Investigating and management of the juvenile lame animal 2 Flashcards
What is osteochondrosis?
- common developmental condition of the articular cartilage
- It is seen in the juvenile animal but its consequences extend into adult life
- The underlying pathology is a failure of ossification of the articular cartilage
- This might arise from abnormal stresses on the cartilage brought about by joint incongruity
- It results in a thickened cartilage which fragments and allows contact of the synovial fluid with the subchondral bone and resulting inflammation. This is seen as sclerosis on radiographs
- The cartilage can form a flap:- osteochondrosis dissecans
- The subchondral bone can fracture:- fragmented coronoid process or there may be a failure of a physis to close:- ununited anconeal process
What is the prevalance and prognosis of osteochondrosis in these joints?
Elbow, Sholder, stifle, hock,
What other joint can get osteochondrosis?
- Elbow:- very common and carries a guarded prognosis
- Shoulder:- rare and prognosis is good
- Stifle:- rare but carries a poor prognosis
- Hock:- uncommon and carries a poor prognosis
- Other sites:- occasionally seen in the lumbosacral joint
What is the prevalance and prognosis of osteochondrosis in the elbow?
- Elbow:- very common and carries a guarded prognosis
- Irrespective of the technique employed the development of degenerative joint disease is inevitable
- Long term medical management of the joint changes set in train by the original lesion can be anticipated
- Warn the owner from the outset
What ate the the 4 manifestation of elbow dysplasia in the dog?
- Fragmented medial coronoid is seen in many breeds but particularly the Labrador, Rottweiler and Bernese mountain
- Osteochondrosis dissecans a lesion of the medial humeral condyle seen in the Labrador in particular and may occur concurrently with FCP
- Ununited anconeal process is seen in the German shepherd dog and Basset hound
- Incomplete ossification of the medial humeral epicondyle (rare and unclear how this sits into the elbow dysplasia picture)
What is Elbow dysplasia?
What breeds are affected?
What is the signalment and clinicla history?
What is the response to medication?
This is a broad term that encompasses all manifestation of osteochondrosis seen in the elbow
* It is very common and has several manifestations but all involve the medial aspect of the joint - hence it is also called Medial Compartment Disease
* It is seen in many breeds but particularly the Labrador, Rottweiler, German shepherd and Basset hound but has not been reported in the cat
* Increased incidence in the male
* 50-90% of these cases are bilateral
* Insidious onset at 5-7 months
* Initially worse on rising
* Moderately responsive to non steroidal medication
What are the clinical signs of Elbow osteochondrosis?
- History of chronic lameness worse on rising
- Tends to hold the limb abducted and externally rotated
- Pain on manipulation particularly internal rotation that loads the medial compartment of the joint
- Pain on flexion with an ununited anconeal process
- Joint effusion
- In chronic cases muscle atrophy
- Always check the contralateral limb
How is radiography for elbow dysplasia performed?
- general anaesthesia
- Two orthogonal views - flexed mediolateral and craniocaudal view
- An extended mediolateral and the so-called lazy craniocaudal view can also be helpful (highlight medial coronoid process
- Remember that the primary lesion may not be identified in the case of those animals with fragmented medial coronoids
- In these animals secondary changes such as sclerosis of the trochlea notch of the ulna and new bone highlighted on the anconeal process in the flexed mediolateral view may be the only indicators of elbow dysplasia
- Early cases may show minimal or no radiographic signs
Elbow dysplasia
What will you see on a radiograph with a fragmented medial coronoid (FCP)
early degenerative changes to the joint but rarely is the primary lesion seen
elbow dysplasia
What will you see on a radiograph with osteochondrosis of the medial humeral condyle?
small deficit seen on the medial condyle. The mineralised cartilage flap can occasionally be seen and there are associated degenerative changes to the the joint
elbow dysplasia
What view do you need to use to see an ununited anconeal process?
fully flexed mediolateral view. Note this condition is a failure of ossification of the growth plate. cf. FCP. The physis should close at 120d
What is seen here?
Medial compartment disease showing irregular
joint surfaces, a deficit in the medial humeral
condyle and poorly defined medial coronoid
what is shown by the red arrow and the white arrows?
Ununited anconeal process (red arrow) and sclerosis to the trochlea notch
What can be seen on this CT?
osteochondrosis in the medial condyle of the canine elbow
What can be seen on this CT?
CT image of an ununited anconeal process
In addition to the primary lesion there is
marked sclerosis of the trochlea notch
(arrowed)
Waht are the benifits of arthroscopy for elbow dysplasia?
- On occasions it will allow detection of lesions not seen with CT
- The magnified image can be very helpful
- It facilitates treatment at the same time as diagnosis
What is seen in the right arthroscopic picture?
Fragmented medial coronoid process
(cartillage has changed colour and there is a kissing lesion on the Medial condyle of the humerus)
What are the treatment options for fragmented coronoid process?
- Conservative management:- weight control, NSAID, platelet rich plasma, stem cell therapy, nutraceuticals, cartrophen?
- Removal of the fragment +/- ulna osteotomy to correct joint incongruency:- may improve the short term outlook for the patient but long term does not reduce the pathology and is performed less often
-
Off loading the medial compartment of the joint to reduce the weight bearing on this aspect of the joint which is the site of the pathology:
- PAUL technique (proximal abducting ulna osteotomy)
- Sliding medial humeral osteotomy
- Partial elbow replacement/joint resurfacing (Arthrex CUE [canine unicompartmental elbow system])
- **Elbow arthrodesis **(surgical fusion):- difficult to obtain the correct limb length to allow good function
- Elbow replacements:- 2 types available Sirius and TATE. Still in their infancy and do not, as yet, result in the consistent outcomes seen in total hip replacement
these will not be done in the young dog but owner needs to be aware that these are option when older
how is osteochrondrosis dessicans treated?
- Generally surgically managed
- Occurs exclusively on the medial condyle therefore medial arthrotomy/ arthroscopy
- Remove fragment and curette deficit
- Can attempt replacement of the deficit with OAT (osteochondral autograft transfer) or SOR (synthetic osteochondral resurfacing) This is when either a synthetic joint surface or a graft from a non weight bearing cartilage covered area of a joint such as the femoral trocheal ridge is harvested and placed in the deficit
- Always look for concurrent fragmented medial coronoid
- Prognosis is fair
What is the surgical management of ununited aconeal process?
- Remove the fragment:- This results in joint incongruity and osteoarthritis(OA)
- Reattachment of the fragment with screw
- Reattachment fragment and ulna osteotomy to lengthen the ulna (it has been postulated that a short ulna, as part of the joint incongruity results in pressure applied to the anconeus and its failure to fuse)
- Results of all these techniques are variable
- In the mature animal treat this condition medically
How is elbow dysplasia incidence reduced?
it is a polygenic inherited disease so trying to prevent it being inherited:
The BVA Kennel/Club Elbow Dysplasia Scheme
* Two mediolateral views:- flexed and neutral or moderately extended
* Each elbow has a maximum score of 3.
* The score of any individual is that of the worse elbow
* Breeding is discouraged from any animal with a score greater than 0
- The estimated breeding value looks at the breed overall as well as the ED score and advises a breeder whether its appropriate to breed from their dog (it is an indication of the genetic value of the dog avoiding the influence of environmental factors such as exercise and diet)
What is the signalment and histrory of shoulder osteochondrosis?
Signalment
* Labrador, Border collie
* 6-8 months old
History
* Lame on rising
* Worse after exercise
* Pain on shoulder extension (lesion on caudal third of glenoid of humerous)
* Scapular muscle atrophy
* Rarer than it used to be
What radiography veiws are needed for shoulder osteochondrosis?
- mediolateral
- caudocranial (in this view the animal is placed in a trough with the body slightly rotated away from the Xray plate)
What is seen on radiography when there is shoulder osteochondrosis?
- Easily seen on plain radiographs with flattened caudal third of humeral glenoid
- Joint mouse or mineralised cartilage flap can be seen on occasions
- Arthrogram can be useful but rarely performed now
What is the surgical management of shoulder osteochondrosis?
Remove the fragment and debride the deficit edges and forage the bone bed to encourage healing with fibrocartilage
or
Limited caudal arthrotomy with flexed shoulder and perform same procedure (modified Cheli approach)
- Can give excellent results
- Some advocate conservative management with vigorous exercise with analgesia to dislodge the flap
What is the signalment and clinical signs of osteochondrosis of the stifle?
Signalment
* 6-12 months
* Labrador retriever
* Staffordshire bull terrier
* Has been reported in the cat
Clinical signs
* Chronic lameness especially on rising
* Joint pain
* Joint effusion
* Differential would be early cruciate disease
How are radiographs taken for diagnosis of osteochondrosis of the stifle?
- The mediolateral in which a pad is placed under the hock to de-rotate the femur and superimpose the femoral condyles
- Either a caudocranial or craniocaudal
A pad should be placed under the stifle to prevent it slipping laterally when taking the caudocranial view
What is seen on radiography when there is osteochondrosis of the stifle?
- Flattened condyle on mediolateral view
- Deficit to either the medial or the lateral femoral condyle on the caudocranial view
- A joint mouse may be seen in the caudal joint pouch on the mediolateral view
- Joint effusion (loss of the subpatellar fatpad)
What is the treatment for osteochondrosis of the stifle?
Generally surgically managed
Arthroscopy/arthrotomy
* Remove fragment and curette deficit
* Can attempt replacement of the deficit with OAT (osteochondral autograft transfer (from non-articular area of joint)) or SOR (synthetic osteochondral resurfacing)
- Prognosis is fair to guarded
What is the signalment and clinical signs of hock osteochondrosis?
- Labradors and Rottweilers
- 6-12 months old
- Lameness particularly after exercise
- Joint effusion to both medial and lateral aspects of talocrural joint
What veiws are needed for radiography of hock osteochondrosis?
- Mediolateral
- Caudocranial or craniocaudal
On occasions when there is a lesion on the lateral trochlea of the talus a flexed view to displace the calcaneus from the image of the trochlea ridge may be helpful
What is seen on radiographs of hock osteochondrosis?
Widened joint space
Flattened aspect of the caudal trochlea
Sclerosis of the subchondral bone
Secondary arthritic changes
OCD of the medial trochlea of the talus
What is the treatment and prognosis for hock osteochondrosis?
Surgical management
* Removal of the osteochondral fragment either arthroscopically or with an open arthrotomy
* Salvage procedure:- pantarsal arthrodesis
Medical management - Weight control, NSAID etc.
Prognosis - Guarded to poor and often a salvage procedure such as a pantarsal arthrodesis is required to manage these cases
Lumbosacral osteochondrosis is a rare condition that infequently causes clinical signs, what are these clinical signs?
Can result in instability and disc extrusion/protrusion and back pain
