Overview. Weight Management. Medical Treatment. Weight Management 11/17/2014. Elbow Dysplasia: Medical and Surgical Treatment

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1 Overview Elbow Dysplasia: Medical and Surgical Treatment Medical Treatment of Osteoarthritis (OA) Surgical Treatment of Elbow Dysplasia Prognosis for Elbow Dysplasia Adrienne Bentley, DVM, DACVS Medical Treatment Weight Management Weight management Exercise moderation NSAIDs Other pain medications Neutraceuticals, supplemented food Miscellaneous other Rehabilitation therapy: Canapp VetSurg 2009 Survey done by Pfizer % of dogs vets deemed overweight: 47% % of dogs owners deemed overweight: 17% % of owners w/ success in dog s weight loss: 8% Association b/w obesity and OA Marshall VCOT 2009 Weight Management German JVIM 2007: Weight loss in pet dogs Fed Obesity Management diet by Royal Canin Calculated MER = 132 x BW 0.73 BW = target weight Mean loss 18% overall, 0.85% per week Energy to achieve loss 50-82% of MER Key points Owner noncompliance Need to recheck, weigh, adjust often Weight Management: Slentrol (dirlotapide) Microsomal triglyceride transfer protein inhibitor Dogs only Cats risk hepatic lipidosis Not in dogs w/ liver disease Not w/ corticosteroids Side effects uncommon, mild Good results w/r/t weight loss J Vet Pharm Ther

2 Quality of Evidence for Treating OA Aragon JAVMA 2007: Systematic Review Searched clinical trials treating OA in dogs Of 381 references, 16 prospective trials Applied FDA evidence-based ranking system Quality of Evidence for Treating OA Strongest evidence for NSAIDs Meloxicam and carprofen (7 trials) Mixed results for supplements Adequan, Cosequin, Glycoflex (1 trial each) Weak evidence for use of glucosamine and chondroitin in people Weak evidence for IA injection of hyaluronan Aragon JAVMA 2007 How I Use NSAIDs Intermittent For 3-7 days after exacerbate lameness Daily Mobility requires daily use CBC, chem, USG q 6-12m Doses (PO) Rimadyl 2.2mg/kg BID Deramaxx 1-2 mg/kg SID Metacam 0.1 mg/kg SID Other Pain Relievers Tramadol: Mu agonist 2-5 mg/kg BID-QID Gabapentin: GABA analogue Wide dose range (TID), taper before discontinue Amantadine: NMDA antagonist Lascelles JVIM 2008 Improved activity when added amantadine (3-5 mg/kg SID) to meloxicam alone Supplemented Food Omega 3 FA less inflammatory eicosanoids Randomized, double-blind, controlled trial 127 dogs with OA 1 joint 6 months test food (Hill s j/d) or control food Omega 3 FA in food are bioavailable Owners noted improvements in rising, walking Second trial with 38 dogs 5.6% improvement in PVF by day 90 Surgical Treatment Diagnostic arthroscopy UAP Therapeutic arthroscopy: medial coronoid disease Therapeutic arthroscopy: humeral OCD Proximal ulnar osteotomy Sliding humeral osteotomy Total elbow replacement Canine unicompartmental elbow arthroplasty Roush JAVMA

3 Elbow Arthroscopy Benefits Reduced morbidity Better visualization Single-session bilateral Beale 2003 Beale 2003 Surgery for UAP: Excision Surgery for UAP: Reattach and/or PUO PUO = Proximal Ulnar Osteotomy Tobias & Johnston 2012 Arthroscopy: Medial Coronoid Disease (MCD) Medial Coronoid Disease Fragment removal vs subtotal coronoidectomy Danielson et al 2006 CT findings Arthroscopy findings Danielson VetSurg

4 Medial Coronoid Disease Case #1: Faith, 18m FS Lab mix, RTL lameness Case #1: Arthroscopy Case #4: Hope, CT, 5y FS MIXB, RTL lameness Case #4: Arthroscopy Arthroscopy: Humeral OCD Goal: healing of defect with fibrocartilage Techniques Curette Motorized burr Subchondral drilling Microfracture Beale

5 Arthroscopy: Humeral OCD Incongruity: Ulnar Osteotomy/Ostectomy Used to treat both types of R/U incongruity Short radius and short ulna Fitzpatrick VetSurg 2009 Wendelburg VetSurg 2014 PUO for Incongruity: Short Radius PUO = Proximal Ulnar Ostectomy PUO for incongruity: Short Ulna PUO = Proximal Ulnar Osteotomy Radioulnar incongruity: Short radius Case #3: Sadie, 6m FS Bassett, bilateral TL lameness Case #3: Arthroscopy 5

6 Ulnar Osteotomy PUO: Complications PUO: Complications PUO 10 dogs with MCD 3D CT pre-op and 2-8m post-op PUO, interosseous lig release, no pin RUI improved at MCP but at LCP Due to 3D rotation of proximal ulna Böttcher VetSurg 2012 Distal Ulnar Osteotomy (DUO)? Distal ulnar osteotomy (DUO) Short ulna PUO (no pin) and DUO w/ interosseous lig release distraction ~4.5mm DUO w/out interosseous lig release very little movement proximal ulna ~1.0mm Short radius PUO (w/ pin) restored mean contact pressures PUO (w/ pin): peak contact pressure (medial) < baseline DUO: restored MCP & PCP only w/ release of interosseous lig & abductor pollicis longus Might VetSurg 2011 Krotscheck VetSurg

7 Ulnar Osteotomy: Unanswered Questions Sliding Humeral Osteotomy (SHO) If/when to do at all? Where to make osteotomy How to orient osteotomy Stabilize? If so, how? Disrupt soft tissues for more movement? Does it depend on Patient s age Specific pathology Amount of RUI Radioulnar incongruity: contact on MCP Shift proximal humerus laterally, load on ulna Goals: joint pain, promote fibrocartilage Only in cases with good cartilage on lateral side (arthroscopy) Preston AJVR 2001 Mason VetSurg 2008 SHO Outcomes Fitzpatrick VetSurg 2009 Major implant failures, humeral fractures Fitzpatrick VetSurg 2014 Improved technique, implants only minor complications Some force plate data improved compared to pre-op Wendelburg VetSurg 2014 Also longer follow-up and force plate analysis Quinn VetSurg dogs (9 elbows) w/ humeral OCD Progression of OA, new FMCP SHO Study Limitations Recent studies = attempt at longer term data Small number of dogs with second scope, force plate data Need better data on non-sho elbow or other controls Total Elbow Replacement (TER) Iowa State TER System Two systems Iowa State (left) TATE (right) Separate humeral & radioulnar implants Tobias & Johnston 2012 Tobias & Johnston

8 TATE TER System TER Complications Severe when occur Elbow luxation Humeral, ulnar fracture Infection Limited revision options Amputation if unilateral Arthrodesis? Tobias & Johnston 2012 Tobias & Johnston 2012 Canine Unicompartmental Arthroplasty (CUE) Partial joint replacement Medial humeral & ulnar implants Only in cases with good cartilage on lateral side Canine Unicompartmental Arthroplasty (CUE) Advantages More physiologic load transmission, kinematics? Less soft tissue disruption Revision options Outcome data Clinical results Franklin VetSurg 2014 Franklin VetSurg 2014 Kyon Partial Elbow Arthroplasty Tough Decisions Treatment algorithm? Based on Outcomes reported in literature Clinical experience Limited by Current understanding of pathogenesis Ability to screen and diagnose components Quality of current studies Smith VCOT

9 Limitations of Elbow Studies Variation in lesions Different nomenclature Different imaging used Multiple procedures per elbow Subjective outcome measures Small study populations Meta-Analysis for Treatment of MCD Evans VCOT 2008 Systemic review for studies with Clinical outcomes, 6m follow-up, comparison group, dogs > 12kg Found 4 studies (1 randomized, controlled) Compared arthroscopy, arthrotomy, and medical Evans VCOT 2008, cont. Arthroscopy better than medical Rx Probability of % in improvement (10-25%) Arthroscopy better than arthrotomy Probability of % in improvement (-7-35%) Arthrotomy not better than medical Rx Probability of % in improvement (-16-23%) Recent Literature on Outcome More objective measures Force plate, gait analysis Goniometry, muscle circumference Advanced CT techniques Longer temporal evaluation Sample size still small Defining MCD group Comparison group to determine treatment effect MCD vs normal MCD pre- vs post-op MCD left vs right Burton VetSurg 2011 Galindo Zamora VetSurg 2014 Barthelemy VetSurg 2014 Krotscheck VetSurg 2014 Prink VetSurg 2010 Farrell VetSurg 2014 Prognosis Improvement in 85% of cases? Percentage of cases with lifelong resolution? Summary Medical management for all dogs Weight, NSAIDs, exercise moderation Arthroscopy Diagnostic, MCD, humeral OCD Treatment of incongruity? Severe medial disease, ok lateral: SHO, CUE Elbow replacement in select cases Need better outcome data 9

10 Acknowledgements Questions? Dr. Ken Bruecker Dr. Ian Holsworth Dr. Kim Agnello When to spay or neuter? Gonadectomy prior to physeal closure delays closure Results in statistically but not clinically significant lengthening of long bones Incidence of elbow dysplasia in early-neutered male Labs (4%) vs intact (0.6%) No difference in female Labs No difference in male or female Goldens Osteochondral Autograft Transfer (OAT) Debride humeral OCD Collect osteochondral graft from stifle Fill humeral defect with graft Kustritz JAVMA 2007 Hart PLOS ONE 2014 Fitzpatrick VetSurg 2009 Proximal Abducting Ulnar Plate (PAUL) Proximal Ulnar Rotational Osteotomy (PURO) Transverse osteotomy, proximal ulna externally rotated 30 Contact pressures medially, laterally MCP moves caudal, abaxial Cuddy VetSurg

11 Bicipital Ulnar Release Procedure (BURP) Biceps-Brachialis Anatomy Rotational incongruity Contraction of biceps brachii/brachialis shear forces on MCP (especially at radial incisure) BURP Tenotomy of distal insertion of biceps brachii/brachialis Weak evidence for this mechanism and BURP efficacy Hulse VCOT 2010 Arthroscopic BURP Technique Intra-articular Corticosteroids Transient relief but cartilage damage with repeated use Suppress cartilage matrix synthesis Use long-acting: Depo-Medrol Limit number of injections: every 6 weeks, 3-4x per year Sedate patient, use aseptic technique Wilson VetSurg 2014 Stem Cell Therapy Black Vet Ther 2007, 2008 Adipose-derived mesenchymal stem cells injected into hips or elbows Improvement in subjective measures First author works for company Vilar BMC Vet Res 2013, 2014 Adipose-derived MSC +/- PRP injected into hips Improvement in PVF and VI (objective force plate) Improvements were short in duration, modest in magnitude De Bakker Vet Quarterly 2013 Excellent review article 11