The forelimb superficial digital flexor tendon (SDFT) is an energy-storing tendon that is highly susceptible to injury during activities such as galloping and jumping, such that it is one of the most commonly reported causes of lameness in the performance horse. This review outlines the biomechanical and biothermal effects of strain on the SDFT and how these contribute to the accumulation of microdamage. The effect of age-related alterations on strain response and subsequent injury risk is also considered. Given that tendon is a slowly healing and poorly regenerative tissue, prompt detection of early stages of pathology in vivo and timely adaptations to training protocols are likely to have a greater outcome than advances in treatment. Early screening tools and detection protocols could subsequently be of benefit in identifying subclinical signs of degeneration during the training programme. This provides an opportunity for preventative strategies to be implemented to minimise incidences of SDFT injury and reduce recovery periods in elite performance horses. Therefore, this review will focus on the modalities available to implement early screening and prevention protocols as opposed to methods to diagnose and treat injuries.

https://beva.onlinelibrary.wiley.com/doi/pdf/10.1111/evj.13331

Microdamage in the equine superficial digital flexor tendon.

BACKGROUND
Overstrain of the superficial digital flexor tendon (SDFT) is a common Thoroughbred racehorse limb injury requiring treatment.


OBJECTIVES
To determine whether treatment of SDFT lesions in flat Thoroughbred racehorses with autologous bone marrow-derived mesenchymal stem cells (BM-MSCs) or allogenic adipose-derived mesenchymal stem cells (A-MSCs) is associated with improved likelihood of returning to racing, when compared to racehorses managed with a controlled exercise rehabilitation program (CERP) alone.


STUDY DESIGN
Retrospective cohort study combining clinical treatment records with race records.


METHODS
Two hundred and thirteen Thoroughbred racehorses were identified. All were prescribed the same twelve-month CERP and 66 also received intralesional BM-MSC and 17 A-MSC treatment. Follow-up was a minimum of two years after return to full race training. Multivariable logistic regression models were used to investigate associations between the treatments and the likelihood of returning to racing and completing five or more (C5+) races post-injury.


RESULTS
Compared to CERP alone, BM-MSC treatment was associated with increased odds of returning to racing (OR 3.19; 95% CI 1.55-6.81) and C5+ races post-injury (OR 2.64; 95% CI 1.32-5.33). Older age and increasing lesion length were associated with a reduced likelihood of returning to racing. Male sex and increased number of pre-injury starts were associated with increased odds of returning to racing. There was no observed increased likelihood of return to racing or C5+ races associated with treatment with A-MSCs compared to CERP alone.


MAIN LIMITATIONS
Due to the retrospective nature of the study it was not possible to ascertain how strictly the CERP was followed. Due to the novelty of the method, the A-MSC treatment group included a limited number of horses.


CONCLUSIONS
In the study population, intralesional BM-MSC treatment was significantly associated with an increased likelihood of returning to racing and C5+ races post-injury compared to CERP alone. Intralesional A-MSC showed no significant association between treatment and the two investigated outcomes.

Treatment of racehorse superficial digital flexor tendonitis - a comparison of stem cell treatments to controlled exercise rehabilitation in 213 cases.

Flexor tendon injuries are a major cause of lameness in performance horses and have considerable impact on equine welfare and the wider horse industry. Ageing and repetitive strain frequently cause varying degrees of tendon micro-damage prior to the recognition of clinical tendinopathy. Whilst B-mode ultrasonography is most commonly utilised for detection and monitoring of tendon lesions at the metacarpal/metatarsal level, the emphasis of recent research has focused on the identification of subclinical tendon damage in order to prevent further tendon injury and improve outcomes. The introduction of elastography, acoustoelastography and ultrasound tissue characterisation in the field of equine orthopaedics shows promising results and might find wider use in equine practice as clinical development continues. Based on the substantial number of research studies on tendon imaging published over the past decade this literature review aims to examine the currently used ultrasonographic imaging techniques and their limitations, and to introduce and critically appraise new modalities that could potentially change the clinical approach to equine flexor tendon imaging.

Equine flexor tendon imaging part 1: Recent developments in ultrasonography, with focus on the superficial digital flexor tendon.

BACKGROUND The range of diagnostic modalities available to evaluate superficial digital flexor tendon (SDFT) injury includes magnetic resonance imaging (MRI), computed tomography (CT) and ultrasonography (US). Direct, comprehensive comparison of multi-modality imaging characteristics to end-point data has not previously been performed using a model of tendinopathy but is required to obtain a better understanding of each modality's diagnostic capabilities. OBJECTIVE To compare CT, MRI and US evaluation to outcome measures for histologic, biochemical and biomechanical parameters using an equine surgical model of tendinopathy. STUDY DESIGN Controlled experiment. METHODS Lesions were surgically created in both forelimb SDFTs of eight horses and imaged using MRI, CT and US at seven time points over 12 months. Imaging characteristics were then correlated to end point histologic, biochemical and biomechanical data using lasso regression. Longitudinal lesion size was compared between imaging modalities. RESULTS Lesion to tendon isoattenuation on CT evaluation correlated with the greatest levels of aggrecan deposition. A significant correlation between cellular density and percentage of tendon involvement on the T2-weighted sequence and signal intensity on the proton density fat saturated (PD FS) sequence was appreciated at the 12-month time point (P = .006, P = .02 respectively). There was no significant correlation between end-point data and US or contrast imaging characteristics. Cross sectional area lesion to tendon measurements were significantly largest on CT evaluation, followed by MRI and then US (P < .001). MAIN LIMITATIONS Experimentally induced tendon injury with singular end-point data correlation. CONCLUSIONS Lesion isoattenuation on CT evaluation suggested scar tissue deposition, while T2-weighted hyperintensity indicated hypercellular tendinopathy even in chronic stages of healing. Non contrast-enhanced MRI and CT evaluation correlated most closely to cellular characteristics of surgically damaged tendons assessed over a twelve month study period. Ultrasonographic evaluation underestimates true lesional size and should be interpreted with caution.

Longitudinal tendon healing assessed with multi-modality advanced imaging and tissue analysis.

How to publish diagnostic imaging studies: Common mistakes and recommendations.

Background: Superficial digital flexor tendon (SDFT) injury is an important health and welfare concern in racehorses. It is generally diagnosed with ultrasonography, predictive ultrasonographic features have not been reported.
Objectives: To determine ultrasonographic features of forelimb SDFT injury at initial presentation in Thoroughbred racehorses, that could predict a successful return to racing (completing > or = 5 races).
Study Design: Retrospective cohort study.
Methods: Digitised ultrasonographic images of 469 horses with forelimb SDFT injuries from the Hong Kong Jockey Club (2003-2014) were evaluated, using a previously validated ultrasonographic scoring system. Six ultrasonographic parameters were evaluated (type and extent of the injury, location, echogenicity, cross-sectional area and longitudinal fiber pattern of the maximal injury zone (MIZ)), as well as horse signalment, retirement date and number of races before and after injury. Data was analysed by generalized linear regression with significance at P<0.05. 
Results: Cases were divided in two groups: 1) For cases of SDFT tendonitis with core lesions, cross-sectional area at the MIZ was the most significant factor determining a successful return to racing (p=0.03). If the lesion was or > or = 50% this decreased to 11-16%. 2) For cases of SDFT tendonitis without a core lesion, longitudinal fiber pattern at the MIZ best predicted a successful return to racing (P=0.002); if the affected longitudinal fiber pattern was or = 75% this decreased to 14%.
Main Limitations: Prognostic information may not be applicable to other breeds/disciplines.
Conclusions: This is the first study to describe ultrasonographic features of forelimb SDFT injuries at initial presentation that were predictive of successful return to racing. The outcomes will assist with early, evidence-based decisions on prognosis in Thoroughbred racehorses.

Ultrasonographic-based predictive factors influencing successful return to racing after superficial digital flexor tendon injuries in flat racehorses: a retrospective cohort study in 469 Thoroughbred racehorses in Hong Kong

Objectives
To describe the placement of self-inflating tissue expanders and clinical outcomes in 12 consecutive cases of reconstruction of distal cutaneous limb defects in dogs.

Materials and Methods
Cases of distal cutaneous limb defect were divided into three groups based on the location of the placement of the self-inflating tissue expanders: Group A (n=4): on, or proximal to, the elbow and stifle; Group B (n=4): distal to the elbow or stifle and proximal to the carpus or tarsus; and Group C (n=4): distal to the carpus or tarsus. Owner satisfaction and clinical outcome were documented.

Results
Thirteen cases were originally included, but one was excluded because of incomplete follow-up. In one case, the self-inflating tissue expanders were removed before expansion started. A mean of five expanders were implanted per dog (range 2 to 9). Devices were removed after a mean of 24 days (range 13 to 42 days). Primary closure was achieved in eight of 11 cases, including all cases from Group A and 75% and 33% of cases from Groups B and C, respectively. All incompletely reconstructed defects or areas of wound dehiscence healed by second intention. Eight of 12 owners were satisfied.

Clinical Significance
Self-inflating tissue expanders can be used as an alternative for the reconstruction of limb defects in dogs in which direct primary closure would otherwise not be achievable. Defects below the carpus and tarsus are more challenging to treat with this method.

/pdf/outcome-of-reconstruction-of-cutaneous-limb-defects-in-dogs-2o4w4ivgsu.pdf

Outcome of reconstruction of cutaneous limb defects in dogs using hygroscopic “self-inflating” tissue expanders

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Papers

Ultrasonographic-based predictive factors influencing successful return to racing after superficial digital flexor tendon injuries in flat racehorses: a retrospective cohort study in 469 Thoroughbred racehorses in Hong Kong

Outcome of reconstruction of cutaneous limb defects in dogs using hygroscopic “self-inflating” tissue expanders