Welcome, About us

Hello and welcome. My name is Sammy L. Pittman, DVM and I am a veterinarian, farrier, and horsemen with a great interest in the field of equine podiatry. My wife and I own and operate Innovative Equine Podiatry and Veterinary Services in Tulsa, Ok. We offer a full line of horse veterinary care. Specializing in health and well being of the hoof to better serve your equine companion. With so much lameness attributed to the lower limb many horses require an out of the box approach to achieve the success desired.
Give us a call and we will be glad to help you in any way we can. Thanks so much.
I will be discussing different Cases and thoughts from our world with the horse. Feel free to contact us via text or call at 918.235.1529 or send an email to iepvs11@gmail.com. Thank you for reading and enjoy

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Monday, October 27, 2014

Whats in a toe angle

Whats in a toe angle?  Here are two foals that would be considered to have a club foot with a toe angle of close to 64 degrees.  However what makes up the angle on the inside dictates what the foot will do and what it takes to manage it.   The foot on the left has a lower bone angle and a  higher Palmar angle.  This is a system that is under higher deep flexor tension rasingbthe heel and palmar angle.  Notice there is more dishing of the toe on the left  radiograph as well.   All indications that the deep flexor acting very heavy on the coffin bone. 

The radiograph on the right has a very large bone angle and lower Palmar angle, and no dishing. 

Palmar angle plus the bone angle will equal the toe angle. 

The hoof on the left will require more attention directed at relieving deep flexor tension via shoeing mechanics (rocker shoe) or surgery (check ligament desmotomy). The hoof on the right will be easier to manage with trimming alone and or low scale rocker shoe to add some foot mass to further protect the fragile coffin bone during development.  

This is why radiographs are so very helpful in managing foot problems.  You will never go wrong gaining specific information about your problem.

Sunday, January 5, 2014

Setting the bar for success in my laminitis cases

Welcome to 2014!  I wanted to review some of my laminitis cases that have proven very successful with regards to quickly adding sole mass and demonstrating an even hoof wall growth from toe to heel.  A couple of cases will also demonstrate how quickly the venogram can change.  Improvement in the blood supply is what we are all after.When you can demonstrate a quickly improving venogram study plus the quick addition of sole depth you can be a more positive about the overall situation.  Success to me is rapid foot recovery and ideally reversing the damaging effects of vascular compression before it creates irreversible bone and soft tissue damage.  Monitoring with venograms will show the level of vascular damage present  and allows a quicker more accurate mechanical therapy.  

For a review on soft tissue parameters measured on a podiatry style radiograph click here.

For a reference on a healthy venogram click here.

The first case is Rocky.  Rocky was first examined about 3 months after the initial insult and was well past the ideal time to completely avert any bone change.  Note the big divot out of the tip of the coffin bone caused by a severely displaced circumflex artery and terminal papillae is supplies. This chronic history, severe coffin bone displacement and venogram indicated the need for a deep flexor tenotomy (cutting of the tendon) after derotational shoeing.  

Note the quick addition of sole mass and a decrease in the amount of rotation within the hoof capsule.  Loss of rotation is not the goal but a common finding after changing the load dynamics by cutting the tendon.  This places a majority of the load towards the back of the coffin bone and can push the tip up in many cases to reduce the amount of rotational displacement and unload the circumflex under the rotated tip of the coffin bone.  Left column is the day of surgery and the right column is 30 days later.  Note the rapid addition of sole under the tip of the coffin bone.  The 3 months prior the hoof wall growth was greater in the heel than in the toe area which is very common with laminitis.  This is secondary to the vascular compression in the front half of the foot.  This is confirmed in the above venogram. The blood supply to the coronary band should be much fuller than demonstrated here.  After the tenotomy the hoof wall began to grow more even as we have unloaded the forces applied by the tendon and allowing a reperfusion of blood to these vital areas.  

 The images in the left are post shoeing radiograph from the 30 day post tenotomy visit and the images on the right are 30 days after that or 60 days post tenotomy.  The inital shoes are glued on and are usually left on for the first 10-12 weeks and many cases are barefoot at that time.  This case was growing so rapidly and to properly manage the palmar angle (prevent from getting into the negative zone) the shoe was removed, the foot trimmed and very lightly nailed back on parallel the the wings of the coffin bone.  Again note the amount of sole depth recovery within this 30 day period.  

The bottom two images are 90 days post tentomy.  This horse is comfortable barefoot and can maintain a zero to slightly positive palmar angle.  

Plan is for this horse to start hand walking daily for 5-10 minutes just to get him out of the stall. Recheck at 4-6 week intervals with radiographs to insure continued foot mass recovery and maintenance of the palmar angle.  This horse may very well be able to do some light riding in another 6-8 months with some turnout.  Because of the severe bone remodeling that had already occurred I am hesitant to say he will return to 100 percent of what he was prior lamintis but can have a good quality of life.  

Case #2  Gracie
Gracie had been guilty of getting into the owners bird seed and dog food and was a touch overweight.  Surprisingly fairly sound and would only rock back on hind quarters in turn.  A considerable amount of coffin bone displacement had already occurred which indicates the syndrome has been rolling for some time.  Owners reported some pain over the last 4 weeks only.  Note the distal divergent horn lamellar zones and loss of sole depth.  

Placed in Nanric modified ultimates the performed a venogram.   Venograms in the left column are the first exams and the right column are venograms performed 9 days later.  Note the improvement in the vascular structure around the tip of the coffin bone.  This is secondary to the wedges unloading the tendon tension by decreasing the distance from its origin to insertion with the coffin bone.  This allows the load to be transferred to the heels an back of coffin bone.  I also measured a 3mm increase in sole depth in this short period.  This is likely due to the unloading of the solar corium directly under the tip of the coffin bone.  Think of placing a clothes pin on your finger smashing is flatter.  It will measure a greater thickness once the clothes pin compression is removed and the tissue is once again filled with blood.  

Below are images that are taken 30 days after placement in the nanric modified ultimates placing the palmar angle at approximately 20 degrees

Below are images that  are  90 days in the ultimates wedges

This demonstrated a rapid change in the vascular pattern with the addition of the wedging and did not require a higher level of deep flexor tendon relief as the previous case in which the tendon was cut.  Just placing a little slack in the tendon system is often all that is required to unload the vascular supply in important compromised areas in the front of the foot and directly under the tip of the coffin bone.  This horse will then be transitioned to a rockered 4pt rail shoe that will continue to offer a greatly reduced load on the flexor tendon, solar corium and the lamellar attachments.  The level of rocker/mechanics will be slowly lowered as long as continued soft tissue response is noted.  

Case #3 is a  mustang that suffered lamintis in all four feet.  The fronts required a deep flexor tenotomy as the circumflex artery was displaced above the tip of the coffin bone and no contrast is noted below the tip of the coffin bone.  The hind venogram was also compromised but to a lesser degree.  The fronts where shod with a derotational tenotomy shoe followed by a deep flexor tenotomy and the hinds were placed in the ultimate wedges.  A follow up venogram performed on a hind foot demonstrated a positive improvement and suggest that a tenotomy is not needed at this time and supports continued use of the wedges.  One can already see the addition of sole depth in this short 10 day period in the fronts and hinds.

On the left below is a venogram of the left hind on initial exam and a follow up venogram 10 days later while wearing the modified ultimates placing the palmar angle at 20 degrees.  Note the significant improvement in vessel filling over the coronary band, the more normal appearance in the circumflex junction and return of solar and terminal papillae.

 Below are radiographs of the fronts.  The images on the left are taken on the day of surgery and radiographs on the right are 30 days post surgery.  Sole depth has easily more than doubled.  This is the rapid response required to quickly unload the vascular structures and aid in prevention of irreversible bone disease and chronic pain.

Below in the left column is 10 days post wedging and 30 days post in the right column.  

Below are the hinds 60 days post placement into the modified ultimates.  

 Below are the fronts 60 days post tenotomy.  Horse is barefoot with greater than 20 mm of sole.  You can see the new growth coming in at the upper hoof wall.  Note this case has very little if any boney changes or remodelling at this tip of coffin bone.  This is what I am shooting for in my laminitis therapy.  Prevent continued vascular compromise as quickly as possible to prevent irreversible bone disease.  This horse will likely go back to doing whatever he wants in two years with some light riding at one post tenotomy.  

These are just three cases from this summer and fall that demonstrated the quick response I am looking for.  Understanding the mechanics relative to the deep flexor and its role in a failing lamellar bond has proven very beneficial in my practice.  Monitoring the failing system with serial venograms will inform you quicker than plain radiographs.  Instead of waiting around for 4-6 weeks to evaluate the response in sole depth and hoof wall growth the venogram will demonstrate the level of compromise days to weeks before any changes can be noted otherwise.  This allows quicker changes in mechanical therapy and less irreversible damage.  This prevents chronic pain and abscesses.  

What do you consider a success?  Patient comfort? What level of sole depth recovery in a period of time do you expect with your laminitis therapy?

Wishing you happy and prosperous new year.

All the best

Sammy L. Pittman, DVM

Monday, June 24, 2013

Upcoming Seminar

A one day lecture and demo at countryside veterinary clinic.  We will look at the basics of mechanical evaluation of the distal limb and review radiographic and venographic evaluation of the equine distal limb.

Friday, May 31, 2013

Hoof wall resection and update on Blackie the laminitis case.

     This is Blackie a previously posted laminitis case.  Click here to see previous radiographs and venograms. He is showing response with added sole depth and comfort. A hoof wall resection was required and I thought it would be a good representation as to what to expect from a hoof wall resection.

Below are radiographs from immediately post deep flexor tenotomy and 60 days post tenotomy.  Noteworthy change on both are additional sole depth under tip of coffin bone.  However continued remodelling of the tip of the coffin bone and a slight increase in palmar angle on the left hoof are suggestive that the dorsal portion still fails to grow at a rate similar to the palmar portion.  This hoof suffered more damage as it was the "club".  Deep flexor tenotomy was not performed at the recommended time.  Significant pathology was identified within 5 days of onset of acute laminitis but owner refused tenotomy at that time.

     A resection is required in laminitis cases that have coronary band swelling that is prolapsing over the hoof wall.  The hoof will act as a tourniquet as the inner laminae experience swelling.  The lack of expansion of the hoof creates massive vascular compression and starves the laminae and coffin bone of needed nutrient flow.  Often times this is all secondary to inflammation arising from compromised soft tissue and bone along the toe and medial quarter as this area tends to receive the most significant load induced vascular compromise when laminae fail to suspend the coffin bone.

     I like to use a cast cutter or multi-purpose oscillating saw to cut through the hoof.  Usually an 1 1/2 in below the hairline is a minimum and often times I find myself removing more at a later date.  The width of resection will depend on amount of coronary band involved and should extend at least  1/2 in wider than the affected coronary band.


Next I use a sharp hook on the end of hoof knife to round and smooth the proximal (upper) edge of the  intact hoof wall.  It is important to perform this prior to removing hoof wall because it will get somewhat bloody after removal and occlude good visualisation. 

Next the hoof wall can easily be removed by grasping one end with half rounds or regular nippers.  Ease of removal is directly related timing of resection.  Resections based on early evidence from venograms are usually more attached  versus the case that has already separated and has drainage.  

One removed, a gentle massage of the coronary papillae and lamina to encourage hemorrhage and lay the papillae in a more normal position pointing downward. Note the lack of hemorrhage in the most compromised region.  

Next 1/2 inch felt heavily coated in silvadene cream is cut to fit the void left behind.  This is tightly wrapped with elastikon as adequate pressure is important to prevent excessive swelling and granulation.  Many times with cases that are far away and I am uncomfortable with the owners ability to maintain a bandage, I will place a cast over the elastikon up to the fetlock to maintain adequate compression.  Preferably, daily changing for the first three days to ensure adequate hoof wall has been removed is recommended.  After that a cast can be applied and changed every 7-10 days or bandage changes every 3-4 days.  Each time a new piece of felt is applied with a fresh layer of silvadene.  I will also use dmso gel applied to the coronary band to aid with inflammation.  


Images below are representative of what the hoof will look like at bandage or cast changes.  This will depend greatly on the amount damage or compromise present.  This case has significant damage with a lot of granulation already present.  Ideally a resection should have been performed much earlier to prevent this level of damage to the coronary papillae.  The first thing you will see is secretion of the secondary matrix horn which signifies the cornification process.  Once this has covered the entire resection site, compression bandaging can be stopped and patient can go without any bandage at all.  I like to see the cornification at the level of the previous hoof wall prior to stoppage of bandaging or casting.  

    Below are images of 5 days post resection.  Notice the medial (inside) and lateral (outside) portions have already began to fill in with secondary matrix horn.  The central portion suffered so much damage that the lamina are dead and unable to secrete matrix.  This will fill and contract very similar to a wound anywhere else on the body via epithelialisation.  A moist environment maintained with bandaging and/or cast will expedite the process.

Below are images from approximately 15 days later.  A cast was placed over felt pad and elastikon for this period.  Note the matrix is at the level of the hoof wall at the medial and lateral aspects and the granulation is reduced to 1/3.  

These images are approximately 30 days post resection.  Continued epithelialisation and secondary horn formation aka cornification.  

Images below are about 6 weeks post resection and complete epithelialisation and cornification has occurred.  At this point it is no longer necessary to apply cast or compressive bandages unless coronary band begins to get inflamed again.