Fasciotomy & neurectomy surgery for PSD: Should I do it?

[tipzythegreat]

His feet are in good shape. He had NPA that was resolved some time ago and long toes and short heels. He wears pads on his hind feet now and moves better than ever.

He’d make a lovely trail horse and can still WTC. He is happy to walk around and casually trot around. He just can’t use his body properly comfortably. He isn’t visibly lame to someone who doesn’t know him.

I don’t want to do stall rest and rehab and walking in the dead of winter. But I will do it if it means I can have even another 2-3 years with my horse. I hope that one day I can have my own property to keep him on.

But maybe it’s a pipe dream and I should let him go

[findthedistance]

My n=1, but I had a horse with a successful fasciotomy & neurectomy. He didn’t love his imprisonment, but he was perfect to rehab despite it being dead of winter.

That said, this was a horse with a mystery RF lameness that predated the PSD by several years. He was serviceably sound with creative shoeing for a while and somewhat worse when the hinds got bad enough to notice. We were hopeful that doing the surgery would allow him to use himself better again and take strain off the RF. It turned out that the PSD was masking the RF and he was more lame in front once the hinds healed. Knowing now what I didn’t know then, that lameness probably originated in his neck.

Would I do the surgery on a horse with no other issues? Yes, and likely right off the bat. Would I do the surgery on a horse with a list of other body issues that might or might not resolve after the rehab? Probably not.

[quietann]

Here is a very lengthy thread from the Eventing board:

https://forum.chronofhorse.com/t/proximal-suspensory-surgery-advice-updates-at-end/207809

The thread hasn’t been updated in a while, but has a lot of different peoples’ experiences.

My mare, one of the cases on that thread, is being retired soon, because the old injuries and poor leg conformation have caught up with her – but I got almost 11 years riding her post-surgery. She is 23 and owes me nothing.

[joiedevie99]

I did the surgery and ended up retiring the horse anyway.

[mmeqcenter]

I would retire him, myself. After having twice seen an abscess go unnoticed due to no apparent lameness in a nerved foot, resulting in bone infections and euthanasia, I’m not a fan of neurectomy.

[Gardenhorse]

@mmeqcenter

I would retire him, myself. After having twice seen an abscess go unnoticed due to no apparent lameness in a nerved foot, resulting in bone infections and euthanasia, I’m not a fan of neurectomy.

Neurectomy for suspensory injuries is very different than a neurectomy for navicular. For suspensories, the main nerve supply to the limb/foot is not affected.

My friend did a fasciotomy/neurectomy on her then 11-year old gelding two years ago. Surgery, recovery, and rehab were uncomplicated. He did get SI injections a few months after the surgery as they felt there was still some soreness there from compensating for the suspensory. He is back in full work (4th level dressage) with no issues.

They have learned that the success of the procedure depends a lot on leg conformation. I would definitely be sure to consult with a vet who has done a lot of these surgeries and understands the role of leg conformation in successful outcomes.

[tipzythegreat]

Mine DOES likely have additional body issues. He definitely has a wonky knee – but we are able to manage it… right now…

I am 100% concerned I’m going to do the surgery and he’ll continue to have mysterious issues.

[tipzythegreat]

That’s my biggest fear. Can you tell me more about the before and after the surgery for your horse?

[tipzythegreat]

I would be OK with injecting the SI even if it’s long term. Do you remember any details of the rehab?

My horse would be going up to Michigan State University. My vet has said he is a candidate as he doesn’t have any fetlock drop which would indicate weakness of the suspensory. He doesn’t have straight hocks or anything like that. We think he’s had this injury for years before I even got him (he is off the track)

[joiedevie99]

@tipzythegreat

Can you tell me more about the before and after the surgery for your horse?

It’s been a while - here’s my best recollection of the timeline. He was diagnosed with strained proximal suspensories (right much worse than left) in October. He was 10 y/o and showing small tour dressage. He was mostly sound, but felt flat. In the steep half pass for the GP you could see the lack of stepping under and across with the right hind. In hindsight, I had switched up my spurs in late August because he felt a little sulky to the leg and I think that may have been the start of it.

Also relevant - he’s a worker bee type that will never say no, and he’s a bit straighter than ideal through the hocks. During his career, his SI was always his weak spot.

Because there were no lesions/tears, we started a bit more conservative. We tack walked, injected with PRP or ProStride (don’t remember), and did some shockwave. In December/January he was looking great and we added in a few straight line trots. The first two weeks felt great, then it felt worse. His insurance coverage for the injury was running out that week. We talked options, and they felt the surgery was his best bet.

They got him in the next morning (this was January/February). We did fasciotomy/neurectomy, and also put in stem cells. Surgery itself was easy. He was in the hospital a full week because he spiked a fever after surgery, but he was eating and happy the whole time. We did suspensory shoes and many months of hand walking. During this time, I started to notice his fetlocks dropping a bit more.

We did a slow careful rehab when he was cleared to start back - months of tack walking, then 30 seconds of trot each way, then 1 minute of trot each way, etc.

He did great until about 8 minutes of trot. We injected hocks and SI to help support the muscle building process, and did another round of stem cells and shockwave. He again felt not right after a while. In the end, I shipped him to a friend for a year of Dr. Green. He babysat yearlings and had a blast. He looked great when I picked him up. Many months later, he flunked out of rehab a third time around the same point in trot.

After 3 full years of rehab post surgery at 13, I moved him to a retirement facility. I keep a snaffle and a bareback pad there and sit on him occasionally. He’s 15 now. His fetlocks are noticeably dropped - but not awful looking to someone who didn’t know him before. We he goes full out to chase his friends, he gallops with his hind legs pushing off together - so I suspect there is some minor discomfort somewhere - but he trots sound.

[tipzythegreat]

Thank you. I think this solidifies my choice to retire. I did conservative too – but he DID come sound. But it isn’t just the cost of surgery, is it? It’s injecting the SI and hocks and everything to help protect it until you realize he’s still sore and you’re out of options. And the dropping of the fetlocks post surgery is a real concern.

I appreciate you taking the time to type this out for me

[ndirish07]

I would do the surgery. I have done the surgery except the neurectomy part as my horse wasn’t a candidate for that. Feb 2020 my horse had left hind PSD and did the fasciotomy with PRP, shockwave and class IV laser. He did stall rest for 5 months, but it wasn’t pure stall rest. He was handwalked as a part of his rehab schedule, and then got some gradual time out in a 12 x 12 box that we increased in size. He just wasn’t out in the field with friends. He rehabbed beautifully and is totally sound and sounder than most horses my vet jogs out without issues-- he got the all clear a year ago in October 2020. Since, he’s back competing in dressage (first/second level) and BN eventing competing (schooling Novice and Training SJ). He remains in the toe plate suspensory shoes and hasn’t ever taken a lame step since.

The neurectomy as others as pointed out is entirely different than that done for navicular. It only affects the suspensory and no other structures in the leg.

PM me if you want more info— happy to talk about this more.

[Libby2563]

You might find this old thread of mine helpful: Neurectomy for suspensories in performance horse...why is this okay?. It mentions this study, which breaks down the surgery success rates for horses with no other issues, horses with straight hocks or hyperextending fetlocks, and horses with no other issues: https://pubmed.ncbi.nlm.nih.gov/21883416/

I did end up doing the surgery on my guy and it was very uneventful with an easy recovery. Unfortunately he did not have a happy ending because he ended up having DSLD/ESPA (confirmed by necropsy at the ripe old age of 5, ugh). I don’t regret trying the surgery though because at least I gave him a shot.

[tipzythegreat]

Thank you. I think my horse might be in group 3 as he has a bit of arthritis in his knee and we don’t know 100% this is all that’s wrong with him. He’s so sore in his stifles and SI that we suspect there may be more wrong.

How long was your rehab? If it wasn’t long or agonizing, I would consider it. I’ve just already done 6 months of 2x a day hand walks and only walking under saddle and it was miserable and depressing.

[Libby2563]

Long story but I only did 2 months of handwalking rehab after the surgery because it became apparent there were bigger issues. There’s a whole thread about his DSLD but hopefully you don’t need to worry about that!

[tipzythegreat]

To anyone interested: I went through with the surgery.

I had his grain transitioning. A date picked to retire him. A hauler lined up. And I was heartbroken. I would lie awake at night crying thinking about not seeing him every day. So, I last minute changed my decision.

The surgery cost was $2200-2600 (still waiting on the final bill) + $500 for hauling roundtrip. The procedure itself was only a couple of hours. I dropped him off Tuesday morning and picked him up Thursday morning. His right hind was done but not his left.

His prognosis is “fair”. The surgeon believes he’ll come back to work… it’s just a question about how long he’ll stay sound since he’s had the injury so long. If you don’t know, the nerve regenerates in about 2 years.

Recovery is 2 weeks stall rest with easy occasional walks. 4 bandage changes at 4 days changing intervals. 2 grams of bute for 3 days, 1 gram of bute for 4 days. 2 hand walks a day after 2 weeks that gradually increase by 5 minutes. Once the bandage is off we can tack walk. 6 week re-check by my local vet. Once he’s cleared we can begin trotting under saddle.

Fingers crossed!

[EventingMaff]

There is a helpful facebook group for PSD with lots of support, experience sharing, ideas, etc.

It does seem that many of the horses do come back to at least be happy trail horses for several years. Some go back to competing and of course there are those for who the surgery doesn’t work. May be a good resource to check out as you go through rehab and rebuild.

Fingers crossed for you and your boy! Sounds like you’re doing everything right by him and he’s lucky to have you!

[the_sandiest_shoes]

Hi! Just wondering how your horse did after the rehab?

[tipzythegreat]

Hi! He is doing OK! It’s now been a year and a half and we struggled a bit cantering under saddle. A solo turnout for him to go wild and re-learn how to canter proved to be all he needed. The only big setback we had was a pretty gnarly stifle kick… but that was totally unrelated and I think some of his issues stem from that.

He’s honestly very similar to how he rode pre-surgery some days – a bit crooked and stiff – but other days he feels great. He does not push as hard with his RH and it’s visible when we do an extended trot, for example.

But I ride him 3 or 4 times a week for about 45 minutes, with 20-25 of that being WORKING. We have been doing trot poles and “jumping” poles on the ground.

I think I just have to accept that “serviceably sound” is the best I’ll get. He’s definitely better than he was right before the surgery, but he’s not as good as he was say the year before he needed the surgery.

Overall, I am happy with my decision. We just celebrated 7 years together and I’m glad to have my best buddy still in working order. Maybe not competitive order, but I don’t think that was ever in the cards.

[tipzythegreat]

To anyone in a similar boat to the one I found myself in 2 years ago:

Kota is doing just fine 2 years post op. In fact, I had the vet out for a lameness evaluation for some maintenance (he’s a bit stiff, crooked and sucked back) and my vet said his suspensory feels as good as she’s ever felt it. It’s cool and tight and completely healed, in her opinion. We did not do ultrasounds (and I haven’t since the surgery, honestly).

At this point, he’s going on 17 and I want to keep him running as long as possible. His hocks were sore and his stifles filled with fluid, so we opted to do a steroid injection on both. Historically I’ve been doing ONLY IRAP on his hocks and his stifles sometimes IRAP sometimes steroid (stifle injections began post op). My hope is to milk these injections for another year.

Work wise, we never got to competing. But I opted to preserve him vs push him over the last 5 years. We no longer take lessons (because we had to move farms) but I think he’d do just fine with a weekly lesson again as of now.

We can extend and collect. We do leg yields and shoulder ins. We don’t really jump, but we occasionally pop over a cavaletti and do a lot of trot poles. I ride 3 or 4 times a week for a working 25 minutes and another 20 of walking.

He’s a good boy, and I am glad to have done the surgery. I don’t regret the journey before the surgery either – I still encourage healing and treating in all ways before resorting to surgery.