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Referral Surgery

Learn more about our Surgical Services here at Oakham

Case Studies

Thorn Penetration Injury

Every winter at Oakham Veterinary Hospital we see a large number of horses with acute synovitis following thorn penetration after a days hunting. Many local riders would agree that incidence of this condition is increasing. These horses are generally found to be lame about 3 hours after the penetration occurred which is far more aggressive than we would expect with other penetration injuries.

To date, there is very little literature for horses or humans on thorn penetration injuries. Currently, we do not know what causes the synovitis or if the response is unique to the blackthorn. We believe the relatively large number of cases seen at Oakham, due to our close proximity to the incredible, surrounding hunt country presents us with a unique opportunity to investigate this serious condition in detail.

In our experience complete removal of all the offending thorn fragments and a lavage of the synovial structure is essential to achieve a rapid return to full athletic function. Thorns and thorn fragments can be located in joints, tendon sheaths, bursas or tendons. In some cases locating and removing the thorn fragments requires sophisticated endoscopic surgical techniques. For instance in hind fetlocks they often pass between the condyles, and are fragmented and deposited on the intersesamoidian ligament.

The aim of our study is to establish the pattern of thorn injuries, evaluate current treatments and investigate the nature of the pathology. We hope the findings will enable us to develop improved treatments and preventative measures. We have expanded the study to include all synovial penetration injuries, so that they may be compared to thorn penetrations, and to provide data for a large multicentre study.

All cases will receive a ‘Gold’ standard treatment protocol that we hope will be subsidised by one of the large drug companies, with whom we are currently in negotiation.  Protocol will include:-

  1. Synoviocentesis, synovial analysis and culture, ultrasound evaluation
  2. Arthroscopic evaluation, lavage and thorn fragment removal
  3. Broad spectrum antibiotics and anti-inflammatories
  4. Hospitalisation for a minimum of 5 days, with appropriate dressings and detailed monitoring

If you would like to discuss the study and how you can be part of it, please contact Neal Ashton or Jim Doles on 01572 722647.

Bone Marrow Concentrate Tendonitis Treatment

Superficial digital flexor tendonitis is a very common injury in equine athletes. Many different treatments have been advocated over the years, each new modality remaining popular for only a short period of time.

Stem cell treatment has, for some time now, been offered as the ‘gold standard’ treatment for acute tendonitis. It was initially thought that the stem cells were incorporated into the repair to produce normal tendon tissue. More recent evidence suggests that they act as cellular conductors, co-ordinating the repair of the tendon. Traditional stem cell treatment uses bone marrow derived mesenchymal stem cells that are cultured in the lab to produce larger numbers of cells. These are then re-suspended in the bone marrow fluid before being injected back into the tendon. One drawback of the culture process is that it takes up to 4 weeks, meaning that treatment is delayed, and repair process has begun before the stem cells have been injected. There is also evidence that the cells become less potent as they are grown in the lab. Whilst we have had some excellent results using stem cells harvested in this way, there have been other cases where the results have been disappointing.

Bone marrow concentrate (BMAC) is a much simpler process of concentrating the cellular part of a larger bone marrow sample. The sample is collected from the horse’s sternum, then processed here at the hospital to produce the concentrate. This means it can be injected into the injury site straight away. This method gives early delivery of high quality stem cells, albeit in smaller numbers than with cultured stem cells. It now seems logical that a smaller number of higher quality cells early in the injury process is a more appropriate treatment.

Oakham Veterinary Hospital is able to offer Bone Marrow Concentrate as a treatment to our referral clients. It is usually performed during an outpatient appointment. All our vets are available to discuss the benefits of this treatment.

Para Nasal Sinus Surgery

Anyone unlucky enough to suffer from sinus pain knows how unpleasant it can be. Horses are no different, and although it is difficult to quantify the degree of pain they are suffering, those horses that have been treated surgically for sinusitis invariably show significant improvement in their temperament and performance.

The most common form of sinus disease that we see at Oakham is primary sinsusitis. Those primary cases with significant chronicity are complicated by inspissation of pus in the ventral conchal sinus, and walling off of the rostral compartment. The original surgery, as described by Paddy Dixon and Henry Tremaine was performed under general anaesthesia and a large flap was created with an oscillating saw. The technique of using large artery forceps to punch a hole for drainage, was successful but often produced dramatic and severe haemorrhage. James Schumacher and Geoffrey Lane refined the technique to use a smaller trephine hole in a standing, sedated horse but the creation of a new drainage osteum was still a very unsubtle technique. ‘not for the faint hearted’

At Oakham we have refined a technique; an ultrasound guided maxillary nerve block is performed to provide excellent analgesia of the sinuses, a technique developed ( and soon to be published) by our intern Jo Goliszek MRCVS.  This facilitates the surgery to be performed under light standing sedation alone.  We then approach the sinuses via two trephine holes about the size of a 5p piece, beneath discrete skin incisions. The surgery is performed using an endoscopic guidance and a minimally invasive, bi-polar electrosurgical technique. The skin incisions are closed in two layers with skin staples with excellent cosmetic results, and thus far we have had no complications.

‘Sinus surgery has become cool’

The second most common cause of sinusitis is apical infection of the caudal cheek teeth.  We have progressively developed the technique for oral extraction of these teeth with the use of nerve blocks, oral endoscopy and trans-buccal instrument access. Now nearly all cheek tooth extractions can be performed orally and elegantly, with a very low complication rate.

‘Cheek tooth extractions are much less daunting’

Other sinus disorders such as progressive ethmoid haematomas, maxillary cysts, fungal granuloma, polyps and neoplasms all benefit from minimally invasive techniques under local anaesthesia in the standing horse.

‘At Oakham all sinus surgery is now performed standing, with minimally invasive techniques that allow the horse to rapidly return to work, and keep their good looks’

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