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An Urban Experience
disease only without affectation of the opposing medial surface of the humeral condyle would be grouped separately to those with coronoid and humeral lesions
of varying degrees. Dogs affected by coronoid disease without affectation of the humeral condyle can be sub- grouped into those affected by  ssuring or fragmentation of the radial incisure regions or  ssuring or fragmentation of the tip regions of the medial coronoid process.
Therefore, comparing medical management, FR, SCO
or various modifying osteotomies may be profoundly  awed since many affected elbows are not ostensibly fragmented, since the pattern of disease is different in individual clinical cases and since studies purporting to compare modalities have not clearly documented the category of disease treated in patient cohorts. If we address only the question, ‘how should we treat dogs with FCP’, that would intrinsically preclude about 40%
of all elbows affected by coronoid disease which are not actually fragmented for example. At present the choice of medical or surgical management, the application of oral and intra-articular medications or physiotherapy
and the choice of various surgical procedures remain largely subjective. There is considerable variability due
to surgeon experience and bias, owner experience and bias,  nances and many patient factors. How do we know if conservative or surgical management works if we do not  rst classify the disease process for an individual at that speci c moment in time and track it throughout life with equally robust interrogation?
Both dog owners and dog breeders are given disparate advice from different sources, and whilst one individual may for example treat all juvenile DED medically because of perceived poor outcomes from FR or SCO, or the perception that surgical intervention may actually worsen the condition, there has been little acknowledgment of responsibility of the veterinary profession for the  aws inherent to such bias, since no two elbows are absolutely identical. Furthermore, even when elbows of individual dogs can broadly be categorised as similar – for example a radial incisure deep  ssure with modi ed Outerbridge Grade 1 cartilage disease of the medial aspect of the coronoid process, but no visible humeral pathology,
two different surgeons may treat this same condition differently. The same is true of late stage disease where the spectrum of options offered varies widely, where bias is a prominent feature of choices offered and where outcomes measures are lacking. The same client may be offered for the same dog by different clinicians oral medication only, or steroid injection only, or stem cell / platelet rich plasma injections only or physio modalities only or an osteotomy only, or medial compartment replacement only or total elbow replacement only or
any combination thereof for severe end-stage medial compartment disease.
There is a distinct paucity of documented case series
comparing techniques and in no publication to date have groups of elbows been scored using CT and arthroscopy and then directly compared prospectively using different surgical or medical management protocols. Additionally, it can be dif cult to ask the families of conservatively managed dogs to allow diagnostic arthroscopy and
yet if the pathology is not graded appropriately, it may be signi cantly misleading to compare the treatment groups. This is even more apparent when comparing elbows which can broadly be categorised as end stage MComD, where evidence is lacking for relative ef cacy of procedures such as PAUL, SHO, CUE or another technique which may be chosen based on intrinsic bias,  nances or available implants.
Paucity of evidence for or against any particular surgical technique is compounded by lack of validated comparable outcomes measures. It is well documented that owner and veterinary assessment scales are  awed, but in clinical practice with signi cant case numbers, often that’s the best that can be achieved and it is superior to subjective clinical opinion of a single individual. Clearly kinetic and kinematic data
are superior to both, but ideally clinician assessment, owner assessment and force plate or motion capture assessment measures should be combined to optimise outcome measure accuracy.
The families of dogs expect results when they sustain  nancial outlay with the objective of reducing or removing pain and lameness with either conservative or surgical management. We need to elucidate by rigorous evidence based medicine whether help or harm is being imbued by either managing developmental disease conservatively or surgically. It may be possible to harm a dog with surgery or to harm a dog by not intervening in a timely fashion. Conservative management does not work for
all dogs and neither does surgery. The real question is how we advise the family of one speci c dog and what is the evidence to justify any approach – medicine, rehab, arthroscopic debridement or another more involved surgical procedure.
All attempts at establishing an algorithm for treatment of the various manifestations of DED, including that presented here, are intrinsically  awed by lack of an evidence-base on which decisions can be made. As a result, this presentation will be offered as subjective clinical opinion based on arthroscopic evaluation of in excess of 3000 dogs affected by DED, in conjunction with available evidence to date for each technique
in each individual circumstance. The limitations are acknowledged, i.e. that the scoring system and the judgments deriving thereof are subject to a constant process of re-evaluation and evolution as more evidence becomes available.
The objectives of this presentation are to enable appropriate clinical examination and judicious

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