Treatment of Hip Dysplasia - Veterinary Surgery · Key points! Early treatment, before OA development ‣ JPS ‣ DPO CANINE HIP DYSPLASIA! Late treatment, after OA development and

15’Aldo Vezzoni, DVM, Dipl. ECVS, Cremona, Italy

[email protected]

New Prospectives in the Treatment of Hip Dysplasia

! 1!

KYON Symposium 2013 Innovations in Veterinary Orthopedics and Trauma

Boston, USA - April 12 - 14

Friday, April 12th 19:00 Welcome Reception Saturday, April 13th 07:00 Registration 07:50 Welcome and meeting organization Session 1 – STIFLE 08:00 Ultra-CL – Arthroscopic Application: Michael Bauer 08:10 Ultra-CL – Research: Juan Pu 08:20 LESS – Research & Clinical Application: Otto Lanz 08:30 TTA-2 – Introduction: Slobodan Tepic 08:40 TTA-2 – Clinical Experience: Joop Hopmans 08:50 TTA-2 – Research: Krista Adamovich 09:00 TT-Crown – Research & Clinical Experience: Zoran Lonĉar 09:10 TT-Crown – Clinical Experience: Simone Niederhäuser 09:20 TT-Crown – Clinical Experience: Hugh Davis 09:30 DISCUSSION moderator: Andy Torrington participants: STIFLE session speakers 10:00 Coffee break & BREAKOUT SESSION 1 Session topics and facilitators are listed below. Session 2 – LANDSCAPES: BUSINESS 11:30 A Family Practice: Randy Acker 11:45 A Distinctive Business Model: Denny Aron 12:00 A Specialty Clinic: John Stephan 12:15 Franchise Operations: Dave Gersholowitz 12:30 DISCUSSION moderator: Preston Stubbs participants: LANDSCAPES: BUSINESS session speakers 13:00 LUNCH Session 3 – LANDSCAPES: SURGICAL INFECTION 14:00 Microbiology and Minimizing Clinical Risk: Scott Weese 14:30 THR – Clinical Experience: Aldo Vezzoni 14:45 Internal Fixation – Clinical Experience: Ayami Nojiri 15:00 DISCUSSION: moderator: Ursula Krotscheck participants: LANDSCAPES: SURGICAL INFECTION session speakers 15:30 Coffee Break

Wednesday, April 24, 13

Key points! CHD is a progressive diseases that develops during the

skeletal growth …... and it always worsens during life

Ferry, GSD, 5 mo. 15 mo. 7 yrs.

CANINE HIP DYSPLASIA


Key points

! Early treatment, before OA development‣ JPS‣ DPO

CANINE HIP DYSPLASIA

! Late treatment, after OA development and progression‣ THR‣ All size dogs


Disease modifying surgeries (JPS,DPO)

! Surgeries that modify hip biomechanics and development in growing dogs

! To stop the subluxation tendency

! To restore hip congruity and save the joint from OA

! Before OA progression (narrow time window)

! Early diagnosis


! Narrow time window

> DARlaxity

> DARlaxity+ OA

OA

time (months)

1 2 3 4 5 6 7 8 9 10 11 12

Disease modifying surgeries (JPS,DPO)


Surgical treatment:! Juvenile Pubic Symphysiodesis (JPS)

" Mathews, Dueland, Patricelli et al., 1999-2001

" 3 - 5 months of age (breed variations)" Selected indications, no clinical signs " Preventive treatment

Early treatment to modify CHD development


JPS Surgical treatment

Before JPS After JPS

Dueland T et al. Effects of Pubic Symphysiodesis in Dysplastic Puppies. Veterinary Surgery 30:201-217, 2001


Best potential residualgrowth:! 12-17 weeks! 22%+8%

Riser’s radiographic pelvic growth study from birth to 52 weeks of age.

PELVIC GROWTH



0

15

30

45

60

Grade AGrade B

Grade CGrade D

Grade E

minor moderate major

Group 1 - JPS

A. Vezzoni et al.: JPS versus conservative management in puppies with CHD VCOT 3/2008; 267-279


Results


Group 2 - Conservative

0

20

40

60

80

Grade AGrade B

Grade CGrade D

Grade E

minor moderate major

A. Vezzoni et al.: JPS versus conservative management in puppies with CHD VCOT 3/2008; 267-279


Results


Hip Arthritis Score

Figure 1. Probability of Degree of Arthritis (osteophytosis) at ≥ 5 Years after JPS Based on Preoperative Distraction Index (DI) Score*

1. Mild ( ) 2. Moderate ( ) 3. Severe ( ) 4. Advanced ( )

A preoperative DI of 0.50 = a 50% probability of at least mild arthritis. “ “ “ “ 0.70 = a 50% “ “ “ “ moderate arthritis. “ “ “ “ 0.74 = a 50% “ “ “ “ severe arthritis. “ “ “ “ 0.81 = a 50% “ “ “ “ advanced arthritis.

Probability of Arthritis

Score

)LJXUH��&OLFN�KHUH�WR�GRZQORDG�)LJXUHV��&$�-36�),*��-2',��),1$/�SGI�

Dueland T. WVOC 2010, Congress, Bologna (Italy), 15th - 18th September p 413

Results





cranial



Surgical efficacy

! Radiographic modifications" Pubic symphysis fusion " Broad and short pubic rami" Widened obturator foramina" Irregular pubic profile" Detectable acetabular fossae


Boiocchi S., L. Vezzoni, A. Vezzoni, V. Bronzo, F. Rossi. Radiographic changes of the pelvis in Labrador and Golden Retrievers after Juvenile Pubic Symphysiodesis (JPS): objective and subjective evaluation- VCOT in press


Labrador, 16 mo., 12 mo. after JPSLabrador, 14 mo., normal

Surgical efficacy



Potential complications

‣ Urethral damage‣ Skin burns ‣ Radio-frequency unit required or recommended ‣ Lack of efficacy (wrong selection, wrong procedure)‣ Ethical consequences‣ No unequivocal sign that the procedure was done


Boiocchi S., L. Vezzoni, A. Vezzoni, V. Bronzo, F. Rossi. Radiographic changes of the pelvis in Labrador and Golden Retrievers after Juvenile Pubic Symphysiodesis (JPS): objective and subjective evaluation- VCOT in press


Novel surgical technique under investigation with Kyon


‣ Proposed by Luca Vezzoni‣ Using Ti staples across the pubic

symphysis‣ No, or limited electrocautery‣ Minimally invasive surgery‣ Drill guide with stopper‣ Leaving a clear rad sign of the

performed procedureWednesday, April 24, 13

! JPS New Surgical Technique by Kyon


! JPS New Surgical Technique by Kyon


Novel surgical technique under investigation


‣ Hopefully in two years from now a report of the clinical study will be available

‣ Phase 1 safety study‣ Phase 2 efficacy study‣ Phase 3 comparison study


! Double Pelvic Osteotomy" 5 - 8 months of age (breed variations)" selected indications, no OA" DPO, in vitro study Haudiquet, 2006" DPO clinical study Vezzoni 2010



!Triple Pelvic Osteotomy


!Double Pelvic Osteotomy


TPO criticism

23

• Less used technique in the last 15 years

• High morbidity for the patient

• High incidence of complications (implant loosening)

• Pelvic narrowing and excessive head coverage

• Increased progress and reliability of total hip replacement



!Double Pelvic Osteotomy

‣ Ischiadic table deformation ‣ Less rotation (5° less), 25° plate > same rotation as 20° plate in

TPO‣ Pelvis geometry and width are not affected‣ Morbidity greatly reduced (no ischiadic pain)‣ No risk of overcorrection‣ Strong fixation of the osteotomy is required


a)

DPO - Results

One-way ANOVA repeated measures p<0.05

* *

*

*

A. Vezzoni et al.: Clinical study of double pelvic osteotomy. VCOT 6/2010; 444-452


b)

One-way ANOVA repeated measures p<0.05

* * *

*

DPO - Results



DPO - ResultsRelationship between pelvic diameters: A (Iliac wings)B (Ischiatic tuberosities)C (Cranio-lateral acetabular rim)

B

C

Pre-op Post-op FU 2 mo.

A/B C/B A/C

0.78 0.79 0.770.88 0.85 0.821.12 1.07 1.06

A



TPO vs DPO - Complications

TPO DPO

Screw loosening yes no

Pelvic narrowing yes no

Excessive head coverage yes no

Abnormal gait yes no

Neurological deficits yes yes

Plate avulsion & fixation failure yes yes

OA progression (wrong case selection, undercorrection) yes yes

• Personal communication on 234 TPOs and 237 DPOs


DPO - Discussion

• Consistent good results • “Better” correction vs TPO• Faster bone healing• Less complications• Renewed interest for early HD treatment• Proper case selection• Be aware of neuro iatrogenic damage• Adequate surgical skill and experience• DPO dedicated implants

Morgan, Golden, M, 13 mo., FU 1 yr.



Golden, 13 mo.1 yr after DPO

Borzoi 15 mo.

Acetabular coverage is restored like in a normal hip

DPO - Discussion


Patient selection for early HD treatmentBuzz, Labrador, M, 5 mo. (1 mo. after unsatisfying JPS)FU 7 month, 1 year of age


Patient selection for early HD treatmentBuzz, Labrador, M, 5 mo. (1 mo. after unsatisfying JPS)FU 7 month, 1 year of age, Distraction Index

0.2 0.1


• Very high, free activity after two months p.o. 25° 25°

Miril, Border Collie, M, 18 mo.

Miril, Border Collie, M, 6 mo.FU 1 yr.

Client satisfaction

DPO - Discussion


Miril, Border Collie, M, 1 y. after bilateral DPO

Client satisfaction

DPO - Discussion

La JollaLa Jolla

• Very high, free activity after two months p.o.


! NGD

DPO dedicated implants

! Hofmann

! Traumavet - Fixin

POLITECNICO DI TORINO

Politecnico di Torino – Dipartimento di Meccanica Corso Duca degli Abruzzi, 24 – 10129 Torino Italia tel: +39 011 5646944 fax: +39 011 5646999 e-mail: [email protected] url: www.polito.it/php/link/?id=275

6

Dipartimento di Meccanica

Fig. 9a

Fig. 9b

La posizione di riferimento è quella in cui il bordo inferiore della placca è fatto coincidere con il profilo ventrale dell’ileo; le posizioni successive si ottengono facendo traslare la placca sull’ileo rispettivamente di 3mm e 5mm (fig. 10). Sulla base dei risultati ottenuti al punto precedente, la linea di osteotomia iliaca scelta è quella inclinata di 0° rispetto all’ortogonale al chiodo guida.


Politecnico di Torino – Dipartimento di Meccanica C orso Duca degli Abruzzi, 24 – 10129 Torino Ita lia te l: +39 011 5646944 fax: +39 011 5646999 e -ma il: cristina .bignardi@ polito.it url: www.polito.it/php/link/?id=275

2

Dipa

rtim

ento

di M

ecca

nica

Per simulare l’inte rvento chirurgico il mode llo è sta to modifica to simulando due osteotomie : una sul piano sagitta le a live llo de l limite media le e la te ra le de l pube , rimovendo il tra tto de l pube che costituisce il margine crania le (fig. 2), l’a ltra sull’ileo (fig. 3).

Fig. 2

Fig. 3

E ’ sta to inoltre rea lizza to il mode llo numerico de lla placca e de lle re la tive bussole e viti (fig. 4).

Fig. 4

Per i materia li considera ti sono sta te ipotizza te le seguenti ca ra tte ristiche meccaniche : osso (modulo di Young E =16000 MPa, coe fficiente di Poisson ν=0,3), accia io (modulo di Young E =190000 MPa, coe fficiente di Poisson ν=0,3), coe fficiente d’a ttrito osso-accia io µ=0,25, coe fficiente d’a ttrito osso-osso µ=0,3.

In figura 5 è riporta to il mode llo numerico rea liz za to.


Politecnico di Torino – Dipartimento di Meccanica C orso Duca degli Abruzzi, 24 – 10129 Torino Ita lia te l: +39 011 5646944 fax: +39 011 5646999 e -ma il: cristina .bignardi@ polito.it url: www.polito.it/php/link/?id=275

2

Dipa

rtim

ento

di M

ecca

nica

Per simulare l’inte rvento chirurgico il mode llo è sta to modifica to simulando due osteotomie : una sul piano sagitta le a live llo de l limite media le e la te ra le de l pube , rimovendo il tra tto de l pube che costituisce il margine crania le (fig. 2), l’a ltra sull’ileo (fig. 3).

Fig. 2

Fig. 3

E ’ sta to inoltre rea lizza to il mode llo numerico de lla placca e de lle re la tive bussole e viti (fig. 4).

Fig. 4

Per i materia li considera ti sono sta te ipotizza te le seguenti ca ra tte ristiche meccaniche : osso (modulo di Young E =16000 MPa, coe fficiente di Poisson ν=0,3), accia io (modulo di Young E =190000 MPa, coe fficiente di Poisson ν=0,3), coe fficiente d’a ttrito osso-accia io µ=0,25, coe fficiente d’a ttrito osso-osso µ=0,3.

In figura 5 è riporta to il mode llo numerico rea liz za to.


! KYON DPO Plate

‣ Still under in vitro testing‣ Hopefully in two years from now a report

of the clinical study will be available‣ Phase 1 safety study‣ Phase 2 efficacy study‣ Phase 3 comparison study

DPO dedicated implants


Kyon Cement-less Total Hip Replacement

Zurich THR

‣ Applicable in growing dogs too

‣ From 5-6 months on

‣ Best age 7-9 months

‣ Faster healing

‣ Bilateral or 4-8 weeks apart

‣ Minimum body weight ~16 kg



Zurich THR

‣ New Mini-THR

‣ For dogs < 16 kg

Cocker CKCS Jack Russel Terrier Yorkshire Terrier Fox Terrier



Zurich THR

‣ New Mini-THR

‣ For dogs < 16 kg

‣ HD

‣ Legg-Calvé-Perthes Disease

‣ Other hip DJD

Griffon M, 2 y. Pinscher F, 8 m.

DSH cat F, 9 y.Cocker Sp. M, 7 m.Wednesday, April 24, 13


Zurich THR

‣ New Mini-THR

‣ First step: intermediate size for

dogs 10 to 16 kg

‣ Further steps for smaller sizes

Cocker spaniel, M, 8 m., 12 kg

18 mm29 mm

> 6 mm



Zurich THR

‣ New Mini-THR

‣ First step: intermediate size for dogs

10 to 16 kg

‣ Further steps for smaller sizes

‣ Smaller dogs, narrower femoral canal

Griffon M, 1 y., 7 kg

12 mm

4 mm



Zurich THR

‣ New Mini-THR

‣ 20 and 18 mm Cups

‣ 12 mm Heads, DC, aspherical (fovea)

‣ XS, S, M, L, XL Heads with 0.75 mm increments

‣ Neck ∅ 4 mm, with ROM 135°

Titanium niobium (TiAl6Nb7)



Zurich THR

‣ New Mini-THR

‣ 20 and 18 mm Cups

‣ Cup inlays are zirconium ceramic

‣ Spherical cavity

Titanium niobium (TiAl6Nb7)



Zurich THR

‣ New Mini-THR

‣ Screws ∅ 2.4 (2.0 drill)



Zurich THR

‣ New Mini-THR

‣ Dedicated reamer

‣ Spherical

‣ ∅ 20 and 18

‣ Jig

‣ Drill guides


Kyon Cement-less Total Hip ReplacementZurich Mini THR

‣ Next step:

‣ ∅ 10 mm Heads

‣ 5 mm Stems

‣ ∅ 16, 14 mm Cups

∅ 12 mm ∅ 10 mm ∅ 8 mm

‣Further step

‣ ∅ 8 mm Heads

‣ 4 mm Stems

‣ ∅ 12, 10 mm Cups Wednesday, April 24, 13

Innovations in Hip Surgery by Kyon

‣ To provide the best surgical tools for any

Hip Condition causing OA

‣ Addressing the expectations of dog and cat

owners

‣ To provide the best quality of life of their

animals


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Documents

Treatment of Hip Dysplasia - Veterinary Surgery · Key points! Early treatment, before OA development ‣ JPS ‣ DPO CANINE HIP DYSPLASIA! Late treatment, after OA development and