Bluegrass Laminitis Symposium Notes
How Lacerum™ Has Improved the Progress of High Scale Foot Damage
Written and presented January 2004 by R.F. (Ric) Redden, DVM
Lacerum™ is an innovative product designed and developed by BelumedX out of Hot Springs, Arkansas. I introduced this product approximately one year ago as a means to aid in the treatment of severe foot injuries and disease. Being innovative and willing to explore the unknown, I adopted this product on a trial basis. This paper will reflect some of my clinical findings.
The first case involves a quarter horse filly, two year old. She presented to me with left rear foot lameness due to a penetrating puncture wound to the solar foot. It appeared that she had stepped on a steel fence post that had broken off in the ground and fractured her coffin bone. It appeared the center of impact was off the center of her frog. The penetrating piece of steel caused multiple fractures of PIII. She was three-legged lame and had permanent drainage from the bottom of her foot. Euthanasia was the recommended course of action as this seemed to be a fruitless case.
I took the case simply because I have had considerable luck treating severe puncture wounds in the past. I applied my typical raised heel, adjustable bar shoe with a toe and hospital plate. This shoe is designed to kick the deep digital flexor out 80-90 percent, allowing the horse to be weight bearing even with the worst puncture wounds. I debrided all the necrotic tissue, and the fracture lines were evident throughout the entire PIII. However, none of the pieces of bone appeared to be sequestrum at the time.
The filly was shod on the right side with a Modified Ultimate to prevent contralimb laminitis. This shoe, used early in the syndrome, has worked well for me in protecting the good foot from contralimb overloading, which depletes the blood supply to the anterior laminae. Consequently, this causes laminitis.
The filly became quite comfortable following surgical clean up and application of the shoe. I treated her off and on over the next few weeks in a very conservative fashion, to simply provide medical support. She was on a Gentocin and penicillin combination, as well as Bute.
Over the next few weeks it became evident that a large fragment of bone that articulated with the majority of the surface of PII had sequestrum and had to be removed. The bone was quite loose through the hole in the bottom of the foot, and it had turned gray to brown in color. This indicates avascular shut down. I teased the piece of bone out, I exposed the majority of the articular surface of PII, and I was pleased to find that the adjacent tissue and bone had a nice, bright pink color with early signs of granulation. I packed the hole with betadine and gauze and proceeded to treat the filly on a bi-weekly basis.
My intent was to get this large area, about the size of a hen egg, to granulate and fill in with a fibrotic mass of tissue that would be a specialized, cushion type tissue. This would hopefully give this filly the means to have a quality life. The owner had a sentimental attachment to the filly, and we wanted to do everything possible to save her life.
In spite of my effort to encourage granulation tissue to fill this void, the response was very slow to nil. It would fill in over the course of two days to a week with a gelatinous mass, but it never had the strength to go ahead and become a firm, bridging membrane over the end of PII. The opening on the bottom had been reduced from approx. 3.5cm wide to about 1cm wide, which gave a false impression that this area was healing well. However, it was easy to break through and find a large cavity underneath.
Having the opportunity to use the Lacerum™, I filled the entire cavity with one dose of Lacerum™ following a flushing with Remex, and sealed the bottom with a hydrogel gauze. I placed the hospital plate over that and hoped for the best. I did this on Tuesday and removed the hospital plate on Friday. I examined the results and was surprised to find that the entire area had filled in with a dense fibrotic tissue. I was unable to penetrate this tissue even with forced pressure with a q-tip.
The following Tuesday, this area was very firm and the granulating surface was reduced from 2.5cm to about .5cm. It took about another month to close completely. The cornification occurred in a very rapid fashion, leaving the smallest defect in the sole. This indicated where we had a difficult three months of treating this foot.
The filly went on to become quite sound. The foot is quite small, but she is being managed with therapeutic shoeing. There is hope that she will live a quality life and become a successful brood mare.
We used the Lacerum™ on several different cases where we had necrotic tissue that was causing us problems. We had mixed feeling on when to use it, how to use it and what to expect. One of my next very meaningful cases was a thoroughbred sale yearling that came to me with a deep puncture wound through the sole of her foot, along the medial sulcus of her frog. The client was devastated because this was one of his big time fillies, and she was the “mortgage burner” of the farm. The injury occurred approximately two months prior to sale time.
I spoke with Dr. Dave Jolly and asked what the effect would be if I lavaged the tract and put the Lacerum™ in the hole, instead of doing the routine roto-rooter clean up. If we cleaned it up in a routine fashion, the filly would definitely miss the sale and would be questionable for the training sale in April. This was not the news the owner wanted to hear, so I elected to lavage the very extensive area. The puncture began at the medial sulcus, bypassing the navicular bursa and tendon by micro-millimeters, and liked only .5cm of protruding from the pastern.
The area was infiltrated with the Lacerum™ growth factor. The bottom was sealed, which was a very different approach. I usually establish ventral drainage for puncture wounds and have had reasonably good luck doing so. However, we sealed the hole to ensure the growth factor stayed in the traumatic canal. The filly was placed on Gentocin and penicillin. She was never very lame, but she was tender on the foot and had quite a bit of edema throughout the tendon and fetlock. The edema dissipated very quickly.
The filly was fitted with a Modified Ultimate so we could reduce tendon pull across this area. We actually put an Ultimate on both front feet to protect from overloading and a laminitic episode of any degree.
I was very pleased with the immediate results, as she became quite comfortable. The plug was pulled two days later, and we lavaged the area with saline. We had a bit of drainage, so we packed the area again using an animal feeding tube to ensure I inserted Lacerum™ to the distal extent of the puncture site. We also found another small tract that went off to one corner. It had slight exudate in it, and it opened through the bulb of the heel. I was able to flush it with Lacerum™ from the exterior, communicating with the original puncture site.
This foot was treated with four Lacerum™ applications over a period of three weeks. At this time the hole had sealed at the bottom, and it was only slightly noticeable with an astute eye. We kept the filly 30-45 days and sent her to the farm wearing a protective shoe so she could prepare for the sale. The filly went to the sale quite sound. She was shod in a normal fashion, and she sold quite well. She was a bit behind in conditioning, which was to be expected considering she was stall bound for six weeks. She has continued with training and being broken, and she should have no ill effects whatsoever.
This case really highlights an important point. If we can use a growth factor to accelerate the normal healing response with foot problems, then we can bypass the normal secondary sepsis that is often devastating to a lot of foot injuries.
The third case involved a broodmare I worked on 4-5 years ago. She had a severe puncture wound, and we were able to save her life. Her PII and PIII, along with the navicular bone, had become one fused mass of bone. She had been quite comfortable and useable as broodmare. She had developed a contralimb overload situation that was a focal, half-foot, laminitic case where she had traumatized the laminae. She also had an ongoing abscess that had totally destroyed the lamellar tissue along the lateral side of her foot.
She presented to us with her coronary band blown out from the heel to the centerline, with exudate and the coronary band swollen over the wall. I told the owner the only chance I had of saving her life was to remove the majority of her hoof wall and hope to find a way to revitalize the dark, unhealthy lamellar tissue.
We elected to go for it, but the owner did not want to spend a great deal of money. I removed the wall, and the underlying laminae had a dark, devascularized appearance and was soft and mushy. It wouldn't, however, debride from the coffin bone when given a little pressure. I was encouraged because I felt that we still had a good anchor attachment. It was treated with Lacerum™ initially, and we got a good response. We then applied ACell™, a biological scaffold that was developed for the purpose of having a place for stem cells to actually stimulate the tissue underneath. Using the two products in conjunction, this mare continued to do very well over the next few weeks.
When I needed granulation tissue, I used Lacerum™. Once the granulation tissue was filled in, I used the ACell™ to enhance specialized cells to speed the cornification. The slides in this paper clearly show the rapid response this mare had. She became amazingly sound over the first 3-4 weeks of treatment. She is now at home, and we see her on a monthly basis. It appears that this mare will continue to be a serviceable broodmare with an acceptable quality life.
These are three basic examples of how Lacerum™ has helped us push the envelope on three different types of cases. It allows us to open a new chapter on treatment regimes. Since January 2003, we have treated approximately 50 different cases with the growth factor, and approximately 20-25 cases with the ACell™. The Lacerum™ is a growth factor, and the ACell™ is a biological scaffold. I have found that they work well in conjunction with each other. I have also found cases where I didn't get the favorable response I expected. With anything new and innovative, there are often limitations. Neither product is a panacea for everything that comes down the road, but I think if you examine the efficacy, and this new concept of treating septic foot and leg injuries, you will find it to be a helpful adjunct to your podiatry unit.