KNOWLEDGE SUMMARY

Keywords: CATS ; CONSERVATIVE; CRUCIATE DISEASE; FELINE; LATERAL FABELO-TIBIAL SUTURE; LONG-TERM; OUTCOME; PAIN

In cats with cranial cruciate rupture are better long-term outcomes achieved by surgical or conservative management?

Philip Montgomery, BVMS^1*

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¹ Wear Referrals, Bradbury, Stockton-on-Tees, TS21 2ES, United Kingdom
* Corresponding author email: Philmontgomery@live.co.uk

Vol 10, Issue 2 (2025)
Submitted 02 Feb 2024; Published: 28 Apr 2025
DOI: https://doi.org/10.18849/ve.v10i2.696

PICO question

In cats diagnosed with isolated rupture of the cranial cruciate ligament, does surgical intervention result in improved long-term function, when compared with conservative management?

Clinical bottom line

Category of research

Treatment.

Number and type of study designs reviewed

One retrospective cohort study comparing surgical management and conservative management.

Strength of evidence

Weak.

Outcomes reported

This study evaluated and compared the long-term Feline Musculoskeletal Pain Index (FMPI) of patients with a cranial cruciate injury (39–87 months post injury). Patients that were managed conservatively showed statistically significant (P = 0.017) lower FMPI scores long term.

Conclusion

Conservative management can be considered in cats presenting with isolated cranial cruciate rupture; however, further research is required to establish the optimum treatment in these cases. Given the limitations of this study and the current lack of evidence, clinicians must rely on their clinical judgement at this point when managing this condition until further research is available.

How to apply this evidence in practice

The application of evidence into practice should take into account multiple factors, not limited to: individual clinical expertise, patient’s circumstances and owners’ values, country, location or clinic where you work, the individual case in front of you, the availability of therapies and resources.

Knowledge Summaries are a resource to help reinforce or inform decision making. They do not override the responsibility or judgement of the practitioner to do what is best for the animal in their care.

The evidence

There is weak evidence provided by Boge et al. (2020) that cats with isolated cranial cruciate ligament rupture managed conservatively may experience less chronic pain and stifle dysfunction than those managed surgically with a lateral tibiofabellar suture. There is no published literature assessing the long term outcomes of any other surgical techniques for the treatment of feline cranial cranial cruciate ligament rupture.

Summary of the evidence

Boge et al. (2020)

Cranial cruciate ligament disease in cats: an epidemiological retrospective study of 50 cats (2011–2016)

Aim: To compare the long term outcomes of surgical and non-surgical management of feline cranial cruciate ligament disease using a Feline Musculoskeletal Pain Score questionaire completed by patient owners.

 

Appraisal, application and reflection

Cranial cruciate disease is an area of active research in veterinary literature due to how frequently cranial cruciate disease occurs in the canine population (Taylor-Brown et al., 2015). Two distinct pathogenesis of cranial cruciate disease in dogs have been proposed: acute traumatic rupture and chronic degeneration (Griffon, 2010). Canine cruciate disease can be managed conservatively or through a range of surgical procedures. Surgical management has been shown to be superior to conservative management in both short- and long-term outcomes in canine patients, based on force plate analysis (Wucherer et al., 2013). Conservative management is still a popular option in small breed dogs (< 15kg) (Comerford  et al., 2013), as historically a successful outcome was reported in 75-90% of cases. (Pond & Campbell, 1972; Vasseur, 1984), however, in  Pond & Campbell (1972), which reported a 90% success rate, this success was based on owner report only, with no objective measurement of lameness performed and so must be interpreted cautiously. Vasseur (1984), reported a successful outcome in only 75% of patients, and showed that this recovery was often prolonged, taking 4 months on average. Of the patients that had a reported resolution of lameness, there was evidence of muscle atrophy in 19% of cases, an increased medial buttress in 67%, 43% had an instability on cranial drawer testing and 100% showed evidence of progression of osteoarthritis (Vasseur, (1984); Brioschi & Arthurs, (2021)). More recently, Kwananocha et al. (2024) demonstrated a similar short-term (12 week) improvement in orthopaedic assessment score, when comparing cases managed conservatively and those managed surgically with tibial plateau levelling Osteotomy (TPLO) in dogs weighing less than 10 kg. However, the TPLO group demonstrated an increase in thigh muscle circumference on the affected leg at 70 days postoperatively that was not demonstrated in the conservatively managed group. It is worth noting that this was a small study, with a short follow-up, significant variation between cases, no force plate analysis, and limited gait assessment, so the similarity in short term outcome must be interpreted very carefully.

Several surgical techniques are used regularly in the treatment of canine cruciate disease, including osteotomy surgeries and techniques that provide extracapsular support (Bergh et al., 2014). The (TPLO) is one of the most commonly reported osteotomy procedures (Bergh et al., 2014), and has been shown to have superior outcomes when compared to lateral fabellotibial suture in canine patients (Gordon-Evans et al., 2013).

The treatment options and outcomes when treating feline cranial cruciate disease are not as well understood as canine cranial cruciate disease due to the lack of published evidence on this topic. The aetiopathogenesis of isolated feline cruciate disease remains unclear; however, a histopathology study of rupture feline cruciate ligaments found no evidence of degeneration (Wessely et al., 2017). Feline cruciate ligament rupture is also reported as part of multiligament traumatic injury to the stifle (Coppola et al., 2021). Multiligament stifle injuries are outside the scope of this Knowledge Summary, which focuses purely on isolated cranial cruciate disease. As in the canine patient, feline cranial cruciate rupture can be treated conservatively, or surgically. Conservative management of feline cruciate disease has been shown as a viable option for management of feline cruciate disease (Stoneburner et al., 2022), with 15/18 (83%) cats reportedly achieving clinical normality within 3 months. The most reported surgical technique for the management of feline cruciate disease is the lateral fabellotibial suture (Harasen, 2005). There are reports of osteotomy procedures in the treatment of feline cranial cruciate ruptures (Minder et al., 2016); however, there are limited case numbers, with no long-term follow-up. Muscle transposition techniques have also been described, transposition of the biceps femoris muscle has been reported in cats with reportedly successful results, however, no follow up on outcomes beyond 90 days postsurgery are available at this time (Sen, 2019).

The evidence for long term outcomes of the different management options for feline cranial cruciate rupture is limited. Cats with previous cranial cruciate disease have been shown to have a long-term gait abnormality (Stadig et al., 2016). In this study six of the 10 cats were managed surgically, and four of the 10 cats were managed conservatively. There was no significant difference between the groups and all cats showed a long-term gait abnormality and behavioral changes.

The only published paper that compares the long-term outcomes between cases managed with surgery to those managed conservatively, reported a lower long-term Feline Musculoskeletal Pain Index (FMPI) score in the conservatively managed cases (39–87 months post injury) (Boge et al., 2020)). However, it is important to recognise that this is a small, retrospective study, with an owner-assessed outcome.

The FMPI score has been evaluated and found to have sound reliability, internal consistency, and good discriminatory ability (Stadig et al., 2019). As this is a general questionnaire of all aspects of the patient’s activity, there is potential that comorbidities contributed to patient scores. As no diagnostic imaging or osteoarthritis scoring was performed in this study, pre-existing underlying joint pathology may have been missed and would contribute to the long term FMPI scores.

The nature and design of the Boge et al study. (2020) means there are limitations that prevent definitive treatment recommendations being made from the findings described. The potential for bias exists due to the retrospective nature, including responder and non-responder bias, and variation in treatment between patients between clinicians over a time period. Multiple factors may have affected if a patient was managed medically or surgically, including surgeon assessment of stifle stability, presence of concomitant injuries, presence of comorbidities, demeanor of patient, degree of pain/lameness and financial factors. Some of these factors may also have affected the healing process, including degree of instability, degree of trauma to the joint, concomitant injuries, and comorbidities. Furthermore, as no diagnostic imaging or osteoarthritis scoring was performed, underlying, undiagnosed joint pathology may have affected to the healing process.

While Boge et al. (2020) adds some credence to conservative management as a treatment option of cranial cruciate disease in cats, the limitations of this study mean that further research would be required before definitive evidence-based recommendation can be made. At this time, clinicians must rely on their clinical judgement of each individual case until further evidence exists.

Gait analysis and force plate analysis are outcome measures that have been used previously in evaluating long-term outcomes in canine cranial cruciate disease (Amimoto et al., (2020)). Applying these methods to feline cranial cruciate disease could aid in a more definitive recommendation in the future.

There has been no long-term comparison of outcomes between conservative management and any other surgical procedures for the management of feline cruciate rupture e.g. TPLO. Therefore, no conclusions can be drawn on the long-term outcomes of these surgeries at this point.

Overall, the current evidence is not sufficient to draw a definitive conclusion on the long-term outcomes of surgical management of feline cranial cruciate ligament disease, compared with conservative management.

Methodology

Search Strategy

 

Exclusion / Inclusion Criteria

 

Search Outcome

 

ORCiD

Philip Montgomery: https://orcid.org/0009-0000-1855-5643

Conflict of Interest

The authors declare no conflicts of interest.

References

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