Retrospective study of 24 cases of septic calcaneal bursitis in the horse

Ultrasonography of the normal donkey tarsus (equus asinus)

Tarsal joint illness is a frequent source of hind limb lameness due to the complex anatomy of the region and the presence of numerous bony and soft tissue structures. Proper lameness diagnosis aims to discover the structure provoking lameness. Ultrasonography documents valuable information of soft tissues and characterizes soft tissue injuries that have heretofore been difficult to obtain either noninvasively or via radiography. The objectives of the current study were to develop and describe a standardized ultrasonographic protocol for investigation of the tarsal region in donkeys. The donkey tarsal anatomy was investigated in 5 cadavers and the tarsi of 11 healthy lameness free adult donkeys were echographically investigated. The dorsal, plantar, lateral and medial aspects of the tarsal region were substantially evaluated at four anatomical landmarks in both the longitudinal and horizontal planes using a multi-frequency 5-12 MHz linear transducer. Sonoanatomy of the extensor and flexor tarsal tendons, collateral and plantar ligaments, and synovial pouches was delineated and described. Systematic echography of the tarsal region allowed accurate localization and thorough exploration of various soft tissues of clinical interest in the donkey tarsus. Sonograms provided in this study should serve as a reference database for tarsal ultrasonography in clinical circumstances.

Regional antibiotic perfusion through the lateral saphenous vein in two horses with septic calcaneal osteitis

In this case report, two horses with chronic refractory infections in the tuber calcanei were successfully managed via intravenous antibiotic regional limb perfusion through the lateral saphenous vein after failure of conventional treatment approaches, including surgery and intravenous regional limb perfusion using the cranial branch of the medial saphenous vein. Surgical delay in these cases may have allowed the development of chronic infection, which prevented the conventional regional perfusion from working effectively. The spatial difference of the vessels relative to the tuber calcanei possibly contributed to the treatment outcome in these horses. This report describes a novel approach for regional antimicrobial perfusion to the equine plantar hock region using the lateral saphenous vein.

Case report: Primary chronic calcaneal bursitis treated with subtotal bursectomy in a cat

A 6-year-old, female spayed Bengal cat with a bodyweight of 6.4 kg was presented with swelling of the bilateral calcaneal region and weight-bearing hindlimb lameness with a 4-month history of unsuccessful conservative therapy. On orthopedic examination, a cyst-like mass around the calcaneal tendon was palpated. Palpating the mass and flexing the tarsal joint triggered pain. Through ultrasonography and magnetic resonance imaging, an inflamed or fluid-accumulated lesion was suspected around the calcaneal tendon, but there was no evidence of calcaneal tendonitis. Swollen calcaneal bursae were removed surgically. Histopathologic examination revealed fibrosis and an edematous feature. The cat was diagnosed with bilateral chronic primary calcaneal bursitis based on history, clinical signs, and diagnostic results. Hence, subtotal bursectomy was performed. At 4 weeks postoperatively, the cat had no pain around the tarsal joints and was ambulating normally. Radiographic and ultrasonographic exams revealed no recurrence of swelling or inflammation in the calcaneal region. Thirteen-month follow-up confirmed acceptable function and no relapse of clinical signs. The inflammation of calcaneal bursa alone can be the primary cause of hindlimb lameness in cats. A cat with hindlimb lameness and swelling on the calcaneal region should be assessed with the possibility of primary calcaneal bursitis. Subtotal calcaneal bursectomy can be considered as an effective treatment for primary chronic bursitis.

A Descriptive Study of the Clinical Presentation, Management, and Outcome of Horses with Acute Soft Tissue Trauma of the Tarsus and the Association with Synovial Involvement

Simple Summary

The hock is commonly involved in traumatic injuries in horses and due to the large number of synovial structures located in the region, this frequently results in synovial infection which is a major and potentially life-threatening complication in horses. The aim of this retrospective study was to describe the clinical presentation, diagnostic procedures, management, and outcome of cases with acute soft tissue trauma to the hock and to identify the clinical features that were associated with synovial infection in these cases. This study found that increased synovial effusion, severe lameness on admission, and the persistence of lameness as well as certain wound locations were more commonly associated with a diagnosis of synovial infection. Advanced diagnostic modalities such as radiographs, ultrasonography, and measurements of inflammatory markers aided in establishing the correct diagnosis. The duration of systemic antimicrobial treatment was shorter than previously reported and many cases received local antimicrobial treatment at the site of injury, which may have improved its efficacy. At the time of discharge, while lameness was still present in some cases, the overall survival was excellent. This study describes the clinical features and treatment of these commonly encountered injuries, and this knowledge may benefit clinicians in the future.

Abstract

The tarsus is one of the most common areas of traumatic injury with associated synovial involvement (SI) in horses. The aim of this retrospective study was to describe the clinical presentation, diagnostic procedures, management (emphasizing the type, duration, and route of antimicrobial administration), and outcome of cases with acute soft tissue trauma to the tarsal region. The presenting clinical features, the results of diagnostic modalities, and the initial response to therapy were assessed for their usefulness to predict SI. Medical records of 72 cases were included and SI was diagnosed in 34 cases (47.2%). Increased synovial effusion, lameness on admission (OR = 4.1; 95%CI 1.0–16.4), persistent lameness (OR = 5.7; 95%CI 1.8–17.9), increased blood SAA values (≥200 mg/L) from initial to second measurement (OR = 4.3; 95%CI 1.2–15.5), and wound location on the plantar/plantarolateral/plantaromedial compared to the lateral aspect of the tarsus (OR = 7.0; 95%CI 1.6–30.9) were associated with SI. Radiographs, ultrasonography, and the use of pressure testing when a wound was present proved to be useful in correctly diagnosing SI. The median duration of systemic antimicrobial administration was 8 (IQR: 5 to 9) days and most horses received local antimicrobial therapy. This study highlights several relevant clinical features and their association with SI and emphasizes the usefulness of local antimicrobial therapy in these cases.

A scoping review of the current evidence on treatment and outcomes following synovial sepsis

BACKGROUND

Synovial sepsis is a frequent cause of morbidity and mortality in horses. Despite advances in diagnostics and treatments, persistent infection or chronic lameness can occur.

OBJECTIVES

To perform a scoping review to identify and evaluate the current evidence on the factors implicated in the success of treatment for synovial sepsis.

STUDY DESIGN

Joanna Briggs Institute scoping review.

METHODS

A protocol was registered, and a systematic literature search was performed on CAB abstracts, Medline, Scopus and Embase. Inclusion and exclusion criteria were developed and studies systematically reviewed against this. Studies relating to factors affecting treatment success following synovial sepsis were retained and data was extracted on study method, population characteristics and factors significantly associated with treatment outcome.

RESULTS

In total, 2338 studies were identified, and 61 were included to full paper analysis. Eight papers reported significant factors, identifying 15 risk factors associated with two measurements of outcome, either survival and/or return to athletic function. The 15 factors were identified and categorised into pre-, intra- and post-operative factors. Risk factors that were identified included the number or type of synovial structures involved, the presence of pannus, tendon and bone pathology, and the use of systemic antimicrobials. There were many discrepancies in inclusion criteria of cases of synovial sepsis as well as measurement and description of outcome variables.

MAIN LIMITATIONS

Non-English language studies or conference proceedings were not included. Only small numbers of papers had similar findings.

CONCLUSIONS

Standardisation of inclusion criteria is essential to enable comparisons and analysis between studies on synovial sepsis. Future studies should use methodologies to reduce bias including multicentre and multinational studies, prospective study design and robust statistical modelling.

Retrospective Evaluation of Septic Subtendinous Calcaneal Bursitis in 29 Cattle

Simple Summary

Infections of the subtendinous calcaneal bursa (SCB) in cattle are mainly caused by pressure sores and directly penetrating wounds. We describe the clinical, ultrasonographic and radiographic findings and outcomes in cattle diagnosed with this condition, including postoperative complications and postoperative survival times. Medical records of 29 cattle with a mean age of 4.1 years were reviewed. Twelve animals (41.4%) showed septic inflammation of the SCB only (group 1) and 17 cattle (58.6%) had a concurrent bone infection at the calcaneal tuber (group 2). Eleven cattle (37.9%) were euthanized after diagnosis due to poor prognosis. Eighteen (62.1%) patients underwent surgical treatment and 15 cattle attained full recovery with a median cumulative postoperative survival time of 23.0 months. Surgically treated patients of group 1 had a success rate of 100%, compared with 70% in group 2. Group 2 cattle with septic inflammation of the SCB and concurrent bone infection had more postoperative complications and tended to have shorter postoperative survival times. In conclusion, cattle exclusively suffering from septic SCB and treated by surgery had a good prognosis.

Abstract

Septic subtendinous calcaneal bursitis in cattle commonly results from hock lesions, and less commonly from penetrating wounds. The goal of this retrospective study was to describe clinical and diagnostic imaging findings, outcomes, postoperative complications and postoperative survival times (SURV-T) in cattle with this condition. Clinical data from 29 cattle with a mean age of 4.1 years were included. Twelve (41.4%) cattle were assigned to group 1 (septic bursitis only) and 17 (58.6%) to group 2 (septic bursitis, concurrent bone infection at the calcaneal tuber (CT) and lesions of the superficial digital flexor tendon. Eleven cattle (37.9%) with comorbidities were euthanized after diagnosis due to poor prognosis. Surgical treatment was performed in 18 (62.1%) patients of which 15 showed full recovery and a median cumulative SURV-T of 23.0 months. The success rate of surgically treated patients was 100% (8/8) in group 1 and 70% (7/10) in group 2. There was no statistically significant association (p > 0.05) between the duration of septic bursitis and concurrent bone infection at the CT with occurrence of postoperative complications and SURV-T. However, there was a clear trend favoring more postoperative complications and shorter SURV-T in cattle with concurrent CT bone infection. In conclusion, cattle with septic subtendinous calcaneal bursitis exclusively have a good prognosis, provided adequate surgical treatment is performed.

Factors Associated With Survival and Return to Function Following Synovial Infections in Horses

Synovial infections (SI) are common in horses of all ages and can be associated with high rates of morbidity and mortality. Identifying factors influencing survival and return to function may be useful for management of affected individuals and determination of prognosis. The objectives of this study were to identify factors associated with survival and return to function of horses and foals with SI presented to an equine hospital. This study is a retrospective case series. Data were collected from medical records of all horses with SI that were presented to a single equine hospital between April 1st, 2008 and May 1st, 2017. Long–term follow up was obtained by a semi-structured telephone questionnaire of clinical outcomes and analysis of online race records. Univariate models were created using generalized linear and linear mixed models to assess factors associated with outcomes. Multivariable models were created using generalized linear and linear mixed models to determine factors significantly associated with outcomes. Of 186 horses presented with SI, 161/186 (86.6%) were treated and 145/161 (90.1%) survived to discharge. The majority of joints were treated with synovial lavage (93.8%). One hundred and twenty horses were included in the return to function analysis and 79 (65%) returned to function. Increasing number of days of treatment with systemic antimicrobials was associated with increased likelihood of survival for each horse (OR 1.15, 95% CI 1.04−1.27, P = 0.025) and when considering each individual synovial structure (OR 1.11, 95% CI 1.04−1.17, P = 0.004). Horses treated with doxycycline were less likely to return to function (OR 0.39, 95% CI 0.19−0.8, P = 0.031). The overall rate of survival of horses treated with SI is good. The likelihood of return to function is lower than for survival. The findings of this study, combined with relevant antimicrobial stewardship practices, can be used as a part of evidence-based decision-making when veterinarians are treating horses with SI.

A multi-centre cohort study investigating the outcome of synovial contamination or sepsis of the calcaneal bursae in horses treated by endoscopic lavage and debridement

Background

Previous studies investigating factors associated with survival following endoscopic treatment of contamination/sepsis of the calcaneal bursa are limited.

Objectives

To investigate the factors associated with survival in horses with contamination/sepsis of the calcaneal bursae treated endoscopically and to describe the bacterial isolates involved in the synovial infections.

Study design

Retrospective analysis of clinical records.

Methods

Medical records from 128 horses with contamination/sepsis of the calcaneal bursae treated by endoscopic lavage at seven equine hospitals were reviewed. A follow‐up questionnaire was used to determine survival and return to athletic performance. Descriptive statistics and Cox proportional hazards survival models were used to determine factors associated with survival.

Results

Horses underwent one (n = 107), two (n = 19), or three (n = 2) surgeries. Survival to hospital discharge was 84.4%. Univariable survival analysis revealed that administration of systemic antimicrobials prior to referral was associated with reduced mortality (hazard ratio, [HR] 0.41, 95% CI 0.18–0.91, P = 0.03). Increased mortality was associated with bone fracture/osteomyelitis (HR 2.43, 95% CI 1.12–5.26, P = 0.03), tendon involvement (≥30% cross sectional area) (HR 3.78 95% CI 1.78–8.04, P = 0.001), duration of general anaesthesia (HR 1.01, 95% CI 1.00–1.02, P = 0.04), post‐operative synoviocentesis (HR 3.18, 95% CI 1.36–7.43, P = 0.006) and post‐operative wound dehiscence (HR 2.5, 95% CI 1.08–5.65, P = 0.04). Multivariable Cox proportional hazards model revealed reduced mortality after systemic antimicrobial administration prior to referral (HR 0.25, 95% CI 0.11–0.60, P = 0.002) and increased mortality with tendinous involvement (≥30% cross‐sectional area) (HR 7.92, 95% CI 3.31–19.92, P<0.001). At follow‐up (median 30 months, range 0.25–13 years, n = 70) 87.1% horses were alive, 7.1% had been euthanised due to the calcaneal injury and 5.7% had been euthanised for unrelated reasons. From 57 horses with athletic performance follow‐up, 91.2% returned to the same/higher level of exercise, 5.3% to a lower level and 3.5% were retired due to persistent lameness of the affected limb.

Main limitations

Retrospective study and incomplete follow‐up.

Conclusion

Endoscopic treatment of contamination/sepsis of the calcaneal bursae has an 84% survival rate to hospital discharge. Tendinous involvement reduced survival whilst systemic antimicrobials administration prior to referral improved survival.

Clinical findings and management of six horses with subtendinous bursitis of the long digital extensor tendon in the hind limb fetlock

OBJECTIVE

To describe the history, clinical signs, and management of six horses in which subtendinous bursitis of the long digital extensor tendon (LDET) in the hind limb fetlock had been diagnosed.

STUDY DESIGN

Retrospective case series.

SAMPLE POPULATION

Six privately owned horses.

METHODS

The medical records of horses presented at the hospital with similar sypmtoms were evaluated and collected. Finally 6 horses met the inclusion criteria and the relevant data were compiled and analysed. In three of the six cases a surgical treatment was carried out.

RESULTS

All horses had similar clinical signs, mainly distention beneath the long digital extensor tendon (LDET) at the level of the hind limb fetlock without associated lameness; the major issues were the presence of cosmetic defects and concern about their functional use in the future. Three of the six horses were treated surgically with bursoscopic debridement. The cosmetic results were excellent in two of these three horses. One horse that underwent an operation experienced a recurrence. None of the horses with bursitis treated medically experienced resolution of the problem.

CONCLUSION

Bursoscopy is a technique to consider for the management of bursitis of the LDET at the level of the fetlock combined with prolonged bandage application when medical treatment has failed to manage the condition.

CLINICAL SIGNIFICANCE

To the best of our knowledge, subtendinous bursitis of the LDET in the hind limb is not a commonly diagnosed condition. This small case series provides some insight into methods for the clinical management of this issue.

Wound Management: Wounds with Special Challenges

Distal limb wounds in horses heal substantially different than trunk wounds, commonly resulting in exuberant granulation tissue and exposed and sequestered bone. Surgical intervention of severe rectovaginal lacerations in the mare should be delayed until the tissues have heeled and scar tissue has remodeled. Wounds resulting in severe hemorrhage require appropriate emergent fluid therapy and potentially transfusion therapy.

Clinical use of antimicrobial regional limb perfusion in horses: 174 cases (1999-2009)

OBJECTIVE

To describe the clinical use of regional limb perfusion with antimicrobials (A-RLP), complications, and outcome in a large series of patients.

DESIGN

Retrospective case series.

ANIMALS

174 horses.

PROCEDURES

Medical records of horses treated with A-RLP between 1999 and 2009 were reviewed. Signalment, primary complaint, horse use, etiology, duration of clinical signs, previous treatment, structures involved, concurrent conditions, A-RLP characteristics, additional treatments, complications, and outcome were recorded. At long-term follow-up, 2 outcomes were investigated: survival rate and return to previous use at the same or higher level. Univariate and multivariate logistic regression analyses were conducted.

RESULTS

Group 1 (96 horses) included septic synovitis. Group 2 (50 horses) included extrasynovial lacerations (23 horses) and fresh, minimally contaminated intrasynovial lacerations without evidence of established synovial infection (27 horses). Group 3 (28 horses) included miscellaneous other conditions. Only minor complications were reported in 12.26% of horses that received IV (n = 155) and 33% of horses that received intraosseous (27) A-RLP. Horses with septic synovitis had a lower survival rate (53.43%) than did horses with lacerations (91.89%). Within group 2, no significant differences in short- or long-term outcomes were found between horses with extrasynovial and fresh, minimally contaminated intrasynovial lacerations. For the horses returning to previous use, 80% of horses with septic synovitis and 72.72% of horses with lacerations were performing at the same or higher level at the time of follow-up.

CONCLUSIONS AND CLINICAL RELEVANCE

The results of the present study indicated that A-RLP is a safe technique with minimal adverse effects. The IV route presented fewer complications than intraosseous injection. Horses with infection of synovial structures had a lower survival rate than did those with acute, minimally contaminated intrasynovial lacerations. The latter had a similar prognosis for horses with extrasynovial lacerations treated with A-RLP.

Injuries of the calcaneal insertions of the superficial digital flexor tendon in 19 horses

REASONS FOR PERFORMING STUDY

Injuries of the calcaneal insertions of the superficial digital flexor tendon and their relationship to displacement of the tendon from the calcaneus have not previously been reported.

OBJECTIVES

To describe findings made on clinical cases with disruption of the calcaneal insertions of the superficial digital flexor tendon (SDFT) including observations on their role in horses with unstable subluxation of the tendon. To describe novel surgical techniques and the results of treatment.

HYPOTHESES

Disruption of the calcaneal insertions of the SDFT is associated with lameness and distension of the calcaneal bursa. Unstable displacement of the SDFT from the calcaneus is a more complex injury than incomplete disruption of one of its calcaneal insertions.

METHODS

The case records and diagnostic images of horses with lesions involving the calcaneal insertions of the SDFT, which were confirmed by endoscopic evaluation of calcaneal bursa between 2005 and 2009, were reviewed.

RESULTS

Nineteen horses were identified including 7 that had unstable displacement of the tendon from the calcaneus. Following endoscopic surgery, 9 of 12 horses with stable tendons and 6 of 7 horses with unstable displaced SDFTs returned to work.

CONCLUSION

Tearing of the calcaneal insertions of the SDFT is associated with lameness and distension of the calcaneal bursa; endoscopic removal of the torn tissue carries a good prognosis. Horses with unstable displacement of the tendon have also disruption of the tendon fibrocartilage cap. Removal of this results in stable subluxation and can return horses to athletic activity. Both lesions can be detected by preoperative ultrasonography.

POTENTIAL RELEVANCE

Tearing of the calcaneal insertions of the SDFT should be included in the differential diagnoses of lame horses with distended calcaneal bursae. Tearing of the tendon fibrocartilage cap in horses with unstable displacement of the SDFT is a plausible explanation of the clinical features of the injury and explains previously unreliable results of reconstructive surgeries. Subtotal resection is a technically demanding technique but appears to offer an improved prognosis.

An anatomic study of the calcaneal bursae in the horse

OBJECTIVES

To establish an injection site for the gastrocnemius calcaneal bursa (GCB), to identify communication patterns between the calcaneal bursae, to estimate the proximal and distal extents of the intertendinous calcaneal bursa (ICB) and to identify variations from previous anatomic descriptions.

STUDY DESIGN

Descriptive anatomic study.

ANIMALS

Cadaveric equine hindlimbs (n=18) from 9 adult horses.

METHODS

Communication between the ICB and GCB was determined in 18 cadaveric hindlimbs by injection of a latex mixture, followed by examination of sequential sagittal sections and documentation of the distribution of the latex mixture and communication sites. The distal and proximal extents of the ICB and subcutaneous calcaneal bursa (SCB), relative to the tuber calcanei (TC) were recorded.

RESULTS

Communication between the ICB and the GCB was confirmed on the medial and lateral aspect in 100% and 50% of limbs, respectively. Communication between the SCB and the ICB, and therefore the GCB, was identified in 39% of limbs. Plantar reflections of the ICB existed in 33% of limbs. Mean extent of the ICB relative to the TC was 7.0 cm distally and 9.6 cm proximally. The SCB often occupies a more distal position than previously reported.

CONCLUSIONS

The ICB and the GCB should be considered 1 synovial structure with 2 communicating compartments.

CLINICAL RELEVANCE

The GCB may be an alternative site for synoviocentesis when there is septic calcaneal bursitis. Improved knowledge of calcaneal bursae anatomy may aid in diagnosis and treatment of lesions involving these structures.

Osseous lesion of the calcaneus following the use of shock wave therapy in a horse

An 8-year-old Dutch warmblood gelding was presented with a mechanical lameness (2/10) because of the presence of a soft tissue injury on the top of the right tuber calcanei. Plain radiographs of the tarsus demonstrated the presence of soft tissue swelling caudal to the right tuber calcanei, without osseous involvement, and ultrasonography revealed excessive scar tissue within and around the superficial digital flexor tendon. Extra-corporeal shock wave therapy was applied on the right hock to decrease the amount of scar tissue. One month after the therapy the lameness was greater (3/10) and a marginal increase in the size of the swelling was found. Periosteal new bone formation associated with an ill-defined radiolucent area and two bony fragments were detected radiographically at the caudo-proximal aspect of the right tuber calcanei. A blister containing oil of croton, camphor, pine and thyme, turpentine and cantharides was applied on the right calcaneus. Twenty days after blister application, the size of the swelling had been reduced by 50% and the degree of lameness had also been decreased (1/10). On clinical re-evaluation 6 months after treatment, the degree of lameness was stable (1/10) and flexion test of the limb was negative.