幼犬髋关节发育不良的管理与手术治疗 Canine Hip ......1. Pathogenesis of canine hip dysplasia •2犬髋关节发育不良的早期诊断方法与评级 2.Early diagnosis

幼犬髋关节发育不良的管理与手术治疗

Canine Hip Dysplasia Management and Surgery

吴仲恒 Zhongheng Wu广州yy宠物医院

华南农业大学兽医学院

Guangzhou YY Pet HospitalCollege of Veterinary Medicine

South China Agricultural University

大纲Outline• 1犬髋关节发育不良的发病机制

1. Pathogenesis of canine hip dysplasia• 2犬髋关节发育不良的早期诊断方法与评级

2.Early diagnosis and evaluation of canine hip dysplasia• 3犬髋关节发育不良的非手术管理

3. Non-surgical management of canine hip dysplasia• 4犬髋关节发育不良的早期手术

4. Early stage canine hip dysplasia surgery• 5犬髋关节发育不良的后期手术

5. Late stage canine hip dysplasia surgery• 6手术结果与并发症

6. Operation results and complications• 7手术并发症的管理

7. Management of complications

1CHD发病机理1CHD Pathogenesis

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髋关节发育不良Hip Dysplasia

正常的髋关节Normal Hip

正常的髋关节Normal Hip


✓ 在年幼就有，伴随终生发展的疾病

been present at young age, with lifelong developing diseases✓ 髋关节-股骨头不稳定和畸形

hip-femoral head unstable and deformity✓ 关节结构不协调导致不能很好地承受体重

discordant joint structure that results in lack of ability to bear body weight ✓ 引起关节形态学的改变

morphological changes of the joint✓ 关节软骨破坏

damage of cartilage

一定有 Must have….


✓ 不正常的关节软骨

Abnormal cartilage✓ 关节炎和进行性的关节纤维化坏死

Arthritis and progressive fibrosis necrosis in joint✓ 关节活动幅度下降

Decreased joint mobility✓ 慢性疼痛和生活质量差

Chronic pain and poor life quality✓ 需要外科手术或者需要长期的药物治疗

Needs surgery or long term drug use

结论Conclusion


ü在出生时没有明显的表现

No obvious symptoms at birth

ü在生长发育的时候慢慢出现症状

Symptoms develop when growing up

ü受到多个基因的影响

Affected by multiple genes

ü环境因素可以使疾病快速发展(营养, 活跃, 年龄, 性格……)

Environmental factors (eg: nutrition, activity, age, personality trait……) can speed up the development of the disease

病因学 Etiology


✓ 持续的关节不协调和不稳定

Persistent discordant and unstable joint

✓ 肌肉和关节囊的松弛

Loose muscle and joint capsule

病理生理 Pathophysiology


• 肌肉与韧带在髋臼窝附近所起到的作用

Function of muscles and ligaments at acetabulum• 动态地维持该部位的稳定性

Dynamically stabilize the area

髋关节发育不良的病理生理Pathophysiology of Hip Dysplasia

为什么在生长发育阶段的受力会保持在关节内？

Why the forces are maintained within the joint during growth?Ø 基因和环境因素 Gene and environmental elementsØ 生长速度 Growth rateØ 肌肉结构 Muscle structureØ 骨骼平衡 (骨骼、肌肉和跟腱) Bone balance (between bones, muscles, and tendons)Ø 软骨下的成骨生长的改变 Ossification change under cartilage during growth


骨头的形态和关节的松弛Morphology of the bone and looseness of the joint

正常Normal

关节松弛Loose joint


骨骼形态不好Poor bone morphology

- 髋臼窝 acetabulum

- 股骨头和股骨颈- Femoral head and neck

关节松弛Loose joint

关节不协调Discordant joint


为什么会出现关节软骨的病变?Why lesions at cartilage?

✓ 不规则的关节面产生摩擦和热量

Friction and heat generated at abnormal joint surface

✓ 在关节表面受力的不均匀分配

Unbalanced force at joint surface✓ 某些部位的关节软骨受力过大（大于1kg/ mm2 ） Too much force (>1kg/ mm2 ) at certain point of the joint


拉布拉多母狗 3.5个月Female Labrador 3.5 months

6个月6 months

3岁3 years

ü 长期研究 Long term study犬髋关节发育不良 Canine Hip Dysplasia

ü 长期研究 Long term study13个月13 months

犬髋关节发育不良 Canine Hip Dysplasia

拉布拉多母狗 3.5个月Female Labrador 3.5 months

6个月6 months

15个月15 months

ü 长期研究 Long term study 犬髋关节发育不良 Canine Hip Dysplasia

拉布拉多母狗 3个月Female Labrador 3 months

6个月6 months

德牧母 6个月F German Shepherd6 months

有各种各样的严重程度病例Variable severities in different cases 拉布拉多母 8个月

F Labrador 8 months

金毛母 4个月F Golden 4 months

拉布拉多母 4.5个月F Labrador 4.5 months

金毛母 3.5个月F Golden 3.5 months


在关节面上的受力情况(kg/mm2 ) (Prieur 80)Force at joint surface (kg/mm2 ) (Prieur 80)

站立 standing

单脚 one foot

走路 walking

跳 leaping

接触面 contact area %: 100% 50% 30% 15%

0.01

0.1

0.2

0.5

0.2

0.35

0.65

1.6

0.3

0.5

1.1

2.8

0.6

1.1

2.2

3.6

220 110 66 33多少 mm2 30kg的狗:Amount mm2 30kg dog

关节生物力学Joint Biomechanics

✓ 弹性下降 Decreased elasticity✓ 软骨硬化 Cartilage rigidification✓ 软骨撕裂,纤维化和细胞死亡 Cartilage tearing, fibrosis

and cell death✓ 软骨下骨头暴露 Exposed bone under cartilage✓ 滑膜炎，关节炎 Synovitis, arthritis✓ 骨象牙化 Eburnation✓ 摩擦，产热 Friction, heat generation✓ 干枯坏死 Desiccated and necrosis

软骨压力过大导致:Cause by too much pressure on cartilage:

关节生物力学Joint Biomechanics

1.幼犬4-14月龄-亚临床症状

4-14 months-subclinical signs

2.幼犬4-14月龄-明显的临床症状

4-14 months-obvious clinical signs

3.成犬-有退行性关节病变相关的症状

Adult-degenerative signs of joint lesion

临床症状（分为三组）Clinical Signs (3 groups)


2 CHD的早期诊断2 CHD Early Diagnosis

1. 幼犬（4-14月龄），亚临床症状 4-14 months-subclinical signs

临床症状 Clinical Signs

ü 表现出比较正常的状态 Appears normalü 以后会发展成退行性关节炎(第三组) Will develop into degenerative arthritis (group 3)ü 早期诊断 Early diagnosisü 可能可以对动物进行合适的手术预防和手术纠正 May use proper surgical prevention or correction on animal


ü 急性的表现 (在DAR 上看到微骨折和亚脱位) Acute signs (minor fracture and dislocation on DAR)ü 各种各样的症状 Variety of symptomsü 不太愿意运动 Unwilling to moveü “变懒惰” Get lazyü “兔子跳” Rabbit leapü 站姿和步态改变 Changes in standing and walking posturesü 使用镇痛药有效 Pain reliever helps

2. 幼犬4-14 月龄-临床上有下列症状 4-14 months-clinical signs

临床症状 Clinical Signs髋关节发育不良 Hip Dysplasia

3. 成犬-有退行性关节炎症状 Adult dog- regenerative arthritis signsü 通常表现出正常

Usually appears normalü 缓慢发展

Slow developmentü 前肢负重

Fore limbs bear weightü 运动功能受限，容易累，喜欢坐

Movement function restricted, easy to get tired, like to sitü 运动、怀孕、年龄增长会变得症状明显

Exercise, pregnant and aging with more severe symptomsü 临床症状与第二组很像

Clinical signs similar to group 2

髋关节发育不良 Hip Dysplasia临床症状 Clinical Signs

早期诊断 Early diagnosisü 预判未来髋关节会变得怎么样 Prognosis for future hip changeü 选择合适的疗法 Choose proper therapyü 影响，延缓和改变髋关节的恶化 Influence, slow and change worsen of the hip jointü 预防性治疗 Preventive treatment


如何作出早期的诊断 How to make early diagnosisü 认识犬髋关节发育不良的早期症状

Recognize early signs of canine hip dysplasiaü 认识犬髋关节发育不良的发展期症状 Recognize symptoms of canine hip dysplasia during developmentü 使用标准的检查方式 Use standard testsü 通过对照此前的长期研究去确认 Use previous long term study


早期诊断 =预防性治疗 Early diagnosis=preventive treatment

ü 预判髋关节未来的发展 Prognosis of future development of the hipü 确认那些狗会高度怀疑有 CHD Identify dogs that are highly suspected to have CHDü 确认这些狗又早期CHD的临床症状 Verify that these dogs have early clinical signs of CHDü 确认这些狗狗已经有CHD的发展期临床症状 Verify that these dogs have developing clinical signs of CHD


ü 4-5月龄，未有症状的犬 4-5 months, without symptomsü 再打疫苗之前有计划地检查 Systematically check before vaccinationü 有症状的狗越早查越好 Earlier check is better for symptomatic dogsü 在深镇静之后完整评估 Complete evaluation after deep sedation

标准的评估方法 Standard evaluation methods


30

CHD 病例评估 CHD case evaluation

§ xray评估 xray evaluation:ü VD 标准位 standard VD viewü VD “蛙式” 位 “frog” VD viewü DAR 位 DAR viewü 分离位 separation view

标准操作规程：在深层镇静和止痛的情况下进行Standard procedures:Under deep sedation§ 髋关节触诊 hip palpation:ü Ortolani sign ü AR - ASü 股骨头包裹情况 femoral head surrounding conditionsü 软骨完整 vs 磨损 Intact vs. worn down cartilage

§ 与已收集的数据比较 Compare with collected data§ 根据现在有的一些参数 Based on existing data A.Vezzoni et al., VCOT 2008 Vezzoni A, Dravelli G, Vezzoni L,et al."Comparison of conservative management and juvenile pubic symphysiodesis in the

early treatment of canine hip dysplasia. VCOT 3:2008

需要的工具所需要的一些测量工具和保定工具Required measuring tools and

stabilization tools

2017-7-27

所需要的一些测量工具和保定工具Required measuring tools and stabilization tools

具体步骤 Specific Procedures：STEP01：麻醉后Ortolani test (定性)

Ortolani test after anesthesia（determine the nature）

STEP02：测量复位角（AR）与脱出角（AS） Measure AR and ASSTEP03：VD标准正位（定性）

Standard VD (determine the nature)

STEP04：VD 蛙式位（定性）

“Frog” VD (determine the nature)

STEP05：DI 分离位，计算DI值 DI separation, calculate DI valueSTEP06：DAR位，测量DAR角度 DAR view, measure DAR

STEP07：对照标准分级表，进行CHD分级。 Classify CHD level according to standard classification table

34

Ortolani test

标准的操作规程 Standard Procedures

ü 髋关节触诊: 脱出角和复位角 Hip palpation: AR and AS

复位角(AR)

ü评估关节被动松弛的程度 Evaluation of passive flexibility of the joint

ü与 DI 相关 Associated with DI

ü如果关节囊增厚会慢慢变小 Smaller angle ifj oint capsule is thickened

脱出角 (AS)

ü主动脱出的程度 Level of active move

ü与背侧髋臼缘DAR的斜度和髋臼缘的形态有关

Associated with dorsal acetabulum edge DAR and acetabulum morphology

ü 10° - 20° 可以预计有CHD

10° - 20° -Predict to have CHD

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ü 髋关节触诊: Ortolani 症状 Hip palpation: Ortolani signs

标准的操作规程 Standard Procedures

用专用工具测量复位角和脱出角Use tools to measure AR and AS

• 把测量尺的头放在耻骨肌起点头侧Put head of measuring scale at beginning of pectineal muscle• 测量尺的体部靠近股骨内侧髁Body of measuring scale close to internal condyle of femur

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进入xray检查步骤Xray test procedures• 标准VD正位 Standard VD view• 标准VD蛙式 Standard “frog” VD view• 分离位 Separation view• DAR位 DAR view

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LOST

评估髋臼窝的深度与对股骨头的覆盖Evaluate depth of acetabulum and coverage of femoral head

把整个股骨头推到髋臼窝里面Push the entire head of femur into acetabulum

§ 蛙式VD 位“Frog” VD view

评估早期的关节炎症状Evaluation of early arthritis

标准分离位Standard separation view

Method of RR.Badertsher, 1977with hip distractor modified by Vezzoni, 1994, produced by FSA, Italy

xray评估关节松弛（Penny Hip）Xray evaluation of Penny Hip

诊断主要指标Important indicator of diagnosis

• 分离指数 DI（DISTRACTION INDEX）=d/r

45

DI < 0,30 生理性松弛，预后良好Physiologic loosen, good prognosis

DI 0,30-0,70松弛增加, 需要注意,可能有各种预后Increase loosen, need attention, variable prognosis

DI >0,70 过度松弛，预后不良Over loosen, poor prognosis

有一定的品种差异Differences among stains

G.S.Smith, D.N.Biery, T.P.Gregor, 1990

预后prognosis分离指标 (DI)

xray评估关节松弛（Penny Hip）Xray evaluation of Penny Hip

案例 Case

• ortolani 阳性

Ortolani positive• d/r >1• 极其严重

Severe

48

DAR 位 DAR view

‣ 测量 DAR 坡度 measure DAR gradient‣ 评估 DAR 完整性和磨损 Evaluate integrity and abrasion of DAR

DAR

50

正常 Normal CHD

DAR 位 DAR view

DAR

✓ 坡度 Gradient

DAR 位

Goniometro di Slocum

Slocum’s DAR Goniometer

FSA - Innovet, Italy生产

DARA

56

DAR角度的意义Meaning of DARü DAR < 6°正常 normal

ü DAR < 7.5°正常-轻度CHD normal-mild CHD

ü DAR ： 8°～10°轻度-中度CHD mild-moderate

CHD

ü DAR >12°中度-严重CHD moderate-severe CHD

üDAR >15°严重CHD severe CHD

要以最严重的一个指标来参考！！Use the most severe indicator as reference!!

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3 犬髋关节发育不良的非手术管理3 Non-surgical management of CHD严重程度为A-B级别的动物

Severe level A-B

75%日粮，降低体重

75% daily diet, lower body weight

适当运动

Proper excercise

保健药物

Health care grugs

NSAID

股骨头中心位置良好Good location of femoral head mid-point

DI <0.5

Ortolani+-

AS 0-5°

DAR<8°

4 早期手术治疗4 Early stage surgery5 后期手术治疗5 Late stage surgery

早期治疗和后期治疗Early stage and late stage treatment• 早期治疗 Early stage treatment• 耻骨联合电灼吻合手术--JPS（3.5-4.5月龄） Juvenile pubic symphysiodesis--JPS (3.5-4.5 months)• 骨盆两处/三处切开手术--DPO/TPO（5-8.5月龄） Double pelvic osteotomy/triple pelvic osteotomy—DPO/TPO (5-8.5 months)• 后期治疗 Late stage treatment• 股骨头切除手术FHO Femoral head osteotomy • 全髋置换手术THR（5月龄以上，最好是9月龄以上） Total hip replacement (over 5 months, over 9 months best)• 半髋置换手术CHR（针对老年动物和髋臼坏死不容易生长的动物） CHR (old animals and acetabulum necrosis)

✓ 年龄: 3.5 - 4.5 m Age:3.5-4.5 m✓ + Ortolani sign ✓ AR 15° - 40°✓ AS 0° - 15°✓ DAR 到 12° 没有 DAR 磨损 DAR up to 12°, no DAS attrition✓ DI 0.4 - 0.7✓ 没有临床症状 No clinical symptoms

JPS的病例选择JPS case selection

Labrador, 3.5 mo.AR 35°AS 15°

DAR 12°

AR 25°AS 5°

DAR 10°

DI 0.5DI 0.7

早期髋关节发育不良的手术Early Hip Dysplasia Surgery

古牧3.5M Ortolani+ as8° DI 0.57-0.58Old English Shepdog

JPS术后Post- JPS• AS=0°或消失

AS=0° or disappear

Border Collie, 7 mo.AR 40°AS 20°

AR 35°AS 15°

DI 0,6 DI 0,6

DAR 12° DAR 12°

‣ 年龄: 5 - 8 months Age:5-8 months‣ + Ortolani sign‣ AR 20° - 40°‣ AS 10° - 20° (25°)‣ ≠ AR-AS > 15°‣ DAR 8° - 20° 轻微的 DAR 磨损

DAR 8° - 20°, slight DAR attrition‣ 没有髋臼窝的增生 No acetabulum hyperplasia‣ DI < 0.8

DPO的病例选择DPO case selection

早期髋关节发育不良的手术Early Hip Dysplasia Surgery

2015年4例4 cases in 2015名字Name

品种Breed

年龄Age

性别Sex

体重Weight

Ortolani症状Ortolani signs

AS（°） AR（°） DI

左Left

右Right

左Left

右Right

左Left

右Right

左Left

右Right

馒头金毛G.R.

6M 公M

18kg + + 16 17 36 37 0.68 0.72

呆瓜金毛G.R.

5M 公M

20kg + + 20 15 42 36 0.79 0.68

上海金毛G.R

6M 公M

18kg + + 20 20 36 41 0.73 0.8

Fika 金毛G.R

7M 公M

25kg + + 13 14 30 35 0.5 0.6

术前评估Preoperative evaluation

• As=0°

术后Postoperation

持续观察1年Monitor for 1 year

6 晚期手术6 Late stage surgery

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股骨头切除VS骨关节炎Femoral head osteotomy vs. osteoarthritis

FHO术后 FHO post operation

术后三个月Post operation 3 months

术后一周内Post operation 1 week 术后四个月

Post operation 4 months

术后八个月Post operation 8 months

FHO术后十年FHO post operation 10 years

早期髋关节发育不良的手术选择Early stage hip dysplasia surgery selection

全髋置换手术

Total hip replacement

有效的手术Efficient surgery

‣ Kyon “Zurich”

THR术后3-8个月THP post operation 3-8 months

选择什么时候做THR手术When to choose THR

ü 6月龄之后，即使做DPO手术也不能纠正髋关节的时候 After 6 months, when DPO cannot correct hip discordantü 成熟的犬，有进行性的关节退变 Adult dog, progressive joint degeneration ü 成年犬/老狗，关节退行性病变 Adult/old dog, degenerative change of the joint

当以下条件：Under following conditions:

如果有其他问题则不要做Do not operate ifü 有其他关节问题，例如膝关节/跗关节问题 Has other joint problems, eg: knee joint/tarsal joint problemü 神经损伤 Nerve injury

7 手术并发症7 Surgical complications• JPS• DPO• FHO• THR

Documents

幼犬髋关节发育不良的管理与 手术治疗 Canine Hip ......1. Pathogenesis of canine hip dysplasia •2犬髋关节发育不良的早期诊断方法与评级 2.Early diagnosis

幼犬髋关节发育不良的管理与手术治疗 Canine Hip ......1. Pathogenesis of canine hip dysplasia •2犬髋关节发育不良的早期诊断方法与评级 2.Early diagnosis