Hello, everyone, and welcome. I'm Dr. Beth Mollison. I'm a veterinary officer here with Clinician's Brief, and I'm very excited to welcome you to today's webinar titled Next-Gen Approaches to Osteoarthritis and Joint Injections in Daily Practice. And before we get started, I do want to take a moment to help you familiarize yourself with the webinar platform. You can rearrange your console to your liking by expanding or shrinking the boxes on your screen. And if you want to bring something back up that you've minimized, use the icons at the if you're joining us live you can ask questions at any time by typing them in that Q&A box on the bottom right side of your screen and should you run into any tech issues you can alert us by submitting your concern in that same Q&A box and a member of our support team will work with you to correct the issue This webinar is approved for one hour of CE, so if you're joining us live after you've viewed the webinar for at least 50 minutes, you can access your CE certificate by clicking on the yellow icon in your toolbar or in the box in the bottom right corner of your console. And if you're viewing this presentation on demand, please reference the CE information box in the bottom right of your screen for instructions on how to get that CE credit. This event today is available with support from our sponsor, Spring, and joining us today and sharing their expertise are Dr. Edward Cahill and Dr. Kathy Riley. Dr. Cahill is an orthopedic, neurologic, and soft tissue surgeon at Animal Medical Center in Copperas Cove, Texas, where he also specializes in CT imaging, endoscopy, and ultrasound services. and Dr. Riley is a veterinarian at Park Place Animal Hospital in Keene, New Hampshire and a member of Springs GP Advisory Board. She is a past delegate of the American Veterinary Medical Association and a past chairperson for the Mononock Humane Society. We are excited to have you both here with us today. So please take it away.

Good evening, I'm Kathy Riley and I'm a general practitioner in New Hampshire. I'm a 1990 graduate from the University of Wisconsin, home of Bucky Badger. Thank you for coming out tonight after a long day. And thanks to Pet Vivo in spring for hosting us tonight. To disclose any conflict of interest, I must share that I am being compensated by Pet Vivo for this webinar. However, the ideas and opinions expressed are all my own. I'm not an expert on osteoarthritis, but I have a keen interest in it since so many of my patients and clients are affected by it. I started practicing before safe NSAIDs were available. Sadly, we euthanized many dogs for osteoarthritis as their quality of life was awful. And they weren't always old dogs. Rimido was a miracle drug, and now we have so many options. I've been practicing for over 30 years, but I am still learning so that I can offer the best innovations to improve my patients' quality of life and longevity. Also, I have personal experience with osteoarthritis, as I had my knee replaced in May. The constant pain affected my life in many ways. It was very painful after standing for so many hours, and I had trouble doing surgery that was longer than 30 minutes or so. Since my surgery, people have commented that my face looks better. I didn't recognize that I was cringing, but apparently I was. We don't have the ability to replace dog's knees at this point, but I want to provide the best relief from pain possible for the pets that I see. Osteoarthritis is very common. It's the number one cause of chronic pain. Juli Goldstein, Juli Goldstein, John Lai, Bryan Monninger, Garry Lowenthal osteoarthritis is no longer considered an old dog disease in fact studies have shown that up to 40 percent of dogs under four years of age have radiographic changes consistent with osteoarthritis We are seeing more cruciate disease than ever. Hip osteoarthritis has been reduced by screening, but that's just in purebred dogs. And elbow dysplasia has limited effective treatments. And trauma is also a cause of future osteoarthritis. Osteoarthritis cannot be cured, but it can be managed. Owners can adapt lifestyle and environment for optimal quality of life. predisposing factors play a large role obesity which is so common adipose tissue is the largest organ in the body and it is pro-inflammatory muscle atrophy from not moving enough muscles help protect joints neutering or spaying before growth plates close has been the topic of studies these studies suggest that earlier spaying and neutering can cause orthopedic issues and cancer More recent analysis have been found the risk to be breed related. There is a chart on the UC Davis website that lists recommendations for 40 breeds. There were major breed differences in vulnerability to neutering, both with regard to joint disorders and cancers. In most cases, the caregiver can choose the age of neutering without increasing the risk of these joint disorders or cancers. Some recommend letting females go through one heat and male dogs waiting until 11 months to neuter and giant breeds to be neutered at 18 to 24 months. Dr. Philip Busby of the University of Mississippi recommends spaying and neutering before six months, except giant breed males waiting until 15 to 18 months. So there may be correlations and you need to discuss the pros and cons with the owners. Again, this is not just an old dog disease. We need to remember that. A little technical difficulty here. So early recognition is key. Synovitis drives osteoarthritis. There is osteoarthritis before we can see radiographic evidence of it. Do a visual gait analysis. Have an assistant walk the dog up and down, back and forth. Help them appreciate what you are seeing. Help them appreciate the pain. Check out the AHA Pain Management Guideline. It's an excellent resource. Early intervention is more effective in slowing down the progression of osteoarthritis, and in terms of dollars and cents, it's much less expensive than trying to address chronic changes once they are established. There are some assessments that can help us instruct clients to realize their pet is in pain. The CBPI, canine brief pain inventory, is 11 questions. It can be a baseline and then be used in the future to evaluate treatment. Another inventory that looks like it'll be very helpful is the Canine Quality of Life and Treatment Satisfaction Questionnaire, the CAOA QOLTS. It looks at the quality of life of the dog and of the owner and treatment satisfaction. Musculoskeletal disease diagnosis is based on physical exam and radiographs. Unfortunately, these have poor sensitivity to early osteoarthritis. Cat scans and MRIs are very sensitive, but are not practical for the general practitioner. 60% of dogs have radiographic evidence of osteoarthritis. There is no incidental RAD finding. If you see radiographic changes, those dogs have osteoarthritis and subsequent pain. Osteoarthritis can affect any age, gender, or breed of dog. One or more joints can be affected. Thank you for joining us. LAMENESS AND STIFF GATE Other signs that owners can see, difficulty navigating stairs, jumping on furniture or into a vehicle, getting up from resting, or even finding a comfortable resting position. It's very difficult for owners to accept that their dog is in pain. Dogs don't yelp like we do. Owners anthropomorphize. If we are in pain, we don't go dancing. We need to help them see what pain is for dogs. One suggestion is to make arthritis part of the conversation at puppy visits. We have to ask the right questions and prepare for a difficult discussion. Get the whole team involved in communication and recheck after starting treatment. And osteoarthritis has human animal bond costs as well. We have a lot of modalities available to us now. It's known that one modality isn't king. The modalities working together has an additive effect. It's not reasonable to expect a single treatment to have optimal results. Our current modalities include interventions such as NSAIDs, nutraceuticals, anti-nerve growth factor monoclonal antibodies, and joint injection. Weight management is so important. Start with puppies emphasizing healthy weight. These are actual before and after pictures. You can see the pain in his face when the dog was overweight. Survey in 2023 by the Association for Pet Obesity Prevention reveals that 59% of pet dogs in the US are overweight, but only 15% of owners think their dog is overweight. Thank you for joining us. The over-the-counter weight loss foods, life protection, healthy weight, fit and trim, reduce fat, and there's actually a food called Fat Dog. These are not helpful for many dogs. Therapeutic weight loss diets have a much higher success rate. Purina, Hills, Imes, and Royal Canin all make therapeutic diets for weight loss. Owners may balk at the cost, but it may save money in the long run and increase the time they have with their pet. Encourage owners, follow up and schedule re-weighs. Don't wait a year to discuss weight gain after the pet has gained more weight. This is a frustrating problem for owners. Clients come in saying, I know we lost weight when the scale tells a different story, or I knew I was gonna get in trouble for her weight, The owners are not in trouble, but the dog is in trouble. It is recommended to check in with owners a few times yearly to let them know you are part of their health care team. And we don't fat shame. We sympathize with the struggle. You can't teach with guilt. In the Perina study, dogs lived an average of two years longer and chronic diseases were less prevalent if they were lean. This is something owners pay attention to. Healthy Weight Fosters Longevity. Overweight dogs cost more, not just in food costs, but in treating problems that obesity causes. Besides osteoarthritis, excess adipose tissue has been linked to chronic kidney disease, urinary tract disease, liver disease, high blood pressure, heart failure, and even some types of cancer, hemangiosarcoma, lymphosarcoma, mast cell disease. There are also higher risk of complications should they need to go under anesthesia because of the added weight on their respiratory system. Exercising regularly can increase the range of motion in the joints, relieving pain and stiffness. Decreased mobility affects quality of life. Synovial fluid possesses all the nutrients joints need to function optimally. Moving the joints provides these nutrients to all the connective tissue surfaces within the joint, such as cartilage. In other words, movement feeds the joints what they need to stay agile and strong. Dogs and people need exercise to maintain muscle strength. Muscles protect the joints. If a dog is reluctant to walk, try three 10-minute walks or two 15-minute walks instead of a 30-minute walk. Allow the dog to rest if painful, although exercise restriction can be difficult for dogs and their owners. I started using a cane and stopped going on walks because of the pain. Dogs will play through the pain. It doesn't mean they're not in pain. A retriever patient that was adopted at three years of age had come to us after getting an upper GI scan, an echo, and an abdominal ultrasound. Zoe would walk a little bit and slip down. The owner thought there was something metabolically wrong. The previous vet was concerned that the owner was exaggerating. We took rads. This dog had the worst hips and knees I have ever seen. We started NSAIDs and supplements. Zoe was a happy dog again. Controlled exercise can also include underwater treadmill, rehabilitation exercises, cavalettis. Remember that motion is lotion to the joint. Be aware of pain and inflammation before embarking on an exercise program. Start treatments first. Enseds reduce swelling and inflammation that causes pain. This is a very important part of treatment. Some practitioners are wary of enseds. Enseds are still necessary. There's not as many long-term side effects as previously thought. An increase in alkaline phosphatase is not a reason to stop enseds. If they have an idiosyncratic liver reaction, it would happen right away. Monitoring blood work should be done yearly to check the effect on the kidneys. NSAIDs will have varying effects in different patients, in side effects and in efficacy. You will see an improvement quickly, but it improves more over time. Owners will give aspirin thinking they are helping their pet. 100% of patients experience GI hemorrhage after just two doses. The washout period should be two weeks at least to give the mucosa time to heal, and aspirin is not specific. Carprofen inhibits COX-2 and spares COX-1. Newer generations are more selective COX-2 inhibitors. It may be a good idea to consider a rotating schedule of two or more drugs to identify which drug is better tolerated, effective, and easier to administer in each patient. Carprofen has published data proving a positive effect on cartilage, both in vitro and in vivo. Interferes with metalloproteinases. We have carprofen, rimidil, deramax, medicam, prevacox, and galoprant. Galoprant does not inhibit prostaglandin production. It's an EP4 prostaglandin receptor antagonist. Galloprin is like any NSAID and needs to be monitored. It's also not a PRN drug and needs to be given on an empty stomach for full efficacy. Recent studies indicate it may not be as effective as other NSAIDs in reducing inflammation, but it has a very high safety margin. They gave dogs 15 times the dose for nine months with no adverse effects. And what about switching between NSAIDs? for drugs with a very short elimination half-life, such as carprofen, which is eight hours, a washout period of three to five days seems excessive, especially if the NSAID is providing substantial relief. On the other hand, a drug like meloxicam with a half-life of 24 hours probably does require a washout period of three to five days. Other analgesics can be very helpful. Amantadine needs to be used with an NSAID, and it only comes as a 100 milligram capsule, which is too big for small dogs. A 30 pound dog needs about 50 milligrams, but it can be compounded. Ketamine can be given sub-Q as regular injections. Both are NMDA meds. They're antagonists to N-methyl-D-aspartate receptors. They provide dissociative analgesia. And unfortunately, it needs to be used in caution with dogs with kidney insufficiency. Gabapentin is not for inflammation. It has no anti-inflammatory effect, but it can help with neuropathic pain. Tramadol is used much less as it is poorly absorbed in dogs. And based on current information, it may not be the best choice to use in osteoarthritis treatment. Thank you for watching. If our clients look at Chewy for glucosamine chondroitin supplements, there are over 70 products to choose from. It's very confusing for owners. Don't be afraid to make a recommendation. You aren't selling, you're advising. Omega-3s are very helpful. They have an anti-inflammatory effect. You need to use a high enough dose, 150 to 175 milligrams per kilogram daily. Again, lots of choices on Chewy. It can cause diarrhea when started. I have owners use a half dose for the first week. And remember that it has anti-clotting effects and should be stopped at least a week before surgery. Recommend products with proven efficacy and bioavailability. I recommend the Nutramax products for this reason. Every Nutramax supplement is tested for harmful contaminants, backed by more than 80 quality checks and guaranteed to meet label claims. Alternative therapies can be helpful. Laser therapy, which is photobiomodulation, is applied to individual affected joints. It's mostly used in office, but there are some home products available. Spinal manipulation and acupuncture can be very helpful. Both need certification to be performed. Both are treated in clinic, reduce joint degradation, alleviate pain, and commonly spinal dysfunction. Massage. Teach owners to perform at home. It is the manipulation of soft tissue. Dog massage may also help relieve anxiety, increase circulation, and enhance immune function. Julius Caesar was known to travel with a masseuse for his benefit as well as for his dogs. And you can also incorporate range of motion with massage. Acoustic High Energy Sound Waves, Shockwave, is used in clinic, sometimes needs sedation. It triggers the activation of the pet's repair system. And PEMF, Pulsed Electromagnetic Field, treats pain, swelling, and also anxiety. There's clinic products and home products. There are loops and beds that deliver PEMF. What else can be done? Focus on the source of the pain. Joint injections can be very effective. They are done after under sedation and after a sterile prep of the joint. You have several options that Dr. Cahill will discuss. Spring is the one I am most familiar with. Spring is a medical device that is composed of natural proteins. It's very effective for most pets. Thank you for watching. My first case was my sister's dog, Otto. He is a scruffy mutt, I mean mixed breed dog, who was two at the time with severe elbow dysplasia. NSAIDs were no longer working. I injected both elbows, had him rest for a week or so. After that, he was walking normally and running and playing like a two-year-old should. and he's still doing very well after two plus years. And the nice thing is I can re-inject his elbows when needed without any concern. I don't know where Otto would be without Spring. Of course, I was nervous giving joint injections at first, but seeing the results made me want to continue recommending Spring. A client said that it was an extraordinary treatment after I injected both knees in their dog Hudson. John Lai, Bryan Monninger, John Lai, Bryan Monninger, John Lai, I have a new perspective on treatment for joint health. Spring is a collagen elastin hydrogel. When injected into a joint, it provides a durable visuolastic scaffold. Originally, the assumption was that it would last 12 to 18 months, but I have several patients that are past the two-year mark. I will now turn things over to Dr. Cahill, who is a surgical specialist.

Good evening, everyone. Thank you for your interest, and I look forward to sharing my thoughts with you. By the way, this is my dog, Danny, who was a major driving factor behind my interest in spring. Regarding any conflict of interest, I am being compensated by Pet Vivo for this presentation. However, the evolution in my use of spring is based on the clinical results that I've seen in my patients over the last two plus years. The case study that I'm going to share with you was done from my own clinical knowledge and to the benefit of my future patients. These thoughts are my own opinions. Kathy's given us an excellent overview, but I just wanted to take a step back and discuss the importance of making an accurate diagnosis before we consider the new treatment option as I will be recommending local treatment of each affected joint. I think the most important part of my exam is an across-the-room gait analysis. I usually have a discussion with the owner about the patient's lifestyle, normal activities, and owner expectations while I watch the patient move around the room and interact with the owner and my team. A hands-on exam and imaging are then used to diagnose all joint involves. It's also important to rule out any concurrent neurologic disease. It's not uncommon to see a lame patient referred for a TPLO that also has contralateral cruciate disease or elbows or hip arthritis, especially in our senior age patients. I feel that it's important to correct surgically treatable conditions first and then manage the secondary arthritic changes. A stable or structurally normal joint is much easier to manage with medical therapy. Sorry about that. This was my treatment algorithm of arthritic patients in the past. I'm a believer in throwing the kitchen sink at these arthritic patients. They hurt and we need to do what it takes to help them. I would typically start with a discussion about the importance of achieving an ideal body weight, usually recommending a metabolic diet. And I also recommended adequate or oral glucosamine and prescribe an NSAID as needed. I would not hesitate to add additional analgesic medications as needed, particularly opioids. Kathy's already covered these in excellent detail, so let's move on to intraarticular therapy. In the past, I generally reserved intraarticular therapy for those patients whose pain was not being effectively managed with other modalities. I preferred adipose stem therapy in younger patients for its anti-inflammatory effect. It is also carcass sparing and I hope for structural regeneration. Overall, I saw good results with only one failure, which was my own dog, Danny. Corticosteroid use was generally restricted to older patients with end-stage arthritis. I always combined it with morphine and hyaluronic acid. It is an effective and anti-inflammatory, but has the potential to damage cartilage with long-term use. In Danny, after the stem cell failure, I initially used Triamcinolone every three to four months, and then eventually ended up using Depo-Medrol every six weeks. I do not have any experience with the radioactive tin product, although I did try and enroll Danny in the trial phase, but I missed the cutoff for inclusions. I first heard about spring in February of 2022. It sounded promising as a potential therapy for elbow arthritis. I had little to offer surgically or medically for most elbow patients, and the recent loss of Danny was still an open wound. I talked to a couple of people at Pet Vivo, including Ann Zieser, who was able to email me a great deal of information as I was traveling to Cuba for a fishing trip. Fischer was fantastic, but I was just as excited about the potential uses of spring in my patients when I got back home. I was not satisfied with the available safety studies, so I signed on as a test site and had owners sign an informed consent statement. Since that time, excellent tolerability studies have been performed in both dogs and cats. I initially limited its use to patients with end-stage joint disease but expanded its use as I saw no adverse reactions and nice results. This slide is Pet Vivo's technical mechanism of action explanation. The video shows the sponge-like nature of the collagen, elastin, hydrogel particles. Vivo studies show that these particles are incorporated in the synovial membrane within several weeks and may secondarily help manage pain associated with synovitis. I suspect that the rapid improvements that we see clinically, almost all of these respond within the first week, is more likely related to a general improvement in the joint fluid lubrication from the spring particles as they absorb and release joint fluid and possibly also the dilutional effects on the interarticular cytokines. My first case using spring was Samson. He was an eight-year-old old English bulldog referred for evaluation of a mass including left ear canal. On examination, he looked miserable with a concurrent atopy, keratitis zika, and severe lameness due to likely elbow and stifle disease. I had a very frank discussion about quality of life before we proceeded with anything. CT scan and biopsy were done to determine if the mass was resectable. While waiting on biopsy results, we started him on medications for atopy, keratitis, and remodeling gabapentin, both for his otic and orthopedic pains. Histopath showed that the mass was benign, so we scheduled a teakaboo. He was more comfortable when he returned for surgery, which went well, and histopathology did confirm a benign mass with complete resection. I then recommended bilateral TPLO to stabilize his knees. Samson's odor was unable to consider this, so I mentioned that I was looking into spring, and I would call her when I got it. I felt that Samson would be an excellent first test case, so I offered treatment at cost. I called her when I got it, and she immediately brought him back in. I split two syringes between the elbows and the knees. At one day, he seemed to be walking more upright. At one week, she noted that Samson was climbing stairs for the first time in years, and at one month... Samson actually jumped off the bed, which he had never done before, and the owner often had to go find him in her large yard as he began wandering again. Prior to spring, he would immediately return to the back porch after relieving himself. It would be an understatement to say that Samson's owner was pleased with the improvements in his quality of life, which continued out to the one-year recall. So regarding my case studies, Samson was injected in April of 2022. The cutoff for inclusion in this series was June 1 of 2024. As of June 1, I injected 158 joints in 74 patients, 73 dogs, one cat. No adverse reactions have been seen except for one patient with bilateral elbow injections who was painful at 24 hours but responded to NSAID therapy and was approved the following day. I actually suspect that discomfort was more likely due to my struggle to inject his joints. One cat had a bilateral shoulder arthritis and showed a slow initial response but was pain-free at one month and has remained pain-free since then. My initial intention was to record the responses of the first 100 joints that I treated. To detail the case study design, it was based exclusively on owner evaluations. One of two veterinary technicians at the hospital called to discuss patient's response. Owners were called one day, one week, one month, six months, and one year. A simple grading scheme was used. Worse, no change. Mild, Moderate, or Marked Improvement. In hindsight, I wish that I'd used one of the standardized pain scoring methods. In this graphic, elbow, stifle, and hips are exclusive to that joint, and multiple joint is combined different joints. Regarding multiple different joints, they range from two to seven. As an example, I had one patient referred for a TPLO who was a 13-year-old golden retriever. She had a partial stable cranial cruciate tear in one knee and concurrent bilateral shoulder, elbow, and hip arthritis. I felt that TPLO was not her best option and recommended treating all seven joints with sprain and she responded beautifully. These are the same results in chart forms. First and very important, no adverse reactions were noted other than the one painful patient at 24 hours. Hip patients had excellent rapid and long-term improvement. Even in elbow patients, which is why I was so interested in spring in the first place, the improvement was far more effective than any other previous treatment options. It became obvious early on that SPRING was both safe and effective. So I expanded its use to include earlier arthritis cases as I really felt that that gives us the best option to control pain and improve joint health in the long run. I am now even using it in selected surgical patients. This continued early on due to a total lack of adverse reactions. I can tell you that everyone on my team associated with SPRING knows how well it works and enjoys hearing the positive feedback received during the callbacks. I even had one owner scratch through his pet's name and put his own name in the treatment consent form after seeing the results in two of his geriatric pets. He had both of his knees replaced a year later, unfortunately. This slide illustrates my new approach to arthritis management. Spring is now included as a first-tier treatment as it simply makes arthritis management easier. The joints are immediately quieter and happier. Many of the patients are receiving an NSAID and a labral prior to referral, but most no longer need the kitchen sink to be comfortable and most often discontinue the use of the NSAID. In fact, Sprint is so effective that I know I need to reevaluate my diagnosis if improvement is not seen by three to four weeks. This also seems to be long duration. My patients are out to two years, and only three elbow patients have needed follow-up injections. It's six, eight, and 10 months, respectively. One of those, Grissom, who is 15 years old, failed to respond to a second elbow injection, so I reexamined him. It turns out that he had cervical pain that I missed at the exam three weeks prior. A lateral cervical disc was seen with CT and he was managed with improved analgesic control. The only way that spring was available for Danny. She was my second dog of a lifetime. and I really struggled to keep her comfortable in her later years. She was a working retriever who loved retrieving and lived to please me. I suspected a forelimb issue early on but radiographs were always negative. She was the first patient I interviewed when I got my CT and it confirmed early elbow arthritis. I treated her elbows with stem cells when I did her first TPLO but she showed no response. I ended up treating her with a kitchen sink and intraarticular corticosteroids with all the extras for the last four years of her life. I have little doubt that spraying would have made her management much easier as it now has for a significant number of my patients. So with that said, let's get some spraying into these disease joints. I do prefer a general anesthetic for after synthesis. I don't want them to struggle and I don't want to rush. These can be painful, so there's no reason to do that. I like a short acting anesthetic like IV propofol and inhalation anesthetics. I'm just doing joint injections, but I will pre-med with an opioid if the joints seem painful due to inflammation. We do recommend a surgical clip and prep of the joints. It's important to pre-mix spring. It's thick and can plug the needle during injection. I vigorously pre-mix the syringe while the joint is being prepped. I generally use a 1 1⁄2-inch 22-gauge needle on a 3cc lure lock syringes filled with LRS. To be sure that you're 100% in the joint and spring is going to go where it's needed, test with LRS. If it injects easily, it's in the joint. If it does not inject easily, gently redirect and try again. I then grasp the needle hole with a heat stat. Twist off the LRS syringe and twist on the spring syringe. If you encounter resistance during the injection, you've probably pushed up against the joint capsule, which is not unlikely because it is thick, you tend to push a little hard and can push it into the joint capsule. Just back it up a couple of millimeters and continue the injection. On occasion, spring will plug the needle and you just need to give it a firm push. then passively move the joint through its full range of motion to evenly distribute it within the joint. Joint injections are something that everybody can do with a little practice. You do not need to be afraid of entering the joint as long as you're careful. There's little risk of cartilage damage if you go slow. Just advance the needle slowly and redirect if you encounter resistance. Helpful references include arthroscopy books and the spring website. Skeleton models are really handy to have as a reference whenever you're starting out. I also strongly recommend cadaver practice to get comfortable. Use the LRS syringe technique I mentioned in the previous slide to confirm joint placement. Even in a cadaver, the joint will fill. So for the stifle, you can use a medullar lateral approach. I've injected 16 stifles with spring at the time of TPLO or extra capsular stabilization when I see severe cartilage erosion. They seem to be much more comfortable even on the first post-op day than would otherwise be expected with their severe arthritis. I inject after post-op x-rays are taken. We simply re-prep and inject. I've also treated eight contralateral stifles with partial cranial cruciate disease at the time of the primary TPLO. And I've staged TPLO in three of the eight. Several of those are well out past a year, so it may offer some benefit. Finding that spring is incorporated into the synovial membrane may offer some hope in partial cranial cruciate tears as it may calm the inflammatory response to ligament fiber exposure. Because of this possible benefit and having no concerns for negative reactions, I injected my current dog, River, injected both knees at the time I did his TP low for a partial tear on his left knee. By the way, he's well on his way to earning a dog of a lifetime title as well. The hip joint may be the easiest to tap despite its depth and spring treatment shows excellent short and long-term results. I have yet to have one need additional medical or surgical therapy. Remember that the sciatic nerve is located caudal to the greater trochanter, so you need to stay to the cranial aspect. Advance the needle perpendicular to the joint. This is where a skeleton model is worth its weight in gold. For me, the elbow is the most challenging joint to consistently tap. I prefer the caudal lateral approach. Palpate the lateral epicondylar crest, insert the needle medial to the crest, and advance the needle toward the anchoneal fossa. Advance slowly and redirect if you encounter resistance. Severe degenerative joint disease does narrow the available window and makes the chronic end-stage joint a challenge. You must carefully redirect when you encounter the osteophytes. The LRS technique will save you in this joint. That's it for me. I hope that you find spring as helpful for your patients as I have. I encourage you to do the work necessary to get comfortable with intra-articular therapy and I promise you that your patients will benefit from your efforts. Thank you for your time.

Wonderful. Thank you both so much. We are going to open up for some questions at this time. Just some quick reminders. You are able to still submit some questions in that Q&A box, so please go ahead and do that if there are any remaining questions. Also, keep an eye on the time. Once we hit 50 minutes, it will be a great time to download that CE certificate from the yellow icons. So let's see here. First question for you guys. And another reminder to our audience, if you want to check out the resource icon, Spring has put some really great resources in there that will likely answer a lot of your most commonly asked questions and get you some great information. So first question is, How many joints do each of you inject per year, would you say? I know we got a little bit of info from Dr. Cahill. And are there any joints that you find you're getting kind of maybe the most bang for your buck? Do you find that you're doing a lot of hips and stifles or anything else to say in regards to what you find yourself actually doing in practice?

I've done mostly knees and then elbows, but I don't have a number per year, but both of those have worked out really well for my patients.

Okay, great. Let's see, anything to add, Dr. Cahill? I know we heard a little bit more about what you were doing in practice.

Yeah, so I certainly got into this initially for the elbow issues, but, and I've injected more elbows than anything else, but it seems like the more thorough you are with your investigations, the more likely you are to see it. So it's very common that we're injecting multiple joints on these guys. And I would say elbows first, knees a second, and...

Dr. Cahill, any specific advice for cats when it comes to this treatment modality?

I think cats are fantastic. I don't feel, I mean, their joints are going to be smaller, so they might be a little more technically demanding in places, but I don't expect that you would have any more difficulty with them as far as their treatment than anything else. Unfortunately, I just don't have a lot of cat fur to me for knees, so it's not something that I get to see very much. I mean, the general practice, we'll see them on occasion, but we just don't see a lot. Okay, great.

The next question says that they have a pet with an FHO that seems to have not maybe healed 100%. Do you feel like that might be a candidate for spring?

I'm going to leave Dr. Cahill to answer that since he's the surgeon.

I wouldn't think that that would do much. I mean, if it's an FHO, I don't think you're going to get enough. I don't think the spring is going to do anything in there for that at all.

Okay, great.

We had one question about contraindications. Is there anything you would see in a joint or in a patient that would make you shy away from using spring?

I can't think of any off the top of my head. I can't think of any off the top of my head.

For me, I see no contraindications whatsoever, unless it's infected. If it's infected, I've had one or two where I've had to remove like a tightrope implant and I will not inject those joints at that time. I just, I don't want to put it in an infected, potentially infected place. Okay, wonderful.

And I'm also hearing from the spring team, just like you said, Dr. Cahill, infection, immune joint disease, severe joint inflammation, just like you said here. Let's see here, next question for you guys. It says, to be sure to inject at the right place in the articulation. Can you speak to how ultrasound might help you find your best injection spot?

That's been suggested to me by the Pet Vivo veterinarians, but I haven't tried it yet.

Okay, wonderful. Let's see, Dr. Cunningham, is there any contraindication with Labrella? We're getting that question a lot.

I do not think so, no. I think Labrella works. Okay, great.

I know we have a lot of questions.

Librella is good for pain, but spring helps with joint health.

I know we've got a lot of questions that have rolled in asking about clinical studies and studies that have gone on. So I do want to direct everyone that has curiosity there to go to the following website. It's https colon backslash backslash www.springhealth.com slash small dash animal dash clinical dash data. And I think you'll be really, again, spells out some really great and interesting studies that Spring has done. All right, Dr. Cahill, the next question kind of scales us back a little bit, just going back to osteoarthritis in general, and wants some advice on how to grade arthritis based on the x-ray. The question says that sometimes they have difficulty putting the whole clinical picture together, and how can you use that x-ray to help guide your clinical decision-making?

I think I'm going to go back to the initial thing that it mentioned that I said about Thank you for joining us. I tend to favor the knee as the primary issue in most cases, especially if there's any instability, then that is the go-to, and I will recommend spring for the hip. In the forelimb, I think the elbow is by far the most common place for arthritis, and I think you have to look at It's very subtle. But like I said, with the elbow, sometimes without a CT scan or arthroscopy, you're not going to pick some of those up. It comes down to more of a... And they can still have full range of motion and not be painful overtly to that But I think I tend to, in the forelimb, I'm going to assume elbow until proven otherwise. Okay, great advice.

We've had several questions roll in about PRP therapy. So, Dr. Cahill, I'm curious how you would talk about these two different options, whether or not you would ever use them in conjunction or how your decision-making process, what that might look like.

I personally favored stem cells over PRP, but PRP certainly has the advantage of being less expensive and being something that you can do in the same day treatment. I'll be totally honest with you, with the advent and my use of spring and what I have seen, I would reserve PRP at this point to tendon and ligament injuries. But even with that, I've injected a supraspinatus tendon, and I've injected an Achilles tendon with spring and had excellent results. So in my hands at this point, spring has really supplanted the use of PRP. Okay, great.

I do also, I know we've had a few questions, of course, about more specifics on doing these joint injections and joint injection protocols. So I would also direct everyone to the SPRING YouTube channel. So you can search SPRING again at spring with a Y, S-P-R-Y-N-G. and you can get a lot of great resources on the YouTube channel. We've had a few people ask kind of similar questions on the same topic and that is do either of you ever give spring injections when a patient is sedated for another procedure? Like would this be safe to do during a dental cleaning? Can either of you weigh on on what you do in clinical practice in those situations?

I've mostly just used the spring when I knew there was a giant problem. We took x-rays to see where the most of the problem was, but I haven't used it with another procedure, but I don't see why not.

Okay, great.

Anything to add there, Dr. Boone? I use it frequently when we're anesthetized for something else. I think that's the perfect time to do it. I would see no issues doing it with a dental. I will say that obviously for me I'm doing it mostly when I'm doing like typically TPLOs or a shoulder or whatever and we'll inject all the joints that it needs to at that time and save it from having to undergo a different anesthetic protocol. I really think that this is the perfect thing to have in the clinic to be able to add to that that Thank you for joining us.

The concern with a dental is, you know, how bad, you know, if it's a stage one dental and it's just a cleaning, that would be different than if there's a lot of bacteria in the mouth, which could be dangerous to the joints.

Absolutely. And I think that's a good place to call out to for a lot of these questions. I know Spring has a technical service veterinarians that are on staff to answer a lot of these common questions, especially as people are building up their comfort level with that. So I would direct everyone to utilize that service. We did have a few people question specifically about success in the carpal joint. Dr. Cahill, do you have any words to add there? I know you've spoken to a few different joints, but what about the carpus?

Most of the issues that I've seen in the carpus have been related to instability. I do not think spring is going to work effectively in that. Now, if it's truly a stable joint with arthritis, I would not see any reason that it couldn't be effective.

Okay, great.

Let's see, I know I'm throwing you guys a lot of questions. We had another good one asking how spring is different from HA. Do you guys, anyone want to speak to that, how it might differ from the HA that people are familiar with?

So the HA has some... Go ahead, Ed.

Go ahead, Kathy. All I can say is that with HA, I think the duration is much shorter, much, much shorter acting than what we're going to see with spring. I mean, spring makes for a long-term, these results have really been long-term, long duration and effective.

Okay, fantastic. Let's see. We had a few people ask a question. Dr. Cahill, did you mention that you do use it post-op on TPLOs? And then we also had another person ask, would this ever be something to give to a contralateral stifle if maybe you have had one CCL tear in a dog?

It is. Currently, I've done 16 knees where I've either done TPLO or extra capsular stabilization. Again, the knees that I'm doing that in when I'm doing my arthrotomy, they have severe degenerative changes in the cartilage, and they're painful. I mean, the TPLO is going to stabilize it, but it's not going to take care of that arthritis. So The spring syringe, the spring product is sterile, but the syringe itself is not. So the way I do that is that I will, after we close, we take our post-op x-rays to confirm everything, and then we simply reprep the joint and inject. If they have contralateral cruciate disease, like a stable partial tear, then yes, I do recommend injecting those. and I did that on my own dog River 10 months ago when we did a TPLO on one knee for a partial tear and I injected both the surgery knee and the contralateral limb just because I feel like if it's I was hoping that his is traumatic, but I don't know that. So I'm just hoping that I can calm the joint down enough to get him through that without having a contralateral TPLO. And in the knee that I did, he was relatively stable, but he had a partial tear. And I think that with incorporation in the synovial membrane, I think there's a reason to hope that spring can help resolve some of that inflammation as well.

Okay, great. Good advice. Let's see. And down to a few questions. So next question is when you have done multiple joints in a single patient, do you recommend doing both joints at the same time or one joint at a time?

I've done both joints at the same time if I'm doing two knees or two elbows on the same on the same pet.

Okay, wonderful. Dr. Cahill, anything to add there or same in your practice?

I'll be honest with you. I think there's no contraindications to doing. If you wanted to do 10 joints, I don't think it would hurt. The most I've personally done is seven, but those dogs feel better immediately. So there's no contraindications at all to me.

Okay, great. Let's see one clarification question. It says the previous slide or one of the slides says joint injections require sedation, but you mentioned anesthesia. Can you clarify which one is needed for these injections?

I do sedation and then I have propofol available if need be. It's a pretty quick procedure, so I don't use general anesthesia. I just use heavy sedation and then propofol if needed. Okay, wonderful.

Let's see, another call out as far as resources for our audience. There is a joint injection volume guideline. I believe that's in the resource tab as well. So that's a great guideline. It's based on size of dog, the target joint, and of course, individual joint characteristics. Let's see. I think we've got time for one final question. Of course, this is a big one for people, but can you guys speak to cost? Maybe Dr. Riley, I'll give this question to you. But when you're talking about this to owners, how do you talk about it in terms of cost? and yeah anything to add there.

So cost-wise, it's $295 per syringe. And depending on the size of the dog and the joints, you know, depends on how much you need. I recently, a dog that we did her knees a little over two years ago, it looks like she needs more. And so we did a comparison with what Labrella would cost for a year versus the spring. And it was about the same, but the spring, you know, actually... Treats the joint and lasts longer than a year in most cases.

Okay, wonderful information. Well, you guys are both a wealth of information. I can tell by our audience engagement. How many questions and how excited everyone is about this? So again, I would direct everyone to that resource tab. I think a lot more questions can be answered there. Another shout out to our audience. Don't forget to download your last reminder, that CE certificate from the yellow icon in the bottom of the toolbar. You can actually log back into this platform at any time if you can't download it now to do it. For those of you, please reference the box in the bottom right corner for info on how to get that CE credit. Another big thank you to both of our speakers today and a big thanks to Spring for making this conversation possible. And to our audience, have a good night and we will catch you next time.