Need help with path forward for severe rotation


Lavinia Fiscaletti
 

Moving this from EC Hoof.

Hello, I have been talking to a few podiatrists and my farrier used one of their markups of radiographs to put Khan in Redden Ultimates which they sent, however I am wondering if there is anything else out there as an alternative for such severe rotation? Additionally, I am struggling to understand what is recoverable or regrows such as hoof wall vs what damage is permanent? We are about 4 months into rotation at this point. The Podiatrist put a lot of emphasis on venograms, but is there anything that can be done at this point to improve circulation/bloodflow? I do not want to do another venogram because when we did do the venogram my vet struggled, it ended up being perivascular and overall was traumatizing for the horse and myself. I am struggling to find a farrier to help her.  Is there anyone who is located in or willing to travels to the upper midwest? Some have suggested trimming myself however I have never even rasped a horse so I do not feel comfortable taking on such a severe case. Thank you for your feedback.

Jessica and Khan
ND, 2021
--
Lavinia, George Too, Calvin (PPID) and Dinky (PPID/IR)
Nappi, George and Dante Over the Bridge
Jan 05, RI
Moderator ECIR


Lavinia Fiscaletti
 
Edited

Hi Jessica,

Based on the rads in your file,there is NO severe bony column rotation, although there may be some slight rotation present. There is some sinking and thin soles. What IS there, is capsular rotation, which is a trim issue. Khan's toes are way too long and being allowed to get longer and longer. This is compromising the hoof integrity and thinning her soles, along with starting to cause some coffin bone deterioration. From your description of what is happening after trims, it sounds like there is material being trimmed from the bottom of her feet - which is why she is becoming so sore after every trim. The bottoms of her feet need to be left alone so she can build sole depth. It's her toes that need to be brought back.

Based on the rad showing the Ultimates application, they are making things very much worse, as they have been improperly applied - please get those removed ASAP and just put her some padded hoof boots while we help you get the trimming situation sorted out. Her toe length needs to be backed up quite a bit more while having her heels lowered so that she isn't being forced to stand on the tips of her coffin bones.Totally agree that another venogram is not a good idea.

Using Jiaogulan will help increase blood flow, but it will also increase the growth rate of her feet, which is not a good thing until the trim can be straightened out. If you would please post a full set of hoof photos, I can help you get her trim squared away. Here's what is needed:

https://ecir.groups.io/g/main/wiki/1472

There is no reason to believe she is not going to recover if you get the trim straightened out. You are (hopefully) already addressing the dietary issues and the possible PPID that are driving the problems, so once you can get the trim squared away, she should be in a position to start regrowing better attached hoof walls. The current walls and damaged lamina do not "heal", they need to be allowed to grow out , which replaces the damaged material with new, healthier material. It takes 9-12 months for a hoof capsule to grow down from the top the the ground and you start counting once all the triggers that are causing the problems have been removed.

If you could give us a better idea of where you are located, we can probably help in finding a trimmer to help your situation.

Hang in there.

--
Lavinia, George Too, Calvin (PPID) and Dinky (PPID/IR)
Nappi, George and Dante Over the Bridge
Jan 05, RI
Moderator ECIR


Sherry Morse
 

Jessica,

Khan's trim needs to be addressed, and as far as I can tell from looking at the pictures you put into your Case History file that did not happen prior to application of the Ultimates.  Were she mine, I'd want to have the trim fixed prior to the application of any appliance.  It will take 9 - 12 months to grow out an entire hoof capsule and in the meantime we recommend using boots for sole protection as Khan has almost no sole at this point.  A good trim will bring her toes back and encourage sole growth but this all takes time.



 

Here’s a link to Khan’s case history.  It might be helpful to others.
--
Martha in Vermont
ECIR Group Primary Response
July 2012 
 
Logo (dec. 7/20/19), Tobit(EC) and Pumpkin, Handy and Silver (EC/IR)

Martha and Logo


 
 


Jessica Gunderson
 

Thank you.  I am located in Fargo, North Dakota. 

Some people have been telling me that the damage done may be irreversible and that a venogram would determine this. I don't understand.  Apologies if this is a dumb question, but I thought that the hoof grows out in a years time.  Are there parts of the hoof such as the circulatory infrastructure that does not grow or cannot repair over time?

I received the metabolic panel back from Cornell and will update my case history but her ACTH is 14.8 pg/mL so most likely not PPID?
--
Jessica and Khan
N.D., 2021
https://ecir.groups.io/g/CaseHistory/files/Jessica%20and%20Khan


Jessica Gunderson
 

The farrier did take toe off for application of the Ultimates but based on my layperson observation he did not take the heel down enough for this apparatus and may have used impression material in a way that is not recommended for this wedge.
--
Jessica and Khan
N.D., 2021
https://ecir.groups.io/g/CaseHistory/files/Jessica%20and%20Khan


Lavinia Fiscaletti
 

Jessica,

Your layperson observations are spot-on.

--
Lavinia, George Too, Calvin (PPID) and Dinky (PPID/IR)
Nappi, George and Dante Over the Bridge
Jan 05, RI
Moderator ECIR


Lavinia Fiscaletti
 

Hi Jessica,

Agree that based on that ACTH, PPID is not a factor - which given Khan's age is not surprising.

Not meaning to be flippant here but who are the "some people" who are suggesting that there is irreversible damage? What damage are they referring to? What are they basing that prognosis on?

Venograms come with their own set own pluses and minuses - which you are well aware of as the last ones were not done correctly. I don't see anything on the rads that suggests there is any irreversible damage here but I do see a trim and shoeing package that are pushing things in a negative direction if not corrected. I don't see that there are any factors supporting the need to risk another venogram at this time.

Not a dumb question - yes, a new hoof capsule grows out completely from top to bottom in 9-12 month's time. The internal structures are not replaced, they need to heal/repair. How long that takes, and how well they do the job, depends on many factors: removal of all the underlying causes; nutritionally tight and appropriate diet to supply all the needed building blocks; time.Once you have these in place, then yu can reassess the situation as warranted.

--
Lavinia, George Too, Calvin (PPID) and Dinky (PPID/IR)
Nappi, George and Dante Over the Bridge
Jan 05, RI
Moderator ECIR


Jessica Gunderson
 

I thought it might be easier to just provide part of a consultation I received, as I do not want to misrepresent anyone's feedback.

"Reviewing the radiographs dated April 21 I conclude. LF reveals slight displacement of the L zone, shallow sole plus cup approx. 10 to 12 mm total and 10-to-12-degree PA. RF HL zone remarkably distended at the distal measurement, less sole depth than the left same amount of cup
May 4 21 Both L zones had remarkable increase in the distal displacement of the L zone. The RF had much less sole and a 15-degree PA the LF sole depth was questionable doe to oblique image the PA was approx. 10 to 12 degrees
June 28th RF HL zone extremely large ratio with large gas line within the laminar wedge, subsolar sepsis thin sole no cup. Remarkable osteoporosis which suggests limited weight bearing.
LF Extremely large HL zone with chronic gas line, about the same amount of sole and noticeable new but minimum new growth at the coronary band and 20-degree PA.
July 6th Rf progressive signs of uncompensated laminitis, resorption of the apex, signs of solar sepsis and further distended hoof capsule distortion. An attempt was made to perform a venogram unfortunately technique difficulties resulted in extensive perivascular contrast injection.
Aug 5 RF Both feet had the heels trimmed to 10-to-12-degree capsule and put in my ultimate. Both coffin bones reveal extensive resorption of the apex. The mechanical benefits of the ultimate can optimize reperfusion at the onset or shortly after and help avoid the cumulative ill effects that invariably haunt the majority of significant bouts of acute laminitis. Applying the ultimate with this degree of vascular damage, the subsequent large PA and destructive soft tissue parameters has limited mechanical benefits as the PA prevents the load from shifting from apex to heel as designed. However, there is some level of mechanics even at this very late stage of the syndrome. Soft Rides are nothing more than cushion boots and have very limited if any mechanical benefits that can adequately reduce the tension on the DDFT as it continues to tear the bone away from its failed antagonist and the domino effect picks up speed. To have any hope of saving Khan’s life and reducing the painful response we must quickly eliminate the force of the DDFT and reposition the load zone of P3 to a zero PA with a minimum of 20 mm of heel mass. The derotation shoeing, decompression trim and shoe placement are technique sensitive as specific goals are to be obtained followed immediately by a DDF tenotomy. The bone damage is permeant as well as a fair amount of the vascular supply but there may be a reasonable chance to enhance healing. The prognosis is directly related to the speed and quality of reperfusion to vital growth centers and the bone. Complications are to be expected and at best a protracted treatment period of 8 to 12 months lies ahead. The bone sepsis will trigger abscesses and potential sequestrum that require immediate attention and continuous monitoring. The RF will be the toughest to deal with as it is the steeper profile foot of the two feet. I will mark the images as I would want them to appear following the trim shoe and tenotomy. I am glad to help walk the farrier and surgeon through my protocol using What’s App consultation if you decide to go forward."


Kirsten Rasmussen
 

Hi Jessica,

Khan's insulin has come down even further so kudos to you for eliminating that factor.  It's clear to me that the pain she is in is related to trim issues and compounding errors made WRT trim throughout the spring/summer.  Her rads show this progression.  Usually we don't get to see the progression so clearly because most people don't have a series of regular radiographs to share like you do. 

In my opinion, what started out as a very manageable capsular rotation that could have been corrected early on with some basic trim adjustments seems to have snow-balled after shoes were nailed on without correcting the trim AND before she had time after her laminitis to grow in a new well-connected hoof capsule (which takes 6-9 months), then further worsened by standing her up in the NANRIC Ultimates on the tips of her coffin bone (which have her putting all her weight on a the very delicate tip of the coffin bone...this is where severe bone loss will start to happen), and now you are discussing tenotomies and euthanasia.  It's true that damaged circulation can be serious and affect outcomes--just google "fatal sinker syndrome" (which is NOT what you are dealing with).  Her circulation may be somewhat compromised right now but the best way to restore it is to get her into padded therapy boots so she can move around and have pressure and release on the sole and frog, which will stimulate circulation.  Then work on the trim corrections needed.  The pain won't go away immediately, but she might show signs of some relief and at least further damage will be stopped.  She is not anywhere near so far gone that she can't recover fully from this.  Tenotomies are an irreversible last resort and I don't think you should be considering it. 

Please ask Lavinia for markups once she is in boots and you have time to photograph her hooves as directed here:
https://ecir.groups.io/g/main/wiki#Photos-and-Hoof-Evaluation-Help

--
Kirsten and Shaku (IR + PPID) - 2019
Kitimat, BC, Canada
ECIR Group Moderator
 
Shaku's Case History
Shaku's Photo Album


Jessica Gunderson
 

Thank you. I would not proceed with tenotomies.  There was a request made for the feedback I received and I am being responsive to that in comparing the different schools of thought regarding laminitis.  The difficulty is in finding a farrier locally or a farrier who is willing to travel to Khan to do the derotation trimmings.  I have never rasped a horse so I am not comfortable taking it on myself.  My farrier is considered the best in the area and this is where we have ended up.  I could possibly find a couple of inexperienced farriers who would be willing to follow instructions however my farrier has been sedating Khan for trims since the onset of laminitis and I do not think that these less experienced farriers are going to be set up for that.  Can these horses be trimmed lying down? I can try but its going to be hard to get a vet to come out for every trim to sedate Khan until she is feeling better depending on how frequent the trims need to be. Are there any farriers who can do this who could travel to Khan, at least initially to start the process with a new farrier?
--
Jessica and Khan
N.D., 2021
https://ecir.groups.io/g/CaseHistory/files/Jessica%20and%20Khan


Eleanor Kellon, VMD
 

The trim is definitely the most pressing issue here but I'd like to address the phenylbutazone use. Bute + omeprazole increases colonic damage https://pubmed.ncbi.nlm.nih.gov/32697849/ .  It is also interfering with abscess mobilization, circulation and healing in general. As I'm sure you have noticed, it doesn't do much for the pain anyway. I would order her some Phyto-Quench pellets https://uckele.com/phyto-quench-pellet.html [use coupon code ECIR] and once you start that begin to taper off the bute - 1.5 g for 2 days, 1 g for 2 days, 0.5 g for 2 days.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Jessica Gunderson
 

Thank you Dr. Kellon, I will do so ASAP.  
--
Jessica and Khan
N.D., 2021
https://ecir.groups.io/g/CaseHistory/files/Jessica%20and%20Khan


Sherry Morse
 

Hi Jessica,

You need a trimmer who is open to doing something different from what he/she may have been taught and think less of this as 'derotation' and more as corrective trimming.  At this point, given the length of Khan's toes, she could have a grinder used on her feet to get rid of most of the excessive toe before you even think about just using a rasp.  Not saying it can't be done using a rasp and nippers, but the grinder is sometimes easier when things have gotten to this point. 

We're not fans of sedating horses for trimming as that brings a whole level of danger with it.  It would be better for Khan if she was trimmed laying down if needed, but if she can stand with one foot in a boot or on thick foam padding or a pile of shavings so the other can be picked up, even that would be better than sedation.  Some horses get done by putting the foot to be trimmed on a block so there's room to use the rasp around the edge without them needing to pick up their foot and transfer weight to the other sore foot.  You may need to experiment to figure out what works best for her but there are many ways to do this without drugs on board.



Eleanor Kellon, VMD
 
Edited

Jessica,

 Contact me privately at drkellon "at" gmail.com. I have some leads for trimmers for you.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Jessica Gunderson
 

I have sent an email titled "Leads on trimmers for Khan" from jr_gundersonn "at" hotmail.  Thank you.
--
Jessica and Khan
N.D., 2021
https://ecir.groups.io/g/CaseHistory/files/Jessica%20and%20Khan