• Closed reduction was attempted and achieved in all canine cases.
• Six out of nine (67%) reduced canine elbows were palpably unstable following closed reduction, and open reduction and surgical stabilisation was performed. A medial or lateral approach to the elbow was made, and collateral ligaments and muscle attachments were repaired by primary repair or with bone anchor screws and figure-of-eight wire. The annular ligament was repaired in two cases. All cases had capsulorrhaphy performed.
• Of the surgically managed canine cases, three (3/9, 33%) were placed in a Spica splint for 14 days following surgery, and three had Kirschner-Ehmer external fixators applied for seven to ten days following surgery. The three non-surgically managed canine cases were maintained in Spica splints for between seven and ten days, and had exercise restricted.

Follow-up veterinary examination was performed at the relevant referral centres between six and 53 months following treatment (all assessed subjectively):

• Lameness: either yes or no, at walk or trot.
• Muscle atrophy compared to contralateral limb: either yes or no.
• Instability compared to contralateral limb: either yes or no.
• Range of motion: either abnormal or normal.
• Pain on palpation: either yes or no.
• Joint thickening: either yes or no.
• Crepitation: either yes or no.
• Radiographic evidence of osteoarthritis: described briefly for each case in the results.

Results of client questionnaire at the time of follow-up (all assessed subjectively):

• Return to work: either yes, no, or not applicable.
• Lameness after exercise: either yes or no.
• Regular use of analgesics: yes or no.
• Overall pleased with results: either definitely, somewhat, or displeased.

• Closed reduction cases (three): one was a companion animal which appeared clinically normal, one was a working dog that returned to active hunting, experiencing mild lameness after activity. Both had mild-to-moderate radiographic evidence of osteoarthritis, and clients were satisfied with the outcome in both cases. The third case had severe radiographic evidence of osteoarthritis, continued lameness, moderate muscle atrophy, required regular analgesia, and the client was unsatisfied with the outcome.
• Open reduction cases (six): in 5/6 (83%) cases, lameness was mild and intermittent, usually apparent after vigorous exercise, degree of radiographic evidence of osteoarthritis was variable (no further information provided); 1/6 (17%) had extensive soft tissue damage at the time of treatment, and showed evidence of severe degenerative joint disease and required regular analgesia at follow-up (53 months following treatment).
• The authors considered the results from both groups to be subjectively comparable, and postulate that severity of initial injury, chronicity of luxation, patient size, and patient activity level are important factors that contribute to outcome.

• It is a retrospective case series, which sits low on the hierarchy of evidence.
• Cases are from 1985 to 1990, meaning techniques and medications may have changed during the study period and since publication.
• Cases are provided from two centres, which may result in less standardisation of treatment protocols.
• There is a small number of cases.
• All outcome measures in both open and closed reduction groups are subjective.
• There is no description of techniques used to determine outcome measures i.e. degree of lameness, degree of radiographic evidence of osteoarthritis.
• Time to follow-up is highly variable (between six and 53 months) between cases, which may have influenced outcome measures.
• Cases had all been referred from primary care veterinary clinics, meaning an unrepresentative sample of more complicated and difficult to manage cases may be included.
• Some outcome measures are listed on a two-point scale (e.g. presence of lameness on a yes or no scale), when it may be appropriate to record the outcome being measured on a multi-point scale.
• Some outcome measures are based on client reports, not veterinary examination.

• Seven canine cases managed by closed reduction followed by coaptation with a Robert Jones bandage for one week, and exercise restriction for four weeks. All seven cases were treated within seven days of the causative injury.
• Ten canine cases managed by open reduction, augmented with primary ligament repair, cortical screw bone anchors and cerclage wire, and/or joint capsule repair as necessary (the number of cases requiring each of these procedures is not stated), followed by coaptation with a Robert Jones bandage for one week, and exercise restriction for four weeks. All cases treated by open reduction were considered ‘chronic luxations’; no further explanation is provided.

• Joint stability; subjectively determined to be either stable or unstable.
• Severity of radiographic osteoarthritis at follow-up examination (one month to two years following surgery); subjectively determined to be mild, moderate, or severe.
• Clinical outcome (lameness) at follow-up examination; subjectively determined to be excellent, good, fair, or poor.

• In the closed reduction group at follow-up examination, joint stability was achieved in 6/7 (86%) cases; severity of radiographic osteoarthritis was mild in 5/7 (71%), moderate in 1/7 (14%), and severe in 1/7 cases; clinical outcome was excellent in 4/7 (57%), good in 1/7 (14%), fair in 1/7, and poor in 1/7 cases.
• In the open reduction group at follow-up examination, joint stability was achieved in 9/10 (90%) cases; severity of radiographic osteoarthritis was mild in 3/10 (30%), moderate in 1/10 (10%), and severe in 6/10 (60%) cases; clinical outcome was excellent in 1/10 (10%), good in 2/10 (20%), fair in 1/10, and poor in 6/10 (60%) cases.

• It is a retrospective case series, which sits low on the hierarchy of evidence.
• Cases are from 1998 to 2004, meaning techniques and medications may have changed since publication.
• Cases are only provided from a single centre.
• There is a small number of cases.
• Outcomes studied are measured subjectively, which may introduce bias.
• Insufficient detail is provided to enable accurate replication of the study (e.g. the methods used to determine joint stability, degree of radiographic osteoarthritis, and clinical outcome).
• Time to follow-up is not specified for each case, and varies wildly (one month to two years), which alone may have affected outcome.
• Insufficient information on patient group selection is provided – the reader is only told that the groups consist of patients presenting within the first week following injury, or are ‘chronic’.

• All dogs were referred because the referring veterinary surgeon could not reduce the elbow or could not maintain elbow in reduction.
• All dogs that presented following acute elbow luxation and were found to have any degree of instability (defined as a range of movement beyond 45 degrees for medial rotations, and 70 degrees for lateral rotation) underwent open stabilisation within four days of the causative injury.
• All elbows were repaired using cortical screw bone anchors and cerclage wire, with primary lateral collateral ligament repair as necessary.
• A support bandage was applied for three days following surgery in all cases.

At follow-up client communication between six and 60 months following surgery:

• Owner satisfaction; subjectively determined by client questionnaire as very satisfied, satisfied, or not satisfied.
• Outcome; subjectively determined by unspecified authors based on a combination of client questionnaire results to assess long-term functional outcome and interpretation of clinical notes (including follow-up examination and radiography between four and six weeks following surgery) as either excellent (never stiff or lame), good (intermittent stiffness or lameness), or poor (frequently stiff or lame).

• Veterinary surgeon-assessed outcome was considered excellent in 2/10 (20%), good in 5/10 (50%), and poor in 3/10 (30%) cases.
• Owners reported that they were very satisfied with long-term outcome in 6/10 (60%), and satisfied in 4/10 (40%) cases.
• The authors suggest that elbow stability should be reassessed 48 hours following closed reduction to determine if surgical stabilisation is required.
• The authors state that bone anchor screws with figure-of-eight wire, and primary ligament repair with nylon suture is an effective means of surgical stabilisation of elbow luxation.
• The authors state that, in general, traumatic elbow luxation results in the majority of dogs suffering from clinically significant stiffness or lameness.

• It is a retrospective case series, which sits low on the hierarchy of evidence.
• Cases are from 2003 to 2009, meaning techniques and medications may have changed since publication.
• Cases are only provided from a single centre.
• There is a small number of cases.
• Cases had all been referred from primary care veterinary clinics, meaning an unrepresentative sample of more complicated and difficult to manage cases may be included.
• The study only reports on a single patient group (those who underwent surgical stabilisation following closed reduction), so a comparison between treatment groups cannot be made.
• Outcomes studied are measured subjectively using non-validated metrology instruments, which may introduce bias.
• Long-term outcome is determined based on client feedback rather than veterinary assessment.
• Time to follow-up is highly variable (six to 60 months) between cases, which may have influenced outcome, and there is no attempt to correlate time-to-follow up and outcome
• Despite cases presenting four-to-six weeks following surgery for re-examination, findings are not reported for this.

• Closed reduction was attempted in all patients within three days of the causative injury.
• The elbows of three dogs whose elbows were severely unstable after closed reduction re-luxated within 24 hours of closed reduction and underwent open reduction. This was achieved either via a medial approach to the elbow to repair the medial collateral ligament using cortical screw bone anchors and a figure-of-eight wire loop (in two dogs), or via a medial and lateral approach to repair a torn medial and avulsed lateral collateral ligament through primary ligament repair and by using a lag screw at the avulsion site, respectively (in one dog).
• External coaptation was employed in all cases, and was achieved using either a Robert Jones bandage (5/14, 36%), light bandage (2/14, 14%), or Spica splint (7/14, 50%) for between one day and four weeks where recorded.

At follow-up client communication between five months and nine years following treatment (clients only responded in 8/14, 57%, of canine cases):

• Outcome; subjectively determined by client questionnaire as either excellent (no noticeable lameness), good (infrequent lameness), fair (persistent lameness), or poor (failure to use the limb).
• Owner satisfaction; subjectively determined by client communication as either satisfied, or not satisfied.

• Eight dog owners replied to the client questionnaire; six from the closed reduction group, two from the open reduction group.
• Outcome was considered excellent in 4/6 (67%), good in 1/6 (17%), and fair in 1/6 closed reduction cases. Outcome was considered fair in 2/2 (100%) of open reduction cases.
• Owners considered themselves satisfied in all cases where questionnaires were completed (8/8).
• The authors consider joint stability following closed reduction to be a positive prognostic indicator, and suggest closed reduction should be attempted as soon as possible following injury. Surgical management is advised in cases of persistent instability following closed reduction (time frame is not specified), or in the presence of avulsion fractures.

• It is a retrospective case series, which sits low on the hierarchy of evidence.
• Cases are from 1999 and 2009, meaning techniques and medications may have changed during the study period and since publication.
• Cases are provided from two centres, which may result in less standardisation of treatment protocols.
• There is a small number of cases.
• Cases are all reported from a referral hospital which may select for more severe or difficult to treat cases (i.e. cases that underwent satisfactory closed reduction were not referred).
• Outcomes studied are measured subjectively using non-validated metrology instruments, which may introduce bias.
• Outcome is measured solely by client feedback rather than veterinary assessment.
• Time to follow-up is highly variable (five months to nine years), which may have influenced outcome.
• There is significant variation in the duration of coaptation, which may have influenced outcome.

• Thirty-five (80%) dogs were treated with closed reduction, with two of these cases requiring surgical repair of the medial collateral ligament using a screw and spiked washer.
• Nine (20%) dogs were treated with open reduction. Additional surgical procedures performed at the time include: lateral collateral ligament repair using non-absorbable, monofilament suture (n=2); repair of the radial annular ligament using a stainless-steel wire prosthesis (n=1); transarticular pinning to maintain reduction for 14 days (n=3).
• External coaptation was employed in 43/44 (98%) dogs with a soft padded bandage (n=10), Spica splint (n=7), cast (n=2), Schroeder-Thomas splint (n=1), or an unspecified bandage (n=23). Duration of coaptation was known in 22 cases, and ranged from one day to six weeks (mean 14 days).

Follow-up client communication and/or veterinary assessment was performed between three and 137 months following treatment and involved:

• In all 44 dogs: result of treatment; determined subjectively by client telephone contact as either excellent (no detectable lameness), good (infrequent weight-bearing lameness, especially after exercise or inclement weather), fair (frequent episodes of lameness), and poor (marked non-weight bearing lameness with abnormal limb function).
• In all 44 dogs: client satisfaction; determined subjectively by client telephone contact as either satisfied or unsatisfied.
• In the 6/44 (14%) of dogs available for follow-up veterinary examination: gait evaluation, limb function and range of motion as determined by physical examination, and radiographic evidence of osteoarthritis, determined subjectively by veterinary assessment.

• Closed reduction group: outcome was rated by clients as excellent in 27/35 (77.1%) cases, 4/35 (11.5%) good, 2/35 (5.7%) fair, 2/35 poor. 33/35 (94%) of clients were satisfied with the outcome.
• Open reduction group: outcome was rated by clients as excellent in 1/9 (11.2%) cases, 4/9 (44%) good, 4/9 fair. 9/9 (100%) of clients were satisfied with the outcome.
• Six dogs presented for veterinary assessment, four from the closed reduction and two from the open reduction group. Closed reduction: 4/4 (100%) showed no detectable lameness andoutcome was rated excellent by the clients; 2/4 (50%) showed mild reduction in range of movement and mild radiographic osteoarthritic change, 50% showed no reduction in range of movement and no evidence of radiographic osteoarthritic change. Open reduction: 2/2 (100%) were lame at walk and outcome was rated fair by the clients; range of movement was decreased in both cases, and there was evidence of severe radiographic osteoarthritic change in both cases.

• It is a retrospective case series, which sits low on the hierarchy of evidence.
• Cases are from 1978 to 1988, meaning techniques and medications may have changed during the study period and since publication.
• Cases are only provided from multiple centres, meaning there is likely to be reduced standardisation of care.
• There is a small number of cases.
• Most outcomes studied are measured subjectively, which may introduce bias.
• Time to follow-up is highly variable between and within patient groups making direct comparisons difficult.
• Joint immobilisation method and duration is highly variable, and includes transarticular pinning as one of the options, which may affect outcome.

• Closed reduction was performed in both cases.
• An unspecified bandage was applied in both cases (for 12 days in case 1 and two days in case 2).
• Exercise was restricted in case 2 for seven days. Exercise restriction was not reported for case 1.

• Clinical outcome; determined subjectively by veterinary assessment at unspecified times following closed reduction, and by client communication at either six weeks (case 1) or eight weeks (case 2) following closed reduction.

• Case 1: the dog was weight-bearing lame on the affected limb after bandage removal, and the client reported intermittent lameness on the affected limb six-weeks following bandage removal.
• Case 2: the dog underwent veterinary assessment at two unspecified times following discharge where no outcome is reported, and the client reported no evidence of lameness eight weeks following bandage removal.

• It is a retrospective case series, which sits low on the hierarchy of evidence.
• Cases are from 1966 to 1970, meaning techniques and medications may have changed during the study period and since publication.
• Cases are only provided from a single centre.
• There is a small number of cases, and there is no explanation or rationale provided for the selection criteria for the two presented cases out of 12 cases identified.
• Follow up is described in extremely limited detail and reporting is not standardised between cases.
• Outcome is measured subjectively, and is partly measured based on client reporting using non-validated reporting systems.
• Management post closed reduction varies between cases, and no explanation is provided for this.

• Seventeen dogs were managed with closed reduction alone.
• Twenty dogs underwent surgical management. Indications for surgical management were inability to perform closed reduction, or persistent instability or reluxation following closed reduction. No case had open reduction without concurrent stabilisation. Surgical stabilisation was grouped into the following categories: a) circumferential suture prosthesis through transcondylar bone tunnels (n=11), b) bone anchor screw placement with prosthetic ligament/orthopaedic wire placement (n=4), c) bone anchor screw placement with prosthetic ligament plus circumferential suture (n=1), d) bone anchor screw with prosthetic ligament plus transarticular pin (n=1), e) bone anchor screw placement with prosthetic ligament plus transarticular external skeletal fixator (n=1), f) open reduction plus transarticular external skeletal fixator (n=1), g) closed reduction plus transarticular external skeletal fixator (n=1).
• Post-reduction, external coaptation or fixation was employed in 30 cases; Spica splint in 20 cases (10 closed, 10 surgical), cast/bandage in seven cases (four closed, three surgical), transarticular external skeletal fixator in three cases (one closed, two surgical). Duration of external coaptation is not listed.

• Quality of life, limb pain, and limb function; assessed subjectively by clients using a validated metrology instrument (Canine Brief Pain Index Questionnaire, Brown et al 2008). This includes four questions that grade severity of the dog’s pain over the previous seven days (rated 0/no pain, to 10/extreme pain), six questions that evaluate limb function over the previous seven days (rated 0/no interference, to 10/extreme interference), and one question to assess overall quality of life (rated poor, fair, good, very good, or excellent).

Quality of life of patients at the time of follow-up client questionnaire (mean 961 days [+/-849 days]) following treatment:

• Closed reduction: quality of life rated excellent in 4/9 (44%) of cases, very good in 4/9 cases, fair 1/9 (11%) cases; mean pain score is reported as 0.19/10 (range 0-1.25); mean limb function is reported as 0.80/10 (range 0-4.67).
• Surgical intervention: quality of life rated excellent in 9/12 (75%) cases, very good in 2/12 (17%) cases, good in 1/9 (11%) cases; mean pain score is reported as 0.90/10 (range 0-3.75); mean limb function is reported as 0.96/10 (range 0-3.83).
• Major post-operative complications occurred in 7/37 (19%) cases: reluxation (n=6) and infection required implant removal (n=1).
• Five reluxations occurred following closed reduction; one was successfully managed with repeat closed reduction, three were surgically stabilised (and included in the surgical group), one was euthanased due to severity of disease. One reluxation occurred following surgical stabilisation with lateral screw and medial prosthetic ligament placement, revision surgery was performed successfully using the same technique.
• Four of the six reluxations occurred in patients with dogs suffering from concurrent orthopaedic injuries in other limbs.

• It is a retrospective case series, which sits low on the hierarchy of evidence.
• Cases are from 2006 and 2013, meaning techniques and medications may have changed during the study period and since publication. This is highlighted in the discussion, as a new surgical technique was described by Farrell et al. (2009) that was employed later in the present study (data presentation prevents correlation of outcome with surgical method employed).
• Cases are provided from five centres, which may result in less standardisation of treatment protocols.
• There is a small number of cases.
• Cases are all reported from referral hospitals which may select for more severe or difficult to treat cases (i.e. cases that underwent satisfactory closed reduction were not included).
• Outcomes studied are measured subjectively by clients rather than by veterinary assessment, which may introduce bias. The metrology instrument used is validated, however.
• There is no mention of duration of coaptation, but it is described as variable, which may have influenced outcome.
• Time to follow-up is highly variable (961 +/- 849 days) between cases, which may have influenced outcome.
• There is variation in the surgical techniques used within the surgically managed group of patients, which may have influenced outcome.
• Patients with concurrent orthopaedic injuries to other limbs were included in the study, which may have influenced outcome. The authors state that four out of the six reluxations occurred in these patients.

• Nineteen dogs with acute lateral luxation were treated with closed reduction, and joint stability was assessed using Campbell’s method. One collateral ligament (specific ligament not stated) was sutured following closed reduction in four of these dogs. Joint immobilisation was achieved with application of a Spica splint, lightweight bandage, or Robert Jones bandage for a mean of 25 days (range two to 42 days). Exercise restriction was recommended for two weeks.
• One dog with acute bilateral luxation and two dogs with chronic elbow luxation were treated with open reduction. Joint immobilisation was achieved with application of a Spica splint or lightweight bandage for one to four weeks.
• Five dogs had a Monteggia fracture; these cases are excluded here as they are considered beyond the scope of this Knowledge Summary.
• Three dogs with chronic (four weeks to one year) elbow subluxation received no treatment, and one dog had an acute lateral luxation and was euthanised at the owner’s request; these cases are excluded from this Knowledge Summary.

Follow-up reported subjectively from between four months and nine years (mean 35 +/- 22 months) following treatment in 24/31 (77%) of cases (three patients received no treatment; one was euthanised at presentation; three were lost to follow up – two from the closed reduction group, one from the open reduction group):

• Owner’s opinion: reported as very satisfied, satisfied or unsatisfied.
• Clinical results, determined based on: decrease in range of movement (none, slight, moderate, or severe); degree of osteoarthritis as assessed by the referring veterinary surgeon or by a member of the university’s veterinary radiology department (none, slight, moderate, or severe); activity after treatment (reported as normal, slightly decreased, or decreased); lameness (reported descriptively, with further quantification as none, mild, moderate, or severe).

• Closed reduction had been attempted by the referring veterinary surgeon in nine cases, but this had failed in six cases, and resulted in severe subluxation in three cases.
• Closed reduction (outcome available in 17 cases): clinical results are reported as excellent in five (29%) cases, good in three (18%) cases, fair in six (35%) of cases, and poor in three cases. The elbow was stable in 10 (59%) of these cases, and these were the only cases to achieve excellent or good outcome. Moderate-to-severe osteoarthritic changes were identified in 10 (59%) of cases. Clients are reported as very satisfied in 10 (59%) cases, satisfied in 5 (29%) cases, and unsatisfied in 2 (12%) cases. Four (24%) cases were operated on later (nine days following closed reduction in one case, timing of surgery unspecified in two cases) to repair collateral ligaments or remove periarticular bone fragments, and outcome is only reported following surgery. The influence of joint instability after closed reduction on poor clinical result is considered significant (p>0.05).
• Open reduction (outcome available in two cases / three elbows, one case suffered bilateral elbow luxation): Clinical results are reported as good in 1 (33%) elbow, fair in 1 elbow, and poor in 1 elbow.
• The presence of an avulsion fracture did not seem to influence joint instability.
• Indications for surgical management include chronic luxations, reluxation, and the necessity to remove bony fragments.

• It is a retrospective case series, which sits low on the hierarchy of evidence.
• Cases are from 1984 to 1996, meaning techniques and medications may have changed during the study period and since publication.
• Cases are only provided from a single centre.
• There is a small number of cases.
• Outcomes are all reported subjectively, including client reporting using non-validated metrology instruments.
• Time to follow-up is highly variable (four months to nine years), which may have influenced outcome.
• Cases that had surgical stabilisation after closed reduction are considered part of the closed reduction group alongside those that did not undergo stabilisation surgery, meaning there is significant variation in treatment protocols in this patient group.
• Cases are all reported from a referral hospital which may select for more severe or difficult to treat cases (i.e. cases that underwent satisfactory closed reduction were not included).
• The authors state that the necessity to remove bony fragments is an indication for surgical management, but do not explain the rationale of this statement, or the method of identifying these problematic fragments.
• The authors state that avulsion fractures do no always require surgical management, which may be considered contradictory to the previous statement.

• All patients underwent closed elbow reduction and had residual joint instability diagnosed using Campbell’s test.
• All patients underwent the elastic transarticular external fixator technique. This involves surgical placement of a transverse pin in the distal quarter of the humerus, and another in the centre of the olecranon. The pins are connected by medially and laterally placed rigid connecting bars with the joint held at 140° for two days. After two days, the connecting bar is replaced with tight elastic bands on the medial and lateral aspects of the joint.
• The elastic transarticular external fixator was kept in place between 12 and 15 days in canine patients.
• Exercise restriction was recommended in all cases, however the duration of this is not listed.

• Case one was considered to have a poor outcome as at nearly two years following surgery, it is reported that the dog does not use its operated limb (it is reported as having suffered limb paralysis with loss of deep pain perception in the operated limb at the time of injury). Range of motion was limited to 25° at the time of implant removal.
• Case two was considered to have a good outcome. At implant removal, the patient was lame in the operated forelimb and in both hindlimbs (the patient suffered concurrent pelvic fractures at the time of injury), with a range of motion in the operated forelimb of 75° at the time of implant removal, and 90° (140° in contralateral limb) at six weeks following surgery. The patient was weight-bearing lame at six weeks following surgery, with the clients reporting increased lameness after exercise, but they were unable to localise the lameness.

• It is a retrospective case series, which sits low on the hierarchy of evidence.
• Cases are only provided from a single centre.
• There is a small number of cases.
• Outcomes are all reported subjectively, including client reporting. There is limited information on the outcome measures used, and how they were assessed. Assessment method varies between patients.
• Time to implant removal was variable, which may have influenced outcome.
• Both dogs with elbow luxation in this study has significant concurrent injuries (limb paralysis with loss of deep pain perception in the operated limb caused at the time of injury, and pelvic fractures with associated lameness, respectively), making follow-up assessment of the outcome of management of the elbow luxation difficult.