VETERINARY TOPICS

JOHN G. PELOSO, D.V.M.

Benefits of MRI
Evidence suggests standing MRI is preemptive screening tool to identify fracture risk in fetlock joint

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Normal

Early subchondral changes

Subchondral lucency

Maladaptive microdamage and sclerosis

Subchondral lucency

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THOROUGHBRED TIMES March 26, 2011

Images courtesy of Elizabeth J. Davidson, DVM, Diplomate ACVS

the rate of bone removal (absorption) to exceed the rate of bone replacement, a process known as non-adaptive bone modeling. This abnormal condition weakens the bone and causes it to become more susceptible to fracture. More specifically, if this process goes undetected, the continued stress of intense exercise on a bone that is already weakened may lead to stress fracture and ultimately catastrophic fracture. Identifying those

horses that have non-adaptive bone modeling is the challenge of trainers and veterinarians that direct these horses. For reasons identified below, this condition is more difficult to identify than is immediately apparent.

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Fetlock issues
In the fetlock, the effect of training and bone modeling occurs in the subchondral bone layer at the back part of the cannon bone just beneath the sesamoids (Figure 1). The subchondral bone layer is the bone just below the cartilage layer. This deep (extra-articular or outside the joint) location of subchondral bone makes the identification of non-adaptive bone modeling difficult to recognize by conventional means such as radiographs or ultrasound (Figure 2). Because these changes are deep within the bone and are not inside the joint, these changes do not cause an increase in joint fluid production (joint swelling) or produce reliable changes on radiographs. If identified early, the same training

ure 5), to excessive thickening or hardening called sclerosis (Figure 6). In the more advanced cases there is extensive subchondral bone loss, which eventually leads to thinning or a secondary collapse of the overlying articular cartilage layer (Figure 7). Thinning and destruction of the cartilage layer creates joint pain, and eventually significant degen-

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HE FETLOCK joint is the most common site of catastrophic fracture in the Thoroughbred racehorse in the U.S., United Kingdom, and Hong Kong, and a reduction in the occurrence of fractures in this location would have a significant impact on the number of Thoroughbred racehorses lost to fractures during training and racing. The fetlock joint is also frequently affected by degenerative conditions that lead to reduced performance and often result in premature retirement. While epidemiologic studies have identified risk factors for fracture formation, practical screening tools to identify the at-risk horse, before a fracture or irreversible joint degeneration occurs, are limited. Recent developments in standing magnetic resonance imaging, or MRI, offer the potential for just such screening. A bone adapts to the demands of training and racing by a process known as bone modeling. Trainers and owners are most familiar with this process when dealing with bucked shins. The process of bone modeling has a similar effect at many locations throughout the equine “in training” skeleton in addition to the shins. It also occurs in the tibia, shoulder (humerus), pelvis (hips), and the fetlock. It is well known that bone increases its size and mass in response to exercise and that these changes are essential if bone is to tolerate the physical demands of training and racing. During normal exercise, bone density increases by bone model-

ing as the bone is stressed during work. Bone is first removed (absorbed) and then it is replaced with more dense bone. In some horses, excess training can cause Trabecular bone

Figure 1

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practices that minimize the effects of bucked shins can also minimize the effects of non-adaptive bone modeling in the subchondral bone of the fetlock. Disease of the subchondral bone of the fetlock has been recognized in Thoroughbred racehorses for many years. In one postmortem study, 67% of all horses had gross evidence of injury to the subchondral bone in at least one fetlock. The pathologic change that occurs in the subchondral bone of the fetlock is termed palmar osteochondral disease (POD). This condition has been diagnosed for several years using a bone scan (Figure 3), which identifies the problem by showing an “increased uptake of radiopharmaceutical at the back of the fetlock joint,” indicating an active problem. A bone scan cannot differentiate the spectrum of disease or the exact anatomic changes that have occurred in that bone (Figure 4). Current thinking suggests that POD progresses from a mild thickening of the subchondral bone (Fig-

Champagne Photography

VETERINARY TOPICS
To view a video of a horse undergoing a standing MRI examination, access www.hallmarq.net

The two MRI images (above) are from a normal horse that has yet to begin training

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Figure 5

Identifying the problem
The question is how horses with this problem can be identified, knowing that it is difficult to recognize in its early stages while recognizing that the disease is most treatable if discovered early. The following clues should increase suspicions. Playing the odds, subchondral bone modeling is responsible for 66% of all lameness in the fetlock, so horsemen in doubt should assume the fetlock is the problem. Greater attention should be paid to changes in personality and training behavior. Are they: • Horses that were previously happy in the barn, that cleaned up their grain, and enjoyed going to the racetrack, but now seem annoyed, do not finish up at mealtime, and are sour when going out to gallop in the morning? • Horses that do not travel as smoothly as they did previously or have become very “choppy”? • Horses that are now tying up but they did not do so previously? An acute lameness after racing or breezing that resolves after two to three days of rest is often a clinical red flag. The lameness can appear subtle because of its evenness: It can occur in both front fetlocks, or both hind or all four fetlocks. This symmetry can cause the lameness to linger and cause a history of poor performance for weeks to months. Finally, exercise riders that report “the horse just doesn’t feel right” are some subtle, nondescript symptoms

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Figure 6

fluid pressure, a more prominent lameness, a positive response to both fetlock joint anesthesia and a low four-point diagnostic nerve block, and fetlock flexion tests, radiographs, and a bone scan are positive. In other words, some of the components of end-stage joint disease are present. To get maximum value from a fetlock MRI, it is imperative the site

The fetlock joint is the most common site for fracture formation in the Thoroughbred racehorse. Good evidence exists to show that these conditions develop deep to the cartilage layer in the subchondral bone due to a silent process known as non-adaptive bone modeling. The condition has two hard realities: It is difficult to identify in its early stages yet its effects are reversible if recognized early. The tools available for disease identification, namely clinical examination, radiology, ultrasonography, or a bone scan, are not sensitive indicators for the spectrum of this condition. MRI is identified as the imaging modality of choice for stressfracture detection in human medicine. MRI can also provide diagnostically valuable images in the standing patient so the risks of general anesthesia are avoided. Racing jurisdictions in the United Kingdom, Europe, and Dubai are currently using this technique for early fracture identification. Therefore, when answering the question, “Is standing MRI the preemptive screening tool to identify fracture risk in the racehorse fetlock joint?” evidence suggests the answer is yes.
John G. Peloso, D.V.M., is founder, owner, and partner of Equine Medical Center of Ocala in Ocala. For more information, please visit

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www.emcOcala.com.

THOROUGHBRED TIMES March 26, 2011

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erative arthritis. In this model, the initial stages of the disease are in the bone only, are visible by standing MRI, and are potentially reversible. In the later stages of the disease, the subchondral bone becomes necrotic and can no longer provide structural support to the articular cartilage layer positioned above. This causes the cartilage layer to collapse (Figure 7) much like a sinkhole that forms when rock dissolves from beneath the land surface. The ultimate consequence of this articular cartilage layer collapse is endstage joint disease and the premature end to a racing career.

that might be helpful. Typical at-risk horses have some of the following clinical characteristics: • In the early stages of the disease, because the condition is outside the joint (subchondral), some of the reliable parts of a lameness diagnosis are not present; • The lameness is mild, there is no joint pressure or filling, and flexion tests and radiographs are negative; and/or • When performing diagnostic blocks, fetlock joint anesthesia is negative but a low four-point nerve block is positive. The later stages of the disease are easier to identify because there is significant articular cartilage involvement. Now there is more joint

Use of MRI
MRI uses magnetism and radiofrequency waves to create an image. It creates many tissue images because it “slices” the fetlock in three planes—left to right, top to bottom, and front to back—thereby providing three different perspectives of the same problem. Specifically, the hydrogen atoms (in water and fat) in tissues are identified in the image with a similar clarity that the radioactive agent is identified on a bone scan. For example, the edema in the latent condyle fracture in Figure 8 shows up as a clear white line against the black bone background. Recognizing the role that edema plays in disease and the ability of MRI to distinguish water and fat, it is obvious why MRI plays such a prominent role in human medicine. Because MRI gives useful information about both bone structure and bone chemistry, it can be used to detect bone injury in the early stages of disease, well before it can be identified on X-rays. The availability of MRI systems for imaging horses under standing sedation and without the need for general anesthesia is particularly beneficial for horses in training as trainers and owners are very reluctant to anesthetize horses for a lameness diagnosis, especially during the racing season. Anesthetic death, a poor recovery from anesthesia, or recovery from general anesthesia on a limb with a hidden orthopedic fracture (see Figure 8) are all legitimate reasons for concern. So, is standing MRI the preemptive screening tool to identify fracture risk in the racehorse fetlock joint? A postmortem study by veterinarian Dr. Tim Parkin of the University of Glasgow demonstrated that, at a slice location just outside the middle ridge of the cannon bone (Figure 6 at white arrowhead), an

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of pain be localized to the fetlock using either a low four-point nerve block or fetlock joint anesthesia. MRI may be indicated where other diagnostic imaging methods such as radiology, ultrasound, and bone scan have provided vague findings, when more detail is required for a known disease process, as an aid to treatment or management protocols, or to monitor healing. Knowledge of the horse’s lameness and medication history is essential when decisions are to be made regarding future serious works and racing schedules. Specific training and clinical details (timing of recent fast works, a 24-hour history of acute lameness that resolved) should be exchanged between the trainer, the racetrack veterinarian, and the veterinarian acquiring and interpreting the MRI images with the goal of maximizing the likelihood of a successful examination.

increase in subchondral bone density greater than 1.6 centimeters correctly identified 90% of cannon bones that fractured. These types of measurements can be developed to screen the at-risk horse with the goal of preventing fracture formation. An MRI examination can be performed on horses under standing sedation so that POD can be detected early in the disease process. Figures 4 to 8 demonstrate the progression of subchondral disease, and the ability of the standing MRI to distinguish the range of changes associated with POD. This could prevent the progression of subchondral damage toward end-stage joint disease (Figure 7) or catastrophic fracture (Figure 8) by modifying the training and racing program. Ongoing debate exists in the U.S. over the value of standing MRI in equine lameness diagnostics. Supporters of high field MRI emphasize the fact that the stronger magnet produces a higher resolution image. Yet in applications such as racehorse fetlock bone screening, where the lower resolution of standing MRI still produces diagnostically valuable images, the ability to scan without general anesthesia is a real benefit. Of available imaging modalities, a bone scan (nuclear scintigraphy) produces the lowest resolution image, yet the role that a bone scan plays in lameness diagnostics is not contested. It is interesting to note that in the United Kingdom, Europe, and Dubai the realities of subchondral bone disease in the Thoroughbred fetlock are routinely being monitored using the standing Hallmarq MRI system (three in Newmarket, one in Ireland, two in France, and one in Dubai) where

an average of 2.4 fetlock examinations are performed per site per month. The MRI images presented in this article were all done in the standing sedated Thoroughbred horse in various stages of training using the Hallmarq MRI system. The cases progress from early in the course of subchondral bone disease (Figure 5), to end-stage joint disease (Figure 7), and early stages of fracture formation (Figure 8).

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