ELBOW DYSPLASIA & ARTHROSCOPY
Fixed-price fees for dogs with suspected or confirmed elbow dysplasia:
Single elbow: £2,500 (dogs <40 kg) £2,650 (dogs >40kg)
Both elbows: £2,960 (dogs <40kg) £3,110 (dogs >40kg)
These fees include the initial consultation, a CT scan of both elbows, anaesthesia, surgery and hospitalisation charges. They include VAT at 20%.
Elbow dysplasia is a general term which describes a number of specific conditions that affect the elbow of growing dogs and lead to elbow osteoarthritis (OA). The most common of these conditions is a condition which historically has been called Fragmented Coronoid Process (FCP). The coronoid process is part of the ulna (which along with the humerus and the radius are the bones which make up the elbow) and bone fragments can form in this area and cause lameness. However, arthroscopy allows far superior evaluation of the elbow compared to a traditional open surgery (aka arthrotomy) and with the advent of arthroscopy we have learnt that fragmentation is not the only abnormality that affects the coronoid process. Therefore, the spectrum of disease we recognise these days is generally referred to as 'coronoid disease' or 'medial compartment disease' -the latter reflecting the additional involvement of the medial part of the humeral condyle in many cases (see the arthroscopic images below).
Medial (inner) aspect of a canine elbow (*medial coronoid process)
Coronoid disease can affect many different breeds of dog but large breeds are most often affected, particularly Labradors, Golden Retrievers and Rottweilers. Signs of forelimb lameness and/or elbow stiffness are often first seen at around 5-8 months of age but can be later. It is appropriate to treat the initial episode of lameness with a period of rest and antiinflammatory pain killers (known as NSAIDs, pronounced 'en-sades'). If lameness persists or is recurrent than x-rays are often taken. X-rays do not allow specific assessment of the coronoid process but they are useful to rule-out other conditions of the elbow and they will often (but not invariably) show evidence of secondary OA which is a good indicator that elbow pathology is present. In order to characterise the pathology however, further investigations will be required and this will generally require referral to an orthopaedic surgeon.
X-rays can give an idea of whether an elbow is normal or not but will rarely provide a specific diagnosis (Vets: click here to check out our easy guide to assessing if an elbow is normal or not). The preferred investigations for dogs with suspected coronoid disease are computed tomography (CT) and arthroscopy. CT is a high-tech form of x-ray imaging which provides much greater detail than traditional x-rays and is sometimes referred to as a 'CAT scan'. CT provides very good detail of the bones making up the elbow allowing the identification of fragments, small fissure fractures in the coronoid process and problems with the alignment of the bones at the elbow. Arthroscopy is a minimally-invasive surgical procedure where small endoscopes are passed into the joint allowing the cartilaginous joint surfaces to be visualised on a monitor. Arthroscopic images are magnified and fluid is used to flush away blood meaning that the detail seen is much greater than could be seen with the naked eye via a traditional open surgery. Arthroscopy therefore allows accurate assessment of the joint surfaces for cartilage wear which often affects the coronoid process and sometimes also the opposite joint surface on the humeral condyle. Because arthroscopy is 'key-hole' surgery, the risks of wound complications and infection are very low (the infection risk is <1% at Anderson Moores).
Left: Transverse CT scan, (*coronoid fragmentation). Right: 3D CT reconstruction, humerus erased (*radioulnar incongruity [malalignment]). (R-radius, U-ulna)
At Anderson Moores we have over a decade of experience of investigating elbow dysplasia with CT and arthroscopy. This has been an area of research interest for Andy and he has published studies on the use of these techniques for investigating elbow dysplasia. One of the conclusions drawn from these studies was that the combination of CT with arthroscopy will identify more lesions of the coronoid process than either technique alone. Our standard protocol at Anderson Moores is therefore to advise CT and arthroscopy which are often performed under the same anaesthetic episode. Elbow dysplasia frequently affects both elbows and if this is supported by the clinical examination and/or x-rays we will frequently investigate both elbows at the same time.
Arthroscopy: *coronoid fragmentation (separate cases). Left: grasping forceps are being used to remove the fragment. Right: the pink area on the humeral condyle (H) is exposed bone due to cartilage wear
As well as providing valuable diagnostic information about the elbow, arthroscopy also allows minimally-invasive treatment of coronoid disease. The type of treatment is dependent on the type of pathology present and thus is determined on the basis of the CT and arthroscopy. Arthroscopic treatment may involve the removal of bone fragments from the elbow, the removal of diseased parts of the coronoid process and the removal of cartilage flaps (OCD flaps). Very occasionally additional procedures such as osteotomy (cutting) of a bone (usually the ulna) may be required if there is incongruity (malalignment) of the bones at the level of the elbow resulting in an abnormal distribution of forces on the joint surfaces.
The prognosis for coronoid disease is variable and seems to be dependent on the type of pathology present. Those dogs with fragmentation of the coronoid process and otherwise relatively healthy joint cartilage have a good prognosis for improvement, although over the long term elbow OA will progress and in some of these dogs will cause further signs of lameness/stiffness later in life. In dogs with marked wear/erosion of the joint cartilage the prognosis is more uncertain but many dogs will still improve following treatment.
Above: Video clip of the arthroscopic removal of a medial coronoid process fragment. First the fragment's attachments to the annular ligament are cut with a 'banana' knife, followed by fragment removal with forceps and then probing for further loose fragments (right elbow, medial portals, 2.4 Storz scope, Stryker videoendoscopy system).
Additional elbow arthroscopy videos can be viewed at our YouTube page: click here!