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J. small Anim. Pract. (1988) 29, 559-563 Fascia lata flap to re-inforce repair of patella ligament injuries in the dog and cat J. A. CULVENOR North Shore Veterinary Hospital, 94 Alexander Street, Crows Nest, New South Wales, Australia ABSTRACT Reports of three cases of patella ligament repair utilising a re-inforcing strip of fascia lata are presented. A description of the technique is given. INTRODUCTION Patella ligament injuries are not common (McCurnin 1976), but are a difficult problem to deal with as the ligament is under great tensile stress and the area is difficult to immobilise. Recent reports (Gilmore 1983, Bloomberg and Parker 1984) describe successful repair. Repair is especially difficult when deficits occur. CASE REPORTS Case 1 A five-year-old neutered male domestic shorthair cat was presented with a sudden onset of hind leg lameness. The foot was placed normally but the cat could not weightbear. Examination revealed swelling and pain in the region of the stifle. Palpation under general anaesthesia revealed a deficit in the patella ligament. Radiographs (Fig. 1) confirmed that on the injured leg the distance from the patella to the tibial crest was increased on flexed views. Surgery was performed and the ligament reduced using 0.8 mm stainless wire passed in a loop proximal to the patella, through the quadriceps attachments, and through a hole in the tibial crest. A bunnel pattern of 1 nylon (Dermalon; Davis and Geck) was used to appose the ligament ends and single interrupted sutures of 3-0 polypropylene (Surgilene ; Davis and Geck) used to appose the ligament sheath. A fascia1 strip was then harvested proximal to the patella from the fascia lata which covers the quadriceps cranially. The following method was used: two incisions were made, one to each side of the patella extending proximally about 1.5 times the distance from the proximal patella 0022-4510/88/0800-0559$02.00 0 1988 BSAVA 559

Fascia lata flap to re-inforce repair of patella ligament injuries in the dog and cat

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Page 1: Fascia lata flap to re-inforce repair of patella ligament injuries in the dog and cat

J . small Anim. Pract. (1988) 29, 559-563

Fascia lata flap to re-inforce repair of patella ligament injuries in the dog and cat

J . A . C U L V E N O R

North Shore Veterinary Hospital, 94 Alexander Street, Crows Nest, New South Wales, Australia

A B S T R A C T

Reports of three cases of patella ligament repair utilising a re-inforcing strip of fascia lata are presented. A description of the technique is given.

I N T R O D U C T I O N

Patella ligament injuries are not common (McCurnin 1976), but are a difficult problem to deal with as the ligament is under great tensile stress and the area is difficult to immobilise. Recent reports (Gilmore 1983, Bloomberg and Parker 1984) describe successful repair. Repair is especially difficult when deficits occur.

CASE R E P O R T S

Case 1 A five-year-old neutered male domestic shorthair cat was presented with a sudden

onset of hind leg lameness. The foot was placed normally but the cat could not weightbear. Examination revealed swelling and pain in the region of the stifle. Palpation under general anaesthesia revealed a deficit in the patella ligament. Radiographs (Fig. 1) confirmed that on the injured leg the distance from the patella to the tibial crest was increased on flexed views. Surgery was performed and the ligament reduced using 0.8 mm stainless wire passed in a loop proximal to the patella, through the quadriceps attachments, and through a hole in the tibial crest. A bunnel pattern of 1 nylon (Dermalon; Davis and Geck) was used to appose the ligament ends and single interrupted sutures of 3-0 polypropylene (Surgilene ; Davis and Geck) used to appose the ligament sheath. A fascia1 strip was then harvested proximal to the patella from the fascia lata which covers the quadriceps cranially. The following method was used: two incisions were made, one to each side of the patella extending proximally about 1.5 times the distance from the proximal patella

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Page 2: Fascia lata flap to re-inforce repair of patella ligament injuries in the dog and cat

560 J . A. CULVENOR

FIG. 1 . (a) Left and (b) right mediolateral views of the stifles of a cat with a patellar tendon injury. Note that in the flexed position the distance from the tibia1 crest to the patella on the injured right side is greatly increased.

Graft +

Patella *

Ruptured ligament *

Tibia1 crest

A B C

FIG. 2. Fascia1 transplant to re-inforce patella ligament repair. A harvesting strip from cranial fascia. B. Graft site sutured and graft reflected B. Graft sutured over the damaged area.

Page 3: Fascia lata flap to re-inforce repair of patella ligament injuries in the dog and cat

PATELLA LIGAMENT INJURIES 561

to the tibial crest. The strip was freed proximally and folded distally to cover the patella, the ligament and the tibial crest. A tug distally ensured the attachment to the patella was firm. The sides of the strip were sutured to the underlying patella tendon and the soft tissue of the tibial crest with 3-0 polypropylene in a single interrupted pattern (Fig. 2).

Wound closure was routine. Postoperatively the leg was placed in a Robert-Jones dressing for two weeks. The wire was removed one month postoperatively. At six weeks postoperatively the leg function was normal and has remained so for 18 months.

Case 2 A 20 kg mixed breed dog was presented following a car accident with lameness in

the right hind leg and a graze to the medial aspect of the stifle. Exploration of the wound revealed that the insertion of the patella ligament on the tibial crest has been abraided and completely avulsed, the remaining ligament barely reaching the tibial crest. After debridement and flushing the ligament was repaired. A wire loop (1.0 mm stainless steel) was passed proximally to the patella and through a hole drilled across the tibial crest, and was tightened sufficiently to bring the end of the ligament into some apposition with the bone. A Bunnel suture of Number 1 nylon was inserted into the ligament and was secured through a hole in the tibial crest. A graft was harvested as in case 1 and similarly sutured with 3-0 polypropylene although the sutures in the tibial crest area had to be fastened through holes in the bone as there was insufficient soft tissue present.

The leg was placed in an extension splint, a half cast of fibreglass casting tape (Delta-Lite; Johnson and Johnson) on the caudal aspect, for four weeks and exercise was restricted for eight weeks. The wire was removed at 10 weeks postoperatively. At 16 weeks postoperatively lameness was minimal and has remained good for 15 months.

Case 3 An eight-year-old female domestic shorthair cat was presented with a right

hindlimb lameness of three days duration. Examination revealed swelling and pain in the stifle. A radiograph revealed a chip fracture of the distal patella (Fig. 3). At surgery the patella ligament at the fracture site was also disrupted. The chip was considered too small for stable reattachment and was therefore removed. The disrupted ligament was repaired as in case 1. Recovery was uneventful and the cat was walking normally 10 days after wire removal at four weeks postoperatively.

D I S C U S S I O N

The repair of major tendons and ligaments is often a challenge and the patella ligament is no exception. The aims of repair are to re-appose the severed ends, hold them securely and relieve tension on the area for sufficient time for healing to be

Page 4: Fascia lata flap to re-inforce repair of patella ligament injuries in the dog and cat

562 J. A. CULVENOR

FIG. 3. Mediolateral view of the stifle of a cat with a facture of the distal portion of the patella.

strong enough to support function. The technique described contributes to all these aims. Tension is relieved with a wire passed proximally to the patella and through a hole in the tibia1 crest as described previously (Hohn 1975), although it must be done carefully to avoid overtightening. The wire should not be placed in a figure-eight fashion as the cross-over would crush the ligament.

A Bunnel suture pattern, three loop pulley or locking loop (Berg and Egger 1986) could be used to re-appose the ligament ends with the locking loop being the best (Tomlinson and Moore 1982). When the ligament is sheared from the bone as in cases 1 and 3 then one end of the suture must be secured around or through the bone. This provides a stronger repair than simple re-apposition (Levine and others 1966). A few small interrupted sutures are helpful to re-appose the ligament sheath.

The fascia1 graft described re-inforces routine ligament repair and is of significant help where deficits occur as in case 2. Surrounding connective tissue has been used elsewhere for additional support of tendon and ligament repair and has been reported in the lateral collateral ligament of the carpus (Roe and Dee 1986), stifle collateral ligaments (McCurnin 1976) and cruciate ligament repair (Arnoczky 1983). Carbon fibre implants have also been used for similar purposes (Aragona and others 1981, Vaughan 1981). Fascia lata has been used as a free graft for the repair of the Achilles Tendon (Braden 1976). Surrounding fascia has the advantages of being readily available, possibly already secured and possessing a useful blood supply.

ACKNOWLEDGEMENT

The author wishes to thank Bozena Jantulike of the Department of Veterinary Anatomy at the University of Sydney for preparation of the illustration.

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