- Email: [email protected]
Autologous Platelet Concentrates as a Treatment for Shoulder Injury in a Horse
Journal of Equine Veterinary Science 31 (2011) 506-510
Journal of Equine Veterinary Science journal homepage: www.j-evs.com
Case Report
Autologous Platelet Concentrates as a Treatment for Shoulder Injury in a Horse Jorge U. Carmona MVZ, MSc, PhD, Catalina López MVZ Grupo de Investigación Terapia Regenerativa, Departamento de Salud Animal, Universidad de Caldas, Manizales, Caldas, Colombia
a r t i c l e i n f o
a b s t r a c t
Article history: Received 02 November 2010 Received in revised form 11 February 2011 Accepted 07 March 2011 Available online 28 May 2011
Shoulder injury is an uncommon cause of lameness in horses. Trauma to the shoulder region may produce bone and soft-tissue damage. The present study describes the case of a severe left shoulder injury caused by blunt trauma in a 6-year-old gelding. Clinical and ultrasonographic examination revealed fracture of the supraglenoid tuberosity of the scapula and of the lesser tubercle of the humerus with fiber disruption and hematoma of the biceps brachii, bicipital bursitis, and suprascapular nerve damage. The gelding was successfully treated with three intralesional injections of autologous platelet concentrates administered at 2-week intervals. Although all these combined injuries took a minimum of 18 to 24 months for full recovery, the gelding reached full recuperation of the affected limb in 10 months. These results suggest that injections of autologous platelet concentrate could provide a therapeutic benefit in the treatment of shoulder bone fractures and soft-tissue injuries in horses. Ó 2011 Elsevier Inc. All rights reserved.
Keywords: Platelet rich plasma Supraglenoid scapular fracture Bicipital bursitis and tendonitis Suprascapular nerve injury Regenerative medicine
1. Introduction Shoulder lameness is uncommon in horses. Direct blunt trauma is the most important cause of shoulder injuries. Shoulder lameness can originate from a bone or soft-tissue lesion [1] or by the combination of these two types of injuries. Fractures of the shoulder bones (scapula and humerus) are the most common osseous lesions [2,3], followed by osteochondrosis and osteoarthritis of the glenohumeral joint [4]. Other conditions that produce shoulder lameness include luxation, septic arthritis, sequestered bone, neoplasia, and osteomyelitis [1]. The most important soft-tissue lesion affecting the shoulder is the suprascapular nerve (SSN) injury [5], followed by bicipital bursitis, tendon and/or muscle injuries [6-8], joint capsule injuries, abscesses, and neoplasia [1]. Fractures of the shoulder region are very rare, but the supraglenoid tuberosity of the scapula [9] and the proximal Corresponding author at: Jorge U. Carmona, MVZ, MSc, PhD, Departamento de Salud Animal, Universidad de Caldas, Calle 65 No 26-10, Manizales, Caldas, Colombia. E-mail address: [email protected] (J.U. Carmona). 0737-0806/$ - see front matter Ó 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.jevs.2011.03.008
humerus (mainly greater tuberosity) are the most susceptible osseous structures [10]. Horses with shoulder fractures that are managed conservatively (administration of nonsteroidal anti-inflammatory drugs [NSAIDs] combined with 3 to 4 months of stall rest followed by 9 to 12 months of pasture turnout) or with surgery usually require a period of 6 to 13 months for full recovery [2,10]. Supraglenoid tuberosity fractures are usually accompanied by SSN damage and subsequently produce denervation atrophy of the supraspinatus and infraspinatus muscles, a condition commonly referred to as sweeney [1,10]. Autologous platelet concentrates (APCs), also known as platelet rich plasma (PRP), are an important source of growth factors (GFs) (including transforming growth factor betas [TGF-bs], platelet-derived growth factor, and hepatocyte growth factor [HGF]) [11,12], that could potentially improve the wound-healing process [13]. There is clinical evidence in human beings [14] and horses [15,16] indicating that APCs are useful to accelerate the reparation of acute and chronic musculoskeletal lesions in both species. The present report describes a case of a severe left shoulder injury with scapular and humeral fractures, SSN damage, bicipital tendon disruption, and bicipital bursitis
J.U. Carmona and C. López / Journal of Equine Veterinary Science 31 (2011) 506-510
507
Fig. 1. Ultrasonographic scans of the origin of the biceps tendon on the supraglenoid tubercle of both scapulae (zone A). (A) The affected left scapular supraglenoid tuberosity shows an interruption of the hyperechoic line with small hyperechoic (bone) fragments (see yellow arrow). (B) Contralateral normal structure.
which was successfully treated with three intra- and perilesional injections of APCs in a 6-year-old gelding. 2. Case Report 2.1. History A 6-year-old gelding, weighing 310 kg, was referred for evaluation of a shoulder injury of the left forelimb caused by an accident 1 month earlier. The gelding had been treated with NSAIDs for 3 weeks, with one dose of intramuscular prednisolone, but the shoulder inflammation and the nonweight-bearing lameness of the affected limb did not improve. 2.2. Clinical and Ultrasonographic Findings Upon arrival at the facility, the gelding was examined and was found to have atrophy of the left supraspinatus and infraspinatus muscles with lateral displacement (abduction) of the forelimb. The temperature, pulse, and respiratory rate were within normal limits. However, the horse had a severe lameness while walking. Physical
examination revealed a large painful swelling over the entire left shoulder region; digital palpation caused a painful response. No crepitus or instability was detected during the manipulation of the forelimb. However, shoulder radiographs were not taken because of soft-tissue swelling and pain that limited the adequate manipulation and flexion of the affected limb. An ultrasonographic (US) evaluation of the affected shoulder was performed with a 3.5 to 5 MHz curvilinear transducer (Falco 100, Pie Medical, Maastricht, The Netherlands) at a scanning depth of 4 to 6 cm, using a US technique described previously [17]. The origin of the biceps tendon on the supraglenoid tubercle of the scapula (zone A) showed an interruption of the hyperechoic line of the bone with small hyperechoic (bone) fragments (Fig. 1A). The evaluation of the biceps tendon over the scapulohumeral joint (zone B) was considered to be normal. However, the examination of the passage of the biceps tendon over the humeral intertubercular groove (zone C) showed a significant edema and fiber disruption with a lateral hematoma of approximately 50% of the transversal section of the biceps tendon (Fig. 2A). At that point, a small interruption of the hyperechoic humeral
Fig. 2. Transverse ultrasonographic scans of the passage of the biceps tendon over the humeral intertubercular groove (zone C) and bicipital bursa. (A) Note significant edema and fiber disruption (see white arrow) with a lateral hematoma of approximately 50% of the transversal section of the biceps tendon (see yellow arrow). (B) A small interruption of the hyperechoic humeral groove line with hyperechoic (bone) fragments corresponding to (see yellow arrow) the lesser tubercle of the humerus. (C) The bicipital bursa presents moderate distension with hypoechoic fluid.
508
J.U. Carmona and C. López / Journal of Equine Veterinary Science 31 (2011) 506-510
Fig. 3. (A) Photograph showing the injection of autologous platelet concentrates (APCs) in the shoulder of the horse. (B) Graphic illustrating the plasma fractions obtained during the tube method protocol for obtaining APCs. Left tube contains the first two platelet concentrates (PCs) obtained by the single centrifugation tube method. Right tube contains the second PCs obtained by the double centrifugation tube method. The fraction PC-C was therapeutically used in this horse. BC ¼ buffy coat; PCV ¼ packed cellular volume.
groove line with hyperechoic (bone) fragments was observed at the level of the lesser tubercle of the humerus (Fig. 2B). In addition, the bicipital bursa was moderately distended with hypoechoic fluid (Fig. 2C). On the basis of anamnesis, clinical findings, and results of US examination, fracture of the left supraglenoid tuberosity of the scapula and fracture of the lesser tubercle of the humerus with severe disruption of the biceps tendon accompanied by bicipital bursitis and SSN damage were diagnosed. 2.3. Medical Treatment and Follow-up The fracture site and the lesions of the biceps tendon and the bicipital bursa were treated with injections of APCs (Fig. 3A) using the tube method [11]. Briefly, whole blood was aseptically drawn from the jugular vein using a 23gauge butterfly catheter (BD Vacutainer, Franklin Lakes, NJ, USA), and placed in 5-mL 3.2% (w/v) sodium citrate tubes. Blood was centrifuged at 120g for 5 minutes. The first supernatant plasma fraction (50%), adjacent to the buffy coat (platelet concentrate-A), was obtained and further centrifuged at 240g for 5 minutes. The second supernatant plasma fraction (25%; platelet concentrate-C) (Fig. 3B) was placed into sterile syringes and activated with calcium gluconate (10%) in 1:10 ratio. The APCs were injected three times at 2-week intervals for each application [15,16]. A total of 10 mL of activated APCs were injected for each injury site during each independent treatment. The APCs used in the gelding presented a mean concentration of 450 35 106 platelets and 9.3 1.5 leukocytes per mL. On the third day after the first application of APCs, the shoulder swelling had decreased and the horse began to support the affected limb when standing (Fig. 4A) The lameness improved during next 10 days and the shoulder inflammation notably diminished on day 10 posttreatment
evaluation (Fig. 4B). The horse was discharged 4 weeks after the second treatment (Fig. 4C) and remained in stall rest for 1 month, followed by rest in a small paddock during the subsequent 2 months. At that time, the horse’s lameness continued to improve at the walk; however, although the degree of shoulder abduction had diminished, it still manifested atrophy of the shoulder muscles. The horse was managed with a gradual schedule of controlled exercise and had fully recovered at 10 months postinjury. At that time the US evaluation of the affected shoulder showed an irregular contour of the supraglenoid tuberosity and the origin of the biceps tendon showed hypoechoic areas with a disorganized echoic pattern in comparison with the contralateral healthy shoulder (Fig. 5). 3. Discussion The use of APCs for the treatment of the case presented here could represent a new therapeutic option for severe injuries involving bones and soft-tissues in horses. Results observed in this horse were very encouraging because the horse improved dramatically after the first treatment with intra- and perilesional injections of APCs, and especially when considering that the severe chronic shoulder swelling and nonweight-bearing lameness had been refractory to NSAIDs and corticosteroid treatments. There is a growing interest in the use of autologous GForiented therapies as treatment for degenerative musculoskeletal diseases in horses [15,16]. In vitro studies demonstrated that equine PRP produces anabolic (manifested by increased production or expression of collagen type I) and proliferative effects on tenocytes and fibroblasts from suspensory ligament [18]. Further, an in vitro study evaluating the effect of PRP on human tendon cells demonstrated increased production of the angiogenic GFs, HGF, and vascular endothelial growth factor [19]. It is
J.U. Carmona and C. López / Journal of Equine Veterinary Science 31 (2011) 506-510
509
Fig. 4. Comparative clinical evolution of the degree of shoulder swollen of the left (affected) forelimb at the third (A), 10 first posttreatment days (B), and before the last treatment (C).
possible that the injection of APCs in gelding of this study had produced complex cellular and biochemical events that accelerated the healing and reduced the inflammation of the severed shoulder tissues, consequently producing a marked analgesic effect [14]. The method used for preparing the APCs used in this study is very simple and cost-effective [11,13]. This method results in higher concentrations of therapeutic GFs such as TGF-b1 [11]. This last peptide possesses paramount biological actions ranging from proliferative effects on cells and anabolic effects on extracellular matrix to generalized anti-inflammatory action [12]. Although many proteins and cells are natural components of APCs, we propose that TGF-b1, platelet-derived growth factor, vascular endothelial growth factor, and HGF concentrated at supraphysiological doses may have potentially contributed to the strong anti-
inflammatory and analgesic action of this autologous preparation [14] when injected in the affected shoulder of the horse in this report. Although encouraging, the present report is very limited because of the absence of radiographs to confirm the results of the US examination [10]. However, the US technique is of value because many bone lesions, mainly those of the proximal humerus, can be missed because of superposition of bone structures (tubercles) or the technical difficulty to position the equipment in an adequate manner, especially when the horse has severe pain and inflammation [7], such as was observed in this report. Biceps brachii tenotomy or tenectomy have been advocated for the treatment of bicipital bursitis, tendonitis, humeral osteitis [8], and for surgical management of supraglenoid tuberosity fracture of the scapula in horses
Fig. 5. Ultrasonographic scans of the origin of the biceps tendon on the supraglenoid tubercle of both scapulae (zone A) 10 months postinjury. (A) The affected left scapular supraglenoid tuberosity presents an irregular contour and the origin of the biceps tendon show hypoechoic areas with a disorganized echoic pattern. (B) Contralateral normal structure.
510
J.U. Carmona and C. López / Journal of Equine Veterinary Science 31 (2011) 506-510
[20]. These surgical procedures are recommended when conservative treatment fails and the lameness persists [8]. The horse used in this report presented with a chronic disease with bicipital bursitis, traumatic biceps tendonitis, and fracture of the supraglenoid tuberosity of the left scapula. Possibly, this horse was a potential candidate for biceps brachii tenectomy as the lameness was severe and refractory to conservative treatment [8]. However, the use of APCs dramatically improved the symptomatology in the first 48 to 72 hours after the first APC injection and the other two doses showed an additive effect on the clinical improvement of the gelding. SSN injury is a common accompanying lesion of equine shoulder injuries, especially when scapular supraglenoid tuberosity fractures occur [1]. Equine SSN injuries usually require 16 to 18 months for full recovery, if they recover at all. Findings of previous reports indicate favorable outcomes to both conservative [5] and surgical treatments [21]. The neurological improvement observed in this gelding was encouraging because full recovery was achieved at 10 months post-APC treatment. Recently, a study in rats revealed that PRP may enhance the peripheral nerve regeneration [22], but this effect has not been confirmed in horses. Taken together, our results suggest that APCs could be used to treat acute or chronic shoulder injuries in horses, as was observed in the present case. These substances could be used individually or in combination with NSAIDs in cases of shoulder injuries involving bone and soft-tissue lesions. The injection of these substances in patients with chronic swelling and nonweight-bearing lameness caused by bicipital bursitis and tendonitis or fractures of the supraglenoid tuberosity of the scapula should be considered before radical surgery. More importantly, additional research and clinical case experience are needed to support an evidence-based response to this innovative treatment regimen before it can be recommended as a routine treatment modality. Acknowledgments The authors thank Ismael Samudio from the Departamento de Nutrición y Bioquímica, Pontificia Universidad Javeriana, Bogotá, Colombia, for the critical review of the manuscript, and Lieutenant Edgar García, MVZ, from the Policía Nacional de Colombia, who referred the case. References [1] Rumbaugh ML, Tetens J, de la Calle J. Shoulder lameness in horses. Comp Cont Educ Pract Vet 2002;24:640-9.
[2] Dyson S. Sixteen fractures of the shoulder region in the horse. Equine Vet J 1985;17:104-10. [3] Carter BG, Schneider RK, Hardy J, Bramlage LR, Bertone AL. Assessment and treatment of equine humeral fractures - retrospective study of 54 cases (1972-1990). Equine Vet J 1993;25:203-7. [4] Semevolos SA, Watkins JP, Auer JA. Scapulohumeral arthrodesis in miniature horses. Vet Surg 2003;32:416-20. [5] Dutton DM, Honnas CM, Watkins JP. Nonsurgical treatment of suprascapular nerve injury in horses: 8 cases (1988-1998). J Am Vet Med Assoc 1999;214:1657-9. [6] Vatistas NJ, Pascoe JR, Wright IM, Dyson SJ, Mayhew IG. Infection of the intertubercular bursa in horses: four cases (1978-1991). J Am Vet Med Assoc 1996;208:1434-7. [7] Whitcomb MB, le Jeune SS, MacDonald MM, Galuppo LD, Judy CE. Disorders of the infraspinatus tendon and bursa in three horses. J Am Vet Med Assoc 2006;229:549-56. [8] Fugaro MN, Adams SB. Biceps brachii tenotomy or tenectomy for the treatment of bicipital bursitis, tendonitis, and humeral osteitis in 3 horses. J Am Vet Med Assoc 2002;220:1508-11. [9] Dart AJ, Snyder JR. Repair of a supraglenoid tuberosity fracture in a horse. J Am Vet Med Assoc 1992;201:95-6. [10] Mez JC, Dabareiner RM, Cole RC, Watkins JP. Fractures of the greater tubercle of the humerus in horses: 15 cases (1986-2004). J Am Vet Med Assoc 2007;230:1350-5. [11] Arguelles D, Carmona JU, Pastor J, Iborra A, Vinals L, Martinez P, et al. Evaluation of single and double centrifugation tube methods for concentrating equine platelets. Res Vet Sci 2006;81:237-45. [12] Carmona JU, Arguelles D, Prades M. Transforming growth factor beta-3 and nitric oxide levels in four autologous platelet concentrates and plasma derived from equine blood. Arch Med Vet 2008;40: 155-60. [13] Monteiro SO, Lepage OM, Theoret CL. Effects of platelet-rich plasma on the repair of wounds on the distal aspect of the forelimb in horses. Am J Vet Res 2009;70:277-82. [14] Sanchez M, Anitua E, Orive G, Mujika I, Andia I. Platelet-rich therapies in the treatment of orthopaedic sport injuries. Sports Med 2009;39:345-54. [15] Arguelles D, Carmona JU, Climent F, Munoz E, Prades M. Autologous platelet concentrates as a treatment for musculoskeletal lesions in five horses. Vet Rec 2008;162:208-11. [16] Carmona JU, Arguelles D, Climent F, Prades M. Autologous platelet concentrates as a treatment of horses with osteoarthritis: a preliminary pilot clinical study. J Equine Vet Sci 2007;27:167-70. [17] Tnibar MA, Auer JA, Bakkali S. Ultrasonography of the equine shoulder: technique and normal appearance. Vet Radiol Ultrasound 1999;40:44-57. [18] McCarrel T, Fortier L. Temporal growth factor release from plateletrich plasma, trehalose lyophilized platelets, and bone marrow aspirate and their effect on tendon and ligament gene expression. J Orthop Res 2009;27:1033-42. [19] Anitua E, Andia I, Sanchez M, Azofra J, Zalduendo MM, de la Fuente M, et al. Autologous preparations rich in growth factors promote proliferation and induce VEGF and HGF production by human tendon cells in culture. J Orthop Res 2005;23:281-6. [20] Bleyaert HF, Madison JB. Complete biceps brachii tenotomy to facilitate internal fixation of supraglenoid tubercle fractures in three horses. Vet Surg 1999;28:48-53. [21] Schneider JE, Adams OR, Easley KJ, Schneider RK, Bramlage LR, Peter J, et al. Scapular notch resection for suprascapular nerve decompression in 12 horses. J Am Vet Med Assoc 1985;187: 1019-20. [22] Elgazzar RF, Mutabagani MA, Abdelaal SE, Sadakah AA. Platelet rich plasma may enhance peripheral nerve regeneration after cyanoacrylate reanastomosis: a controlled blind study on rats. Int J Oral Maxillofac Surg 2008;37:748-55.
Journal of Equine Veterinary Science journal homepage: www.j-evs.com
Case Report
Autologous Platelet Concentrates as a Treatment for Shoulder Injury in a Horse Jorge U. Carmona MVZ, MSc, PhD, Catalina López MVZ Grupo de Investigación Terapia Regenerativa, Departamento de Salud Animal, Universidad de Caldas, Manizales, Caldas, Colombia
a r t i c l e i n f o
a b s t r a c t
Article history: Received 02 November 2010 Received in revised form 11 February 2011 Accepted 07 March 2011 Available online 28 May 2011
Shoulder injury is an uncommon cause of lameness in horses. Trauma to the shoulder region may produce bone and soft-tissue damage. The present study describes the case of a severe left shoulder injury caused by blunt trauma in a 6-year-old gelding. Clinical and ultrasonographic examination revealed fracture of the supraglenoid tuberosity of the scapula and of the lesser tubercle of the humerus with fiber disruption and hematoma of the biceps brachii, bicipital bursitis, and suprascapular nerve damage. The gelding was successfully treated with three intralesional injections of autologous platelet concentrates administered at 2-week intervals. Although all these combined injuries took a minimum of 18 to 24 months for full recovery, the gelding reached full recuperation of the affected limb in 10 months. These results suggest that injections of autologous platelet concentrate could provide a therapeutic benefit in the treatment of shoulder bone fractures and soft-tissue injuries in horses. Ó 2011 Elsevier Inc. All rights reserved.
Keywords: Platelet rich plasma Supraglenoid scapular fracture Bicipital bursitis and tendonitis Suprascapular nerve injury Regenerative medicine
1. Introduction Shoulder lameness is uncommon in horses. Direct blunt trauma is the most important cause of shoulder injuries. Shoulder lameness can originate from a bone or soft-tissue lesion [1] or by the combination of these two types of injuries. Fractures of the shoulder bones (scapula and humerus) are the most common osseous lesions [2,3], followed by osteochondrosis and osteoarthritis of the glenohumeral joint [4]. Other conditions that produce shoulder lameness include luxation, septic arthritis, sequestered bone, neoplasia, and osteomyelitis [1]. The most important soft-tissue lesion affecting the shoulder is the suprascapular nerve (SSN) injury [5], followed by bicipital bursitis, tendon and/or muscle injuries [6-8], joint capsule injuries, abscesses, and neoplasia [1]. Fractures of the shoulder region are very rare, but the supraglenoid tuberosity of the scapula [9] and the proximal Corresponding author at: Jorge U. Carmona, MVZ, MSc, PhD, Departamento de Salud Animal, Universidad de Caldas, Calle 65 No 26-10, Manizales, Caldas, Colombia. E-mail address: [email protected] (J.U. Carmona). 0737-0806/$ - see front matter Ó 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.jevs.2011.03.008
humerus (mainly greater tuberosity) are the most susceptible osseous structures [10]. Horses with shoulder fractures that are managed conservatively (administration of nonsteroidal anti-inflammatory drugs [NSAIDs] combined with 3 to 4 months of stall rest followed by 9 to 12 months of pasture turnout) or with surgery usually require a period of 6 to 13 months for full recovery [2,10]. Supraglenoid tuberosity fractures are usually accompanied by SSN damage and subsequently produce denervation atrophy of the supraspinatus and infraspinatus muscles, a condition commonly referred to as sweeney [1,10]. Autologous platelet concentrates (APCs), also known as platelet rich plasma (PRP), are an important source of growth factors (GFs) (including transforming growth factor betas [TGF-bs], platelet-derived growth factor, and hepatocyte growth factor [HGF]) [11,12], that could potentially improve the wound-healing process [13]. There is clinical evidence in human beings [14] and horses [15,16] indicating that APCs are useful to accelerate the reparation of acute and chronic musculoskeletal lesions in both species. The present report describes a case of a severe left shoulder injury with scapular and humeral fractures, SSN damage, bicipital tendon disruption, and bicipital bursitis
J.U. Carmona and C. López / Journal of Equine Veterinary Science 31 (2011) 506-510
507
Fig. 1. Ultrasonographic scans of the origin of the biceps tendon on the supraglenoid tubercle of both scapulae (zone A). (A) The affected left scapular supraglenoid tuberosity shows an interruption of the hyperechoic line with small hyperechoic (bone) fragments (see yellow arrow). (B) Contralateral normal structure.
which was successfully treated with three intra- and perilesional injections of APCs in a 6-year-old gelding. 2. Case Report 2.1. History A 6-year-old gelding, weighing 310 kg, was referred for evaluation of a shoulder injury of the left forelimb caused by an accident 1 month earlier. The gelding had been treated with NSAIDs for 3 weeks, with one dose of intramuscular prednisolone, but the shoulder inflammation and the nonweight-bearing lameness of the affected limb did not improve. 2.2. Clinical and Ultrasonographic Findings Upon arrival at the facility, the gelding was examined and was found to have atrophy of the left supraspinatus and infraspinatus muscles with lateral displacement (abduction) of the forelimb. The temperature, pulse, and respiratory rate were within normal limits. However, the horse had a severe lameness while walking. Physical
examination revealed a large painful swelling over the entire left shoulder region; digital palpation caused a painful response. No crepitus or instability was detected during the manipulation of the forelimb. However, shoulder radiographs were not taken because of soft-tissue swelling and pain that limited the adequate manipulation and flexion of the affected limb. An ultrasonographic (US) evaluation of the affected shoulder was performed with a 3.5 to 5 MHz curvilinear transducer (Falco 100, Pie Medical, Maastricht, The Netherlands) at a scanning depth of 4 to 6 cm, using a US technique described previously [17]. The origin of the biceps tendon on the supraglenoid tubercle of the scapula (zone A) showed an interruption of the hyperechoic line of the bone with small hyperechoic (bone) fragments (Fig. 1A). The evaluation of the biceps tendon over the scapulohumeral joint (zone B) was considered to be normal. However, the examination of the passage of the biceps tendon over the humeral intertubercular groove (zone C) showed a significant edema and fiber disruption with a lateral hematoma of approximately 50% of the transversal section of the biceps tendon (Fig. 2A). At that point, a small interruption of the hyperechoic humeral
Fig. 2. Transverse ultrasonographic scans of the passage of the biceps tendon over the humeral intertubercular groove (zone C) and bicipital bursa. (A) Note significant edema and fiber disruption (see white arrow) with a lateral hematoma of approximately 50% of the transversal section of the biceps tendon (see yellow arrow). (B) A small interruption of the hyperechoic humeral groove line with hyperechoic (bone) fragments corresponding to (see yellow arrow) the lesser tubercle of the humerus. (C) The bicipital bursa presents moderate distension with hypoechoic fluid.
508
J.U. Carmona and C. López / Journal of Equine Veterinary Science 31 (2011) 506-510
Fig. 3. (A) Photograph showing the injection of autologous platelet concentrates (APCs) in the shoulder of the horse. (B) Graphic illustrating the plasma fractions obtained during the tube method protocol for obtaining APCs. Left tube contains the first two platelet concentrates (PCs) obtained by the single centrifugation tube method. Right tube contains the second PCs obtained by the double centrifugation tube method. The fraction PC-C was therapeutically used in this horse. BC ¼ buffy coat; PCV ¼ packed cellular volume.
groove line with hyperechoic (bone) fragments was observed at the level of the lesser tubercle of the humerus (Fig. 2B). In addition, the bicipital bursa was moderately distended with hypoechoic fluid (Fig. 2C). On the basis of anamnesis, clinical findings, and results of US examination, fracture of the left supraglenoid tuberosity of the scapula and fracture of the lesser tubercle of the humerus with severe disruption of the biceps tendon accompanied by bicipital bursitis and SSN damage were diagnosed. 2.3. Medical Treatment and Follow-up The fracture site and the lesions of the biceps tendon and the bicipital bursa were treated with injections of APCs (Fig. 3A) using the tube method [11]. Briefly, whole blood was aseptically drawn from the jugular vein using a 23gauge butterfly catheter (BD Vacutainer, Franklin Lakes, NJ, USA), and placed in 5-mL 3.2% (w/v) sodium citrate tubes. Blood was centrifuged at 120g for 5 minutes. The first supernatant plasma fraction (50%), adjacent to the buffy coat (platelet concentrate-A), was obtained and further centrifuged at 240g for 5 minutes. The second supernatant plasma fraction (25%; platelet concentrate-C) (Fig. 3B) was placed into sterile syringes and activated with calcium gluconate (10%) in 1:10 ratio. The APCs were injected three times at 2-week intervals for each application [15,16]. A total of 10 mL of activated APCs were injected for each injury site during each independent treatment. The APCs used in the gelding presented a mean concentration of 450 35 106 platelets and 9.3 1.5 leukocytes per mL. On the third day after the first application of APCs, the shoulder swelling had decreased and the horse began to support the affected limb when standing (Fig. 4A) The lameness improved during next 10 days and the shoulder inflammation notably diminished on day 10 posttreatment
evaluation (Fig. 4B). The horse was discharged 4 weeks after the second treatment (Fig. 4C) and remained in stall rest for 1 month, followed by rest in a small paddock during the subsequent 2 months. At that time, the horse’s lameness continued to improve at the walk; however, although the degree of shoulder abduction had diminished, it still manifested atrophy of the shoulder muscles. The horse was managed with a gradual schedule of controlled exercise and had fully recovered at 10 months postinjury. At that time the US evaluation of the affected shoulder showed an irregular contour of the supraglenoid tuberosity and the origin of the biceps tendon showed hypoechoic areas with a disorganized echoic pattern in comparison with the contralateral healthy shoulder (Fig. 5). 3. Discussion The use of APCs for the treatment of the case presented here could represent a new therapeutic option for severe injuries involving bones and soft-tissues in horses. Results observed in this horse were very encouraging because the horse improved dramatically after the first treatment with intra- and perilesional injections of APCs, and especially when considering that the severe chronic shoulder swelling and nonweight-bearing lameness had been refractory to NSAIDs and corticosteroid treatments. There is a growing interest in the use of autologous GForiented therapies as treatment for degenerative musculoskeletal diseases in horses [15,16]. In vitro studies demonstrated that equine PRP produces anabolic (manifested by increased production or expression of collagen type I) and proliferative effects on tenocytes and fibroblasts from suspensory ligament [18]. Further, an in vitro study evaluating the effect of PRP on human tendon cells demonstrated increased production of the angiogenic GFs, HGF, and vascular endothelial growth factor [19]. It is
J.U. Carmona and C. López / Journal of Equine Veterinary Science 31 (2011) 506-510
509
Fig. 4. Comparative clinical evolution of the degree of shoulder swollen of the left (affected) forelimb at the third (A), 10 first posttreatment days (B), and before the last treatment (C).
possible that the injection of APCs in gelding of this study had produced complex cellular and biochemical events that accelerated the healing and reduced the inflammation of the severed shoulder tissues, consequently producing a marked analgesic effect [14]. The method used for preparing the APCs used in this study is very simple and cost-effective [11,13]. This method results in higher concentrations of therapeutic GFs such as TGF-b1 [11]. This last peptide possesses paramount biological actions ranging from proliferative effects on cells and anabolic effects on extracellular matrix to generalized anti-inflammatory action [12]. Although many proteins and cells are natural components of APCs, we propose that TGF-b1, platelet-derived growth factor, vascular endothelial growth factor, and HGF concentrated at supraphysiological doses may have potentially contributed to the strong anti-
inflammatory and analgesic action of this autologous preparation [14] when injected in the affected shoulder of the horse in this report. Although encouraging, the present report is very limited because of the absence of radiographs to confirm the results of the US examination [10]. However, the US technique is of value because many bone lesions, mainly those of the proximal humerus, can be missed because of superposition of bone structures (tubercles) or the technical difficulty to position the equipment in an adequate manner, especially when the horse has severe pain and inflammation [7], such as was observed in this report. Biceps brachii tenotomy or tenectomy have been advocated for the treatment of bicipital bursitis, tendonitis, humeral osteitis [8], and for surgical management of supraglenoid tuberosity fracture of the scapula in horses
Fig. 5. Ultrasonographic scans of the origin of the biceps tendon on the supraglenoid tubercle of both scapulae (zone A) 10 months postinjury. (A) The affected left scapular supraglenoid tuberosity presents an irregular contour and the origin of the biceps tendon show hypoechoic areas with a disorganized echoic pattern. (B) Contralateral normal structure.
510
J.U. Carmona and C. López / Journal of Equine Veterinary Science 31 (2011) 506-510
[20]. These surgical procedures are recommended when conservative treatment fails and the lameness persists [8]. The horse used in this report presented with a chronic disease with bicipital bursitis, traumatic biceps tendonitis, and fracture of the supraglenoid tuberosity of the left scapula. Possibly, this horse was a potential candidate for biceps brachii tenectomy as the lameness was severe and refractory to conservative treatment [8]. However, the use of APCs dramatically improved the symptomatology in the first 48 to 72 hours after the first APC injection and the other two doses showed an additive effect on the clinical improvement of the gelding. SSN injury is a common accompanying lesion of equine shoulder injuries, especially when scapular supraglenoid tuberosity fractures occur [1]. Equine SSN injuries usually require 16 to 18 months for full recovery, if they recover at all. Findings of previous reports indicate favorable outcomes to both conservative [5] and surgical treatments [21]. The neurological improvement observed in this gelding was encouraging because full recovery was achieved at 10 months post-APC treatment. Recently, a study in rats revealed that PRP may enhance the peripheral nerve regeneration [22], but this effect has not been confirmed in horses. Taken together, our results suggest that APCs could be used to treat acute or chronic shoulder injuries in horses, as was observed in the present case. These substances could be used individually or in combination with NSAIDs in cases of shoulder injuries involving bone and soft-tissue lesions. The injection of these substances in patients with chronic swelling and nonweight-bearing lameness caused by bicipital bursitis and tendonitis or fractures of the supraglenoid tuberosity of the scapula should be considered before radical surgery. More importantly, additional research and clinical case experience are needed to support an evidence-based response to this innovative treatment regimen before it can be recommended as a routine treatment modality. Acknowledgments The authors thank Ismael Samudio from the Departamento de Nutrición y Bioquímica, Pontificia Universidad Javeriana, Bogotá, Colombia, for the critical review of the manuscript, and Lieutenant Edgar García, MVZ, from the Policía Nacional de Colombia, who referred the case. References [1] Rumbaugh ML, Tetens J, de la Calle J. Shoulder lameness in horses. Comp Cont Educ Pract Vet 2002;24:640-9.
[2] Dyson S. Sixteen fractures of the shoulder region in the horse. Equine Vet J 1985;17:104-10. [3] Carter BG, Schneider RK, Hardy J, Bramlage LR, Bertone AL. Assessment and treatment of equine humeral fractures - retrospective study of 54 cases (1972-1990). Equine Vet J 1993;25:203-7. [4] Semevolos SA, Watkins JP, Auer JA. Scapulohumeral arthrodesis in miniature horses. Vet Surg 2003;32:416-20. [5] Dutton DM, Honnas CM, Watkins JP. Nonsurgical treatment of suprascapular nerve injury in horses: 8 cases (1988-1998). J Am Vet Med Assoc 1999;214:1657-9. [6] Vatistas NJ, Pascoe JR, Wright IM, Dyson SJ, Mayhew IG. Infection of the intertubercular bursa in horses: four cases (1978-1991). J Am Vet Med Assoc 1996;208:1434-7. [7] Whitcomb MB, le Jeune SS, MacDonald MM, Galuppo LD, Judy CE. Disorders of the infraspinatus tendon and bursa in three horses. J Am Vet Med Assoc 2006;229:549-56. [8] Fugaro MN, Adams SB. Biceps brachii tenotomy or tenectomy for the treatment of bicipital bursitis, tendonitis, and humeral osteitis in 3 horses. J Am Vet Med Assoc 2002;220:1508-11. [9] Dart AJ, Snyder JR. Repair of a supraglenoid tuberosity fracture in a horse. J Am Vet Med Assoc 1992;201:95-6. [10] Mez JC, Dabareiner RM, Cole RC, Watkins JP. Fractures of the greater tubercle of the humerus in horses: 15 cases (1986-2004). J Am Vet Med Assoc 2007;230:1350-5. [11] Arguelles D, Carmona JU, Pastor J, Iborra A, Vinals L, Martinez P, et al. Evaluation of single and double centrifugation tube methods for concentrating equine platelets. Res Vet Sci 2006;81:237-45. [12] Carmona JU, Arguelles D, Prades M. Transforming growth factor beta-3 and nitric oxide levels in four autologous platelet concentrates and plasma derived from equine blood. Arch Med Vet 2008;40: 155-60. [13] Monteiro SO, Lepage OM, Theoret CL. Effects of platelet-rich plasma on the repair of wounds on the distal aspect of the forelimb in horses. Am J Vet Res 2009;70:277-82. [14] Sanchez M, Anitua E, Orive G, Mujika I, Andia I. Platelet-rich therapies in the treatment of orthopaedic sport injuries. Sports Med 2009;39:345-54. [15] Arguelles D, Carmona JU, Climent F, Munoz E, Prades M. Autologous platelet concentrates as a treatment for musculoskeletal lesions in five horses. Vet Rec 2008;162:208-11. [16] Carmona JU, Arguelles D, Climent F, Prades M. Autologous platelet concentrates as a treatment of horses with osteoarthritis: a preliminary pilot clinical study. J Equine Vet Sci 2007;27:167-70. [17] Tnibar MA, Auer JA, Bakkali S. Ultrasonography of the equine shoulder: technique and normal appearance. Vet Radiol Ultrasound 1999;40:44-57. [18] McCarrel T, Fortier L. Temporal growth factor release from plateletrich plasma, trehalose lyophilized platelets, and bone marrow aspirate and their effect on tendon and ligament gene expression. J Orthop Res 2009;27:1033-42. [19] Anitua E, Andia I, Sanchez M, Azofra J, Zalduendo MM, de la Fuente M, et al. Autologous preparations rich in growth factors promote proliferation and induce VEGF and HGF production by human tendon cells in culture. J Orthop Res 2005;23:281-6. [20] Bleyaert HF, Madison JB. Complete biceps brachii tenotomy to facilitate internal fixation of supraglenoid tubercle fractures in three horses. Vet Surg 1999;28:48-53. [21] Schneider JE, Adams OR, Easley KJ, Schneider RK, Bramlage LR, Peter J, et al. Scapular notch resection for suprascapular nerve decompression in 12 horses. J Am Vet Med Assoc 1985;187: 1019-20. [22] Elgazzar RF, Mutabagani MA, Abdelaal SE, Sadakah AA. Platelet rich plasma may enhance peripheral nerve regeneration after cyanoacrylate reanastomosis: a controlled blind study on rats. Int J Oral Maxillofac Surg 2008;37:748-55.