The past, present and future in scaffold-based tendon treatments

Summary
Reasons for performing study: Foot pain is a common cause of equine lameness and there have been significant limitations of the methods available for the diagnosis of the causes of foot pain (radiography, nuclear scintigraphy and ultrasonography). Until recently, magnetic resonance imaging (MRI) in the horse has been limited to examination of cadaver limbs.

Objectives: Our purpose was to 1) describe MRI of the foot in live horses, 2) describe MRI findings in horses with foot pain in which a definitive diagnosis could not be established by alternative means and 3) correlate MRI findings with other methods of clinical investigation.

Methods: The feet of 15 horses with unilateral (12) orbilateral (3), forelimb (14) or hindlimb (1) lameness associated with foot pain of previously ill-defined origin were examined using MRI. The horses were examined in right lateral recumbency under general anaesthesia, with the feet positioned in the isocentre of a flared end 1.5 Tesla GE Signa Echospeed magnet. Images were obtained in sagittal, transverse and dorsal planes using 3-dimensional (3D) T2* gradient echo (GRE), spoiled gradient echo, fat-saturated 3D T2* GRE and short inversion recovery sequences. Image acquisition took approximately 1 h.

Results: Abnormalities of the distal interphalangeal joint (DIP) cartilage and /or subchondral bone, periarticular osteophyte formation, distension of the DIP joint capsule with or without synovial proliferation, distension of the navicular bursa with or without evidence of chronic inflammation, surface and core lesions in the deep digital flexor tendon, abnormal signal within the navicular bone, evidence of mineralised fragments in the distal sesamoidean impar ligament, irregular outline of and signal in the medial cortex of the distal phalanx, and an abnormal signal on the dorsal aspect of the distal phalanx consistent with laminitis were identified.

Conclusions: MRI permits the diagnosis of a variety of lesions involving different structures within the foot that cannot be diagnosed using other means, thus enhancing our knowledge of the causes of foot pain.

Potential relevance: With further experience it is likely that lesions involving other structures will also be identified. Long-term follow-up data is required to determine the prognosis for the injuries described.

Magnetic resonance imaging of the equine foot: 15 horses.

Objective—To determine outcome of Standardbred racehorses with moderate to severe midbody suspensory ligament desmitis (MSD) treated by means of ultrasound-guided intralesional injection of a single dose of platelet-rich plasma (PRP) followed by a program of gradually increased exercise. Design—Nonrandomized clinical trial. Animals—9 Standardbred racehorses. Procedures—Following injection of PRP, horses were allowed a controlled, gradual return to exercise. Race records for the year prior to injury and for 3 consecutive years after horses returned to racing were reviewed. For comparison purposes, race records of 9 Standardbred racehorses with no history of MSD racing at the same time were also reviewed. Results—All 9 horses with MSD returned to racing after treatment; median time to return to racing was 32 weeks. All 9 horses raced at least once during the first and second years after returning to racing, but only 5 raced during the third year. When number of starts, total earnings, and earnings per start...

Intralesional injection of platelet-rich plasma followed by controlled exercise for treatment of midbody suspensory ligament desmitis in Standardbred racehorses.

Horses can gallop within hours of birth, and may begin training for athletic competition while still growing. This review cites studies on the effects of exercise on bone, tendon and articular cartilage, as detected by clinical and research imaging techniques, tissue biochemical analysis and microscopy of various kinds. For bone, alterations in bone mineral content, mineral density and the morphology of the mineralized tissue are the most common end-points. Apparent bone density increases slightly after athletic training in the cortex, but substantially in the major load paths of the epiphyses and cuboidal bones, despite the lower material density of the new bone, which is deposited subperiosteally and on internal surfaces without prior osteoclastic resorption. With training of greater intensity, adaptive change is supervened by patho-anatomical change in the form of microdamage and frank lesions. In tendon, collagen fibril diameter distribution changes significantly during growth, but not after early training. The exact amount and type of protracted training that does cause reduction in mass average diameter (an early sign of progressive microdamage) have not been defined. Training is associated with an increase in the cross-sectional area of some tendons, possibly owing to slightly greater water content of non-collagenous or newly synthesized matrix. Early training may be associated with greater thickness of hyaline but not calcified articular cartilage, at least in some sites. The age at which adaptation of cartilage to biomechanical influences can occur may thus extend beyond very early life. However, cartilage appears to be the most susceptible of the three tissues to pathological alteration. The effect of training exercise on the anatomical or patho-anatomical features of connective tissue structures is affected by the timing, type and amount of natural or imposed exercise during growth and development which precedes the training.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1469-7580.2006.00547.x

The response of bone, articular cartilage and tendon to exercise in the horse.

Summary
Reasons for performing study: The differential diagnosis of foot pain has long proved difficult and the use of magnetic resonance imaging (MRI) offers the opportunity to further the clinical understanding of the subject.

Objectives: To determine the incidence of deep digital flexor tendon (DDFT) injuries in a series of 75 horses with lameness associated with pain localised to the digit, with no significant detectable radiographic or ultrasonographic abnormalities, using MRI; and to describe a variety of lesion types and relate DDF tendonitis with anamnesis, clinical features, response to local analgesic techniques and nuclear scintigraphic and ultrasonographic findings.

Methods: All horses undergoing MRI of the front feet between January 2001 and October 2002 were reviewed and those with DDFT injuries categorised according to lesion type; horses with primary tendonitis (Group I) and those with concurrent abnormalities of the navicularbone considered to be an important component of the lameness (Group II). The response to perineural analgesia of the palmar digital nerves and palmar (abaxial sesamoid) nerves, intra-articular analgesia of the distal interphalangeal (DIP) joint and analgesia of the navicularbursa were reviewed. The result of ultrasonography of the pastern and foot was recorded. Lateral, dorsal and solar pool and bone phase nuclear scintigraphic images were assessed subjectively and objectively using region of interest (ROI) analysis.

Results: Forty-six (61%) of 75 horses examined using MRI had lesions of the DDFT considered to be a major contributor to lameness. Thirty-two horses (43%) had primary DDFT injuries and 14 (19%) a combination of DDF tendonitis and navicular bone pathology. Lesions involved the insertional region of the tendon alone (n = 3), were proximal to the navicular bone (n = 23) or were at a combination of sites (n = 20). Lesion types included core lesions, focal and diffuse dorsal border lesions, sagittal plane splits, insertional injuries and lesions combined with other soft tissue injuries. Many horses had a combination of lesion types.

Lameness was abolished by palmar digital analgesia in only 11 of 46 horses (24%). Twenty-one of 31 horses (68%) in Group I showed >50% improvement in lameness afterintra-articular analgesia of the DIP joint, whereas 11 of 12 horses (92%) in Group II had a positive response. Twelve of 18 horses (67%) in Group I had a positive response to analgesia of the navicular bursa.

Nineteen horses had lesions of the DDFT extending proximal to the proximal interphalangeal joint seen using MRI, but these were identified ultrasonographically in only 2 horses. Scintigraphic abnormalities suggestive of DDFT injury were seen in 16 of 41 horses (41%), 8 in pool phase images and 8 in bone phase images. Conclusions and potential relevance: DDFT injuries are an important cause of lameness associated with pain arising from the digit in horses without detectable radiographic abnormalities. Lameness is not reliably improved by palmar digital analgesia, but may be improved by intra-articular analgesia of the DIP joint in at least 68% of horses. Ultrasonography is not sensitive in detecting lesions of the DDFT in the distal pastern region, but a combination of pool and bone phase scintigraphic images of the digit is helpful in some horses. Further follow-up information is required to determine the prognosis for horses with lesions of the DDFT in the digit and to establish whether this is related to lesion severity and/or location.

Lameness in 46 horses associated with deep digital flexor tendonitis in the digit: diagnosis confirmed with magnetic resonance imaging.

Summary
Reasons for performing study: Contamination and infection of synovial cavities are a common occurrence in clinical practice and, if inadequately treated, may have career or life threatening consequences for affected horses

Hypothesis: The objectives in treating contamination and infection of joints, tendon sheaths and bursae are most effectively met by endoscopic surgery

Methods: Over a 6 year period, cases of synovial contamination and infection admitted to a referral clinic were evaluated and treated endoscopically The horses received local and systemic antimicrobial drugs with minimal nonsteroidal anti-inflammatory medication but no other medical or surgical treatment All arthroscope and instrument portals and, when ever possible, all traumatic wounds were closed Diagnostic information, endoscopic observations and results of treatment were evaluated retrospectively

Results: A total of 140 affected animals were referred and 121 cases were treated endoscopically These involved 70 joints, 29 tendon sheaths, 10 bursae and in 12 cases a combination of synovial cavities The most common aetiologies were open wounds (n = 54) and self-sealing punctures (n = 41) Foreign material was identified endoscopically in 41 but predicted prior to surgery in only 6 cases Osteochondral lesions were evident at surgery in 51 and recognised before surgery in 25 cases; 32 horses had intrathecal tendon or ligament defects

Follow-up information was obtained for 118 animals; 106 (90%) survived and 96 (81%) returned to their preoperative level of performance The presence of osteitis/osteomyelitis, other osteochondral lesions and marked deposits of pannus were associated with nonsurvival For those animals which survived, non-Thoroughbred horses, a combination of synovial structure involvement and regional iv antimicrobial administration were associated with reduced post operative performance Marked pannus, regional iv antimicrobial administration and duration of systemic antimicrobial administration were associated with a group combining nonsurviving animals and those with reduced post operative performance

Conclusions: Endoscopic surgery makes a valuable contribution to the management of synovial contamination and infection

Potential relevance: The information obtained from and therapeutic options offered by endoscopy justify its early use in cases of synovial contamination and infection

Endoscopic surgery in the treatment of contaminated and infected synovial cavities.

Forelimb navicular bones and associated soft tissues were collected from 3 groups of horses and subjected to pathological examinations. The groups consisted of 38 horses with clinical navicular disease (ND) and 2 control groups, with no history of forelimb lameness, consisting of 25 age-matched mature horses (A-MC) and 9 immature horses (IC). Histological and histomorphometric studies were performed on tissue samples from 10 ND, 10 A-MC and 5 IC horses. Gross changes seen only in ND horses included: full thickness defects in the palmar surface fibrocartilage, palmar cortex erosion, medullary lysis, flexor digitorum profundus tendon (FDPT) surface fibrillation, FDPT core lesions and adhesions between the FDPT and navicular bone. Palmar surface partial thickness fibrocartilage loss and distal border fragmentation were seen with a significantly greater incidence in ND than in A-MC and not observed in IC. Remodelling of the proximal border, FDPT surface colouration, palmar surface fibrocartilage colouration and proximal border entheseous bone were identified in ND and A-MC but not in IC. Mid-ridge synovial fossae and horizontal depressions in the palmar surface were identified in all groups. Histologically palmar fibrocartilage thinning and loss were associated with reduced palmar fibrocartilage cell density and chondrocyte cluster formation. Palmar fibrocartilage fibrillation, palmar cortical bone defects, fibromyxoid stromal change in the medulla, medullary pseudocyst formation and entheseous new bone formation were all seen in ND. The adjacent FDPT showed fibrillation, tag formation and degeneration of the dorsal surface. Necrotic foci were also present within the body of the tendon. Although not always present, medullary bone pseudocysts, separate mineralised foci and most changes on the dorsal surface of the FDPT were specific to ND. Bone histomorphometric parameters were compared among groups. Cross-sectional area reduced from the sagittal ridge to the medial and lateral margins of each navicular bone. IC navicular bones had a smaller subchondral area, subchondral bone volume and a greater osteoid volume than in the AC, indicating that these differences were age-related. In ND the medullary area was decreased but the trabecular bone volume increased. The palmar subchondral area was increased but contained bone with an increased porosity and osteoid volume. Changes occurred from the medial to the lateral margins of the bone in horses with ND indicating remodelling of the bony elements throughout the bone in ND. The histological and histomorphometric changes in the navicular bone and palmar fibrocartilage were considered.

Gross, histological and histomorphometric features of the navicular bone and related structures in the horse

Summary
Reasons for performing study: Proximal suspensory desmitis (PSD) is diagnosed with increasing frequency in horses and radial pressure wave therapy (RPWT) is a widely used therapy for painful orthopaedic conditions in man and dogs There are, however, few published data as to the outcome of its use in PSD

Objective: To evaluate the use of RPWT in the treatment of chronic or recurrent PSD in the horse, an injury which carries a poor prognosis for return to athletic function with conservative management alone

Hypothesis: RPWT and controlled exercise improves the prognosis of chronic or recurrent PSD in the horse when compared to previously published results of controlled exercise alone

Methods: The use of RPWT in the management of chronic or recurrent proximal suspensory desmitis (PSD) was evaluated in 65 horses Diagnosis was based on response to local analgesia, ultrasonography and radiography Horses were classified according to severity of ultrasonographic lesions, whether fore- or hindlimbs were affected, and duration of lameness prior to diagnosis Horses were treated 3 times at 2-week intervals and followed a controlled exercise programme; they were reassessed clinically and ultrasonographically 10–12 weeks after diagnosis, when further exercise recommendations were made dependent upon the animal's progress

Results: Forty-one percent of horses with hindlimb lameness and 53% with forelimb lameness were nonlame and returned to full work 6 months after diagnosis The prognosis was significantly affected by the ultrasonographic grade at the time of diagnosis and by ultrasonographic evidence of resolution of the lesion in hindlimb cases

Conclusions: These findings, when compared to previously published results of treatment using controlled exercise alone, suggest that RPWT improves the prognosis for PSD in the hindlimb

Potential relevance: RPWT is a useful treatment modality for chronic or recurrent PSD when combined with controlled exercise Further studies are required on the effect of RPWT employing histology and biomechanics in order to fully evaluate its use on equine tissues

Treatment of chronic or recurrent proximal suspensory desmitis using radial pressure wave therapy in the horse

Summary

Reasons for performing study: Until recently, the pathogenesis of noninfected tenosynovitis of the digital flexor tendon sheath (DFTS) has been considered obscure. With the advent of tenoscopy some inciting causes have been described, but to date few cases with a precise diagnosis have been reported.



Hypothesis: Tenoscopic surgery enables accurate diagnosis and facilitates treatment of noninfected tenosynovitis of the DFTS.



Methods: The case records of all horses with noninfected tenosynovitis of the DFTS admitted to a referral clinic over a 7-year period were evaluated retrospectively. Follow-up information was obtained by telephone questionnaire.



Results: A total of 76 horses were referred; all were evaluated tenoscopically and 11 of these subsequently were explored by open surgical techniques. The most common diagnoses were marginal tears of the deep digital flexor tendon (DDFT) (n = 44) and tears of the manica flexoria (MF) (n = 23). Greater than 6 months' follow-up information was available for 61 animals, of which 68% were sound and 54% returned to preoperative levels of performance. Sheath distension was eliminated in 33% and improved in 69% of horses. Marginal tears of the DDFT, marked preoperative distension and open surgical repair of deep digital flexor lesions were associated with reduced levels of post operative performance: Marginal tears were associated with post operative lameness and long tears with a reduced performance level compared with short tears. Marginal tears of the deep digital flexor tendon, marked preoperative distension and increasing duration of clinical signs also were associated with lack of improvement in distension following surgery.



Conclusion: Tenosynovitis of the DFTS may result from tears in the deep or superficial digital flexor tendons, manica flexoria or other structures with synovial communication. To date, these can be identified confidently only by tenoscopy, which also permits appropriate lesion management.



Potential relevance: The diagnostic information obtained from and therapeutic options offered by tenoscopy justify its early use in cases of noninfected tenosynovitis of the DFTS.

Noninfected tenosynovitis of the digital flexor tendon sheath: a retrospective analysis of 76 cases.

The paper describes a series of cases with longitudinal tears in the superficial or deep digital flexor tendons within the digital flexor tendon sheath. This appears to be a previously unreported condition. Twenty cases are described, one horse was affected bilaterally. Nineteen defects involved the deep digital flexor tendon and in 2 horses the manica flexoria of the superficial digital flexor tendon was torn. All affected horses were lame and there was marked distension of the digital flexor tendon sheaths. Ultrasonography revealed nonspecific signs of chronic tenosynovitis but not the cause. Diagnosis was established by tenoscopy in 9 cases and by open surgical exploration in the remainder. In 7 limbs, the deep digital flexor tendon lesions were treated by removal of the torn fibrils under tenoscopic control. In the remaining cases they were removed and the defects were repaired with absorbable suture material. Wound closure in all open cases included repair of the palmar/plantar annular ligament. Eleven horses became sound and returned to work, 3 improved but were lame on returning to work and 2 horses did not improve following treatment. At the time of reporting, 4 horses are sound and in controlled ascending exercise regimes. It is concluded that longitudinal tears of the digital flexor tendons should be considered in the differential diagnosis of tenosynovitis of the digital flexor tendon sheath. The results presented suggest that accurate diagnosis and specific treatment justify surgical investigation.

Tenosynovitis associated with longitudinal tears of the digital flexor tendons in horses: A report of 20 cases

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