Wednesday, February 28, 2018

New German X-ray Guidelines for Pre-Purchase Exams

We are proud to offer this article, recently published by the German St. Georg magazine. It concerns changes to the guidelines for x-rays used in Germany as part of the pre-purchase process. This is often an important step for breeders, and many of the same issues apply in North America that are discussed in this article. 

Our thanks to Edda Selinger, of JES Breeding Farm in Alberta, Canada, and owner of Holsteiner stallion Carthago Sun I, who translated the article from the German and also spoke with St. Georg and obtained permission for to print it. 

First published in Germany's oldest equestrian publication, St.GEORG.
Article copyright © 2018 St. Georg magazine, translation copyright © 2018 Edda Selinger.

Article by Jan Toenjes in the German Equestrian Sports Magazine St. Georg, dated January 1, 2018. Visit

St. GEORG Photo

The German Veterinary Association drastically changed the parameters with regard to the interpretation of X-rays used in the pre-purchaseexamination of horses. The X-ray guide for 2018 did away with the grading of X-rays. And X-raying the horse’s back has been eliminated. 

The clinical examination is the most important part of any pre- purchase examination: The veterinarian checks the general condition of the horse, including heartbeat, breathing, eyes and teeth etc. He/she touches the legs from top to bottom – wants to sense the condition of the horse. What the experienced hand feels and the keen eye alerts is more relevant than whatever is later displayed on the radiograph. This holds especially true for the clinical examination of the horse’s movement: Walk and trot on solid ground, straight and turning, lunging. Flexion tests, executed by an experienced equine veterinarian, offer additional information. 

The clinical test is concluded with o.b.B. (ohne besonderen Befund = no special findings).

Anticipated with uneasiness: The X-rays 

As part of the pre-purchase examination, X-rays are an additional tool, to pinpoint possible risks in the bone structure. This is the moment when both parties, buyer and seller, become anxious. Would the X- rays disclose something that would jeopardize the sale? A shadow on the X-ray! Hints of changes in a joint? A zyst? End of a dream! The buyer is disappointed, not only for the financial loss, but also the emotional investment coming to nothing. 

And the seller is asking himself, if his horse that had just shown a dynamic trot, suddenly became a sport invalid.

X-ray Guidelines 2018 

Professor Dr. Christoph Lischer is a friendly man with an engaging smile. But two words will exasperate him: “X-ray Grades” and “TÜV”, short for “Technischer Überwachungs-Verein” which inspects and certifies cars and other machinery to be in good working order. In his opinion many horses were absolutely unjustly labeled with “health risks” in the last few years, which hampered their future in a big way. Lischer is a member of the Expert Commission who has completely revamped the previous guidelines with the RöLF 2018 = Guidelines for the X-ray examination of the horse. These experienced veterinarians were determined to put emphasis again on the “clinical examination” and to limit the “excessive dependence” on X-ray grading. The experts decided to radically overhaul these guidelines. X-ray grading was completely tossed. The Commission is of the opinion that this school- note grading creates an expectation that one X-ray examination will completely cover any deviation in the horse’s skeleton. In the opinion of the experts from the Association of Equine Medicine, this cannot be expected of any veterinarian to determine.

New Version 

The release of the revised X-ray guidelines, including the reclassification of X-rays used in the pre-purchase examination, is supported by the Federal Veterinary Chamber, the German Veterinary Medicine Society and the Federal Association of Practicing Veterinarians. Information events are scheduled for the next few months throughout Germany. 

An important goal is, along with the explanation of the findings, to stress that the purchase of a living being = Horse is not the same as buying another commercial asset. Although lawyers will try in legal proceedings to argue, sometimes successfully, that these transactions are comparable. 

“A thorough clinical examination is the most important basis in assessing the actual physical condition of a horse in the pre-purchase inspection. The X-ray examination (and findings) is seen as an additional assessment tool and is only considered a small part in the overall report.”

This is new 

X-ray ratings were completely eliminated, i.e. categories I, II, III and IV with in-between classifications, seven in total. According to RöLF (2018) X-ray images will be evaluated as follows: 

Pictures which show the normal X-ray anatomy or anatomical variants that are of no functional importance, are graded “o.b.B.”= no findings. 

All findings that deviate from this “normal” X-ray anatomy, are noted in the Report. These are either findings where the risk of causing a lameness cannot be safely assessed, or findings that are subject to a lameness risk. These latter “risk findings” will be especially noted. 

The new approach by the Commission is based on current international text-books and scientific studies. Veterinarians have still access to a detailed description of their findings under a reference number. Furthermore, an App has been developed where the examiner can access sample X-ray pictures. This enables him, via Smartphone or Tablet, to check immediately how to interpret his findings. 

Prior to RöLF (2018) twelve X-ray pictures were "standard," to which could be added pictures of knees and spine.

Additional X-ray pictures 

The RöLF (2018) no longer includes X-raying the back (spine) of the horse. Scientific studies have shown that a prognosis based on such images is dubious in pre-purchase examinations. A slightly changed position of the X-ray machine can turn a supposedly healthy back into a serious case of “Kissing Spines”. When these spots are selectively X-rayed, often a different and better picture of the vertebras evolves – the Patient has a sound spine after all. 

Theses covering many cases have shown that back problems can differ tremendously in clinical and X-ray presentation. According to Professor Lischer: “New scientific research indicates that, up to now, these findings have been over-interpreted”.

On the other hand we found that with regard to hoof, hoof and fetlock joint more pictures are needed, to cover the crucial areas well. “The parallelism of the hoof wall with the outline of the navicular bone offers an important indication, if the horse possibly suffered from “Hufrehe” = Founder at one time. This can only be established with a clear picture from the side of the hoof”, notes Professor Lischer from his experience. To accommodate such and similar cases 18 pictures are now standard. 

Professor Lischer: “The previous standard projections do not cover all possible areas for scrutiny. The assessment in the 2018 X-ray Guide is based now on 18 images. A standard X-ray picture, for instance, does not always conclusively show, if a deviation is indeed inside a tendon or band. “Shaded areas” are not always an indication of a tendon injury. They may be due, for instance, to a calcified spot in the subcutaneous area or a scar in the skin – completely unrelated to the bone structures.” 

If the veterinarian feels a take from a different angle or an Ultrasound would clarify his findings, the client should be consulted. Such examinations may offer additional information which as such are not included in the RöLF (2018). The veterinarian has to discuss the results of these additional images with the client as they are not included in the contract for an X-ray assessment. 

Summing up: Every horse is an individual and “indications with regard to the general condition of a riding horse by radiograph” is not possible. For this reason “TÜV” and “X-ray Grades” have been eliminated. 

“We should not forget that above all, we are assessing healthy riding horses that are carefully examined in a pre-purchase situation”, says Professor Lischer.

These Locations will be X-rayed 

18 Standard X-ray pictures outlined in the X-ray Guide 2018.

Front Legs
1. Hoof 90° focused on the Navicular bone
2. Toe 90° focused on the Fetlock joint
3. Hoof 0° According to Oxspring, picture of Coffin bone and Pastern as well as part of the Pastern bone. It is strongly recommended to remove any shoes. If not removed, the examining veterinarian has to document this fact.

Hind legs
4. Toe 90° focused on the Fetlock joint with most of the hoof in the picture
Ancle bone
5. Ankle bone 0°
6. Ankle bone ca. 45°
7. Ankle bone ca. 135°

8. Knee ca. 90°
9. Knee ca. 180°
Not all mobile X-ray machines are capable of producing good pictures of the knee. If in doubt, a clinic with suitable equipment should be used.

Interview with Prof. Lischer 

St. Georg: What is the main difference between the new X-ray Guide and its predecessors 

Prof. Lischer: Dropping the ratings of X-rays. In our experience, they created more confusion than assisting in the assessments. 

But the purchaser knew what to do with X-ray rating I. Super. Buy! 

We should forget about the X-ray ratings as soon as possible. The problem was: Hardly any horse presents “perfect” X-ray pictures. But there are many cases with X-ray deviations all over the world that would unlikely lead to lameness. 

Until the TÜV separates us 

The word TÜV should be eliminated from the equine vocabulary! The TÜV was established to check-up on boilers of locomotives. The horse is not a machine, therefore “No TÜV”. 

You are now incorporating more standard X-ray pictures, but dropping the X-rays of the back? 

We defined additional positions for taking radiographs, since experience has shown that only in this way important sections can be examined thoroughly: Pastern and Fetlock joint of the fore legs are now X-rayed separately. The KNEE section will be X-rayed from two levels – from the side as before and from back to front. We also X-ray the Hock now on three levels instead of two. 

… the back? 

This was dropped in the RöLF 2018 since research has established that the value of these pictures is inadequate. Adding to this, we have often seen radiographs that do not reflect the actual condition of the Spine and its Vertebras.

If the horse shows clinical signs, i.e. pain when palpated or limits of back mobility, X-rays of the back can be taken, if the client asks for it. But this is not part of the standard Pre-purchase assessment. If we have a finding in the clinical examination, it should always be taken seriously. 

How can I be certain that my veterinarian is competent in Pre- purchase assessments? Is there a Certification process? 

This has (not yet) been introduced, but would in my opinion be a good idea. If the purchaser asks around, he should find a competent equine veterinarian with sufficient experience in pre-purchase examinations. If a colleague does this only sporadically, he may not be the right one.

The History of the X-ray Guide 

The new X-ray Guide, in force on January 1, 2018, was compiled by the X-ray Commission of the Society for Equine Medicine. The Commission members were Dr. Gerd Brunken, Dörverden; Dr. Werner Jahn, Bargteheide; Prof. Dr. Christoph Lischer, Berlin; Dr. Eberhard Schüle, Dortmund; and Prof. Dr. Peter Stadler, Hannover. 

The X-ray Guide is a German feature. A first initiative was taken in 1993 to standardize radiographs with regard to the Pre-purchase assessment of horses and make them comparable. The first Edition was released in 2002, which included X-ray ratings. The Guide was updated in 2007 and the X-ray classification defined differently. 

Also this version did not have the intended result. It led to the emphasis on radiographs to the detriment of the clinical examination, which scientific research did not support. The new version 2018 incorporates a completely new approach. Any findings are no longer rated, but described. The consumer has now the advantage of a clear picture with regard to findings that are red-flagged.

Career Path of University Professor Dr. Christoph J. Lischer Dipl. ECVS (European College of Veterinary Surgeons), finished studies at Zurich University in 1989, worked there as Intern till 1993. Additional training in the USA 1993/1994 and in China 1997/1998 (acupuncture). After some time as University Lecturer at Vetsuisse, Zurich, he became Professor of Equine Surgery in Glasgow. He is now the ”CEO” of the Equine Clinic, General Surgery and Radiology of the department of Veterinary Medicine at the Free University of Berlin.

Click here to read the original article in St. Georg magazine in German

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