All right. Well, good morning, everyone. I, a beautiful sunny Saturday morning out there.

I, the kids have been banned from my room, so I'm hoping that they don't make any guest appearances. My youngest has got form on that, but that's another completely separate story. .

So today's remit is to give a little bit of an overview on wound management and just to see what's out there on the horizon in terms of research, so that you don't have to go digging out all the papers and just give you a flavour of, what, you know, might be, products or, techniques that you might be using going forwards. And I don't think I have to tell anyone who works in equine practise how important, being familiar with how to approach equine wounds is, because it's a a a critical aspect of, equine primary care. And we know that it's a common cause of emergencies, second most common in one study.

And we know that most of these are trauma, traumatic injuries are sort of wound related. And again, it's not just UK studies. We know that, other international studies, you know, for example, a study in New Zealand, that was wounds for the 3rd most common reason for vets seeing, horses.

I'm thinking a little bit more broadly for those of you who are dealing with working Equis, which, are, you know, a population that I think is so vital and maybe a little bit underrepresented in some of our publications. We know that wound management, traumatic wounds, rubs and sores, etc. Really important in that.

Population and obviously have not only equine welfare issues, but also issues for the owners and, you know, livelihoods. And as you'll know, horses have an amazing propensity to develop all sorts of wounds in some of the most unlikely situations, and can create some, some real challenges for us. And as a vet, we may be dealing with a very acute wound, or we may be dealing with something more chronic that an owner might have started treating themselves or your colleagues may have been treating for a while.

In any, any anatomic location that you can think of. And, obviously, with our training, it's really important that we have a a good knowledge of the possible anatomic structures involved, because that wound may not just involve the skin, but the, the deeper structures that involved may actually be the ones that are potentially more life-threatening. And wounds can be fairly simple to treat in some situations, but other wounds can require quite long-standing, very expensive, treatments, and which can create lots of challenges for owners.

And, I think challenges for us as vets and finances often is something that can really limit what we're able to do. And that initial decision making and what, how we choose to manage a wound is, is really important. I've already mentioned that you might have life-threatening complications, either a need to, stop acute haemorrhage or identify a horse that's got, a potential septic synovial structure, a fracture.

And identifying those wounds were actually surgical repair is optimal. And my mantra when I'm teaching the finding of students is that, you know, wounds around eyes in particular, and, and nostrils, we can do lots of reconstructive techniques with, with lots of other areas, but, the eyelids in particular are just something that we're never able to, to reconstruct properly using other types of skin. So, those, those areas are absolutely critical.

And the principles around surgical management of wounds is covered in in many textbooks and review articles. So I'm not going to run through all of that today. But the main factors for me, when I'm thinking about wounds and horses is economics, I think, becomes the overriding factor, because there's lots of things that we can do, but ultimately, how much money an owner is able to or is willing to spend on a horse is often one of our constraints.

We have to think about function, because that's what we want our horses to do. you know, most of them are not necessarily paddock pets. They've got a role to play.

Horses are not cheap to keep, for, you know, horse owners. And then finally, we think about the, the cosmesis. And for most horses, and we're lucky with our veterinary companions certainly compared to the human field where obviously cosmetic, outcome, particularly in facial areas, is, is really key and has an impact on people's quality of life.

For our hairy aqui friends, cosmesis might not be the primary outcome that's most important. But then if you think about your show horses, actually a cosmetic outcome may be fairly critical for that horse's, ongoing, sort of life and, and use. So there are a few things I was going to pull out from some of the, from some of the research, and I haven't, this isn't going to be a sort of a really structured and include absolutely everything that's in the literature at the moment, but I just pulled out some studies that I thought were useful, sort of, talking points.

And an area that I think is really key, and I think we all know it anyway, but it's, recognising. How important it is, that we, educate our owners, and not just at the time that we're necessarily called out to see a horse, but just in our general interactions with our clients, whether it be through, emails, with newsletters, client evenings, Facebook, and, and Twitter communications. And I think this article, you know, really highlights the fact that, a lot of horse owners are quite keen, I think, maybe more so compared to other, owners, you know, like your small animals.

A lot more horse owners are quite keen to treat vets without the expense and hassle of getting a vet out. But very depressingly, in that paper, you know, wounds and trauma were the most, one of the most common causes of death or euthanasia in those horses. And it's an area that particularly interests me.

We've done some work at the University of Liverpool, looking at sociology and understanding how people and different groups of people think and behave. And just remembering that it's not our patient making decisions about when they need to be seen and whether they think that their wound is healing as it should be. You're relying on the owner, who is the gatekeeper to that horse's treatment.

So, you know, any discussion that, you know, we have around wounds has always got to take into account how we communicate the need to do things, to owners and finding out what buttons we have to press to get different types of horse owners, whether it's the A hobby, horse owner who has very little knowledge about horses right through to the professional horse owner who's had horses for 50 years and, and possibly, considers themselves to know a bit more than vets in, in some situations. So, that's really important. And I, I find it quite depressing, seeing some of the posts on some of the horse owner forums, just about this, sort of, Lay sort of opinions on, on how to treat wounds and lack of veterinary intervention.

I'm not even going to go into the turmeric, arguments, but, all these lotions and potions that owners love concocting that probably do, do more harm than good, but we'll, we'll come back onto that. And this is a study that was done at the University of Nottingham, and I, I would imagine they're in the process of getting this already for publication. But I thought this, again, was a very timely, study, and actually looking at, you know, what the, the sort of the horse owner, this is obviously a UK study.

You know, surprising that, you know, there are a number of horses that aren't vaccinated, in the UK, you know, it's variable as to how many horses are insured, but also that owners don't, you know, get that some wounds actually, even if they're small, might be. Potentially life threatening and some wounds may be really in a status where they're not gonna heal for a very long time because there's something delaying treatments, but the owners don't recognise, you know, the importance of having a veterinary opinion. So, that, that owner education really is, key.

So coming on to a sort of a an evidence-based, approach, and this is an area that I'm really passionate about. My research background is, as an epidemiologist, whilst I'm an equine surgeon, as my sort of my main clinical interest, epidemiology is, something that, I've been, sort of undertaking and epidemiological studies for a number of years. And wound healing is, you know, an area that I think has probably received less attention from an evidence-based veterinary medicine approach compared to some other topics, such as, you know, equine colic.

And I'm sure you'll be familiar with this, pyramid of evidence, and, just this awareness that, the type of studies dictate, you know, what that quality of, of evidence, is, and that when we're making, decisions about how to manage a wound, that we are, using an evidence base, to, to try to justify that. And I think The veterinary profession is a little bit behind in our medical colleagues, when you hear our our medical colleagues discussing about the pros and cons of various treatment options, they have the advantage of a lot more high quality evidence to to go on. But that doesn't mean to say, just because we don't have it there, that we shouldn't just give up on the idea that we can use an evidence-based approach.

So what's new and potentially exciting in the equine wound healing area? Well, I thought this was quite a timely topic, given that in the equine Veterinary Journal, the beaver primary clinical care guidelines have just literally been published. So I'm going to run through these, just to give you an idea of, of, of what they looked at.

And I'm going to need to make sure that I don't forget about my poll questions as well. There will be a poll question coming up shortly. So this was a panel based review of the literature and use of a framework to appraise the evidence out there.

It's a framework that's used in, in the human field to try to develop some evidence-based guidelines on how optimal wound management, should be, you know, potentially conducted in the horse. And there were 3 main areas, that they were asked to focus on based on feedback from equine vets, looking at how we lavage and, you know, what topical treatments we apply to wounds, debriding and closing wounds, and, therapies, that might be, used to aid wound healing. So, my first, I think my first poll question is going to come up if the team are able to to pull that up.

So, I just wanted to get an idea of what you most commonly used to lavage your equine wounds, and I think we were going to give 30 seconds to to run this poll. I'll read those out for you, Deborah, so you know what they what people come back with. So people can vote as Jonathan Pecock was on yesterday was calling people lurkers who would answer the question.

So, let's see if everybody will have a go at it. There is . No wrong answer.

I know some people maybe aren't involved as much in equine but do . Do give it your best shot. To vote So we've got 73% same sterile saline, 7% saying dilute chlorhexidine, and then 20% just lavage it with water, and there's nobody using povidone, iodine or commercial wound cleanser.

OK. All right. That's, that's really interesting, and I guess that is what I would, generally expect.

So, listen to these, these guidelines that have come up. So one of the first questions was, is tap water as effective as saline for flushing, wounds and horses? And, oh, I don't know why it's .

Yeah. So, there were actually no veterinary studies looking at this, so they had to go into the into the human literature. And some of you may be aware of some of these studies from the human literature.

But actually, there is no evidence that sterile saline is any better than than clean tap, you know, sort of drinking quality tap water, and then the absence of cleaner drink. Standard tap water, use of cooled boiled water or distilled water would be, a, a, a better option than sterile saline, which I think is really interesting, because I think a lot of people have been taught over the years to use sterile saline. But actually, there isn't actually any evidence about that.

And obviously, a bag of saline, you know, does tot up to the the costs for for treatments. And then looking at use of antiseptic solutions, to reduce the rate of wound infection. And again, you'll notice a sort of common theme from here, and we'll come back onto this, and there were no sort of veterinary studies identified that were of a high enough level to be considered, and there was actually very limited evidence from the human studies.

But there was some limited evidence that, dilute povidone iodine, had some benefits, compared to, not, lavaging with a povi iodine solution for contaminated wounds. So I thought that was, that was quite interesting. And I think from a, an equine point of view, I think it is an area that we do need to do, some, some more work on.

But we'll, we'll come back on, onto that. And then looking at antiseptic and best concentration for primary wound lavage again, something that we, you know, really hammer home to the students and trying to avoid, use of any, lavage solutions that might be cytotoxic. And again, no veterinary studies, that were sufficient quality to be considered.

But in human patients, there were, fewer surgical site infections, when, patients had had wounds irrigated with antibacterial solutions, versus those not having antibacterial solutions. But they were, they surprising, there was no evidence on the optimal concentrations on antiseptics for, for wound lavage. So again, you know, an area that does need a lot more study, but I think, again, the principles of lavage, I was always taught that dilution is the solution to pollution, and I think that probably holds true that actually getting rid of as much debris, including organic matter, soil, hair, etc.

From the wound is probably the most important thing in reducing that bacterial load. And obviously, thinking about antimicrobials and this is an area that I'm sure there have been other other talks in this area given. Via webinar bets, but, being very aware of our duty to reduce, antimicrobial, usage, looking at whether, topical, antimicrobials reduce the rate of wound infection compared to systemic antimicrobials.

And again, a, a real lack of, suitable quality, veterinary studies. Some moderate evidence from the human literature that topical silver sulfurizing reduces microbial loads, but again, a little bit of a sort of a caveat there that, silver can have some detrimental effects and wounds in the jury in, in human sort of form was a little bit out on that. But again, it just highlights that we really don't have the answers to all these questions through, proper, properly conducted studies.

Lavage pressure, again, no veterinary studies, but, in human studies, the 13 pounds per square inch is one of my favourite student questions asking what PSI stands for. And, that was found to be the optimal one, which when you think about what we're generally, using, with a 35 or 60 mil syringe and an 18 or 19 gauge needle, those are generally the, the pressures that that we're using. So, it's interesting just to, to see the human studies that have, demonstrated that and and know that we're, we're kind of at the right sort of ballpark for, for doing that.

So then they asked about, you know, a variety of different things and whether they, you know, improve, healing, rates and outcomes. So these ones are, are listed here. So for debridement, there was some evidence, again from the human fields that these debridement pads, debrief soft can be quite useful.

There was no clear evidence about use of chemical agents for wound debridement. And again, quite limited evidence again, from the human field, there are some veterinary studies, but again, looking at very specific aspects of wound healing. So things like the versagettes, 2 is the, current model, are certainly things to consider for highly contaminated wounds, but again, the evidence, base out there is quite limited.

And maggot therapy again, very limited evidence within the veterinary fields, but certainly is something to consider for necrotic hoof defects and some deep-seated abscesses that can't, can't really be treated by any other means. And looking at wound closure, again, no evidence about sutures or staples, no clear evidence. There was some contradictory findings in equine studies about those closure methods on surgical site infections and wound complications.

And as you know, that's often dictated by, the, the location, and whilst staples are faster to apply, that they're not suitable for, areas under, under high tension. And then methods to enhance wound healing that they looked at. They looked at manuka honey and found evidence that it does improve and speed of healing.

We'll come back onto Manuka, honey. But there's, that there was insufficient evidence about use of, light, sort of laser therapy or therapeutic, ultrasounds, which again, is quite interesting, given that, they're quite heavily marketed for, for use in, in non-healing wounds. So that's just a very sort of quick summary of, of those guidelines.

And I think that, you know, if you're interested in wound healing, they're certainly worth reading. And it is, it's clear that obviously we need to do more sort of well conducted field studies in, in equine wound healing, and I think you know, something that is really important for us to do over the next few years is develop ways in which, vets, within first opinion practise can, participate, more easily in those kind of studies. Because what I'm going to show you next is, obviously, the more sort of research, side of things, which uses, wound healing models, which are another sort of, challenge.

But they're different to what, you know, the wounds that we're seeing in the real life situation, which is so variable. And that's why, these studies haven't been conducted. It's not that people aren't interested in it, it's just the complexities of comparing, ponies and horses and a wound on a distal limb compared to a, a thorax.

And obviously, every individual wound is different in terms of how long it's been there, how it's been sustained. Comorbidities. So, it is a challenging area, but that isn't to say that we shouldn't be be doing it.

And I think it would be great to have, first opinion vet's really geared up to help assist generating this evidence. So, in terms of achieving optimal outcomes, I think what we generally aim to do is get first intention healing. And you, as you can see with the the nostril wound here, you know, it's critical to get good anatomic position.

This is not suitable for second intention healing, and is going to heal quite nice and quickly. But obviously, if we've got, loss of tissue, particularly over an area of of movement, or, this is a, a horse out in the Gambia that had fallen onto a fire, sustaining a nasty burn injury. You just may not have the ability to get first intention healing and you're going to have to rely on second intention healing.

And these, I think for vets in practise and vets in referral centres as well can be incredibly frustrating and expensive to deal with. And I think the expense and the economic limitations that as vets, we have to deal with compared to our human medical counterparts does make wound healing incredibly, frustrating for everyone involved. So, is there anything we can do to assist second intention wound healing in our equine patients?

So, again, I'm just gonna present a series of studies, and I'm not going to go into a huge amount of depth with these, if you're interested in particular aspects of this, a lot of the papers actually are open access, so you can, you can go and have a read of them. But it's all about thinking about things that we can do to, to, to speed, wound healing and get that wound to heal as quickly as possible and remove those factors that might be delaying it. And we know from, research, previously conducted and ongoing research that the bacterial load within a wound are really, really critical.

And that this, a propensity for bacteria, particularly bacteria like pseudomonas, to form these biofilms that prevent, sort of effective penetration by systemic antimicrobials are really, really important. So thinking about that, that wound environment and how we can, minimise that bacterial load, from those bacteria that really do delay, wound healing is, is really important. So, some recent studies I've just pulled out, some that were done in the last few years, looked at, you know, how we can sort of get a better handle on how much of a bacterial load.

And this is a classic example of a wound that's got a biofilm. This is a slimy, quite smelly wound that, quite, you know, clearly is likely to have a significant load of bacteria. But, are we, you know, able to sort of get a handle on, how much, a load is there?

And I'd strongly, you know, if you're not, a vet who doesn't use, bacteriology and culture and sensitivity testing in your, equine wounds, I think it is something that is really, important to get a handle on, on what's going on in there. So this was a study that was conducted just to look at, you know, how best you can judge a bacterial load going on in a wound. And the bottom line is that you don't need to take a biopsy, which is more invasive, that you can, take a swab and get an idea of, the sort of the quantitative, you know, load of bacteria.

In a wound, and, that actually it was quite difficult to clinically, just grossly assessing wounds, actually, get a good idea of, you know, how, yeah, many sort of bacteria species and, and how intense that load was, was very difficult to determine. And I, I put this slide up. This is a different study that was published in fairly recently, looking at, thinking about what's going on at a cellular and and molecular level and stepping back from this, sort of looking at it with our own eyes and just thinking what is actually going on at a cellular level in those wounds.

And this study was looking at patterns of, differences in wound healing between limbs and thorax, which we know are different, and in response to bacterial inoculation with Staph aureus and and Pseudomonas. And, they showed that obviously, the, the healing of distal limbs was less, was slower and was less organised, which we, we know from previous studies already. And that there were similarities in, the expression of, different factors such as, interleukin 1 beta, IL 6, MP9.

And, importantly, they identified that this, cellular communication network factor, CCN1, might be something that requires further investigation. So, obviously, we still, we, we've got a, a, a better handle on what's going on at a cellular level, but there are lots of things that we still don't know about horse wounds. And again, the more we understand about optimising healing in in horse wounds, the more it gives us an idea of therapeutic strategies to, to assist that.

And I thought this was a really interesting study again, this is one that's been published relatively recently. Just looking at, the microbiome of, of wounds. And I'm sure you've heard quite a lot about the microbiome.

It's something that in the human research fields, at the gut microbiota, for example, is, something that's been shown. It's been really interesting in people because it doesn't just affect your gut function, it can have effects on, neurological function, immune system and function. But I think it's, really interesting seeing how, you know, the improvements in, next generation, sequencing can be used to look at back normal bacteria in so many different situations.

So this study, looked at, some, created sort of standardised, wounds. These were full thickness wounds, either in the distal extremity. Of the, forelimbs or the thorax, and they looked at differences, on horses, whether they were bandaged or not as well, and looking at the bacterial, composition.

So, the interesting thing was that the normal skin microbiota is actually quite similar, between horses, which may not, come as a, you know, complete, surprise. But, again, it's quite interesting to see that, you know, Fusa bacterium and actinnobacillus were, more common, particularly in the limb wounds compared to the thoracic wounds, and the impact that bandaging had on that, skin microbiome. And they they saw some quite predictable changes in patterns of how the bacteria changed, and particularly as wound healing, progressed.

And this sort of thought that those normal bacteria that should be in, in the skin actually might be key to assisting, wound healing. And what we're really wanting to avoid is those, more, nasty sort of bacterial species, for example, Eseudomonas becoming the predominant population. So I think this is really interesting and again may help us better understand the effects of some of the therapies that we can use to try and improve wound healing.

And sort of stepping onto that, when you're thinking about bacteria, good and bad bacteria, you'll hear all the TV adverts on use of probiotics, you know, good gut bacteria. And I thought this was a, a really interesting study. This was one that was Jacintha Wilming did.

It was a randomised, single blinded multi-enter study that and they looked at use of a commercial topical pro probiotic that had a variety of three sort of main bacterial species to Lactobacillus ones and one biidobacterium species. And they looked at this in wound healing. These were sort of traumatic wounds seen in the general equine population.

And I thought this was quite interesting because it did show that the probiotic treated wounds did have a quicker reduction and halving of the wound surface area compared to untreated wounds. And importantly, they also looked at the safety aspects and looked at systemic effects, like, for example, increases in serum amyloid A, of which there were none. So, I think again, you know, those may be things that we start to see being used a little bit more and manipulating that, microbiome more in a topical way rather than, relying on, systemic antimicrobials.

And coming onto antimicrobial use, I think the veterinary profession has recognised the importance of us being really careful about our choice of bacteria and really thinking about antimicrobial resistance, which obviously from a global perspective is one of the key challenges that we face together with. Pandemics, as we know all too well, and a variety and, and climate change, but antimicrobial resistance is, is one of the big ones on that list. So we do have a responsibility to consider how we're using antimicrobials.

And I think from my experience of dealing with with wounds, I think that antimicrobials are overused, particularly systemic ones, and particularly in wounds healing by second intention. And in the human fields, this is an area that's been looked at and this is a sort of a consensus statement that was put out by medics involved in wound healing, just about, you know, proper use of antimicrobials. Obviously, we've got the Protect me guidelines, but I think, it's a, a particular emphasis on these, granulating wounds and horses on very, very long, antimicrobial, therapies that probably, have minimal effects, and we should, really think about whether those antimicrobials are justified and whether we need to be doing something different with that wound.

So thinking, you know, away from systemic use of antimicrobials might think of more regional use, and this was a study that was performed relatively recently, that looked at intravenous regional profusion with Amicain and actually demonstrated that it had no effect on the Staph aureus, sort of model of, of wound healing. So, you know, we, we really need to be, sort of coming away from that, sort of throwing antimicrobials that, wounds that are slow to heal, and really, thinking about other, other strategies, that may be more effective in, controlling that, that, bio burden on that wound. So I'm gonna come into some of the more pure sort of research wound studies now, and I'm I'm only gonna cover them sort of briefly just to give you a taster of some of the things that are probably, you know, being looked at most at the moment.

And I think one good thing is that the horse is actually a really good model for human research. And whenever you have a model like that, that usually means that there's money there because in the human healthcare field. Wound healing is a massive industry.

I've just cited some of the, the costs that have come out, some of the private, US, health providers. And there's a huge amount of money spent on, on wound healing and then the effects that, wounds, have, on, on people. So, horse wound models, do have benefits, and not only for human health, and obviously the money that we may be able to get to conduct these studies, but also, obviously, then benefits are, equine patients.

Manuka honey, that's my next poll question. So if you could bring that one up for me. So, the question was, do you use honey routinely in your equine wound management?

So we've got a choice between no. Yes, but you only use medical grade manuka honey. Yes, you use manuka honey only, but you're not sure if it's medical grade or not.

Or yes, you use any type, including non-medical grade honey. And if you use, if you maybe use multiple things, maybe choose the one that you use most frequently. So I'll give you time to get your answers in.

So people are voting away at the moment, so there's 36% who say they don't use honey. 21% who use medical grade, 14% saying they're not sure, but you know they use for honey. And then 29% saying use any type including non-medical grade honey.

So it's a bit of a split there I suppose if you say manuka honey altogether is 35%, no is 36%, and yes, anything basically is 29%. Yeah, so, yeah, so I think honey, is, I'll just I'll just I'll get you to close that. And so I think honey is a really interesting area and it's, it's encouraging, and I think it's that reflects that honey has come much more into the fore in equine wound healing.

And, so it's, I'm sure you know that manuka honey, there's a manuka tree, which is produced by, and it has, this, antibacterial property that provides this unique manuka factor, and the more sort of of that UMF factor, the higher rated it is. So this is an example of a study that looked at, Manuka honey that was UMF 20, which contains obviously more of the manuka factor versus 1 of 5, which is a sort of a lower strength. These, the higher the the manuka the UMF level, the more expensive, it's always the way, the more expensive these are.

So it's that sort of balance between cost and and benefits. But this was a a wound healing. The one, the study on the left that looked at some wounds and the manuka honey of UMF 20 healed quicker and better than either the the food grades, honey or the UMF 5.

But, you know, the differences were not, you know, really much, and it's sort of thinking of that, you know, these, sort of studies that show a significant difference or not, and sort of weighing up that sort of, you know, how clinically relevant is that, that difference and what's the cost benefits of it. So, certainly, there is really good evidence out there that Manuka honey, does, aid wound healing in certain stages of wound healing. And I thought this is a, a study, oh, sorry, that's only just been published.

I'll come back onto my side, that's only just been published in equine Veterinary Journal, but looked at use of honey, just over the top of the linear alba prior to closing the absocutaneous tissues and skin in horse laparotomies and showing that it was protective against surgical site infections. So, I think honey is a really, interesting, product, and it's good to see that, you know, bats out there are are using it and obviously it's been used since Egyptian, times, as well. OK.

So, I was just going to look at some other therapies that that might be used. So, I've already mentioned about light therapy, and again, the evidence in the literature is sort of quite sort of poor and quite mixed, but this is a relatively recently published study that demonstrated that it had no Difference on healing. And actually, the light treated wounds did actually have slower healing, which I think is really interesting.

So, again, you know, you see owners, and particularly the professional horse owners, you know, wanting their their laser machines for wound healing, but actually the scientific evidence to support it's actually not really there. Negative pressure wound therapy devices, there've been a few case reports out there over the years, and, and they do have benefits, obviously, in taking away some of that, sort of fluid that accumulates obviously creates opportunities for bacterial multiplication. But again, I don't think we're quite there with using these for aids, and this study demonstrated that whilst, you know, it was a, a, a useful, product to try to use, there are still problems with, particularly adhesiveness, getting these to stick on our, our, hairy horses, which is very different, obviously, to human skill, skin, sorry, and, sort of flexibility of these devices and how well horses tolerate them.

And again, cost with these is sometimes an issue, but I'm aware that there are some options for renting some of these devices. So it may be an option that more of us are able to use in a more cost effective way, but I don't think we're quite there with the systems, at the moment. Just gonna mention gallium.

This is a study that looked at gallium in in wound healing. It's a sort of a semi metallic, sort of product. It's, it's got antimicrobial, effects.

And this was used in the model of, of wound healing, in the horse, and it did show, reduced healing times, reduced fire burden with Staphylococcus aureus, reduced formation of excessive granulation tissue, and improved, sort of the histology scores and things like increased TGF beta. So, again, this was looking at a sort of a commercial product, and I think it's, it's really good to see that, you know, that there is some testing. I think it's really important to show, show that there has been some evidence of efficacy before these products just get blindly marketed.

Out there. So that is something that we may see a bit more, and again, good to see, you know, a sort of a, a non, sort of a topical therapy with, you know, an option to reduce, you know, you know, have an antimicrobial effect rather than using systemic antibiotics. It's interesting that, cannabis related products seem to get in there and I do sort of see, these products being sort of used a bit randomly for any, you know, anything seems to go, but again, it's important that, you know, these studies are actually tested.

So this was, a honey, a sort of, based study that looked at, a kind of bidiol, I can never say it, act, agent being added to it, and actually they didn't show, any, positive, you know, sort of beneficial effects, but they did feel that it warranted, further study. So I think, you know, when these sort of things, these new exciting products come out, you know, there there is a lot of use of these without proper testing and certainly at the moment, there's a bit of a lack of evidence about their use in wound healing. And I'm not gonna spend too much time on this, but, you know, we're all aware of stem cell therapies, you know, being used for, for lots of different areas and wound healing wouldn't be an exception to that.

And again, I think it's an area that we're only really just starting to really understand, you know, the sort of the cellular mechanisms. And, you know, it's an area that I think we're gonna see, more research coming out in. But, you know, there's still quite a lot of work to do there to show, you know, the, the true benefits and in a practical situation.

And I think, you know, this is the sort of the holy grail of wound healing is trying to get them to, to heal faster and all these lotions and potions and expensive therapies. But we also have to remember that wounds can only epithelialize at a maximum rate. And thinking about the cost benefits and these, you know, quite sometimes quite expensive products or devices.

But actually, if that wound isn't healing, is there another, you know, more sort of basic fundamental reason why? So this horse pictured has got an excessive granulation tissue and clefting, which would be one of the characteristic signs of a sequetrum. So until this sequetrum has been removed, this wound is going to be in a perpetual state of chronic ongoing inflammation.

And obviously thinking of factors such as movements and infection, etc. So I suppose it was just whilst for companies, it's great that they can make money out of, you know, having all these fancy products, but actually, when we're already in a situation where also only have a finite limit on how much they want to or are able to spend on wound healing, then we have to really think about, you know, the cost benefits of these products, and actually, you know, not neglect the fact that we need to think about other ways to speed healing. And surge, you know, the surgical option, I think horse donor always perceive surgical management as more expensive option.

But the minute you start, you know, reaching out for the bandaging materials for that, you know, double layer band limb bandage and a horse, you know, automatically, the costs start mounting, especially if you're performing, you know, a bandage changes every, you know, 3 days. And actually, you know, having that discussion with an owner at an early, early stage before they've spent 9 months having a limb, repeatedly bandaged and invariably the horse sedated, because they've got sick and tired of their wounds being fiddled with, and they've been on box rest. That actually, you know, surgical wound reconstruction and grafting might be the more economic and result in better quality healing.

And I, I thought this, this is slightly, slightly off topic, with the, what we're talking about. We're not talking about hip replacements, but I think it's sort of just, resonated with me in that we always, the key thing that we're trying to get is something perfect. You realise the skin.

How perfect it is and trying to replace it with something else. You never get something that's quite perfect. But, skin grafting can result in something that maybe isn't absolutely perfect and cosmetically doesn't look absolutely the same, but it's actually very high quality and high functioning.

So something to consider. So, wound construction can be performed at the time of injury or as a delayed thing. And I've just put in an example, this, typically, it's always a show horse, isn't it?

But typically, this was a horse that presented to me, and this was the wound as, not long after it happened, actually, it was right down to the, right down to the periosteum, and, it was a, a hind limb, and had this sort of flap of skin that had concertinaed back, and actually this flap of skin was a saving grace. And this, I'm not going to show you all the photos in between, but this was the wound by the time we'd surgically reconstructed it a number of weeks later, when the owner had already realised that she was going to run out of money by bandaging it, you know, and going down that route. But we were able to get, well, the horse went back to the showroom, we were able to get a very, very nice, wound reconstruction, which wouldn't have been achieved, by allowing it to heal by second intention and also would have been much more expensive and taken much longer.

So don't, you know, do consider the surgical options, and I think it's really important to spell it out to horse owners that it might actually be the cheaper option of the two, and might be the better quality, end results. And you can, even if a wound is a few weeks down the line, you can still in in some ways, it's sometimes better because you can get a hold on the bacterial infection if the wound's been grossly contaminated at the time. And just a little word about skin flaps, unless they're obviously necrotic, those skin flaps can be an absolute godsend.

So before you reach out for that scalpel blade to chop away a skin flap, think twice. Because without this skin, this skin flap, which you can't really see properly, but that could Be extended all the way across the wound, even several weeks later, there are various techniques you can use to, to, you know, use that skin, but that skin was absolutely precious and allowed us to get a really good outcome. So I'm just gonna briefly mention skin grafting, and I think that was one of my final poll questions if we're able to bring that up.

So, how many of you would feel confident performing pinch or punch skin grafting? So you've got a choice of no, you wouldn't be prepared to try. No, but you'd like to learn more about how to do it.

Yes, you've never done it, but you'd like to give it, you'd give it a go, and yes, you would perform it routinely. I'll just give you a little bit of time to to do that. Yeah, we've got Nobody not willing to try, so that's, that's good.

Just allowing people to vote for another couple of seconds. Nobody's performing it routinely. Deborah, so we've got no, but I would like to learn more about how to do it.

Yes, never done it, but we'd give it a go. It's 54% and no, but I'd like to learn more is 46%. So it's really split between those two.

It's a sort of Brexit result, 446. So, yeah, so, pinch and punch graphs are easy to perform in in field situations. It doesn't take much in the way of equipment, and, maybe, maybe that's a topic, maybe for a future, webinar, a real practical how to.

But, you know, it's described in some textbooks. But I think there are some key tips and and tricks. One thing to say, it doesn't get absolutely Perfect healing.

I'd say this is the extreme, that, most of them would heal a little bit sort of better with this. The owner actually loved this because she thought her horse was very unique in having tufty hairs, but you don't necessarily get the the most cosmetic outcome, but it definitely speeds healing, and it is, I would strongly encourage as a new graduate, I had, I'd never seen it being done. And I can think of several cases that I would have saved, owners and horses and myself a lot of time and tears, trying to get wounds to heal if I'd actually, tried that.

So, just to finish off, this is a little bit more advanced, but just so you're aware of some of the things that we've got, wound reconstruction, if you've got enough skin. You've got the techniques for pinch and punch grafting in the fields, slightly more advanced here, but, full thickness skin grafting is something that is fairly, easy to do and could be done in the standing patient. The key thing is making sure that you've got, wherever you're placing the graft is ready to take a graft and that the graft doesn't, fail.

But, this paper very nicely describes, the technique and, and various applications of it. And meek micrografting, just to finish off, this was a case, that I dealt with, that will, meat can be done quite easily, in a standing patient. It's just having the, equipment, but you don't need the full, meat kit to be able to do this.

But this was a horse who'd sustained a wound to the metatarsis that the owner didn't want to go down the route of doing anything with, because she thought it was going to be too expensive and wanted to trim and ended up sort of starting to treat it themselves. But they soon realised that this wound was really going nowhere. And these are not taken that far apart.

This is just a matter of a couple of weeks apart and just showing the effect that bandaging, appropriate, topical, medications and antimicrobial dressings, can have, we didn't have this source on any systemic antimicrobials, but this is ready for grafting. Jacintha Wilming actually, gave us a hand doing this. She's the person who's really driven, this technique and, knows more about it than anyone else.

But this was, us performing the, the skin grafting, these are the grafts, a few days down the the road. And this is once the, the horse had actually gone home and the, the sight is, this is just, you can see the bits of hair. And actually, now you can, you can notice that there's a slight difference in the colour of the skin, but it's head and it, it's regular and it looks absolutely beautiful and a delighted owner.

And this cost far less than leaving this horse to heal by second intention and got a much better cosmetic effect. So, just so you know that those things are out there. All right, so just to sort of type up I've sort of gone through a variety of things, in this talk, which I hope give you some things to think about.

It is really important before you start treating that equine wound to think about what's the evidence, particularly with the novel therapies, which are not without their expense and thinking about the cost benefit. And I think it is really important that we keep wound care affordable for horse owners, otherwise, we're just gonna price ourselves at the market and actually make the situation even worse and owners aren't going to seek our help. It's really important that we do reduce our use of systemic antimicrobials, particularly with these wounds healing by second intention.

And, you should be thinking about sort of topical antimicrobial agents and, and dressings. We do need more veterinary studies, and I think these should include not just the experimental ones, which obviously have their limitations and obviously from a general public point of view, you know, we have to think about, you know, experimental models and the challenges that provides. And I think it is really important that vets in the field, understand that they can play a really, key role in generating that evidence and that you can do field studies.

And thinking about owner education, and not just at the time that the horse has developed that wound, but thinking about it beforehand, and, that it's appropriate, wound management, and they understand, you know, what a difference we can make and that that turmeric isn't everything. And finally, that, again, sort of, I think vets in practise, to a degree, and certainly horse owners have the perception that sending a wound off for surgical reconstruction or advanced grafting can be expensive, but actually it can be a much more cost effective time saving, saving alternative that actually results in a much, much better outcome for the owner and the horse. So thank you very much and I'm very happy to take any questions.