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Scilimati N, Pepe M, Pressanto MC, Angeli G, Beccati F. Multimodal Diagnostic Imaging to Identify Septic Apophysitis of the Proximal Humerus in a Thoroughbred Foal. J Equine Vet Sci 2021; 101:103448. [PMID: 33993941 DOI: 10.1016/j.jevs.2021.103448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 03/06/2021] [Accepted: 03/10/2021] [Indexed: 11/19/2022]
Abstract
A 4-month-old Thoroughbred filly was referred for evaluation of severe left forelimb lameness of 24 hours duration. Radiographic projections of the shoulder revealed mild irregularity and sclerosis of the proximal humeral apophysis. Ultrasonographic examination showed a moderate increase in the amount of anechogenic synovial fluid within the intertubercular bursa and scapulohumeral joint, and irregularity of the ossifying bone surface of the intermediate tubercle of the humerus. Computed tomographic (CT) examination revealed a circular hypoattenuating area at the level of the proximal apophysis of the humerus. CT imaging in this case was essential for an early identification of the septic foci and it allowed ultrasound-guided sample from the lesion for the selection of targeted antibiotic therapy.
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Affiliation(s)
- Nicola Scilimati
- Department of Veterinary Medicine, Veterinary Teaching Hospital, University of Perugia, Perugia, Italy.
| | - Marco Pepe
- Department of Veterinary Medicine, Veterinary Teaching Hospital, University of Perugia, Perugia, Italy
| | - Maria Chiara Pressanto
- Department of Veterinary Medicine, Veterinary Teaching Hospital, University of Perugia, Perugia, Italy
| | - Giovanni Angeli
- Department of Veterinary Medicine, Veterinary Teaching Hospital, University of Perugia, Perugia, Italy
| | - Francesca Beccati
- Department of Veterinary Medicine, Veterinary Teaching Hospital, University of Perugia, Perugia, Italy
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Ludwig EK, van Harreveld PD. Equine Wounds over Synovial Structures. Vet Clin North Am Equine Pract 2018; 34:575-590. [DOI: 10.1016/j.cveq.2018.07.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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Woodford NS, Puzio J, Parker RD. Idiopathic infectious arthritis of the coxofemoral joint in a mature horse. EQUINE VET EDUC 2016. [DOI: 10.1111/eve.12527] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
| | - J. Puzio
- Endell Equine Hospital; Salisbury Wiltshire UK
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Meijer MC, Weeren PR, Rijkenhuizen ABM. Streptococcus equi in the fetlock joint of a mature horse. EQUINE VET EDUC 2012. [DOI: 10.1111/j.2042-3292.2001.tb01889.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kay AT, Hunt RJ, Rodgerson DH, Spirito MA, Santschi EM, Payne RJ. Osteomyelitis of the patella in eight foals. Vet Surg 2012; 41:307-15. [PMID: 22225421 DOI: 10.1111/j.1532-950x.2011.00937.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To describe the characteristics of osteomyelitis lesions of the patella and to report short- and long-term outcome after treatment in 8 foals. STUDY DESIGN Retrospective case series. ANIMALS Foals (n = 8). METHODS Medical records (2003-2007) and radiographs of foals that had osteomyelitis of the patella were reviewed. Inclusion criteria included clinical, radiographic, and surgical findings consistent with osteomyelitis of the patella, and a long-term follow-up of >15 months. Information acquired included signalment, hematologic and serum biochemical profile results, clinical and radiographic signs, surgical technique and perioperative treatment. Follow-up radiographs were evaluated and outcome was determined from veterinary examination, race records, and telephone questionnaire. RESULTS Six foals survived long term (15 months-4 years); all had intralesional and systemic antimicrobial therapy, along with synovial lavage and antimicrobial medication. All were sound and achieved either yearling sales (n=3), show hunter or racing (2). Two foals died in the short term from renal failure and suppurative peritonitis secondary to cecal perforation, 1 remaining lame with suppurative osteonecrosis confirmed at necropsy. This foal was not administered intralesional antimicrobial therapy. CONCLUSIONS Prompt medical and surgical therapy for osteomyelitis of the patella can result in a good prognosis for soundness and a potential athletic career. Concurrent septicemia or other systemic perinatal disease can result in prolonged therapy and delayed recovery.
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Ribera T, Monreal L, Armengou L, Ríos J, Prades M. Synovial fluid D-dimer concentration in foals with septic joint disease. J Vet Intern Med 2011; 25:1113-7. [PMID: 21781162 DOI: 10.1111/j.1939-1676.2011.0758.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Increased synovial fibrinolytic activity (detected by increases in synovial D-Dimer concentrations) has been observed in different joint diseases in humans and adult horses, presumably in order to minimize fibrin deposition within the joint and thus avoid its detrimental effects. OBJECTIVE To investigate fibrinolytic pathway activation in joint sepsis in foals by measuring synovial D-Dimer concentrations. ANIMALS Eighteen septic foals with septic joints, 9 septic foals without septic joints, 9 systemically healthy foals with septic joint, and 3 controls are included. METHODS Prospective observational clinical study of foals admitted for septic arthritis. Synovial D-Dimer concentration and routine synovial fluid analysis were performed. Diagnosis of joint sepsis was made whenever synovial total nucleated cell count was >30,000 cells/μL, synovial total protein >4 g/dL, and neutrophil percentage of >80%, or synovial fluid culture resulted positive. Results were compared among groups by general lineal models. RESULTS Synovial D-Dimer concentration was significantly (P < .001) higher in the foals with septic joints compared with foals without joint disease (P < .001). CONCLUSIONS AND CLINICAL IMPORTANCE Septic joint disease is associated with a marked increase of synovial D-Dimer concentration (marked activation of the fibrinolytic activity) within the affected joint. Although further studies are needed, the measurement of synovial D-Dimer concentration may be considered a complementary diagnostic marker of septic joint disease.
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Affiliation(s)
- T Ribera
- Servei de Cirurgia Equina, Universitat Autònoma de Barcelona, Barcelona, Spain.
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Smith LJ, Mellor DJ, Marr CM, Mair TS. What is the likelihood that a horse treated for septic digital tenosynovitis will return to its previous level of athletic function? Equine Vet J 2010; 38:337-41. [PMID: 16866201 DOI: 10.2746/042516406777749155] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
REASONS FOR PERFORMING STUDY Septic digital tenosynovitis is a serious problem in the horse, with a poor prognosis being reported for recovery. HYPOTHESIS The occurrence of septic digital tenosynovitis would significantly reduce the likelihood of a horse returning to its previous level of athletic function. METHODS Medical records of 90 horses treated for septic digital tenosynovitis were reviewed. Data retrieved included age, sex, location of inciting cause of sepsis, time from onset of clinical signs to presentation for treatment, and whether the horse survived to be discharged. Long-term outcome was determined through telephone questionnaires. Univariate analyses of categorical variables were conducted for each outcome. RESULTS Overall, 87.8% of horses (79/90) survived to be discharged from the hospital. Only one factor examined was shown to have a significant effect on outcome. A delay of 1-7 days between onset of clinical signs and presentation for treatment reduced significantly the likelihood of the horse surviving to be discharged from the hospital. Of the horses discharged from the hospital, long-term follow-up was available for 72 horses, with 54.2% (39/72) returning to their previous level of athletic function. CONCLUSIONS Only approximately 50% of horses treated for septic digital tenosynovitis returned to their previous level of athletic function following resolution of synovial sepsis. POTENTIAL RELEVANCE Accurate figures allowing a realistic assessment of the athletic future of a horse following treatment for septic digital tenosynovitis are of value to both the owner and treating veterinarian.
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Affiliation(s)
- L J Smith
- Institute of Comparative Medicine, Faculty of Veterinary Medicine, University of Glasgow, UK
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CRIBB NICOLAC, BOURÉ LUDOVICP, BRAD HANNA WJ, AKENS MARGARETEK, MATTSON SHAWNE, MONTEITH GABRIELLEJ, WEESE JSCOTT. In Vitro and In Vivo Evaluation of Ferric-Hyaluronate Implants for Delivery of Amikacin Sulfate to the Tarsocrural Joint of Horses. Vet Surg 2009; 38:498-505. [DOI: 10.1111/j.1532-950x.2009.00518.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Diagnostic imaging of the equine tarsal region using radiography and ultrasonography. Part 1: The soft tissues. Vet J 2009; 179:179-87. [DOI: 10.1016/j.tvjl.2007.08.030] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2007] [Revised: 08/19/2007] [Accepted: 08/26/2007] [Indexed: 11/24/2022]
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Abstract
Much has been learned in the past decade about osteomyelitis. The inhibitory mechanisms of the "biofilm slime" layer that is formed by bacterial extracapsular exopolysaccharides and binds to bone, joints, and implants are now better understood than in the past. The surface colonization of bacteria that occurs within these biofilms is a biologic phenomenon that is somewhat unique to orthopedic infections. This survival strategy of bacteria is effective, and it is important for veterinarians who treat osteomyelitis to be aware of current diagnostic and therapeutic treatment modalities. The practitioner should be aware of the most common bacteria associated with osteomyelitis and the traditional treatments that are still used. Current therapeutic treatment modalities, such as antibiotic- impregnated polymethylmethacrylate, antibiotic-impregnated plaster of Paris, and regional perfusion, have become routine, however, and have been responsible for improving the prevention and outcome of osteomyelitis in the horse. It is the intent of this article to make equine veterinarians aware of current information as well as the future treatments of osteomyelitis.
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Affiliation(s)
- Laurie R Goodrich
- College of Veterinary Medicine, Colorado State University, 300 West Drake Road, Fort Collins, CO 80523, USA.
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Lescun TB, Vasey JR, Ward MP, Adams SB. Treatment with continuous intrasynovial antimicrobial infusion for septic synovitis in horses: 31 cases (2000–2003). J Am Vet Med Assoc 2006; 228:1922-9. [PMID: 16784387 DOI: 10.2460/javma.228.12.1922] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE-To determine clinical findings, complications, and outcome of septic synovitis in which continuous intrasynovial antimicrobial infusion (CIAI) was used for local antimicrobial delivery in horses. DESIGN-Retrospective case series. Animals-22 adult horses and 9 foals (horses<1 year of age). PROCEDURES-Records of horses with septic synovitis that had CIAI during treatment were reviewed. The association between clinical variables and whether horses performed their intended use following treatment was determined. RESULTS-42 synovial cavities were treated via CIAI. Twenty-nine cases were chronic (>7 days) in nature, 15 had been refractory to standard treatments, and 13 synovial infections had associated osteomyelitis. Mean duration from infection to initiation of CIAI was 19.7 days, and mean duration of CIAI was 6.1 days. Temporary discharge from the catheter site at the time of removal was evident in 8 horses. Dysfunction of the infusion system occurred in 2 horses and was corrected during the course of treatment. No long-term complications were reported. Thirty-nine (93%) synovial infections in 29 (94%) horses were resolved. Twenty adult horses and 8 foals were discharged from the hospital, and 19 of 24 horses with long-term follow-up performed their intended use. CONCLUSIONS AND CLINICAL RELEVANCE-CIAI was a useful adjunctive treatment for septic synovitis and allowed intrasynovial antimicrobial delivery into a variety of synovial cavities.
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Affiliation(s)
- Timothy B Lescun
- Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Purdue University, West Lafayette, IN 47909-1248, USA
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Witte S, Rodgerson DH. What is your diagnosis? Swelling of the soft tissue around the carpal joint. Osteomyelitis of the accessory carpal bone. J Am Vet Med Assoc 2005; 227:551-2. [PMID: 16117061 DOI: 10.2460/javma.2005.227.551] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Stefan Witte
- Davidson Surgery Center, Hagyard Equine Medical Institute, 4250 Iron Works Pike, Lexington, KY 40511, USA
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Pille F, Martens A, Schouls LM, Peelman L, Gasthuys F, Schot CS, De Baere C, Desmet P, Vandenberghe F. Detection of bacterial DNA in synovial fluid from horses with infectious synovitis. Res Vet Sci 2004; 77:189-95. [PMID: 15276769 DOI: 10.1016/j.rvsc.2004.04.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2004] [Indexed: 11/22/2022]
Abstract
Standard culturing techniques are often unrewarding in confirming diagnosis of synovial infection in the equine patient. Several human studies report the use of sensitive polymerase chain reaction (PCR) techniques for the detection of bacterial involvement in acute synovitis. However, successful extraction of bacterial DNA directly from clinical samples from horses without prior culture has not been reported yet. The goal of this study was to develop a sensitive and reliable method for molecular detection and identification of bacterial species in synovial fluid from horses with infectious synovitis. Synovial fluid samples from 6 horses with culture confirmed synovial infection were used for broad range 16S rRNA gene PCR. Synovial aspirates of 2 healthy horses were used as negative controls. Following extraction and purification of synovial fluid DNA, all samples were processed by touchdown PCR. Amplicons were detected by reverse line blot hybridisation and visualised with chemiluminescence. Pathogen-specific detection of 16S rRNA gene sequences was successful in all 6 synovial fluid samples. No bacterial DNA was detected in the aspirates from the negative control horses using touchdown PCR followed by 25 additional cycles of amplification. The identity of the pathogens was confirmed by DNA sequencing of the amplicons. It can be concluded that broad range 16S rRNA gene PCR followed by reverse line blot hybridisation is a promising technique for detection of bacterial DNA in synovial fluid samples. Further research should aim at the detection of bacterial DNA in synovial fluid samples suspected of infection but having negative culture results. When the 16S PCR proves to be reliable and more sensitive than standard culturing techniques, it may become a powerful tool in the diagnosis of synovial infection.
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Affiliation(s)
- F Pille
- Department of Surgery and Anaesthesiology of Domestic Animals, Faculty of Veterinary Medicine, Ghent University, Salisburylaan 133, B-9820 Merelbeke, Belgium.
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Wilmink JM, van Weeren PR. Differences in wound healing between horses and ponies: Application of research results to the clinical approach of equine wounds. ACTA ACUST UNITED AC 2004. [DOI: 10.1053/j.ctep.2004.08.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Wright IM, Smith MRW, Humphrey DJ, Eaton-Evans TCJ, Hillyer MH. Endoscopic surgery in the treatment of contaminated and infected synovial cavities. Equine Vet J 2004; 35:613-9. [PMID: 14515964 DOI: 10.2746/042516403775467225] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
REASONS FOR PERFORMING STUDY Contamination and infection of synovial cavities are a common occurrence in clinical practice and, if inadequately treated, may have career or life threatening consequences for affected horses. HYPOTHESIS The objectives in treating contamination and infection of joints, tendon sheaths and bursae are most effectively met by endoscopic surgery. METHODS Over a 6 year period, cases of synovial contamination and infection admitted to a referral clinic were evaluated and treated endoscopically. The horses received local and systemic antimicrobial drugs with minimal nonsteroidal anti-inflammatory medication but no other medical or surgical treatment. All arthroscope and instrument portals and, whenever possible, all traumatic wounds were closed. Diagnostic information, endoscopic observations and results of treatment were evaluated retrospectively. RESULTS A total of 140 affected animals were referred and 121 cases were treated endoscopically. These involved 70 joints, 29 tendon sheaths, 10 bursae and in 12 cases a combination of synovial cavities. The most common aetiologies were open wounds (n = 54) and self-sealing punctures (n = 41). Foreign material was identified endoscopically in 41 but predicted prior to surgery in only 6 cases. Osteochondral lesions were evident at surgery in 51 and recognised before surgery in 25 cases; 32 horses had intrathecal tendon or ligament defects. Follow-up information was obtained for 118 animals; 106 (90%) survived and 96 (81%) returned to their preoperative level of performance. The presence of osteitis/osteomyelitis, other osteochondral lesions and marked deposits of pannus were associated with nonsurvival. For those animals which survived, non-Thoroughbred horses, a combination of synovial structure involvement and regional i.v. antimicrobial administration were associated with reduced post operative performance. Marked pannus, regional i.v. antimicrobial administration and duration of systemic antimicrobial administration were associated with a group combining nonsurviving animals and those with reduced post operative performance. CONCLUSIONS Endoscopic surgery makes a valuable contribution to the management of synovial contamination and infection. POTENTIAL RELEVANCE The information obtained from and therapeutic options offered by endoscopy justify its early use in cases of synovial contamination and infection.
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Affiliation(s)
- I M Wright
- Reynolds House Referrals, Greenwood Ellis & Partners, 166 High Street, Newmarket, Suffolk CB8 9WS, UK
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Wright I. Arthroscopic surgery in the management of contamination and infection of joints, tendon sheaths, and bursae. ACTA ACUST UNITED AC 2002. [DOI: 10.1053/ctep.2002.35587] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Booth TM, Butson RJ, Clegg PD, Schramme MC, Smith RK. Treatment of sepsis in the small tarsal joints of 11 horses with gentamicin-impregnated polymethylmethacrylate beads. Vet Rec 2001; 148:376-80. [PMID: 11321553 DOI: 10.1136/vr.148.12.376] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Gentamicin-impregnated polymethylmethacrylate beads were used to treat infective arthritis in the small tarsal joints of 11 severely lame horses. Under general anaesthesia, between five and 10 beads were placed into a 7 to 8 mm tract drilled across the affected joint and, in all except one horse, they were left in place for 14 days. Two of the horses were euthanased for reasons other than persistent tarsal joint sepsis, but the other nine survived and seven of them returned to their previous level of athletic performance.
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Affiliation(s)
- T M Booth
- Department of Veterinary Clinical Sciences and Animal Husbandry, Large Animal Veterinary Teaching Hospital, University of Liverpool, Leahurst
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Chan CC, Murphy H, Munroe GA. Treatment of chronic digital septic tenosynovitis in 12 horses by modified open annular ligament desmotomy and passive open drainage. Vet Rec 2000; 147:388-93. [PMID: 11073001 DOI: 10.1136/vr.147.14.388] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
A modified open annular ligament desmotomy followed by passive open drainage was used to treat 12 horses with chronic digital septic tenosynovitis due to trauma in the form of open wounds or self-sealing punctures. The surgical approach included complete transection of the palmar/plantar annular ligament of the fetlock and proximal digital annular ligament, which facilitated the removal of fibrin, selective debridement and synovectomy, followed by lavage of the digital sheath. The incision was partially closed leaving a 2 cm gap open distally to allow for passive open drainage. Gentamicin was administered intrathecally during surgery. Postoperatively the horses received ceftiofur and non-steroidal anti-inflammatory drugs. A sterile bandage was used to protect the wound until the gap had healed completely by second intention. Infection was controlled in 11 of the horses which all returned to their previous levels of work, but one horse was euthanased as a result of the persistence of the infection and financial considerations.
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Affiliation(s)
- C C Chan
- The Ashbrook Equine Hospital, Knutsford, Cheshire
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Meijer MC, van Weeren PR, Rijkenhuizen AB. Clinical experiences of treating septic arthritis in the equine by repeated joint lavage: a series of 39 cases. JOURNAL OF VETERINARY MEDICINE. A, PHYSIOLOGY, PATHOLOGY, CLINICAL MEDICINE 2000; 47:351-65. [PMID: 11008444 DOI: 10.1046/j.1439-0442.2000.00290.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The condition of septic arthritis was treated in 12 foals with 21 affected joints (Group I) and in 27 adult horses. The adult horses were divided into three groups, based on aetiology of the condition: haematogenous (Group II, n = 6), iatrogenic (Group III, n = 6), and perforating trauma (Group IV, n = 15). The treatment consisted of an initial systemic antibiotic that anticipated the microbial agents that were considered most likely per group, repeated through-and-through joint lavages every other day and non-steroidal anti-inflammatory drugs. The antibiotics were adjusted to the results of bacteriological culture and susceptibility tests. Joint lavages were continued until the white blood cell count dropped below 15 G/l and bacteriological culture was negative, after which a single dose of a short-acting corticosteroid was administered intra-articularly. Joint recovery rate in group I was 71%. Patient recovery rate of the foals, however, was lower (42%). Three foals were killed for reasons other than arthritis; one foal because of an arthritis-related problem and three foals because of persistent arthritis. Overall joint recovery rate, equalling patient recovery rate, in the adult horses was 81%. The expected predominance of Streptococcus spp. in haematogenous arthritis in adult horses was not confirmed, indicating that in these cases also, an initial antibiotic treatment with a broad-spectrum combination is preferable. It is concluded that with intensive treatment, the prognosis of septic arthritis in the adult horse can be classified as fair to even good. Results in the foals are not as good, but this seems to be more due to the specific problems surrounding the equine neonate than to unresponsiveness to the treatment.
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Affiliation(s)
- M C Meijer
- Department of Equine Sciences, Faculty of Veterinary Medicine, University of Utrecht, The Netherlands.
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