Surgical repair of hip dysplasia in dogs

Femoral head ostectomy procedure - Cavalier King Charles Spaniel

Question: Hi! My 2 3/4 yr old Cavalier King Charles Spaniel was diagnosed with severe hip dysplasia at a few months of age. We took her to two teaching hospitals both of which confirmed the diagnosis. She also has had stomach ulcers which restricts treatment. After this winter, she has been experiencing a great deal more lameness and recently had episodes of pain where she would cry loudly and fall back and lie down. After a shot of cortisone which seemed to provide minimal relief we decided to proceed with an FHO procedure. I guess we were hoping that we would wake up one day and she would be miraculously cured. My concern is that we have been told this breed is too small to be considered for a total hip replacement. Therefore the FHO, a salvage technique has been offered. My worry is that Rose is a large Cavalier weighing in at a muscular 27lbs. As opposed to the top weight usually seen at 17/18 lbs. She isn`t fat but muscular. So you see this FHO as being compromised by her size? Will the loss of skeletal support be a problem or will her muscular body be helpful? Thanks a lot. I respect and love this website! Marcia

Answer: Marcia;

The success of femoral head ostectomy procedures is very good for patients weighing less than 50 lbs. Good muscling would be an advantage in post-operative recovery. This procedure usually works even in obese patients in this weight range but obesity is one factor that worries me when I am contemplating an FHO procedure for a patient. The other factor I worry about is a loss of muscling due to the hip dyplasia causing disuse of the affected limb. Since these do not seem to be problems for Rose, the odds are good that the FHO will help a great deal. I am not aware of any new developments in availability of total hip replacement prostheses for small dogs (less than 50 lbs) so it probably is true that total hip replacement is not an available option.

Good luck with this. The odds are in your favor that it will help.

Mike Richards, DVM 3/10/2001

FHO and other options for severe hip dysplasia in Cavalier

Video: Surgical repair of hip dislocation in dogs.flv

Question: I have a Cavalier King Charles Spaniel who was diagnosed with severe hip dysplasia at less than a year. She is now almost 3 years old and weighs about 20/23 lbs. She is very muscular and big for this breed. We were told that because of her size she was not a candidate for hip replacement. FHO was given as the possible solution. Because she appears to get around ok, we opted not to proceed with the FHO. I had concerns with it possibly leaving her with side effects- skeletal support type of things. I have been told the FHO would be just as much a solution down the road as today. Do you agree or do you think we should be proceeding with surgery? Thanks.

Answer: M;

At the present time, to the best of my knowledge, no one makes hip prostheses for hip replacement surgery for dogs smaller than about 50 lbs. (in this range, anyway). So hip replacement isn`t an available option.

Femoral head ostectomy works pretty well in dogs that weigh less than 35 to 50 lbs. and who are not obese. It works best if it is done before the progression of the arthritis associated with hip dysplasia begins to cause the dog to loss muscle mass from not using the leg or legs that are affected. As long as there is good muscle mass, it probably doesn`t matter too much how soon the surgery is performed. When it works, which is most of the time in smaller patients, this surgery does provide a great deal of pain relief, though. So I tend to favor doing the surgery when it is clear to me, or to the client, that the surgery is inevitably going to be necessary. Most of the time it is only necessary to do surgery on one hip, as this provides enough relief to keep the patient comfortable.

The flip side of this discussion is that small dogs also tend to be able to compensate reasonably well for the hip problems, especially if only one hip is involved. Medications for arthritis, such as aspirin, etodolac (Etogesic Rx) and carprofen (Rimadyl Rx) often provide enough pain relieving effect for small dogs with hip dysplasia problems to be comfortable (or at least appear to be that way). So I do think it is reasonable to wait on surgery as long as you keep track of the muscling of the rear legs and consider surgery if there starts to be any noticeable loss of muscle mass in one or both legs.

Mike Richards, DVM 2/8/2001

Femoral head ostectomy (FHO) or Total hip replacement (THR) - continued

Question: Dear Dr. Richards, Thanks so much for your quick response! I found the information very useful, and when my vet returns my call, I will ask him some of the questions you posed. The one additional issue I`m wondering about is what Hershey will and will not be able to do after a femoral ostectomy. Will he be able to chase a squirrel? Jump on the couch? Stand on his hind legs to steal food? How limited will his hip motion and future activities be if he has this kind of surgery?

Answer: Laurie;

Most dogs that are less than 30 lbs. in body weight and are not overweight have use of the leg after femoral head ostectomy (FHO) that is nearly indistinguishable from normal use. Above this weight, there is usually some reduction in function, most commonly seen as an inability to jump in and out of the car, or activities like this. After a period of physical therapy, usually lasting about 6 weeks, most dogs have nearly normal use of the limb and this improves for several months after that. When examined, it is possible in most cases to detect a reduction in the range of motion of the limb but this is not usually detectable in observing every day activities.

There is usually very little visible problem with the limb for activities other than those related to jumping. Really big dogs, usually those over 100 lbs. in body weight, sometimes have noticeable disability in the form of limping or weakness of the rear leg that has had the FHO procedure and they sometimes become weak in their rear legs at an earlier age than would be expected from normal wear and tear arthritis formation. The skill of the surgeon has some bearing on the outcome of FHO surgery, so it is important to find out how successful the surgeon has been i the past, or at least how often this surgery has been performed by the surgeon.

The one dog in our practice that I really still consider to be a failure for this surgery was actually a very small dog. It did not seem to be in the pain it was prior to the surgery but it didn`t use the rear leg much again. I can`t decide if that was because it really didn`t need to at its weight or if something about the surgery just didn`t go well. The owners were OK about the situation because prior to surgery there was strong evidence of pain in the joint but it still bothered me for a long time that she would not use the leg except when it was necessary for balance or tasks like going up and down stairs that were easier if all four legs were used. I try never to forget that there are no guarantees in surgery, in part because of this patient. On the other hand, we had a patient in our practice who had to have both hips replaced (two total hip replacements). One of the implants developed an infection and had to be removed, so the dog essentially had a femoral head ostectomy on one side and a total hip replacement on the other side at that point. She did very well on both rear legs until she was quite old. So even though the plan was to go all out and have two total hip replacements, the combination on one FHO and one THR worked well in this patient.

Mike Richards, DVM 12/24/2000

Femoral head ostectomy (FHO) or total hip replacement (THR)

Question: Dear Dr. Richards, I wrote to you last year about my four year old beagle Hershey who has hip dysplasia. Since that time, Hershey has started limping badly, and as acupuncture hasn`t helped, he is scheduled for (right) hip surgery in a week. New Xrays show that his femoral head has made its own socket about an inch above the real one. Also, Hershey often hops on three legs, and the vet says this is a strain on his other joints. Therefore, I am not questioning the need for the surgery, just questioning the TYPE. The vet said that since Hershey is a small dog, 38 pounds, he would be given a femoral ostectomy rather than total hip replacement. I expressed some concerns about the ostectomy as my neighbor`s beagle had it, still limps and has one leg shorter than the other, but the vet told me that this procedure is very successful for small dogs and would alleviate Hershey`s pain. However, another vet in the office told me that Hershey wouldn`t be able to use his hip as fully after the surgery (not that he can now). I was feeling okay about the surgery until I started reading about it on the internet, and now I am confused. What I have read says that Hershey`s range of motion may be "severely compromised" with a femoral ostectomy, and even you said to someone in the vet info digest that the surgery would provide only "reasonable" comfort and was an option for people who "cannot afford total hip replacement". My vet knows that I can afford the more complicated surgery, and there is an orthopedic specialist there from Cornell there who is outstanding and who does all these procedures. My mom had total hip replacement about a year ago, and she is doing great! Given this, I wonder why they are not giving Hershey total hip replacement. It seems like this would offer him the most complete recovery and the fewest post surgical problems. Is there some other reason I am missing as to why he should be given the femoral ostectomy rather than the total hip replacement? Is it more risky or something? I am really nervous about this surgery, and if his bones are going to be cut off, I want to be sure I am making the right decision and am giving him the best possible chance for a normal life. Any clarification you could offer about why one surgery would be selected over the other would be greatly appreciated. Thank you, Laurie;

Answer: Laurie;

The implants for total hip replacement (the socket that goes in the pelvis and the replacement ball of the hip that goes into the femur bone) may be too large for a dog that weighs 38 lbs. I know that there has been some work on making smaller sized hip replacement devices but have been unable to find exact references for size. If there is an orthopedic surgeon in your area who is doing hip replacement surgery he or she should be able to tell you if they can get a device small enough for your dog. My understanding is that the replacement hips that have been used in the past were too large for most dogs that weigh less than 45 to 50 pounds.

Femoral head ostectomy (FHO) doesn`t work as well as total hip replacement (THR) when I do the femoral head ostectomy surgery and a specialist does the hip replacement (the situation in our practice). However, it is highly likely that there are surgeons much more skilled than I am at doing the FHO surgery and I have seen many strong defenses for the FHO surgery made by surgeons who are skilled at this procedure and who insist on proper aftercare.

Prior to the availability of THR, I was happy with the results of all of the FHO surgeries we did, with one exception, when comparing the way the patient felt before the surgery and after a reasonable healing period (two to three months). This included some very large dogs and even some large patients where we performed FHO surgery on both hips. However, after having a number of patients who have had THR surgery, I feel like FHO is a second choice surgery when total hip replacement is a viable option. That is the question in Hershey`s case, though --- there is a good chance he is small enough that this surgery simply isn`t an option.

If his hip is already dislocated enough to be forming a false joint, it seems almost certain that he would do much better after femoral head ostectomy surgery, since part of the healing process will already be done (the formation of the false capsule) prior to the time of the FHO surgery.

If this isn`t the information you are looking for, please feel free to write again and ask for clarifications.

Mike Richards, DVM 12/19/2000

Hip replacement surgery and assessing possible heredity problems in selecting a dog

Question: Dear Doctor,

First, I want to thank you for your informative reply regarding questions I had a few months ago concerning my HD dog, (who also had MCT`s in Feb) Leda.

I have three questions to bother you with this time. I am still researching and contemplating THR for Leda. I have investigated the University of Florida Vet. school and a veterinary orthopedic specialty practice in Orlando, both places do THRs. The university uses a prosthesis that is cemented in place. The orthopedic hospital uses a prosthesis held in place by three or four screws (the example they showed had three). They say they have been using the no cement procedure for about a year now and have had very good results. They claimed there is less chance for allergic reaction and infection because there is no cement used. They said less of the femur is hollowed and therefore there is a better blood supply to promote healing. They suggested that the bone eventually envelops the screws and forms around them, and the prosthesis. I think they said this method has been used at for a while at several universities (Of course, they explained this in a much clearer and more scientific manner than I can !) with excellent results. The surgeon I spoke with seemed genuinely excited and confident about this THR procedure. He says they had done 18 since January 99 (this was in July) and predicted around 2 a month on the average. Well, it sounds all very promising to me but then I`m an easy sell! Also, he did not push the surgery at all. He said Leda seems to have decent function despite the ugliness of the rads. I guess I`m saying that I didn`t feel I was being pressured. What I would like to know is what your opinion is regarding traditional cemented THR vs. no cement THR. Pros and cons of each, if you would. I might add that the price is practically the same ($2500 university, $2600 for private hospital) for each procedure. In fact, the private hospital said their price included all...x-rays, etc. The University didn`t exactly specify what their price included. The hospital is closer to my home (2 hr. drive vs. 4+ hrs. to the university) but ultimately the distance doesn`t matter. Thanks, I will be looking forward to your thoughts on this.

My next question is unrelated to HD! I have been contemplating the purchase of a Doberman Pinscher pup from a future breeding a local breeder is planning. She had a litter three years ago and another litter last year, by the same dogs. Several of the dogs from both litters have remained local and belong to the same obedience club as I do, so I`ve seen her pups develop into adults. She has clearances done on the parent dogs, for HD, Thyroid, PRA and about anything (especially things particular to Dobes) she can screen for. Dogs hips from the first litter have come back fair, good and excellent (not all of the pups have been x-rayed). None of the offspring have had any health problems (well, one supposedly had juvenile acne) until now. The breeder has just found out that one of the bitches she kept from the first litter (now 3 yrs. old) may have lymphoma. They pulled a needle biopsy today, but her vet is confident that this is the problem. Is this hereditary? If the diagnosis is as expected, do you think this is a serious reason to not consider a pup from a future breeding? I was feeling pretty good about one of this breeder`s pups as a future pet/obedience dog, especially because I`ve been able to observe the dogs she`s bred, firsthand and over time. What do you think?

One last thing.....in your practice, what breed (besides mixed) has struck you as being the healthiest, in general? Just curious!

Thank you very much and I apologize for this correspondence being so long and wordy!

Sincerely, C. M.

A: C. M.

We have had two patients in our practice with cementless hip prostheses. One has died but the hip did well her entire life (I`m guessing but I think about 8 years after replacement). The other one is still doing fine at this time. We have had a larger number of dogs have cemented hip replacements. One dog had a severe reaction and/or infection (definitely at least partly infection) associated with the cement and had to have additional surgery due to this. It was not possible to keep the prosthesis in and the situation was difficult but she was able to function OK since her other hip replacement did fine and since she adjusted OK to the modified femoral head ostectomy on the affected leg. I do not know the incidence of complications but suspect it may be slightly higher for cemented hips -- but not much higher. That is strictly a guess and I could be wrong.

There is no scientifically validated information that I know of that establishes that lymphoma is hereditary in dogs. However, there is a lot of evidence that it occurs more frequently in some dog breeds (most notably golden retrievers and Labs) and so many vets suspect that there is some hereditary component. I don`t think that I would make the jump to the conclusion that this dobe`s relatives are overly affected based on one case, though. If you have the choice of breeding with another dog that will provide equal benefits in improving the genetic potential of your dobe`s ancestors then I might lean towards the other dog if had no problems. If the dogs from this line are clearly superior to other dogs you have the option of arranging a breeding with, then I don`t think I`d worry too much about the lymphoma unless other cases appear in the line. Since you can`t know that in advance, it is reasonable to assume it won`t happen at this time and adjust accordingly, later.

I don`t think that I can answer your last question. Not because I don`t want to but because veterinarians spend a lot of time remembering what is wrong with different dog breeds and not much time noticing what is right about them. I can think of good features of lots of breeds but there is always a voice in the back of my head going "but that breed has allergies/portosystemic shunts/cancer/hip dysplasia.....", and so on.

Mike Richards, DVM 10/21/99

Hip repair - femoral head ostectomy

Q: I recently had a dog injured and he suffered a dislocated hip. The local vet wants to operate and remove the ball from the femur. Saying that this will form a false joint. While in surgery he cannot just relocate the hip because it probably won`t stay. Why would a bone with the ball removed be more likely to stay and form a false joint with scar tissue than one with the ball intact? thanks for your reply, Sam

A: Sam- You don`t say how large your dog is, but that has some bearing on the outcome of the surgery you describe, a femoral head ostectomy. In this surgery, the ball portion of the hip joint (the femoral head) is removed and the bone smoothed, if necessary, so that no bone to bone contact occurs between the pelvis, which contains the now empty socket and the remaining portion of the femur. The joint is not stablized, it is destroyed. While that sounds bad, in almost all dogs under 40 to 50 lbs in weight, this surgery will provide reasonable comfort. A "false joint" forms, consisting of fibrous scar tissue around the bone end. This forms in the muscles over the hip, which fortunately are strong enough to provide some stability. It is less painful than leaving the dislocated femoral head rubbing against the pelvic bone.

The shoulder joint is naturally constructed in a similar fashion, although it has more stabilization. In dogs over 50 pounds of body weight there is more concern that the joint will not be functional due to the need for more weight bearing capacity. Most of the time, there is still reasonable comfort even in big dogs but the outcome is more questionable in these dogs.

There are alternatives.

1) Stabilization of the joint can be attempted. Many vets are reluctant to do these surgeries because some of them are technically difficult and all of them have a moderate failure rate. It is disconcerting to do surgery, collect a large fee, have to explain the failure to the client and then have to go back and do a femoral head ostectomy anyway. There are several possible stabilization procedures, including pinning the femoral head to the hip socket, moving the portion of the bone where muscle attachment occurs to a different site on the femur to provide more stability, toggle pinning the femoral head and several other stabilization techniques. It may be necessary to ask for referral to a surgical specialist for these procedures as many general practitioners are not comfortable doing them.

2) Total hip replacement. This is an option in some cases when hips can not be stabilized but it is necessary to consider this on a case by case basis. Again, this surgery requires referral to a surgical specialist in most cases. Very few veterinary practices have the capability of doing hip replacement surgery.

Video: Canine Hip Dysplasia- FHO Surgery

If an alternative stabilization technique doesn`t work, femoral head ostectomy remains an option. You do end up paying for two surgeries when one of the other stabilization methods fail but if they work, the outcome is better for your dog. I am sorry, but I do not know what the success rates of the various surgeries would be as it depends a lot on the individual surgeon`s experience and skill.

Mike Richards, DVM

Femoral Head Ostectomy (FHO) and Triple Pelvic Osteotomy (TPO)

Q: I have a boxer/pit-bull mix male dog who is suffering from hereditary hip problems, and is starting to have problems walking. The x-rays my vet took indicate that he needs surgery to solve the problem. I will be visiting a specialist this Friday- I also know that this type of procedure is frequently very successful. However, I know that it will be difficult or almost impossible for me to afford the cost of the procedure. What advice do you have for someone like me? Are there any groups that I can contact for help?

Thanks for your advice!

A: I do not know of any organizations that help with the medical expenses for orthopedic surgeries. That doesn`t mean that there aren`t some. In most cases, it is best to contact local humane organizations in your area to see if they have a program for assisting people with pets through expensive procedures. One of our local humane societies will do this in special cases.

It is hard to tell from your letter which surgery you might be discussing. There are several surgical options for hip dysplasia, depending on the size and age of the dog. In young dogs, with hips still in the development stage, a triple pelvic osteotomy (TPO) may be the best approach. There are other surgeries done at this age, as well. The advantage of these surgeries done during development is that they can resolve the problem lifelong in many instances. They are technically complex surgeries and are usually done by specialists or at larger veterinary hospitals. In older dogs, the best choice for relief of severe hip dysplasia is a total hip replacement. These can usually only be done in dogs that weigh more than 50 lbs. or so due to the size of the hip replacement parts. They are also very expensive. It is generally less expensive to have this surgery done at a veterinary school hospital but it is still well over a thousand dollars per hip on the average. For many people, this isn`t an option. There are better anti-inflammatory/analgesic medications now than in the past. Rimadyl (Rx), which was recently approved, may help a great number of dogs live fairly comfortably who can not have surgery for whatever reason. Arthricare (Rx) is a new formulation of aspirin for dogs and is easier to administer and may be more effective than plain aspirin tablets. If medical therapy is not sufficient and hip replacement not financially feasible, many dogs will get partial relief from a surgery known as a femoral head ostectomy (FHO). In this surgery, the "ball" portion of the femur is just removed. The dogthen has no bone to bone contact in the hip joint. Due to the way dogs move, this causes less problems than you might think. Most dogs are more comfortable after recovery from this surgery (they are more painful for a few weeks while recovering). This surgery is very effective in dogs weighing less than 50 pounds and still pretty good even in dogs weighing much more than this.

If it is at all feasible, the better surgeries can be a good deal in the long run because of reduced medication costs and greater reliability in relieving the problem. If they are not possible, don`t rule out medical treatment or FHO surgery. Your vet can give you a better estimate of the long term prognosis for your individual dog based on physical exam findings, temperament, etc.

Mike Richards, DVM

Hip Dysplasia - triple pelvic osteotomy

Q: Mike Richards:

You appear to have a narrow view of surgical correction for dysplastic animals. I would invite you to investigate Ohio Sate University and their solution for helping fix animals with hip dysplasia.

We have a 10 year old German Shepherd female that was diagnosed with CHD during her third month of life. We had the two choices you described, terminating the animals life or, something new.

Dr. Olmstead suggested a triple pelvic osteotomy. He broke the pelvis in three places, reshaped it to ensure the ball would seat more firmly and deeply into the hip socket, and screwed it all together with a metal plate to maintain the curve.

2 years ago the inevitable began- joint deterioration. She now uses carprofen daily and it has made the difference.

From 3 months old to 10 years old and counting. You need to pay more attention to other events and update your position.

A: Seymour;

I do mention triple pelvic osteotomy, as you can see. It is a surgical option for dogs that are still in the growth phase and is successful enough that it should be considered if clinical signs of dysplasia occur in this age group.

I hope to have time someday to revise the existing pages rather than just adding information through answering other questions which Michal posts online in the appropriate areas. Right now, I have to rely on people to use the search engine to find all the references to a disorder or disease that occur on our site. It is good to be reminded to point that out occasionally.

Mike Richards, DVM

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