Elbow Dysplasia refers to four diseases:
1.Fragmented Coronoid Process (FCP) or Medial Coronoid Disease (MCD) 2.Ununited Anconeal Process (UAP) 3.Osteochondritis dissecans (OCD) 4.Elbow incongruity (EI)
These diseases are unrelated in their development. Each disease occurs independently of the others, although some dogs can be affected by more than one disease.
MCD/FCP is a “multifactorial” disease. Genetic factors have been shown to be most important in affected dogs, and we recognize a number of breeds of dog that are most commonly affected (e.g. Labradors, Retrievers, Rottweilers, Bernese Mountain Dogs). Other factors such as rapid growth as a puppy, obesity, dietary / nutritional problems, and hormonal imbalances may all contribute to development of disease.
The “coronoid process” is a normal part of the ulna - one of the major three bones that make up the elbow joint (ulna, radius and humerus). It forms the part of the ulna which sits under the humerus at the base of a cup-shaped part of the ulna called the ulnar notch.
FCP/MCD starts by formation of micro-cracks in the bone of the coronoid process - a type of stress fracture. This happens due to excessive mechanical forces being transmitted through the coronoid process. We believe that the precise cause of this varies between different dogs, but in most dogs is a result of abnormal shape, size or mechanical relationship between the three major bones that make up the elbow joint – for example where the radius is slightly short, where the ulnar notch doesn’t fit properly or where the muscles pull excessively on the ulna by comparison with the radius. As the micro-cracks form, bits of bone and cartilage can fracture off completely (Fragmented Coronoid Process) or the cartilage covering on top of the bone (within the elbow joint) can become damaged or eventually worn away (Medial Coronoid Disease).
As soon as MCD/FCP starts to develop, osteoarthritis (inflammation of the cartilage, fluid, fluid sac / synovium and bones) immediately starts to develop too. Most dogs already have OA by the time they see us and it cannot be cured, but can be effectively managed for most patients.
The symptoms caused by MCD/FCP are very variable. The most common symptoms include forelimb lameness, stiffness, elbow pain, reluctance to exercise or play, or general depression. However, many dogs have the disease in both elbows, and may become accustomed to the disease over a long period of time, so the symptoms may very subtle and may only become apparent following examination by an experienced orthopaedic surgeon.
MCD/FCP is typically diagnosed by a combination of examination by an experienced orthopaedic surgeon, x-rays of the elbow joints, and arthroscopy (examination of the elbow joint by keyhole surgery). No single test in isolation can reliably diagnose MCD/FCP in all dogs, and occasionally further tests such as CT or MRI scans and laboratory tests may be needed to confirm a diagnosis. X-rays alone can be inconclusive and may be non-specific for MCD/FCP.
Various treatment options are available. The best treatment option for each dog can only be recommended following thorough assessment of the severity of disease, particularly on clinical examination, x-rays and arthroscopy.
1.Non-surgical management Four basic methods are usually recommended:
Body weight management Exercise modification and physiotherapy Anti-inflammatory / pain relief medications Nutraceutical supplements (e.g. glucosamine, chondroitin sulphate, pentosan polysulphate, Green-lipped Mussel extract)
2.Surgical removal of cartilage flap / débridement Surgical removal of the cartilage flap in OCD allows the cartilage defect to heal by scar cartilage formation over the course of several weeks. Scar cartilage (fibrocartilage) is less robust than healthy joint (hyaline) cartilage, so although this allows some of the joint inflammation to resolve in the short-term, the joint will remain abnormal with ongoing development of osteoarthritis and cartilage wear. We currently recommend this surgery for very small or shallow disease lesions and this can be done arthroscopically (keyhole).
REFERRAL OPTIONS
3.Osteochondral Autograft Transfer System (OATS) Over recent years, the OATS™ (Arthrex, Naples, FL) system has been modified for use in the canine elbow. This system has been used for many years in human joints to resurface cartilage lesions including OCD, with positive long-term results. It involves collection of a cylinder of bone and cartilage from a non-contact area of a healthy joint (usually the knee) and transplanting it into a joint affected by OCD in order to resurface the cartilage defect with healthy hyaline cartilage. This procedure is often combined with an ulnar osteotomy (cutting one of the bones in the forearm) to protect the new cartilage cap, and excellent results have been achieved in a large number of dogs by this technique.
More recently, this technique has been modified to allow transplantation of synthetic polyurethane cylinders instead of bone and cartilage cylinders, avoiding the need to collect the cylinder from the knee joint and reducing surgical time.
4.Total Elbow Replacement (TER) In some dogs with long-standing elbow OCD (usually those also affected by other forms of elbow dysplasia as well as OCD), osteoarthritis may be extremely severe with little healthy cartilage. In this circumstance, the procedures above may be unable to restore comfortable, functional joint use. Total Elbow Replacement is a “salvage” procedure (i.e. it is performed as a last resort where other treatments will be ineffective) and involves replacing the entire elbow joint surface with metal and plastic implants.
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