Clean Run Magazine - April 2008 - 77

COURTESY SHERMAN CANAPP Figure 2. Chronic FCP with severe osteoarthritic progression Figure 3. JDS diagnosed on arthroscopic examination Figure 4. Arthroscopic fragment removal Orthopedic Examination On physical examination discomfort is usually noted on direct palpation of the medial compartment of the elbow joint, specifically the medial coronoid process. Discomfort may also be noted on hyperflexion of the elbow. Most dogs with JDS are reluctant to allow for full endrange flexion. In chronic cases, full flexion may not be obtained. Crepitus (“popping or grinding sensation”) may be noted when placing the elbow through range of motion. Some investigators suggest that the carpus should be placed in a flexed, externally rotated position while the elbow is extended. Joint effusion (fluid leakage) may be detected as a fluctuant swelling beneath the lateral or medial epicondyle of the humerus. Depending on the chronicity, atrophy may be noted in the affected forelimb. tests, and “palpation” of intra-articular tissues using arthroscopic instrumentation. Arthroscopic exploration of the elbow provides a definitive diagnosis of JDS when a fragment or cartilage fissure is observed as shown in Figure 3. In a small percentage of cases, advanced imaging (nuclear scan, CT, MRI) indicates fragmentation of the coronoid but arthroscopic observation does not reveal a fissure or fragment. In such cases, the fissures (microcracks) are believed to be within the coronoid bone beneath the cartilage surface. surgical approach of fully opening the joint. Medical Management Following arthroscopic treatment, dogs are typically prescribed NSAIDs for 14 days to help decrease inflammation and discomfort. Adequan (polysulfated glycosaminoglycans), an injectible joint protective agent, is also recommended following arthroscopic treatment and is administered intramuscularly twice a week for up to four weeks. Adequan has been shown to decrease the amount of degradative enzymes (that stimulate inflammation and cartilage erosion) as well as promote repair and regeneration of cartilage. In addition, an oral joint protective agent such as Dasuquin, which contains glucosamine, chondroitin sulfate, avocado/soybean unsaponifiables (ASU), +/- methylsulfonylmethane (MSM), is recommended as a daily supplement for life. The anti-inflammatory properties and pain-reducing effects of these supplements have been well-documented. There is also evidence that they may have a cartilageprotective effect. Treatment Treatment of JDS is multimodal and includes a combination of medical and surgical management as well as rehabilitation therapy. The objectives of therapy should be to first remove the inciting cause so that medical management and rehabilitation can be effective (think of this as first taking the pebble out of the shoe). Through a multimodal approach it is possible to relieve pain and maintain limb function, as well as to return the dog to a normal level of activity. Diagnostics In addition to history, gait analysis, physical examination, orthopedic and neurologic examinations, further diagnostic tests used to differentiate causes of elbow pathology currently consist of hematology, biochemical profile, urinalysis, arthrocentesis, imaging modalities, and arthroscopy. Unfortunately, radiographs (x-rays) have been shown to be of little value because of difficulty identifying the fragment or line of separation using standard radiography. In some chronic cases, however, radiographs may reveal secondary evidence of bony remodeling consistent with osteoarthritis. These changes may include sclerosis (thickening or hardening) within the ulnar notch, and remodeling along the anconeal process and MCP. Advanced diagnostic imaging modalities such as CT scans, MRI, nuclear scans, and arthroscopy may allow confirmation of the condition. Arthroscopic evaluation of the elbow joint allows direct observation of all major intra-articular structures with magnification, “dynamic” evaluation of tissues during elbow range-of-motion April 08 | Clean Run Arthroscopy Arthroscopy is an excellent modality for diagnosing JDS as well as a minimally invasive means of treatment. Arthroscopic removal of the fragments is recommended not only to remove the inciting cause of lameness but also to help prevent the progression of osteoarthritis. Arthroscopic treatment may include a combination of techniques such as fragment removal, debridement of diseased tissues, creation of vascular access by abrasion arthroplasty, forage, microfracture, and subtotal coronoid ostectomy depending on the progression and severity of disease as seen in Figure 4. Arthroscopy is not only a great diagnostic modality, allowing for superior visualization of structures within the joint, but also has less soft tissue trauma, shorter surgery and hospitalization times, decreased risk of infection, and shorter recovery times compared to the traditional Rehabilitation Therapy R e h abi l it at i on t h e r apy fo l l ow i ng arthroscopic treatment includes a combination of techniques such as cryotherapy (ice therapy), modalities (such as laser therapy), manual therapies, and a home exercise program. Rehabilitation therapy is used to help decrease post-operative inflammation and swelling, build muscle mass, improve comfort and increase range of motion. This improved muscle mass and range of motion will provide long term pain relief as well as better overall function of the limb and improved quality of life. Therapy sessions are typically performed at a rehabilitation center weekly and the exercise program at home 2 to 3 times a day. Recovery following arthroscopic treatment for JDS is typically 2 to 3 months with return to sport at approximately 4 to 5 months. 77

Clean Run Magazine - April 2008

Table of Contents for the Digital Edition of Clean Run Magazine - April 2008