Hind limb lameness – immature Large breed dog

Approach to lameness

  • Hip dysplasia
  • Osteochondrosis
  • (Patellar luxation)
  • (Cranial cruciate ligament disease)
  • Other causes
  • –      Metaphyseal osteopathy
  • –      Nutritional secondary hyperparathyroidism

 

Approach to the lame dog

  • What are you trying to achieve?

–      Why is the dog lame? Dx

–      Txt & prognosis

  • How are you going to get there?
  • History

–      Onset (acute or chronic, inciting cause?), duration, progression, previous lameness, response to any previous tx, general health

–      History and signalment guide you towards diagnosis

 

Approach to the lame dog

General physical examination

Orthopaedic examination

  • Systematic
  • Lameness (yes, no, maybe),  severity, which leg(s)
  • Muscle atrophy
  • Joint effusions, fibrosis, range of motion, crepitus, instability, PAIN
  • Bone pain
  • Neurological abnormalities
  • Findings guide you towards diagnosis and focus further investigation

 

Hip dysplasia

  • Developmental disease
  • Laxity and secondary osteoarthritis

–      Both cause pain and lameness

–      Laxity source of pain in immature dog, OA in adult dog (combination)

bilateral hip dysplasia dog arthritis

Aetiology – genetic and environmental factors

 

How does a dog with hip dysplasia present?

  • Often characteristic gait – swings pelvis from side-to-side
  • Lameness may be uni or bilateral
  • Difficulty rising
  • Audible click / clunk
  • Poor muscle mass of hindlimbs

Are there characteristic orthopaedic exam findings?

  • Pain on hip extension

Hip dysplasia How are you going to confirm the diagnosis?

1.  Radiography under sedation

  • Ventrodorsal extended
  • Lateral

2.  Palpation under sedation

  • The Ortolani test

 

BVA/KC Hip Scoring Scheme

Hip dysplasia diagnosis – beyond the basics

  • Orthopedic Foundation for Animals hip grading system (www.offa.org)
  • Has recently been compared to PennHip:

 

TX;

  • Conservative management

–      Usually considered first

  • Surgery

–      Reduce degree of hip laxity – pelvic osteotomy or pubic symphysiodesis

–      Salvage procedures – joint excision or prosthesis

What do you need to know?

  • Good understanding of conservative management
  • Awareness of surgical options and when they are appropriate

 

Conservative management

  • Bodyweight and body condition
  • Non-steroidal anti-inflammatory drugs
  • Low impact exercise / physiotherapy
  • Neutraceuticals / alternative therapies
  • Beneficial to maintain slender body condition
  1. Bodyweight and body condition

–      Reduces lameness in dogs with HD and OA

–      Reduces development of HD in genotypically predisposed dogs

 

  1. Non-steroidal anti-inflammatory drugs
  • Many different ones out there
  • E.g. meloxicam, carprofen, firocoxib
  • Differences in COX selectivity
  • Good evidence to support efficacy
  • Mainstay of osteoarthritis treatment in dogs
  • Possible side effects – gastrointestinal, renal

 

  1. Low impact exercise / physiotherapy
  • For example swimming
  • Not much evidence other than opinion to support this
  • Still worth discussing with owners / adding to treatment plan
  • Polysulfated glycosaminoglycans (PSGAG)
  • Semisynthetic product structurally similar to GAG
  • Stimulate collagen synthesis, inhibit breakdown in vitro
  • Some (limited) evidence to support improvement in lameness in dogs with HD and OA
  • Diets
  • Omega 3 fatty acid (fish oil) supplemented foods (e.g. Hills® J/D)
  • Increasing tissue levels of omega 3 FA decreases levels of omega 6 FA and overall effect is to suppress inflammation
  • Evidence supports use of these diets in dogs with OA, including hip OA
  • Acupuncture
  1. Neutraceuticals / alternative therapies

 

Surgical options – decreasing joint laxity

1.  Triple pelvic osteotomy

  • Not for everyone- generally less than 1yr old
  • They have a positive Ortolani sign
  • With no radiographically obvious secondary OA
  • Hip OA will still progress post operatively
  • Performed in puppies 12-20 weeks old
  • W/ radiographic abnormalities not CS
  • Premature closure of pubic symphysis induced by electrocautery
  • Usually combined with neutering procedure
  • Not well established in UK
  1. Juvenile pubic symphysiodesis

 

Surgical options – salvage

  1. Femoral head and neck ostectomy
  • Eliminates contact between femoral head and acetabulum = ↓discomfort
  • Pseudoarthrosis (false joint) forms
  • Limb function should improve but will probably never be normal
  • Better results in smaller dogs
  • Consider as “plan C” for hip dysplasia i.e if all else fails and dog is not a candidate for THR

–        Aim for complete removal of head and neck

  • Performed through craniolateral approach
  • Straightforward surgery
  • Useful technique for other conditions e.g. Perthes’ disease, hip luxation salvage – in practice

 

  1. Total hip replacement
  • Replacement of diseased hip with prosthesis
  • Better function than FHNO, best option for large breed dogs
  • Much more technically demanding procedure
  • Much more expensive
  • Risk of significant complications
  • Good outcome if all goes well
  • Cemented and cementless systems available
  • Micro systems available for toy dogs and cats
  • Potential complications include luxation, infection and fracture
  • Referral procedure

 

 

Osteochondrosis dissecans in the hindlimb

–        Young dog.

Osteochondrosis dissecans

  • Disorder of endochondral ossification
  • Affects articular cartilage surface
  • Dissecans describes formation of a cartilage flap
  • Secondary osteoarthritis will develop
  • Stifle – femoral condyles (lateral usually)
  • Tarsus – trochlear ridges of talus (medial usually)
  • Hip – uncommon but can affect femoral head

 

Presentation

  • Lame young (4-8 months) large breed dog
  • Affected joint is effused and painful
  • Radiographically look for defect in articular surface

TX;

1. Conservative management – most appropriate where OA is already advanced

2. Removal of cartilage flap by arthrotomy or arthroscopy

–      Removes source of inflammation and discomfort

–      Defect heals by fibrocartilage formation

–      Clinical outcome better for some joints than others

3. Osteochondral grafts are now being explored

  • Cores of cartilage and bone harvested from non-weightbearing regions
  • Implanted in OCD defect
  • Cartilage and bone become integrated in new location
  • Initial results encouraging

 

 

patellar luxation in large breed dogs

  • Why is the patella luxating?
  • Tibial or femoral deformity?
  • Need to correct deformity
  • Referral situation

luxating-patella-dog-knee 

Cranial cruciate ligament disease

  • Increasingly common in skeletally immature dogs
  • Treatment options may be more limited
  • Useful to be able to differentiate “puppy” from pathological cranial drawer- Puppy drawer has a distinct “end point”

Cranial cruciate ligament disease

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About Annettevet

I'm a Norwegian practicing as a veterinarian in Durham, England. I`ve recently qualified as a veterinarian at Glasgow University. This is a blog about my experiences as a vet student and now as a veterinarian. “The greatness of a nation and its moral progress can be judged by the way its animals are treated”
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