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Is neurectomy of the deep branch of the lateral plantar nerve and fasciotomy effective?
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Proximal suspensory desmitis in the hindlimb is a common condition and can be a therapeutic challenge. After the first publications [1,2] about the technique of neurectomy of the deep branch of the lateral plantar nerve combined with a fasciotomy, this technique has gained popularity and became a regularly performed surgical technique. In our clinic the technique is also being used frequently but has never gained as much popularity as in some other veterinary institutions. We started using the technique, but during the same procedure also treated the affected ligament with porcine urinary bladder matrix and later on with platelet enriched plasma (PRP) or bone marrow concentrate (BMAC). In selected cases this was also combined with an osteostixis procedure. At present we use the technique as a sole procedure. In the literature a high success rate has been reported up to 91% [1–3], with low complication rates. In clinical practice the technique was not always experienced in such a positive way. Although there are no well described cases in the literature, the technique has been criticised by anecdotal reports of horses having a fatal breakdown of the suspensory after neurectomy and fasciotomy surgery has been performed. Exacerbating the desmopathy after surgery is feared and well discussed among surgeons performing the surgery and referring veterinarians sending the horses for surgery. Pauwels et al. [4] described neurogenic atrophy of the muscle fibres of the proximal part of the suspensory ligament after a neurectomy of the deep branch of the lateral plantar nerve. This made us concerned about the load-bearing capacity of the proximal suspensory ligament after surgery. It made us change our approach in the clinical cases in a way that the chronic cases that we selected for the surgery would first need to heal in further by a conservative programme before taking them to surgery. This conservative programme consists of a controlled exercise programme based on frequent ultrasound examinations and treating the affected proximal suspensory ligament with BMAC and/or PRP. To stimulate the healing further, we use frequent shockwave treatments. The group of patients that are treated conservatively are critically evaluated and then taken to surgery at a later stage of the healing process. The recent paper by Dyson and Murray [5] gave us even more tools to prevent and predict poor outcomes. In their paper, horses with primary proximal suspensory desmopathy in association with straight hock conformation and/or hyperextension of the metatarsophalangeal joint all remained lame. This was associated with deterioration of the ultrasonographic appearance of the suspensory ligament. A low (44%) success rate was encountered in the group of patients that had additional problems besides a hindlimb proximal desmopathy. The effectiveness of neurectomy of the deep branch of the plantar nerve in this latter group especially could be improved by a better controlled veterinary management of the horse before and after the surgical technique is performed.
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Affiliation of the authors at the time of publication
Veterinair centrum Someren, Slievenstraat 16, 5711PK Someren, The Netherlands
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