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Surgery > Hip > Flashcards

Hip Flashcards

1
Q

What is the definition of hip dysplasia

A

Abnormal development of the coxofemoral joint resulting in hip laxity Laxity results remodeling Remodeling leads to degeneration

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2
Q

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

A

Etiology is multifactorial

Genetics (polygenic)

-Epigenetics

Environmental (nongenetic)

  • body wt
  • nutrition
  • pelvic muscle mass

Both are necessary Neither is individually sufficient

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3
Q

What is the typical presenting signalment of hip dysplasia?

A

Large breed dogs

Equal sex distribution (M:F)

Classic biphasic presentation

Young dogs

5-12 months

Laxity

Mature dogs

Highly variable onset/severity

Chronic/recurrent signs

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4
Q

What are the PE and history findings on a patient with hip dysplasia?

A

History

Exercise intolerance

Bunny hopping gait

Difficulty rising/stiff after rest

Reluctant to climb stairs or jump

May see with ANY bilateral HL lameness

Sits “to the side” – avoiding hip flexion

PE:

Stance

Rear base-wide (compensatory)

Rear base-narrow (degeneration)

Forward weight shift

Gait – “hip sway”

Difficulty rising/sitting

Sits frequently in exam room

Muscle atrophy – quadriceps, biceps

Palpation:

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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5
Q

What are the gait abnormalities associated with hip dysplasia and their implications?

A

Stance:

  • rear based wided
  • rear based narrwo
  • forward weight shift
  • sits to the side- avoiding hip flexion

Gait:

  • hip sway/ model walk
  • bunny hopping gait
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6
Q

What is the Orolani sign?

A

In a young patient

  • palpable laxity- subluxate femoral head

Ortolani Test

  • 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

negative in older patients d/t remodeling

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7
Q

Why is Ortolani sign absent in mature dogs?

A

Remodeling

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8
Q

What is the Ortolani test for?

A

A positive sign is a distinctive clunk which can be heard and felt as the femoral head relocates anteriorly into the acetabulum. Speficially, this test is for posterior dislocation of the hip

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9
Q

What radiographic view is considered diagnostic for hip dysplasia?

A

hip extended view with internal rotation of distal limbs

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10
Q

What is this and what does it signify?

A

Morgan’s line

This is a well-defined linear density between the femoral head and the greater trochanter

represents an early osteophyte

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11
Q
A

Puppy Line

Indistinct density

Similar location to Morgan’s line

Clinically insignificant

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12
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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13
Q

If hip dysplasia is present in one litter mate, will be in another liter mate to the same degree?

A

NO! Because you have to have genetic and non-genetic factors!

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14
Q

Generally describe the OFA and it’s limitations and benefits

A

OFA

generals

  • single ventrodorsal pelvis view with hip extended
  • 7- point ordinal scale, excellent to severe

CANNOT CERTIFY HIPS BEFORE 24 MONTHS

-positioning underestimates subluxation

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15
Q

Generally describe the PennHip and it’s limitations and benefits

A

generals:

  • distraction applied under anesthesia
  • measure the distance of the femoral head to acetabulum center

Lower DI=less laxity

can do at 16 weeks

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16
Q

What are the ideal values?

A

PennHip= <0.3 is ideal

50% for OFA

17
Q

What is the medical management for hip dysplasia?

A
  • nutritional management- lower ca/vit. d/energy in a puppy- weight management in adult dog
  • excerise modulation
  • WEIGHT MANAGMENT IS THE MOST IMPORTANT
18
Q

Which procedures are considered corrective?

A

Juvenile Pubic symphiodesis

and triple pelvic osteotomy

19
Q

Juvenile Pelvic Symphiodesis

A

Fuse pubic symphysis with cautery- makes pelvis more broad and wide

“Tethers” growth of pelvis

“Rolls” acetabulum ventrally (ventroversion)

Only useful < 20 weeks of age

Assess risk: PennHIP at 16 weeks

If patient is at risk, consider JPS

Relatively noninvasive

Low complication rate

  • benefit unlikely after 20 weeks
20
Q

Triple Pelvic Osteotomy (TPO)

A

Improve femoral head coverage

Rotate acetabulum dorsally

Indications

Clinical signs of hip dysplasia

Ortolani test – distinct “clunk”

Angle of reduction < 30º

No radiographic evidence of DJD

6-8 months of age (approximately)

Osteotomy of pubis, ischium, ilium

Fixation of ilium with angled plate

Rolls acetabulum dorsally

Allows “capture” of hip

Repositioning of

acetabulum makes

THR challenging

  • Case selection very imporant-
  • long term function good to excellent
21
Q

Total Hip replacement

A

Degenerative joint replaced with prostheses

Femoral stem

Acetabular cup

Timing depends on multiple factors

Generally, delay procedure as much as possible

Skeletal maturity – adequate bone stock

Has been done at 7-8 months of age

Success closely related to experience of surgeon

Cemented and cementless systems

Cemented - seated in PMMA

Cementless

Components coated (hydroxyapatite)

Stability depends upon bony ingrowth into implants

Ideal treatment for large, active dogs

Micro implants available for small dogs, cats

Luxation

Infection

Femur fracture

Loosening

Bone resorption around cement

Failure of ingrowth

Failure => explantation => FHO

Complication rate < 10%

22
Q

Femoral Head ostectomy(FHO)

A

Femoral Head and Neck Excision Arthroplasty

Ideally done after skeletal maturity (> 9m)

Conformation of femur, tibia

Stifle abnormalities

Remove entire head and neck of femur

Osteotome, oscillating (sagittal) saw

Femoral Head and Neck Excision Arthroplasty (FHNEA)

Ideally done after skeletal maturity (> 9m)

Pseudarthrosis

Muscles and tendons provide support

Immediate postop limb use essential

ROM and PT exercises encouraged

Conformation of femur, tibia

Stifle abnormalities

Remove entire head and neck of femur

Osteotome, oscillating (sagittal) saw

23
Q

What are the progonosis of a THR vs FHO?

A

Total Hip Replacement - $$$$$$

> 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

24
Q

What is the most common etiology of coxofemoral luxation?

A

Trauma

25
Q

What is the difference between a caudoventral vs a crainodorsal luxation and which is more common?

A

Direction of femoral head vs. acetabulum

Caudoventral

Falls or “splits” – excessive abduction of limb

Femoral head traped ventral to ischium

Craniodorsal luxation

Most common (>90%)

Pull of gluteal muscles

Greater trochanter displaced dorsally

26
Q

What is the presentation of a caudoventral luxation?

A

Non-weightbearing

Greater trochanter recessed/difficult to palpate

Leg is held abducted and flexed

Stifle internally rotated

Affected limb longer

27
Q

What type of luxation is this?

A

caudoventral luxation

28
Q

What is the treatment for caudoventral luxation?

A

Reduce hip

Closed reduction usually successful

Open reduction viable option if needed

Early reduction is essential

General anesthesia

Muscle relaxation

Epidural is ideal

29
Q

What is the post treatment for a caudoventral luxation?

A

Put joint through ROM to clear debris

Apply hobbles 10-14 days

Level of the stifle

Prevent abduction

Ehmer sling is contraindicated

Dorsal joint capsule intact

Ventral capsule torn

30
Q

How do craniodorsal luxations present?

A

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

31
Q

What do you do for a closed reduction for crainodorsal luxation?

A

Early reduction essential

General anesthesia

Muscle relaxation

Good analgesia protocol

Epidural ideal

Contraindications

Dysplastic hip

Fracture – pelvis or femur

Grasp tarsus, externally rotate limb

Distal traction, bring femoral head distal to acetabulum

Internally rotate limb after femoral head clears acetabulum

Opposite hand

Thumb on acetabulum

Index finger on trochanter

32
Q

What kind of joint can you not save?

A

a dysplastic joint

33
Q

What do you do post-reduction for a craniodorsal luxation?

A

Put joint through ROM to clear debris

Test stability – if unstable => open reduction

Ehmer sling 4-14 days

Radiographs

Confirm reduction

Confirm reduction following Ehmer placement

Confirm reduction prior to removing Ehmer sling

(Abduction

Internal rotation

Pushes femoral head away from damaged craniodorsal joint capsule)

If reluxated at any point => open reduction

34
Q

When is a closed reduction of the hip contraindicated?

A

Dysplastic hip or a fracture of the pelvis or femur

35
Q

Capsulorraphy

A

Simply refers to closing the joint capsule torn by the trauma

Heavy gauge suture

May not be possible in severe cases

Usually insufficient as sole repair

36
Q

What is the pathophysiology behind Legg perth’s?

A

ischemia to femoral head causes necrosis

revascularization–> new bone

37
Q

What is affected when the triangular relatinship is altered on craindorsal coxofemoral luxation?

A

Crest of illium, greater trochanter, and tuber ischii

38
Q

Dx?

A

Leg- Perreth’s disease

Surgery (11 decks)

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