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Discussion on Prognosis for Arthrodesis & Pain Relief of Front Fetlock after Alcohol Injection

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Renee Hayes
New Member
Username: reneehay

Post Number: 3
Registered: 7-2008
Posted on Thursday, Jul 10, 2008 - 2:01 pm:   Edit PostPrint Post

Please Help Me. My mare has complete collapse of the medial side of the front fetlock resulting from a show injury 8 months ago. She was hospitalized 4 weeks ago after an A-Cell injection for 3 days for severe 4+ lameness. Prior to the A-Cell we also tried IRAP and Shock Wave. Each treatment has resulted in increased inflamation and pain.
She is scheduled at the hospital for an intra-articular ethyl alcohol fetlock injection to produce arthrodesis and provide pain relief on Friday (tomorrow). (Surgical arthrodesis of the joint was considered to be too invasive because of the time lapse between December and March and the possibility of founder on the good leg.)
The objective for the alcohol injection is the complete collapse and fusion of the joint in order to relieve the pain and save her life.
This procedure is experimental. The only experience the hospital specialist and my field vet have is arthrodesis of hock and pastern joints. I love my mare and I am very worried that I will only make her worse and she will have to be euthanized anyway. The specialist does not think that complete fusion is possible since it is highly mobile and a front fetlock (weight). Please help me - does anyone have any experience with the outcome of this procedure? Please help me. }}P
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Robert N. Oglesby DVM
Moderator
Username: dro

Post Number: 21011
Registered: 1-1997
Posted on Thursday, Jul 10, 2008 - 6:40 pm:   Edit PostPrint Post

Hello Renee,
This procedure has not been studied exactly for the reason the specialist states: the mobility of the fetlock makes fusion without concurrent fixative surgery very unlikely. Is this considered the first step prior to doing surgery in an attempt at pain relief?
DrO
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Renee Hayes
New Member
Username: reneehay

Post Number: 4
Registered: 7-2008
Posted on Saturday, Jul 12, 2008 - 1:52 pm:   Edit PostPrint Post

Dr. Oglesby, Thank you so much for responding. Yes, it is for pain relief and surgery is not an option. We are willing to do the surgery but In March they advised against it because it is the front left fetlock, and so invasive that the probability was very high that she would founder and she would have other problems related to complete lower leg fusion. With the exception of the fetlock, there is no arthritis in any of her lower joints so they were hoping that it would help with her mobility. I asked about surgery again in May and they told me since so much time has passed since December that surgery will most certainly result in her foundering in the good leg. They checked for signs of founder when she was at the hospital in May and there were some small changes but nothing to indicate founder at that time. I have rescheduled her hospitalization and procedure for Thursday - Jul 17th so I can do more research. I don't want to put her through the procedure if it's not going to help her. The doctors are not sure how much it will help with the pain. Renee
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Robert N. Oglesby DVM
Moderator
Username: dro

Post Number: 21018
Registered: 1-1997
Posted on Saturday, Jul 12, 2008 - 7:14 pm:   Edit PostPrint Post

I don't understand Renee. What does "complete collapse of the medial side of the front fetlock" mean? What exactly is your horse's diagnosis? I can't put it together with the idea of chemical arthrodesis. Neither the location nor the implied instability would seem to indicate it.
DrO
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Renee Hayes
New Member
Username: reneehay

Post Number: 5
Registered: 7-2008
Posted on Wednesday, Jul 16, 2008 - 1:04 am:   Edit PostPrint Post

Dr. O, to clarify this is the detail from the discharge reports on April 4, and June 7, 2008. - - (April 4) "Radiographs showed near complete collapse of the medial aspect of the left front fetlock with sclerotic bone. There was periosteal roughening on the proximomedial aspect of P1 consistent with the attachment of the collateral ligament." Recommendations at that time were: "...very few treatment options due to the lack of previous response to therapy [shock-wave). IRAP injections or surgical arthrodesis can be considered." (We discussed the option of surgical arthrodesis at that time but both doctors advised that the prognosis would be poor due to long rehabilitation and time lapse since December. They felt that the fetlock would continue to collapse on its own and hopefully she would eventually be pasture sound.) Our field vet proceeded with the IRAP injections which increased the inflammation and pain. Shortly after the IRAP procedure our vet suggested we try a new experimental procedure called A-Cell. I was concerned about the A-Cell procedure because when researched I found that it is mostly used to repair ligaments and tendons. Nonetheless we agreed to it because we thought that it might help her. The day following the A-Cell procedure her leg became so inflamed that she stopped eating and could barely walk in very soft footing (shavings). I was unable to control the pain per my vets instructions: (1.5 grams of bute 2x's per day & 9 cc's of banimine 2x's per day, and surpass on fetlock 1x per day) so I took her to the hospital. The June 7 discharge report states: "Her physical exam parameters were within normal limits except for the left front...Pitting edema was present around the fetlock especially on the lateral side extending from the carpus to the foot. Radiographs were taken and showed significant joint collapse medially that had progressed since April. Bony lysis was also seen in the sesamoid bones likely due to disuse. Lateral radiographs of the feet showed a mild angle deviation from the coffin bone to the dorsal hoof wall but no conclusive evidence of founder. Bloodwork findings, including a CBC and BUN/Creatinine, were within normal limits. A furazone sweat was placed in order to help decrease the inflammation and swelling. My mare was also started on antibiotics (penicillin, gentamicin) and anti-inflammatories (Equioxx)." "The swelling decreased over the weekend and the left front fetlock was tapped on June 9. Analysis of the joint fluid (total protein 4.4, white cell count 1400) showed joint was not septic. The joint was injected with Amikacin." The hospital vet and our field vet consulted and recommended that we return my mare to the hospital to have her fetlock injected with alcohol in 3-4 weeks. - - Background information: My mare was taken to a horse show in December and reportedly very lame during the 2 day event. We were informed that our mare was given Bute Saturday night and then shown all day on Sunday. We were informed on Monday that our mare was lame off and on over the weekend and that she was given bute. We were unable to attend the show and would have scratched had we known that she was lame on the first day. She was examined by another doctor from our vets practice the week following the show. At that time, our mare was lame but was able to perform all gates without too much pain. She was blocked and it was determined that she may have strained a ligament. She was injected with several medications in the fetlock and was treated for the initial diagnosis. The evening of the injections our mare's leg was swollen, she had a slightly raised temperature, but was able to walk on her leg so our vet did not feel it was anything to worry about. When she did not improve over the 2 week period, we requested that our vet examine her to make sure that we didn't miss anything the first time around. Our vet found our mare to be very lame. He examined and blocked her lower leg. He took field radiographs and ultrasound and found a chip fracture. Our vet's recommendation was shock wave therapy. Several weeks went by before the shock wave and our mare seemed to slightly improve and had to be given ACE in order to be hand walked. She was administered shock wave several weeks later and became very swollen and lame. Her fetlock was very warm to the touch. I was very concerned since I knew that inflammation can cause a great deal of damage. She had a series of 3 shock wave treatments a week apart and by the end of the 3rd week was extremely lame. At that time, our vet took radiographs again and the cartilage had narrowed on the inside of the fetlock. Our vet proceeded with treatments of HA and Adequan injections (spelling?). When she did not improve we took her to the hospital and found that the destruction of her cartilage had progressed and within a short time span had almost completely been destroyed on the inside of the fetlock (April 4). The hospital vet informed us that our mare had torn her collateral ligament and it destabilized her fetlock joint. The hospital vet found the chip fracture but did not feel it was the reason she had become lame. We were informed at that time that our best hope was that she may be pasture sound in a year and possibly could become a brood mare depending on the stability of her leg. (We feel that our vet did everything he could do based on his initial exam and diagnosis — medicine isn't a perfect science especially in the field without the tools of being in a hospital environment.) But now we are left with our mare who we love dearly and it's very difficult to see her in so much pain. She now must be on pain medicine (Equioxx and Banamine) everyday. Some days are good, and some days she can barely walk. We don't want to put her through anymore procedures if it will cause her more pain. I know the purpose of the Alcohol is to help with the pain and possibly help the fetlock to fuse on its own but if the prognosis is poor why put her through it? I have hoped to find any information on fusion of the fetlock by alcohol injection but have not come across any medical studies that might help me make an informed decision. Based on the information published on this website and your discussions the prognosis is poor. Thank you for any guidance you can provide. I have an appointment on Thursday at the hospital to x-ray to confirm status of the injured leg and also to see if there are an signs of founder on her good front leg and then we are just not sure if we should go forward depending on those results, or let her live out her life, however short, since she is happy, healthy, eating, nickering. However do not have our heads in the sand, she cannot live in a 12x24 paddock for long. You help and advice will be much appreciated.
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Robert N. Oglesby DVM
Moderator
Username: dro

Post Number: 21041
Registered: 1-1997
Posted on Wednesday, Jul 16, 2008 - 6:22 pm:   Edit PostPrint Post

Since we have not examined the horse we cannot give a prognosis and I remain uncertain exactly what is meant by "collapsed". The joint space????However is there anyone who has examined the horse giving you better than a poor prognosis for this course of action? I agree with you if the prognosis poor why put her through it?
DrO
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Renee Hayes
Member
Username: reneehay

Post Number: 6
Registered: 7-2008
Posted on Wednesday, Jul 16, 2008 - 9:51 pm:   Edit PostPrint Post

Thank you for responding Dr. O. I am sorry if I did not clearly answer your question. But yes, the joint space has collapsed on the inside of her left fetlock. The fetlock is bone to bone.

I have a series of radiographs showing the progression of the loss of cartilage. She has a small amount of good cartilage left in the joint space and it's not collapsing straight across so our vets are concerned that fusion will not be possible on its own. They are hoping that the alcohol injection will destroy the remaining cartilage, the joint will fuse, and in the meantime will provide pain relief.

We have tried everything except surgical fusion at this point and both vets feel that it's worth a try. However, because of the pain she has endured with the other procedures, I am not sure it's worth experimenting on her again. I was hoping that you could provide some insight or have knowledge of studies or trials that may help us make the best decision possible.

We are taking her to the hospital tomorrow morning and will take radiographs of both legs to determine her current condition and will proceed from there. If there is no hope, and the injection will not provide significant pain relief, we may have her euthanized there. If there is a chance of significant pain relief and it will buy her some time to see if the fetlock will fuse on its own, then we will give it a try. I am just worried that she will injure herself further if she feels a lot better but we do nothing to stabilize the joint. Already I can hear the joint moving and popping when I apply standing wraps or when she puts weight on her leg to turn. Do you think we have a valid concern and do you know of any studies that may help with our decision? Thank you again for your help. Renee
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Robert N. Oglesby DVM
Moderator
Username: dro

Post Number: 21048
Registered: 1-1997
Posted on Thursday, Jul 17, 2008 - 7:02 am:   Edit PostPrint Post

I don't believe any orthopedist would think there would be any hope of arthrodesis of the fetlock without surgical stabilization with screws and plates. As far as I know it has not been attempted precisely for this reason.
DrO
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Erika L
Member
Username: erika

Post Number: 1293
Registered: 10-2002
Posted on Thursday, Jul 17, 2008 - 8:48 am:   Edit PostPrint Post

Renee, I just wanted to add that I can only imagine your heartache over this. You obviously care a lot about this horse and are sure to do the right thing for her.
My thoughts and prayers are with you both.
ERika
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