Development of a quantitative multivariable radiographic method to evaluate anatomic changes associated with laminitis in the forefeet of donkeys

Objective-To establish and validate an objective method of radiographic diagnosis of anatomic changes in laminitic forefeet of donkeys on the basis of data from a comprehensive series of radiographic measurements. Animals-85 donkeys with and 85 without forelimb laminitis for baseline data determination; a cohort of 44 donkeys with and 18 without forelimb laminitis was used for validation analyses. Procedures-For each donkey, lateromedial radiographic views of 1 weight-bearing forelimb were obtained; images from 11 laminitic and 2 nonlaminitic donkeys were excluded (motion artifact) from baseline data determination. Data from an a priori selection of 19 measurements of anatomic features of laminitic and nonlaminitic donkey feet were analyzed by use of a novel application of multivariate statistical techniques. The resultant diagnostic models were validated in a blinded manner with data from the separate cohort of laminitic and nonlaminitic donkeys. Results-Data were modeled, and robust statistical rules were established for the diagnosis of anatomic changes within laminitic donkey forefeet. Component 1 scores ≤ -3.5 were indicative of extreme anatomic change, and scores from -2.0 to 0.0 denoted modest change. Nonlaminitic donkeys with a score from 0.5 to 1.0 should be considered as at risk for laminitis. Conclusions and Clinical Relevance-Results indicated that the radiographic procedures evaluated can be used for the identification, assessment, and monitoring of anatomic changes associated with laminitis. Screening assessments by use of this method may enable early detection of mild anatomic change and identification of at-risk donkeys.     

Management of the Dorsal Hoof Wall and Its Potential Effects on the Laminitic Hoof

Appropriate management of the equine hoof during chronic laminitis varies by protocol and practitioner. Sequential removal of the dorsal hoof wall was examined in-vivo on a laminitic horse at the walk, revealing an increase in solar force under the margin of the distal phalanx as measured through the use of an in-shoe force measuring system.     

Treatment of solar prolapse using the heart bar shoe and dorsal hoof wall resection technique

This paper describes the treatment of 10 horses suffering from acute laminitis using the heart bar shoe and a dorsal hoof wall resection technique. All cases had progressed to prolapse of the tip of the pedal bone covered by solar corium through the horny sole; in one case the exposed tip of the distal phalanx became visible. Nine cases of distal phalangeal rotation and one case of distal displacement of the distal phalanx (sinking) are described. Two animals were destroyed because of the degree of lameness, one remains slightly lame at the trot and the remaining seven have returned to their previous use at comparable levels of performance.     

MAGNETIC RESONANCE IMAGING OF THE EQUINE DIGIT WITH CHRONIC LAMINITIS

Chronic laminitis is a severe disease affecting the equine digit. It was hypothesized that magnetic resonance (MR) imaging would improve visualization of structures within the foot and pathology associated with chronic laminitis. This study aimed to describe the MR imaging findings in chronic laminitis, compare different pulse sequences for visualization of pathology, and to compare MR imaging with standard radiography. Twenty (10 forelimb, 10 hindlimb) cadaver limbs from 10 horses clinically diagnosed with chronic laminitis (group L) and 10 limbs without laminitis (group N) were used. Lateromedial radiographs and sagittal and transverse MR images of the foot were obtained. Radiographs and MR images were evaluated for anatomic definition and evidence of pathology. Dorsal hoof wall thickness and angle of rotation and displacement distance of the distal phalanx were measured. Comparisons were made between group L and N, forelimb and hindlimb within each horse, and MR imaging and radiography. Features consistently noted with MR images in group L, but not detected using radiography, included laminar disruption, circumscribed areas of laminar gas, laminar fluid, and bone medullary fluid. Other findings seen only on MR images included increased size and number of vascular channels, alterations in the corium coronae, and distal interphalangeal joint distension. Magnetic resonance imaging allowed better definition of laminar gas lines and P3 surface irregularity observed on radiographs. Based on measurements, group L had a greater angle of rotation, distal displacement, and dorsal hoof wall thickness than group N; forelimb hoof wall thickness was greater than hindlimb; and distal displacement and hoof wall thickness measurements were smaller using MR imaging than radiography, but had a similar pattern. It is concluded that there are features of chronic laminitis consistently observed using MR imaging and that these may be additional to features observed radiographically.     

RADIOGRAPHIC APPEARANCE OF THE NAVICULAR BONE AND DISTAL INTERPHALANGEAL JOINT AND THEIR RELATIONSHIP WITH OSSIFICATION OF THE COLLATERAL CARTILAGES OF THE DISTAL PHALANX IN FINNHORSE CADAVER FOREFEET

Radiographic findings in the navicular bone and distal interphalangeal joint as well as the ossification status of the collateral cartilages of the distal phalanx were evaluated in 100 Finnhorse cadaver forefeet. The most common shapes of the proximal articular margin of the navicular bone were convex and straight. Remodeling of the navicular bone was common, especially on the lateral extremity. No bony fragments were identified at the distal flexor margin even though this area appeared irregular in several feet. Several large, rounded or lollipop-shaped synovial invaginations were identified in only six feet. The thickness of the flexor cortex varied considerably, and the corticomedullary junction was uni- or bilaterally indistinct in nine feet. The shape of the sagittal ridge of the flexor cortex was commonly flat but varied. It appeared locally irregular or indistinct in 17 feet, but changes elsewhere along the flexor cortex were rare. Osteophytosis on the dorsal and palmar margins of the distal interphalangeal joint and entheseophytosis on the dorsal aspect of the middle phalanx and on the extensor process of the distal phalanx were common. "Possibly significant" ossification of the collateral cartilages (high side-bones or separate centers of ossification) was present in 36 feet; all grades of ossification in the proximal/ palmaroproximal direction as well as palmar ossification were seen. A statistically significant relationship was found between entheseophytosis on the proximal flexor margin of the navicular bone and "possibly significant" ossification. Osteophytosis on the palmarodistal margin of the middle phalanx was more common in feet with a relatively long distal phalanx, suggestive of palmar ossification. Radiographic changes in the navicular bone or in the distal interphalangeal joint did not otherwise appear to be associated with ossification of the collateral cartilages of the distal phalanx in Finnhorses.     

An investigation of the shape of the hoof capsule in hindlimbs,its relationship with the orientation of the distal phalanx and comparison with forelimb hoof capsule conformation

There is limited information documenting hind foot conformation. The objectives of the study were to describe the shape of the hoof capsule of hindlimbs from the lateral aspect in horses of variable breeds, and, within horses, to compare the conformation of the hoof capsule of forelimbs and hindlimbs and determine the orientation of the distal phalanx within the hoof capsule in hindlimbs. Lateral photographs of the fore and hind feet (n = 225) and lateromedial radiographs of the hind feet (n = 29) were obtained. Differences among breed and shoeing status groups were assessed using multivariable mixed-effects linear regression models. Angular parameters and ratios of linear measurements were compared between fore and hind feet; angular radiological variables and photographic parameters of the hind feet were compared. The mean dorsal hoof wall angle for hind feet (50.9°±3.7°) was smaller than forefeet (51.8°±3.9°) (P = 0.04). The mean heel angles for hind feet (36.4°±9.6°) were smaller than forefeet (40.1°±9.3°; P < 0.001). Dorsal hoof wall (P < 0.001) and heel (P = 0.002) angles were larger in unshod than shod feet. In the hind feet, the dorsal hoof wall was parallel to the dorsal aspect of the distal phalanx. The median angle of the distal phalanx to the horizontal (angle S) was 0.6° (interquartile range: −1.4, 2.3°). There was a positive relationship between angle S and the hoof wall angle (W); each 1° increase in angle S was associated with 0.6° increase in angle W (P < 0.001). Angle S was also positively associated with photographic heel angle; each degree increase in the angle S was associated with 1.8° increase in the heel angle (P < 0.001). It was concluded that the angle of the distal phalanx to the horizontal in hindlimbs is smaller than published values for forelimbs. The orientation of the distal phalanx in hindlimbs is correlated with external characteristics of the hoof capsule.     

Deep digital flexor tendon force and digital mechanics in normal ponies and ponies with rotation of the distal phalanx as a sequel to laminitis

REASONS FOR PERFORMING STUDY: Previous studies have implicated tension in the deep digital flexor tendon (DDFT) in the rotation of the distal phalanx (DP) after the breakdown of the dorsal laminae caused by laminitis. Howeveer, once the DP has rotated, the DDFT should become shorter, reducing the force it exerts on the DP. OBJECTIVE: To compare DDFT force and ground reaction forces (GRFs) in normal ponies and ponies with rotation of the DP as a sequel to laminitis. METHODS: Six normal ponies (Group 1) and 6 sound ponies with 6-13 degrees of rotation of the DP in relation to the dorsal hoof wall (Group 2) were assessed at trot using forceplate and motion analysis. The force in the DDFT was calculated by assuming that the extending moment at the distal interphalangeal (DIP) joint resulting from the GRF was equal to the flexing moment created by the force in the DDFT during the stance phase (inverse dynamics). RESULTS: In early stance, the peak DDFT force (mean+/-s.d.) in the normal ponies was 1.92+/-1.63 N/kg. However, in Group 2, the point of zero moment was palmar to the centre of rotation of the DIP joint for the first 40% of stance and hence DDFT force was zero. Force in the DDFT reached a peak of 10.00+/-3.56 N/kg at 60.7+/-5.6% of stance in Group 1 and 6.41+/-1.37 N/kg at 79.2+/-9.6% of stance in Group 2. CONCLUSIONS: DDFT force in Group 2 laminitic ponies was much reduced until late stance, when it neared normal values. POTENTIAL RELEVANCE: Further studies of ponies with rotation of the DP as a sequel to laminitis should assist farriery aimed at reducing the force in the DDFT through the breakover phase of stance to protect damaged dorsal laminae.     

Decreased expression of p63, a regulator of epidermal stem cells, in the chronic laminitic equine hoof

Reasons for performing study: Abnormal epidermal stem cell regulation may contribute to the pathogenesis of equine chronic laminitis. Objective: To analyse the involvement of p63, a regulator of epidermal stem cell proliferative potential, in chronic laminitis. Methods: Epidermal tissues from skin, coronet and lamellae of the dorsal foot were harvested from 5 horses with chronic laminitis and 5 control horses. Tissues were analysed using histopathology, immunofluorescence microscopy and quantitative immunoblotting Results: Hoof lamellae of laminitic horses had a lower frequency of p63 positive cells than control lamellae, particularly in the distal region. Quantitative immunoblotting confirmed reduced p63 expression in the laminitic distal lamellar region. The decreased p63 expression in laminitic epidermal lamellae was most apparent in the abaxial region adjacent to the hoof wall and highly associated with the formation of terminally differentiated, dysplastic and hyperkeratotic epidermis in this region, whereas lamellae from control horses maintained high p63 expression throughout the axial‐abaxial axis. Conclusions: Expression of p63 in equine skin resembles that reported in other species, including man and rodents, suggesting that p63 can serve as a marker for the proliferative potential of equine epidermal stem cells. p63 expression was significantly lower in the chronic laminitic hoof than in that of control horses, suggesting laminitic hoof epithelium has more limited proliferative potential with a shift towards differentiation. This may reflect reduced activity of epidermal stem cells in laminitic hoof. It is proposed that p63 contributes to the maintenance of hoof lamellae and that misregulation of p63 expression may lead to epidermal dysplasia during lamellar wedge formation. Potential relevance: This study suggests that loss of epidermal stem cells contributes to the pathogenesis of equine laminitis. Autologous transplantation of p63‐positive epidermal stem cells from unaffected regions may have regenerative therapeutic potential for laminitic horses.     

Unilateral white line disease and laminitis in a quarter horse mare

A 5-year-old quarter horse mare presented with unilateral, severe, chronic forelimb lameness. Radiographs revealed extensive hoof wall separation and capsular rotation of the distal phalanx. Treatment included dorsal hoof wall resection, phenylbutazone, a bar shoe, and stall rest. Whether white line disease or laminitis was the primary lesion remains unclear.     

The pathogenesis and treatment of osteomyelitis and laminitis in a stallion after the prolonged topical application of formalin to the distal phalanx

A 12-year-old Quarterhorse stallion was presented with a severe lameness in the left forefoot. There was a 3 cm diameter cavity in the sole that extended to the solar surface of the distal phalanx. Radiographs revealed an osteomyelitis and a sequestrum which probably developed following the prolonged topical application of 10 percent formalin. The sequestrum was removed and the infected bone curetted under general anaesthesia. The horse was shod with heart bar shoes on both front feet 7 days after the surgery. Eight months later, radiographs showed marked rotation of the distal phalanx despite continual shoeing with heart bar shoes. Surgical resection of the dorsal wall of the hoof at the toe removed the pressure applied by the laminar wedge, and combined with the stabilising and supporting action of the heart bar shoe, permitted realignment of the distal phalanx approximately 30 degrees closer to the normal skeletal axis by 26 days post-operatively. This case highlights some of the recent developments in the treatment of laminitis and suggests that effective treatment is possible if the value of the animal warrants the time and investment.     

ULTRASONOGRAPHY OF THE SOLAR ASPECT OF THE DISTAL PHALANX IN THE HORSE

Ultrasonographic examinations were performed on the solar aspect of the distal phalanx of 10 feet of five normal live horses (Group 1), 22 feet of seven normal cadavers (Group 2), and nine feet of five horses with pathology of the dorsal solar aspect of the distal phalanx (Group 3). Lateromedial radiographs of the distal phalanx were made in all groups, and in Group 2, digits were sagitally sectioned after imaging. The ultrasonographic and radiographic appearance of the sagittal solar aspect of the distal phalanx was described. Measurements of the distance between the sole and the distal tip of the distal phalanx (A), the solar aspect of the apex of the frog and the distal phalanx (B), and the body of the frog's surface and flexor surface of the distal sesamoid bone (C) were made ultrasonographically, radiographically, and on the sectioned cadaver specimens. There was no statistical difference between the radiographic, ultrasonographic, and direct cadaver measurements in A and C. In B, there was a statistical difference between the radiographic, ultrasonographic, and cadaver measurements-most likely as a result of the difference in trimming of the frog apex. Ultrasonographic and radiographic examination of the nine feet of the five horses in Group 3 were performed and the abnormalities described. Color flow and power Doppler ultrasonography were performed on the normal sagittal solar distal phalanx, on the impar distal sesamoidean ligament, and at the insertion of the deep digital flexor tendon on the facies flexoria of the distal phalanx. Power Doppler in these horses showed blood flow at 0.16-0.48 kHz at the tip of the distal phalanx and at 0.16 kHz at the deep digital flexor tendon insertion and in the impar distal sesamoidean ligament. Using color flow Doppler in normal horses mean blood flows ranged from 1.8 to 5.4 cm/s at the tip of the distal phalanx and 1.8-2.0 cm/s at the deep digital flexor tendon insertion and in the impar distal sesamoidean ligament.     

Quantitative assessment of increased sensitivity of chronic laminitic horses to hoof tester evoked pain

Reasons for performing study: To evaluate quantitative sensory testing (QST) of the feet of laminitic horses using a power‐assisted hoof tester. Hypothesis: Hoof Compression Thresholds (HCTs) can be measured reliably and are consistently lower in horses with chronic laminitis than in normal horses. Methods: HCTs of chronic laminitic (n = 7) and normal horses (n = 7) were repeatedly measured using a hydraulically powered and feedback controlled hoof tester. Data from 2 tests, at 3 sites in both forefeet, during 3 sessions were collected and statistically analysed using linear mixed models. Results: The mean ± s.e. HCT for the laminitic horses was 29.6 ± 3.5 kg/cm² and for horses in the normal group was 59.8 ± 4.3 kg/cm². Residual variance was the largest of the error components and was greater (P<0.001) for the normal horses; none of the other components significantly differed between the 2 groups. Averaging of HCTs from each foot could produce a test with intraclass correlation coefficients of 0.83 for the normal group and 0.87 for the laminitic group, with an estimated sensitivity of 0.94 and a specificity of 0.93. This test would permit detection with 80% power and 95% confidence of a reduction of over 40% in the difference in mean HCTs between laminitic and normal horses following effective treatment provided that the experimental groups are of 9 or more horses. Conclusions: HCTs can be safely and reliably measured experimentally using this hoof tester. The level of variability found indicates that, under these conditions, treatments may need to produce at least a 40% improvement to be detected. Simplification of the hoof tester, training of the horse and repeated testing may permit the method to be used clinically to detect changes in the HCTs of individual laminitic horses but these potential improvements will require further investigation. Potential relevance: Measurement of HCTs can provide an additional means for assessing the effectiveness of treatments for alleviation of chronic equine laminitis.     

The treatment of laminitis in horses

The structural and vascular anatomy of the healthy equine foot is compared with the pathologic changes in the foot of horses with acute and chronic laminitis. The structural and vascular abnormalities present in the foot of horses with laminitis are demonstrated in order to explain the abnormal manner in which their feet grow. The medical, surgical, dietary, and endocrine management of acute and chronic laminitis is discussed. Various forms of hoof trimming beneficial to the reestablishment of normal digital perfusion, normal hoof growth, and normal spatial orientation among the distal phalanx, hoof wall, and sole are described. Guidelines for the provision of frog support provided by adjustable heart-bar shoes are presented.     

Bovine laminitis: clinical aspects, pathology and pathogenesis with reference to acute equine laminitis

This review deals with the features of clinical and subclinical laminitis in cattle. Prominent clinical signs of acute laminitis are a tender gait and arched back. The sole horn reveals red and yellowish discolourations within five days. In subacute and chronic cases clinical signs are less severe. In chronic laminitis the shape of the claws is altered. Laminitis is frequently followed by sole ulceration and white zone lesions. Blood tests showed no significant changes for laminitic animals. Arteriographic studies of claws affected by laminitis indicated that blood vessels had narrowed lumens. Gross pathology revealed congestion of the corium and rotation of the distal phalanx. Histopathologic studies indicate that laminitis is associated with changes of the vasculature. Peripartum management and nutrition are important factors in its aetiology. It is hypothesised that laminitis is evoked by disturbed digital circulation. In the pathogenesis of acute laminitis three factors are considered important: the occurrence of thrombosis, haemodynamic aspects of the corium, and endotoxins which trigger these pathologic events.     

A Novel Approach to the Treatment and Prevention of Laminitis: Botulinum Toxin Type A for the Treatment of Laminitis

Laminitis is an inflammation of the lamina of hoofed animals. According to the United States Department of Agriculture (USDA), laminitis impacts approximately 2% of the horse population each year. Because of the severity of the inflammation and chronic pain, it is frequently necessary to euthanize these horses. Surviving horses may be left useless, with resultant economic and social impact on the industry. Current interventions for laminitis are based on supportive care and alteration of biomechanical forces on the digit. The transition from laminitis to laminar failure (founder) is believed to be caused by the “weight of the horse and the forces of locomotion driving the bone down into the hoof capsule.” We hypothesize that an important factor is the torsional forces placed on the distal phalanx (coffin bone) by the deep digital flexor muscle and tendon. The paralyzing effect of botulinum toxin will result in a decrease of these torsional forces and therefore will aid in the prevention or treatment of the sequelae of laminitis. Seven horses with varying degrees of laminitis were evaluated. Each underwent pretreatment and posttreatment radiographs as well as pretreatment and posttreatment Obel grading. Each horse received botulinum toxin type A injected into the belly of the deep digital flexor muscle. In all cases there was radiographic stabilization of pedal displacement from the dorsal hoof wall. Obel scores showed improvement of 1 to 2 grades during the time monitored.     

Expression of endothelin in equine laminitis.

Biosynthesis of endothelin-1 (ET-1), the most potent endogenous vasoconstrictor yet identified, is increased following myocardial infarction (MI) in man. Pathological events which occur in the connective tissues of the equine hoof during laminitis are similar in some respects, to changes occurring in the myocardial connective tissues following MI in man. The objective of this study was to determine whether ET-1 expression in connective tissues obtained from the hoof of laminitic horses is increased compared with tissues obtained from healthy horses. Expression of ET-1 in connective tissues of the equine hoof was measured following tissue extraction from 3 groups of horses: horses in which acute laminitis had been induced by the administration of starch; chronically foundered horses; nonlaminitic horses. The concentration of ET-1 in laminar connective tissues obtained from all laminitic horses (1573.0 +/- 392.8 pg/g of tissue; n = 10) was increased when compared with tissues obtained from nonlaminitic horses (392.5 +/- 117.4 pg/g of tissue; n = 5) (P<0.05). The concentration of ET-1 in laminar connective tissues obtained from the experimentally induced, acute laminitic horses (1043.6 +/- 254.4 pg/g of tissue; n = 7) and from the spontaneously affected, chronic laminitic horses (2808.3 +/- 878.6 pg/g of tissue; n = 3) was increased compared with the control group (P<0.05, P<0.01, respectively). The concentration of ET-1 in laminar connective tissues obtained from the chronic laminitic horses was greater than that of the experimentally induced, acute laminitic group (P<0.05). It is suggested that the data provide a strong argument that increased ET-1 expression in the connective tissues of the equine hoof represent a potentially important and hitherto unrecognised component of the pathophysiology of equine laminitis. Further studies are needed to determine whether inhibitors of ET-1 converting enzyme or antagonists of ET-1 receptors might be useful in the treatment and prevention of laminitis in horses.     

Clinical Outcome of 14 Obese,Laminitic Horses Managed with the Same Rehabilitation Protocol

A specific method of rehabilitation was used to manage obese horses with laminitis, and clinical outcome was evaluated after 5 to 20 months. Clinical data from 14 similar laminitis cases were statistically analyzed to evaluate response to rehabilitation. Data were analyzed using repeated measures or logistic regression methodologies. Each horse presented as obese and laminitic with no history of a systemic inflammatory disease. The rehabilitation method emphasized a mineral-balanced, low nonstructural carbohydrate diet; daily exercise; hoof trimming that minimized hoof wall loading; and sole protection in the form of rubber hoof boots and/or hoof casts. Distal phalanx alignment within the hoof capsule was significantly improved, and hoof wall thickness was significantly decreased (P < .0001) following treatment. Solar depth was significantly increased (P < .0015). Reduction of palmar angle measurements was detected in acutely and chronically affected horses. This treatment effect was statistically greater for horses with chronic laminitis than for horses with acute laminitis (P interaction < .0001). Horses were 5.5 times more likely to be sound post-treatment than before treatment. Daily exercise, dietary modification, and removal of ground reaction force from the hoof wall were foci of the rehabilitation program. Hoof care and husbandry as applied to these horses may be an effective method of rehabilitation of horses from obesity-associated laminitis.     

Surgical treatment of septic pedal osteitis in horses: nine cases (1980-1987)

Over an 8-year period, 9 horses with septic pedal osteitis were admitted to the New York State College of Veterinary Medicine. Septic pedal osteitis was defined by the presence of purulent exudate combined with radiographic evidence of lysis of the distal phalanx. The condition described involved only the distal phalanx, the laminae and hoofwall, and the soft tissues of the sole. Treatment included curettage and removal of the affected portion of the distal phalanx through a ventral approach to the foot, combined with systemic administration of antibodies. Of the 9 horses, 7 returned to soundness and original function within 12 weeks after surgery. During the early postoperative period, 2 horses died from causes unrelated to the surgery or to septic pedal osteitis.