Preliminary Study Evaluating Tests Used To Diagnose Canine Cranial Cruciate Ligament Failure

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PAPER

Preliminary study evaluating tests


used to diagnose canine cranial
cruciate ligament failure
OBJECTIVE: To estimate specificity, sensitivity, positive predictive
value and negative predictive value of tests and signs used for the
diagnosis of cranial cruciate ligament failure in dogs.
METHODS: One stifle in each of 42 dogs was examined: 25 affected
and 17 control dogs. All dogs were subjected to the following tests
when conscious: cranial drawer, tibial compression, patellar tendon
palpation and palpation of the medial aspect of the joint. Under general
anaesthesia, cranial drawer and tibial compression tests were
repeated and a lateral stifle radiograph was taken to evaluate changes
of the infrapatellar fat pad. The results were analysed using a 232
table method. Sensitivity, specificity, positive predictive value and
negative predictive value were estimated.
RESULTS: The sensitivity of the cranial drawer and tibial compression
tests was surprisingly low when performed on conscious patients but
significantly better when performed under anaesthesia. Similarly,
palpation of the medial aspect of the stifle joint cannot be
considered a reliable indicator of cranial cruciate ligament injury.
Patellar palpation and radiographic assessment showed excellent
sensitivity, specificity, positive predictive value and negative
predictive value.
CLINICAL SIGNIFICANCE: In the diagnosis of cranial cruciate ligament, it
is essential that the clinician is aware of each tests features and
limitations to reduce the risk of misdiagnosis.
B. CAROBBI AND M. G. NESS*
Journal of Small Animal Practice (2009)
50, 224226
DOI: 10.1111/j.1748-5827.2008.00723.x
Accepted: 16 November 2008; Published
online: 13 March 2009

Dick White Referrals, Station Farm, London Road,


Six Mile Bottom, Newmarket CB8 0UH
*Croft Veterinary Hospital, 37-39 Croft Road,
Blyth, Northumberland NE24 2EL

224

INTRODUCTION
Failure of the cranial cruciate ligament
(CCL) and associated secondary stifle osteoarthritis (OA) is the most common cause
of chronic hindlimb lameness in the dog
(Ness and others 1996). Lameness caused
by complete or partial failure of the CCL
may be acute or insidious in onset, and
although secondary osteoarthritis is inevitable, the character and severity of the resultant lameness are variable.
The diagnosis of CCL failure is usually
made by physical and radiographic examination. The physical examination should
Journal of Small Animal Practice

include palpation to detect presence of


joint swelling or bony thickening and manipulation to detect instability of the joint
(Henderson and Milton 1978, Johnson
and Johnson 1993, Moore and Read
1996, Jerram and Walker 2003). Radiologically, there might be evidence of osteophyte
formation and/or changes to the infrapatellar fat pad shadow (Moore and Read 1996,
Jerram and Walker 2003).
Palpation is usually performed on both
stifles simultaneously in the standing
patient. In dogs with a recent CCL failure,
a joint swelling can usually be appreciated
just caudal to the patellar tendon (Jerram
and Walker 2003), which is characterised
by a loss of definition of that tendon. In dogs
with a more chronic CCL failure, loss of
patellar tendon definition might still be evident and, in addition, a thickening of the
medial aspect of the joint capsule may be
detected.
Two tests have been described and
widely used to detect stifle joint instability
because of CCL failure: the cranial drawer
test (CDT) and the tibial compression test
(TCT). However, both tests have the
potential to produce false negative results.
Henderson and Milton (1978) suggested
that each of these tests gave similar results
for recent CCL failures, but both are unreliable in the diagnosis of chronic CCL failure. However, they did not provide data to
support their assertions. Moore and Read
(1996), in a review of CCL rupture in dogs,
made similar statements about the unreliability of these tests, but again, no data were
provided in support of their opinion. More
recently, Jerram and Walker (2003) stated
that palpation and joint laxity are highly
sensitive indicators of CCL rupture but
that chronic periarticular fibrosis, partial
CCL rupture and tense patients may hinder evaluation of stifle instability, but, once
more, the authors provided no data to support their assertions. Elsewhere, a range of
diagnostic indicators of CCL failure have
been described including the clinical, historical and radiological features, which
accompany canine CCL, but there is
remarkably little supporting evidence, and

 Vol 50  May 2009  2009 British Small Animal Veterinary Association

Reliability of tests and signs for CCL failure

no single test or sign has been shown to be


universally applicable or reliable.
The purpose of this study was to estimate the specificity, sensitivity, positive
predictive value (PPV) and negative predictive value (NPV) of a number of tests
and signs commonly used in the diagnosis
of CCL failure in dogs.

MATERIALS AND METHODS


Data collection
Forty-two dogs were examined, both stifles
were evaluated as part of a standard physical examination, and a single joint of each
patient was included in the study. Twentyfive affected dogs had the diagnosis of
partial or complete CCL failure, confirmed
subsequently by inspection of the ligament
either at arthrotomy or by arthroscopy
during a therapeutic surgical procedure.
Seventeen control dogs that were anaesthetised for reason other than for investigation of stifle lameness were examined.
These were dogs with no clinical or radiographic sign of stifle abnormality both at
the time of evaluation and again at a second
clinical and radiographic examination six
to 12 weeks later.
Every dog was subjected to the following
tests and assessments while conscious:
CDT and TCT with the dog lying in lateral
recumbency and patellar tendon palpation
test and palpation of the medial aspect of
the joint with the dog standing. The
CDT and TCT were repeated with the
patient under general anaesthesia. In addition, two standard orthogonal radiographic views centred on the stifle were
collected and evaluated for evidence of
change to the infrapatellar fat pad.
Diagnostic testing
The CDT was performed with the dog in lateral recumbency. The thumb and the index
finger of one hand were placed on the lateral
fabella and the patella, respectively, and the
thumb and the index finger of the other hand
were positioned behind the fibular head and
on the tibial crest, respectively. While the
femur was held stable, the tibia was forced
cranially and caudally without altering the
angle of the stifle joint. The test was repeated
with the stifle held in varying degrees of
extension and flexion.
Journal of Small Animal Practice

The TCT was performed as described


by Henderson and Milton (1978). With
the dog in lateral recumbency, one hand
grasps the metatarsus, while the other hand
gently holds the femoral condyles with the
index finger placed along the patellar tendon to the tibial crest. The tibiotarsal joint
is alternatively flexed and extended to
detect cranial translation of the tibia.
Patellar tendon palpation involved evaluating the patellar tendon for evidence of loss
of sharpness or definition because of an
underlying joint swelling, synovitis, etc.
Medial aspect palpation involved examination of the medial aspect of the stifle
joint for signs of bony or dense fibrous
thickening, especially in the region of the
medial collateral ligament.
For each test, or radiographic evaluation, the result was recorded as normal,
abnormal or dont know.

were, in fact, normal. For the second analysis, all the dont knows were counted as if
they were, in fact, abnormal. For each test,
the sensitivity and specificity were estimated along with PPV and NPV.
Sensitivity is defined as the proportion
of true positives identified as such; specificity is the proportion of true negatives identified as such. PPV is the proportion of test
positives that are truly positive, and NPV is
the proportion of test negatives that are
truly negative.

Statistical analysis
Each set of results was analysed twice using
a 22 table method: the first time, all the
dont know results were counted as if they

Each of the tests evaluated in this study


depends to a large extent on clinical judgement and learned skill. The dont know
group was included to reflect the essential

RESULTS
The results are summarised in Tables 1
and 2.

DISCUSSION

Table 1. Sensitivity, specificity, PPV and NPV calculated for each test with all dont
know results counted as if they were normal
Tests

Dont know in normal (%)


Sensitivity

Specificity

PPV

NPV

60
64
100
68
92
88
100

100
100
100
100
100
100
100

100
100
100
100
100
100
100

6296
6538
100
68
8947
85
100

Cranial drawer (CP)


Tibial compression (CP)
Patellar tendon palpation (CP)
Medial aspect palpation (CP)
Cranial drawer (GA)
Tibial compression (GA)
Radiograph

PPV Positive predictive value, NPV Negative predictive value, CP Conscious patient, GA Under general anaesthesia

Table 2. Sensitivity, specificity, PPV and NPV calculated for each test with all dont
know results counted as if they were abnormal
Tests

Cranial drawer (CP)


Tibial compression (CP)
Patellar tendon
palpation (CP)
Medial aspect
palpation (CP)
Cranial drawer (GA)
Tibial compression (GA)
Radiograph

Dont know in abnormal (%)


Sensitivity

Specificity

PPV

NPV

60
64
100

8235
8235
100

8333
8421
100

5833
6086
100

76

9411

95

7272

96
92
100

8823
8235
100

9230
8846
100

9375
875
100

PPV Positive predictive value, NPV Negative predictive value, CP Conscious patient, GA Under general anaesthesia

 Vol 50  May 2009  2009 British Small Animal Veterinary Association

225

B. Carobbi & M.G. Ness

subjectivity of these diagnostic tests. We


were keen to explore the possibility that,
for example, the confident finding of a cranial
drawer sign might be a usefully accurate and
precise predictor of CCL failure but the
diagnostic sensitivity and specificity of the
test overall might be diminished by those
cases in which the result was equivocal.
In our study, the sensitivity of the CDT
when performed on conscious patients was
surprisingly low but significantly better
in anaesthetised patients. The CDT in
conscious dogs is, perhaps, the most commonly used diagnostic test for CCL injury,
and our results indicate that reliance on this
test in the conscious patients will result in
significant numbers of CCL cases being
misdiagnosed as cruciate-normal, and 40
per cent of dogs with proven CCL failure
do not have cranial instability detectable
with the CDT.
When cases with a score of dont know
were counted as normal, the specificity and
PPV of all tests are 100 per cent this is in
part a reflection of the relatively small numbers of patients in this study but also the
consequence of the ability of the clinicians
performing these tests to recognise normality. However, when dont know results
were counted as if they were abnormal,
the reliability of most of the commonly
used cruciate tests is lower. This evidence
indicates the diagnostic weakness of tests,
which rely upon the subjective judgement
of the clinician, and the use of the CDT, the
TCT or palpation of the medial aspect of
the stifle joint will result in some dogs with
CCL failure being misdiagnosed as normal, while only 58 per cent of patients that
test negative are truly negative. The test is
better, but still not perfect, when performed on anaesthetised patients.
Results for the TCT were similar to those
for CDT, and although results were consistently better in anaesthetised patients, both
tests lacked adequate sensitivity and specificity. Henderson and Milton (1978) suggested (without supporting data) that this
poor performance was because of the development of secondary arthrosis in chronic
CCL failure. Although it could be argued
that our dogs had acute disease because they
were evaluated at the time of first presentation for hindlimb lameness, our data cannot
scientifically support or refute Henderson
and Milton (1978) claim as data about dura226

tion of clinical signs upon presentation were


not available in all dogs. We are aware that
analysing tests performed on a population of
dogs with more chronic CCL failure would
give even less favourable results; however,
there are no scientific data to support this
speculation.
In addition, CDT and TCT show no
agreement in only 80 per cent of cases.
They were both positive in 13 and both
negative in seven of the affected dogs. They
gave opposite results in the remaining five
patients. When they were repeated under
anaesthesia, the disagreement was still present in one patient.
In the normal group, two dogs showed
no agreement (CDT dont know and TCT
negative in one dog and the opposite in the
other) and two dogs resulted as dont know
at both tests. Under general anaesthesia,
three patients had the same results and
one patient who had both tests results as
dont know remained dont know when
considering the TCT.
Patellar tendon palpation and radiographic assessment of the infrapatellar fat
pad were excellent diagnostic tests with perfect sensitivity, specificity, PPV and NPV.
Both tests detect joint swelling only, which
is not specific to CCL failure. However, it
should be considered that a diagnosis of
CCL failure diagnosis is the result of the
combination of a vast amount of data
retrieved from history, physical examination,
radiographic examination and diagnostic
tests. This approach effectively excludes dogs
with non-CCL-related stifle disease.
Although this work was a preliminary
study involving only a relatively small
number of patients, the evidence indicates
that there are considerable differences
among the sensitivities, specificities, NPVs
and PPVs for the commonly used tests for
diagnosis of cruciate ligament failure in the
dog. Furthermore, perhaps the most commonly used test the CDT in a conscious
dog appears remarkably unreliable.
In conclusion, this preliminary work
casts doubt upon the reliability of the
two more commonly used tests for diagnosis of CCL failure, CDT and TCT, as they
do not allow detection of CCL failure in all
affected dogs. In contrast, patellar tendon
palpation and radiographic assessment of
the infrapatellar fat pad predicted cruciate
failure in all affected cases but, as these tests
Journal of Small Animal Practice

evaluate secondary stifle OA, there is a risk


of false positive results in patients with stifle
OA secondary to pathology other than cruciate failure.

LIMITATIONS
Affected dogs were confirmed by direct
inspection of the damaged CCL either at
arthrotomy or by arthroscopy at the time
of therapeutic surgery. Control dogs were
considered normal on the basis of a single
radiographic examination plus two normal
clinical examinations at least six weeks apart.
However, because dogs in the control group
did not undergo CCL inspection, there is
a possibility of false negatives in this group.
All tests were performed by two surgeons
(one board certified and the other a thirdyear surgical resident with substantial veterinary orthopaedic experience), and it is likely
that different testers will generate different
results. The investigation of interobserver
variability relating to these diagnostic tests
would be an area for further study.
Although CDT and TCT could be
claimed to be evaluating primary evidence
of CCL failure, all the other tests are evaluating evidence of secondary stifle joint
arthrosis. As such, they can be expected
to be positive with any stifle joint arthrosis,
irrespective of cause; so they are not specific
indicators of CCL failure. This is a potential source of false positive results, which
could influence our analysis of the diagnostic accuracy of these tests. However, this
effect is likely to be small because CCL failure is by far the most common cause of
canine stifle joint arthrosis.
References
HENDERSON, R. A. & MILTON, J. L. (1978) The tibial compression mechanism: a diagnostic aid in stifle injuries. Journal of American Animal Hospital
Association 14, 474-479
JERRAM, R. M. & WALKER, A. M. (2003) Cranial cruciate ligament injury in the dog: pathophysiology,
diagnosis and treatment. New Zealand Veterinary
Journal 51, 149-158
JOHNSON, J. M. & JOHNSON, A. L. (1993) Cranial cruciate
ligament rupture. Pathogenesis, diagnosis, and postoperative rehabilitation. Veterinary Clinics of North
America: Small Animal Practice 23, 717-733
MOORE, K. W. & READ, R. A. (1996) Rupture of the cranial cruciate ligament in dogs part II. Diagnosis
and management. Compendium of Continuing
Education for Veterinarians 18, 381-391
NESS, M. G, ABERCROMBY, R. H, MAY, C, TURNER, B. M, &
CARMICHAEL, S. (1996) A survey of orthopaedic conditions in small animal veterinary practice in Britain. Veterinary and Comparative Orthopaedics
and Traumatology 9, 43-52

 Vol 50  May 2009  2009 British Small Animal Veterinary Association

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