Coxofemoral luxation Overview of surgical options and recent - - PowerPoint PPT Presentation

Coxofemoral luxation

Overview of surgical options and recent research

• Alex Santamaria

Southpaws Specialty Surgery For Animals

Overview

• Anatomy
• Etiology and pathophysiology
• Diagnosis
• Treatment

– Closed Reduction and stabilization – Open reduction and stabilization

• Recent research

Picture by: Tobias

Anatomy of the hip

• Diarthrodial

articulation

• Primary stabilisers

– Ligament of the head of the femur – Joint capsule – Dorsal acetabular rim

• Secondary

stabilizers

– Acetabular labrum – Joint fluid – Periarticular muscles

Basher AWP , Walter MC, Newton CD: Traumatic coxofemoral luxation in the dog and cat. Vet Surg 15:356, 1986. Bone DL, Walker M, Cantwell HD: Traumatic coxofemoral luxations in dogs, results of repair. Vet Surg 13:263, 1984.

Etiology and pathophysiology

• Most common joint to be luxated

– 90% all joint luxated in dogs and cats – Motor vehicle causes 80% – Craniodorsal ~75% all coxofemoral luxations

Web

Diagnosis

• Clinical findings

– Craniodorsal

• Non weight bearing

lameness (usually)

• Pain on hip palpation
• Holding limb in

external rotation and adduction

• Apparent shortening
• f effected limb

– Caudoventral

• Pain, lameness,

abduction, apparent lengthening of limb

Tobias

• Palpation

– Inverted triangle

• Cranial dorsal iliac

spine

• Ischiatic tuberosity
• Femoral head

– Displacement of the thumb on palpation of the ischial notch

BCF technolog

Diagnosis continued

• Radiographs

– Displacement of the femoral head out of the acetabulum

• Craniodorsal
• Caudoventral

Ablin LW, Gambardella PC: Orthopedics of the feline hip. Comp Contin Educ 13:1379, 1991 Schrader SC: Orthopedic surgery. In Sherding RG, editor: The cat—diseases and clinical management, ed 2, New York, 1994, Churchill-Livingstone, Inc., p 1649.

Treatment options

• No treatment

– Cats- can form a pseudoarthosis that will allow movement and minimal pain

• All dogs should be treated

– Golden period

• Less then 72 hours post luxation
• When treating must consider

– Open vs Closed techniques

Photos: Fossum 4th edition page 1318

Closed techniques

• Manually replacing

– Craniodorsal

• Holding the hock and the

pelvis

– Externally rotating – Pull distocaudally – Internally rotate and abduction

• Reluxation due to

– Inta-articular fracture – Muscle contracture – Soft tissue/ hematoma in acetabulum – Inflammation of the ligament of the head of the femur – Periarticular fibrosis

*McLaughlin RM: Traumatic joint luxations in small animals. Vet Clin North Am Small Anim Pract 25:1175, 1995.

Augmentation of closed reduction

• Ehmer sling

– Flexes the hips, abducts and internally rotates the femur – 10-14 days

• Allows periarticular soft tissue to heal

– Complications

• Slipping
• Foot swelling
• Rubs and ulceration
• Necrosis of distal extremity
• Reluxation (15-71%) *
• Decreased with new Dogsleggs “vest

with Ehmer sling”

– Allows removal and range of motion exercises

Tobias *Thacker C, Schrader SC: Caudal ventral hip luxation in the dog: a review of 14 cases. J Am Anim Hosp Assoc 21(Suppl 2):167, 1985. **Beale BS, Lewis DD, Parker RB, et al: Ischio-ilial pinning for stabilization of coxofemoral luxations in twenty-one dogs: a retrospective evaluation. Vet Comp Orthop Traumatol 7:56, 1991.

• Hobbles

– Prevents limb abduction – 80% return to normal gait and function (Thacker et al.

1985)

– Usually in place for minimum of 14 days

• Ischioilial pinning (DeVita

pin)

– In place 2-4 weeks – Then removed, further exercise restriction for 4-6 weeks – Complications ~ 32% **

• Migration of pin
• Reluxation ~ 25%
• Sciatic nerve injury
• Damage to femoral head
• Joint sepsis

McLaughlin RM, Tillson DM: Flexible fixation for craniodorsal coxofemoral luxations in dogs. Vet Surg 23:21, 1994

• External fixators

– Rigid – Flexible

• 2 pins placed in proximal

femur and ilium that are connected by flexible band

• Allows joint movement

and weight bearing

• In paced 2 weeks

– Study performed in 4 dogs » Luxation did not

• ccur in these 4 dogs
• Complications

– Rupture on bands – Distal migration of pins – Reluxation of femoral head – Septic arthritis – Sciatic nerve injury – Ulceration

Open reduction and stabilization

• Multiple techniques available

– Main benefits

• Allow exploration of joint
• Removal of hematoma and soft tissue in the

acetabulum

• Application of internal fixation
• Examination of cartilage damage to the femoral

head, neck and acetabular rim- therefore better idea on future formation of arthritis

Fossum *Basher AWP , Walter MC, Newton CD: Traumatic coxofemoral luxation in the dog and cat. Vet Surg 15:356, 1986. , Bone DL, Walker M, Cantwell HD: Traumatic coxofemoral luxations in dogs, results of repair. Vet Surg 13:263, 1984.

Open reduction and stabilization

• 1. Capsulorrhapy

– Large non absorbable monofilament suture – Horizontal mattress or cruciate patterns – Ehmer sling in placed post surgery for 1-2 weeks

• Success

– 83-90% of cases *

• Problems

– Insufficient joint capsule remaining to perform this procedure

Tobias *Braden TD, Johnson ME: Technique and indications of a prosthetic capsule for repair of recurrent and chronic coxofemoral luxations. Vet Comp Orthop Traumatol 1:26, 1988. , Johnson ME, Braden TD: A retrospective study of prosthetic capsule technique for treatment of problem cases of dislocated hips. Vet Surg 16:346, 1987.

• Prosthetic capsule techniques

– Two bone screws/ anchors (dorsal to acetabular rim) – Second anchor point in femur

• Placement side dependent

– Large suture material in figure 8 pattern

• Success *

– 66-100% » Excellent ~ 65% » Good ~ 67% » Mild lameness ~ 18% » Severe lameness ~ 18%

• Complications

– Damage to articular cartilage – Reluxation through the web – Transient lameness for 4-10 weeks post surgery

Open reduction and stabilization

Fossum *Fox SM: Coxofemoral luxations in dogs. Comp Contin Educ 13:381, 1991. , McLaughlin RM: Traumatic joint luxations in small animals. Vet Clin North Am Small Anim Pract 25:1175, 1995.

Open reduction and stabilization

• Transposition of the

greater trochanter

– Routine greater trochanteric

• steotomy leaving

gluteal musculature in tact and moving it more distally

• Allows contraction of

the gluteal muscle to abduct and internally rotate the femoral head to keep it seated in the acetabulum

– Success rates » ~84% *

Tobias *Hunt CA, Henry WB: Transarticular pinning for repair of hip dislocation in the dog: a retrospective study of 40 cases. J Am Vet Med Assoc 187:828, 1985.

Open reduction and stabilization

• Transarticular pinning

– Pin inserted through femoral head and neck into the acetabulum

• Pin placed to penetrate the medial

wall of the acetabulum

– Ehmer sling 2-4 weeks – Pin removed 2-3 weeks – Further 4 weeks restriction

• Success

– ~80% * – Worse in larger dogs

• Complications

– Cartilage damage – Sciatic nerve damage – Pin migration – Perforation of rectum – Pin bending or breakage – Osteoarthritis

*Demko JL, Sidaway BK, Thieman KM, et al: Toggle rod stabilization for treatment of hip joint luxation in dogs: 62 cases (2000–2005). J Am Vet Med Assoc 229:984, 2006.

Open reduction and stabilization

• Toggle rod stabilization

– Two holes dilled to allow placement of a toggle and suture

• Acetabulum- allows placement of

toggle attached to suture

• Neck and head of femur- allows

placement of suture which is secured to the lateral aspect of the femur

– Suture tied with the hip reduced

• Multiple ways to attach the suture

– Button, tied, crimped etc

• Success

– 89%* » With a 11% reluxation rate (70% of these occurred when presented > 7 days post injury) – 85-88% owners reported satisfactory results

– Multiple types of toggle and sutures that are recommended

*Lubbe AM, Verstraete FJM: Fascia lata loop stabilization of the coxofemoral joint in the dog and cat. J Small Anim Pract 31:234, 1991 **Kilic E, Osaydin I, Atalan G, et al: Transposition of the sacrotuberous ligament for the treatment of coxofemoral luxation in

• dogs. J Small Anim Pract 43:341, 2002, Ozaydin I, Kilic E, Baran V, et al: Reduction and stabilization of hip luxation by the

transposition of the ligament sacrotuberale in dogs: an in vivo study. Vet Surg 32:46, 2003

Open reduction and stabilization

• Fascia lata loop stabilization

– Use of a harvested strip of fascia lata – Attached to the femur

• Success *

– 1 retrospective paper showed good results in 10 dogs and 2 cats

• Transposition of the sacrotuberous

ligament

– Ischial insertion of the sacrotuberous ligament is cut to include a piece of ischial bone

• Two small holes are drilled in the small

section of bone to allow suture to pass through them

• Ligament is passed from medial to lateral

through the acetabular tunnel

• Then passed through a bone tunnel in

femoral head and neck and secured below the grater trochanter

– Complications » Similar to that of toggle rod stabilization

*Martini FM, Simonazzi B, Del Bue M: Extra-articular absorbable suture stabilization of coxofemoral luxation in dogs. Vet Surg 30:468, 2001

Open reduction and stabilization

• Extra articular iliofemoral suture

– 1 hole placed lateral and medial in the ilium (just cranial to the acetabulum), a right angle is used to grab the suture from under the ventral aspect of the ilial body – 1 hole from caudal to cranial through the femur just distal to the insertion

• f the gluteal muscles
• Non weight bearing sling placed for

7-10 days

• Exercise restriction for up to 8 weeks
• Success *

– Report with 14 patients – No relaxations or complication noted at this stage – No reduction in range of motion

• Femoral head and neck excision

arthroplasty

• Total hip replacement

Vet Surg 41 (2012) 948-953

Recent research

• Mechanical analysis of 12 toggle

suture constructs for stabilization of coxofemoral luxations

– Tested

• 3 toggles

– Piermattei toggle- 3/32" Steinmann pin – (A), modified Piermattei- 0.045" Kirschner wire – (B) and Securos (C)

• 4 different sutures

– OrthoFibre, Ethibond, Nylon and FiberWire

• Testing showed

– Modified Piermattei failed by toggle deformation – Piermattei and Securos failed by suture breakage at the eyelet

• Piermatteri- #5 OrthoFiber had

significantly higher failure load then Piermatteri #5 Ethibond and both of these constructs were more superior to all

• ther toggle suture constructs

Recent research

• Modified Knowles toggle pin technique

with monofilament suture for treatment

• f 2 caudoventral hip luxations

– 1 dog and 1 cat – Cat had a successful outcome – Dog developed femoral neck fracture 2 month post surgery

• Suspected to be due to erosion of the neck in

conjunction with the tunnel of the femoral neck could have lead to weakness of the neck

Vet Comp Orthop Traumatol 3/2010

Recent research

• Combined intra-extra-articular techniques for

stabilisation of coxofemoral luxation

– Nylon tape tied in a clove hitch around the femoral neck- placed as a bridge over the ischial spine to create acetabular roof

• 2 mature dogs
• Both sound and no reluxations occurred

Rochereau VCOT 2012

Recent research

• Stabilization of coxo-femoral luxation using

tendonesis of the deep gluteal muscle- 65 dogs and cats

– Screw and washer placed through the deep gluteal tendon and fixed in a hole drilled dorsal to the rectus femoris origin.

• Capsulorrhaphy was performed in 15/66 cases
• No reported complications noted in the operative and

post operative period

• 2 weeks post surgery lameness was noted in 47/65

patients

• No reluxation in 26 dogs and 8 cats between 8-13

weeks post surgery

– Success » Excellent outcome in 32/34 cases » Good outcome in 2/34 cases

• All but 2 dogs had normal range of motion and were

sound

– Complications » Length of screw

• Too long- protrudes into pelvic cannel and can

cause damage to descending colon

• Too short/ over tightening- these were left in

place and caused no noted problems in the study

Vet Comp Orthop Traumatol 1/2012

Recent research

• Correction of craniodorsal coxofemoral luxation in cats and small

breed dogs with modified Knowles technique and braided polyblend TightRope system

– 4 cats and 5 small dogs – All weight bearing day 1 post surgery – Median lameness score out of 0-5 at 6 weeks was 0 – All returned to normal levels of exercise according to phone convocation with owners ~16 weeks post surgery – Minor complication in one animal with post operative swelling of the surgery site