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Does tendon firing quicken time to recovery for superficial digital flexor tendon injury?

Clinical Scenario

You are at a Thoroughbred racing yard to perform some routine preventive work, when one of the trainers asks you to have a look at a 4 year old gelding that has gone suddenly lame the day before on the left fore.  You can see that there is marked swelling and pain around the mid section of the superficial digital flexor tendon (SDFT). You share your suspicion that the horse has suffered a SDFT injury and start a discussion over diagnosis and treatment. The trainer however does not think this horse is very valuable and asks for your view over tendon firing as he feels he has had some success with the procedure in the past.  You don't routinely fire tendons but wonder if there is any evidence to support the practice over restricted exercise...

3-Part Question (PICO)

In [horses with superficial digital flexor tendonitis] does [tendon firing plus restricted exercise compared with restricted exercise alone] result in a [quicker time to recovery]?

Search Strategy and Summary of Evidence

Search Strategy

MEDLINE(R) In-Process & Other Non-Indexed Citations and MEDLINE(R) 1946 to Present using the OVID interface

(horse.mp. OR horses.mp. OR equine.mp. OR equines.mp. OR equus.mp. OR exp Horses/)

AND

(superficial digital flexor tendon.mp. OR superficial digital flexor tendonitis.mp. OR superficial digital flexor tendinitis.mp. OR superficial digital flexor tendinopathy.mp. OR SDFT.mp.)

AND

(firing.mp. OR fired tendon.mp. OR fired tendons.mp. OR thermocautery.mp. OR thermo-cautery.mp. OR cautery.mp. OR exp Cautery/)

CAB Abstracts 1910 to Present using the OVID interface

(horse.mp. OR horses.mp. OR equine.mp. OR equines.mp. OR equus.mp. OR exp Horses/)

AND

(superficial digital flexor tendon.mp. OR superficial digital flexor tendonitis.mp. OR superficial digital flexor tendinitis.mp. OR superficial digital flexor tendinopathy.mp. OR SDFT.mp.)

AND

(firing.mp. OR fired tendon.mp. OR fired tendons.mp. OR thermocautery.mp. OR thermo-cautery.mp. OR cautery.mp. OR exp Cautery/)

Search Outcome

MEDLINE

  • 2 papers found in MEDLINE search
  • 0 papers excluded as they don't meet the PICO question
  • 0 papers excluded as they are in a foreign language
  • 1 papers excluded as they are review articles/in vitro research/conference proceedings
  • 1 total relevant papers from MEDLINE

CAB Abstracts

  • 1 papers found in CAB search
  • 0 papers excluded as they don't meet the PICO question
  • 0 papers excluded as they are in a foreign language
  • 0 papers excluded as they are review articles/in vitro research/conference proceedings
  • 1 total relevant papers from CAB

Total relevant papers

1 relevant papers from both MEDLINE and CAB Abstracts

Summary of Evidence

Witte et al. 2016 Republic of Ireland

Title:

Comparison of treatment outcomes for superficial digital flexor tendonitis in National Hunt racehorses

Patient group:

National Hunt racehorses presented to a single clinic between June 2007 and July 2011

Study Type:

This study is described by the authors as a case-control study. However, considering the aims and hypotheses, the study also features aspects of cohort or case series studies. Therefore standard questions have been used to appraise this study.

Outcomes:
  • Age

  • Sex

  • Horse origin (ex-store, ex-flat, point-to-point)

  • Treatment

  • Lesion severity (taken from ultrasonic cross sectional measurements at the zone of maximum injury)

  • Number of days to first race after injury

  • Minimum, median and maximum intervals between all races post-injury

  • Additional outcomes data obtained from the Racing Post:
  • Total number of pre- and post-injury races
  • Binary variables of completion of 1, 3 and 5 races
  • Pre- and post-injury total distance raced in furlongs
  • Pre- and post- injury maximum RPR (handicap rating)
  • Number of days to first race after injury
  • Minimum, median and maximum intervals between all races post-injury
Key Results:
  • National Hunt horses with injuries mild in severity were more likely to receive controlled exercise alone than any other treatment type
  • 24 horses with superficial digital flexor tendon injuries received a recommendation for controlled exercise and 38 received bar firing plus a recommendation for controlled exercise
  • When comparing all outcomes relevant to post-injury racing, no significant differences were found between treatment groups
Study Weaknesses:
  • The study design is somewhat difficult to identify
  • Basic data and statistical methods are not described in adequate detail for the study to be replicated
  • Multiple statistical comparisons have been performed, testing a large number of hypotheses
  • A method of statistical adjustment for multiple comparisons is not described
  • A post-hoc power calculation suggests that the study was significantly under-powered, particularly in relation to differences between controlled exercise and bar firing
  • The treatment that horses received appeared to be influenced by the SDFT lesion severity
  • It is unclear how many of the horses actually did receive controlled exercise
  • Ethical approval is not commented upon
  • All cases were seen at a single clinic
  • There appear to be numbers of horses missing from tables and text (e.g. Table 2)
Attachment:
Evidence appraisalEvidence appraisal

Comments

The aim of this BET was not the primary aim of this paper, therefore there are few findings reported on this specific question. However, the authors of the paper do focus on this topic in their discussion.

Tendon firing or thermocautery appears to be a contentious ethical issue in the UK and in other countries. The British Equine Veterinary Association (BEVA) and the Australian Veterinary Association have issued position statements on the use of thermocautery. Links to the position statements from these organisations are included in the References section at the end of this BET. 

In response to a request for an up-to-date position statement, the RCVS replied by email with the following guidance on 21st December 2016: "The RCVS considers all forms of firing including “pin-firing”, “bar–firing”, “line-firing”  and “blistering” to be “mutilations” (practices which RCVS Council considers ineffective and/or lacking justification as methods of treatment and which should be discontinued).  The RCVS highlights that, although it has not happened to date, firing could be called into question under the Animal Welfare Act of 2006 and therefore that there is potential criminal liability for anyone carrying out the procedure. The RCVS is duty bound to act if it receives a complaint or if there has been a criminal offence."

Bottom line

This study provides weak evidence that tendon firing does not quicken time to recovery for superficial digital flexor tendon injury. 

Disclaimer

The BETs on this website are a summary of the evidence found on a topic and are not clinical guidelines. It is the responsibility of the individual veterinary surgeon to ensure appropriate decisions are made based on the specific circumstances of patients under their care, taking into account other factors such as local licensing regulations. Read small print

References

Witte S, Dedman C, Harriss F, Kelly G, Chang Y-M, Witte TH (2016) Comparison of treatment outcomes for superficial digital flexor tendon injury in National Hunt racehorses. The Veterinary Journal 216: 157-163

BEVA postion statement on thermocautery: https://www.beva.org.uk/Portals/0/Documents/Working%20For%20Change/Thermocautery%202014%20approved.pdf [Accessed 21st December 2016]

Australian Veterinary Assocation position statement on thermocautery of horses: http://www.ava.com.au/policy/71-thermocautery-horses [Accessed 21st December 2016]. 

About this BET

First author:
Zoe Belshaw
Second author:
Marnie Brennan
Institution:

CEVM, University of Nottingham

Search last performed:
2016-12-19 13:10:56
Original publication date:
2016-12-21 13:10:56
Last updated:
2016-12-21 13:10:56
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