Arthroscopic Treatment of Forelimb Lameness
Jeffrey P. Christ, DVM, Residency Trained in Surgery
Veterinary Specialty & Emergency Center
Forelimb lameness in dogs can be a frustrating diagnostic challenge. Many patients experience a subtle lameness that is difficult to localize to a specific joint. Even when obvious discomfort is associated with one joint of the forelimb, treatment of these conditions can be challenging due to small lesions present in tight joint spaces. Common causes for forelimb lameness in young dogs can be attributed to diseases of the elbow or shoulder joints. Elbow pain may arise from any one of many specific etiologies, including fragmented coronoid processes (FCP), ununited anconeal process (UAP), or osteochondrosis dissecans (OCD). Shoulder lesions often present in young dogs may include osteochondrosis dissecans or partial tears of the biceps tendon (bicipital tenosynovitis).
The examining clinician should be cognizant of other etiologies that can cause forelimb lameness (i.e. intra- or extra- articular neoplasia, septic arthritis, immune-mediated polyarthropathy, and others). Although open approaches can be used to treat any of these conditions, arthroscopic treatment can offer a less invasive and equally effective treatment for any of these conditions in the shoulder and elbow joints.
Localization of forelimb lameness via a physical examination presents the first challenge in treatment.
A complete orthopedic examination of the affected and contralateral limb is necessary as many conditions can have a bilateral presentation, although may be asymmetrical in severity. Each joint should be palpated and taken through a full range of motion, being meticulous in assessing for discomfort, effusion, crepitus, and/or increased laxity. Although the shoulder and elbow are the most commonly affected joints, the digits, carpal joints, long bones, and soft tissue structures should not be ignored. Joints should be placed in valgus stress where indicated, particularly the shoulder joint, to assess for instability or laxity of the joints. Thorough neurologic examination should be performed concurrently to rule out nervous causes for forelimb lameness (i.e. cervical myelopathy or brachial plexus dysfunction).
After a particular joint is suspected as the source, survey radiographs of the affected region are often the first diagnostic step and can provide useful information. Joint incongruence, degenerative joint disease, and osteophytosis can be present from any condition affecting the joint and may raise concern for long-term prognosis, if severe. If effusion is present, arthrocentesis can be performed prior to any surgical procedure to rule out septic arthritis and immune mediated arthropathy.
Serologic testing for tick borne diseases is also prudent as these are a common cause of arthropathy and lameness. Although of limited utility, ultrasound may help to confirm or support a specific diagnosis, particularly in the shoulder joint. Bicipital tenosynovitis may be definitively diagnosed via ultrasound, even if survey radiographs prove unremarkable. If standard work-up does not result in a diagnosis, computed tomography is a helpful tool that can provide higher resolution and detail of the joint and smaller processes present within.
Arthroscopy of the joint provides many advantages over an open approach. Visualization of the joint surfaces and the ability to identify smaller lesions is significantly improved in comparison with open approaches. The accessibility and magnification provided with arthroscopy allows for a far more complete assessment of joint health, particularly of the articular cartilage.
Arthroscopy has the advantage of allowing both diagnostic capability but also therapeutic value. Most lesions present in the elbow and shoulder can be treated via two small portals, obviating the need for a more invasive and painful approach. Patients undergoing arthroscopic surgery can typically be discharged from the hospital the same day the procedure is performed. Patients should generally be restricted from exercise for 6 weeks following arthroscopic surgery and recheck examinations performed at 2 and 6 weeks post-operatively.
Prognosis after arthroscopic surgery depends primarily on the condition being treated and the severity of secondary joint changes (i.e. degenerative joint disease) present at the time of surgery. Both bicipital tenosynovitis and OCD of the shoulder can have excellent return to function if no osteoarthritis is present at the time of surgery. Prognosis following treatment of FCP can be variable, dependent upon the severity of osteoarthritis and age at the time of surgery. Those less than 1 ½ years of age often have a favorable prognosis, with 70% having improvement following fragment retrieval.
Those older than 3 years of age or with significant secondary joint disease improve little following fragment retrieval. Prognosis following debridement of elbow OCD lesions is guarded, with a large number of dogs developing secondary arthritis and requiring prolonged medical therapy.
Although it is a newer treatment modality in veterinary medicine, arthroscopy is developing into the standard of care for many joint diseases and can offer advantages that are not possible with open surgical procedures.
If you have any questions about arthroscopic treatments in general, or to discuss a specific case that may be appropriate for treatment, please call Dr. Jeffrey Christ at 484-567-7999 or 484-567-7997 (Referring Vet Direct Line).
Dr. Jeffrey Christ is a residency-trained surgeon at the Veterinary Specialty & Emergency Center. The Veterinary Specialty & Emergency Center operates state-of the-art emergency and specialty veterinary hospitals that are open 24/7/365 in Levittown PA, Philadelphia PA and Conshohocken PA. For more information about our world-class emergency and specialty care, please visit VSEC on the web at www.VSECVET.com.