
Fig. 1 . Fourteen-week-old Springer spaniel Fig. 2 . Seven-month-old collie with a) a
with a) a supracondylar fracture of the femur, supracondylar fracture of the femur, and b)
and b) fixation with crossed Kirschner wires . fixation with a lag screw (4 . 5 mm cortex
screw) .

a) b) c)
Eleven-week-old Labrador with a) a T fracture of the distal femur . b) Fixation with two lag
Fig . 3 .
screws (4 mm cancellous screw) . c) Union complete five weeks post-operatively .

Avulsion of the tibial tuberosity

(Dingwall & Sumner-Smith, 1971 ; Pettit & Slatter, 1973 ; Denny, 1975 ; Withrow et al.,
1976)
Fracture of the tibial tuberosity is an avulsion injury which is usually caused by a fall or
jumping. The fracture occurs in immature dogs, particularly the racing greyhound


116 BRITISH VETERINARY JOURNAL, 141, 2

between four and eight months of age . The fragment is distracted by the pull of the
quadriceps exerted through the patella and straight patellar ligament . Initial fixation is
achieved with two Kirschner wires or a lag screw used in combination with a tension
band wire (Fig . 7) to counteract the pull of the quadriceps . The fracture normally heals
within four to six weeks and the implants can be left in situ unless loosening causes a soft
tissue reaction .

a) b)
Fig . 4 . Seven-year-old whippet with a)
a transverse fracture of the patella, and
b) fixation with a wire suture and wire
tension band .
a) b)
Fig. 5 . Six-year-old Irish setter with a) comminuted
fracture of the patella caused by 0 . 22 rifle bullet, and
b) radiograph taken two months after patella had been
replaced with an allograft . (By permission : H .R .
Denny, 1985, Veterinary Annual, 25th edn, p . 254) .

a) b)
Fig . 6, Tension band wire Fig. 7 . Five-month-old greyhound with a) an avulsion of the
used to protect repair of the tibial crest, and b) fixation with a lag screw (4 mm cancellous)
straight patellar ligament . and a tension band wire .


THE CANINE STIFLE I I

Fracture of the proximal epiphyses of the tibia

Separations and fracture separations of the proximal epiphyses of the tibia are occasion-
ally encountered in the immature dog . The epiphyses are displaced caudally in relation
to the metaphysis . If the tibial tuberosity is still firmly attached to the proximal epiphysis
of the tibia, fixation is simply achieved with a tension band as shown in Fig . 8 . If there is
gross displacement of the epiphyses (Fig . 9a), the proximal tibial epiphysis is stabilized
with two Kirschner wires driven down through the medial and lateral side of the
epiphysis into the metaphysis (Fig . 9b), before the tibial tuberosity is fixed with a tension
band wire as shown in Fig . 9c .

a) b) e)

Fig. 8 . Six-month-old crossbred with a) Salter type II fracture separation of the proximal tibial

epiphyses . b) Fixation with Kirschner wires and a tension band . c) Healing complete at eight weeks .

a) b) e)
Fig .
9. Eight-month-old whippet with a) separation and gross displacement of the proximal tibial
epiphyses . b) Fixation with two Kirschner wires and a tension band wire . c) Healing complete at 10

weeks .

LIGAMENT INJURIES

Ligament injuries include :

1 . Rupture of the anterior cruciate ligament and meniscal injuries (rupture of the
posterior cruciate ligament is rare) .
2 . Rupture of a collateral ligament .
3 . Rupture of the straight patellar ligament (see patellar fractures) .


118 BRITISH VETERINARY JOURNAL . 141 . 2

Rupture of the anterior cruciate ligament

Rupture of the anterior cruciate ligament is the main indication for surgery of the stifle
joint . The clinical features and recent trends in treatment are summarized below .
Clinical features. Rupture of the anterior cruciate ligament can occur in any breed of
dog . The peak incidence is at six years old, with a lesser peak at two years . In the younger
dog there is usually a sudden onset of lameness at exercise or through the dog catching its
leg in a fence or other obstacle . In the older dog, lameness is often more insidious in onset
and perhaps this is related to degenerative change in the ligament before rupture . The
typical clinical features include :
1 . Sudden onset of lameness.
2 . The leg is carried with the stifle slightly flexed .
3 . After seven to 10 days, the dog uses the leg when walking but at rest stands with the
toe just touching the ground .
4 . The thigh muscles atrophy .
5 . `Clicking' noises maybe heard when the dog is walking due to the femoral condyles
slipping in and out of their normal position on the menisci .
6 . Normally the anterior cruciate ligament prevents cranial displacement of the tibia
on the femur. Abnormal movement in this direction is diagnostic of anterior cruciate
ligament rupture and is known as the anterior draw sign .
7 . Joint instability leads to degenerative joint disease . In the larger breeds of dog,
weighing 15 kg or more, this is characterized by periarticular osteophyte formation . In
the small breeds of dog, minimal osteophytic reaction occurs .
8 . The stifle gradually restabilizes by periarticular fibrosis which is particularly
marked over the medial side of the joint .
9 . Restabilization occurs within six to eight weeks and the lameness may resolve
during this period, especially in small breeds . In larger breeds, varying degrees of
lameness tend to persist because of the osteoarthritic changes which have occurred
during restabilization .
Treatment. Small breeds of dog with anterior cruciate ligament rupture are treated
conservatively with six to eight weeks rest . If lameness has not resolved during this period
and the stifle is still unstable, surgical replacement of the ligament is undertaken . In
larger breeds of dog, early surgical stabilization of the stifle is recommended to prevent
the development of osteoarthritis . The fact that numerous techniques have been
described since Patsaama's original work on anterior cruciate ligament rupture in 1952
suggests perhaps that none is entirely satisfactory but the description by Arnoczky et al.
(1979) of the `over the top' procedure for anterior cruciate ligament replacement rep-
resented a major advance .
A graft consisting of the medial third of the straight patellar ligament, a wedge of the
patella, patellar tendon and fascia lata is passed through the stifle joint along the path of
the original anterior cruciate ligament (Fig . 10a) . The free end of the graft is pulled over
the top of the lateral condyle of the femur where it is sutured to the periosteum (Fig . 10b) .
The graft overlies the origin of the anterior cruciate ligament and at no time during
flexion or extension of the stifle is it subjected to excessive tension . In most other intra-
articular techniques, particularly those in which a prosthesis or graft is passed through
bone tunnels, it is difficult to replicate the origin of the anterior cruciate ligament
accurately . This leads to excessive tension on the replacement ligament as the stifle is
flexed and results in excessive wear and early breakdown . The `over the top' techniques


THE CANINE STIFLE 11 1 )

offer a distinct advantage in this respect . It has been demonstrated in experimental dogs
that the patellar ligament graft is revascularized within 20 weeks, and at one year the
vascular and histological appearance of the graft resembles that of a normal anterior
cruciate ligament (Arnoczky, Tarvin & Marshall, 1982) .
Biomechanically, the `over the top' technique has many advantages over the other
methods of anterior cruciate ligament replacement and gives excellent results, particu-
larly in large and giant breeds of dog . However, the operation in its original form presents
some technical difficulties, particularly in the preparation of the patellar segment of the
graft and passage of the graft through the joint .
A much simpler `over the top' technique was described by Hulse et al. (1980) in which
the lateral third of the patellar ligament and fascia lata was used as a graft . A bio-
mechanical analysis of the method was subsequently reported (Butler et al., 1983 ; Hulse
et al., 1983) ; the results were encouraging with a gradual reduction in joint instability and
an increase in the stiffness and strength of the graft .
However, even at 26 weeks following surgery, the material properties of the graft were
considerably weaker than those of the normal anterior cruciate ligament . Nevertheless no
mechanical failures of the graft were seen in in-vivo laboratory tests, and in a series of 38
operations in clinical cases 93% of animals regained normal limb function (Shires, Hulse
& Liu, 1984) . Similar results in clinical cases have been reported by Denny & Barr (1984) .
`Over the top' procedure using the lateral third of the straight patellar ligament and fascia lata as a
graft. The fascia lata, patella and straight patellar ligament are exposed through a
lateral parapatellar skin incision . A graft consisting of the lateral third of the straight
patellar ligament and fascia lata is prepared (Fig . 10c) . Starting from the tibial crest the
straight patellar ligament is split with a scalpel longitudinally through the lateral third .
The incision is curved laterally just before reaching the patella and is then extended
proximally into the fascia lata . A parallel incision is made in the fascia lata caudal to the
first, and a strip 1 to 1 . 5 cm wide is prepared . The strip is reflected ventrally but the
attachments to the tibial crest are retained (Fig . 10c) . A lateral arthrotomy incision is
made and the patella is dislocated medially . The stifle is inspected, torn ligament
remnants, torn meniscal tissues and accessible periarticular osteophytes are removed as
necessary .
The lateral joint capsule is reflected with a Hohmann retractor (Straumann, Gt Britain
Ltd) to reveal the lateral femoral condyle and fabella (Fig . 10d) . A small vertical incision
is made through the femoro-fabellar ligament into the posterior compartment of the
joint . The stifle is flexed and a graft passer (graft passer can be constructed from a 4 mm
diameter Steinmann pin) (Oosterom, 1982) is inserted through this incision into the
intercondylar fossa and directed into the anterior aspect of the joint (Fig . 10d) . The graft
is threaded through the `eye' of the graft passer and the instrument is used to draw the
graft through the stifle .
The patella is replaced, the graft is pulled tight over the lateral condyle and the free
end is sutured to the femoro-fabellar fascia using braided steel of monofilament nylon
sutures (O Braided Suture Wire, Flexon steel, Davies & Geck, American Cyanamid Co)
(Fig . 10e) . The position of the joint during suturing is not critical as there is even tension
on the graft through the whole range of stifle movement . Wire or nylon sutures are used
to close the joint capsule and fascia lata . The rest of the wound closure is routine and a
Robert Jones bandage is applied for seven days . Skin sutures are removed at 10 days . Ex-


120 BRITISH VE 1 ERINARY, 1 Ot'RNA1 . . 141 . 2

ercise is restricted to walking on a leash for six weeks and then gradually increased . Dogs
carry the affected leg for an average of three weeks (range one to 12 weeks) following surg-
ery . There is then a gradual improvement in limb function with recovery in 12 weeks in
most animals .

-Graft sutured
to the
periosteum of
the lateral
condyle

Fig. 10 . `Over the top' technique for treatment of anterior cruciate ligament rupture . a) Passage of
the graft through the joint using the graft passer . b) Graft passed through the stifle over the origin of
the original anterior cruciate ligament and the lateral condyle of the femur . c) Cruciate replacement
using the lateral third of the straight patellar ligament (A) and fascia lata (B) as a graft . Preparation
of the graft . d) Passage of graft through the stifle . (A) Lateral joint capsule retracted with Hohmann
retractor to reveal lateral femoral condyle . (B) Incision in femoro-fabellar ligament . (C) Graft passer
introduced through incision (B) . (D) Graft passed through `eye' of graft passer . e) (A) Graft in situ .
(B) Free end of graft sutured to femoro-fabellar ligament and periosteum of lateral condyle . (Denny
& Barr, 1984)

Meniscal injuries
Meniscal injuries occurred as a complication of rupture of the anterior cruciate
ligament in 53% of a series of 113 dogs described by Flo & De Young (1978) who have
classified meniscal tears and described the technique for medial meniscectomy . The
medial meniscus is injured more frequently than the lateral because of its more rigid
ligamentous attachments .


THE CANINE STIFLE l'1

During the anterior draw movement the medial meniscus moves forward with the tibia
and the femoral condyles crush its caudal horn . Repeated crushing can cause meniscal
tearing and detachment which in turn cause erosion of the femoral condyle . The
meniscal parenchyma has poor healing properties (Pearson, 1971) and this has led to the
development of techniques for partial or total meniscectomy .

Collateral ligament rupture

Rupture of the collateral ligament may occur alone or in combination with rupture of
the anterior cruciate ligament . Manipulation of the stifle reveals abnormal movement in
a medial or lateral direction . If the medial collateral ligament has ruptured the tibia can
be displaced laterally in relation to the femur and the medial side of the stifle can be
hinged open . The reverse applies if the lateral collateral ligament has ruptured . Tra-
ditionally the collateral ligament has been replaced with a figure-of-eight wire anchored
around two screws, one placed at the origin and one at the insertion of the ligament . This
method is satisfactory if the medial ligament is affected but the shape of the proximal
tibia and fibula makes it difficult to place a screw accurately at the insertion of the lateral
collateral ligament . This problem is simply overcome by anchoring the wire under the
head of the fibula (Fig . 11 a) . If rupture of the anterior cruciate ligament is complicated by
rupture of the collateral ligament then the cruciate ligament is replaced by the `over the
top' technique using a long strip of fascia lata . Having anchored the fascia lata to the
lateral condyle of the femur, the free end of the strip is passed under the head of the fibula
and sutured to itself (Fig . 11 b) to create a lateral collateral ligament .

Fig . 11 . a) Replacement of the lateral Fig. 12 . Three-year-old Labrador with a

collateral ligament using a screw and wire . b) chronic avulsion of the long digital extensor
Replacement of the anterior cruciate ligament tendon . A large fragment of bone can be seen
and the lateral collateral ligament using fascia within the joint just anterior to a defect in the
lata . lateral condyle of the femur (arrow) .


1 22 BRITISH VETERINARY JOURNAL , 141,2

MUSCLE AND TENDON INJURIES

Avulsion of the tendon of origin of the long digital extensor muscle

(Denny & Minter, 1973 ; Pond, 1973 ; Vaughan, 1979)
The tendon of origin of the long digital extensor muscle is an intra-articular structure
which arises from the lateral condyle of the femur . Avulsion of the tendon occasionally
occurs in young dogs of the larger breeds ; the average age of recorded cases is six months .
There is a sudden onset of lameness, the leg is carried and there is swelling and pain but
no instability on manipulation of the stifle . After the acute phase has subsided, mild
lameness persists with slight discomfort on palpation . A lateral radiograph of the stifle
should reveal the avulsed fragments of bone and an erosion in the lateral femoral condyle
(Fig . 12) . Surgical reattachment of the tendon is carried out using a lag screw if the bone
fragment is large enough or by suturing the tendon to the joint capsule .

Displacement of the tendon of origin of the long digital extensor muscle

Single case reports of caudal displacement of the tendon from the tibial sulcus have
been described by Addis (1971) and Bennett & Campbell (1979) . The tendon can be
retained in the sulcus using a wire suture .

Avulsion of the origin of the popliteus muscle

Single case reports of this injury have been described by Pond & Losowsky (1976) and
Eaton-Wells & Plummer (1978) . There was a sudden onset of lameness at exercise with
stifle swelling and pain but no instability . A lateral radiograph showed a defect at the site
of origin of the popliteus with bone fragments and also caudoventral displacement of the
popliteal sesamoid bone . The tendon was reattached to the femoral condyle with a screw
in one case and sutured to the long digital extensor tendon in the other .

Avulsion of the origin of the lateral head of the gastrocnemius muscle

(Chaffee & Knecht, 1975 ; Vaughan, 1979 ; Reinke, Kus & Owens, 1982)
There have been four case reports of this injury, which causes swelling and pain over
the caudal stifle and hyperextension of the hock . The diagnosis is confirmed radio-
graphically by demonstrating ventral displacement and possibly fracture of the lateral
fabella . The head of the gastrocnemius muscle must be reattached to the femur using
wire if the dog is to regain normal limb posture .

REFERENCES

ADDIS, F . (1971) . Nuove concoscenze sulla palologia del muscolo extensore digitorum longus del
cane . Folia veterinaria 1, 630 .
ARNOCZKY, S . P ., TARVIN, G . B ., MARSHALL, J . L . & SALTZMAN, B . (1979) . The `over-the-top'
procedure: a technique for anterior cruciate ligament substitution in the dog . Journal of the
American Animal Hospital Association 15, 283 .
ARNOCZKY, S . P., TARVIN, G . B . & MARSHALL, J . L . (1982) . Anterior cruciate ligament replacement
using patellar tendon : an evaluation of graft revascularization in the dog . Journal of Bone and Joint
Surgery 64A, 217 .
BENNETT, D . & CAMPBELL, J . R. (1979) . Unusual soft tissue orthopaedic problems in the dog . Journal
of Small Animal Practice 20, 27 .
BETTS, C . W . & WALKER, M . (1975) . Lag screw fixation of a patellar fracture . Journal of SmallAnimal
Practice 16, 21 .


THE CANINE STIFLE 123

BRINKER, W . O ., PIERMATTEI, D . L . & FLO, G . L . (1983) . Handbook of Small Animal Orthopaedics and
Fracture Treatment. Philadelphia, London, Toronto : W . B . Saunders Co .
BUTLER, D . L ., HULSE, D . A ., MAY, M . D ., GROOM, E . S ., SHIRES, P. K ., D'AMBROSIA, R . & SHOJI, H .
(1983) . Biomechanics of cranial cruciate ligament reconstruction in the dog . II . Mechanical
properties. Veterinary Surgery 12, 113.
CHAFFEE, V. W . & KNECHT, C . D . (1975) . Avulsion of the medial head of the gastrocnemius in the
dog . Veterinary Medicine/Small Animal Clinician 70, 929 .
DENNY, H . R . (1975) . The use of the tension band in treatment of fractures in the dog . Journal of
Small Animal Practice 16, 173 .
DENNY, H . R . & BARR, A . R . S . (1984) . An evaluation of two 'over the top' techniques for anterior
cruciate ligament replacement in the dog . Journal of Small Animal Practice 25, 759 .
DENNY, H . R . & MINTER, H . (1973) . The long term results of surgery of canine stifle disorders .
Journal of Small Animal Practice 14, 695 .
DINGWALL, J . S . & Su MNER SMITH, G . (1971) . A technique for repair of avulsion of the tibial tubercle
in the dog . Journal of Small Animal Practice 12, 665 .
E.ArON-WELLS, R . D . & PLUMMER, G . V . (1978) . Avulsion of the popliteal muscle in an Afghan
hound . Journal of Small Animal Practice 19, 743 .
FLo, G . & DE YOUNG, D . (1978) . Meniscal injuries and medial menisectomy in the canine stifle .
Journal of the American Animal Hospital Association 14, 683 .
HINKO, P . J . (1974) . Lag screw fixation for distal femoral epiphyseal fractures . Journal of the American
Animal Hospital Association 10, 61 .
HuLSE, D . A ., MICHAELSON, P ., JOHNSON, C . & ABDELBAKI, Y . Z . (1980). A technique for recon-
struction of the anterior cruciate ligament in the dog : preliminary report . Veterinary Surgery 9, 135 .
HuLSE, D . A ., BUTLER, D . L ., KAY, M . D ., BoYES, F . R., SHIRES, P . K ., D'AMBROSIA, R . & SHOJI, H .
(1983) . Biomechanics of cranial cruciate ligament reconstruction in the dog . In-vitro laxity
testing . Veterinary Surgery 12, 109 .
KNIGHT, G . L . (1956) . The use of transfixion screws for the internal fixation of fractures in small
animals . Veterinary Record 68, 415 .
OOSI FROM, R . A . A . (1982) . Intra-articular graft passer. Veterinary Surgery 11, 132 .
PAATSAMA, S . (1952) . Ligament injuries in the canine stiflejoint . Dissertation, University of Helsinki .
PEARSON, P . T . (1971) . Ligamentous and meniscal injuries of the stifle joint . Veterinary Clinics of North
America 3, 489 .
PE IT I', G . D . & SLA'J I ER, D . H . (1973) . Tension band wires for fixation of avulsed canine tibial
tuberosity . Journal of the American Veterinary Medical Association 163, 242 .
POND, M . J . (1973) . Avulsion of the extensor digitorum longus muscle in the dog : A report of four
cases . Journal of Small Animal Practice 14, 785 .
POND, M . J . & LOSOWSKY, J . M . (1976) . Avulsion of the popliteus muscle in the dog . A case report .
Journal of the American Animal Hospital Association 12, 60 .
REINKE, J . D., Kus, S . P. & OWENS, J . M . (1982) . Traumatic avulsion of the lateral head of the
gastrocnemius and superficial digital flexor muscles in a dog . Journal of the American Animal
Hospital Association 18, 252 .
SHIRES, P . K ., HULSE, D . A . & Liu, W . (1984) . The under-and-over fascial replacement technique for
anterior cruciate ligament rupture in dogs : A retrospective study . Journal of the American Animal
Hospital Association 20, 69 .
St MNER-SMI I H, G . & DINGWALL, J . C . (1973) . A technique for repair of fractures of the distal femoral
epiphysis in the dog and cat . Journal of the American Animal Hospital Association 9, 171 .
VAUGHAN, L . C . (1979) . Muscle and tendon injuries in dogs . Journal of Small Animal Practice 20, 711 .
VAUGHAN, L. C . & FORMSTON, C . (1973) . Experimental transplantation of the patella in dogs . Journal
of Small Animal Practice 14, 267 .
W1 I HROw, S ., DE ANGELIS, M ., ARNOCZKY, S . & ROSEN, H . (1976) . Tibial crest avulsion . Journal of the
American Veterinary Medical Association 168, 132 .