Transcript Elbow Dysplasia - Veterinary Specialists of South Florida
VSSF presents the following case study.
OSTEOCHONDROSIS
Andrea Gale
“Buddha”
• • • 7 month MI Rottweiler Several week history of pain when rising No other health concerns ▫ Owner treating yard for ticks • PE ▫ 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 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 B TID 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 ▫ Osteochondritis dissecans ▫ Ununited anconeal process ▫ Fragmented coronoid process Signalment History PE – orthopaedic and neurologic Radiology +/- MRI, CT or nuclear scintigraphy ▫ 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 x linked 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
• • Remove the cartilaginous flap Debride underlying subchondral bone • Several surgical techniques exist ▫ Medial approach and arthrotomy
ARTHROSCOPIC
• • • • • 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
POST OPERATIVE CARE
• Limb should be placed in a light pressure bandage for 24 48 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 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. 3 rd 2007. Ed. Mosby, Slatter, Douglas. Textbook of Small Animal Surgery. 3 rd Saunders, 2003.
Ed. Thrall, Donald E. Textbook of Veterinary Diagnostic Radiology. 5 th Ed. Saunders, 2007 Trostel, C. et al. Canine Lameness Caused by Developmental Orthopedic Diseases: Osteochondrosis. Compendium, 2002. Vol 24 (11): 836-853.