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  Discussion on Degeneration of the meniscal ligament
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New Member:
kiwi1

Posted on Tuesday, Mar 13, 2007 - 8:34 pm:

Hi Dr. O,

I just got back from an ultrasound which shows my horse to have a deformed meniscal ligament. The ultrasounds shows a hole between the bone and the ligament. It almost resembles a shriveled up prune. The attending vets want to try rest for a few months and HA injections but have told me the outcome is poor. Could surgery help? Also another vet said a new treatment called Tildren might be a option? I guess I'm just hoping to get my horse sound enough to do some light riding from time to time.
Moderator:
DrO

Posted on Wednesday, Mar 14, 2007 - 4:47 am:

Welcome back Sandy,
To evaluate the horse we need a detailed description of the findings on the ultrasound and what they think is the cause of the pathology. Based on their US findings what type surgery did they propose to correct the problem?

As general observations, neither rest or HA injections are not going to correct a instability in the joint do to a deformity of the ligament. I cannot figure out how Tildren makes any sense here. This is a calcium sparing drug whose main action is on bone, how do they purpose this might help your soft tissue problem?
DrO
New Member:
kiwi1

Posted on Wednesday, Mar 14, 2007 - 6:10 am:

Thanks for the welcome back, Dr. O

The diagnosis was damage to the left meniscal ligament without an overt tear. There was active inflammation in the area and the thought was to see if rest/HA could make the horse sound. My question is since the horse has been in active work for much of his life with some minor lameness in that leg from time to time, why would the instability show now? My vet replied that the joint was slowly becoming unstable and it was until now that it became an issue. I guess my next question to anyone is how would surgery help with a degenerative meniscus? And a second question, Dr. O, what have been your experiences on returning a horse to soundness with this type of injury? I was told the prognosis is guarded to poor.

Thanks for your thoughts
Moderator:
DrO

Posted on Wednesday, Mar 14, 2007 - 6:51 pm:

Concerning the possible benefits of surgery, the damaged areas are creating inflammation that will result in osteoarthritis. If the damaged areas can be debrided without further destabilizing the joint you will have decreased inflammation. However if there is an ongoing degenerative process I don't see how the surgery will help and may be the reason for the prognosis.

The prognosis will vary tremendously depending on the specific findings so there is no more accurate prognosis we can offer than the one offered by the veterinarian who did the exam. If you really are looking for a informed second opinion I would recommend you forward the records to an equine orthopedic surgeon and see what they say, though they may want to repeat the US exam and will not put forth a final diagnosis/prognosis until they actually get their endoscope in the joint and visualize the damage and the overall condition of the joint.
DrO
New Member:
kiwi1

Posted on Friday, Mar 16, 2007 - 7:30 am:

One more question, Dr. O.

I questioned my vet one more time on if he thought this was an acute injury or one that is showing degeneration. He told me that he really does not know since he has really never seen an injured meniscus without an overt tear to it. So, in theory, if I gave the horse strict stall rest for 30-60 day, and if the injury was acute, I would see some healing/decreasing inflammation of the meniscus via an ultrasound? I'm in the process of finding a person/clinic to give me a second opinion but in the meantime, I thought I would see if my theory holds any truth.

Thanks
Moderator:
DrO

Posted on Saturday, Mar 17, 2007 - 9:03 am:

Though without knowing your horses particular condition I cannot say what is needed for your horse, in general meniscal tears will need surgery to remove the damaged areas. The ongoing trauma to the the damaged pieces cause further inflammation and DJD. This is a pretty good study of 80 cases but remember that your horse's prognosis depends on his particular findings.

Equine Vet J. 2003 Jun;35(4):402-6.
Meniscal tears in horses: an evaluation of clinical signs and arthroscopic treatment of 80 cases.
Walmsley JR, Phillips TJ, Townsend HG.
The Liphook Equine Hospital, Forest Mere, Liphook, Hampshire GU30 7JG, UK.

REASONS FOR PERFORMING STUDY: There is little published information available describing clinical signs, arthroscopic findings and prognosis of meniscal injuries in horses. OBJECTIVES: To evaluate the effect on the outcome not only of the arthroscopic findings and treatment, but also of the clinical and radiographic signs in these horses. METHODS: The following were recorded for each case: the meniscal injury, graded according to severity; clinical and radiographic findings prior to surgery; any concurrent injury in the joint seen at arthroscopy. The effect of these factors and the grade of injury on the outcome were analysed using Fisher's exact test or Chi-square analysis. Only horses whose meniscal injury was judged to be the primary cause of lameness were included in the series. RESULTS: A series of 80 meniscal injuries were diagnosed and treated arthroscopically by the authors at the Liphook Equine Hospital and 47% of horses returned to full use. Statistically, poor prognosis was associated with increasing severity of the meniscal injury, the presence of concurrent articular cartilage lesions and radiographic abnormalities in the joint. Arthroscopic treatment of many lesions was limited by the inaccessibility of parts of the femorotibial joint. POTENTIAL RELEVANCE: Further work is required to improve and evaluate arthroscopic techniques for the treatment of these injuries.
DrO
Member:
mrose

Posted on Saturday, Mar 17, 2007 - 10:56 am:

We have a now 18 yr. old mare who had arthroscopic surgery ten years ago on her right knee. She had totally severed her meniscis. The surgery helped her a lot and after a long rehab we were able to use her as a trail horse and lesson horse for several years. She now has lots of arthritis in the knee and can no longer flex her knee fully. However, she is still sound enough to run and buck in the field. At the time of the surgery the doctor said he had never done this surgery on such an old mare. The horses he usually treated were young race horses, and their success rate was pretty good. He said he felt that age played a large part in the success of the surgery as did, of course, the rehab protocol. Also, most of the horses he treated hadn't totally severed the tendon but only torn it. Overall, we were pleased with our mare's result.
New Member:
kiwi1

Posted on Wednesday, Mar 21, 2007 - 1:40 pm:

Thanks Dr. O

I did get another opinion from a respected surgical vet who said that the ultrasounds of the meniscus in question look more like fluid around the one side of the joint, not degenerative, but could not be sure. His suggestions mirrored my vets with strict stall rest for 45-60 days and a reevaluation at that time. His thoughts were that if the lameness improved even one degree (he is 2/3 on a jog and 3/4 flexed)that we are heading in the right direction. If not, perhaps arthoscopic surgery to see what is going on in the joint and take it from there. As they say, time is the healer of all wounds, so I hope this rings true in my case. I'll try to post back in a month or two to give an update.
Moderator:
DrO

Posted on Thursday, Mar 22, 2007 - 6:30 am:

Thanks Sandy,
DrO
New Member:
kiwi1

Posted on Friday, Apr 6, 2007 - 8:33 am:

Hi Dr. O

It has been almost one month and my guy is still not improving with stall rest. Now I'm dealing with the issues of a very upset horse that has resulted in stall weaving, walking and cribbing since his layup. The drugs are helping to an extent but still not making him completely quiet, especially in the AM when the horses go out. Anyway Dr. O, I did recieve a report from U of Penn regarding my guy's condition. This was based on the ultrasound performed about a month ago. They said,

"the medial meniscus was heterogenous and did not conform to the margin of the distal femur. The medial femorotibial joint contained an increased amount of anechoic fluid and hypoechoic thickened synovium. The abnormalities in the left medial meniscus are most likely due to chronic degenerative changes and his lameness is most likely due to a combination of soft tissue and osseous changes in the medial aspect of the stifle."

Interesting enough, when I spoke to the Dr. at U of Penn she said this was a tricky injury to either rest completely or put in a controlled exercise program. In fact she put in her notes that the horse should be walked up to 45 minutes a day while stall resting 2-3 months but primary vet wanted complete stall rest. I decided to go the conservative route and rest completely.

I consulted my primary vet last night and he said that the lack of improvement shows that this is a pretty serious/chronic condition and wants to modify the treatment to small turnout for the next 30 days and then a joint injection of steroid/HA to get him back on track. I guess I'll summarize my questions for you Dr. O to keep you less confused.

1. Is 30 days stall rest enough time to give this type of injury to see even the slightest improvement? I know all horses and injuries have their own time schedule but I wanted to have an idea when enough is enough.

2. The horse is on complete stall rest. I read your article on rehabbing tendons so I'm thinking maybe some handwalking is in order? I've heard different theories to whether or not you should move on this type of injury. What about small paddock rest?

3. Thoughts on injecting the joint with steroid? I know this is a big no-no with high motion joint like the stifle.

Thanks for your time and attention to my situation.

Sandy
Member:
dres

Posted on Friday, Apr 6, 2007 - 10:00 am:

Sandy I am rehabbing a just 4 year old filly.. she had been on complete stall rest now for 5 1/2 months ... The injury is not the same but stall rest is stall rest.. Can you have a baby sitter next to your horse at all times..? I Know i rotated a horse next to mine 24/7.. she was never alone not for a minute.. Can you hang your hay up high in a hay bag so he has to work for his food? And is it possible to give him a bigger stall then the normal 12X12 ? Just some ideas that helped us get thru // getting thru this horrid ordeal.

On the first day God created horses, on the second day he painted them with spots.
Moderator:
DrO

Posted on Friday, Apr 6, 2007 - 6:48 pm:

Not having seen the injury, I cannot really comment on the treatment plan. However I don't remember an acute stifle injury that took less than 60 days stall rest to return to soundness and I have stalled such horses up to 6 months. The review does suggest this is not a acute injury however.

I disagree that steroids are not a big no-no in high motion joints, though osteoarthritis is high motion joints is often difficult to help. When there is uncontrolled acute inflammation they can greatly improve the joint environment. If you are uncertain about the treatment you should discuss this possibility with U Penn to see if there might be some applicability to your case or if they feel there is a specific contraindication.
DrO
Member:
kiwi1

Posted on Thursday, May 3, 2007 - 1:22 pm:

Hi Dr. O

It has been almost two months since I stall bound my horse for his stifle injury. After a treatment of shock wave, hand walking and rest, I have not seen an improvement. And to make matters worse, he is now developing a cough. We are putting him on some medication and changing the hay but I read your article on heaves and I'm worried that this could turn into a chronic problem. So now I'm at a crossroads, turn him out in a small paddock and risk hurting his stifle which I spend two months trying to rehab or keep him in and risk breathing problems (he's an event horse) down the road. Any suggestions which one is the lesser of the two evils or should I just flip a coin?
Member:
dres

Posted on Thursday, May 3, 2007 - 2:23 pm:

Sandy, can you create an outdoor stall the size of your stall with the step in posts we have been discusing on another thread..? He then will be out in the fresh air but still in a small confined space?? This is what I am doing with my filly that is on complete stall rest for the past 6 months..
Just a thought..

On the first day God created horses, on the second day he painted them with spots.
Moderator:
DrO

Posted on Friday, May 4, 2007 - 12:47 pm:

Sandy,
until the cough is gone can you find a hay replacer? Then you could gradually reintroduce the dust free hay. Given the two options in most cases I would go for the limited outdoor turn out, the smaller the better. Ann's idea is a good one.
DrO
Member:
kiwi1

Posted on Wednesday, May 30, 2007 - 10:22 am:

Okay...got the coughing under control with medication and a baby sitter for my guy which stops him from running around in his stall (stirring up the shavings). Just an update on his stifle, I took him to New Bolton yesterday for a shock wave treatment and reevaluation. Again when I trotted him out, they said he was pretty much lame. After a brief ultrasound, the bone spur that was in the joint is now gone? (I did not know that could happen) and the meniscus is starting to look a bit more regular but the horse's comfort level is still the same. Again I asked about joint injections and the vet said with all that is going on in his joint, injections will only be a temporary thing. There was also concern since he has moderate arthritis in both hocks as well as locking stifles, the lack of movement may be hurting him. So in addition to the daily walks, he is allowed to go on small turnout for a few hours a day as long as he is not running. I guess I'm disappointed in the lack of improvement in three months but I was assured that things like this (if it can be healed) take time, like a year or so...Anyway, I will post back in August when I take him for his five month checkup.
Moderator:
DrO

Posted on Thursday, May 31, 2007 - 5:29 am:

Thanks for the update sandy and disappointed things are not looking better, but I have had stifle injuries take longer than 3 months so there may be hope yet.
DrO
Member:
kiwi1

Posted on Friday, Jun 1, 2007 - 2:39 pm:

One final question, Dr. O

What if this is a chronic condition in the joint and almost a perfect storm scenario type of situation? He has locking stifles, particularly the left hind, moderate arthritis in the left hock and some sort of degenerative changes in the stifle. Previous to me going to U of Penn, the horse would warm out of the lameness after 10-15 minutes of work. Now on complete stall rest and limited movement, wouldn't this just cause more issues? I asked them last week about joint injections, and they said there was too much inflammation in the joint that injections would make little or no difference. I'm just wondering the more he sits, the worse he gets. I know when I don't move, things tend to tighten up a bit, if you know what I mean. U of Penn is talking up to a year of stall rest to see if there is really something damaged in the joint, meanwhile, I'm wondering if this is just going to make him worse by the lack of deliberate and active movement. I guess my question is how do you tell if something is chronic or acute? Or a combination of both?
Moderator:
DrO

Posted on Friday, Jun 1, 2007 - 6:48 pm:

Hello Sandy,
The best diagnostic technique, and the best chance of determining the nature of the injury, is an endoscopic exam.
DrO
Member:
kiwi1

Posted on Monday, Jul 30, 2007 - 2:49 pm:

Well it's been over five months since the initial injury and my guy is still lame. I did have my horse injected with a steroid only about a month ago which improved him to be servicebly sound in about two weeks but unfortunately, he was turned out without sedation, ran, and became lame. New ultrasounds show the same chronic changes in the meniscus with some inflammation to the collateral ligament. I'm assuming that he damaged his collateral ligament during his running episode but also the ultrasound turned up some cartiledge damage to the subconDrOyl bone. It almost looks like a small lip/tear that is on the surface. Anyway, new vet said he has had some good success with IRAP with these types of injuries. I also looked into stem cell and they forwarded me an article on how they regrew a goats meniscus using stem cell. Looking at your previous responses, I take it that you are not a big fan of these therapies since they are relatively lack substantial test groups and/or proof that they work. Any thoughts or am I at the end of my rope? Has extended, long term stall rest ever help the soundness of horses with chronic stifle issues?

Much thanks
Moderator:
DrO

Posted on Tuesday, Jul 31, 2007 - 5:59 am:

Sandy your next step would be an endoscopic exam with the hope that there are some lesions that could be cleaned up. At the least you could might receive a more firm diagnosis/prognosis.

Alternatively you could repeat the steroid (I would include hyaluronate), and start treatment for arthritis (see Overview of Arthritis) but the success of this remains uncertain.
DrO
Member:
kiwi1

Posted on Wednesday, Aug 8, 2007 - 2:50 pm:

Hi Dr. O

I decided to take you advice and get the surgery done. I'm a little nervous about putting my guy on the table. Is this procedure relatively safe? After watching the movie Ruffian the other month, I'm a bit concerned when they wake up.
Member:
mrose

Posted on Wednesday, Aug 8, 2007 - 7:35 pm:

Hi Sandy, I am just "butting in" to tell you that I've had four different horses that have had to have surgery under a general, one of them twice. None of them had any problems in recovery, and all were up and about in a few hours none the worse for wear except for their various "repairs." Infact, I was just thinking, Libby had to be put under three different times - once for her MRI, though I think that was just a really heavy sedation, not anesthesia.
Moderator:
DrO

Posted on Friday, Aug 10, 2007 - 12:28 pm:

Hello Sandy,
Anytime horses are fully anesthetized there are risks but all in all the chance of a serious complication small with and experienced well equipped group.
DrO
Member:
kiwi1

Posted on Wednesday, Aug 22, 2007 - 5:00 pm:

Hi Dr. O

An update on my horse. I did proceed with the arthoscopy with him and found out that he tore his cruciate 2/3 of the way, in which the meniscus was torn as well and other stuff in the joint as a result of the instability. Basically the surgeon said the joint was toast. She thought that with proper pain meds, he would lead a normal life as a pasture pet but eventually the joint would result in me putting him down at a later date. I appreciate your help and support in this matter. Although the prognosis is grave, I am finally relieved that I have the answer and can go on from here. Thanks for your wisdom and advice.

Sandy
Member:
mrose

Posted on Wednesday, Aug 22, 2007 - 5:44 pm:

Sandy, did the surgeon clean up the joint while doing the arthroscopic exam? If so, you may be pleasantly surprised at how well your guy does, at least for a few years. After our mare's knee surgery we did the hand walking each day building up to full turnout. Although she now, 10 years later, has a lot of arthritis in the knee, she gets around remarkably good and can still run around in the fields with the other horses. As stated above, we were able to use her for quite a few years before her arthritis got too bad.
Moderator:
DrO

Posted on Thursday, Aug 23, 2007 - 6:56 am:

I am sad to hear that Sandy but not surprised, your history and previous findings all suggested a serious problem but as you say now you can move forward with a better plan. I would be interested is Sara's question about what was done during surgery. Occasionally check in and let us know how the mare is doing.
DrO
Member:
kiwi1

Posted on Tuesday, May 27, 2008 - 6:29 pm:

Hi Dr. O

Just wanted to check in to let you know of my horses progress. I decided not to put down my horse because of the injury and try to let nature heal him by just pulling his shoes and turning him out in a pasture. At first, it was very painful and I had my doubts but as time progressed, he really has improved! To be honest, he runs around and seems fairly sound even at the trot! One vet gave me hope and said sometimes scar tissue forms on these injuries and gives some stability to the stifle joint. I'm planning on having him reevaluated in the next month with flexions and ultrasound to see what is going on in the joint. At least I am optimistic that I might be able to take him out on a hack from time to time! I guess my point is I've learned a valuable lesson that sometimes with enough time, things can heal. Oh and by the way, he is on no meds! Pretty cool!
Member:
paul303

Posted on Tuesday, May 27, 2008 - 11:41 pm:

Oh, my goodness, Sandy. Pretty good news! Many thanks for the update. Could you possibly let us know how things progress? Here on HA, we learn so much from your experiences. Thanks again for the update. Best of luck, always.
Moderator:
DrO

Posted on Wednesday, May 28, 2008 - 6:17 am:

I am delighted to hear that your horse is comfortable and progressing well. This does return us to Sara's previous question of what did the surgeon do while in the joint. Did you get a report from the surgeon?.
DrO
Member:
kiwi1

Posted on Wednesday, May 28, 2008 - 6:31 am:

Hi Dr. O

The vet at Mid Atlantic who did the surgery said when she opened up the joint, there was so much damage and inflammation that she felt it was best not to do anything at all. She said that the meniscus was too torn and damaged to really "clean it up". Her greatest concern was the development of arthritis on his ultrasounds and x-rays from the span of 6 months. She felt that this would eventually get him and he would be required to be on pallative care for the rest of his life. I'm sure that any sort of work will cause him injury but at least he is pasture sound.
Moderator:
DrO

Posted on Thursday, May 29, 2008 - 6:23 am:

Thanks sandy, Certainly not an encouraging report but it sounds like your horse is doing a bit better than expected but I think you are right, work under saddle is likely to increase the lameness.
DrO
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