Transcript Hip Dysplasia

Dilemmas in
Canine Hip Dysplasia:
Surgery vs Rehab
Krista Halling, DVM, CCRP, Dip ACVS
Kristine 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 sensitivity
High 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
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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
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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
7
6
5
4
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2
1
0
3m
6m
12 m
18 m
Laxity
5y
OA
8 yr
10 yr
12 yr
Non-Surgical Management
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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
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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
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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
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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
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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
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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
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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
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10
Age
5
Degree of laxity
0
3 m 6 m 12 18
Clinical signs
m m
Radiographic signs
Laxity
Concurrent morbidities
Response to nonsurgical therapy
Client’s expectations
Client’s financial ability
5 y 8 yr 10 12
yr yr
OA
Thank you