No, no, no. Thank you though. Do not play an OK. So let me share my screen.

Alright, I can't remember if I got last week. I think I got to just medical management so I will take it from there. I also apologize if I had presented view on last week. I thought ever might chat with me and tell me that Presenter View Sonic and see all my my notes but he didn't. 'cause he's far too polite.

So we started here again. So what options are there for us? So we went through all of this.

Just come out there and then we got as far as medical management I think, so I'll just wait through that and then just talk about the indications for surgery. So I think we got. We got to this slide and so really in a lot of cases we don't need to have surgery in a lot of cases. Don't get a storage unit. I think there's lots of options that we can pursue before that. This is a adapted excuse me pyramid, which I think is quite useful.

Spice and Johnson chapter. This is the version for the previous one, the current one and you know I think surgery is is a smaller option. Though I would say that again it's a little bit like cruise ship. I think it's also case picking as well and look at what you have and I think I'll talk about later about those certain dogs that you might want to do earlier than other types of dogs. And you can see that the bottom of the pyramid, so lots of different things are down here.

And this you know, I just therapy. I use quite a lot now. So we've got Suzanne in the hospital and we use her shoes and act. Part registered therapists and and I would only recommend that passed. That's what Suzanne tells us to do, and that's what we do. So we either say to the clients if they have someone they really trust are there is an accpac registered person to use them. I don't know if anybody had a look at this and this is a useful website set up by girl call Hannah Sharp.

Ann and I don't have any of you seen that, but it's a very good website for to send your clients to to explain about canine osteoarthritis.

So moving on from that, obviously this is a source of algorithm. Again, without device three years ago on what you are looking at in terms of the different types of dogs.

Sparky were fit into this immature dogs with no secondary signs of osteoarthritis, and there were dogs that potentially fit it into the triple pelvic osteotomy category, particularly dogs that were under 6 to 10 months of age with no osteoarthritis signs.

Him and then there came a group that were younger than that. So less than five months old man, and they had a risk distraction index. So a distraction index of between 3 and .5 bearing mind. Probably 1.3 one point 7 bearing in mind that anything over .7 to one is probably affected. So obviously it's dogs that are higher than normal, which is 0.3 on the Penn Hip distraction Index and that may be at risk and those dogs and potentially may be eligible for things.

JPS or juvenile puke simplicity surgery so I don't know if any of your do not receive people doing that. I know it's something that people sometimes do, particularly in areas where they have got a ability to do pen here for a pen here validated system that you can actually if you have seen a lot of these young dogs that might happen at risk distraction index then the theory will be you do JPS surgery at the same time as a.

And you sure and and the thing with that is that's just a naturally occurring DPL TPO, so that cessation of the growth of the pubic synthesis that then turns the pelvis onto the femoral head. So that's what that does.

An then.

If the owner so it back here gets to the amenable to medical therapy. If they're not, then I mean I think a lot of most drugs are. Most dogs are really. If they're not, then there's other things like mature dogs, sorry, and they want to have surgery. This is obviously you don't really want to be doing anything like a total hip replacement really until they are over 9 to 10 months of age and then you have things like again, this.

Is a is it? I think again is is is quite dated now because I think any dog over 10 months ago can have a hip replacement. I think small dogs and micro dogs nano dogs definitely I think have got higher incidence of and it has been reported. I think we'll see it in the registry as well. Particularly Lost Souls are cemented. Still they've got a higher incidence of complications and a lot of people historically performed from head and neck on those.

Him then.

Medical managers I think is 1 and all flash was two. Now the one category. So So what you're saying is you're looking at different things? Is it immature? Hasn't no away? Is it less than five months old? But yes, it is hasn't got potentially could have a GPS, has gotten afriski distraction index is it older than five months old? Yes it is, but it has no way they want to go with a triple pelvic osteotomy or DPO. I would think in most cases we if we see dogs this young we get them back and then we do total hip on them.

Also think moments is coming out is these looks like dogs. They talked about area which is these bilateral subluxated hips and I think if you see them I think you need to watch them because I think they are dogs that if you leave to remodel overtime they will have more problems and may have more problems anyway. So I certainly think if you prefer in dogs or dogs are having to glitter. Placements are very looks OID. The owners need to be cancelled but they certainly may have more complications so they sort of Beecher algorithm a little bit over here because I think.

Those dogs I would very watch them quite closely. If you X-ray them at about.

Often they will have rides quite early on, 'cause they'll be struggling and then you need to wrap them really again within probably six months. I would say for a total hip replacement, so don't let your extras go out to take more than six months and it's 4 views specific views that when you go on the course and so we see vets that will X-ray them for us, will X-ray them for diagnosis 6 seven months, and then they'll get them back and we'll just send them straight into some real X Ray them. Or that's the way to do it rather than actually actually taking another set of extras.

And because they'll need to have templating xrays and those dogs, I think of the clients are up for it. I think probably do need to be done sooner rather than later, but you do need to keep an eye on those that they're not super remodeling.

OK, so again I'm going to work through this 'cause we want to talk about surgery and you're all doing certificate. I think. Remain things to remember a body weight, pain relief and diet and exercise. And I think things that we would use a lot generally are non steroidal's and then add in paracetemol 10 makes working TID. I would I just put a dog today on Amantadine. I would use Amantadine then after that and paracetemol either work pretty quickly then if they're struggling.

Mountain is my first line rather than gabapentin for musculoskeletal orthopedic things. If you've got a dog that's potentially got lumbosacral disease that talked about that last week, then that might be a dog that you're concerned. If it's got a little bit of back pain and that would be your indication in the majority of June and gabapentin and Amantadine is 3 to 5 mix parking once today and gabapentin generally. 5 to 10 makes per kig and five mix for cake TID. We would generally temper that to the dogs of the dogs are getting very drowsy on that then we back it down.

If it's there two drowsy on that TID you might be super basically need to teach her the door. Sometimes I'm warning them that they may get Tyrion that.

Ham piracy small alot of us so see I grew up with empowered LV an which again don't dose according to the box dose. According to the mix. So we generally do 10 mix for kick TID an I would generally start that we use it for five to seven days after surgery anyway and we will give that Perry operatively in everything we would do really.

Put it, put it in chronic dogs. If the non steroidal be my first line after within our stride line it is off licence doing that but but you I. I mean there's a lot of people using that long term in dogs.

Amantadine is something that was used a few years ago, and there's a nice study and done by Duncan Lascelles. And again, it's meant to prevent chronic wind up, and he did a study in the in the J van and it was a placebo and Amantadine group and they found a significant difference using gait analysis and a.

An under client specific outcome measure, which is like a questionnaire validated questionnaire and difference in the placebo group versus the dogs that had a mountain. So there was some reasonable evidence based work done that a few years ago now, but it was a nice study so I think the main thing would demand today is again 3 to 5 minutes working on today's how I use it is I think it improves their demeanor. That's what it really does. It makes them feel much happier. I put young hip dog on it today.

Gabapentin again interesting. I had to look at this last week to see if there was anything on these. There's very little that I could find again in the literature on people looking at these for use in small animals particularly, but we.

Gabapentin again, is not something I would use. I have used it on their nieces use it sometimes with Amantadine. I prefer to use one or another book orthopedically and my professor preference and I'm probably the first person that does use it is is Amantadine. I've used quite a lot of that. Gabapentin you can use can also use in cats. Very good for aphasia center of the case report and we did a few years ago on on for cats that had muscular skeletal issues and that was it was tolerated very well and those cats are not actually. That paper is been really heavily cited because again, there's not much out there or not.

Things like stem cell therapy. I mean there's people have done lots of the Spanish group, anvil are in others and then this study here. For years ago there are people putting stem cells into Austria through dogs hips. I think again the admin space is poor and there may be some benefit in terms of suppressing the inflammatory profile. What's going on joints? That's the theory of using stem cells.

Interestingly, we've had a student and for the new year we've had a fourth year vet student who did a welcome student ship in the summer and he's just done. A meta analysis is just finishing it on the use of stem cells from managing crucial ligament disease in both human and in dog, 'cause we repeatedly student looked at stem cells in humans and dogs, and Interestingly, out of something like 1700 papers he has got 7 papers.

But I've got any sort of evidence based outcome, which is really scary. And that's between dog and man is about four human papers.

Come on, there's a on the street for dog papers. Really, really interesting that actually when you look a lot of the actual outcome basis and basically humans for using that in the news is is really poor and slightly scary an I think any of us expected that.

Again, and I logged on to an exercise pre imposed.

In terms of conservative management, and there's been some worked on looking at exercise programs, this paper in 2016 looking at weight loss with exercise problems in dogs. Obviously that had the weight class. I mean, Institute of did sort of progressed better with their exercise program. Again, if you look at dogs that have an exercise with gait analysis, you can find that the dogs basically have got reduced peak bird. Basically loading in Austria.

Yes, it's parents patients.

It basically they do better if you exercise them and then in this paper in 2012 I think I said this Saturday that did really nice epidemiological study and found that the dogs that were off Hadley offered exercise at at 12 months which had a hip away. Did have reduced clinical signs that that sort of fits to what we do as well in in in in us, in human medicine. And there's been so some very nice reserves of management and.

Setting bar paper was probably the first one in the sort of Seminole study on this, and then Mike Farrell went back and repeated it 20 years later and he actually found interesting Lee that that 54% of dogs had still required medication after conservative management hip away. That was really interesting paper, and then I think these papers there old. I know there old, but actually the one thing is that I haven't put this into this before, but I put in the other day. Is that body weight? If you've got an 11 to 18% body weight lost.

It's got six that can impact on clinical signs, and that was by impulse are easy in.

Impulsar easy and in 2000 and again this beautiful study by Keely and others where they restricted Labradors. They gave basically they gave sibling Labradors and pairs. They gave one last, so the genetically very very similar experimental dogs and they gave one lock restricted food and give the other lot an Adlib food and they all had an at risk DI and the dogs that had the Adlib food developed. Signs of hip dysplasia.

And hip osteoarthritis compared to the much more acceleration restricted dogs. And again, that is a really, really beautiful seminal study and very very high impact paper.

OK, so when do we generally need surgery? So think that algorithm you talk if we go back to it. But generally we need surgery when we have a key.

Oh

look, maybe as I say it looks OID and the clients want to do something before it becomes profoundly remodeled and when they become profoundly or models that more chance of them getting a complication and the basically dislocating hip when you've got failed internal medical management. And I think in a lot of cases I would save dogs. Really have to propped up on meds, alot of them are sore for the 1st.

When they start to get bigger, so they start to develop those signs. When they're five 6, seven months of age, is there skeleton their their body weight catches up with their skeleton growth and they're very sore. You get them over the sore home an and then a lot of the plateau. So again, and the hip registry for the average age. Really for dogs is about 1 year old and lingers a lot of cases that basically there are very sore and they they they go into having a hip replacement at that point.

And so said earlier. So generally of sorry so. So generally we talk about surgery around the hip for crepaway.

I'm sorry so interventions preventative so that would be our JPS potentially RDP. Oh I think the JPS potentially you doing it earlier. Maybe you're correct in the anatomy before you get lots of signs last Earth ritis but you remember my little diagram with the osteoarthritis and the disease and the sort of gone through the little sort of triangle. So they both basically both start at the same point. So again I think with the GPS I'll talk about in a second and definitely not.

Definitely needs to be done in dogs that are in.

The dogs that have very no signs or no remodeling are no obvious radio graphic signs of osteoarthritis.

An important to keep an eye on them so you can have a look at examination questionnaires so the clinical metrology questionnaires such as the canine brief pain inventory or canine low arlaud Liverpool osteophytes and dogs, and so the Helsinki Helsinki Pain Index. So there are a few of them out there and force page analysis if you have an dogs you have flare up so I think it's important to really keep an idea of.

You know that they're not going up and down, but there are having a solid deterioration and maybe get clients to develop Diaries in terms of that. Important to assess the individual and what's required. Also, be mindful, I think I said this last day. Every dog at over 100 has to have a complication, so whether it's 5% or 10% or 15%, there's 15 out of 100 dogs are going to have a complication or 15 out of 100 cats are going to have complications, so somebody has to be in the category so.

You need to pick your owners on if owners are talking themselves out of surgery. I wouldn't be jumping in to encourage them to have surgery. I think you all know that that is a poisoned chalice, that one and so just be mindful.

I think again I'll talk about in a second people called him. Will be you scolding salvage procedures such as don't think they really necessary? I think formal head and neck is probably salvage procedure. I think a total hip replacement so I think it's probably a little unfair to call it salvage procedure, particularly doing it in a young animal. But talk about that in a second.

And then if there's specific condition that is not going to get better from service management with the clinical signs are not going to improve conservative management. So things like Calvin Perth's disease Arma topsail officer in the cache and whatever you want to call it, they're not going to necessarily improve the conservative management, so they potentially will need surgery. Historically. When I first started in orthopedics, and totally replacements where this order left for as long as possible, I think probably there is now much more particularly, these looks like dogs dogs that I talked about. There is much more evidence than in people as well, that probably you're better doing them sooner rather than later in terms of the function.

And so you want to probably do them before you get all the joint associated difficulty, because don't forget it's an organ, so it's got tendons and ligaments around it and muscle. They all get inflamed. They all get slash kinds. They all have fibrosis. All the procedures that happened with us urethritis, but it happens around the joint and the joint organ is failing. So if you leave it too long, then you've got everything else that is going to have to be retrieved, not just joint. So I think maybe it's a balance.

And so preventatives that earlier is triple pelvic or not, to jewel pelvic osteotomy. The JPS or talked about Palace of Generation interviews. I've done that. I've done that about two or three times. I've done very much an. I don't know if that works or some papers after staying at works and John Force Plate analysis, but I'm not necessarily convinced and have done that once or twice in a German Shepherd. And then I put down salvage. Yeah, I think for her neck is definitely a salvage procedure.

Because you're taking some tonight, but you're not putting anything back in. I think it's maybe a little bit tough. Wanna talk.

Hip replacement, but again you are removing the joint so so names could improve the laxity and correctly automated. So a little bit of like TP Lo Ann and then others are potentially you're taking the joint out and so inverted commas salvage procedures.

An so.

Again, with the particularly the TPO, I think it hasn't been shown that long term Duna TPO avoids them getting osteoarthritis. And I think that's why it's really gone out of fashion. It did start off being a triple pelvic osteotomy, where you cut the bone in three places. So in the alien the issue and the pubis, and now it's just gone so you don't make this causing the issue and you just go straight into the pubis and then cut the alien and you just turn this whole segment here an.

That's what currently people that do these so people like out of zone. It does a lot of depots and again the ideal candidates are no prime, no secondary modeling. So this dog has got nice, possibly blunted as timely rims. It doesn't have, it's got maybe a tiny bit of flattening on his femoral heads. It's got no M remodeling of its former next, and so at the moment this hasn't got any. It has got medial divergences. Subluxation but it's not it certainly is.

Pronounced this dog isn't look, so it it just has hip dysplasia and I'm will have away, but it's certainly not pronounced. A lot of work was done on actually the rotation and there was quite a lot of kind of Eric work done on this and found that the ideal rotation of this segment is 20 degrees. Problem is that if you rotate much more than that then you get difficulties with pelvic narrowing and obstipation and obviously there are special implants you can see these ones here and so there's actually predesigned and pass with different people. Make these plates.

And there's these canine pelvic osteotomy plates. See pops and that you can put on them.

So there you go. So the idea is that you caught it and rotated and you set it back on to the femoral head. So instead of sitting out a second, I'll and the GPS is actually a sort of a natural version of that.

And again, this is Alva, so nice and quiet. Little work on this and found that there was less complications such as DP. Oh, he just acts of of hip replacements as well. I think they all come from all over Italy to see him an and that actually the DPL was was less invasive than simpler and the the coverage was presented coverage of the femoral head was increased to 50 to 72% which is what you want.

Ham complications with this, the implants tend to loosen, so these early sacral screws, unless they're in the sacrum, had really horrible horrible complications. About 62% of them losing, so a lot of them are to be removed. I know this is hardly anybody in this country in the UK. Does this, hardly anybody? I would say Ann. And again, if the osteotomy fails then it's just not very nice. Really unholy mess and so.

And you can't. If you look there, you can see where that's where the sciatic goes. So if you do an earlier shaft fracture and I did see someone I worked with in Bristol or the residents when I was doing my PhD, stick a screw through the stakeholder. This sciatic nerve and that's all Contacts leg off. So don't you do need to remember that the the sorry it's jumping jumping thing you do need to remember that and the static does come down here and just be very careful so yeah so you can get.

Neurapraxia

and they said that their dogs improved tonight 92% and and also they improved with force plate analysis.

An in dogs that had TPO's but they didn't have very many control groups are they didn't have any sort of non operate control groups. A lot of those studies so actually and also the case criteria is a very select craze. Criteria that you would select to do that with, but it certainly doesn't prevent away and this is a picture given to me by John Innes and for years ago and he worked in an input. But this is a picture of a JPS which is again.

We recommend to try and do this at the same time as neutering nice. We don't in dogs less than 20 weeks of age and you're you're doing a spotted core free down the pubis, basically down the pubic synthesis you're doing is spotted EMCOR to reach trying to rest it and what that then does it gives you a gives you natural TPO VPL.

And again, you're getting those joints very early, so getting those joints before five months is not necessary and also routinely doing X Rays for distraction industries. 'cause that's the one you want to do it in those higher risk dogs and is not something that our practice currently does. Certainly as in the UK in general, there may be some practices that do that in the UK, but it's not currently a population that we see that you may do, that the Ralph I don't know if you're doing those at the Ralph Grace but but I think.

Alan might be someone else did his residency over here, but he's Italian, but so I think you have to have that degree of practice that you're seeing. People are breeders and people are bringing those dogs into less than five months of age. You're doing your pen here prepended, validated your final. They've got high risk. Use them and you do JPS on them.

So again, so if you think back to that, you need to be really diagonals and then by about four months of age and then and then you need to be doing it before 20 weeks. So you've got a very limited time window and so in the studies that were done on this again the JPS bugs did better with conservative if they had mild plotters, an if they had very mild signs if they didn't have mild signs or they had pronounced signs at.

Any pronounce any away signs about age four to five months, then they would not do better. The conservative management and have no effect after 22 weeks, so I think it's a nice idea, but I think you have to capture them earlier. I think currently in our practice in Liverpool, let's not population of animals we see.

So again, without the idea is that there in users, because if they've got a A you're using a laxity task to try and look at them in the population. Then in theory you want to get removing them from the.

When breeding population and so they need to be neutered and you can do it at neutering an again unipolar extra extra courses. Something it's very simple you doing spotting so two to three millimeters apart and you're doing it in the first third half. Simple sale distance from the cranial part. Again, be very careful so you're putting a malleable one of those big ribbon malleable tractors under the Donnell organs in the cranial.

In the cranial parts of the incision, and they don't need some restricted exercise afterwards.

As anybody any questions, I'm on that so far I'm not going through quickly on that. Evan, you wanna send it today. I've got Daisy Daisy welcome Daisy.

I think Daisy said that she was going to attention. Might have some technical issues so OK, and you're one of my friends who lives in Majorca and does JP? S because he has the capacity to do the Penn hip. And just to reiterate what you were saying about the sort of the client base, he says that most of the owners who present dogs for JPS are breeders that have had experience with hip dysplasia in the past. They are already aware of the possibility of JPS and they're sort of coming to him saying.

You know, is this something that we could investigate so it you know, that that part of the discussion is already done and dusted.

Yeah, I think I think it's just a population. If you see it on your into the swing of it, I think you can do it, but if you haven't publication comments here, you don't and we just don't see that here. I mean, I teach it in the lectures to students. We just don't see it. It's not not the way it sort of works with us visiting a lot of dogs presented sort of 68 months and that's when we see them and then they come to us.

OK, grant so and innovation. The hip is quite simple to do. You sort of making cranial approach to hip and then you sort of scrape off the more technical enough scrape off and basically over the acetabulum and the dorsal part of the acetabulum, and in front of the acetabulum. The idea is that you're getting the cranial gluteale.

Parts of the sciatic obturator femoral branches of that nerve so you're sort of taking over the dorsal acetabular rim and then cranial to where you go down towards the Director Ann from wrist attachments where you might put a suture into for a illegal family researcher. Don't anybody ever tell Nash that's reported so nice. Study on that few years ago and so again I don't know. I've done it twice. I've done it and I think I've done it into German Shepherd dogs and again some old studies on this now.

An, but no necessarily real difference.

Three months and then also.

In one study they did do gait analysis and they found the non operated. So the one that didn't have the correcting you literally using the correct to scrape off the periosteum Ann.

Decrease in the non operated operated lamb and then again suggest improvement minus 2% another early and there was 50% improved with the pressure mounts.

When it was more objectively Simon, so I don't know. It's something that may be potentially can do some people talk about it, but I'm not. I'm not sure. Again, it can be something positive potential you can do. I think we've got a more and again, that that was before we had a gamut of things like Amantadine, gabapentin, and other drugs that we sort of have. Now when I first started sooner speaks, we had a thing called static ARP, which is now middle and that was it and phenibut sold for the cash, the little Red Smarty tablets in which God bless, hope none of you have ever seen them but.

Yeah, we skip final users. Cats, my brother gave brothers, veterans and so again loads of sort of weird and wonderful things an that people loads. Sort of weird and wonderful map things that people have done in the past. All sorts of trochanteric, osteotomies and shelf osteotomy, reason but bossy otomies and again along time ago, people would cut the pectineal. I did see one dog actually recently had a pectineal myectomy. It's from the first one ever seen in many, many, many years, and.

Um, but I I'm not something I think a lot of people necessarily do know.

So and we move on to salvage femoral head and neck excision is a reasonable thing to do, and I think if you have an option, I think total hip replacement is definitely a better thing to do. I think if everything goes well, I do think their function is is better an so it is family had an excellent revolt affair. Languages, you know that it does work and I think the one thing I would say that with you is that they.

It's the only time I see students you will know this, but it's the only time that you cut up on that. You have to exercise, exercise, exercise, exercise, exercise. The only time you could have on your text size so they really need to be exercised and that that correlates with the degree of function they have to have. So they need to be out. You need to be getting them physio or they need to be getting the dog up and down stairs as soon as the stitches are out you can do slow walks with them as well to really get them to place it. Obviously our friends the Terriers want to just keep their legs up in the air.

So we really need to make sure that they do use it rather than hopping around. Return to function is is longer than I would say would hip. So 6 to 8 months under never completely backed control of the other leg.

I'm better in smaller dogs for sure. We are told and dull. At larger dogs. You know there are lots of people that probably done these in larger dogs 'cause they do not have any other options to do anything else.

And so I think if it's, I suppose if it's if it's use our and I mean The thing is dogs that have failed hip replacements end up with a very expensive femoral head neck excision. But in general I think their function they function. I mean, I don't know the dogs that we have in the registry that explantations.

We haven't sort of. We haven't looked at that and drilled and very deeply into that yet. We do not go to the moment, but I think those dogs have reasonable function. It's not ideal, but again, you know none of them are having catastrophic events where they're putting the dogs to sleep that we know of. So you know, I suppose they have a major complication, whether not having a catastrophic complication, so to speak, if you go with that category by Jimmy Cook another few years ago, and I think it's very important to do good technique with the femoral head and neck excision, so I think that's really important. So if you are going to do one, make sure and use.

Strongly use your whole set principles and really important and Halsted principles, note selves or something you can be asked in an exam so noodles and a less of an principles or things you can be asked in exams so you know, I think that's really important for surgical exam to be able to list drop off your holstead principles and it is quite common sense but important you know and I think that fits with doing this sort of level of surgery. Doesn't need to be done well.

And when I, when I did locum years ago in down South, I remember the boss of the practice doing a family had an excision and I still remember if the care he took and it wasn't something I don't think he did very often, but the care he took to organize themselves to get organized. And it was like it was like he was doing a hip replacement. He was so particular about everything was everything else. Keenan you know and I I do think it's as you do think that there is a you know don't chop strawberry jam the muscle.

Make sure you do nice approach. Make sure you saw everything nicely and just be really proud of your nice little approach and for your outcome. Again, really important to rehab them. There's only time you cut a bone that you're rehabbing the the devil out of them and so get them using it. Get them, get them, get the wounds stuck together and potentially in the sutures out and get them walking up and down stairs and everything you can get them to do again. Ideally if they can afford to go to a physiotherapist then that's really helpful.

And again try, we can say to the students and do your do you post up. Don't forget to do your post op radiograph say that's the students all the time to make sure that you've got a good same with the hip luxation be mindful if you produced a hip take an extra dollars taken extra effort before you send it out the door. Don't say to yourself it's in. It's going to stay in. It's definitely in because it could come out so at least if you've got that X Ray that you got when you got back in order.

But it's really important for your, for your indemnity and we had a dog a few years ago that they had femoral head and neck to the wrong side. Now I have no idea how they on the other side was horrendous. That had a confirmation number, mountain boxer Ann and I have no idea. Had clients didn't. I mean we, it wasn't our position to our budget. Our position to say anything but we had to say to the first opinion. But just to tell you that we think you've done the wrong side.

An so.

Remember, Checklist Checklist, Checklist checklist, checklist, and it's so important if you're not using checklists already, I'm sure you all are just double check. Check double check check and just really you know. I know it sounds mad but but just you know double check. Double check it happens. Oh my God it happens anyway so just be mindful to take off the femoral head and neck. This is one of mine and this does not have the femoral neck tag. No I didn't go back into this. I think if it was now I will go back into this because I think I've done the other side.

Dog was OK with the cavalier, but I would definitely go back into this now that I would not be happy with that at all. And so the way to really avoid that you can measure on the radiograph to know you can just measure from the tippy or you can pre measure from the tip your femoral head back to where you want to call it. You want to be coming down the line by the lesser cancer and this one actually decide was quite good but you want to be coming down and taken all that off and again you can measure it and the way to avoid getting yourself in trouble is make sure the patellas.

Pointed to the Sky very, very important. But Alas, the Sky always tell students that and so total hip replacement. Oh my God, Evan said she's actually spent 40 minutes and she's got a total hip replacement. So the anticipation. That's the only reason I've got here is just with that. He said to me last week and said they were going to turn up. If you say there's going to be a whole session on hip replacement.

Anyway, sorry for the disappointment, it's more important. It's like the box of chocolates. It's the whole thing. It's not just. It's all the little parts of the box of chocolates. Rodney, Nolan.

And so I think it is successful. I think. Actually, worryingly, I think it. Probably they are pretty good up to about 12 once you get them passed about 10 to 12 weeks I think. Probably worryingly, I think maybe we are as a profession and reporting the complications in. This is something we've seen in the in hip registry, so I would say watch this space and I think again it depends an an. It's a little bit like people. I think the more of these do you do, the better you are at them. I think the more.

At Liverpool, we've got a team of people and I haven't been in for awhile. Haven't been involved in not some recently because I've been at home, but you know, I think as a part of a team I think we do these as the part of a team, and I think particularly with cementless total hip replacements, they definitely need to retreat. People that watch what's going on. 'cause there's so reliance or get the same system correct and the cups correct in terms of the angles. And they're not something I would advise.

Anybody to do? Unless they've got significant amount of training, orthopedics, it's just. It's not worth stress it. You know it might make you feel. May be great that you've done it all hip replacement. But if that's how you work and how you get your kicks, but the stress of actually what goes wrong and how catastrophic it can be if it goes wrong, I don't think it's worth at an so generally we would have said it was more of a salvage thing. I think now they're being done a lot more frequently and earlier.

And I think because people aren't doing T pose. Particularly. I think we wait like the algorithm said. Maybe give him appear conservative management, try not let them get remodeled so once they get his remodel does this then they become quite difficult to do because it becomes very hard to try and ascertain this the the true acetabulum. So that's why I'm saying about the basically look side one. This would have been potential oxide one, but you can see that you've got all this angle of inclination and the femoral head and neck remodeling as opposed to the one I showed you with the no.

An primary science.

And that then has to. You then have to make sure you know where you're going to cost us an on the cancer is gone, so it's trying to fail with cancer is. And then they asked. Problem is completely remodeled and in fact there's been no femoral head within this acetabulum for a very long time. So you can imagine that, then put in this hip back in. Then the muscles are trying to accommodate what's going on here, because they've all fibros and got very tight and and that's when you get problems.

With them wanting to come back out again.

So generally cements the mentalist. Generally the systems are biometrics, Kyon and Helica. There the main systems that instrumentation have got a system, but I'm not sure how many people actually use that, but they do have that even got any of those on their precious tree and so they do. They do market one and this is certainly did an biometrics, probably the most common one in this country. Again, there's people in Europe and people use the muscles. Kyon is the second most common one and that's gotta screw in implant.

An. The biometrics one is cemented cementless and hybrid, so hybrid is a combination of two, which is generally a cement less cups or biological fixation cop, so that suppress fish which you do on your templating. Your X Rays and you're. They generally have cemented stem because they are more difficult than were associated with more be affects. See if X is and cement, and the effects this meant less.

And then you've got the standard. You've got large systems, and then you've got nano or micro which takes you right down to cats. And if there is increasing amount of people doing Cat total hip replacements which will talk about the 2nd.

And I think probably the smaller ones are more predisposed between dogs to having complications for sure. And the larger ones. So your new fees, your Saint Bernard. Again, dogs that have higher complications. So the ones you want to do and are border collies and slim Labradors. Basically there your own.

The balkcom really with.

And they do brilliantly afterwards, and the next day they walk. And we do epidurals and ours, or local blocks, and they look fantastic.

Again.

I would say a few years ago with dogs or bilateral, probably only 20 to 2025 to 50% of dogs ever have to have the second side done, so if they have one side done they may not have the second side done. I think I I think that I think most dogs are unilateral as opposed to cats which a lot of cats tended to be bilateral loan from the hip registry and so I was chatting. I'm still in everything. I was chatting to John Dice, who's probably the one of the world leading surgeons on total hip replacement in Ohio. And he was saying that actually.

A lot of dogs that come from all of America see him and one of the main reasons they're not operating on dogs is because they're overweight, so their obese. So do not be doing hip replacements. It'll be stocks. It is a disaster because you cannot get down. You think? Well, why doesn't make such a difference? Because you can't retract the femur. You can't get down far enough because you've got this watch of tissue, so you can't get down far enough to get your instrument syntactically remote. 'cause if you imagine you've got to get down, you've got everything out of the way. It gets out to redeem your.

Cup and then you have to get the famous the one you have to get everything down to sort of turn femur. When you've done, your farmer had an excision so that you can get it flat so you can get everything down. If you've got a very very adult was a lot of padding so to speak, and then it's very difficult to actually get that so that you can turn the femur out outwards to actually get your implants into it. So it's very, very important that they do need to lose weight before they come, and it's not an emergency unless it's something you're doing for a femoral head neck.

Fracture for example.

And so again, I've said already, lots of different options. The most common one probably is hybrid in this country and I would think the hybrids probably overtaken that, probably with the little ones now so.

Hold the micro and Nano currently are cemented their currently cemented an so the standard wounds tend to be so anything bigger than probably a 15K dog and then yeah 1315 kilos off then they tend to. You can probably you can do them both biological which is BFX cementless or cemented which you see effects an.

This is an example of a dog who's had a hybrid and standard, so this side here is had a cemented so you can see this meant going up here into the US problem and you can see the ring tells you the thing called the angle of lateral opening, which is very nicely done this years ago saying it's dangling opening is greater than 45 degrees of greater chance of luxation. Basically that ring needs to look like not a full circle, but like an Alex and then that's a nice position.

I am and it's got a cemented got cement as cemented stem so that's the CFX and that's had a lateral suture part around it as well, so it may have had some degree of laxity and now we've got better. Let let length of next so you can put a longer neck on so that avoids that sort of laxity and then, but they end up being externally rotated so they may walk with them. A walk looking a little bit like John Wayne for awhile. One thing it's worth checking if with these is if dogs have got patellar luxation

and hip replacements can make them worse. So it's really important to examine the dogs and check before you do the hip surgery on them, about whether they've got and patellar patellar luxation. And this is a hybrid. So this is a biological fixation cop an and you can see it's got no cement but it's gotta cook. That's probably could have gone in a little bit deeper to this pelvis and some of the Americans will talk about breaching the acetabular wall, and that's probably not something you want to do. I've seen a dog fractured stab him after that.

An later on an adopter I was involved in doing. My second Garth didn't turned 16 and it came back last year with a fractured acetabulum. After two or three years, so it can happen suddenly, but can happen later as well, and a lot of people like to do these hybrids because the Cup is actually not necessary straightforward getting, but it's actually less catastrophic if you get it wrong, whereas I think the effect stems you have to be very because they are filling their filling, the.

Fame or you have to be very particular on where they go. So there was a lot when they first people server start using them as a lot of dogs getting family Fishers and then getting fractures. If you see a family treasure, if you do cement cement less time than you do need to wire them before you make the. When you're in there an.

If they go well, some interest ones, they are so nice and so easy and you don't have to, you know, but you do need a team of two or three people that really know what they're doing will press on the side telling you to keep your hands and one person in front of you tell me which way to keep your hands. Answer To direct merged so it's actually really quite difficult to do with with just one or two surgeons. You do need two or three people to tell you what you're doing, 'cause you're doing a press fit.

And so again, the advantages of having the VFX would be the fact that you've not got sent in there, which is a mantle and awake for infection and causes losing. So you really want to try an or we. We certainly moved on to those we have been doing. Those probably in younger rather than older animals. And so again you want to have a degree of elasticity within the stem itself. As you put the sense very within the born self as he put them in.

Older animals tend to have disuse and tend to be more brittle, so may break easier enough anecdotal.

There were some people were putting bolts a little bit like the Kyon so that there is an action.

2 bolts bolts that you can put in here to help avoid zan to help you put those cementless ones in a void fissures and something we've done. Particularly in Liverpool. The one thing you need to be also mindful of with the BF xris mentalist is that you put them into dogs that I've got champagne flutes so they need to be like that. The confirmation needs to be like a champagne flute whereas if you've got a dog that's got us in color stove pipe so it's like straight up straight down.

Which German shepherds have? They're not. They're predisposed time fractures, and you shouldn't put the semantics implants into them.

He cares not something. Again there was some loosening in the first generation. We went to pay. I've written a paper on that with Hamish. Danny would put quite a few down and an Matt and Oh my God, what's Matthew second name kind of looks like an.

Much warmer, yeah? Who actually was a student at Bristol, but he's a born of him and Hamish works together. Any Annie's taking over his mantle of orthopedic nicetown in Bristol and he.

It they put it quite lottery tickets and they found the 1st generation tends to loosen so that split second generation in an.

And I mean all of them for complications. And I would say probably put that down.

And goodnight, I'm an so contraindications again skin disease and irisys. I've got a dog came to see us recently and that's almost godlight noises. It's got very on the border. Leishman ISIS, but it's really difficult to know what advise her to do to rescue dog from Romania. I'm sure you guys are all seeing rescue animals from all over the world now with all sorts of bad things. It's very difficult because of course The thing is the light and ISIS could we could.

Group could recrudesce an if you put a dog through a big surgery like a hip replacement. It's such a difficult thing and I I you know, ultimately they have to make the decision ultimately and you all know this. Ultimately they have to make the decision and you can only guide them what to do and you can push them. But you know it's sometimes it's like, well, these are. These are risks you know, and I'm sure you will get people to sign stuff you know even on the concert sheet or on the on the on the Time Warner Residences now lecture.

Who's spoken to all he he would actually get people to write on our clinical exam. She would put down all the complications and he would get them signed and get an assignment on the consent form and nothing save that necessarily covers here but you know they do have to take responsibility. Sometimes all you can do is really guide them and I think you know sometimes in medicine I think they're telling you very little. They tell you very little and hopefully that's getting better. But you go with it and I suppose in some ways we're nearing the other way. When you're ready to pro fantastic listen telling everybody, every single thing.

And sometimes they can't actually cope with that, so you do need to get them to make a decision and skin disease. Not really ideal, not treated specially. We're going to see effects into them an age. Yeah, I think once they get beyond a certain age, I don't think we do. Many hips in dogs after 8 years of age to be honest. To be very careful they haven't got something else. So myositis, lumbar sacral disease, nerve root tumors at hoco CD, cruise ship disease, cruise ship disease, crucial disease, Christian disease.

An there your biggest asset at the last night, I'll say it again, but actual Hippo, a bilateral harkaway secondary Jones City, bilateral stifle disease, immune mediated disease, and lumbar sacral disease. So just remember all those different things, or in your gamut, you know, if the hip is normal, if the hip is normal, it's not. It's big like a normal stifle radiographically. If there is no Fusion to not go into it. If you can put your hand on your heart and say my radiographs are very good, I can see no Fusion. Do not go into it.

You could scroll push, but I would just not open it an but again, I think I'd need to have an exhibition. If you've got a normal hip and the dogs got really bad signs.

You know, and you're not, it's somewhere else. It's somewhere else. Just it's happened to me a few times. It happens to everyone, but it hasn't. You know if something looks really awful, you're thinking what is explained. This tape doesn't look terrible, and so you know, do remember everything else.

They are expensive. It depends where you go. If we went down to see Grace, we'd be taken our gold bullion with us would be would be my son's reading. Treasure Island would be having long John Silver with us. He'd be bringing his gold coins on his leg and we won't ask her in which they are. If you come up to Typhoid City, typhoid cities much cheaper, so will will. What will do is will get well. Get well, get them up to Liverpool. I can come. They can have a maths ecover test and they get their dogs hip replacement done and will have change in their hands.

For Grace, and so I think it just depends where you go to an where about.

Four and a half, five in total. And then there are some people. I don't know if they're doing this the Ralph. There are some people. There's some fixed practices, downsides that give a guaranteed price, and that covers everything. So if there's any complications, then you've got. You know if you're charging 7 say resource and seven, then that is a guaranteed price. Now again, there are some practices. I know this from the registry. There are some practices that actually get people back to have X Rays every year to guarantee that price so.

Anyway, I don't know, but certainly you know if they go round, we charge a revision fever about 1000 pounds. If it goes wrong, but of course, as you know, once you have one complication, you may have others, right? I'm going to move onwards so I have been talking a bit about hip replacement so you did come, you did get value for money and anyway, so I don't know. I think complications are possibly higher than we like to think they are an. I would say watch this space. I think there are probably.

Probably 10 to 15%. We are told that their lasts than that. I don't know. I think unless we've got serious client unhappiness, I think our registry showing that the clients or clients are Eakin aside there thrown us under the bus, and so I think there's more complications than than potentially has been previously published, but it's probably about 1010%. The most common warnings luxation, and again, most of them occur.

Within the 1st two to three months and that's why we say for the first Check 8 weeks, they need to be strictly rested. They need not to be jumping over gates. They need not be jumping up and down birdie stairs. They need to be strictly rested for the first 8 weeks to try and let everything settle down.

Because you have done her family had an excision, you have had to do a gluteal tenotomy so you have had to cut muscle muscles and tendons. So you do need things to settle down. An rug Susanna was talks about. So not lots of wooden floors. If you can, we write a really detailed discharge note. I think that's very important. I'm sure you will do that anyway. And we do put words. Like I said this last day, catastrophic if you don't follow what we've told you to do so, just don't an ice auger. It's do that. Garths Garth Arthur said.

Discharge notice like if you do not do this, your dog will explode in 5 minutes like it's really. If you do not do this, your dog get a catastrophic you in capitals and he's right, he's absolutely right because it's back to that responsibility. You know you you need. You're doing your bit. You're doing your best. You're doing a lovely surgery. You've had palpitations during the surgery. Have sweat it. You know it's awful. And then they go and let the dog run away or something awful so you know, I think it's really important to put that onus on them as well.

Specially if you did good job an repeat radiographs is I very interesting at all vetting I did last Monday about actually, as somebody did it in Cambridge, actually looking at repeating X Rays for two pillows which is quite interesting, but I I think if it's an uncomplicated Tupelo, whatever that is. But I do have to repeat the radiographs on these. I think I didn't say. Actually I sort of said it. Templating for these is really for the diametric school and it depends on what system you're using.

The templating is generally three or four reviews and the beard. The biometrics one is a VD pelvis, a open air glass over the two legs for open an.

Unnatural an sorry and open a classroom where it's on its side and it's a lateral and open leg lateral where you can see both legs rather than the opening clash with just the one. The index when you're interested in and then as saffron media with two legs open and then a craniocaudal femur which I always called the Kama Sutra. They all laugh at me but that's where you put the dog on its back and then you shoot you put bring bring the leg forward and then you shoot down through the femur. That is a lovely view and if you ever want to get it.

Femur template for putting Duna fracture. Put the dog on its back and pull forward for the normal. Like if you want templated for a family fractures. That's a really nice view 'cause you get a lovely straight and femoral view.

An Oh my God.

So I was going to say just so basically.

What was I going to say? So after you've got the radiographs then you just restart, increasing your exercise and I don't know. I mean, again, it depends if there if they've got a guarantee or not an I will keep an eye on them as well. I mean I lost my clients, I get them to email me, but what we've seen with the load questionnaires as the dogs go out and we've got some dogs now that are nearly ten years out. The load score is starting to creep back up again, so and that makes sense because if they've got other musculoskeletal issues then they gain their mobility, is getting affected and they're getting older so the load story goes right down after surging then creeps back up again.

Hey so I'm going to finish in the second. We've got the two papers on the hip registries be VOA universalism, hip registry. There's now 1700 hips on it and I think we had $400 applies this year that did a modified low questionnaire. We did 30% complication rate out of those, so 100 dogs an just over 100 dogs had a complication rate and 70% of those have not been reported by the vets so.

Well, I don't know. I think. I mean, there's several things going on there, but certainly I think maybe the complications are higher than possibly we would like to say. But again, it's it's probably not as much as that it will be somewhere in between. Cats and cats. Yeah, definitely. More people are doing hip replacements in cats. They are small and challenging. Definitely gonna course to those. This cats got bilateral hip dysplasia. Here you can see it.

This is really hot off the press as in this week. Ann Veronica, who was one of our insurance, is going to write this up so 56th hips. Don't say you don't get hot off the press stuff in the in the Liverpool starting P half a heart.

And she found that about 74% then were domestic shorthair pretty shorter. So not all pedigree interesting. Most of them were male, neutered, an again a median age range was two years so young, so young and a lot of them had mostly topsail, IRC and 72% of them are bilateral, so a lot of them are two hips. Put in complications, nine at 56 hips which wasn't too bad, and that normally occur within the 1st three months and was luxation.

And nine at 5 out of that, nine had two or more complications, which meant that if your cats have complications start with, you're going to keep going with that and a lot of them ended up next consultation just to let you know an and the we actually the feline must go skeletal pain index, and they significantly censored that the owners had a very good satisfaction, so there you go. So I'm done. Sorry I'm just over an.

Again, hip osteoarthritis for those things that have been here for the long haul, and lots of things can contribute to it.

Happytime logically work. It's not very clear out their offices with some work done more recently with subset looking at dogs that potentially got osteoarthritis. An dogs generally associated spacing of cats. Are you say it was primary. I think cats do you also get his lazy ***? Sean and I also think that perhaps the last drops email new shirts.

There's a lot more we can do medically now or flat morana do fairly heavily believe in.