Hip Dysplasia Treatment in Puppies

Objective, meaningful data upon which we can make solid treatment recommendations for our patients’ well- being is the intent of evidence-based medicine (EBM). Study designs are stratified from strongest (Class I) to weakest (Class IV) evidence (Table 1) to train clinicians to critically analyze published reports. To effectively utilize EBM, clinicians and researchers must be trained to ask the right questions. Large-scale, prospective, randomized, blinded, placebo-controlled clinical trials are costly and time-consuming. Before seeking strong  objective evidence (answers), we should first evaluate our questions. What do we really want to know? What do our pet-owning clients want to know? Why do they seek our services? Pets are often presented to us in hopes that we can improve their health related quality of life as compared to natural progression of the disease/injury. As such, many studies collect strong, objective data that is, unfortunately, of little help in our answering our clients’ real questions. “Will he be able to climb the stairs”?
“Will she still be able to go on 10 kilometer hikes”? In the study of juvenile-stage canine hip dysplasia ( jCHD), we often use outcomes such as dorsal acetabular rim (DAR) slope, acetabular angle, radiographic osteoarthritis (OA) scores, and force-plate data as surrogate measures for what we really want to know. It takes significant inference to get from any of these measures to accurately answer our clients’ questions. This is often the case in medical studies in which we measure Disease-Oriented Evidence (DOE) rather than Patient-Oriented Evidence that Matters (POEM). It is vitally important when reading study results to assess the strength of the data, but also its usefulness in providing the answers to our real questions.

Surgical Treatment Options
Triple pelvic osteotomy (TPO) rotates the DAR laterally over the femoral head. TPO may be indicated for young dogs (usually 4.5 to 10 months old) with symptoms of CHD, but without palpable, radiographic, or arthroscopic evidence of degeneration. My criteria include a positive Ortolani sign (with angles of reduction/subluxation of 20-40o/5-20o and distinct palpable transitions between subluxation/reduction) and a DAR radiograph showing no significant blunting. TPO improves radiographic hip joint congruence, palpable hip stability, weight-bearing on force plate analysis, and reduces OA development as compared to untreated controls. Most studies show TPO slows OA development, but cannot be regarded as OA-preventative. Symptomatic improvement from TPO (positive patient-oriented outcome) has been reported despite progressive radiographic OA (negative disease- oriented outcome). Many TPO reports are not ideal because they are not randomized or blinded and they rely upon control data from the untreated hips of unilateral TPO-treated patients. Reported complications include fixation failure, sciatic nerve injury, urethral entrapment and pelvic canal collapse. While the collective data on TPO makes it difficult to answer our clients’ difficult questions, it is suggestive of treatment efficacy when TPO is used for appropriate indications. [...]