Pulse - May 2023 - 14

PULSE SPECIAL SECTION
Reconsidering Approach for
Extracapsular Stabilization CCL
Deficient Stifles
Rodrigo Roca, DVM (Practice Limited to Surgery)
T
reatment of cruciate ligament
disease in canine
stifles using an extracapsular
implant is centered around the
lateral circumfabellar suture
technique. The origin of the
technique dates to the 60s when
Childers described a suture technique
to augment the Patsaama
intrarticular graft.
The technique was modified by Flo, and
this has become the staple of the extracapsular
" lateral " suture. Additional extracapsular techniques
that have fallen out of favor include the
fibular head transposition, Fascia lata imbrication,
and lateral retinacular imbrication.
The lateral suture technique performs by
mimicking the function of the native CCL. Its
proximal circumfabellar attachment relies on
the purchase of the femorofabellar ligament
and its rigidity, while the distal tibial attachment
relies of the bone-suture interface within
a tunnel in the proximal tibial metaphysis.
Tension of the suture implant is secured with
crimps or a suture knot. Overall, the technique
is associated with minimal morbidity.
Historically, complications with suture failure
either by suture breakage, suture pull out,
loss of elastic properties of the suture, and
failure of the crimps/knots were deemed catastrophic
but only seen in approximately 17%
of cases (Casale et al). Recent arthroscopic
documentation confirmed the potential for
violation of the caudolateral joint space with
the implanted suture material. Finally, Tinga et
al. evaluated stability of the cruciate deficient
stifle after undergoing a traditional lateral circumfabellar
suture technique and concluded
that the technique failed to stabilize the knee
during the mid-stance phase of the gait cycle.
Adaptations to the lateral suture have described
anchoring of the suture via suture bone
anchors and buttons to the femur and tibia at
pseudoisometric points. The bone-anchor interface
generally withstands higher yield and
failure loads compared to the circumfabellar
attachment. This procedure is more technically
demanding and requires the surgeon to
acquire specialized implants and undergo the
training necessary to learn the technique.
Similarly, Tinga et al. has also evaluated stability
of biomechanically altered stifles in the
same manner as for the circumfabellar lateral
suture. Results confirmed biomechanical altering
procedures to improve stability of the
cruciate deficient stifle unlike the traditional
circumfabellar lateral suture. The preference at
my practice is for biomechanical altering procedures
while reserving extracapsular implants
for toy breeds of dogs where a bone plate is
not feasible or for cases with excessive internal
rotation and/or persistent cranial tibial
displacement where the extracapsular implant
will serve as a secondary implant rather than
for primary stabilization.
With this recent evidence, surgeons should
strive to reconsider the extracapsular technique
and opt for a more rigid fixation either
via bone anchors and buttons or considering
biomechanical stabilization procedures. P
Results confirmed
biomechanical
altering procedures
to improve stability
of the cruciate
deficient stifle unlike
the traditional
circumfabellar lateral
suture.
CCLRs - Management
14
MAY 2023
PULSE
Pulse - May 2023

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