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  Discussion on Steroids or surgery for annular ligament constriction
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New Member:
cally

Posted on Sunday, Jun 4, 2017 - 9:53 am:

My connemara x tb 11 year old mare has recently been diagnosed with annular ligament synDrOme/constriction unrelated to any injury in both hinds, right worse than left. She has had windgalls since I got her 3 years ago and has been on and off lame in this time (at worst 2/10s lame on right hind and 1/10 on left), when not fully lame she has a shortened walk and finds canter work challenging. So ... given the fact that this constriction has been going on for a while, should I go straight for the surgery or should I give corticosteroid injections a go first (I was thinking each injection might last 3 months and I would try 2 rounds of this treatment). I know it's difficult to say without seeing the horse and the scans but in general is there any hope for successful treatment with injections where the condition has been going on for so long?
Moderator:
DrO

Posted on Tuesday, Jun 6, 2017 - 8:49 am:

Welcome cally,
It depends on how firm the diagnosis is: if this is truly a chronic annular ligament constriction tenosynovitis, steroids have little chance at real relief. The comment that suggest there are times she is not lame suggests that this may not be the whole story. But then you qualify this suggesting she is all the time lame just not at the same intensity...The only new news on the surgery is well summarized in the following report which states that instrumentation and experience with the surgery contribute to success:

Equine Vet J. 2012 Jul;44(4):412-5.
Use of a radiofrequency probe for tenoscopic-guided annular ligament desmotomy.
McCoy AM1, Goodrich LR.
Author information
Abstract
REASONS FOR PERFORMING STUDY:
Annular ligament desmotomy is commonly performed in horses with chronic tenosynovitis. Previously reported tenoscopic techniques have limitations related to haemorrhage and awkward instrumentation. Radiofrequency (RF) energy affords precision and excellent haemostasis and may be a good alternative to sharp transection of the annular ligament in horses.
OBJECTIVE:
To describe a technique for using a RF probe for tenoscopic-guided annular ligament desmotomy and to report the clinical outcome of horses in which it was performed.
METHODS:
Cadaver specimens (n = 14) and live horses undergoing unrelated terminal procedures (n = 2) were used to optimise the tenoscopic-guided RF annular ligament desmotomy technique. Records were examined for all horses undergoing annular ligament desmotomy with an RF probe from 2003 to 2008 for which follow-up of >1 year post operatively was available.
RESULTS:
The annular ligament was successfully transected in the cadaver and live horse model limbs using 2 different commercially available RF probes. Complete transection was achieved with practice and confirmed on gross dissection. Histopathology did not reveal any collateral damage to surrounding tissue. Follow-up of >1 year was available for 6 of 7 clinical cases. Four of 6 horses returned to work. Owners were satisfied with the outcome in all cases.
CONCLUSIONS:
Desmotomy using a RF probe allows precise tissue transection under tenoscopic guidance without damage to surrounding structures or haemorrhage. With experience, it is an easily performed technique. In clinical patients, an acceptable outcome may be expected.
POTENTIAL RELEVANCE:
Tenoscopic-guided RF annular ligament desmotomy offers advantages, including reliable haemostasis and precise tissue transection, over previously reported techniques and is a viable surgical alternative for treating horses with annular ligament desmitis and other complex pathology within the tendon sheath.
New Member:
cally

Posted on Tuesday, Jun 6, 2017 - 11:14 am:

Hi Thanks for this. I've actually now decided against the surgery as this seems a pretty drastic solution and not without risk. Would therapeutic ultrasound on the annular ligament be worth trying?
Moderator:
DrO

Posted on Thursday, Jun 8, 2017 - 5:56 pm:

What type US therapy are you talking about? We have an article on Extracorporal Shock Wave Therapy at HorseAdvice.com » Diseases of Horses » Lameness » Treatment Methods » Extracorporeal Shock Wave Therapy .
DrO
New Member:
cally

Posted on Sunday, Jun 11, 2017 - 5:34 pm:

I was thinking of Ultrasound heat therapy as I understand the shock wave therapy is very expensive and recent studies have shown not very effective. I'm looking to find a way of treating the thickened annular ligaments without surgery. The x-rays also revealed a bone chip in her fetlock but the vet/surgeon did not seem so concerned about this. Should I be asking more questions about the bone chip and taking it out? Is there any other way of seeing better the size it is and how much damage it has done to the joint/cartilege without arthroscopy please?
Moderator:
DrO

Posted on Monday, Jun 12, 2017 - 11:52 am:

The most comprehensive nonsurgical exam would be MRI but would require referral to a equipped hospital and best done under anesthesia though not always required. Diagnostic ultrasound can help with most of the questions you have but I stress this should be done by someone with certifications and extensive experience in the use of diagnostic us. Since your horse is lame yes I think a review of the bone chip is in order and a lot will depend on size and location so examination of the radiographs by a equine orthopedic surgeon seems reasonable. As to the use of therapeutic us for annular ligament constriction resulting in tendonitis, I have no peer reviewed research on this.
DrO
PS While researching this I did find another less invasive surgical procedure that applies to PAL desmitis without tendonitis. The abstract is followed by a description of the procedure from the article:


Abstract
Journal of the American Veterinary Medical Association
January 1, 2005, Vol. 226, No. 1, Pages 83-86
https://doi.org/10.2460/javma.2005.226.83


Primary desmitis of the palmar and plantar annular ligaments in horses: 25 cases (1990–2003)

Julie D. McGhee, DVM Nathaniel A. White, DVM, MS, DACVS Laurie R. Goodrich, DVM
Marion duPont Scott Equine Medical Center, Virginia-Maryland Regional College of Veterinary Medicine, Virginia Tech, Leesburg, VA 20177. (McGhee, White); Present address is 6675 Glenville Rd, Glen Rock, PA 17327. (McGhee); Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY 14853. (Goodrich)
Objective—To determine clinical and ultrasonographic abnormalities in horses with primary desmitis of the palmar or plantar annular ligament (PAL) and the response to treatment.
Design—Retrospective study.
Animals—25 horses.
Procedure—Data collected from medical records included signalment, horse use, affected limb, severity and duration of lameness, results of diagnostic tests performed, ultrasonographic findings, treatment, and outcome.
Results—All horses had a prominent swelling in the region of the affected PAL, and signs of pain were evident during palpation of the swelling. In all horses, the affected PAL was thicker than normal as determined ultrasonographically. Twenty horses had hypoechoic regions in the PAL. Four horses, including 1 horse with 3 affected limbs, were treated by means of PAL desmoplasty, 9 were treated by means of PAL desmotomy, and 12 were treated with rest. Follow-up information was available for 21 horses. All 4 horses that underwent PAL desmoplasty, 4 of 7 horses that underwent PAL desmotomy, and 7 of 10 horses treated with rest alone became sound.
Conclusions and Clinical Relevance—Results suggest that primary desmitis of the PAL may be a cause of lameness in horses. Although significant differences in outcome between horses treated with rest alone versus PAL desmoplasty versus PAL desmotomy were not identified, because it is less invasive, PAL desmoplasty should be considered for treatment of horses with PAL desmitis that do not respond to conservative treatment and do not have any evidence of constriction of the digital flexor tendons. (J Am Vet Med Assoc 2005;226:83–86)

Description of the procedure:
For PAL desmoplasty, local or general anesthesia was used, depending on the number of limbs affected and tractability of the horse. Hypoechoic lesions of the PAL were identified ultrasonographically, a No. 11 scalpel blade was stabbed through the skin and subcutaneous tissues into the hypoechoic lesions, and the ligament was carefully incised but not transected. Ultrasonographically, the scalpel blade could be identified as a hyperechoic line. Depending on surgeon preference, the scalpel blade was inserted perpendicular to the fibers of the PAL and approximately 50% of the thickness of the ligament was transected or the scalpel blade was inserted parallel to the ligament fibers and abaxial to the lesion, and the lesion was entered without transecting any part of the ligament and without penetrating the digital sheath or superficial digital flexor tendon. In the latter case, several stab incisions were necessary to open larger lesions. Because skin incisions were < 5 mm long, no sutures were used after PAL desmoplasty. A sterile bandage was applied, and horses were confined to a stall for 6 weeks, except for hand walking beginning 1 to 2 weeks after surgery. Followup ultrasonography and lameness evaluation were performed 6 weeks after surgery. If horses were progressing well, owners were instructed to allow exercise in a small paddock for an additional 4 to 6 weeks prior to initiating light work.
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