11/21/2018 - Diagnosing Penn, Part 5 (Treatment)

This took an extra day to get out because of the massive ups and downs my own emotions are taking on an almost daily basis since Thanksgiving. I had settled into a generic dead feeling about all things horses, but all the emotions were stirred up getting the last post together.

Collateral Ligament Badness

So where we left off, the collateral ligaments were #1 on the vet's list, with the coffin effusion and navicular issues neck and neck for #2.

Without treatment on the collateral ligaments, Dr Allen gave him at best, a 30% chance of being sound again. He suggested PRP injections into each CL, with shockwave following each injection. He gave a 40-60% chance of soundness if we did that. He also recommended some shoeing changes to help support the ligaments while they heal.

The shoe on the right is the one they took off Penn. It's his right front shoe, you can see the medial branch is wider and the whole thing is rolled. The shoe on the left is what the vet wants on him instead, but Penn's shoes need the other branch widened. It's basically a regular shoe with a cut of a second shoe welded to the inside. The vet thought steel shoes would eventually get too cumbersome and recommended an aluminum pre-made shoe eventually. And no more pad since that nullifies the effect we're going for.

He said we can also do PRP injections into both coffin joints for the effusion. He said that the injections he got back in August seem to have done their job, but he thought the effusion was coming back and we could readdress it.

The last thing he wanted to address were the navicular issues- he suggested another round of Osphos. He said it lasts between 3 and 6 months, so people generally do Tildren because it lasts about double the time. They end up costing about the same though in the long run.

Doing my due diligence, I asked how much all of these options cost. I already knew the cost of shockwave and Osphos, but not the PRP. Umm... let's call it "cost prohibitive" to do 4 PRP injections, plus 2 shockwave treatments. The cost for 2 PRPs was probably among the more expensive things we've done for Penn, aside from the 5 shockwave treatments that his insurance already covered.

Keeping in mind the reasonable vs unreasonable vs cost, we opted to go short term. Coffin injections and Tildren mean nothing if the collateral ligaments don't heal. We felt, while expensive, the PRP injections for the collateral ligaments were Penn's only real shot at soundness. We also opted for Osphos since while expensive, it's almost reasonable compared to everything else. Lastly, we decided to take new hoof balance x-rays. I didn't realize the ones from August would be considered old by now!

Part of the decision for no PRP injections for the coffin joints is I wasn't sold that Penn's coffins are actually hurting him, which sounds awful. Sure, his coffin joint in both fronts has some funny bone growth, but I'm betting it's always been there and isn't brand new. He was sound at one point in time. He felt a lot better after the steroid coffin injections in August, but about 2 weeks later he started to revert back, so I don't think they did much, and even Dr Cricket said they didn't appear to have worked for him.

We made all these decisions late Tuesday. Penn slept over at VEI so he'd be available when they were ready for him.

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Before I got to the vet office Wednesday morning, they had taken him to the back for his hoof balance x-rays.

11/21/2018
Did you know that horses who 'toe out' generally have P1s that are different lengths on the medial and lateral sides? The medial (inside) side of both of Penn's fronts are drastically different lengths than the lateral (outside). I mean, it wasn't as obvious to me in the previous x-rays, but the first thing I asked was, "I'm guessing it's not normal for the P1 to look like that?" Dr Allen was happy I noticed, and basically said there's nothing we can do about that.

8/16/2018

11/21/2018

8/16/2018

Will his legs ever be perfect? No. Are they better? I'd like to think so. He's still flat footed, but he's less crooked. It looks like he somehow has even less sole in those 3 months... though I will say he had an uneven amount of sole and we did fix that. His toe can still be brought back a bit. After Dr Allen looked at the new x-rays, he did hem and haw over pads- he immediately said, "I can see why Cricket put him in pads." and then had a good think over what he wanted to do, but eventually decided on no pad. The ligament support is more important than the sole coverage right now, and the pad interferes with the ligament support since it goes across the foot.

What I'm curious about, and I didn't talk to Dr Allen about it, but the vet who did Penn's PPE noticed he was crooked and said they could have addressed it as a baby (but then of course she's like, no matter, it's fine!). I'm wondering if he received different nutrition or care (ahem, better... I have many reasons to believe his VET breeder was much closer to a backyard breeder than thoughtful vet breeder), if his legs could have been straighter. Would leg braces have encouraged the bone to grow more on the deficient side?

Dr Allen also said something curious, he thought Penn had a sheared heel on the right front. He pointed out how the inside heel was taller than the outside. Not really knowing what that meant, I said OK and logged it down. He asked for the medial side of the right foot to be trimmed down over time. I had to look it up after I got home, then I immediately went out and looked at Penn's feet.

Top hoof is the right, bottom is the left. Apparently the right foot is sheared. I mean, I see it, but it's very very slight. The right hand side of the picture is the inside of the foot.

I came in while they were finishing up his x rays and putting his neck catheter in to pull blood for his PRP. They shaved his coronary bands at that time too. I did get a chuckle out of that- they always say how good he is and I told them he might be funny about the clippers, and they were like, "Really?" They flicked them on and he immediately became agitated and spooky. I asked that they touch his shoulder with them running and then he'll stand for it. They looked at me like I had 12 heads, but did it, and sure enough he stood like a gentleman and let them shave him... though, he did watch them very suspiciously!

Penn got some time to just be a horse after that. I took him out to hand graze while the team was prepping for his injections and the PRPs were spinning in the centrifuge. 

I got to be there for the PRP injections, and it was absolutely fascinating. I had a real job to do while they were doing that, so I couldn't take pictures of anything, but basically a team of 5 people is what it takes to get this done (vet doing injections with sterile hands, vet working the ultrasound with sterile hands, tech taking x-rays, tech handing everyone else things, and someone to hold the horse).

The method Dr Allen developed to inject PRP into the coffin collateral ligaments is ultrasound guided, x-ray confirmed, and pulling the needle out slowly as he injects. I'll bullet out how everything worked:

• One of the vets did nerve blocks to the entire foot in both front feet to help prevent any pain from bothering Penn while they were injecting.
• Scrub the lateral side of the left front and the medial side of the right front coronary band area thoroughly since the injections will be quite deep.
• Sedate Penn.
• Set Penn's front hooves up on two wooden blocks, since they needed to take x-rays during the procedure.
• They started with the right front. Dr Allen placed the needle while being guided by ultrasound by the other vet, with the extra tech turning knobs and pressing buttons on the ultrasound machine.
• The x-ray tech would place the x-ray plate and aim the hand held unit and take front and side images to make sure the end of the needle was placed in the wing of the coffin bone.
• Dr Allen confirmed placement, then proceeded to 'push the plunger' and slowly draw out the needle, thereby injecting PRP solution up the length of the ligament.
• Repeat for the left front. The right front was placed correctly the first time, but the left front was much more difficult to place. He got it though.
• Pressure is placed over the injection site, especially over the left front because it well hell bent on spewing lots of blood. Ok well maybe it wasn't lots, but blood runs really easily in short alcohol soaked hair, haha!
• Shockwave was done immediately following each injection, and then both of Penn's fronts were wrapped up.

And because I may as well share all the cool shit from this shitshow of a week, I have the placement x-rays too! 

Penn was a champ for his injections, everyone said what a good boy he was. In my head I was like, "How could he not be? You nerve blocked him and sedated him. He should be an angel." Apparently that isn't always enough. He didn't even need to be twitched. That's cool, I'm happy if everyone loves Penn, that means I've done my job in teaching him to behave, even if it majorly sucks. After he woke up a bit (and even at his Friday visit), all of the staff were stuffing him full of treats because they just liked working with him.

Dr Allen was happy with how the injections went. As he was doing the actual injection, I was sitting there thinking, "OMG why isn't it going in? Do they have a bad syringe that's sticking and broken?" He was shaking with effort to get the fluid out of the syringe. Apparently this is a very good sign. It means the tissues are still healthy. He said the horses who he can just squeeze the fluid into easily are generally shredded inside.

So Penn's final notes included:

• Changes to his shoeing with extra wide medial branch of the RF and lateral branch of the LF shoes. Slowly take away from the medial side of the RF to help fix the sheared heel.
• Two more rounds of shockwave to each collateral ligament, for a total of three rounds. He got the first round on 11/21, he got the second on 12/12, and he'll get the third on 1/2.
• Hand walk for a week after he gets home (this is already completed).
• A follow up appointment should be scheduled for 90 days after his 3rd round of shockwave.
• Limited turnout in generally pristine conditions, tranquilize as needed. Keep him as quiet as possible.
• Tack walk 3-5 days a week for 20-30 minutes until his recheck in spring.

They sent me home with a bottle of ace because the "minimal" bouncing he's been doing in turnout is unacceptable- he must only walk and stand. No trotting, bucking, playing, etc. I don't want to use reserpine because of the diarrhea risk, and because those COTH threads were scary. I did talk to a friend who used it on her horse, not knowing about the more rare side effects... and while he was generally fine, he hasn't been the same mentally since).

I've been a bit of an emotional train wreck since this vet visit. First was the, "We have a plan and we'll see how it goes", then the "OMG HE'S NEVER GOING TO BE OK AGAIN", then there was a strange "He's going to be just fine!" period, followed by a more mellow "he's not going to be ok" period. There's a bunch of stuff up in the air, and it won't settle back down until his recheck, which is kind of what I think it killing me a bit. I'm having trouble making it out to the barn to do his walks. I get out there 3-4 days a week now instead of 4-5 that I used to. I'm burned out on horses in general on top of being sad for Penn.

Dr Allen was hopeful I'd be able to start trotting him after his spring recheck, so I think that's keeping me running a bit. Do the rehab properly. Penn deserves it.