Practitioner Issue 2 2013

The Practitioner Published by the Florida Association of Equine Practitioners, an Equine-Exclusive Division of the Florida Veterinary Medical Association Issue 2 • 2013

Photo Courtesy of L. Chris Sanchez, DVM, PhD, DACVIM

Fe at u r i n g

OCTOBER 17 – 20, 2013 Sue Dyson,

MA, VetMB, PhD, DEO, FRCVS

Mike Ross, DVM, DACVS

Boca Raton Resort & Club • Dyson & Ross News Hour • One-On-One with Dyson & Ross • Rehab Case Studies The Human & Equine Athlete ▶▶▶ Complete Details on Pages 14 -19 ◀◀◀

Advanced Equine Sports Medicine - The Whole Horse Approach

Program Highlights

9th Annual Promoting Excellence Symposium

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The President's - past the quarter pole: OFF AND RUNNING WITH THE FAEP . . .

–

Anne L. Moretta, VMD, MS - FAEP President

A

s equine practitioners we need a strong sense of community. We need to build healthy professional and personal relationships with each other for mutual support. As a group we are able to make change. We must not forget that we ‘belong’ to each other and we can empower our professional ideals to make change and create growth. As a group, throughout our veterinary careers we can educate, we can learn, we can teach the next generation, and share common professional life experiences through many venues. Our FAEP educational events afford a great environment to share ‘our community’.

Over the past several years, our association has experienced exponential growth. There has been a significant increase in attendance at our meetings and a major increase in industry support. We are grateful to our educational partners for their continued support; and without their commitment our meetings would not be possible. Our conference attendees are a diverse group of veterinarians from all over the world, and they are an integral part of our efforts to provide quality veterinary education.

I want to encourage you to come to beautiful, sunny Florida and connect with your veterinary colleagues from across the world to experience one, or both of our world-class continuing education programs this fall. Our ‘community’ venues offer smaller, cohesive, colleague-to-colleague experiences with nationally and internationally-recognized speakers.

The 9th Annual Promoting Excellence Symposium in the Southeast will be held October 17 – 20, 2013 at the Boca Raton Resort and Club in Boca Raton, Florida, a fun, family oriented destination. Our symposium will integrate "a whole horse approach" with equine sports medicine topics. There will be an in-depth Master Class on the Neck and Back with Dr. Philippe Benoit and an in-depth Ophthalmology program with Dr. Dennis Brooks. The symposium will also include Performance Horse Cardiology, Internal Medicine, Lameness, Regenerative Medicine, Imaging, Surgery, Neurology, and GI topics. Our special ‘Dyson and Ross News Hour’ will be featured again this year along with their interactive lameness case studies.

Our innovative equine rehabilitation track will cover the kinesiology and biomechanics of injury. Our focus this year will be on the evidence-based practice of rehabilitation using human models and translating this to the equine athlete. Our notable speakers will look at how injury occurs so we as veterinarians can best prevent or treat injuries. Please view our PES meeting information in more detail in this issue of The Practitioner.

The 51st Annual Ocala Equine Conference will be held at the Ocala Hilton from November 15 – 18, 2013. Our keynote speaker will be Dr. Scott Palmer, past president of AAEP, speaking on Medication Issues in Racing. We are offering an exciting Advanced Dentistry Wet Lab featuring dental extractions and periodontal disease, and a Field Procedures ‘How To’ Wet Lab. I need to extend my special thanks to all of the FAEP council members whose commitment of time, energy, and ideas create successful and relevant programs for our participants. Our industry partners realize how important and timely our educational venues are. Their support is the backbone to our success.

Thanks to the support and commitment of the FAEP council and our Executive Director, Phil Hinkle and his staff, our 4th Annual Equine Foot Symposium held June 28 – 29, 2013 in Orlando, Florida was a resounding success. Mitch Taylor, CJF, led our unique “hands-on” foot and distal limb dissection lab. Our wet lab participants were able to follow Mitch Taylor’s anatomy discussion with an innovative, close-up live streaming video of his dissections. Our FAEP council and some of our notable speakers were on hand to provide one-on-one answers to our participants’ anatomical questions. Educational and entertaining!

Resolve To Be Involved in 2013. Join our FAEP Community.

There are many talented veterinarians in our community. We invite you to join us as committee members to help plan our educational meetings, and help with the scientific articles for the publication, The Practitioner. Help us work together to keep our meetings dynamic and relevant. Participation and feedback from our membership and attendees is a crucial part of what makes our programs successful.

Our entire FAEP council is looking forward to meeting you at our upcoming continuing education this fall. Please send your registrations in!

Promote Excellence in your practice by taking home new tools and the most up to date equine veterinary information from our fall meetings.

• EXECUTIVE COUNCIL • •

•

Suzan C. Oakley, DVM, Diplomate ABVP (Equine)

Gregory D. BonenClark, DVM, Diplomate ACVS

FAEP Council President-Elect FAEP Council Past President

oakleyequine@gmail.com gbonenclark@fevaocala.com

Mr. Philip J. Hinkle

Executive Director phinkle@fvma.org

Amanda M. House, DVM, Diplomate ACVIM housea@ufl.edu

Liane D. Puccia, DVM pucciavet@aol.com

Corey Miller, Jacqueline S. Shellow, DVM, MS, Diplomate ACT DVM, MS Representative to the FAEP Council Vice President cmiller@emcocala.com FVMA Executive Board rrichter@surgi-carecenter.com cmiller@emcocala.com Ruth-Anne Richter, BSc (Hon), DVM, MS

The Practitioner is an official publication of the Florida Association of Equine Practitioners, an Equine-Exclusive Division of the Florida Veterinary Medical Association.

4 The Practitioner

Issue 2 • 2013

IN THIS ISSUE

Strength since 1962

6 | Post‐surgery Rehabilitation

- CE Kawcak, DVM, PhD, Diplomate ACVS & ACVSMR

9 | Equine Infectious Diseases in the Performance Horse

- Amanda M. House, DVM, DACVIM

14 | 9

th

Annual Promoting Excellence Symposium

22 | Return to Performance in Horses with Colic Surgery - Robert Mackay, BVSc, PhD, DACVIM

24 | Lameness Associated with the Shoulder Joint and Biceps Bursa

- Lisa A. Fortier, DVM, PhD, DACVS Call 855.228.PLIT (7548) today for an evaluation of your insurance portfolio and a free premium quotation.

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Details on Page 14 Advanced Equine Sports Medicine - The Whole Horse Approach

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Post-surgery Rehabilitation – A Combined Approach to Maximizing Tissue Strength and Function

by Christopher E. Kawcak, DVM, PhD, Diplomate ACVS & ACVSMR concern with stall confinement and restriction of exercise, which is a double-edged sword since restriction of exercise is needed to prevent further injury and allow damaged tissues to heal, yet normal tissues suffer from the confinement.

Information is lacking on when tissues are healed to a point that exercise can be established, and veterinarians must rely on experience and subjective interpretation of clinical parameters to establish protocols.

Exercise is anabolic to all musculoskeletal tissues up to a certain point of strain and strain rate. Although cartilage, bone and soft tissues respond differently to various levels of mechanical stress, a particular threshold of stress can be reached at which exercise can be damaging to tissues either in the form of onetime strain or fatigue damage that accumulates over time, ultimately leading to gross damage.

Characterizing and Monitoring Injury Protocols for rehabilitation are often based on the nature of the injury and the clinical and imaging findings after surgery.

Initial characterization of the injury by both imaging and surgical examinations allows the clinician to put the horse into a specific category of rehabilitation protocol. Combined with medical therapy, subsequent examinations are critical to success.

Acute Joint Lesions

P

ost-operative rehabilitation in horses is often difficult because of the size and behavior of the horse, and the lack of objective data for guiding protocols. Consequently, owners are often faced with 2- 6 months of hand walking and subsequent increase in exercise of a horse that has been confined to a stall and/or run during that time. The objectives of this presentation are to present information on the importance of exercise during the post-operative period, the importance of pain control and disease monitoring during this time, and information on practical methods of rehabilitating a horse from a musculoskeletal injury.

Tissue Injury and Response to Exercise All musculoskeletal tissues respond in multiple ways to exercise.1-4 Lack of exercise or limb immobilization causes significant atrophy of all musculoskeletal tissues.5,6 This is the 6 The Practitioner

Injuries that cause intraarticular damage are usually the endstage of chronic fatigue damage. However, injuries from acute trauma do occur. Osteochondral fragmentation is common in racing breeds and the prognosis and rehabilitation protocols for these are well established. Relatively large retrospective studies have been performed, giving the industry good evidence of prognosis for various severity of lesions. Prognosis in most instances is related to the severity of articular cartilage damage.

For those cases with small lesions and minimal damage, two weeks of stall rest followed by four weeks stall rest and hand walking are usually enough rest before the horse goes back in some kind of low level work, depending on the use of the horse.

This can consist of small turnout, equiciser or riding. At this stage most performance horses go back under tack and trail ride or begin jogging. Cantering is not needed at this stage since the impulsive loading of jogging can begin to stimulate the healing of affected tissues and the nonaffected tissues. Recheck examinations typically occur at two and six weeks, and then at key times when increased exercise will occur. The goal here is to be assured that no lingering lameness remains so the trainer can safely increase exercise. Intra-articular therapy may be needed Issue 2 • 2013

at recheck points in order to reduce any transient synovitis that may occur. If the horse does well, but then begins to experience lameness, it is important to objectively characterize the source of pain. Equine athletes typically have soreness in several locations, and resumption of exercise after a layup will typically induce pain in other areas. As an example, if a horse has a history of sore hocks, then increased work after a long layoff will likely induce stress and pain in those hocks. This can often be a good sign during the rehabilitation phase, as the horse, in this example, has attained a level of conditioning that is typical of his work.

More severe lesions often require some form of biologic or nonbiologic therapy to reduce inflammation and pain in order to enhance the ability to perform rehabilitation exercises.

Corticosteroids, hyaluronan, polysulfated glycosaminoglycans, IRAP, PRP or mesenchymal stem cells may be needed depending on the severity of damage. Regional venous perfusion with corticosteroids can also be used to try and reduce joint capsule inflammation and reduce pain. Joint capsule thickening is often involved with these cases, and immediate postoperative passive range of motion (60-90 flexions and extensions, asking for more flexion with time, twice daily are recommended) can be beneficial. However, medical augmentation with Surpass therapy is sometimes needed. In these cases, a dose of Surpass is applied to the site 30 minutes prior to exercise. At two weeks, this can be augmented with hand walking for four to six weeks, followed by riding.

Underwater treadmill therapy has gained popularity over the last several years, and objective data on its effectiveness is beginning to emerge. Various protocols exist, and the author typically begins therapy after suture removal at two weeks.

Acute joint injuries can be a challenge to manage since the severity of damage may not be fully characterized until weeks to months after the injury. Acute osteochondral fragmentation typically occurs in unusual locations in the joint, and the unknown component of these injuries is the severity and extent of joint capsule damage. Enthesiophytes may not be visible for several weeks to months after injury, making an accurate prognosis difficult to give. In these cases, the author begins a course of regional venous perfusion with corticosteroids in anticipation of the problem. Postoperative movement is essential, and hand walking may begin soon after surgery along with passive range of motion exercises. Swimming can also begin at suture removal depending on the degree of articular cartilage damage.

Chronic Joint Lesions

Horses with chronic joint injuries are difficult to manage because they are often chronically lame with reduced range of motion. Therefore, the primary pain and disease process needs to be addressed, as well as the pain and physiologic changes at remote sites. This compensatory change in use can sometimes limit the successful return to exercise. However, it must be emphasized that with chronic lesions, a permanent change in limb use, may result. Some horses are able to successfully perform with this in a humane manner. If articular cartilage lesions in these cases are severe, then exercise must be limited in the early phases so fibrocartilage can fill in the defect. However, passive range of motion, swimming and adjunct therapies such as chiropractic, acupuncture, etc. may have some benefit www.faep.netâ€

at this stage. The author has recommended shockwave and laser therapies for these cases.

Adhesive Tenosynovitis or Bursitis

Horses with significant adhesive tenosynovitis or bursitis generally fall into two categories: those with associated tendon damage and those without. The former is difficult to manage, as the horse needs rest for the tendon, but requires motion for decreasing the chances of adhesion reformation. In these cases, the author uses intrathecal hyaluronan once weekly for three weeks starting at the time of suture removal and begins passive range of motion exercises days after surgery. For the latter cases, in which tendon damage is not present, the horse begins hand walking within days of surgery in order to load the limb and prevent adhesion formation. Medical therapy is also used, but an aggressive approach is used. Swimming, underwater treadmill therapy and early return to riding are used in these cases, and are guided by the horse’s soundness. Combined therapies are also used, by alternating riding and water therapy.

Annular Ligament Desmitis

Horses that undergo transection of the digital annular ligament are aggressively put back into some form of work. However, care must be taken as some of these horses will get sore in the postoperative period. Intrathecal medication and follow-up ultrasound examinations may be needed in these cases.

Neurectomy and/or Fasciotomy for Proximal Suspensory Desmitis

The rehabilitation protocol for horses undergoing surgery for hind proximal suspensory desmitis depends on the severity of ligament damage. Those with chronically thickened ligaments are put back under saddle at suture removal and can be back into work in four weeks. The rehabilitation protocol for those with suspensory desmitis is dependent on the severity of damage.

Articular Fracture Recent evidence has shown that most Thoroughbred racehorses with cumulative stress-induced injury in the third metacarpal condyles can return to work after 60-90 days of freechoice exercise.7 However, some require internal fixation if a fracture persists. Otherwise, most articular fractures require internal fixation to align the joint surface, then rest to allow for the formation of bone across the fracture. However, continued stall rest beyond a certain period can be detrimental to healing, therefore, loading is required to stimulate full healing.

Fine Line Between Too Much AND Not Enough The most difficult part of instituting a rehabilitation program is determining when exercise can be increased.

Diagnostic imaging and level of soundness can be used, but The Practitioner  7

constant monitoring is needed to ensure that not too much, or not enough exercise is being used. In addition, the prognosis for a specific surgery can vary by breed and use, which must also be taken into account. With the advancement of inertial sensors for characterizing gait, more objective measures may be used in the future to guide these protocols.8,9 References: 1. Dykgraaf, S., E. C. Firth, et al. (2008). "Effects of exercise on chondrocyte viability and subchondral bone sclerosis in the distal third metacarpal and metatarsal bones of young horses." Vet J 178(1): 53-61.

2. Kawcak, C. E., C. W. McIlwraith, et al. "Effects of early exercise on metacarpophalangeal joints in horses." Am J Vet Res 71(4): 405-11.

3. Moffat, P. A., E. C. Firth, et al. (2008). "The influence of exercise during growth on ultrasonographic parameters of the superficial digital flexor tendon of young Thoroughbred horses." Equine Vet J 40(2): 136-40.

4. Nugent, G. E., A. W. Law, et al. (2004). "Site- and exercise-related variation in structure and function of cartilage from equine distal metacarpal condyle." Osteoarthritis Cartilage 12(10): 826-33.

5. Van Harreveld, P. D., J. D. Lillich, et al. (2002). "Clinical evaluation of the effects of immobilization followed by remobilization and exercise on the metacarpophalangeal joint in horses." Am J Vet Res 63(2): 282-8.

6. Van Harreveld, P. D., J. D. Lillich, et al. (2002). "Effects of immobilization followed by remobilization on mineral density, histomorphometric features, and formation of the bones of the metacarpophalangeal joint in horses." Am J Vet Res 63(2): 276-81.

8 The Practitioner

7. Tull, T. M. and L. R. Bramlage "Racing prognosis after cumulative stressinduced injury of the distal portion of the third metacarpal and third metatarsal bones in Thoroughbred racehorses: 55 cases (2000-2009)." J Am Vet Med Assoc 238(10): 1316-22.

8. Kawcak, C. E., C. W. McIlwraith, et al. "Effects of early exercise on metacarpophalangeal joints in horses." Am J Vet Res 71(4): 405-11.

9. Moorman, V. J., R. F. Reiser Ii, et al. "Validation of an equine inertial measurement unit system in clinically normal horses during walking and trotting." Am J Vet Res 73(8): 1160-70.

Christopher Kawcak DVM, PhD, DACVS, DACVSMR Dr. Kawcak graduated from Colorado State University with a DVM in 1991. He interned at Rood and Riddle Equine Hospital and then finished a residency at Colorado State University in 1995. He completed his PhD in joint pathophysiology in 1998, and is currently a Professor of Surgery in the Equine Orthopaedic Research Center at Colorado State University. He is Head of the Equine Section and specializes in Equine Lameness and Surgery.

Issue 2 • 2013

Equine Infectious Diseases in the Performance Horse

by Amanda M. House, DVM, DACVIM

Introduction Equine infectious diseases continue to emerge and re-emerge, infecting horses across the US and beyond. This paper will focus on pigeon fever, vesicular stomatitis, equine herpes virus, piroplasmosis, and strangles. A brief overview of the clinical course, treatment, state regulations, outbreak status and relevant information will be presented.

Pigeon Fever For the first time in recent history, Florida is seeing a large number of cases of pigeon fever in horses. In 2012, the state was reporting over 60 suspected equine cases in Okaloosa, Walton, and Marion counties. The majority of cases were confined to the Panhandle. This disease is caused by Corynebacterium pseudotuberculosis, which is a gram-positive rod. Horses and small ruminants typically get different strains of the infection, but cattle can get both types. In goats, the disease is known as caseous lymphadenitis, and affected animals will have external abscesses (the head, behind the ears, on the neck, shoulder or flank are some typical locations). Abscesses also occur in infected horses and cattle. Natural transmission from horses to goats or vice versa is not thought to commonly occur. Corynebacterium pseudotuberculosis is a soil organism that can survive for months, to even years in direct sun. The largest numbers of cases are www.faep.net

typically reported in the dry months of fall and winter.

Many things about this disease in horses are still not completely understood, such as the incubation period. The incubation period can be variable…. from weeks to even months.

The bacteria can enter the horse through the skin, wounds, or abrasions in the mucous membranes. Horses with pigeon fever may have a poor appetite, fever, lethargy, swelling along the chest or ventral abdomen, and/or lameness. Three forms of the disease can occur in the horse: external abscesses, internal abscesses, and ulcerative lymphangitis. The most common form of pigeon fever is the development of external abscesses.

These occur in about 90% of the cases. The disease got its name because abscesses will commonly occur in the pectoral region which becomes swollen and painful. In addition to the pectorals, abscesses may form on the prepuce, mammary gland, axilla, limbs, inguinal region, head, and other areas. There is no breed or sex predilection for acquiring the infection, although young horses may have some increased risk. The second form of the disease is internal abscessation, which has been reported in about 8% of cases. The most common site of internal abscesses is the liver, although they can be associated with other organs as well. The third form, ulcerative lymphangitis, is a severe cellulitis that occurs in the fewest number of cases. Clinical cases of ulcerative lymphangitis have severe lameness and swelling The Practitioner 9

of the limb. blanched and raised vesicles or blisters on the mouth, tongue, Definitive diagnosis of pigeon fever is made by culturing the lips, nostrils, hooves, and/or teats, and crusting scabs on the bacteria from an abscess or draining wound. There is a blood test muzzle, lips, and ventral abdomen. Fever may be noted as well. available (the synergistic hemolysis inhibition (SHI) test), but the Most horses recover in 2 weeks without specific therapy. results depend on the severity and length of infection; therefore, Transmission of VS is not fully understood; although insects, a negative serology does not rule out the disease. In fact, early in mechanical transmission, and movement of animals have all been the disease horses may have a negative SHI test. The SHI test is implicated. Direct contact with infected animals or exposure to helpful in horses with internal abscesses, as the titers are typically fluid from ruptured vesicles will spread the disease. Treatment very high (>1:512). Ultrasound examination may be a helpful is supportive, and may include non-steroidal anti-inflammatory diagnostic tool in these cases as well, especially for identifying drugs. Most infected horses will recover. Infected horses should internal abscesses in the abdominal cavity. be isolated, and infected farms are typically quarantined for 21 Treatment of pigeon fever is accomplished with drainage of days after the last lesion has healed. Since VS is considered a external abscesses. Abscesses should be allowed to mature and foreign animal disease, any case with clinical signs consistent then drained and flushed with antiseptic solutions. Purulent with VS will warrant an investigation by a state or federal foreign material drained from abscesses is highly infectious and must be animal disease diagnostician (FADD). The Florida Division of carefully handled and disposed of. Collecting as much purulent Animal Industry has released the following information: material as possible into a waste bag for disposal is critical to “To protect Florida’s livestock industry the Division of reduce the risk of other horses being exposed. Bedding of infected Animal Industry within the Florida Department of Agriculture, horses should be properly disposed of as well. Pain medication has increased import requirements for livestock originating may be indicated for horses with severe or deep abscesses or from VS affected states, as stated in Florida Administrative lameness. Topical fly treatment around wounds and draining areas Code 5C-3.002(5). A summary of the Florida VS import is critical to reduce the possibility of biting insects transmitting requirements are: the infection. Systemic antibiotics may be utilized for treatment All hoofed animals entering Florida from a VS affected state on a case-by-case basis. In routine cases with external abscesses, must have an Official Certificate of Veterinary Inspection antibiotics may prolong the course of the disease and are typically (OCVI) dated within 5 days of entry into Florida, not required. However, antibiotics are appropriate in cases with The OCVI must include the following VS statement severe disease or reoccurrence of infection. Long-term systemic

 “All animals susceptible to Vesicular Stomatitis (VS) antibiotics are required for treatment of horses with internal identified and included in this OCVI for shipment have been abscesses, which have a reported mortality rate of 40% (Aleman examined and found to be free from clinical signs and vectors et al). Fortunately, Corynebacterium pseudotuberculosis is usually of VS and have not been exposed to VS virus and have not sensitive to most antibiotics (including penicillin), but culture been within 10 miles of a VS-infected premises within the and sensitivity of a sample of purulent material is recommended last 30 days.” to direct therapy. Aleman et al reported that 90% of horses will  A prior permission number must be included on recover with no reoccurrence of infection. Approximately 8-9% the OCVI. The permission number can be obtained by calling of infections may persist for a year or reoccur, but the mortality 850-410-0900, rate for horses with external abscesses is <1%.  Exemption: Florida origin livestock returning to Unfortunately, no vaccine exists to prevent pigeon fever. It is Florida within 30 days of issuance of the Florida OCVI will recommended to isolate infected animals, especially if draining be allowed re-entry, but will be placed under quarantine until wounds/abscesses are present. Stalling affected horses will inspected 14-21 days after re-entry into the state. PLEASE help reduce contamination of the pasture environment with NOTE: Livestock returning to Florida from a VS affected infectious material. Ideally, horses should be treated in an area state, with a the Florida origin OCVI, will be quarantined for with concrete or rubber flooring that can be disinfected. Although 14-21 days pending inspection of the animals by a Division no reports exist of humans being infected from horses, there are of Animal Industry representative. Florida livestock owners reports of humans being infected with the sheep strain of the not wanting to be quarantined on re-entry into Florida should disease. Infection in people has occurred from the consumption obtain an OCVI from the affected state and comply with of infected unpasteurized milk or milk products, close contact requirements as stated above.” with infected animals, handling contaminated equipment, or exposure of wounds with infected material. Therefore, wearing gloves when handling infected horses is recommended. Fly Managing Strangles Outbreaks sprays and feed through fly control may both be beneficial for Strangles, infection with the bacteria Streptococcus equi subsp. insect control. equi, is a reportable disease in some states (such as Florida), and requires notification of the state veterinarian. Movement of any Vesicular Stomatitis horses on or off the farm should be stopped, and new horses Vesicular stomatitis (VS) is caused by vesicular stomatitis should not be introduced. It is recommended to take the rectal virus, in the family Rhabdoviridae, and affects cattle, horses, temperature of all of the horses on the premises twice daily. swine, and occasionally small ruminants and camelids. VS is Monitoring the rectal temperature and isolating horses at the a reportable disease, and looks identical to Foot and Mouth first sign of fever is one of the most effective ways to stop the disease in cattle. The typical incubation period is 2-8 days. The spread of infection. Infected horses can transmit the bacteria to most common clinical signs in the horse are excess salivation, healthy horses 1-2 days after they develop a fever.

10 The Practitioner

Issue 2 • 2013

An isolated area should be set up for horses with fever and any other signs of illness (nasal discharge, etc). Extreme care should be taken not to mix horses with infection, horses exposed to horses with strangles, and unexposed horses. Ideally, three groups of horses should be created: 1) infected horses 2) horses that have been exposed to or contacted infected horses and 3) clean horses with no exposure. No nose-tonose contact or shared water buckets should occur among the groups! Unexposed horses should be kept in a "clean" area, and should ideally have separate caretakers, cleaning equipment, grooming equipment, water troughs and pasture, since people and equipment can transfer the infection from horse to horse.

Extreme care, handwashing, and disinfection of supplies must be observed by everyone involved. If different individuals cannot care for infected and healthy horses, then healthy horses should always be dealt with first. Dedicated protective clothing such as boots, gowns or coveralls, and gloves should be utilized when dealing with infected horses.

Thorough cleaning and disinfection is critical when dealing with any infectious disease. All water troughs should be thoroughly cleaned and disinfected daily during an outbreak.

Read the label instructions on disinfectants to be sure they are used at the correct dilution and are active against S. equi. All surfaces and stalls should be disinfected following removal of manure and organic material. Manure will inactivate bleach and iodine type solutions. Manure and waste feed from infected horses should be composted in an isolated location, not spread on the pastures. Pastures that were utilized for sick horses should be rested for a minimum of 4 weeks. Fortunately, S. equi does not live for a prolonged time in the soil (about 3 days).

A serious challenge when dealing with an outbreak of strangles is identifying the horses that are carriers of the bacteria but are not showing any signs of illness. These horses can shed the bacteria for weeks, months, or even years, and serve as a continual source of reinfection for a farm. Ideally, all horses on the farm should be tested for strangles. The bacterial culture combined with PCR identifies carriers with a 90% success rate. Nasal pharyngeal swabs or washes can be done to sample the horses for infection. The washes improve the chance of identifying carrier horses. Additionally, all sick horses should test negative 3 consecutive times before being put back with healthy horses. Previously infected horses can shed the bacteria for weeks to months, or even years in rare cases; therefore, 3 negative test samples are recommended prior to reintroduction to the healthy herd. For the most accurate diagnosis of carriers and horses without obvious clinical signs, upper airway and guttural pouch endoscopy should be performed.

Vaccination is one method for prevention and control of infection with S. equi. However, vaccination cannot guarantee disease prevention. With strangles, vaccination will most likely reduce the severity of disease in the majority of horses infected after they are vaccinated. The intranasal vaccination results in the best local immunity. Vaccination is generally not recommended during an outbreak of strangles. If there are horses on the farm with no clinical signs of infection (fever, nasal discharge) and no known contact with sick horses, vaccination may be considered. Horses that have had the disease within the previous year also do not need to be vaccinated. Once recovered from an active infection, 75% of horses have immunity for 1-2 www.faep.netâ&#x20AC;

years. Vaccination of horses recently exposed to strangles (that have high antibody levels) may result in purpura hemorrhagica.

Vaccination is only recommended in healthy horses with no fever or nasal discharge. It takes about one month from vaccination for immunity to develop. Therefore, if vaccination is elected, be certain to vaccinate horses in advance of transport or potential exposure to new horses.

Equine Piroplasmosis In the last few years, over 500 horses in the United States had tested positive for equine piroplasmosis (EP). Although this disease can cause severe hemolytic anemia and vasculitis necessitating euthanasia, it can also be silent and cause no apparent signs at all. Piroplasmosis is a reportable disease, and its emergence is affecting equine transportation across state lines and to other countries.

Piroplasmosis is caused by the protozoan parasites Babesia caballi and Theileria equi (formerly called Babesia equi). It also can affect donkeys, mules, and zebras; but clinical disease in those equids is rare. The disease is transmitted by ticks and other biting insects; however, shared needles and/or blood contamination has been implicated in several disease outbreaks.

Once horses are infected with T. equi, carrier status may be lifelong. Carrier horses are also capable of transmitting the disease to ticksâ&#x20AC;&#x201D;vectors that can transmit it to other horses.

The disease is considered endemic in Africa, Central and South America, Asia, the Middle East, the Caribbean, and the Mediterranean. The U.S. has not been considered an endemic region. When infection occurs, T. equi tends to be the most common agent, rather than B. caballi. However, infection with both parasites can occur simultaneously.

Once horses become infected with the parasite, it usually takes between 5 and 30 days for any signs of the disease to appear. As previously stated, infected horses may not have any signs of EP at all. Generally, affected horses display nonspecific signs that can look similar to other diseases. Fever, depression, anorexia, pale or icteric mucous membranes, and edema of the limbs or along the ventral abdomen have been commonly reported. Reddish-brown or discolored urine may also be observed. Laboratory abnormalities typically include anemia and thrombocytopenia.

The Practitionerâ&#x20AC;&#x201A; 11

Several laboratory tests are available for diagnosis of EP. Occasionally, the parasite can be seen on microscopic examination of a blood smear. The U.S. Department of Agriculture (USDA) standard test is the cELISA (competitive enzyme-linked immunosorbent assay). Specific laboratories (the National Veterinary Services Laboratories, Texas Veterinary Diagnostic Services Laboratories, Florida’s State Diagnostic Laboratory) have been identified to run the tests and report the results. The Bronson Animal Disease Diagnostic Laboratory (BADDL, formerly Kissimmee Animal Disease Diagnostic Laboratory) in Florida was approved by the USDA for equine piroplasmosis testing. BADDL can test blood samples for interstate and intrastate purposes, but the National Veterinary Services Laboratories is still testing all international transport samples.

Horses that test positive for equine piroplasmosis MUST be quarantined. Local veterinarians can work with state and federal veterinarians to ensure that manageable quarantine guidelines are being followed and are in place. Although there are several drugs (imidocarb, etc) that have been identified for treatment of piroplasmosis, the organisms can be refractory to treatment, and the carrier state is difficult to clear. Euthanasia for positive horses is not necessarily required, nor is it being recommended in every case by the USDA, especially since so many positive horses are asymptomatic. State and USDA veterinarians are working in conjunction with local veterinarians and owners to determine the best recommendations for each positive horse. Some owners elect to transport positive horses out of the country—to countries that have endemic piroplasmosis— but that is not a palatable option for most. In addition to quarantine, there is a treatment research program available for positive horses. This program is in conjunction with Washington State University and Dr. Don Knowles. Owners and their local veterinarians work with the USDA and Dr. Knowles to determine if they have a horse that is eligible for enrollment.

The outbreak of equine piroplasmosis in Florida in 2008 identified 20 positive horses. Twenty-five quarantines were placed in Manatee, Polk, DeSoto, Lake, and Dade counties; seven premises had positive horses. The last premise in Florida was released from quarantine in February of 2009. Since then, additional positive cases were reported in September of 2010.

Fortunately, tick surveillance in Florida thus far has not revealed evidence of natural (tick) transmission. Blood contamination from shared needles was implicated in the outbreak. Unlike Florida, tick transmission was identified in the Texas outbreak.

The USDA and state veterinarians are involved in an ongoing investigation in that state.

Fortunately, it does not appear that tick transmission has been significantly involved in EP transmission outside of the affected premises in Texas. However, people can spread this disease from horse to horse, and we can prevent that mode of transmission. All dental, surgical, and tattoo equipment must be thoroughly disinfected between horses. Horses have contracted the disease though the use of shared needles and/or syringes, as well as from blood transfusions. A new sterile needle and syringe should be used for each injection, whether into a muscle or a vein. Additionally, a previously used needle should never be inserted into a drug or vaccine multidose vial—and owners/ trainers should be reminded of these infection control measures.

12 The Practitioner

Work with your veterinarian to ensure that all equipment is thoroughly cleaned and disinfected between horses. EP is still a very uncommon disease in the U.S., but it is critical to be vigilant and follow preventative measures.

Equine Herpes Virus Equine herpes virus occurs worldwide as a cause of respiratory disease, neurologic disease, and abortion. Although outbreaks of equine herpes virus myeloencephalopathy (EHM) have been sporadic, they seem to be occurring with increasing prevalence.

The disease is spread from horse to horse contact via respiratory and nasal secretions. Vaccination reduces shedding but is not protective against EHM. Recent outbreaks have been reported across the United States, and included Florida in February/ March of 2013. The neurotropic strain of the virus is more likely to cause EHM, however, research on equine herpesvirus at this time does not support that the strains should be treated differently from an isolation and biosecurity standpoint. As demonstrated in our recent FL outbreak, the wild-type strain is capable of causing EHM. Additionally, both virus strains are similar with regards to peak titers of virus shedding, suggesting that they have a similar capacity to spread in a population of horses. Equine herpesvirus serves as an excellent reminder of the importance of good biosecurity practices. Horses with fever should be monitored closely and treated as suspect infectious disease cases. Horses returning home from large events ideally should be monitored, optimally twice a day, for the development of fever. If horses are returning home from events where a potential exposure may have occurred, they should be isolated from other horses on the farm. EHV-1 is spread primarily by horse to horse contact through respiratory secretions, but can also be spread through contact with contaminated hands, clothes, tack, grooming equipment, feed buckets, trailers, etc. moving from horse to horse. Hand washing and the disinfection of equipment between animals is of paramount importance. The virus is not particularly hardy in the environment, surviving about a week in most circumstances. It is easily killed by most disinfectants when those practices are utilized.

Positive horses should be isolated from the rest of the herd.

Use separate grooming/feeding/cleaning equipment. Use of dedicated clothing or gowns, gloves, boots, and caps are recommended for management of infected horses, in addition to foot baths and hand washing/sanitizers. Positive horses should not be moved from the stall or paddock where they are being isolated, if at all possible. Temperature should be checked twice daily. Repeat testing of positive animals can proceed as their fever and other signs resolve, but waiting 21 days from initial positive can maximize the possibility of obtaining a negative result. For previously positive horses, obtain three negative buffy coat and nasal swab PCR tests before clearing them from isolation.

Diagnostic testing (AAEP recommendations): Wear disposable gloves and change gloves between each horse Collect whole blood into EDTA and label sample (preferably have an assistant label samples) If a twitch is used to restrain the horse it must be washed and disinfected between horses Nasal swab collected using Dacron tipped swab with plastic Issue 2 • 2013

shaft. Swab should be in contact with nasal mucosa for at least several seconds.

Place swab in viral transport media or other transport solution (such as saline) recommended by laboratory performing the test and label sample. Use a small volume of transport fluid (less than 2 mL) to avoid over-dilution of the sample.

Perform hand hygiene between horses sampled and put on new pair of examination gloves Keep samples cool but not frozen and ship by overnight delivery Request real-time or nested PCR test and virus isolation If sample reported as PCR positive, request typing of the virus Sample Submissions for EHV Testing (please note the list is not comprehensive): Nasal swab, Nasal Wash, Whole blood (purple top) for real time PCR: Equine Diagnostic Solutions, LLC 1501 Bull Lea Rd. Suite 104 Lexington, KY 40511 859-288-5255; http://www.edslabky.com/ Nasal swab, respiratory secretions, blood (purple top) for quantitative PCR and genotype: Real-time PCR Lab 3110 Tupper Hall One Shields Ave UC Davis, SVM Davis, CA 95616-8737 Phone: 530-752-7991; Fax: 530-754-6862 http://www.vetmed.ucdavis.edu/ceh/ehv1_diagnostic.cfm

Further References: 1. http://www.freshfromflorida.com/ai/pdf/WebsiteAnnouncementPigeonFever.pdf 2. Aleman MR and Spier SJ. Corynebacterium pseudotuberculosis infection.

In Large Animal Internal Medicine, 3rd Ed. Smith BP, 2002, Mosby, Inc, St. Louis, MO; pp1078-1083.

www.faep.net

3. Sweeney CR, Timoney JF, Newton JR, and Hines MT. Streptococcus equi Infections in Horses: Guidelines for Treatment, Control, and Prevention of Strangles. J Vet Intern Med 2005; 19: 123-134.

4. http://w w w.aphis.usda.gov/animal _ health/animal _diseases/ piroplasmosis/downloads/ep_protect_your_horses_en_sp.pdf 5. http://www.aphis.usda.gov/publications/animal_health/content/ printable_version/fs_equine_piro.pdf 6. http://www.doacs.state.fl.us/ai/index.shtml 7. http://www.aaep.org/images/files/EquineHerpesvirusFinal030513.pdf

Amanda M. House DVM, DACVIM Dr. Amanda House is a Clinical Associate Professor in the department of large animal clinical sciences at the University of Florida’s College of Veterinary Medicine. She is a large animal medicine clinician in the equine hospital and coordinates equine continuing education and outreach programs at the College of Veterinary Medicine. Dr. House is the Director of the Practice-Based Equine Clerkship program and the Equine Research Program. She completed her BS in Animal Science from Cornell University. After graduating from Tufts University School of Veterinary Medicine in 2001, Dr. House completed an internship and large animal internal medicine residency at the University of Georgia’s Veterinary Teaching Hospital. Dr. House became board certified in large animal internal medicine in 2005. Her professional interests include neonatology, infectious disease, and preventative health care.

The Practitioner 13

Your Invitatio

9th Annual Promoting

Advanced Equine Sports Medici

OCTOBER 17â&#x20AC;&#x201C;â&#x20AC;&#x2030;20, 2013 Boca Raton Resort & Club

Welcome to

Boca Raton Resort & Club, A Waldorf Astoria Resort 501 East Camino Real, Boca Raton, Florida, 33305

Old world elegance with modern-day luxury resort living The Boca Raton Resort & Club, a Waldorf Astoria Resort, has reigned as an icon of elegance for more than 80 years. It was built by legendary American architect Addison Mizner, and today, the resort remains faithful to its glamorous past, while radiating a vibrant energy, offering infinite modern amenities to every type of guest.

Offering

13 Nationally & InternationallyAcclaimed Speakers delivering 41 hours of Cutting-Edge Continuing Education.

GOLD PARTNERS

Platinum PARTNER

Speci a l Th a nk s to our 20

on To Attend

Excellence Symposium

ine -The Whole Horse Approach

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at the Boca R aton Resort & Club from one of the Special FAEP Room R ates below:

Ensure Your Room at the Host Hotel, Reserve Today!

FAEP Special Room Rates Rates Include the Hotel's $22 Daily Resort Fee. Bungalow Room Bungalow Suite Cloister Room Tower Room Tower Junior Suite Beach Club Standard Room Beach Club Ocean Vista Room

$159.00 $199.00 $159.00 $179.00 $219.00 $199.00 $219.00

RESORT FEES: Resort Fees include bellman gratuities for arrival and departure; resort transportation within the resort; unlimited local and toll-free calls; in-room high speed internet; in-room coffee and tea; newspaper; Resortâ&#x20AC;&#x2122;s fitness centers use; BoardEZ (for printing boarding passes), golf bag storage and Notary Services.

VALET PARKING: There is a discounted $20.00 overnight valet parking charge for guests driving in.

Complimentary self-parking is only available for the guests with Bungalow accommodations.

End roup Rates G l a eci Sp

mber 16, e t p Se

013 Educ at ion a l Pa rtn er s LUITPOLD ANIMAL HEALTH

20 1 3

Distinguished Speakers Kent Allen, DVM, Certified in Equine Locomotor Pathology (ISELP)

Sue Dyson, MA, VetMB, PhD, DEO, FRCVS

Steve Reed, DVM, DACVIM

Jennifer Skeesick, PT, DPT, SCS

Edwin Bayó, JD

Jose Garcia-Lopez, VMD, DACVS

Virginia Reef, DVM, DACVIM, DACVSMR

Michael Torry, PhD

Philippe Benoit, DVM

Eric Mueller, DVM, PhD, DACVS

Mike Ross, DVM, DACVS

Dennis Brooks, DVM, PhD, DACVO

John Peloso, DVM, DACVS

Sheila Schils, PhD

Offering Florida’s New Requirement on Laws & Rules & Dispensing Legend Drugs  2 hours in Laws & Rules Governing the Practice of Veterinary Medicine in Florida  1 hour in Dispensing Legend Drugs

Gener al Information Advanced Registration

No-shows are not refundable.

The FAEP strongly recommends that you register in advance for our 9th Annual Promoting Excellence Symposium. Registration is required for all aspects of the meeting. Your registration includes all CE sessions, access to the Marketplace, Friday and Saturday lunch, conference proceedings and all breaks held in the Marketplace. Advanced registrations are taken at the FAEP office until September 16, 2013. After this date, a late registration fee of $50 will be added to all registrations, including on-site registrations.

Continuing Education Hours

Confirmation A confirmation of your registration will be mailed to your from the FAEP. Please contact us if any information in the confirmation is incorrect for timely correction of the error.

Cancellation Policy Cancellation deadline for a full refund of registration fees minus a $50 administrative charge is September 16, 2013. Cancellations should be submitted to the FAEP in writing and acknowledged by the above date to be eligible for a refund.

Each 50-minute lecture is worth one continuing education credit. Attendees can earn up to 28 credit hours. For your convenience in recording your CE hours, one certificate will be included in your registration packet. It is your responsibility to document the sessions you attend and the number of hours you receive.

Air Transportation Two major airports service the Boca Raton region of southern Florida. The Fort Lauderdale / Hollywood International Airport (FLL) is only 24 miles to the south, while the Palm Beach International Airport (PBI) is situated just 28 miles north of Boca Raton.

Near at hand is the Pompano Beach Airpark, which is 7.56 miles away from Boca Raton.

AAVSB RACE This program has been submitted (but not yet approved) for 41 hours of continuing education credit in jurisdictions that recognize AAVSB RACE approval. However, participants should be aware that some boards have limitations on the

number of hours accepted in certain categories and/or restrictions on certain methods of delivery of continuing education. Call Diana Ruiz at (800) 992-3862 for further information. A maximum of 28 credit hours can be earned at this conference.

Symposium Marketplace The FAEP’s 9 th Annual Promoting Excellence Symposium will provide exhibitors and attendees with the greatest value. It will be a hub of activity; the showcase for industry; providing a valuable opportunity for networking and interaction among industry representatives and veterinary professionals.

Marketplace Hours Thursday, October 17 ... 5:35 p.m. – 7:00 p.m.

Friday, October 18 ... 8:00 a.m. – 6:30 p.m.

Saturday, October 19 ... 8:00 a.m. – 4:20 p.m.

Be sure to stop by and visit! Our industry partners will display the very latest in equine-exclusive products and services.

Additional Questions Contact the FAEP toll free at (800) 992-3862.

S che d u le Thursday, October 17 Time

Room 1

12:50 p.m.

- 1:00 p.m.

Welcome

1:00 p.m. 1:50 p.m.

Is Standing MRI the Future for Pre-Fracture Risk Assessment in the Thoroughbred Racehorse Fetlock?

Friday, October 18 Time

Room 1

8:00 a.m. 8:50 a.m.

The Dyson and Ross News Hour

8:55 a.m. 9:45 a.m.

The Dyson and Ross News Hour

Dr. John Peloso 1:55 p.m. 2:45 p.m.

Wobblers: Conservative Management vs.

Surgery and a 5-Year Follow Up Dr. Steve Reed

2:50 p.m. 3:40 p.m.

Break - Visit the Marketplace

Stress Fractures, Track Surfaces Plus Other Issues

Changes in Medical Standards for Treating the Equine Eye Dr. Dennis Brooks

Dr. Steve Reed Break

11:25 a.m. 12:15 p.m.

Equine Rectal Exam: What am I Really Feeling?

A Laparoscopic Perspective

Interactive Colic Case Presentations and Practitioner Discussions Dr. Eric Mueller

5:35 p.m. 7:00 p.m.

Dr. Sue Dyson and Dr. Mike Ross

Dr. Mike Ross

Dr. Eric Mueller 4:45 p.m. 5:35 p.m.

10:30 a.m. 11:20 a.m.

Room 2

Dr. Sue Dyson and Dr. Mike Ross

9:45 a.m. 10:30 a.m.

Peripheral Neuropathies

3:40 p.m. 3:50 p.m.

3:50 p.m. 4:40 p.m.

At

Proximal Injuries of the Accessory Ligament of the Deep Digital Flexor Tendon and Patellar Ligament Injuries

Equine Ophthalmic Exam and Emergency Evaluation: The Must-do Procedures for Every Eye

Dr. Sue Dyson

Dr. Dennis Brooks

12:15 p.m. 1:35 p.m.

1:35 p.m. 2:25 p.m.

Complimentary Lunch in the Marketplace

Enostosis-like Lesions: Where do we Stand?

Dr. Mike Ross

Dr. Dennis Brooks

Marketplace Cocktail Reception

Dyson & Ross News Hour Keep up with published scientific equine clinical advancements of the past year through brief, yet specific reviews of selected papers presented by the Dyson & Ross News Hour at the FAEP’s 9th Annual Promoting Excellence Symposium.

Sue Dyson, MA, VetMB, PhD, DEO, FRCVS, is Senior Orthopaedic Clinician in the Centre for Equine Studies at the Animal Health Trust, United Kingdom. Michael Ross, DVM, DACVS, is Professor of Surgery at the School of Veterinary Medicine, New Bolton Center, Kennett Square, PA. Hear what these well-respected and knowledgeable leaders of the equine profession have to say about the latest important clinical information that practitioners need to know. Many of the featured issues to be discussed are either too brief or too new to be included in this year’s scientific program. This is one news program you won’t want to miss!

Ophthalmic Surgery: Where We Are and What We Can Do Now?

2:30 p.m. 3:20 p.m.

Is This Horse Lame or is it Neurological?

Dr. Steve Reed

Heart Size, Training and Performance: What is the Evidence?

Dr. Virginia Reef

3:20 p.m. 3:50 p.m.

3:50 p.m. 4:40 p.m.

Break - Visit the Marketplace

Diagnosis and Management of Conditions Affecting the Navicular Bursa Dr. Jose Garcia-Lopez

4:45 p.m. 5:35 p.m.

Not Racing Fast Enough: Is There Enough Heart?

Dr. Virginia Reef

What's New in Regenerative Medicine from a Clinician's Standpoint

Medical Ultrasonography of the Poorly Performing Horse

Dr. Jose Garcia-Lopez

Dr. Virginia Reef

5:35 p.m. 6:30 p.m.

Marketplace Cocktail Reception

Continuing Education Credits This program has been approved by

 Florida Board of Veterinary Medicine, DBPR FVMA Provider # 31  Approved as New York State Sponsor of Continuing Education Pending Race Approval

- American Association of Veterinary State Boards RACE Provider #532

Fo r m o r e d e t a i l s , p l e

t - A - G lance Saturday, October 19 Time

Room 1

Room 2

7:00 a.m. 7:50 a.m.

Dispensing Legend Drugs

8:00 a.m. 8:50 a.m.

Surgical Management of Soft Tissue Injuries: Update Dr. Mike Ross

The Science of Rehabilitation

The Value of Ridden Exercise during Lameness Investigation and Saddle Slip as an Indicator of Hindlimb Lameness Dr. Sue Dyson

Biomechanics of Joints: Human and Horse

Sunday, October 20 Time 6:15 a.m. 7:05 a.m.

Mr. Edwin Bayó

Room 1

Florida Laws and Rules Governing the Practice of Veterinary Medicine Part I Mr. Edwin Bayó

8:55 a.m. 9:45 a.m.

9:45 a.m. 10:30 a.m.

10:30 a.m. 11:20 a.m.

11:25 a.m. 12:15 p.m.

12:15 p.m. 1:35 p.m.

1:35 p.m. 2:25 p.m.

Dr. Sheila Schils

Case Studies

Rehabilitation of High Suspensory Injuries

Dr. Sue Dyson and Dr. Mike Ross

Dr. Kent Allen

Complimentary Lunch in the Marketplace

Masterclass: Clinical Evaluation and Treatment of the Equine Neck

Evidence-based Evaluation and Treatment of Cervical Disorders in the Human Population and the Relationship of these Principles to Horses Dr. Jennifer Skeesick

Masterclass: Clinical Evaluation and Treatment of the Equine Back Dr. Philippe Benoit

Evidence-based Evaluation and Treatment of Sacral Illiac Disorders in the Human Population and the Relationship of these Principles to Horses Dr. Jennifer Skeesick

3:20 p.m. 4:20 p.m.

4:20 p.m. 5:10 p.m.

Break - Visit the Marketplace

Masterclass: Clinical Evaluation and Treatment of the Equine Pelvis Dr. Philippe Benoit

5:15 p.m. 6:05 p.m.

Rehabilitation Case Studies - The Human and Equine Athlete

8:55 a.m. 9:45 a.m.

Rehabilitation Case Studies - The Human and Equine Athlete

9:45 a.m. 10:00 a.m.

Drs. Benoit, Allen, Torry, Skeesick, Schils

Drs. Benoit, Allen, Torry, Skeesick, Schils Break

10:00 a.m. 10:50 a.m.

Rehabilitation Case Studies - The Human and Equine Athlete

10:55 a.m. 11:45 a.m.

Rehabilitation Case Studies - The Human and Equine Athlete

Drs. Benoit, Allen, Torry, Skeesick, Schils

Dr. Kent Allen

Dr. Philippe Benoit

2:30 p.m. 3:20 p.m.

8:00 a.m. 8:50 a.m.

Dr. Mike Torry

High Suspensory Injuries: Conformation Faults that Lead to Injury

Dr. Sue Dyson and Dr. Mike Ross

Florida Laws and Rules Governing the Practice of Veterinary Medicine Part II Mr. Edwin Bayó

Break - Visit the Marketplace

Case Studies

7:05 a.m. 7:55 a.m.

Biomechanics of Joint Injury: Prevention and Treatment Dr. Mike Torry

Masterclass: Rehabilitation for Problems Which Affect the Back Dr. Philippe Benoit

a s e v i s i t w w w. f a e p. n e t

Drs. Benoit, Allen, Torry, Skeesick, Schils

Rehab Case Studies - The Human & Equine Athlete Case Studies of Rehabilitation Protocols from Start to Finish Get involved! A full morning of case studies from the entire staff of rehabilitation presenters is planned. Each horse will be followed from diagnosis through the completion of the rehabilitation protocols – what worked, what didn’t, what could have been tried? Have you ever had a case like this? Speak up, we want to hear about your experiences, too. In addition, one of the most distinguished clinicians currently in human rehabilitation will be on hand to discuss another perspective – what would happen if this horse were a human?

Leave with some solid ideas on protocols that you can use in your practice.

One-on-one with Dyson & Ross Take advantage of this rare opportunity to reserve a oneon-one consultation with world-renowned equine clinical specialists, Dr. Mike Ross and Dr. Sue Dyson. Drs. Ross and Dyson will avail themselves to you for private 15-minute sessions throughout the day on Friday and Saturday in the PES Marketplace.

Limited time slots are available and you are requested to secure your individual meeting by making your appointment early, and pre-reserving your time with the experts. Please select your preferred time on the registration form. Final confirmation for these limited appointments will be sent prior to the symposium.

Appointments are strictly on a first-come, first-served basis.

This is a valuable opportunity to benefit from the expertise of these two illustrious clinicians in a private, undisturbed meeting. Have your questions answered; discuss the latest industry issues; confer on the most advanced techniques and innovations in equine clinical practice.

PRE -R 9 Annual Promoting Excellence Symposium & S EGIST AV ER N E$ October 17 - 20, 2013 • BOCA RATON, FL 50 OW !!

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FAEP’s Charter Fishing Tournament – Thursday, October 17th , 7:30 AM - 12:00 PM Includes - Transportation, License, Tackle, Bait and 1/2 Day of Fun!

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$95.00

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The Practitionerâ&#x20AC;&#x201A; 21

Return to Performance in Horses with Colic Surgery

by Anthony Blikslager, DVM, PhD, Diplomate ACVS of horses, cosmetic appearance may preclude return to use and performance in animals used for showing such as halter events and performance such as dressage, which is not supposed to be taken into consideration by the judge, but unfortunately distracts judges and tends to lower scores. In addition, owner opinion that a benign abdominal wall defect renders the animal unsound or unfit for athletic activity may cause lower than expected numbers for return and performance. In some cases, owners or trainers may have a good point. Veterinarians should adequately counsel clients to ensure that hernias are surgically repaired if necessary and that horses are not unnecessarily retired for clinically insignificant abdominal wall defects.

Affect of post-operative diarrhea

Introduction Return to intended use and performance following colic surgery is of major concern to horse owners. The potential for return to performance is weighed against the cost of surgery, intensive post-operative care, and prolonged convalescence. In two studies, the authors report an 81%1.i and 90.1%1.ii return to expected performance following colic surgery. However, the factors related to reporting the likelihood of return to use (much like prognosis for recovery from surgery) are critical when talking to owners whose horses are involved in performance. Some owners are hoping to save the lives of their horses, but many owners would like to know if the cost of critical care and surgery will affect performance. One very important factor to take into consideration is that although veterinarians at specialty hospitals tend to think in terms of short-term survival (the likelihood of surviving to discharge), and rehabilitation is considered to be three months (one month of stall rest, one month of small paddock rest, and one month of return to exercise), a more realistic rehabilitation period is six months. What are the reasons for this?

Affect of Incisional Herniation Incisional herniation has a reported incidence of 8-16% following exploratory celiotomy. In a recent study2, we found that incisional hernia formation placed horses at 3-fold the risk for failure to return to use at the six- month interval, and a 3.5-fold risk for failure to return to use at the one-year interval.

Decrease in return to use at six months is likely attributed to recommendations such as restricted activity, prolonged stall rest, or hernia belt application, and this may have dramatic effects on muscle mass and strength. Depending upon the type of use 22 The Practitioner

Recent studies have shown that diarrhea develops in approximately 30% of horses postoperatively. This is likely because of disruption of the microbiome of the large colon, and greater consideration using pre or probiotics should be given to reduce this percentage. In a study recently performed at NC State University, development of postoperative diarrhea, while in the hospital, increased the risk for failure to return to use at six months. Diarrhea itself does not seem to be a primary cause for the delay in return to exercise. Rather, malabsorption associated with the diarrhea may result in decreased body condition and prolong convalescence. Horses with postoperative diarrhea may also have a delayed recovery due to prolonged or latent infection with an organism such as salmonella.

Laminitis In the recent study from North Carolina State University, horses with laminitis are significantly less likely to return to use at six months, and use and performance at one year. As laminitis often results in permanent debilitation and persistent lameness, this finding was not surprising. Fortunately, laminitis is generally reported as a rare complication (approximately 1-3%) in postoperative colic patients. Our study did not support a common clinical opinion that horses with strangulating lesions are less likely to return to performance when compared to their surgical counterparts with a simple lesion type. Interestingly, the return to use in the strangulating obstruction group was significantly higher at six months when compared to horses with a non-strangulating lesion type. In our study, a strangulating lesion was not considered to be a protective factor using common sense, but related factors in this group likely contribute to this observation. Prolonged hospitalization and more aggressive prevention, monitoring, and intensive care of secondary complications may decrease the risk for return to use. For example, owners who were willing to invest in a more expensive surgery and aftercare associated with resection and anastomosis may be more likely to value the performance of Issue 2 • 2013

Orthopedic Conditions Horses with a history of stall rest for an orthopedic condition at the time of celiotomy were significantly less likely to return to full performance at one year. However, in the NC State study, there was no significant difference at the six- month follow-up interval for return to use or performance. The delay in return to full performance at one year only is most likely a result of recurrent lameness. In practical terms, horses with a lameness issue and the need for colic surgery may regain performance because of stall or paddock rest, but the owner should think clearly about return to exercise after two conditions: colic and lameness. These cases can generally be saved, but performance is unlikely.

Conclusions The overall return to general use and performance following colic surgery is fair (approximately 50%). A history of previous celiotomy, stall rest for an orthopedic condition, hernia formation, post-operative diarrhea, and laminitis place horses significantly at risk for return to the expected performance following colic surgery. Targeted owner education regarding postoperative rehabilitation, continued treatments to restore the colonic microbiome, and correct treatment of incisional infection to prevent hernia repair, may improve the return to performance after colic surgery.

References: 1. i. Wiemer, P., Bergman, H.J., van der Veen, H. and Pruissen, L. (2002) Colic surgery in the horse, a retrospective study of 272 patients. Tijdschr.

Diergeneeskd 127, 682-686. ii.

Van der Linden, M.A., Laffont, C.M. and Sloet van OldruitenborghOosterbaan, M.M. (2003) Prognosis in equine medical and surgical colic. J. Am. Vet. Med. Ass. 17, 343-348.

2.

Davis, W., Fogle, C.A., Gerard, M.P., Levine, J.F., and Blikslager, A.T. (2013)Return to use and performance following exploratory celiotomy for colic in horses: 195 cases (2003-2010). Equine Vet. J. 45:224-228.

Anthony Blikslager, DVM, PhD, DACVS Dr. Anthony Blikslager is a professor of equine surgery and gastroenterology at North Carolina State University. His laboratory focuses on how intestinal mucosa repairs after insults such as ischemia. Dr. Blikslager is an associate editor for the Equine Veterinary Journal and serves on the Editorial Review Board of the American Journal of Veterinary Research. He also is an active member of the American Gastroenterological Association, has more than 120 peer-reviewed publications, and continues to work in the clinic on horses with colic.

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The Practitioner 23

LAMENESS ASSOCIATED WITH THE SHOULDER JOINT AND BICEPS BURSA

by Lisa A. Fortier, DVM, PhD, DACVS

L

ameness of the shoulder joint and biceps bursa are relatively rare. Because shoulder pathologies are uncommon and relatively difficult to diagnose, treatment can be delayed, leading to an increase in secondary osteoarthritis in the case of the shoulder joint. Further, there are very few large studies documenting treatment and outcome following specific injuries or treatments to guide the clinician.

Localization of lameness to the shoulder region can be straightforward in cases when there is associated swelling or pain on palpation, but in many cases intra-articular or bursal anesthesia is necessary to confirm clinical examination findings. Horses with fractures or luxations of the shoulder joint are acutely, and initially, severely lame and have localized swelling.

In less severe cases, joint effusion cannot be palpated because of the overlying musculature, but a painful response can often be elicited following deep palpation of the notch between the cranial and caudal prominences of the greater tubercle of the humerus.

Less specific signs of shoulder lameness include shoulder muscle atrophy – best viewed from above, pain on extension or flexion of the shoulder joint, a narrow ipsilateral hoof with a long heel, and, typical of forelimb lameness, signs of a shortened anterior phase of the stride. Nuclear scintigraphy can help localize the cause of lameness to the shoulder joint.

When the lameness is localized to the shoulder region, radiographs should be obtained. If bicipital bursitis or biceps tendinitis is suspected, an ultrasonographic examination should be performed. Although not currently available for imaging equine shoulders, magnetic resonance imaging (MRI) is considered the method of choice for evaluation of shoulder pain in people because it provides detailed information on all bone and softtissue components of the shoulder. Radiographs of the shoulder joint can usually be obtained in the standing horse, although higher quality images are achieved when the horse is under general anesthesia because of the absence of motion artifact.

The horse’s leg is extended forward to center the shoulder joint over the trachea for a standard mediolateral, or a more specific cranioproximal-craniodistal oblique view of the proximal portion of the humerus projection, to diagnose long oblique fractures of the greater tubercle. Normal survey radiographs do not exclude the shoulder as a cause of lameness, particularly in cases of osteochondrosis (OC) or other pathologies of the humeral head or glenoid cavity. In cases where survey radiographs are normal and OC is suspected, positive- or double-contrast radiography should be performed.

INTRASYNOVIAL ANESTHESIA OR SYNOVIAL CENTESIS When clinical examination findings do not definitively localize the lameness to the shoulder joint or bicipital 24 The Practitioner

bursa, diagnostic intrasynovial anesthesia can be useful.

Local anesthetic (20 mL) is delivered into the shoulder joint using an 18-gauge, 8.9-cm spinal needle inserted in the notch between the cranial and caudal prominences of the greater tubercle of the humerus. The needle is directed toward the elbow of the opposite limb, parallel to the ground, and is advanced until bone or cartilage is contacted. Extrasynovial deposition or leakage of local anesthetic solution out of the shoulder joint can block the suprascapular nerve, resulting in lateral subluxation of the scapulohumeral joint, thereby producing the clinical appearance of sweeney. If the suprascapular nerve is inadvertently blocked, the horse should be placed in a box stall until the anesthetic wears off to prevent injury. In horses with intact cartilage that covers subchondral bone abnormalities, there might be minimal or no improvement in lameness following intra-articular anesthesia.

The bicipital bursa is entered approximately 4 cm proximal to the distal aspect of the deltoid tuberosity. An 18-gauge, 8.9-cm spinal needle is inserted between the biceps brachii muscle and the humerus and directed proximomedial to approximately 4 cm in depth, where 5 to 10 mL of local anesthetic is injected. Synovial fluid can usually be aspirated from both the shoulder joint and bicipital bursa to confirm intrasynovial needle placement,and therefore, deposition of local anesthetic or for synovial fluid analysis and culture in cases where infection is suspected.

Cadaveric and pre-clinical studies suggest that ultrasonographic guidance can be helpful for performing injection/ centesis of the shoulder joint or biceps bursa, but clinical experience was the most important factor for success. A thorough knowledge of the regional anatomy is essential to successfully perform these clinical techniques.

OSTEOCHONDROSIS Osteochondrosis (OC) is reported in the shoulder joint less often than in other sites such as the tarsocrural or femoropatellar joint. Clinical signs usually appear in horses 4 to 12 months old, and the lesions can be bilateral. Clinical examination in combination with conventional or contrast radiography reveals that the majority of shoulder OC lesions in horses are osteochondritis dissecans (OCD) lesions (cartilage flaps). Typical radiographic signs include irregular areas of subchondral bone with radiolucent areas surrounded by sclerosis. Contrast radiography more clearly delineates the presence and extent of undermined cartilage flaps and aids in determining a more accurate preoperative prognosis than one based on plain radiographs Continued on Page 26 Issue 2 • 2013

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Osteochondrosis of the humeral head and glenoid alone. Subtle cartilage lesions might not be detected using current imaging modalities, and diagnostic arthroscopy should be used if clinical examination, intra-articular anesthesia, or nuclear scintigraphy implicate the shoulder joint as the source of lameness. Secondary osteoarthritis (OA) develops rapidly in cases of shoulder OCD, and radiographs should be carefully scrutinized preoperatively for signs of OA, because the prognosis for future athletic function is poor in affected horses. Radiographic signs of shoulder OA include flattening of the humeral head and glenoid cavity, remodeling of the caudal rim of the glenoid, and subchondral bone sclerosis of the humeral head or glenoid cavity.

Arthroscopic surgery with débridement of loose cartilage flaps and curettage of abnormal underlying subchondral bone is the treatment of choice for shoulder OCD lesions.

Repair of cartilage flaps using polydioxanone pins has been successful in select cases of OCD involving the femoropatellar and metacarpophalangeal joints and should be considered for cases of shoulder OCD. Only cases with smooth, partially attached, unmineralized cartilage flaps should be considered for repair with polydioxanone pins.

There are few reports on the outcome of surgical or conservative treatment for shoulder OCD in horses. All of them have limited case numbers and should be interpreted with some caution. The most recent report indicates that the prognosis for return to soundness with or without surgery is poor with 25% (8/32) of horses returning to their intended use. Of the 32 horses in the study, 18 were operated and 14 were treated conservatively. Only 15% of potential racehorses became sound for the intended use while 67% of non-racehorses achieved their intended purpose. This study also suggested that there is no significant interaction between unilateral versus bilateral involvement or lesion severity. In two earlier studies which had fewer horses intended for racing, the prognosis for return to athletic function following arthroscopic debridement was considered good, even for middle-aged horses, with approximately 80% of horses achieving soundness. The prognosis is considered to be poor when osteoarthritis (OA) is detected on preoperative radiographs although this has not been evaluated in a clinical series because most of these horses are not operated on due to a poor prognosis. It should be noted that lesions identified during arthroscopy are often 26 The Practitioner

more extensive than suggested by radiography.

FRACTURE OF THE SUPRAGLENOID TUBERCLE Supraglenoid tubercle fractures are usually simple, intraarticular epiphyseal fractures. These fractures occur most commonly in horses younger than 2 years of age, and are either the result of direct trauma or are avulsion fractures caused by tension from the biceps tendon, which originates on the supraglenoid tubercle. Horses with supraglenoid tubercle fractures are able to bear weight, but they are variably lame and reluctant to fully extend the affected limb.

Careful visual inspection and palpation of the cranial aspect of the shoulder will be suggestive of a supraglenoid tubercle fracture. In chronic cases, shoulder muscle atrophy will be present. Radiography of the shoulder is diagnostic. On a mediolateral radiographic projection, the fracture fragment is typically displaced in a cranioventral direction as a result of tension from the biceps brachii and coracobrachialis muscles, which originate on the supraglenoid tubercle. More recently, a cranioproximalcraniodistal oblique view of the proximal portion of the humerus has been suggested as a more reliable radiographic projection to diagnose long oblique fractures of the greater tubercle and should be included in a thorough radiographic series. The radiographs should be carefully evaluated for signs of OA (described previously), which will decrease the prognosis for athletic function.

Several treatment options are available, and the therapy chosen will depend on the duration of the fracture and the intended use of the horse. Conservative management, for all but the smallest fractures, typically results in residual lameness and OA of the shoulder joint. Surgical options include repair of the fracture or removal of the fracture fragment. The goal of surgical repair should focus on restoring articular congruity of the glenoid cavity to

Glenoid Cyst Issue 2 • 2013

prevent the development of OA. Therefore, if the fracture is chronic (longer than 1 week), enough bone remodeling will have occurred to preclude accurate reduction of the fracture, and the fragment should be removed. In acute fractures, if a substantial (one third or greater) portion of the glenoid cavity is involved, internal fixation should be considered to reconstruct the glenoid articular surface and provide maximal opportunity for future athletic performance. Acute fracture fragments that involve only a small portion of the glenoid cavity can be removed with no apparent impact on future athletic performance.

Fractures of the supraglenoid tubercle are rare and therefore there are few reports regarding surgical outcome.

Return to athletic function depends on the amount of cartilage damage present at the time of surgery and, in cases where the fracture fragment is removed, the amount of glenoid cavity removed with the fracture fragment.

Both of these factors are assumed to be directly related to development of shoulder OA. The few reports that are available regarding supraglenoid tubercle fractures in the horse suggest that the prognosis for athletic function is fair-good following either fracture removal or internal fixation, but poor with conservative treatment. The most recent study indicates that 9 of 10 horses treated surgically and only 2 of 5 treated conservatively returned to athletic function.

MISCELLANEOUS OTHER FRACTURES Fractures of the neck or body of the scapula or proximal humerus are rare, but have been described. These fractures are usually the result of trauma, and horses are variably lame. Horses with complete fractures of the body of the scapula or scapular neck will be unable to bear weight. A standing mediolateral radiograph with the affected limb pulled forward will reveal the fracture site. If the neck of the scapula is involved, function of the suprascapular nerve should be evaluated (described later in “Suprascapular Nerve Injury”). Internal fixation of complete or longitudinal fractures of the scapula has been described using internal fixation with multiple plates.

Incomplete fractures can be managed conservatively.

The cranial and caudal aspects of the greater tubercle of the proximal humerus can fracture in different configurations. If the entire greater tubercle fractures transversely, the scapulohumeral joint can luxate.

When clinical examination or nuclear scintigraphy suggests involvement of the greater tubercle, a caudal proximolateral to cranial distomedial oblique (skyline) radiograph of the proximal humerus should be obtained to diagnose the fracture. Depending on the size of the fracture fragment and the muscular attachments involved, the fragment may be treated conservatively, removed, or repaired using cortex or shaft screws placed in lag fashion.

Deltoid tuberosity fractures of the proximal humerus have also been reported. The fractures are most commonly the result of a kick injury and have associated wounds.

Oblique radiographs and ultrasonography are diagnostic.

Rest and wound treatment result in return to athletic www.faep.net

function.

SCAPULOHUMERAL JOINT LUXATION Scapulohumeral joint luxations are rare in horses and are traumatic in origin. Because of their traumatic nature, concurrent fractures of the scapula or proximal humerus can occur. The horses are non-weight-bearing and might have shoulder atrophy if the luxation is chronic. The humeral head can be palpated lateral, or less commonly cranial, to the scapula. Standing caudolateral to craniomedial oblique-view radiographs best demonstrate the luxation. The radiographs should be carefully evaluated for fractures of the humeral head or scapula, particularly involving the lateral rim of the glenoid.

Closed reduction followed by scapulohumeral joint arthroscopy to evaluate the articular surfaces and remove cartilage debris resulted in return to sound performance in one case. Closed reduction should be attempted before an open approach is performed to preserve intact lateral musculature of the shoulder joint and minimize the potential for re-luxation of the shoulder joint postoperatively. The ultimate outcome for most horses with scapulohumeral luxation is shoulder OA and severe lameness, resulting in euthanasia. Arthrodesis of the scapulohumeral joint has been successful in one small (250 kg) horse and in miniature horses. There are very few reports detailing repair of scapulohumeral joint luxation, but the prognosis for soundness following repair appears to be poor because of resultant crippling shoulder OA. PATHOLOGIES OF THE BICEPS BRACHII, INFRASPINATUS TENDON, AND THEIR ASSOCIATED BURSAE The biceps brachii muscle originates on the supraglenoid tubercle as a bilobed, tendinous structure, and it inserts on the medial radial tuberosity. It passes over the proximal, cranial aspect of the humerus, where it is bound to the intertubercular groove by a tendinous part of the superficial pectoral muscle. It acts to flex the elbow joint and provides some stability to the shoulder. Passively, it limits elbow joint extension when the shoulder joint is in flexion, and limits shoulder joint flexion when the elbow joint is extended. The intertubercular (bicipital) bursa lies between the proximal biceps tendon and the humerus.

Horses with bicipital bursitis or biceps tendinitis exhibit pain when the biceps is grasped and pulled laterally. Nuclear scintigraphy can be helpful in any of the vascular, soft tissue, or bone phases, but a definitive diagnosis requires intrasynovial anesthesia. After localizing the lameness to the biceps region, an ultrasonographic and radiographic examination of the biceps region should be obtained. Normal ultrasonographic morphology of the biceps tendon and bicipital bursa have been reported.

Caudolateral to craniomedial oblique radiographs of the proximal humerus are required to identify concurrent lesions involving the humeral tubercles.

Various pathologies have been reported in association The Practitioner 27

with the biceps tendon or bicipital bursa including bursitis, tendinitis, ossifying tendinitis, medial displacement of the biceps tendon, and infectious bursitis. Congenital hypoplasia of the minor tubercle of the humerus with subsequent medial luxation of the proximal tendon of the biceps brachii has also been reported in four mature horses. Simple biceps tendinitis is managed conservatively, but surgical intervention should be considered for horses with idiopathic or infectious bursitis or with chronic bicipital bursitis.

The infraspinatus tendon extends from the infraspinatus muscle, and courses over the lateral side of the shoulder joint and the caudal eminence of the humeral greater tubercle to its insertion on the dorsolateral humerus. The infraspinatus bursa is located between the infraspinatus tendon and the caudal eminence of the greater tubercle.

The normal ultrasonographic appearance of the infraspinatus tendon and bursa has been reported. Injury to the greater tubercle of the humerus and infraspinatus tendon with sepsis of the infraspinatus bursa has been reported in three horses. In all cases, ultrasonography was more sensitive than radiographs for detecting osseous and soft tissue injuries. All three horses became sound following lavage of the bursa, removal of fracture fragments when present, and administration of intrasynovial and systemic antimicrobials.

Endoscopy of the bicipital bursa in normal and infected bursae has been described. The horse is positioned in lateral recumbency, with the affected limb uppermost. The bursa is distended with 100 mL lactated Ringer’s solution as described under “Intrasynovial Anesthesia.”

A combination of bicipital bursitis, biceps tendinitis, and humeral osteitis has been reported in horses. This disease complex is thought to be a manifestation of chronic bursitis or tendinitis and can be infectious or traumatic in origin. Affected horses are severely lame and unresponsive to conservative therapy. Ultrasonography of the biceps bursa is consistent with bursitis, radiographs of the proximal humerus reveal osteolytic changes associated with the lateral tuberosity.

Complete transection of the biceps tendon results in a fair prognosis for return to soundness. If purulent material is found within the biceps brachii tendon, then a tenectomy should be considered. There are too few reports of the various tendon or bursa problems to provide an accurate prognosis. As with most synovial structures, the prognosis for return to sound function ranges from guarded to good depending on the structures involved and the duration of clinical signs.

lateral motion or shoulder slip during weightbearing on the affected limb. This gait can be replicated by selective anesthesia of the suprascapular nerve which supports the role of the suprascapular nerve in joint stability.

If damage to the nerve is severe, the characteristic gait can be apparent immediately following injury, but more typically, a shoulder slip is not apparent for a few days to weeks after injury. Clinical signs do not indicate the degree of nerve damage, and there is no diagnostic method to determine the degree of recovery each horse will achieve. Electromyography should be used to confirm that the suprascapular nerve, and not the brachial plexus, is the site of injury. Electromyography is only useful to evaluate nerve function from 7 days after an injury.

Conservative management consisting of box stall rest alone results in a good return to function. However, shoulder stability takes an average of 7 months to return. Surgical decompression of the suprascapular nerve can hasten the return of shoulder stability, diminish the amount of shoulder muscle atrophy, and return the horse to function sooner than that accomplished with conservative therapy alone.

The prognosis for return to sound riding following conservative management or scapular nerve decompression is good. Atrophy of the supraspinatus and infraspinatus muscles might not completely resolve in all cases.

SUPRASCAPULAR NERVE INJURY (SWEENY) The suprascapular nerve is typically damaged as the result of trauma to the cranial shoulder where the nerve courses across the neck of the scapula. The suprascapular nerve innervates the infraspinatus muscle, which provides the majority of lateral support to the shoulder. As a result, horses with suprascapular nerve injury have a 28 The Practitioner

Issue 2 • 2013

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The Practitioner 29

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