Monthly Update February 2012

Diagnosis of Juvenile Canine Hip Dysplasia (JCHD) CT Corner

By William B. Henry, Jr. DVM, DACVS. Our surgeons have 10 years experience using
JPS Sx. Dr. Henry will give a detailed 2-hour lecture on Juvenile Pubic See the case study video below to
illustrate how we are using CT as a
Symphysiodesis, providing 2 hours of CE on March 14.
valuable tool in our hospital group:

View video, Porker: Female Lab with front

limb lameness (6.24 min) , here:
http://www.youtube.com/watch?
"I'm only 14 weeks old but my v=T3X0y5ZY_mk&feature=youtu.be
hips hurt when I run and play.
Please help me..."
Continuing Education
Fenway, PennHIP DI 0.56
Opportunities

Drs. Henry, Briere and Reese lead CE

courses throughout the year for practicing
The subjective diagnosis of JCHD was described via the Ortolani sign in 1985 in the veterinarians on a wide range of topics in
veterinary literature1. Prior to that it was described in children in 1937 by Dr. veterinary surgery. Register online!
Ortolani, an Italian pediatrician 2.
February 22, 2012:
Dr. Henry, "Degenerative Lumbosacral
The objective diagnosis of juvenile canine hip dysplasia (JCHD) became available Stenosis (L7-S1 Disease)"
when Dr. Gail Smith, a Professor of Surgery at the University of Pennsylvania
School of Veterinary Medicine, developed the PennHIP method of diagnosing hip March 14, 2012:
dysplasia with predictable accuracy as early as 16 weeks of age in 19903. Dr. Smith Dr. Henry, "Juvenile Pubic Symphysiodesis
also holds a PhD. In biomedical engineering. (JPS)"

The early diagnosis of JCHD was further confirmed and expanded by Dueland and March 21, 2012:
co-workers. They demonstrated the accuracy of PennHIP Distraction Index (DI) in Dr. Briere, "Tibial Tuberosity
even younger puppies4 . Advancement"

April 25, 2012:

Distraction Index measurement (PennHIP method) was the most accurate in Dr. Briere, "Wound Management and Skin
predicting the development of DJD (p less than 0.001). Distraction index Reconstruction"
radiography in puppies 6-10 weeks and 16-18 weeks was the most reliable
predictor of hip dysplasia.

What is JPS Sx? From Our Clients

Dueland and co-workers then described the use of Juvenile Pubic Symphysiodesis
surgery (JPS Sx) - closure of the cranial portion of the pubic symphysis - as a
treatment for JCHD in 20015.

Application of Evidence Based Medicine

Systematic Review of the Literature Describing Surgical Treatments for Canine Hip
Dysplasia concluded JPS Sx and total hip replacement (THR) had the strongest
evidence to support their clinical efficacy6.

Ortolani Sign
The Ortolani maneuver described in children can be easily learned and used in
"A picture of Sydney post surgery! Thanks
sedated puppies 10 to 18 weeks old to determine the presence of pathologic hip
to [the doctors] and the entire staff for
laxity. such a successful surgery/outcome."
- Bennett Green
Continued next page
 Abstract: Nearly 99% of Golden
Retrievers Have Pathologic
Hip Laxity

Age-Dependent Prevalence of Radiographic

Hip Osteoarthritis of Canine Hip Dysplasia in
Golden Retrievers

Authors: Karbe GT1, Pater ER2, Gregor

TP3, McKelvie PJ4, Smith GK5

The diagnosis of canine hip dysplasia (CHD)

1a 2b largely depends on the presence of
radiographic osteoarthritis (OA), laxity or both
at the time of evaluation.

Routine hip evaluations are performed at 2

years of age; however recent data indicate
linear increase of OA-prevalence with age
throughout life. This study aimed to investigate
the age-dependent prevalence of hip OA in a
group of Golden retrievers (GLDR).

Materials and Methods

PennHIP records of previously evaluated GLDR,
<7 years of age were analyzed. Joint laxity (D1)
and radiographic OA were recorded. For
statistical analysis dogs were grouped by DI-
interval: A(0.30-0.39), B(0.40-0.49), C(0.50-
3c 0.59), D(0.60 -0.69), E(0.70-0.79) and F(0.(0.80-
0.89).
Palpation for Ortolani: The puppy is sedated and held in dorsal recumbence: Place
your hand on the flexed knee and push the femur straight downward (dorsally) Results
9,814 GLDR with mean age of 1.5 years and
toward the acetabulum (1a). Continue to apply downward (dorsally) pressure on mean DI of 0.55 were included. Radiographic
the femur and abduct it towards the table (2b). At some point, usually between 20 OA was present in 13% of the dogs, OA was not
and 45 degrees of abduction, the hip will relocate into the acetabulum, often found in dogs with DI<0.30. OA-prevalence
creating an audible sound (3c). increased linearly with age irrespective of DI
(R2=O.863, p=0.0003) and when grouped by DI
-interval (R2B=0.930, R2c=0.969, R2D= 0.925,
See video demo of Ortolani Maneuver here: R2E=0.974). Relative risk for OA doubled with
http://www.youtube.com/watch?v=KP-0oKZsPnE&feature=youtu.be every one-year increase in age (RR=1.89) and
every 0.10 DI increase (RR=2.44).
A negative test does not rule out hip laxity, it may be a result of insufficient patient
Discussion/Conclusion
relaxation, osteoarthritis or severe abnormality of the coxofemoral anatomy. Prevalence of radiographic OA in this group of
GLDR increased linearly with age and DI. Dogs
with lax hips had earlier onset of OA and
presumably faster disease progression. Nearly
all (99%) GLDR in this study had joint laxity in
the OA-susceptible range (DI>O.30), therefore
Left: VD pelvic radiograph of an 11 week old Pit Bull OA-prevalence would likely continue to
Crossbred showing severe JCHD. `This puppy did not increase with age. It can be concluded that a
have any Ortolani Sign because he has "no hip large number of dogs evaluated at 2 years of
joint". This is shown to emphasize the importance of age are falsely diagnosed as CHD-free.
radiographs as well as palpation when evaluating Acknowledgments: PennHIP Analysis Center,
puppies for JCHD. Malvern, PA

1
Department of Clinical Studies, School of
Veterinary Medicine, University of
Pennsylvania, Philadelphia, PA
2
Northern California Veterinary Specialists,
Sacramento, CA
3
Department of Clinical Studies, School of
Veterinary Medicine, University of
PennHIP Radiographs: Pennsylvania, Philadelphia, PA
PennHIP radiographs are a series of 4
Department of Clinical Studies, School of
three radiographic views (hip extended, distraction, Veterinary Medicine, University of
and compression views) that allow assessment of Pennsylvania, Philadelphia, PA
5
Department of Clinical Studies, School of
subluxation and objective measurement of hip laxity,
Veterinary Medicine, University of
reported as a Distraction Index (DI). Pennsylvania, Philadelphia, PA

Right: Fenway, PennHIP Extended View

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 PennHIP Distraction View
Fenway, DI 0.56 pre-op

Fenway, PennHIP Compression View

The compression view is used to calculate the DI.

The technique uses the dog's neutral hip angle and a distraction device to yield the DI.

Juvenile Distraction Device Adult Distraction Device

The DI is a number from 0.00 to 1.00 that quantifies the maximum amount the hip luxates out of the acetabulum under passive
conditions. PennHIP distraction indices are highly predictive for the risk of development of osteoarthritis in puppies as early as
10 weeks of age or older - the higher the DI the greater the chance of developing OA later in life. Puppies less than 18 weeks
old that have a positive Ortolani and/or PennHIP DI of 0.40 or higher are candidates for JPS Sx. A DI of 0.30 or less is normal
and those puppies will not have an Ortolani Sign. They will not develop JCHD or OA later in life nor carry the genes for CHD.

The distance from the center of the hip distraction view and the center of the
hip in the compression view is divided by the radius of the hip, gives the DI.

Treatment of Juvenile Canine Hip Dysplasia (JCHD):

Juvenile Pubic Symphysiodesis (JPS Sx) is a prophylactic surgical procedure performed in puppies 10 to 18 weeks of age that
have been diagnosed with JCHD. This surgical technique was developed through an increased ability to diagnose JCHD in very
young puppies objectively via PennHIP Distraction and greater recognition of pubic symphysis abnormalities in children with
hip dysplasia7.

JPS Sx. is a minimally invasive, day patient surgical procedure associated with little post-operative morbidity. The procedure
causes premature closure of the cranial pubic symphysis. The pubic symphysis is responsible for much of the longitudinal
growth of the pubis. Premature closure of the cranial pubic symphysis results in shortened acetabular branches of the pubic
bones. This, combined with the normal growth elsewhere in the pelvis, results in outward rotation of the acetabuli, thereby
improving acetabular coverage of the femoral heads. This is similar to the effect gained by a triple pelvic osteotomy (TPO), but
it occurs gradually during the puppies rapid growth phase.

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Closure of the cranial pubic symphysis is accomplished either with an electrocautery needle applied through the physeal
cartilage following a special protocol for time and wattage, or by removal of the physeal cartilage with a No. 12 and No. 15
scalpel blades, small bone ronguers and curettes, followed by cauterization of the bone edges. With either technique the
insertion of the pubic tendon must be removed to allow placement of a protective instrument to avoid urethral damage.
Following surgery, the puppies are restricted to leash walks, avoiding strenuous exercise as much as possible to avoid further
stretching of the ligament of the femoral head, until the acetabular rotation stops the subluxation, which can take 4 to 8
months depending on the age at which the surgery was done and the degree of laxity.

All puppies who have JPS Sx are PennHIP certified. Then they are palpated for Ortolani a repeat extended VD radiograph and DI
are done at 4 months post-op, and in some cases with high pre-op DIs, at 8 months post-op.

Fenway, 28-week post-op DI View Fenway, 50 week post-op DI 0.15 Fenway 5 years post-op at work
(Distraction VD, DI 0.56 pre-op) in her duck blind

JPS Sx is more successful when done at an early age when a significant potential for growth remains, especially in puppies with
high DIs. A successful outcome is one in which Ortolani is eliminated and DI is less than 0.30 are achieved.

10-week-old Golden Retriever puppy DI

pre-op 0.78 and 0.68
Golden Retriever 2 years post-op VD
(pre-op DI 0.78 and 0.68)

Golden Retriever 2 years post-op DI 0.10 and 0.15.

Will never have any hip OA.

JPS Sx done successfully precludes more invasive surgery later, ie. TPO, FHO or total hip replacement (THR).

Conclusion
Hip dysplasia is a very prevalent disease and as such primary care veterinarians should strive to become competent in early
detection of hip laxity, the Ortolani exam. This will enable better counseling of clients regarding breeding background and
potential for JCHD in young puppies (OFA vs. PennHip exam in the Dam and Sire).

Discussing exercise goals and exercise tolerance for newly acquired hip dysplasia prone breeds should be done at an early age,
8-10 weeks, as there are now surgical options in juvenile puppies that are minimally invasive and minimally expensive when
compared to later options (TPO, FHO, THR).
1
Chalman J A , Butler H C. Coxofemoral joint laxity and the Ortolani sign. JAAHA 1985; 21:671-676
2
Ortolani, M: Un Segno Poco c sua Impatanza per la Diagnosi Precoce di Prelussaziona Congenital Dell'anca. Pediatria 45: 129, 1937
3
Smith G K, et al New concepts of coxofemoral joint stability and the development of a clinical stress-radiographic method for quantitating
hip laxity in the dog. JAVMA vol. 196, No. 1, 1990.
4
Early Detection of CHD: Comparison of Two Palpation and Five Radiographic Methods. Dueland and co-workers JAAHA 1998; 34:339-47.
5
R.T. Dueland et al, Effects of Pubic Symphysiodesis in Dysplastic Puppies. Vet. Surg. 30:201-217; 2001
6
Bergh M S et al VOS abst. 2011
7
Mathews AM J Vet Res.57: 127-1433, 1996.
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