Tack Box Talk
Tack Box Talk
Osteochondrosis: The story of surgical fixes for bony problems
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Dr. Mike Fugaro and Dr. Singen Elliot, both equine surgeons in New Jersey discuss how osteochondrosis develops, and how it can be relatively straightforward to address. Not just a young racehorse problem, OCs can lie undetected and asymptomatic for years.
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Kris Hiney: Welcome to Extension Horses Tech Box Talk series, Horse Stories with a Purpose. I'm your host, Dr. Kris Hiney, with Oklahoma State University, and today we're going to be talking about OCDs, or Osteochondrosis diseccans.
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Kris Hiney: It's a crazy long word, and we need some definitions to go with it. So, with us today are two equine surgeons, because this is gonna have a surgical fix, Dr. Mike Fugaro. So welcome, Dr. Fugar.
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Mike Fugaro: Hello, welcome, thank you.
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Kris Hiney: And also, Dr. Sinjen Elliott, so welcome, Dr. Elliott.
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Singen: I thank you all for having us.
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Kris Hiney: So, excited to have you both, and both of you practice in New Jersey, is that correct?
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Mike Fugaro: Correct.
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Singen: Yeah, we're actually more or less down the road from each other.
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Mike Fugaro: I love the East Coast.
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Singen: Oh, yes.
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Kris Hiney: Right. But OCDs can happen anywhere, right?
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Singen: Absolutely.
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Mike Fugaro: Yep.
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Kris Hiney: Alright, so I started out with a hard word, so the… what OCD actually is, so maybe you guys could help us out. Why is that name what it is, and what exactly is this syndrome?
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Mike Fugaro: Go ahead, Dr. Elliott.
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Singen: Oh, great, excellent. I suppose I'm the closest to residency and having to answer, you know, exam questions on this, so,
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Singen: So it's, osteochondrosis really, typically, in horses, osteochondrosis is probably the most accurate, and really what it is, is it's a disease that affects
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Singen: the blood supply to the cartilage template of the bones that are growing in young animals, essentially, right? So…
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Singen: There is… typically, your bones form from a cartilage template, that's horses or dogs, or cats or people, and obviously, as you're growing, it's got blood supply to nourish it, etc, and small irregularities or changes in the blood flow can affect
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Singen: The bone that is being laid down on that cartilage template, and that is what essentially forms these osteochondrosis, or these bone fragments, in the joint.
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Singen: the, they tend to happen, particularly in horses, but in other species as well, in fairly consistent locations, so there are pre-delection sites, places where they happen more frequently. But essentially, they all start out, in young horses, where the bone is being laid down.
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Singen: And it just doesn't quite form right, and therefore you get this small fragment of bone that's just not actually unified with the parent bone.
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Kris Hiney: So, I have two follow-up questions on that. So, you said, you know, more likely osteochondrosis, so… and maybe just OCD sounds better. So, most of them are just OCs, so osteochondrosis versus the D is when it's kind of…
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Kris Hiney: Come off the bone, so to speak.
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Singen: Yes, my understanding, and Mike, jump in and tell me if I'm completely forgetting this already, but the D part, the dissecans, is actually something you see more frequently in small animals, actually, and my wife's actually a small animal surgeon, and so if I don't say this right, she'll be very upset with me, I'm sure. But yes, you're absolutely right. The diseccans part is really talking more about
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Singen: cartilage damage and sort of cartilage flap that comes up. It's a slightly different…
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Singen: mechanism by which it happens, and for the most part is sort of medical semantic mumbo-jumbo, from the standpoint of you're probably going to treat all of them in exactly the same way, and realistically.
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Singen: From an owner's standpoint, it doesn't… doesn't truly matter.
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Mike Fugaro: So, that's why we had… Yeah, and that's why I had Dr. Elliott answer, because he answered it much better than I would with it, but I will say, not all of these fragments
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Mike Fugaro: become dislodged. Some horses can have them in place, and when you go in arthroscopically or surgically, you can sometimes see the cartilage is unchanged. It looks visually normal. Now, it's probably not. There probably is some pathology. The question is, is…
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Mike Fugaro: It's kind of like the foundation of a house. You have the surface there, but if the foundation underneath is not steady and stable, you're going to have damage with it, which is part of the problem, and that's why the diseccans, or when I went through school back in the Stone Ages, it was taught that it was, like, again, that dissection part of it. Diseccans doesn't stand for dissection, but that's how it was interpreted. And all of these OCDs kind of get lumped into one category, and they're
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Mike Fugaro: are…
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Mike Fugaro: minutiae to it that Singen and I know about, but that doesn't make a difference. It's still the same treatment.
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Kris Hiney: So I just dated myself by adding the D then, so clearly I was a back and.
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Mike Fugaro: No, they haven't changed it yet, it still hasn't changed.
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Kris Hiney: Crazy yet.
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Singen: No, no, absolutely not.
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Kris Hiney: It's okay!
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Kris Hiney: Alright, so before we get to the horses, I do have a… this is a weird question, and I kind of just follow whatever rabbit trails. So you said it's common in small animals, and common in horses. Do people ever have these?
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Mike Fugaro: I believe they can, but I don't think it's in the quantities that we've seen. I think I do remember them, but that's… that's completely off the cuff. I don't know.
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Singen: Yeah, I would say that's very much off the cuff for me. I can't think of the last paper
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Singen: that I saw… mostly… I do a lot of neck work, so I've done a little bit more familiar with some neck stuff in people, but not, not so much the OCs. I think it would happen as well, but I just don't think it's as frequent.
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Kris Hiney: Okay.
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Mike Fugaro: And we do think, even though it hasn't truly been formulated, that there is a genetic component to this.
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Mike Fugaro: And then there are, developmental factors of this that can be created, specifically nutrition-based, or lack of nutrition. I almost said environmental, but I don't think environment has anything to do with it, but it's probably more the management and.
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Kris Hiney: Friday, right.
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Mike Fugaro: of these guys.
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Kris Hiney: And actually… What?
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Singen: Oh, I was just saying, I think that's… it's a good point as to why we sort of also see it more in animals, and probably why I would argue that it's still more significant or prevalent, I suppose, in horses, is some of those… the environmental things are more about the fact that they are
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Singen: outdoor animals, right? And so, things that have a major contributing source are things like
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Singen: infection, sepsis, so foals get, you know, you get a mild umbilical infection. Nothing that needs surgery, nothing that needs hospitalization, it's got a little drainage, not a big deal, it's a horse, you put it on some antibiotics, it's all good.
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Singen: But that… it's a young animal, it's more likely that those bacteria get into the blood, those bacteria in the blood therefore affect blood supply and then predispose it. So, horses or foals that have some sort of infection are significantly… I want to say it's something like 70-80% more likely to end up with OCD.
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Kris Hiney: Fantastic.
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Singen: Fragments than horses that have no infection as foals.
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Singen: But…
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Kris Hiney: That's cool, I hadn't heard that, so…
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Singen: And so it's certainly one of the risk factors for it, but that's where you get into, like, the environmental things. Yeah, I agree. It's not the environment that's the problem, necessarily, more a fact that, you know, horses will lie down and sleep in their poo, as opposed to our dogs and our cats, and generally our people.
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Kris Hiney: Oh, no, if you're talking about developmental, isn't that all what a baby is? I was just…
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Kris Hiney: I don't really radiograph them to see if we're gonna keep them or not, like… This is true. Alright, so we'll get back to the horse part here. So, for an owner,
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Kris Hiney: How would they know that their horse might…
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Kris Hiney: have one of these. Probably, I'm thinking here more symptomatically, and then we'll talk about, like, radiographs and some of the pre-purchase-y kind of things.
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Mike Fugaro: So, they may or may not have lameness. It depends on the joint, depends on the location, depends on if the fragment has moved.
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Mike Fugaro: Typically the joints will have swelling. We use that term called effusion, that's E-F-F.
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Mike Fugaro: usion, and… Is that how you spell that? Usion, I will write that.
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Singen: And…
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Mike Fugaro: And,
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Mike Fugaro: they may or may not be painful to, like, flexing of the joint. Usually it's not, but the symptomatic part will be mostly just that. You'll have swelling of a joint, plus or minus lameness.
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Mike Fugaro: and then it's a matter of taking radiographs, and then the truth of the matter is, sometimes it's taking multiple radiographs, because sometimes you don't see it the first time, if you're looking at, you know, young stock. And, I mean, these can show up
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Mike Fugaro: I guess it can show up as early as a few months of age, like 6 months of age. Is that a correct statement, Sinjin? Have you seen 6 months before?
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Singen: Yes, and I mean, I'd argue you could see it earlier, potentially. However, at that age, I would never do anything about them at that age unless they were truly free-floating in the joints, and I could prove that, because they may actually heal back, especially at that young of an age.
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Mike Fugaro: And then most of us see it probably once they're into that year to 3 to 5 years, depending on what's being done with the horse.
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Mike Fugaro: And, you know, in most cases, of course, those foals are just being allowed, and weanlings and yearlings are just allowed to be, you know, pasture ornaments and live out, so people aren't touching their legs as much. So, until they start getting used a little bit more and touched and handled, that's when people start noticing it. So, it's probably been there that whole time.
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Mike Fugaro: It's just a matter of once you
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Mike Fugaro: make note of it. So, in general, I mean, I don't do a lot of young stock, Singen sees younger horses than I do, but I would say probably in that, you know, 2 to 4, maybe 5-year range is where you're seeing it most prevalently. Is that a… would you say that, Singen?
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Singen: Yeah, I would agree, and I would say that probably, certainly at our hospital, and probably a lot of horses or hospitals that are doing young horses, probably have a similar distribution to this, is that when we're talking about our young racehorses, thoroughbreds, standard breads, we're basically seeing all of them as one-year-olds, right? Mostly because as
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Singen: racing horses, they are all getting screened for these sorts of things because it's a known thing, because they're probably going to go into sales, because it could affect… it could potentially affect performance, but it certainly could affect sales performance if you have those.
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Singen: And people want to get them removed sooner rather than later, if for no other reason, to make sure that the radiographs are clean, that they don't have fragments, and that they don't become an issue when the horse starts into training. So, oftentimes those,
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Singen: sort of higher-end or just general racehorses, it's sort of a well-known thing. Yearling come up, you're gonna do some maturity rads, and just sort of check and make sure that, yep, you've got the things that you want before a horse goes into the sale.
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Singen: But then, particularly with, like, our warm bloods, our sport horses, things like that, it's much more common to see them, yeah, like, 2 to 5 year old, and it's usually when they actually present with some sort of clinical signs, like swelling. So, I actually just, the most recent horse I did, this past week.
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Singen: came to me, had bilateral OCD lesions in the hawks.
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Singen: And the only reason it was known was because the horse actually had just a little bit of swelling in a sheath. The vet, one of our vets went out to go and look at it, and was like, hey, I know there's a little bit of swelling in the sheath, it doesn't seem to be a problem, but did you notice that the left hock was big? Maybe we should take radiographs and see if there's something there.
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Singen: The horse wasn't… wasn't lame, it, like, had no issues, it was running around just fine, but had a little bit of swelling. We took radiographs, saw that it was there, so before it becomes an issue, before it becomes a…
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Singen: more of a lameness issue. Get them out, get them clean, make sure they don't dislodge, and cause more of a problem.
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Mike Fugaro: And I'm seeing them in old… now, my population is an older demographic. I'm seeing horses that are maybe on pre-purchases, where it's an off-track thoroughbred or standard bred that's being converted, so I'm seeing it probably at, let's say, anywhere from 5 to 10 years of age. I can find some other ones that have kind of gone through
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Mike Fugaro: sale after sale, and maybe they're in their teens, and like Dr. Elliott said, have never had a problem. It's actually been there the whole time, and people have never, done the surgery, and sometimes you don't have to, but…
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Mike Fugaro: The challenge with it is once the fragment comes off, they typically will become lame. I had a situation, the horse was 18, it was purchased by a boarder.
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Mike Fugaro: The trainer had owned it before, and it was a lesson horse for them, and the boarder bought it from the trainer.
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Mike Fugaro: Hadn't had any problems, and then, of course, the owner buys it, and it was a stifle.
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Mike Fugaro: And a very large fragment came off, and this horse had probably the most swelling of a stifle I've ever seen, and was cripple lame. Like, I actually thought it had a fracture somewhere, and that's the first time I saw that one before. That was pretty aggressive.
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Mike Fugaro: And actually, Dr. Elliott's colleague over at the hospital did surgery on that for me. And we had to on that one, because it looked like… it looked like a snow globe of fragments.
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Mike Fugaro: The piece was probably about, oh, 3 to 4 centimeters long, which doesn't sound huge, but in a joint, that's a monster.
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Kris Hiney: Yeah.
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Mike Fugaro: And then when the horse went moving around, it just kind of fragmented into smaller pieces. Now it's like, imagine having a whole bunch of pebbles in your shoe and walking on your heels with it. That's what that horse was experiencing.
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Kris Hiney: So, on the young horse thing, so you said, and I'm probably more familiar with these, kind of, in that racehorse population, because they do screen them, right? So I do know, like, all the horses that go through sales, they have radiographs.
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Kris Hiney: The people that are looking at the horses can look at the radiographs, and so they're trying to make sure that they're clean. But I've also heard, so this would be where… I don't know if this is true, I'm gonna ask you guys.
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Kris Hiney: Like, some of them, they'll leave because… or… or maybe not leave, but they can get better? Like, they go away. Is that a thing?
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Singen: Yes. I would say yes.
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Singen: And I think it does, again, it sort of depends where they are. I think the most common place, and Mike, tell me if your experience is different, you've certainly been doing this longer than I have, the…
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Mike Fugaro: You called me old.
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Mike Fugaro: I mean, really.
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Kris Hiney: How dare you?
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Mike Fugaro: How dare you?
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Singen: I think you've got less gray hairs than I do at this point.
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Mike Fugaro: Edit that out right now.
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Singen: I need your, I need your regiment, whatever that is. It's looking fantastic. It's a bold spot back here, miss.
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Singen: But I would say the most common ones that I see actually go away are more likely to be stifled, and they're more likely to be ones that I've seen as a sixth
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Singen: to 12 months old, and potentially by the time they're 24 months old, it may have regressed and actually healed up. Those are probably really the only ones that I, for the most part.
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Singen: C that, actually.
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Singen: go away. I do think, and Mike had mentioned earlier, there are plenty of ones that… they're not necessarily a source of lameness, and you don't necessarily have to remove them. There are absolutely horses that live their whole lives with them in place, they're well attached to the bone, and
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Singen: they're probably not going anywhere. I think that's probably a… it's a bit of a tricky thing to know. Specifically on radiographs, it's a tricky thing to know. Now, if you really wanted to MRI and or probably do a contrast arthrogram CT,
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Singen: to say, okay, how much surrounding cartilage is there around this OC fragment versus the bone itself to try and see how well is it attached?
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Singen: then you might have a better idea, but on radiographs alone, you sort of don't know, and so it's more of a matter of
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Singen: it probably won't do anything, but if for some reason it breaks away, that's when you have a problem, and like Mike said, it's like having a pebble in your shoe, except this time it's rubbing away at the articular cartilage, which is what then potentially causes arthritis and things like that, so not only
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Singen: Discomfort and lameness right now, but something that could potentially cause joint damage that affects tomorrow as well.
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Mike Fugaro: And the only thing I'll add on to that, like, I don't think you're… I think the age is important on that one, those that I think will go away. We're not doing this in the 2 and 3 and 4 years of age, like, it's either gonna happen in those first couple years, or probably…
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Mike Fugaro: I don't know, I'm probably not much past 2 years of age, so I think that's gonna go away.
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Mike Fugaro: But, like, 15, we shouldn't be having a conversation. It's not gonna go away. That's what you got.
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Kris Hiney: Nope.
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Kris Hiney: So, an owner with a young horse, then, how… how would they make that decision to do surgery or not surgery? I mean, do you ever go with a, well, let's wait till they're too… I mean, with a racehorse, I get it, because they start training so early, but…
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Kris Hiney: I mean, that's a hard decision, because anytime a horse does surgery, right? Like, it's a… it's a thing.
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Singen: Yep.
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Singen: I mean, again, you're definitely, this is where the bias of speaking to two surgeons probably…
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Kris Hiney: Right. You're like… Take it out!
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Singen: I mean, without wishing to be too flippant about it, yeah, like, as a young horse, because there's an unknown, and because, frankly, for the majority of them.
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Singen: the prognosis is really quite good. It's a fairly straightforward, very routine surgery. It's minimally invasive.
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Singen: I tend to say, if it's a young horse, get it out now before it's a problem. The… the potential… I will say, Stifles is one of the ones that I will think about more, just because
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Singen: you can have some more lingering things sometimes with stifles. It can be just a little bit trickier,
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Singen: But, as, you know, Mike's story points out, sometimes, you know, it's been 18 years, and then something happens. That's certainly the more rare case, for sure. I would say that I see… I certainly, at least, have seen very few horses over the age of
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Singen: 5 that have had a known OC that suddenly broke away randomly.
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Singen: But it is absolutely the possibility, you know, a possibility, and therefore, particularly in a young horse that has one,
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Singen: you know, I would say that is absolutely the time to take care of it, and not have to worry about the unknowns in the future.
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Mike Fugaro: And I agree, with a young population, to me, it is such a simple procedure. I mean, this is what we're trained in, in our surgery residency. It's the mainstay. It is…
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Mike Fugaro: fun, it is relatively simple, it's not without its complications, but it's… it's what most surgeons want to be doing. So we definitely have a bias there. But on the flip side of it.
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Mike Fugaro: it is a very successful procedure, and there'd be no reason in my head not to do it. Now, when I see the horse in the older age.
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Mike Fugaro: Now it's actually a better question. Is it worth going and doing the surgery or not?
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Mike Fugaro: And I probably would say in most of my population, if he's not having a clinical problem, then, you know, ride it out a little bit longer.
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Kris Hiney: Okay.
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Singen: And I tend to… I sort of tend to agree, and probably go similar with that, is that I want to know that it's there. I would tell people that… same thing, is that it's probably not gonna cause a lameness issue, but also, it's important to know that it's there, because as soon as that joint gets swelling in it.
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Singen: don't just… don't just inject it without taking another set of radiographs. Don't just medicate it and give it time and keep going on it. Make sure you've got another set of radiographs to make sure that that swelling isn't because that's dislodged, because you definitely want to get that out as soon as possible if it does.
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Singen: it's probably more rarer that that's gonna happen, but but yeah, I tend to agree, and those older horses, when I do see them in, like, a 6, 7, 8, 10-year-old, something like that, it's almost guaranteed to have been there for its whole life, and hasn't been causing an issue, and therefore it's probably not.
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Singen: But I will also sort of remind people
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Singen: That if the horse has any resale value, there's any possibility that the horse is likely to have another set of pre-purchase rads, they will be found, and they will be considered a blemish, and so you might end up with somebody who wants to negotiate price, or is then turned off because it has it, and so, even in an older horse.
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Singen: I'm not opposed to, okay, well, let's just go and get this out.
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Singen: Even if it's not a problem. But the caveat mostly being is that if it's not a problem, it may not be a problem, and you may not need to be doing it.
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Mike Fugaro: And Dr. Elliott just brought up an interesting point, because I had a situation. I used to teach at an undergraduate university, and we had a horse that was mid to late teenager, had an OCD, and every time that horse came up lame, it could have been a completely opposite leg, you know, not even that leg. It was always… that OCD was the reason by…
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Mike Fugaro: the staff, the trainers, the students, and I said… I was like, wait a minute, it is not that.
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Mike Fugaro: Not that. And I even went and would block it, and say, look, it's not lame because of this, because it didn't block out, but it is a thing that horse people focus on, because it's on an x-ray, it's really easy to see, and you just focus on it, and you cannot get past that sometimes. So, I hate to say it, in some cases, you're doing it to keep everybody sane.
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Singen: or you're doing it to… I usually always tell my students, and I would tell my, I would tell my owners the same thing, is that you want to treat the horse, don't treat the image, but sometimes it's one of the things that I would potentially treat the image, because it's just…
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Singen: Saves headache in the long run.
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Kris Hiney: Fair.
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Kris Hiney: So what's the, like, recovery time for the horse? And then I'm gonna ask you the hard question, like, so, what's the average bill? And I know it varies from place to place, but in general ballpark, if somebody needs to have one done, what's gonna cost them?
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Mike Fugaro: You're up on that big guy.
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Singen: What was the first part of the question again?
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Kris Hiney: The horse's recovery time?
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Singen: Oh, yeah.
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Kris Hiney: And, like, yeah, what's the owner looking at here?
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Singen: Okay, well, generally, so for… for a standard, straightforward OC fragments that… that's coming out, and I'm gonna, you know, excluding more complicated ones or big things that have other…
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Singen: complicated things. Straightforward OC fragment removal. For the most part, I'm telling people recovery time is about 6 weeks. It's gonna be 2 weeks in a stall with bandaging.
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Singen: At the end of 2 weeks, the sutures are gonna be removed, bandaging can stop, and go to 30 days of individual, small paddock turnout, and then you're probably gonna be fine to go back into, sort of, GenPop, or start training again, something like that.
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Singen: there is sort of plus or minus, you know, a round of injections afterwards. There's actually some… there's a newer paper out recently on the use of PRP
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Singen: or, it was looking at PRP or hyaluronic acid as an intraarticular therapy after removal of the OCs, which I think a lot of us do. Mike, I don't know if you'd
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Singen: did, or do standardly. I certainly typically will say to do a dose of HA into the joint a week after suture removal, but this paper suggests that it may not make any difference, actually, in the long run. It still makes me feel better to do it.
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Singen: And I know when my, 2 years ago, when my wife bought a new horse, a 3-year-old Oldenburg, it had, OC lesions in both of its hocks, and I said, great, that's perfect, because that is a great prognosis, I can negotiate the bill, and I can take those out myself for a cheaper cost than most people. So it was, and for him, we did. We injected HA, and I actually did a course of Legend, post-operatively as well, just to…
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Singen: Just to try and keep everything nice and happy, but generally speaking, it's about a 6-week recovery time.
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Singen: 6 to 8 weeks, probably, depending on who your surgeon is. And, I think for us.
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Singen: at least a single-site arthroscopy is probably gonna run you… it's gonna run you about $4,000. And that's gonna be, for the most part, come in the day before surgery.
315
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Singen: then the day of surgery, and typically going home the day after, or two days after, with a bandage change in between, and meds to go home. Sort of that whole thing will be somewhere around that for one joint. Multiple joints will get a little bit more expensive. You know, if we're doing two or three joints, it might get into the $45,000 to $5,000, potentially, if you're doing multiple joints, but single joint, probably around
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Singen: The 4,000 mark.
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Mike Fugaro: And I'll say, I know a little bit of numbers around the U.S. with it, and I think that's probably a pretty good average, but I think you could go up to, like, 6 in some places as well.
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Kris Hiney: Okay.
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Mike Fugaro: Per single sign.
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Mike Fugaro: And I'll… go ahead, Sinjen.
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Singen: I was gonna say, I imagine you could probably go down to about 35, maybe? I don't know that there are many people doing them for much less than that.
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Kris Hiney: Okay.
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Mike Fugaro: I'll date myself. When I came through my residency, the protocol after, doing the surgery was to put a course of intraarticular Adequan in the joint, which they don't… they don't make an intraarticular Adequan anymore, to do that.
324
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Kris Hiney: So, so now it's off-label, then.
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Mike Fugaro: That's correct. No, it was, it was a special, it was a different version of Adequan. It didn't have, preservative in it.
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Kris Hiney: Gotcha. Interesting. So what about these things? And I'm sure that you guys are purveyors of the intranets as well, like the things that are advertised that will, you know, you feed it and it goes away. Like, I mean, come on, that's working, right?
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Mike Fugaro: Well, we're both from New Jersey, we can sell you a bridge, too, if you want to do that.
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Singen: Yes.
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Mike Fugaro: You know, I don't think you can prevent those. I don't think a supplement or any of those, you know, I'll use the term snake oil.
330
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Mike Fugaro: products, it's not gonna change it, but that doesn't change people's thoughts, and people love shopping at night, and, you know, spending online time, and that's…
331
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Mike Fugaro: you know, there's a lot of great marketing out there. I mean, look, are there some products that are out there that are probably beneficial? There probably are. The thing is that most of the nutraceuticals, and that's the general term for supplements, have not gone through any clinical trials or FDA approval
332
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Mike Fugaro: And they may go through a trial, but it's, like, on 5 horses. That's… that's not a true…
333
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Mike Fugaro: Trial test of a horse.
334
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Mike Fugaro: So, you know, they can say it can cure cancer, nobody can disprove them on that, because they have no idea if that's correct or not. So I… I tell people, you know, people love to spend their money on supplements, but I tell them, look, there's probably no harm in it.
335
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Mike Fugaro: it's probably wasting your money, but in this case, this one's a very… I mean, this disease has been around even before my stone ages of school time, so, like, this is not new, and we've got this pretty locked up. I was gonna ask Sinjen.
336
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Mike Fugaro: I don't think I've seen any papers, but have you seen anybody trying to use orthobiologics instead of removing these OCDs?
337
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Singen: I have. I'm, I'm trying to think… I'm almost certain that I will have done it at some point. Oh, okay. Per owner request, right? They wanted to try something, and, I couldn't talk them out of it. They really wanted to try something before surgery, and…
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Singen: again, that's sort of same thing. I don't think it's gonna hurt, and, you know, if you're really… that's really something you want to try, you've read something, like, I'm happy to do it, and make sure to do it safely. I mean, you know, I've got… I've got bills to pay, so, you know. But,
339
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Singen: I can't think of a specific horse, and probably mostly because I haven't had one that's actually made a notable difference to it. I can imagine the thought process behind it is…
340
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Singen: If you have…
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Singen: essentially, right, what you need is for the completion of mineralization of the cartilage that's there. The problem really is that you no longer have the osteoprogenitor cells in that cartilage
342
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Singen: to allow the bone to form, right? So, when you have… a growth plate is actually, you know, is cartilage, but it's got the right cell population to form
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Singen: new bone and new bone cells from that. When you have these OC fragments, because they've been separated from the cartilage, the cartilage you have separating the fragment is actually mature cartilage. It's not…
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Singen: this typical healthy cartilage, but it is mature from the standpoint of it. It's not got cells that are gonna develop into bone, and so if you're adding an orthobiologic, do you stimulate
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Singen: the transition of things, I think the answer's probably not, because I don't think you have the cells there to begin with. Now, if you were to, like, inject stem cells into the cartilage of the OC, I still think that probably isn't going to do anything, and I'm sure there are,
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Singen: Oh, goodness, Kyle Ortvet or, Lauren Schnabel or Lynn Pezzinite would, be wringing their hands and sending.
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Mike Fugaro: Oh, yeah.
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Singen: messages if they could hear me say to you on this, because they know far more about all of that than I would.
349
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Mike Fugaro: But I haven't seen any studies out there that people are doing. And honestly, if you're going to do.
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Singen: Not either.
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Mike Fugaro: Because, Chris, you'd have to do that under anesthesia as well, so if you're gonna put… anesthetize the horse, then do the surgery, take it out.
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Singen: Check it out, yeah.
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Mike Fugaro: And what happens is, after you remove the fragment, and the cartilage usually has to be removed as well, so technically you have a spot of arthritis. That's basically what arthritis is, a lack of cartilage, or deterioration of the cartilage.
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Mike Fugaro: especially the younger horses will form a fibrocartilage, which is not cartilage, but it's something reasonably as a replacement for it, and they do tend to have a functional area, for that. So I'd rather do that in the younger horse, let them heal, do your orthobiologic afterwards, after the procedure. I like that idea, and then, you know, and
355
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Mike Fugaro: let it heal the way it is. Now, in my 15-year-old that I'm seeing.
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Mike Fugaro: probably not worth it. We're not gonna do that. We're probably putting injections into it to calm things down, and deal with it until the fragment… if it releases, then we have to address it.
357
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Kris Hiney: So, for my non-surgeon brain here, when you're talking about orthobiologics, I'm either envisioning, like, you're doing, like, some tissue mesh sort of thing, or, like, nanobots. So what the…
358
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Mike Fugaro: Yeah, it's… this is the latest craze, and this is where the next… not even 5 years are all gonna go. So, the first ones that people would have heard of is PRP, which is…
359
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Kris Hiney: Play lately.
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Mike Fugaro: rich plasma, okay, so…
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Kris Hiney: No doubt.
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Mike Fugaro: various… there are various growth factors and other proteins in that, both inflammatory and anti-inflammatory, that help heal. There are,
363
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Mike Fugaro: stem cells, where you can actually harvest stem cells. I think down the road, we're going to see banks of stem cells. Right now, that's under FDA purview, and you really can't do that, from other horses for
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Mike Fugaro: general population, they're doing that in research situations. And then you go into the road of IRAP, and there are combinations of IRAP and PRP together in certain products. IRAP is interleukin-1 receptor antagonistic protein.
365
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Mike Fugaro: Which is a fancy term for interleukin-1 as one of the proteins that we see in inflammation. If you suppress that, you decrease the amount of inflammation. That's the real simplified version. But where things are going now, we're using… there are Amnion products and other products that are deriving
366
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Mike Fugaro: And they can even be from PRP-derived things, where you're taking cells and proteins, I should take that back, it's not so much cells, it's proteins.
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Mike Fugaro: very, very small molecules, and harvesting them, and preserving them, and putting that in. And that's where we're… and they're gonna be on the shelves, on our trucks, ready at our disposal.
368
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Mike Fugaro: probably in the next 5 years. But that's currently where everything's going. And that falls into, in human medicine, where they're going with peptide therapies, same type of thing. I think in humans, they do more on the…
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Mike Fugaro: hormone side, and I'm not sure that I understand all the hormones. Well, I know I don't understand the hormones, but it's… it's, again, these proteins that have both anti-inflammatory properties and inflammatory or regenerative properties.
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Kris Hiney: Gotcha. So my imagination was off the wall.
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Mike Fugaro: You're not so far off, I mean, that's where…
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Singen: We're gonna be. Oh, yeah.
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Kris Hiney: Okay.
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Mike Fugaro: That's, by the way, very confusing. It's confusing for us as veterinarians, and it's ridiculously confusing for horse owners, and all I can say is just keep listening to it, and we'll clear it up together. It's just going to take a few years for us to all get it together.
375
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Singen: For sure.
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Kris Hiney: Yeah, because PRP and stem cell, like, that's been… I mean, a lot of worse people are used to that, I feel, that that's kind of become a common thing, but…
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Mike Fugaro: And I… I predict, and I don't tell the companies this, those are… in 5 years, those are not going to be used
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Mike Fugaro: that'll be the minority. In fact, I think they'll… because what they're doing is instead of using all of those proteins and molecules in those samples of fluid, in this case it's part of the blood, they're actually getting purified samples of the specific proteins that you want out of that.
379
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Mike Fugaro: And that's what they're injecting in.
380
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Kris Hiney: Okay.
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Mike Fugaro: That's what peptide therapy is. You're focusing on very specific molecules, and these are ridiculously small molecules, so you said nanoparticles. That's not wrong. That's where it's heading.
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Kris Hiney: Okay. Well, I mean, I'm a nutritionist, you say peptide, I'm like, is it a dipeptide, tripeptide? Like…
383
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Kris Hiney: You've always…
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Mike Fugaro: surpassed my knowledge.
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Kris Hiney: That's well.
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Kris Hiney: Same on you, then. That simple stuff. So, okay, so I… so the prognosis is relatively good, then, right? Is there any time that…
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Kris Hiney: that it's… Like, should an owner, if they find the horse has one, like, is this ever…
388
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Kris Hiney: Not go so well?
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Mike Fugaro: engine. Hit him with it.
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Singen: Oh, God. I mean, yes, of course, the answer is, of course, yes, and there are any number of reasons why that might happen. You know, the… I would say probably the most common
391
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Singen: We sort of bring up stifles again, right?
392
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Singen: Having really large… the lateral trochlear ridge of the stifle is probably the most common predilection site for the stifle, anyway.
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Singen: And, where that's located, basically the groove where the kneecap sits. That's where it is. And you can have some pretty significant ones there, pretty large ones there, and those are ones that are…
394
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Singen: that are tricky, that are more… potentially more likely to have issues, more likely to have arthritic changes down the road, because you're just gonna get wear and tear on the kneecap, essentially. So, like, that would be an example of one that probably doesn't have as rosy a prognosis. I would still, you know.
395
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Singen: treat it similarly, but with the sort of caveat that I'm potentially more inclined to want to leave it alone until it is actually a problem, because as soon as I take away all of that bone and cartilage, I will then have a defect that creates more damage to the kneecap, the cartilage on the kneecap.
396
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Singen: But, you know, apart from those, and some… maybe some other…
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Singen: more atypical ones. The, you know, the major issues come up with if something happens to go wrong, so you get
398
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Singen: for example, a septic joint afterwards, right? The risk for it is low.
399
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Singen: You know, we're talking on the, like.
400
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Singen: 1%, you know, type risk. It's very low, but as I usually tell people, if it's your horse that it happens to, it's 100% of your horse that it's happened to, so the fact that you're in the 1% doesn't really matter.
401
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Singen: But that's probably the majority of the time when things go wrong. There are occasionally some…
402
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Singen: weird OCDs that come up. So, there was a recent paper that was actually looking at,
403
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Singen: OCD fragments in the back of the coffin joints.
404
00:53:32.220 --> 00:53:44.450
Singen: they're not common. The case report was a case report of 7 of them that happened, I think, over a 10-year period, and those all had a pretty poor prognosis, and mostly because that is not a very
405
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Singen: highly accessible location. There's a lot of important soft tissue structures back there that can potentially be affected by just localized inflammation and or the surgery itself to remove them.
406
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Singen: And that's not ideal, but is certainly in the sort of minutiae of ones that happen.
407
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Singen: you know, I see… again, I see… I do a lot of neck things, and most commonly, neck OC fragments, when they happen in the articular process joints in the neck, are
408
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Singen: typically think that they're probably asymptomatic, and they're probably not clinically relevant. However, I am actually doing a surgery, did one, yes, last week, and another one next week, on a horse that has significant pathology.
409
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Singen: maybe not specifically secondary to the OC fragments, but both of the joints that have pathology that I'm doing surgery on have OC fragments on as part of them, and it's certainly not helping things, right? Those are absolutely the atypical ones, but just happen to be ones that probably had
410
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Singen: a bad OC in the… in a joint that was predisposed to be enlarged and have other pathology, and that was just an unfortunate combination.
411
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Singen: of factors that went into it. So,
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Singen: Those cases are… are the atypical ones, and generally speaking, are gonna be ones that your surgeon's gonna have
413
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Singen: is gonna know about, and is gonna have a much longer conversation with you about, hey, this is not a typical OC, this is a larger-than-normal OC, this is something outside of the realms of normal, and therefore.
414
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Singen: prognosis is different.
415
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Singen: always worthwhile reaching out and asking, right? It's one of the things that, you know, I get… as a surgeon, right, I get referring vets sending me, even just, you know, text messages with pictures, hey, what do you think of this? What should I tell the owner, sort of thing, like…
416
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Singen: find… find a surgeon in your area, somebody who you'd refer to, or, you know, just a friend anywhere, right? And just send them an email, send them a text message, what do you think? How would you… how would you… what would you tell an owner about this? And, you know, probably, I don't know, what do you think, like, 90% of these are gonna fall into that good prognosis, straightforward.
417
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Mike Fugaro: Yeah.
418
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Singen: And it's maybe 10% at most that are gonna be the quote-unquote weird ones.
419
00:56:02.350 --> 00:56:05.659
Mike Fugaro: being high, I think it's probably closer to 95 and 5, honestly.
420
00:56:05.660 --> 00:56:06.680
Singen: I think that's fair.
421
00:56:06.680 --> 00:56:21.849
Mike Fugaro: And I think it's fair, I mean, Sinjin mentioned a couple other joints. It really can happen in any joint. My associate in my practice, she lost her older horse a couple years back, and when a necropsy was done on the horse, they actually found a very large OCD fragment in his hip joint.
422
00:56:21.850 --> 00:56:29.389
Mike Fugaro: I… I wouldn't have expected that. He didn't have arth… well, we didn't think he had arthritis in that area. Certainly had arthritis in other places.
423
00:56:29.420 --> 00:56:43.599
Mike Fugaro: And I don't think that was clinically relevant to the horse, but it really can happen anywhere. The one thing I was going to bring out in terms of a complication, and we've been discussing a very, typical fragment-type situation, but…
424
00:56:43.720 --> 00:56:50.189
Mike Fugaro: in the categories of OCD, and it's not quite the same, but it gets lumped in, are the cysts.
425
00:56:50.190 --> 00:56:50.510
Singen: Yeah.
426
00:56:50.510 --> 00:57:02.449
Mike Fugaro: and assist, and I think Sinja was intentionally avoiding it, but assist… assist is basically a hole in the bone, and they can develop over time. They kind of…
427
00:57:02.500 --> 00:57:08.699
Mike Fugaro: They can start off as something very small and form this very large kind of teardrop.
428
00:57:08.740 --> 00:57:17.439
Mike Fugaro: void in the bone. It's going to be adjacent to the, joint surface, at least on an x-ray, and
429
00:57:17.440 --> 00:57:36.970
Mike Fugaro: When it eventually communicates with the joint, they can be asymptomatic, and this is one of the biggest things when we do pre-purchases that we're looking for, and particularly in certain locations, like the stifle, and there's a specific location called the medial femoral condyle, we see that that's one of those things that we
430
00:57:36.970 --> 00:57:53.000
Mike Fugaro: often recommend people walk away from that horse right then and there, even if it's jumping huge jumps or doing whatever you want it to be doing. We say to them that you don't want that scenario. Now, there are some recent treatments that we're doing to try to
431
00:57:53.080 --> 00:57:57.320
Mike Fugaro: mitigate those, but I… I don't think anything is a…
432
00:57:57.600 --> 00:58:14.560
Mike Fugaro: solution, it's a, you know, lesser of best treatment. And the current method of treatment, and I will age myself, because there's been a lot of different treatments that are out there, and when I started, it's completely full circle. The solution right now is putting a screw
433
00:58:14.560 --> 00:58:17.990
Mike Fugaro: across the cyst, or adjacent to the cyst.
434
00:58:17.990 --> 00:58:18.680
Kris Hiney: together.
435
00:58:18.680 --> 00:58:25.110
Mike Fugaro: Well, it's not even that it has to hold the bone, because you're really just placing the metal, and the surgeon that really developed it
436
00:58:25.190 --> 00:58:40.990
Mike Fugaro: the reason she did it, her name is Elizabeth Sanchi, she had noticed that when she was putting screws in full bone, she noticed the bone around the screw was laid down at a much thicker rate and faster rate, so…
437
00:58:41.590 --> 00:58:53.459
Mike Fugaro: she came up with the idea, she goes, well, what if I put a screw next to the cyst? Will it lay down more bone? And it actually has. And she was the first one to do it. She was at Ohio State at the time when she did it, and…
438
00:58:53.460 --> 00:59:06.720
Mike Fugaro: She published a great study, and really, she's the pioneer of that particular procedure. When I was going through school and my residency, you were doing grafts, you were taking bone and cartilage grafts from other horses.
439
00:59:06.720 --> 00:59:22.279
Mike Fugaro: like a dowel and putting it in. They were using sheep allografts, they were growing cartilage in petri dishes and trying to put it back in there. We were injecting with steroids in there. So there's a lot of things that have been tried, because cysts are, like I said, one of the…
440
00:59:22.340 --> 00:59:31.839
Mike Fugaro: We don't like seeing them on pre-purchases, we don't like seeing them in horses in general, because when they're sound, they go great, but when they go lane, they're really tough to manage in some cases.
441
00:59:33.170 --> 00:59:40.149
Kris Hiney: And so that's essentially… it's a pit in the bone underneath the cartilage, then, rather than a cartilage defect.
442
00:59:41.760 --> 00:59:42.819
Singen: Well… Yes.
443
00:59:42.820 --> 00:59:45.299
Mike Fugaro: Yes. Yes and no. You answered that one, stinging.
444
00:59:46.470 --> 01:00:03.620
Singen: I was gonna say is that, yes, like, the primary finding that you see on radiographs is that defect in the bone, so it's really a subchondral injury, and the defect to the cartilage itself can be variable, for sure. There,
445
01:00:03.630 --> 01:00:16.850
Singen: Sometimes you'll go in surgically to take a look at them, and it's actually very difficult to find, because the cartilage over top may be just mildly dented, and sometimes you've got a whole grate sort of opening and holes, so…
446
01:00:16.950 --> 01:00:20.469
Singen: As opposed to… the most recent
447
01:00:20.620 --> 01:00:25.809
Singen: research and data on OC fragments.
448
01:00:25.960 --> 01:00:44.049
Singen: says that it's much more of this vascular model. There's still conflicting, thoughts about how the cysts form, there are still multiple different theories, and probably because there are multiple different ways that you actually get these cysts that form, so you could potentially have what's called a
449
01:00:44.580 --> 01:00:58.779
Singen: Oh, like a pressure necrosis, where you've got a small defect in the cartilage that forms, wear and tear, injury, something like that, and acts as a one-way valve that just pressurizes joint fluid, and therefore that pressure causes the hole in the bone.
450
01:00:58.780 --> 01:01:09.680
Singen: Then you've got ones that really are more like an OC lesion, as in it was a developmental defect, where the cartilage didn't grow normally, and there's an inflammatory component to it, therefore.
451
01:01:09.680 --> 01:01:21.480
Singen: And that's probably also why there is variability in the results that you get from it, because of the fact that the actual mechanism by which the pathology developed in the first place
452
01:01:21.910 --> 01:01:30.009
Singen: is just different. But over… overall, I would say that the most promising, currently,
453
01:01:30.030 --> 01:01:45.099
Singen: sort of treatment is the screws, and the way that that's been developing as well is we're starting to get, instead of stainless steel screws, we're starting to actually get bone screws that we're putting in to help try and fill the defects, so you can actually get,
454
01:01:45.360 --> 01:02:00.409
Singen: You know, basically bone allograft screws to put in and fill and use to fill a defect that hopefully will help affect the biomechanics, as well as providing the initial scaffolding for new bone to develop.
455
01:02:01.750 --> 01:02:04.410
Kris Hiney: Exciting. All kinds of new stuff they're doing.
456
01:02:04.410 --> 01:02:05.600
Singen: All sorts of stuff.
457
01:02:05.900 --> 01:02:15.639
Kris Hiney: Very cool. Well, I want to be respectful for you guys' time, but I had… I had more questions, so I don't know if I should ask you this, or just be like, alright, we've done enough here, so…
458
01:02:15.640 --> 01:02:19.290
Mike Fugaro: up to you, I have time, Syndr's gotta go, that's fine too, I will do whatever.
459
01:02:19.290 --> 01:02:21.040
Singen: I've got time.
460
01:02:21.040 --> 01:02:28.959
Kris Hiney: So, I wanted to ask, and I'm not asking for aging here, but, like, one of the other things that you hear about is the genetic…
461
01:02:29.520 --> 01:02:30.009
Singen: And part of their.
462
01:02:30.010 --> 01:02:44.060
Kris Hiney: genetics to it. Obviously, genetics and management, and it all goes together. We tend to hear about these in racehorses, but probably be… I don't know, my presumption is because we look.
463
01:02:44.120 --> 01:02:50.420
Kris Hiney: So therefore, you see in a much different frequency, but from your practice.
464
01:02:50.500 --> 01:02:59.950
Kris Hiney: Is this a horse issue, or do you see, kind of, lines of horses, types of horses, etc, that this is more common in?
465
01:03:01.510 --> 01:03:08.480
Mike Fugaro: I think a lot of it's anecdotal, because we just don't have the data that's substantiate it. When I was going through school.
466
01:03:08.700 --> 01:03:27.590
Mike Fugaro: the standard breads were very much, you know, the number one that we would see it in, and I think it's correct that you were looking at them, and it definitely thought there were lines, but in order to truly define that, you have to do some pretty significant research. I'll… I'll digress and talk about HYPP that we see in the Quarter Horse
467
01:03:27.590 --> 01:03:35.849
Mike Fugaro: industry. The only reason we were able to do that is the Breed Association mandated that everybody had to do genetic testing.
468
01:03:35.850 --> 01:03:55.290
Mike Fugaro: on their horses to become eligible so that they were able to define that this was from a lineage of Impressive, Impressive being the sire on it. But I don't know that anybody or any other disease or any other society has mandated that to actually come up with those numbers.
469
01:03:55.410 --> 01:04:07.679
Mike Fugaro: So, the answer to your question is, is I… yes, there probably is, but we don't have the research to substantiate that right now. It's just people saying, well, I've seen it in this line quite a bit, and others, and…
470
01:04:07.950 --> 01:04:14.330
Mike Fugaro: that's fine, you can have impressions, but you do have to substantiate it. I don't know, is there something that I'm missing there, Dr. Elliott?
471
01:04:14.490 --> 01:04:20.669
Singen: No, I think that's pretty fair. I think that there's probably also some degree to which you have…
472
01:04:20.780 --> 01:04:27.239
Singen: It's not always the case, like, especially in some of the, you know, breeding, you do have breeding that's sort of…
473
01:04:27.530 --> 01:04:39.110
Singen: spreads a little bit, but you also have some, like, industry standards in terms of husbandry and in terms of some of the risk factors for it as well that come up, which play a role, right? So, genetics
474
01:04:39.500 --> 01:04:51.579
Singen: we're fairly certain genetics plays a role of some sort, right? And there are… there are some predilections, there are some breeds out there that are slightly more predisposed to certain types of OCs versus others, but
475
01:04:52.050 --> 01:05:13.140
Singen: there have also been, there was another recent paper, I want to say it's in Lusitano's, but I now… I don't think that's quite right, I think it's a different breed, but where they specifically were… it's another sort of one of these… Lusitano's not that, but it's a slightly more obscure breed where they had a little bit more control, and they specifically attempted to
476
01:05:13.230 --> 01:05:32.770
Singen: used genetics to breed it out, to get rid of the predisposition, and they found they had a really difficult time doing that. Like, they really made little to no difference in the prevalence, despite selective breeding, to try not to get the OC fragments. So, it is something that genetics probably plays a role in, as in…
477
01:05:32.940 --> 01:05:49.969
Singen: there are some… you are predisposed to it happening, but you still need the bacteria, or the trauma to the cartilage, to the blood supply, or the something at just the right day of development to actually have it occur. So just because you're predisposed doesn't mean you're gonna get it.
478
01:05:50.070 --> 01:06:02.800
Singen: And even if you're not predisposed, you may still have an overwhelming, nidus for developing it because it has the basis in blood supply, and there are so many things that can affect that.
479
01:06:03.310 --> 01:06:20.579
Kris Hiney: Right, and hopefully people understand that, you know, your example for HYPB, that's a single point mutation, that's very easy to track down, versus this is gonna be, you know, presumably multi-genes that are feeding into this syndrome, versus, you know…
480
01:06:20.820 --> 01:06:22.620
Kris Hiney: You have it or you don't.
481
01:06:22.620 --> 01:06:29.319
Singen: I would think so, and again, I would also caveat that, is that genetics is definitely not my area of expertise, so…
482
01:06:29.320 --> 01:06:33.520
Mike Fugaro: Come on, guys! So, so far beyond my brainpower.
483
01:06:33.520 --> 01:06:37.310
Singen: I… I am a glorified mechanic, I…
484
01:06:38.260 --> 01:06:49.779
Kris Hiney: That's okay, we need those, so… Well, I… this has been great. I think this is really good. I now know a new term, so I can, use orthobiologics when I'm talking about PRP and IRAP.
485
01:06:49.780 --> 01:06:50.610
Singen: Yeah.
486
01:06:50.610 --> 01:06:59.060
Kris Hiney: And have a new category. Looking forward to dipeptides and tripeptides, or maybe they're longer, and polypeptides. So that's exciting.
487
01:07:00.030 --> 01:07:05.479
Kris Hiney: We'll be looking for new treatments, but definitely want people to feel like this is not…
488
01:07:05.710 --> 01:07:16.179
Kris Hiney: You know, the end of the world, that there may be treatment options and therapies that can be done, so, it's always best to be informed rather than, you know, resorting to sheer panic.
489
01:07:16.860 --> 01:07:17.900
Singen: Absolutely.
490
01:07:19.070 --> 01:07:27.500
Kris Hiney: Well, again, really appreciate, your time, and this has been another episode of our Tack Box Talk, Horse Stories with a Purpose.