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Management of Canine Traumatic Hip Luxation

Management of Canine Traumatic Hip Luxation (THL)

Luxation of the coxofemoral joint is responsible for approximately 64% of all traumatic luxations.  Most dogs with THL are older than 7 months because trauma in dogs under this age usually results in fracture of the femoral head or neck.  Management of THL is complicated by several factors including hip dysplasia, avulsion fracture of the femoral head at the attachment of the ligament of the femoral head (5-10% of cases), coxofemoral joint cartilage damage, severe disruption of the joint capsule, and other concurrent soft tissue and orthopedic injuries secondary to the trauma that caused the luxation (35-55% of cases).  Information on the two major types of luxation will be presented along with methods of treatment.

A.Craniodorsal Luxation

a)95.5% all luxations are craniodorsal and 83% of those are caused by automobile induced trauma.

b)Males and females are equally affected.

c)35-50% of THL cases have additional traumatic injuries.

d)5-10% have femoral head fractures.

e)3-6% of THL's are bilateral.

f)Clinical Signs

1.Affected limb may appear shorter.

2.Limb is held in adduction and external rotation with external stifle rotation and internal tarsal rotation.

3.Crepitus and pain are usually noted on flexion and extension of the hip.

g)Diagnosis/Patient Assessment

1.Ventrodorsal and lateral radiographic projections will confirm the diagnosis.  Be sure the dog is well positioned and the films are of excellent quality so you can adequately evaluate the hip for OA, hip dysplasia, etc.

2.Look for other orthopedic injuries on the radiographs such as avulsion fractures, pelvic fractures, and spinal injuries.

3.Always take chest radiographs to rule out serious chest injuries and diaphragmatic hernia.

4.Confirm that the bladder and the cruciate ligaments are intact.

5.Perform a complete blood screen and complete physical examination.

h)Evaluation: The status of the coxofemoral joint is critical to selecting the proper course of treatment.  The following are factors to be noted prior to selecting a treatment plan. 

1.Evaluate the amount of hip subluxation and acetabular coverage of the femoral head on the opposite limb to estimate how normal the luxated hip was prior to injury.

2.How much remodeling and OA/DJD of the coxofemoral joint is present.

3.Are there injuries of the opposite limb that will force the dog to use the THL limb immediately after hip reduction?

i)Treatment Plan

1.If there is significant OA/DJD then femoral head and neck excision (FHNE) or total hip replacement (THR) are probably necessary.  However, if the hip feels stable after closed reduction, then you may want to evaluate the dog over a few weeks to see how it does prior to performing surgery.  Rarely a dog will surprise me and recover well in spite of radiographic signs of OA-DJD.

2.If the hip looks normal but hip laxity is suspected then a triple pelvic osteotomy (TPO) will probably be necessary to ensure adequate reduction and minimize post reduction OA/DJD formation.

3.If the hip looks relatively normal then closed reduction should be attempted because closed reduction is successful at least 50% of the time in normal appearing hips.  Always confirm reduction radiographically. If the hip cannot be reduced, if it easily reluxates, if there is an articular fracture or if closed reduction fails then open reduction is necessary.  Open procedures can be divided into intercapular and extracapsular categories.

a.Extracapsular Techniques

1.Joint capsule reconstruction (reluxation rate of 9.5% to 17.4%)

2.Prostatic Capsule technique (reluxation rate of 6%)

3.Single iliofemoral suture.  Technique: A hole is drilled transversely through the femur at the base of the greater trochanter.  An ileal tunnel is drilled as dorsoventrally as possible near the origin of the rectus femoris muscle.  A suture (#3 Vicryl) is passed in figure-eight fashion through the tunnels and over the femoral neck under the deep gluteal muscles (no reluxations in 14 cases).

4.Don't use De Vita Pin (sciatic nerve injury)

a.Intracapsular Techniques

1.Toggle Pin: Allows dog to weight-bear immediately postoperatively (reluxation rate 18-25%).

2.Transarticular Pin: Usually best for dogs under 30 pounds.  80% of smaller dogs in one study had good results.  7% reluxate. Pin may break and must always be removed after 2-3 weeks. Dog kept in sling while pin is in place.

j)Post-op Management

1.If possible keep limb in an Elmer sling for 2 weeks postreduction.

2.Restrict activity to no running, jumping, climbing, or walking or slick surfaces for 3 to 8 weeks.

3.Return slowly to full activity with 2 weeks of leash walking only.

4.Expect some long-term postoperative lameness in about 30% of cases in spite of the closed or open technique used.

5.Failure rate reported to be between 8-20%.

6.Most dogs require 8-16 weeks to return to optimal function.

Caudoventral luxation

a)3.2% of all hip luxations.

b)Has much better prognosis than craniocaudal luxation.

c)Trauma is most common cause.

d)Closed reduction is almost always successful because the attachment of the joint capsule to the dorsal acetabular rim is almost always preserved.

e)Activity restriction is the same as craniodorsal luxation but a sling is usually not indicated.