Treatment of Proximal Patellar Hesitation (PPH): STEP THREE
Now that we've gotten your horse fit and the problem is still persisting we can consider further treatment in the form of surgery. At The Atlanta Equine Clinic we combine two surgical techniques in an attempt to alleviate PPH/IUPF. Both techniques are performed in the standing (sedated) horse at the barn.
The first technique is called fenestration or "splitting". As you may know, the technique involves splitting or separating the ligament fibers within the medial (inside) and middle distal patellar ligaments. This creates defects within the ligament which fills in with scar tissue. As the scar tissue matures and organizes, it contracts, thereby shortening the ligament and repositioning the patella (or kneecap).
The second technique involves infusing a counterirritant (or "blister") to irritate the tissues and accentuate ligament contraction. As originally described, the technique consisted of infusing the counterirritant (usually 2% iodine in almond oil) adjacent to the medial and middle distal patellar ligaments. With irritation/ inflammation of these tissues we inevitably cause the formation of scar tissue. With maturity, the scar tissue contracts thereby shortening the ligaments and surrounding tissues. The patella is repositioned in a location whereby IUPF is less likely to occur.
We have had the most success performing a technique that combines the splitting and blistering strategies. Rather than split the fibers with a scalpel blade, we simply split them using an 18-gauge 1.5" needle. Consequently, no external (skin) incision is required. As we remove the needle from between the ligament fibers we infuse a small amount (or trail) of counterirritant into the remaining defect or tract. This stimulates the developing scar tissue to contract even further than it would on its own.
We have been performing the procedure for over 20 years with very good success. The cost of the procedure is about $500 for both stifles.
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