The Practitioner Published by the Florida Association of Equine Practitioners, an Equine-Exclusive Division of the Florida Veterinary Medical Association Issue 2 • 2012
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FAEP’s 8th Annual Promoting Excellence Symposium October 11-14, 2012 • Naples, FL Advanced Equine Sports Medicine From Start To Finish
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Letter from the President
EXECUTIVE COUNCIL Gregory D. BonenClark, DVM, Diplomate ACVS FAEP Council President
Anne L. Moretta, VMD, MS FAEP Council Vice President
email@example.com Jacqueline S. Shellow, DVM, MS FAEP Council Past President
firstname.lastname@example.org Mr. Philip J. Hinkle Executive Director
COUNCIL REPRESENTATIVES J. Barry David, DVM, Diplomate ACVIM
Amanda M. House, DVM, Diplomate ACVIM
Suzan C. Oakley, DVM, Diplomate ABVP (Equine) FAEP Council
email@example.com Liane D. Puccia, DVM
Ruth-Anne Richter, BSc (Hon), DVM, MS
firstname.lastname@example.org Corey Miller, DVM, MS, Diplomate ACT FAEP Council Representative to the FVMA Executive Board
The Practitioner is an official publication of the Florida Association of Equine Practitioners, an EquineExclusive Division of the Florida Veterinary Medical Association.
Dear Fellow FAEP Members, This second issue of The Practitioner for 2012 marks the halfway point of our year. The Practitioner has become a quarterly publication. We have made this change in order to increase the distribution and quality of The Practitioner. More than 35 percent of our membership is from outside the state of Florida and reaching out to each of our members meant increasing distribution nationwide. This current issue of The Practitioner has a lameness and imaging theme that I think many of you will appreciate reading. This issue of The Practitioner also marks the halfway point of my tenure as council president and I have some thoughts to share with you. The continuing education landscape for equine practitioners in this country has changed since the FAEP was founded in 2005. Many more opportunities to fulfill CE requirements have become available over the last seven years. The FAEP Council continuously questions and discusses how much CE is appropriate? How many events should we sponsor? Should we do wet labs on a regular basis? How can we best meet the CE needs of our members as well as represent their legislative interests in Tallahassee? This year, we have chosen to offer two conferences because we believe that more is not necessarily better. As such, we will continue to offer the foot symposium on an every-other-year basis. The name of our flagship conference in the fall of every year is the “Promoting Excellence” symposium. This name was not chosen by accident. We believe that pursuing excellence is an attitude and that our mission to promote excellence via high quality CE is our responsibility. At each event that we have sponsored in the last seven years, we have asked for and received feedback from the attendees about the speakers, the venue, the dates and the timing of events. Our current and future schedule is a direct result of this feedback. Our organization has evolved and exists to better serve your needs. The FAEP Council has recently completed the finishing touches on our 8th Annual Promoting Excellence Symposium that will be held at the Waldorf Astoria Naples, FL from October 11-14. (Complete details regarding this symposium are found on pages 13-19 of this issue.) The second conference, the 50th Annual Ocala Equine Conference, will be held from November16-19. Dr. Barry David has arranged an excellent group of speakers (Drs. Anthony Blikslager, Jack Easley, Rob Mackay, Virginia Reef, and Tom Yarborough) to present topics in medicine, surgery and dentistry. Additionally, we are offering a dentistry wet lab that Dr. Easley has agreed to facilitate. This conference looks to be another very good opportunity to fulfill any CE requirements that you may need at the end of the year. Details of this conference will be highlighted in the next issue of The Practitioner. We hope to see you in Naples and/or Ocala this year! Sincerely, Greg BonenClark, DVM, Diplomate ACVS 2012 FAEP Council President
In This Issue 6 | Blind Splint Complex and Suspensory Desmitis
24 | Dynamic Video Endoscopy: A Second Renaissance in the Understanding of Upper Airway Disease
8 | Nasal Discharge: Where’s 20 | Digital Sheath Tenosynovitis: 2 Diagnosis, Treatment and Prognosis
4 The Practitioner
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The Practitioner 5
Blind Splint Complex and Suspensory Desmitis By Michael W. Ross, DVM, DACVS
Introduction Suspensory desmitis should be classi- factors such as the horse’s use and level of fied according to the affected limb (fore- competition, conformation and breed play limb, hind limb), duration of injury (acute, important roles in determining prognosis. chronic-recurrent), level of injury (origin, body, branch or branches, insertion), coex- Accurate Diagnosis istent (concurrent) injury to the distal An in-depth discussion of diagnosis of sesamoidean ligaments, and if there is complex suspensory injury is beyond the complex injury, suspensory desmitis and scope of these notes, but to determine the innervation. However, from the DBLPN involvement of adjacent bony structures. authentic source of pain causing lameness arise the important medial and lateral In order to understand and compare vari- is paramount1. plantar metatarsal nerves which descend ous methods to manage simple suspensory A few comments regarding diagnostic to innervate the fetlock joint (see below). desmitis you are compelled to consider analgesia of this important area are in If completed as a stand-alone technique these important classification criteria. order.1 The high plantar/palmar perineu- without first performing low plantar For instance, horses with hind limb ral block should be used to localize pain analgesia, sub-tarsal analgesia may lead proximal suspensory prognosis have a to the metatarsal/metacarpal region. For the clinician to the erroneous impression much worse prognosis than those with the metatarsal region, the medial and lat- pain is emanating from the proximal SL. a similar degree of injury in the forelimb. eral plantar nerves and medial and lateral In a recent study, horses were managed Horses, with recurrent suspensory des- plantar metatarsal nerves are blocked just for desmitis of the origin of the SL with mitis cannot be expected to respond as distal (approximately 1.5 cm) to the tarso- desmoplasty and fasciotomy; but criteria those with acute injury. Horses in which metatarsal joint. Variations of this block for inclusion of cases suggested that pain the body of the suspensory ligament (SL) are often used, but it is important to recog- was localized to the proximal metacarpal/ is injured as a result of extension either nize that sub-tarsal analgesic techniques metatarsal regions by use of only subfrom initial injury at the origin or by targeting the lateral plantar nerve, or its carpal or sub-tarsal analgesia without first incremental injury originally involving deep branch, will not block the medial blocking the distal limb.3 only a branch but subsequently the body plantar nerve and false negative results In the forelimb distal palmar outpouchof the SL, have a guarded to poor prog- could be obtained. More importantly, false ings of the carpometacarpal joint complinosis. Complex suspensory injury includes positive results incriminating the proxi- cate interpretation of diagnostic analgesic the blind splint complex and occurs at the mal aspect of the SL as a source of pain techniques.4,5 In the hind limb, distal planorigin (avulsion fracture of the palmar can occur. Sub-tarsal analgesia should be tar outpouchings of the tarsometatarsal cortex of the third metacarpal [McIII] performed only after results of low plantar joint can potentially be penetrated when or third metatarsal bone [MtIII]), longi- analgesia are observed, since most injec- high plantar analgesic techniques are pertudinal fracture of the proximal palmar/ tion techniques in the sub-tarsal region formed. However, outpouchings of the plantar cortex of the McIII/MtIII, chronic are likely to desensitize the plantar meta- joint were not seen in magnetic resonance insertional osteitis (increased radiopac- tarsal nerves, important contributors to images in a recent study comparing imagity indicating chronic bony change), body innervation to the metatarsophalangeal ing modalities in the plantar metatarsus.6 (adhesions between the second and fourth joint. In only 5% of limbs was the tarsometatarmetacarpal [McII/MtIV] and metatarsal A recent injection technique was sal joint inadvertently penetrated when [MtII/MtIV] bones), at the level of the described and has become popular in the high plantar analgesia was performed at branches (chronic recurrent branch des- diagnosis of proximal suspensory desmi- a level of 1.5 cm distal to the tarsometamitis with or without involvement of the tis; the deep branch of the lateral plantar tarsal joint. In the same study, inadvertent distal aspects of the Mc/Mt II/IV bones), nerve (DBLPN) is blocked approximately penetration of the tarsal sheath occurred and at the insertion of the branches to the 15 mm distal to the head of MtIV, just axial in 40% of limbs.7 proximal sesamoid bones (PSBs) (chronic to MtIV, at a depth of 25 mm.2 While, in Care must be taken when interpreting sesamoiditis, abaxial avulsion fragments, theory, this block is done in close proxim- diagnostic analgesia. The lateral planapical fractures of the PSBs). ity to the DBLPN, it is within the same tar nerve, which courses plantar to the Clinical characteristics and manage- fascial compartment as the parent branch origin of the SL, gives off a deep branch ment of complex suspensory injury are leading to the possibility of blocking this that innervates the proximal aspect of the detailed below. Many other important important contributor to distal limb SL and gives off branches which continue 6 The Practitioner
Issue 2 • 2012
distally as the lateral medial plantar meta- can easily be misconstrued as coarse tratarsal nerves that course on the axial beculae because of surrounding increased aspects of each respective splint bone. radiopacity and lack of a crisp fracture line. Blocking the DBLPN provides analgesia In a lateromedial or flexed lateromedial of the origin of the SL, the plantar cortex radiographic image, increased radiopacof the MtIII and partial analgesia of sites ity of the endosteal surface and medullary more distal to the level of and including cavity of the McIII is often seen. Scintithe metatarsophalangeal joint. graphic examination is quite useful and Accurate interpretation of diagnostic most often reveals focal mild-to-intense analgesia is critical when planning the increased radiopharmaceutical uptake surgical procedure, neurectomy of the (IRU), roughly in a triangular pattern in DBLPN (NDBLPN), which has received lateral scintigraphic images and often in a considerable attention recently as a sur- linear pattern in dorsal images. Incongrugical approach to management of proximal ity of the palmar cortex of the McIII can suspensory desmitis (see below).1,8,9 His- be seen ultrasonographically; and if associtological changes consistent with nerve ated suspensory desmitis is present, the compression were identified in horses situation becomes complex suspensory undergoing NDBLPN and nerve compres- injury. Fractures occur distal to the origin sion was proposed as a possible cause for of the SL, but it is compelling to assume residual pain in horses even after desmitis the presence of this important structure resolved.9 concentrates forces in this general area In that study, 62% of horses returned to predisposing to fracture. The presence of soundness after neurectomy9, whereas 19 proximal suspensory desmitis worsens of 20 horses with neurectomy and laminar prognosis considerably. Palpation to deterfasciotomy were reported to have returned mine the presence of swelling associated to the previous level of performance.8 The with the proximal aspect of the SL and DBLPN that is resected and was studied ultrasonographic examination to confirm lies within the dense metatarsal, but out- the diagnosis are important. side the laminar fascial planes. RecogniMagnetic resonance imaging (MRI) can tion of neuritis in this segment indicates be useful if horses have stress reaction or compression of the deep branch may be stress fracture of the McIII or the MtIII occurring within this fascial compartment. without obvious radiological evidence of fracture. Fractures heal with 4-6 months Longitudinal Fracture of the rest and it does not appear necessary to Palmar Cortex of the McIII combine surgical management such as and the MtIII forage or internal fixation with proper This fracture involves, most commonly, rest. What is proper rest? A minimum the palmar cortex of the McIII, but occa- of 4 months of rehabilitation without sionally occurs in the hind limb affecting early race training and without turn out the MtIII10. This fracture occurs most com- exercise is recommended – 4 weeks stall monly in young horses, 2- and 3-year-olds rest, 4 weeks stall rest with hand walking, in race training, but can occur in non-race- 4 weeks walking in a mechanical walker horses and in older horses. Horses often or with a rider up, and 4 weeks walking have mild undiagnosed forelimb lameness and light trotting in a mechanical walker, that becomes acute and pronounced, are with a rider up, in a jog cart or some other painful to palpation along the proximal, suitable step up in exercise program withpalmar metacarpal region; and lameness out rigorous training. Turn out exercise is is abolished or substantially improved avoided in particular in horses with surwith both sub-carpal and middle carpal rounding suspensory desmitis and to limit diagnostic analgesic techniques. Occa- the possibility of recurrence or aggravasionally, mild improvement is seen using tion of suspensory injury. low palmar analgesia. In general, affected horses have a simple fracture near the Avulsion Fracture of the Palmar origin of the SL on the McIII without Cortex of the McIII/MtIII concurrent suspensory desmitis. This The clinical characteristics, diagnofracture can only be seen reliably in a dor- sis and management of horses with this sopalmar (DP) radiographic image and injury are quite similar to that described courses roughly in a longitudinal direction, for longitudinal fracture. This injury medial to the axis of the McIII. Fractures occurs more frequently in the forelimbs; www.faep.net
and while occurring in the hind limbs, radiological identification of an actual fragment is more difficult in the hind limbs. Fragmentation occurs at the distal aspect of the origin of the SL and horses with this injury more often have concurrent suspensory desmitis. Horses with chronic suspensory desmitis can become suddenly, acutely lame and radiographic images reveal obvious increased radiopacity reflective of chronic injury. Small avulsion fractures occur in already weakened bone. The separation between horses with chronic recurrent suspensory desmitis and associated osteitis of the palmar/plantar cortex of the MIII/MtIII without fracture and those with a radiological identifiable fracture fragment is likely arbitrary. Prognosis is good in horses with fracture without surrounding suspensory desmitis and guarded to poor in those with complex suspensory injury. Some consideration should be given to aggressive management such as fasciotomy, bone marrow injection, NDBLPN, or a combination of various surgical and conservative approaches in horses with chronic, recurrent hind limb suspensory desmitis and avulsion injury of the MtIII (see below).
Adhesions of the SL to the McII/MtII and McIV/MtIV and Associated Suspensory Desmitis – Blind Splint Complex? Without using MRI, the diagnosis of a “blind splint” can remain a mystery, and even using this modality there are sources of pain that remain undiscovered. However, MRI is useful in the diagnosis of adhesions between the SL and the associated small metacarpal bones.11 Horses most often have chronic, recurrent lameness and have been managed using local injections, rest, anti-inflammatory agents, extracorporeal shock wave therapy, and therapeutic ultrasound among other modalities. Pain causing lameness is localized to the metacarpal region using sub-carpal analgesia. A unilateral 2-point block, blocking the palmar metacarpal and palmar nerve on the affected side of the limb above the painful region of the suspected adhesion, provides more comprehensive analgesia than does simply locally infiltrating the suspected region. Infiltration of local anesthetic solution along the abaxial surface of a splint exostosis will not resolve pain resulting from The Practitioner 7
adhesions on the axial surface of the splint bone. Radiographs usually reveal an abaxially located exostosis that may be smooth or mildly proliferative; but there is often subtle evidence of extension, axially. Axial extension of a splint exostosis could encroach on the nearby SL and cause pain or localized suspensory desmitis without adhesions. Ultrasonographic examination can reveal suspensory body desmitis and dynamic imaging with the limb elevated from the ground will often show the ligament is adhered to the axial aspect of the affected small metacarpal bone. Exostoses can be seen in longitudinal images and focal suspensory desmitis is confirmed. MRI can be quite useful in defining the lesion; however, given lack of clinical response, chronic pain refractory to therapy and pain causing lameness localized to the site, surgery can be recommended without the use of MRI. Surgical exploration of painful splints suspected of causing complex suspensory injury should be reserved for horses with chronic, refractory pain, in which conventional methods have failed. The horse is placed with the affected side of the affected limb uppermost and a dorsal-based curvilinear incision is used to approach the affected region. Most often extensive adhesions among all tissue planes are encountered, and may involve other nearby soft tissue structures such as the accessory ligament of the deep digital flexor tendon, or peritendonous tissue over the digital flexor tendons themselves. It can be difficult to determine what is adhered to what, but in most horses the actual fibers of the SL are not adhered, but it is the superficial and laminar fascia surrounding the SL, which is adhered. Perhaps it makes little difference since it appears there is constriction of the SL and restriction of movement. Adhesions often involve the axial aspect of the involved splint bone at an actual exostosis, which is removed using an osteotome, and smoothed using a bone rasp. A liberal amount of the adhered superficial and deep fascia is removed (fasciotomy) and adhesions are sharply incised (adhesiolysis). The portion of splint bone is left intact (neither is the distal aspect removed nor is segmental ostectomy performed). Some consideration could be given to segmental ostectomy, but removing the splint bone from the site, distally, potentially causes additional adhesions and pain 8â€‚ The Practitionerâ€
after surgery. Local injections into the SL, a time-honored technique, has value in if desmitis exists (bone marrow, bone horses with branch desmitis and avulsion marrow concentrate, platelet-rich plasma), injury at the distal attachment to the PSBs can be performed. If bone marrow derived and can be combined with ostectomy of mesenchymal stem cells were cultured, the the small metacarpal/metatarsal bones cells can be injected at the time of surgery, and of apical and abaxial fractures of the or injected under ultrasonographic guid- PSBs. Branch desmitis can be chronic or ance after surgery. Hyaluronan is injected recurrent and in some horses non-healing between the SL and smoothed axial aspect core lesions are found. These horses are of the involved splint bone. Only the sub- prime candidates for ligament splitting, cutaneous tissues and skin are closed; no bone marrow injection or potentially attempt is made to suture the metacarpal/ debridement using palmar/plantar fetlock metatarsal, since this tissue was removed arthroscopic approaches. Pain can origi(fasciotomy) and is the very tissue causing nate from the suspensory branch withcompartment syndrome and contributing out the presence of an actual core lesion; to adhesions. The horse is given 2 weeks enlarged painful branches may not appear of stall rest and then 4 weeks of stall rest to be active, ultrasonographically, but are with deliberate hand walking program, painful to palpation and pain-causing followed by 4-6 weeks of walking with a lameness can be localized using diagnostic rider up. Length of rest is determined by analgesia. In a limited number of STB racethe degree of suspensory desmitis and horses with chronic recurrent branch despreoperative lameness grade. Therapeutic mitis, I have combined ligament splitting ultrasound may help during rehabilitation. with bone marrow injection with fair sucShock wave therapy is delayed for a mini- cess. In sports horses splint bone fractures mum of 45 days after surgery. The surgery are unusual but these horses are prone to site is always thickened and undoubtedly the development of chronic, recurrent fibrous tissue forms in the deep portion branch desmitis. To split the suspensory of the incision; whether or not adhesions ligament I prefer to use numerous linear form is questionable, but they are likely. incisions made in fan-like fashion with a While the cosmetic appearance at the site double-edged tenotome. Needle decomis often questionable (firm fibrous swell- pression of core lesions in the suspensory ing, smooth proliferative changes along ligament lacks merit in my experience the abaxial aspect of the involved splint since many horses with suspensory desbone form), outcome has been favorable mitis lack distinct core lesions; the ultrain a limited number of horses. (All of 4 sonographic and healing characteristics of horses became sound and went back into horses with suspensory desmitis differs full work, but in one horse a similar con- from those with superficial digital flexor dition developed in the contralateral limb tendonitis. 1 year after requiring surgery. In an elite event horse, recurrent lameness prompted Surgical Management of re-operation in the original surgery site Suspensory Desmitis 14 months later. This horse returned to I have used the combination of fascieventing after both surgical procedures). otomy and bone marrow injection (fresh Inflammation and lameness do not resolve liquid bone marrow or bone marrow conquickly, but prognosis is likely 75%. centrate) in jumpers, dressage horses and STB racehorses with chronic, recurrent Suspensory Branch Desmitis suspensory desmitis with fair to good Chronic, recurrent branch desmitis can results. Most horses have severe, chronic, be a frustrating clinical problem. Be aware recurrent hind limb lameness with large that pain associated with a branch desmi- cross-sectional area measurements, tis can be abolished with intra-articular involvement of the origin and body of analgesia of the nearby metacarpo/meta- the ligament, have fetlock drop, straight tarsophalangeal (fetlock) joint and com- hock conformation and are upper-level monly there is concurrent osteoarthritis of horses. Fasciotomy is done to reduce the the fetlock joint. It is important to evalu- potential for compartment syndrome ate the distal aspects of the splint bones in the proximal metatarsal (metacarpal) and the PSBs for the presence of frac- region, to reduce compression on nearby tures or small fragmentation. Ligament nerves and to improve gliding function of splitting (modified Asheim procedure), the enlarged suspensory ligament. Bone Issue 2 â€˘ 2012
marrow injection is done to augment reparative healing in combination with fasciotomy. Return to previous level of competition is strict criteria for success given the pre-injury level of these horses but is estimated at 40-50%. Recurrence of desmitis is common, however. Fasciotomy is performed most commonly using a medial approach. In the proximal metatarsal (metacarpal) region there is a dense fascia that is confluent with the tarsal and carpal retinaculum. There a loose, thin “lamellar” fascia overlying the suspensory ligament deep to the deep digital flexor tendon. The dense and lamellar fasciae attach to the plantar/palmar aspect of Mt(Mc)IV. A 6-8 cm incision is made in the proximal medial metatarsal (metacarpal) region beginning approximately 3 cm distal to the tarsometatarsal joint (TMTJ). The dense metatarsal fascia is incised first using a #11 scalpel blade on the plantar aspect of MtIV; the incision is extended both proximally and distally using a straight Mayo scissors from the level of the TMTJ to the distal extent of the lesion (usually mid-body). Since both dense and lamellar fascia attach to MtIV it appears fasciotomy cuts both layers. The origin of the suspensory ligament can be palpated or seen by retracting the deep digital flexor tendon in a plantar direction. Liquid bone marrow (60-80 ml) is harvested from the sternum using a #11 Jamshidi needle and 60 ml syringe and injected directly into the suspensory ligament (origin – through the incision) or through pre-placed needles (when there is concomitant branch desmitis). Bone marrow concentrate can be used but volume is usually between 10-12 ml if 60 ml of fresh bone marrow is harvested. Subcutaneous tissues and skin are closed routinely. Horses are given a minimum of 4 months of controlled exercise WITHOUT TURN OUT EXERCISE that includes 4 weeks of stall rest, followed by 4 weeks of stall rest with hand walking, followed by 4 weeks of walking with a rider-up (or in a jog cart) and followed by 4 weeks of walking a light trotting before beginning into an early training program. Fasciotomy can be performed using a lateral approach and with this approach NDBLPN can be performed (while using plantar retraction of the DDFT, the DBLPN can occasionally be seen from a medial approach, the lateral approach is best if neurectomy is being considered). www.faep.net
Lateral plantar neurectomy is performed using a 6-8 cm incision along the dorsolateral edge of the superficial digital flexor tendon (SDFT), centered at the level of the tarsometatarsal joint. The DBLPN can be found between the SDFT and long plantar ligament, coursing parallel to the parent lateral plantar nerve. The DBLPN courses abruptly dorsally and enters a small depression in the proximal aspect of the SL. A 2-cm segment is removed. Occasionally the DBLPN is surprisingly hard to find. After NDBLPN horses do not immediately become sound and it takes 2-4 months for substantial improvement, in particular in those horses managed for chronic, recurrent suspensory desmitis in which cross sectional areas are greatly enlarged. While catastrophic breakdown of the suspensory has not been reported, experience is lacking. References
1. Ross MW: The metatarsal region, in Ross MW, Dyson SJ (eds): Diagnosis and Management of Lameness in the Horse (Ed 2). St Louis, Elsevier (Saunders), 2011. 2. Hughes TK, Liashar E, Smith RK: In vitro evaluation of a single injection technique for diagnostic
analgesia of the proximal suspensory ligament of the equine pelvic limb, Vet Surg 36:760,2007. 3. Hewes CA, White NA: Outcome of desmoplasty and fasciotomy for desmitis involving the origin of the suspensory ligament in horses: 27 cases (19952004), J Am Vet Med Assoc 229:407,2006. 4. Ford TS, Ross MW, Orsini PG: The communications and boundaries of the middle carpal and carpometacarpal joints in horses, Am J Vet Res 49:2161,1989. 5. Ford TS, Ross MW, Orsini PG: A comparison of three techniques for proximal palmar metacarpal analgesia in horses, Vet Surg 18:146,1989. 6. Bischofberger AS, Konar M, Ohlerth S, et al: Magnetic resonance imaging, ultrasonography and histology of the suspensory ligament origin: a comparative study of normal anatomy of warmblood horses, Equine Vet J 38:508,2006. 7. Dyson SJ, Romero JM: An investigation of injection techniques for local analgesia of the equine distal tarsus and proximal metatarsus, Equine Vet J 25:30, 1993. 8. Bathe AP: Plantar metatarsal neurectomy and fasciotomy for treatment of hindlimb proximal suspensory desmitis, Vet Surg (abstr) 32:480,2003. 9. Tóth F, Schumacher J, Schramme M, et al: Compressive damage to the deep branch of the lateral plantar nerve associated with lameness caused by proximal suspensory desmitis, Vet Surg 37:328,2008. 10. Ross MW, Ford TS, Orsini PG: Incomplete longitudinal fracture of the proximal palmar cortex of the third metacarpal bone in horses. Vet Surg 17:82,1988. 11. Zubrod CJ, Schneider RK, Tucker RL: Use of magnetic resonance imaging to identify suspensory desmitis and adhesions between exostoses of the second metacarpal bone and suspensory ligament in four horses. J Am Vet Med Assoc 224:1815,2004.
Michael W. Ross, DVM, DACVS ++ Dr. Ross is a Professor of Surgery at New Bolton Center, University of Pennsylvania, School of Veterinary Medicine. He developed and is Director of the Nuclear Medicine Program at New Bolton Center. Dr. Ross has broad clinical interests including equine gastrointestinal, respiratory, and musculoskeletal surgery, but in recent years has concentrated efforts in the area of orthopedic surgery with a particular interest in arthroscopic surgical techniques. Equine lameness diagnosis and management has always been a clinical focus, with a special emphasis in the Standardbred and Thoroughbred racehorse. ++ Following graduation from Cornell University’s New York State College of Veterinary Medicine in 1981, he completed a large animal internship program there, completed a three-year large animal surgical residency program at New Bolton Center where he was appointed Lecturer in Surgery from 1985-1988, Assistant Professor of Surgery from 1988-1993, and Associate Professor of Surgery from 1993-1999. ++ Dr. Ross became a Diplomate of the American College of Veterinary Surgeons in 1986 and is an active member of the American Association of Equine Practitioners. ++ He is the author of more than 295 scientific papers, proceedings, abstracts and book chapters. Dr. Ross coauthored (with Dr. Sue Dyson) a new lameness textbook and companion CD, “Diagnosis and Management of Lameness in the Horse,” published December 2002 by WB Saunders (Elsevier Science), a culmination of more than 30 years of study and interest in clinical examination and management of the lame horse.
The Practitioner 9
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The odds of us doing something about it are even higher. The simple truth is that all of your clients’ horses are at risk for ulcers. It’s time to reduce the risk with ULCERGARD® (omeprazole). It’s the only medicine approved by the FDA to prevent equine stomach ulcers.*
Amie Allen, Veterinarian Technician, ULCERGARD advocate and user since 2007.
Take action at ulcergard.com.
* When administered for 8 or 28 days, ULCERGARD is proven to effectively prevent stomach ulcers in horses exposed to stressful conditions. 1
Mitchell RD. Prevalence of gastric ulcers in hunter/jumper and dressage horses evaluated for poor performance. Association for Equine Sports Medicine, September 2001.
IMPORTANT SAFETY INFORMATION: ULCERGARD can be used in horses that weigh at least 600 pounds. The effectiveness of ULCERGARD in the prevention of gastric ulcers in foals and weanlings has not been evaluated. Safety in pregnant mares has not been determined. 26012_THE PRACTITIONER_SOG_VET_FA.indd 1
®ULCERGARD is a registered trademark of Merial Limited. ©2012 Merial Limited, Duluth, GA. All rights reserved. EQUIUGD1126-A (07/11)
6/14/12 3:02 PM
The Practitioner 11
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12 The Practitioner
Issue 2 • 2012
wel e J n w The Cro ida’s of Flor st! a o C f l Gu
October 11-14, 2012 Naples, FL
Advanced Equine Sports Medicine From Start To Finish OFFERING: Nationally- and InternationallyAcclaimed Speakers
39 • • • •
Hours of Cutting-Edge Continuing Education that includes
Lameness Imaging Neonatology Pre-purchase Exams
• Internal Medicine • Regenerative Medicine • Rehabilitation – Cases Video Dry Lab
FAEP’s 8th Annual Promoting Excellence Symposium in the Southeast • October 11-14, 2012 Naples, FL
FAEP’s 8th Annual Promoting Excellence Symposium in the Southeast
FAEP’s 8th Annual Promoting Excellence FAEP’s 8th Annual Promoting Excellence Symposium in the Southeast • October 11-14, 2012 Naples, FL
Advanced Equine Sports Medicine
Distinguished Speakers & Topics Norm Ducharme, DVM, MSc, DACVS »» Recognition, Significance and Treatment of Select Upper Airway Abnormality in Horses »» Specialized Upper Airway Exam: Laryngeal Ultrasound and Dynamic Endoscopy
Lisa Fortier, DVM, PhD, DACVS »» PRP, ACP, ACS, BMAC: Differences, Similarities, and Indications for Clinical Application »» Lameness Associated with the Shoulder Joint and Biceps Bursa »» Case Studies in Regenerative Medicine
Scott Hay, DVM »» Purchase Evaluation in Thoroughbreds of Racing Age
Amanda House, DVM, DACVIM »» Infectious Diseases in the Performance Horse: Update for 2012
The Pre-purchase Exam Lecture Track
Robert Hunt, DVM, MS, DACVS »» Management of Conformation in the Young Thoroughbred »» Purchase Evaluation in the Juvenile Thoroughbred
Christopher Kawcak, DVM, PhD, DACVS, DACVSMR »» Practical Use of Regenerative Therapies for Surgically Treated Injuries »» Practical Use of Medications for Lameness – Updates on Recent Findings »» Post-surgery Rehabilitation – A Combined Approach to Maximizing Tissue Strength and Function »» Case Studies in Regenerative Medicine »» Case Studies of Rehabilitation Protocols from Start to Finish
Betty Marion, JD with Law Offices Kubicki Draper »» Preventing Pre-purchase Exam Claims and the Legal Realities »» Specific Claim Reviews and Actual Cases
Nina Mouledous, DVM with the AVMA PLIT »» Preventing Pre-purchase Exam Claims and the Legal Realities »» Specific Claim Reviews and Actual Cases
Christiana Ober, DVM »» Practical Applications of Regenerative Medicine in Sport Horse Practice »» Case Studies in Regenerative Medicine »» Purchase Examination of the English Sport Horse
Russell Peterson, DVM, MS »» Evaluation and Management of Commonly Encountered Neck and Back Conditions in Sport Horses »» Post-Injury Rehabilitation of the Distal Limb – A Clinician’s Approach to Diagnostics, Therapy and Rehabilitation Protocols for Injuries in Sport Horses »» Case Studies of Rehabilitation Protocols from Start to Finish
Special Feature This Year!
Preventing Pre-purchase Exam Claims and the Legal Realities WHAT TO DO SO THE BUYER WON’T SUE! Hear (and hopefully heed!) the suggestions of veterinarian, Nina Mouledous, DVM of the AVMA PLIT, and attorney, Betty D. Marion, J.D., on what you can do now to reduce the likelihood of a suit against you in connection with a pre-purchase examination. This discussion will include the legal realities faced when a suit occurs. Purchase Examination of the English Sport Horse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Christiana Ober, DVM Pre-purchase Examination for the Western Performance Horse. . . . . . . . . . . . . . Tracy Turner, DVM, MS, DACVS Purchase Evaluation in the Juvenile Thoroughbred. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Robert Hunt, DVM, MS, DACVS Purchase Evaluation in Thoroughbreds of Racing Age. . . . . . . . . . . . . . . . . . . . . . . . . . Scott Hay, DVM Specific Claim Reviews and Actual Cases Veterinary and Legal Analysis. In the words of Bill Gates, “Your most unhappy customers are your greatest source of learning.” Veterinarian Nina Mouledous, DVM of the AVMA PLIT, and attorney Betty D. Marion, J.D., will present facts, circumstances and analysis of real life pre-purchase examination claims and then answer your questions about those examples.
Symposium in the Southeast featuring
Dr. Mike Ross Mike Ross, DVM, DACVS »» The Ross Orthopedic News Hour »» The Fetlock Joint – A 30-year Perspective »» The Lameness Quiz
Sheila Schils, PhD »» “Boots On The Ground” What are the Rehabilitation Protocols that Practitioners, Rehabilitation Centers and Clients are Actually Following? »» Case Studies of Rehabilitation Protocols from Start to Finish
Theresa Spitznagle, PT, DPT, MHS, WCS »» Horse and Human Rehabilitation, Back and Neck– Current Theories and Clinical Practice in Human Rehabilitation and What may be Applicable to Horses: Movement System Syndromes of the Thoracic and Cervical Spine »» Horse and Human Rehabilitation, Pelvis – Current Theories and Clinical Practice in Human Physical Therapy and What may be Applicable to Horses? Movement System Syndromes of the Pelvis »» Case Studies of Rehabilitation Protocols from Start to Finish
Tracy Turner, DVM, MS, DACVS »» Getting Started on the Right Foot »» Pre-purchase Examination for the Western Performance Horse »» Equine Rehabilitation From Start to Finish »» Case Studies of Rehabilitation Protocols from Start to Finish
Natasha Werpy, DVM, DACVR »» Ultrasound of the Foot – A Review of Technique and Abnormalities that can be Reliably Detected »» How MRI Has Changed the Way I Read Radiographs and Perform Ultrasound Examinations »» Multiple Modality Case Presentations – How to get the Most From Imaging in the Diagnosis of Lameness
Pamela Wilkins, DVM, MS, PhD, DACVIM-LA, DACVECC »» Prognostic Indicators for Survival and Athletic Outcome in Critically Ill Neonatal Foals »» The ‘Dummy’ Foal: What You Can Do in the Field »» The Best of 2012-2013: Breaking Clinically Relevant Papers in Medicine
Rehab Cases – Video Dry Lab Case Studies of Rehabilitation Protocols from Start to Finish
Get involved! A full morning of case studies from the entire staff of rehabilitation presenters is planned. Each horse will be followed from diagnosis through the completion of the rehabilitation protocols – what worked, what didn’t, what could have been tried? Have you ever had a case like this? Speak up, we want to hear about your experiences, too. In addition, one of the most distinguished clinicians currently in human rehabilitation will be on hand to discuss another perspective – what would happen if this horse were a human? Leave with some solid ideas on protocols that you can use in your practice.
The Ross Orthopedic News Hour – Relevant recent papers in equine literature will be reviewed and critiqued; emphasis will be placed on papers dealing with topics in equine lameness and orthopedic conditions. The Fetlock Joint – A 30-year Perspective – What we knew in the early 1980s to what we now know about the fetlock will be discussed. Evolution of imaging techniques pertinent to the fetlock joint and other relevant areas of lameness diagnosis will be highlighted as will the most common cause of lameness and poor performance in racehorses. The Lameness Quiz – This two-hour session will test your knowledge of gait deficits, stride characteristics and the interaction between the forelimbs and hindlimbs. Numerous videos of horses with gait deficits will be shown initially and later each case will be reviewed and concise explanations and recommendations given. Be prepared for audience participation and bring paper and pencil!
FAEP’s 8th Annual Promoting Excellence Symposium in the Southeast • October 11-14, 2012 Naples, FL
From Start To Finish
Host Hotel FAEP’s 8th Annual Promoting Excellence Symposium in the Southeast • October 11-14, 2012 Naples, FL
Waldorf Astoria Naples
475 Seagate Drive Naples, FL 34103 (888) 722-1267 To Ensure Your Accommodations, Reserve Your Room Today! Request FAEP Special Group Rate of $169.00 plus taxes FAEP Special Group Rate Deadline September 20, 2012 Reserve Your Room Today! Call Group Reservations Department, (888) 722-1270. Request the FAEP’s Special Group Rate! Group Rate Extended Stay Three Days Prior and Post Conference, Subject to Availability
An Oasis of Serene Beauty
Experience the pure ease of Waldorf Astoria Naples – a perfect blend of modern luxury and eco-friendly design – where style and substance exist in perfect balance, and impeccable service exceeds every expectation.
On-Site Recreation Activities
Three Luxurious Resort Pools
Golden Door® Spa
Fitness Center World-Class Tennis Facility Golf Course designed by Rees Jones
Canoeing Kayaking Windsurfing Snorkeling
A warm, effortless level of hospitality greets you at the Waldorf Astoria Naples. This inviting beach property sets the standard for treating guests and families to endless activities, incredible nearby sights, and an unmatched level of service and attention. We invite you to explore this unique Florida resort, and indulge in a truly special getaway. Located on 23 manicured acres along the Gulf Coast of Florida Adjacent to miles of natural mangrove estuary waiting to be explored Minutes from designer shopping, family attractions, the Caribbean Gardens at Naples Zoo and the Florida Everglades
Sailing Relax on the pristine beach
Special Thanks to our 2012 Educational Partners The FAEP Executive Council would like to thank the following FAEP Educational Partners for their support of our mission to provide the highest quality equine-exclusive continuing education in the Southeast. Their support of our programs keep your registration fees affordable. Please visit the “Marketplace” and thank them for their support!
Naples GraNde GOlf club – Thursday, OcTOber 11, Tee Times: 7:35 a.m. TO 7:52 a.m.
Golf will include: » Green Fees » Cart Rental
» Range Balls » Roundtrip Transportation from the Waldorf Astoria
*Golf club rentals are available at an additional fee. FORE! Join fellow conference attendees on an optimum golf course for players of all skill levels at the private Naples Grande Golf Club. Acclaimed golf architect Rees Jones designed a par 72 championship course that proves both interesting and challenging. Each hole at this demanding course promises an exhilaratingly new experience. With extraordinary elevations and unique water features expertly incorporating the indigenous Florida foliage, this course offers stunning fairways for year-round play. Conference attendees will discover true entertainment at Waldorf Astoria Naples– a beachside oasis, offering the best in championship golf for all skill levels. We look forward to seeing you on the green! Each player on the winning team will be awarded a tournament plaque for the lowest score!
FAEP’s FISHING TOURNAMENT
Thursday, OcTOber 11 – 7:30 a.m. TO 12:00 p.m.
Fishing Charter includes: » Charter Boat with Captain and First Mate » Round Trip Shuttle Transportation to and from the Marina » Tackle & Gear
» Fishing Licenses » Bait/Chum » Cleaning Fish
Fish Florida style with Capt. Allen Walburn and A & B Charters, voted number one sport fishing charter boat in Southwest Florida, for a day of fishing, action and fun! Your charter boat is new, fast, comfortable and equipped with all Coast Guard safety equipment, state-of-the-art electronics, custom fishing tackle, a courteous, experienced first mate that tends to your every need, and a seasoned captain with more than three and a half decades of fishing experience. Fishing tackle, bait, ice, coolers and fishing licenses are included with the charter and the catch is cleaned and bagged by the crew, at no charge. Your crew will transport you offshore to catch Grouper, Snapper, shark and more! Anglers will be competing for three award categories – the biggest fish, the most fish and the most unusual fish. Good luck and tight lines!
FAEP’s 8th Annual Promoting Excellence Symposium in the Southeast • October 11-14, 2012 Naples, FL
FAEP’s GOLF TOURNAMENT
FAEP’s 8th Annual Promoting Excellence Symposium in the Southeast • October 11-14, 2012 Naples, FL
Membership has its privileges Your Invitation To Attend Dear Colleagues, It is an honor to personally invite you to join us for the FAEP’s 8th Annual Promoting Excellence Symposium “Advanced Equine Sports Medicine from Start to Finish” being held October 11-14 at the Waldorf Astoria Naples. This year’s symposium features world-renowned speakers presenting the latest advances in equine sports medicine: Regenerative Medicine, Lameness, Imaging, Surgery, Medicine and Rehabilitation. The Waldorf Astoria Naples is a beautiful resort venue and our list of Distinguished Speakers “speaks” for itself. I would like to particularly thank Drs. Anne Moretta and Suzan Oakley for the many hours they have worked in putting this program together. This symposium is an exceptional opportunity to fulfill your CE requirements in a stunning beachside property at a reasonable price. If you’re not already a member, for one low annual fee, you will receive dual membership in the FAEP/FVMA. Join today and receive the remainder of 2012 and all of 2013 for the price of one year. Your membership will also enable you to take advantage of the discounted member registration fee for the Promoting Excellence Symposium. We hope you will join us for this exceptional continuing education opportunity and I look forward to seeing you at the Waldorf Astoria Naples, the crown jewel of Florida’s Gulf Coast. Your escape awaits! Greg BonenClark, DVM, Diplomate ACVS FAEP Council President
General Information Advanced Registration The FAEP strongly recommends advanced registration for our 8th Annual Promoting Excellence Symposium. Registration is required for admission to all aspects of the meeting. Your registration includes all CE sessions, access to the Marketplace, Friday and Saturday lunch, conference proceedings and all breaks held in the Marketplace. Registrations must be submitted to the FAEP office by Friday, Sept. 28, 2012. There will be a late registration fee of $50.00 charged to all those postmarked or received by fax, email or online after this date. Registrations made at the door will be charged the late fee of $50.00.
Symposium Marketplace The FAEP ’s 8 th Annual Symposium Marketplace will provide exhibitors and attendees with incredible value Friday and Saturday during our four-day conference weekend. This is a great opportunity for you to take advantage of face-to-face contact with equine industry representatives.
Symposium Marketplace Hours Thursday, Oct. 11.. . . . . . 5:30 p.m. – 7:00 p.m. Friday, Oct. 12.. . . . . . . . . 8:00 a.m. – 6:30 p.m. Saturday, Oct. 13. . . . . . . 8:00 a.m. – 4:20 p.m.
Air Transportation The destination airport for the Florida Association of Equine Practitioner’s 8 th Annual Promoting Excellence Symposium is Southwest Florida International Airport (RSW) in Fort Myers, FL, located only 30 miles from the Waldorf Astoria Naples.
Airport Shuttle Service Round trip and one-way shuttle services are available between the Southwest Florida International Airport and the Waldorf Astoria Naples. RESERVATIONS ARE REQUIRED FOR GUARANTEED SERVICE. Special FAEP rates have been prearranged as follows: • Luxury Sedan Service for up to four guests is $59.00 • Van Service for up to 10 guests is $109.00 • Fees shown above are one-way transportation charges excluding driver gratuity.
Once your travel plans are finalized, please contact Classic Transportation by calling toll free (800) 553-8294 or locally (239) 394-1888 or you can visit them on the web www.classictluxurytransportation.com. All drivers will greet passengers inside airport terminal at baggage claims and handle luggage transfer to vehicle.
AAVSB RACE This program has been submitted (but not yet approved) for 39 hours of continuing education credit in jurisdictions that recognize AAVSB RACE approval. However, participants should be aware that some boards have limitations on the number of hours accepted in certain categories and/or restrictions on certain methods of delivery of continuing education. Call Amber Coon at (800) 992-3862 for further information. A maximum of 24 credit hours can be earned at this conference.
Complete Symposium details at www.faep.net
8th Annual Promoting Excellence Symposium in the Southeast October 11 - 14, 2012 • Naples, FL PRE-REGISTRATION DEADLINE SEPTEMBER 28, 2012
Register today & save! After September 28th add $50 per registrant.
Easy Ways To Register
FAEP/FVMA 7131 Lake Ellenor Drive Orlando, FL 32809
Email College Year of Graduation One registration per form. Please duplicate this form for additional registrants. Membership q Yes, I would like to take advantage of the FAEP/FVMA joint membership special offer and register A for the 8th Annual Promoting Excellence Symposium in the Southeast as a member! FAEP/FVMA New I qualify for the following Membership Categories (please check one) Member Rate q Regular Member $236.00 q Recent Graduate (within last 2 years) $131.00 q State/Federal Employee $131.00 q Part-Time Employed $131.00 q Non-Resident $79.00 __________ Symposium Registration* FAEP/FVMA Member On or Before September 28 q $445.00 After September 28 q $495.00 To register at the discounted member rate, your 2012 FAEP/FVMA dues must be current!
On or Before September 28 q $645.00 After September 28 q $695.00
Student Registration – Currently enrolled in an AVMA-Accredited Veterinary College. q $125.00 School Attending ____________________________________________________________________________________
*Includes Proceedings, All CE Sessions, Lunch on Friday & Saturday and access to the Marketplace and social events
(800) 992-3862 (407) 851-3862
Spouse Registration – Includes Lunch on Friday and Saturday and allows entrance to the Marketplace and social events. Spouses who wish to attend C.E. sessions must pay full registration fees. Spouse/Guest Name _________________________________________________________________________________
Rehab Track Only – Rehab Professionals (Non-Veterinarians) Includes Marketplace access & Lunch on Saturday (Veterinarians who wish to attend the Rehab Track only, must pay full registration fee.)
Rehab Only Fee
FAEP’s Annual Golf Tournament – Thursday, October 11th Includes - Green Fees, Cart Rental and Range Balls!
q $ 149.00
FAEP’s Charter Fishing Tournament – Thursday, October 11th Includes - Transportation, License, Tackle, Bait and 1/2 Day of Fun!
q $ 149.00
E Cancellation Policy
If received by Sept. 28, 2012, your registration fee will be refunded, minus a $50 administrative charge. Cancellations not received in writing and acknowledged by the FAEP by the date required will not be eligible for a refund. No-shows will not be refunded.
( Make checks payable to the FAEP/FVMA)
Total Registration Fee
$ 95.00 $ $275.00 $
q Check Enclosed Charge my credit card q VISA q MC q AMEX q DISCOVER Credit Card # Exp. Date Name on Card Signature
FAEP’s 8th Annual Promoting Excellence Symposium in the Southeast • October 11-14, 2012 Naples, FL
Digital Sheath Tenosynovitis: Diagnosis, Treatment and Prognosis By CAROL GILLIS, DVM, PhD, DACVSMR
he digital sheath is a complex synovial structure which surrounds the superficial (SDF) and deep (DDF) flexor tendons from proximal to the fetlock joint distally to mid-pastern. Normally, the sheath contains a small amount of synovial fluid, which serves to promote gliding of the flexor tendons around the palmar/plantar aspect of the fetlock joint. With severe inflammation the sheath can become greatly distended, reaching to mid-metacarpus proximally, and/or ”herniating” palmar to the SDF tendon on midline. Digital sheath swelling is frequently dismissed as a blemish rather than a lameness issue. In fact, in more than 20% of cases with swelling, lameness will eventually occur and can be career ending. Early diagnosis using ultrasound, followed by appropriate therapy, can avoid future performance problems.
The ultrasound image above is of a digital sheath distended with anechoic fluid
Clinical signs of digital sheath synovitis (Stage 1 synovitis) reflect the degree of inflammation, which can be categorized into 3 stages. It is not II), clinical signs include mild to moderate product secretion may cause the patient uncommon for athletic horses to present intermittent lameness; often seen first, (if to be more consistently lame, or, if the with swelling (Stage 1 synovitis) of uni- the horse has only one limb affected), as an horse is bilaterally affected, to have a conlateral or bilateral forelimb or hind limb attempt by the horse to guard the affected sistently shortened caudal phase to the digital sheaths. Often, sheath distension sheath by failing to fully extend the fet- stride and decreased fetlock drop. Ultrasodecreases following exercise. The disten- lock. This is seen as a decreased drop in nographic examination will reveal extension is fluidly fluctuant on palpation. The the fetlock during the stance phase of gait sive synovial proliferation, often covering patient is sound, non-painful or minimally compared to the opposite fetlock. This can the surfaces of the flexor tendons, and painful to sheath palpation, and mildly be most readily detected by observation one or more adhesions between the tento moderately positive to fetlock flexion. of the horse from behind at a walk. If the dons and the sheath wall. Often, chronic Ultrasonographic examination reveals a horse has bilateral digital sheath synovitis, digital sheath synovitis is accompanied moderate amount of fluid in the affected the decreased fetlock drop is more difficult by damage to either the superficial or sheath(s), with no evidence of synovial to assess, but can be exacerbated by flex- deep flexor tendons, probably due to the proliferation or adhesions between the ion of the fetlock(s). The digital sheath is same wear and tear process that caused tendons and sheath walls. It is important firm rather than fluid on palpation, and sheath synovitis; in addition to being to fully evaluate a horse presented at this one aspect of the sheath, usually the lat- exposed long term to the inflammatory stage to determine the cause of digital eral aspect, will be more distended. The products circulating in the sheath, being sheath distension, particularly if only one horse will be positive to fetlock flexion, compressed by synovial proliferation, and limb is affected as this strongly indicates as this maneuver compresses the sheath. finally, due to active pulling on the tenoverload from lameness elsewhere. Foot Ultrasonographic examination will reveal dons by adhesions in the sheath. balance can also be a contributory factor, distension of the sheath with fluid and Septic digital sheath synovitis. The in particular uneven heel height between proliferative synovial lining. Proliferative horse will be Grade IV-V/V lame on the paired limbs or long-toed, low-heeled foot tissue may also begin to cover the surfaces affected limb, reluctant to place the heels shape. of the flexor tendons. of the foot on the ground, and will likely If synovitis progresses from the effuIf synovitis progresses to Stage 3, not tolerate fetlock flexion. The digital sive stage to synovial proliferation (Stage synovial proliferation and inflammatory sheath will be distended, painful, and 20 The Practitioner
Issue 2 • 2012
firm on palpation. Ultrasonographic evaluation will reveal highly cellular fluid in the acute stage accompanied by fibrin and adhesions in more chronic cases. An ultrasound guided aspirate will confirm sepsis and provide material for culture and sensitivity testing.
Treatment and Prognosis Treatment of Stage 1 synovitis is medical, and may consist of 2-3 weeks of local or systemic anti-inflammatory medication, cold hosing/icing of the affected limb(s), placement of the patient on a course of IM Adequan and supplementation with oral glucosamine and hyaluronic acid. A full lameness evaluation is indicated at this time to diagnose and treat any inciting causes. Corrective shoeing, if needed, should be implemented. If the digital sheath does not decrease substantially in size after 2-3 weeks of therapy, injection of the sheath is indicated. As long as the horse is in full athletic use, medical treatment may be required to prevent progression to Stage 2 synovitis. Prognosis for Stage 1 synovitis is excellent. Treatment of Stage 2 synovitis includes the above. Patients that do not respond fully to medical treatment may require tenoscopy to remove excess proliferative synovial tissue. Tensocopy must be followed by aggressive medical therapy, generally including a series of hyaluronic acid
The ultrasound image below is of a digital sheath distended with effusion and synovial proliferation (Stage II synovitis)
and steroid injections. Small edge tears in the flexor tendons may be detected on tenoscopy that were obscured by proliferative synovium on ultrasound. If so, the tendon will need a rehabilitation period of 6-8 months to heal. Prognosis for Stage 2 synovitis is fair to good for full athletic work, if appropriate treatment is
performed in a timely manner. Treatment of Stage 3 synovitis requires medical and surgical treatment, as outlined above for Stage 2. Prognosis for Stage 3 synovitis is guarded for full athletic use. Without treatment, these patients may progress to lameness even at a walk. Treatment of septic tensosynovitis involves appropriate antibiotic therapy and flushing which may include tenoscopy to remove debris. It is critical for a successful outcome to concurrently treat for inflammation; otherwise the infection can be eliminated only to find that the horse continues to be lame from Stage 3 synovitis.
The ultrasound image above is of a digital sheath that has extensive synovial proliferation (between +s) and thick adhesions to the superficial and deep digital flexor tendons (Stage III synovitis). Both flexor tendons have sustained edge tears.
Surgery involves first a thorough exploration of the tendon sheath, superficial digital flexor, deep digital flexor, and intersesamoidean ligament. All proliferative masses are removed. Adhesions present between the tendons and the tendon sheath are likewise debrided back to their bases. Similar adhesions between the tendons are managed by severing the adhesions midsubstance and debriding only one edge back to the base. This is important for reducing the potential of two apposing tendinous lesions scarring together and increasing the risk of new adhesion formation. The Practitionerâ€‚ 21
Arthroscopy Images courtesy of Tom Yarbrough, DVM, DACVS
Arensburg L, Wilderjans H, Simon O et al. “Nonseptic tenosynovitis of the digital flexor tendon sheath caused by longitudinal tears in the digital flexor tendons: A retrospective study of 135 tenoscopic procedures”. Equine Vet J 2011 Jun 8 epub. Gillis CL. “Soft tissue injuries: tendinitis and desmitis” ” In Equine Sports Medicine and Surgery, Eds Hinchcliff & Kaneps. Saunders 2004. pp 412-433 Barr, A.R.S., Dyson, S.J., Barr, F.J. and O’Brien, J.K. (1995) Tendonitis of the deep digital flexor tendon in the distal metacarpal/metatarsal region associated with tenosynovitis of the digital sheath in the horse. Equine vet. J. 27, 348-355 Dik, K.J., Dyson, S.J. and Vail, T.B. (1995) Aseptic tenosynovitis of the digital flexor tendon sheath, fetlock and pastern annular ligament constriction. Vet. Clin. N. Am.:Equine Pract. 11, 151-162 Gerring, E.L. andWebbon, P.M. (1984) Fetlock annular ligament desmotomy: a report of 24 cases. Equine vet. J. 16, 113-116. Nixon, A.J. (2003) Arthroscopic surgery of the carpal and digital tendon sheaths. Clin.Tech. Equine Pract. 1, 245-256. Schramme, M.C. and Smith, R.K.W. (2003) Disease of the digital synovial sheath, palmar annular ligament, and digital annular ligaments. In: Diagnosis and Management of Lameness in the Horse, 1st edn., Eds: M.W. Ross and S.J. Dyson,Saunders Elsevier, Missouri. pp 674-681. Smith,M.R.W. andWright, I.M. (2006) Noninfected tenosynovitis of the digital flexor tendon sheath: a retrospective analysis of 76 cases. Equine vet. J. 38, 134-141. Wilderjans, H., Boussauw, B., Madder, K. and Simon, O. (2003) Tenosynovitis of the digital f lexor tendon sheath and annular ligament constriction syndrome caused by longitudinal tears in the deep digital flexor tendon: a clinical and surgical report of 17 cases in Warmblood horses. Equine vet. J. 35, 270-275. Wright, I.M. and McMahon, P.J. (1999) Tenosynovitis associated with longitudinal tears of the digital flexor tendons in horses: a report of 20 cases. Equine vet. J. 31,12-18.
22 The Practitioner
Carol Gillis, DVM, PhD, DACVSMR ++
Dr. Carol Gillis is a graduate of UC Davis School of Veterinary Medicine, developed a sport horse practice and became one of the first equine veterinarians to perform ultrasound examinations on the musculoskeletal system of horses. Dr. Gillis returned for an equine surgery residency at UC Davis. Following completion of the residency, she obtained a PhD in equine tendon pathophysiology. Concurrently, she established the equine ultrasound service at UC Davis, pioneering ultrasound of the musculoskeletal system at the University and creating courses and wet labs to train veterinary students, residents and veterinarians on how to perform and interpret ultrasonographic examinations. Dr. Gillis has developed many exam protocols for previously unexamined sites on the horse, is the author of more than 50 scientific publications on equine soft tissue injury diagnosis and treatment in journals such as the American Journal of Veterinary Research and the Journal of the American Veterinary Medical Association; and recently was an author of “Equine Sports Medicine and Surgery.” Dr. Gillis has presented on Equine Sports Medicine topics nationally at the American Association of Equine Practitioners and the American College of Veterinary Surgery meetings and internationally in the United Kingdom, France, Japan, Dubai, Argentina and Mexico. Dr. Gillis has performed more than 22,000 ultrasound examinations of the horse and guided successful treatment of problems identified. Most recently, she has developed a sports medicine consulting practice in Aiken, South Carolina and is a charter member of the American College of Veterinary Sports Medicine and Rehabilitation
Issue 2 • 2012
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The Practitioner 23
Dynamic Video Endoscopy:
A Second Renaissance in the Understanding of Upper Airway Disease By John B. Madison, VMD, DACVS
hen horses are examined for upper airway problems, in the majority of cases, the condition can be diagnosed with an accurate history, laryngeal palpation, and a resting endoscopic exam. Occasionally, however, these findings are normal or not diagnostic of the problem and a dynamic exam must be performed in order to figure out the cause of the problem. In the past, these horses were examined on a high speed treadmill (HSTM). The introduction of HSTM exams in the 1980s led to a renaissance in the problems (like dorsal displacement of the understanding of dynamic upper airway soft palate and pharyngeal collapse) were conditions and greatly improved our abilfrequently not reproduced on the HSTM ity to diagnose and treat these conditions because the horses were not wearing a in the equine athlete. The endoscopic bridle, were not in the same head set, and appearance of horses exercising at near were not exercising under conditions simiracing speed on a treadmill, along with lar to what they experience during compethe measurement of upper airway prestition. Therefore, the competitive drive or sures, led to a tremendous leap forward anxiety that can sometimes accompany in our understanding of dynamic condiexercise during competition could not be tions of the upper airway. The technique reproduced leading to many false negative also allowed us to better understand why exams. some surgical procedures were failing and resulted in modifications of some of The introduction of over-the-ground the surgical procedures that were being video endoscopy (OTG) has all but elimiperformed. nated these false negative exams by allowThere were, however, some disadvaning the horses to be examined under the tages to the use of HSTM exams on cliniexact conditions under which the probcal cases. The horse had to be shipped to a lem occurs. As long as the horse exhibits facility with a high speed treadmill and the the problem during the examination, it is horse had to be acclimated to the treadhighly likely that the cause will be identimill before the exam could be performed. fied. For these reasons OTG endoscopy has Depending on the skill of the operators, replaced the HSTM as the “gold standard” this could take the better part of a day. in the diagnosis of dynamic upper airway The ability to elicit the problem seen while conditions. The HSTM, in my opinion, is the horse was under tack was also partly obsolete as a tool for use in clinical cases dependent on the skills of the treadmill and now is an instrument used primarily operator, but was also dependent on the in research. Conditions that are more comproblem being investigated (e.g. not all monly observed with OTG endoscopy (e.g. problems would be readily induced on the frequent false negatives on HSTM endosHSTM). If the operator did not have the copy) include: experience and confidence to exercise the horse to near exhaustion, some dynamic conditions were missed (e.g. dynamic collapse of the left arytenoid). Other 24 The Practitioner
Dynamic collapse of the left arytenoid (particularly in horses with normal (grade 1 or 2) resting laryngeal function Ventral deviationof the ape of the corniculate process Axial deviation of the aryepiglottic folds Dorsal displacement of the soft palate (DDSP) Pharyngeal collapse
Axial deviation of the aryepiglottic folds
Dynamic collapse of the left arytnoid
Issue 2 • 2012
The second “old wives tale” is that coughing and aspiration following laryngoplasty are a result of “over abduction” of the arytenoid. Aspiration of food and water following surgery, in my opinion, has little or nothing to do with the degree of abduction, but has to do with how hard the suture had to be pulled to achieve that degree of abduction. I have no scientific studies to base this opinion on other than the repeated observation that I can take a coughing horse with intermediate arytenoid abduction and replace the sutures, obtain a greater degree of abduction and have the coughing stop. In coughing horses that are intermediately abducted, I nearly always abduct them further at the second surgery. In my own cases that are maximally abducted, I return them to maximal abduction, but with less tension on the sutures and nearly always have the coughing and aspiration stop. It appears to take less tension on the sutures to achieve the same degree of abduction when re-doing a laryngoplasty for coughing and aspiration. I have seen badly aspirating horses with all degrees of arytenoid abduction including what anyone would consider a complete lack of abduction. Therefore, in my opinion, as a veterinarian examining a post op laryngoplasty that is coughing, your assessment should be that the horse is experiencing a well documented complication following laryngoplasty that occurs because part of the mechanism to keep food and water out of the airway during swallowing has been disabled by the surgery. This is much different than telling the owner that the surgeon over abducted the arytenoid, which I believe to be untrue, but regardless of whether you believe me or not, it doesn’t do anyone any good to make that accusation. The fix for the problem is to either remove the sutures or to replace them with sutures that aren’t tied quite as tightly.
OTG endoscopy is also an excellent tool pulls against the suture so, from a purely in evaluating the causes of poor outcomes mechanical analysis, you wouldn’t expect in post surgical patients. OTG endoscopy abductor function to cause sutures to cut also has potential use in pre-purchase through unless there is continued motion evaluations, although this use has not yet of the arytenoid, and therefore, cycling of been widely exploited. the suture (more on that in a minute). If The minimal equipment necessary you look at retrospective studies of larygfor an OTG exam are a video endoscope noplasty, there is no difference in failure that attaches to the bridle with a battery rates between horses with grade 3 (parpowered light source and the capability to tially paralyzed) and grade 4 resting (comrecord video images. Other features found pletely paralyzed) laryngeal function. In on some of the scopes are the ability to addition, in the 1990s it became popular transmit wireless video to a stationary to perform a recurrent laryngeal neurecviewing station, it pumps to clear mucus tomy at the time of a tie back in horses from the scope intermittently, remote with some laryngeal function. That procontrol adjustment of the scope using a cedure resulted in no improvement in joystick, GPS positioning, which allows the failure rate so it has been abandoned. speed calculations; and a microphone to One important caveat here, however, is record respiratory noise. that regardless of the degree of remainAlthough not specifically related to ing function, it is important that the surOTG endoscopy, I would like to use the geon abduct the arytenoid further than “bully pulpit” of this forum to dispel, what I the horse can abduct on his own or the believe to be, some “old wives tales” about suture will be cycled with each swallow throat surgery. These are commonly held and during vocalization. This becomes beliefs that we have all been taught, but I especially important in horses that have believe to be wrong, based on my clinical normal resting function, but dynamically experience. collapse during OTG endoscopy. In these The first “old wives tale” is that you horses, maximal abduction of the aryteshould wait for a horse to become com- noid must be achieved (the left side should pletely paralyzed before performing a tie look like the right side at full abduction). back. The supposed basis for this belief is that it has been taught for years that John B. Madison, VMD, DACVS a tie back is more likely to fail in horses ++ Dr. Madison is a 1981 graduate of the University of Pennsylvania School of Veterinary with some arytenoid movement than in Medicine. He did an internship and surgical residency at New horses that are completely paralyzed. This Bolton Center and spent the next 11 years of his career in academic is, in fact, untrue. It has been known for practice at New Bolton Center and the University of Florida. ++ In 1997, Dr. Madison started Ocala Equine Hospital, a surgical practice some time in cases of idiopathic laryngeal in Ocala, FL with a caseload that is primarily racing Thoroughbreds. hemiplegia (ILH) that adductor function ++ In 2001, the surgical practice merged with two ambulatory is usually lost before abductor function. practices to form the present Ocala Equine Hospital, P.A. It is adduction of the arytenoid that www.faep.net
The Practitioner 25
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The Practitioner 27
Nasal Discharge: Where’s It Coming From And What We Can Do About It By Eric J. Parente, DVM, Diplomate ACVS
asal discharge can represent some- to guttural pouch mycosis. Severe trauma thing benign, life threatening or can result in avulsion of the longus capitis anything in between. Often horses muscle from the insertion of the basispheare placed on antimicrobials for any nasal noid bone and moderate bleeding from the discharge because of limited ability to eval- guttural pouch. Blood seen from the nasouate the problem and effectively treating maxillary opening can be secondary to the horse. However, with advanced diag- trauma and bleeding into the sinus withnostic imaging and newer surgical tech- out external signs of trauma. Radiographs niques, the effectiveness of treating such will often reveal a fluid line. Treatment is patients has improved dramatically. not necessary, but antimicrobial treatment In most cases, nasal discharge is not is recommended to prevent secondary an emergency, but any horse with nasal sinusitis. Neoplasia or fungal infections hemorrhage should be evaluated imme- that cause epistaxis are usually seen easily diately. While bilateral epistaxis is most on endoscopic examination. Treatment of commonly from exercise induced pulmo- neoplasia is often unrewarding but fungal nary hemorrhage and not life threaten- infections can be treated effectively with ing, a severe bleed from the guttural pouch topical anti-fungals if a method to ensure could be from one or both nares and is life long contact time is instituted. threatening. Guttural pouch hemorrhage Progressive ethmoid hematomas are is most often the result of a mycotic infec- very common. Unlike guttural pouch tion eroding through major arteries in the mycosis, they typically cause a small pouch lining. A large volume of blood evi- volume, intermittent bleed not associated dent on endoscopic examination at the with exercise. It is extremely rare to have guttural pouch opening is often the only facial deformity and the source of bleedevidence needed prior to referral for sur- ing could be within the nasal passage (ethgery. Trying to endoscopically evaluate the moid recess), within the sinuses, or both. inside of the guttural pouch close to the Endoscopic and radiographic evaluations time of a severe bleed is usual futile since are essential to fully appreciate the extent the amount of blood within the pouch will of the lesion, since they can often be in obscure visualization. Surgery is aimed multiple sites. Small lesions can also exist at obstructing blood flow through the within the sinus without obvious radiomajor vessels in the lining of the guttural graphic abnormalities, so caution must be pouch. Ligation at the cardiac side as a sole used in interpretation of radiographs. procedure is often ineffective because of In many cases therapy may consist of retrograde flow, so the vessels must be intralesional formalin injections under obstructed or embolized on the cranial endoscopic guidance in the standing side as well. If there is not an opportunity horse on an outpatient basis. While this to obstruct vessel cranial to the lesion, technique is very client/patient friendly ligation at the cardiac side can be effec- and effective at abating clinical signs, it tive in a small percentage of horses. The is unlikely to provide a “cure.” Previous surgery not only prevents further hemor- reports of success have been based on telerhage but also causes the mycotic lesions phone follow-up and not follow-up endosto resolve without any medical therapy. copy or radiography. Many patients have Any evidence of neurologic disease (laryn- recurrence after several years and it may geal dysfunction or dysphagia) should be be, in part, because what we see within the determined prior to surgery. nasal passage is just the tip of the lesion Other causes of epistaxis to consider and we are not effectively treating the are trauma, neoplasia, fungal infections, base or origin. Laser ablation may be more or ethmoid hematomas. All of these are effective than intralesional formalin, but typically of a much lower volume relative would require significantly more expense 28 The Practitioner
and repeated treatments with large lesions. For this reason, laser treatment is usually reserved for the smaller lesions. Our current treatment regimen for hematomas within the ethmoid recess is to treat with intralesional formalin at 4-week intervals until they are <1cm in diameter and then perform laser ablation. Treatment of sinus hematomas is dependent upon the size of the hematoma. When moderate or small hematomas are found within the sinus cavity, laser ablation/debridement is performed via a standing sinoscopic procedure. Larger hematomas within the sinus require extirpation via sinusotomy. Intralesional formalin treatment via trephine has been ineffective. After extirpation, the sinus and nasal passage are packed with sterile gauze and the packing is removed 3 days post operatively. A large opening is left between the sinus and nasal passage which provides an avenue to see within the sinus via standard endoscopy in the future. Since we have seen hematomas recur or arise in different areas with long-term follow up, endoscopy is recommended initially at 6 months and then annually. Any lesions found can then be treated by intralesional formalin or laser ablation before they become substantial in size. Purulent discharge is often found from the sinus cavity (as evidence from nasomaxillary opening) or guttural pouch. Primary bacterial infections of the sinus without an underlying cause are common. Many patients will respond favorably to antimicrobial therapy without further diagnostics or treatment. Long-term antimicrobials are usually required and if there is not an immediate response, further evaluation should be performed. Endoscopy will be helpful in confirming the source of discharge; guttural pouch or sinus involvement. Radiography is commonly the next diagnostic procedure performed. If there is soft tissue density not consistent with a fluid line, or abnormalities with the Issue 2 • 2012
teeth, referral should be considered. If frontal sinus provides the best access for the only radiographic abnormality is the visualization and potentially treatment. presence of fluid within the sinus, then Debriding the caudal ventral conchal bulla culture and lavage can be performed in allows passage of the scope into the rosthe standing horse in the field. A small tral maxillary sinus and ventral conchal trephine hole just rostral and ventral to sinuses. There is minimal risk of complicathe eye will allow placement of a teat can- tion and significant cost savings. nula for aspiration and lavage. The only Very large abnormalities within the potential disadvantage is if the surgical paranasal sinuses may not be amenable site becomes a nidus of infection. Rea- to sinoscopy and require a sinusotomy. sons against standing culture and lavage Whether a frontal or maxillary sinusotwould be any radiographic indications of omy is performed is dependent on the size abnormalities not consistent with a pri- and location of the lesion. When properly mary sinusitis. Oral examination should performed, these heal without any cosbe complementary to the endoscopic and metic blemish. Some surgeons advocate radiographic evaluations to determine if standing sinusotomies. While these can any teeth abnormalities are resulting in a be very effective, the primary advantage secondary sinusitis. is not requiring anesthesia but there are The more severe or persistent cases of limitations on what can or should be persinusitis may require surgical interven- formed safely. tion. Sinoscopy is a technique to see what References: is represented radiographically within the Seleced Freeman DE: Sinus disease. In Parente EJ (ed). The sinus and possibly treat it without placVeterinary Clinics of North America Equine Practice: Respiratory Disease. Philadelphia: Saunders; ing the horse under general anesthesia. It 2003:19(1):218–222. can be performed in the standing, sedated Perkins JD, Windley Z, Dixon PM, Smith M, Barakzai horse, with local anesthetic and on an outSZ. Sinoscopic treatment of rostral maxillary and ventral conchal sinusitis in 60 horses. Vet Surg. patient basis. One or two small holes are 2009 Jul;38(5):613-9. made into the sinus cavities (similar to the idea of arthroscopy). A hole over the
Eric J. Parente, DVM, DACVS ++ Dr. Parente is an Associate Professor of Surgery at New Bolton Center, University of Pennsylvania, School of Veterinary Medicine. He has specialized in performance evaluations and upper respiratory surgery. ++ He earned his veterinary degree from Cornell University, completed his internship at Rood and Riddle Equine Clinic, and then his surgical residency at New Bolton Center. ++ Dr. Parente received his board certification from the American College of Veterinary Surgeons in 1994 and continues to be an active member on various committees, as well as a presenter at its annual symposium. ++ He is internationally recognized as a respiratory surgeon and is well published in both texts and journals.
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The Practitioner 29
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Issue 2 • 2012
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The Practitioner 31
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