Radiographic Diagnosis

for
Canine Hip Dysplasia

18 August 2021

Napaporn Senarat DVM, MSc, DTBVS, CCRP

Rehabilitation Center and Orthopaedic Surgery unit
Veterinary Teaching Hospital, Kasetsart University
 Canine Hip Dysplasia
• Hip dysplasia is abnormal development of
coxofemoral joints.

• Occurs principally in large dogs but also affects

small dogs and cats.

• Typically bilateral but can be asymmetric.

 Canine Hip Dysplasia

• There are several factors influence the phenotypic

expression of HD.

• HD is an age-related disorder.

• A variable amount of time must elapse before

radiographic changes manifest.
 Canine Hip Dysplasia
• The earliest recognised changes in the
coxofemoral joints are :-

- perifoveal cartilage erosion

- hypertrophy of the round ligament

- synovial effusion
(Pascual-Garrido, C. et al(2018), Canine hip dysplasia: A
- synovitis natural animal model for human developmental
dysplasia of the hip. J. Orthop. Res., 36: 1807-1817)

• Testing for signs of joint laxity by palpation.

 Hip Development VS
Radiography
• At 30 days of age :

- The earliest dysplastic joint changes are

observed.
(Courtesy : Carol Beuchat, 2015)
- An edematous of round ligament with torn
fibers

- Capillary haemorrhage at the tearing sites.

- Increased synovial fluid volume

 Hip Development VS
Radiography
• At 7 weeks of age :

- Can be seen subluxation of the femoral

head.

- Underdevelopment of the craniodorsal

acetabular rim.

- The joint capsule is stretched.

- The ligament of the head of femur is

lengthened.
 Hip Development VS
Radiography

• At 60 - 90 days of age :

- Increasing the degree of subluxation.

- Thickening and stretching of the joint

capsule.

- The femoral head contact with the

acetabular rim.

Significant radiographic changes

are evident.
 Hip Development VS
Radiography
• At 60 - 90 days of age :

-When subluxation occurs, the articular cartilage is worn and

roughened on the dorsal surface of the femoral head.

- Cartilage fibrillation
- Remodelling of the
femoral head
Hip Joint Laxity
 Hip Joint Laxity

• Hip joint laxity is the most important risk factor

for the development of OA.

1. Passive Laxity = subjectively scored or

measured on a hip radiograph of a dog while
under sedation anaesthesia.

2. Functional Laxity = the pathologic form of

laxity occurring during normal weight
bearing.
 Functional Laxity on joint Mechanics

Joint mechanics with Results of functional

functional laxity
Normal joint mechanics
• The forces applied by
• Sum of forces spread surrounding muscles.
out over a large surface
• The forces on dysplastic
area.
hip are applied over a
smaller surface area.
laxity over time
• Functional hip laxity
results in erosion of the
femoral head and
flattening of the
acetabulum.
 Hip Joint Laxity
• Hip joint laxity resulting in abnormal force distribution
across the joint.

• Leading to premature wear of the articular

cartilage and micro fractures in the
subchondral bone.
Hip Laxity Measurements

Hip laxity measurements methods

1. Norberg angle (NA)

2. Distraction index (DI)

3. Percentage of femoral head coverage

(%FHC)
 How to diagnose
Canine Hip Dysplasia?
 • Signalment and history

• Physical examination
and palpation

• Imaging examination

Magnetic Gait
Computer
Radiograph Ultrasound Resonance Analysis
tomography
Imaging
 Signalment and History

• CHD can affect any breed of dog.

• Clinical signs -> slight discomfort to severe acute

or chronic pain.

• Can be divided into two forms

- Severe form : in the juvenile

- Chronic form : in the mature dog

 • Typically present between 5 and
12 months of age.

• Sudden onset of unilateral or

Sev e r e f or m bilateral.

• Lameness, bunny hopping,

reluctant to walk or run, exercise
intolerance

Histological Stretching and

Microfracture of
tearing of the joint
examination the dorsal
capsule (synovitis),
of juvenile ligaments and acetabular rim
dogs with HD muscle. from overloadings
 • Because of the disease
progresses.
Chronic
form
• Patients suffer pain most
often related to DJD.

• Can present with sudden onset of

clinical signs or chronic
presentation.

• Patients often present with a history of

bilateral or unilateral pelvic limb lameness,
difficulty rising, reluctant to walk or run.
 Physical Examination

• Many breeds at high risk of CHD have

a high incidence of other causes of
HL lameness.

- panosteitis, OCD, avascular

necrosis in juvenile dog

- CCLR, lumbosacral disease,

neoplasia in mature dog
 Physical Examination

Wide-based stance Narrow-based stance

 Physical Examination
Gait pattern of CHD

• Swing of the caudal body part

• Shortening gait

• Stifle and hock are relatively

extend.
 Physical Examination

Palpation of the hindlimb

• Assess quality of muscle mass, ROM of hip joint and

also crepitation test

• Ortolani test : hip started dislocated and test will

reduce the hip

• Barlow test : hip start reduced and test will dislocate

the hip

• Barden test
 Ortolani Test : Lateral Position

• Hip started dislocated and test will reduce the hip

 Ortolani Test :
Dorsal Position

• Hip started
dislocated and test
will reduce the hip
When you need to
confirm CHD by
radiography.
Radiography in CHD

• HD is defined as radiographic
evidence of joint laxity or signs of
osteoarthritis.

• Numerous radiographic projections

can be used to evaluate and screen
patients.
 1. Hip-Extended radiography

Norberg angle (NA) and

2.
femoral overlap (%FHC)
Radiography
in CHD
3. Distraction-stress radiographs

Dorsal acetabular rim

4. (DAR) view
Hip-Extended Radiography
 Hip-Extended Radiography
• Proper positioning of this view often requires heavy
sedation and/or general anaesthesia.

• Achieved the radiography by

- Placing the animal in dorsal recumbency

- Extending the HL caudally (parallel)

- Slightly internally rotating the femurs.

Hip-Extended Radiography
 Hip-Extended Radiography
• A properly radiograph should
include

- A symmetric pelvis

- Parallel and fully extended

femurs

- Patellas are centered within

the femoral trochlear
 Hip-Extended Radiography
• Common errors in positioning include

- Failure to fully extend the limbs

- Inadequate internal rotate of the femurs.

 Hip-Extended Radiography

• But… false-negative
diagnoses with this
technique may occur.
Hip-Extended Radiography
• The main advantages of the hip-extended radiograph is the
ability to evaluate the joint for signs of osteoarthritis.

• Radiographic evidence of osteoarthritis of the coxofemoral

joint includes

1. Femoral periarticular osteophyte formation

2. Subchondral sclerosis of craniodorsal acetabulum

3. Osteophytes along the acetabular margin

4. Joint remodelling
Normal mature coxofemoral joint

• At least half the femoral head

lies medial to the dorsal
acetabular margin (white arrow).

• The cranial margin of the

femoral head is separated from
the adjacent acetabulum by

- a fine radiolucent line.

- shape of the radiolucent joint

space is symmetric.
Moderate hip dysplasia

• Remodelling of the
acetabulum.

• The cranial acetabular

margin is angulated (black
arrow)

• Acetabulum is shallow

• The wedge-shaped joint

space (white arrows)
created.
Subsequent radiographic changes

• Perichondral osteophyte

D J D formation

• Remodelling of the femoral

head and neck

• Remodeling of the
acetabulum

• Increase opacity of
subchondral bone of the
femoral head and acetabulum
 Hip-Extended Radiography

• There are two radiographic features have been reported

to represent early osteophyte formation.

• These characteristics can be used to predict later

development of more characteristics signs of
osteoarthritis.

1. Caudolateral curvilinear osteophyte (CCO, or

Morgan line)

2. Circumferential femoral head osteophyte (CFHO)

 1. Caudolateral curvilinear osteophyte (CCO)

“Morgan line”

• A line of enthesophytes
on the caudal aspect of
the femoral neck

• Early sign of coxofemoral

degenerative joint
disease.
 “Puppy Line”

• The puppy line is a more

subtle opacification of the
femoral neck seen in the
area of the CCO in young
dogs.
 Morgan line vs Puppy Line

• It is important to differentiate between the puppy line and

the Morgan line.

• The puppy line represents an incidental finding and often

gone by 18 months of age.

• The puppy line has no correlation with later development

of OA.
 Morgan Line vs Puppy Line

• The puppy line is located in a similar location to the Morgan line.

• The puppy line is more diffuse and subtle when compared with the Morgan line.
2. Circumferential femoral head osteophytes
(CFHO)
• A radiopaque line that encircles the junction of the femoral head
and neck at the region of the attachment of the joint capsule.

CCO

CFHO
 Hip-Extended Radiography
• The degree of subluxation can be subjectively evaluated
or objectively quantified using methods such as

- Norberg angle (NA)

- Percentage of femoral head coverage (%FHC)

 Hip-Extended Radiography
• This radiographic position is the one most often used by
screening organisations such as

- Orthopaedic Foundation for Animals (OFA)

: scoring 1-7 at 24 months

- Fe ́de ́ration Cynologique Internationale (FCI)

: grading A-E at 12 months

- British Veterinary Association/Kennel Club (BVA/KC)

: scoring 0-6 and 0-5 at 12 months

Norberg Angle (NA)
and
Femoral Overlap
Norberg Angle and Femoral Overlap

• The Norbert angle (NA)

and femoral overlap
(%FHC) represent ‘the
degree of femoral
subluxation or laxity’.

• Seen on hip-extended
radiographs.
 Laxity Measurements by Norbert Angle

• NA is a measurement of femoral head displacement from

the acetabulum.

• Calculated by :

1. Drawing the center of each femoral head.

2. Make a line connecting the centre of femoral head.

3. Drawing a line from centre of each femoral head to

the craniolateral acetabular rim on the same side.

4. Measure the angle.

 Laxity Measurements by Norbert Angle

• NA ≥ 105 degree is considered normal.

• NA < 105 degree are consistent with hip laxity.

 Laxity Measurements by Percentage of
Femoral Head Coverage

• %CHF is a measurement of femoral head

displacement from the acetabulum.
 Laxity Measurements by Percentage of
Femoral Head Coverage

• %FHC less than 50% = increase laxity and poor

femoral head coverage.
Norberg Angle and Femoral Overlap

Disadvantages

• Significant effect of pelvic positioning on the

measurement.

• The possible effect of hip extension on joint laxity.

• Slight rotation of the pelvis will affect both NA and %FHC.

• Reference value for the NA with dysplastic hips can vary

between breeds.
Distraction-Stress Radiographs
Distraction-Stress Radiographs

• The technique that used to estimate the degree of

passive laxity of the coxofemoral articulation.

• Estimation the ‘functional laxity’ is an ideal.

• A method that accurately determines functional laxity

is not currently available.
The distraction stress radiography methods
most commonly used include :

Flu c
̈ kiger
PennHIP Subluxation
Index
Dorsolateral
Subluxation
The PennHIP
 PennHIP
• University of Pennsylvania Hip Improvement Program.

• This technique requires sedation or anaesthesia the

patient and the distraction device.
 PennHIP

1. A standard hip-extended
radiographs

Three radiograp
hic
exposures are A neutral stance-phase
made.
2.
compression radiograph

A neutral stance-phase
3.
distraction radiograph
1. Standard Hip-Extended Radiograph for
PennHIP
2. Compression Radiograph for PennHIP

• With the dorsal recumbency.

• The pelvic limbs are held with

the femora vertical.

• Hold the hocks with tibia parallel

to the X Ray table.

• The stifle held in ninety degree

of flexion.
3. Distraction Radiograph for PennHIP

• Dorsal recumbency

• Femurs are placed in

neutral position

• Hind limbs are held with

the femurs positioned
neutrally

• A distraction device is
placed between the
femurs.
3. Distraction Radiograph for PennHIP

• The femurs are pressed

against the bars of the
distractor, which act as
fulcrum.

• Lateral force is translated to

the proximal femur, and any
laxity leads to subluxation
 PennHIP

A. A standard hip-extended radiographs -

evaluate the joint for signs of OA.

B. A neutral stance-phase compression

radiograph - determine joint congruency
(compression index)

C. A neutral stance-phase distraction

radiograph - determine the degree of
passive laxity (DI)
 Laxity Measurements by Distraction Index

• DI is the measurement of maximal femoral head displacement from the

acetabulum.

• Calculated by

1. Drawing the geometric center of the femoral head.

2. Drawing the geometric center of acetabulum

3. Measurement the distance (d) between the geometric centre of (1) and
(2)

4. Measurement the radius (r) of the femoral head

5. Dividing by d/r
 d d
DI = d/r

r r

• The DI ranges from 0 to >1

- 0 representing full congruency of the hip joint (no subluxation)

- 1 representing complete luxation.

Laxity Measurements by Distraction Index

• DI greater than 0.3 = increase laxity and risk of OA.

• For example : DI = 0.71 means the femoral head comes

out of the joint by 71%
 Compression Index

• The compression radiograph is

used to evaluate joint congruency
and compression index (CI)

• CI = the laxity index for the

compression view

- Compression index = 0 -> inability

to fully compress the joints.

- Compression index = 1 ->

complete congruity.
 PennHIP

Advantage

• Its ability to predict the future development of OA in

younger animals as young as 16 weeks of age.

• The ability to develop breed-specific DI profiles.

• Used for determine candidacy for preventive

procedures such as JPS.
 PennHIP

Disadvantages

• Requires special training to certify users

• Requires special equipment

• Multiple radiographic projections required

• Personnel exposure during radiographic exposure is

difficult to avoids
Dorsolateral Subluxation
 Dorsolateral Subluxation

• To quantify the degree of hip joint laxity via

measurement of dorsolateral subluxation (DLS) of
the hip joint.

• This technique requires the anaesthetised animal.

• Place the animal in kneeling, sternal recumbency

with femora adducted and stifle flexed.
Positioning for DLS

• Sternal recumbency in a
rubber mold.

• The hip flexed to a weight

bearing angle.

• Femur adducted.

• Stifle flexed.
 Dorsolateral Subluxation

• The femoral heads are forced to subluxate in a

dorsolateral direction.

• The degree of subluxation is quantified by

assessment the percent of femoral head coverage
(%FHC)

• DLS score of 56% has been reported to have similar

clinical implications as DI score of greater than 0.3.
 Dorsolateral Subluxation
Limitations

• Long-term studies in large populations of dogs are

lacking.

• DLS score is highly dependent on proper patient

positioning.

• DLS score can be affected by arthritic changes within

joint.
Dorsal Acetabular Rim View
(DAR)
 Dorsal Acetabular Rim View
• The DAR view was first described by Slocum and
Devine in 1990.

• This radiographic view is used to evaluate the

dorsal aspect of acetabular rim.
 Dorsal Acetabular Rim View
• The patient is anaesthetised and placed in sternal
recumbency.

• The rear limbs are pulled cranially.

• Held the rear limbs close to the animal’s body.

• Place a spacer below the tarsi.

 Dorsal Acetabular Rim View
Correct radiographic positioning results in
superimposition of :-

• The ilial wings

• The ilial body

• Acetabulum

• Tuber ischii

• An unobstructed view of the dorsal acetabular

 Dorsal Acetabular Rim View

• The DAR view is useful to document the degree of

joint damage.

- Sharply pointed in the normal dog

- Rounded and blunted with joint damage.

• Diagnostic quality images can be difficult to obtain is

the limitation of this technique.
 Take Home Message!

• A properly and correctly positioned is useful as a

screening tool for hip dysplasia.

• No test is perfect and practitioners must understand

the limitations of the modality.

• Early detection and treatment is the key to slowing the

progression of DJD.