FRANKIE

— A & S

“Thank you so much for looking after Frankie so well during a long 4 months! We really are grateful for your professionalism and your empathy. Were so glad to have him back with four legs!"

Ewing Walker
Orthopaedic Vet Referrals
Portadown & Richhill,
Co Armagh
Ireland

004428 38 871942

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© 2019 VetOrtho Referrals.

Arthroscopy (key hole joint surgery)

Arthroscopy (key hole joint surgery)

Arthroscopy has long been the gold standard for investigation & surgery of human and equine joint disease due to the minimal disruption of joint structures and the more rapid return to function post surgery. There are many applications for arthroscopy in small animal surgery in particular for investigation of shoulder Osteochrondrosis/ OCD, elbow disease, meniscal injuries and shoulder instability & bicepital tendon disease.

Due to the small skin incision and minimal periarticular trauma involved most dogs are weight bearing immediately after arthroscopic surgery with less post op complications than with standard open arthrotomy. Also Minimally invasive arthroscopy gives a clear and extremely detailed picture of the joint structures.

The surgical instruments used arthroscopically are very small- approx 2-3 mm in size and the detail of magnification is seen in the videos- during the surgery this view is displayed in HD resolution on a 19” stryker monitor to allow accurate diagnosis and surgery. Arthroscopic surgery allows detailed visualisation and surgical treatment of lesions which cannot be seen clearly  at open joint surgery with the benefit of less post operative pain, faster recover and very small 3mm operative sites.

Elbow Dysplasia- FCP, UAP, OCD, Joint Incongruity

Elbow dysplasia is a broad term to cover 4 conditions of the elbow which may occur on their own or in conjunction with some of the others- each condition requires specific treatment

 

Fragmented coronoid process FCP

Ununited anconeal process- UAP

Joint incongruity

Osteochrondritis dissecans of the medial humeral condyle- OCD

Fragmented coronoid process

We have found arthroscopy most useful to date in the investigation, diagnosis and treatment of fragmented coronoid process (FCP) in elbow disease as this condition cannot be easily diagnosed from radiography until late in the disease when evidence of osteoarthritis has already occurred. This condition occurs frequently in Labradors, Golden Retrievers, Rottweilers and Newfoundlands and presents as a persistent sometimes bilateral foreleg lameness at 6-7 months old onwards, although many dogs present many years later in life.

Minimally invasive arthroscopy gives a clear and extremely detailed picture of the cartilage surface and permits probing for fissures and flaps, allowing diagnosis and surgery to be performed before the onset of advanced osteoarthritis. The earlier the diagnosis and treatment of OCD / FCP the better is the long term outcome.

Arthroscopic examination of the elbow of a 2 year old Rotweiller dog with foreleg lameness.

Multiple fragments of the coronoid process are removed followed by arthroscopic subtotal coronoidectomy (removal of part of the coronoid bone).
These loose fragmented coronoid process lesions which move on weight bearing, are a cause of persistent pain & lameness. Both the fragmented cartilage lesions and the underlying yellowish coloured avascular subchondral bone will be removed arthroscopically.The yellowish coloured avascular bone can be seen on the underside of the white cartilage covered fragments and its exposure within the joint will lead to significant DJD. Avascular bone is bone which has lost it blood supply.

Once the fragmented coronoid lesion on the ulnar bone has been removed, the view indicates the region where the lesion had been sitting in the foreground and in the background we can see the normal cartilage covering the radial head- which is moving as we rotated the leg.The edges of the lesion will now be freshened to leave a smooth edge using either a hand burr or a motorised shaver and then a partial removal of the remaining coronoid process in the region of the lesion is performed using a motorised shaver (subtotal coronoid ostectomy SCO), and the joint is then thoroughly flushed to remove any loose cartilage fragments.

In cases of FCP with significant cartilage lesions affecting the humerus bone (kissing lesions) or in cases of co-existing OCD of the medial humeral condyle a proximal ulnar osteotomy may also be recommended in addition to fragment removal and subtotal coronoidectomy. Ulnar osteotomy involves cutting the ulnar bone at an oblique angle below the elbow joint and allowing it to heal over the following weeks. This additional treatment results in significant short term lameness while the ulnar heals but may benefit the dog long-term by allowing an improvement in joint incongruity.

FCP relates to tiny crack formations of over small area of the ulnar bone (the coronoid process) which come together leading to fissures or fragments to form.

Not all cases have obvious fragments and only have coronoid disease.

FCP is best visualised by arthroscopy (key hole examination) to diagnose and assess the entire elbow for co-existing conditions such as kissing lesions on the humerus &OCD.

The entire area of affected coronoid may be removed along with any free fragments. 

Effective pain medications are given intra-articularly immediately post op and followed up with injectable and oral medications for several days

Because arthroscopy is a minimally invasive surgery, both elbows can be examined and treated arthroscopically at one surgery. Due to the small surgical sites of 3-4 mm diameter there is greatly reduced post operative pain compared to open joint surgery so most dogs are walking on the operated legs immediately after surgery, and recover more quickly that after open surgery.

Various treatments are recommended for FCP and veterinary opinions vary and alternative methods of treatment are currently undergoing clinical trials. Unfortunately the exposure of the bone underneath the cartilage (subchondral bone) to the joint, will stimulated the development of osteoarthritis.

 

No treatment is available which will prevent osteoarthritis developing once it has begun, and all cases will require management of the elbow osteoarthritis by weight control, exercise modulation (regular controlled exercise), NSAIDs (anti inflammatory) medications and pain control.

 
 
 
Ununited anconeal process UAP

Ununited anconeal process (UAP) occurs because of failure of this small piece of bone on the ulnar to fuse onto the rest of the bone by 20 weeks of age. UAP is seen fairly commonly in German Shepherd dogs and we have found that proximal ulnar ostectomy has lead to a reduction in lameness and a fusion of the UAP in most cases where the UAP is quite stable. This may be assessed arthroscopically. Additionally the ununited anconeal process UAP may be repaired with a lag screw placement into the fragment using a guide wire and a cannulated screw. This is particularly useful if the UAP is unstable. Arthroscopic examination of the elbows is recommended as co-existing FCP may also be present in a percentage of cases.

Osteochrondritis dissecans of the medial humeral condyle (OCD)

1.5cm cartilage flap removed by arthroscopic surgery from an OCD lesion on the medial humeral condyle of a 7 month old chocolate Labrador.

Osteochrondritis dissecans of the medial humeral condyle (OCD)

- a cartilage flap may be present on the medial humeral condyle with exposure of the subchrondral bone causing lameness, pain and osteoarthritis. Treatment for small focal flaps is by removal of the flap and debridement of the underlying bed. Small areas will heal by fibrocartilage repair, however larger defects, in particular if incongruity is present, may also benefit from a proximal ulnar osteotomy. Ulnar osteotomy involves cutting the ulnar bone at an oblique angle below the elbow joint and allowing it to heal over the following weeks. This additional treatment results in significant short term lameness while the ulnar heals but may benefit the dog long-term by allowing an improvement in joint incongruity.

Unfortunately if OCD is present, FCP is also frequently present requiring subtotal coronoidectomy.

Ongoing research into cartilage grafting techniques may provide additional benefit in these cases.

 
Joint incongruity

Joint incongruity- this may be one of the most important factors in the development of elbow disease and may lead to the formation of some of the other conditions referred to as elbow dysplasia. It may be seen a step at the level of the ulnar and radial bones as they articulate with  the humerus leading to uneven wear of the joint surfaces which may lead to cartilage erosions and may be associated with FCP. This incongruity may be difficult to fully appreciate as it may occur at different levels within the joint, eg radius and ulnar at rest, dynamic incongruity depending on the position of the foot- especially pronation and supination, or between the curved portions of the ulnar and humerus.

 

Various treatments are recommended for the various conditions included under the term “elbow dysplasia” and veterinary opinions vary and alternative methods of treatment are currently undergoing research and clinical trials.

Unfortunately, although arthroscopic treatment may help many of these cases, FCP, OCD and UAP conditions all expose the bone underneath the cartilage (subchondral bone) to the joint will stimulate the development of osteoarthritis.

No treatment is available which will prevent osteoarthritis developing once it has begun, and all cases will require management of the elbow osteoarthritis by weight control, exercise modulation (regular controlled exercise), NSAIDs (anti inflammatory) medications and pain control.

“Elbow dysplasia” is perhaps not the most useful term as it may lead to confusion. Each of the four conditions are individual conditions and may occur on their own, or co-exist in the same joint. OCD and FCP for example have different underlying reasons for development and genetic factors.

Shoulder Arthroscopy- Osteochrondrosis (OCD)

Shoulder arthroscopy- normal dog

Because arthroscopy is a minimally invasive surgery, both shoulders can be examined and treated arthroscopically at one surgery. Due to the small surgical sites of 3mm diameter there is greatly reduced post operative pain compared to open joint surgery so most dogs are walking on the operated legs immediately after surgery, and recover more quickly that after open surgery.

Effective pain medications are given intra-articularly immediately post op and followed up with injectable and oral medications for several days

Osteochrondrosis / OCD of the shoulder is also very successfully treated by arthroscopic flap removal.

Shoulder arthroscopy- OCD lesion dog

Above- OCD flap

Left- subchondral bone bed after OCD flap removal, before debridement. After removal of the main fragments, the subchondral bone bed is now curretted until healthly bleeding bone is reached, ensuring all cartilage fragments are removed. This now allows the lesion to heal with replacement of the diseased cartilage with a new fibrocartilage surface.

Above- shoulder OCD flap removal with arthroscopic grasping forceps

Above- The remaining areas of the joint are inspected for disease and loose flap fragments and flushed.

 
Shoulder Arthroscopy- Bicepital tendon disease and instability
 

Arthroscopy of the shoulder joint is performed for treatment of osteochrondrosis OCD of the humeral head, and also for assessment of injury to the soft tissue supporting ligaments- bicepital tendon and collateral ligaments (medial glenohumeral ligament)- which leads to shoulder instability

Shoulder arthroscopy- bicepital tendon examination

Shoulder arthroscopy- cranial and caudal joint examination

Stifle (knee) Joint Arthroscopy- dog

Stifle (knee) arthroscopy is useful for assessing injury to the menisci and cruciate ligaments and in the treatment of OCD of the femoral condyle.

Effective pain medications are given intra-articularly immediately post op and followed up with injectable and oral medications for several days

Because arthroscopy is a minimally invasive surgery, both stifle (knee) joints can be examined and treated arthroscopically at one surgery. Due to the small surgical sites of 3mm diameter there is greatly reduced post operative pain compared to open joint surgery so most dogs are walking on the operated legs immediately after surgery, and recover more quickly that after open surgery.

 
 
Hip arthroscopy- dog

Arthroscopy of the hip is useful to determine if cartilage damage is already advanced prior to triple pelvic osteotomy TPO surgery for Hip dysplasia in dogs.

Dogs with advanced cartilage disease are not suitable and may be best managed with conservative treatment or later THR Total Hip Replacement if indicated and if conservative treatment has been unsuccessful.