Use of an autogenous cancellous bone graft in the treatment of subchondral bone cysts in the medial femoral condyle of the horse

The clinical features, diagnosis and radiological findings of eight cases of a subchondral bone cyst involving the medial condyle of the femur are described. Surgical treatment, which comprised performing an arthrotomy of the femorotibial joint, curetting and packing the cystic cavity with an autogenous cancellous bone graft, is described.     

Treatment options and long-term outcomes of horses with subchondral lucencies of the medial femoral condyle

Subchondral lucencies (SCL) occur in the equine medial femoral condyle (MFC) and can cause lameness and impair performance. Treatment of MFC SCL has evolved over the last 40 years from rest alone to cyst injection to several surgical procedures. Horses most commonly develop MFC SCL in the first 18 months of life, and expectations for performance and sales can impact therapeutic decisions. These complications mean that a single treatment plan cannot be applied to every SCL. An additional issue is accurate long-term performance data. Long-term follow-up can also be difficult to obtain due to horse movement, confidentiality issues after sales, and the complexities of finding new owners and getting their cooperation. This short communication reviews available racing information from publications reporting treatment of MFC SCL and provides long-term follow-up racing data on 13 horses treated with a transcondylar screw. Horses receiving a transcondylar screw raced as well as horses treated with other procedures and had longer careers, further supporting the use of this technique in the treatment of MFC SCL.     

Results of treatment of subchondral bone cysts in the medial condyle of the equine femur with an autogenous cancellous bone graft

The results of surgical treatment of 10 subchondral bone cysts, all located in the medial femoral condyle, are presented. A cancellous bone graft was used in nine cases and a two component acrylic bone cement was used in the case of an extremely large cyst. Eight out of the 10 cases made a satisfactory clinical recovery.     

Comparison of bone healing by demineralized bone matrix and autogenous cancellous bone in horses

OBJECTIVE: The purpose of this study was to compare bone healing induced by equine demineralized bone matrix (DBM) to autogenous cancellous bone graft (ACB) or no graft (control) in a rib-defect model in horses. STUDY DESIGN: The osteogenic properties of ACB and DBM were evaluated in bilateral 19-mm circular defects created in the outer cortex of the 6th and 8th ribs of each horse. ANIMALS OR SAMPLE POPULATION: Eight mature horses. METHODS: Three rib defects in each horse were randomly treated with each of the 3 treatment groups, and the fourth rib defect received a random treatment. Rib sections, including the defects, were harvested 56 days after implantation and examined for bone mineral density, percent ash and calcium and graded for signs of radiographic and histological healing. RESULTS: All ribs were fractured at the defect site and were classified as nonunion fractures 56 days after implantation. There were no significant differences among groups in bone mineral density and signs of radiographic or histological healing. There was an increased volume of bone in control and ACB-treated sites compared with DBM-treated sites. Rib defects treated with ACB were significantly higher in percent ash and calcium than those treated with DBM. DBM elicited no inflammatory reaction, and remodeling occurred around the periphery and within vascular channels of the decalcified particles. CONCLUSION: DBM particles remodel from the periphery, which may explain the significantly lower percent ash, calcium, and bone when compared with ACB, because 2- to 4-microL pieces of DBM may act as space-occupying masses until completely mineralized. There was no evidence of enhanced healing associated with the use of DBM in this model. CLINICAL RELEVANCE: Particles of 2 to 4 mm DBM should not be used as an aid to fracture repair because particles of this size interfere with normal mineralization. However, our model of nonunion fracture healing may be useful in future studies.     

Effect of beta-tricalcium phosphate in surgically created subchondral bone defects in male horses

beta-Tricalcium phosphate (TCP) was evaluated as a synthetic bone grafting material in horses. Sixteen horses were randomly assigned to 4 groups of 4 horses. In each horse, an 11-mm by 10-mm circular defect with a smooth margin was created surgically in the weight-bearing surface of both third metacarpal bones (McIII) and the left third metatarsal bone. The defect in the left McIII was filled with TCP, the defect in the right McIII was filled with a mixture of 50% autogenous cancellous bone (ACB) and 50% TCP, and the defect in the left third metatarsal bone was not filled to serve as a control. Nuclear imaging and radiographic evaluation of surgical sites were performed at postsurgical week (PSW) 4 and 13 in group-I horses and at PSW 26, 39, and 52 in groups-II, -III, and -IV horses, respectively. Horses in groups I, II, III, and IV were euthanatized at PSW 13, 26, 39, and 52, respectively, and specimens were harvested for histologic evaluation. Results were compared among treatment methods, as well as among time intervals. The greatest activity at defect sites was seen in group-I horses at PSW 4. Activity counts in limbs of group-I horses at PSW 13 and counts in limbs of group-II horses at PSW 26 were not significantly (P less than or equal to 0.05) different. Activity counts in groups-III and -IV horses at PSW 39 and 52, respectively, were less than those in groups I and II. However, there was no significant difference in activity counts between limbs implanted with TCP or ACB:TCP.(ABSTRACT TRUNCATED AT 250 WORDS)     

Arthroscopic autologous osteochondral mosaicplasty for the treatment of subchondral cystic lesion in the medial femoral condyle in a horse

An 11-year-old, Hungarian half-bred stallion was presented with a history of mixed left hindlimb lameness of 6 months duration. Subchondral bone cyst of the medial femoral condyle and injury of the medial meniscus were diagnosed. Osteochondral autograft transplantation (mosaic arthroplasty) was performed, taking grafts from the less weight-bearing medial border of the medial femoral trochlea of the affected limb, and transplanting them into the cyst during arthroscopy. The lameness was evaluated prior to and one year after the operation with a motion analysis system during treadmill exercise. Considerable improvement of the lameness and the clinical signs as well as successful transplantation of the grafts, and a new hard joint cartilage surface of the medial femoral condyle could be detected during follow-up arthroscopy. Osteochondral autograft transplantation seems to bee a possible alternative for treating subchondral cystic lesions of the medial femoral condyle in horses. A new technique for the surgical treatment of a subchondral cystic lesion of the medial femoral condyle in the horse is described.     

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 subchondral cystic lesions of the medial femoral condyle of mature horses with growth factor enhanced chondrocyte grafts: a retrospective study of 49 cases

Reasons for performing study: To evaluate the long‐term clinical outcome after allogeneic chondrocyte and insulin‐like growth factor‐I (IGF‐I) grafting of subchondral cystic lesions (SCLs) of the femoral condyle in horses. Objective: To test the hypothesis that chondrocyte and IGF‐I grafts will improve the long‐term clinical outcome in arthroscopically debrided SCLs. Methods: Medical records of 49 horses with SCLs of the femoral condyle treated by debridement and implantation of chondrocytes and IGF‐I were reviewed. Preoperative radiographs were obtained, and caudocranial radiographic projections were used to establish a ratio between cyst and femoral condyle size. Arthroscopic cyst debridement followed by filling of the bone void with autologous cancellous bone (45 horses) or tricalcium phosphate granules (4 horses) was performed. A paired syringe containing a fibrinogen and chondrocyte mixture in one syringe and calcium‐activated bovine thrombin with IGF‐I in the other was used to cover the surface. A successful outcome was defined as a horse that performed to its intended use without lameness. Results: A successful outcome was achieved in 36 of 49 horses (74%). Preoperative radiography was performed in all horses, with 33 horses having unilateral SCLs of the medial femoral condyle, 15 horses having bilateral SCLs of the medial femoral condyle, and one horse having bilateral SCLs of the lateral femoral condyle. Median age of the horses was 3.3 years. Fifteen horses had preoperative radiographic and arthroscopic evidence of osteoarthritis (OA). A successful outcome was not influenced by age of horse, presence of pre‐existing osteoarthritis or preoperative size of the subchondral cyst. Grafting resulted in success for 80% of horses >3 years old, and in 80% of horses with OA. Conclusions: Implantation of allogeneic chondrocytes supplemented with IGF‐I is an effective treatment for horses with SCLs of the femoral condyle, and particularly for older horses and horses with pre‐existing osteoarthritis. Potential relevance: Chondrocyte implantation may offer a greater chance of long‐term success in older horses and horses with osteoarthritis than has been previously reported with cyst debridement alone.     

The effect of intra-articular methylprednisolone acetate and exercise on equine carpal subchondral and cancellous bone microhardness

Dorsal carpal osteochondral injury is a major cause of lameness in horses undergoing high intensity training. Intra-articular corticosteroid treatment is used commonly to manage exercise-associated articular pain, but its use remains highly controversial in the equine athlete. This project, therefore, aimed to compare the mechanical properties of intra-articular MPA and diluent-treated middle carpal subchondral and cancellous bone in horses undergoing a short-term treadmill exercise programme. It was hypothesised that subchondral and cancellous bone mechanical properties are influenced by intra-articular administration of methylprednisolone acetate (MPA). Eight 2-year-old female horses had MPA or diluent administered into contralateral middle carpal joints at 14 day intervals, for a total of 4 treatments per horse. Horses underwent a standard treadmill exercise protocol until euthanasia (Day 70). Standard sites were located on the dorsal aspect of third, radial and intermediate carpal bones. Osteochondral samples from each test site were divided into subchondral bone and cancellous bone portions. These were dried, resin-embedded and gold-coated. Microhardness measurements were obtained at each test site. No significant effect of intra-articular treatment was detected. At each site, cancellous bone trabecular struts had an 18-19% higher microhardness value than the overlying subchondral bone. These findings indicate that intra-articular administration of MPA at this dose has no effect on subchondral or cancellous bone adaptation to short-term exercise and, therefore, on the propensity of carpal bones to injury. Further investigation into the calcified cartilage layer, effect of different corticosteroid preparations and diffusion of medication are required.     

Arthroscopic injection of corticosteroids into the fibrous tissue of subchondral cystic lesions of the medial femoral condyle in horses: a retrospective study of 52 cases (2001-2006)

REASONS FOR PERFORMING STUDY: There are no published results of subchondral cystic lesions (SCLs) in the medial femoral condyle (MFC) treated with arthroscopic injection of corticosteroids into the lining of the cyst. OBJECTIVES: 1) To determine the success rate for treatment of SCLs in the MFC with arthroscopic injection of the fibrous tissue of the cyst with corticosteroids. 2) To identify any factors that may predict outcome. HYPOTHESES: Injection of the fibrous tissue of SCLs of the MFC with corticosteroids utilising arthroscopic guidance yields a similar or higher chance for intended performance than does arthroscopic debridement as previously reported; this technique will be effective for treating SCLs in older horses. METHODS: Horses with clinical and radiographic evidence of a SCL in the MFC were injected with corticosteroids under arthroscopic guidance, and case records and radiographs were reviewed retrospectively. A telephone survey of referring veterinarians, owners and trainers was conducted. RESULTS: Thirty-five of 52 (67%) cases were classified as successful involving 73 SCLs of which 56 (77%) were classified as successful. There was no significant association between age group (age3 years) and outcome, or cyst configuration and outcome. Significantly more unilateral SCLs (28/31 [90%] SCLs) were classified as successful than bilateral (28/42: 67%). There were significant differences in outcome based on the surgeon operating the case and an association between pre-existing radiographic findings of osteophytes and negative outcome. CONCLUSIONS: Injection of SCLs utilising arthroscopic guidance is an effective alternative method of surgical treatment of SCL. POTENTIAL RELEVANCE: This technique offers a similar chance of success as has been reported with debridement and may allow for a shorter period of convalescence. If unsuccessful, the option remains to debride the cyst in a second surgery.     

Effects of autogenous cancellous bone on healing of homogenous cortical bone grafts

A comparative clinical and histological study was made of the effects of autogenous cancellous grafts on the rate of healing of homogenous cortical bone grafts in dogs: their right foreleg received homogenous bone grafts and their left foreleg received pre-drilled homogenous bone grafts filled with autogenous cancellous bone. Histologically, the use of homogenous cortical grafts with pre-drilled holes and autogenous cancellous bone appeared to accelerate reorganization and development of these grafts. This was seen particularly 1–2 months post-operatively and at nine months when the graft in the left leg was made up of spongy bone marrow; whereas the right leg graft still contained compact dead bone and the marrow was filled with fibrous tissue.     

Comparison of two grafting methods in 4.0-mm drill defects in the third metacarpal bone of horses.

In 6 horses, bilateral metacarpal vertical series of three 4.0-mm unicortical drill holes were made. At random, one of each series of 3 holes was filled using a sternal 4.0-mm cancellous bone cylinder or a slurry of cancellous bone injected into the hole or left as an empty control. All horses had lateral metacarpal xeroradiographs at monthly intervals. Three horses (6 metacarpi) were examined post mortem after 4 months and 3 others after 6 months. Immediate through 4-month post-operative xeroradiographs demonstrated increased density in the holes with cancellous cylinders and no difference could be seen between the untreated controls and holes injected with slurry. From 5 months, no radiographic difference could be seen between the treatment groups. No consistent histological difference between treatment groups could be detected. In conclusion, no justification for clinical grafting of 4.0-mm unicortical dorsal metacarpal drill holes could be found.     

Arthroscopic findings in horses with subtle radiographic evidence of osteochondral lesions of the medial femoral condyle: 15 cases (1995-2002)

OBJECTIVE: To determine arthroscopic findings in lame horses with subtle radiographic lesions of the medial femoral condyle. DESIGN: Retrospective study. ANIMALS: 15 horses examined because of lameness that had subtle radiographic evidence of osteochondral lesions involving the medial femoral condyle in at least 1 joint. PROCEDURE: Medical records were reviewed, and results of physical examination, radiography, and arthroscopy were recorded. Follow-up information was obtained through reexamination of the horses or telephone conversations with the referring veterinarians, owners, or trainers. RESULTS: Lameness severity ranged from grade 1 to 3 on a scale from 0 to 5. Radiography and arthroscopy were performed on 28 stifle joints. The 4 unaffected joints in 4 horses with unilateral hind limb lameness that underwent bilateral arthroscopy had no radiographic lesions, but 2 of the 4 had arthroscopic lesions. Of the remaining 24 joints, 20 had radiographic evidence of flattening of the apex of the medial femoral condyle and 4 had minimal subchondral lucency. Lesions were identified arthroscopically in 18 of the 20 joints with flattening of the condyle and in all 4 joints with subchondral lucency. Treatment consisted of abrasion arthroplasty or microfracture. Seven of the 9 horses with focal cartilage lesions and 2 of the 6 horses with generalized cartilage lesions were reportedly sound without any evidence of joint effusion at the time of final follow-up. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggest that horses with hind limb lameness and subtle radiographic lesions of the medial femoral condyle are likely to have arthroscopically apparent cartilage lesions and subchondral bone defects.