Sliding Humeral Osteotomy: Medium-Term Objective Outcome Measures and Reduction of Complications With a Modified Technique

Effect of Medial Opening Wedge and External Rotational Humeral Osteotomies on Medial Elbow Compartment Pressure: An Ex Vivo Study

OBJECTIVE

 The aim of this study was to assess if the level of osteotomy (50 or 75% the length of the humerus), osteotomy angle (5, 10, or 20 degrees), direction of bone alteration (external rotational or medial opening wedge osteotomies), or orientation of osteotomy (perpendicular to the humeral long axis or perpendicular to the weight-bearing axis of the limb) affect pressure through the medial compartment of the elbow.

STUDY DESIGN

 Humeral osteotomies were performed at 50 and 75% the length of the humerus on 12 canine cadaver thoracic limbs and patient-specific three-dimensional (3D) printed plates applied to induce the desired alteration. Sensors were placed into the medial and lateral aspects of the elbow joint and the limb compressed to 90 N in a universal testing system.

RESULTS

 Increasing the angle of the induced change had a significant effect on the decreased load through the medial compartment. Performing the osteotomy at 75% of humeral length from proximal was significantly more effective at reducing the medial elbow load than performing it at 50%. Opening wedge osteotomies were more effective than external rotational osteotomies, but both were effective. Changing the direction of the osteotomy (comparing transverse to oblique) did not significantly affect the load reduction through the medial compartment.

CONCLUSION

 Performing an osteotomy at a more distal location along the humerus and increasing the angle of the induced change increased the effectiveness of load-shifting humeral osteotomies.

Population pharmacokinetic meta-analysis of five beta-lactams antibiotics to support dosing regimens in dogs for surgical antimicrobial prophylaxis

The Pharmacokinetic/Pharmacodynamic (PK/PD) relationship of antimicrobial drugs (AMD) for surgical prophylaxis has been poorly studied, hampering evidence-based decision making around AMD dosing and timing. Our objective is to use PK/PD principles to inform (1) the timing of administration and (2) the interval for re-administration of AMD used peri-operatively in dogs. Raw plasma concentrations of cefazolin, cefuroxime, cefalexin, amoxicillin and ampicillin were retrieved from original intravenous studies performed in dogs. E. coli and methicillin-susceptible staphylococci were identified as possible intraoperative contaminants and their epidemiological cut-offs (ECOFF) were retrieved from the EUCAST database. Individual PK data were refitted with non-linear mixed effect models (Phoenix®). We performed Monte Carlo simulation to compute i) the 95th percentile of time of peak concentration in the peripheral compartment (informing timing between administration and first incision) and ii) the duration for which at least 90% of dogs maintain a free plasma concentration above ECOFF (informing timing of re-administration: 1.5-4 h). Cefazolin (22-25 mg/kg), cefuroxime (20 mg/kg), cefalexin (15 mg/kg) and amoxicillin (16.7 mg/kg) reached peak peripheral concentrations within 30 min, but ampicillin (20 mg/kg) required 82 min, respectively. For methicillin-susceptible staphylococci, cefazolin and cefuroxime require re-administration every 2 h, whereas cefalexin and both amoxicillin and ampicillin can be readministered every 3 and 4 h, respectively. For E. coli, only cefazolin provided adequate perioperative coverage with 2-hourly administration, where cefuroxime and cefalexin failed uniformly. Alternatively, ampicillin and amoxicillin (critically ill dogs) may cover E. coli contaminations, but only if readministered every 1.5 h. These PK-derived conclusions provide a rationale for perioperative AMD administration timing.

Long-term outcomes in dogs with elbow dysplasia, assessed using the canine orthopaedic index

BACKGROUND

Elbow dysplasia (ED) is an important cause of lameness in dogs. This study aimed to report long-term outcomes in dogs with elbow osteoarthritis.

METHODS

Demographic data, medical management, and scores from The American College of Veterinary Surgeons' Canine Orthopaedic Index (COI) were collected from owners of dogs radiographically screened for ED, graded as normal, mild, or moderate. Telephone interviews were performed in 2017 (Q1), followed by an email survey in 2020 (Q2). The association between ED grade and deterioration in COI scores over time was evaluated with logistic regression.

RESULTS

A total of 765 replies were collected for Q1 and 293 for Q2. At Q2, 222 dogs (76%) were alive, with a median age of 8 years (range 5-12 years). No association was found between ED and changes in COI score over time or between ED and survival (p = 0.071). Dogs with mild and moderate ED were treated with analgesic medications to a higher degree than dogs without ED (p < 0.05).

LIMITATIONS

Only owner-assed data were assessed; no clinical orthopaedic examination or follow-up radiographic evaluation was performed.

CONCLUSIONS

No association was found between the grade of ED and the worsening of clinical signs in dogs with elbow osteoarthritis.

Lateral Approach and Plate Rod Sliding Humeral Osteotomy in Dogs-A Short Case Series

Five dogs of different breeds and ages were diagnosed with medial compartment disease of the elbow (MCDE). To resolve the condition, a modified technique using a lateral approach and plate/rod sliding humeral osteotomy (SHO) was considered. All dogs recovered uneventfully after surgery. There were no major complications, and all dogs were significantly improved compared to pre-operative condition. This novel technique of adding a pin, based on the alteration of the original technique, optimized resistance to fixation failure. An additional benefit was that the lateral approach was surgically familiar and easily allowed bone grafting. All five dogs treated with the novel approach had improved scores for pain and lameness. This study showed that SHO was more stable and less technically demanding with the addition of an intramedullary pin. This is the first report of a lateral approach and plate rod sliding humeral osteotomy to treat MCDE in dogs.

The use of lateral arthroscopy portals for the management of bilateral osteochondritis dissecans of the radial head in an English bulldog

OBJECTIVE

To report a case of bilateral radial head osteochondritis dissecans (OCD) in a dog treated via lateral elbow arthroscopy portals.

STUDY DESIGN

Case report.

ANIMALS

Six month old female spayed English bulldog.

METHODS

The dog was presented for a left thoracic limb lameness localized to the elbow. Computed tomography revealed bilaterally symmetrical mineralized fragments in the lateral compartment of the elbow joint and blunting of the medial coronoid processes. The fragments were associated with a thin donation bed along the caudolateral articular surface of the radial head with moderate surrounding subchondral bone sclerosis. Bilateral elbow arthroscopy was pursued. Arthroscopy was initiated via a standard medial approach, which allowed for abrasion arthroplasty of the radial incisure and medial coronoid process but provided insufficient access to the radial head lesions. A lateral arthroscopic approach was subsequently performed and provided excellent access to the radial head for fragment retrieval and abrasion arthroplasty.

RESULTS

Histopathology of the radial head fragments revealed mild cartilage degeneration and retention of cartilaginous cores within subchondral bone, consistent with OCD. Complete resolution of lameness and elbow pain were observed on clinical examination 5 months postoperatively.

CONCLUSION

Radial head OCD can occur as a rare component of elbow dysplasia in growing dogs, and fragment retrieval with abrasion arthroplasty via lateral arthroscopic portals may be an effective treatment option.

Proximal Abduction Ulnar Osteotomy (PAUL): Short- and Long-Term Evaluation in Dogs Presenting Medial Compartment Disease

Simple Summary

Developmental elbow disease is one of the main causes of lameness in the canine species and occurs often in large and giant breed dogs. The most frequent manifestation of this pathology is known as medial compartment disease due to a physiological overload in the medial region of the elbow. It is considered as a complex disease and the treatment is focused on relieving the pain and slowing the progression of osteoarthritis. The Proximal Abduction Ulnar Osteotomy (PAUL) technique is one of the newest techniques whose purpose is the transmission of loads from the medial to the lateral compartment. In this prospective case series, the authors use the combination of elbow arthroscopy and the PAUL technique and report a significant improvement in clinical signs, showing a low major complications rate with a high degree of owner satisfaction.

Abstract

The aim of the study is to report the results obtained from performing a Proximal Abduction Ulnar Osteotomy (PAUL) technique in a cohort of dogs with medial compartment disease with short- and long-term follow-up, assessing the perception of the owners and describing the long-term complications associated with the technique. This is a clinical prospective study, including dogs diagnosed with medial compartment disease treated with elbow arthroscopy and PAUL between 2013 and 2020. Long-term follow-up data and postoperative complications were registered, and a questionnaire adapted from Fitzpatrick et al. 2009 was collected from owners. Thirty-three elbows in 26 dogs were included. The duration of follow-up ranged from 4 to 61 months (median: 24.76 months). At the end of the study, 73.1% of the owners reported excellent satisfaction and 74.1% of the owners would repeat the surgery in the same circumstances. The owner questionnaire showed a greater capacity to walk and run, without lameness and pain, and climb up and down stairs a year after surgery, being constant at the end of the study. Major postoperative complications were documented in 4/33 elbows (12.12%), including delayed union, implant failure, and osteophytosis of the medial aspect of the coronoid process. In conclusion, elbow arthroscopy and the PAUL technique achieved an evident improvement in the quality of life of patients with great satisfaction for most of the owners.

Canine Elbow Dysplasia: Medial Compartment Disease and Osteoarthritis

Erosion of the articular cartilage of the medial compartment of the elbow (the humeroulnar articulation) secondary to incongruency associated with elbow dysplasia or traumatic injury has been termed, medial compartment disease. When nonsurgical strategies to manage osteoarthritis (OA) fail, surgical solutions may be warranted. Surgical strategies reduce pain through off-loading of the medial compartment by load-shifting osteotomies of the humerus or ulna. Other strategies involve replacement of portions or all of the articular surface of the medial compartment. With global elbow joint OA (medial and lateral compartment), a total elbow replacement may be required.

Long-Term Prognosis of Quality of Life in Dogs Diagnosed With Mild to Moderate Elbow Dysplasia in Sweden

Objective: The objective of this study was to increase knowledge regarding long-term prognosis of mild to moderate elbow dysplasia (ED) using a canine orthopedic index.

Study Design: Cross-sectional observational study.

Sample Population: Sixty dogs randomly selected from each of five different breeds and three ED groups: ED0 (control), ED1, and ED2, based on the Kennel Club's screening results. The total number of selected dogs was 900 (60^*5^*3).

Methods: Questionnaires were administered to owners by telephone interview. Bayesian network modeling was used to assess the relation between ED grade, treatment options, dog demographics, and quality-of-life indicators.

Results: Seven hundred sixty-five questionnaires were collected (85% response rate), of which 61 concerned dogs euthanized due to osteoarthritis. There was no direct association between ED grade and owner's perceived quality of life, but ED1 and ED2 dogs were more likely to receive veterinary care and subsequent NSAID treatment compared to ED0 dogs. A significant association was found between the occurrence of euthanasia due to orthopedic disease and ED scores 1 and 2 in the sample (p < 0.001).

Conclusion: The degree of osteoarthritis was not directly associated with the canine orthopedic index, except for ED2 and lameness score. It can be speculated that owners who paid closer attention to orthopedic symptoms and perceived them as impairing their dogs' lives were also more likely to seek veterinary care and get treatment, irrespective of the ED grading.

Impact: ED1-graded dogs had a lower risk than might be expected to develop visible clinical symptoms and showed a similar quality of life as dogs with ED0. ED2-graded dogs were more likely than ED0-graded dogs to have their lives impaired by lameness, according to the owners' perception.

Mid- to Long-Term Outcome after Arthroscopy and Proximal Abducting Ulnar Osteotomy Versus Arthroscopy Alone in Dogs with Medial Compartment Disease: Thirty Cases

OBJECTIVE

 The aim of this study was to determine owner-assessed mid- to long-term outcome for dogs with medial compartment disease treated arthroscopically with fragment removal with or without proximal abducting ulnar osteotomy (PAUL).

STUDY DESIGN

 This was a retrospective clinical study.

MATERIALS AND METHODS

 Records from 30 dogs with medial compartment disease treated with arthroscopy with or without PAUL were retrospectively reviewed over a 5-year period. Proximal abducting ulnar osteotomy cases were matched to arthroscopy-alone controls based on bodyweight and modified Outerbridge score. Outcome was assessed via owner questionnaire using the Canine Brief Pain Inventory (CBPI), frequency of non-steroidal anti-inflammatory drug (NSAID) administration and owner-assessed overall improvement.

RESULTS

 Canine Brief Pain Inventory score for dogs in the PAUL group was not significantly different from the control group (p = 0.54). Non-steroidal anti-inflammatory drug administration was similar between groups (p = 0.61) and there was no significant difference between modified Outerbridge score and outcome (p = 0.57) over a median of 43 months post-surgically (range: 7-66 months). Canine Brief Pain Inventory and NSAID use were affected by the age of the dog with dogs greater than 3 years of age at the time of surgery having a higher CBPI score and increased NSAID use regardless of the surgery that was performed. Overall, owner-assessed improvement was not different between groups (p = 0.72).

CLINICAL SIGNIFICANCE

 Proximal abducting ulnar osteotomy showed no owner-assessed benefit over arthroscopic medial coronoid fragment removal for dogs with medial compartment disease and modified Outerbridge score of 3 or greater. A prospective, blinded, controlled clinical trial is warranted to determine the appropriate clinical application of the PAUL procedure.

Effect of proximal abducting ulnar osteotomy (PAUL) on frontal plane thoracic limb alignment: An ex vivo canine study

OBJECTIVE

To determine the effect of proximal abducting ulnar osteotomy (PAUL) on frontal plane thoracic limb alignment in standing and recumbent positions.

STUDY DESIGN

Ex vivo cadaveric study.

SAMPLE POPULATION

Canine thoracic limbs (n = 15 limb pairs).

METHODS

Limbs were acquired from healthy Labrador retrievers that had been euthanized for reasons unrelated to this study. A limb press was used to obtain standing and recumbent caudocranial radiographs before and after PAUL. Foot lateralization and rotation were directly measured in standing position. Mechanical joint angles were determined using full limb radiographic montages and the center of rotation of angulation (CORA) method for pre-PAUL (Pre), 2-mm PAUL (PAUL2), and 3-mm PAUL (PAUL3). Data are reported as mean ± SD and 95% CI. Mixed linear modeling was used to identify differences in limb alignment values and foot position, with significance established at P ≤ .004.

RESULTS

There were differences in five of 12 limb alignment values pre-PAUL and post-PAUL in standing and recumbent positions. In the standing position, there was an increase in mechanical medial proximal radioulnar angle (Pre, 80.6° ± 2.5°; PAUL2, 82.6° ± 2.4°; PAUL3, 84° ± 2.4°) and a decrease in elbow compression angle (Pre, 1.4° ± 1.3°; PAUL2, 1° ± 0.9°; PAUL3, 0.8° ± 1°). There was a movement of mechanical humeral radioulnar angle (Pre, -8.9° ± 2.8°; PAUL2, -6.1° ± 2.7°; PAUL3, -5.2 ± 2.7°), mechanical thoracic humeral angle (Pre, 3.9° ± 1.7°; PAUL2, 2.4° ± 1.4°; PAUL3, 2.6° ± 1.5°), and elbow mechanical axis deviation (Pre, 1.9% ± 1.1%; PAUL2, 0.9% ± 1.1%; PAUL3, 0.4% ± 1.4%) toward a value of "0" representing coaxial alignment of the limb. The foot underwent lateralization (Pre, 1.4 ± 0.6 cm; PAUL2, 1.8 ± 0.7 cm; PAUL3, 2.3 ± 0.7 cm) and external rotation (Pre, 10.5° ± 4.7°; PAUL2, 13.7° ± 5.1°; PAUL3, 16° ± 6.6°).

CONCLUSION

In the ex vivo setting, PAUL resulted in translation of the mechanical axis of the thoracic limb from a medial to lateral direction through alterations in limb alignment values associated with the elbow, humerus, and proximal radius/ulna.

CLINICAL SIGNIFICANCE

Additional studies are required to determine whether PAUL alters thoracic limb alignment in client-owned dogs.

Effect of intraarticular inoculation of mesenchymal stem cells in dogs with hip osteoarthritis by means of objective force platform gait analysis: concordance with numeric subjective scoring scales

Background

Subjective pain assessment scales have been widely used for assessing lameness in response to pain, but the accuracy of these scales has been questioned. To assess scale accuracy, 10 lame, presa Canario dogs with osteoarthritis (OA) associated with bilateral hip dysplasia were first treated with mesenchymal stem cells. Then, potential lameness improvement was analyzed using two pain scales (Bioarth and visual analog scale). These data were compared with similar data collected using a force platform with the same animals during a period of 6 months after treatment.

Results

The F test for intraclass correlation showed that concordance in pain/lameness scores between the 2 measuring methodologies was not significant (P value ≥ 0.9213; 95 % confidence interval, –0.56, 0.11). Although subjective pain assessment showed improvement after 6 months, force platform data demonstrated those same animals had returned to the initial lameness state.

Conclusion

Use of pain assessment scales to measure lameness associated with OA did not have great accuracy and concordance when compared with quantitative force platform gait analysis.

Electronic supplementary material

The online version of this article (doi:10.1186/s12917-016-0852-z) contains supplementary material, which is available to authorized users.

COMPUTED TOMOGRAPHIC FINDINGS IN CANINE ELBOWS ARTHROSCOPICALLY DIAGNOSED WITH EROSION OF THE MEDIAL COMPARTMENT: AN ANALYTICAL METHOD COMPARISON STUDY

Medial compartment erosion is an advanced stage of medial coronoid disease, an important cause of elbow lameness in dogs, with treatment and the expected prognosis depending on the extent of the cartilage lesions. The identification of specific computed tomographic (CT) findings might facilitate the nonsurgical diagnosis and add to treatment decision making. Aims of this retrospective, analytical, method comparison study were to describe CT findings in elbows of dogs arthroscopically diagnosed with medial compartment erosion and to compare CT vs. arthroscopic findings. A total of 56 elbows met inclusion criteria. Elbows with focal (n = 13), diffuse (n = 11), and complete (n = 32) erosion were compared. Prevalence findings for CT lesions were as follows: periarticular osteophytosis (100%), abnormal shape of the medial coronoid process of the ulna (96.4%), and subchondral bone defect of the medial part of the humeral condyle (MHC; 96.4%). The three groups significantly differed for presence of medial coronoid process fragmentation, radial head subchondral bone sclerosis, and widening of the humeroulnar joint space. No significant agreement was found between CT and arthroscopy for presence of a subchondral bone defect of the MHC. A significant agreement was found between CT and arthroscopy for presence of fragmentation of the medial coronoid process. However, some of the calcified body/fragment(s) visualized on CT in the region of the medial coronoid process could not be identified via arthroscopy. Findings indicated that an accurate estimation of the extent of the elbow cartilage lesions still requires arthroscopic joint inspection.