My name is Matt Schiffman and I am a fourth-year veterinary student at Purdue College of Veterinary Medicine. Recently, my dog Ducky had a Total Hip Replacement to repair his left hip joint due to worsening Hip Dysplasia. At the time of diagnosis, I was extremely concerned and overwhelmed by the many options and cost considerations that were presented to me. Hip surgery is very invasive and intricate, and the decision required careful thought, research, and financial planning. During the process, I had a lot of questions and considerations on deciding the best plan and treatment for Ducky.
Throughout a pet’s lifetime, there might be situations where owners may be hesitant about a procedure, the price, and the necessity of the surgery, as well as all of the challenges that come with postoperative care. I spent extensive time researching the surgery and exploring all my options. What was missing was an accessible and concise Q&A with someone who had already gone through the process with a pet of their own. Through these 20 questions, I hope to provide insight on my thought process and guidance to pet owners facing similar surgical decisions.
1. What is Hip Dysplasia?
Hip Dysplasia (HD) is a multi-factorial disease (has multiple etiologic causes including congenital, nutritional, and hereditary) where there is joint laxity and osteoarthritis in the hip joint.
2. How is Hip Dysplasia diagnosed?
Typically, dogs with HD are diagnosed at a young age via radiographs. Typical changes in a HD radiograph include flattening of the femoral head, shallowing of the acetabular groove, decreased contact between the femur and acetabulum, and changes related to osteoarthritis.
3. What are the clinical signs of Hip Dysplasia?
Typical clinical signs include exercise intolerance, lameness, pain, difficulty rising, and a “gallop-gait.”
4. Can Hip Dysplasia be managed conservatively?
Yes, conservative management generally consists of a combination of mechanisms to reduce progression of joint damage and alleviate discomfort. Conservative management may include chondroitin sulfate and glucosamine supplementation, omega-3 fatty acid supplementation, controlled physical activity, weight loss, physical therapy, and NSAIDs if necessary.
5. What are the surgical options for Hip Dysplasia?
There are four surgical options for Hip Dysplasia: Juvenile Pubic Symphysis (JPS), Total Pelvic Osteotomy (TPO), Femoral Head Osteotomy (FHO), and Total Hip Replacement (THR). JPS is only an option in dogs less than 18 weeks of age, TPO is a fine option for dogs older than 18 weeks of age and have no signs of osteoarthritis. FHO and THR are salvage procedures that can be performed as early as nine to 10 months of age.
6. How did I know which treatment method was right for Ducky?
Initially, I opted with conservative management for Ducky. I started him on Hills J/D, added a joint supplement, and watched for signs of pain and lameness when running, playing or exercising. I also got Ducky to lose a few pounds by tightly regulating his diet and controlling treat intake. The weight loss helped decrease the weight-bearing load on his hind limbs.
7. How did I know which surgical procedure Ducky needed? Femoral Head Osteotomy or Total Hip Replacement?
I did a lot of research on each surgical procedure to decide which was best for Ducky. I read textbooks, summary reports, peer-reviewed journal articles, and consulted veterinary orthopedic surgeons. The difference between the two procedures is that in the FHO, the head of the femur is cut off and the hip joint forms a fibrous pseudo-joint. THR is when the head of the femur is removed, and an implant replaces the ball (femur) and socket (acetabulum) of the joint. The biggest difference between these two procedures are the functional outcomes, with THR having a higher quality and percentage of functional outcome (lameness, exercise tolerance, etc.) than FHO. THRs functional outcomes range from good to excellent while FHO functional outcomes max out at good and often need physical therapy to reach a good functional outcome.
8. What are the complications of Total Hip Replacements, and which ones are the most common?
THR complications have been reported including luxation, infection, aseptic loosening, femoral fracture, and granuloma formation. The most common complications are aseptic loosening and luxation. The success rate for treating complications varies significantly depending on the nature and severity of the complication. Complications related to anesthesia, such as urinary incontinence with hydromorphone administration, may occur as well.
9. How is a vet student able to afford a surgical procedure such as a Total Hip Replacement?
The price for a THR for one hip can range from $4,500 up to $10,000 in some locations. Knowing Ducky would need surgery at some point, I began putting money aside and saving when I adopted him. Luckily, a local specialty and referral hospital was working on a clinical trial for a new THR implant (Centerline BFX) in dogs < 5 years of age, > 50 lbs, and with no other underlying orthopedic, neurologic, or other health conditions. The clinical trial surgery cost was half the normal cost at that hospital and included the surgery, anesthesia, hospitalization, medication, follow up visits, post-operative x-rays, and rehabilitation services offered at the hospital. Through summer jobs, working during vacations/breaks, and good budgeting over the span of two years, I had saved enough money to cover the cost of the clinical trial.
10. How is the BFX Centerline Implant and surgery different than a traditional Total Hip Replacement?
The Centerline BFX implant is different from a traditional THR implant in that the new implant is placed without reaming of the femur or the use of bone cement. It also uses biological fixation, which is biologically compatible and therefore minimizes adverse reactions, encourages bone growth, and avoids complications related to the use of cement such as loosening or infection.
11. Why did I decide to have the surgery performed at that specific time? Why not earlier or later?
We opted for conservative management for as long as we could. While Ducky’s X-rays showed pretty significant Hip Dysplasia, clinically he was great. My professors have taught us to always “treat the patient” as opposed to the disease. At time of confirming diagnosis upon adoption in May 2018, we opted for conservative management.
At three years old, one year after I adopted Ducky, his signs began to worsen. Ducky began to have a little bit more trouble getting up and down, started to gallop more when running, and started showing some signs of lameness when walking. In May 2019, we scheduled a consultation with an orthopedic surgeon. Together, we decided it was best for Ducky to surgically repair his left hip. The surgery was scheduled for July 31st, 2019. The end of summer vacation was the best for me as it allowed me to spend as much time as I needed to help Ducky recover early on while then working him into a controlled environment and routine as I returned to school for my third year of vet school.
12. What was the recovery process like?
The recovery process consisted of eight to 12 weeks of cage rest, exercise restriction and controlled leash-walking. The restriction also included no stairs, no jumping on couches, or running and playing. We began physical rehabilitation after his staples were removed 14 days post op and continued rehabilitation weekly through the 12 weeks.
13. What precautions did I take to ensure a smooth recovery?
The first precaution I took was the scheduling of his surgery. I wanted the surgery to occur later in the summer so that 1) Ducky had most of the summer to be outside, swim, go on short walks to continue losing weight, 2) I could spend as much time as I needed to helping Ducky recovery early on, and 3) He would be in my family house for only a short amount of time before we went back to vet school at Purdue early August. My family house has stairs and would have caused more difficulties during recovery than my house at Purdue which has no stairs to worry about. In addition, the simple and structured routine environment of vet school allowed me to rest Ducky in a crate while I was at school for the day, a practice he was already used to.
The next set of precautions included blocking off couches, adding traction mats to hardwood flooring so Ducky did not slip, and covering his incision site with a blanket so he did not lick or bite the incision site before the staples were removed 14 days post-op.
14. How does physical rehabilitation help in the Total Hip Replacement recovery process?
The goal of rehabilitation after THR is to restore the long-term, pain-free use of the operated limb. Initially, rehabilitation therapy is designed to improve overall postoperative comfort, range of motion (ROM), early use of the postoperative limb, and facilitate healing. The later stages of rehabilitation therapy are continuation of improvement in ROM and muscle mass to facilitate return to function once surgical healing is satisfactory.
15. What exercises were included in Ducky’s rehabilitation plan?
Physical rehabilitation was performed starting four days postoperatively and continued weekly for 12 weeks. For the first two weeks following surgery, exercises were performed, including passing range of motion (PROM), massage, cold packing, assisted standing and weight shifting, and five to eight minutes of controlled walking. Two weeks after surgery, home exercise was combined with in hospital physical rehabilitation exercises. Additional exercise incorporated included: sit/stands, massage, assisted standing and weight shifting, cookie stretches, underwater treadmill therapy, cavaletti rails, bosu/physio ball weight shifting, hills/stairs climbing, and controlled leash-walking of weekly increasing intervals. Following completion of the physical rehabilitation program, Ducky had successfully restored hind limb function, regained hind limb muscle mass, and improved joint range of motion.
16. How long was the recovery and rehab process?
From start to finish, the recovery and rehabilitation process lasted 12 weeks. Postoperative X-rays were then performed at six weeks, three months, and six months. The next set of X-rays will be performed at 12 months in July 2020.
17. Could the procedure and recovery process be done without rehabilitation?
While the procedure and initial recovery process (i.e.: first two weeks) are typically done without physical rehabilitation, physical rehabilitation is extremely important thereafter, and is widely considered the standard of care after surgery.
18. How is Ducky doing since the surgery?
Ducky is doing excellent! He enjoys running around, playing fetch, and chasing rabbits. He has shown no signs of lameness and is moving better than ever. He is extremely happy with his new hip.
19. What about Ducky’s other hip?
Ducky’s right hip was not nearly as bad as his left hip, so we are holding off on any sort of procedure right now and continuing with conservative management.
20. Interested in learning more about Ducky and his journey recovering from a Total Hip Replacement?
Check out my website. I have been documenting Ducky’s journey the last 10 months, including X-ray updates, physical rehabilitation photos and videos, and much more.
Journal Articles and Resources of Interest if interested in further reading:
- Anderson, A. “Treatment of Hip Dysplasia.” The Journal of Small Animal Practice 52.4 (2011): 182-189. Web.
- Dycus, David L, David Levine, and Denis J Marcellin-Little. “Physical Rehabilitation for the Management of Canine Hip Dysplasia.” Veterinary Clinics of North America: Small Animal Practice 47.4 (2017): 823-50. Web.
- Harper, Tisha A.M. “Conservative Management of Hip Dysplasia.” Veterinary Clinics of North America: Small Animal Practice 47.4 (2017): 807-21. Web.
- Olmstead, Marvin L. “Total Hip Replacement.” Veterinary Clinics of North America: Small Animal Practice 17.4 (1987): 943-55. Web.
- Richardson, Daniel C. “The Role of Nutrition in Canine Hip Dysplasia.” Veterinary Clinics of North America: Small Animal Practice 22.3 (1992): 529-40. Web.
- Schachner E, Lopez M. Diagnosis, prevention, and management of canine hip dysplasia: a review. Vet Med (Auckl). 2015;6:181-192