KNOWLEDGE SUMMARY

Keywords: ARTHROSCOPY; CANINE; CONSERVATIVE MANAGEMENT; DOGS; ELBOW DYSPLASIA; MEDIAL CORONOID DISEASE

Does conservative or arthroscopic management of canine medial coronoid disease lead to improved outcomes?

Anant Andy Banerjee, BSc (Hons) BVetMed CertAVP (GSAS) MRCVS^1*

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¹ The Grove Veterinary Hospital, Fakenham, Norfolk, United Kingdom
* Corresponding author email: abanerjee@hotmail.co.uk

Vol 10, Issue 1 (2025)
Submitted 05 Dec 2023; Published: 04 Feb 2025
DOI: https://doi.org/10.18849/ve.v10i1.700

PICO question

In dogs diagnosed with medial coronoid disease, does arthroscopic surgical intervention, compared with conservative management, result in improved mobility and reduced pain?

Clinical bottom line

Category of research

Treatment.

Number and type of study designs reviewed

Three studies were identified directly addressing the PICO question. One paper was a retrospective cohort study, another study was a prospective randomised control trial, and the third was a non-randomised non-blinded observational study.

Strength of evidence

Weak.

Outcomes reported

The first study was a prospective non-randomised study that did not identify a difference in gait evaluation at the 52 week recheck in dogs treated conservatively compared to those treated arthroscopically, with lameness exacerbated in the arthroscopic treatment group until the 26 week recheck. The second study, a retrospective non-randomised cohort study, showed greater, but not statistically different, owner-reported clinical metrology scores in dogs treated arthroscopically compared to those treated conservatively. Liverpool Osteoarthritis in Dogs (LOAD) and Pain Severity Scores (PSS) were higher but not statistically significant, yet Pain Interference Scores (PIS) were statistically significantly higher at 52 weeks in arthroscopically treated dogs compared to conservatively treated dogs. Age at diagnosis and at time of questionnaire completion were statistically significant for LOAD, PSS, and PIS, with older dogs having higher scores. The third study performed a non-blinded observational study assessing canine patients with bilateral medial coronoid disease, with unilateral arthroscopic subtotal coronoidectomy performed on the most clinically affected limb. Radiographs and computed tomography (CT) imaging were performed at diagnosis, with radiographs taken at follow-up. At the time of follow-up, arthroscopically treated limbs had a higher radiographic score than those treated conservatively, although a significant improvement in lameness was seen at the walk in arthroscopically treated limbs. Conservatively managed dogs showed an unchanged (non-significant) gait. Radiographic changes did not appear to correlate to severity of clinical signs.

Conclusion

The quality of the published evidence available to answer the PICO question is weak, due to the design of the three reviewed studies. Low patient populations in these three studies also hinder the statistical power of any recommendations made. None of the three studies assesses the complex nature of medial coronoid disease to clearly answer the question posed. The decision to recommend arthroscopy over conservative management therefore depends on the judgement and experience of the veterinary surgeon attending the case. Additionally, assessment of the imaging findings is important when discussing prospective treatment options.

How to apply this evidence in practice

The application of evidence into practice should take into account multiple factors, not limited to: individual clinical expertise, patient’s circumstances and owners’ values, country, location or clinic where you work, the individual case in front of you, the availability of therapies and resources.

Knowledge Summaries are a resource to help reinforce or inform decision making. They do not override the responsibility or judgement of the practitioner to do what is best for the animal in their care.

Clinical scenario

A 9-month-old male entire Labrador presents to your practice with a 2-month history of intermittent left thoracic limb lameness. Physical examination reveals a 2/5 left thoracic limb lameness with pain localised to the elbow joint. Computed tomography (CT) of the elbow joints is recommended which shows an in situ apical to radial incisure fissure of the medial coronoid process with no apparent radioulnar incongruity of the left elbow joint. You discuss two treatment options with the owners: either conservative management with analgesia, a moderated activity regime and physical therapies, or arthroscopic assessment of the joint and fissure removal. The owners ask which treatment option is most likely to lead to reduced pain as well as a return to normal function. You want to be able to provide the most efficacious treatment option to the owner.

The evidence

Three studies were identified from literatures searches performed on PubMed and CAB Abstracts that answered the PICO. The first study was a prospective randomised control trial (Burton et al., 2011). The second was a retrospective cohort study (Dempsey et al., 2019). The third was a non-blinded observational study (Seidler et al., 2023) where patients were identified from radiographs and computed tomography taken retrospectively then followed prospectively. All three papers assessed the short- and medium-term effects of conservative management compared to arthroscopic management of medial coronoid disease in canine elbow joints. Burton et al. (2011) used objective force platform analysis. Dempsey et al. (2019) used owner-reported outcome measures for assessment of differences between the treatment groups. Seidler et al. (2023) used a combination of radiographic assessment, CT assessment, owner-reported outcome measures, and subjective gait analysis. None of the studies could demonstrate major clinically significant differences between treatment outcomes between conservative or arthroscopic management.

Summary of the evidence

Burton et al. (2011)

Conservative versus arthroscopic management of medial coronoid process disease in dogs: a prospective gait evaluation

Aim: Prospectively evaluate conservative management versus arthroscopic treatment of medial coronoid disease over a 52 week period.

 

Dempsey et al. (2019)

A comparison of owner-assessed long-term outcome of arthroscopic intervention versus conservative management of dogs with medial coronoid process disease

Aim: Evaluate owner-assessed long-term outcome of dogs with medial coronoid disease treated with arthroscopy or conservative management using a combined owner-reported outcome questionnaire.

 

Seidler et al. (2023)

Dogs with bilateral medial coronoid disease can be clinically sound after unilateral arthroscopic fragment removal—preliminary study

Aim: Evaluate the outcome of conservative management as compared to arthroscopic subtotal coronoidectomy in a canine subject with bilateral medial coronoid disease.

 

Appraisal, application and reflection

The PICO question is intended to be narrow in its focus. Whilst being the most commonly diagnosed pathology of elbow dysplasia, medial coronoid disease (MCD) is only one feature of this complex syndrome. There are a myriad of different pathologies within elbow dysplasia, including fragmentation of the medial coronoid process (FMCP), osteochondrosis dissecans (OCD) of the medial humeral condyle, elbow incongruity, and ununited anconeal process (UAP) (Vezzoni & Benjamino, 2021). There are a variety of different reported outcomes for surgery or conservative management for the varied pathological presentations of elbow dysplasia identified. Therefore, this narrow PICO question only addresses part of the complex treatment recommendations for dogs with elbow dysplasia. In addition, MCD itself can present in different ways and the treatment for these may differ. These different pathologies are poorly defined in most studies.

Analysis of the three papers (Burton et al., 2011; Dempsey et al., 2019; Seider et al., 2023) relating to the PICO question shows overall weak evidence to suggest arthroscopy is superior to conservative management for dogs with MCD.

Burton et al. (2011) demonstrated no therapeutic benefit of arthroscopic management of FMCP compared to conservative management in gait evaluation by 52 weeks. Lameness was exacerbated in the arthroscopically managed group up to 26 weeks compared to the conservatively managed group, then lameness was comparable between both groups at 52 weeks. The very small numbers of patients within both treatment groups (11 dogs treated arthroscopically versus 9 dogs treated conservatively) imbues an inherently low statistical power to this study. Whilst the clear strength of this study is its prospective nature, its non-randomised design and low patient populations are significant limitations, meaning that the possibility of findings being significant or non-significant is low.

Dempsey et al. (2019) performed a retrospective assessment of cases over 8 years looking at owner-reported outcomes using two clinical metrology instruments (CMI’s). No differences between the treatment groups could be identified on linear regression of the difference CMI’s performed. No power study was performed to assess the numbers of patients required to assess statistical differences. Additionally, the arthroscopic group contained a heterogenous population of different arthroscopic treatments performed (inspection alone, chondroplasty, fragment removal). The morbidity of each of these may not have been accounted for on result analysis given the low numbers of some of these treatments. Additionally, no LOAD or CBPI scoring was performed at the outset of each patient’s treatment, making it difficult to assess the effect of treatment on initial pre-treatment levels of lameness or pain. These factors may contribute to the lack of statistically significant findings within this study. Strengths of this study include the larger patient populations than the Burton et al. (2011) paper, use of validated outcome measures such as CMI’s and use of computed tomography (CT) to score the extent of elbow disease. The lack of a power study to assess patient population sizes for statistical significance is the main limitation of this study. Some of the results are close to statistical significance and may ultimately be clinically significant were patient populations large enough.

Seidler et al. (2023) used 24 dogs with bilateral MCD, using the less affected limb as a control to assess the effect of surgery on the most clinically affected limb. Whilst 80% of patients (19/24 elbows) treated with arthroscopy showed a deterioration in IEWG radiographic scoring, only 42% of conservatively managed patients (10/24) showed worsening in IEWG scoring. Subjective gait assessment was improved in 50% of dogs where arthroscopy was performed at walking with 30% showing improvement at trotting. Gait patterns in conservatively managed patients remained largely unchanged. Whilst Liverpool Osteoarthritis in Dogs (LOAD) scoring was helpful in assessing changes between treatment groups, the author of this Knowledge Summary review struggles to understand how clients could have effectively differentiated mobility differences between limbs using the LOAD questionnaire as each dog enrolled in the study in effect acted as its own control. No LOAD questionnaire was performed prior to the study commencing, making comparability of scores (to differentiate any differences in outcome before and after both treatment types) impossible. Lack of blinding was also noted in the clinician performing lameness assessments. Many of the dogs within the study were over 36 months in age, therefore spectrum of disease and comparability of findings to other studies, such as the Burton et al. (2011) paper, is challenging as patients in that study were less than two years of age. Arthroscopic treatment tended to show improvements in clinical gait pattern when walking despite radiographic findings showing deterioration in scores.

There were several papers within the literature search that could not be included in this review as they did not completely answer the PICO question. Burton (2023) recently published a literature review of arthroscopic treatments for the assessment and management of MCD in dogs. 9 papers were found that relate to removal of fragments in dogs with MCD. These include studies by Bouck et al. (1995), Burton et al. (2011), Dempsey et al. (2019), and Meyer-Lindeberg et al. (2003). Additional papers reviewed included Huibregtse et al. (1994), Theyse et al. (2000), Barthélèmey et al. (2014), Galindo-Zamora et al. (2014), and Read et al. (1990). Meyer-Lindenberg et al. (2003) suggested more favourable outcomes in dogs having arthroscopy (60.1% good outcome) compared to arthrotomy (45.6% good outcome) for FMCP. No direct comparison was performed in this paper with conservative management. When assessing overall improvement in lameness (good and satisfactory groups), there is no statistical difference in dogs treated by arthrotomy (73.7%) or arthroscopy (92.5%) for dogs with FMCPs alone (Meyer-Lindenberg et al., 2003).

Barthélèmey et al. (2014) identified improvement in gait analysis which approached significance when compared to pre-operative values in a prospectively assessed group of 15 dogs having arthroscopic management of MCD by a mixture of fragment removal, subtotal coronoidectomy, and ulnar osteotomy. Galindo-Zamora et al. (2014) identified an improvement in kinetic variables following arthroscopy in a group of 14 dogs with unilateral MCD treated with arthroscopic removal and subchondral bed burring. Both studies lack a control population, therefore their comparability to patients treated conservatively need to be carefully considered.

Whilst papers directly comparing conservative to arthroscopic management are reported within the Burton (2023) review, some papers using prospective gait analysis documented some improvement in function versus pre-treatment lameness. Additionally, many of these papers do not contain a control population of patients treated with conservative or non-surgical management, which makes comparison of the available data very challenging. Also, not all studies have had equivalent diagnostic imaging performed, with some being assessed radiographically and others having had CT performed. It is for these reasons specifically that this review article was not included within the analysed papers relating to the PICO question. Other studies have documented the relative success of arthroscopic management for dogs with MCD (Cruz & Mason, 2022; Garnier et al., 2023; Lahiani et al., 2023) but are prone to type II error with low patient numbers and a lack of control population make the assessment of the results gathered makes application of this information difficult. Interestingly though, a ECVS survey of 132 specialist surgeons with over 1200 years of surgical experience showed that the majority of specialists recommend arthroscopic FMCP removal in a juvenile dog with focal elbow dysplasia with a high chance of functional improvement (Farrell et al., 2018), which seems to contradict the current evidence base.

Interpretation of meta-analysis results performed by Evans et al. (2008) must be undertaken with caution, given the inconsistencies in the papers assessed at that time regarding conservative management techniques and lameness scoring systems. A more recent meta-analysis of the available evidence was performed by Kähn et al. (2023). Data from relevant studies was selected via the Preferred Reports Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines and extracted with subsequent analysis by three meta-analyses: success rate, mean difference and standardised mean difference. 14/494 papers were identified including many of the previously mentioned papers, and the Burton et al. (2011) and Dempsey et al. (2019) papers critically appraised by the author. Standardised mean difference meta-analysis was used due to observer bias from the two other meta-analyses employed, confirming that no statistical differences were identifiable between medical and surgical therapies.

Therapeutic elbow arthroscopy itself is a procedure with known morbidity and does not fully resolve lameness in all dogs. Second-look arthroscopic in dogs following previous arthroscopic subtotal coronoidectomy (Coppieters et al., 2016) on average 2.2 years following arthroscopic treatment showed a number of additional pathologies such as medial compartment cartilage erosion. Perry & Li (2014) identified a major complication rate of 4.8% (36/750) and minor complication rate of 10.7% (76/750) of cases in a retrospective assessment of complications in 750 arthroscopically managed cases.

CMIs have been increasingly used in veterinary medicine to provide validated means of assessing clinical outcomes. CMIs achieve this by providing scoring metrics which can then be statistically assessed by means of client-based observational questionnaires. Since the initial documented validity of LOAD, by Hercock et al. (2009), multiple validated CMIs have been introduced to veterinary medicine for both dogs and cats (Benito et al., 2013; Muller et al., 2016) in a variety of languages (Alves et al., 2022; Ragetly et al., 2019). LOAD and Canine Brief Pain Inventory (CBPI) CMIs are used the most frequently. The LOAD questionnaire is a validated CMI generating a score out of 52 based on 13 questions, assessing mobility in general and also when exercising. The CPBI is a two-part CMI generating a pain severity score (PSS) out of 40 from four questions graded from 0–10 and a pain interference score (PIS) out of 60 from six questions graded similarly (Brown et al., 2007). An additional overall quality of life score (QoL) is rated on a five-point scale categorised from poor to excellent. Regardless of the scoring system used, higher CMI scores have been shown to be associated with a greater degree of osteoarthritis and potentially worse outcomes (Alves et al., 2022). The use of LOAD and CBPI provides useful data within the Dempsey et al. (2019) study, yet the low patient population in both study groups underpowers the statistical relevance of the data analysed. Recall bias is noted with CMI use in medium- to long-term follow-up analysis (Pappa et al., 2023), and therefore prospective analysis of CMIs should be considered. The design of the Dempsey et al. 2019 study retrospectively analysing LOAD and CPBI at 12 months following treatment with no scoring performed at date of treatment commencement could therefore succumb to recall bias. Further studies assessing the impact of conservative versus arthroscopic management of canine MCD should prospectively use a CMI from the date of commencing treatment and stratifying outcomes subsequently over time.

Assessment of outcomes after conservative versus arthroscopic management of MCD needs to account for the spectrum of disease identified within affected elbow joints. Studies to date do not complete account for this. Consequently, it is not yet possible to provide a conclusive answer to the PICO question as to whether arthroscopic surgical intervention results in improved mobility and reduced pain when compared with conservative management for dogs with MCD. Careful consideration of signalment, physical examination findings, and the results of diagnostic imaging should be made prior to discussing treatment recommendations with owners on a case-by-case basis. Given the lack of high-quality statistically significant data, strong recommendations for arthroscopic management of MCD cannot currently be made. Based on the evidence described above with the methodological weaknesses and low patient populations of the three studies relevant to this PICO question (Burton et al., 2011; Dempsey et al., 2019; Seider et al., 2023), clinicians could therefore consider treating these cases with a period of conservative management. Arthroscopy would therefore then be reserved for cases refractory to conservative management. The merits and disadvantages of arthroscopy based on the available literature should be discussed with owners at the time of diagnosis so an informed decision can be made.

Methodology

Search Strategy

 

Exclusion / Inclusion Criteria

 

Search Outcome

 

Acknowledgements

The author would like to thank Clare Boulton (Head of Library and Knowledge Services, RCVS Knowledge) for assisting with the literature sources and refining search terms.

ORCiD

Anant Andy Banerjee: https://orcid.org/0009-0008-2145-2408

Conflict of Interest

The author declares no conflicts of interest.

References

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