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The stifle joint

image of The stifle joint
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Abstract

The main indications for imaging of the stifle joint are similar to those for other joints: pain elicited upon examination of the joint or in the surrounding bones; joint swelling/effusion or soft tissue swelling around the joint; instability/positive cranial drawer or tibial compression test on physical examination; pre- and postoperative assessment associated with stifle joint surgery; and assessment for growth deformities, e.g. genu valgum, or developmental conditions. This chapter considers radiography; normal anatomy; alternative imaging techniques and abnormal imaging findings.

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Figures

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15.1 ML views detailing the normal radiological anatomy of the canine stifle joint. (a) Skeletally immature dog (5 months old). (b) Skeletally mature dog. 1 = femur; 1a = distal femoral epiphysis/femoral condyle; 1b = distal femoral physis; 1c = trochlear ridges; 2 = patella; 3 = lateral fabella (gastrocnemius); 4 = medial fabella (gastrocnemius); 5 = popliteal sesamoid; 6 = tibia; 6a = proximal tibial epiphysis; 6b = tibial tuberosity; 6c = proximal tibial physis; 7 = fibula; 7a = proximal fibular epiphysis; 8 = extensor fossa; 9 = infrapatellar fat pad; 10 = caudal fascial planes; 11 = origin of the gastrocnemius muscle.
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15.2 Photograph of positioning for a ML view of the right stifle joint of a 3-year-old Great Dane. The left stifle joint is tied back to prevent it obscuring the view and a foam wedge is placed under the right hock joint for support.
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15.3 ML views detailing the normal radiological anatomy of the feline stifle joint. (a) Skeletally immature cat (10 months old). (b) Skeletally mature cat. 1 = femur; 1a = distal femoral epiphysis/femoral condyles; 1b = distal femoral physis; 1c = trochlear ridges; 2 = patella; 3 = lateral fabella (gastrocnemius); 4 = medial fabella (gastrocnemius); 5 = popliteal sesamoid; 6 = tibia; 6a = proximal tibial epiphysis; 6b = proximal tibial physis; 6c = tibial tuberosity; 7 = fibula; 7a = proximal fibular epiphysis. (Courtesy of C Gibbs)
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15.4 Photograph of positioning for a CdCr view of the right stifle joint of a 4-year-old German Shepherd Dog. The dog is placed in sternal recumbency and the thorax is supported with sandbags.
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15.5 Positioning for a CdCr view of the right stifle joint of a 3-year-old Great Dane using a horizontal beam. The cassette is placed cranial to the affected stifle joint, which is elevated with a foam wedge. The X-ray tube is lowered to the level of the stifle joint and centred using the light beam diaphragm.
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15.6 Positioning for a CrCd view of the stifle joint. The dog is placed in dorsal recumbency, the cassette is placed under the stifle joint and the primary beam is centred distal to the femoral condyles. It may be necessary to place a foam pad under the distal limb. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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15.7 CrCd views detailing the normal radiological anatomy of the canine stifle joint. (a) Skeletally immature dog (5 months old). (b) Skeletally mature dog. 1 = femur; 1a = distal femoral epiphysis; 1b = distal femoral physis; 1c = medial femoral condyle; 1d = lateral femoral condyle; 2 = patella; 3 = lateral fabella (gastrocnemius); 4 = medial fabella (gastrocnemius); 5 = popliteal sesamoid; 6 = tibia; 6a = proximal tibial epiphysis; 6b = tibial tuberosity; 6c = proximal tibial physis; 7 = fibula; 7a = proximal fibular epiphysis.
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15.8 CrCd views detailing the normal radiological anatomy of the feline stifle joint. (a) Skeletally immature cat (10 months old). (b) Skeletally mature cat. 1 = femur; 1a = distal femoral physis; 1b = medial femoral condyle; 1c = lateral femoral condyle; 1d = medial femoral condyle; 2 = patella; 3 = lateral fabella (gastrocnemius); 4 = medial fabella (gastrocnemius); 5 = popliteal sesamoid; 6 = tibia; 6a = proximal tibial epiphysis; 6b = proximal tibial physis; 6c = tibial tuberosity; 7 = fibula; 7a = proximal fibular epiphysis. (Courtesy of C Gibbs)
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15.9 Positioning and radiography of the stifle joint for a CrDi-CrPrO view of the patella. (a) The patient is placed in dorsal recumbency with the stifle joint flexed, the cassette is placed proximal to the joint and the X-ray beam is centred on the patella. (b) Radiograph of a normal stifle joint of a 2-year-old Staffordshire Bull Terrier showing the patella (white arrow), the medial and lateral trochlear ridges (black arrows) and the trochlear groove (arrowhead). Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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15.10 Diagram of the positioning for a stressed CrCd view of the right stifle joint to demonstrate a tear of the lateral collateral ligament. The patient is placed in dorsal recumbency, the cassette is placed under the stifle joint and the joint is subjected to a three-point stress by means of straps. The primary beam is centred (+) using the landmarks described in the text. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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15.11 ML views of a stifle and hock joint of a 5-year-old Labrador Retriever cross, used for the measurement of the tibial plateau angle. The stifle joint should be in a neutral position and the hock flexed for correct positioning for these radiographs. It is important to ensure that the medial and lateral femoral condyles are superimposed. (a) The cranial and caudal aspects of the tibial plateau (arrowheads), the tibial intercondylar tubercles (black arrow) and the centre of the talus (white arrow) are marked. (b) A line is drawn between the cranial and caudal aspects of the tibial plateau and another is drawn between the tibial intercondylar tubercles and the centre of the talus. At the point of intersection of these lines, a perpendicular line is drawn to the line that extends from the talus to the tibial intercondylar eminences. The resultant angle (arrowed) is the tibial plateau angle. (Courtesy of S Butterworth)
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15.12 Fully extended (135 degrees) ML stifle view of a 3-year-old Labrador Retriever with CCLR, used for TTA/MMP measurements. The cranial and caudal tibial eminences are marked with black dots and connected with a black line. A line is drawn perpendicular to this line from the origin of the patellar tendon and extended distally. The distance this line sits from the level of the cranial aspect of the tibial tuberosity (arrowed) is the required advancement (cage or wedge size for TTA or MMP procedure, respectively). The central dot represents the intercondylar tubercles.
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15.13 ML views of canine stifle joints: (a) 6-year-old cross-breed with a multipartite popliteal sesamoid (arrowed); (b) 2-year-old Golden Retriever with a multipartite fabella (arrowed).
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15.14 Bone window dorsal plane CT scans of the normal stifle joint of a 3-year-old Greyhound: (a) without contrast; (b) with contrast. CT without contrast is excellent for bony detail, however, the addition of contrast highlights soft tissue structures such as the cruciate ligaments (arrowed).
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15.15 Scintigraphic lateral left and right stifle bone phase scans. Note the increased uptake of isotope in the distal femur and proximal tibia (arrowheads) of the right stifle joint compared with the left stifle joint.
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15.16 ML view of a stifle from an 8-year-old cross-bred dog with a distal apical patellar fracture (arrowhead), with associated mineralized fragment (arrowed). Note the proximal displacement of the patella.
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15.17 ML view of a stifle with an incidental transverse patellar fracture in a 2-year-old Russian Blue cat. (Courtesy of S Langley-Hobbs, University of Bristol)
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15.18 Left and right ML views of the stifle joints of a 5-month-old cross-bred dog. (a) Note the tibial tuberosity avulsion fracture (arrowed) with associated mineralized fragments (arrowhead). (b) A Salter–Harris type II fracture of the proximal tibial physis (arrowed) and a fractured fibula (arrowhead) are present.
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15.19 Radiographs of the stifle of a 10-month-old Domestic Shorthair cat with a distal femoral physeal fracture (Salter–Harris type II) (arrowed). (a) ML view; (b) CrCd view.
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15.20 (a) ML and (b) CrCd views of the stifle of a 3-year-old male cross-bred dog with avulsion of the long digital extensor tendon, showing an enlarged extensor fossa radiolucent defect (arrowed) and an associated mineralized fragment (arrowhead). This dog had a concurrent CCLR.
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15.21 ML view of the stifle of a 5-year-old German Pointer with gastrocnemius tendon avulsion, showing marked caudodistal displacement of one fabella (black arrow) with the other fabella in its normal position (white arrow).
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15.22 (a) ML and (b) CrCd stifle views of a 6-year-old Domestic Shorthair cat with severe ligamentous disruption. The femur is displaced caudodistally (black arrows) and laterally (white arrow), suggestive of collateral and cruciate ligament injuries.
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15.23 ML views of canine stifles with CCLR. (a) Acute case. A marked joint effusion is present, obscuring the margin of the infrapatellar fat pad and displacing the fascial planes caudally (arrowed). (b) Chronic case. This radiograph is suggestive of a rupture of the CCL, with enthesophytes at the CCL insertion point (white arrow) and associated osteoarthrosis, showing marked joint effusion (black arrow) and osteophytes (arrowheads) on the trochlear ridges, proximal and distal patella, tibial plateau and fabellae.
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15.24 (a) ML and (b) CrCd views of the stifle of a 2-year-old Labrador Retriever with an avulsion of the CCL, showing a mild joint effusion and a mineralized intra-articular fragment (arrowed).
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15.25 T1W MRI scans of the stifle joint of a 5-year-old Labrador Retriever. (a) Sagittal image showing a disrupted CCL (arrowhead) and a normal caudal cruciate ligament (arrowed). (b) Image lateral to the sagittal plane showing a triangular hypointense normal lateral meniscus (arrowed). (c) Image medial to the sagittal plane showing an abnormal medial meniscus with the caudal part absent (arrowed).
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15.26 CrCd (stressed) view of the stifle joint of a 3-year-old cross-bred dog with a lateral collateral ligament tear, showing marked opening of the lateral joint space (arrowed).
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15.27 ML view of a stifle joint from a 5-year-old cross-bred dog with a patellar ligament rupture. (a) Preoperative view showing marked proximal displacement of the patella. (b) Sagittal ultrasonogram showing disruption of the tendon fibres, a central hypoechoic area and thickening at the site of rupture. Proximal is to the left of the image. (c) Postoperative view showing normal position of the patella. The circular radiolucent areas in the patella and tibial crest are where surgical implants have been passed.
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15.28 Abnormal imaging findings in the stifle joint of a 3-year-old Akita with a meniscal injury 6 weeks following surgical stabilization of a CCLR with leader line and metal crimps. (a) ML view of the stifle joint showing increased intra-articular radiopacity suggestive of fluid accumulation obscuring the infrapatellar fat pad. (b) Sagittal ultrasonogram of a medial meniscal tear from the same dog, showing heterogeneous echogenicity and prolapse of the margin of the meniscus.
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15.29 Canine stifle radiographs demonstrating the abnormal imaging findings associated with congenital medial patellar luxation. (a) ML view. Note partial superimposition of the patella on the distal femur. (b) CrCd view. There is medial deviation of the proximal tibia (arrowhead) and medial luxation of the patella. (c) Skyline view. The patella is displaced to the medial side of the trochlear groove (white arrow), and the trochlear groove is shallow (black arrow).
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15.30 Surface shaded reconstruction of a bone window CT in a 2-year-old cross-bred dog with grade IV medial patellar luxation.
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15.31 ML view of the stifle of a 6-year-old Border Collie, showing mineralization and cranial luxation of a meniscus (arrowed).
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15.32 CrCd view of the right stifle of a 4-month-old Great Dane with a mild genu valgum. Note the mild lateral deviation of the distal limb.
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15.33 (a) ML and (b) CrCd stifle views of a 9-month-old English Bull Terrier with OCD, showing evidence of flattened femoral condyles (black arrowheads), intra-articular joint mice (white arrowhead), subchondral deficit of the articular surface of the lateral condyle (arrowed) and a joint effusion.
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15.34 A sagittal CT image in a bone window of the stifle of a 5-month-old English Bull Terrier, showing a saucer-shaped defect in the medial femoral condyle surrounded by poorly defined subchondral sclerosis and a joint effusion.
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15.35 ML view of the stifle joint of an 8-year-old Labrador Retriever with severe osteoarthrosis, showing osteophytes and enthesophytes on the tibia, trochlear ridges, proximal and distal patella and fabellae (arrowheads); mineralized fragments (arrowed) and a joint effusion are also visible.
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15.36 Postoperative stifle views of a 4-year-old cross-bred dog following a TPLO (Slocum technique) to manage CCLR. (a) ML and (b) CdCr views used to assess implant position, osteotomy site and limb alignment. The most common complications with this procedure are (c) patellar ligament thickening and (d) tibial fracture and screw breakage. (a, b, Courtesy of R Pettitt; c, d, Courtesy of S Butterworth)
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15.37 Postoperative views of the stifle of a 3-year-old Rottweiler following a TTA to manage CCLR. (a) ML and (b) CdCr views used to assess cage/plate size, osteotomy site and limb alignment. The most common complications with this procedure are (c) tibial fracture, patella ligament thickening and implant breakage.
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15.38 Postoperative views of the stifle of a 2-year-old Labrador Retriever following a MMP to manage CCLR. (a) A ML view is used to assess implant position, osteotomy site and limb alignment. Proximal tibial fracture, infection and (b) wedge displacement are reported complications with this procedure.
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15.39 ML views of a canine stifle joint showing septic arthritis secondary to surgery for CCLR. (a) There is marked intra-articular swelling with a crimp and leader line present. (b) Four weeks later, marked soft tissue swelling is present around the joint, with marked joint effusion and pinpoint radiolucencies in the femoral condyles and proximal tibia (arrowheads).
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15.40 ML views of canine stifle joints with neoplasia. (a) Synovial sarcoma: showing several 5 mm radiolucencies in the distal femur and proximal tibia and marked soft tissue swelling around the joint (arrowed). The wire is from previous CCL surgery. (b) Histiocytic sarcoma: showing increased intra-articular radiopacity, particularly cranially in the area of the fat pad, and a punched-out radiolucency in the distal patella. (c) Osteosarcoma of the proximal tibia: showing marked soft tissue swelling around the joint, mineralization of the soft tissues, increased radiopacity and irregularity of the proximal tibia (arrowheads). This is an unusual case because the patient is still skeletally immature and the tumour appears to enter the joint, which is rarely seen with osteosarcoma.
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15.41 ML view of the stifle of a 3-year-old Domestic Shorthair cat with synovial osteochondromatosis, showing multiple intra- and periarticular smooth mineralized opacities (arrowheads) located in the synovium.

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