Lameness associated with foot pain: results of magnetic resonance imaging in 199 horses (January 2001--December 2003) and response to treatment.

REASONS FOR PERFORMING STUDY: The diagnosis of foot-related lameness often remains elusive and it can be difficult to offer rational treatment, or to predict outcome. OBJECTIVES: To describe the spectrum of injuries of the foot identified using magnetic resonance imaging (MRI), to determine their relative prevalence among MRI diagnoses and to establish the long-term results of treatment. METHODS: The MR images of horses examined from January 2001--December 2003 were reviewed. Horses were selected for MRI if the pain causing lameness was localised to the foot using perineural analgesia but any clinical, radiological or ultrasonographic abnormalities were insufficient to explain the degree of lameness. The clinical significance of lesions identified using MRI was determined with reference to the results of local analgesia, radiography, ultrasonography and nuclear scintigraphy. Follow-up information was obtained in January 2004 for horses which had been examined 6-36 months previously and the outcome classified as excellent (horse returned to full athletic function without recurrent lameness), moderate (sound, but only in light work), or poor (persistent or recurrent lameness). RESULTS: One hundred and ninety-nine horses underwent MRI examinations. Deep digital flexor (DDF) tendonitis was the most common injury (59%) with primary injury in 65 horses (33%) and a further 27 horses (14%) having lesions of the DDF tendon and navicular bone. Seventeen percent of horses had injuries to multiple structures, including 24 with DDF tendonitis. Desmitis of a collateral ligament (CL) of the distal interphalangeal (DIP) joint was the second most common injury (62 horses, 31%), with primary injuries in 30 horses (15%) and a further 32 horses (16%) that had CL desmitis in conjunction with other injuries. Prognosis was best for horses with traumatic injuries of the middle or distal phalanges, with 5 of 7 horses (71%) having an excellent outcome. Horses with primary lesions of the DDF tendon or CL of the DIP joint had excellent results in only 13 of 47 (28%) and 5 of 17 horses (29%), respectively. Horses with combined injuries of the DDF tendon and navicular bone, or primary navicular bone abnormalities, had a poor outcome, with the majority of horses suffering persistent lameness. CONCLUSIONS: A wide variety of lesions associated with foot pain were identified using MRI, a high proportion of which were primary soft tissue injuries with a guarded prognosis for return to full athletic function. POTENTIAL RELEVANCE: It is now possible to propose more rational treatment strategies for the variety of foot injuries identified using MRI than had previously been possible; however, further information concerning aetiopathogenesis of these injuries is needed to improve their management.

Concentration of methylprednisolone in the centrodistal joint after administration of methylprednisolone acetate in the tarsometatarsal joint.

REASONS FOR PERFORMING STUDY: The centrodistal (CD) and tarsometatarsal (TMT) joints are often injected individually with a corticosteroid to resolve lameness caused by osteoarthritis (OA). There are no data available regarding diffusion of methylprednisolone (MP) from the TMT joint to the CD joint. HYPOTHESIS: A therapeutic concentration of MP diffuses into the CD joint after methylprednisolone acetate (MPA) is administered into the TMT joint. OBJECTIVE: To measure the concentration of MP in the CD joint after MPA was administered into the TMT joint. METHODS: MPA was administered into a TMT joint of 16 horses. At different times, the ipsilateral CD joint of these horses was injected with a small amount of saline and recovered saline was measured for concentration of MP using high performance liquid chromatography. RESULTS: Six hours after administration of MPA into the TMT joint, a therapeutic concentration of MP was found in all 10 CD joints sampled at this time. CONCLUSIONS: Horses with pain arising from the distal 2 joints of the hock can be treated by administering MPA into the TMT joint alone. POTENTIAL RELEVANCE: Administering MPA into the TMT joint only, to treat OA of the distal 2 hock joints, reduces the difficulties and risks associated with centesis of the CD joint.

Osteoarthritis of the talocalcaneal joint in 18 horses.

REASONS FOR PERFORMING STUDY: Talocalcaneal osteoarthritis (TO) is an uncommon cause of moderate to severe hindlimb lameness, on which only isolated case reports have been published to date. OBJECTIVES: To review the clinical features of TO and determine optimal methods for diagnosis, management and prognosis. METHODS: The case records from 4 referral centres of 18 horses showing hindlimb lameness considered, as a result of clinical investigation, to be caused by TO, were reviewed. RESULTS: TO affected mature sports and pleasure horses (age 7-16 years) and caused moderate to severe lameness, usually of sudden onset with no obvious inciting cause. There were few localising signs, other than worsening of lameness by hock flexion. Tarsocrural joint analgesia produced improvement in lameness in 6/11 horses (55%) and perineural analgesia of the tibial and fibular nerves complete soundness in 6/14 horses (43%) in which it was performed; 7/14 horses (50%) showed a further substantial improvement. Radiological findings included subchondral bone lysis and sclerosis and irregular joint space width, seen most obviously in a lateromedial view. Nuclear scintigraphy revealed marked uptake of radiopharmaceutical predominantly plantaromedially in the region of the talus in the 7 horses in which it was performed. Fourteen horses were treated conservatively with box- or pasture-rest, with or without intra-articular corticosteroids, hyaluronic acid or polysulphated glycosaminoglycan, and all remained lame. Intra-articular corticosteroids appeared to have no effect in any horse. Of 10 horses receiving conservative management only, 6 were subjected to euthanasia, 3 were retired and 1 remained in light work, but was still lame. Two horses treated by either partial tibial and fibular neurectomy or subchondral forage failed to regain soundness and were retired. Six horses were treated by surgical arthrodesis of the talocalcaneal joint with 2 or three 5.5 mm AO screws introduced obliquely across the joint from the plantarolateral aspect of the calcaneus, which resulted in improvement in lameness in all cases. CONCLUSIONS: Osteoarthritis of the talocalcaneal joint causes acute onset severe lameness, but clinical findings and diagnostic analgesia often fail to identify precisely the site of pain. Consistent radiographic changes suggested TO was contributing to the lameness and this diagnosis was supported by nuclear scintigraphy. The poor success of conservative treatment (including intra-articular medication) suggests that surgical arthrodesis is the treatment of choice, although the prognosis is still poor for a return to full soundness. POTENTIAL RELEVANCE: The clinical features described should facilitate more accurate diagnosis and prognosis. A novel surgical treatment is described which appears to offer significant improvement in the lameness. Further work is necessary to determine the causes of this condition and more effective management.

Effect of age at presentation on outcome following arthroscopic debridement of subchondral cystic lesions of the medial femoral condyle: 85 horses (1993--2003).

REASONS FOR PERFORMING STUDY: Subchondral cystic lesions of the medial femoral condyle (SCMFC) are well documented in horses < or =3 years; arthroscopic debridement or enucleation of the cyst is currently the surgical treatment of choice. However, studies of occurence and outcome following surgery in older horses are lacking. OBJECTIVE: To identify factors important in outcome for horses with SCMFC treated by arthroscopic debridement. HYPOTHESIS: Age of horse at presentation has a significant influence on return to work following arthroscopic treatment for SCMFC. Clinical and diagnostic findings are also significant with respect to prognosis. METHODS: A retrospective review of medical records from 6 equine referral centres identified 85 horses that underwent arthroscopic debridement of SCMFC. Clinical examination, radiographic and arthroscopic findings were analysed together with follow-up data. Univariable analysis and multivariable logistic regression models were used to determine factors affecting return to soundness. Event-time analysis was performed to evaluate return to work. RESULTS: Older horses (>3 years) were less likely to return to soundness (P = 0.02) or to work (P = 0.04) than younger horses (< or = 3 years). Of 39 horses age 0-3 years, 25 (64%, 95% CI 49-79%) returned to soundness. Of 46 horses age >3 years, 16 (35%,95% CI 21-49%) returned to soundness. In addition, cartilage damage at sites other than the SCMFC negatively affected prognosis (P = 0.05). The hospital where treatment was performed had no influence on return to soundness. CONCLUSIONS: Older horses carry a worse prognosis for both return to soundness and return to work. POTENTIAL RELEVANCE: It is important for clients to be made aware of the difference in outcome between age groups.

Treatment of chronic or recurrent proximal suspensory desmitis using radial pressure wave therapy in the horse.

REASONS FOR PERFORMING STUDY: Proximal suspensory desmitis (PSD) is diagnosed with increasing frequency in horses and radial pressure wave therapy (RPWT) is a widely used therapy for painful orthopaedic conditions in man and dogs. There are, however, few published data as to the outcome of its use in PSD. OBJECTIVE: To evaluate the use of RPWT in the treatment of chronic or recurrent PSD in the horse, an injury which carries a poor prognosis for return to athletic function with conservative management alone. HYPOTHESIS: RPWT and controlled exercise improves the prognosis of chronic or recurrent PSD in the horse when compared to previously published results of controlled exercise alone. METHODS: The use of RPWT in the management of chronic or recurrent proximal suspensory desmitis (PSD) was evaluated in 65 horses. Diagnosis was based on response to local analgesia, ultrasonography and radiography. Horses were classified according to severity of ultrasonographic lesions, whether fore- or hindlimbs were affected, and duration of lameness prior to diagnosis. Horses were treated 3 times at 2-week intervals and followed a controlled exercise programme; they were reassessed clinically and ultrasonographically 10-12 weeks after diagnosis, when further exercise recommendations were made dependent upon the animal's progress. RESULTS: Forty-one percent of horses with hindlimb lameness and 53% with forelimb lameness were nonlame and returned to full work 6 months after diagnosis. The prognosis was significantly affected by the ultrasonographic grade at the time of diagnosis and by ultrasonographic evidence of resolution of the lesion in hindlimb cases. CONCLUSIONS: These findings, when compared to previously published results of treatment using controlled exercise alone, suggest that RPWT improves the prognosis for PSD in the hindlimb. POTENTIAL RELEVANCE: RPWT is a useful treatment modality for chronic or recurrent PSD when combined with controlled exercise. Further studies are required on the effect of RPWT employing histology and biomechanics in order to fully evaluate its use on equine tissues.

An in vitro study to compare 5 different techniques for injection of the navicular bursa in the horse.

Numerous different techniques for injection of the navicular bursa have been described but there is little conformity between these descriptions. A literature review was performed and techniques for injection of the navicular bursa were categorised into 5 approaches. This study was performed to evaluate the reproducibility of each technique and to assess which technique was consistently most successful. Five inexperienced operators performed each technique on 5 cadaver forelimbs. Once a needle had been placed, a radiograph was taken to confirm placement was in accordance with the description of the technique. Contrast agent was then injected and another radiograph taken to determine whether the navicular bursa had been injected successfully. The position of the navicular bone was highly predictable as a point 1 cm distal to the coronary band and halfway between the most dorsal and most palmar aspect of the coronary band. The use of this point as a landmark for injection of the navicular bursa allowed a high degree of accuracy and reliability of needle placement, irrespective of foot conformation.

Endoscopic examination of the tarsal sheath of the lateral digital flexor tendon in horses.

This study was designed to develop a reliable technique for endoscopic examination of the tarsal sheath of the lateral digital flexor tendon of horses. The anatomy of the tendon sheath and associated structures was studied in detail in cadavers before determining portals for the insertion of an arthroscope into the sheath. Approaches into the sheath through the proximal pouch and through the flexor retinaculum, at the level of the sustentaculum tali, were performed and compared in cadavers. The proximal pouch portal permitted visualisation only of the proximal half of the sheath, while the approach through the retinaculum allowed examination of the entire sheath. The normal endoscopic appearance of the tarsal sheath was studied. The endoscopic approach was subsequently used to examine and treat 5 horses with tarsal sheath tenosynovitis, including 2 cases of chronic, traumatic tenosynovitis and 3 of subacute septic tenosynovitis. Four of these horses had fragmentation of the sustentaculum tali. The technique allowed adequate examination of the sheath and debridement of adhesions and lesions within the lumen of the sheath. Fragments dorsal to the medioplantar edge of the sustentaculum tali could not be visualised endoscopically and had to be removed after widening of the wound. All 5 horses survived. Follow-up enquiries (8-31 months) revealed that the horses were all reported to be sound. Four were performing at their previous level of activity, 1 was used for hacking. The 2 cases presented with chronic tenosynovitis had residual sheath distension with no associated loss of function. A prospective study, including longer term follow-up investigation, is currently being performed.

Radiological study to evaluate suspected scapulohumeral joint dysplasia in Shetland ponies.

A radiological study was performed to test the hypothesis that osteoarthritis of the scapulohumeral joint in Shetland ponies is secondary to shoulder dysplasia. Animals were selected into 3 groups: Group 1: Shetland ponies with a radiological and clinical diagnosis of scapulohumeral osteoarthritis (n = 8); Group 2: Shetland ponies without forelimb lameness (n = 12); Group 3: Horses/ponies without a history or clinical signs of forelimb lameness (n = 22). Anatomical indices were measured from mediolateral radiographs of a scapulohumeral joint from each animal. There was a significant difference in the mean radius of curvature of the glenoid cavity of the scapula (RCG) between the 3 groups (MANOVA test, P = 0.003). The mean RCG of both Group 1 (P = 0.001) and Group 2 (P = 0.022) was significantly greater than that of Group 3. There was no significant effect of group on the radius of curvature of the humeral head or on the Conformity Index. There was a significant effect of group on the Glenoid Ratio (MANOVA test, P = 3 x 10(-6)). The mean Glenoid Ratio was significantly lower in both Group 1 (P = 2 x 10(-6)) and in Group 2 (P = 0.006) than in Group 3. These results indicate that the glenoid cavity of the scapula is 'flatter' and 'shallower' in Shetland ponies which we postulate to be a primary dysplasia in this breed.

Effect of anaesthesia of the palmar digital nerves on proximal interphalangeal joint pain in the horse.

REASONS FOR PERFORMING STUDY: Anaesthesia of the palmar digital nerves is claimed to attenuate lameness in some horses that are lame because of pain in the proximal interphalangeal (PIP) joint. OBJECTIVE: To determine the response of horses with pain in the PIP joint to anaesthesia of the palmar digital nerves. METHODS: Horses were video recorded trotting before and after induction of pain in the PIP joint and 10 mins after anaesthesia of the palmar digital nerves. The palmar digital nerves were anaesthetised 3 times at different sites, and the video recorded gaits were scored subjectively. RESULTS: The median lameness score of gaits after administration of 2% mepivacaine 1 cm proximal to the cartilages of the foot was not significantly different from the median lameness score before anaesthesia of the palmar digital nerves (P > or = 0.05), although that of 1 of 6 horses improved markedly. The median lameness score was significantly (P < or = 0.05) improved after mepivacaine was administered 2 and 3 cm proximal to the cartilages of the foot. CONCLUSIONS: The PIP joint is unlikely to be anaesthetised when the palmar digital nerves are anaesthetised at the proximal margin of the cartilages of the foot. POTENTIAL RELEVANCE: Pain within the PIP joint cannot be excluded as a cause of lameness when lameness is attenuated by anaesthesia of the palmar digital nerves at any site proximal to the proximal margin of the cartilages of the foot.

Treatment of intrasynovial infection with gentamicin-impregnated polymethylmethacrylate beads.

Gentamicin-impregnated polymethylmethacrylate beads were used in the treatment of infective synovitis in 12 horses and 10 cattle. They had either proved refractory to standard treatments (lavage, debridement, joint drainage and systemic antibiotics) or had evidence of osteomyelitis adjacent to a synovial cavity. All the animals were severely lame. All the cattle and six of the horses had radiological evidence of osteomyelitis in communication with a synovial cavity. The beads were placed intrasynovially under general anaesthesia and left in place for 14 days. One horse and one calf were euthanased owing to continued infective arthritis. The infection was eliminated from the other 20 cases and six of the horses returned to full athletic use. Eight of nine calves with E-type infective arthritis and osteomyelitis returned to their intended food production or breeding programmes.

Scapulohumeral osteoarthritis in 20 Shetland ponies, miniature horses and falabella ponies.

This paper describes the clinical and diagnostic features of 20 cases of scapulohumeral osteoarthritis in Shetland ponies, miniature horses and falabella ponies. The history and clinical signs were similar in all the cases Radiographically they all had consistent changes which consisted predominantly of articular osteophytes and periarticular enthesiophytes. Six of the cases had radiographic evidence of dysplasia of the scapulohumeral joint, although it was uncertain whether this was a primary or a secondary finding. No specific treatment appeared to be advantageous. At follow up, six of the ponies had to be euthanased owing to continuing severe lameness; the other 14 ponies remained lame, but were maintained at pasture by the occasional use of oral non-steroidal anti-inflammatory drugs. No definitive aetiology for the condition was identified, but it is proposed that an underlying dysplasia, or lack of collateral support may predispose the scapulohumeral joint of miniature horse breeds to the disease.

Use of a bioabsorbable implant for the repair of severed digital flexor tendons in four horses.

A new bioabsorbable implant composed of poly-L-lactic acid was used to repair the severed digital flexor tendons of four horses. The limbs were immobilised with distal casts which were changed after six to eight weeks and removed after 12 to 16 weeks. The horses were followed clinically and ultrasonographically for from seven to 19 months after the surgery. The ultrasonographic examination after the cast had been removed showed that the implants had been well incorporated into scar tissue. Two of the horses were mildly lame at the trot seven months after the surgery, but had returned to work after 12 months. The other two horses are still lame. No complications were observed with the implant.

Treatment of sepsis in the small tarsal joints of 11 horses with gentamicin-impregnated polymethylmethacrylate beads.

Gentamicin-impregnated polymethylmethacrylate beads were used to treat infective arthritis in the small tarsal joints of 11 severely lame horses. Under general anaesthesia, between five and 10 beads were placed into a 7 to 8 mm tract drilled across the affected joint and, in all except one horse, they were left in place for 14 days. Two of the horses were euthanased for reasons other than persistent tarsal joint sepsis, but the other nine survived and seven of them returned to their previous level of athletic performance.

The effect of intralesional injection of bone marrow derived mesenchymal stem cells and bone marrow supernatant on collagen fibril size in a surgical model of equine superficial digital flexor tendonitis.

REASONS FOR PERFORMING STUDY: Collagen fibril size is decreased in repair tissue following tendon injury compared to normal tendon matrix in horses. Mesenchymal stem cells have been suggested to promote regeneration of tendon matrix rather than fibrotic repair following injury, although this concept remains unproven. OBJECTIVES: To explore the hypothesis that implantation of autologous mesenchymal stem cells derived from bone marrow into a surgically created central core defect in the superficial digital flexor tendon (SDFT) of horses would induce the formation of a matrix with greater ultrastructural similarities to tendon matrix than the fibrotic scar tissue formed in control defects. METHODS: Tissue was collected 16 weeks after induction of injury and 12 weeks after treatment from normal and injured regions of control and treated limbs of 6 horses and examined using transmission electron microscopy. Collagen fibril diameters were measured manually with image analysis software and surface areas calculated. Three parameters assessed for normal and injured tissue were mass average diameter (MAD), collagen fibril index (CFI) and the area dependent diameter (ADD). RESULTS: Normal regions from both treated and control limbs displayed higher MAD and CFI values, as well as a characteristic bimodal distribution in fibril size. Injured regions from both treated and control limbs displayed significantly lower MAD and CFI values, as well as a unimodal distribution in fibril size. There were no significant differences between treated and control limbs for any of the parameters assessed. CONCLUSIONS: Intralesional injection of autologous bone marrow derived mesenchymal stem cells had no measurable effect on the fibril diameter of collagen in healing tissue in the SDFT of this experimental model 16 weeks after injury. POTENTIAL RELEVANCE: Favouring matrix regeneration over fibrotic repair may not be the mechanism by which autologous mesenchymal stem cells assist healing of tendon injury.