"Any of us dealing with laminitis have our successes, but we've also had our share of failures," said Bill Baker, DVM, of Equine Associates in Hawkinsville, Ga., at the recent Bluegrass Laminitis Symposium. "These failures are usually the most memorable, but least-discussed cases. This is unfortunate, because we can all learn from failures--those lessons are where successes are born. Hopefully you will learn from my mistakes and ignorance so you will not have to repeat them."
During the Laminitis Symposium, held Jan. 25-28 in Louisville, Ky., Baker, who is both a veterinarian and a farrier, presented a discussion of six case studies and what they taught him not to do in treating laminitis. He began by describing the following common causes of treatment failure.
No plan "Plan the work and work the plan," he recommended. "Do the diagnostics and assessments in order to be able to plan the work. Have the skill, technique, and materials available to be able to work the plan. And if you don't have these, don't start!"
Available skill The case exceeds the skill level currently available (of the veterinarian, farrier, and/or owner).
Finances "I don't care how many people tell you money is no object, it is an object," Baker said. "With an awful lot of these cases, you get in the middle of it and they go high-scale (the damage is revealed to be very severe), and it's more than the owner's willing to deal with."
Owner influence during treatment "My rule is that owners are the financial backers and ultimate decision makers, but I don't want them getting under the horse and trying to help me out," he noted.
Too many chiefs and not enough Indians "If you don't have someone in charge to make the plan and people around to work the plan, you set yourself up for failure," he commented.
Lack of owner compliance with care/aftercare "When I've spent months on this horse, I have a list of take-home instructions on what I want them to do with diet and exercise, and what the horse can and can't do," he said. "When I see the horse back for a reset and we're back to the beginning, and the owner says, 'He was fine when I rode him yesterday'--against my instructions--that just overturned the whole boat."
Poor communication with client and farrier "Be forthright and honest with yourself and your client," he recommended. "There are no instant heroes when treating laminitis. Speak in common language, not veterinary terminology--be understood!"
Case 1: A Heart Bar for Every Horse
Baker described this 6-year-old cutting mare as Obel grade III lame (reluctant to move and obviously lame in all circumstances) in both front feet after an acute onset of laminitis. She had some rotation (of the coffin bone) in both front feet apparent on radiographs (X rays, with her feet nerve blocked to attenuate pain), and received anti-inflammatory medications for initial treatment. Two days later, her hoof walls were resected (cut away, because they were separated from the bone already) and heart bar shoes were applied.
Within a week she was more lame, and within another week she was constantly down, her coffin bones had prolapsed through the soles, and she was euthanatized. Baker described the following lessons he took away from this case, in hindsight.
- Radiographs must be properly taken and measurements made to evaluate the case.
- Don't attempt to treat all cases the same way.
- "Nerve blocks may help you but not the horse--you have numbed their feet, allowing them to bear full weight on damaged tissue and cause more and more damage. Don't block these horses!" he urged.
- Lack of planning and experience can certainly lead to failed cases. Don't blame the shoe. Blame the application.
Case 2: Know When to Walk Away
This 12-year-old obese Paso Fino gelding was described as "a chronic laminitis case with acute episodes." Baker recalled that he came off the trailer without too much lameness, but apparently the horse's front feet were blocked for the 200-mile trip to the hospital (he commented that this is not recommended, as a nervous horse in a trailer can do a lot of additional damage to his feet when he can't feel pain in them).
He said the horse overall was not a very severe case, and was treated with a corrective trim, some medications, and shoeing with Natural Balance shoes and cushion support. The horse's feet were not blocked again, despite urging from the owner.
"We reset him four weeks later and he was doing well," Baker reported. "Then the owner declared the horse well and discontinued treatment. Three months later, the horse was Obel grade III lame and she brought him back to us." The horse's feet had deteriorated significantly, with more rotation compared to the original radiographs and very little sole left beneath the tip of the coffin bone, which had rotated below the circumflex blood vessels (that normally run beneath the coffin bone) in both feet.
"The owner wanted partial therapy (no tenotomy) and a guarantee of soundness after treatment," he said. "This was a no-win situation for myself and the horse, so I fired myself from the case."
- Don't start a case without knowing the owner's expectations and limitations.
- Don't allow the owner to dictate therapy (except when there are multiple financial options available).
- Owners can sabotage the best of plans through lack of knowledge. Educate them and make them part of the solution, not part of the problem.
- If you can't work with the owner as a team, walk away. You can't save them all.
Case 3: Evaluating Venograms
"My goal for using venograms (radiographs taken with contrast media in the foot's blood vessels to evaluate blood flow and any vessel damage) is to tell clients what to expect," Baker said. "They're prognostic indicators."
He discussed a 13-year-old Quarter Horse mare with bilateral rear chronic laminitis (affecting both hind feet). "I looked at the venogram that had been done at the referring hospital (on the left hind foot, which appeared more severe on a plain radiograph) and saw no blood flow in the foot," Baker recalled. "Because of this, the referring hospital had recommended euthanasia, and the owner asked for a second opinion (mine). As it turned out, failure of the tourniquet (used to keep the contrast media in the foot long enough for the radiograph) caused the lack of contrast in the foot seen on the venogram."
- Venograms are an excellent tool when interpreted and performed properly.
- If venograms and the clinical picture differ markedly, re-evaluate. "This horse was almost destroyed because of these films," he commented. "Don't be so quick to destroy the horse; this can't be reversed!"
Case 4: Ultimate Wedges
This 3-year-old Quarter Horse mare became lame in both forefeet from laminitis five days before presentation. She was referred to Baker, who radiographed the mare and placed her in Redden Ultimate Wedge shoes.
"I did not radiograph the mare (to evaluate her hoof measurements) after putting on the shoes, and 72 hours later she had developed separation at both coronary bands," he said. "Twenty-four hours later she displaced distally (her coffin bones moved downward through her hooves) big time. Both front hooves separated at the coronet from quarter to quarter and she was euthanized."
- "Ultimate Wedges are excellent tools in the hands of someone skilled in their use," Baker said.
- "The palmar angle (angle the bottom of the coffin bone makes with the ground) has to be less than 5° when the Ultimates are placed on the feet (if the palmar angle is higher, the extra weight on the tip of the coffin bone drives it through the sole)," he said. "Trim and radiograph the horse post-trim to see how you did."
- Don't sit there and watch a horse fall apart. If it isn't working, change it, but find out why it isn't working.
- "I have since used the Ultimates with great success," he reported.
Case 5: Putting It All Together
Baker described this 3-year-old mare as having an acute onset of laminitis in both front feet. She had been given the corticosteroid dexamethasone at the onset of laminitis.
"Corticosteroids in the face of laminitis are bad!" he stated. "They cause a change in the walls of blood vessels, which can affect blood flow to the foot.
"We started DMSO (dimethyl sulfoxide, an anti-inflammatory medication), Bute (phenylbutazone), applied Ultimate Wedges, and applied ice therapy for 48 hours," he reported. "She was walking okay, but the venogram showed a stark loss of contrast (loss of blood flow) at the coronary cascade. She developed separation of the hoof walls at the coronet in both left and right fores in the quarters and the heels--she was a true bilateral sinker.
"Our treatment plan included bilateral hoof wall ablation (removal of the hoof walls in both front feet) and bilateral transfixation casts with pins (casts built around pins through the cannon bones, used to support the horse's weight and 'float' the feet)," he went on. "She did great and began improving, but after a week, she got cast in her stall and had an open fracture of her left hind leg and we had to euthanize her."
- You can do everything right and bad things can still happen.
- With each new treatment technique, there are new complications that can follow.
- "I have since performed several hoof wall ablations in sinkers successfully," he said. "I think this an appropriate alternative to amputation if performed early in the circulatory collapse of the foot."
- If the horse and owner are willing to try, never give up until it's over.
About the Author
Christy West has a BS in Equine Science from the University of Kentucky, and an MS in Agricultural Journalism from the University of Wisconsin-Madison.
POLL: University Equine Hospitals