pISSN 1598-298X
J Vet Clin 31(2) :125-128 (2014)
125
Treatment of Recurrent Coxofemoral Joint Luxation by Total Hip Replacement in a Dog
Jooho Kim, Su-Young Heo, Minsu Kim, Kichang Lee, Namsoo Kim and Haebeom Lee1
College of Veterinary Medicine, Chonbuk National University, Jeonju 561-756, Korea (Accepted: September 26, 2013)
Abstract : A 7-year-old, intact female Golden Retriever weighing 38 kg was referred for left coxofemoral joint luxation.
On physical examination, pain and crepitus were noted atthe left hip joint during joint extension. Radiological examination revealed coxofemoral joint luxation and mild degenerative bone changes in the left hip joint. We performed minimally invasive arthroscopy-assisted reduction with TightRope® as a treatment option; however, the left coxofemoral joint was reluxated after one month postoperatively. We performed cementless total hip replacement (THR) of the luxated left coxofemoral joint. At tenmonths after surgery, the dog could sit, stand, walk normally and jump comfortably without lameness. The thigh girth measurement of the operated limb was 108.6% of the contralateral limb. Based on the present case, THR can be a successful treatment for coxofemoral joint luxation in dogs with failed coxofemoral joint reduction.
Key words : Hip luxation, total hip replacement, osteoarthritis.
Introduction
The hip joint is the most frequently dislocated joint in dogs, comprising up to 90% of all joint luxations (17). Traumatic injury is the most common cause of hip luxation; however, the joint may also luxate secondary to hip dysplasia. The ball-and-socket configuration of the hip joint is a major stabi- lizing feature, and the round ligament and the joint capsule provide passive stability, which is important in preventing lux- ation of the hip joint. These structures may become stretched, as in hip dysplasia, allowing luxation (4). The basic goals of hip luxation treatment are early return to function with joint reduction and restoration of joint stability (15). Closed reduc- tion is the most common form of treatment, but failure rates are reported to be as high as 50% to 70% (16). Closed reduc- tion can be accomplished for uncomplicated luxations in the first five days after the injury (5). As the hip luxation becomes more chronic, numerous changes make closed reduction less likely to succeed. If closed reduction is not feasible or fails, surgical reduction and stabilization may then be considered.
Surgical techniques including primary capsulorrhaphy, pros- thetic capsulorrhaphy, toggle pin, triple pelvic osteotomy, transacetabular pinning, dynamic external fixator and ischio- ilial pinning are utilized for joint stabilization. However, re- luxation following surgical reduction of hip luxation has been reported in dogs with hip dysplasia (3). Although the pres-
ence of hip dysplasia reportedly does not increase the rate of recurrence following reduction, the outcome of open or closed hip reduction in dogs with hip dysplasia and osteoarthritis is considered poor (17). Femoral head and neck ostectomy (FHNO) may be indicated as a salvage procedure in cases in which reduction has failed (15). However, most FHNO patients do not have a completely normal gait in the operated hip, which is more apparent in larger dogs although some reports shows good outcome after FHNO in large dogs (7,8).
Additionally, the operated joint is weak, as evidenced by decreased circumference of the quadriceps muscle in at least 50% of dogs, periodic lameness after strenuous exercise, and subjectively lesser ability to jump, which is most common in large dogs (7). Canine total hip replacement (THR) is an accepted method of treatment for dogs with disabling dis- eases including hip dysplasia, coxarthrosis, hip luxation, and intra-articular fractures. THR improves function and dimin- ishes pain in the affected joint, with a reported success rate of 92% to 98% based on follow-up examinations (11). Cemented and cementless THR systems are clinically used, and although both methods are reliable and stable long-term, cementless fix- ation is preferred. While a cemented THR system use acrylic bone cement to form to form a mantle between the stem and to the bone, implant fixation with a cementless THR system is a biological osteointegration into a porous cup surface and anchors the stem to the medial cortex of the femur with lock- ing screws (6). The purpose of this paper is to describe the successful treatment of coxofemoral joint luxation in a dog with failed reduction of coxofemoral joint luxation using a cementless THR.
1Corresponding author.
E-mail: seatiger76@jbnu.ac.kr
126 Jooho Kim, Su-Young Heo, Minsu Kim, Kichang Lee, Namsoo Kim and Haebeom Lee
Case
A 7-year-old, intact female Golden Retriever weighing 38 kg was referred to the Chonbuk Animal Medical Center with left hip luxation. Close reduction was performed by the refer- ral hospital but was not effective.
On physical examination, severe pain and crepitus were noted on the left hip joint during joint extension. Thigh cir- cumference and excursion angle measurements were obtained under sedation (Table 1). On radiological examination, the left femoral head was not seated within the acetabulum and was positioned in the craniodorsal direction. Additionally, bilateral hip dysplasia and mild degenerative changes were observed.
We performed cementless THR for the luxated left hip joint.
The patient was premedicated with butorphanol (0.3 mg/kg, IV), and anesthesia was induced with propofol (6 mg/kg, IV).
Anesthesia was maintained using isoflurane, and epidural anesthesia was performed with 8.5 ml of 2% lidocaine. A skin incision was made on the lateral aspect of the thigh to approach the hip joint. The patient was positioned with the hemipelvis superimposed in the sagittal plane during the sur- gery. The femoral head was removed using a bone saw, the proximal aspect of the femoral canal was opened, and the bone marrow was reamed for insertion of the femoral stem.
Trial femoral implants were used to confirm proper implant size and anatomic alignment of the femoral stem. The acetab- ulum was completely exposed and reamed with an acetabular
reamer. The prosthetic implants, acetabular cup and femoral stem, were inserted at each position. A prosthetic femoral head was connected to the femoral stem and was reduced into the acetabular cup. Before suturing, a bacterial culture was performed, and no microorganism growth was found.
Daily physical rehabilitation including cold therapy, warm compresses, and controlled exercises were administered. On the first two days after surgery, cold therapy was applied, and warm compresses were applied for the next five days. In the first postoperative week, the patient was strictly confined indoors and then was restricted to a leash while outdoors for the next four weeks of recovery. Walks were initially 15 min- utes each, twice per day, and the activity continued to increase in speed.
Immediately after surgery, the anteversion angle of the femoral neck was determined to be 22o according to com- puted tomography, the angle of lateral opening was 45o, and the angle of inclination was 22o. On physical examination, prolonged knuckling was present but disappeared three days after surgery.
The thigh circumference and excursion angle measurements were obtained at one month and ten months postoperatively by the same observer (Table 1).
One month after surgery, radiographs showed good con- gruity between the femoral head and the acetabular cup. At ten months after surgery, the patient could sit, stand, walk normally and jump comfortably without lameness. The radio- graphs did not reveal any complication including luxation or development of degenerative changes of the acetabulum (Fig 1).
Discussion
Luxation of the coxofemoral joint is the most commonly reported joint luxation in dogs. Treatment options for reduc- tion of coxofemoral joint luxation include close reduction and open reduction for restoration of joint stability. Successful reduction of coxofemoral joint luxation is affected by body weight, presence of other injuries, pre-existing joint disease, and integrity of the joint capsule and articular cartilage (15). If coxofemoral joint reduction fails, a salvage procedure should be considered. In the present case, open reduction of the cox- ofemoral joint luxation using TightRope® fixation failed. We chose THR rather than FHNO as the salvage procedure
Fig 1. Ventrodorsal radiographic projections. A: Preoperatively. B: Immediately postoperatively. C: Ten months postoperatively.
Table 1. Clinical features of the THR preoperatively and one month and ten months after surgery
Preoperatively 1 month 10 months Thigh circumference (cm)
Operated limb Non-surgical limb
36 37
30 32
38 35 Flexion (o)
Operated limb Non-surgical limb
ND 55
58 54
53 54 Extension (o)
Operated limb Non-surgical limb
ND 151
151 155
160 157 ND, not done.
Treatment of Recurrent Coxofemoral Joint Luxation by Total Hip Replacement in a Dog 127
because FHNO has a less consistent outcome in dogs weigh- ing more than 20 kg. In a retrospective study of 132 dogs and 51 cats that had FHNO, 84% of patients had dorsal displace- ment of the femur, 75% had muscle atrophy, 74% had restricted range of motion, and 32% had pain on passive movement (12).
THR is an effective treatment option for disabling condi- tions of the coxofemoral joint. THR effectively provides pain relief and results in the optimal mobility in dogs. In the present case, ten months after THR, the radiographs showed maintained joint reduction, the dog showed good movement without lameness and the owner was satisfied. The thigh girth measurement in the THR operated limb was 108.6% of the contralateral limb. This result showed that limb function in the THR limb was better than that in the contralateral limb.
The most common complications associated with THR include hip luxation, femur fractures, aseptic loosening of the acetabulum-acetabular cup and/or the femoral stem, patella luxation infection, pulmonary embolism, incision granuloma, medullary infarction and sciatic neurapraxia (SN) (9,10,14).
SN is a rare THR complication in animals. The prevalence of SN after primary canine THR has been reported as 2.3% (221 THR cases), 3.6% (96 THR cases), and 1.9% (1000 THR cases) (2). The potential causes of SN in a dog after THR include direct or indirect mechanical incision or compres- sion of the nerve, thermal injury, or nerve stretching during reduction and entrapment. Neurological signs consistent with SN include conscious proprioceptive sensory deficits, such as prolonged knuckling. Full recovery from SN after THR is also common in dogs, although the recovery time is highly vari- able (2). In the present case, prolonged knuckling after THR was present on physical examination, which disappeared three days after surgery.
In our patient, THR resulted in satisfactory clinical func- tions, and no complications except recovered SN were observed during the ten-month follow-up period.
In conclusion, THR can be a successful treatment for cox- ofemoral joint luxation in dogs with failed coxofemoral joint reduction.
Acknowledgement
This work was supported by Basic Science Research Pro- gram through the National Research Foundation of Korea funded by the Ministry of Education, Science and Technol- ogy (NRF-2013R1A1A2009546).
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128 Jooho Kim, Su-Young Heo, Minsu Kim, Kichang Lee, Namsoo Kim and Haebeom Lee
대퇴관절 전치환술을 이용하여 개의 재발되는 대퇴관절 탈구증의 치료
김주호·허수영·김민수·이기창·김남수·이해범1
전북대학교 수의과대학
요 약 : 38 kg, 7년령의 골든리트리버가대퇴관절탈구증으로 의뢰되었다. 신체검사에서는 왼쪽 뒷다리를 신전시킬 때 통 증과 염발음이 확인되었다. 방사선 검사를 통해 왼쪽 대퇴관절 탈구증 및 경도의 퇴행성 골변화가 관찰되었다. 치료로 서 TightRope®를 이용한 최소침습 관절경적 정복을 하였으나, 수술 후 한달이 지나 재탈구가 발생하였다. 이에 대해 무시멘트형 대퇴관절 전치환술을 실시하였다. 수술 후 10개월 경과된 결과, 환자는 정상적으로 앉기, 서기, 보행을 보 였으며, 특이한 파행없이 편안하게 뛸 수 있었다. 수술한 뒷다리의 허벅지둘레는 반대쪽 다리의 그것에 비해 108.6%
였다. 이 증례를 통해 대퇴관절 전치환술은 대퇴관절 정복이 실패하여 재탈구된 개의 대퇴관절 탈구 치료에 효과적인 수술법이 될 수 있다.
주요어 : 대퇴관절 탈구증, 대퇴관절 전치환술, 골관절염
