Last October I embarked on a series of posts detailing the economics and other mechanics of hip disease in dogs. But somehow life intervened and I only got part 1 and part 2 completed before being swept away on some other, more immediately compelling Dolittler mission.
To atone for my sins of omission, here’s the last enrty in this three part series. Perhaps the most interesting of the three, this entry deals in the big-ticket items that attend hip dysplasia.
But first, a recap:
Hip dysplasia is a disease of the ball and socket mechanism known as the “coxofemoral joint” (aka, “hip joint”). It happens when the bones that make up the ball and socket portions of the joint aren’t well formed, or when they’re less-than-perfectly aligned in relation to one another. In all cases, the upshot is painful rubbing of the two joint surfaces, which inevitably leads to osteoarthritis (and more pain).
Luckily, not all dogs will inherit this malformation to the same degree. In fact, small breed dogs with mild to moderate hip dysplasia may live long, normal lives without the need for intervention beyond proper exercise, weight control and supplements (more on this later). However, most moderate to severe sufferers of medium and larger breeds will almost certainly not fare so well.
Though the worst cases will make themselves known in puppyhood, the vast majority will suffer a slow burn version that only begins to makes itself known after a few years of life. Though most cases of hip dysplasia end the same way (with pain and immobility), the progression varies widely depending on the degree of malformation/misalignment.
Diagnostic approaches also vary––though by no means so widely. The two basic methods for measuring the degree of dysplasia (OFA and PennHIP) both rely on X-ray evaluation of the joints.
Now for the nuts and bolts of today’s topic:
As if living with hip dysplasia weren’t bad enough, there’s the other cost to consider: treating it. And this, too, varies as widely as the different degrees to which hip dysplasia presents itself. Nonetheless, there is one absolute point that I’ll make at the outset:
Severe hip dysplasia is a surgical disease. In other words, treating it relies almost exclusively on surgical approaches to the hip joint. And these are invariably expensive, though some significantly more so than others.
Total Hip Replacement (THR): End-stage hip dysplasia (where pain is poorly controllable and near-complete immobility results) only has one good treatment: a total hip replacement, which is by far the most expensive surgical approach to hip dysplasia. The only other option at this point is euthanasia. And it’s not my favorite, given that hip disease is now so treatable, expensive though it may be.
What’s expensive? OK let’s go there: Hip replacements (in which the entire joint is replaced with artificial components made specifically for pets) go from $3,500 a hip (the very lowest I’ve ever heard) to about twice that. And because so many sufferers are bilaterally affected, a two-sided hip replacements is usually better than its unilateral version. Yes, that’s $7,000 to about $14,000.
Compared to the human version, however, this highly specialized procedure (almost always performed by a team of board-certified veterinary surgeons who are additionally schooled and certified in this approach) goes for less than a tenth of its human equivalent (and they are equivalent in most every way).
Another note: With improvements in the non-cemented implants now used in THR, pets can be treated younger by way of preventing the pain and immobility that will invariably manifest in moderate to severely affected dogs. We don't have to wait until the hips have reached end-stage levels before intervening surgically with this "gold standard" approach.
Back to the other options:
The good news is that if it’s caught early enough (before osteoarthritis sets in and/or before muscle loss results from reduced mobility) several other surgical options are on the table.
Triple Pelvic Osteotomy (TPO): This method is best for dogs that have been diagnosed with hip dysplasia before major signs are present (pups, in particular). It cuts the pelvis in three places so that the ball of the femur lines up better with the socket of the hip joint.
Femoral Head Osteotomy (FHO): This approach cuts off the head of the femur, preventing painful rubbing in the joint and allowing the muscles in the are to pick up the slack. Again, this is best for pets who still have a lot of muscle in the area. In other words, these candidates don’t yet have major changes due to hip dysplasia.
Juvenile Pubic Symphysiodesis (JPS): Though not commonly employed, this method aims to intervene early––very early––at 12 to 16 weeks of age. The goal is to fuse the bones of the pubis (on the pelvis) before they close naturally (they're open for a while in pups). This changes the alignment of the hip sockets so they can hook up with the ball part of the joint in a more natural way. Unfortunately, studies have not shown a high enough success rate for this surgery to render it popular. Moreover, the 12 to 16 week limit makes it an impractical option for those who only learn later that their dogs are affected (severe hip dysplasia is not often diagnosed until 4 to 6 months).
For all non-hip replacement kinds of surgeries, $1,000 to $3,000 per hip is the norm. But remember, the particular veterinary hospital’s priciness, its geographic location and the quality/experience of the surgeon may well dictate an even higher price.
That’s why board-certified surgeons will almost inevitably provide higher-end estimates for hip dysplasia treatment. Their experience means better outcomes for dogs. Moreover, their high tech hospitals and staff also command higher prices, even when we’re not talking about a total hip.
Post-operatively, you should also consider the possible need for rehabilitation services. These can cost anywhere from $50 to $150 per session, and can add up fast if your dog requires 10-20 sessions to recover from surgery. Most don’t, it’s true, but almost all patients will benefit from this kind of care after major orthopedic surgery.
But now comes the inevitable question...
What if a $2,000-5,000 treatment is impossibly out of reach?...or means the next five years will require you eat peanut butter and jelly sandwiches off paper plates as you whittle down the debt, dollar by dollar? What can you do in these cases?
Ultimately, your only choice in this case is to either go broke, rob a bank, get another job or treat the pain and work hard at keeping weight down and maintaining muscle through low-impact exercise (such as swimming).
Since the majority of you will have become well-accustomed to treating pain in these cases, it's what most of you who suffer from the financial inability to treat hips surgically end up doing. But you should know that this is an expensive proposition, too. Large breed dogs, especially, will typically require $20 to $100 in pain relieving medications and treatments every month––if not more for those willing and able to splurge on the more expensive supplement options (i.e., Adequan).
Doing the math on a large breed dog, this means up to $1,200 a year for moderate to severe pain. And what's the intangible cost of the inability to completely manage it? Hmmm...
Sure, it's a depressing end to a great Monday morning topic. But there you have it. The good, the bad and the ugly of hip dysplasia treatment costs. Better late than never, right?
Add Comment55 Comments
I was under the impression that the FHO technique had a maximum dog-weight, something like 30 or 40 pounds, over which it was definitely not recommended. Has that recommendation changed in recent years?
Cats can have dysplasia as well, though nowhere near the same magnitude of incidence. I have a Rex Devon who has limped on his left side ever since he was 6 months old or so. He's now almost 4, and I'm starting to think that FHO might figure in his future at some point. However, as long as he keeps a very healthy body weight and can jump and run faster than any other cat I've ever known, he may only develop joint arthritis when he is much older, at which point I may choose to use pain control instead of surgery.
brebis noire June 22nd, 2009 01:37:45 PM
Dr. K, what's your experience with the duration of symptom relief following a regimen of Adequan injections (or any of the posters who have experience with this treatment)? I'm considering it for my 50-lb. dog who has moderate hip dysplasia, bilaterally, with moderate osteoarthritic changes according to her rads. Clinically, she does ok - willing and able to run, jump, play, and generally be very active w/no lameness (she's about 8 years old), but she does have some slight changes in her gait and some stiffness rising. I'm having a a hard time finding a vet who's used it in more than a few patients. Any input would be appreciated.
anna June 22nd, 2009 02:30:30 PM
Anna: I use LOTS of Adequan--because my clients say it works. And I'd rather not toy with drugs if my patients can get away with Adequan and glucosamine alone (yes, even some moderate hip dysplasia patients can, as long as they're lean and stay reasonably well-muscled).
Lately, I've been using the twice a week for four weeks regimen. I'll then stop for a month or so--or at least until my clients report that its effects have worn off.
But I've also met dogs for whom Adequan is woefully inadequate--either because their pain is too severe or because it doesn't seem to have any effect at all. (This latter group is a minority.)
To make these regimens affordable, I sell it to my clients after teaching them how to administer an intra-muscular injection. That way they don't have to come in twice a week and pay for an in-hospital injection every time (almost twice as expensive).
Dr. Patty Khuly June 22nd, 2009 02:43:18 PM
brebis noire: I've never heard that there's a weight limit per se. In fact, I had one 70-lb patient undergo it last year (after the family and the surgeon decided she was well-muscled enough to do well). I assume it's used more frequently on our smaller/leaner patients only because they're less likely to be as severely affected by the loss of muscle mass. I'll ask the surgeon specifically next time I talk to him, though.
Dr. Patty Khuly June 22nd, 2009 02:47:10 PM
FWIW, I've been under the impression that FHO is best for smaller pets (less than 40 lbs.) for whom the false joint that is created is adequate given their weight, or for very active pets whose activity level is especially conducive to the formation of a false joint. I think one of the vets I work for told me...can't seem to remember. Maybe I read it here, lol.
anna June 22nd, 2009 06:30:54 PM
Dr K, Mary Strauss asked (in comments for part 2) if you were going to be doing a follow up on early treatment, to which you replied yes. Did you do that ? (and I missed it ?), or do you still plan to ?
I may have missed it due to handrearing a litter born last October 10th, so I may well have been a zombie at the time LOL (I can laugh about it now, but no joke at the time I can tell you).
Unfortunately one of those pups has developed a rare (according to the orthopaedic specialist) condition normally seen in Bernese Mountain Dogs, and linked to polydactylism (extra digits), she was born with double dewclaws on her hind legs. She has twisted hock joints and is already showing signs of arthritis in there, so all I can do is be pro-active against arthritis. She's on neutraceuticals and adequan, plus restricted excercise to prevent further injury to her still growing joints.
Alison June 22nd, 2009 09:18:52 PM
Alison: The TPO is the most commonly cited "early" treatment option. As to angular limb deformities (as in twisted hocks), that's another story. Sure, it plays into the joints above and will certainly contribute to their misalignment, but it's up to you and your vet/surgeon whether another, non-hip procedure "downstream" of the deformity (i.e., repairing the hock problem itself) might not be a better option in the long run. btw, this is definitely a question for a veterinary surgeon skilled in treating angular limb deformities (many are not, as I'm learning while doing research for my own twisted pup).
Dr. Patty Khuly June 22nd, 2009 10:21:47 PM
Alison: PS: There is a procedure that may be helpful for your pup and you may want to research it a bit: the Ilisarov method for correcting these deformities may be helpful. Google search it and ask your orthopedist if he/she has any thoughts about this approach for your "little" one's condition.
Dr. Patty Khuly June 22nd, 2009 10:25:52 PM
Re: the FHO weight limit, no, my 3 y.o., 75 lbs Ridgeback had both hips done within seven months of one another last year. The first surgery did not go well due to misc post-op problems related to pain management and chewing out the stitches and staples, but the second was a breeze for both of us. Mostly because I inadvertantly persuaded the vet hospital to board her for a week post-op, but that's another story entireliy. ;)
She had started to lose muscle, but the various doctors I consulted said that it was either the FHO, and now, or she was going to deteriorate very rapidly. Replacement wasn't an option for *her* (according to both TAMU TVMH and Gulf Coast Specialists) because she was too young and after five years with the replacements there was an increasing risk of infection. Since my poor girl was of the opinion that she wasn't ready to give up yet (after all, she's only a puppy...) she got what she asked for.
Despite her relative youth, TPO wasn't an option in this case because the head had mushroomed (and fractured) so severely. "Blind", upon first seeing a radiograph taken at 2 y.o., most ortho specialists guessed that the dog was 7 y.o. I had her evaluated three times and ended up having the surgery done by my normal vet -- who just graduated in 06 and hadn't done one before! I had confidence in him and I was happy to give him the experience, since I'd known him since he was in school.
Since the surgery, she's been on Rimadyl / Carprofen and that's kept the inflamation manageable. I'd like to wean her off of it, but I'm afraid that it doesn't seem practical ... she limps and then sometimes starts to act aggressive without it. We have an exercise program that involves a lot of low-impact movement in the backyard. I wish I had a pool or hot tub so that she could swim, but that's not practical at this point.
For anyone with a dysplasic dog, make sure you 'shop around' and explore all the different options before you commit to one.
Karl Katzke June 23rd, 2009 01:08:18 AM
Alison: Just remembered a post about this (from years back). Enjoy.
Dr. Patty Khuly June 23rd, 2009 08:51:33 AM
As a veterinary surgeon, I agree with Dr. Khuly's assessment: "End-stage hip dysplasia (where pain is poorly controllable and near-complete immobility results) only has one good treatment: a total hip replacement". I would actually go further and say it is not only reserved for end-stage dysplasia, but is ideal for dogs with dysplasia that is early, but obviously only progressing. The reason for this is simply one of humanity: hip dysplasia hurts, and we cannot reverse it. All other strategies (from glucosamine chondroitin, adequan, NSAIDS, etc.) are simply strategies to decrease pain, but they do not eliminate it. FHOs invariably leave residual pain. In dogs over about 40 pounds or so, the residual pain is often significant enough to require daily medications anyway. Owners commonly will comment that coordinated medical management will allow their dogs to run and play again. If any one of us had a source of pain that was so great that we needed daily doses of prescription-strength Motrin in order to get up and be active, we would say that it was unacceptable. That is precisely the condition our pets with hip dysplasia face: pain so constant they have to be on prescription-level pain killers each day in order to function. A THR is meant to eliminate that pain. The arguments against THR are cost and invasiveness. The technology behind hip replacements is rapidly improving, with new implants showing great success with relatively few complications. THR now are the primary recommendation for any dog or cat with hip dysplasia pain that weighs 8-10 pounds or more, and is at least about 7 months old. I honestly hate to say this, but from a purely medical perspective, all other treatments are second best, and are simply compromises. The tragedy is that the cost of the procedure is what usualy disqualifies patients. Most animals are only disqualified for medical reasons after the dysplasia is medicaly managed for too long, and allowed to progress to a point where a THR cannot be performed. (This unfortunate situation can happen to dogs as early as 1 year of age, depending on theri pattern if dysplasia.) While there are many reasons to avoid THRs, when you look at the management of chronic pain, there are few medical treatments that exist that are as effective in eliminating chronic pain as a THR. It truly is that good when done early.
Marc June 23rd, 2009 10:25:36 AM
I have gotten some x-ray 101's recently, as several of my seniors are being monitored via thorough exam. This is probably no surprise to those well-versed in OFA and Penn-Hip but nonetheless an interesting tidbit to me.
It revolves around the issue of "cavitation" and the misleading presentation on x-rays. Wow, sure does "look" like a serious issue, with gaps between ball & socket. Two twelve year olds, one with double "cavitation" and the other with one side. And not a speck of arthritis.
Just kind of a side note to the issue, but one worth mentioning as an incidental finding. Cavitation is the same process as cracking your knuckles with a release or shift of joint fluid appearing as a shaded area on x-ray and rendering a laxity DI measurement impossible.
Barbara A./NH June 23rd, 2009 11:45:31 AM
Marc: But what about Karl's surgeon's reservations on the issue of TPO implant longevity? Does that mean an implant may need to be replaced five years down the line? Is there any research on this or is implant failure in the distant future merely one of any number of risks?
Dr. Patty Khuly June 23rd, 2009 02:34:25 PM
They may have been referring to the old cemented version of the total hip replacement implants. With that old technology, there is a worry that the cement will loosen or get infected after several years. The new implants are not cemented, but rather are ingrowth (meaning the bone grows into the implant, holding it, and adapting over time to changes in bony structure). Today, we reserve cemented implants for older dogs with osteoporosis that cannot support the new technology, so longevity issues don't really apply. The new non-cemented implants have been reliably implanted in dogs as young as 5 months old, and they are expected to last some 12 to 15 years. (The main mode of failure is wearing out of the UHMWPE cup liner, much like in humans). I peresonaly have seen dogs with these implants walking with no apparent lameness 14 years after bilateral THRs.
Marc June 23rd, 2009 03:19:29 PM
What do you think about the Juvenile Pelvic Symphysiodesis? I'm a vet in the UK, and one of my colleagues has recently started doing this, with apparently good outcomes (but the dogs are still quite young). It strikes me as being a better option than the TPO as it's less invasive, and requires less strict post-op restriction. Is it a procedure that is done much where you are?
Jess June 23rd, 2009 03:59:03 PM
Unfortunately, the Juvenile Pubic Symphysiodesis (JPS) has not lived up to its early promise. Two recent articles show that either there is little difference between JPS and TPO (Journal of the American Veterinary Medical Association;230: 206-210, 2007) or that it is only helpful in cases of mild dysplasia (Veterinary and Comparative Orthpaedics and Traumatology;21: 267-279, 2008.) The biggest barrier to the JPS is identifying puppies which have mild dysplasia and would benefit, as the surgery has to be perfomed between 16 and 20 weeks of age to have any hope of being successful. The few cases I have done have progressed to signs of hip arthritis that is little different from what I would expect to see if nothing at all had been done (and I was taught the technique by the great Kyle Mathews himself).
Marc June 23rd, 2009 05:54:54 PM
Marc, that's interesting. It's possible that the two surgical specialists that I consulted were not able to do the newer technique you specified -- I know that TAMU just recently started offering it. The evaluations were done just a year ago in April.
As for her health -- I still have to limit her mobility some, and she still some days is a bit lame on one leg or the other. It's a constant process of strengthening and working with her. But she's excited to play fetch and chase birds in the backyard again, which makes both of us happy compared to where she was a few years ago. I know what she looks like when she's in pain, when she hurts but is working through it, and I know what she looks like when she's happy and excited. These days she's happy and excited more often than not!
It's not ideal by far, but for a state government employee on a budget, she's doing pretty good. Now, if my boy dog would stop breaking out through the side of crates...
Karl Katzke June 23rd, 2009 07:49:29 PM
Marc: One more Q: How about a total hip after one of these other procedures has proved unsuccessful or less-than-curative? Is a THR even possible after an FHO? I would think it would be for the TPO and JPS (sorry I didn't mention this one in my post, I will amend it) but never for a FHO once a false joint has formed--if ever. Thoughts?
btw, for those of you curious about this: a JPS (juvenile pubic symphysiodesis) is a tricky procedure that fuses the pubic symphysis prematurely in very young pups. The idea is that the hips will the rotate out to accommodate the ball of the joint. the hard part is that identifying these cases needs to happen so early (by 20 weeks, as Marc mentioned) that only dogs with the benefit of PennHIP's early diagnostic ability are decent candidates. (Again, I prefer PennHIP to OFA by a long shot, and not just because I went to Penn.) However, because owners/veterinarians must be astute enough to recognize the need to evaluate the hips this early, this procedure is rarely on anyone's radar. It seems the outcomes of the studies on the JPS seal that deal--for now, anyway. Glad we discussed it, though.
Dr. Patty Khuly June 23rd, 2009 09:28:09 PM
A THR is possible after an FHO, but is technicaly difficult. "technicaly difficult" translates into more chances of complications, especialy malpositioning of implants. In reference to Karl's dog's case, as well as the question of a THR after an FHO, I have to say that the decision-making behind when a dog or cat is or is not a candidate for a THR is very complicated, and is an area of very involved discussion. There are several reasons why a patient would be a poor candidate for a THR, from bone loss/osteoporosis, degree of luxation (how far the ball has migrated away from the socket), other anatomic anomalies, etc. All these can only be reliably evaluated with a careful orthopedic exam and high-quality X-rays.
Marc June 24th, 2009 08:54:58 AM
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