190 Surgical Treatment
of CR and to assess the health of the meniscus,
the cranial and caudal cruciate ligaments, and
cartilage surfaces. Medial meniscal tears should
be debrided, or medial meniscal release may be
considered to decrease the risk of late meniscal
tears (see Chapters 35 and 36). An approach to
the lateral distal femur and proximal tibia is
then completed, including incising the fascia
lata and reflecting the biceps femoris caudally.
The stabilizing material is then placed in the
plane between the joint capsule and fascia
lata. Before closure, the stability and range of
motion of the joint should be tested to ensure
appropriate stability has been obtained while
maintaining adequate range of motion.
General care after surgery
Initially, animals should be kept kenneled at
all times with periodic sling walks for elimina-
tion purposes only. Starting at 2–3 weeks after
surgery, focused, controlled rehabilitation activ-
ity can be initiated and should promote a recov-
ery of function after ES procedures (Marsolais
et al. 2002). Rehabilitation during the postoper-
ative period is discussed in Chapter 42. Activity
restriction is maintained for 12–16 weeks after
surgery to prevent over-stressing the stabiliz-
ing structure. This is particularly important for
those ES procedures that depend on the forma-
tion of implant-stimulated periarticular fibrosis
for long-term success. Weight reduction should
also be prescribed if appropriate.
Biological extracapsular stabilization
ES was first performed using biological mate-
rials; multiple techniques have been described.
First introduced during the 1960s, fascial imbri-
cation techniques rely solely on tightening the
soft tissues lateral and medial to the joint to pre-
vent cranial tibial subluxation (McCurninet al.
1971; Pearsonet al. 1971). A second technique
uses a local strip of fascia lata that extends from
the tibial tuberosity and is threaded around
the fabella (Aikenet al. 1992) in an orientation
that approximately mimics the trajectory of the
native CrCL to limit cranial tibial subluxation
and internal tibial rotation. A third technique,
fibular head transposition, was introduced in
1985 (Smith & Torg 1985). By advancing the
fibular head cranially, the lateral collateral liga-
ment is oriented in an oblique direction similar
to the native CrCL, limiting both cranial tibial
subluxation and internal tibial rotation (Smith
& Torg 1985; Mullen & Matthiesen 1989). Sev-
eral studies using subjective outcome measures
have reported reasonable success rates for these
techniques (McCurninet al. 1971; Pearsonet al.
1971; Smith & Torg 1985; Mullen & Matthiesen
1989; Aikenet al. 1992). Generally, the most com-
mon complications associated with biological
ES techniques in clinical cases are recurrent or
persistent clinical lameness and/or stifle insta-
bility, occurring in one-fourth to one-third of
cases in most reports (McCurninet al. 1971;
Pearsonet al. 1971; Mullen & Matthiesen 1989;
Aikenet al. 1992; Chauvetet al. 1996). Recurrent
stifle instability likely results from stretching of
the surgically repositioned soft tissues that are
providing stability in the immediate postoper-
ative period (Dupuiset al. 1994). Fibular head
transposition has additional potential complica-
tions including fibular head fracture and soft-
tissue irritation, seroma, or infection associated
with the required metal implants (Smith & Torg
1985; Mullen & Matthiesen 1989). These biolog-
ical ES techniques are now rarely used due to
unacceptably low success rates and high com-
plication rates, although fascial imbrication is
often combined with other primary stifle stabi-
lization procedures for augmentation.Extracapsular stabilization with
synthetic materialsThe use of synthetic materials is now more com-
mon than biological techniques for ES (Korvick
et al. 1994). Most commonly, a pliable linear
implant (‘suture’) is passed from the caudodis-
tal femur to the cranioproximal tibia across
the lateral aspect of the joint, between the fas-
cia lata and the joint capsule. A variety of
types of ES using synthetic materials have been
described, including the lateral fabello-tibial
suture (Figure 25.1), TightRope CCL®(Arthrex
Vet Systems, Naples, FL, USA) (Figure 25.2),
various bone anchor techniques (Figure 25.3),
and the Ruby Joint Stabilization System (Kyon
Veterinary Surgical Products, Boston, MA)
(Figure 25.4).