Management Plan

Surgical management is indicated for complete tears of the cranial cruciate ligament.  The 
primary objectives of surgery are to re-establish stifle stability and thoroughly explore the 
stifle for concurrent intra-articular damage. One of the most common post-surgical 
complications after having repaired the CCL is a damaged meniscus.  It has been shown 
that in dogs with a complete CCL tear, 50-60% of dogs have a concurrent meniscal tear, 
and this influences the choice of surgery.  Total menisectomy is generally indicated for 
meniscal damage, though partial and total menisectomy have both been shown to result in 
degenerative joint disease.  Leaving any part of the normal meniscus has been shown to 
cause lameness, as with partial menisectomy. It is important to not only debride the CCL, 
but the damaged meniscus and periarticular osteophytes (although too soon for 
osteophyte formation in this case_ more commonly seen in 2-3 weeks) by helping to 
restore ultimate joint function.

Surgical therapy is divided up into two main groups: reconstruction techniques and 
primary repair with augmentation.  Primary repairs alone are not feasible because there is 
limited ability of the ligament to heal directly with scar tissue and the remaining stumps 
to undergo collagen degeneration.  Also, recognition of the initial injury is not immediate 
in many cases.  Therefore, primary repairs are not used commonly and should always be 
supplemented with a reconstructive technique.  Reconstruction is achieved by either an 
intracapsular or extracapsular technique.  Which technique is chosen is left up to the 
surgeonÕs preference, but all have been shown to have a success rate around 90%.  

Intracapsular reconstrucions consist of passing autogenous tissue (medial 1/3 of the 
patella tendon and proximal fascia; central third of the patella tendon and proximal 
fascia; and lateral fibers of the patella tendon and distal fascia lata) through the joint to 
mimic the course of the cranial cruciate ligament.  The central and lateral patella tendon 
grafts are tougher, and can withstand greater loads and absorb more energy to maximum 
load than the medial autograft.  One technique involves passing the autogenous tissue 
(usually the medial 1/3 of the patellar tendon and/or a patellar wedge) through the joint 
using the Òover-the-topÓ method or passing the tissue through predrilled holes in the 
femur and/or tibia and attaching it with suture to the joint capsule.  The other 
intracapsular reconstruction is the Òunder and over techniqueÓ.  An autogenous graft is 
left attached to the tibia, passed through the joint and attached to the caudal and lateral 
side of the distal femur.  This mimics the natural cruciate ligament and prevents cranial 
displacement of the tibia during weight bearing.  The technique is from the lateral 
parapatellar approach.  The lateral 1/3 of the patellar tendon is dissected from the patella 
along with a strip of the fascia lata.  The graft is pulled through a small incision in 
between the fabella and the femur and sutured to the lateral femur via a screw and 
washer. The Òover-the-topÓ intracapsular method may be difficult to get through the joint, 
however neither technique has been proven to be more effective

For intracapsular repair, a soft bandage is applied over the surgical site and it maintained 
for two weeks.  The screw and washer should be removed 2-3 months post-operatively.


Graft material undergoes a time dependent biological and mechanical change.  
Revascularization, repopulation with cells for eventual collagen synthesis and re-
organization does occur.  A protracted period of restricted ability is necessary during this 
time for 2-3 weeks.  Unfortunately considerable graft strength is lost over time.  Laxity in 
the stifle joint also recurs and the articular cartilage may undergo softening and 
development of vertical clefts between cartilage cells.  Stretching and loss of strength 
may also be caused by improper graft placement or inadequate intercondylar notch width.  
And even though the success rate is very high (90%), some studies have shown that 
degenerative joint disease may occur subclinically in radiographs 12-18 months after 
intracapsular stabilization.  Up to 20% of cases may incur a similar CCL injury in the 
contralateral limb. 

Extracapsular stabilization is a technique where non-absorbable suture is used to anchor 
the femur to the tibia. Most extracapsular reconstructions are generally easier to perform. 
The suture is passed through the femoral fabellar ligaments, and 
then through a hole in the tibial crest. When tied tightly, the sutures prevent cranial 
displacement of the tibia during weight bearing. Suture reactions are seen in 10% of 
stabilization patients. 

Fibular head transposition involves advancement of the lateral collateral ligament to 
eliminate the instability caused by CCL rupture. This is accomplished by advancement of 
the femoral head, which is the point of insertion for the lateral collateral ligament. The 
end result is that the collateral ligament helps to prevent the tibia from sliding forward 
during weight bearing.  

The tibial plateau leveling procedure (TPLO) involves changing the angle of the tibial 
plateau by during an osteotomy of the proximal tibia. The femur then tends to slide 
forward on the tibial plateau, and the result is the cranial cruciate ligament is no longer 
needed for stabilization of the femur. Consequently, the caudal cruciate ligament 
becomes more involved and important for stifle stability. This procedure requires special 
plates, an osteotomy blade, and is very expensive. The immediate results post-surgery are 
very good, but if the procedure does not provide long term stabilization the results are 
catastrophic.  
 
It is usually beneficial to combine both extracapsular and intracapsular methods to 
achieve more permanent stability in large breed dogs such as labradors.  Our general 
recommendations are to employ the Òunder-and-overÓ intracapsular technique with the 
extra-capsular method utilizing suture stabilization..  The overall success rate for this 
procedure is very high, and return normal function can be expected within 12 weeks.