Challenges with an 8 week post-op FHO on an 18 month old Rottweiler

[Guest guest]

8 weeks ago my clinic was referred an 18 month old MN Rottweiler for a TPLO.

When we examined the dog and took radiographs, we discovered that the lameness

was not due to a CCL rupture but was from a previous hip fracture that had been

undiagnosed. Our surgeon elected to perform a FHO and found that the head of

the femur was ankylosed to the acetabulum. PROM was performed immediately

post-op until he was awake and then we iced the hip and continued rehab TID for

the first week. He was extremely painful on hip extension and was non-weight

bearing in the first week so the surgeon thought there may still be some bone

that needed to be filed down. We did another surgery 2 weeks post-op and took

more bone off of the femur and filed it more. He was toe touching the week

following this surgery and would bear a little weight if I supported his

opposite hip when he walked. He developed a large seroma over the incision site

and the owner was allowing him to lick at his incision so we drained the fluid

and cultured it with no significant growth. We covered the bases with

antibiotics anyway. He was still painful on hip extension but had no trouble

with flexion of the stifle or hip. He stopped using the leg once we sent him

home and a third surgery was performed 4 weeks from the first one. This time,

the surgeon filed the acetabulum down more to ensure that there was no possible

bone contact. We had been managing his post operative pain with Metacam SID and

Tramadol at 4 mg/kg TID. A Neurologist I spoke thought it might be sciatic pain

and suggested that we also try Gabapentin. He did much better with the

Gabapentin and was using the leg about 60% of the time. Again, we sent him home

and he came back on 3 legs. At this point he has significant muscle atrophy (I

also did NMES while he was in clinic)and still cries out with hip extension. He

is pretty much non-weight bearing and I have now convinced the owner to try a

local UWTM as we do not have one at this time. The owner has no money and I

have done all of the rehab for free (sucker!). I have tried everything I can

think of to get him to use his leg but to no avail. He did well on his first

UWTM session but on the second he refused to use it and would sit down in the

treadmill. He will swim a bit but mostly uses his front limbs. I am extremely

frustrated and feel very bad for this dog (the owner, I could do without ).

Any suggestions? We still have him on Gabapentin but I don't know what else to

try at this time. Does anyone have any experience with this particular

challenge?

Thanks!

Penny Radostits, RAHT, CCRP

Crestwood Veterinary Centre

Edmonton, AB Canada

[Guest guest]

How about some cold laser and some adequan? I know there's no real hip joint, but the poor fellow has now had insult to 2 major joints and maybe there's been more trauma hx that has been undiagnosed. Sounds as if this was an old injury so who knows what else is going on.

jeanne olson dvm

[Guest guest]

Penny,

I really thought that you would have more feedback to your questions by now

since this is a rather common postop orthopedic complication. These are very

difficult cases and the longer your patient remains non-weight bearing the

longer the care required to restore a more normal function will be. First you

have a patient that is most likely in chronic pain, at least my similar patients

have been. This chronic or maladaptive pain process began a long time ago,

perhaps even before the first surgery. Trauma induced by 3 surgical procedures

has most likely added to the pain process. At this time I would hope that there

is no bone to bone contact and that the medial side of the femur where the

osteotomy was performed is smooth and not producing trauma to surrounding

tissues and/or acetabular area. Unfortunately if this is still a problem only

surgery will correct. Do you have the most recent radiographs?

Rehabilitation is impossible until the chronic pain process has been brought

under control with pharmaceuticals and physical medicine. In addition to your

NSAID consider tramadol 5mg/kg q4-6h for several days, gabapentin 5-10mg/kg

q8-12h, amantadine 100mg qd. Gabapentin can be titrated upward every few weeks

if needed. A careful examination to localize the areas of pain is absolutely

necessary. The areas that I often localize pain in these patients in in the hip

flexors (m.psoas major, m. sartorius, m. tensor fascia latae and m. rectus

femoris), all on the side of the non weight bearing. The areas where pain is

localized are most likely myofascial trigger points that form in the overworked

muscles. The vastus group on the contralateral pelvic limb maybe painful due to

repeated eccentric contractions during ambulation. Physical medicine modalities

to treat myalgia can include therapeutic laser, previously mentioned by Dr.

Olson, analgesic acupuncture, manual techniques of muscle massage to release

MTrPs (i.e ischemic compression). All of these modalities should be followed by

gentle passive ROM exercises.

Once your patient begins to toe-touch then light rehabilitation exercises to

cause activation of pelvic limb muscles can be started including multiple

sessions in the underwater treadmill. As your patient improves be careful not

to let the perform explosive exercises at home. They should always be under the

control of a leash. I am attaching a video of a similar patient, NWB for 3

months, post FHO (2 surgeries). We had this patient in rehab for 5 months and

approximately 50 sessions.

http://vimeo.com/16964735

Good Luck!

Rick Wall

[Guest guest]

Hi Penny

I too am dealing with an FHO that is not healing as quickly as I would like but I have dealt with a number of these. I would agree with Rick that pain control is paramount with these guys. I have had good success with tramadol and gabapentin as far as pharmaceutical go. Painful muscles especially iliopsoas seem to be a common problem. I use a lot of heat, stretching, manual therapy--often SI joint is painful, chiropractic, therapeutic laser and massage. I will often put these guys into the water just to off weight them and do weight shifting that way to get some muscle activation. Do not forget the other limbs and shoulders as these are often areas of pain. Acupuncture is a large component of my practice as well and I too have the patient that took 6 months to recover.

Unfortunately this procedure , in my locale at least, is often not done by a boarded surgeon and has more complications than most--or maybe I just see the ones that do.

Best of luck

Jan Huntingford

Essex Animal Hospital

Canine Rehab and Fitness

[Guest guest]

Jan,

<<<<<<<<< " Do not forget the other limbs and shoulders as these are often areas

of pain. " >>>>>>>>>>>>>>>>

Excellent comment! I am in total agreement!

Rick

[Guest guest]

Thanks Rick! I viewed the attached video that you supplied and it was like

watching my patient! This information is very useful indeed! I appreciate the

feedback and will continue to work on this. If I can figure out how to send

them, I will post his post-op radiographs from the 3rd surgery. It's been a

busy week and no time to post anything. In any case, I really appreciate

everyone's comments! Thanks! Nice to know I'm no alone

Penny

>

> Penny,

>

> I really thought that you would have more feedback to your questions by now

since this is a rather common postop orthopedic complication. These are very

difficult cases and the longer your patient remains non-weight bearing the

longer the care required to restore a more normal function will be. First you

have a patient that is most likely in chronic pain, at least my similar patients

have been. This chronic or maladaptive pain process began a long time ago,

perhaps even before the first surgery. Trauma induced by 3 surgical procedures

has most likely added to the pain process. At this time I would hope that there

is no bone to bone contact and that the medial side of the femur where the

osteotomy was performed is smooth and not producing trauma to surrounding

tissues and/or acetabular area. Unfortunately if this is still a problem only

surgery will correct. Do you have the most recent radiographs?

>

> Rehabilitation is impossible until the chronic pain process has been brought

under control with pharmaceuticals and physical medicine. In addition to your

NSAID consider tramadol 5mg/kg q4-6h for several days, gabapentin 5-10mg/kg

q8-12h, amantadine 100mg qd. Gabapentin can be titrated upward every few weeks

if needed. A careful examination to localize the areas of pain is absolutely

necessary. The areas that I often localize pain in these patients in in the hip

flexors (m.psoas major, m. sartorius, m. tensor fascia latae and m. rectus

femoris), all on the side of the non weight bearing. The areas where pain is

localized are most likely myofascial trigger points that form in the overworked

muscles. The vastus group on the contralateral pelvic limb maybe painful due to

repeated eccentric contractions during ambulation. Physical medicine modalities

to treat myalgia can include therapeutic laser, previously mentioned by Dr.

Olson, analgesic acupuncture, manual techniques of muscle massage to release

MTrPs (i.e ischemic compression). All of these modalities should be followed by

gentle passive ROM exercises.

>

> Once your patient begins to toe-touch then light rehabilitation exercises to

cause activation of pelvic limb muscles can be started including multiple

sessions in the underwater treadmill. As your patient improves be careful not

to let the perform explosive exercises at home. They should always be under the

control of a leash. I am attaching a video of a similar patient, NWB for 3

months, post FHO (2 surgeries). We had this patient in rehab for 5 months and

approximately 50 sessions.

>

> http://vimeo.com/16964735

>

> Good Luck!

>

> Rick Wall

>

[Guest guest]

Hi,

 

I had a similar patient that I treated for approximately 6 weeks.  He was improving but not at the level that I thought he should be.  I sent him back to the RDM (who is not a Board certified surgeon) and he needed a second surgery.  Unfortunately, after that the owners were out of funds and have elected to pursue rehab on their own.  The dog was only 1.5 years old and had severe muscle atrophy so needless to say I was disappointed that I didn't get him back.

 

On another note, I received a call this week about another FHO case.  This is a 4 y.o. MN Shiba Inu who spontaneously luxated his hip.  After reducing the hip and spending 4 days in an Emher sling it luxated again. The surgeon (Board certified) determined that an FHO was best for this guy.  The surgeon also recommended that rehab be started immediately.  I work with this Dr. a lot and I know him well.  He is very good. The owners (due to cost) elected to have the sx done at the local Humane Society.  The Dr. there told them to keep the dog on strict crate rest with no activity for 10 days.  No range of motion, no stretching, no walking, nothing.  Luckily they did some research ahead of time and are coming in for a consult today.  So to generate some more discussion, what if anything can I politely do to educate this Dr.?

 

Thank you,

Blanchard LVT, CMT, CCRP

Animal Rehabilitation Center of Michigan, Inc.

Waterford, MI 

 

Thanks Rick! I viewed the attached video that you supplied and it was like watching my patient! This information is very useful indeed! I appreciate the feedback and will continue to work on this. If I can figure out how to send them, I will post his post-op radiographs from the 3rd surgery. It's been a busy week and no time to post anything. In any case, I really appreciate everyone's comments! Thanks! Nice to know I'm no alone

Penny

>> Penny,> > I really thought that you would have more feedback to your questions by now since this is a rather common postop orthopedic complication. These are very difficult cases and the longer your patient remains non-weight bearing the longer the care required to restore a more normal function will be. First you have a patient that is most likely in chronic pain, at least my similar patients have been. This chronic or maladaptive pain process began a long time ago, perhaps even before the first surgery. Trauma induced by 3 surgical procedures has most likely added to the pain process. At this time I would hope that there is no bone to bone contact and that the medial side of the femur where the osteotomy was performed is smooth and not producing trauma to surrounding tissues and/or acetabular area. Unfortunately if this is still a problem only surgery will correct. Do you have the most recent radiographs?

> > Rehabilitation is impossible until the chronic pain process has been brought under control with pharmaceuticals and physical medicine. In addition to your NSAID consider tramadol 5mg/kg q4-6h for several days, gabapentin 5-10mg/kg q8-12h, amantadine 100mg qd. Gabapentin can be titrated upward every few weeks if needed. A careful examination to localize the areas of pain is absolutely necessary. The areas that I often localize pain in these patients in in the hip flexors (m.psoas major, m. sartorius, m. tensor fascia latae and m. rectus femoris), all on the side of the non weight bearing. The areas where pain is localized are most likely myofascial trigger points that form in the overworked muscles. The vastus group on the contralateral pelvic limb maybe painful due to repeated eccentric contractions during ambulation. Physical medicine modalities to treat myalgia can include therapeutic laser, previously mentioned by Dr. Olson, analgesic acupuncture, manual techniques of muscle massage to release MTrPs (i.e ischemic compression). All of these modalities should be followed by gentle passive ROM exercises.

> > Once your patient begins to toe-touch then light rehabilitation exercises to cause activation of pelvic limb muscles can be started including multiple sessions in the underwater treadmill. As your patient improves be careful not to let the perform explosive exercises at home. They should always be under the control of a leash. I am attaching a video of a similar patient, NWB for 3 months, post FHO (2 surgeries). We had this patient in rehab for 5 months and approximately 50 sessions.

> > http://vimeo.com/16964735> > Good Luck!> > Rick Wall>