Joint Disease in younger dogs – a ‘Practice Dilemma’

Practice Dilemmas – the “stiff” young dog

Welcome to the first in a series of “Practice Dilemmas”, a series of articles that will examine real-world situations where the way forward isn’t immediately obvious. The aim is to explore some of the available solutions, to help support your decision making in consults.

Picture the situation…

“Harry” is a four year-old, bouncy Labrador. However, he’s also noticeably overweight, coming in at a condition score of 7/9. Now, that’s not a disaster (we’re sure we’ve all seen bigger dogs), but it might be that his mobility is starting to suffer.

Today, while still his normal rambunctious self, his owners are concerned seems to be walking a bit oddly. On the walk into the consult room, you have to agree – there’s a definite hint of “stiffness” around the back end. On examination, you find that the range of motion in both coxofemoral joints definitely seems reduced. Unfortunately, in this case radiography doesn’t give us a nice clear diagnosis, either. While he might have mild hip dysplasia, it’s certainly not marked enough to say it’s conclusively the cause of his gait anomaly. You might see a few rogue osteophytes, but certainly not radiographic signs of significant osteoarthritis.

A grey area

These grey areas, of course, are something you deal with every day in practice. The question, though, is where do we go from here? Harry’s doting owners want the best for him – but right now, what is that? Of course, you’re best-placed to make that call as the clinician on the spot – but here are a few thoughts to ponder next time you see a Harry in the consult room.

Surgical options

A total hip replacement is widely described as a curative option for severe hip dysplasia, as well as a salvage procedure for a range of other end-stage coxofemoral problems. However, right now that feels like overkill – especially if you’re not totally convinced that dysplasia is severe enough to warrant such invasive, expensive and extensive treatment. Given there are conservative options that haven’t been explored, the expense, and the rates of clinically significant complications (roughly 10-20% reported, (1)), you may well decide that it’s rather too early to jump straight into major surgery at this stage.

Pharmaceutical options

The mainstay of managing osteoarthritic patients has long been non-steroidal anti-inflammatories. And of course, if he’s uncomfortable we’re sure that you’ll want to make sure Harry’s on a suitable analgesic regime.

However, long term NSAID use isn’t without its own problems – while the datasheets generally describe adverse effects as “very rare”, published data make it very hard to establish the actual incidence of side effects in real-world conditions. Of those trials available, 62% report some adverse reactions (2).

So, since we don’t have a firm diagnosis of osteoarthritis yet for Harry, and it isn’t going to make a dramatic difference to his underlying joint health, are NSAIDs indicated yet? Yes, analgesia is often essential, but perhaps we should be considering other approaches as well.

Weight control

It’s pretty well recognised now that carrying extra weight is a major contributor to poor joint health and, ultimately, osteoarthritis. More importantly, all the evidence suggests that losing weight would reduce the severity of his clinical signs and delay progression (3). So we’d definitely be thinking about trying to get some of that weight off him.

Now that’s more a communications issue – do his owners’ understand the impact his weight is having on him? Is there anything else you can do to support them? Are there any other diet options that might be more effective? The key with dieting dogs is so often getting the clients on side.

And it might be that seeing him starting to stiffen up will be just the thing to encourage them to try a bit harder to resist those pleading eyes at supper time…

Biological therapy

With more and more biologics coming onto the market, we’re not going to try and review all of the options out there. However, between PRP, mesenchymal stem cells and other grafting technologies, there’s a lot of interest in this area. Most of these require a significant investment by the owner, however; and some require a great deal of veterinary input. Again though – is a little bit of joint stiffness really an indication for such aggressive therapy?

Metabolic Modification

Ultimately, the goal here is to promote good joint health, without causing more problems than we’re solving. And this might be a very good point to start looking at high quality joint supplementation, to help support Harry’s chondrocytes undergoing early metabolic changes.

Not only are joint supplements safe for Harry, but they’re affordable for his owners. And unlike some other options, with modern formulations like YuMOVE, you won’t have to wait for months to see if you’re having any effect – research at the Royal Veterinary College has shown that we can reasonably expect visible results within six weeks.

In the end…

Harry is of course a fictional dog. But there are hundreds like him being seen in veterinary practices across the UK. Dogs who are just starting to show signs of poor joint health, and joint stiffness, but without a firm diagnosis. Components such as glucosamine, green-lipped mussel extract (containing chondroitin and omega-3 fatty acids), manganese, hyaluronic acid, and vitamins C and E, are a great start to better joint health, either before or alongside other therapeutic options.

Multimodal therapies are increasingly being seen as the “go to”, as multimodal analgesia, anaesthesia and neuroleptanalgesia was a generation ago. Pre-emptive medication in heart disease is now the norm (4), and as a result we’re seeing better and better outcomes. Perhaps it’s time to consider a combination of disease modification techniques from the very beginning to promote joint health as well, rather than waiting until the patient has deteriorated to the point where we feel we can justify more aggressive treatment?

References:

• Forster KE, Wills A, Torrington AM, et al. (2012) “Complications and owner assessment of canine total hip replacement: a multicenter internet based survey”. Veterinary surgery : VS. 2012;41(5):545-550.
• Monteiro-Steagall BP, Steagall PVM, Lascelles BDX. (2013) Systematic Review of Nonsteroidal Anti-Inflammatory Drug-Induced Adverse Effects in Dogs. Journal of Veterinary Internal Medicine. 2013;(5):1011.
• Kirkby, K.A. and Lewis, D.D. (2012), “Canine Hip Dysplasia: Reviewing the Evidence for Nonsurgical Management”. Veterinary Surgery, 41
• Boswood A, Häggström J, Gordon SG, et al (2016) “Effect of Pimobendan in Dogs with Preclinical Myxomatous Mitral Valve Disease and Cardiomegaly: The EPIC Study-A Randomized Clinical Trial”. J Vet Intern Med. 2016 Nov;30(6):1765-1779.