OSTEOCHONDROSIS 0195-5616/98 $8.00 + .

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OSTEOCHONDRITIS DISSECANS
OF THE HUMERAL HEAD
Spencer A. Johnston, VMD

Osteochondritis dissecans (OCD) of the humeral head is frequently

identified as a cause of forelimb lameness in the dog. Surgical removal
of the cartilage flap remains the preferred method of treatment in dogs
demonstrating clinical signs of lameness and pain. This article will
review the pertinent literature regarding humeral head OCD, present
diagnostic and therapeutic options, and discuss surgical treatment of
this condition. Etiology, pathophysiology, and radiographic diagnosis of
osteochondrosis (OC) and OCD are discussed in detail in other articles
in this issue.

PATHOPHYSIOLOGY, PAIN, AND HEALING

OC is an abnormality of endochondral ossification in which the

cartilage of the epiphysis fails to form subchondral bone. This results in
thickened, abnormal cartilage which is susceptible to injury. 20 The site
most commonly affected in the canine shoulder joint is the caudal-
central or caudal-central-medial region of the humeral head. The reason
this area of the humeral head is predisposed to OC is not fully under-
stood but may be related to an increased cartilage thickness in this
region in the normal dog. 14• 43 It is believed that trauma (physiologic or
supraphysiologic) from contact between the abnormal cartilage of the
humeral head and the glenoid cavity of the scapula predisposes to
vertical fracture of articular cartilage and formation of the cartilage flap
characteristic of an OCD lesion. 14• 15• 3 3, 4 3

From the Department of Small Animal Clinical Sciences, Virginia-Maryland Regional

College of Veterinary Medicine, Virginia Tech, Blacksburg, Virginia

VETERINARY CLINICS OF NORTH AMERICA: SMALL ANIMAL PRACTICE

VOLUME 28 • NUMBER 1 • JANUARY 1998 33

34 JOHNSTON

It has been stated that pain associated with humeral head OCD
results from synovial fluid contacting subchondral bone,37, 45 because
dogs are rarely lame or show pain when thickened cartilage is present
without a cartilage flap (OC) but show pain and lameness once vertical
fracture of the articular cartilage occurs (OCD), 40 The origin of pain
associated with joint disease is a complex subject, however. Joints are
richly innervated, with nociceptors (pain receptors) present in the synov-
ium, joint capsule, tendons, ligaments, periosteum, and subchondral
bone, 3 Sensitization of nociceptors, which causes a decrease in nocicep-
tive threshold, results from the action of biochemical mediators such
as cytokines and prostaglandins which are present in diseased joints.
Nociceptor stimulation occurs due to chemical stimulation by inflamma-
tory mediators like bradykinin or from mechanical stimulation by move-
ment or direct pressure. Chemical stimulation of nociceptors also aug-
ments the responsiveness of mechanoreceptors to mechanical stimuli.
Because free nerve endings are present in subchondral bone, 22' 46 it is
possible that pain associated with OCD is due to exposure of subchon-
dral bone to inflammatory mediators present in the synovial fluid of the
affected joint An alternative theory is that synovitis, which accompanies
OCD,41 , 42 may not be severe enough to cause clinical signs of pain and
lameness until cartilage fracture occurs. Cartilage fracture and exposure
of subchondral bone may result in the release of microscopic cartilage
fragments, and free cartilage fragments are known to cause synovitis. 21
If synovitis is present, pain may be due to either chemical or mechanical
stimulation of nociceptors throughout all the tissues of the joint. Another
potential source of pain is stimulation of nociceptors in subchondral
bone due to motion between the cartilage flap and subchondral bone, or
to altered mechanical loading and altered transmission of pressure to
subchondral bone or other periarticular tissues.
When a cartilage flap dislodges or is surgically removed, there is
complete exposure of the subchondral bone to synovial fluid, yet pain
and lameness rapidly abate. This suggests that motion between the
cartilage flap and subchondral bone, or altered mechanical loading and
altered transmission of pressure to subchondral bone or other periarticu-
lar tissues, has an important role in pain production. It is also possible
that joint lavage associated with arthrotomy or arthroscopy and removal
of the cartilage flap decrease the amount of cartilage debris and inflam-
matory mediators present in the joint, thereby decreasing synovitis. Joint
lavage has been demonstrated to decrease pain in osteoarthritic joints
when used as an isolated treatment. 6' 12, 16
Healing of osteochondral defects occurs by the production of fibro-
cartilage.2 Methods to stimulate fibrocartilage production include full-
thickness curettage (removal of calcified cartilage and eburnated sub-
chondral bone) and forage (the drilling of multiple, small holes in
subchondral bone). The purpose of both techniques is to disrupt sub-
chondral blood vessels and cause bleeding, which leads to fibrin clot
formation over the exposed subchondral surface. Undifferentiated mes-
enchymal cells from the bone marrow enter the fibrin clot, differentiate
 OSTEOCHONDRITIS DISSECANS OF THE HUMERAL HEAD 35

into chondroblasts and chondrocytes, and are responsible for forming

fibrocartilage. 2 ' 35 Nevertheless, experimental evidence suggests that full-
thickness curettage and removal of subchondral bone result in biome-
chanical changes and decreased quality of reparative tissue; 17 therefore,
this procedure is not recommended. An alternative to full-thickness
curettage is superficial intracortical debridement (abrasion arthroplasty).
This technique involves abrasion of the subchondral surface just deep
enough-usually 1 to 3 mm-to cause subchondral bleeding without
disruption of the subchondral bone plate. There are conflicting results
regarding the benefit of this technique in human beings with osteoar-
thritic joints. 2 Although no studies have been performed comparing the
benefits of abrasion arthroplasty or curettage to those of forage for the
treatment of OCD lesions in dogs, studies in rabbits suggest that forage
provides better long-term results than abrasion arthroplasty, perhaps
due to an anchoring effect of the reparative tissue in the multiple, small
drill holes. 19 Irrespective of the method used, the fibrocartilage formed
does not duplicate the composition, structure, or mechanical properties
of normal articular cartilage. 2' 17 Furthermore, a relationship between the
extent and type of repair tissue present and long-term results with
respect to pain or lameness has not been established in animals or
humans. 2
Other methods for resurfacing osteochondral defects are currently
being explored. Options include the use of soft tissue grafts such as
periosteum or perichondrium, cell transplantation using chondrocytes
or undifferentiated mesenchymal cells, the use of growth factors to
stimulate cartilage repair, and the use of biologically derived or artificial
matrices to deliver growth factors and stabilize cells in the defect_Z, 17
Transplantation of articular cartilage using either autologous grafts or
allografts is also being studied. 2' 17 Although the results using these
techniques are variable and the procedures are experimental, they offer
promise that surgical intervention may some day result in restoration of
a normal articular surface.
Use of continuous passive motion has been demonstrated to stimu-
late pluripotential mesenchymal cells to differentiate into hyaline-like
articular cartilage, prevent the formation of adhesions, and increase the
final range of motion of the joint. 31 , 32 Unfortunately, reparative cartilage
formed by this or any other current treatment method does not persist
and tends to deteriorate once weight bearing is resumed. 11 ' 17 Although
the use of continuous passive motion is impractical in the dog, this work
suggests that use of the limb without transmission of large loads across
the joint (manual passive motion, swimming) may be beneficial follow-
ing surgical treatment of OCD.

INCIDENCE AND SIGNALMENT

The incidence of humeral head OCD in dogs has been reported as

0.22% for male dogs and 0.09% for female dogs presenting to veterinary
36 JOHNSTON

teaching hospitals in the United States.29 The largest study29 reports a

male:female ratio of 2.24:1, and smaller studies report ratios ranging
from 2:1 to 6:1.1, 13, 24, 27, 29, 36, 44 Humeral head OCD most frequently
occurs in large- and giant-breed dogs, although some large-breed dogs,
including the Doberman Pinscher, Collie, and Siberian Husky, are at
low risk for this condition. 29 OCD of the humeral head has been reported
in the cat-25
Onset of lameness associated with humeral head OCD generally
occurs when an animal is from 4 to 8 months of age. The median age of
onset identified from review of four studies that specifically listed the
age of lameness onset ranged between 5 and 6 months. 4 ' 13, 24, 44 The
median age recorded in other studies that reported age at presentation
for surgery ranged from 7.0 to 9.5 months. 4' 5, 13, 24, 36, 42, 44 The reason for
the difference in age between these two sets of studies could be due to
owner delay in presenting the patient to a veterinarian for diagnostic
evaluation of lameness or might relate to the recommendation given by
many veterinarians that conservative management be attempted first in
young dogs before proceeding to surgical intervention. Both of these
factors are likely to be involved. It should also be noted that review of
studies evaluating dogs with humeral head OCD indicates that approxi-
mately 17% of patients are 12 months old or older at the time of
diagnosis or surgery.4, 5, 13, 24, 29, 36, 42,44

CLINICAL SIGNS

Affected dogs present with a weight-bearing lameness of varying

severity. Lameness tends to worsen following exercise and frequently
improves after a period of rest. A shortened forelimb stride may be
noted due to reluctance to flex and extend the shoulder joint. A head
bob may be seen, where the head is raised during weight bearing on
the affected limb and lowered during weight bearing on the contralateral
forelimb. If both forelimbs are affected equally, a head bob may not be
seen; however, the stride will be shortened bilaterally, and the patient
may be reluctant to stand or move.
Physical examination will frequently reveal pain on extension and
flexion of the shoulder joint. Most normal dogs tolerate full flexion and
extension of the shoulder joint; however, dogs with humeral head OCD
typically resist these manipulations, withdraw the limb, and may vocal-
ize when the shoulder joint is flexed or extended. Manipulation of
the shoulder joint may exacerbate the lameness. Mild atrophy of the
supraspinatus, infraspinatus, and deltoideus muscles may be present
and can be recognized because of prominence of the spine of the scapula.
Joint swelling or effusion is difficult to appreciate because of the overly-
ing musculature. Direct pressure over the tendon of the biceps brachii
muscle may result in mild discomfort due to synovitis extending into
the bicipital tendon sheath. Other developmental abnormalities of the
canine forelimb such as elbow dysplasia (fragmented medial coronoid
 OSTEOCHONDRITIS DISSECANS OF THE HUMERAL HEAD 37

process, ununited anconeal process, OCD of the medial humeral con-

dyle) and panosteitis should be ruled out.

DIAGNOSIS

Diagnosis is based on signalment, history, and the results of physi-

cal and radiographic examination. The mediolateral radiographic
projection is the most useful view for making a diagnosis (Figs. 1, 2, 3,
4). The caudocranial view is useful when attempting to determine the
location of a detached cartilage flap (joint mouse) (Figs. 3 and 4) but is
rarely used to establish the initial diagnosis.
Sedation greatly facilitates radiographic positioning. Even well-be-
haved dogs will resist restraint and will move when experiencing pain,
and full extension of the forelimb-a pain-inducing manipulation for
dogs with humeral head OCD-is necessary to provide diagnostic radio-
graphs. The dog is positioned in lateral recumbency with the affected
limb down, and the head and neck are extended. Traction is placed on
the affected limb so that the shoulder is pulled cranially and ventrally
to avoid superimposition on the thorax and neck. The opposite limb is
retracted caudally to avoid superimposition of that shoulder on the

Figure 1. Mediolateral radiographic projection of the shoulder joint of a 9-month-old Mixed-

breed dog. Note the flattening of the caudal portion of the humeral head and associated
radiolucent defect of the subchondral bone (arrows). These findings are consistent with
osteochondritis dissecans of the humeral head.
38 jOHNSTON

Figure 2. Mediolateral radiographic projection of the shoulder joint of a 7-month old Irish
setter with osteochondritis dissecans of the humeral head. The caudal border of the
humeral head is irregular, and there is reduced radiodensity of the subchondral bone. A
mineralized cartilage flap (arrows) is associated with the lesion.

shoulder of interest. Routine radiographic examination of the opposite

shoulder is recommended, because humeral head OC often occurs bilat-
erally.
The diagnosis of OC or OCD is confirmed by the presence of a
radiolucent area on the caudal aspect of the humeral head (see Fig. 1).
This radiolucent area corresponds to the region of the endochondral
defect, where there is failure of cartilage to form normal bone. If the
lesion is mild, slightly oblique views may accentuate the subtle defects.
The cartilage flap of an OCD lesion is mineralized in approximately 26%
of affected joints,:w allowing it to be seen on plain radiographs (see Fig.
2). Unmineralized attached or detached flaps are not visible on plain
radiographs. Radiographic changes consistent with osteoarthritis (see
Fig. 3) such as osteophyte production, increased subchondral bone den-
sity, and glenoid cavity or humeral head remodeling are noted infre-
quently in young dogs (< 1 year) but may be present in older dogs.
Occasionally, mineralized joint mice are identified in the bicipital tendon
sheath (see Figs. 3 and 4). These dogs are typically lame and painful;
they respond dramatically to surgical removal of the joint mice.
Arthrography is valuable for detecting joint mice within the bicipital
tendon sheath (see Fig. 4) and caudal joint pouch and for identifying
cartilage status (presence of a cartilage flap or thickened cartilage with-
 OSTEOCHONDRITIS DISSECANS OF THE HUMERAL HEAD 39

Figure 3. Mediolateral radiographic projection (A) of the shoulder joint of a 3-year-old

Golden retriever. Multiple radiodense ossicles are present in the bicipital tendon sheath
(straight arrow) and the caudal joint pouch (small curved arrow). An osteophyte is present
on the caudal margin of the glenoid (curved open arrow) and the caudal aspect of the
humeral head (large curved arrow). Caudocranial radiographic projection (B) of the shoulder
joint demonstrates that there are multiple radiodensities (arrows) located on the medial
aspect of the proximal humerus. These radiodensities represent ossicles present in the
bicipital tendon sheath.

out a dissecting flap); it also allows for the evaluation of joint

effusion. 40· 41 Joint mice were identified in the bicipital tendon sheath in
approximately 10% (8 of 76) of canine shoulders in which both arthrogra-
phy and arthrotomy were performed.39 In only 12% (1 of 8) of canine
joints with joint mice present in the bicipital tendon sheath were the
joint mice identified on plain radiography. This study did not report the
clinical signs of dogs with joint mice in the bicipital tendon sheath, and
it did not include any dogs with joint mice in the bicipital tendon sheath
that did not have surgical treatment. Therefore, the consequence of
failure to remove nonmineralized joint mice in this location is unknown.
Nevertheless, it is likely that dogs with undiagnosed and unremoved
bicipital tendon sheath joint mice have a less than optimal response to
treatment even if arthrotomy, including removal of the remaining carti-
lage flap and forage of the subchondral bone bed, is performed.

UNILATERAL AND BILATERAL LESIONS

Humeral head OC or OCD may occur either unilaterally or bilater-
ally. Although affected dogs typically present with a unilateral lameness,
40 jOHNSTON

Figure 4. Mediolateral radiographic projection (A) and caudocranial (B) radiographs of the
left shoulder joint of a 2-year-old Labrador retriever. Mild irregularities in density to the
subchondral bone of the humeral head are evident and a small calcific density is noted
adjacent to the area of irregular density in the humeral head (open arrow). In addition, a
bony density is present on the medial aspect of the proximal humerus in a location that
would be compatible with an ossicle in the bicipital tendon sheath. An arthrogram (C) was
performed by injecting positive contrast agent into the shoulder joint. This contrast agent
demonstrates the ossicle noted on the plain radiographs to be located in bicipital tendon
sheath (arrows). (From Carrig CB: Diagnostic imaging of osteoarthritis. Vet Clin North Am
Small Anim Pract 27:777, 1997; with permission.)
 OSTEOCHONDRITIS DISSECANS OF THE HUMERAL HEAD 41

radiographic evaluation frequently demonstrates bilateral lesions. Bilat-

eral radiographic lesions have been reported to occur in 20% to 85% of
cases, but review of reported studies indicates that 50% of dogs pre-
senting with humeral head OCD have radiographically detectable le-
sions bilaterally. 4• 5 • 8• 13• 24• 27• 29• 36• 42 Despite the radiographic appearance of
bilateral lesions, most dogs demonstrated lameness in only one leg, with
only 21% of dogs with bilateral radiographic lesions exhibiting clinical
signs in both forelimbs. 4, 13, 27, 3o, 36, 4o, 42
The outcome of patients with radiographically identifiable lesions
in the humeral head but no clinical signs has been examined. The most
extensive work in this area has been done by van Bree. 40 In this study,
bilateral shoulder arthrography was performed on 40 dogs with radio-
graphically identified bilateral humeral head OCD lesions. A loose carti-
lage flap was identified in 37 dogs and a detached cartilage flap (joint
mouse) was identified in 3 dogs. All of these patients had clinical signs
of pain and lameness in the affected limb. Thirty-five of 40 dogs had a
radiographic lesion in the contralateral limb that was not associated with
clinical signs of pain or lameness. Further evaluation of the radiographic
change in the contralateral joint of these 35 dogs revealed that 18 joints
had evidence of thickened cartilage without a loose cartilage flap, 12
had a loose cartilage flap, and 5 had a detached cartilage flap (joint
mouse). Further surgical treatment was required within 2 to 4 months
in 6 of the 12 joints with a loose cartilage flap. No further surgical
treatment of the contralateral joint was necessary in any other dog
during a follow-up period of 1 to 7 years.
This work suggests that signs of pain and lameness are associated
with a loose cartilage flap or a detached cartilage flap. If a cartilage flap
is present without the dog showing signs of pain and lameness, there is
a 50% probability that surgical intervention will eventually be required.
If a joint mouse is present and the patient is demonstrating clinical signs,
surgical removal of the joint mouse will likely resolve the lameness. If
a joint mouse is present in the caudal joint pouch and the patient does
not exhibit clinical signs of pain and lameness, these signs are unlikely
to develop later.

SURGICAL AND CONSERVATIVE MANAGEMENT

Dogs demonstrating clinical signs associated with humeral head

OCD will recover more rapidly with surgical treatment than dogs treated
conservatively. 1• 8 The recovery period following surgery is approxi-
mately 1 to 2 months, with many dogs having clinically normal ambula-
tion by the fourth postoperative week or sooner. The recovery period
(assuming lameness resolves) following conservative treatment is ap-
proximately 7 months. 1• 8 Recovery following surgery is usually com-
plete, with 75% (30 of 40) of patients showing no lameness, 22.5% (9 of
40) showing minimal lameness, and 2.5% (1 of 40) having consistent
lameness at a mean interval of 3 years following surgery. 29
These studies support the recommendation for surgical treatment
42 JOHNSTON

in dogs presenting with clinical signs of pain and lameness and demon-
strating radiographic changes consistent with OCD. The presence of
clinical signs suggests that a vertical fracture of the articular cartilage
has occurred. Once a cartilage flap is present, it is unlikely to reattach.
The only way that clinical signs resolve (other than with surgical treat-
ment) is if the flap dislodges. This has led Olsson23 to recommend that
dogs with clinical signs of OCD be exercised vigorously so that the
cartilage flap will be dislodged. Although detachment of a cartilage flap
may lead to relief of clinical signs, cartilage fragments can migrate to
the biceps tendon sheath, or they may accelerate or perpetuate the
production of inflammatory mediators and degradative enzymes associ-
ated with osteoarthritis. This can result in continued or future lameness.
One study that included eight joints with detached cartilage flaps re-
vealed that three joints in which the joint mouse was not lodged in the
caudal pouch required surgical removal of a detached flap to relieve
pain and lameness, although five joints in which joint mice were in the
caudal joint pouch had an excellent outcome without surgical interven-
tion.40
Treatment of dogs with bilateral lesions is typically based on clinical
signs. Although dogs demonstrating mild clinical signs in the contralat-
eral limb can have a satisfactory outcome if treated conservatively, it is
the author's recommendation that all dogs demonstrating clinical signs
in an affected limb undergo surgery. Thus, if a dog has muscle atrophy,
altered gait, or pain on extension or flexion (or both) of both shoulder
joints and radiographic signs are consistent with OCD, surgical treat-
ment is recommended for both shoulders. If a question exists regarding
the severity of clinical signs or the significance of a radiographic lesion,
arthrography is recommended.
When clinical signs and radiographic lesions are present bilaterally,
the author recommends operating on both sides concurrently. All dogs
undergoing arthrotomy, especially those having concurrent bilateral
arthrotomy, require appropriate analgesia in the immediate postopera-
tive period. This includes narcotics in the form of opioid agonists such
as morphine (0.5-1.0 mg/kg administered intramuscularly or subcutane-
ously every 2-6 hours) or oxymorphone (0.05-0.2 mg/kg administered
intramuscularly or subcutaneously every 2-6 hours) or agonist/ antago-
nists such as butorphenol (0.2-1.0 mg/kg administered intravenously,
intramuscularly or subcutaneously every 1-2 hours) or buprenorphine
(0.005-0.02 mg/kg administered intramuscularly or intravenously every
4-8 hours). 9 Addition of an anxiolytic agent such as acepromazine (0.02-
0.05 mg/kg administered once intravenously, subcutaneously, or intra-
muscularly) will frequently help to smooth recovery in these patients.
Analgesics may be administered either pre- or postoperatively but defi-
nitely prior to recovery in order to provide the greatest analgesic effect.
Following recovery from anesthesia, administration of a nonsteroidal
anti-inflammatory drug such as carprofen (2.2 mg/kg administered
orally every 12 hours) or a nonsteroidal anti-inflammatory drug/narcotic
combination such as acetaminophen (300 mg) and codeine (60 mg) given
 OSTEOCHONDRITIS DISSECANS OF THE HUMERAL HEAD 43

orally at the dosage of 1 to 2 mg/kg (based on the codeine portion)

every 8 hours will help provide analgesia and facilitate ambulation
when administered for 3 to 5 days following surgery. An alternative
method of providing analgesia is the use of fentanyl transdermal
patches, with a 50-jJ-g/h patch applied to dogs weighing 10 to 20 kg, a
75-iJ-g/h patch to dogs weighing 20 to 30 kg, and a 100-1-1g/h patch to
dogs more than 30 kg. 9 These patches are applied 12 to 24 hours prior to
surgery so that adequate plasma concentrations of fentanyl are reached
preoperatively and are effective for 3 days. Fentanyl transdermal patches
provide the advantage of analgesia during recovery from anesthesia
which extends into the postoperative period, although additional analge-
sia may be required in the immediate postoperative period.
Regardless of the method of analgesia used, it is important to
recognize that analgesia should not be withheld as a means of restricting
activity postoperatively. Postoperative recovery, whether surgery is per-
formed unilaterally or bilaterally, is usually rapid, with good ambulation
returning within 1 to 2 weeks and normal or near normal ambulation
returning within 1 to 2 months.

SURGICAL APPROACH

The osteochondral defect is most frequently located in the caudal-

central or caudal-central-medial region of the humeral head. Because the
standard surgical approaches are all performed, to varying degrees, from
the lateral side, manipulation of the limb (extension, flexion, internal and
external rotation) during the procedure is necessary. Preparation and
draping of the entire limb is recommended to facilitate this manipula-
tion. Manipulation of the limb and application of countertraction by a
surgical assistant, when appropriate, will increase the ease with which
the procedure can be completed.
The three standard approaches to the canine shoulder are the crania-
lateral approach, the caudolateral approach (with variations on manipu-
lation of the teres minor muscle and tendon), and the caudal approach.
All allow adequate exposure of the caudal humeral head by an experi-
enced surgeon. Complete descriptions of these approaches are found in
surgical texts. 26• 28
The craniolateral approach has two variations: tenotomy of the
infraspinatus muscle or acromion osteotomy and tenotomy of the infra-
spinatus muscle. Acromion osteotomy is not recommended due to post-
operative morbidity. The caudolateral approach has multiple variations,
including cranial retraction of the teres minor muscle, separation be-
tween the teres minor and infraspinatus muscles with caudal retraction
of the teres minor muscle, and tenotomy of the teres minor and cranial
retraction of the infraspinatus muscle. The caudal approach involves
separation between the scapular head of the deltoideus muscle and the
lateral head of the triceps muscle.
Knowledge of regional anatomy will aid in making the skin incision
44 JOHNSTON

in the appropriate location for any of these approaches. An appropriately

placed skin incision will decrease the amount of undermining of skin
and subcutaneous tissue necessary to gain adequate exposure, thereby
decreasing the chance of postoperative seroma formation. Self-retaining
retractors such as Gelpi perineal retractors will aid in providing ade-
quate exposure. Because the exposure using the caudolateral and caudal
techniques is limited, the surgeon will frequently be working in a re-
stricted space. Adequate lighting (overhead lighting that can be focused
or use of a surgical headlamp) is a valuable aid to allow adequate
visualization of tissues.
Because exposure to the caudal-central region of the humeral head
is the limiting factor with the surgical approach, studies have been
performed comparing exposures attained with the craniolateral and
caudolateral approaches as well as with two variations of the caudolat-
eral approach. The craniolateral approach offers significantly greater
exposure of the articular surface of the humeral head as compared with
the caudolateral approach with cranial retraction of the teres minor
muscle. 18 This may be advantageous if an assistant surgeon is not avail-
able. Postoperative force plate analysis on days 21 and 28, however,
revealed that dogs undergoing the craniolateral approach had a peak
vertical force (a measure of weight bearing) that was significantly less
than that demonstrated by dogs operated on using the caudolateral
approach. 18 A decreased range of motion was also noted on postopera-
tive day 35 in dogs operated on using the craniolateral approach when
compared with dogs operated on using the caudolateral approach. 18 A
further consideration when choosing the craniolateral approach is that
access to the caudal joint pouch for removal of joint mice may be
limited. 26
Evaluation of two variations of the caudolateral approach deter-
mined that exposure to the articular surface of the humeral head was
greatest with cranial retraction of the teres minor muscle as compared
with caudal retraction of the teres minor muscle and cranial retraction
of the infraspinatus muscle. 27 Although exposure using the caudolateral
approach is less than that with the craniolateral approach, the region of
the humeral head exposed is the area most frequently affected by an
OCD lesion. Extension of the shoulder and internal rotation of the
humerus are necessary to visualize and provide access to the OCD lesion
when using a caudolateral approach. In the author's opinion, if an
assistant is present, the caudolateral approach with cranial retraction of
the teres minor muscle is the preferred approach as compared to the
craniolateral approach or the caudolateral approach with caudal retrac-
tion or tenotomy of the teres minor muscle. This approach provides
satisfactory exposure while creating minimal trauma and postoperative
morbidity.
A direct comparison between the craniolateral or caudolateral ap-
proach and the caudal approach has not been made. An advantage of
the caudal approach is that it provides greater access to the medial
portion of the joint cavity. The presence of a joint mouse in this area
would be an indication for the caudal approach. In both studies per-
 OSTEOCHONDRITIS DISSECANS OF THE HUMERAL HEAD 45

formed to evaluate the caudal approach, the authors commented that it

was necessary to have an assistant manipulate the limb while the sur-
geon performed curettage of the OCD lesion on the humeral head?· 38
Creating complete luxation of the humeral head has been described
to give maximal exposure of this structure. 10 Although superior access
to the humeral head is provided using this technique, the lesion location
with OCD of the humeral head is so specific that access to the entire
humeral head is usually not necessary. Even though this technique
seems to be excessively traumatic, the recovery time reported following
this procedure was similar to that reported for the other surgical ap-
proaches.10
If a joint mouse or joint mice are identified within the bicipital
tendon sheath, surgical removal is indicated to alleviate pain and lame-
ness. This is performed through a craniomedial approach to the shoul-
der.26 Although this approach can be completed through the skin incision
for the caudolateral approach if the skin is undermined, the extensive
undermining required will predispose to seroma formation. A separate
cranial skin incision over the region of the biceps brachii tendon helps
to avoid this complication. Many dogs with joint mice in the bicipital
tendon sheath have significant lameness which results in muscle atro-
phy. Occasionally, the joint mice are palpable within the tendon sheath
prior to surgery, making the surgical approach relatively easy. The
approach requires cranial retraction of the brachiocephalicus muscle and
partial transection of the insertions of the superficial and deep pectoral
muscles. If not palpable percutaneously prior to surgery, the joint mice
are usually palpable following this surgical exposure, and an incision
can be made directly over the joint mouse. Once the free fragments are
removed, the tendon sheath is repaired using small-diameter (3-0 or
4-0), absorbable suture material.
Arthroscopic treatment of humeral head OCD has been reported. 24·
41 · 42 Advantages of arthroscopy include a more thorough examination of
the synovium and articular cartilage (including the articular surface of
the glenoid, which is usually inaccessible with conventional arthrotomy),
decreased soft tissue trauma, decreased operative time, and rapid post-
operative recoveryY· 42 Although these advantages undoubtedly apply
in the hands of an experienced arthroscopist, the availability and cost of
equipment and training as well as the lack of significant morbidity
with surgical arthrotomy all suggest that veterinarians will perform
conventional arthrotomy in a majority of cases.

SURGICAL MANIPULATIONS

The cartilage flap usually remains attached to the surrounding

cartilage at the cranial or craniomedial extent of the lesion. This attach-
ment can usually be broken and the flap removed by placing a thin
instrument such as a Freer periosteal elevator between the subchondral
bed and cartilage flap and applying a twisting motion. Alternatively, a
46 JOHNSTON

scalpel blade or bone curette can be used to detach the flap. This is done
with caution to prevent iatrogenic damage to surrounding tissues.
Once the cartilage flap is removed, the subchondral bed should be
examined, and all cartilage not firmly attached to the subchondral bone
is removed. A Freer periosteal elevator is useful for determining cartilage
attachment. Although the bone-cartilage interface is normally quite firm
and only considerable force will cause osteochondral separation in areas
of normal tissue, probing the subchondral bed should be done with care
to avoid unnecessary damage to the articular surface. The edges of the
cartilage should be trimmed using a sharp bone curette so that they are
perpendicular to the subchondral surface. Beveled edges inhibit filling
of the defect with fibrocartilage. 30
Examination of the subchondral bed will reveal one of three presen-
tations: (1) a roughened, bleeding surface consistent with exposed sub-
chondral bone; (2) a roughened, dull white, soft surface consistent with
reparative fibrocartilage; or (3) a hard, smooth, ivory-colored surface
consistent with eburnated bone. If bleeding bone or reparative fibrocar-
tilage is present, no further treatment is necessary, as healing occurs
through the production of fibrocartilage which occurs if there is an
adequate blood supply. If an eburnated surface is present, creating
vascular access by curettage (abrasion arthroplasty) or forage will pro-
mote healing. If abrasion arthroplasty is performed, care should be taken
to minimize the subchondral bone defect created while establishing
vascular exposure.
Once the cartilage flap has been removed and subchondral bone
has been assessed and treated, the caudal joint pouch should be explored
for the presence of joint mice. The joint is flushed with saline to remove
any remaining cartilage fragments. The joint capsule is closed using 3-0
interrupted, absorbable sutures. The deltoideus fascia is apposed with
3-0 absorbable suture. The subcutaneous tissue is closed with 3-0 absorb-
able suture, with care taken to eliminate dead space by tacking down
each successive layer. Routine skin closure completes the procedure.

POSTOPERATIVE CARE

Recovery from surgery in which a muscle separation technique is

used occurs relatively quickly. Dogs will frequently walk on the oper-
ated limb immediately postoperatively or within 1 to 2 days, have little
lameness within 2 to 4 weeks, and be clinically normal by 1 to 2 months
postoperatively if not sooner. Because rapid recovery of ambulation
normally occurs, it is recommended that exercise be restricted to leash
walks for a minimum of 4 weeks postoperatively in order to decrease
stress placed on periarticular soft tissues and developing reparative
fibrocartilage.
Seroma formation is the most frequent complication of shoulder
arthrotomy. Many factors contribute to seroma formation, including the
amount of tissue undermining, hemostasis, inadequate closure of dead
 OSTEOCHONDRITIS DISSECANS OF THE HUMERAL HEAD 47

space, and patient activity. In the author's opinion, tissue undermining

and inadequate closure of dead space are the most frequent causes of
seroma formation. Failure to close the joint capsule does not contribute
to seroma formation. 34 Appropriate closure of dead space requires sutur-
ing of the deep fascia, subcutaneous tissues, and skin.
The prognosis for recovery from humeral head OCD is good. Dogs
with pre-existing degenerative changes are less likely to have an excel-
lent outcome. Information regarding the progression of osteoarthritis
in surgically treated limbs is sparse. Clinical experience suggests that
radiographic changes consistent with mild to moderate osteoarthritis are
present in many shoulder joints affected with humeral head OCD when
they are examined years after surgical treatment and that these changes
have minimal clinical significance.

CONCLUSIONS

The caudal-central region of the humeral head is a common site for

OCD. If clinical signs of pain and lameness are present along with
radiographic changes consistent with OCD, surgical treatment is recom-
mended. The caudolateral approach with cranial retraction of the teres
minor muscle provides good exposure to the cartilage flap and subchon-
dral defect and results in minimal postoperative morbidity. In dogs
with clinical and radiographic evidence of bilateral humeral head OCD,
concurrent bilateral surgery is appropriate and practical, particularly if
the caudolateral approach is used. The long-term prognosis for recovery
is good.

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Address reprint requests to

Spencer A. Johnston, VMD
Department of Small Animal Clinical Sciences
Virginia-Maryland Regional College of Veterinary Medicine
Virginia Tech
Blacksburg, VA 24061-0442