Elbow Dysplasia

Developmental elbow disease (aka “elbow dysplasia”) is a common cause of front limb lameness, especially in our skeletally immature medium to large breed dogs.

Elbow dysplasia is more of an umbrella term that encompasses any abnormal development of the elbow. In particular it includes:

While fragmentation/fissuring of the medial coronoid process is the most common, some dogs can be affected by more than one abnormality in the elbow.

Why and how does it happen?

Elbow dysplasia is a multifactorial disease occurring due to genetics, rapid growth, obesity, dietary/nutritional problems, and hormonal imbalances.

During development 3 bones have to develop to create a “C” shape to the elbow. These are the humerus (upper arm bone) and the radius and ulna (lower arm bones). The coronoid process is a little beak of bone (almost like a triangle) that is part of the ulna and sits just under the humerus.

Many theories exist as to why the coronoid process will become damaged but it is suspected there are micro-cracks that develop due to excessive forces being transmitted through the coronoid process. This excessive force could possibly be from an abnormal shape, size, or relationship of the coronoid process with the humerus and/or radius.

As the micro-cracks form bits of bone and cartilage can fissure or fracture off. When this happens, there is inflammation and pain within the joint. Because of the inflammation and abnormal mechanics of the elbow there will be the development of osteoarthritis (OA).

Clinical Signs:

The clinical signs will vary but in general dogs will present with stiffness/lameness upon rising or after heavy play. In some situations, the lameness will be intermittent and may resolve quickly, or it may be more consistent.

Some dogs will self-limit their play or may not be as active as other puppies.

It is important to remember that no young dog should be stiff upon rising or take time to warm out of a lameness.

If you notice any subtle signs in your dog with a front limb lameness please contact Fusion Veterinary Orthopedics.

Diagnosis:

The diagnosis of elbow dysplasia at Fusion Veterinary Orthopedics is based on a gait analysis, orthopedic examination, and imaging such as radiographs (X-ray) or a CT scan in our advanced imaging center.

Some patients may be painful on direct palpation of the elbow; however, Dr. Dycus tends to look for more subtle signs such as resistance to elbow flexion or body language changes.

Treatment:

It is VERY important to understand that no matter what is done there will be arthritic changes in the joint in a patient with elbow dysplasia. The goals of treatment are to improve comfort, and hopefully slow down and minimize the progression of osteoarthritis (OA)

There are two options for treatment: conservative management and surgical management.

Conservative management consists of a PRP and extracorporeal shockwave series (ECSWT) followed by a period of exercise restriction, and formal rehabilitation at Fusion Veterinary Orthopedics,

From a surgical standpoint, at Fusion Veterinary Orthopedics, we believe in being as minimally invasive as possible. Therefore, treatment begins with a minimally invasive arthroscopic procedure (small camera inserted into the elbow) to evaluate the degree of cartilage damage, degree of incongruity, and address any abnormalities that may be present. If a fragment is noted we will remove it and in some cases we will perform a subtotal coronoid-ostectomy (removal of a small portion of the coronoid process). Following the arthroscopic procedure Dr. David Dycus will perform ECSWT along with injecting PRP.

In some patients a proximal ulnar osteotomy will be performed. This is making a cut in the ulna to allow the pull of the triceps to adjust the ulnar alignment to try and improve stress on the coronoid process. If this is performed patients are sent home in a splint for a few weeks.

What happens after surgery?

Recovery from elbow surgery is long and slow. While we expect to see subtle improvements over the next 12 weeks, the true effect of changes may take 6 months to 1 year to be appreciated. In addition, it is important to remember that the arthroscopic procedure is step 1 in the management of osteoarthritis. There will be times in the future when your pet may experience stiffness, soreness, or limping due to progression of osteoarthritis.

After surgery you dog will need a period of rest and relaxation of about 8-12 weeks. This means no running, jumping, or playing.

Excessive activity will lead to implant breakdown, soft tissue injuries, or delayed healing.

The first 2 weeks after surgery is a lot of rest and relaxation. Because we have just performed surgery, many patients will be more lame after surgery. After the two-week mark Dr. David Dycus will prescribe at home exercises along with slow controlled leash walking.

If staples/sutures are present they will be removed, or the incision evaluated at approximately 2 weeks after surgery and radiographs will be needed around 8 weeks and possibly 12 weeks after surgery to evaluate healing. At these rechecks an orthopedic exam will also be performed to ensure the surgical site is healing as expected.

Just as with people, at Fusion Veterinary Orthopedics, we recommend physical rehabilitation beginning 2 weeks after surgery. Rehabilitation will involve once to twice weekly formal rehabilitation sessions along with at home exercises. We have noted quicker healing, maintenance of muscle mass and range of motion, and superior outcome in the patients that undergo formal rehabilitation. Furthermore, rehabilitation offers an outlet of energy in a controlled manner so that your dog is still able to maintain some activity while healing. Patients that have been treated conservatively usually require once to twice weekly rehabilitation for a period of about 3-6 months.

Following surgery, we recommend that patients begin oral joint supplements and omega-3 fatty acids, maintain a healthy body weight, and remain active once healed from surgery. These things will be the beginning blocks along with surgery to minimize and slow down the progression of OA.

Osteoarthritis Management

Basic osteoarthritis management consists of joint supplements (Dasuquin Advanced, Antinol plus, and Flexidin Advanced) omega-3 fatty acids (Welactin 3TA), Adequan injections, daily exercise through controlled leash walking, daily play time (with avoidance of high impact activities), and weight control.

If at any point your pet experiences a flare-up the goal will be to determine what can be done to get the flare-up under control so that he/she may resume back to his/her status quo. Potential management strategies include joint injections (please see below), formal rehabilitation (please see below), and pharmaceutical management (anti-inflammatories for 1-4 months, gabapentin, amantadine, etc.).

Our goal is to only use pharmaceutical management intermittently. There will likely come a time in the future when your pet may benefit from daily pharmaceutical management, such as a daily anti-inflammatory.

At Fusion Veterinary Orthopedics, we may recommend intra-articular injections (Hyaluronan, platelet rich plasma, cortisone, or synthetics) to help improve comfort in the painful joints.

Hyaluronan (HA) is a joint protective agent, which can decrease inflammation within the joint. Specifically, it increases the joint fluid viscosity, increases cartilage (GAG) formation, and decreases degradative enzymes and cytokines (which cause inflammation/synovitis). This medication is commonly used for the treatment of osteoarthritis in humans, horses, and dogs. The injections may be given under sedation weekly for 3 weeks. Eighty percent of dogs respond well to the HA injections, 10% respond fair, and 10% do not respond at all. For those that do not respond, we may recommend a series of injections of either platelet rich plasma or corticosteroid (Triamcinolone) injection in the joints.

Platelet rich plasma (PRP) injections are another option for management of osteoarthritis to act as more of a “clean anti-inflammatory.” Blood would be collected and processed in our biologic medicine laboratory to collect the platelets. The platelets in PRP have a high concentration of growth factors that promote diminishing the inflammatory response. Following PRP injections some patients may experience a “PRP flare” that can last 24-72 hours. A “PRP flare” will result in worsening lameness; however, some consider this to be a “good inflammatory” response associated with positive effects of the PRP. At Fusion Veterinary Orthopedics, typically PRP is provided in conjunction with shockwave therapy with 3 treatments each separated by 2 weeks.

If formal rehabilitation therapy is recommended it will help to speed recovery by decreasing inflammation and swelling, building muscle mass, increasing range of motion, and improving overall comfort. We have a complete rehabilitation service at Fusion Veterinary Orthopedics; however, if the drive is too far other locations can be used. To help locate a certified rehabilitation therapist in your area please visit the NC State’s rehabilitation certification website (https://www.ncsuvetce.com/canine-rehab-ccrp/ccrp-practitioners/) or visit the Canine Rehabilitation Institute’s website (http://www.caninerehabinstitute.com).

There is no “cure” for osteoarthritis; however, it is a life-long management commitment. The treatment of osteoarthritis is a multi-modal approach including weight management, exercise, oral joint supplements, intra-articular products as needed and appropriate pain management as needed. Your pet’s long term osteoarthritis management will be through a team approach with Fusion Veterinary Orthopedics and your regular veterinarian. To learn more about the management of osteoarthritis please visit www.caninearthritis.org.

Are there any complications?

At Fusion Veterinary Orthopedics, we take great pride ensuring our patients return to as normal function as soon as possible. With arthroscopy the complication rate is low. Anytime we perform surgery, there is the chance of infection. Infection rates are low, and during surgery your dog will be given antibiotics and, in some cases, will be sent home with antibiotics after surgery. Lack of improvement is also a possible concern. Given the unpredictable nature of elbow disease some dogs will maintain an intermittent to constant limp.