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