CaseStudy

The patient we have the opportunity to present today has been showing right front hang-leg lameness since January. This case not only demonstrates how functional orthopaedics works – it also shows how it can help even “hopeless” patients.

The husky Dante was presented to the in-house vet with a suspected muscle strain. However, anti-inflammatories and physiotherapy prescribed beforehand did not bring any relief. Therefore, he was presented to our practice in April.

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Functional orthopaedics

Functional orthopaedics deals with orthopaedic structures and their pathology. In particular, it is concerned with mobility. This includes:

• The degrees of freedom of joints and limbs.
• Structural physiological and pathological findings.
• General (dys)function of the joints as well as
• Regional orthopaedic structures (such as at the pelvic girdle or spine).

In the case presented here, the dog’s shoulder is the focus. The terms Range of Motion (ROM) and Range of Freedom (ROF) play a special role. They provide information about the function or – in this case – the dysfunction of a joint, whether it is normal, altered, or even physiologically or pathologically conspicuous. 

The examination of functional orthopaedics, like all specialisations, demands a great deal of time and experience. It also requires a lot of time and experience to recognise breed-specific changes in the dogs. The treatment differs greatly, also with regard to the size and mass differences of the patients. In addition to experience and time, a fine instinct is required to meet the individual requirements of the patients.

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The goal of functional orthopaedics

In a nutshell: Dogs are orthopaedically examined to detect and treat structural changes.

It is generally assumed that a lameness in a dog must be caused by dysplasia, osteoarthritis or some other defective structure. This assumption is largely correct: 50-60% of lameness in dogs can be attributed to this. The rest of the cases, however, have a functional cause.

It can be stated that in these instances, the statics or dynamics are altered without structural pathologies being present. These cases are usually related to the architecture or anatomy of the dog. 

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Where is functional orthopaedics important?

Without going into great detail, this is particularly the case with the

1. Shoulder girdle and
2. pelvic girdle.

The shoulder limb mass in dogs is important precisely because, unlike in humans, it is not structured as a rotator cuff, but as a synsarcosis. In concrete terms, this means that the shoulder limb mass is connected to the rib cage by a flange and can therefore slide along it in a relatively unstable manner. ROM and ROF play a special role here. 

Another point is that many canine shoulder pathologies are cases of soft tissue pathology. As a result, many pathologies cannot be diagnosed by X-ray, ultrasound, MRI or CT. Therefore, in addition to the aforementioned sensitivity of the orthopaedic examination, functional diagnostics are indispensable. This includes gait diagnostics with the “Inertial Sensor Unit” or IMU for short.

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What principles does functional orthopaedics follow?

When we talk about functional orthopaedics, we have to keep the following aspects in focus:

1. Stimulus-response principle,
2. Form-function-changes, the
3. Arndt-Schulze rule and the
4. Adaptability of orthopaedics.

Let us first look at point a), which is also taught as “actio=reactio”. Specifically in dog medicine: If the dog romps and plays unrestrained and eventually falls violently, this has consequences. These can occur immediately, but also with a delay. It is precisely this that must be taken into account in the case of lameness of the shoulder or pelvic limb masses.

Point b) also comes into play here: a pathology can be structural or functional as well as absolute or relative. In hip joint dysplasia, for example, one speaks of an absolute form-function change. One speaks of relative pathologies in connection with pain in the ISG or a tilted pelvis in the high or low position.

The Arndt-Schulze rule can be explained very briefly. Every physiological movement trains and promotes the stability of the skeletal system as well as the musculature. On the other hand, overstraining movement or overtraining can have pathological consequences. Basically, it is a matter of moderation. This motto is especially important for growing puppies. 

The adaptability of the orthopaedic system can have positive effects. It can mean that the consequences of endurance, strength and speed training are transferred to the orthopaedic system at all times. On the other hand, however, there are also negative consequences.

A practical example is the hopping of smaller dogs. Normally this is associated with the dogs’ patella. However, if the habitual patella is not the cause, there is often no explanation. Generally, the bouncing is subsequently treated as a “tic” – which is absolutely not true. After all, the dog does not show any orthopaedic compulsions or comparable behaviour. Functional orthopaedics provides information here and attributes the problem to the biomechanics of the pelvis. Through romping, playing and uncoordinated movements, these biomechanics changed, while the growth plates are still open due to the dogs’ young age. These changes are subsequently reflected in the pelvic limb mass. Variations in statics result in variations in dynamics. Bouncing is a countermeasure designed to compensate for specific differences in frequency, step or stridelength. A suitable analogy is a differential in automobiles: This compensates for differences in wheel revolutions of the axle, for example in curves.

It is also worth mentioning at this point, in addition to functional orthopaedics, the role of functional neurology – also in relation to the bouncing of smaller dogs. More of this at another time.

In summary, it must be stated that functional orthopaedics and thus statics and dynamics must increasingly find their way into veterinary orthopaedics – with the inclusion of biomechanics and its rules. Functional diagnostics will provide the necessary basis for the treatment of non-structural disorders.

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You can also watch a video of Dante’s case:

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For more information on kinematic gait analysis and the correct build-up of puppies, take a look at our book “LUPOMOVE® PUPPY – THE INNOVATIVE DEVELOPMENT AND PROPHYLAXIS PROGRAMME FOR PUPPIES”.

Puppy, 9+ weeks old, supporting leg irregularity of the front-right limb since one week.

This real-life case is presented by the World Veterinary Organisation for Kinematically Controlled Orthopaedics, Neurology and Rehabilitation. It´s founder and chairman of the board is Dr. med. vet. Patrick Blättler Monnier. 

Initial problem 

The little puppy moved in with the family only a week ago. Shortly before that, she had come from a breeder in the north. She was intended as a bitch for breeding.

The day after, Sammy started to limp. The owner made an appointment for an orthopaedic puppy consultation with us.

The supporting leg irregularity in the front on the right is clearly visible. The toe axis there is turned outwards, there is toe widening. There is also swelling of the forefoot joint. The axis of the right shoulder phalanx seems to be turned obliquely inwards, moreover, two toes are almost dropped on one line. The narrow position of the shoulder limbs is striking, as is the drawn up back and the very steep position of the hindquarters.

Orthopaedic functional examination

In addition to the angulated toe axis and the swelling in the forefoot joint, it is particularly noticeable that the extension of the right shoulder is clearly reduced. The puppy reacted with defensiveness to the examination. The left shoulder could be moved normally. A verdigris fracture cannot be excluded. 

Therefore, an X-ray of the paw is taken and a kinematic examination is carried out as part of the LupoMove® Puppy programme.

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X-Ray diagnostics

Both x-rays of the paw showed no abnormalities. A fracture could be ruled out and no other structural changes were found.

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Kinematics 

It is remarkable that the stance phase of the front-left leg is 0.29 sec and of the front-right 0.14 sec. The difference is 100%. 

The difference in extension/flexion between right and left was also considerable, caused by the unloading posture of the right limb and the overloading of the left. 

The flat “average step” curve of the left limb compared to the values of the other limbs, also a result of overloading, is also striking.

After the diagnosis, the tarsal joint and the rotation axis were treated orthopaedically-manually and then measured kinematically. The direct difference can be seen in the light blue results before treatment compared to the dark blue results afterwards.

The kinematic mobility of the shoulder was partially restored, but not to the desired extent.

Therefore, the findings from the video analysis came into play and were included in the treatment.

In the second orthopaedic-manual treatment, the left shoulder limb was treated manually, as well as the hindquarters, i.e. the pelvis and both hind legs. Again, a kinematic control was carried out.

This time, the result was satisfactory.

The values of the third measurement are highlighted in purple. It shows that the stance phase at the front right has clearly increased. It increased from 0.14 sec to 0.26, on the left side it is only slightly higher at 0.28. The puppy’s gait is almost symmetrical again. The extension/flexion also normalised, the average ROM evened out. This can be seen well in the development of the “average step” curve of the left shoulder limb. 

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Conclusion

The acute appearing limp of the right shoulder limb was directly related to the left shoulder limb as well as the hindquarters. Both changes are semi-acute and could not have been distinguished without the kinematic examination. 

The limp, which could have been interpreted as a consequence of the malloading and overloading of the right shoulder limb, is only part of the problem. Not only the right shoulder limb, but also an orthopaedic malposition in the pelvis and the left shoulder limb affected the puppy’s gait.

Without the kinematic treatment and LupoGait® the examination would not have been so efficient; this is precisely the advantage of the orthopaedic-kinematically controlled puppy consultation.

What could have happened – The imprinting and conditioning of altered movement and pain processes in the puppy.

This patient came to us because of a supporting leg irregularity on the right front. Unfortunately, limping is not uncommon at the age of 10 weeks – but without the kinematic, differentiated diagnosis, the puppy’s altered gait pattern, especially the incorrect and overloaded posture, would have remained undetected.

The pain process and the altered movement can quickly be conditioned.

We would like to explain what the consequences would have been without the treatment.

Young dog diseases such as hip and elbow dysplasia, osteochondrosis or panostitis are epigenetic diseases. This means they result from genes that are encoded and expressed by environmental factors. This is where the altered movement of the puppy arose.

The triggering environmental factors that mobilise the genes are not uncommon.

All the more reason to present changes in gait directly to a professional, orthopaedic puppy consultation. 

Here we determine these external, triggering environmental factors in order to reduce and minimise them. In this way we strengthen or restore the health of the puppies.

However, there are other points that need to be taken into account in such gait changes. These are above all

• Conditioning of the altered gait with consequences for the orthopaedics
• Imprinting of the pain process and thus the behaviour.

The second point in particular is very important, because it must be assumed that the psycho-social part of the imprinting in the puppy can be strongly and potentially negatively influenced. Pain is a stressor in the puppy; in our opinion one of the most powerful, often severely affecting behaviour, but also general health.

From a behavioural perspective, pain can make it difficult to interact positively with other dogs and puppies, as well as with the owner or strangers. The main behavioural modalities are fear and aggression, but restraint to apathy and lassitude can also result. A puppy loses his open and fun way of exploring and investigating. He is less carefree. He can withdraw, seem reserved.

The stressor “pain” also has an influence on general health, resistance and the immune system. Stressed dogs, and those in pain, fall ill significantly faster. Parasitoses occur more often. 

A good example is Giardia: these bacteria are only facultatively pathogenic. Healthy puppies do not get sick from them. Stressed dogs often have prolonged diarrhoea and are more often resistant to therapy.

The last point we would like to make is about cognitive learning. A puppy in pain is generally slower to learn and less likely to pick up new activities. 

The puppy may also be generally withdrawn, or the dog may react with behaviour similar to stimulus overload. These psycho-social behaviours should always be investigated for pain as a cause. These behaviours strongly influence the imprinting, conditioning and learning curve of the puppy and young dog.

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Unwanted imprinting of movement

The altered gait pattern also has a strong influence on general movement, balancing and therefore also on statics and dynamics, in other words: the biology of orthopaedics.

Movement is first controlled and regulated in the periphery at the bone, joint and musculature. This is where we find the muscle and joint receptors. The information generated there is passed on centrally via the spinal cord and brain stem. This data is processed in the midbrain and cerebellum before it is transported to the cerebrum. Here, the movement is consciously coordinated and responded to. This information is then passed back to the periphery via the data highway and results in action. 

If we show such disturbances in the puppy in the 10th week of life without treating them purposefully, we lay the foundation for gait and movement abnormalities as well as pain. Neither vets nor dog owners are sufficiently aware of this fact. Only with movement diagnostics, in particular with LupoGait®, can these pathologies be detected.In order to counteract these pathologies, a professional, ortho-kinematic puppy consultation, such as within the framework of LupoMove® Puppy, is the only variant to treat disorders at an early stage and to prevent the consequential damages shown.

Watch Sammy’s case as a video:

A street dog fights hip dysplasia and pain

Frida’s journey begins as a street dog in Romania. As a young puppy, she was found in a rubbish bag. An international animal welfare organisation rescued her and brought her to Germany to her new family. Her new-found happiness lasted only a short time, however, because soon after her arrival she developed difficulties walking. Shortly after, she was no longer able to stand.

Her condition was diagnosed as bilateral hip dysplasia;

her condyle didn’t sit properly in the socket, often popping out. The cartilages rubbed against each other, which after a while destroys their natural shock-absorbing function and can lead to hip arthritis. All this caused Frida severe pain. A juvenile pubic symphysiodesis, a minimally invasive procedure on the growth plate, was to serve as a temporary solution. Frida was still too young to have an artificial hip joint.

Diagnosis and symphysiodesis

She was clearly informed that the further treatment would have to be divided into two steps. On the one hand, a short-term therapy, the symphysiodesis, to support Frida’s growth in the next months, to reduce her pain and to allow her a more normal socialisation.

In the medium term, two artificial hip joints will have to be inserted afterwards.

Furthermore, the owner was shown the exact costs and therapeutic consequences for the dog, as well as the duration and type of rehabilitation and regeneration. 

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Symphysiodesis – Frida’s first operation

Following the examinations, Frida immediately underwent a juvenile pubic symphysiodesis. This means that the pubic symphysis is surgically closed at an early stage. The technique itself is a relatively new procedure that was first successfully applied to guinea pigs and has also been successfully applied to canine patients for some years.

It is a prophylactic preventative surgery that is used primarily in growing dogs that show a great tendency to hip dysplasia and loose hips.

Laser surgery is used to cause a portion of the pubic symphysis to ossify. As a result, the lower, rear part no longer grows, while the upper part continues to form. This results in a better roofing of the femur bones than would have been the case without therapeutic measures – the stability of the joints is increased.

The symphysiodesis was successful, as was the post-operative check: Frida no longer walks with a severe limp.

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New hip joint from 3D printing

The reactive hip is the cause of Frida’s problems. Frida is now older – so an artificial hip joint for the left side was considered. The orthopaedic examination only confirmed this. However, no simple, cementless TEP (total endoprosthesis) was to be inserted. A 3D-printed TEP was created based on the bone and pelvic structure. 

For this purpose, Frida was first referred for a CT study. The data collected was processed and used to create a model corresponding to the hip prosthesis. The model was tested to see if it could be attached to the bone and work correctly from a biomechanical point of view. The tests were successful – a prosthesis for the left side was created, which was inserted before the end of autumn 2022. Physiotherapeutic measures following the operation should help her to walk evenly.

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Frida’s fight against hip problems continues: second operation necessary

Frida came through the operation well overall, and the control of the newly implanted hip was also successful. In January of this year, Frida again developed difficulties when walking: she again showed an irregular gait; in addition, she has pain in her right hip.
The left leg turns outwards and Frida is also sensitive at the back left, at the operated hip. The owner came for an orthopaedic re-evaluation. 

In movement, the left, operated side turns outwards, while the right side shows a clear slope leg lameness. The overall movement is uneven as well as irregular.

Reactive hip and uneven leg length:
The challenges of Frida’s orthopaedic examination

The examination of the left pelvic limb, hip and knee are unremarkable and not painful. The right side, however, is quite reactive:

X-ray

On both projections it is clearly visible that the right limb mass is not in the socket. The standing DAR technique should show this: Colour processed blue is a normal hip and red is Frida’s hip when there was no TEP.
This is the reason why the right limb is shorter than the left.

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Summary

As seen on the video and x-rays: 

Although Frida is doing better overall, the right side, which was not operated on, luxates upwards. A second operation for the defective hip joint is inevitable.
However, if the second operation adjusts the length of the limb and allows the head of the femur to move in the socket, Frida’s quality of life can be restored. Inflammation and pain can heal and healthy movement will be possible.
The second artificial hip joint for Frida will be custom-made for her, just like the one on the left side. Frida’s bones are too thin and the general situation too bad to use a standard prosthesis. The use of the second artificial hip joint will enable a stable position of the right femoral head in the socket. For Frida, after the healing process and exercise therapy, this is the prospect of a life fit for a dog – Full of healthy and painless exercise.

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Frida’s story continues!

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