Femoral Head and Neck Excision
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Article Written by Dr. Daniel A. Degner, Board-certified Veterinary Surgeon (DACVS)

Key Points

The femoral head and neck excision is a salvage procedure used to treat painful hip conditions

This surgery has the best outcome in small to medium breeds of dogs and cats

For an optimal recovery, rehabilitation therapy at home in conjunction with therapy at an animal rehabilitation center is recommended


Anatomy

The pelvis is made of four bones: the ilium, acetabulum, pubis, and ischium. In the immature animal, these bones are not fused together, but as the pet matures, these bone fuse together in one confluent bone. The ilium joins the pelvis to the lower part of the spine called the sacrum.

The hip joint consists of a ball (femoral head) which is at the end of the femur bone and socket (acetabulum). This joint joins the hind limb to the pelvis. The joint is held together with a very strong round ligament (sometimes called the teres ligament) and the joint capsule. The muscles that surround the hip joint also provide very good support to the joint.

 

 

 

 

 

 

Diseases Treated by Femoral Head and Neck Excision

Hip dysplasia is a very common disease that affects large breed dogs. This disease is caused by the abnormal development of the hip as a puppy grows. Bad genetics are a major contributing factor. Sometimes the dam and sire of the affected puppy have no physical evidence of hip dysplasia. If this occurs, the parents likely have hidden genes for the disease. Hip dysplasia results in looseness of the hip joints. Because the joints are loose the head and socket of the hip become deformed. The socket becomes shallow and the head of the femur gets flattened. Arthritis develops in the joint and causes pain. Clinical signs of hip dysplasia can be seen by 4 months of age, however, many dogs are 8 to 12 months of age. Some dogs seem to experience signs of hip dysplasia when they are a couple of years old and others in the geriatric years. Warning signs of hip dysplasia may first start out as exercise intolerance. Bunny hopping, stiffness on rising after a rest, lameness on a limb, and atrophy of the muscles of the hind limbs are other typical clinical signs.

Dislocation of the hip is another condition that requires surgery. If signs of arthritis are present with dislocation the hip or if the dislocation is chronic, then the hip should not be placed back into the socket. Instead, total hip replacement or femoral head and neck excision should be performed.

Severe fractures of the acetabulum or of the head or neck of the femur sometimes that cannot be repaired likely will require femoral head and neck excision.

A form of degeneration of the hip joint, called Legg-Calve-Perthes disease that is found in small breed dogs , is due to damage of blood supply to the femoral head. This disease causes the femoral head to collapse and pain results. The more economical treatment is FHO, but total hip replacement is now available for this size of dog.

      

Summary of diseases that could benefit from femoral head and neck excision

Hip dysplasia

Dislocation of the hip with concurrent arthritis

Fractures of the hip joint which are not repairable (head of femur or acetabulum)

Legg-Calve-Perthes disease

 

Preparation for surgery

The pet should be fasted prior to surgery, as instructed by the surgical team. Water is usually permitted up to the time of admission to the hospital. An antacid such as Pepcid AC may be prescribed and should be administered by 6 AM on the day of surgery; this treatment will help reduce the risk of esophagitis (heartburn) in the postop period. The surgical team should be informed of any medications that your pet is currently receiving. The pet should not receive any aspirin within 1 week of surgery, as this medication will thin the blood and increase the risk of bleeding. Just prior to surgery, your pet will receive a sedative, have an intravenous catheter placed for the administration of intravenous fluids and intravenous medications, be induced under general anesthesia with medication(s), and have a breathing tube (endotracheal tube) placed to allow delivery of oxygen and gaseous anesthesia. The surgical site will be clipped and cleansed with an anti-septic solution in preparation for surgery. While under general anesthesia, the pet's breathing will be assisted with a ventilator and vital parameters such as heart rate, respiratory rate, core body temperature, blood pressure, oxygenation of the blood (pulse oximetry), exhaled carbon dioxide (capnography), and heart rhythm (EKG) will be monitored to ensure the pet's well being. Pain will be controlled both during and after surgery with analgesics (pain-controlling medication); we routinely place an epidural catheter for administration of narcotics during surgery and for two days after surgery. Please note that each surgical and anesthesia team may elect to chose a different, but effective analgesia protocol.

 

Treatment

The pet will be anesthetized and the entire limb and hip to be operated will be clipped. An incision is made over the hip region. The hip is exposed and the femoral head and neck is removed. The muscle, fat and skin layers are then closed. If deemed necessary, the femoral head is submitted for microscopic evaluation (histopathology) by a pathologist. After the surgery, fibrous tissue will form in the region of the hip joint which prevents bone rubbing on bone. The muscles hold the hip in place. The operated limb will be slightly shorter than prior to surgery, but this does not cause any functional problems. The illustration right shows the normal hip and operated hip (FHO).

 

 

 

 

 

 

 

In the radiograph below, this dog has had both femoral heads removed.  Take note of the femoral head and neck excision site on the right (R) which was recently done; the excision is very clean and prevents the bone from rubbing on the hip socket (called the acetabulum) of the pelvis.  Also take note that the left hip has also had the FHO procedure, but this one was operated years ago and new bone has grown on the site of the FHO; it is not contacting the pelvis and is not causing any clinical problems.

      

 

 

 

After Care and Convalescence

A prescribed analgesic medication should be administered in the postop period at home. Nonsteroidal anti-inflammatory medications are very beneficial to reduce pain at the surgical site and encourage weight bearing. In some cases, antibiotics may be prescribed.

Activity is not limited after surgery. In fact, exercise will help to maintain a good range of motion of the hip joint. The owner should do rehabilitation therapy using the surgeon's recommendations until the pet is using the limb normally. Flexion and extension of the hip joint is essential in the recovery period. Rehabilitation therapy will help prevent adhesions from forming, thus maintaining a good range of motion of the hip region. If possible, swimming should be started after the incision has healed. It is also highly recommended that rehabilitation therapy sessions be scheduled with a professionally trained therapist.

Most dogs will start to bear a small amount of weight on the limb within 2 weeks after surgery. Within 4 to 6 weeks the pet should bear a moderate amount of weight on the limb. By 2 to 3 months after surgery, recovery is complete.

The pet should be examined 2 weeks and 2 months after surgery to ensure that the hip region is healing well.

Most small pets do well following femoral head and neck excision surgery. Larger dogs can also do well, but some weakness on that limb frequently can be seen. This is due to the muscles supporting the region of the hip instead of the actual joint. As a result, heavy exercise can cause the pet to become stiff or lame. Anti-inflammatory medication can be given to give your pet relief if needed. If your pet is a medium to large breed dog, total hip replacement is the preferred technique over the femoral head and neck excision surgery.

 

Complications

As with any surgery, complications may arise. Even though rare, anesthetic death can occur. With the use of modern anesthetic protocols and extensive monitoring devices (blood pressure, EKG, pulse oximetry, inspiratory and expiratory carbon dioxide levels, and respiration rate), the risk of problems with anesthesia is minimal. Infection is also an unusual complication, as strict sterile technique is used during the surgery. Poor range of motion of the hip joint can occur and is usually due to a lack of rehabilitation therapy. If your pet is not using the limb very well after 2 to 3 weeks, anti-inflammatory therapy should be continued for another 2 to 4 weeks. Sciatic nerve damage is a rare complication of FHO surgery, but frequently is a transient problem.

rev 9/25/11

Frequently Asked Questions After Surgery

When should my dog have the first bowel movement after surgery?

  • Many dogs will not have a bowel movement for the first 4 to 5 days after surgery
  • Reasons that a dog will not have regular bowel movements after surgery include:
    • The dog has been fasted prior to surgery
    • Dogs do not eat well during the hospital stay
    • They frequently do not eat well when they go home
    • They are fed highly digestible food that produces little stool
    • Pain medication that contain narcotics (such as morphine, fentanyl patches, and tramadol) can be constipating
  • If a pet does not have a bowel movement on the 5th day of being home, a stool softener such as metamucil can be fed
    • Dose of metamucil is 1 tsp per 25 Kg mixed in with each meal (canned dog food); feed immediately after mixing, as the metamucil will gel the food and may make it less palatable

My pet had surgery and will not eat.  What can be done?

  • Dogs
    • Most pets will not eat their regular dog food after surgery, especially if it is kibble.
    • Offer a cooked diet having a 1:1 ratio of a protein source and carbohydrate source.  The protein source can be any meat (example: chicken breast, turkey breast, lean hamburger) that is low in fat and should be cooked (drain off all fat after the meat has been cooked).   The carbohydrate can be pasta, potato or white rice.
    • Try canned dog food; to enhance the flavor sprinkle a very small amount of garlic powder or chicken or beef broth (Chicken-in-a- MugTM or Beef-in-a-MugTM products)
    • Try Gerber strained meats for babies such as the chicken, beef, turkey, or veal
    • Try Hill's A/D diet available at most veterinary hospitals
    • Hand feeding: place a small amount of food in the mouth so that your dog gets the flavor
    • Warm the food slightly in a microwave, as the food will be more aromatic; stir the food before feeding and test the temperature on the bottom side of your wrist; it should only be luke warm.
    • Remember that most pets will not eat the first day or two after they get home from surgery
  • Cats
    • Offer smelly foods that contain fish such as tuna or smelly cat foods
    • Try Gerber strained meats for babies such as the chicken, beef, turkey or veal
    • Hand feeding:  with your finger place a small amount of food on the roof of your cat's mouth; use a syringe to get soft food into the mouth
    • Warm the food slightly in a microwave as the food will be more aromatic; remember to stir the food before feeding and test the temperature; it should be only luke-warm
    • Some cats will only eat dry food, try kibble if your cat normally has been fed that food
    • Petting and stroking your cat frequently will help to stimulate appetite
    • Remember that most pets will not eat the first day or two after they get home from surgery
    • Appetite stimulants such as cyproheptadine may be helpful
    • If your cat refuses to eat anything for 7 days a stomach tube or nasogastric tube should be placed to provide nutrition so that a serious liver problem (hepatic lipidosis) does not develop

My pet is vomiting.  What can be done?

  • The first thing for you to discern is whether your pet is vomiting or regurgitating.  Both will result in fluid or food being brought up.  Vomiting always will have heaving or retching of the abdomen prior to expulsion of the vomitus.  Regurgitation is not associated with heaving and the pet usually just opens the mouth and fluid or food will be expelled.  Usually the regurgited material will be clear or brown colored fluid. 
  • Next is to identify the cause of the vomiting or regurgitation.
  • Causes and treatment of vomiting after surgery
    • When some pets return home after a stay in the hospital they may drink excessive amounts of water at one time and then vomit; if this appears to be the case, the water should be limited to frequent smaller amounts.
    • Medications such as antibiotics, narcotics or nonsteroidal anti-inflammatory medication commonly cause vomiting after surgery.  In order to see which medication is causing the problem, the administration of each drug should be separated 2 hours apart.  Usually the pet will vomit or appear nauseated (drooling and sick look) within 1 hour of administration of the medication that they are sensitive to.  The antibiotic in some cases may be changed to a different one, or may be discontinued. 
    • Stomach upset from anesthesia is a potential cause of vomiting and will pass within a couple of days. 
    • An uncommon cause of vomiting after surgery is internal organ failure.  Blood testing will confirm this problem. For this reason vomiting should not be ignored if it persists for more than 24 hours.
    • If your pet had surgery of the bowels or stomach, vomiting is always a concern, as it may indicate that infection of the abdominal cavity, called peritonitis, is present.  Do not ignore this sign.
    • Symptomatic treatment of vomiting involves withholding food for 12 to 24 hours, then introducing small amounts of bland food such as rice and lean cooked hamburger, if your pet does not vomit after that then gradually wean him/her back onto the regular diet after 3 days.  In order to decrease the acidity of the stomach, Pepcid AC 0.5 mg/kg can be given by mouth twice daily for 5 days.  Metoclopramide and Cerenia are good anti-vomiting medications for dogs and cats.  You should always consult a veterinary healthcare professional before administering medication.
  • Causes and treatment of regurgitation after surgery
    • The most common cause of regurgitation is reflux of acid from the stomach into the esophagus while your pet is under anesthesia.  Acidic fluid from the stomach can cause a chemical burn of the esophagus and result in a bad case of heart burn, called esophagitis.  This results in poor motility of the esophagus, therefore water and food will accumulate in this structure.  In most cases, esphagitis is self-eliminating and will resolve within two or three days. 
    • If the esophagitis is severe the esophagus may develop one or more strictures.  A stricture is a narrowing or stenosis of the esophagus and does not allow passage of food down the esophagus, in regurgitation that lasts longer than one week.  This problem should be brought to the attention of your pet's doctor within the first two weeks so that it can be treated by ballooning the stricture (minimally invasive procedure, as it is done with the aide of an endoscope).  If an esophageal stricture is chronic surgery is needed.
    • Symptomatic treatment of regurgitation caused by esophagitis includes feeding bland food, and administering a coating agent (sucralfate) and an acid blocker (omeprazole or other).  Consult a veterinary health care professional if the regurgitation continues for more than a couple of days.

How do I know that my dog is in pain following surgery?

  • Signs of pain include
    • crying
    • biting if you get near the surgical site
    • grimacing (lips are pulled back and the the dog looks anxious)
    • tragic facial expression
    • panting
    • restlessness and unable to sleep; pacing
    • if abdominal surgery was done the pet will not lie down on the incision, or will continually sit up in spite of appearing very tired
    • the worst pain will be for the first 2 to 3 days after surgery

What can I do to control my dog's pain?

  • Narcotic medications that control pain: tramadol, butorphanol, Duragesic (fentanyl patch)
  • Anti-inflammatories used to control pain: Deramaxx, Rimadyl, Previcox, or Etogesic
  • If an orthopedic surgery has been done cold packing the surgical site may be helpful
    • A cold pack may be a pack of frozen peas, crushed ice in a Ziploc bag, or a cold gel pack; place a thin barrier between the skin and the cold pack.  An alternative to a cold pack is to freeze water in a styrofoam cup; after frozen cut the bottom of the styrofoam cup out. Cool the surgical site around the incision by rubbing the exposed ice directly on the skin in a circular pattern.  Cooling the surgical site helps to numb the area.

How do I know that my cat is in pain following surgery?

  • Pain is more difficult to assess in cats versus dogs, as signs can be more subtle and they usually do not vocalize when in pain
  • Signs of pain in a cat include the following:
    • biting if you get near the surgical site
    • growling or deep cry
    • not wanting to eat
    • hiding and not wanting to be near owner (remember that this could also be caused by the cat just being upset about leaving home and coming back)

What can be done for pain at home for my cat?

  • Pain medication such as buprenorphine or a Duragesic (fentanyl) patch
  • Tylenol will kill a cat as they lack abundant glutathione enzyme in the liver
  • Anti-inflammatories can be used, but the dose is much less than dogs

Is it okay for my pet to lick the incision?

  • If a dog licks the incision, the healing process may be delayed.
  • Licking can remove stitches and cause the incision to open
  • Licking can become a severe habit that is difficult to break
  • Licking can cause infection as the mouth has many bacteria
  • Dogs will frequently lick the incision when the owner is not watching such as at night time; if the skin looks red or excoriated the most common cause is from licking.
  • To stop your pet from licking the following can be tried:
    • Elizabethan collar can be placed on the neck; this will not help stop your pet from scratching at the region
    • Cervical collar (bite not collar) is a less awkward device and can be effective at stopping a pet from licking the surgical site
    • A tee shirt can be used to cover an incision on the chest or front part of the abdomen; gather the waist of the shirt up over the dog's back and wrap an elastic band around this part of the shirt.
    • A bandage or sock can be used to cover an incision on a limb; fasten the top of the sock to the dog's limb with tape.
    • Bitter apple can be applied around the incision; many dogs will continue to lick  after application of this topical
    • Bitter Apple and Liquid HeetTM (obtain this from a drugstore...it is used for sore muscles) mixed in a 2:1 ratio can be applied around the skin incision
    • Antipsychotic medication in some cases is needed

Board-certification by the American College of Veterinary Surgeons

What does it mean?

  • Four years of advanced training in surgery beyond the Doctor of Veterinary Medicine Degree

  • Experience in the development of new surgical treatments

  • Rigorous examination by the American College of Veterinary Surgeons to ensure competency in advanced surgical techniques

  • Assurance that a veterinarian is a surgical specialist

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