Femoral head and neck excision in a large dog

Re: Femoral head and neck excision in a large dog

Niall Taylor — Mon, 30 Jun 2014 22:45:45 GMT

[quote user="Michael Woodhouse"]Read what Malcolm said...[/quote]

Like I said - obviously being really dense...

Thanks

Niall

Re: Femoral head and neck excision in a large dog

Michael Woodhouse — Mon, 30 Jun 2014 22:00:59 GMT

[quote user="Niall Taylor"]OK, well, I'm obviously being really dense then - how can you have a luxated hip when you've got no femoral head or neck?[/quote]

Read what Malcolm said:

[quote user="Malcolm Ness"]Dr Colin Stead who was ortho surgeon at Edinburgh and a very wise and experienced clinician presented some work he had done following up dogs with traumatic hip laxations treated by closed reduction[/quote]

The vets thought they had returned the hips and the owners thought they had done well, despite ongoing luxation......

Re: Femoral head and neck excision in a large dog

Niall Taylor — Mon, 30 Jun 2014 21:44:33 GMT

[quote user="Malcolm Ness"]

No. Reluxation of the initially treated leg that had not been noticed/appreciated until late follow up.

[/quote]

OK, well, I'm obviously being really dense then - how can you have a luxated hip when you've got no femoral head or neck?

Niall

Re: Femoral head and neck excision in a large dog

Linda Filshie — Mon, 30 Jun 2014 20:07:40 GMT

Thanks for your input Malcolm - much appreciated. I especially like your point about being more proactive about actually repairing femoral neck fractures in cats, as in a few places I locumed it almost seemed to be a first line treatment to whip off the femoral head. Strange stuff, especially given the old adage that if you put a cat in a room together with its bones it will heal.

In total coincidence I saw a 3yo GSD late last week for vaccination that had a FHO last year to treat a fracture/dislocation. The owners did report it as "doing well"! It is occasionally stiff on rising but can manage an hour long walk without obvious discomfort (although ball chasing is out as the owner has discovered it leaves the dog lame for the next few days).

Re: Femoral head and neck excision in a large dog

Malcolm Ness — Mon, 30 Jun 2014 13:10:31 GMT

No. Reluxation of the initially treated leg that had not been noticed/appreciated until late follow up.

Re: Femoral head and neck excision in a large dog

Niall Taylor — Sun, 29 Jun 2014 22:18:20 GMT

[quote user="Malcolm Ness"]Amongst the dogs reported to be "doing well" by owner and referring vet were a significant proportion (I think about a third) of patients that were shown radiographically to be living with a permanently luxated hip.[/quote]

Not quite clear on this one, Malcolm - presumably you mean a sub-luxated hip in the opposite leg

Niall

Re: Femoral head and neck excision in a large dog

Malcolm Ness — Wed, 25 Jun 2014 09:12:47 GMT

I have come to this a bit late.

Femoral head and neck ostectomy (FHO) is a long-established salvage procedure. Indications are unmanageable hip pain and or dysfunction and unreconstructable fractures. Accepted wisdom holds that FHO is great in cats and small dogs but less good in larger dogs. There is no doubt that following FHO the dog or cat remains significantly lame and disabled - that is not to say that they aren't considerably better than before the surgery nor that the level of activity possible after FHO is unacceptable. Many dogs and cats after FHO will function more than adequately as apparently comfortable and reasonably active pets.

Poor outcomes are more likely to be seen with larger, more active dogs though a poor outcome is by no means inevitable even in the largest dog. Surgical technique almost certainly has a big part to play - a competent cranio-lateral approach which minimises muscle-cutting and other soft tissue injury plus excision using a well-placed oscillating saw is almost certainly better than a gluteal myotomy/tenotomy and a sub-optimally placed chisel osteotomy.

Case selection is worth considering - FHO is a salvage procedure for consideration when other less invasive treatments have failed or are likely to fail. I am unsettled by the prospect, for example, of FHO in skeletally immature dogs with HD when most of these dogs can be expected to improve markedly as they mature. Similarly, cats with femoral capital physeal fractures can be repaired (and the cat returned to functional normality) using a couple of K wires (or even one k wire cut in half) with a skill level similar to that needed for a decent FHO.

Outcome assessment of FHO cases is fraught with difficulty and reports of dogs and cats "doing well" after surgery abound. Beware! A number of years ago, Dr Colin Stead who was ortho surgeon at Edinburgh and a very wise and experienced clinician presented some work he had done following up dogs with traumatic hip laxations treated by closed reduction. Amongst the dogs reported to be "doing well" by owner and referring vet were a significant proportion (I think about a third) of patients that were shown radiographically to be living with a permanently luxated hip. Dogs, it has been said have "three legs and a spare" and if the other three legs are good, it can be surprisingly difficult to appreciate a problem in the fourth.

Re: Femoral head and neck excision in a large dog

David Mills — Sun, 22 Jun 2014 20:51:12 GMT

Depends on the presentation - for painful HD, despite maximising exercise, yes. Earlier the better to prevent excessive muscle wastage.

Luxation? Would always try a TA pin first, straightforward to place and usually do ok in my hands (no figures).

Re: Femoral head and neck excision in a large dog

John Flynn — Sun, 22 Jun 2014 19:20:53 GMT

[quote user="Linda Filshie"]John - in the ones you did with traumatic luxations did you try reduction and ehmer slinging first or did you go straight for FHNE?[/quote]

Obviously case dependent blah, blah, blah... but...

On most occasions, closed reduction and ehmer sling first (or DeVita pin), though I certainly have gone straight to FHNE on occasions. I think one's approach is very much coloured by one's proficiencies and previous successes/failures when it comes to traumatic hip luxations.

I have done various open reduction and stabilisation techniques over the years also with mixed success, and reasonably like the iliofemoral suture tehcnique, but like anything done by an amateur I'm sure I don't get as good results as dedicated orthopedists and I would personally encourage a junior member of the profession to become proficient at doing a "good" FHNE which will help them deal with most cases in a reasonable manner before worrying too much about the various open stabilisation techniques.

I've not yet had a case of a traumatic luxation that I regretted doing a FHNE on (though I appreciate that is most likely down to good fortune), whereas I have had a couple where I've seriously regretted open stabilisation, one only a copule of years ago in a CKCS with concurrent pelvic fractures (for which cage rest for 3 wks would have likely sufficed): it re-luxated and the owner didn't want to put through further surgery - I'd be pretty confident that the dog would be still running around today if I'd FHNE'd first time round.

I've not come across much published on FHNE in the dog, but there was one poor quality publication a few years back that might be of interest to you:

Fattahian, H. et al (2012) Excision Arthroplasty of the Hip Joint in Dogs: The Role of Age, Weight, Degenerative Joint Disease on the Outcome. Kafkas Univ Vet Fak Derg. 18(3), pp. 431-436

Their summary of which I've pasted below:

"Summary

The present clinical study was to evaluate the relationship between weight, degenerative joint disease (DJD) and age on the

outcome in dogs underwent excision arthroplasty operation. 105 dogs have been referred to clinic with lameness on hindlimb. Dogs

were younger than 1 year (50 dogs), 1 to 5 years (24) and older than 5 years (31 j.The rest of them were less than 10kg and the rest were

heavier than 10kg. Lameness during walking was scored between zero to 5. Radiographic findings were showed that degenerative joint

change, hip dyspiasia and luxation. Excision arthroplasty of the hip joint was performed. Walking status was examined postoperatively.

Intra-group data showed in dogs younger than 1 year, weight was not an effective factor, and association between DJD and the

outcome was statistically significant in both weights. DJD had effective role in dogs more than 10kg in comparison to less than 10kg.

The association between DJD and the outcome wasn't statistically significant in dogs 1 to 5 years in both weights. In elder dogs, weight

wasn't a main factor, and association between DJD and outcome was statistically significant in both weights. In latter group, DJD had

effective role on the outcome in dogs less than 10 kg in comparison with more than 10 kg."

If you're actively looking more info on getting started with the technique in large breed dogs then you can send me a PM as I think I have some resources that might be of interest.

Re: Femoral head and neck excision in a large dog

Richard Carter — Sun, 22 Jun 2014 14:30:46 GMT

Trying not to sound the dinosaur but these were pretty standard treatment even in first opinion practice for HD. The procedure was developed from human surgery so if a grown man can cope, pretty sure a lab/ GSD with weight spread around should be ok. We were taught the caudal approach in university so that the messy things like the sciatic nerve are actually identified before going into the joint capsule and wielding large chisels whereas I do the craniolateral approach for cats that have fractured the femoral necks.

Re: Femoral head and neck excision in a large dog

Mark Holmes — Sun, 22 Jun 2014 12:30:28 GMT

I would go further and say that they can almost do "better" than small dogs - I think that their size forces use of the leg earlier than small dogs who can often be so happy on three legs they don't use the leg for some time. This was my experience at the PDSA at least - although the bigger dogs were of predictable breed type and of a notoriously stoic nature - the exact opposite of small dogs.

Re: Femoral head and neck excision in a large dog

Linda Filshie — Sun, 22 Jun 2014 10:49:02 GMT

Thanks guys - useful to know its a viable technique for larger dogs. It was something I would never have even thought about doing in cases of severe DJD in a big lab or GSD .

John - in the ones you did with traumatic luxations did you try reduction and ehmer slinging first or did you go straight for FHNE?

And it's been said before but I'll say it again - vetsurgeon is a fab resource. Previously I'd probably have discussed with my colleague (who hates orthopaedics) then waited til I went on some relevant CPD to ask the question (and may well have forgotten all about it in the interim).

Re: Femoral head and neck excision in a large dog

Utlendigur — Sun, 22 Jun 2014 10:13:31 GMT

[quote user="John Flynn"]

I have done a number of FHNE in larger dogs (labs/GSD) with severe djd, as well as those with traumatic luxations.

In my experience they appear to have done "well".

[/quote]

Re: Femoral head and neck excision in a large dog

John Flynn — Sun, 22 Jun 2014 06:11:03 GMT

I have done a number of FHNE in larger dogs (labs/GSD) with severe djd, as well as those with traumatic luxations.

In my experience they appear to have done "well".

I'm not personally convinced of the argument that cats / small dogs do better, though I suspect they may be more forgiving of poor technique?

Re: Femoral head and neck excision in a large dog

Jenny Smith — Sun, 22 Jun 2014 01:46:34 GMT

My head nurse has a husky x GSD who has had bilateral FHNE. Her hips were horrible due to dysplasia and the only real options were hip replacement or FHNE as the pain was not controlled on oral medications. She elected to have the FHNE due to how mental her dog is and concerns about being able to properly rest her post THR.

Since then Daisy hasn't looked back, she had some hydrotherapy early on to help get her muscle mass back up to where it should be, but watching her run around now she is much better than she was pre-op.

Jenny

(p.s. I know one anecdote isn't much scientifically!)

Re: Femoral head and neck excision in a large dog

Alan Tevendale — Sat, 21 Jun 2014 23:30:32 GMT

My wife recently went on a CPD course covering exactly this. They were told that while small dogs having undergone a FHNE tend to do excellent; larger dogs generally do good.

I was pretty surprised to hear that myself as I had always had the same impression as you did.