Pull out a veterinary textbook, look up canine elbow dysplasia and under the prognosis section you’ll discover the one word that says it all¾guarded. Elbow dysplasia is one of the most frustrating orthopedic challenges out there, not least as dogs age and succumb to the inevitable secondary changes brought on by the consequences of a less than perfect cubital joint.
Arthroscopy provides an early, excellent opportunity to address many of the fundamental underlying imperfections¾the fragmented coronoid process, the humeral osteochondrosis lesion, the ununited anconeus¾but regardless of whether we opt for a medical or a surgical approach, degenerative changes will take place in the form of osteoarthritis. The goal of periarticular new bone and fibrous scar tissue may prove initially beneficial, reducing and restricting painful motion, but over time, the progressive nature of these adaptive changes can have a severe and debilitating effect that has a major negative impact on quality of life.
Pain management has emerged as a vital specialty in its own right, not least in the management of chronic elbow arthritis. But what are your options when you’ve worked your way through the non-steroidal anti-inflammatories, the joint supplements, you’ve tried the physical therapy, the weight control and the holistic approaches? Do we have anything else to offer?
Moseley, an eight-year-old, neutered male Labrador made me realize that the answer is definitely yes. Mosely presented to Angell with a six-year history of left forelimb lameness that had been getting progressively worse during the last year. He had worked his way through carprofen, gabapentin, tramadol and Adequan, but chronic lameness and pain were significantly impacting limb function. His owners were interested to find out if there was anything else we might offer.
From a surgical standpoint, when it comes to end stage elbows, elbow arthrodesis and even amputation are reserved for cases of intractable pain where euthanasia has become a realistic consideration. Now, thanks to recent advances in surgical techniques and available implants, total elbow replacement has become a viable option.
There are many types of elbow replacement systems commercially available, but Mosely underwent a surgery using the TATE system, designed by Dr. Randy Acker, and manufactured by Biomedtrix. The system is described as semi-constrained, making use of the existing joint capsule and implant shape to impart stability. It is non-cemented, employs a bone “milling” technique to increase precision and reduce time, and takes out the problematic micromotion between the radius and ulna by fusing these bones at the time of implantation.
Dr. Acker was kind enough to join me for Moseley’s procedure. Like most dogs that undergo this procedure, Moseley was discharged two days after surgery. Exercise restriction is essential for the next two to three months and physical therapy, especially hydrotherapy, can be a highly beneficial to their recovery. In an unpublished collection of data from thirty elbow replacements, 95% of owners reported a good to excellent improvement in attitude and activity due to reduction in pain. Complications were noted in less than 7% of dogs.
The surgical procedure is technically demanding and the implant costs are high. However, the use of non-cemented implants, a medial approach to the elbow, combined with fusion of the radius and ulna, can create an arthroplasty of a challenging joint capable of results far more appealing than the grim alternative of elbow arthrodesis or even limb amputation.