Hip Dysplasia in Dogs - Triple and Double Pelvic Osteotomy
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Article Written by Dr. Daniel A. Degner, Board-certified Veterinary Surgeon (DACVS)

Animal Surgical Center of Michigan

5045 Miller Road

Flint, MI 48507

www.animalsurgicalcenter.com

Phone: 810-671-0088

Key Points

The triple or double pelvic osteotomy is an excellent surgery used to treat hip dysplasia in immature dogs

Candidates for this surgery should

  • be less than 1 year of age

  • have minimal to no arthritis

  • have a crisp positive Ortolani sign

Lameness typically resolves in about 3 months after surgery

Success rate for this surgery is about 90%


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 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.

 

 

 

 

 

 

What is Hip dysplasia

Hip dysplasia is a very common disease that affects larger breed dogs. This disease is the abnormal development of the hip as a puppy grows. Bad genetics are a major contributing factor. Sometimes the mother and father of the affected puppy are clinically normal and seemingly have good hips. If this is the case, the parents likely have hidden genes for hip dysplasia.

The first stage of hip dysplasia is looseness of the hip joints due to laxity of the ligament and joint capsule that holds the hip in place. In addition, pooly developed muscles of the hips can be a factor. Look at Fig 1 and 2 below and see the looseness of the left (L) hip joint (ball of femur not seated in socket) versus the right hip joint labeled R.  One can be fooled by plain x-rays of the hips as they may appear to be fitting very well, but in reality they are quite loose. It is important to do a complete orthopedic examination to determine if the hip joint will pop in and out of the hip socket. If the joint is loose, the hip partially dislocates with each step the dog takes and the joint will gradually become deformed. The socket becomes shallow and the head of the femur becomes flattened. Arthritis develops in the joint and causes pain.

Occasionally, the hip joint will be very loose and it will become completely dislocated with minimal trauma. This usually causes the pet to become suddenly lame. Occasionally, only one hip has dysplasia, but more commonly both hips are affected.

 

Signs

Clinical signs of hip dysplasia can be seen as early as 4 months of age; however, many dogs are 5 to 8 months of age when a problem is first noticed. Early clinical signs of hip dysplasia start out as exercise intolerance (puppy only plays for short periods of time) or an awkward gait of the hind limbs. Bunny hopping, stiffness on rising after a rest, lameness, and atrophy of the muscles of the hind limbs are typical clinical signs. Some dogs seem to experience signs of hip dysplasia when they are a couple of years old and others in the geriatric years.

 

Diagnosis

A diagnosis of hip dysplasia is based on a combination of history, clinical signs, physical examination findings, and radiographs. A decision to perform a pelvic osteotomy should not be based only on radiographs. The ideal candidate for a pelvic osteotomy should have minimal to no degenerative osteoarthritis on radiographs and a positive Ortolani sign (the surgeon feel the hip crisply pop in and out of the joint during the examination). The angle at which the hip pops back in the joint should be less than 40 degrees (angle of reduction). In the event that your pet is not a candidate for a pelvic osteotomy, total hip replacement may be recommended.

 

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.

 

Pelvic osteotomy surgery

The TPO involves making three separate surgical incisions to cut the pelvis in three places (black lines denote cuts in the pelvis - fig below). One incision is in the groin, the second is on the rump, and the third is over the side of the hip region. The last incision is the largest of the three. The pelvis is cut in three places and then rotated to the desired amount. A plate and screws are used to secure the pelvis in the rotated position. The rotation of the pelvis captures the head of the femur, thus prevent the joint from popping in and out. Clinically this dog was pain-free and did not have any lameness after healing had taken place.  Some arthritis has developed in the joint, but it usually does not progress to the degree of an unoperated dysplastic hip.

The double pelvic osteotomy (DPO) is preferred over the the triple pelvic osteotomy (TPO), as it results in less pain to the patient. With this procedure, only the ilium and the pubic bones are cut, leaving the ischium intact. Therefore, one less surgical incision is also needed. With the double pelvic osteotomy procedure, a specialized locking plate and locking screws are recommended. This also reduces the risk that the plate and screws will loosen in the postop period; x-ray right - months after surgery the femoral head is deeply seated in the cup of the hip joint. If the pelvis cannot be adequately rotated during the surgery will I resort to a TPO; this problem may be present if the patient is a little older (greater than 10 months of age).

 

Review of how the TPO and DPO works (illustration right - pelvis, as viewed from the hind end with the back part of the pelvis removed)

Before the pelvis has been rotated the femoral head does not seat very well in the acetabulum (labeled "Untreated").

After the pelvis has been rotated, the femoral head is seated in the acetabulum (labeled "Treated"). Note: put cursor over image to see rotation of pelvis

      

After care and convalescence

A prescribed oral pain reliever should be administered in the postop period at home. Nonsteroidal anti-inflammatory medications may be a part of the pain management protocol, but long-term administration of this medication is not recommended, as it may impede healing of the bone. In some cases, antibiotics may be prescribed.

A bandage may be applied to the incision until it is sealed. This bandage should be kept clean and only needs to be kept over the incision for about one or two days. The incisions should be checked daily for signs of infection during the first few weeks after surgery.

During the first 2 weeks after surgery, a sling should be placed under the belly, just in front of the hind limbs for the first 2 weeks to prevent slipping and falling when going outside. A bath towel or commercially available sling can be used for this purpose. Exercise restriction must be continued for 3 months. During the first 2 months the pet should be kept in the house on good footing (avoid slippery flooring); if needed put some throw rugs or strips of outdoor carpeting material on slippery floors. Short leash walks are permitted for elimination purposes. After the first 2 months, leash walks can be initiated and gradually increased.

The surgeon will monitor the healing process with at least two follow-up exams. The first is scheduled at two weeks after the surgery. During the second exam, at 6 weeks after the surgery, radiographs will be made again to evaluate the healing process.

By one day after surgery, most dogs will start to bear a mild to moderate amount of weight on the operated limb. By 6 to 8 weeks, the lameness should be dramatically improved. By 3 to 4 months after surgery, the pet should be completely sound on the operated limb(s).

 

Potential Complications

As with any surgery, complications may arise. Even though rare, anesthetic death can occur. Infection is also an unusual complication, as strict sterile technique is used during the surgery and antibiotics are administered during surgery. Excessive activity or exercise within the first 2 months can also lead to complications. The screws and plate that are used to hold the rotated pelvic bone in place could come loose or even break. This is not a concern once the bone has healed. The sciatic nerve which lies on the inner side of the pelvic bone could become bruised or damaged, which could result in loss of function of the limb. This is an unusual, but typically temporary complication. Obstruction of the urethra (tube leading from bladder) has been reported in the literature, but this is rare. Another complication could be severe progression of hip arthritis. In the event that this occurs and your pet has painful hip joints, a total hip replacement may be needed. Some arthritis will develop in the hip joint, but usually does not cause clinical lameness/stiffness. Development of severe arthritis that causes profound lameness is uncommon.

 

Prognosis

In general, about 90% of the dogs having the TPO or DPO surgery will be greatly improved, if not normal. Some mild arthritic changes can develop with time, but this usually does not cause signs of lameness or stiffness until the pet is geriatric.

 

Rev 9/15/11

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

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  • Experience in the development of new surgical treatments

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