What is Arthroscopy?

Arthroscopy is a minimally invasive diagnostic and/or therapeutic procedure for joints using a small camera (endoscope/arthroscope). To insert the arthroscope into the joint, one or more very small incisions are made in the skin, allowing for a thorough inspection of the intra-articular structures (structures within the joint). The arthroscope provides a magnified view. Arthroscopic techniques can treat some pathological conditions by introducing specially designed instruments through additional small openings (portals) into the joint. Arthroscopy is performed sterilely in the operating room.

What are the Advantages of Arthroscopy?

Joints can be treated using an arthrotomy (surgical opening of the joint), which involves a several-centimeter-long skin incision followed by dissection through muscle layers to reach the joint. The surrounding soft tissues are then retracted to inspect the joint.

In contrast, arthroscopy is performed through very small incisions. Multiple small portals are less traumatic than a single open access. The magnified view is often much better than what a standard “open” access to the joint provides. Besides offering a better view of the intra-articular structures, arthroscopy significantly reduces trauma to the surrounding tissue. As a result, arthroscopically treated patients experience less postoperative pain and recover faster than those treated through an open standard approach. Therefore, whenever possible, we aim to address intra-articular (within the joint) pathologies arthroscopically.

The value of arthroscopy compared to a standard approach is most impressive when comparing the details visible during the inspection of the shoulder, elbow, carpus (wrist), hip, and ankle. In fact, arthroscopy can be extremely useful for diagnosis when physical examination findings and X-rays, or even more advanced imaging like computed tomography (CT) or magnetic resonance imaging (MRI), are inconclusive.

Which Joints are Commonly Arthroscoped?

The joints most commonly examined and treated arthroscopically are the shoulder, elbow, and knee. While the carpus (wrist), hip, and tarsus (ankle) have been described and can also be examined in large dogs, the need for arthroscopic examination of these joints is less frequent.

Elbow Dysplasia (ED)

Why is the Anatomy of the Elbow So Important?

The elbow joint is formed by three bones: the humerus (upper arm bone), which provides the bony support of the upper arm from the shoulder to the elbow; the ulna (forearm bone), which extends from the elbow to the paw along the back of the forearm; and the radius (forearm bone), which bears the primary load along the front of the forearm. All three of these bones must develop and grow at the same rate to fit perfectly at the elbow. In a healthy joint, the elbow moves smoothly and allows the patient to walk without pain.

What is Elbow Dysplasia?

Elbow dysplasia occurs when the bony components of the elbow—the humerus, ulna, and radius—do not fit together precisely or when the cartilage covering the joint surfaces of the elbow does not form properly. ED and secondary osteoarthritis are the most common causes of front limb lameness in dogs.

Classically, ED consists of one or a combination of the following forms, listed below. These can occur in either one or, more commonly, both elbow joints.

• Medial Coronoid Disease: The coronoid process is a bony protrusion on the ulna that articulates with the humerus and radius. There are many forms of this disease, ranging from cartilage wear and small cracks/fissures to the detachment of bone fragments (Fragmented Coronoid Process (FCP)).
• Elbow Joint Incongruence: Different lengths of the radius and ulna or step formation between the radius and ulna.
• Osteochondrosis / Osteochondritis Dissecans (OC/OCD): A condition characterized by cartilage lesions and the formation of loose cartilage/bone fragments that float in the joint.
• Isolated Anconeal Process (IPA): In this form of ED, a bony projection (anconeal process) of the ulna fails to fuse properly during growth.

What Causes ED?

Most patients with ED are young dogs, and a genetic cause is suspected. Studies show that elbow dysplasia is a polygenic inherited disease, with FCP, OCD, and IPA being inherited traits independently of each other. Unfortunately, there is currently no DNA test for dogs to diagnose genetic defects or identify carriers of the disease. It is known that both sire and dam contribute equally to the likelihood of developing ED (Maki et al. 2002). It is important to note that affected puppies may come from non-affected parents (Hazelwinkel and Nap 2009) but with affected grandparents. Therefore, affected dogs should not be used for breeding.

Large breed dogs, such as those listed below, are overrepresented:

• Bernese Mountain Dog
• German Shepherd
• Golden Retriever
• Labrador Retriever
• Newfoundland
• Rottweiler
• Saint Bernard
• Basset Hound

In contrast to genetic predisposition, older dogs, especially very active sporting dogs (agility, flyball, etc.), may suffer from traumatic fractures of the medial coronoid process, also known as “Jump Down Syndrome.” The prognosis for this differs from that of ED.

What Are the Consequences of ED?

All the forms listed above produce loose bone and/or cartilage fragments in the joint, which can irritate like a pebble in your shoe! Therefore, early diagnosis and appropriate treatment are crucial to ensure the best quality of life for your pet. The term “arthritis” describes inflammation within a joint. The longer an elbow joint is affected, the worse the prognosis. Severe arthritis leads to pain, lameness, and a reduced quality of life.

How Do I Know if My Dog Has ED?

Clinical signs associated with ED can be observed in young (5-12 months old) and older adult dogs. Younger dogs usually present with one of the aforementioned conditions, while older dogs may exhibit a “Jump Down Syndrome” (see above) or advanced arthritis. Front limb lameness, which worsens with activity, is the most common clinical symptom. With bilateral lameness, the lameness may sometimes switch from one side to the other. The degree of lameness can vary from mild to severe. Often, the elbow and carpal joint seem to be externally rotated. The elbow joint may be swollen, and sometimes, due to restricted flexion, dogs may swing the leg outward while walking.

How is ED Diagnosed?

Upon examination, pain, swelling, and restricted movement of the elbow can be detected. In addition to a thorough clinical and orthopedic examination, X-rays (radiographs) should be taken. It is important to note that in some cases, significant degenerative changes may not be visible on X-rays despite significant elbow disease. However, in many cases, they still provide clues to the underlying cause. Further diagnostics may include computed tomography (CT), magnetic resonance imaging (MRI), or arthroscopy. Arthroscopy allows for minimally invasive diagnosis as well as, if indicated, surgical treatment.

How is ED Treated?

Treatment depends on the underlying condition. Non-surgical treatment includes weight management, physical therapy, weight loss, nonsteroidal anti-inflammatory drugs (NSAIDs), and pain medications (such as Rimadyl, Metacam, Gabapentin). Supplements to support joint health (e.g., Omega-3 fatty acids, glucosamine-chondroitin sulfate, MSM) may also be used. Sometimes, medical laser therapy or acupuncture is recommended. Finally, joint injections with hyaluronic acid or steroids (to reduce severe joint inflammation) and injections with platelet-rich plasma (PRP) (to restore and rebuild potentially damaged cartilage) may be used. These treatments do not always improve lameness. Particularly regarding stem cell or PRP injections, scientific studies in dogs are rare and controversial. However, these treatments seem to help in some cases for both humans and horses. If the above options lead to improvement, it is important to note that they only serve as a temporary measure: while they may cover your pet’s symptoms, the underlying cause is typically not treated, and repeated treatment may be required if clinical symptoms recur.

When is Surgery Indicated?

Early surgical management of ED offers the best chance to minimize arthritic changes in affected elbows, but it must be emphasized that almost all dysplastic elbows will develop some degree of arthritis. Older dogs with advanced arthritis may still benefit from arthroscopic surgery to some extent, but the benefits are less predictable.

Treatment of ED via Arthroscopy:

The use of an arthroscope is the preferred method for diagnosing and treating many cases of elbow dysplasia. Loose bone or cartilage fragments can be removed, and diseased cartilage can be debrided, allowing new blood vessels to enter the area and fill the defect with cartilage replacement. Joint fluid and tissue samples can be collected if indicated.

What is the Postoperative Care?

After surgery, dogs often show a greater degree of lameness than before the operation. This is normal and will improve over time. To help your dog through the postoperative phase, specific instructions (e.g., cooling, physical therapy, pain medications, anti-inflammatory drugs) will be provided based on the specific patient and underlying disease. Specialized rehabilitation protocols are closely related to the long-term outcome of ED treatment. In other words, if you overly restrict your dog after surgery, the result will not be as good as with physical rehabilitation. Think of it like humans—if someone undergoes surgery and then sees a physical therapist, their joint function will be better than if no postoperative therapy is provided. It’s the same for dogs.

Rehabilitation protocols vary depending on the disease form and extent of joint disease. However, all protocols are designed to gradually increase the activity level and intensity over a specific period. For dogs with severe elbow dysplasia, this therapy may last up to 3 months. The goal is to reduce joint discomfort, improve joint flexibility, and enhance strength and endurance.

What is the Prognosis for ED?

The prognosis depends on the underlying problem and the extent of joint damage at the time of diagnosis. With appropriate therapy, many patients show improvement. However, an orthopedic elbow condition can be difficult and sometimes frustrating for all involved to treat. Dogs can progress from a situation without radiological signs of joint disease to end-stage elbow arthritis.

Summary

ED must be diagnosed and treated early to achieve the best outcome. Thorough diagnostics are necessary, as numerous other issues can lead to front limb lameness in dogs, primarily the shoulder. Treatment should be performed by experienced surgeons. Arthroscopy is the gold standard for diagnosing and treating elbow diseases. Postoperative physical therapy is essential. Numerous therapeutic methods are currently researched and applied to treat dogs with end-stage elbow diseases. There is no miracle treatment to successfully treat every individual patient with ED, and therefore the prognosis for returning to completely normal function should be approached with caution.

Author ©: Dirsko J.F. von Pfeil, Dr.med.vet., DVM, DACVS, DECVS, DACVSMR, DECVSMR
ACVS Founding Fellow, Minimally Invasive Surgery (Small Animal Orthopedics)
European Board of Veterinary Specialisation (EBVS®) European Specialist: Small Animal Surgery

References:

• Maki K, Groen AF, Liinamo AE, Ojala M (2002): Genetic variances, trends, and mode of inheritance for hip and elbow dysplasia in Finnish dog populations. Animal Science 75, 197–207
• Hazelwinkel HAW and Nap RC (2009a): Elbow dysplasia; a definition and known aetiologies. Proceedings of the 24th Annual Meeting of International Elbow Working Group. pp 6-18

Fracture Management – General Information

Fracture management aims to fully restore functionality and anatomical alignment of bones and joints, which is essential for an active, pain-free life. We are highly trained in numerous fracture management techniques, and the high standards required of our Diplomates ensure that our patients receive care at the highest veterinary medical level. We treat all types of bone fractures according to AO (Arbeitsgemeinschaft Osteosynthese) standards. All our operating rooms are fully equipped and technologically up-to-date.

Most fractures result from trauma, such as traffic accidents, falls from heights (especially in cats), or dog bites in cats and small dogs. In contrast to traumatic fractures, pathological fractures are relatively rare. A pathological fracture is a bone fracture that occurs under normal stress due to bone weakening from an underlying condition (e.g., bone tumor, metabolic diseases, hyperparathyroidism).

How are fractures classified?

Fractures can be classified based on the fracture line, the number of bone fragments, whether the skin barrier over the fracture is intact, and many other criteria. If a bone breaks into two pieces/parts, it is referred to as a “simple fracture.” With multiple bone fragments, it is called a “comminuted fracture.” Open fractures are bone fractures with an associated open injury to the soft tissues around the fracture site and can be highly contaminated. Closed fractures are those where the skin barrier over the fracture remains intact. Sometimes, no external signs of the fracture are visible, while other times, abrasions or extensive skin defects like contusions can be observed.

Fractures in young animals are classified differently. Their bones contain a cartilage zone near the ends of each long bone, known as the growth plate. This growth plate is the most fragile part of the bone and is thus frequently affected when force is applied. Fractures of the growth plate are classified using the Salter-Harris system.

Preparation for Fracture Management:

Animals with fractures often suffer from severe trauma. These patients must be thoroughly examined to ensure there are no other potentially life-threatening injuries. Trauma from a traffic accident or a fall from a height can cause blunt injuries to the chest, abdominal organs, spine, or head trauma. In addition to a thorough clinical examination, X-rays of the chest and abdomen, laboratory tests, and a complete neurological examination may be indicated.

How is a fracture treated?

Depending on the type of fracture, various treatment methods are available. Your surgeon will explain the different methods and provide recommendations based on a thorough consideration of all factors. Fracture management is just the first step in a lengthy process. Proper postoperative care is essential to achieve a successful outcome. You will receive specific recommendations for postoperative management and care of your pet. Please follow these instructions and contact us if you have any questions.

The following sections describe various methods of fracture management.

Conservative Fracture Treatment with Splints or Casts:

Many patients with greenstick fractures can be successfully treated with a cast or splint. A greenstick fracture (named after the bending behavior of green, soft wood) is an incomplete bone fracture where the surrounding elastic bone membrane (periosteum) is preserved or only torn on the convex side.

Fractures of the metacarpal or metatarsal bones can also be treated this way. The cast is an alternative to the traditional plaster cast. The support material consists of glass and/or synthetic fibers (polypropylene, nylon, polyester) coated with a resin. In some cases, a splint may be used instead of a cast. With splinting, the limb is padded like with a cast, but the splint is usually applied to only one side of the limb and is not wrapped around it. Pressure sores are common complications associated with external coaptation, and such bandages need to be regularly monitored and changed.

Intramedullary Nailing:

An intramedullary nail is a stainless steel rod inserted into the medullary cavity of a long bone to stabilize a fracture. Intramedullary nailing is one of the oldest forms of fracture fixation and is often used in conjunction with other osteosynthesis methods.

Locking Nails:

In this form of osteosynthesis, a strong nail is inserted into the medullary cavity of a bone and secured with transverse screws. This setup not only provides good stability against bending forces but also neutralizes axial and rotational forces. Locking nails are limited to long bones that allow access without joint damage. The advantages of locking nails include minimally invasive biological fracture management and faster healing with fewer complications. Locking nails have been routinely used in human medicine for over 50 years. Dr. von Pfeil contributed to the development of a locking nail (I-Loc).

Plate Osteosynthesis:

Plate osteosynthesis is one of the most common and successful methods of fracture management. Bending forces, torsional forces, compression, shear forces, and tensile forces are the forces acting on a fracture site. Properly applied bone plates can counteract all these forces and ensure very stable fracture management. A stable fixation increases the likelihood of uncomplicated bone healing. Plates come in various sizes and designs. The choice of plate depends on the nature of the fracture and the desired effect on the fracture, such as compression, neutralization, or bridging. While anatomical reduction and stabilization enable direct bone healing, this method has the drawback of potentially disrupting blood supply at the fracture site. With minimally invasive plate osteosynthesis (MIPO), based on biological osteosynthesis, the fracture is fixed with minimal disruption of blood supply compared to anatomical reduction and stabilization.

Angular Stable Plate Osteosynthesis:

Angular stable implants have continuously evolved over the past two decades in both human and veterinary medicine, leading to significant advancements in fracture management across various anatomical regions. Angular stable plate osteosynthesis aims to minimize trauma during surgery through small incisions while preserving bone and surrounding tissue blood supply. Angular stable plates function like external fixators but are placed beneath the skin. The bone is fixed in the position it is in, without being pulled to the plate by screws. A precise contouring of the plate to the bone is not required. Therefore, anatomically pre-shaped angular stable plates offer the possibility of minimal invasive insertion through keyhole accesses. This approach preserves the periosteal blood supply of the bone and optimizes biological healing conditions. Nowadays, angular stable plates offer significant advantages in stability and quality of care with convincing results.

Combination of Plate and Intramedullary Pin (Plate-Rod Technique):

Severe comminuted fractures are often treated with a combination of plate and intramedullary pin. In comminuted fractures, small fracture fragments are present, and excessive manipulation of these fragments can unnecessarily destroy blood supply. In such cases, it is crucial to minimize manipulation of the fragments. The intramedullary nail is placed first, allowing alignment of the femur and subsequent attachment of the plate. The plate is adjusted to the shape of the upper and lower fragments and secured with screws to the main fragments. Biomechanical studies have shown that this technique provides significant mechanical strength in fracture management.

External Fixator:

In this method, drill wires are inserted into the bone distal and proximal to the fractured area. This technique is quick, minimally traumatizing, and the wires can be removed without further invasive surgery. External fixation is very stable against axial compression and rotational forces but less effective against bending forces. The weakness of an external fixator against bending forces can be balanced with an additional intramedullary pin. Generally, at least two drill wires per bone fragment are required, which are then connected and stabilized with an external bridge. This bridge can be made of standard metal clamps and connecting rods or lightweight moldable polymer plastics (Techno-Vit®). Despite the fracture-near stabilization with minimal access trauma and preservation of soft tissues, this method also has certain complications. For example, patients can catch the external fixator on furniture or other obstacles, and the entry points of the drill wires are potential entry points for germs. The risk of infection increases with more “disturbance” and movement or shifting of skin and subcutaneous tissue around the pins. To protect the sutures and fixator, a bandage may be applied.

Postoperative Care:

Fracture management is only the first step toward recovery. Careful postoperative follow-up ensures optimal healing and is therefore part of successful treatment. During the postoperative phase, it is crucial to work closely with your surgeon and your veterinarian to avoid potential complications. During postoperative follow-up, we, together with your pet’s veterinarian, will monitor the healing process, perform bandage changes, and take follow-up X-rays. Additional physiotherapeutic measures will depend on the healing phase and the individual patient’s complaints.

Author: Dirsko J.F. von Pfeil, Dr. med. vet., DVM, DACVS, DECVS, DACVSMR, DECVSMR

ACVS Founding Fellow, Minimally Invasive Surgery (Small Animal Orthopedics)

European Board of Veterinary Specialisation (EBVS®) European Specialist: Small Animal Surgery

PRP (Platelet Rich Plasma) Therapy

In therapeutic PRP (Platelet Rich Plasma) therapy, the patient’s own processed blood is used to accelerate the healing of injured wounds, ligaments, tendons, muscles, and joints. For instance, the healing phase for tendon injuries is significantly shortened, and the newly formed tissue largely matches the original cell quality, allowing for good resilience. Due to its anti-inflammatory effects, PRP therapy is also used to treat arthritis, reducing inflammation in the affected joint. Blood is drawn from the patient and processed using a centrifuge to concentrate the platelets. Since the body does not react negatively to its own blood, side effects are very rare.

• Osteoarthritis
• Tendon injuries
• Fractures