Read how Edamis provided the final and exact answer to a clinical question of a longstanding and recurrent history of severe lameness.
History:
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Chronic intermittent LH lameness, up to 3-4/5.
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Most prominent on soft ground and outside leg.
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Former lateral suspensory branch pathology with resolution.
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With training again very lame LH (new referring DVM):
- strongly positive flexion test
- no fissure/fracture pathology on RX
- 50% positive high suspensory block (DBLPN), further mild improvement after TMT block. No P/T nerve block performed given severity of lameness.
Medical imaging – nuclear medicine:
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Patient referred for bone scan (scintigraphy)
- moderate to strong focal IRU at the plantarolateral 3rd metatarsal bone with more diffuse capture along the tarosmetatarsal joint and 3rd tarsal bone.
History:
-
Chronic intermittent LH lameness, up to 3-4/5.
-
Most prominent on soft ground and outside leg.
-
Former lateral suspensory branch pathology with resolution.
-
With training again very lame LH (new referring DVM):
- strongly positive flexion test
- no fissure/fracture pathology on RX
- 50% positive high suspensory block (DBLPN), further mild improvement after TMT block. No P/T nerve block performed given severity of lameness.
Medical imaging – nuclear medicine:
-
Patient referred for bone scan (scintigraphy)
- moderate to strong focal IRU at the plantarolateral 3rd metatarsal bone with more diffuse capture along the tarosmetatarsal joint and 3rd tarsal bone.
Medical imaging – sMRI:
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Standing MRI for detailing lesions found on scintigraphy:
- chronic active desmopathy of the proximal suspensory ligament, with a large, mildly active core lesion of the dorsosagittal and lateral collagenous bundles, associated with:
- chronic active enthesopathy of the 3rd metatarsal bone, with mild focal bone marrow lesion (BML, edema-like) as well as strong suspicion of a large plantarolateral avulsion fragment
- further detailing of bone lesions was advised
Medical imaging – sCBCT:
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standing CBCT for detailing lesions found on MRI:
- confirmation and lesional detailing of a large plantarolateral avulsion fragment of the 3rd metatarsal bone, with significantly irregular and resorptive margins of the fragment bed suggesting fragment instability
- the exact extent and location with all possible surgical approaches were defined
Medical imaging – MSCT-guided surgery:
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MSCT-guided surgery under general anesthesia after bone lesion detailing and surgical planning on sCBCT:
- excision of the avulsion fragment through a lateral (4th) metatarsal fenestrating approach
- no additional approach through the PSL needed
Courtesy of: Mathieu Foucaud DVM, Resident ECVS
Case discussion:
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Given the longstanding and recurrent history of severe lameness, the inconclusive blocking pattern suggestive of bone pain and most importantly the active resorptive aspect as well as of course the exact detailing of the avulsion fragment (bed) on sCBCT, the decision to perform surgery was made.
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Although nuclear medicine and sMRI identified the lesion and cause of lameness in this case, sCBCT provided the final and exact answer to the clinical question.
