Hip dysplasia, bilateral
HISTORY AND VISIT SUMMARY:
Klaus, a 1 year old male in tact German Shepherd, presented to Cornell’s Orthopedic Service for evaluation of previously diagnosed hip dysplasia. Klaus was diagnosed in October of 2010, at which time radiographs were taken. His radiographs at the time revealed evidence of subluxation of both joints, with the right worse than the left. He was prescribed Tramadol and started on neutraceuticals (Duralactin, NuVetPlus, Dasuquin and fish oil). He has been given Tramadol on an as needed basis; this was only given twice, the last dose in December. His exercise level was decreased and hydrotherapy was performed for one month (Nov-Dec 2010).
On January 19, he presented to a board-certified surgeon to be evaluated for surgery. He showed decreased range of motion and pain on flexion and extension of both hip joints and positive Ortolani signs on both sides. Blood work and urinalysis were normal and a total hip replacement was recommended once he was fully grown and mature. He was sent home and has continued physical rehabilitation and has been kept restricted in his activity. He has been otherwise doing well at home and is up to date on vaccines. He is not presently on any medications apart from heartworm and flea and tick preventative.
On presentation, Klaus was bright, alert and responsive (BAR) and his vital parameters were within normal limits. His physical examination and basic neurologic exam were also normal. On orthopedic exam, Klaus had a grade 2/5 (consistent but weightbearing) on both of his hindlimbs, with the right worse than the left. He was painful on palpation of the lumbosacral area of his spine; this is likely related to his hip pain. There was some soft tissue popping in his hock joints bilaterally, but no pain was elicited. His hips had decreased range of motion and pain on extension bilaterally. The remainder of the exam was normal.
The options for surgical correction of Klaus’s hip dysplasia were discussed with the owners, who elected to take him home and discuss their options.
Hip Dysplasia is an inherited condition, passed down through generations. Unfortunately there is not a cure for this disease and with time, this condition can worsen. Our goal in treating animals with hip dysplasia is to take as much stress as we can off the abnormal joint and to keep them as comfortable as possible. Medical management can sometimes be the only management needed for animals with hip dysplasia. The treatment of hip dysplasia is multifaceted: reduce pain and discomfort, decrease clinical signs, slow the progression of the disease, promote the repair of damaged tissue, and improve the quality of life. The main components of medical management are weight loss, modified exercise, and medications such as NSAIDs (ex. Metacam, Rimadyl) and nutraceuticals (chondroprotectants; ex. Glucosamine, Chondroitin). It has been shown that dogs that are kept on the thin side or just slightly underweight do better and feel better long term. Activities like walking on grass and swimming can be great exercise. However full out running and walking on concrete surfaces can be hard on joints and are discouraged. Klaus has been appropriately medically managed since his diagnosis in October. Due to the severity of his condition and the goal of getting him back to some atheltic function, surgical correction is recommended. Surgical options include:
1. Femoral Head and Neck Ostectomy: This is a procedure where the part of the femur that articulates with the hip is cut off and removed. This removes the source of the pain from his hip joint. He will not have a completely normal gait, as one leg will be slightly shorter than the other, but it will be better than his current gait and much less painful. The muscles around the free end of the femur will contract around it and scar tissue will form to act like a false-joint. The range of motion in the hip following this repair is not as great as with a total hip replacement and how well they do following surgery greatly depends on the quality of post-operative physical therapy. This procedure will require committment to building up Klaus’s musculature and allowing him to adapt to the new positioning of his “false joint.” He should be able to return to some level of athletic function without pain; however, given his size and the nature
of the procedure, it will not return him to as normal function as would a total hip replacement.
2. Total Hip Replacement: This procedure involves removing the head of the femur and replacing it with an implant that mimics a normal femoral head with an attached stem. The socket portion of the joint in the pelvis is also replaced to fit with the new acetabular implant. This will ideally give Klaus a pain-free hip with more normal function. The outcome for this surgery is less dependent on intense physical therapy, as most dogs do well very shortly after surgery however strict post operative care is essential for a postive outcome. Complications of a total hip replacement include infection, hemorrhage, nerve damage and implant failure. Please note that hip implants do have a finite, unpredictable lifespan (typically estimated to be 10-15 years). An additional complication of THR is femoral fracture, and this risk is increased in German Shepherds because their femurs are thin compared to other breeds.
For either of these procedures, the right hip would be fixed first and it may become necessary to fix the left. If an FHO is performed, it will not be possible to go back and place a total hip replacement. Conversely, however, if a THR becomes infected, an FHO would be the final result. Increased loading and stress on the left hip following surgical correction of the right will occur with either surgery; however, it may be decreased with the THR. Post-operative management will be a commitment with either surgery. Following THR, Klaus should be kept on STRICT exercise restriction, on a leash at all times and crated if necessary. NO jumping or running should be allowed. Following FHO, Klaus should begin to use his hip early to promote scar tissue formation for the “false joint”, and this will require several months of physical therapy. Either procedure carries a risk of infection; however, this risk is increased when implants are used.
A Complete Blood Count, Chemistry panel and urinalysis should be performed to rule out any infection before surgery is performed. This and pre-operative radiographs may be done about a week before surgery. Either of the surgical options would help to make Klaus more comfortable. If have any more questions before making your decision, please do not hesitate to call. In the meantime, please continue to medically manage Klaus. He is at a perfect weight right now and his exercise should continue to be controlled. The neutraceuticals he is presently on may be continued. If he appears more painful than usual or becomes acutely worse, please call the hospital right away.
Thank you for bringing Klaus to Cornell University’s Hospital for Animals. If you have any other questions regarding his treatment options, do not hesitate to call Dr. Knapp-Hoch at (607)-253-3060.