Thursday, August 13, 2020

3396. VIDEO. Stefanie. Dislocated hip. Successful closed reduction using the Ehmer Sling for 2 weeks.

Stefanie to create video with the following script.
VIEW THIS EXCELLENT VIDEO MADE AS AN EXAMPLE.









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HOOK


On 27 July 2020, Mr Anderson WhatsApp to me two X-rays of Claris, her 14-year-old female spayed Maltese. 




Claris had become lame after a walk downstairs 2 days ago.   



Many Singaporeans walk the dog in the morning or evening. They must wear a face mask
during this period of Covid-19 pandemic 



I viewed the two X-rays. In the first X-ray, Claris has a left hip dislocation. 
See the arrow showing that the left hip had popped out of the hip joint. This is called a dorso-lateral dislocation of the hip.
  






The 2nd X-ray shows it is the left femoral head of the femur that has had popped out of the hip joint


The vet who took the X-rays had quoted her the cost of surgery.
The surgery is called femoral head osteotomy (FHO) or femoral head excision to create a false joint without pain. In this way, the dog can walk almost normally without limping or dragging the dislocated foot. However the cost quoted by Singapore vets varies from S$2,000 - $4,000. (Stefanie to draw an illustration of FHO).
"Did she fall down from a height or into a drain?" I WhatsApp. "Hip dislocations in dogs are usually due to traumatic from falls from a height while being carried or from falling into a drain."




















This is a BE KIND TO PETS Vet Educational Video.







Mrs Anderson lives in a 10th floor condo near downtown in Singapore.  Her domestic helper walks the dog in the park daily for the past years.

But something extra-ordinary happened to Claris during one walk 2 days ago.   




"What had happened? Did Claris fall while being carried?"  I WhatsApp her.


Mrs Anderson WhatsApp the reply:

"No Claris didn’t fall...
My helper took her downstairs for a pee and according to her as they were walking back to the lift Claris gave a loud yelp which even my son heard from our home on the 10 floor 😢 

She loves running around playing hide and seek and she also loves jumping up onto the sofa and our beds too..."


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Stefanie: The below is not a good sample of a WhatsApp phone text image, but gives you the idea.

Now we are more careful in now allowing her those jumps... she still wants to try though













Stefanie to illustrate an actual WhatsApp phone screen with text and emoji.










"Please bring the dog to Toa Payoh Vets for an examination," I WhatsApp Mrs Anderson.



AT TOA PAYOH VETS.




On 27 July 2020, Mr Anderson, a gardener who loves fashionable face mask, brought Claris for examination. This was the era of the Covid-19 pandemic outbreak. Every person must wear a face mask to protect himself or herself from infectious respiratory droplets and to keep a safe distance of at least 1 metre from each other. 







Dr Daniel Sing examined Claris.


"Claris is 14 years old. A very old dog," he said. "She is a high anaesthetic risk for hip surgery as her heart may stop beating during the long FHO surgery. May I suggest Claris' leg limb be immobilised close to her body using the Ehmer Sling for 14 days?" 


Mr Anderson was relieved that there was a non-surgical treatment. 

"Her dislocated hip joint will be manipulated back into the joint. She will be under a short 10 minutes of gas anaesthesia for this manipulation. The anaesthetic risk will be lower since the duration of anaesthesia is short."






"Also, this procedure will be much less expensive," Dr Daniel said. "However, it is not guaranteed to resolve the hip dislocation. Around 50% of the cases may be ineffective."

Mr Anderson signed a Consent Form for anaesthesia and surgery.


(Stefanie to do illustrations of how the sling is applied ---2 images are shown. See more images below. But not to copy images exactly---use Dr Daniel's dog patient).











more images --- see below.  Do internet research for other images and illustrate the "combined" images as yours.












EHMER SLING WAS performed. Claris went home on the same day.










Claris was confined to a small area for 2 weeks. In this way, she would not dislodge the bandage and dislocate her hip. Healing of the damaged joint would take place during the 2 weeks.  






2 weeks later, Mrs Anderson took off the Ehmer Sling and got an X-ray done by the vet clinic nearby.
The X-ray showed that Dr Daniel Sing had successfully reduced the hip dislocation using the Ehmer Sling.



27 July 2020.  Hip dislocation. The x-ray shows the left femoral head of the femur has popped out of the hip joint



Narrate "See the X-ray on 27 Jul shows the hip dislocated. The X-ray on 14 Aug shows no hip dislocation after 2 weeks of Ehmer Sling application.


As Mrs Anderson had no time to come to Toa Payoh Vets for a review and she had done another X-ray at the vet near her apartment,  I WhatsApp Mrs Anderson for 3 videos of Claris walking showing her left and right side, back and forth movements. She sent me the videos.



No lameness of the left hind leg as Claris walks up and down


  
No lameness of the left hind leg as Claris walks past the viewer



                      The left hind leg is able to bear weight as it touches the floor without pain.



CONCLUSION

The Ehmer Sling had successfully enable Claris to walk normally in this case. 
"You will need to confine Claris to a small area for another 4 weeks," I WhatsApp Mrs Anderson. "Any strenuous activity will cause the left hip joint to dislocate."

Mrs Anderson was very careful.
"I have my home-made sling for Claris," she WhatsApp me her sling image.





What caused this hip dislocation? 

I suspect that the active old dog had sprinted to go home after the walk. She slipped on her left side, dislocating the left hip. 

Her screams were so loud that they could be heard on the 10th floor.

There was a possibility of a fall when carried by the domestic help, but only Claris will know. And dogs can't talk, just like "dead men tell no tales!"



CREDITS














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THE FOLLOWING IS NOT FOR STEFANIE. These are research notes and drafts for the script for the video production which must have 3 emotional elements: 

ATTRACTION (HOOK)
TENSION
SATISFACTION


-------------------------------------------------------- Dog is  very old at 14 years.
Had two bladder operations at Toa Payoh Vets to remove bladder filled with stones some years ago.
Femoral head excision was not advised today as the dog is at high anaesthetic risk.
Ehmer sling was done by Dr Daniel on 27 Jul 2020

14 Aug 2020
X-ray. No left hip dislocation after 2 weeks on Ehmer sling and confinement.











 The flank, abdomen, and distal limb are examined daily for sores, inflammation, and edema. If pressure sores or wounds develop, modify the sling or remove it immediately. Monitor the abdominal band in male dogs for urine contamination and irritation of the underlying skin.




Maintain the Ehmer sling for a minimum of 7 to 10 days (maximum, 14 days) and remove only after coxofemoral reduction is confirmed by repeated orthogonal radiographs.


The owner removed the sling after 2 weeks. She used her own "sling".



On 12 Aug 2020, I phoned her to take 3 videos of the dog walking and trotting. She had a family emergency and so would not be coming to Toa Payoh Vets for an X-ray to confirm that the left hip joint is reduced.

The dog was not limping. She could bear some weight on her left hind limb. But she still need another 4 weeks of confinement



Dogs should be kept under cage confinement for the period of Ehmer sling application and for a minimum of 4 weeks after removal. Voluntary use of the limb by the patient should begin within 1 or 2 days as stiffness decreases, then gradually increase on a daily basis following removal of the sling. Gentle physical rehabilitation consisting of daily hip range-of-motion exercises can be initiated 4 to 6 weeks after sling removal. Controlled leash walks or underwater treadmill therapy may also be beneficial to restore normal use and function.


CONCLUSION.
The vet needs to apply his canine anatomy knowledge to replace the dislocated femoral head into the hip join. The technique in layman's terms as follows:

Under the isoflurane gas anaesthesia, the dislocated left limb was pulled backwards. The limb was rotated outwards. The vet then placed his hand on the femoral head and guided it inside the hip joint.
Then he applied the Ehmer Sling. He must ensure that the femoral head was still inside the joint by the end of application. He used his fingers to check its position.

There was no X-ray done to lower medical costs. An X-ray done 2 weeks later, after the Ehmer sling was removed (maximium duration of sling is 2 weeks). It showed no left hip dislocation. The dog was walking normally with no "lameness."

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VIDEOS
The Ehmer Sling is an alternative treatment to femoral head osteotomy operation as the dog is 15 years old and may die under anaesthesia and surgery. The dog had a left dislocated hip. She was cast in an Ehmer Sling for 2 weeks. After 2 weeks, her bandage was removed. This video shows the dog's left hind leg bearing weight. There is a chance of lameness of the left hind limb returning---the dog must not be moving a lot for the next 4 weeks. Updates and images at: https://2010vets.blogspot.com/2020/08/3396-dislocated-hip-conservative.html



This dog had 2 bladder operations to remove the bladder stones. Now, again, full of bladder stones as she does not follow up on check ups. She fed either Royal Canin or Hills' Prescription diet for struvites but the stones recurred.  I asked her to send me the stones for chemical analysis as soon as possible.More info and images will be posted here after stone analysis.


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REFERENCE:
https://www.cliniciansbrief.com/article/ehmer-sling-canine-orthopedic-surgery


The Ehmer Sling in Canine Orthopedic Surgery


James K. Roush, DVM, MS, DACVS, Kansas State University
Walter C. Renberg, DVM, MS, DACVS, Kansas State University





Case Selection & Management
Proper case selection for Ehmer or Figure-8 sling use is critical to a successful outcome. The Ehmer sling was designed to maintain the head of the femur in the acetabulum after closed reduction of a craniodorsal coxofemoral luxation, to prevent weight bearing, and to limit hip motion during healing. It should not be used in dogs with ventral coxofemoral luxation, which should be treated with hobbles to prevent limb abduction.
Related Article: Closed Hip Reduction

Best results are obtained in dogs with acute luxations <24 amenable="" and="" applied="" bandage="" be="" care.="" confinement="" continual="" dogs="" duration="" ehmer="" hours="" in="" luxations="" not="" of="" should="" slings="" temperaments="" to="" with="">1 week duration, luxations associated with fractures of the adjacent acetabulum, poor hip comformation (hip dysplasia), or dogs that are unable to ambulate on the contralateral limb. Ehmer slings can be difficult to apply in obese or chondrodystrophic dogs. Ehmer slings may be useful after internal fixation of acetabular or femoral head and neck fractures to temporarily prevent weight bearing.
Success of Ehmer sling application is enhanced by appropriate technique during reduction. Hip radiographs must be taken and evaluated before reduction to identify dogs with acetabular fractures or ventral luxations and are not candidates for Ehmer sling application.
Reduction should be attempted in anesthetized dogs with craniodorsal hip luxations. Reductions are best accomplished by a manipulative sequence composed of external rotation of the affected limb while simultaneously providing distal traction to the limb and countertraction to the inguinal area. While traction is maintained, the limb should be internally rotated and simultaneous distal pressure to the greater trochanter applied to facilitate reduction. After reduction and before sling application, the coxofemoral joint should be put through multiple complete range-of-motion exercises while medial pressure is applied to the greater trochanter to clear the acetabulum. Orthogonal radiographs of the affected hip should be performed and evaluated after Ehmer application to confirm reduction of the coxofemoral joint.
Aftercare
Daily examination of the hip and Ehmer sling determines effectiveness of the sling for maintenance of internal rotation, flexion of the coxofemoral joint, and limb abduction. Loss of internal rotation, hip flexion, or abduction are indications for immediate sling replacement. The position of the greater trochanter in ventral relationship to a line that connects the ilial wing and ischiatic tuberosity should be palpated daily to confirm continued hip reduction, and the joint should be palpated through a shortened range of motion to confirm continued smooth function. The flank, abdomen, and distal limb are examined daily for sores, inflammation, and edema. If pressure sores or wounds develop, modify the sling or remove it immediately. Monitor the abdominal band in male dogs for urine contamination and irritation of the underlying skin.

Maintain the Ehmer sling for a minimum of 7 to 10 days (maximum, 14 days) and remove only after coxofemoral reduction is confirmed by repeated orthogonal radiographs. Reluxation rates of 15% to 71% have been reported after closed reduction1; however, the specific reluxation rate after closed reduction and Ehmer sling application has not been reported. Owner evaluation scores are better after closed reduction than after femoral head and neck excision, extracapsular suture stabilization, and De Vita pinning.2 Direct comparisons of recurrence rates or owner satisfaction between closed reduction, Ehmer sling, and more recently developed techniques (eg, toggle pin, rod repair) have not yet been reported.
Related Article: Effective Casting Techniques

Dogs should be kept under cage confinement for the period of Ehmer sling application and for a minimum of 4 weeks after removal. Voluntary use of the limb by the patient should begin within 1 or 2 days as stiffness decreases, then gradually increase on a daily basis following removal of the sling. Gentle physical rehabilitation consisting of daily hip range-of-motion exercises can be initiated 4 to 6 weeks after sling removal. Controlled leash walks or underwater treadmill therapy may also be beneficial to restore normal use and function.
What You Will Need
  • 1 to 2 rolls of 2-inch wide porous, nonelastic adhesive tape.

See article for details of how to apply the Ehmer Sling application. Images without explanation are shown here.











WALTER C. RENBERG, DVM, MS, DACVS, is professor and section head of small animal surgery at Kansas State University. Dr. Renberg, who has more than 20 years of experience as orthopedic surgeon, is co-author of the textbook Small Animal Bandaging, Casting, and Splinting Techniques.

JAMES K. ROUSH, DVM, MS, DACVS, is Doughman professor of surgery at Kansas State University. He has more than 30 years of experience in veterinary orthopedic and neurologic surgery, small animal orthopedic research, and surgical training of residents and students. Dr. Roush earned his DVM from Purdue University and his MS from University of Wisconsin–Madison.






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