It's a pleasure, talking today. And the next case I want to present. Is Raffy.
And Raffy is in many aspects. A typical example of a dog affected by advanced stage elbow dysplasia and, subsequent osteoarthritis. And he will give us the opportunity to explore in detail options for these severely affected cases.
So here he is, Rafi, a 9 year old male neutered Labrador retriever with his owner. He has been diagnosed with right elbow dysplasia when he was young. And had also, similar to the case, Nicola just presented, a fragmented medial coronal process removed on the right elbow.
And for many years, the dog, was doing all right, but he had always regular episodes of stiffness and occasional lameness on the right, usually after exercise and subsequent rest. Overall, however, the dog continued to have a very active lifestyle, and he, he loves to exercise. The owner presents now, the dog because the dog has been deteriorating since, the treatment for a left cruciate ligament rupture a year ago, and it's now more permanently lame.
He struggles to get going in the morning. He gets tired very easily and slows down after 30 minutes of exercise, and the owner wants to know if and what can be done to make the dog better. So we do initial clinical and orthopaedic workup in our examination.
We start with a gait analysis looking at the dog, and here we see Ray walking. And He's lame. 3 out of 5 on his right forelimb.
On pipation of the elbow, we can find that the, the right elbow feels thickened. There is obvious crepitus, and the decrease of, range of motion. There is pain or manipulation of the joint, and the left elbow is mildly thickened.
But has a good range of motion. There's no discomfort on any other joints and then no other findings. So we localise the source of pain and discomfort to the right elbow.
And the dog has a history of being diagnosed with elbow dysplasia and problems. So the question is, do we need any further workup at this moment? We have A dog already previously diagnosed with elbow dysplasia.
So one option. Could be that the problems are related with continuing or progressing joint pathology in combination with osteoarthritis. However, we also need to exclude differential diagnosis.
Infection, could be one, and we do know that dogs with preexisting joint disease are more likely to develop, Bacterial infective, arthritis in the joint. It could also be a fracture and rather than a, a typical, bone fracture. In these cases with joint disease, we sometimes see acute fracturing of osteoarthritis-related new bone formation, which can Lead to lameness also often then we have a more acute onset of more severe lameness.
Neoplasia is something to consider, of course. And then we also need to have in the back of our mind, non-elbow related causes, and that's why we need to do a very thorough clinical examination to rule that out. Further workup, however, can also help us in Then formulating a treatment plan for the dog because the exact findings and diagnosis related with the elbow dysplasia complex can affect our treatment options.
So therefore, yes, we do need further workup, and some form of diagnostic imaging will be the next step. Radiographs often look like this. This is a typical example.
Of, a very abnormal early looking elbow joint and with a lot of new bone formation, some perarticular new borne formation here also in the area of the flexor tendons. That can help us to diagnose that there is severe osteoarthritis present, but does not give us much detailed information in regards to what exactly is going on in the joint. And therefore, also in an advanced case, like this, CT is a good next step, to assess the changes in the joint.
And we see here, reconstruction, images, the horizontal view, which shows us here the ulna and this is the area of the media coronoid process. There is extensive new bone formation, around the joint here also in the area of the radius. And then we have a large, new bone formation or a combination of, remnants of the medial coronial process with new bone formation, cranial of the joint.
We can see that also here in the Sagitta View, extensive new born formation, where it is difficult to decide from the CT if mobility of, this new born formation could contribute to discomfort. And therefore, To really get a comprehensive idea what is going on in the joint, we also need arthroscopy. Before that, having the dog under sedation for the CT is a good opportunity to do an arthrocentesis.
I completely agree with what Nicola, said that, this should be A routine part of our workup, to exclude infection and Which would be a typical psychological view here on the left side. Excuse me. With a large number of neutrophils, which are often non-degenerative, in the joint, and often we cannot detect bacteria, but that nonetheless, that would be a typical, picture of a suspected bacterial infected, arthritis.
In a joint with degenerative joint disease, we see typically a large number of monocular cells, like we see here on the right side. So the next step is therefore then for Raffi to do a diagnostic right elbow arthroscopy, and I say diagnostic, rather than therapeutic. Because this is really the aim of this arthroscopy and we We do the arthroscopy already knowing that it's unlikely that with the arthroscopy, we will be able to make the dog, better at this point.
But it helps us to assess the joint. So here we have the view of the right elbow joint. We are, we are looking from quadro medially into the cranial aspect of the joint.
And this is the area of the mediao coronoid process, and we see there is a full thickness. Cartilage defect all along the medial corner process. We see here there is some 3, fibrous cartilage, and some synovivili, reaching from cranium medially inside the joint.
And in the background, we see the radial head, with the blue star. And when we do some pronation, supination, then that will rotate. And when we look between radial head and medialronoid process, we see that there's all, there's a rim of Fluffy looking fibrous cartilage.
When we look proximal into the joint in the area of the medial humeral condyle, we see also their full thickness, cartilage defect with very typical longitudinal ridges, from, defect into the bone also, and that is a very typical. Image of what we then call medial compartment disease. Here.
We see that on the lateral aspect, it's still, some cartilage left, but further lateral on the lateral condyle, are areas with fibrillation of the cartilage and also areas of full thickness cartilage defects also on the lateral condyle. Then, as I said from the CT, we were wondering if this, this new borne formation cranially is mobile and therefore, it's useful to approach that with a needle here on the top. And here is that bone formation cranially, and that can then be probed.
Even if it's mobile, in these cases, it's always questionable if removing that anything will contribute to make these dogs better and most likely, that's not the case. For our diagnosis for Rafi that he is symptomatic. He has clinical signs related with severe osteoarthritis and medial and lateral compartment disease.
And this is typical for advanced stage elbow disease related with elbow dysplasia in the first case. I have, written here that, to that to highlight that it is relevant to distinguish between medial compartment disease and medial coronoid. Process disease.
And sometimes the abbreviation gets, get mixed up, and not all authors distinguish in that way just to highlight that MCP, can be used for both. And therefore, I prefer, to abbreviate it them, in, in that way to make that distinction clear. In regards to treatment options, I would like to look at two scenarios.
One, and this is in regards to pre-existing treatment. Scenario one. Rafi has as a current treatment that he has been on meloxicam for years, so a non-steroidal, his body condition score is 7 out of 9 and he gets 160-minute walk a day.
Now we need to assess what treatment, will be most adequate, for Rafi and what options we have. And I show you here a very busy slide and don't want to go through that in detail. But I put it up and you can, go back to that, and look at it if you're interested, because this is an example of an algorithm.
Guide us through the different treatment options of elbow dysplasia. That was first suggested by Noel Fitzpatrick, and, this here is, based on one suggestion of, Mickelson, 2013. And, I am updating that according to new evidence which is coming out.
And the idea behind this. Behind it is Who help us to approach treatment options in the most evidence, guided way. For Ray, we are looking here at this section of the algorithm.
We have diagnosed him with end stage disease, with severe degenerative joint disease, and this leaves us with Treatment options of a comprehensive conservative management and I want to Start here, talking about, in more detail what comprehensive conservative management means. Rafi is so far on one non-steroidal and exercise. However, a comprehensive conservative treatment entails, a, a wider range of treatment aspects.
The four cornerstones are the body weight, exercise modification, multimodal pain management, and then, looking also at dietary supplements and functional food. I also put here physio and hydrotherapy because that goes hand in hand with exercise modification. As Ben already alluded to, the body weight is a very significant factor in development, further development, but also in clinical science related with osteoarthritis.
In 2010, Marshall et all investigated the effect of weight loss on lameness in obese dogs with osteoarthritis. And this is a study I Often mentioned in my discussion with owners, because the result is very encouraging for owners. They showed that a weight loss of 6 to 8% already had a positive effect on the signs of lameness.
And this is often a number which is, encouraging for owners to start working on a weight loss programme. However, Germanin at all, showed in 2015 when they investigated the success of controlled weight loss, that there is a risk of a high dropout rate. 32% stopped, prematurely the weight loss programme, and they showed, Alex German, and, his co-authors that it's more likely that, an animal remains in the weight loss programme when they Lose weight earlier on, so have a, have a good success early on and Also, the ones who are fed a commercially available diet.
So it also needs to be relatively easy, and these are things we can consider when we discuss this further with the owners. Multimodal pain management, as I said, is also one of the mainstays of Treating dogs with the advanced osteoarthritis and we're looking at Non-steroidals as a first line, or first line drugs. And it's not uncommon that dogs with osteoarthritis are treated only with non-steroidals.
However, this is often not sufficient. And in most cases, we need to combine the non-steroidals with other drugs of these, severely advanced, osteoarthritic cases. We can combine it with paracetamol or codeine, that would be Pardal.
Oral opioids don't play a big role. Tramadol, can be used, but, with a questionable, success, gabapentin has been shown to be Very useful, in these long-standing cases because, it can treat the windup successfully. So that has become one of our most frequently used, drugs in combination, with non-steroidals and amantadine, can be added, in, these cases as well.
Exercise modification is also an important aspect, that's something which is, occasionally misunderstood, and, interpreted as Reduction of exercise. And this has only been shown to be useful in an acute flare-up of a chronic degenerative joint disease, then it can be useful to have a shorter period of More strict rest, but medium and long term, we want a good amount of regular exercise for these, cases, which has been the best clinical effect. And here, it's also where physio or, in particular, hydrotherapy comes into play because that offers A very good opportunity for low impact exercise, and, in my experience, this is very successful in most of these cases.
In regards to dietary supplements and functional food, there have been several reviews, studies coming out over the last years, and I don't want to go into any of those in detail, but what we know. So at the moment is that we have most evidence for functional food containing long chain omega 3 fatty acids, and that is currently our recommendation to add into the treatment plan. Looking at our scenario one, again, the current treatment.
With only one non-steroidal, the dog is overweight, and, it has a long walk. There are, there is a scale of adjusting that treatment, adding further medication, working on a weight loss programme, adding hydrotherapy, and adjusting the exercise to split it in several walks. And, that could lead to, a good improvement.
However, it could also be that the dog is already on much more treatment and that that he has been on yrocopsy for years. He had been on tramadol but switched already to gabapentin. One year ago, also is on paracetamol, codeine, functional food.
He has a good body condition score. He is already on once per week hydrotherapy, and he has an optimal exercise regime. And in these cases, we need to look at other treatment options.
When we go quickly back to our, algorithm, we, as surgeon, as surgeons are, of course, always very interested to also know, are there any surgical options available. Then we'll talk in more detail about different, osteotomies, which has the aim to shift the weight from the, medial compartment to the lateral. In a dog with very advanced osteoarthritis, these procedures might not be adequate because the symptoms are not only related with medial compartment disease, but also with the per-articular new borne formation, and all.
Sequences. However, one surgery, the canine unit compartmental elbow might, still be an option for these more advanced cases, with medial compartment disease, and then we'll talk about this procedure in more detail. However, when we look at Rafi, then we need to consider that.
Likely there's a contraindication to you that in cases of lateral compartment disease, so Rafi might not be the best candidate for this surgery. Looking at other options, there are the groups of intra-articular injections and shock wave therapy. And I just added them here, into our.
Armamentarium of treating these advanced cases. There is a wide range of intra-articular injections available from platelet rich plasma to stem cell and stem cell therapy as regenerative treatment options, hyaluronic acid, polyacrylamide, hydrogel, two more classic ways of injecting corticosteroids or newer ways of botulinum toxin. We don't have time at the moment to go in more details, but if you have questions, so that, please ask.
Extracorporal shock wave. Uses pressure waves to deliver energy deep into the body and this is an example. This is Doc Murphy being treated at our firm in Cambridge.
And We are, we are doing a trial currently and looking mainly at the effect of extracorporal shockwaves in patients with long-standing pain. The shock waves are thought to stimulate the own, the body's own healing either by mechanically breaking down calcium deposits or also, and also diminishing pain by affecting the nerves in the area and also an anti-inflammatory effect. The Good thing is that, it's easy to apply.
The dogs tolerate it very well. They don't need to be sedated, but it requires weekly treatments. It's usually a course of 6 weeks, and current results suggest that it takes a Little while for an effect to be seen.
Highest effect seems to be seen just after the 6 weeks. And currently there is, it's not clear how long that effect can last, but it's an interesting and promising area to investigate further. It's also important, always, but in my experience, in these cases, also, in particular, to monitor the outcome.
Because this also helps the owners to go through the journey with their dog in Finding the right treatment, changing the treatment, and adjusting the treatment. We have different options and, we are working mainly with patient owner reported outcome measures and, I think, mm, the others will also talk about that a little bit more, and, objective outcome measures, others, like, gait analysis, treadmill. Kinematic treadmill, analysis or force plate.
And this is useful to establish a baseline because these dogs are never normal when we see them. To then assess any treatment we do. And this is an example of, Ray's report from last year when he came, and, that helps us then, to assess our treatments.
And then lastly, what salvage procedures do we have available for these dogs with end-stage DJD of their elbow joints? Generally, we're looking at options like total elbow replacement, elbow arthrodesis, possibly also amputation. Elbow replacements, the, the first system has become available many years ago.
Mike and, was leading the way and that, in the meantime, we have, the two systems Tate, and, here in the UK, from John Innes, developed, Sirius there recently has the newest, the news, news generation has come out where, in which the radius is not fixed anymore, and that allows pronation and supination and, that will be interesting to see what effect that had has. So far, the risk of complications is still Very high laxation and fractures are here, the, the, dreaded complications. And in that way, it's by far not comparable to the situation of the hip joint, where we have a total hip replacement, which Has an extremely good outcome, which is not yet the case with the elbow joint.
Therefore, case selection is very important and, the, it's still not a routine procedure. However, I think it's very useful to tell all owners already early on when they're dying, have their dogs diagnosed with elbow dysplasia, what treatment options are available and also mention the salvage options, which helps them in their overall planning. Elbow arthrodesis is another salvage procedure.
Which can be in selected cases considered the different surgical options biomechanically, preferably is a caudal plate application, but that's very complex, and, also here these lateral plates have been developed. There is a review, already from quite a while ago, and, that showed that all dogs have an obvious gait abnormality, which is to be expected, but they, can have a reasonable outcome. So that's something to be considered.
Amputation is in many of these dogs not really an option to consider because they are very commonly affected by multiple limb problems, other orthopaedic problems. Therefore, Owner expectation and compliance, I believe, is also an important, point to discuss with these owners, and, to discuss with these owners the disease in the, in, in a, in a positive and forward looking way. Zoe Beelcho has shown in her PhD that owners of dogs with osteoarthritis are often Really desperate, they feel.
Often really sad, that their dog cannot exercise anymore. They are missing themselves the option to exercise with the dog, and, they can become very frustrated. And in my experience, it can be helpful to take the time, to discuss all these options with the owners to explain why this is a journey rather than a one-off treatment.
And to reassure them that you accompany them on this journey, in the search for the best possible treatment for that particular patient. That leaves us back, looking back at Raffy's further treatment, so in scenario two, and this is actually Ray's, true scenario, he already has a long list of very Comprehensive treatment options. So we have been treating him, intra-articularly and, he has also had shock wave therapy and, currently, he's doing better again.
And with this, I thank you very much for your attention, and I will hand over to Mark with the next case now. OK. So, the case I've got, there's some significant overlap with some of the others.
My dog doesn't have a name, but it, this could be Lottie, or it could be Raffi at some point, in the future. It's a 7 year old Labrador who has already been diagnosed with elbow dysplasia and subsequent osteoarthritis. It's got a long history of a, of a chronic fall in lameness, but there's been an acute deterioration.
Previously, done arthroscopy on this joint and, and the dog has significant medial compartment disease, cartilage loss on the, on the medial humeral condyle here, and on the ulna. There isn't going to be lots of images of this patient because they're they're very similar to what you've seen earlier. This dog has established osteoarthritis.
There's significant peri-articular new bone formation, there's chronic remodelling of the coronoid process and, fragmentation either of an osteophyte or, or the coronoid process itself. On the sort of clinical examination of these dogs, the lameness will be variable to a certain degree, because although we're talking about a patient that's had an acute deterioration, they sometimes improve by the time you see them. So the owners report that they may report that they were significantly worse the day before, but they've got a little bit better.
There's often muscle atrophy because these cases are chronic. There will be a decreased range of motion in these joints, extension and flexion, a variable degree of pain and crepitus. There's often some soft tissue thickening, relating to the chronic nature of, of the disease.
And there can also be some swelling around the elbow, and distal to the elbow in cases that have septic arthritis. And there may be a variable degree of effusion, . Sometimes that's because you can't palpate it because there's so much thickening around the joints and the soft tissues.
Why is this elbow painful? Well, we often group all these dogs together as having elbow dysplasia, but strictly speaking, it's the younger dogs with the primary disease that have elbow dysplasia. And over time, it's the, the secondary osteoarthritis that causes the problems.
Now we, we know this dog has osteoarthritis and it has been managed conservatively relatively successfully until this acute deterioration. Arthritic elbows hurt or arthritic joints hurt for a number of reasons, sinusitis, thickening of the joint, stretching of the capsule and the soft tissues. You can certainly with chronic arthritis, make a joint worse by doing those things.
There can be subchondral bone exposure, increased venous pressure in the subchondral bone, and particularly in the elbow, medial collapse of the joint causing an altered mechanical axis. Joint pain itself is variable, so, that may account for a deterioration, you know, pain in your arthritic joints can, can range from aching to, to be exercise related and the mechanism of the pain can change over time. We can also have peripheral discomfort and in these chronic cases, central pain which, which can flare up at times.
What we really want to know with this dog is why has it suddenly got worse? Is it a flare-up? Has there been a fresh fragmentation of the coronoid process, or an osteophyte?
Is there infection, and that one would be the, the key for me because we see a number of these dogs that have an acute deterioration due to a a a a secondary septic arthritis. Is there neoplasia, Is there a tumour somewhere, either around the elbow? I think the 222 other things to always think about with these cases is.
Is it the elbow? So we know this dog has chronic arthritis in its elbow, but is that what's causing its recent lameness? So is the pathology somewhere else on the limb?
Or in fact is the pathology somewhere else on the dog? So I've certainly seen cases with, with known. Elbow osteoarthritis that have got suddenly worse because they've got hind limb problems, hip dysplasia, bilateral cruise ship disease, for example, that's caused them to shift their weight forwards.
And that's made them more uncomfortable on a, a thoracic limb. But have they recently gained some weight? You know, we've talked in the previous, or we've heard in the previous talk, sorry, that the effect that weight gain can have, and sometimes that can result in a, a, a deterioration as well.
These cases that have an acute deterioration are frustrating because it can sometimes feel a bit like a treatment failure. You've been, you know, seeing these patients often, over a long period of time. You've been managing them with all the conservative strategies that we've talked about before, they may have previously had a surgery, and they suddenly get worse and it can often make you feel like you've, you've done something wrong or you should have done something differently.
So there's frustrations certainly for the clinician at that point of view. These cases can also be pretty distressing for the owner. They're often, you know, aware that their dogs have a chronic condition, and they're, they're used to that.
They may have altered its exercise, etc. Altered its lifestyle, but when they get acutely worse, they can start to question the dog's quality of life, and, and that can be upsetting. I think what we need to do with these cases when we have an acute deterioration is that we, we need to, to work out if it is just a flare-up.
Now what's a flare up? Well, osteoarthritis doesn't progress is a progressive condition that gets worse over time. But it doesn't get worse in a straight line.
You will have peaks and troughs. Often dogs will improve following a flare-up. They may not get back to quite where they were before, but often they will get significantly better.
With these cases, we need to make sure that there's nothing else going on, that, that we need to intervene with. So what to do with these cases? Well, I, I think the first thing to say is, is don't panic if you see a dog that has an acute deterioration.
It's not necessarily a treatment failure, and as we said, the owner might be worried, particularly about the dog's quality of life. Don't presume that it is the elbow. Don't presume that it is the condition that you've been treating for the last number of months.
These dogs will often need some analgesia, they can be really uncomfortable, . But having said that, You don't need to rush into necessarily a whole host of diagnostics or changing your treatment plan plan if it is just a flare up, some of these dogs may get better anyway. You might not actually need to change anything, you might just need to give these patients some analgesia and some time.
From a diagnostic point of view, the, the biggest thing is ruling out other causes. That comes down to a, a good clinical examination. So we've talked about the clinical examination of, of, of arthritis, and of, of dogs with elbow dysplasia in the, in the previous talks, and that doesn't, really differ with these cases.
But you need to examine the rest of the limb and the rest of the dog. Repeat imaging, well. We've heard of the benefits of of CT earlier on, versus radiographs and and that doesn't necessarily change in this case.
There is a bit of a question about repeat imaging and, and whether it will actually change what you do. And I suppose that really depends on when you last did any imaging. So if this dog's had an acute deterioration, but you saw it two weeks before and did a CT scan, doing a CT scan might not actually change what you do.
However, if you haven't done any imaging on a dog for a while, or it's clinical signs of change, so we're suspicious of neoplasia, radiographs or a CT scan might rule in or rule out those things. The biggest one, I think from a diagnosis, or to get a diagnosis with these cases is, is a joint tap or arthrocentesis, particularly to rule out sepsis. So Joint taps, are, are probably underused diagnostic in, in orthopaedics.
And if you don't do them regularly, they can be a bit daunting. They're particularly daunting in an, in an arthritic elbow. So, a few tips from, from me really about how I would approach these cases.
I would go medially and caudal. That, is, is similar to a portal we use when we're, we're doing arthroscopy, but I think it's the easiest way to get into these arthritic joints. So I'd lie the dog on the table with its affected limb down.
It's helpful to use a sound bag under the elbow to act as a bit of a fulcrum to open the joint space up. And I would draw an imaginary line between the, the medial epicondyle and the electronon. And I would go that at the middle of that line.
I know I direct my needle in where that yellow arrow's going towards the joint space. And I think in these arthritic joints, that's a repeatable way to to get in and to find the joint space. I'd use a 19 to 21 gauge needle inch to 1 inch and a half as we said earlier on.
And if you do diagnose that this dog has, an infection. They often need, or it's helpful, to flush these drinks out, and you can do that at the same time. So you'll have a needle going in the back where you've done your drink tap where the star is, you can add another needle to act as a, as an egress portal.
You can flush these joints out arthroscopically. That's not what I do. I don't think it's, strictly necessary.
Necessary. What I would do is attach a giving set to, to my first needle, with a 500 mil bag of Hartman's, put another needle into the joint where that star is to act as an egress portal, and force, by hand, by squeezing the fluid bag, that fluid, through the joint, via the giving set. Another way to do it, is just with a syringe, so you repeatedly fill a 1020 mil syringe, with clear fluid instil it into the joint in your needle and then suck it back out again and keep doing that until the fluid runs clear.
When you've done your joint tap, you, you can often diagnose a, a septic joint via gross examination of the fluid. It's often turbid, there's often a significantly higher volume than you would expect. You don't need to be, I'm certainly not a, a, a pathologist, but, you know, I can make a smear and have a look down a microscope and you will, it's often pretty clear in these cases that there's a significant number of degenerate neutrophils.
I would send these samples for culture and, I would use a blood culture medium, and cytology as well, if I've got any questions, about the diagnosis. I will flush the joints out, at that point, at the same time as diagnosis, if you will. And pending culture, I'll get these dogs onto some broad spectrum antibiotics for, up to 72 hours intravenously, .
I will use Zinif 20 megs per gig every 8 hours. These dogs are often really painful, and they, they need methadone every 4 to 6 hours. Excuse me, .
And When you get your culture results back, you, may then change your antibiotic, depending on those culture results. But these dogs need 4 weeks minimum of oral antibiotics when they go home. It's important to be, to be honest with owners that the, this lameness may persist for days or weeks.
These dogs can be quite slow to recover. There is a risk of recurrence. And even if these dogs make a recovery, they may not be as good as before, sepsis in a joint causes significant inflammation and can damage the articular cartilage.
The other reason for an acute deterioration that you really need to rule out is neoplasia. The, the number one would be an osteosarcoma. Now we will always sort of the proximal humerus would be the, the primary site distal radius ulnar.
So away from the elbow, but you can get osteosarcomas at the elbow. You can also get histocytic and synovial sarcomas in the soft tissues around the elbow. So don't just consider the elbow, you need to, to think about the potential for neoplasia and the rest of the limb, and that will, you know, hopefully be picked up on your clinical examination.
The other one to mention would be a a a brachial plexus tumour or a peripheral nerve sheath tumour. And those will present slightly differently, . Those dogs will often have severe and, and rapidly reported muscle atrophy.
They may be monopyretic. They will have proprioceptive deficits on clinical examination, reduced or absent spinal reflexes. Sometimes you can get pain on axillary palpation, and some of these dogs, depending on the, the location of the lesion, may have Horner's syndrome, or reduced, panicular reflex.
Diagnosing neoplasia, clinical examination may give you some idea, long bone pain, severe pain or manipulation of the joints, neurological deficits. Repeated imaging, will be helpful, particularly if it's a primary bone tumour, you will see that on a radiograph. And one of the benefits we talked about of, of X-rays versus CT earlier on is that you can quite easily image the whole leg with a radiograph, whereas a CT it's more difficult to do that.
Who often focus on a particular area. The benefit of, of a CT over radiographs is the increased sensitivity when it comes to staging. So if you're highly suspicious of neoplasia, you can CT the chest at the same time.
Equally, you can do that radiographically, of course. Depending on, on, on what you see on your imaging, you may consider a biopsy, that's a bone biopsy, a soft tissue biopsy, would depend on, on the type of neoplasia you're suspicious of. And again, as was mentioned earlier, from a treatment point of view with these dogs, it's difficult, because they're often not a candidate for amputation because el dysplasia and often, and, and osteoarthritis is often a bilateral disease.
So these are often not patients that will cope well with an amputation because of the disabilities they have on the other thoracic limb. The other sorts of treatment options that would be going through my mind. Excuse me.
At this point, would really reflect on, or, or, or go back to, to, to changing our management strategy and what we need to do. And I know Ben will discuss some of these further in the next talk. But it's this slide really is what's appropriate with these dogs that are having a flare up.
Well, do we need to change our conservative management strategies? Well, maybe, and I'll show you a slide about that shortly. Do we need to change our medical options?
Well, possibly, you know, it might be worth changing to a different non-steroidal, introducing an opioid. Arthroscopic evaluation of these dogs as Hayer said, . It is often diagnostic rather than therapeutic.
I struggle to, to think that some of these dogs with significant osteoarthritis will improve, from taking a little bit more bone out. So they're often not cases that that I, well, it's not a treatment I will recommend for these cases. Ben we'll talk about osteotomies, sliding humour osteotomies and Paul, and the salvage treatments of arthrodesis or elbow replacement.
I'm not sure that there are things that I would consider following an acute deterioration. But there are things that you may have to mention to the owner at this stage if the dog continues to have flare-ups, or, or doesn't recover from the, the problem, the acute deterioration that it's had. Excuse me.
I have talked about the intra-articular therapies, steroid injections may be appropriate, with a flare-up, it's incredibly important to rule out sepsis before you inject steroids into a joint, stem cell treatments, platelet rich plasma, hydrogel type treatments. Again, I think the jury is out on those, and they would not be things that I would be using, in these patients with an acute deterioration immediately. They may be things I would consider, further down the line, altering my management strategy for an osteoarthritic patient going forwards.
Altering our medical treatments, well, certainly with these dogs, they can be very uncomfortable, . I think they often do require opioids. Certainly the dogs with septic arthritis need a period of hospitalisation, in many cases while they're having intravenous antibiotics, and their level of discomfort will be such that they, they do need methadone.
You may need to, to add some additional oral, analgesia, paracetamol, codeine, in the form of Pardday. You can consider tramadol, gabapentin, and mantadine. About 10% of dogs will become refractory to one, anti-inflammatory or another.
So considering a change of non-steroidal going forward, might be appropriate with a, an appropriate, treatment interval. I would normally say 3 to 4 days, . That really comes into the, to, to the management once you've got the dog over this flare up.
So for me, a treatment plan, seeing a dog with known elbow dysplasia, osteoarthritis, medial compartment disease, it's had an acute flare-up. I would rule out any other pathology as a priority, and that will involve clinical examination. Definitely a joint tap, particularly if you have peri-articular swelling, and edoema, which can often track down the leg, and probably some repeat imaging.
Now that may not be a, A repeat CT scan, radiographic assessment may be good enough for those cases. And if we can rule out anything else, I would treat this as a flare-up. I would evaluate ongoing conservative and medical management and consider surgical treatments probably at a later date.
And when I say a later date, one flare-up doesn't suddenly mean these, these dogs need an elbow replacement, but if they're having recurrent flare-ups or they're they're non-responsive to treatment, then that might be when you start to consider the, the, the salvage options. In summary, if I determined that this case had had an acute deterioration simply due to a flare-up, I would agree that you really need 4 weeks minimum of conservative management, to, to, to see an improvement. I would sort of aim to get this dog back to where it was before the flare-up.
And I would give 4 weeks of non-steroidals or advise, 4 weeks of non-steroidals and strict rest. Consider ongoing weight loss if that's required. During that initial period, just to try and get the strength to, to, to settle down.
Some, some gentle passive range of motion is acceptable. If there's an improvement to that point, I would consider gradual introduction of physiotherapy and hydrotherapy, depending on the patient. And after the 1st 4 weeks, I'd have a look at another 4 weeks of gradually building up this dog's exercise levels, starting at 10 minutes, 2 to 3 times a day with an aim of a gradual reduction of non-steroidals.
I think that the, the key thing here is regular reexamination and and progress reports from the owners and then going forward considering additional drugs and surgery if they're required. A lot of these cases that have a deterioration. Won't have a tumour, they won't have a septic elbow, they'll just be suffering from a flare up, and it, it's key to, to, to communicate that with the owners that flare-ups are to be expected.
As we said earlier on, arthritis would be expected to get worse over time but not in a straight line. Ideally, we would like to get rid of those peaks and troughs, so that the the the the condition progresses in a sort of steady way. It's probably a bit unrealistic to think we can achieve that, but if we can smooth those peaks out, by altering our conservative management going forward, I think that that would be the primary aim.
So that would be my approach to a case with an acute deterioration. I know there's a bit of an overlap with some of the others earlier on and and what Ben I think is about to go through. But, yeah, thanks for letting me discuss that case.
Over to you again, Ben, I think. Yeah, Ben, no. Ben, we've got just over 20 minutes left.
We've a little bit of leeway to run over by kind of 5, 10 minutes max after 10 a.m. But yeah, if we aim for about kind of 25 minutes for the next two sessions, that would be great.
Yeah, no worries. I will try and make up some time. Can you hear me just to confirm, I'm off mute?
Yeah, you're fine. I've unmuted you. Brilliant.
OK, yes, thanks Mark. . Great.
So yes, thanks to the other three presenters for those cases and yeah, covering pretty much everything that I haven't, so that's great. So this is Molly, a genuine case. I've just finished writing a most recent referral letter for this dog while Mark was speaking there.
So that tells you how long in advance I prepared my talk. She is or she was when I first saw her, an eight year old working cocker spaniel. Little bit on the chubby side.
She'd been laying on for limbs, shifting really and variable for, for over 2 years. The only couldn't give me an exact amount. And she had had arthroscopic debridement of fragmented coronoid process by another surgeon 2 years earlier.
When she came to see me then, the referring vet had been doing a great job of medical management. She was on a very good regime of medication. She'd been on a non-steroidal thyrococcy in this case, for over a year and PardV as the only licenced formulation of paracetamol in the UK.
She'd been on that at a pretty appropriate dose for over a year, and she'd recently, been started on gabapentin. Currently, her exercise was limited to short lead walks. The owners had noticed, in recent weeks, increased lameness, especially after exercise that was worse after rest.
And for the last few weeks at least they've been consistently worse on the left for limb. They completed for me a load questionnaire. So load is one of these owner reported outcomes measures that Heidi mentioned.
And, you know, as, as she said, they're really, really useful for managing long term OA cases, whether it's elbow, hip, or, or whatever. Load is one that was developed by our colleague Proffinis here when he was at the university. And then I spent a bit of time when I was there validating this questionnaire as part of a larger OA study that I did.
And when the owner completed the questionnaire for Molly, her load score was 34. And if you look at some of the data that I gathered, we had data on over 200 dogs with confirmed away. And if we, sort of distribute the scores from those dogs, this is, this is the graph that we got.
So when we're looking at a score of 34 here, you know, we're right up in the sort of severe and extremely affected range. And when you look at it, see if my clinical notes are here. From the clinical exam.
You, you wouldn't say that her lameness was, was all that bad, actually. But what these questionnaires gather, is data about all the different aspects that make up the construct of OA. What we see in the examination room is, is really lameness and pain.
But that doesn't account for altered behaviour, reduced exercise, tolerance, stiffness after rest, you know, all these other components of OA, which really only the owner can gather. So useful, in terms of getting the information that we can't get, but also useful in tracking progress as we'll see as I work through this case. So bilateral elbow pain, reduced range of motion, thickening in the elbows.
So our options at this point, which we discussed at length with the owners were to continue the current treatment. The main, the main argument for that is that she'd really only just been started on the gabapentin. Now, if gabapentin works, and it does so by reducing central sensitization.
And, and, and, and dampening down that wind up that we see in chronic OA cases. It's probably gonna need more than a couple of weeks to do that. So, you know, one option here is just to give that a bit more time to work, see how things go.
The other aspect of of that is exactly as, as Mark demonstrated nicely with those graphs there, that the clinical status of dogs with their way is not linear, goes up and down. And what we might have been seeing here with Molly is just a little bit of a protracted flare. And, you know, that might not be the time.
To, jump in, and change a treatment protocol that up until that point has been, has been working pretty well. She wasn't on any, me, sorry, supplemented diet, so we could have had a chat about that. And we had a chat about all the sort of intra-articular options that you've got like steroids, hyaluronan, PRP, stem cells, etc.
And we had a bit of a chat about surgical options as well. Ultimately, at that first consultation, what we decided to do was just give her a little bit more time on that gabapentin alongside her other medication, see how things went. So again, so if I, if I'm going to do that, I would generally, if I'm going to do a treatment change, a medical treatment change, I would generally give that at least 6 weeks to see if it's gonna work, providing that the, the dog is, is, you know, not in too much pain.
I mean, if I'm suspicious of a joint sepsis or something else, that was covered in Mark's case, I'd jump in quicker. But he only came back two months later and certainly didn't think there was an improvement. If anything, they thought it was worse.
The load score was 35, about the same. You can expect a little bit of variance from, from time to, you know, from, from different, time points. And although we discussed all the other surgical options, we opted for repeat arthroscopic exploration and intra-articular stem cell treatment in this case.
I'm not saying that was the, the, a better or a worse thing to do. Than any of the other options, medically, you know, I'm talking about the stem cells there. But I certainly wasn't inclined to approach any of the surgical options at this stage without doing the arthroscopic exploration first.
And again, hopefully, the reasons for that will become apparent. So, this is, an image from, Molly's scope session. So the first thing to say is that there were no free osteochondral fragments.
There were no intra-articular fragments that we could remove, to help her. What we could see was that the, the cartilage on the medial compartments of the bone, and this is the joint, sorry, this is the medial side of the humer condyle, the trochlear, and this is the coronary process down here. We've got this, these areas of full thickness cartilage erosion.
A patchy cartilage cover here, but none here, none here. This is subchondral bone that you're looking at. But laterally, unlike the case that Heidi showed you, actually, the lateral compartment of Molly was completely sort of clean on arthroscopic examination.
Complete is a strong word. It was relatively spared, but spared enough. So what Molly has is a variant of Alba dysplasia away that we now term medial compartment disease because the, the changes are, lateralized really to, to the medial compartment.
And the guys from Ghent, published this lovely review about 5 years ago in VOT, on medial compartment disease. So this is a sort of typical radiograph of a normal dog on the left and a, and a dog. That probably has medial compartment disease on the right.
Now, let me just see what my next slide is here. I'll come back to the, to the canine radiography in a moment. Parallels have been drawn, probably fairly between medial compartment disease in the elbow of dogs and medial gonarthrosis in the knees of humans because it's, it's a phenomenon that we see in humans where you get this, preferential wear and erosion of the medial side of the knee joint, causing, causing pain in people.
Now, the key difference in radiography between dogs and people, is that in people, this view is taken in weight bearing. OK? And that's really important because what this view shows you, is a complete lack of cartilage between the medial femoral condyle and the medial tibial condyle here.
But because the dog, because the person is weight-bearing when the radiograph is taken, we can say for sure that there is interposing tissue here, cartilage and meniscus between the lateral femoral condyle and the lateral tibial condyle. So because it's weight bearing, we know that this is definitely true, there's nothing interposing here, and we know that this is definitely true. There is something interposing here.
Let me just check my next slide again. OK. OK, back.
Radiography in dogs is different though, because it is very rarely taken in weight-bearing. These are not weight-bearing radiographs. So what we can say confidently from this radiograph on the right is that there is no cartilage left in the medial compartment of the joint because we have contact between the medial part of the humeral condyle and the ulna.
It looks as though there probably is cartilage preserved in the lateral aspect, but because this is non-weight bearing, we can't say for sure. This could just be the result of a little bit of inadvertent virus stress placed on the elbow when the radiograph was taken. So that's a big difference between human medial gone arthrosis and medial compartment disease in people, in dogs.
We could not confidently diagnose medial compartment disease on radiographs in dogs. Although CT gives you more information, the same is true with CT. It's non-weight bearing.
So if we don't see a joint space, good, we know there isn't one, we know we've got full thickness erosion. But if we do see a joint space, we can't say that that's not just due to distraction. So for me, the only way that we can confidently diagnose medial compartment disease and By diagnosing medial compartment disease, I'm stressing that we need to make clear that the only changes or, or the severe changes are restricted to the medial compartment only.
So we can diagnose OA, we can diagnose degenerative disease, etc. On CT and radiography, but we can only be sure of the relative preservation of the cartilage of the lateral compartment with arthroscopy. So this is a talk about management of medial compartment disease.
For me, the only way we can differentiate between global joint OA and medial compartment disease definitively is with arthroscopy. And that's part of the reason why we, we scope Molly, want to see where we stood. So your options for management of medial compartment disease.
Well, one option, which, you know, a lot of human orthopaedic surgeons and, and musculoskeletal clinicians, would, would, go for, and a lot of vets would go for as well. You say, well, OK, so what if the, the changes are relatively worse in the medial compartment. It's still OA and we manage it like OA.
So we're going to manage it medically like OA and we're gonna manage it surgically like we would OA. But there is, it does open up the avenue or, or the potential to explore the treatment of this as, as medial compartment treatment, medial compartment disease only. The two options that are useful for this in people are uni compartmental knee replacement, so a hemiarthroplasty where just the medial side of the joint is replaced.
And high tibial osteotomies which aim to shift the load. From the medial aspect of the joint. Over to the lateral aspect.
We need to be careful when we extrapolate behaviour and findings from human orthopaedics to canine orthopaedics. A key driver of uni compartmental knee replacement and load bearing change osteotomies at the high tibi osteotomy in people is to preserve as much of the joint as possible. To allow a total joint arthroplasty to be performed later down the line.
And the big difference between dogs and people here is that in people, a total knee replacement might need to last for decades. So if you present with severe end stage medial gonarthrosis. In your late 40s, early 50s.
The surgeons are gonna be very cautious about putting a total knee replacement in because it could need to last you 2030, 40 years. So, these procedures are used in people very frequently to delay the requirement for a total knee replacement. That is not the same situation as we have in dogs.
But let's just talk about the principles of treatment. So what I have on screen here is a schematic diagram of a front on view of a dog's forelimb. Top circle is the shoulder joint, bottom circle is the foot.
This circle is the carpus, and what we have here are the medial and lateral compartments of the elbow. This is the load bearing axis. The load bearing axis is drawn as a straight line from the centre of the shoulder to the middle of the foot.
And in a normal dog in a normal weight bearing situation, that load bearing line is going right through the middle of the elbow, and we know from cadaveric studies that the elbow is loaded about 50/50 medial and lateral compartments. If we make an osteotomy, and what I've illustrated here is a distal humeral osteotomy, and we induce some valgus, so we're shifting the foot out to the lateral side, we end up with a situation like this. The dog can't bear weight like this, so we assume that what happens is the foot is brought under the shoulder to meet that load bearing line there.
And what that does is bring the load through the lateral aspect of the elbow, more so than the medial, medial aspect of the elbow. So, so that's what we're trying to achieve here. We're trying to offload the medial compartments and, and increase the lateral compartment.
Few different ways of doing that and I am gonna start rushing here. We're, we're we're tight on time and, and a lot of this is of academic interest only. A few different ways of doing that.
Back in the, noughties, this group at Davis, did a sequence of cadaveric studies, really nice studies looking at a humeral wedge osteotomies, inducing that valgus and humeral sliding osteotomies whereby the distal part of the humerus is is shifted medially. And they looked at load bearing in the elbow joint. An earlier paper, Fujita showed that both of these osteotomies changed contact area.
But in Mason's study, this one I've got illustrated here, where they use contact pressure, they found that the sliding humour osteotomy better move the load to the lateral aspect. And the wedge osteotomy kind of, went out the window from then on, probably unfairly in my opinion, but we'll, we'll, we'll discuss that on another day perhaps. A new generation devices, along with a few surgeons, developed the sliding humer osteotomy.
And the big proponent of this procedure in this country and globally really was was Noel, Noel Fitzpatrick, and he presented a, he's reported a couple of case series. In the first case series, there was a very high complication rate with, with pretty catastrophic complications that were challenging to, to deal with. And, and it was this complication rate and the complexity of these.
In fairness, combined with the lack of clinical evidence to show that it worked. Really meant that SHO is never really caught off. I don't know too many orthopods that do that.
OK. In fairness, Noel has published the more recent case series with a lower complication rate. How much of that is down to design iterations and procedure iterations, and how much of that is down just to, you know, him getting better at doing them.
We don't know. But, but either way, it seems unlikely that SHOs are going to take off anytime in the near future. Interestingly, what has taken off and what is a big growth procedure, is the pole, which is the proximal abducting ulnar osteotomy.
Developed by Ingo file in combination with Keon. OK. What's interesting, about the pool is, just how successful it is proving to be and, and, and how common a procedure it is, being performed, on the basis of, of, of very little, supportive data.
So here's our lines again, the pole is inducing valgus, in the antebrachium, and the dog is bringing the foot back under the foot and we're, we're loading the, the lateral aspect of the joint. Let's have a look at the data. So, this is about the only peer-reviewed journal that I'm aware of on Paul, which is a mechanical study, looking at the effect of Paul on the contact mechanics of the elbow.
And they looked, in this study at the effect of Paul on congruent elbows and on elbows with induced incongruency. And what they did is they measured contact area at baseline, lateral and medial, after doing a 2 millimetre pool, a 3 millimetre pool and repositioning the foot. And all these graphs come from a dog that the congruent elbow.
And what we can see here is that in this mechanical model. At a very model, the pool had absolutely no effect on any of these, measured, pressure, values. OK.
So it didn't seem to be doing much, in those dogs. In the incongruent, elbows, it did have a bit of an effect. What we see from baseline to inducing the incongruency.
We see a, A change in the loading, and that's sort of changed and taken back to, to baseline when you do a poll. But what the authors of this study concluded is that the pole has no effect on the medial compartment pressure in the congruent elbow. It may ameliorate medial compartment pressure in the incongruent elbow, but that doesn't seem to be as a result of a medial to lateral shift.
And therefore, we need to investigate this a lot more before we sort of fully understand it. Just flicking back to the, The pictures there. I think the problem I have with the pole intuitively is that it makes the assumption that limb position changes below the osteotomy.
But given the fact that we're only cutting one out of the two major bones in this limb segment, I would have concerns that actually the opposite might be true, that the proximal fragment might move. And if that's happening, then actually you could be increasing the load in the medial compartments. But all that is conjecture.
What we really want to know is what's the clinical outcome with Paul? And so far, as I say, as far as I'm aware, nothing published in peer-reviewed literature. This presentation by Aldo Vioni is available online.
And it just reports the, the outcomes of the first few cases that they performed at their centre, and again, sort of relatively high complication rates here. So sorry to interrupt, we're running very low on time now so if you want to get some questions in, we've got about 1015 minutes max. Yeah, no problem.
I reckon I've got about 4 minutes of talking. OK. OK, so that's, that's the pool.
Which is, you know, the canine equivalent of the high tibi osteotomy. Kine equivalent, or equivalent of the unique compartmental knee that we see in people are the Q, which is developed by Arthrex and stands for the canine uni compartmental elbow. Heidi mentioned this.
And this is a very, very focal joint resurfacing, procedure whereby just the, the coronoid region and the opposing humeral trochlear region are resurfaced with these implants. Challenging surgery, challenging access because of the collateral, ligaments. Again, no, clinical, reports in the peer-reviewed literature.
I think that to buy into the principle of Q, you really have to believe that the pain and the lameness associated with elbow dysplasia related OA is down to the focal contact pressures. You really have to ignore sinusitis and the osteoarthritic changes in the rest of the joint. So I think the problem with Q for entirely my own opinion, and, and there are some very well renowned advocates of this procedure.
The, the, the problem for me is that in order for this to have any chance of success, you probably need to do it quite early when the rest of the joint is relatively spared. And it's quite a big thing to do to a dog that early on, in disease. So again, not something that we do here and, and not something that, is, is hugely, hugely popular in the UK at least.
Kean are working on this uni compartmental elbow system with Kirk Wendelberg. Nothing. Published on this yet, this is in, a much earlier stage of development.
It'll be interesting to see what happens as, as this comes to fruition. All right, we're chucking on here. So, as I said, just wrote the referral letter, for Molly.
I saw a couple of weeks ago or last earlier this week, actually. She's now 10 years old. She's put on a bit of weight, so she's got a body condition score of 7 out of 9.
The owners report that her function improved for a few months, after the, stem cell treatment, but the last few months, they feel as though she's got a bit worse. So she's back onto shortly walks only. She's on exactly the same medication she was on before.
This is where the value of the load comes in, because to me, when I looked at Molly, I thought she looks pretty much the same as she did last time. And again, you know, I wasn't particularly, motivated to, to, rock the boat too much. It's been a couple of years since the owner completed the load questionnaire and they completed it.
It was exactly the same score as when she first presented to us. It's just a really nice tool to be able to say to the owner, look, I know you perceive that she's a lot worse at the moment. But you know, that, that probably is largely perception and although she may have deteriorated a little bit, you know, the load isn't completely sensitive to the minutes change.
Actually, in the grand scheme of things, she's probably about where she was. But she had put on weight, and you know, I've got a whole discussion here on, on body weight. Heidi has already covered this as a, as a general point really well.
Another point here is that Biomechanics and increased body weight, have this, into play. And I think with medial coronary disease, you know, a fat dog is forced to hold their legs, hold their feet a little bit further out than they, they might do, especially if they're carrying weight around their chest and on their legs. And what that's doing is actually The opposite of what all those load shifting osteotomies are trying to do.
It's actually increasing the rate, the weight down the medial compartments of the the elbow. And this is a this is a great human study, which I don't have time to go into now that that discusses in in in in length, that interplay between body weight and biomechanics. So, my primary advice to the owner at this visit, was this, and I would say that if you take away one nugget of information from my two presentations today, take away this formula for resting energy requirements.
And body weight, and the requirements of the feeding requirements for weight loss, because I use this in virtually every, OA consult now. This is just a formula to calculate the calorific requirements of this dog when you want to get weight off them. And that's what we did.
We have advised, a two month period of weight loss, and I'm going to see Molly again, in 6 to 8 weeks. We'll see how she's doing, and I would hope that she will have improved with that. So thank you very much.
I'm sorry that as a group, we have overrun, I think I've made back a couple of minutes in that presentation. And as Sean says, we, we've probably got 10 minutes or so in which we can answer some questions that may have come up over the course of the last 2 hours. Thanks very much.
Thanks very much, Ben. Yeah, so we've got about 10 minutes or so to talk through some questions. There's been a few coming in, and Heidi, thanks for answering some in the chat in the Q and A box.
If you have any more questions, do send them in. The one that I was going to ask and someone else asked, I can't get the name now. I think it was Wendy, tramadol in dogs, what's the efficacy?
There's been some debate around that recently. Yeah, I did, I did, write, something. So, there, there are, concerns about the efficacy of, tramadol.
A recent study, by Bazburg at all, did not demonstrate any clinical benefit for dogs with osteoarthritis of elbow or stifle. Also, in 2014, Delgado and all assessed tramadol for postoperative analgesia. In dogs after inoculation, they, did, have no evidence.
So that's why, many orthopaedic surgeons, have, have been turning away from tramadol. How is that with the others? Great, thank you.
If anyone wants to see those answers that Heidi wrote, they're in the Q&A box under the answered tab. One of the questions I had, which wasn't really covered was, the use of osteotomies in younger dogs. Is that, very common?
Well, I'll, I'll, I'll give you my view on that and I'm sure the others might do as well. I mean, Nicky showed a really nice slide of a, ulnar osteotomy in combination with a lag screw for management of UAP. And for me, that is the only indication for which I'll use an osteotomy, in a juvenile dog.
Unless it is the rare case where there is an absolutely blindingly obvious incongruity. You know, I think if you can see it on a radiograph, You know, and, and, and what we're really looking at there is a, radioulnar growth discrepancy. You know, then I, then I will do a corrective osteotomy.
I, I, I don't do them routinely for a, a joint that is grossly congruent, personally, I, I think that the problem with them is, or the, the problems with them are, there's no evidence that it works clinically. So if there's no evidence that it works clinically, it's got to be pretty safe for you to consider doing it. And I don't actually think it's, it's all that safe a procedure to do.
The dogs definitely get a lot worse afterwards. And, you know, once they're sort of getting sort of skeletal maturity. Sort of one year plus certainly.
Actually that the non-union rate is pretty high. And I know that that has been improved with the, sort of oblique orientations of the osteotomy. But you know, I, I put this in exactly the same box as I put an awful lot for surgical treatments that are described for, for el dysplasia and that's I wouldn't do them to my own dog, so I wouldn't do them to a clients.
I don't know if this, how the other speakers feel about that, I'd be interested to hear. I, I, it's Mark here. I would agree with Ben on that front that for me.
There's a bit, well, a fair bit lacking in the evidence that these, osteotomies make a difference in dogs, and there's a reasonable chance that you could make them worse or they could have a complication that they need to get over. So, I don't tend to perform poor or sliding humal osteotomies in, in any young patients I see. Completely agree that maybe the, the occasional dog with a very, very obvious incongruity that you would use a dynamic.
Osteotomy and but other than that, nope. I Go ahead. Sorry.
I agree that, an oblique, biobli osteotomy still creates quite a bit of morbidity. I reserve that for cases, of incongruity, as assessed on CT also they're not standing CTs or weight-bearing CTs. They are good standardised, ways, to, to assess that.
And, I've become, a little bit more proactive. I used to be, quite conservative, similar to you, Mark and Ben as well, but I have become more proactive, in assessing patients, also and considering them for Paul in a younger age when they show early signs of medial compartment disease. And I would consider, interestingly, more for the advanced cases, as I've said already earlier, .
But and with the idea to standardise them to get data, which is still missing, I agree on that. Right, OK. Annette has asked, is Amantadine safe to use alongside NSAIDs and which dose do you use?
Yes, I mean, I, I, I, I use that very, very frequently. And, you know, Ben Wernham's study, which is sort of the main study that's cited when people are using amantadine, for dogs, you know, it was used alongside meloxicam. And, and in fact, the outcome measure that they used in that study, was, along with the fact that, Well, the main outcome measure that they used was that the dogs that were receiving Amantadine, that the dose of meloxicam was able to be lowered more so than the dogs that weren't receiving Amantadine.
So that the whole study was based on it being co-administered with NSAIDs. It is 3 to 5 mg per kilogramme once a day. Yeah, exactly.
Yeah. There's a good few questions coming in about the multimodal analgesia, most along the, the kind of theme of combining them. Catherine asked, do you use Pardelle alongside NSAIDs in the deterioration cases or do you alternate therapies?
Yeah, I, I did answer them also in written, so that's used alongside. Yeah. Great.
I think that's the main theme of the questions that have come in. So at this point, I'd just like to thank, our speakers and everyone who's, who's joined us this morning. Just at the end of the, webinar, there will be a survey we'd really appreciate if you could, fill that in and also my colleague Rob will post a link to your goodie bag, in the chat box.
So if you just have a look there. Rob will post that and you can avail of our goodie bag. So yeah, just over to, thanking you all again, speakers and audience for joining us this morning.