dilemmas in canine hip dysplasia: surgery vs rehab krista halling, dvm, ccrp, dip acvs kristine lee,...
TRANSCRIPT
![Page 1: Dilemmas in Canine Hip Dysplasia: Surgery vs Rehab Krista Halling, DVM, CCRP, Dip ACVS Kristine Lee, PT, CCRT](https://reader033.vdocuments.site/reader033/viewer/2022051401/5697bfa81a28abf838c99780/html5/thumbnails/1.jpg)
Dilemmas in Canine Hip Dysplasia:
Surgery vs Rehab
Krista Halling, DVM, CCRP, Dip ACVSKristine Lee, PT, CCRT
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Hip Dysplasia
• Most common orthopedic condition in dogs
• Multifactorial • Hip joint laxity
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Canine Hip Joint
• Normal at birth• Dysplastic changes as
early as 30 d• Lengthening of round
ligament • Subluxation• Osteoarthritis
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Hip Dysplasia
• Coxofemoral laxity is the key ingredient
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Diagnosis• Extended hip
radiographic view
Low sensitivityHigh specificity at 6 mo
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Diagnosis
• OFA• Static image during
extension• Congruency and 2ary
changes• Normal, Borderline,
Dysplastic (mild, mod, severe)
• > 2 yrs old
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Diagnosis
• PennHIP• Distraction in neutral
position
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Diagnosis
• Distraction Index• Correlates with OA (primary risk
factor)• > 16 wks old
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Diagnosis: Ortolani Sign
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Disease Progression• Linear progression of disease• Biphasic presentation
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Puppy Phase
• Subluxation• Tearing of joint
capsule• Stretching of round
ligament• Microfractures of
acetabulum• Muscle strain
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Puppy Phase
• 5 to 12 mth old• Sudden onset hind limb lameness• Bunny hopping• Swaying hind end gait• Reluctance to rise, ambulate, do
stairs
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Puppy Phase
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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
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Adult Phase
• Mature (> 2 yrs old)
• Progression of OA over time
• Laxity may persist• Acute, subacute,
chronic signs
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Adult Phase
• Difficulty rising• Reluctance to walk, do stairs• Uni- or bilateral lameness• +/- Ortolani sign• Ddx torn CCL
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Adult Phase
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Adult Phase
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Management of Hip Dysplasia
Treat the patient, not the radiographs
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Management of Hip Dysplasia
Treat the patient, not the radiographs
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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
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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”)
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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
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Pharmaceuticalss
• Structure-modifying:• Protect cartilage matrix and
chondrocytes from degredation• PS GAGs • Essential Fatty Acids • Chondroitin sulfate, glucosamines
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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”)
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Rehabilitation for Hip Dysplasia
• Physical treatments, preventative therapies and rehab can play a large role in the management of the canine HD patient
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Therapeutic Goal
• To create the best possible musculoskeletal environment for pain free hip function and to slow the process of DJD
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Approach
• Exercise• Manual therapy• Weight management• Modalities• Education and home
exercise/maintenance program
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What does the human literature say?
• Well functioning gluteal muscles are needed for walking ability, gait symmetry and prevention of OA
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What does the human literature say? (cont’d)
• Exercise program should be designed to strengthen gluteals and associated hip musculature
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Strengthening Exercises
• Gross motor strengthening -Leash walking in “Figure 8” pattern-Underwater treadmill walking-Sit-to-stand exercise-Incline/hill walking-Destination jumping
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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
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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
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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
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Manual Therapy (cont’d)
• Massage and soft tissue release of affected musculature
• Manual therapy management of associated lumbar, sacroiliac and neurodynamic structures
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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
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Modalities
• Neuromuscular electrical stimulation (NMES)
• Transcutaneous electrical nerve stimulation (TENS)
• Laser• Heat
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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
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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
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Surgical Options
• Prophylactic: mitigate laxity before onset of OA
• Salvage: mitigate end-stage pain from OA
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Surgical Options: Prophylactic
• Juvenile Pubic Symphysiodesis• 12 to 16 weeks old• Mild to mod laxity only• Rotation of acetabulum • Decreases distraction index
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Surgical Options: Prophylactic
• Triple Pelvic Osteotomy• < 10 mths old• Free of OA
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Surgical Options: Salvage
• Total Hip Replacement• Skeletally mature• Medium to large breed• Lifetime risk of complications
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Surgical Options: Salvage
• Femoral Head Ostectomy• Any age• Any breed• Rehabilitation is crucial
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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
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Thank you