Comparison of computer-assisted surgery with conventional technique for the treatment of axial distal phalanx fractures in horses: an in vitro study

OBJECTIVES: To compare the precision obtained with computer-assisted screw insertion for treatment of mid-sagittal articular fractures of the distal phalanx (P3) with results achieved with a conventional technique. STUDY DESIGN: In vitro experimental study. SAMPLE POPULATION: Thirty-two cadaveric equine limbs. METHODS: Four groups of 8 limbs were studied. Either 1 or 2 screws were inserted perpendicular to an imaginary axial fracture of P3 using computer-assisted surgery (CAS) or conventional technique. Screw insertion time, predetermined screw length, inserted screw length, fit of the screw, and errors in placement were recorded. RESULTS: CAS technique took 15-20 minutes longer but resulted in greater precision of screw length and placement compared with the conventional technique. CONCLUSION: Improved precision in screw insertion with CAS makes insertion of 2 screws possible for repair of mid-sagittal P3 fractures. CLINICAL RELEVANCE: CAS although expensive improves precision in screw insertion into P3 and consequently should yield improved clinical outcome.     

Conservative treatment of intra-articular distal phalanx fractures in horses not used for racing

OBJECTIVE: To determine the success rate and whether specific patient and treatment factors influenced the outcome after conservative treatment with a bar shoe with quarter clips of intra-articular fractures of the distal phalanx in horses not used for racing. DESIGN: Retrospective study. SAMPLE POPULATION: Thirty-two client-owned horses. PROCEDURE: Hospital records of horses that had been treated conservatively for intra-articular fractures of the distal phalanx at Skara Equine Hospital or Halland Animal Hospital in Sweden between 1995 and 2001 were reviewed. Racehorses in active training and horses affected with other musculoskeletal diseases were excluded from the study. Follow-up was performed by questionnaire and telephone inquires to the owners 1 to 7 years after injury. RESULTS: Twenty-two horses (69%) returned to their previous or expected level of use and did not wear their bar shoe when they were put back into training. There was no statistically significant correlation between outcome and patient or treatment variables, or bony union of the fracture. CONCLUSIONS AND CLINICAL RELEVANCE: Conservative treatment of intra-articular fractures of the distal phalanx carries a fair prognosis for return to previous or expected level of use in horses not used for racing. Radiographic evidence of fracture healing and age of the patient do not seem to influence the prognosis. Horses not used for racing do not need to be shod with a bar shoe with quarter clips for the rest of their athletic career.     

Computer-assisted surgery for screw insertion into the distal sesamoid bone in horses: an in vitro study

OBJECTIVE: To compare the precision of computer-assisted surgery with a conventional technique (CV) using a special guiding device for screw insertion into the distal sesamoid bone in horses. STUDY DESIGN: In vitro experimental study. SAMPLE POPULATION: Cadaveric forelimb specimens. METHODS: Insertion of a 3.5 mm cortex screw in lag fashion along the longitudinal axis of intact (non-fractured) distal sesamoid bones was evaluated in 2 groups (8 limbs each): CV and computer-assisted surgery (CAS). For CV, the screw was inserted using a special guiding device and fluoroscopy, whereas for CAS, the screw was inserted using computer-assisted navigation. The accuracy of screw placement was verified by radiography, computed tomography, and specimen dissection. RESULTS: Surgical precision was better in CAS compared with CV. CONCLUSION: CAS improves the accuracy of lateromedial screw insertion, in lag fashion, into the distal sesamoid bone. CLINICAL RELEVANCE: The CAS technique should be considered for improved accuracy of screw insertion in fractures of the distal sesamoid bone.     

Nonsurgical management of type II fractures of the distal phalanx in 48 Standardbred horses

OBJECTIVE: To evaluate nonsurgical management of type II fractures of the distal phalanx in Standardbred horses. DESIGN: Retrospective study of 48 affected horses. RESULTS: Most fractures occurred on the lateral palmar process of the left forelimb or the medial palmar process of the right forelimb; 81% of horses were considered sound enough to return to training and 63% raced. Of those returning to racing, 41% competed in > 10 races, 37% in 2 to 10 races and 22% in only 1 race. There was no difference in performance before and after fracture. Twenty-four of 25 horses had a bar shoe fitted for > 50% of the treatment phase. Of those horses returning to training without a bar shoe, 89% refractured at the same site. Sixty percent of horses returning to training with a bar shoe raced successfully. The total convalescent time, the time rested in a box and the time spelled in a paddock were similar for horses returning to racing and those that did not. The age of the horse had no effect on the ability to return to racing. CONCLUSION: The prognosis for type II fractures of the distal phalanx is guarded. It is advisable to fit a bar shoe on the horse during convalescence. Horses returning to training and racing with a bar shoe appear less likely to refracture the distal phalanx. Those horses that return to racing can perform at a level similar to that prior to fracture.     

Palmar process fractures of the distal phalanx in foals: A review

Distal phalanx fractures are well documented in adult horses, but our knowledge of such fractures in foals is limited. Recent studies showed a high incidence of distal phalanx palmar process (PP) fractures in foals, the aetiology is not yet known. Several hypotheses have been suggested as possible causes, including uneven compressive forces, unequal forces from the deep digital flexor tendon, composition and shape of the PP, and conformation. A better understanding of the aetiology and predisposing factors requires further research. Radiography is the commonly used imaging modality for diagnosis of such fractures; however, those fractures might be missed on routine radiographic projections. In order to have a high probability of identifying fractures, a series of 5 radiographs including the oblique views is required. This article reviews the incidence of distal phalanx PP fractures and discusses the diagnosis of such fractures.     

Palmar or plantar process fractures of the distal phalanx in riding horses: 22 cases (1994–2003)

No case series exists in the literature describing palmar/plantar process fractures (PPFs) of the distal phalanx in a nonracehorse population. We aim to describe the distribution of these injuries, together with their clinical, radiographic and scintigraphic features. In a retrospective case study, horses were selected based on radiographic evidence of a PPF. Data were collected relating to clinical and lameness examination, radiography, scintigraphy, management and follow‐up information. Oblique and flexed oblique radiographic views of the distal phalanx are the most sensitive in detecting PPFs of the distal phalanx and this study concluded that fractures of palmar or plantar process are likely to be missed in horses showing mild lameness if oblique radiographic views of the palmar process are not included.     

Arthroscopic surgery for osteochondral fractures of the proximal phalanx of the metacarpophalangeal and metatarsophalangeal (fetlock) joints in horses

Arthroscopic surgery for osteochondral fractures of the proximal phalanx was performed on 74 fetlock joints of 63 horses for a total of 87 fractures during a 2-year period. The medial dorsal proximal aspect of the proximal phalanx of the forelimbs was most commonly involved (59 fractures), followed by the lateral aspect (26 fractures), and 2 fractures occurred in the fetlock joint of the right hindlimb. At surgery, 82 fragments were removed and 5 fragments that had healed or were embedded in the joint capsule were not removed. Of the fragments removed, 15 were fixed firmly to the proximal phalanx, 63 were easily movable by arthroscopic instruments (but had soft tissue attachments to the proximal phalanx), and 4 were floating free within the joint. Arthroscopic surgery allowed excellent visualization and appreciation of the attachments of fragments and their stage of healing. Horses returned to full race training at an average of 11 1/2 weeks (range, 6 to 24 weeks). Thirty eight of 46 horses (82.6%) with adequate postoperative follow-up returned to athletic performance at least equal to that before fetlock injury.     

Computed tomography to identify preoperative guidelines for internal fixation of the distal sesamoid bone in horses: an in vitro study

Objective: To assess the reliability of computed tomography (CT) to identify the direction of implant insertion for cortical screws along the longitudinal axis of intact (nonfractured) distal sesamoid bones. Study Design: In vitro study. Sample Population: Cadaveric paired equine forelimbs (n=16). Methods: Insertion of a cortical screw in lag fashion along the longitudinal axis of intact (nonfractured) distal sesamoid bones was evaluated in 2 groups (3.5 and 4.5 mm) of 8 paired limbs. In each group, the direction of the distal sesamoid bone was determined by CT (Equine XTC 3000 pQCT scanner). Screw placement was verified by specimen dissection. Implant direction was considered satisfactory if the entire screw length was within the distal sesamoid bone and not damaging the articular or flexural surfaces. Results: In our sample and according to our criteria, the proportion of satisfactory direction of screws was 0.63 (5/8) for 4.5 mm implants, and 0.87 (7/8) for 3.5 mm implants. Conclusions: CT is a useful imaging modality to identify anatomic landmarks for insertion of a 3.5 mm cortical screw in the distal sesamoid bone.     

Short incomplete sagittal fractures of the proximal phalanx in ten horses not used for racing

Objective— To describe short incomplete sagittal fractures of the proximal phalanx (type Ia P1 fractures) in horses not used for racing and report outcome.
Study Design— Retrospective study.
Animals— Horses (n=10) with type Ia P1 fractures.
Methods— Retrieved data of horses with type Ia P1 fractures were signalment, history and results of orthopedic examination. Radiographs were re-evaluated for position and length of the fracture line, presence of osteoarthritis or subchondral cystic lesions (SCL), periosteal new bone formation and subchondral sclerosis. Conservative treatment (n=4) included box confinement for 2 months followed by 1 month of hand walking. Surgical therapy (n=6) consisted of internal fixation by screws inserted in lag fashion in 5 horses. Concurrent SCL were debrided by curettage via a transcortical drilling approach. In 1 horse, only SCL curettage but not internal fixation was performed. Outcome was assessed on a clinical and radiographic follow-up examination in all horses.
Results— Mean follow-up time was 27 months (median, 13.5 months; range, 9 months to 9 years). All horses treated with internal fixation were sound at follow-up and had radiographic fracture healing. Of the 4 horses managed conservatively, 3 remained lame and only 1 horse had radiographic evidence of fracture healing. Catastrophic fracture propagation occurred in 2 horses not treated by internal fixation, 20 and 30 months after diagnosis, respectively.
Conclusions— Horses with a type Ia P1 fracture treated surgically had a better outcome than those managed conservatively and lack of fracture healing seemingly increases the risk of later catastrophic fracture.
Clinical Relevance— Surgical repair of type Ia P1 fractures should be considered to optimize healing and return to athletic use.     

Comparison of forced oscillation with the conventional method for histamine bronchoprovocation testing in horses

OBJECTIVE: To compare response of horses to histamine bronchoprovocation (HBP), using total respiratory resistance (Rrs) measured by forced oscillatory mechanics (FOM) with dynamic compliance (Cdyn) and pulmonary resistance (RL) measured by the esophageal balloon method. ANIMALS: 10 horses with various degrees of airway reactivity. PROCEDURE: The 2 methods for measuring airway responses to HBP were performed on separate days. Endpoints compared were increase of 150 or 200% of baseline Rrs (PC150Rrs, PC200Rrs) and to 150% of baseline RL (PC150RL) or decrease to 65% of baseline Cdyn (PC65Cdyn). Frequency dependence of respiratory mechanics, using FOM, was evaluated, using the slope of Rrs over 1 to 3 Hz and the ratios of Rrs at 1 Hz to Rrs at 2 and 3 Hz (Rrs1Hz/Rrs2Hz, Rrs1Hz/Rrs3Hz) and of Rrs at 2 Hz to Rrs at 3 Hz (Rrs2Hz/Rrs3Hz). Effect of histamine on frequency dependence was assessed. RESULTS: Correlation with PC65Cdyn was high for PC150Rrs (rs = 0.93) and PC200Rrs (rs = 0.96). Correlation between PC65Cdyn and PC150RL was weakly positive (rs = 0.61). The slope of Rrs over 1 to 3 Hz changed significantly between baseline (-0.07+/-0.09 cm H2O/L/s/Hz) and final histamine dose (-0.28+/-0.10 cm H2O/L/s/Hz). The Rrs1Hz/Rrs3Hz and Rrs2Hz/Rrs3Hz differed significantly (P < 0.05 between baseline [1.27+/-0.36 and 0.96+/-0.11, respectively] and final histamine dose [1.62+/-0.37 and 1.09+/-0.14, respectively]). CONCLUSIONS: Correlation between histamine-induced changes in respiratory mechanics, as measured by FOM and the pneumotachograph-esophageal balloon method, was good. The FOM results indicated frequency dependence of respiratory mechanics during HBP. CLINICAL RELEVANCE: A noninvasive method of measuring airway reactivity will facilitate routine evaluation of horses with suspected small airway disease and may be suitable for field studies.     

In vitro responses of distal airways in horses with recurrent airway obstruction

Distal airway segments (ID, 3 to 4 mm; length, 5 mm) from 2 groups of horses were isolated and suspended in tissue baths filled with Krebs solution, aerated with 5% CO2 in oxygen and maintained at 37 degrees C. Responses to exogenous acetylcholine, isoproterenol, or electrical field stimulation were compared. Control horses (n = 30) had no history of recurrent airway obstruction, whereas principal horses (n = 15) had recurrent airway obstruction and were studied during an acute episode of airway obstruction. Although the distal airways contracted in response to the cumulative half-logarithmic addition of acetylcholine (10(-10) M to 10(-3) M) in both groups, bronchi obtained from principals were less sensitive to acetylcholine than were bronchi obtained from controls. Tetdrodotoxin-sensitive electrical field stimulation-induced contractions were observed in both groups of airways, but the tension achieved in principal bronchi was less than in controls. All electrical field stimulation-induced contractions were abolished by atropine, indicating that the only excitatory innervation of equine distal airway is through the parasympathetic system. To examine the effect of isoproterenol and determine inhibitory innervation, bronchi were precontracted with histamine. Electrical field stimulation did not cause relaxation of precontracted bronchi in either group, thus indicating that distal airways lack inhibitory innervation. Isoproterenol caused similar, dose-dependent relaxation in both groups.     

Osteochondral fragmentation of the palmarolateral/plantarolateral aspect of the distal phalanx in four horses: A novel location

Four horses presenting for lameness were diagnosed with unilateral osteochondral fragmentation (OCF) of the palmarolateral/plantarolateral aspect of the distal phalanx within the distal interphalangeal joint (DIPJ). Histological evaluation of one case supported a diagnosis of osteochondritis dissecans (OCD), with patient age and history from two cases suggesting a traumatic origin. Lesion appearance on conventional radiography, computed tomography (CT), nuclear scintigraphy and magnetic resonance imaging (MRI) are described. Fragmentation was best identified on dorsal 65° proximal-palmaro/plantarodistal oblique (D65°PrPDiO/D65°PrPlDiO) and dorsal 65° proximal-palmaro/plantarodistal lateral oblique (D65°Pr45°L-PDiMO/D65°Pr45°L-PlDiMO) radiographic projections of the foot, but articular pathology appeared more severe on cross-sectional imaging modalities. In all cases, lameness was refractory to conservative management. Arthroscopic evaluation of the DIPJ was performed in three horses, although the lesion was inaccessible in two. In one horse, access to the lesion was possible due to increased joint laxity, presumably due to concurrent soft tissue injury. One horse was euthanased after failed conservative management, one was pasture sound following palmar digital neurectomy 12 months after initial presentation, one returned to racing and one was lost to follow-up. Osteochondral fragmentation at this location has not previously been described, treatment options are limited and the prognosis appears to be poor.     

Comparison of an alcohol-based hand rub and water-based chlorhexidine gluconate scrub technique for hand antisepsis prior to elective surgery in horses

This prospective clinical study evaluates the effectiveness of an alcohol-based hand rub (Avagard™) for pre-surgical hand antisepsis in an equine hospital and compares it with traditional scrubbing technique using 4% chlorhexidine gluconate sponges and water. Prior to elective surgery, 3 board-certified surgeons were randomly assigned to hand antisepsis with either technique. Culture samples of each hand were taken at 4 times: before and after neutral soap hand wash, after scrub or rubbing technique, and after surgery. There was no significant difference in mean bacterial colony forming units between scrub and rub techniques over the 3 time periods (P = 0.6), controlling for initial counts. One horse from the scrub group had a skin incision infection following stifle arthroscopy; this was resolved with medical treatment. The alcohol-based hand rub is equivalent in efficacy for pre-surgical hand antisepsis to traditional water-based scrubs in an equine hospital setting.     

Management of comminuted fractures of the proximal phalanx in horses: 64 cases (1983-2001)

OBJECTIVE: To report the outcome of surgical treatment of comminuted fractures of the proximal phalanx in horses. DESIGN: Retrospective study. ANIMALS: 64 horses. PROCEDURE: Medical records and radiographs were reviewed to obtain information regarding signalment, fracture classification, and treatment. Follow-up information was obtained by telephone conversation or evaluation of production records. RESULTS: Thirty-eight horses had moderately comminuted fractures of the proximal phalanx. Two horses were euthanatized immediately. Fractures of the proximal phalanx in 36 horses were repaired with open reduction and internal fixation with a successful outcome in 33 (92%) horses. Reconstruction of the fracture was performed in most horses by use of a long curved incision, transection of the collateral ligament of the metacarpophalangeal or metatarsophalangeal joint, and open exposure of the proximal articular surface of the proximal phalanx. Twenty-six horses had severely comminuted fractures of the proximal phalanx. Six horses were euthanatized immediately. One horse was euthanatized after 9 days of treatment with a cast alone. Severely comminuted fractures of the proximal phalanx in 13 horses were treated with an external skeletal fixation device, and fractures healed in 8 of those horses. Six horses with severely comminuted fractures of the proximal phalanx were treated with transfixation pins incorporated into a fiberglass cast, and fractures healed in 4 horses. CONCLUSIONS AND CLINICAL RELEVANCE: Moderately comminuted fractures of the proximal phalanx can be successfully repaired; however, fractures that are too severe to permit accurate reconstruction of the fragments remain difficult to treat and horses have only a fair prognosis for survival.     

Necrosis of the collateral cartilage of the distal phalanx in horses: 16 cases (1970-1985)

The medical records of 16 horses with necrosis of the collateral cartilage of the distal phalanx were reviewed. Typical history included a laceration or puncture wound over the affected cartilage, resulting in persistent drainage proximal to the coronary band. All horses had signs of lameness. The duration of drainage prior to admission to the hospital ranged from 5 days to 5 months. The involved cartilages were left front lateral (n = 4), right front lateral (n = 5), left rear lateral (n = 1), right rear lateral (n = 4), left front medial (n = 1), and left rear medial (n = 1). The affected cartilage was curetted or resected in 13 horses, and conservative treatment was used in 3 horses. Follow-up information on 15 horses (2 to 72 months after discharge) revealed that 66% were sound and able to perform at their previous level. One horse was euthanatized 2 months after discharge from the hospital because it had septic arthritis of the distal interphalangeal joint. The outcome of treatment for each horse was evaluated with respect to the duration of drainage and the method of treatment. Horses with drainage of less than 1 month's duration had a better prognosis for eventual soundness, compared with horses with drainage of greater than or equal to 1 month's duration prior to initiation of treatment. Nine of the 13 horses managed surgically and 1 of the 3 horses managed conservatively were sound at follow-up evaluation.     

Laparoscopic surgical technique for repair of rectal and colonic tears in horses: an experimental study

OBJECTIVE: To determine the efficacy of laparoscopic surgical techniques for repair of rectal lacerations in horses. STUDY DESIGN: Experimental study. ANIMAL OR SAMPLE POPULATION: Thirty-two segments of equine bowel placed in an equine pelvitrainer, 8 equine cadavers, and 3 normal horses. METHODS: In experiment 1, 3 laparoscopic intestinal-repair techniques were evaluated in an equine pelvitrainer: suturing with needle holders, with an automatic suture device, and stapling with a hernia stapler. In experiment 2, descending colon lacerations were sutured laparoscopically using needle holders in a pelvitrainer and in equine cadavers. In experiment 3, iatrogenic rectal lacerations were sutured laparoscopically with needle holders in horses under general anesthesia. These horses were evaluated for 7 days' postoperatively by clinical examination and blood and peritoneal fluid analysis. The horses were euthanatized 7 days' postoperatively and necropsied. The repaired colonic segments were collected for determination of bursting pressures, degree of luminal narrowing, and microscopic examination of the suture line. RESULTS: For the 3 techniques, there was no significant difference in repair time or degree of luminal narrowing, but bursting pressure was higher in segments repaired by use of needle holders or with the suture device. Colonic and rectal lacerations were sutured successfully with laparoscopic needle holders. No major complications were recorded. At necropsy, adequate healing was confirmed by a high bursting strength (>140 mm Hg) and by histologic examination. CLINICAL RELEVANCE: A novel laparoscopic method can be used to repair iatrogenic rectal lacerations in horses. Whether this method may be used for clinical cases of rectal tears must be investigated.     

Comparison of intra-articular drilling and diode laser treatment for arthrodesis of the distal tarsal joints in normal horses

REASONS FOR PERFORMING STUDY: Anecdotal reports suggest that laser-facilitated arthrodesis of the distal tarsal joints improves the prognosis compared with intra-articular drilling but no objective comparisons have been performed. OBJECTIVES: To evaluate intra-articular drilling and laser-facilitated arthrodesis using in situ and in vivo techniques. METHODS: Fourteen cadaver limbs were evaluated in situ for chondrocyte viability after both surgical techniques. In vivo, one randomly selected limb was subjected to laser-facilitated arthrodesis and the other underwent intra-articular drilling in 6 normal horses. Clinical examinations were performed at 1, 3 and 5 months. Two horses were subjected to euthanasia at 1, 3 and 5 months. RESULTS: Significantly more chondrocyte death was observed with laser-facilitated arthrodesis compared to drilling, but the overall degree suggested only a focal effect. In vivo, both groups demonstrated minimal post operative morbidity. There was more evidence of arthrodesis seen at all time points with intra-articular drilling. CONCLUSIONS: This study demonstrated that changes associated with ultimate arthrodesis occur earlier after intra-articular drilling of the distal tarsal joints than laser-facilitated arthrodesis, although clinically affected horses may respond differently. POTENTIAL RELEVANCE: Intra-articular drilling may provide earlier arthrodesis of the distal tarsal joints, but not necessarily a better long-term result.