Suspensory desmitis: Diagnosis using real-time ultrasound imaging

The textural and dimensional characteristics of the appearance of the normal suspensory ligament lends itself well to diagnosis of clinical disease of this structure. Following injury to the suspensory ligament there are changes that involve inflammation, and structural compromise. These changes may be manifest in a spectrum of severity, and documentation may be provided using real- time ultrasound imaging. Ultrasound imaging of the soft tissues in the equine extremity is an important aid; in diagnosis of lameness, prognosis, monitoring of healing, and retrospectively, in determining the more efficacious therapeutic regimens. To illustrate pathologic change of the suspensory ligament, selected cases of suspensory desmitis with varying degrees of severity are discussed.     

Superficial digital flexor tendonitis in the horse

The superficial digital flexor tendon (SDFT) is an elastic structure that during maximal exercise appears to operate close to its functional limits. The biomechanical and biochemical responses to exercise, injury, and healing are still poorly understood but ongoing research is providing valuable new information which is addressed in this review. It appears that the SDFT matures early, after which time it has limited ability to adapt to stress and undergoes progressive degeneration. Focal hypocellularity, collagen fibril degeneration, selective fibril loading and alterations in the noncollagenous matrix occur primarily within the central core region of the midmetacarpal segment. Current treatment strategies have had equivocal results in returning animals to optimal athletic activity. To date it would seem that progressive rehabilitation programmes coupled with regular ultrasonographic evaluations are a cost-effective and comparable strategy when compared to surgical treatment methods. Recent interest in pharmacological modulation of intrinsic healing of collagenous structures has led to the investigation of various growth factors as potential therapeutic aids in the healing of tendon injuries. However, one of the major goals in tendon research, and one which holds the most optimism for success in the immediate future, is the prevention of tendon injuries.     

Kinematics and ground reaction forces in horses with superficial digital flexor tendinitis

OBJECTIVE: To measure and correlate kinematic and ground reaction force (GRF) data in horses with superficial digital flexor tendinitis. ANIMALS: 6 sound horses. PROCEDURE: Horses were evaluated before (sound evaluation) and after (lame evaluation) induction of superficial digital flexor tendinitis in 1 forelimb (randomized) by injection of collagenase. As each horse trotted, kinematic data were collected by use of an optoelectronic system, and GRF data were measured by use of a force plate. Three-dimensional kinematic and GRF data were projected onto a 2-dimensional sagittal plane. RESULTS: Lame limbs had significantly lower peak vertical GRF, less flexion of the distal interphalangeal joint, and less extension of the metacarpophalangeal joint, compared with compensating limbs. Carpal joint kinematics did not change. Compensating limbs had a more protracted orientation throughout the stance phase and higher braking longitudinal force and impulse; however, total range of rotation from ground contact to lift off did not change. Transfer of body weight from lame to compensating limbs was smooth, without elevation of the body mass into a suspension phase. Propulsive components of longitudinal GRF did not differ between limbs. CONCLUSIONS AND CLINICAL RELEVANCE: In horses with experimentally induced superficial digital flexor tendinitis, changes in vertical GRF were reflected in angular excursions of the distal interphalangeal and metacarpophalangeal joints, whereas changes in longitudinal GRF were associated with alterations in the protraction-retraction angle of the entire limb.     

Effect of sodium hyaluronate in collagenase-induced superficial digital flexor tendinitis in horses.

Superficial digital flexor tendinitis was induced in each forelimb of 8 horses by injecting 4,000 U of collagenase into the midmetacarpal region of the tendon. In each horse, each tendon was treated 24 and 96 hours after the collagenase injection with SC injections of sodium hyaluronate (treated limbs) or an equal volume of 0.9% NaCl solution (control limbs). Exercise was restricted for the first 3 weeks of the study, and a controlled exercise program was instituted for the remainder of the study. Horses were evaluated clinically for lameness, tendon swelling, and midmetacarpal limb circumference. Ultrasonographic examinations were performed regularly (11 examinations/horse) throughout the study, and all horses were euthanatized 12 weeks after collagenase injections. Tendons from 4 horses were harvested for biomechanical testing, and samples were obtained from tendons from the remaining 4 horses for biochemical analysis of collagen. Samples were obtained from all tendons for microscopic evaluation. Significant differences between treated and control tendons were not noticed in any of the variables examined in live horses, although trends toward less lameness in treated limbs and toward better healing on ultrasonographic examination in control limbs were recorded. Significant differences were not noticed in biomechanical or biochemical evaluations, and the only significant (P < 0.05) microscopic finding was more severe inflammation in tendons from treated limbs. This study did not reveal significant benefits of treatment with sodium hyaluronate outside a synovial sheath on tendon repair in collagenase-induced tendinitis.     

Net joint moments and joint powers in horses with superficial digital flexor tendinitis

OBJECTIVE: To determine whether analysis of net joint moments and joint powers is a suitable technique for evaluation of mechanics and energetics of lameness in horses and to measure effects of superficial digital flexor tendinitis. ANIMALS: 6 sound horses. PROCEDURE: Horses were evaluated before (sound evaluation) and after (lame evaluation) induction of superficial digital flexor tendinitis in 1 forelimb by injection of collagenase. Recordings were made with an optoelectronic system and a force plate as horses trotted. Net joint moments and joint powers in the sagittal plane at each joint in the forelimbs during the stance phase were determined. Peak values were determined, and mechanical energy absorbed and generated at each joint was calculated. Comparisons were made between contralateral limbs during sound and lame evaluations. RESULTS: Lame limbs had significant reductions in peak values for net joint moments on the palmar aspect of metacarpophalangeal (fetlock), carpal, and humeroulnar joints. Total energy absorbed was significantly lower at every joint in lame limbs, compared with compensating limbs. CONCLUSIONS AND CLINICAL RELEVANCE: Horses with superficial digital flexor tendinitis had significant differences between lame and compensating limbs for net joint moments and joint powers at all joints, indicating that the gait of horses with superficial digital flexor tendinitis is energetically inefficient. Assessment of net joint moments and joint powers is a useful tool in evaluating equine lameness.     

Superficial digital flexor tendon healing: ultrasonographic evaluation of therapies.

Until recently, it was difficult to critically evaluate tendon healing in vivo. Superficial digital flexor tendon injuries were considered healed when the injured tendon was cold, non-painful, adequate time had passed for tendon healing to occur, and no recurrence of the injury was detected when the horse returned to athletic work. This article discusses how ultrasonography has revolutionized the diagnosis, treatment, and management of tendon injuries.     

Calculated forelimb flexor tendon forces in horses with experimentally induced superficial digital flexor tendinitis and the effects of application of heel wedges

OBJECTIVE: To calculate forces in the flexor tendons and the influence of heel wedges in affected and contralateral (compensating) forelimbs of horses with experimentally induced unilateral tendinitis of the superficial digital flexor (SDF) tendon. ANIMALS: 5 Warmblood horses. Procedure-Ground reaction force and kinematic data were obtained during a previous study while horses were trotting before and after induction of tendinitis in 1 forelimb SDF and after application of 6 degrees heel wedges to both forehooves. Forces in the SDF, deep digital flexor (DDF), and the suspensory ligament (SL) and strain in the accessory ligament (AL) of the DDF were calculated, using an in vitro model of the distal region of the forelimb. RESULTS: After induction of tendinitis, trotting speed slowed, and forces decreased in most tendons. In the affected limb, SL force decreased more than SDF and DDF forces. In the compensating limb, SDF force increased, and the other forces decreased. After application of heel wedges, SDF force in both limbs increased but not significantly. Furthermore, there was a decrease in DDF force and AL strain. CONCLUSIONS AND CLINICAL RELEVANCE: The increase in SDF force in the compensating forelimb of horses with unilateral SDF tendinitis may explain the high secondary injury rate in this tendon. The lack of decrease of SDF force in either limb after application of heel wedges suggests that heel wedges are not beneficial in horses with SDF tendinitis. Instead, heel wedges may exacerbate the existing lesion.     

Active expression of matrix metalloproteinase-13 mRNA in the granulation tissue of equine superficial digital flexor tendinitis

The DNA microarray analysis for matrix metalloproteinase (MMP)-related mRNA expression in equine superficial digital flexor tendinitis indicated that mRNA level of MMP-13 was apparently up-regulated in the tendinitis as compared to normal tendon. In situ hybridization also revealed that fibroblastic cells proliferated in the granulation tissue generated in the tendinitis actively expressed MMP-13 mRNA. On the other hand, in normal tendon, a few fibroblastic cells and vascular components lied in the endotenon barely expressed its mRNA, but other cellular components in the tendon bundle were not positively hybridized. As mentioned above, MMP-13 but not other collagenases or gelatinases, may play an important role in tendon injuries in the racehorses.     

Tenectomy of the superficial digital flexor tendon as a treatment of suspected septic tendinitis and tenosynovitis of the digital flexor tendon sheath followed by rehabilitation with an orthotic device

A 15-year-old Sports horse gelding was referred for nonweightbearing lameness of the left hindlimb. Septic cellulitis was diagnosed and managed medically. After 14 days, septic tenosynovitis of the digital flexor tendon sheath (DFTS), with septic tendinitis of the superficial (SDFT) and deep (DDFT) digital flexor tendons, became evident. Surgical resection of the intrathecal portion of the septic SDFT was performed. Post-operatively, a half-limb cast was placed on the operated limb for 10 weeks followed by an articulated orthotic support boot during a rehabilitation period of 6 weeks. The horse recovered and regained long-term pasture soundness. Ultrasonography demonstrated the presence of bridging connective tissue in the location of the resected SDFT.     

Superficial digital flexor tendonitis in Thoroughbred race horses: outcome following non-surgical treatment and superior check desmotomy

Objective This study documents the results of non-surgical treatment and treatment by superior check desmotomy in Thoroughbred racehorses with superficial digital flexor (SDF) tendonitis. Design A prospective study was made of 124 thoroughbred racehorses with unilateral or bilateral SDF tendonitis. Procedure The flexor tendons were assessed by physical and ultrasonographic examination before treatment, and the lesions detected in affected tendons were characterised according to lesion type, length and cross-sectional area. Ninety three horses were managed non-surgically and 31 by superior check desmotomy. Recurrent or new injuries were defined as injuries affecting a previously injured superficial digital flexor tendon, the contralateral SDF tendon, or the suspensory ligament (interosseous muscle) in either forelimb. Results No statistically significant difference was found in ultrasonographic lesion severity between treatment groups. Horses managed by superior check desmotomy were 1.3 times more likely to complete five or more races than horses managed non-surgically (95% confidence limits 0.93–1.82). Horses treated surgically were 1.2 times more likely to develop recurrent or new injuries after returning to training than horses managed non-surgically (95% CL 0.95–1.55). Horses under-going superior check desmotomy were 5.5 times more likely to develop suspensory desmitis than horses treated non-surgically (95% CL 1.13–26.4). There was no difference in the time to recurrent or new injury between treatment groups. Conclusion There was no statistically significant difference between treatment groups in the proportions of horses able to complete five or more races after an episode of superficial digital flexor tendonitis. Superior check desmotomy did not appear to offer an advantage over non-surgical treatment in preventing recurrent or new injuries in Thoroughbred racehorses. Horses undergoing superior check desmotomy appeared to be at greater risk of developing suspensery ligament injuries than horses managed non-surgically.     

Superficial digital flexor tendon lesions in racehorses as a sequela to muscle fatigue: a preliminary study

REASON FOR PERFORMING STUDY: Racing and training related lesions of the forelimb superficial digital flexor tendon are a common career ending injury to racehorses but aetiology and/or predisposing causes of the injury are not completely understood. OBJECTIVES: Although the injury takes place within the tendon, the lesion must be considered within the context of the function of the complete suspensory system of the distal limb, including the associated muscles. METHODS: Both muscle and tendon function were investigated in vivo using implanted strain gauges in 3 Thoroughbred horses walking, trotting and cantering on a motorised treadmill. These data were combined with assessments of muscle architecture and fibre composition to arrive at an overview of the contribution of each muscle-tendon unit during locomotion. RESULTS: The superficial digital flexor muscle has fatigue-resistant and high force production properties that allow its tendon to store and return elastic energy, predominantly at the trot. As running speed increases, deep digital flexor tendon force increases and it stabilises hyperextension of the fetlock, thus reinforcing the superficial digital flexor in limb load support. The deep digital flexor muscle has fast contracting properties that render it susceptible to fatigue. CONCLUSION: Based on these measurements and supporting evidence from the literature, it is proposed that overloading of the superficial digital flexor tendon results from fatigue of the synergistic, faster contracting deep digital flexor muscle. POTENTIAL RELEVANCE: Future research investigating distal limb system function as a whole should help refine clinical diagnostic procedures and exercise training approaches that will lead to more effective prevention and treatment of digital flexor tendon injuries in equine athletes.     

Identification of surgically-induced longitudinal lesions of the equine deep digital flexor tendon in the digital flexor tendon sheath using contrast-enhanced ultrasonography: an ex-vivo pilot study

Background

Longitudinal tears in the lateral aspect of the deep digital flexor tendon are the most common causes of pain localised to the equine digital flexor tendon sheath. However conventional ultrasonographic techniques provide limited information about acute lesions. Ultrasonographic contrast agents are newly developed materials that have contributed to advancement in human diagnostic imaging. They are currently approved for intravenous use in human and animal models. In this study we described intrathecal use in the horse. This study was undertaken to evaluate the reliability of standard and angle contrast-enhanced ultrasonography to detect and characterize surgically-induced longitudinal lesions in the deep digital flexor tendons.In this pilot study surgically-induced lesions were created in the lateral aspect of the deep digital flexor tendon within the digital flexor tendon sheath in 10 isolated equine limbs to generate a replicable model for naturally occurring lesions. Another 10 specimens were sham operated. All the limbs were examined ultrasonographically before and shortly after the intrasynovial injection of an ultrasound contrast agent containing stabilised microbubbles. The images were blindly evaluated to detect the ability to identify surgically-created lesions. The deep digital flexor tendons were dissected and a series of slices were obtained. The depth of longitudinal defects identified with contrast-enhanced ultrasound scans was compared to the real extent of the lesions measured in the corresponding gross tendon sections.

Results

Contrast-enhanced ultrasonography with both angle and standard approach provided a significant higher proportion of correct diagnoses compared to standard and angle contrast ultrasonography (p < 0.01). Contrast-enhanced ultrasonography reliably estimated the depth of surgically-induced longitudinal lesions in the deep digital flexor tendons.

Conclusion

Contrast-enhanced ultrasound of the digital flexor tendon sheath could be an effective tool to detect intrasynovial longitudinal tears of the deep digital flexor tendon, although an in vivo study is required to confirm these results for naturally occurring lesions.     

Prediction of intramuscular fat percentage in live swine using real-time ultrasound

Purebred Durocs (n = 207) were used to develop a model to predict loin intramuscular fat percentage (PIMF) of the longissimus muscle in live pigs. A minimum of four longitudinal, real-time ultrasound images were collected 7 cm off-midline across the 10th to the 13th ribs on the live animal. A trained technician used texture analysis software to interpret the images and produce 10 image parameters. Backfat and loin muscle area were measured from a cross-sectional image at the 10th rib. After harvest, a slice from the 10th to the 11h rib loin interface was used to determine carcass loin intramuscular fat percentage (CIMF). The model to predict loin intramuscular fat percentage was developed using linear regression analysis with CIMF as the dependent variable. Initial independent variables were off-test weight, live animal ultrasonic 10th rib backfat and loin muscle area, and the 10 image parameters. Independent variables were removed individually until all variables remaining were significant (P < 0.05). The final prediction model included live animal ultrasound backfat and five image parameters. The multiple coefficient of determination and root mean square error for the prediction model were 0.32 and 1.02%, respectively. An independent data set of Duroc (n = 331) and Yorkshire (n = 288) pigs from two replications of the National Pork Board's Genetics of Lean Efficiency Project were used for model validation. Results showed the Duroc pigs provided the beat validation of the model. The product moment correlation and rank correlation coefficients between PIMF and CIMF were 0.60 and 0.56, respectively, in the Duroc population. Results show real-time ultrasound image analysis can be used to predict intramuscular fat percentage in live swine.     

Diagnosis of feline haemoplasma infection using a real-time PCR assay

Haemobartonella felis has been reclassified within the genus Mycoplasma as Mycoplasma haemofelis and 'Candidatus Mycoplasma haemominutum', collectively referred to as the feline haemoplasmas. A total of 78 cats from the Johannesburg area that had blood samples submitted to a private veterinary laboratory were tested using a real-time polymerase chain reaction (PCR) assay able to detect and distinguish the two feline haemoplasma (basonym Haemobartonella) species. All samples had been diagnosed with haemoplasma infection by cytological examination of blood smears. Statistical analysis was performed to evaluate associations between haemoplasma status, age, and haematological and biochemical parameters. On PCR assay 43 cats (55%) were haemoplasma negative, 25 (32.1%) positive for 'Candidatus Mycoplasma haemominutum', 5 (6.4%) positive for Mycoplasma haemofelis and 5 (6.4%) positive for both species. Significant inverse correlation was found between the amount of M. haemofelis DNA present in the blood and the haematocrit value. Cats that were positive for M. haemofelis showed macrocytic regenerative anaemia, monocytosis and thrombocytopaenia. This report documents the existence of both haemoplasma species in cats in South Africa.     

Injection of the insertion of the deep digital flexor tendon in horses using radiographic guidance

Insertional tendinopathies of the DDFT have been reported both as the sole lesion and as part of a multifocal lesion (Dyson et al. 2003). Computed tomography (CT) and magnetic resonance imaging allow specific diagnosis of deep digital flexor tendon lesions within the hoof capsule; however, direct intralesional treatment of such lesions is difficult because of the hoof's rigid structure. A technique designed to mimic intralesional injection of insertional tendinopathies of the DDFT in the standing horse using radiographic guidance was assessed. Radiographic and contrast CT imaging and sectioning of the limbs confirmed accurate injection in all cases although inadvertant administration of injectate into adjacent structures was also evident.