Q: Dr. Mike, My 8 yo GSD has been diagnosed with mild hip dysplasia. She has been given Rimadyl in the past for a flare but suffered from bloody diarrhea and vomiting after 4 days of treatment. At the same time she was also started on Cosequin DS. Obviously she should not be given Rimadyl again but I'm have a couple questions regarding treatment:
1. Could the Cosequin DS have also contributed to her adverse reaction? I'm not sure about the side effect profile of this product.
2. What are her future options for treatment for acute pain? I'm not sure I'd be comfortable with even a short course of steroids given her reaction to the NSAID.
3. If she truly needs steroids do you have any information about the addition of a drug like ranitidine or omeprazole to prevent GI problems?
I have not heard of bloody diarrhea associated with the use of Cosequin (tm) or other glucosamine/chondroitin products. However, we have had at least one dog in our practice who developed diarrhea without blood when given glucosamine/chondroitin products that was a repeatable circumstance and I have talked with other vets who have had similar experiences. So I suspect that there are a few dogs who develop diarrhea as the result of the use of glucosamine and/or chondroitin use. In general these are pretty safe products, though. We have had some clients who reported vomiting associated with the administration of glucosamine and chondroitin and there are anecdotal reports of disturbances in glucose levels in diabetic patients when using glucosamines. There is some concern about exacerbation of pre-existing bleeding disorders due to the similarity in chemical structure between glucosamines and heparin. Since shepherds are somewhat prone to bleeding disorders this may be something to think about due to the bleeding that occurred in association with the diarrhea when Rimadyl (tm) was administered, even though it isn't highly likely to be a problem.
I would not rule out the use of all non-steroidal anti-inflammatory (NSAID) medications based on a reaction to one of them. Individual patients seem to react differently to the various NSAIDs and it is often possible to use a different one without problems. Among the NSAIDs it seems reasonably safe to use aspirin, carprofen (Rimadyl Rx), etodolac (Etogesic Rx), ketoprofen (Orudis tm - 1mg/kg/day, may be best to use intermittently) and meloxicam (not yet available in the U.S., in in Canada). All of the NSAIDs do have some potential to cause problems, usually gastrointestinal, liver or kidney related. This risk has to be weighed against the potential for pain relief and improvement in the quality of life. Based on our practice experience the quality of life improvement can be dramatic and justifies taking small risks, however your experience with carprofen does give rise to higher worries than exists in most cases. I wouldn't totally rule out the possibility of trying a different NSAID in the future if the arthritic pain associated with hip dysplasia becomes more severe.
It is acceptable to use cimetidine (Tagamet tm), famotidine (Pepcid AC tm), ranitidine (Zantac tm) and misoprostol (Cytotec Rx) to lessen the gastrointestinal effects of NSAIDs in cases in which they are irritating but it still seems necessary to consider their use.
For pain relief associated with hip dysplasia there are several additional options. Narcotics can be used with good success in some dogs. We use hydrocodone/acetaminophen (Vicodin Rx) combination medications in our practice for chronic pain fairly frequently and it seems to be beneficial to many patients. This combination can't be used in cats due to the acetaminophen and rarely acetaminophen causes liver damage in dogs, as well. Hydrocodone is available without acetaminophen and it is acceptable to use codeine (0.5 to 2mg/kg every 8 to 12 hours). Amitriptyline (Elavil Rx), seems to help in chronic pain when used alone or in conjunction with narcotics. While I think it works better when used with narcotics, we do have one patient on amitriptyline alone for chronic hip dysplasia because it seems to do well with amitriptyline as the sole drug. Morphine ( 0.5mg/kg every 4 to 6 hours) works well for chronic pain relief as well but we usually try to reserve this use to really difficult cases when all other medications fail. Fentanyl patches (Duragesic Rx) are an effective short term solution for moderate to severe pain in dogs and some veterinarians use these more chronically but we have not tried this approach, yet.
Corticosteroids are very effective anti-inflammatory medications. They have wider ranging systemic side effects than most of the other medications used in veterinary medicine, though. For this reason, most veterinarians prefer to avoid the chronic use of corticosteroids for conditions that can be treated with other medications. However, there is a time in the course of hip dysplasia when the risk/benefit balance begins to favor the use of corticosteroids, as well. While corticosteroids can cause gastrointestinal problems, including ulcers, this effect is less common with cortisones than with non-steroidal anti-inflammatory medications. Misoprotol doesn't seem to help much with cortisone induced ulcers but the H2 blockers (famotidine, ranitidine, cimetidine) might be helpful. In general, though, I don't think that it is really necessary to use these medications in conjunction with steroids unless the dosage is high or daily use (as opposed to every other day use) has to be continued for long periods of time.
Using anti-oxidants, such as Vitamin E (up to 2000U/day) and marine fish oils (3V Capsules tm) may be beneficial to some patients with chronic inflammatory disorders. Glucosamine (500mg/25lbs body weight/day) and chondroitin (400mg/25 lbs body weight/day) are widely used for chronic anti-inflammatory effects and there are now some better studies that do support their use.
I wouldn't rule out hip replacement surgery, either. This works really well in 90% of the patients who have surgery and the relief post surgically is sometimes really dramatic. It is more costly initially but I suspect that many of our clients spend more money in the long run treating the chronic pain and the dog gets the benefit of not having the pain that has to be treated. While it is probably overkill for most dogs with mild pain I don't see any reason not to consider it for a patient who has reactions to pain medications.
I hope that this is helpful. I think that there will be additional choices in non-steroidal medications for dogs, including one or more of the newer C0X-2 inhibitors (a human example would be celecoxib (Celebrex Rx) being approved for use in dogs. That may be helpful for dogs like yours who have stronger gastrointestinal reactions to the medications that have more of a COX-1 or mixed COX-1/COX-2 effect.
Mike Richards, DVM
Q: My golden was just diagnosed with chd in both hips. I started her on glucoflex already. I just read several studies on ester-c and they sound really promising. Have you heard of this and if so would you reccomend this? Also her parents were just bred again. I was told they have both been xrayed and had good hip. I looked on the ofa registry and there is no record of this. Her mother is due at the end of the month. I know that some of the people are planning on breeding the female puppys from that litter. If the puppys are ofa good could they be bred. I would think that they could carry the genes for chd and should not be bred. Am I wrong? Thank you Shari
I am sorry that it took so long to get to your question. I checked the two databases that I have access to for studies on esther-C and found none that seemed to relate to hip dyplasia. Vitamin C, but not specifically ester-C, has been studied several times in relation to hip dysplasia and was not helpful in controlled studies. To the best of my ability to tell, there is little risk associated with the use of Vitamin C in a dog past the growth phase, so it wouldn't worry me if one of my clients wanted to try it, though.
The genetics of hip dysplasia are pretty complicated, since it is a disorder that is affected by the more than one gene and also by environmental influences, especially the weight of the puppy as it grows. However, the best advice seems to be to try to get information from multiple generations. The reason for this is that even when two dogs with hip dysplasia are bred, there are likely to be as many as 25% or more of the puppies who will have good hips despite their parent's problems. But these dogs have a much higher risk of passing on hip dysplasia to their offspring than if they had been from a breeding in which both parents had good or excellent hips. In that case, the odds of a puppy having good hips might be as high as 75% or more. I have attended one seminar in which this issue was discussed in detail and the person presenting the talk said that knowing only the parent's hip status improved your chances of getting a puppy without hip dysplasia only by about 25%. Knowing two generations improved the odds by about 50 to 75% and knowing three generations improved the chances to about 75%. These were not presented as hard facts, just as general guideline for the value of the information. She felt that even knowing more generations than this did not help in breeds prone to hip dysplasia but that it was obvious that with a large number of generations in which selection was made to eliminate carriers hip dysplasia could be eliminated. She used greyhounds as an example. They have been selected for speed for so long that orthopedic conditions that might interfere with speed are lower in the breed, including hip dysplasia.
It would help a lot if there was good reporting of all testing for hip dysplasia in a breed so that it was possible to look at multi-generational pedigrees and the occurrence of this and other disorders and then make breeding selections based on that knowledge. At this time, that isn't possible, though. It is definitely worthwhile to ask for proof of an OFA or PennHip test result for hip dypslasia, though. I know of many instances in which clients of mine purchased puppies with the assurance that the parents had "good hips" when they were never actually tested.
Mike Richards, DVM
Hip dysplasia literally means an abnormality in the development of the hip joint. It is characterized by a shallow acetabulum (the "cup" of the hip joint) and changes in the shape of the femoral head (the "ball" of the hip joint). These changes may occur due to excessive laxity in the hip joint. Hip dysplasia can exist with or without clinical signs. When dogs exhibit clinical signs of this problem they usually are lame on one or both rear limbs. Severe arthritis can develop as a result of the malformation of the hip joint and this results in pain as the disease progresses. Many young dogs exhibit pain during or shortly after the growth period, often before arthritic changes appear to be present. It is not unusual for this pain to appear to disappear for several years and then to return when arthritic changes become obvious.
Dogs with hip dysplasia appear to be born with normal hips and then to develop the disease later. This has led to a lot of speculation as to the contributing factors which may be involved with this disease. This is an inherited condition, but not all dogs with the genetic tendency will develop clinical signs and the degree of hip dysplasia which develops does not alway seem to correlate well with expectations based on the parent's condition. Multiple genetic factors are involved and environmental factors also play a role in determining the degree of hip dysplasia. Dogs with no genetic predisposition do not develop hip dysplasia.
At present, the strongest link to contributing factors other than genetic predisposition appears to be to rapid growth and weight gain. In a recent study done in Labrador retrievers a significant reduction in the development of clinical hip dysplasia occurred in a group of puppies fed 25% less than a control group which was allowed to eat free choice. It is likely that the laxity in the hip joints is aggravated by the rapid weight gain.
If feeding practices are altered to reduce hip dysplasia in a litter of puppies, it is probably best to use a puppy food and feed smaller quantities than to switch to an adult dog food. The calcium/phosphorous to calorie ratios in adult dog food are such that the puppy will usually end up with higher than desired total calcium or phosphorous intake by eating an adult food. This occurs because more of these foods are necessary to meet the caloric needs of puppies, even when feeding to keep the puppy thin.
If clinical signs of hip dysplasia occur in young dogs, such as lameness, difficulty standing or walking after getting up, decreased activity or a bunny-hop gait, it is often possible to help them medically or surgically. X-ray confirmation of the presence of hip dysplasia prior to treatment is necessary. There are two techniques currently used to detect hip dysplasia, the standard view used in Orthopedic Foundation for Animals (OFA) testing and X-rays (radiographs) utilizing a device to exaggerate joint laxity developed by the University of Pennsylvania Hip Improvement Program (PennHIP). The Penn Hip radiographs appear to be a better method for judging hip dysplasia early in puppies, with one study showing good predictability for hip dysplasia in puppies exhibiting joint laxity at 4 months of age, based on PennHIP radiographs.
Once a determination is made that hip dysplasia is present, a treatment plan is necessary. For dogs that exhibit clinical signs at less than a year of age, aggressive treatment may help alleviate later suffering. In the past a surgery known as a pectineal myotomy was advocated but more recent evidence suggests that it is an ineffective surgical procedure. However, administration of glycosaminoglycans (Adequan Rx) may help to decrease the severity of arthritis that develops later in life. Surgical reconstruction of the hip joint (triple pelvic osteotomy) is helpful if done during the growth stages. For puppies with clinical signs at a young age, this surgery should be strongly considered. It has a high success rate when done at the proper time.
Dogs that exhibit clinical signs after the growth phase require a different approach to treatment. It is necessary to determine if the disorder can be managed by medical treatment enough to keep the dog comfortable. If so, aspirin is probably the best choice for initial medical treatment. Aspirin/codeine combinations, phenylbutazone, glycosaminoglycosans and corticosteroids may be more beneficial or necessary for some dogs. It is important to use appropriate dosages and to monitor the progress of any dog on non-steroidal or steroidal anti-inflammatory medications due to the increased risk of side effects to these medications in dogs. If medical treatment is insufficient then surgical repair is possible.
The best surgical treatment for hip dypslasia is total hip replacement. By removing the damaged acetabulum and femoral head and replacing them with artificial joint components, pain is nearly eliminated. This procedure is expensive but it is very effective and should be the first choice for treatment of severe hip dyplasia whenever possible. In some cases, this surgery may be beyond a pet owner's financial resources. An alternative surgery is femoral head ostectomy. In this procedure, the femoral head (ball part of the hip joint) is simply removed. This eliminates most of the bone to bone contact and can reduce the pain substantially. Not all dogs do well following FHO surgery and it should be considered a clear "second choice".
Hip dysplasia may not ever be eliminated by programs designed to detect it early unless some effort is made to publish the results of diagnostic tests such as the OFA evaluation or PennHIP evaluations, openly. This is the only way that breeders will be able to tell for certain what the problems have been with hip dysplasia in a dog's ancestry.
When an older dog is exhibiting signs of pain associated with this condition it is often possible to help them dramatically through medication and simple steps like providing a warm bed or warm spot to rest during the day. There is no advantage to pain and steps should be taken to ensure that the older dog is not in pain. Regular exercise can be very helpful and weight loss can have dramatic effects on the amount of discomfort a dog experiences.
Working with your vet to come to the best solution for your dog and your situation will enable you and your dog to enjoy life to its fullest, despite the presence of hip dysplasia.
Mike Richards, DVM
Q: Female Mastiff, 5 months old. Two weeks ago she started doing "the walk" ...back legs close together, difficulty rising from laying position. Some hopping. I know the walk.
The gate into the barn area had been left open by the kids. The goats were out and our older mastiff goes literally 'nutso' when he has a chance to chase the goats. The puppy was in on the crazyness... and I believe she got knocked around by the older mastiff possibly running over her or running into her. I didnt see the action, although I did rescue her from the barn area when I realized what was going on. This of course is my preferred reasoning for her new walk, although hip dysplasia is seriously bothering my questioning area of the brain...!!
From that date to present, we are doing the bunny hop occasionally and the legs close together walk. She seems to be getting somewhat better as the weeks go on, although this 'bothers' me greatly....those words of 'hip dysplasia' pop up. Yesterday a visitor over here, knowing nothing of the previous weeks rough play, said that dog has 'hip dysplasia'. The bunny hop... This visitor also did not know she was a puppy either...
1. Assuming she was injured a few weeks ago, what is the standard healing period of a growing puppy with some kind of back end injury?
2. I dont want to run the gamete with unnecessary x-rays so your knowledge will help me in knowing how long to expect healing or take a look at possible hip displasia.
3. Is it possible for a pup this age to show clinical signs of hip dysplasia?
4. What can I do for her?
5. Is walking and training safe to do with her while she shows these signs of back leg problems i.e. teaching sit and heel. She is sitting off balance and rarely straight on her back feet.
It is definitely possible for a five month old puppy to have clinical signs of hip dysplasia. When clinical signs are present, it is almost always possible to diagnose hip dysplasia from X-rays, if it is the cause of the signs. This would be a good age to get a diagnosis, if you would consider reconstructive surgery of the hip joint (triple pelvic osteotomy), a procedure that must be done while the puppy is still growing. It is also possible that the clinical signs could be due to another problem, such as a strain or sprain of one of the joints in the leg, a pelvic injury or a back injury. Other problems, such as osteochondrosis, sometimes cause lameness in one or both rear legs as well.
Puppies with hip dysplasia often have more discomfort at some times than at other times. There can be periods of soreness and then apparent recovery even though the disorder is present the whole time. Recurrences of the soreness are common, though. It is a good idea to consider X-rays if you see a pattern of intermittent lameness in a young dog.
Strains and sprains usually heal within two to three weeks. Back injuries can take a very long time to heal, or may not ever heal completely. At some point, it may become necessary to try to differentiate between hip dysplasia and a back injury. If back problems are present, neurologic deficits are more likely to be visible, with signs such as dragging the toes or problems with placement of the feet occurring. It is often possible to tell if a neurologic injury is present through a physical exam but it doesn't rule out a problem with hip dysplasia being present at the same time.
It may be helpful to use glucosamine and chondroitin at this age to try to limit the inflammation and provide the necessary nutrients for joint repair. Pain relief can be useful. I still like aspirin as first choice for puppies with hip dysplasia but it can be irritating to their digestive tract. Weight control is very important in limiting the progression of hip dysplasia. If the puppy is overweight at all, a diet may help more than anything else.
I think that moderate exercise is not likely to cause additional problems and may help due to increases in muscle strength and possibly joint mobility. Heavy exercise will increase joint inflammation and could potentially make the dysplasia worse. Sitting can be pretty hard on puppies with hip dysplasia and if pain is observed, or if the puppy shows obvious reluctance to sit, it would be best not to push the issue. Teaching the puppy to heel should be no problem.
It really would be best to have X-rays taken to see if hip dysplasia is present, to assess how bad it is, if it is present and to plan what to do for the puppy. This is especially true if it is possible to consider surgery such as the triple pelvic osteotomy. If you know that surgery is out of the question, then it isn't nearly as important to have the X-rays because medical therapy, weight control and restricting exercise to moderate activity will have to be plan.
Hope this helps some.
Mike Richards, DVM
Q: My mastiff mix has been diagnosed w/ hip dysplasia. I have him on gloucosamine (glyco-flex) and was wondering if Synovi-Msm is better, worse, the same or no comment. It's all very confusing. The glycoflex has made a world of difference... that is until I took him to the vets on Thurs for vomiting (at 12:30 AM), to which his doc put him in the hospital on an IV and took xrays. All very good measures since he diagnosed 'pancreitis". I know... what a week of GREAT?!? health care news.
Anyway, he was hospitalized for two days. After which I brought him home and promptly allowed him to swim (after a little rest. Since it's almost impossible to keep him out of "his" pool). Well, after being confined for 2 days, and with bad hips to boot, I let him swim, which he LOVES!!! to do. Well he has carried his back leg, to the point I thought he had broken it, since Saturday. Upon another recheck by the doc, he said complete rest. NO SWIMMING!! That was probably the worst thing to do after his confinement. Well, he has his acupuncture treatment in the morning (1st ever). Hopefully this will help!! I've had good referrals from other patients who received it for dysplasia, and they swear by it. Doc, any comments that you think might help? The glyco-flex? The vet has him also on ammoxycillyn for the pancreitis, and changed his diet. Thanks, Michael.
There are studies that support the use of glucosamine and chondroitin for chronic degenerative joint disease in both dogs and humans. The best of the studies involved stifle injuries but it seems reasonable to assume that there would be similar effects in other joints.
I am not aware of similar good scientific studies supporting the use of methylsulfonylmethane (MSM), but there are veterinarians who believe that it is helpful and there is no reason that I know of that you can not use MSM and glucosamine at the same time.
At some point it is likely that glucosamine, chondroitin and other "neutroceutical" agents will not be sufficient for control of discomfort associated with hip dysplasia. At that time, the use of non-steroidal anti-inflammatory medications such as aspirin, carprofen (Rimadyl Rx) or etodolac (Etogesic Rx) may be necessary.
If there is severe degenerative joint disease hip replacement surgery works well in large breed dogs and provides more comfort than medications, although it is an expensive option.
I am not aware of any problems with glucosamine leading to pancreatitis so I would not worry too much about using it again, unless there was a recurrence of the problem with future administration of the medication.
We have some clients who have had acupuncture for their dogs with hip dysplasia and the opinions have varied from not helpful to very helpful. It is a safe thing to try so I see no reason not to.
I think that swimming is usually a good exercise for dogs with hip dysplasia since it is low impact but it does help if exercise if regular and moderate, rather than intermittent. It is probably a good idea to give a dog whose had recent pancreatitis a few days off from exercise, though.
Mike Richards, DVM
Q: Hi Doc!
Recently attended a lecture on PennHip, given at our Dog Obedience Club. It was very convincing! It included a slide show where OFA GOOD Rottie hips were PennHip-ed and found to have unacceptable laxity. Scary, because OFA "Goods" and "Fairs" are considered acceptable breeding prospects.
What are your thoughts on PennHip vs. OFA?
The vet that did the presentation is one of the two in our county even offering PennHip. He mentioned that if you use PennHip at 16 weeks, and you get a good rating, you can feel free to start running and jumping your dog at 1 year old. This is contrary to what I have always heard, specifically, that you shouldn't do any heavy jumping or street work with a dog until 24 months. What are your views on this?
I'm really interested in this area because I'm hoping to get a Doberman puppy for obedience work, this fall. Currently, I have a Bullmastiff with cruciate problems and a "Pitboxer" with hip dysplasia.
You may recall that I wrote to you last year in a quandary about whether to have a total hip replacement on my 8 year old HD Pitboxer, Leda, and whether or not to go with the cemented or cementless procedure. Well, in March she had a Zurich cementless hip replacement on the right side. She's had no apparent complications so far. She's still recovering (can't be off leash yet, climb stairs/furniture, play with her dog buddies) and has an x-ray recheck scheduled for Aug. 7th. She still doesn't put full weight on it when she's standing, but walks well with it. The muscles on that side are still somewhat atrophied, but improving. I'm hoping for the best and praying I did the right thing for her. My only complaint so far, and it isn't really a big one, is that when the surgeon was promoting the operation, he gave the impression that after eight weeks my dog would be off chasing squirrels and the like. There really is a lot of diligence required to manage a dog properly during recovery. I would say that an owner should be prepared for more than eight weeks of recovery. Just my opinion.
So, I want to thank you for all the information you gave me that helped make decisions regarding Leda.
I'm trying to do everything I possibly can to avoid similar heartbreaking orthopedic problems in the upcoming Doberman pup.
Thanks Again! Sincerely, Chris
I am not certified to do PennHip evaluations and have no personal experience with this procedure, at all. We do not have many dog breeders among our clients and I do not anticipate a strong demand for this procedure in our practice, since we only do OFA evaluations once or twice a year, probably. Because of the my former association with the Pet Care Forum on AOL and this web site, I have followed the literature on this technique for some time, though. I just thought I ought to make a disclaimer for the information that follows, since there is some chance that I am misinterpreting it due to a lack of experience with the procedure.
The PennHip procedure evaluates the amount of laxity in the hip joint. The distraction index is based on the percent of the femoral head (ball of the hip joint) that lies outside the acetabulum (socket of the hip joint) when a distracting force, using special equipment, is applied to the joint. So if the head of the femur is tightly contained in the socket, it might only be able to force 10% (distraction index of 0.10) of it out of the acetabulum with the technique but if it is loosely contained in the socket it may be possible to force 90% of the femoral head out of the socket (distraction index of 0.90). Dogs with distraction indices of less than 0.3 are unlikely to develop hip dyplasia as they have little laxity in their hip joints. Dogs with distraction indices over 0.7 are very likely to develop hip dyplasia at some time in their lifetime. Dogs with values between 0.3 and 0.7 are harder to make predictions about but the lower the value, the less likely it is that hip dysplasia will develop. The procedure may be done as early as 4 months of age (I have seen some information on even earlier evaluations). This is my understanding of the basics of this procedure.
The OFA procedure is a standard X-ray view of the hips taken with the dog on its back and the rear legs extended and rotated inward (an uncomfortable and unusual position for them to be in). This evaluation is helpful if done at ages as early as four to six months but the OFA will not certify dogs until two years of age. There is no requirement that veterinarians submit all X-rays taken, as with the PennHip procedure, so it is widely accepted that a lot of people choose not to submit the films for evaluation when it is obvious their dog has hip dysplasia to the veterinarian taking the X-rays, making it hard to evaluate the meaning of the data collected using this procedure. The fact that dogs can not be certified until two years of age is a problem, since many breedings occur before this age and there are dogs who are graded fair or good who develop arthritis consistent with hip dypslasia later in life. Taking the X-rays with or without anesthesia can affect the results to some degree but I am not sure how much. OFA evaluation is available to any veterinarian with a good X-ray machine so it is more widely utilized. Dogs that show clear signs of hip dysplasia on the X-rays usually develop clinical signs of the disease, but some do not.
I think that the PennHip procedure for evaluating hip joint laxity has some advantages over the traditional OFA (Orthopedic Foundation of America) evaluation for hip dysplasia and that it is a good tool for evaluating the desirability of using a particular dog for breeding purposes. I like the fact that most dogs who are evaluated using this technique have the results included in a database so that breed trends can be compiled and examined. The results are less subjective than those obtained through the OFA technique.
I think that it is generally accepted that joint laxity is a better predictor of the potential for the development of hip dysplasia than other available tests. However, this is a better tool for evaluating the breeding population than it is for evaluating any particular dog. It is my understanding that it is not possible at this time to use the PennHip distraction index score to predict accurately whether an individual patient will go on to develop clinical signs of hip dypslasia, except perhaps for dogs with low (less than 0.30) distraction indices. Just because joint laxity exists and therefore the potential for hip dysplasia is greater, doesn't mean that it will actually develop in a particular patients. Weight control during growth, the amount and type of exercise the dog does, traumatic experiences, pain tolerance and many other factors influence whether a particular dog will actually show clinical signs of hip dyplasia. This, and the need for special training and equipment, are probably the major reasons that the procedure has not gained wide acceptance yet among general veterinary practitioners. As veterinary clients become better educated about pet health care, I think that the difficulty in explaining how to interpret the distraction index for a puppy will get a little easier, making it more likely that veterinarians will accept this procedure.
With all that said, what would I do in your position?
The first step is to evaluate the parents of a puppy you wish to consider purchasing. You do have to remember that evaluation of the hips of the parents is only one part of the puzzle. The parents of a puppy should have good personalities and it is good to evaluate other breed related problems, such as von Willebrand's disease in dobermans. With regard to hip evaluation, though, it would make me happiest if the parents had PennHip evaluations if one or both are less than two years of age and OFA certification if they are over two years of age. This gives both the predictive factors for breeding associated with the PennHip procedure and an idea of how these factors were expressed. It is probably not likely that you will find many breeders utilizing both of these tests, though. I think that either one is OK if the breeding took place between two adult dogs over two years of age who were judged good by either evaluation.
What would I do to evaluate the puppy? If you intend to breed the puppy later in life, I think it is helpful to the breed to collect PennHip data and therefore, I would encourage you to do this. This is even true for a puppy that you are not going to breed, if you wish to further the information available for the breed. From the standpoint of an individual puppy's potential for developing hip dysplasia, though, I have mixed feelings. I think that standard radiographs are pretty good at showing development of the disorder in an individual and that combined with clinical signs they are the best way, currently, to decide whether or not surgeries such as as triple pelvic osteotomy or hip replacement, are necessary.
I wish that I could answer your question about jumping and street work. I am not sure I know what street work entails but that doesn't matter too much, because I couldn't find enough information relating to the impact of early exercise on orthopedic problems to be sure of anything. I will try to continue to check into this. Please feel free to ask this question again in the future, in case I forget to post something online that I find.
Mike Richards, DVM
Q: Hi Dr. Mike,
You are the first Vet I have found that I would take my dog to and not worry about him. Your latest newsletter is Brilliant and I am sure that you take as much time with your patients as you did writing the newsletter and it is a wonderful thing to see. Thank You.
My question is, what are the signs of Hip Dysplasia? I have a muscle bound, vibrant 112 pound mutt, GSD/Bloodhound/Lab/Ridgeback- those are the breeds that I can see him in readily- that is a Super Frisbee player, he can leap 3 feet up in the air to catch the Frisbees and Loves the game. But sometimes his legs go out from under him and sometimes it looks like his hind legs step in the same place when I am walking behind him. He may just be prancing or it may be something that I didn't notice before but my first dog was paralyzed in his hind legs and tail from a car accident and while it was easy to put him in a K-9 cart because he weighed 40 pounds, I don't want to see Corduroy go thru the same thing because I didn't recognize early signs of something. He's 2 1/2 years old, doesn't show that he is in any pain or any discomfort but I want to make sure that I'm not doing anything to harm him as well. Basically, I can't remember if it's when they walk kind of stiff legged or when they walk in the same spot that is an indication of hip problems.
I have a pet care business and of the dogs that I walk regularly it's about half and half that have hip problems that walk stiff legged or in the same spot so maybe I'm just worrying for nothing. I just wanted to be sure my information was correct before going in for X-rays, since he LOVES going to the Vets and we have to hold his tail still from wagging and his head down from giving kisses when he needs an X-ray- he once came down wrong from jumping over a fallen tree and had injured his 'ankle' but that was obvious since he wouldn't put any pressure on it.
Anyway, thanks for your help, my Vet is off on vacation for the next couple of weeks which is why I'm writing to ask you. And by the way, I agree that they do just as well, if not better on cooked meats, actually I've seen no difference and have over 300 regular clients on a variety of diets. Although I do think that they do better on All Natural or Organic kibbles- with fresh stuff mixed in- like Flint River and Innova than on Dog Chow and the other grocery store and pet store brands, but that's just a personal bias.
I think that any abnormal movement of the rear limbs may be an indication of hip dysplasia, since the arthritis associated with this condition can occur in one or both legs and can occur to varying degrees. In addition, it is not uncommonly associated with elbow dysplasia, which can further alter the normal gait. I think that in young dogs the movement that is considered to be a strong sign of the potential for hip dysplasia is a gait in which both hind legs move in unison, usually referred to as "bunny hopping." There may be some correlation between laying on the chest with the rear legs straight out behind as the "preferred" resting position and hip dypslasia but I am not as convinced that this sign correlates strongly with hip dysplasia among my patients. In dogs that are beginning to suffer from the arthritis associated with hip dysplasia the first signs noticed by many owners are difficulty rising from a lying down position and reluctance to exercise as much as was previously the norm for a patient.
I worry more about cruciate ligament rupture and tendon/muscle injuries in Frisbee playing dogs than I do hip dysplasia. I have lots of athletic friends who suffer similar injuries but continue to play their sports, so I assume that this is a risk that dog would probably chose to take, though. So I don't advise my clients to stop playing with pets just on the chance they might be injured by the activity unless it is really high risk to the patient.
The best way to determine the potential for hip dysplasia is to take X-rays. It isn't a bad idea to check for this in susceptible breeds, especially in active patients. It can help in planning how much exercise to encourage and makes early use of analgesics reasonable to consider. Since Corduroy is a willing patient, it should be possible to get reasonably good X-rays without anesthesia, which makes it a very safe procedure.
Hope this answers your question. If not, feel free to write for clarification.
Mike Richards, DVM
Q: Dear Dr. Mike:
We have two miniature daschunds (litter mates) who enjoyed long, daily walks around the neighborhood for the 1st year of their lives. At one year, they each developed a limp on the back right leg, as well as a bunny-hop when we walked very far. The limp looks like they are skipping by not putting weight on the back right leg. This symptom is variable, and usually shows up most at the beginning and end of a walk, with "skips" occurring every half dozen steps or so.
Our vet diagnosed Sasha with hip dysplasia based on results of a standard x-ray and said that she was almost already a surgical candidate at the age of one year. Sasha's sister, Alafair, showed nothing seriously wrong that could be identified on x-ray, but the diagnosis was similarly presumed to be hip dysplasia due to her symptoms and her litter-mate's x-ray.
I have read useful information on your web site about hip dysplasia, and am glad to have discovered you. I am hoping that you could also provide some specific answers to the following questions about my little dogs:
1) Since Sasha's limp has improved, is she less likely to need surgery someday?
2) Do you agree that Alafair has hip dysplasia despite her lack of standard x-ray findings? Should I take her somewhere for more precise diagnostic testing? If so, any idea where (we are in Las Vegas)?
3) Both dogs seem happy and playful. Limping is not observable in the house or yard, only on walks. Sasha is sometimes hesitant to jump up on the couch and often prefers not to be picked up, occasionally protesting with a little yelp. Do you suppose their discomfort is mild?
4) Do you agree with regime of 250 mg cosamine and one-quarter tablet of a 300mg etogesic tablet daily for 13 lb. Sasha and 11 lb. Alafair? Rimadyl was discontinued when one dog had stomach upset and we read more we grew concerned about side effects in dogs starting medicine so young.
5) Do you agree with our exercise regime (much reduced) which we limit to leisurely strolls of 200-400 yards twice a day? They would like more but favor that back right leg a bit more when we go further.
6) What do you think is likely to happen with our dogs condition in the future at this rate with regard to progression of the problem, changes in treatment plan, etc. ? Is there anything else we can do to remediate the problem or at least slow its progresssion?
We will eagerly await your reply. Thanks so much!
Sincerely, Dachshund Lovers
I'll try to answer your questions in the order you asked them and put some clarifications in later.
1) If the limp is improved that is a good sign that Sasha would not need surgery.
2) The degree of pain and disability with hip dysplasia does not always correlate well with the X-ray signs. Some dogs have really bad hip X-rays and no dysfunction while others have only moderate damage visible on X-rays and seem to have a lot of pain. If there are almost no signs of hip dysplasia then I really do think it would be a good idea to consider other possible causes, though.
3) OK, here is where I have to let my prejudice show. I think that for a dachshund patient with these signs it would be a good idea to consider the possiblity of intervertebral disc disease, even if hip dysplasia is present. I just think that it is a good idea to always keep in mind the particular problems known to occur in a breed when symptoms of it appear. Not wanting to jump on the furniture and crying when being picked up could be signs of disc disease (and do occur with hip dysplasia or luxating patellas, too). Luxating patellas (dislocating kneecaps) are are really common in small dogs and cause many of the same signs as hip dysplasia and back disorders. You can often feel the kneecap dislocate if you rest one hand on it and then flex the leg with the other hand.
4) Sasha weighs about 6 kg and Alafair weighs about 5 kg. The dose for etodolac is 10 to 15mg/kg. So Sasha should get 6 x 10 (60mg) to 6 x 15 (90mg). Alafair should get 5 x 10 (50mg) to 5 x 15 (75 mg). Since 1/4th of a 300mg tablet is 75mg, Sasha is in the mid dose range and Alafair right at the top of the dose range. While this is theoretically OK, it would be a good idea to keep a close eye on Alafair for signs of gastrointestinal upset or inappetance. If these occur, discuss this with your vet right away.
The dosages used for glucosamines vary some among vets but it seems to be pretty same to use, so this dose should be OK.
5) I tend to favor exercise but that is a personal bias that doesn't have to do much with science -- I am a runner and a rower and so I think everyone and everything should exercise. It does help with weight control and if you stick to flat surfaces it shouldn't hurt to go further. In humans, it really does appear that exercise is gaining favor in the face of arthritis problems and even disc problems, though. But you should ask your vet, too. After all, he or she knows the degree of damage visible.
6) I think that you are actually doing most of the things necessary. Weight control is very important. There is a small chance that one of your dogs might actually be overweight for their body size but it doesn't seem too likely, given their weights. I think moderate exercise is important and I would include distances as long as a mile or so as moderate for a dachshund, personally.
There are a couple of points I think I need to expand on, a little.
First, I think that there is at least some reason to consider back problems. Back problems can be hard to evaluate and the treatment for them isn't different from what you are doing -- but if sudden weakness or paralysis develops you should be prepared for it and know what to do (surgery within 24 to 48 hours is necessary, so a decision has to be made before the problem occurs). If there is an orthopedic or neurology specialist in your area, it might be worthwhile to consult with them. I don't honestly know how frequent hip dysplasia is in dachshunds, but we don't find it very often. I think the prognosis is good that Sasha will do OK -- but having someone experienced in the possible disorders check her will give you the best idea of the long term prognosis.
Your dogs are too small for hip replacement surgery, unless there are new prosthetic devices I am unaware of. Therefore, your surgical options are limited. At their age (past their growth period), the only surgical option I can think of is femoral head ostectomy. Since this surgery essentially destroys the hip joint there is no real reason to rush into it. The surgery works best when it is done before muscle wasting occurs but it is almost always successful in dogs weighing less than 30 lbs., so your guys are in the right weight range. If Sasha has to have surgery later, it will probably work well. In the meantime, I think I'd base medication and exercise and things like that on the amount of pain she is showing -- if she seems to be doing well, she probably is.
Lastly, lots of little dogs don't like to be picked up. That would probably be true of big dogs, too -- but people don't try to pick them up. Resisting or crying a little may not be signs of pain, they may be signs of protest. It would be nice to be able to ask them how they feel but we can't so you have to guess. You know them best, so you can probably guess better than anyone else.
Hope this helps.
Mike Richards, DVM
Q: Dear Dr. Mike,
My dog, Leda, is a Pitbull/Boxer cross, female, seven years old. She has bilateral hip dysplasia. When she was two years old I took her to an orthopedic specialist. He said due to arthritic changes present, she was no longer a TPO candidate. As she was hardly symptomatic at this time, he suggested buffered aspirin up to twice a day. He said to monitor her and recheck in a couple of years or as needed if anything changed. My regular vet, at that time, was going into holistic and alternative vet medicine (He now has a holistic only practice and I am now with a conventional vet). He did a surgery on her where the muscles on the insides of her hind legs were cut. He also implanted tiny gold beads at acupuncture points in both hips and spine. She has been on Glycoflex and antioxidants since the HD diagnosis. She also gets Adequan IM once every three weeks. All has been going pretty well.
When she turned six, I decided to have her x-rayed again and evaluated once more at the orthopedic specialist. The reevaluation was delayed by a bloat incident, which was caught early and resolved without surgery during an overnight stay at an Emergency Clinic and another day at the regular vet. I am now doing all the recommended bloat preventative measures (small feedings, soaking food, raised eating position, restricted activity at mealtimes, etc.) and have not had another incident. Ortho reevaluation was again delayed by a large, ugly corneal ulcer that required weeks of treatment by a veterinary ophthalmologist to heal. Finally, in Jan. we were set up to xray. That week, a small tumor on her back thigh appeared and started to bleed. While under anesthesia for the x-rays, they took that one off and found two others, chest and groin. Histopathology indicated grades 1 and 2 mast cell tumors with clean margins. The surgeries were redone for wider margins, just in case. Leda has just finished 6 months of prednisilone, cimetidine and benedryl. She's still on the latter two meds. Hip radiographs were ugly, even to the untrained eye.
Finally got her to the specialist. Advanced degenerative changes, severe dysplasia, candidate for THR. He didn’t think FHO was a good choice because of her size (65 lb.) and the condition of her hips (both pretty nasty). He said he could and would do the THR surgery now if I wanted but didn't know whether I would see much improvement in her function. He said she was stoic, but didn't indicate she was in that much pain. She had reduced range of motion when extending the legs. He then said he saw no problem maintaining her with Rimadyl as needed.
I don’t really know what I should do, in the best interest of my dog. She doesn't have to be an athlete or anything, just a pet. She is a very active dog, who given the opportunity, would fetch and chase game until she dropped. On the other hand, she is equally happy to sleep on the couch and just do walks and restricted ball playing. She does not limp at all when walking or trotting (although her walk is somewhat stiff legged in the back). Faster than that, she does lift the leg on the more affected side higher, but she does use it - she just has a limp (the older, “country” vet at the practice called it a “hitch in her giddyup”), of sorts. She does put less weight on the worse side, when standing, but she is using the leg. She still has decent muscle mass in her hind legs but they are not as muscular as the front of her body. She seems to have little difficulty rising. She goes up stairs freely.
My concerns surround how much pain she is in, the risks of the surgery itself, the consequences of delaying due to her age, the consequences of going ahead regarding the mast cell situation, etc., etc.
What length of time without reoccurrence of MCTs would the condition be “cured” or is it never considered cured? Could the surgery itself affect the reoccurrence or spread of MCTs? One of my regular vets expressed concern over the prosthesis and cement causing a mast cell response. The procedure they're using at the Orthopedic facility I went to uses no cement, just screws, but what of the prosthesis itself?
How can pain be accurately accessed in dogs? Would I be delinquent in waiting until she shows more impairment? Might she never degenerate beyond the point she's at now? What are the guidelines for quality of life assessment? (I’ve seen dogs chained outside for their whole lives that appear to be happy, yet I would consider that a poor quality of life). How is it that her x-rays are so ugly but she is getting around seemingly well? Have you seen that situation a lot? Makes me think that perhaps the arthritic changes stabilize the joint or are the body's way of trying to fix the problem. Could the gold beads possibly be responsible for her getting around so well? When I agreed to let the holistic vet try it, I didn't have much faith, but I figured it probably would do little harm.
As far as financial concerns, I know it is an expensive procedure (what credit cards are for, right?) but if it is necessary I will manage it without regret.
Doctor, any opinions or ideas you have on Leda’s situation, would be welcomed. I realize the difficulty in assessing a case when you haven't actually examined the patient, but any answers, thoughts and suggestions you can provide will be greatly appreciated.
Thanks for you help and also thank you for VetInfo Digest. It’s very informative and I look forward to every issue.
There were a lot of questions in the text of your note, so if I miss one, please point it out.
Mast cell tumors that are grade 1 are supposed to have about a 10% chance of being metastatic. Mast cell tumors of grade 2 are supposed to have about a 10 to 25% chance of being metastatic. So the odds are pretty good that the mast cell tumors will not recur but 25% is one in four -- so there is also some chance they will. Rechecking regional lymph nodes, checking the buffy coat (in a blood sample) for mast cells, possibly considering bone marrow aspirate, considering spleen and liver biopsy and at least chest X-rays (+/- abdominal X-rays), would probably be a good idea prior to considering extensive surgery in a patient who has had mast cell tumors removed within a year or so. I think that for mast cells it takes about 5 years of being free from them before it is really reasonable to talk about a cure. That obviously complicates the decision making regarding surgery somewhat, but I do think they are separate issues in most respects.
I wish we could ask our patients questions, sometimes. Pain evaluation is one of the number one reasons I long for that ability. Just like people, pets are very variable in their ability to cope with pain and in their reactions to it. Some dogs and most cats are really stoic about pain. But I'm sure they appreciate relief from it. It is just really hard to tell who is being stoic and who really isn't bothered much.
Hip dysplasia is notorious for having a poor correlation between X-ray signs of the disease and the functional ability of the patient. Dogs with horrible X-rays may have nearly normal activity levels while dogs with moderate signs seem to be crippled by the disorder.
Decrease in the range of motion does seem to correlate some with pain. In experimental studies, force plate analysis seems to correlate pretty well with the degree of pain the patient experiences. For this test, a device that measures the pressure applied by the feet to a force plate as the dog walks or stands is used. Dogs that are in pain in one or more legs apply less pressure to the foot that is pained, which can be measured. This works best for injuries involving one leg but can work for injuries involving more than one leg as long as not all of them are involved. Obviously, most practices can't do this test. Difficulty rising is a sign of pain in most cases, I think. General grumpiness, weight loss, inappetance, decreased activity and other non-specific signs also occur. In the end the best thing is probably to assume that there is pain when similar disorders or diseases cause pain in humans. Using this criteria, there is a good chance that Leda would appreciate having artificial hips.
I have no idea if the gold beads are helping. It is possible.
Hip replacement works a lot better before there is a lot of muscle loss and sometimes degenerative changes can get severe enough to interfere with the surgery. I tend to think that it is better to go ahead and do it when it seems inevitable that it will be required. The problem is that with the signs seen in your note is it does seem possible that medical treatment may continue to sustain Leda, although she would have to deal with at least some pain on a chronic basis. That makes the choice tougher, but I would still lean towards doing surgery in a dog of my own.
I couldn't find anything to indicate that mast cell tumors are more common around previous surgical sites but some tumors are, so I can see your vet's concern over that.
To sort of sum this up:
If money is not a major concern and it is possible to have a good work-up to evaluate for the spread of the mast cell tumors, which turns out to be negative, then I would really lean towards hip replacement, if I was making this decision. I am an optimist and I'd just hope for the best on the mast cell metastasis concern.
If money is a major concern (as in you would be disappointed to spend $2500 and find out six months later that the mast cells had recurred), then you do have lots of evidence that Leda is at least accommodating her condition well and you shouldn't feel guilty about continuing medical treatment. Most people would make that decision, I suspect.
Hope this helps, some.
Mike Richards, DVM
Q: Dr. Mike,
Is it possible to get a good set of hip x-rays on a dog for OFA certification without using General Anesthesia? Also, what are the views required for this certification?
I have a problem with using GA for something that is technically an elective procedure, but I suppose as a predictor of possible future health concerns it might be considered worth the risk.
Your thoughts would be appreciated.
The short answer is yes. The longer answer is that it depends a lot on the dog and it also depends on what state you live in. Positioning is critical for OFA films and the positioning is a least a little uncomfortable, to outright painful, for the dog, depending on how bad its hips really are. To position a dog for an OFA film the dog is rolled onto its back and then the rear legs are stretched out straight and the stifles (knees) turned in so that they are parallel with the kneecap centered in the patellar groove. The legs usually have to be pressed down toward the table to keep them both straight and parallel. This full extension of the hip is painful for a dog that has hip dysplasia and probably uncomfortable even for a normal dog. I imagine that it feels a little like a person does when they try to stretch too far when doing toe touches.
We will try to get OFA films without anesthesia if a client requests it and understands that we may charge extra if it takes several attempts to get a good radiograph. When it is obvious that the dog is not going to cooperate with us we usually try sedation with acepromazine and butorphenol or oxymorphone. Most of the time this will work and it seems to be a little safer than general anesthesia. When even this is insufficient the dog is usually sedate enough to allow us to mask it down with isoflurane gas and we have not yet had an anesthetic death using this protocol. Plus the isoflurane is rapidly excreted from the system, so the dog wakes up quickly. Currently propofol may be another good option in anesthesia for quick procedures like an OFA film but we haven't used this anesthetic agent yet. It is rapidly absorbed and recovery is also rapid so anesthesia time is reduced.
I don't practice in New York but it is my understanding that veterinarians and their assistants are not allowed to hold patients for X-ray procedures in that state. If that is the case then anesthesia is the only option I can think of to obtain proper positioning.
When we are suspicious that the patient does have hip dysplasia we will sometimes do a preliminary film without trying to achieve perfect positioning, only pushing the dog as far as it will allow us to showing pain or discomfort. If these films show obvious hip dysplasia there is little need to try for OFA certification. This does skew the overall breed evaluations done by the OFA because they don't get the films from dogs with bad hips but it is better for the individual patient.
While there are probably lots of people who would disagree, I view the OFA testing (and the Penn-Hip testing) as being good for the breeds by helping to eliminate a disorder that is partially genetic and that affects a lot of dogs. I don't see a lot of value in doing OFA screening for an individual patient who will not be bred as a means of predicting future orthopedic problems since most veterinarians can read the radiographs well enough to figure out if a dog needs, or may need, surgical correct
Michael Richards, D.V.M. co-owns a small animal general veterinary practice in rural tidewater Virginia. Dr. Richards graduated from Iowa State University's College of Veterinary Medicine in 1979, and has been in private practice ever since. Dr. Richards has been the director of the PetCare Forum...