Displasia de Cadera VetGrad

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HipDysplasia
TimHutchinsonBVScCertSASMRCVS22/03/2016
Hip Dysplasia

INTRODUCTION
Of all the developmental orthopaedic disorders, hip dysplasia is probably the most widely known. However, misconceptions
and poor advice persist, particularly from breeders so that vulnerable joints are damaged early in life, initiating the
degenerative cycle of osteoarthritis.
AETIOLOGY AND PATHOGENESIS

Regardless of the ultimate severity of the condition, a dog with hip dysplasia is born with normal hips; the subsequent
development of the dysplastic joints depends on a mixture of genotypic and phenotypic effects. The developing joint relies
upon the coordinated growth of five bones (ilium, ischium, pubis, acetabular and femoral head), joint capsule, surrounding
musculature and intraarticular structures (articular cartilage, synovial fluid and the teres ligament) and the phenotypic
influences to which they are subjected (principally nutrition and exercise).
For the normal development of the coxofemoral joint there should be minimal joint laxity. This ensures that the femoral head
and acetabulum are maintained in close contact throughout all normal movements. With this inherent congruency comes an
even loaddistribution from the femoral head to the acetabulum and the joint develops correspondingly in a normal fashion.
Young growing bones are a very plastic tissue and their shape will develop according to the forces applied through them: a
congruent joint with normally distributed load will continue to develop normally.
Conversely, in the development of a dysplastic joint there is increased joint laxity, resulting in subluxation of the joint, which
becomes particularly pronounced during exercise. The result is that the surfaces of the joint available for weightbearing are
reduced in area and are often inappropriate (such as the acetabular rim). This has two main effects: firstly, there is focal
damage to the acetabular rim and femoral head; secondly, because of the reduced load applied directly through the
acetabulum the joint fails to develop its intended shape, leading to incongruency.
Joint Laxity...is key to the development of the disorder, however, this in itself is multifactorial. Laxity arises as the result
of an increased volume of synovial fluid; increased elasticity of the fibrous supporting structures (joint capsule and teres
ligament); and decreased support from the surrounding musculature. Different genes are responsible for the development of
these different tissues, which complicates the heritability of the condition.
It is possible to assess the laxity of the coxofemoral joint subjectively (see diagnosis) and to measure it objectively.
Important research by Gail Smith1,2 has shown that the degree of joint laxity (or the degree to which the femoral head can be
distracted from the acetabulum) can be measured as the distractive index, with a value of 0 representing no distraction of the
femoral head from the acetabulum (no laxity) and a value of 1.0 representing maximum distraction (complete subluxation).
Smith extended this idea to show that a distractive index of 0.3 was the cutoff point for the development of dysplasia and
went on to suggest that some breeds (e.g. greyhounds) had populations with distractive indices almost exclusively <0.3 and
therefore did not develop the disorder; whereas other breeds (e.g. German Shepherd dogs) had indices >0.3 and were
therefore almost exclusively at risk of developing dysplastic hips.
Exercise is both useful and damaging for the developing joint and as a general rule it is the type rather than the quantity of
exercise that is the problem: controlled exercise ensures that the joint moves in a defined range and encourages load transfer
through the femoral head to the acetabulum and therefore favours the development of a congruent joint. Uncontrolled
exercise, such as ball chasing and jumping, allows the femoral head to move out of the acetabulum (to the limit of the joint
laxity) and impact on the acetabular rim. This impact trauma causes the development of microfractures along the rim,
resulting in pain and remodelling of the bone. Inflammatory changes cause synovial effusion, which further compounds the
laxity. Articular cartilage on the focused loadbearing part of the femoral head and acetabulum is damaged and the vicious
cycle of osteoarthritic degeneration is established.
Nutrition also plays a role. It is rare, today, to find a commercially prepared food for dogs that is not well balanced
nutritionally (though many owners, often under a breeders illinformed advice, will still supplement a diet with raw meat and
in doing so distort the calcium to phosphorous ratio), so rather than dietary imbalance the main current nutritional problem is
overfeeding3 leading to rapid growth and weightgain. Impact damage through uncontrolled exercise on a lax joint is
exacerbated by increased bodyweight (therefore increased impact force) and rapid growth in height may lead to increased
leverage on these vulnerable joints.
The greater the degree of joint laxity the less force is required to distract the joint and cause damage hence when selecting
dogs for breeding purposes it is important to assess the laxity of the joints.
HISTORY AND CLINICAL SIGNS

The detection of hip pain in a young dog is relatively straightforward for the clinician and susceptible breeds are well
recognised. Breeds most at risk of developing hip dysplasia are listed on the BVA/KC website
http://www.bva.co.uk/public/documents/Breed_Specific_Statistics_2012.pdf. Clinically, dysplastic dogs present as two
distinct subgroups: young dogs with signs associated with the development of the condition and older dogs with osteoarthritis
secondary to the developmental disorder.
Juvenile dogs
Puppies are usually presented between 4 and 12 months of age with a history of lameness of one or both back legs and pain.
Owners frequently report a bunnyhopping gait the puppy uses both back legs together and thrusts with its back rather than
swinging the painful hips individually. Signs may be insidious in onset or present as an acute lameness and typically the dog is
stiff after rest. On examination there is discomfort on hip manipulation particularly extension. There may be palpable (and
even audible) clunks with a very lax joint when it reduces following subluxation. In extreme cases this can be detected by
resting the hands over the joints and rocking the dog from side to side.
Adult dogs
The history is typical of degenerative joint disease: stiffness after rest, decreased exercise tolerance, difficulty climbing
steps, behavioural changes etc. There is hip stiffness and discomfort on examination as well as decreased range of motion and
possibly crepitus.
It is essential to perform a full clinical examination and to exclude other orthopaedic causes for the lameness, especially stifle
disease (cruciate disease or patellae luxation) and lumbosacral disease.
DIAGNOSIS
The breed, presenting clinical signs and full examination give a reasonable degree of certainty to a presumptive diagnosis.
However, definitive diagnosis relies on examination of the joints with a relaxed (heavily sedated or anaesthetised) patient and
radiography. The main purpose of this examination is to demonstrate subluxation of the coxofemoral joints and to try to
quantify (subjectively) this degree of laxity.
Palpation
With the dog in lateral recumbency, the stifle is flexed to allow the distal femur to be grasped in one hand. The other hand
rests over the pelvis with the thumb over the greater trochanter of the femur. The stifle is adducted and the femur pushed
proximally (the hand on the pelvis preventing movement of the dog). These actions allow subluxation of the femoral head so
that it rides up onto the dorsal acetabular rim. Maintaining the proximal thrust on the femur, the limb is abducted until the
femoral head slips back over the dorsal acetabular rim and reduces into the acetabulum. This sudden reduction is
accompanied by a palpable, and often audible thud this is referred to as the Ortolani Sign. This laxity and Ortolani Sign
can also be demonstrated bilaterally with the dog in dorsal recumbency and the femurs forced perpendicularly towards the
table. However, the benefit of assessing each joint individually is that the degree of laxity when the femoral head abducts
from the acetabulum can be felt with the overlying thumb. With experience this measurement whilst still subjective can be
quite accurate.
It is possible to measure the angle at which the hip reduces from its subluxated position and also the angle at which it
subluxates when the limb is rotated from an abducted position. These two angles may be useful in planning reconstructive
procedures such as triple pelvic osteotomy.
The Ortolani sign
Fig 1. The left hand supports the pelvis, with the thumb on the greater trochanter; the stifle is flexed and the distal femur grasped firmly in the
right hand.
Fig 2. The stifle is adducted and the femur pushed proximally to subluxate the femoral head
Fig 3. The stifle is abducted to allow the femoral head to reduce
Radiography
The standard radiographic positioning required for ventrodorsal hip radiographs is familiar to all vets. Additional views, such
as a skyline view to assess the dorsal acetabular rim, may be useful for preoperative planning.
When assessing any hip radiographs though, it is important to be systematic and evaluate all parts of the joint, from the
perspectives of joint morphology and degenerative changes:
Morphology... essentially involves the degree of subluxation, congruency and the Norberg Angle.
1.
Subluxation the femoral head should be viewed as a complete circle and its
centre point determined (the use of actetate overlays can be of assistance
here). The line of the dorsal acetabular rim should also be located. In a normal
joint the centre of the femoral head should lie medial to the dorsal acetabular
rim this ensures good dorsal coverage to the femoral head in normal load
bearing. With mild subluxation the centre point lies close to or even over the
acetabular rim and consequently the area of the joint available for load
bearing is reduced. With more severe luxation the centre of the femoral head is
outside the dorsal acetabular rim and in extreme cases (complete luxation) the
medial aspect of the femoral head itself has moved beyond the rim.
2. Congruency the contours of the cranial acetabulum and the cranial aspect
of the femoral head should be noted. In a normal, congruent joint these two
curves are parallel. As subluxation increases so does the incongruency.
3. Norberg Angle two lines are marked on the radiograph: one extends from
the centre of the femoral head cranially in a sagittal plane; the other is drawn
from the centre of the femoral head to the lateral limit of the cranial
acetabular rim. The angle between these lines is the Norberg Angle. In a normal
joint this angle will be positive and greater than 15 degrees (the line to the
cranial acetabular rim diverges laterally from the body of the dog). As
subluxation and maldevelopment of the acetabulum increase the angle will
reduce and even become negative.
Degenerative changes
Consistent with any osteoarthritic joint there will be the presence (in varying degrees) of new bone formation, sclerosis and
remodelling. One of the earliest indicators is the presence of the Morgans Line. This is a radiodense line extending from the
base of the femoral neck to the trochanteric fossa and is the result of new bone formation along the insertion of the joint
capsule. All parts of the joint should be examined for pathologic changes: cranial, caudal and dorsal acetabulum, acetabular
fossa, femoral head and neck.
N.B. When assessing the severity of the condition it is important to treat the dog, not its radiographs! Radiographic changes
confirm the diagnosis of hip dysplasia, but the clinical severity can vary widely between dogs with apparently similar films.
TREATMENT
Juvenile dogs
Treatment of young dogs has two aims: controlling pain and trying to promote optimum joint formation. With this in mind
treatment should begin before the onset of clinical signs, through the education of owners of susceptible breeds! The vicious
circle of joint laxity > abnormal load bearing > abnormal development > incongruency > laxity begins at a young age and
the key time for joint damage is between 8 and 20 weeks of age. Time should be spent with owners at the primary vaccination
course discussing issues such as weight gain and the type of exercise appropriate for the pup. Frustratingly, breeders still sell
many pups with the advice dont exercise until over six months old, with the result that the exuberant young dog bounces
round the garden, whereas its energy would be better diverted towards plentiful controlled lead walking.
Once clinical signs of the problem are evident and diagnosis has been made, treatment will focus on conservative or surgical
options:
Conservative treatment
It is well documented4 that hip morphology can be improved in a clinically affected young dog by controlling its exercise so
that direct load transmission from the femoral head through the acetabulum can improve the shape of the joint as it
continues to develop. Conservative treatment will therefore centre on the use of moderate amounts of controlled (short lead)
exercise coupled with analgesia through the use of an appropriate nonsteroidal antiinflammatory drug (NSAID). Hydrotherapy
may be very useful at this stage to promote muscle development over the hindquarters (and therefore increasing the support
for the lax joints) without the concussive injury associated with walking and running. This should continue until the dog is
skeletally mature (12 18 months depending on the breed).
This simple noninvasive treatment regime is the treatment of choice for mild cases and whilst surgical options can improve
the results, conservative treatment can still be appropriate and yield good results if surgery is contraindicated or financially
constrained. However, it does require significant discipline on behalf of the owner and possibly a lifestyle change, so time
spent educating the client is vitally important.
Surgical options
These are aimed at either improving the morphology of the joints by creating joints with increased loadbearing acetabular
contact (triple pelvic osteotomy, juvenile pubic symphysiodesis, augmentation of the dorsal acetabular rim etc.), or the use of
artificial implants to create a false joint (total hip arthroplasty). Indications for these surgeries are well documented and
beyond the scope of this article.
Adult dog
At this stage of the disease process treatment is aimed at controlling the signs associated with osteoarthritis. The holy
trinity of arthritis control is:
1. Pain relief through the judicial longterm use of an appropriate NSAID.
2. Exercise control controlled (lead) exercise encourages movement of the joints through their normal range of motion and
limits extremes of flexion and extension and shearing forces.
3. Weight loss forceplate studies have shown that the peak vertical force through joints can be up to five times the dogs
bodyweight, so tackling obesity is a major tool to reduce impact injury to the joints.
Careful discussion with the client will be required because the above measures may necessitate lifestyle changes and
significant input on their behalf. It is also important to manage a clients expectations: a client who views success as being
able to return to the terraces to watch his favourite football team will be far more satisfied than one who expects to return to
the pitch itself!
Once these golden rules of arthritis control are in place, adjunctive therapies such as hydrotherapy, physiotherapy, massage
and, possibly, nutritional support may prove useful. However, it is vital that the holy trinity is embraced first and that other
measures are seen as adjuncts.
If the above measures provide a good quality of life for the dog, then they can be continued for the rest of its life, with
regular veterinary checks to offer support and tweak the management as required. If response is poor then surgical options
may be considered. Essentially at this stage surgery is merely salvage in nature and involves either total hip arthroplasty or
femoral head and neck excision. The choice may be financially dependent.
ASSESSMENT OF DOGS FOR BREEDING
A scheme for assessing hips of breeding dogs was first introduced to the UK in 1965, with a simple pass or fail result. This
was replaced in 1984 by the scheme still in use today. Each hip is assessed on a standard ventrodorsal radiograph and scored,
in nine categories, out of a total of 53 per hip. Of these nine categories two (subluxation and Norberg Angle) are concerned
with the underlying morphology and the other seven relate to remodelling changes associated with secondary osteoarthritis.
Despite its virtues and good intent, the scheme is inherently flawed for several reasons:
1. Only a small part of the score derives from those criteria that are directly associated with the underlying laxity.
2. The degree of laxity is inferred rather than measured directly.
3. Radiographic changes associated with osteoarthritis increase with the age of the animal, so the same dog could produce
two different scores if radiographed at different times in its life. It is conceivable that a dog could be radiographed at one
year old and be considered good for breeding, but radiographed again five years later and rejected!
4. There is the potential for false negative results: a dog with significant laxity, but reared in a very controlled manner, could
have radiographically good hips.
For these reasons it is vital that the vet taking the radiograph should examine the joints thoroughly and discuss the results of
the examination together with the score of the radiograph with a client considering using the dog for breeding. A low score
below the breed mean average does not mean that the dog has normal hips!
Gail Smith and coworkers at the University of Pennsylvania, have devised an alternative scoring scheme that is based on the
degree of laxity present in the joints. Two radiographs are taken. The first is a standard VD view. The second view is taken
with the joints distracted a fulcrum is placed between the thighs and the stifles compressed together so that the femoral
heads are abducted from the acetabulae to the extent allowed by the degree of laxity. The distance that the femoral head has
moved (proportional to the size of the femoral head) is called the distractive index and correlates very closely with the
likelihood of displaying clinical signs of hip dysplasia.
Unfortunately, in order to obtain films for this PennHIP scheme there must be manual holding of the animal during
radiography and this is not permissible under current UK H&S legislation, although several UK orthopaedic surgeons are
currently trying to develop a distracting device that willobtain consistent results and satisfy the Health and Safety Executive.
This article was provided by Merial, makers of Previcox:
References:
1. Smith GK, Biery DN and Gregor TP. New concepts of coxofemoral joint stability and the development of a clinical stress
radiographic method for quantitating hip joint laxity in the dog. J Am Vet Med Assoc, 1990; 196: 5970.
2. Smith GK, Gregor TP, Rhodes WH and Biery DN. Coxofemoral joint laxity from distraction radiography and its
contemporaneous and prospective correlation with laxity, subjective score and evidence of degenerative joint disease from
conventional hipextended radiography. J Am Vet Med Assoc, 1993; 54: 10211042.
3. Smith GK, Biery DN, Kealy RD and Lawler DF. Clinical significance of osteoarthritis and hip dysplasia findings in the
restricted feeding trial. The Purina Pet Institute Symposium: Advancing life through diet restriction. St Louis MO. September
2021, 2002 p2728.
4. Barr ARS, Denny HR and Gibbs C. Clinical hip dysplasia in growing dogs: the longterm results of conservative management.
JSAP, 1987; 28: 243252.
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2017610 VetGradHomeTheWebsiteForVets

AETIOLOGY AND PATHOGENESIS

HISTORY AND CLINICAL SIGNS

The Ortolani sign

Fig 3. The stifle is abducted to allow the femoral head to reduce

1. Pain relief through the judicial longterm use of an appropriate NSAID.

ASSESSMENT OF DOGS FOR BREEDING

2. The degree of laxity is inferred rather than measured directly.

This article was provided by Merial, makers of Previcox:

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