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 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

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

Thank you