Transcript Elbow Dysplasia - Veterinary Specialists of South Florida

VSSF presents the following case study.
OSTEOCHONDROSIS
Andrea Gale
“Buddha”
• PE
• 7 month MI Rottweiler
• Several week history of pain
when rising
• No other health concerns
▫ Owner treating yard for ticks
▫ Abnormal findings:
 Pain on flexion and
extension of both elbows
 R>L
 Severe joint effusion
bilaterally
 R>L
 Severe tick infestation
Differential Diagnosis
• Elbow Dysplasia
▫ Un-united Anconeal Process
▫ Osteochondrosis Dessicans
▫ Fragmented Coronoid
Process
▫ Elbow Incongruity
 Malalignment and
malformation of joint
 Un-united medial epicondyle
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Trauma
Septic arthritis
Panosteitis
Hypertrophic Osteodystrophy
Diagnostics
• Radiographs
▫ Mild periosteal reaction of
the horizontal portion of the
anconeal process in the R
elbow.
▫ Focal subchondral bone
defects in the medial humeral
condyle of both humeri.
• Diagnosis :
• Osteochondritis dissecans of
the L and R distal humeri.
• DJD of the right elbow
Diagnosis: OCD and DJD
Treatment
• Medical Management
▫ Deramaxx 75mg: ½ t PO SID
▫ Tramadol 50mg: 1 ½ t PO
BID
▫ Frontline Spray: 1 spray/lb
▫ Preventic Collar
• Advised strict exercise
restriction and short leash
walks only until surgery
SurgicalTreatment
• Bilateral Elbow Arthroscopy
▫ Large, osseous chondral
fragments off the medial
coronoid process with some
fibrous attachment
▫ fragmented medial coronoid
processes bilaterally
Post Op & Follow Up
• Light pressure bandage placed
• Oral Antibiotics
▫ Simplicef 100mg – 1t PO SID
• NSAID
▫ Deramaxx 75mg – 1/2t PO
SID
• Tramadol 50mg – 1 1/2t PO BTID
• Exercise Restriction
• 6 weeks Post Op
▫ Doing well
▫ Still weak at arising
▫ Restricted to leash walks
 30min x2 per day
DEVELOPMENTAL ORTHOPEDIC
DISEASES
• DIFFERENTIAL DIAGNOSIS:
THORACIC LIMB
• Common cause of lameness
and pain in young dogs
▫ Dx – challenging
 Signalment
 History
 PE – orthopaedic and
neurologic
 Radiology +/- MRI, CT or
nuclear scintigraphy
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Osteochondritis dissecans
Ununited anconeal process
Fragmented coronoid process
Elbow incongruity
Angular limb deformity
Panosteitis
Hypertrophic osteodystrophy
Retained cartilaginous core
Traumatic injuries
 fracture, luxation,
subluxation, avulsion,
strain/sprain
OCD of Humeral Condyle
DEFINITIONS
• OSTEOCHONDROSIS
▫ AN ABNORMALITY OF
ENDOCHONDRAL
OSSIFICATION
• OSTEOCHONDROSIS
DISSECANS
▫ Implies actual separation
between this region of
thickened cartilage and the
underlying bone
 Convex surfaces
 Most commonly – shoulder,
elbow, stifle and hock joint
Normal Epiphyseal Devlopment
• Epiphyseal growth centre –
secondary
• Ring of productive
chondrocytes form on the
periphery
• Chondrocytes facing the
articular surface form articular
cartilage
▫ Superficial region
▫ Deeper portion
▫ Requires vascularization for
calcification
PATHOPHYSIOLOGY
• The mechanism of OCD
▫ Primary disturbance or failure of
endochondral ossification
 increased articular cartilage thickness
• A) Cartilage Nutrition Theory
▫ Increased thickness of cartilage
impedes diffusion of nutrients from
synovial fluid
 Basal layers cartilage degenerate
necroses
• B) Focal Compression Theory
▫ Increased pressure prevents
/decreases perfusion and vascular
invasion
▫ Lack of vascular supply and failure of
cartilage transformation
GROSS PATHOLOGY
• Primary gross lesion is a
dissecting intracartilaginous
separation b/w the calcified
and non calcified layers
• Four grades
▫ 1)Grossly normal articular
surface with a small
subchondral bone defect
▫ IV) vertical fracture of the
articular cartilage and
separation of the resulting
flap from the underlying bone
ETIOLOGY
• Diet and growth rate
▫ Increased energy intake,
growth rates and birth
weights ***
• Hormonal balance
• Trauma
▫ Intense exercise; ischemia
• Joint morphometry
• Genetics
▫ High incidence of FMCP and
OCD occurring
simultaneously
▫ Multifactorial heritability
▫ Difference in sex incidence
▫ Dominant, recessive or xlinked gene
 Consider sterilization
SIGNALMENT
• Highest in Newfoundlands, Labrador
retrievers and golden retrievers
▫ Other breeds: Bernese Mountain dog,
Chow chow, GSD, mastiff, old
English sheepdog, Rottweiler, and
standard poodle
• OCD/FMCP = higher in males
• Age of Onset: 4 to 7 months
• Age of Diagnosis: 6 to 18 months
HISTORY
• Mild to severe weight bearing
lameness of variable duration
• Recumbency, reluctant to
stand or move if severe
bilateral disease
• Generalized muscle atrophy of
the affected forelimbs
• Swelling of the elbow joint
CLINICAL FINDINGS
Orthopaedic examination
▫ Affected elbow slightly
adducted
▫ Decreased ROM
 Flexion
 Crepitation
▫ Joint Pain & Effusion
▫ Varying degrees of lameness
RADIOGRAPHY
• Craniocaudal and both
standard and flexed
mediolateral views
• Both elbows
• Medial aspect of the humeral
trochlea
▫ Most evident on
craniocaudal view
• Other radiographic changes
include
▫ Sclerosis
▫ Osteophytosis
TREATMENT OPTIONS
• Medical
▫ Weight restriction
▫ Exercise control
▫ Analgesic therapy
▫ Chondroprotective Agents
 Glucosamine chondroitin
manganese ascorbate
 Cosequin
SURGICAL MANAGEMENT
SURGERY
ARTHROSCOPIC
• Remove the cartilaginous flap
• Debride underlying
subchondral bone
• Becoming more popular
• Allow exploration of the entire
joint
• Removal of the cartilage flap
• Microfracture or abrasion with
curette or burr
• ++ limited invasiveness and
improved visibility provided
by magnification, arthroscopic
treatment is preferred
• Several surgical techniques
exist
▫ Medial approach and
arthrotomy
POST OPERATIVE CARE
• Limb should be placed in a
light pressure bandage for 2448 hours
• Confined to leash walking for 4
to 6 weeks
• Gradual return to full activity
• Physical therapy is
recommended during the
recovery phase
PROGNOSIS
• GUARDED
▫ Surgical or medical
treatment
• Progression of secondary DJD
• Early surgical treatment
decreases lameness but may
not prevent progression of OA
SUMMARY
• Abnormal endochondral
ossification
• Common lameness in immature
dogs
• PE and radiographs to diagnosis
• Treatment –surgical intervention
• P/O medical management for OA
QUESTIONS??
• References
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Anderson, Mark A. Oral Chondroprotective Agents. Part I.
Compendium 1999. 21(7).
Beale, Brian S. Small Animal Arthroscopy. Saunders, 2003.
Daniel, Gregory. Overview of Skeletal and Joint Lesions
Seen during Canine Growth. Western Veterinary
Conference, 2003.
Fossum, Theresa. Small Animal Surgery. 3rd Ed. Mosby,
2007.
Slatter, Douglas. Textbook of Small Animal Surgery. 3rd Ed.
Saunders, 2003.
Thrall, Donald E. Textbook of Veterinary Diagnostic
Radiology. 5th Ed. Saunders, 2007
Trostel, C. et al. Canine Lameness Caused by Developmental
Orthopedic Diseases: Osteochondrosis. Compendium, 2002.
Vol 24 (11): 836-853.
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