Veterinary Surgery

Veterinary Surgery
30:201-217, 2001
Effects of Pubic Symphysiodesis in Dysplastic Puppies
R. TASS DUELAND, DVM, MS, Diplomate ACVS, WILLIAM M. ADAMS, DVM, Diplomate ACVR,
JAMES P. FIALKOWSKI, BS, ALISON J. PATRICELLI, DVM, KYLE G. MATHEWS, DVM, MS, Diplomate ACVS,
and ERIK V. NORDHEIM, PhD
Objective—To determine the long-term effects of juvenile pubic symphysiodesis (JPS) in dysplastic
puppies.
Study Design—Prospective, randomized, clinical trial.
Animals—Seven dysplastic Chesapeake Bay retrievers and 2 beagle-crosses (BX1 and 2).
Methods—Five puppies had JPS performed with electrocauterization at 12, 16, 20, 22, and 24 weeks
of age, respectively. Two puppies served as controls. BX1 and BX2 were used to obtain biopsies of
the symphysis. Hips were evaluated for: pelvic development (transverse computerized tomography
for acetabular angle [AA] and dorsal acetabular rim angle [DARA]); laxity [hip extended and stress
radiography [distraction index (DI)]); Ortolani maneuver with reduction angles; acetabular coverage
(Norberg angles); and function (coxofemoral range of motion, hip pain, and gait analysis by
force-plate technique at 44 and 137 weeks of age).
Results—The pubis fused prematurely in every puppy that was operated on with the JPS technique.
Greater acetabular responses were related to younger ages at surgery. The final mean AA in dogs that
had JPS was 25° greater than preoperative values; 40% increased over control. The DARA final mean
was 10°, 52% less than preoperative values and 46% less than control. The final mean DI in dogs
having JPS was 0.28, 47% improved over preoperative values and 58% better than control. Mean
pelvic dimensions in dogs that had JPS were 18% less than control. Gait analyses were normal for
all dogs at 137 weeks. No urinary or bowel complications occurred.
Conclusions—Significant ventrolateral acetabular rotation, increased hip coverage, diminished hip
laxity, normal pain-free gait, and insignificantly reduced pelvic size occurred after JPS.
Clinical Significance—Dysplastic hips in young dogs were significantly improved by JPS.
© Copyright 2001 by The American College of Veterinary Surgeons
C ANINE HIP DYSPLASIA (CHD) is often painful

for the affected dog and financially and emotion-
ally taxing for dog owners and breeders. Treatments
treatment resulting in beneficial hip remodeling would
be advantageous.
Imaging techniques10-16 and palpation14,17 can be
for animals that are clinically affected by CHD include used for early recognition of hip laxity, a predictor of
medical care1,2 (anti-inflammatory drugs, rest, re- secondary degenerative joint disease (DJD).11,13,14,16
stricted exercise, weight reduction) and surgical op- With improved ability to identify dogs at risk for DJD,
tions (excision arthroplasty, triple pelvic osteotomy simple, early surgical intervention has become more
[TPO], and total hip arthroplasty).3-9 Surgical options feasible.
can be expensive and may result in considerable Juvenile pubic symphysiodesis (JPS) in immature
postoperative morbidity. A less-extensive surgical guinea pigs,18 in normal dogs,19 and in CHD-suscep-
From the Department of Surgical Sciences, School of Veterinary Medicine, and the Department of Statistics, University of
Wisconsin-Madison, Madison, WI; and the College of Veterinary Medicine, North Carolina State University, Raleigh, NC.
Presented at the American College of Veterinary Surgeons Symposium, Chicago, IL, 1998, and the 27th Annual Conference of the
Veterinary Orthopedic Society, Val d’Isere, France, 2000.
Supported by the Companion Animal Fund, School of Veterinary Medicine, University of Wisconsin-Madison, an anonymous
Chesapeake Bay retriever breeder, and the Morris Animal Foundation, Englewood, CO.
Address reprint requests to Dr. R.T. Dueland, School of Veterinary Medicine, 2015 Linden Dr., Madison WI 53706.
© Copyright 2001 by The American College of Veterinary Surgeons
0161-3499/01/3003-0002$35.00/0
doi:10.1053/jvet.2001.23350
201
1532950x, 2001, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1053/jvet.2001.23350 by National Health And Medical Research Council, Wiley Online Library on [02/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
202 PUBIC SYMPHYSIODESIS IN DYSPLASTIC PUPPIES
tible dogs20 resulted in bilateral acetabular rota- (ROM) and pain response (hip extension) were performed.
tion18,19 and pubic growth arrest.18-20 The objectives After sedation and anesthesia, the following tests were
of the current study were to determine: if dogs with conducted: hip ROM was repeated, Ortolani maneuver with
CHD would respond similarly as the guinea pig to JPS reduction angle measurement, distraction radiographs
induced by electrocautery techniques, and whether the (PennHIP), Orthopedic Foundation for Animals (OFA)
radiography, and pelvic computed tomography (CT). Pup-
results were sustainable over a longer term. The
pies were then positioned in dorsal recumbency and pre-
hypotheses were that JPS would result in: significantly
pared for aseptic surgery. A 2- to 3-cm ventral midline skin
improved acetabular rotation, improved coxofemoral incision was made over the pubic tubercle and cranial pelvic
coverage, decreased hip laxity, a benign decrease in symphysis. The skin, subcutaneous soft tissue, rectus ab-
pelvic inlet area, and normal gait. dominus, adductor, and aponeurosis of the gracilis muscle
fascia were incised and minimally reflected to expose the
MATERIALS AND METHODS pubic portion (cranial half) of the pelvic symphysis.21
Electrocauterization of the pubic symphysis in CR1-3 and
Nine dogs were used: 7 Chesapeake Bay Retrievers CR7 puppies was performed utilizing a standard cautery
(CR1-7) (4 males and 3 females) and 2 female Beagle-cross unit (Birtcher Medical Systems, Irvine, CA) with a unipolar
dogs (BX1, BX2). All CR puppies were dysplastic. Six CR electrode (spatula, 3 mm ⫻ 27 mm; Consolidated Medical
littermates (CR1-6) were prospectively and randomly as- Co, Inc, Utica, NY). With the contact electrode at a 30-W
signed to surgical treatment or untreated control groups. The coagulation setting and with multiple 5- to 10-second spray
study was approved by the University of Wisconsin Insti- contacts, the full thickness of the pubic symphysis was
tutional Care and Use Committee and was conducted within vaporized and ablated (subjective assessment) through to
the US National Institutes of Health Guide for the Care and the inner periosteal layer. The depth of cauterization in CR1
Use of Laboratory Animals and the Animal Welfare Acts was determined after release of the insertion of the rectus
(US PL 89-544;91-279). abdominus muscle on the pelvic brim, which enabled the
To thoroughly investigate the JPS technique, 19 various surgeons’ finger to be inserted into the pelvic canal. Palpa-
evaluations were included (see below). Except for pain tion enabled the surgeon to deflect the rectum and urethra
evaluation, procedures involving manipulation or surgery laterally and to detect and prevent the electrode from
were performed under general inhalant anesthesia. Testing perforating the symphysis. In subsequent procedures, the
was initiated at 8 weeks of age for CR1-6 and repeated at rectus muscle release was deemed unnecessary and was
monthly intervals (for 4 months), with 2 long-term fol- omitted. Instead, during cauterization, by visual observation
low-up evaluations at 44 and 137 weeks of age. For the combined with probing of the symphyseal surface with a
seventh dog (CR7), testing and surgery was initiated at 22 hemostat or with the cautery electrode (current off), pene-
weeks of age, because it was returned to the breeder due to tration by the electrode through the inner (dorsal) pubic
clinical signs of hip dysplasia. For CR7, the final follow-up periosteum was avoided. To more precisely evaluate the
tests were at 44 and 68 weeks of age. The 68-week results zone of thermal damage caused by electrocauterization, the
were included in the mean JPS 137-week results. Dogs BX1 2 BX dogs were cauterized with a needle electrode (22.5-
and BX2 underwent JPS, and biopsy samples were obtained gage [0.7-mm] diameter ⫻ 32-mm length; Consolidated
for histopathological evaluation (see Histology); no other Medical Co, Inc) technique, and biopsy samples were
tests were performed on those 2 dogs. obtained at a later time. With the needle technique, pubic
symphyseal depth was estimated from CT measurements,
and the electrode was inserted to this depth. Cauterization
Surgery
was applied at 2-mm intervals along the length of the pubic
Five CR dogs had JPS performed at: 12 weeks (CR1), 16 symphysis. BX1 received a dose of 40 W for 10 seconds at
weeks (CR2), 20 weeks (CR3), 22 weeks (CR7), and 24 6 sites, and BX2 received 40 W for 20 seconds at 6 sites.
weeks of age (CR4); CR5 and CR6 were evaluated as Thirteen days later, using general anesthesia and aseptic
controls (no surgery). General anesthesia was achieved technique, a sagittal saw (3M Corp, St. Paul, MN) was used
using 0.05 mg/kg acepromazine intramuscularly (IM) (Fort to obtain an 8 ⫻ 16-mm en bloc central pubic-ischial
Dodge Animal Health, Ft. Dodge, IA) and 0.1 mg/kg symphyseal biopsy specimen from each BX dog (see
butorphanol IM sedation (Fort Dodge Animal Health), Histology).
followed at 30 minutes by 15 mg/kg thiopental sodium All surgical and biopsy wounds including the fascia and
(Abbott Labs, North Chicago, IL) intravenously (IV) to subcutaneous tissue were sutured with 3-0 polyglyconate
effect, and maintenance of anesthesia with isoflurane and (Davis & Geck, Wayne, NJ) and the skin apposed with
oxygen through a semiclosed circle system. Cefazolin (22 either staples (3M Health Care, St. Paul, MN) or subcutic-
mg/kg IV) was administered at the induction of anesthesia. ular 3-0 polyglactin 910 (Ethicon Inc, Somerville, NJ).
Before sedation and anesthesia hip range of motion Butorphanol tartrate (0.4 mg/kg IM every 4 hours, as
DUELAND ET AL 203
needed) was given postoperatively for discomfort. Most CR (cm2), acetabular area (mm2), and pubic symphyseal height
dogs were comfortable after surgery and discharged the and width (mm).
same day of surgery. Transverse CT scans of the pelvis of each dog were taken
The needle electrode JPS technique was also performed, using 1.5- to 3-mm slice widths. Scans were performed with
as previously described, in dog CR4 at 24 weeks of age. the dogs in sternal recumbency with the rear legs flexed and
CR4 had 30 W delivered for 10 seconds to a depth of 6 mm abducted. For CT data collection, only central acetabular
to each of ten 2-mm interval pubic sites. images were used. Image inclusion criteria were: (1) the
presence of bilateral mid-acetabular notches; (2) large,
well-rounded femoral-head images; and (3) a symmetrical,
Test Procedures and Data Obtained central pubic symphysis and rami (Figs 1-3). Using CT
1. Hip ROM subjective evaluation (unmeasured) of images, lines were drawn from the dorsolateral acetabular
flexion, extension, internal and external rotation, abduction, margin through the ventrolateral acetabular margin of each
and adduction maneuvers were scored as normal or abnor- hip and extended until they intersected. The angle formed
mal. was measured and termed the acetabular angle (AA) (Figs 1
2. Pain response— graded as ⫹/⫺ at full hip extension. and 3). To determine each hip’s individual acetabular angle
3. Ortolani maneuver17 graded as ⫹/⫺ for hip sublux- (IAA), a vertical line was drawn from mid-vertebra through
ation. The maneuver was performed with the dog in lateral the mid-pubic symphysis, intersecting the previously drawn
recumbency. acetabular lines (not illustrated).
4. Hip reduction angle (HRA)22—the angle at which the Pelvic width was arbitrarily determined as the maximal
subluxated hip reduced, as measured with a goniometer distance between the inner ilial borders. Pelvic height was
(Synthes, Inc, Paoli, PA) during the Ortolani maneuver. defined as the length of a perpendicular line drawn from the
5. Dynamic ultrasonography (DUS)13— hip laxity ventral vertebral border to the pubic symphysis. Pelvic inlet
(mean distraction distance, mm) measured from 3 hard- area and acetabular area were calculated from oval-shaped
copy images obtained at 8 weeks of age in dogs CR1-6. best-fit tracings of mid-acetabular CT images calculated
6. Distraction index (DI-PennHip method).10,11 using NIH software (Image version 1.61, NIH, Bethesda,
7. DJD— determined by a hip-extended view; Orthope-
dic Foundation for Animals (OFA).14,23,24 DJD was scored
blinded (by W.M.A.) as: 0, a completely normal hip with no
radiographic pathology; 1⫹, if only a femoral-neck enthe-
sophyte (Morgan line)24 was present without any femoral
head malalignment; 2⫹, indicative of Morgan line(s) plus
femoral-head malalignment; or 3⫹, indicative of femoral-
neck osteophyte(s), femoral-head malalignment, and ace-
tabular osteophytes or acetabular remodeling.
8. Pubic symphyseal length (determined from the hip-
extended radiographic view) for surgical purposes (length
of the cranial half of the pelvic symphysis equaled radio-
graphic length minus 10% magnification factor).
Norberg angles.25 Mean values were measured in con-
trol(s) at 7 time intervals from 8 weeks to 137 weeks.
Norberg coxofemoral coverage values were obtained from
dogs that had JPS preoperatively, monthly until 6 months of
age, and at 44 and 137 weeks of age.
9. PennHIP compression (NorCOMP).10
10. PennHIP distraction (NorDIS).10
11. OFA view (NorOFA). CT (Siemens Medical Sys-
tems, Wawautosa, WI; and GE, Milwaukee, WI) was
initiated at 8 weeks of age for controls and performed on
Fig 1. Preoperative transverse mid-acetabular CT image of a
each dog that had JPS immediately before surgery. CT
12-week-old male Chesapeake retriever taken with the dog in
images and hard copies with a centimeter scale were used to sternal (prone) recumbency with the limbs flexed. The lines
determine measurements 12 through 15. drawn from the dorso-lateral and ventro-lateral margins of the
12. Acetabular angle (AA) (description below). acetabula intersect to form the AA. The AA measured 45°. The
13. Urethral-pubic distance (UPD) (mm). arrowhead identifies the urethra with the rectum dorsal to it.
14. Dorsal acetabular rim angle (DARA).15,22 Note the open (radiolucent) cartilaginous pubic symphysis
15. Pelvic dimensions: width, height, pelvic canal area centrally and the peripheral radiolucent ilio-pubic junctures.
witt, MI)—Evaluation of all CR dogs included force-plate

measurement of peak vertical force and vertical impulse
normalized to body weight.26-28 The determination of the
weight-distribution percentage between thoracic and pelvic
limbs27 was performed at 44 and 137 weeks of age. The
dogs were fast-walked/trotted at a speed between 1.7 to 2.5
m/s with a minimum of 3 valid data points for each limb
used for calculations of mean peak vertical force and
impulse.27 Due to dog CR5’s temperament, at 44 weeks,
only 1 valid gait recording could be made. Light sensors
were used to record and discriminate valid trials in regard to
speed and acceleration.
18. Morbidity and mortality—All CR and BX dogs were
observed closely for any problem with urinary, bowel, and
hip function throughout the duration of the study. One
control dog died at 16 weeks. All dogs were privately
owned after the surgery and were closely observed.
Fig 2. This transverse CT image is from the same dog and 19. Other considerations—(1) dog weights, (2) operative
age as Fig 1. Illustrated are the lines drawn to identify the time, and (3) statistical analyses. Various statistical methods
DARA. The central vertical line is intersected by lines that and tests were employed to analyze the data (see Appendix
form the DARA. The more dorsal DARA line overlies the for itemization); significance was defined at P ⱕ .05.
plane of the dorsal acetabular articular surface; the ventral
DARA line is perpendicular to the vertical central line. The
right DARA angle illustrated is 32°. The distance between the RESULTS
dotted lines delineates the urethral-pubic distance (UPD),
which is measured in millimeters. *The os penis. Dynamic ultrasonography, hip palpations, and radi-
ography indicated early hip laxity in all 7 CR dogs
before surgery (see below).
MD). The acetabular area’s lateral border was the AA line
between dorsal and ventral acetabular borders; the other
Surgical Observations
borders were the bony acetabular margins.
The pubic symphysis on transverse CT image has a With a contact electrocautery technique, a cavita-
trapezoidal shape with the dorsal width narrower than the tional defect was created in the pubic symphysis of
ventral width. Each dog that underwent JPS was measured
preoperatively and controls measured at 16 weeks of age,
with the dorsal and ventral values combined to determine
the mean pubic symphyseal width. Each hip’s DARA
angle22 was also obtained from acetabular images by
drawing 3 lines: 1, the central pelvic height line; 2, a line
superimposed on the plane of each dorsal acetabular sub-
chondral articular surface (this line intersected the vertical
line); and 3, a line drawn at a right angle to line 1 at the
intersection of lines 1 and 2 (Fig 2).
16. Histology—JPS was performed on BX1 and BX2 at
20 weeks of age; biopsies were obtained 13 days later. Fresh
1-mm-thick central sagittal pubic sections were cut, stained
immediately with calcein green and ethidium homodimer
red (C&E) (Molecular Probes, Inc, Eugene, OR), and
examined within 4 hours using confocal laser microscopy
(MRC-600, LSCM, Bio-Rad, Hempstead/Cambridge, UK).
Fig 3. This transverse CT image is of the same dog as in Figs.
Additional tissue was fixed in 10% neutral-buffered forma-
1 and 2, but taken at 137 weeks of age. The dog received JPS
lin, decalcified with citrate-buffered formic acid, embedded surgery at 12 weeks of age. The AA measures 94°. Note the
in paraffin, sectioned to 5 ␮m, stained with toluidine blue solid bony pubic symphysiodesis and the almost-horizontal
and hematoxylin-eosin, and examined by light microscopy dorsal acetabular rim angles (not marked). Compare these
for thermal damage. DARA angles (each approximately 6°) to the preoperative
17. Force-plate gait analysis (Sharon Software Inc, De- DARA image in Fig 2.
DUELAND ET AL 205
operated dogs that was approximately 3 to 5 mm wide, Four control hips were Ortolani-positive at 16 weeks,
4 to 6 mm deep, and 1.0 to 2.5 cm in length (the larger and both hips remained positive at 44 and 137 weeks
defects were in older and bigger dogs). This cavity in the remaining control (Table 1). There was signif-
resulted from thermal ablation and vaporization of icant Ortolani improvement in dogs that had JPS
symphyseal tissue. With the needle electrode tech- comparing preoperative values to 44- and 137-week
nique, the symphyseal tissue around the needle follow-up values (P ⫽ .02 and P ⫽ .01, respectively;
showed initial blanching (desiccation) and then dark- Table 1, Appendix).
ened with continued electrode contact time (protein
denaturation/coagulation). The resultant needle holes Hip Reduction Angle
in the symphysis were slightly larger after cauteriza-
tion than the diameter of the electrode (see Histology The 10 Ortolani-positive JPS hips had a mean hip
results). reduction angle (HRA) of 32° on the day of surgery
Cauterization at 12, 16, 20, and 22 weeks of age, (range, 20°-45°). The mean HRA at the 44- and
respectively, caused cessation of growth of the pubic 137-week follow-ups was 6° (P ⫽ .01; range 0°-40°)
portion of the pelvic symphysis, as seen by bony and 3° (P ⫽ .003; range 0°-15°), which was an 81%
fusion (symphysiodesis) on follow-up CT and radio- and 91% decrease, respectively, from preoperative
graphic examinations. Because the dogs were not mean values. The mean was calculated by including
imaged weekly after surgery, the exact length of time the zero postoperative values from negative Ortolani
to bony fusion was not determined. Dog CR7 had hips. Dog CR4 (JPS at 24 weeks of age) remained
fused 14 weeks after surgery. Fusion in dogs CR1, 2, Ortolani-positive bilaterally, with a mean HRA of 15°
and 3 was observed at the 44-week recheck. In dog at 137 weeks, a decrease of 25° from the day of
CR4, cauterized by needle electrode (30 W for 10- surgery (P ⫽ .14).
second durations) at 24 weeks of age, the bony bridge The HRA improved in each dog that had JPS.
did not encompass the full depth of the symphysis at Compared with preoperative reduction angle values
44 weeks of age. However, by 137 weeks, complete (mean, 32° ⫾ 11°; range, 15°-45°; 10 hips), the
bridging had occurred. 44-week JPS mean values were 6.1° ⫾ 13.4° (0°-40°;
Hip ROM Table 1. Ortolani Results
Initial ROM and long-term follow-up ROM were PreOp/

Group Dog ID Hip 8 wk Age (wk) 44 wk 137 wk*
normal for all dogs (treated and control).
Control CR5 L ⫺ ⫹ 16 ⫹ ⫹
CR5 R ⫹ ⫹ 16 ⫹ ⫹
Pain Response
CR6 L ⫺ ⫹ 16 na na
With the exception of CR7 (at 22 weeks of age), CR6 R ⫹ ⫹ 16 na na
JPS CR1 L ⫺ ⫹ 12 ⫺ ⫺
there was no subjective evidence of hip pain in dogs CR1 R ⫹ ⫹ 12 ⫺ ⫺
that had JPS, either preoperatively or on follow-up CR2 L ⫺ ⫹ 16 ⫺ ⫺
examinations. The surviving control dog, CR5, had CR2 R ⫹ ⫹ 16 ⫺ ⫺
CR3 L ⫺ ⫹ 20 ⫹ ⫺
subjective evidence of pain bilaterally on passive hip CR3 R ⫹ ⫹ 20 ⫺ ⫺
extension at 44 and 137 weeks of age. CR4 L ⫹ ⫹ 24 ⫹ ⫹
CR4 R ⫹ ⫹ 24 ⫹ ⫹
CR7 L na ⫹ 22 ⫺ ⫺
Ortolani Maneuver CR7 R na ⫹ 22 ⫺ ⫺
At 8 weeks of age, 7 of the 12 hips from the NOTE. All littermates (CR1-6) had at least 1 hip Ortolani-positive (⫹)
Chesapeake litter were Ortolani-positive (at least 1 hip at 8 weeks of age. The JPS-surgery dogs were bilaterally Ortolani-positive
in each of 6 dogs). Preoperatively, 10 of 10 hips of at their respective preoperative ages, and both control dogs were bilaterally
positive at 16 weeks of age. Except for the oldest dog at surgery (24
dogs that underwent JPS had positive Ortolani signs. weeks), all surgery dogs were Ortolani-negative at 137 weeks’ postoper-
Seven of these 10 positive hips converted to Ortolani- atively.
negative by week 44, and 8 of 10 positive hips were Abbreviations: JPS, juvenile pubic symphysiodesis surgery group; CR,
negative at the final follow-up exam (137 weeks of Chesapeake retriever; PreOp, preoperative; ID, identification; na, not
available; ⫹, positive; ⫺, negative.
age) (P ⫽ .01). The 2 hips remaining positive were in * Sixty-eight-week data of CR7 dog included in JPS mean 137-week
the oldest dog at the time of surgery (24 weeks of age). values.
10 hips; P ⬍ .001), and the 137-week value was 3.6°

⫾ 6.3° (0°-15°; 10 hips; P ⬍ .001).
The averaged reduction angle of control (CR5) hips
did not change significantly from 12 weeks (55°) to
137 weeks (31°; P ⫽ .27).
DUS
There was no significant difference (P ⫽ .32)
between the DUS mean distraction distance (laxity)
for dogs that had JPS (2.54 ⫾ 1.3 mm) versus controls
(3.30 ⫾ 0.8 mm) at 8 weeks of age. A greater than
2-mm distraction distance was interpreted as hyper-
laxity.13 Fig 4. These DI results illustrate the averaged values of both
hips plotted from 12 weeks to 137 weeks of age. At 44 weeks,
Radiography there had been a marked decrease in DI in the JPS dogs. Dog
CR4’s laxity (surgery at 24 weeks) remained static after 44
Stressed Hip Views. At age 8 and 16 weeks, there weeks, whereas 3 of 4 of the other surgery dogs continued to
was no difference between mean DI of preoperative improve (decrease) in DI from 44 to 137 weeks of age. Dog
CR7’s last evaluation was at 68 weeks (16 months of age).
JPS hips vsersus control hips (P ⫽ .52 and P ⫽ .30,
Control CR6’s 12- and 16-week data (mean DI, 0.52; Table 2)
respectively; Table 2). At the 44-week and 137-week was not plotted, because long-term data were not available.
follow-ups, the mean DI value of dogs that had JPS
was 0.38 and 0.28, respectively. At both follow-up
ages, mean JPS values were significantly less than the mean DI was significantly less than control at 44
mean preoperative DI values (P ⬍ .01 and P ⬍ .001, weeks (P ⫽ .003), as was JPS versus control at 137
respectively; Fig 4, Table 2). The R2 values were .73 weeks (P ⫽ .001; Table 2). The control DI decreased
and .35, respectively, when mean hip DI values were from 0.78 to 0.66 in the same time frame (from 44
regressed versus age at surgery.The 44-week JPS weeks to 137 weeks).
Hip-Extended View: DJD Evaluation. Of 10
Table 2. Distraction Index preoperative JPS hips (5 dogs; mean, 19 weeks), 7 hips
were scored as 1⫹ DJD, and 3 hips were scored as 2⫹.
PreOp/
In 2 control dogs at 16 weeks, 1 dog (CR5) had two
1⫹ hips, and the other control had two 2⫹ hips.
Control CR5 L 0.41 0.79 16 0.72 0.69 At 44 weeks, 2 JPS hips originally scored as 2⫹
CR5 R 0.55 0.71 16 0.83 0.62 were judged as 1⫹. The original seven 1⫹ JPS hips
CR6 L 0.45 0.46 16 na na
CR6 R 0.70 0.43 16 na na remained 1⫹. The control dog (CR5) remained 1⫹ in
JPS CR1 L 0.50 0.50 12 0.08 0.27 both hips.
CR1 R 0.59 0.59 12 0.30 0.20 At 137 weeks, the DJD score of hips from dogs that
CR2 L 0.55 0.41 16 0.37 0.23
CR2 R 0.65 0.46 16 0.35 0.23
had JPS remained the same as at 44 weeks (nine 1⫹,
CR3 L 0.43 0.56 20 0.39 0.18 one 2⫹). The JPS dog with a 2⫹ hip was the dog
CR3 R 0.41 0.53 20 0.59 0.25 operated on at 24 weeks of age. The control dog (CR5)
CR4 L 0.52 0.56 24 0.47 0.47
CR4 R 0.41 0.62 24 0.47 0.53
had progressed to 2⫹ DJD in both hips.
CR7 L na 0.47 22 0.39 0.23†
CR7 R na 0.59 22 0.38 0.25† Norberg Angles
Control Mean 0.53 0.60 16 0.78 0.66
SD 0.13 0.18 0 0.08 0.05 The smallest angles were found in hip distraction
JPS Mean 0.51 0.53 19 0.38 0.28
SD 0.09 0.07 5 0.13 0.12
(NorDIS), the largest values in hip compression (Nor-
Comp), with an intermediate value seen with the
Abbreviations: JPS, juvenile pubic symphysiodesis surgery group; CR, NorOFA hip extended position. NorDIS values were
Chesapeake retriever; PreOp, preoperative; na, not available. significantly different from NorOFA and NorCOM in
* Sixty-eight-week data of CR7 dog included in JPS mean 137-week
values. controls, JPS preoperative, JPS 44 weeks, and JPS 137
† Sixty-eight-week values of CR7. weeks (Table 3). NorCOM and NorOFA JPS results
DUELAND ET AL 207
Table 3. Data and Statistical Analysis of Norberg Angles CT

Position Mean SD N t-Group Acetabular Angle. The mean AA of preoperative
JPS-treated dogs (mean 19 weeks) was 56°. At fol-
Control
NorCOM 105.7 3.7 20 A low-up at 44 weeks of age, the mean JPS AA was 78°,
NorDIS 78.8 4.4 20 B a 22° increase (P ⫽ .02). The change in AA from
NorOFA 95.2 3.4 20 C preoperative to postoperative for each dog at 44 weeks
Preop
NorCOM 107.4 3.9 10 A
and 137 weeks versus initial age at surgery was
NorDIS 83.3 4.9 10 B analyzed using regression analysis with the natural log
NorOFA 99.9 6.2 10 C of the change in AA and ages at surgery. Results
44 wk
NorCOM 111.6 3.3 10 A
indicated a highly significant relationship with earlier
NorDIS 94.1 9.8 10 B age of surgery to increased degrees of AA at both
NorOFA 106.9 8.6 10 A follow-up ages (R2 ⫽ .97, P ⫽ .003, and R2 ⫽ .98,
137 wk
P ⫽ .002, respectively).
NorCOM 108.8 3.4 10 A
NorDIS 96.0 6.1 10 B At the 137-week follow-up, the mean AA of JPS-
NorOFA 107.2 6.3 10 A treated dogs was 81°, a 25° increase from preoperative
values (P ⫽ .02; Table 5, Fig 5). Percentage-wise,
Mean Mean ANOVA
Group NorDIS NorOFA N P comparing the increase in 137-week AA value versus
the preoperative AA value, the CR1 (JPS at 12 weeks
Control 78.8 95.2 20 ⬍.0001 of age) value was 108% greater, the 16-week surgery
Preop 83.4 99.9 10 ⬍.0001
44 wk 94.1 106.9 10 .0062
was 42% greater, the 20-week was 39% greater, the
137 wk 96.0 107.2 10 .0007 22-week was 25% greater, and the 24-week was 22%
greater than preoperatively (mean, 56 ⫾ 32%; Table
Abbreviations: NorCOM, Norberg measurement with hip compression
5). Comparing percentage-wise the increase in JPS
stress; NorDIS, Norberg measurement with hip distraction stress; NorOFA,
Norberg measurement with OFA positioning; N, number of individual hip AA values at 137 weeks to control 137-week value,
measurements; ID, identification; PreOp, preoperative. CR1 (12 weeks old) was 62% greater, 16-week was
* CR7 68-week data were used in JPS 137-week mean calculations. 52% greater, 20-week was 29% greater, 22-week was
† CR7 68-week values.
A, B, C, different letter(s) indicate significant difference between
groups; similar letter(s) indicate an insignificant difference. Table 4. Norberg Distraction Angle (NorDIS) Data
were not different from each other at 44 and 137 Preop/

weeks, but were different in controls and at preoper-
ative times (Table 3). On this basis, NorOFA and Control CR5 L 85 76 16 80 79
NorCOM are similar, and therefore interpreted as not CR5 R 80 78 16 73 80
as discriminating as NorDIS in measuring acetabular CR6 L 85 86 16 na na
CR6 R 79 87 16 na na
coverage. JPS CR1 L 81 93 12 118 96
The mean control (CR5) NorDIS value from 7 CR1 R 79 87 12 99 105
sequential time intervals (8 weeks-137 weeks) was CR2 L 82 86 16 95 98
CR2 R 82 88 16 92 99
77.7° ⫾3.5°. Preoperative JPS dogs and both controls CR3 L 89 80 20 94 95
(at 16 weeks) had a similar mean NorDIS value. JPS CR3 R 92 81 20 85 96
final mean NorDIS values at 44 and 137 weeks were CR4 L 84 78 24 84 87
CR4 R 89 79 24 85 85
94° and 96°, respectively. At follow-up, the mean of CR7 L na 88 22 95 97†
JPS individual hip values indicated approximately 17° CR7 R na 83 22 94 102†
(20%) greater coverage (P ⬍ .001) versus control, and Control Mean 82 82 16 77 80
11° (13%) greater coverage versus the preoperative SD 3 6 0 5 1
JPS Mean 85 84 19 94 96
value (P ⬍ .03) (Table 4). SD 5 5 5 10 6
Abbreviations: NorCOM, Norberg measurement with hip compression

Pubic Symphyseal Length stress; NorDIS, Norberg measurement with hip distraction stress; NorOFA,
Dependent on age progression, the pubic symphy- Norberg measurement with OFA positioning; N, number of individual hip
measurements; ID, identification; PreOp, preoperative; na, not available.
seal length increased from 10 to 25 mm between 12 to * CR7 68-week data were used in JPS 137-week mean calculations.
24 weeks of age. † CR7 68-week values.
Table 5. Acetabular Angle Data and Ages When Measured between 8 and 16 weeks of age. In the remaining
PreOp/
control, there was no further increase in AA from 16
Group Dog ID 8 wk Age (wk) 44 wk 137 wk weeks to 137 weeks of age (Table 5).
The individual (right or left) acetabular angles
Control CR5 50 61 16 60 58
CR6 48 53.7 16 na na
(IAA) were also measured and were consistently half
JPS CR1 na 45.3 12 90 94 of the AA value in both JPS and control dogs. This
CR2 na 62 16 86.7 88.3 indicated a symmetrical response of the pubic sym-
CR3 na 54 20 71 75
CR4 na 55 24 64.3 67
physis in each dog.
CR7 na 64.6 22 80 80.5* DARA. The mean DARA value of 7 dogs (5 JPS
Control Mean 49.0 57.4 16 60.0 58.0 dogs preoperatively plus 2 controls at 16 weeks of age)
SD 1.4 5.2 0 na na
was 19.7° ⫾ 5.9° (14 hips). The mean DARA of JPS
JPS Mean na 56.2 19 78.4 81.0
SD na 7.6 5 10.7 10.7 dogs at 44 weeks (10 hips) and at 137 weeks (10 hips)
was 8.5° and 8.9°, respectively. The change in DARA
Abbreviations: ID, identification; PreOp, preoperative; Age (week), age
preoperatively versus age at surgery for JPS 44- and
in weeks when measured (controls) or age when measured before surgery
(JPS); na, not available. 137-week rechecks was significant: R2 ⫽ .95 (P ⫽
* CR7 68-week value used. .005) and R2 ⫽ .77 (P ⫽ .05), respectively (Fig 7).
The DARA of JPS dogs showed a 60% improvement
39% greater, and 24-week was 16% greater (mean (decrease) over control value at 44 and 137 weeks.
JPS, 43 ⫾ 25%; Table 5). The mean DARA of controls was 22° at 16 weeks and
Based on an exponential decline model (Appendix), 21.5° at 44 and 137 weeks (Table 6). If the JPS-dog
the change in AA would be 10.4% less for each later value with surgery at 24 weeks (CR4) was included,
week (between 12 and 24 weeks) that surgery was the mean JPS DARA improvement was not significant
performed. For example, the AA value would be from control at 44 weeks or at 137 weeks (P ⫽ .06 and
expected to decrease by 10.4% for JPS performed at P ⫽ .12, respectively). However, when this oldest
16 weeks compared with surgery at 15 weeks of age. surgery dog value was excluded, then both 44-week
As such, using the exponential decline model values and 137-week JPS DARA results were significant
predicted, the change in AA for JPS performed at 12 (P ⫽ .03 and P ⫽ .02, respectively; Table 6).
weeks was 46.2°, at 16 weeks was 29.9°, at 20 weeks Urethral-Pubic Distance. The mean urethral-pu-
was 19.3°, at 22 weeks was 15.5°, and at 24 weeks of bic distance (UPD) value (mm), combining controls at
age predicted improvement would be 12.4°. The actual 16 weeks and preoperative JPS images, was: 7.4 ⫾ 4.4
and calculated AA improvements from JPS at specific (range, 1.7-13). There was no significant difference
weeks are illustrated in Fig 6 (R2 ⫽ .98). (P ⫽ .68) in UPD of dogs with full rectums 6.7 ⫾ 4.9
In the 2 control dogs, the mean AA had increased 8°
Fig 6. Change in AA (degrees) is plotted against each age of

Fig 5. AA data plotted against time shows marked AA surgery. This exponential decline (decay) model (see text and
increases in dogs by 44 weeks of age after JPS surgery. There Appendix) illustrates the actual changes in AA (}, F, solid
was less increase in AA in dog CR4 after surgery, and no line) and predicted change in AA ({, E, dotted line) at 44- and
increase long-term in the control. 137-week follow-ups. The R2 value is highly significant.
DUELAND ET AL 209
Table 7. Mean Pelvic Growth Data
Inlet Area Width Height

Age (mm2) (mm) (mm)
Control (N ⫽ 1) 16 wk 1,533 36 57
44 wk 3,023 56 69
137 wk 3,543 59 79
JPS (N ⫽ 5) Preop (19 wk) 1,638 ⫾ 365 38.6 ⫾ 6.2 54.2 ⫾ 6.5
44 wk 2,442 ⫾ 213 51.5 ⫾ 1.7 57.8 ⫾ 3.8
137 wk* 2,698 ⫾ 201 54.8 ⫾ 1.7 61.2 ⫾ 3.7
Abbreviation: Preop, preoperative.

* CR7’s 68-week data included.
Fig 7. Linear regression of actual and predicted DARA

and 64%, for JPS 33% and 42%, respectively. Pelvic
changes at 44-week and 137-week follow-ups vs age at surgery.
height increases for control were 21% and 39%, and
for JPS 6% and 13%, respectively. Therefore, at 137
(1.7-13; n ⫽ 5) versus empty/partially full rectal UPD weeks, the JPS dogs had a decrease in the mean pelvic
values 9.0 ⫾ 5.7 (5-13; n ⫽ 2). dimensions of 18% versus the control dimensions
(Table 7).
Pelvic Dimensions Growth increases for control from 44 to 137 weeks
in pelvic area, width, and height were 17%, 5%, and
The JPS groups’ mean preoperative pelvic inlet area 15%, respectively, for a combined average growth of
(mean age, 19 weeks) was 7% greater, width 5% 12.3%. For JPS dogs, the increased growth from 44 to
greater, and height 5% less than control CR5 (16 137 weeks was 11%, 6%, and 6%, respectively, for a
weeks of age). At 44 weeks, JPS area was 19% less, combined average of 7.7%. Therefore, the total pelvic
width was 8% less, and height 16% less than control growth value of JPS dogs was 4.6% less than control
values. At the 137-week follow-up, JPS area was 24% in that time frame (Table 7).
less, width 7% less, and height 22% less than control The 44- and 137-week combined right and left
(Table 7). acetabular areas of JPS dogs was insignificantly larger
The sequential growth of control pelvic dimensions than control: 13% (P ⫽ .25) and 6% (P ⫽ .50),
from 16 weeks to 44 and 16 weeks to 137 weeks were: respectively.
pelvic inlet area—increased 97% and 131%, respec- The combined mean pubic symphyseal dimensions
tively. For the JPS group (mean preoperative age 19 of JPS preoperatively and 16-week controls were:
weeks), area increases were 49% and 65%, respec- dorsal width, 3.3 mm; ventral width, 7 mm; and the
tively. Pelvic width increases for controls were 56% combined mean symphyseal width was 5 ⫾ 2.1 mm.
Pubic symphyseal height was 5.6 (n ⫽ 7).
Table 6. Dorsal Acetabular Rim Angle
Histology
PreOp/
Group Dog ID Age (wk) 44 wk 137 wk Symphyseal biopsy specimens revealed spherical
cavitated areas with adjacent thermal cellular damage
Control CR5 20.5 16 21.5 21.5
(necrosis), similar to previous reports.29-31 The zone
CR6 23.5 16 na na
JPS CR1 31.5 12 5.3 6.3 of cellular death and damage with the 40-W, 10-
CR2 17.0 16 2.8 9.0 second dosages appeared subjectively less than the
CR3 15.8 20 10.0 8.1 40-W, 20-second dose. However, the thermal necrotic
CR4 17.4 24 15.0 18.5
CR7 12.0 22 9.2 2.8* areas overlapped somewhat, so exact dimensions of
Control Mean 22.0 16 21.5 21.5 each dosage response were unobtainable. The diame-
SD 2.1 0 na na ter of thermal damage was approximately 4 to 6 mm,
JPS Mean 18.7 19 8.5 8.9
SD 7.4 5 4.7 5.8
similar to another report.32
Abbreviations: PreOp/Age (week), age when measured (controls) or age Force-Plate Analysis
when measured before surgery; ID, identification; na, not available; mean,
value from combined right and left data. At 44 weeks of age, the mean weight-distribution
* CR7’s 68-week data used. values of JPS dogs were normal.27 Mean peak vertical
force (PVF) was 62% for thoracic limbs and 38% for
pelvic limbs, and the impulse was 64% thoracic and
36% pelvic, whereas the unoperated control PVF
value was 79% and 21% (P ⫽ .001 and P ⫽ .0002,
respectively; Fig 8A). At 137 weeks, there was no
difference between JPS dogs and control in both mean
PVF and impulse; thoracic limb distribution was 63%
and pelvic limbs was 37% (Fig 8B). The 24-week JPS
dog (CR4) had a slight (but not significant) decrease in
pelvic limb weight bearing at 137 weeks.
Morbidity/Mortality
No perioperative or postoperative morbidity oc-
curred in JPS or in biopsied dogs relative to hemosta-
sis, or urinary, bowel, and hip function. The 2 female
BX dogs had slight, spontaneously resolving wound
edema after the second surgery (biopsy). Both dogs
later became pregnant and delivered normally 6
months’ postbiopsy. Every dog used in this project
was adopted to a private home. No clinical problems
were reported by owners when interviewed at the last
follow-up. Unfortunately, 1 control dog (CR6) died,
after testing, of anesthetic complications at 16 weeks
of age. One JPS-treated dog (CR7) was normal ac-
cording to the owner, at 105 weeks of age (83 weeks’
postoperatively), when it died in an auto accident.
Other Considerations
Dog Weights. At 8 weeks of age, the mean weight
of CR littermates was 6.5 kg (14 lbs). At the final
follow-up, the mean weight of JPS dogs was 40.4 kg
(89 lbs; range, 33-51 kg [73-112 lbs]; median, 38 kg
[84 lbs]), with control weight 30 kg (66 lbs).
Operative Time. The mean surgical time for the
5 JPS procedures was 33 ⫾7 minutes (range, 25-50
minutes).
Fig 8. (A) Bar graph of force-plate weight distribution at the
DISCUSSION 44-weeks-of-age follow-up. Note that the control dog bears a
significantly lesser amount of weight on the pelvic limbs
JPS surgery, performed on young dysplastic (lax) compared with JPS surgery dogs (P ⴝ .001). This decrease
may be due to bilateral pelvic limb discomfort from coxofem-
dogs using electrocautery, resulted in premature clo- oral degenerative joint disease. ( ), 44-week thoracic limb;
sure of the pubic physes. Surgery significantly im- (■), 44-week pelvic limb. (B) Force-plate weight distribution at
proved all objective and subjective preoperative hip 137 weeks of age. Note that the control dog now has weight
evaluation values (Tables 1-6, Figs 1-9). The results distribution similar to the JPS surgery dogs. The dog operated
confirmed all the study hypotheses and fulfilled the on at an older age (24 weeks) has decreased (insignificantly)
the weight distribution of the pelvic limbs compared with the
objectives of the investigation—that JPS surgery ini-
other dogs. This dog had radiographic progression of degen-
tiated acetabular rotation in dysplastic dogs similar to erative hip joint disease compared with preoperative radio-
that reported in a guinea pig model,18 and that these graphs. ( ), 137-week thoracic limb; (■), 137-week pelvic
beneficial results appeared to be long-term. Therefore, limb.
DUELAND ET AL 211
similar pelvic and acetabular changes have occurred in measured.18,19,33,34 In our current and recent study,32
both species tested, and in both normal young dogs19 AA and IAA are transverse pelvic CT measurements
and in our dysplastic dogs. with the slice-plane including mid-acetabulum, the
The technique used in this study differed slightly urethra, and pubic symphysis. Swainson et al’s19 slices
from that used in the original report.18 A higher are more cranial, because their views appear to include
wattage and contact time was used because of the the urinary bladder and acetabula, but not the urethra
increased tissue mass in dogs compared with guinea and pubic symphysis. Their zero-time mean ventro-
pigs. Electro-thermal damage to tissue is related to version angle was approximately 27°, whereas ours
power, temperature, contact time, tissue resistance, was 57°. This variation continued proportionately at
and waveform.29-31 We chose the unipolar electrode to follow-up, because their values were in the 25° to 35°
eliminate exposing the inner surface of the pubic range,19 whereas our control maintained 58°, and
symphysis, a necessity with bipolar equipment. Ace- mean JPS AA was 81° (Table 5). This difference could
tabular improvements were similar in our dysplastic be breed-related but is more likely just a variation of
dogs when compared with normal greyhounds that had CT positioning and CT slice selection.
problems with implanted staples.19 We feel it important to emphasize that radiographic
We agree that premature pubic growth arrest ap- coxofemoral values derived from OFA, PennHIP,
pears to modify the acetabular growth by decreased Norberg angle, and Farese et al16 are influenced by hip
pelvic canal height and width. The shortened pubic laxity and limb positioning, whereas AA and DARA
rami cause tension (traction) on the ventral acetabula, measurements are determined from bony acetabular
which results in ventro-lateral acetabular rotation.18,19 conformation only.
Maximal AA rotation (49°) was found in the youngest Within our experimental protocol and with the
surgery dog (12 weeks of age), and the least rotation Chesapeake retriever breed, all results indicate that
occurred in the eldest dog at surgery (24 weeks of age; early JPS surgery was essential in obtaining significant
Figs 3 and 5, Tables 5 and 6). improvements in the various parameters evaluated.
The initial baseline and mean preoperative tests in The mean AA values at 137 weeks versus mean
CR dogs showed: DUS hip distraction values were preoperative values showed a 45% improvement, and
⬎2.0 mm, DI values were ⬎0.50, 2 Norberg angle a 40% improvement versus the 137-week control
techniques were ⬍105°, and all JPS dog hips palpated value. Also, in number of AA degrees gained, JPS
Ortolani-positive preoperatively and by 12 weeks in surgery at 12 weeks or 16 weeks of age was 5 times
controls. These data, indicative of hip joint lax- and twice more effective, respectively, than surgery
ity,10,11,13,14,17 remained to the day surgery was per- performed at 24 weeks of age.
The 10.4% calculation decrease in AA change was
formed. Initial control values did not change signifi-
based on a “decline” or “decay” model (see Appen-
cantly over time. Permanent hip-remodeling changes
dix). For each week that surgery is postponed, the
from JPS surgery were essentially completed by 44
decrease in AA change is approximately 10.4%. For
weeks of age; therefore, we elected to include CR7’s
our data, with surgery at 12 weeks of age, we would
68-week data in the JPS 137-week mean results. With
expect a change (increase) in AA of 46.25°. If we
2 exceptions (CR6, CR7), all dogs were observed for
delayed surgery until 13 weeks, the change would be
over 2.5 years. The beneficial results of JPS surgery
41.44° (46.25 minus [46.25 times .104 ⫽ 4.81°]). At
were maintained with no progression of hip-degener-
14 weeks, the change would be 41.44 minus (41.44
ative changes in that time frame. This may imply that
times .104), and so on.
some degree of long-term results is possible.
Previous reports of direct measurements by radio-
graphs and CT of normal, dysplastic, and postopera-
Acetabular Position tive pelvic specimens suggest 20° of lateral acetabular
rotation per hip to be advantageous for hip stabil-
The terms acetabular angle (AA), individual AA ity.8,28,33,35 Dog CR4, operated on at 24 weeks of age,
(IAA), angle theta, acetabular version, ventroversion, only gained a modest 6° of rotation in each hip (AA
and acetabular ventroversion are similar in that they 12°), an indication that surgery was performed too late
define the ventro-lateral rotation or angulation of the for adequate remodeling to occur.
acetabula. They differ in how they were obtained and The DARA results also relate to the rotational
changes of the acetabula, specifically to the slope

angle of the dorso-lateral portion of the acetabular
articular surface (Fig 2). Dorsal acetabular rim
angles have generally been obtained by specially
positioned pelvic radiographic or CT views where
the radiographic beam is passed “through the long
axis of the ilium.”15,22 We found DARA images
were more easily obtained, visualized, and mea-
sured using our described CT imaging criteria in the
prone (sternal) frog-leg position, rather than the
previously reported strapped flexed spinal posi-
tion.15,22 The DARA measurement is related to the
acetabular index radiographic measurement used in
infants.36 The mean 8.9° DARA values in JPS dogs
at 137 weeks was within the range previously
reported as normal.22 The JPS dogs’ DARA values
significantly improved by 58% versus preoperative
values and improved by 65% versus control (Table
6), whereas the control DARA values remained
generally static between 16 and 137 weeks. The
DARA value, although uncommonly used clini-
cally, was useful in this research as a second-
objective acetabular value, reinforcing the new AA
measurement as a reliable indicator of acetabular
rotation. Fig 9. This hip extended (NorOFA) radiograph was taken at
137 weeks of age of the dog that had JPS surgery at 12 weeks
of age. The NorOFA hip measurements were left, 115° and
right, 116°. In contrast, the distracted Norberg angles (Nor-
Coxofemoral Coverage DIS) measured left, 96° and right, 105°. Therefore, the NorDIS
method more accurately illustrates the extent of hip laxity that
When objectively measuring acetabular coverage in was not evident on the hip-extended view. Note the excellent
hips with laxity, a previous study14 and the current coverage of the femoral heads.This JPS pelvic canal has a
data (Table 3) indicated that the distracted PennHIP rectangular shape rather than the usual more-ovoid shape.
view (NorDIS) was more discriminating than NorOFA The pelvis and hips have an appearance similar to a healed
bilateral TPO.
positioning (Fig 9). Therefore, we suggest that NorDIS
may be more valuable for Norberg measurement,
rather than using the hip-extended radiographic tech- Hip Laxity
nique.
The distraction radiographic technique is a reliable
Femoral-head coverage evaluated by NorDIS mea- method to ascertain hip laxity in dogs 4 months of age
surements showed an improvement of 10° and 12° in or older.11,14 In this and other work,14 we have found
44- and 137-week JPS dogs, respectively, with a mean DI, NorDIS, and NorOFA valuable for CHD screening
137-week NorDIS value of 96°. This brought the in dogs younger than 4 months of age if hip laxity was
femoral-head coverage close to the normal value of moderate to severe. For example, in JPS dogs in this
99°.34 JPS surgery improved NorDIS 14% over pre- study, the mean DI at 8 weeks remained unchanged to
operative value and 20% over the control value. These the mean surgery age of 19 weeks. In controls, there
values indicated significant long-term JPS improve- was an insignificant DI increase (P ⫽ .64) from 8
ment of mean coverage values. In contrast, the control weeks to 16 weeks. However, from 8 weeks to 44
(CR5) NorDIS value did not improve over time (Table weeks of age, there was a 47% increase in control
4). The JPS dog with the poorest mean NorDIS laxity (DI ⫽ 0.78; P ⫽ .03). At the 137-week
response (7.5°) was, again, the eldest dog (CR4) at follow-up, the control DI had decreased 15% to 0.66.
surgery (24 weeks). This later DI decrease may be a result of soft-tissue
DUELAND ET AL 213
reaction associated with progression of DJD to a 2⫹ Pelvic Dimensions

score. In dog CR4 (24 weeks old at surgery), there was
A theoretical disadvantage of JPS surgery, as with
minimal improvement in laxity, with a mean DI of
TPO surgery, is the resulting decrease in pelvic inlet
0.50 at 137 weeks, only a 15% improvement from
area.19,33,39 The 24% decrease over control at 137
preoperative value, whereas the mean DI improvement weeks occurred mainly by the decrease in pelvic
of the other 4 JPS dogs was 55%. height, a 22% decrease versus control height. The
In addition to the improved acetabular position and average combined growth increase (area, width,
improved femoral-head coverage, improvement of DI, height) from 16 weeks to 137 weeks in control was
Ortolani, and HRA values also indicated that a bene- 78%. During comparable ages, the JPS growth in-
ficial soft-tissue response had occurred. The mean JPS crease was 12% less. However, the smaller pelvic size
DI improved (decreased) 28% from preoperatively to of JPS dogs was not significant statistically or clini-
44 weeks, and with additional time, DI improved by cally. It is of interest that the control’s pelvic mean
47% at 137 weeks. Mean JPS DI values were 49% and combined growth increase (area, width, and height) of
42% of control value at 44 and 137 weeks, respec- 12% from 44 to 137 weeks agreed with the 10% pelvic
tively. This significant decrease in laxity agrees with appositional growth increase from 52 to 104 weeks
Swainson et al’s findings.19 previously quoted to Morgan.18
Ortolani signs were positive in 10 of 10 hips
preoperatively and in 4 of 4 control hips at 16 weeks UPD Distance
of age (Table 1). A positive Ortolani at 16 weeks of
age has been reported as highly predictive of DJD The urethra of both sexes was anatomically close (7
development by 1 year of age.14 In JPS dogs, by 44 mm) to the pubic symphysis as viewed in the prone
weeks, 7 of 10 Ortolani-positive hips had converted (sternal) CT position. Although the UPD distance
to negative, and at 137 weeks, 8 of 10 hips were would likely be greater (safer) in the dorsal recum-
Ortolani-negative. The 2 JPS hips that remained bency position of surgery, evacuation of the rectum
Ortolani-positive at 48 and 137 weeks were in the may further increase UPD distance and therefore
dog operated on at 24 weeks of age (Table 1). It is seems prudent before cautery techniques. The close
known clinically that Ortolani-positive hips may proximity of the urethra to the pubic symphysis
eventually test negative with age. The reason has warrants surgical awareness to prevent inadvertent
been attributed to soft-tissue reaction to DJD and thermal damage to pelvic organs. A small abdominal
wear erosion of the dorsal acetabular rim. Because incision cranial to the pubis18 or trans-rectal palpa-
the control and the oldest JPS dog at surgery both tion32 is used to digitally reflect pelvic structures
retained their Ortolani-positive hips, and DJD did during cauterization.
not progress in the other JPS dogs, we believe that
the conversion to Ortolani-negative by 4 of 5 JPS Histology
dogs was related to the benefits of surgery and not to The tissue response to cautery is time- and power-
age or DJD. dependent. With the contact technique, thermal necro-
The 137-week mean HRA in the JPS group de- sis is readily visible as sparking occurs and tissue is
creased 91% from the mean preoperative value; only carbonized and vaporized. With the needle electrode
the oldest JPS dog at surgery (24 weeks) and the technique, the electric field lines in tissue are radial, so
control dog had positive HRAs. Recent work by cell damage occurs in a spherical pattern.32
Beauregard et al37 and Charette et al38 indicates that The confocal laser microscopy technique utilized
the HRA is significant in predicting the incidence of calcein green, a fluorogenic substrate that is only
later DJD, with the larger the angle, the greater the cleaved in viable cells and ethidium homodimer red
incidence of DJD. They also reported an associated fluorescent stain, which only passes through nonviable
relationship with the DARA angle. (thermally damaged) cell walls (“live-dead stains”).
Possible explanations for all the above-described The extent (mm) and border of thermal necrosis was
improvements in JPS dogs’ hips include: better coxo- thereby readily apparent colorometrically. Histologi-
femoral congruency secondary to greater acetabular cally, there was adequately extensive thermal injury
coverage, and the tightening of soft-tissue structures as (4- to 6-mm diameter necrosis) at each needle site to
a response to diminished hip forces.19,34,35 cause permanent damage to both the central mature
chondrocytes as well as to the peripheral germinal progression of radiographic DJD. The implication is
cells of the symphysis.29,31 that JPS may potentially improve DJD, or arrest or
delay the progression of DJD. A larger number of
dogs and longer follow-up periods are needed to
Gait
determine the clinical significance of these findings.
All owners reported no lameness with exercise at
both follow-up periods. The weight distribution, using
Other Considerations
force-plate technology, of normal-dog peak vertical-
force values is approximately 60% distributed to the The dog’s mean weight was in the large-dog cate-
thoracic limbs and 40% to the pelvic limbs.27 How- gory, with every CR dog weighing ⬎30 kg (⬎66 lbs)
ever, the control dog (CR5) showed a significantly at final follow-up.
decreased pelvic limb weight distribution (by force Operative time, equipment (standard OR cautery
plate) when compared with JPS dogs at 44 weeks (Fig unit), and instrumentation requirements were modest.
8A). This indicated hip discomfort,26-28,40 because The surgical aftercare requirements were minimal,
there were no other orthopedic problems in the pelvic especially when compared with TPO surgery. Unre-
limbs or spine, and the control dog also had pain on stricted exercise was allowed after the incision healed.
passive extension of each hip. By 137 weeks, the Neutering of JPS dogs is not only advised, but
control dog had normal weight distributions in spite of strongly recommended to eliminate dysplastic dogs
a mean DI of 0.66 and a 2⫹ DJD score in each hip. from the gene pool and to avoid misrepresentation of
Regarding the abnormal gait at 44 weeks in the control treated animals.
dog and reverting to a normal gait at 137 weeks, this In current and other experimental dogs,32 plus our
is not unusual clinically. Many dogs with CHD are clinical cases,41 no adverse effects with JPS surgery
painful from approximately 6 to 14 months of age and have been seen in approximately 50 dogs with follow-
then improve until symptomatic again due to progres- ups at 1 to 2 years of age. Although a reduction in JPS
sion of DJD later in life. mean pelvic dimensions occurred from JPS surgery,
Gait results of CR4 (24 weeks old at surgery) at 44 there were no clinical implications. Clinically, many
weeks were normal; however, at 137 weeks, there was symptomatic CHD cases are recipients of TPO sur-
a decrease in pelvic limb weight distribution, although gery, generally at 28 weeks of age or older, receiving
not significant. We interpret this dog as being operated a 20° or 30° lateral rotation plate.28,33,39,42,43 Al-
on at too late an age for an optimal remodeling though controversy exists in CHD diagnostic method-
response. It was of interest that dog CR1, which had ology,13,14,37,38,44-46 the earliest possible treatment of
the largest AA increase of 49° (24.5° per hip) over hip laxity/CHD is crucial. Our results and others
preoperative value, had no limitation in gait or in hip indicate greater potential for beneficial acetabular
ROM including abduction. remodeling at an earlier age.19,41-43 Current results
indicate that JPS surgery at 12 to 16 weeks of age
appears to give the most benefit. However, dogs CR3
Radiographic DJD
and CR7, respectively 20 and 22 weeks of age at
Acknowledging the subjectiveness of radio- surgery, resulted in lesser, but still significant, hip
graphic interpretation, of 10 JPS hips scored preop- improvements (Tables 2, 4-6, Figs 4-6). Dog CR7
eratively, the 7 hips scored as minor DJD (Morgan became asymptomatic 1 month postoperatively. Our
line[s] only) did not degenerate further. Two mod- results indicate that dogs 24 weeks of age or older
erate DJD hips improved to minor DJD, and 1 hip would not benefit adequately from JPS surgery, be-
initially scored as moderate DJD remained moder- cause further pelvic growth and acetabular remodeling
ate. The improved hips were in early-age JPS dogs is limited. Whether giant breeds may benefit at that
(12 and 16 weeks of age at surgery). Both control age, due to their continued growth, needs investiga-
hips progressed from minor to moderate DJD. The tion.
“late-surgery” dog (24 weeks old at surgery) had a To determine whether the approximate 10.4%
progression of radiographic DJD over time. This weekly rate of change in acetabular rotation after JPS
was the only JPS dog to deteriorate radiographically surgery is verifiable, or is similar in other breeds, also
to a 2⫹ DJD hip grade, whereas the JPS dogs requires additional studies. If the AA improvement
operated on at earlier ages appeared to have no rate proves reliable, then it may be possible to accu-
DUELAND ET AL 215
rately preplan the exact optimal age to perform JPS The needle JPS method may be amenable to a
surgery to obtain a certain desired improvement in percutaneous technique using methods under
AA. The degree of DI improvement may be less study.29,31,32,41,49
predictable. The initial DI results are encouraging, The JPS procedure produced symmetrical ventro-
especially over a longer period of time (until 137 lateral rotation of acetabula with beneficial results
weeks of age). similar to the TPO technique. Both contact and
Our findings are limited in this preliminary study needle cautery32 techniques were quick, technically
by a small sample size, early loss of 1 control dog, simple, and appear reliable—with no internal fixa-
and the late loss of a treated dog. However, our tion devices or special postoperative care needed.
significant 44-week results, at the time of substan- The JPS technique appears likely to match or exceed
tial pelvic maturity,47 were verified at the 137-week the TPO results seen in dogs28,40 and humans.50 In
follow-up. We interpret this as an indication of addition, early JPS should not complicate any hip
continued long-term results. Both contact and nee- surgery, if needed later, such as excision arthro-
dle electrocautery techniques were successful. plasty, various osteotomies, or total hip replace-
There was no surgical morbidity in 5 dogs operated ment.
on from 12 to 24 weeks of age and followed until
2.6 years of age. Although our follow-up time was
considerable, even longer (6- to 8-year) rechecks are ACKNOWLEDGMENTS
needed for increased accuracy regarding degree of
DJD and lameness.48 Further in-depth studies of The authors thank Stephanie Bartlet, John Bogdanske,
effects of various ablation techniques (laser, radio- Jennifer Devitt, Jordan Kobilca, Jeff Yu, Kenneth Waller,
frequency), other methods of symphysiodesis,19 and Melodie McPherson, Theresa Breunig, Dr. Yan Lu, Vicki
surgery performed at a variety of ages41 are needed. Kalscheur, Dr. Robert O’Brien, and Peter Crump.
APPENDIX
Measurement Comparison Statistical Test
Ortolani JPS-Preop vs. Postop McNemar’s test

Distraction Index (DI) JPS-Preop vs. Postop Paired t test
Control-16 wk vs. 44 or 137 wk Independent t test
JPS vs. control Independent t test
Age at surgery vs. change in DI Linear regression
Norberg Angle NorComp vs. NorDis vs. NorOFA ANOVA with least-significant difference
NorDis vs. NorOFA Paired t test
Norberg Distraction JPS-Preop vs. Postop Paired t test
Control-16 vs. 44 or 137 wk Independent t test
Norberg Angle Norberg angle vs. DI Linear regression
Acetabular Angle (AA) JPS-Preop vs. Postop Paired t test
AA vs. age at surgery Linear regression
Change in AA vs. age Decline model51 (below)
Dorsal Acetabular Rim Angle (DARA) JPS-Preop vs. Postop Paired t test
Change in DARA vs. age Linear regression
NOTE. To determine the relationship between change in AA and age at surgery, an exponential decline (decay) model51 was used:
change ⫽ c共e⫺rt兲
where t is time in weeks (age at surgery), c is an effective intercept (change at zero weeks), and r is the decline rate per week. The key parameter
is r, the rate constant. Given r, the weekly decrease in the AA change is given by e⫺r. This exponential decline model can be linearized by taking
the log (base e) of both sides, resulting in:
1n change in AA ⫽ 1n c ⫺ rt
and r can be estimated by linear regression. For the calculated decline rate, there was a 95% confidence interval.
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Effects of Pubic Symphysiodesis in Dysplastic Puppies

C ANINE HIP DYSPLASIA (CHD) is often painful

witt, MI)—Evaluation of all CR dogs included force-plate

Hip ROM Table 1. Ortolani Results

Initial ROM and long-term follow-up ROM were PreOp/

10 hips; P ⬍ .001), and the 137-week value was 3.6°

Table 3. Data and Statistical Analysis of Norberg Angles CT

were not different from each other at 44 and 137 Preop/

Abbreviations: NorCOM, Norberg measurement with hip compression

Fig 6. Change in AA (degrees) is plotted against each age of

Table 7. Mean Pelvic Growth Data

Inlet Area Width Height

Abbreviation: Preop, preoperative.

Fig 7. Linear regression of actual and predicted DARA

changes of the acetabula, specifically to the slope

reaction associated with progression of DJD to a 2⫹ Pelvic Dimensions

Ortolani JPS-Preop vs. Postop McNemar’s test

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