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Discussion on IRAP in Hock

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Esther Pearce
New Member
Username: pearce1

Post Number: 1
Registered: 4-2009
Posted on Tuesday, Apr 14, 2009 - 6:52 am:   Edit PostPrint Post

I have an 8 year old warmblood gelding who has been diagnosed with mild arthritic changes in the TMT joints of both left and right hocks. We competed successfully in dressage until he went lame behind (2/5) - in hindsight I think he had been stiff off and on for a while.

Nerve blocks were performed ruling out pain from the foot and fetlock. A scintigraphic evaluation indicated increased radiopharmaceutical uptake in the left TMT joint other than that he looked fine. A radiographic evaluation supported scintigraphic findings showing mild arthritic changes in both hocks. "Dig" received injections of Hyaluronic Acid and Triamcinalone into each hock which seemed to do the trick for about 6 weeks, infact he was so fantastic and enthusiastic I could hardly ride him to begin with! He had also seen a chiropractor and wore ceramic hock boots for 3 hours daily during this time. I should mention he had a flare from the injections which was treated with hosing and bute.

At this stage we decided he would be a candidate for IRAP which I believe can be effective when other injections are losing effect. He has had 3 injections now but shows no improvement. My vet actually had to ask a senior vet to do the injection into the right joint as it was so difficult to get in - the hardest she has seen. The vet suggested I ride him as he might "free up" but after 2 weeks of light hacking he seemed worse rather than better so I flagged it.

I feel so sad for him, he has gone from being a lunatic in the paddock (galloping, passaging, rearing, bucking - generally doing all he could to give me a heart attack) to a sedate horse who might trot a few steps if his life depended on it. He rests his back feet whenever possible and seems to pad around for a comfortable footing while he eats his breakfast and tea. Interestingly he seems a little more comfortable now I've had his shoes taken off. Generally he looks well, good coat, bright eye, still gives me attitude when I fiddle around with his cover... He is getting Cortaflex as a supplement. My question is where to from here, my vet is suggesting I've done all I can and that perhaps we will never get to the bottom of it. Does the fact that the injections were difficult to put in suggest fusing may be in progress? Any advice would be so appreciated.
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Robert N. Oglesby DVM
Moderator
Username: dro

Post Number: 22765
Registered: 1-1997
Posted on Tuesday, Apr 14, 2009 - 7:10 pm:   Edit PostPrint Post

Welcome Esther,
Occasionally you find a TMT jt. difficult to inject but I have trouble passing judgement on the meaning of someone else's failure to get in. This would be a better question for the practitioner. Narrowing jt spaces accompanies fusion so it would be a possible explanation but I would not say it is or isn't an indication that fusion is eminent.

If the diagnosis is firm and medical therapies exhausted surgical fusion would be the next step if the goal is to return the horse to soundness as soon as possible. For more on this see Diseases of Horses » Lameness » Joint, Bone, Ligament Diseases » Arthrodesis and Joint Fusion for Arthritis.
DrO
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Esther Pearce
New Member
Username: pearce1

Post Number: 2
Registered: 4-2009
Posted on Thursday, Apr 16, 2009 - 3:47 am:   Edit PostPrint Post

Thank you for your comments. I've been speaking to a senior vet at the practice today and we plan to block the TMT joints to ensure this is the only source of the problem. He said the xray (or was it the scintigraphy?) showed a "moth eaten" look - this was 5 months ago. Is there any way to check how far along the joints are to fusing on their own before going ahead and having them surgically fused?

In your article you mention that horses can become usably sound, have you known any horses following fusion that have continued to have dressage careers?

What is a typical outcome (I do realise there is a 65% - 85% success rate) as far as injections and supplement requirements in the future years following fusion?

I'd love to hear from any members who have experience in this area.
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Robert N. Oglesby DVM
Moderator
Username: dro

Post Number: 22785
Registered: 1-1997
Posted on Thursday, Apr 16, 2009 - 11:07 am:   Edit PostPrint Post

I think articular anesthesia an excellent place to begin.

Yes I have known horses that came 100% sound following TMT arthrodesis. By clicking the National Library of Medicine link at the bottom of the Arthrodesis article above you will find numerous reports of horses that came sound following surgical and/or chemical arthrodesis.
DrO
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Esther Pearce
New Member
Username: pearce1

Post Number: 3
Registered: 4-2009
Posted on Sunday, Apr 19, 2009 - 10:04 pm:   Edit PostPrint Post

Hi Dr O

My vet has phoned today suggesting potentially the use of ethyl alcohol in the hock once the articular anesthesia has confirmed our suspicions. They are planning to use some sort of product before the xrays to ensure there is no communication with the other joints.

I cannot find a lot on this subject other than the study using 8 mares a few years ago. Is this more commonly used since the study?

From our conversation it seemed we would not be using GA during the procedure, does this seem unusual or risky? I believe my horse would be the first to be treated in this way by my clinic.

Thanks for an excellent site.
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Robert N. Oglesby DVM
Moderator
Username: dro

Post Number: 22811
Registered: 1-1997
Posted on Monday, Apr 20, 2009 - 9:59 am:   Edit PostPrint Post

You are welcome and thanks for your support.

No I don't think it has become commonly used but individual case reports have been encouraging, though we have had one member it did not work for so ended up doing mechanical arthrodesis. Search on ethyl arthrodesis. Our article on arthrodesis, that I reference above, describes a paper of 16 cases and is the last published piece I can find.
DrO
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Esther Pearce
New Member
Username: pearce1

Post Number: 4
Registered: 4-2009
Posted on Wednesday, May 20, 2009 - 6:26 am:   Edit PostPrint Post

Hi Dr O

My lovely horse was reshod by someone experienced at shoeing for spavin and taken back to the vet for the blocks. I worked him once prior to the visit to ensure he would show his lameness clearly for the vets - he was still terribly lame behind.

I got lucky on the check up day as 4 equine vets looked at him trotting up and down. Apparently he was noticeably sounder (but not perfect) after a nerve block to the TMT joint. They put in a contrast and also xrayed this joint. The two senior vets thought the joint had narrowed a little from the previous xray.

This is the strange bit. After trotting up and down the concrete all day Dig seemed much improved. In his paddock he was once again cantering around and acting like the class clown which was fantastic. Days later he still seemed much improved, so much so I was beginning to doubt the ethyl alcohol was needed. I rode him and although much improved I could still feel he was not quite right so went ahead with the ethyl alcohol injection.

I was told that providing he looked sound I could go ahead and ride him. 2 weeks later he still feels much better and in great spirits but still feels a little stiff when I sit on the diagonal to the right, perfect to the left. He looks awesome when I trot him up in hand. I took him to a chiropractor just for my own piece of mind (I view them in more of a physio type way, good to check correct muscling etc) and aside from being a little sore on his rump the chiropractor thought he looked excellent and well muscled. He still looks a little uncomfortable when eating hard feed and seems to rest his right foot a lot but hey perhaps I'm just paranoid.

Anyway, here is my question. In your opinion does the ethyl alcohol numb the whole problem area by denerving it or does it take the joints fusing to see the full effect? I guess what I mean is should my horse be pain free immediately following this treatment?

I just want to add how thrilled I am with my vets being willing to try this new treatment. My horse was the second they have done, apparently the other horse has recovered really well and is currently back in training. Just to clarify my above comment - GA was not used but Dig was sedated and xrays used to ensure needles were in exactly the right positions, lots of hands on deck!
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Robert N. Oglesby DVM
Moderator
Username: dro

Post Number: 23008
Registered: 1-1997
Posted on Wednesday, May 20, 2009 - 7:40 am:   Edit PostPrint Post

It is a good question and I don't have a clear answer based on lots of cases. We know from a case reported on this site where there was failure to fuse following injection which suggests it takes fusion. We know that the treatment can be minimally irritating in some horses from initial reports where healthy joints were treated. So you may even see a worsening of lameness with initial treatment. But your feeling that the alcohol is neurotoxic is correct and their may be some individuals or some dosage rates that (concentration and amount) that result in improvement.
DrO
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