Caudal proximal tibial deformity and cranial cruciate ligament rupture in small-breed dogs

INTRODUCTION

Cranial cruciate ligament disease is themost common orthopaedic conditionaffecting the stifle in the dog (Ness andothers 1996). Several factors have beenproposed in its aetiopathogenesis, includ-ing degenerative mechanisms and trauma(Bennett and others 1988, Slocum andSlocum 1993, Vasseur 1993).

Cranial tibial thrust is defined as an internally generated force that causes theproximal tibia to translate cranially(Slocum and Devine 1983). This force is created by compression between thefemur and the tibia. Compression varieswith the dog’s activity. It has been hypothe-sised that, in normal dogs, the cranial tibial thrust is opposed by active and passive mechanisms. The cranial cruciateligament and the menisci may act as passive mechanisms and the action of thehamstring muscles as an active mechanism.Excessive cranial tibial thrust may result indamage to the cranial cruciate ligament. The magnitude of the tibialthrust may depend not only on the amountof compression, but also on the slope of thetibial plateau (Slocum and Slocum 1993).Altering the slope of the tibial plateau has

been shown to control the cranial tibialthrust (Warzee and others 2001).

Read and Robins (1982) described a caudal deformity of the proximal tibia,leading to an excessive caudal slope of thetibial plateau, in five large dogs. Thesedeformities were associated with rupture ofthe cranial cruciate ligament. The outcomeof surgical stabilisation was poor. The initial cranial cruciate ligament rupture and the poor results of surgery may have been linked to the detrimental effectsof the excessive cranial tibial thrust sec-ondary to the excessive slope of the tibialplateau.

Dogs weighing less than 15 kg with cranial cruciate ligament rupture are con-ventionally managed non-surgically unlessthere is a concomitant meniscal injury(Vasseur 1993). In a retrospective study(Vasseur 1984), 24 of 28 (85 per cent)dogs weighing 15 kg or less were consid-ered to be normal or improved, regardlessof the presence of stifle instability, after anaverage follow-up period of 36 months.The remaining four (15 per cent) dogsunderwent medial meniscectomy and surgical stabilisation.

Selmi and Padilha Filho (2001)described cranial cruciate ligament ruptureassociated with proximal tibial deformityin three poodles and two poodle-crossdogs. An abnormal tibial plateau angle wasthought to be responsible for the cranialcruciate ligament rupture. These dogs weresuccessfully managed by a proximal tibialwedge ostectomy combined with a lateralfabellotibial stabilising suture. A boneplate was applied medially as the singlemechanism of fixation and dogs wereallowed to resume normal activity 15 daysfollowing surgery. One dog sustained a tibial fracture at the distal end of theplate.aaa

The purpose of this study was todescribe the clinical and radiographic features, details of surgical managementand the outcome in eight small dogs withlameness associated with caudal deformityof the proximal tibia and concomitant cranial cruciate ligament rupture.

PAPERS

C. MACIAS, W. M. MCKEE AND C. MAY

Journal of Small Animal Practice (2002)43, 433–438

Eight dogs presented with chronic hindlimb lameness associated

with cranial cruciate ligament rupture. Seven were small terriers.

A caudal deformity of the proximal tibial shaft, originating at the

proximal tibial physis, and an excessive caudal slope of the tibial

plateau were present bilaterally in all dogs. The deformity was

thought to be responsible for the cranial cruciate ligament failure

and poor response to conservative management. Tibial plateau

angles were in excess of 26° in all dogs. The lameness was bilateral

in three dogs. There was complete cranial cruciate ligament rupture

in seven stifles and partial rupture in four. There were no meniscal

injuries. Surgical correction resulted in a significant improvement

(P<0·0001) in all dogs, with a mean follow-up of 12 months (range

three to 24 months). There were no complications.

Caudal proximal tibial deformity and cranial cruciate ligament rupture in small-breed dogs

JOURNAL OF SMALL ANIMAL PRACTICE • VOL 43 • OCTOBER 2002 433

Willows Referral Service, 78 Tanworth Lane, Solihull, West Midlands B90 4DF

Caudal proximal 27/2/03 18:02 Page 433

434 JOURNAL OF SMALL ANIMAL PRACTICE • VOL 43 • OCTOBER 2002

MATERIALS AND METHODS

AnimalsEight dogs with hindlimb lameness relatedto rupture of the cranial cruciate ligamentand caudal deformity of the proximal tibiawere referred to the authors for surgical cor-rection of the deformity between April1999 and February 2001. Seven of thesedogs were small terriers. Age ranged fromthree and a half to nine years (median sixyears). Bodyweight ranged from 5 to 15 kg(median 10·9 kg). Four dogs were male andfour were female.

Clinical findingsIn all cases, the lameness had developedgradually. There was initially a ‘skipping’intermittent lameness of a hindlimb whichlater became more persistent. Conservativemanagement with controlled activity andthe use of non-steroidal anti-inflammatorydrugs had been unsuccessful in all cases.Three dogs subsequently presented withlameness of the contralateral limb.

The degree of lameness was graded on anumeric scale as 0 (no lameness), 1 (verymild), 2 (mild), 3 (moderate), 4 (severe) or5 (non-weightbearing). All affected stifleswere examined for a cranial drawer sign.Arthrocentesis and cytological examina-tion of the joint fluid of the affected stiflewas performed in all cases to exclude thepossibility of sepsis.

Preoperative radiographyStandard, non-stressed orthogonal views ofthe affected and contralateral stifles were obtained and details regarding thepresence of intra-articular effusion, periar-ticular new bone formation and the position of the tibia in relation to the femurwere recorded. The periarticular new boneformation was graded as mild, moderate orsevere. Mediolateral radiographs of the cruswere obtained, as described by Morris andLipowitz (2001), in order to measure thetibial plateau angle (Fig 1).

SurgeryFollowing premedication with acepro-mazine (ACP Injection; Vericore) 0·05mg/kg and papaveretum (PapaveretumInjection; Martindale Pharmaceuticals)0·03 mg/kg, general anaesthesia wasinduced with thiopentone sodium(Intraval Sodium; Merial Animal Health)5 mg/kg and maintained with a balancedmixture of oxygen, halothane and nitrousoxide. The affected limb was clipped and prepared for aseptic surgery. Amoxycillin/clavulanic acid (Augmentin Intravenous; SmithKline Beecham Pharmaceuticals) was administered intra-venously at 20 mg/kg and repeated at 10 mg/kg every 90 minutes for the dura-tion of the surgery. Carprofen (Rimadyl;Pfizer) 2 mg/kg was given as a singleintravenous dose prior to surgery.

The dog was positioned in dorsolateralrecumbency with the affected limb down-wards. A medial skin incision was madefrom the patella to the midshaft of thetibia. The stifle joint was exposed via anarthrotomy incision medial to the straightpatellar tendon. The use of a stifle distractor (Veterinary Instrumentation)and Gelpi retractors aided inspection ofthe medial and lateral menisci without the need for lateral luxation of the patella.A cranial closing wedge ostectomy was performed immediately distal to the insertion of the medial collateral ligament using an oscillating saw. Thetwo osteotomies were made to converge

3 to 5 mm cranial to the caudal cortex of the tibia (Fig 2) and the ostectomy was completed with a single saw cutthrough the caudal cortex. The tibia was repaired with a medially applied plate, in some cases combined with a pin and interfragmentary wire. The excised bone was divided into small fragments and placed around theostectomy site. Wound closure was routine.

Postoperative radiographs wereobtained to evaluate the repair and thepostoperative tibial plateau angle.

Postoperative careA modified Robert Jones dressing wasapplied to the limb for the first 24 hourspostoperatively. Carprofen, at 2 mg/kgtwice daily, and amoxycillin-clavulanicacid (Synulox; Pfizer), at 12·5 mg/kg twicedaily, were administered orally for fivedays. Owners were advised to limit thedog’s activity to short lead walks for sixweeks.

Postoperative assessmentAll dogs were evaluated six weeks post-operatively. The degree of lameness was assessed and graded as previouslydescribed. Orthogonal radiographs of the proximal tibia were obtained to assess the progression of bone healing andthe implants. Long-term follow-up wasobtained by clinical examination or

FIG 1. (A)Preoperative lateralradiograph of thecrus showingdeformity of thecaudal proximaltibia. The tibialcrest is barelydistinguishable and caudal bowingof the proximalfibula is apparent.The tibia appearssubluxatedcranially and thetibial plateau issloped caudally. (B) Preoperativelateral radiographof the crus showingmeasurement ofthe tibial plateauangle (�)

A B



by telephone. Owners were asked to evaluate the degree of lameness, if present,in comparison to preoperative lameness(ie, much improved, slightly improved, noimprovement, or worse).

Statistical analysisThe degree of lameness preoperatively andat six weeks postoperatively was analysedusing a paired t test.

RESULTS

Clinical findingsDetails of the affected limb(s) and theduration and severity of lameness arerecorded in Table 1. All affected limbs hadsignificant thigh muscle atrophy. Six limbs had a demonstrable cranial draweron stifle manipulation. A cranial drawertest was resented in the other five limbs.The tibial tuberosity appeared prominentin all dogs.

Preoperative radiography In all dogs, radiographs of the stifles (n=16)showed increased intra-articular radiopac-ity and mild (n=7), moderate (n=5) orsevere (n=4) periarticular new bone forma-tion. Cranial displacement of the tibia wasnoted in all dogs (Fig 3). Radiographs ofthe crus showed a caudal deformity of theproximal tibia with a barely distinguishabletibial crest (see Fig 1). The tibial plateauappeared grossly abnormal, with a markedcaudal slope. Caudal bowing of the proxi-mal fibula was noted in all cases. Details ofthe preoperative tibial plateau angles arerecorded in Table 2.

Outcome of surgeryIntra-articular examination revealed com-plete rupture of the cranial cruciate liga-ment in seven stifles and partial rupture infour. All medial and lateral menisci weregrossly normal.

The tibial ostectomy was stabilisedusing a medially applied 2·7 mm dynamic

1 9 MN Bichon frise 12·7 R 12 42 3·5 FN WHWT* 10·5 R 3 33 3 F WHWT 8·3 R 2 44 6 FN Jack Russell 5 L 3 5

terrier5* 7·5 MN WHWT 12·8 L 12 4

R 1 46* 4 FN Cairn terrier 6·5 R 24 4

L 8 37* 6 M Cairn terrier 11·3 R 6 4

L 0·3 58 4·5 M Jack Russell 15 R 18 4

terrier cross

*Contralateral limb also affectedWHWT West Highland white terrier, M Male, MN Male neutered, F Female, FN Female neutered

Case Age Gender Breed Weight (kg) Limb(s) Duration of Degree ofnumber (years) affected lameness lameness

(months)

Table 1. Clinical parameters of eight dogs with caudal proximal tibialdeformities and cranial cruciate ligament rupture

FIG 2.Preoperativelateralradiograph ofthe crus.Lines havebeen drawn toindicate theostectomysite. Theosteotomylines converge3 to 5 mmcranial to thecaudal cortexof the tibia toprevent varusdeviation of the tibiafollowingreduction ofthe ostectomy

FIG 3. Preoperative lateral radiograph of thestifle of dog 2. There is moderate periarticularnew bone formation and increased intra-articular radiopacity, consistent with jointeffusion

1 31 16 15 262 37 21 16 NA3 36 18 18 NA4 26 11 15 285 35 20 15 35

35* 20 16 356 30 15 15 30

30* 17 13 307 33 19 14 34

34* 20 14 338 33 7 26 31

*Contralateral limb, NA Not available

Case number Preoperative tibial Postoperative tibial Change in Contralateral limbplateau angle plateau angle tibial plateau tibial plateau angle

angle

Table 2. Preoperative and postoperative tibial plateau angle and contralateraltibial plateau angle in eight dogs with caudal proximal tibial deformities andcranial cruciate ligament rupture



compression plate in three limbs and a 2·7mm dynamic compression plate and a pinin eight limbs. Interfragmentary wire wasalso used in one dog.

Postoperative radiography confirmedthat the ostectomy gap had been satisfacto-rily reduced in all cases. The tibia appearedto be located in a more neutral position,with no evidence of cranial displacement(Fig 4). The postoperative tibial plateauangles are detailed in Table 2.

Postoperative assessmentAt six weeks following surgery, all dogsshowed a significant (P<0·0001) improve-ment in the severity of lameness, asassessed by clinical examination (meanlameness score preoperatively 4, range 1 to5; mean lameness score at six weeks post-operatively 2, range 1 to 3) (Table 3).Radiographs revealed progression of bonehealing in all cases, with no evidence ofimplant complications (Fig 5).

Four dogs were available for further follow-up examination. The outcome inthe remaining cases was obtained by tele-phone (Table 3). Eight limbs were gradedas 0 (no lameness) and three as 1 (verymild lameness). Mean follow-up time was12·6 months (range three to 24 months).All owners evaluated the lameness as muchimproved.

DISCUSSION

Caudal deformity of the proximal tibiawas found to predispose to cranial cruciate ligament rupture in five largedogs (Read and Robins 1982), five minia-ture poodles and poodle-cross dogs(Selmi and Padilha Filho 2001) and thedogs in this study. Excessive stress on thecranial cruciate ligament as a consequenceof the altered conformation has been pos-tulated as the mechanism of injury (Readand Robins 1982).

Cranial displacement of the tibia wasobserved radiographically in all of thecases in this series without the need forstress views. Cranial subluxation of thetibia can be obtained in stress radio-graphic views of stifles with cranial cruci-ate ligament rupture (De Rooster andothers 1998, De Rooster and Van Bree1999). This suggests that the cranial dis-placement of the tibia noted in the dogsof this report is a consequence of the tibial deformity and not secondary to apartial or complete failure of the cranialcruciate ligament.

Slocum and Slocum (1993) proposedthat there is a direct relationship betweenthe tibial plateau angle and the magni-tude of the cranial tibial thrust. Morrisand Lipowitz (2001) showed significantdifferences between the tibial plateauangle of dogs with no evidence of cruciatedisease and that of dogs with cruciate dis-ease. A mean tibial plateau angle of 18°was measured for dogs without evidenceof cranial cruciate ligament disease ordegenerative joint disease in the stiflecompared with 24° for dogs with cranial

FIG 4. Preoperative lateral (A), postoperative lateral (B) and postoperative caudocranial (C)radiographs of the left crus of dog 7. A medial plate and a pin have been used to stabilise the tibialostectomy. The tibial plateau angle is reduced. The tibia does not appear to be subluxated cranially

FIG 5. Lateral (A) andcraniocaudal (B) radiographsof the right crus of dog 7 at 12 weeks postoperatively,showing complete bonehealing with no evidence of implant loosening ordisplacement

A

BA

B C



cruciate ligament injuries. Read andRobins (1982) and Selmi and PadilhaFilho (2001) used different guidelines tomeasure the tibia plateau angle, resultingin different sets of values. Although theirmeasurements clearly indicate abnormaltibial plateau angles, comparisonsbetween the studies are difficult.

It is probable that the tibial plateauangle was a significant factor in the cra-nial cruciate ligament failure and subse-quent lameness in the small-breed dogsdescribed here, especially consideringtheir poor outcome following non-surgi-cal management despite the absence ofmeniscal injuries. The overrepresentationof terriers may be because these breedshave, on average, an increased tibialplateau angle compared with other smallbreeds of dogs, or it might be there isanomaly in the growth of the tibia presentin these chondrodystrophoid dogs. Fur-ther prospective studies would be neededto verify which, if either, was the case.Interestingly, all the dogs from the onlyprevious report of small dogs with proxi-mal tibial deformities were poodles orpoodle-crosses (Selmi and Padilha Filho2001). This may reflect differences in therelative numbers of different breeds indifferent countries or, perhaps, differ-ences in conformation within breeds indifferent countries.

Read and Robins (1982) suggestedthat retardation of growth of the caudalaspect of the proximal tibial physis wasresponsible for the caudal proximal tibia

deformity. Trauma to the physis, com-pressive forces resulting in damage to thephyseal blood supply, and muscle imbal-ance between the quadriceps and gastro-cnemius groups were proposed aspossible causes of abnormal physealdevelopment. Terriers are overrepre-sented with respect to the developmentof tibial tuberosity avulsion fractures,either alone or in combination withproximal tibial physeal separation. Ifunattended, these injuries can lead to anabnormal caudal slope of the tibialplateau (Pratt 2001). Excessive tractionof the tibial tubercle during quadricepscontraction during a traumatic event washypothesised as being responsible forsuch fractures (Pratt 2001). There was noknown history of trauma in the dogs inthe present series and the overrepresenta-tion of terriers within the group and thebilateral tibial conformation supports thehypothesis that abnormal tibial develop-ment was the underlying aetiology.

Levelling the tibial plateau by a cranialclosing wedge ostectomy or by a tibialplateau levelling osteotomy using a circu-lar saw blade was originally proposed as asurgical procedure to eliminate cranialtibial thrust in the management of cranialcruciate ligament rupture in large-breeddogs (Slocum and Devine 1984, Slocumand Slocum 1993). An in vitro experi-mental study in cranial cruciate deficientstifles has shown that 6·5 ±0·9° may represent the optimal tibial plateau anglethat provides stifle stability by minimis-

ing cranial tibial thrust. A tibial plateauangles of less than 6·5 ±0·9° can result inreversal of the tibial thrust so that this iscaudally directed and may then lead toabnormal stress on the caudal cruciate ligament (Warzee and others 2001). Theauthors are unaware of any studies defin-ing an optimal postoperative tibialplateau angle in clinical cases. Consider-ing the evidence for a multifactorialaetiopathogenesis of cranial cruciate liga-ment failure, including possible breedvariations in gait as well as tibial plateauconformation and limb position duringweightbearing, and the fact that the mag-nitude of tibial thrust may vary through-out different phases in the weightbearingpart of the stride, it seems unlikely that asingle optimal angle for the tibial plateaucan be defined on the basis of anatomicalmeasurements of the tibia alone. In thisstudy, a closing wedge ostectomy ofapproximately 15° was performed in anattempt to correct the tibial deformityand neutralise the excessive cranial tibialthrust generated by the abnormal tibialplateau angle without compromisingoverall tibial length and bone healing.The significant improvement in lamenessscores observed at six weeks followingsurgery further suggests that it may not beessential to adjust the tibial plateau angleto the precise level described in the invitro study to obtain a satisfactory clinicaloutcome, at least in small dogs with cra-nial cruciate ligament rupture associatedwith caudal proximal tibia deformity.

The ostectomy was finished as a singlecut in the caudal aspect of the tibia inorder to ensure direct bone contact, as theintact fibula would otherwise force thetibia into varus deviation. The ostectomywas performed as proximally as possiblewithout damaging the medial collateralligament to maximise the effects of thecorrection on the tibial plateau. A singlebone plate was used as the main fixationdevice. Additional stability was achievedin seven cases with a pin. In one dog, aninterfragmentary wire was placed foradditional stability because one of the

1 4 2 1 (e) 112 3 1 1 (e) 113 4 3 0 (e) 104 5 3 0 (t) 135 4 2 0 (t) 24

4* 2 0 (t) 226 4 2 0 (t) 15

3* 2 0 (t) 127 4 2 0 (e) 14

5* 2 1 (e) 38 4 1 0 (t) 4

*Contralateral limb, (e) Follow-up examination, (t) Follow-up telephone conversation

Case number Degree of Degree of Degree of Follow-uplameness at lameness six lameness at time (months)presentation weeks postoperatively follow-up

Table 3. Degree of lameness at presentation, six weeks postoperatively and at follow-up in eight dogs with caudal proximal tibial deformities and cranialcruciate ligament rupture



screws securing the plate failed to achieveadequate bone purchase. No complica-tions were encountered and all ostec-tomies progressed to complete boneunion.

Meniscal injuries are common in dogswith cranial cruciate ligament failure,with Bennett and May (1991) and Floand DeYoung (1978) reporting an inci-dence of 49 per cent and 53 per cent,respectively, in predominantly largebreeds. Impingement of the medialmeniscus between the femoral condyleand the tibial plateau, secondary to stifle instability, is thoughtto be the cause (Slocum and Slocum1993, Vasseur 1993). Meniscal injuriesare thought to be uncommon in smalldogs with cranial cruciate ligament rup-ture (Vasseur 1984), although it has been proposed that secondary meniscal injuryaccounts for the poor outcome in dogsweighing less than 15 kg with cranial cruciate ligament injuries that are man-aged conservatively (Vasseur 1993).Examination of the menisci in the dogs inthe present series was technically difficult,despite the use of special retractors andthe aid of a focal source of illumination,because of the small size of the dogs and the steep tibial plateau. The apparentabsence of meniscal injuries in these dogsmay be the result of the deformity beingconfined to one plane and the permanentcranial displacement of the tibia, as these factors may reduce the risk of meniscalimpingement.

Complete cranial cruciate ligamentrupture had occurred in seven stifles and partial rupture in four stifles. All 16 stifles had degenerative changes and thisfurther suggests that the presence ofosteoarthritis is likely to be a consequenceof the tibial deformity and secondary cranial cruciate ligament injury. Whetherthe dogs with unilateral lameness will develop a contralateral lameness over time remains to be seen. A longer follow-up would help to provide additional information in this regard as up to 60 per cent of dogs with bilateral

degenerative joint disease at the time of initial diagnosis of cruciate ligamentrupture would be expected to developcontralateral cruciate ligament failurewithin 10 to 22 months (Doverspike andothers 1993).

ConclusionsThe similar conformation of the tibiae inthe small dogs in this series to thosereported by Read and Robins (1982), and the poor functional outcomesobtained by these authors, led to thedecision to manage the current cases by correcting the deformity using a cranialclosing wedge ostectomy. The poorresponse to conservative care, the absenceof associated meniscal injuries and the very positive surgical resultsobtained, justify the use of a cranial closing wedge ostectomy in the manage-ment of cranial cruciate ligament disease occurring secondarily to an abnormal tibial plateau angle in small-breed dogs.In addition, the good clinical outcomeseen in this study suggests that the addi-tion of a lateral fabellotibial suture, asdescribed by Selmi and Padilha Filho(2001), is unnecessary. Although thelong-term results of the surgery need fur-ther evaluation, it is possible that earlysurgery, prior to functional failure of thecranial cruciate ligament, will favourablymodify the progression of degenerativedisease in affected stifles.

AddendumIn addition to cases 5, 6 and 7, since thesubmission of this manuscript, cases 2, 3and 4 have also re-presented with lamenessof the contralateral limb and have beensuccessfully managed by exploratoryarthrotomy and cranial closing wedgeostectomy.

AcknowledgementsThe authors wish to thank the veterinarysurgeons who referred the cases, the nursing staff for their support and Dr D. Marcellin-Little for reviewing the manuscript.

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Caudal proximal tibial deformity and cranial cruciate ligament rupture in small-breed dogs