Dilemmas in Canine Hip Dysplasia: Surgery vs Rehab Krista Halling, DVM, CCRP, Dip ACVS Kristine Lee,...
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Transcript of Dilemmas in Canine Hip Dysplasia: Surgery vs Rehab Krista Halling, DVM, CCRP, Dip ACVS Kristine Lee,...
Dilemmas in Canine Hip Dysplasia:
Surgery vs Rehab
Krista Halling, DVM, CCRP, Dip ACVSKristine Lee, PT, CCRT
Hip Dysplasia
• Most common orthopedic condition in dogs
• Multifactorial • Hip joint laxity
Canine Hip Joint
• Normal at birth• Dysplastic changes as
early as 30 d• Lengthening of round
ligament • Subluxation• Osteoarthritis
Hip Dysplasia
• Coxofemoral laxity is the key ingredient
Diagnosis• Extended hip
radiographic view
Low sensitivityHigh specificity at 6 mo
Diagnosis
• OFA• Static image during
extension• Congruency and 2ary
changes• Normal, Borderline,
Dysplastic (mild, mod, severe)
• > 2 yrs old
Diagnosis
• PennHIP• Distraction in neutral
position
Diagnosis
• Distraction Index• Correlates with OA (primary risk
factor)• > 16 wks old
Diagnosis: Ortolani Sign
Disease Progression• Linear progression of disease• Biphasic presentation
Puppy Phase
• Subluxation• Tearing of joint
capsule• Stretching of round
ligament• Microfractures of
acetabulum• Muscle strain
Puppy Phase
• 5 to 12 mth old• Sudden onset hind limb lameness• Bunny hopping• Swaying hind end gait• Reluctance to rise, ambulate, do
stairs
Puppy Phase
Puppy Phase: Resolution
• 12 to 18 mth old• Fibrosis of joint capsule• Healing of microfractures and
thickening of acetabular rim• Decrease or resolution of clinical
signs
Adult Phase
• Mature (> 2 yrs old)
• Progression of OA over time
• Laxity may persist• Acute, subacute,
chronic signs
Adult Phase
• Difficulty rising• Reluctance to walk, do stairs• Uni- or bilateral lameness• +/- Ortolani sign• Ddx torn CCL
Adult Phase
Adult Phase
Management of Hip Dysplasia
Treat the patient, not the radiographs
Management of Hip Dysplasia
Treat the patient, not the radiographs
Disease Progression
3 m 6 m 12 m 18 m 5 y 8 yr 10 yr 12 yr0
1
2
3
4
5
6
7
Laxity OA
Non-Surgical Management
• Goal in puppies: control pain d/t laxity
• Goal in adults: control pain d/t OA• Pharmaceuticals• Mesenchymal stem cell therapy• Body weight• Rehabilitation (“Prehab”)
Pharmaceuticals
• Symptom-modifying:• Decrease inflammation of synovial
lining and fluid, mitigate stimulation of pain pathways
• NSAIDs: 2 to 4 weeks• Analgesics: gabapentin or
tramadol for 7 to 14 days
Pharmaceuticalss
• Structure-modifying:• Protect cartilage matrix and
chondrocytes from degredation• PS GAGs • Essential Fatty Acids • Chondroitin sulfate, glucosamines
Non-Surgical Management
• Goal in puppies: control pain d/t laxity
• Goal in adults: control pain d/t OA• Pharmaceuticals• Mesenchymal stem cell therapy• Body weight• Rehabilitation (“Prehab”)
Rehabilitation for Hip Dysplasia
• Physical treatments, preventative therapies and rehab can play a large role in the management of the canine HD patient
Therapeutic Goal
• To create the best possible musculoskeletal environment for pain free hip function and to slow the process of DJD
Approach
• Exercise• Manual therapy• Weight management• Modalities• Education and home
exercise/maintenance program
What does the human literature say?
• Well functioning gluteal muscles are needed for walking ability, gait symmetry and prevention of OA
What does the human literature say? (cont’d)
• Exercise program should be designed to strengthen gluteals and associated hip musculature
Strengthening Exercises
• Gross motor strengthening -Leash walking in “Figure 8” pattern-Underwater treadmill walking-Sit-to-stand exercise-Incline/hill walking-Destination jumping
Strengthening Exercises (cont’d)
• Fine motor control/muscle timing - 3 legged standing- Diagonal leg standing- Exercises can be done in conjunction
with Neuromuscular Electrical stimulation (NMES) on the gluteals of the weight bearing leg to facilitate a better contraction
Strengthening Exercises (cont’d)
• Balance, coordination and body awareness exercises• Walking across raised plank of
wood/beam• Wobble board• Mini trampoline with perturbations• Backwards walking• Obstacles/weaves
Manual Therapy (cont’d)
• Joint compressions/approximations– Stimulates joint proprioceptive fibres
and activates postural reflexes– Coxofemoral compressions applied
dorsally through the shaft of the femur or medially through the greater trochanter and neck of the femur
Manual Therapy (cont’d)
• Massage and soft tissue release of affected musculature
• Manual therapy management of associated lumbar, sacroiliac and neurodynamic structures
Weight control
• Conservative treatment does not “cure” hip dysplasia so development of osteoarthritis (OA) may still occur
• Weight management is important in decreasing weight bearing stresses on joints and supporting tissues
• Research indicates that obese puppies with hip dysplasia had more resultant DJD than those whose weight was well managed
Modalities
• Neuromuscular electrical stimulation (NMES)
• Transcutaneous electrical nerve stimulation (TENS)
• Laser• Heat
Evidence?
• A long term study followed 68 dogs diagnosed with clinical HD that were managed conservatively for 10 years – 76% of the animals were evaluated at
the end of the study• 63% had no discomfort with forced hip
extension;• 79% had normal ROM; and • 72% had normal exercise tolerance
Summary
• A conservative approach to the treatment of canine HD should include exercise, manual therapy, weight management and physical modalities
• Further investigation is needed on the rehabilitation or physical therapeutic management of dysplastic dogs
Surgical Options
• Prophylactic: mitigate laxity before onset of OA
• Salvage: mitigate end-stage pain from OA
Surgical Options: Prophylactic
• Juvenile Pubic Symphysiodesis• 12 to 16 weeks old• Mild to mod laxity only• Rotation of acetabulum • Decreases distraction index
Surgical Options: Prophylactic
• Triple Pelvic Osteotomy• < 10 mths old• Free of OA
Surgical Options: Salvage
• Total Hip Replacement• Skeletally mature• Medium to large breed• Lifetime risk of complications
Surgical Options: Salvage
• Femoral Head Ostectomy• Any age• Any breed• Rehabilitation is crucial
Decision Making
• Age• Degree of laxity• Clinical signs• Radiographic signs• Concurrent morbidities• Response to nonsurgical therapy• Client’s expectations• Client’s financial ability
3 m6 m 12 m
18 m
5 y 8 yr
10 yr
12 yr
0
4
8
Laxity OA
Thank you