Lucy Easton takes an in-depth look at Cranial Cruciate Ligament Disease in dogs, interviews some veterinary experts, and talks to the owner of a Labrador who has been through the disease and come out safely on the other side
Cranial Cruciate Ligament Disease is something that all Labrador owners need to be aware of. If your Labrador has hurt his back leg, is limping or appears to be lame, this will be one of the first things that your veterinarian is going to consider. Because CrCl damage in Labradors is a big problem.
In this article we are going to look at what cranial cruciate ligament disease is, how it affects our Labradors and what can be done about it. I have been talking to orthopedic veterinarians Dr Neil Embleton and Dr Veronica Barkowski, about the surgical management of cranial cruciate ligament disease in the Labrador Retriever: And they have been sharing their experience of CrCl disease, and some important information about an innovative new treatment.
We have also been speaking to the owner of a beautiful Labrador who has been affected by CrCl disease, who has kindly agreed to share her experiences of managing life with a Labrador suffering from it.
What Is the CrCl?
The Cranial Cruciate Ligament is also known as the CrCl. It is a ligament which connects the bone above the knee to the one below it.
Neil Embleton explains how this ligament should help your dog to walk freely and easily when it’s functioning normally: “The CrCl is a major stabiliser of the dog’s stifle (knee joint) and it performs two main functions: limiting cranial tibial translation (forward shin bone movement), and controlling the amount of internal tibial rotation (inward shin bone rotation).”
What is Cranial Cruciate Ligament Disease?
When a dog has cranial cruciate ligament disease, the joint stops working in the way the it is supposed to. “As the level of disease in the CrCl progresses, its ability to perform these functions decreases, leading to progressive instability of the knee joint. The consequence of which is pain, lameness, loss of comfortable range of motion in the affected limb and progressive osteoarthritis.”
Are Labradors More Likely To Get CrCl Disease?
Dr Embleton and Dr Barkowski believe that there are proportionately higher rates of CrCl disease in Labradors, when compared with other breeds.
“Cranial cruciate ligament (CrCl) disease continues to be the most common orthopedic disease affecting the hind limb of the dog. As a breed, Labrador Retrievers are predisposed to CrCl disease, it has been suggested that the incidence of CrCl disease in Labradors is two to five times more likely than the general dog population. Although no genetic role has been demonstrated, the frequency of disease affecting both hind limbs strongly supports a genetic link.”
CrCl Disease Symptoms
The first sign of CrCl disease in Labradors is usually lameness. The dog may have trouble putting weight on one of their back legs, or have a distinctive drag or swing to their gait. There may also be swelling and tenderness in the area. If you see any of these signs in your Labrador, then you need to take them to the veterinarian for a thorough examination.
If your Labrador is overweight he is more likely to suffer from ligament damage, or if you only exercise him in infrequent but very strenuous bursts, this is something to watch out for as well.
Diagnosing CrCl Disease in Labradors
When you take your Labrador to the veterinarian, they will want to establish the cause of the limp and whether it is due to CrCl disease.
They will do this by observing the way that your Labrador walks, by feeling his joints and by taking x-rays of his bones. In some cases they may choose to use an MRI or exploratory surgery if it is an unusual case.
Common CrCl Disease Treatments
Your veterinarian will advise you on the best treatment for your Labrador’s CrCl disease based upon their diagnosis of his specific condition, and based upon their own experience. There are a number of surgical treatments available for CrCl disease, as Neil explains.
“There are currently many surgical treatment options for canine CrCL deficiency including extracapsular suture procedures using monofilament or multifilament braided materials and geometry modifying osteotomy procedures, including tibial plateau levelling osteotomy (TPLO) and tibial tuberosity advancement (TTA).”
Extra-capsular Suture Procedures
The extra-capsular suture procedure involves replacing the damaged ligament with man-made alternative. This is produced in the form of a stitch or suture, made of a monofilament or multi-filament braided material, similar to strong fishing line. This holds the joint in a natural position, allowing the dog to move his leg correctly.
The aim is that scar tissue will eventually replace the use of the suture, and support the leg in this manner. It is thought to be a more successful option for smaller and less lively dogs, although it can be used on larger breeds such as Labradors. If your veterinarian advises an extra-capsular suture procedure, then your dog will need to be on severely limited exercise for at least four months after his surgery.
Tibial Plateau Levelling Osteotomy (TPLO)
Another option for CrCl disease treatment is TPLO. It is a more modern procedure, which involves more invasive surgery. A veterinary surgeon will make a circular cut in the tibia and realign the bone, to give a more stable base for the dog to walk on. This movement will be held in place by plates and screws. This method is sometimes preferred for larger, heavier dogs or for more active personalities.
Again, a healing period of rest of at least four months is advised after surgery in order to get the best results.
Tibial Tuberosity Advancement (TTA)
Tibial Tuberosity Advancement (TTA) is similar in approach to TPLO. However, the bone is cut in a linear fashion, in order for the tibia to be moved to a different angle. Like TPLO it requires plates and screws to stay in place initially, and although they are not required after healing they are rarely removed. It also has a long period of recovery, where you will need to keep your dog on limited exercise to reduce the risk of re-fracturing the bone before it has healed.
TTA Case Study
A friend of The Labrador Site, Julie Clayton, has personal experience of the TTA treatment, as her chocolate Lab Charlie was sadly diagnosed with CrCl disease as a puppy. She has kindly shared her journey with us.
Charlie’s Early Symptoms of CrCl
“Charlie was 8 months old, and he started limping on his hind leg. I took him to the vet who said lead walks (rest) for 10 days and anti-inflammatories. After 10 days, Charlie was still limping and hip dysplasia was suspected, so we did x-rays, and found out Charlie’s hips were perfect.
So the vet said more rest, and suspected a pulled muscle etc. After another 10 days rest, Charlie seemed fine, and the vet said we could return to normal.
The first time Charlie got off lead after the 20 days rest, he galloped round (as a young Labrador will) and suddenly stopped and was severely lame. We got him back to the car, and went to the vet. We saw a young vet, not very experienced, who said it was a pulled muscle, gave more anti-inflammatories and said more rest.
As it happened, I had an appointment the next day to see a canine physiotherapist, she said Charlie had a torn ligament and told me to go and see an orthopaedic vet, which I did the next day. He diagnosed a ruptured cruciate ligament.”
What Happened Next
“It was absolutely dreadful finding out this was the problem, and reading about the operation that was required and the length of the recovery period. And also the worry about what the outlook would be for such a young dog. Plus, the practical difficulties it was going to present.
At the time, both my partner and I worked, and we had dog walkers and day care arrangements in place – all of those were useless for a dog recovering from surgery and needing a long and careful rehabilitation. I’d also just started to really get into gundog training with Charlie, and instead of continuing with all the fun training, I was looking at months and months of rest and major surgery.
It just felt like a nightmare, as anyone must feel who gets a puppy must feel when they get a diagnosis of something like this (or elbow or hip dysplasia etc).”
Waiting For CrCl Treatment
“As Charlie was only 8 months when this happened, the orthopedic vet recommended a very highly qualified surgeon, and these two vets agreed that it would be better to wait until Charlie was over a year old before doing the operation.
The surgical procedures of both TTA and TPLO involve cutting the bone to change the angle of the tibial tuberosity in the stifle, using an implant to hold the bones in a different angle while they heal.
The vets thought this was best done only after a dog had finished his bone growth and his growth plates had healed. So Charlie was on lead walks for 5 months, until he was 13 months old, and then we booked him in for surgery.”
Rehabilitation After CrCl Surgery
“It turned out that Charlie had a completely ruptured ligament and a tear in his meniscal cartilage. He recovered well, and I was very, very careful in his rehabilitation. I absolutely did everything by the book, to the letter.
“My vet was also quite cautious about the timescale for the rehabilitation, and Charlie spend another 3 months on lead, and then his exercise was built up very gradually over another two – then 10 months after diagnosis, we returned to normal. The surgeon had told me, very clearly, that the likelihood was that Charlie would rupture his other cruciate ligament, and he did, only 6 months after we had returned to normal.”
Charlie’s Next CrCl Surgery
“This time, as soon as Charlie showed a tiny limp, I had him seen by an orthopaedic specialist the next day, who suspected a ruptured ligament.
We took the decision to operate, and Charlie had a 50% ruptured ligament, which would have completely ruptured left untreated. Charlie recovered very well from the second operation, as he did the first, and we repeated the whole slow, careful rehabilitation. He returned to normal slightly faster the second time, and was cleared by the vets to return to full exercise 4 months post op.”
“Now, he is a year after his last operation, and shows very little sign there was ever anything wrong. He isn’t quite as good as new, his muscle mass on his back legs is good but not fantastic, and he’ll sometimes mis-step if he tries to turn at high speed. But he exercises freely for 2 to 3 hours a day, and lives a happy and energetic life.
“Arthritis will be present in his legs, and will progress to some degree, but hopefully we won’t see any signs of that for years yet.”
New CrCl Disease Treatment.
Although as you can see the current treatments can have great success, veterinarians have come up with a new surgical technique which could be even more helpful, as Neil Embleton explains: “There is currently no uniformly accepted best treatment of the canine CrCL deficient stifle. Joint contact mechanics are altered by all current techniques and a decrease in range of motion (ROM) and progression of osteoarthritis are common findings postoperatively.”
This means that although they are helpful, the joint could experience further problems in the future even after surgery.
“Dr. Stanley Kim suggested that the optimal surgical treatment for the CrCL deficient stifle provides immediate stabilization of the unstable stifle joint while allowing normal joint contact mechanics and movement in all planes. This was the premise that the Simitri Stable in Stride ® procedure was based on.”
Simitri Stable in Stride Procedure
Our two veterinary surgeons explain how the Simitri Stable in Stride procedure came about, and how it works:
“Our goal was to design and develop an implant that would provide immediate and continuous translational and rotational stability while minimally affecting stifle biomechanics.
After six years of evidenced based research, the Simitri Stable in Stride® internal stifle stabilizing implant was developed. Based on an in silico comparison using a 3D computer model, stifle joint biomechanics were improved in the Simitri-managed stifle compared to the CrCL-deficient stifle joint and the Simitri treated CrCL deficient stifle was predicted to return ligament loads and tibial kinematics closer to the state of the intact CrCL stifle than did the TPLO managed stifle.
The Simitri Stable in Stride® implant is comprised of two, surgical grade stainless steel plates; the femoral (thigh bone) plate and the tibial plate. The femoral plate has a ball and stem that interconnects with the tibial plate via an 8 mm travel channel within the articulating insert.
The insert is composed of ultrahigh molecular weight polyethylene (UHMWPE), this is the same material used in human total hip and knee replacements. The plates are positioned on the inside of the affected leg and attached above and below the knee joint with six cortical locking screws. The entire implant remains outside the knee joint, but under the skin and muscle.
The video below is a fascinating demonstration of exactly how the Simitri implant is located and attached in a canine patient. Please note: there are shots of an actual dog’s leg during surgery – not for the overly squeamish!
The Simitri Stable in Stride® implant immediately provides continuous translational and rotational stability while minimally affecting the normal function and movement of this joint. The implant is indicated as a primary repair method for cranial and or caudal cruciate ligament disease and as a secondary treatment for multiple knee ligament damage (stifle derangement).
The surgical procedure takes approximately 55-65 minutes to perform. No muscles or bones are cut during the procedure making it a less invasive surgery. A comprehensive postoperative homecare handout consisting of massage, passive range of motion and controlled leash walking is provided. Recovery, depending on age, level and duration of disease, generally takes four months.
The potential advantages of the Simitri Stable in Stride® procedure are: immediate and continuous translational and rotational stifle stability regardless of the position of the knee, or the phase of the stride, less invasive and less painful than procedures that require cutting of bone (TPLO, TTA), minimal effect on joint biomechanics, no osteotomy related complications and less restrictive postoperative management.”
Getting help with Cranial Cruciate Ligament Disease
If your Labrador has suffered from cruciate ligament problems, then you are welcome to share your experiences in the comments section below. Cranial cruciate ligament disease must be diagnosed by a veterinary surgeon. Treatment options will depend on the dog, your surgeon will discuss these with you.
If you have any concerns about your Lab’s legs or gait, or any other aspect of his health – always seek advice from a veterinarian. Coping with a dog after surgery and during rehabilitation can be tough. But there is light at the end of the tunnel! Do join the forum where you’ll find help, support, and sympathy during this challenging time.
For more information about the Simitri Stable In Stride implant visit the New Generation Devices website
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