Surgical and Orthopedic Service DetailsTo learn more about any of the services below, simply select the topic to reveal more information.
“Hip Dysplasia is a terrible genetic disease because of the various degrees of arthritis (also called degenerative joint disease, arthrosis, osteoarthrosis) it can eventually produce, leading to pain and debilitation.” http://www.offa.org/hd_info.html
“Elbow dysplasia is a general term used to identify an inherited polygenic disease in the elbow of dogs. Three specific etiologies make up this disease and they can occur independently or in conjunction with one another.”http://www.offa.org/ed_types.html
Often, hip and/or elbow certification radiographs are performed on breeding-age dogs, to receive a categorization to the current hip and/or elbow condition. These are often represented by “excellent, good, fair, or poor”. The OFA website explains this grading in further detail.
These images are required to be taken at a particular positioning, as requested by OFA. Sometimes, this may require light to heavy sedation. It is best to withhold food the morning of your scheduled appointment. In some rare cases, it may be helpful to plan on leaving your pet, with us, for a couple hours, though usually, these images can be obtained during a regularly scheduled appointment time. It is also important to accurately submit your dog’s information. We would like you to bring a copy of your pet’s AKC (or other) registration paperwork, as well as tatoo, and microchip information. You may also pre-fill out the application by clicking here.
Payment can be made directly to OFA and will be collected by VRCC Surgery at the time of your appointment. Please refer to the application for pricing. All digital images and application information will be handled and submitted by VRCC though you will receive the results directly from OFA.
PennHIP is a not-for-profit veterinary health service at the University of Pennsylvania. The PennHIP method of evaluation is very accurate in its ability to predict the onset of osteoarthritis (OA). Osteoarthritis, also known as degenerative joint disease (DJD), is the hallmark of hip dysplasia (HD).
PennHIP is a specialized technique of radiographic screening method for hip evaluation. The integrity and commitment to the education and improvement of HD in the dog happens in three ways. First, the radiographic technique assesses the quality of the canine hip and measures canine hip joint laxity. Second, only veterinarians trained by PennHIP to perform the PennHIP methodology properly are certified to submit radiographs. All data is submitted resulting in a continually expanding database of information that is continually monitored. Third, PennHIP publishes its findings in scientific journals and shares findings with interested breed clubs and other canine publications. For more information, please click here.
For PennHIP evaluation, you dog will need to be placed under a short general anesthesia. It is important to achieve full joint laxity which is usually not achievable without general anesthesia. The anesthetic event is usually very short, approximating 10-15 min. in duration. While anesthesia does have some risk, we try to alleviate concern by employing a full-time, board certified veterinary anesthesiologist. During the procedure, we will place an IV catheter and administer a medication to allow anesthesia maintenance with gas inhalant. Once we complete our evaluation and radiographs, we will safely and comfortably recover your pet.
For your pet’s safety, we would recommend withholding food after 10 p.m. the evening before the procedure and allowing them to stay in our care for an hour or two for monitoring post anesthesia.
Payment for this procedure will be made directly to VRCC Surgery and collected at the time of your appointment. All digital images and application information will be handled and submitted by VRCC Surgery though you will receive the results directly from PennHIP. We will also receive the results and will place them in your pet’s file for future reference.
While hospitalized, our surgeons, anesthesiologists, and technicians take a team approach to our patients’ care. Your pet is never left unattended, and will receive 24 hour care. Our highly trained veterinary technicians place patient care and comfort in the highest of priorities and are held to high standards of practice. Patients requiring intensive hospitalized care may be transferred to, or managed by, another department within VRCC as determined by current needs of the patient, practice, and day.
While VRCC Surgery hours are limited to Monday – Friday 7 am – 5 pm, VRCC is staffed 24 hours a day. After our patient care team has evaluated and stabilized the patients for the evening, the overnight team takes over. Our overnight staff is given specific information about each patient including procedure precautions, preexisting conditions, special handling instructions, etc., as well as emergency phone numbers to reach the surgeon overnight. They are happy to relay information to the owner in regards to patient condition and behavior. In fact, we often encourage owners to call and check on their hospitalized pets before they head off to bed.
For this tool to be helpful it is important for it to be performed by a skilled radiologist. We are lucky to have enlisted the help and expertise of Jennifer Grimm DVM, DACVR (veterinary radiologist). Once it is determined by the surgeon that an ultrasound scan is needed, we will schedule a time for Dr. Grimm and you to return; usually at a later date. The ultrasound results will be interpreted by the surgeon and discussed with you to create a proper treatment plan for your pet.
For follow up care, we ask that if you have any concerns regarding your pet’s wound, bandage or covering, that you call us directly. Sometimes, texting or emailing a photograph of the wound or bandage can help us determine the condition of the wound and the need to have it seen. While we practice a team approach with your family veterinarian, many times they are not comfortable with care and maintenance of wounds, and we ask that follow up care be limited to us until the wound is healed or the bandage removed by the surgeon.
- Injuries to the carpal joints and bones are common in dogs. Most of these are soft tissue injuries, involving the ligaments and joint capsule only, and a usually a result from either acute traumatic events, or activities that cause sudden repetitive sprains to the joints’ supportive structers. Radiographs (x-rays) are always needed following injury to this area to examine the small bones of the carpus and to determine if any fractures exist. Sprains are the most common injuries in performance dogs, and sprains to the carpal and tarsal joints are the most likely to go undiagnosed.
- Injuries to the carpus occur commonly following automobile trauma, jumping from a height, or jumping over a barrier. While most animals are normal prior to the injury, it must be remembered that animals with underlying disease processes, such as rheumatoid arthritis or systemic lupus erythematosis, may require less trauma to cause an injury than normal dogs.
- Non-steroidal anti-inflammatory medications are seldom of much help in relieving the symptoms. Some advocate splinting of the carpus, although the importance of this is unclear, especially since it does not appear to be important and has generally been abandoned in the treatment of the condition in humans.
- Fractures can occur in any of the bones of the carpus, although they are infrequent. Dislocations of the carpus can occur along any of the joints. If there is severe damage to ligaments and other structures that support the carpus, fusion of the joint (a surgical procedure called “arthrodesis”) may be necessary, and there is one condition called hyperextension deformity is related to nutrition in puppies affects the carpus.
- Many injuries to the tarsus fall under this category. This injury is the result of severe twisting injuries of the tarsus, severe scrape injuries, or hyperextension of the joint.
- The injury may involve the tearing of one or both of the collateral ligaments, facture of one or both of the malleoli, or fracture of the tibial tarsal bone.
- Any combination of the above is also possible.
- Animals with subluxation or luxation of the joint usually carry the affected limb. The lower part of the limb seems to dangle or swing because of its incomplete attachment to the remainder of the limb.
- Chronic luxation or subluxation may be present as animals fully weight bearing.
The CrCL is similar to the anterior cruciate ligament (ACL) in people. The knee (stifle) joint of the dog is one of the weakest in the body, and just as football players frequently suffer knee injuries, the dog is also prone to knee injuries. This is because within the knee joint, there are no interlocking bones, instead, the femur (thigh bone) sits on top of the tibia (shin bone), and is joined with several ligaments.
If the tibial plateau (top) has an excessive backwards slope, this can predispose dogs to rupturing their CrCL. When severe twisting of the joint occurs, the most common injury is a rupture of the CrCL. When the CrCL is torn, it allows the tibia to slide backwards. The limb is then difficult to bear weight on without collapsing.
Other factors can accelerate the injury. These include:
- Inadequate conditioning
- Obesity is the most controllable factor. Overweight dogs are far more likely to sustain a cranial cruciate ligament injury than lean dogs.
- Poor conformation,
- Luxating or slipping kneecaps
- Chronic inflammation or arthritis in the stifle joint
The underlying pathology of OCD is associated with the failure of the normal bone and joint growth process. As growth occurs, the body begins to ossify the cartilage model eventually leaving only a thin uniform layer of cartilage at the end of the bone known as the joint surface. When osteochondrosis occurs, a thickened area of cartilage results. Because cartilage gets its nutrition as a result of diffusion from the synovial fluid (joint fluid), the thickened area of cartilage can result in death of the chondrocytes in the deep layers of the osteochondrosis lesion. As the chondrocytes die, that area of cartilage can become weaker with time and eventually result in a cartilage flap forming. This is termed osteochondrosis dissecans (OCD). OCD is painful because of the inflammation within the joint.
Along with the elbow, the shoulder, stifle, and tarsal joints can be affected by OCD. Arthroscopic removal of the cartilage flap, and debridement of the OCD is the recommended treatment of choice. In general, dogs with shoulder OCD have an excellent prognosis following arthroscopic flap removal and microfracturing. Dogs with elbow, stifle, and tarsal OCD have a less-favorable prognosis.
Waiting for the animal to grow to maturity without any correction may cause for formation of deviation beyond correction or allow subluxation or luxation of the elbow or carpus to develop. Successful reconstructive surgery at that point is near impossible. In the older animal (close the growth plate closure or beyond), surgical correction can be corrected completely when the problem is recognized and toward an end point.
The proper management of radial and ulnar physeal plate injuries is difficult and requires the clinical judgment of the surgeon. Treatment depends upon the period of growth remaining. Typical correction of angular limb deformities requires osteotomy(ies) of the radius and/or ulna.
- Genetic factors increase the risks of developing this condition.
- Most studies conclude that hip dyplasia in a parent will most often be seen in the offspring as well.
- Dysplastic hips are painful and lack smooth movements.
- Symptoms are rarely extreme. Usually, only mild to moderate lameness is noted, which may or may not suddenly worsen. Dogs who hold the affected leg up or scuff their toenails when walking, or seem very painful in the rear legs, typically have other problems including (but not limited to), knee and spinal cord conditions.
- Quality of life for the dog can be severely affected. To reduce pain, the animal will typically reduce its movements. Signs include:
- Difficulty climbing stairs
- Altered gait when walking or running
- Restricted movement or extension of the rear legs
- Selection of the appropriate treatment option for this condition is dependent on many factors such as:
- Severity of hip dyplasia
- Development of osteoarthritis (OA)
- Degree of pain or discomfort
- Owner expectations
- Financial constraints
- Many dogs with pain and lameness associated with hip dysplasia can be effectively managed with conservative methods (i.e., without surgical intervention). Conservative methods include:
- Weight management (extremely important)
- Moderation of excessive exercise/activity
- Providing warm comfortable bedding
- Use of non-steroidal anti-inflammatory drugs
- Physical rehabilitation
- Using oral supplement(s), as needed.
- Several preventive surgical options can be considered for young growing puppies with hip dysplasia; however clinical efficacy of these procedures remains controversial, and is limited by candidacy of the dog. For these dogs, there are two surgical options available.
- Juvenile Pubic Symphysiodesis (JPS)
- Double Pelvic Osteotomy (DPO)
- If the dog has severe hip pain and the quality of life is decreased, and if conservative methods are not effective, surgical treatment should be considered. For these dogs, there are two surgical options available.
- Total hip replacement (THR)
- Femoral head and neck ostectomy (FHO).
The patella, or kneecap, is a small bone buried in the tendon of the extensor muscles (the quadriceps muscles) of the thigh. The patella normally rides in a femoral groove within the stifle. Patellar luxation is a condition where the knee cap rides outside the femoral groove when the stifle is flexed. It can be further characterized as medial or lateral, depending on whether the kneecap rides on the inner or on the outer aspect of the stifle.
Most dogs affected by this disease will suddenly carry the limb up for a few steps, and may be seen shaking or extending the leg prior to regaining its full use. As the disease progresses in duration and severity, this lameness becomes more frequent and eventually becomes continuous. In young puppies with severe medial patellar luxation, the rear legs often present a “bow-legged” appearance that worsens with growth. Large breed dogs with lateral patellar luxation may have a “knocked-in knee” appearance, combining severe lateral patellar luxation and hip dysplasia.
Surgical treatment is typically considered in grades 2 and over:
- Grade I: Knee cap can be manipulated out of its groove, but returns to its normal position spontaneously
- Grade II: Knee cap rides out of its groove occasionally and can be replaced in the groove by manipulation
- Grade III: Knee cap rides out of its groove most of the time but can be replaced in the groove via manipulation
- Grade IV: Knee cap rides out of its groove all the time and cannot be replaced inside the groove
One or several of the following strategies may be required to correct patellar luxation:
- Reconstruction of soft tissues surrounding the knee cap to loosen the side toward which the patella is riding and tighten the opposite side.
- Deepening of the femoral groove so that the knee cap can seat deeply in its normal position. (Figure 2c) This was previously achieved by rasping the cartilage, leaving exposed bone in contact with the patella. Surgeons now recess a wedge or rectangular block of cartilage and bone over the femoral groove to preserve contact between the knee cap and underlying cartilage.
- Transposing the tibial crest (Figure 5), the bony prominence onto which the tendon of the patella attaches below the knee (see first paragraph). This will help realign the quadriceps, the patella and its tendon.
- Correction of abnormally shaped femurs is occasionally required in cases where the knee cap rides outside of its groove most or all the time. This procedure involves cutting the bone, correcting its deformation and immobilizing it with a bone plate.
The procedures that will best address the problem are selected on an individual basis by the surgeon that has examined the patient.
The surgeon that has operated on your pet will best be able to advise you and establish a personalized post-operative treatment plan. For example, pain medications may be prescribed for a week after surgery. Physical therapy, with compresses and gentle, passive flexion and extension of the knee, may be recommended shortly after surgery. Exercise is typically limited to leash walks for 6 to 14 weeks depending on the procedures performed and factors affecting the healing capacities of your pet. Radiographs may be repeated at regular intervals to monitor bone healing.
Over 90% of owners are satisfied by the progress of their dog after surgery. The prognosis is less favorable in large dogs, especially when patellar luxation is combined with other abnormalities, such as angulation of the long bones or hip dysplasia.
Osteoarthritis is expected to progress on radiographs. However, this does not necessarily mean that your dog will suffer or be lame as a result. Keeping your pet trim and encouraging swimming/walking rather than jumping/running will help prevent or minimize clinical signs of osteoarthritis. Oral supplements and/or a specific diet may be recommended to promote cartilage function and minimize the progression of osteoarthritis.
Some degree of knee cap instability will persist in up to 50% of cases. This does not cause further lameness in the majority of cases. Migration or breakage of surgical implants used to maintain bones in position occurs rarely. Infection is a rare complication.
What Will Happen if Patellar Luxation is Left Untreated?
Every time the knee cap rides out of its groove, cartilage (the normal lining of bones within joints) is damaged, leading to osteoarthritis and associated pain. The knee cap may ride more and more often out of its normal groove, eventually exposing areas of bone. In puppies, the abnormal alignment of the patella may also aggravate the shallowness of the femoral groove and lead to serous deformation of the leg. In all dogs, the abnormal position of the knee cap destabilizes the knee and predisposes affected dogs to rupture their cranial cruciate ligament, at which point they typically stop using the limb.
Because it seems likely that this condition could be passed genetically, dogs diagnosed with patellar luxation should not be bred.
Diagnosis of FMCP and MCD can be challenging. The diagnosis is initially based on a careful orthopedic examination. Radiographs (x-rays) are of limited use in the diagnosis of FMCP. The FMCP fragment and damage to the cartilage cannot be seen on radiographs. Arthroscopy is recommended for the diagnosis of FMCP and MCD because it allows early and accurate diagnosis and treatment. This can usually be done in 15 – 30 minutes per elbow, and many dogs may be treated on an out patient basis.
In mild cases in which the small fragment is easily removed, the prognosis to return to normal activity is good. Most of these dogs return to normal activity over a few weeks to two months with little to no lameness. Anti-inflammatory medications, joint supplements, or rest after heavy activity may be necessary, but there is no evidence that more fragments will occur, and the progression of osteoarthritis (OA) is slow.
In more severe cases, where there is a large fragment and significant cartilage damage, the patient will likely have some degree of lameness even after arthroscopic removal of the FMCP.
Dogs with Medial Compartment Disease (MCD) 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 (TER). Total elbow replacement may be indicated when the cartilage is severely damaged throughout the elbow joint.
See Treatment Options, for more information.
Often, angular limb deformities are combined with rotational deformities in the femur and tibia. When this occurs, the treatment may involve osteotomy, but adequate treatment can be difficult.
- Is performed for the early treatment of hip dysplasia.
- Dogs should be 4 -5 months of age or younger.
- Dogs should have a distraction index (DI) between 0.4 to 0.7.
- This is measured using the PennHIP technique.
- The growth plate from the center of the pelvis (pubis) is stopped (using cautery), allowing the other parts of the pelvis to grow, and the sockets of the hips will rotate over the ball of the hip.
- The result is a stable hip joint that has a much less chance of developing significant arthritis.
- The surgery is usually performed on an out-patient basis.
- Complications include:
- Failure to ablate the pubic growth center, and the pelvis grows normally.
- Damage to the urethra (very rare when the procedure is performed by a skilled surgeon)
- Mild narrowing of the pelvic canal which usually only poses problems with birthing.
Infraspinatus contracture is a term used to describe contracture of the tendon of insertion of the infraspinatus muscle. This condition is rare, and most often affects large-breed dogs, working dogs in particular. Though the condition is not usually painful, but may create a disability. Repetitive micro trauma, blunt trauma, and osteo-fasial compartment syndrome have been reported to cause this problem.
Dogs affected, as a consequense, have most or all the internal rotation of the humerus in relation to the scapula lost. This lack of rotation is a reliable clinical sign for diagnosis of the disorder. The treatement of this disorder is usually done by tenotomy of the tendon of insertion of the infraspinatus muscle and release of capsular adhesions of the tendon. Put simply, this means a cut is made near where then tendon connects to the humerus, and additional surrounding tissues are also released to gain full range of motion of the shoulder. This releases the tension on the scarred muscle, and immediately returns the shoulder joint to a full range of motion. After the surgical site heals, the patients appear pain-free and fully functional without any enforced restrictions.
Recommendation for prevention of this condition is recommended by completing a thorough warm-up routine. Gradual conditioning over weeks before advancing to strenuous activities can help minimize damage. If an injury to the muscle occurs, damage may be minimized by treating the muscle inflammation. This can be done using cold packs, anti-inflammatory medications, and physical therapy.
- These type of fractures may take many forms
- If the fracture happens while the joint is in hyperextension, the radius may chip at the proximal dorsal border of the radius.
- Typically the radial carpal bone is crushed when the joint is overloaded (in a fall from a height).
- Transverse (cross) fractures with major medial (inside) and lateral (outside) fragments can occur, but these are uncommon.
- CLOSED REDUCTION AND FIXATION
- Small fragment fractures or massively crushed fractures are treated by conservative mean.
- Reduction is not possible, so the carpus is immobilized in a full extension splint for 2 to4 weeks.
- If small chip fractures do not unite or continue to cause discomfort, they may need to be removed surgically.
- Small fragment fractures or massively crushed fractures are treated by conservative mean.
- OPEN REDUCTION AND INTERNAL FIXATION (SURGERY)
- Large fracture fragments are managed by open reduction and fixation.
- Fixation is usually performed using k-wires or lag screws.
- Post operative management may include a support dressing, but usually firm external support is not needed.
- Passive and active manipulation is encouraged soon after surgery to maintain good range of motion.
- Secondary degenerative joint disease with loss of motion is to be expected.
- Early weight bearing and activity is aimed at restoring as much range of motion as possible.
- Secondary degenerative joint disease with loss of motion is to be expected.
- CLOSED REDUCTION OR FIXATION
- Is not possible. This is due to the constant distraction by the gastrocnemius muscle (Achilles tendon).
- SURGICAL REDUCTION AND FIXATION
- Standard form of fixation is a tension band wire and pins.
- Are rare if a tension band wire is used.
- Failure is due to delayed healing, non-union, or total fixation failure.
- Is for full return to function is excellent if properly treated.
- Is a similar surgical technique to Triple Pelvic Osteotomy (TPO), but excludes the ischiatic osteotomy.
- Is a surgical procedure for the treatment of canine hip dysplasia.
- The objective is to alter the dog’s own natural hip joint, by eliminating the laxity and preventing the progression of arthritis.
- Dogs with complete luxation of the hip, grade IV hip dysplasia, are not candidates for this procedure.
- This surgery is reserved for younger dogs who still have a hip joint worth saving, and who meet stringent pre-operative requirements set my the surgeon.
- Dogs, who are candidates, are:
- Usually 5-10 months old.
- Have hip sockets deep enough to accommodate the hip bone after rotation.
- Have hip joints that are free of arthritis.
- The pelvis is cut in two places (at the pubis, and at the ilium), allowing the acetabulum (socket of the hip) to be rotated ventroversion a predetermined amount, to fit a specifically designed bone plate. This allows better coverage of the ball and therefore a more stable hip joint.
- Until that point is reached, the patient should remain very quiet.
- Young dogs have softer bone, making them higher risk for implant failure.
- Radiographs taken at 6 weeks post op, will confirm bone healing, and the patient will be allowed to increase their activity slowly.
- The rotation is held in position using a special plate and screws.
- It takes approximately 6 to 8 weeks for the bones to heal solidly.
- The pelvis is cut in two places (at the pubis, and at the ilium), allowing the acetabulum (socket of the hip) to be rotated ventroversion a predetermined amount, to fit a specifically designed bone plate. This allows better coverage of the ball and therefore a more stable hip joint.
- The complications after unilateral or bilateral DPO were lower than after TPO because the elimination of the ischiatic osteotomy allowed for increased stability of the pelvis. The surgical technique of DPO is a little more demanding than that of the TPO because of the difficulty in handling and rotating the acetabular iliac segment, but this is offset by the elimination of the ischial osteotomy.
- The success rate of DPO or TPO is 85% to 90%, if it is performed on an appropriate candidate.
Predisposing factors to bicipital tenosynovitis include the presence of an OCD flap in the tendon sheath, elbow dyplasia with secondary loss of elbow joint flexion, obesity, or repetitive motion. The condition is often managed conservatively, using rest and anti-inflammatory medications. Sometimes the injection of methylprednisolone acetate injected intra-articuarly is also a treatment choice, and is followed by rest and sometimes a second injection. Transection of the bicipital tendon and release or reattachment to the proximal portion of the humerus is a treatment choice to be considered in patients responding poorly to 2 to 3 months of rest.
- Is severe damage of the ligaments that support the wrist of the forelimb.
- Special radiographs (x-ray) pictures can help to diagnose a dislocation at one or more of the three joints in the carpus. A dislocation of any or all of these is generally termed “hyperextension.” When weight-bearing, a hyperextended carpus allows the paw to drop closer to the ground than normal. The condition is usually quite painful.
- Minor cases of hyperextension of the carpus may be successfully treated with a splint or bandage and strict rest.
- Most hyperextension situations require more aggressive treatment. This is especially true among the medium to large breed dogs. Fusion of the joint, a surgical procedure known as “arthrodesis,” is necessary in many cases to restore function.
- In cases of complete dislocation, surgical reconstruction of the medial and lateral collateral ligaments followed by external fixation may result in a success of 50% or less.
- Most animals with subluxatons or luxation require some level of joint arthrodesis, whether that is a partial joint fusion, or complete joint fusion is directly dependent on the degree of damage to the ligaments and soft tissue.
- If only one collateral ligament is affected, the displacement may also be valgus (veering outward) or varus (veering inward).
- This injury is commonly treated by placing screws with heavy duty suture in a fashion that mimics the natural ligament.
- Treatment methods must therefore resist the tensile forces.
- Fractures of the calcaneus exhibit swelling caudal to the tarsus, and crepitation may be found on physical exam.
- Non surgical management for healing is also not appropriate for calcaneal fractures because bandaging or splint application is ineffective in countering the forces produced by the Achilles muscle-tendon unit.
With calcaneal fracture repaires, the pull of the gastrocnemius muscle must be countered with a tension band wire, lag screws, or a plate.
Splinting post operatively is often necessary until bone healing is observed on radiographs (x-rays).
When this ligament is ruptured, there is an abnormal increase in the internal rotation of the tibia on the femur. This increase in rotation causes the medial femoral condyle to place an excessive twisting force on the relatively immobile medial meniscus. The twisting action may stretch the concave inner border of the meniscus and tear it in a transverse fashion. In some cases, the meniscus is crushed between the medial femoral condyle and the medial tibial condyle. When a rotational force is added, a longitudinal tear in the medial portion of the meniscus may result. A longitudinal tear that displaces its medial portion into the joint is called a “bucket-handle” tear. In extreme flexion, the caudal horn of the medial meniscus is compressed between the femur and tibia and can be easily damaged. In this position, rotational forces may tear the caudal attachment of the medial meniscus, allowing its caudal horn to move about freely. in some instances, the freely moving segment of the meniscus in a caudal horn tear or bucket-handle lesion may displace into the joint and interfere with flexion or extension.
Reports of lateral meniscal injury are rare and are usually associated with massive joint trauma. The loose connection of the lateral meniscus to the joint capsule and the absence of collateral ligament attachment make it less likely to be caught between the femoral and tibia condyles than the less mobile medial meniscus.
While meniscal injury can occur in conjunction with acute cranial cruciate ligament rupture, a higher percentage of meniscal lesions are associated with chronic joint instability. These degenerative meniscal lesions develop even when there is no primary meniscal injury. Joint instability produces an unphysiologic gliding and shearing motion that can squeeze the menisci between the femur and tibia and cause them to degenerate. The microstructure of the fibrocartilage is altered.
Injury to the meniscus usually occurs in association with rupture of one or both of the cruciate ligaments. In the case of caudal horn tears, or detachments, of the medial meniscus the instability resulting from cruciate ligament insufficiency may cause the caudal horn of the meniscus to fold on itself as the medial femoral condyle passes over it. This action may produce a “clicking” or “snapping” sound and is said to be diagnostic of meniscal injury. While such a sign may be suggestive of meniscal damage, it is my opinion that the meniscus can be accurately evaluated only by arthrotomy and visualization throughout the range of motion. By flexing and extending the opened joint and applying a cranial or caudal stress to the tibia, lesions of the caudal horn of the meniscus should become apparent. In some cases of cranial cruciate ligament rupture in which the caudal attachment of the medial meniscus has been stretched, the caudal horn may be seen to displace cranially upon flexion of the stifle. This does not necessarily indicate damage to the meniscus, since it will usually return to its normal position upon extension of the joint. These lesions should be evaluated carefully to avoid unwarranted removal of the meniscus.
Various techniques are used to repair a damaged meniscus. The likelihood that severe degenerative changes will occur within the joint is decreased if the meniscus can be salvaged. In most cases, only incomplete verticle tears are candidates for repair.
Meniscal release is a controversial procedure which involves freeing the posterior part of the meniscus. The theory is that the release allows the meniscus to avoid being crushed and damaged by an unstable joint. Previously, meniscal release was commonly performed any time a cruciate injury was repaired. However, a 2008 study by Pozzi, et al, from the Department of Veterinary Clinical Sciences at Ohio State University, found that meniscal release does not prohibit degenerative changes leading to arthritis in the joint and is comparable in this respect to total meniscectomy. Therefore, many orthopedic surgeons are more selective when performing this procedure.
Indications for meniscectomy have been the subject of controversy. Partial transverse tears or isolated peripheral detachments appear to do well clinically in the stabilized joint and therefore need not be removed. In most instances, however, it is advocated to perform a partial meniscectomy with removal of only the damaged portion of the meniscus.
While most veterinary surgeons agree that meniscectomy is the treatment of choice for severe meniscal damage, the advantage of partial versus total meniscectomy is debated.
Regeneration of the menisci following total resection has been observed. This regenerated tissue originates from the vascular perimeniscal tissues and grossly resembles fibrocartilage. This regeneration, is not uniform and is not present in every case.
In cases where surgery is not practical, particularly in smaller breed dogs, medications to relieve pain and reduce inflammation may be used to treat meniscal injuries. Options include nonsteroidal anti-inflammatory medications (NSAIDs), glucosamine and chondroitin. Medications to relieve pain are also used and include tramadol.
Generally, the anconeal process and ulna fuse by 24 weeks of age. After this age, lameness will develop if the anconeal process remains separated. German Shepherds, Basset Hounds, and Saint Bernards have the highest incidence of UAP. It is considered a genetically transmitted disorder and affected individuals should not be bred.
This condition can affect one or both elbows. The dog will be lame on the involved limb(s). Additionally, the elbow may appear swollen and painful, especially when the leg is extended. Most cases are seen in young dogs between six and twelve months of age. Quite commonly, without treatment, the joint will become severely painful and useless. The dog will walk on three legs, or not at all if both elbows are involved. The condition worsens with age, with severe arthritic changes occurring.
Dogs with an un-united anconeal process may have other abnormalities of the bones in the elbow joint. Radiographs (x-rays) are needed to confirm the diagnosis. Once confirmed, surgery is generally recommended. Several surgical procedures can be used to either attach the anconeal process with screws, or remove it completely. Even with surgery, the function of the elbow joint is usually compromised to some degree, though most of the pain is resolved.
Since the structures of the shoulder are typically malformed, surgical correction is not recommended. Clinical management usually involves restriction of activity and/or use of analgesics and/or anti-inflammatory medications.
Aquired luxations are the result of direct trauma to the shoulder region. This may be from automobile trauma, falls from heights or by twisting injuries to the shoulder. In addition to complete luxation, these forms of trauma may also cause acquired subluxation. Subluxation often leads to chronic instability, degenterative arthritis, and progressive lameness that may result in disuse.
Closed reduction of the acute luxation can be accomplished with ease. If not done early, the formation of an organize hematoma, or fibrous mass occupying the glenoid cavity may prevent reduction success. If closed luxation reduction is possible, a sling should be placed holding the shoulder in a stable position, and not allow too much internal rotation of the humeral head.
Open reduction and surgical fixation is necessitated when joints have been chronically luxated or when closed reduction of the luxation is unsuccessful. There are numerous techniques described for surgical fixations, and which technique used is dependent on the surgeon involved.
Recurrent shoulder luxation is a problem for a small population of dogs. Often the joint will be luxated and relocated by the animal many times a day. Closed reduction is very simple, but unsuccessful. Open reduction and fixation with an appropriate joint capsule imbrication and tendon transposition technique is necessary. Postoperative external immobilization of the should is necessary.
Chronic shoulder luxation implies an animal with a shoulder luxation of a long-standing nature. Typically these animals have obvious gait abnormality, but are without pain due to joint ankylosis. They probably have as good a result as can be expected with this condition.
Fracture of the glenoid rim or the scapualr tuberosity accompanied by soft tissue tearing may result in fracture with dislocation of the shoulder. The fracture must be surgically reduced and following fixation steps may be taken to stabilize the shoulder luxation.
Fractures of the scapular neck, supraglenoid tubercle, glenoid, and glenoid rim are less common, and are treated by coaptation when appropriate and by rigid internal fixation when necessary. As in any intra-articular fracture, the common complications include diminished range of motion; discomfort associated with mild, moderated or severe DJD. The typical dog or cat will have slight degenerative joint disease and minor complications.
- The joint is permanently fused by removing the cartilage of the joint surfaces and placing bone graft in the joint.
- The joint is stabilized using metal implants so that the bone can heal together (fuse).
- Stress radiographs are very important in deciding which method or arthrodesis (partial or complete) is appropriate for the patient.
- Pancarpal (complete) arthrodesis is used more often that partial carpal arhrodesis, and even though motion in the carpus is eliminated, reasonable function of the limb remains.
Some common problems may require arthrodesis.
- Carpal joint instability.
- May be associated with erosive and non erosive immune-mediated joint disease and septic or fungal arthritis.
- Due to loss of articular cartilage or injury to supporting ligament structures.
- Chronic osteoarthritis that is non responsive to medical management.
- Loss of carpal bones or supporting ligament structures due to resection of neoplastic (cancerous) conditions.
- Congenital malformations of the carpus resulting in luxations or complete or partial agenesis of carpal bones.
- Radial nerve injury
- Must have remaining cutaneous sensation (feeling in the skin) of the palmer region to avoid self-mutilation.
Arthrodesis may be accomplished by using external fixators and pins, or bone plate fixation.
- Bone plate fixation represents the best combination of rigid fixation.
- Bone plate fixation has the fewest complications.
- External skeletal fixation is an excellent technique to use in cases of shear or open wounds.
Postoperative external support with a splint is essential in most surgical procedures
- Except tension band principle repairs.
- Protects the implants from excessive loading (weight bearing) while fusion happens.
- External support is maintained until radiographs (x-rays) show evidence of signification joint fusion (usually 4 to 8 weeks).
- Implant removal is not necessary, but it may be needed in cases of implant migration, or breakage, infection or persistent lameness, after fusion is complete.
- Attempts to place weight on the limb cause the carpus and/or tarsus to collapse in a plantigrade stance.
- If the calcaneus (heel bone) is fractured, the animal may walk plantigrade on the limb or may be nonweight bearing.
- Pain, swelling, and crepitus are present in the affected limb.
- Varus or valgus (inward or outward) deviation of the foot is usually present.
- Racing greyhounds most often develop fractures of the central tarsal bone.
High detail radiographs using specialized views are usually sufficient to make the diagnosis. In some cases, MRI or CT may be helpful.
CLOSED REDUCTION AND FIXATION
Minor chip fractures that are away from the articular (joint) surface do well if placed in splints.
Nonarticular (non-joint) but well-aligned fractures of the neck of the tibial tarsal bone also do well if splinted.
Massively comminuted fractures are often impossible to fix internally and are treated best in rigid external fixation.
In all instances the talocrural joint should be placed in a normal standing angle.
- In some instances closed reduction is considered adequate.
OPEN REDUCTION AND INTERNAL FIXATION (SURGERY)
Simple two-part fractures are fixed best using multiple Kirschner wires or cortical interfragmentary lag screws. Because of comminution it is often necessary to maintain distraction of fracture fragments with a device and to pack the defect with a cancellous graft(bone graft).
Severely comminuted fractures that cannot be repaired require talocrural arthrodesis.
Chip fractures of the trochlear lips may be removed or, preferably, replaced using small Kirschner wires, which are countersunk below the articular (joint) surface.
- Open reduction is difficult at best, due to the anatomical constraints that prevent full visualization of the tibial tarsal bone.
AVULSION OF THE LONG DIGITAL EXTENSOR TENDON
- The long digital extensor tendon originates on the lateral distal aspect of the femur above the joint surface.
- When this tendon avulses, it usually takes along with it a small piece of bone; so, on radiographic examination there will be a chip fracture located within the joint.
- The fracture fragment will usually be in the lateral cranial compartment of the joint and will still be attached to the long digital extensor tendon.
- This injury is usually diagnosed arthroscopically, but treated by a small arthrotomy through a lateral incision. The avulsed tendon is replaced using a simple mattress suture of wire through the bone.
- The animal is restricted in exercise and immobilized in a bandage or rigid splint for 2 weeks. Good results are obtained through this procedure, but the condition is rather uncommon.
AVULSION INJURIES OF THE COLLATERAL LIGAMENTS
- Occasionally avulsion of a collateral ligament will be seen on either the medial or lateral aspect.
- If a piece of bone is associated with this avulsion, either lag screw fixation or two Kirschner wires will be adequate to stabilize the fragment.
- Sometimes it is necessary to rebuild the structer of ligament damage using screws, washers and heavy duty suture or wire.
- External immobilization will be needed in some instances to maintain integrity of the fixation following injury. Immobilization is usually maintained for 3 to 4 weeks depending on the type of internal fixation used.
FRACTURES THROUGH THE DISTAL END OF THE FEMUR
- Fractures through the distal end of the femur into the joint are common.
- Most of these fractures can be handled with multiple small Kirschner wires and sometimes with a tension band wiring technique.
- The small defects that remain fill with granulation tissue and eventually with fibrocartilage, producing a functional joint.
FRACTURES OF THE PROXIMAL TIBIA
- Fractures of the proximal tibia include avulsion fractures of the tibial crest, which are usually treated with tension band wiring techniques.
- Proximal physeal fractures of the Salter type I and 11, which affect the stifle joint, are common in the proximal tibia.
- Occasionally comminuted fractures will cross the joint surface and involve the tibial plateau.
- Avulsion fractures of the cranial cruciate ligament are also seen, with a small piece of bone associated with the distal end of the cruciate. In most dogs this piece cannot be returned to its original place and is removed when the ligament is debrided at the time of surgical repair and stabilization with a cruciate ligament replacement.
- Most tibial plateau fractures can be handled with either a buttress plate or simple Kirschner wires into the metaphysis to stabilize the fracture.
- Most fractures of the knee joint seem to occur in the femur, and fractures of the proximal tibia are less common.
DISLOCATION OF THE KNEE
- Complete dislocation of the knee is uncommon.
- The usual presentation allows for complete cranial and caudal drawer movement, indicating rupture of both cranial and caudal cruciate ligaments as well as at least one collateral ligament, usually the medial collateral ligament, giving complete instability to the stifle joint. Vascular injury can occur, causing rupture or blockage of the popliteal artery.
- The problem of complete dislocation of the knee is not easily resolved. There are three basic choices of treatment, as described below.
- CLOSED TREATMENT
- The closed treatment of complete dislocation of the stifle joint is accomplished by using a lateral spica splint or equivilant. Results are quite variable, and will usually take 4-8 weeks to determine outcome.
- CLOSED REDUCTION AND LIGAMENT RECONSTRUCTION
- Most, if not all, dislocations of the stifle joint in the dog can be reduced through closed manipulation.
- Following this, physical examination and stress radiographs will reveal which ligaments will need open reconstruction. The menisci may be torn or damaged. Removal of the menisci is done only if they are completely mobile. Sometimes the menisci appear to be uninjured.
- The reconstruction that is necessary to stabilize the joint involves prevention of cranial drawer movement, prevention of medial or lateral instability by associated collateral ligaments and caudal drawer. This can usually be accomplished by reconstruction of one collateral ligament (the other usually is intact) and stablization of the cranial cruciate ligament. The caudal cruciate is usually untouched and the caudal joint capsule may be reefed or tightened to help stabilize the caudal drawer.
- Following this procedure external immobilization is used for 3 to 4 weeks. Results of the reconstruction can be quite variable.
INTERNAL FIXATION WITH NO RECONSTRUCTION
- In some small animals it is possible to stabilize the knee with internal fixation using a small Steinmann pin to hold the knee in proper position. No other attempt is made to correct the internal derangements of the stifle joint, and external immobilization may be used to prevent fracture of the internal fixation device.
- The pin is introduced through the lateral distal femur just above the lateral trochlear ridge of the femur, passes through the intercondylar joint space, into the joint and through the tibial plateau, and out through the medial portion of the tibia just below the tibial plateau. The intramedullary pin is left in place for 3 to 4 weeks and then removed; no other treatment is provided.
- Small animals are more apt to have a good result with this technique than are larger dogs.
- Following immobilization of the stifle joint with any of these methods, return to functional use may be quite limited. Analgesics and physical therapy may be helpful in some cases. If pain is a persistent problem with or without instability, surgical arthrodesis of the stifle joint may be considered as a method to return the dog to useful function of its limb.
- Complete dislocation of the stifle joint of the dog and cat remains a difficult problem to treat successfully. The infrequent nature of the injury does not allow any one person to have a large enough series of cases to make adequate recommendation of treatment modalities.
- Patellar fractures are uncommon and most occur as a result of direct trauma. Almost all fracture types are intra-articular. In avulsions or complete fractures that include quadriceps tearing, the patellar ligament may be lax; however, most patellar fractures do not include complete quadriceps tearing. Radiographs are needed to arrive at a definitive diagnosis.
- Closed reduction is impossible owing to the constant pull of the quadriceps; distraction will be maintained, and nonunion will result. As a result of the nonunion and irregular articulating surface, degenerative arthritis of the knee can be anticipated.
- Open reduction and fixation is accomplished by a lateral or medial parapatellar arthrotomy incision, or by athroscopic visulation allowing pin placement. Either of these methods will allow for complete visualization of the fracture fragments as well as of the articular surface.
- Reduction is accomplished by placing the knee in extension, thus relaxing the quadriceps. Small fragments or multiple small comminuted fragments must be removed.
- Only large pieces possessing articular cartilage need to be reduced. If necessary, up to one half of the patella can be resected.
- METHODS OF FIXATION
- Fixation is achieved best using a classic tension band wire or any solid wiring technique that firmly aligns the fragments and is tied over the cranial surface of the patella.
- Simple interfragmentary screw fixation may be used in the patella. Sometimes, a tension band wire should also be applied to prevent the screw from bending and failing.
- AFTERCARE AND COMPLICATIONS
- Most animals are placed in an extension style splint or cast for 6-8 weeks, and is dependent on ossificaiton.
- The most common complication is fixation failure.
- The second most common problem is secondary degenerative joint disease. This can be minimized by prompt, adequate internal fixation.
- Nonunion may occur but is rare.