Thursday, February 13, 2014

On the Case: Foal Foot Bone Sequestrum Infection, Surgery and Recovery with Fraley Equine Podiatry

"It's just a gravel." "This wet weather is causing him to abscess." "He gets an abscess every winter." "He's been lame from that abscess for too long..."

When is it time to worry about a hoof abscess? When it grows from a sniper site of infection to a battlefield, when a horse does not respond to standard antibiotic treatment, or when it becomes obvious that it's not an abscess, after all.

Last week, Chriselliam, the champion filly in Europe and winner of the Grade 1 2013 Breeders Cup Juvenile Fillies, was euthanized because a severe, advanced foot infection raged out of control. In spite of the best care available, her life could not be saved. The problem wasn't colic or laminitis or a deadly systemic disease: it was a particularly aggressive foot infection.

1. A radiograph revealed the presence of a sequestrum near the coffin joint in a foal's foot in Kentucky.

It is difficult for people to understand how and why an infection in the foot, so far from the horse’s vital organs, can threaten a horse’s life.

The whys list is long: ineffective antibiotics, delays in treatment or referral, wound contamination, incomplete drainage, over-aggressive treatment, irregular oral medications, or the most common reason of all: the caregiver just thought it would get better, eventually, because abscesses always had before. Why bother the vet?

When and if a horse survives a severe infection, it might be left with a bone infection, a scarred hoof or a susceptibility to further infections in the future.

When I saw the photos of this case from Lexington, Kentucky that had been treated successfully by vets and farriers at Fraley Equine Podiatry, I thought it showed what a foot infection can do to a horse’s foot.

2. November 21: Infection had erupted in several places at the coronet.

Luckily, this case responded to surgery and intensive treatment to stem the infection.

Many times, people are annoyed by stubborn abscesses, but it’s not the time to sit back and assume that antibiotics will take care of things. This case, too, began as a simple infection and just didn’t quit.

3. November 21: The infection was worsening in spite of the referring veterinarian’s treatment, which included systemic antibiotics, hoof soaks and poultices. When we tapped the coffin joint, it was infected as well.

In this case, the cause of the infection was a tiny bony fragment, known medically as a sequestrum.

According to the veterinary reference book Clinical Radiology of the Horse (3rd edition) by Butler, Colles, Dyson, Kold and Poulos, a sequestrum like the one found in this foal's foot is "a necrotic fragment of bone; a sequestrum usually is a sharply demarcated sclerotic fragment separated from the parent bone by a zone of radiolucency and an outer rim of sclerotic bone."

4. November 21: This is another view of the pastern before the surgery.
Surgical treatment: "We removed the sequestrum surgically, with the horse standing. The margins of the coffin bone were cleaned up as well as a portion of the collateral cartilage."

5. November 21: A probe inserted into the foot at the heel quarter came out at the coronet, clearly illustrating that the wall was detached.

Medical treatment: "Systemic antibiotics were changed, based on culture results. Antibiotics were also placed directly into the coffin joint and antibiotics were given via regional perfusion, as well.

"Oftentimes, success depends on the virulence of the "bug", which may be resistant to multiple antibiotics. In this case, we were able to culture the infection and that was crucial to the outcome."

6. November 21: The detached hoof wall was surgically removed.

In addition to removing the sequestrum, the detached section of the hoof wall had to be removed.

7. November 21: This is the portion of detached hoof wall that was removed.

After the surgery, the foot was kept in a firm bandage so it could be changed. Initially, it was changed on a daily basis.

8. November 26: Five days after surgery, the exposed tissue show signs of responding to the antibiotics and topical treatment.

In these and the following photos, the red staining is evidence of the strong iodine applied to the foot.

9. November 26: The sole of the foot five days after surgery

Iodine was applied to the pastern and foot to toughen the newly keratinized tissue as it grew.

10. December 9: The recovering foot, 18 days after surgery.

The foal was confined to a stall under mid-January. As the infection resolved, the bandaged packs were changed only every other day and eventually twice a week.

11. December 9: Healing on the bottom of the foot after 18 days.

After January 15, the foal was allowed to go to a small paddock, wearing a foot pack.

12. January 15: It's been eight weeks since the surgery. This checkup showed a marked growth of hoof wall at the heel quarter. The coronet is returning to a normal contour. The unpigmented hoof wall clearly shows the legacy areas that will need to grow out over time.

Extreme winter weather in Kentucky this year affected this foal's treatment. "The injury is currently still protected by a light foot pack because of the hard frozen ground here at the moment. This foal will likely go barefoot in a couple of weeks."

13. January 15: The sole after eight weeks of healing.

It has now been almost 90 days since the surgery was performed. The foal is sound at the walk. These photos (14 and 15) were taken this week.

14. February 8: 78 days after surgery, the foal is sound at the walk. His hoof wall tells its story. The new growth from the wall and the normal contour of the hairline suggest a brighter future than might have been expected.

Prognosis: The prognosis is good for this foal to live a comfortable life. At the moment, there are no signs of arthritis in the coffin joint. It is very possible this horse will be able to compete athletically.

15. February 8: The damaged zone of hoof wall is growing toward the ground and will continue to be trimmed until a tight wall to sole juncture from heel to heel is reached.

Thank you to Bryan Fraley, DVM, who documented the case. Be sure to check the Fraley Equine Podiatry page on Facebook, where the team posts photos of cases they are treating, shoes they are making, shiny red trucks they are driving, and cute dogs that are underfoot when they work. A condensed version of this case may be referenced there.

Thank you for Dr. Miguel Paricio and Dr. Bryan Fraley for photos.

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