Conservative management of meniscal injury associated with cranial cruciate disease

RE: Conservative management of meniscal injury associated with cranial cruciate disease

Martin Atkinson — Thu, 17 Mar 2016 12:21:05 GMT

I think that there is a huge danger that an occasional orthopaedic surgeon is likely to damage the joint more digging around than the theoretical problems that may occur with leaving the damaged meniscus in place. Given there is, as Malcolm suggests, no clear evidence either way a first opinion surgeon repairing a ruptured ACL by lateral suture would well to leave the joint well alone unless there is significant persistent post operative lameness. My personal experience is that almost all the dogs I have repaired by a lateral suture have made a full recovery with no detectable lameness and I've never looked inside the joint!

RE: Conservative management of meniscal injury associated with cranial cruciate disease

Stephen Williams — Thu, 17 Mar 2016 09:57:29 GMT

Thank you for the concise clarification of the issue Malcolm! The ESVOT reference is useful also, thanks. The controversy is interesting and I will watch the webinar!

Steve

RE: Conservative management of meniscal injury associated with cranial cruciate disease

Malcolm Ness — Thu, 17 Mar 2016 06:58:11 GMT

As this thread confirms, this whole subject remains rather controversial. Previously, "accepted wisdom" stated that you must open every joint, debride the torn ligament, inspect the meniscus and perform a partial meniscectomy in the case of meniscal injury.

Unfortunately, there is no good evidence to support that approach. There are two papers being published in JSAP by Danni McCready - these are a precis of a much longer, Cochrane style, systematic review of the literature on this subject.

In short, there is no proven method of reliably diagnosing meniscal injury; there is no evidence that meniscal injury is invariably problematic; there is no way of repairing a meniscal injury (the current response to finding a meniscal injury is to trim it up - i.e. make it a bigger, tidier meniscal injury!). Everything focuses on the medial meniscus but there are papers suggesting that the lateral meniscus is injured just as frequently yet it is typically ignored even by the most enthusiastic meniscal surgeons.

There is little doubt that lameness associated with a meniscal injury is a complication of cruciate failure and cruciate surgery affecting perhaps 4-8% dogs operated but there is no evidence to suggest that that complication can be avoided, or reduced by stifle exploration and meniscal inspection/surgery at the time of cruciate surgery.

In short, Danni's papers will provide evidential support for your report and I spoke at the ESVOT conference last year on the same subject - there will be a paper in the proceedings that you can cite.

There is an awful lot of controversy surrounding cruciate failure and its treatment. I am doing a Webinar for the Webinar Vet later this month looking at these uncertainties and controversies if anybody is interested.

RE: Conservative management of meniscal injury associated with cranial cruciate disease

Rob Loxley — Thu, 10 Mar 2016 23:35:09 GMT

[quote user="John Flynn"]PS - I think the biggest argument in favour of arthrotomy/arthroscopy as standard is to confirm your diagnosis - i.e. to check that it is actually cranial cruciate ligament failure![/quote]

Has the world come full circle on debriding the torn ligament yet?

Also by arthrotomy do we mean a large lateral or mini medial approach?

RE: Conservative management of meniscal injury associated with cranial cruciate disease

Stephen Williams — Thu, 10 Mar 2016 23:27:16 GMT

Thank you for the well-made points John, input appreciated! I seem to remember removing the occasional osteophyte in the past. It is interesting to consider the relative merits of evidence vs expert opinion in area of cruciate disease. The oft quoted figure of over $1 billion spent in the US cruciate market was built on a fairly weak actual evidence base it would seem, yet review papers seem very prescriptive about what should be done, particularly from that side of the pond.

Steve

RE: Conservative management of meniscal injury associated with cranial cruciate disease

John Flynn — Thu, 10 Mar 2016 20:13:18 GMT

[quote user="Stephen Williams"]meniscal lesions can heal with a conservative approach[/quote]

I don't think this is strictly correct (meniscal injuries in the non-vascular part are not thought to heal as I understand it).

I think the first unanswered question is whether the clinical outcome is sufficiently positively affected in the presence of a meniscal injury by cutting away the damaged bits versus leaving them alone. The second and even more relevant question is whether the clinical outcome will be sufficiently positively affected by you cutting away the damaged bits versus leaving them alone.

For analogy: it used to be popular to rongeur off big osteophytes during cruciate surgery, but did it do any good... probably not as no-one ever talks about doing it these days. As such, you do not read opinions that arthrotomy/arthroscopy should be done as standard in order to assess the degree of osteoarthritis present - it becomes irrelebvant if you can't do anything meaningful after your assessment.

[quote user="Stephen Williams"]I was rather hoping to reference this from the literature[/quote]

I think all you are going to find are expert opinions, I am not aware of any reliable evidence to answer this question. If you search on this forum you may be able to reference a soundbite from Malcolm Ness in support of your approach.

Let us know if you turn anything interesting up!

PS - I think the biggest argument in favour of arthrotomy/arthroscopy as standard is to confirm your diagnosis - i.e. to check that it is actually cranial cruciate ligament failure! This is perhaps a stronger argument in some cases than others.

RE: Conservative management of meniscal injury associated with cranial cruciate disease

David Mills — Thu, 10 Mar 2016 18:43:33 GMT

There was a review in the recent JSAP about meniscal injury. Evidence generally low/incomplete. Open access here:

http://onlinelibrary.wiley.com/doi/10.1111/jsap.12433/epdf

RE: Conservative management of meniscal injury associated with cranial cruciate disease

Stephen Williams — Thu, 10 Mar 2016 17:25:48 GMT

My rather tiring review (I didn't realise just how many cruciate papers there are out there) suggests not yet, lateral suture seems to have a positive evidence base. Early papers found no benefit of TPLO vs Lat suture, tho more recently TPLO/TTA seems to have crept ahead of LS in the ratings. What none of the papers seem to do is group dogs by weight, my practitioner view was that LS is a smaller dog thing. It would be interesting to see a 10-15 kg dog comparison of LS v other methods, as far as am aware that's not been done. Not the same thing at all as comparing the techniques in large dogs ?

Steve

RE: Conservative management of meniscal injury associated with cranial cruciate disease

Hannah Wynne Richards — Thu, 10 Mar 2016 17:04:00 GMT

Does this mean that a lateral suture will like the over the top technique become condemned?

Wynne

RE: Conservative management of meniscal injury associated with cranial cruciate disease

Stephen Williams — Thu, 10 Mar 2016 16:50:45 GMT

Hi Rob

It seems to be consensus in the literature, though that's not the same thing as GP consensus of course. Specalist orthopaedic surgeons round these parts also always seem to open the joint. Yes you would either have to open the joint or arthroscope then walk away from injuries in half the cases to perform a proper trial, as you say I guess that's why I may not be finding much. MRI would at least be a non-invasive diagnostic approach for such a triaL

Incidence is high btw, up to about 70% depending which study you read, there's a Ness paper in the Feb 16 JSAP. I think diagnostic sensitivity plays a part, the better it is the more appear to be found.

Steve

RE: Conservative management of meniscal injury associated with cranial cruciate disease

Rob Loxley — Thu, 10 Mar 2016 16:43:39 GMT

[quote user="Stephen Williams"]despite the consensus modern view that meniscal exam should be a standard part of the procedure[/quote]

is it? via arthrotomy?

[quote user="Stephen Williams"]I've missed comparing conservative vs surgical management of known canine meniscal injury?[/quote]

I'd look at what the incidence of meniscal injury is in 1st operated stifles - detected either via arthroscopy or arthrotomy (not sure how good MRI is...) - and see if you think that justifies an arthrotomy on each case?
It's difficult however to find literature that compares the recovery from surgery of non-damaged meniscal cases if an arthrotomy has/hasn't been performed since we don't have a good non-invasive test (again correct me if I'm wrong).