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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
Q

What is the prognosis for corrective procedures for hip dysplasia?

A
  • Less effective for severe laxity (high DI)
    *
26
Q

What is done in a THR? What are the indications?

A
  • 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
Q

What is the difference between cemented and cementless THR systems?

A
  • Cemented–sealed in PMMA
  • Cementless
    • Components coated (hydroxyapatite)
    • Stability depends on bony ingrowth into implants
28
Q

What is an FHO? When is it indicated?

A
  • 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
Q

How does FHO work and what is the recommended post-op care?

A
  • Pseudarthrosis
  • Muscles and tendons provide support
  • Immediate postop limb use essential
  • ROM and PT exercises encouraged
30
Q

What is the prognosis for salvage procedures in hip dysplasia?

A
  • 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
Q

What is the common etiology of coxofemoral luxation?

A
  • Trauma
    • Associated with thoracic injury
    • Associated with other fractures
    • Treat life-threatening injuries FIRST
32
Q

What is the difference between craniodorsal and caudoventral luxation?

A
  • 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
Q

What are the PE findings of a patient with caudoventral coxofemoral luxation?

A
  • Non-wt. bearing
  • Greater trochanter recessed/difficult to palpate
  • Leg is held abducted and flexed
  • Stifle internally rotated
  • Affected limb longer
34
Q

What are the PE findings in a dog with craniodorsal coxofemoral luxation?

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
35
Q

How is hip luxation diagnosed?

A
  • Radiographs
    • Rule-out fractures
    • Straight line
36
Q

When is closed reduction of hip displacement not indicated?

A

Dysplastic hip

Fracture–pelvis or femur

37
Q

What maneuvers are required following closed reduction of a hip displacement?

A
  • 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
Q

What coaptation methods are used in craniodorsal luxation vs. caudoventral luxation?

A
  • Craniodorsal
    • Ehmer sling
      • Abduction
      • Internal rotation
      • Pushes femoral head away from damaged craniodorsal joint capsule
  • Caudoventral
    • Hobbles
39
Q

What are the indications for open reduction of the coxofemoral joint?

A
  • Pelvic/acetabular fracture
  • Femoral fractures
  • Unstable closed reduction
  • Recurrent closed reduction
40
Q

What are the objecties for open reduction of the coxofemoral joint?

A

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
Q

What are the 3 most commonly used procedures for correcting coxofemoral luxation?

A
  • Capsulorrhaphy
  • Prosthetic capsule
  • Toggle pin
42
Q

Explain the capsulorrhaphy procedure for treatment of coxofemoral luxation

A
  • Closing the joint capsule torn by trauma
  • Heavy gauge suture
  • May not be possible in severe cases
  • Usually unsufficient as sole repair
43
Q

What is the prosthetic capsule procedure in the treatment of coxofemoral luxation?

A
  • 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
Q

Explain the toggle pin/rod procedure in the treatment of coxofemoral luxation

A
  • 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
Q

When are salvage procedures indicated for coxofemoral luxation?

A

Hip dysplasia

46
Q

What is the prognosis for coxofemoral luxation?

A
  • 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
Q

What is the pathophysiology of Legg-Perthes disease?

A
  • 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
Q

What is the signalment for Legg-Perthes disease?

A

*

49
Q

What is the typical history/PE findings of a patient with Legg-Perthes disease?

A
  • Signs of hip pain
    • Slow onset, progressie: necrosis
    • Acute, non-wt.bearing: pathologic fracture
  • Chronic remodeling
    • Muscle atrophy
    • Crepitus
    • Decreased ROM
50
Q

How do you diagnose Legg-Perthes disease?

A
  • 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
Q

Diagnosis?

A

Legg-Perthes disease

52
Q

Diagnosis?

A

Legg-Perthes disease

53
Q

What is the treatment for Legg-Perthes disease?

A
  • Medical therapy unhelpful
  • Femoral head ostectomy
  • THR may be considered
  • No reason to delay procedure if > 8-9mo
54
Q

What is the prognosis for Legg-Perthes disease?

What is the aftercare?

A
  • 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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