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Ethanol injection to facilitate arthrodesis

Discussion in 'General Issues and Discussion Forum' started by Mart, Oct 22, 2012.

  1. Mart

    Mart Well-Known Member


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    Hi

    Anyone have any information regarding using ethanol injection for mid/ forefoot joints in humans. Some intesting recent publications in veterinary journals below - I can't find any reference to human studies or heard anything anecdotally.

    The main concern I see is establishing absence of comunication into joints which would need to be spared. I guess arthrography would be gold standard to acheive this.

    Any thoughts?

    Cheers

    Martin

    Foot and Ankle Clinic
    1365 Grant Ave.
    Winnipeg Manitoba R3M 1Z8
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com






    Vet J. 2012 Jul;44(4):399-403. doi: 10.1111/j.2042-3306.2011.00512.x. Epub 2011 Dec 1.
    Use of ethanol in the treatment of distal tarsal joint osteoarthritis: 24 cases.

    Lamas LP, Edmonds J, Hodge W, Zamora-Vera L, Burford J, Coomer R, Munroe G.
    Source

    Structure and Motion Laboratory, Royal Veterinary College, AL97TA, UK. llamas@rvc.ac.uk

    Abstract

    REASONS FOR PERFORMING THIS STUDY: Intra-articular ethanol has been described to promote distal tarsal joint ankylosis. Its use and results in clinical cases affected by osteoarthritis (OA) have not been reported.
    OBJECTIVES:


    To describe and evaluate the results of treatment of distal tarsal joint OA by facilitated ankylosis stimulated by intra-articular ethanol injection.
    METHODS:

    Twenty-four horses met the inclusion criteria of tarsometatarsal and centrodistal joint OA diagnosed by a positive response to intra-articular analgesia, radiographic evaluation and recurrence of lameness ≤ 4 months after intra-articular medication with a corticosteroid. Horses were sedated and, following a radiographic contrast study of the tarsometatarsal joint, medication with 2-4 ml of either 100% pure ethanol (G100) or a 70% ethanol (G70) solution was applied. Horses were classified as improved based on a 50% reduction from initial lameness grade combined with an increase in exercise level.
    RESULTS:

    Of the 24 horses included in this study, 20 had the treatment performed bilaterally and 4 unilaterally. All horses were available for initial follow-up examination and 21 for a second one 6-9 months after treatment. This represented a total of 44 treated limbs and 35 available for long-term follow-up. Of these, 21/35 (60%) were considered improved, which corresponds to 11/21 horses (52%). Of 21 horses, 4 (19%) deteriorated and 2 of these developed significant complications related to treatment.
    CONCLUSIONS:

    Distal tarsal joint ankylosis with ethanol should be considered a safe and economic treatment in cases of distal tarsal joint OA that fail to show long-term improvement with intra-articular corticosteroid treatment.
    POTENTIAL RELEVANCE:

    Ethanol should be considered in the treatment of certain cases of distal tarsal joint OA. The importance of performing an adequate radiographic contrast study of the tarsometatarsal joint prior to treatment is highlighted.


    Vet Surg. 2011 Apr;40(3):291-8. doi: 10.1111/j.1532-950X.2010.00794.x. Epub 2011 Jan 18.
    Evaluation of ethyl alcohol for use in a minimally invasive technique for equine proximal interphalangeal joint arthrodesis.

    Wolker RR, Wilson DG, Allen AL, Carmalt JL.
    Source

    Department of Large Animal Clinical Sciences Department of Veterinary Pathology, Western College of Veterinary Medicine, University of Saskatchewan, Saskatoon, SK, Canada. ryan.wolker@usask.ca

    Abstract

    OBJECTIVE:

    To determine whether intra-articular 70% ethyl alcohol alone (IAEA) or in combination with 2 percutaneously placed transarticular lag screws (EA-TLS) would result in arthrodesis of the equine proximal interphalangeal (PIP) joint.
    STUDY DESIGN:

    Experimental.
    ANIMALS:

    Healthy horses (n=6), aged 1.5-3 years, free of lameness, diagonally paired front and hind PIP joints.
    METHODS:

    Six milliliters 70% ethyl alcohol was injected into randomly selected diagonally paired front and hind PIP joints. Thirty days later, 2 parallel 5.5 mm cortical screws were inserted in lag fashion across the hind PIP joints and the limbs were cast. Horses were confined for 60 days after surgery before free exercise was permitted. Serial lameness examinations were performed at 1, 6, and 10 months. Radiographs of the PIP joints were obtained before injection with alcohol (front, hind PIP joints), at 6 and 10 months (front PIP joints) and 1, 3, 6, and 10 months (hind PIP joints). At 10 months, horses were euthanatized and gross and histopathologic examination of the treated joints was performed.
    RESULTS:

    Horses had variable cartilage thinning (more severe in hind PIP joints) and dorsal bone proliferation. One front and 1 hind PIP joint were fused 10 months after alcohol injection.
    CONCLUSIONS:

    Ethyl alcohol injected alone or in combination with percutaneously placed transarticular lag screws failed to reliably produce fusion of the PIP joint.
    © Copyright 2011 by The American College of Veterinary Surgeons
     
  2. Mart

    Mart Well-Known Member

    Re: ethanol arthrodesis

    couple more citations for those interested

    Cheers

    Martin

    Foot and Ankle Clinic
    1365 Grant Ave.
    Winnipeg Manitoba R3M 1Z8
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com



    Alcohol-facilitated ankylosis of the distal intertarsal and tarsometatarsal joints in horses with osteoarthritis.
    Carmalt JL, Bell CD, Panizzi L, Wolker RR, Lanovaz JL, Bracamonte JL, Wilson DG.
    SourceDepartment of Large Animal Clinical Sciences, Western College of Veterinary Medicine, University of Saskatchewan, Saskatoon, SK S7N 5B4, Canada. carmalt_vet@hotmail.com

    Abstract
    OBJECTIVE: To assess the safety and efficacy of alcohol-facilitated ankylosis of the distal intertarsal (DIT) and tarsometatarsal (TMT) joints in horses with osteoarthritis (bone spavin).

    DESIGN: Prospective clinical trial.

    ANIMALS: 21 horses with DIT or TMT joint-associated hind limb lameness and 5 nonlame horses.

    PROCEDURES: 11 horses (group 1) underwent lameness, force-plate, and radiographic examinations; following intra-articular analgesia, lameness and force-plate examinations were repeated. Nonlame horses were used for force-plate data acquisition only. Following localization of lameness to the DIT and TMT joints, contrast arthrographic evaluation was performed; when communication with the tibiotarsal joint was not evident or suspected, 70% ethyl alcohol (3 mL) was injected. Group 1 horses underwent lameness, force-plate, and radiographic examinations every 3 months for 1 year. Ten other horses (group 2) underwent lameness and radiographic examinations followed by joint injection with alcohol; follow-up information was obtained from owners or via clinical examination.

    RESULTS: Significant postinjection reduction in lameness (after 3 days to 3 months) was evident for all treated horses. Twelve months after injection, 10 of 11 group 1 horses were not lame; lameness grade was 0.5 in 1 horse. Follow-up information was available for 9 of 10 group 2 horses; 7 were not lame, and 2 remained mildly lame (1 had a concurrent problem in the injected limb, and the other had DIT joint collapse that precluded needle entry).

    CONCLUSIONS AND CLINICAL RELEVANCE: Intra-articular alcohol injection in horses with bone spavin resulted in a rapid (usually within 3 months) reduction in lameness and joint space collapse.

    Am J Vet Res. 2006 May;67(5):850-7.
    Use of intra-articular administration of ethyl alcohol for arthrodesis of the tarsometatarsal joint in healthy horses.
    Shoemaker RW, Allen AL, Richardson CE, Wilson DG.
    SourceDepartment of Large Animal Clinical Sciences, Western College of Veterinary Medicine, University of Saskatchewan, Saskatoon, SK S7N 5B4, Canada.

    Abstract
    OBJECTIVE: To evaluate the efficacy and safety of intra-articular administration of ethyl alcohol for arthrodesis of tarsometatarsal joints in horses.

    ANIMALS: 8 healthy female horses without lameness or radiographic evidence of tarsal joint osteoarthritis.

    PROCEDURE: In each horse, 1 tarsometatarsal joint was treated with 4 mL of 70% ethyl alcohol and the opposite joint was treated with 4 mL of 95% ethyl alcohol. Lameness examinations were performed daily for 2 weeks, followed by monthly evaluations for the duration of the 12-month study. Radiographic evaluations of both tarsi were performed 1 month after injection and every 3 months thereafter. Gross and histologic examinations of the tarsi were undertaken at completion of the study.

    RESULTS: Horses had minimal to no lameness associated with the treatments. Radiography revealed that 8 of 16 joints were fused by 4 months after treatment, with significantly more joints fused in the 70% ethyl alcohol group. Fifteen of 16 joints were considered fused at postmortem examination at 12 months. Gross and histologic examinations revealed foci of dense mature osteonal bone spanning the joint spaces. Bony fusion appeared to be concentrated on the dorsolateral, centrolateral, and plantarolateral aspects of the joints. Significant differences were not detected between treatment groups for lameness or pathologic findings.

    CONCLUSIONS AND CLINICAL RELEVANCE: Administration of ethyl alcohol into the tarsometatarsal joint of healthy horses appeared to facilitate arthrodesis of the joint in a pain-free manner. Results warrant further investigation into the potential use of ethyl alcohol in horses clinically affected with osteoarthritis of the tarsometatarsal and distal intertarsal joints.
     
  3. msdds1

    msdds1 Member

    I am a dentist who suffered severe LisFranc and had it "fixed" and due to the failure, had a bone fusion on top 3 mets a few months ago. Still have pain on 2 mets as they did not fuse and am not keen for more surgery.
    Started to search for an injectable alternative. Of course there is Prolotherapy but was looking for other alternatives.
    I am amazed that things as simple as Alcohol injections is not even attempted in humans.
    Why not? Seems like the same as using DMSO on horses but not people. Why not?

    A podiatrist should attempt a study. I will come and be your first subject.
     
  4. Ian Drakard

    Ian Drakard Active Member

    thanks msdds1 for giving this a bump. completely missed it back in october. Have you found anymore stuff on it Martin?
     
  5. Mart

    Mart Well-Known Member

    No - I suspect this study has not been done in humans. I am in middle of a study currently and no headroom for anything else. I am very interested in taking this on but no time to write up a decent proposal for several months. I would be interested I collaborating if anyone else interested in planning a proposal. I don't have a sure sense of risk for harmful outcome which would be main concern for viability of study. Any opinions out there on that issue?


    cheers Martin
     
  6. msdds1

    msdds1 Member

    From what I have read with horses, it does not seem to have major negative effects, just does not work as the main one. But I would be willing to help write a proposal or do some "leg" work if someone needs help. I have never written a proposal but can help. I was thinking about calling a few of the doctors (Vets) on the studies and maybe even a local equestrian vet, and asking them some in dept questions.
    Some Naturopath use alcohol injections for trigger point injections.
    Also don't Podiatrists use it for neuromas and for permanent nerve blocks?
    I guess one would have to be careful to get the alcohol in the right area, close to the joint space and not near any nerves.
    The more difficult part would be what dosage and or concentration.
    They do make freeze dried Ethyl alcohol so I guess it might be better to have less but more concentrated. Maybe some kind of vehicle or vasoconstrictor to keep it in the joint space and not diffuse out.
    Keep foot in walking cast to help minimise joint movement.
    Dr. H
     
  7. msdds1

    msdds1 Member

    Also, as aLisFranc survivor, there are a lot of blogs out there with patients with chronic suffering with LisFranc fractures. They might tear down your door if they thought it might help.
     
  8. Mart

    Mart Well-Known Member

    My thoughts too are risk, especially if already failed surgery, would be low. However we don't know if that is true. I use ethanol injections for plantar digital neuritis which has been unresponsive to corticosteroid injection with mixed outcomes. Reported post injection pain for a day seems only unwelcome effect. It would seem likely that intraarticular ethanol might permanently destroy nociception and whist that in short term might make patient feel better in long term if joint is not properly stabilized lead to complications comparable to neuropathic joints.

    Did you have your TMT stabilized with a plate or staple? If not what was done for the post lisfranc injury?

    Glad to get some interest in this idea going here.

    cheers Martin
     
  9. Paul Bowles

    Paul Bowles Well-Known Member

    We used to use sclerosing alcohol for plantar HD intradermally as per Dr Gary Dockerys great published work. Also used it for perineural fibromas when I was in public health - was a favourite of the general surgeons if I remember correctly.
     
  10. Mart

    Mart Well-Known Member

    What was theoretical and observed effect in these cases?

    cheers Martin
     
  11. Paul Bowles

    Paul Bowles Well-Known Member

    The plantar lesions some ulcerated, some didnt. Some resolved. Some didn't - the theory behind it from Dockery is that the sub dermal fibrosis is broken down by the injection and the tissue moves more freely transversley reducing sheer stress. Neuromas I am not sure - it is meant to "shrink" the lesion. I would imagine it not only shrunk the lesion but denervated it to a large extent.
     
  12. msdds1

    msdds1 Member

    The doctor used the arthritic nodules ground up and placed into to spaces of the 3 top mets and used an external fixator placed for 3 months. No cast, walked around 5 days later.
    I would think that the question to ask one of the people on the horse hoof studies is what mechanism they think leads to the fusion. I horse hoof similar to bone?
     
  13. msdds1

    msdds1 Member

    If I call one of principals on the studies, I would love to have a list of questions.
    I have my own but it would be helpful if you all as podiatrists would send me the questions you would ask.
     
  14. Mart

    Mart Well-Known Member

    Not a bad idea. I am in France on holiday for a couple of weeks. I first was introduced to the idea of these injections by an equine orthopedist who I am collaborating with on Another project. When I get home I'll have a chat with him and see if he has some ideas about how to Approach a human study. I would anticipate ethical approval will be difficult without being able show evidence that benefits would likely outweigh risks.

    cheers Martin
     
  15. msdds1

    msdds1 Member

    Great. Have a great vacation. I will try to find out some info and will post it when I get it.
     
  16. Mart

    Mart Well-Known Member

    The injections in the horse study were into joint spaces the hoof proper is quite a different and uniquely fascinating anatomy.

    Hiking through the gorges here I was thinking more about the diffences in biomechanics of human TMT vs equine forefoot. Also it from your perspective we should have a look at the condition of your damaged joints because if the joint space is inaccessible to needle then the idea is moot for you at least. Do you have pre and post op digital imaging you could post here or email me personally?

    cheers Martin
     
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