There are a wide range of treatment options currently available within veterinary practice for the management of osteoarthritis. One option which should be considered and ruled in or out when considering a patient management plan is surgery.
There are multiple surgical options available for the management of osteoarthritis, which differ according to the joint(s) affected. The goals of surgical treatment are similar regardless of the procedure performed, and include to improve pain, to maintain or maximise joint function, and/or to slow the progression or remove the changes within the joint associated with osteoarthritis (Cook and Payne, 1997). This article focuses on rehabilitation following some of the most common procedures referred for rehabilitation therapies following surgical management, including:
- Joint replacement surgery
- Arthrodesis
- Excision arthroplasty
- Arthroscopy.
Joint replacement surgery
Total hip replacement
Total hip replacement is most often considered as a management option for skeletally mature dogs who are not responding successfully to conservative management (Dycus et al, 2022). It is a procedure associated with a high success and low complication rate, with success reported as being between 80–98%, based on the status of pain and function assessed both clinically and radiographically, and by owner feedback (Henderson et al, 2017). The more common complications following total hip replacement include luxation, femoral fracture, issues relating to wound healing, implant loosening, acetabular fracture and sciatic neurosis (Henderson et al, 2017).
The main goals of rehabilitation following total hip replacement are to allow the patient pain-free functional use of the affected limb (Dycus et al, 2022). The techniques selected for rehabilitation therapy can be divided according to patient stage following treatment, as the goals at each stage vary. This is shown in Table 1.
Table 1.
Goals depending on stage of rehab and suitable treatment options
| Patient stage post-surgery | Goals | Appropriate treatment options |
|---|---|---|
| Acute | Provide analgesia |
|
| Prevent complications |
|
|
| Sub-acute | Provide analgesia Promote wound healing Promote joint range of motion Promote limb loading Initial strengthening |
|
| Chronic | Further strengthening of operated on and contralateral limb |
|
Acute post-operative stage
Most patients will be hospitalised in the immediate post-operative period (Marcellin-Little et al, 2015). This allows for monitoring of the patient's pain by the veterinary team, and the provision of appropriate pharmaceuticals in order to manage this. The period of hospitalisation will vary depending on the individual needs of the patient and the existence of complications.
Rehabilitation techniques which may be employed during this period include cryotherapy. This can begin in the immediate post-operative period and be continued throughout the inflammatory phase (generally up to 3 days following surgery) in order to reduce pain and swelling (Brown and Tomlinson, 2021). Cold packs can be applied directly to the wound in a sterile fashion, and left in place for 10–15 minutes, repeated every 4 hours.
Massage (gentle effleurage strokes) can be employed in the acute stage in order to improve circulation and reduce oedema.
Passive range of motion exercises are recommended for use in the immediate post-operative period in human total hip replacement patients (Marcellin-Little et al, 2015), and are beneficial to canine patients if the patient is comfortable enough to tolerate them. Ensuring the exercises are performed in a sagittal plane to prevent adduction/abduction, which may increase the likelihood of luxation, is paramount. The use of aids such as non-slip mats and a chest harness, together with a sling to provide patient support is also key in the acute post-operative stage. Assisting the patient into a stand position and preventing adduction/abduction in order to allow the patient to travel outdoors for toileting is key.
The application of electrotherapy modalities available to the therapist such as pulsed magnetic field therapy or laser are useful at this stage in order to promote wound healing and assist with pain management (Brown and Tomlinson, 2021).
Sub-acute post-operative stage
Depending on the individual patient, the sub-acute stage may be managed in the hospital setting, or with the patient at home being treated as an out-patient.
Early intervention with rehabilitation techniques at this stage is key in order to influence the organisation of scar tissue, prevent restrictions in joint range of motion and to promote early strengthening through limb-loading (Marcellin-Little et al, 2015).
Performing passive range of motion exercises (in a sagittal plane) and stretching exercises are appropriate techniques employed to maintain and improve joint range of motion. For passive range of motion exercises, the limb should be supported by a trained therapist, and moved through flexion and extension in a slow, smooth fashion until natural resistance is met; starting with the digits and moving up towards the hip. Each joint should be manipulated 7–10 times. For patients with a restricted range, applying heat to increase tissue pliability, and following the passive range of motion exercises with stretches (where the range of motion is encouraged to improve through gentle pressure applied by the therapist and held for around 10 seconds if possible) is appropriate.
Loading of the limb with support provided by a sling should be encouraged in the sub-acute stage. A sling is usually necessary for 2–3 weeks post-operatively, until the patient is walking confidently, at which point a harness and lead alone can be used (Marcellin-little et al, 2015). Limb loading can begin with standing practice, and the application of gentle weight shifts by the therapist by pulsing the patient's weight on and off the limb, either through the patient's chest harness or a point of control such as the shoulder region. Walking out with harness support to allow the patient to toilet several times a day also allows for gentle limb loading and is the initial approach taken to strengthening.
The application of electrotherapy may be continued throughout the sub-acute phase to continue the benefits outlined above.
Chronic stage (from 2–3 weeks postoperatively)
It is expected that around 2–3 weeks postoperatively that the patient should be using and loading the limb. Any lack of use at this stage may be suggestive of complications which should be investigated (Marcellin-Little et al, 2015). Management of the total hip replacement patient throughout the chronic phase is likely to consist of a combined home exercise program and arranged out-patient rehabilitation sessions.
Strengthening exercises and active range of motion exercises are selected at this stage, for application to the patient both in the home environment by the owner and by a rehabilitation therapist during a treatment session. There are multiple exercises available, some examples include:
- Controlled walking using a harness and leash (initially 5 minutes 3–4 times daily, increasing by 1–2 minutes per walk per week)
- Walking up gentle uphill slopes (this shifts the patient's centre of gravity caudally and so promotes hind limb strengthening, but also promotes hip extension)
- Rhythmical stabilisations, pulsing the patient's weight on and off their hind quarters
- Rhythmical stabilisations with the patient's front feet elevated on a block to promote further hip extension
- 3-legged stand exercises initially performed on a flat surface, progressing to performing the exercise with the patient's front feet elevated on a block
- Hydrotherapy performed in the underwater treadmill, progressing to the use of an incline to further promote hip extension. Alignment from the therapist or the use of therabands can be useful in order to ensure movement is entirely within the sagittal plane
- Walking the patient slowly over low placed Cavaletti poles, in order to promote hip extension.
Uncomplicated patients who have undergone total hip replacement are expected to have normal limb use within around 12 weeks of surgery (Dycus et al, 2022).
Elbow replacement surgery
There are many surgical procedures available for the management of elbow disease when there is severe, end-stage disease present and the patient cannot be successfully managed medically (Fernee-Hall and Janovec, 2021). These options include the sliding humeral osteotomy, proximal abducting ulnar osteotomy, joint replacement and arthrodesis. A partial elbow replacement, or canine unicompartmental elbow replacement is an option which may be considered for dogs with severe medial compartment disease, and involves resurfacing part of the elbow joint with an implant to provide a smooth, gliding surface. It is often considered the surgical option of choice above a total elbow replacement as it is a less invasive procedure because bone cutting is not required, and carries a faster recovery rate and lower complication rate (Coppieters et al, 2015). Outcomes assessed in 2015 found that full function was present in 47.6% of cases following canine unicompartmental elbow replacement surgery, acceptable function was present in 43.7% of cases and unacceptable function in 8.7% of cases (Cook et al, 2015). Due to the complex nature of the elbow joint when compared to the hip joint, total elbow joint replacements are less reliable than total hip replacements in terms of successful outcome. The rate of complications is high (60%) (De Sousa et al, 2016) and a much higher percentage of dogs had an unacceptable outcome (24%) (De Sousa et al, 2016) when compared with dogs which have undergone the canine unicompartmental elbow replacement procedure; however, further studies would be useful to truly appreciate outcome.
As a result of the high risk of complications, patients who have undergone total elbow replacement should receive a cautious approach to rehabilitation, and the process of rehabilitation is likely to be lengthy when compared to patients who have undergone total hip replacement (Marcellin-Little et al, 2015). This approach would entail limiting techniques to heat/cryotherapy, electrotherapy for pain management, passive range of motion exercises, massage and assisted standing/walking out for toileting purposes until post-operative radiographs have been taken at 6 weeks to ensure implant stability (Marcellin-Little et al, 2015). Following this confirmation, land-based physical therapy including active range of motion exercises (such as Cavaletti poles, rhythmical stabilisations and 3-legged stands); and hydrotherapy in an underwater treadmill can be initiated.
As total elbow replacement surgery eliminates the patient's ability for supination, there is likely to be an increase in compensatory rotation of shoulder joint, placing more strain on the surrounding structures and increasing the likelihood of injury (Marcellin-Little et al, 2015). Focusing on strengthening these structures is therefore likely to benefit the patient and should be considered when taking into account therapeutic exercises completed throughout the rehabilitation sessions and incorporated as part of a home program.
Knee replacement surgery
Total replacement of the stifle joint is regularly performed in human patients, and is thought likely to become a more commonly performed surgery in the canine patient for the management of stifle osteoarthritis in the future (Yurtal et al, 2022). To date, the author has not treated a patient following total knee replacement.
Arthrodesis
Arthrodesis of the elbow joint is a salvage procedure considered for patients who cannot be managed successfully on a medical basis, and for whom amputation is not a viable option, such as those suffering from multi-limb osteoarthritis. The procedure is performed on an infrequent basis, possibly as a result of the high rate of complications (Dinwiddie et al, 2021).
Arthrodesis of the carpus is the most commonly performed arthrodesis procedure, followed by partial tarsal arthrodesis. The surgical procedures follow a common principle: removal of the articular cartilage, cancellous bone grafting, followed by rigid internal fixation of the joint at a functional angle. External coaptation is normally performed following surgery (Cook and Payne, 1997), for a period of 1–3 months, depending on the age of the patient and the progression of the union (Pozzi et al, 2020). The goals regardless of the joint operated on are also common: to surgically stabilise the joint in order to minimise pain while maintaining limb function (Dinwiddie et al, 2021). The biomechanics of the patient are altered, and compensatory movement through the other joints allows ambulation to take place (Cook and Payne, 1997).
While external coaptation is in place, restricted exercise is advised, and so rehabilitation is limited to addressing pain (including compensatory pain) through use of thermal therapies, electrotherapies and massage; and performing passive range of motion of the other joints of the affected limb. Once external coaptation is removed and post-operative radiographs confirm stabilisation; strengthening the affected limb, and addressing compensatory issues due to changes in biomechanics can begin.
A number of techniques can be employed by the rehabilitation therapist in order to facilitate this, including (but not limited to):
- Controlled walking on a harness and leash
- Hydrotherapy in the underwater treadmill
- Land based physiotherapy including rhythmical stabilisations, 3-legged stand exercises, sit-to-stand exercises, down-stand exercises, slow weaving, walking over Cavaletti poles, and, eventually, use of instability equipment such as wobble cushions to allow for core and limb strengthening
- A home exercise program including some of the exercises listed above
- Soft tissue massage to address muscle tension
- Electrotherapy to assist with compensatory pain.
Excision arthroplasty
Excision arthroplasty is a salvage procedure, aimed at improving the function and comfort levels of patients affected by severe osteoarthritis of the hip, through the removal of the painful articulation site. Removal of the femoral head and neck allows for the formation of a pseudoarthrodesis, which enables adequate functional mobility and a reduction in pain (Cook and Payne, 1997).
This procedure is best suited to small dogs weighing less than 20 kg (Harper, 2017) and success rates are good, ranging from 63–80% depending on the study (Cook and Payne, 1997). Rehabilitation following femoral head and neck excision is extremely important, as post-operative physical therapy (as well as pre-operative muscle mass) appear to be important features affecting the outcome of the patient (Harper, 2017).
Maintaining range of motion through the pseudoarthrosis is vital, and so passive range of motion exercises should be initiated as soon as the patient is comfortable enough to tolerate them (within 48 hours) (Dycus et al, 2022). This, coupled with early limb loading and strengthening (through exercises such as short lead walks, rhythmical stabilisations and assisted standing) to promote pseudoarthrosis formation, forms the basis of rehabilitation principles for these patients in the early postoperative period.
Initiating hydrotherapy in the underwater treadmill (using an incline if available), together with controlled harness-leash walks incorporating gentle uphill slopes promotes hip extension, and can be initiated from around 10–14 days postop.
Arthroscopy
Arthroscopy of the elbow joint is a safe means by which to investigate the pathology associated with joint disease and so aid diagnosis. It also plays a role in treatment through allowing the ability to perform procedures such as joint lavage, debridement of damaged tissues – such as loose cartilage flaps, synovectomy or bursectomy, and lysis of tissue adhesions within the joint (Cook and Payne, 1997). This can be useful in the treatment of osteoarthritis secondary to conditions such as osteochondritis dissecans and developmental elbow disease.
In the immediate postoperative period following arthroscopy, thermal therapy, electrotherapies, massage and passive range of motion exercises are indicated in order to minimise inflammation, assist with pain management and encourage circulation.
Early loading through controlled lead walking and physical therapy including low-impact therapeutic exercises can begin in the subacute phase (3–10/14 days) following arthroscopy; with the introduction of techniques for strengthening such as underwater treadmill hydrotherapy and higher impact land-based physiotherapy exercises once the skin incision has healed.
Conclusions
Surgical management of osteoarthritis is indicated for patients severely affected by osteoarthritis for which conservative management alone is not achieving the desired results. The joint(s) of the body worse affected by osteoarthritis determine which surgical options are available for consideration. Regardless of the condition selected, rehabilitation is indicated in order to maximise patient outcome, and is likely to be beneficial in the long-term to continue to assist with pain management and maximising joint function, and to help manage compensatory issues.
KEY POINTS
- Surgical options for management of osteoarthritis should be considered as a possibility for patients in whom conservative management alone is not considered successful.
- Four of the most common surgical procedures performed for osteoarthritis management include joint replacement surgery, arthrodesis, excision arthroplasty and arthroscopy for exploration (often together with other procedures such as debridement).
- The joint(s) affected by osteoarthritis is likely to determine which options are available for the individual patient.
- Rehabilitation following surgical management of osteoarthritis is key in order to improve patient outcomes.
- The time frame for initiating rehabilitation and treatment modalities selected is dependent on the type of surgery performed, and the stage in recovery of the patient.