Racing performance of Thoroughbred racehorses with suspensory ligament branch desmitis treated with mesenchymal stem cells (2010-2019)

BACKGROUND

Suspensory ligament branch desmitis (SLBD) is a common injury in Thoroughbred racehorses. Orthobiologic treatment of these injuries is a relatively new approach, and there is limited information available on post injury racing performance in racehorses treated with mesenchymal stem cells (MSCs).

OBJECTIVES

To assess racing performance post injury in Thoroughbred racehorses with SLBD treated with MSCs.

STUDY DESIGN

Retrospective case series.

METHODS

Medical records of racehorses with SLBD treated with MSCs from 2010 to 2019 were reviewed. All horses were treated with allogeneic stem cells injected locally at the time of diagnosis and subsequently received 3-4 treatments with autologous bone-marrow derived MSCs. Ultrasonographic and radiographic images were evaluated to determine the degree of suspensory branch injury and sesamoiditis of the associated proximal sesamoid bone. Race performance was assessed by career length, class of races, number of starts and earnings post injury. Race performance of horses that raced pre and post injury were compared.

RESULTS

Of 69 treated horses, 71% (49/69) [95% CI: 59%-81%] raced post injury. Horses that had raced pre injury were more likely to race post injury (90% [18/20]) than horses that did not race pre injury (63% [31/49]; p = 0.03). Females were less likely to race post injury than males (52% [11/21] vs. 79% [38/49], respectively; p = 0.02). In the 18 horses that raced pre and post injury, the number of races, earnings and earnings per start were not significantly different pre and post injury. The average career length of all horses that raced post injury was 29.5 months.

MAIN LIMITATIONS

Retrospective study design and lack of controls.

CONCLUSIONS

Treatment with MSCs resulted in a majority of Thoroughbred racehorses with SLBD racing post treatment. Racing pre injury and being male was positively associated with racing post injury.

Navicular bone fracture and severe deep digital flexor tendinopathy after palmar digital neurectomy in two horses

Background

Navicular syndrome is a common cause of forelimb lameness in horses. Beyond changes to the navicular bone itself, horses with a clinical diagnosis of navicular syndrome often have pathology associated with other components of the navicular apparatus, including the navicular bursa, deep digital flexor (DDF) tendon, collateral sesamoidean ligaments, and impar ligament. Palmar digital neurectomy (PDN) is often used as a salvage procedure for horses diagnosed with navicular syndrome that become unresponsive to medical management. There are many potential complications associated with PDN, some of which are debilitating.

Case Description

This report describes two cases of navicular bone fracture with severe DDF tendinopathy and distal interphalangeal joint subluxation/hyperextension that occurred 12 and 19 weeks after bilateral forelimb PDN.

Conclusion

These two cases highlight the importance of proper patient selection before PDN due to the high incidence of undiagnosed soft tissue pathology in conjunction with radiographic evidence of navicular syndrome. Advanced imaging of the digit is recommended to identify and characterize any soft tissue pathology associated with the navicular apparatus before pursuing PDN to avoid disease progression and catastrophic injury.

Percutaneous ultrasonic debridement of equine tendinopathy and desmopathy: A report of 10 cases

Background

Tendinopathy and desmopathy are significant causes of morbidity in horses.

Aim

To evaluate the use of percutaneous ultrasonic debridement (PUD) as a treatment for chronic tendinopathy and desmopathy in the horse.

Methods

Eight adult horses with 10 affected limbs presented for lameness, ranging from 60-700 days postinjury. Diagnostic ultrasound identified the following: suspensory branch desmitis (n = 1), suspensory body desmitis (n = 2), Achilles tendinopathy (n = 1), desmitis of the accessory ligament of the deep digital flexor (DDF) tendon (n = 1), DDF tendinopathy (n = 2), and superficial digital flexor tendinopathy (n = 3). All horses had demonstrated lameness ranging from grade 1 to 4 [American Association of Equine Practitioners (AAEP) scale], with a mean pretreatment grade of 2.7. All horses underwent PUD using the Tenex Health TX® System.

Results

Follow-up results were available from 6 to 41 months (mean, 23.2 months). Follow-up ultrasound imaging demonstrated improvement in fiber alignment and architectural change in all cases. All horses had a reduction in lameness from the treated tendon or ligament (AAEP grade 0-1; mean AAEP grade, 0.2) following a single treatment; lameness completely resolved in 8 of 10 treated limbs. No adverse events occurred in any case. No horses in this study developed a recurrence of their original lesion.

Conclusion

Horses in this study demonstrated improvement following the PUD procedure. The procedure was well-tolerated and safe. Removal of tendinopathic scar tissue with PUD resulted in a return to function and without recurrence of the original lesion in all horses.

Fast, non-eccentrically loaded exercise worsens tendinopathic healing responses in a murine model

OBJECTIVE

To advance the understanding of how alterations in exercise speed and grade (flat vs 17° incline or decline) affect the quality of tendon healing, and to determine if a biomarker relationship exists between serum levels of a ColX breakdown product (CXM) and animals exposed to treadmill running protocols.

ANIMALS

35 male mice (C57BL/6J), 8 weeks of age.

PROCEDURES

Mice were preconditioned on a treadmill for 14 days. Tendinopathy was then induced by 2 intra-tendinous TGFβ1 injections followed by randomization into 7 exercise groups. Exercise capacity and objective gait analysis were measured weekly. Mice were euthanized and histopathologic analysis and evaluation of serum CXM levels were performed. Statistics were conducted using a 2-way ANOVA (exercise capacity), Mixed Effects Model (gait analysis, effect of preconditioning), and 1-way ANOVA (gait analysis, the effect of injury, and rehabilitation normalized to baseline; CXM serum analysis), all with Tukey post hoc tests and significance set to P < .05.

RESULTS

Exercise at a fast-flat speed demonstrated inferior tendinopathic healing at the cellular level and impaired stance braking abilities, which were compensated for by increased propulsion. Mice exposed to exercise (at any speed or grade) demonstrated higher systemic levels of CXM than those that were cage rested. However, no ColX immunostaining was observed in the Achilles tendon or calcaneal insertion.

CLINICAL RELEVANCE

Exercise at a fast speed and in absence of eccentric loading components (incline or decline) demonstrated inferior tendinopathic healing at the cellular level and impaired braking abilities that were compensated for by increased propulsion.

Intralesional bone marrow and superior check desmotomy is superior to conservative treatment of equine superficial digital flexor tendonitis

BACKGROUND

Superficial digital flexor tendon (SDFT) injury is common in racehorses and a significant cause of lost training days and wastage in the industry.

OBJECTIVES

To compare the post-injury performance of Thoroughbred and Standardbred racehorses diagnosed with SDFT tendonitis treated with intralesional bone marrow and superior check desmotomy or managed conservatively and further to compare this performance with that of uninjured racehorses.

STUDY DESIGN

Retrospective and case-controlled.

METHODS

Medical and race records of racehorses treated surgically or managed conservatively for SDFT tendonitis were collated. Signalment, lesion severity and treatment were identified and performance post-injury compared. Performance of the treatment groups was further assessed by comparison with uninjured racehorses matched for age, sex, number of starts pre-injury and randomly selected from the cases' last races.

RESULTS

The study population comprised 114 racehorses divided into surgical (39/114), conservative (38/114) and control groups (37/114). Horses that had surgery were more likely to return to racing than those managed conservatively (OR 4.7 95% CI [1.6-14.3], P = .006). Standardbreds were more likely to return to race compared with Thoroughbreds (OR 4.0 95% CI [1.2-13.3], P = .03). There was no statistically significant difference in the average number of placings, average number of wins and post-injury earnings between the surgically treated and conservatively managed groups (P = .9, P = .9 and P = .7, respectively). The average number of lifetime starts post-injury/post-selection between surgery, conservative and control groups were not statistically significantly different (P = .2). Surgically treated horses had a statistically significantly shorter time to start post-injury compared with the conservative group (P = .04).

MAIN LIMITATIONS

The retrospective nature of the study precludes an actual fit as a nonrandomised clinical trial and the nonrandomised nature of the allocation of the treatment groups is biased.

CONCLUSIONS

Surgical intervention of superficial digital flexor tendonitis in racehorses suffering flexor tendon injury showed a higher likelihood of return to racing than conservative treatment.

Use of non-contrast-enhanced computed tomography to identify deep digital flexor tendinopathy in horses with lameness: 28 cases (2014-2016)

OBJECTIVE

To describe the use of non-contrast-enhanced CT to identify deep digital flexor (DDF) tendinopathy in horses with lameness attributed to pain in regions distal to the metatarsophalangeal or metacarpophalangeal joints.

DESIGN

Retrospective case series.

ANIMALS

28 client-owned horses.

PROCEDURES

Medical records were searched to identify horses that underwent non-contrast-enhanced CT with or without high-field MRI as part of an evaluation for lameness localized to areas distal to the metacarpophalangeal or metatarsophalangeal joint in ≥ 1 limb. Horses were included in the study if they had ≥ 1 DDF tendon lesion (DDF tendinopathy) identified. Signalment, lameness examination findings and response to perineural anesthesia, imaging modality, anesthetic agents and duration of anesthesia, and imaging findings were recorded. Data were summarized descriptively.

RESULTS

Bilateral imaging was performed for all horses, irrespective of unilateral or bilateral lameness. Nine of 28 horses underwent both CT and MRI, and all DDF tendon lesions identified by one modality were identified by the other. Of 48 limbs with DDF tendinopathy, 46 (96%) had core lesions and 35 (73%) had dorsal border irregularities. Median anesthesia time for CT and CT followed by MRI was 15 and 110 minutes, respectively.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggested that non-contrast-enhanced CT was useful for identifying DDF tendinopathy in horses with lameness localized to the phalangeal regions, and this was supported by consistency of findings in a subset of horses that underwent MRI. Further research is needed to confirm these results.

Randomized controlled trial demonstrates the benefit of RGTA® based matrix therapy to treat tendinopathies in racing horses

A randomized controlled trial was performed on racing horses, to evaluate the efficacy of a new class of therapeutic agents in regenerative medicine—ReGeneraTing Agents^® (RGTA^®), to treat tendinopathies. Preliminary uncontrolled studies on tendon healing in racing horses with RGTA^® (OTR4131)—Equitend^® showed encouraging results, justifying performing a randomized, controlled, multicenter study with a two-year racing performance follow up. The objective of this study was to evaluate the effect of Equitend^® versus placebo on acute superficial digital flexor tendonitis in racing French Standardbred Trotters (ST). Twenty-two ST were randomly and blindly assigned to receive with a ratio of 2 to 1, a single Equitend^® (n = 14) or placebo (n = 8) intralesional injection under ultrasonographic guidance. Horses were evaluated over 4 months, by clinical and ultrasonographic evaluations (day 0, months 1, 2, 4), and their racing performances followed up over the 2 years after treatment. During the first month of treatment, a significant decrease in the cross-sectional area (CSA) was found in the Equitend^® group (p = 0.04). After 4 months, the number of Equitend^® treated horses with an improved CSA was significantly higher than the placebo-treated horses (p = 0.03571). The Equitend^® group returned to their pre-injury performance level, racing in, and winning, significantly more races than the placebo group (p = 0.01399 and 0.0421, respectively). Furthermore, recurrence was significantly higher in the placebo group than in the Equitend^® group (71.4% vs 16.6%, p = 0.02442). In conclusion, we measured a significant, short-term, reduction effect on CSA and demonstrated a long-term beneficial effect of intralesional injection of Equitend^® for the treatment of superficial digital flexor tendonitis on racing ST, racing 2. 3 times more often than placebo, with 3.3 times fewer recurrences maintaining pre-injury performance level. This study may open the way for the development of a human treatment of tendonitis.

Effect of track surface firmness on the development of musculoskeletal injuries in French Trotters during four months of harness race training

OBJECTIVE To evaluate the effect of track surface firmness on the development of musculoskeletal injuries in French Trotters during 4 months of race training. ANIMALS 12 healthy 3-year-old French Trotters. PROCEDURES Horses were paired on the basis of sex and body mass. Horses within each pair were randomly assigned to either a hard-track or soft-track group. The counterclockwise training protocol was the same for both groups. Surface firmness of each track was monitored throughout the training period. Radiography, ultrasonography, MRI, and scintigraphy were performed on all 4 limbs of each horse before and after 2 and 4 months of training. Lesions were described, and lesion severity was classified with a 5-point system, where 0 = no lesions and 4 = severe lesion. RESULTS 86 lesions were identified, of which 46 (53.5%) were classified as potentially clinically relevant (grade, ≥ 2). Of the 18 moderate and severe lesions, 15 were identified in horses of the hard-track group, and 10 of those were in forelimbs. Moderate to severe tendinopathy of the superficial digital flexor tendon of the forelimb developed in 3 of the 6 horses of the hard-track group but none of the horses of the soft-track group. Metatarsal condyle injuries were more frequent in horses of the hard-track group than horses of the soft-track group. Severe lesions were identified only in left limbs. CONCLUSIONS AND CLINICAL RELEVANCE Results indicated that track surface firmness is a risk factor for musculoskeletal injuries in horses trained for harness racing.

Single ultrasound-guided platelet-rich plasma injection for treatment of supraspinatus tendinopathy in dogs

The effect of a single platelet-rich plasma injection for supraspinatus tendinopathy was assessed in 10 dogs. Subjective (owner-assessed) improvement in lameness and function were seen in 40% of dogs with improved tendon heterogeneity and echogenicity in 60%. There were no significant changes in gait reaction forces 6 wk after treatment.

Focal experimental injury leads to widespread gene expression and histologic changes in equine flexor tendons

It is not known how extensively a localised flexor tendon injury affects the entire tendon. This study examined the extent of and relationship between histopathologic and gene expression changes in equine superficial digital flexor tendon after a surgical injury. One forelimb tendon was hemi-transected in six horses, and in three other horses, one tendon underwent a sham operation. After euthanasia at six weeks, transected and control (sham and non-operated contralateral) tendons were regionally sampled (medial and lateral halves each divided into six 3 cm regions) for histologic (scoring and immunohistochemistry) and gene expression (real time PCR) analysis of extracellular matrix changes. The histopathology score was significantly higher in transected tendons compared to control tendons in all regions except for the most distal (P ≤ 0.03) with no differences between overstressed (medial) and stress-deprived (lateral) tendon halves. Proteoglycan scores were increased by transection in all but the most proximal region (P < 0.02), with increased immunostaining for aggrecan, biglycan and versican. After correcting for location within the tendon, gene expression for aggrecan, versican, biglycan, lumican, collagen types I, II and III, MMP14 and TIMP1 was increased in transected tendons compared with control tendons (P < 0.02) and decreased for ADAMTS4, MMP3 and TIMP3 (P < 0.001). Aggrecan, biglycan, fibromodulin, and collagen types I and III expression positively correlated with all histopathology scores (P < 0.001), whereas lumican, ADAMTS4 and MMP14 expression positively correlated only with collagen fiber malalignment (P < 0.001). In summary, histologic and associated gene expression changes were significant and widespread six weeks after injury to the equine SDFT, suggesting rapid and active development of tendinopathy throughout the entire length of the tendon. These extensive changes distant to the focal injury may contribute to poor functional outcomes and re-injury in clinical cases. Our data suggest that successful treatments of focal injuries will need to address pathology in the entire tendon, and that better methods to monitor the development and resolution of tendinopathy are required.

Clinical and diagnostic imaging characteristics of lateral digital flexor tendinitis within the tarsal sheath in four horses

Lateral digital flexor tendonitis is a rarely reported cause of hind limb lameness in performance horses. The purpose of this retrospective study was to describe clinical and diagnostic imaging findings for a group of horses with lateral digital flexor tendinitis within the tarsal sheath. Equine cases with a diagnosis of lateral digital flexor tendonitis and magnetic resonance imaging (MRI) studies of the affected region were retrieved from North Carolina University’s medical record database. Recorded data for included horses were signalment; findings from history, physical examination, lameness examination, and all diagnostic imaging studies; treatment administered; and outcome. Four horses met inclusion criteria. Lameness was mild/moderate in severity and insidious in onset in all patients. Responses to flexion tests were variable. All horses showed positive improvement(70–90%) in lameness after tarsal sheath analgesia. Radiographic, scintigraphic, and ultrasonographic findings were inconclusive. For all horses, MRI characteristics included increased T2, PD, and STIR signal intensity within the lateral digital flexor tendon in the area of the tarsal sheath. Tarsal sheath effusion was slight in three horses, and mild/moderate in one horse. With medical treatment, two horses were sound at 6-month follow up, one horse was sound at 1-year followup, and one horse had a slight persistent lameness (grade 1/5) at 9-month followup. Findings supported the use of MRI for diagnosing lateral digital flexor tendonitis within the tarsal sheath in horses. Affected horses may have a good prognosis for return to athletic performance following appropriate medical treatment.

Beneficial effects of autologous bone marrow-derived mesenchymal stem cells in naturally occurring tendinopathy

Tendon injuries are a common age-related degenerative condition where current treatment strategies fail to restore functionality and normal quality of life. This disease also occurs naturally in horses, with many similarities to human tendinopathy making it an ideal large animal model for human disease. Regenerative approaches are increasingly used to improve outcome involving mesenchymal stem cells (MSCs), supported by clinical data where injection of autologous bone marrow derived MSCs (BM-MSCs) suspended in marrow supernatant into injured tendons has halved the re-injury rate in racehorses. We hypothesized that stem cell therapy induces a matrix more closely resembling normal tendon than the fibrous scar tissue formed by natural repair. Twelve horses with career-ending naturally-occurring superficial digital flexor tendon injury were allocated randomly to treatment and control groups. 1X10(7) autologous BM-MSCs suspended in 2 ml of marrow supernatant were implanted into the damaged tendon of the treated group. The control group received the same volume of saline. Following a 6 month exercise programme horses were euthanized and tendons assessed for structural stiffness by non-destructive mechanical testing and for morphological and molecular composition. BM-MSC treated tendons exhibited statistically significant improvements in key parameters compared to saline-injected control tendons towards that of normal tendons and those in the contralateral limbs. Specifically, treated tendons had lower structural stiffness (p<0.05) although no significant difference in calculated modulus of elasticity, lower (improved) histological scoring of organisation (p<0.003) and crimp pattern (p<0.05), lower cellularity (p<0.007), DNA content (p<0.05), vascularity (p<0.03), water content (p<0.05), GAG content (p<0.05), and MMP-13 activity (p<0.02). Treatment with autologous MSCs in marrow supernatant therefore provides significant benefits compared to untreated tendon repair in enhancing normalisation of biomechanical, morphological, and compositional parameters. These data in natural disease, with no adverse findings, support the use of this treatment for human tendon injuries.

[Musculotendinopathy of the gastrocnemius muscle in a Labrador Retriever. A case report]

Musculotendinopathy at the origin of the gastrocnemius muscle is a rare disease mostly described in herding dogs. The etiology is based on repeated myotendinous strain of the muscle in athletic dogs. Clinically, the patient displays chronic pelvic limb lameness and pain at the lateral fabella during palpation of this area. There is no instability of the stifle present. Radiographic findings (osteophyte formation at the origin of the muscle and the lateral fabella) support the potential diagnosis. Magnetic resonance tomography shows edematous changes and enhancement after intravenous application of contrast agent in the area of the origin of the lateral gastrocnemius head. With conservative treatment (i. e. leash confinement, NSAID application and physiotherapy) the prognosis is good. This case report describes clinical findings, diagnostic imaging, therapy and long-term outcome of an athletic Labrador Retriever presented with this disease.

Continuous peripheral neural blockade to alleviate signs of experimentally induced severe forelimb pain in horses

OBJECTIVE

To investigate the efficacy and safety of a low-volume, single-catheter, continuous peripheral neural blockade (CPNB) technique to locally deliver bupivacaine to alleviate signs of severe forelimb pain resulting from experimentally induced tendonitis in horses.

DESIGN

Randomized controlled experimental trial.

SAMPLE

14 horses and 5 forelimbs from equine cadavers.

PROCEDURES

Horses underwent collagenase-induced superficial digital flexor tendonitis in the midmetacarpal region of 1 forelimb. To deliver analgesia, a closed-tip catheter was placed from lateral to medial, approximately 12 cm distal to the accessory carpal bone, between the suspensory ligament and accessory ligament of the deep digital flexor tendon. Success of catheter placement and anesthetic delivery was documented ex vivo in 5 forelimbs from equine cadavers. Effective analgesia in affected forelimbs of horses from continuous (n = 7) versus intermittent (7) local anesthetic delivery (intermittent peripheral neural blockade; IPNB) was compared over a 3-day period.

RESULTS

Horses that received CPNB in the affected forelimb were less lame than horses that received IPNB. A lower proportion of CPNB-treated horses had behavioral and physiologic signs of pain, compared with IPNB-treated horses. Neither technique completely blocked the sensation of pain or resulted in swelling in the distal portion of the forelimb, vasodilation, or an increase in lameness. After removal, Staphylococcus aureus was cultured from 1 catheter tip.

CONCLUSIONS AND CLINICAL RELEVANCE

For short-term treatment, CPNB was more effective than IPNB for reduction in signs of severe pain in the distal aspect of the forelimb of horses.

Treating navicular syndrome in equine patients

Navicular syndrome is a chronic, progressive condition affecting the navicular bone and bursa, deep digital flexor tendon (DDFT), and associated soft tissue structures composing the navicular apparatus. The treatment options for navicular syndrome are as varied as the proposed causes of the condition. The severity of clinical signs, intended use and workload of the horse, and owner compliance with therapy are important considerations in developing a treatment plan. Nonsurgical treatment of navicular syndrome consists of rest, hoof balance and corrective trimming/shoeing, and medical therapy, including administration of systemic antiinflammatories, hemorheologic medications, and intraarticular medications. While surgical therapy can include desmotomy of the collateral (suspensory) ligaments of the navicular bone, palmar digital neurectomy is more commonly performed when medical therapy is ineffective. Recently, adjunct therapies, such as acupuncture and extracorporeal shock wave therapy, have also been used to treat horses with navicular syndrome. Because of the wide range of pathologic changes and the lack of a definitive cure associated with navicular syndrome, treatment is directed toward the individual horse, focusing on the management of clinical signs to alleviate stress and retard degenerative changes of the navicular bursal and navicular regions.

Lameness associated with foot pain: results of magnetic resonance imaging in 199 horses (January 2001-December 2003) and response to treatment

REASONS FOR PERFORMING STUDY

The diagnosis of foot-related lameness often remains elusive and it can be difficult to offer rational treatment, or to predict outcome.

OBJECTIVES

To describe the spectrum of injuries of the foot identified using magnetic resonance imaging (MRI), to determine their relative prevalence among MRI diagnoses and to establish the long-term results of treatment.

METHODS

The MR images of horses examined from January 2001--December 2003 were reviewed. Horses were selected for MRI if the pain causing lameness was localised to the foot using perineural analgesia but any clinical, radiological or ultrasonographic abnormalities were insufficient to explain the degree of lameness. The clinical significance of lesions identified using MRI was determined with reference to the results of local analgesia, radiography, ultrasonography and nuclear scintigraphy. Follow-up information was obtained in January 2004 for horses which had been examined 6-36 months previously and the outcome classified as excellent (horse returned to full athletic function without recurrent lameness), moderate (sound, but only in light work), or poor (persistent or recurrent lameness).

RESULTS

One hundred and ninety-nine horses underwent MRI examinations. Deep digital flexor (DDF) tendonitis was the most common injury (59%) with primary injury in 65 horses (33%) and a further 27 horses (14%) having lesions of the DDF tendon and navicular bone. Seventeen percent of horses had injuries to multiple structures, including 24 with DDF tendonitis. Desmitis of a collateral ligament (CL) of the distal interphalangeal (DIP) joint was the second most common injury (62 horses, 31%), with primary injuries in 30 horses (15%) and a further 32 horses (16%) that had CL desmitis in conjunction with other injuries. Prognosis was best for horses with traumatic injuries of the middle or distal phalanges, with 5 of 7 horses (71%) having an excellent outcome. Horses with primary lesions of the DDF tendon or CL of the DIP joint had excellent results in only 13 of 47 (28%) and 5 of 17 horses (29%), respectively. Horses with combined injuries of the DDF tendon and navicular bone, or primary navicular bone abnormalities, had a poor outcome, with the majority of horses suffering persistent lameness.

CONCLUSIONS

A wide variety of lesions associated with foot pain were identified using MRI, a high proportion of which were primary soft tissue injuries with a guarded prognosis for return to full athletic function.

POTENTIAL RELEVANCE

It is now possible to propose more rational treatment strategies for the variety of foot injuries identified using MRI than had previously been possible; however, further information concerning aetiopathogenesis of these injuries is needed to improve their management.

Medical management of superficial digital flexor tendonitis: a comparative study in 219 horses (1992-2000)

REASONS FOR PERFORMING STUDY

There is a lack of long-term follow-up data for outcome of medical treatment of superficial digital flexor (SDF) tendonitis.

OBJECTIVES

To determine whether intralesional injection of hyaluronan, beta aminoproprionitrile fumarate (BAPN) or polysulphated glycosaminoglycans (PSGAG) or systemic administration of PSGAG yielded better results than a controlled exercise programme alone in the management of SDF tendonitis, with a minimum follow-up period of 2 years after resumption of full work; and to determine whether reinjury rate was related to sports discipline and whether fibre alignment score (FAS) at 4 months could predict outcome.

METHODS

In Study 1, 50 horses were managed by controlled exercise alone (Group A), 50 were treated with intralesional injection of hyaluronan (Group B), 20 received intralesional and systemic treatment with PSGAG (Group Ci) and 30 received systemic treatment with PSGAG (Group Cii). Horses in Groups B, Ci and Cii followed the same controlled exercise programme as Group A. In Study 2, 69 horses (Group D) were treated by intralesional injection of BAPN and followed a modified controlled exercise programme. Horses were re-examined clinically and ultrasonographically at intervals. Follow-up data were obtained for horses 2 years after resuming full work and for up to 6 years.

RESULTS

There was no significant difference in reinjury rate of the treated limb(s) between Groups A, B, Ci and Cii (42.5-44.4%) (P>0.9). The reinjury rate (16%) in the treated limb(s) in Group D was significantly lower than in the other groups (P<0.001). However, when injury rate of the uninjured limb was considered, the results were similar to Study 1. In Study 2, the FAS at 4 months after treatment was a good predictor of outcome (P<0.001). Reinjury rates for different disciplines were similar in the 2 studies, with the risk of reinjury ascending from showjumpers to event horses to National Hunt and flat racehorses.

CONCLUSIONS

Treatment with BAPN reduced the risk of reinjury in the treated limb, although the overall rate of subsequent injury was not affected. FAS at 4 months after treatment is a good predictor of outcome in the treated limb(s).

POTENTIAL RELEVANCE

This study provides long-term follow-up data in horses from a variety of sports disciplines that can be used to provide prognostic information.

Cell phenotypic variation in normal and damaged tendons

Injuries to tendons are common in both human athletes as well as in animals, such as the horse, which are used for competitive purposes. Furthermore, such injuries are also increasing in prevalence in the ageing, sedentary population. Tendon diseases often respond poorly to treatment and require lengthy periods of rehabilitation. The tendon has a unique extracellular matrix, which has developed to withstand the mechanical demands of such tensile-load bearing structures. Following injury, any repair process is inadequate and results in tissue that is distinct from original tendon tissue. There is growing evidence for the key role of the tendon cell (tenocyte) in both the normal physiological homeostasis and regulation of the tendon matrix and the pathological derangements that occur in disease. In particular, the tenocyte is considered to have a major role in effecting the subclinical matrix degeneration that is thought to occur prior to clinical disease, as well as in the severe degradative events that occur in the tendon at the onset of clinical disease. Furthermore, the tenocyte is likely to have a central role in the production of the biologically inadequate fibrocartilaginous repair tissue that develops subsequent to tendinopathy. Understanding the biology of the tenocyte is central to the development of appropriate interventions and drug therapies that will either prevent the onset of disease, or lead to more rapid and appropriate repair of injured tendon. Central to this is a full understanding of the proteolytic response in the tendon in disease by such enzymes as metalloproteinases, as well as the control of the inappropriate fibrocartilaginous differentiation. Finally, it is important that we understand the role of both intrinsic and extrinsic cellular elements in the repair process in the tendon subsequent to injury.

Field technique for the resection of the distal interphalangeal joint and proximal resection of the deep digital flexor tendon in cows

A modified technique for the resection of the distal interphalangeal joint and the proximal resection of the deep digital flexor tendon in cows is described. Septic arthritis of the joint was diagnosed in eight Holstein cows and treated in the field. Four of the cows were diagnosed with ascending tendonitis during the resection of the joint and their tendons were also resected. All the animals remained moderately to severely lame for two weeks postoperatively but quickly recovered and were sound within five months. Eight months after the last surgery only one cow had been culled, 321 days after its surgery, for reproductive failure. The other seven cows had survived for a mean period of 308 days, with a range from 235 to 392 days.

Nucleotide structure of equine platelet-derived growth factor-A and -B and expression in horses with induced acute tendinitis

OBJECTIVE

To characterize the nucleotide sequence of equine platelet-derived growth factor (PDGF)-A and -B and analyze temporal expression of these genes in equine tendon after induced tendinitis injury. Animals-18 mature horses.

PROCEDURES

Genes for equine PDGF-A and -B were reverse transcribed and sequenced from synovial tissue mRNA obtained from a 3-year-old horse. Collagenase-induced lesions were created in the tensile region of the superficial digital flexor tendon in 14 horses; 3 horses served as uninjured control animals. Tendons were harvested and total RNA was isolated from experimental horses 1, 2, 4, 8, and 24 weeks after collagenase injection. Temporal gene expression for PDGF-A and -B was determined by use of quantitative PCR analysis.

RESULTS

Equine PDGF-A shared 83.8% sequence and 87.5% peptide homology with human PDGF-A, with a discrepancy of 70 bp from the human sequence. Equine PDGF-B was similar in length to the human gene, sharing 90.3% and 91.7% nucleotide and peptide identity, respectively. Expression of PDGF-A mRNA in collagenase-induced tendinitis lesions was unchanged, compared with expression for normal control tendon, and remained steady throughout the 24-week study. Expression of PDGF-B mRNA decreased over time, and the expression at 24 weeks was significantly reduced, compared with expression in normal and acutely injured tendon.

CONCLUSIONS AND CLINICAL RELEVANCE

Injured tendon mounts a minimal constitutive PDGF-A or -B mRNA response. Serial exogenous treatment with either PDGF isoform within the first 2 to 4 weeks after tendon injury may bolster the meager PDGF paracrine-autocrine intrinsic response to injury.

The evaluation of extracorporeal shock wave therapy on collagenase induced superficial digital flexor tendonitis

Extracorporeal shock wave therapy (ESWT) is being used to treat desmitis and tendonitis in horses. This paper compares the clinical, ultrasonographic and histological characteristics of ESWT treated collagenase induced superficial digital flexor tendon (SDFT) lesions, versus untreated controls. This blinded study utilizes six mature, healthy horses where bilateral forelimb SDFT lesions were induced. One forelimb was treated while the other served as an untreated control. Three shock wave treatments were administered at three week intervals. At weekly intervals, ultrasonograms were used to measure: 1) percentage lesion at the maximum injury zone (MIZ), 2) the grey scale of the SDFT at the MIZ, 3) the percentage disruption of the longitudinal fibres at the MIZ. The data were also summed from 8-20 cm distal to the accessory carpal bone. Measurements of the external width of the SDFT were obtained through the study period. Examinations were performed on four occasions to evaluate heat, response to palpation, presence/character of swelling over the SDFT, and lameness. At the completion of the study all tendons were evaluated histologicalally. The lesion size, grey scale, and longitudinal fibre disruption at the MIZ, and sum of each variable changed significantly over time, however, there was no difference between treated and control groups. Histopathology showed increased neovascularization in treated tendons (p = 0.001). When compared to untreated controls, ESWT did not change the ultrasonographic appearance of the tendons. However, it did increase neovascularization.

DEEP DIGITAL FLEXOR TENDONITIS IN THE EQUINE FOOT DIAGNOSED BY LOW-FIELD MAGNETIC RESONANCE IMAGING IN THE STANDING PATIENT: 18 CASES

Injury to the distal aspects of the deep digital flexor tendon (DDFT) is an important cause of lameness in horses. The purpose of this study was to review the magnetic resonance imaging (MRI) findings of 18 horses affected by DDFT injuries in the foot. The MRI was performed with the horses standing using an open low-field (0.21 T) MRI scanner. The results were compared with those previously reported for horses using high-field MRI. Eighteen of 84 horses (21%) with undiagnosed forefoot pain were found to have lesions affecting the DDFT. The history, clinical findings and results of radiography, diagnostic ultrasonography and nuclear scintigraphy of these horses were reviewed. The duration of lameness ranged from 1 to 12 months, and the severity varied from 1/10 to 6/10. Fifteen horses had unilateral lameness (right fore in nine, left fore in six), whereas three horses were bilaterally foreleg lame. Radiological changes, considered of equivocal significance, were found in six of 18 horses. Ultrasonographic changes involving the DDFT were identified in only one of nine horses. DDFT lesions were detected in both T1- and T2-weighted MRI sequences. Four different types of lesions were identified: core lesions, sagittal splits, dorsal border lesions, and insertional lesions. Combinations of different lesion types within the same horse were common. The types and locations of the DDFT lesions were similar to those previously reported using high-field MRI. The use of low-field standing MRI avoids the necessity for general anesthesia and access to conventional high-field MRI scanners. However, studies comparing the results of standing low-field MRI with high-field MRI (and other imaging procedures) are required before the sensitivity and specificity of the technique can be assessed.

Supraspinatus tendinosis associated with biceps brachii tendon displacement in a dog

A 4-year-old spayed female Australian Cattle Dog (Blue Heeler) was evaluated because of right forelimb lameness of 5 months' duration. Orthopedic evaluation revealed signs of pain localized to the cranial aspects of both shoulder joints. Via magnetic resonance imaging, the mass of the supraspinatus tendon insertion in both shoulder joints was increased, compared with findings in cadavers of clinically normal dogs; additional imaging procedures revealed that, compared with clinically normal tendons, the tendon had increased signal intensity that was consistent with increased fluid content. The increased supraspinatus tendon mass in each shoulder joint was associated with medial displacement of the biceps brachii tendon, which was more severe in the right limb. Arthroscopic evaluations of both shoulder joints revealed no abnormalities. The dog underwent surgery, and the abnormal parts of the tendons were resected. The most prominent finding on histologic examination of excised tissues was severe myxomatous degeneration. The lameness resolved, and at 22 months after surgery, the dog was reported to have had no recurrence of lameness. The clinical signs and histologic appearance of the tendons in this dog strongly resemble findings associated with tendinosis in humans. Decompression of the biceps brachii tendon may have contributed to the successful outcome after surgery in this dog. Supraspinatus tendinosis should be considered among the differential diagnoses in dogs with uni- or bilateral forelimb lameness.

Risk factors for injury to the superficial digital flexor tendon and suspensory apparatus in Thoroughbred racehorses in New Zealand

AIM

To investigate risk factors for injury to the superficial digital flexor tendon (SDFT) and suspensory apparatus (SA) of the forelimbs in Thoroughbred racehorses in New Zealand.

METHODS

Poisson and negative binomial regression, with exposure time represented by cumulative training days for each horse, were used to relate explanatory variables to the incidence rate (IR) of cases of inflammation of the SDFT (n=51), and injuries involving the SA (n=48) in a population of 1,571 commercially- trained racehorses over 554,745 study days. Only the first occurrence of an injury for any one horse was eligible for inclusion. Separate analyses were run for data from horses in training regardless of whether they had started in a trial or race, and using a subset of these data restricted to those preparations associated with at least one start in a trial or race. Results were reported as incidence rate ratios (IRR) and 95% confidence intervals (CI).

RESULTS

Male horses had a higher risk of injury to the SA (IRR 2.57; p=0.005) and tended to have a higher risk of injury to the SDFT (IRR 1.74; p=0.09) than female horses. Increasing age was associated with increased risk of injury. Horses aged 4 and > or =5 years were 6.76 (p<0.001) and 15.26 (p<0.001) times more likely to incur injury to the SDFT, and 2.91 (p=0.02) and 3.54 (p=0.005) times more likely to incur injury to the SA, respectively, than 2-year-olds. Horses were more likely to suffer an injury to the SDFT or SA in a training preparation that was not associated with any starts in official trials or races compared with those preparations that were associated with more than one start (p<0.001), and more likely to injure the SA compared with preparations containing one start (p=0.03). The IR of injury to the SDFT tended to be lower between November-January (IRR 0.78; p=0.08) and February-April (IRR 0.75; p=0.08) compared with August-October. Incidence of injury to the SDFT or SA was not associated with the cumulative distance raced in the last 30 days of a training preparation.

CONCLUSION

This study identified risk factors for injury to the SDFT and SA in Thoroughbred racehorses in New Zealand. Injuries were more likely in males, older horses and in horses in training preparations without any starts. There was no evidence of association between injury and cumulative high-speed exercise.

Mechanism of cell death in inflamed superficial digital flexor tendon in the horse

The aim of the present study was to clarify the presence and determine the role of apoptosis in the degenerative process of the superficial digital flexor tendon (SDFT) in the horse. Samples were obtained from normal and inflamed SDFTs of horses. To detect apoptosis and to identify apoptotic cells, the samples were subjected to immunohistochemical labelling and Western blot analysis. Although a large number of cells in degenerate areas showed positive reactions with caspase-3 and single stranded DNA antibodies, cells in normal tendon samples showed very weak reactions. Excessive apoptosis was confirmed by the results of Western blot analysis, which showed a significant increase in activated caspase-3 protein in the inflamed SDFTs, suggesting that apoptosis occurred in the tendinocytes via a caspase-3-dependent pathway. This is the first report of excessive apoptosis in inflamed SDFT of the horse. The results indicate that apoptosis may play an important role in the process of degeneration of the tendon as well as other tissues.

Arthroscopic Biceps Tenodesis: Technique and Results in Six Dogs

Biceps tenodesis was performed using an arthroscopic-assisted technique on six dogs diagnosed with chronic bicipital tendon pathology. The technique was performed using two different fixation methods (i.e., cannulated interference screw, cannulated screw and tissue washer). All six dogs had successful outcomes in terms of return to full function at a mean follow-up time of 11.7 months after surgery. Arthroscopic biceps tenodesis is a feasible option for surgical management of biceps tendon pathology, and it may have advantages over open tenodesis and open or arthroscopic tenotomy. Further study is needed before definitive recommendations regarding indications, complications, and prognosis associated with arthroscopic biceps tenodesis can be made.

Prevalence of superficial digital flexor tendonitis and suspensory desmitis in Japanese Thoroughbred flat racehorses in 1999

REASONS FOR PERFORMING STUDY

Overstrain injuries to the superficial digital flexor tendon (SDFT) and suspensory ligament (SI) are among the most common musculoskeletal injuries which contribute to the considerable wastage of racing Thoroughbreds. Many epidemiological studies have demonstrated the prevalence of and risk factors for tendon injury when racing but have not included those injuries sustained during training. However, since tendon injury during training is seen commonly in clinical practice, it is appropriate to determine the overall prevalence of tendon injury sustained during both training and racing.

OBJECTIVE

To determine the prevalence of overstrain injury to the SDFT and SL during training and racing among Thoroughbred flat racehorses in Japan in 1999.

METHODS

A retrospective study was performed using a sample population of 10,262 Thoroughbred racehorses. The medical information database of Thoroughbred racehorses registered by the Japan Racing Association (JRA) in 1999 was analysed for SDFT and SL overstrain injury diagnosed by a veterinarian employed by JRA during training and racing. Jump racehorses were excluded from this study.

RESULTS

The prevalence of forelimb SDFT tendonitis and SL desmitis was 11.1% (1130 cases) and 3.61% (370 cases) of the population, respectively. In the hindlimb, there were 0.06% (6 cases) and 0.14% (14 cases), respectively. Risks of SDF tendonitis in the forelimb in 3-year-olds or older horses were significantly higher than in 2-year-olds. In contrast, the risk of SL desmitis in the forelimb at age 3 and 4 years was 2.23 and 2.11 times higher, respectively, than in 2-year-olds, but this increased to 5.07 times in those age > or = 5 years. Entire males were at greater risk in comparison to females and geldings.

CONCLUSIONS

The results suggest that the prevalence of SDF tendonitis and SL desmitis in the forelimb was associated with the horse's age and sex. The prevalence of SL desmitis increased further with age compared with SDF tendonitis, possibly reflecting a more rapid accumulation of degeneration in this structure.

POTENTIAL RELEVANCE

The age-related risk demonstrated in this study provides further support that overstrain injuries are associated with accumulated degeneration. These data provide a valuable resource for further research into the aetiology of tendon injury in the racehorse.

Septic tenosynovitis of the tarsal sheath of an Arab gelding and suspected sepsis of the lateral digital flexor tendon subsequent to bacterial peritonitis

A 21-year-old Arab gelding with clinical signs of acute peritonitis had a perforating ulcer on the mesenteric border of the jejunum which resulted in localised contamination of the abdomen with ingesta. The affected segment of jejunum was resected and the abdomen was lavaged extensively. Postoperatively, the gelding was treated with broad-spectrum antibiotics, non-steroidal anti-inflammatory drugs and intravenous fluids, but after four days it became acutely non-weight bearing on its right hindlimb, and a tendonitis of the lateral digital flexor tendon within the tarsal sheath was identified ultrasonographically. The septic tendonitis was treated with broad-spectrum antibiotics but progressed proximodistally within the tendon until it involved both the tarsal sheath and the associated tarsocrural joint, necessitating the euthanasia of the gelding.

Quantitative evaluation of equine deep digital flexor tendon morphology using magnetic resonance imaging

Injury of the distal aspect of the deep digital flexor tendon (DDFT) is a recognized cause of lameness, but diagnosis is difficult. This study aimed to improve understanding of DDFT morphology and pathology using retrospective evaluation of magnetic resonance (MR) images. We hypothesized that: (1) The distal aspect of the DDFT in normal horses would have a repeatable proximal/distal pattern and symmetry between limbs and between lobes; (2) DDFT dimensions would be related to bodyweight, navicular bone dimensions and hoof size; (3) this symmetry and pattern would be lost in DDFT injury; and (4) DDFT size would increase with injury. MR images of 64 live horse limbs, 26 with no identified DDFT lesion and 38 with identified DDFT abnormalities, and 19 normal cadaver limbs were analyzed. Using standardized transverse images, measurements of DDFT cross-sectional area, medial-lateral (ML) width and dorsal-palmar depth were obtained at six preselected sites. A uniform distal to proximal shape pattern was identified in all horses. The flattened crescent shape at the insertion changed to a deeper bilobed shape more proximally, with the mid-navicular area having the greatest cross-sectional area. Strong ML (P < 0.0006) and left/right symmetry (P < 0.02) were observed. In addition, there was a strong association between DDFT cross-sectional area and horse weight (P = 0.005) and between DDFT and navicular bone ML width (P = 0.004). Symmetry between sides or between lobes was lost at sites with a unilateral lesion and correlation between horse weight and DDFT cross-sectional area was lost in the presence of lesions. DDFTs with core lesions had a consistent increase in cross-sectional area overall, but other lesion types had no significant increase in size. The shape and symmetry seen in normal tendons could be related to the mechanical demands placed upon individual lobes. The limited increase in cross-sectional area with injury may be explained by the restrictive structures of the hoof, possibly explaining the ongoing pain seen in such lesions.

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

REASONS FOR PERFORMING STUDY

The differential diagnosis of foot pain has long proved difficult and the use of magnetic resonance imaging (MRI) offers the opportunity to further the clinical understanding of the subject.

OBJECTIVES

To determine the incidence of deep digital flexor tendon (DDFT) injuries in a series of 75 horses with lameness associated with pain localised to the digit, with no significant detectable radiographic or ultrasonographic abnormalities, using MRI; and to describe a variety of lesion types and relate DDF tendonitis with anamnesis, clinical features, response to local analgesic techniques and nuclear scintigraphic and ultrasonographic findings.

METHODS

All horses undergoing MRI of the front feet between January 2001 and October 2002 were reviewed and those with DDFT injuries categorised according to lesion type; horses with primary tendonitis (Group I) and those with concurrent abnormalities of the navicular bone considered to be an important component of the lameness (Group II). The response to perineural analgesia of the palmar digital nerves and palmar (abaxial sesamoid) nerves, intra-articular analgesia of the distal interphalangeal (DIP) joint and analgesia of the navicular bursa were reviewed. The result of ultrasonography of the pastern and foot was recorded. Lateral, dorsal and solar pool and bone phase nuclear scintigraphic images were assessed subjectively and objectively using region of interest (ROI) analysis.

RESULTS

Forty-six (61%) of 75 horses examined using MRI had lesions of the DDFT considered to be a major contributor to lameness. Thirty-two horses (43%) had primary DDFT injuries and 14 (19%) a combination of DDF tendonitis and navicular bone pathology. Lesions involved the insertional region of the tendon alone (n = 3), were proximal to the navicular bone (n = 23) or were at a combination of sites (n = 20). Lesion types included core lesions, focal and diffuse dorsal border lesions, sagittal plane splits, insertional injuries and lesions combined with other soft tissue injuries. Many horses had a combination of lesion types. Lameness was abolished by palmar digital analgesia in only 11 of 46 horses (24%). Twenty-one of 31 horses (68%) in Group I showed > 50% improvement in lameness after intra-articular analgesia of the DIP joint, whereas 11 of 12 horses (92%) in Group II had a positive response. Twelve of 18 horses (67%) in Group I had a positive response to analgesia of the navicular bursa. Nineteen horses had lesions of the DDFT extending proximal to the proximal interphalangeal joint seen using MRI, but these were identified ultrasonographically in only 2 horses. Scintigraphic abnormalities suggestive of DDFT injury were seen in 16 of 41 horses (41%), 8 in pool phase images and 8 in bone phase images.

CONCLUSIONS AND POTENTIAL RELEVANCE

DDFT injuries are an important cause of lameness associated with pain arising from the digit in horses without detectable radiographic abnormalities. Lameness is not reliably improved by palmar digital analgesia, but may be improved by intra-articular analgesia of the DIP joint in at least 68% of horses. Ultrasonography is not sensitive in detecting lesions of the DDFT in the distal pastern region, but a combination of pool and bone phase scintigraphic images of the digit is helpful in some horses. Further follow-up information is required to determine the prognosis for horses with lesions of the DDFT in the digit and to establish whether this is related to lesion severity and/or location.

Endoscopic surgery in the treatment of contaminated and infected synovial cavities

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.

Localization of cytokines in tendinocytes of the superficial digital flexor tendon in the horse

Although inflammatory activation of cytokines have been analyzed in various tissues, there have only been a few and as-yet-inconclusive studies on cytokines in equine tendons. In this study, the localizations of 4 cytokines (IL-1alpha, IL-1beta, TNFalpha and IFNgamma) in tendinocytes of the equine superficial digital flexor tendon (SDFT) were analyzed by the use of an immunohistochemical method. In inflamed tendons positive staining for all 4 cytokines antibodies were detected in endotedinieum cells and vascular epithelial cells. In contrast, negative or trace immunoreactions were obtained in many tendinocytes in the normal tendon. The variation in cellular immune responses depending on the kind of cytokine may reflect the physiological/pathological condition of the SDFT.

Insulin-like growth factor-I improves cellular and molecular aspects of healing in a collagenase-induced model of flexor tendinitis

Flexor tendinitis is a common and debilitating injury of elite and recreational athletes. Healing may be improved through intratendinous injection of insulin-like growth factor-I (IGF-I), which has been shown in vitro to stimulate mitogenesis and enhance tendon matrix production. This study investigated the effects of intratendinous injection of IGF-I on tendon healing in an equine model of flexor tendinitis. Collagenase-induced lesions were created in the tensile region of theflexor digitorum superficialis tendon of both forelimbs of eight horses. Treated tendons were injected with 2 microg rhlGF-I intralesionally every other day for 10 injections, while controls received 0.9% NaCl. Tendon fiber deposition and organization were evaluated serially using ultrasonography throughout the 8 week trial period. Following euthanasia, the tendons were harvested and DNA, hydroxyproline, and glycosaminoglycan content determined, mechanical strength and stiffness evaluated, gene expression and spatial arrangement of collagen types I and III assessed by northern blot and in situ hybridization, and tendon fiber architecture assessed by polarized light microscopy. Local soft tissue swelling was reduced in the IGF-I treated limbs. Similarly, lesion size in IGF-I treated tendons was smaller 3 and 4 weeks after initiation of treatment. Cell proliferation and collagen content of the IGF-I treated tendons were increased compared to controls. Mechanically, IGF-I treated tendons showed a trend toward increased stiffness compared to saline treated controls. Considered together with the decreased soft tissue swelling and improved sonographic healing, these data support the potential use of intralesional IGF-I for treatment of debilitating tendon injuries.

Biomechanical implications of uphill training on the aetiology of tendinitis

It has been reported that a small decrease in the strain in the superficial digital flexor tendon (SDFT) occurs if the toe is raised during walking. Although walking on a slope appears similar to raising the toe, it is unclear whether uphill exercise decreases the strain in the SDFT. Because the force or strain on tendons is one of the important factors leading to tendon stress injury, we hypothesised that reducing the force in the SDFT during exercise may prevent tendinitis. The purpose of this study was to determine the effects of treadmill inclination on the force in the SDFT in the walking horse. 'Arthroscopically implantable force probes' (AIFP) were implanted into the SDFT of the forelimb of 4 horses. The AIFP output was recorded during walking on a treadmill inclined at 0%, 3%, 8% and then 0% again. When the inclination increased from 0 to 8%, the first peak of force in the SDFT decreased significantly, the second increased significantly, but the maximal force and the area under the force-time curve did not change. In conclusion, uphill walking on an inclined treadmill did not decrease the maximal force in the SDFT or the area under the force-time curve, however, the patterns of force were altered. Future research should focus on the force distributions of tendons and ligaments at faster gaits, because the effects of a change in hoof angle and slope may be greater at faster gaits.

Correlation of cartilage oligomeric matrix protein (COMP) levels in equine tendon with mechanical properties: a proposed role for COMP in determining function-specific mechanical characteristics of locomotor tendons

Over-strain injury of the superficial digital flexor tendon (SDFT) is a common injury in the horse. Tendon appears to adapt to loads placed on it during development, but fatigue damage accumulates after skeletal maturity, which is inadequately repaired and predisposes to clinical tendinitis. In any population of horses, there is a wide variation in SDFT mechanical properties. A noncollagenous protein, cartilage oligomeric matrix protein (COMP), is particularly abundant during growth in the equine SDFT and has been proposed to have an organisational role in the formation of collagenous matrices. This study aimed to determine whether COMP levels were correlated to mechanical properties at skeletal maturity. Tendons from 2 groups of 12 horses were analysed: Group 1 horses with restricted age, 2 years +/- 2 months, showed a significant correlation between both ultimate tensile stress modulus of elasticity and stiffness and COMP, while Group 2 mature horses with varying age did not, because of age- and exercise-induced loss of COMP. These data supports the hypothesis that COMP is an important mediator in the growth of tendon. This data would suggest that the identification of low COMP levels in tendon during growth would indicate horses prone to tendon injury and methods of promoting COMP synthesis during growth would potentially improve tendon quality and reduce the risk of subsequent tendinitis.

The effect of recombinant equine growth hormone on the biomechanical properties of healing superficial digital flexor tendons in horses

OBJECTIVE

To evaluate the effect of recombinant equine growth hormone (rEGH) on the in vitro biomechanical properties of healing superficial digital flexor tendon (SDFT) in horses.

STUDY DESIGN

Completely randomized design.

SAMPLE POPULATION

Twelve Standardbred horses, 3 to 7 years of age, with ultrasonographically normal forelimb SDFT.

METHODS

One week after induction of collagenase (2,000 U) induced superficial flexor tendonitis, horses were randomly divided into groups of 6. One group was administered intramuscular rEGH (10 microg/kg/day for 1 week, then 20 microg/kg/day for 5 weeks), whereas the other group (control subjects) were administered an equivalent volume of saline (0.9% NaCl) solution. At the end of this 6-week treatment, horses were killed and one forelimb SDFT from each horse was harvested for biomechanical testing under uniaxial tension. Results were analyzed using an unpaired Student's t test; significance was set at P <or=.05.

RESULTS

SDFT from horses treated with rEGH had significantly larger mean cross-sectional areas and lower mean values for ultimate and yield tensile stress, whereas tendons from the control group were biomechanically stiffer than those from the rEGH-treated horses.

CONCLUSIONS

Administration of rEGH to horses for 6 weeks, 1 week after collagenase induced injury to the SDFT, resulted in a significant increase in tendon cross-sectional area, a concomitant reduction in ultimate and yield tensile stress, and reduced tendon stiffness.

CLINICAL RELEVANCE

Using this model of tendonitis, rEGH had a negative effect on the biomechanical properties of equine SDFT in the early phases of healing. Based on our results, administration of rEGH to treat superficial flexor tendonitis cannot be recommended.

Recombinant equine growth hormone does not affect the in vitro biomechanical properties of equine superficial digital flexor tendon

OBJECTIVE

To evaluate the effect of recombinant equine growth hormone (rEGH) on the in vitro biomechanical properties of normal adult equine superficial digital flexor tendon (SDFT).

STUDY DESIGN

Completely randomized design.

SAMPLE POPULATION

Nine Standardbred horses, 6 to 9 years of age with ultrasonographically normal forelimb SDFT.

METHODS

Six horses were administered intramuscular (IM) rEGH at 10 microg/kg/day for 1 week, and then 20 microg/kg/day for another 5 weeks; 3 horses (control subjects) were administered an equivalent daily volume of sterile water IM. Horses were killed at the end of the 6-week treatment period, and both forelimb SDFT were harvested and stored at -70 degrees C. In vitro biomechanical testing was performed under uniaxial tension. Results were analyzed using a general linear model of analysis of variance; significance was set at P <.05.

RESULTS

There were no differences in cross-sectional area, maximal load at failure, yield load, ultimate and yield tensile strain, ultimate and yield tensile stress, or stiffness between tendons from control and treated horses.

CONCLUSIONS

Administration of rEGH to adult Standardbred horses for 6 weeks had no detectable effect on the in vitro biomechanical properties of normal SDFT.

CLINICAL RELEVANCE

Administration of rEGH does not modulate the in vitro biomechanical properties of SDFT from adult Standardbred horses.

Magnetic resonance imaging application to live horse for diagnosis of tendinitis

Six live horses with various stages of acute to chronic superficial digital flexor (SDF) tendinitis were examined using magnetic resonance imaging (MRI). In each case, MRI findings were compared to the corresponding ultrasonographic (USD) and histologic findings, to establish the usefulness of MRI. In the acute cases, lesions characterized by hemorrhage were well defined as high signal intensity on MRI and hypoechoic regions on USD. Chronic tendon fibrosis was slightly hyperechoic and difficult to distinguish from the normal tendon tissue around the original injury by using USD. In contrast, MRI visualized the chronic lesion as a low intensity signal, which could be distinguished from the black background of the normal SDF tendon tissue. This study clearly demonstrated MRI was the better imaging modality for the objective detection of chronic scar tissue in live horses. These findings, from living horses, suggest an advantage of MRI in the clinical application to diagnose tendinitis in cases where there is chronic scar tissue that is difficult to discern on USD.

Calculated forelimb flexor tendon forces in horses with experimentally induced superficial digital flexor tendinitis and the effects of application of heel wedges

OBJECTIVE

To calculate forces in the flexor tendons and the influence of heel wedges in affected and contralateral (compensating) forelimbs of horses with experimentally induced unilateral tendinitis of the superficial digital flexor (SDF) tendon.

ANIMALS

5 Warmblood horses. Procedure-Ground reaction force and kinematic data were obtained during a previous study while horses were trotting before and after induction of tendinitis in 1 forelimb SDF and after application of 6 degrees heel wedges to both forehooves. Forces in the SDF, deep digital flexor (DDF), and the suspensory ligament (SL) and strain in the accessory ligament (AL) of the DDF were calculated, using an in vitro model of the distal region of the forelimb.

RESULTS

After induction of tendinitis, trotting speed slowed, and forces decreased in most tendons. In the affected limb, SL force decreased more than SDF and DDF forces. In the compensating limb, SDF force increased, and the other forces decreased. After application of heel wedges, SDF force in both limbs increased but not significantly. Furthermore, there was a decrease in DDF force and AL strain.

CONCLUSIONS AND CLINICAL RELEVANCE

The increase in SDF force in the compensating forelimb of horses with unilateral SDF tendinitis may explain the high secondary injury rate in this tendon. The lack of decrease of SDF force in either limb after application of heel wedges suggests that heel wedges are not beneficial in horses with SDF tendinitis. Instead, heel wedges may exacerbate the existing lesion.

A simplified technique for diagnostic and surgical arthroscopy of the shoulder joint in the dog

A modified technique is presented for surgical and diagnostic arthroscopy of the shoulder joint in the dog. The technique involves access to the joint through two points only; one was created in place of the drainage needle-cannula, which was replaced with a portal, while the second was located more caudally compared with previous techniques. Using a changing guide rod system the two portals are completely interchangeable in order to perform easier arthroscopic surgery either in the cranial or caudal aspect of the joint. The presence of only one portal caudal to the lateral collateral ligament allows more freedom of movement and avoids interference between the arthroscope and the instruments. The modified procedure was performed on 33 joints affected by osteochondritis dissecans or tenoligament diseases and facilitated straightforward diagnostic examinations, and simple and rapid surgical procedures.

Effects of beta-aminopropionitrile on equine tendon metabolism in vitro and on effects of insulin-like growth factor-I on matrix production by equine tenocytes

OBJECTIVE

To investigate effects of beta-aminopropionitrile and a combination of insulin-like growth factor (IGF)-I and beta-aminopropionitrile on metabolism of equine tendon fibroblasts.

SAMPLE POPULATION

Flexor tendon explants from 3 horses.

PROCEDURE

Explants received 1 of 4 treatments (control, IGF-I, beta-aminopropionitrile, and IGF-I/beta-aminopropionitrile) for 10 days, and message expression for collagen types I and III was assessed by use of in situ hybridization. Histologic findings, new protein production, and quantitative determinations of glycosaminoglycan, DNA, and de novo collagen synthesis were made.

RESULTS

Insulin-like growth factor-I stimulated an anabolic response in tendon. Collagen synthesis and glycosaminoglycan and DNA content of explants were all increased. Beta-aminopropionitrile significantly suppressed collagen synthesis, which was not ameliorated by concurrent IGF-I treatment. Beta-aminopropionitrile caused alterations in cell morphology characterized by large round cells with eccentric nuclei and decreased density of collagen fibers. Protein production and collagen type-III mRNA expression were reduced in these cells.

CONCLUSIONS AND CLINICAL RELEVANCE

Treatment with beta-aminopropionitrile resulted in decreased production of protein and collagen synthesis, which could be expected to suppress tendon healing. The negative effects of beta-aminopropionitrile could not be abrogated by addition of IGF-I to the medium. Treatment resulted in alterations in cell morphology and matrix consistency, which could further delay tendon healing. Beta-aminopropionitrile may impair tendon healing at a cellular level by decreasing collagen production or increasing rate of degradation of existing matrix. Because of reduced crosslinking during beta-aminopropionitrile treatment, in combination with transiently decreased tensile strength, alterations in collagen content and structure may weaken the healing tendon.

Muscle transplant in the rabbit's Achilles tendon

Achilles tendinopathy (AT) is a degenerative disorder resulting from functional overload, especially during running and jumping, with some inflammatory features at the insertions, bursae, and paratenon. The Achilles tendon is poorly vascularized, especially in the middle third, and the consequent slow metabolic rate allows it to work at very low oxygen tensions but prevents on the other hand a rapid healing.

PURPOSE

To create an animal model to study a novel surgical technique employed in AT: transplanting some fibers of the soleus muscle into the tendon in order to improve its vascularization and healing and to study the histological appearance of the soleus graft incorporated in the tendon.

METHODS

We operated on 10 white New Zealand rabbits (eight rabbits underwent the procedure, two rabbits the sham operation with incision of the tendon without graft). Two animals were euthanized at 1 wk, 1, 2, and 3 months.

RESULTS

Histology showed that after 3 months the muscle fibers were still viable within the tendons, interspersed within connective tissue fibers. Tendon and muscle tissues were intimately fused.

CONCLUSIONS

The persistence of the soleus muscle pedicle graft within the Achilles tendon tissue is an index of sound blood supply. This surgical model is suitable for application in further studies on tendon healing.

Superficial digital flexor tendon healing: ultrasonographic evaluation of therapies

Until recently, it was difficult to critically evaluate tendon healing in vivo. Superficial digital flexor tendon injuries were considered healed when the injured tendon was cold, non-painful, adequate time had passed for tendon healing to occur, and no recurrence of the injury was detected when the horse returned to athletic work. This article discusses how ultrasonography has revolutionized the diagnosis, treatment, and management of tendon injuries.