- Hip dysplasia is a very common disease that affects larger breed dogs. This disease is the abnormal development of the hip as a puppy grows. Bad genetics are a major contributing factor. Sometimes the mother and father of the affected puppy are negative for the disease. If this is the case, the parents likely have hidden genes for the disease.
- The first stage of hip dysplasia is looseness of the hip joints. Look at Fig 1 below and see the looseness of the left (L) hip joint (ball of femur not seated in socket) versus the right hip joint labeled R. One can be fooled by plain x-rays of the hips as they may appear to be fitting very well, but in reality they are quite loose. It is important to do a complete orthopedic examination to determine if the hip joint will pop in and out of the hip socket. If the joint is loose, the hip partially dislocates with each step the dog takes and the joint gradually becomes deformed. The socket becomes shallow and the head of the femur becomes flattened. Arthritis develops in the joint and causes pain.
- Occasionally the hip joint will be very loose and it will become completely dislocated with minimal trauma. This usually causes the pet to become suddenly lame. Occasionally only one hip has dysplasia, but more commonly both hips are affected.
- Clinical signs of hip dysplasia can be seen as early as 4 months of age, however, many dogs are 8 to 12 months of age. The clinical signs first start out as exercise intolerance or an awkward gait of the hind limbs. Bunny hopping, stiffness on rising after a rest, lameness, and atrophy of the muscles of the hind limbs are typical clinical signs. Some dogs seem to experience signs of hip dysplasia when they are a couple of years old and others in the geriatric years.
- A diagnosis of hip dysplasia is based on a combination of history, clinical signs, physical examination findings, and radiographs. We do not base a decision to perform a triple pelvic osteotomy only on radiographs.
- The ideal candidate for triple pelvic osteotomy should have minimal to no degenerative osteoarthritis seen on radiographs and positive Ortolani sign (the surgeon feel the hip crisply pop in and out of the joint). The angle at which the hip pops back in the joint should not be more than 40 degrees (angle of reduction).
- In the event that your pet is not a candidate for the triple pelvic osteotomy, total hip replacement may be recommended.
Triple pelvic osteotomy surgery
- The triple pelvic osteotomy involves making three separate surgical incisions to cut the pelvis in three places (black lines denote cuts in the pelvis - Fig 1). One incision is in the groin, the second is on the rump, and the third is over the side of the hip region. The last incision is the largest of the three.
- The pelvis is cut in three places and then rotated to the desired amount.
- A plate and screws are used to secure the pelvis in the rotated position (Fig 3). The rotation of the pelvis captures the head of the femur, thus prevent the joint from popping in and out (Fig 4).
- Note that the head of the femur is not seated in the cup of the hip joint (acetabulum) in Fig 2 before surgery; Fig 4 - months after surgery the femoral head is deeply seated in the cup of the hip joint. Clinically this dog was pain-free and did not have any lameness on the limb after healing had taken place, whereas prior to surgery the dog was clearly painful and had profound lameness. Some arthritis has developed in the joint, but it usually does not progress to the degree of an unoperated hip.
Review of how the TPO works (illustration below is of a pelvic as viewed from the hind end)
- Before the pelvis has been rotated the femoral head does not seat very well in the acetabulum
- After the pelvis has been rotated, the femoral head has much better coverage (dashed line)
After care and convalescence
- After surgery has been completed intensive care is provided. Pain control after surgery is maintained with an epidural at the time of the surgery and morphine is given in the postop period as needed. While at home, oral pain medication may be needed and a prescription of Tylenol #4 will be given to you at the time of discharge of your pet. A pain patch (fentanyl patch) will be applied to the skin and will constantly release pain medication for about 4 to 5 days.
- A bandage is sometimes applied to the incision until it is sealed. This bandage should be kept clean and only needs to be kept over the incision for about one or two days.
- It is important to support the hind limbs with a sling for the first 2 weeks to prevent slipping and falling when going outside. A bath towel or commercially available sling can be used for this purpose.
- Antibiotics may be given after surgery to help prevent against infection.
- Exercise restriction must be continued for 3 months. During the first 2 months the pet should be kept in the house on good footing (avoid slippery flooring). Short leash walks are permitted for elimination purposes. After the first 2 months, leash walks can be initiated and gradually increased.
- Most dogs will start to bear a small amount of weight on the limb within a couple of days after the surgery. By 6 to 8 weeks the lameness should be dramatically improved, and by 3 to 4 months after surgery the pet should be using the operated limb(s) very well.
- In general, about 90% of the dogs having the TPO surgery will be greatly improved, if not normal. Some mild arthritic changes can develop with time, but this usually does not cause signs of lameness or stiffness.
- As with any surgery, complications may arise. Even though rare, anesthetic death can occur. With the use of modern anesthetic protocols and extensive monitoring devices (blood pressure, EKG, pulse oxymetry, inspiratory and expiratory carbon dioxide levels, and respiration rate), the risk of problems with anesthesia is minimal.
- Infection is also an unusual complication as strict sterile technique is used during the surgery and antibiotics are administered during surgery.
- Excessive activity or exercise within the first 2 months can also lead to complications. The screws and plate that are used to hold the rotated pelvic bone in place could come loose or even break. This is not a concern once the bone has healed.
- The sciatic nerve which lies on the inner side of the pelvic bone could become bruised or damaged, which could result in loss of function of the limb. This is an unusual complication and if it does occur is usually temporary.
- Obstruction of the urethra (tube leading from bladder) has been reported in the literature, but this is rare.
- Another complication could be severe progression of hip arthritis. In the event that this occurs and your pet is still painful in the joints, total hip replacement may be needed. Some arthritis will develop in the hip joint, but usually does not cause clinical lameness/stiffness. Development of severe arthritis that causes profound lameness is uncommon.
Frequently Asked Questions After Surgery
When should my dog have the first bowel movement after surgery?
- Many dogs will not have a bowel movement for the first 4 to 5 days after surgery
- Reasons that a dog will not have regular bowel movements after surgery include:
- The dog has been fasted prior to surgery
- Dogs do not eat well during the hospital stay
- They frequently do not eat well when they go home
- They are fed highly digestible food that produces little stool
- Pain medication that contain narcotics (such as morphine, fentanyl patches, and tramadol) can be constipating
- If a pet does not have a bowel movement on the 5th day of being home, a stool softener such as metamucil can be fed
- Dose of metamucil is 1 tsp per 25 Kg mixed in with each meal (canned dog food); feed immediately after mixing, as the metamucil will gel the food and may make it less palatable
My pet had surgery and will not eat. What can be done?
- Most pets will not eat their regular dog food after surgery, especially if it is kibble.
- Offer a cooked diet having a 1:1 ratio of a protein source and carbohydrate source. The protein source can be any meat (example: chicken breast, turkey breast, lean hamburger) that is low in fat and should be cooked (drain off all fat after the meat has been cooked). The carbohydrate can be pasta, potato or white rice.
- Try canned dog food; to enhance the flavor sprinkle a very small amount of garlic powder or chicken or beef broth (Chicken-in-a- MugTM or Beef-in-a-MugTM products)
- Try Gerber strained meats for babies such as the chicken, beef, turkey, or veal
- Try Hill's A/D diet available at most veterinary hospitals
- Hand feeding: place a small amount of food in the mouth so that your dog gets the flavor
- Warm the food slightly in a microwave, as the food will be more aromatic; stir the food before feeding and test the temperature on the bottom side of your wrist; it should only be luke warm.
- Remember that most pets will not eat the first day or two after they get home from surgery
- Offer smelly foods that contain fish such as tuna or smelly cat foods
- Try Gerber strained meats for babies such as the chicken, beef, turkey or veal
- Hand feeding: with your finger place a small amount of food on the roof of your cat's mouth; use a syringe to get soft food into the mouth
- Warm the food slightly in a microwave as the food will be more aromatic; remember to stir the food before feeding and test the temperature; it should be only luke-warm
- Some cats will only eat dry food, try kibble if your cat normally has been fed that food
- Petting and stroking your cat frequently will help to stimulate appetite
- Remember that most pets will not eat the first day or two after they get home from surgery
- Appetite stimulants such as cyproheptadine may be helpful
- If your cat refuses to eat anything for 7 days a stomach tube or nasogastric tube should be placed to provide nutrition so that a serious liver problem (hepatic lipidosis) does not develop
My pet is vomiting. What can be done?
- The first thing for you to discern is whether your pet is vomiting or regurgitating. Both will result in fluid or food being brought up. Vomiting always will have heaving or retching of the abdomen prior to expulsion of the vomitus. Regurgitation is not associated with heaving and the pet usually just opens the mouth and fluid or food will be expelled. Usually the regurgited material will be clear or brown colored fluid.
- Next is to identify the cause of the vomiting or regurgitation.
- Causes and treatment of vomiting after surgery
- When some pets return home after a stay in the hospital they may drink excessive amounts of water at one time and then vomit; if this appears to be the case, the water should be limited to frequent smaller amounts.
- Medications such as antibiotics, narcotics or nonsteroidal anti-inflammatory medication commonly cause vomiting after surgery. In order to see which medication is causing the problem, the administration of each drug should be separated 2 hours apart. Usually the pet will vomit or appear nauseated (drooling and sick look) within 1 hour of administration of the medication that they are sensitive to. The antibiotic in some cases may be changed to a different one, or may be discontinued.
- Stomach upset from anesthesia is a potential cause of vomiting and will pass within a couple of days.
- An uncommon cause of vomiting after surgery is internal organ failure. Blood testing will confirm this problem. For this reason vomiting should not be ignored if it persists for more than 24 hours.
- If your pet had surgery of the bowels or stomach, vomiting is always a concern, as it may indicate that infection of the abdominal cavity, called peritonitis, is present. Do not ignore this sign.
- Symptomatic treatment of vomiting involves withholding food for 12 to 24 hours, then introducing small amounts of bland food such as rice and lean cooked hamburger, if your pet does not vomit after that then gradually wean him/her back onto the regular diet after 3 days. In order to decrease the acidity of the stomach, Pepcid AC 0.5 mg/kg can be given by mouth twice daily for 5 days. Metoclopramide and Cerenia are good anti-vomiting medications for dogs and cats. You should always consult a veterinary healthcare professional before administering medication.
- Causes and treatment of regurgitation after surgery
- The most common cause of regurgitation is reflux of acid from the stomach into the esophagus while your pet is under anesthesia. Acidic fluid from the stomach can cause a chemical burn of the esophagus and result in a bad case of heart burn, called esophagitis. This results in poor motility of the esophagus, therefore water and food will accumulate in this structure. In most cases, esphagitis is self-eliminating and will resolve within two or three days.
- If the esophagitis is severe the esophagus may develop one or more strictures. A stricture is a narrowing or stenosis of the esophagus and does not allow passage of food down the esophagus, in regurgitation that lasts longer than one week. This problem should be brought to the attention of your pet's doctor within the first two weeks so that it can be treated by ballooning the stricture (minimally invasive procedure, as it is done with the aide of an endoscope). If an esophageal stricture is chronic surgery is needed.
- Symptomatic treatment of regurgitation caused by esophagitis includes feeding bland food, and administering a coating agent (sucralfate) and an acid blocker (omeprazole or other). Consult a veterinary health care professional if the regurgitation continues for more than a couple of days.
How do I know that my dog is in pain following surgery?
- Signs of pain include
- biting if you get near the surgical site
- grimacing (lips are pulled back and the the dog looks anxious)
- tragic facial expression
- restlessness and unable to sleep; pacing
- if abdominal surgery was done the pet will not lie down on the incision, or will continually sit up in spite of appearing very tired
- the worst pain will be for the first 2 to 3 days after surgery
What can I do to control my dog's pain?
- Narcotic medications that control pain: tramadol, butorphanol, Duragesic (fentanyl patch)
- Anti-inflammatories used to control pain: Deramaxx, Rimadyl, Previcox, or Etogesic
- If an orthopedic surgery has been done cold packing the surgical site may be helpful
- A cold pack may be a pack of frozen peas, crushed ice in a Ziploc bag, or a cold gel pack; place a thin barrier between the skin and the cold pack. An alternative to a cold pack is to freeze water in a styrofoam cup; after frozen cut the bottom of the styrofoam cup out. Cool the surgical site around the incision by rubbing the exposed ice directly on the skin in a circular pattern. Cooling the surgical site helps to numb the area.
How do I know that my cat is in pain following surgery?
- Pain is more difficult to assess in cats versus dogs, as signs can be more subtle and they usually do not vocalize when in pain
- Signs of pain in a cat include the following:
- biting if you get near the surgical site
- growling or deep cry
- not wanting to eat
- hiding and not wanting to be near owner (remember that this could also be caused by the cat just being upset about leaving home and coming back)
What can be done for pain at home for my cat?
- Pain medication such as buprenorphine or a Duragesic (fentanyl) patch
- Tylenol will kill a cat as they lack abundant glutathione enzyme in the liver
- Anti-inflammatories can be used, but the dose is much less than dogs
Is it okay for my pet to lick the incision?
- If a dog licks the incision, the healing process may be delayed.
- Licking can remove stitches and cause the incision to open
- Licking can become a severe habit that is difficult to break
- Licking can cause infection as the mouth has many bacteria
- Dogs will frequently lick the incision when the owner is not watching such as at night time; if the skin looks red or excoriated the most common cause is from licking.
- To stop your pet from licking the following can be tried:
- Elizabethan collar can be placed on the neck; this will not help stop your pet from scratching at the region
- Cervical collar (bite not collar) is a less awkward device and can be effective at stopping a pet from licking the surgical site
- A tee shirt can be used to cover an incision on the chest or front part of the abdomen; gather the waist of the shirt up over the dog's back and wrap an elastic band around this part of the shirt.
- A bandage or sock can be used to cover an incision on a limb; fasten the top of the sock to the dog's limb with tape.
- Bitter apple can be applied around the incision; many dogs will continue to lick after application of this topical
- Bitter Apple and Liquid HeetTM (obtain this from a drugstore...it is used for sore muscles) mixed in a 2:1 ratio can be applied around the skin incision
- Antipsychotic medication in some cases is needed