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Tips for the surgical repair of a torn cranial cruciate ligament

The Han-de ligature can be used for all the extracapsular techniques, or the intracapsular ligament replacement technique, or for any combination of these techniques.

Described here is a bone-to-bone fixation, similar to other so called ‘isometric’ placement techniques, but this one is simpler and less expensive.

  • Place the patient in dorsal recumbency.

  • Use a standard lateral parapatellar approach to the stifle joint.

  • Reflect the lateral fascia to expose the lateral distal femur.

  • Identify the lateral fabella, the lateral collateral ligament and the long digital extensor tendon.

  • Using a trocar pointed pin [1.5mm diameter for the Size 1 Han-de ligature] make a shallow hole at the femoral 'isometric point'. To find this point, identify the joint line between the distal fabella and the lateral femoral condyle. The entry point is in the femoral condyle below the distal/cranial border of the fabella.

  • Avoid damage to the origin of the lateral collateral ligament.

  • Then on the medial femur, feel for the mid shaft of the distal femur at a level just proximal to the trochlea. Make a stab incision through the fascia and muscle and blunt dissect to expose the medial cortex of the femur.

    • Either, drill an angled hole through the medial cortex at this point and place the point of a C-drill guide into the hole. Align the guide with the preplaced hole on the lateral side and drill a bone tunnel across the femur.

    • Or, place a finger tip on the medial cortex and with a drill bit or Steinman pin on the lateral condyle ‘eye ball’ the correct alignment of the drill to aim at your finger tip. With a little practise, this gives accurate results. Take care to remove your finger tip before the drill exits the medial cortex.

  • Place the loop passer up the bone tunnel and withdraw a loop of strong suture material.

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  • For the tibia 'isometric point', identify by palpation the long digital extensor tendon in its groove, and the cranial bone tubercle adjacent to this groove. If it is difficult to identify this tubercle, wait until the joint is opened. The long digital extensor tendon can then be seen and the cranial tubercle easily identified.

  • With a trocar point make a shallow , angled hole in the tubercle. In very small animals the hole is placed just ventral to the tubercle.

  • Select a point on the medial tibia level with the insertion of the patella ligament.

  • Drill a bone tunnel [1.5mm diameter for the Size 1 Han-de ligature] to join these two points. Use a C-drill guide or ‘eye ball’ the drill alignment.

  • Use the loop passer to place a loop of suture material through the bone tunnel.

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  • Now open the stifle joint, trim off the torn cruciate ligament, inspect the joint and repair meniscal damage as required.

  • Use your routine closure of the joint.

  • Then change your surgical gloves, open the Han-de ligature and pull the ligature to lock onto the toggle.

  • Place the ligature into the loop in the femur and pull the ligature through to the lateral femoral condyle. Check that the toggle lies snugly on the medial cortex.

  • Decide whether or not the ligature, when pulled taut, will interfere with the lateral collateral ligament. If it will, then place the ligature under the collateral ligament.

  • Place the ligature into the tibial loop and pull through to the medial tibia.

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  • Place the second toggle on the ligature. With the stifle joint in slight extension tie a surgeon’s knot with a couple of throws over the second toggle.

  • Check the joint for full range of motion, interior rotation of the tibia and for an anterior draw. A very slight anterior draw is permissible – 2-3mm cranial translation.

  • Do not over tighten the ligature, otherwise the lateral compartment of the joint is compressed. It has been suggested that the optimum tension for an extracapsular stabilisation should be 3kg [30N]. [C.Tonks et al, Veterinary Orthopedic Society Annual Conference 2009].

  • Once satisfied with the joint tension and stability, complete the knot tie with multiple [4] throws.

 

Posterior cruciate stabilization
If this is considered necessary, one technique is to use the Han-de ligature anchored under the fibular head [see lateral collateral repair for details] and sutured through the proximal patellar ligament.

 

 



The Han-de Ligature®


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