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18th May 2006
by Kimberly S. Herbert
Modern surgical and recovery techniques, combined with meticulous care, have been the prescription that has brought Nureyev so far through an ordeal that would have spelled destruction for many other horses.
Dr. J.D. Howard, resident veterinarian for Walmac International (John T.L. Jones Jr., general manager) near Lexington , has been closely attending Nureyev since the stallion's accident on May 5. On that morning, Dr. Howard received a call informing him that a mare was arriving to be bred to Nureyev. The stallion was brought up to perform the service, then turned out in his paddock.
Dr. Howard returned to his office and poured a cup of coffee. Not more than 10 or 15 minutes had elapsed, when the call came that Nureyev was badly injured. The son of Northern Dancer was standing at the gate holding his right hind leg up. When Dr. Howard arrived, he knew immediately that the injury was serious.
"The part (just below his right hock in the joint) was just like it was on a swivel," recalled Dr. Howard. "It just flopped. I thought, 'There's no way.' "
A fear of the worst did not deter the effort, however, and Dr. Howard bandaged the leg to keep the fracture site from being unduly jarred and moved. A Hayes Horse Ambulance was called, and Nureyev was transported to the Hagyard-Davidson-McGee surgical clinic, where the leg was radiographed.
"It was a complete luxation of the proximal intertarsal joint," explained Dr. Howard. "Most of them don't even try to get fixed with an injury like that. But considering who he was, we thought we should at least try something.
"Nobody had much hope, before the surgery, during the surgery, or even after the surgery, really. We probably gave him a 10 percent shot (of making it) even after the surgery. It went back together real nice. Dr. (Paul) Thorpe did a super job getting it back."
Dr. Thorpe was assisted in the surgery by Dr. J.D. Wheat, head of the veterinary surgery department at the University of California at Davis, Dr. Michael A. Spirito of Hagyard-Davidson-McGee, and Dr. Craig Franks. Dr. Wheat happened to be in town for the Kentucky Derby (gr. I) and canceled his return flight to assist in the surgery.
Four screws were surgically inserted through the joint to stabilize it, then a full leg cast was put on from Nureyev's foot to his stifle. Nureyev remained in a recovery stall at the surgery unit of Hagyard-Davidson-McGee for about a week, "to find out if he was going to make it," said Dr. Howard.
"For the first couple of weeks we didn't know if we were going to have blood supply in that area or not," said Dr. Howard. "We thought we'd change the cast one of these days and the leg would just be rotten. So probably every five minutes, someone was trying to smell down in the cast to see if we could smell anything. We were paranoid about it."
"Right after the surgery, he got around pretty good," said Dr. Howard. "After talking to Dr. Thorpe we decided possibly because it was completely dislocated there was a lot of nerve damage in there. The fracture site and probably most of the leg was numb. So he did get around all right. I think that gave us a few false hopes, initially."
Nureyev recovered in a sling, which helped support his weight with a canvas-type full-belly strap attached to an overhead hydraulic hoist. The sling allowed him some freedom of movement while keeping him upright. After about two days of rapid movement, the fatigue and pain began to tell.
"Probably eight or 10 times I think he tried to give up on us," recalled Dr. Howard. "He would get so fatigued and tired he'd slump down in the sling and get that cast all the way underneath him. Then he tried a couple of times to get it under him to stand. A couple of times it was like he said, 'to heck with it,' and wouldn't even try to get up.
"The only way we could get him going was to slap him around his head to make him mad. Then when he got mad enough, he'd lay his ears back and come at you. Then he'd get to his feet. I guess we did that a dozen times, anyway, the first few days. He sure had that give-up look about him."
After Nureyev accepted the cast and the sling, and it was decided he might recover, there was the problem of where to stable him. He was becoming agitated in the close confines of the recovery stall, and the regular hospital barn at Hagyard-Davidson-McGee also housed mares and foals -- not proper company for a recuperating stallion.
A special single-stall barn was built on the edge of the facility's property, about 30 yards from the hospital barn and 25 yards from the surgery center. The wooden plank barn was built in about three days, with a single 18-by-18-foot stall and an alcove where an attendant could sit. The barn contained a sling with hydraulic hoist, and air conditioner, lightning rod, windows, and fans. One end of the barn could be opened completely, or with a board in place would be made to resemble a half-door on a stall, only larger. A phone was installed, and a separate metal building was erected for storage.
Once the barn was built, however, there arose the problem of how to get Nureyev from the surgery recovery stall to his new housing without further injury. He could move around on the full-leg cast, and Dr. Howard said he thought the horse physically could have made the trip walking. The danger would be in his becoming excited or agitated by other horses at the facility.
"When I worked in California ," said Dr. Howard, "they had those real nice ambulance vans for horses that break down on the racetrack. They are on hydraulics. Press a button and it lowers flush to the ground, so he horse doesn't have to step up. Of course, California was too far, but Mr. Jones called around. He knew a person at Louisiana Downs that was in charge of the racetrack, and they had a similar kind of ambulance. So they were very nice and they put their van on a semi-truck and hauled it here overnight.
"So we got to use a nice ambulance van. We backed it up to the doors (of the surgery suite), but he still had to walk probably 20 feet from the recovery stall out to the trailer. It was not a long ride -- probably not more than 30 yards from the front door to his barn -- but it felt like it took three days to get there.
During days, there were usually three people attending the stallion -- Dr. Howard, Kenneth Aubrey, the assistant farm manager at Walmac, and Aida Bossio. At night, Nureyev's regular groom, Wayne Reinsmith, would stay, with either Greg or Jeff Banks, brothers that work at Walmac, also present.
After Nureyev was moved into his own barn, he experienced about six weeks of improvement. He seemed to like the barn, and he could maneuver the sling around his stall. The sling was on an overhead rail to allow forward and backward movement as well as let Nureyev turn completely around under his own power.
Nureyev's leg cast had been changed three times in the first six to seven weeks after surgery, and it was decided to change it one more time. Everything was radiographically in place, and his injury was healing nicely. He was tranquilized in his stall and laid down on a mat. With every cast change, Dr. Howard had worried about it being too tight or something bothering the stallion. This time, the worry became reality.
"I stuck around that evening," said Dr. Howard. "Along about midnight , he broke out in a cold sweat a starting panting like a dog -- doing nosedives in the sling. I was afraid the cast was too tight and medicated him through the night. The next morning, I called Dr. Thorpe, and he came early and we decided maybe the cast was too tight and removed it. At that time, it was healed enough that we thought it might withstand the leg just being supported with bandages."
The cast was removed, and standing bandages were applied. The change relieved a large part of the stallion's discomfort, but only for a few hours. Soon, Nureyev again started sweating, panting, and showing signs of severe pain.
The leg was radiographed and it was discovered that somehow two of the four screws had been broken. One was cracked, but both pieces were still in alignment. The other, which was on the inside of the leg in the worst area of the break, was badly broken and had to have one broken end removed.
"That was the start of all our problems," said Dr. Howard with a sigh. "Nureyev started experiencing new pain, and after seven weeks or so with the stress he already had, that's when things started happening."
Nureyev did not want to use his leg, and muscle atrophy became a problem in the leg and hip. Since the leg had gone from a fairly stable condition with the cast to an unstable condition without it, the decision was made to reapply the cast. Without the cast, the injured area was allowed more movement, and with the movement came more pain. The cast was put on, but Nureyev quit eating and became lethargic.
Then, in the latter part of June, Nureyev was afflicted with a respiratory infection. The problem was not pneumonia, but was serious. After treatment, the stallion began to feel better.
Then on the Fourth of July, Nureyev "just wasn't right," said Dr. Howard. "He didn't eat. In the evening, he gradually got worse. His temperature was real high. He started panting. He had a bowel movement that was real loose -- even worse than a cow -- and it had a strong odor.
"We were afraid he was going to try to break into colitis. We worry about that with horses that are under stress for a long period of time."
A blood sample was drawn and taken to Dr. Doug Byars and Dr. Jim Becht at Hagyard-Davidson-McGee's diagnostic medicine facility. Nureyev's electrolytes were depleted, and his white count was low. He was, in fact, on the verge of colitis.
"It probably would have been the end of him if he had gotten colitis at that point in time," reflected Dr. Howard.
For 48 hours, Dr. Howard gave Nureyev intravenous fluids, along with antibiotics. When the stallion showed no interest in eating, he also was given nutrients intravenously. After three days, Nureyev began to show sign of recovery.
"We won that battle," said Dr. Howard with satisfaction. "He was pretty pitiful looking for three or four days. That was the worst he'd been to that point."
Nureyev's stool firmed up and the odor gradually went away, but his leg still was not responding as it should. He had gone from a horse that was walking pretty well with a cast to a horse that was three-legged lame and had been very sick a couple of times in seven or eight weeks.
For several weeks after the incident on the Fourth of July, every day was different for Nureyev. Some days he would walk and move around without much problem on his leg; the next day he would be lame. He was easily fatigued and had lost much of his will to fight. He was able to tolerate a cast for about a week, then would begin banging it against the side of the stall.
(The casting process was handled differently after his bout with the intestinal problem. He was sedated and left to stand during the procedure. Nureyev would end up wearing nine or 10 casts in a 14-week period.)
Nureyev had been severely stressed by his fight with intestinal disease.
"He'd slump down in the sling, but he really couldn't rest," said Dr. Howard with empathy. "The sling was real binding. To me, he was just getting worse by the day. He just didn't act like he wanted to do anything. He'd stand around, eat a little bit -- it was all due to him being so tired and stretched out."
A crisis had arrived. Dr. Howard knew that Nureyev was failing. The stallion's great strength was fading, and his will to fight was ebbing. Something had to change, or Nureyev would not survive.
"So, one evening, I had to send Kenny (Aubrey) back to the farm and I was sitting there looking at him by myself and said, 'Well, I'm the one supposed to be taking care of him' So I made a decision.
"I had the guys (working at the surgery unit) bring over the big blue mat (which is about eight inches thick and 10 feet long). I figured this might be the end of him, trying to do this, but he was heading down that same path anyway.
"I was in the stall by myself, and he was slumped down in the sling trying to rest. Real easy, I pulled that mat over right next to him and laid it down. With the hoist, and rubbing on him and talking to him, I let him down maybe four or five inches. I went lower and lower. About the fifth time, he was pretty close to being all the way on the mat. I pushed him over and lowered it.
"For the first time in 59 days, he finally got off his feet," marveled Dr. Howard.
Each day after that first attempt, Dr. Howard would very gently lay Nureyev down for a period of rest -- from one to 3 1/2 hours -- then hoist him back up with the sling. Nureyev began to be more confident with the procedure and with other people around, and it became a twice-a-day ritual.
From 59 days after his accident to the present, Nureyev is laid down daily on his blue mat to rest.
"That's probably the biggest part of him gradually getting better," said Dr. Howard. "He just started being a different horse after that first day when he got to lay down. It kind of kept him going. There are not too many horses -- especially stallions -- that would let you lay them down like that and get them back up."
In August, after the horse's 14 weeks in casts, Dr. Howard began to worry about the leg becoming useless.
"The longest you hear of a cast being on is seven, eight weeks, maybe 10 weeks in a rare instance," said Dr. Howard. "Usually if a horse has to keep one on past 10 weeks, the thing isn't going to heal. The leg is in a cast and not being used. The bone becomes brittle. They've got to get weight-bearing on it at a maximum of 10 weeks or you're looking for a lot of complications regardless of whether the initial injury heals or not."
Changing the cast was a very painful experience for Nureyev. The leg that had been held firmly in place suddenly was given movement. When Nureyev tried to move it without the cast, the pain was terrible.
"There were a couple of times I barely got the cast back on, even with a lot of medication for the pain," said Dr. Howard.
The veterinarian had decided the cast would have to come off, but was worried about the transition from being firmly supported to having little support on the injured limb. If Dr. Howard tried to use only bandages, there would be movement in the injured area and more pain. With pain comes stress, and with stress comes other problems -- laminitis, colitis, or perhaps another respiratory infection.
"So we decided to go with a brace," said Dr. Howard.
When the last change was made at about 14 weeks, Nureyev was anesthetized and laid down one last time. With the cast removed, Nureyev's right hind leg was measured so a brace could be ready when the last cast was removed.
To obtain a brace, Dr. Howard contacted Mike Farley, who had been involved in brace work with humans before starting work with foals and adult horses. Farley said there was an adult brace in Lexington that was not being used. The brace formerly had been worn by the dam of Miswaki (who stands at Walmac).
The brace was re-fitted by Farley, and blacksmiths Steve Collins and David Nadeau worked with him to make a shoe that would attach to the brace and hold it in place. The brace was put on two weeks after the last cast had been applied. Dr. Howard said it worked very well in place of the cast, and Nureyev had little pain while wearing the brace.
"It gave him just enough support and confidence," said Dr. Howard. "He took right to it and started bearing weight on it. That was another big hurdle to get over."
The brace was kept in place continuously for about four weeks after Nureyev was taken out of his last cast. About the first of September, Dr. Howard gradually started weaning Nureyev from the brace. He was out of the brace for 30 minutes the first day, then an hour the next day. Nureyev was worked up to having the brace off 12 hours at a time. On Sept. 18, the brace was removed permanently.
In his final three days of wearing the brace, Nureyev was allowed outside his stall without the sling for the first time. He was walked about 15 feet away from the barn to a grass and dirt area outside his stall. Then on Sept. 19, Nureyev was walked for the first time outside without support for his injured leg.
"He bears weight on it and walks on it good," said Dr. Howard, "but he still has some constant, dull pain, and probably will until that joint is completely fused. Radiographically, it looks like it's about 60 % there.
"Until it fuses, there probably is some little movement in that injured area, which is real painful. He still experiences some pain, but it's not intolerable pain where he has to be medicated or it keeps him from eating or doing what he wants to do."
With the use of casts comes muscle atrophy to an injured limb. Since August, Dr. Howard has been working with Nureyev to try to get the muscle atrophy reversed. He, along with Mimi Porter, has used electro-stimulation, ultrasound, and laser therapy, as well as the hand-walking.
"He's gradually coming back," said Dr. Howard with satisfaction. "When he first came out of the cast, his flexor tendons and his suspensory ligaments felt like strings of spaghetti. You could hardly palpate his suspensory ligament."
"It's going to take a lot of time, but we're going in the right direction," surmised Dr. Howard. "Whether or not he'll be used next season, we really haven't decided. If he is used, it will be delayed as far as the regular season goes. But we really can't make that decision right now until we see how good he gets in the next three-to-four weeks."
Under construction at Walmac is a private barn and breeding facility for Nureyev. He is scheduled to remain at Hagyard-Davidson-McGee until the middle of November.
The last phase of Nureyev's convalescence before he could be returned to Walmac will be weaning him away from the sling that he has worn since May.
"Before we move him to the new facility, he needs to be confident in laying down and getting up on his own without the sling," said Dr. Howard. "I'd hate to undo any healing. The joint is pretty stable now, but I just don't want to take that chance. I want to get as much healing in that joint as possible and stabilize it before we try to move him."
Nureyev's new stall at Walmac will be twice as big as his current 18-by-18 foot home because he will not be able to be turned out for a long time. Dr. Howard said Walmac will install an Aquatred (underwater treadmill) to use in rehabilitating Nureyev and will continue with the hand-walking for at least a year.
"I think he's got a pretty good chance (of being breeding sound)," said Dr. Howard. "I think nobody would want to say one way or the other right now. I think a lot of people would be disappointed if he couldn't breed.
"He's beaten the odds, by a long way."