Early recognition of joint laxity is the key to preventing cartilage damage from progressive joint laxity.
Treatment Option 1:
Puppies as early as 10 weeks old can be diagnosed with abnormal joint laxity accurately (see Diagnostics) and treated surgically by the procedure, Juvenile Pubic Symphysiodesis (JPS). Between 10 and 18 weeks old, when a puppy is given their shots, they should be examined by the primary care veterinarian or an ACVS board-certified veterinary surgeon to determine the absence or presence of pathological joint laxity which could result in CHD.
A recent study that reviewed many peer reviewed published scientific studies i.e. evidence based medicine stated, "JPS surgery is a method of consistently providing normal pain free hip function". JPS is a minimally invasive surgery that closes a growth plate at the bottom of the pelvis. This results in selective growth of the pelvis and the hip cup (acetabulum) increasingly covering the ball (femoral head) as the puppy grows during the following 4–6 months. Patients may be able to go home the same day after this procedure.
During those 4–6 growing months, following JPS surgery, leash walks are acceptable but strenuous off leash exercise is discouraged until follow up exams at 10 months of age confirm the dog will have pain free hip function.
Weight management and rapid growth should be managed with measured amounts of low protein dry food diets (20–21%) for rapidly growing large breed puppies from an early age and following JPS surgery until 12 months of age.
JPS is a technique for stopping the growth of the pubis (part of the pelvis) to alter the growth/shape of the pelvis, while increasing the ball’s degree of coverage by the socket to diminish hip laxity. It is a relatively minor surgical procedure and puppies less than 18 weeks of age must have it performed. However, since most puppies of this age do not show symptoms of CHD, early diagnosis by way of examination and special x-ray techniques are critical.
Treatment Option 2:
Double or Triple Pelvic Osteotomy (DPO/TPO) is another option for immature dogs (ideally less than 8–10 months old) with CHD but no visible radiographic arthritic changes. These surgical procedures involve cutting the pelvic bone in two (DPO) to three places (TPO) and rotating the segments to improve coverage of the ball by the socket and decrease hip laxity (Figure 4). TPO has been used successfully in dogs and children for decades. Recent advancements in implant (locking plates and screws) technology now allow similar results with only two cuts made in the bone (DPO), thus a less invasive procedure.
The best time to recognize pathologic hip laxity is when the young dog is neutered (spayed or castrated) between 6–8 months old. This can often be done by the primary care veterinarian who does the sterilization procedure. An x-ray must be taken and the hips can be palpated for joint laxity (see methods under Diagnostics) Immature dogs with lameness and early evidence of hip arthritis are not ideal candidates for DPO/TPO, nor are dogs with very severe hip laxity, as some puppies have no functional hip joint by 6 months of age.
Treatment Option 3:
Total Hip Replacement (THR), the third surgical option, can be used in young dogs who cannot be successfully treated with JPS or DPO/TPO surgeries. They must be managed medically until they are mature enough for THR, at least a year old. THR, based on evidence based medicine via multiple peer reviewed publications is the second surgical method that provides the most normal pain free function in dogs with CHD.
This surgical procedure eliminates hip pain by reproducing the mechanics of a normal hip joint with a more natural range of motion and limb function. As with humans, canine THR involves replacement of both the ball and socket with metal and polyethylene (plastic) implants (Figure 6). These components are fixated in place with bone cement, metal pegs, or “press fit” (bone ingrowth) methods.
Treatment Option 4:
The last surgical option to alleviate the pain secondary to severe hip laxity/dysplasia is femoral head ostectomy (FHO) surgery. This surgical procedure can be done at any age and can provide enough comfort in a dog weighing less than 60–70 lbs to avoid the daily use of anti-inflammatory pain medication, thus avoiding costs and side effects that limit or negate its use.
Young dogs that do not meet the criteria for DPO/TPO or JPS procedures, or dogs who do not respond satisfactorily to medical treatment alone may benefit from FHO. This technique involves removing the femoral portion of the hip joint (i.e., the ball) to reduce the pain produced by abnormal hip joint contact that wears away the joint cartilage, and the stretching of the soft tissues around the joint due to laxity (Figure 5).
Following an FHO, a “false joint” develops with the muscles around the hip now transferring the forces from the leg to the pelvis during limb movement. The goal of an FHO is to relieve the pain associated with CHD, not to maintain/recreate normal hip function. Two weeks following FHO surgery the puppy/adult dog is encouraged to exercise, often receiving anti-inflammatory drugs daily during the initial 1–2 months post-op. Then these drugs may only be necessary intermittently.
FHO dogs must remain slim throughout their lives and follow a limited exercise program i.e. leash walks and confinement to the yard and house. They cannot be athletic dogs who hunt, do agility, high level obedience, run with their owners, etc. If those activities are what the owner wishes to do with their dog, then a THR would be necessary.
This treatment option is dependent on many factors. Age, weight, degree of hip laxity, lifestyle of the owner and their tolerance for the cost incurred for medication and in some cases physical therapy.
AGE: Often used in middle aged to older dogs who have gained weight and live a relative sedentary life style.
WEIGHT: All dogs with CHD should be kept very slim from the outset, from very young to old age. It is the most effective least expensive long term method of keeping them as comfortable as possible.
DEGREE OF HIP LAXITY: This can vary greatly depending on the degree of hip laxity. The severely affected puppy with no functional hip joints at 6 months of age is destined for a life of daily pain with minimal exercise. The other end of that wide spectrum is the dog with hip laxity that is present but does not manifest itself until middle age. In this case, the cartilage damage progresses more slowly because of less severe hip laxity.
LIFE STYLE: Highly active owners or owners who introduce another young active dog/child to their home find they have an older dog with CHD. CHD dogs cannot be highly active/athletic without surgery. There are no medical management programs that will allow that lifestyle comfortably. A more sedentary, low impact lifestyle is a more realistic outcome with medical management.
WHAT DOES MEDICAL MANAGEMENT ENTAIL?
1) Maintenance of minimal body weight.
2) Limited exercise routine i.e. leash walks of a length the dog tolerates comfortably.
3) Daily or intermittent (a better option if it can be done effectively) use of non-steroidal anti-inflammatory drugs (NSAIDs). These drugs can be very effective in relieving pain. However, NSAIDs can have significant side effects that if used daily must be monitored with blood tests to avoid kidney and liver damage. The monitoring interval depends on the age of the dog and the dosage level of the drug. Ideally the lowest daily dose that provides obvious comfort should be used for long term therapy. If the maximum daily dose is required, the risk of side effects is greater and the cost of the drug and monitoring can exceed the cost of surgical intervention if the dog is young or middle aged.
4) Cartilage protective supplements are often recommended, however there is no evidence in peer reviewed literature that they provide any help in cartilage repair or protection against wear/damage.
5) Physical therapy can be helpful in dogs who lead a very sedentary life style because the owners work long hours. The dog, like ourselves, become stiff if they do not move around frequently. Joint movement and muscle strength help keep them comfortable and more mobile. Physical therapy is also used for dogs undergoing surgery for CHD. This helps strengthen the muscles and increases the speed of recovery.