In 1984, Casscellsstated "Diagnostic arthroscopy and, perhaps
evenmore important, arthroscopic surgery constitute what is
probably the outstanding achievement in orthopedic surgery
in the past decade" (Casscells1984). While the author of this
statement would probably admit to being biased, it is a
fair reflection on the success and acceptance of the role of
arthroscopy in human orthopedics. Although generally
considered a modern surgical procedure, the technique took
considerable time to develop. The first endoscopic examin-
ation of a knee joint was performed in 1918 by ProfessorTakagi
at the University of Tokyo (Takagi 1933). Later the technique
was pioneered in the United States by Burman and colleagues
(Burman 1930, Burmanet aI1934). The first practical arthro-
scopewas developed by Watanabe (a pupil of Takagi) in 1960
(Watanabe 1960), and he also developedsomebasic principles
for arthroscopy of the knee. In 1965, his techniques were
brought to North American by Robert Jackson of Toronto
(Jackson1987).
In the early 1970s, the arthroscope began to achieve real
clinical use (Casscells1971, Jackson& Dandy 1972), and the
first course in arthroscopy of the human knee in the United
States was given in 1973. The procedure of diagnostic
arthroscopy initially met with considerable skepticism within
circles of human orthopedic specialists until its value was
demonstrated in the total evaluation of the knee (Dandy &
Jackson 1975, Watanabe et a11978, Casscells1980). There-
after, arthroscopy became firmly established as a diagnostic
tool in human orthopedic practice, and these early days have
been the subject of reviews by Casscells(1987) and Jackson
(1987); the interested reader is referred to these sources for
more information.
In the middle of the 1970s, arthroscopy moved into the
second phase of its development, with the realization of the
potential to perform surgery under arthroscopic visualization
(O'Connor 1974, 1977, Dandy 1981, Jackson 1983). The
development of appropriate techniques and suitable instru-
mentation followed (Johnson 1977, O'Connor 1977, Dandy
1981). It also became apparent that the therapeutic advan-
tages of arthroscopy included not only the surgical procedures
per se (which can be grouped under the heading of surgical
arthroscopy or arthroscopic surgery) but also the benefits
from joint lavage and lysis of adhesions (Jackson 1974,
O'Connor 1974). The advantages were low morbidity, early
postoperative movement and reduced hospitalization times.
Impressive advances then occurred in both technology
and technique.The first arthroscopic surgery was meniscectomy
in humans, followed by procedures such as patellofemoral
malalignment, abrasion arthroplasty, shaving for chondro-
malacia, and synovectomy. The advantages of arthroscopic
meniscectomy have been well documented and arthrotomy is
now a rarity (Pettrone 1982, McGinty 1987). The manage-
ment of conditions involving the meniscus is also a good
example of how new conceptshave evolved from the increased
diagnostic accuracy afforded by arthroscopy and the potential
to re-examine a knee with minimal morbidity Gackson1986).
The most important of these new concepts was probably the
preservation of meniscal tissue, which led to the technique of
partial meniscectomy and then to initial arthroscopic repair
(Keene et al 1987). The development of more complex
procedures followed and cruciate repairs are now performed
arthroscopically (Shrock & Jackson 1996). The use of
arthroscopy in man now encompassesthe shoulder, elbow,
wrist, digital, ankle, hip, and temporomandibular joints
Gohnson 1986). It is the most common orthopedic procedure
performed today; current estimates cite approximately 9000
orthopedic surgeons performing arthroscopy in the United
States alone (McGinty 1987).
Arthroscopy in the horse has gone through a similar
evolution. In 1949, the human pioneer Watanabe reported
arthroscopy of the equine hock. Large animal arthroscopy
was first presented in the German literature in 1973
(Knezevic pers com 1984) and appeared in the English
language in 1975 and 1977 (Smith 1975, Knezevic& Wruhs
1977). Diagnostic arthroscopy of the equine carpus was first
reported in 1974 (Hall & Keeran 1975), but was described
more extensively by McIlwraith & Fesslerin 1978. Reports of
its use in other joints followed and diagnostic arthroscopy of
the equine stifle joint was reported in 1982 (Nickels & Sande
1982).
As in human orthopedics, use of the arthroscope in horses
extended into surgical practice as technology and techniques
of triangulation developed. Some surgical manipulations
under arthroscopic visualization in the horse were mentioned
by Knezevic & Wruhs in 1977, but arthrotomy remained the
acceptedmeans of completing surgery. The first description of
equine arthroscopic surgery involved the carpus (Ommert
1981, Valdez et al1983) and further descriptions involved
the carpal, fetlock, tarsocrural, and femoropatellar joints
198J). Uescriptions of diagnostic and surgical arthroscopic
procedures in the carpal, fetlock. tarsocrural and femoro-
patellar joints were detailed in textbook form in 1984
(McIlwraith 1984b). At that time, the first author used
arthroscopic surgery as the routine method of joint surgery
for virtually all conditions, with the exception of subchondral
cystic lesions of the medial condyle of the femur. some carpal
slab fractures. and fractures of the proximal sesamoidbones.
Arthroscopic techniques were subsequently developed and
described in the second edition of the book in 1990
(McIlwraith 1990a). The use of arthroscopic surgery in the
treatment of third carpal slab fractures was reported by
Richardson in 1986; its use in the treatment of subchondral
cystic lesions in the medial condyle of the femur was docu-
mented originally by Lewis in 1987. Techniques for diagnostic
and surgical arthroscopy of the shoulder were described in
1987 (Bertone & McIlwraith 1987. Bertone et al 1987.
Nixon 1987). At the time of the second edition, arthroscopy
had also been performed in the distal interphalangeal.
proximal interphalangeal, and elbow joints. Arthroscopes
had also been used in the sinuses and tendon sheaths
(McIlwraith 1990a).
By 1990, arthroscopy in the horse had gone from being a
diagnostic technique used by a few veterinarians to the
accepted way of performing joint surgery. Prospective and
retrospective data substantiated the value of the technique in
the treatment of carpal chip fractures (McIlwraith et al19 8 7).
fragmentation of the dorsal margin of the proximal phalanx
(Yovich & McIlwraith 1986). carpal slabfractures (Richardson
1986), osteochondritis dissecans of the femoropatellar joint
(Martin & McIlwraith 1985a, McIlwraith & Martin 1985),
osteochondritis dissecansof the shoulder (Bertone et alI987).
and subchondral cystic lesions of the femur (Lewis 1987).
During this period. the use of diagnostic arthroscopy led to
the recognition of previously undescribed articular lesions,
many of which are now also treated using arthroscopic
techniques.
Since 1990. there has been further sophistication of
techniques: new ones have been developed and treatment
principles have been changed based on new pathobiologic
knowledge and further prospective and retrospective studies
defining the success of various procedures. Many of these
recent advances have been recorded in a recent publication
(McIlwraith 2002a). For example. there has been further
documentation of success rates following arthroscopic
removal of fragments from the dorsoproximal margin of the
proximal phalanx (Kawcak & McIlwraith 1994, Colon et al
2000). Advances in understanding the pathogenesis of
osteochondral disease and fragmentation in the carpus and
fetlock have also been reported (Kawcak et al 2000. 2001).
which naturally led to progress in diagnosis and treatment.
Parameters for the surgical treatment of joint injury have
been carefully defined (McIlwraith & Bramlage 1996).
Arthroscopic treatment of fractures in the previously con-
sidered inaccessible palmar aspect of the carpus has been
described (Wilke et al 2001) together with arthroscopy of
the palmar aspect of the distal interphalangeal joint
also led to understanding of the contribution of soft tissue
lesions to joint disease. In the carpus, tearing of the medial
palmar intercarpal ligament was first reported by Mcllwraith
in 1992 and its implications discussed by Phillips & Wright
(1994) and Whitton et al (1997a,b,c).
In the fetlock joints, successrates following arthroscopic
removal of osteochondral fragments of the palmar/plantar
aspect of the proximal phalanx have now been documented
(Foerner et al 1987, Fortier et al 1995), and results for
arthroscopic treatment of osteochondritis dissecans of the
distal dorsal aspect of the third metacarpal/metatarsal bones
have been reported (Mcllwraith & Vorhees 1990). Results of
arthroscopic surgery to treat apical (Southwood & Mcllwraith
unpublished data), abaxial (Southwood et al 1998a), and
basilar (Southwood & Mcllwraith 2000) fragments of the
sesamoidbones are also available in the literature.
Since the last edition, the results of arthroscopic surgery
for the treatment of osteochondritis dissecans in the tarso-
crural joint have been documented (Mcllwraith et al1991)
and the arthroscopic approach and intra-articular anatomy
of the plantar pouch of the joint have also been described
(Zamos et aI1994).
Considerable advances have been made in arthroscopic
surgery of the stille joints. The results of arthroscopic surgery
for the treatment of osteochondritis dissecans of the femoro-
patellar joint have been reported by Foland et al (1992). The
syndrome of fragmentation of the distal apex of the patella
was recognized and its treatment reported (Mcllwraith
1992). The use of arthroscopic surgery for treating certain
patellar fractures was discussed in the previous edition
and has since been reported in the literature (Marble &
Sullins 2000).
In the femorotibial joints, the use of arthroscopic surgery
to treat subchondral cystic lesions of the medial condyle of
the femur (Howard et al19 9 5) and proximal tibia (Textor et al
2001) have been reported. Cartilage lesions of the medial
femoral condyle have also been described (Schneider et al
1997). Arthroscopy has allowed great advancesin the recog-
nition and treatment of meniscal tears and cruciate injuries
(Walmsley 1995, 2002; Walmsleyet al2003). It has also been
used to remove fragments from the intercondylar eminence of
the tibia (Mueller et al1994) and allow internal fixation of
another case of intercondylar eminence fracture (Walmsley
1997). Techniqueshave also beendevelopedfor diagnostic and
surgical arthroscopy of the caudal pouches of the femorotibial
joints (Stick et al 1992, Hance et al 1993, Trumble et al
1994). In addition, a single cranial arthroscopic approach to
all three joint compartments has been developed by Boening
(1995) and further reported by Peroni & Stick (2002).
Diagnostic and surgical arthroscopy of the coxofemoral
joint has been described (Nixon 1994, Honnas et al1993),
lesions identified and surgical treatments performed. The use
of the arthroscope is also no longer confined to the limbs, and
the anatomy of the temporomandibular joint has been
described recently (Weller et aI2002).
The use of arthroscopy in assisting repair with internal
fixation of articular fractures has become routine. This
includes fractures of the metacarpal/metatarsal condyles and
carpal slabfractures (Richardson2002, Bassage& Richardson
1998, Zekas et aI1999), Techniques have been described for
evaluation and treatment of so-called small joints, such as the
distal and proximal interphalangeal joints (Boening 2002,
Boening et a11990, Vail & McIlwraith 1992, Schneider et al
1994), In addition, joints in which lamenessis less commonly
encountered. such as the elbow can also be examined
and treated arthroscopically (Nixon 1990),
Arthroscopic techniques for cartilage repair have been
developed and recently reviewed (McIlwraith & Nixon 1996,
Nixon 2002b), In general, we have tried to developtechniques
that enhance both the quantity and hyaline characteristics of
cartilage repair tissue while using the well-documented
advantages of arthroscopic surgery. Techniques include
cartilage debridement, cartilage reattachment. chondroplasty
and subchondral microfracture (micropicking) (McIlwraith &
Nixon 1996, Frisbie et al1999, Nixon 2002b).
The use of the arthroscope for evaluation and treatment of
tendon sheath problems has been another area of major
advancement. The arthroscope has been used to assessand
treat tenosynovitis of the digital flexor tendon sheath, and
techniques for endoscopically assisted annular ligament
releasehave beendescribed (Nixon 1990b. 2002a. Nixon et al
1993. Fortier et aI1999). Intrathecal longitudinal tears of
the digital flexor tendons have also been described by Wright
& McMahon (1999) and by Wilderjans et al (2003). The
arthroscope has also been increasingly useful for carpal sheath
conditions (McIlwraith 2002a. Nixon et a12003, Textor et al
2003); arthroscopic approaches have been described by
Cauvin et al (1997) and Southwood et al (1998b). Removal
of radial osteochondromas using arthroscopic visualization
is a significantly improved technique to open approaches
(Squire et al 1992) and has produced excellent results
(Southwood et al1999, Nixon et al2003, McIlwraith 2002b).
The use of tenoscopic division of the carpal retinaculum to
openthe carpal canal has been recently described (Textor et al
2003) and superior check ligament desmotomy is now done
arthroscopically (Southwood et al 1997, Kretz 2001. Tech-
niques for tenoscopy of the tarsal sheath have been described
by Cauvin et al (1999) and methods of treatment reported by
Nixon (2002a).
Synovial bursae have also been examined with the
arthroscope. Techniques have been described for arthroscopy
for the intertubercular bursa (Adams & Turner 1999), the
calcanealbursa (Ingle-Fehr & Baxter 1998). and the navicular
bursa (Wright et aI1999). To date, reports in the literature
have beendominated by casesof contamination and infection.
but lesions which explain previously undiagnosed lameness
referable to these sites have now been identified and treated
endoscopically.
Specific advantages of arthroscopy as a diagnostic
and surgical tool are mentioned throughout this book.
General advantages of the technique previously recognized
include:
1. An individual joint canbeexaminedaccuratelythrough a
small (stab)incision and with greateraccuracythan was
previously possible. With the availability of such an a
traumatic technique. numerous lesions and "new" con-
ditions that are not detected radiographically can be
recognized.
2. All types of surgical manipulations can be performed
through stab incisions under arthroscopic visualization.
The use of this form of surgery is less traumatic, less
painful, and provides immense cosmetic and functional
advantages. Surgical intervention is now possible in
situations where it would not have been attempted
previously. The decreasedconvalescencetime with earlier
return to work and improved performance is a significant
advance in the management of equine joint problems. The
need for palliative therapies is decreased,as is the number
of permanently compromised joints.
The initial optimism and advantages of arthroscopy in
equine orthopedic practice suggestedin the first two editions
of this book have been substantiated. It is now accepted that
equine arthroscopic surgery has revolutionized equine ortho-
pedics. Problems have and will continue to be encountered,
but we know now that many are avoidable. Although the
technique appears uncomplicated and attractive to the
inexperienced surgeon, some natural dexterity, good three-
dimensional anatomical knowledge, and considerablepractice
are required for the technique to be performed optimally.
Experience and good case selection are of paramount
importance and reiterating a passagefrom the first edition of
this book remains as pertinent today:
In 1975. arthroscopywas underused and needlessarthrotomies
were performed. The pendulum is now swinging rapidly in the
other direction. The current tendency in arthroscopy is toward
overuse. Some surgeons seems to be unable to distinguish
between patients who are good candidates for arthroscopy and
thosewho are not. and the trend istoward arthroscopy in patients
in whom little likelihood existsof finding any treatable disorder.
(Casscells1984).
Threeyearslater,anotherauthor statedthat
of those 9,000 North American surgeonsand the other surgeons
of the world performing arthroscopy,many are ill-prepared and
are therefore,not treating their patients fairly, Overuseand abuse
by a few is hurting the many surgeonswho are contributing to
orthopedic surgery by lowering patient's morbidity, decreasing
the cost of health care, shortening the necessarytime of patients
returning to gainful employment,and adding to the development
of a skill that has madea profound change in the surgical care of
the musculoskeletalsystem. (McGinty 1987).
Arthroscopy remains the most sensitiveand specificdiagnostic
modality for intrasynovial evaluation in the horse. This
is somewhat in contrast to human orthopedics, where
arthroscopy predominately is used for surgical interference
and much of its diagnostic function has or is being replaced
by magnetic resonance imaging (MRI). Arthroscopy has
continued to be of great benefit in the horse, with increased
recognition of soft tissue lesions in joints, tendons, sheaths,
and bursa. However, as stated above, while there are many
benefits gained from arthroscopy, it is technically demanding
and the need for training remains.
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Pettrone FA. Meniscectomy: arthrotomy versus arthroscopy. Am J
Sports Med 1982: 10: 355-359.
Phillips TJ, Wright 1M. Observations on the anatomy and pathology
of the palmar intercarpal ligaments in the middle carpal joints of
Thoroughbred racehorses. Equine Vet J 1994; 26: 486-491.
Richardson DW. Technique for arthroscopic repair of third carpal
bone slab fractures in horses. J Am Vet Med Assoc 1986; 188:
288-291.
Richardson DW. Arthroscopically assisted repair of articular
fractures. Clin Equine Pract 2002; 1: 211-217.
Schneider RK, Ragle CA, Carter BG, et al. Arthroscopic removal of
osteochondral fragments from the proximal interphalagealjoint
of the pelvic limbs in three horses. J Am Vet Med Assoc 1994;
207: 79-82.
Schneider RK, Jenson p, Moore RM. Evaluation of cartilage lesions
on the medial femoral condyle as a cause of lameness in horses:
11 cases (1988-1994). J Am Vet Med Assoc 1997; 210:
1649-1652.
Selway Sf. Arthroscopic surgery: the carpal and fetlock joint. Proc
Am Assoc Equine Pract 1983; 29: 95-109.
Shrock KB, Jackson DW. Arthroscopic management of the anterior
cruciate ligament -deficient knee. In: McGinty JB (ed), Operative
Arthroscopy, 2nd ed Philadelphia: Lippincott Raven; 1996:
511-530.
Smith M. Arthroscopy in large animals. Proceedings of the 11th
Conference of the European Society of Veterinary Surgery, 1975.
Southwood 11, Mcllwraith CWoArthroscopic removal of fracture
fragments involving a portion of the base of the sesamoidbone in
horses. J Am Vet Med Assoc 2000; 217:2 36-240.
Southwood 11, Stashak TS, Fehr IE, et al. Lateral approach for
arthroscopic removal of solitary osteochondromas from the
distal radial metaphysis in three horses. J Am Vet Med Assoc
1997; 210: 1166-1168.
Southwood 11, Trotter GW, Mcllwraith CWoArthroscopic removal of
abaxial fracture fragments of the proximal sesamoid bone in
horses: 47 cases (1989-1997).J Am Vet Med Assoc 1998a; 213:
1016-1021.
Southwood 11, Stashak TS, Kainer RA. Tenoscopicanatomy of equine
carpal flexor synovial sheath. Vet Surg 1998b; 27: 15D-157.
Southwood 11, Stashak TS, Kainer RA, et al. Desmotomy of the
accessory ligament of the superficial digital flexor tendon in the
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Squire KR, Adams SB, Widmer WR, et al. Arthroscopic removal of a
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--~ "-"" -
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WatanabeM. TakedaS. The 21

Tokyo:IgakuShoin.1978.
Weller RR, Maieler 1}. Bowen

Whitton RC. McCarthy RoseRJ.The intercarpal ligaments of equine

mid-carpal joint. Part 1: the anatomy of the palmar and
 ~
of instrumentation is available for human
arthroscopic surgery, but much of it is unsuitable and
unnecessary for equine arthroscopy. Many of the operating
instruments are expensive and fragile; for equine use a
limited amount of equipment is generally essential or
appropriate. The descriptions and recommendations in this
text are based on the authors' experiences and personal
choices and numerous substitutions can be made. Obviously,
the potential for variation is extreme, and it is necessary to
continue to evaluate new instrumentation as it becomes
available or as new arthroscopic procedures are developed.
This chapter represents the authors' current views on
instrumentation.
The availablearthroscopesvary in outer diameter,working
length, and in lens angle, which may be straight (0°) or
angledfrom 5° to 110°. Many manufacturersmarket 4 mm
diameterarthroscopeswith 0°, 30°, or 70° lens anglesand
working lengths of 160-175 mm. The field of view is often
115° or more,leadingto their classificationas "wide field of
view" arthroscopes. Most manufacturers produce small
arthroscopes,usually 2.7 mm diameter arthroscopeswith
30° or 70° lensangles;a short 2.7 mm diameterarthroscope
with 300 or 700 lens angles; and a 1.9 mm diameter arthro-
scope with 300 lens angle. Generally. surgeons should choose
the largest diameter arthroscope that can safely be inserted
and maneuvered without causing damage. Small diameter
arthroscopes with appropriate operating instrumentation
have been developed for use in human carpal. metatarso-
phalangeal. and temporomandibular joints (Poehling 1988).
However.these are fragile. allow lessillumination. and provide
a much smaller field of view (900 for 2.7-mm scope and 750
for 1.9-mm scope). Small diameter arthroscopes usually also
have a shorter working length (50-60 mm) because the
excessiveflexibility of a longer instrument increases the risk
of breakage (Poehling 1988). More recently. a complete range
of sizes has also become available in video arthroscopes.
which are coupled directly to the video camera. This obviates
the need for a coupler and eliminates the potential for fogging
between the arthroscope eyepiece and camera Gackson &
Ovadia 1985). Flexible arthroscopes have also had a period of
limited use. but generally failed to provide true flexibility and
optical clarity (Takahashi & Yamamoto 1997). Combined
approaches.using a rigid arthroscope for most of the procedure
and a flexible arthroscope to accessdifficult areas of the hip.
ankle. or knee in people. have added to the more thorough
evaluation of these joints (Takahashi & Yamamoto 1997).
A 4 mm diameter arthroscope with a 25 or 300 lens angle
fulfills most needs of the equine surgeon (Fig. 2.1). A 4 mm
700 arthroscope can occasionally provide improved visualiz-
ation of specific areas of some joints such as the tarsocrural.
shoulder. and palmar/plantar aspect of the metacarpo/
 Nephew -Dyonics8 (Fig. 2.3), the 300 Hopkins rod lens
telescope made by Karl Storzb,and the 300 direct view and
video arthroscopes made by Strykerc. Comparable-sized
arthroscopes are also available from Linvatecd,Richard WoW,
Zimmerl, Olympus8, Arthrexh, and other companies. The
advantages of the 25-300 angled lens are: (1) it provides an
increased field of vision; (2) rotating the arthroscope
increases the visual field without moving the arthroscope;
and (3) the end of the arthroscope can be placed at some
distance from the lesions, allowing easier accessto the area
with instruments and minimizing the risk of damaging the
arthroscope.
All arthroscopes are used within a protective stainless steel
sleeve or cannula (Fig. 2.4). For a 4-mm arthroscope the
sleevehas a 5 mm or 6 mm diameter, and is connected to the
arthroscope through a self-locking system that varies between
manufacturers. The sleevehas one or two stopcocksfor ingress
and/or egress fluid systems. The second stopcock is useful if
the surgeon uses gas and fluid distention interchangeably
during arthroscopy; otherwise, a sleeve with one stopcock
offers greater freedom of movement. A rotating stopcock is
critical to allow the ingress fluid line to be positioned away
from the limb and/or instruments as required. The space
between the sleeve and arthroscope allows flow of ingress

tarsophalangeal joints. Figure 2.2 illustrates the different
fields of view of a 250 arthroscope and a 700 arthroscope in
the same position in a tarsocrural joint. Popular choices in an
arthroscope for routine equine arthroscopy include the 300
videoarthroscope and direct view arthroscopes from Smith &
..Smlth&Nephew-Dyonlcs.150MlnutemanRoad. Andover.MA01810.
Tel: (978) 749-1000. www.smith-nephew.com
.~arIStonVeterlnaryEndoscopy.175 CremonaDrive.Goleta.CA 93117.
Tel: (800) 955-7832. www.ksvea.com
.'Stryker. 5900 OpticalCourt. SanJose.CA95138. Tel: (800) 624-4422.
www.strykerendo.com
.dLlnvatec-Conmed Co. 11311 Concept Blvd.. Largo. FL 33773.
Tel: (800) 237-0169. www.linvatec.com
.'RIchard Wolf. 353 CorporateWoodsParkway. Vernon Hills. IL 60061.
Tel: (847) 913-1113. www.richardwolfusa.com
.rZlmmer. PO Box 708. 1800 West Center St.. Warsaw. IN 46581.
Tel: (800) 613-6131. www.zimmer.com
.SOlympus America Inc.. 2 Corporate CenterDrive. Melville. NY 11747.
Tel: (800) 848-9024. www.olympusamerica.com
.hArthrex. 2885 South Horseshoe Drive. Naples. FL 34104.
Tel: (800) 933-7001. www.arthrex.com
 sleeveshave a wider diameter (5.8-6.0 mm

Theseso-calledhigh-flow sheathsare very

for insertion of the sleeve in

In joints with a thick fibrous capsule

usedto penetratethe
sharp trocars for insertion and blunt

in the sleeveare now largely redundant.

the arthroscopeis provided by a fiberoptic
from a light source. The cable should be a

use of extremelylight-sensitivevideo

by Richard Wolf Medical Instru-

with these light sources using video printers;

careful control of the white balance of the

A light source with a flash unit is largely

-

Dyonics 300XL xenon 300 W source, a Baxter-Edwards!

capture. The sources may be high-intensity
illumination, xenon arc lamps (100-500 W), or
vapor lamps (McGinty 1984). The xenon light
-the replacement
Reliant 300 W xenon source, and a Stryker X-6000 500 W
xenon source (Fig.2.7). The bulbs last from 350 to 500 hours,
which represents a recurring cost for busy practices.
Light sources that automatically adjust the light intensity
are useful to minimize the need for manual adjustment of

cold light fountain with 175 or 300-W lamp .'Baxter-Edwards, Baxter Healthcare Corp,OneBaxter Parkway,Deemeld.
-,--,- 2.7),
IL 60015. Tel: (847) 948-2000. www.baxter.com

~
light intensity. Most have a feedback electrical signal from the
camera control to light source for intensity adjustment. The
Dyonics AutoBrite IITM Illuminator, the Stryker X-6000TM
light source, the Baxter-Edwards ReliantTM xenon light
source, and the Karl Storz light source all employ useful
intensity feedbackcontrol. Most have the option to use this in
an automatic mode or to switch to manual to override the iris
control. Additionally, many video camera control systems
now also compensate for variation in light intensity, which
reduces the need for light source intensity changes.

Video cameras
Diagnostic and surgical arthroscopy can be performed by
direct visualization through the arthroscope; however, this is
now rarely practical and is no longer recommended. The risks
of contaminating the surgical field and instruments are
obvious. In addition, depth perception and ability to perform
fine movementsare severelycompromised with the monocular
vision of a small image. Projection of images through a video
screen corrects these deficiencies and allows simultaneous
observation of the procedure by several participants Gackson
& Ovadia 1985). Additionally, video documentation through
still image capture, video recorders, and digital video capture
systems (described later) provide sound surgical training,
client satisfaction, and legal sense.Lightweight video cameras
are attached directly to the eyepiece of the arthroscope
(Fig. 2.8), eliminating the need for the eyeto go to the arthro-
scope. This also provides a more comfortable operating
position since the surgeon can stand up straight, and the
hands can be placed at any level. It is also possible for an
assistant to hold the camera, which allows the surgeon use of
both hands to manipulate instruments for fine control or
accessto difficult sites.
Solid-state video cameras are now conveniently small and
light and can be attached directly to videoarthroscopes,
eliminating the coupler and any chance of fogging (Fig. 2.9).
The united arthroscope and camera can be cold soaked,
and/or gas sterilized. The solid-state cameras currently
available produce an image from either one or three chips, or
more accurately, closed coupled device (CCD)chips (Whelan
&Jackson 1992, Johnson2002). Thesechips produce excellent
image quality. Most modern cameras use digital enhancement
of the image, including motion correction algorithms, but
still output as an analog signal Gohnson 2002). Fully digital
cameras such as the Stryker 988TMvideo camera can write
directly to a CD without capture devices,and provide a dense
950 lines per inch image that requires an upgraded monitor
to derive the most benefit from its circuitry. Durable and high the flash autoclave cycle. in addition to more routine methods.
image-quality video cameras used by the authors are These cameras are well sealed. making them durable. but
available from Karl Storz (Telecom SL camera), Smith & have previously been available only as single-chip devices.
Nephew -Dyonics (ED-3 and D3 three-chip cameras; HD900 reducing the image quality. The authors' preferred method of
single-chip camera), Stryker Endoscopy (888 and 988 three- sterilization is with ethylene oxide gas (see Sterilization of
chip cameras), and Arthrex. Severalmanufacturers produce Equipment). This requires a minimal exposure/ventilation
autoclavable cameras: for example, the Smith & Nephew - time of 12 hours and. therefore. is usually suitable only for
Dyonics 337 three-chip camera, which can be sterilized using the first surgery each day: Cameras for subsequent surgeries

sleeve.In countries where ethylene oxide is not
moisture betweenthe arthroscopeand camera
largely eliminated with cameraswhich have large,
vents is employed.the problemcan be
and also by using warm irrigating fluid. Anti-
irrigation system
polyionic fluid is used for joint distention and
~ during surgical arthroscopic procedures. The
an intravenous set connected to
to apply pressure(Fig. 2.10). This method is satis-
is economical and provides distention superior to
feed developedby suspendingthe fluids abovethe
gravity flow through sleeves
used in human small joint surgery are also frequently
inadequate (Oretorp & Elmersson 1986). The hand pump
allows the surgeon to broadly control the degree of distention
as well as the irrigation flow rate. A relationship between
fluid pressure and fluid extravasation into the soft tissues has
been recognized in man (Morgan 1987); extravasation
occurs at approximately 50 mmHg (Noyes et al 1987).
Control of fluid pressure is therefore desirable.
The most popular system for fluid delivery is now a
motorized pump. Such pumps can provide both high flow
rates and high intra-articular pressures.rThe simplest and
favored pump for two of the authors (C.WM. and I.M.W) is
an infusion pumpk, such as the one illustrated in Fig. 2.11.
Such pumps are relatively inexpensive (Table 2.1) and provide
high flow rates on demand, which is particularly useful for
distention of large synovial spaces (see also Chapter 3), but
automatic control of the pressure is lacking (Bergstrom &
Gillquist 1986, Dolk & Augustini 1989). If an outflow portal
is not open, excessive intra-articular pressures may cause
joint capsule rupture (Morgan 1987). Extravasation of fluid
is also a complication whenever excessive pressures are
generated, and compartment syndrome has occurred using
mechanical pressure delivery systemsin man.
The ideal pressure and flow automated pump should be
capable of delivering necessary flow rates on demand, keep
pressure at adequate yet safe levels, and include safety
features such as intra-articular pressure-sensitiveshutdowns
and alarms (Ogilvie-Harris & Weisleder 1995). Many new
pumps meet these criteria, including pumps made by Arthrex,
Stryker Endoscopy,Smith & Nephew -Dyonics, Karl Storz,
Inc., Baxter Health Care Corp, One Baxter
 and Linvatec (see Table 2.1; Figs 2.12-2.14). Most provide
pressures from 0 to 150 mmHg and fluid flows as high as
2 L/min. All but the 3M! and Linvatec pumps sense joint
pressures through the single delivery fluid line. These features
facilitate visualization when large joints or motorized
equipment result in a demand for high fluid flows. From a
reliability perspective,the roller pump design of the Arthrex,
Stryker, and Karl Storz pumps provide advantages over th(
centrifugal and piston pump design of other manufacturers
The significant cost of these sophisticated fluid deliver)
systems can be reduced by tubing lines that do not requirt
complete replacement of the entire pump assembly durin{
multiple case schedules. An example is the Arthrex pumI
assembly(seeFig. 2.12) which replaces only the sterile line t<
the patient between cases,providing new fluid delivery foJ
less than one-third the cost of a complete roller pump an<
patient line set-up. Pressure and flow automated pumps arl
more expensive (seeTable 2.1) and involve a more comple;
set-up procedure during preparation for surgery. Howevel
equipment prices are often reduced or rolled into a minimun
purchase of tubing, so the actual equipment cost can b
passedon to each case. Set-up and calibration are simpler 0]
some pumps than others (see Table 2.1). A nitrogen drivel
flutter valve pump with no electrical parts (Davolm)is a cos1
effective intermediate-style pump that bridges betweel
gravity feed and pressure-driven pumps (Fig. 2.15). Thi
system has been used by one author (A.J.N.) for many year
and is economical, simple to set up, pressure sensing, and ca
deliver high flow rates (Smith & Trauner 1999). The di:
advantages are the relatively slow recognition of pressUl
drops in the joint and the noise of the flutter valve pum
assembly.
The use of a balanced electrolyte solution, such as lactat(
Ringer's or Hartmann's solutions, rather than saline for joil
distention has beenrecommended based on studies that sho

.'3M Orthopedics
Pro :ts Division, 3M Cent. MN
1000. Tel: (888) 364. 77. www.mmm.com
rIossettCrossroad,PO.275.
www.davol.com

No 31
us
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1.0 No 69 Good
saline is not physiologic and inhibits normal synthesis of
proteoglycans by the chondrocytes of the articular cartilage
(Reagan et al1983). Any matrix depletion of the cartilage
during normal arthroscopic procedures would be minor and
certainly not permanent Gohnson et aI1983), but when the
cost of each fluid is similar, the use of the most physiologic
solution is logical. The results of another study evaluating
the acute effects of saline and lactated Ringer's solution on
cellular metabolism demonstrated an acute stress to both
chondrocytes and synoviocytes immediately after irrigation
with both fluids, although this was greater with saline. These
stress patterns (monitored by evaluating relative ATP
regeneration) are apparent after 24 hours, appear to
be returning toward normal by 48 hours, and are not
significantly different from control values 1 week later. Based
on these results, protection from full activity during this time
period was considered advisable (Straehley 1985).
Gas insufflation has been used routinely in equine arthro-
scopy by two of the authors G.B. and A.J.N.). Several types
of gas insufflators are available. Most have a small internal
reservoir gas tank, including the Karl Storz and Richard WoU
units (Fig. 2.16). Others, such as those from Unvatec, Stryker,
and Directed Energy, use a direct step-down valve system
from a commercial tank (Fig. 2.17). Arguments have been
advanced for the use of gas insufflation of the joint rather
than fluid distention during arthroscopy (Eriksson & Sebik
1982); the gaseousmedium (carbon dioxide, helium, or nitrous
oxide) results in a sharper image with higher contrast. As
well as being useful for photographs, some evidence exists
that it may offer an increased degree of accuracy in assessing
cartilage damage in some situations (Eriksson& Sebik 1982).
In addition, it can prevent synovial villi from interfering with
the visual field. However, a pressure-regulating device and a
special system are necessary for gas insufflation. In addition,
gas escapes easily after removal of any appreciable mass
 portal. Gas emphysema,pneumo-
have been identified as
arthroscopy Gager 1980), and

better visualization when synovial

bone graft and fibrin-based

but many procedures start with liquid distention and only use
gas for short periodsof defined activity, which limits emphysema.
Removal of small particles by suction obviously requires a fluid
medium, and fluid irrigation will also be necessaryat the end of
any procedure for lavageand removal of debris.
At this stage,the authors considerthe use of fluid irrigation
more convenient and experience with the use of fluid can
eliminate many of the problems associated with synovial villi
obstructing visualization. No additional equipment is necessary;
and although the imagesobtained have somewhat lesscontrast
compared with images from gas-filledjoints, superficial dalhage
to the articular cartilage and other lesions are seen more
readily in the form of floating strands. Nonetheless,the addition
of gas may be a necessaryand convenient step in the future if
bone grafting, laser surgery,or fibrin-based cell grafting become
an important feature of arthroscopic surgery.

Egress cannula
An egresscannula (Fig. 2.18) is a necessaryitem for most
arthroscopicprocedures.It has an accompanyinglocking
 trocar with either a sharp stylet or conical obturator. The
cannula is used to flush fluid through the joint in order to
clear blood and debris and optimize visibility. The outer end
has a luer attachment through which fluid can be aspirated
or to which a long, flexible egress tube can be attached to
transmit fluid to a bucket on the floor rather than having it
spillover the surgical site or equipment. The authors use a 2-
or 3-mmegress cannula (Fig. 2.18a) routinely at the beginning
of the arthroscopic procedure to flush the joint and to probe
and manipulate lesions. A larger diameter (4. 5-mm) cannula
(Fig. 2 .18c) can be used at the end of the procedure for
clearing debris. The 3-mm cannula usually is inserted without
the use of the stylet, because a portal has been made with a
blade. A conical obturator (Fig. 2.18d), however, is useful to
facilitate placement of the larger 4.5-mm cannula at the end
of the procedure.
Hand instruments for
arthroscopic surgery
As mentioned previously, a myriad of instruments are avail-
able from arthroscopic equipment manufacturers (Caspari
1987, Gross 1993, Ekman & Poehling 1994), most of which
are neither suitable nor necessary for equine arthroscopic
surgery. The instruments presented in this section are those
used by the authors to perform the procedures described in
this book. It is accepted that there are alternative, and
possibly better, ways to perform any given task and tech-
niques certainly will change. The current list is written with
the philosophy of keeping arthroscopy simple and practical
without compromising standards. A combination of
specialized arthroscopic instruments and instruments not
designed specifically for arthroscopic surgery is used.
Blunt Probe
This standard arthroscopic instrument (Fig. 2.19) is necessary
for diagnostic as well as surgical arthroscopy. Suitable probes
Fig. 2.19
(A) Variety of arthroscopic probes, from
large to small format, and with round.
rectangular and thumb plate handles.
(B) Probe ends vary in shape and size.
~
areavailablefrom all arthroscopicinstrumentmanufacturers.
Probesfrom differentmanufacturersvary in length and end
configuration. The probe end can be round, square or
rectangularand can vary from 3 to 6 mm in length. Longer
tips on the probecan hamperentry to the joint bytangling in
the capsule,while smallerprobesare easyto insert but are
more proneto bending.A 3-mmrectangularend probewith
taperedshaftis convenientand durable(seeFig. 2.19). The
handle on probescan vary from a round smoothshaft. to a
rectangular shaft, which is easier to grasp, and to the
additionof a thumb bar for directedapplicationof pressure.
Forceps
Currently. the authors use seven different forceps for
retrieving fragments and trimming lesions (Figs 2.20-2.24).
1. Routine use. The workhorse in most arthroscopy packs is
the Ferris-Smith intervertebral disc rongeur. For removal
of large fracture fragments and osteochondritis dissecans
flaps. a pair of Ferris-Smith cup rongeurs with a 7-inch
shaft and a straight 4 x 10-rom bite (Scanlan Instruments)
is used. These forceps are better than other types for this
purpose. Variation exists with regard to the shape of the
jaws on different 4 x 10-rom Ferris-Smith rongeurs. A
narrow-nosed pair made by Sontec (Scanlan) is useful for
carpal and proximal phalangeal fragments. They pass
through the instrument portal easily and are appropriate
for small and medium-sized fragments (Fig. 2.20). Another
pair of Ferris-Smith rongeurs with a 6 x l2-rom cup is
used for larger fragments (Fig. 2.20). A set with the jaw
angled up and with a 4 x 10-rom cup are also useful in
some tight situations. Some surgeons use a pituitary
rongeur for longer fragments.
2. Small fragments. Also recommended is a pair of straight
ethmoid rongeurs with a 5-rom bite (Richard Wolf or
Scanlan Instruments). These instruments have a pointed
nose and are useful for procedures involving chip fractures
off the proximal aspectsof the first phalanx (seeChapter 5).
3. Long-handled forceps. A more verSatIle and longer
alternative to the Ferris-Smith rongeur is the Mcilwraith
arthroscopy rongeur (Fig. 2.21), made by Sontec
Instruments? Pituitary rongeurs are also used by other
arthroscopic surgeons for the same purpose.
4. Tight spaces. A small angled rongeur with slightlJl
pointed tip (Fig. 2.22), often referred to as a patella
rongeur (Sontec or Richard Wolf), is especially useful foI
retrieving small fragments from difficult places, including
.nSontec (formerly Scanlan) Instruments Inc., 7248 Tucson Wa~
Englewood, CO 80112. Tel: (800) 821-7496. www.Sonte.
Instruments.com
 the palmar surfaceof the metacarpalcondyleor proximal
phalanx, the palmar recessesof the midcarpaljoint, and
the underside of the patella. The use of sharp-edged
rongeur-typeinstruments is preferredin most situations
whenpiecesto beremovedare still attachedby softtissue.
5. Loose bodies. Loosebodiescanberetrievedwith custom
equine loosebody forceps,since most loosebodyforceps
availablein catalogsof arthroscopicinstrumentsare not
strong enough. For instance,Zimmerhas takenthe basic
Ferris-Smithdesignand changedthe endsof the jaws for
specificpurposes.
6. Cutting forceps. Basketforcepsare used occasionally
(Fig. 2.23) for removal of cartilaginous flaps of osteo-
chondritisdissecansin the femoropatellarjoint. A narrow,
modifiedbasketforceps(seeCutting Instruments section)
is useful for severing soft tissue structures such as
villonodular pads.
7. Broken instrument retrieval. A fragmentforcepswith a
malleable shaft is also occasionally useful, but not
essential.Theseforcepsare illustrated in Figure 2.24 and
are madeby ScanlanInstruments(Sontec).
Elevators and osteotomes
The instruments primarily used for separating fragments
from parent bone include a small round-end curved periosteal
elevator or a straight narrow osteotome. Examples include
the small (6-mm) round-end SynthesO elevator, the 5-mm
Mcllwraith-Scanlan elevato~, and the 4-mm cottle osteotome
(Scanlan) (Fig. 2.25). An extra small (3-mm) curved Synthes
elevator is also occasionally useful (Fig. 2.25). A markedly
curved sharp-end periosteal elevator (Fig. 2.26) is useful for
removing apical sesamoid fragments (Foerner elevator;
Scanlan Instruments; see Chapter 5).
Cutting instruments
Numerous cutting instruments are available. Their use is
limited to certain situations. If sharp severance of structures
is required. special arthroscopic cutting instruments should
be used. The authors have used both reusable blades and
disposable blade systems (Fig. 2.27), made by Karl StOrzb,
."Synthes (USA),POBox 1766, 1690 RussellRoad,Paoli, PA 19301. Tel:
(800) 523-0322. www.synthes-chur.ch
.nSontec (formerly Scanlan) Instruments Inc., 7248 Tucson Way,
Englewood.CO80112. Tel: (800) 821-7496. www.SontecInstruments.
com
.~arl Stol"lVeterinaryEndoscopy.175 CremonaDrive. Goleta,CA93117.
Tel: (800) 955-7832. www.ksvea.com
 Wolfe, BeaverP,Dyonics, Acufex-Smith & Nephe~, Concept-
Linvatec-Zimmer, and Bard-Parker. Sheathed blades are
also available and eliminate the risk of inadvertent
damage to other structures when introducing the blade
(Fig.2.28).
.nSontec (formerly Scanlan) Instruments Inc.. 7248 Tucson Way.
Englewood.CO80112. Tel: (800) 821-7496. www.SontecInstruments.
com
."Richard Wolf. 353 Corporate WoodsParkway. Vernon Hills. IL 60061.
Tel: (847) 913-1113. www.richardwolfusa.com
."Beaver SurgicalProducts.Becton-Dickinson.BDMedicalSystems.1 Becton
Drive. Franklin Lakes.NJ 07417. Tel: (800) 237-2762. www.bd.com
.qAcufex Microsurgical Inc.. Smith & Nephew. 150 Minuteman Road.
Andover. MA 01810. Tel: (978) 749-1000. www.smith-nephew.com

.
 Acquisition of the commonlymarketed hook scissorsis
not recommendedfor equine arthroscopy.The bestscissor-
type cutting instrument available currently is the very
narrow basketforceps (Scanlan-Mcllwraith scissoraction
rongeur)(Fig.2.29).
The authorshavefound little indicationfor the retrograde
or hook knives. other than those availablefor arthroscopic
annular ligament transection(seeChapter13). A menisco-
tome can be useful for breaking down fibrous capsule
attachmentswhen freeing a chip as it makesa cleanercut
than a periostealelevator.

Curettes
Curettes are used for debridement of most osteochondral
defects, including those remaining following removal of
traumatic or developmental fragmentation, evacuation of
subchondral bone cysts, and debridement of foci of infection.
Closed spoon curettes are suitable for most purposes, but
open ring curettes may be preferable for the center of lesions
(Figure 2.30). Straight and angled spoon curettes, either 0 or
00 in size, are generally preferred for routine applications
(Fig. 2.30). A rasp is rarely necessary for smoothing debrided
bone regions in joints, but may be useful for smoothing larger
areas such as after radial osteochondroma removal. These
instruments are available in straight, offset convex and
concave designs from various manufacturers, including
Stainless Manufacturing Incr.

Self-sealing cannulas
The use of self-sealing sleevesor cannulae is a logical answel
to the loss of fluid through instrument portals. Either devict
can be used by screw insertion into the tarsocrural, shoulder
or femoropatellar joints, but they are not useful in the carpu!

.'Stainless Manufacturing In
CO91773.
and fetlock because of the close proximity of joint capsule
and lesion. Disposable self-sealing 4.5-10-mm operating
cannulae are available through several manufacturers
(Arthrex, Dyonics, Richard Wolf, or Acufe~). They are useful
for repeatedly introducing small forceps, hand tools, and
shavers,but in the horse, removal of osteochondral fragments
is the most common procedure, and this can only rarely be
done through such cannulae. A 10-mm (I.D.) threaded self-
sealing disposable cannula with insertion obturator (Clear-
trac; Dyonics -Smith & Nephew) has been useful in shoulder
arthroscopy (Fig. 2.31), otherwise operating cannulae are
still rarely used in equine arthroscopic surgery.

Vacuumattachments
Various instruments, including forceps and curettes, are
available with attachments so that suction can be applied as
they are used. The S.2-mm DyoVac (Fig. 2.32) suction punch
rongeur (Smith & Nephew -Dyonics) is used by one of the
authors (A.J.N.) for minor synovial resection, cartilage and
soft bone removal, or larger soft tissue pad or meniscus
trimming. As such, this versatile rongeur gets more use than
most instruments in routine arthroscopy. Further, it often
prevents having to set up motorized equipment. Use of
suction enables instant removal of debris as it forms during
debridement within the joint. However, with the high fluid
pressures used in equine arthroscopy, suction is often un-
necessary as free material is often spontaneously flushed out
through the suction channel. The use of suction during any
procedure requires an increased rate of ingress fluid delivery.
In general, the authors prefer to perform hand debridement
without suction, reserving it for use with motorized instru-
ments or to remove debris at the end of surgical procedures.
Motorized instrumentation
A large assortment of motorized arthroscopic instruments
are available from most of the equipment manufacturers.
h & Nephew. 15049-1000.
www.sm
While motorized equipment should be used only with due
consideration to the synovial environment and tissues. these
instruments are extremely efficient and some surgical
procedures can only be done effectively with such equipment.
Synovial resection. whether performed locally to improve
visualization of lesions or therapeutically on a subtotal basis.
can only effectively be performed with motorized apparatus.
Similarly, some large areas of osseousdebridement. such as
in shoulder or stifle osteochondrosis, become impossible to
complete reasonably without such equipment. The basic
concept of motorized instruments is a rotating blade within a
sheath to which suction can be applied. This pulls soft tissue
into the mouth of the blade and removes debris (Graf and
Clancy 1987). Most currently available systemsare powered
electrically and consist of a control unit attached by an
electrical cord to a motorized handpiece. The latter may be
operated by buttons on the handpiece or via a foot pedal to
the control unit (Fig. 2.33).
 Cutting heads or blades for the motorized units can be
divided into three broad groups: (1) blades designed to
remove soft tissues such as synovium, plicae, and ligament
remnants; (2) blades to trim denser soft tissues such as
menisci; and (3) burrs for debriding bone. These blades are
mostly available in disposable forms, although renewed
interest in reusable blades has resulted from the economic
downturn in medical practice. However, even disposable
blades can be cleaned, sterilized and reused for a limited
number of procedures (not recommended by manufacturer).
In the authors' experience, this has been a safe practice.
Generally,"fatigue" damage to the blades occurs at the plastic
attachment to the handpiece or in the drive shaft of curved
synovial resectors.
The authors have experience with the Smith & Nephew -
Dyonics Arthroplasty SystemTM,the Richard Wolf Surgical
Arthro Power System, The Baxter-Edwards system, the
Stryker System, and the Karl Storz meniscotome. Dyonics
developed the original shaver, and the third- and fourth-
generation Dyonics systems (PS3500 and EP-1 shavers), are
still very popular. However,blade availability for these models
is becoming increasingly limited, and many surgeons are
upgrading to the Dyonics Power Mac system, or seeking a
different manufacturer. Current shavers have integrated
suction with hand control of suction intensity. Some
manufacturers such Smith & Nephew -Dyonics and Stryker
also have speed and rotation direction controls on the
handpiece. Rotation speedsup to 8000 rpm and bidirectional
capabilities are useful. The hand units of the Dyonics and
Stryker shavers are relatively heavy compared to Storz, Wolf,
and Baxter shavers, but the heavier units are generally more
powerful. All modern shaver motors can be autoclaved and
most can be flash-autoclaved or cold-sterilized as necessary.
Most shavermotors recognize the blade type that the user has
inserted and controls the motor speedrange accordingly. Foot
control of shaver speed and direction, including oscillation
mode, is standard.
Each manufacturer provides a broad range of disposable
blades,which often come with 6-8 cutting tip designsand with
shaft diameter sizesof 5.5,4.5, or 3.5 mm. Some of thesehave ment, villonodular pad removal, and meniscus and soft bone
a curved shaft 2 cm from the tip to allow greater maneuver- debridement, The round or oval burrs are occasionally used
ability around joints. Additionally, a miniblade range of 2.0 in chronic degenerate joints, although other blades have
and 2.9-mm cutters with a variety of tip ends also are some value in similar situations.
available. Three broad types of disposableblades (which can Modern synovial resector units are much more useful than
be subjected to multiple uses)are available (Fig. 2.34): previous types. Design changes including larger apertures,
higher speeds,narrower diameter drive shafts (easier debris
1. smooth edged resectors, e.g. Dyonics Synovator and full
clearance), spiral flutes down the length of the drive shaft,
radius blades (in 3.5, 4.5, and 5.5 mm diameter sizes)
and application of suction, have all contributed to better soft
2. toothed edged resectors, e.g. Dyonics Orbit Incisor, Incisor
tissue resection and less clogging. The oscillating mode
Plus, RazorCut, Turbotrimmer, and Turbowhisker blades
capability of the motor (the unit switches automatically
(in 3.5, 4.5, and 5.5 mm diameter sizes)
between forward and reverse) facilitates cutting of fibrous
3. burrs, round or oval, e.g. Dyonics Abrader and Notch-
tissues and decreases clogging between the blade and
Blaster in round burrs, and Dyonics Acromionizer,
housing. The speed control is computerized, with a variable
Acromioblaster, and StoneCutter in oval elongated burrs
speedcapacity from 0 to 8000 rpm. High speedsare necessary
(in 2.5, 3.5,4.0, and 5.5 mm sizes).
when using the burr, whereas slower speedsare used with the
The smooth-edged resector blades are appropriate for soft tissue blades.
synovectomy. The toothed-edged resector (for trimming Stocking of all the blade types is unnecessary; most
denser soft tissue) can be used for articular cartilage debride- surgeons developa preference for 1 or 2 soft tissue blades,and
 a burr. In the Dyonics range, the authors prefer the 5.5-mm
full radius blade (#7205307) for villonodular pads and
menisci, the 4.5-mm rotatable curved orbit incisor
(#7205320) or Incisor Plus (#7205687) for most other soft
tissue resection, and the 4.0-mm Acromionizer (oval burr;
#7205326) or 4.0-mm Abrader (round burr; #7205324) for
bone debridement (seeFig. 2.34). Recently, a range of dual-
use combination tips (Dyonics BoneCutter) have been intro-
duced, which resect both soft tissue and bone. These are
available in synovator and full-radius styles, and minimize
both inventory and the need to switch blades in surgery.
Use of suction on shavers generally improves cutting
performance. However, attention to the degree of filling of
the suction bottle is required to prevent the automatic suction
shut-off engaging, which can then allow fluid to flow back
from non-sterile tubing and couplers at the bottle through
the sterile patient line and out the shaver into the joint or
onto the sterile field. It has been recognized as a potential risk
in the use of shavers for some time (Bacarese-Hamilton et al
1991), and it is particularly likely to happen when the fluid
ingressruns out at that same moment, removing the positive
pressureforcing joint fluid into the suction line. Prevention
requires suction to be maintained on the tubing at all times,
or at the very least ensuring the joint is pressurized during
suction bottle exchange.
Electrosurgical and
radiofrequency devices
Considerableinterest and concurrent concern surrounds the
use of radiofrequency (electrosurgical) devices for cartilage
and synovial soft tissue procedures (Polousky et al 2000,
Medveckyet al2001, Lu et al2001, Lee et al2002; Sherk et al
2002). Radiofrequency (RF) devices utilize extremely high-
frequency alternating current (e.g. 330 kHz compared to the
60 Hz of regular alternating current), which passes to the
tissue at the applicator tip and then through the body to exit
at a wide grounding plate, essentially as for all electrosurgical
units. The cutting and vaporizing capability depends on the
power and waveform settings. High power settings and low
voltage tends to cut, while low power settings at relatively
high voltage denatures and coagulates tissues (Sherk et al
2002). Used in the liquid environment of the joint, both of
these modes have found a place for excision of tissue (plica,
adhesions,villonodular masses),or denaturation of cartilage
(cartilage sculpting or chondroplasty). Radiofrequency
devicesused in a cutting mode, at the lowest settings that will
still cut plica, ligament, menisci, or masses,seemto be safe if
the probe is directed away from cartilage and does not dwell
on bone (Polousky et al 2000, Lee et al 2002). Similarly,
thermal capsular shrinkage using low power settings has
many proponents and seems relatively low risk (Medvecky et
al 2001). However, RF devices used for thermal chondro-
plasty at recommended settings penetrate to the subchondral
bone and cause chondrocyte death (Lu et al 2000, 2001).
Despite the apparent smoothness of cartilage after RF
chondroplasty, the later necrosis can be devastating, and is
the subject of ongoing debate. investigation. and litigation
(Lee et al 2002). Given these issues. RF for chondroplasty
should be avoided until further studies define safe settings.
and the use of RF probes in cutting modes for capsule. check
ligament. or annular ligament transection should use the
minimal power settings that still achieve the desired effect.
and should absolutely avoid cartilage and underlying bone.
Lasers
Lasershave beenused in arthroscopic procedures for removal
of fibrillated cartilage. synovial proliferation and masses.and
for transection of plical and other adhesive syndromes
(Lubbers & Siebert 1997. Janecki et al 1998. Smith &
Trauner 1999). They have declined in popularity in recent
years due to the continued high cost of the units and concern
over thermal damage to the cartilage and underlying bone
(Atik&Tali 1999. Sclamberg & Vangsness2002). Lasertypes
include COpNd:YAG. Ho:YAG. and excimer wavelengths. The
use of CO2lasers has diminished. while Ho:YAG and excimer
lasers have persisted (Roth & Nixon 1991. Smith & Trauner
1999. Doyle-Jones et al 2002). Laser capsule shrinkage for
shoulder and knee disorders and laser-assisted partial
meniscectomy remain the primary use in man (Lubbers &
Siebert 1997. Smith & Trauner 1999). Laser chondroplasty
has been controversial and. despite an excellent appearance
following lasersculpting. later cartilage necrosisand mounting
researchevidence suggestthe use of laser for cartilage debride-
ment is dangerous unless extreme care in power settings and
methods of application are employed Ganecki et al 1998.
Sclamberg & Vangsness2002; Atik et al2003).
Laser-assisted arthrodesis of the distal tarsal joints
provides a minimally invasive method for cartilage debride-
ment and articular desensitization (Hague & Guccione
2000). Eventual distal intertarsal and tarsometatarsal joint
arthrodesis can develop;however. resolution of the symptoms
of bone spavin do not necessarily require radiographically
defined obliteration of these joints.
Still photography
Historically,still photographicimageshave beenrecordedon
35-mm film using a camerawith a quick mount adaptorto
the arthroscope. However,this is time consuming, risks
contaminating the surgical field, and is extremely light
sensitive.A practical alternative is to use a digital camera
such as a Nikon Coolpix 4500 fitted with an endoscope
adaptor,e.g. Karl Storzrapid coupling adaptor (Fig. 2.35).
Imagesare viewedon a screenon the back of the camera,
storedon a memorycard,and may be downloadedlater to a
computerfor imageadjustmentand archiving.
Video documentation
-
Capture of video clips as analog video on a ~-inch VCR i:
simple and cost-effective for case documentation. It does not
however, provide duplicate copies to provide the owner or
trainer with surgical documentation, nor does it provide easy
accessto an individual caseburied in the middle of a 120-min
video tape. Review of a video and subsequent image capture
for still printing is also very time consuming and does not
lend itself well to the flow of information to the client. How-
ever, video and s-video formatted VCRs have become very
cheap, and are better than no documentation. Further, simple
video digitizing programs, such as Windows MoviemakerTM
(Microsoft), iMovieTM (Apple), VideoStudio 6TM (ULead
Systems), or Pinnacle Studio Version 7TM(Pinnacle Systems
Inc), all provide a means to capture video from !-inch tapes as
digital video (e.g. MPEG format) or as digital still images (e.g.
JPEGformat) that can then be stored electronically or printed
out for several cents an image on a color ink-jet printer.
Additionally, digital video clips can be edited, trimmed,
spliced, and assembled into an annotated presentation
using these programs. Other capture systems using Hi8
video capture have been described and for a complete review
of arthroscopic image documentation, the reader is
directed to a recent review which provides an in-depth
comparison of systems, cabling, connectors, and output
devices (Frisbie 2002).
Digital ima~e capture and
storage devices
Arthroscopic image printing and storage has undergone
significantimprovementalong with the electronicrevolution
of the previous decade.The simplesttechnique for image
documentationis electroniccapture and printing on a dye
sublimation printer (Brown 1989. Johnson2002). Self-
contained units such as the SonyMavigraphS(Fig. 2.36).
.'Sony Electronics, 1 Sony Drive, Park Ridge, NJ 07656. Tel:
(201) 930-1000. www.sonystyle.com
capture the image (often by clicking a button on the video
camera), and store and arrange the images during the
surgery. A 3.5 x 5 or 6 x 8-inch print is produced when a
preset number of images have been accumulated to memory.
The print quality (300 dpi) from a high end, digitally
enhanced, 3-chip camera can be photographic quality
(Brown 1989). The authors have used the Sony Mavigraph
UP-5600MD, Mavigraph UP-5200MD and the Mavigraph
UP2900 color video printers. The UP-5600MD provides
excellent image quality at approximately $1 per page. These
units sell for $4,000-$6,000. More economical storage can
be provided from small devices such as the Sony MavicapTM
electronic capture and storage device. This stores images on
floppy disks, which can then be printed on an office computer
and inexpensive color ink-jet printer.
Complete digital capture and storage devices for arthro-
scopic use are manufactured by Karl Storz, Stryker, and
Dyonics. All three units are expensive, but store both digital
still images (TIFF format-with Storz AIDA and JPEGformats
with others) and digital video clips (MPEGI or 2), with the
touch of a button on the camera head. The Stryker SDCPro
2TMand the Storz AIDA are the more sophisticated units in
the field of digital storage devices (Figs 2.37 and 2.38). The
units have touch screen patient input, and image editing for
still image output. Image printing can be done in the surgery
by attaching an inexpensive HP deskjet printer, while still and
video images are also savedon the system's hard drive. At the
completion of each case,the files are savedon CD or DVD. The
software in the unit provides versatile settings that allow
extensive customization of image capture and compression,
image editing, output styles, text addition, and internet
access. Retail prices range from $12,000 to $16,000. The
Smith & Nephew -Dyonics Vision 625 Digital Capture

(Fig. 2.39) providesmany similar featuresto the
be via zip disk or CD drive. and the
$9,700 to $12,000.
of equipment
steam autoclaving shortens the useful life of an
by causing deterioration of the adhesives
the major lenses. Seals and bonding between
materials may deteriorate from thermal shock; various
materials expand and contract at different rates in response
to the rapid temperature changes in a steam autoclave. Some
manufacturers sell autoclavable arthroscopes, which provide
a more durable arthroscope for steam sterilization. Gas
sterilization with ethylene oxide is effective and safe, but it is
not always available, is time consuming and does not allow
multiple procedures in a day using a single set of
instruments.
Consequently, the use of a 2% solution of activated
dialdehyde (Cidex@,Surgikos Inc:) was developedas an agent
for cold sterilization procedures. Cidex Plus@ has a 30-day
shelf life after reconstitution, compared to the 14-day span of
Cidex@,which provides cost savings for frequent users. The
safety and effectiveness of Cidex has been documented in
12,505 human arthroscopic procedures (Johnson et al
1982). A 0.4% infection rate was noted in this series. The
arthroscope and surgical instruments are soaked for a
minimum of 10 minutes. It has been stated that more than
30 minutes of soaking can be damaging to the lens system of
the arthroscope (Minkoff 1977). Glutaraldehyde polymerizes
on standing. When this occurs, crystals can form and cause
clouding of arthroscope lenses.
The surgeon or assistant should be double gloved and
removes the instruments from the Cidex and places them in a
sterile tray. The instruments are washed with sterile water or
saline (Fig. 2.40) and transferred to the surgery table where
they are dried after the surgeon's outer gloves are removed.
Ancillary instruments (towel clamps, scalpel handle, needle
holder, and thumb forceps) can be previously autoclaved
within the tray, which is then used for washing the soaked
instruments. Rinsing of the equipment must be done with
care to avoid damage to the camera and arthroscope from
sharp-edged hand tools.
.'SurgikosInc.. POBox 90130, Arlington, TX 76004. Tel: (817)465-3141
 accumulates, stopcocks and other moving parts cease to
function smoothly. Surfactant-containing solutions can also
erode epoxy and other thermal plastics. From personal
experience, severe damage resulted when soaking a camera
in such a solution. Another recommendation is that plastic
basins be used to soak instruments (McDonald 1984). These
basins reduce electrolytic corrosion, which can occur when
metal instruments are soaked in metal pans.
The question of the potential for Cidexto cause a chemical
reaction in joints was addressed in the literature (Harner
1988). Results of studies in rabbits showed that Cidex
induced a diffuse synovial inflammation when present intra-
articularly at concentrations of 10 ppm or greater. The
degree of synovial inflammation is proportional to the
concentration of Cidex. At 1000 ppm, chondrolysis occurs.
When using a single-rinse basin, the concentration of Cidex
in the rinse basin is 100-300 ppm; if the same rinse solution
is used, the concentration can be 1000 ppm by the fifth
procedure. Clearly, fresh-rinse solutions should be used for
each procedure. A double rinse reduces the Cidex concen-
tration in the second rinse to the order of 1 ppm. Mter
irrigation of the joint with 1 liter of saline, however, the
intra-articular concentration of Cidex is less than 1 ppm,
regardless of the rinse technique (Harner 1988).
Toxicity and safety issueshave reduced the use of Cidex in
many practices. An effective and less toxic alternative is the
peracetic acid SterisTMsystemU,which uses a liquid peracetic
acid (35%), acetic acid (40%), hydrogen peroxide (6.5%), and
sulfuric acid (1 %) soak,followed by a water rinse, for a total of
4 cyclesin a closed system,to provide sterile and virtually dry
equipment for arthroscopy (Fig. 2.41). Each sterilizing run
has a chemical indicator strip (min 1500 ppm) included to
verify the sterility of the instruments. The disadvantages are
the cost of the unit, and the process requires 30 minutes
rather than 10 minutes to complete,so emergency sterilization
for a dropped instrument still requires Cidex.
In many parts of Europe, the use of Cidex is no longer
permitted. A safe alternative is MedDisTM instrument
disinfectantV, which relies on halogenated tertiary amines,
hexamethylene biquanide hydrochloride, ethyl alcohol,
dodecyclamine, and sulfonic acid to sterilize instruments.
The 2% dialdehyde solution is properly classified as a This solution is diluted to 5%, and is then bactericidal,
disinfectant. The chemical is considered bactericidal in fungicidal, and virucidal after a 10-minute exposure, and
10 minutes, destroying all bacteria, including Myobacterium, tuberculocidal and sporicidal within 30 minutes. Shelf life
tuberculosis, Pseudomonas aeruginosa, and viruses. It is after activation is 14 days. It also has safety advantages in
sporicidal in 10 hours and therefore is considered a sterilizing that it is non-irritant, non-fuming, non-corrosive, and has no
agent after use for 10 hours Uohnson et al1982). reported effects on metal or glassendoscopecomponents.
A number of glutaraldehyde-based disinfecting solutions
are available. Use of a solution that does not contain a
surfactant is recommended (Cidex-activated dialdehyde Surgical assistants
solution does not contain a surfactant). Surfactants may leave
a residue, causing stiffening of moving parts and potential Becauseof the unique instrument requirements and the need
electrosurgical malfunction. Because surfactants lower the to have a smooth sequential system during the operation,
surface tension of the disinfection solution, the disinfectant scrub nurses or technicians participating in operative
can penetrate small cracks and crevices. This penetration arthroscopy must be especially trained. It cannot be
creates a rinsing problem, because high surface tension .USteris 20. SterisCorp, 5960 ReisleyRoad.Mentor. OR44060. Tel: (800]
prevents water from entering the cracks and crevices and 548-4873. www.steris.com
removing the disinfectant. As this disinfectant residue ."Medichemlnternational. POBox 237, SevenOaks. Kent TNI 5 02J. UK

that an assistanttotally familiar with the
and draping systems tend to be determined by the
preference, cost of drapes, and the safety and
minimal or extensivedraping by
vary from simple reuseablecloth
the horse, severalsmall drapes for
The sticky drapes (loban, 3M!) is a very
of liquid used in arthroscopy. Application of an adhesive
drape followed by one or two surrounding impervious drapes,
and finally a large disposable drape is standard (Fig. 2.42).
For simplicity, a large sticky drape provides a good sterile field
to which an experienced user can then apply a large
disposable drape directly, to complete the sterile set-up. It is
critical that the surgeon and his assistants not drag the
disposabledrape across the prepared joint (double shuffling)
or the inner surface of the disposable drape that has con-
tacted the animal will then rest over the joint to be operated.
Inexperienced users should add a quadrant of additional
draping between the adhesive drape and the large arthro-
scopy drape, to increase the margin of safety. Large drape
systemsare manufactured by Gepcowand Veterinary Surgical
ResourcesX.Some arthroscopy packs also contain disposable
gowns. In general, most manufacturers offer a range of pack
contents, so individual preferences can be accommodated.
Clearly, the complete systems lack nothing, but can be ex-
pensive (up to $82). The arthroscopy drape pack can be
ordered for unilateral or bilateral arthroscopy, the latter pro-
viding two rubber dammed areas, one per joint, with 30-38
inches between them. Thesecan be cumbersome to apply, but
provide exceptional large sterile fields without the need for
other body sheets.The authors also vary the type of draping
to the situation; numerous drapes around the foot will limit
accessfor coffin joint arthroscopy or digital sheath tenoscopy,
whereas full draping systems are easy to apply around the
stifle or hock, and provide ready access to all the joints
comprising these articulations.
Care and maintenance of equipment
Most care and maintenance issues should be covered by
instructions with individual equipment items. However.
repair of arthroscopes is a costly and all too frequent concern
in equine arthroscopy. All arthroscope vendors repair their
own telescopes.However. the cost can vary (depending on the
extent of damage) from $1.000 to $2.200 (almost the cost of
a new arthroscope). Third-party vendors repair arthroscopes
from most manufacturers. One of the larger repair companies
.13M Orthopedics Products Division. 3M Center. St. Paul. MN 55144-
1000. Tel: (888) 364-3577. www.mmm.com
.wGepco. GeneralEconopakInc.. 1725 North 6th Street.Philadelphia. PA
19122. Tel: (888) 871-8568. www.generaleconopak.com
.'Veterinary Surgical Resources.Inc. POBox 71. Darllngion. MD 21034.
Tel: (800) 354-8501. www.vetsurgicalresources.com
is Instrument Makarr. The cost of repair generally ranges from
$350 to $600. However, the repair vendor should always
provide a free assessmentof damage and a quote for repair. A
more informed decision for repair or replacement can then
be made.

Pressure and cold bandaging

Preoperativeand postoperativepressurebandaging is common
practice in equine arthroscopy. but use of combination cold
and pressuredeviceshas beenunderutilized. The value of cryo-
bandaging following acute injury is well known to horse
trainers and owners but largely ignored in the immediate post-
operative phase by surgeons.The use of wet ice and ice slushes
should obviously be avoided. given the recent incisions into
the joints. However. dry cold products have a role in reducing
the postoperative pain and swelling that is recognized in
human arthroscopy and in the rehabilitation of athletes
(Barber et al1998. Martin et al2001). Somecryo-cuff devices
combine both cold and pressure massagesystems (Fig. 2.43)
.'Instrument Makar. Division of Smith & NephewInc. EndoscopyDivision.
150 Minuteman Road. Andover. MA 01810. Tel: (800) 343-5717.
www.endoscopy1.com

al 1995). Thesedevices'have beenused fol-
and the resolu-
particularly periarticular swelling, has
the holmium:YAG laser cause osteonecrosis?
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IA. Bhamra M. Jackson AM. Arthroscopic
, 'sepsis. Ann R Coil Surg
McGuire DA. Click S. Continuous-flow cold therapy
, anterior cruciate ligament reconstruction.
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.'Equine Cryo-Cuff,GameReadyCoolSystems Inc., 929 CameliaSt,Berkeley,
CA 94710. Tel: (866) 266-5797. www.gameready.com
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arthroscopic instruments: a
setup and equipment. Orthop Clin
impressions of a new technique
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Janecki CJ,Perry MW. Bonati AO. Bendel M. Safeparameters for laser
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principles can be applied to the other joints. The
maneuversin the different joints are
evaluation of the patient
undergoing an arthroscopicprocedurefor a
or suspectedintra-articular problem must first be
These principles may be taken for granted by
,. The hazard of avoid-
has also been noted in association with
1983).
the lack thereof) are discussed
preparation
- femoropatellar joint.
skin incisionsso that a hair or portion of hair is not
into the joint on insertion of the arthroscopeor
arthrocentesis sites. it has been concluded
the skin over the midcarpal and
joints can be accomplished without
and surgical scrub for the surgeon is routinely done with
either povidine iodine or chlorhexidine gluconate. The
authors have switched to the latter. The iodophors have
several disadvantages,including diminished effectivenessin
the presence of organic matter, a high incidence of dermal
irritation, potentially unreliable residual activity, and toxicity
(Phillips et al 1991, Rosenberg et al1976). CWorhexidine
closely fulfills all the criteria of an ideal preoperative patient
skin preparation: having a broad spectrum of antimicrobial
activity, it reduces bacterial numbers quickly by disrupting
the bacterial cell membrane and precipitating cellular
contents, has excellent residual activity (even in the presence
of organic material), and causes minimal skin irritation
(Stubbs et al1996). However, it should be noted that in a
study evaluating the effectivenessof a 5-minute surgical scrub
using either a one-brush or two-brush technique in clean and
dirty surgical procedures, and also comparing the efficacy of
povidone iodine with cWorhexidine as surgical scrub solutions,
both povidone iodine and cWorhexidine were equally effective
in decreasing bacterial numbers on the skin, given a variety
of contamination levels present before the scrub procedure
(Wan et al1997).
The authors perform all arthroscopic surgical procedures
in the carpus, dorsal fetlock, tarsus, and stifle joints, with the
horse in dorsal recumbency, except in isolated instances
when the facilities do not allow this positioning. Arthroscopic
surgery on carpal, fetlock, and tarsocrural joints is quite
feasible with the horse in lateral recumbency, but if entry
sites for the arthroscope need to be switched (when chips are
in both sides of the joint or in the same location bilaterally),
rolling the horse during surgery often is necessary. Dorsal
recumbency is mandatory for arthroscopic surgery in the
The method of draping is the choice of the individual
surgeon. Becauseof the fluid involved, an impervious draping
systemis needed(Fig. 3.1). The use of adhesive barrier drapes
is also recommended. Some problems have occurred with
some of these products in regard to adhering to the skin
satisfactorily. In this regard, Iobana drapes are superior.
.8Ioban. 3M Orthopedics Products Division. 3M Center. St. Paul. MN
55144-1000.
Arthroscope insertion and positioning
A 6- to la-mm skin incision is made at the site of insertion of
the arthroscope (Fig. 3.2). The various sites of insertion of
the arthroscope and instruments for each joint are detailed in
later chapters. In the carpal joints. the incision is made
between the extensor carpi radialis and common digital
extensor tendons for a lateral approach and medial to the
extensor carpi radialis tendon for a medial approach. Also.
these incisions are made before distention of the joint with
fluid so that the puncture site position in relationship to these
tendons and their sheaths is carefully placed. The position of
the tendon sheath can be obscured once the joint is
distended. If the arthroscope is not introduced in the proper
site, the maneuverability can become limited and undesirable
penetration of certain structures (such as bursae or tendon
sheaths) may occur.
In joints other than the carpus, distention is performed
prior to making portals. as avoidance of tendon sheaths is
not an issue and the distended joint aids in portal location A No. 11 or No. 15 scalpel blade is then used to make a
(Fig. 3.3). This distention prevents damage to the articular portal in the joint capsule. A conical obturator is placed
cartilage when the trocar or conical obturator penetrates the within the arthroscopic sheath and this combination is used
joint capsule. to insert the sheath through the fibrous joint capsule with a
 gentle twisting motion (Fig. 3.4). The sheath is initially
inserted perpendicularly to the skin surface. avoiding any
tendency to angle toward the ultimate position of the scope.
This position is to obviate opening a subcutaneous dissection
plane. Advancement of the sheath within the joint is
achieved most safely by use of the blunt or conical obturator,
becausethe articular cartilage is at risk for damage when the
sheath containing the arthroscope is advanced. This risk has
been decreased by improved congruity between the ends of
the sheath in relationship to the end of the arthroscope in
currently available instruments. The authors no longer use
the sharp trocar for insertion of the arthroscopic sleeve in
any joint.
Once the arthroscopic sheath is in place, the blunt
obturator is replaced with the arthroscope, and the fiberoptic
light cable and the ingress fluid system are attached to the
arthroscope and the sleeve, respectively (Fig. 3.5). The
ingress fluid line has been cleared of air bubbles to avoid
entry of the latter into the joint. Direct arthroscopic visualiz-
ation of the joint can then be performed (extremely rare
nowadays) (Fig. 3.6), or the video camera (seeChapter 2) can
be attached. depending on the method used by the surgeon.
If the camera has not been soaked. the use of a sterile
sleeveis necessary.If using a sleeve.it is important to ensure
a watertight seal of the cover over the head of the
arthroscope.
After insertion of the arthroscope. in the case of the
carpus, the instrument portal through the joint capsule is
made with a direct perpendicular stab with a No. 15 or
No. 11 blade (Fig. 3.6). In other joints, the instrument portal
is made in the same fashion. but often a needle is placed
in the proposed position and visualized. and, if appropriately
located, the instrument portal through skin and joint
capsule is then made. The authors' prefer to create the portal
and then insert the small egress cannula without using
a trocar or obturator (Fig. 3.7).
 Any cloudinessor hemorrhage within the joint can be
cleared by opening the egresscannula and pumping fluid
through the ingresssystem.Regardingthe use of the egress
cannula in the carpal and fetlock joints, the holes in the
cannula must not extendmorethan 6- 7 mm fromthe end of
the cannula. If they do, the cannula should be shortened
appropriately.Otherwise,someholes will not be within the
joint but will be within the subcutaneoustissues,promoting
rapid extracapsularextravasationof fluid.
Oncethe view is clear,the stopcockon the egresscannula
is closedduring visualization;otherwise,villi waving within
the flowing fluid obstructthe view (Fig.3.8).This pointneeds
emphasizingbecauseother authors in equine arthroscopy
mention the difficulties with synovial villi obstructing the
visual field, and advocatethe use of adjunctive synovial
membraneresection.This procedurenecessitatesthe use of
motorized equipment. Alternatively, gas distention rather
than liquid distentionpreventsthis problem. In diagnostic
arthroscopyof the human knee,the useof both a suspended
fluid sourceand constantflow of fluid through the kneehave
been recommended (Crane 1984). In the authors' opinion,
this technique is unsatisfactory in the carpus and fetlock of
the horse because of the smaller size of the joint and the
increased amount of synovial villi. As referred to
subsequently, villi interposition is not a problem in
arthroscopic procedures in the human knee, but it is often a
major one in the horse, necessitating the use of different
techniques to handle this situation. The use of closed
distention obviates the problem of villi interposition rather
well in most instances.
Any fluid system capable of exerting pressure within the
joint has the potential to cause its own complications (Noyes
& Spievack 1982). Joint capsule rupture in the human knee
at about 200 mmHg pressure has been recorded, and this
rupture in turn causes severeextracapsular extravasation of
fluid. Flexion of the joint markedly elevates the pressure in a
given joint. Severeflexion changes during equine arthroscopy
are rare, but a situation of high intra-articular pressure can
developeasily.The choices of fluid systems were discussedin
Chapter 2. The requirements for joint distention in equine
arthroscopy are quite high; at the same time, however, it is
important to be aware that excessivepressure can exacerbate
the degree of fluid extravasation with or without joint
capsule rupture. For these reasons, the authors do not
recommend the use of constant pressure fluid administration
systems, including fluid bags with pressure cuffs or bulb
syringe pressure cuffs or direct gas insufflators. Two of the
authors use a Cole-Parmer system where variable flow rates
can be changed quickly. In this way a slow flow rate is used
under the closed examination and then this flow rate can be
increased as necessary when there is an open instrument
portal. Pumps used in human arthroscopy have improved
(see Chapter 2) and are generally now available free if
sufficient delivery tubing is purchased. The system recently
developed by Arthrex@ has been used in the horse and is
effective.
During arthroscopic surgery, once a larger instrument or
fragment passesthrough a portal in the joint capsule, some
degree of constant fluid egressthrough this portal is unavoid-
able. Consequently, some villi interposition occurs. For this
reason, the diagnostic examination must be completed before
surgical removal of large fragments from the joint. For the
same reason, a small (2.7-3.0 mm) egresscannula is used for
an initial flush. This avoids a large instrument portal and the
continuous fluid flow during the initial examination.
The arthroscopist should be continually reminded that
visualization could be enhanced greatly by rotating the
arthroscope. Simply by rotating the arthroscope (without
changing the position of the arthroscope), the visual field of
view is greatly increased. This generally obviates the need for
a 700 arthroscope.
Arthroscopic surgery and the principle
of triangulation
Although the details of arthroscopic surgery for each joint
are presented in later chapters. the principle of arthroscopic
 here becausethe use of both the
and they are used according to
Two basic techniques have beendevelopedfor arthroscopic
-
Although it
orthopedic practice (Carson 1984), the technique
not beenused in equine surgery and thereforeis not
The secondtechnique is triangulation. which involves
one or more operating instruments through
-~
the instrument and the arthroscopeforming
3.9, (and alsoin Figs.4.21 to 4.23) and it is
to handle all of the various surgical requirementsin
--
as well as surgicalarthroscopy.To be ableto use
technique effectively,the surgeon must developthe
confined space while using monocular vision, which
.,
For arthroscopic surgery, instrument portals are made in
, .on the joint and the site of the
Cannulas or sleeves are rarely used at instrument
for reasons mentioned in Chapter 2. To create an
a skin incision is made followed by a stab
the joint capsule with the use of a No. 11 or 15
blade. These techniques have been noted previously
3.6). In the carpus, the first author (C.WM.) makes
for the instrument portal before placement
whereas, in other joints, it is made after
placement and the position is then dictated by
Use of the probe in
diagnostic arthroscopy
For effective diagnostic arthroscopy, the use of a probe
through an instrument portal is important, both to evaluate
defects that cannot be discerned with vision alone and to
provide an index of size by comparison of the lesions with the
probe (seeFig. 3.9). In the carpus, the egresscannula is often
used as a probe to palpate lesions. This technique is a "short
cut", often eliminating the need for another instrument
insertion. On the other hand, the blunt, hooked probe is
important in assessingsuspect articular cartilage in cases of
osteochondritis dissecans,and its use is a routine part of the
procedure. Elsworth et al (1986) noted, "arthroscopy with-
out the use of the probe is an incomplete investigation," and
that routine use of the probe is essential in training for
arthroscopic surgery.
Post-arthroscopic irrigation and closure
When the arthroscopic procedureis completed,using an
openegresscannula and pumping fluid through the joints
effectivelyflushesdebrisfrom the joint. Typically,the larger,
4.5 mm cannula is usedso that all debrisis removed(in the
femoropatellarjoint a larger 6 romcannula is used).
No suturesare requiredto closethe joint capsuleportals.
One or two sutures are placed in the skin incisions. One
suture is usually sufficient. The authors prefer a simple
interrupted pattern to a cruciate pattern, to avoidinverting
the skin edge.In human arthroscopy,some authors have
madea casefor not suturing skin incisions(Williamsonand
Copeland1988). Cosmeticadvantageshave beenproposed
and someindividuals believehematomaor stitch abscesses
are less likely to occur. Suturing is consideredthe safer
alternativein the horse.Specificpostoperativemanagement
is discussed in the individual joint chapters.
The publicity associated with surgical arthroscopy has
overshadowed the use of the arthroscope in diagnostic
evaluation of the joint. It is well recognized that traditional
diagnostic methods used in the evaluation of joint disease
(clinical examination, plain and contrast radiography, and
synovial fluid analysis) have definite limitations, particularly
in evaluating articular cartilage changes. The diagnostic use-
fulness of arthroscopy in the evaluation of equine joint disease
was documented in 1978 (Mcllwraith & Fessler1978). The
use of the arthroscope as a surgical decision maker in human
orthopedics is well established (Hots & Hoerbooms 1979). As
mentioned previously, however, arthroscopy is an adjunctive
diagnostic technique and should not replace traditional
diagnostic methods. The hazards of not evaluating a joint
radiographically prior to arthroscopy are documented in
man Goyce& Mankin 1983). As discussedin later chapters,
obtaining both pre-and postoperative radiographs should be The tautness of the joint capsule and ligaments limits the
mandatory in equine arthroscopy. ability to examine certain joints or areas of certain joints.
Arthroscopy is valuable in assessingsynovial membrane. including the medial aspect of the antebrachiocarpal joint.
articular cartilage. intra-articular ligaments. and menisci (in the medial aspect of the patellofemoral articulation. and
the stifle). The ability to perform diagnostic arthroscopy of much of the femorotibial joint. Pitfalls of examining articular
parts of the equine femorotibial joints has furnished con- cartilage include over-interpretation. owing to magnmcation.
siderable amounts of new information and much progress and failure to recognize normal variations in morphology in
has been made in this area since the last edition of this text. the joint.
The usefulness of diagnostic arthroscopy in enabling the
clinician to make a diagnosis when no other technique can do
so is worthy of emphasis. These conditions include tears in
the cruciate ligaments as well as the medial palmar
Observation of debris in the
synovial fluid
intercarpal ligament. meniscal injuries. and radiographically
"silent" osteochondral fragmentation. subchondral bone
Before discussing specific examination of the synovial
disease.and various articular cartilage lesions.
membrane and cartilage, we should acknowledge the
presence of debris that is often noted on initial observation of
a joint before flushing. Usually, this debris is flushed out and
Knowledge of normal anatomy
is not further defined; however, some potentially valuable
information may be lost. In a series of human knee
Before valid interpretations of changes in the joint can be
arthroscopic cases reviewed by Mori (1979), debris was
made, the surgeon must know the arthroscopic anatomy.
found in 46 of 732 joints examined. The author classified the
This prerequisite, in turn, means relearning joint anatomy,
debris into four groups: precipitation of fibrin (14 cases);
which constitutes the first learning step in arthroscopy, be it
degeneration and necrosis of villi (20 cases);desquamation of
diagnostic or surgical. Knowledge of dynamic as well as static
articular cartilage (9 cases);and metaplasia of villi (3 cases).
anatomy is necessary. The surgeon needs to know the
Necrosis of villi was considered to result from a cycle of
changes that occur with variations in joint position.
remission and recurrence of acute inflammation, such as
Since embarking in arthroscopy, the authors have gained
rheumatoid arthritis. When remission of acute inflammation
a considerable amount of knowledge regarding joint
began at the root of villi as a result of steroid use, it induced
anatomy, particularly with regard to the synovial membrane
ischemic necrosis at the periphery. Thinner and longer villi
and other soft tissue structures (Fig. 3.10). In addition to the
have a greater tendency to become necrotic. These ideas
smooth and villous areas, specific to certain sites in the joint,
appear to be subjective and were not supported by histologic
a number of normal plicae (folds) are present that have not
data, but they may well provide an explanation for some
been documented in equine anatomy texts. The positions of
findings in the evaluation of horses.
these folds are noted in later chapters.

Evaluation of synovial membrane

and synovitis

The morphologic features of the synovial membrane and its

villi can be visualized better with arthroscopy than by
examination of a gross specimen or during arthrotomy (Bass
1984). When arthrotomy is performed, villi tend to cling to
the synovial membrane and cannot therefore be seen
distinctly. In arthroscopy, because the observation is
performed in a fluid medium, the shape of the villi stands out
distinctly, and transillumination allows improved visual-
ization of the villous vascularity. The magnification of the
arthroscope also facilitates definition. The degree of magnifi-
cation varies, however,depending on the distance of the object
from the end of arthroscope. If the end of the arthroscope is
1 mm from the object, the magnification is 10 times; at a
1 cm distance, no magnification is noted (Crane 1984).
The morphologic features of synovial villi in the horse
have been classified (McIlwraith & Fessler 1978). This
classification does not cover all possibilities, but some degree
of nomenclature is required to document various changes
with synovitis. Rather than use a simple classification system,

the arthroscopic surgeon needs to be able to recognize the
synovial pattern for specific areas of each joint. Definition of
abnormalities depends on a sound knowledge of the normal
distribution and characteristics of the villi. For example, in
the normal i.e. middle carpal joint, polyp-like filamentous villi
are typical of the dorsomedial and dorsolateral areas of the
joint (see Fig. 3.10). In the far medial portion of the joint,
the synovial membrane is smooth, white, and without villi.
The presence and morphology of normal synovial plicae and
the normal intra-articular ligaments need to be known
(Fig. 3.11).
The surgeon needs to recognize the many variations of
normal synovium that exist and the degree of change that
can occur with minimal clinical compromise.
Synovitis manifests in a number of forms that have yet to
be completely characterized:
1. Hyperemia is typical of acute synovitis (Fig. 3.12). It may
be accompanied by some degree of edema and fibrin
deposition.
2. Petechiation can be observed.
3. Development of small, hyperemic villi in abnormal
locations.
4. Thickening of villi and an increase in density of villi
(Figs 3.13 and 3.14).
S. Formation of new types of villi (e.g. cauliflower-like villi).
6. Atrophy of villi and total flattening of villous areas with
fibrin band deposition and adhesion formation.
7. Formation of plump polypoid villi with detachment of
these massesto form "rice bodies".
Note also that some areas or pieces of light-colored avascular
synovium can often be mistaken for a loose body.
In a number of instances of traumatic joint disease,such
as cases involving carpal chips, chronic fibrotic changes
develop in the synovial membrane. In these cases, however,
the clinical signs may not differ from those noted in instances
In
pathologic changes in the synovial mem-
carpal chip fractures are associated
with Hemosiderosis may also be seen in the
synovial membrane.
Synovial membrane biopsy can be performed conveniently
by using the arthroscope. Although there are limitations in
the histologic evaluation of synovial membrane (McIlwraith
1983), it is usefulin the diagnosisof septic arthritis. Diagnostic
arthroscopy and a biopsy sampling constitute a standard
protocol before lavage of infected joints. The degree of
synovial proliferation and pannus formation and the presence
of articular cartilage compromise can also be assessedduring
this procedure. With biopsy of synovial membrane in any
type of diseased joint, it is important to realize that normal
areas of synovium appear alongside areas of inflammation.
For this reason, blind biopsy is considered to have limited
value and a biopsy under arthroscopic visualization is the
only worthwhile procedure. This opinion is supported by
findings of a recent study in man in which macroscopic signs
of inflammatory activity in the synovial membrane varied
considerably within a single joint (Lindblad & Hedfors 1985).
In addition, a higWy significant correlation was found between
the local macroscopic (arthroscopic) signs of inflammatory
activity and microscopic findings.
Although specific vasculature changes are considered to
occur in association with various arthritic entities and blood
vessels can be seen easily in normal villi, the conventional
arthroscope lacks the magnification for detailed observation
of fine vascular structures. A magnifying arthroscope has
been developed and used in Japan (Inoue et al1979). The
details of the capillary network of the capsule and synovium
have been better defined in this fashion (seeFig. 3.12B). The
visual angle of the lens system is small and the visual field
with good focus is narrow. A preliminary investigation was
reported in which researchers used another microendoscope
with the ability to pass from panoramic vision to contact view
at four different magnifications, including microscopic
observation of vitally stained cells (Fizziero et al1986). On
the basis of these preliminary findings, the authors thought
the capabilities of the device went some way toward bridging
the gap between the conventional arthroscope, the light
microscope, and the scanning electron microscope.
The changes observedin experimentally induced synovitis
are good examples of the sequential changes that occur in
synovitis (McIlwraith & Fessler 1978). They highlight not
only the changes that can be observed but also the fact that
repeated examinations provide a good dynamic under-
standing of the synovial membrane. In this study, in which
synovitis was induced by using filipin, hyperemia was
significant initially. Petechiation of the villi and abnormal
development of small hyperemic villi in the medial aspect of
the carpal joint were frequent findings. Membranous fan-like
and cauliflower-like villi were seen in these joints, whereas
they do not appear in normal joints. In more severely in-
flamed joints, fusion of villi across the joint and the presence
of fibrinoid strands and adhesion formation were evident.
Chronic fibrotic changes were noted in the later stages,with
 Fig. 3.12
(A) Hyperemic synovial villi in a case of
acute synovitis of the carpus. (8) View of
same area using magnifying arthroscope.

.
~
 villi becoming thicker and denser as the disease text, is that of synovectomy; its use in man was described by
Highgenboten in 1982. It is frequently used in the horse to
the use of arthroscopy, new conditions can be facilitate the diagnostic process by allowing examination
Structures that are normal but have not of an otherwise obscure region. Synovectomy is greatly
facilitated by improved soft tissue blades for motorized units
dorsomedial intercarpal ligament in the midcarpal (see Chapter 2).
Arthroscopic synovectomy has been performed in human
.This hemophiliac patients (Casscells1987, Limbird & Dennis 1987).
often overlies a communication between the femoro- It reduced the frequency of bleeds and, with continuous
joint and the medial femorotibial joint. In man. passive motion, arthroscopic synovectomy resulted in good
" (contributing to symptomatology of the
postoperative motion (Limbird & Dennis 1987), and has been
a new clinical entity with the shown more recently to be cost-effective in treating hemo-
of arthroscopy. This condition is not common and philiac patients (Tamurian et al 2002). Results of another
assessment must be made to exclude other causes of study in man suggest intra-articular release of adhesions is
Levesque 1984). The most commonly efficacious in the management of arthrofibrosis of the knee
clinical situation is that of medial patellar plica (chronic stiffnessof the knee) subsequentto previous operative
plica (Richmond & procedures (Parisien 1988). Local synovectomy has been
1983, Nottage et al1983). A direct blow, repeated used in human knees where hypertrophy of the synovium in
or nonspecific synovitis may be the inciting event the anteromedial aspect of the joint following trauma has
to fibrosis and hypertrophy of the synovial plica. caused mild chondromalacic change on the medial femoral
occur as the plica bowstrings over the medial condyle and knee pain. Arthroscopic debridement of this
the femur. Secondary chondromalacia may also pathologic tissue significantly improves symptoms (Chow et
The authors still consider acquired plica-associated al2002). Equivalent indications may be found in the horse.
a normal Figure 3.16 illustrates hemarthrosis and the biopsy of a piece
structure is best exemplified in the horse by of synovial membrane.
and fibrosis of the dorsal synovial pad of the Potentially, clinicians could use synovectomy to treat
3.15). equine conditions involving chronic synovitis. However,
experimental work in the horse has questioned the beneficial
effects of synovectomy: Studies by Jones et al (1993, 1994)
and Theoret et al (1994) have reported that arthroscopic
Arthroscopic synovectomy synovectomy in equine joint tissues has short-lived reversible
changes on standard synovial fluid characteristics and
The remainder of this book deals in large part with clinical lameness. Both team of investigators reported that
arthroscopic surgery to correct various conditions of the regeneration of the synovial membrane was not apparent by
joint. One procedure that has been performed relatively little 30 days after arthroscopic synovectomy Gones et al1994)
in any equine joint. and is not addressed elsewhere in this and incomplete by 120 days (Theoret et al 1994). These
 the mechanical and laser techniques were performed. Horses
were evaluated at 1. 3. and 6 months. Villous regeneration
did not occur in any horses after surgical synovectomy. All
synovial membranes healed with a fibrous subintima and less
populated intima. The CO2laser was capable of performing a
more superficial synovectomy than that achieved with
mechanical synovectomy using a motorized arthroscopic
synovial resector. The authors also cQncluded that
mechanical or CO2laser synovectomy could be performed in
the horse. but additional evaluation was needed before the
physiologic significance of the lack of villous regeneration
is known.
The authors of this textbook are concerned about capsular
defects and fibrosis following synovectomy. We recommend
localized synovial resection to improve visualization. but
caution against using more generalized synovial resection as
a therapeutic measure. at least in traumatic joint disease.The
use of the resector for eliminating fibrin in infected joints is
another issue and is discussedin Chapter 14. Hemarthrosis of
the synovial membrane is seencommonly in the carpal canal
in association with radial osteochondroma and may be
occasionally seenin joints. Acute hemarthrosis is commonly
seenin the early stage of severejoint injury as also occurs in
man (Butler & Andrews 1988).

Evaluation of intra-articular ligaments

and menisci

Arthroscopyhasenabledveterinariansto diagnoseotherwise
unrecognized lesions of the medial palmar intercarpal
(Mcllwraith 1992) (Fig.3.17; seealso Chapter4) and cranial
cruciate (Walmsley 2002), meniscal (Walmsley 2002)
ligamentsand femorotibialmenisci(WalmsleyetaI2003).

studies were performed in normal equine joints whereas,

obviously, many clinical applications of synovectomy occur
in inflamed or infected joints,
Another study was performed to determine if arthroscopic
synovectomy had a beneficial or deleterious effect on
articular cartilage in equine joints with an induced synovitis
(Paliner et al1998). The authors concluded that synovectomy
in inflamed joints could be more deleterious to the articular
cartilage integrity than inflammation alone and that
synoveGtomyin normal joints has later effects (between 2 and
6 weeks), which may be a response to the remodeling of the
synovial membrane after resection (Palmer et aI1998).
Another study compared synovial regeneration in the
equine carpus after mechanical or CO2 laser synovectomy
(Doyle-Jonesetal2002). Twelve horseswere randomly divided
into three groups. The antebrachiocarpal and midcarpal
joints were randomly assigned to treatment so that each
horse had one joint as a control (arthroscopic lavage), one in
which a mechanical or CO2laser partial dorsal carpal syno-
vectomy was performed, and one in which a combination of
 of articular cartilage despitenormal radiographs.All the

of diagnostic arthroscopy is the evalu-

cartilage (Casscells 1984). Evidence of
changes in the cartilage can be recognized
only when lesions extend into the sub-
or over sufficient area to cause loss of joint
Many situations of cartilage compromise are less
than this, but they may still represent significant
A recent study in people recorded chondral
lesions in 1000 consecutive knee
2002). The lesions were classified
recognized by the International Cartilage
Society (ICRS). Chondral or osteochondral lesions
61 % of patients. Focal defects were found in
the patients and, in these individuals, 61 % related
.knee problem to a previous trauma. A con-
anterior cruciate injury was found in
26% of patients, respectively. Mean osteochondral
2.1 cm2 and the main defect was found
58%, patella in 11 %,lateral
condyle 9%, trochlear in 6%, and
tibia in 5% of patients. This study showed the pre-
horses wrinkled. and enfoldedcartilage,
and, probe could be inserted into the
addition to focal lesions,4 of the 11
horseshad generalizeddamageto cartilage on the medial
femoralcondyle.Thesefocal cartilagelesionson the femoral
condyleweredebrided.In 2 of 4 cases,debridementwas not
possible;6 of 7 horseswith focal cartilagelesionstreatedby
debridementrecoveredcompletelyand resumed previous
activities.
The arthroscope allows better detection of articular
cartilage damage than gross visual inspection at post-
mortem. Evensuperficialfibrillation can be recognizedwith

of various parameters rather

cartilage loss is also very common in the horse,

associated with osteochondral chip fragments
carpus (Figs 3.18 and 3.19). Less severe changes
-in the fetlock in association with chip fracture
3.20-3-22) and in most instances of osteoarthritis
to osteochondritis dissecans. In most joints, the

reported as a cause of lameness in eleven horses

et al 1997). Cartilagechange was revealedat
the arthroscope because of the combined effects of fluid
suspension of the fibrillated collagen fibers. magnification.
and transillumination (see Figs 3.18 and 3.20). Partial
thickness and full thickness erosions represent more severe
changes in the articular cartilage (Fig. 3.20-3.27). Disease
involving the subchondral bone can also be recognized
(Fig. 3.27 and 3.28). Other entities of cartilage damage. such
as wear lines. are also recognized with the use of diagnostic
arthroscopy (Fig&3.29 and 3.30). The significance of these
changes is discussedin later chapters. The use of instruments
to define the size of the lesion is also important. Methods of
debriding cartilage defects are dealt with in Chapter 17.
Before the advent of arthroscopic S\lfgery. the first author
(C. W.M.) performed diagnostic arthroscopy on joints to
ascertain further the potential value of surgery (such as

Electrosurgery using high-frequency (HF) equipment
(described in Chapter 2) has been used in both human and
equine arthroscopy. One of the authors G.B.)has used it quite
extensively in the horse. In humans. in addition to surgery on
the synovial membrane and joint capsules,most arthroscopic
meniscal surgeries are routinely done with the electroknife by
at least one group (Kramer et al1992). When using such
instrumentation, care must be made to avoid contact with
the cartilage.
Thermal chondroplasty with radiofrequency energy (RFE)
has garnered widespread interest over recent years. There are
two systemsavailable for clinical application: monopolar RFE
and bipolar RFE (Lu et al 2002). Evaluation of both types of
instrument on fresh osteochondral sections derived from
patients undergoing partial or total knee replacement
revealed that the depth of chondrocyte death in the mono-
polar RFE treatment group was significantly less than in the
bipolar group. The authors pointed out that there could be
significant chondrocyte death. The study also showed that it
took at least 15 seconds for both bipolar and monopolar
RFEto contour a 1 cm2 chondromalacic cartilage defect to a
relatively smooth surface as shown by scanning electron
microscopy (Lu et al2002). The investigators concluded that
when thermal chondroplasty was applied clinically, it could
result in various degrees of cartilage smoothness and
potentially significant chondrocyte death.
The case for the use of lasers has also been made in joints
(Palmer 1996). However, evaluation in clinical cases has
revealed unwanted subchondral bone necrosis when an
articular cartilage lesion is debrided.
Arthroscopic lavage
and debridement
The usefulnessof lavage in traumatic arthritis had been
claimed prior to arthroscopic surgery becoming routine
(Norrie 1975). The adjunctive lavage that goes with
arthroscopicsurgeryhas alwaysbeenconsideredbeneficial.
althoughthereis no clear documentationof this effect.How-
ever,the benefit of partial thickness chondrectomywhere
there is cartilage fibrillation or minor exfoliation is more
 3.31). The use of such debridement along
, C C but controlled
of the rabbit patella with no evidence of
in either the superficially or deeply shaved areas
--& Shephard 1987). Ultrastructural studies after
cartilage shavings question knee regeneration
Schmid 1987). A
trial of arthroscopic surgery for osteoarthritis
knee in humans caused considerablecontroversy
2002). The authors concludedthat the out-
lavage and debridement of osteoarthritic
based on the severity of degeneration, continues to
horse.the authors feel that lavageis an important
part of arthroscopic procedures by reducing
cartilage. A useful rule is that if articular
is attached to subchondral bone it should be left
Second look arthroscopies provide an opportunity to
the amount of healing that has occurred in
3.32).
References
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surgical procedures and initially served
1983. 1984. Mcilwraith et al
surgery and the earlier return to exercise, (Martin & McIlwraith 1985). Two portals are also useful if
rather than continuing training
medication to the detriment of joints and
was the
arthroscopy in the carpal joints as well as a
of case selection,adjunctive management,and
can be anticipated. In most instances, the
are common to all joints, but they are
of arthroscopic surgery.The key to successful portal. On the other hand, if the examination also reveals a
is attention to detail and authors will
throughout the small featuresthat are
and prognostic procedure (Mcllwraith &
~.. Mcllwraith 1991) as well as for the surgical
of articular injuries. The general role of the
arthroscopic anatomy of the carpal joints is
middle carpal (intercarpal) or ante-
portal for eachjoint. Using two dorsal
of movement because of reduced soft tissue tension around
the arthroscope and a reduced tendency to slip out of the
joint when examining areas close to the arthroscopic portal
surgery is going to be performed on both sides of a joint. In
addition, villi in the area of arthroscopic entry will
sometimes compromise visualization in that area of the joint.
Examination through one portal has been greatly facilitated
by the development of the angled-view arthroscope. It is
important always to evaluate the whole joint before
commencing surgical manipulation. For example, if the pre-
surgical diagnosis is that there is fragmentation of the distal
radial carpal bone, the arthroscope is placed dorsolaterally
and once a clear view is obtained, a quick examination of all
the potential areas for injury can be made. If the only
arthroscopic finding is the chip on the distal radial carpal
bone, then this is removed through a dorsomedial instrument
fragment on the distal intermediate carpal bone, then after
removal of the radial carpal chip, the arthroscope and
instrument are swapped as the fragment on the intermediate
carpal bone can be more conveniently visualized and
removed using a dorsomedial arthroscope portal and a
dorsolateral instrument portal.
It is also possible to insert the arthroscope into the lateral
palmar outpouchings of both middle carpal and antebrachio-
carpal joints as well as medial outpouching of the ante-
brachiocarpal joint. The most common indication for surgery
is removal of fragments from the palmar aspect of the joints,
but this approach has been used to retrieve a broken piece
of instrument (McIlwraith 1990, Dabareiner et al 1993,
Wilke et aI2001).
Due to the anatomic differences, examination and surgery
of the middle carpal joint is easier than the antebrachio-
carpal joint: whereas the middle carpal joint tends to open as
a hinge, the antebrachiocarpal joint is shaped so that its
movement is both rotational and gliding. The gliding
movement of the joint tends to tuck the dorsal edge of the
radius beneath the joint capsule and the joint capsule
attaches closely to the proximal marginal edge of the inter-
mediate and radial carpal bones. In addition, the convex
curvature of the distal medial and lateral aspectsof the radius
make access to the medial and lateral joint angles slightly
more difficult. The narrow angle between the radius and the
proximal radial carpal bone in the medial aspect of the joint
can also make instrument manipulation more difficult in
this area.
The general technique for introducing the arthroscope
into the joint was described in Chapter 3. Two arthroscopic
portals are useful for either the middle carpal or antebrachio-
carpal joint: dorsolateral and dorsomedial. The lateral
approach is better for visualizing the medial aspect of the
joint and the medial entry is better for seeing the lateral
aspect. For example, when the operation involves a lesion on
the medial half of the joint, the instrument is introduced
through the medial portal and the arthroscope enters
through the lateral portal and vice versa. Thorough
exploration of the carpal joints is therefore possible by using
both lateral and medial entries.
Although arthroscopy in the carpal joints can be
performed with the animal in lateral or dorsal recumbency,
the latter has greater versatility. When switching sides with
the arthroscope (as is usually necessary if lesions are on both
sides of the joint), rolling of the horse or doing surgery
"upside down" is necessary if it has been placed in lateral
recumbency. Some surgeons have suggested that the dorsal
recumbency position causes tightening of the joint capsule
over the dorsal face of the carpus, and that a loose fragment
can be located more predictably in the lateral or medial
cul-de-sac of the joint when the animal is in lateral
recumbency. However,the authors have not found these to be
limiting factors and in reviewing arthroscopic surgical
procedures performed on 1000 carpal joints in 591 horses by
the first author (C.W.M.) 45% were operated bilaterally. For
this reason, all descriptions of both diagnostic and surgical
arthroscopy in the carpal joints are presented as in dorsal
recumbency, i.e. proximal is below and distal is above. This
position is also taught in the authors' laboratory classes.
Learning arthroscopic anatomy in this manner is an important
prerequisite to performing arthroscopic surgery. Positioning
and preparation of the carpus are illustrated in Chapter 3.
Initially, the most important aspect is to learn the specific
landmarks that allow orientation within the carpal joints and
these are described in the examination techniques below.
Arthroscopic examination of the
middle carpal (intercarpal) joint
The choice of arthroscopic portal depends on the primary
area the surgeon wishes to examine. The lateral portal is
halfway between the extensor carpi radialis tendon and the
common digital extensor tendon and midway between the
two rows of carpal bones with the joint flexed at approxi-
mately 70°. The medial arthroscopic portal is made sufficiently
medial to the extensor carpi radialis tendon to avoid its
tendon sheath. The skin incision for these portals is made
before distention of the joint to avoid damage to the tendon
sheaths. By contrast, the periarticular anatomy of
fetlock, tarsocrural, and femoropatellar joints allows r
liberties with placement of the portals, and prior j
distention is an assetto localization of the correct portal
After joint distention, the arthroscope is inserted int(
joint as described in Chapter 3. Examination with
arthroscope inserted through the lateral portal comme
with the visual field in the medial aspect of the middle c~
joint (Fig. 4.1). The dorsomedial intercarpal ligaIJ
extending from the dorsal medial aspect of the radial c~
bone to the medial joint capsule is commonly obse
(Fig. 4.1C). This dorsomedialligament has been previc
describedas a synovial plica (Mcllwraith 1990). Withdral
the arthroscope and angling the lens proximad aU
inspection of the articular surface and dorsal margin oj
radial carpal bone (Fig. 4.2). Continued withdrawal of
arthroscope allows visualization of the junction betweer
radial and intermediate carpal bones (Fig. 4.3). Rotati(
the arthroscope allows inspection of the palmar aspect 0
joint and the articulation between the radial, intermed
and third carpal bones (Fig. 4.3C). Also in this view i!
synovial fossain the medial palmar aspect of the third c~
bone and the medial palmar intercarpal ligament (MP
This fossa is normal; it is a site of communication witt
palmar pouch of the middle carpal joint, and may be a sit
lodgment of small particles that break free during art
scopic surgery. During examination of the articular mill
of the radial and intermediate carpal bones, the joint caI
attachment is some distance from the articular rim, all01
excellent visualization of the dorsal margins of these bol
The arthroscope is advanced slightly and the arthros(
lens is angled distad to visualize the second carpal bone
the medial portion of the third carpal bone (Fig. 4.4). S
withdrawal allows additional visualization of the remai
dorsal margin and body of the radial facets of the third c~
bone (Fig. 4.5). If the arthroscope is then moved so tha
tip sweepslaterad and the eyepiecemediad, the intermel
facet of the third carpal bone and the more central aspe
the joint can be visualized (Fig. 4.6). By continuing
motion, the lateral aspect of the intercarpal joint ca
visualized. (These areas are illustrated here, using the m
arthroscopic approach.)
When the arthroscope is inserted through the d(
medial portal the tip is passedto the most lateral aspect 0
joint where the angle formed by the ulnar and fourth c~
bones is visualized (Fig. 4.7). Withdrawal of the arthros
permits evaluation of the articular surfaces of the ulnar
intermediate carpal bones as far as the junction of the I
with the radial carpal bone (Fig. 4.8). A similar mane
with the lens directed distad and palmad allows examin.
of the fourth carpal bone (Fig. 4.9) and the lateral half 0
third carpal bone (Fig.4.10). There is also a synovial plica
the transverse dorsal intercarpal ligament at the juncti(
the third and fourth carpal bones (Fig. 4.10C).
Additional maneuvers may be necessary to augmen
examination. For example, for detailed examination oj
dorsal synovial recessesbeyond the articular surfaces, tt
of the arthroscope may be placed between the dorsal sur
 Diagnostic Arthroscopy of the Carpal joir

,/
./

'"/'

Fig. 4.2
Distal radial carpal bone (R). (A) Diagram of arthroscope
position and visual field. (8) Arthroscopic view; 2. Second carp,
bone; 3,Third carpal bone L, medial palmar intercarpal ligamer
4, fourth carpal bone. I, Intermediate carpal bone; U, ulnar
carpal bone; CD, common digital extensor tendon; ECR,
extensor carpi radialis tendon.

of the carpal bones and the capsular reflections. Synovial 1

in the dorsomedial and dorsolateral aspects of the joint n
obscure the view of some parts of the dorsal rims of the bol
despite joint distention. In these cases,use of an instrum,
to push them out of the way is appropriate.

Arthroscopic examination of the

Fig. 4.1
antebrachlocarpal
~
(radiocarpal) joint
Medial aspect of the middle carpal joint. (A) Diagram of
arthroscope position. (B) Arthroscopic view. R, radial carpal Arthroscopic examination of the antebrachiocarpal joint
bone; 2, second carpal bone; 3, third carpal bone; CD,
conducted in the same fashion as for the middle carpal job
common digital extensor tendon; ECR, extensor carpi radialis
tendon. (C) Closer view of field in B. P, Normal synovial plica
except that the flexion angle in the carpus is decreased(leg
(dorsomedial intercarpal ligament).
extended to 120-130°). The leg is straightened to facilitc
maximal visualization of the dorsal aspectsof the radial aJ
,/
,,19 Diagnostic and Surgical Arthroscopy of the Carpal joints
Fig.4.3
Junction of the radial and intermediate carpal bones.
(A) Diagram of arthroscope position and visual field. Dorsal
(B) and palmar (C) arthroscopic views. R, radial carpal bone;
I, intermediate carpal bone; medial palmar intercarpal ligament.
Fig.4.4
Second carpal bone (2) and the medial aspect of the third car~
bone (3). (A) Diagram of arthroscope position and visual fie
(B) Arthroscopic view. (C) A more palmar view of the third
carpal bone. including the fossa at the medial palmar aspect I
the junction of the second (2) and third (3) carpal bones as
well as the medial palmar intercarpal ligament (L). Also note
the median ridge of the third carpal bone dividing radial and
intPrmprJi"tPf"rpt.
 joints

R
A' -

Fig.4.T
Ulnar (U) and intermediate (I) carpal bones. (A) Diagram of a~roscope position and visual field. (8) Arthroscopic view.
Intermediate facet of the third (3) carpal bone.

Fig. 4.8
Distal articular surface of the intermediate carpal bone (I). (A)
Diagram of arthroscope position and visual field. (B and C)
Arthroscopic views. Note the edge of the radial carpal bone
(R) and synovial plica (P) between intermediate and radial
carpal bones. $, synovial membrane.

--
1111_i,
 A

carpal bones and distal radius (and this is

As in the middle carpal joint. the dorsolateral arthroscopic

Cis halfway between the common digital extensor and
extensor carpal radialis tendons. and the dorsomedial
portal is medial to the extensor carpi radialis tendon. The
choice of portal depends on the area of primary interest with
respect to visualization and (usually) surgical intervention.
The site of the medial portal is at the center of a triangle
formed by the extensor carpi radialis. the distal rim of the
radius. and the dorsal rim of the radial carpal bone. This
portal area is in the smallest space in either of the carpal
joints and because of marked narrowing of the joint. the
tight nature of the capsular attachments. and the convex
nature of the articulation. the surgeon has to be careful when
inserting the arthroscope to avoid excoriation of the articular
cartilage.
 Arthroscopic examinationof the antebrachiocarpaljoint
will be described,beginning with the arthroscopeinserted
through the lateral portal and visualizationof the medialside
of the joint. The distalradius and the proximal radial carpal
bone form the medialjoint angle.Rotationof the lensdistad
allowscloseinspectionof the medialportion of the proximal
articular surfaceof the articular surfaceof the radial carpal
bone (Fig. 4.11). Withdrawing the arthroscopic slightly
allows examinationof the entire proximalradial carpalbone
to the levelof its junction with the intermediatecarpalbone
(Fig.4.12).
The arthroscopeis then rotated so that the lens is angled
proximadto examinethe medialaspectof the distal articular
surfaceof the radius (Figs4.13 and 4.14}. As in the middle
carpaljoint. the lateral aspectof the joint can be examined
through the samelateral arthroscopicportal by moving the
eyepiece mediad and the tip laterad and then rotating t
scope appropriately. For purposes of palpation and surge
however, examination of the lateral aspect of the joint is b
performed through a medial arthroscope portal.
By switching to a medial portal, the most lateral aspec
the antebrachiocarpal joint is examined. The arthroscoP(
rotated wit!1 the lens pointed distad to visualize the proxin
articular surface of the ulnar carpal bone and the late
aspect of the proximal articular surface of the intermedi:
carpal bone (Fig. 4.15). Withdrawing the arthroscope allo
examination of the entire proximal surface of the int
mediate carpal bone (Fig. 4.16), and tilting of the arthrosco
tip distad allows inspection of the junction of the intermedi
and radial carpal bones (Fig. 4.17).
By returning the tip of the arthroscope to the late
aspect of the joint and rotating the arthroscope so that 1
lens is directed proximad, the lateral aspect of the
radius can be examined (Figs 4.18 and 4.19). On a
lateral view, the articular groove between the lateral s
process and the distal epiphysis of the radius (fused i
adult) can be seen; in a young horse, it can be seen
completely separated fissure. With withdrawal and roti
the entire lateral half of the joint can be scanned. inCll
the midsagittal ridge of the distal radius (Fig. 4.19C). Gr
in the central portion of the radius are commonly obs
and are considered normal.
As mentioned with the middle carpal joint. addil
maneuvers may be necessary in some joints to fac
complete examination of the dorsal articular sur
including use of instruments to retract the villi and chaJ
the flexion angle of the joint.
 examination of the palmar the antebrachiocarpaljoint, the swelling is proximal
middle carpal and the perceivedjoint line. A No. 11 bladeis then usedto cre
joints a portal and the arthroscopecan be inserted.Figures4.2
and D showarthroscopicviews of the lateral aspectinto
palmar aspectof the middle carpal and antebrachioca
both middle carpal and antebrachiocarpal joint. respectively.
.

surgery is removal of frag-

been used to retrieve a broken piece of instrument
1990. 1996, Dabareineret al1993, Wilke et al
The position for placing the arthroscope in the lateral
front. swelling will be revealed.In the caseof
Maintenance of joint distention
The arthroscopist must direct the operation to ensure 1
maintenance of joint distention. This is not usually a probl
at the time of initial examination when the only patent pOI
is that for the arthroscope. If an egress cannula is placed
the other side,varying the closure of the cannula still ea~
controls distention. However, once there is a patent instl
ment portal and instrument manipulations have b
performed. some flow of fluid from the joint is inevitable
this requires an increased rate of fluid input to main!
distention. Once an instrument portal is losing flui(
number of aspectsare important to avoid the developmer
subcutaneous fluid accumulation. Placing a finger over
skin incision to stop fluid flow will only promote filling in
subcutaneous plane. Similarly. pumping fluid when a ch
being pulled through the subcutaneous tissue and skin
may block the skin outlet and cause fluid to collect 1
cutaneously. Fluid ingress should also be minimized dill
instrument manipulations because these can facilitate
opening up of the subcutaneous tissue planes. again allO\l
fluid extravasation.
Another problem. once an instrument portal is mad,
that if the joint must be re-entered with the arthroscope; I
joint distention is present to facilitate re-entry. This is D
commonly encountered with biaxial fragmentation. me
chips requiring a lateral arthroscope and medial instrun
portals and lateral chips requiring medial arthroscope
lateral instrument portals. The reinsertion of the arthros(
requires experience and care to avoid iatrogenic damag
the cartilage. The arthroscopic sheath and conical obtur
are manipulated carefully back into the joint. the arthros(
is inserted. and the joint is redistended. The use of "switcl
sticks" in human arthroscopy to facilitate these maneu
has been described Gohnson 1986). but the authors be!
these are not necessary in the equine carpus. Removing
arthroscope from one portal and placing it in another 1
consequent escape of fluid is usually associated with S
bleeding and the joint will need to be flushed be
visualization is satisfactory.

Arthroscopic Surgery for

Removal of Osteochondral
Chip Fragments
Current status and advantages of
arthroscopic surgery
The feasibility of returning horses to racing more quj
after arthroscopic removal of carpal fragments brol
arthroscopic surgery into strong demand. Some of
advantages of arthroscopic surgery have been simplified
overstated. but it is now universally adopted for treatmel
carpal fragmentation.
On the basis of a review of 1000 arthroscopic proced
for removal of carpal chip fragments (Mcllwraith et al19
and continued experiencesince then. a number ofadvant
can be listed. Many of these are applicable also to other jo
1. Visualization is superior to that with arthrotom
improves diagnostic accuracy and. consequently. r
definite treatment.
 to periarticular tissuesand the joint
only is the cosmetic result excellent but also
, to overall joint function is minimized.
trauma to the soft tissues is also significant to
the articular cartilage, which may undergo
deterioration secondary to soft tissue
the joint (with elimination of
on multiple joints can occur in the same
race successfullyin the same or a higher class. A
lowering in class. however.is more typical for
racehorsesafterarthrotomy.
6. Horses return to training earlier and thus less fitness a
musculoskeletaladaptation are lost. Thesefactors contribl
to an earlier return to racing.
Problems and poor results have been encountered, and ;
addressed at appropriate points throughout the chap1
Many small problems can be avoided by technique chang
and one of the main purposes of this textbook is to stl
the beginning arthroscopist past some of these pitfa
Unfortunately, poor results can often be related to inadequ;
ability, experience,or practice. To be able to operate effectiv
on any carpal chip lesion using arthroscopic surgery i~
reality, but it requires skill and practice. Above all, it a
requires a disciplined systematic approach. The techniql
presented in this chapter are not the sole means
performing surgery; however, whatever changes the surge
makes, he or she should still use a systematic approach
every case.The approachesdescribedhave worked for the
authors and also for the veterinarianswho haveundertaken
the arthroscopictraining coursesthat the authorshavecon-
ducted worldwide (Mcllwraith 2002). Modification and
refinement of techniquescontinue and it is the authors'
philosophyto disseminatethis information through training
coursesand publications.
Presurgical information
As with any surgical candidate, as complete a history as
possible is obtained. This history is often difficult with
racehorses, and duration or time that the chip fracture has
been present is often not clear. Treatment history frequently
is uncertain, particularly with reference to intra-articular
corticosteroid medication, but the authors feellessconcerned
with operating on horses soon after corticosteroid adminis-
tration than was the case with arthrotomy.
In most cases, the horses exhibit mild to moderate
lameness. Severe lameness is usually associated with major
articular damage. Radiographs should always be taken of
both legs; bilateral and/or clinically silent lesions are
common and these frequently are in the same location in
both limbs. There is also a lack of correlation between radio-
graphic and arthroscopic findings, which is usually reflected
in arthroscopic findings that are more severe than those
suggested by radiographic examination (Mcllwraith et al
1987). The same disparity was noted in human osteo-
arthritic knees (Lysholm et al198 7). Specific problems in this
regard with chip fractures at various sites in the carpal joint
are addressedin the appropriate section.
Relevant pathobiology
The carpal and fetlock joints are the most common instances
where traumatically induced osteochondral chip fragmentation
occurs. Although chip fragments have been frequently con-
sidered as acute injuries and present with acute clinical signs,
it is now recognized that many of these fragments come from
pathologic joint margins, previously altered by subchondral
bone disease (Pool & Meagher 1990), and more recent work
in the first author's (C.W.M.) laboratory has documented the
development of microdamage in association with exercise.
The microdamage manifestedas a combination of microcracks,
diffuse microdamage, cell death, and subchondral bone
sclerosis (Kawcak et al 2000, 2001) and it is suggested that
such changes lead to the clinical osteochondral fragmentation
seenin the carpal and the fetlock joints.
It has been proposed that chip fractures of the joint
margins in the carpus can arise from either fragmentation of
the original tissue of the joint margin (previously altered by
disease as mentioned above), or within the base of peri-
articular osteophytes forming in joints as part of the osteo-
arthritis syndrome. Experience with arthroscopic surgery of
carpal fragmentation suggests that both mechanisms occur
and for this reason, the authors now prefer using the term
"fragment" rather than "fracture" for the osteochol
pieces that are created. Such fragments almost invar
occur as a consequence of microdamage and thus cou
classified as pathologic fractures. In some instances the II
appears as a "fresh" fracture line through an artil
surface with no visible subchondral change, but in
instances subchondral disease is seen arthroscopically
certainly exists at the microscopic level.
Osteochondral fragmentation has direct physical effec
the joint because of the loss of the smooth articular su
and indirect effects due to the release of articular car1
and bone debris, which leads in turn to synovitis. S
compromise of the articular surfaces leads to instabili
does tearing of fibrous joint capsule and ligaments.
synovial membrane responds directly to mechanical tr.
and indirectly to injury elsewhere in the joint. High i
articular pressures generated by synovial effusion
promises the microstability, and the normal, slightly ne~
atmospheric pressure in joints is lost. Damage to synovio
also liberates matrix metalloproteinases, aggrecal
prostaglandins, free radicals and cytokines (princi
interleukin 1 or 11-1), which could lead to articular carl
degeneration (McIlwraith 1982). Chronic articular i
results in fibrosis of the joint capsule and consequent II
motion. Arthrofibrosis is recognized as an important prc
in humans. The cause is still unknown, but the use of s
arthroscopic techniques is considered critical in
minimization of arthrofibrosis in man (Finerman & ~
1992).
The primary indication for surgical treatment of c
chondral fragments in the carpus is to minimize arti
insult and to prevent development of osteoarthritis
(McIlwraith & Bramlage 1996). It should be recognizec
a joint is rarely returned to "normal" and that signiJ
defectscan potentially lead to some degree of microinsta
and progression to osteoarthritis. Nonetheless,relative j
amount of damage, the athletic horse can come back t(
level performance despite some damage.
Location of intra-articular fragments
Table 4.1 illustrates the incidence and location of (
chondral fragments in the dorsal carpal joints as report
the first author (C.WM.) in a series of 1000 carpal"
(Mcllwraith et al 1987). The affected joints were in
horses, of which 220 were racing Thoroughbreds. 349
racing Quarter Horses. 5 were racing Appaloosas,and 6
racing Standardbreds. The others included 2 barrel-r
Quarter Horses, 3 roping Quarter Horses, and 6 other I
horses.
Of the 591 horses. 278 horses were 2 years old, 196
3 years old, 52 (55%) were 4 years old, 47 were 5 ye,
older, and 18 did not have their age documented. In
horses, osteochondral fragments were noted in one ca
whereas 265 (45%) horses had bilateral lesions. Arthro~
surgery was performed on a significantly greater numl
joints per horse in Quarter Horses compared with Thor(
breds. Specifically,in the Thoroughbreds, operations inv
 Arthroscopic Surgery for Removal of Osteochondral Chip Fragmem

1 joint in 142 horses. 2 joint in 70 horses, 3 joints in 14

horses,and 4 joints in 1 horse. In the Quarter Horses,1 joint
in 144 horses. 2 joints in 130 horses, 3 joints in 46 horses.
and 4 joints in 30 horses were affected (Mcllwraith et al
1987).
Unpublisheddata from a European author (I.M. \1\7:)
suggests
a similar distribution of lesions, although the relative
frequency of fragments from the proximal third carpal bone
and distal intermediate carpal bone are reversed. Readersare
also cautioned that lesion distribution may vary in other
practicesin which breed/use manipulation is different.

General technique for carpal chip removal

As discussed briefly in Chapter 3, surgery is performed by
using the technique of triangulation (see Figs 4.21-4.23).
Specificdetails on the arthroscopic and instrument approaches
for operations involving chip fractures in different locations

Distribution of carpal chip fragments.

540 intercarpal (midcarpal) joints

Distal radial carpal bone 475
Distal intermediate carpal bone 106
Proximal third carpal bone 60
Total 641
460 Radiocarpal (antebrachiocarpal) joints
Distal lateral radius 167 Fig. 4.22
Distal medial radius 96 Removal of a carpal chip fragment from the intercarpal joint
Proximal radial carpal bone 168 using Ferris-Smith cup rongeurs: (A) grasping of the fragment
Proximal intermediate carpal bone 273 (B) removal of fragment through the skin.
Proximal ulnar carpal bone 1
Total 705
Source: Mcllwraith et al1987

with a closed egress needle (A) and a probe (B) to evaluate the mobility of a carpal chip fragment

are included in subsequentsections,but the generalrule is
that for a fragment on the medial side of the joint, the
arthroscope passes through the lateral portal and the
instrumentsenterthrough a medialportal. Forlesionson the
lateral side of the joint, the arthroscopeis placedthrough a
medial portal and instrumentsthrough a lateralportal.
The basicprotocolfor surgeryof all carpal fragmentation
is similar. A diagnosticarthroscopicexaminationis always
performedfirst. The egressis openedto flush the joint if
visualizationis lessthan optimal. Whenthe view is clear,the
egressis closedand can then be used to palpate areas of
fragmentation(seeFig.4.21A). Alternatively,a probecanbe
used (seeFig. 4.21B), but the egressworks well for pre-
liminary palpationand savesan extra instrumentpassage.
The egresscannula is then removedand the instrument
portal through the joint capsuleusually closes,at leastuntil
the time that a larger instrument (which increasesthe
diameterof the portal) is used.If the fragmentis freshand
mobile on palpation,immediateinsertionof graspingforceps
is appropriate.The fragmentis grasped,and the forcepsare
rotatedto freethe chip of softtissueattachments(if theseare
sIgnmCarn), oelore II ISremovea ~seeng, ':I:.L.L.). l'ems-~
arthroscopic rongeurs are most commonly employed. j
size is chosen to enclose the fragment as complete
possibleto minimize loss,as this is brought through the
capsule, subcutis, or skin (see Fig. 4.22). Rongeurs w
jaw size of 4 x 10 mm are suitable for most fragmen1
locations. Tearing a fragment loose from its soft t
attachment by twisting the forceps may not seeI
aesthetically pleasing or relate well to basic sur
principles, as sharp severance of the attachments, I:
minimizes the risk of creating a free-floating fragment.
If attachments at the fracture line are strong all(
fragment cannot be displaced with initial probing, a :
Synthes or Mcllwraith-Scanlan elevator is used to sep
the chip from the parent bone (seeFig. 4.23). Also, whe
chip has considerable fibrous capsular insertions, as typ
occurs with fragmentation of the distal lateral radius
elevator or a fixed blade arthroscopy knife can also be us
separate these attachments before removal of the frag
with forceps.
Although rarely necessary,when a chip is long-star
and bony reattachment is developing or has develope
osteotome may be used to free the fragment from the p,
bone. The osteotome is positioned through the instru
portal and is placed in the old fracture line by the sur
using arthroscopic visualization. An assistant strike:
osteotome according to the surgeon's direction. A I
osteotome or an elevator and hammering is preferred
sharp osteotome by some surgeons as it is thought to b
likely to make a new fracture line through normal bon
Foerner pers comm 1984).
In many cases of chronic fragmentation, Ferris-5
rongeurs are used to remove the fragments directly wi1
prior separation. This usually works well, but attemr
remove normal bone in this fashion may break the pin lir
of the forcep blades. If there is extensive bone prolifer.
the use of a motorized burr for debridement of lesions c:
considered, but such indications are rare, and the val
surgery in such casesis always questionable.
Once fragments are removed, the defect is debrided.
step is discussedin detail later and is usually performed
rongeurs and curettes (Fig. 4.24). Other osseous defect:
may be debrided at this time. Kissing lesions are evalu
but when they are of partial thickness, they usually ar
debrided.
The joint is then flushed by opening the egress car
and manipulating the tip in the area of the lesion (Fig. 4
The egress can also be used to rub off small tags of carl
and bone. Placement of the larger, 4.5-mm egress car
should follow, to remove larger fragments (Fig. 4.25). Su
may be appliedto this cannula, but it is not routinely perfo
in the carpus. Lavage should continue until the joi
macroscopically cleared of debris. Occasionally, a frag
migrates away from the fracture site and is either free flo
or attached to synovial membrane (Fig. 4.26). In such (
it is removed with forceps.
At the completion of irrigation of the joint, the porta
closed by using skin sutures only (Fig. 4.27). The incisior
 Arthroscopic Surgery for Removal of Osteochondral Chip Fragmel

(A) external view. (8) arthroscopic view.

Fig. 4.25
Arthroscopic view of flushing debris from central area of middle carpal joint. (A) External view. (8) Arthroscopic view.

Fig. 4.26
Free fragment in the joint (A) and adhered to synovial membrane (8).
covered with a sterile nonadhesive dressing and adhesive
gauze, before an elastic or padded bandage is applied
(Fig,4.28).
The size of fragments that can be removed arthro-
scopically has no limit. The skin incision has to be extended in
some instances but additional incising of the joint capsule is
not usually required. Failure to lengthen the skin incision can
result in the fragment being lost or trapped in the subcutis. In
exceptional cases,a single absorbable suture may be placed
in the joint capsule after removal of a particularly large
fragment.
Postoperative or intraoperative radiographs to ensure grasped. Any soft tissue attachments to the fragment ill
removal of all fragments are recommended. Although it is severed while the fragment is held with forceps or a tOW
important that no loose fragments remain in the joint, some clamp. Occasionally, insertion of the arthroscope int
osseous densities in the radiographs may not be candidates subcutaneous pockets. with either no or little fluid flow, ca
for removal. In addition, osteophytes away from the articular assistin location of fragments.
margin and within the joint capsule (or enthesophytes)are of
less concern. For any fragment or spur completely buried
within the joint capsule, dissection out of the capsule is
Specific sites of carpal chip
unnecessary and is excessively traumatic. The surgeon
should be certain that such fragments are indeed outside the
fragmentation and their treatment
joint cavity and it is important to recognize that one should
Dorsodistal radial carpal bone
treat the patient rather than the radiograph. Veterinarians
involved in obtaining follow-up radiographs of arthroscopic The dorsodistal aspect of the radial carpal bone is the mo
surgery patients should also be aware of this principle before common site for carpal fragmentation. It is the easie
proclaiming to the client or the trainer that "a chip has been operative site in the carpus, but has the greatest range I
left in the joint." pathologic change seen at arthroscopy relative to what
If radiographs reveal evidence of a fragment remaining in seen on radiographs. The arthroscope is placed through tl
the joint, further arthroscopic examination is performed. lateral portal with the lens-angled proximad and the instrl
When a fragment has lodged subcutaneously, the area is ments are brought through the medial portal (Fig. 4.29
palpated and swept with a pair of hemostats. When the Fragmentation can occur anywhere along the distal dors
fragment is located, it is brought to the skin incision, and margin of the radial carpal bone.
 and flexed lateromedialviews and dorsolateral-

lateromedialradiographic view has beenusedto

boneloss.it is

at this site is particularly poor. In addition. chip

have been found on the distal radial carpal bone
not visualizedon any of the radiographicviews.
thesefragmentsare on the dorsolateralcorner of
projectedin

As with any chip fractures, the size of distal radial carpal

lesion varies widely. The smallest lesions manifest

in the distal dorsal margin (Figs 4.31 and 4.32),

examined arthroscopically, such lesions usually
.-,,- .'. '.31Band

Larger osteochondral fragments are easily identified

."(Figs 4.33 and 4.34). At arthroscopy, the
33). There is also
particularly
palmar to the fragmentation (Fig. 4.33). Grading degree of
articular cartilage damage is discussed more fully in a
subsequentsection.
Radiographs also do not often predict accurately the extent
of bone fragmentation in the distal radial carpal bone. Both
the amount of cartilage degeneration that extends back from
the edge of the defect and the amount of subchondral bone
loss vary considerably. Loss of bone is typically related t<
finding soft defective bone at surgery. which requires debride
ment. Such changes in the distal radial carpal bone can bt
severe when the radiographic changes appear rather mild
Often the degree of clinical compromise (lameness an,
synovial effusion) is a better indicator of the state of the join1
than are the radiographs. The presence of bloody or brown
synovial fluid on initial entry into the joint is also usually a

strong indicator of severe damage within the joint. In some
instances, radiographs provide an indication of marked bone
loss in association with chip fractures (Fig. 4.35), but usually
the bone loss is more than is anticipated (Fig. 4.36). In either
case, when loss of bone is marked, there is loss of joint
congruity and, potentially, instability. In instances where
bone remains but there is Grade 3 articular cartilage loss,
radiographs do not predict the amount of damage at all
(Fig. 4.37). After removal of fragmentation, detac]
cartilage is removed and exposed subchondral bone debri
to healthy margins (Fig. 4.38).
The prognosis is related to the amount of cartilage ani
bone loss and decreases with loss of bone along the en
dorsal margin of the bone. The relationship between progn.
and articular cartilage loss is more difficult to pred
particularly in racing Quarter Horses where the first aut.
(C.WM.) has had horses with complete loss of articl
cartilage from the distal radial carpal bone that have cc
back and won at Stakes level (see Fig. 4.37). Actual figu
based on follow-up with these cases are presented in a s
sequentsection.
Fragmentation frequently will be found adjacent to
medial plica, which has also beendescribedas the medial dol
intercarpal ligament (MDIC) (Wright 1995). This origin~
on the distal dorsal medial aspect of the radial carpal bc
and has an oblique course to insert on the medial joint caps
(Selway 1991). On arthroscopic examination, its degret
confluence with the joint capsule is quite varied and
ligament cannot always be identified. The MDIC ligam
may function as part of the medial collateral ligament, re
carpal bone displacement during weight bearing, or assisl
production of "closed-pact" position in preparation
loading (Wright 1995). It has beentheorized that the ligam
can act like a "leather hinge" on a box, becoming entrap]
between the second and third carpal and radial carpal bol
when the joint is extended. This can lead to "rocking" of
carpal bones and, thus, osteochondral degeneration wit]
the middle carpal joint (Selway 1991). Using this ratioru
Selway (1991) recommendedremoval of the protruding MI
ligament to a level of confluence with the joint capsule.1
authors believe that current evidence does not supporl
primary etiological role for the MDIC ligament in fragm(
tation and therefore do not practice or recommend prop}
lactic desmotomy. There is no doubt that the origin of t
ligament is commonly involved in degeneration and fragmt
tation of the dorsodistal medial aspect of the radial car)
bone, but all evidence suggests that this is not causati
Removal of fragments attached to the DMIC ligament ~
result in tearing and frayed tissue that can be debrided w
basket forceps or a motorized synovial resector (Fig. 4.39).
Dorsodistal intermediate carpal bone
Chip fractures of the dorsodistal aspect of the intermedi,
carpal bone occur most commonly on the medial facet. L
commonly. fragments are located lateral to the medi
divisional ridge on the distal articular surface where they c
be radiographically "silent". Osteophytosis may also be Sf
at this site. The pre-surgical radiographs that most frequen
demonstrate fragmentation are the flexed lateromedial (L
and the dorsomedial-palmarolateral (DMPLO) projectic
(Fig. 4.40).
The approach for operating on the distal intermedi.
carpal bone lesions is illustrated in Figure 4.41. T
arthroscope is placed through the medial portal and t
instrument enters through the lateral portal. Visualizatior
 usually good (Fig. 4.42), but the instrument angle is no
convenient for these lesions as for those on the distal ra
carpal bone. Becausethe distance from the instrument po
to the lesion is often small, opening forceps inside the job
sometimesdifficult. This can be aided (if fragmentation at
site is predicted preoperatively) by making the lateral po
closer to the distal row of carpal bones. Lesions on the n
medial portion of the intermediate carpal bone can be n
difficult to visualize completely because differeIJ
movement between radial and intermediate carpal b(
when the carpus is flexed produces a "step" in the mil
carpal joint.
Lesions of the distal intermediate carpal bone vary in :
but most are small and have relatively little associ;
degeneration. In these cases,the prognosis is good. Exten
loss of cartilage and bone can occur but this is far
common than on the distal radial carpal bone and is usu
more predictable on radiographs.
During operations involving an intermediate carpal t
lesion, even if it is the only fragment demonstrated ra
graphically, the surgeon should evaluate the distal r.

Fig. 4.38
Arthroscopic views before (A) and after (8 and C)
debridement of bone loss from distal radial carpal bone.
There is bone loss along the entire width of the radial carpal
bone.

bone,becauseradiographicallysilent lesions on the
aspect of the radial carpal bone have been en-
When these occur, surgery can be performedin
using the same lateral instrument portal as
medial side of the intermediate carpal bone should be
-during procedures involving distal radial carpal
.fragments
(Fig. 4.43). In this case we use
medial instrument portal that is used for distal radial
of arthroscope and instruments is often required to perform
the removal.
Dorsoproximal third carpal bone
Fragments from the proximal third carpal bone can
sometimesbe more difficult to operatethan chip fragments
in other locations in the middle carpal joint
frequently in the center of the joint and are 10
the extensor carpi radialis tendon. In additiol
capsule is closer to the articular margin than is tI
the radial and intermediate carpal bones. Becal
factors, joint distention may not be as effective
clear visualization of the fragment. Also, the cb
at this site may extend beyond the attachment
capsule.
In a paper published on the incidence, lo(
classification of 371 third carpal bone fractures in
incomplete fractures of the radial facet occurred i
large proximal chip fractures of the radial facet (
140 cases, small proximal chip fractures of the]
occurred in 18 cases, medial corner fractures 0
13 cases, frontal plane slab fractures of the rad
39 cases,large frontal plane fractures involving 1
and intermediate facets occurred in 35 cases,fract
intermediate facet occurred in 13 cases, and s~
fractures of the third carpal bone occurred i:
(Schneider et alI988).
The most useful preoperative radiographs i
(DLPMO) projections (Fig. 4.44A). '
DDiO) is also useful in further
(Fig. 4.44B). Thin slab fractures
arthroscopic removal. but most
with screw fixation using,
subsequent sections). Figure
reversed position could be
third carpal bone than is the
manipulation of
fractures may be typical chip-type
Partial slab fracture that extend
distad and exit dorsad -.-,-
to arthroscopic surgery. Thin slab j
thickness of the third carpal bone can also be ren
using the arthroscopic technique although cut1
carpometacarpal joint capsule attachments with
difficult. however.
The prognosis for third carpal chip fractures an(
slabfractures is variable. As in other sites in the middJ
joint, the prognosis is excellent with small, well
fragments accompanied by minimal degenerative
Postoperatively,new bone proliferation is a potential]
when the fracture line extends deep into the c
attachments. Multiple fragments off the third
bone may occur. When these fragments are large ant
bone from the joint is significant. instability is a p
problem.
 Arthroscopic Surgery for Removal of Osteochondral Chip Fragment

Fig. 4.41
Diagram of positioning of arthroscope and instrument during
operations involving a distal intermediate carpal bone chip
fragment.

Fig. 4.42
Arthroscopic views of fragments of distal intermediate carpal bone (radiographs of these fragments are in Fig. 4.40). (A-B) Small
fragment in left carpus (C-F) Large fragment in right carpus. continued
Fig. 4.43
Fragment on distal intermediate carpal bone found during
diagnostic arthroscopy for removal of a fragment on distal rad
carpal bone. The fragment is on the most-medial margin of thE
distal intermediate carpal bone and in this case was removed I
a medial instrument portal.
Dorsoproximal radial carpal bone
The technique for operating on fragmentation at this site is
illustrated in Figure 4.49. Thesefractures are usually identified
preoperatively with standing and flexed lateromedial and
dorsolateral-palmaromedial oblique DLPMO radiographs. As
with other sites,the size of lesions can vary widely (Figs 4.50
and 4.51). The arthroscope is placed through a lateral portal
and the instrument enters through a medial portal. The
fragments can usually be well visualized and often are
relatively small (see Fig. 4.50), although significant loss of
bone occurs occasionally (seeFig 4.51).
With the standard medial portal, instruments must
approach the lesion almost end-on, and manipulation can be
more difficult than on the distal aspect of the radial carpal
bone. Repeated manipulation tends to cause subcutaneous
extravasation and the medial aspectof the antebrachiocarpal
joint is also narrower than other locations. Occasionally, a
lateral arthroscopic portal can be used (Fig. 4.52).
The amount of cartilaginous damage associat
these chips is variable. and the prognosis varies aCC
Although marked erosion of the proximal surfacI
radial carpal bone can occur there, it is a su
impression that the antebrachiocarpal joint appea
more forgiving than the middle carpal joint in hor
similar degrees of loss from the proximal versus 11
articular surfaces of the radial carpal bone.
Proximal intermediate carpal bone
The technique for operating on chip fractures at th
illustrated in Figure 4.53. Standing and flexed later
(LM) and/or dorsomedial-palmarolateral oblique (:
radiographs (Fig. 4.54) are most useful in ide
fragmentation of the proximal intermediate carp;
These fragments can be small, distinct and easily]
(Fig. 4.54), but. often. they are large and extend a c
QO Diagnostic and Surgical Arthroscopy of the Carpal joints

Fig. 4.48
Arthroscopic views of a partial slab fragment of the third carpal bone. (A and B) Surface defect at proximal-distal length of the
fragment respectively. (C) At removal of the fragment. (D) At debridement.

Fig. 4.49
(A) Diagram of positioning of arthroscope and instrument during operations involving a chip fracture off the proximal aspect of\
the radial carpal bone. (B) Making instrument portal.
§;7 Diagnostic and Surgical Arthroscopy of the Carpal Joints

Fig. 4.51
Radiograph (A) and arthroscopic views (8 and C) of large displaced chronic fragment from the dorsoproximal margin of the rad
carpal bone.

Fig. 4.52
(A and B) Fragmentation of the proximal radial carpal bone encountered during removal of a proximal intermediate carpal bon
fragment and being removed using a lateral instrument portal.
 abledistance into the joint capsule attachments (Fig. 4.55). In
such cases. prior separation of capsular attachments in
addition to separation at the fracture line is recommended.
Occasionally, a chronic chip or the spur associated with it
might have an intracapsular portion. In these cases, the
intra-articular portion is removed with rongeurs or a burr as
far as the capsular reflection only. Postoperative radiographs
often do not appear as satisfactory as following fragment
removal. Nonetheless, this is considered preferable to the
capsular trauma necessaryto remove intracapsular fragments
and/or new bone. As with fragments in other locations, a
relatively small fragment may be associatedwith considerable
loss of articular cartilage.
Proximal ulnar carpal bone
Fragments at this site are rare. To perform arthroscopic
surgeryfor this lesion,the arthroscopeis placedmediallyand
instruments enterthrough the lateralportal.
Lateral aspect of the distal radius
These fragments are usually best demonstrated on a
dorsomedial-palmarolateral (DMPW)radiographicprojection
(Fig.4.56A). Theycan be displaced,non-displaced, singleor
multiple,and frequentlyare larger than fragmentselsewhere
in the carpal joints. Often the fragments
radiodensity, loss of infrastructure,
new bone formation. Occasionally, the
radiographic views do not demonstrate a
event, a skyline (DPrDDiO) view of the
recommended (Fig. 4.56B).
The technique for operating on chip fractures of the dorso-
lateral margin of the distal radius is illustrated in Figure 4.57.
The arthroscope is inserted through the medial portal and
instruments are passed through the lateral portal. The
position of the fragments necessitates that instruments are
directed distad so that their shafts lie at an angle close to the
dorsal aspect of the carpus. The fragments are usually large
(;?;1 cm wide), with the most proximal portion attached to the
fibrous joint capsule. These fractures are also commonly
comminuted with a wedge-shaped osteochondral fragment
palmar to the largest dorsal fragment.
The size of the fragment can be assessed reasonably
accurately from preoperative radiographs. Damage is usually
limited to the defect created by the fragments. only and
cartilage loss does not usually extend peripheral to the defect
(Figs 4.58 and 4.59). The arthroscopic appearance depends
on the age of the fragments. In many such cases the dorsal
fragment appears to be acute and the palmar wedge shaped
fragment appears to be longer standing. In acute fragmen-
tation there is usually hemorrhage within the fracture. When
8§ Diagnostic and Surgical Arthroscopy of the Carpal joints

Fig. 4.57
Diagram (A) and external view (B) of arthroscope and instrument during operations involving a chip fracture off the distal lateral
radius.

Fig. 4.58
Arthroscopic view of relatively small distal lateral radius fragment of a right carpus prior to removal (A), at elevation (8), at
removal with Ferris-Smith rongeurs (C), and after removal and debridement (D).
 : fragments, the larger fragment is usually
superficial fragments, and a deep search is
in these cases. With fractures of long-standing,
, include areas of capsular tearing. This should be perform(
Before retrieval, large fragments are elevated (Fig. 4.59)
attachments severed with a periosteal elevator.
cup rongeurs are used to remove fragments.
usually necessary to twist the rongeurs after grasping
fragment to ensure that the fragment is free of attach-
ments before making an attempt to pull it through the joint
capsule. Enlargement of the skin incision is commonly
necessary to bring these fragments out through the skin.
Figure 4.60 depicts a chronic distal lateral radius fragment
that was associated with osteochondral diseaseperipheral to
the fracture. Damage is rarely more extensive that that noted
here, unless the lesion is chronic and mobile. Removal of
large fragments that extend proximally into the capsular
reflection can result in penetration of the synovial sheath
of the extensor carpi radialis or common digital extensor
tendon.
Mter removal of the fragment, the depths of the defectare
carefully explored to find any remaining fragments. Some
bony proliferation proximal to the defects within the fibrol
joint capsule is common, and should be left alone. Debridl
ment follows the basic principles outlined previously, but mc
carefully and in a conservative manner in order to limit tl:
potential for traumatizing the adjacent tendon sheath and 1
avoid further capsulitis.
When these fractures are of long duration, the fractul
line may be obscured and the fragment is usually recognize
by the presence of articular erosions and irregularities.
Despite their size, the prognosis for chip fractures of th
distal lateral radius is good. This is generally considered to b
the result of different biomechanical influences and becaus
the remaining articular surface is usually not damaged to an
great degree compared to other sites of carpal fragmentatior
Medial aspect of the distal radius
Fragmentation at this site is best demonstrated in
dorsolateral-palmaromedial oblique (DLPMO) radiograpl
(Fig. 4.61). The technique for removing fracture fragment
from the medial aspect of the distal radius is illustrated il
Figure 4.62. The arthroscope is placed through the latera
portal and the instruments through the medial portal. A
with distal lateral radius fragments, the instruments ar
angled rather flatly against the knee and directed proximac
These fragments are similar to their lateral counterparts il
that the surface damage is usually localized to the area of th
fragment. However. smaller fragments are more commol
medially but large ones can occur (Fig. 4.63). Methods (
surgical removal are the same as those described for later~
radius fragments. but sometimes on the most medial portio]
of the bone. accesswith forceps is more difficult than laterall:
The surface manifestation of these fragments varies like dist~
lateral chips. and the use of the curette may be necessary fo
chronic lesions (Fig. 4.64). Removal of very large dist~
medial radius fragments can potentially cause trauma to th
extensor carpi radialis tendon shealth with consequeIJ
synovial herniation (Fig. 4.65).
Diagnostic and Surgical Arthroscopy of the

it is
on first, as subcutaneous fluid extravasation is more likely to
occur in the antebrachiocarpal joint. The loss of irrigating
fluid after creation of a large instrument portal means that
the surgeon will need to switch to the opposite side of the
joint to operate on a chip on the other side, and insert the
arthroscope into a relatively non-distended joint. If time has
, between the two entries, some blood may be in the
which can be cleared by irrigation. The bleeding is
from a previously debrided subchondral bone
and occurs after loss of joint distention. With joint
and irrigation, subchondral bleeding is usually
Removal of osteophytes or spurs
The removal of spurs or osteophytes is appropriate if
have fractured off or if their interposition into the joint]
them likely candidates for later fracture. Figure
demonstrates spurs that were removed. These spurs n
removed with Ferris-Smith rongeurs. curettage, an ostec
or burr.
Most spurs that are visible radiographically ar
candidates for removal. In many instances the experi
surgeon can predict whether an attempt at removing (
is appropriate by examining the radiographs. As a gt
rule. however, the surgeon should maintain an open
and examine the spur at the time of arthroscopic su
This statement is not to say that every carpus with a Spl
candidate for arthroscopic surgery. As experienced clini
know, many small spurs noted in 2-year-old horses are I
evidence of previous synovitis and capsulitis. and are
current clinical importance.
Articular cartilage and bone
deBeneration in association with carpal
chip fractures
The presence of articular cartilage degeneration associated
with carpal chip fragments and the debridement of degenerate
cartilage were mentioned previously, although this problem
deserves specific attention. For convenience, four grades of
articular surface damage, as evaluated arthroscopic ally, have
been made (Mcllwraith et al 1987) and are illustrated in
Figure 4.67:
1. Minimal fibrillation or fragmentation at the edge of the
defect left by the fragment, extending no more than 5 mm
from the fracture line (Fig. 4.67 A and B).
2. Articular cartilage degeneration extending more than
5 mm back from the defectand including up to 30% of the
articular surface of that bone (Fig. 4.67C and D).
3. Loss of 50% or more of the articular cartilage from the
affected carpal bone (Fig. 4.67E).
4. Significant loss of subchondral bone (usually distal radial
carpal bone lesions) (Fig. 4.67F and G).
The amount of articular surface loss should be documente
on surgical notes and may be recorded by way of a drawin
(Fig. 4.68). Significant bone loss causes loss of cubodi~
congruency (Fig. 4.67F and G).
More subtle degreesof cartilage damage have been define
and graded in man (Pritsch et al 1986) and the recent~
defined ICRS grading system (Cartilage Injury EvaluatioJ
System 2002) is gaining acceptance. These classification
should not be confused with the system just described
Although a more detailed breakdown of damage may b,
appropriate for guiding treatment. it may have limited ValUI
in defining prognosis.
Debridement of defects after chip
fracture removal
A discussion of the rationale for debridement after fragmeni
removal necessitates a brief review of current knowledg(
regarding healing of tissues. particularly articular cartilage
These considerations are also important with regard tc
postoperative management and convalescent time. Tradition.
 Erosion and Chips

Proximal
carpal row

Right

Distal
carpal row

r
Partial thickness
kissing lession

and debridement.

ally, repair of articular cartilage has been considered in two
situations: (1) superficial defects that do not penetrate the full
thickness of the articular cartilage, and (2) full-thickness
defects, which extend to subchondral bone. Superficial
defectsin equine articular cartilage do not heal, whereas full-
thickness defects heal through formation of granulation
tissue and its subsequent metaplasia (Riddle 1970).
In studies involving the horse, the nature of the replace-
ment tissue in the full-thickness defect varied between
investigators. In one study, the authors noted that whereas
3 mm, full-thickness defects were repaired satisfactorily at 3
months, defects of 9 mm in diameter were not completely
replaced at 9 months (Convery et aI1972). The repair tissue
was a variable mixture of fibrous tissue, fibrocartilage, hyper-
cellular cartilage, and (occasionally) bone, whereas another
defects curetted experimentally were covered with
granulation tissue 1 month later. This tissue underwentmetap
change to form fibrocartilage by 2 months and
imperfect hyaline cartilage by 6 months. In another carpal
study, Grant (1975) noted that the defectsfilled with a deeper
layer of immature hyaline cartilage and a more superficial
layer of fibrocartilage. Synovial adhesions were also present.
The repair most closely resembled the adjacent normal
hyaline cartilage when there were few synovial adhesions. If
synovial adhesions were significant. the defects filled with a
more primitive fibrocartilage and fibrous tissue. The authors
therefore concluded that proximity of the lesion to the
synovial membrane was potentially an advantage to healing.
Hurtig et al (1988) created large (15 mm square) and
small (5 mm square) full-thickness lesions in weightbearing

--
.
investigator reported complete healing of both 4 mm and 8
mmdiameter, full-thickness defects (Grant 1975). In a classic
study on the carpus, Riddle (1970) demonstrated that full-
thickness
and nonweightbearing areas of the antebrachiocarpal,
middle carpal, and femoropatellar joints. Repair had occurred
in most small defects at the end of 9 months by a combination
 of matrix flow and extrinsic repair mechanisms, although
elaboration of matrix proteoglycans was not complete at this
time. Better healing occurred in small weightbearing lesions
when compared to large or nonweightbearing lesions.
Synovial and perichondrial pannus interfered with healing
of osteochondral defects that were adjacent to the cranial
rim of the third carpal bone. Large lesions had good repair at
2.5 months postoperatively; however, by 5 months, clefts
between the reparative tissue and subchondral bone were
common. Later, the clefts became undermined flaps of fibrous
tissue that were disrupted by normal biomechanical forces,
resulting in exposed subchondral bone.
Grant (1975) also found no correlation between increased
healing time and improved tissue quality in full-thickness
defects; defects at 54 and 67 weeks contained more fibro-
cartilage and less hyaline cartilage than defects at 42 and
47 weeks. Work in other species also has revealed hyaline
cartilage at early stages of healing. There is therefore indirect
evidence that, at 4 months. defects in the articular cartilage
have reached the limit of healing capacity and. by 12 months.
the replacement tissue has begun to degenerate.
More recent work in the first author's (C.W.M.) laboratory
comparing normal healing in full-thickness defects at 4 and
12 months has demonstrated that the percentage of Type II
collagen will progressively increase from 0% at 4 months to
80% at 12 months. The hexosamine level is about half the
amount in normal cartilage at 4 months. and slightly less
than the 4 month level at 12 months (Vachon et al 1992,
Howard et aI1994). The current state of articular cartilage
healing has been reviewed (Mcllwraith & Nixon 1996) and is
now the subject of a separate chapter in this textbook.
The authors have also had the opportunity to operate bn a
number of carpal joints for the second time after the animals
have raced and have observed that the healing of defects
varies (Fig. 4.69). In repair areas subjected to histologic
analysis, fibrous tissue predominated. For all experimental
studies in which cartilage healing in some form was demon-
strated, these joints were never subjected to the continual
exercise and trauma of a racehorse. Since the authors
question how much functional healing occurs, debridement
of partial-thickness defects is not performed. Cartilage is
aneural and how much trouble many partial-thickness defects
cause is questionable. Commonly, these defects are kissing
lesions in association with fragments, and the best treatment
is to remove the initiating cause, i.e. the fragment. Whether
more than fibrous tissue will fill the defectsis unclear, and one
should therefore be conservative in creating further defects or
enlarging ones already present. The results of a study in man
involving follow-up arthroscopy of patients treated for
chondromalacia of the knee with or without cartilaginous
shaving supports a conservative approach to management of
partial-thickness defects. The conclusions were that only
loosely hanging articular cartilage should be shaved, and
that softened, non-loose, fissured articular cartilage should
be spared (Friedman et aI1987).
The authors also adopt a relatively conservative approach
with regard to debridement of deeper defects that remain
after fragment removal. Rough edgesor adjacent undermined
or fragmented cartilage is removed. This protocol is base
the belief that loose cartilage is irritating and may detach
its prospects of healing onto bone are virtually nil. Par
thickness erosion adjacent to a full-thickness defect is
subjected to curettage if the cartilage that remarn
attached solidly to the bone. Full-thickness defects
debrided to the level of subchondral bone. Any soft defe
bone is also removed.
In summary, based on both research evidence and ~
we have observed, the authors feel that a conser Vi
approach when it comes to debridement of fibrillatiol
thinning of articular cartilage should be taken. In 0
instances, when cartilage is separated and may appear
thickness, the calcified cartilage layer may still be pre~
Failure to remove the calcified cartilage layer will cause
healing response. With experience, one can recognize
difference between the calcified cartilage and the:
chondral bone (Frisbie et al 2001, unpublished data). ,
debridement of subchondral bone, in an adult animal,
relatively straightforward to recognize defective, gran
(and often necrotic) bone and distinguish it from S
healthy subchondral bone. The distinction is more difficu
the young animal, where the subchondral bone is quite
In contrast, when the subchondral bone of a carpal defe
hard and sclerotic, the use of subchondral microfracture
aid accessto stem cells and growth factors in the cancel
bone and has been used in clinical cases (Frisbie et al 2(
unpublished data).
Deepor extensive debridement using motorized equipn
is unnecessary in most cases.If debridement extends be}
the level of attachment of the joint capsule, it can resu
increased capsulitis and bone proliferation. In relating S
of these ideasto follow-up management, if the actual matc
that fills fresh, localized chip fragments is not of m
concern and the area of the defect is small, then, if 0
sources of irritation have been removed, atWetic func
should be limited only by soft tissue healing. For this rea
horses with acute fragmentation and with minimal evid(
of long-standing adaptive failure can return to training i
6-8 weeks.
When the lesions are more severe, the limitation
cartilage healing are more significant. If the area ofcarti
erosion is larger, then some form of healing is required,
the importance of intact subchondral bone support
effective articular cartilage healing is relevant. De
mination of the conditions that are necessary or optir
healing requires further investigation. At present, the aut!
assume that extra time is required when subchondral hea
is necessaryto restore a weightbearing surface. However,
time requirements and physical factors for bone healinJ
Grade 4 lesions have yet to be determined. In chronic, con
cated cases, a minimum of 4-6 months rest is curre
recommended.
With the possible exception of infected joints I
Chapter 14), therapeutic synovial resection with the
of motorized equipment is not recommended. Locali
synovectomy is only performed occasionally to facili'
visualization.
 management
5 daysto decreasepain. reducesynovitis.and facilitate horses and clients. In general. a better result can be expect
.Resultsof a double-blind.randomized with a horse that has proven racing ability and an owner th
less operated on by the first author (C.WM.) has provided objecti
(;'synovitis. and less effusion postope~atively(6gilvie~Harris et
r
al1985). They also had more rapid return of movement and
quadriceps function, and their return to work and sport was
significantly faster. The administration of antimicrobial
drugs is a matter of individual surgeon preference.
Based on current knowledge of cartilage healing. it is
subjectively recommended that exercise be avoided for the
first week after surgery to enable the blood clot to organize
andto allow granulation tissueto commenceformation. Passive to or better than the pre-injury level, 49 (11.0%) hc
flexion and hand walking begin after 7 days and the level of
exerciseis then progressivelyincreasedin line with the severity carpus. 23 (5.2%) were retired without returning to trainin
of articular compromise. In horses with simple. fresh frag-
ments (Grade 1 lesions), training may begin at 6 weeks. As
the damage in the joint increases. the convalescent time
should be appropriately increased. Horses with Grade 2
cartilage loss should have a minimum of 3-months rest; with
Grade 3 and 4 lesions the horses should have 4-6-months
rest. Rehabilitation protocols including underwater treadmill
or swimming may be recommended if available.
Postoperative use of hyaluronan (HA) and polysulfated
glycosaminoglycans (PSGAGs)is variably favored by different
clinicians. The authors do not consider HA a necessary or
consistent part of the postoperative routine. In most cases.
the synovial HA levels are expectedto return to normal in the
convalescentperiod. If the articular damage at the time of
surgery is of relatively low grade. then most cases resolve
after a single treatment. PSGAG (Adequan@)is administered
when there is significant articular cartilage degeneration and
exposure of subchondral bone. Although there may be little
effecton defect healing. ongoing cartilage degeneration may
beinhibited (McIlwraith 1982. Yovich et al1987). Clinically.
a good response to PSGAG treatment is seen in the cases
with severe articular cartilage damage. An initial intra-
articular injection of Adequan@ (250 mg with 0.5 ml
Amikacin sulfate) is recommended followed by weekly
intramuscular injections of 500 mg. Corticosteroid therapy
after arthroscopic surgery is only recommended when there
is severe. persistent synovitis. Overall, arthroscopic surgery
as a therapeutic procedure is best followed by rest and
physical therapy (controlled exercise).
Case selection, prognosis, and results
Although fragments of all ages and size are amenable to
arthroscopic surgery, not all horses are good surgical
candidates. Here, accurate communication with owners and
trainers is important to preserve the reputation of the
technique before embarking on chronic cases with less
certain prognoses.The first author (C.W.M.) has had pleasiJ
results with horses that have had multiple chip fragments
as many as four carpal joints along with chronic chan~
However, selection should be applied with regard to bo
understands the prognosis.
Follow-up information on the first 1000 carpal joir
information to give clients regarding prognosis (McDwraith et
1987). Arthroscopic surgery was effective in removing'
osteochondral fragments as well as treating other lesior
There were no casesof intra-articular infection and fewoth
complications. The overall functional ability and cosmel
appearance of the limbs were excellent.
Post-surgical follow-up information was obtained for 44
racehorses. After surgery, 303 (68.1 %) raced at a level equ
decreasedperformance or still had problems referable to tl
28 (6.3%) sustained another chip fracture. 32 (7.2%) develop
other problems. and 10 (2.2%) sustained collapsing sIc
fractures while racing. When horses were separated into fO
categories of articular damage. the performance in the t\\
most severely affected groups was significantly inferior. Or
hundred thirty-three of 187 horses with Grade 1 dama~
(71.1 %),108 of 144 with Grade 2 damage (75.0%), 41 of 7
with Grade 3 damage (53.2%). and 20 of 37 horses wil
Grade 4 damage (54.1 %) returned to racing at a level equ,
to or better than the pre-injury level. The successrate in casl
with Grade 1 and Grade 2 lesions was significantly greatc
than that in caseswith Grade 3 and Grade 4 lesions. The dal
from racing Quarter Horses and racing Thoroughbreds we)
divided. In 277 Quarter Horses, 81 of 112 (72.3%) wit
Grade 1 lesions, 72 of 96 (75.0%) with Grade 2 lesions. 26 c
46 (56.5%) with Grade 3 lesions. and 13 of 23 (56.5%) wit
Grade 4 lesions returned to racing successfully. In 16
Thoroughbreds. 51 of 73 (69.9%) with Grade-1 lesions. 3
of 47 (76.6%) with Grade 2 lesions, 14 of 30 (46.7%) wit
Grade 3 lesions. and 7 of 14 (50%) with Grade 4 lesior
returned to racing successfully.Thesedata demonstrate a leI
favorable prognosis for horses with severe damage but als
that many horses can still come back and race successfully.
has been observed subjectively that. in more severe cases.
shorter racing career can be anticipated due to recurrer
carpal problems, including refragmentation.
In five Quarter Horses used for roping, barrel racing. (
rodeo, all but one with a Grade 3 lesion returned to successf
performance. The pleasure and hunter horses had successf
results in all six cases (one Grade 1, two Grade 2, thre
Grade 3. and one Grade 4 lesions). The results of surger
were also assessedin relation to the location of lesions. anI
horses with a single site (or the same site bilaterally) involve
were included (Table 4.2).
In racing Quarter Horses. the prognosis associated wit]
involvement of the third carpal bone was significantly wors
than lesions in other sites. In Thoroughbreds, third Carpc
and radial carpal bone lesions had the poorest prognoses. ]
 I relative to the joint involved, 63.3% of
Horses and 66.2% of Thoroughbreds with middle
carpal joint involvement returned to racing. For the
antebrachiocarpal joint. 82.7% of Quarter Horses and
65.5% of Thoroughbreds returned to racing successfully. If
both middle carpal and antebrachiocarpal joints were
involved. 64.7% of Quarter Horses and 64.7% of Thorough-
breds returned to racing.
Sincethe publication of thesedata 15 years ago. ther
havebeena numberof changesin clinicalpracticesthat maJ
influencefuture results.Theseinclude:
1. Earlier intervention and thereforea higher percentageoj
Grades1 and 2 lesionsbeingpresentedfor surgery.
2. Attemptsto enhanceosteochondralhealing (Chapter16),
including subchondralmicrofracture.
3. More aggressive postoperative protocols, including
medicationand physiotherapy.
Osteochondral fragments from the palmar aspects of the
carpal bones have been recognized and removed (Mcllwraith
1990, Wilke et al 2001, Dabareiner et al 1993). In some
instances these fragments are not surgical candidates, and
when they are traumatic avulsions associated with other
problems. the prognosis is typically poor (Wilke et al 2001).
Small discrete osteochondral fragmentation can involve
any of the palmar surfaces of the carpal bones. with the
radial carpal bone being most frequently involved. The dorsal
articular surface of the accessory carpal bone. and the
palmar surfaces of the ulnar and fourth carpal bones are
involved less frequently. Large partial slab fractures of the
palmarolateral surface of the intermediate carpal bone also
occur, and are largely inaccessible for arthroscopic removal
or reattachment (Dabareiner et al19 93).
Fractures of the palmaromedial perimeter of the radial
carpal bone (Fig. 4.70A) have been described in 10 horses
(Wilke et al2001). These fractures are thought to result from
compression injury, with the palmar perimeter of the radial
carpal bone impacting on the surface of the radius, during
falls onto the flexed knee. Arthroscopic removal can be done
through a palmaromedial approach to the antebrachiocarpal
joint (Fig. 4.70B-D), which gives ready accessto the palmar
perimeter of the radial carpal bone and caudal aspect of the
radius. The dorsal regions of the antebrachiocarpal joint are
usually examined first, and concurrent damage to the
articular surface of the radius and proximal row of carpal
bones is debrided. The arthroscope portal is then made in the
distended palmaromedial outpouching of the antebrachio-
carpal joint. Examination of the palmar surfaces of the
carpal bones commences medially, and the arthroscope can
be redirected and introduced further to view the medial
perimeter of the intermediate carpal bone and accessory
carpal bone articulations. Most fractures are not radio-
graphically confirmed for weeks to months after injury, and
the chip fragment can initially be obscured at surgery by soft
tissue proliferation (Wilke et aI2001). An instrument portal
is developed adjacent to the arthroscope entity and motorized
equipment used to remove synovial proliferation. The
fracture of the palmar surface of the radial carpal bone can
then be removed. Results in 10 horses with palmar fracture of
the radial carpal bone suggested that simple fractures of the
palmar perimeter should be removed as soon as they are
identified (Wilke et al 2001). Salvage for riding was pre-
dominantly defined by the extent of osteoarthritis evident at
the time of surgery. Caseswhere the damage was confined to
only the area of the chip and where the fracture was removed
soon after injury tended to have less osteoarthritis and did
better after arthroscopic surgery. Concurrent injury to the
medial collateral ligament or avulsion of portions of the radius
substantially diminished the prognosis.
Palmar fractures of the other carpal bones are less
frequently encountered. These include fractures of the fourth
and ulnar carpal bone, the accessory carpal bone, and the
intermediate carpal bone. The accessory carpal bone can be
fractured during compression injury to the flexed knee
(nutcracker effect). The most common accessorycarpal bone
fractures are longitudinal frontal plane fractures that divide
the accessory carpal bone into a dorsal and palmar portion.
These fractures do not involve the articular cartilage of the
dorsal facets of the accessory carpal bone and are not
considered candidates for an arthroscopic repair. Most of
these fractures spontaneously develop a functional fibrous
union. Smaller fractures of the proximal or distal articular
surfaces of the accessory carpal bone can occur, disrupting
the articulation of the accessory carpal bone with the
remainder of the carpus, and generally requiring removal
(Fig. 4.71). The proximodorsal aspect of the accessory carpal
bone can be examined using a palmarolateral approach to
the antebrachiocarpal joint. A voluminous proximal palmaro-
lateral joint pouch can be palpated after distension of the
joint. The arthroscope portal is made in the proximal portion
of this outpouching, leaving the region over the proximal
perimeter available for instrument access(seeFig. 4.71). The
fracture fragment is then identified, the soft tissue attach-
ments and synovial proliferation debrided, and the fragment
removed using rongeurs. Fractures of the distal portion of
the accessorycarpal bone are less frequent, and accessto this
outpouching of the antebrachiocarpal joint is limited.
The palmarolateral aspect of the midcarpal joint can be
entered for removal of fractures of the ulnar and fourth
carpal bone. The arthroscope portal can be made without
difficulty; however, synovial tissue removal will be required to
completely identify the fracture fragment during removal.
There are no case series available to provide a basis for
prognosis; however, the authors' limited experience suggests
these fractures are a source of lameness, which can be
substantially improved by removal.
Fractures of the palmar surface of the intermediate carpal
bone can involve a small wedge-shaped articular portion
detached from the proximal perimeter of the intermediate
carpal bone or a larger palmar slab fracture of the palmar
surface, extending from the antebrachiocarpal joint to the
midcarpal joint. Removal of smaller fragments through the
carpal tunnel has been reported; however. arthroscopic
removal has not been described. Palmaromedial and
palmarolateral approaches to the antebrachiocarpal joint
reveal only the medial aspectof the intermediate carpal bone.
The lateral portion of the intermediate carpal bone. where
the fractures have been described. is obscured by the
accessorycarpal bone attachments.
Arthroscopic Surgery for
Subchondral Bone Disease
Theselesions were initially described in the proximal aspect of
the third carpal bone. A number of radiographic changes
may be evident on tangential "skyline" views of the third
carpal bone including sclerosis,lytic lesions. or linear defects
variously interpreted as incompletefractures or "pre-slab"
lesions. Sclerosis of the radial facet is a well-recognized
change and some authors suggest that it is a primary lesion,
often preceding more serious change, such as cartilage
damage or gross fracture (DeHaan et al198 7). These authors
also suggest that early recognition of sclerosis of the third
carpal bone may help to prevent the occurrence of more
serious changes (DeHaan, et aI1987). Sclerosisis considered
to arise with training and racing. However, whether the
sclerosisleads to articular cartilage lesions or the same forces
that can cause sclerosis also cause articular cartilage lesions
directly has yet to be ascertained. Arthroscopy of a small
number of joints that had sclerosis as the only radiographic
sign, revealed wide variability in the gross appearance of the
overlying cartilage (Richardson 1988) and this author agrees.
So-called third carpal bone diseasepresents as a persistent
carpal problem that does not respond to medication and is
characterized by lytic change evident on skyline radiographs
of the third carpal bone (Fig. 4. 72A). Frequently, some degree
of surrounding sclerosisaccompanies the lytic changes. Most
lesions occur on the radial facet; they may be single or
multiple and range from linear to circular in outline on
skyline radiographs (Richardson 1988). The proximal sub-
chondral bone is particularly thick and denseso that damage
and lysis in this area results in dramatic radiolucency in
tangential projections.
Arthroscopically, these lesions manifest as an area of
defective subchondral bone, with the overlying cartilage
absent,a depressionin the articular cartilage, an undermined
cartilage flap, or fragmented cartilage (Fig. 4.72B and C). In
some cases there is overt fragmentation of the subchondral
bone, which, since it is non-displaced and cannot be imaged
in profile, is not recognized radiographically. Loose tissue is
removed and the lesion is debrided with a curette. The
defective bone is often granular in nature. A rim of intact
tissue on the dorsal margin of the third carpal bone usually
remains, although in some casesthe defective tissue exteru
out through this margin. Also. if the remaining rim
narrow. it is removed to the level of the defect.
It is now recognized that subchondral bone disease c~
occur at other locations and may be the precursor
exercise/work-induced osteochondral fragmentation. Clinic
signs associated with subchondral bone diseasesare simil
to animals with osteochondral fragmentation. However. pI
surgical diagnosis (at locations other than the third carp
bone) is difficult; the disease is rarely demonstrable radi
graphically. The best example is the distal radial carpal bolJ
where lesions can consistently be found arthroscopicaJ
(Fig. 4.73).
Subchondral bone diseasehas also been seen on the dist
radial, proximal third, proximal radial. intermediate carp
bones. and on the distal radius (lateral and medial) (Fig.4.7:
Figure 4. 73H illustrates subchondral bone diseaseon the mo
palmar areas of the second and radial carpal bone.
The post-surgical protocol is determined by the degree
articular compromise. using criteria similar to other carp
arthroscopic procedures. In one report of 13 Standardbr,
casesinvolving the third carpal bone. 8 returned to racing,
of these in their original class (Rosset al1989).
 More recent work has investigated the relationship within 30 months post-examination(Uhlhorn & C
betweenincreasedbone densityin the third carpalboneand 1999). However,it was alsorecognizedthat there wa
racing (Younget al1991). Regionalvariationsin trabecular number of third carpal bones with severesclerosis
bone density and stiffness have been implicated in the course,no arthroscopicintervention, and this limit
pathogenesisof third carpal bone fractures (Young et al canbeconcludedfrom this study.
1991). In addition. subchondral lucency. commonly in
combination with sclerosisof the third carpal bone radial
fossa.has been associatedwith acute. moderateto severe
lamenessreferableto the middlecarpaljoint in Standardbred
racehorses(Rosset al1989). Investigatorsin Swedenhave
looked at subchondralsclerosisand subchondrallucencyin
the third carpalbonein Standardbredhorsesdiagnosedwith
traumatic carpitis and related it to clinical appearanceand
prognosis for racing. Subchondral lucency was found Twenty-four cases of tearing of the medial palmar
significantlyto influencethe degreeof lamenessand the time carpal ligament (unpublished data) were reported
to start. but did not significantlyaffectthe chanceof racing previous edition of this text. Since then there ha
 Arthroscopic Surgery for
Treatment of Carpal
cystic lesions are commonly noted in the Slab Fractures
clinically significant lesions will occur and are
to intra-articular analgesia.A Current status of surgery
the proximal radial carpal bone that was sympto-
illustrated in Figure 4.77. The cystic lesion was Various forms of frontal and sagittal slab fractures occur
arthroscopicallyand the opening found, the the carpal bones. of which the most common is a fron
and the joint flushed(Fig.4.77). plane slab fracture of the third carpal bone. The advanta~
offered by arthroscopy are such that repair of carpal sl
fractures under arthroscopic visualization is now t
technique of choice. Arthroscopic evaluation of the entire
joint and fracture reduction are superior to those obtained by
radiography, fluoroscopy, or of direct observation, and
surgical trauma is minimized (Richardson 2002). These
features comply entirely with the AD goals of atraumatic
operative technique, accurate anatomic reduction, rigid
internal fixation, and early postoperative ambulation.
Recognizing concomitant damage that will detract from a
successful outcome also enhances clinical success. Case
selection is important and animals with poor conformation,
evidence of asymmetric limb loading, or failure of osseous
adaptation, and horses with poor athletic histories are
unlikely to produce rewarding results.

Removal of slab fractures of the third

carpal bone

The authors' general philosophy is that whenever articular

surfaces can accurately and safely be reconstructed, this
should be the primary treatment goal. Thin displaced and
irreducible slab fractures of the third bone can be removed
arthroscopically (Fig. 4.78). Standard dorsolateral arthroscopic
and dorsomedial instrument portals are employed. Removal
of the fragment necessitates sharp dissection from the dorsal
joint capsule and associated transverse dorsal intercarpal
ligaments. This is most effectively achieved with a fixed blade
knife and use of straight and curved elevators. A motorized
synovial resector is useful during dissection in order to
maximize visibility. Once the fragment is loose, it is mani-
pulated proximally in order that it may be grasped with large
arthroscopic rongeurs. These then are twisted in order to free
the last remaining soft tissue attachments before the
fragment is removed. Enlargement of the skin incision is
frequently necessaryat this point. Debridement of the fracture
bed follows and, in addition, limited debridement of the joint
capsule and dorsal intercarpal ligaments is appropriate.

Lag screw fixation of slab fractures

of the third carpal bone
The most common slab fracture of the third carpal bone
occurs in the frontal plane and involves the radial (medial)
facet. Less commonly, there may be sagittal or parasagittal
fractures in the medial one-third of the radial facet and in
some animals there may be slabfractures of the radial facet in
both frontal and sagittal planes. Frontal plane slab fractures
can also run the full mediolateral width of the third carpal
bone, including radial and intermediate facets. Occasionally,
frontal plane slab fractures will involve the intermediate
(lateral) facet only. and dorsolateral palmaromedial oblique radiograpl
The degree of lameness varies from mild to severe. projections. Comminution occurs most commonly at t
Fractures in a frontal plane are usually accompanied by proximal margin of the fracture and may be seen
marked distention of the middle carpal joint and frequently dorsolateral-palmaromedial oblique and flexed lateromed
also by pain on palpation of the third carpal bone. Fractures projections. Detection of comminution is important
in the sagittal plane usually produce lesssevereclinical signs. surgical planning and prognostication. Flexed dorsoproxim
Frontal plane fractures are usually apparent on lateromedial dorsodistal (skyline) projections define the dimensions a
 the fracture (Fig. 4.79). Comminution or the
osseousinfrastructure in the fracture
but may also be identified in dorsomedial-
"
,-
some non-displacedfractures may heal with
articular insult; consequently, the risks of
fractures has also been shown to enhance
healing (Mitchell & Shephard 1980). Internal
of unstable or displaced slab fractures is usually
to control pain and rapid development of prog-
.some cases, thin frontal plane stab fractures
third carpal slab
recognized advantages of
surgery, there was no disruption of the
but all are basedon that originally developed
planning is important and the surgeon
oblique radiographic projections (see Fig. 4.79).
: can be repaired with AD/ ASIF cortex screws of
3.5 mm or 4.5 mm diameter. This is determined
I recumbency. The former offers greater versatility of
positioning and also permits bilateral surgical
movement between the standard position for
The middle carpal joint initially is evaluated utilizing the
1 arthroscopic portal. In acute injuries there is
permit visibility. This is usually performed through a
-'" : portal. The dorsal compartment of
and any additional lesion noted. Non-displaced fractures
have variable amounts of cartilage disruption (Fig. 4.8IC).
Some fractures. which on radiographic examination appear
non-displaced. are found to be unstable at arthroscopic
evaluation. Displaced fractures frequently are accompanied
by additional cartilage loss and there may also be commin-
ution, which most commonly occurs as a wedge in the
proximal palmar margin of the fracture. Reduction (when
necessary) is effected most effectively by flexion and this
should be performed progressively.Defects are debrided prior
to repair (Fig. 4.80) and any comminuted fragments tl
preclude complete reduction should be removed. Surgic
opinion is divided on the fate of large palmar fragments.
these can be retained and stabilized in the repair, SOl.
surgeons prefer this option to removal and conseque
creation of a large proximal articular deficit.
The medial and lateral margins of the fracture are mark,
by percutaneous insertion of 22- or 23- gauge needl
(Fig. 4.81). A spinal needle is then placed midway betwe4
these two needles.close and parallel to the proximal articul
surface. and directed across the midpoint of the fracture
close to 900 as possible (Fig. 4.81). This needle is the mc
important directional guide for implant placement. Conti
uration of most slab fractures of the radial facet of the thi
carpal bone is such that the tip of this needle usually lodg
in the palmar fossa of the bone. It is important that med
and lateral marker needlesare used to determine the positil
of this needle; the eccentric position of the arthroscope aJ
its inclined lens angle mean that accurate determination
the midpoint of the fracture from the arthroscopic ima
alone is not possible.Once the spinal needle has been placf
a further 20- or 23- gauge needle is inserted into t]
carpometacarpal joint directly distal to its point of entry.
required, a radiograph is made to ascertain proximal-disl
positioning of the screw (Fig. 4.82).
At this stage some surgeons remove the arthroscope b
the authors' preference is for this to be held by a surgic
assistant. A short (stab) incision is made midway between t]
spinal needle and the marker needle in the carpometacarp

a No. 10 or 11 scalpel blade. This incision should
which at
A glide
is drilled in the fragment using the spinal needle as a
guide (Fig. 4.83). Once this has reached the
insert sleeveis positioned in the glide hole.
some displaced fractures in which a small amount of
articular incongruity persists. limited fragment manipulation
can be performed at this time. Leaving the arthroscope in situ
permits direct visualization of the process and continuous
monitoring of reduction and repair. The thread hole is then
drilled to the palmar surface of the bone (Fig. 4.84). This
depth is checked against the preoperative measurements.
before a countersink is used to create an appropriately sized
bed for the screw head. The strongly convex dorsal face of the
third carpal bone means that this is important for all screw
sizesto avoid point contact and maximize efficiency of com-
pression and to avoid protrusion of the screw head into the
joint capsule. dorsal intercarpal ligaments. and tendon of
insertion of the extensor carpi radialis. The reduction can be
assessedarthroscopic ally and radiographs should also I
taken at this point to ensure optimal implant placeme
(Figs. 4.85 and 4.86).
Unstable comminuted fragments and detached cartila
are removed at this time and the joint is lavaged. Skin portc
only are closed in a routine manner and a padded dressiI
applied for the immediate postoperative period. Follow-\
radiographs of a repaired frontal slab fracture are present!
in Figure 4.87. Displaced fractures of the radial facet of tI
third carpal bone are managed in the same fashion wi
regard to fixation. However, one is frequently left wi'
significant defects at the articular surface. There is usually
defective subchondral bone wedge or multiple piecesand aft
removal a large size defect remains (Fig. 4.88). In oth
situations, there can be a number of comminuted fragmen
that require removal, leaving a major defect on the later
aspect of the fracture (Fig. 4.88D and E).
Frontal fractures also occur, involving both the radial ar
intermediate facets, and are generally repaired with tv
screws (Fig. 4.89). Individual fractures of the intermedia
facet of the third carpal bone also occur and are wc
identified on dorsomedial-palmarolateral radiographs; thl
are usually repaired with a single 3.5 mm screw (Fig. 4.90
Sagittal and parasagittal fractures of the radial facet of tI
third carpal bone are inherently more stable than fractures
a frontal plane. They are best identified on skyline radio
raphs and sometimes are also seen on dorsopalmi
projections (Fig.4.91). Arthroscopic evaluation usually revec
a fracture line commencing in the dorsal margin of the bO
at the junction of its middle and medial one-thirds. TI
fracture may then curve to exit the articulation between 11
second and third carpal bones or may extend in a straight IiI
toward the palmar fossa of the third carpal bone (Fig. 4.9]
Conservative management has been discussed for sagitt
fractures in the third carpal bone (Fischer and Stover 1987
Half of the cases managed conservatively healed. Comm
nution is rare and cartilage loss uncommon. The principles
repair are similar to those described above for fractures in
frontal plane. However, there is a small window for safe ar
effective internal fixation, which necessitates implal
placement close to the dorsal margin of the articulatic
between the second and third carpal bones (Fig. 4.9]
Fortunately, fragment size is such that large implants are nl
required and the head of a 3.5 mm AO/ASIF cortex scre
can be safely placed at this site (Fig. 4.92).
Fractures which occur in both frontal and sagittal planl
can involve a number of configurations, and these will dete
mine the sites for appropriate implant placement. Non
theless, the principles applied individually to fractures i
frontal and sagittal planes apply. In some instances it may I
necessary, in order to avoid impingement of implants, 1
place these at differing proximodistallevels within the bon
Frontal plane fractures that involve the radial and inte
mediate facets of the third carpal bone can occur in a numb!
of configurations. The basic arthroscopic approach is c
described for frontal plane slab fractures involving the radi,
facet only. However, it will usually be necessaryto insert t\\
screws in order to produce effective compression and stab
Diagnostic and Surgical Arthroscopy of the Carpal Joints

Fig.4.83
Diagram (A) and external views (B and C) of drilling 4.5 mm diameter hole in a frontal plane slab fracture of the third carpal bonE
 Arthroscopic
of frontal plane slab fracture of the third carpal
fixation.Thesemay involvepairs of 4.5 mm or 3.5 mm or a
combination of screw sizes (Fig. 4.89). Slab fractures
involvingonly the intermediatefacetof the third carpalbone
should be approachedusing dorsomedialarthroscopyand
dorsolateralinstrument portals. Theseusually are repaired
with a single 3.5 mm screw(Fig.4.90).
Postoperative management
Routinely padded dressings are used in the immediate
postoperative period but in horses with large unstable
fractures use of a sleeve cast in recovery from general
anesthesia and in the immediate postoperative period
is appropriate. Most animals are confined to a stall for
2-4 weeks and this is followed by a 6-8 week period of
increasing amounts of walking exercise. Flexion exercise is
encouraged immediately after surgery and should continue
until a full and unrestricted range of flexion consistently is
obtained. At the end of the walking period. progressive
increase in exercise is permitted and this may involve
, continued controlled exercise. such as ridden trotting
exercise or free exercise in a small paddock. Swimming may
for Treatment of Carpal
also be beneficial at this point. The total convalescent pert
is usually approximately 6 months.
With appropriate screw placement, complications a
uncommon. A further fracture extending to the screw and/t
creation of a chip fracture at this site has beenrecogniz(
there is good clinical or radiological evidenceim
implants in lamenesslocalizing to the middle carr
joint, screws are not removed.
Results
In the series of 23 horses with third carpal slab fractul
reported by Richardson (1986),17 had a 6-month or lon~
follow-up interval. Ten of the 17 horses returned successfu
racing; 1 horse was training soundly, and trained well b
retired because of other injuries. One horse was unalt
return to training because of injury that had occurr
simultaneously with the slab fracture, 2 did not recover w
enough to train, and 1 was lost to follow-up. At the time
writing, 6 horses had less than a 6-month follow-up periodw
progressing well and 1 developed radiographic signso
In uncomplicated cases,the cosmetic appec
 Diagnostic and SurgicalArthroscopy of the Carpal Joints

Fig. 4.85
Diagram (A), external view of screw placement (B) and radiograph confirming appropriate screw placement (C) in repair of fronta
plane slab fracture of the third carpal bone.

111_lli~
Fig.4.91
Radiographs (A and B) and arthroscopic view (C) of sagittal
fracture of the third carpal bone. A needle has been inserted
to ascertain position of implant placement.
ance of each carpus was reported as good. with only a small
swelling over the screw (Richardson 1986). Horses with
displaced slab fractures have a poorer prognosis for return to
racing than do those animals with undisplaced slabfractures.
because the latter are associated with more severedamage to
the joint surfaces (Bramlage 1983). This situation remains
the same whether treatment involves arthroscopy or
arthrotomy. Similarly. the prognosis worsens when loss of the
wedge of cartilage and bone at the proximal articular surface
leaves a large defect after fixation (Bramlage 1983).
There have been two other retrospective studies published
on third carpal slab fractures and their repair. However,these
did not generally involve arthroscopic surgery and care
should be taken in extrapolating results. In one paper, the
caserecords and radiographs of 155 horses with third carpal
bone slab fractures were reviewed (72 Thoroughbreds and 61
Standardbreds) (Stephens et al 1988). Of 73 fractures in
Standardbreds, 37 were repaired by screw fixation. 18 were
surgically removed. and 18 were treated conservatively.
the 82 Thoroughbreds with a third carpal fractures. 46 w
repaired with screws. 21 had the fragment removed. and
received rest only. The effect of treatment on outcome was ]
significantly different. Fracture characteristics did]
significantly affect outcome. but did influence treatm,
selection. In Standardbreds. 77% if the horses raced aJ
injury: in Thoroughbreds. 65% raced. Earnings per st
declined in each breed. but the decline was more pronoun
in Thoroughbreds (Stephens et alI988).
In a second study of 31 cases of racing Thoroughbr
with third carpal slab fractures. all cases were trea
surgically. Twenty-one (67.6%) horses raced at Ie
once after recovery from the surgery: In 11 claiming hor:
the claiming value decreased from a mean of $13.900 t
mean of $6.500, the mean finish position was 5.8 :t 3
before injury and 5.6 :t 3.30 after surgery (Martin e1
1988).
Treatment of Other Carpal
Slab Fractures
Slab fractures of other carpal bones are uncommon but also
can be assessed.reduced, and repaired under arthroscopic
guidance. Frontal plane slab fractures of the radial carpal
bone are assessed arthroscopically through dorsolateral
portals in both middle carpal and antebrachiocarpal joints.
Fracture margins are marked with percutaneous needlesand
the trajectory of implants is determined with a spinal needle
in a manner similar to that employed in corresponding
fractures of the third carpal bone. The fracture configuration
will determine the size and number of implants necessary.
Figure 4.93 illustrates a slab fracture of the radial carpal
bone which was repaired arthroscopically. Sagittal slab
fractures of the intermediate radial of third carpal bone have
been found at arthroscopy; the fractures have been generally
treated by removing the slab fragment. but in a recent case
with internal fixation with a 2.7 -mm screw. Arthroscopy also
is the technique of choice for the repair of reconstructable
fractures of multiple carpal bones. These involve most
commonly the radial and third carpal bones and the
technique is varied to accommodate the variations of each
individual fracture (Fig. 4.94). Such cases should be fitted
with a sleeve cast for recovery from general anaesthesia and
for the immediate post-operative period. Slab fractures of the
fourth and intermediate carpal bones have been reported
(Auer et al 1986). Poor results were achieved after screw
fixation with arthrotomy.
Arthroscopic repair of large chip fractures can, in SO
instances be an alternative to removal. This is based on tl
premise that reconstruction of articular surfaces is preferal
to creation of a large osseous defect (Grade 4 lesion). TI
necessary caveats are that fragments should be of sufficie
size and have adequate osseousinfrastructure for placeme
of a screw and that the process of reconstruction should
lesstraumatic than removal. Most chip fractures are repair
with 2.7 mm AO/ASIF cortex screws although on occasio
these may be sufficiently large for use of 3.5 mm diame1
screws. The latter may be employed in repair of frontal pIa
fractures of the third carpal bone that extend from its proxin
articular surface (usually the radial facet), to exit with t
dorsal surface of the bone proximal to the carpometacarlj
Chip fractures of the dorsodistal margin of the rad
carpal bone (Fig. 4.95), dorsoproximal margin of the till
carpal bone and dorsoproximal margin of the radial carl
bone have been repaired using 2.7 mm diameter screv
Delineation of the fracture is performed in a manner simi]
to that describedfor the repair of slabfractures. Most fragmeI
which are amenable to repair will exit the bone within t.
capsular reflection and/or associated intercarpalligamen
This point can be determined, if necessaryby radiographica
guided needle placement. The position for screw placemel
in most instances is within the synovial cavity and therefc
the drilling process and insertion of implants can
performed under direct arthroscopic visualisation. Healing
repaired carpal chip fractures has been documented but,
date there have been no published results.

References
Auer JA. Watkins JP.White NA. et al. Slabfractures of the fourth and
intermediate carpal bones in 5 horses. J Am Vet Med Assoc 1986;
188: 595-601.
Bramlage LR. Surgical diseases of the carpus. Vet Clin North Am
(Large Anim Pract) 1983; 5: 261-274.
Convery FR. Akeson WHo Keown GH. The repair of large
osteochondral defects -an experimental study in horses. Clin
Orthop 1972; 82: 253-262.
Dabareiner RM. Sullins KE. Bradley W. Removal of a fracture
fragment from the palmar aspect of the intermediate carpal bone
in a horse. J Am Vet Med Assoc 1993; 203: 553-555.
DeHaan CEoO'Brien TR. Koblik PD. A radiographic investigation of
third carpal bone injury in 40 racing Thoroughbreds. Vet Radiol
1987; 28: 88-92.
Finerman GAM. Noyce FR (eds): Biology and biomechanics of the
traumatized synovial joint: The knee as a model. Rosemount 11:
American Academy of Orthopedic Surgeons. 1992.
Firth EC.Deane. GibsonK. et al. Current studies in carpal diseaseand
function in the horse. Vet Cond Educ. Massey University. New
Zealand 1999; 135: 81-89.
Fischer AT. Stover SM. Sagittal fractures in the third carpal bone in
horses: 12 cases(1977-1985). J Am Vet Med Assoc 1987; 191:
106-108.
Friedman MI. Gallick GS.Brna JA. et al. Chondromalacia of the knee:
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plate microfracture technique augments healing of large
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comparative study of untreated and X-irradiated defects.
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Howard RD. McIlwraith CWoPowers BE. et al. Long-term fate and
effects of atWetic exercise on sternal cartilage autografts used for
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location on equine articular cartilage repair. Can J Vet Res 1988;
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equine midcarpal joint, Part I: The anatomy of the palmar and 1414.
 Arthroscopy has proven to be a most valuable technique in
the metacarpophalangeal and metatarsophalangeal (fetlock)
joints. Its original use was principally, in arthroscopic surgery
in the dorsal aspect of the joint but then extended into the
palmar/plantar aspect. Arthroscopic surgery in the dorsal
aspectof the fetlock joint is probably the best equine example
of what can be achieved with joint distention.
The same advantages that have been discussed in the
carpus hold for arthroscopic surgery in the fetlock. The
indications for arthroscopic surgery in the metacarpo-
phalangeal and metatarsophalangeal joints include the
following conditions:
1. Osteochondral fragments of the proximal dorsal aspectof
the proximal (first) phalanx.
2. Erosions of articular cartilage and subchondral bone
disease on the dorsal proximal aspect of the first
phalanx.
3. Synovial pad fibrotic proliferation (villonodular synovitis)
of the metacarpophalangeal joint.
4. Other forms of proliferative synovitis.
5. Osteochondritis dissecans of the sagittal ridge of the
third metacarpal or metatarsal bones (McIIl/MtIIl).
6. Osteochondral fragments associated with the proximal
palmar or proximal plantar aspect of the proximal
phalanx.
7. Removal of apical fragments of the proximal sesamoid
bone.
8. Removal of abaxial fragments of the proximal sesamoid
bones.
9. Removal of basilar fragments of the proximal sesamoid
bones.
10. Lesions of the intersesamoidean ligament.
11. Axial osteitis of the proximal sesamoidbones.
12. Avulsions of the suspensory ligament insertions.
13. Subchondral cystic lesions of McIIl.
14. Lesions of the dorsal plicae.
15. Chondral fractures.
16. Fibrous joint capsule tears.
17. Assistance in repair of condylar fractures of the
McIIl/MtIIl and fractures of the proximal phalanx.
18. Other selected proximal sesamoid fractures.
Arthroscopic examination of the fetlock joint may be
indicated specifically as a diagnostic procedure or as part of
an arthroscopic surgical procedure (McIlwraith 198'4).
The latter situation is more common, although diagnostic
arthroscopy is indicated in cases involving a lameness
problem that has been localized to the fetlock but for which
the radiographic signs are equivocal. The procedure is most
valuable if synovial effusion is present or if the area of
lamenesshas been identified as intra-articular on the basis of
a response to intra-articular analgesia and when there has
not been a responseto conservative treatment.
A complete arthroscopic examination of the metacarpo-
phalangeal or metatarsophalangeal joint is not possible.Two
arthroscopic approaches are required to achieve as effective
an examination as possible of both the dorsal and palmar
(plantar) components.
Each diagnostic examination will be described. Because
the dorsal approach most commonly is performed on the
metacarpophalangeal joint, it is described for that joint. The
only difference in examination of the metatarsophalangeal
joint is that it may be more difficult because of the decreased
ability to maintain extension of the joint. The plantar (palmar)
examination is facilitated by flexion and this is especially
convenient in the hilid limb.
Arthroscopic examination of the dorsal
metacarpophalangeal joint
This arthroscopic examination ~an be performed with the
horse in dorsal or lateral recumbency. If lateral recumbency
is used. the horse should be positioned so that the site for
arthroscopic entry is up. For the same reason of versatility
mentioned in Chapter 4 with regard to the carpal joint. the
use of dorsal recumbency is preferred. While the leg is being
surgically prepared and draped. it is held by an assistant or is
suspendedin a mechanical device (Fig. 5.1). Draping can be
completed with the fetlock resting back on the elbow or
appropriatelysuspendedsothe joint remainsextended.
Insertion of the arthroscope
The metacarpophalangeal joint is distended with fluid
(Fig. 5.2) before making the arthroscopic portal. In this joint,
distention facilitates the recognition of the correct place for
the arthroscopic portal and minimizes the risk of iatrogenic
trauma to the joint on entry of the arthroscopic sleeve. There
are no tendon sheaths to avoid as in the carpus, and the
surgeon does not have to be concerned with exact local-
ization of structures before distention.
Distention is performed by using approximately 35 ml of
fluid and inserting a needle across the dorsal aspect of the
proximal sesamoid bone into the palmar pouch of the fetlock
(see Fig. 5.2). Adequate distention can be recognized easily
with bulging of the joint capsule on either side of the
common digital extensor tendon. The outpouching of the
distended joint is more prominent lateral to the common
digital extensor than it is medial to it, despite the insertion of
the lateral digital extensor tendon, which ramifies over the
joint capsule lateral to the common digital extensor tendon;
this is penetrated when the lateral portal is created.
The site for the laterally placed arthroscopic portal is in the
proximolateral quadrant created by distending the joint
maximally (Fig. 5.2). A No. 11 blade is used to incise the skin
and stab through the joint capsule (seeFig. 5.3). The arthro-
scopic sleevecontaining a conical obturator is then inserted
through the joint capsule, initially perpendicular to the skin
and then parallel to the articular surface of Mclll to avoid
iatrogenic damage to this area (Fig 5.4). Entry is completed
by advancing the sheath proximad to avoid iatrogenic
damage to the midsagittal ridge of the distal metacarpus (see
Fig. 5.4). The sheath can then be directed distad once over the
sagittal ridge.

If the arthroscopic portal is made in the more proximal
dorsal pouch, the sheath can be advanced across the joint in
a transverse direction without causing damage to the
midsagittal ridge of the metacarpus. The position described
here for the arthroscopic portal is different than in the
previous edition of this text (McIlwraith 1990a). It represents
a modification initially suggested by Foerner (pers comm
1984), in that by taking the portal more proximad, it was
possible to better visualize the proximal lateral aspect of the
proximal phalanx.
When the arthroscopic sleeve is inserted so that its tip
touches the medial capsule, the arthroscope is inserted and
the examination can begin. It is easy to enter the sub-
cutaneous tissue plane when inserting the arthroscopic
sleeve in the dorsal aspect of the fetlock, and care is
warranted during both the joint distention step as well as
with insertion of the arthroscopic sleeve to avoid this
problem. The authors prefer to use this proximal arthroscopic
portal in the metacarpophalangeal joint to avoid iatrogenic
damage to the midsagittal ridge of the metacarpus and to
provide the best overall view of the dorsal aspect of this joint.
A more distal portal along the dorsal margin of the metacar-
pophalangeal joint immediately proximal to the proximal
phalanx, however,can provide convenient visualization of the
proximal border of the first phalanx.
As in the carpus, creation of an instrument portal and
insertion of an egresscannula or probe are the next steps. A
useful measure is to insert a needle at the proposed instru-
ment portal location to check if such a site is appropriate
(Figs 5.5 & 5.6). The use of aI needle to ascertain ideal
positioning for the instrument portal represents a departure
from what was previously described in the carpus. However,
the carpus is unique and the skin incisions for the instrument
portal are made prior to joint distention and insertion of the
arthroscope merely to avoid entering an extensor tendon
sheath. There are no such issues in the fetlock joint, or most
other joints for that matter. The practice of inserting a needle
to ascertain the ideal position for instrument insertion and
surgical maneuverabilityis commonto all joints other than
the carpus.By making a skin incision with a scalpeland No.
11 blade.the surgeoncreatesthe instrument portal through
the joint capsule(Fig. 5.7). The small egresscannula can
then be inserted through this portal without the trocar. An
arthroscopic examination can then commence. At the
completionof arthroscopy,the skin incisionsonly are closed
(Fig.5.8).
Diagnostic arthroscopy of the dorsal
pouch of the fetlock Joint
With slight retraction of the arthroscope and looking across
the joint. the first area visualized is the proximal portion of
the dorsal joint proximal to the articular cartilage of the
distal metacarpus, where the synovial membrane forms a
reflection (Fig. 5.9). At this transition zone,the synovium has
a flap, or pad. that varies in size, and the surgeon must be
familiar with the normal range (see Fig. 5.9). Synovial pad
fibrotic proliferation (villonodular synovitis) manifests as an
enlargement of this flap. Apart from the flap, the synovial
membrane in the remainder of this dorsal area is non-villous.
The articular surface of the medial condyle and mid-
sagittal ridge of McIIl can then be examined by rotating
the arthroscope so that the lens is angled distad
(Fig. 5.10). The tip of the arthroscope is then moved distad
(eyepiece moving proximad) to inspect the dorsal articular
edge of the proximal medial eminence of the proximal
phalanx (Fig. 5.11). The synovial membrane of the dorsal
joint capsule is also evaluated during these maneuvers. The
synovial membrane is notably more villous as one progresses
distad and villi can sometimes obscure the view of the
proximal dorsal rim of the first phalanx. The synovial mem-
brane attaches immediately adjacent to this rim, and use of
instruments (including the egress needle) to allow improved
inspection of the first phalanx is common practice during
both diagnostic and surgical arthroscopy in this area.
Withdrawing the tip of the arthroscope further and moving i
across the sagittal ridge laterally (eyepiecemoving medially
permits inspection of the lateral condyle of the distal meta
carpus as well as the proximal lateral aspect of the proxim~
phalanx (Fig. 5.12).
The examination just described enables recognitiol
and characterization of synovial pad fibrotic proliferatiol
(villonodular synovitis), other forms of synovitis, fragment
off the proximal dorsal aspect of the proximal phalanx, wea
lines and erosions on the distal articular surface of Mcll
osteochondritis dissecans of the midsagittal ridge an
condyles of Mclll, tears of plicae and joint capsule. articula
components of fractures of Mclll and proximal phalanx. an
subchondral cystic lesions of Mclll.
Arthroscopic examination of the
palmar or plantar fetlock joint
This examination can be performed with the horse in dorsI
or lateral recumbency, the position varying with th
condition being operated. The authors preferred later!
recumbency when operating on fragments associated wit
the palmar/plantar aspect of the proximal phalanx in tb
past, but now use dorsal recumbency for all evaluation~
conditions in the palmar/plantar compartment. While flexio
from an assistant is sometimes needed, advantages includ
less hemorrhage, convenient operating position for plant~
(palmar) chip fragments, as well as sesamoid fragmen1
and the ability to put instrument portals in either medial (
lateral pouch.
Insertion of the arthroscope
The joint is prepared for surgery and distended by placing th
needle in the palmar pouch using the approach described b
Misheff & Stover (1991). With the joint distended, a ski
incision is made with a No. 11 blade in the proximal part (
the bulging capsule (Fig. 5.13). The arthroscopic sheath and
conical obturator are inserted perpendicular to the skin
initially, and then are directed distad (Fig. 5.14). The fetlock is
in 30-450 flexion at this time to facilitate passage between
the distal metacarpus/metatarsus and the proximal sesamoid
bones. The degree of flexion is controlled by an assistant and
the flexion angle varies depending on the area being
examined (for instance, increased flexion is used to bring the
proximal palmar aspect of the proximal phalanx into view).

Diagnostic arthroscopy of palmar

(plantar) pouch of the fetlock joint

Examination of the metacarpo- or metatarsophalangeal joint

commences with the arthroscope perpendicular to the skin
and the lens oriented proximad (Fig. 5.15). The unusual
synovial membrane of the proximal recess of the joint can be
visualized. Rotation of the arthroscopic lens palmad allows
inspection of the apices of the sesamoid bones and the
intersesamoidean ligament (Figs 5.16 and 5.17).
The tip of the arthroscope is then advanced distad (this
can be done safely if the joint is flexed and distention is
maintained) to examine the articular surfaces of the sesamoid
bones and the intersesamoidian ligament palmad and the
articular surface of the distal palmar Mclll dorsad (Fig. 5.18).
Advancement of the arthroscope continues until the base of
the sesamoids is visualized (Fig. 5.19) and. with increased
flexion. the proximal palmar rim of the proximal phalanx can
be noted (Fig. 5.20).
Diagnostic arthroscopy of the palmar or plantar pouch of
the fetlock joint is now a commonly used procedure. Indi-
cations for arthroscopic surgery in the palmar or plantar
pouch include palmar/plantar proximal fragments off the
proximal phalanx. apical. abaxial and basilar osteochondral
fractures of the proximal sesamoid bone, osteitis of the axial
portion of the sesamoid bones and tearing of the inter-
Removal of osteochondral fragments
sesamoidian ligament. diagnostic arthroscopy for synovitis
from the proximal dorsal aspect
and capsulitis as well as adjunctive visualization for reduction
of the proximal phalanx
of lateral condylar fracture of Mclll/MtlII and assessmentof
associateddamage. For diagnostic examination of a capsulitis
Before the advent of arthroscopy, surgical removal of these
or a suspectedosteoarthritis problem. inspection of the dorsal
fragments was not routine, becausesome surgeons questioned
compartment is performed initially. followed by palmar or
the benefits of surgical invasion of this area with arthrotomy
plantar examination in most situations.
(Raker 1973, 1985, Meagher 1974). Now, a horse with
problems referable to the fetlock joint and radiographically
evident fragments associated with the proximal dorsal aspect
of the first phalanx is a candidate for arthroscopic surgery.
Arthroscopic surgery can provide a faster return to full
function and help minimize the degenerative changes that
could possibly develop. All the advantages of arthroscopic
The indications for arthroscopic surgery have been previously surgery discussed in Chapter 4 relative to the carpus are
listed. equally applicable when discussing arthroscopic surgery in
 Of probablyincreasedimportance is the need the dorsal joint capsule. and this may be difficult to
atraumatic surgery. The dorsal joint capsule ascertainfrom the radiographs.The neophytearthroscopistshou
proximal first phalanx tend to be less forgiving to try initially to limit his casesto those involving
freshacutechips that are both looselyattachedto the bone
radiographic and arthroscopic manifestations of and accessible.
proximal dorsal chip fractures vary (Figs 5.21-5.27). There The location of thesefragments,as representedby one ofthe
may be fresh fracture fragments or more chronic rounded author's (C.WM.)publicationsreporting on 439 fetlockjoints
fragments. The typical fragment involves the proximal in 336 horses,is givenin Tables5.1 and 5.2.
eminence, but in some situations (more typical in the racing
Quarter Horse), the fragments extend distad into fibrous joint
capsule attachments (see Fig 5.24). Frontal fractures Technique
appropriate for internal fixation are considered separatelybelow. For all cases of proximal dorsal fragments of the proximal
Most importantly, all fragments, if accompanied byclinical phalanx, the arthroscope is inserted through a proximallateral
signs, are indications for surgery. The damage evident portal as previously described. The instrument andarthros
arthroscopically will always be more extensive than what is approach for operating on chip fragments offthe
seen on radiographs. Consequently, many referred casesareoften lateral and medial eminences respectively,are represented
ones with persistent evidence of synovitis and capsulitisdespite
diagrammatically in Figures 5.28 and 5.29. We recommendperform
medical therapy and relatively minor fragmentation all arthroscopic surgery in the dorsal pouch of the
or with only a radiographic defect off the proximal phalanx(Fig. fetlock joint with the same arthroscopic portal in the
5.25). Occasionally the fragment will be free withinthe proximal lateral aspectof the dorsal pouch. After a completediagno
joint (Fig. 5.26). Uncommonly, the fragment is embedded arthroscopy, the osteochondral fragments are

in
Metacarpophalangeal and Metatarsophalangeal joints

Fig. 5.21
Removal of a small chip fragment (arrow) off the proximal
dorsal medial eminence of the proximal phalanx. (A and B)
Lateral-medial and DLPMO radiographs. C, Arthroscopic
views before (C), during elevation (D), during removal with
Ferris-Smith rongeurs (E), curetting defect. continued
 If a fragment is present on the proximal lateral
, it is removed first. A lateral instrument portal is

5.5). The needleplacementis lateral and midway down M

incision, and the instruments are then placed. If a

fragment is present, a medial instrument portal is
--

If a synovial pad fibrotic

.it can usually be removed through the same

the instrument portal is created, the tip of the

must be located sufficientlyproximad to avoid
damage to the arthroscope. By using the proximal

.The lesion is initially evaluated with

(or the egress cannula), as in the carpal joints. The
.manifestations of the fragments vary con-
and cannot usually be predicted from the radio-
a fresh chip, the fracture line may be evident, the

lesion Overall (%) RH (%) TB RH (%) QH RH (%) Others (%)

Fragments only 96 (28.6) 87 (28.0) 62 (33.0) 25 (21.0) 9 (36.0)
Fragments + other fetlock lesions 140 (41.7) 124 (39.9) 93 (22.7) 27 (22.7) 16 (64.0)
Fragment + carpal arthroscopy 63 (18.7) 63 (20.3) 19 (10.1) 44 (37.0)
Fragment + carpal arthroscopy + other fetlock lesions 37 (11.0) 37(11.8) 14 (7.4) 23 (19.3)
Total 336 311 188 119 25
TB,Thoroughbred; QH, Quarter Horse, RH, racehorse.
Source:from Kawcak & Mcllwraith 1994.

5.25).
 Sometimes the fragment can be recognized only as
a roughening of the proximal phalanx. Occasionally,the chipis
embedded in the joint capsule, and this situation can berec
if the fragment projects into the joint; otherwise,
such a density will probably not be found, and the final
diagnosis of a capsular mass is based on the absence of a
fragment on arthroscopic examination despite its presence
on radiographs. Finally, fragments may already be totally free
within the joint (Fig 5.26).
The grasping forceps commonly used to remove the
fragments are Ferris-Smith intervertebral cup rongeurs
(Fig. 5.21E). Low-profile 4 x 10 mm Ferris-Smith rongeurs
have the ideal combination of strength and ability to access
the fragment. As in the carpus, the use of forceps that can
enclose the fragment minimizes the risk of leaving fragments
in the joint. Twisting of the instrument to ensure breakdown
of soft tissue attachments is carried out before withdrawal of
the fragment.
The surgical manipulations to remove the fragment
will depend on the arthroscopic features described above. A
10 x 4 mm Ferris-Smith low-profile rongeur forceps is used to
remove a totally free chip. If a fragment is small, fresh, and
has minor soft tissue attachments as ascertained by palpation
with the egress cannula direct removal with forceps is also
appropriate. For all chips with significant attachments, the
fragment is initially freed by using a periosteal elevator. For
chips that have a strong fibrous union, the elevator is used to
pry the fragment off the bone. The elevator can also be used
to break down capsular attachments to the dorsal aspect of
the fragment. A curette is useful for more strongly attached
fragments. Because of suspected sensitivity of the dorso-
proximal area of the fetlock joint, the surgeon should limit
removal when it has fibrous joint capsule attached to it
(Fig. 5.30 and 5.31).
If a fracture line extends distad deep into the capsular
attachment area and it is not displaced, surgical removal is
not indicated. Fixation with a small fragment screw is
sometimes indicated (seebelow).
After removal of the fragment, the defect remaining is
inspected (see Figs 5.21, 5.22 and 5.30), as is the nearby
area of dorsal capsule, to ensure that no fragments remain.
This latter inspection must involve palpation as well as
fragment can be moved easily and is attached only at the visualization, as the fragments can merge into the capsule.
synovial membrane reflection. Displacement of the fragment The defect commonly has some tags or raised edges of
facilitates identification and removal. Figure 5.21 illustrates cartilage that can be removed with a pair of ethmoid or
the sequence of events in removing a fresh fragment, 2 x 10 mm Ferris-Smith rongeurs (the pointed nose enables
including elevation. removal with Ferris-Smith rongeurs, these forceps to enter the narrow areas where the fragment
curetting of the defect. removal of small pieces with ethmoid was removed). Alternatively, a curette may be used. Debride-
forceps, and lavage. In other cases the cartilage over the ment of the bone is done carefully with a small (2-0) curette
fragment is intact and elevation is required to define with care taken not to cause damage to the fibrous joint
the fragment. With larger fragments, the attachments of the capsule (Figs 5.31).
fragment at the joint capsule may well be more extensive Variable degrees of articular cartilage damage on the
(Fig. 5.22). With mor~ chronic chips. the fragments tend to distal metacarpal or metatarsal condylar surface may be
be more rounded (Fig. 5.23). Some fragments have deep noted. In many cases,no damage is apparent, but varying
attachments in the joint capsule and require more separation degrees of wearline formation are apparent in some cases
(proximal Fig. 5.24). In some cases.the dorsoproximal rim of (Fig. 5.31C) and full-thickness erosion may be seen in other
the first phalanx may only show a defect on lateromedial cases (Fig. 5.3ID). When these lesions are more severe,the
radiographs. but an oblique radiograph will show a small prognosis is not as favorable (Kawcak & McIlwraith 1994).

fragment.
 Unlessa capsular mass projectsinto the joint. it is not
Also. it is not considerednecessaryor beneficialto
arthroscopy in such a case has been to ascertain
.' -of the radiographically apparent mass. If the
of the joint is in satisfactory condition. the prog-
is still good with an osseous mass remaining in the
the sizeor numberof fragmentsthat can
undergo surgery. The surgeon must consider
bone being removed. the amount of exposed
bone being left in the joint. and the amount of
created by the arthroscope or instrument portals.
rather to the amount of capsular attachment to the
the joint is flushed with fluid by
open egress cannula over the site of the defect.
portals are sutured and the leg is bandaged. The
is maintained for at least 2 weeks after surgery.
walking commences after 1 week. With simple fresh
the horses can be put into training after 6-8 weeks.
horses with more extensive involvement, the con-
time is increased for a variable period up to
after surgery, but some veterinar-
.As discussedin the section concerning the
.-to the patient's recovery is
results with arthroscopic surgery for uncomplicated
fractures are associated with severe capsulitis. wear lines.
osteoarthritis. or extensive fragmentation of the proximal first
phalanx. the progn!;)sis decreases accordingly. As with the
carpus. surgical intervention can still improve the status of
these patients. but communication to owner and trainer is
important to ensure that no one is disappointed. Even with
suchprecautions. however. some peoplehave short memories.
The results of arthroscopic surgery in 74 fetlock joints of
63 horses (35 Thoroughbreds and 28 Quarter Horses) over a
2-year period were initially reported by Yovich & Mcllwraith
(1986). Larger numbers have replaced these data. The results
of arthroscopic surgery were reported in 1994 in 336 horses
with 572 osteochondral fragments removed from 439 fetlock
joints (Kawcak & Mcllwraith 1994). Of these horses. 311
were racehorses. including 188 Thoroughbreds. 119 Quarter
Horses. 2 Standardbreds. 1 Racing Arabian and 1 racing
Appaloosa. There were 25 non-racehorses. A single meta-
carpophalangeal joint was operated on in 220 horses. and
both metacarpophalangeal joints were operated on in 97
horses. a single metacarpophalangeal joint in 17 horses. both
metatarsophalangeal joints in one horse and all 4 fetlock
joints in one horse. Fragmentation of the proximal phalanx
was the only lesion in the fetlock joints of 96 horses. Along
with fragmentation, 140 horses had other lesions in the
fetlock, comprising 64 with wear lines. 11 with articular
cartilage erosion. 15 with chronic proliferative synovitis. 4
with osteochondritis dissecans,and 45 with a combination
of the above lesions. Carpal arthroscopy for the removal of
osteochondral chips was performed concomitantly in 100 of
these horses (Table 2).
Follow-up was available for 286 horses (85.1%): 208
(73%) returned to their previous use. of which 153 horses
(73.6%) returned to the same level of performance and
55 (26.4%) returned to performance, but at a lower class; 18
horses (6.3%) developed another fragment and 60 (21 %) of
horses did not return to their previous use. Of the 270
racehorses with follow-up. 196 (72%) returned to racing and
141 (51.7%) of these raced at the same or a higher level.
18 (6.6%) of the racehorses developed another fragment and
56 (21.0%) were in the failure category. Of the non-
racehorse group, 12 of 16 (75%) returned and 4 (25%) did
not return to their previous use at the same level of
performance. The difference of return to previous use between
racehorses and non-racehorses was not significant. The
overall successrate in horses with fragments only returning
to use was 85.9%; with fragments and other fetlock lesions. it
was 75%; with fetlock fragments and carpal arthroscopy con-
comitantly. it was 68.6%; and with fragments plus carpal
arthroscopy and other fetlock lesions, it was 80.6%.
In a third study done to examine the longevity of
postoperative careers and quality of performance of 461
Thoroughbred racehorses after arthroscopic removal of
dorsoproximal osteochondral fragments from the proximal
phalanx. 659 chip fragments were removed arthroscopically
from 574 joints and 461 horses presented for lameness or
decreased performance attributable to the chip fractures
(Colon et al 2000). It was found that 89% of the horses
(411/461) raced after surgery and 82% (377/461) did so at
the same or a higher class; 68% of the horses raced in a
stakes or allowance race postoperatively. This paper con-
firmed that the quantity and quality of performance was not
diminished after arthroscopic treatment of dorsoproximal
fragments, and that surgical removal of a chip fragment
preserved the economic value of a racing Thoroughbred.
allowing a rapid and successive return to racing at the
previous level of racing performance (Colon et al 2000).
Horses that raced before and after surgery (258) had an
average of 8.4 starts (median = 6) before surgery and 13
(median = 11) after surgery.The averagetime between surgery
and first postoperative start was 189 days (median = 169);
87% of the horses racing before surgery (224/258) returned
to race at the same or higher class. The average earnings per
start after surgery was less than the average earnings before
surgery in 61 % of these horses and greater in 32%.
Colon et al (2000) considered the 11 % postoperative
failure rate to be pessimistic due to various factors. It was
noted that horses that did not race after surgery tended to be
older at the time of surgery and had raced more times pre-
operatively. They concluded that the lack of return to racing
was not related to chip incidence. location or size,as these did
not differ between the raced and unraced group. They
carefully measured fragment size and concluded that it did
not affect post-surgical racing prognosis: 48% of the surveyed
horses had at least one fragment larger than the mean and
87% of these raced after surgery. They concluded that the
hypothesis that "the smaller the chip fragment, the better the
prognosis" was rejected by these findings. However, they
noted that it was not possible in their study to compare post-
operative racing performance to arthroscopic visualization of
articular cartilage health or associated intra-articular
cartilage lesions. They did point out, appropriately, that
usually the articular cartilage damage is not severe and can
be managed medically.
Arthroscopic removal of dorsoproximal
chip fractures of the proximal phalanx
in standing horses
This technique has been described and reported in 104
horses (Elce & Richardson 2002). Given skilled technique, it
is feasible to perform arthroscopic surgery in the dorsal
aspect of the fetlock in this fashion. However, we would only
recommend it if, for some reason, general anesthesia is some-
how not possible or inconvenient. Throughout this textbook,
the authors recommend surgery under general anesthesia.
Erosions of articular cartilage and
subchondral bone disease on proximal
dorsal eminences of proximal phalanx
As seen in the carpus, there is a spectrum of disease on the
proximal dorsal aspect of the proximal phalanx ranging from
separation of articular cartilage and loss of articular cartilage
to degenerative disease of the subchondral bone. Previously
discussed osteochondral fragments are considered to be
pathologic fractures and are the end result of a gradation of
microdam~ge, microfractures, and cellular death (Kawcak et al
2000). This range of lesions occur in the same locations as
previously described for osteochondral fragments and the
surgical management is the same.
The referring clinical signs are also similar, but radio-
graphically there may only be a suspicion of disease.However,
on arthroscopic examination, the various manifestations of
articular cartilage separation (Fig. 5.32A), articular cartilage
erosion (Fig 5.32B), and subchondral bone disease(Fig 5.32C
and D) are encountered. Separated cartilage and bone is
removed. Defective bone is debrided (larger pieces removed),
and the area lavaged. The prognosis is comparable to
completely separated osteochondral fragments in this area.
Treatment of frontal fractures of
proximal dorsal aspect of the proximal
phalanx using lag screw fixation
Frontal fractures of the dorsal aspectof the proximal phalanx
occur regularly. The clinical signs are very similar to other
osteochondral fragments on the proximal dorsal rim, an
radiographs are used to make the definitive diagnosis. VI
have encountered cases in the hind limbs bilaterally an.
because of the consistent location of these fracturt
involving both the proximal medial eminence and sagitt
groove,a developmental predisposition may be present.
In the previous edition of this book, the use of rest w~
advocated, as these fractures can heal (McIlwraith 1990a
However,since that time, caseshave beenencountered that ill
not heal and continued to cause clinical signs. The recon
mendation now is to provide compression of these fractur!
with 2.7 mm AD/ ASIF cortical screws.
Arthroscopic surgery is performed with the norm.
arthroscopic approach to the dorsal pouch and with tb
limbs in extension. Examination of the joint will confirm tb
presence of the fracture (Fig. 5.33). Needles are placed t
ascertain ideal positioning of the screw and, after a sta
incision is made in the appropriate location, a 2.7 mm hole
drilled obliquely down through the fracture fragment. Tb
hole is generallyperpendicular to the fracture line. Radiograpl
are made to confirm appropriate positioning and that tb
glide hole is beyond the fracture line. A 2.0 mm hole is cor
tinued beyond this. After counter-sinking, a 2.7 mm diamete
36 mm long cortical bone screw is then placed to comprel
the fracture. Debridement is then performed in the fractur
line, if appropriate. The manifestations at the fracture lin
will vary and sometimes no bone is required to be remove
(see Fig. 5.33); other times, debridement in a comparabl
fashion to a slab fracture is required.
Treatment of slnovial Rad fibrotic
proliferation (vilionodular synovitis)
The condition initially designated as villonodular synoviti
(Nickels et al19 76) and later describedas chronic proliferativ
synovitis (van Veenendaal& Moffatt 1980, Kannegieter,199C
is seen in the metacarpophalangeal joint. It involves
proliferative response from the synovial pad in the proximc
dorsal aspect of the joint and, therefore, the term synovic
pad fibrotic proliferation (Dabereiner et al19 9 6) is preferre(
The term pigmented villonodular synovitis was originall
used to describe pedunculated growths forming in th
synovial linings of tendon sheaths and joint in man Gaffe et c
1941). These fibrous masseswere polyp-like formations th.
originated from the synovial membrane and were often pi~
mented with hemosiderin. Villonodular synovitis in human:
therefore, should not be confused with enlargement of th
synovial pads of the equine metacarpophalangeal joint.
Classically,the condition was initially demonstrated wit:
contrast arthrography, and it has been treated successful
with arthrotomy (Nickels et al1976, Haynes 1980). Neithe
contrast arthrography nor arthrotomy is used anymorc
because of the development of ultrasound examination i
diagnosis (Steyn et al1989) and arthroscopic surgery as th
treatment technique. The synovial pad of the metacarp(
phalangeal joint is a fold (plica) of fibrous connective tissu
located in the proximal recess of the dorsal compartment (
 the metacarpophalangeal joint at the joint capsule attach-
ment to Mcill. The synovial pad is normally 2-4 mm in
thickness and tapers to a thin edge at its distal border (White
1990). Its function is unknown, but its structure and location
suggestthat the pad acts as a contact interface or cushion
betweenthe proximal dorsal rim of the proximal phalanx and
the dorsal surface of distal third metacarpal bone (Mcill)
during full extension of the fetlock joint (White 1990).
Repetitive trauma during fast exercise can result in irritation
and enlargement of the synovial pad and development of
clinical signs of lameness and chronic joint effusion that
often resolves temporarily with rest and intra-articular
medication. There is commonly radiographic evidence of
bone remodeling, with a concavity at the distal dorsal aspect
of Mcill, and this is suggestive of synovial pad proliferation
(Fig. 5.34A). Ultrasound is now the method of choice to
further define this proliferation (Fig. 5.34B). Although this
condition is commonly seenin the racehorse, it has been seen
in other horses not subjected to fast athletic exercise (loSasso
& Honnas 1994), and in the previous edition of this text, a
contrast-enhanced view of the disease in a mule was
presented.
The medical records, radiographs, and ultrasound
examinations have been reported in 63 horses with
metacarpophalangeal joint synovial pad proliferation
(Dabareiner et aI1996). All the horses had lameness. joint
effusion. or both of these clinical signs. associatedwith one or
both metacarpophalangeal joints. Bony remodeling and
concavity of the distal dorsal aspect of McIII immediately
proximal to the metacarpal condyles was identified by radio-
graphy in 71 joints (93%) (Fig. 5.34); 24 joints (32%) had
radiographic evidence of a chip fragment located at the
proximal dorsal aspect of the proximal phalanx. Fifty-four
joints (71%) were examined by ultrasound. The mean:t SD
sagittal thickness of the synovial pad was 11.3 :t 2.8 mm.
(The authors also reported that the synovial pad was
considered abnormal if the thickness was greater than 4 mm
on the sagittal view. the distal margin was rounded. or hypo-
echoic regions were observed within the pad.) Seventy-nine
percent of the horses had single joint involvement. with equal
distribution between the right and left forelimb. In addition to
pre-surgical diagnosis of this condition. it is also quite
common to encounter thickened and enlarged synovial pads
at arthroscopic surgery (usually when doing the surgery for
removal of a proximal dorsal fragment from the proximal
phalanx) (Mcllwraith 2002).
The surgical approach used when operating on horses
with this condition arthroscopically is illustrated in Figure
5.35. The authors in most cases use a single instrument
approach. A two-instrument approach has also beendescribed
 sometimes be noted when the indication for arthroscopic
surgery was originally the removal of fragments. Conversely.
fragments may be encountered off the proximal dorsal aspect
of the proximal phalanx at the time of arthroscopic surgery
for removal of a proliferated pad when the fragments
were not visible with pre-surgical radiographs. Obviously,
a complete examination of the dorsal pouch is done with any
of these arthroscopic procedures and lesions appropriately
dealt with.
In a report of 68 joints in 55 horses treated by arthroscopic
surgery, 60 joints (88%) had debridement of chondral or
osteochondral fragmentation from the dorsal surface of the
distal metacarpus beneath the synovial pad (more frequently
done than by us) and 30 joints (44%) had a bone fragment
removed from the medial or lateral proximal dorsal eminence
of the proximal phalanx (Dabareiner et alI996).
Arthroscopic laser extirpation of metacarpophalangeal
synovial pad proliferation has been described in 11 horses
(Murphy and Nixon 2001). Elevenclinical caseswere operated
on in this fashion and followed up. All were treated by intra-
articular laser extirpation using either CO2 or an Nd:YAG
laser with arthroscopic guidance. Mean synovial pad
thickness, measured ultrasonographically, was 9 Inm, and 7
(64%) of the horses had radiographic evidence of remodeling
of the dorsal cortex of distal McIIl; 3 horses (27%) had con-
current dorsal proximal fractures of the proximal phalanx.
All 11 horses returned to training within 90 days of surgery
without recurrence of the lesion. Nine horses (82%) sustained
race training and apparently improved their performance
(Mcllwraith 1990a. 2002). With the arthroscope in the lateral following surgery based on follow-up conversation with the
portal. the instrument portal is made medially. Dabareiner et al owners. The use of the CO2 laser requires gas distention of
(1996) considered excision of a portion of the synovial pad to the joint. The authors cited advantages with the laser tech-
be necessary if it was enlarged and inelastic when probed nique that included their ability to be used arthroscopically,
during surgery or if hard nodules could be felt within the pad. better visualization of the joint, better access to lesions on
The mass can sometimesbe torn off by using grasping forceps both sides of the sagittal ridge, reduced convalescence time,
that have a cutting edge(Fig. 5.36A and B). Alternatively, the and better cosmetic and functional results. However, with our
mass can be severed at its base by using a flat knife (Fig. current abilities at conventional arthroscopic surgery, it is
5.36C and D) (see Chapter 2). Disposable scalpel blades questionable if these advantages exist anymore.
should not be used because they may break within the joint. Postoperative management in casesinvolving proliferative
After severing the base. the proliferated pad is removed with synovitis treated arthroscopically is the same as for those
Ferris-Smith rongeurs (Fig. 5.36E) and the base trimmed involving chip fragments of the proximal phalanx. Horses
with basket forceps or a motorized resector. Proliferation of that have synovial pad proliferation without articular
the synovial pad is more common medially than laterally cartilage loss or proximal phalangeal fragments can return to
and. consequently. surgery often involves removal of the racing in 8 weeks, whereas horses with more extensive
medial portion alone. However, examination should be made cartilage damage or more significant proximal dorsal frag-
to ensure that there is not similar proliferation in the lateral mentation of the proximal phalanx should get 3-4 months
portion. If there is. the arthroscope is placed medially and the before training is resumed.
instrument laterally to remove the lateral portion. In one Follow-up on 50/55 horses was obtained for the previously
report in the literature. complete or partial excision of both cited study of Dabareiner et al (1996): 43 (86%) horses that
medial and lateral synovial pads was achieved in 42/68 joints had surgery returned to racing, with 34 (68%) racing at an
(Dabareiner et al1996). The medial synovial pad only was equivalent or better level than before surgery. Horses that
excised or trimmed in 21 joints and 5 joints had removal returned to racing, at a similar or equal level of performance
limited to the lateral pad. were significantly younger than horses returning at a lower
Once the pad is removed, there may be some full-thickness level or not racing. In contrast, the same authors reported
erosion with minor debris where debridement is indicated 8 horses (8 joints) with synovial pad proliferation and
(Fig. 5.36F). More commonly. the bone is left alone. but if remodeling of the distal dorsal aspect of McIIl being treated
there are any elevated cartilage tags. these are trimmed. As medically at the owner's request. Intra-articular sodium
has been previously noted. enlarged. thickened pads will hyaluronate was administered intermittently in these
Arthroscopic Surgery of the Fetlock Joints

8 horsesand systemicnonsteroidalanti-inflammatorymedi-
cations were also administeredfor variable periods.Three
(38%)of the medicallytreatedhorsesreturnedto racing and
only 1 horseracedbetterthan the pre-injury level.
Treatment of other forms of
proliferative synovitis
Occasionally, forms of proliferative synovitis that are not
localized to the dorsoproximal aspectof the joint are seen(see
Chapter 3). Typically, these casespresent as chronic synovitis
and capsulitis that is non-responsive to symptomatic intra-
articular or systemic anti-inflammatory treatments. In some
cases, diagnostic arthroscopy has revealed proliferated,
thickened, and enlarged synovial villi in the dorsal
compartment of the metacarpophalangeal joint (Fig. 5.37).
The treatment has been resection of these villi, and the
overall results have been good.
Treatment of osteochondritis dissecans
of the distal dorsal aspect of Mc111/Mt111
in the metacarpopharangeal and
metatarsophalangeal joints
There is a divergence of opinion as to what is considered
osteochondritis dissecans (OCD)within the fetlock joint and
also those entities that might be considered to be appropriate
to include in the term developmentalorthopedic disease
(Mcllwraith 1993). It is undisputed that OCD of the dorsal
aspect of the distal McIII and MtIII is a manifestation of OCD
and this is the condition described below. The condition was
initially described as OCD of the sagittal ridge of the third
metacarpal and metatarsal bones (McIII/MtIII) (Yovich et al
1985). but this term has been modified after recognition that
the diseaseprocess commonly extends onto the condyles of
MclII and MtlII (Mcilwraith & Vorhees 1990). These cases
were evaluated and treated on the basis of having clinical
signs; the problem was assessedin 65 horses (Mcilwraith &
Vorhees 1990). In one radiographic study, OCD changes on
the dorsal aspect of the sagittal ridge of MclII or MtIII was
seen in 118/753 yearling Standardbred trotters with 61
forelimbs and 147 hind limbs affected (GroendahI1992).
Fragments from the proximal palmar/plantar margin of
the proximal phalanx have also been reported as osteochon-
drosis (Foerner 1987, Nixon 1990), but it is not now generally
accepted that osteochondrosis is the pathogenesis. The
treatment of this condition is described later in this chapter.
The third condition described as OCD are proximal dorsal
fragments of the proximal phalanx in young horses. While
these fragments, at least in racehorses, have long been
consideredto be traumatic in origin, there is evidence some of
these fragments having an osteochondrosis basis, at least
when they present in yearlings. The treatment of these con-
ditions is also described in this chapter. Dorsal bony
fragments in the metacarpo- and metatarsophalangeal joints
were diagnosed in 36 (4.8%) of 753 yearling Standardbred
trotters on a radiographic survey (Groendahl19 92) and were
seen in 34 forelimbs and 14 hind limbs. A fourth condition
initially described as OCDof the palmar metacarpus (Hornoff
et a11981) is now accepted to be a traumatic entity and not
a syndrome of osteochondrosis. It will not be considered
further here, as it is not an arthroscopic surgical condition.
Osteochondritis dissecans of the distal dorsal aspect of the
MclII/MtlII can occur in both metacarpo- and metatarso- !
phalangeal joints, but it is more common in the latter. The.'
lesions vary in their radiographic manifestations, from a I
subchondral defect to defects associated with fragments;
(Fig. 5.38). In some cases,fragments break away completely
from the primary lesion and become loose bodies. The
presenting clinical signs include synovial effusion of the
fetlock joint with or without lameness.The horses are usually
yearlings (Yovich et al1986). In most instances, the patients
are weanlings to yearlings and quite often are presented for
treatment prior to sale. In some instances, training and
racing may have occurred before the symptomsdevelop.
Although the degree of lameness varies, a positive response
to a fetlock flexion test is usually elicited, and radiographs i
confirm the presence of lesions associated primarily with the
sagittal ridge of MclII/MtIlI. ;
For purposes of treatment decision and prognosis, the j
lesions have been divided into three types:
.Type I is that in which a defect or flattening is the
only visible radiographic lesion
.Type II is that in which fragmentation is associated
with the defect
.Type III is that in which there is a defect or flattening
with or without fragmentation plus one or more
loose bodies.
Oblique radiographs should be taken as well as dorsopalmar
(plantar) and lateral/medial radiographs for the purpose
of discerning the medial or lateral condyles of MclII/MtlIl
(Mcilwraith & Vorhees 1990). Based on an initial study
Fig. 5.38
Examples of the radiographic appearance of osteochondritis
dissecans (OCD) of the fetlock joint (A) Type I OCD of the
midsagittal ridge of the metatarsophalangeal joint. (B) Type II
OCD. (C) Type III OCD.
Yovich et al19 85), it was felt that Type II and Type III OCDesions
should be treated surgically and many Type I lesionsrvould
resolve, In a second study of 15 cases with Type Iesions
that were treated conservatively, 12 resolved clinicallymd
8 of these showed remodeling of the lesions with
mprovement on radiographic examination (Mcilwraith &torhees
1990), In 3 casesthe clinical signs persisted: in 2 of
hese, the radiographs showed no ch~nge and the horses
:ventually underwent surgery, whereas, in the other case,the
:linical and radiographic signs progressedand the horse was
lot operated on,
In 8 cases of Type II lesions where owners requested:onservative
management, 2 eventually underwent surgery)ecause
of the persistent clinical signs, Clinical signs)ersisted
in 5 others, but surgery was not performed, The
:linical signs improved in only 1 horse, In most of these casesrvhere
clinical signs persisted, the fragmentation also)rogressed
radiographically. It was also clear in this study
:hat clinical signs of effusion may appear before definitive:adiographic
changes. Progression of someType I lesions wasloted:
such casesdo not develop osseous fragmentation, but:he
lesions progress to become larger defects, particularly on:he
condyles (seen on oblique view radiographs). Some cases
Jf Type II lesions improved radiographically. These were
~enerallycaseswith small fragments that fused to the parent-Jone
such that a spur resulted.
Based on the above knowledge, arthroscopic surgery is;onsidered
the appropriate treatment if fragments are
~resent (Type II and III lesions). In other cases in which a
lefect only is detectable radiographically, the decision for
;urgery is based on the degree of clinical signs, the size and
ocation of the defect, and the planned use of the horse.
The arthroscopic approach is the same as that forragments
off the proximodorsal aspect of the proximal
Jhalanx or synovial pad proliferation, using a proximally or
listally placed instrument portal, depending on the location
Jf the fragment or loose body (seeFig. 5.39). When operating
In metatarsophalangeal joints, an effort must be made tolchieve
complete extension. In some cases,the OCD lesionllanifests
as a defect within the sagittal ridge (Fig. 5. 40A and
B),and curettage is performed. More commonly, osteochondralragments
may be within the defect or have loose attach-llents
to the area (Fig. 5.40C-E). In these cases,the fragment
s removed and any defective articular cartilage is debrided:Fig.
5.40F). Loosefragments are located and removed (usually
with Ferris-Smith rongeurs). As mentioned previously,Ilndermined (Fig. 5.43B). But in most instances. there will be a rounded
cartilage may extend medial and lateral from the fragment (Fig. 5.43C and D). Rarely,extensive fragmentation
,agittal ridge of McIlI and MtlII, and it must also be debrided.JCDmay be present (Fig. 5.43E-G).
can also occur on the metacarpal or metatarsal condyles:Fig. Aftercare in these casesis the same as for a chip fragment
5.41). Type III lesions are treated with fragment removalmd off the proximal dorsal aspectof the proximal phalanx. Many
debridement (Fig. 5.42). of these horses are young and therefore have long periods for
Diseaseand fragmentation of the proximal dorsal aspectofthe convalescencebefore being put into training.
proximal phalanx typical of OCDis seenquite commonlyIn The prognosis is based on the appearance of the joint
young horses. The radiographic manifestations are of a during surgery as well as on the age of the horse. If there is
,mall fragment on the proximal dorsal aspect of the proximal no other damage or only a minimally sized defect in the
phalanx (Fig. 5.43). The arthroscopic manifestations can sagittal ridge, the prognosis is good. Follow-up data reveal
vary, as illustrated in Figure 5.43. In some instances, there that when extensive lesions extend medial or laterad from the
will be a flap with diseasedbone underneath, typical of OCD sagittal ridge or distad to involve the loaded area of the

articulation. clinical problems may arise when the horse
engages in athletic activity.
In a series of 42 horses that were operated on with
arthroscopic surgery. there were a few Type I lesions (usually
operated on as they had not responded to conservative
treatment or if an individual joint in a horse being treated for
a Type II or Type ill lesion happened to have a Type I lesion).
Forty-two horses in this series reported included 20
Thoroughbreds. 8 Quarter Horses. 7 Arabians. 4 Warmbloods.
1 Standard bred. 1 Percheron. and 1 Appaloosa (McIlwraith
& Vorhees 1990). Forelimbs were involved in 10 horses. hind
limbs were involved in 15 and both fore and hind limbs were
involved in 17 horses. One fetlock joint was operated in 10
horses. 2 fetlocks in 17 horses. 3 fetlocks in 1 horse. and
4 fetlocks in 14 horses. Forty-eight cases involved the
proximal 2 cm of the sagittal ridge. where 11 extended distal
to this point. In 44 instances. lesions involved the lateral
and/or medial condyles of the metacarpus or metatarsus.
with or without lesions of the sagittal ridge.
Of the 42 horses operated on. follow-up was obtained in
28. eight horses were convalescing and in 6 the follow-up
was unavailable. Surgery was successfulin 16 (57.1 %) of the
28 cases and 12 were unsuccessful (42.8%). Of the 12
unsuccessful cases. 7 were still considered to have a problem
in the fetlock joint (25%): 3 were unsuccessful for other
reasons; 1 was unsuccessful for unidentified reasons but was
considered to be normal in the fetlock joint; and 1 horse died.
The successrate was also found to be related to other factors.
There was a trend for the successrate to be higher for surgery
in hind limbs compared to forelimbs. On the one hand. in the
forelimbs only 2 cases were successful and 6 were un-
successful.whereas in the hind limb 7 were successfuland 3
were unsuccessful. When both fore and hind limbs were
involved. there were 7 successesand 3 failures. Type III
lesions had 4 successesand 4 failures. whereas Type II lesions
had 10 successesand 4 failures (difference not statistically
significant). Only 3/12 cases with erosions or wear lines
present at arthroscopy were successful. whereas 13/16 with
no erosions were successful (p = 0.0029). Probably related to
that. there was a significantly inferior result when a defect
was visible on the condyle on oblique radiographs. When a
defect was visible. 6/13 were successful. whereas if a defect
was not visible. 10/15 were successful (p = 0.0274). Osteo-
phytes were also negative prognosticators (3/9 with osteo-
phytes on the proximal phalanx were successful. whereas
13/19 with no osteophyteswere successful). I
It was concluded that surgical management of Type II and '
Type III lesions will allow athletic activity in a fair number of
cases. but clinical signs will persist in 25%. Whether the
surgery will be successfulor not will be affected by the extent
of the lesions. as evident arthroscopically (and in some
instances. radiographically). as well as by the presence of
osteophytes.erosions. and wear lines. Since the Mcllwraith &
Vorhees (1990) paper was published. the first author feelsthe
success rate has improved further because of earlier
intervention and. particularly with radiographing horses at a
young age to ensure clean joints at yearling sale.
Debridement of subchondral cystic
lesions of the third metacarpal bone
The distal Mclll is one of the less common locations for
subchondral cystic lesions. but they do occur with relative
regularity (Nixon 1990, Mcllwraith 1990b). Most horses are
aged 2 years old or less when clinical signs become apparent
and they usually have a history of recently increased physical
activity (such as entering athletic training). The diagnosis is
confirmed with radiographs (Fig. 5.44A and B). As with most
subchondral cystic lesions. they occur in a location subject to
maximal weightbearing during the support phase of the
stride. Once a cystic lesion becomes clinically apparent. the
prognosis for athletic soundness is variable and appears to
be dependent on several factors. including the anatomic
location of the lesion. the presence of any associated
degenerative changes in the joint and the treatment regime
(surgical or conservative) chosen (Bramlage 1993).
Prior to the use of arthroscopic surgery. most caseswere
managed conservatively and empirically and with limited
success (Mcllwraith 1982). If conservative therapy was not
successful. a dorsal arthrotomy was recommended surgically
to debride the lesion and this technique has been more
recently replaced by arthroscopic surgery. The technique is
less invasive and provides the advantage of clear visual
assessmentof the articular surfaces of the joint.
The arthroscopic approach depends on the location of the
cystic lesion. The majority of lesions are on the medial
condyle of the distal metacarpus. in which case the arthro-
scopeand the instrument are both placed medially (Fig. 5.45).
In order to expose the opening of the subchondral cystic
lesion. flexion is required. and so having the arthroscope on
the same side obviates the potential problem that flexion
creates (sagittal ridge interfering with the arthroscopic
position). The arthroscope is placed laterally for a cystic lesion
on the lateral condyle or the sagittal ridge. With flexion. the
opening of the cystic lesion can be visualized (Fig. 5.44). A
needle is used to ascertain the ideal position for debridement;
this tends to be distal and axial over the cystic lesion. The
cystic lesion is then debrided with a curette and pieces
removed with forceps. The cartilaginous edges are trimmed
and debris removed by flushing. Drilling of the cystic lesion is
no longer performed.
A 4-6-month lay-up period is recommended with these
cases.The initial 2 months involve stall confinement with a
program of hand walking. A seriesof caseshave beenreported
(Hogan et al1997) and serve as a basis for prognosis. Sub-
chondral cystic lesions (SCLs) in the distal McIIl were
surgically treated in 15 horses. The median age at presen-
tation was 18 months (range 10 months to 12 years) with
lOllS horses less than 2 years old. The SCLswere confined to
the front limbs in all cases. with two horses having bilateral
lesions. Lesions were isolated to the medial condyle of McIIl
in 13 I 15 horses; a cystic lesion occurred in the lateral condyle
in 1 horse and in the sagittal ridge in another. One horse with
bilateral lesions had an additional cystic lesion located in the
right medial femoral condyle. Fourteen of 15 horses had a
history of moderate lameness attributable to the metacarpo-
phalangeal joint; the lesion was an incidental finding in
1 horse. Duration of lameness ranged from 4 weeks to
8 months and was either acute in onset or occurred inter-
mittently and was associated with exercise. Fetlock flexion
significantly exacerbated the lameness in all cases. Synovial
effusion was absent in 8 (53 %) of cases.
Cystic lesions were curetted arthroscopic ally in 12 horses.
and through a dorsal pouch arthrotomy in 3 horses.
Concurrent osteostixis of the cystic cavity was performed in 7
of the horses. 12/15 horses (80%) were sound for intended
usefollowing surgery. 2 horses did not regain soundnessand result of fracture rather than a manifestation of osteo-
follow-up information was unavailable in 1 horse. The total chondrosis.
period of follow-up was 1-6 years. Follow-up radiograph The principal radiological sign is that of a fragment
examinations were available for 9 horses. Mild periarticular located between the base of the sesamoid bone and the
osteophyte formation and enthesophyte formation at the proximal aspectof the proximal phalanx; it is usually halfway
dorsal joint capsular attachments was present in 5 of the between the sagittal groove and the lateral or medial
9 horses.Bony infIlling of the cystic lesion was detectable in eminence of the first phalanx and is not always associated
8 horsesand enlargement of the cystic cavity was observed in with a defined defect on the first phalanx. Although initially
1 horse. Based on this study, it would appear that surgical the condition was considered peculiar to the Standardbred
treatment of SCLs in the distal McIlI should result in a (Pettersson & Ryden 1982), cases occur in Thoroughbreds
favorableoutcome for athletic use (Hogan et al1997). and the condition is reasonably common in Warmblood
breeds.
Typically, the horses will be admitted with a history of
Removal of axial osteochondral lameness. Lameness at examination will be mild and.
fragments of the proximal commonly, the history is that of subtle lameness reported by
palmar or plantar aspect of the the trainer and manifested at high speed as a rough gait or
proximal phalanx break in stride (Fortier et al199 5). In one series of casesof 82
horses receiving lameness examination at admission. 17
These fragments, described as Type 1 osteochondral frag- (21 %) horses had slight to moderate positive results on hind
ments of the palmar-plantar aspect of the fetlock joint limb flexion. Synovial effusion of the metatarsophalangeal or
(Foerner 1987), were initially reported as chip fractures metacarpophalangeal joint was reported in 19/119 (16%) of
(Birkeland 1987) and avulsion fractures (Pettersson& Ryden horses; 155/164 (95%) fragments were in the metatarso-
1982). Since that time, Foerner (1987) suggested that this phalangeal and 9/164 (5%) involved the metacarpophalangeal
condition is another manifestation of osteochondrosis based joints. The medial plantar eminence of the proximal phalanx
on its incidence and age of occurrence of the fragments. was the location of 114/164 (70%) fragments. Bilateral frag-
However,more recent publications have argued for a traumatic ments were observed in 21 (18%) horses. whereas 15 (13%)
etiology.Hind limb fetlock joints with plantar osteochondral horses had concurrent medial and lateral lesions within the
fragments were collected from 21 horses (17 Standardbred same joint. Standardbred racehorses represented 109 (92%)
trotters, 4 Swedish Warmblood riding horses) and the of those affected (Fortier et al 1995). In another series of
morphology of the osteochondral fragments in adjacent 26 cases.23 of the horses were racing Standard breds and 3
tissues studied by dissection, high-resolution radiography, were racing Thoroughbreds (Whitton & Kannegieter 1994).
andhistology (DaIin et al 1993). The fragments were attachedto The most common reason for presentation in this series was
the short s~samoidian ligaments and had a smoothcartilage an inability to run straight at high speeds. Only 8 horses
coverin'g on the surface facing the joint cavity. presented for lameness. although on examination, 19 were
Histologydid not show any evidence of osteochondrosis. Theauthors lame. A positive flexion test was recorded in 90% of affected
suggested that plantar osteochondral fragments arethe fetlock joints and effusion was present in 48%.
result of an outwardly rotated hind limb axis and sub- To be considered a surgical candidate, the patient must
sequent point loading in the medial fetlock area. Repeated have demonstrable lameness referable to the fetlock, in
high tension loads in the short sesamoideanligaments maycause addition to a radiographically demonstrable fragment
fragments of tissue with osteogenicproperties to avulse (Fig. 5.46). The fragment can be identified on the lateral and
from the proximal phalanx into the ligament, later forming flexed lateral views. Dorsoplantar radiographs taken with the
osteochondralfragments. This pathogenesisdoes not accountror fetlock flexed have also beenrecommended (Birkeland 1972),
lateral fragments, which also occur occasionally. Other but the authors have not used this technique. For optimal
work by the same authors had shown that plantar osteo-chondral definition of the location of the lesion. however, a special
fragments most often occur in the hind limbs andare oblique view with the tube at a 300 angle distad is useful
more frequently in the medial part of the joint (Sandgren (Fig. 5.46B). Both oblique views are essential as lesions can
~t al 1993). It has also been demonstrated that thesefragments be biaxial.
develop early in life and are often possibleto detect Non-surgical treatment usually lowers the horse's
~yradiography before 3 months (Carlsten et aI1993). performance (Barclay et al 198 7). Arthroscopic surgery is
A second study had beendone on osteochondral fragmentsrom now the standard technique. Dorsal or lateral recumbency
the axial proximoplantar/proximopalmar region of the can be used. The authors prefer dorsal recumbency as the
?roximal phalanx in 38 joints in 30 horses: 28/30% of thelorses instrument portal can conveniently be made laterally or
were Standardbreds and 28/30 had a low-gradeameness. medially. However. some flexion of the joint from an assistant
All but one of the horses had hind limb involve-Dent.may be required. If the surgery is done in lateral recumbency,
Of 143 fragments removed, 71% involved the medial the side where the fragment is located should be up and the
lspect of the joint and had to be dissected from a covering of:ynovial
arthroscope and instrument approaches will be made from
tissue (Nixon & Pool 1995). The histologic appear- the same side. The arthroscope is placed in the plantar orpalmar
Lncein these cases suggested that these fragments were a joint pouch. as previously described. after distending
 \
The arthroscopeis positionedto visualizethe distal
the joint; an assistantmay facilitate this step by
flexion on the joint. After assuring the correct
portal is made distal to the arthroscopic
, .5.47). The portal is made so that the
comes across transversely. Often, the fragment
can aid visualization.The fragment
separatedfrom the soft tissue with a knife and is
by using a Ferris-Smithcup rongeur (Fig 5.48).
of this fragment leavesa defect within the joint
and short-digital sesamoideanligaments,and any
--
plantar defect in the normal phalanx is
appropriatebut is not usually necessary.Figure
and Figure 5.50 illustrates medial and lateral
condition is one of the few in equine arthroscopic
for which the use of sharp dissectionis essential.
used,including a tenotomy
knife. a banana knife. a narrow bistoury. and an Arthro-
LokTMretractable blade. We prefer a broad. flat blade. The
disposable No. 11 blade should not be used because of the
risk of breakage. Electrocautery probes have been used more
recently for this dissection (Boure et al1999).
The immediate postoperative care is the same as for other
arthroscopic procedures in the fetlock joint. A period of
2-3 months rest before training resumes is recommended.
There have been two reports of treatment of these osteo-
chondral fragments with follow-up. Whitton & Kannegieter
(1994) reported on 21 horses.in which 16 horseshad returned
to racing: 12 horses had improved their performance. while 3
horses showed no improvement. and 1 horse was retired for
other reasons. Degenerative changes within the fetlock joint
were detected at surgery in 8 horses. Four horses were treated
conservatively: 1 horse returned to its previous level of
performance temporarily after intra-articular medication.
1 horse showed no improvement. and 2 horses were resting
at the time of the report.
A larger case series of 119 horses (109 Standardbred
horses)had follow-up in 87 racehorses and 9 non-racehorses
(96). In 55/87 (63%) racehorses and 100% of 9 non-
racehorses,performance returned to preoperative levels aft
surgery. Fragment numbers or distribution and concurre
OCD of the distal intermediate ridge of the tibia or tars
osteoarthritis were not significantly associatedwith outcom
Abnormal surgical findings, consisting of articular cartila:
fibrillation or synovial proliferation, were significant
(p <0.001) associated with adverse outcome: these findin
were documented in 31 % of the 32 horses without success
outcome and only 2% of the 55 horses with successfulou
come (Fortier et al1995).
Arthroscopic excision of these fragments has bel
describedin 23 Standardbred racehorsesusing electrocaute
probes (Simon et al 2000). A 1.5% glycine solution in i
Arthropump was used to maintain joint dissectio
Transection was performed using loop probes alone (
alternatively, with hook electrocautery probes to dissect tI
fragment free prior to Ferris-Smith rongeur removal. Thirt
five fragments in 28 joints were removed from either the 11
or the right hind limb in 23 Standardbred racehorses. Six hi
biaxial fragmentation. An ipsilateral (n = 9) or contralater
(n = 26) triangulation approach was used. The autho
concluded that the loops and probes can be safely used
excise osteochondral fragments of the plantar proxim
phalanx. They considered dissection using electrocaute
probes to be more precise and easier to perform than tI
previously described sharp dissection technique. No folIo,
up was given. It has since been recognized that glycine is n
necessary for this procedure.

Removal of fragments of the proximal

sesamoid bones
Osteochondral fractures amenable to removal occur at tl
apical, abaxial, and basal margins of the proximal sesamo
bones. Arthroscopic techniques for the removal of the
fragments have been developed. Previous dogma had pr
posed limitations of fragment removal based on the size
the fragment and the degree of attachment to the suspenso
and distal sesamoidian ligaments. However, current folio,
up on the first author's cases that have been treated arthr
scopically suggest that limitations should be redefined. i
a generalization, the hypothesis that the prognosis w
decrease with greater involvement of both bone and s(
tissue attachments is still valid. but the actual proportions a
higher than previously thought.
The diagnosisof sesamoidfractures is made radiographicaJ
(Fig. 5.51) and special views are used to clearly delineate tl
abaxial involvement. Arthroscopic surgery for the removal
sesamoid fragments is performed with the horse in eith
lateral or dorsal recumbency (the authors prefer the latteJ
The technique for an apical sesamoid fragment is illustratl
in Fig. 5.52. The arthroscope is placed in the most proxim
portion of the palmar or plantar pouch of the fetlock joint
all cases. With partial flexion of the joint, a needle is used
ascertain the ideal placement for the instrument portal. T]
instrument portal can be ipsilateral or contralateral, aJ
both techniques are illustrated in Figures 5.53 and 5.5
 Sharp dissectionis used to separatethe apical
from the suspensoryligament using a flat blade.
.blade (Foerner-Scanlanelevator)is used to
the abaxial attachment (seeFig. 5.53).
of the fragment, it is removed with Ferris-
(see Fig. 5.53). Soft tissue attachments are
with basket forceps or a motorized resector. The
debrided with a curette. Fragmentation of apical
-more than 1/3 of the articular surface
considered ideal candidates for surgery. Apical
fragments in foals can be treated in the same
5.55).
arthroscopic approach is used for surgery on
fragments. Case selection can sometimes be a
-~ radiographs (Fig. 5.56) do not clearly
an abaxial fracture as articular. then a "skyline"
'. view should be taken (Palmar 1982).
approach is illustrated in Fig. 5.57. Sharp
dissection with the flat blade is limited to severing the
suspensory ligament attachments (see Fig. 5.56C). It is
important that the instrument portal is made appropriately
distad so that the knife can sever the suspensory ligament
attachments from the abaxial fragment. After removal. the
bone and cartilage are debrided with a curette. A motorized
resector is used to debride the suspensory ligament tags.
Fragmentation of both the apex and abaxial region of the
sesamoid bone can occur concomitantly (Fig. 5.58). The
arthroscopic technique for these fragments is the same as for
removing them independently. Generally. the abaxial
fragment is removed first. followed by the apical fragments
(Fig. 5.58B-D).
Basal sesamoid fragments are candidates for arthroscopic
removal when no other pathologic changes are present
in the fetlock joint (at least on radiographs) (Fig. 5.59). A
reasonable number of fragments are of sufficiently small
size that their removal does not compromise the distal
sesamoidian ligament attachments. The exact size limitations
have recently been defined (Southwood et al 1998).
'hetechnique is illustrated in Figure 5.60. Both ipsilateralnd horses raced after surgery. Small fragments were classified
contralateral arthroscope and instrument positions areossible.
with a proximodistal length less than 10 mm or less than
The arthroscope is placed in the same fashion as for 25% of the sesamoid bone, and large fragments had a
llrgery on apical and abaxial fragments. The instrument is proximodistallength more than 10 mm or more than 25% of
rought in below the base of the sesamoid bone. Sharp the sesamoidbone (Southwood et al2000).
issectionis used to sever the fragments from the capsularnd In a series of 47 cases of arthroscopic removal of abaxial
distal sesamodian ligament attachments. The defects are fragments from the proximal sesamoid bone. follow-up
len debrided (bone and soft tissue) and the joints lavaged~ig. information was obtained for 41 horses (35 racehorses. 6
5.59 and 5.61). non-racehorses). Twenty-five of 35 (71%) racehorses were
The resultsof apical, abaxial, and basal sesamoidfragments, able to return to racing (16 in the same class, 9 in a lower
~spectively,have been documented recently. On reviewingle class); all 6 non-racehorseswere able to return to performance
results of 82 cases of apical fractures of the proximal~samoidat the same level. Horses with small fracture fragments or
bone of horses, follow-up data were obtained for 54~cehorses:
fractures involving the abaxial surface of the proximal
36/54 (67%) horses returned to racing, 28 sesamoidbone only had a more favorable outcome compared
52%)in the same class and 8 (15%) in a lower class; 14/18 with horses with large apical-abaxial fractures (Southwood
78%)horses with small apical fractures returned to racing,1 et aI1998).
in the same class and 3 in a lower class. 11/19 (58%) withIrge There were 10 (21 %) Grade 1 fractures, 23 (49%) Grade 2
apical fractures returned to racing and all raced in thewe fractures and 14 (30%) Grade 3 fractures. All 5 horses with
class; 11/17 (65%) horses with apical-abaxial fractures~turned
Grade 1 fractures returned to racing (4 in the same class and
to racing, 6 in the same class and 5 in a lower class. 1 in a lower class).Twelve of 18 horses with Grade 2 fractures
ic the horses that had raced before surgery, 33/40 (83%) returned to racing (9 in the same class and 3 in a lower class).
Eight horses with Grade 3 fractures returned to racing (3 inthe
same class and 5 in a lower class). Four racehorses had
not raced prior to surgery; 2 of these horses raced after
surgery.and 2 did not race before or after surgery. Compared
with horses with large fragments. horses with smallfragments
returned to racing in the same class more often;
however.the differences were not significant.
The results of arthroscopic removal of fracture fragments
involving a portion of the base of the proximal sesamoidbone
have also been reported (Southwood & Mcilwraith 2000).
There were 24 racehorses and 2 non-racehorses. Twelve
(50%) of the racehorses returned to racing and started in at
least2 races; 8/14 of horses with Grade I fractures (~ 25% of
the base involved) and 4/10 with Grade n fractures (>25%.
but < 100% of the base involved) had a successfuloutcome;
10/16 without associated articular disease had successful
outcomes compared with 2/8 with associated articular
disease.However. fragment size and presence of associated
articular disease were not significantly associated with
outcomes (probably related to the relatively low numbers). It
wasconcluded that horses with a fracture fragment involving
a portion of the base of the bone removed arthroscopically
have a fair prognosis for return to racing.
Therehas also beena report of the use of electrocautery
probesin arthroscopicremoval of apicalsesamoidfracture
fragmentsin 18 Standardbredhorses(Boureet al 1999). The
fracture fragmentswere approachedthrough an ipsilateral
(3) or contralateral(15) arthroscopictriangulationtechnique.
Distentionof the joints was achievedusing a 1.5%glycine
solutionand the suspensoryand intersesamoidianligament
attachmentsto the abaxialand axial margins of the apical
fragmentweretransectedusing a hook electrocauteryprobe.
Subsequently.the palmar (plantar) soft tissue attachments
weretransectedwith a loop electrocauteryprobe.After being
freed of soft tissue attachments,the apical fragment was
removed with Ferris-Smith intervertebral disc rongeurs.
Eighteenapical sesamoidfragmentswere removedfrom the
left (8) and right (8) hind limbs and the left (1) and right (1)
forelimb. Apical fragments occurred in 15 lateral and 3
medial proximal sesamoidbones.It was proposedthat the
electrocauteryprobemade an easyand precisedissectionof
all softtissueattachments;10/14 horsesreturned to racing
(7/9 horsesthat racedbefore surgeryraced again and 3/5
horsesthat had not racedbeforesurgeryraced afterwards).
Figure 5.61G illustrates the use of an ArthrexTMelectro-
cauteryprobeto removea basalsesamoidbonefragment.
Axial osteitis of the proximal sesamoid
bones and fraying ofintersesamoidean
ligaments with detachment from
proximal sesamoid bone
Casesof this have beenrecognizedand treated arthroscopically.
Arthroscopic surgery in 5 cases (out of 8 seen) has been
reported (Dabareiner et al2001). Typically. the horses present
because of lameness and they mayor may not have synovial
effusion (6/8 in the casesreported by Dabareiner et al2001).
Two cases had diffuse cellulitis and effusion of the digital
flexor tendon synovial sheath. All horses had osteolysis of the
axial border of the proximal sesamoid bone on radiographs.
In 5 horses. arthroscopy of the palmar or plantar pouch of all
the metacarpophalangeal or metatarsophalangeal joint and
of the digital sheath was performed. In the remaining 3 horses.
only the palmar or plantar pouch of the metacarpophalangeal
or metatarsophalangeal joint was examined. Damage to the
intersesamoidian ligament was seen in all horses and
consisted of discoloration. fraying. and detachment from the
associated proximal sesamoid bone. Osteochondral fragmen-
tation and osteomalacia involving the axial borders of the
proximal sesamoid bone was also seen in all joints. After
debridement, the palmar or plantar pouch of the affected
joint communicated with the distal synovial sheath through
the disrupted ligament. Figure 5.62 illustrates the radiographic
and arthroscopic manifestations of such a case.
Follow-up information was obtained for all horses. All
5 horses without evidence of sepsisreturned to their previous
use with the median recovery time of 9 months. However,
one of these horsesremained Grade 1/5 lame and radiographs
obtained 1 year after surgery revealed secondaryosteoarthritis
of the affected metacarpophalangeal joint. Two horses were
radiographed 12 months after surgery revealing remodeling
of the sesamoid bones with a smooth contour to the axial
margins of the sesamoidbone.
Instances of focal bone disease involving the sesamoid
bones have been encountered elsewhere. The pathogenesisis
unknown, but areas of focal subchondral bone diseaseoccur
and have been treated with debridement of defective tissue
(Fig. 5.63).
Arthroscopically assisted repair of
lateral condylar fractures of the distal
Mclll and Mtlll
Arthroscopy allows an optimal means of assessing and
repairing lateral condylar fractures. The use of the arthroscope I
allows verification of articular alignment as well as ,
compressionof the fracture and a completediagnostic examin- i
ation of the joint. With correct technique. even displaced
fractures can be accurately reduced and repaired without a ':
large surgical exposure (Richardson 2002).
Arthroscopic Surgery of the Fetlock joints j§Z
cif!!D
 evaluation of the horse to detect axial

Fig. 5.64). A complete set of radiographs

dorsopalmar/dorsoplantar projections to

(CWM & IMW) perform surgery with the

recumbency while one (AJN) uses lateral
!\ tourniquet is not used. After surgical pre-
:lraping. needles are placed and a radiograph
,0 ascertain the ideal positioning of the screws
(Fig. 5.65). The fracture is inspected arthroscopically
(Fig. 5.66). An alternative technique for ascertaining the
position of the distal screw on the radiograph by bisecting an
imaginary line extending from the palmar/plantar wing o
the proximal phalanx to the palmar dorsal edge of the
condyle has been described by Richardson (2002). A No. 10
scalpel blade is used to make a 1 cm incision over the latera]
condylar fossa for the initial glide hole. A 4.5 mm glide hole is
drilled to the fracture plane (Fig. 5.67). A 3.2 mm hole is
drilled beyond this (Fig. 5.68) and. after light countersinking,
a 52 or 54 mm4.5 mm diameter cortical bone screw is placed
to compress the fracture (Fig. 5.69A). Additional screws
are placed proximally as appropriate for fracture length
(Fig. 5.69B & C). One author (AJN) prefers 5.5 mm diametel
screws for all condylar fracture repair. with 4.5 mm screws
occasionally used for the most proximal screw in a lon~
condylar fracture.
With displaced fractures it is important to not drill thf
glide hole into the parent bone. Large AO/ ASIF reductiolJ
forceps are used to reduce the fracture (Fig. 5.70). Thf
arthroscope is then placed in the dorsal pouch and used t(
monitor the reduction of the fracture. The forceps are place,
at or above the level of the physeal scar. Usually a combi.
nation of varus/valgus stress. dorsal flexion and sligh!
internal rotation reduces the fracture (Richardson 2002)
When reduction is perfect. the fracture is clamped again
It is important to ensure reduction of the fracture using ~
palmar arthroscopic examination as well. The palmar/plantaJ
approach is very useful in reducing displaced fractures. Th(
arthroscope can be advanced into the fracture gap to visualis(
and remove fragments inhibiting reduction. After reduction
screws are placed in the same fashion as described for ~
nondisplaced fracture. Figure 5.70 shows a displacedcondylaJ
fracture before and after reduction.
A second reason for the examination of the palmar 0]
plantar aspect of the joint is that varying degrees of con
comitant injury to the proximal sesamoid bones can OCCU
Debridement of cartilage erosion on the sesamoidfollowed bJ
microfracture may be necessary.Severedamage is considerel
a negative prognosticator. It is not possible to obtain a goO
examination of the distal palmar aspect of the metacarpus
Fragments and debris that result from distal palma]
comminution of the fracture are removed following elevatioI
with a probe or small curette. Prior to reduction. ever~
attempt should be made to remove comminuted fragment
from the fracture line in displaced fractures since this wi!
reduce the possibility of ideal fracture apposition.

Horses with non-displaced fractures typically have a
4-month lay-up period. Screw removal varies between
different surgeons but in general. only screws that cross
tubular corticesneed to be removed.There have beentwo
recentstudieson the prognosisfor lateralcondylarfractures
(Bassage& Richardson1998. Zekaset aI1999). Horseswith
non-displacedcondylarfractureshavean excellentprognosis
for returning to athletic function. The prognosisfor those
with displacedfracturesis poorer.
The study by Zekas et al (1999) correlated condylar
fracture characteristics and type of treatment with subsequent
capacity for athletic activity, as well as determining the
chacteristics of healing that affect prognosis after repair of
fractures of the third metacarpal/tarsal condyles; overall,
65% of horses started in a race post-injury, in a mean time of
9.7 months with a mean of 13.7 races post-injury. Having
raced pre-injury did not convert to an advantage to starting
post-injury, but non-starters, pre-injury tended to take longer
to return to racing. In horses starting pre- and post-injury,
66% improved or maintained their race class level after
surgery, whereas 64.2% decreased their race earnings post-
injury; 85% of the fractures received internal fixation, of
which 70% were complete fractures; 87% of horses with
incomplete-nondisplaced fractures treated conservatively
raced post-injury. The percentage of horses starting in a race
post-injury for incomplete nondisplaced, complete nondis-
placed, and complete displaced fractures treated with
internal fixation were 74%, 58%, and 50%, respectively.Colts
(72%) raced post-injury more frequently than fillies (53%)
and it was suggested that this may represent a truer
probability of starting in a race post-injury: 52% of horses
with articular fragments within the condylar fracture were
able to race post-injury.
Horses were more likely to start if radiographs at
2-4 months revealed no evidence of the fracture except the
presence of lag screws. Based on this series of studies, the
majority of horses with proper treatment were able to return
to racing regardless of the fracture characteristic. Prognosis
appeared to be affected by the severity of the injury to the
joint, the presence of articular comminution, and the quality
of surgical repair. There were 14/16 horses (87%) treated
without surgery that raced after a lay-up period.
This study was particularly interesting in that 58% of
complete nondisplaced fractures and 60% of horses with
complete displaced fractures were able to race post-surgery.
The authors concluded that the similar number of horses
racing in these two groups may indicate that a fracture being

complete is more of a factor in prognosis than the non-
displacement. if care is taken to reduce and fix the fracture
accurately.
References
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BassageLH. Richardson DW. Longitudinal fractures of the condyles
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McIlwraith CW Osteochondritisdissecansof the metacarpophalangeal
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Misheff MM. Stover SM. A comparison of two techniques for
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Raker CW: Calcification of the equine metacarpophalangeal joint
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joint and osteochondral fragments in the fetlock joints in
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16: 31-37.
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excision of osteochondral fragments of the proximoplantar aspect
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Southwood 11. McIlwraith CWoArthroscopic removal of fracture
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 .has become a most important technique
diagnosis as well as for surgery in the femoropatellar
femorotibial joints (Martin & McIlwraith 1985,
.c 1984,Folandetal1992.Nickels&Sande
, Moustafa et a11987, Lewis 1987, Walmsley 2002,
al 2003). Diagnostic and surgical arthroscopy
of the arthroscope into
femoropatellar joint
If both legs are involved, each leg should remain
postoperativefemoralnerveparesisor quadriceps
Alternatively,the legs may be elevatedand tied
that tensionis not concentratedon the quadriceps
The skin portal for the arthroscope is located between the
middle and lateral patellar ligament, and halfway between
the tibial crest and the distal aspect of the patella (Fig. 6.1).
This arthroscopic portal allows a complete diagnostic
examination of the femoropatellar joint as well as fulfilling all
needs for observation during surgical manipulations. An
8-mm stab incision is made through the skin, superficial fascia,
and deep fascia into the femoropatellar fat pad (Fig. 6.1B).
The sleeve and conical obturator are manipulated through
the stab incision in the skin and fascia and then angled 450 to
the skin in a proximal direction (Fig. 6.2). The femoropatellar
joint space is entered by gently manipulating the obturator
and arthroscope sleeveunder the patella and over the femoral
trocWea. This maneuver may be facilitated by elevation of the
distal limb. If resistance is encountered, the sleeve and
obturator are not forced but are directed more laterally to lie
under the lateral part of the patella facet and over the lateral
trochlear ridge of the femur. At this location. the patella can
be displaced further from the trochlear ridge. which allows
the sleeveto slide proximally more easily.
When the sleeveis positioned to the hilt. the obturator is
removed and is replaced with the arthroscope. The light cable
and ingress fluid line are attached and the joint is distended.Figure
6.3 demonstratesthe position of the arthroscopic sheath
at the completion of insertion and the diagrams in Figure 6.4
show the position of the arthroscope at the beginning of the
diagnostic examination.
Normal arthroscopic anatomy
The suprapatellar pouch is the first area of the joint visible
when the arthroscopic sleeveis situated beneath the patella
and rests in the intertrochlear groove (seeFig. 6.4). This area
is large. but the synovial membrane lining the pouch can be
visualized on all surfaces of the pouch. The proximal extent of
the suprapatellar pouch may be poorly illuminated with low
output light sources.
The articular surface of the patella and intertrochlear
groove can be visualized by withdrawing the arthroscope
from this position (Fig. 6.5). Specific examination of each area
can be achieved by rotating the arthroscope. The suprapatellar
pouch disappears from view as the arthroscope is withdrawn
and eventually the tension of the patellar ligaments abruptly
forces the arthroscope out from beneath the patella. At this
stage. the distal apex of the patella is visualized resting in the
intertrochlear groove (Fig. 6.6). A fringe of villous synovium
usually overhangs the distal margin of the patella.
Longitudinal defects are often observed in the central part of
the intertrochlear groove and apparently are normal.
particularly in the more distal regions of the groove.
The medial trochlear ridge and the medial aspect of the
distal patella can be visualized by rotating the arthroscope
and directing the angled field of view toward the medial
aspect of the joint (Fig. 6.7). Despite joint distention, thepatella
and medial trochlear ridge remain in close appositionin
this case, in contrast to the same area on the lateraltrochlear
ridge. The medial trochlear ridge is then examined
by moving the distal end of the arthroscope carefully along
the length of the ridge (the eyepiece of the arthroscope is
moving proximally during this maneuver) (Figs 6.8 and 6.9).
This will visualize also the medial patellar fibrocartilage and
conjoined medial patellar ligament. Advancing the arthro-
scope over the medial trochlear ridge and viewing caudally,
one can view the synovial recessbeyond the medial trochlear
ridge. In some cases,a fold of synovial membrane overlies the
distal extremity of the medial trochlear ridge (Fig. 6.10B). If
this fold is elevated,a communication into the medial femoro-
tibial joint may be apparent: this communication can permit
the passageof the arthroscope and visualization of the cranial
aspect of the medial condyle.
The arthroscope is returned to the proximal aspect of the
medial trocWear ridge and is rotated laterally and across the
intertrochlear groove to the lateral trochlear ridge (Fig. 6.11).
With fluid distention, the patella is separated from the lateral
trocWear ridge in this aspect of the joint. This separation
facilitates examination of the proximal aspect of the lateral
trochlear ridge as well as the undersurface of the patella, and
also allows advancement of the arthroscope proximally into

the suprapatellar pouch without risk of damage to the
articular surfaces (as mentioned previously, this is the reason
why moving the arthroscope sleeve laterally facilitates initial
entry of the arthroscope into the joint). The synovial mem-
brane in the lateral aspect of the joint adjacent to the area of
articulation of the lateral trochlear ridge and distal patella is
smooth and non-villous (seeFig. 6.11), but if becomesquite
villous distal to this point. The entire length of the lateral
trochlear ridge is then explored by moving the distal end of
the arthroscope distad and advancing the arthroscope
further into the joint as necessary (Figs 6.12 and 6.13). This
maneuver involves moving the eyepiece of the arthroscope
mediad and proximad. The synovial membrane is villous
adjacent to the distal one-half of the lateral trochlear ridge
(Fig 6.12B) and fluid distention is often critical to allow a
clear view of this area. The trochlear ridge is examined until
the synovial reflection of the distal extremity is encountered
(seeFig. 6.13). In the event of the view being obscured by
hypertrophied synovial villi, viewing of a specific area of the
trochlear ridges can be improved with gradual flexion. As the
arthroscope is moved axially from the lateral trochlear ridge.
the distal aspect of the intertrochlear groove can be
examined. Irregular cartilagenous protuberances and creases
are commonly seenand are considered normal (Fig. 6.14).
The
Diagnostic arthroscopy of
clinical conditions
primary indication for arthroscopy of the femoropatellar
joint has been in cases of osteochondritis dissecans. Surgical
intervention for this condition is discussed in a separatesection.
Arthroscopic surgery also has value in casesof distal
patellar fragmentation and patellar fractures. Diagnostic
arthroscopy of the femoropatellar joint is also performed incases
of persistent femoropatellar effusion in which theradiograp
changes are equivocal or absent. In some ofthese
animals, articular cartilage lesions may be seen on the
articular surface of the patella. Some appear to be cases of
OCD but in others the changes are consistent with what isdescribed
as chondromalacia in the human knee. Thepathogen
and significance of such an entity in the horseis
still uncertain. If such changes in the articular cartilage
are visualized, the pathologic area is debrided (chondro-
plasty) and clinical improvement has occurred after such
treatment in equine patients.
The use of the probe in evaluating all cartilage lesions.
particularly those of osteochondritis dissecans. cannot beoveremp
The portal for a probe can be made virtually
anywhere in the femoropatellar joint as there are no
adjacent tendon sheaths and bursae. The usual locations
for instrument portals when operating on lesions atvarious
positions within the femoropatellar joint arepresented
subsequently. These portals are also sites forprobe
entry. Surgeons can ascertain optimal sites for probe
penetration by inserting an l8-gauge 1.S-inch needleinto
the joint to determine if the site and angle are
satisfactory.
Insertion of the arthroscope into the
cranial pouch of the medial
femorotibial joint
horse is positioned in dorsal recumbency with the leg in
flexion (approximately 900 at hock and stifle). The leg is
surgically prepared and draped. Three approaches have been
used for diagnostic arthroscopy of the medial femorotibialjoint:
cranial (Moustafa et al198 7), lateral (Lewis 1987), and
craniolateral (Nickels & Sande 1982). All approaches provide
an effective examination of the cranial part of the medial
femorotibial joint. The authors use the first two approaches.
and they are described. The cranial approach allows more
consistent examination of the intercondylar (cruciate) area.
On the other hand. the lateral approach leaves a clear area
cranially for instrument placement when operating on
medial condylar lesions.
Cranial approach. The medial femorotibial joint may
be distended with sterile fluid through an 18-gauge needle
Diagnostic Arthroscopy of the Femorotibial joints
Femoropatellar and Femorotibial joints

Fig. 6.5
Patella (P) and trochlear groove (T), with arthroscope under
the patella, at the level of the proximal trochlear groove. (A)
Diagram of visual field (circle). (B) Arthroscopic view.
 Femoropatellar
andFemorotibial
Joints

.,
inserted cranially, but the first author (C.W.M.) generally finds
this unnecessary. For the cranial approach, a skin incision is
made and continued through the fascia between the middle
and medial patellar ligament about 2 cm proximal to the tibial
crest. The arthroscopic sleevecontaining the conical obturator
is then inserted through the fat pad in a slightly proximad,
caudad, and axial direction until it penetrates the medial
femorotibial joint capsule (Fig. 6.15). Entry into the joint is
confirmed by observation of the joint features or egressof fluid
on removal of the conical obturator (if joint is predistended).
The arthroscope is then inserted and the examination can
begin (Fig. 6.16).
Lateral approach. The site of the arthroscopic portal
is caudal to the lateral patellar ligament, cranial to the long
digital extensor tendon, and 2 cm proximal to the tibial spine
(Lewis 1987) (Fig. 6.17). The arthroscopic cannula with
conical obturator in place is then directed medially and
slightly caudad to penetrate the synovial membrane in the
lateral aspect of the medial femorotibial joint (Fig. 6.18A).
The obturator is removed and the arthroscope is inserted.
After checking that the arthroscope is in the cranial
compartment (Fig. 6.18B), the joint is distended, and the
examination begins (Fig. 6.19).

Approach to the cranial pouch of

the medial femorotibial Joint
from femoropatellar joint

This technique was originally describedby Boening (1995)

and subsequentlyreported in the United Statesby Peroni&
Stick (2002). A longer arthroscope is preferred for this
technique.The femoropatellarjoint is entered through the
normally describedportal betweenthe lateral and middle
patellar ligaments. mid-way betweenthe patellar and tibial
crests.The slit-likeopeningscommunicatingwith the medial

.in some casesthe lateral femorotibial joints
a window betweenthe respectivefemorotibialjoint
of the axial aspectof the femorotibial joints. but examination
further laterally and medially is limited.
Normal arthroscopic anatomy of
the cranial compartment of the
medial femorotibial joint
The medial intercondylar eminence of the tibia and axial side
of the medial condyle of the femur can be easily located in the
distal medial aspect of the joint and used as a reference point
(Fig. 6.20). The cranial ligament of the medial meniscus and
cranial cruciate ligament are also observed. The cranial
ligament of the medial meniscus and the cranial portion of
the medial meniscus are visible by moving the arthroscope
medially along the distal aspect of the medial condyle
of the femur (Fig. 6.21).
 and Femorotibial joints

The tip of the arthroscope is retracted to the center of the

joint and the arthroscope is rotated upward to visualize the
central weightbearing area of the medial condyle of the
femur (Fig. 6.22). Visualization of the medial and cranial
aspects of the medial condyle of the femur may be facilitated
by some extension of the joint (Fig. 6.23). Visualization of the
medial collateral ligament. however. requires a more medial
arthroscopic approach. Further retraction of the arthroscope
reveals the proximal axial portion of the medial condyle
and the caudal cruciate ligament running proximodistal
beneath the synovial membrane (Fig. 6.24). A better view
of the cruciate ligaments can be obtained with the cranial
approach. but a complete examination can be done with
either approach.

Insertion of the arthroscope intothe

cranial compartment of the
lateral femorotibial joint

approaches to this joint have been described by bothNickels

& Sande (1982) and Moustafa et al (1987), and arefavored
over a cranial or a lateral approach. Attempts to createa
direct lateral portal are inhibited by the lateral collateral
ligament and the lateral patellar ligament. and by the tendon
of origin of the long digital extensor. A portal between themiddle
and lateral patellar ligaments can be used, butarthroscopic
manipulation is limited.
For the medial approach to the lateral femorotibial joint as
originally described by Moustafa et al (1987), the arthroscope
(after approaching the medial femorotibial joint using the
cranial approach) is returned to the intercondylar reference
point in the medial femorotibial joint. The lateral femorotibial
joint may be pre-distended with fluid through an 18-gauge

Medial
and Femorotibial joints

needle inserted between the lateral patellar ligament and the

lateral collateral ligament, but this is not necessary. The
arthroscope then views the synovial septumcranial to the inter-
condylar eminence of the tibia. In this position, the arthroscope
is replaced with the conical obturator, and the sleeve is in-
serted caudolaterally behind the long digital extensor tendon,
to the far side of the joint. The arthroscope is then placed in
the sleeveand the arthroscopic examination commences.
Alternatively, the lateral femorotibial joint may be
approached directly without prior arthroscopic examination
of the medial femorotibial joint. The lateral femorotibial joint
is distended as described previously, and an 8-10-mm skin
incision is made medial to the middle patellar ligament. The
arthroscopic sheath and trocar is then advanced caudolaterally
to penetrate the joint capsule on the cranial side and advanced
to the lateral side of the joint.
 A

Normal arthroscopic anatomy of cranial cruciate ligament can be seen axially under
median septum (Fig. 6.28). A small area of 1-,
the cranial compartment of the
lateral femorotibial joint visible axial to these structures.

After entry,the initial view should includethe lateral aspect

of the lateral femoral condyle,as well asthe poplitealtendon Insertion of the arthroscoJ?e into the
within its synovial diverticulum (Fig. 6.25). Withdrawal of caudal pouch of the medial
the arthroscoperevealsthe lateral femoralcondyleand the femorotibial joint
lateral meniscus (Fig. 6.26). Further medial, the cranial
ligamentof the lateral meniscusand the lateral tibial condyle
maybe visualized,as well asthe long digital extensortendon joints are small. The stifle is positioned in 90-1200 of flexion.
under the synovial membrane and within the sulcus The joint is distended with a spinal needle placed
muscularisof the tibia (Fig.6.27). With further withdrawal
and rotation of the arthroscope,the lateral aspectof the
 ~
\ ~\~.\
I
.,,
,
\
\\
\\

.: ~, Lateral
"'/
condyle

Medial
condyle

;z::
Lateral
Medial I

approach
if/!
P
Popliteal
tendon i

!i
I

The arthroscopic portal can be made in the i

plane as the needle.but 3 cm caudally;In consideration

described the level of the portal as 2.5 cm proximal to ..

distal level of the medial meniscus and 3 cm caudal
the medial collateral ligament. This approach provides
adequate view of the axial aspect of the joint (Fig. r -
Making the portal 3 cm more proximad to allow for a
instrument portal has been described by other
(Hance et al ~

prior use of the spinal needle. More caudal entry of

arthroscope, 6 cm caudal to the medial collateral ]

better examination of the caudal horn of the

Additionally,it leavesmore room for instrumententry.

Normal arthroscopic anatomy of the

caudal pouch of the medial
femorotibial joint

are initially visualized (Fig. 6.30).'

medial meniscus may be ';". .

i
!
2002).
IW;;,
of the pouch and the outline of the caudal cruciate ligament
may sometimes (rarely) be noted axially beneath the joint
capsule. coursing in a proximodistal direction.
Insertion of the arthroscope into the
caudal compartment of the lateral
femorotibial joint
Theseapproachesare basedon the descriptionsof Trumble et al
(1994), Hance et al (1993), and Stick et al (1992). It is
important to be aware that the peroneal nerve lies 7 cm caudal
to the lateral collateral ligament and so no portal should be
made this far caudally. The popliteal tendon divides the
caudal lateral femorotibial joint. Distention is performed with
a spinal needle placed caudal to the collateral ligament. For
examination proximal to the popliteal tendon, the portal is
placed 2.5 cm proximal to the tibial plateau and 3 cm caudal
to the collateral ligament (Fig. 6.29) (Walmsley 2001).
Structures seen through this portal are limited to the lateral
femoral condyle and the proximal border of the popliteal
tendon. To view the pouch distal to the popliteal tendon. the
portal is located at the level of the tibial plateau. 1.5 cm
caudal to the lateral collateral ligament. and the arthroscope
is placed through the popliteal tendon to allow examination
of the more caudal articulation of the joint. It was noted by
Trumble et al (1994) that the tendon of the popliteal tendon
being contiguous with the joint capsule of the caudal pouch
of the lateral femorotibial joint makes arthroscopic explo-
ration of this pouch particularly dillicult.
Normal arthroscopic anatomy of the
caudal compartment of the lateral
femorotibial joint
With the proximal arthroscopic portal. it is possible to view
the proximal border of the popliteal tendon and the lateral
femoral condyle (Fig. 6.31). Using the distal portal through
the popliteal tendon it is possible to examine the caudal
 meniscus, part of the caudal aspect of the lateral
, the intra-articular portion of the popliteal
but this examination is
arthroscopy of clinical
in the femorotibial
cases of cystic lesions of the medial condyle of the
.1987). Surgical intervention for this condition
1987; Turner et a11988. McIlwraith 1995
1995. 2002). Lewis described the arthroscopic
in 20 cases of unilateral lameness. with a positive
the medial femoro-
but without major radiographic abnormalities. A
.was abnormality of the articular surface of
distal weightbearing portion of the medial femoral
abnormalities included fibrillation of the articular
partial- to full-thickness erosion, sometimes
and, in some cases,
cartilage flaps. Abnormalities of the medial
were evident in 9 cases,including mild to marked
and degeneration of the proximal surface. A
3 casesand a partial avulsion/
of the cranial ligament of the medial meniscus was
1 case. Examination of the menisci was difficult in all
and Lewis (1987) noted a lack of ability to adequately
the caudal segments of the meniscus. Lewis also
the use of surgical arthroscopy in 2 cases of tibial
fractures. One of the 2 horses was completely sound
could resume full function; the other was periodically
mild degree when heavily used. Of the 20 casesin
revealed articular cartilage
nonsteroidalanti-inflammatory agent therapy,
Turner et al (1988) reported the confirmation of cranial
, .injury in 5 cases by the use of femorotibial
A cranial approach with the arthroscope
used. Arthroscopic examination revealed the following
disruption of the septum surrounding the
ligaments and separating the medial and lateral
joint compartments; increase in the joint space
with ligamentous laxity; synovitis; and areas of
a partial longitudinal tear of the cranial
ligament in 1 case (the horse also had a cranial
ligament at its insertion adjacent to the tibial
tearing of the cranial attachment of the lateral
the
included
medial femoral condyle, and a complete tear of the cranial
cruciate ligament in 1 case.
More recently, the use of arthroscopy to both diagnose and
treat vertical tears of the cranial horn of the meniscus and
the cranial ligament of the meniscus has been described
(Walmsley 1995). The most recent use of arthroscopic surgery
in 80 casesof meniscal tears in the horse has been described
by Walmsley et al (2 003). Schneideret al (199 7) also described
the use of medial femorotibial arthroscopy to evaluatecartilage
lesions on the medial femoral condyle as a cause of equine
lameness in 11 cases.These conditions will be discussed in
more detail separately.
As noted previously, the septum separating the lateral and
medial femorotibial joint compartments is commonly
disrupted in association with cruciate ligament injury; a
cranial approach to the medial femorotibial joint will also
allow examination of the lateral femorotibial joint in these
cases. If both cranial and cruciate (and medial collateral)
ligaments are disrupted, the resulting laxity will allow greater
visualization of the femorotibial articulations and menisci.
Osteochondritis dissecans
Arthroscopic surgery has emerged as the only surgical tech-
nique to treat osteochondritis dissecans (OCD)in the femoro-
patellar joint. It has replaced arthrotomy eliminating local
problems with wound healing and reducing the need for rigid
postoperative management. The techniques presented sub-
sequently are based on the experience of the authors with
clinical cases of OCD in the femoropatellar joint and the
follow-up data that have been generated from these cases
(Mcllwraith 1984, Mcllwraith & Martin 1984,1985; Martin
& Mcllwraith 1985. Foland et al1992). Although successful
results can be obtained by using arthrotomy, potential com-
plications include seroma formation. local cellulitis and
fasciitis, and wound dehiscence (Pascoe et al 1980, 1984;
Trotter et aI1983).
Preoperativeconsiderations
Preoperative diagnosis of OCD is based on clinical and
radiographic signs. The clinical signs that initially prompt the
attention of owners are lameness and/or synovial effusion of
the femoropatellar joint. The diseaseis not breed-specific,but
it is a diseaseof young horses. In some instances. however. no
clinical problems are apparent until the horse is in training or
has raced (Mcllwraith & Martin 1985). Lesions that manifest
at this stage are generally less severe. Clinical examination
generally reveals some degree of synovial effusion as a
consistent finding. Lameness ranges from nondiscernible
through subtle gait changes (shortened anterior phase of
stride, low arc of flight. and unusual flight path with the stifle
rotated outward and the hock inward) to obvious lameness
with a stiff gait and difficulty in getting up. Animals may have
difficulty in trotting with a preference to canter or "bunny-
hop" is common.
The radiographic manifestations of the disease vary.
Lesions most commonly occur on the lateral trochlear ridge
but are also seen on the medial trochlear ridge of the femur
and/or on the patella (Table 6.1). The lesions in turn may be
localized to a small area or be distributed along the entire
length of the trochlear ridge. The most common radiographic
manifestation of OCDis a defect (with or without discernible
fragments) on the lateral trochlear ridge of the femur
(Fig.6.32). Defectscan be describedas concave (seeFig. 6.32),
flattened (Fig. 6.33), cystic, or undetermined. Lesions on the
medial trochlear ridge usually manifest as a concave defect
(when evident radiographically), but often are not visible on
radiographs (due to a normal subchondral bone contour)
(Fig. 6.34). Lesions can also be observed (less frequently) in
various parts of the patella and manifest as some form of
subchondral defect (Fig. 6.35).
For many years the authors recommended arthroscopic
surgery for all casesof osteochondritis dissecans,particularly
if an athletic career is planned. However, the study by
McIntosh & Mcllwraith (1993) shows that, with conservative
management (stall or pen confinement for 60 days). then a trainer request for the problem to be assured of correction
number of femoropatellar OCDcases can heal. Based on this also leads to early surgical treatment. Persistence of synovial
study. if defects are less than 2 cm long and less than 5 mm effusion is always an indication for surgery. When the
deepand there is no obvious mineralization or fragmentation severity of the changes is too severe, surgery is not recom-
of the flap on radiographs. conservative therapy is a viable mended. A direct comparative study was done comparing
option. It has also been pointed out by Dik et al (1999) that radiographic and arthroscopic findings in the femoropatellar
up to age 8 months it is possible for radiographic lesions on joint (Steinheimer et al 1995). It is rare to find an arthro-
the femoral trochlear ridges to resolve. In a longitudinal study scopic lesion less severe than the radiographic insinuation.
of Dutch Warmblood foals, radiographed at 1 month old and On the other hand, it is common to find more pathologic
subsequently at 4-week intervals, the mid-region of the lateral change at arthroscopic surgery than predicted by radio-
femoral trocWear ridge becameradiographically abnormal from graphs.
3 to 4 months old. Subsequent progression of radiographic
abnormalities was usually followed by regression and
resolution. with the appearance returning to normal at Technique
8 months old in most cases. At 5 months old. 20% of the A number of different instrument portals are used to perform
stifles were abnormal radiographically, but at 11 months old surgery at various locations in the femoropatellar joint.
this percentage had decreasedto 3%. Normal and abnormal Previously, six different triangulation approaches were used
appearances were permanent from 8 months old (Dik 1999). to operate on the various lesions of osteochondritis dissecans
The authors currently recommend that all lesions greater in the femoropatellar joint and were discussed in the second
than 2 cm in length or 5 mm in depth. or any lesion that edition of this text. However, exact sites for instrument entry
contains osseous densities in the presence of synovial do not need to be rigidly fixed. Rather, the use of an I8-gauge
effusion. be treated with arthroscopic surgery. In some of the disposable spinal needle is now recommended to ascertain
cases that can potentially heal conservatively. owner or the ideal location for an instrument portal (Fig. 6.36). In all
cases,a l-cm incision is made through the skin and super-
ficial and deep fascia, and using a stab incision with a No. 11
blade completes entry into the joint. The various instruments
are then inserted through the portal as required (Fig. 6.37).
The various surgical approaches are illustrated in Figures
6.38-6.43. In all instances, we are using the same arthro-
scopicportal between the lateral and middle patellar ligament
although it is noted that an arthroscopic portal between the
middle and medial patellar ligaments has also been used for
operations involving lateral trochlear ridge lesions (Bramlage
perscomm 1987).
Lesions on the proximal one-half of the lateral trochlear
ridge are reached through a portal proximolateral to the
arthroscopic portal (seeFig. 6.38). The instrument may pass
either lateral to or (usually) through the lateral patellar
ligament when using this portal. If the entry is too far lateral,
the instrument cannot be manipulated up and over the
lateral trochlear ridge. Passing the instrument through the
lateral patellar ligament does not seem to be of any
consequence. Lesions of the proximal portion of the medial
trochlear ridge are reached by using a portal between the
medial and middle patellar ligaments. entering the skin distal
to the lesion (Fig. 6.39).
To effectively operate the underside of the patella. an
instrument portal must be level with or distal to the arthro-
scopic portal and usually 2 cm lateral to the arthroscopic
portal (seeFig. 6.40). If this portal is more proximal than the
arthroscopic portal. the end of the instrument cannot make
contact with the undersurface of the patella. The portal is
made lateral to the middle patellar ligament. depending on
the position of the lesion on the patella. To operate on lesions
on the distal aspect of the lateral trochlear ridge. the same
arthroscopic portal is used as that chosen for the proximal
trochlear ridge. although the arthroscope is directed distad.
The instrument portal is made low over the distended
femoropatellar joint through or immediately adjacent to the
lateral patellar ligament (Fig. 6.41). For lesions on the distal
aspect of the medial trochlear ridge. a distal portal is usually
made between the middle and medial patellar ligaments
(Fig. 6.42). If the lesion on the medial trochlear ridge is
located on the trocWear groove (axial) side of the distal medial
trochlear ridge. however. a medial portal does not always
allow the instrument to reach this location. In this instance.
a lateral instrument portal. allowing the instrument to pass
under the middle patellar ligament. is necessary (Fig. 6.43).
 fragmentation within the articular cartilage and sub-

chondral bone (Figs 6.44 and 6.45). This situation is

common when ossified flaps or fragments have been observed

on preoperative radiographs. When the lesions manifest

radiographically as subchondral defects in the trochlear

ridge. chondral or osteochondral flaps are also commonly

found. Gross and histopathologic examinations frequently

confirm osseous tissue in the cartilage fragments and flaps,

even when they are not discernible on radiographs.

In either situation, the flaps are manipulated and elevated,

usually by using a periosteal elevator or rongeurs (see

Fig 6.45). The flaps are then removed by using Ferris-Smith

intervertebral disk rongeurs or an equivalent instrument (see

Fig 6.37 and Figs 6.44-6.48). The flap is removed in

successive bites with the rongeurs. leaving it attached at its

proximal edge. This technique reduces the chance of the flap

slipping from the grasp of the forceps and becoming a loose

body. In joints in which the subchondral defect does not

contain a distinct flap, the nature of the lesion varies from a

dimple to an openly eroded lesion. Fragments of cartilage

within a matrix of granulation or fibrous tissue may be noted a

within the defect. After removal of the flap or fragments,

undermined articular c?ftilage unattached to subchondral

bone is removed by using Ferris-Smith rongeurs or basket

forceps (see Figs 6.46 and 6.47).

Debridement of the remaining subchondral defect is then

performed. Hand curettage is used in most cases. A motorized

burr can be effective in debriding the defects to healthy

subchondral bone (Fig 6.50) but can easily result in excessive

loss of tissue. A hand curette is used in most cases (see

Figs
between 6.45-Fig.
normal 6.47).
and pathologic
Curettage bone. allows better

At the completion of subchondral debridement, tags

---

mined,unattachedarticular cartilageremains.

Manipulations of the surgical instruments vary, but a
sequential protocol is generally followed. A number of cases
are used to demonstrate the manipulations (Figs 6.44-6.48).
In all cases,the lesions are initially evaluated with a probe.
The probe is useful in defining the limits of an osteochondral
or chondral flap as well as for assessingits mobility. The probe
is also used to evaluate any cracking, wrinkling, or fibrillation
in the articular cartilage. If the cartilage is cracked but firmly
attached to subchondral bone, it is not removed. Normal-
appearing articular cartilage is also probed, particularly if
radiographs have revealed lesions in the subchondral bone in
that area. If intact cartilage overlies a subchondral defect,the
probe breaking through the articular cartilage into the defect
locates the lesions and the undermined articular cartilage is
then removed.
The most common form of pathologic change encountered
on arthroscopic examination of osteochondritis dissecans of
the lateral trochlear ridge of the femur is flap formation or
commonly occur as raised areas of articular
trochlear ridge lesions,with the use of
portal (Figs6.39, 6.42, 6.45, and 6.47).
and on the axial sides of the trochlear ridges. It is
common to see OCD lesions on the ~ ~c ,-- ~
is gaugedby inserting a spinalneedle.but generally
ridge will not allow accessto the lesion.
arthroscopeand instrument is depictedin Figure
graphs indicate severe intraarticular disease and surgery
contraindicated (Fig. 6.49)
Primary OCD lesions of the patella are uncommon, "--
they do occur (Fig. 6.51).-
 ",' Femoropatellar and Femorotibial joints
Wi
,~

.,
 for lesions on the trochlear ridges, with removal of
.In addition to primary osteochondritis
of the patella. degenerative erosive lesions that
of cartilage (with bone sometimes) are seen on the
in association with lateral trochlear ridge OCD
6.51B). The usual site for these patellar lesions is the
-it articulates
the area of osteochondritis dissecans on the lateral
ridge. Histological examination of these buds of
in one of the author's (A.J.N.) laboratory suggest
Lack of correlation between radiographic lesions and
pathologic changes found intraoperatively are a
feature of osteochondritis dissecans of the femoropatellar
joint. This lack of correlation takes a number of forms: (1)
cartilaginous change more severe than expected. based on
the subchondral lesions seen on the radiographs; (2)
cartilaginous lesions on the trochlear ridge or patella where
no subchondral bone changes were radiographically
detectable; or (3) less severe cartilaginous change than
expected (usually taking the form of intact articular cartilage
over radiographically lucent subchondral change). The
various radiographic defects observed manifest in a number
of ways during arthroscopic examination. Usually some form
of cartilaginous flap or islands of cartilage and a fibrous tissue
stroma are present within a concave defect (seeFigs 6.44 and
6.45); other casesinvolve a dimple-type defect or an area of
cartilage fibrillation or loss with or without undermined or
detached articular cartilage. In some instances. intact
cartilage is separated from the bone (seeFigs 6.45 and 6.47).
 Osteochondral bodies that have detached from the
primary trochlear ridge lesions can be a challenging surgical
problem. They may be free within the joint or embedded
within the synovial membrane and joint capsule. If these
bodies are totally free within the joint. the surgeon must
grasp the fragment carefully without pushing it away and
causing it to float up into the suprapatellar pouch (Fig. 6.52).
Switching off the ingress fluids at this stage can decreasethe
fluid flow and minimize movement of the loose body. Prior
fixation of the loose body with a needle is also of help in this
situation.
In instances of large fragments. the skin incision is
enlargedto facilitate removal and occasionally the deepfascial
incision is also enlarged.However.a proximal instrument portal
abovethe patella into the suprapatellar pouch can be used to
remove large fragments with satisfactory results. A spinal
needleis used to confirm the correct position before incising a
portal through the quadriceps muscle into the suprapatellar
pouch. Large fragments are removed more easily through this
portal because they do not have to come through the inelastic
deepfascia. as occurs with the conventional lateral or medial
instrument portals. As in other joints, the skin alone is
sutured and no healing problems have been observed.
It is difficult to make specific recommendations with
regard to how to manage osteochondral massesembeddedin
the synovial membrane or in the fibrous joint capsule. For
cases in which the loose body is attached to synovial
membrane but is clearly visible within the joint, removal is
indicated and can be performed arthroscopically without
problems. For a less-visibleor less-accessiblelesion, arthrotomy
can be performed and the first author (C.W.M.) has used this
technique in one instance of such a lesion (Mcllwraith &
Martin 1985). It is questionable if removal of this mass was
necessary and the authors favor leaving it alone when it is
embedded within the joint capsule. Formation of osseous
bodies in the soft tissue has occurred postoperatively, and
similar lesions have been noted on radiographs obtained after
arthrotomy (Pascoe et aI1984). Horses with these osseous
masses can race, leading to the interpretation that these
animals do not need surgery.
 Contraindications for surgery include lateral luxation of
the patella owing to excessive loss of the lateral trochlear
ridge, and secondary remodeling changes of the patellar
identified radiographically (seeFig. 6.49).
At the completion of the surgical procedures for osteo-
chondritis dissecans, the joint is liberally lavaged and
vacuumed to ensure removal of small debris released at the
time of surgical debridement. A special, larger egresscannula
has been developed for this purpose. It is 8 mm in diameter
and is 20 cm in length. It is inserted until its tip lies within the
suprapatellar pouch (Fig. 6.53A). The suction tubing can be
applied directly to the end. A motorized fluid system is critical
in flushing this joint. Use of this specialegresscannula at the
end of the procedure is most appropriate, because the debris
collects in the suprapatellar pouch and an instrument of
large diameter is necessary to allow its removal. An alter-
native is to insert a large diameter cannula into the supra-
patellar pouch through a portal proximal to the patella.
After completion of the procedure and suturing of the
incisions, a sterile loban@ drape is placed over the surgery
site in lieu of a bandage (Fig. 6.53B).
Pin fixation of large osteochondritis dissecans fragments
has been described in man (GuhI1984). Note, however, that
such fragments have a rigid bony component, which is rarely
present in the equine case. Recently, a technique for using
PDSOrthosorb@pins has beendescribedby Nixon et al (2004)
for fixing large OCD flaps (see Chapter 16). A very select
group of OCD lesions are suitable for reattachment. The
cartilage of the flap must be relatively smooth, not calcified,
and have at least some residual attachment to the sur-
rounding cartilage. The arthroscopic PDSpin kit can then be
used to secure the flap in multiple locations. Reattachment,
revitalization, and most, importantly, filling of the sub-
chondral bone defect occurs within 8-12 weeks of :
the rapid return of ,
follow-up radiographs (Fig. 6.54). This compares
with the trochlear ridge defect remaining after
ment, particularly for the discerning buyer of
yearlings. It should be stressed, however, that
OCD flaps of the femoral trochlear ridges do not fit :
guidelines established for reattachment and need to
debrided.

I
Postoperativemanagement
Horses generally receive procaine penicillin and gentamicin
sulfate perioperatively and phenylbutazone before surgery
and for 5 successive days. This regimen is a precaution
against any development of interfacial swelling. Most cases
are simple to manage. and the horse can be discharged soon
after surgery. Hand walking commences after 1 week to allow
some clot organization within the defect. After this time, it is
theorised that exercise will facilitate modulation of the tissue
within the defect toward some form of fibrocartilage. On the
basis of follow-up results, the horse can return to light
training 3 to 4 months postoperatively,depending of the age
of the animal.
ResultsThe
results of arthroscopic surgery performed in the first
40 cases of osteochondritis dissecans involving 24 horses
were reported by McIlwraith & Martin (1985). More recently,we
published the results of arthroscopic surgery for the treat-
ment of OCD in 250 femoropatellar joints in 161 horses
(Foland et al 1992). There were 82 Thoroughbreds, 39
Quarter Horses, 16 Arabians, Warmbloods, and 15 others of
various breeds. There were 53 females and 108 males: 22
horses were less than 1 year old at the time of surgery, 68
were yearlings, 36 were 2 year olds, 21 were 3 year olds, and
14 were either 4 years old or older: 91 had bilateral
involvement and 70 had unilateral disease.
Follow-up information was obtained on 134 horses,
including 79 racehorses and 55 non-racehorses. Eighty-six
(64%) of these 134 horses returned to their intended use, 9
(7%) were in training at the time of publication, 21 (16%)
were unsuccessful, and 18 (13 %) were unsuccessful due to
other defined reasons. Horses with Grade I lesions (less than
2 cm in length) had a significantly higher successrate (78%)
than did horses with Grade II (2-4 cm) or Grade III (greater
than 4 cm) lesions (63% and 54% successrates respectively).
A significantly higher successrate was also noted for horses
operated on as 3 year olds compared with the remainder of
the study population. A significantly lower successrate was
noted for yearlings than for the remainder of the population.
There was no significant difference as related to gender
involved, racehorse vs non-racehorse, lesion location, uni-
lateral vs bilateral involvement, presenceor absenceof patellar
or trochlear groove lesions, or presence or absence of loose
bodies.
Although a permanent clinical cure would likely be anti-
cipated with this surgery in most cases,the nature of healing
within the defects is less certain. On the basis of long-term
follow-up radiographs obtained in horses that are sound, it
seemsirregular contours in the subchondral bone frequently
persist. After debridement, defects presumably fill with fibrous
tissue or fibrocartilage, but this supposition is based on
minimal amounts of follow-up necropsy data (Pascoe et al
1984) or second-look arthroscopy (Fig. 6.55). Whatever the
tissue that fills the defect, it seems to provide satisfactory
stroma for articulation. No lateral trochlear ridge lesion is
necessarilytoo big to negate surgery but more detailed
follow-up evaluation of larger lesions in elite athletes would
be appropriate. As mentioned previously, if lateral luxation of
the patella is present, surgery is contradicted. Limitations for
healing have been described in the medial condyle of the
femur (Converyet al19 72), but our clinical data support some
form of functional filling of these defects on the trochlear
ridges.
 The condition is characterized by osteochondral fragmen-
tation of the distal aspectof the patella. In the initial report of
15 horses, the problem was unilateral in 6 horses and
bilateral in 9 and occurred in 8 Quarter Horses, 3 Thorough-
breds, 2 American Saddlebreds, 1 American Paint and 1
Warmblood/Thoroughbred cross. A previous medial patellar
desmotomy had been performed on 12 of the 15 horses.
The condition manifests as hind limb lameness and
stiffness ranging from mild to severe. There is fibrous
thickening in the stifle area in all cases associated with
previous medial patellar desmotomy (the fibrosis is centered
over the desmotomy site) and synovial effusion is normally
present and recognizable if the fibrosis is not too extensive.
The radiographic changes include bony fragmentation,
spurring (with or without an associated subchondral defect),
subchondral roughening, and subchondral lysis of the distal
aspect of the patella (Fig. 6.56).
The treatment is arthroscopic surgery. In the initial series
the lesions at arthroscopy varied from flaking, fissuring,
undermining, or fragmentation of the articular cartilage to
fragmentation and/or lysis of the bone at the distal aspectof
the patella (Fig. 6.57). The subchondral bone was involved in
all cases that had a previous medial patellar desmotomy. Of
the 12 horses that had a previous medial patellar desmotomy,
8 horses became sound for their intended use, 1 horse was
sold in training without problems, 1 horse was in early
training without problems at the time of publication, 1 horse
never improved and 1 horse was in convalescence. Of the
three cases that did not have a medial patellar desmotomy,
2 horses performed their intended use, but 1 horse was un-
The healing potential of horses that have undergone satisfactory. In these instances, there was no severe bone
operations at 2-3 years of age may be less than that of involvement. It is possible that such cases are equivalent to
younger aniJIlals. Fortunately. these older horses typically the chondromalacia syndrome described by Adams (1974).
have smaller defects. complete resurfacing of which may not
be as critical for athletic function. Our published data for
3 year olds supports this conclusion (Foland et alI992).
Preoperativeconsiderations
A common question from clients regarding surgery for The history in these cases usually involves the development of
OCD of the stifles is what is the likelihood of having more hind limb lameness referable to the stifle, usually after medial
lesions develop or will the problem developin other joints? Of patellar desmotomy. In most instances, the specific indication
the 161 horses operated on for femoropatellar OCD.12 under- for the medial patellar desmotomy is unknown (performed by
went concurrent surgery for other lesions as well as femoro- other veterinarians). Subsequent to desmotomy, a gonitis
patellar arthroscopy (Foland et aI1992). Five of these horses develops and persists. Femoropatellar effusion may be present
had OCDlesions in both metatarsophalangeal joints. 4 horses in addition to pericapsular fibrosis. The lameness is typically
had OCD of the tarsocrural joint. 2 horses had subchondral obvious at the trot but is observable commonly at the walk.
cystic lesions of the medial femoral condyle. and 1 horse had Radiographs of the femoropatellar joint reveal either a defect
OCDof a scapulohumeral joint. In other words. the likelihood in the bone at the distal aspect of the patella or bony
of lesions developing elsewhere is low. Also. the more recent fragmentation (usually associated with an observable defect)
work by van Weeren & Barneveld (1999) shows that if a of the distal aspect of the patella (see Fig. 6.56). On the basis
horse is operated on at 11 months of age or older. there of a lack of clinical improvement as well as the presence of
is no likelihood of additional lesion development in the radiographic lesions in these cases, arthroscopic surgery is

femoropatellar joint. recommended.

Fragmentation of the distal patella

This condition was mentioned in the second edition of this
textbook. It has now been further explained and reported in
the literature (McIlwraith 1990) and its pathogenesis
explained (Gibson & McIlwraith 1991).
Technique
An arthroscopic examination of the femoropatellar joint is
performed as previously described. The lesion is identified on
the distal patella and any other changes in the joint are
noted. A distal lateral arthroscopic portal is made to allow an
 well as damage elsewhere (seenoccasionally).The frag-ments During this period.Lewisdevelopedan arthroscopic
are removedby using a medial or lateral portal asappropriate. for use in these cases and reported 77 cases. of Itechn

Instruments may include a banana blade, which follow-up data are available in 67 (Lewis 1987). This

elevator, Ferris-Smith rongeurs, and motorized abrader. latter technique was then adoptedby the first author andrepo
In occasional instances,a fracture of the medial patellarfibrocartilage in the secondedition of this text.
without osseousinvolvement may be seen(Fig.
6..e0).
A retrospectivestudy of five performancehorses withpatellarPreoperative considerationsThe
fracturestreatedwith arthroscopicremovalhas beenreported typical clinical sign is lamenessin one or both hind limbs
(Marble & Sullins 2000). Four of five horseshadfractures
at a trot. In some horses, lameness is subtle and is noticeable
of the medial aspectof the patella and one horsehadonly during riding. Historically, some of these horses can bein
a fracture of the lateral aspect. Arthroscopy wasperformed training for considerable periods of time, with clinical signsman
in the femoropatellar joint using techniquesdescribed only after a certain amount of work has beendone
previously.There were no complicationswith the Most horses swing the leg medially and the lamenessisacce
joint or the arthroscopicportal incisions. Recoveryperiodsranged when trotting in a circle with the affected leginsid
from 3 to 5 months. All horsesrecoveredcompletely Medial femorotibial analgesia localizes the lesion but aresp
from surgeryand performedat the sameor a higher levelof can also be obtained with femoropatellar blockade.
competitionasbeforearthroscopy. Any change in the external appearance of the stifle isminim
Mild distention of the femorotibial joint may be
seenin more chronic cases.It is more common to seefemoro-pate
effusion (Howard et al1995).
The lesion is apparent radiographically. Both flexed lateraland
caudocranial views (Figs 6.61 and 6.62) are useful to
ascertain the location and sizeof the lesion. The typical lesionis
round or oval with a defect at the articular surface ofvary
size (seeFig 6.61). Such lesions may be bilateral. In
lesions of the medialcondyle other cases,a small flattened or concave defect (seeFig 6.62)
of the femur may be present. Most commonly, the latter lesion is seen inthe
stifle opposite to one manifesting lameness and exhibitinga
For 8 years,the first author (C.W.M.)treated subchondralcystic
large cystic lesion or as an incidental finding on pre-purchaseradio
lesions of the femorotibialjoint using a femorotibial of yearlings. Although surgical debridement ofcysti
arthrotomy with goodresults (Mcilwraith 1983. White et al lesions is being described here, there are a number of

Cystic
1988).

other options that have beenused. Historically,cancellous
bone grafting has beenused (Kold & Hickman 1984), but
resultswith this techniquethrough arthrotomy at leastwere
not as goodas simple debridement(White et aI1988). More
recently,somecontrolledwork with cancellousbonegrafting
in experimentallycreated 12.7 mm diameter and 19-mm
deepdefectsin the medialfemoral condyle and a 6-month
evaluation period showed that healing was similar in grafted
and ungrafted defectsin the equine medial femoral condyle at
6 months Uackson et al 2000). This suggested that surgical
debridement alone rather than adjunctive bone grafting of
cystic lesions is the treatment of choice.
The development of subchondral cystic lesions has been
associatedwith osteochondrosis and trauma. Whereas osteo-
chondrosis was initially consideredthe exclusivepathogenesis.
observations of cystic enlargement after surgery prompted
further investigation into the pathogenesis of these lesions
and to reasons why they may potentially expand. Work in the
first author's (C.W.M.) laboratory (Ray et a11996), showed
that it was possible to consistently produce (5/6 cases)
subchondral cystic lesions by creating a 5 mm diameter, 3 mm
deep defect in the subchondral bone at the central
weightbearing portion of the medial condyle of the femur.
Other work then revealed that the fibrous tissue of
subchondral cystic lesions (removed surgically) released
nitric oxide, PGEz,and neutral metalloproteases into culture
media after in vitro culturing. It was also shown that
conditioned media of the cultured tissue was capable of
recruiting osteoclasts and increasing their activity (von
Rechenberg et al 2000). It was therefore felt that fibrous
tissue could play an active role in the pathologic processesof
bone resorption occurring in the subchondral cystic lesions
and may be partially responsible for the slow healing rate and
expansion of these lesions. For this reason, the first author
(C.W.M.) has in recent years injected corticosteroids at the
time of surgical debridement. Recentreports by Sandler et al
(2002) suggest that simple debridement still has a high
success rate. On the other hand, reports of arthroscopic
intralesional injection of corticosteroids (Vandekeybus et al
1999) have prompted evaluation of this technique and this
will also be described.
Technique
The authors have previously used a cranial arthroscopic portal
between the middle and lateral ligaments with a cranial
instrument portal medial to the arthroscopic portal initially.
The technique developed by Lewis (1987) is superior,
however, and is now routinely used by the author. This latter
technique is described here (Figs 6.63 and 6.64).
The procedure is performed with the horse under general
anesthesia in dorsal recumbency. The leg is flexed such that
the stifle and hock are approximately at 900 angles. Stabilizing
the leg in this position is recommended. The medial
femorotibial joint can be distended with irrigating solution,
but for experienced surgeons, this is generally not necessary
and the arthroscope is inserted through the lateral portal
between the lateral patellar ligament and the origin of the
long digital extensor tendon as previously described. Examin-
ation of the medial femorotibial joint is also performed as
previously described.
The characteristic dimple in the articular cartilage over-
lying the subchondral cystic lesion is visualized (Fig. 6.65)
and the location for the instrument portal is determined by
placement of a needle (seeFig. 6.64A). The instrument portal
 Femoropatellarand FemorotibialJoints

I'
~
 madeusing an 8 mm incision through the skin and
and a stab through the joint capsulewith a No. 11
.This portal must be positionedso that
site of the lesionperpendicular
the articular surface to enable effective surgical mani-
are removed by using a curette and rongeurs (see
In someinstancesa motorizedburr is usedto assist
The configurations of the cystic lesions at arthroscopy
and can be multi-loculated. Typically debridement of
subchondral tissue continues to normal bone. Because
be a difficult decision.Cartilagethat is overhangingthe
hole is conservatively cut back to gain sufficient accessto the
cystic lesion, but not more than that. More recently, one of
the authors (AJN)has beenusing cancellous bone graft in the
base of the cystic lesion and adding fibrin with cells on top
(see Chapter 16). Although drilling of the cystic lesion has
been abandoned because it appeared to be associated with
enlargement of cysts (Howard et al1995), micro fracture has
been perfomed in the walls of the cystic lesions and it is a
subjective impression that it is quite useful.
Following debridement, the joint is lavaged liberally and
suction is also applied after this procedure. The skin portals
are closed with simple interrupted sutures. Care is taken
during initial debridement of the contents of the cyst to
remove defective tissue immediately from the joint and to
minimize debris accumulation elsewhere. Debris is released
into the joint. but it generally accumulates in the inter-
condylar area lateral to the medial condyle. A special effort is
made during lavage and suctioning of the joint to remove all
debris from this area.
Postoperative management
Perioperatively,the horse receivesprocaine penicillin and
phenylbutazone. The patient is confined to a stall for
2 months. Hand walking commencesat the time of suture
removal. A minimum of 4 more months pasture rest is
recommendedbefore training resumes.Training should
resumeonly if the horseis sound at a trot afterthis time. In
the series of casesreported by Lewis. the postoperative
convalescence in casesthat were ultimately successful varied
from 4 to 18 months and averagedapproximately7t months
(Lewis1987).
Results
In the series reported by Lewis, complete soundness for
intended use was achieved in 34 of the 67 cases based on
follow-up information from the owners. In addition, 14 horses
were sound enough that they were used as intended, despite
occasionalmild lamenessin the affectedlimb. Of the remaining
19 horses, various degrees of residual lameness presented a
problem for athletic use as intended; however, some animals
were used for less stressful activities and were satisfactory in
that respect. In summary, the overall satisfactory outcome for
intended use was 72% (48 of the 67 cases).Of the 19 failures
for intended use, 11 were from a group of 28 potential race-
horses, producing a 39% failure rate. Eight were from a group
of 39 horses intended for other use (cutting, reining, roping,
and pleasure), representing a 21 % failure rate in these types
of horses. Lewis concluded that several factors could affect
the prognosis, including age (younger horses in general had a
better prognosis), unilateral versus bilateral lesions (cases of
bilateral involvement were somewhat less successful),signifi-
cant training or use before surgery (generally decreasedthe
prognosis), previous administration of intra-articular medi-
cation (subjectively, the author thought prior corticosteroid
injection was detrimental to the ultimate outcome), radio-
graphic appearance (the broader opening of the cyst at the
articular surface was associated with a less favorable prog-
nosis), pre-existing degenerative joint disease (poorer prog-
nosis), and intended use (racehorseswere the most difficult to
return to intended use).
Howard et al (1995) described the results of arthroscopic
surgery for subchondral cystic lesions in the medial femoral
condyle in 41 horses. There were 17 Quarter Horses, 15
Arabians, 8 Thoroughbreds, and 1 Holsteiner with 28 (68%)
of the horses being 1-3 years old. For all horses, the owner's
complaint was mild to moderate hind limb lameness, or an
altered gait. Bilateral radiographic abnormalities of the medial
femoral condyle were detected in 27 horses. Nineteen of the
27 horses had lesions identified bilaterally at arthroscopic
surgery. In addition to the subchondral cystic lesion, 13 joints
in 11 horses had an osteochondritis dissecans lesion
from the opening of the subchondral cystic lesion. ~
debridement performed by arthroscopy was the only
ment for 37 lesions in 23 horses.
drilling of the defect bed was performed in 23 lesions
18 horses. Complete follow-up information
39 horses: 22 (56%) horses had a successful result
17 (44%) horses had an unsuccessful result.
results because of factors not directly attributed to
subchondral cystic lesion of the medial femoral
(censored analysis), 23 of 31 '
result and 8 of 31 (26%) horses had,
Within this group of horses, the prognosis for a
sex, size of ]
lesion was drilled, the presence of
with the subchondral cystic lesion, or whether the
enlarged after surgery. Compared
Arabians, Quarter Horses had a poorer]
Follow-up radiographs were available for 14 horses.
these 14 horses, the subchondral cystic lesion --
significantly with drilling of the lesion bed at the time
surgery.
Lesions were classified on radiographic appearance
either Type I lesions (10 mm or less in depth.
surface of
II lesions (more than 10 mm in depth and
conical or spherical) (see Fig. 6.61B), or Type ill
(flattened or irregular contours of the subchondral j
the distal aspect of the medial femoral condyle. 1
regression showed a significant association between
types as assessedfrom preoperative radiographs and ~
types based on surgical assessment. However, '
in six joints; of the SCL that appeared to be Type I
were later determined to be Type I on the basis of
scopic findings. Of the 15 joints that appeared to ~
three had a Type I SCL.six:
four appearedto be norma
attachedto the subchondralbone on palpation
and no surgical treatmentwas done; however.
stifle of thesehorsesdid havea surgicallesion.
not performedon two of the joints with a SD. Given
lesional injection of 40 mg of MPA (Depo-Medrol@)to
regime. The latter technique ' -
supported by more recent work demonstrating that
fibroustissueof
 cause
achieving
lesionwas
(Howard et al amount of
surface disrupted by measured
at the 1
into two groups: those with lesions that involved
or less cartilage surface and those with greater
15 mm of disruption. During the period between 1989
150 clinically lame Thoroughbred horses with a
214 subchondral cystic lesions had surgery. Of the
86 (58%) horses had unilateral lesions and 64
were raced, whereas 77% of the siblings
whereas 71% of males raced;
61 % (79) of the horses raced as 3 year oIds, and 51%
(55) of the horses raced as 4 year olds. The number of starts
and average earnings per start for the horses that had been
operated on were less than their maternal siblings for their
2- and 3-year-old racing careers, but were similar to their
siblings for the 4-year-old racing year. Of the 49 horses with
Type I lesions, 34 (69.3%) horses started a race in their career,
whereas 62 (61.3%) horses with Type II lesions started. This
indicated that radiographically assessedlesion depth was of
little consequencein defining the prognosis.
Additionally, there were 91 (60.6%) horses with less than
or equal to 15 mm of surface debridement and 59 (39.3%)
horses with greater than 15 mm of surface debridement. Of
the 91 horses with 15 mm or less of surface disrupted, over
70% started at least one race, whereas only about 30% of the
59 horses with greater than 15 mm of cartilage surface
involvement started a race. The amount of cartilage surface
affected seemedto be a better predictor of successthan lesion
depth.
Most recently, one author (C.W.M.) has treated a number
of cases with intralesional injection of corticosteroid
(triamcinolone acetonide) under arthroscopic visualization
(Fig. 6.66). In 2-year-old Thoroughbreds, everyone at this
stage has been able to go back into training at 2 months, with
already some increased density in their cystic lesions. The
results are very preliminary. The technique's rationale is
basedon the findings of von Rechenberget al (2000). It is
possiblethat this technique offers an ability to return the
athlete to racing more quickly than arthroscopicdebride-
mentdoes.

Articular cartilage lesions on medial

condyle of femur
These cases will be detected during diagnostic arthroscopy of
the stifle. A typical signalment will be lameness with possible
synovial effusion, positive response to hind limb flexion tests
and response to intra-articular local anesthesia of the stifle
(Schneider et al199 7). Lameness will be localized to the stifle
by analgesia and the diagnosis confirmed with arthroscopic
examination. Diagnostic arthroscopy of the medial femoro-
tibial joint is performed as previously described. Of 12 joints
in 11 horses that were affected with this condition and
described by Schneider et al (1997), all horses had focal areas
of damage to articular cartilage on the weightbearing surface
of the medial femoral condyle. Cartilage was dimpled,
wrinkled, and folded and was not firmly attached to the
subchondral bone (Fig. 6.67). Palpation of damaged cartilage
with a blunt arthroscope probe consistently revealed an area
of loose cartilage through which the probe could be easily
inserted into the subchondral bone. Fibrillation and exposure
of subchondral bone were also evident in some horses. The
location of the lesions was at the same site as for horses with
medial femoral condylar cysts. Areas of separated cartilage
should be debrided. In some instances of extensive damage,
what can be done surgically is limited as extensive debride-
ment will not produce a successfulresult.
In the report of Schneider et al (1997), follow-up inform-
ation was available for all horses. Six of seven horses that
were treated for focal cartilage lesions recovered completely
and resumed activities (successful racehorse, horse used in
three-day eventing, jumper, dressagehorse, trail riding horse,
and pleasure horse). One racehorse that had intermittent
lameness in the affected limb did not resume activities. Only
1 of the 4 horses with generalizeddamageto articular cartilage
became clinically normal (show horse that was retired and
used for pleasure riding). Two of the other 3 horses were
Standardbredracehorsesand the remaining case was a
Quarter Horse used for ranch work. Thesehorses were unable
to resume their previous activities as a result of persistent
lameness. It is therefore concluded that horses with general-
ized cartilage damage have a poor prognosis for becoming
clinically normal and performing well after treatment.

Subchondral cystic lesions of the

proximal extremity of the
tibia in horses
This condition is relatively uncommon. When it occurs, it is
typically present at a young age. In one report of 12 cases,the
mean age of these horses at presentation was 12.3 months
old, with a range of 6-24 months old (Textor et al 2001).
Horses will present with severity of lameness from 0 to 3 and ~
in all casesthe lameness can be exacerbated by stifle flexion.!
Stifle joint effusion (with pouch undefined) was present in
 6 of the 12 horses previously described. In 6 horses, intra-
articular anesthesia improved the lameness in 4 horses and
this was unchanged in 2 horses (these had extensive deep
lesions of the lateral tibial condyle). In 6 horses the lesions
were considered to be the result of osteochondrosis and were
solitary lesions involving the lateral tibial condyle without
other signs of joint disease(Fig. 6.68). In 5 out of 6 horses in
which the lesions were considered to be the result of osteo-
arthritis (OA), there was a well-defined cystic lesion of the
medial condyle of the tibia and signs of mild to marked OA,
including remodeling the proximal extremity of the tibia,
osteophyte formation on the medial aspect of the tibia and
femur, and subchondral bone sclerosis.
A technique for arthroscopic surgery has been reported
(Textor et al 2001) and cases arthroscopically approached
had lesions located in the cranial third of the tibial plateau. In
horses with lesions involving the lateral tibial condyle, the
lateral aspectof the femorotibial joint was arthroscoped using
a medial portal, as described previously, with the arthroscope
inserted between the middle and medial patellar ligaments.
Lesions would typically be identified cranial and immediately
lateral to the lateral tuberosity of the intercondylar eminence
(see Fig. 6.68). The cranial ligament of the lateral meniscus
usually obscured the stoma and the ligament was retracted
cranially or bluntly divided with the probe to expose the
stoma. Lesions were curetted to healthy bone.
If the lesion was located in the proximomedial aspect of
the tibia (medial to the intercondylar eminence), the medial
femorotibial joint was approached through a lateral portal
and, again, lesions would be identified by probing through the
fibers of the cranial ligament of the medial meniscus in a
manner similar to that described for lesions lateral to the
intercondylar eminence. In the paper of Textor et al (2001),
arthroscopic debridement was performed in 4 horses in
which the lesions were considered to be the result of
osteochondrosis and in 3 horses with osteoarthritis. Three
horses in which SCL were considered to be the result of
osteochondrosis performed athletically after debridement.
Two horses with moderate OA returned to work after
arthroscopic debridement, but at a lower level of athletic
performance. One horse with SCLrelated to osteochondrosis
responded to medical treatment and went on to race.

Fracture of the medial tibial

intercondylar eminence

Although these fractures have been associated with avulsion

of the insertion of the cranial. cruciate ligament (Prades et al
1989. Mueller et aI1994).tt is the first authors experience,as
well as that of Walmsley (2002), that this is not usually the
case. It is quite common to have these fractures with minimal
damage to the cranial cruciate ligament (Fig. 6.69-6.71).
even when they are quite large. The injury can of coUrse be
accompanied by damage to other structures. There is obvious
lameness and signs localizing the problem to the femorotibial
joint. The fracture can be diagnosed on radiographs. In cases
of isolated fracture, the usual treatment is removal of the
fractured portion through a cranial instrument portal in the
medial femorotibial joint (Mueller et al 1994). One author
has pointed out that if the fracture causes significant
disruption to the surrounding tissues. lag screw fixation is
preferred (Walmsley 1997). In the case described, fixation
was performed using a cranial arthroscopic portal with an
extra instrument portal in line with the angle of the implant.
The prognosis in these casesis related to absenceor presence
of other injury in the joint. The authors have treated cases
both by internal fixation and with arthroscopic removal.
Injuries to the cruciate ligaments
Cruciate ligament injury in the horse was initially described
by Sanders-Shamis et al (1988) and Prades et al (1989).
Complete rupture of the cranial cruciate ligament in the
horse is catastrophic and it is unusual to examine these cases
arthroscopically (Fig. 6.72). Less severe injuries to cruciate
ligaments can be regularly diagnosed with diagnostic
arthroscopy. It has been pointed out that sometimes strains
and partial ruptures may be diagnosed ultrasonographically
if the examiner has considerable experience (Cauvin et al
1996). However, arthroscopy is the preferred choice for a
definitive diagnosis.
Diagnostic arthroscopy of the cranial pouch of the medial
femorotibial joint can be done through a lateral or cranial
portal. The cranial portal will give better overall visualization
of the cruciate ligaments in the intercondylar notch, but both
approaches can be used. A typical partial-thickness tear will
involve the body of the cranial cruciate ligament, rather than
the insertion. This is consistent with experimental work that
has shown cranial cruciate ligaments fail in mid-body (Rich &
Glisson 1994), at least in the pony. However, avulsion at both
the tibial and femoral insertions of the cranial cruciate
ligament has been reported (Edwards & Nixon 1996, Prades
et al 1989). Caudal cruciate ligament injury has been
described in the literature (Moustafa et al1987), but is un-
common. Caudal cruciate injuries observed arthroscopically
generally appear as longitudinal shredding of the femoral
origin, although radiographic lesions associated with the
tibial insertion of the caudal cruciate can occasionally be
seen. Cranial cruciate injury can vary from hemorrhage on
the synovial membrane covering the cruciate ligaments
or mild fiber disruption to more severe fiber disruption
 .Grade III, a severetear of the meniscus and ligament
that extends beneath the femoral condyle so that the
limits of the tear cannot be seen.
It is less common to see tears of the meniscus in the caudal
pouch of either the medial or lateral femorotibial joint,
although this probably reflects the reduced frequency that
surgeons successfully enter and examine the caudal pouches.
For meniscal tears in the cranial portion of the meniscus
(medial femorotibial joint), the arthroscope is usually placed
through the lateral portal, as visualization is satisfactory and
it is out of the way of the instrument. Meniscal injuries
seen in the horse can be categorized as vertical radial
(transverse) vertical longitudinal, vertical flap or bucket
handle, or as horizontal transverse (Fig. 6.74). True bucket
handle tears, as seen in man are rare in the horse. A cranial
instrument portal is made and the torn portion removed. This
can be accomplished with a combination of Ferris-Smith
rongeurs, biopsy suction forceps, or motorized equipment
(Figs 6.75-6.77). The aim is to leave a clean edge of healthy
meniscus. One of the authors (A.J.N.)has used intraarticular
suturing of the meniscus in four horses. The meniscal tear
should be clean, vertical, and relatively fresh. Suturing can be
achieved by using flexible needles (Fig. 6.78) (Nitinol,
Arthrex Corporation, Florida) to tie mattress sutures through
the tear, and more complex tears can be sutured with a
Bankart shoulder repair device (Fig. 6.79) (Arthrex Corpo-
ration, Florida) used in an upside-down configuration. Trans-
verse vertical tears can be more difficult to trim or suture,
since they orientated across the structure of the meniscus
(Fig. 6.80). Additionally, they occur more commonly in the
central (medial) to caudomedial portion of the meniscus and
can be difficult to even visualize.
Similarly, tears of the lateral meniscus will be encountered
on exploration of the lateral femorotibial joint using the
portal that starts in the medial femorotibial joint. Access can
be a little more difficult with the arthroscopic portal in this
joint as the long digital tendon and popliteal tendon are both
present intra-articularly. Avulsion fracture of the insertion of
the cranial ligament of the lateral meniscus can cause
meniscal instability (see Fig. 6.81). This site is predisposed,
and in one author's opinion (A.J.N.), occurs as frequently as
tears in the lateral meniscal body.
In the initial report of Walmsley (1995), there were
5 horses with a vertical tear in the cranial horn and cranial
ligament of the medial meniscus and 2 horses with similar
injuries in the lateral meniscus. All the lesions had similar
characteristics and the tear was about 1 cm from the junction
of the axial border of the meniscus and the cranial ligament
of the meniscus ligament. In all but one case it was in-
complete, with much of the torn tissue loosely attached to the
axial part of the meniscus from where it was removed. The
remaining meniscus abaxial to the tear was displaced
cranially and abaxial and its torn edges were debrided. In
those cases, 3 horses returned to full competition, 1 horse
was useable for hacking, 2 were convalescing and 1 was lame
after 1 year. Walmsley (1995) pointed out that these lesions
were quite different from the vertical meniscal tears, which
occurred in the cranial horn of the meniscus at least 1 cm
abaxial to the junction of the meniscus and its cranial
ligament and involved separation of meniscal tissue on either
side of the tear. The author was also uncertain as to whether
fraying was symptomatic or associatedwith age and use. This
paper served as the hallmark for making meniscal injuries a
recognizable syndrome.
A later retrospective study described 80 cases of
meniscal tears in horses (Walmsley et al 2003). Inclusion
criteria were:
1. Lameness localized to the femorotibial joint with clinical
confidence (in most cases that involved intra-articular
diagnostic analgesia).
2. Diagnostic arthroscopy identifying an abnormality in one
or both of the femorotibial menisci.
3. The meniscal injury was considered to be the primary
lesion in the joint.
The medial meniscus was involved in 60 casesand the lateral
in 20 cases.Forty-three tears were Grade I. 20 were Grade
n, and 17 were Grade Ill. Distention of either or both
the femoropatellar and femorotibial joint was recorded in
31 horses, but in 14 of these, distention was recorded in only
the femoropatellar joint. The relative likelihood of joint
distention was nine times greater among horses with Grade n
and III injuries (17/20,13/17), respectively,as compared to
horses with Grade I injuries (4/43). The median lameness
Grade was 3 (on a scale of 5); the response to intra-articular
analgesia was positive in 59/65 horses in which it was
performed and, in 45/76 horses in which the information
was recorded, the flexion test worsened the lameness. Radio-
graphic abnormalities were seenin 38 horses and increased
with severity of lesions. New bone formation on the medial
intercondylar eminence of the tibia occurred in 23 cases
and OA of the femorotibial joint was evident in 18 cases.
Mineralization of soft tissue structures was seen in
six cases.
Walmsley et al (2003) used the Outerbridge (1961)
human grading system for articular cartilage lesions. Lesions
in the articular cartilage of the medial femoral condyle (MFC)
or lateral femoral condyle (LFC)were recorded as:
.circumscribed areas of prominent fibrillation less
than 1.5 cm in diameter, (similar to those graded as
Outerbridge Grade 2)
.generalized fibrillation extending over larger areas,
associated with a parent thinning of the articular
cartilage (similar to Outerbridge Grade 3)
.superficial, mild fibrillation (similar to mild Outer-
bridge Grade 3)
.full-thickness lesions of variable size in which the
subchondral bone could be palpated with a probe
(similar to Outerbridge Grade 4)
.shear lesions or chondral flaps characterized by the
presence of torn flaps of articular cartilage
.thickened, softened, enfolded, or fissured articular
cartilage (similar to Outerbridge Grade 1, but more
severeand with fissuring)
.small (about 3 mm), raised plaques of firm cartilage
tissues sometimes containing shiny, yellowish tissue.
 Left Tibia

Horizontal transverse

Vertical radial (transverse)

Bucket handle

B Vertical Flap Vertical longitudinal

Fig.6.74
(A) Schematic diagram of the menisci and associated ligaments. (8) Types of meniscal tears: horizontal; vertical radial; vertical
..
 abnormalities of the femoral or
recorded in 61 horses. These

and 12 of 17 Grade ill tears. Full-thickness

generalized fibrillation of the articular
3 and 4) lesions were recorded
horses and these had a median age of 10 years old
3-22). Concurrent cranial cruciate ligament injury
in 12 cases. Twenty-five other horses showed

Overall,47% of affectedhorsesreturned to full use.The

Gradewas 63% for GradeI tears,56%

concurrent cruciate injury were followed up and

Of the horses with radiographic technique (Sopera & Hunter 1992) with No.3 polYglactin
more were lame 910 (Vicryl).
follow-up as compared to those that did not have a Meniscal tears, particularly the longitudinal tears
75% vs 10/34 described by Walmsley et al (2003) as Gradeill, can progress
.In the series of cases by Walmsley et al (2003), into the mid-portion and even the caudal horn of the
I lesions were not debrided, but consideration was meniscus. Any meniscal tear where the abaxial (medial) and
to suturing. It was not considered practical in most caudal termination cannot be discerned needs to be explored
but one Grade III lesion was sutured using the further by examination through the caudal joint pouch of
of the laparoscopic extracorporeal knotting the femorotibial joint. Discrete tears of the caudal horn of the
 medial meniscus can also occur (Fig. 6.82). The authors now
always examine the caudal portion of the medial femorotibial
joint. even if a tear in the cranial horn appears contained.
The medial meniscus is predominately affected; the lateral
meniscus caudal horn has been involved only once in our
experience.Vertical longitudinal tears of the medial meniscus
have also been seen(Fig. 6.83). Mineralization of the meniscus
is a late-stage development (Fig. 6.84) and frequently signals
chronic meniscal tearing. Surgical aims in mineralized cases
should be to trim all protruding portions that impact on the
caudal surface of the femoral condyle. debride free or
fibrillated soft portions of the meniscus and suture any
longitudinal tears that are not disintegrated. Manipulation of
instruments in the caudal compartment is tedious. particu-
larly since the depth of the damaged meniscus from the skin
surface is often 6-8 cm. Trimming of caudal horn meniscal
tissue is best accomplished with a motorized resector,
particularly the large-format tooth synovial resectors such as
the orbit incisor or Synovator. Removal of mineralization
generally requires an arthroburr.
In common with other species, macerated tears of the
menisci carry a poor prognosis for return to working sound-
ness as the loss of fibrocartilagenous meniscal tissue is
usually marked. These injuries frequently also extend into the
central inaccessible regions of the meniscus so that removal
of torn tissue often is incomplete.
~
Other indications for arthroscopic
surgery in caudal pouches
the caudal aspectof the femoralcondylesin foals
examination of the caudal pouches has been
(Hance et al 1993). We have also used this approach
The caudal compartment of the medial femoral
is quite voluminous and free fragments can be
the instrument portal is vital in reaching the
and avoiding instruments and the arthroscope
with each other as they penetrate deeper to
free pieces.
The caudal portion of the caudal r
medial femorotibial joint (Fig. 6.85). However,
ence of authors, disruption of the insertion of
(evident radiographically) may not be visible
arthroscopy. Moreover, the popliteal artery is ~
this ligament and exposure of the caudal cruciate
motorized resection of the covering joint capsule would
hazardous. A caudal cruciate ligament avulsion in ;'
has been defined with imaging (Roseet aI2001).

Vet
, Zugang.Teil 1:
11:
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examination
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Akeson WH. Keown GR. The repair of large osteo-
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-Nixon. AJ. Avulsion of the cranial cruciate ligament in
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~- -Mcllwraith CWoTrotter GW. Arthroscopic surgery for
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et al. Lesions of the caudal
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842-850.
WA, Stick JA, Arnoczky Sp, Nickels FA. The effect of
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J. Results of treatment of subchondral bone cysts
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CWoSurgery of the hock. stifle and shoulder. Vet Clin
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Experience in diagnostic and surgical arthroscopy
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-.Treatment of osteochondritis dissecans and
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Mcllwraith CWoOsteochondral fragmentation of the distal aspect of
the patella in horse. Equine Vet J 1990; 22: 157-163.
Mcllwraith CW Osteochondritis dissecans of the femoropatellar
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Mcllwraith CW, Martin GS. Arthroscopy and arthroscopic surgery in
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Mcllwraith CW, Martin, CS. Arthroscopic surgery for the treatment
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Marble GP, Sullins KE. Arthroscopic removal of patellar fracture
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Martin GS. Mcilwraith CWoArthroscopic anatomy of the equine
femoropatellar joint and approaches for treatment of osteo-
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Moustafa MAl. Boero II. Baker GJ. Arthroscopic examination of the
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Mueller POE. Allen D. Watson E. Hay C. Arthroscopic removal of a
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Nickels FA. SandeR. Radiographic and arthroscopic findings in the
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Outerbridge R. The etiology of chondromalacia of the patella. JBone
Joint Surg (Br) 1961; 43: 752.
Nixon AJ. Fortier LA. Goodrich LR. Ducharme NG. Arthroscopic re-
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Pascoe JR. et al: Osteochondral defects of the lateral trocWear
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1984; 13: 99-110.
Prades M. Grant VD. Turner TA. Injuries of the cranial cruciate
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Ray CS. Baxter GM. Mcilwraith CWoet al. Development of sub-
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Rich RF. GlissonRR. In vitro mechanical properties and failure mode
of equine (pony) cranial cruciate ligament. Vet Surg 1994; 23:
257-265.
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Sandler EA. Bramlage LR. Embertson RM. Ruggles AJ. Frisbie DD.
Correlation of lesion size with racing performance in Thorough-
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Schneider RK. Jenson P. Moore RM. Evaluation of cartilage
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 ~

tarsocrural (tibiotarsal) joint has proven highly
both diagnosticand surgical arthroscopy.The
the other joints, new discoveries have caused
in the indications for diagnostic arthroscopy as
as an increase in the spectrum of surgical conditions
tarsocrural joint. For instance, before the use of
surgical intervention was not considered
a tarsocrural joint manifesting effusion and/
unless it had a radiographic lesion. Now we
that not all cases of tarsocrural OCD, for instance,
radiographically. Although this finding further
the limitations of radiographs, it does, however,
to define and treat cases of "idiopathic synovitis"
undefined. In addition,
other joints, OCD can be treated conveniently with
and the same advantages exist.
diagnostic arthroscopy in the tarsocrural
dorsal and plantar. The dorsal approach
a dorsomedial (craniomedial) arthroscopic portal.
approach involves a plantarolateral or plantaro
arthroscopic portal. Most arthroscopic cases involve
, ,. In the previous
The tarsocrural joints are shaved on both sides of the joint.
The draping system includes an adhesive barrier and
impermeable drapes (Fig. 7.1). The joint is distended before
making the skin incisions. The skin incisions for the
arthroscopic and instrument approaches are located to the
sides of the group of extensor tendons on the dorsal aspect of
the joint (the long digital extensor, the peroneus tertius, and
the cranialis tibialis tendons). These structures are col-
lectively referred to in the remainder of the text as the
extensor tendons. As a general principle, all portals are made
close to (approximately 1 cm from) the extensor tendons to
maximum visualization.
Arthroscopic examination using a
dorsomedlal approach
The dorsomedial approach is used most commonly. If the
arthroscopic portal is made close to the cranialis tibialis and
peroneus tertius tendons. a large portion of the dorsal aspect
of the joint can be seen. The approach provides excellent
visualization of the cranial or dorsal compartment of the
tarsocrural joint. including the trochlear ridges and trochlear

were described. However. with the exception of

the lateral malleolus of the tibia. a dorsolateral
.An appropriately placed

areas where surgery is done. Therefore diagnostic

in this text are now limited to those seen with a
..approach.
In all situations, the patient is in dorsal recumbency. This

which is important for triangulation. but also the

flexion of the joint is easily controlled. The leg may
or hangs free. With relevance to arthroscopic
also minimizes the risk

.
groove of the talus. Flexing and extending the joint, which
brings different areas of the trochlear ridges into view, can
increase the area of visualization. The corresponding area of
the distal tibia from the medial malleolus to the distal inter-
mediate ridge is also visible. Many adult horses also have an
opening that allows visualization of the proximal intertarsal
(talocentral) joint distally. Inspection of the synovial lining of
the dorsal aspectof the tarsocrural joint can also be performed.
The joint is distended using a needle placed through the
dorsomedial pouch with the leg in extension (see Fig. 7.1).
The skin portal is made slightly dorsal to the center of the
distended dorsomedial outpouching and just below the
palpable distal end of the medial malleolus. and the arthro-
scopic sleeve and conical obturator are inserted (Fig 7.2).
This position is ideal for visualization within the joint. If the
arthroscope is placed more medially, it is difficult to pass the
arthroscopic sheath over the trochlear ridges of the talus
across the joint. The skin portal is made sufficiently large
(8-10 mm) to ensure that the saphenous vein is not directly
beneath the incision and to avoid its penetration. In many
horses, the arthroscope portal can be made between the
saphenous vein and the extensor tendons, and this location
provides optimal visualization of the deeper region of the
intermediate ridge. A No. 11 blade is then used to continue
the portal through the fibrous capsule. The sleeveand conical
obturator are then inserted until contact with the medial side
of the talus is made (Fig. 7.2). The joint is then flexed,
enabling the arthroscopic sleeveand obturator to pass across
the joint, over the top of the trochlear ridges. and beneath
the extensor tendons (this maneuver is impossible in an
extended joint).
The arthroscopic portal can also be made with the joint
flexed, eliminating the need to flex the joint during placement
of the sheath; however. the landmarks (as well as location of
the saphenous vein) are more easily identified with the limb
in extension.
Examinationcommenceson the lateral
and its articulation with the tibia. This view
lateral malleolus (Fig. 7.3). c
visualize the central lateral trochlear ridge (Fig.
further distad, the distal part of the lateral
comes into the visual field (Fig. 7.5). In this
of the arthroscope. The view of the arthroscope
and the arthroscopeis withdrawn
oriented in a plantar direction to
of the trochlear groove of the talus (Fig. '
of the trochlear groove is visible further distally
addition. the talocentral (proximal intertarsal) j
visualized (see Fig.
usually patent in very young foals. A
the talus (Fig. 7.7E).
Further withdrawal of the arthroscope
rotation, so that the view is proximal and
visualization of the proximal
ridge and its articulation with the distal tibia (Fig.
the medial malleolus is possible (Fig. 7.9). The
aspects of the medial trochlear ridge can be -
allows examination of the medial side of
dorsomedial pouch (Fig. 7.12).
With this approach. imposition of soft tissue sometimes
makes examination of the lateral trochlear ridge and other
 (Tibiotarsal) Joint
areasof the lateral part of the joint challenging.It requires
the end of the arthroscopeto be closeto the lateraltrochlear
ridge of the talus along with the use of the instrument to
retract soft tissue. However,with practice, this becomes
reasonablyeasy.
Arthroscopic examination using plantar
lateral or plantar medial approaches
These approaches are used far less commonly. They allow
excellent visualization of the remaining (proximal) portions
of the lateral and medial trochlear ridges that are not
visualized by using the previously describeddorsal approaches.
Eachtrochlear ridge is bestevaluated by using an arthroscopic
approach through the same side (Fig. 7.13). The principal
benefit of using the plantar approaches is allowing examin-
ation of defects in the proximal portion of the trochlear
ridges. the removal of loose bodies in the plantar pouch, and
the treatment of sepsis and osteomyelitis. This approach
sometimes also is useful to access fractures of the lateral
malleolus of the tibia. Virtually all of the synovial lining of
the plantar joint pouch can be inspected through use of these
approaches. Additionally, the planfar aspect of the distal tibia
and the deep digital flexor tendon (DDFT) within its tendon
sheath can be seen,but these observations have not provento
be of major clinical relevance. Since the second edition, the
approach to the plantar pouch has been reported in the
refereed literature (Zamos et al 1994). Joint distention is
critical for the plantar lateral approach, and is done by
placing a needle in the center of the plantar pouch which
usually allows adequatedistention. The skin portal is made in
the center of the plantar outpouching with the tarsus flexed
at 90°. The arthroscopic sheath is placed in the joint using
the blunt obturator. The surgeon should be careful to avoid
damaging the trochlear ridges of the talus. Viewing
commences with the hock flexed (Fig. 7.13).
Introduction of the arthroscope through a plantaromedial
or plantarolateral portal located in the center of the plantar
pouch puts the arthroscope immediately dorsal to the tarsal
synovial sheath surrounding the DDFT and plantar to the
trochlear ridges of the talus. This permits evaluation of the
plantar aspects of the medial and lateral trochlear ridges of
the talus as well as the trochlear groove, the distal tibia
(plantar aspect of intermediate ridge) and the articular
portion of the tendon sheath containing the DDFT (see
 7.13). Througha plantarolateralarthroscopicportal. the spavin) is noted in the young horse, even when the radio-
c -
graphic signs are negative. In addition, arthroscopy is an
and the lateral malleolus can also be observed if excellent means by which to evaluate the joint in a case of
., ., , Withdrawing the arthro-
severe synovitis, suspected
The general aspects of
discussed in Chapter 3. Septic
young horse can be evaluated and

If a plantaromedial arthroscopic portal is used, directing
arthroscope dorsally allows observation of the dorso-
malleolus cannot be seen.
By extending the joint more (approximately 120°), the
, and lateral dorsal cul-de-sacs of the joint can be
Chapter14. Arthroscopyalso permits identification of soft
tissuelesionssuchastearsof the collateralligaments.within
or communicating with the tarsocrural joint. As in otherjoints.
arthroscopyis superiorto radiographicexaminationor
synovialfluid analysisfor diagnosisin the tarsocruraljoint.

enhanced examination of the proximal areas of the

arthroscopy of the
joint
Arthroscopic surgery has proven to be an excellent tool in the
The most common indication for arthroscopyin the tarso- tarsocrural joint and is indicated for the following conditions;
crural joint is for the surgical treatment of OCD.In some 1. Osteochondritis dissecansof the distal intermediate ridge
instances. however. OCD is .and
dissecans of the lateral and medial
examination.For this
3.
~
2.
 4. Osteochondritisdissecansof the medial malleolus of
the tibia.
5. Removalof lateralmalleolarfragments.
6. Debridementof septiclesionsof the trochlear ridges of
the talus.
7. Removalof fibrin in septicarthritis.
8. Treatmentof someforms of proliferativesynovitis.
9. Traumaticlesionsand osteoarthritis.includingdiagnostic
arthroscopyin casesof lamenessand hemarthrosis.
10. Intra-articular fracturesof the tarsocruraljoint.
11. Retrieval of fragments from the talocentral (proximal
intertarsaljoint).
12. Tears/avulsionsof the collateralligaments.13.
Tears/avulsionof the joint capsule.

Osteochondritis dissecans of
the tarsocrural joint

In our experience, OCD of the dorsal aspect of the distal

intermediate ridge of the tibia is the most common indication
for arthroscopic surgery in the equine tarsocrural (tibiotarsal)
joint. A review of a series of cases of OCDof 318 tarsocrural
joints treated by arthroscopic surgery (McIlwraith et al19 91)
provides an indication of the location of these lesions
(Table7.1).
Lesions were seen most frequently on the intermediate
ridge of the distal tibia, followed by the lateral trochlear ridge
of the talus, and the medial malleolus, respectively. Lesions
were also seen at multiple sites in 22 joints. Loosebodies were
present in 8 joints; 5 of them had separated from inter-
mediate ridge lesions and 3 fragments had separated from
lateral trochlear ridge lesions.
These lesions occurred in 203 horses (Table 7.2).
Horses with OCD of the intermediate ridge of the tibia
usually have joint effusion and/or lameness. Commonly, the
clinical situation is joint effusion in the young horse of
yearling age; lameness is often not evident. Careful examina-

Location Number of Joints

Intermediate ridge of the distal tibia
Lateral trochlear ridge of the talus
Medial malleolus of the tibia
Intermediate ridge of the tibia plus the
lateral trochlear ridge (both)
Intermediate ridge plus medial malleolus
of the tibia (both)
Intermediate ridge plus medial trochlear
ridge of talus
Lateral trochlear ridge of the talus and the
medial malleolus of the tibia (both)
Medial trochlear ridge of the talus
Lateral and medial trochlear ridges of the
talus (both)
Total
From Mcllwraith et a11991.
244
37
12
tion, however, often reveals a gait abnormality, which may
relate solely to decreased flexion in the tarsus owing to
increased synovial fluid pressure.
In the 1991 retrospective study of 303 joints in which
synovial effusion was recorded, it was the presenting clinical
sign in 261 (86.1%). In racehorses, effusion was present in
166 joints (81 %) and absent in 39 joints. In non-racehorses,
effusion was present in 95 joints (96.9%) and absent in
318 3 joints. The degree of lameness was not recorded con-
sistently, but usually was designated as mild. The exception
was when a severelesion was present on the lateral trochlear
 Tarsocrural
(Tibiotarsal)
joint

.,
Once the fragment is elevated. an appropriately sized pair of
grasping forceps is introduced and the fragment is grasped
(Fig. 7.17). The grasping forceps are then rotated to break As with all other OCD lesions, thearthroscopic
down any remaining soft tissue attachments and withdrawn. manifestations in c -~ .
.""
As discussed in Chapter 4. the forceps should enclose the
fragment. In many instances in the tarsocrural joint. how-
ever. due to the large size of fragments this is not always
possible.as in the caseillustrated in Fig. 7.18. As the fragment but an osteochondritis dissecans flap was found.

is pulled through the joint capsule. fluid flow is again stopped that
crural in joint
the case
had illustrated
an effusion in but
Fig. no
;

to minimize the development of subcutaneous fluid extra-

~
vasation. As in other joints. larger fragments may necessitate
enlargement of the skin incision. Otherwise. the surgeon
runs the risk of losing the fragment subcutaneously.
The defect from which the fragment was removed is then
evaluated (Figs 7.16 and 7.17) and any additional fragments
are removed. Light curettage elevates any tags of tissue pouch of the tarsocrural joint, or descend
within the defect or at the edge of the defect. which are
removed with forceps or rongeurs. The surgeon must pay
particular attention to the most plantar portion of the defect, the loose fragments and debridement of the primary]
where fragments may remain but cannot be visualized. are needed.
Reduced flexion and careful probing of the defect along the
edge facing the trochlear groove can reveal additional bandage -(
fragments and these need to be loosened and removed. The and Elasticon@ -J
joint then is lavaged copiously. Postoperative radiographs are operation. Maintenance of J
are removed is particularly important since these incisions
are prone to dehiscence and later sepsis.
The patients can be discharged from the clinic on the first
postoperative day. Therefore the protocol depends on the
severity of the case. Animals should be hand walked for
4 weeks and then allowed small paddock or controlled light
exercise for an additional 4 weeks. Some clinicians consider
the use of sodium hyaluronate or polysulfated glycosamino-
glycan (Adequan@) useful 30 days postoperatively. Training
can resume in 8-12 weeksunless some other clinical problem
arises. Because of the early return to exercise. trainers are
more willing to stop training and remedy the problem while it
is fresh. The same advantages as discussed with regard to
carpal and fetlock fragments apply to operations involving
the tarsocrural joint.

Treatment of osteochondritis dissecans

of the trochlear ridges
The technique for arthroscopic surgery of lesions on the
lateral trochlear ridge of the talus is illustrated in Figure
7.21. Typical cases of OCD of the lateral trochlear ridge are
illustrated in Figures 7.22-7.24. Defects on the trochlear I
ridge may have an OCD flap in situ (Fig. 7.22), an osteo- I
chondral fragment at the distal aspect of the lateral trochlear i
ridge (Fig. 7.23), or both a primary lesion and a loose body
remote from the lesion that is totally free or embedded in the
synovial membrane (Fig. 7.24). The presenting clinical signs
associatedwith OCDof the lateral trochlear ridge of the talus
may be the same as with lesions on the intermediate ridge of
the tibia or they may be more severe. The severity of the
clinical signs is usually related to the amount of lateral
trochlear ridge that is affected.
For cases of OCD or fragmentation of the trochlear ridges,
a triangulation approach using a medial arthroscope and
lateral instrument portals is used (seeFig. 7.21). As discussed
in the section concerning diagnostic arthroscopy, when a
dorsomedial arthroscopic approach is made, the medial
trochlear ridge on the near side is visualized easily, but the
lateral trochlear ridge may be difficult to visualize because of
the closer apposition of the extensor tendon bundle and associ-
ated joint capsule on this side. In all instances, use of a needle
to ascertain the optimal site for the instrument portal is recom-
mended. It should be recognized that the technique for lateral
trochlear ridge debridement is more difficult than that used
for intermediate ridge lesions. In the report on arthroscopic
surgery for the treatment of OCD in 318 tarsocrural joints
(Mcllwraith et alI991), one of the two surgeonswas still doing
arthrotomy for lateral trochlear ridge lesions. Therefore, in
that published report, the relative percentage of lateral troch-
lear lesions is smaller than a large population would provide
because only the first author's (C.WM.) lateral trochlear ridge
caseswere included. Although arthroscopic surgery for lateral
trochlear ridge lesions is more challenging than for distal
intermediate ridge problems, all lateral trochlear ridge lesions
can be effectively managed using arthroscopic techniques.
The principles of fragment removal are the same as
described for osteochondritis dissecans of the intermediate
ridge. Debridement to healthy subchondral bone is important
in the more involved trocWear ridge lesions. Any osteochondral
flap or fragment on the trochlear ridge is elevated and
removed and the lesion is debrided (Fig. 7.24). Loose bodies
a-e removed. Fragments embeddedin the synovial membrane
[13rC

,-¥ ,-"ilJUV"'U JJ .'-'-".1 ...'" VJ"JU1"'.

OCD lesions on the medial trochlear ridge of the talus are
rare, but do occur occasionally. When they occur, they are
typically on the trochlear ridge immediately distal to the tibia
when the leg is straight (Fig. 7.25). There were 3 casesin the
initial series published by McIlwraith et a11991. All cases
presented as typical undermining of the cartilage in this
same position on the medial trochlear ridge (Fig. 7.25). The
arthroscopic approach is illustrated in Figure 7.26.
Bone spurs and fragments (so-called dewdrop lesions)have
been identified distal to the medial trochlear ridge of the
talus. These spurs and fragments are typically extraarticular
and are generally considered normal radiographic variations
that are of no clinical significance (Shelley & Dyson 1986)
(Fig. 7.27). Surgical intervention generally is not indicated.
Most articular lesions (depressions) on the medial trochlear
ridge of the talus are incidental findings at arthroscopy (see

Osteochondritis dissecans of the

medial malleolus of the tibia
mentation of the I dial malleolus is tht:Iinical.
nIrQ Irgical.
mon location and th radiographic.

L M
findings are consistent with OCD.The axial intra-
portion of the medial malleolus is affected. Such
must be distinguished from fractures of the medial
that typically involve the entire malleolus, ex-
manifestations of OCD in the medial malleolus
. mediate ridge lesions. There was no significant relationship
in our experience. the more common situation is the
, effusion and/or lameness when animals are
broken or beginning with race training or racing.
usually confirm the presence of a lesion (Fig. 7.28),
A dorsomedial arthroscopic portal is used (Fig. 7.29). The
, is extended. A needle is then used to decide on the
position for the instrument portal. but because of
positioning of the fragment it needs to be also in the
pouch and is axial to the arthroscopic portal
7.29). The instrument portal is axial and usually slightly
distal to the level of the arthroscopic portal. The fragment is
then elevated away using an elevator or osteotome,depending
on the degree of attachment remaining before fragmentation
is removed and the defect debrided (Figs 7.30 and 7.31).
Results of arthroscopic surgery
for treatment of osteochondritis
dissecans of the tarsocrural joint
The results of arthroscopic surgery for the treatment of OCD
in 318 tarsocrural joints in 225 horses have been reported
(Mcilwraith et al 1991). Arthroscopic surgery was an
effective technique for treating OCD of the tarsocrural joint.
The overall functional ability and cosmetic appearance of the
limbs were excellent. Post-surgical follow-up information was
obtained for 183 horses, of which 140 (76.5%) horses raced
successfully or performed their intended use following
surgery. Of the remaining 43 horses, only 11 horses were still
considered to have a tarsocrural joint problem. Nineteen
horses developed other problems precluding successful per-
formance, 8 horses were considered poor racehorses without
any lameness problems, 3 horses were euthanized because of
septic arthritis (all associated with the horse getting the
bandage off within 24 hours of surgery), and 2 horses died
from other causes.There was no significant effect of age, sex,
or limb involvement on the outcome. The successrate relative
to three size groups for intermediate ridge lesions was 27/33
(81.8%) for lesions 1-9 mm in width, 86/116 (74.1%) for
lesions 10-19 mm in width, and 41/47 (87.2%) for lesions
20 mm or more in width (no significant difference).
When successrate was considered relative to the findings
of additional lesions at arthroscopy, 16/19 (84.1%) with
articular cartilage fibrillation, 5/10 (50%) with articular
cartilage erosion or wear lines (seeFig. 7.32),3/5 (60%) with
loose fragments (Fig. 7.33), 0/2 with proliferative synovitis
and 0/1 with joint capsule mineralization were successful.
There was a significantly poorer outcome in racehorses with
articular cartilage degeneration or erosion (p < 0.05).
The synovial effusion resolved in 117/131 racehorse
joints (89.3%) and in 64/86 non-racehorse joints (74.4%).
The outcome for synovial fluid effusion was significantly
inferior for lesions of the lateral trochlear ridge of the talus
and medial malleolus of the tibia compared to distal inter-
between resolution of effusion and successful performance
outcome.
More recently, the results of 64 Thoroughbreds and 45
Standardbred horses treated for OCD of the tarsocrural joint
with arthroscopic surgery prior to 2 years of agewere reported
and were compared to those of other foals from the dams of
the surgically treated horses (Beard et al 1994). For the
Standardbreds, 22% of those who had surgery raced as
2 year olds and 43% raced as 3 year olds, compared with 42%
and 50% of the siblings that raced as 2 year olds and 3 year
olds respectively. For the Thoroughbreds, 43% of those that
had surgery raced as 2 year olds and 78% raced as 3 year olds
compared with 48% and 72% of the siblings that raced as
 2 year olds and 3 year olds, respectively.The median number
of starts for surgically treated horses was lower than the
median number of starts for siblings for all groups except 3-
year-old Thoroughbreds. Median earnings were lower for
affected horses than for siblings for both breeds and both age
groups. There was a tendency for horses with multiple lesions
to be less likely to start a race than horses with only a single
lesion; however, the difference was significant only for 2-year-
old Standardbreds. Mfected Standardbreds and Thorough-
breds were less likely to race as 2 year olds than were their
siblings. It is noted that this study was quite different from the
first follow-up study (McIlwraith et al 1991); the selection
criteria and control groups were different and racing
performance was not analyzed by year in previous studies. In
another study, horses treated for OCD of the dorsal inter-
mediate ridge of the tibia performed as well as matched
controls (Laws et aI1993).

Subchondral cystic lesion of proximal

trochlear groove of talus uptake of technetium on a bone scan and diagnostic
arthroscopy detected a hole and cystic lesion in the trochlear
lesionsare uncommon,but havebeenseen(Fig,7.34).Thegroove (using a plantar approach). A medial plantar
case illustrated in Figure 7.34 showed an increased arthroscope approach and a lateral plantar instrument entry

These
allow debridement of trochlear groove cystic lesions. Some
lesions can be quite deep,despite minor radiographic abnor-
malities (Fig. 7.34). Flexion of the joint after insertion of the
arthroscope is used to exposethe cyst entry. Needle insertion
then guides the instrument portal.

Fractures of the lateral malleolus

These fragments are encountered less commonly than OCD
fragments and appear to be traumatic in origin. The important
point to note with fragments of the lateral malleolus is that a
relatively small portion of the lateral malleolus is actually
intra-articular; most of it is enclosed within the collateral
ligaments. A caseexample is provided in Figure 7.35. Both a
dorsolateral arthroscope and instrument portals are used
and the arthroscope portal is axial to the instrument portal.
This permits dissection of the fragmentation from the lateral
collateral ligaments and then removal and subsequent
debridement of the parent bone and ligamentous attachments.
 If fragmentation runs the full dorsoplantar width of the
lateral mallelous. the arthroscope can usually be pushed
through the traumatic defect. from the dorsal to the plantar
compartments of the joint. Sometimes there will be frag-
mentation that will hinge on the short collateral ligaments
into the plantar pouch or indeed become loose bodies in the
plantar pouch and these can be retrieved with the arthroscope
passing from dorsal to plantar and an instrument portal
created laterally in the plantar pouch. Such procedures are
difficult. because most of the fragments are embedded within
soft tissue. and inexperienced arthrocopists may use radio-
graphic localization with needles and/or external dissection
down to the fragment.
Other intra-articular fractures of the
tarsocrural joint
These fractures are relatively uncommon. Figure 7.36-7.39
show some examples of cases that may be encountered.
Fractures can occur through the medial malleolus of the tibia
and will show different manifestations than medial malleolus
OCD.There will be an obvious linear fracture line and usually
the fragment is displaced distally (Fig. 7.36). The fragments
are removed arthroscopically and prognosis will be related to
whether the long medial collateral ligament can be left intact.
Fragments may occur off the proximal plantar aspect of the
medial trocWear ridge (Figs 7.37 and 7.38) and are operated
on using an approach through the plantar pouch. Larger
displaced fracture fragments may also occur off the medial
trochlear ridge (Fig. 7.39).
Occasionally,fractures amenable to lag screw fixation will
occur in the talus; these are usually in a sagittal plane
(Fig. 7.40). Small linear fractures have been repaired with
one screw, but the cases illustrated in Figure 7.40 required
three cortical screws.
Retrieval of fragments from the
talocentral (proximal
intertarsal) Joint
Fragments will occasionally be seenin the dorsal talocentral
joint. They are often under a plica or a fibrous membrane. The
dorsomedial arthroscopic portal is the same for all other
surgery and allows visualization into the talocentral joint
(Fig. 7AI). A needle is used to decide on optimal placement of
the instrument portal. In some cases, a medial instrument
portal will be satisfactory, while in most we have used a
lateral instrument portal to retrieve the fragment from under
the joint capsule or plica. Exchange of arthroscope and
instrument portals may be useful and in several cases,a third
incision, medial and distal, in the dorsomedial joint pouch
has been required. Resection of the perimeter of the opening
between the tarsocrural and talocentral joints is often
necessary to identify and retrieve loose fragments from the
dorsomedial recess of the joint (Fig. 7AI).
 Tarsocrural
(Tibiotarsal)
joint

.,
Tears and avulsions of the collateral
ligaments of the tarsocrural joint

Tearsof the collateralligamentsare most commonlaterally.

The majority involve the short collateralligamentsonly. A
will havelong collateralligamentinvolvement.and less
the shortmedialligament.All
present with lameness.tarsocrural distention. and
phase and later there may be an irregular abaxial
to the malleolus. Ultrasound usually detectsdis-
(Fig. 7.42). Arthroscopically,the torn ligamentous
into the dorsal compartmentand is
with a motorizedresector(Fig.7.43).
Treatment of proliferative synovitis
Occasionally, severe proliferative synovitis occurs in the
tarsocrural joint, and debridement of some of the tissue
(partial synovectomy) can offer some relief" The authors have
used both hand instrumentation or motorized instru-
mentation (the latter is usually better) for debridement in
these cases.
Treatment of septic arthritis and septi
osteomyelitis
The use of arthroscopy in the treatment of septic osteomyelit
lesions of the talus was mentioned previously. ArthroscoI
has also been used to remove fibrin from patients wit
septic arthritis and is considered to emulate the successfl
results achieved with arthrotomy (Bertone et aI1987). Tl.
management of sepsis in synovial structures is discussed i
Chapter 14.
Aftercarl
Careful maintenance of a bandage postoperatively is critic;
(Fig. 7.44). As discussed with regard to osteochondrit
dissecansin the intermediate ridge, routine aftercare involv(
1 month of stall rest with hand walking and then son:
limited exercise before training commences at 2-4 month
depending on the amount of disease. In cases of oste(
arthritis or septic arthritis, the period of convalescence m8
vary. In cases of proliferative synovitis, anti-inflammatoI
therapy is often indicated. Intra-articular corticosteroi
administration also has been used.
Reference:
Beard WL, Bramlage LR, SchneiderRK. EmbertsonRM. Post-operativ
racing performance in Standardbreds and Thoroughbreds wit.
osteochondrosis of the tarsocrural joint: 109 cases(1984-1990
JAmVetMedAssoc 1994: 204: 1655-1659.
Bertone AL. McIlwraith CWoJones RL. et al. Comparison of variou
treatments for experimentally induced equine infectious arthritii
AmJ Vet Res 1987: 48: 519-529.
Dik KJ. Emerink E. van Weeran PRoRadiographic development (
osteochondral abnormalitis in the hock and stifle of Dutc
Warmblood foals from age 1 to 11 months. Equine Vet J 199~
Suppll. 31: 9-15.
Hoppe F. Radiological investigations of osteochondrosis dissecansi
Standardbred Trotters and Swedish Warmblood horses. Equin
VetJ 1984: 16: 425-429.
Laws EG. Richardson DW. Ross MW. et al. Racing performance i
Standardbreds following conservative and surgical treatment fc
tarsocrural osteochondrosis. Equine Vet J 1993: 25: 199-202.
McIlwraith CWoSurgery of the hock, stifle and shoulder. Vet Cli
North Am Large Anim Pract 1983: 5: 333-362.
McIlwraith CWoFoerner JJ,Davis DM. Osteochondritis dissecans c
the tarsocrural joint: Results of treatment with arthroscopi
surgery. Equine Vet J 1991: 23: 155-162.
McIlwraith CWoFoerner JJ.Diagnostic and surgical arthroscopy 4
the tarsocrural joint. In: McIlwraith CW (ed). Diagnostic an
surgical arthroscopy in the horse. 2nd edn. Philadelphia; Lea an
Febiger,1990: 161-193.
Shelley J. Dyson S. Interpreting radiographs. 5. Radiology of tl:
equine hock. Equine VetJ 1984; 16: 488-495.
Zamos DT. Honnas CM, Hoffman AG. Arthroscopic approach an
intra-articular anatomy of the plantar pouch of the equir
tarsocruraljoint. Vet Surg 1994; 23: 161-166.
 surgery of the shoulder is not a common
in horses and two of the authors' (C.W.M. and
experience over 20 years includes only 114 cases,
all but eight of those cases involving osteochondrosis.
techniques for performing arthroscopic surgery of the
have been described:a craniolateral approach.
shoulder joint immediately caudal to the infraspinatus
(Nixon 1987. Bertone & McIlwraith 1987b). In
the use of arthroscopic surgery for treating osteo-
and the results achieved in 11 horses (13
have been published (Bertone & McIlwraith
1987a). (Note: in this discussion osteochondrosis is a collective
term for osteochondritis dissecans (OCD) and subchondral
cystic lesions, as both commonly occur together.)
Conservative (non-surgical) treatment of osteochondrosis
of the shoulder has met with minimal success,particularly In
the limited numbers of horses able to enter athletic activities
(Meagher et al 1975, Nyack et al 1981, Rose et al 1986).
Rapid onset of osteoarthritis and a general delay in definitive
diagnosis often limit the response to surgery. Early surgical
reports describe several animals that responded well to treat-
ment by arthrotomy (Schmidt et a11975, Mason & Maclean
1977, DeBowes et al 1982, Nixon et al 1984); however,
extensive soft tissue dissection is necessary and the cranio-
medial aspect of the joint may not be visualized (Nixon et al
1984). Other complications include loss of lateral joint stability
(Schmidt et al 1975) and seroma formation (Nixon et al
1984). These complications are not only avoided with
arthroscopy but also the minimally invasive nature of
arthroscopy provides many of the intraoperative and post-
operative advantage~ seenin other joints. On the other hand,
arthroscopy of the shoulder is more technically complex. and
in adult horses it can be a particular challenge.
Surgical Anatomy of
the Shoulder
The shoulder is a relatively tightly articulated diarthrodial
joint. and consists of the rounded articular surface of the
humeral head and the depressed concavity of the glenoid
.
surface of the scapula. Collateral and stabilizing support for
the shoulder is derived from periarticular tendons and
ligaments. Lateral support is provided by the supraspinatus
and infraspinatus tendons of insertion, while medial support
is formed by the subscapularis tendon of insertion and a
plical fold, referred to as the medial glenohumeral ligament.
The primary cranial stabilizer is the biceps tendon of origin.
Similarly, caudal support is derived from the tendons of origin
of the teres minor and deltoideus muscles. Access for the
arthroscope and instrument entry is limited to the lateral
aspects by the close association of the scapula with the
thorax. Finally, the accessible portions of the shoulder are
functionally divided into cranial and caudal regions by the
infraspinatus tendon of insertion.
Insertion of the arthroscope
The horse is positioned in lateral recumbency. with the
affected limb uppermost and unsupported in a slightly
adducted position. The leg is draped so that traction can be
applied to the limb during surgery. After aseptic preparation
and draping of a wide sterile field. the appropriate landmark
for insertion of a spinal needle immediately cranial to the infra-
spinatus tendon and proximal to the notch dividing the greater
tubercle of the humerus into cranial and caudal components
is identified (Fig. 8.1). An 18-gauge. 3-inch spinal needle is
inserted at this location at an angle approximately 250 caudal
and distal to penetrate the shoulder joint cranial cul-de-sac
(Fig. 8.2). The needle is advanced until the tip contacts
articular cartilage. and about 60 ml of a balanced electrolyte
solution are then injected to distend the joint (Fig. 8.3).
The spinal needle is removed. and when the craniolateral
approach to the shoulder is selected. a 5-mm vertical skin
incision is made in the same location (if it is not made before
placement of the spinal needle). For the lateral approach. the
skin incision for the arthroscope portal is made 1 cm caudal
to the palpable caudal border of the infraspinatus tendon.
The arthroscopecannula and conical obturator are then
inserted through the joint capsulein the samedirection as
the I8-gauge spinal needleunder the infraspinatustendon
toward the caudal aspectof the joint (Fig. 8.4). Entry into
the joint is confirmed by removing the obturator and
observinga flow of fluid from the cannula.The arthroscope
is then placed within the cannula. and the diagnostic
arthroscopic evaluation can commencefrom this position
(Fig.8.5).

Normal arthroscopic anatomy

Systematic examination of the joint begins with the tip of the
arthroscope in the caudal aspect of the joint. In this position,
the caudal humeral head (ventrally), glenoid (medially), and
synovial membrane (laterally) can be visualized (Fig. 8.6).
The arthroscope and cannula are then withdrawn along the
lateral aspect of the joint to allow visualization of the lateral
rim of the glenoid medially, the humeral head ventrally, and
the synovial surface of the infraspinatus tendon laterally. The
synovial membrane adjacent to the infraspinatus tendon is
arranged in longitudinal bands and is relatively devoid of villi
(Fig. 8.7). At this stage, elevation of the limb to a position
 to the floor (as opposedto the adductedposition)

the joint capsule on the humeral head. and the lateral

8.8). Returning

the humeral head.The tip of the arthroscopeis

, the synovial membrane underlying the biceps

tendon, and the cranial aspect of the humerus (Fig. 8.9).
With the joint maximally distendedso the glenoid and humeral
head are separated,the tip of the arthroscope is inserted over
the humeral head and under the glenoid toward the medial
side of the joint. The articular surface of the glenoid and/or
caudomedial humeral head can be closelyexamined by rotating
the viewing angle of the scope 180°. Traction on the limb at
this stage also facilitates the procedure. The medial aspect of
the glenoid and humeral head are inspected as well as the
medial surface of the synovial membrane, which contains a
normal plica, devoid of villi, which has beenreferred to as the
medial glenohumeral ligament, despite the fact it is not truly
a ligament (Fig.8.10). In mature horses,complete examination
of the medial and caudomedial aspects of the shoulder joint
become more difficult. Additional traction can aid exposure,
but accesscan be limited unless erosion and malformation of
the humeral head are extensive.
Lateral arthroscopic approach
An alternative approach for arthroscopic examination of the
shoulder joint uses a direct lateral approach (Nixon 1987). In
this approach, the arthroscope penetrates the joint 1-2 cm
caudal to the infraspinatus tendon, entering betweenthe infra-
spinatus and teres minor muscles (Fig. 8.11). This approach
allows examination of the cranial, lateral, and caudal portions
of the humeral head and the glenoid cavity, and portions of
the medial aspectdepending on the age of the horse and extent
of disease.In most situations it also allows good visualization
of the caudomedial aspect of the humeral head (Fig. 8.12),
which can be difficult to examine using the craniolateral
approach. Additionally, it also leavesthe portal cranial to the
infraspinatus tendon available for the egresscannula. In adult
horses the cranial portal can also provide access for the
surgeon to insert a curved, blunt-tipped forceps across
the non-articular portion of the shoulder joint to engage the
glenoid notch and distract the humeral head from the glenoid
by rotation of the forceps. This allows the arthroscope to be
advanced safelyto the medial aspect of the joint (Fig 8.13). A
third portal. 2-4 cm caudal to the arthroscope entry portal,
is used as an instrument portal for arthroscopic surgery by
triangulation. This method of internal distraction precludes
the need for external traction; however. since it risks
iatrogenic damage to the cranial aspect of the humeral head,
it is generally used only in heavily muscled mature horses.
For surgical debridement of most OCD lesions, the younger
age of the horse and the chronicity of the disease provide
sufficient laxity that fluid distention and axial traction are
adequate to allow accessto most regions of the articulation.
The primary indication for diagnostic arthroscopy of the
shoulder joint is the evaluation and treatment of osteo-
chondrosis section). Diagnostic arthroscopy is also indicated
when lameness is localized to the shoulder by response to
intra-articular anesthesia but when
are equivocal. In such cases, fibrillation of the
dissecans.the arthroscopic findings do :-
with the radiographic changes. and the diagnostic examin-
ation is a critical part of the arthroscopic procedure. Arthro- l
scopy is also appropriate in cases of septic arthritis. both for
evaluating the articular cartilage and for treatment. 1
Using a probe during diagnostic arthroscopy of the
shoulder joint is critical. An instrument portal is necessary
for probe placement. and creation of this portal is describedin
the next section. The optimal site to insert the probe is
ascertained using an I8-gauge. 3-inch spinal needle.
In addition to defining intra-articular disease entities.
arthroscopy has been used in human patients with shoulder
instability and in assessingcasesof supraspinatustendinitis
(Cofield 1983), ruptured biceps tendon, and loose body
removal Oohnson1986). Such indications have not been
recognizedin the horse as yet; the horse does not have a
glenoidlabrum.
Arthroscopic Surgery of the
Shoulder joint for Treatment
of Osteochondrosis
As mentioned previously, non-surgical treatment of osteo-
chondrosis in the equine shoulder has rarely allowed horses
to regain athletic capability. Three different arthrotomy
approaches have been used to treat cases of osteochondrosis
in the equine shoulder. Complications of loss of lateral
support (Schmidt et al197S), limited access(DeBowes et al
1982), and seroma formation (Nixon et al1984) have been
seen, but probably of more importance is the fact that
complete visualization of the articulation is not possible with
an arthrotomy incision (Nixon et al1984). Extensive traction
is also critical to the performance of the procedure.
Arthroscopy provides advantages over arthrotomy in both
avoiding these complications as well as providing additional
benefits through the minimally invasive approach. It should
be stressed,however, that adequate arthroscopic visualization
and surgical manipulation in the equine shoulder joint are
more difficult than in other joints described previously in
this text.
The material presented is based on the experience of the
authors, both in evaluating the approaches in cadavers as
well as involvement in 114 clinical cases,including a pre-
viously published series of cases of osteochondrosis with
follow-up (Nixon 1986, Bertone & McIlwraith 1987a).
Preoperative considerations
Most patients manifest clinical signs before 1 year of age.The
age of presentation doesdepend somewhat on the observation
skills of the owners. In some cases,a recent history of lameness
may be described.Contracted conformation of the feetsignifies
more accurately the duration of a problem. Preoperative
clinical signs include lameness with a shortened cranial
phase of stride. Some horses show resentment to firm digital
pressure caudal to the infraspinatus tendon. Extension and
flexion of the shoulder joint is also resented in some cases.
Intra-articular anesthesia of the shoulder joint improves or
eliminates the lameness in most cases. However, when the
articular cartilage over subchondral bone defectsis still intact,
intra-articular local anesthesia may not generate a response.
Intra-articular anesthesia is performed by using the same
landmark as previously described for placing the spinal needle
during arthroscopy. The absence of these localizing clinical
signs, however, does not rule out the presence of osteo-
chondrosis in the shoulder. In many instances,
is evaluated after the elimination of problems in 1
limb with the use of nerve blocks.
The diagnosis of osteochondrosis is confirmed]
graphically. Standing radiographs may be taken. and
are sometimes necessary to provide images of r
quality to rule out the presence of any lesions in I
Radiographic signs of osteochondritis dissecans in
humeral head include malformation of the.
flattening and/or undulation of the bone caudally,
caudal portion of the humeral head, particularly
physeal junction, may be seen. Occasionally, ( .
development is evident without other radiographic
osteochondritis dissecans.
Radiographic abnormalities in the scapula that
considered to relate to osteochondrosis j ,
of osteochondritis dissecans, osteochondral
and abnormal flattening of , c .
8.16). In most instances, the glenoid cavity develops
border.More chronic shoulder OCDcaseshave
formation on the caudal aspect of the glenoid. In
instances. however. r ." ,
articular ( .-'-
1987a).
Arthrography of the shoulder' .-
a technique to diagnose OCD. but more importantly.
to those that are eroded to the extent that they are
salvage (Nixon & Spencer: ' -, --
head and glenoid cavil,
that one cartilage surf
prognosis,and can lead to surgery and generallya
outlook(Fig.8.18).
Arthroscopic technique
A thorough exploration of the scapulohumeral joint,
previously described, is performed as the first step. r
exploration involves probing all visible lesions as well
entry for triangulation during arthroscopic surgery in
shoulder, is illustrated in 1 .-.
is selected to permit accessto the caudal humeral r
central articular surface of the glenoid. To determine
location. an I8-gauge spinal needle is inserted about (
caudal to the infraspinatus tendon and 4 cm distal (-
arthroscopic portal (Fig. 8.20). This location usually f

When the needle position is judged to be satisfactory, an
8 mm skin incision is made at that location. and a stab
incision is continued into the muscle mass with the use of a
No. 11 or 15 blade (Fig. 8.21). A conical obturator is inserted
along the same path to ensure the presence of a workable
portal. It is important that fluid pressure be at a minimum at
this time. When the portal is unobstructed. intermuscular
extravasation of fluid is minimal, although it usually becomes
a problem later during surgery, regardless of the portal size.
The shoulder is one of the few sites where screw-in self-
sealing cannulae are useful to prevent massive subcutaneous
fluid accumulation. They limit the size of instrument entry,
and so must be at least 7 mm internal diameter to be useful
(described in Chapter 2). A blunt probe is initially passed
through the instrument portal to evaluate the lesions in thejoint.
to palpate the articular cartilage peripheral to the
defects,and to explore the extent of the undermined cartilage
in osteochondritis dissecanslesions as well as the openings of
subchondral cystic lesions. The presence of all lesions and
their degree is ascertained before any surgical manipulations
are performed (Fig 8.22-8.31).
This caudolateral instrument portal is used for debriding
most lesions. Laterally located defects are easier to operate
than medially placed lesions. Therefore, procedures involving
lesions on the medial side of the joint are performed first
while maximal joint distention can be maintained. and
separation of the glenoid and humeral head are achieved.
Adjunctive traction is also sometimes necessary at this stage
 as well. Surgical intervention on laterally placed lesions is still
possible later. when joint distention has decreased.
Humeral head defects (see Figs 8.23 and 8.24) are
debrided initially with a hand curette or periosteal elevator;
large pieces of cartilage are removed by using Ferris-Smith

~
rongeurs (Fig. 8.32). A motorized resector can be used for
debriding large lesions. The resector works well in the
debridement of easily accessiblehumeral head lesions. When
the defect is deeper within the subchondral bone, however,
the resector and/or burr may not reach, and a right-angled
curette is used. Angled motorized resectors (see Chapter 2)
can be very helpful to accommodate to the curvature of the
humeral head. Similarly, small angled rongeurs (patellar
forceps) can be helpful to enter deep OCDlesions and retrieve
cartilage flaps or debride subchondral bone (Fig. 8.34). At the
completion of subchondral bone debridement, the edges of
the defect are debrided with a hand curette and Ferris-Smith
rongeurs. When intact articular cartilage overlies a sub-
chondral defect(a common manifestation with osteochondritis
dissecans in the shoulder), all cartilage superficial to the
defect is removed and the defect beneath is debrided. Figures
8.30 and 8.31 depict defects on the humeral head after
debridement.
Similarly, articular cartilage fissures,areas of erosion, cyst-
like lesions, and detached articular cartilage in the glenoid
(Figs. 8.25-8.29) are debrided and removed by using Ferris-
Smith disk rongeurs, patellar forceps, curettes (both straight
and angled) and occasionally the motorized resector or burr.
The concave shape of the glenoid sometimes makes
accessibility with the straight resector blade difficult. An
angled resector and the right-angled curette are particularly
useful for debriding extensive lesions and deep lesions.
Osteochondral fragments are rare in the shoulder.
In some cases,an additional cranial incision or exchange
of the arthroscope and instrument portals is needed to gain
instrument accessto the cranial aspect of the joint (Figs 8.35
and 8.36). Alternatively, using the lateral arthroscope entry
technique, the arthroscope remains caudal to the infraspinatus
tendon, leaving the existing portal cranial to the infra-
spinatus tendon free for rongeurs or curettes, which replace
any egress cannula that have been placed during the initial
phase of surgery. Instrument entry through the cranial portal
allows removal of free osteochondral fragments from the
cranial cul-de-sac of the joint or access to lesions of the
humeral head that extend more cranial than normal
(Fig. 8.37).
At the completion of the procedure, the joint is lavaged by
using a large-bore (4.5 mm) egress cannula through the
instrument portal (Fig. 8.33). Suction is usually applied at
some stage to ensure removal of debris. As discussed in
 a focal subchondralcystic lesionmay alsobe noted.

the cyst(Fig.8.25).

Postoperative management
Antibiotics are administered perioperatively and for 2 days i
postoperatively.Phenylbutazone is administered on the day of j
the operation and for the successive 3-5 days. Horses are
confined to a stall for 10 days, at which time hand walking
commences. We usually start with hand walking for
5 minutes per day, with incremental increases of 5 minutes
each week to 30 minutes per day. Horses are then turned out
for periods of 4-12 months before forced exercisebegins.

Problems and complications

and surgical manipulation are more difficult in tJ

shoulder joint than in most other joints in which arti
surgery is commonly performed. A definite J '

most people experience one or more of the

difficultiesand complications.

Arthroscopic placement in the joint

Chapter 3. the use of a motorized pump is important in casesinvolving
extensive lesions. With an open large bore egress Difficulty can be experienced with this step. Accurate t
cannula in position fluid flow is usually set at maximal to placement of the spinal needle. predistention of the joint. and
lavage the joint effectively. practice alleviate this problem.
As recorded previously (Bertone & McIlwraith 198 7a). the
lesions found at arthroscopy are usually more extensive than
Difficulty in establishing triangulation
they appeared radiographically. In most instances. the
cartilaginous changes extend beyond the limits of the sub- Visualizing the spinal needle is dillicult in certain cases due to
chondral bone abnormalities observed on the radiographs. the depths of the joint from the skin surface, but the severity
particularly in the glenoid of the scapula. In some horses in of this problem decreases with surgical practice. Changes in
which radiographically the lesion appears limited to the limb position and difference in the size of the patient can
glenoid or humeral head, additional lesions are found confuse the operator. For most instances in which access to
arthroscopically on the opposing articular surface. The most the joint was not achieved initially, the needle was placed too
common arthroscopic abnormalities of the humeral head are cranial and/or too proximal. Maintaining the limb in an
cartilage discoloration with undermining and erosion down unsupported, adducted (resting) position facilitates joint
to subchondral bone on the caudal aspect of the articular entry by widening the lateral aspect of the joint.
surface (see Figs 8.23 and 8.24). In some instances. a lesion
is not visible initially and probing is required to ascertain the
Extravasation of fluids
area of undermined cartilage. The most common arthroscopic
abnormality in the glenoid is cracked undermined articular Extravasation occurs in all shoulder arthroscopy cases to
cartilage with fissure formation and fibrillation (see some degree. During surgery the amount of fluid in the peri-
Figs 8.25-8.29). An additional common finding is friable, articlar tissue increases. causing increased extra-articular
defective subchondral bone. and these lesions may extend pressure. This increase in turn produces technical difficulty,
quite deeply. In most horses. the center of the glenoid cavity such as collapse of the joint space and decreased ability to see
is most severelyaffected. Occasionally.however,lesions extend and manipulate instruments. An efficient surgical procedure
laterally to the glenoid rim, and the bone of the glenoid rim is critical in operations involving the shoulder. A clear.
may also be fragmented (see Fig. 8.29). In other instances, unobstructed instrument portal. careful control of fluid
the medial portion of the glenoid is affected. Although a ingress and judicious use of self-sealing cannulae also
diffuse osteochondritis dissecans lesion is the most common improve surgical procedures in this region.
Difficulty in reaching potential lesions
In some instances. the surgeon may visualize lesions and not
be able to reach them with the instruments. Theselesions are
usually located on the caudomedial surface of the humeral
head of adult horses and become even more difficult to access
in well-muscled patients. In one series (Bertone & McIlwraith
1987a), the problem of inadequate instrument length was
encountered in three horses. Debridement of these areas can
be performed in young horses without difficulty, where traction
on the limb opens the joint space and facilitates curettage of
the medial surfaces. However, the ideal instrument for
reaching medial lesions in larger horses has not been found.
Long rongeurs are rare, and instruments with somecurvature
are also difficult to find. It is important to advise owners that
complete debridement may not be achieved when the horse
weighs 500 kg or more. Large accumulations of subcutaneous
fluid also contribute to inadequate instrument length, and
periodic application of pressure massageto drive fluid out the
skin portals often improves access to remote regions of the
humeral head.
Damage to instruments
The instrument portal passes through 6-8 cm of muscle
before entry into the joint. Manipulation of the instruments
is restricted by this muscle mass. The instrument portal can
be enlarged, but. in certain instances, the probe or trocar has
been bent when removed.
One possible solution to the difficulty sometimes experi-
enced in maintaining separation of the glenoid and humeral
head (this distance becomes critical when fluid extravasation
inhibits distention) is placing the patient in dorsal recumbency.By
suspending the leg and lowering the table slightly, "gravity
traction" may provide a less energy-consuming alternative.
The authors have not tried this technique. The possibility of
damaging the brachial plexus is one potential hazard.
Transient paresthesia in the upper extremities after shoulder
arthroscopy involving traction was reported in man, andbrachial
plexus strain versus joint accessibility with different
shoulder positions has been described (Klein et al19 8 7).
Results
The initial series of 11 horses reported by the authors
included one postoperativecomplication (Bertone & Mcllwraith
1987a): a subcutaneous infection with Actinobacillus sp.
produced swelling and drainage from the incision 48 hours
after surgery. The incision and subcutaneous tissues were
opened. flushed. and allowed to heal by second intention.
Moderate swelling in the shoulder region in all horses.
resulting from leakage of lavage fluid subcutaneously and
intramuscularly. generally resolved within 7 days.
None of the horses were more lame postoperatively. and all
improved clinically from within 2 weeks of the operation
until the time of follow-up evaluation. Nine of the 11 horses
achieved soundness and 8 horses remained sound. Seven
horses were completely sound at a jog within 4 months. Five
horses were atWetically sound and were being shown, ridden,
or raced after 5-20 months. A sixth horse was sound when
beginning race training. A seventh horse was pasture sound
and was to begin race training at the time of the report. An
eighth horse showed well in halter for 12 months, but
shoulder lameness returned. This horse was donated, and a
necropsy was performed. The ninth and tenth horses were
not completely sound at 11 months. The eleventh horse
improved but remained lame and could not be used for
athletic performance.
Follow-up radiographic assessmentrevealed improvement
in contour of the humeral head and joint space and more
even density of the humeral epiphysis and the glenoid of the
scapula in 6 horses. One of these horses showed marked
improvement in subchondral bone density and surface
contour of the glenoid cavity. In 2 of the remaining 5 horses,
the caudal border of the glenoid cavity had remodeled to
appear more like the contralateral joint. In the fourth of the
6 horses, radiographs obtained 1 year later showed a sub-
chondral cystic lesion in the scapula (1.5 cm in diameter)
that had not been present previously (Fig. 8.38). However,
this horse was athletically sound. The contour of the glenoid
articular surface and its caudal border was smoother post-
operatively and the subchondral osteosclerosiswas reduced
in thickness. In the fifth horse in this group, an osteophyte on
the humeral head had enlarged, but improvement was noted
in joint contour of both the humeral head and glenoid cavity
(Fig. 8.39). Radiographs obtained from one of the two horses
that improved but were still lame showed no improvement in
the glenoid lesion radiographically. In the horse where
euthanasia was chosen when it deteriorated clinically, the
humeral epiphysis was severelydistorted with a defect in the
articular surface contour, a subchondral cystic lesion, and a
small intra-articular fracture of the cranial margin of the
glenoid cavity.
In summary, all 11 horses improved clinically. Soundness
was achieved in 9 horses, and 5 of 11 horses have been used
athletically. Two horses did not become sound. One of these
horses was young but had extensive lesions of the glenoid
cavity and humeral head; a large osteophyte also developed.
The other horse was 4 years of age at the time of surgical
intervention and did show some clinical but no radiographic
improvement. One horse developed severe degenerative
changes in the joint after being sound for 8 months. It seems
that considerable healing response can be obtained if surgical
treatment occurs in a timely fashion.
Hand curettage was satisfactory for treating most lesions,
but the motorized resectors and burr provided the most
efficient debridement of articular cartilage and subchondral
bone in both the scapula and humerus, and it avoided the
potential difficulties associated with hand curettage.
Osteochondrotic lesions of the humeral head were the easiest
to debride, especially in horses that were yearlings or
younger, because they had less muscle mass as well as more
flexible periarticular structures. However, the lesions were
accessibleeven in older horses when the joint was distracted.
Traction is extremely important for access to extensive
scapular lesions, but arthroscopic surgery in the treatment of
these lesions is recommended only for surgeons with
considerable experience with this technique.
Euthanasia was chosen for four horses in this study. On the
basis of ideas concerning postoperative healing gained from
these four cases,it appeared that lesions of the humeral head
healed with successivelayers of hyaline cartilage, fibrocartilage,
and fibrous tissue. Whether the hyaline cartilage represented
remnants from surgery or transformation of fibrocartilage to
hyaline cartilage is unclear. The quality of the repaired tissue
varied. From necropsy findings in three cases in which
glenoid lesions were debrided, it seemedthese lesions did not bearing areas, contributing to expansion of i
heal as well as similar lesions of the humeral head. The defects in the bone (Landells 1953).
were filled with mixtures of fibrous tissue and fibrocartilage. The radiographic evidence of remodeling of the
In addition, cystic lesions in the bone also developed. cavity and humeral head in six horses less than 1 ~
The development of cystic lesions in the subchondral bone may help explain the clinical improvement in severe
of the glenoid subsequent to surgery is an interesting finding.
This may be a sequel to untreated osteochondritis dissecans Since this published series. the authors have
or to debridement in which the articular cartilage is removed
down to subchondral bone. Subchondral bone cystic lesions and humeral head and have achieved considerable
improvement. ] , .
can form in normal joints if full-thickness articular cartilage
defects are created surgically in weightbearing areas
(Kold et al1986). These lesions can develop within 6 months,
and some authors state that intra-articular synovial fluid to avoid operating on these types of lesions usually
high detail preoperative radiographs or even [ .'
pressure may exceed subchondral bone pressure in weight-
 Additionally. older horses may have a poor prognosis because of osteochondritis dissecans. In each instance. thehorse
cartilage remodeling decreaseswith advancing age. was involved in athletic activity when the problemdevelop
A more recent survey of 70 cases of one author (C.W.M.)reveals The lesions manifested arthroscopic ally as areas of
an overall successrate for return to athletic activity fibrillation and were treated with debridement.
of 45%.

Articular fracture
Arthroscopic Surgery for fractures of the glenoid and portions of the perimeter ofthe
Other Clinical Entities humeral head can lead to severe lameness, and requireremoval
of fragments to improve the outcome. Fragmentation
in the Shoulder of the cranial or caudal glenoid rim can be removed
arthroscopically, while larger fractures generally require
compression by lag screw insertion. Extensive craniocaudallyoriented
Osteoarthritis fractures of the glenoid cavity, which extend
proximally to involve the neck of the scapula, may require
The authors have been involved in sevencasesin which the both arthroscopic debridement and small fragment removal,
horse was considered to have degenerative articular cartilage and then screw compression. These types of fracture can
lesions of the humeral head that differed from the typical appear normal in lateromedial radiographs, largely because
of the minimal craniocaudal displacement of the fracture.

Septic arthritis/osteomyelitis
and weanlings are predisposed to septic physitis andosteomy
which can seeda joint and necessitate furtherdebridem
Routine arthroscopy of the shoulder for
fibrinectomy and removal of inspissated debris is required for
resolution in advanced cases.Lateral or cranial arthroscopic
approaches provide visualization of the joint surfaces
sufficient to allow debridement of synovial membrane andcartilage
The large caudal and cranial cul-de-sacs need
particularly aggressivelavage and manual fibrin removal toreduce
the bacterial load. Debridement of deeper lesionsinvolving
cartilage and subchondral bone may occasionallybe
necessary (Fig. 8.40). Placing ingress drains for antibiotic
delivery can also improve the outcome. Additional detail isprovided
in Chapter 14.

AL. McIlwraith CWoArthroscopic surgery for the treatment

of osteochondrosis in the equine shoulder joint. Vet Surg 1987 a;
16(4): 303-311.Bertone
AL. McIlwraith CWoArthroscopic surgical approaches and
intraarticular anatomy of the equine shoulder joint. Vet Surg
1987b; 16: 312-317.
Cofield RH. Arthroscopy of the shoulder. Mayo Clin Proc 1983; 58:
501-508.DeBowes
RM. Wagner PC. Grant BD. Surgical approach to the equine
scapulohumeral joint through a longitudinal infraspinatus
tenotomy. Vet Surg 1982; 11: 125-128.
Johnson u,. Arthroscopic surgery principles and practice. 3rd edn.
St. Louis: Mosby; 1986.
Klein AH. France JC. MutscWer TA. Fu FH. Measurement of brachial
plexus strain in arthroscopy of the shoulder. Arthroscopy 1987;
3: 45-52.Kold
SE. Hickman J. Melsen F. An experimental study of the healing
process of equine chondral and osteochondral defects.Equine Vet
J 1986; 18: 18-24.

References
cases
Some
Foals
Bertone
Landells JW. The bone cysts of osteoarthritis. J Bone Joint Surg Br
1953; 35-B: 643-649.
Mason TA. Maclean AA. Osteochondrosis dissecans of the head of
the humerus in two foals. Equine Vet J 1977; 9(4): 189-191.
Meagher DM. Pool RR. O'Brien TR. Osteochondritis of the shoulder
joint in the horse. Proc Am AssocEquine Prac 1975; 19: 247-256.
Nixon AJ. Diagnostic and operative arthroscopy of the equine
shoulder joint. Vet Surg 1986; 15: 129.
Nixon AJ. Diagnostic and surgical arthroscopy of the equine
shoulder joint. Vet Surg 1987; 16: 44-52.
Nixon AJ, Spencer CPoArthrography of the equine shoulder joint.
Equine VetJ 1990; 22(2): 107-113A.
Nixon AI. Stashak TS. et al. A muscleseparating
...,
Vet Surg 1984; 13; 247-256.
Nyack B. Morgan JP. et al. Osteochondrosis of the shoulder
the horse. Cornell Vet 1981; 71: 149-163.
osteochondrosis in the horse. Proc 31st Annual Conv
1986.
Schmidt GR. Dueland R. Vaughan JT. .-
the equine shoulder joint. Vet Med/Small An Clin 1975;
542-547.
 ER
diseases such as osteochondral fragmentation,
, or traumatically induced cartilage
frequency to warrant techniques for arthro-
surgery of the various pouches of the elbow joint.
'humeral condyle or
a seconddescribingsevenhorses (Hopenet al 1992).
Other lesions. including osteochondritis dissecans
.the humeral condyles. may be more appropriately
by surgical debridement. Arthroscopic techniques
access to the cranial portions of the humeral
.both condyles and to the anconeal
the ulna using a caudoproximal approach via the
complexity of periarticular neurovascular structures
inherent risks of elbow arthroscopy are well known in
(Lynch et al1986, Thomas et al1987, Baker & Jones
1999). and have also been described to a limited extent in the
horse (Nixon 1990). Overall, arthroscopic accessto the cranial
regions of the elbow in man and horses is relatively simple.
while the caudal compartments are more challenging, with
increased risk to adjacent neurovascular structures (Nixon
1990. Poehling & Ekman 1994. Baker & Jones1999).
The elbow joint of the horse is a complex articulation of the
humerus. radius, and ulna. All three bones are intimately
connected by substantial collateral ligaments. As a result.
distraction of the humeroradial articulation and humeroulnar
articulation results in little separation of the articular
surfaces and therefore limited accessto regions predisposed
to disease.particularly the proximal surface of the radius. For
the humeral condyles,this can be overcome to some extent by
the large range of motion of the elbow, allowing articular
surfaces to be exposed by flexion or extension. The tight
articulation essentially divides the elbow to a cranial joint
pouch, a limited caudal joint pouch, and a large proximo-
caudal joint pouch surrounding the anconeal process.
Approaches to the cranial portion of the elbow joint place
small terminal branches of the radial nerve at risk as they
arborize and terminate in the antebrachial extensor muscle
bellies. The arthroscope entry avoids these branches; how-
ever, instrument accesscranially, through the muscle bellies,
may impact on several small branches of the radial nerve. No
clinical repercussions,including extensor muscle dysfunction,
have been recognized. The caudomedial approach to the
elbow joint penetrates between the muscle bellies of the flexor
carpi radialis and flexor carpi ulnaris, and inadvertent entry
caudal to the flexor carpi ulnaris places the arthroscope close
to the ulnar nerve coursing over the caudomedial aspect of
the humerus and continuing down the medial aspect of the
ulna. Similarly, inadvertent entry to the elbow joint cranial to
the flexor carpi radialis muscle belly places the median nerve
at risk. During the caudomedial approach to the elbow, the
instrument entry often penetrates through the flexor carpi
ulnaris muscle belly, but also without repercussion. The
caudal extremity of this approach also may impact on
portions of the ulnar nerve. The approach to the olecranon
pouch of the elbow penetrates the distal terminal portions of
the triceps musculature or tendon of insertion; however, no
significant neurovascular structures are at risk using this
approach.
Positioning
Positioning for arthroscopy of the elbow is dictated by the site
of surgical disease. Only dorsal recumbency will allow
simultaneous accessto all three pouches of the elbow joint.
However, this can increase the degree of difficulty in
arthroscopic accessto the caudoproximal olecranon pouch.
For accessto specific diseaseconditions involving the cranial,
caudal, or caudoproximal region of the elbow, lateral
recumbency is preferred. The cranial pouch and the caudo-
proximal pouch of the elbow can be accessed with the
affected limb uppermost, while access to the caudomedial
pouch requires the affected limb to be placed down on the
surgery table. Repositioning the horse from affected limb
down to affected limb uppermost during the surgical
procedure is another possibility, although this delays the
surgical process.is manpower demanding, and risks breaks in
sterile procedures.

Craniolateral approach to the elbow

The horseis positionedin lateralrecumbencysothe limb can
be manipulatedinto extensionand flexion of the elbowjoint.
After preparationand draping,the elbowjoint is distended
throughthe cranialpouchwith 40-60 mlof lactatedRinger's
solution.The cranial perimeterof the humeroradialarticu-
lation is palpatedcranialto the lateral collateralligamentand
a 5-mm stabincisionmade approximately2-3 cm cranialto
this palpablecollateral ligamentborder.The musclebelly of
the common digital extensorforms a cranial limit to the
triangular target area for accessof the arthroscope.If the
entry is made too close to the cranial palpable border of
the lateral humeralcondyle.manipulationwithin the cranial
pouch of the elbowbecomesmore difficult. The arthroscope
sleeveis inserted across the cranial pouch of the elbow
joint, and the obturator exchangedfor the forward oblique
viewing arthroscope(Fig.9.1). The cranialarticular surfaces
and cranial joint pouch of the elbowcan then be examined
(Fig. 9.2). The arthroscopeis insertedas deeplyas possible
to examine the craniomedialmargins of the radius and
humerus. A 700 arthroscopemay be usefulin this region;
however,it is not essential.Withdrawal of the arthroscope
identifies the medial followed by the lateral condyles
of the humerus, with a large synovial fossa interposed
betweenthe two (seeFig. 9.2). Further withdrawal of the
arthroscoperevealsthe lateral portion of the humeroradial
articulation and the lateral collateral ligament. The
cranial joint pouch of the elbow is voluminous and easily
examined.
An instrument portal can be made cranial to the
arthroscopeentry, afterplacing a 7.5 cm x 18-gaugespinal
needle.This portal usually penetratesbetweenthe ante-
brachial extensormusclebellies,generallywhere a shallow
division can be palpatedbetweenthe extensorcarpi radialis
and commondigital extensormuscles.The midcranialregion
should be avoided to minimize potential damage to the
transversecubital artery. For lesionsinvolving the cranio-
lateral extremityof the radius or lateralhumeralcondyle.the
arthroscopeand instrument entry portal can be exchanged
to provide instrument accessto the lateral portions of the
articular perimeter.Following completionof the procedure.
fluid is expressedfrom the joint and the skin incisionsclosed
with interrupted sutures.
Fig. 9.1
Arthroscopic technique for access to the cranial pouch of the
elbow joint. Arthroscope entry is made in the triangle formed
by the craniolateral curvature of the lateral condyle of the
humerus, the proximal perimeter of the craniolateral surface
of the radius, and the caudal border of the muscle belly of the
common digital extensor tendon. Instrument entry can be
made between the muscle bellies of the common digital
extensor and extensor carpi radialis muscles.
Caudomedial approach
to the elbow joint
Dorsal positioning can be used if accessto !
joint pouches is expected, as previously described.
preparation and draping, the site for arthroscope
identified by systematically palpating from cranial!
to identify the medial collateral ligament, the r
the approximation of flexor carpi radialis and flexor I
ulnaris muscle bellies. A needle is inserted to identify
humeroradial articulation,
articular level and between the muscle bellies of the i-
carpi radialis and flexor carpi ulnaris is identified.
palpable division between these muscle bellies is i
more easily at the mid-radius level, and the
tracked proximally to the point 2-3 cm distal to the
the humeroradial articulation. The palpable'
overlying superficial pectoral muscles and
fascia. Insertion of the arthroscope proximal to the level of
the humeroradial articulation places the ulnar neuro-
vascular structures at risk. particularly if a second entry for
instruments is then made caudal to the flexor carpi ulnaris
muscle belly.
Mter insertion of the needle to the caudomedial aspect of
the joint. the elbow is distended with 60 ml of lactated Ringer's
solution and a 5 mm skin incision made for entry of the
arthroscopesleeveand obturator(Fig.9.3). The arthroscope
sleevewith obturator in placeis advancedproximally in an
oblique direction to enter the caudomedialaspect of the
elbowjoint pouch. Whencartilage or bone are encountered
and joint fluid is returned through the egressoutlets on the
arthroscope sleeve,the conical obturator is replaced by
the arthroscope.In many instancesthe arthroscopesleeve
can be insertedto its limit. as it penetratesinto the caudal
 limb is made easier by positioning the horse in lateral rather
than dorsal recumbency. Manipulating the tip of the
arthroscope caudally. exposesthe trochlear notch of the ulna
and the apposing articular surface of the humeral condyles
(Fig. 9.4). Further caudally, the intrusion of the medial epi-
condyle of the humerus. and the proximal regions of the
trochlear notch of the ulna are evident (Fig. 9.4). The large
tendon of origin of the humeral head of the deep digital
flexor tendon is also visible. The space between the trochlear
notch of the ulna and this mobile tendon provides accessto
the caudoproximal cul-de-sac of the elbow. However. for ease
of surgical manipulation, the caudoproximal approach to this
cul-de-sac using a lateral accesstechnique is recommended
(describedlater).
Instrument entry portals are made through the muscle
belly of the flexor carpi ulnaris. caudal to the arthroscope
portal. The most suitable path for instrument entry is selected
after inserting a 7.5 cm long spinal needle. This provides
ready accessto the medial condyle and the medial aspectsof
the lateral condyle. The central regions of the capitular fovea
of the radius cannot be accessedsurgically.

Caudoproximal approach to the

elbow Joint
The voluminous caudoproximal pouch of the elbow joint can
be accessedusing approaches similar to those described for
arthrocentesis of the elbow (Stashak 1987). This approach is
best done with the horse in lateral recumbency with the limb
free to be manipulated through flexion and extension. The
joint is distended with 60-80 ml of lactated Ringer's solution
using a 7.5 cm spinal needleinserted overthe lateral epicondyle
to enter the lateral portion of the caudoproximal cul-de-sac of
the joint. Needle entry is approximately level with the point of
the elbow,and caudal to the palpable lateral epicondyle of the
humerus. The spinal needle is angled distally and cranially to
target the anconeal process of the ulna. Following removal of
the needle,the skin incision for arthroscope entry is made in
a similar location and the arthroscope sleeve and conical
obturator inserted, angling distally and cranially to contact
cul-de-sac of the elbow and farther into the caudoproximal the articular surface of the anconeal process (Fig. 9.5). The
cul-de-sac surrounding the anconeal process. A standard obturator is then exchanged for the arthroscope. allowing
forward oblique arthroscope is inserted and the caudal examination of the voluminous caudoproximal joint pouch
regions of the elbow examined. The medial humeral condyle (Fig. 9.6). The anconeal processand proximal portions of the
is readily visible (Fig. 9.4). The caudal perimeter of the humeral condyles are readily visible (Fig. 9.6). Flexion of the
humeroradial articulation is a convenient landmark to elbow exposes the entire caudal one-half of the humeral
commence examination of the joint (Fig. 9.4). The articular condyles for surgical procedures. Instrument entry for
surfaces of the humeral condyles, particularly the medial access to lesions is then made by preplacing a 7.5 cm
condyle. are readily evaluated. Flexion of the elbow improves spinal needle to give direct accessto lesions on the anconeal
the exposure of the caudal portions of the humeral condyles. process or humeral condyles. This entry usually perforates
Portions of the weightbeai"ing articular surface of the radius terminal portions of the triceps musculature and occasion-
can be seen. but the arthroscope cannot be advanced ally the tendon of insertion on the olecranon. Hand
between the radius and humerus (Fig. 9.4). Distraction of the instruments and motorized burrs can be inserted for surgical
medial aspect of the humeroradial joint by abduction of the debridement.
 of the radius (capitula fovea of the radius). Conservative
therapy of subchondral cystic lesions of the proximal radius
is generally accepted as the treatment of choice for these
subchondral cysts (Hopen et a11992) (Fig. 9.8) but surgical
treatment has also been successful (Bertone et al1986). OCD
lesions of the humeral condyles can involve the caudal one-
half of either the medial or lateral condyle (Hopen et al19 92).
The flap lesions present as lysis on radiographs, similar to
OCD lesions in most other sites in the body (Fig. 9.9). Access
to lesions of the medial humeral condyle is provided using the
caudomedial arthroscopic approach. This provides visualization
but dillicult triangulation to lesions of the lateral condyle
(Fig. 9.10). Use of the caudoproximal approach with the
elbow fully flexed provides better access to the lateral condyle.
Triangulation is also easily accomplished using instrument
entry through the triceps muscle or the -;
junction. This is a rare site for OCD in the horse. -
ence is limited j , ,

author (A.J.N.). 7"'-

favorable.
planning with
to decide
all going
the onmost
to athletic
appropriate'work. 1 .'

approach to the humeral condyles requires a flexed

simpler, safer, and provides more extensive room

manipulate surgical instruments. Similar controversy:
rounds treatment of elbow OCDin ] ,--
Pill et al2003), although the results of
surgical treatment.

Fractures of the craniolateral portion

of the humerus
The craniolateral portion of the distal humerus,particularly
the lateral portion of the humeral condyle,is exposedto
external impact injury, which can dislodgeintra-articular
osteochondralfragments(Fig. 9.7). Removalof thesefrag-
mentsis generallysimpleusing the craniolateralarthroscopic
access.After examination of the remainder of the cranial
aspectsof the elbow joint, the arthroscopeand instrument
portals are reversed,placing the arthroscopethrough an
instrument portal approximatelybetweenthe musclebellies
of the extensorcarpi radialis and commondigital extensor.
This leavesthe more lateral portal for rongeur entry for
fracture removal. Debridementof the subchondralbed is
routine and debriscanbe flushedfrom the joint with a large
egresscannula. The extentof articular involvementusually
definesthe expectedoutcome,although the predisposed area
for impactfracture is generally2-4 cm in length.
Fragmentation of the anconeal
The anconeal process can develop fragmentation
manifestation of osteochondrosis, f
process using the caudoproximal approach is
simple (Fig. 9.11). Fragment removal can be r
using triangulation i ' '- ,- ;
fragments are rare in this location, and many of
fragments should be considered trauma-induced. :
complex fractures of the I '
fixation. The open lateral approach to the anconeal
during plate application to the olecranon f
simple, and arthroscopy can be utilized to i
the free fragment either during the plating
(Fig. 9.11) or at a later time.

Osteochondrosis and osteochondritis
dissecans of the elbow
Osteochondrosis of the elbow usually takes the form of either
OCD flap lesions of the humeral condyles or subchondral
cystic lesions of the proximal radius. To date, there are no
arthroscopic techniques that will provide accessto the head
Septic arthritis
involved in hematogenous septic processes in foals.
lateral aspect of the joint also has minimal: r .
and is a common site for kicks from other animals'
frequently penetrate the joint through or adjacent to
lateral collateral ligament. Lavage and flushing of
compartments of the elbow joint represents minimal therapy
for septic arthritis (see Chapter 14). Recalcitrant casesneed
arthroscopic exploration, using debridement of inspissated
and fibrinous material, and partial synovectomy of
proliferative regions. Arthroscopic exploration also allows
evaluation of the cartilage surfaces of the humerus and ulna,
and debridement of any areas that have developed separation
from the subchondral bone. The accessto the cranial pouch prominent regions for osteophyte formation include
of the elbow joint is relatively simple using the craniolateral cranial aspect of 1
approach and, similarly, accessto the proximal caudal joint
pouch can be provided using the caudoproximal approach.
Both can be accomplished with the patient in lateral lavage and chondroplasty for arthritis are questionable
recumbency. The necessity to enter the smaller joint pouch review in Chapter 17); ]
associated with the caudomedial arthroscopic approach is matic relief may be provided for severalyears.
questionable. Most areas of the joint can be adequatelylavaged
and inspissated material removed from the more voluminous
cranial and caudoproximal pouches. Drains can be instilled
or antibiotic repository devices placed in either or both of the
cranial or caudoproximal pouches. The outcome for synovial
sepsisis described in Chapter 14, and is generally dictated by Despite the complexity of the elbow articulation and
the extent of osteomyelitis in the subchondral bone. proximity to important neurovascular structures. (

complication during arthroscopic procedures around 1

Arthroscopy for osteoarthritis
Arthroscopic exploration and debridement of areas of cartilage
degeneration in osteoarthritis is occasionally warranted.
depending on the extent of osteophytosis in the elbow. The
elbow is subcutaneous fluid accumulation, which can
extensive using the approaches described. Distention I
visualization should be used in moderation, '
easilyexaminedwith moderatedistention.
 Necropsy examination of horses used in the development
of arthroscopic approaches to the elbow showed minor areas
of muscle hemorrhage associatedwith instrument entry during
triangulation (Nixon 1990). The primary concern in elbow
arthroscopy is surgical planning to provide accessto the lesions
without the necessity for repositioning the horse. The use of
dorsal recumbency can result in difficulty in orientation and
manipulation. but should be taken into consideration when
all three compartments of the joint need to be examined.
References
Baker CL Jr. Jones GL. Arthroscopy of the elbow. Am J Sports Med
1999; 27: 251-264.
Bertone AL. Mcllwraith CWoPowers BE et al. Subchondral osseous
cystic lesions of the elbow of horses: conservative versus surgical
treatment. J Am Vet Med Assoc 1986; 189: 540-546.
Hardy J. Marcoux M. Eisenberg H. Osteochondrosis-like lesion of the
anconeal process in two horses. J AmVet Med Assoc 1986; 189:
802-803.
Hopen LA, Colahan PT,Turner TA, Nixon AJ. Nonsurgical treatment
of cubital subchondral cyst-like lesions in horses: seven cases
(1983-1987). J Am VetMed Assoc 1992; 200: 527-530.
Krijnen MR, Lim L, Willems WI. Arthroscopic treatment of
osteochondritis dissecans of the capitellum: report of 5 female
athletes. Arthroscopy 2003; 19: 210-214.
Lynch GJ, Meyers JF, Whipple TL, Caspari RB. Neurovascular
anatomy and elbow arthroscopy: inherent risks. Arthroscopy
1986; 2: 190-197.
Nixon AJ. Arthroscopic approaches and intraarticular anatomy of
the equine elbow. Vet Surg 1990; 19: 93-101.
Pill SG, Ganley TJ, Flynn IM, Gregg JR. Osteochondritis dissecansof
the capitellum: arthroscopic-assisted treatment of large, full-
thickness defects in young patients. Arthroscopy 2003; 19:
222-225.
Poehling GG,Ekman EF.Arthroscopy of the elbow. J Bone Joint Surg
1994; 76A: 1265-1271.
Stashak TS. Diagnosis of lameness. In: Stashak TS (ed.), Adams'
lameness in horses. Philadelphia: Lea and Febiger; 1987:
150-153.
Thomas MA, Fast A, Shapiro D. Radial nerve damage as a
complication of elbow arthroscopy. Clin Orthop 1987: 130-131.

recognize, and the need for arthroscopic evaluation
diagnostic arthroscopy and
surgical correction of problems in the hip are
rare. They may be in part due to the inherent
of isolating problems to the coxofemoral joint,
horses with chronic lameness. Moreover, the
associated with surgical therapy often diminish
for arthroscopic exploration. However, an
awareness of hip joint diseases and the use of
imaging modalities such as nuclear scintigraphy and
thermography, coupled with increased use of intra-articular
anesthesia, have increased the likelihood of establishing a
definitive lameness associated with the coxofemoral joint. A
logical extension of improved diagnostic capabilities is the use
of arthroscopic examination with a view to surgical correction
of some diseases. Arthrotomy of the hip joint is difficult,
results in limited exposure of relevant structures, is debilitating
for the horse and surgeon, and is accompanied by high-wound
healing complication rates: given this, it is rarely warranted
for any surgical disease of the hip, other than separation of
the proximal femoral capital physis. However, arthroscopy
for diagnostic purposes is feasible, particularly in foals
(Honnas et aI1993).
Diagnostic arthroscopy has been used to evaluate tearing
of the ligament at the head of the femur (round ligament),
osteoarthritis (qA) , fracture of the acetabulum, and osteo-
chondrosis (DC) in the hip (Nixon 1994). In man, diagnostic
arthroscopy of the hip is a useful technique to establish a
diagnosis, as well as aid in treatment; it actually altered the
preoperative diagnosis in 53% of 328 patients (Baber et al
1999). Given the preoperative use of computed tomography
(CT) and magnetic resonance imaging (MRI) in man, these
results represent a marked increase in diagnostic usefulness
of arthroscopy. In foals, arthroscopic surgery is particularly
valuable in the treatment of sepsisinvolving the coxofemoral
joint, and in the treatment of osteochondrosis (Nixon 1994).
.
~
The clinical signs associated with clinical hip lameness in
horses vary, depending on whether the derangement is a
result of developmental disease in foals and weanlings,
trauma to the hip resulting in tearing of the ligament of
the head of the femur, degenerative osteoarthritis, or fracture
of various portions of the acetabulum (Rose et al 1981,
Miller & Todhunter 1987, Nixon et al1988). Under the best
of circumstances, the diagnosis of hip disease is often
protracted, leading to osteoarthritis as a common sequela.
When the lamenessis marked, muscle atrophy of the affected
hind limb is evident in the gluteal and quadriceps mus-
culature, facilitating an earlier diagnosis. More obscure
upper hind limb lameness may take more diligence in the
work-up. Diagnostic manipulative tests are useful; however,
the definitive diagnosisoftenrequires intra-articular anesthesia.
Rectal examination is also recommended, although palpable
enlargements have been recorded in only 50% of acetabular
fractures (Rutkowski & Richardson 1989). and many other
conditions including OCand OA are not detected using rectal
examination.
Nuclear scintigraphy has improved the diagnostic
specificity for chronic hind limb lameness. but still lacks the
conclusive nature of intra-articular anesthesia. Blocking the
hip can be difficult until some familiarity with the surface
anatomic landmarks is gained. Later confirmation and
staging of the degree of the hip joint involvement can be
provided by radiographs. Good-quality radiographs require
general anesthesia.and ventrodorsal and oblique ventrodorsal
views for evaluation of the acetabulum and femoral heads.
Moderate and severe degenerative osteoarthritis, osteochon-
drosis, osteochondritis dissecans (OCD),and luxation or sub-
luxation of the hip are apparent on hip radiographs. Less
obvious hip diseases,such as tearing of the ligament of the
head of the femur and mild osteoarthritis, may not be evident
on routine radiographs. These lesions may need to be
identified through direct visualization during arthroscopic
examination.

Arthroscopy is indicated for the diagnosis of hip joint disease,
particularly in cases in which radiographs provide little
additional information after a positive intra-articular
anesthetic response has been obtained and as a therapeutic
tool for other conditions. Arthroscopic examination of the hip
joint in horses has been described in a limited case series
(Honnas et al199 3, Nixon 1994). Arthroscopic visualization
was useful in determining the extent of cartilage damage
associated with fractures of the acetabular rim, in several
cases where radiographically visible small fractures were
identified associated with the periphery of the acetabular rim,
in assessingthe degree of tearing of the ligament of the head
of the femur, and in cases where cartilage defects were
evident during examination of horses with hip joint lameness
but no radiographic lesions (Nixon 1994). Intra-articular
debridement of torn and partially torn ligaments of the head
of the femur, debridement of OCD of the acetabulum, and
cystic lesions of the femoral head have been described (Nixon
1994). Similarly, arthroscopic lavage and synovectomy with
debris removal is a u~eful method for improving the response
in foals with infectious arthritis of the hip.
Surgical technique
Arthroscopic examination of the hip joint is readily
accomplished in foals and can be performed with some
difficulty in horses up to 500 kg. In larger horses, exam-
ination of the articular structures is less complete; the
procedure is more technically demanding and is associated
with more surgical trauma to the articular and periarticular
structures than encountered during hip arthroscopy in foals.
However, hip joint laxity associated with persistent effusion
provides a largely unrecognized advantage in adult horses
with chronic hip disease. With appropriate axial traction on
the affected hind limb. the femoral head can be distracted
from the acetabulum sufficiently to allow examination of
large portions of the femoral head and acetabulum.
The horse is anesthetized and positioned in lateral
recumbency with the affected limb uppermost. The entire
lateral region of the hip and gluteal muscle is draped for
surgery with the affected limb supported but free to be
mobilized during surgery. An arthroscope entry portal is
made at the site that has been previously described for intra-
articular anesthesia (Stashak 1987, Nixon 1994). A skin
incision is made between the cranial and caudal portions of
the greater trochanter, entering approximately 2 cm proximal
to the palpable level of the trochanter (intertrochanteric fossa)
(Fig. 10.1). This provides arthroscopic access to both the
cranial and caudal recesses of the hip joint. The joint is
initially distended with 60-80 ml of lactated Ringer's
solution administered through a 15-20-cm spinal needle or
th~ stvl~tt~ frQm a 15-cm intravenQUScatheter. The arthro-
to penetrate the joint of horses less than j
arthroscope sleeve and 4-mm forward oblique viewing
arthroscope (Fig. 10.2). However,a longer arthroscope (25-cm
arthroscope, Karl Storz Endoscopy, Goleta, CA) is useful for
more complete examination in adult horses (Fig. 10.3). The
arthroscope sleeve and conical obturator are inserted
through the skin and angled 200 ventral and 200 cranially,to
follow the dorsal (proximal) contour of the femoral neck
(Fig. 10.1). The lateral portion of the hip joint is penetrated,
the obturator removed, and the arthroscope inserted. The
standard 25 or 300 forward oblique viewing arthroscopes are
satisfactory for examination of most regions of the hip joint. iJ
A 700 arthroscope is useful but not essential to examine the 1
skin portal, for fluid egress and later instrument access,is
made 4-5 cm cranial to the arthroscope portal. using a
1 5-cm spinal needle or catheter stylette to define the path for
instrument entry prior to skin incision.
Visualization of the articular surface of the cranial,
lateral, and caudal regions of the hip joint is accomplished
with the limb supported in a horizontal position (Fig. 10.4).
Manipulation of the limb into a flexed and extended position
allows other regions of the femoral head to be viewed. Given
the depth of the joint from the skin surface. manipulation of
the limb must be done with care, to avoid damage to the
arthroscope. Distraction of the limb by axial tension is vital
for a complete examination of the hip. This allows the
arthroscope to be inserted between the femoral head and the
acetabulum. In immature horses, distraction and arthroscope
insertion can be accomplished easily and allow examination
of the deeperregions of the joint (Fig. 10.5). In older horses,
distraction and increased intra-articular fluid pressures are
more important to allow visualization of the femoral head
and round ligament of the head of the femur (Fig. 10.6). Joint
distraction can be provided by axial tension on the limb from
an assistant or by mechanical devices such as a winch
attached to the surgery wall. The torso of the horse must be
stabilized on the surgery table when distraction techniques
are used. An intraoperative decision can be made as to the
necessity and degree of mechanical distraction. The use of
surgical assistants is necessary for arthroscopy of the hip
joint in adults, primarily to manipulate the limb and to
provide axial distraction when required.
Instrument access is generally provided through the
cranial instrument portal after developing a path to the hip
joint through the tendinous insertion of the middle gluteal
muscle using a conical obturator. The arthroscope and
instrument portals can be exchanged for better examination
of the caudal acetabular rim. This allows entry for rongeurs 1
and curettes through the original arthroscope portal. which j
can then be directed into the caudal regions of the joint. A j
long 6-mm diameter egress cannula (Sontec Instruments. j
Englewood, CO)or a second arthroscope sleeveis suitable for 1
fluid egress after surgical debridement. The use of motorized j
instruments is possible in small and moderate-sized horses,
but use of motoriz~(J ~m1inm~nt ~f!n h~ limitp(J hv thp (Jpnth

instruments and motorized equipment need to be inserted to
the limits of their length. Pressing in on the skin and gluteal
musculature occasionally allows an extra 1-2 cm of effective
length to be garnered from routine surgical instruments.
Long rongeurs and long egress cannulae are useful (Sontec
Instruments). Most surgical triangulation techniques in the
hip are difficult. Debridement of cartilage lesions of the
femoral head and removal of free bodies and debris within the
cranial and caudal recessesof the joint can be achieved with
persistence. Lesions in the acetabulum can be more difficult
to debride. In smaller horses, examination and debridement
of torn portions of the round ligament of the head of the
femur can be achieved. Osteochondrosis cysts of the head of
the femur and fractures of the caudal acetabular rim are
particularly difficult to adequately debride.
Femoral head cartilage lesions
generally have either focal or more widespread
lesions associated with the femoral head and/or
the ligament of the head of the femur when
arthroscopic ally. Focal articular
confined to the cranial aspect of the femoral head
from the cartilage lesion(Fig. 10.7). Removalof the
improved lameness in two racehorses.More
osteophyte formation is often evident over
caudal perimeter of the acetabulum (Fig. 10.8).
moderate osteoarthritis, most of these osteophytes
lesions of the femoral head can be accomplished
appropriate manipulation of curettes and rongeurs
combination with axial distraction. A moderate
iatrogenic damage to surrounding cartilage is always
possibility during debridement of these lesions
advanced cases of hip joint osteoarthritis can
arthroscopy (Fig. 10.9), however, lasting -
following debridement of fibrillated regions is rare.
Tearing of the ligament of the
head of the femur
Fraying and tearing of
of hip joints from small breed horses.but can also be
of this ligament can occur, and the outlook even
debridement is guarded (Fig. 10.10). Tearing in -
hreeds. nHrtif'111Hrlv miniHt11re horses f'Hn he Hdp,
in those cases with incomplete rupture of the ligament
(Nixon 1994). Manipulation of biopsy punch rongeurs
and motorized equipment is necessary for
debridement of the visible portions of the
accessory ligament of the head of 1
difficult to visualize. and lesions in this
recognized.

Osteochondrosis and
dissecans

the lateral half of the femoral head. Lesions in the

areas up to and including I

insertion of the ligament of the head of the femur.
deeper,more medial, aspects of l' ,
adequately visualized.
extensive effusion, the hip joint is easily distracted. i '
better debridement of OCD lesions. Subchondral
the depths of the cyst can rarely be adequately debrided.
Secondary packing of the debrided cysts with cancellous
bone or other graft materials has not been possible.Cartilage
lesions associated with the caudal perimeter of the
acetabulum may not necessarily represent OCD. but can be
debrided with long rongeurs.
Acetabular chip fractures
Small fractures of the cranial and caudal perimeter of the
acetabulum can be removed with rongeurs. More extensive
fractures can be removed with some difficulty; however, the
outcome is rarely satisfactory, due to the resultant instability
of the coxofemoral articulation (Fig. 10.13). Most of these
proceduresare tedious and time-consuming due tothe increased
depths of the joint from the skin surface. Insertion of instru-
ments targeting the acetabular rim also places the sciatic
nerve at risk, if the instrument rides over the acetabular rim
and exits the dorsal (proximal) perimeter of the hip joint.
Infectious arthritis
Arthroscopy provides an effective means for lavage and
debridement of debris from septic hip joints. The voluminous
cranial and caudal recessesof the hip joint frequently contain
fibrinous and purulent debris. which can be removed by
large-bore egress cannulae. or retrieved using rongeurs or
motorized resectors. Lavage can also be facilitated by a
second instrument entry portal for an egresscannula in the
caudal recess of the hip joint. Careful insertion of all instru-
ments into the caudal region of the hip is necessaryto avoid
trauma to the sciatic nerve.
There are no large series of cases to describe the results of
diagnostic or surgical arthroscopy for any of the conditions
in the equine hip. Diagnostic arthroscopy has been useful in
the treatment of septic hip joints in foals; however. a delay in
diagnosis and involvement of other joints is common in foals.
and reduces the likelihood of a sound horse. Diagnostic
arthroscopy is also very useful to establish the severity of
cartilage injury in mild and moderate degenerative osteo-
arthritis. Severalcaseshave had focal cartilage injuries which
responded particularly well to local debridement. The
establishment of a more accurate prognosis is also a useful
benefit of hip arthroscopy.
Surgical debridementcan be expectedto improve the
outcome with osteochondrosis and OCD conditions of the
hip. Improvement in lameness after debridement of OCDflap
lesions on the acetabular perimeter and after debridement of
subchondral cysts of the femoral head have beenseen.Access
for debridement of femoral head lesions depends on the
lateromedial location of the cysts within the femoral head.
Debridement of relatively shallow cysts can be accomplished.
and deeper cysts can be opened to some extent although
debridement is incomplete. In foals and miniature horses,
debridement of fraying and tearing of the ligament of the
head of the femur can be easily performed, and at least with
incomplete rupture, the results are quite satisfactory.
Removal of frayed ligament fibers and lavage of debris from
the joint improve the degree of lameness and minimizes the
likelihood of secondary osteoarthritis. Synovectomy of
portions of the accessiblesynovial membrane also appears to
improve the postoperative response in these cases.Complete
disruption of the ligament of the head of the femur results in
permanent lameness. and long-term improvement after
arthroscopyhas not beenseen.Theselesionsneed further
stabilization.and techniquesfor hip stabilizationhave not
beensuccessful in adult horses.
The prognosisfor a horsewith hip diseasedependson the
type of lesion. extent of degenerativeosteoarthritis.and the
completenessof lesiondebridement.In somecircumstances
hip arthroscopyhas improved the prognosis.whereas in
other casesthe extentof osteoarthritisand cartilagedamage
has preventeda satisfactoryoutcome.Basedon limited case
experience.arthroscopicdebridementof OCDlesionsin the
hip appearsto improvethe prognosis.whereasa diagnosisof
completerupt,ure of the head of the ligament of the femur
is a predictor of continued lameness.Synovectomyand
debridement of portions of incomplete rupture of the
ligament of the head of the femur have been useful in
providing lasting improvement in the level of lameness.
Removalof chip fracturesassociatedwith the acetabularrim
is possible;however.significant improvementin outcomeis
evident only with small fragments.Largerlesionsresult in
destabilizationof the articulation and little long-termbenefit.
References
Baber YF, Robinson AH, Villar RN, Is diagnostic arthroscopy of the
hip worthwhile? A prospective review of 328 adults investigated
for hip pain, J Bone Joint Surg (Br) 1999; 81: 600-603.
Honnas CM, Zamos DT, Ford TS. Arthroscopy of the coxofemoral
joint of foals. Vet Surg 1993; 22: 115-121.
Miller CL, Todhunter R. Acetabular osteochondrosis dissecans in a
foal. Cornell Vet 1987; 77: 75-83.
Nixon AJ. Diagnostic and operative arthroscopy of the coxofemoral
joint in horses. Vet Surg 23, 377-385.
Nixon AJ, Adams RM, Teigiand ME. Subchondral cystic lesions
(osteochondrosis)of the femoral heads in a horse.J Am Vet Med
Assoc 1988; 192: 360-362.
Rose JA, Rose EM, Smylie DR. Case history: acetabular
osteochondrosis in a yearling thoroughbred. J Equine Vet Sci
1981; 1: 173-175.
Rutkowski JA, Richardson DW. A retrospective study of 100 pelvic
fractures in horses. Equine VetJ 1989; 21:256-259.
Stashak TS. Diagnosis of lameness. In: Stashak TS (ed.),
Philadelphia: Lea and Febiger; Adams'lameness in horses. 1987:
150-153.
 16 Warmblood horses were reported. An arthroscopic
approach to the palmaroproximal and plantaroproximal
aspect of the distal interphalangeal joints was subsequently
developed by Vacek et al (1992), who describedthe anatomy.
It was the author's opinion that most conditions affecting
Introduction these aspects of the coffin joint such as navicular bone
fractures, arthrosis of the distal interphalangeal joint,
As in other small joints. arthroscopy in the distal and proximal penetrating wounds and septic arthritis, did not produce
interphalangeal joints has specific features. The major radiographic lesions in the acute phase and diagnostic
differences between arthroscopy in "large" and "small" joints arthroscopy was essential in establishing the diagnosis.
are as follows: Recently Brommer et al (2001) described a case of a Warm-
.Exact anatomic positioning of arthroscope and blood yearling suffering from an osteochondral fragment at
instrumental portals is extremely important in all the palmaroproximal aspect of the DIP (Figs 11.1 and 11.2).
smalljoints. They successfullyremoved the fragment. which consisted of a
.Limited distention in small joints results in limited bony core completely surrounded by cartilage. They used a
field of view. lateral arthroscopic portal and a medial instrument portal.
.Limited distention and limited mobility in small joints Another clinical use for this approach is in evacuation of
leads to difficulties in orientation. cystsin the navicular bone (Zierz et al2000).
.The tip of the arthroscope and the tips of instruments
are always close to tissue.
.The tip of the arthroscope is always close to the tip of
hand instruments. which increases the risk of lens
damage.
.Diagnostic inspection of a small joint is done mainly
by lateral movement and rotation of the telescope
rather than by inserting and withdrawing the
arthroscope as in big joints.
.Re-arthroscopy is almost always performed through
the same initial portals.
.It is delicate surgery with delicate surgical equipment
-equipment breakage or equipment failure can result
in irretrievable loss of foreign bodies.
.Air bubbles from escaping gas develop easier in small
joints than in large joints.
.Foals. yearlings. and ponies might require smaller
diameter (2.7 mm) arthroscopes.

General considerations
The author's G.B.)technique of diagnostic and surgical use of
the arthroscope in the dorsal aspect of the distal interpha-
langeal joint (DIP) was first described in 1990 (Boening et al
1990). The arthroscopic technique and long-term results in
Indications
Indications for coffin joint arthroscopyinclude diagnostic
inspectionof thedorsalpouchor of thepalmar/plantarpouch
of the joint, removalof osteochondralfragmentsor avulsion
fragments,removal of osteophytes(Bramlage1988), syno-
vectomy,debridementand joint lavage.The most common
indication in the dorsal distal interphalangealjoint is the
removal of fragmentsof the extensorprocessof the distal
phalanx(Fig. 11.3).

Diagnostic arthroscopy of the dorsal

pouch of the distal interphalangeal joint

Insertion of the arthroscope

The horse is under general anesthesia in dorsal recumbency.
The surgical leg is either passively flexed and loose or
extended and supported in a stand. Some authors prefer a
loose limb and, therefore, an assistant is needed for joint
manipulation and support. After surgical preparation for
aseptic surgery, the operating field is draped with sterile
adhesive antibacterial barriers in addition to a large
impervious arthroscopy drape. The articulation is extended
and an 18- or 16-gauge needle is inserted into the dorsal joint
cavity (Fig. 11.4), which is then distendedwith sterile isotonic
polyionic Ringer's solution.
 The dorsal joint capsule bulges easily with distention and
a No. 11 scalpel blade is used to make a 5 mm vertical skin
incision about 3 cm proximal to the coronary band and about
3 cm lateral or medial of the sagittal midline. This incision
continues into the joint cavity. These landmarks assure an
optimal position for the arthroscope -a portal too close to the
coronary band and too far from the sagittal plane creates
major problems in DIP joint arthroscopy. Misplacement of
portal sites also incurs the risk of hitting a major blood vessel
(Fig. 11.5) and the loss of orientation. As in all arthroscopic
procedures. the shorter the distance from skin to joint cavity.
the better.
The arthroscopic sleeveis introduced and positioned in the
distal interphalangeal joint by the use of a blunt obturator to
penetrate the fibrous joint capsule (Figs 11.6 and 11.7). Once
the sleeve is in the joint. the obturator is exchanged for the
arthroscope. and the camera. light cable. and fluid and gas
ingress line are attached. The diagnostic arthroscopic
evaluation can commence from this position. One author GB)
prefers gas distention with carbon dioxide. as he considers it
superior for all diagnostic and surgical procedures; a parallel
fluid distention line is used for postoperative lavage. Hand
instruments such as probes. forceps. rongeurs and cannulas
are introduced through the instrument portal. This is
determined by the use of a hypodermic needle.
Normal arthroscoPic anatomy of distal
interphalangeal joint
The dorsal pouch of the distal interphalangeal joint represents
about 30% of the entire joint. The main landmark for this
part of the joint is always the extensor process of the distal
phalanx (Fig. 11.8). From there the dorsal concave part of
the articulation of the second phalanx and the convex part of
the articulation of the third phalanx can be visualized. By
rotation and relocation of the tip of the arthroscope. the
lateral and medial rim of the articulation and the attachment
of the joint capsule and the extensor tendon become visible.
Hyperflexion. hyperextension. and medial and lateral hoof
rotation will expose additional. deeper parts. of the articu-
lation. With this approach. even lateral or medial aspects of
the distal articulation of the middle phalanx will become
visible. By careful withdrawal and positioning the tip of the
arthroscope into a more proximally orientated position. the
dorsal joint capsule and the proximal reflection of the joint
capsule can be examined.
Diagnostic arthroscopy of the
palmar/plantar poucf1 of the distal
Interphalangeal joint
Indications
Forthe palmar/plantar approachthe horsemaybepositioned
in either dorsal or lateral recumbency.Dorsal recumbency
 (Boening 1995). The palmar/plantar pouch of the DIP is
quite spacious in the axial area, but surgical removal of
CD
fragments remains challenging. Through contralateral:
instrument portals, only limited mobility of the
hand instruments can be achieved.

1.\". Insertion of the arthroscope -palmar/plantar

aspect
For inspection of the palmar/plantar aspect of the (
interphalangeal joint. it is preferable to have the horse
lateral recumbency. For preoperative distention of i
an I8-gauge.:. ..
Up to 25 ml of sterile saline can be injected.:.- -
into the dorsal: " .r
palmar/plantar pouch. which is then used i ' --
landmark to aid in exact positioning of the incision
~'I
f lli!~
\ ,~
distention is palpable immediately axial to ;
collateral cartilage. A 5 mm vertical skin incision is
~---'
;.~
directly over the lateral or medial aspect of
palmaro/plantaroproximal pouch. Landmarks for;
orientation are the collateral cartilage (keep
'I J~
'"!
artery and nerve (keep axial) and the deep digital
,11/1- tendon and the digital tendon sheath (keep abaxial).
il.111
JI
Esmarch bandage and/or a tourniquet can help to I
.m

! '\\\~~' \\\ ~~t

!\1
'- I., ~~
, .\\}~
If .\ \'I' i~
~\. A conical obturator within ( .
« \~\\ advanced (Figs 11.9 and 11.10) parallel to the
plantar rim of the second phalanx. f' .,
,
In\ of the frog. Introduction of the sheath under j-
guidance is useful if available.
Entrance into the joint is marked by flow of fluid
the open stopcocks. Once in the joint cavity, (-
Fig.11.7 replaced by the 300 arthroscope and joint distention
Diagram of arthroscope position -dorsal pouch of the distal
maintained by either fluid or gas.
interphalangeal joint. CD, Common digital extensor tendon.

offers a more easy contralateral instrumental approach distal interphalangeal joint, the limited maneuverability
(Boening et al1990, Mcllwraith, 1990a).
The use of fluoroscopy for anatomic orientation is helpful. in the coffin joint will be closed after completion of
ination and/or surgery' .-, .
Under such visualization, the insertion of the arthroscope,
insertion of hand instruments, and the identification of the Sterile bandaging incorporating the entire hoof is
fragment's side can be achieved. In the palmar/plantar pouch value. The risk of
of the coffin joint (seeFigs 11.1 and 11.2) fragment removal and secondary joint infection is directly correlated
is the most common indication for arthroscopic surgery improper bandaging. If loose bandages expose i'
(Brommer et al 2001). These fragments are either free
floating and OCDin origin or embeddedin the joint capsule or even loss of the patient from joint infection might result. The
ligaments. Lesions that are the result of secondary bone bandages should be changed every second day until primary
metaplasia can be detected in these areas. In such cases their healing of the skin incisions is achieved.
appearance seems to be flattish and generally accompanied
by signs of degenerative joint disease.A further indication for
Normal arthroscoPic anatomy -palmarol
palmar/plantar coffin joint arthroscopy is debridement of cystic
lesions at the proximal rim of the navicular bone (Zierz etal plantaroproximal aspect
2000). The technique can be combined with cancellous bone The midsagittal ridge of the dorsal articular border of the
grafts, in which CO2gas distention of the joint is required navicular bone is the first structure to identify (Fig. 11.11).
"
-~I
-
1.,1~:
,.1
~
 DDF

I~

.~
.'(',.

..J~/

The entire proximal border of the navicular bone plus the

attachment of the joint capsule to this bone can be examined
by moving the tip of the arthroscope in a palmar or plantar
direction. At the medial aspect of the joint and also on the
lateral aspect of the joint. parts of the collateral sesamoidean
ligaments can be identified. These structures are not intra-
articular but they are visible through the joint capsule at
these locations. To view these ligaments the tip of the arthro-
scope has to be directed distally in between the navicular
bone and the palmar/plantar articulation of the second
phalanx. Hyperflexion causes the navicular bone to move
away from its contact point with the second phalanx and this
exposesmore of the distal axial parts of the joint cavity.
Arthroscopic surgery of the dorsal distal
extensor process of the distal phalanx. 'I
be securely embedded
...,
in the attachment of the
Their size and outline varies from 2 mm up to 30 mID
diameter. They can be round with a smooth outline. as
osteochondritis dissecans (OCD) fragments. or in ,. --
with traumatic fractures they might appear more i
in shape.
A complete set of preoperative radiographs :-
important information about the size and location of
--

interphalangeal joint for treatment of plantar view are standard; slightly oblique views can
extensor process fragments helpful in casesof an abaxial fragment. ( --~-
(CT)images may -~
Indications of the damage, and, finally, arthroscopic accessibility. -
After arthroscopic identification the fragment
The most common indication for arthroscopy of the dorsal

1
distal interphalangeal joint is the removal of fragments of the with a periosteal elevator and removed from the joint by
of small cup rongeurs. Most of the fragments.

bit is recommended. In case of

synovitis.The protruding synovialvilli

ment. In suchcasesthe use of
helpsto improvevisibility.

processare much more difficult to access(Figs 11.12

mental portal (Vail & McIlwraith 1992) and:

might be impossible to remove from the joint at all
Fig. 11.14).

of postoperati~ osteoarthritis. Osteophytes and new

formation. and trauma and damage to the coronary
and to the attachment of the common digital
tendon are potential complications after dorsal coffin
arthrotomy.
One author (Hertsch 1972) removed'
arthrotomy I
longer an appropriate option
scopyis the method of choice for all sizes of fragments.

Preoperative considerations

ments are often found on pre-purchase examination. j

scopic surgery in such cases, therefore, is prophylactic

"cosmetic" in nature. However, we feel that many joints with
so-called silent fragments develop secondary lesions, such as
proliferative synovitis and articular cartilage damage.
In lame horses, the prognosis for complete recovery is still
good as long as there are no signs of secondary new bone
formation. The earliest signs of secondary osteoarthritis are
osteophytes on the dorsal aspect of the middle phalanx and
they are usually most obvious on oblique radiographic views.
Arthroscopic technique
The surgical technique for extensor processfragment removal
follows the steps of diagnostic coffin joint arthroscopy
described earlier in this text. The instrument portal is
carefully selected to permit access to the central articular
surface. To determine the location of the instrument portal.
an 18-gauge needle is inserted about 3 cm medial to the
sagittal line and 3 cm proximal to the coronary band. As
most fragments are small, the tip and cutting edges of the
needle can be used as a probe and for initial cut down of
minor attachments of the fragment. When the needle
position is judged to be satisfactory,a 5 rom stab incision with
a No. 11 scalpelblade is made in the skin and continued into
the joint. It is important to use well designed, strong, and
unbreakable hand instruments (Fig. 11.15). In cases of
instrument failure, pieces may disappear into an inaccessible
area of the joint cavity.
The fragment is identified and the attachment to the
connecting tissue is severed with a V-shaped periosteal
elevator.The surgeon then identifies the softtissue line between
the fragment and the remaining coffin bone and carefully
elevatesthe 4agment from its origin (Fig. 11.16-11.19).
Narrow cup alligator forceps or low profile rongeurs are
introduced into the joint and the fragment securely grasped,
rotated (to make sure there are no remaining attachments),
and removed from the joint cavity. At completion of the
procedure, the defectcreated by the fragment is debrided and
the joint cavity is lavaged using a 4.5 mm egresscannula.
In chronic cases,secondary hypertrophic reaction of the
synovial membrane, combined with soft tissue fibrosis, can
make identification and removal of fragments a challenge.
In such cases,it is helpful to remove the interfering synovium
by the use of a mechanical synovial resector. In chronic
cases, various stages of cartilage damage become visible.
Discoloration, fibrillation, and erosion up to full-thickness
loss of cartilage will be in proportion to the duration of the
initial disease.Intraoperative radiographs may be necessary
to ensure that all parts of the fragment are removed.
Postoperativemanagement
Special care is taken with bandaging, keeping in mind that
bandage failure will result in exposure of the surgical incision
and potential contamination with manure. It is important
that the bandage covers the entire hoof. An elastic. adhesive
bandage prevents slippage. Bandages are carefully monitored
and changed until the skin sutures are removed 12 days after
the procedure. Horses are confined to a stall for a minimum of
12 days and then hand walked daily for 15 minutes. Riding
and more intensive training can start 3 to 6 weeks after the
surgery. Antibiotics and phenylbutazone are administered
postoperatively for a period of 3 days.
Problems and complications
The most common problem in dorsal coffin joint arthroscopy
is inadequate visualization. Suitable case selection and
accurate placement of both arthroscope and instrument
portals alleviates this problem. Only with optimal placement
can effective triangulation be achieved. The most common
mistakes are having the portals too far lateral or medial
and/or to close too the coronary band. If a fragment or part
of a fragment becomes loose it might be extremely difficult to
relocate. Loose fragments either disappear further distally in
the joint or move into the proximal pouch of the joint. Re-
arthroscopy within a few days after the first attempt is an
option if the fragment cannot be found.
Results
Since the first report in 1988 there have only been case
reports published.Boening et al (1990) described 14 of 16
lame horses that recovered full athletic function after
arthroscopic removal of extensor process
component,
may develop (Gabel& Bukowieckie 1983).
another choice but incurs the risk of secondary
failure. The implant at this location is exposedto
cyclic loading and can break. The obvious
operative time with less incisional exposure,
visibility within the joint, and shortened
period.
Arthroscopic surgery of other
conditions in the ~istal
joint .
Abaxial articular fragments
Other. intra-articular fragments (seeFigs 11.12 and 11..
including osteochondral chip fractures or '
& McIlwraith 1992, McIlwraith & Goodman
visibility of i
might still be a challenge (Fig. 11.22). The
approach is routine. .
portal site for hand instruments is located either
medial to the extensor tendon. An 18-gauge
characterized by significant porosity of the bone,
reduction and fixation of the fragment is not {
Periosteal elevators are used to free ligamentous attachments
and motorized arthroscopic cutting instruments can be used
for resection of hypertrophic synovial membrane. fibrous
bands, and for final cleaning up of the fragment bed. Joint
lavage and skin closure follow the surgical procedure. These
patients require securebandaging for 10 days and box rest for
another 3 weeks,followed by hand walking for an additional
3 weeks. Visibility and accessibility seem to be the most
demanding features of these cases.

Fragments in the palmarolplantaroproximal

pouch of the distal interphalangeal joint
Osteochondral fragments located in the palmar/plantar
aspect (Figs 11.23 and 11.24) of the DIP proximal to the
navicular bone are rare (Brommer et al 2001. Wagner et al
1982). Such fragments could be caused by an avulsion
fracture of the middle phalanx or navicular bone. trauma to
the articular cartilage with secondary ossification. or osteo-
chondrosis. With arthroscopy of the palmar/plantar
 capsule at all or inadvertent intrusion into the navicular
bursa or digital tendon sheath. Using fluoroscopic assistance,
anatomically correct positioning can be achieved and
essential structures in close proximity to each other can be
protected. Injection of fluid into the dorsal aspectof the joint
results in distention of the palmar/plantar pouch, which is
then an important additional landmark to aid in exact
positioning of the arthroscope sheath.

Distal phalanx cysts

Cysts of the central weight bearing surface of the distal
phalanx occur infrequently, and have beentreated with intra-
articular medication and transcortical drilling. Most respond
transiently to medication. and transcortical debridement
through hoof wall windows has been complicated by recur-
rent abscessationand lameness. Intra-articular approaches
for debridement have been described recently in 11 horses
proximal pouch of the DIP.the proximalarticular margin of (Story & Bramlage 2004). Dorsal arthroscopic approaches
the navicular bone can be visually assessed. The palmar with the distal interphalangeal joint extended and the joint
aspectof the distal articular margin of the middle phalanx. distracted allow access for cyst debridement (Fig. 11.25).
the collateral sesamoidean ligamentsof the distal sesamoid Successfulreturn to work was reported in 10 of the 11 horses,
bone. and the joint capsule are further structures in the which is a considerable improvement compared to results of
visual field.The distal margin of the navicular bone and the extra-articular and conservative approaches.
articulation betweenthe middleand distalphalanxcannotbe
visualized(Vaceket al 1992). Arthroscopyin the palmar/
plantar pouch of the joint can be accompaniedby problems Proximal navicular cysts
such as hemarthrosis and iatrogenic damageto articular Surgical treatment of cyst-like defects of the proximal rim or
cartilage. Most errors are related to incorrect placementof body of the navicular bone was reported by Zierz et al (2000).
the arthroscopesheath.resulting in failure to enterthe joint Referring to a technique published by Wolter & Ratusinski
 co
':;J

\,,~ 11J

l,f;
'-1

II~: I II,\
*.
(1985), they drilled out bone cysts in the navicular bone of 5
'I
horses.The arthroscopic approach was according to Vaceket al I'
(1992). After the insertion and positioning of the arthroscope,
V1. 11
they created a contralateral portal for a 4.5 mm drill and
~J
sleeve. The cyst was identified and subsequently drilled
through diagonally. As soon as the drill reached the cyst,
there was a significant loss in drill resistance. All 5 horses
were Warmbloods from 6 to 16 years of age (3 show jumpers,
1 dressage,and 1 pleasure horse). Horse 1 was re-operated
9 months after the first surgery; 7 months after the second
surgery there was significant progress in bone remodeling at
the cyst site. Horse 2 was considered to be completely healed
and was back in work 5 months after the surgery. Horse 3 Fig. 11.27
became sound and went back into training after 12 weeks. Diagram of arthroscope position in the dorsal pouch of the
There are no reports on the outcome of horses 4 and 5. This proximal interphalange359al joint. CD, Common digital
report is contrary to experiences with drilling cysts in the extensor tendon.
medial femoral condyle, where progression of cyst enlarge-
ment after drilling has been observed.
Arthroscopy of the dorsal pouch of the
proximal interphalangeal joint
Limited spacein the dorsal pouch makes accurate location of
arthroscopic portals critical. The limb should be fixed in
maximal extension and placement of the obturator and
arthroscopic cannula into the joint is facilitated by distending
Reports of arthroscopy of the proximal interphalangeal joint the joint with fluid from the palmar/plantar aspect
are rare in the equine veterinary literature (Mcllwraith (Fig. 11.26). The cannula should be inserted along the dorsal
1990b, Schneider et al1994). One report describes a single proximal margin of the middle phalanx to the center of thejoint.
case and the second a group of 3 Standardbred racehorses Ideally. the arthroscopic portal is in the distal aspects ofthe
where osteochondral fragments were removed from the dorsal pouch (Fig. 11.27). Placement too far proximallylimits
dorsal aspect of the proximal interphalangeal joint. In the the ability to view the entire dorsal joint space. Optimal
latter study, after arthroscopic removal of the fragments from placement results in sufficient space in the joint to allowfragments
the dorsal proximal interphalangeal joint, all 3 horsesreturned to be removed safely. Small alligator-cup, or lowprofile
to training and raced successfully. Ferris-Smith rongeurs are recommended because of

III
({{~:
~t;:'"
:f!/lv
1):~
space limitation. The intra-articular anatomy of the dorsal
proximal interphalangeal joint is simple and consists of the
dorsal distal articular cartilage of the proximal phalanx as
well as the dorsal rim of the middle phalanx and joint capsule
attachments (Fig. 11.28). This dorsal proximal rim of the
middle phalanx is the usual location for osteochondral chip
fragments (Fig. 11.29 and 11.30). Fragments found at this
location could possibly result from osteochondrosis. These
fragments usually cause synovitis. which results in local
swelling of the proximal interphalangeal joint and associated
lameness. Intra-articular anesthesia is essential for proper
diagnosis. To establish the exact location of the operative
site for fragment removal, at least four preoperative
radiographs are required. Size and anatomic location of the
fragment may be identified with a dorsopalmar/plantar, a
latero-medial, and two oblique views using
radiographic films.
Following removal of fragments, ---' "---
padded bandaging of the surgical site for 1 0 days
confinement for 2 weeks post-surgery.
hand-walked for another 2 weeks. The,
allowed to train for a period of 6-8 weeks after surgery.
Arthroscopy of the
p<?uchof the proximal
Joint
So far there are no reports found on arthroscopy of
palmar/plantar pouch of '
in the literature. Although fragmentsoccur in the palmar/
plantar aspectof the pastern,it has beensuggestedthat the
capsularand ligamentousattachmentslimit entry into the
central part of the joint (McIlwraith 1990).
Fragments located in the axial palmar/plantar pouch
are found occasionally on pre-purchase examination
(Fig. 11.31). Thesecasesoften show only Grade1 lameness
and insignificant clinical signs like joint distention and
positiveflexiontest;someare without anylameness.
Fragments.that are located abaxialand which originate
from the proximal lateral or medial rim of the middle
 , \iI\!'
~~
DDF

f~

"

"
,

.
~
J
2 cm proximal to the margin of the distal condyle of
proximal phalanx (Fig. 11.26), close to the
/- plantar margin, the obturator and cannula
the palmar/plantar pouch aiming axially (Fig. 11.33
11.34). The axial palmar/plantar pouch is quite
(Fig. 11.35), r

The instrument portal can be ipsilateral or

orientation of portals and fragment identification.

After fragment removal, the joint is debrided and I
and the skin is closed. The postoperative training
phalanx, remain casesfor mini-arthrotomy as they cannot be
accessed arthroscopically (Fig. 11.32). The pathogenesis of interphalangeal joint arthroscopy. One author GB)
the avulsed abaxial fragments is traumatic; these fragments
will create significant lameness in the acute stage. of the proximal interphalangeal joint on 5 occasions:
For surgery of axial palmar/plantar fragments in the European Warmblood horses and 1 pony: Three of
proxinlal interphalangeal joint, one of the authors OR)prefers cases showed Grade I lameness which could be, after
the horse in lateral recumbency, while the remaining authors
prefer dorsal recumbency. The joint is pre-distended with
polyionic Ringer's solution by the use of a 16-gauge hypo- joint. All fragments.ranging from 4 to 12 mm
dermic needle. The landmarks for palmar/plantar injection
are about 2-3 cm proxinlal to the palpable distal condyle of
the proxinlal phalanx. After making a 5 mm skin incision had failedpreviouspre-purchaseexaminations.Only

}
.1
 after surgery. In this case the fragment could be visualized
arthroscopically in between the distal condyles of I
proximal phalanx. but was inaccessible.

References
the 1st Advanced Arthroscopic Surgery Course, I
University,1988.
Boening
-
KJ. Contact-Arthro-Microscopy and synovial

Annual ECVSScientificMeeting,
--
Konstanz,1995: 71-72.

EquinePract 1990; 311-317.

Brommer H. Rijkenhuizen ABM. van den Belt AIM. Keg
Arthroscopic removal of an osteochondral fragment at
palmaroproximal aspect of the distal interphalangeal.
Equine Vet Educ 2001; 13(6): 294-297.
Gabel AA. Bukowieckie CF. Fractures of the phalanges. Vet'
North Am Large Anim Pract 1983; 5: 233-260.
Hertsch B. Diagnosis and treatment of pedal bone fractures. ~
Tieriirztl Wochenschr 1972; 79(21): 524-532.
Mcllwraith CWo Other uses for arthroscopy in the horse.

horse. Philadelphia: Lea & Febiger 1990a: 219.

McIlwraith CWo Other uses for arthroscopy in the

horse. Philadelphia: Lea & Febiger; 1990b: 220.

Mcllwraith CWoGoodman NL. Conditions of i

of osteochondral
joint of the pelvic limbs in three horses. JAVMA
79-82.
Story MR. Bramlage LR. Arthroscopic debridement of
bone cysts in the distal phalanx of 11 horses :--
EquineVetJ2004; 36: 356-360.

articular anatomy
aspects of distal interphalangeal joints. Vet Surg 1992;
257-260.
Vail TB. McIlwraith CWoArthroscopic removal of ' C
fragment from the middle phalanx of a horse. ~
269-272.
Wagner PC. Modransky PD. Gavin PRoGrant BD.
..-

Equine Pract 1982; 4: 9-15.

Wolter D. Ratusinski C. Das extraartikuliire. I

1985; 88:425-431.
ZieI"lJ. Schad D. GiersemehlK. Chirurgische Moglichkeiten
Versorgung von Strahlbeinzystensowie Strukturdefekten
Strahlbein.pferdeheilkunde2000; 16:171-176.

out of this group of 5 horses had a problem in the front limb;

all the others were affected in a hind limb. The horse with the
fragment in the front leg was not lame before surgery and did
not show lameness after fragment removal. All horses with
affected hind limbs became sound and could go back into
training; 1 of the horses with a hind limb fragment exhibited
no evidence of pre-surgical lameness nor did it develop any
signs of lameness post-surgically. Only the pony stayed lame
 Tenoscopy of the Digital
Flexor Tendon Sheath
Introduction
The primary indication for tenoscopy of the digital flexor
tendon sheath is assessmentand treatment of the various
manifestations of chronic, proliferative, so-called "complex
tenosynovitis" of this sheath. Chronic tenosynovitis is a
relatively common problem of the digital flexor tendon sheath,
particularly in the hind limbs. Most mild and moderate forms
of tenosynovitis cause only low-grade lameness and 'can be
managed medically. More severe tenosynovitis cases, and
those chronic cases that have disruption of the tendon
sheath, the various mesotenons. the annular ligament, or the
flexor tendons themselves,may result in a more profound and
self-perpetuating cycle of increasing tendon sheath fibrosis
and annular ligament thickening (Fortier et al1999). Teno-
synovial massesand adhesions can developas a consequence
(Watrous et al 1987). These latter types of complex
tenosynovitis not only require surgical intervention but also
generally have a reduced prognosis for good cosmetic out-
come and return to complete soundness (Fortier et al1999,
Wilderjans et al 2003). The duration of symptoms seems
particularly relevant to the final outcome of these cases.
Pathogenesis
Acute tenosynovitis can result from tearing of various portions
of the digital flexor tendon sheath, the mesotenons, or linear
tears in the flexor tendons within the sheath. Recalcitrant
tenosynovitis and secondary constriction due to the palmar/
plantar annular ligament can then follow acute tenosynovitis
(Dik et al19 95). Progressivefibrous thickening of the sheath
and the intimately attached annular ligament can compress
and restrict the free movement of the flexor tendons through
the fetlock canal (Adams 1974, Gerring & Webbon 1984,
Verschooten & Picavet 1986, 1988). The consequences
include turgid fluid accumulation within the tendon sheath.
enlarging tenosynovial massesalong the abaxial portions of
the flexor tendons, particularly in the proximal portion of the
digital flexor tendon sheath. and adhesions spanning from
the tendons to the dorsal and abaxial parietal layers of the
CHAPTER
digital flexor tendon sheath(Ragland1968. Dik et a11995.
Fortieretal1999. All are exquisitelysensitive.Surgicaltreat-
ment of these complexcasesis appropriateto debridethe
primary tendondefectand stopthe cycleof annular ligament
constrictionandongoingsheathirritation (Fortieretal1999).
Preoperative assessment
Lamenessoriginating from the digital flexor tendon sheath is
confirmed by intrathecal anesthesia, and should be followed
by a thorough ultrasonographic assessment. Particular
attention should focus on the extent of tendonitis of the
superficial digital flexor tendon (SDFT)and the deep digital
flexor tendon (DDFT), since they profoundly affect the
prognosis and the decision for surgery (Barr et al 1995).
Additionally, ultrasonographic evaluation determines the
thickness of the tendon sheath wall and palmar annular
ligament, and definesthe number, and lateral or medial attach-
ment, of tenosynovial massesthat need to be addressedat the
time of surgery (Stanek & Edinger 1990, Dik et al 1991,
Redding 1991). Central core lesions of the flexor tendons can
be treated by injection or stab incision at the time of surgical
section of the annular ligament. Linear clefts within the
DDFT and occasionally the SDFT present special problems in
repair, with most requiring debridement, and some requiring
suture repair (Wright & McMahon 1999). In the authors'
experience ultrasonographic examination is not sensitive in
detecting linear clefts in the tendon structure. Any ultra-
sonographic suggestion of echolucencies within the surface
one-third of the flexor tendons is highly suspicious, and this
region should b'~ carefully assessedduring endoscopic explo-
ration. Additionally, adhesions and soft tissue masses within
the tendon sheath, as well as between the SDFT and DDFT,
need to be removed. Presurgical preparation and draping
must provide accessto both lateral and medial portions of the
digital flexor tendon sheath, to allow instrument access to
these tissues for removal or sectioning.
Surgical anatomy
The digital flexor tendon sheath consists of a parietal and
visceral layer that provide the inner lining of the sheath and
the surface layer of the enclosed tendons, respectively. The
intimal layer is several cell layers thick, and is supported by

dense subintimal and sheath fibrous layers (Hago et aI1990).
The digital flexor tendon sheath extends from the junction of
distal and middle thirds of the third metacarpus/metatarsus
to the level of the middle phalanx and navicular bone
(Fig. 12.1). The sheath enclosesthe SDFTand DDFT, both of
which have mesotenon attachments to the tendon sheath.
Cut annular ligament
The most robust mesotenon extends from the palmar midline
of the SDFT to the adjacent tendon sheath (Figs 12.2 and
12.3). Short thick mesotenons also extend from the proximo-
medial and proximolateral margins of the DDFT.The proximal
portion of the DDFT is encircled by a complete but thin sleeve
of the SDFTknown asthemanicaflexoria (seeFigs 12.1-12.3),
which ensures alignment of the tendons during their passage
around the fetlock. The digital flexor tendon sheath has its
proximal reflection and attachment to the full circumference
of both the SDFT and DDFT, which forms the proximal
endpoint of the sheath cavity. In the distal portions of the
digital flexor tendon sheath, the DDFT has several dorsal and
a single palmar/plantar mesotenon attachment (seeFig. 12.1,
inset). There is also a small encircling component (the digital
manica) of the SDFT (see Fig. 12.1, inset), which stabilizes
the SDFT against the DDFT during the final path toward
 Proximal phalanx
4 ~..~ ,-'
,~~.J"~("
'".~
.,:,r"';' ~'
Lateral oblique
sesamoidean
~~.
r;,"', ~.
f..~i~
.Medialoblique,
sesamoidean
ligament
Straight -
sesamoidean
ligament

Vinculae

of digital sheath
Digital sheath wall

tendon insertion (Nixon 1990c, Redding 1991 1993). The gentlyin a proximodorsaldirection
SDFTcan be seento bifurcate and exit the digital flexor tendon
sheath in the region of the distal portion of the proximal dorsal recessesof the sheath (see Fig. 12.5). High
phalanx (Fig. 12.4). Vascular supply to the flexor tendons is
derived through the mesotenon and digital sheath reflections. wall of a fibrosed tendon:
Synovial fluid from the tendon sheath has a similar com- the initial phases of digital flexor tendon sheath
position to that from joints, with slightly reduced hyaluronic allowing time for the tissues to expand and
acid content (Malark et aI1991). hemorrhage and synovial fluid to 1 ' ,
through severalneedles.

should involve entry outside the manic a flexoria,

Tenoscopic techniques many of the larger tendon sheath massesdevelop (Fig.

Diagnostic tenoscopy canal and inserted beneath the manica

The standard approach to the digital flexor tendon sheath
uses a skin entry portal for the arthroscope on the palmaro/
plantarolateral aspect of the sheath between the annular
ligament and proximal digital annular ligament (Fig. 12.5).
Distention of the tendon sheath defines an outpouching at
this site. A skin incision is made slightly palmar/plantar to
the center of this prominent outpouching, to allow the
arthroscope to be directed proximally through the fetlock
canal, and then to be redirected for examination of the distal
tendon sheath region (seeFig. 12.5). Entry of the arthroscope
sleeveand conical obturator needsto be performed with care,
since the flexor tendons in chronic caseshave fragile epitenal
surface layers. and iatrogenic damage is a possibility. The skin
incision and entry portal through the fibrotic tendon sheath
need to be slightly larger than normal, so thatthe arthroscope
sleeve and obturator enter easily. Once the sleeve and
obturator have entered the digital sheath, they are pushed
the proximal DDFT. Linear clefts i
found at this~vel, which may correspond to ,
stricted region of the fetlock canal when the limb
SDFT, paying particular attention to adhesions and
massesdirectly between the flexor tendons (Fig. 12. '; -
the arthroscope is withdrawn from I
redirected palmar/plantar to the SDFT, where the
mesotenon attachment is evident (seeFig. 12.7).
sheath is restricted. In such cases, examination can
improved by severing the annular ]
phases of the surgical procedure, (
tendon sheath masses and other adhesions. The
Fig. 12.6
Tenoscopic view of the fetlock canal region with the arthroscope
inserted distal to the annular ligament and looking proximally (as
in Fig. 12.5). The lateral sesamoid (Ses). annular ligament (AL).
manica flexoria (MF) of the SDFT (S). and the DDFT (D) are
evident. Ses
 ~

instrument entry is made in the dorsolateral region of the surgical examination and treatment of complex cases.
proxinlal cul-de-sac of the digital flexor tendon sheath (see tourniquet is ]
Fig. 12.5). This is defined by needle entry followed by scalpel ment of a septic digital flexor tendon sheath.
incision. The entry to the digital flexor tendon sheath should lateral skin entry then provides
be palmar to the neurovascular bundle, to avoid damage to
these structures. Preoperative placement of a tourniquet is motorizedresectors.As resectionof
routine and is a useful means to limit hemorrhage from skin
entries, adhesion and mass removal sites, and the annular medial
layer of entry
1_- can
---~---be made ~---
to the proximal portion of 1
ligament division. particularly if this is done early in the

flexor Ienaun ~Il~ltLIl
LU ItUUW ~llLLY VI lla11U 111"" U111"1'." =1"motorized
resectors for direct accessto synovial massesandadhesions
(Fig. 12.8).
Redirection of the arthroscope into the distal regions ofthe
digital flexor tendon sheath permits evaluation of bothsurfaces
of the DDFT and the dorsal surface of the SDFT,the
digital manica, and the mesotenon (vinculae) (Fig. 12.9).
Ultimately, the arthroscope can be inserted to the distal limits
of the digital flexor tendon sheath. Generally, proliferativemasses
and adhesions are less prevalent in the distal regions
of the sheath.
Reversal of the instrument and arthroscope portals allows
examination of the digital flexor tendon sheath using a
proximal approach (Fig. 12.10). Instruments can be inserted
through the distal skin portal, allowing further motorized
resection of adhesions and masses associated with the
flexor tendons and tendon sheath distal to the level of
the fetlock.
.eno~~op'~ mu~~"~'"UYU"UU"~~"'" ..u..~~'"..v..
Open tendon surgery for removal of tenosynovial massesand
adhesions delays initiation of exercise postoperatively and
predisposes to adhesion reformation (Watrous et al 1987,
Nixon 1990b). Tenoscopic examination of the digital flexor
tendon sheath is preferred, as the minimally invasive approach
provides complete access to most of the sheath contents,
permits multiple mass removal, and allows early return to
walking in the convalescent period (Nixon 1990c). Large
tenosynovial masses can be challenging to remove, and
complete assessmentcan be difficult until some of the tissue
is resected. Preoperative ultrasonography is used to target
and develop a plan for mass removal (Fig. 12.11). Straight
J '
~lade, Dyonics -Smith & Nephew,Andover,MA), with relatively
\Tidecutting apertures and active suction, allow entry of theissue
to the cutting blade. Biopsy punch rongeurs (Dyovac
;.2, Dyonics -Smith & Nephew), biopsy cutting forceps,etractable
blades, and arthroscopic scissors can all be useful
Drremoval of masses(Fig. 12.12). The biopsy punch rongeur
s useful for removal of adhesions; however, motorized'esectors
provide more efficient soft tissue mass removal.
Nith large masses,a secondinstrument portal may be required
0 provide tension on the mass while it is severed at its basemd
removed using hand instruments. Access to the region
)etweenthe DDFTand SDFTwill require an instrument entry
;hrough the proximal portion of the manic a flexoria of the)DFT.
The original skin portal in the dorsal lateral surface of:he
proximal portion of the digital flexor tendon sheath canJe
used; however, a separate incision needs to be developed
through the surface of the manica flexoria to allow instru-ments
to enter between the DDFT and SDFT. The authorsl1ave
not recognized complications associated with these
additional perforations. Bleeding from the sheath and
epitenon surface of the tendons after mass resection can be
profuse,and a tourniquet becomesmore important as disease
chronicity increases. In most circumstances, the palmar/
plantar annular ligament is transected after removal of
tendon sheath masses. However, if movement through the
fetlock canal is restricted, the annular ligament should bedivided
early.
"U"~C,"L'VII vI LII'" """"""""",.,,'
annular ligamentThe
only effective treatment for genuine palmar/plantarannular
ligament constriction is surgical division. A simpleannular
ligament transection can be accomplished withoutthe
need for tenoscopy,but in many cases constriction is part
of a complex tenosynovitis syndrome which requires
resection of tissues in addition to the annular ligament.
Tenoscopically assisted annular ligament transection can be
accomplished free hand using a variety of right-angled
blades, or preferably using a slotted cannula (Dyonics -Smith
& Nephew, Andover, MA) for better control of the blade
(Fig. 12.13). This latter technique was developed for carpal
tunnel surgery in man (Chow 1989. 1999). and has been
adapted without change to the instrumentation for annular
ligament releasein horses (Nixon et al1993). The advantages
of tenoscopic annular ligament release include the precision
of the cut, the safety of identifying and avoiding vital structures
such as the manica flexoria and flexor tendons, and the
extensive dissection that can be performed through limited
entry wounds. which provides better wound healing with
less risk of dehiscence and earlier postoperative exercise
(Nixon et al 1993). Placement of the slotted cannula is
critical to facilitate insertion of the arthroscope and 900
angled blade. The proximal entry portal should be dorsal in
the digital flexor tendon sheath and the distal exit portal
plantar/palmar. to allow the arthroscope or blades to clear

the heel-bulbs (Fig. 12.14). Interference of the heel-bulb with
the arthroscope and video camera can be frustrating,
particularly in breeds such as Cobbs.
The cannula with obturator in place is inserted from
proximal to distal using arthroscopic visualization (see
Fig. 12.14). The insertion path must be external to the
manica flexoria, or this ring of the SDFTwill be divided along
with the annular ligament. As the slotted cannula and its
ribbed obturator near the distal portal. the tip of the
arthroscope is retracted 5 mm into its sleeve, to create a
docking portal for the obturator of the slotted cannula
(Fig. 12.15). This is then advanced, pushing the arthroscope
and sleeve out of the tendon sheath and allowing the slotted
cannula to exit the arthroscopic skin portal. The ribbed
obturator is then removed from the slotted cannula, and the
unsheathed arthroscope inserted to view and confirm
positioning with respect to the flexor tendons, the sesamoid
surface, and the palmar/plantar annular ligament. The slot
in the cannula is then oriented to open directly toward the
annular ligament (Fig. 12.14D), before the 900 angled blade
is inserted and drawn across the fibers of the annular
ligament to sever the full thickness of the ligament
(Fig. 12.16). Complete division is verified by external palpa-
tion of the blade tip beneath the skin, transillumination of
light from the arthroscope through the skin, and direct visual
evidence of a lack of remaining ligament fibers along the path
of the transection. Hemorrhage is flushed from the cannula
and tendon sheath, the cannula is removed. and the skin
incisions sutured if no further procedures are required. In
many cases the arthroscope is reinserted. the annular
ligament desmotomy inspected. and further exploration and
surgical procedures performed. The increased maneuver-
ability of the arthroscope within the digital flexor tendon
sheath provides a more complete assessmentof the adequacy
of adhesion and mass removal.
Several single portal carpal tunnel release devices have
beendeveloped for use in man (Arthrex. Naples, FL; Linvatec,
Largo, FL). Both work for release of the annular ligament in
horses. However, it is rare not to require a proximal and distal
entry for other digital flexor tendon sheath procedures, so a
single entry portal system has less utility in the horse.
Tendon linear clefts
An increasingly recognized syndrome involves longitudinal
clefts in the DDFT and less frequently in the SDFT.The linear
clefts can penetrate a variable distance into the substance of
the tendon, and in some instances have been extensive. The
treatment of choice is tenoscopic debridement (Fig. 12.17),
which has proved superior to suture repair following open
surgical approaches (Wright & McMahon 1999, Nixon
2002a). Length of tears in the DDFT can extend from 4 to
10 cm, and frequently involve the DDFT from the level of mid
proximal phalanx to extend beyond the level of the apex of
the proximal sesamoid bones. The depth of linear cleft varies
from penetration to the center of the DDFT (seeFig. 12.17),
to more superficial fiber erosion. Trimming of exposedtendon
fiber can be accomplished using a combination of biopsy
punch rongeurs (Dyovac 5.2), and motorized resectors with
both side and forward aperture, which are also effective in
trimming down epitenal and tendon fiber damage. The aim
should be a relatively smooth tendon surface. Access to the
region between the DDFT and SDFT may also be required to
trim linear clefts in the DDFT that extend proximal to the
sesamoid,(bones,and this needs an entry through the
proximal portion of the manica flexoria for instrumentation,
as described earlier.
In some casesthere may be tearing of the manica flexoria.
This may result from ongoing pressure within the fetlock
canal associated with constriction by the palmar/plantar
annular ligament, or may arise as primary lesions. Depending
on the extent of the tear, the edges of the cleft can be
debrided, or the manica resected in toto using arthroscopic
scissors, knives or motorized resectors (Fig. 12.18). No
attempt at suture repair has been used. Other pathologic
conditions can develop associated with chronic constriction
of the annular ligament, including separation of the palmar
mesotenon of the SDFT.These areas can be trimmed, and any
secondary adhesions resected. The aim of digital flexor
tendon sheath adhesion removal should be free motion of the
flexor tendons within the digital flexor tendon sheath.
Alternating the arthroscope entry from the distal to the
proximal portals is necessaryto allow complete assessmentof
the adequacy of the surgical procedures. Tears of the
proximal mesotenon of the DDFT and of the digital manica
have also been encountered by one of the authors (I.M.W.).

Postoperative care
Sodium hyaluronan (NaHA; 20-40 mg) is frequently injected
into the tendon sheath at the time of wound closure.
Researchin horses and smaller experimental animals indicates
NaHA reduces the formation and reformation of tendon
adhesions in the sheath area and enhances intrinsic tendon
healing (Weiss et al1986, Amiel et al1989, Gaughan et al.
1991, Moro-oka et al 2000). Additionally, intrathecal local
anesthetic installation provides good postoperative pain
control. The use of long-acting anesthetic agents such as
bupivacaine provides 4-6 hours of postoperative analgesia. A
firm bandage is also applied, not only to provide a sterile
environment but also to add counterpressure that provides
additional comfort to the operated limb. The bandage is
usually maintained for 3-4 weeks after surgery.
Antibiotics such as potassium or procaine penicillin are
commenced prior to surgery and continued for 1 or 2 days
~
postoperatively. Surgery around the bulb of the heel and the
distal portion of the digital sheath can be difficult to establish
and maintain a sterile field, particularly around the ergot,
and antimicrobial drugs are a useful precaution. Longer-term injection of NaHA is recommended 2
pain control is provided with nonsteroidal anti-inflammatory Injection of the digital flexor tendon sheath is
agents such as phenylbutazone (4.4 mg/kg orally), which is
usually administered for 7-10 days after surgery to minimize
tissue inflammation and swelling. intravenous NaHA (Legend,Bayer Corp, Animal
Hand walking for increasing periods commences 2-3 days ShawneeMission,KS)may alsobe useful.
after surgery:Long periods of walking exerciseare particularly Return to work'
helpful if tendon adhesions were present at surgery. A secondary tendonitis, which frequently delays return
compromise between incisional healing and the beneficial exercisefor 6-12 months.
affects of early exercise is usually reached on a case-by-case
basis. Use of mechanical walkers, swimming, and passive ultrasonographic examination is useful to evaluate
responseof the flexor tendons. particularly where linear
tendontearsweretrimmed or corelesionswereinjectedwith
growth factors or NaHA at the time of palmar/plantar
annular ligamenttransection.

Results and prognosis

Endoscopic mass removal and annular ligament division in
25 horses followed for 1-7 years revealed a normal cosmetic
outcome in 10 horses, and an improved cosmetic outcome in
12 of 22 horses (Fortier et alI999). Lamenesswas eliminated
in 18 horses (72%) and improved in another 4 horses, while
3 horses remained lame. The poorest responsewas evident in
2 horses with concurrent tendonitis in the region of the
fetlock canal. The cosmetic outcome was inversely related to
preoperative duration of clinical signs and the severity of
synovial masses. Additionally, a longer history of symptoms
led to a thicker annular ligament on preoperative ultrasono-
graphy, which was frequently later confirmed at surgery. The
results following debridement of linear tears in the DDFT
have also been reasonably good (Wright & McMahon 1999,
Wilderjans et aI2003).
Tenoscopy of the Carpal
Simple constrictive syndromes due to a wound, desmitis of
the palmar/plantar annular ligament, or chronic fibrosing
Sheath
synovitis of the tendon sheath have a good prognosis for
return to work after annular ligament transection. The Introduction
outlook is guarded where extensive tendon adhesions are
resected,as these casesoften have residual obliteration of the The carpal sheathhas beenused for many yearsto refer to
tendon sheath cavity with tendon tie-down in the proximal what is now listed in Nomina Anatomica as the common
and distal limits of the sheath. A better prognosis can be carpal sheathof the digital flexortendons.Throughout this
afforded by an aggressive tenoscopic dissection to free the chapter,we referto this structure as the "carpal sheath" for
tendons within the tendon sheath. the sakeof brevity and readerfamiliarity. Additionally,other
terms occasionally used to indicate the carpal sheath include
"carpal flexor tendon sheath" and "carpal canal". The carpal
canal will be used to describe that subcomponent of the
carpal sheath bound by the carpal flexor retinaculum,
spanning from the accessory carpal bone to the carpal
ligament.
Carpal sheath conditions that result in chronic and often
insidious lameness have been increasingly recognized and
examined by exploratory endoscopy (McIlwraith 2002a,
Textor et al 2003, Nixon et al 2004). Many of the clinical
components of carpal sheath/carpal canal lameness may be
interrelated. Radial osteochondroma,radial physeal exostoses,
tendonitis or myotendonitis of the proximal portion of the
digital flexors, and idiopathic carpal tunnel syndromes may
all result in lameness and/or sheath distention. These con-
ditions frequently have little to differentiate them based on
their clinical appearance. Endoscopic examination is useful
for assessmentand confirmation of the diagnosis of many of
these syndromes, and can then be followed by definitive
repair. Arthroscopic approaches to the carpal sheath have
been described (Cauvin et a11997, Southwood et alI998).
Removal of radial osteochondroma under arthroscopic
visualization is simple and effective, and eliminates the deep
dissectionnecessarywith open approaches(Squire et al1992,
Southwood et al1997, ter Braake & Rijkenhuizen 2001).
Additionally, many horses have caudally protruding bony
exostosesassociatedwith the closeddistal physis of the radius
(Nixon et al 2004). These exostosesare considered to result
from previous physitis and when centrally placed can
penetrate the carpal sheath and excoriatethe DDFT (Nixon et al
2004). Idiopathic carpal canal syndrome can arise from
damage to the carpal retinaculum, carpal sheath, myo-
tendinous junction of the flexor tendons, and fracture of the
accessory carpal bone. Tenoscopic division of the carpal
retinaculum can be used to open the carpal canal and release
pressure on the digital flexor tendons (Textor et al2003). This
reduces the risk of complications associated with open
surgery, including persistent swelling, seroma formation,
wound dehiscence and fistula formation.
Surgical anatomy
The carpal sheath is a voluminous synovial cavity that
extendsfrom the levelof the lowermiddlethird of the radius
to the uppermiddlethird of the metacarpus.It envelopsthe
SDFTand DDFTand their myotendinousjunctions during
passagethrough the carpal canal. Functionally,the carpal
sheath provides protection and lubrication. and minor
metabolicsupport.to bothtendonsastheytraversethecarpal
canal.The parietal and visceralsurfacesof the carpal sheath
are morphologically similar to the digital flexor tendon
sheath.The carpal sheathis more spaciousproximal to the
level of the accessorycarpal bone. where it contains both
SDFTand DDFTand the radial head of the DDF,coursing
from the caudalaspectof the radiusto its aponeurosison the
DDFT(Fig. 12.19). The medial side of the SDFTwithin the
carpal sheathalsohas an intimately attachedmedialpalmar
artery and nerve (Fig. 12.20), which can be compressedin
carpal canal syndromes. These are rarely viewed during
routine carpal sheath tenoscopy because the approach is
generally from the lateral aspect. The SDFT and DDFT are
closely intertwined during their passage through the carpal
sheath, and have a common and extensive mesotenon that
exits from the caudomedial aspect of the tendons and
attaches to the caudal aspect of the carpal sheath (see
Fig. 12.20). This effectively prevents complete examination of
the carpal sheath using lateral surgical approaches. Other
important neurovascular structures that lay outside of the
carpal sheath (see Fig. 12.18), are relevant in carpal canal
release (Textor et al 2003), and should be avoided in the
tenoscopic dissection. The substance of the carpal flexor
retinaculum forming the carpal canal and the distal extent of
the proximal check ligament can be seen intruding on the
medial wall of the carpal sheath in the center and proximal
regions, respectively(seeFig. 12.19). Vascular support for the
SDFTand DDFT is provided through the mesotenon attach-
ment, the proximal and distal carpal sheath reflections to the
tendons, the radial head of the DDFT, the proximal check
ligament attachment to the SDFT,and the entry of vessels
through the myotendinous junctions. The carpal sheath fluid
has a similar composition to digital flexor tendon sheath
fluid. The carpal sheath becomes considerably reduced in
diameter distal to the carpal canal (Fig. 12.21), which limits
the mobility of instruments during tenoscopic examination,
despite the fact the mesotenon is thinner in the distal recessof
the sheath.
Tenoscopic techniques
Introduction
The role of radiographically evident bony exostoses and
osteochondromas in causing damage to the DDFT and carpal
sheath effusion are well described. and tenoscopic removal
has been curative (Squire et a11992. Southwood et al1997,
Mcllwraith 2002a, Nixon etal2004). Carefulultrasonographic
examination of the carpal sheath has also identified soft
tissue lesions within the tendons or carpal sheath. and provides
better preoperative information for planning the tenoscopic
access. Casestwith carpal sheath effusion but without an
obvious radiologic or ultrasonographic cause are frequently
treated initially with a combination of intrathecal NaHA and
corticosteroids. If lameness and/or distention persists,
diagnostic tenoscopic examination is warranted.
Diagnostic arthroscopy of the carpal sheath
The authors use variations of the standard proximolateral
approach to the carpal sheath as described by Southwood et al
(1998). This technique allows evaluation of the entire
proximal portion of the carpal sheath, including the carpal
canal region, but provides limited access to the metacarpal
region of the sheath. Insertion of the arthroscope into the
distal region of the carpal sheath improves examination of
this area (Cauvin et aI1997).
 Extensor carpi
Common digital .radialis tendon
extensor tendon """
\
Medial
l'
.~
~ collateral
Lateral .' ~. ligament
collateral In
,.
"
ligament
Radial
carpal b.
~q
i

-\ -Medial
Palmar carpal' palmar a.,n.
ligament Medial palmar v.
Radial a.
Carpal flexor
retinaculum

A "Lateral palmar v.
Mesotenon MEDIAL
LATERAL

.
~
 Extensor carpi
Common digital radialis tendon
extensor tendon \
Lateral digital extensor
tendon and lateral.
collateral ligament.
Accessorioquartal and .
accessoriometacarpal
ligaments
'\ Medial palmar a.,n.
A Lateral palmar a.,v.,n.'
Surgery can be performed with the horse in dorsal
recumbency, or in lateral recumbency with the affected limb
uppermost. Dorsal recumbency is generally preferred by the
authors. It has obvious advantages for bilateral evaluation
and significantly reduces intraoperative hemorrhage. Lateral
recumbency facilitates tenoscopy through the distal (meta-
carpal) portal and some surgeons find the operating position
to be more comfortable. In both situations, the carpus is
positioned in slight (approximately 15-20°) flexion. The
carpal sheath is distended with 50-60 ml of lactated Ringer's
solution and the arthroscope entry portal is made laterally,
6-8 cm proximal to the remnant of the radial physis. This
allows examination of the carpal sheath, while leaving the
region between the arthroscope entry and the distal physis of
the radius available for instrument entry (Fig. 12.22).
Initial examination from the lateral approach reveals
the caudal aspect of the radius, and the lateral portion of the
DDFT, which at this level obscures most of the SDFT
(Fig. 12.23). The SDFT can be examined later by rolling the
DDFT with a probe, but this exposes only small portions of
the tendon; complete examination of the SDFT is difficult
using the lateral approach. The common mesotenon for
the SDFTand DDFT attaches to the caudolateral aspect of the
carpal sheath, and effectively prevents examination of the
SDFT over its caudal and medial surfaces. In the more distal
regions of the carpal sheath, the SDFT emerges, although
better examination of this tendon is provided through a
palmarolateral portal 4-6 cm distal to the accessory carpal
bone (Cauvin et aI1997).
Maneuvering the arthroscope to examine the more
proximal regions of the carpal sheath reveals the radial head
of the DDFT coursing from its aponeurosis on the DDFT
cranially to curve and expand into its origin on the caudal
aspect of the radius (see Fig. 12.23). The proximal check
ligament can also be identified within the medial wall of the
Medial
collateral
ligament
middle carpal
joint
Flexor carpi
Medial palmar v.
carpal sheath immediately cranial to the radial head of the
DDFT,but can be more clearly defined by using an instrument
to probe for the intrusion of the ligament into the sheath (see
Fig. 12.23).
The arthroscope can then be redirected to more caudal
regions of the carpal sheath, examining the caudal surface of
the DDFT and a small portion of the SDFT (see Fig. 12.23).
The arthroscope can be inserted from the lateral to medial
direction to assess these areas of the SDFT and can be
inserted a small distance between the SDFTand DDFT before
encountering the common mesotenon joining the DDFT and
SDFT.
Further examination of the craniomedial depths of the
carpal sheath reveals the transversely oriented fibers of the
carpal flexor retinaculum, forming the medial boundary to
the carpal canal (Fig. 12-24). The proximal and distal limits
of the retinaculum are not as distinct as the intrusion formed
by the proximal check ligament. The proximal border of the
retinaculum can be recognized only by the adjacent caudal
protuberan~ of the physeal scar of the radius. The distal
border of the retinaculum can be determined by digital
pressure over the caudomedial portion of the carpal sheath,
which can easily be indented only beyond this distal margin.
The distal regions of the carpal sheath can be examined
beyond the level of the carpometacarpal joint, but mobility
distal to this level is restricted. Examination of the most distal
regions of the carpal sheath can be performed by inserting
the arthroscope through the palmarolateral surface of the
carpal sheath in the proximal metacarpus (Cauvin et al
1997), and viewing proximally. This can be difficult with the
horse in dorsal recumbency, but the limb should be draped to
allow this portal if needed.The arthroscope portal can also be
made in the palmaromedial surface of the sheath at this level
but, with the horse in dorsal recumbency, manipulating the
arthroscope becomes even more difficult.
~
Removal of radial osteochondroma
Radial osteochondromas originating on the caudal portion of
the radial metaphysis penetrate a variable distance into the
carpal sheath (Fig. 12.25). They are usually lateral and can
be easily identified arthroscopically. An 18-gauge spinal
needle is used to identify an appropriate instrument portal
directly over the mass (Squire et al 1992). An osteotome
(4 rom Cottle) is used to separate the osteochondroma from
the caudal aspectto the radius. The osteochondroma is then
retrieved using large rongeurs, and the bony bed smoothed
using a curette, bone rasp, or motorized burr. Secondary
damage to the DDFT may require debridement with biopsy
rongeurs or motorized apparatus. Finally, debris is flushed
from the sheath before routine skin closure.
One of the principal advantages of tenoscopy compared to
open surgery for removal of osteochondroma is the ability to
assessand treat tendon lesions, which also allows for a more
accurate prognosis. Fibrosis and thickening of the carpal
sheath secondary to osteochondroma is common, and an
assessmentof the degree of resultant carpal canal stenosis
can also be obtained tenoscopically. If there is evidence of
carpal canal constriction, which can be subjectively deter-
mined by the limitation to arthroscope movement through
the carpal canal, release of the carpal flexor retinaculum can
also be accomplished (see later description).

Removal of radial physeal exostoses

Radial physeal exostosesare removed using a similar
techniqueto that for radial osteochondroma(Nixon2002a,
Nixon et al 2004). Most clinically relevant radial physeal
exostosesinvolve protrusion of one or two caudally directed
physeal remnants (Fig. 12.26). The lateral remnant is
generally more severe than the medial, and they can form a
valley through which the DDFTcourses. Damage to the DDFT
can be extensive,including excoriation of the epitenon, linear

recumbency. Penetration of the thin sheath surrounding the
flexor carpi radialis tendon is routine. and is an important
landmark since it defines the medial endpoint for the
dissection (Nixon 1990a). Exchange of arthroscope and
instrument portals is often useful to improve visualization
during division of the more proximal regions of the check
ligament. With experience. it is generally easier to perform
the entire surgery with the arthroscope placed in the more
distal instrument portal. The instrument and arthroscope
tend to follow a sinlilar plane, making triangulation more
difficult during the latter portion of the surgery. However,the
proximal fibers of the check ligament can be identified and
divided using biopsy rongeurs. Use of a radiofrequency probe
(Arthrex, Naples, FL) has been helpful to divide the proximal
check ligament more cleanly (Fig. 12.30). However, because
the probe cuts cleanly, and it can be difficult to seethe depths
of the division between the closely apposed divided edges,
particularly in the proximal region of the check ligament.
At the end of the procedure, the surface of the flexor
tendons should be carefully examined to be sure there are no
additional tendon injuries that may influence prognosis or
require treatment. Severalcaseshave also had tearing of the
aponeurosis of the radial head of the DDFT with the main
structure of the DDFT (Fig. 12.31). This has been recognized
by three of the authors; however, the clinical significance of
this lesion is still unclear.
Carpal tunnel syndrome
The carpal flexor retinaculum can be released using
the tenoscopic access portal described above. but with
the arthroscope directed distally rather than proximally
(Fig. 12.32) (Textor et aI2003). Identification of the fibers of
the carpal flexor retinaculum that form the medial aspect of
the carpal tunnel is accomplished using digital pressure
followed by insertion of a needle to define the distal and
proximal extent of the retinaculum. An instrument portal is
then made 10-15 mm proximal to the accessorycarpal bone.
This should be defined by prior insertion of a spinal needle to
verify there will be sufficient angulation for instrument
accessto the distal aspect of the retinaculum. If the incision
is made immediately adjacent to the accessory carpal bone. it
can be difficult to insert instruments obliquely to accessthe
distal portion of the retinaculum. Arthroscopic release of
the retinaculum is performed in the visible portion cranial
to the SDFTand DDFT. Partial flexion of the carpus is used to
allow retraction of the DDFT within the carpal canal and
exposure of the~visible fibers of the carpal retinaculum. The
incision in the ,retinaculum is made 5-10 mm caudal to its
confluence with the palmar carpal ligament. which forms the
palmar surface of the carpal joints (Fig. 12.33). Transection
is confirmed by entry into the tendon sheath of the flexor
carpi radialis. This is a major landmark in safely performing
carpal retinaculum release. Severing the carpal retinaculum
more caudally risks perforation of the radial artery or medial
palmar vein. The palmar retinaculum predominantly runs on
the deepsurface of the flexor carpi radialis tendon. although
there are some portions that are superficial (medial) to
this tendon (Textor et al 2003). The retinaculum is divided
with a curved serrated blade or radiofrequency probe. cutting
proximally from the distal edge until 1 cm beyond the
proximal border of the accessory carpal bone. The carpal
sheath is then probed to ensure there are no thickened
 areas containing residual fibers of the carpal retinaculum,
either proximally or distally. The flexor carpi radialis tendon
should be visible throughout the entire transected area
(Fig. 12.34).
If necessary, the dissection can be continued superficial
(medial) to the flexor carpi radialis tendon, by retraction of
this tendon cranially and division of the superficial lamina of
the flexor retinaculum (see Fig. 12.34). The surgeon should
decide whether to continue the dissection through this thin
medial portion of the carpal retinaculum. This is based on the
degree of relief of the carpal canal, which can be assessedby
the increased ease of movement of the arthroscope and the
increase in viewable structures within the carpal canal.
Severing the medial portion of the retinaculum can be done
safely,since the radial artery is approximately 7 mm caudal
to the flexor carpi radialis tenqon. However,the medial palmar
vein is only 2-4 mm caudal to this site, and careful dissection
is necessaryto avoid perforating this vessel.
In clinical cases,the carpal sheath and flexor retinaculum
have been thickened predominantly on the deep (inner)
portion, forming the visible interior layer of the retinaculum
overlying the flexor carpi radialis tendon. Division of only this
portion of the retinaculum has been adequate to resolve
carpal canal symptoms in two horses in a recent publication
(Textor et al 2003), and a further seven horses operated
on since then. However, a larger case series has not been
published. Secondary carpal canal syndrome, developing as a
result of radial physeal exostoses,or myotendonitis and/or
tendonitis of the contained flexor tendons, may also benefit
from division of the carpal retinaculum, using the same
rationale as described for treating flexor tendonitis within the
confines of the palmar annular ligament at the fetlock (Nixon
1990b). The procedure is simple. has few risks of wound
healing complications. and can often be added to other pro-
cedures during the tenoscopic examination and treatment of
disorders of the carpal sheath contents.
Postoperative care
The use of tenoscopic techniques to evaluate the carpal
sheath and address specific pathology has minimized wound
healing complications. The need for extended wound support
by bandaging and limitation of postoperative exercise has
also been reduced. Return to an active walking program is
rapid, and the extent of layoff from work is then dictated only
by the pathology of the tendons themselves rather than the
surgical approach. Animals are usually given perioperative
antimicrobial,l:lrugs. Intrathecal NaHA (20-40 mg) is
commonly usep, both at surgery and 2-3 weeks later. Follow-
up intravenous NaHA may also be useful, commencing
4-6 weeks after suture removal. Bandage support should be
provided to keep the arthroscopic and instrument portals
covered for the first 5-10 days after surgery. This usually
consists of light bandages, sponges. and adhesive elastic
bandage. Most horses undergoing tenoscopic procedures of
the carpal sheath show little lameness beyond the initial day
of surgery. Intrathecal anesthetics such as bupivacaine are
useful during surgery but generally are unnecessary in the
control of postoperativepain. Nonsteroidal anti-inflammatory
agents are usually given for 2-3 days after surgery.
Horses are confined to the stall for the initial 1-2 days after
surgery. and small periods of hand walking are then
instituted. A balance is necessary between an early return to

walking exerciseand healing of carpal sheathstructures.
Adhesions associatedwith surgery in the carpal sheath
appearto berare.
Results and prognosis
There are several individual case reports or small case series
describing tenoscopic removal of osteochondroma, excision
of exostosesof the caudal aspect of the physis of the radius,
and release of the carpal tunnel (ter Braake & Rijkenhuizen
2001. Mcllwraith 2002a. Textoret al2003, Nixonet al2004).
These reports suggest exostoses from the physeal remnant
and osteochondroma arising from the metaphyseal region
present with similar carpal sheath effusion and lameness.
and both resolve with mass removal (Mcllwraith 2002a.
Nixon et al 2004). Lameness and effusion resolved in all 10
cases reported with radial exostosis (Nixon et al 2004). A
series of horses having endoscopicallyassistedcheck ligament
division has also been described (Kretzschmar & Desjardins
2001). This procedure was considered minimally invasive
and was completed in lesstime than open division. It has also
resulted in a renewed interest in the use of proximal check
ligament desmotomy for treating SDF tendonitis. However.
one of the authors (A.J.N.) recommends the procedure
should be performed bilaterally in all horses. regardless of
age. since a 6% incidence of bowed tendon in the opposite
limb has been recorded in a recent study (Nixon 2002b).
The prognosis following repair methods using carpal
sheath tenoscopy largely depends on the original pathology.
Ultrasonographic examination followed by tenoscopic
evaluation and treatment provides critical information for
the prognosis, and the structure and duration of the
convalescent interval. The prognosis following removal of
osteochondroma and exostosesof the caudal perimeter of the
physis of the radius is good to excellent (Held et al 1988.
Squire et al 1992, Southwood et al 1997. ter Braake &
Rijkenhuizen 2001, Nixon et al 2004). The prognosis
following carpal retinacular release is unknown. although
"".,
,';:;'",'
~.:. ,
Flexor retinaculum
Medial palmar a., n.
-a., v., n.
five horsesundergoingtenoscopiccarpal canal releasehave
recoveredfrom the lamenessassociatedwith the carpal
sheath region (Textor et al 2003). The prognosisfor SDF
tendonitistreatedby proximal checkligamentdesmotomyis
difficult to determinebecauseof the influencesof ancillary
treatmentto the tendon,exerciseprotocol,and the amount of
time providedfor convalescence.
Tenoscopy of the Tarsal
Sheath
Introduction
The nomenclature surrounding the tarsal sheath and the
DDFThas been through severalchanges. The DDFT has been
referred to as the flexor hallucis longus and as the flexor digiti I
tendon. The m()re recent term for the DDFT is the "lateral
digital flexor tendon". However, the use of DDFT is still
extremely common among surgeons and has been continued
here for the sake of clarity. Persisting lameness associated
with tenosynovitis of the tarsal sheath (thoroughpin) is
relatively common, and can result from trauma to the fibrous
layers of the tarsal sheath, damage to the mesotenon attach-
ments of the DDFT within the tarsal sheath, and tendonitis of
the DDFT itself (Van Pelt etal1969, Van Pelt 1969, Dik &
Merkens 1987. Mcllwraith 2002b). Additionally. the DDFT
courses over the sustentaculum tali. which can be injured
through direct trauma, resulting in bone proliferation and
damage to the flexor tendon as it undergoes directional
change through the region of the hock (Edwards 1978,
Dik & Merkens 1987). The tarsal sheath is not invested by
as dense a constrictive flexor retinaculum as the carpal
sheath. and although "tarsal tunnel syndrome" is possible,it
is poorly characterized (Van Pelt et a11969. Van Pelt 1969,
 Indications for tarsal sheath tenoscopy include a chronic
tenosynovitis that is poorly responsive to medical therapy.
These cases may be improved by debridement of massesand
adhesions spanning from the tarsal sheath parietal lining to
the DDFr. Severalother manifestations of chronic tenosynovitis
may be tenoscopically debrided. including tears of the DDFT,
mineralizing masses within the tarsal sheath. and mineraliz-
ation of the surface and deeperstructures of the DDFT.Removal
of fragmentation of the sustentaculum tali, and debridement
and lavage of contaminated or infected tendon sheaths are
also major indications for tenoscopy (MacDonald et al1989.
Welch et a11990. Santschi et al1997, Cauvin et al1999,
Mcllwraith 2002b)
Surgical anatomy
The structures and associationsof the tarsal sheath and
the enclosedDDFTthroughout its coursearound the hock
have beendescribed(Cauvin et al1999). The tarsal sheath
commences6-7 cm proximal to the level of the medial
malleolus, and extends approximatelyone fourth of the
distance down the third metatarsus (Fig. 12.35). The
enclosedDDFThas a continuous mesotenonattachmenton
its caudo/plantaromedialmargin, which is relatively thin
and contains obviousfine vasculature(seeFig. 12.35 and
Fig.12.36). This can limit visualizationof caudaland caudo-
lateral portions of the DDFT,dependingon the position of
the arthroscopeaccessportal. The DDFTalso has several
small vinculae in the proximal recesses of the tarsal
sheath (Cauvin et al 1999). As the DDFT approaches the
sustentaculum, the tarsal sheath becomes narrowed by the
flexor retinaculum forming the tarsal tunnel (Fig. 12.37).
The distal cul-de-sac of the tarsal sheath is narrow and
slightly better defined on the plantar aspect of the DDFT. This
cul-de-sac contains a synovial fold attached to the DDFT and
the dorsomedial sheath wall, which forms a blind dorsomedial
pouch (Fig. 12.38). The lateral extension of the tarsal sheath
extends more distal than the medial terminal cul-de-sac, both
of which can be viewed tenoscopically.The tendon of insertion
of the medial digital flexor tendon (MDFT) (flexor digitorum
longus), which has a separate tendon sheath, conjoins with
the DDFT ilIimidiately distal to the termination of the tarsal
sheath.
There are no major neurovascular structures within the
tarsal sheath, but there are several neurovascular bundles
associated with its outer fibrous layers that need to be
recognized when making instrument portals. Proximally, the
divided tibial nerve that has become the medial and lateral
plantar nerves, the medial tarsal artery, and the recurrent
tarsal vein are located in the caudomedial fibrous layers (see
Fig. 12.36). The recurrent tarsal vein is in a more medial
location, and is susceptibleto injury when making instrument
portals. More distally, at the level of the sustentaculum tali,
the medial and lateral plantar nerves, arteries, and veins are
located caudally, deep in the fibrous layers of the tarsal
sheath, but also within the confines of the tarsal flexor
retinaculum (see Fig. 12.37). Distally, the chestnut overlies
Fig. 12.37
(A) Labeled diagram of B showing relevant structures in the cross-sectional specimen of the tarsal sheath at the level of the mid-
sustentaculum tali. (B) Cross-sectional specimen of the sustentaculum level of the tarsal sheath.The sheath cavity contains red latex.
(C) Same cross section with DDFT retracted to show medial mesotenon attachment spanning from the DDFT to the tarsal sheath.
 Long digital
Dorsal
metatarsal-
artery Till
Lateral digital
extensor tendon
TIV
'\,,~\
\\\ \
Long plantar ~
ligament
Lateral plantar a.,v.,n. Chestnut
A Tarsal sheath
cavity
the tarsal sheath medially, and has to be avoided. The lateral
plantar neurovascular structures are positioned along the
plantarolateral perimeter of the termination of the sheath
and are relatively protected (Fig.12.38).
Tenoscopic techniques
Diagnostic tenoscopy of the tarsal sheath
Several approaches to the tarsal sheath have been described,
but the preferred arthroscopic entry is a central medial portal
made 1-2 cm proximal to the sustentaculum tali (Fig. 12.39).
This permits visualization of both proximal and distal regions
of the sheath (Cauvin et aI1999). Examination and debride-
ment of the visible portions of the DDFT and many areas of
the sustentaculum tali can be performed using instrument
portals directly over or immediately distal to the sustenta-
culum tali.
The central medial approach can be performed with the
horse in dorsal or lateral recumbency with the limb extended.
Hemorrhage is slightly reduced by using dorsal recumbency.
and a tourniquet is useful for hemorrhage control when
using lateral recumbency, since the affected limb is down. The
tarsal sheath is distended with saline if it is not already
markedly enlarged. The voluminous outpouching of the
proximomedial aspect of the tarsal sheath is readily palpated.
A skin incision is made in the distal region of this proximal
outpouching. approximately level with the medial malleolus
of the tibia. The arthroscope sleeveis inserted in a proximal
direction to commence the examination in the proximal
region of the tarsal sheath (Fig. 12.39). The mesotenon of
the DDFT originates from the caudal/plantaromedial border
of the DDFT and provides a barrier to complete examination
of the caudal and medial portions of the tarsal sheath
(Fig. 12.35). However,this layer is relatively thin. and can be
perforated in several areas if necessary, allowing the
arthroscope to view the caudal portions of the proximal
pouch of the tarsal sheath. A separate instrument entry,
directly over lesions,is preferred for easeof triangulation. The
dorsomedial or plantaromedial arthroscope entry incision
into the sheath is positioned largely based on the location of
the predominant lesions, dorsal or plantar, to the mesotenon.
With the arthroscope directed proximally, the DDFT
and proximal reflection of the tarsal sheath are evident
(Fig. 12.40). The mesotenon and medial and cranial/dorsal
surfaces of the DDFTare readily examined. Redirection of the
arthroscope more distally reveals the DDFT as it curves
over the sustentaculum tali (Fig. 12.40). Limited portions of
the fibrocartilage surface of the sustentaculum forming the
support surface for the DDFT can also be examined. The
DDFTcan be retracted after a local instrument portal is made,
which improves access to the caudolateral surface of the
sustentaculum (Fig. 12.40). The medial extremity of the
sustentaculum is extrasynovial and cannot be viewed
tenoscopically.lhis area is also the most frequent site for
bony exostosis.and fragmentation, which may then have to
be removed using open approaches. Over the sustentaculum
the tarsal sheath is confined by the tarsal flexor retinaculum,
which stabilizes the DDFT (Fig. 12.40). Redirection of the
arthroscope allows the DDFTto be viewed as it curves distally
(Fig. 12.41). When the arthroscope entry has been made
dorsal to the mesotenon,the sustentaculum and dorsal surface
of the DDFTare readily examined. Advancing the arthroscope
further distally allows examination of the remainder of the
sustentaculum and the DDFT as it courses toward the distal
termination of the sheath. The medial mesotenon is thicker
and somewhat compressed within the tarsal canal (Fig.
12.41), and to facilitate examination of the distal regions of
the DDFT and sustentaculum, sequential entry both dorsal
and plantar to the mesotenon allows complete assessmentof
 ~~~.'\::\..~.::==::::::::::::~,/s(""

Tibia
\\
Medial malleolus "'"
of tibia
.; DDFT

Medial trochlear
ridge of talus

Sustentaculum
It
tali
Calcaneus

'/
,,/
// i~

~.
t"'\
\

the DDFT surfaces and the weightbearing surfaces of the
sustentaculum.
A distomedial approach to the tarsal sheath is less
frequently necessary (Fig. 12.42). The retinaculum of the
tarsal sheath is more dense distally, and the chestnut provides
a problem for sterile skin preparation. However, examination
of this area is occasionally necessary,and a skin incision can
be made 1-2 cm proximal to the level of the chestnut over
the medial aspect of the distended tarsal sheath (Fig. 12.42).
The DDFT can then be seen as it courses over the distal
portions of the sustentaculum tali. Surgical procedures in
the distal limits of the tarsal sheath are more difficult, due to
the small volume of the tarsal sheath at this level and the
overlying retinaculum. Additionally, the converging MDFT
and check (accessory) ligament immediately distal to the
tarsal sheath narrow the sheath as the distal limits are
approached.
Tenosynovial mass and adhesion resection
~
Ultrasonogr~phic evaluation of cases with chronic tarsal
sheath distention frequently reveals tenosynovial masses
within the sheath (Fig. 12.43). Further inflammation and
advancing fibrosis of the tarsal sheath restrict the free range
of motion of the DDFTwithin the tarsal sheath. Mineralization
is a late complication of chronic disease, and can involve
portions of the mesotenon as well as the surface layers of the
DDFT(Fig. 12.44). Removal of most tenosynovial massescan
be accomplished using the central medial approach to the
tarsal sheath (Fig. 12.45). After a thorough examination, an
18-gauge 7.5 cm spinal needle is used to define the most
appropriate portal for mass removal. The neurovascular
structures caudal/plantar to the tarsal sheath can be avoided
by penetration with arthroscope and instruments immediately
adjacent to the cranial-caudal midline, allowing entry either

~
""
~
~
side of the mesotenon. This provides accessfor mass removal
and debridement of the medial surfaces of the DDFT
(Fig. 12.45). Massescan involve the inner layers of the tarsal
sheath, or become more pendulous and float between the
DDFT and the tarsal sheath lining (Fig. 12.46). With chronic
disease, the tarsal sheath can become quite thick, and
examination of the sheath contents can be slow and tedious.
High ingress fluid pressure frequently results in subcutaneous
fluid accumulation, making the surgical exploration more
difficult. A gradual increase in the areas available for examin-
ation can be accomplished using motorized resection of
proliferative synovium. Masses can be removed with scissors
and rongeurs, biopsy punch rongeurs, motorized resection
(Fig. 12.47), or radiofrequency probes, depending on the
density of the masses. Large masses and mineralized areas
may need a second instrument portal to allow the mass to be
stabilized prior to transection at its base. Mineralized masses
generally result from dystrophic mineralization of chronic
lesions and are more common in the tarsal sheath than the
equivalent syndromes in the carpal sheath. Radiographically
evident mine~lization of the DDFT can be differentiated from
mineralizatiqn in the mesotenon and sheath by comparing its
position on extended and flexed radiographs. Motorized
resection of massesand surface proliferation of the DDFT can
be associated with hemorrhage. Tourniquet application
proximal to the tarsal sheath may be helpful, but most
hemorrhage is controlled by the pressure of the ingress fluid.
Distention with gas is an alternative if bleeding continues to
hamper the diagnostic examination and further massremoval.
Mineralization can extend down to the terminal portions
of the tarsal sheath, and a second arthroscope and/or instru-
ment entry in the distal medial recess of the sheath may be
required. After removal of masses,the sheath is flushed prior
to routine skin closure. Intrathecal administration of NaHA
may be helpful in reducing reformation of tendon sheath
adhesions.
Debridement of the sustentaculumtali
The sustentaculum tali is prone to trauma over its plantaro-
medial aspect, resulting in bone proliferation within or
adjacent to the insertion of the retinaculum on the calcaneus.
Some wounds also cause contamination or infection of the
tarsal sheath. The most medial areas of bone proliferation are
beyond the medial extremity of the tarsal sheath. Resectionof
accessibleproliferative bone, and debridement of the DDFT-
bearing surfaces of the sustentaculum, can be accomplished
using the central medial arthroscope entry, with instrument
portals made directly over the sustentaculum. Alternatively,
and sometimes additionally, the distomedial portal (Figure
12.42), is required for arthroscope entry, to allow complete
examination of the medial edges of the sustentaculum and
the lateral perimeter of the tarsal tunnel as it curves
proximally. Fragmented or infected foci in the sustentaculum
can be removed and/or debrided using hand instruments.
Further details concerning the principles of treating
contaminated or infected lesions are provided in Chapter 15.
Postoperative care
Wound healing complications associated with tenoscopic
evaluation of ;he tarsal sheath are generally minimal.
Exercise can b~ initiated 2-4 days after surgery, depending on
the degree of lameness.Horses respond to tenoscopic surgery
of the tarsal sheath differently, and some can be quite lame
postoperatively.This can be controlled at the time of surgery
by intrathecal deposition of bupivacaine at the time of closure,
while postoperative pain relief is provided with nonsteroidal
anti-inflammatory agents. More severe reactions to surgery
or the primary disease can be treated using epidurally
administered morphine and detomidine. Horses with disease
processes involving the sustentaculum tali frequently also
have damage to the dorsal surface of the DDFT, and are
more lame than horses with tarsal sheath tenosynovitis.
Additionally, follow-up medication to the tarsal sheath is
more likely to be necessary,and includes intrathecal NaHA
and follow-up intravenous NaHA. Repeat ultrasonographic
examination is also useful in these cases to assessreturn of
tenosynovial masses,and to evaluate tendon healing.

Results and prognosis

There are few published case studies of tarsal sheath
tenoscopy (Cauvin et aI1999). Contaminated and infected
cases represent a large proportion of the tarsal sheaths
requiring tenoscopy (MacDonald et al1989, Santschi et al
1997, Cauvin et al1999. McIlwraith 2002b). Their outcome
is often improved by tenoscopic debridement and lavage, but
osteomyelitis of the sustentaculum is considered a serious
complication (MacDonald et al1989. Santschi et aI1997).
Non-infected tarsal sheath tenosynovitis can be improved by
mass removal and synovectomy, depending on the extent of
dystrophic mineralization.
Tenoscopy of the Extensor
Tendon Sheaths
Indications
The extensor tendon sheaths are prone to injury due to their
location on the dorsal aspect of the limb (Mason 1977, Platt
& Wright 1997). Blunt trauma can result in variable degrees
of tendonitis and chronic effusion of the sheath. A small
number of these cases do not spontaneously resolve, but
progress to develop intrathecal adhesions and soft tissue
masses. This can involve the sheath of the extensor carpi
radialis, the common digital extensor, or rarely the lateral
digital extensor or extensor carpi obliquis in the forelimb. In
the hind limb, the lateral digital extensor seemspredisposed
to injury and chronic distention. The long digital extensor
sheath can be distended; however, this sheath merges with
that of the tibialis cranialis and the fascia of the dorsal aspect
of the tarsus, and has little free spaceto distend with fluid or
allow tenoscopic examination.
Extensor tendon fiber disruption varies from none to
moderate (Fig. 12.48), and the most consistent features
include fibrous thickening of the sheath and secondary mass
and adhesion formation. Ultrasonographic evaluation reveals
areas of fibrinous and fibrous tissue deposition, considerable
amounts of free fluid. and quite often relatively normal tendon
fiber architecture (Fig. 12.49). Lameness is variable but
restricted carpal flexion is common. In some cases tenoscopy
is undertaken to improve the cosmetic appearance of the
limb. The presence of infection usually results in more severe
lameness. St~plechase horses are predisposed to thorn
penetration of the forelimb extensor sheaths, which can lead
to obvious lameness and the need for more aggressive
surgical and medical therapy (Platt & Wright 1997).
Tenoscopic techniques
Tenoscopy of the extensor sheaths can be done in lateral or
dorsal recumbency. The arthroscope portal to the affected
extensor sheath is generally made toward the proximal or
distal extremity of the sheath, depending on ultrasonographic
evidence of the more severely affected region, which is
reserved for the instrument portal. Examination of the interior
of the sheath often reveals adhesions and proliferative
masses. Most masses are combinations of fluid pockets or

organizing fibrinous deposits (Fig. 12.50). Instrument portals
are made as necessaryto allow rongeur and motorized resector
access for soft tissue debridement. The aims of debridement
include removal of proliferative massesand re-establishment
of free motion of the affected tendon. Synovectomy should be
used judiciously in an attempt to reduce fluid accumulation
in the sheath. After removal of synovial masses,the use of
tie-down sutures can occasionally be employed to reduce
dead space within the enlarged tendon sheaths (Fig. 12.51),
although postoperative bandaging is considered more
important. Cosmetic results can be difficult to achieve in
chronically distended extensor sheaths, unless some attempt
at reducing the extensor sheath volume is utilized. Syno-
vectomy of the parietal surfaces of the extensor sheath and
.
pressure bandaging, occasionally with the use of splinting,
can be effective in achieving cosmetic results. Occasionally,
the use of cast-bandage combinations may also be necessary.
Use of tenoscopic approaches to close spontaneous or iatro-
genic fistulae between the carpal joints and the common
digital extensor tendon sheath or the tendon sheath of the
extensor carpi radialis have been largely unsuccessful. A
combination of arthroscopically assisted synovectomy and
limited openapproachesfor suture are generallyrecommended
for these fistulae.
Results of open treatment of chronic extensor sheath
tenosynovitis are fair to good in the limited series of casesin
the literature (Mason 1977, Platt & Wright 1997). In the
authors' experience, tenoscopic treatment of the sheaths of
the extensor carpi radialis and common digital extensor.
and the sheath of the lateral digital extensor of the hind limb.
has allowed more aggressivedebridement with good resolution
of lameness. Cosmetic appearance after debridement of most
distended extensor sheaths can be substantially improved.
although most have some residual fibrosis.
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Van Pelt RW. Riley WF. Jr. Tillotson PI. Tenosynovitis of the dee
digital flexor tendon in horses. Can Vet J 1969; 10: 235-243.
Verschooten F. PicavetTM. Desmitis of the fetlock annular ligamer
in the horse. Equine VetJ 1986; 18: 138-142.
Verschooten F. PicavetTM. Desmitis of the fetlock annular ligamer
in the horse. Vet Ann 1988; 28: 98-101.
Watrous BJ. Dutra FR. Wagner PC. Schmotzer WB. Villonodula
synovitis of the palmar and plantar digital flexor tendon sheath
and the calcaneal bursa of the gastrocnemius tendon in th
horse. Proc AAEP 1987; 33: 413-428.
Weiss C. Levy HI. Denlinger J. Suros JM. Weiss HE. The role of NE
hylan in reducing postsurgical tendon adhesions. Bull Hosp Joir
Dis Orthop Instit 1986; 46: 9-15.
Welch RD. Auer JA. Watkins JP. Baird AN. Surgical treatment <
tarsal sheath effusion associated with an exostosis on the ca
caneus of a horse. J Am Vet Med Assoc 1990; 196: 1992-1994
Wilderjans H. Boussauw B. Madder K. Simon O.Tenosynovitis of tb
digital flexor tendon sheath and annular ligament constrictio
syndrome caused by longitudinal tears in the deep digital flexc
tendon: a clinical and surgical report of 17 cases in warmbloo
horses. Equine VetJ 2003; 35: 270-275.
Wright 1M. McMahon PI. Tenosynovitis associated with longitudinl
tears of the digital flexor tendons in horses: a report of 20 case:
Equin~etJ 1999; 31: 12-18.

Introduction
Bursoscopy is a term which has crept into common usage to
describe intrathecal endoscopy of synovial bursae. These are
closed sacs. found interposed between moving parts or at
points of unusual pressure and may be congenital or acquired.
Congenital bursae develop before birth and are located in
constant positions. They may be subfascial. subligamentous.
submuscular. or subtendinous. The latter are most common
and are found between tendons and bones at points where
the tendon direction changes. The bursal side of the tendon
and bone are fibrocartilaginous and in most circumstances
the bursal margins are covered with villous synovium. In a
classicalwork. translated by Ottaway & Worden(1940). Muller
(1936) described 22 congenital subtendinous bursae in the
horse. The principal congenital bursae of clinical importance
(from an endoscopic perspective)are the calcaneal bursa. the
intertubercular (bicipital) bursa. and the podotrochlear
(navicular) bursa. Interestingly. techniques describing their
endoscopic evaluation were all published within 2 months of
each other by Ingle-Fehr & Baxter (1998). Adams & Turner
(1999). and Wright et al (1999). respectively.
Acquired. also called reactive. functional. or pathological
bursae. are formed after birth. They are most common over
osseous prominences and may be subcutaneous. The most
common etiology is synovial metaplasia within encapsulated
seromas or hematomata. The most frequent sites of acquired
bursae are subcutaneous or subfascial over the calcaneus
and olecranon and either subcutaneously or between the
extensor tendons and fibrous joint capsule of the metacarpo-
phalangeal and metatarsophalangeal joints.
All bursae are amenable to evaluation with an arthroscope.
In man. techniques have been described for endoscopic
treatment of the subacromial (Ellmann 1987). deep infra-
patellar (Klein 1996). trochanteric (Bradley & Dillingham
1998) and retrocalcaneal (van Dijk et al 2001) bursae.
Techniques reported include ablation. removal of tendinous
tears and mineralization. debridement of fibrocartilaginous
and osseouslesions. and decompressionprocedures.including
relief of impingement lesions. debridement of torn tissue.
ligament resection. and synovectomy (Levy et al1991. Klein
1996. Bradley and Dillingham 1998. van Dijk et al 2001.
Suenaga et al 2002). Endoscopic resection of acquired
olecranon and prepatellar bursae in man have also been
described (Kerr & Carpenter 1990. Kaalund et al 1998.
Ogilvie-Harris & Gilbart 2000). All authors report improved
evaluation, reduced postoperative care, earlier return of
mobility, reduced convalescenceand morbidity, and improved
results compared with open surgical procedures,
Standard arthroscopic equipment is suitable for al~ bursal
endoscopy and the usual principles of fluid distention with
triangulation of arthroscope and instruments apply. In
congenital bursae, portals are made abaxial to associated
tendons. Corporate experience of bursal endoscopyis (as yet)
limited, and thus understanding of bursal pathophysiology is
in its infancy. It appears that bursae respond to aseptic insult
in a manner similar to tendon sheaths but little is as yet
known about healing of the fibrocartilaginous surfaces.
Endoscopy has resulted in identification of previously un-
reported lesions and it appears likely that the diagnostic and
surgical advances that have followed arthroscopy and
tenoscopy will also be enjoyed with bursoscopy.The response
to open wounds and/or other introduction of contaminants
is common to all synovial cavities. However, with establish-
ment of infection, the response of congenital bursae has
some features in common with tendon sheaths and some in
common with diarthrodial joints.
Current indications for endoscopy of congenital bursae
include lameness referable to the bursa, investigation of
bursal distention, contamination and infection. Some cases
will have radiologic and/or ultrasonographic changes, but
there is invariably bursal distention. Lesions identified and
treated endosc~ically include defects in the fibrocartila-
ginous surface of tendons and bones, osseous fractures,
lesions of adja~ent ligaments, contamination, and infection.
The principal indications for endoscopy of acquired bursae
are contamination and infection.
Calcaneal Bursa
There are two congenital calcaneal bursae (Fig. 13.1). The
largest has as its plantar margin the superficial digital flexor
(sdf) tendon and. dorsally, is bordered by the tendon of
insertion of gastrocnemius,the calcaneus,and the long plantar
ligament (Fig. 13.2). A smaller bursa, which is sometimes
conjoined, lies between the tendon of insertion of gastro-
cnemius and the calcaneus (Fig. 13.3).
Technique
Endoscopy of the calcaneal bursa may be performed with a
horse in lateral or dorsal recumbency. with the limb in an
extended position. The technique described by Ingle-Fehr &
Baxter (1998) is appropriate for the majority of circumstances
(Fig. 13.4). Following standard preparation of the site. if
the bursa is not distended markedly then it is inflated
further. A 1.1 x 40 mm (19-gauge x 1.5 inch) needle is
inserted between the sdf tendon and the plantar ligament
distal to the medial or lateral retinacular insertion of the
former and the bursa is distended maximally (Fig. 13.5A). A This approach permits thorough examination of
skin portal is created approximately 10 mm distal to the
retinaculum, medially or laterally. and this is extended with a evaluationrequires rotation of the arthroscopein order
No. 11 or 15 blade through to the bursa. The arthroscopic utilize its lens angle effectively.Instrument portals
sleeve with a conical or blunt obturator is then inserted and created at appropriatelocations. as determined by
directed proximally, initially between the sdf tendon and long
plantar ligament. and then plantar to the calcaneus and the retinacular insertions of the sdf tendon and may
gastrocnemius to the proximal limit of the bursa (Fig. 13.5B). ipsilateral or contralateral to the arthroscope.
Endoscopic anatomy
Proximally, the bursa contains villous synovium. Almost
circumferential evaluation of the tendon of insertion of
gastrocnemius is possible (Fig. 13.6). It is at this site that
there may be communication with the underlying bursa
between the tendon of insertion of gastrocnemius and
the calcaneus and, if present, this is usually identifiable.
Proximally, the sdf tendon may exhibit some evidence of
longitudinal fiber orientation and proximal to the calcaneal
tuber there are sometimes visible shallow transverse lines or

ridgesin its dorsalsurface:asthe sdf tendonapproachesthe
calcaneusand becomeswider in a mediolateralplane.these
are replaced by an amorphous fibrocartilaginous surface
(Fig. 13.7). However.obliquelyangledfibresare identifiable.
extending mediallyand laterally from the sdf tendonto the
abaxial margins of the calcaneus:theseare the medial and
lateral retinacular insertions of the sdf tendon (Fig. 13.8).
Fibrocartilagealsocoversthe apexof the calcanealtuberand
far as the retinacular insertions of the sdf tendon.
With further (distal) withdrawal of the arthroscope,
plantar ligament emerges from the fibrocartilage of
calcaneal tuber. As this courses distally, it
ligamentous form (Fig.
that the camera
distal recessof the bursa, the arthroscopemay be
Villous synovium covers the capsular reflection from
plantar ligament to the dorsal surface of the sdf tendon.
where there may once again be discernible ligamentous form.
Clinical application
Lesions identified and treated endoscopically include
osteolytic lesions in the calcaneal tuber. tearing of the
retinacular insertionsof the sdf tendon.tendonitisof the sdf
tendon.traumatic fragmentationof the calcaneus,contam-
ination through openwounds,and puncturesand infection.
Osteolytic lesions of the calcaneal tuber
Regions of osteolysis in the calcaneal tuber have been
reported by Ingle-Fehr & Baxter (1998) and Bassage et al
(2000). Affected animals present with distention of the
calcaneal bursa and lameness that is responsiveto intrathecal
local analgesia. Radiographs demonstrate radiolucencies in
the proximal plantar margin and/or apex of the calcaneal
tuber (Fig. 13.10). Ultrasonography confirms distention of the
calcaneal bursa and may also reveal disruption of the proximal
plantar margin of the calcaneus and irregular echogenicity of
the adjacent insertion of gastrocnemius. At endoscopy,there
may be discoloration of the calcaneal fibrocartilage with soft,
crumbling, and apparently degeneratebone exposedby use of
a blunt probe. Removal of the degenerate bone and debride-
ment has resulted in return to soundness but the number of
cases is small and thus confident prognostication is difficult.
The etiology of such lesions is unknown. Previous authors
have tentatively suggestedthat these may be avulsion injuries
of the plantar ligament (Ingle-Fehr & Baxter 1998), or of
gastrocnemius (Bassage et aI2000).
Tearing of the retinacular insertions of the
superficial digital flexor tendon
Tearing of the medial (most commonly) or lateral retinacular
insertions of the sdf tendon has been associated with
contralateral luxation or subluxation of the tendon from the
apex of the calcaneal tuber (Sullins 2002). Partial tears of
the retinaculi have beenidentified on endoscopic examination
of the calcaneal bursa in animals with lameness, which
localizes to a distended calcaneal bursa. A tentative diagnosis
may be obtained ultrasonographically, but a definitive
diagnosis is obtained endoscopically. In acute lesions there
may be hemorrhage at the site but torn fibrils are discernible
(Fig. 13.11). Tearing and herniation of disrupted tendon
fibrils is generally more obvious in long-standing cases
(Fig. 13.12A). Removal of torn fibrils and debridement of the
parent tendon is performed with a motorized synovial resector
(Fig. 13.12B). Casestreated in this manner have returned to
soundness.
Traumatic fragmentation of the calcaneus
E.xternal trauma, usually as a result of falls or kicks from
other horses, ~ay result in intrathecal fragmentation of the
calcaneal tuber. These may be open or closed. Most fractures
are identified radiographically and, when the apex of the
calcaneus is involved. flexed plantaroproximal-plantarodistal
oblique (skyline) projections are most useful.
Endoscopyshould be performed with ipsilateral arthroscope
and instrument portals. When accompanied by wounds, the
surgeon should look diligently for the presence of hair and
foreign material. Fragments are removed with appropriately
sized arthroscopic rongeurs and the fracture bed debrided
with curettes. In some instances foreign material may be
embeddedin bone. Lesions should be debrided using the same
principles as applied with osteochondral fragmentation in
diarthrodial joints but fibrocartilagenous margins always
appear less sharply demarcated than their hyaline counter-
parts (seeFig. 14.9).
 capsules and an intervening fat pad. '
the humerus bears three tubercles: lateral
(lesser),and ~ intermediate tuberosity (tubercle). The over-
lying tendon is bilobed and indented markedly by the inter-
mediate tuberosity. The medial lobe is slightly larger than its
lateral counterpart. A tendinous band envelops the tendon
and bursa in the region of the humeral tuberosities. Over the
humeral tuberosities the biceps tendon is partly cartilaginous
and presents a smooth fibrocartilaginous bursal surface. The
I ntertubercular (Bicipital) musculotendinous junction of biceps brachii lies in the distal
portion of the bursa. which terminates just proximal to the
Bursa deltoid tuberosity of the humerus.

The intertubercular bursa is found between the tendon of

origin of biceps brachii and the cranial margin of the Technique
humerus (Fig. 13.13). The bursa envelops the medial and
lateral margins of the tendon, and proximal to the humerus Endoscopyis performed with the horse in lateral recumbency,
is separated from the scapulohumeral joint by their fibrous with the affected limb uppermost and positioned parallel to
 Fig. 13.14
Horse positioned for endoscopy of the left bicipital bursa.

the ground (Fig. 13.14). In the majority of circumstances a

distal arthroscopic portal. as described by Adams & Turner
(1999) (Fig. 13.15), is most suitable but occasionally there
are advantages to a proximal arthroscopic portal. Generally,
pathologic bursae are distended and there is no advantage to
further distention. A skin portal is made using a No. 11 or 15
blade over the craniolateral margin of the humerus 2-3 cm
proximal to the deltoid tuberosity. Using a conical obtur~tor
the arthroscopic cannula is directed axially and proximally
through the brachiocephalicus muscle and between the
cranial margin of the humerus and the tendon of origin of
biceps brachii. Entry of the bursa is usually accompanied by
flow of synovial fluid from the cannula. and this is advanced
proximally before the arthroscope is inserted (Fig. 13.16A
and B). Instrument and/or additional arthroscopic portals
may be made proximal to the lateral tuberosity of the humerus
utilizing a percutaneous 1.2 x 90 mm (18 g x 3.5 inch)
needle as a guide (Fig. 13 .16C). If necessary.arthroscopy and
instrument portals can be interchanged (Fig. 13 .16D). At the
end of the diagnostic and surgical procedures the skin portals
may be closed in a routine manner and the wounds protected
by oversewing swabs or gauze pads as stent bandages.

Endoscopic anatomy
Proximal to the humeral tuberosities the bursal synovium is
villous and covers the supraglenoid tuberosity of the scapula,
the origin of biceps brachii, and the voluminous bursal recess
cranial to the scapulohumeral joint. At this level, the proximal
portion of the biceps brachii tendon has visible fiber orientation Fig. 13.15
(Fig. 13.17). Withdrawing the arthroscope provides visualiza- Distal endoscopic approach to the bicipital bursa; D = deltoid
tuberosity of humerus; B = tendon of origin of biceps brachii;
tion of the lateral tuberosity and abaxial side of the inter-
S = supraglenoid tubercle of the scapula; J = scapulohumeral
mediate tuberosity of the humerus. These and the overlying
biceps brachii tendon are covered with smooth fibrocartilage joint.
(Fig. 13.18). The tight interdigitation of the tendon and the
cranial surface of the humerus precludes evaluation of the
medial tubercle and axial side of the intermediate tubercle of
the humerus from this arthroscopic position. Abaxial to the
lateral margin of the lateral tubercle of the humerus there is
a cover of fine synovial villi through which tendinous bands
from pectoralis ascendens are seen perpendicular and
attaching to the lateral tuberosity. With further withdrawal
of the arthroscope. a synovial plica is visible at the lateral
margin of the intertubercular groove (Fig. 13.19). At this level
the arthroscope can be insinuated between the biceps brachii
tendon and fibrocartilagenous surface of the humerus as
far axial only as the intermediate tubercle (Fig. 13.20).
Approaching its distal margin the fibrocartilage is slightly
irregular (Fig. 13.21). Beyond this point the cranial surface of
the humerus and biceps brachii tendon and musculotendi-
nous junction are covered by villous synovium (Fig. 13.22).
In the distal recess it is possible to visualize also a small area
of the fibrocartilage medial to the intermediate tubercle (Fig.
13.22) and to push the arthroscope axially to obtain limited
visualization of the distal medial lobe of the tendon. Utilizing
a proximolateral arthroscopic portal. the most proximal
margin of the intermediate tubercle and a small portion of
the medial lobe of the tendon can be visualized (Fig. 13.23).

Clinical application
intrathecal fragmentation of the supraglenoid tubercle of the
Endoscopy of the bicipital bursa has been used in the scapula and lateral tuberosity of the humerus together with
investigation of lameness referable to this site and to treat contaminated and infected bursae.
Traumatic bicipital bursitis
Booth (1999) reported a horse with lameness.localizingto
the bicipital bursa. that was accompaniedby radiologicand
ultrasonographicabnormalities. Endoscopyrevealedwide-
spread loss of fibrocartilage from the humerus. with
adhesions to the bicipital tendon. The extensive nature of the
lesions precluded treatment but endoscopy was considered
diagnostically useful. The authors have seenloss of humeral
fibrocartilage with fibrillation of the adjacent bicipital tendon
(Fig. 13.24) and rupture of the lateral wall of the bursa in
horseswith lamenesslocalizingto this site.Thesecaseshave
.~,.. ,
I OJ..
.

beentreated endoscopicallyby debridementof torn and/or '-~'Oo"

detachedtissue.

Fragmentation of the supraglenoid tubercle

and lateral tuberosity of the humerus
If
Most fractures of the supraglenoid tubercle of the scapula
produce large fragments that involve the articular surface
and approximate to the physealline. However, occasionally,
I ii:1
'\

smaller more proximal fragments can displace distally and

are intrathecal with respectto bicipital bursa. Such fractures
can be visualized, removed. and associated tissues debrided
Ii 'I'
r!,
endoscopically.
Intrathecal fragmentation of the lateral tuberosity of the
humerus is most commonly associated with penetrating
wounds. Radiologic signs can be subtle but frequently are
highlighted by craniomedial-caudolateral oblique projections.
llitrasonography may also image fragmentation at this site. I\~\\
~~\ ~
This may be removed and the fracture bed debrided utilizing "\ ~
the arthroscope and instrument portals described above.

Contamination and infection

I
\\\
~ 'c. ~ "'r,"'?
"
Endoscopic evaluation and treatment of an infected bursa
has been described by Tudor et al (1998). The authors have
endoscopically managed contaminated and infected bicipital
'~1
bursae (seeFig. 14.5), including cases with infected osteitis/ '~.'
-1\\
osteomyelitis of the humeral tuberosities. The use of proximal
'\ ~:
and distal arthroscopeand instrument portals is recommended.
Treatment follows the principles detailed in Chapter 14.

Podotrochlear (Navicular)
Bursa
The dorsal margins of the navicular bursa are, from distal to
proximal, the impar ligament, the palmar/plantar surface of
the navicular bone, the navicular suspensory ligaments, and
the intervening T ligament. The latter is thin and consists of
little more than the fibrous capsules of the distal inter-
phalangeal joint, digital flexor tendon sheath, and navicular
bursa. The dorsal surface of the deep digital flexor (ddf)
tendon forms the palmar/plantar margin of the bursa.
Technique
Endoscopic evaluation of the navicular bursa is performed
with the distal limb joints in a slightly flexed position. The
horse may be in either dorsal or lateral recumbency. Dorsal
recumbency facilitates triangulation and use of medial and
lateral arthroscope and instrument portals. whereas lateral
recumbency is favored for investigation and treatment of
solar penetrations. The technique described originally by
Wright et al (1999). and subsequently by Cruz et al (2001)
~
and Rossignol & Perrin (2003), permits the most compre-
hensive evaluation of the bursa. A 5-mm skin incision is made
proximal to the collateral cartilage on the abaxial margin of
the ddf tendon, palmar/plantar to the digital neurovascular
bundle. The arthroscope cannula with a conical obturator is
then introduced through the skin wound and advanced
distally and axially, dorsal to the ddf tendon to enter the
bursa at approximately the midpoint of the middle phalanx
(Fig. 13.25). As the bursa is entered, there is usually a loss of
resistance to advancement of the cannula and the obturator
is then withdrawn and replaced by the arthroscope.
An instrument portal can be created using a similar
technique on the contralateral side of the limb following a
trajectory established by prior insertion of a 1.2 x 90-mm
(18 g x 3.5-inch) stiletted needle.
Using the above technique, the trajectory of the arthro-
scopic cannula is proximodorsal to distopalmar/plantar. If
the trajectory is too dorsal, then it is likely that the arthro-
scopic sleeve will pass through the T ligament and into the
palmar/plantar compartment of the distal interphalangeal
joint. In such circumstances, the sleeveshould be withdrawn
and realigned to a more palmar/plantar direction before it is
advanced again distally. This approach to the navicular bursa
may also result in penetration of the digital flexor tendon
sheath. In this event the arthroscope may be positioned
dorsal to the ddf tendon at the distal reflection of the sheath
wall before the arthroscope is withdrawn and replaced once
again with a conical obturator. Advancement of the cannula
in the trajectory described above along the dorsal surface of
the ddf tendon, will usually result in successfulentry into the
navicular bursa. It is also possible to enter the digital flexor
tendon sheath, electively pass the arthroscope distally dorsal
to the ddf tendon and, then, use cutting instruments to create
portals on the dorsal and palmar/plantar sides of the
T ligament into the distal interphalangeal joint and navicular
bursa, respectively (Fig. 13.26).
Endoscopic anatomy
Evaluation of the bursa usually commences distally. Here.
villous synovium reflects off the ddf tendon and impar
ligament (Fig. 13.27). A slight withdrawal of the arthroscope
will allow evaluation of the sagittal ridge of the navicular
bone and the adjacent surface of the ddf tendon. The
palmar/plantar surface of the navicular bone is covered by
relatively homogeneous fibrocartilage. although in some
animals there is a shallow indentation (sometimes termed a
synovial fossa) in the sagittal ridge where the overlying
fibrocartilage is thinner. The dorsal surface of the ddf tendon
is indented to varying degrees for the sagittal ridge of the
navicular bone (Fig. 13.28). In someanimals the dorsal surface
of the ddf tendon presents a relatively homogeneous surface,
whereas in others there is evidence of a longitudinally
oriented fiber pattern. Movement of the arthroscope medially
and laterally peRmitsevaluation of the abaxial margins of the
bursa. This is ~nerally easieston the side contralateral to the
arthroscope but with rotation of the lens can be achieved also
on the ipsilateral side. At the margins there are plical
reflections between the ddf tendon and the abaxial margins
of the navicular bone (Fig. 13.29). If the arthroscope is then
returned to an axial position and withdrawn slightly further,
this will visualize the proximal margin of the navicular bone
and reflection of the T ligament from this site (Fig. 13.30).
Abaxially, this thickens to blend imperceptibly into the
insertions of the suspensory ligaments of the navicular
bone. Further proximally, the bursal reflection from the ddf
tendon, suspensory, and T ligaments is covered by villous
synovium (see Fig. 13.30). Proximal to the navicular bone.
the dorsal surface of the dill tendon has a recognizable
fiber pattern.
 date.thereareinadequatenumbersto assess
the potential for
endoscopicsurgeryto enhancecasemanagement.

Penetrating injuries of the navicular bursa

The management principles for contamination and infection
of the navicular bursa are similar to those of other synovial
cavities and are dealt with in Chapter 14. However, at this site
there are a number of features that merit special attention.
The navicular bursa may be punctured by penetrating
wounds in the palmar/plantar one-half of the solar surface of
the foot. The risk and site of penetration are determined by
the length of the penetrating object and its trajectory. In
order to reach the navicular bursa, there must be a penetrating
wound in the~ddf tendon and, in some circumstances,
perforating objfcts may continue also proximally through the
T ligament and into the digital flexor tendon sheath or, more
commonly, distally through the impar ligament and into the
distal interphalangeal joint.
The bursa is evaluated utilizing an arthroscopic portal, as
described above (Wright et al1999). In acute casesthere will
usually be drainage of fluid from the puncture as soon as the
application bursa is inflated (Fig. 13.31). Thorough evaluation of the bursa
should be performed in all cases to include identification of
Currently, the principal indication for endoscopy of thenavicular the puncture wound (Fig. 13.32) and detection of foreign
bursa is evaluation and treatment of contaminationand material (Fig. 13.33). Penetrating objects may also produce
infection resulting from penetrating wounds. The defects in the navicular fibrocartilage and/or underlying
contribution of the technique to the evaluation of lamenesslocalizing
palmar/plantar subchondral bone. Instruments are generally
to this site has yet to be evaluated. Intrathecallesions
introduced through the penetrating wound (Fig. 13.34).
have been identified, removed, and debrided but, to From this site, removal of foreign material and pannus and

Clinical
debridement of contaminated and infected tissues may

The ddf tendonis debridedby rotating a motorizedsynovial

resectoraround its circumference.

be evaluated and treated by redirecting the

cannula with c

approachedin a conventionalmanner.
At the end of the procedures, arthroscopic
instrument skin portals are closedroutinely. Unless
undermining of laminar tissues, solar wounds

dressing.
The resu~ of 10 of 16 (Wright et al1999) and 15 of 27
(Wright 20P2) animals being sound and returning to their
pre-injury useis significantlybetter than with opensurgical
techniques (Richardsonet al 1986, Steckel et al 1989,
Honnaset al199 5). Thereis also greaterpain relief,reduced
postoperativenursing and medicalrequirementsand fewer
complicationswith endoscopictreatment.

Diagnostic endoscopy
Endoscopy of the navicular bursa may provide useful
information in the evaluation of lameness localizing to this
area but, as yet, its use has been limited. Lesions identified
have included fragmentation of the distal margin of the bone
(Fig. 13.35), tearing of the impar ligament (Dyson 2002) and
ddf tendon (Fig. 13.36), and disruptionof the fibrocartilage
of the bone and ddf tendon (Fig. 13.37). However,the
number of diagnosticexaminationsperformedis small and
clinically correlativestudiesare lacking.

References
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BassageIJI ll. Garcia-Lopez J. Gurrid EM. Osteolyticlesionsof the
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BoothTM. Lamenessassociatedwith the bicipitalbursa in an Arab
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BradleyDM. DillinghamMF. Bursoscopyof the trochantericbursa.
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Ottaway CW, Worden AN. Bursae and tendon sheaths of the hor~
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Introduction
Diarthrodial joints, tendon sheaths, and bursae are closed
spaces with a similar mesenchymal synovial lining that
produces and maintains a selective physical, cellular, and
biochemical environment. The principles of synovial contam-
ination and infection are similar for each of these cavities.
Contamination results from the introduction of micro-
organisms and can occur through openwounds or self-sealing
punctures, by hematogenous spread, local extension of a
perisynovial infection, or iatrogenically. Open wounds and
self-sealing punctures may also introduce foreign material.
Infection follows when the microorganisms reproduce and
colonize the synovial cavity. The principal potentiating
factors for establishing infection are considered to be the
presence of foreign material and/or devitalized tissue, the
nature and number of contaminating organisms, and
immunologic compromise, particularly in young animals.
Following colonization of the synovium, a combination of
bacterial pathogenicity and host-immune response lead to
the release of a variety of enzymes and free radicals, which
result in massive inflammation and ultimately destruction of
the tissues in the synovial cavity. The acute inflammatory
response following inoculation of microorganisms is charac-
terized by a rapid influx of inflammatory cells, predominately
neutrophils (Bertone & Mcllwraith 1987). A plethora of
destructive enzymes have been detected in synovial fluid from
infected joints, including collagenase, caseinase, lysozyme,
elastase,cathepsin G, and gelatinase (Palmer & Bertone 1994,
Spiers et al 1994). These appear to originate both from
invading neutrophils and activated synoviocytes. Together
with other inflammatory mediators, such as eicosanoids,
interleukins, and tumor necrosis factor (Bertone et al1993)
and the disturbed synovial environment in joints, these
trigger production of degradative enzymes by chondrocytes
(such as stromelysin, aggrecanase,collagenase,and gelatinase).
There also is reduced proteoglycan synthesis (Palmer &
Bertone 1994).
Established infection frequently results in the production
of an intrasynovial fibrinocellular conglomerate (pannus).
This may cover foreign material and devitalized tissue. and
act as a nidus for bacterial multiplication; it is rich in inflam-
matory cells. degradative enzymes and radicals. It is also a
barrier to synovial membrane diffusion. thus compromising
further intrasynovial nutrition and limiting access for
circulating antimicrobial drugs. The quantity and nature of
pannus appears to be dependent on the type and number
of infecting organisms. and its production is also enhanced
by the presence of foreign material. Its presence has been
associatedwith increasing duration of clinical signs. presence
of osteochondral lesions. and presence of osteomyelitis
(Wright et aI2003).
The objectives in treating contamination and infection are
similar for all synovial structures: removal of foreign material.
debridement of contaminated/infected and devitalized tissue.
elimination of microorganisms.removal of destructiveenzymes
and radicals. promotion of tissue healing. and restoration of
a normal synovial environment. A number of techniques have
been described which include use of drains Gackman et al
1989). through and through lavage (Koch 1979). open surgery
(Rose& Love 1979. Honnas et al1991a. Bertone et al1992.
Schneider et,.al 1992a. Baxter 1996). and endoscopy
(Mcllwraith ],983. Bertone et a11992. Wright et al1999.
2003. Frees et al 2002). Variations of these techniques have
also been described. These include open surgery followed by
insertion of closed suction (Mcllwraith 1983) or open passive
(Santschi et a11997) drains or by open drainage (Bertone et al
1992. Schneider et al 1992a) and endoscopy followed by
closed suction drainage (Rosset al1991. LaPointe etal1992).
fenestrated drains (Honnas et al1991b). or creation of an
open draining wound (Bertone 1999).
In treating joint infection in man. arthroscopy is con-
sideredto offer severaladvantagesover lavage and arthrotomy.
including improved visualization. identification of foreign
material and infected or devitalized tissue. and access to a
larger area of synovial surfaces(Dory & Wantelet 1985. Jackson
1985. Parisien & Shaffer 1990). Arthroscopy is reported to
ensure an efficiently evaluated, cleaned, debrided,
decompressedjoint with minimal morbidity,

to other treatments Garrett et al1981, Ivey & Clark 1985,

& Shaffer 1990, Bussiere & Beaufils 1999, Stutz et al2000,

Wirtz et a12001. Vispo Seara et aI2002).
Four stages of joint infection have been reported in man
(Gachter 1985. cited by Stutz et aI2000):
.Stage I: turbid fluid, hyperemic synovium, possible
petechial bleeding, no radiologic changes.
.Stage II: severe inflammation. fibrinous deposition,
purulent fluid, no radiologic changes.
.Stage III: thickening of the synovial membrane.
villous adhesions and compartment formation, no
radiologic changes.
.Stage IV: aggressive pannus with infiltration of the
cartilage, possibly undermined cartilage. radiologic
signs of subchondral osteolysis, possible osseous
erosions. and cysts.
These stages are related to but do not follow precisely
temporal categorization. Vispo Seara et al (2002) adopted this
classification and recommended the following arthroscopic
treatment protocols for each category:
.Stage I: thorough irrigation of all joint compartments.
.Stage II: removal of fibrin and clots. sometimes also
with a limited synovectomy followed by I (above).
.Stage III: as II, but with resection of adhesions and
subtotal synovectomy.
.Stage IV: as above. but including removal of detached
cartilage and debridement of osseouslesions.
Stutz et al (2000) and Vispo Seara et al (2002) also reported than in other endoscopic procedures and control of ]
correlation between the stage of the disease process. rhage improves the efficiency of the procedures significantly.
prognosis, and the number of arthroscopic procedures In most cases.
required. Like all attempts to categorize clinical disease,this made utilizing standard endoscopic portals as described in
classification suffers from oversimplification. Nonetheless, it preceding chapters. It is important in all circumstances to
provides a useful comparative guide. evaluate fully each structure and thus to use all available
portals. examining dorsal and palmar/plantar or cranial and
caudal compartments. and also, whenever appropriate,
evaluating each cavity from both medial and lateral sides.If a
tourniquet is used,the surgeon should take particular care in
the creation of portals (especially into the digital flexor
tendon she~h), as neurovascular bundles are less readily
Evaluation appreciated,and iatrogenic damage is possible.
An initial lavage of the cavity is usually necessaryin order
Most contaminated and infected synovial cavities are to clear discolored synovial fluid. A thorough systematic
amenable to endoscopic evaluation and surgery. Occasionally, evaluation should follow, examining the whole intrasynovial
there will be sufficient capsular disruption to preclude environment and. in turn, all of the contained structures.
inflation but in some individuals, even if there is marked Particular attention should be paid to the vicinity of wounds
tissue loss on one aspect of the limb, other synovial compart- (Fig. 14.1).
ments may be treated endoscopically.The absenceof adequate Acute synovial infection is characterized endoscopically
synovial space precludes the use of endoscopy in few sites, by severesynovitis (Fig. 14.2). In the absenceof osteochondral
the most frequently affected examples being the centrodistal defects. chronic joint infection is characterized by cartilage
(distal intertarsal) and tarsometatarsal joints. degeneration (Fig. 14.3). but if subchondral bone is breached
Endoscopyis performed under general anesthesia and the then infected osteitis/osteomyelitis may result. If the epitenon
patient should be positioned to permit all-round accessto the is intact. chronic tenosynovitis is characterized by synovial
affected synovial cavity(ies). Esmarch bandages and tour- proliferation and adhesion formation (Fig. 14.4). whereas if it
niquets are recommended for distal limbs. Generally,there is is disrupted there is usually rapid intratendinous collagenolysis.
 coveravillous synoviumand in someadvancedcasesit also
coversarticular cartilageand tendonsurfaces.

Foreign material
In the presence of open wounds or self-sealing punctures, the
surgeon should be aware of the potential presence of foreign
material within the synovial cavity. Frees et al (2002) found
intrasynovial foreign material in 4/20 (20%) of tenoscopically
investigated wounds involving the digital flexor tendon
sheath, whereas Wright et al (2003) documented foreign
material in 41 of 95 (43%) horses with wounds or punctures
into synovial cavities which were investigated endoscopically.
In the latter series, foreign material was predicted pre-
operatively in only 15% of animals (Fig. 14.7). The majority
are free floating but the foreign material may also be
adherent to pannus or synovium, embeddedin osteochondral
lesions or foun~in penetrating soft tissues.The most common
contaminantsure hair and wood (Fig. 14.8A). An association
has been demonstrated in man between the presence of
foreign material and the development of infected synovitis
following penetrating wounds (Reginato et alI990). Foreign
material acts as a nidus for infection and causesphysical and
biochemical irritation within the synovial environment.
Large pieces may be removed with Ferris-Smith rongeurs
(Fig. 14.8B), small pieces by a motorized synovial resector,
and if embeddedin bone, curettes may be necessary.

The features of chronic infective bursitis are similar to both

infected arthritis and tenosynovitis (Fig. 14.5). Debridement
Pannus is usually identified first over areas of villous
synovium and, as it increases in mass, villi become obscured In the seriesreportedby Wrightet al (2003),51 of 121 (42%)
(Fig. 14.6) If the infective process continues, pannus will also horseshad endoscopicallyidentifiableosseousor chondral
 lesions, of which only 25 (49%) were predicted before
endoscopy. Fragmentation may be removed with rongeurs.
Foreign material may be embedded in the fracture bed
(Fig. 14.9) and debridement of contaminated or infected
fracture sites is invariably appropriate. Foci of osteitis/
osteomyelitisare generallydebulked with rongeurs (Fig. 14.10)
before debridement with curettes. Motorized burrs are rarely
indicated. When debriding chondral or osteochondral defects
in bursae, the surgeon should be cognizant that fibrocartila-
genous m~ins will invariably be less well defined than their
hyaline co1interparts in diarthrodial joints.
Penetrating wounds and punctures of tendon sheaths and
bursae may result in defects in the associated tendons
(Fig. 14.11) and frequently articular wounds will also
traumatize periarticular ligaments; an incidence of 34% has
been documented (Wright et al 2003). Removal of detached
contaminated and infected tissue is appropriate and may be
achieved with a motorized synovial resector. Occasionally,
discrete detached pieces of tendon or ligament are removed
more satisfactorily by sharp dissection using arthroscopic
scissors or knives.
Piecemeal removal of pannus preserves underlying
synovium and is appropriate with localized deposits. When
pannus is widespread, use of a motorized synovial resector is
usually required, although this almost invariably results in at

~
least partial synovial resection. The authors' preference in
motorized resectors, for safety and efficiency, is an enclosed,
serrated blade. This is used in a to-and-fro oscillating mode
with suction applied to draw material into the blade. Angled
blades are also available and can be useful in some areas.
It is suggestedthat synovium may harbor bacteria, sequester
inflammatory cells, release potent inflammatory mediators,
and be a source of immunologic components of inflammation
(Riegels-Nielson & Jensen 1984, Riegels-Nielson et aI1991).
Synovectomy has therefore been proposed to be of benefit in
treating infected arthritis (Rosset al1991, Bertone et al1992)
although some surgeons consIder its use should be limited
(Parisien & Shaffer 1990). The authors generally remove
contaminated/infected synovium that is adjacent to wounds
and punctures. More extensive resection is performed in the
presence of marked pannus deposits, which are usually
associatedwith long-standing infective processes.Regeneration
of normal villous synovium does not occur following
synovectomy (Theoret et al1996, Doyle-Jones et al 2002),
but the clinical implication of this and potential compromise
compared to the benefits of synovectomy have not been
determined.
Lavage
Lavage is visually directed, high pressure, and should be
performed thoroughly until all areas of the synovial cavity
are visibly clean (Gaughan 1994, Thiery 1989, Smith 1986).
The fluid of choice is sterile buffered polyionic solution
(Bertone et al 1987a. Baird et al 1990) and this should
be delivered by a pump system capable of rates in excess of
500 ml/minute. It is important to move the arthroscope. and
thus the fluid ingress. repeatedly to all parts of the cavity in
order to produce effectivelavage.The surgeon should be aware
of all synovial sulci as. without individual attention. fluids
will frequently flow over or past pockets of debris in these
sites.This is particularly important in tendon sheaths. where.
in addition to moving around the tendons. the arthroscope
should be insinuated betweenthese structures. The mechanical
action of flushing removes small. free-floating debris. debulks
microorganisms. and reduces the load of destructive radicals
and enzymes. Lavage is also thought to raise the pH from the
acidic environment produced by infective processes. This
in turn imprDKesthe action of several antimicrobial drugs.
including aInil1ogiycosides(Mcllwraith 1983). Effectivelavage
invariably requires multiple ingress and egress portals. In
animals with wounds or punctures. these may also serve as
instrument and egressportals (Fig. 14.12).
Potential additives to lavage fluid include antimicrobial
drugs. antiseptics. dimethyl sulfoxide. and fibrinolytics. Anti-
microbial preparations used by the authors include a combi-
nation of sodiumbenzylpenicillin (2.5 x 106 ill) with gentamicin
sulfate (250 mg). or alternatively ceftiofur sodium (500 mg).
amikacin sulfate (500 mg). or enrofloxacin (500 mg). added
to the final liter of lavage fluid. There is no objective evidence
to support the use of antimicrobial drugs in this manner.
although administration of an aqueous antimicrobial on
completion of lavage has been suggested to be of benefit
(Nixon 1990). Antiseptic solutions appear to offer no

advantages over buffered polyionic solution (Bertone et al
1986) and, evenin dilute concentrations may produce synovial
irritation (Bertone et al1986, Wilson et aI1994). Dimethyl
sulfoxide has been recommended as part of the final lavage
(Bertone 1996,1999, Frees et al2002). Its efficacy has not
benefits have been documented, but deleterious
equine cartilage matrix metabolism have been
(Matthews et al 1998. Smith et al 2000), J
the use of fibrinolytics have been mentioned in the human
literature (Jackson 1985), but they are uncommonly
employed in veterinary medicine, With the advent of
endoscopic removal of fibrinoid deposits, their use largely
appears superfluous.
Wound management
Arthroscope and instrument portals are closed routinely.
Traumatic wounds are debrided or (preferably) excised to a
clean/ contaminated state and then if possible these also are
closed. This is based on the premise that endoscopic surgery
can thorou~y cleanse synovial cavities and that a closed
wound minj,mizesthe risk of further and/or secondary conta-
mination or infection. These principles contrast with those of
others in the literature (Gibson et al 1989, Schneider et al
1992a, Baxter 1996) who advocate open management of
infected synovial cavities in order to maintain decompression.
Such alternatives include closed suction drainage (Ross et al
1991, LaPointe et a11992), fenestrated drains (Honnas et al
1991b), or creation of an open draining wound (Bertone
1999), techniques which the authors also advocate in cases
of chronic infection. Solar punctures are debrided, dressed,
and managed as open wounds. Traumatic wounds elsewhere
in which soft tissue loss precludes closure should be debrided
as rigorously as if closure was to be effected. The wound is
then dressed and the limb immobilized while second
intention healing ensues.

When wound healing will be optimized by limb immobiliz-
ation. casts may be fitted. A nonadherent dressing is applied
over the wound with a thin layer of conforming bandage.
This is followed by a layer (approximately 5 mm) of plaster of
Paris and then layered fiberglass. Two of the authors (CWM.
AJN) rarely use plaster of Paris anymore. Thermoplastic
polymer may be applied around the solar surface to resist
abrasion and slipping. Counterpressure should be applied to
all other sites: this limits extravascular exudation of fluid.
promotes primary wound healing. and reduces pain (Nixon
1990. Bertone 1999). It can be applied effectively to the distal
limb with layered compressed cotton wool (as used in
constructinga RobertJonesbandage).Commercial.tailored
elasticizedbandagesare effectiveon the carpus and tarsus.
whereas in the proximal limb stent bandages may be
oversewn.
Local antimicrobial therapy
At the completion of surgery, antimicrobial drugs may be
given by regional intravenous (iv) technique. Regional anti-
microbial drugs have been shown to produce high and
prolonged levels in synovial fluid (Whitehair et al1992a) and
their efficacy in treating experimentally induced infected
arthritis in horses has also been reported (Whitehair et al
1992b). Foals have been given 1 x 106m of sodium benzyl-
penicillin with 100 mg of gentamicin sulfate or amikacin
sulfate or, alternatively 100 mg of ceftiofur sodium. Other
animals have received sodium benzylpenicillin (2.5 x 106 m)
with gentamicin sulfate (500 mg) or, alternatively, amikacin
sulfate (500 mg), ceftiofur sodium (500 mg), or enrofloxacin
(500 mg). The dosesall are empiric and have been used safely
in the authors' practices.
Antimicrobial drugs may also be given as intrasynovial
deposits, by continuous infusion, or by elution from impreg-
nated polymethylmethacrylate (PMMA) beads or collagen
sponges. A number of authors have recommended intra-
synovial injection of antimicrobial drugs (Lloyd et al1990,
Schneider et al 1992a, McClure et al 1993, Baxter 1996,
Bertone 1999, Frees et al2002). Dosagesare empiric but it is
generally recommended that drugs are given at not greater
than a single systemic doseand that this is not repeated at less
than 24-hour intervals (Baxter 1996). Infusion catheters
have been used for continuous administration of gentamicin
into the tarsocrural joint of horses for up to 5 days (Lescunet al
2000). This produced> 100 x the MIC (minimum inhibitory
concentration) reported for common equine pathogens. The
use of antimicrobial-impregnated PMMA is based on the
principle that the antimicrobial drug will be released from
the cement over time, thereby achieving continuous anti-
microbial action in situ (Weisman et al 2000). Many of the
commonly used antimicrobial/PMMA combinations achieve
higher local antimicrobial concentrations than can be
achieved through systemic administration (Tobias etal1996).
However, in-vitro elution tests suggest that antimicrobial
concentration at tissue level may be below the MIC for most
bacteria after 2-3 days (Weisman et al2000). Antimicrobial-
impregnatedPMMA beadsmay be depositedusing arthroscopic
techniques but a second surgical procedure will be necessary
for their removal. Wire breakagecan be a problem (Butson et al
1996) and their use has also been associated with intra-
articular trauma and capsulitis (Farnsworth et al 2001).
Collagen sponges also can be deposited using endoscopic
techniques. They are slowly absorbed and are reported to
have no irritant effect, although marked wound exudation
has been reported (Summerhays 2000). These techniques
may not be necessary in acute cases but the authors
recommend their consideration in cases of recalcitrant or
recurrent infection.

Systemic antimicrobial drugs are appropriate in all cases.
In most situations antimicrobial choice must, at least initially,
be made without the results of bacterial isolation and
susceptibility determination. It is thus based on a knowledge
of the likely microbial populations involved in contamination
and infection of equine synovial cavities. Furthermore, with
the exception of juvenile infective arthritis of hematogenous
origin, results of bacterial isolation are frequently unrewarding
and/or contribute little to the choice of effective antimicrobial
regimes. When synovial contamination has a hematogenous
etiology, single organisms may be responsible for infection.
However, horses that develop synovial infection following
wounds are likely to have multiple bacterial involvement
(Schneider et al 1992b). Reported bacterial studies and
susceptibility patterns suggest that a cephalosporin/
aminoglycoside combination is likely to be most efficacious
but that most organisms are likely to be susceptible to a
synergistic combination of penicillin and an aminoglycoside
(Snyder et al1987, Moore et al1992, Schneider et aI1992b).
Wright et al (2003) reported the use of sodium benzylpenicillin
at > 30,000 ill/kg iv every 8 hours and gentamicin sulfate at
2.2 mg/kg iv every 8 hours. Single daily gentamicin adminis-
tration at 6.6 mg has been proposed as an alternative. It is
suggested that this achieves greater peak and lower trough
concentrations in serum and thus provides greater immediate
bactericidal effect, longer duration of post antibiotic effect
(PAE),and reduced risk of nephrotoxicosis (Godberet aI1995).
However, the period of effective concentrations of gentamicin
in tissues added to the PAEis also exceededby every 8 hours
administration at 2.2 mg/kg (Godber et al 1995). Also,
gentamicin toxicity in horses is rare and there is no docu-
mented reduction in incidence with once daily administration.
In the authors' experiencein animals which have no additional
medical compromise, the three times daily regime has been
safeand is clinically efficacious.
With wounds involving the foot or wounds contaminated
by soil or feces, supplementing the above regimen with
metronidazole at 20 mg/kg orally every 8 hours is logical.
Anaerobic species are important contributors to orthopedic
infections in horses and a 25% isolation rate from post wound
infected arthritis has been reported (Moore et al 1992).
The majority of these bacteria are susceptible to penicillin.
The most common isolates that are resistant to penicillin are
Bacteroidesspp. which are common fecalcontaminants. These,
and all other anaerobic isolates from orthopedic infections
are susceptible to metronidazole (Moore et aI1992).
The authors also have used a penicillin/amikacin
combination: penicillin dosed as above with amikacin sulfate
at 6.6 mg/kg iv every 8 hours. Low incidences of resistance
to amikacin have been reported among common equine
orthopedic isolates (Snyder et al19 8 7) and organisms isolated
from horses with gentamicin resistance have demonstrated
susceptibility to amikacin (Orsini et al19 89). With known or
suspected staphylococcal involvement, such as casesof iatro-
genic infection (LaPointe et al1992, Schneider et a11992b),
ceftiofur sodium is a logical choice at 3-4 mg/kg iv every
8 hours either alone or in combination with gentamicin sulfate
dosed as above. Enrofloxacin at 5 mg/kg iv every 24 hours or
7.5 mg/kg orally every 24 hours has a broad spectrum of
activity that includes staphylococci. It also has been useful in
the treatment of aminoglycoside-resistant Gram-negative
bacteria (Orsini & Perkous 1992). Chondrotoxicity has been
reported at higher than clinically used doses (Beluche et al
1999, Davenport et al 2001, Egerbacher et al 2001) and,
consequently, caution has been expressed with respect to its
use in foals (Orsini & Perkous 1992, Baxter 1996).
Determination of an appropriate duration of antimicrobial
administration is difficult. The authors prioritize clinical signs
of response and continue antimicrobial administration until
there is a consistent improvement in lameness, together with
reduced synovial distention, adjacent soft tissue swelling,
surface temperature, and engorgement of visible draining
veins. The use of sequential synovial fluid analysis has also
been advocated (Bertone 1999). Largely based on experiences
of experimental joint infection (Bertone et a11987b), other
authors have employed or recommended protracted adminis-
tration of antimicrobial drugs (Gibsonet al1989, Honnas et al
1991b, Gaughan 1994, Frees et aI2002). In a review of 121
cases of synovial contamination and infection treated endo-
scopically,there was a mean period of antimicrobial adminis-
tration of 13 days (Wright et al 2003). A shorter period of
antimicrobial administration required with arthroscopic
treatment of infected joints compared to other techniques
has also been reported in man (Smith 1986).
Nonsteroidal anti-inflammatory drugs have beenadvocated
in the treatment of synovial infection to provide analgesia
and to limit deleterious effects of inflammatory mediators
on the synovial environment (Bertone & McIlwraith 1987,
Gaughan 1994, Baxter 1996, Cook & Bertone 1998,
Schneider 1999). There is some support for the concept in an
experimental rabbit model (Smith et al 1997). However, in
this experiment,the treatment comparisons were only between
administration of antimicrobial drugs or administration of
antimicrobial and anti-inflammatory drugs; there was
no surgical decompression or lavage, etc. Evidence that
systemically administered therapeutic doses of nonsteroidal
anti-inflammatory drugs suppress deleterious effects of
intrasynovial ~flammatory mediators is lacking (May & Lees
1996). These\drugs may partially lessen release of factors
involved in joint tissue breakdown (Lee et al 2003), but
administration of nonsteroidal anti-inflammatory drugs
effectively obviates use of clinical parameters, particularly
lameness, in determining response to treatment (McIlwraith
1983, Gaughan 1994). Current opinion in assessingpotential
benefits of postoperative administration of nonsteroidal anti-
inflammatory drugs is therefore divided. This is reflected in
the diversity of clinical use in the authors' practices, although
all use nonsteroidal anti-inflammatory drugs for provision of
perioperative analgesia.
Intermittently, the use of other, adjunctive medicaments
have also been recommended, principal of which is post-
operative intrasynovial hyaluronan. Benefits have been
reported in an experimental model of tarsocrural infection
(Brusie et al199 2) and it has been advocated in clinical cases
of infected tenosynovitis (Nixon 1990, Gaughan 1994, Frees
et aI2002).
Movement is necessary for restoration of a normal
synovial environment and endoscopypermits an early return
to exercise (Nixon 1990, Frees et al2002, Vispo Seara2002).
The association between immobilization and cartilage
degeneration has been well documented (Palmoski et al19 79,
Josza et al1987, Videman 1981, Kallio et aI1988). Benefits
from early instigation of exercise,in the form of continuous
passive motion, have been demonstrated in experimental
models (Salter et al1981) and reported in clinical cases in
man (Parisien & Shaffer 1990, Perry et aI1992). Dynamic
loading counteracts effects of inflammatory mediators, such
as bacterial lipopolysaccharide, on chondrocyte metabolism
and it is suggested that this may have contributed to
successfulmanagement of articular infection (Lee et al2 003).
Whenever possible,the authors recommend walking exercise
to commence in1mediately after surgery and a graduated,
controlled exercise program follows in line with tissue
compromise.
Close clinical monitoring is critical in the immediate post-
operative period. Since most synovial structures will be
enclosed in bandages at this time, pain is the most sensitive
indicator of response to treatment. In the face of progressive
lameness or lack of clinical improvement. complete case re-
evaluation, including repeated radiographs, ultrasonographs.
and synoviocentesis, is always merited. If potential reasons
for relapse or lack of response can be identified, then manage-
ment can be changed in a logical manner. Since endoscopy
maximizes intrasynovial evaluation, this is also indicated in
recurrent or recalcitrant cases. Repeated endoscopy has
proved useful in detecting and removing foreign material,
infected bone, and intra-articular sequestra that were not
present or identified at the first surgery (Wright et al 2003).
When no satisfactory explanation for a poor response or
relapse has been identified, then lack of susceptibility of the
causative organisms to the current antimicrobial regimen
should be considered and modification is frequently appro-
priate. It always remains possible that infecting organisms
are susceptible but that they have not been exposed to the
antimicrobial drugs at an appropriate level; nonetheless, a
change in regimen is usually made at this time.
Results of endoscopic surgery in treating clinical cases of
contaminated and infected synovial cavities have been
reported by a number of authors (Gibson et al1989, Rosset al
1991, LaPointe et al1992, Schneider et a11992a. Steel et al
1999. Wright et al1999, 2003. Freesetal2002). Arthroscopy
and partial synovial resection were reported to be inferior to
arthrotomy and open drainage in the treatment of experi-
mentally induced infection of tarsocrural joints (Bertone et al
1992). However, this experiment does not reflect many
features found in clinical cases of synovial contamination
and infection. Arthrotomy was also associated with an
increased risk of secondary infection by other organisms and
postoperative fibrosis and required a greater degree of post-
operative care. The senior author of this report now also
recommends endoscopyas a primary line of therapy (Bertone
1999). Frees et al (2002) reported 18 of 20 (90%) cases
surviving and 14 (70%) returning to athletic soundness
following tenoscopic treatment of contaminated and infected
digital flexor tendon sheaths. A retrospective analysis of 121
cases of contaminated and infected synovial cavities treated
endoscopically reported a 90% survival rate, with 81% of
animals returning to their preoperative level of performance.
Negative prognostic indicators included involvement of the
navicular bursa, the presence of marked pannus, and the
presenceof osteochondral lesions (Wright etal2003). Neither
of these studies found a correlation between the duration of
clinical signs prior to endoscopy and case outcome. In a
comparable series of 192 cases treated by combinations of
lavage, open surgery, drainage, intrasynovial antimicrobial
drugs, and systemic antimicrobial drugs, 73% of 126 animals
>6 months of ageand 45% of foals < 6 months of agesurvived
and 56% of 52 adult horses returned to performance
(Schneider et a11992b).
The authors currently suggest that management of
contaminated and infected synovial cavities is optimized by
endoscopic treatment. This permits thorough evaluation,
with appropriate debridement, effective lavage, and minimal
tissue trauma. Multiple synovial cavities may be treated
simultaneously, there is early pain relief, few complications,
and minimal postoperative care. Animals are able to make an
early return to exerciseand the prognosis appears to be better
than with other reported regimens.
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Introduction
There are only very few reports in the veterinary literature on As the TMJis another small joint. all specificfeatures for small
equine temporomandibular joint (TMJ) disorders. Early joints described previously for arthroscopic surgery of the
clinical reports (Blasse 1909, Hardy & Shiroma 1991, distal and proximal interphalangeal joints can be adapted.
Holmlund 1992) point out a relation between teeth and jaw The TMJ is an incongruous joint formed ventrally by the
abnormalities and TMJ diseases. It was never clear if condylar process of the mandibular head and dorsally by the
abnormalities in teeth secondarily create TMJ diseasesor vice zygomatic process of the temporal bone. As in all joints which
versa. Recently,clinical attention has been drawn to disorders are incongruous. a fibrocartilaginous disk is interposed to
of this joint as possiblereasons for headshaking, misbehavior, level out the incongruity. This disk has an elongated.
"back problems", and head tilt. roundish appearance,and is about 5 mm thick at the border.
In humans, TMJ problems are much more commonly Even in adult horses. the center of the disk is thinned and
diagnosed; 5-12% of North American people develop transparent (Fig. 15.3). The TMJ is completely divided into
significant and treatable disorders of the TMJ (Rugh & two compartments: the dorsal disco temporal compartment
Solberg, 1985). is more spacious than the ventral disco mandibular
The few reports in the veterinary field describe mainly articulation. Both compartments have caudal recesses;the
dramatic situations such as luxation (Barber et al 1985), dorsal caudal recess allows arthroscopic accessto the disco
intra-articular fractures (Hurtig et al 1984), and septic temporal joint and the caudal ventral recess to the disco
arthritis (Warmerdam et alI997). These few reports might mandibular compartment. A significant joint capsule. as well
give a wrong impression of actual percentage of TMJ dis- as a lateral and a caudal (elastic) ligament, assure lateral
orders. An initial report was presented by Boening (1996) of
a horse suffering from orthopedic symptoms which were later
localized as primary TMJ disease.He described a clinical case
of a German Warmblood dressagehorse with chronic "back
problems" and active head tilt which was attributed to a
transverse, unilateral tear in the joint disk of the TMJ. The
diagnosis was made arthroscopically after previous scinti-
graphy of the head (Fig. 15.1), followed by intrasynovial
anesthesia. This horse improved significantly after partial
arthroscopic removal of the articular disk, debridement, and
lavage. Postoperatively, this horse received repeated intra-
articular corticosteroid injections.
Increasing use of imaging and minimally invasive
techniques has led to increased opportunities for diagnostic
and therapeutic procedures. Different authors (Tietje, et al
1996, Weller et al1999a, 1999b, Stadtbiiumer & Boening
2000, 2002, Maierl et al2000) have described the anatomy,
pathogenesis, radiologic and sonographic findings, (Fig.
15.2), computer tomography abnormalities, and arthro-
scopic approaches, as well as therapeutic and arthroscopic
surgery.
 For unilateral arthroscopy of the TMJ, the horse is under
general anesthesia and in lateral recumbency -for a bilateral
approach, dorsal recumbency is an option. After spacious
shaving and aseptic preparation the caudal recessus of the
disco temporal joint is predistended with about 10-15 ml of
polyionic R~er's solution. The insertion of a hypodermic
needle is made immediately adjacent to the dorsal aspect of
the palpable condylar process. A skin incision is made with a
No. 11 scalpel blade right over the bulging rostral joint
capsule before the joint capsule is penetrated with an
arthroscopic sleeveand a conical obturator of the 4 mm 300
arthroscope (Figs 15.4 and 15.5) and advanced in a rostro-
medial direction. The arthroscopic portal to the rostral recess
of the ventral compartment is located immediately rostral to
the mandibular caput and ventral to the joint space.To enter
stabilizationof this joint. For invasivemanipulation of the this compartment the sleeve has to be advanced in a more
TMJ.the more ventrally locatedtransversefacial artery and horizontal plane and in a medial direction. This joint
vein and the transverse facial branch of the auricular- compartment is even smaller than the dorsal compartment
temporal nerve have to be prelocated.Another structure of and does not allow surgical manipulation. In this particular
importance is the rostral-dorsal part of the parotid gland. compartment, because of the limited space.there is a higher
partially coveredby the parotid-auricularmuscle. risk of iatrogenic cartilage damage.
 Once in the joint, gas distention (CO2) prevents the
protrusion of synovium. After diagnostic evaluation of
the joint. the ideal site for the instrument portal (about 1 cm
further dorsally) is determined by inserting a hypodermic
needle. Routine exploration of articular structures is followed
by passive movement of the mandible. This will exposerostral
parts and allow disk palpation with a probe. Figures 15.6to
15.10 show examination of the proximal compartment
with the temporal bone aboveand the disk below.Figures
15.6 and 15.7 are central and medial views respectively.
Chondropathyon the temporal articular surface can be
seenin Fig 15.8 with more chronic change in Fig 15.9.
Penetrationof the medial joint capsuleresults in exposure
of massetermuscle fibers. Each arthroscopic procedure
is followed by lavage and skin closure with simple inter-
rupted sutures.
Temporomandibular Joint

Table 15.1 Horses with diagnosis of inflammation of the temporomandibular joint (TMJ) (1996-2000)

Sound after 6 weeks

postoperatively

Slight chronic Scintigraphy: left TMJ hot Chronic, diffuse Improved, but still irregular
headshaking. behaviourai spot +, ultrasound: proliferative synovitis headshaking
problems distended joint filling

Swelling TMJ with Ultrasound: joint Post-traumatic Improved, easy work

reduction of jaw distention, hemarthrosis, significant possible
motility intrasynovial lesion joint capsule
hyper-echogenic
structures

Case 4 Chronic swelling, right Scintigraphy: right hot Significant traumatic Sound,no symptoms after
Warmblood, joint capsule after colic spot +++, ultrasound: synovitis and 6 weeks
distended joint, increased proliferation of villi +++
6-year-old,gelding,
showjumper thickness joint capsule

Case 5 Significant back Scintigraphy: right hot Subtotal, transverse, Sound and back to full
Warmblood, problems, compression spot ++++, ultrasound: axial rupture of articular work after 4 months
9-year-old mare pain right TMJ, bilateral thickened joint capsule disk, secondary mechanical
dressage teeth abnormalities synovitis, free floating
bony fragment, small size

Resu Its graphy,and diagnostic/surgicalarthroscopy (Table 15.1).

Obviousclinical syndromesuch as fractures,luxations. and
septic arthritis were not encountered in this study. The
An initial clinical seriesinvolving 5 Warmbloodhorseswasreported
by Stadtbaumer& Boening(2002). Over 4 years ageranged from 6 to 12 years: 4 horseswere Warmbloods
(1996-2000), they diagnosedTMJdiseasesusing different and one was a Quarter Horse; there were 3 geldingsand
diagnostictools suchas scintigraphy,ultrasonography,
radio- 2 mares.
 Treatment is summarized in Table 15.1. The outcome was
excellent in three of five horses. with the symptoms in the
remaining two improved. The authors emphasised the need
for careful examination of the TMJ in extended orthopedic
work-up when horses are presentedwith back problems.
behavior problems. and headshaking.
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Introduction
Arthroscopy involves. in most circumstances. hospitalization
of horses and general anesthesia. which can both result in
complications to case management. In addition. there are a
number of intraoperative and postoperative complications
that are of particular importance with respectto arthroscopy.
The nature and incidence of complications in human arthro-
scopyhave beendocumented for the most commonly operated
joints and will be reviewed briefly. Documentation of compli-
cations in equine arthroscopy is limited (McIlwraith 1990).
Complications of
Arthroscopy
in Man
The most common joint for human arthroscopy is the knee.
Three surveys have reported complication rates of 0.8%
(DeLee1985). 0.56% (Small 1986). and 1.68% (Small 1988).
However. in a smaller series. Sherman et al (1986) reported a
complication rate of 8.2%. Complication rates of 9% for arthro-
scopyof the ankle and 9.8% for the foot and ankle combined
were published by Ferkel et al (1996) and Ferkel et al (2001).
respectively.Complications occurred in only 1.6% of hip arthro-
scopies reported by Griffin & Villar (1999). None of these
were major or long term and most were attributed to use of
traction techniques. Kelly et al (2001) reported serious compli-
cations in 0.8% and minor complications (which all resolved)
in 11 % of arthroscopic procedures in the elbow. whereas
Reddy et al (2000) documented an overall incidence of 1.6%
at this site. The highest reported incidence of complications in
man appearsto be associatedwith arthroscopy of the shoulder.
where Berjano et al (1998) reported a 10.6% incidence.
The specific complications encountered in man vary with
individual joints and also with the surgical techniques used.
The most common complications associatedwith arthroscopy
of the human knee are presented in Table 16.1. The
commonest complication associated with foot and ankle
Hemarthrosis Ligament injury
Infection Neurologic injury
Thromboembolism Fracture
Anesthetic complications Adhesion formation
Instrument breakage and/or failure Postoperative effusion
Articular pain Wound healing complications
Complex regional pain syndrome Ecchymoses
Data from Delee (1985). Small (1986.1988) and Sherman et al (1986) reviewed
by Allum (2002).
(Ferkel et al 2001) and elbow (Kelly et a12001) arthroscopy
is neurologic injury caused by iatrogenic damage to adjacent
neural trunks. Systemic complications in man include cardio-
pulmonary events,atelectasis,pulmonary embolus,myocardial
infarction, and death. Preoperative complications include
incorrect diagnosis, lack of preoperative planning, and failure
to obtain appropriate preoperative studies (Ferkel et al2001).
A number of factors have been identified as predisposing
to complications. Small (1986) and Ferkel et al (2001)
recognized complex surgical procedures such as meniscal
repair and reconstruction of the anterior cruciate ligament
as being associated with an increased incidence of compli-
cations. Indust&! injuries, meniscectomy,abrasionarthroplasty,
patients of gre'aterthan 50 years of age,and tourniquet time
were associated with increased risk by Sherman et (1986).
Allum (2002) commented that, surprisingly, the incidence of
complications was unrelated to surgeon experience.
In making recommendations to minimize complications
associatedwith arthroscopy of the knee, Allum (2002) made
four specific recommendations:
1. Use of a sharp trocar should be avoided.
2. Instruments should be used only if they can be seenclearly.
3. Tissuesshould never be cut blindly but always under direct
visualization.
4. Care should be taken with power instruments, particularly
when suction is applied, as this can rapidly result in joint
evacuation and compromised visibility.
The importance of thorough three-dimensional anatomic
knowledge and location of the correct sites for creation of
portals has been emphasized in the shoulder (Boardman &
Cofield (1999) and ankle (Ferkel et al 2001). The use of
appropriately sized instruments was also recommended by
Ferkel et al (2001).
Postoperative infection rates of 0.08%, 0.1 %, 0.23%, and
0.42% have been reported following knee arthroscopy by
(DeLee (1985), Sherman et al (1986), D'Angelo & Ogilvie-
Harris (1988), and Armstrong et al (1992), respectively.
Barber et al (1990) reported a postoperative infection rate of
1.4% following arthroscopy of the ankle. The higher
incidence at this site was attributed to thinner skin, less
subcutaneous tissue and reduced local healing compared to
the knee. Factors which predisposeto infection include longer
operating times, an increased number of procedures during
each surgery, prior surgical procedures, chondroplasty and
soft tissue debridement (Armstrong et aI1992). Concurrent
administration of corticosteroids has also been identified as
producing an increased incidence of postoperative infection
(Armstrong et al1992, Gosal et al1999, Kelly et al 2001).
Allum (2002) states that most surgeons undertaking
arthroscopy of the knee routinely do not use prophylactic
antimicrobial drugs except for complex procedures such as
reconstruction of the anterior cruciate ligament. However,
D'Angelo & Ogilvie-Harris (1988) have suggested that they
may be indicated on a cost/benefit basis. Prophylactic
antimicrobial drugs have been reported to reduce the
infection rate associated with arthroscopy of the foot and
ankle (Ferkelet a12001) and their use has also beenadvocated
with arthroscopy of the elbow (Kelly et al2001) and should~r
(Berjano et aI1998). In the face of postoperative infection the
recommended treatment in man consists of intravenous
antimicrobial drugs, repeated arthroscopy with debridement
and vigorous high-volume lavage (Armstrong et al 1992,
Ferkel et al2001, Allum 2002).
If instruments break, creating loose intra-articular debris,
Allum (2002) recommends that, if the fragment is visible, the
fluid should be switched off and the piece retrieved. If the
piece is not visible, then lavage may flush it into view or it
may be localized with conventional radiographs or fluoroscopy.
Occasionally, magnetic instruments may aid retrieval (e.g.
Golden RetrieveTMfrom Instrument Makar, Inc., Okamos,MI).
Pain is uncommon after diagnostic arthroscopy or simple
surgical procedures but may be a problem following extensive
soft tissue interference such as meniscal repair, synovectomy,
or intra-articular reconstruction of ligaments (Allum 2002).
This may be controlled by intra-articular opiates Ooshi et al
1992) or local analgesics (Chirwa et al 1989). Complex
regional pain syndrome, which has also been termed reflex
sympathetic dystrophy, is a complex, unpredictable, and
variable problem which has proved difficult to define, predict,
or prevent (Allum 2002).
Iatrogenic damage to articular cartilage is considered
the most frequently unreported complication of arthroscopy
of any joint (Ferkel et al 2001). Small joints are most
susceptible and long-term sequelaeare unknown (Ferkel et al
2001).
Perisynovial neurovascular structures can be injured
by incorrect portal placement (Boardman & Cofield 1999,
Ferkel et al 2001, Kelly et al 2001). More remote neural
injury can result from inappropriate patient positioning or
manipulation and from extrasynovial fluid extravasation
(Kim et al2002).
Postoperative effusion can be considered a sign of
unresolved lesions. Dandy (1987) has reported an incidence
varying between zero and 15% and ascribed the effusion to
inflammatory synovitis. Hemarthrosis is said to have an
incidence of 1% in human arthroscopy (Allum 2002). It is
treated by lavage and instillation of local analgesic and
epinephrine.
In arthroscopy of the knee, the use of skin sutures has
been reported to carry a higher complication rate than the
use of adhesive tape (Fairclough & Moran 1987) or leaving
wounds open (Maffulli et alI991). No significant differences
were reported between the latter two techniques (Hussein &
Southgate 2001). By contrast, the use of skin sutures is
associated with a reduced complication rate in foot and
ankle arthroscopy (Ferkel et al2001). Also, an increased rate
of drainage or erythema was noted with adhesive tape
compared to sutures in arthroscopy of the elbow (Kelly et al
2001). If synovial fistulae result. treatment is focused on
immobilization (DeLee 1985, Proffer et alI991).
Hemarthrosis
Hemarthrosis is not usually a significant problem. Distal limb
hemorrhage is invariably reduced when animals are in dorsal
recumbency compared to those positioned laterally. Use of an
Esmarch bandage and tourniquet may be of benefit when
dealing with lesions in which hemorrhage may be anticipated.
Examplesinclude contaminated and infected synovial cavities
and tenoscopy of the digital flexor tendon sheath. In most
other situations. hemorrhage is controlled by the pressure
generated by i,rigating fluids. However. if the joint is exited,
left undistended. and then re-entered, the surgeon will
encounter hemorrhage. particularly from debrided tissues. In
such instances. flushing with an open egress cannula,
followed by closure of the cannula and redistention, is all
that is necessary to eliminate the problem. The same
procedure is performed if hemarthrosis is present at the time
of initial entry.
The fact that hemorrhage is minimized with distention is
important to note, particularly with reference to debridement
of subchondral defects. During curettage of subchondral
bone, hemorrhage (as seenduring arthrotomy) is not evident
while the joint is distended. The surgeon must therefore
either use other criteria to evaluate an appropriate depth of
debridement or must release fluid pressure in order to assess
bleeding from subchondral bone.
 Obstruction of view by synovial villi femur.Assessment of thesesitescan usuallybe madeusing a
probeto displacethe villi, but frequentlysufficientvisualiz-
Within each synovial cavity there are regions of villous and ation to permit confidentand accuratesurgicalinterference
avillous synovium. Synovial villi may obstruct arthroscopic will require local synovial resection (Fig. 16.2). This is
visualization throughout a synovial cavity or this may be a performed most efficiently with motorized apparatus with
localized problem. When generalized, this problem is usually suctionattached.Resectionshould alwaysbe limited since,
associated with either inadequate distention or excessivefluid althoughthe clinical implicationsare unknown, it has been
movement. Distention may be limited by inadequate delivery demonstratedthat regenerationof normal villous synovium
of fluid. capsular fibrosis. or the development of extrasynovial doesnot occur (Theoretet a11996. Doyle-Jones et aI2002).
extravasation of fluid. Excessivefluid movement can occur In addition. overzealoususe of motorized apparatus may
with an open outflow portal. This is seen most commonly resultin trauma to the fibrouscapsule.
with an open egress cannula or an excessively large and
patent instrument portal. The latter can occur as a technical
error but more commonly follows removal of large intra-
articular fragments. For these reasons, initial arthroscopic
examination should be performed with a closedegresscannula.
In addition, whenever feasible, large fragments should be
removed after small fragments. Many mechanical pumps
will deliver fluids at rates up to 1 liter/minute. These will
compensate for excessivefluid outflow in many situations,
but at high flow rates bubbles are frequently produced, which
also result in diminished visualization. Fluid exit through a
large, patent instrument portal can also be controlled to some
degree by retention of an instrument within the portal.
However. the surgeon must try not to prevent fluid outflow by
placing a finger over the instrument portal. as this will result
in rapid extrasynovial extravasation.
Proliferative synovial villi may obscure articular margins
and lesions in these locations. Common examples include
fragmentation of the dorsoproximal and plantaroproximal
articular margins of the proximal phalanges (Fig. 16.1) &nd
osteochondritis dissecans of the lateral trochlear ridge of the
 Many of the problems associatedwith obstructing synovial
villi are reduced or eliminated by use of gas distention.
Extrasynovial extravasation of fluid
Extravasation of irrigating fluid into the subcutis and other
fascial planes is a problem commonly encountered when
learning arthroscopic techniques but occurs, to some degree,
even with the most experienced surgeon, The principal
predisposing factors are the shape of instrument portals,
excessive perfusion pressure in the presence of obstructed
outflow, and instrument manipulation.
Instrument portals in which the incision in the skin and
extra-articular tissues is smaller than the opening into the
joint will result in dissecting lines of fluid through fascial
planes. This can occur quickly and may be controlled
effectively by minimizing perfusion pressure at the time of
portal creation and also by completing the incision through
the skin before the blade is advanced into the joint. The shape
of a No. 11 blade assists also, since this creates a triangular
incision with the apex of the triangle at the point of the blade.
An obstructed outflow with excessiveperfusion pressure can
occur while instruments (particularly large instruments) are
being inserted or manipulated. It results also during removal
of large fragments, while these are being pulled through the
instrument portal. Selective reduction in perfusion pressure
at this time will reduce the severity of the problem signifi-
cantly. Similarly, repeated instrument entry and/or a large
range of instrument movement through a portal will open up
and/or weaken fascial planes with the same result. Noyes &
Spievack (1982) demonstrated that excessiveintra-articular
fluid pressure potentiates subcutaneous extravasation of fluid.
The site at which surgeons experience most difficulties
with extravasation of fluid is the scapulohumeral joint. Here,
caudal instrument portals must traverse not only the skin
and subcutis but also several centimeters of muscle and
multiple fascial planes. The ability of the periarticular
muscles and their fascial planes to imbibe fluid can result in
restricted articular distention and thus loss of visibility and
surgical access,particularly to lesions which are axial in the
joint. Since this joint generally requires a high perfusion
pressure to maintain arthroscopic access, particular care
should be taken in the creation and use of instrument portals.
Some degree of extra-articular extravasation is inevitable.
The surgeon should be cognizant of its occurrence and
plan surgical procedures such that more axially located
lesions are treated first. Also, once extravasation has begun
surgical access time will be limited. Extrasynovial fluid
accumulation can also hamper instrument entry to the stifle
joints and both carpal and tarsal tendon sheaths. These areas
can be reduced considerably by temporary cessation of
ingress fluid and firm massage of fluid from skin portals.
Surgery can then recommence. At the end of surgery large
quantities of subcutaneously extravasated fluid may result
in excessive tension in skin sutures. This can usually be
ameliorated by simple hand massage of the site prior to
closure.
In most circumstances extravasated fluid dissipates within
24 hours of surgery. Occasionally.when associatedwith large
fascial planes such as those adjacent to the femoropatellar
joint. this may take longer.
Iatrogenic damage to articular cartilage
Full- and partial-thickness defects in articular cartilage can
be created iatrogenically: this occurs most commonly when
the joint is being entered and particularly when there is
minimal distention. It can be limited by careful technique and
use of a conical obturator (rather than a sharp trocar) in the
arthroscopic sleeve.
Arthroscopic portals should be made using a blade directly
into synovium and the sleeve then can be passed along this
pathway with minimal resistance. Use of two hands, one to
advance the cannula and the second positioned adjacent to
the skin portal to act as a bridge or brake, is recommended. In
addition. the surgeon should angle entry of the arthroscopic
sleeveand subsequent instruments away from the direct line
of articular surfaces. When minor scuffing of the cartilage
does occur, it does not appear to be of major significance
(Dick et al19 78. McIlwraith & Fessler1978).
Iatrogenic damage to other tissues
Perisynovial structures may be damaged inadvertently during
creation of arthroscope and/or instrument portals. Obviously,
the risk is dependent on proximity to portal sites. Elements of
the palmar/plantar neurovascular bundle may be traumatised
in surgery of the digital flexor tendon sheath. Use of an
Esmarchbandage and tourniquet appearsto be a predisposing
factor in making the bundle difficult to identify. The surgeon
is usually unaware of damage during surgery. Laceration of
the palmar/plantar artery may become apparent on release
of the tourniquet or by the presence of postoperative
hemorrhage during recovery from general anesthesia. This
usually is controlled by the application of counterpressure.
Damage to the palmar/plantar nerve may be clinically silent
but a painful neuroma may develop at the site.
The carpal s~aths of extensor carpi radialis and common
digital extensor tendons can be penetrated by injudicious
placement of arthroscope and instrument portals. This is
usually apparent to the surgeon as intra- and postoperative
distention of the sheath. These sheaths can also be
traumatized during removal of large fragments from the
craniodistal margin of the radius. The tendon sheath of the
common digital extensor is most commonly affected when
fragments are removed from the craniolateral margin (inter-
mediate facet) of the radius.
Intrasynovial instrument breakage
The most common cause of instrument breakage is the use of
inappropriate force. It follows that the incidence of this
 problem usually decreasesas a surgeon gains experience. If
loose pieces are created within the synovial environment,
then fluids should be stopped immediately or the perfusion
rate reduced dramatically in order to maintain the fragment
in the visible field. An appropriate grasping instrument should
then be inserted and the fragment removed. If the piece dis-
appears from view, a systematic search should follow, bearing
in mind that most pieces will be metallic and therefore will
gravitate to dependent areas (Fig. 16.3). If this fails to locate
the debris, then intraoperative radiography should be employed
(Fig. 16.4). Magnetic retrievers are available but the limited
frequency of their use makes the cost hard to justify.
Prevention is certainly better than cure and the surgeon
should avoid excessivebending or lever movements. The use
of fixed rather than disposable blade cutting instruments
within joints is also recommended. DisposableNo. 15 scalpel
blades and the shafts of small angled spoon curettes are
considered to be particularly vulnerable to intra-articular
breakage.
Ferris-Smith arthroscopic rongeurs are a workhorse of
equine arthroscopic surgery. However,if used inappropriately,
particularly if attempts are made to twist firmly attached
bone, then the pin linking the blades will shear. This disarms
the instrument completely but does not produce debris. The
pin can be replaced by manufacturers.
Minor trauma to the distal window of the arthroscope will
result in cumulative image artifacts and loss of clarity,
whereas major trauma can cause complete loss of image.
There is generally no intrasynovial debris. Trauma to the
glass is minimized principally by careful surgical techniques
and it is vital to maintain a direct view of instruments during
surgical procedures. Protection of the distal window is aided
also by a slightly recessed arthroscope position within the
cannula.
Sudden movement during surgery, which occurs most
commonly if an animal begins to wake, can bend or break
instruments (Fig. 16.5).
Intrasynovial foreign material
Tiny metallic fragments have been seen following impact of
instruments on the arthroscopic sleeveor sometimesfollowing
other "metal on metal" contact. Such debris is usually flushed
out with the irrigating fluid or may become embedded in the
synovial membrane. No detrimental effects have been
recognized.
When needlesare used either to inflate a synovial cavity or
to determine sites for appropriate instrument portals. these
may cut small pieces of skin. which are carried into the
synovial space. This is seen most frequently with stiletted
needles. If adhesive drapes are employed. then needles will
also carry small pieces of plastic into the synovial space.Such
debris is readily flushed from the synovial environment and
no adverse effects have been recognized. The risk of pushing
larger pieces of plastic into the synovial cavity or adjacent
tissues can be reduced by removing the adhesive material
from the immediate vicinity of portals. Plastic fragments can
result in swelling and discharge when lodged in the subcutis.
Infection
The incidence of intrathecal infection following arthroscopic
surgery in horses has not been documented but appears rare.
Nonetheless. the potentially devastating consequences of
iatrogenic synovial infection mean that aseptic techniques
should never be compromised. Direct visualization has been
identified as an obvious potential source of contamination
but its use is now virtually obsolete. The authors have
implicated inadequate or premature removal of postoperative
bandagesin casesof postarthroscopic infection of tarsocrural
joints.
There is no consensus on the use of prophylactic anti-
microbial drugs with arthroscopic surgery, although the
authors all useperioperativemedication. Penicillin preparations
are most commonly employed. One frequently used regimen
is intravenous sodium benzylpenicillin at >20,000 ill/kg
given at the time of anesthetic premedication followed by
three similar postoperative doses at 8-hour intervals. Alter-
natives include a similar protocol with potassium penicillin or
use of intramuscular procaine penicillin. When implants are
used or if there is a history of recent intra-articular medi-
cation, then a combination of penicillin and gentamicin may
be employed.
Infected cellulitis and/or fasciitis have beendocumented as
uncommon sequelae to arthroscopic surgery. All cases
appear to have resolved following systemic administration of
antimicrobial drugs. Drainage from skin portals or surgically
created sites mayor may not occur (Fig. 16.6):-
Occasionally, small skin abscessesor suture sinuses are
encountered. These almost invariably require no treatment
and resolve when sutures are removed, although in some
cases a small fibrous lump may persist at the site. Infection
can also follow suture removal if this is not performed
appropriately. may not be so in the tarsocrural joint. Mild synovial distention
may persist without clinical significance. for example when
preoperative distention has been long-standing. In the
Postoperative distention/synovitis absence of additional clinical signs. such as lameness and
reduced or resented flexion. mild distention usually does not
Distention usually signifies persistent synovitis and thus justify further investigation or treatment. Marked synovial
ongoing intra-articular (or intrathecal) problems.However, distention is more likely to result when active intrasynovial
this is an oversimplification.Thereis variability accordingto lesions persist and re-evaluation is indicated. If causative
site, e.g. in the femoropatellarjoint persistentdistentionis lesions are not identified. then treatment of the synovitis may
frequentlya sign of continuedintra-articular lesionsbut this be beneficial.
Failure to remove fragments
In surgery for removal of traumatic or developmental
fragments it is possible. particularly in cases with multiple
fragmentation. that all pieces are not removed. There are a
number of possible explanations which fall into two broad
categories: those fragments which may be identified
immediately after surgery and those that are identified later.
The former category includes the simple surgical error of
failing to identify lesions. Predisposing factors include
inadequate preoperative examination -e.g. failure to identify
fragments that may be medial and lateral in a joint and
incomplete arthroscopic evaluation of the joint. At some sites
-e.g. the dorsoproximal margin of the proximal phalanx -
fragmentation can be covered by proliferative synovium and
may not be apparent until this is lifted with a probe. In some
animals there is a distinct dorsal recess of the joint capsule at
this site. which also can obscure fragments. At other sites -
e.g. in animals with multiple. loose osteochondral fragments
in the femoropatellar joint -it may be difficult to determine
accurately from preoperative radiographs the exact number
of fragments which need to be accounted for. It should also be
appreciated that some fragments identified radiographically
may be embedded within the joint capsule. Current opinion
suggests that the dissection necessaryto identify and remove
these is not justified. Failure to remove fragments is limited by
a thorough preoperative evaluation and the surgeon should
ensure that all identified fragments are accounted for at
surgery. Within individual joints. loose fragments move
frequently to consistent locations. e.g. into the suprapatellar
pouch of the femoropatellar joint (Fig. 16.7) or the inter-
condylar fossa of the medial femorotibial joint. These sites
should always be assessedat the end of each surgery and
debris removed. Use of intraoperative and postoperative
radiography has been recommended (and can help avoid
litigation), but is not necessarily an assurance.
Lesions that may be identified some time after surgery and
misinterpreted as failure to remove fragments include new
bone deposits at the site of previous lesions, fragmentation
of the same, additional new fragments, and dystrophic
mineralization in adjacent soft tissues.
Postoperative cal?sulitis, entheseous
new bone, and soft tissue
mineralization
In many instances capsulitis may be present preoperatively,
such as when there is tearing of the fibrous joint capsule
(Fig. 16.8) or can be anticipated when articular damage is
severe.Problems can also develop with surgical trauma to the
joint capsule. Traumatic attempts at removing capsular frag-
ments, trauma to the capsuleduring debridement, particularly
with motorized apparatus, and undue trauma to the sensitive
transition zone of the joint can all cause problems.
Problems associated with positioning
Transient failure to extend hind limb joints on recovery from
general anesthesia has been noted following long surgical
procedures in which (usually both) hind limbs are fixed in an
extendedposition. Somecasesare thought to be associated
with a femoralneuropathyor neuromyopathyinvolving the
quadricepsmuscles.Others appearable to fix the proximal
joints but fail to extendthe metatarsophalangeal and inter-
phalangealjoints. In both instances,symptoms generally
subside quickly. The problem is readily controlled by
supportingextendedlimbs during surgeryand by flexing the
contralaterallimb while this is not undergoingsurgery.
Pain
Anesthetists frequently report that distention of the digital
flexor tendon sheath is more painful than joint distention.
Postoperatively, the degree of pain exhibited by horses
appears proportional to soft tissue (particularly tendon and
ligament) involvement. However,this is usually transient and
requires little more than analgesia provided by nonsteroidal
anti-inflammatory drugs for 24 hours after surgery. It has
been reported that horses with extensive articular or tendon
sheath derangements can be maintained on lower levels of
inhaled anesthetic agents and have improved recovery by
using bupivacaine or mepivacaine for initial synovial inflation.
One author (AJN) now u~es such a protocol routinely.
Generally, most complications can be avoided by good
techniqueand none precludethe advantagesof arthroscopic
surgery.The problemswith equinearthroscopicsurgeryare
mainly technicaland anatomic.Goodtechniquecomeswith
training and experienceand the benefits of practice on
cadaverlimbs cannotbe overemphasized.
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Articular cartilage rarely reforms a functional hyaline
surface after injury. Most simple cartilage lacerative injuries
reach a benign non-healing phase,which remains unchanged
over time (Mankin 1982, Hunziker & Rosenberg1996). Deeper
cartilage lesions, violating the tidemark and extending into
the subchondral bone plate, result in an improved healing
response (Campbell 1969). This is largely due to the pro-
liferation of undifferentiated mesenchymal cells from the
deeper tissues. In horses, spontaneous healing in cartilage
defectsprogressesfrom granulation to fibrous tissue and finally
fibrocartilage (Riddle 1970). The fibrous tissue undergoes
progressive chondrification to form a fibrocartilaginous mass,
looselyattached to the original cartilage edges.The subchondral
bone plate occasionally reforms to the same approximate
level as the adjacent undamaged bone, but in cartilage lesions
that do not involve substantial erosion of the underlying
bone. the reformed subchondral bone plate may be higher
than the surrounding normal bone plate (Frisbie et aI1999).
Immediately above the reformed subchondral plate, areas of
cartilage proliferation predominate. The deeper cartilage
layers and surface fibrous tissue generally follow a pattern of
decreasing cellularity as the defect matures. At 12 months.
type II collagen content approaches normal but proteoglycan
levelsare only about half that of normal (Howard et aI1994).
The phenomenon of matrix flow, an intrinsic repair mechanism.
may also contribute to healing of articular cartUage defects
by centripetal collapse of the perimeter of the lesion
(Ghadially & Ghadially 1975). In small defects. this can
result in significant reduction in lesion size, but in defects
over 9 mm, matrix flow is proportionally insignificant
(Convery et al1972).
Depth of injury (full or partial thickness). the size of the
defect, location in relation to weightbearing or nonweight
bearing areas. and the age of the animal. influence the repair
rate and resiliency of new cartilage surfaces. The healing of
chondral and osteochondral defectsis more completein young
animals. due to the increasedmitotic capacity of chondrocytes,
more active matrix synthesis, and closer proximity to the
vascular supply in the depths of the articular-epiphyseal
complex cartilage (Madsen et al19 83). Examples of improved
repair capacity are easily seen in the resurfacing potential
following osteochondritis dissecans (OCD) flap removal in
weanlings compared to debridement of articular erosions in
adults. The size of the lesion is critical. Convery et al (1972)
showed that lesions in the equine femorotibial joint less than
3 mm in diameter healed with little residual deformity
(Convery et al 1972). More recently, Hurtig et al (1988)
determined that lesions larger than 15 mm2 in surface area
(3 x 5 mm rectangle) tended to show reasonably good repair
at 5 months but degeneratedwith increasing time (Hurtig et al
1988). These studies indicate that most clinically relevant
defects in adults cannot be expected to heal well. The
metaplasia of fibrous tissue to fibrocartilage is not always
evident, and depending on the time of examination, degener-
ation to fibrous tissue and later mechanical erosion of the
repair tissue can occur. Repair tissue is biomechanically
inferior to normal articular cartilage, even though the histo-
logic appearance is often fibrocartilage or even hyaline-like
tissue (Ahsan & Sah 1999). Repair tissue generally has
significantly less proteoglycan and to some extent type II
collagen than normal cartilage. Additionally, the development
of subchondral architecture and re-establishment of a tide-
mark is often irregular and inconsistent. This creates stress
risers and susceptibility to cartilage deterioration with normal
joint activity. Poor-quallty, relatively short-lived repair cartilage
has led to the development of pharmacologic and surgical
methods to improve the repair process.
Techniques that enhance the quantity and hyaline charac-
teristics of cartilage repair tissue, would allow the surgeon to
improve the long-term outcome when debriding cartilage
lesions, particularly in challenging conditions of the stifle,
carpus, and shoulder. These techniques should meet several
important criteria:
1. be achievable arthroscopically
2. result from local manipulations or use of simple transplant
tissues
3. be available to surgical specialists with minimal delay
between the diagnosis, decision for surgery, and the
institution of the surgical repair
4. be reasonably economical
5. be well tested in a research setting, and able to offer
advantages in durability and hyaline quality in the repair
tissue
6. be amenable to the variety of shapes and locations of
acute, subacute, and in some instances chronic, cartilage
lesions in the joint.
No one arthroscopic system routinely provides all of these
advantages. Indeed, those with inherent simplicity such as
cartilage debridement, forage, and microfracture meet many
of the criteria for simplicity, economy, and minimal delay
between diagnosis and repair, but provide lessassuredhyaline
cartilage and cartilage durability than many of the more
complex transplant methods. Techniques for cartilage repair
that are clinically used or have been studied in a research
setting can be subdivided into two categories: local
manipulative procedures or cell and tissue transplantation
techniques.

Local manipulative procedures

Surgical techniques that rely on simple manipulative
procedures include:
.cartilage debridement
.chondroplasty to remove partial-thickness fibrillation
.cartilage reattachment
.forage or drilling of the subchondral bone using a
drill to provide a uniform diameter perforation
through the subchondral plate
.microfracture or micropick, which uses a tapered
surgical awl to perforate the subchondral bone to
open marrow spaces
.abrasion arthroplasty,using a motorized burr to remove
a uniform layer of eburnated cartilage and bone
.spongiallzation (saucerization) of the subchondral
plate to open up larger marrow spacesby removal of
greater thicknesses of the subchondral bone.

Cartilage debridement
Some form of cartilage debridement is common during
arthroscopic surgery. As a simple rule, fibrous interpositional
,,'
tissue or exposed loose bone should be removed from full-
thickness defects. Debridement should continue down to
firm, normal appearing, subchondral bone plate. Maintaining
as much subchondral bone as possible keeps the bone and
overlying cartilage repair tissue contoured to the normal
congruency of the opposing joint surface, thereby enhancing
the chance of healing cartilage tissue persistence. However,
the remaining bone must be viable. Crumbly, brownish bone
should always be removed by debridement, using either hand
instruments or motorized equipment (Fig. 17.1). At least for
the carpus, the amount of residual bone after debridement is
an important parameter in determining the prognosis for
return to athletic activity (McIlwraith et al19 8 7, McIlwraith
1990). Several studies indicate the advantage of removal of
full-thickness fibrillated cartilage. However, more debate sur-
rounds the potential advantagesof debriding partial-thickness
cartilage defects down to subchondral bone. in efforts to
encourage new cartilage formation from subchondral bone
cellular and growth factor elements (Baumgaertner etal1990.
Hubbard 1996). Consensus appears to favor not debriding
partial-thickness fibrillated cartilage, but rather leaving it
attached to the calcified cartilage and underlying bone
(Mcllwraith 1990). Partial-thickness defects have been
shown to remain physically unchanged for at least 2 years
(Mankin 1982). Conversely, some symptomatic benefit for
several months can be derived from chondroplasty of the
obviously fibrillated portion of partial-thickness defects,
 Repair Methods

which is described in more detail later (Thompson 1975, while leaving perpendicular cartilage defectwalls (Fig. 17.2).
Kim et al 1991). In summary. chondroplasty reduces the A controlled study in dogs indicated the benefit of perpen-
possibility of damaged cartilage leaching degraded cartilage dicular cartilage walls following debridement, compared to
matrix fragments, including collagen, proteoglycan, and beveled edges,which tended to increase the overall dimension
cellular components to the synovial fluid. where they of the healing defect (Rudd et al198 7).
increase synovitis and concurrent lameness (Thompson Exposed subchondral surfaces can be smoothed either
1975). with hand tools, which include curettes, rasps,and rongeurs,
Full-thickness cartilage lesions are debrided to removeresidualor with motorized burrs. Several types of burr heads are
portions of the calcified cartilage layer, which tends available, varying from spherical to oval acromioplasty or
to retard the development of well-attached cartilage repairtissue notchplasty blades, which have an elongated profile for
from the subchondral bone and surrounding cartilage.The maximum bone removal effect (seeChapter 2). Hand tools are
most appropriate tools for cartilage debridement include generally preferred to avoid excessivebone loss; however, for
a seriesof spoonand ring curettes that allow adequateremovalof large areas of irregular hard bone, a burr may expedite the
residual fibrous areas attached to the subchondral bone procedure and provide a better end result. Since the need for
substantialbone removalis low. an inventoryof a singleburr
type is recommended.

Chondroplasty
Resection of the protruding surface strands of partial-
thickness cartilage fibrillation has been promoted as a
mechanism to reduce cartilage-derived detritus entering the
synovial environment (Thompson 1975. Childers & Ellwood
1979. Kim et al1991. Altman et al1992). Motorized synovial
abraders are used to smooth the surface of the more seriously
damaged cartilage. The residual cartilage then presents a
more uniform non-clefted surface, which may be more
durable and incites less synovitis than the large surface area
presented by multiple strands of fibrillated cartilage. The
concept seems simple. but there is a paucity of evidence
documenting any discrete benefit. either in reducing synovial
levelsof fragmentedproteoglycan and collagen or in abrogating
the symptoms of synovitis. Despite this, the technique has
empirical benefits and has been used in equine arthroscopy
for trimming extensive areas of partial-thickness fibrillated
cartilage. The most frequent site for application in the horse is
the stifle (Fig. 17.3). TrocWear ridge OCD in mature horses
(>3 years) is often accompanied by fibrillation of the sur-
rounding cartilage and the patella. Chondroplasty has been
used to trim these areas to smooth articular cartilage and
seems to reduce the incidence of persistent effusion when
these horses re-enter competition. No controlled clinical or
experimental data support chondroplasty in the horse. so its
use remains controversial. It may be preferable to doing
nothing. but the resection depth should only involve the
fibrillated surface and not be aggressively pursued down to
the subchondral bone, since the ensuing repair tissue rarely
has the hyaline characteristics of the original deep cartilage
layers that were resected.
Chondroplasty cannot be efficiently performed without
sharp motorized abraders. Disposable cutting heads are
recommended. Attached suction is also helpful in drawing
and holding the cartilage fronds into the shaver blades. A
"whisker" technique is used to avoid penetration of the intact
deeperlayers of cartilage. Benefits in man have beendescribed worked satisfactorily on large flaps in the fetlock, hock and
for months to years after chondroplasty; however. as much as stifle, where undulating OCDcartilage has been salvaged by
6 months symptomatic relief has also been attributed to pinning to th~ underlying bone (Nixon et al 2003a). The
synovial washout using a saline lavage (Hubbf1rd 1996). intervening fi~rosis between cartilage and bony defect should
be removed if the procedure can be performed without
disturbing remaining perimeter attachment. A 1.2 rom K-wire
Cartilage reattachment
is then used to drill through the cartilage flap and into the
Some cartilage flaps in the stifle. hock, and fetlock can be underlying bone (Fig. 17AA). With changes in the degree of
potentially salvagedand reattached (Nixon etal2003a). While flexion of the joint, multiple K-wire perforations can be made,
not common, an OCDcartilage flap that is relatively smooth all perpendicular to the surface. The soft tissues are protected
and has not detached on its entire perimeter can be elevated by insertion of the K-wire through an arthroscopic guide
and the underlying necrotic cartilage and marrow fibrosis cannula. The kit also contains five 40 rom long x 1.3 rom
debrided. The flap can then be replaced and secured with diameter pins, each of which can be cut in half to provide two
polydioxanone (PDS) pins (OrthoSorb, Ethicon-Johnson & pins approximately 20 rom in length. Except in cases with
Johnson) (Fig. 17.4), or PLLA tacks (Chondral darts, Arthrex. extremely deep subchondral defects. these pins adequately
Naples, FL). Importantly, the OCD flap must be worth secure the OCD flap. For deeper lesions, pins can be cut
reattaching, which requires a smooth congruous surface, longer. up to the entire 40 rom pin. After carefully drilling the
minimal fibrillation, and some perimeter continuity. This has K-wire to end 1 rom short of the anticipated pin length. the
PDS pin is inserted down the cannula and pushed into place
using the obturator (seeFig. 17.4B). Approximately 1 mm of
pin is left protruding from the surface of the cartilage so it can
be flattened level with the articular surface to make a securing
head to the PDS pin. Any excess pin can be removed with
a biopsy punch rongeur or other severing rongeur (see
Fig. 17AC). Multiple pins are inserted approximately 10 mm
apart so that the entire cartilage flap is securely reattached to
the subchondral bone. As few as 2 and as many as 10 PDS
pins have been inserted (Nixon et al 2003a).
Use of the multi-shot chondral dart system (Arthrex,
Naples, FL) for simultaneous multiple anchoring with bidi-
rectional barbed pins is being explored, and appears a satis-
factory alternative to PDS pins. Rapid resolution of effusion
and subchondral bone lysis on radiographs is a consistent
feature (Fig. 17.5), and reformation of the subchondral
contour was complete in all but 2 of 16 joints in 12 horses
(Nixon et aI2003a). This compares favorably to debridement
of OCDlesions,which generallyleavesa depressedsubchondral
bone plate at the lesion site. Eleven of the 12 horses were not

lame, and it appearedthat reattachment was a valuable
option to salvage the dissectedhyaline cartilage flap in
selectedcases.
Forage
Forageor subchondralbonedrilling has beenexploredin the
horse.Therationaleis to perforatethe subchondralboneand
allow entry of subchondralmarrow elements.vasculature.
and growth factors to the defect,which then contribute to
cartilage repair. It is simple and inexpensive. However, in a
controlled study using arthrotomy approaches, it did not
provide superior healing in defects on the equine third carpal
bone (Vachon et aI1986). Similarly, it did not benefit healing
of partial-thickness cartilage defects in the same third carpal
bone model (Shamis et al1989).
Subchondral bone forage or drilling was introduced into
human arthroscopy in the 1960s (Pridie 1959, InsalI1974).
Since then it has been frequently used to improve cartilage
quality following chondromalacia of the patella (Childers &
Ellwood 1979). Historically, the most frequent site for
subchondral bone forage in the horse was the sclerotic rim
associatedwith subchondral cystic lesions (Mcllwraith 1983,
White etal1988). The use of this technique has diminished, as
reports of cyst enlargement subsequent to forage have been
published (Howard et al 1995), and surgeons have found
difficulty in arthroscopically making drill holes that are
perpendicular to a defect. The technique has largely been
replaced by microfracture.
Microfrocture
The use of microfracture. or micropick as it has been referred
to in equine arthroscopy, has many of the advantages
associated with forage, including focal penetration of the
dense subchondral plate to expose defects to the benefits of
cellular and growth factor influx, as well as improving
anchorage of the new tissue to the underlying subchondral
bone and to some extent the surrounding cartilage (Rodrigo
et al 1994, Frisbie et al 1999, Breinan et al 2000). The
simplicity of microfracture comes from the use of a tapered
awl (Unvatec, Largo, FL; Arthrex, Naples, FL), instead of a
parallel-sided twist drill. Using the awl abrogates the need for
powered instrumentation to perforate the subchondral bone.
giving additional control over the placement of the
perforation, and also allowing the formation of a tapered entry
to the subchondral marrow spaces.The microfracture awls
should penetratethe subchondral bone deepenough (2-4 mm)
to provide ready access to the marrow spaces, thereby
maximizing cellular and anabolic growth factor delivery
(Fig. 17.6). The microfracture awl also tends to make a crater
in the subchondral bone. which may playa role in better
attachment of, the cartilage repair tissue (Lee et al 2000).
Microfracture, 'holes are generally placed 3-5 mm apart and
cover the entire debrided area in a cartilage lesion (see
Fig. 17.6). It is also important to microfracture the sub-
chondral bone on the perimeter of the cartilage lesion to
encourage new tissue at the junction of repair tissue and
residual cartilage. The technique has become popular in
human arthroscopy (Rodrigo et a11994, Blevins et a11998,
Steadman et al2001. 2002), and is now frequently compared
to chondrocyte transplantation as one of the two most
frequently employed techniques to improve cartilage healing.
One experimental study in the horse documented improve-
ments in the quantity of tissue and the hyaline quality of the
cartilage (collagen type n content) at 4 and 12 months after
micro fracture of full-thickness cartilage defects (Frisbie et al
1999). Improvements in early gene expression of cartilage
specificmarkers were evident within 8 weeks of microfracture
(Frisbie et aI2003).
The technique clearly has advantages over forage and
transplantation methods, including ease of application using
arthroscopy, use of a simple hand tool. the relative economies
of the equipment required, the simplicity and minimal
planning required to use the technique. and the apparent
increase in cartilage repair tissue that deve~ps after the
procedure. ...
Results of microfracture in equine clinical syndromes
have not been published. However, individual experiences
with micro fracture have included focal and severe cartilage
defects on the carpal bones, femoral condyles and trochlear
ridges. proximal sesamoidsand distal metacarpal/metatarsal
condyles, and the trochlear ridges of the talus (seeFig. 17.6).
Anecdotal evidence of improved cartilage healing has
been derived from the use of microfracture at each of these
sites. Further case numbers and comparative studies are
required before a definitive recommendation can be made
for its use. Of the available local manipulative procedures
that follow debridement of cartilage lesions, microfracture
appears to have the most benefit with the least cost and
complexity.
Abrasion arthroplasty
Abrasion arthroplasty uses a motorized burr to resect a
uniform layer of residual cartilage and eburnated subchondral
bone Gohnson 1986. 2001). Eburnated bone is often charac-
terized by a surface layer of non-viable bone Gohnson2001).
which forms a barrier to effective cartilage repair. Abrasion
arthroplasty. a.it was originally conceived Gohnson 1986).
removes this superficial layer of dead subchondral plate.
thereby exposing vascular tufts from the deeper marrow
spaces. In addition. it provides access to a viable pool of
marrow-derived stem cells that could participate in cartilage
repair. Use of motorized equipment is necessary due to the
sclerosis associated with subchondral bone eburnation. The
result is a coalescing group of fibrocartilaginous tissue tufts
Gohnson 1986. 1991. Menche et al1996). Although. it has
been used to a limited extent. particularly for areas of
eburnation of the trochlear ridges of the talus. widespread
experience with this technique in horses is lacking. and there
are no published reports documenting other possible sites for
abrasion arthroplasty. The utility of arthroplasty has been
reduced by the introduction of marrow stimulating tech-
niques such as micro fracture. which perforate the sub-
chondral bone plate at multiple sites over eburnated or for focal cartilage injury in the knee has been reported
debridedcartilageregionsand allow reformationof cartilage (Niedermann et a1198S, O'DriscoII1998, 1999). On balance,
repair tissue while still maintaining the subchondralplate the disadvantage of an arthrotomy for insertion of periosteal
contour. grafts in man is not outweighed by the potential benefits in
hyaline cartilage. Additionally, in an equine study, periosteal
transplants to the stifle occasionally induced vascularization
Spong;al;zat;on
of the healing cartilage, which led to exuberant tissue and
Spongialization can be considered an extension of abrasion mineralization in the repair, both of which were detrimental
arthroplasty. since extensive areas of the subchondral bone to the formation of durable hyaline cartilage (Nixon et al
plate and overlying cartilage are removed (Ficat et aI1979). 2002, unpublished data).
Resection extends through the subchondral bone. essentially In other equine studies, autogenous periosteal transfer to
exposing the defect to the marrow spaces that then parti- the radial carpal bone provided no additional advantage to
cipate in cartilage repair. Given the benefitsto maintaining sub- defects healing spontaneously (Vachon et a11991a, 1991b).
chondral bone architecture. we do not consider there is any Moreover, there was a tendency for synovial pannus and
indication for the use of spongialization in equine arthroscopy. adhesions to overwhelm the healing defects (Vachon et al
1991b). In other research studies, the application of auto-
genous periosteal grafts as a mechanism to secure autogenous
Transplantation procedures chondrocyte grafts in full-thickness cartilage defectsprovided
better cartilage repair than periosteal graft alone (Breinan et
In mature horses most debriding and marrow stimulatory
al 1997), and is probably the only widespread clinical
techniques result in fibrocartilage formation with modestbio-
application of periosteal grafts in cartilage repair in man
mechanical capabilities. The use of supplemental free cells.
(Brittberg et al 1994). In horses, there are no reports of
various vehicles containing cells. or entire tissues such as
successful clinical application of periosteal grafting in
periosteum or cartilage grafts have been advocatedto improve
the modest impact that these local manipulative procedures cartilage repair.
have on both the quality and quantity of cartilage repair
tissue. Transplantation procedures can be classifiedaccording Perichondrium
to the origin of transplanted tissue: (1) periosteal trans-
Severalresearchgroups have studied the use of perichondrium
plantation. (2) perichondrial transplantation. (3) autogenous
rather than periosteum for improved cartilage repair (Ohlsen
cartilage (articular. sternal. or auricular) transplantation.
& Widenfalk 1983. Kwan et al 1989. Coutts et al 1992.
(4) osteochondral transplantation. (5) chondrocyte trans-
Bruns eta11992. Ritsilaet a11994. Bouwmeester etaI2002).
plantation. and (6) pluripotent stem cell transplantation.
While these tissues behave similarly to periosteum. various
There is a considerable body of literature that describesthe
investigators considered they were more programmed toward
potential advantages derived from transplantation of whole
a chondrocyte lineage. and should hold special benefits for
tissues. The disadvantages with these methods and the tissues
cartilage repair. In a study comparing free grafts of perichon-
they transfer predominantly hinges on the limited application
drium to periosteumimplanted in equinejoints. perichondrium
by arthroscopic means. Arthrotomy is required for insertion
did not produce significant cartilage (Vachon et al 1989).
of periosteum. perichondrium. intact cartilage. and osteo-
Perichondrial grafting holds few benefits over other techniques.
chondral grafts. Similarly. tissue-engineeredcartilage analoges
and is rarely mentioned in clinical applications in horses or
such as chondrocytes cultured on collagen. polygiycolic acid
man (Ritsila et a11994. Bouwmeester et aI2002).
(PGA). or PGA/polylactic acid (PGA/PLA). or newer synthetic
materials such as hyaluronan membranes. are also difficult or
impossible to implant arthroscopically. This serious practical OsteochondralGrafts
limitation has tempered interest in using thesrimplants. ~
The use of o~teochondral autograft and allograft has been
through several periods of clinical interest. Originally,
Periosteum autogenous osteochondral shell grafts were favored because
Autogenous periosteal transplants have improved the of the secure attachment to the recipient bed afforded by the
quality of repair tissue in various animal models (Rubak bony portion of the graft. The overlying cartilage was well
1982, O'Driscoll & Salter 1984, 1986, Hulse et al 1986, attached at its base since it was harvested as an osteo-
O'Driscoll et a11986, Moran et aI1992). Moreover, high- chondral composite, and the graft also had minimal gapping
quality hyaline cartilage was produced when transplantation at the cartilage perimeter. However. research and clinical
was combined with the use of continuous passive motion in evaluations were tempered by the limited availability of auto-
rabbits. Subsequent application in man has been limited to genous osteochondral graft and the donor site morbidity. Few
carefully selected cases over the last 10 years (Niedermann et al sites in man or animals can sacrifice considerable areas of a
1985, O'Driscoll 1999). However, the surgery is extensive joint for donation as osteochondral grafts. The use of allo-
and includes harvest of tibial periosteum and arthrotomy for graft osteochondral shell grafts was designed to overcome
suture attachment of the periosteal flaps to irregular-shaped these limitations. Several investigators have found utility in
lesions in the human knee. Application of periosteal grafts the use of fresh osteochondral hemiarthroplasty shell allografts
 created widespread instability and joint pain (Meyers et al
--
articular cartilage biopsies are harvested arthroscopically
1989, Ghazavi et al1997, Chu et a11999. Aubin et a12001. from minimally weightbearing regions of the injured knee,
Gross et al 2002). However, it should be stressed that these
propagated ex vivo in cell culture, and later implanted under
are not dowels but entire femoral condyle shell grafts. an autogenous periosteal tissue patch (Brittberg et al1994).
The immunogenicity with allografts, particularly the
The indications for the procedure include previously failed
osseous component is also of concern (Elves & Zervas 1974,
surgery, large lesions, and minimal secondary osteoarthriti~
Strong et al1996). (Brittberg et al 2001, King et al 2002). These indications
More recently. mosaicplasty. using autogenous osteochondral include extensive focal defects and osteochondritis dissecans
dowel grafts. has become popular (Hangody et al1997. 1998.
(Robert & Bahuaud 1999, Peterson et al 2000,2002). The
2001a, Jakob et al 2002). This technique has recently been delivery of cells requires an arthrotomy, and the harvest and
arthroscopically performed in the human knee. and involves suture attachment of a periosteal patch is tedious and tech-
harvest of osteochondral dowels from less weightbearing
nically demanding. Both factors complicate the surgery as
regions of the same joint, and insertion of these dowels to well as the postoperative course. There are still several un-
reconstruct a relatively congruous joint surface (Hangody et al resolved questions, including the ideal number of chondro-
1998. 2001a). Considerable research data support the clinical cytes to transplant and most particularly the role of the
application of osteochondral dowel grafting. The technique periosteum in the technique. The periosteum has been shown
has been used successfully in the horse (Bodo et al 2000).
by others to contribute to cartilage healing (O'Driscoll1999).
Other investigations of autogenous and allograft osteochondral
One study compared chondrocyte transplantation secured
dowel transfer in horses have yielded mixed results (Hurtig with a periosteal patch to defects treated with periosteal
1988. Hurtig et al2001). The technical difficulties associated patches without chondrocyte implantation, and found no
with careful graft harvesting and the precision and crafting
difference between the healing tissue after a year (Breinan
needed for heterotopic graft insertion in the recipient bed have et al19 97). Clinical outcome in multiple studies in man have
detracted from wider clinical application (Pearce et aI2001).
reported good to excellent results, with 80-90% return to
Additionally. empty spaces that naturally form between pain-free function for femoral condyle defects and slightly
inserted osteochondral dowels heal poorly and allow synovial lower successrates for lesions on the patella (Minas 1998,
fluid entry to the bone tunnels of adjacent dowels.
2001, Richardson Evans et al1999, Minas & Peterson 1999,
Several instrument systems are available for the harvest Peterson etal2000, 2002. Minas & Chiu 2000, Brittberg et al
and implantation of osteochondral dowels in man and animals.
2001, Lindahl et al 2001). Long-term studies are becoming
These include the mosaicplasty system (Acufex -Smith & available for patients treated with autogenous chondrocyte
Nephew. Andover. MA). the osteochondral autograft transfer repair, one of which shows that 84% of patients had a
system (OATS -Arthrex. Naples. FL), and the consistent osteo- successful outcome from 2 to 9 years after the procedure
chondral repair system (COR -Innovasive), that have been
(Richardson et al1999, Peterson et al2000, 2002, Brittberg
marketed for use in man. Frequently. "mosaicplasty" is used et al2001, Minas 2001).
as an umbrella term for all of these techniques, despite its In horses,chondrocyte implantation techniques have been
trademark use for the Acufex -Smith & Nephew instrumen:' examined in a variety of matrix carrier vehicles (Hendrickson
tation. The benefits of autogenous osteochondral dowel transfer et al1994, Sams & Nixon 1995, Fortier et aI2002a). Initial
include immediate weightbearing capabilities. relatively good research trials indicated the significant effect of chondrocyte
integration of the bony portion of the dowel. and the long-
implantation using a fibrin vehicle (Hendrickson et aI1994).
term data available from clinical trials (Hangody et al2001b,
Subsequent methods to enhance the matrix vehicle, using
Mendicino et al 2001. Jakob et al 2002). In horses. the
tissue-engineering approaches with collagen matrix scaffolds,
arthroscopic application of osteochondral dowel transfer is did not provide a satisfactory improvement in repair (Sams &
cumbersome. harvest of the osteochondral plugs can be Nixon 1995, Sams et al 1995). The addition of anabolic
challenging due to the optical aberrations associated with growth factors was initiated to bolster the matrix elaborated
arthroscopic viewing, and insertion of the osteochondral
by transplanted chondrocytes. Initial studies used vehicles
dowels can be technically demanding. Until the technical
containing growth factors, but no cells, with the expectation
difficulties associated with dowel insertion can be further that a repositofH of a growth factor would enhance repair
minimized. widespread use in horses is likely i~ be limited. tissue from pluclpotent cells arising from the subchondral bed
Experimental work suggests mosaicplasty techniques also (Nixon et aI1999). Insulin-like growth factor-1 (IGF-1) has
become more difficult in mature horses (Bodo et al 2001). been extensivelyevaluated for its effect on chondrocyte activity
Despite this. a case report of mosaicplasty for repair of a (Luyten et al1988, Nixon et al 1998, Fortier et al 1999),
subchondral bone cyst of the medial femoral condyle in a
although other growth factors have also been found to
horse has been published (Bodo et aI2000).
stimulate proliferation, migration, matrix synthesis, and dif-
ferentiation. Many of these growth factors, including basic
fibroblast growth factor,transforming growth factor-g (TGF-g),
Chondrocyte transplantation
and epidermal growth factor, induce beneficial effects to
Autogenous chondrocyte implantation is one of the few FDA- cartilage healing (Mankin et al1991, van den Berg 1995,
approved tissue engineering techniques to treat articular Trippel et al1996, O'Connor et al2000). Local treatment of
 ubiquitous matrix that further isolates them from the host
immune response. Comparison of studies in the horse clearly
documented the benefits of allograft cells compared to defects
without cells (Hendrickson et a11994). Allograft chondrocyte
persistence has also been assessedin horses, using a marker
of male cells (the SRY gene) to track the survival of male
allograft transplants in female recipients (Ostrander et al
2001, Hidaka et al 2003). This polymerase chain reaction-
based assayindicated persistence of equine allograft cells at
8 months, ranging from 0 to 28% (Hidaka et al 2003). Most
assaysof the persistence of allograft cells in more vascularized
locations indicate rapid cell loss Oackson & Simon 2002).
Despite cell loss, enhanced repair can be induced, either by
the initial impact of the allograft cells, or the later enhanced
elaboration of paracrine growth factors and matrix that may
improve the quality of cartilage repair. Clearly, however, an
autogenous cell would be an advantage. Recent studies in the
horse, using autogenous chondrocytes seededonto a collagen
membrane and inserted via arthrotomy, have yielded en-
couraging results (Frisbie 2003, unpublished data). Use of
bone marrow-derived pluripotent mesenchymal stem cells
(MSCS)is one solution to the limited availability of predeter-
mined chondrocytes.

Pluripotent mesenchymalstem cell transplantation

The use of a pluripotent cell to enhance cartilage repair has
been investigated for severalyears. Initial studies in the rabbit
indicated MSCscould enhance cartilage repair (Wakitani et al
1994, Grande et al 1995, Johnstone & Yoo 1999, 1m et al
chondral or osteochondral defects with growth factors has
2001). Follow-up work in small animals demonstrated that
the potential to stimulate a more durable and hyaline-like
MSCs can be partially induced down chondrocyte lineages
repair, provided the defect penetrates to the level of the sub-
(Butnariu-Ephrat et aI1996). Studies in the horse indicate
chondral bone, Despite the interest in many different growth
that, bone marrow-derived MSCs can be harvested an4i
factors, IGF-1 has the most potential to provide practical
cultured for sufficient time in defined media to differentiate
results in cartilage repair (described in more detail later).
toward a chondrocyte lineage (Fortier et a11998f. However,
Studies in the horse indicate that IGF-1 combined with
in-vivo studies in the horse report little advantage after
chondrocytes results in superior cartilage repair compared
8 months in a femoral trochlear ridge cartilage defect model
with other cell-based methods for repair (Fortier et aI2002a).
(Wilke et al2001). Moreover,bone marrow-derived stem cells
Practical application of chondrocyte and growth factor
from horses are tedious to culture, and accumulation of
transplantation techniques is being pursued in the horse. An
sufficient numbers to graft large articular defects can take up
integral part of chondrocyte implantation is the development
to a month. Additionally, the yield from mature horses
of a banked source of allograft chondrocytes. Use of allograft
(representing the majority of a clinic caseload) is reduced
cells raises questions concerning the immune response.
over yields fr~m immature animals, making the accumu-
Several studies document an immune reSponse to the
lation of sufficient cells for grafting age-dependent but
chondrocyte cell wall, which is both predictable and aggressive
generally very slow (Fortier et al 1998, Huibregtse et al
(Moskalewski et a11966, Elves 1974, Gertzbein et a11977,
2000). Overcoming these limitations will require further
Kawabe & Yoshinao 1991, Lance et al 1993). However,
research before this source of cells becomes a practical
chondrocytes implanted in vehicles,such as fibrin, hyaluronan,
replacement method for fully differentiated chondrocytes.
or synthetic composites. are immediately protected from the
immune response (Heyner 1969). Additionally, chondrocytes
Growth factors
are somewhat unique in that they are implanted in a
relatively poorly vascularized region. Synovial fluid bathes Several naturally occurring polypeptide growth factors play
the surface of cartilage repair areas,and the only direct access an important role in cartilage homeostasis.The differentiating
to vascularity comes through the defect base. To this end, and matrix anabolic promoting activity of IGF-1 and TGF-B
defects that do not penetrate the subchondral bone plate, and are particularly important in counteracting the degradatory
are implanted with chondrocytes in an attachment vehicle, and catabolic activities of cytokines, serine proteases..and
have some immediate protection against the immune neutral metalloproteases (Fortier et al 1997. Nixon et al
cascade. Furthermore. chondrocytes rapidly elaborate a 1998). The manipulation of this balance in diseaseconditions
such as arthritis and acute cartilage injury may be possible by
exogenous administration of IGF-l and TGF-B(Tyler et al1989.
Nixonetall998. 1999, Fortier et alI999). In-vitro chondro-
cyte monolayer and cartilage explant culture studies show
IGF-l and TGF-B generally stimulate matrix elaboration and
mitogenic effects (Fortier et a11997, Frisbie & Nixon 1997.
Nixon et aI1998). Three-dimensional culture assessmentof
the impact of these same growth factors on equine chondro-
cyte metabolism. using fibrin gels to provide a stable suspension
culture resembling cartilage matrix (Fortier et aI1999), also
confirmed enhanced proteoglycan and collagen synthesis
and resulted from exposure to IGF-l concentrations of
50-100 ng/ml and TGF-B levels of 5-10 ng/ml (Fortier et al
1997. Fortier et alI999). Further studies in the horse have
largely focused on IGF-l, since TGF-B was toxic at moderate
concentrations and IGF-I was stimulatory to chondrocyte
metabolism. even when present in excess concentrations
(Fortier et al2002b). In-vivo investigations of articular repair
following TGF-B administration also showed synovitis and
osteophyte development. both of which are alarming features
of TGF-Buse in these animal studies (van den Berg et al199 3.
van Beuningen et a11994. van den Berg 1995). Given these
results. IGF-l was selected as a suitable growth factor for in-
vivo studies in the horse. Slow-releasedelivery of IGF-l within
the cartilage defect. to facilitate matrix production in local
and transplanted chondrocytes, provides a mechanism for
enhanced cartilage repair (Nixon et alI999). Elution studies
using IGF-l-laden equine fibrin indicated that stimulatory
levels of IGF-l (greater than 50 ng/ml) remained for up to
3 weeks following an initial loading dose of 25 ~ (Foley &
Nixon 1997). In-vivo evaluation of a fibrin vehicle loaded
with 2 5 ~g of IGF-l and polymerized in situ in cartilage lesionS
in the femoropatellar joints, showed improved cell population
with a more cartilage-like architecture after 6 months (Nixon
et alI999). However. markers of hyaline cartilage such as
type II collagen had increased to only 47%. far short of the
90% expected in normal articular cartilage. Nevertheless.
simple fibrin vehicle grafts used in control stifles did not
significantly enhance healing. with mean type II collagen Preparation of autogenous fibrinogen. The horse's
content of 39%, similar to the healing in empty full-thickness jugular vein area is aseptically prepared for whole blood
defects (Hendrickson et alI994). Other studies using injected collection. A commercial 500 ml blood pack containing acid
combinations of IGF-l and pentosan polysulfate show citrate dextrose (Travenol) is used for whole blood harvest.
attenuation of the symptoms of synovitis in osteoarthritis The blood cell~are allowed to settle in a refrigerator for
models in dogs (Rogachefsky et alI993). In geiIeral, IGF-l several hours before titrating off the plasma. The cells are
seems to have better application in combination with then discarded and the plasma aliquoted to 50 ml centrifuge
chondrocyte grafts. where more complete cartilage repair tubes prior to freezing at -80°C overnight. The plasma is then
develops (Fortier et al 2002a). Evaluation of stifle lesions 8 allowed to slowly thaw in a refrigerator for 30-36 hours, and
months following implantation of a mixture of chondrocytes the fibrinogen-rich cryoprecipitate collected by centrifugation
and 25 ~ of IGF-I. showed considerably improved joint at 3000 g at O°Cin a swinging bucket centrifuge. Approxi-
repair, with 58% type II collagen and better cartilage mately 0.5-0.75 ml of cryoprecipitate fibrinogen can be
integration at the defect edges (Fortier et al 2002a). collected from each 50 ml tube of plasma (Fig. 17.8A). As a
precaution against contamination at collection or handling,
a bacterial culture is submitted prior to using the product for
Clinical applications of chondrocyte
cell grafting. Fibrinogen can be stored refrigerated for several
transplantation days, or frozen for later use.
Clinical resurfacing trials in horses have used a regimen of Chondrocyte banking. Chondrocyte isolation requires
autogenous fibrin laden with 50 IJ.gof IGF-l and 30 million the services of a laboratory equipped for cell culture. Allo-
chondrocytes per ml of fibrin. graft chondrocytes are harvested from foals destroyed for
noninfectious disease, most frequently irreparable fractures
or severecongenital deformities. Cartilage slices are harvested
aseptically from the stifle, shoulder, or elbow, and the cells
isolated from their matrix by overnight collagenase digestion
(Nixon et alI992). The cells are then counted and dimethyl
sulfoxide (DMSO)added to the culture medium prior to freezing
and storage in liquid nitrogen. When the cells are required,
48 hours lead time is neededto thaw the cells and then briefly
culture to allow removal of any dead cells, before collection
for use in surgery.
Clinical application. At the time of surgery the chondro-
cytes are mixed with fibrinogen and stored at 4°C. IGF-l
(50 flg) is added to 250 or 500 units of activated thrombin, to
provide a two-component system for immediate injection.
Thrombin is obtained from Sigma-Aldrich Corporation
(Fig. 17.8B), and the lyophilized powder reconstituted with
calcium chloride (40 mmol), and sterilized by filtration
through a 0.2 ~ millipore syringe filter. At surgery, the poly-
merization process develops immediately upon injection of
the two components into the articular defect (Fig. 17.8C).
Arthroscopic lesion debridement is followed by gas insuffiation
for the few minutes required for fibrin injection. This allows
drying of the defect using Q-tips or surgical sponges applied
to the end of a hemostat. Drying of the subchondral bed and
surrounding intact cartilage allows better application of the
naturally adhesiveproperties of fibrin. The polymerizing liquid
nature of fibrin allows contouring of the cell transplant to the
irregularities of many joint surfaces (Fig. 17.9).
Clinical application of chondrocyte grafting in horses has
included traumatic cartilage lesions of the third carpal bone,
fetlock metacari'al condylar fractures,and OCDor subchondral
cystic lesions qF the fetlock (14 horses) and stifle (43 horses).
Chondrocyte augmentation following third carpal bone slab
fracture repair and shoulder OCD debridement have resulted
in few horses capable of returning to athletic work. However,
results for stifle OCD and subchondral cyst grafting of the
stifle and fetlock have been generally good. Complete radio-
graphic filling has occurred in more than half of the stifle
subchondral cysts radiographed at or beyond 12 months post-
operatively (Fig. 17.10), and 73% of stifle subchondral cysts,
including failures of previous simple debridement alone, have
been in athletic work for a minimum of 2 years. Similarly,
fetlock subchondral cYstshave been treated using arthroscopic
extirpation and grafting (Fig. 17.11). Radiographic filling of
the fetlock cysts can be slow, and residual deeperlytic regions
can remain despite athletic performance (Fig. 17.12). All but
two horses more than 12 months postoperative have entered
athletic work. Both of these caseshad evidence of remodeling
due to osteoarthritis at the time of grafting.
Future directions
Numerous tissue-engineered cartilage composites have been
developed for cartilage repair during the past 10 years, using
the concept of artificial implantable hyaline-like cartilage.
None of these techniques have entered clinical practice. The
predominant reason for failure with preformed cartilage
analoges is the lack of integration of the cartilage-like
material to the subchondral bone and, most particularly, the
surrounding cartilage. Most composites that begin to take on
the biomechanical characteristics of cartilage before integ-
ration will fail. For this reason, soft, self-polymerizing and
self-contouring grafts that are placed as liquids or soft
composites and attach to the surrounding tissues are more
likely to succeed.Thesegrafts accumulate intrinsic mechanical
competency as the cells synthesize their own matrix, which
allows a better stress transition to adjacent cartilage. Equine
studies with autogenous chondrocytes cultured on collagen
matrix allow implantation of a soft composite, and the results
have beenencouraging. Allograft chondrocytes can potentially
offer younger, more metabolically active cells, which have
better replicative capacity. However, as methods to induce
chondrogenesisin MSCsbecomemore efficient, use of an auto-
genous cell of bone marrow origin that has been extensively
programmed using a combination of growth factor peptide
and gene modulations may provide a differentiated chondro-
cyte (Nixon et al 2000). Moreover, the addition of anabolic
growth factors to the cell mixture, including IGF-l and several
from the transforming growth factor superfamily, particularly
BMP7 and/or BMP2, will promote long-term matrix synthesis
and chondrocyte persistence (Nixon et al 2000). Studies of
IGF-I and BMP7 gene enhanced chondrocyte function in
equine models suggest both stimulate extraordinary early
healing, be~nd that seen in unstimulated chondrocyte
implanted cartilage defects (Goodrich et al2002, Hidaka et al
2003). Long-term provision of an anabolic growth factor
(IGF-I) and an anticatabolic factor (1L-1 receptor antagonist)
using gene therapy has shown encouraging results, at least in
vitro (Nixon et al 2004b).

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A arthroscopy bone degeneration 94
advantages of 3 bone density in third carpal bone 104
abaxial plica, endoscopic view 421 bone scintigraphy. temporomandibular
complications in man 447-8
abrasion arthroplasty 461-2 joint (TMJ) 441
development 1-3
accessory carpal bone (ACB) 101, 385 bulb pump 11-12
early applications 1-3
accessory ligament of superficial digital burrs. round or oval 22
evolution 1-3
flexor, desmotomy of 386 bursae
general technique 31-46
acetabulum, chip fracture removal 345 acquired 409
historical review 1-3
adhesion resection 398-400 calcaneal 409-13
human 15
adhesions 404 clinical application 421-4
human knee 34
amikacin 436 intraoperative problems 448-51 communication between 410
amikacin sulfate 435 joint surgery 2 congenital 409
aminoglycosides 436 learning technique 45 contamination and infection 419
anatomy 36, 48 dissection 410
overuse and abuse 3
anconeal process, fragmentation 332 distention 410
overview 1-3
anesthesia, recovery of 64 positioning problems 453-4 endoscopic anatomy 411-12.420
angled rongeurs 321 seealso diagnostic arthroscopy; surgical endoscopic view with arthroscope close
annular ligament arthroscopy; and under specific to entry portal and angled
severing 377 proximally 412
applications
tenoscopically assisted division 376 endoscopic view at apex of tuber 412
arthrotomy 1
antebrachiocarpaljoint 36, 47,59,88,99, articular cartilage 72 intertubercular (bicipital) 414-19
108 degeneration 94 lateral endoscopic approach 411
arthroscopic examination 49-56 medial approach 411
erosion 152-3
most lateral portion 56 osteolytic lesions of calcaneal tuber
evaluation 41-3
antebrochiocarpal joint, with recurrent 412-13
iatrogenic damage 448. 450
hemarthrosis 40 lesions on medial condyle of femur 254 podotrochlear (navicular) 419-25
antimicrobial drug therapy 435 proximal endoscopic view 411 -
separation 153
postoperative care 436-7 bursoscopy 409-26
articular fractures 2-3
prophylactic 448, 452 clinical application 412-13.417-\9
articular surface
Arthrex Continuous wave AR 6400S pump general technique 409
damage 93
13 reconstruction 124 overview 409
Arthrex pump assembly 12
autoclavable cameras 10
arthritis 345, 436
autoclaving 25
arthrofibrosis of the knee 39 autogenous fibrinogen, preparation 465 C
arthroscope 7-9 avascular synovium 37
angled lense 7-8 calcaneus
axial osteitis of proximal sesamoid bones
available types 8 t1exedplantaroproximal-plantarodistal
186 Jo
conical obturator 9 V '! oblique radiograph 413
,
direct view 8 intrabursal fracture 433
fields of view 8
B traumatic fragmentation 413
insertion 32-4, 59 Bacteroidesspp. 436 camera coupler 11
magnifying 3 7 basal sesamoid fragment 184 capillary network 37
minor trauma to distal window 451 basket forceps 18. 20 capitular fovea of proximal radius 334
positioning 32-4, 90 Baxter-Edwards system 22 capsulitis, postoperative 453
protective stainless steelsleeve or biceps brachii carpal canal 382
cannula 8 endoscopic view 417 instrument insertion level 393
range of sizes 7-9 indentation produced by 311 tenoscopically assistedrelease 392
rotating 34, 48, 54-6 bicipital bursa use of term 380
self-locking sleeve8 endoscopy415-16 carpal chip fractures 94, 99
small diameter 7 infection 430 carpal chip fragments
arthroscopic portals 4 proximal recess416 distribution 61
arthroscopic probes 16 blade types 22-3 repair with small fragement screws 124
arthroscopic surgery seesurgical blunt obturator 33 specific sites 64-93
arthroscopy blunt probe 16 carpalchipremoval43,61-4
carpal flexor tendon sheath. use of term cold bandaging 28-9 desmotomy of accessoryligament of
380 collagen sponges435 superficial digital flexor 386
carpal fragmentation. basic protocol 62 comminution 110-11, 113, 118 dewdrop lesions at distal aspect of medial
carpal joint 36.38.47-127 common digital extensor tendon 133 trochlear ridge of talus 292
anatomy 47 computer-based simulations 45 diagnostic arthroscopy
arthroscopic view 34 condylar fracture adjunctive diagnostic technique 35-9
diagnostic arthroscopy 47-58 AO/ASIF reduction forceps 194 carpal joint 47-58
skin incision 32 arthroscopic monitoring 191 femoropatellar joint 197-9
carpal lesions 147 conical obturator 32-3 femorotibial joint 199-223
carpal retinaculum 3 consistent osteochondral repair system limitations 36
carpalsheath (COR)463 pitfalls 36
craniomedial depths 382 contamination problems and complications 447-54
cross-section anatomy 381-2 endoscopic evaluation and surgery 428 use of probe 35
diagnostic arthroscopy 380-91 management 427-39 usefulness of 36
lateral approach 382 postoperative care 436-7 seealso specific applications
postoperative care 391-3 postoperative monitoring 437 digital camera 23-4
proximolateral 392 results and prognosis 437 digital extensor tendon sheath, multiple
standard entry point 383 coxofemoral joint seehip joint masses406
surgical anatomy 380 cranial cruciate ligament 220 digital flexor tendon sheath
tenoscopic view 384-5 cranial cul-de-sac 321-2 adhesions between flexor tendons and
tenoscopy 379-93 cranial ligament 219 dorsomedial aspect of tendon sheath
use of term 379-80 of lateral meniscus, avulsion fracture 375
carpal slab fractures 3. 109-22. 124 264 anatomic structures 366
current status of surgery 109-10 cruciate injuries 2, 256 composite tenoscopic view 370, 372
carpal tunnel syndrome 388-91 cubital joint see elbow joint diagnostic tenoscopy 368-71
cartilage curettage of undermined and separated distention of 454
change 41 cartilage 63 infection 429
damage 146. 442 curettes 20 medial instrument portal for resector
debridement 456-8 cutting forceps 18 entry 371
degeneration and immobilization 437 cutting heads or blades for motorized units pathogenesis 365
disruption III 22 penetrating wound 434
erosion 342 cutting instruments 18-20 postoperative care 376-7
irregularity 343 types available 19 results and prognosis 3 77-9
lesions 340 cystic lesions of medial condyle of femur reversed arthroscope entry 373
reattachment 458-60 246 standard tenoscopic approach 369
response to injury 455 structures 367-8
shavings 45 surgical anatomy 365
seealso articular cartilage
D tenoscopy 365-79
cartilage repair 3. 455-72 debridement44-5.62. 71-2. 83-4. 86. ultrasound image 374
future directions 467 88,106.108. Ill. 118. 142. 150. seealso deep digital flexor tendon sheath
manipulative procedures for 456-62 153.161-4.184.188.287.334. digital image capture and storage devices
methods 455-67 344-6.429-32 24-5
caudal cruciate ligament 217 after chipfractureremoval94-6 digital video capture 9-10
caudal medial femoral condyle 221 cartilage456-8 discotemporal articulation under gas
caudal medial meniscus 221 conservativeapproach96 distention 443-4
caudal pouches. arthroscopic surgery 264 foreignmaterial430 disposableblades 22
ceftiofur sodium 435-6 !)umeralhead320 ~ distal articular surface of radius 55, 57
'-osteochondritisdissecans(OCD)33~ ..
central trochlear groove of femur 233 distal digital flexor tendon sheath,
cephalosporin 436 subchondralcystic lesion164-7, 251 endoscopic view 420
chip fractures 60 suspensorydefectwith motorized distal epiphysis of radius 56
chondrocyte resector176 distal intermediate carpal bone 74-6
banking 465-6 suspensoryligamenttags with distal intermediate ridge of tibia,
clinical applications of transplantation motorizedresector175 osteochondritis dissecans (OCD)
465 sustentaculumtali 401 281-6
death 23 using motorizedequipment96 distal interphalangeal joints 2,347-59
grafting. clinical application 466 usingmotorizedresector187 abaxial articular fragments 356-7
transplantation 463-5 deepdigital flexortendon(DDFT)278. coffin joint arthroscopy 348
chondrocyte-IGF-1 grafting of 365-8.371-4.376-80.382.384-8. coffin joint under carbon dioxide gas
subchondral cyst of femoral condyle 395.397-400.404.421 distention 355-6
466 endoscopicappearances of penetrating diagnostic arthroscopy
chondroplasty 458 wounds423 dorsal compartment 351
chondrotoxicity 436 nomenclature393 dorsal pouch 348-9
Cidex-activated dialdehyde solution 26 rupture of bodyof radialhead391 palmar compartment 353
closed coupled device (CCD)chips 10 tearing of dorsalsurface425 palmar/plantar pouch 349-52
distal interphalangeal joints (Continued)
dorsal approach for joint distention and
palmar location of arthroscope
portal 352
fracture of dorsomedial perimeter of
distal condyle surface of middle
phalanx 357
fragments in palmaro/plantaroproximal
pouch 357-8
free-floating osteochondral fragment 347
general considerations 347
insertion of arthroscope 348-9
palmar/plantar aspect 350
normal arthroscopic anatomy 349
palmaro/plantaroproximal aspect
350-2
osteochondral fragment 348
osteochondritis dissecans (OCD)354
palmar cul-de-sac 358
position of arthroscope 350
palmar/plantar aspect 352
position of hypodermic needle 348
postoperative management 356
preoperative considerations 354-5
problems and complications 356
radiograph of abaxial intra-articular
traumatic avulsion fracture of
middle phalanx condyle 354
results of arthroscopy 356
surgical arthroscopy for treatment of
extensor process fragments 352-6
surgical technique 355
distal lateral radius 85-7
fragmentation 88
distal medial radius 89-90
distal medial trochlear ridge 206
axial aspect 231
distal metacarpus 42
drilled hole 192
fractures of lateral condyle 189
distal navicular bursa. endoscopic view
420
distal phalangeal blood supply 349
distal radial carpal bone 43. 49. 65. 68.
70. 72. 107
distal radius
lateral aspect 85-9
medial aspect 89-90
distal recess.endoscopic view 418
distal sesamoideanligaments 184
distended extensor carpi radialis tendon
sheath 406
distention 11-12.32.48
digital flexor tendon sheath 454
maintenance 57-8
postoperative 452
dorsal arthroscopic portals 47
dorsal aspect of proximal phalanx. frontal
fractures of 152
dorsal metacarpophalangeal joint 453
dorsal pouch
of fetlock joint 132
insertion of arthroscope 130
synovial membrane proliferation 158
dorsalrecumbency48
dorsalsynovialpad.fibrousthickening
39
dorsalsynovialrecesses 48
dorsodistalarticular surfaceof radius 58
dorsodistalintermediatecarpalbone
69-73
dorsodistalradial carpalbone64-9
dorsolateralarthroscopicportal 53
dorsolateral-palmaromedial (DLPMO)
obliqueviews65. 73-4. 78. 89
dorsolateralpouch,synovialmembraneof
272
dorsomedialeminenceof proximalphalanx
148
dorsomedialintercarpalligament39. 48
dorsomedialjoint pouch278
dorsomedial-palmarolateral(DMPLO)
projection69. 85
dorsomedialportal 53
dorsoproximalchipfracturesof proximal
phalanx 152
dorsoproximalmargin of radial carpal
bone82
dorsoproximalradial carpalbone78
dorsoproximalthird carpalbone 73
drapesand drapingsystems27
DyonicsDyoVacsuctionpunchrongeurs
21
DyonicsInteliJETpump 14
DyonicsPowerMac system22
DyonicsPS3500EPpowershavingsystem
21
E tearing of ligament 340-4
egresscannula 15-16, 33-5, 62,131,
240, 295, 320
egressflushing 171
egressneedle 340
elbow joint 327-36
anatomy 327
arthroscopic approaches 327-36
arthroscopic surgery 332
caudomedial approach 328-30
caudomedial portions 331
,;;-l'caudomedial pouch 330 ~ to patella and distal femur at initial
caudoproximal approach 330
caudoproximal aspect 333
caudoproximal pouch 332
complications334-6
cranial pouch 328-9
craniolateral approach 328
osteoarthritis 334
osteochondritis dissecans (OCD)332
osteochondrosis 332
positioning for arthroscopy 327-8
septic arthritis 332-4
triangulation 336
electrolyte solution 12, 308
electrosurgery 44
devices 23
malfunction 26
elevators 18-19
endoscopy
calcaneal bursa 410
intertubular bursae 414
management of contamination and
infection 427-39
enrofloxacin 435-6
entheseous new bone 453
epinephrine 448
esteotome 19
ethmoid forceps 141
ethmoid rongeurs 16-17
exfoliation 44-5
extensor carpi radialis (ECR)53.405-6
extensor tendon sheath
removal of mass 407
tenoscopy 403-7
extrasynovial extravasation of fluid
450
F
fasciitis 452
femoral condyle 217
chondrocyte-IGF-l grafting of
subchondral cyst 466
femoral head
cartilage erosion, over cranial portion
342
cartilage irregularity 343
cartilage lesions 340
complete rupture and contraction of
proper ligament 343
lateral portions 342
partial rupture of ligament 344
subchondral cystic lesion 344
femoropatellar joint 2
clinical conditions 199
diagnostic arthroscopy 197-9
fragments in proximal pouch 239
insertion of arthroscope 197
insertion of arthroscopic sheath 199
lateral approach 212
normal arthroscopic anatomy
197-9
relationship of arthroscope and sleeve
entry 200
surgical arthroscopy 223-46
femoropatellar pouch, egresscannula to
flush debris from 240
femorotibial joint 2,36
arthroscopic portals for caudal pouches
220
clinical conditions 223
cranial approach 199-212
diagnostic arthroscopy 199-223
insertion of arthroscope 199-212
into caudal compartment 222
into caudal pouch 218-20
normal arthroscopic anatomy
of caudal compartment 222-3
of caudal pouch 220-2
of cranial compartment 218
femur fractures2 humerus
articular cartilage lesions on medial fragmentation47. 88. 93 cranial aspect 311
condyle 254 anconealprocess332 craniolateral portion 332
central trochlear groove 233 calcaneus413 endoscopic view 417-18
concave subchondral defects of medial carpusand fetlock2 lateral tuberosity 419
condyle 249 distalmargin of navicularbone424 loss of fibrocartilage 418
cystic lesions of medial condyle 246 glenoid 319 osteochondritis dissecans (OCD)315
postoperative management 252 multiple sites93 hyaluronan 436
preoperative considerations 246-9 patella242-5 hyperemic villi 37
results 252-4 fragments.failure to remove453 hypertrophic medopatellar plica 39
technique 249-52 frontal fracture of proximalphalanx152.
flattened lesion on lateral trochlear 154
ridge 225 fucalsubchondralbonedisease43 I
lateral trochlear ridge 228-9,232-3, IGF-l 465.467
235,238 ~ infectedcellulitis 452
medial condyle 214,216 infection
medial trochlear ridge 226, 229, 233, GameReady for pneumaticpressureand
coldbandaging28 classification428
236 endoscopicevaluationand surgery428
osteochondritis dissecans (OCD)226
gasdistention34
gasemphysema15 iatrogenicsynovial451
subchondral cystic lesion of medial intrathecal451
gasinsufflator 14-15
condyle 248, 250, 467, 469 management427-39
gentamicin435-6. 452
Ferris-Smithrongeurs 17, 62, 88-9, 157, postoperative care436-7
gienohumeralligament312
170-2,177-8,185,228,295,317, postoperative complications451-2
320-1 glenoid
articular fracture 325 postoperative monitoring 437
fetlock joint 2,60 resultsand prognosis437
cranial rim 311
diagnostic arthroscopy 129-36 stagesof 428
dorsal pouch of 132 cyst debridement321
cystic lesion315. 318 treatmentprotocols428
insertion of arthroscope 132-5 infectiousarthritis 436
loose plantar fragments in 172 fragmentation319
osteochondritis dissecans
(OCD)315.318 hip joint 345
palmar or plantar 132-5 infraspinatustendon308.310.312
palmar or plantar pouch 135-6 osteochondrosis 324
underminedcartilage 319 instrumentportal 33. 35
surgical arthroscopy 136-95 instrumentation7-30
fetlock lesions 147 gram-negativebacteria436
growth factors464-5 breakage448.450-1
fibrillation 41-2, 44-5, 261 brokeninstrumentretrieval 18
lateral patellar ligament 247 careand maintenance2 7-8
fibrotic changes 37-8 H hand instruments16-23
fibrotic synovial pad proliferation 157 hemarthrosis448 motorized21-3
fibrous joint capsule, tearing 453 synovialmembrane40 seealsospecifictypesand applications
flexed dorsoproximal dorsodistal (skyline) hemorrhagictenosynovialmass403 intercondylareminencefracture2
projections 110-11flexor hemostats64 intermediatecarpalbone 52.54. 57
digitorum longus seemedial digital high-frequency(HF)equipment44 InternationalCartilageRepairSociety
flexor tendon (MDFT) hip joint 2, 337-46 (ICRS)41. 94
flexor retinaculum 395 arthroscopicexamination338-40 interphalangealjoints 347-64
superficial lamina 391 arthrotomy 337 distalphalanxcysts358
tenoscopic view 394 cranial. middle.and caudalaspects341 proximal navicularcysts358-9
flexor tendons, cross-section anatomy diagnosticarthroscopy337-40, 345 seealsodistalinterphalangealjoints;
381-2 diseases of 337 proximalinterphalangealjoints
"' ,
flow-regulated roller pump 12 infectious arthritis 345 intersesamoidean ligament137-8
fluid egress 34 osteochondritisdissecans(OCD)344-6 detachmentfrom proximalsesamoid
fluid extravasation 34 osteochondrosis 344-6 bone 186
fluid ingress line 33 preoperativeassessment 337 intra-articular fragments.locationof 60-1
fluid irrigation system 11-15 surgicalarthroscopy340-5 intra-articular ligamentsand menisci.
fluid pumps, types and properties 12-13 histologicanalysis95 evaluation40
fluid system, complications 34 historytaking 60 intrasynovialevaluation3
focal bone disease 188 hookknives20 intrathecalendoscopyof synovialbursae
Foerner elevator 19 hookscissors20 409
forage 460 human arthroscopy15. 35 intrathecalNaHA 391
forceps 16 humeralhead ipsilateralarthroscope183
foreign material articular fracture 325 irrigation 11.59.62
debridement 430 debridement320
detecting and removing 437 osteochondrosis 324
intrasynovial451 positioningof arthroscopefor surgery J
in synovial cavity 429 321 joint capsule35, 64
 K collateral ligament 276medial osteochondritis dissecans(OCD)158-62
condyle 133. 215-16 palmar pouch136
kissing lesion62. 71 subchondral cysts of 467-9 pannusdeposits430
knee joint medial digital flexor tendon (MDFT) 395 ultrasonographyof dorsalaspect431
arthrofibrosis39 medial dorsal intercarpal ligament (MDIC) metacarpophalangeal joints 129-96
complicationin arthroscopy447 69 metacarpus137
human 34 medial eminence 149 metaplasiaof villi 36
postoperativeinfectionratesfollowing medial femoral condyle 207medial metatarsophalangeal joint
arthroscopy448 femorotibial joint indicationsfor arthroscopy129
recommendations to minimize approach to cranial pouch 212-13 osteochondritis dissecans(OCD)158-62
complicationsassociatedwith lateral approach 213 metatarsophalangeal joints 129-96
arthroscopy447 manipulation of arthroscopic sleeve metronidazole436
knee regeneration45 and conical obturator 213 microfracture460-1
normal arthroscopic anatomy of middle carpaljoint 47.49.51.59.95
L cranial compartment 213-14 arthroscopicexamination48
lameness3. 60. 110.223.246.325.365. positioning of arthroscope 212. 214 middlepatellarligament. avulsionof 247
377.380.393.424 rupture of cruciate ligaments 258 midsagittalridge 133
largefragments.removalof 34 surgical arthroscopy 246-64 mineralization400. 402
lasers40. 44 medial humeral condyle. osteochondritis mosaicplasty463-4
typesand applications23 dissecans (OCD) 335 motorizedequipment21-3.39.96.
lateralcondylarfossa.glidehole 192 medial lateral condyle 219 175-6.187.424.458
lateralcondylarfracture.repair of 186. 190 medial malleolus 278 multiplejoints 59
lateralcondyleof distal metacarpus. displaced fracture 299 multiple sites.fragmentationat 93
fracturesof 189 osteochondritis dissecans (OCD) 293-4 Myobacteriumtuberculosis 26
lateral digital extensortendon 133 position of arthroscope and instrument
lateraldigital flexortendon393 294
medial meniscus 215-16
N
lateraleminence149
lateral femoralcondyle218-20. 222 fibrillation of free border of cranial navicularbone
lateralfemorotibialjoint. insertion of horn 261 fibrillatedfibrocartilageon sagittalridge
arthroscopeinto cranial compartment longitudinal tear of caudal horn 265 425
214 longitudinal tear of cranial horn 261-2 fragmentationof distal margin 424
lateralhumeral condyle.cranial portion transverse vertical meniscal tear 264 proximal margin421
334 medial palmar intercarpal ligament sagittalridge421
lateralmeniscus218-19 (MPICL) 37.48.104-6 navicularbursa
lateral palmar intercarpal ligaments medial patellar fibrocartilage 246 acute endoscopy 422
(LPICL)105 fracture of 247 diagnosticendoscopy 424-5
lateral patellarligament.fibrillation 247 medial patellar ligament 205 endoscopicapproach419
lateral portal 48 medial patellar plica syndrome 39 penetratinginjuries 421-4
lateral recumbency48 medial plica 73 proximalrecess424
lateral styloidprocess56 medial portal 54 treatmentof penetratingwound 435
lateral tibial condyle219-20 medial sesamoid bone. basal fragment 182 necropsyexamination336
lateral trocWearridge208-10.228-9. medial tibial intercondylar eminence. necrosisof villi 36
232-3. 235. 238. 241 fracture of 256 nephrotoxicosis 436
distal aspect230 medial trochlear ridge 204-5. 207.229. Nitinol sutureneedle263
lateromedialprojection69. 73-4. 78 231.233.236 nitrogendrivenflutter valve assembly12.
lavage44. 432-4. 448 meniscal injuries 257-64 14
meniscalligament injuries 257-64 {i nonsteroidalanti-inflammatorydrugs436
light cable33
light generators9 meniscal tears 2. 260 nuclearscintigraphy337
light intensity 9-10 meniscectomy in humans 1
light sources9-10 meniscotome 22
meniscus
0
long digital extensortendon(LOE)219
long-handledforceps17 and associatedligaments 260 obturator32-3. 99.131.213.309.376-7
loosebodies18 removal of axial portion 261 olecranon.cranial cortexof 336
loosebodyforceps18 repair technique 263 operatingarthroscope35
mercury vapor lamps 9 osteoarthritis(OA)60. 343
metacarpal/metatarsal condyle fractures 3 elbowjoint 334
M metacarpophalangeal joint 38 in humans45
McIlwraith arthroscopicrongeurs 17 arthroscopic examination 129-32 progressive111
McIlwraith fragmentforceps18 indications for arthroscopy 129 secondary111
McIlwraith-Scanlanelevator18 infection 429 shoulderjoint 325
magneticretrievers451 insertion of arthroscope 130-2 osteochondralautografttransfersystem
manipulativeproceduresfor cartilage insertion of arthroscopic sheath and (OATS)463
repair 456-62 conical obturator 131 osteochondralchip fragmentation60

medial
osteochondraldisease2. 44 middlecarpaland antebrachiocarpal proximal check desmotomy 389
osteochondralerosion43 joints. arthroscopicexamination57 proximal check ligament 386.390
osteochondralfragments60.65.147.453 palmarolateraloutpouching59 proximal dorsal aspect of proximal
palmar aspectof carpaljoints 99-100 pannus phalanx. removal of osteochondral
proximal dorsalaspectof proximal depositsin scapulohumeraljoint 432 fragments from 136-52
phalanx 136-52 formation 37 proximal dorsal eminences of proximal
proximalpalmar or plantar aspectof removal430 phalanx 152
proximal phalanx167-72 partial thicknesschondrectomy44-5 proximal dorsomedial eminence of
osteochondralgrafts462-3 patella202-4. 208 proximal phalanx 146.153
osteochondralhealing99 articular surface230 proximal intermediate carpal bone 78. 82-4
osteochondritisdissecans(OCD)2. 16. 18. fractures245-6 proximal interphalangeal joints 359-64
105.223-42.269.315.466 fragmentation242-5 arthroscopy of dorsal pouch 359-60
cartilage flap re-attachment459 postoperativemanagement245 arthroscopy of palmar/plantar pouch
chronic lesions237 preoperativeconsiderations242 360-4
debridement335 results245 avulsion fracture of abaxial distal
distal dorsal aspectin technique242-5 condyle of first phalanx 361
metacarpophalangeal and osteochondritisdissecans(OCD)227. osteochondritis dissecans (OCD)361
metatarsophalangeal joints 158-62 238 position of arthroscope for
distal intermediateridge of tibia 281-6 secondaryremodeling238 palmar/plantar pouch 362
distal interphalangealjoints 354 patellaforceps18 removal of palmar middle phalanx
distribution of lesions224 patellarongeur 17-18 osteochondral fragmentation from
elbowjoint 332 patellofemoralarticulation36 axial midline of palmar pouch 364
glenoid315.318 pathologicplicaein man 39 proximal intertarsal joint (PIT) 274
hip joint 344-6 penicillin 436.452 proximal phalangeal fracture 144
humeral head318 periarticularosteophytes60 proximal phalanx 2. 133-5. 139
humerus 315 periarticular swelling29 dorsomedial eminence 148
lateral trocWearridge224-6. 460 periarticular tissues59 dorsoproximal chip fractures 152
medialhumeral condyle335 perichondriumfor improvedcartilage fragmentation of plantaroproximal
medialmalleolus293-4 repair462 articular surface 449
patella227 periosteumtransplantation462 frontal fractures 152. 154
postoperativemanagement241 perisynovialstructures lateral eminence 147
preoperativeconsiderations223-6 iatrogenicdamage450 multiple fragments associated with
proximalinterphalangealjoints 361 injury 448 lateral plantar process 171
results241-2 petechiationof villi 37. 429 osteochondral fragments of proximal
shoulderjoint 319 phenylbutazone97. 322 palmar or plantar aspect 167-72
surgical treatment279 photography23 proximal dorsal aspectof. removal of
tarsocrural (tibiotarsal)joint 269. 280 plica-associated disease39 osteochondral fragments from
technique226-40 pluripotent mesenchymalstemcell 136-52
osteochondroma. tenoscopicremoval393 transplantation464 proximal dorsal eminences of 152
osteochondrosis pneumoperitoneum15 proximal dorsal fragments of 139
arthroscopictechnique314-22 pneumoscrotum15 proximal dorsomedial aspect 143
elbowjoint 332 polymethylmethacrylate (PMMA)beads435 proximal dorsomedial eminence of 146.
glenoid324 poplitealtendon222 153
hip joint 344-6 post-antibioticeffect(PAE)436 proximodorsal aspect 147
humeralhead324 post-arthroscopicirrigation and closure35 proximal radial carpal bone 54. 82
preoperativeconsiderations314 postoperative care436 proximal radius. capitular fovea of 334
shoulderjoint 314-25 pos~operative complications451-4 t proximal sesamoid bones
postoperativeeffusion448 ' apical-abaxial fragmentation 181
osteomyelitis325
osteophytes92-3 postoperative
monitoring 437 axial osteitis 186
osteotome18. 62. 385 preoperativeevaluation31 removal of fragments 172-85
preoperativepreparation31 proximal third carpal bone 43
pressurebandaging28-9 proximal ulnar carpal bone 85
p pressuremanagementsystems28-9 Pseudomonas aeruginosa26
pain and pain relief401. 454 probeuse 16 pumps 11-14. 34
palmar carpalligament(PCL)385 in diagnosticarthroscopy35 punctate erosions 41
palmar intercarpalligaments.tearing in medialpalmar intercarpalligament
104-5 37
R
palmar osteochondralwedge87 proliferativesynovialvilli 449
palmar/plantar annular ligament. proliferativesynovitis158. 305 radial carpal bone 42, 57, 66, 69, 71,
transection371-4 proximalarticular surface53-4 80-1,92,95,98-9,106,108
palmar pouch intermediatecarpalbone 56 large fragment off dorso distal margin
fetlockjoint 135-6 proximal aspectof intermediatecarpal 125
metacarpophalangeal joint 136 bone83 slab fracture 123-4
 radial osteochondroma 40
osteoarthritis325 caudalpouches264
removal of 385
osteochondritisdissecans(OCD)319 current status58-9
radial physeal exostoses,removal of 385-8
osteochondrosis 314-25
radiofrequency devices 23 femoropatellarjoint 223-46
placementof arthroscope322 limb suspendedfor 32
radiofrequency energy (RFE)44 postoperativemanagement322 medialfemorotibialjoint 246-64
radiography problemsand complications322
postoperative 36,119,125 post-surgicalfollow-upinformation97
radiographand positivecontrast
preoperative 36,119,125 postoperativemanagement97. 115
arthrogram 316 postoperativeprotocol 102
radius resultsof surgicalarthroscopy323-5
distal articular surface of 55, 57 preoperativeinformation60
septicjoint 325 preoperativeplanning III
distal epiphysis of 56
specificindicationsand techniquefor principle of 34-5
dorsodistal articular surface of 58
diagnosticarthroscopy312 problemsand complications59. 447-54
Richard Wolf Surgical Arthro Power
surgicalanatomy307 prognosis97
System 22
triangulation 317.322 relevantpathobiology60
Ringer's solution 442 seealsoscapulohumeraljoint
rongeurs 16-18, 20-1, 62, 321
removalof osteochondralchip
skinabscesses 452
seealso Ferris-Smith fragments58-99
skin incision 32.35.48.64.89.282 results97.115-22
suturing 35 shoulderjoint 314-25
5 skinportals.closure132 seealsospecificapplications
skinsutures.complicationrate 448
scalpel blade 32.35 surgicalassistants26-7
slabfracturesseecarpalslabfractures
Scanlan-Mcllwraith scissor-action suspensory ligament tags resection with
slottedcannula 376-7
rongeurs 20 synovial resector 179
smallfragments16-17 sustentaculumtali. debridement401
scapulohumeraljoint 307-26 Smith& NephewDyonicsArthroplasty
caudal aspect 309 suturesinuses452
System22 sutures35
cranial aspect 311 smoothedgedresectors22
exploration 314 synovectomy 39-40. 96
sodiumbenzylpenicillin435-6. 452 capsulardefectsand fibrosisfollowing
lateral aspect 310 softtissuemineralization453
medial aspect 312 40
spinalneedle282.307-8.314.317.322. carbondioxidelaser40
pannus deposits in 432 340
seealso shoulder joint effecton articular cartilagein equine
spongialization462 joints 40
sclerosis of third carpal bone 100
spooncurettes20 equinejoint tissues39
self-sealing cannula 20-1 spurs92-3
septic arthritis 306. 325 human hemophiliacpatients39
stemcelltransplantation464
diagnosis 37 mechanical40
sterilization10-11. 25-7 synovial449-51. 3649
elbow joint 332-4 stifle joints 2
septic osteomyelitis 306 synovialbursae3
StorzAIDA digitalimagecaptureand intrathecal endoscopy 409
septic physitis 325 storagedevice25
sesamoid bone 137-9. 367
Strykerarthroscopypump14 synovial diverticulum 218
basal fragment of 183
StrykerSDCPro 2 digital videoand still synovial effusion 280
fracture 172. 180
imagestorageand printing system25 synoviall1ap 133
fragmentation of 185 StrykerSystem22
shavers 22 synoviall1uid
subchondralbone42 bloody or brown 65-6
suction use on 23 disease100--4.152-3
sheath insertion 32-3 debris in 36
drilling 460 synovial fold 39
sheathed blades 19 subchondralcyst2.108-9.164-7.254-6.
sheathed knife system 20 synovial fossa 273-4
467-9 :0, synovial membrane 36-7, -
shoulderjoint
§libchondrallucency104 205, 220, 273-4
arthroscopic surgery 31~25 subchondralmicrofracture99
caudal aspect 313 biopsy 37
subfascialcellulitis452 dorsal pouch 158
damage to instruments 323 suction
diagnostic arthroscopy 307-14 applications21
difficulty in reaching potential lesions evaluation 36-9
use on shavers23 hemarthrosis of 40
323 sulcusmuscularis218
final position of arthroscope within proliferation 39.158
superficialdigital flexortendon (SDFT)
38. resection of 170
sheath 309
fluid extravasation 322 365-8.371-4.378-80.384.386. synovial pattern 37
388.413-14 synovial proliferation 37.
insertion of arthroscope 307-8
supraglenoidtubercle.fragmentation419
insertion of arthroscopic sheath and
suprapatellarpouch201 40
obturator 309
surgicalarthroscopy44 synovialresection96
lateral approach 309-12
advantagesof 58-9 synovialresectorunits 22
medial aspect 313 basictechniques35
normal arthroscopic anatomy 308-9 caseselection97 infection427-39
synovial villi 38. 49 intra-articular fractures299
morphologic features 36 osteochondritis dissecans(OCD)
280. 296
obstruction of view by 449-51 results291-4
synovitis plantarlateral or plantar medial
changes in 37 approaches278-9
evaluation 36-9 positioningof arthroscope270
experimentally induced 37 puncturewound in dorsolateralaspect
forms 37 428
post-operative 452 surgicalarthroscopy279-306 290-1
proliferation and thickening of synovial aftercare306
villi 38 tearsand avulsionsof collateral extremity254-6
ligaments305
tarsus.fracture of proximalplantar aspect tight spaces17
T of medialtrochlearridge 300-1 toothededgedresectors22
talocentraljoint temporomandibularjoint (TMJ)441-5 transillumination36
fragmentsdislodgedfrom medial arthroscopicapproach442-3
trochlearridgeand entered articular disk442
dorsomedialpouch304 bone scintigraphy441 traumatic joint disease37. 40
retrieval of fragments299 clinicalresults444-5 triamcinoloneacetonide253
talus diagnosisof inflammation444 triangulation 1
centralmedial trocWearridge 277 discotemporalcompartment441-2 elbowjoint 336
dewdroplesionsat distal aspectof medialpenetrationof joint capsule444 principle of 34-5
medial trocWearridge 292 overview441 shoulderjoint 317.322
distalmedial trocWearridge277 preoperativeconsiderations441-2 trochleargroove202-3.211
distaltrocWeargroove274 proximal compartment443
lateraltrochlearridge 272 ultrasoundimage442 U
lateral trochlearridgeand distaltibia ventral discomandibulararticulation
ulnar carpalbone52. 85
junction 271 441
medialtrocWearridge273-4, 276, 278 ulnar fracture.mid-shaft336
tendonlinear clefts374-6
and distaltibia and medialmalleolus ultrastructuralstudies45
tendonsheath
junction 275 problems3
osteochondritisdissecans(OCD) seealsoextensortendonsheath V
286-91 tenoscopy365-408 vacuumattachments21
osteomyelitisof dorsodistallateral carpalsheath379-93 vasculaturechanges37
trocWearridge434 diagnostic368-71 VCRs 24
sagittalfracture 303 digital flexortendonsheath365-79 videocameras10-11
subchondralcystic lesionof trochlear extensortendonsheath403-7 video documentation10. 23-4
groove294-5,297 massremoval/adhesiontransection videorecorders10
wearlines on medialtrochlearridge295 371 lightweight single-chipor three-chip10
tarsal sheath resultsand prognosis393 videoarthroscopes 8. 11
centromedialapproach398 tarsal sheath3.393-402 videotape9. 24
cross-sectionalspecimen396-7 techniques368-76. 380-91. 397-401 villi
diagnostictenoscopy397-8 tenosynovialmasses398-400. 403 metaplasia36
distal aspect401 and adhesions371 necrosis33
distal region400, 404 tenosynovitis petechiation37.429
inflammation402 acute 365 1'$ proliferativesynovial449
medialaspect395 chronic 365 synovial36. 38.49.449-51
nomenclature393 complex365 visualization47
postoperativecare 401-2 thermal chondroplasty44 villonodular synovitis152-8
proximal region396. 399 third carpalbone43.78-80.97.102 villous regeneration40
surgicalanatomy395-7 bone density104 villous synovialmembrane210. 219
sustentaculumlevel396 lag screwfixation of slabfractures viruses26
tenoscopy393-402 110-15
resultsand prognosisof tenoscopy sagittalfracture 121-2 W
402 sclerosisof 100
tenosynovitis402 slabfracture 109-10.112.114-16. wearlines 42, 44
wound healingcomplications401 wounds
118-20.124
tarsal tunnel 395 third metacarpalbone healingcomplications401
tarsal tunnel syndrome393 debridementof subchondralcystic management434-5
tarsocruraljoint 269-306 lesions164-7 postoperativecare436-7
diagnosticarthroscopy269-79 subchondralcystin medialcondyle468
dorsomedialapproach269-79 tibia 218 X
insertion of arthroscopicsleeve270 distalintermediateridge273 xenonlight sources9-10