Canine hip dysplasia: reviewing the evidence for nonsurgical management

Mechanical osteoarthritis of the hip in a one medicine concept: a narrative review

Human and veterinary medicine have historically presented many medical areas of potential synergy and convergence. Mechanical osteoarthritis (MOA) is characterized by a gradual complex imbalance between cartilage production, loss, and derangement. Any joint instability that results in an abnormal overload of the joint surface can trigger MOA. As MOA has a prevailing mechanical aetiology, treatment effectiveness can only be accomplished if altered joint mechanics and mechanosensitive pathways are normalized and restored. Otherwise, the inflammatory cascade of osteoarthritis will be initiated, and the changes may become irreversible. The management of the disease using non-steroidal anti-inflammatory drugs, analgesics, physical therapy, diet changes, or nutraceuticals is conservative and less effective. MOA is a determinant factor for the development of hip dysplasia in both humans and dogs. Hip dysplasia is a hereditary disease with a high incidence and, therefore, of great clinical importance due to the associated discomfort and significant functional limitations. Furthermore, on account of analogous human and canine hip dysplasia disease and under the One Medicine concept, unifying veterinary and human research could improve the well-being and health of both species, increasing the acknowledgement of shared diseases. Great success has been accomplished in humans regarding preventive conservative management of hip dysplasia and following One Medicine concept, similar measures would benefit dogs. Moreover, animal models have long been used to better understand the different diseases' mechanisms. Current research in animal models was addressed and the role of rabbit models in pathophysiologic studies and of the dog as a spontaneous animal model were highlighted, denoting the inexistence of rabbit functional models to investigate therapeutic approaches in hip MOA.

Establishment of an ultrasound-guided protocol for the assessment of hip joint osteoarthritis in rabbits-A sonoanatomic study

Ultrasound (US) has emerged as one of the most applied imaging tools to diagnose musculoskeletal disorders and assist in guided intra-articular administrations. Nevertheless, in evaluating the rabbit hip joint, there is a need for an ultrasonographic approach. Therefore, this study aimed to describe the hip sonoanatomy, develop and validate a US-guided protocol to assess the hip joint in rabbits and apply this protocol in vivo. This study was carried out in three phases, phase I: a pilot cadaveric study, to assess the applicability of different US approaches in the hip of rabbits and, consequently, develop a detailed US-guided protocol (2 rabbit cadavers, n = 4 hips); phase II: validation of the established US-guided protocol through a numerical scoring system in healthy joints (11 rabbit cadavers, n = 22 hips), and, lastly, phase III: application of the US-guided protocol in vivo in osteoarthritic joints (5 rabbits, n = 5 hips). A total of six planes were validated, two in the ventral approach and four in the dorsal approach. The ventral transverse plane was deemed more informative regarding the hip joint sonoanatomy, enabling the identification of a greater number of structures when compared to the other planes. Nevertheless, this study suggested that the isolated application of a plane was deemed insufficient for a complete and detailed evaluation of the hip joint anatomy, rendering it necessary to employ other planes complementarily. Furthermore, the established US-guided protocol allowed a definitive diagnosis of OA, and osteophytes and capsular hypertrophy were among the defects most frequently detected. This novel study provided US anatomical landmarks for forthcoming therapeutic research and monitoring of OA development, granting the accurate identification of osseous and cartilaginous defects.

Endocannabinoid System Receptors at the Hip and Stifle Joints of Middle-Aged Dogs: A Novel Target for the Therapeutic Use of Cannabis sativa Extract in Canine Arthropathies

The endocannabinoid system (ECS) has emerged as a potential therapeutic target in veterinary medicine due to its involvement in a wide range of physiological processes including pain, inflammation, immune function, and neurological function. Modulation of the ECS receptors has been shown to have anti-inflammatory, analgesic, and immunomodulatory effects in various animal models of disease, including dogs with osteoarthritis. The goal of this study was to identify and compare the cellular expression and distribution of cannabinoid receptor type 1 (CB1R) and type 2 (CB2R) and the cannabinoid-related G protein-coupled receptor 55 (GPR55) on the synovial cells of hip and stifle joints of seven dogs of different breeds without overt signs of osteoarthritis (OA). The synovial membranes of seven hips and seven stifle joints were harvested post mortem. The expression of the CB1R, CB2R, and GPR55 present in the synovial tissues was investigated using qualitative and quantitative immunofluorescence and Western blot (Wb) analysis. Synoviocytes of the stifle and hip joints expressed CB1R, CB2R, and GPR55 immunoreactivity (IR); no significant differences were observed for each different joint. Cannabinoid receptor 2- and GPR55-IR were also expressed by macrophages, neutrophils, and vascular cells. The ECS receptors were widely expressed by the synovial elements of dogs without overt signs of OA. It suggests that the ECS could be a target for the therapeutic use of Cannabis sativa extract in canine arthropathies.

Systematic review of postoperative rehabilitation interventions after cranial cruciate ligament surgery in dogs

Objective

To critically evaluate the evidence for rehabilitation interventions following surgery for cranial cruciate ligament disease (CCLD) in dogs.

Study design

Systematic review.

Methods

Google Scholar and Pubmed databases were searched for studies evaluating postoperative CCLD rehabilitation interventions from 1990 until March 2020 per the international Prospective Register of Systematic Reviews (PROSPERO). Each study was assigned a level of evidence score from I to IV and a risk of bias (RoB) score by 2 reviewers, and by a third reviewer, when consensus was not reached.

Results

Nineteen studies met the inclusion criteria. Twelve comprised randomized, controlled trials (Level II), 6 were nonrandomized or nonblinded (Level III), and one was retrospective (Level IV). Nine studies had high RoB scores. Sixteen studies yielded positive results. Therapeutic exercise had the most studies with positive results but all had high RoB. Cold compression therapy had 3 supporting studies (2 Level II, low RoB). Extracorporeal shockwave yielded 2 positive Level II studies (low‐moderate and high‐moderate RoB) and photobiomodulation had 1 positive study (Level II, low RoB) with objective outcomes. A negative outcome was noted in 1 photobiomodulation study. There was 1 supporting study on electrical stimulation and there was none on low‐intensity pulsed ultrasound.

Conclusion

This systematic review supports the use of rehabilitation interventions in recovery of postoperative CCLD in dogs; however, many studies had a high risk of bias.

Clinical significance

There is a lack of class I level evidence in veterinary rehabilitation. This study supports therapeutic exercise and cold compression therapy for postoperative CCLD rehabilitation. Existing studies on other modalities are limited and demonstrate conflicting results.

Comparing Hip Dysplasia in Dogs and Humans: A Review

Hip dysplasia (HD) is common in both humans and dogs. This interconnection is because humans and dogs descended from a common ancestor and therefore have a similar anatomy at micro- and macroscopic levels. Furthermore, dogs are the animals of choice for testing new treatments for human hip dysplasia and orthopedic surgery in general. However, little literature exists comparing HD between the two species. Therefore, the aim of this review is to describe the anatomy, etiology, pathogenesis, diagnostics, and treatment of HD in humans and dogs. HD as an orthopedic condition has many common characteristics in terms of etiology and pathogenesis and most of the differences can be explained by the evolutionary differences between dogs and humans. Likewise, the treatment of HD shows many commonalities between humans and dogs. Conservative treatment and surgical interventions such as femoral osteotomy, pelvic osteotomy and total hip arthroplasty are very similar between humans and dogs. Therefore, future integration of knowledge and experiences for HD between dogs and humans could be beneficial for both species.

Chronic pain and gait analysis in dogs with degenerative hip joint disease treated with repeated intra-articular injections of platelet-rich plasma or allogeneic adipose-derived stem cells

This prospective, comparative, randomized, horizontal, and double-blind clinical study investigated the clinical efficacy of leucocyte-poor platelet-rich plasma (PRP, n=8) or allogeneic adipose-derived stem cells (ADSC, n=8) in dogs with bilateral degenerative hip joint disease (DHJD). Sixteen dogs were treated with two intra-articular injections of PRP or ADSCs, within a 30-day interval. The Canine Brief Pain Inventory (CBPI), the Helsinki Chronic Pain Index (HCPI), and Visual Analogue Scales for pain (VAS-pain) and locomotion (VAS-loc) were assessed by the dog owners. Analysis-of-gait using a force plate, response to palpation (VAS-palp), and the descriptive numerical scale for pain (DNS) were measured by a veterinarian. The assessments were performed before (baseline), 30 and 60 days after the first treatment. Data were analyzed using the unpaired t test, paired Wilcoxon test, Fisher’s exact test, and Mann-Whitney and Friedman tests (P<0.05). Compared with baseline HCPI, CBPI, VAS-pain, and VAS-palp scores reduced 41%, 52%, 51%, and 48% (P=0.0001–0.03) at 60 days in the ADSC group. In PRP-treated dogs, CBPI, VAS-loc, and DNS scores decreased by 43%, 43%, and 33% at 60 days, respectively (P=0.0003–0.011). Based on CBPI data, the rate of success at 60 days was 75% and 25% in the ADSC and PRP groups (P=0.13), respectively. Both therapies were apparently safe and effective to reduce chronic pain in dogs with bilateral DHJD during a 60-day period. However, a trend towards greater improvement was provided by the ADSC treatment.

Use of Reticulated Hyaluronic Acid Alone or Associated With Ozone Gas in the Treatment of Osteoarthritis Due to Hip Dysplasia in Dogs

This study aimed to evaluate reticulated hyaluronic acid alone or associated with ozone gas in the treatment of osteoarthritis due to hip dysplasia in dogs. Fourteen client-owned dogs were randomly assigned into two groups: Group 1—single intra-articular injection of hyaluronic acid; Group 2—single intra-articular infiltration injection of hyaluronic acid associated with ozone gas. Each hip joint received an average of 0.75 mL of reticulated hyaluronic acid ultrasound-guided. Ozone gas at a dose of 45 μg/mL was incorporated into hyaluronic acid by insufflation. Dogs were evaluated for body condition scoring, orthopedic examination and radiographic scores of the hip joints, goniometric measurements of the hip joints, visual gait score, and kinetic analysis. The evaluations were conducted immediately before treatments (M0), and at days 30 (M1), 60 (M2), and 90 (M3) after treatments. There were no significant differences in body mass and body condition scoring (5-point scale) in each group in all evaluation moments. The scores of orthopedic examination of the hip joints showed statistical differences in each group between moments (M0 > M3), but differences were not observed between groups. No statistical differences were found for radiographic scores in each group between moments, but differences were observed between groups immediately prior to treatments (G1 > G2) and 90 (G1 > G2) after treatments. Goniometric measurements of hip flexion and extension showed no significant differences in each group between moments or between groups. No statistical differences between groups were found concerning the lameness score. There were significant differences for lameness score among moments in Group 1, being M0 > M2 and M0 > M3, and Group 2 in which M0 > M1, M0 > M2, and M0 > M3. The mean percentage of change of PVF and VI between M3 and M0 in Group 1 was almost null and in Group 2 was positive, being 31.1 ± 29.4 and 10.6 ± 25.4, respectively. In conclusion, the intra-articular viscosupplementation alone or associated with ozone gas allowed improvement of lameness scores and orthopedic examination score. In Group 2 the association of ozone gas had better results on kinetic analysis.

Evaluation of plasma trace elements and oxidant/antioxidant status in Boerboel dogs with hip dysplasia

Changes in plasma concentrations of trace elements and oxidants/antioxidants were evaluated in twenty healthy Boerboels of both sexes and median age of 2 years. Antero-posterior and flexed lateral radiographs of the hip were obtained using digital x-ray machine and hip grading was done according to Fédération Cynologique Internationale (FCI) system. Blood was collected from the cephalic vein for determination of plasma concentrations of manganese (Mn), magnesium (Mg), copper (Cu), cobalt (Co), malondialdehyde (MDA), superoxide dismutase (SOD), glutathione (GSH), glutathione peroxidase (GPX) and Vitamin E. Correlation between the parameters was done using Pearson’s correlation. Eleven (11/20) of the Boerboel dogs had hip dysplasia (HD), comprising five (5/9) males and six (6/11) females. Plasma Mn, Cu and Co were insignificantly higher in Boerboels with normal hips than those with HD. MDA concentration was significantly (p<0.05) lower in Boerboels with normal hips (0.75 ± 0.84 µmol/L) than in dogs with HD (1.77 ± 0.78 µmol/L), while SOD was significantly (p<0.05) higher in Boerboels with normal hips (0.65 ± 0.22 U/ml) than with HD (0.32 ± 0.16 U/ml). It was concluded that there were differences in plasma oxidants/antioxidants between Boerboel dogs with normal hips and those with hip dysplasia suggesting their role in the pathogenesis of canine hip dysplasia

Intra-articular botulinum toxin A (BoNT/A) for pain management in dogs with osteoarthritis secondary to hip dysplasia: A randomized controlled clinical trial

The aim of this study was to evaluate the efficacy and safety of the intra-articular (IA) injection of botulinum toxin type A (BoNT/A) to the management of chronic pain in dogs. In a randomized, controlled, double-blinded study sixteen dogs with osteoarthritis secondary to hip dysplasia were distributed into two groups: 25 IU BoNT/A (BoNT) or saline solution (Control) was administered IA in each affected joint. All dogs received oral supplements (90 days) and carprofen (15 days). The dogs were assessed by a veterinarian on five occasions and the owner completed an assessment form at the same time (baseline to 90 days). The data were analyzed using unpaired-t test, Fisher's exact test, analysis of variance and the Tukey's test (P<0.05). There were no differences between groups in the veterinarian and owner assessments. Lower scores were observed in both groups during 90 days after IA therapy in the owner assessments (P<0.001). Compared with baseline, the Vet score was lower from 15-90 days after IA injection in the BoNT group, and at 15 and 30 days in the Control group (P<0.001). Both treatments were safe and reduced the clinical signs associated with hip osteoarthritis. However, IA BoNT/A (25 IU) did not provide better pain relief than the control treatment.

Cranial cruciate ligament structure in relation to the tibial plateau slope and intercondylar notch width in dogs

Cranial cruciate ligament (CCL) rupture is one of the most common orthopedic conditions in dogs. The pathogenesis of CCL rupture is not fully described and remains to be elucidated fully. Several hypotheses have been proposed to explain the etiology of these changes. The objective of this study was to investigate structural changes in the CCL in relation to the tibial plateau angle (TPA) and the intercondylar notch (ICN) width in dogs. Fifty-five skeletally mature dogs were included in this study. ICN width and TPA measurements were obtained from intact CCL stifles. Samples of the CCL, caudal cruciate ligament (CaCL), and femoral head ligament (FHL) were harvested and stained for routine histological and immunohistochemical analysis. Microscopic changes in the ligaments were observed and were found to correlate with the TPA and ICN width values. The degree of structural changes within the CCL was observed to correlate with an increasing TPA and a narrowing ICN width. Changes in the CCL are likely to be caused by excessive forces acting through the ligament in stifles with a high TPA. Chondroid metaplasia of the CCL is an adaptation to abnormal mechanics within the stifle joint caused by altered bone morphology.

Comparison of autogenous cancellous bone grafting and extra-corporeal shock wave therapy on osteotomy healing in the tibial tuberosity advancement procedure in dogs

Objectives: To compare optical values in the osteotomy gap created after a tibial tuberosity advancement (TTA) treated with autogenous cancellous bone graft, extracorporeal shock wave therapy, a combination of auto-genous cancellous bone graft and extra -corporeal shock wave therapy, and absence of both autogenous cancellous bone graft and extracorporeal shock wave therapy using densitometry.

Methods: Dogs that were presented for surgical repair of a cranial cruciate ligament rupture were randomly assigned to one of four groups: TTA with autogenous cancellous bone graft (TTA-G), TTA with autogenous cancellous bone graft and extracorporeal shock wave therapy (TTA-GS), TTA with extracorporeal shock wave therapy (TTA-S), and TTA with no additional therapy (TTA-O). Mediolateral radiographs at zero, four and eight weeks after surgery were evaluated to compare healing of the osteotomy gap via densitometry. An analysis of variance was used to compare the densitometric values between groups.

Results: At four weeks after surgery, a significant difference in osteotomy gap density was noted between TTA-GS (8.4 millimetres of aluminium equivalent [mmAleq]) and TTA-S (6.1 mmAleq), and between TTA-GS (8.4 mmAleq) and TTA-O (6.4 mmAleq). There were no significant differences noted between any groups at the eight week re-evaluation.

Clinical significance: There were no significant differences in the osteotomy gap density at eight weeks after surgery regardless of the treatment modality used. The combination of autogenous cancellous bone graft and extracorporeal shock wave therapy may lead to increased radiographic density of the osteotomy gap in the first four weeks after surgery. Densitometry using an aluminium step wedge is a feasible method for comparison of bone density after TTA in dogs.

High energy focused shock wave therapy accelerates bone healing

Objectives: To evaluate the influence of shock wave therapy (SWT) on radiographic evidence of bone healing after tibial plateau leveling osteotomy (TPLO).

Methods: Healthy dogs between two to nine years of age that underwent TPLO were randomly assigned to receive either electro- hydraulic SWT (1,000 shocks) or sham treatment (SHAM). Treatment or SHAM was administered to the osteotomy site immediately postoperatively and two weeks postoperatively. Three blinded radiologists evaluated orthogonal radiographs performed eight weeks postoperatively with both a 5-point and a 10-point bone healing scale. Linear regression analysis was used to compare median healing scores between groups.

Results: Forty-two dogs (50 stifles) were included in the statistical analysis. No major complications were observed and all osteo -tomies healed uneventfully. The median healing scores were significantly higher at eight weeks postoperatively for the SWT group compared to the SHAM group for the 10-point (p <0.0002) and 5-point scoring systems (p <0.0001).

Clinical significance: Shock wave therapy applied immediately and two weeks post -operatively led to more advanced bone healing at the eight week time point in this study population. The results of this study support the use of electro-hydraulic SWT as a means of accelerating acute bone healing of canine osteotomies. Additional studies are needed to evaluate its use for acceleration of bone healing following fracture, or with delayed union.

A retrospective study on findings of canine hip dysplasia screening in Kenya

AIM

The current study was undertaken to evaluate the findings of canine hip dysplasia screening in Kenya.

MATERIALS AND METHODS

Records for 591 dogs were included in this study. The data was obtained from the national screening office, Kenya Veterinary Board, for the period between the years 1998 and 2014. Monthly screening records were assessed and information relating to year of evaluation, breed, sex, age, and hip score captured. Descriptive statistics of hip scores was computed based on year, sex, age, and breed.

RESULTS

A total of 591 records from the year 1998 to 2014 were retrieved at the National Screening Centre, the Kenya Veterinary Board. Each record was examined and data pertaining to year of screening, the breed, sex, age of the dogs, and the total hip score were recorded. The highest number of dogs screened for hip dysplasia (HD) was in the year 2009 and the lowest in the year 1998. More females than males were screened for HD and the mean age of all the dogs was 22.9±12.7 months. The most common breeds of dogs screened during the study period were German Shepherd (67.0%), Rottweiler (15.6%), and Labrador Retriever (12.2%). The mean hip score for the 591 dogs was 15.1±10.9 and the median 12.0. The mean hip scores per breed were; German Shepherd (16.3±12.1); Golden Retriever (16.0); Hungarian Vizla (15.0); Labrador Retriever (3.0±6.7); Great Dane (13.3±3.2); Rottweiler (12.2±8.2); Doberman (10.3±4.2); Rhodesian Ridgeback (9.6±3.8); and Boxer (9.3±0.6). Based on the hip score, moderate to severe HD was diagnosed in 16.6% of the dogs, mild HD in 32.7%, Borderline HD in 37.7%, fair HD in 6.9%, and good HD in 6.1%.

CONCLUSION

Canine HD is a common occurrence in Kenya with most dogs suffering mild to border line HD. In addition, German Shepherd and Golden Retriever appear to be the most affected breeds. It is therefore recommended that stringent measures be imposed to dog breeding programs to avoid transmission of this undesirable trait and consequently improve the welfare and the quality of dog breeds in Kenya.

Diagnosis, prevention, and management of canine hip dysplasia: a review

Canine hip dysplasia (CHD) is a polygenic and multifactorial developmental disorder characterized by coxofemoral (hip) joint laxity, degeneration, and osteoarthritis (OA). Current diagnostic techniques are largely subjective measures of joint conformation performed at different stages of development. Recently, measures on three-dimensional images generated from computed tomography scans predicted the development of OA associated with CHD. Continued refinement of similar imaging methods may improve diagnostic imaging techniques to identify dogs predisposed to degenerative hip joint changes. By current consensus, joint changes consistent with CHD are influenced by genetic predisposition as well as environmental and biomechanical factors; however, despite decades of work, the relative contributions of each to the development and extent of CHD signs remain elusive. Similarly, despite considerable effort to decipher the genetic underpinnings of CHD for selective breeding programs, relevant genetic loci remain equivocal. As such, prevention of CHD within domestic canine populations is marginally successful. Conservative management is often employed to manage signs of CHD, with lifelong maintenance of body mass as one of the most promising methods. Surgical intervention is often employed to prevent joint changes or restore joint function, but there are no gold standards for either goal. To date, all CHD phenotypes are considered as a single entity in spite of recognized differences in expression and response to environmental conditions and treatment. Identification of distinct CHD phenotypes and targeting evidence-based conservative and invasive treatments for each may significantly advance prevention and management of a prevalent, debilitating condition in canine companions.

Efficacy of an oral hyaluronate and collagen supplement as a preventive treatment of elbow dysplasia

One hundred and five Labrador dogs were randomly divided into two groups to determine the number of animals that develop elbow dysplasia when treated with an oral supplement compared to untreated ones. Efficacy of the oral treatment was also evaluated once illness was diagnosed. The supplement (Hyaloral) contained hyaluronic acid, hydrolysed collagen, glucosamine, chondroitin sulphate, and gamma oryzanol. Clinical evaluation of the elbow joints was completed at months 3, 6, 12, and 20 by orthopaedic evaluations, radiography, serologic and blood analysis, and veterinarian evaluation of dysplasia symptoms. All side effects were recorded. In the control group, 33.3% of the dogs developed radiographic evidence of elbow dysplasia compared to 18.5% in the treated group. Symptoms of dysplasia at 12 months differed between the treated (12.5%) and control (61.5%) animals, and were significantly different at 20 months (p < 0.05). Differences in lameness along with movement and swelling of the elbows between groups were observed after 12 months. The treated group had improved significantly by the last visit (p < 0.05). No adverse side effects were reported. In conclusion, oral treatment with Hyaloral may have a potential cumulative action that provides protection against dysplasia and significantly improves symptoms of elbow dysplasia.

Acupoint injection of autologous stromal vascular fraction and allogeneic adipose-derived stem cells to treat hip dysplasia in dogs

Stem cells isolated from adipose tissue show great therapeutic potential in veterinary medicine, but some points such as the use of fresh or cultured cells and route of administration need better knowledge. This study aimed to evaluate the effect of autologous stromal vascular fraction (SVF, n = 4) or allogeneic cultured adipose-derived stem cells (ASCs, n = 5) injected into acupuncture points in dogs with hip dysplasia and weak response to drug therapy. Canine ASCs have proliferation and differentiation potential similar to ASCs from other species. After the first week of treatment, clinical evaluation showed marked improvement compared with baseline results in all patients treated with autologous SVF and three of the dogs treated with allogeneic ASCs. On days 15 and 30, all dogs showed improvement in range of motion, lameness at trot, and pain on manipulation of the joints, except for one ASC-treated patient. Positive results were more clearly seen in the SVF-treated group. These results show that autologous SVF or allogeneic ASCs can be safely used in acupoint injection for treating hip dysplasia in dogs and represent an important therapeutic alternative for this type of pathology. Further studies are necessary to assess a possible advantage of SVF cells in treating joint diseases.

A systematic review of the literature describing the efficacy of surgical treatments for canine hip dysplasia (1948-2012)

OBJECTIVE

To systematically evaluate the literature reporting outcome of surgical treatments for canine hip dysplasia (CHD) and to evaluate whether adequate evidence exists to support a procedure that will allow a consistent return to normal function.

STUDY DESIGN

Systematic literature review.

ANIMALS

Dogs with naturally occurring CHD.

METHODS

An a priori question was defined and a computer-based bibliographic search was performed on PubMed, Medline, CAB Abstracts, and Veterinary Information Network through November 2012. Studies were compared and evaluated with regard to surgical technique, study design, outcome measurements, evidence classification, and evidence quality. Unilateral surgeries with >6 months postoperative follow-up were included.

RESULTS

Manuscripts (n = 477) were identified and reviewed; 17 met the inclusion criteria. One study provided level I evidence, 2 provided level II evidence, 3 provided level III evidence, and 11 provided level IV evidence relative to the study question. The most common outcome measurements were orthopedic examination (70.6%), owner interview (70.6%), and visual gait observation (64.7%). Three studies used objective kinetic gait assessment. Two studies with level III evidence (total hip replacement) and 1 study with level IV evidence (juvenile pubic symphysiodesis) documented a consistent return to normal function after surgery.

CONCLUSIONS

Despite a large number of publications describing clinical outcome after surgical treatments for CHD, few provided strong evidence to allow an adequate assessment of therapeutic efficacy.