Bone and Joint Disease 2024 PDF

BONE AND JOINT DISEASE ALISON LIVESEY NOVEMBER 2024  LEARNING OBJECTIVES Describe bone pathology Revise bone physiology Describe the diagnostic approach to bone disease Describe a treatment plan and prognosis Describe joint disease Describe investigation, treatment and prognosis of...

BONE AND JOINT DISEASE ALISON LIVESEY NOVEMBER 2024  LEARNING OBJECTIVES Describe bone pathology Revise bone physiology Describe the diagnostic approach to bone disease Describe a treatment plan and prognosis Describe joint disease Describe investigation, treatment and prognosis of joint disease  REVISE BONE PHYSIOLOGY Osteoblast- make new bone Osteocyte- principal bone cells Osteoclast-resorption of bone Organic- type 1 Collagen & proteoglycan Flexibility Inorganic- Calcium Phosphate (Hydoxyappatite Crystals) Rigidity  C A U S E S O F B O N E PAT H O L O G Y DAMNIT-V Developmental, Degenerative Anomalous, Autoimmune Metabolic Nutritional, Neoplastic Idiopathic, Inflammatory, Infectious Toxic, Traumatic Vascular C AT E G O R I E S O F B O N E PAT H O L O G Y ▪ Congenital ▪ Chondrodysplasia-dwarfism ▪ Developmental ▪ Osteochondrosis/Hip dysplasia ▪ Angular Limb Deformities ▪ Hypertrophic Osteodystrophy ▪ Pituitary Dwarfism ▪ Metabolic Bone Disease ▪ Fibrous Osteodystrophy ▪ Hypervitaminosis A C O N G E N I TA L P R E S E N T AT B I R T H Congenital elbow luxation left side-pug  D E V E L O P M E N TA L Short Ulna Ulnar growth plate becomes damaged Radius continues to grow Leg is deviated - carpal valgus Many surgical treatments available Patellar luxation (can be congenital) Patella luxates medially or laterally Graded I-IV Both bone and joint disease  M E TA B O L I C Nutritional osteodystrophy Normally young dogs or cats on all meat diets Lameness, pain and difficulty standing Radiography shows poor mineralisation Thin cortices Often folding fractures Treatment: put on adequate diet  N U T R I T I O N A L M E TA B O L I C H Y P E RV I TA M I N O S I S A Nutritional Cats fed exclusively on liver Presentation-stiff neck Extensive vertebral exostoses on cervical spine Treatment-removal of liver from the diet Some cats do not recover  M E TA B O L I C - R E N A L H Y P E R PA R AT H Y R O I D I S M Renal hyperparathyroidism Diseased Kidney cannot excrete phosphate Parathyroid stimulation leads to bone demineralisation Bones of the skull become soft Most commonly toy breeds Treatment of underlying renal disease Prognosis may be poor ) Arq. Bras.Med Vet (2022) Zootec 74 6 10889-1095  T R A U M AT I C Fracture Periosteal Reaction-more common in juvenile Fracture treatment discussed in another lecture INFECTION-OSTEOMYLEITIS Osteomyelitis Can be caused by haematogenous spread Most commonly following fracture repair May see pain, lameness, swelling sinus tracts Treatment-may involve implant removal/replacement and antibiotics  NEOPLASIA Most commonly osteosarcoma “Around the knee” “Away from the elbow” Aggressive tumours which metastasise Main differential osteomyelitis Blastomycosis-not in the UK Primary bone tumours do not cross joints Treatment-amputation and chemotherapy Possibly limb sparing Prognosis-usually poor in dogs Metastasis less common in cats  OTHER BONE TUMOURS Fibrosarcoma-uncommon Multiple myeloma-Multiple osteolytic lesions Synovial tumours (rare) Solitary osseous plasmacytoma Metastatic tumours Multiple Myeloma NEOPLASIA VS BONE CYST Osteosarcoma-see Bone cyst-focal lesion periosteal new bone, cortical destruction  DISEASES OF UNKNOWN ORIGIN Marie’s disease or hypertrophic osteopathy Associated with a mass in the Chest Periosteal Reaction of Distal Bones Normally metacarpals and metatarsals If mass is removed then bony lesions improve Causes lameness and pain DISEASES OF UNKNOWN ORIGIN Craniomandibular osteopathy Normally West Highland White Terrier Present at 3-7 months pain and pyrexia May be unable to open jaw Supportive care-supportive care and prednisolone Gemmill, T. (2008) In Practice 30-36  DISEASES OF UNKNOWN ORIGIN Hypertrophic osteodystrophy Large breed dogs 4-6 months Also called metaphyseal osteopathy Pain at metaphysis Dogs may be unwell, pyrexic Radiographic changes around the metaphysis Causes proposed Vitamin C Deficiency, CDV Treatment-most patients recover with supportive care DISEASES OF UNKNOWN ORIGIN Panosteitis Usually affects German Shepherd Dog 5-12 months Often present unwell-pyrexic Improve with NSAIDS Return shortly after lame on another leg Radiography shows opacity inside the joint Treatment-analgesia. Most patients spontaneously improve  DIAGNOSIS OF BONE DISEASE-HISTORY Signalment - Age, sex, breed Owner Observations Lameness Duration Worsening or Improving Affect of exercise Recent trauma/ Wound DIAGNOSIS OF BONE DISEASE Clinical examination Presence of wound or laceration assess depth- bone palpable? discharge- nature Fragments of bone Fracture palpable Orthopaedic Examination Symmetry Muscular atrophy Posture Limb palpation-heat, pain, swelling Gait visual assessment-lameness Other clinical disease  LESION LOCATION AND DISTRIBUTION Monostotic Age Polystotic Age Primary Bone Older Metastasis Older Neoplasia Osteomyelitis- Any Osteomyelitis- Young Trauma/Local Haematogenous spread extension Fracture- Trauma Any Metabolic Disease Young Osteochondrosis Young Sunday, 07 November 2021 12  DIAGNOSIS OF BONE DISEASE Imaging Radiography Ultrasound CT MRI Scintigraphy Biopsy  COMPUTED TOMAGRAPHY A 3D image is generated from a large series of 2D radiographic images taken around a single axis of rotation  MAGNETIC RESONANCE IMAGING Allows better imaging of soft tissue structures Provides a less detailed examination of bony structures Useful in small animals to assess brain and spinal cord BONE BIOPSY Performed when lesions require histological characterisation or culture and sensitivity testing Provide definitive diagnosis when neoplasia is suspected determine prognosis formulate a treatment plan Osteomyelitis Culture and sensitivity help to guide treatment and antimicrobial choice Sample the centre of the lesion and transitional zone between normal and abnormal bone T R E AT M E N T A N D P R O G N O S I S Dependent on underlying disease and owner expectations  JOINT DISEASE DIARTHRODIAL JOINT-FRICTIONLESS MOVEMENT Provides frictionless pain free movement  DISEASES OF JOINTS Congenital Developmental- Hip and elbow dysplasia, OCD, patellar luxation Neoplastic (not very common) Degenerative- Osteoarthritis, cruciate ligament rupture, secondary to developmental joint disease Inflammatory infectious autoimmune  CLINICAL FINDINGS Pain Discomfort Joint swelling Reduced range of movement Crepitus Muscle atrophy Bone changes Do not forget general clinical examination-pyrexia?? Examine gait for lameness-must rule out neurological disease  C L I N I C A L E X A M I N AT I O N F I N D I N G S Osteoarthritis older animal gradual onset lameness mild to moderate to severe depending on stage of disease lameness may improve with exercise reduced ROM and bony changes may be palpable in advanced cases Septic Arthritis-any age wound near a joint acutely and severely lame +/- pyrexia Osteochondrosis- Young animal joint effusion Immune-Mediated Polyarthritis- Young Dog Multi-limb Pyrexia  D E V E L O P M E N TA L - PAT E L L A R L U X AT I O N Stifle extensor mechanism-quadriceps, patella, patellar tendon Grade I: Patella can be manually luxated but returns to normal position when released Grade II: Patella luxates with stifle flexion or manual manipulation and remains luxated until stifle extension or manual replacement Grade III: Patella luxates continually. It can be replaced but reluxates spontaneously when manual pressure is removed Grade IV: Patella luxated continually and cannot be replaced Medial patellar luxation more common-75%  DEVELOPMENTAL-OSTEOCHONROSIS DISSECANS Predilection sites in the dog Canine Joint Location Shoulder Prox. Humeral head Elbow Distomedial aspect of humeral trochlea Stifle Lateral and Medial Femoral Condyles Femoral Trochlea Hock Medial and Lateral Trochlear Ridge of Talus Frequently bilateral Sunday, 07 November 2021 34  OSTEOARTHRITIS Disease of the articular cartilage- although many components contribute to disease progression and clinical signs – subchondral bone, synovial membrane, joint capsule, ligaments Predisposing factors Ageing “wear and tear” Exercise/trauma Conformation Sepsis Secondary to developmental orthopaedic disease Repeated medication of the joint Genetics Obesity-weight/stress  Osteoarthritis- Pathophysiology 1. Inflammatory process begins in synovium, cartilage, joint capsule or subchondral bone 2. Initiates a cascade of inflammatory mediators from primary tissue of insult 3. Domino effect of inflammatory process into secondary tissues 4. These in turn release inflammatory mediators 5. Enzymatic degradation of the cartilage Sunday, 07 November 2021 36  SEPTIC ARTHRITIS Inflammatory response – Vasodilation and influx of neutrophils – Release of inflammatory cytokines/enzymes Fibrin clot traps bacteria – Protect the bacteria – Reduce synovial nutrient exchange Cartilage destruction and extension to subchondral bone Results in PAIN and swelling of the affected joint ➔Ultimately can result in degenerative osteoarthritis  INFLAMMATORY JOINT Arthritis DISEASE Degenerative Inflammatory Immune – Osteoarthritis Infectious Mediated Polyarthritis ***Bacterial, Erosive and Non- Viral, Erosive Forms Mycoplasma Sunday, 07 November 2021 38 I N F L A M M AT O RY A R T H R O PAT H Y Immune mediated joint disease-erosive or non-erosive NON EROSIVE IMMUNE BASED P O LYA R T H R I T I S Joint effusion Shifting leg lameness Neutrophils on Pyrexia cytology Can be secondary to exotic disease e.g. Leishmania  DIAGNOSIS OF JOINT DISEASE Clinical Findings Imaging Synoviocentesis Direct Visualisation- Arthroscopy Immune based-rheumatoid factor Haematology and Biochemistry  DIAGNOSIS Clinical examination findings History Observation Palpation Pain/Discomfort Joint Swelling/effusion Range of movement reduced Crepitus Muscle atrophy(disuse) Bone changes General Clinical Examination- pyrexia?? Gait visual assessment- Lameness  DIAGNOSTIC IMAGING -RADIOGRAPHY Radiographic findings Periarticular osteophytes Entheseophytes-occur on ligaments Erosion of subchondral bone surface :Subchondral sclerosis Subchondral cyst formation Reduced joint space Increased synovial mass (swelling of soft tissues) Mineralization of soft tissues  DIAGNOSIS OF JOINT DISEASE Ultrasound (not used commonly for diagnosis of joint disease in small animal practice Examination limited to peripheries of joint Assess joint effusion Cartilage lesions which are not visible on radiographs may be picked up by ultrasonography Assess wounds follow tract foreign material present? Associated soft tissue damage COMPUTED TOMAGRAPHY 3D image of Joint enables better evaluation of pathology  DIAGNOSIS OF JOINT DISEASE Synovioscentesis Normal Appearance Pale yellow/transparent, high viscosity Low in white bloods cells and total protein Abnormal appearance Serosanguinous/turbid/reduced viscosity High white blood cells and total protein >90 % Neutrophils  SYNOVIAL FLUID Dog and Cat Parameters Chapter 7, Manual of Diagnostic Cytology of the Dog and Cat, Dunn, 2018 Sunday, 07 November 2021 47  DIAGNOSIS OF JOINT DISEASE Arthroscopy Allows direct visualisation of the joint Diagnostic and therapeutic Commonly used for diagnosis and treatment of elbow disease  MANAGEMENT OF JOINT DISEASE Specific surgical options will be discussed next year Provide analgesia Control articular inflammation Limit damage to the articular cartilage Promote healing Improve quality of life S U R G I C A L M A N A G E M E N T O F C R U C I AT E DISEASE TPLO TTA Lateral Suture MANAGEMENT OF JOINT DISEASE Developmental osteochondrosis One option-conservative management Rest: Stable rest, cage rest Anti-inflammatory Analgesic Nutrition Reduction of body weight Reduction of energy in diet **Correct Ca:P ratio in diet Prognosis-dependent on severity. Early intervention improves prognosis MANAGEMENT OF JOINT DISEASE Surgical management of osteochondrosis Surgical or arthroscopic removal of cartilage flap Prognosis depends on severity of the lesion and secondary degenerative joint disease  MANAGEMENT OF JOINT DISEASE Management of osteoarthritis Physical Therapy Acute: rest, cold therapy, early mobilisation Chronic: Gentle exercise, hydrotherapy Anti-inflammatory/Analgesia Non-Steroidal Anti-Inflammatory Drugs(NSAIDs) Most commonly used treatment Concerns with toxicity- gastrointestinal, renal Many different forms available *must use COX 2 selective NSAID in small animals Meloxicam Librela (dogs) Solensia(Cat)-Monoclonal antibody therapy Surgery-Arthrodesis (only appropriate for certain joints) Joint replacement- primarily hip joint Adjunctive treatments-pentosan polysulphate (Cartrophen)  T R E AT M E N T O F J O I N T D I S E A S E Manage of septic arthritis Joint lavage Remove bacteria/debris, inflammatory mediators Take sample of joint capsule for culture and sensitivity  M A N A G E M E N T O F I M M U N E M E D I AT E D JOINT DISEASE Immune mediated joint disease Analgesia Identification and treatment of underlying disease Immunosuppressive therapy-glucocorticoids Prognosis guarded Relapse common QUESTIONS? ?