Normal anatomy of the hip joint

The hip joint connects the hind limb to the pelvis and consists of a round part (femoral head) and a pelvic “cup” (acetabulum). The two parts are connected by a joint ligament and capsule. These are strong connective tissue structures that hold the two bones together. 

 

The area where the two bones have contact is called the articular surface and is covered by smooth articular cartilage. In a healthy dog, all these features ensure that the joint works smoothly and is stable.

 

Hip dysplasia

Dysplasia means "improper development". The main cause for the development of hip dysplasia is the presence of laxity (instability) of the joint at an early age.
Most dogs with dysplasia are born with normal joints, but due to genetic reasons, the tissues around the joint form too lax during growth.
More often the disease is bilateral and affects both joints.

A key element in dysplasia is the fact that the bones do not stay close to each other and there is pathological mobility between them. The joint capsule and ligament gradually stretch, causing the joint surfaces to lose contact with each other. This instability is called subluxation and causes subsequent osteoarthritis changes in the long term.

 

 

Osteoarthritis is progressive, degenerative joint disease that can cause chronic discomfort. This is characteristic of the late form of hip dysplasia.

 

 

Cause of hip dysplasia

The widely accepted cause is genetic predisposition, although other factors like obesity and hyperactivity can affect the clinical manifestation of the disease. It has been clarified that the genes that determine the development of the disease are more than hundred.

 

Signs of hip dyplasia

Hip dysplasia is one of the most common orthopaedic diseases in dogs. Most often it affects large breed dogs, very rarely small dogs and cats.
Dysplasia is usually detected between 6 and 12 months of age. 
Clinical signs include stiffness, reluctance for playful behaviour, painful getting up, difficulty climbing stairs, and gait abnormalities including lameness in one or both hind limbs. 
In fact, the manifestation of the disease has two peaks - lameness in young dogs under one year or later - after the development of arthritic changes, usually after the 3rd year. 

 

 

In young dogs pain and lameness may not appear early, but later in life they may develop arthritis and chronic lameness.

 

Diagnosing hip dysplasia

The diagnosis is usually made by combination of clinical tests and x-ray examination. In the advanced form of osteoarthritis, the diagnosis is usually easy.

When it comes to young animals (between 4 and 6 months of age) without clinical signs, determining whether a dog is affected by dysplasia can be more difficult. 
There are several specific clinical manoeuvres and tests to detect abnormal laxity of the hip joint - Ortolani, Barlow tests, etc., which are performed under sedation (light anaesthesia).

 

 

Early diagnosis (screening) of the problem is important for young dogs of predisposed breeds. It should be considered at the age of 4 months - a period in which the clinical signs are not manifested yet and objective opinion is very important.
Early detection provides opportunities for more successful conservative therapy (weight, activity) as well as an option for minimally invasive surgical treatment like symphysiodesis - an early fusion of the pubis.

 

Breeds most often affected by dysplasia

The disease mainly affects dogs of large and giant breeds. Small breeds of dogs and cats are less commonly affected. 
Commonly affected breeds are German Shepherd, Labrador and Golden Retriever, Rottweiler, Dogue de Bordeaux, Newfoundland, Cane Corso, St. Bernard, Chow Chow, English Bulldog etc.

 

Hip dysplasia treatment

Treatment options for hip dysplasia vary, and the most important factor in decision making is the severity of the clinical signs.
Hip dysplasia could also be an accidental finding as part of a breeding screening test.
In other dogs, clinical signs are severe and treatment should focus not only on current clinical signs but also on potential long-term consequences.

It is important to know that dysplasia is not necessarily a debilitating condition. Fortunately, the anatomy of the hip joint tolerates serious imperfections and many patients lead a normal life even in the presence of joint pathology.
Canine hip dysplasia is a common but not devastating disease.

 

Non-surgical treatment of hip dysplasia

Most often, conservative therapy is aimed at treating the osteoarthritis caused by the disease.
The osteoarthritis is a chronic condition that cannot be cured, but rather alleviated. The approach is multi-modal with best results when the below means are combined.

Weight control - optimizing the body weight is the first thing that is recommended for a patient with dysplasia. Any treatment, surgical or not, benefits from weight reduction.

Physical activity and exercise - the patients with dysplasia need activity that provides good range of motion, muscle training and balanced joint load. 
Swimming, slow walking, slow stair climbing are useful exercises, although the activity program is best when planned individually, with regard to the degree of osteoarthritis and weight. 
Chronic immobilisation can be more harmful than activity. It is important for the dog to be active on daily basis.
Intense “Saturday-Sunday exercises” may worsen the condition.

Massages and passive motion exercises are simple physiotherapeutic procedures, which can be done at home.
There are also more sophisticated methods, used by professionals physiotherapists as hydro-therapy, acupuncture, +/- electrical stimulation, stretching and core balance, physical methods like deep heat with ultrasound.

Changes in daily activities - climbing up and down stairs can be a serious source of discomfort for some patients and avoiding them or using devices (ramps, stairs) can reduce painful moments.

Heat and sleeping surface - signs of arthritis often get worse in cold and humid weather. That is why it is important to provide warmth to your pet.
Dog clothes, shorter walks in cold weather, warm rooms, thick padded sleeping surfaces are factors that help reduce the signs of arthritis.

 

Drug therapy

Drugs often prescribed for the disease are divided into two main groups:

Anti-inflammatory – they have powerful analgesic effect, which gives visible and quick results by alleviating the pain.
Their long-term use (months, years) carries a risk of gastro-intestinal problems as erosive gastritis, enteritis, colitis.

Osteoarthritis modifying drugs - glucosamine and chondroitin, Perna Canaliculus, methyl-sulfonyl-methane (MSM), Vitamin C, omega-3 fatty acids and others.
These are nutritional supplements that are very popular in the treatment of arthritis, both in animals and humans.
Glucosamines give cartilage-producing cells (chondrocytes) a building substance for the synthesis of new cartilage and the replacement of damaged cartilage. These drugs are not painkillers and take about 6 weeks to take effect. They have virtually no side effects.
Polysulfated glycosaminoglycans are injectable preparation with a complex action in improving the synthesis of the joint matrix. A course of several weekly injections often has a beneficial effect.

 

Surgical treatment of hip dysplasia

Surgical treatment is divided into procedures that improve the anatomy of the hip joint (early treatment) and salvage ones, which replace the joint (late treatment).

 

Juvenile pubic symphisiodesis (JPS)

A minimally invasive technique, aiming early fusion of the two bones of the pubis, allowing the remaining pelvic bones to develop optimally, improving the coverage of the acetabulum and reducing the risk of developing arthritis. The operation is simple and involves "electro-cauterization" (thermal exposure) of part of the pubis and there is virtually no risk of complications.

Early diagnosis is very important in this case, as the intervention can be performed up to 16-18 weeks of age. The surgery is preventive in nature and is suitable only for puppies with mild to moderate x-ray changes and without clinical signs.

 

 

Triple pelvic osteotomy (TPO)

Triple pelvic osteotomy is a classic technique that is used less nowadays due to the availability of a better alternative - Double pelvic osteotomy. However, it is still suitable for young dogs, usually up to 10 months of age, which show increased laxity of the hip joints with no severe degenerative changes.
The procedure involves surgical cutting of the pelvic bone in three places and repositioning of the femoral head and acetabulum in order to restore the weight-bearing joint surface and eliminate subluxation.
The operation is serious, but can have very good results in appropriate candidates.

Double pelvic osteotomy (DPO) is a newer technique that is a modification of the above. Technically more difficult, but there are advantages such as shorter operative time, fewer postoperative complications and the patient's gait does not change. It permits to correct both joints at the same time.

 

 

Total Hip Replacement (THR)

This is the best option for treating dogs with advanced degenerative changes due to hip dysplasia. The surgery involves removing the existing joint and replacement with high-tech implant.
This costly procedure is otherwise characterised by very good results. The intervention is technically challenging and should be performed only by experienced surgeons.
There are two types of implants - cement and cement-less, the latter having a number of long-term advantages.
"Micro" implants for cats and small breeds of dogs are as well available.

Both hips are never operated simultaneously in patients who need such surgery. A minimum interval of 6 weeks between the operations is required.

The success rate of THR varies depending of the surgeon's experience and is approximately 85-95%.
One of the main advantages of the operation is the rapid recovery of the patients - sometimes within a few days after the intervention.
Most of them return to normal functioning (including work activity).

 

 

Femoral Head and Neck Osteotomy, FHNO 

This technique includes removal of the femoral head and neck, thus forming connective tissue pseudo-joint.
This is an end measure, used in grave degenerative changes, when the conservative treatment options are exhausted and the joint replacement is not feasible.
The newly formed false joint is painless and permits for increased activity, but the range of motion and the stability are diminished.
For best results, the patient must be up to 20 kg, but event in this case the result might be unpredictable.
The main shortcoming is the slow recovery which can be up to 8 months for the larger patients.
Often after FHNO, intensive physiotherapy is recommended for faster recovery.

 

 

 

	Total hip replacement	Femoral head and neck osteotomy
Post op functionality	Excellent! Athletism	Good for a pet, limited hip range of motion, some degree of limb instability.
Price	Very high	Relatively low
Post op care	Pain free after the surgery. Despite of this, strict activity restriction is needed for 6 months post op.	Discomfort after the procedure. Early usage of the limb is highly encouraged, including physiotherapy like swimming, water-threadmill, etc.   Long use of painkillers is indicated.
Complications	Vary between 5-10 %, but could be serious. Salvage revision solution is de-implantation. This leaves the patient with result similar to FHNO.	Not often. The most common one is suboptimal recovery in large breeds dogs.

 

 

 

 

 

 

Prevention 

Nutrition, activity and weight control are factors that can influence the progression of the disease.
Breeding selection is of great importance as by breeding animals only with healthy joints, the incidence of the disease can be significantly reduced.

 

Conclusion
 

• Hip dysplasia is a widespread orthopaedic disease that mainly affects large breeds of dogs. 
• The first manifestations have two peaks - at early age and after the third year of life.
• The causes of the disease are genetic.
• A narrow correlation between the instability (laxity) of the hip joint during growth and later arthritic changes has been definitely proven.
• In early diagnosis the most important are distraction x-ray examinations and clinical tests under sedation.
• There are surgical and drug therapies, depending of the individual degree of the problem.
• The best prevention of the disease is breeding only animals without dysplasia in their pedigree. 

 

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What is patellar luxation?

The patella (knee cap) is a small bone located at the base of the quadriceps muscle tendon. Its function is to act as a fulcrum in the movement of the knee joint. When bent and stretched, it slides into a special sulcus (trochlea) on the front part of the femur bone.

In some dogs, the patella is displaced (luxated) from this normal route, which adversely affects the proper function of the joint. As a consequence the altered biomechanics, some patients develop varying degrees of lameness and osteoarthritis in the long term.

 

 

How can I tell if my pet has patellar luxation?

Patellar luxation is a common condition. It most often affects dogs (rarely cats) of small breeds. Clinical signs appear most often at an early age of 4-10 months. A characteristic "skipping" lameness is often observed, in which the animals limp for a few steps and then quickly return to normal. Other animals are lame all the time (large breeds), and when both knees are affected, the dogs have a stiff posture with the weight transferred to the front of the body.

 

 

What is the cause of patellar luxation?

The reasons for the development of pathological conformation of the limbs are genetic. In fact, most animals are born with normal joints, but early in life they develop abnormalities in the of muscles and tendons.

Most often the deviation of the patella is to the medial (internal) aspect of the knee joint. When the mechanism of the quadriceps muscle is displaced in this direction, it acts as a "bowstring" and causes deformity of the growth of the bones of the limb. The trochlea, in which the patella is to be placed, does not develop properly and is sometimes even completely missing.

 

 

What could be the consequences for the affected joint?

In case of luxation of the patella on the joint surface, damage to the articular cartilage is possible. This is one of the reasons for more permanent pain and potentially progressive osteoarthritis. Also, the abnormal direction of traction of the thigh muscle causes internal rotation of the tibia relative to the femur, which can strain the cranial cruciate ligament. This is why it is common for patients with medial patellar luxation to eventually damage their cruciate ligament further in life.

 

 

How is patellar luxation diagnosed?

Patellar luxation is usually diagnosed during a clinical examination by an orthopaedic specialist.
To assess the bone deformities leading to patellar luxation, it is necessary to perform specific radiographic projections. To avoid false artifacts, it is extremely important to position the patient correctly, which is only possible with the use of sedation (superficial anesthesia).
Less often, computed tomography (scanner) is required for assessment of the condition in complex cases.

 

 

What are the degrees of patellar luxation?

The classification of patellar luxation is based on the mobility of the cap relative to the femoral trochlea:

Grade 1: The patella can be luxated under pressure, but returns immediately to its place;

Grade 2: The patella is displaced spontaneously in flexion and extension of the knee, but also spontaneously reduces itself;

Grade 3: The patella is permanently luxated, but can be reduced under pressure;

Grade 4: The patella is permanently luxated and cannot be reduced.

 

 

How is patellar luxation treated?

Sometimes patellar luxation is found accidentally during a routine clinical examination. In adult dogs, this accidental finding suggests a conservative approach.

In young animals of small breeds, treatment depends on the degree of luxation and clinical signs.

The conservative approach is appropriate for grade 1 and 2, without clinical signs (lameness). In higher degrees (3 and 4) and in all clinically manifested cases, surgical treatment is required.

Large breeds of dogs always require surgical treatment, regardless of the degree of luxation.

 

 

What is the non-surgical treatment of patellar luxation?

In fact, there is no real non-surgical treatment for the problem. Some measures, such as weight control, physiotherapy and painkillers, can help control clinical signs.

 

 

Surgical treatment of patellar luxation

Surgery is recommended in dogs with lameness as a result of patellar luxation.
There are many surgical techniques. Their main purpose is to restore the normal direction of traction of the quadriceps muscle relative to the skeleton of the limb. This requires correction of bone, cartilage and soft tissue structures.

There are two groups of techniques: Classic (simple) techniques and more invasive corrective osteotomies.
In fact, a single surgical technique is rarely adequate enough, often a combination of methods is required.

 

 

Classic techniques (simple) - are applied independently in mild degrees of the disease, when there are no serious bone deformities.

Transposition of the tibial ridge.

After a partial osteotomy, a small area of ​​the tibia that terminates the patellar tendon is moved inward or outward to correct the direction of muscle tension.
The fixation is with small pins; healing takes about 4 weeks.

 

 

Trochleoplasty

When the femoral trochlea is shallow, it may be necessary to deepen the sulcus. This includes a special remodeling of the bone and cartilage wedge, which deepens its position.

 

 

Reconstruction of soft tissues

Often the soft tissues on both sides of the patella are either too tight or too loose. Reconstructions are usually performed to release tight tissues and tighten (suture) loose tissues.

 

 

Corrective osteotomies

In some dogs (mostly large breeds) with high-grade patellar luxation, the deformity of the femur or the tibia are very important causative factors.
To decreases the risk of recurrence, in certain cases it is strongly indicated to correct the bone by a procedure, called osteotomy.
This is a more invasive surgery in which the bone is cut and a bone wedge is removed, and the new shape is fixed with a plate and screws. B
one healing in these cases usually takes about 6 weeks.

 

 

Patellar Grove replacement

In rare cases of severe arthritis affecting the femoral trochlea, a partial joint replacement is indicated. For this purpose, a commercial PGR prosthesis with a very smooth (diamond) surface is used, which replaces the altered cartilage structure.

 

 

Will my dog ​​recover fully after the operation?

Your dog's physical activity should be strictly limited for a period of about 6 weeks. This is a period in which the tissues in the area heal and the knee joint adapts to the new biomechanics.
Overloading the limb at this time can lead to complications and slower recovery.
In certain cases, during this period, physiotherapy may be indicated to speed the recovery.

After the 6-week postoperative period, a follow-up examination is needed to confirm the healing of the tissues around the knee. Upon confirmation, the dog can return to normal physical activity without restrictions.

 

 

Is the congenital patellar luxation different?

This is the most severe form of the disease, in which the patient is born with luxated patellae. Some authors call this form grade 5 because the severity of bone deformities is unusually advanced.
With delayed diagnosis, distorted bone structures, shortened muscles and ligaments make treatment extremely challenging. Unfortunately sometimes normal clinical recovery is impossible.
If you notice a strange gait and conformation of the limbs in young puppies, it is necessary to consult a veterinarian as soon as possible in order to avoid delays in treatment.

 

 

CONCLUSION

• The patellar luxation is a very common disease in dogs.
• In some cases, the condition does not cause serious clinical signs, but in others it poses a serious risk to the quality of life of the patients.
• The diagnosis of the condition is easy through a clinical examination.
• Detailed assessment requires special X-rays under sedation; rarely computed tomography.
• Clinically manifested cases require surgical therapy.
• The prognosis for recovery is good. The exception may be the most severe congenital forms.

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What is intervertebral disc disease?

Intervertebral disc disease is the most common disease of the spine in dogs (much less common in cats). 
Intervertebral discs are fibrocartilage structures between the vertebrae that allow micromovement and act as shock absorbers. They consist of a fibrous outer ring (anulus), and jelly-like core (nucleus). 

OpenStax College, CC BY 3.0, via Wikimedia Commons

Degeneration of the intervertebral discs leads to changes in the histological structure that reduce their elastic properties.
The end result can be a “rupture” of disc material (disc herniation) and compression of the spinal cord.

Laboratoires Servier, CC BY-SA 3.0, via Wikimedia Commons

 

What causes intervertebral disc disease and which breeds are predisposed?

Some breeds (chondrodystrophoid) are genetically predisposed to intervertebral disc degeneration. In them, changes (dehydration) in the structure of the connective tissue begins at an early age 
Such are young (up to 5-6 years old) small breeds of dogs as Dachshund, Basset hound, Japanese hin, lhasa apso, Shih tzu, Pekingese, Cocker spaniel, and others. The reason for this is that they were genetically selected for the exterior of “dwarf dogs” and most of these dogs have a long body and short limbs.
Unfortunately, exterior selection has led to a defect in the development of cartilage of the entire skeleton, including the intervertebral discs.
An abnormal elasticity of the discs in them, can  lead to disc herniation and compression of the spinal cord. 

There are three types of disc herniation-  Hansen I, Hansen II и Hansen III.

Acute disc herniation (Hansen type I, extrusion)
Small breeds of dogs at a young age (between 2 and 6 years) are most often affected. Larger breeds are very rarely affected.
Clinical signs usually  appear suddenly.  

Disc herniation is most easily described as „extrusion“ or leakage of the internal contents of the intervertebral disc.
When the disc changes, it loses its stability and even normal movements (especially torsion) lead to its rupture. Unfortunately, this is always to the vertebral canal, therefore compressing the spinal cord.
The speed of extrusion and the volume of the ruptured disc affect the severity of the spine damage.
The severity of the clinical signs varies from pain syndrome to complete paralysis.
Severe cases of herniated disc (Hansen type I) are an emergency that requires prompt consultation with a veterinary surgeon.

"Disc Disease" (Hansen type II, protrusion)
This disease is similar to disc disease in humans. Instead of extrusion of the center of the disc, there is a prolapse (protrusion) of the periphery.
Unlike acute rupture, the symptoms usually develop more slowly and progressively. Larger breeds of dogs (German Shepherd, hunting breeds), at a later age of 5-12 years, are relatively more often affected.

Laboratoires Servier, CC BY-SA 3.0, via Wikimedia Commons

Traumatic disc herniation, Hansen type III - acute noncompressive hernia
The cause of this type of hernia is a specifically directed spinal cord trauma, which leads to an explosive loss of the normal disc nucleus in the event of a sudden traumatic rupture of the ring (annulus). A small amount of normal disc material injures the spinal cord without subsequent compression.
Clinical signs are usually paralysis and pain.
The prognosis varies, and in mild to moderate cases, improvement is possible with rehabilitation and physiotherapy without surgery.
In severe cases, myelomalacia (a necrotic process in the spinal cord) can develop, which can be fatal.

 

How a ruptured disc affects the spinal cord?

Figuratively, the spinal cord is very similar to a cable, which consists of thousands of small wires. When pressed, the transmission of information through the many microscopic threads is disrupted.
In a herniated disc, the nucleus is pushed up and compresses the spinal cord or the nerves that come out of it.
Pressure on the nerve root results in varying degrees of acute pain (nerve root signature), and if enough disc material has been expulsed into the canal, the spine is compressed and neurological deficit develops.

 

Is a sudden onset possible?

Disc degeneration occurs relatively slowly - for weeks and months, but the disc herniation itself usually develops very quickly.
Some dogs develop severe paralysis within an hour. The faster the onset, the greater is the need of emergency veterinary care.

 

How can I tell if my dog ​​has a herniated disc?

The most common symptom is back or neck pain.
In addition to vocalization, common signs are unusual posture (head bowed), trembling, rapid breathing, reluctance to move, difficulty ascending and descending furniture / stairs.
In more severe cases, there may be difficulty walking, ranging from weakness to complete paralysis.
The most severe cases are those with paralysis, lack of bladder control and loss of sensation.
If the paralysis affects all four limbs, the disc hernia is in the neck area.

 

How to diagnose a herniated disc?

The first guideline is a history of pain, incoordination, or paralysis without a history of trauma.
Clinical examination usually reveals whether there is a neurological deficit of the spinal cord.
Another important detail is the breed of the patient. If the dog is one of the predisposed breeds, the diagnosis is even more likely.
In some cases, a simple (plain) x-ray may help localize the problem, but the results can be misleading. The normal and often the degenerated disc are X-ray-negative.
When the patient needs surgery and the plain radiography fails to detect the problem, it is necessary to use more advanced diagnostic imaging tools - contrast examination (myelography), computed tomography (scanner) or magnetic resonance imaging.

 

What are the degrees of neurological deficit?

First degree is characterized by mild pain and is usually self-limiting within few days.
Second degree causes moderate to severe pain that persists longer.

Third degree partial paralysis (paresis) and incoordination of movements.

A 2-year-old French bulldog with third-degree neurological deficit due to an acute disc herniation.

 

In grade four, there is paralysis (inability to stand up), but with deep sensitivity.

Fourth degree neurological deficit

 

The most severe, fifth degree is characterized by complete paralysis and lack of deep sensitivity.
Switching from one stage to another can take place within an hour or a day.

7-year-old Dachshund with fifth-degree neurological deficit.
With a strong stimulus, the dog does not turn around and does not feel anything.
Lacks deep sensitivity.

 

When is conservative therapy applied?

Drug treatment can be used in patients with pain syndrome or in patients with mild deficiency. Less commonly, this therapy may be successful in more severe cases.
Dogs that have lost their sense of deep pain need urgent (within hours) surgery.
The disadvantages of conservative treatment are more frequent recurrence of clinical signs and a greater chance of permanent neurological deficit.
The most important element of conservative therapy is restriction of movement (cage rest).
Restricting the patient's movements can prevent further extrusion of disc material.
The body's natural regenerative potential can lead to self-healing of the spinal cord.

 

When is surgery required?

Patients with neurological deficits (paresis) may need surgery (decompression) because the prognosis is statistically much better than with conservative treatment.
In general, surgical treatment leads to faster recovery and less likelihood of recurrence.
Cases with loss of deep sensitivity (paralysis) definitely require urgent surgery and have worse prognosis.

 

What is the success rate in treating disc herniations with or without surgery?

Degree and duration	Recovery
	Without surgery	With surgery
II degree up to 1 week:	80-90 %	90-95 %
II degree over 1 week:	60-70 %	90-95 %
III degree:	30-40 %	85-95 %
IV degree up to 3 days:	< 25 %	85-95 %
IV degree over 3 days:	< 20 %	60-70 %
V degree up to 24 hours:	< 5 %	50 %
V degree over 24 hours:	< 5 %	20 %
V degree over 72 hours:	< 5 %	< 5 %

 

What does the operation involve?

The most commonly used is decompressive surgery in which the ruptured disc material is removed from the spinal canal.
The specific surgery technique depends on the location of the problem.
In the neck area, a ventral approach is preferred or the so-called "ventral slot".

In the thoracolumbar region, the so-called "hemilaminectomy" is most commonly performed.

For lumbosacral problems, dorsal laminectomy is used, in which, figuratively speaking, "the roof" of the canal in the area is removed, which allows direct visualization of the end of the spinal nerves.

A particular challenge is the treatment of chronic disc herniation (protrusions). They require a more technically complex intervention - a corpectomy, which removes a small part of the vertebral body.

When can my dog ​​go home after surgery?

The duration of the postoperative stay in the clinic varies depending on the level of comfort (pain), functional status and control of urination.

 

How long do patients recover from surgery?

The rate of recovery is individual, as it depends on the severity and duration of spinal compression. The mildest cases recover in days, the more severe in weeks.
Unfortunately, in some cases, permanent deficits that do not improve over time are possible.
Postoperative physiotherapy can significantly accelerate the rate of recovery of patients with paresis.

 

Are there solutions if my dog ​​doesn't regain his neurological function?

Many dogs can continue to enjoy life with wheelchairs.
However, these patients require daily help to empty their bladder.
Paralyzed patients can evacuate their bladder with the help of the owners (manual compression in the area). The technique is not difficult and can be easily mastered with the help of demonstration and practice.

 

Can the problem recur?

With a well-performed spinal operation, it is very unusual to have a problem with the same disc. However, degeneration of any of the other disks is possible.
Up to 10% of patients may have a second serious problem that requires surgery.

 

Is there prevention?

There is no proven method to reduce the likelihood of developing disc disease (including dietary supplements).
Keeping the patient in good physical condition is always useful in diseases of the musculoskeletal system.

In the event of degenerative changes in the discs, it is possible to perform preventive surgery (so-called fenestration), which has been shown to reduce the chance of acute prolapse of the affected disc.

 

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Injury of the cranial cruciate ligament in the stifle is one of the most common orthopaedic problems in dogs and the most common cause of osteoarthritis in the knee joint.

 

 

Cranial cruciate ligament is a strong collagen fibre structure that attaches the femur to the tibia, preventing a sliding motion between hem. The ligament also prevents hyperextension and internal rotation of the knee.

Damage to the anterior cruciate ligament in humans is most often traumatic (typically a sport injury).
It is important to notice that the mechanism of damage in dogs is different from that in humans.
Most commonly, the ligament is not damaged due to trauma, but degenerates over time (similar to the thinning of the threads of a rope). This, as well as anatomical differences, is the reason why treatment in dogs is so different from that in human medicine.

 

What is the cause of cruciate ligament disease?

It has been found that in most patients the ligament degenerates gradually. The exact trigger remains unclear. Genetic factors are assumed, as some breeds are particularly predisposed - Labradors, Rottweilers, Boxers, Staffordshire Terriers, Jack Russell Terriers and others.
Dogs of these breeds are often affected by bilateral ligament disease at a relatively early stage in life.
Unfavourable factors are obesity, anatomical conformation, hormonal imbalance (castration in females) and some inflammatory conditions of the joint.

 

What happens in the joint after the rupture of the ligament?

In short, rupture of the ligament causes instability and pathological movements in the stifle joint.

 

 

Subsequently this leads to the development of osteoarthritis in the affected joint.
The joint tissue destruction causes release of substances called “inflammatory mediators”.
Due to inflammatory factors and the presence of mechanical instability, osteoarthritis in the knee can progress quite quickly - the joint capsule becomes inflamed (synovitis) and subsequently thickens chronically (fibrosis).

At some point secondary damage to the medial meniscus is common. This structure serves as a "shock absorber" between the tibia and the femur and consists of fibrous cartilage, softer than bone. Because of the instability, each time the dog uses the affected leg, the femur "slips" and presses on the meniscus.
When the meniscus is damaged, the arthritic changes progress quickly, and the pain becomes permanent.

In cases of acute rupture, serious intra-articular inflammation ensues (with collection of fluid in the knee joint i.e. effusion). This is associated with severe pain and the animal does not use the leg at all.

 

When should I suspect that my dog ​​has a cruciate ligament disease?

Lameness of varying degrees is the most common symptom. Lameness may appear suddenly, but sometimes occurs gradually as a progressive condition.

 

 

5-year-old malamute with acute bilateral rupture of the cruciate ligaments

Sometimes both stifle joints are affected at the same time. These patients may reluctantly stand up and transfer the weight to the front of the body.
In severe cases, some dogs do not want to stand up at all, which can lead to a misconception about a neurological problem.

 

How is cruciate ligament rupture diagnosed?

In dogs with a complete ligament rupture, the diagnosis is easily made by a clinical examination and X rays evaluation performed by an experienced orthopaedic surgeon.
Certain clinical tests are pathognomonic (very typical) for cranial cruciate ligament injury.
In dogs with partial rupture or early degeneration, diagnosis may be more difficult and may require specific tests - stress radiographs.
It is important that the X-rays are of optimal quality, which requires sedation (light anaesthesia).
Arthroscopy (“key hole” surgery) is sometimes required to confirm the diagnosis.

 

 

How is cruciate ligament rupture treated?

Conservative management

Medical approach is recommended only when the risks of anaesthesia and surgery are unacceptable (e.g. severe heart disease, immune diseases, etc.). The essence of the conservative treatment are: weight control, physiotherapy and painkillers (anti-inflammatory).

Surgical treatment

This is the recommended treatment for this disease.
The goal is to optimise the patient's recovery without long-term exercise restriction and medication support. Dogs over 15 kg do not recover well clinically without surgical treatment.
Small dogs and cats have a better chance, although recovery usually takes several months and is rarely complete.

There are various surgical techniques. Roughly, they can be classified into those that replace the damaged ligament and those that change the geometry of the knee and redistribute the forces acting on the joint.

Ligament replacement techniques

Surgical techniques to replace ligament in humans have been practised for decades. Unfortunately, in dogs, these techniques using soft tissue transfer or synthetic materials have little chance of achieving a good clinical outcome. This is because the replacement tissues are not as strong and are located in the same unfavourable biomechanical environment that caused the initial damage. The unpredictable results of this type of techniques is why they are not our choice for therapy. Exceptions are acute traumatic conditions with multigamentous (of multiple ligaments) injuries.

Tibial Plateau Levelling Osteotomy (TPLO)

TPLO is considered the "gold standard" in the treatment of cranial cruciate ligament rupture. The technique involves creation a radial (semicircular) cut in the upper part of the tibia and rotation of the bone segment, in such a way that the existing slope of the tibial plateau is corrected. The bone is fixed in the new position using custom plate and screws. Unlike other techniques, TPLO can be performed on any patient size - from mini breeds to giant ones.

 

 

 

Tibial tuberosity advancement (TTA)

This newer technique follows a similar principle as TPLO, but a straight cut in the tibia is made, so the tibial tuberosity is positioned more cranially (forward). The main principle of this geometric correction is to change the direction of "pulling" force of the quadriceps muscle. This creates force through the knee joint, which neutralizes the tendency of the femur to shift back relatively to the tibial plateau.

 

 

What are the advantages of TPLO and TTA?

Because bone healing is more effective than “ligament” one, the geometric osteotomies are more successful than the alternative techniques. The main practical benefit is: the limb function recovers very well in relatively short period of time.
In some animals with bilaterally ruptured ligaments, simultaneous treatment of both stifles in one surgery is possible.

 

What is the success rate of TPLO and TTA?

As a general rule, over 90% of dogs return to normal activity after TPLO or TTA. This usually means that the dogs are doing so well, that the owners are unable to detect visible lameness.
Normally, dogs should regain unrestricted activity without the need for long term medication. Young working dogs may return to normal heavy duty activity.

The success rates for TPLO and TTA are quite similar in short term. TTA has a bit faster recovery time (2-3 weeks faster). On the other hand, publications demonstrate that TPLO is better in the long term. In a study, TPLO surgery patients showed a recovery of 90% of the norm, compared to 75% of the group operated with TTA.

The decision whether TPLO or TTA is the appropriate technique is made based on the individual characteristics and anatomy of the patients.

 

What are the potential complications after cruciate ligament surgery?

Fortunately, the incidence of complications is relatively low when the operation is performed by an experienced surgeon. Giant breeds, hyperactive dogs and patients with bilaterally ruptured ligaments are at greater risk for complications.

The two most common serious complications are infection and mechanical instability.

Infection is very serious but treatable condition that requires the use of antibiotics. In some cases, implants removal may be needed after achieving solid bone healing. In most animals, the implants remain in place for life and do not cause any problems.
Mechanical instability may occur in very hyperactive dogs. The treatment of most of them is conservative (resting), and surgical revisions are rarely required.
A rare complication is late meniscus damage (more common with TTA). This generally may occur up to 2-3 months after surgery. Treatment requires arthroscopic examination and removal of the damaged segment of the meniscus.

Other rare complications are inflammation of the patellar ligament. This type of soft tissue inflammation does not require surgical revision. Requires activity restriction and physiotherapy treatment (laser, ultrasound, etc.)

 

How important is the postoperative period?

In fact, this period and the care applied can be as important as the operation itself.
The first four weeks are especially important - a period in which the body adapts and builds new tissues around the implants.

 

 

After the surgery of your pet we will provide you with a detailed program for postoperative care and therapy.
The two basic rules in the postoperative period are: no licking of the wound (for 14 days) and limited physical activity (between 4 and 6 weeks).

 

How long will it take for your dog ​​to recover?

Clinical recovery (lack of lameness) takes from 3 weeks to 3 months, depending on the initial duration of the problem, the patient's weight and activity, the type of surgical technique, the presence of other injuries and other factors.

 

Is there a prevention of the disease?

There is no effective prevention of the condition. However, some measures can reduce the likelihood of the ligament rupture. Maintaining good body condition in combination with regular moderate exercise in large breeds can protect against musculoskeletal diseases.
Recent research provide data that early castration in female dogs has potential adverse effects on joint health.

 

CONCLUSION

• Cranial cruciate ligament rupture is a quite common disease in dogs.
• In some cases, the clinical signs are typical and the diagnosis is easy. In others, the diagnosis is not straightforward and specific tests may be required.
• In most cases, the disease demands surgical correction.
• The TPLO technique is the "gold standard" for therapy with the best long-term results.
• Patients are rarely suitable for conservative non-surgical therapy.
• The characteristics of individual patients require an individual approach to determine the best therapeutic approach.

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I work mainly with planned, non-emergency cases.
In exceptional circumstances, I can treat some emergencies (such as acute spinal compressions).

I have an online system for organizing the work, own professional equipment for surgical interventions, high-class surgical instruments, including power tools and a portable arthroscopic tower, as well as various systems of implants - locking plates, ring external fixation.

I am committed postoperatively to medical consultation and patient follow-up.

 

List of activities that I perform:

In the field of diagnostics:

• full orthopedic examination
• complete neurological examination

Radiographic examinations:

• joint and dynamic projections with contrast
• obtaining and examination of cerebrospinal fluid
• contrast (myelographic) examination of the spine
• reading and interpretation of radiographs, computed tomography, MRI
• issuing of international certificates for hip and elbow dysplasia
• issuing of regionally recognized patellar luxation certificates

Other:

• arthroscopic (minimally invasive) examination of joint diseases
• joint punctures and examination of synovial fluid
• 3D planning of orthopedic surgical interventions
• examinations and consultation of surgical patients from other fields
• oncology, upper respiratory tract (e.g. brachycephalic syndrome), plastic reconstruction of defects

In the field of surgical interventions:

Orthopedics:

• treatment of all types of fractures and traumatic dislocations - conservative and operative treatment (with accent on internal fixation)
• minimally invasive method of fracture treatment (MIPO)
• surgical treatment of anterior cruciate ligament rupture - TPLO and TTA techniques
• surgical treatment of patellar luxation, including corrective osteotomies and trochleal prosthetics (PGR)
• hip arthroplasty ("artificial joint") - system of implants "Biomedtrix"
• diagnostic and therapeutic arthroscopic surgery
• treatment of osteochondrosis, elbow dysplasia (fragmented coronoid process), inspection of menisci and cruciate ligaments
• surgical treatment of all forms of elbow dysplasia - corrective osteotomies (including PAUL), restoration of ununited anconeal process
• restoration of joint defects through autotransplantation of bone and cartilage grafts (osteochondral transfer)
• surgical treatment of bone deformities - acute or gradual correction (Ilizarov's method)
• limb sparing techniques for tumor diseases of the limbs
• integrated percutaneous amputation prosthesis (ITAP) in distal amputations
• permanent immobilization of joints (arthrodesis) - as a final option for the treatment of joint injuries
• ostectomy of the head and neck of the femur

Spinal and neurosurgery:

• surgical treatment of acute disc and chronic hernias - ventral slot, chemylaminectomy, corpectomy
• surgical treatment of the atlantoaxial instability
• surgical treatment of spinal and cerebral arachnoid cysts
• stabilization of vertebral dislocations - fractures and subluxations
• removal of brain and spinal tumors
• ventriculo - peritoneal shunt in hydrocephalus
• ventriculoscopy of the cerebral ventricles
• neuroanastomosis in peripheral nerve damage

Thoracic surgery, respiratory system and other:

• surgery of thoracic tumors
• resection of lung lobes
• correction of diaphragmatic hernia
• surgical treatment of chylothorax - ligation of the ductus thoracicus, pleurodesis
• corrections for brachycephalic syndrome
• correction of laryngeal "narrowing"
• laryngeal paralysis, laryngeal collapse
• abdominal and perineal surgery
• all conventional techniques in the field
• skin plastics and reconstructions
• all conventional techniques in the field, including free vascular grafts

The examinations will are done in

Ortoclinica - veterinary orthopaedics and neurosurgery - Sofia, Mladost 2, Andrey Saharov blvd. 245

You can book an examination appointment here.

 

Making of an appointment for surgery

The surgical interventions are preceded by an examination and discussion of the state. 
This is the reason you cannot make an appointment for an operation via this site.
However, in exceptional circumstances, it is possible directly to plan a surgery.
If the examination is truly impossible for some reason, please contact me - (Please enable JavaScript to view this email address)

 

Online consultation

The remote consultation carries the risk of inaccurate medical conclusion due to the lack of thorough clinical examination. Therefore they have only guiding value.
It is always preferable, if possible, to arrange for a physical examination and discussion of the findings.
If the examination is really impossible and online consultation is required, please contact me - (Please enable JavaScript to view this email address)

It is important in such cases, to provide precise and concise information about the patient and the status - breed, sex, clinical signs and duration, previous treatment.
Also to attach previous diagnostic examinations results (such as X-rays for example).

The price of an online consultation is 50 BGN

The principal parts of my work are surgeries for correction of bone deformities, stifle surgery (ruptured cruciate ligaments, patellar luxation etc.), minimally invasive techniques, arthroscopy, fracture treatment and hip replacement.

In the recent years, I have gained extensive experience in the field of the limb sparing techniques. These are difficult orthopedic interventions that require multidisciplinary training - in oncology, vascular anastomosis, skin grafting, special materials (implants, bone substitutes) and the use of software operation planning.

Characteristic for this field of medicine is the variety of options, without one single “golden standard”.
The success often depends on an innovative approach and collaboration with specialists in other fields (e.g. software specialists).
I am familiar with the world-renowned surgical methods and I have contributed to the development of some innovations.