Evaluating treatment choices for tendon, ligament injury and joint disease in the horse - DVM
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Evaluating treatment choices for tendon, ligament injury and joint disease in the horse


DVM360 MAGAZINE


ESWT


Photo 3: The use of ultrasound-guided, shock-wave equipment (as shown here) has greatly improved both the delivery and the success of this treatment in the horse.
"I am still very pleased with the results I am getting with shock-wave treatment (extracorporeal shock-wave therapy, or ESWT)," says Dr. Hugh Warsham of Foxdale Equine in Georgia. "I treat mostly hunter/jumper injuries, and case selection is very important to success, but for suspensory ligament desmitis shock-wave has been great."

Most practitioners agree that ESWT works best for injuries located proximally in the suspensory and that forelimb injuries respond better than hind-limb problems.

Shock-wave therapy has been receiving attention for its effects on problems of the equine spine as well.

"I have been treating back stiffness, largely from issues related to the spinous processes and have found that horses respond well, though I cannot be sure if they are responding to actual osseous remodeling and repair or to the well-documented analgesic effect noted with ESWT," says Warsham.


Photo 4: Bone remodeling along the edges of the navicular bone contributes to the pain and lameness seen in this condition. Tildren functions by slowing bone destruction and new osteophyte production, and is believed to help lessen the inflammation, cellular destruction and pain in these cases.
This modality is still believed to be the best option for non-healing fractures and problems of the splint bones.

"ESWT has worked well for me in cases of reactive splint bones, especially with axial suspensory ligament involvement," says Warsham.

Platelet-rich plasma

Platelet-rich plasma, on the other hand, is favored by a number of clinicians for the treatment of many ligament and tendon conditions and for use in cases of proximal suspensory desmitis rather than ESWT. Dr. Andris Kaneps of the New England Equine Medical and Surgical Center states, "In our hands, PRP alone has been effective in resolving 75 percent to 80 percent of high- to mid-body suspensory desmitis cases.

"I have used PRP for any significant tendon or ligament injury I have encountered."

PRP does provide a substantial increase of non-specific, local-tissue growth factors, and Kaneps explains that these factors last much longer than one might expect — several months in some laboratory animal studies.

"The advantages of PRP are," according to him, "relatively low cost, autologous, easy to do on an outpatient basis and excellent results for most soft-tissue injuries."

Many clinics are combining PRP and stem cells for tendon and ligament injuries.

This "best of both worlds" treatment seems to have a synergistic effect in some types of injuries. Kaneps uses fat-derived stem cells for their anti-inflammatory properties and for the promotion of tissue-growth factors.

"I have used a combination of fat-derived stem cells and PRP for the injection of suspensory-branch injuries because we have success only in slightly fewer than half of the horses with this injury that we inject with PRP alone," Kaneps says. The PRP/stem-cell combination is considered by him, Warsham and others to improve that treatment success rate substantially.

Stem cells

Many clinicians are using either fat-derived or bone marrow-derived stem cells for the treatment of many types of tendon and ligament injuries, and some use stem cells for joint therapy as well. The benefits are similar to those for PRP, and many performance clients have embraced this therapy because, with the cells coming from the same horse, there is no withdrawal time and horses can have their joints injected almost right up to the start of competition.

Statistics for stem-cell treatment of tendon and ligament injuries generally are good, with most studies reporting about a 70 percent return to function for these horses. Dr. Ted Vlahos of Sheridan, Wyo., urges caution with stem-cell tendon and ligament repair, however. "We have been very happy with the use of fat-derived stem cells for soft-tissue repair," says Vlahos. "We have noted that this treatment will produce outstanding healing, and a horse's ultrasound scan will look remarkable at two months post-treatment. These roping and cutting horses in our practice will not have fully functional tendons and ligaments at that point, so additional healing and rehabilitation time must be allowed," he advises.

An early return to work for these athletes, based on a normal ultrasound scan as was the previously used procedure, can mean re-injury and additional lost performance time.


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Source: DVM360 MAGAZINE,
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