ELBOW MASS IN A DOG

Written by Marielle Goossens, DVM, DACVIM, Noelle Bergman, DVM, MS, DACVIM (Oncology) and Kendra E.F. Knapik, DVM, DACVIM (Oncology)

 

Phineas, a 7-year-old Flat Coated Retriever, was presented to Peak for evaluation of left thoracic limb lameness of 10 month duration. During physical examination, marked soft tissue swelling and decreased range of motion of the left elbow was noted. Radiographs of the left elbow showed marked bone proliferation associated with the elbow joint. The radiographic and physical exam findings were most consistent with a mass arising from the elbow joint. Since neoplasia was the top differential diagnosis for a mass in the elbow of a middle-aged Flat Coated Retriever, thoracic radiographs were ordered. No evidence of intrathoracic metastasis was observed. A CT scan was performed next, and a mass enveloping the left elbow was confirmed. An incisional biopsy of the mass was taken prior to recovering Phineas from anesthesia.
 

 
The histopathologic diagnosis was a sarcoma, and the pathologist was most suspicious that this tumor was of histiocytic origin given the signalment of the patient, tumor location, and the microscopic features of the biopsy. The mitotic index was 14, and there was marked anisocytosis and anisokaryosis with multifocal cytomegaly, karyomegaly, and multinucleated giant cells. The neoplastic cells extensively invaded the adjacent skeletal muscle. Other differentials for a tumor arising from the joint that were considered included a synovial cell sarcoma and other soft tissue sarcomas. Phineas was referred to the Oncology Service for consultation regarding the biopsy findings.

 

Diagnostic Work Up

Special stains were ordered to confirm the diagnosis of histiocytic sarcoma. The neoplastic cells were diffusely positive for both CD18 and CD204, which are two markers for cells of histiocytic origin.

Histiocytic sarcoma (HS) is a malignant neoplasm of histiocytic cells. Dog breeds that are overrepresented with this neoplasm include Bernese Mountain Dogs, Flat-Coated Retrievers, and Rottweilers.These tumors can present in two main forms: localized and disseminated. The localized form involves a single primary tumor arising from a joint, cutaneous or subcutaneous tissue, lung, or essentially anywhere in the body. Patients with the disseminated form present with an advanced stage of disease and often with multiple visceral organs involved. Most commonly the liver, spleen, lungs, and lymph node are affected. The prognosis for dogs with the localized form of the disease is significantly better than the disseminated form. The localized form of HS has been shown to have a median survival time beyond 500 days following treatment compared to several months with the disseminated form. Commonly, patients with the disseminated form present with signs of systemic illness including weight loss, anorexia, vomiting, and occasionally, fever. Despite the superior prognosis, localized histiocytic sarcomas still have a high risk of metastasis to lymph nodes, lung, liver, spleen, and other organs.

Treatment and Follow-up

Given the high risk of metastasis, an abdominal ultrasound was recommended for Phineas. No evidence of abdominal metastasis was observed. Since Phineas’ disease was confined to his elbow based on the staging tests, a left forelimb amputation was recommended followed by chemotherapy with CCNU (lomustine). Periarticular forms of HS have been shown to have a significantly improved prognosis over HS arising from other organs. Periarticular HS that has not metastasized has been shown to have a median survival time of 980 days following treatment in one study. While amputation is the treatment of choice, palliative radiation therapy can also be used to help control pain in patients that are not candidates for amputation.

CCNU is the chemotherapy drug of choice for HS. The response rate in the gross disease setting has been reported to be 40-60%. For patients that develop progression of their disease with CCNU, doxorubicin with zoledronate (a bisphosphonate) is another option. This combination of drugs has displayed synergistic cell death in in vitro studies evaluating HS. Anecdotally, impressive responses have been observed with this drug combination in practice as well.

Phineas recovered well from his forelimb amputation despite concurrent orthopedic diseases (elbow dysplasia and history of a TPLO on a hind limb). His orthopedic diseases were managed with a combination of carprofen, gabapentin, amantadine, and Dasaquin. Following limb amputation, Phineas was started on chemotherapy. He received 6 doses, which were administered every 3 weeks. Restaging tests with thoracic radiographs and abdominal ultrasound were performed in the middle of the chemotherapy protocol and again at the end. No evidence of metastatic disease was observed at either time point. We have continued to monitor Phineas with these staging tests every 3 months. Phineas was diagnosed in August 2016 and was clear of disease on his most recent staging tests.


REFERENCES:
  1. Withrow, S.J., D.M. Vail, R.L. Page. Small Animal Clinical Oncology. St. Louis: Elsevier Saunders, 2013. Print.
  2. Klahn, SL, BE Kitchell, NG Dervisis. Evaluation and comparison of outcomes in dogs with periarticular and nonperiarticular histiocytic sarcoma. J Am Vet Med Assoc 239.1 (2011): 90-96.
  3. Skorupski, KA, et al. CCNU for the treatment of dogs with histiocytic sarcoma. J Vet Intern Med 21.1 (2007): 121-126.
  1. Skorupski, KA, et al. Long-term survival in dogs with localized histiocytic sarcoma treated with CCNU as an adjuvant to local therapy. Vet Comp Oncol 7.2 (2009): 139-144.
  1. Hafeman, SD, D Varland, SW Dow. Bisphosphonates significantly increase the activity of doxorubicin or vincristine against canine malignant histiocytosis cells. Vet Comp Oncol 10.1 (2012): 44-56.

A Lameness Puzzle

Written by Marielle Goossens, DVM, DACVIM

 

Presentation and Physical Exam

Daniel, a 3 year old, male, castrated, Golden Retriever presented to Dr. Kurt Schulz at Peak’s Surgery service for evaluation of a 2 month history of worsening lameness of the right hind leg. Radiographs of the right knee joint had only shown some soft tissue swelling and no other abnormalities. Daniel had no other clinical problems. The lameness improved on Rimadyl.

Physical exam revealed a non-weight bearing lameness of the right hind leg with swelling of the right knee joint. The only other abnormality on physical exam was a II/VI right systolic heart murmur.

Diagnostic work up

Dr. Schulz performed joint taps which showed neutrophilic inflammation of the right knee joint and normal joint fluid cytology in the other joints (total nucleated cell count of 19,490 with 55% neutrophils, 30% large mononuclear cells and 15% small to intermediate size lymphocytes). Culture of the joint fluid was negative.

A vector borne disease profile was submitted to NCSU and was negative for all tested diseases, including tick-borne diseases.

Daniel was transferred to Dr. Marielle Goossens in the Peak Internal Medicine service for further work up of the neutrophilic mono arthritis. A search was started for an underlying disease that could have triggered the neutrophilic inflammation in the right knee joint.

Patient Workup:

    • A full profile and urinalysis at Idexx only showed a mildly increased ALT of 145 and the remainder of all values were normal.
    • An ultrasound of the abdomen was normal.
    • Thoracic radiographs were normal.
    • Cardiac work up by Dr. Don Brown showed mild ventricular hypertrophy and some aortic valve insufficiency, but no evidence of endocarditis. Systemic blood pressure was normal.
    • A Blastomycosis urine antigen test was sent to Mira Vista laboratories and showed a weak positive test, below the limit of quantification.
    • After speaking with Mira Vista Diagnostics about these results, Blastomycosis and Histoplasmosis serum antibody EIA testing was performed.
    • While waiting for these results, repeat radiographs were obtained of the right knee joint. They showed right stifle effusion and evidence of active osseus lesions at the distal lateral metaphysis and increased medullary opacity, which had not been observed on radiographs 2 months prior (fig. 1).
    • A CT and bone biopsy of the right knee joint were performed. Histopathology showed neutrophilic to granulomatous osteomyelitis with new bone formation and osteolysis.
    • Special stains were performed for fungal organisms and showed low numbers of broad based budding fungal organisms, consistent with Blastomyces Dermatitidis (fig. 2).

Fig. 1: Radiograph of the knee joints showing the subtle bone changes in the right knee joint.

Fig. 2: Histopathology of the bone biopsy showing the broad based fungal organisms consistent with Blastomycosis Dermatitidis.

At the same time as the biopsy results came back, the antibody titers also came back from Mira Vista Diagnostics. The Blastomycosis antibody was negative, but the Histoplasma IgG antibody EIA was high positive.

Treatment and Follow up

Daniel was started on itraconazole after the bone biopsy was taken prior to receiving the results back , as the suspicion for blastomycosis was high. He was treated with generic itraconazole at 5 mg/kg PO once a day. His lameness started to improve within about 2 weeks after starting this treatment and the pain relief medications that he had been on, were gradually discontinued.

Daniel was treated with itraconazole for a total of 8 months. We treated him for 1 month beyond the point of when no further improvement of the boney lesions on the radiographs, could be determined. His urine blastomycosis antigen level had returned to negative prior to this time.

Daniel is now about 2.5 months out after finishing the itraconazole. His first recheck urine antigen level was negative. So far, he is doing well. His urine blastomycosis level antigen test will be performed again at 3, 6, 9 and 12 months after he finished the itraconazole, as relapse of the blastomycosis is common during the first year after finishing treatment. Repeat knee radiographs will also be taken intermittently over this coming year, to make sure that the boney changes remain quiescent.

Case Discussion

Blastomycosis is a diagnosis that is being made more frequently in Vermont and upstate New York over the past several years. What is interesting about Daniel’s case is that he presented with lameness in just one leg and he was not systemically ill. Initially, the only change in him was a swollen, painful knee joint with neutrophilic inflammation in that one joint, with no radiographic changes for the first 2 months of his lameness. We have seen several other cases that presented with neutrophilic inflammation in one joint with or without radiographic changes, that ended up being diagnosed with blastomycosis.

Cases like Daniel’s make us realize, that we need to have the differential of blastomycosis on our rule-out lists for many cases that present to us.

As most of you know, blastomycosis can present itself in our patients in many ways, including:

    • Panophthalmitis
    • Uveitis
    • Mass effects
    • Lymphadenopathy
    • Draining tracts
    • Bone lysis
    • Classical presentation of blastomycosis in the lungs (snow storm effect).

The diagnosis is often straightforward by performing the urine blastomycosis antigen test. Sensitivity of this test is over 90%, but false negatives do occur, and we have seen these negatives several times at Peak.

If the urine antigen test is negative, consider cytology and/or histopathology as these techniques are considered the gold standard method for diagnosis. Antibody detection can also be used in antigen negative cases, as we performed in Daniel.

The sensitivity of the AGID method has ranged from 17% to 83% and experience in clinical practice has been unfavorable. The sensitivity of the EIA method is superior to AGID, supporting its use as an aid in the diagnosis of blastomycosis in antigen negative cases.

A Final Note on Blastomycosis

We have seen many cases being treated successfully after the blastomycosis diagnosis. Blastomycosis in the lungs or in the central nervous system, has a higher chance of an unsuccessful treatment. There is evidence that longer treatment may reduce relapse. Relapse rates of 18-25% are listed in the first year after finishing treatment. Recommendations have been made that at least a four to six months course of itraconazole should be given to reduce the likelihood of relapse.

At Peak, we recommended continuing therapy one month beyond resolution of all clinical findings, including eye exam, chest radiographs or bony changes, and one month after the urinary antigen was negative. We then check urine antigen levels at 1, 3, 6, 9, and 12 months after finishing treatment, to make sure we catch a relapse of the blastomycosis prior to the development of symptoms.

Canine Unicompartmental Elbow Resurfacing (CUE)

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Severe elbow arthritis

Severe elbow arthritis. The pink area is exposed bone where the cartilage has been worn away

About severe elbow arthritis in dogs

Osteoarthritis from coronoid disease and other forms of elbow dysplasia may result in complete loss of cartilage on the weight-bearing surfaces of the medial joint structures resulting in what veterinarians call Medial Compartment Disease (MCD). This is the “end stage” form of elbow dysplasia where the inside part of the joint collapses with eventual grinding of bone on bone. Interestingly and importantly, the larger lateral (outside) part of the elbow joint appears normal in the vast majority of patients.  Medial compartment disease can be diagnosed in dogs as young as 6 months of age or may become apparent in any age after that.

How can medial compartment disease be treated?

Options such as oral medications, joint injections, and physical therapy may be beneficial in some cases for at least a period of time and should be discussed with your veterinarian. When surgical treatment is deemed necessary, as is often the case, the Canine Unicompartmental Elbow (CUE) is a safe and effective option to consider. The CUE was developed by Dr. Schulz (Peak) and Dr. Cook (University of Missouri) with the Arthrex corporation. It was developed as a treatment for MCD for dogs in which arthroscopic treatment and the nonsurgical options are no longer successful. By focusing on the specific area of disease (the medial compartment), the CUE implant provides a less invasive, bone-sparing option for resurfacing the bone-on-bone medial compartment while preserving the dog’s own “good” cartilage in the lateral compartment. This medial resurfacing procedure reduces or eliminates the pain and lameness that was caused by the bone-on-bone grinding.

Cobalt chrome and titanium implant

This implant is made of cobalt chrome and titanium and is inserted in the upper bone (humerus) of the joint to restore the gliding surface

Is the CUE a major surgery?

The CUE procedure is an open surgery but only takes about one hour to perform. Unlike total elbow replacements it does not require major bone cutting and a large surgical approach. The recovery from CUE is much faster than from total elbow replacements and the outcome appears to be much better.

Polyethylene and titanium implant

This implant is made of polyethylene and titanium and is placed in the lower bone (ulna) of the elbow joint. It articulates with the other implant resulting in a low friction pain free articulation for the elbow.

What can I expect after CUE surgery?

You will be sent home with antibiotics and pain-relieving medications for your dog. A bandage will be placed on the limb, which you will need to keep clean and dry. The bandage will be changed after one week and maintained for at least two weeks after surgery. Sutures will be removed approximately two weeks after the procedure. Your dog must be restricted to rest in a kennel or crate, with controlled leash walking only, for eight weeks after surgery. Follow-up examination and assessment of healing will be performed 8-10 weeks after the procedure, at which time rehabilitation exercises will be initiated to allow a progressive return to full activity levels by six months after surgery. Full athletic function is not expected until three to six months after surgery, at which time a final assessment will be performed.

Our client information sheet on the CUE can be downloaded here:

  Canine Unicompartmental Elbow Resurfacing (CUE)

Laryngeal Paralysis

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Laryngeal paralysis is a common upper respiratory disease of dogs. It most often affects large breed dogs such as Labrador retrievers and Golden retrievers but it can affect any dog of any breed or size. Normally when a dog inhales the larynx (voice box) opens to allow air into the trachea and lungs. The larynx closes between breaths to prevent food and water from going into the trachea and lungs. In laryngeal paralysis the muscle that opens the larynx stops functioning. This results in a very narrow passageway to get air into the lungs instead of the normal wide-open larynx. Dogs with laryngeal paralysis have difficulty inhaling and the harder they try the more difficult it becomes to inhale adequate air.

Views of the larynx.

Fig.1 – Views of the larynx. The top view is of a normal larynx. The middle is a laryngeal opening in a dog with laryngeal paralysis. The bottom is the appearance of the larynx following a tie back procedure.

What are the signs of laryngeal paralysis?

Several signs may suggest that a dog has laryngeal paralysis:

  • Harsh breathing – laryngeal paralysis usually leads to a characteristic harsh breathing sound that gets louder with exercise. This noise is caused by air passing through the narrow space in the larynx.
  • Voice change – laryngeal paralysis will often cause a change in a dogs bark, making it sound more hoarse.
  • Coughing – Some dogs may have a cough with laryngeal paralysis that sounds like it comes from the throat.
  • Gagging – Many dogs with laryngeal paralysis may gag when they eat or drink.

How is laryngeal paralysis treated?

Laryngeal paralysis is best treated by surgery. There are several surgical options although one procedure, the “tie-back” is the most accepted and most commonly performed by Board Certified surgeons.

Tie back

In the tie back procedure the larynx is approached through the side of the neck. The failed muscle is then identified and replaced with a suture to permanently open the larynx on one side. This procedure produces the best airway with the least complications of any of the available surgeries.

Partial arytenoidectomy

In this procedure the portions of the larynx that obstruct the airway (the arytenoids) are removed by scissor or laser through the mouth. This procedure is not recommended because of the high risk of scar formation that can severely obstruct the airway.

Castellated laryngofissure

This procedure enlarges the airway through a complicated series of incisions and reconstructions from the underside of the neck. There have been no definitive advantages shown with this procedure and it is rarely performed.

Permanent tracheostomy

A permanent tracheostomy should only be performed when a tie back procedure will not correct the airway obstruction. Dogs with permanent tracheostomies cannot swim and may have other chronic airway complications.

For additional information about Laryngeal Paralysis: laryngeal paralysis

TPLO Cruciate Repair

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Cranial Cruciate Ligament Injury

Cranial cruciate ligament rupture (CCLR) is the most common orthopedic injury in dogs. In people, the same ligament is called the anterior cruciate ligament. In both species the ligament may stretch or tear, leading to pain and osteoarthritis. CCLR can make the menisci vulnerable to tearing, which is quite painful. The menisci are two small cushions of fibrocartilage that sit between the bones of the knee.

The signs of CCLR vary, but they include an acute onset of lameness followed by mild improvement but continued lameness. Other dogs experience a moderately progressive lameness particularly associated with exercise or lameness when the dog gets up after resting.

Diagnosis

CCLR is first diagnosed by palpation (examination and manipulation by hand). X-rays are routinely taken in dogs with CCLR, but this disease cannot be diagnosed on x-rays because the ligament does not appear on radiographs.

Treatment

Surgery is recommended for most dogs with CCLR. In very small dogs it is possible for the knee to improve in stability without surgery as the body lays down scar tissue, but in most dogs adequate stabilization of the knee will usually not be achieved, and the pain and lameness will continue.

More traditional surgical treatments of CCLR involve replacing of the ligament with either a natural or synthetic material. In these procedures, natural fibrous tissue, nylon suture, or wire is used to stabilize the knee. These procedures have been used for more than half a century, and the results are good in many cases. The main concern with these procedures is that the stabilizing material can stretch or break, after which the knee is stabilized by scar tissue. This may lead to a decrease in the range of motion of the joint. We recommend extracapsular suture surgery for smaller dogs (less than 35 pounds) or when medical or financial limitations prohibit performance of a Tibial Plateau Leveling Osteotomy (TPLO).

Tibial Plateau Leveling Osteotomy

The most widely used technique in treatment of CCLR by board certified surgeons is the TPLO. In this technique, the lower bone of the joint (tibia) is cut and rotated to eliminate the abnormal motion of the knee during normal activity. The advantage of this procedure is that it does not rely on materials that can stretch or break to stabilize the knee. We recommend TPLO in most of our medium and large patients and particularly in more active dogs.

How the TPLO Works

Studied have demonstrated that if the lower bone of the knee (the tibia) is steeply sloped at the level of the joint, the upper bone of the knee (the femur) is always sliding down the tibia. This constant sliding places strain on the cruciate ligament, possibly causing it to fail. The TPLO procedure corrects the tibial plateau angle to eliminate the sliding and the instability of the knee and the accompanying pain and slowing the progression of osteoarthritis.

Cruciate Surgery at Peak

Cruciate surgery at Peak Veterinary Referral Center is performed by a highly experienced and caring team who prioritize your pet’s welfare. Dr Schulz has been performing cruciate surgery including TPLO for over 15 years. He served as chief of surgery at the University of California and has published over 60 manuscripts in canine orthopedics. He is an author of several books including Small Animal Surgery, Small Animal Arthroscopy, and the Pet Lovers Guide to Joint Problems and Osteoarthritis.

At Peak we feel it is important to educate owners and help them make the best decision for their pet and their family. In many cases surgery may be performed the same day as your initial appointment.

Total Hip Replacement

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Osteoarthritis is one of the most common diseases of dogs, affecting up to 25% of all dogs during their lifetime. The hip and knee are the most common locations but have dramatically different causes and treatments.

The majority of osteoarthritis of the hip is due to hip dyspla­sia. This disease is a result of genetics which leads to poor hip conformation and laxity and subluxation (loose joints) while the dog is young. As the dog ages the joints actually tighten up but the resulting poor fit of the joint (incongruence) leads to grinding of cartilage and inflammation of the joint. Many adult dogs with severe hip dysplasia and osteoarthritis have no normal cartilage remaining in their hip joint.

The common signs of osteoarthritis of the hips in dogs are limping and exercise intolerance. Exercise intolerance is actually the most common while fewer dogs actually limp with hip dysplasia.

There are two broad categories of management of hip dys­plasia and osteoarthritis in dogs. They are medical and surgical. It is important to remember that even when surgical management is elected, medical management may be necessary still. This is particularly true when one hip receives surgical therapy but the opposite side remains diseased.

Medical management

Medical management of hip dysplasia includes 5 treatment principles:

  • management of body weight
  • nutritional supplementation
  • moderation of exercise
  • physical therapy
  • medications

Surgery

Surgery for hip dysplasia is indicated when medical man­agement no longer maintains quality of life and function. It may also be indicated when medical management causes complications. The decision to pursue surgical treatment should be made by the owner in consultation with the veterinarian but the owner must decide on quality of life.
There are two surgical options for the mature dog with hip osteoarthritis. They are femoral head and neck ostectomy (FHO) and total hip replacement (THR).

FHO

FHO is an excellent option in small dogs (and cats). In this surgery the ball of the ball and socket joint is removed. The hip then works by having the leg supported by the gluteal muscles. (This procedure was developed for treatment of hip infection in people.) Because of their small body weight small dogs and cats tolerate this procedure very well. In larger dogs the outcome is not always as good but it may be necessary for financial or medical (infection) reasons. Ultimately the outcome of this procedure is unpredictable but is probably improved by combining the procedure with professional physical therapy.

THR

Total hip replacement has been performed in thousands of dogs in the US and the world. The outcome is generally excellent in 85% to 90% of dogs; however when complications occur they can be frustrating and expensive. Traditionally THR was always performed as late in life as possible because of concern for the implants wearing out. The development of cementless implants allows THR in patients as young as 8 months of age.

Tightrope Cruciate Repair

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The Tightrope technique is an excellent alternative to the TPLO for treatment of cruciate ligament rupture in dogs of any size. This technique works similar to older suture techniques but is significantly stronger and simpler. The tightrope technique is stronger because it relies on small bone tunnels and stainless steel surgical “buttons” to secure the suture. This is much stronger than traditional methods of securing the suture. In addition, the suture is human orthopedic surgical grade material which is far superior to traditional materials used to stabilize the knee of dogs.

The Tightrope technique is an alternative for clients who are concerned with the bone cutting required in the TPLO.  The Tightrope can be performed with arthroscopic assistance so only a few small incisions are required.

Studies to date suggest that the Tightrope has  excellent results similar to those of the TPLO.

Sliding Humeral Osteotomy

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A new Treatment for Elbow Dysplasia in Dogs

Elbow dysplasia and the secondary arthritis are the most common causes of foreleg lameness in dogs. Fragmented coronoid process (FCP) is the most common form of elbow dysplasia in dogs. In this disease, a fragment of bone and cartilage of one of the bones of the elbow joint (ulna) is broken off. More important, the rest of the joint may be normal or there may be additional cartilage damage, including severe full-thickness cartilage loss. Damage to the cartilage in dogs with elbow dysplasia is called Medial Compartment Disease because it commonly results in severe erosion of the cartilage of the medial aspect of the joint.

Diagnosis of FCP and Medial Compartment disease (MCD)

Diagnosis of FCP and MCP can be challenging. The diagnosis is initially based on a careful orthopedic examination. X-rays (radiology) are of limited use in the diagnosis of FCP. The FCP fragment and damage to the cartilage cannot be seen on x-rays. We recommend arthroscopy for the diagnosis of FCP and MCD because it allows early and accurate diagnosis and treatment

Dogs with Medial Compartment Disease usually require more continuous medical treatment of osteoarthritis and owners should consider additional surgical treatment options.

Advanced surgical treatments of Medial Compartment Disease include Sliding Humeral Osteotomy (SHO) and total elbow replacement.

Total elbow replacement may be indicated when the cartilage is severely damaged throughout the elbow joint. Numerous total elbow replacements have been designed over that last 15 years and to date none has been proven to be safe and effective enough for routine use.

Sliding Humeral Osteotomy

Sliding Humeral Osteotomy (SHO) was developed in the Orthopedic Research Laboratory of the University of Californita by Dr Schulz. This procedure is based on similar procedures that are performed on people for arthritis of the knee. The procedure realigns the limb to shift the forces off of the area of cartilage damage and back on to healthy cartilage. This relieves the pain of grinding of bone on bone and gives the damaged joint an opportunity to heal.

The sliding humeral osteotomy procedure is the result of almost 10 years of laboratory research. These studies have demonstrated that the sliding humeral osteotomy significantly decreases joint pressure in the medial side of the elbow joint.

Clinical results

Over the last 3 years the SHO procedure has been performed in over 70 dogs. Careful clinical studies have been performed to evaluate the efficacy of this procedure. The majority of dogs undergoing SHO have decreased lameness by 12 weeks postoperatively with many dogs having no visible lameness at a 26 week evaluation. The owner satisfaction rate following SHO has been nearly unanimous.

SHO surgeons

Surgeons performing the SHO procedure are all highly experienced orthopedic veterinary surgeons. They have completed a course covering the theory, indications, and application of the SHO technique.

Shoulder OCD

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Osteochondrosis of the shoulder joint is a common cause of lameness in dogs. Fortunately the outcome with surgical treatment is generally excellent when arthroscopy is performed early in life.

What is OCD of the shoulder?

OCD (osteochondrosis dessicans) is probably the leading cause of osteoarthritis of the shoulder joint. Shoulder OCD occurs when a piece of cartilage separates from the underlying bone. Pain is due to inflammation of the joint and exposure of nerves in the bone under the cartilage flap.
Shoulder OCD in dogs has been demonstrated to be a genetic disease and cannot be caused by diet or exercise although excessive exercise in a dog with untreated shoulder OCD may make the lameness more severe.
OCD of the shoulder is usually found in young dogs ranging from 6 months to 2 years of age.
The clinical sign of shoulder OCD is lameness of one or both forelegs. Dogs with shoulder OCD may have trouble getting up and often have some muscle loss and pain when the joint is moved.

How is Shoulder OCD Diagnosed?

The diagnosis of shoulder OCD is usually straight­forward because most lesions are easy to see on radiographs (x-rays) of the shoulder joint. The normal curve of the joint surface is interrupted by a flat area representing the abnormal cartilage.

 

How is Shoulder OCD Treated?

Treatment of shoulder OCD should be strongly considered by dog owners because surgical removal of the flap almost always results in elimination of the lameness whereas nonsurgical management often results in continued limping and may result in severe osteoarthritis later in life.
Removing the cartilage flap lets the underlying bone heal, stops the irritation of the joint, and keeps the flap from moving into another part of the joint where it might cause other problems. We strongly recommend using arthroscopy to re­move the flap to avoid large incisions and for a faster recovery.

Are there complications?

Complications with arthroscopic treatment for shoulder OCD are very rare (less than 2 percent). The most common complication is swelling of the shoulder that resolves in several days. Anesthetic complications, infection, or nerve damage are very uncommon.

What is the outcome of treatment?

The outcome with arthroscopic treatment of shoulder OCD is generally excellent with complete resolution of lameness over several months following surgery. Physical therapy can accelerate the recovery. In most cases there is little residual arthritis which may be apparent after very heavy exercise or as the dog becomes much older.

Arthroscopic Surgery at Peak

Arthroscopy at Peak Veterinary Referral Center is performed by a highly experienced and caring team who prioritize your pets welfare. Dr Schulz has been performing arthroscopy for over 15 years and is an author of the only textbook on small animal arthroscopy. In many cases surgery may be performed the same day as your initial appointment and because ar­throscopy is minimally invasive, many patients may go home the same day.
Dr Schulz served as chief of surgery at the University of California and has published over 60 manuscripts in canine orthopedics. He is an author of several books including Small Animal Surgery, Small Animal Arthroscopy, and the Pet Lovers Guide to Joint Problems and Osteoarthritis.

At Peak we understand the importance of your pet to your lives. Our philosophy is to educate owners and help them make the best decisions for their pet and their family.

Hip Dysplasia

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Hip dysplasia in your dog

x-ray of normal hips

Osteoarthritis is one of the most common diseases of dogs, affecting up to 25% of all dogs during their lifetime. Osteoarthritis of the hip and knee are the most common locations but have dramatically different causes and treatments.

The majority of osteoarthritis of the hip is due to hip dysplasia. This disease is a result of genetics which lead to poor hip conformation and laxity and subluxation (loose joints) while the dog is young. As the dog ages the joints actually tighten up but the resulting poor fit of the joint (incongruence) leads to grinding of cartilage and inflammation of the joint. Many adult dogs with severe hip dysplasia and osteoarthritis have no normal cartilage remaining in their hip joint.

Exercise intolerance is actually the most common while fewer dogs actually limp with hip dysplasia.
In young dogs one of the most common signs of hip dysplasia is “bunny hopping” where the dog uses both hind limbs simultaneously.

Medical management

Medical management of hip dysplasia include 5 treatment principles.

  1. Management of body weight
  2. Nutritional supplementation
  3. Moderation of exercise
  4. Physical therapy
  5. Medications

Surgery

THERE ARE SEVERAL SURGICAL OPTIONS FOR THE YOUNGER DOG WITH HIP DYSPLASIA. THEY ARE-

x-ray of arthritic hips from hip dysplasia

  • juvenile pubic symphodesis (JPS)
  • triple pelvic osteotomy (TPO)
  • femoral head and neck ostectomy (FHO)
  • total hip replacement (THR)

JPS

JPS is a technique of correcting the anatomy of the pelvis in a dog that is still growing. This relatively simple technique changes the anatomy of the pelvis by changing the rate of growth at one of the growth centers. This procedure is only effective in puppies under 20 weeks of age.
In JPS an electroscalpel is used to slow the growth of the pelvis at the pubic symphysis.

Triple Pelvic Osteotomy

Triple pelvic osteotomy has the same effect as JPS in increasing the coverage of the socket of the pelvis over the ball of the femur. In this procedure the pelvis is cut and rotated because the skeleton is or is nearly completely grown. Triple pelvic osteotomy is a common and safe procedure that is usually very well tolerated by dogs. In most cases they are walking on the operated leg immediately after surgery.

FHO

FHO is an excellent option in small dogs (and cats). In this surgery the ball of the ball and socket joint is removed. The hip then works by having the leg supported by the gluteal muscles. Because of their small body weight small dogs and cats tolerate this procedure very well. In larger dogs the outcome is not always as good . Ultimately the outcome of this procedure is unpredictable but is probably improved by combining the procedure with professional physical therapy.

THR

Cementless (left) and cemented (right) total hip replacements

 

Total hip replacement has been performed in thousands of dogs in the US and the world. The outcome is generally excellent in 85% to 90% of dogs; however when complications occur they can be frustrating and expensive. Traditionally THR was always performed as late in life as possible because of concern for the implants wearing out. If you are considering total hip replacement in your dog please see our handout on total hip replacement in the dog.