Clinical and Radiological Evaluation of Modified DARthroplasty Using Rib Allograft Impregnated with the Mesenchymal Cells & PRP in Dogs

Document Type: Infectious agents- Diseases- Surgery

Authors

Department of Surgery and Radiology, Faculty of Veterinary Medicine, University of Tehran,Tehran, Iran

Abstract

BACKGROUND: Hip Dysplasia is a frequent orthopedic disease that is characterized by early joint sublux- ation. The DARthroplasty technique is a two-part process that involves applying bone graft to increase the femoral head coverage with a low morbidity rate and the long term is known results.
OBJECTIVES: This study was aimed to investigate the radiographic and clinical changes after transplanting the rib allograft impregnated with PRP and MSCs in the treatment of hip dysplasia in a dog. The current study was conducted to assess the effectiveness of modified DARthroplasty.
METHODS:12 dogs were selected, all of them operated by the modified induced hip dysplasia. Afterward, an approximately 25 mm segment rib was harvested and transplanted at slot approximately 7 mm broad and 12.5 mm high, close craniodorsally to the joint capsule origin, and secured with a 2 mm cortical bone screw in each recipient dog. PRP and MSCs were injected into the gap around allograft. Subsequently, they were divided into 3 subgroups of 4 dogs in each group, control, PRP, and MSCs. 6 months after the surgery, all dogs were subjected to clinical and radiographic evaluations.
RESULTS:Clinically, all dogs showed no sign of orthopedic disorder which was determined by Ortolani sign, and no muscle atrophy and pain were elicited in the hip joint. One dog showed a slight lameness degree about two weeks and one case had seroma but was immediately treated by aspiration and pressure bandage. Upon ra- diographic examination, no dislocation of the rib allograft could be detected. Bone proliferation was observed. Dogs in all groups showed NA and PC increase with MSCs (5.25 ± 0.3 and 22.5 ± 0.81), PRP group (6.5 ± 0.43 and 20.5 ± 0.12) and control group (6.5 ± 0.35 and 19 ± 1.23) at six months postoperatively.
CONCLUSIONS: This study showed that rib bone allograft with PRP and MSCs can be quite effective on joint congruency and stability in symptomatic dogs due to hip dysplasia.

Keywords


Article Title [Persian]

ارزیابی بالینی و رادیوگرافی آرتروپلاستی سقف استابلوم تغییر یافته بافت پیوندشده دنده پوشش داده شده با سلولهای مزانشیمی وپلاسمای غنی از پلاکت در سگ

Authors [Persian]

  • علیرضا بشیری
  • داود شریفی
  • محمد ملازم
گروه جراحی و رادیولوژی، دانشکده دامپزشکی دانشگاه تهران، تهران، ایران
Abstract [Persian]

زمینه مطالعه:  دیسپلاژی لگن یکی از بیمارهای متداول ارتوپدی است که به همراه دررفتگی مفصل به وقوع می‌پیوندد. روش آرتروپلاستی سقف استابلوم دو مرحله‌ای می‌باشد و بر اساس آن گرفت استخوانی برای افزایش پوشش سر استخوان ران به کار می‌رود که مطالعات کمی بروی آن انجام شد و متعاقباً نتایج بلند مدت و میزان به‌کارگیری کمی دارد. 
هدف:  هدف از مطالعه حاضر، ارزیابی تغییرات رادیواگرافی و بالینی بعد از پیوند شدن بافت دنده پوشش داده شده با یا بدون سلول‌های مزانشیمی و پلاسمای غنی از پلاکت در درمان دیسپلازی لگن در سگ. در این مطالعه میزان اثرگذاری آرتروپلاستی سقف استابلوم تغییر یافته مورد بررسی قرار می‌گیرد.     
روش کار: 12 سگ انتخاب شد و همه آن‌ها در ابتدا تحت عمل جراحی القای دیسپلازی اصلاح شده قرار گرفتند. سپس یک قطعه 25 میلی‌متری از دنده استخراج شد و در یک حفره تقریبا با پهنای 7 میلی‌متری و عمق 5/12 میلی‌متری در بالا و جلو منشأ کپسول مفصلی مفصل لگنی رانی بوسیله پیچ 2 میلی‌متری کورتیکال به هر سگ پیوند شد. پلاسمای غنی از پلاکت و سلول‌های بنیادی مزانشیمی به محل پیوند تزریق شد. متعاقباً حیوانات در سه گروه چهارتایی قرار داده شدند: گروه کنترل، گروه پلاسمای غنی از پلاکت و گروه سلول‌های بنیادی مزانشیمی. 6 ماه پس از جراحی، همه سگ‌ها مورد ارزیابی بالینی و رادیولوژی قرار گرفتند. 
نتایج:  از لحاظ بالینی هیچکدام از ‌سگ‌ها اختلال ارتوپدی که با علامت اورتولانی مشخص می‌شود، مشاهده نشد همچنین کاهش حجم عضلات و درد در مفصل لگنی رانی نشان داده نشد. در یکی از سگ‌ها لنگش خفیف به مدت دو هفته دیده شد و در یک مورد دیگر سروما تشکیل شد که با کشدن محتوای آن و بانداژ فشاری درمان شد. در ارزیابی رادیوگرافی هیچ علامت جابه‌جایی دنده مشاهده نشد. پرولیفراسیون استخوانی مشاهده شد. سگ‌ها در در تمامی گروه‌ها افزایش زاویه نوربرگ و درصد پوشش داده شده سر استخوان ران برای گروه سلول‌های مزانشیمی مغز استخوان (25/5±3/0 و 22/5±81/0)، برای گروه پلاسمای غنی از پلاکت (5/6±43/0 و 5/20±12/0) و کنترل (5/6±3/0 و 19±23/1) در شش ماه پس از عمل نشان داده شد.  
نتیجه گیری نهایی:  نتایج این مطالعه نشان می‌دهد که بافت پیوند شده دنده پوشش داده شده با سلول‌های مزانشیمی و پلاسمای غنی از پلاکت می‌تواند کاملاً در یکپارچگی و استحکام مفصل در سگ‌های با علائم دیسپلازی مفصل لگنی رانی مؤثر باشد

Keywords [Persian]

  • دیسپلازی مفصل
  • آرتروپلاستی سقف استابلوم
  • سلول‌های مزانشیمی
  • پلاسمای غنی از پلاکت

 

Introduction

Hip dysplasia is an impaired development of the hip joint characterized by subluxation or complete luxation of joint with subsequent mild to severe degenerative changes mani- fested by pain and lameness (Tomlinson and Cook, 2002). The incidence of hip dysplasia is highest in large and giant breeds and has increased in the past 50 years which is a con- cern for dog owners, dog breeders, and vet- erinarians (Comhire and Snaps, 2008; Smith, 1998). While the definitive diagnosis of hip dysplasia must be based on the radiograph, other screening methods include clinical signs, palpation, ultrasound, computed to- mography, and magnetic resonance imaging (Flückiger, 2008; Ginja et al., 2009; Butler and Gambino, 2017). Treatment options of hip dysplasia range from conservative (ad- ministration of nonsteroidal anti-inflamma- tory drugs, chondroprotective drugs, weight maintenance, exercise moderation, complete rest, dietary changes, physical therapy, con- fining to restricted cages, nutraceuticals, acupuncture, and stem-cell therapy) to sur- gery (Marx et al., 2014; Vilar et al., 2014; Dycus et al., 2017; Corral, 2018). The surgi- cal options can be divided into two groups, depending on the animal’s age: (1) therapies aimed at alleviating pain consist of total hip replacement, femoral head, and neck os- tectomy, pectineal myectomy, coxofemoral denervation and (2) therapies aimed at pre- venting or lessening the amount of future degenerative joint disease(DJD) include ju- venile pubic symphysiodesis, triple pelvic osteotomy, double pelvic osteotomy, fem- oral neck lengthening, intertrochanteric os- teotomy and DARthroplasty (Moses, 2000; Denny et al., 2018; Witte, 2019). DARthro- plasty directly increases the size of the ac- etabulum by promoting the coverage of the


 

femoral head through implanting graft bone to the lateral rim (Slocum, 1998; Jacobs et al.; 2004, Grzegorzewski et al., 2013). DAR- throplasty is a relatively new center of atten- tion procedure for the prevention of early detrimental effects of luxation on joint el- ements (Yaprakci et al., 2014). Also, it has not been performed long enough to collect results from a large number of patients and there are  no  short-  or  long-term  scientif- ic studies documenting the effectiveness of DARthroplasty in the treatment of canine hip dysplasia (Luck, 2007). Mesenchymal stem cells (MSCs) are multipotential cells that can differentiate into osteoblasts, chondrocytes, stromal cells, adipocytes, fibrous tissue, myoblasts, tenocytes and become more com- monly utilized to promote bone graft fusion rate (Anderson et al., 2013, Lee et al., 2011). Platelet-rich plasma (PRP) containing many growth factors such as transforming growth factor-β, platelet-derived growth factor and insulin-like growth factor that  are involved in bone healing and tissue repair and also as an augmentation procedure to improve im- plant healing (Roffi et al., 2013, Jensen et al., 2005). This study aims to report the use of al- lograft bone impregnated with mesenchymal stem cells derived from bone marrow and platelet-rich plasma in canine DARtroplasty and to retrospectively evaluate the clinical and radiographic outcome after a 6-month follow-up.

Materials and Methods

In this study, twelve neutered adult male mongrel dogs, weighing ~ 22.5 ± 2.5 kg, were provided at 12 months of age by the University of Tehran (Tehran, Tehran Prov- ince, Iran). All experimental procedures involving animals were conducted accord-

 

 

 

ing to the Ethical Principles in Animal Ex- periments adopted by Faculty of Veterinary Medicine Research Committee and were ap- proved by the Experts Research Committee in Faculty of Veterinary Medicine Universi- ty of Tehran, Protocol 2345/95/2016. First- ly, animals received vaccination and they were wormed and castrated. After, the dogs underwent a radiographic and physical and orthopedic examination to obtain baseline information. Secondly, while coxofemoral luxation and hip osteoarthritis models have been previously described (Ozaydin et al, 2003, Little et al., 2016), a modified model of coxofemoral subluxation to induction of hip dysplasia was provided by capsulotomy, ligament capitis osis femoris transaction and capsulorrhaphy with craniolateral approach (Figure 1, A). Dogs were assessed to be at-risk for CHD by evidence of hip laxity, which was defined as orthopedic examina- tion and radiographs.

All dogs were subsequently divided into 3 groups of four dogs each: Control (acetab- ular coverage with allograft), PRP (acetab- ulum was covered by allograft impregnated with PRP), and MSCs group (covered ace- tabular with allograft and MSCs).

Surgical technique

Modified DARthroplasty was carried out on all dogs. Animals were taken off-feed for 12 h and water was withheld for 2 h. All re- search dogs were premedicated with a Ket- amine (10 mg/kg, IM, Alfasan, Netherlands) and Xylazine (0.5 mg/kg, IM, Alfasan, Neth- erlands) and afterward the left coxofemoral area was thoroughly clipped. After receiving a prophylactic dose of Cefazolin (22 mg/kg, IV, Exir, Iran), anesthesia was inducted by a combination of Ketamine (5 mg/kg, IV) and Diazepam (0.25 mg/kg, IV, Caspian Tamin, Iran). Following endotracheal intubation, in-


halation anesthesia was maintained with 2% Isoflurane in Oxygen via a rebreathing cir- cuit. Animals were positioned in left lateral recumbency, then thorax and left coxofem- oral region were aseptically prepared for the surgery with betadine and alcohol. After rou- tinely reaching the hip joint with a dorsal ap- proach, an arch-shaped  slot,  approximately 7 mm broad and 12.5 mm high, was created close dorsally to the joint capsule origin into the subchondral bone from the cranial end in anterior direction using a high speed round burr. An appropriate 2 mm cortical bone screw was selected based on measurement by depth gauge and radiograph. After ad- justment, the rib allograft was firmly packed into the slot and secured to the recipient bed with screw in a lag fashion in such a way as to cover the posteriolateral aspect of the fem- oral head and to rest on the capsule (Figure 1, B). The motion of the hip was checked to find out whether the graft did not restrict its full range, and where necessary the graft was made smaller. The next step included metic- ulous reinsertion of gluteal muscles and clo- sure of the wound routinely.

Allograft collection

Before the beginning of primary surgery, standard lateral approach to the right thorax on the area of greatest convexity was applied to harvest an approximately 25 mm segment of the 8th left rib, which was wrapped in sterile saline (0.9% NaCl) solution soaked gauze sponge to be transplanted in a recipi- ent dog which was prepared simultaneously. (Aranda et al., 2008; Boudrieau et al., 2004; Makridis et al., 2012).

PRP preparation

For obtaining autologous PRP, before each operation, peripheral venous blood was drawn into tubes containing an anticoagulant (ACD) under standard aseptic technique.

 

 

 

The four 10 ml ACD tubes were filled for each of the four dogs in the second group and immediately transferred to the laborato- ry. Blood samples were centrifuged (Smart- PReP2, Centrifuge, Harvest Plymouth .MA) for 5 min at 1000 g so that its three compo- nents (Erythrocytes, buffy coat, and plate- let-poor plasma) were formed based on the density of blood components. The buffy coat layer was closely collected by a pipette and pooled in a separate tube which was spun for a second time for 15 min at 1500 g so that the PRP portion was taken from the surface, 3 ml of PRP mixed with calcium chloride solu- tion was obtained. Four syringes  contain- ing PRP were delivered to operation room  so that a volume of 3 ml of PRP contain-  ing 882±199×103 plate‌let/μl was utilized around allograft site for each dog (Bearden et al., 2017; Lee et al., 2014; Messora et al., 2014; Shin et al., 2017; Dallari et al., 2016; Aldirawi et al., 2018).

Bone marrow MSCs isolation

Under strict aseptic condition bone marrow was obtained from the iliac wing of dogs three weeks before transplantation surgeries. Under anesthesia and using a Jamshidi bone marrow needle (15G), 9 mL bone marrow was aspirat- ed into a syringe containing 1mL heparinized saline solution. Immediately specimens were sent to the cell-culture facility. The BM-hep- arin blood was diluted at a 1:1 ratio with Dul- becco’s modified Eagle’s medium (DMEM; Gibco, USA) high glucose and carefully laid over the 3 ml Lymphosep density gradient medium (Biowest, France) in a 15 ml conical tube and then centrifuged for 30 min at 400 ×g. The mononuclear cell layer at the plasma-Fi- coll interface was removed and  resuspend-  ed in DMEM and finally centrifuged  at 400 gr for 10 min twice. The mononuclear cells were plated in tissue culture flasks at a den-


sity of 1×105 cells per 25 cm2 10% fetal bo- vine serum (FBS; Gibco, USA), 1000 IU/ml penicillin, and 100 μg/ml streptomycin were added to culture flasks and incubated at 37°C with 5% CO2 and 95% air at 100% humidity. Four days after the initial culture, plates were washed with Dulbecco’s Phosphate Buffered Saline (DPBS) to remove the nonadherent cell. From this point on, every 2nd day, we changed the medium until a confluence of 70-80% was achieved. The BMSCs, adherent cells, were harvested with 0.25% trypsin-ED- TA and subcultured until at passage 3 they were used in the third group. MSCs were in- jected into the gap around allograft in specif- ic dogs from which they had been collected. (Callegaro et al., 2018; Bearden et al., 2017; Jo et al., 2017; Long et al., 2013; Rafatpanah et al., 2018; Grabowski and Robertson, 2013; Mirghasemi et al., 2017; Thua et al., 2015).

Post–operative care

Radiographs were taken immediately af- ter the surgical procedure to be assessed as the baseline date for comparative purposes with follow-up radiograph  examinations  at 6 months. After recovery from general anes- thesia, the dogs were transferred to their re- spective cages. Cefazolin (22.5 mg/kg, IV), was administered every 12 h for five days and Tramadol (2 mg/kg q12h, Alborz Darou, Iran) was given for 3 days and changed to oral Tramadol (4 mg/kg q12h, Alborz Darou, Iran) for 5 days. Skin sutures were removed within 14 days. The orthopedic examination was conducted at 2 months and 6 months postoperatively also neurological examina- tions were performed to exclude conditions other than a hip disorder.

Evaluation

Ventrodorsal hip_extended radiographs were used to calculate Norberg angle and estimate femoral head coverage using the

 

 

 

scoring system developed by the Orthope- dic Foundation for Animals (OFA) via an MX-20 Cabinet X-ray System (35 kV, 300 μA and 240 s) under sedation (IM Ketamine (10 mg/kg) and Xylazine (0.5 mg/kg) and af- terward an IV cocktail of Ketamine (5 mg/ kg) and Diazepam (0.25 mg/kg)). The radio- graph image was used for diagnosis, DJD score (0-4), Norberg angle (NA), percent coverage (PG) of the femoral head by ace- tabulum, graft position, metallosis around screws, bone proliferation associated with the graft. The Clinical variables evaluated include Ortolani maneuver, gait observation for gross lameness score (an abnormality of gait or posture), muscle atrophy (decrease in mass of muscle), the hip extension to detect pain with passive movement and range of motion, presence of seroma (Off and Ma-


tis, 2010; Dueland et al.,  2010).  DJD also is known as  osteoarthritis,  was  defined  as a noninflammatory, noninfectious degener- ation of articular cartilage characterized by bone formation at the synovial margins and by fibrosis of periarticular soft tissue. Nor- berg angle (NA) was characterized as the re- lationship of the center of the femoral head to the craniolateral aspect of the dorsal ace- tabular rim, a NA of 105o or greater has been considered to indicate normal status. Percent Coverage is an indication of the support pro- vided by the acetabulum to oppose the force transmitted from the femur, a  PC  of  50% or greater was normal status (Figure 1, C). Ortolani sign was defined as the “clunk” or shift palpated as the femoral head enters the acetabulum during the abduction of the hip.

  

 

                       

       
A

B                                                                       C

 

Figure 1. Radiographic images show (A) a hip subluxation following the modified induced coxofemoral subluxation proce- dure which is measured by NA and PC parameters in a standard ventrodorsal projection and (B) after a modified DARthro- plasty, the femoral head was completely covered with the rib allograft. (C) An illustration of periosteal reaction and allograft remodeling on the radiograph and indicates the amount of acetabular coverage.

 

 

Table 1. Clinical tests performed, time tested and percentage of the dogs tested.

 

 

 

Control

 

PRP

 

MSC

 

 

 

Before Surgery

After Sur- gery

Before Surgery

After surgery

Before Surgery

After Sur- gery

Ortolani   Sign Negative

Positive

 

 

0

 

1

 

 

 

(100%)4

 

 

 

(100%) 4

 

 

 

(100%)4

(100%)4

 

(100%)4

 

(100%)4

 

Lameness None Slight Mild Moderate

Severe or intermittent non- weight-bearing

 

Non-weight-bearing   most of the time

 

 

0

 

1

 

2

 

3

 

4

 

5

 

 

 

 

 

 

(50%)2

 

(25%)1

 

(25%)1

 

 

 

 

 

 

(75%)3

 

(25%)1

 

 

 

 

 

 

 

(50%)2

 

(50%)2

 

 

 

 

 

 

 

(100%)4

 

 

 

 

 

 

 

(75%)3

 

(25%)1

 

 

 

 

 

 

 

(100%)4

Musculature   (hip and thigh) regions

 

Normal

Some atrophy Marked   atrophy

 

 

0

 

1

 

2

 

 

 

 

)100%(4

 

 

 

 

)100%(4

 

 

 

 

)100%(4

 

 

 

 

)100%(4

 

 

 

 

)100%(4

 

 

 

 

)100%(4

(Pain)on the hip extension None

Mild   to moderate (turning or) pulling on the limb

 

Severe   (vocalisation or aggression)

 

 

0

 

1

 

2

 

 

(25%)1

 

(75%)3

 

 

 

 

(100%)4

 

 

(25%)1

 

(75%)3

 

 

 

 

(100%)4

 

 

 

(50%)2

 

(50%)2

 

 

 

 

(100%)4

Seroma None A little

A lot

 

 

0

 

1

 

2

 

 

(100%)4

 

 

(75%)3

 

(25%)1

 

 

(100%)4

 

 

(100%(4

 

 

(100%)4

 

 

(100%)4

 

 

Results

The authors have performed the DARthro- plasty with rib allograft on 12 hips. All dogs completed the study without major compli- cations. According to the same clinical re- sults that have been obtained at 3 months


and 6 months after surgery and the absence radiographs between post-op and 6 months, the comparison was mentioned between pre- operative and by next six months. In the control group, one graft was fixed using two screws that did not present a significant dif-

 

 

Table 2. NA and PC study showing means and standard errors in control, PRP , and MSC groups before and after 6 months of grafting.

 

 

Control

 

PRP

 

MSCs

 

NA

PC

NA

PC

NA

PC

Before Surgery

101.25±1.29

40.25±2.04

101.75±1.39

41.75±2.16

103.25±0.82

43.75±1.47

After Surgery

107.75±1.64

59.25±3.27

108.25±1.82

62.5±2.28

108.5±1.12

66.25±2.28

 

 

ference in that final result compared with the other dogs. All dogs that showed positive Ortolani sign before surgery was converted to a negative after surgery. Eleven dogs had no apparent lameness at 6 months, whereas the other one had some lameness for approx- imately 2 weeks due to soft tissue injury in the control group. After the third week, all dogs had a subjectively normal gait. Post- operative re-evaluation indicated that  all dogs had normal range of motion without pain during passive movement of the limb. Muscle atrophy did not occur after surgery (Table 1). In the PRP group, one early patient had a little seroma, which was due to loose muscle closure. This responded well to aspi- ration without any sign of infection. In the MSCs group, one graft appeared slightly cra- nial to its expected location but fortunately, it was considered enough to cover the femoral head. None of the dogs revealed any DJD and metallosis findings radiographically. No dislocation of the allograft was observed in any of the dogs until to be remodeled (Fig. 1, C). The mean ± SD value of the preoperative NA was 101.25 ± 1.29 (range, 100o to 103o; median 101o), 101.75 ± 1.39  (range,  100o to 104o; median 101.5o) and 103.25 ± 0.82 (range, 102o to 104o; median 103.5o) for control, PRP and MSCs, respectively. After surgery, the mean ± SD of the same parame- ter increased to 107.75 ± 1.64 (range, 105o to 109o; median 108.50), 108.25 ± 1.82 (range,


107o to 109o; median 108.5o)  and 108.5 ±

1.12 (range, 107o to 110o; median 108.5o). In the control group, the PC values were 40.25% ± 2.04% (range, 37% to 42%; me- dian 41%) and 59.25% ± 3.27% (range, 55% to 64%; median 59) before and after surgery, respectively, and this increase was elicited in the PRP 40.25 ± 2.04% (range, 39% to 45%; median 41.5%) and 62.5% ± 2.28% (range, 60% to 62%; median 61) pre and post-op- eration,  respectively.  The  PC  surged   from

43.75 ± 1.47% (range, 42% to 46%; median 43.5%) to 66.25% ± 2.28% (range, 64% to 70%; median 68) postoperatively in MSCs group (Table 2). Bone proliferation was not- ed at the cranial aspect of the implant in all recipient dogs.

Discussion

DARthroplasy is a surgical intervention intended to improve the biomechanics of the hip, hip joint congruity, decrease abnormal hip joint laxity, normalize  articular  stress- es and reduce hip pain. It can be performed bilaterally and done with routine bone in- struments with a minimal fixation for a rea- sonable cost compared to other procedures (Witte, 2019). Dogs clinically affected by  hip dysplasia with palpable  or  radiograph- ic joint laxity before articular cartilage is badly damaged, are candidates for this pro- cedure (Hupp et al.,  2007).  DARthroplasy is also a viable surgical option for dogs in

 

 

 

which juvenile pubic symphysiodesis, triple pelvic osteotomy, and total hip replacement are precluded by cost, age, degree of laxity. This technique is an advanced procedure  and should be performed only by expert sur- geons and contraindicated when there are signs of advanced DJD, breakdown of the dorsal acetabular rim, or neurological dis- ease. Early reports indicated that the animals with significant DJD but without instability are not considered candidates for it, because the function of this procedure is to improve stability. This procedure results in an excel- lent return to normal function unless com- plications occur. Although temporary sciatic neuropraxia, screw breakage, infection and seroma have been reported as complications secondary to biocompatible osteoconductive polymer shelf arthroplasty, in our study none of them occurred postoperatively other than seroma in one case which responded to as- piration and pressure bandage. In this case, appropriate muscle suturing and dead space obliteration could have been useful to pre- vent seroma formation. To support our the- ory as to whether the modified procedure could lead to radiographic improvement of congruency and hip stability, NA and PC were analyzed before and after surgery, and the results of our analysis demonstrated a remarkable increase of NA and PC for hips and a subsequent decrease of subluxation and joint incongruency in all groups. Since both positive Ortolani incidence and NA  and PC in dogs had improved significantly at six months, our study demonstrated cox- ofemoral stability occurs following modi- fied DARthroplasty. Bone proliferation has been reported at the cranial of an implant on ilial wing and neck 17 weeks after surgery which was observed in our radiograph eval- uation indicating an active ossification site.


In Slocum’s series of cases, none of the pa- tients that have undergone DARthroplasty have demonstrated painful signs, which was already evident in our study. In our study,  the autologous bone graft was not applied since it is already known that it is the most effective bone substitute due to the presence of osteoprogenitor cells inside the graft that are reported to survive after transplantation (Kruyt et al., 2004) and it cannot be further enhanced by the addition of adjuvant factors, because of the presence of differentiated osteoblasts (Ronald et al., 2004). Although from a clinical point of view, a combination of bone allografts with ostegenetic factors is of great relevance, in the current study was radiologically observed the reliable bone healing at all groups, however, in PRP and MSCs groups the appreciable bone healing and remodeling were discerned. This result was probably because radiographs were taken only one time at 6 months postoper- atively. The absence of growth factors and multipotent MSCs from the periosteum and bone marrow causes bone allograft fracture and nonunion (Jensen et al., 2004, Long et al., 2013). The use of MSCs and PRP had  no adverse events and post-op complications clinically so MSCs or PRP impregnated al- lograft is a viable alternative if a dog needs bone grafting. In our experiment, the local injections of MSCs and PRP seem to have good clinical efficacy in distraction osteo- genesis, however, further investigations are needed. Shelf arthroplasty (or biocompati- ble orthopedic polymer shelf arthroplasty) was reported by Sertl and Jensen in the late 1980s as a new surgical treatment for the canine hip. In the procedure, for extending the dysplastic lateral rim on the acetabulum, a commercial polymer as a bony shelf was used (Sertl and Jensen, 1990). Although this

 

 

 

procedure provided a high rate of successful functional recovery, hip dysplasia may prog- ress after surgery since BOP material failed to be osteoconductive, despite the positive early anecdotal reports. Therefore, it can no longer be advised for hip dysplasia treatment in young dogs. After 27 years, dorsal acetab- ular rim arthroplasty, or DARthroplasty, has been described in which strips of corticocan- cellous bone from the ipsilateral ilial wing as an autograft are placed in a slot above the hip joint capsule origin (Hupp et al., 2007; Luck, 2007). To date, a few published re- ports of clinical results are available to ac- curately determine indications, effective- ness, and prognosis of shelf arthroplasties or DARthroplasty other than human medicine with numerous descriptions and variations. At present, only Slocum’s description of technique and results are available in vet- erinary medical publications (Slocum et al., 1998). The modified DARthroplasty tech- nique deserves to be thoroughly investigated as a surgical option for canine hip dyspla-  sia and subluxation treatment. However, a long-term func‌tional analysis using larger animal models is required to prove it. Also, future studies on a more definitive method to evaluate osseous integration and histologic examination to further qualify the degree of bony fusion of the grafts and recipient beds is necessary.

Conclusion

The current study indicates that rib bone allograft with PRP and MSCs increases the augmentation of the dorsal  acetabular  rim to promote the biological remodeling of the femoral head within the acetabulum. It re- sults in a favorable clinical function of the hip and a good outcome. Moreover, this pro- cedure helps to reduce the subluxation of

 

the femoral head, thereby helping to restore the biomechanical function of the hip joint. However, we believe that more  high-quali- ty studies with follow-up are needed before recommending the modified DARthroplasty procedure as an equal surgical alternative to Shelf arthroplasty.

Acknowledgments

The study was financially supported by the University of Tehran. This work was com- pletely performed at the Specialized Teach- ing and Research Small Animal Hospital of University of Tehran. The authors are grate- ful to Dr. Massoumeh Jabbari Fakhr for her help in MSCs preparation and Rouhoulah Esanejad and Davood Faskhoudi for their assistance in the execution of this study.

Conflict of Interest

The authors declared that there is no con- flict of interest.

AlDirawi A. A., Sharifi D., Soroori S., Bokaie S., Mokhtari R., Bashiri A., Shad H., Esanejad R., Faskhoudi D. (2018). Clinical and radiological evaluation of transplanted fresh ear cartilage im- pregnated with the mesenchymal cells and PRP in treatment of growth plate injury in lamb. Iran J Vet Med, 12(4), 238-291. https://doi.org/10.22059/ ijvm.2018.257195.1004897

Anderson J., Jeppesen N., Hansen M., Brady C., Gough A. and Fowler Z. (2013). First metatarso- phalangeal joint arthrodesis: comparison of mes- enchymal stem cell allograft versus autogenous bone graft fusion rates, Surg Sci, 4(5), 263-267. https://doi.org/10.4236/ss.2013.45051

Aranda, J. L., Varela, G., Benito, P., and Juan, A. (2008).  Donor   cryopreserved   rib   allografts for chest wall reconstruction. Interact Cardio- vasc  Thorac   Surg,   7(5),   858–860. https://doi.

Bardens J. W., Hardwick H. (1968). New obser-

 

 

 

vations on the diagnosis and cause of hip dys- plasia. Vet Med Small Anim Clin, 63, 238. PMID: 5183841

Boudrieau, R. J., Mitchell, S. L., and Seeherman,

H. (2004). Mandibular reconstruction of a par- tial hemimandibulectomy in a dog with severe malocclusion. Vet Surg, 33(2), 119–130. https:// doi.org/10.1111/j.1532-950x.2004.04019.x PMID: 15027973

Butler, R.J., and Gambino, J. (2017). Canine hip dys- plasia diagnostic imaging. Vet Clin North Am Small Anim Pract, 47(4), 777-793. https://doi. org/10.1016/j.cvsm.2017.02.002 PMID: 28576269

Callegaro S. G. M., Tadeu L. P. F. S., do Nascimen- to L. R., Pippi, N. L. (2018). Adult stem cells in the healing of fractures and bone grafts. Revista MVZ Córdoba, 23(1), 6537-6551. https://doi. org/10.21897/rmvz.1248

Comhaire F. H., Snaps F. (2008). Comparison  of two canine registry databases on the prevalence of hip dysplasia by breed and the relationship of dysplasia with body weight and height. Am J Vet Res, 69, 330 https://doi.org/10.2460/ajvr.69.3.330

PMID: 18312130

Corral, C. (2018). Canine hip dysplasia: aetiology and treatment. The Veterinary Nurse, 9(5), 246– 250. https://doi.org/10.12968/vetn.2018.9.5.246

Dallari, D., Fini, M., Stagni, C. (2006). In vivo study on the healing of bone defects treated with bone marrow stromal cells, platelet-rich plasma, and freeze-dried bone allografts, alone and in com- bination. J Orthop Res, 24, 877–888. https://doi. org/10.1002/jor.20112 PMID: 16609976

Denny, H.R., Linnell, M., Maddox, T.W., and Comerford, E.J. (2018). Canine total hip replace- ment using a cementless threaded cup and stem: a review of 55 cases. J Small Anim Pract, 59(6), 350-356. https://doi.org/10·1111/jsap.12827

PMID: 29574978

Dueland,  R. T., Adams, W. M., Patricelli, A. J.,  Linn,

K. A., and Crump, P. M. (2010). Canine hip dyspla- sia treated by juvenile pubic symphysiodesis. Vet Comp Orthop Traumatol, 23(5), 306–317. https:// doi.org/10.3415/vcot-09-04-0045 PMID: 20740258

Dycus,  D. L.,  Levine,  D.,  and  Marcellin-Little, D.

J. (2017). Physical rehabilitation for the manage- ment of canine hip dysplasia. Vet  Clin  North Am


Small Anim Pract, 47(4), 823–850. https://doi. org/10.1016/j.cvsm.2017.02.006 PMID: 28576271

Flückiger M. (2008). Scoring radiographs for canine Hip Dysplasia—The big three organizations in the world. Eur J Comp Anim Pract, 17, 135.

Ginja M. M. D., Ferreira A. J., Jesus S. S., et al. (2009). Comparison of clinical, radiographic, computed tomographic and magnetic resonance imaging methods for early prediction  of  ca- nine hip laxity and dysplasia. Vet Radiol Ultra- sound, 50, 135. https://doi.org/10.1111/j.1740-

Grabowski G., Robertson R. N. (2013). Bone al- lograft with mesenchymal stem cells: A critical review of the literature. Hard Tissue, 22;2(2), 20. https://doi.org/10.13172/2050-2303-2-2-438

Grzegorzewski A., Synder M., Kmiec K., et al. (2013). Shelf acetabuloplasty in the treatment of severe Legg-Calve-Perthes  disease:   good   outcomes at midterm follow-up. Biomed Res Int, 2013, 859483. https://doi.org/10.1155/2013/859483

PMID: 24377097

Hupp J., Pfeil I., Buder A., et al (2007). Dorsal ac- etabular rim arthroplasty, a retrospective study. Praktische Tierarzt 88, 398.

Jacobs R., Moens P., Fabry G. (2004). Lateral shelf acetabuloplasty in the early stage of Legg-Calve- Perthes disease with special emphasis on the remaining growth of the acetabulum: a prelimi- nary report. J Pediatr Orthop B, 13, 21–8. https:// doi.org/10.1097/00009957-200401000-00004 PMID: 15091254

Jensen, T. B., Rahbek, O., Overgaard, S., Soballe, K. (2005). No effect of platelet rich plasma with fro- zen or processed bone allograft around nocement- ed implants. Int Orthop, 29(2), 67-72. https://doi. org/10.1007/s00264-004-0622-6 PMID: 15685457

Jo K.,  Kim Y.,  Lee  S. H., Yoon  Y.  S.,  Kim W.   H.,

Kweon, O.‐K. (2017). Effect of canine cortical bone demineralization on osteogenic differentiation of adipose‐ derived mesenchymal stromal cells. He- liyon, 3(8), e00383. https://doi.org/10.1016/j.heliy- on.2017.e00383 PMID: 28856336

Kruyt M. C., Dhert W. J., Oner C., et al. (2004). Osteo- genicity of autologous bone transplants in the goat. Transplantation, 77, 504–509. https://10.1097/01. tp.0000107283.19336.daPMID:15084925

 

 

 

Lee W. S., Suzuki Y., Graves S. S., et al. (2011). Ca- nine bone marrow-derived mesenchymal stromal cells suppress alloreactive lymphocyte prolifer- ation in vitro but fail to enhance engraftment in canine bone marrow transplantation. Biol Blood Marrow  Transplantat,  vol.  17,  no.  4,  pp. 465–

PMID: 20457265

Lee D.H., Ryu K. J., Kim J. W., Kang K. C., Choi Y.

R. (2014). Bone marrow aspirate concentrate and platelet-rich plasma enhanced bone healing in dis- traction osteogenesis of the tibia. Clin Orthop Relat Res, 472(12), 3789-97. https://doi.org/10.1007/ s11999-014-3548-3 PMID: 24599650

Little D., Johnson S., Hash J., Olson S. A., Estes B. T., Moutos F. T., Lascelles B. D., Guilak F. (2016). Functional outcome measures in a surgical model of hip osteoarthritis in dogs. J Exp Orthop, 3 (1), 17. https://doi.org/10.1186/s40634-016-0053-5

PMID: 27525982

Long, T., Zhu, Z., Awad, H. A., Schwarz, E. M., Hilton, M. J., and Dong, Y. (2014). The effect of mesenchymal stem cell sheets on structur- al allograft healing of critical sized femoral defects  in  mice.  Biomaterials,  35(9),   2752–

2759.         https://doi.org/10.1016/j.biomateri-

Luck D. R. (2007). DARthroplasty: overlooked and underused. VOS, Abstracts.

Makridis, K. G., Ahmad, M. A., Kanakaris, N. K., Fragkakis, E. M., and Giannoudis, P. V. (2012). Reconstruction of iliac crest with bovine cancel- lous allograft after bone graft harvest for symphy- sis pubis arthrodesis. Int Orthop, 36(8), 1701– 1707. https://doi.org/10.1007/s00264-012-1572-z

PMID: 22729663

Marshall W. G., Bochstahler B. A., Hulse D. A., et al. (2009). A review of osteoarthritis and obe- sity: current understanding of the relationship and benefit of obesity treatment and prevention in the dog. Vet Comp Orthop Traumatol, 22, 339. https://doi.org/10.3415/VCOT-08-08-0069

PMID: 19750285

Marx C., Silverira M. D., Selbach I., et al. (2014). Acupoint injection of autologous stromal vascular fraction and allogeneic adipose-derived stem cells to treat hip dysplasia in dogs. Stem Cells Int, 2014, 391274. https://doi.org/10.1155/2014/391274


PMID: 25180040

Messora M. R., Nagata M. J. H., Fucini S. E., Pola

N. M.,  Campos  N.,  de Oliveira G. C. V.,  Bosco

A. F., Garcia V. G., Furlaneto F. A. (2014). Effect of platelet-rich plasma on the healing of man- dibular defects treated with fresh frozen bone allograft: A radiographic study in dogs. J Oral Implantol, 40(5), 533–541. https://10.1563/AA- ID-JOI-D-12-00175 PMID: 25295885

Mirghasemi S. A., Sadeghi M. S., Rahimi-Gabaran N., Baghban-Eslaminejad M. (2017). Biological optimization of cortical bone allografts: A study on the effects of mesenchymal stem cells and par- tial demineralization and laser perforation. Acad J Surg, 4(2), 31-6.

Moses P. (2000). Alternative surgical methods for treating juvenile canine hip dysplasia. Aust Vet J, 78(12).

Off W, Matis U. (2010). Excision arthroplasty of the hip joint in dogs and cats. Clinical, radiographic, and gait analysis findings from the Department of Surgery, Veterinary Faculty of the Ludwig-Max- imillian’s  University  of   Munich,   Germany. Vet Comp Orthop Traumatol, 23, 297-305.

PMID: 20945541

Ozaydin I., Kiliç E., Baran V. et al. (2003). Reduction and stabilization of hip luxation by the transpo- sition of the ligamentum sacrotuberale in dogs: an in vivo study. Vet Surg, 32, 46-51. https://doi. org/10.1053/jvet.2003.50009 PMID: 12520489

Rafatpaneh Baigi R., Sharifi D., Golbakhsh M., So- roori S., Aramesh F., Bashiri A. (2018). Clinical and radiographic evaluation of osteodisc allograft impregnated with mesenchymal stem cells for replacement of normal cervical disc in dog. EC Veterinary Science, 3(3), 373-378.

Roffi A., Filardo G., Kon E., Marcacci M. (2013). Does PRP enhance bone integration with grafts, graft substitutes, or implants? A systemic review. BMC Muscoskletal Disorders, 14, 330. https://doi.

Roldan J. C., Jepsen S., Miller J., et al. 2004. Bone formation in the presence of platelet-rich plas- ma vs. bone morphogenetic protein-7. Bone, 34, 80–90.  https://doi.org/10.1016/j.bone.200.09.011

PMID: 14751565

Sertl G. O., Jensen D. J. (1990). Biocompatible os-

 

 

 

teoconductive polymer (BOP) shelf arthroplasty for the surgical treatment of hip dysplasia. In: Ca- nine orthopedics, Whittick WG, (ed) 1st ed, , Lea and Febiger, Philadelphia,USA, 481.

Schachner, E.R and Lopez, M.J. (2015). Diagnosis, prevention, and management of canine hip dys- plasia: a review. Veterinary Medicine Research and Reports, 2015(6), 181-192. https://doi.

Shin, H. S., Woo, H. M., and Kang, B. J. (2017). Op-

timisation of a double-centrifugation method for preparation of canine platelet-rich plasma. BMC Vet    Res,   13(1),    198.  https://doi.org/10.1186/

Slocum B., Slocum T.D. (1998). DARthroplasty. In: Current Techniques in Small Animal Surgery. Bo- jrab MJ, editor. 4th edition., MD: Williams and- Wilkens, Baltimore,USA, 1168–1170.

Tomlinson, J. L., Cook J. L. (2002). Effects of degree of acetabular rotation after triple pel- vic osteotomy on the position of the femoral head in relationship to the acetabulum. Vet Surg, 31, 398–40. https://doi.org/10.1053/

Thua T. H. L., Bui D. P., Nguyen D. T., Pham D.

N.,  Le Q. B.,  Nguyen  P.  H., Tran  N. V.,  Le  P.

Q., Boeckx W. D., De Mey A. (2015). Autolo- gous bone marrow stem cells combined with al- lograft cancellous bone in treatment of nonunion. Biomedical Research and Therapy, 2, 409–417. https://doi.org/10.7603/s40730-015-0029-6

Vilar J. M., Batista M., Morales M., et al. (2014). As- sessment of the effect of intraarticular injection of autologous adipose-derived mesenchymal stem cells in osteoarthritic dogs using a double blind- ed force platform analysis. BMC Vet Res, 10, 143. https://doi.org/10.1186/1746-6148-10-143

PMID: 24984756

Witte P. G. (2019). Hip  dysplasia:  understanding the options (surgical  management).  Compan- ion animal, 24, 5. https://doi.org/10.12968/ coan.2019.24.5.249

Yaprakci
M. V., KAYA Ü. (2014). Evaluation of Block Type Autograft DARthroplasty
operation
and
its
results
in the treatment of canine hip dis- plasia disease in a Turkish shepperd dog.
Ko- catepe Vet, 7(2),
73-78.
https://doi.org/10.5578/kvj.8324