4th Treatment- Ethyl Alcohol Injection

After 3 years of managing Bailey’s high ringbone with 24 hour pasture opportunity, a maintenance exercise program, bute, equioxx, shoes, pads, barefoot, cortisone injections, I have come to my last chance to make her comfortable and hopefully able to be ridden, even at a walk.

Any lameness can be tough for a veterinarian to treat and resolve, but pastern joint lameness caused by osteoarthritis can be especially problematic. Stephanie Caston, DVM, Dipl. ACVS, discussed possible options for managing pastern osteoarthritis at the 2010 American Association of Equine Practitioners Convention, held Dec. 4-8 in Baltimore, Md.  Chemical joint fusion using ethyl alcohol was one treatment she and colleagues examined in a recent study.  In low-motion joints, sometimes the solution to lameness troubles is physiologic fusion (fixation of the joint so it can’t move) called ankylosis, to relieve pain and discomfort. Ankylosis occurs naturally in some joints, but Caston noted that ongoing joint disease in itself is unlikely to result in complete ankylosis. Typically, veterinarians manage such low-motion joints using arthrodesis (surgical fusion) with a variety of approaches ranging from lag screws and plates to drilling away the cartilage to laser surgery or chemical injections with irritating substances (to induce fusion). Many of these orthopedic solutions are expensive and fraught with long recovery periods.  Caston presented an alternative chemical approach to surgical arthrodesis, injecting sterilized 75% ethyl alcohol (Everclear grain alcohol) into an osteoarthritis-affected pastern joint.  Nancy S. Loving, DVM

I discuss this option with my veterinarian, Dr. Alfredo Romero who is a lameness expert.  He is aware of this relatively new and barely documented procedure, and has preformed a similar procedure on the hock joint, but never with the pastern joint.  He discusses with me the pros and cons.  I call around the area for input from Cornell and other well respected veterinarians who assure me I am in the best hands with Dr. Romero, although they will not do the procedure.

Having a veterinarian specialists that is forward thinking in treatment and compassionate about my horse, my goals, and me was key to moving forward with this procedure.

September 19, 2013.  I have built this procedure date up in my mind for a few weeks since I discovered the process written above while googling any hope for high ringbone and contacting my veterinarian Dr. Alfredo Romero, DVM, Dipl. ACVS, Diplomate American College of Veterinary Surgeons, in regards to having this done to Bailey.  Today was the day that she would be cured in my mind!  Dr. Romero came to my barn for the procedure.  This became in the end a wrong choice by me, as he had suggested I bring Bailey to his state of the art surgical facility.  Dr. Romero sedated Bailey and the goal was to inject somewhere between 6-10cc ethyl alcohol into her pastern joint.

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The process to to get the ethyl alcohol into the joint space goes basically  like this:

-first numb the area,

-then place a needle into the joint,

-then take a radiograph to be sure it is in the correct position,

-then IF it is in the correct position, dye is injected to be sure it goes in the joint and not outside the joint,

-then if all that is correct, the ethyl alcohol is injected. 

These multiple steps prior to injection are crucial because if the ethyl alcohol gets out of the joint it can damage ligaments permanently. 

This was done many many many many many many times that day without success.  Dr. Romero went above and beyond in his determination to get into Bailey’s joint, but she had so much deterioration around the joint, he could not manipulate her joint enough for a safe injection.  It wasn’t going to happen at my barn today.  I was completely devastated, and honestly, I think Dr. Romero felt my pain too.  He left saying he could try again at his facility where he felt he would have a sterile safe environment for Bailey’s joint to be manipulated and hopefully injected.  After my initial pity party, I scheduled an appointment to have the procedure re-tried on September 30, 2013.  Fingers Crossed till then.

I contact Dr. Romero as I am concerned what the outcome will be if he cannot get at least 6cc into Bailey next week.  He tells me that is not a major problem.  It just means that the joint space has started to fuse and so space is reduced.

The difference between choosing the ethyl alcohol fusion compared to the surgical fusion was huge for me- both financially and physically.  With the ethyl alcohol fusion, other than the needle injected, there is nothing else that effects the outside of the horse for this procedure.  There is no exterior first aid through recovery.  There is no specific stall rest.  Life for the recovering horse, according to what little I could find about this procedure, can be uncomplicated.  With the surgical procedure, there is months of stall rest.  There is cutting through skin, drilling, inserting screws, plates, stitching and exterior wounds which can lead to infection.  There is always the chance the horse won’t even make it through the surgery.  Casts are put on and need to be changed.  It is quite an ordeal for an average horse owner, although it can have a high success rate.  It was certainly not something I could tackle at my barn for her lengthy recovery period from that procedure.  Bailey also was a horse who had not been locked in a stall for three years now, and I couldn’t see doing that mentally to her, let alone physically.

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September 30, 2013.  We are off to Syracuse Equine Veterinary Specialists facility in Manlius, NY.  With the help of a good friend and her trailer, we load Bailey up for what I hope is going to be a successful day.  Dr. Romero knowing how emotional I am over this, politely suggests I leave for about an hour and let him work on Bailey.  As hard as it was to leave her, I wanted my doctor to have the privacy and concentration to get this done.  About an hour later I receive a call that is has been a success, and 8cc of ethyl alcohol was injected into her joint.  I am able to load Bailey back onto the trailer and bring her home that day.  Now only time will tell her outcome.

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Bailey is comfortable and not in pain the first 48 hours since she is still numb from the procedure.  She gets around fine.  Since this is uncharted waters, everyday is a new day with no real guidelines as what to expect.  I am told she will go through many stages of in and out of pain.  As the nerve endings die off she will not feel pain, as the joint fuses together like a broken bone would heal, she may feel pain.  Since Bailey is the only horse at the barn, my hope is she will fuse beautifully since she will not be frolicking with other horses.  Also, I had selected this time of year knowing winter was coming and she will by choice spend more time standing around in the stall eating hay and allowing the joint to fuse from less movement.

October 1, 2013.  Bailey is fine

October 2, 2013.  Bailey very sore, won’t put any weight on foot.  Administer 2 grams of bute in the am and pm.

October 3, 2013. Bailey very sore, won’t put any weight on foot.  Administer 2 grams of bute in the am and pm.

October 4, 2013. Bailey very sore, won’t put any weight on foot.  Administer 2 grams of bute in the am and pm.

October 5, 2013.  Bailey very sore, won’t put any weight on foot. Barely walking, doing a three legged hop.   Administer 2 grams of bute in the am and pm.

October 6, 2013.  Some improvement.  Administer 2 grams of bute in the am and pm.  She is a remarkable horse with such a big heart.

October 8, 2013.  Bailey is walking better.  I have a previous planned trip to California and leave boarding the plane relieved that Bailey is getting better.  I would be gone for 5 days and Dave was here to feed her and keep me posted on how she was doing.

October 15, 2013.  It is now 2 weeks since Bailey was injected with ethyl alcohol and she is not doing good at all.  I was returning from California to Syracuse. Dave had said Bailey was not getting up in her stall the last day.  It is not the recovery I had read about when I was deciding to do this.  With so little follow up on the recovery everyday was pretty much unknown.  That was the hardest for me as an owner.  I never knew what is normal for the recovery.   Thankfully I did have the best veterinarian taking care of Bailey and me!  Every time I contacted him, and it was pretty much daily for the first month, he was always helpful since he had a calming effect in assuring me to be patient and continue to contact him if I was concerned.  Since Bailey looks worse than ever, I call Dr. Romero to come out and examine Bailey.

EXAM – Post alcohol injection of the pastern 2 wks ago. Bailey is increasingly
uncomfortable. On exam today, Bailey is 4/5 lame, with sensitivity to palpation of the pastern joint, no sensitivity to hoof testers. Recommendations: continue observation and increase bute to 3g/day, consider adding gabapentin if lameness persists. Will call on thursday with update.

October 16, 2013.  Slight improvement.  Administer 2 grams of bute in the am and pm.

October 17, 2013.  Not much difference.  Continue 2 grams of bute in the am and pm.

October 24, 2013.  Pretty bad again.  Left leg seems to be getting worn out.  Leg wrap on left leg is suggested.

October 28, 2013.  It has been 28 days since the procedure.  Bailey is having a good day.  Walking pretty good.  Still giving bute but I have cut back to 1 gram in the am, and 1 gram in the pm.

There are now questions I need to ask Dr. Romero.  Do we inject Bailey again?  I have read that the clinical studies all did another injection of ethyl alcohol after one month.  I also talk to a veterinarian at Equine Affaire that has done the procedure and he says he injects after a month.  Dr. Romero is not suggesting another injection.  He assures me that a month ago he got all he could possibly inject into the joint, and further injection was not necessary.  I am satisfied with the decision not to do another injection, plus quite frankly, I was seeing some level of comfort return to Bailey and did not want to go through this past month again.  I still didn’t know what to expect for the next 6 or more months until we x-ray again.

November 12, 2013.  42 days after injection, Bailey walking pretty good on the soft coating of snow.  Her left leg is still wearing the neoprene wrap for strength.

From this point on, Dr. Romero nicely suggests I close the curtains and let Bailey recover.  Unfortunately I tell him I have no curtains on the back of the house, but I follow the doctors orders and let nature do its part on Bailey’s recovery through the winter months.





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