Elbow dysplasia surgical options

RE: Elbow dysplasia surgical options

Malcolm Ness — Mon, 11 Apr 2016 11:54:15 GMT

[quote user="Neil Wheadon"]1) In young dogs there is a differential growth of the radius and ulna. In effect it places axial pain onto the elbow joint, this differential growth corrects itself and so it 'appears' that the NSAID's are having an effect.[/quote]

It seems overwhelmingly likely that a discordant growth between ulna and radius is a significant part of the pathogenesis of this condition. Similarly, it seems likely that the degree of incongruity within the elbow joint might vary across time. However, the suggestion that the problem can "correct itself" is unproven. Certainly, some dogs suffer a lot with apparently modest structural alterations to the elbow while others have really ugly elbows with which they cope very well. I have come across a few dogs with CT confirmed coronoid process abnormalities yet no clinical or radiographic evidence of disease. There is no doubt that the condition is not well understood and any surgical adventure should be tinged with caution and any new procedures properly evaluated before being widely used. The fact is that most dogs with elbow dysplasia will do remarkable well with no, or relatively low grade, veterinary interference.

[quote user="Neil Wheadon"]I spoke to a specialist recently who suggested that many cases are in fact panosteitis which is producing the apparent elbow pain and this resolves and that the elbow pathology is not much incidental but isn't the primary reason behind the pain.[/quote]

Careful clinical examination should differentiate ED from panosteitis and certainly, clinical exam supported with appropriate radiography should keep the two apart but I agree that sometimes the two will occur in the same dog and it is difficult to attribute pain and improvement to one condition or the other. Some clinicians have the mind-set that ED is a progressive condition that demands intervention and that is used to justify surgical intervention. The fact that many of these dogs were set to improve spontaneously can be misinterpreted as surgical success.

Others have mentioned the PAUL procedure - which sounds rational and has been widely used but without evidence of a useful effect over the improvement that might have been expected spontaneously. The distal ulnar osteotomy was something we looked at many years ago - we could not justify its use because the normal anatomy of ligaments and other soft tissues uniting the ante brachium limits the potential for movement in the elbow after a distal osteotomy. In effect, the elbow morphology did not change in response to DUO surgery.

RE: Elbow dysplasia surgical options

Nhombokisheni — Fri, 08 Apr 2016 10:48:25 GMT

I also came across this article http://m.vet.sagepub.com/content/45/2/197.full - things manor be as clear cut as in my uni notes......

RE: Elbow dysplasia surgical options

Hannah Wynne Richards — Fri, 08 Apr 2016 08:29:19 GMT

Presumably you mean distAl - or did you boil it and drink what came off with tonic?

Wynne

RE: Elbow dysplasia surgical options

grumpyoldman — Fri, 08 Apr 2016 08:15:05 GMT

Once the proximal medial tip of the radius breaks off path is ongoing. We have tried a few PAUL surgeries but its too early to say whether they did any better than the conservative approach. I think a DUO (distil ulnar osteotomy) early may be better early than a (proximal ulnar osteotomy ), later but its a narrow window of opportunity ,and your never going to know how many would have gotten better anyway.

I do remember a few years ago ,a tale of two chocolate labrador puppies ,one uninsured ,owned by the milk man ,had a DUO (what can you do for £300) and did very well ,still comes in today. The second had a big fat pet plan with wealthy well healed clients , it got referred , had repeated X-rays arthroscopy CT , conservative management and a Body bag at 3 . So if your going to cut something do it early on.

RE: Elbow dysplasia surgical options

Neil Wheadon — Wed, 06 Apr 2016 14:14:34 GMT

[quote user="Malcolm Ness"] I advise conservatism - extended NSAIDs and full activity. Many dogs improve markedly over a few weeks and though some stiffness and lameness persists, this usually mitigates as the dog passes skeletal maturity.[/quote]

Interesting

Is there any credence in the theory that

1) In young dogs there is a differential growth of the radius and ulna. In effect it places axial pain onto the elbow joint, this differential growth corrects itself and so it 'appears' that the NSAID's are having an effect.

2) I spoke to a specialist recently who suggested that many cases are in fact panosteitis which is producing the apparent elbow pain and this resolves and that the elbow pathology is not much incidental but isn't the primary reason behind the pain.

Is there any credence in this?

Neil

RE: Elbow dysplasia surgical options

Nhombokisheni — Wed, 06 Apr 2016 11:37:25 GMT

Thank you for the input....interesting.

RE: Elbow dysplasia surgical options

Malcolm Ness — Wed, 06 Apr 2016 08:54:52 GMT

The short answer is that none of the proposed surgical interventions for elbow dysplasia have been shown to be of any benefit.

Total elbow arthroplasty is a salvage procedure with a very different indication from the various coronoidectomy procedures. Elbow replacement is technically demanding, costly and associated with high complication rates, even when the better implants are used by the most experienced surgeons.

Coronoidectomy appears to be a rational surgical response to a disease associated with a manifestly damaged coronoid but there is scant evidence to show that removing, or otherwise altering the coronoid is of any benefit to the dog or its elbow in the short, medium or long term. That is inconvenient information for those who like to use arthroscopes and 'operate' on almost every elbow.

The plethora of other operations are a response to the fact that cronoidectomy - no matter how it is dressed up - is ineffective. These procedures, too, follow the same trajectory - they are revealed as the next big thing and become unreasonably popular before the realisation hits that the dogs are not really benefitting and the surgeons move on to the next thing.Some of these operations are major undertakings and carry a significant risk of failure and complication.

There is some evidence that elbow joint incongruity is a preceding pathology and it makes sense to try and identify then address that. The PAUL procedure marketed by Kyon is one such attempt and it has its advocates. Neil Burton at Bristol is working on a system that gives very precise alterations to ulnar or radial length that is aimed at correcting underlying incongruity and hopefully minimising subsequent elbow pathology. It has the advantage of being a relatively non-traumatic option for the dog.

When presented with a young dog suspected with ED, I investigate with careful clinical exam and radiography. Arthroscopy and CT can give nice pictures but the information they yield is not of proven clinical benefit to the patient nor does it alter management so I struggle to justify spending the clients money on such investigations. Given the paucity of evidence to show any benefit to surgical intervention, I advise conservatism - extended NSAIDs and full activity. Many dogs improve markedly over a few weeks and though some stiffness and lameness persists, this usually mitigates as the dog passes skeletal maturity. Episodic NSAIDs may be needed lifelong but most of these dogs function well as active, happy pets.

A few do not do well - elbow pain persists and I will sometimes operate on those performing a coronoidectomy (open or arthroscopically) and some dogs seem to improve, at least in the short term. Certainly, many owners will tell you that the dog has improved!

The worst cases, and they are a minority, progress it seems in spite of anything you do and these are the dogs that end up with euthanasia, arthrodesis or elbow replacements.