Cranial cruciate ligament rupture and its surgical correction is one of the most common reasons we see patients as Vetrehabbers. Being aware of the possible complications that may result from this surgical procedure can help us to more effectively rehabilitate our patients.  

CCLR complications are best discussed in relation to the specific surgical procedure performed, since procedures vary and different implications arise from each. There are also specific complications in relation to cats, to rehabilitation and to the use of braces.  

Below is a brief summary of our interview with Dr David Dycus, who discusses the common complications of CCLR surgery.

 

What was the inspiration for writing the textbook on CCLR complications?

A colleague of mine approached me with the idea of speaking more about the complications that come up with cruciate ligament surgery. I felt that there was already a great deal of information out there in publications and in our courses. He felt that more was needed. His brother, who is a human surgeon, let us know that in the human industry there are entire textbooks dedicated to dealing with the complications that can occur in response to a particular surgical procedure or condition. The idea for the textbook was born.

After discussing the idea with a publisher, we put together a proposal and from there started the process of writing and speaking to authors.

Writing the book was a time-consuming and complex process that has taken us about three years.

We devoted each chapter to a type of CCLR repair, breaking it up into intracapsular repair techniques, extracapsular repair techniques and osteotomy techniques. There is a chapter on cats, one on complications associated with rehabilitation, and another on arthroscopy and the complications that can occur there.

We tried to make it a mix between a textbook and a coffee table book. It’s very easy to follow with lots and lots of pictures.  

 

In light of these complications, what would you recommend to the Vetrehabber with a case that is not doing well?

If we are seeing a patient that is not doing well, regardless of who we are within the MDT, we first have to be the advocate for the patient. We need to let the owner know that the animal is not progressing in the way we expected or would like them to.

The starting point that I recommend is to send the patient back to the surgeon for a recheck. The individual who is performing rehab is in the best position to recognise complications, as they are seeing the patient on a regular basis.

The second step is learning to recognise whether a complication is related to the original surgery and needs to be corrected, or whether it is related to the speed of progression of rehabilitation and the tissue healing and capability of the tissue. We may perhaps need to back off with rehabilitation or change the direction of rehabilitation.

The biggest reason an animal might not do well initially may be related to meniscal pathology that was either not addressed or was missed at the time of surgery.

There are nuances to every procedure, which is why the textbook is so valuable. The reason a dog following TPLO might not do well will be different from why a dog following extracapsular procedure might not do well. While all of them have knee surgery, different tissues are manipulated and various complications of these differences can cause the dog not to do as well as expected after one of these procedures. Meniscal pathology is common after all of the procedures but can be higher after certain procedures.  

Very rarely do we as individuals who are providing rehabilitation cause the complication. However, we do need to look at and understand tissue healing so that we are not pushing the patient to create undue stiffness or soreness that might cause a setback or slow progression. We can therefore use rehab not only to address those things, but also to pick up on complications early, before they become more of a catastrophic problem.  

 

What are the most common complications of each of the surgical procedures?

With extracapsular repairs, complications can be related to a lack of stability in the stifle. Many times that arise because of not utilising appropriate landmarks, so that when the dog walks there is still instability.

For intracapsular repairs… it’s a tough one to answer, but one of the biggest issues is either stretching or tearing of the graph prematurely.

With osteotomy procedures, a lot of it is in terms of cutting the bone, how kind we are to the soft tissues, and ensuring we don’t have implant damage. With the development of walking plate technology and improvements in implants, the likelihood of plates and screws falling apart is low these days.

Things like surgical site infections are a big factor. In-depth scrutiny of the surgical site is essential to allow an aggressive approach to minimise surgical site infections.

There are other aspects, like inadvertently induced rotation or torsional angles on the bone after an osteotomy leading to a loading pattern that is atypical, which can be problematic.

The inflammatory response within the stifle can continue post-operatively, with some patients experiencing a residual or continued inflammatory response. We don’t necessarily pay enough attention to that thought process, or to patellofemoral pain. In people, it’s a bigger deal. There are some things that are likely under-recognised within the veterinary industry regarding these procedures.

 

I used to see a lot of patients with chronic CCL with a great deal of muscle wastage and patella luxation, which usually corrected after a period of strengthening. Do you find this, too?

Yes. We can think of patella luxation in one of two scenarios, one being when there is really severe quadriceps atrophy. This will be a little more patella mal-tracking. Alternatively, there can be substantial peri-articular fibrosis on the medial aspect of the stifle wanting to pull on the retinaculum. Strengthening will help resolve this.

I have also seen patella luxation after an osteotomy procedure as a result of the procedure, where we inadvertently shift or move something and induce patella luxation.

 

What are some of the top complications in cats?

Interestingly enough, we have all these ideas on osteotomy procedures in dogs and how they stabilise the knee, and we carried those thought processes over to the cat. However, the studies don’t support stabilising the cat’s stifle in the same way as we do the dogs. A lot of work still needs to be done in this area.

Also, recognising meniscal calcification and what the importance is of that either pre-operatively or postoperatively.

In cats we don’t see the same typical degenerative breakdown of the cruciate ligament, so many times it is combined with other ligament damage or what we call a deranged stifle. I think this often gets missed in the cat prior to a surgical correction, and this can affect the outcome significantly.

 

Are there any circumstances where you recommend a conservative approach for CCL instead of a surgical approach?

Yes – this would apply in patients that have what I would call a competent stable partial tear, where we can see a little bit of offloading, some stiffness or soreness, intermittent lameness, no or very little pain during flexion and extension, and some radiographic evidence of effusion.

In patients that are at very high risk for anaesthesia, we will discuss conservative management.

The age factor is a difficult one, with many owners starting to question surgery from about 10 years onwards. There isn’t really a line in the sand in this regard. We need to think more about thorough diagnostics for these guys to ensure that we are not missing something prior to surgery.

We have a whole chapter in the book dedicated to the complications associated with orthotics as well. Some dogs can be good candidates for orthotics, and with the advances in what is available and what can be done, this is an exciting area. Hopefully, the chapter will allow rehab therapists and vets to chat to owners in much more detail about the expectations they can have when going this route.

 

Where can Vetrehabbers purchase your textbook?

The easiest way is to visit my personal website, DrDavidDycus.com. There is a hyperlink that pops up to purchase the book through Amazon. You can also purchase directly from Amazon.

 

Conclusion

The various surgical procedures commonly conducted for cranial cruciate ligament rupture predispose to different possible complications. As Vetrehabbers, we are in an ideal position to identify complications early and quickly in our patients, and to refer them back before the complications become potentially catastrophic.

We highly recommend listening to the full interview with Dr David Dycus here:

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