Coxofemoral luxation presentation copy

Coxofemoral
luxation
Overview of surgical options and
recent research
!
Alex Santamaria
Southpaws Specialty Surgery For Animals
Overview
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Anatomy
Etiology and pathophysiology
Diagnosis
Treatment
– Closed Reduction and stabilization
– Open reduction and stabilization
• Recent research
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
Picture by: Tobias
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
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.
Diagnosis
• Clinical findings
– Craniodorsal
• Non weight bearing
lameness (usually)
• Pain on hip palpation
• Holding limb in
external rotation and
adduction
• Apparent shortening
of effected limb
– Caudoventral
• Pain, lameness,
abduction, apparent
lengthening of limb
Web
• Palpation
– Inverted triangle
• Cranial dorsal iliac
spine
• Ischiatic tuberosity
• Femoral head
– Displacement of the
thumb on palpation of
the ischial notch
Tobias
Diagnosis continued
• Radiographs
– Displacement of the
femoral head out of
the acetabulum
• Craniodorsal
• Caudoventral
BCF technolog
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
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.
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
Photos: Fossum 4th edition page 1318
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
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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
*McLaughlin RM: Traumatic joint luxations in small animals. Vet Clin North Am Small Anim Pract 25:1175, 1995.
• 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% **
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Migration of pin
Reluxation ~ 25%
Sciatic nerve injury
Damage to femoral head
Joint sepsis
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.
• 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
occur in these 4 dogs
• Complications
– Rupture on bands
– Distal migration of pins
– Reluxation of femoral
head
– Septic arthritis
– Sciatic nerve injury
– Ulceration
McLaughlin RM, Tillson DM: Flexible fixation for craniodorsal coxofemoral luxations in dogs. Vet Surg 23:21, 1994
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
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
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Success
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83-90% of cases *
Problems
–
Insufficient joint capsule
remaining to perform
this procedure
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
• 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
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.
Open reduction and stabilization
• Transposition of the
greater trochanter
– Routine greater
trochanteric
osteotomy 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% *
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
• 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
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Cartilage damage
Sciatic nerve damage
Pin migration
Perforation of rectum
Pin bending or breakage
Osteoarthritis
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
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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
*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
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Fascia lata loop stabilization
– Use of a harvested strip of fascia lata
– Attached to the femur
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Success *
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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
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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
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Complications
» Similar to that of toggle rod
stabilization
*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
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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
of 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
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Femoral head and neck excision
arthroplasty
Total hip replacement
*Martini FM, Simonazzi B, Del Bue M: Extra-articular absorbable suture stabilization of coxofemoral luxation in dogs. Vet
Surg 30:468, 2001
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
other toggle suture constructs
Vet Surg 41 (2012) 948-953
Recent research
• Modified Knowles toggle pin technique
with monofilament suture for treatment
of 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
Recent research
• Combined intra-extra-articular techniques for
stabilisation of coxofemoral luxation
– Nylon tape tied in a clove hitch around the femoral neckplaced as a bridge over the ischial spine to create
acetabular roof
• 2 mature dogs
• Both sound and no reluxations occurred
Vet Comp Orthop Traumatol 3/2010
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
Rochereau VCOT 2012
Recent research
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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
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Vet Comp Orthop Traumatol 1/2012