Vol. 22, No.
2 February 2000
CE Refereed Peer Review
FOCAL POINT
★ Arthroscopy is highly effective
for diagnosing and treating
elbow dysplasia.
KEY FACTS
■ Arthroscopy provides equal or
greater information about the
joint than does standard
arthrotomy.
■ Subtle joint lesions that are not
easily diagnosed can be seen
and treated with arthroscopy.
■ The 30˚ foreoblique scopes
are the most practical for small
animal arthroscopy.
■ Distending the joint before
arthroscopy assists in locating
the joint and helps avoid
damaging the articular cartilage.
■ A medial approach provides
greater visualization of the most
commonly affected area.
Canine Elbow
Joint Arthroscopy:
Introduction and
Description of
Technique
Specialty Veterinary Surgery—Orthopedic, Neurologic, Endoscopic, PC
Larkspur, California
Andrew E. Sams, DVM, MS
ABSTRACT: Arthroscopy is effective for the diagnosis and treatment of many orthopedic prob-
lems of the canine elbow joint. Minimal morbidity encourages early examination and detection
of pathologic changes. A cartilage resurfacing technique is indicated in many cases of elbow
dysplasia; abrasion chondroplasty is one such technique that can be performed with arthro-
scopic assistance. This article discusses arthroscopic equipment and principles, the technique
for medial approach elbow joint arthroscopy, and the adjunctive role of ulnar osteotomy or os-
tectomy in elbow joint arthroscopy.
T
agaki created the first arthroscope in 19201,2; the instrument was 7.3 mm
in diameter and too large for clinical use. Forty years later, the first prac-
tical arthroscope was developed by Watanabe, who also described some
of the principles of arthroscopic surgery.1 In the early 1970s, arthroscopy began
to be used to diagnose knee problems (particularly meniscal and anterior cruci-
ate ligament tears) in humans.3,4 By the early 1980s, arthroscopic treatment was
gaining widespread use.5–7 Once arthroscopic surgical treatment was developed,
the use of arthroscopy grew rapidly.
Arthroscopy was first used clinically in dogs 20 years ago to evaluate the stifle
joint.8 Although reports of canine arthroscopy of the stifle joint, shoulder, and
coxofemoral joint were published throughout the 1980s,9–16 use of arthroscopy
in canine orthopedics was not widespread. The 1990s saw a marked increase in
the use and interest in canine arthroscopy. Elbow, stifle, shoulder, coxofemoral,
and hock arthroscopy, as well as arthroscopic treatment of lesions, have been de-
scribed.17–23
Arthroscopy provides equal or greater information about the joint than does
standard arthrotomy.1,2 Arthroscopy provides a greater area of visualization, illu-
Small Animal/Exotics Compendium February 2000

mination, and magnification of 2). In 1966, Hopkins invented a

the joint space and causes less tis- rod lens system (Figure 2), which
sue disruption. Greater visualiza- allowed for greater magnification,
tion allows surgeons to recognize better light transmission, higher
and treat lesions that are not seen resolution, more contrast, and a
via arthrotomy. Magnification of wider field of view.25
the image through the arthro- Arthroscopes still have a system
scope, along with the bright light of rod-shaped lenses to transmit
source and a fluid environment, the image to the eyepiece, but
allows surgeons to detect many most lenses are angled (typically
subtle joint lesions (Figure 1). 30˚ or 70˚) at the tip (Figure 3).
These advantages and the devel- The angled (i.e., foreoblique) lens
opment of arthroscopic treatment greatly increases the surgeon’s field
methods have allowed arthroscopy of view during rotation of the
to become the standard for treat- scope; however, the greater the an-
ing many joint problems in hu- gle is, the more difficult it is for
mans and horses. In addition, the Figure 1—Intraarticular view of the elbow joint beginning arthroscopists to orient
technique is minimally invasive of a 15-month-old male Labrador retriever. The themselves. Almost all arthroscopy
and is associated with almost no dog had been lame for 4 months. A complete is performed using foreoblique
morbidity, factors that encourage radiographic evaluation showed no lesions. The scopes, whereas many thoraco-
arrow indicates a lesion of the medial coronoid
early examination and detection process involving cartilage and subchondral scopic and laparoscopic proce-
of pathologic changes and that ide- bone. The lesion was treated with a motorized dures are done with straight (0˚)
ally lead to earlier treatment and shaver. scopes. The 30˚ foreoblique scopes
better results. are the most practical for small an-
Another advantage is that the imal arthroscopy; 70˚ scopes are
arthroscope and instrument portal incisions are smaller useful when an arthroscopist needs to view an area al-
and require only one or two staples or sutures for closure. most perpendicular to the tip of the scope.
The small size of the incision reduces patient-related Arthroscopes are available in many diameters and
trauma to the incision, dehiscence, and scar formation in lengths. For small animal arthroscopy, 1.9- to 2.7-mm
deep tissue and skin. Less scar formation also provides a diameter scopes are appropriate for most procedures. A
more cosmetically pleasing result. Lack of disruption to 4.0-mm scope may be used occasionally but is too large
the tissue planes precludes postoperative seromas. Fur- for most procedures. Arthroscopes are housed in a can-
thermore, in a recent study, dogs were more comfortable nula, a metal tube that has one or two ports to allow
24 hours after arthroscopy than after arthrotomy for fluid ingress or egress; the cannula also protects the
fragmented medial coronoid scope from being bent or dam-
process of the elbow joint aged (Figure 4). Arthroscop-
and osteochondrosis of the ists should be aware of the
shoulder.24 Clients are gener- diameter of the cannula used
ally, pleased that arthroscopic with the arthroscope—one
wounds require little care scope can be used with differ-
and that their dogs do not ent-sized cannulas. Cannulas
need Elizabethan collars or and/or scopes that are too
extensive bandages after sur- large can damage cartilage,
gery. Learning arthroscopic so great care must be taken
skills takes time and requires in choosing an appropriate-
the purchase of specialized sized scope.
equipment.
Hand Instruments
ARTHROSCOPIC Figure 2—The first arthroscopes (top) consisted of standard Hand instruments are
EQUIPMENT lenses in hollow tubes. The Hopkins arthroscope (bottom), used for probing lesions and
The earliest arthroscopes con- which had rod-shaped lenses, was a major advancement in removing cartilage flaps and
sisted of hollow tubes with arthroscope design and is still in use today. (Courtesy of Karl fragments (Figure 5). I use
Storz Endoscopy)
lenses placed inside (Figure forceps that are 2.75 mm in

ROD LENS SYSTEM ■ FOREOBLIQUE LENSES ■ CANNULAS

Compendium February 2000 Small Animal/Exotics

diameter for large flaps or frag- One of two techniques can be

ments and 2.0 mm for small flaps used to place the cannula in the
or fragments. Many types of hand joint. With the first technique, a
instruments are available. Ring conical trocar enters the joint com-
and spoon curettes are useful for pletely, the trocar is removed, and
cartilage debridement. An angled the arthroscope is placed in the
palpation probe is also helpful to cannula.
determine the integrity of the car- With the second technique, a
tilage and bone in question. Hy- sharp trocar is used to introduce
podermic and spinal needles (18 the cannula into the joint. As
and 20 gauge [g]) function well as soon as the joint capsule is en-
probes if they are used carefully; tered, the sharp trocar is replaced
they are also effective for fluid with a conical or blunt trocar be-
egress. fore the cannula is passed deep
Figure 3—The ends of 0˚ (i.e., straight; top) and into the joint; this prevents the
Endoscopic Motor 30˚ foreoblique (bottom) arthroscopes. (Cour- sharp trocar from damaging the
Drive (Shaver) tesy of Karl Storz Endoscopy) articular cartilage. The trocar is
Endoscopic motor drives that removed, and the arthroscope is
have blades for shaving cartilage placed and locked in the cannula.
and resecting bone are invaluable When using this technique, sur-
(Figure 5). They can be used to geons must be careful to avoid
shave fibrillated cartilage, perform damaging the articular cartilage.
abrasion chondroplasty, and re- A halogen or xenon light source
move anchored fragments through is necessary to illuminate the sur-
abrasion and aspiration. The full- gical field. Xenon provides the
radius cutter blades are useful for brightest light source but is also
removing cartilage and small more expensive. A fiber-optic light
amounts of subchondral bone. cable is needed to attach the light
The most useful sizes range from source to the arthroscope. To mi-
2.0 to 3.5 mm, depending on the Figure 4—(Top to bottom) A cannula; 2.7-mm, nimize damage to the light fibers,
size of the joint or area. The 3.5- 30˚ arthroscope; sharp trocar; and conical tro- the cable should not be bent at
mm blade works well for the el- car. (Courtesy of Karl Storz Endoscopy) acute angles.
bow joints in many large dogs. The joint can be viewed directly
The blade must be small enough through the eyepiece of the scope;
to avoid damaging the surround- however, this method greatly hin-
ing cartilage. Abrasion burrs are ders the procedure. It is uncom-
useful for removing cartilage and fortable for the surgeon; requires
larger amounts of bone. Many one hand to hold the eyepiece;
abrasion burrs can cut less or more prohibits the assistant from seeing
aggressively, depending on which inside of the joint; and places the
direction the burr is spinning; I surgeon’s face close to the surgery
usually use the burr in the less ag- site, which creates a risk for con-
gressive direction of rotation. tamination. Ideally, a camera is at-
tached to the eyepiece. The cam-
PRELIMINARY PROCEDURES era converts the optical image into
The joint should be distended Figure 5—(Top to bottom) Shaver handpiece (en- an electronic signal and transmits
doscopic motor drive), two shaver blades, and a
with a physiologically balanced ion- it through a cable to a camera pro-
pair of grasping forceps.
ic solution before the scope is in- cessor unit and then to a large
serted. Distention assists in locating video monitor, a video recorder, an
the joint and helps avoid damage to the articular carti- image digitizer for data storage, and a printer. Cameras
lage. To begin, the cannula, with a trocar inside, is placed come in one- and three-chip varieties; the number of
in the joint by means of a stab incision. Trocars are avail- chips determines the resolution of the image. Three-
able with sharp (pyramidal), conical, or blunt tips. chip cameras provide the best resolution and detail;

ABRASION BURRS ■ JOINT DISTENTION ■ LIGHT SOURCE

Small Animal/Exotics Compendium February 2000

however, a good one-chip camera is sufficient in most

Your comprehensive
situations.
To maintain clear visualization within the joint, fluid
guide to diagnostic
must flow continuously to remove debris and blood. A
port on the arthroscope sheath allows the ingress of flu-
ultrasonography
id, thereby flushing debris away from the lens and pro- Nautrup and Tobias
viding better visibility than would fluid ingress at anoth-
er site. An egress needle is placed into the joint to allow
fluids to exit the joint. Egress can also occur through a
shaver port or an instrument if either is in place. Fluids
can be allowed to enter the joint by gravity, a fluid pres-
surization bag, or a pump specifically designed for
arthroscopy. A relatively larger cannula and a large bag
of fluids (5 L) are often needed if gravity fluid flow is to
be used. I use a pump or pressurization bag. Surgeons
must be careful not to force fluids into the joint without
allowing for fluid egress, or fluid will escape from the
joint and extravasate into surrounding tissues. Extrav-
asated fluid collapses the joint capsule, thereby making
visualization, as well as additional port placement, more
difficult. New
ARTHROSCOPIC TECHNIQUE
Arthroscopy is particularly useful in treating elbow dis-
orders in dogs because it allows earlier diagnosis and

149
more complete treatment and is associated with minimal
morbidity. Earlier diagnosis coupled with a more com- $
plete understanding of the pathologic changes involved
should allow veterinarians to treat elbow joints more ef- Robert E. Cartee, Editor
fectively. 400 pages, hard cover
1597 illustrations
Anatomy
The elbow, a ginglymus joint with limited rotation, is
composed of the distal humerus, proximal radius, and ■ Sonographic diagnosis in dogs and cats,
proximal ulna. The distal humerus is called the humer- including ultrasound, M-mode, pulsed
al condyle and is divided into a small lateral area called and color Doppler echography
the capitulum and a larger medial area called the
trochlea.26 Correct use of the terms can cause confusion ■ Echocardiography, abdominal and pelvic
because the humeral condyle is often referred to as hav- sonography, and fetal ultrasonography
ing separate medial and lateral condyles. The correct
terms are used in this article, with commonly used ■ Case illustrations using conventional
terms provided in parentheses. radiography, computed microfocal
tomography, specimen photography,
Medial Approach and line drawings
I use the medial approach almost exclusively because it
provides greater visualization of the most commonly af- ■ Recognition of the disease process and
fected area (i.e., the medial aspect of the joint); it also al- courses of treatment
lows easier access for treatment. A 30˚ foreoblique arthro-
scope is appropriate for most elbow arthroscopies. A
2.7-mm scope is best suited for large- to medium-sized el-
bow joints; a 2.4-mm, 30˚ foreoblique scope works well
CALL OR FAX TODAY TO ORDER
for medium-sized elbow joints; and a 1.9- or 2.0-mm, 30˚ 800-426-9119 • Fax: 800-556-3288
foreoblique scope is appropriate for small elbow joints. Price valid only in the US, Canada, Mexico, and
the Caribbean. Request international pricing.
Email: books.vls@medimedia.com
FLUID EGRESS ■ TERMINOLOGY
Small Animal/Exotics Compendium February 2000

The hair is clipped from the then connected. A needle (18- or

shoulder to the distal radius and
ulna. The dog is placed in dorsal
recumbency with a sandbag under
the elbow joint to allow abduc-
tion of the joint and to facilitate
internal rotation of the radius and
ulna. The limbs are suspended to
allow surgical preparation. The
distal limb is wrapped in an im-
pervious disposable drape and is
then wrapped with a sterile ban-
dage. An iodophor-impregnated
adhesive drape is applied over the
surgery site.
The joint is abducted, and the
radius and ulna are rotated inter- Figure 6A
nally (Figure 6). Figure 6A shows
the elbow in a neutral position,
whereas Figure 6B demonstrates
opening the medial aspect of the
joint with abduction and internal
rotation.
The joint is entered carefully
with a 20-g, 2.5-cm needle ap-
proximately 1 cm distal and 0.3
to 0.5 cm caudal to the medial
epicondyle. The needle must be
perpendicular to the long axis of
the limb. The joint is infused
with 2 to 5 ml of 2% lidocaine,
which is followed by lactated
Ringer’s solution to gently distend
the joint. Lidocaine is used be- Figure 6B
cause it has a faster onset of ac- Figure 6—(A) Humeroulnar joint space with the amount of internal rotation and
tion than does bupivacaine. 27 elbow joint in a neutral position. (B) Humero- abduction; and medial coronoid
Overzealous distention can rup- ulnar joint space with the leg abducted and the process and medial collateral liga-
ture the joint capsule. Next, a radius and ulna internally rotated. Arrows indi- ment. The egress fluid needle is
longitudinal stab incision is made cate the location of the arthroscopic portal.
through the skin and superficial
fascia with a No. 11 or 15 blade alongside the needle.
The arthroscope sleeve and conical trocar are inserted
by using a gentle twisting motion and by angling in a
very slight cranial and axial direction. I routinely use
the conical trocar to avoid damaging the joint. Damage
to the articular surface occurs easily when the sharp tro-
car is used in the elbow joint. If the sharp trocar is
used, the joint should be entered only superficially, af-
ter which the sharp trocar is replaced with the conical
trocar and the sleeve is inserted further into the joint.
The conical trocar is removed as the cannula slides
deeper into the joint, and the arthroscope is inserted.
The port for fluid ingress, light source, and camera are
20-g, 1.5- or 3.8-cm) or cannula is
used for fluid egress in the area of
the medial coronoid process. I
place the egress needle directly
over, or immediately caudal to, the
coronoid process. The needle then
functions as both a fluid egress
and as a probe. The location of
the median nerve must be noted if
the egress portal is placed cranial
to the medial coronoid process. I
place my instrument portal caudal
to the medial collateral ligament.
When fluid egress has allowed
clear visualization of the joint, sys-
tematic examination of the joint is
begun. The scope is pointed proxi-
mally and caudally until the
trochlear notch comes into view.
The tip of the scope is then moved
cranially, and the oblique face of
the scope (not the camera) is rotat-
ed to allow visualization of the dor-
sal and ventral aspects of the joint.
Structures seen in order from
caudal to cranial are as follows:
trochlear notch of the ulna, medi-
al aspect of the capitulum (“lateral
humeral condyle”); trochlea (“me-
dial humeral condyle”); lateral
coronoid process, if deep in the
joint; middle and caudal aspect of
the radial head, depending on the
used to carefully probe and define
the lesion and confirm that the
needle is in the correct location for the instrument por-
tal. If the needle cannot reach all areas of the lesion, the
needle must be relocated.
Once the proper location for the instrument portal is
located, a stab incision in the skin and superficial fascia is
made and a conical trocar and cannula or a conical trocar
alone can be placed into the joint. I generally do not leave
a cannula in the instrument portal for elbow surgery;
however, a cannula is useful in some situations. Once the
portal is established in the correct location, the trocar or
trocar and cannula used to create the portal are removed.
The hand instrument or arthroscopic shaver blade is then
placed into the joint. After treating the lesion, the cannu-

SURGICAL PREPARATION ■ LIDOCAINE ■ MEDIAN NERVE ■ TROCHLEAR NOTCH

Compendium February 2000 Small Animal/Exotics

la is placed back in the instrument areas of partial-thickness damage

portal. The joint is then thoroughly to the cartilage.
lavaged to remove all debris. Bupi-
vacaine is injected into the joint for Ulnar Osteotomy or
postoperative analgesia.28,29 Skin in- Ostectomy as
cisions are closed with staples or su- Adjunctive Treatment
tures. Ulnar osteotomy or ostectomy
is indicated in dogs in which the
Specific Treatment of Lesions articular surface of the ulna is in-
Fragmented coronoid processes congruent with the articular sur-
(Figure 7) can be removed with face of the head of the radius. Os-
grasping forceps or an endoscopic tectomy is needed in more severe
motor drive. If full-thickness dam- cases of incongruity. I also per-
age to the cartilage surrounding the form proximal ulnar osteotomy in
fragment bed has occurred, the car- Figure 7—Fragmented medial coronoid process dogs with cartilage wear lesions on
tilage can be shaved down to bleed- (arrow) in a 1.5-year-old female Labrador re- the trochlea or ulna. Osteotomy
ing subchondral bone (i.e., abrasion triever. to decrease loads on damaged ar-
chondroplasty; Figure 8) or the ticular cartilage may help reduce
damaged articular area can be frac- pain.37,38 The ulnar osteotomy or
tured in several small sites (i.e., mi- ostectomy ideally allows the medi-
crofracture). 30–33 Abrasion chon- al coronoid process to be congru-
droplasty is also performed on the ent with the head of the radius or
condyle or ulna in any area of full- slightly recessed from the articular
thickness cartilage damage. Abra- surface. This should relieve some
sion chondroplasty should be done contact on the coronoid process
carefully to remove as little sub- and trochlea.39 Dogs with a frag-
chondral bone as possible. In a re- mented medial coronoid process
cent study, arthroscopic examina- undergoing arthrotomy have
tion was done on 148 elbow joints shown improvement when ulnar
diagnosed as a source of lameness; osteotomy was performed in con-
83 of 148 (67.5%) joints examined junction with the arthrotomy.39
had cartilage wear lesions on the Decreasing the load on the area of
trochlea.23 In my experience, abra- damaged cartilage should reduce
sion chondroplasty, microfracture, Figure 8—Bed of a fragmented medial coronoid discomfort, protect early forma-
or forage (i.e., drilling holes into the process (arrow) that was removed with grasping tion of fibrocartilage, and ideally
bone) is often indicated on the me- forceps and a motorized shaver. improve the quality of the fibro-
dial aspect of the condyle as well as cartilage that forms.37 If ulnar os-
on the medial coronoid area in dogs teotomy or ostectomy is indicated
with elbow disorders requiring arthroscopy (Figure 9). bilaterally, I typically perform one osteotomy or ostecto-
Hemorrhage from the subchondral bone forms a clot that my at the time of the arthroscopy and the second proce-
becomes fibrous tissue and, over time, modulates into fi- dure approximately 6 weeks later, depending on the rate
brocartilage.30 The extent to which fibrocartilage resem- of healing. A seroma may form at the osteotomy or os-
bles hyaline cartilage varies; although it does not attain tectomy site in some dogs, but it resolves with conserva-
the biomechanical properties of normal articular tive treatment. Surgeons should be careful to differenti-
cartilage,35,36 fibrocartilage is an improvement over ex- ate between a seroma and a possible joint infection.
posed subchondral bone.35,36 Cartilage on the edges of the
defect should be cleanly resected with a curette. Osteo- Postoperative Care
chondral flaps from the medial aspect of the humeral Patients are generally discharged from the hospital
condyle can be removed with grasping forceps, and the the day after surgery with a 10-day course of low-dose
defect is debrided as described for the coronoid process. NSAIDs and a 2-day course of butorphanol (0.1 to
Partial-thickness cartilage damage may be superficial- 0.15 mg/kg orally three times a day). Dogs that have
ly shaved with a full-radius cutter to remove fibrillated had abrasion chondroplasty must be strictly rested for
cartilage. Abrasion chondroplasty is not performed on the first 2 weeks to protect the immature fibrocartilage.

FRAGMENTED CORONOID PROCESS ■ FIBROCARTILAGE ■ ABRASION CHONDROPLASTY

Small Animal/Exotics Compendium February 2000

Interested
Leash exercise can be increased
gradually over the next 8 to 10 in
weeks; this regimen gives the
fibrocartilage time to mature.
Clinical results of arthros-
writing for
copy in dogs are encouraging.
It is important to remember
COMPENDIUM?
that lesions do not heal more
rapidly or better with arthros-
copy than with arthrotomy, but
they may be treated earlier and
more completely, leading to For small animal
better results. Short-term stud-
ies have demonstrated that dogs articles, please contact
are more comfortable 24 hours
Figure 9—Abrasion chondroplasty of a kissing
after arthroscopy than after Dr. Douglass Macintire
lesion with full-thickness damage to the troch-
arthrotomy for osteochondrosis
lear cartilage. Penetration of abrasion chondro- (email macindk@
plasty is just deep enough to stimulate bleeding of the shoulder and fragmented 24
from the subchondral bone. As little subchon- coronoid process of the elbow. vetmed.auburn.edu;
dral bone as possible should be removed during Whether the clinical results of
the procedure. arthroscopy are superior to phone 334-844-6032).
those of arthrotomy needs fur-
ther study, including accurate
classification of the extent and nature of the lesions treated.

CONCLUSION
Arthroscopy is clinically useful in the diagnosis and treatment of orthope- For exotics articles,
dic disorders of the elbow joint in dogs and has many marked advantages
over conventional arthrotomy. Proficiency in arthroscopic technique and use please contact
of the proper instruments are essential for a positive outcome.
Dr. Branson Ritchie
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About the Author
Dr. Sams is Director of Specialty Veterinary Surgery—Or-
thopedic, Neurologic, Endoscopic, PC, a referral orthope-
dic and neurosurgery practice in Larkspur, California. He
is also affiliated with the Madera Pet Hospital in Corte
Madera, California, and Pets Unlimited, San Francisco,
California. He is a Diplomate of the American College of
Veterinary Surgeons.