Lovely. Thank you, Safia. Welcome, everyone.

I hope you can hear me well and you're not going to struggle too much with my French Quebecois accent. And so let's make a start. So for tonight, well, Sofia has always done the quick introduction, so we just passed, we'll go through our learning objectives and then do quick.

View of the equine stifle and meniscus anatomy, which will be clinically applied. Update on equine stifle diagnostics. Update on equine meniscal tears, update on equine typho pathologies, and then and with a small section on meniscular disease and its relation to osteoarthritis, which was the main subject of my master's.

So introduction shall we just passed. Yes, so I am a professor at the University of Nottingham. I do lecture there to students of every year, but my main work is based at Oakton Veterinary Hospital, in the Midlands.

So going into the learning objectives quickly, at the end of this webinar, you should be familiar with clinically relevant stifle anatomy, including soft tissue emesis to be proficient in selecting diagnostic analgesic techniques as it pertains to this title. Joint and synovial communications to be proficient at choosing appropriate radiographic views to diagnose particular type of joint or soft tissue conditions, to be familiar with the diagnostic modalities is useful for equine type of disease and their limitations. And finally, to be familiar with the diagnostic modality is useful, particularly for meniscular injury and horses, as well as their limitations.

So a quick review of the stifle and the horse and also meniscus anatomy. Menisci are semicircular fibrocartilaginous structures that are located between the femur and the tibia and the sky joints. Obviously the femur is a very rounded structure, and the tibia is very flat.

So menisci are there to increase the congruency between the femoral condyle and the flattered tibial plateau. They also decrease the friction between the two bones, and they contribute to even distribution of loads across the joint. The minuscule ultrastructure has been extensively studied in other species, for example, in bovine, human, rabbits, and even in dogs, but it's not really been well looked at in horses yet.

This picture here on the bottom left. Is a picture from a couple of years ago already from a human minister. So you can see really quickly that the organisation of the fibres is very complex and it's very much related to the biomechanical role of them in the sky and the joint.

Human meniscal are composed of 70 to 75% water, about 22% collagen, and less than 1% of different glycose aminoglycans. As I said before, the collagen fibre organisation is very complex and it reflects the difference. Functions of the meniscus.

For example, we know that in the inner portion of the meniscus, the meniscus sustained compressive forces in the axle aspect and tensile forces more on the outer region around here. Now I wanted to go through anatomy quickly, but I wanted it to be a little bit applied so we can all remember a little bit some of the things because it's always a little bit tedious for everyone to review anatomy, even for myself with the job that I do. So if you have a recent paper to go to to View the really, really good anatomy that is clinically applied.

This is a really good publication that's recent from EVG in 2017 that came out of Colorado State University. It's a radiographic localization study that looked at the emphasis in the equine stifle. They looked at all of the structures that are written down here on the slides.

So cranial and coar cruciate ligaments, medial and lateral collateral ligaments, long and lateral digital extent tendons, patellar ligaments, meniscus to the ligaments, and others. We will go through these, and we'll use this paper really with the pictures to go through the relevant anatomy of the cipher joint. So if we start with the cranial cruciate ligament, we know that the origin as a reminder of the cranial cruciate ligament is the caolateral aspect of the intercondylar fossa of the femur, and the insertion is down here where you have the arrowhead on the medial intercondylar eminence of the tibia.

Clinically speaking, the two most useful reographic projections that you want are the coocranial or coop proximal cranial distal oblique view, which is the view here on the left, and you also have your coomed or cranio lateral oblique view, which is represented on the right. Now looking at the caudal cruciate ligament, slightly different, and the origin is from the cranium medial aspect of the interconylar fossa of the femur. The insertion is located on the coomedl border of the media condyle of the tibia, which is again represented by the arrowheads.

For the caudal cruciate ligament, the two most useful radiographic projections with the lateral medial and the other oblique, which is the caolateral cranio media obligia. Looking at the medial collateral ligament, quite simple, the origin and the medial femoral epicondyle represented by the arrow here on the lateraledal view. And it then sets on the media proximal aspect of the tibia and also is related to some theory articular region of the condyle and the epiphysis.

So this is only to say that your insertion of the middle collateral ligaments sometimes it surprises people. It's quite long. It's not really focused on one point.

It's quite a long insertion. The two most useful views to identify problems of the medial collateral ligament would be lateral medial projection and then once again, you called the cranial, so coop proximal cranial distal oblicul. And once again we can see that the insertion is much longer than the origin of that specific ligament.

For people who don't know as well, the medial collateral ligament and the horse, which is different than in humans, is actually attached to, the medial meniscus, and it's attached to the body of the the medial meniscus, which is not the same, for the lateral compartment. Speaking of the lateral collateral ligament, the origin of that ligament is the lateral femoral epicondyle, and it inserts on the head of the fibula, again, an insertion that is rather long and it extends distally almost until the junction with the diaphysis of the fibula. Two most useful views later remedial and caudal proximal cranial distal oblique views.

Looking into the long digital extensor tendon now and origin at the extensor fossa of the lateral condyle of the femur, then starts out the extensor process of the 3 phalanx. So on these radiographs here, only the origin is highlighted. You can see it very well on the lateral meal projection.

And but even better on a quadrilateral cranioidal oblique view. And careful sometimes when you look at a lateraled view and there is a little bit oblique, it does happen that we have superposition of That fossa onto the lateral trochlear region. Sometimes it can be confusing, for example, a little irregularity that could be consistent with some OCD, which actually is not the case.

It's only the obliquity of the projection that is a little bit tricky. Lateral digital extensive tendon origin on the proximal tibia fibula and also in part with the lateral collateral ligament, and inserts much more distally on the limb on the lung. Extending most useful views to the proximal cranial distal oblique view like on the left here and on the right coomid cranial lateral oblique views where you can also see the origin.

Now the patellar ligaments, we remember that in horses there are 3 patellar ligaments, which is the same as in the cattle and very different than in humans and in dogs, which they have only 1 patellar ligament. So if we start with the lateral patellar ligament origin, quite simple on the lateral surface of the patella, insert most of the most cranial and lateral border of the tibial tuberosity. You can see it best on the lateral immediately.

The lateral medial view actually is the best view for imaging all of the patellar ligaments, so that's quite easy to remember. For the middle patellar ligament, the origin is the cranial aspect of the patella, and it inserts in the groove between the most lateral and medial margins of the tibi velocity. The middle patellar ligament insertion is the one that is the most distal of all of the three patellar ligaments here we can see in the picture.

And finally, the medial patellar ligament origins from the medial aspect or surface of the patella. It is the most proximal origin of all three patellar ligaments and the cells on the medial border of the tibial tuberosity. Once again, lateraledl is your best friend's view if you are interested in imaging and the origin and insertions of the patellar ligament in horses.

Now looking into the menisci, if we start with the lateral meniscus itself and remember that a little something special about the lateral meniscus is there is a meniscal femoral ligament that is located caudally and a little something special as well. The insertion of that ligament is superimposed onto the cranial cruciate ligament. So you definitely will need a coocranial projection to differentiate.

It's all very well explained in the paper and here it's much easier to see. For example, this is your insertion of the meniscal femoral ligament on the arrowhead, you have the causal, . Meniscus of the ligament of the lateral meniscus and the double arrowhead, the cranial meniscus of the ligament of the lateral meniscus.

So origin of the lateral meniscus, it's the origin basically as the cranial meniscus of the ligament. On the lateral aspect of the intercondylar eminence of the tibia, and then the insertion is on the caudal aspect of the tibia caudal medially. The two best views to have a look at the insertion and the origin of the lateral meniscus are the lateral meal and the coocra.

This is only to image the difference between the projections on the picture that I've just added at the minute now is the original picture that I showed before from the cranial cruise ship. So if we thought, for example, here, that is a little bit confusing between. The insertion of the meniscal femoral ligament and then we said when we do the coocranial, it's easy to differentiate.

So on the right side here will be your meniscal femoral ligament and on, if we come back to the left side, this is your cranial cruciate attachment right there. Medial meniscus, which will be, and as you'll see later, it usually is the most relevant in horses origin, medial aspect of the intercondylar eminence of the tibia over there and the insertion on the caudal aspect of the intercondylar eminence of the tibia again, same views lateraledial and coocranial, and we can highlight really well both of these structures and again. And the attachment of the meniscus onto the tibia is provided by a cranial and a caudal meniscusidal ligament, medial and lateral, obviously if they belong to the media or the lateral meniscus.

I want to show here this is a transverse view just for a little reminder and so obviously on this side the medial meniscus to the right and the lateral meniscus to the left with the little stars or image, the cranial meniscus to the ligament, medial and lateral. The small triangles, the caudal meniscus to the ligaments, and the difference here with the black dot is the meniscal femoral ligament, which I would say is only a part of the lateral meniscus, not the nasal meniscus. No.

Update on equine's stifle diagnostics. The accurate diagnostic of meuscule and stifle pathology in general is known to be very challenging. We know that the MRI is the current gold standard diagnostic modality for diagnosis of meniscular disease in men, but it's only still possible only in a few.

Centres worldwide, even now in 2019, and arthroscopy is often used together with ultrasound, but both of these modalities only allow visualisation of about 20 or 30% of the aqua menisci and are therefore inherently limited. Altrainography, however, has the advantage of being minimally invasive. Because of these limitations, our capacity to diagnose lesions of the equal meniscus and the stifle in general are still limited.

Rasiographs and ultrasonography usually are the go to modalities for the majority of the practitioners, as they are more widely available. And this publication here, which is quite recent, it's only to help people understand a little reminder about how to take a good, code of proximal cranial and distal oblique view. This is just, a publication that was looking at different angles to try and image best the width of the femoral joint space in the horse, and they have identified that the best.

The angle is usually about 10 degrees and proximal distal, so coal proximal to distal for the angulation. This will give you the best evaluation of your medial compartment, which usually will be the site of injury or disease in the horse, not exclusively, but most often, as we will see a little bit later on in the presentation. Speaking of ultrasound and very, very interesting publication from EVE from 2017, it came out of the centerer in France.

It's publication on the ultrasound. Diagnostic of cranial meniscus, the ligament injury in the medial meniscus, which is an injury that is seen a lot in spoiled horses. They were looking at the mopathy, antiopathy, and also synovial cysts that are all located in the cranial meniscus of the ligaments.

So if you look here on the picture, number 4 is the cranial cruciate. Number 2 is the crass, the lateral meniscus, the ligament, sorry, and the right side here. Number 3 is the major cranium meniscus of the ligament.

So this is again a good picture with a little. Line here that is oftentimes see as natural labour in this specimen, which is interesting in that paper. They have opened a couple of stifle and they did find out that this was actually a pathology.

So it's a very, very interesting, publication. They also describe really well the positioning, so it's an ultrasound examination that is done obviously standing under sedation. We need the stifle to be flexed and we need to hold the probe.

In the transverse position on the top image here on the right side you can see number 1 is the mindset, so the intercondylar eminence of the scia. Number 3 here is your attachment to cranial meniscus to the ligament, medial, and then the 2 here is your cranial horn of the medial meniscus. So this should be your normal.

Image. And when we look at the mopathy test, for example, there's a couple of things to note. Number one is very irregular, at the level of the bone and the insertion of the ligament onto the bone.

Now, the fibres of the cranial meniscus of the ligaments are nonexistent or very disrupted. There is a lot of fibrosis. Around the area and there's also a lot of thickening also around the ligaments.

So plenty of good pictures if you're interested and you want to know more about ultrasound of the cranial meniscus. It's only on the middle one, but it's very interesting for images, and it's not very difficult once you've done a couple and to have a good picture if you have a cooperative patient, obviously. Diagnostic analgesia is also employed by many veterinary surgeons to locate the origin of laminus that would be coming from the stifle.

The latest data in the literature, there's been many studies about communication between all of the three compartments, and we remember that in the stifle joint and the horse there are 3 main compartments the femoral patellar joint or compartment, the medial femoral joint, and the lateral femoraltibial joint. So the most recent data, which is from that publication here in 2017, American Journal of Veterinary Research, they mentioned that the communication rate or, yes, the communication rate. Between the middle femotebral joints and the femo patellar joint is about 66%.

So in 67% of the cases there was a communication between the medial femote joint and the femoral patellar joint. They've identified the communication between the medial femote joint and the lateral femotebral joint in 8%, and the communication between the femoral patellar joint and the lateral femoral joint in 4% of the cases. So that study.

It was very good. They actually injected every compartment with an 18 gauge spinal needle. They've injected 30 mL total volume of local anaesthetic, and then they opened up some stifles to look if there was an Not expansion, but if the dye went into different compartments.

So how many of our injections were successful or not, and they've also put some of the stifles in the CT to image the angulation of the needle. So very interesting. And this is a study using an eight age needle and you just need to go to the skin only once.

So on one insertion point, which is about 1 to 2 centimetre proximal to the proximal cell. It's all over here and also in the middle of your middle or nasal patellar ligament. If you are interested in injecting the medial femoral to the joints, you need to direct your needle towards the axial aspect of the medial femoral condyle.

And if you are interested in going into the lateral femote joint, then you need to withdraw your needle land and in the skin and direct it then towards the cranial aspect of the lateral femoral condyle. With that technique, they have reported a successful injection of the medial femo joint in about 88% of the cases. 92% of the cases were of the lateral femote joint injections were successful, and they were able to inject all the femoatellar joints very well.

This study again comes from Colorado and plenty of these injections were done by students. So if you're interested in trying, and change a little bit your technique, and you want to see what it does, and you don't need a lot of practise, to try that injection technique, and very interesting study. And the angulation or the resurrection of the needle doesn't seem to be a problem.

. For the horses. Just a reminder about the landmarks over here. And now we're gonna look a little bit more into some of the meniscus.

And the stifle in general. So just as a quick introduction, this is a very interesting study. We don't have a lot of biomechanical study and horses, and I'm not going to go into a lot of the details.

It's already a little bit of an older study, but it was very interesting. Because they have described how the meniscus moves with the range of motion. So when the picture on the right side, there are, there is, well, there are two lines, and the white line represents the delienation of the menisci in full flexion, and the black line represents the menisci in full extension.

So this means that the menisci undergoes significant changes in conformation. During the entire range of motion, they go from a C shape and an extension to an L-shape inflexion. That group has found that the cranial horn of the medial meniscus experiences significantly more compressive strain compared to the cranial horn of the lateral meniscus.

They've also found that the cranial horn of the nasal meniscus had the lowest craniocaudal translocation through the range of motion. Interestingly enough, the coal horn of them in the sky, which is the most injured area in men, has the most cranucco had more, sorry, cranico translocation than the cranial horn, so it moves more than the cranial horn. And the study is interesting because in horses until a couple of years ago, the majority of the people thought that mescular injury involved almost exclusively the cranial horn and the media meniscus and the lateral meniscus, which was and is related to the fact that we really had and have a lot of trouble imaging.

The body of the meniscus and the caudal horn. So that group had hypothized. This is a group from Michigan here, family and colleagues, they hypothesised that the cranial horn of the medium meniscus could become entrapped between the tibia and the femur during flexion because it moves less.

There's less cranial called the translocation. And that this could be an explanation why the cranial horn of the major meniscus, has been the prime site for measculpas and horses. However, A more recent study from Colorado has revealed the tears of the menucule body and of the caudal horn, which were diagnosed on ultrasound.

So another very interesting and recent study that is worth looking at. The publication compared the detection of meniscular pathology between ultrasound and arthroscopy, and these are live cases, and they found that ultrasound was best to identify lesions of the meniscus. And as I said before, they've identified with the ultrasound the lesions of the meniscal body and also of the caudal horn.

The medial meniscus was found to be the most injured or injured most often, more often than the lateral meniscus, and this is a finding that's already been described by multiple other people and other publications. Interestingly enough, I've just spoken about the ultrasound that's a very good diagnostic modality and to image the cranial meniscu tibial ligament and the medial one, especially from the publication of Amiliwaro. But in that publication here they found that it was easier to diagnose pathology of the meniscus to ligament using arthroscopy.

Meniscule tears have now then been identified in all of the minuscule segments on the femoral surface, as we said, since this publication here, we know that minuscule tears and horses can affect the cranial horn, hair, and the body and the caudal horn. And while there are multiple types of minuscule tears that are described in humans, the majority of the minuscule pairs that are identified in horses are longitudinal in appearance. This is a publication from last year from the group that I was part of in Montreal before I moved to the UK.

This is a paper that's part of my master's, and these are just two really good pictures to show that effectively there are tears of the cranial horn. This is a median meniscus, yes, with a proper tear of the cranial horn, which does not extend into the cranial meniscus of the ligament. And there is also some degeneration of the meniscule tissue that we can see on the caudal horn right there.

And this is another proper there that is more longitudinal in the orientation with some surface fibrillation. So our study, this study was an X vivo study. Which is very different than an in vivo study, obviously.

It has, some limitations, but it was very interesting to see that there are things that we cannot see, with our current diagnostic modalities, I'm afraid. Now in this X-vivo study, the presence of the meniscal tear was considered together with the presence or not of osteoarthritis in the femote joints, and we also found that the medial meniscus seemed to be more affected by mescule tears in general or the generation of the meniscal tissue than the lateral meniscus. So.

And on the left side we can see microscopic scoring, and on the right side histologic scoring. In that study, the histology and was considered gold standard to confirm that effectively the microscopic tests were actual tests, and both of these scoring were in agreement to say that the medial meniscus present more pathology than the lateral meniscus. In that same study of ex vivo and tears in the meniscus, we have also identified tears of the i surface, and to our knowledge, these were, this was the first time that some fibrillation or pathology was identified on the surface, probably because it's a study and it's about the only and only occasion you'll have to have a look at the civil surface.

This is not something that we could really see reliably with the ultrasound. It's also not something we could image well or, well, not at all an arthroscopy and with the MRI we're not there yet. So tis of the tibi surface were identified in our study, and there were some proper tiles that were partial thickness in the samples that we have, and almost all of the horns and the major meniscus had at least some fib.

Fibrillations were great 2 on that study. If we come back on the femoral surface, there were some partial tears in cranial horns, lateral meniscus, mental meniscus, and also in the body of the lateral meniscus. Equi stifle pathologies, as you are all aware, there are many pathologies affecting the stifle.

For tonight we will concentrate only on the pathologies that had some significant findings if you want, in the last couple of years or significant advancement. So first of all, there has been a substantial body of literature that has looked into subchondral cyst-like lesions in the mifemoral combine in the last 5 years. So on the right side here is the latest classification system.

Which is not something that you need to know by heart, obviously, but it always helps. So this, grading system is more recent. There was one before from 2008 and 2009.

This one here makes a lot of sense and goes as follows. So grade one is only a flattening. So we're looking at the media aspect here.

Yes, meal femoralonar, meal seal plateau, and the meal collateral ligament. This is the meal trochlear ridge of the femur. So in this area there we're in the meal femoral joint.

In this area here we would be in the femoral patellar joint, the patella up here. So a grade one, a subchondral bonesy or scytlike lesion represents this is the essentially classification. A flattening or a small defect of the former condyle only.

Grade 2, it's a dome shaped lucency endochodyle that is less than 10 millimetre. Grade 3 is a little bit special. It is a lucency that is quite easy to see, and the condyle, however, there is no evidence of cloaca or communication between the con the cyst and the actual joint space.

Grade 4 Alucency in the middle femoral condyle that is more or equal to 10 millimetre and once again has a dome shape. This one definitely extends to the articular surface and has a wide communication with the articular surface grade 5. A type of cyst that is again dome shaped but has a narrow cloaca, so narrow communication with the joint space, which is different from the grade 4, and then grade 6, while it's the presence of a grade 4 or grade 5 somewhere on the condyle.

In addition, there will be other lucentcies either adjacent to the main lucency in the condyle or otherwise into the proximal meal for the plateau. It is well known that the cysts contain myxomatous material, and it has been hypothesised that the cyst lining produces inflammatory mediators. There's been plenty of different treatments that have been attempted, namely intra-articular injections or intralesional injections of course.

Christyros, for example, tryinallo acetamide or mesopprednisolone, just to name a couple, and these are often done under ultrasound guidance or not or even under arthroscopic guidance. Recently, the fashion of curating or the bring the inside of the cyst has faded, I have to say because it's been related to some damage of the underlying meniscus. The latest treatment developed is the placement of the transconylar screw to stimulate the healing of the subchondral bone cyst, which is believed to stimulate if you want the body to lay some trabecular bone.

Inside the cystic cavity. Here is the publication of the same individual that did the new classification that's coming out from the United States. This study, it was an in vivo study using real horses that are still alive and that will raise horses for the majority, with 26 horses that were part of the study.

And basically, what they did is, as you can see here in the pictures on the left side, they took a cranial caudal projection, and in this case, they used the 20 degree angle, proximal distal to image really well the condyle and it also gives you a really, really good, idea of the communication of the cyst or the wide, the width of the communication of the cyst with the 20 if there is one. And also an oblique view to image the condyle even more a children the lateral craniumed which should be taken at 3 degree oblique. So what happened then is we are able to place a screw.

It's just a screw that is placed in like fashion majority of the time. It's a normal screw that we would place for fracture fixation. For example, it's a screw that goes through the condyle and it doesn't come out in the joint.

Ideally, usually the screw is inserted, inserted right by the medial collateral ligament, and we should aim to insert the screw somewhere in between the tip and the distal aspect of the medial intercondylar eminence of the tibia. The success in that study was defined as a filling of 50% or more of the radiolucency of visible on radiographs at the 120. This was observed in about 75% of the cases in that study, and this is similar to the success rates of other treatment methods.

They found again a little bit similar to in other studies that their technique or their method was less successful if the horse was more than 3 years old, if the horse was a male horse, and also if there had been previous attempts of injecting the joint with corticosteroid treatment. So we can see really interesting that by placing the screw. Stabilising the condyle is going to stimulate the production of trabecular bone and healing of the cyst.

And that paper there is, I believe, if I remember correctly, one horse that went first I laugh and others removed the screw at the at the demand of the owners and The cyst came back after they've removed the screw. They have removed the screw from other horses, in which case it it didn't come back, but this is something that has been described. The cause of the subchondral bone cyst-like lesion is debatable, but bone trauma due to overload is at the moment the likely mechanism.

There are substantial differences in the tension and the shared stresses at various stages. Of formation of the subchondral bone cyst, which suggests that there is further bone damage as the result of the subchondrule lucency. This is a paper again from the same group.

I'm looking at basically when cysts have different shapes, they are always usually in the same location on the cranial aspect of the medial condyle. And depending on the size, what are the changes, and there are definitely are some changes and some impact on the bone when the cyst enlarged. So the tensile and the comprehensive stresses are elevated and there is tension that is focused on the axle and abaxy edge of the cyst.

Another very recent publication on something completely different. This is if you want a multicentric study looking into fractures of the mesent condylar eminence of the tibia, I decided to present it because, well, having sat my board recently, there is not a lot of information about that. And in that paper there is a lot of very useful information, namely prognostic, and this is a study with cases, plenty of cases from the UK, cases from Belgium, cases from France.

And it includes 21 horses was only published last year. And so the type of injury that is in cause and that publication here is usually caused by a lateral force or trauma, lateral trauma that is applied to the nasal femoral condy, which is how we think the fracture happens of the nasal intercondylar mens. And the fracture is if the mouse can work over here on the caudal cranial view and then on the lateraled view pointed out by the arrow substantial fragment right here.

In this publication, 12 horses had a history of trauma and associated acute onset, onset of lameness. All the horses were treated by arthroscopic removal, and 62% of the horses returned to their previous level of exercise. Four horses remained lame, 2 of which just remained lame, and 2 of which had to be euthanized because of persistent lameness from that limb.

So if there is a case that you see a fracture of the mop, arthroscopic removal seems to be insulated at the moment. Meniscular disease and osteoarthritis. This is the second part of my master's and part of that publication that I have presented a little bit earlier.

So we looked at the first part I presented earlier was the lesions of the meniscus, and then we wanted to compare the lesions of the meniscus. Were they present if there were signs of osteoarthritis in the joint or were they not present if there were signs of osteoarthritis. So briefly, just to explain how we determined if there was osteoarthritis in the joint, we looked at the distal femur and the proximal tibia.

We separated these structures in three different sections, a cranial section, a middle section, and a caudal section. And then, that the Lassa, that was a collaborator from Montreal, she scored each of these sections for the presence of osteophyte and also for the presence of cartilage degeneration. And then we came up with a total ferocondi score and a total cellotra score.

So there were two different scores, one for osteophytes and one for cartilage degeneration, which are two features of osteoarthritis, considered features of osteoarthritis, in medicine. We found that the meniscal disease increased with the presence of osteoarthritis, especially in the nasal femoralidal joint. So if we look on the right side, we have the cartilage score on the top row.

And then the menisci, the menisci score on the the X, and then we can see in the mellfemoral joint that when the score of the menisci increased, the score of the cartilage degeneration increases as well, and this was more important than the melfemote joint compared to the lateral femoral joint. We observed the same for osteophytes. So again, A correlation between the presence of osteophyte and me menistyle.

This was much more important. There was not really any relation between the presence of osteophyte and the scores of the meniscus and the latter fe multiple joint. Probably because the osteophytes and the cartilage degeneration, well, definitely the osteophyte is the majority of the time, if not always present in the meal femotebral joint compared to the lateral femotebral joint.

So the meniscus scores correlated most with the present of osteophytes in the joint, and this is interesting because we can see osteophytes on radiographs. Obviously we cannot see cartilage degeneration on radiographs, but it's quite useful to think that if you have, if you see osteophyte and development on radiographs, one would think that you could have some associated menucular disease in the joint. We also found that meniscular disease increased with age, and we found that this was true for microscopic meniscular scores and also for histologic meniscular scores.

So when horses, when the horses in our study were older and they seemed to have higher scores for meniscular injury or meniscular disease, what we have not established yet, and this is them. The subject of of other ongoing studies is how much of this is down to degeneration and how much of this is down to a primary lesion and also one of the very interesting to establish is which one comes first a bit like in humans, they don't have the answer yet. Is it the Osteoarthritis that comes first in the joint and then causes degeneration or secondary injury to the meniscus or do primary mescular injury then cause changes in the joint that are compatible eventually and will lead to the development of osteoarthritis.

And this is something and information that we don't have in horses yet and a source of great debate in human medicine still. I hope you have enjoyed the presentation, and if you have any questions, I will be happy to entertain this at the minute. That's great, thank you very much.

Yeah, really, really comprehensive, talk, reminds me a lot about equine and, and the stifle anatomy that, I'd actually. It's just one of those joints that, I think confuses a lot of people. And, yes.

Yeah. So there was just one question regarding, say there's more medial lesions on the medial meniscus and on the medial side. Is that the same reason as dogs due to the, similar arrangement of ligaments and Most, .

Yeah. Yeah, no, it's a great question actually. And I don't think I have the answer only because the arrangement of the joints and horses is so different, than dogs.

We definitely know and it's been established that the horse, is a model for studying. Osteoarthritis in humans, so I think they definitely compare more, but unfortunately the horse presents multiple challenges because of the size and also for our access of treatment and diagnosis. But presumably from what we know now, it's pretty much the same as in humans actually.

Yeah, OK. So sticking with the minuscule theme, so imaging for meniscule disease, would arthroscopy be, the, the way to best diagnose diagnosis and also has any work been done or do you have any, anecdotal evidence about prognosis and or potentially management of damage to, the meniscus, or is that early days? No, actually it's a great question, and I think until the publication from Adrian, everyone used arthroscopy as the gold standard if you want, and which is not a mistake at all because unfortunately, you know, we all would like to have access to an MRI, but you know, an MRI of the stifle and the horse, you need to.

Done under general anaesthesia with an open bore magnet which is available in one centre in the and I think in 5 centres in the world. So that doesn't work. I would say ultrasound if people have access to ultrasound, definitely try, try and develop the technique and the skills to do it because you can be quite .

It's a good, it's a good modality and you have good chances to find something. Arthroscopy is a great diagnostic modality, but a little bit like for the same reason I said before, the The stifle joint in the horse has so much soft tissue surrounding the joint. Unfortunately, our access to the joint, even with arthroscopy, if we go in the cradle compartment and the curar compartment, we still don't see the entirety of the meniscus because it's it's impossible to defect the joint like we would do, and you know, to have a look at the joint in the dog, for example, and Yeah, presumably MRI is the best, but at the minute I would definitely try and develop skills of ultrasound if I was someone who doesn't have them yet.

And if you see something and you want cancer in it, arthroscopy, definitely would be still at the the way to go forward, I believe. Yeah. OK, thank you.

And then, final question, just regarding the steroid injections and subchondral cystic lesions, and based on the on the data that you presented that said there was. Increased risk of failure, is that correct with steroid injection if a joint had been medicated with steroids beforehand. In that case, you ever see any subchondral cystic lesions, would you say steroid injections are contraindicated and you're better off preparing for surgery in the first instance?

It's a tough question, I would say. And personally, I believe a lot in the hypothesis of strengthening the medial femoral condyle with the transcondylar screw. I have had very good success with it personally, and the publications are quite strong and the evidence for It's quite strong.

Unfortunately, if we still look down into the literature, everything has more or less a 75% success rate. So, and you know, this is one study. I'm not saying we need to stop injecting subcontra bos with steroids at all.

It might be worth trying once, but a screw is definitely an option as well if people want to try something new. Fantastic. Thank you very much.

Yeah, yeah, that's all the questions. So thank you again, really fascinating, talk, really, really enjoyed that. Thanks also to Bailey's for sponsoring it, and we'll hopefully, see you at another webinar soon.

Thank you very much.