Monthly Archives: March 2017

Condylar Fractures: No Longer A Career Ending Injury

Palm Beach Equine Clinic (PBEC), located in Wellington, FL, offers advanced diagnostic imaging, world-renowned surgical talent, and state-of-the-art facilities necessary to quickly diagnose, treat, and repair horses with condylar fractures, making PBEC one of the leading facilities in the U.S. for condylar fracture repairs.

With thanks to the technology required for early diagnosis and experienced surgeons on staff, horses that are admitted to PBEC for condylar fracture repairs are more likely to return to training quickly. Most commonly seen in Thoroughbred racehorses and occasionally polo ponies or eventing horses, a condylar fracture was once considered a career-ending injury. Today, however, advances in technology aid in a full recovery with horses regularly returning to competition in their respective divisions.

What is a Condylar Fracture?

A condylar fracture is a repetitive strain injury that results in a fracture to the cannon bone above the fetlock due to large loads transmitted during high-speed exercise. On a radiograph, a condylar fracture appears as a crack that goes from the fetlock joint up the cannon bone. Lateral fractures many times exit the bone usually one-third of the way up the bone. Medial fractures will oftentimes spiral up to the hock or knee. Medial fractures are much more common in the hindlimb than the forelimb. It is the spiral fractures that are more difficult, due to the fact that the extent of the spiral cannot be identified radiographically. If the surgeon cannot identify the fracture, then that part of the fracture cannot be repaired.

“A condylar fracture is a disease of speed,” said Dr. Robert Brusie, a surgeon at PBEC who estimates that he repairs between 30 and 50 condylar fractures per year. “A fracture to the left lateral forelimb is most common in racehorses as they turn the track on a weakened bone and increased loading on the lateral condyle.”

Condylar fractures are further categorized into two classes. An incomplete and non-displaced fracture means that the bone fragment is not separated from the cannon and is still intact with its original position. A complete and displaced fracture means the fragment has detached from the cannon bone and this fracture can often be visible under the skin. Displaced condylar fractures have a somewhat lower prognosis due to the fact that soft tissue structures, such as the joint capsule, become torn. When these structures heal, they are thicker, which makes the joint less flexible.

“Most lateral condylar fractures are fairly simple for us to fix,” said PBEC surgeon Dr. Weston Davis. “Medial condylar fractures tend to be more complicated configurations because they often spiral up the leg. Those require more advanced imaging and more advanced techniques to fix.”

What is the Treatment?

The first step to effectively treating a condylar fracture through surgery is to accurately and quickly identify the problem. PBEC’s Board-Certified Radiologist Dr. Sarah Puchalski utilizes the advanced imaging services at PBEC to assist in the diagnosis.

“Stress remodeling can be detected early and easily on Nuclear Scintigraphy before the horse goes lame or even develops a fracture,” said Dr. Puchalski. “Early diagnosis of stress remodeling allows the horse to be removed from active race training and then return to full function earlier. Early diagnosis of an actual fracture allows for repair while the fracture is small and hopefully non-displaced.”

Once identified as a condylar fracture, PBEC surgeons step in to repair the fracture and start the horse on the road to recovery. Depending on surgeon preference, condylar fracture repairs can be performed with the horse under general anesthesia, or while standing under local anesthesia and sedation. During either process, surgical lag screws are used to reconnect the fractured condyle with the cannon bone.

“For a very simple and small non-displaced fracture, we would just put in one to two screws across the fracture,” explains Dr. Davis. “The technical term is to do it in ‘lag fashion’, such that we tighten the screws down heavily and compress the fracture line. Many times the fracture line is no longer visible in x-rays after it is surgically compressed. When you achieve good compression, the fractures heal very quickly and nicely.”

More complicated fractures, or fractures that are fully displaced, may require more screws to align parts of the bone. For the most severe cases of condylar fractures, a locking compression plate with screws is used to stabilize and repair the bone.

Severe condylar fractures often require general anesthesia, but for PBEC surgeon Dr. Jorge Gomez, approaching a simpler non-displaced condylar fracture while the horse is standing helps to aid in a faster recovery and successful surgical outcome.

“I think it takes the risk of anesthesia away and is a faster surgery from the time the horse comes in to the time the horse recovers,” said Dr. Gomez. “I will just sedate the horse and block above the site of the fracture. Amazingly, horses tolerate it really well, and it is very convenient for medial condylar fractures. In these cases, the fracture can spiral all the way up through the cannon bone, and they have a tendency to develop complete catastrophic fractures that can happen at any time after the injury. That risk can be significantly increased by the recovery from general anesthesia. Our goal is always to have the best result for the horse, trainers, and us, as veterinarians.”

According to Dr. Gomez, the recovery time required after a standing condylar fracture repair is only 90 days.

While Dr. Brusie, Dr. Davis, and Dr. Gomez are all seasoned in quickly and effectively repairing condylar fractures, PBEC is helping them to stay on the cutting edge of surgical techniques. PBEC is currently renovating its facility with plans to give surgeons a new approach to fix condylar fracture repairs. A set of stocks and surgeon’s pit have been added with the ability to give the surgeon eye-level access to the fracture with the patient standing and subsequently simplifying the procedure by reducing the risk from recumbent recovery.

What is the Prognosis?

One of the most common questions regarding an equine injury is, “Will the horse return to work?” Thanks to advanced imaging and surgical techniques, the answer to that question when involving a condylar fracture is most likely, “Yes.” At PBEC, a condylar fracture diagnosis rarely results in the end of a racehorse’s career.

Diagnostic imaging plays a major role in assisting to diagnose, surgically map, and follow up on condylar fractures. After primary use to diagnose a condylar fracture, digital radiographs are also used after surgery to ensure that a fracture repair was completely successful. According to Dr. Davis, scanning two planes during and after surgery gives a full view of the fracture and repair techniques, immediately indicating the success of the procedure before moving the horse on to recovery.

“A condylar fracture was once considered the death of racehorses, and as time and science progressed, it was considered career-ending,” said Dr. Brusie. “Currently, veterinary medical sciences are so advanced that we have had great success with condylar fracture patients returning to full work. Luckily, with today’s advanced rehabilitation services, time, and help from mother nature, many horses will come back from an injury like this.”

Palm Beach Equine Clinic provides experience, knowledge, availability, and the very best care for its clients. Make Palm Beach Equine Clinic a part of your team!

Palm Beach Equine Clinic Offers Advanced Laboratory Facilities to South Florida and Beyond

Wellington, Florida – Palm Beach Equine Clinic (PBEC), based in Wellington, FL, boasts one of the most advanced laboratory facilities in the country with onsite equipment capable of performing internal hematology, chemistry, and microbiology testing, as well as many regenerative therapies. The facilities provide a plethora of services that are not only useful to PBEC veterinarians, but also the many veterinarians who visit South Florida during the winter show jumping, dressage, and polo seasons.

Functions of the PBEC Lab

Coupled with technologically advanced imaging services, state-of-the-art surgical capabilities, and care from renowned veterinarians, PBEC takes pride in their onsite laboratory, which offers vital services to a range of clients providing rapid results.

Most commonly used, hematology is the study of blood, its chemistry, and components. A complete blood count or CBC determines the number and type of white and red blood cells circulating through the bloodstream. This can be quickly and easily performed in PBEC’s onsite laboratory. Changes in these blood cells can indicate inflammation, infection, or disease. Quick diagnosis leads to more proactive and efficient treatment plans.

A clinical chemistry is the study of the chemical composition of a sample. Typically, the liquid portion of blood (either serum or plasma) is used for testing components such as electrolytes, kidney enzymes, and muscle enzymes. The serum or plasma is evaluated to determine the efficiency and health of specific organs.

Finally, microbiology is the study of small organisms such as bacteria, viruses, fungi, and other single-celled life forms. Hundreds of microbiology tests can be performed at PBEC to look for signs of infection. The cultures are used to identify a specific bacteria or fungus present and sensitivity tests are used to determine which treatment, such as an antibiotic, will most effectively treat the infection.

For PBEC veterinarian Dr. Samantha Miles, having an on-site laboratory with many different services enables her to provide faster and more affordable results to her clients and the horses in her care.

“We tend to get results so much faster in our own lab,” said Dr. Miles. “Also, an in-house culture is much less expensive than sending the sample away. It takes 24 hours to run a culture and 24 hours after that for the sensitivity. So usually it takes 48 hours to get a full culture and sensitivity, whereas to send that away you’re looking at least at 72 hours minimum and sometimes it’s a couple days longer than that.”

While laboratory technologies are common in determining a diagnosis and identifying different infections and viruses; they can also be used to more effectively and quickly treat common equine problems such as colic.

“There has been a lot of research lately comparing blood lactate to the abdominal fluid lactate, and the difference being a good indicator of whether a colic is surgical versus medically managed,” said Dr. Miles. “Sometimes it’s obvious, but not always so it is really helpful to have that capability. What we do is test a blood lactate sample using a lactometer, which takes about a minute. If a horse is dehydrated and has a higher lactate in the abdomen, we will rehydrate the horse and take it again. If the lactate value doesn’t decrease after rehydration we have a good indication that it is a real number and there is a surgical problem.”

Regenerative Therapies

According to Dr. Miles, some of the most impressive functions of the PBEC laboratory include its regenerative therapy capabilities, such as stem cells, PRP (platelet rich plasma) and IRAP treatments. These can be applied to previously difficult to manage joint diseases and injuries using natural-occurring proteins, cells, and other natural processes originated from within the body of the horse. Essentially, these treatments use the horse’s own biological mechanisms to stimulate healing without the use of steroids or other drugs.

Stem cells are commonly derived from bone marrow which are cultured and multiplied into millions of stem cells. The cultured stem cells are injected into the affected tendon, ligament, or joint to encourage healing. PRP is another byproduct that is internally sourced from blood platelets in a matter of minutes. The platelets are combined with numerous growth factors that are released upon activation and can enhance healthy inflammatory cells in areas of tissue injury, form new blood vessels, new connective tissue, and aid in the regeneration of skin when injected.

IRAP, stands for Interleukin-1 Receptor Antagonist Protein, is used to treat equine athletes that are susceptible to musculoskeletal injuries and osteoarthritis or degenerative joint disease. Joint trauma results in the release of inflammatory mediators such as Interleukin-1 (IL-1). IRAP uses a horse’s own anti-inflammatory protein found within the blood to counteract the destructive effects of IL-1 to slow the process of osteoarthritis. The process works by binding to the IL-1 receptors in the joint and blocking the continuation of damage and inflammation.

“We often see joint damage in sport horses because of the nature of their work, but we try to avoid overuse of steroids in joints because steroids can have long term effects on cartilage,” said Dr. Miles. “This is a way we can manage joint disease and stop inflammation without having to consistently use steroids every time. Some of our clients will maintain their horses on IRAP alone for joint injections.”

Most recently, PBEC has added a Pro-Stride machine, which is a new up and coming treatment that combines PRP and IRAP treatments, but provides faster results.

Pro-Stride will reduce pain associated with arthritis and deliver anti-inflammatory proteins capable of slowing cartilage damage and improving mobility through the Interleukin-1 Receptor Antagonist Protein. The process can provide pain relief for up to one year following a single injection, which includes 20 minutes of blood processing in the PBEC laboratory with no incubation period.

“I believe we are learning more about these technologies with more advanced science behind what they do and how they do it, “ said Dr. Miles. “These treatments are natural, drug free, competition safe and necessity drives the need for regenerative therapies in the sport horse world.

“It’s all these new regenerative therapies that I think make our lab more state-of-the-art,” continued Dr. Miles. “They set us apart and are also tools that referring vets can make use of. The bottom line is that we have the ability to get horses back significantly faster after injury by using these therapies.”

An Expert Team

The laboratory at PBEC offers 24-hour service with quick and efficient processing of blood work and test results. While veterinarians, or interns under the supervision of a veterinarian, are involved in a lot of the laboratory processing, the PBEC laboratory is also staffed by 24-hour technicians who run blood work at any time day or night. As a result, test results are returned to veterinarians and subsequently horse owners even faster.

“We are lucky enough to have access to the technologies found in the PBEC lab and work with people who have the experience, knowledge, and training to run such an advanced facility,” said Dr. Miles. “We always look forward to welcoming new and returning referring vets to the equipment, technology, and innovation that we have available at PBEC. We take pride in our symbiotic relationship with veterinarians visiting Florida from around the country and the world.”

More About Dr. Samantha Miles

Dr. Samantha Miles is originally from Toronto, Ontario, Canada. She moved to Kansas as a child and completed her undergraduate studies at Kansas State University. In 2015, she graduated from the University of Edinburgh School of Veterinary Studies in Edinburgh, Scotland. She is now a member of the Royal College of Veterinary Surgeons.

Her main interests within veterinary medicine are diagnostic imaging, lameness, rehabilitation, and alternative therapies. Outside of the clinic, she enjoys running, hiking, and travel.

 

The Importance of Correct Farriery During the Intense Show Season Explained by Dr. Stephen O’Grady

Wellington, FL – Palm Beach Equine Clinic (PBEC) of Wellington, FL, proudly offers advanced services to referring veterinarians and clients in equine podiatry with the expertise of Dr. Stephen O’Grady. As the show season continues on, some horses may be experiencing foot soreness or new lameness that could be related to their farriery.

The importance of good quality hoof care in the competition horse can’t be denied. The equine hoof is unique, as it is comprised of a group of biological structures that follow the laws of biomechanics (Figure 1). The farrier is a major asset during the show season as he or she can be proactive in maintaining the health of your horse’s feet and thus preventing lameness.

There are three very important aspects of farriery science that the farrier will use to keep your horse sound, which are trimming the foot in conjunction with the size and placement of the horseshoe. Typically, a farriery session will begin with an evaluation of the conformation of each hoof from the front, side, and behind to observe the height of the heels. Next, the farrier should observe the horse in motion to see whether the horse’s foot lands heel first, flat or toe first. All this information is considered and evaluated before the farrier begins shoeing.

Regarding the trim, many farriers no longer use the term ‘balance the foot’ – which has no meaning – and have begun to use guidelines or landmarks when approaching the trim. The guidelines used are trimming to achieve a straight hoof-pastern axis, using the widest part of the foot which correlates to the center of rotation, and trimming the palmar foot (heels) to the base of the frog or to the same plane as the frog (Figure 2, 3).

A closer look at these three guidelines, which are all interrelated, will help to show their importance. If the dorsal (front) surface of the pastern and the dorsal surface of the hoof are parallel or form a straight line, then the bones of the digit (P1, P2, P3) are in a straight line, and the force from the weight of the horse will go through the middle of the joint. Furthermore, and equally important, if the hoof-pastern axis is straight, the weight will be distributed evenly on the bottom of the foot.

The second guideline is the center of rotation (COR), and as the COR is located a few millimeters behind the widest part of each foot, it allows the farrier to apply appropriate biomechanics to each foot. The foot is trimmed in approximate proportions on either side of the widest part of the foot, which provides biomechanical efficiency.

Lastly, one should trim the palmar section of the foot to the base of the frog or trim such that the heels of the hoof capsule and the frog are on the same plane. Adherence to this guideline keeps the soft tissue structures (frog, digital cushion, ungula cartilages) within the hoof capsule, which are necessary to absorb concussion and dissipate the energy of impact.

We must remember that heels do not grow tall, they grow forward. If we allow the heels to migrate forward, the soft tissue structures will be forced backward out of the hoof capsule. Furthermore, as the heels migrate forward, the weight is placed on the bone and lamellae, thus bypassing the soft tissue structures of the foot. Allowing the heels to migrate forward also decreases the ground surface of the foot. An example of this guideline is shown in Figures 4A & 4B, where the palmar foot was trimmed appropriately and a size larger shoe was applied to properly distribute the weight.

These three guidelines can be applied to any foot and they serve as a basis for maintaining a healthy foot and a basic starting point for applying farriery to a horse with poor foot conformation or one with a distorted hoof capsule. Figures 5A & 5B will illustrate a hoof where all three of these guidelines have been applied.

Many horses are given a rest from competition, which includes their feet, following a heavy competition load such as Wellington’s Winter Equestrian Festival. Many horses arrive with very reasonable foot conformation, but upon arrival the farriery can change and many horses are shod with various specialty shoes, wedges, pads, pour-ins, etc. as a means of protection, and perhaps, to enhance their performance.

As the season progresses and the workload increases, the sole thickness starts to decrease and the feet become softer from multiple baths; now the farriery that was applied for protection may be causing pressure on the thinner, softer structures of the foot, thus becoming somewhat detrimental. Furthermore, the horses continue to be trimmed and shod on a monthly basis and the change in the integrity of the hoof structures without investigating can cause horses to be over-trimmed. Additionally, as the season starts into March, the structures of the foot deteriorate further as a result of the workload, and many horses become foot sore. At this point, the farrier options are limited because they may have been used at the beginning of the season.

Luckily, Palm Beach Equine Clinic offers a farriery consultation service to both veterinarians and farriers. This unique service provides a second opinion or ‘another set of eyes’ to both professions when treating difficult farriery cases for ideas on other options to help these foot sore horses.

Palm Beach Equine Clinic provides experience, knowledge, availability, and the very best care for its clients. To find out more, please visit www.equineclinic.com or call 561-793-1599.

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