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Small animal surgery I > Hips > Flashcards

Hips Flashcards

1
Q

What is the definition of hip dysplasia?

A

Abnormal development of the coxofemoral joint resulting in hip laxity

  • Laxity results in remodeling
  • Remodeling leads to degeneration
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2
Q

What are the nongenetic factors that contribute to the expression of hip dysplasia?

A
  • Pelvic muscle mass
    • Between breeds–greyhound vs. GSD
    • Within breed
  • Body weight
    • Rapid weight gain predisposes to disease
    • Overweight dogs develop OA earlier
  • Nutrition
    • Dietary Ca/vitamin D
      • Restrict
    • Energy: restrict
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3
Q

What is the typical presenting signalment of hip dysplasia?

A
  • Large breed dogs
  • Equal sex distribution
  • Classic biphasic presentation
    • Young dogs
      • 5-12mo
      • Laxity
    • Mature dogs
      • Highly variable onset/severity
      • Chronic/recurrent signs
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4
Q

What are the PE findings associated with hip dysplasia?

A
  • Stance
    • Rear base-wide (compensatory)
      *
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5
Q

What is the typical history of a patient with hip dysplasia?

A
  • Exercise intolerance
  • Bunny hopping gait
  • Difficulty rising/stiff after rest
    *
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6
Q

What is found on palpation of a patient with hip dysplasia?

A
  • Pain on extension
  • Young patient
    • Palpable laxity–subluxate femoral head
    • Ortolani test or Ortolani “sign”
  • Mature patient/chronic disease
    • Decreased ROM in extension
    • Crepitus
    • No palpable laxity due to remodeling
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7
Q

What is the Ortolani test?

A
  • Requires sedation
  • Dorsal or lateral recumbency
  • Hand position: stifle, dorsal to pelvis
  • Push stifle proximally to subluxate
  • Slowly abduct stifle
  • Palpable/audible “clunk” = positive test
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8
Q

Why is the Ortolani only done in immature patients?

A

It is negative in older patients due to remodeling

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9
Q

Which radiographic view is considered diagnostic for hip dysplasia?

A

VD view of pelvis

Hip extended view

Internal rotation of distal limbs

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10
Q

What do you look for when evaluating radiographs for hip dysplasia?

A
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11
Q

What is Morgan’s line?

A
  • Well-defined linear density between the femoral head and the greater trochanter
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12
Q

What is the puppy line?

A
  • Indistinct density
  • Similar location to Morgan’s line
  • Clinically insignificant
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13
Q

What are the typical radiographic findings of hip dysplasia?

A
  • Early
    • Caudal curvilinear osteophyte (Morgan’s line)
    • Puppy line–self-limiting, not significant
  • Subluxation prior to remodeling
    • Increased joint space
    • Poor acetabular coverage: >/= 50% is normal
  • Femoral neck: coxa valga, thickening
  • Femoral head: flattening, sclerosis
  • Osteophytosis, DJD
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14
Q

T/F: Hip dysplasia can be expressed very differently among litter mates

A

TRUE

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15
Q

What are the 2 most common methods for hip dysplasia screening?

A

Orthopedic foundation for animals (OFA)

PennHIP

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16
Q

Describe the OFA hip dysplasia evaluation

A
  • Single VD pelvis view
  • Hips extended
  • Stifles internally rotated
  • 7-point ordinal scale, excellent to severe
  • Cannot certify hips before 2yrs old
  • Compliance questionable in NA
  • Positioning underestimates subluxation
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17
Q

Describe the PennHIP evaluation for hip dysplasia

A
  • Distraction applied under ax
  • Measure distance of the femoral head center to acetabulum center
  • DI = distance : radius of femoral head
  • Lower DI = less laxity
    • DI < 0.3 is ideal
  • Does not change after 16wks​
  • Estimate of risk for OA only, not clinical signs
  • Estimate of risk is breed-specific
  • Probability of OA
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18
Q

T/F: When treating hip dysplasia you should treat the radiographs, regardless of clinical signs

A

FALSE

Treat the dog, not the radiographs

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19
Q

What are treatment decisions for hip dysplasia based on?

A
  • Owner compliance
  • State of disease (OA present already
  • Age of dog
  • Responsiveness to treatment (if medical management tried first)
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20
Q

What are the various options for medical management of hip dysplasia?

A
  • Similar to arthritis
  • Nutrition management
    • Lower Ca/vitD/energy in puppies
    • Wt. management in adults
  • Exercise modulation
  • Physical therapy
  • NSAID
  • Wt. management most important
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21
Q

What is the difference between corrective and salvage procedures in the treatment of hip dysplasia?

A
  • Corrective
    • Take advantage of skeletal immaturity
    • Juvenile pubic symphiodesis (JPS)
    • Triple pelvic osteotomy (TPO, DPO)
  • Salvage–preserve function
    • Generally reserved for when medical tx fails
    • Femoral head ostectomy (FHO)
    • Total hip replacement (THR)
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22
Q

Describe JPS and when it should be used

A
  • Fuse pubic symphysis with cautery
  • “Tethers” growth of pelvis
  • “Rolls” acetabulum ventrally (ventroversion)
  • Only useful < 20wks of age
    • Assess risk: PennHIP at 16wks
    • If patient is at risk, consider JPS
  • Relatively noninvasive
  • Low complication rate
23
Q

What does a TPO do? What are the indications?

A
  • Improve femoral head coverage
  • Rotate acetabulum dorsally
  • Indications
    • Clinical signs of hip dysplasia
    • Ortolani test–distinct “clunk”
    • Angle of reduction < 30degrees
    • No radiographic evidence of DJD
    • 6-8mo of age (approximately)
24
Q

Describe a TPO

A
  • Osteotomy of pubis, ischium, ilium
  • Fixation of ilium with angled plate
  • Rolls acetabulum dorsally
  • Allows “capture” of hip
  • Repositioning of acetabulum makes THR challenging
25
What is the prognosis for corrective procedures for hip dysplasia?
* Less effective for severe laxity (high DI) *
26
What is done in a THR? What are the indications?
* Total hip replacement * Degenerative joint replaced with prosthesis * Femoral stem * Acetabular cup * Timing depends on multiple factors * Generally delayed as long as possible * Skeletal maturity--adequate bone stock * Success closely related to surgeon experience * Ideal for treatment of large, active dogs * Micro implants available for smaller dogs
27
What is the difference between cemented and cementless THR systems?
* Cemented--sealed in PMMA * Cementless * Components coated (hydroxyapatite) * Stability depends on bony ingrowth into implants
28
What is an FHO? When is it indicated?
* Femoral head ostectomy * Femoral head and neck excision arthroplasty (FHNEA) * Ideally done after skeletal maturity (\> 9mo) * Conformation of femur, tibia * Stifle abnormalities * Remove entire head and neck of femur * Osteotome, oscillating (sagittal) saw
29
How does FHO work and what is the recommended post-op care?
* Pseudarthrosis * Muscles and tendons provide support * Immediate postop limb use **essential** * ROM and PT exercises encouraged
30
What is the prognosis for salvage procedures in hip dysplasia?
* THR--$$$$$ * \> 90% success * Near-normal to normal function * Complications can be catastrophic * FHO--$$ * Long, steady recovery * Smaller patients: virtually normal function * Larger patients: improved comfort/function
31
What is the common etiology of coxofemoral luxation?
* Trauma * Associated with thoracic injury * Associated with other fractures * **Treat life-threatening injuries FIRST**
32
What is the difference between craniodorsal and caudoventral luxation?
* Craniodorsal * Most common (\> 90%) * Pull of gluteal muscles * Greater trochanter displaced dorsally * Caudoventral * Falls or "splits"--excessive abduction of limb * Femoral head traped ventral to ischium
33
What are the PE findings of a patient with caudoventral coxofemoral luxation?
* Non-wt. bearing * Greater trochanter recessed/difficult to palpate * Leg is held abducted and flexed * Stifle internally rotated * Affected limb longer
34
What are the PE findings in a dog with craniodorsal coxofemoral luxation?
* Affected leg held in relaxed extension * Foot beneath body, stifle externally rotated * Affected leg shorter * Loss of normal triangular relationship * Pain/crepitus on manipulation/extension
35
How is hip luxation diagnosed?
* Radiographs * Rule-out fractures * Straight line
36
When is closed reduction of hip displacement not indicated?
Dysplastic hip Fracture--pelvis or femur
37
What maneuvers are required following closed reduction of a hip displacement?
* Put joint through ROM to clear debris * Test stability--if unstable--\>open reduction * Ehmer sling 4-14 days * Rads * Confirm reduction * Confirm reduction following Ehmer placement * Confirm reduction prior to removing Ehmer * If reluxated at any point--\>open reduction
38
What coaptation methods are used in craniodorsal luxation vs. caudoventral luxation?
* Craniodorsal * Ehmer sling * Abduction * Internal rotation * Pushes femoral head away from damaged craniodorsal joint capsule * Caudoventral * Hobbles
39
What are the indications for open reduction of the coxofemoral joint?
* Pelvic/acetabular fracture * Femoral fractures * Unstable closed reduction * Recurrent closed reduction
40
What are the objecties for open reduction of the coxofemoral joint?
Reconstruct joint capsule and adjacent soft tissues to hold hip in reductino -OR- Maintain reduction temporarily with implant until soft tissues heal (Several procedures often used in combination)
41
What are the 3 most commonly used procedures for correcting coxofemoral luxation?
* Capsulorrhaphy * Prosthetic capsule * Toggle pin
42
Explain the capsulorrhaphy procedure for treatment of coxofemoral luxation
* Closing the joint capsule torn by trauma * Heavy gauge suture * May not be possible in severe cases * Usually unsufficient as sole repair
43
What is the prosthetic capsule procedure in the treatment of coxofemoral luxation?
* Drill hole transversely across femoral neck * Bone screws and washers placed in dorsal acetabulum * Nonabsorbable, large-diameter suture * Through femoral bone tunnel * Around screws in figure 8 pattern
44
Explain the toggle pin/rod procedure in the treatment of coxofemoral luxation
* Prosthetic capital ligament * "Toggle" = non-absorbable, large-diameter suture attached to pin or wire * Toggle placed through medial acetabulum * Suture material through femoral neck * Secured on lateral aspect of femur
45
When are salvage procedures indicated for coxofemoral luxation?
Hip dysplasia
46
What is the prognosis for coxofemoral luxation?
* Closed reduction * 50% success rate overall * More successful if recent injury (\< 24hrs) * Higher with caudoventral luxation * Lower with dysplasia, other trauma * Open reduction * 80-90% success * Good to excellent limb function * **Expect DJD over time**
47
What is the pathophysiology of Legg-Perthes disease?
* Cause: unknown * Ischemia to femoral head causes necrosis * Collapse of epiphysis with loading * Fragmentation of articular surface * Revascularization --\> new bone * Malunion of fractured femoral head * DJD results from incongruent joint
48
What is the signalment for Legg-Perthes disease?
*
49
What is the typical history/PE findings of a patient with Legg-Perthes disease?
* Signs of hip pain * Slow onset, progressie: necrosis * Acute, non-wt.bearing: pathologic fracture * Chronic remodeling * Muscle atrophy * Crepitus * Decreased ROM
50
How do you diagnose Legg-Perthes disease?
* Radiographs * Early changes * Radiopacity of lateral femoral head * Focal bony lysis--"motheaten" or "apple core" * Later changes * Flattening, mottling of femoral head * Collapse, thickening of femoral neck * If rads normal: repeat in 1 mo
51
Diagnosis?
Legg-Perthes disease
52
Diagnosis?
Legg-Perthes disease
53
What is the treatment for Legg-Perthes disease?
* Medical therapy unhelpful * Femoral head ostectomy * THR may be considered * No reason to delay procedure if \> 8-9mo
54
What is the prognosis for Legg-Perthes disease? What is the aftercare?
* Good prognosis--as for salvage procedure * Warn owners of risk for contralateral diseae * Aftercare as for salvage procedure * Wt. management * Analgesics * PT

Small animal surgery I (25 decks)

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