Medial Coronoid Disease Research Articles

The use of planar bone scintigraphy and HiSPECT for diagnosis of primary and concomitant flexor enthesopathy in the canine elbow

To investigate the possibilities and limitations of planar bone scintigraphy and high resolution single photon emission computed tomography (HiSPECT) to diagnose flexor enthesopathy and to distinguish primary flexor enthesopathy from the concomitant form. A prospective study of 46 dogs with primary flexor enthesopathy, concomitant flexor enthesopathy, medial coronoid disease, and normal elbows was performed. All dogs underwent planar bone scintigraphy and HiSPECT imaging. The obtained images were visually scored for increased radiopharmaceutical uptake in the medial humeral epicondylar and medial coronoid process region using a score from 1-3. Planar bone scintigraphy demonstrated increased radiopharmaceutical uptake in all diseased elbow joints, except for one. HiSPECT demonstrated increased radiopharmaceutical uptake of the medial humeral epicondyle in nearly all clinically affected joints with primary and concomitant flexor enthesopathy. Additional uptake of the medial coronoid process was recorded in all clinically affected joints with concomitant flexor enthesopathy and in six out of 18 with primary flexor enthesopathy. No difference in intensity of the uptake was noticed. Planar bone scintigraphy allows the attribution of lameness to the elbow joint in cases of primary flexor enthesopathy with minimal or even absent radiographic changes. The more detailed HiSPECT enables the localization of pathology within the elbow joint and is a sensitive technique to detect flexor enthesopathy. However HiSPECT is insufficient to distinguish primary from concomitant flexor enthesopathy.

Anatomical study of fibrous structures of the medial aspect of the canine elbow joint

Forces exerted by fibrous structures on the medial aspect of the canine elbow joint have been reported to be involved in elbow pathology. The purpose of this paper is to...

Het nut van intra-articulaire anesthesie als diagnosemiddel voor manken bij de hond

Manken bij de hond is soms moeilijk te lokaliseren omwille van weinig uitgesproken pathologische veranderingen of onduidelijke klinische symptomen. Intra-articulaire anesthesie wordt voorgesteld als een diagnostisch middel om het manken te lokaliseren. Na een beschrijving van de voorbereiding, de techniek en de punctieplaatsen, wordt een overzicht gegeven van een reeks patiënten aangeboden met verschillende gewrichtsproblemen. De studie gaf aan dat intra-articulaire anesthesie toepasbaar was in ieder gewricht, zolang de clinicus ervaring had en de honden gesedeerd waren. De intra-articulaire anesthesie was positief in 87% van de gevallen en problemen aan het ellebooggewricht, meer bepaald een losse processus coronoideus, was de grootste indicatie voor intra-articulaire anesthesie.

Diagnostic intra-articular anaesthesia of the elbow in dogs with medial coronoid disease

Assessment of the effect of intra-articular anaesthesia on lameness caused by medial coronoid disease. This study included 90 dogs that were evaluated for the complaint of unilateral forelimb lameness. All dogs were suspected of having an elbow problem for which orthopaedic examination and radiographs showed inconclusive findings. Following a short sedation, mepivacaine was injected intra-articularly to determine whether lameness was caused by a suspected elbow problem. This effect was compared with the final diagnosis based on computed tomography and arthroscopy. Out of 90 dogs, 78 (87%) dogs had an improvement of lameness after injection of the local anaesthetic, which confirmed the elbow joint as the primary source of lameness. A positive response was seen in all types of medial coronoid lesions. A false negative result was observed in 12 dogs (13%). Medial coronoid disease is represented by different types of pathologic lesions including chondromalacia, fissures, fragments, and medial compartment disease. Diagnosis may be difficult because of limited clinical or radiographic signs or a combination of both. Intra-articular anaesthesia can be a helpful diagnostic tool to localize the problem by eliminating pain and reducing lameness to a great extent in all types of coronoid lesions.

Computed tomography of ununited anconeal process in the dog

The purpose of this study was to describe computed tomography (CT) features of the ununited anconeal process and relate them with the following elbow dysplasia signs: medial coronoid disease, medial humeral condyle changes, osteoarthritis (OA), and radioulnar incongruence. Computed tomographic images of dogs older than six months with an ununited anconeal process were evaluated (n = 13). Ununited anconeal process features were described as being complete or incomplete, and the degree of displacement, volume, and presence of cysts and sclerosis were also evaluated. Medial coronoid disease was defined as an irregular medial coronoid process shape, presence of sclerosis and fragmentation. Medial humeral condyle changes were defined as subchondral bone flattening, lucencies, and sclerosis. Osteoarthritis was graded depending on the osteophytes size. Radioulnar incongruence was measured on a sagittal view at the base of the medial coronoid process. Eleven elbows had a complete and two had an incomplete ununited anconeal process. All ununited anconeal processes had cystic and sclerotic lesions. Seven ununited anconeal processes were displaced and six were non-displaced. Mean ununited anconeal process volume was 1.35 cm3 (0.61 cm³ - 2.08 cm³). Twelve elbows had signs of medial coronoid disease (4 of them with a fragmented medial coronoid process), and one elbow did not show any evidence of medial coronoid disease. Ten elbows had medial humeral condyle changes. One elbow had grade 1 OA, seven elbows had grade 2, and five elbows grade 3. All elbows had radioulnar incongruence: three elbows had a negative and 10 elbows had a positive radioulnar incongruence. Mean radioulnar incongruence was 1.49 mm (0.63 mm - 2.61 mm). Computed tomographic findings were similar in the majority of the elbows studied: complete ununited anconeal processes with signs of medial coronoid disease, positive radioulnar incongruence, high grade of OA, sclerotic medial humeral condyle changes, and large ununited anconeal process volumes. Incomplete small ununited anconeal process volumes could be associated with a lower incidence of medial coronoid disease or medial humeral condyle changes. We recommend performing preoperative CT of elbows with an ununited anconeal process to evaluate concurrent lesions.

Primary flexor enthesopathy of the canine elbow: imaging and arthroscopic findings in eight dogs with discrete radiographic changes

To describe the radiographic, ultrasonographic, computed tomography (CT), magnetic resonance imaging (MRI), and arthroscopic findings in eight dogs with elbow lameness caused by primary flexor enthesopathy. Clinical study. Eight client-owned dogs. In all dogs, lameness was localized to the elbow by clinical examination. Radiographic examination, ultrasound, CT and MRI were performed prior to arthroscopy. In seven dogs, surgical treatment and subsequent histopathology were performed. Primary enthesopathy of the medial epicondyle was diagnosed in eight dogs (13 joints) by combining the minimal radiographic changes with specific ultrasonographic, CT, MRI and arthroscopic findings at the medial epicondyle. In all joints, any other pathology could be excluded. Histopathology of the affected tissue revealed degeneration and metaplasia in the flexor muscles. Primary flexor enthesopathy at the medial epicondyle is an unrecognized condition and is a possible cause of elbow lameness in the dog. Diagnosis is based on specific imaging and arthroscopic findings. The most important cause of elbow lameness in dogs is medial coronoid disease. Often this condition presents with minimal radiographic and arthroscopic changes. In these cases, primary enthesopathy of the medial epicondyle should be considered as a differential diagnosis, in order to make the correct treatment decision.

Quantification of Humeroulnar Incongruity inLabradorRetrievers with and without Medial Coronoid Disease

To quantify humeroulnar incongruity on elbow radiographs in Labrador Retrievers with or without medial coronoid disease (MCD). Retrospective study of 92 elbows. Radiographic projections of elbow joints from Labrador Retrievers with MCD (n = 42 elbows; 26 dogs) and without MCD (n = 50 elbows; 25 dogs). The congruity of the humeroulnar joint was measured using an index of subluxation (SI) for each elbow. SI was defined as the distance between the centers of 2 circles drawn along the margins of the incisura trochlearis and the trochlea of humerus on mediolateral digital radiographic projections, normalized by the radius of the circle circumscribing the humeral trochlea. SI was compared between right and left elbows with and without pathology using a Wilcoxon test for paired data, and between normal and abnormal groups with a Wilcoxon test for unpaired data. Mismatch between ulnar curvature and curvature of humeral trochlea and radioulnar incongruency were also noted (Wilcoxon test). The intraobserver repeatability, correlation between SI and radioulnar incongruency, and between SI and mismatch elbow curvature were estimated with a Pearson's correlation coefficient. Intraobserver repeatability of SI measurement was high (r = 0.97). Mean ± SD humeroulnar incongruity (SI) was greater in elbows with MCD (18.5 ± 6.6) than in the normal elbows (1.7 ± 2.0, P < 0.001). The difference between the diameters of the curvatures of the ulnar and humeral trochlea was greater in elbows with MCD (12.5 ± 4.4) than in the normal group (10.7 ± 4.1, P < 0.05). A moderate correlation was found between the degree of humeroulnar incongruity and a radioulnar step (r = 0.63); however, no correlation was identified between SI and the difference between the diameters of the curvatures of the ulnar and humeral trochleae (r = 0.14). We propose a radiographic index to measure humeroulnar incongruity on mediolateral digital radiographic projections. This index (SI) supports the presence of humeroulnar incongruity in Labrador Retrievers with MCD. Further evaluation of its reproducibility and clinical importance are warranted. Although there is a moderate correlation between humeroulnar incongruity and radioulnar incongruency, causation has not been established.

Observer variability and sensitivity of radiographic diagnosis of canine medial coronoid disease

Medial coronoid disease (MCD) is a very common form of elbow joint disease and it's radiographic diagnosis can be challenging since it is frequently based on the detection of rather subtle primary or secondary changes than on a large primary lesion. We hypothesized that accuracy of radiographic diagnosis of MCD is highly dependent on training and experience level. Radiographs of 102 canine elbows were evaluated for MCD by four observers with different levels of training and experience. All elbows underwent CT scans and arthroscopy. Sensitivity and specificity of radiographic and CT interpretation was determined using arthroscopy as a gold standard. Interobserver and intraobserver agreement (reliability and repeatability) were assessed by using Cohen's Kappa (κ) statistic. The sensitivity (92.4-96.7%) of the two experienced observers was almost comparable to that of CT (100%) and significantly higher than that of the two less experienced observers (77.2-80.4%). Reliability of the radiographic diagnosis of MCD was better between observers with higher experience level (κ= 0.74) than between observers of lower or different experience levels (κ=0.07-0.42). Repeatability was better in experienced (κ= 0.73-0.88) than in less experienced observers (κ= 0.31-0.42). Our results confirm that training and experience play important roles in reaching high sensitivity, reliability and repeatability for the radiographic diagnosis of MCD. Although radiography is inferior to CT in imaging of the medial coronoid process itself, sensitivity of radiographic diagnosis MCD can be significantly improved with observer experience almost reaching that of CT. Therefore, it is advised that radiographic screening for MCD should be performed by specialists experienced in the radiographic evaluation of elbow joint disease.

Radiographic evaluation of osteotomized ulnar segments following arthroscopic treatment for canine medial coronoid disease

To assess movement of ulnar segments radiographically, following proximal and midshaft ulnar osteotomy or ostectomy after arthroscopic treatment for dogs diagnosed with medial coronoid disease. Fragmentation and cartilage wear were treated arthroscopically and the presence of incongruity confirmed. Osteotomies were performed at the mid-point or proximal third of the length of the ulna. The distance of separation between the ulnar segments and the adjacent radius were measured and followed by serial radiographs postoperatively until healing had occurred. Proximal oblique osteotomies located at one-third the length of the ulna were associated with the most movement of the ulnar segments, most notably of the proximal segment. Osteotomies or ostectomies performed in the middle demonstrated less segmental movement and on average, slightly longer time to heal. Movement of the ulnar segments in both groups occurred immediately, and then peaked at two to four weeks postoperatively, tending to plateau thereafter. Radioulnar incongruity is considered a facet of the aetiopathogenesis of canine medial coronoid disease. This creates abnormal loads and focal wear along the medial coronoid process. Performing an oblique osteotomy at a location measured at the proximal third of the length of the ulna allows increased movement of the proximal segment, which may result in unloading of the medial compartment. Performing an osteotomy or ostectomy distally dampens segmental movement due to constraint of the interosseous ligament. These findings suggest that a proximal oblique osteotomy at this location creates immediate favourable movement with low morbidity.

An update on coronoid disease Part 1: Diagnosis

FMCP and joint incongruency can be challenging conditions to diagnose and treat, and considerable controversy still exists regarding their aetiology, pathogenesis and optimal treatment. FMCP is typically characterised by fissuring and fragmentation of the cartilage and bone over the lateral aspect of the medial coronoid process. Osteochondral fragments may remain in situ or may separate from the base of the coronoid process and become displaced (Grondalen & Grondalen, 1981). It is important to note that not all lesions affecting the medial coronoid process are adequately described by the term FMCP. Many lesions involve varying degrees of cartilage erosion of the medial part of the coronoid process with or without concomitant fragmentation, therefore some authors suggest the term (medial) coronoid disease rather then FMCP to encompass the entire spectrum of lesions (Moores et al., 2008).

Evaluation of a Collagenase Generated Osteoarthritis Biomarker in the Synovial Fluid from Elbow Joints of Dogs with Medial Coronoid Disease and Unaffected Dogs

To evaluate whether synovial fluid concentrations of an osteoarthritis biomarker in dysplastic canine elbows with medial coronoid disease (MCD) are elevated compared with unaffected elbows and to determine if these concentrations correlate to the degree of articular cartilage damage. Cross sectional clinical study. Dogs (n=19; 35 elbows) with MCD and dogs (8; 16 elbows) with unaffected elbows. Concentrations of a collagenase-generated cleavage neoepitope of type II collagen (Col2-3/4C(long mono), or C2C) in joint fluid from elbows were analyzed and compared between dogs with MCD and unaffected dogs. Correlation of C2C concentration with subjective grading of articular cartilage surface damage was also evaluated. Mean (+/-SD) C2C concentration from MCD dogs was significantly higher (112.3+/-24.8 ng/mL) than in unaffected dogs (76.1+/-16.9 ng/mL; P<.05). There was a moderate correlation between cartilage damage grade and increasing C2C concentrations (P<.05, r=0.62) C2C concentrations are elevated in the synovial fluid of dogs with MCD compared with unaffected elbows, and a moderate, significant correlation was identified between these concentrations and subjective grading of articular cartilage damage. This preliminary data suggest that C2C concentrations in synovial fluid may have potential as a biomarker for diagnosis of articular cartilage damage associated with MCD and as a means of objectively determining the degree of articular cartilage damage.

Elbow lameness in dogs of six years and older

To report on the frequency and distribution of lesions of the medial coronoid process in dogs of six years of age and older, and to describe the arthroscopic findings in the affected joints. To compare those lesions seen in 'old' dogs with those seen in 'young' dogs between the ages of five and 18 months. A retrospective study of dogs six-years-old and older admitted for elbow lameness and subsequent elbow arthroscopy. The dogs were divided into groups according to the lesions of the medial coronoid process diagnosed during arthroscopic examination and computed tomography (CT). The radiographic degree of osteoarthritis (OA) and arthroscopically diagnosed lesions on the medial humeral condyle are described. In 51 'old' dogs, five types of lesions could be identified on arthroscopy and CT: chondromalacia-like lesions (2%), fissures (27.5%), non-displaced fragments (12%), displaced fragments (27.5%), and erosions within the medial compartment without fragmentation (31%). A significantly different distribution of lesions was seen in 'young' dogs: fissures (23%), non-displaced fragments (45%), displaced fragments (29%), and erosions within the medial compartment without fragmentation (3%). No difference in radiographic degree of OA was seen between the two groups. This study demonstrates the relatively high incidence of medial coronoid disease in dogs older than six years of age, and it highlights one particular problem in 'old' dogs: the complete erosion of the medial compartment.

Early Clinical Experience with Osteochondral Autograft Transfer for Treatment of Osteochondritis Dissecans of the Medial Humeral Condyle in Dogs

To establish whether osteochondral autograft transfer (OAT) procedures for osteochondritis dissecans (OCD) of the canine elbow would restore articular contour, resurface osteochondral defects with hyaline cartilage, and resolve lameness in the short term. Case series. Dogs (n=27) with medial humeral condylar OCD. After arthroscopic assessment, the medial humeral condyle was exposed by arthrotomy. Medial coronoid disease (MCD) was managed by subtotal coronoid ostectomy, then the OCD lesion debrided and OATS instrumentation used for resurfacing the defect with osteochondral core grafts collected from the stifle. Recipient sockets were created to maximally resurface OCD lesions. Six elbows also had proximal ulnar osteotomy. Outcomes measures included subjective clinical, radiographic, and arthroscopic examination at 12-18 weeks. Of 33 treated elbows, 30 also had MCD. Accurate reconstruction of the medial humeral condylar surface was achieved in all joints. Lameness resolved in 3-13 weeks in 26 of 31 limbs with follow-up. Arthroscopic outcomes for elbows with concomitant MCD but without proximal ulnar osteotomy were variable (14/24 good, 5/24 intermediate, 5/24 poor). Short-term outcome for OCD without MCD (n=2) and when proximal ulnar osteotomy (n=5) was performed were positive. Long-term assessments of 7 dogs suggested minimal donor site morbidity. OAT procedures are technically feasible in the canine elbow. In elbows with concurrent MCD, proximal ulnar osteotomy may improve likelihood of positive clinical outcome. OAT procedures warrant further evaluation as a treatment option for selected cases of OCD involving the canine medial humeral condyle.

Radiographic and Arthroscopic Findings in the Elbow Joints of 263 Dogs with Medial Coronoid Disease

To report clinical, radiographic, and arthroscopic findings in dogs with thoracic limb lameness attributed solely to disease of the medial aspect of the coronoid process (MCP). Case series. Dogs (n=263) with MCP disease (MCD; 437 elbows). Clinical records (January 2000-July 2006) and radiographs were reviewed and pertinent data recorded. Radiographic interpretation included measures of periarticular osteophytosis, gross assessment of MCP integrity, and measurement of ulnar subtrochlear sclerosis (STS). Statistical analysis was performed to evaluate associations between data; confidence interval was set at 95%. Labrador Retrievers were 50.2% of all dogs with MCD. Mean age at diagnosis was 32 months and duration of lameness was 14.5 weeks. Thirteen elbows (3%) were considered radiographically normal. Osteophytosis was identified on the anconeal process (70.2%), radial head (37.3%), and lateral epicondyle (56.5%), and STS was identified in 86.7% of elbows. Median osteophytosis score was 1; mean absolute osteophytosis score was 1.7. Arthroscopic findings included: fissuring (18.3%) and fragmentation (64.1%) of the MCP and kissing lesions (49.0%) of elbows. Median-modified Outerbridge score of the MCP was 2 and the humeral condyle, 0. Weak or moderate correlations were found between osteophytosis and modified Outerbridge scores and weak correlation between modified Outerbridge scores of the MCP and medial humeral condyle. Wide ranges in clinical, radiographic, and arthroscopic findings are recognized in dogs with MCD but correlations between such factors are generally weak. Radiographic and arthroscopic findings do not correlate with owner-reported duration of lameness. Radiographic measures of osteophytosis are poor predictors of severity of arthroscopic pathology for MCD.

Subtotal Coronoid Ostectomy for Treatment of Medial Coronoid Disease in 263 Dogs

To document clinical outcomes after subtotal coronoid ostectomy (SCO) for treatment of medial coronoid disease (MCD). Prospective clinical study. Dogs (n=263) with MCD. MCD was treated by a combination of SCO via mini-arthrotomy, cage confinement (6 weeks), leash restricted exercise (12 weeks) and pentosan polysulfate administration. Outcomes were assessed by clinical examination in the short-term (324 elbows), owner questionnaires (146 dogs), clinical examination (90 dogs), subjective assessment of gait (110 elbows) and radiographic examination (180 elbows), 4 months to 7 years 7 months after surgery. One intraoperative complication occurred (1 elbow with fissuring of the ulna) and 8.2% elbows had immediate postoperative complications, the most common being wound infection (7%). Improvement in subjective lameness assessment to a score of 0 was noted at 5 weeks in 74.4% of elbows (veterinary) and 45.6% (owner) and at 12 weeks in 71.5% (veterinary), and 91.2% (owner). Subjective assessments of outcomes in the medium-term revealed 81.9% dogs remained sound, with significantly (P<.05) improved daily function scores compared with preoperative values, 83.5% of dogs received no NSAID. Clinical examination revealed good limb function and subjective assessment showed 51% of limbs were free from lameness. Radiographic progression of osteophytosis occurred on average by one grade. Management of MCD using the described management regime, including SCO via mini-arthrotomy, deserves consideration and comparison with existing treatment methods. Management of MCD by SCO can be considered when gross fissuring or fragmentation of the MCP is not evident. This technique does not require specialized instrumentation.

Radiographic analysis of trochlear notch sclerosis in the diagnosis of osteoarthritis secondary to medial coronoid disease

Trochlear notch sclerosis (TNS) as assessed by radiography has been shown to be increased in elbow dysplasia (ED) associated medial coronoid process disease (MCD). The aims of this study were to investigate whether two defined radiographic tests evaluating TNS would increase the sensitivity of detecting osteoarthritis secondary to MCD, and to assess whether there was a correlation between increasing TNS with severity of MCD. Sixty-one dogs with MCD (121 elbows) were selected from the imaging database. The controls were nine cadavers (18 disease-free elbows). Standard International Elbow Working Group radiographs and CT scans were taken of each elbow. Plain radiographs were analysed using various assessments: osteophyte grade (0-3), coronoid grade (0-3), TNS descriptive grade (0-3) and TNS ratio. The TNS ratio was calculated from the depth of ulnar sclerosis at the level of the disto-cranial margin of the humeral condyles divided by the cranio-caudal ulna depth. The TNS descriptive assessment and ratio both increased the overall sensitivity of diagnosing osteoarthritis secondary to MCD above the other radiographic tests. The sensitivity of the TNS ratio at <0.3 mm was 91%-96% and the TNS descriptive assessment was 77%-96%. Radiographic TNS significantly increased with increasing severity of coronoid disease grade as evaluated by CT p < 0.01. The finding that TNS increases the sensitivity of diagnosing osteoarthritis secondary to MCD is valuable to those that have neither a CT scanner nor arthroscopy readily available. The assessments described in this study are easy to apply and do not require any sophisticated technology in order to detect sclerosis.

Computed Tomographic Features of Incomplete Ossification of the Canine Humeral Condyle

To describe computed tomographic (CT) features of canine elbows with incomplete ossification of the humeral condyle (IOHC) and investigate co-existing incongruence in the elbow joint. Case control study. Dogs with IOHC (n=20; 38 elbows) and 25 normal elbows. Elbows with IOHC and normal elbows were assessed by CT. Standardized dorsal and sagittal reconstructions were created at 3 levels using image analysis software to obtain single measurements of the humero-radial and humero-ulnar joint spaces. On dorsal plane reconstructions, joint space measurements were obtained at the center point of the humero-radial and humero-ulnar articulations. Joint incongruity was defined as the difference between the humero-radial and the humero-ulnar joint spaces. Nineteen dogs (95%), all Spaniel breeds, had either bilateral IOHC demonstrable as a saw-toothed intercondylar complete or incomplete hypoattenuating defect with hyperattenuating margins, or IOHC with contralateral humeral condylar fracture (HCF). Joint incongruity values for IOHC were compared with those of normal elbows. Significant differences were noted at the levels of the medial coronoid apex (P<.0001) and base (P<.004) indicative of humero-ulnar incongruence. Evidence of medial coronoid disease in 10 elbows (26%) and degenerative joint disease in 30 elbows (79%) was also found. Presence of elbow incongruence may be an underlying factor in failure of ossification centers to fuse leading to IOHC. IOHC is clearly defined by CT, and it should be considered in larger Spaniel breeds, with a chronic forelimb lameness or HCF.