Indian Journal of Animal Research

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A Clinical Study on Total Hip Replacement using Cemented Prosthetics for Management of Hip Dysplasia in Dogs

N. Venkatesh1,*, K. Jagan Mohan Reddy2, E.L. Chandra Sekhar3, N. Rajendranath4
1Department of Veterinary Surgery and Radiology, College of Veterinary Science, Rajendrangar, Hyderabad-500 030, Telangana, India.
2Department of Surgery and Radiology, College of Veterinary Science, Korutla, Jagytial-505 326, Telangana, India.
3Department of Veterinary Clinical Complex, College of Veterinary Science, Rajendrangar, Hyderabad-500 030, Telangana, India.
4Department of Anatomy, College of Veterinary Science, Rajendrangar, Hyderabad-500 030, Telangana, India.

ABSTRACT

Background: The current study was undertaken to evaluate the clinical efficacy of cemented prosthetics for total hip replacement   for management of hip dysplasia in dogs. Total hip arthroplasty will eliminate pain and, restore function of hip joint.

Methods: The dogs with clinical signs of coxofemoral joint affections were diagnosed using standard hip extended ventrodorsal radiographs of pelvis. Those dogs which are not responded to the medical management, with severe degenerative changes and osteoarthritis were selected for surgical management  for total hip replacement. The femoral stems used in this study were small (4) and Medium (2). The size of the acetabular cup used ranges from 20 to 22 mm outer diameter. The bone cement used was polymethyl methacrylate (PMMA) low viscosity type bone cement (Simplex-P). Clinical evaluation of the treated dogs on 2nd day post operatively indicated functional outcome (on the basis of WOMAC score) as excellent in four dogs and good in 2 dogs as the mean  scores  of parameters was 1.0±0.36, 0.83±0.65, 0.83±0.40, 1.0±0.68, 0.50±0.34, 0.66±0.33, 1.50±0.50, 1.16±0.47, 0.50±0.34, 1.50±0.42, 2.0±0.51 and over all mean of functional outcome is 11.33± 4.06 out of 40 points, lower scores reflect better function than higher scores. Radiological and clinical assessment are excellent to good in four cases and poor  in two cases, with  mean  score of 0, 0.83, 1.50±0.5,0,0,0, 1.16±0.40,0, 1.33±0.84. The mean score of radiological and clinical assessment was 4.88±1.85 out of 40 points, lesser score indicates effectiveness of the surgical procedure. The lamenessfrom grade V improved onby 45 days to  grade I except one dog at grade II, by 60th day,  all 5 dogs progressed to grade I and one dog to grade II. The post-operatively radiographic  evaluation on day one revealed hip showing cup of the prosthesis into acetabulum. 

Result: Total hip replacement using  cemented  prosthetics for management of  Hip dysplasia in dogs was found to be effective in dogs with more than 20 kg body weight  and returned to normal limb function after 45th post operative day in 4 out of 6-dogs, whereas in other  two dogs, there is a complication of loosening of acetabullar cup after 60 days, the complications will be addressed  with uncemented implants. 

INTRODUCTION

Canine hip dysplasia affects bone growth and remodelling, resulting in abnormal friction between both joint surfaces and, subsequently, joint deformity and degenerative joint disease (DJD) (Lohi and Nicholas, 2009).
 
Hip dysplasia is a disease with varying degree of laxity of hip joint and varying degrees of shallow acetabulum and flattening of femoral head, leading to osteoarthritis. (Smith et al., 2012).
 
The clinical sign along with Ortolani test for assessing joint laxity were used for diagnosis (Corr, 2007). The first radiographic signs of canine hipdysplasia, seen as early as 7 weeks of age, are subluxation of the femoral head and under development of the craniodorsal acetabularrim (Smith et al., 2012).
 
Treatment of hip dysplasia include medical or surgical. Surgical treatment should be the option when the response to the conservative management was not satisfactory (Schulz and Dejardin, 2003).
 
Total hip arthroplasty consists of femur component the stem and the head is made of stainless steel or cobalt chrome or titanium, acetabular component is made of ultra high molecular weight polyethylene (UHMWPE) cup and for fixing polymethyl methacrylate (PMMA) bone cement is used (Olmstead et al., 1983 and Hulse and Johnson, 2007).

The surgical options recommended for each dog differ depending on age and clinical condition. Hence, the present work was to evaluate the clinical efficacy of cemented prosthetics in total hip replacement for repair of canine hip dysplasia.

MATERIALS AND METHODS

Anamnesis
 
A total of 98 clinical cases of canine hip dysplasia were recorded in dogs during the period of the study. The  breed wise was Labrador retriever 26.5% (26), German Shepherd 20.4% (20), Goldenretriever 17.3%(17), Non-descript 8.1% (8), Great Dane 3.0% (3), Pomeranian 4.0%  (4), Doberman  5.1% (5), Pug 5.1% (5), Rottweiler 4.0% (4), Saint Bernard 6.1% (6). The age distribution  in dogs less than one year, one to four years, four to eight years and above eight years were 48.1% (48), 22.2% (22), 10.2% (10) and 18.3% (18) respectively.Gender distribution was 61.2% (61) and 38% (38) in males and females respectively. The 6 selected dogs for total hip replacement were males and average age ranges from 29.33±13.55 days and 27.5±1.80 kg and duration of lameness ranging from 54.6±13.31 days (Table 1).

Table 1: Details of dogs selected for the study.


 
Pre-operative observations
 
Among the 6 selected dogs for surgery, the signs of Bunny hopping gait (n=4), difficulty in rising (n=6), exercise intolerance and reluctance to walk or run (n=4), Hip asymmetry (n=4) and atrophy of thigh muscles (n=3) were noticed in dogs with hip dysplasia (Table 2). The dogs with hip dysplasia with hip subluxation test and Ortolani sign. (Table 3). These laxity measurements are calculated from radiographs for Norbergangle and the distraction index measured on the distraction radiograph (Table 4) were used for diagnosis. Norberg’s angle were less than 105° and distraction index of 0.71 is consistent with increased laxity and high risk for developing osteoarthritis. Pre-operatively all dogs with Hip dysplasia exhibited grade III to grade IV lameness (normal weight bearing at rest and favours the affected limb) Vasseur et al (1995) (Fig 1).

​

Table 2: Clinical signs exhibited by dogs selected for the study.



​

Table 3: Physical examination findings of dogs selected for the study.



​

Table 4: Norbergs angle and distraction index in all cases.



Fig 1: Pre-operative weight bearing of the dogs in all cases of dogs with hip dysplasia showing bunnyhop gait and pointing hind foot limb to ground.



All dogs with hip dysplasia pre-operative radiographs showed moderate to severe periarticular osteophyte formation, osteophytes on the cranial and caudal acetabular margins with varying degree of subluxation (Fig 2).

​

Fig 2: Shows hip dysplasia with moderate to severe periarticular osteophyte formation, osteophytes on the cranial and caudal acetabular margins with varying degree of subluxation.


 
Planning of surgery
 
The hip Joint is accessed through cranio lateral approach  good  visualization of the joint as described by Johnson (2014).
 
Anaesthesia
 
Xylazine hydrochloride at the rate of 1 mg/kg body weight and Ketamine hydrochloride @ 10 mg/kg  intramuscularly were used for producing sedation, later  induction was done with propofol at the rate of 5 mg/kg body weight intravenously and maintained with isoflurane anaesthesia with 100 per cent oxygen and maintained in IPPV with setting of respiration rate 15 minute, Inspiratory.
 
Implants
 
The femoral stem and acetabular cup was designed in different sizes viz. size- S, size- M and size- L. The size of the acetabular cup used ranged from 20 to 25 mm outer diameter. The head sizes used were small (4) and medium (2) in the study which were  from ultra high molecular weight polyethylene (UHMWPE) (Fig 3).

​

Fig 3: Implants used in the present study.


 
Surgical procedure
 
Craniolateral approach for femoral neck and head and acetabulum. The superficial fascia of the biceps femoris muscle incised along the cranial border of the biceps and the biceps were retracted caudally to reveal the tensor fascia lata and superficial gluteus muscle. Exposure to the dorsal aspect of the joint capsule was enhanced by performing tenotomy of the superficial gluteus at the greater trochanter. Partial tenotomy of deep gluteal muscle insertion (tag deep gluteal tendon with suture, aiding in retraction and identification of tendon for closure). Using an oscillating saw, the femoral head ostectomy was performed. The femoral canal was reamed with femoral reamer. The acetabulum was reamed with acetabular reamer to remove the remnants of tissues attached to the acetabular surface and to convert the acetabulum into hemisphere for the exact placement of the acetabular cup. Final reaming was made with finer acetabular reamer and was directed in such a way to achieve 20 to 30° of anteversion. The cranial and medial aspect of the acetabulum was reamed, with taking precaution not to over ream the dorsal rim. Three to four anchoring holes for keying of the PMMA to the acetabulum over the dorsal rim of acetabulum were made using drill bit of appropriate size. The PMMA- bone cement was prepared by mixing monomer and polymer in a sterile cup (First generation cement mixing technique) to come to doughy consistency by hand mixing and rolled into ball and was impacted into acetabulum. The acetabular cup was impacted with an acetabular cup impacter, the cup holds firmly in the acetabular cavity within 2 to3 minutes after fixation. After fixation, the cup was checked for integration and firmness for loosening. The stem was inserted in normoversion or slight retroversion to prevent luxation and improper wear on tear on the head and acetabular component.  The head was fixed to the stem and then the femoral head was reduced into the acetabulum by slight flexion and internal rotation of the femur. The capsule was closed with PGA 1-0 by simple interrupted fashion. The muscle tenotomy performed was closed with PGA 1-0 in interrupted fashion.  The muscle, subcutis and skin were closed as per standard methods as mentioned earlier (Fig 4).

Fig 4: Surgical procedure for total hip replacement with cemented prosthetics in dog.

RESULTS AND DISCUSSION

In the present study the out of 6 dogs, the etiology was overweight in 4-dogs  and  in 2-dogs it was due to slippery floor along with genetic predisposition  which is in agreement with  Krontveit et al., (2010) where as some other authors   Madsen et al., (1991) reported that abnormal and delayed endochondral ossification in the coxofemoral joint has been identified in 15 day old dogs that developed CHD at the age of 12 months old and Fries and Remedios (1995) opined that excess dietary calcium and vitamin D may contribute to the development of canine hip dysplasia in genetically predisposed animals, Krontveit et al., (2012) reported that puppies £3 months of age should not be allowed access to stairs, but should be allowed outdoor exercise on soft ground in moderately irregular land to decrease the risk for developing hip dysplasia.
 
In the present study, the age distribution in dogs is in congruence with Arunprasad et al., (2012) and Srinivasamurthy (2015). 
 
In the present study, gender wise distribution is in congruence with Arunprasad et al., (2012) and Srinivasamurthy (2015) contrary incidence in females  are more by Coopman et al., (2008) where as  others  reported no difference in sex for incidence of hip dysplasia are Fries and Remedios (1995) and Stanin et al., (2011).
 
In the present study, all the dogs exhibited the signs with varying degrees of lameness is in congruence with Arunprasad (2009) Tobias and Johnston (2012) and Srinivasamurthy (2015).  
 
The dogs with hip dysplasia were negative for the abduction external rotation test and hip extension test but positive for hip subluxation test and Ortolani sign. The Norberg’s angle for both limbs for all cases  were less than 105 degrees is considered  abnormal and distraction index for all cases were more than 0.3. and diagnosis of canine hipdysplasia were based on subluxation (hiplaxity) and radiographic evidence of degenerative joint disease. These findings are in congruence with the findings of several authors like Schachner and Lopez (2015) and Peterson (2017).
 
The implant was made up of 316 L medical grade stainless steel.  The bone cement used in this study was polymethyl methacrylate (PMMA).  The acetabular cup   and corresponding femoral stem of small (4) and medium (2) size were used in 6 cases. This is in accordance with Arunprasad (2009).
 
The normal angle of anteversion was 20 to 27°. The acetabular cup used in this study ranged from 20  to 22 mm outer diameter with radio opaque wire for defining the lateral angle of the cup. The same procedure were used by several workers for cemented total hip replacement  like Iwata et al., (2008); Arunprasad (2009); Minto et al., (2011); Fitzpatrick et al., (2012) whereas Ni et al., (2005) reported the uncemented femoral fixation had better long term outcome, especially for younger patients and Iwata et al., (2008) carried out a retrospective study to compare outcomes between cemented and uncemented total hip arthroplasties,  and found that uncemented  total hip replacement  had better results.
 
Post-operative clinical observations
 
Clinical evaluation of the treated dogs on 2nd day post operatively indicated functional outcome (on the basis of WOMAC score) as excellent in four dogs and good in 2 dogs  as the scores of  different parameters like  Experience stiffness in the morning or after rest, Has trouble climbing stairs, Posture for toileting, Symmetry when sitting down, Sleep disruption, Vocalisation at rest, Exercise tolerance, Severity of limp, Off leash activity, Ease of jumping, Distance the pet walk on leash with comfort, mean  scores  is 1.0±0.36, 0.83±0.65, 0.83±0.40, 1.0±0.68, 0.50±0.34, 0.66±0.33, 1.50±0.50, 1.16±0.47, 0.50±0.34, 1.50±0.42, 2.0±0.51 and over all mean of functional outcome is 11.33± 4.06 out of 44 points, Lower scores reflect better function than higher scores (Table 5). Whereas WOMAC scoring index was by standard hip extended radiograph for radiological and clinical assessment performed as per, that included the mean score of canal fill, cement mantile width, presence of radiolucent line, cement porocity, postion of stem, position of cup, pain on deep palpation, early complication  and late  complication  are excellent to good in four cases and poor  in two cases. WOMAC scoring index was found to be mean scores of 0, 0.83, 1.50±0.5,0,0,0, 1.16±0.40,0, 1.33±0.84. The mean score of radiological and clinical assessment was 4.88 ±1.85 out of 40 points, lesser score indicates effectiveness of the surgical procedure (Table 6). The results were in congruence with other s like Iwata et al., (2008), Minto et al., (2011) and Arunprasad et al., (2015).

Table 5: Functional assessment scoring by owners assessment questionnaire (WOMAC score) (Iwata et al., 2008).



Table 6: Clinical and radiological scoring for total hip replacement (WOMAC score) (Iwata et al., 2008).


 
Lameness grading
 
In the present study, it is observed on post-operative day one, all the dogs showed lameness of grade V, evidenced by lifting of limb off the ground. Whereas by day 7, 4 dogs   progressed to grade II and one  dogs  to grade III and another to grade IV,  by day 15 all dogs progressed to grade II  except dog 5. By  day 45, all dogs progressed to grade I except  one dog at grade II, by 60th day,  all 5  progressed to grade I and one  dog to grade  II (Table 7) (Fig 5).  Similar results were reported by Minto et al., (2011), Fitzpatrick et al., (2012)  and Arunprasad et al (2015).
 
​

Table 7: Showing the pre and post operative grading of lameness in dogs subjected to total hip replacement (Vasseur et al., 1995).



Fig 5: Post operative weight bearing on the dogs under gone total hip replacement.



Post-operative radiographic observations
 
The radiographic evaluation post-operatively on day one   revealed hip showing cup of the prosthesis into acetabulum. (Fig 6) The stem of the prosthesis was fixed in the femoral canal and occupied the entire diameter of femoral canal till the end of study period, (Fig 7) whereas in two dogs, the where cup loosening of the acetabular cup was noticed after 60 days. This is in congruence with Ota et al., (2005) and Andrews et al., (2008).

Fig 6: Immediate post operative radiographs of dogs showing postion of implant in total hip replacement technique.



Fig 7: Post operative radiographs of dogs showing position of implant in total hip replacement technique on day 30.


 
Complications
 
The acetabular cup loosening was noticed for which the implant was removed and made to form pseudo arthrosis as in case of excision arthroplasty (Fig 8). The dogs showed partial weight bearing at rest and while walking. The complications reported by other workers are Andrews et al., (2008) also reported similar complications where as Vezzoni et al., (2013) also described the application of  cementless acetabular component specifically designed for the treatment of cup loosening.

Fig 8: Radiograph showing the acetubular cup loosening in case no-5.

CONCLUSION

The present clinical study on total hip replacement using cemented  prosthetics for management of  Hip dysplasia in dogs  was found to be effective technique in dogs with  more than 20 kg body weight and in dogs over 20 kg, the   complications of loosening of acetabullar cup after 60 days would be  addressed with  uncemented  implants  which are more costly and need surgeon’s expertise and following standard procedure.

CONFLICT OF INTEREST

All authors declared that there is no conflict of interest.

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