Q: I have a Labrador retriever named Mac. He is 3 years old and he has recently been diagnosed as having arthritis in his elbows. One side is a little bit worse than the other, but they are both affected, and he limps and becomes very stiff and sluggish after playing hard or going for walks.
My vet sent us to a surgeon who recommended that the elbows have arthroscopic surgery to take loose fragments, called “the coronoids,” out of the joints. She said that this is better than a conventional surgery and will help with the overall function, and longevity, of the joints. Thoughts?
Henri Bianucci: Mac has what is colloquially referred to as elbow dysplasia. As with the more commonly understood condition of hip dysplasia, this refers to a joint that is malformed. There are a number of individual abnormalities, which can affect the elbow, that fall under this general umbrella. They can be present alone or in combinations. The more of them that are present, the worse it is for the joint.
These are all developmental problems and begin in early puppyhood as the joint is forming.
The elbow comprises three large bones. The one above, where your biceps are, is called the humerus. The lower two are the paired radius and ulna. Developmental abnormalities can involve any or all of these bones. Because the radius and ulna are paired and comprise the lower surface of the joint, they must be perfectly aligned. If they are not, the condition is known as elbow incongruity. The other abnormalities generally involve the failure of normal bone or cartilage development, which leads to defects in the joint surface.
One of these developmental bone problems, known as an ununited anconeal process, can be treated with a relatively simple surgery, if it is diagnosed early enough, usually by around 9 months of age. Treated early, this condition can be completely reversed, resulting in excellent long-term function. Of the elbow abnormalities, this is the only one that can make such a claim.
The other conditions are most commonly either what Mac has, or a cartilage problem known as osteochondritis dissecans. (OCD). As stated by the surgeon, these are best treated with an arthroscopic procedure. This describes a surgery in which the loose fragments of bone or cartilage are removed from the joint using a small scope, and small instrument portals. This also is referred to as minimally invasive surgery.
Compared to conventional, or open approaches, minimally invasive surgery allows for smaller incisions, less tissue disruption and supposedly shorter healing times and less pain. Studies have produced varying results, but as clients increasingly demand minimally invasive procedures, the surgeon’s skill sets and available equipment have improved, leading to better results. It is now generally accepted that minimally invasive procedures offer these advantages.
It is fascinating to see these procedures performed. The tiny scope is inserted into the joint and the image is projected onto a high resolution screen. The inner world of the joint is displayed in dazzling clarity, and the defects are quickly identified and treated. At completion, the scopes are withdrawn and the little incisions are closed with a drop of glue.
So, yes, if one is going to treat an elbow affected by a fragmented coronoid process, this is absolutely the way to do it. But just because this method allows us to perform the procedure does not mean we should be doing it. These are all short-term considerations. The real question is: What is to be gained by performing this procedure as opposed to doing nothing at all? The answer, with fragmented coronoids, in a 3-year-old dog, is not much.
Even when performed in a puppy, the expectation is that you will alleviate pain, possibly for a few years. But long term, there is little difference in function, or the development of arthritis. In fact, a recent study demonstrated no difference in the progression of arthritis or limb function between dogs who underwent surgery and those treated medically. In older dogs, the expectation of pain relief is much shorter, sometimes only three to six months, and the progression of arthritis is unaffected.
Before the widespread availability of scoping equipment, surgeons would be less inclined to open the joint of an older dog with elbow dysplasia because it was more traumatic, and offered little benefit. Now that the scope can be preformed with minimized pain, it seems that the willingness to get into these joints has returned. These procedures may offer no objective evidence that they alter the course of the disease, but when they are packaged with catch phrases like “minimally invasive” and “sports medicine,” they are much more palatable.
So when these procedures are offered, look beyond the procedure itself and ask for evidence that they will actually provide a long-term benefit for a given condition in a patient of a certain age. Keep in mind that all of this equipment comes at a cost. The pain may be most acute in your wallet.
Dr. Henri Bianucci and Dr. Perry Jameson are with Veterinary Specialty Care LLC. Send questions to firstname.lastname@example.org.