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In 1984, Casscellsstated "Diagnostic arthroscopy and, perhaps Impressive advances then occurred in both technology

evenmore important, arthroscopic surgery constitute what is and technique.The first arthroscopic surgery was meniscectomy
probably the outstanding achievement in orthopedic surgery in humans, followed by procedures such as patellofemoral
in the past decade" (Casscells1984). While the author of this malalignment, abrasion arthroplasty, shaving for chondro-
statement would probably admit to being biased, it is a malacia, and synovectomy. The advantages of arthroscopic
fair reflection on the success and acceptance of the role of meniscectomy have been well documented and arthrotomy is
arthroscopy in human orthopedics. Although generally now a rarity (Pettrone 1982, McGinty 1987). The manage-
considered a modern surgical procedure, the technique took ment of conditions involving the meniscus is also a good
considerable time to develop. The first endoscopic examin- example of how new conceptshave evolved from the increased
ation of a knee joint was performed in 1918 by ProfessorTakagi diagnostic accuracy afforded by arthroscopy and the potential
at the University of Tokyo (Takagi 1933). Later the technique to re-examine a knee with minimal morbidity Gackson1986).
was pioneered in the United States by Burman and colleagues The most important of these new concepts was probably the
(Burman 1930, Burmanet aI1934). The first practical arthro- preservation of meniscal tissue, which led to the technique of
scopewas developed by Watanabe (a pupil of Takagi) in 1960 partial meniscectomy and then to initial arthroscopic repair
(Watanabe 1960), and he also developedsomebasic principles (Keene et al 1987). The development of more complex
for arthroscopy of the knee. In 1965, his techniques were procedures followed and cruciate repairs are now performed
brought to North American by Robert Jackson of Toronto arthroscopically (Shrock & Jackson 1996). The use of
(Jackson1987). arthroscopy in man now encompassesthe shoulder, elbow,
In the early 1970s, the arthroscope began to achieve real wrist, digital, ankle, hip, and temporomandibular joints
clinical use (Casscells1971, Jackson& Dandy 1972), and the Gohnson 1986). It is the most common orthopedic procedure
first course in arthroscopy of the human knee in the United performed today; current estimates cite approximately 9000
States was given in 1973. The procedure of diagnostic orthopedic surgeons performing arthroscopy in the United
arthroscopy initially met with considerable skepticism within States alone (McGinty 1987).
circles of human orthopedic specialists until its value was Arthroscopy in the horse has gone through a similar
demonstrated in the total evaluation of the knee (Dandy & evolution. In 1949, the human pioneer Watanabe reported
Jackson 1975, Watanabe et a11978, Casscells1980). There- arthroscopy of the equine hock. Large animal arthroscopy
after, arthroscopy became firmly established as a diagnostic was first presented in the German literature in 1973
tool in human orthopedic practice, and these early days have (Knezevic pers com 1984) and appeared in the English
been the subject of reviews by Casscells(1987) and Jackson language in 1975 and 1977 (Smith 1975, Knezevic& Wruhs
(1987); the interested reader is referred to these sources for 1977). Diagnostic arthroscopy of the equine carpus was first
more information. reported in 1974 (Hall & Keeran 1975), but was described
In the middle of the 1970s, arthroscopy moved into the more extensively by McIlwraith & Fesslerin 1978. Reports of
second phase of its development, with the realization of the its use in other joints followed and diagnostic arthroscopy of
potential to perform surgery under arthroscopic visualization the equine stifle joint was reported in 1982 (Nickels & Sande
(O'Connor 1974, 1977, Dandy 1981, Jackson 1983). The 1982).
development of appropriate techniques and suitable instru- As in human orthopedics, use of the arthroscope in horses
mentation followed (Johnson 1977, O'Connor 1977, Dandy extended into surgical practice as technology and techniques
1981). It also became apparent that the therapeutic advan- of triangulation developed. Some surgical manipulations
tages of arthroscopy included not only the surgical procedures under arthroscopic visualization in the horse were mentioned
per se (which can be grouped under the heading of surgical by Knezevic & Wruhs in 1977, but arthrotomy remained the
arthroscopy or arthroscopic surgery) but also the benefits acceptedmeans of completing surgery. The first description of
from joint lavage and lysis of adhesions (Jackson 1974, equine arthroscopic surgery involved the carpus (Ommert
O'Connor 1974). The advantages were low morbidity, early 1981, Valdez et al1983) and further descriptions involved
postoperative movement and reduced hospitalization times. the carpal, fetlock, tarsocrural, and femoropatellar joints
198J). Uescriptions of diagnostic and surgical arthroscopic also led to understanding of the contribution of soft tissue
procedures in the carpal, fetlock. tarsocrural and femoro- lesions to joint disease. In the carpus, tearing of the medial
patellar joints were detailed in textbook form in 1984 palmar intercarpal ligament was first reported by Mcllwraith
(McIlwraith 1984b). At that time, the first author used in 1992 and its implications discussed by Phillips & Wright
arthroscopic surgery as the routine method of joint surgery (1994) and Whitton et al (1997a,b,c).
for virtually all conditions, with the exception of subchondral In the fetlock joints, successrates following arthroscopic
cystic lesions of the medial condyle of the femur. some carpal removal of osteochondral fragments of the palmar/plantar
slab fractures. and fractures of the proximal sesamoidbones. aspect of the proximal phalanx have now been documented
Arthroscopic techniques were subsequently developed and (Foerner et al 1987, Fortier et al 1995), and results for
described in the second edition of the book in 1990 arthroscopic treatment of osteochondritis dissecans of the
(McIlwraith 1990a). The use of arthroscopic surgery in the distal dorsal aspect of the third metacarpal/metatarsal bones
treatment of third carpal slab fractures was reported by have been reported (Mcllwraith & Vorhees 1990). Results of
Richardson in 1986; its use in the treatment of subchondral arthroscopic surgery to treat apical (Southwood & Mcllwraith
cystic lesions in the medial condyle of the femur was docu- unpublished data), abaxial (Southwood et al 1998a), and
mented originally by Lewis in 1987. Techniques for diagnostic basilar (Southwood & Mcllwraith 2000) fragments of the
and surgical arthroscopy of the shoulder were described in sesamoidbones are also available in the literature.
1987 (Bertone & McIlwraith 1987. Bertone et al 1987. Since the last edition, the results of arthroscopic surgery
Nixon 1987). At the time of the second edition, arthroscopy for the treatment of osteochondritis dissecans in the tarso-
had also been performed in the distal interphalangeal. crural joint have been documented (Mcllwraith et al1991)
proximal interphalangeal, and elbow joints. Arthroscopes and the arthroscopic approach and intra-articular anatomy
had also been used in the sinuses and tendon sheaths of the plantar pouch of the joint have also been described
(McIlwraith 1990a). (Zamos et aI1994).
By 1990, arthroscopy in the horse had gone from being a Considerable advances have been made in arthroscopic
diagnostic technique used by a few veterinarians to the surgery of the stille joints. The results of arthroscopic surgery
accepted way of performing joint surgery. Prospective and for the treatment of osteochondritis dissecans of the femoro-
retrospective data substantiated the value of the technique in patellar joint have been reported by Foland et al (1992). The
the treatment of carpal chip fractures (McIlwraith et al19 8 7). syndrome of fragmentation of the distal apex of the patella
fragmentation of the dorsal margin of the proximal phalanx was recognized and its treatment reported (Mcllwraith
(Yovich & McIlwraith 1986). carpal slabfractures (Richardson 1992). The use of arthroscopic surgery for treating certain
1986), osteochondritis dissecans of the femoropatellar joint patellar fractures was discussed in the previous edition
(Martin & McIlwraith 1985a, McIlwraith & Martin 1985), and has since been reported in the literature (Marble &
osteochondritis dissecansof the shoulder (Bertone et alI987). Sullins 2000).
and subchondral cystic lesions of the femur (Lewis 1987). In the femorotibial joints, the use of arthroscopic surgery
During this period. the use of diagnostic arthroscopy led to to treat subchondral cystic lesions of the medial condyle of
the recognition of previously undescribed articular lesions, the femur (Howard et al19 9 5) and proximal tibia (Textor et al
many of which are now also treated using arthroscopic 2001) have been reported. Cartilage lesions of the medial
techniques. femoral condyle have also been described (Schneider et al
Since 1990. there has been further sophistication of 1997). Arthroscopy has allowed great advancesin the recog-
techniques: new ones have been developed and treatment nition and treatment of meniscal tears and cruciate injuries
principles have been changed based on new pathobiologic (Walmsley 1995, 2002; Walmsleyet al2003). It has also been
knowledge and further prospective and retrospective studies used to remove fragments from the intercondylar eminence of
defining the success of various procedures. Many of these the tibia (Mueller et al1994) and allow internal fixation of
recent advances have been recorded in a recent publication another case of intercondylar eminence fracture (Walmsley
(McIlwraith 2002a). For example. there has been further 1997). Techniqueshave also beendevelopedfor diagnostic and
documentation of success rates following arthroscopic surgical arthroscopy of the caudal pouches of the femorotibial
removal of fragments from the dorsoproximal margin of the joints (Stick et al 1992, Hance et al 1993, Trumble et al
proximal phalanx (Kawcak & McIlwraith 1994, Colon et al 1994). In addition, a single cranial arthroscopic approach to
2000). Advances in understanding the pathogenesis of all three joint compartments has been developed by Boening
osteochondral disease and fragmentation in the carpus and (1995) and further reported by Peroni & Stick (2002).
fetlock have also been reported (Kawcak et al 2000. 2001). Diagnostic and surgical arthroscopy of the coxofemoral
which naturally led to progress in diagnosis and treatment. joint has been described (Nixon 1994, Honnas et al1993),
Parameters for the surgical treatment of joint injury have lesions identified and surgical treatments performed. The use
been carefully defined (McIlwraith & Bramlage 1996). of the arthroscope is also no longer confined to the limbs, and
Arthroscopic treatment of fractures in the previously con- the anatomy of the temporomandibular joint has been
sidered inaccessible palmar aspect of the carpus has been described recently (Weller et aI2002).
described (Wilke et al 2001) together with arthroscopy of The use of arthroscopy in assisting repair with internal
the palmar aspect of the distal interphalangeal joint fixation of articular fractures has become routine. This
includes fractures of the metacarpal/metatarsal condyles and previously possible. With the availability of such an a
carpal slabfractures (Richardson2002, Bassage& Richardson traumatic technique. numerous lesions and "new" con-
1998, Zekas et aI1999), Techniques have been described for ditions that are not detected radiographically can be
evaluation and treatment of so-called small joints, such as the recognized.
distal and proximal interphalangeal joints (Boening 2002, 2. All types of surgical manipulations can be performed
Boening et a11990, Vail & McIlwraith 1992, Schneider et al through stab incisions under arthroscopic visualization.
1994), In addition, joints in which lamenessis less commonly The use of this form of surgery is less traumatic, less
encountered. such as the elbow can also be examined painful, and provides immense cosmetic and functional
and treated arthroscopically (Nixon 1990), advantages. Surgical intervention is now possible in
Arthroscopic techniques for cartilage repair have been situations where it would not have been attempted
developed and recently reviewed (McIlwraith & Nixon 1996, previously. The decreasedconvalescencetime with earlier
Nixon 2002b), In general, we have tried to developtechniques return to work and improved performance is a significant
that enhance both the quantity and hyaline characteristics of advance in the management of equine joint problems. The
cartilage repair tissue while using the well-documented need for palliative therapies is decreased,as is the number
advantages of arthroscopic surgery. Techniques include of permanently compromised joints.
cartilage debridement, cartilage reattachment. chondroplasty
and subchondral microfracture (micropicking) (McIlwraith & The initial optimism and advantages of arthroscopy in
Nixon 1996, Frisbie et al1999, Nixon 2002b). equine orthopedic practice suggestedin the first two editions
The use of the arthroscope for evaluation and treatment of of this book have been substantiated. It is now accepted that
tendon sheath problems has been another area of major equine arthroscopic surgery has revolutionized equine ortho-
advancement. The arthroscope has been used to assessand pedics. Problems have and will continue to be encountered,
treat tenosynovitis of the digital flexor tendon sheath, and but we know now that many are avoidable. Although the
techniques for endoscopically assisted annular ligament technique appears uncomplicated and attractive to the
releasehave beendescribed (Nixon 1990b. 2002a. Nixon et al inexperienced surgeon, some natural dexterity, good three-
1993. Fortier et aI1999). Intrathecal longitudinal tears of dimensional anatomical knowledge, and considerablepractice
the digital flexor tendons have also been described by Wright are required for the technique to be performed optimally.
& McMahon (1999) and by Wilderjans et al (2003). The Experience and good case selection are of paramount
arthroscope has also been increasingly useful for carpal sheath importance and reiterating a passagefrom the first edition of
conditions (McIlwraith 2002a. Nixon et a12003, Textor et al this book remains as pertinent today:
2003); arthroscopic approaches have been described by
In 1975. arthroscopywas underused and needlessarthrotomies
Cauvin et al (1997) and Southwood et al (1998b). Removal were performed. The pendulum is now swinging rapidly in the
of radial osteochondromas using arthroscopic visualization other direction. The current tendency in arthroscopy is toward
is a significantly improved technique to open approaches overuse. Some surgeons seems to be unable to distinguish
between patients who are good candidates for arthroscopy and
(Squire et al 1992) and has produced excellent results
thosewho are not. and the trend istoward arthroscopy in patients
(Southwood et al1999, Nixon et al2003, McIlwraith 2002b). in whom little likelihood existsof finding any treatable disorder.
The use of tenoscopic division of the carpal retinaculum to (Casscells1984).
openthe carpal canal has been recently described (Textor et al
2003) and superior check ligament desmotomy is now done Threeyearslater,anotherauthor statedthat
arthroscopically (Southwood et al 1997, Kretz 2001. Tech-
niques for tenoscopy of the tarsal sheath have been described of those 9,000 North American surgeonsand the other surgeons
of the world performing arthroscopy,many are ill-prepared and
by Cauvin et al (1999) and methods of treatment reported by are therefore,not treating their patients fairly, Overuseand abuse
Nixon (2002a). by a few is hurting the many surgeonswho are contributing to
Synovial bursae have also been examined with the orthopedic surgery by lowering patient's morbidity, decreasing
arthroscope. Techniques have been described for arthroscopy the cost of health care, shortening the necessarytime of patients
returning to gainful employment,and adding to the development
for the intertubercular bursa (Adams & Turner 1999), the of a skill that has madea profound change in the surgical care of
calcanealbursa (Ingle-Fehr & Baxter 1998). and the navicular the musculoskeletalsystem. (McGinty 1987).
bursa (Wright et aI1999). To date, reports in the literature
have beendominated by casesof contamination and infection. Arthroscopy remains the most sensitiveand specificdiagnostic
but lesions which explain previously undiagnosed lameness modality for intrasynovial evaluation in the horse. This
referable to these sites have now been identified and treated is somewhat in contrast to human orthopedics, where
endoscopically. arthroscopy predominately is used for surgical interference
Specific advantages of arthroscopy as a diagnostic and much of its diagnostic function has or is being replaced
and surgical tool are mentioned throughout this book. by magnetic resonance imaging (MRI). Arthroscopy has
General advantages of the technique previously recognized continued to be of great benefit in the horse, with increased
include: recognition of soft tissue lesions in joints, tendons, sheaths,
and bursa. However, as stated above, while there are many
1. An individual joint canbeexaminedaccuratelythrough a benefits gained from arthroscopy, it is technically demanding
small (stab)incision and with greateraccuracythan was and the need for training remains.
l'\eTerence~ t!oruer Lf\. NIXon Aj. Uucharme NG. et al. Tenoscopic examinatioI
and proximal annular ligament desmotomy for treatment 0
equine 'complex' digital sheath tenosynovitis. Vet Surg 1999; 28
l\.oams MN. rurner lA. hndoscopy of the intertubercular bursa in 429-435.
horses.JAmVetMedAssoc 1999; 214; 221-225. Frisbie DD. Trotter GW, Powers BE, et al. Arthroscopic subchondra
Bassage LH II. Richardson DW. Longitudinal fractures of the bone plate rnicrofracture technique augments healing of larg(
condyles of the third metacarpal and metatarsal bones in chondral defects in the radial carpal bone and medial femora
racehorses; 224 cases(1986-1995). J Am Vet Med Assoc 1998; condyle of horses. Vet Surg 1999; 28: 242-255.
212: 1757-1764. Hall ME. Keeran RJ. Use of the arthroscope in the horse. Vet Me(
Bertone AL. Mcllwraith CW: Arthroscopic surgical approaches and Small Anim Clin 1975; 70: 705-706.
intra-articular anatomy of the equine shoulder joint. Vet Surg Hance R. Schneider RK. Embertson RM, et al. Lesions of the cauda
1987; 16: 312-317. aspect of the femoral condyles in foals: 20 cases (1980-1990)
Bertone AL. McIlwraith CWoPowers BE. Trotter GW. Stashak TS.
JAmVetMedAssoc 1993; 202: 637-646.
Arthroscopic surgery for the treatment of osteochondrosis in the Honnas CM. Zamos DT. Ford TS. Arthroscopy of the coxofemora
equine shoulder joint. Vet Surg 1987; 16: 303-311. joint of foals. Vet Surg 1993; 22: 115-121.
Boening KJ. Die arthroscopie des kniegelenkes bein pferd uber einen Howard RD. Mcllwraith CWoTrotter. GW: Arthroscopic surgery fol
zentralen zugang ou teill: Methodik Pferdehilkund 1995; 11: subchondral cystic lesions of the medial femoral condyle iI1
247. horses: 41 cases (1988-1991) J Am Vet Med Assoc 1995; 206
Boening KJ. Arthroscopic surgery of the distal and proximal 846-850.
interphalangeal joints. Clin Equine Pract 2002; 1: 218-225. Ingle-Fehr IE. Baxter GM. Endoscopy of the calcaneal bursa in horse.
Boening KJ. Saldern FC. Leendertse I. Rahlenbeck F. Diagnostic and VetSurg 1998; 27: 561-567.
surgical arthroscopy of equine coffin joints. Proc Am Assoc Jackson RW:The role of arthroscopy in the management of the
Equine Pract 1990; 36: 331-317. arthritic knee. cun Orthop 1974; 101: 28-35.
Brommer H. Rijkenhuizen AM. van den Belt HAM. et al. Arthroscopic Jackson RW:Current concepts review. Arthroscopic surgery. J Bone
removal of an osteochondral fragment at the palmaroproximal
Joint Surg (Am) 1983; 65: 414-420.
aspect of the distal interphalangeal joint. Equine VetEduc 2001; Jackson RW: The scope of arthroscopy. Clin Orthop 1986; 208:
13: 294-297. 69-71.
Burman MS. Arthroscopy or the direct visualization of joints. An Jackson RW. Memories of the early days of arthroscopy:
experimental cadaverstudy. JBone Joint Surg. 1930; 13: 669-695. 1965-1975. The formative years. Arthroscopy 1987; 3: 1-3.
Burman MS. Finkelstein H. Meyer L. Arthroscopy of the knee joints. --
J Bone Joint Surg 1934; 16: 255-268.
Casscells SW: Arthroscopy of the knee joint: a review of 150 cases.
J Bone Joint Surg (Am.) 1971; 53: 287.1971. Johnson LL. Lompl"nenslve arLnroscoplCexamination of the knee.
Casscells SW. The place of arthroscopy in the diagnosis and StLouis: Mosby; 1977.
treatment of internal derangement of the knee: an analysis of Johnson 11. Arthroscopic surgery: principles and practice. St. Louis:
1.000 cases. Clin Orthop 1980; 151: 135-142. Mosby; 1986.
Casscells SW. Arthroscopy: diagnostic and surgical practice. Kawcak CE, Mcllwraith CW: Proximodorsal first phalanx osteo-
Philadelphia: Lea and Febiger; 1984. chondral chip fragments in 320 horses. Equine Vet J 1994; 26:
Casscells SW: The early days of arthroscopy in the United States. 392-396.
Arthroscopy 1987; 3: 71-73. Kawcak CE, Mcllwraith CW, Norrdin RW, et al Clinical effects of
Cauvin ERJ. Munroe GA. Boyd JS. Endoscopic exannnation of the exerciseon subchondral bone of carpal and metacarpophalangeal
carpal flexor tendon sheath in horses. Equine Vet J 1997; 29: joints in horses. AmJ Vet Res2000; 61: 1252-1258.
459-466. Kawcak CE, McIlwraith CW, Norrdin RW, et al. The role of
Cauvin ER. Tappres'IJ. Monroe GA. et al. Endoscopic examination of subchondral bone in joint disease:a review. Equine Vet J 2001;
the tarsal sheath of the lateral digital flexor tendon in horses. 33: 120-126.
Equine VetJ 1999; 31: 219-227. Keene CCR, Paterson RS, Teague DC. Advances in arthroscopic
Colon JL. Bramlage LR. Hance SR. Embertson RM. Qualitative and surgery. Clin Orthop 1987; 224: 64-70.
quantative documentation of the racing performance of 461 Knezevic RF,Wruhs O. Arthroscopy in the horse, ox, pig, and dog.
thoroughbred racehorses after arthroscopic removal of dorso- VetMed. Rev 1977; 1: 54-63.
proximal first phalanx osteochondral fractures (1986-1995). Kretz MR. Clinical evaluation of 49 tenoscopically assisted superior
Equine Vet J 2000; 32: 475-481. check ligament desmotomiesin2 7 horses. Proc Am Assoc Equine
Dandy DJ. Arthroscopic surgery of the knee. Edinburgh: Churchill Pract 2001; 47: 484-487.
Livingstone; 1981. Lewis RB. Treatment of subchondral bone cysts of the medial
Dandy DJ. Jackson RW. The impact of arthroscopy on the condyle of the femur using arthroscopic surgery. Proc Am Assoc
management of disorders of the knee. J Bone Joint Surg (Br) Equine Pract 1987; 33: 887-893.
1975; 57: 346-348. Marble GP, Sullins KE. Arthroscopic removal of patellar fracture
Foerner JJ.Barclay WP. Phillips TN. et al. Osteochondral fragments of fragments in horses: 5 cases(1989-1998). J Am Vet Med Assoc
the palmar/plantar aspect of the fetlock joint. Proc Am Assoc 2000; 216: 1799-1801.
Equine Pract 1987; 33: 739-744. Martin GS, Mcllwraith CW: Arthroscopic anatomy of the equine
Foland JW. McIlwraith CWoTrotter GW. Arthroscopic surgery for
femoropatellar joint and approaches for treatment of osteo-
osteochondritis dissecans of the femoropatellar joint of the horse. chondritisdissecans. VetSurg 1985; 14: 99-104.
Equine Vet J 1992; 24: 419-423. Martin GS,Mcllwraith CWoArthroscopic anatomy of the intercarpal
Fortier LA. Foerner ll. Nixon AJ. Arthroscopic removal of axial and radiocarpal joints of the horse. Equine Vet J 1985; 17:
osteochondral fragments of the plantar/palmar proximal aspect 373-376.
of the proximal phalanx in horses: 119 cases(1988-1992). J Am
McGinty JB. Arthroscopy: a technique or a subspecialty?Arthroscopy
Vet Med Assoc 1995; 206: 71-74. 1987; 3: 292-296.
McIlwraith CWoThe use of arthroscopy. synovial fluid analysis and Caudal radial exostosisas a cause
synovial membrane biopsy in the diagnosis of equine joint
disease. In: Equine Medicine and Surgery. 3rd edn. American
Veterinary Publications. Santa Barbara, 1982.
McIlwraith CWoArthroscopic surgery-atWetic and developmental
lesions. Proc Am Assoc Equine Pract 1983: 29: 103-110. '1977,
McIlwraith CWoArthroscopy in Retrospect. Proc Am Assoc Equine Equine Vet Sci 1981; 5:
Pract 1984a: 30: 57-66. 177-182.
Mcllwraith CW Diagnostic and Surgical Arthroscopy in the Horse. Peroni]F, Stick JA. Evaluation of a cranial arthroscopic approach to
Lenexa: Veterinary Medicine Publishing Company. 1984b. the stifle joint for the treatment of femorotibial joint disease in
McIlwraith CWoExperiences in diagnostic and surgical arthroscopy horses: 23 cases (1998-1999). J Am VetMed Assoc 2002: 220:
in the horse. Equine VetJ 1984c: 16: 11-19. 1046-1052.
McIlwraith CWoDiagnostic and surgical arthroscopy in the horse Pettrone FA. Meniscectomy: arthrotomy versus arthroscopy. Am J
(2nd edn) Philadelphia: FA. Lea & Fibiger; 1990a. Sports Med 1982: 10: 355-359.
McIlwraith CWoOsteochondral fragmentation of the distal aspect of Phillips TJ, Wright 1M. Observations on the anatomy and pathology
the patella in horses. Equine Vet J 1990b; 22: 157-163. of the palmar intercarpal ligaments in the middle carpal joints of
McIlwraith CW:Tearing of the medial palmar intercarpal ligament Thoroughbred racehorses. Equine Vet J 1994; 26: 486-491.
in the equine mid-carpaljoint. Equine VetJ 1992; 24: 367-371. Richardson DW. Technique for arthroscopic repair of third carpal
McIlwraith CW (ed). Arthroscopy -An Update. Clinical Techniques bone slab fractures in horses. J Am Vet Med Assoc 1986; 188:
in Equine Practice. Vol. 1. No.4. W.B. Saunders December: 288-291.
2002a; 199-281. Richardson DW. Arthroscopically assisted repair of articular
McIlwraith CWoOsteochondromas and physeal remnant spikes in fractures. Clin Equine Pract 2002; 1: 211-217.
the carpal canal. Proc. 12th Ann Vet Symp 2002b: 168-169. Schneider RK, Ragle CA, Carter BG, et al. Arthroscopic removal of
McIlwraith CWoBramlage LR. Surgical treatment of joint injury. In: osteochondral fragments from the proximal interphalagealjoint
McIlwraith. CWoTrotter GW (eds). Joint disease in the horse. of the pelvic limbs in three horses. J Am Vet Med Assoc 1994;
Philadelphia: WB Saunders. 1996: 292-317. 207: 79-82.
Mcllwraith CWoFesslerJ. Arthroscopy in the diagnosis of equine Schneider RK, Jenson p, Moore RM. Evaluation of cartilage lesions
joint disease.J Am V~t Med Assoc 1978; 172: 263-268. on the medial femoral condyle as a cause of lameness in horses:
McIlwraith CWoFoerner }P. Davis DM. Osteochondritis dissecans of 11 cases (1988-1994). J Am Vet Med Assoc 1997; 210:
the tarsocrural joint: results of treatment with arthroscopic 1649-1652.
surgery. EqVetJ.1991; 23: 155-162. Selway Sf. Arthroscopic surgery: the carpal and fetlock joint. Proc
McIlwraith CWoMartin GS. Arthroscopy and arthroscopic surgery in Am Assoc Equine Pract 1983; 29: 95-109.
the horse. Comp Cont Educ 1984: 6: S46-S53. Shrock KB, Jackson DW. Arthroscopic management of the anterior
McIlwraith CWoMartin GS. Arthroscopic surgery for the treatment cruciate ligament -deficient knee. In: McGinty JB (ed), Operative
of osteochondritis dissecans in the equine femoropatellar joint. Arthroscopy, 2nd ed Philadelphia: Lippincott Raven; 1996:
VetSurg 1985; 14: 105-116. 511-530.
McIlwraith CWoNixon AJ. Joint resurfacing: attempts at repairing Smith M. Arthroscopy in large animals. Proceedings of the 11th
articular cartilage defects. In: joint disease in the horse. Conference of the European Society of Veterinary Surgery, 1975.
McIlwraith cw: Trotter GW (eds). Philadelphia: WB Saunders; Southwood 11, Mcllwraith CWoArthroscopic removal of fracture
1996: 317-334. fragments involving a portion of the base of the sesamoidbone in
McIlwraith CWo Vorhees SM. Management of osteochondritis horses. J Am Vet Med Assoc 2000; 217:2 36-240.
dissecans of the dorsal aspect of the distal metacarpus and Southwood 11, Stashak TS, Fehr IE, et al. Lateral approach for
metatarsus. Proceedings 36th Annual Meeting Am Assoc Equine arthroscopic removal of solitary osteochondromas from the
Pract 1990; 36: 547-550. distal radial metaphysis in three horses. J Am Vet Med Assoc
McIlwraith cw: Yovich Jv; Martin GS. Arthroscopic surgery for the 1997; 210: 1166-1168.
treatment of osteochondral chip fractures in the equine carpus. Southwood 11, Trotter GW, Mcllwraith CWoArthroscopic removal of
J Am Vet Med Assoc 1987; 191: 531-540. abaxial fracture fragments of the proximal sesamoid bone in
Mueller FOE. Allen D. Watson E. et al. Arthroscopic removal of a horses: 47 cases (1989-1997).J Am Vet Med Assoc 1998a; 213:
fragment from an intercondylar eminence fracture of the tibia in 1016-1021.
2-year-old horse. J Am Vet Med Assoc 1994; 204: 1793-1795. Southwood 11, Stashak TS, Kainer RA. Tenoscopicanatomy of equine
Nickels FA. Sande. B. Radiographic and arthroscopic findings in the carpal flexor synovial sheath. Vet Surg 1998b; 27: 15D-157.
equine stifle. J Am Vet Med Assoc 1982; 181: 918-922. Southwood 11, Stashak TS, Kainer RA, et al. Desmotomy of the
Nixon AJ. Diagnostic and surgical arthroscopy of the equine accessory ligament of the superficial digital flexor tendon in the
shoulder joint. Vet Surg 1987; 16: 44-52. horse with the use of a tenoscopic approach to the carpal sheath.
Nixon AJ. Arthroscopic approaches and intra-articular anatomy of VetSurg 1999; 28: 99-105.
the equine elbow. Vet Surg 1990a; 19: 93-101. Squire KR, Adams SB, Widmer WR, et al. Arthroscopic removal of a
Nixon AJ. Endoscopy of the digital flexor tendon sheath in horses. palmar radial osteochondroma causing carpal canal syndrome in
VetSurg 1990b; 19: 266-271. a horse. J Am Vet Med Assoc 1992; 201: 1216-1218.
Nixon AJ. Diagnostic and operative arthroscopy of the coxofemoral Stick JA, Borg LA, Nickels FA, et al. Arthroscopic removal of osteo-
joint in horses. Vet Surg 1994; 23: 377-385. chondral fragment from the caudal pouch of the lateral femoro-
Nixon AJ. Arthroscopic surgery of the carpal and digital tendon tibial joint in a colt. J Am Vet Assoc 1992; 200: 1695-1697.
sheaths. Clin Tech in Equine Pract 2002a; 1(4): 245-256. Takagi, K. Practical experience using Takagi's arthroscope. Nippon
Nixon AJ. Arthroscopic techniques for cartilage repair. Clin Tech SeikeigekaCakkai Zasshi, 1933; 8: 132.
Equine Pract 2002b; 1(4): 257-269. Textor JA, Nixon AJ, Lumsden J, et al. Subchondral cystic lesions
Nixon AJ. Sams AE. Duchame NG. Endoscopically assisted annular of the proximal extremity of the tibia in horses: 12 cases
ligment release in horses. Vet Surg 1993; 22: 501-507. (1983-2000). J Am Vet Med Assoc 2001; 218: 408-413.
l'extor JA. Nixon AJ. Fortier LA. Tenoscopic release of the equine dorsomedial intercarpal ligaments of the mid-carpal joint. Vet
carpal canal. Vet Surg 2003; 32: 278-284. Surg 1997a; 26: 359-366.
Trumble TN. Stick AJ. Arnoczky SF. et al. Consideration of anatomic Whitton RC. Rose RJ.The intercarpal ligaments of the equine mid-
and radiographic features of the caudal pouches of the carpal joint. Part II: the role of the palmar intercarpal ligaments
femorotibial joints of horses for the purpose of arthroscopy. Am J in the restraint of dorsal displacement of the proximal row of
VetRes 1994; 55: 1682-1689. carpal bones. Vet Surg 1997b; 26: 367-373.
VacekJR. Welch RD. Honnas CM. Arthroscopic approach and intra- Whitton RC. Kannegieter NJ. Rose RJ.The intercarpal ligaments of
articular anatomy of the palmaroproximal and plantaroproximal the equine mid-carpal joint. Part III: clinical observations in 32
aspect of distal interphalangeal joints. Vet Surg 1992; 4: racing horses with mid-carpal joint disease.Vet Surg 1997c; 26:
257-260. 374-381.
Vail TB. Mcllwraith CWoArthroscopic removal of an osteochondral Wilderjans H. BoussawB, Madder K. Simon O. Tenosynovitis of the
--~ "-"" -
fragment from the middle phalanx of a horse. Vet Surg 1992; 4:
269-272.
ValdezH. Richmond J. Wain L. Fackelman G. Operative arthroscopy
in the horse. Equine Pract 1983; 5: 39-42.
Walmsley JP.Vertical tears in the cranial horn of the meniscus and
its cranial ligament in the equine femorotibial joint: 7 casesand
their treatment by arthroscopic surgery. Equine Vet J 1995; 27:
20-25.
Walmsley Jp. Fracture of the intercondylar eminence of the tibia
treated by arthroscopic internal fixation. Equine Vet J 1997; 29:
148-150.
Walmsley JP. Arthroscopic surgery of the femorotibial joint. Clin
Tech Equine Pract 2002; 1: 226-233.

cases.EquineVetJ2003; 35: 402-406.


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
~

with 300 or 700 lens angles; and a 1.9 mm diameter arthro-


scope with 300 lens angle. Generally. surgeons should choose
of instrumentation is available for human the largest diameter arthroscope that can safely be inserted
arthroscopic surgery, but much of it is unsuitable and and maneuvered without causing damage. Small diameter
unnecessary for equine arthroscopy. Many of the operating arthroscopes with appropriate operating instrumentation
instruments are expensive and fragile; for equine use a have been developed for use in human carpal. metatarso-
limited amount of equipment is generally essential or phalangeal. and temporomandibular joints (Poehling 1988).
appropriate. The descriptions and recommendations in this However.these are fragile. allow lessillumination. and provide
text are based on the authors' experiences and personal a much smaller field of view (900 for 2.7-mm scope and 750
choices and numerous substitutions can be made. Obviously, for 1.9-mm scope). Small diameter arthroscopes usually also
the potential for variation is extreme, and it is necessary to have a shorter working length (50-60 mm) because the
continue to evaluate new instrumentation as it becomes excessiveflexibility of a longer instrument increases the risk
available or as new arthroscopic procedures are developed. of breakage (Poehling 1988). More recently. a complete range
This chapter represents the authors' current views on of sizes has also become available in video arthroscopes.
instrumentation. 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
The availablearthroscopesvary in outer diameter,working approaches.using a rigid arthroscope for most of the procedure
length, and in lens angle, which may be straight (0°) or and a flexible arthroscope to accessdifficult areas of the hip.
angledfrom 5° to 110°. Many manufacturersmarket 4 mm ankle. or knee in people. have added to the more thorough
diameterarthroscopeswith 0°, 30°, or 70° lens anglesand evaluation of these joints (Takahashi & Yamamoto 1997).
working lengths of 160-175 mm. The field of view is often A 4 mm diameter arthroscope with a 25 or 300 lens angle
115° or more,leadingto their classificationas "wide field of fulfills most needs of the equine surgeon (Fig. 2.1). A 4 mm
view" arthroscopes. Most manufacturers produce small 700 arthroscope can occasionally provide improved visualiz-
arthroscopes,usually 2.7 mm diameter arthroscopeswith ation of specific areas of some joints such as the tarsocrural.
30° or 70° lensangles;a short 2.7 mm diameterarthroscope 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

..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
tarsophalangeal joints. Figure 2.2 illustrates the different .rZlmmer. PO Box 708. 1800 West Center St.. Warsaw. IN 46581.
fields of view of a 250 arthroscope and a 700 arthroscope in Tel: (800) 613-6131. www.zimmer.com
the same position in a tarsocrural joint. Popular choices in an .SOlympus America Inc.. 2 Corporate CenterDrive. Melville. NY 11747.
Tel: (800) 848-9024. www.olympusamerica.com
arthroscope for routine equine arthroscopy include the 300 .hArthrex. 2885 South Horseshoe Drive. Naples. FL 34104.
videoarthroscope and direct view arthroscopes from Smith & 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!


Reliant 300 W xenon source, and a Stryker X-6000 500 W
capture. The sources may be high-intensity xenon source (Fig.2.7). The bulbs last from 350 to 500 hours,
illumination, xenon arc lamps (100-500 W), or which represents a recurring cost for busy practices.
vapor lamps (McGinty 1984). The xenon light Light sources that automatically adjust the light intensity
-the replacement 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
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
sleeve.In countries where ethylene oxide is not motorized pump. Such pumps can provide both high flow
rates and high intra-articular pressures.rThe simplest and
moisture betweenthe arthroscopeand camera 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.
largely eliminated with cameraswhich have large, Such pumps are relatively inexpensive (Table 2.1) and provide
high flow rates on demand, which is particularly useful for
vents is employed.the problemcan be distention of large synovial spaces (see also Chapter 3), but
automatic control of the pressure is lacking (Bergstrom &
and also by using warm irrigating fluid. Anti- 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
irrigation system generated, and compartment syndrome has occurred using
mechanical pressure delivery systemsin man.
polyionic fluid is used for joint distention and The ideal pressure and flow automated pump should be
~ during surgical arthroscopic procedures. The
capable of delivering necessary flow rates on demand, keep
an intravenous set connected to pressure at adequate yet safe levels, and include safety
features such as intra-articular pressure-sensitiveshutdowns
to apply pressure(Fig. 2.10). This method is satis- and alarms (Ogilvie-Harris & Weisleder 1995). Many new
pumps meet these criteria, including pumps made by Arthrex,
is economical and provides distention superior to Stryker Endoscopy,Smith & Nephew -Dyonics, Karl Storz,
feed developedby suspendingthe fluids abovethe

Inc., Baxter Health Care Corp, One Baxter

gravity flow through sleeves


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

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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 reservoir gas tank, including the Karl Storz and Richard WoU
solution is logical. The results of another study evaluating units (Fig. 2.16). Others, such as those from Unvatec, Stryker,
the acute effects of saline and lactated Ringer's solution on and Directed Energy, use a direct step-down valve system
cellular metabolism demonstrated an acute stress to both from a commercial tank (Fig. 2.17). Arguments have been
chondrocytes and synoviocytes immediately after irrigation advanced for the use of gas insufflation of the joint rather
with both fluids, although this was greater with saline. These than fluid distention during arthroscopy (Eriksson & Sebik
stress patterns (monitored by evaluating relative ATP 1982); the gaseousmedium (carbon dioxide, helium, or nitrous
regeneration) are apparent after 24 hours, appear to oxide) results in a sharper image with higher contrast. As
be returning toward normal by 48 hours, and are not well as being useful for photographs, some evidence exists
significantly different from control values 1 week later. Based that it may offer an increased degree of accuracy in assessing
on these results, protection from full activity during this time cartilage damage in some situations (Eriksson& Sebik 1982).
period was considered advisable (Straehley 1985). In addition, it can prevent synovial villi from interfering with
Gas insufflation has been used routinely in equine arthro- the visual field. However, a pressure-regulating device and a
scopy by two of the authors G.B. and A.J.N.). Several types special system are necessary for gas insufflation. In addition,
of gas insufflators are available. Most have a small internal 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 areavailablefrom all arthroscopicinstrumentmanufacturers.
cannula is used to flush fluid through the joint in order to Probesfrom differentmanufacturersvary in length and end
clear blood and debris and optimize visibility. The outer end configuration. The probe end can be round, square or
has a luer attachment through which fluid can be aspirated rectangularand can vary from 3 to 6 mm in length. Longer
or to which a long, flexible egress tube can be attached to tips on the probecan hamperentry to the joint bytangling in
transmit fluid to a bucket on the floor rather than having it the capsule,while smallerprobesare easyto insert but are
spillover the surgical site or equipment. The authors use a 2- more proneto bending.A 3-mmrectangularend probewith
or 3-mmegress cannula (Fig. 2.18a) routinely at the beginning taperedshaftis convenientand durable(seeFig. 2.19). The
of the arthroscopic procedure to flush the joint and to probe handle on probescan vary from a round smoothshaft. to a
and manipulate lesions. A larger diameter (4. 5-mm) cannula rectangular shaft, which is easier to grasp, and to the
(Fig. 2 .18c) can be used at the end of the procedure for additionof a thumb bar for directedapplicationof pressure.
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 Forceps
facilitate placement of the larger 4.5-mm cannula at the end Currently. the authors use seven different forceps for
of the procedure. retrieving fragments and trimming lesions (Figs 2.20-2.24).
1. Routine use. The workhorse in most arthroscopy packs is
Hand instruments for the Ferris-Smith intervertebral disc rongeur. For removal
of large fracture fragments and osteochondritis dissecans
arthroscopic surgery
flaps. a pair of Ferris-Smith cup rongeurs with a 7-inch
As mentioned previously, a myriad of instruments are avail- shaft and a straight 4 x 10-rom bite (Scanlan Instruments)
able from arthroscopic equipment manufacturers (Caspari is used. These forceps are better than other types for this
1987, Gross 1993, Ekman & Poehling 1994), most of which purpose. Variation exists with regard to the shape of the
are neither suitable nor necessary for equine arthroscopic jaws on different 4 x 10-rom Ferris-Smith rongeurs. A
surgery. The instruments presented in this section are those narrow-nosed pair made by Sontec (Scanlan) is useful for
used by the authors to perform the procedures described in carpal and proximal phalangeal fragments. They pass
this book. It is accepted that there are alternative, and through the instrument portal easily and are appropriate
possibly better, ways to perform any given task and tech- for small and medium-sized fragments (Fig. 2.20). Another
niques certainly will change. The current list is written with pair of Ferris-Smith rongeurs with a 6 x l2-rom cup is
the philosophy of keeping arthroscopy simple and practical used for larger fragments (Fig. 2.20). A set with the jaw
without compromising standards. A combination of angled up and with a 4 x 10-rom cup are also useful in
specialized arthroscopic instruments and instruments not some tight situations. Some surgeons use a pituitary
designed specifically for arthroscopic surgery is used. rongeur for longer fragments.
2. Small fragments. Also recommended is a pair of straight
Blunt Probe ethmoid rongeurs with a 5-rom bite (Richard Wolf or
Scanlan Instruments). These instruments have a pointed
This standard arthroscopic instrument (Fig. 2.19) is necessary nose and are useful for procedures involving chip fractures
for diagnostic as well as surgical arthroscopy. Suitable probes off the proximal aspectsof the first phalanx (seeChapter 5).

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.

~
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 Elevators and osteotomes
phalanx, the palmar recessesof the midcarpaljoint, and
the underside of the patella. The use of sharp-edged The instruments primarily used for separating fragments
rongeur-typeinstruments is preferredin most situations from parent bone include a small round-end curved periosteal
whenpiecesto beremovedare still attachedby softtissue. elevator or a straight narrow osteotome. Examples include
5. Loose bodies. Loosebodiescanberetrievedwith custom the small (6-mm) round-end SynthesO elevator, the 5-mm
equine loosebody forceps,since most loosebodyforceps Mcllwraith-Scanlan elevato~, and the 4-mm cottle osteotome
availablein catalogsof arthroscopicinstrumentsare not (Scanlan) (Fig. 2.25). An extra small (3-mm) curved Synthes
strong enough. For instance,Zimmerhas takenthe basic elevator is also occasionally useful (Fig. 2.25). A markedly
Ferris-Smithdesignand changedthe endsof the jaws for curved sharp-end periosteal elevator (Fig. 2.26) is useful for
removing apical sesamoid fragments (Foerner elevator;
specificpurposes.
6. Cutting forceps. Basketforcepsare used occasionally Scanlan Instruments; see Chapter 5).
(Fig. 2.23) for removal of cartilaginous flaps of osteo-
chondritisdissecansin the femoropatellarjoint. A narrow, Cutting instruments
modifiedbasketforceps(seeCutting Instruments section)
is useful for severing soft tissue structures such as Numerous cutting instruments are available. Their use is
villonodular pads. limited to certain situations. If sharp severance of structures
7. Broken instrument retrieval. A fragmentforcepswith a is required. special arthroscopic cutting instruments should
malleable shaft is also occasionally useful, but not be used. The authors have used both reusable blades and
essential.Theseforcepsare illustrated in Figure 2.24 and disposable blade systems (Fig. 2.27), made by Karl StOrzb,
are madeby ScanlanInstruments(Sontec).
."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 While motorized equipment should be used only with due
prevents having to set up motorized equipment. Use of consideration to the synovial environment and tissues. these
suction enables instant removal of debris as it forms during instruments are extremely efficient and some surgical
debridement within the joint. However, with the high fluid procedures can only be done effectively with such equipment.
pressures used in equine arthroscopy, suction is often un- Synovial resection. whether performed locally to improve
necessary as free material is often spontaneously flushed out visualization of lesions or therapeutically on a subtotal basis.
through the suction channel. The use of suction during any can only effectively be performed with motorized apparatus.
procedure requires an increased rate of ingress fluid delivery. Similarly, some large areas of osseousdebridement. such as
In general, the authors prefer to perform hand debridement in shoulder or stifle osteochondrosis, become impossible to
without suction, reserving it for use with motorized instru- complete reasonably without such equipment. The basic
ments or to remove debris at the end of surgical procedures. concept of motorized instruments is a rotating blade within a
sheath to which suction can be applied. This pulls soft tissue
Motorized instrumentation into the mouth of the blade and removes debris (Graf and
Clancy 1987). Most currently available systemsare powered
A large assortment of motorized arthroscopic instruments electrically and consist of a control unit attached by an
are available from most of the equipment manufacturers. electrical cord to a motorized handpiece. The latter may be
h & Nephew. 15049-1000. operated by buttons on the handpiece or via a foot pedal to
www.sm 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 the subject of ongoing debate. investigation. and litigation
full radius blade (#7205307) for villonodular pads and (Lee et al 2002). Given these issues. RF for chondroplasty
menisci, the 4.5-mm rotatable curved orbit incisor should be avoided until further studies define safe settings.
(#7205320) or Incisor Plus (#7205687) for most other soft and the use of RF probes in cutting modes for capsule. check
tissue resection, and the 4.0-mm Acromionizer (oval burr; ligament. or annular ligament transection should use the
#7205326) or 4.0-mm Abrader (round burr; #7205324) for minimal power settings that still achieve the desired effect.
bone debridement (seeFig. 2.34). Recently, a range of dual- and should absolutely avoid cartilage and underlying bone.
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 Lasers
both inventory and the need to switch blades in surgery.
Use of suction on shavers generally improves cutting Lasershave beenused in arthroscopic procedures for removal
performance. However, attention to the degree of filling of of fibrillated cartilage. synovial proliferation and masses.and
the suction bottle is required to prevent the automatic suction for transection of plical and other adhesive syndromes
shut-off engaging, which can then allow fluid to flow back (Lubbers & Siebert 1997. Janecki et al 1998. Smith &
from non-sterile tubing and couplers at the bottle through Trauner 1999). They have declined in popularity in recent
the sterile patient line and out the shaver into the joint or years due to the continued high cost of the units and concern
onto the sterile field. It has been recognized as a potential risk over thermal damage to the cartilage and underlying bone
in the use of shavers for some time (Bacarese-Hamilton et al (Atik&Tali 1999. Sclamberg & Vangsness2002). Lasertypes
1991), and it is particularly likely to happen when the fluid include COpNd:YAG. Ho:YAG. and excimer wavelengths. The
ingressruns out at that same moment, removing the positive use of CO2lasers has diminished. while Ho:YAG and excimer
pressureforcing joint fluid into the suction line. Prevention lasers have persisted (Roth & Nixon 1991. Smith & Trauner
requires suction to be maintained on the tubing at all times, 1999. Doyle-Jones et al 2002). Laser capsule shrinkage for
or at the very least ensuring the joint is pressurized during shoulder and knee disorders and laser-assisted partial
suction bottle exchange. meniscectomy remain the primary use in man (Lubbers &
Siebert 1997. Smith & Trauner 1999). Laser chondroplasty
has been controversial and. despite an excellent appearance
Electrosurgical and following lasersculpting. later cartilage necrosisand mounting
radiofrequency devices researchevidence suggestthe use of laser for cartilage debride-
ment is dangerous unless extreme care in power settings and
Considerableinterest and concurrent concern surrounds the methods of application are employed Ganecki et al 1998.
use of radiofrequency (electrosurgical) devices for cartilage Sclamberg & Vangsness2002; Atik et al2003).
and synovial soft tissue procedures (Polousky et al 2000, Laser-assisted arthrodesis of the distal tarsal joints
Medveckyet al2001, Lu et al2001, Lee et al2002; Sherk et al provides a minimally invasive method for cartilage debride-
2002). Radiofrequency (RF) devices utilize extremely high- ment and articular desensitization (Hague & Guccione
frequency alternating current (e.g. 330 kHz compared to the 2000). Eventual distal intertarsal and tarsometatarsal joint
60 Hz of regular alternating current), which passes to the arthrodesis can develop;however. resolution of the symptoms
tissue at the applicator tip and then through the body to exit of bone spavin do not necessarily require radiographically
at a wide grounding plate, essentially as for all electrosurgical defined obliteration of these joints.
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
Still photography
high voltage denatures and coagulates tissues (Sherk et al
Historically,still photographicimageshave beenrecordedon
2002). Used in the liquid environment of the joint, both of
35-mm film using a camerawith a quick mount adaptorto
these modes have found a place for excision of tissue (plica,
the arthroscope. However,this is time consuming, risks
adhesions,villonodular masses),or denaturation of cartilage
contaminating the surgical field, and is extremely light
(cartilage sculpting or chondroplasty). Radiofrequency
sensitive.A practical alternative is to use a digital camera
devicesused in a cutting mode, at the lowest settings that will
such as a Nikon Coolpix 4500 fitted with an endoscope
still cut plica, ligament, menisci, or masses,seemto be safe if
the probe is directed away from cartilage and does not dwell
adaptor,e.g. Karl Storzrapid coupling adaptor (Fig. 2.35).
Imagesare viewedon a screenon the back of the camera,
on bone (Polousky et al 2000, Lee et al 2002). Similarly,
storedon a memorycard,and may be downloadedlater to a
thermal capsular shrinkage using low power settings has
computerfor imageadjustmentand archiving.
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 Video documentation
bone and cause chondrocyte death (Lu et al 2000, 2001). -

Despite the apparent smoothness of cartilage after RF Capture of video clips as analog video on a ~-inch VCR i:
chondroplasty, the later necrosis can be devastating, and is 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 capture the image (often by clicking a button on the video
for still printing is also very time consuming and does not camera), and store and arrange the images during the
lend itself well to the flow of information to the client. How- surgery. A 3.5 x 5 or 6 x 8-inch print is produced when a
ever, video and s-video formatted VCRs have become very preset number of images have been accumulated to memory.
cheap, and are better than no documentation. Further, simple The print quality (300 dpi) from a high end, digitally
video digitizing programs, such as Windows MoviemakerTM enhanced, 3-chip camera can be photographic quality
(Microsoft), iMovieTM (Apple), VideoStudio 6TM (ULead (Brown 1989). The authors have used the Sony Mavigraph
Systems), or Pinnacle Studio Version 7TM(Pinnacle Systems UP-5600MD, Mavigraph UP-5200MD and the Mavigraph
Inc), all provide a means to capture video from !-inch tapes as
UP2900 color video printers. The UP-5600MD provides
digital video (e.g. MPEG format) or as digital still images (e.g. excellent image quality at approximately $1 per page. These
JPEGformat) that can then be stored electronically or printed units sell for $4,000-$6,000. More economical storage can
out for several cents an image on a color ink-jet printer. be provided from small devices such as the Sony MavicapTM
Additionally, digital video clips can be edited, trimmed, electronic capture and storage device. This stores images on
spliced, and assembled into an annotated presentation floppy disks, which can then be printed on an office computer
using these programs. Other capture systems using Hi8
and inexpensive color ink-jet printer.
video capture have been described and for a complete review Complete digital capture and storage devices for arthro-
of arthroscopic image documentation, the reader is
scopic use are manufactured by Karl Storz, Stryker, and
directed to a recent review which provides an in-depth Dyonics. All three units are expensive, but store both digital
comparison of systems, cabling, connectors, and output still images (TIFF format-with Storz AIDA and JPEGformats
devices (Frisbie 2002). 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
Digital ima~e capture and the field of digital storage devices (Figs 2.37 and 2.38). The
storage devices units have touch screen patient input, and image editing for
still image output. Image printing can be done in the surgery
Arthroscopic image printing and storage has undergone by attaching an inexpensive HP deskjet printer, while still and
significantimprovementalong with the electronicrevolution video images are also savedon the system's hard drive. At the
of the previous decade.The simplesttechnique for image completion of each case,the files are savedon CD or DVD. The
documentationis electroniccapture and printing on a dye software in the unit provides versatile settings that allow
sublimation printer (Brown 1989. Johnson2002). Self- extensive customization of image capture and compression,
contained units such as the SonyMavigraphS(Fig. 2.36). image editing, output styles, text addition, and internet
.'Sony Electronics, 1 Sony Drive, Park Ridge, NJ 07656. Tel: access. Retail prices range from $12,000 to $16,000. The
(201) 930-1000. www.sonystyle.com Smith & Nephew -Dyonics Vision 625 Digital Capture
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
(Fig. 2.39) providesmany similar featuresto the sterile tray. The instruments are washed with sterile water or
saline (Fig. 2.40) and transferred to the surgery table where
be via zip disk or CD drive. and the they are dried after the surgeon's outer gloves are removed.
$9,700 to $12,000. 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
of equipment instruments. Rinsing of the equipment must be done with
care to avoid damage to the camera and arthroscope from
steam autoclaving shortens the useful life of an sharp-edged hand tools.
by causing deterioration of the adhesives
the major lenses. Seals and bonding between .'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
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
that an assistanttotally familiar with the 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
and draping systems tend to be determined by the .'Veterinary Surgical Resources.Inc. POBox 71. Darllngion. MD 21034.
preference, cost of drapes, and the safety and 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
Motorized
--
arthroscopic instruments: a

setup and equipment. Orthop Clin

impressions of a new technique


..-Vet

.Proc 34th Ann Mtg Orthopaedic


: 332.
Jackson DW. Ovadia DN. Videoarthroscopy: present and future
developments. Arthroscopy 1985; 1: 108-115.
JagerR. Technical and instrumental requirements of arthroscopy of
the knee joint. Endoscopy 1980; 12: 261-264.
Janecki CJ,Perry MW. Bonati AO. Bendel M. Safeparameters for laser
chondroplasty of the knee. Lasers SurgMed 1998; 23: 141-150.
Johnson DH. Basic science in digital imaging: storage and retrieval.
Arthroscopy 2002; 18: 648-653.
Johnson 11. Shneider DA. Austin MD. et al. Two per cent
glutaraldehyde: a disinfectant in arthroscopy and arthroscopic
surgery. J Bone Joint Surg Am 1982; 64: 237-239.
Johnson RG. Herbert MA. Wright S. et al. The response of articular
cartilage to the in vivo replacement of synovial fluid with saline.
Clin Orthop 1983; 285-292.
al 1995). Thesedevices'have beenused fol- Lee EW. Paulos LE. Warren RF. Complications of thermal
energy in knee surgery -Part II. Clin Sports Med 2002; 21:
753-763.
and the resolu-
Lu Y. Edwards RH. III. Cole BJ. Markel MD. Thermal chondroplasty
particularly periarticular swelling, has with radiofrequency energy. An in vitro comparison of bipolar
and monopolar radiofrequency devices.Am J Sports Med 2001;
29: 42-49.
Lu Y. Hayashi K. Hecht P. The effect of monopolar radiofrequency
energy on partial-thickness defects of articular cartilage.
Arthroscopy 2000; 16: 527-536.
Lubbers C, Siebert WE. Holmium:YAG-laser-assisted arthroscopy
versus conventional methods for treatment of the knee. Two-year
results of a prospective study. Knee Surg Sports Traumatol
the holmium:YAG laser cause osteonecrosis? Arthrosc 1997; 5: 168-175.
113. Martin SS. Spindler KP. Tarter JW. Detwiler K. Petersen HA.
IA. Bhamra M. Jackson AM. Arthroscopic Cryotherapy: an effective modality for decreasing intraarticular
, 'sepsis. Ann R Coil Surg temperature after knee arthroscopy. Am J Sports Med 2001; 29:
288-291.
McGuire DA. Click S. Continuous-flow cold therapy McDonald R. Rigid endoscopes. Proper care and maintenance.
, anterior cruciate ligament reconstruction. AORN J 1984: 39: 1236-1242.
130-135. McGinty JR. Photography and arthroscopy. In: Casscells SW (ed.).
an infusion pump in arthroscopy. Arthroscopy: diagnostic and surgical practice. Philadelphia: Lea
& Febiger; 1984.
Producing still imagesin arthroscopy.Arthroscopy Medvecky MI. Ong BC. Rokito AS. Sherman OH. Thermal capsular
shrinkage: basic science and clinical applications. Arthroscopy
RB. Current development of instrumentation for 2001; 17: 624-635.
.Clin Sports Med 1987; 6: 619-636. Minkoff J. Arthroscopy -its value and problems. Orthop Clin North
Augustini B-G. Three irrigation systems for motorized Am 1977; 8: 683-706.
.surgery: a comparative experimental and clinical Morgan CD. Fluid delivery systems for arthroscopy. Arthroscopy
: 307-314. 1987; 3: 288-291.
Synovial regeneration in Noyes FR. Good ES. Hoffman SD. The effect of flexion angle on
carpus after arthroscopic mechanical or carbon pressure-volume relationships in the human knee. Proc Ann
.Vet Surg 2002; 31; 331-343. Mtg AANA.
EF. Poehling GG. Principles of arthroscopy and wrist Ogilvie-Harris DJ. WeislederL. Fluid pump systems for arthroscopy:
a comparison of pressure control versus pressure and flow control.
.. Arthroscopy 1995; 11: 591-595.
fluid medium. Orthop Clin North Am 1982; 13: Oretorp N. Elmersson S. Arthroscopy and irrigation control.
Arthroscopy 1986; 2: 46-50.
Arthroscopic documentation. Clin TechEquine Pract PoeWing GG. Instrumentation for small joints: the arthroscope.
.1: 270-275. Arthroscopy 1988; 4: 45-46.
Polousky JD. Hedman TP. Vangsness CT Jr. Electrosurgical methods
.'Equine Cryo-Cuff,GameReadyCoolSystems Inc., 929 CameliaSt,Berkeley, for arthroscopic meniscectomy: a review of the literature.
CA 94710. Tel: (866) 266-5797. www.gameready.com Arthroscopy 2000; 16: 813-821.
Reagan BF. McInerny VK. Treadwell BV. Zarins B. Mankin HJ. Smith CP.Trauner KB. Arthroscopic laser surgery: a revisitation. Am
Irrigating solutions for arthroscopy. A metabolic study. J Bone J Knee Surg 1999; 12: 192-195.
Joint Surg Am 1983: 65: 629-631. Straehley D. The effect of arthroscopic irrigating solutions on
Roth JE. Nixon AJ. Pulsed carbon dioxide laser for cartilage cartilageandsynovium. Trans 31stAnnMtgORS 1985; 15: 260.
vaporization and subchondral bone perforation in horses: 1. Takahashi T. Yamamoto H. Development and clinical application of
Technique. clinical results. and synovial fluid response. Vet Surg a flexible arthroscopy system. Arthroscopy 1997; 13: 42-50.
1991: 2018: 190-199. Whelan JM. Jackson DW:Videoarthroscopy: review and state of the
Sclamberg SG. Vangsness. CT Jr. Laser-assistedchondroplasty. Clin art. Arthroscopy 1992; 8: 311-319.
Sports Med 2002: 21: 687-691. ix. Whitelaw GP. DeMuth KA. Demos HA. Schepsis A. JacquesE. The
Sherk HH. VangsnessCT. Thabit Gill. Jackson RW Electromagnetic use of the Cryo/Cuff versus ice and elastic wrap in the post-
surgical devices in orthopaedics. Lasers and ramofrequency. operative care of knee arthroscopy patients. Am J Knee Surg
J Bone Joint Surg Am 2002: 84-A: 675-681. 1995; 8: 28-30.
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
principles can be applied to the other joints. The (Phillips et al 1991, Rosenberg et al1976). CWorhexidine
closely fulfills all the criteria of an ideal preoperative patient
maneuversin the different joints are 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
evaluation of the patient of organic material), and causes minimal skin irritation
(Stubbs et al1996). However, it should be noted that in a
undergoing an arthroscopicprocedurefor a study evaluating the effectivenessof a 5-minute surgical scrub
or suspectedintra-articular problem must first be using either a one-brush or two-brush technique in clean and
dirty surgical procedures, and also comparing the efficacy of
These principles may be taken for granted by povidone iodine with cWorhexidine as surgical scrub solutions,
,. The hazard of avoid- both povidone iodine and cWorhexidine were equally effective
has also been noted in association with in decreasing bacterial numbers on the skin, given a variety
1983). of contamination levels present before the scrub procedure
the lack thereof) are discussed (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
preparation 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
- femoropatellar joint.
skin incisionsso that a hair or portion of hair is not The method of draping is the choice of the individual
into the joint on insertion of the arthroscopeor 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
arthrocentesis sites. it has been concluded some of these products in regard to adhering to the skin
the skin over the midcarpal and satisfactorily. In this regard, Iobana drapes are superior.
joints can be accomplished without

.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 entry of the latter into the joint. Direct arthroscopic visualiz-
inserted perpendicularly to the skin surface. avoiding any ation of the joint can then be performed (extremely rare
tendency to angle toward the ultimate position of the scope. nowadays) (Fig. 3.6), or the video camera (seeChapter 2) can
This position is to obviate opening a subcutaneous dissection be attached. depending on the method used by the surgeon.
plane. Advancement of the sheath within the joint is If the camera has not been soaked. the use of a sterile
achieved most safely by use of the blunt or conical obturator, sleeveis necessary.If using a sleeve.it is important to ensure
becausethe articular cartilage is at risk for damage when the a watertight seal of the cover over the head of the
sheath containing the arthroscope is advanced. This risk has
arthroscope.
been decreased by improved congruity between the ends of After insertion of the arthroscope. in the case of the
the sheath in relationship to the end of the arthroscope in carpus, the instrument portal through the joint capsule is
currently available instruments. The authors no longer use made with a direct perpendicular stab with a No. 15 or
the sharp trocar for insertion of the arthroscopic sleeve in No. 11 blade (Fig. 3.6). In other joints, the instrument portal
any joint. is made in the same fashion. but often a needle is placed
Once the arthroscopic sheath is in place, the blunt in the proposed position and visualized. and, if appropriately
obturator is replaced with the arthroscope, and the fiberoptic located, the instrument portal through skin and joint
light cable and the ingress fluid system are attached to the capsule is then made. The authors' prefer to create the portal
arthroscope and the sleeve, respectively (Fig. 3.5). The and then insert the small egress cannula without using
ingress fluid line has been cleared of air bubbles to avoid a trocar or obturator (Fig. 3.7).
Any cloudinessor hemorrhage within the joint can be been recommended (Crane 1984). In the authors' opinion,
cleared by opening the egresscannula and pumping fluid this technique is unsatisfactory in the carpus and fetlock of
through the ingresssystem.Regardingthe use of the egress the horse because of the smaller size of the joint and the
cannula in the carpal and fetlock joints, the holes in the increased amount of synovial villi. As referred to
cannula must not extendmorethan 6- 7 mm fromthe end of subsequently, villi interposition is not a problem in
the cannula. If they do, the cannula should be shortened arthroscopic procedures in the human knee, but it is often a
appropriately.Otherwise,someholes will not be within the major one in the horse, necessitating the use of different
joint but will be within the subcutaneoustissues,promoting techniques to handle this situation. The use of closed
rapid extracapsularextravasationof fluid. distention obviates the problem of villi interposition rather
Oncethe view is clear,the stopcockon the egresscannula well in most instances.
is closedduring visualization;otherwise,villi waving within Any fluid system capable of exerting pressure within the
the flowing fluid obstructthe view (Fig.3.8).This pointneeds joint has the potential to cause its own complications (Noyes
emphasizingbecauseother authors in equine arthroscopy & Spievack 1982). Joint capsule rupture in the human knee
mention the difficulties with synovial villi obstructing the at about 200 mmHg pressure has been recorded, and this
visual field, and advocatethe use of adjunctive synovial rupture in turn causes severeextracapsular extravasation of
membraneresection.This procedurenecessitatesthe use of fluid. Flexion of the joint markedly elevates the pressure in a
motorized equipment. Alternatively, gas distention rather given joint. Severeflexion changes during equine arthroscopy
than liquid distentionpreventsthis problem. In diagnostic are rare, but a situation of high intra-articular pressure can
arthroscopyof the human knee,the useof both a suspended developeasily.The choices of fluid systems were discussedin
fluid sourceand constantflow of fluid through the kneehave 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 Use of the probe in
and they are used according to
diagnostic arthroscopy
For effective diagnostic arthroscopy, the use of a probe
Two basic techniques have beendevelopedfor arthroscopic 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
Although it probe (seeFig. 3.9). In the carpus, the egresscannula is often
used as a probe to palpate lesions. This technique is a "short
orthopedic practice (Carson 1984), the technique cut", often eliminating the need for another instrument
not beenused in equine surgery and thereforeis not insertion. On the other hand, the blunt, hooked probe is
important in assessingsuspect articular cartilage in cases of
The secondtechnique is triangulation. which involves osteochondritis dissecans,and its use is a routine part of the
one or more operating instruments through procedure. Elsworth et al (1986) noted, "arthroscopy with-
-~

out the use of the probe is an incomplete investigation," and


the instrument and the arthroscopeforming that routine use of the probe is essential in training for
arthroscopic surgery.

3.9, (and alsoin Figs.4.21 to 4.23) and it is


to handle all of the various surgical requirementsin Post-arthroscopic irrigation and closure
--

as well as surgicalarthroscopy.To be ableto use When the arthroscopic procedureis completed,using an


technique effectively,the surgeon must developthe openegresscannula and pumping fluid through the joints
effectivelyflushesdebrisfrom the joint. Typically,the larger,
confined space while using monocular vision, which 4.5 mm cannula is usedso that all debrisis removed(in the
., femoropatellarjoint a larger 6 romcannula is used).
For arthroscopic surgery, instrument portals are made in No suturesare requiredto closethe joint capsuleportals.
, .on the joint and the site of the
One or two sutures are placed in the skin incisions. One
Cannulas or sleeves are rarely used at instrument suture is usually sufficient. The authors prefer a simple
for reasons mentioned in Chapter 2. To create an
interrupted pattern to a cruciate pattern, to avoidinverting
a skin incision is made followed by a stab the skin edge.In human arthroscopy,some authors have
the joint capsule with the use of a No. 11 or 15 madea casefor not suturing skin incisions(Williamsonand
blade. These techniques have been noted previously
Copeland1988). Cosmeticadvantageshave beenproposed
3.6). In the carpus, the first author (C.WM.) makes and someindividuals believehematomaor stitch abscesses
for the instrument portal before placement are less likely to occur. Suturing is consideredthe safer
whereas, in other joints, it is made after alternativein the horse.Specificpostoperativemanagement
placement and the position is then dictated by 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,
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).
the arthroscopic surgeon needs to be able to recognize the In addition, a higWy significant correlation was found between
synovial pattern for specific areas of each joint. Definition of the local macroscopic (arthroscopic) signs of inflammatory
abnormalities depends on a sound knowledge of the normal activity and microscopic findings.
distribution and characteristics of the villi. For example, in Although specific vasculature changes are considered to
the normal i.e. middle carpal joint, polyp-like filamentous villi occur in association with various arthritic entities and blood
are typical of the dorsomedial and dorsolateral areas of the vessels can be seen easily in normal villi, the conventional
joint (see Fig. 3.10). In the far medial portion of the joint, arthroscope lacks the magnification for detailed observation
the synovial membrane is smooth, white, and without villi. of fine vascular structures. A magnifying arthroscope has
The presence and morphology of normal synovial plicae and been developed and used in Japan (Inoue et al1979). The
the normal intra-articular ligaments need to be known details of the capillary network of the capsule and synovium
(Fig. 3.11). have been better defined in this fashion (seeFig. 3.12B). The
The surgeon needs to recognize the many variations of visual angle of the lens system is small and the visual field
normal synovium that exist and the degree of change that with good focus is narrow. A preliminary investigation was
can occur with minimal clinical compromise. reported in which researchers used another microendoscope
Synovitis manifests in a number of forms that have yet to with the ability to pass from panoramic vision to contact view
be completely characterized: at four different magnifications, including microscopic
observation of vitally stained cells (Fizziero et al1986). On
1. Hyperemia is typical of acute synovitis (Fig. 3.12). It may
the basis of these preliminary findings, the authors thought
be accompanied by some degree of edema and fibrin
the capabilities of the device went some way toward bridging
deposition.
the gap between the conventional arthroscope, the light
2. Petechiation can be observed.
microscope, and the scanning electron microscope.
3. Development of small, hyperemic villi in abnormal
The changes observedin experimentally induced synovitis
locations.
are good examples of the sequential changes that occur in
4. Thickening of villi and an increase in density of villi
synovitis (McIlwraith & Fessler 1978). They highlight not
(Figs 3.13 and 3.14).
only the changes that can be observed but also the fact that
S. Formation of new types of villi (e.g. cauliflower-like villi).
repeated examinations provide a good dynamic under-
6. Atrophy of villi and total flattening of villous areas with
standing of the synovial membrane. In this study, in which
fibrin band deposition and adhesion formation.
synovitis was induced by using filipin, hyperemia was
7. Formation of plump polypoid villi with detachment of
significant initially. Petechiation of the villi and abnormal
these massesto form "rice bodies".
development of small hyperemic villi in the medial aspect of
Note also that some areas or pieces of light-colored avascular the carpal joint were frequent findings. Membranous fan-like
synovium can often be mistaken for a loose body. and cauliflower-like villi were seen in these joints, whereas
In a number of instances of traumatic joint disease,such they do not appear in normal joints. In more severely in-
as cases involving carpal chips, chronic fibrotic changes flamed joints, fusion of villi across the joint and the presence
develop in the synovial membrane. In these cases, however, of fibrinoid strands and adhesion formation were evident.
the clinical signs may not differ from those noted in instances 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 horses wrinkled. and enfoldedcartilage,
changes in the cartilage can be recognized and, probe could be inserted into the
only when lesions extend into the sub- addition to focal lesions,4 of the 11
or over sufficient area to cause loss of joint horseshad generalizeddamageto cartilage on the medial
Many situations of cartilage compromise are less femoralcondyle.Thesefocal cartilagelesionson the femoral
than this, but they may still represent significant condyleweredebrided.In 2 of 4 cases,debridementwas not
A recent study in people recorded chondral possible;6 of 7 horseswith focal cartilagelesionstreatedby
lesions in 1000 consecutive knee debridementrecoveredcompletelyand resumed previous
2002). The lesions were classified activities.
recognized by the International Cartilage The arthroscope allows better detection of articular
Society (ICRS). Chondral or osteochondral lesions cartilage damage than gross visual inspection at post-
61 % of patients. Focal defects were found in mortem. Evensuperficialfibrillation can be recognizedwith
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-

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
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
Electrosurgery using high-frequency (HF) equipment The usefulnessof lavage in traumatic arthritis had been
(described in Chapter 2) has been used in both human and claimed prior to arthroscopic surgery becoming routine
equine arthroscopy. One of the authors G.B.)has used it quite (Norrie 1975). The adjunctive lavage that goes with
extensively in the horse. In humans. in addition to surgery on arthroscopicsurgeryhas alwaysbeenconsideredbeneficial.
the synovial membrane and joint capsules,most arthroscopic althoughthereis no clear documentationof this effect.How-
meniscal surgeries are routinely done with the electroknife by ever,the benefit of partial thickness chondrectomywhere
at least one group (Kramer et al1992). When using such there is cartilage fibrillation or minor exfoliation is more
3.31). The use of such debridement along books, attending seminars, and viewing video recordings.
, C C but controlled
"Hands on" training and practice, however, is essential.
Instruction and practice on cadavers is the most common
of the rabbit patella with no evidence of way veterinary clinicians have improved their skills before
in either the superficially or deeply shaved areas embarking on clinical cases.Animal cadavers have also been
--& Shephard 1987). Ultrastructural studies after used in the training for arthroscopy in humans (Voto et al
cartilage shavings question knee regeneration 1986); however, artificial models have also been used
Schmid 1987). A successfully.More recently, there has been some development
of equine artificial bones with joint capsules, but at present,
trial of arthroscopic surgery for osteoarthritis cadaver material is inexpensive and readily available.
knee in humans caused considerablecontroversy An interesting prospect for the future is the development
2002). The authors concludedthat the out- of computer-based simulations of arthroscopic surgery
for training and testing of arthroscopic skills (Medical
Simulations. Inc.. Williamstown. MA). Use of simulators will
increase particularly in learning human arthroscopic
techniques. There will probably be lessuse in the horse where
lavage and debridement of osteoarthritic cadaver material is still more available.
based on the severity of degeneration, continues to

horse.the authors feel that lavageis an important


part of arthroscopic procedures by reducing

Bass AL. Lesions of the synovium. In: Casscells SW (ed.).


Arthroscopy. diagnostic and surgical practice. Philadelphia: Lea
cartilage. A useful rule is that if articular & Febiger: 1984.
is attached to subchondral bone it should be left Bots RAA. Boerbooms AMT. Indications for arthroscopy and mono-
Second look arthroscopies provide an opportunity to and polyarticular arthritis. Am RheumDis 1979; 38: 337-340.
the amount of healing that has occurred in Butler JC. Andrews JR. The role of arthroscopic surgery in the
3.32). evaluation of acute traumatic hemoarthrosis in the knee. Clin
Orthop 1988; 228: 150-152.
Carson RW. Meniscectomy and other surgical techniques using the
operating arthroscope. In: Casscells SW (ed.) Arthroscopy. dia-
gnostic and surgical practice. Philadelphia: Lea & Febiger; 1984.
CasscellsSW:Lesions of the articular cartilage. In: CasscellsSW (ed.)
Arthroscopy. diagnostic and surgical practice. Philadelphia: Lea
& Febiger; 1984.
Casscells SW. Commentary; the argument for early arthroscopic
synovectomy in patients with severe hemophilia. Arthroscopy
1987; 3: 78-79.

References
Chow JC. Hantes M. Houle JB. Hypertrophy of the synovium in the
May, Lees. Non-steroidal anti-inflammatory drugs. In: McIlwraith
anteromedial aspect of the knee joint following trauma: an
CW, Trotter GW (eds) Joint disease in the Horse. Philadelphia:
unusual cause of knee pain. Arthroscopy 2002; 18: 735-740.
WB. Saunders; 1996: 223-237.
Crane J. Technique of diagnostic arthroscopy. In: CasscellsSW (ed.).
Mitchell N, Shephard N. Effective patellar sharing in the rabbit.
Arthroscopy. diagnostic and surgical practice. Philadelphia: Lea J Orthop Res 1987; 5: 388-392.
& Febiger; 1984. Mori Y. Debris observed by arthroscopy of the knee. Orthop Clin
Doyle-Jones PS. Sullins KE. Saunders GK. Synovial regeneration in NorthAm. 1979; 16: 579-593.
the equine carpus after arthroscopic mechanical or carbon dioxide
Moseley JB, O'Malley K, Petersen NJ, et al. A controlled trial of
laser synovectomy. Vet Surg 2002; 31: 331-343.
arthroscopic surgery for osteoarthritis of the knee. N Engi J Med
Elsworth CP.Drabu K. Hodson J. Noble J. To probe or not to probe. In:
2002; 347: 81-88.
Proceedings and Reports of Universities. Colleges. Councils. Norrie RD. The treatment of joint disease by saline lavage.
Associations and Societies. J Bone Joint Surg (Br) 1986; 68: 842.
Proceedings 21st Annual Meeting of the American Association
FizzieroL. ZizziF.Leyhissa R. Ferruzzi A. New methods in arthroscopy. of Equine Practitioners, Boston, MA, 1975; 91-94.
Preliminary investigation. Ann Rheum Dis. 1986; 45: 529-533. Nottage WM, Sprague NF, Auerbach BJ, Shahriarce H. The medial
Hague BA. Honnas CM. Simpson RB. Peloso JG. Evaluation of skin
patellar plica syndrome. AmJ Sports Med 1983; 11: 211-214.
bacterial flora before and after aseptic preparation of clipped and
Noyes FR, Spievack ES. Extra-articular fluid dissection in tissues
non-clipped arthrocentesis sites in horses. Vet. Surg. 1997; 26: during arthroscopy. A report of clinical cases and a study of
121-125. intra-articular and thigh pressures in cadavers. Am J Sports Med
Highgenboten CL. Arthroscopic synovectomy Orthop Clin North Am
1982;10:346-351.
1982; 13: 399-405. O'Connor RL. Arthroscopy. Philadelphia: JBLippincott; 1977.
Hjelle K. Solheime Strand T. Muri R. Brittberg M. Articular cartilage Palmer SE.Instrumentation and techniques for carbon dioxide lasers
defects in 1000 knee arthroscopies. Arthroscopy 2002; 18: in equine general surgery. Vet Clin North Am Equine Pract 1996;
730-734. 12: 397-414.
Inoue K. Yoshio O. Nishioka K Satoh Y. Mikanagi K. Examination of
Palmer JL, Bertone AL, Malemud CJ, Mansour J. Changes in third
the vascular network in the knee synovium and capsule with the
carpal bone articular cartilage after synovectomy in normal and
magnifying arthroscope. Orthop. Clin. North Am. 1979; 10: inflamed joints. Vet Surg 1998; 27: 321-330.
549-557. Parisien JS.The role of arthroscopy in the treatment of postoperative
JacksonRW. Arthroscopic surgery (current concepts review). J Bone
fibroarthrosis of the knee joint. Clin Orthop 1988; 229: 185-192.
Joint Surg (Am) 1983; 65: 416-420. Phillips MF, Vasseur PB, Gregory CR. Chlorhexidine diacetate versus
Jackson RW. Dietreichs C. The results of arthroscopic lavage and
povidone-iodine for pre-operative preparation of the skin: a
debridement of osteoarthritic knees based on the severity of
prospective randomized comparison in dogs and cats. J Am Anim
degeneration: a 4 to 6 year symptomatic follow-up. Arthroscopy
HospAssoc 1991; 27: 105-108.
2003; 19: 13-20. PoeWing GG. Degenerative arthritis. Arthroscopy and research
Johnson 11. Letter to the editor. Arthroscopy 2002; 18: 683-687.
(editorial). Arthroscopy 2002; 18: 683-687.
Jones D. Barber S. Doige C. Synovial fluid and clinical changes after
Rosenberg A, Alatatry SD, Peterson AF. Safety and efficacy of the
arthroscopic partial synovectomy of the equine middle carpal antiseptic cWorhexidine giuconate. Surg. Gynecol. Obstet. 1976;
joint. Vet. Surg. 1993; 22: 524-530.
143: 789-792.
JonesD. Barber S. Jack S. et aI. Morphological effects of arthroscopic
Richmond JC, McGinty JB. Segmental arthroscopic resection of
partial synovectomy in horses. Vet. Surg. 1994; 23: 231-240. the hypertrophic mediopatellar plica Clin Orthop 1983; 178:
Joyce KJ. Mankin HI. Caveatarthroscopes. Extra-articular lesions of
185-189.
bone simulating intra-articular pathology in the knee. J. Bone
Schmid A, Schmid F. Ultrastructural studies after arthroscopical
Joint Surg. (Am.) 1983;65: 289-292.
cartilage shaving (abstract). J Arthroscopy 1987; 3: 137.
Kramer J. Rosenthal A. Moraldo M. Mueller KM. Electrosurgery in
Schneider RK, Jenson p, Moore RM. Evaluation of cartilage lesions
arthroscopy. Arthroscopy 1992; 8: 125-129. on the medial femoral condyle as a cause of lameness in horses:
Kinnard P. Levesque RY. The plica syndrome. A syndrome of 11 cases(1988-1994). JAVMA 1997; 210: 1649-1652.
controversy. Clin. Orthop. 1984; 183: 141-147. Stubbs WP, Bellah JR, Vermaas-Hekman D, Purich B, Kuplis PS.
Knezevic PF. Wruhs O. Arthroscopy in the horse. ox. pig. and dog.
Chlorhexidine giuconate versus cWoroxylenol for pre-operative
Vet Med Rev 1977; 1: 53-63.
skin preparation in dogs. VetSurg 1996; 25: 487-494.
Limbird TJ. Dennis SC. Synovectomy and continuous passive motion
Tamurian RM, Spencer BE, Wojtys EM. The role of arthroscopic
(CPM)in hemophiliac patients. Arthroscopy 1987; 3: 74-77.
synovectomyin the management of hemarthrosis and hemophilia
Lindblad S. Hedfors E. Intra-articular variation in synovitis. Local
patients: Financial prospective. Arthroscopy 2002; 18: 789-794.
macroscopic and microscopic signs of inflammatory activity are Theoret C, Barber S,Moyana T, et al. Repair and function of synovium
significantly correlated. Arthritis Rheum. 1985; 2: 977-986. after total arthroscopic synovectomy of the equine antebrachio-
Lu Y. Edwards RB. Nho S. et al. Thermal chondroplasty with bipolar
carpal joint. Vet Surg 1994; 23: 418.
and monopolar radiofrequency energy: effect of treatment time Voto SJ,Clark RN, Zuelzer WA. ArthrQscopic training using pig knee
on chondrocyte death and surface contouring. Arthroscopy
joints, Clin. Orthop 1988; 226: 134-137.
2002; 18: 779-788.
Walmsley Jp. Arthroscopic surgery of the femorotibial joint. Clin
Mcllwraith CWoThe use of arthroscopy. synovial fluid analysis and
TechEquine Pract 2002; 1: 226-233
synovial membrane biopsy in the diagnosis of equine joint
Walmsley JP,Phillips TJ and Townsend HCG Meniscal tears in horses;
disease.In: Equine medicine and surgery. 3rd edn. Santa Barbara: an evaluation of clinical signs and arthroscope treatment of
American Veterinary Publications; 1983. 80 cases.Equine Vet J 2003; 35: 402-406.
Mcllwraith CW:Tearing of the medial palmar intercarpal ligament Wan Py, Blackford JT,Bemis DA, et aI. Evaluation of surgical scrub
in the equine midcarpal joint. Equine Vet J 1992; 24: 547-550.
methods for large animal surgeons. Vet Surg 1997; 26: 382-385.
Mcllwraith CW; FesslerJF. Arthroscopy in the diagnosis of equine
Williamson DM, Copeland SA. Suturing arthroscopy wounds: brief
joint disease.J Am Vet Med Assoc 1978; 172: 263-268. report. J Bone Joint Surg (Br) 1988; 70: 146.
middle carpal (intercarpal) or ante-
surgical procedures and initially served
portal for eachjoint. Using two dorsal

of movement because of reduced soft tissue tension around


1983. 1984. Mcilwraith et al the arthroscope and a reduced tendency to slip out of the
joint when examining areas close to the arthroscopic portal
surgery and the earlier return to exercise, (Martin & McIlwraith 1985). Two portals are also useful if
surgery is going to be performed on both sides of a joint. In
rather than continuing training addition, villi in the area of arthroscopic entry will
medication to the detriment of joints and 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
was the 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
arthroscopy in the carpal joints as well as a radial carpal bone, the arthroscope is placed dorsolaterally
of case selection,adjunctive management,and and once a clear view is obtained, a quick examination of all
can be anticipated. In most instances, the the potential areas for injury can be made. If the only
are common to all joints, but they are arthroscopic finding is the chip on the distal radial carpal
bone, then this is removed through a dorsomedial instrument
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 fragment on the distal intermediate carpal bone, then after
throughout the small featuresthat are 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-
and prognostic procedure (Mcllwraith & carpal joint: whereas the middle carpal joint tends to open as
~.. Mcllwraith 1991) as well as for the surgical a hinge, the antebrachiocarpal joint is shaped so that its
of articular injuries. The general role of the movement is both rotational and gliding. The gliding
movement of the joint tends to tuck the dorsal edge of the
arthroscopic anatomy of the carpal joints is 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 sheaths. By contrast, the periarticular anatomy of
curvature of the distal medial and lateral aspectsof the radius fetlock, tarsocrural, and femoropatellar joints allows r
make access to the medial and lateral joint angles slightly liberties with placement of the portals, and prior j
more difficult. The narrow angle between the radius and the distention is an assetto localization of the correct portal
proximal radial carpal bone in the medial aspect of the joint After joint distention, the arthroscope is inserted int(
can also make instrument manipulation more difficult in joint as described in Chapter 3. Examination with
this area. arthroscope inserted through the lateral portal comme
The general technique for introducing the arthroscope with the visual field in the medial aspect of the middle c~
into the joint was described in Chapter 3. Two arthroscopic joint (Fig. 4.1). The dorsomedial intercarpal ligaIJ
portals are useful for either the middle carpal or antebrachio- extending from the dorsal medial aspect of the radial c~
carpal joint: dorsolateral and dorsomedial. The lateral bone to the medial joint capsule is commonly obse
approach is better for visualizing the medial aspect of the (Fig. 4.1C). This dorsomedialligament has been previc
joint and the medial entry is better for seeing the lateral describedas a synovial plica (Mcllwraith 1990). Withdral
aspect. For example, when the operation involves a lesion on the arthroscope and angling the lens proximad aU
the medial half of the joint, the instrument is introduced inspection of the articular surface and dorsal margin oj
through the medial portal and the arthroscope enters radial carpal bone (Fig. 4.2). Continued withdrawal of
through the lateral portal and vice versa. Thorough arthroscope allows visualization of the junction betweer
exploration of the carpal joints is therefore possible by using radial and intermediate carpal bones (Fig. 4.3). Rotati(
both lateral and medial entries. the arthroscope allows inspection of the palmar aspect 0
Although arthroscopy in the carpal joints can be joint and the articulation between the radial, intermed
performed with the animal in lateral or dorsal recumbency, and third carpal bones (Fig. 4.3C). Also in this view i!
the latter has greater versatility. When switching sides with synovial fossain the medial palmar aspect of the third c~
the arthroscope (as is usually necessary if lesions are on both bone and the medial palmar intercarpal ligament (MP
sides of the joint), rolling of the horse or doing surgery This fossa is normal; it is a site of communication witt
"upside down" is necessary if it has been placed in lateral palmar pouch of the middle carpal joint, and may be a sit
recumbency. Some surgeons have suggested that the dorsal lodgment of small particles that break free during art
recumbency position causes tightening of the joint capsule scopic surgery. During examination of the articular mill
over the dorsal face of the carpus, and that a loose fragment of the radial and intermediate carpal bones, the joint caI
can be located more predictably in the lateral or medial attachment is some distance from the articular rim, all01
cul-de-sac of the joint when the animal is in lateral excellent visualization of the dorsal margins of these bol
recumbency. However,the authors have not found these to be The arthroscope is advanced slightly and the arthros(
limiting factors and in reviewing arthroscopic surgical lens is angled distad to visualize the second carpal bone
procedures performed on 1000 carpal joints in 591 horses by the medial portion of the third carpal bone (Fig. 4.4). S
the first author (C.W.M.) 45% were operated bilaterally. For withdrawal allows additional visualization of the remai
this reason, all descriptions of both diagnostic and surgical dorsal margin and body of the radial facets of the third c~
arthroscopy in the carpal joints are presented as in dorsal bone (Fig. 4.5). If the arthroscope is then moved so tha
recumbency, i.e. proximal is below and distal is above. This tip sweepslaterad and the eyepiecemediad, the intermel
position is also taught in the authors' laboratory classes. facet of the third carpal bone and the more central aspe
Learning arthroscopic anatomy in this manner is an important the joint can be visualized (Fig. 4.6). By continuing
prerequisite to performing arthroscopic surgery. Positioning motion, the lateral aspect of the intercarpal joint ca
and preparation of the carpus are illustrated in Chapter 3. visualized. (These areas are illustrated here, using the m
Initially, the most important aspect is to learn the specific arthroscopic approach.)
landmarks that allow orientation within the carpal joints and When the arthroscope is inserted through the d(
these are described in the examination techniques below. 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
Arthroscopic examination of the permits evaluation of the articular surfaces of the ulnar
middle carpal (intercarpal) joint intermediate carpal bones as far as the junction of the I
with the radial carpal bone (Fig. 4.8). A similar mane
The choice of arthroscopic portal depends on the primary with the lens directed distad and palmad allows examin.
area the surgeon wishes to examine. The lateral portal is of the fourth carpal bone (Fig. 4.9) and the lateral half 0
halfway between the extensor carpi radialis tendon and the third carpal bone (Fig.4.10). There is also a synovial plica
common digital extensor tendon and midway between the the transverse dorsal intercarpal ligament at the juncti(
two rows of carpal bones with the joint flexed at approxi- the third and fourth carpal bones (Fig. 4.10C).
mately 70°. The medial arthroscopic portal is made sufficiently Additional maneuvers may be necessary to augmen
medial to the extensor carpi radialis tendon to avoid its examination. For example, for detailed examination oj
tendon sheath. The skin incision for these portals is made dorsal synovial recessesbeyond the articular surfaces, tt
before distention of the joint to avoid damage to the tendon 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 Fig.4.4
Junction of the radial and intermediate carpal bones. Second carpal bone (2) and the medial aspect of the third car~
(A) Diagram of arthroscope position and visual field. Dorsal bone (3). (A) Diagram of arthroscope position and visual fie
(B) and palmar (C) arthroscopic views. R, radial carpal bone; (B) Arthroscopic view. (C) A more palmar view of the third
I, intermediate carpal bone; medial palmar intercarpal ligament. 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 eyepiece mediad and the tip laterad and then rotating t
will be described,beginning with the arthroscopeinserted scope appropriately. For purposes of palpation and surge
through the lateral portal and visualizationof the medialside however, examination of the lateral aspect of the joint is b
of the joint. The distalradius and the proximal radial carpal performed through a medial arthroscope portal.
bone form the medialjoint angle.Rotationof the lensdistad By switching to a medial portal, the most lateral aspec
allowscloseinspectionof the medialportion of the proximal the antebrachiocarpal joint is examined. The arthroscoP(
articular surfaceof the articular surfaceof the radial carpal rotated wit!1 the lens pointed distad to visualize the proxin
bone (Fig. 4.11). Withdrawing the arthroscopic slightly articular surface of the ulnar carpal bone and the late
allows examinationof the entire proximalradial carpalbone aspect of the proximal articular surface of the intermedi:
to the levelof its junction with the intermediatecarpalbone carpal bone (Fig. 4.15). Withdrawing the arthroscope allo
(Fig.4.12). examination of the entire proximal surface of the int
The arthroscopeis then rotated so that the lens is angled mediate carpal bone (Fig. 4.16), and tilting of the arthrosco
proximadto examinethe medialaspectof the distal articular tip distad allows inspection of the junction of the intermedi
surfaceof the radius (Figs4.13 and 4.14}. As in the middle and radial carpal bones (Fig. 4.17).
carpaljoint. the lateral aspectof the joint can be examined By returning the tip of the arthroscope to the late
through the samelateral arthroscopicportal by moving the 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-


Maintenance of joint distention
been used to retrieve a broken piece of instrument
1990. 1996, Dabareineret al1993, Wilke et al The arthroscopist must direct the operation to ensure 1
maintenance of joint distention. This is not usually a probl
The position for placing the arthroscope in the lateral 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~
front. swelling will be revealed.In the caseof 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 6. Horses return to training earlier and thus less fitness a
musculoskeletaladaptation are lost. Thesefactors contribl
to an earlier return to racing.
only is the cosmetic result excellent but also
, to overall joint function is minimized.
Problems and poor results have been encountered, and ;
trauma to the soft tissues is also significant to addressed at appropriate points throughout the chap1
the articular cartilage, which may undergo Many small problems can be avoided by technique chang
deterioration secondary to soft tissue and one of the main purposes of this textbook is to stl
the beginning arthroscopist past some of these pitfa
the joint (with elimination of Unfortunately, poor results can often be related to inadequ;
ability, experience,or practice. To be able to operate effectiv
on multiple joints can occur in the same 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
race successfullyin the same or a higher class. A presented in this chapter are not the sole means
lowering in class. however.is more typical for performing surgery; however, whatever changes the surge
racehorsesafterarthrotomy. makes, he or she should still use a systematic approach
every case.The approachesdescribedhave worked for the "fragment" rather than "fracture" for the osteochol
authors and also for the veterinarianswho haveundertaken pieces that are created. Such fragments almost invar
the arthroscopictraining coursesthat the authorshavecon- occur as a consequence of microdamage and thus cou
ducted worldwide (Mcllwraith 2002). Modification and classified as pathologic fractures. In some instances the II
refinement of techniquescontinue and it is the authors' appears as a "fresh" fracture line through an artil
philosophyto disseminatethis information through training surface with no visible subchondral change, but in
coursesand publications. instances subchondral disease is seen arthroscopically
certainly exists at the microscopic level.
Osteochondral fragmentation has direct physical effec
Presurgical information the joint because of the loss of the smooth articular su
and indirect effects due to the release of articular car1
As with any surgical candidate, as complete a history as and bone debris, which leads in turn to synovitis. S
possible is obtained. This history is often difficult with compromise of the articular surfaces leads to instabili
racehorses, and duration or time that the chip fracture has does tearing of fibrous joint capsule and ligaments.
been present is often not clear. Treatment history frequently synovial membrane responds directly to mechanical tr.
is uncertain, particularly with reference to intra-articular and indirectly to injury elsewhere in the joint. High i
corticosteroid medication, but the authors feellessconcerned articular pressures generated by synovial effusion
with operating on horses soon after corticosteroid adminis- promises the microstability, and the normal, slightly ne~
tration than was the case with arthrotomy. atmospheric pressure in joints is lost. Damage to synovio
In most cases, the horses exhibit mild to moderate also liberates matrix metalloproteinases, aggrecal
lameness. Severe lameness is usually associated with major prostaglandins, free radicals and cytokines (princi
articular damage. Radiographs should always be taken of interleukin 1 or 11-1), which could lead to articular carl
both legs; bilateral and/or clinically silent lesions are degeneration (McIlwraith 1982). Chronic articular i
common and these frequently are in the same location in results in fibrosis of the joint capsule and consequent II
both limbs. There is also a lack of correlation between radio- motion. Arthrofibrosis is recognized as an important prc
graphic and arthroscopic findings, which is usually reflected in humans. The cause is still unknown, but the use of s
in arthroscopic findings that are more severe than those arthroscopic techniques is considered critical in
suggested by radiographic examination (Mcllwraith et al minimization of arthrofibrosis in man (Finerman & ~
1987). The same disparity was noted in human osteo- 1992).
arthritic knees (Lysholm et al198 7). Specific problems in this The primary indication for surgical treatment of c
regard with chip fractures at various sites in the carpal joint chondral fragments in the carpus is to minimize arti
are addressedin the appropriate section. insult and to prevent development of osteoarthritis
(McIlwraith & Bramlage 1996). It should be recognizec
a joint is rarely returned to "normal" and that signiJ
Relevant pathobiology defectscan potentially lead to some degree of microinsta
and progression to osteoarthritis. Nonetheless,relative j
The carpal and fetlock joints are the most common instances amount of damage, the athletic horse can come back t(
where traumatically induced osteochondral chip fragmentation level performance despite some damage.
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
Location of intra-articular fragments
pathologic joint margins, previously altered by subchondral Table 4.1 illustrates the incidence and location of (
bone disease (Pool & Meagher 1990), and more recent work chondral fragments in the dorsal carpal joints as report
in the first author's (C.W.M.) laboratory has documented the the first author (C.WM.) in a series of 1000 carpal"
development of microdamage in association with exercise. (Mcllwraith et al 1987). The affected joints were in
The microdamage manifestedas a combination of microcracks, horses, of which 220 were racing Thoroughbreds. 349
diffuse microdamage, cell death, and subchondral bone racing Quarter Horses. 5 were racing Appaloosas,and 6
sclerosis (Kawcak et al 2000, 2001) and it is suggested that racing Standardbreds. The others included 2 barrel-r
such changes lead to the clinical osteochondral fragmentation Quarter Horses, 3 roping Quarter Horses, and 6 other I
seenin the carpal and the fetlock joints. horses.
It has been proposed that chip fractures of the joint Of the 591 horses. 278 horses were 2 years old, 196
margins in the carpus can arise from either fragmentation of 3 years old, 52 (55%) were 4 years old, 47 were 5 ye,
the original tissue of the joint margin (previously altered by older, and 18 did not have their age documented. In
disease as mentioned above), or within the base of peri- horses, osteochondral fragments were noted in one ca
articular osteophytes forming in joints as part of the osteo- whereas 265 (45%) horses had bilateral lesions. Arthro~
arthritis syndrome. Experience with arthroscopic surgery of surgery was performed on a significantly greater numl
carpal fragmentation suggests that both mechanisms occur joints per horse in Quarter Horses compared with Thor(
and for this reason, the authors now prefer using the term 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
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:
are included in subsequentsections,but the generalrule is considered, but such indications are rare, and the val
that for a fragment on the medial side of the joint, the surgery in such casesis always questionable.
arthroscope passes through the lateral portal and the Once fragments are removed, the defect is debrided.
instrumentsenterthrough a medialportal. Forlesionson the step is discussedin detail later and is usually performed
lateral side of the joint, the arthroscopeis placedthrough a rongeurs and curettes (Fig. 4.24). Other osseous defect:
medial portal and instrumentsthrough a lateralportal. may be debrided at this time. Kissing lesions are evalu
The basicprotocolfor surgeryof all carpal fragmentation but when they are of partial thickness, they usually ar
is similar. A diagnosticarthroscopicexaminationis always debrided.
performedfirst. The egressis openedto flush the joint if The joint is then flushed by opening the egress car
visualizationis lessthan optimal. Whenthe view is clear,the and manipulating the tip in the area of the lesion (Fig. 4
egressis closedand can then be used to palpate areas of The egress can also be used to rub off small tags of carl
fragmentation(seeFig.4.21A). Alternatively,a probecanbe and bone. Placement of the larger, 4.5-mm egress car
used (seeFig. 4.21B), but the egressworks well for pre- should follow, to remove larger fragments (Fig. 4.25). Su
liminary palpationand savesan extra instrumentpassage. may be appliedto this cannula, but it is not routinely perfo
The egresscannula is then removedand the instrument in the carpus. Lavage should continue until the joi
portal through the joint capsuleusually closes,at leastuntil macroscopically cleared of debris. Occasionally, a frag
the time that a larger instrument (which increasesthe migrates away from the fracture site and is either free flo
diameterof the portal) is used.If the fragmentis freshand or attached to synovial membrane (Fig. 4.26). In such (
mobile on palpation,immediateinsertionof graspingforceps it is removed with forceps.
is appropriate.The fragmentis grasped,and the forcepsare At the completion of irrigation of the joint, the porta
rotatedto freethe chip of softtissueattachments(if theseare 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 loss vary considerably. Loss of bone is typically related t<
palmar to the fragmentation (Fig. 4.33). Grading degree of finding soft defective bone at surgery. which requires debride
articular cartilage damage is discussed more fully in a ment. Such changes in the distal radial carpal bone can bt
subsequentsection. severe when the radiographic changes appear rather mild
Radiographs also do not often predict accurately the extent Often the degree of clinical compromise (lameness an,
of bone fragmentation in the distal radial carpal bone. Both synovial effusion) is a better indicator of the state of the join1
the amount of cartilage degeneration that extends back from than are the radiographs. The presence of bloody or brown
the edge of the defect and the amount of subchondral bone synovial fluid on initial entry into the joint is also usually a
(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
strong indicator of severe damage within the joint. In some at this site. The pre-surgical radiographs that most frequen
instances, radiographs provide an indication of marked bone demonstrate fragmentation are the flexed lateromedial (L
loss in association with chip fractures (Fig. 4.35), but usually and the dorsomedial-palmarolateral (DMPLO) projectic
the bone loss is more than is anticipated (Fig. 4.36). In either (Fig. 4.40).
case, when loss of bone is marked, there is loss of joint The approach for operating on the distal intermedi.
congruity and, potentially, instability. In instances where carpal bone lesions is illustrated in Figure 4.41. T
bone remains but there is Grade 3 articular cartilage loss, arthroscope is placed through the medial portal and t
radiographs do not predict the amount of damage at all 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.
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

bone,becauseradiographicallysilent lesions on the Partial slab fracture that extend


aspect of the radial carpal bone have been en- distad and exit dorsad -.-,-
When these occur, surgery can be performedin
using the same lateral instrument portal as to arthroscopic surgery. Thin slab j
thickness of the third carpal bone can also be ren
medial side of the intermediate carpal bone should be using the arthroscopic technique although cut1
-during procedures involving distal radial carpal carpometacarpal joint capsule attachments with
.fragments difficult. however.
(Fig. 4.43). In this case we use The prognosis for third carpal chip fractures an(
medial instrument portal that is used for distal radial slabfractures is variable. As in other sites in the middJ
joint, the prognosis is excellent with small, well
of arthroscope and instruments is often required to perform fragments accompanied by minimal degenerative
the removal. Postoperatively,new bone proliferation is a potential]
when the fracture line extends deep into the c
attachments. Multiple fragments off the third
Dorsoproximal third carpal bone
bone may occur. When these fragments are large ant
Fragments from the proximal third carpal bone can bone from the joint is significant. instability is a p
sometimesbe more difficult to operatethan chip fragments 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 amount of cartilaginous damage associat
these chips is variable. and the prognosis varies aCC
The technique for operating on fragmentation at this site is Although marked erosion of the proximal surfacI
illustrated in Figure 4.49. Thesefractures are usually identified radial carpal bone can occur there, it is a su
preoperatively with standing and flexed lateromedial and impression that the antebrachiocarpal joint appea
dorsolateral-palmaromedial oblique DLPMO radiographs. As more forgiving than the middle carpal joint in hor
with other sites,the size of lesions can vary widely (Figs 4.50 similar degrees of loss from the proximal versus 11
and 4.51). The arthroscope is placed through a lateral portal articular surfaces of the radial carpal bone.
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).
Proximal intermediate carpal bone
With the standard medial portal, instruments must The technique for operating on chip fractures at th
approach the lesion almost end-on, and manipulation can be illustrated in Figure 4.53. Standing and flexed later
more difficult than on the distal aspect of the radial carpal (LM) and/or dorsomedial-palmarolateral oblique (:
bone. Repeated manipulation tends to cause subcutaneous radiographs (Fig. 4.54) are most useful in ide
extravasation and the medial aspectof the antebrachiocarpal fragmentation of the proximal intermediate carp;
joint is also narrower than other locations. Occasionally, a These fragments can be small, distinct and easily]
lateral arthroscopic portal can be used (Fig. 4.52). (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 in the carpal joints. Often the fragments
such cases. prior separation of capsular attachments in radiodensity, loss of infrastructure,
addition to separation at the fracture line is recommended. new bone formation. Occasionally, the
Occasionally, a chronic chip or the spur associated with it radiographic views do not demonstrate a
might have an intracapsular portion. In these cases, the event, a skyline (DPrDDiO) view of the
intra-articular portion is removed with rongeurs or a burr as recommended (Fig. 4.56B).
far as the capsular reflection only. Postoperative radiographs The technique for operating on chip fractures of the dorso-
often do not appear as satisfactory as following fragment lateral margin of the distal radius is illustrated in Figure 4.57.
removal. Nonetheless, this is considered preferable to the The arthroscope is inserted through the medial portal and
capsular trauma necessaryto remove intracapsular fragments instruments are passed through the lateral portal. The
and/or new bone. As with fragments in other locations, a position of the fragments necessitates that instruments are
relatively small fragment may be associatedwith considerable directed distad so that their shafts lie at an angle close to the
loss of articular cartilage. dorsal aspect of the carpus. The fragments are usually large
(;?;1 cm wide), with the most proximal portion attached to the
Proximal ulnar carpal bone fibrous joint capsule. These fractures are also commonly
comminuted with a wedge-shaped osteochondral fragment
Fragments at this site are rare. To perform arthroscopic palmar to the largest dorsal fragment.
surgeryfor this lesion,the arthroscopeis placedmediallyand The size of the fragment can be assessed reasonably
instruments enterthrough the lateralportal. accurately from preoperative radiographs. Damage is usually
limited to the defect created by the fragments. only and
Lateral aspect of the distal radius cartilage loss does not usually extend peripheral to the defect
(Figs 4.58 and 4.59). The arthroscopic appearance depends
These fragments are usually best demonstrated on a on the age of the fragments. In many such cases the dorsal
dorsomedial-palmarolateral (DMPW)radiographicprojection fragment appears to be acute and the palmar wedge shaped
(Fig.4.56A). Theycan be displaced,non-displaced, singleor fragment appears to be longer standing. In acute fragmen-
multiple,and frequentlyare larger than fragmentselsewhere 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 bony proliferation proximal to the defects within the fibrol
superficial fragments, and a deep search is joint capsule is common, and should be left alone. Debridl
in these cases. With fractures of long-standing, ment follows the basic principles outlined previously, but mc
, include areas of capsular tearing. This should be perform(
carefully and in a conservative manner in order to limit tl:
Before retrieval, large fragments are elevated (Fig. 4.59) potential for traumatizing the adjacent tendon sheath and 1
attachments severed with a periosteal elevator. avoid further capsulitis.
cup rongeurs are used to remove fragments. When these fractures are of long duration, the fractul
usually necessary to twist the rongeurs after grasping line may be obscured and the fragment is usually recognize
fragment to ensure that the fragment is free of attach- by the presence of articular erosions and irregularities.
ments before making an attempt to pull it through the joint Despite their size, the prognosis for chip fractures of th
capsule. Enlargement of the skin incision is commonly distal lateral radius is good. This is generally considered to b
necessary to bring these fragments out through the skin. the result of different biomechanical influences and becaus
Figure 4.60 depicts a chronic distal lateral radius fragment the remaining articular surface is usually not damaged to an
that was associated with osteochondral diseaseperipheral to great degree compared to other sites of carpal fragmentatior
the fracture. Damage is rarely more extensive that that noted
here, unless the lesion is chronic and mobile. Removal of
Medial aspect of the distal radius
large fragments that extend proximally into the capsular
reflection can result in penetration of the synovial sheath Fragmentation at this site is best demonstrated in
of the extensor carpi radialis or common digital extensor dorsolateral-palmaromedial oblique (DLPMO) radiograpl
tendon. (Fig. 4.61). The technique for removing fracture fragment
Mter removal of the fragment, the depths of the defectare from the medial aspect of the distal radius is illustrated il
carefully explored to find any remaining fragments. Some 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
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
it is demonstrates spurs that were removed. These spurs n
removed with Ferris-Smith rongeurs. curettage, an ostec
on first, as subcutaneous fluid extravasation is more likely to or burr.
occur in the antebrachiocarpal joint. The loss of irrigating Most spurs that are visible radiographically ar
fluid after creation of a large instrument portal means that candidates for removal. In many instances the experi
the surgeon will need to switch to the opposite side of the surgeon can predict whether an attempt at removing (
joint to operate on a chip on the other side, and insert the is appropriate by examining the radiographs. As a gt
arthroscope into a relatively non-distended joint. If time has rule. however, the surgeon should maintain an open
, between the two entries, some blood may be in the
and examine the spur at the time of arthroscopic su
which can be cleared by irrigation. The bleeding is This statement is not to say that every carpus with a Spl
from a previously debrided subchondral bone candidate for arthroscopic surgery. As experienced clini
and occurs after loss of joint distention. With joint know, many small spurs noted in 2-year-old horses are I
and irrigation, subchondral bleeding is usually evidence of previous synovitis and capsulitis. and are
current clinical importance.
Articular cartilage and bone The amount of articular surface loss should be documente
deBeneration in association with carpal on surgical notes and may be recorded by way of a drawin
chip fractures (Fig. 4.68). Significant bone loss causes loss of cubodi~
congruency (Fig. 4.67F and G).
The presence of articular cartilage degeneration associated More subtle degreesof cartilage damage have been define
with carpal chip fragments and the debridement of degenerate and graded in man (Pritsch et al 1986) and the recent~
cartilage were mentioned previously, although this problem defined ICRS grading system (Cartilage Injury EvaluatioJ
deserves specific attention. For convenience, four grades of System 2002) is gaining acceptance. These classification
articular surface damage, as evaluated arthroscopic ally, have should not be confused with the system just described
been made (Mcllwraith et al 1987) and are illustrated in Although a more detailed breakdown of damage may b,
Figure 4.67: appropriate for guiding treatment. it may have limited ValUI
in defining prognosis.
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). Debridement of defects after chip
2. Articular cartilage degeneration extending more than fracture removal
5 mm back from the defectand including up to 30% of the
articular surface of that bone (Fig. 4.67C and D). A discussion of the rationale for debridement after fragmeni
3. Loss of 50% or more of the articular cartilage from the removal necessitates a brief review of current knowledg(
affected carpal bone (Fig. 4.67E). regarding healing of tissues. particularly articular cartilage
4. Significant loss of subchondral bone (usually distal radial These considerations are also important with regard tc
carpal bone lesions) (Fig. 4.67F and G). 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 defects curetted experimentally were covered with
situations: (1) superficial defects that do not penetrate the full granulation tissue 1 month later. This tissue underwentmetap
thickness of the articular cartilage, and (2) full-thickness change to form fibrocartilage by 2 months and
defects, which extend to subchondral bone. Superficial imperfect hyaline cartilage by 6 months. In another carpal
defectsin equine articular cartilage do not heal, whereas full- study, Grant (1975) noted that the defectsfilled with a deeper
thickness defects heal through formation of granulation layer of immature hyaline cartilage and a more superficial
tissue and its subsequent metaplasia (Riddle 1970). layer of fibrocartilage. Synovial adhesions were also present.
In studies involving the horse, the nature of the replace- The repair most closely resembled the adjacent normal
ment tissue in the full-thickness defect varied between hyaline cartilage when there were few synovial adhesions. If
investigators. In one study, the authors noted that whereas synovial adhesions were significant. the defects filled with a
3 mm, full-thickness defects were repaired satisfactorily at 3 more primitive fibrocartilage and fibrous tissue. The authors
months, defects of 9 mm in diameter were not completely therefore concluded that proximity of the lesion to the
replaced at 9 months (Convery et aI1972). The repair tissue synovial membrane was potentially an advantage to healing.
was a variable mixture of fibrous tissue, fibrocartilage, hyper- Hurtig et al (1988) created large (15 mm square) and
cellular cartilage, and (occasionally) bone, whereas another 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 or fragmented cartilage is removed. This protocol is base
elaboration of matrix proteoglycans was not complete at this the belief that loose cartilage is irritating and may detach
time. Better healing occurred in small weightbearing lesions its prospects of healing onto bone are virtually nil. Par
when compared to large or nonweightbearing lesions. thickness erosion adjacent to a full-thickness defect is
Synovial and perichondrial pannus interfered with healing subjected to curettage if the cartilage that remarn
of osteochondral defects that were adjacent to the cranial attached solidly to the bone. Full-thickness defects
rim of the third carpal bone. Large lesions had good repair at debrided to the level of subchondral bone. Any soft defe
2.5 months postoperatively; however, by 5 months, clefts bone is also removed.
between the reparative tissue and subchondral bone were In summary, based on both research evidence and ~
common. Later, the clefts became undermined flaps of fibrous we have observed, the authors feel that a conser Vi
tissue that were disrupted by normal biomechanical forces, approach when it comes to debridement of fibrillatiol
resulting in exposed subchondral bone. thinning of articular cartilage should be taken. In 0
Grant (1975) also found no correlation between increased instances, when cartilage is separated and may appear
healing time and improved tissue quality in full-thickness thickness, the calcified cartilage layer may still be pre~
defects; defects at 54 and 67 weeks contained more fibro- Failure to remove the calcified cartilage layer will cause
cartilage and less hyaline cartilage than defects at 42 and healing response. With experience, one can recognize
47 weeks. Work in other species also has revealed hyaline difference between the calcified cartilage and the:
cartilage at early stages of healing. There is therefore indirect chondral bone (Frisbie et al 2001, unpublished data). ,
evidence that, at 4 months. defects in the articular cartilage debridement of subchondral bone, in an adult animal,
have reached the limit of healing capacity and. by 12 months. relatively straightforward to recognize defective, gran
the replacement tissue has begun to degenerate. (and often necrotic) bone and distinguish it from S
More recent work in the first author's (C.W.M.) laboratory healthy subchondral bone. The distinction is more difficu
comparing normal healing in full-thickness defects at 4 and the young animal, where the subchondral bone is quite
12 months has demonstrated that the percentage of Type II In contrast, when the subchondral bone of a carpal defe
collagen will progressively increase from 0% at 4 months to hard and sclerotic, the use of subchondral microfracture
80% at 12 months. The hexosamine level is about half the aid accessto stem cells and growth factors in the cancel
amount in normal cartilage at 4 months. and slightly less bone and has been used in clinical cases (Frisbie et al 2(
than the 4 month level at 12 months (Vachon et al 1992, unpublished data).
Howard et aI1994). The current state of articular cartilage Deepor extensive debridement using motorized equipn
healing has been reviewed (Mcllwraith & Nixon 1996) and is is unnecessary in most cases.If debridement extends be}
now the subject of a separate chapter in this textbook. the level of attachment of the joint capsule, it can resu
The authors have also had the opportunity to operate bn a increased capsulitis and bone proliferation. In relating S
number of carpal joints for the second time after the animals of these ideasto follow-up management, if the actual matc
have raced and have observed that the healing of defects that fills fresh, localized chip fragments is not of m
varies (Fig. 4.69). In repair areas subjected to histologic concern and the area of the defect is small, then, if 0
analysis, fibrous tissue predominated. For all experimental sources of irritation have been removed, atWetic func
studies in which cartilage healing in some form was demon- should be limited only by soft tissue healing. For this rea
strated, these joints were never subjected to the continual horses with acute fragmentation and with minimal evid(
exercise and trauma of a racehorse. Since the authors of long-standing adaptive failure can return to training i
question how much functional healing occurs, debridement 6-8 weeks.
of partial-thickness defects is not performed. Cartilage is When the lesions are more severe, the limitation
aneural and how much trouble many partial-thickness defects cartilage healing are more significant. If the area ofcarti
cause is questionable. Commonly, these defects are kissing erosion is larger, then some form of healing is required,
lesions in association with fragments, and the best treatment the importance of intact subchondral bone support
is to remove the initiating cause, i.e. the fragment. Whether effective articular cartilage healing is relevant. De
more than fibrous tissue will fill the defectsis unclear, and one mination of the conditions that are necessary or optir
should therefore be conservative in creating further defects or healing requires further investigation. At present, the aut!
enlarging ones already present. The results of a study in man assume that extra time is required when subchondral hea
involving follow-up arthroscopy of patients treated for is necessaryto restore a weightbearing surface. However,
chondromalacia of the knee with or without cartilaginous time requirements and physical factors for bone healinJ
shaving supports a conservative approach to management of Grade 4 lesions have yet to be determined. In chronic, con
partial-thickness defects. The conclusions were that only cated cases, a minimum of 4-6 months rest is curre
loosely hanging articular cartilage should be shaved, and recommended.
that softened, non-loose, fissured articular cartilage should With the possible exception of infected joints I
be spared (Friedman et aI1987). Chapter 14), therapeutic synovial resection with the
The authors also adopt a relatively conservative approach of motorized equipment is not recommended. Locali
with regard to debridement of deeper defects that remain synovectomy is only performed occasionally to facili'
after fragment removal. Rough edgesor adjacent undermined visualization.
management 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
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
understands the prognosis.
Follow-up information on the first 1000 carpal joir
less operated on by the first author (C.WM.) has provided objecti
(;'synovitis. and less effusion postope~atively(6gilvie~Harris et information to give clients regarding prognosis (McDwraith et
r
al1985). They also had more rapid return of movement and 1987). Arthroscopic surgery was effective in removing'
quadriceps function, and their return to work and sport was osteochondral fragments as well as treating other lesior
significantly faster. The administration of antimicrobial There were no casesof intra-articular infection and fewoth
drugs is a matter of individual surgeon preference. complications. The overall functional ability and cosmel
Based on current knowledge of cartilage healing. it is appearance of the limbs were excellent.
subjectively recommended that exercise be avoided for the Post-surgical follow-up information was obtained for 44
first week after surgery to enable the blood clot to organize racehorses. After surgery, 303 (68.1 %) raced at a level equ
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 decreasedperformance or still had problems referable to tl
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- 28 (6.3%) sustained another chip fracture. 32 (7.2%) develop
ments (Grade 1 lesions), training may begin at 6 weeks. As other problems. and 10 (2.2%) sustained collapsing sIc
the damage in the joint increases. the convalescent time fractures while racing. When horses were separated into fO
should be appropriately increased. Horses with Grade 2 categories of articular damage. the performance in the t\\
cartilage loss should have a minimum of 3-months rest; with most severely affected groups was significantly inferior. Or
Grade 3 and 4 lesions the horses should have 4-6-months hundred thirty-three of 187 horses with Grade 1 dama~
rest. Rehabilitation protocols including underwater treadmill (71.1 %),108 of 144 with Grade 2 damage (75.0%), 41 of 7
or swimming may be recommended if available. with Grade 3 damage (53.2%). and 20 of 37 horses wil
Postoperative use of hyaluronan (HA) and polysulfated Grade 4 damage (54.1 %) returned to racing at a level equ,
glycosaminoglycans (PSGAGs)is variably favored by different to or better than the pre-injury level. The successrate in casl
clinicians. The authors do not consider HA a necessary or with Grade 1 and Grade 2 lesions was significantly greatc
consistent part of the postoperative routine. In most cases. than that in caseswith Grade 3 and Grade 4 lesions. The dal
the synovial HA levels are expectedto return to normal in the from racing Quarter Horses and racing Thoroughbreds we)
convalescentperiod. If the articular damage at the time of divided. In 277 Quarter Horses, 81 of 112 (72.3%) wit
surgery is of relatively low grade. then most cases resolve Grade 1 lesions, 72 of 96 (75.0%) with Grade 2 lesions. 26 c
after a single treatment. PSGAG (Adequan@)is administered 46 (56.5%) with Grade 3 lesions. and 13 of 23 (56.5%) wit
when there is significant articular cartilage degeneration and Grade 4 lesions returned to racing successfully. In 16
exposure of subchondral bone. Although there may be little Thoroughbreds. 51 of 73 (69.9%) with Grade-1 lesions. 3
effecton defect healing. ongoing cartilage degeneration may of 47 (76.6%) with Grade 2 lesions, 14 of 30 (46.7%) wit
beinhibited (McIlwraith 1982. Yovich et al1987). Clinically. Grade 3 lesions. and 7 of 14 (50%) with Grade 4 lesior
a good response to PSGAG treatment is seen in the cases returned to racing successfully.Thesedata demonstrate a leI
with severe articular cartilage damage. An initial intra- favorable prognosis for horses with severe damage but als
articular injection of Adequan@ (250 mg with 0.5 ml that many horses can still come back and race successfully.
Amikacin sulfate) is recommended followed by weekly has been observed subjectively that. in more severe cases.
intramuscular injections of 500 mg. Corticosteroid therapy shorter racing career can be anticipated due to recurrer
after arthroscopic surgery is only recommended when there
carpal problems, including refragmentation.
is severe. persistent synovitis. Overall, arthroscopic surgery In five Quarter Horses used for roping, barrel racing. (
as a therapeutic procedure is best followed by rest and rodeo, all but one with a Grade 3 lesion returned to successf
physical therapy (controlled exercise). 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
Case selection, prognosis, and results were also assessedin relation to the location of lesions. anI
horses with a single site (or the same site bilaterally) involve
Although fragments of all ages and size are amenable to were included (Table 4.2).
arthroscopic surgery, not all horses are good surgical In racing Quarter Horses. the prognosis associated wit]
candidates. Here, accurate communication with owners and involvement of the third carpal bone was significantly wors
trainers is important to preserve the reputation of the than lesions in other sites. In Thoroughbreds, third Carpc
technique before embarking on chronic cases with less and radial carpal bone lesions had the poorest prognoses. ]
I relative to the joint involved, 63.3% of Sincethe publication of thesedata 15 years ago. ther
Horses and 66.2% of Thoroughbreds with middle havebeena numberof changesin clinicalpracticesthat maJ
carpal joint involvement returned to racing. For the influencefuture results.Theseinclude:
antebrachiocarpal joint. 82.7% of Quarter Horses and
1. Earlier intervention and thereforea higher percentageoj
65.5% of Thoroughbreds returned to racing successfully. If
Grades1 and 2 lesionsbeingpresentedfor surgery.
both middle carpal and antebrachiocarpal joints were
2. Attemptsto enhanceosteochondralhealing (Chapter16),
involved. 64.7% of Quarter Horses and 64.7% of Thorough-
including subchondralmicrofracture.
breds returned to racing.
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 remainder of the carpus, and generally requiring removal
articular surface of the accessory carpal bone. and the (Fig. 4.71). The proximodorsal aspect of the accessory carpal
palmar surfaces of the ulnar and fourth carpal bones are bone can be examined using a palmarolateral approach to
involved less frequently. Large partial slab fractures of the the antebrachiocarpal joint. A voluminous proximal palmaro-
palmarolateral surface of the intermediate carpal bone also lateral joint pouch can be palpated after distension of the
occur, and are largely inaccessible for arthroscopic removal joint. The arthroscope portal is made in the proximal portion
or reattachment (Dabareiner et al19 93). of this outpouching, leaving the region over the proximal
Fractures of the palmaromedial perimeter of the radial perimeter available for instrument access(seeFig. 4.71). The
carpal bone (Fig. 4.70A) have been described in 10 horses fracture fragment is then identified, the soft tissue attach-
(Wilke et al2001). These fractures are thought to result from ments and synovial proliferation debrided, and the fragment
compression injury, with the palmar perimeter of the radial removed using rongeurs. Fractures of the distal portion of
carpal bone impacting on the surface of the radius, during the accessorycarpal bone are less frequent, and accessto this
falls onto the flexed knee. Arthroscopic removal can be done outpouching of the antebrachiocarpal joint is limited.
through a palmaromedial approach to the antebrachiocarpal The palmarolateral aspect of the midcarpal joint can be
joint (Fig. 4.70B-D), which gives ready accessto the palmar entered for removal of fractures of the ulnar and fourth
perimeter of the radial carpal bone and caudal aspect of the carpal bone. The arthroscope portal can be made without
radius. The dorsal regions of the antebrachiocarpal joint are difficulty; however, synovial tissue removal will be required to
usually examined first, and concurrent damage to the completely identify the fracture fragment during removal.
articular surface of the radius and proximal row of carpal There are no case series available to provide a basis for
bones is debrided. The arthroscope portal is then made in the prognosis; however, the authors' limited experience suggests
distended palmaromedial outpouching of the antebrachio- these fractures are a source of lameness, which can be
carpal joint. Examination of the palmar surfaces of the substantially improved by removal.
carpal bones commences medially, and the arthroscope can Fractures of the palmar surface of the intermediate carpal
be redirected and introduced further to view the medial bone can involve a small wedge-shaped articular portion
perimeter of the intermediate carpal bone and accessory detached from the proximal perimeter of the intermediate
carpal bone articulations. Most fractures are not radio- carpal bone or a larger palmar slab fracture of the palmar
graphically confirmed for weeks to months after injury, and surface, extending from the antebrachiocarpal joint to the
the chip fragment can initially be obscured at surgery by soft midcarpal joint. Removal of smaller fragments through the
tissue proliferation (Wilke et aI2001). An instrument portal carpal tunnel has been reported; however. arthroscopic
is developed adjacent to the arthroscope entity and motorized removal has not been described. Palmaromedial and
equipment used to remove synovial proliferation. The palmarolateral approaches to the antebrachiocarpal joint
fracture of the palmar surface of the radial carpal bone can reveal only the medial aspectof the intermediate carpal bone.
then be removed. Results in 10 horses with palmar fracture of The lateral portion of the intermediate carpal bone. where
the radial carpal bone suggested that simple fractures of the the fractures have been described. is obscured by the
palmar perimeter should be removed as soon as they are accessorycarpal bone attachments.
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 Arthroscopic Surgery for
soon after injury tended to have less osteoarthritis and did
better after arthroscopic surgery. Concurrent injury to the
Subchondral Bone Disease
medial collateral ligament or avulsion of portions of the radius Theselesions were initially described in the proximal aspect of
substantially diminished the prognosis. the third carpal bone. A number of radiographic changes
Palmar fractures of the other carpal bones are less may be evident on tangential "skyline" views of the third
frequently encountered. These include fractures of the fourth carpal bone including sclerosis,lytic lesions. or linear defects
and ulnar carpal bone, the accessory carpal bone, and the variously interpreted as incompletefractures or "pre-slab"
intermediate carpal bone. The accessory carpal bone can be lesions. Sclerosis of the radial facet is a well-recognized
fractured during compression injury to the flexed knee change and some authors suggest that it is a primary lesion,
(nutcracker effect). The most common accessorycarpal bone often preceding more serious change, such as cartilage
fractures are longitudinal frontal plane fractures that divide damage or gross fracture (DeHaan et al198 7). These authors
the accessory carpal bone into a dorsal and palmar portion. also suggest that early recognition of sclerosis of the third
These fractures do not involve the articular cartilage of the carpal bone may help to prevent the occurrence of more
dorsal facets of the accessory carpal bone and are not serious changes (DeHaan, et aI1987). Sclerosisis considered
considered candidates for an arthroscopic repair. Most of to arise with training and racing. However, whether the
these fractures spontaneously develop a functional fibrous sclerosisleads to articular cartilage lesions or the same forces
union. Smaller fractures of the proximal or distal articular that can cause sclerosis also cause articular cartilage lesions
surfaces of the accessory carpal bone can occur, disrupting directly has yet to be ascertained. Arthroscopy of a small
the articulation of the accessory carpal bone with the number of joints that had sclerosis as the only radiographic
sign, revealed wide variability in the gross appearance of the remains, although in some casesthe defective tissue exteru
overlying cartilage (Richardson 1988) and this author agrees. out through this margin. Also. if the remaining rim
So-called third carpal bone diseasepresents as a persistent narrow. it is removed to the level of the defect.
carpal problem that does not respond to medication and is It is now recognized that subchondral bone disease c~
characterized by lytic change evident on skyline radiographs occur at other locations and may be the precursor
of the third carpal bone (Fig. 4. 72A). Frequently, some degree exercise/work-induced osteochondral fragmentation. Clinic
of surrounding sclerosisaccompanies the lytic changes. Most signs associated with subchondral bone diseasesare simil
lesions occur on the radial facet; they may be single or to animals with osteochondral fragmentation. However. pI
multiple and range from linear to circular in outline on surgical diagnosis (at locations other than the third carp
skyline radiographs (Richardson 1988). The proximal sub- bone) is difficult; the disease is rarely demonstrable radi
chondral bone is particularly thick and denseso that damage graphically. The best example is the distal radial carpal bolJ
and lysis in this area results in dramatic radiolucency in where lesions can consistently be found arthroscopicaJ
tangential projections. (Fig. 4.73).
Arthroscopically, these lesions manifest as an area of Subchondral bone diseasehas also been seen on the dist
defective subchondral bone, with the overlying cartilage radial, proximal third, proximal radial. intermediate carp
absent,a depressionin the articular cartilage, an undermined bones. and on the distal radius (lateral and medial) (Fig.4.7:
cartilage flap, or fragmented cartilage (Fig. 4.72B and C). In Figure 4. 73H illustrates subchondral bone diseaseon the mo
some cases there is overt fragmentation of the subchondral palmar areas of the second and radial carpal bone.
bone, which, since it is non-displaced and cannot be imaged The post-surgical protocol is determined by the degree
in profile, is not recognized radiographically. Loose tissue is articular compromise. using criteria similar to other carp
removed and the lesion is debrided with a curette. The arthroscopic procedures. In one report of 13 Standardbr,
defective bone is often granular in nature. A rim of intact casesinvolving the third carpal bone. 8 returned to racing,
tissue on the dorsal margin of the third carpal bone usually 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

to repair (Fig. 4.80) and any comminuted fragments tl


preclude complete reduction should be removed. Surgic
oblique radiographic projections (see Fig. 4.79). opinion is divided on the fate of large palmar fragments.
: can be repaired with AD/ ASIF cortex screws of these can be retained and stabilized in the repair, SOl.
3.5 mm or 4.5 mm diameter. This is determined 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
I recumbency. The former offers greater versatility of (Fig. 4.81). A spinal needle is then placed midway betwe4
positioning and also permits bilateral surgical these two needles.close and parallel to the proximal articul
surface. and directed across the midpoint of the fracture
movement between the standard position for close to 900 as possible (Fig. 4.81). This needle is the mc
important directional guide for implant placement. Conti
The middle carpal joint initially is evaluated utilizing the uration of most slab fractures of the radial facet of the thi
1 arthroscopic portal. In acute injuries there is carpal bone is such that the tip of this needle usually lodg
in the palmar fossa of the bone. It is important that med
permit visibility. This is usually performed through a and lateral marker needlesare used to determine the positil
-'" : portal. The dorsal compartment of of this needle; the eccentric position of the arthroscope aJ
its inclined lens angle mean that accurate determination
and any additional lesion noted. Non-displaced fractures the midpoint of the fracture from the arthroscopic ima
have variable amounts of cartilage disruption (Fig. 4.8IC). alone is not possible.Once the spinal needle has been placf
Some fractures. which on radiographic examination appear a further 20- or 23- gauge needle is inserted into t]
non-displaced. are found to be unstable at arthroscopic carpometacarpal joint directly distal to its point of entry.
evaluation. Displaced fractures frequently are accompanied required, a radiograph is made to ascertain proximal-disl
by additional cartilage loss and there may also be commin- positioning of the screw (Fig. 4.82).
ution, which most commonly occurs as a wedge in the At this stage some surgeons remove the arthroscope b
proximal palmar margin of the fracture. Reduction (when the authors' preference is for this to be held by a surgic
necessary) is effected most effectively by flexion and this assistant. A short (stab) incision is made midway between t]
should be performed progressively.Defects are debrided prior spinal needle and the marker needle in the carpometacarp
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
a No. 10 or 11 scalpel blade. This incision should frontal plane. However, there is a small window for safe ar
which at effective internal fixation, which necessitates implal
A glide placement close to the dorsal margin of the articulatic
is drilled in the fragment using the spinal needle as a between the second and third carpal bones (Fig. 4.9]
guide (Fig. 4.83). Once this has reached the Fortunately, fragment size is such that large implants are nl
insert sleeveis positioned in the glide hole. required and the head of a 3.5 mm AO/ASIF cortex scre
some displaced fractures in which a small amount of can be safely placed at this site (Fig. 4.92).
articular incongruity persists. limited fragment manipulation Fractures which occur in both frontal and sagittal planl
can be performed at this time. Leaving the arthroscope in situ can involve a number of configurations, and these will dete
permits direct visualization of the process and continuous mine the sites for appropriate implant placement. Non
monitoring of reduction and repair. The thread hole is then theless, the principles applied individually to fractures i
drilled to the palmar surface of the bone (Fig. 4.84). This frontal and sagittal planes apply. In some instances it may I
depth is checked against the preoperative measurements. necessary, in order to avoid impingement of implants, 1
before a countersink is used to create an appropriately sized place these at differing proximodistallevels within the bon
bed for the screw head. The strongly convex dorsal face of the Frontal plane fractures that involve the radial and inte
third carpal bone means that this is important for all screw mediate facets of the third carpal bone can occur in a numb!
sizesto avoid point contact and maximize efficiency of com- of configurations. The basic arthroscopic approach is c
pression and to avoid protrusion of the screw head into the described for frontal plane slab fractures involving the radi,
joint capsule. dorsal intercarpal ligaments. and tendon of facet only. However, it will usually be necessaryto insert t\\
insertion of the extensor carpi radialis. The reduction can be 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 for Treatment of Carpal

of frontal plane slab fracture of the third carpal

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

, continued controlled exercise. such as ridden trotting


exercise or free exercise in a small paddock. Swimming may
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 surgically removed. and 18 were treated conservatively.
swelling over the screw (Richardson 1986). Horses with the 82 Thoroughbreds with a third carpal fractures. 46 w
displaced slab fractures have a poorer prognosis for return to repaired with screws. 21 had the fragment removed. and
racing than do those animals with undisplaced slabfractures. received rest only. The effect of treatment on outcome was ]
because the latter are associated with more severedamage to significantly different. Fracture characteristics did]
the joint surfaces (Bramlage 1983). This situation remains significantly affect outcome. but did influence treatm,
the same whether treatment involves arthroscopy or selection. In Standardbreds. 77% if the horses raced aJ
arthrotomy. Similarly. the prognosis worsens when loss of the injury: in Thoroughbreds. 65% raced. Earnings per st
wedge of cartilage and bone at the proximal articular surface declined in each breed. but the decline was more pronoun
leaves a large defect after fixation (Bramlage 1983). in Thoroughbreds (Stephens et alI988).
There have been two other retrospective studies published In a second study of 31 cases of racing Thoroughbr
on third carpal slab fractures and their repair. However,these with third carpal slab fractures. all cases were trea
did not generally involve arthroscopic surgery and care surgically. Twenty-one (67.6%) horses raced at Ie
should be taken in extrapolating results. In one paper, the once after recovery from the surgery: In 11 claiming hor:
caserecords and radiographs of 155 horses with third carpal the claiming value decreased from a mean of $13.900 t
bone slab fractures were reviewed (72 Thoroughbreds and 61 mean of $6.500, the mean finish position was 5.8 :t 3
Standardbreds) (Stephens et al 1988). Of 73 fractures in before injury and 5.6 :t 3.30 after surgery (Martin e1
Standardbreds, 37 were repaired by screw fixation. 18 were 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 Arthroscopic repair of large chip fractures can, in SO
bone are assessed arthroscopically through dorsolateral instances be an alternative to removal. This is based on tl
portals in both middle carpal and antebrachiocarpal joints. premise that reconstruction of articular surfaces is preferal
Fracture margins are marked with percutaneous needlesand to creation of a large osseous defect (Grade 4 lesion). TI
the trajectory of implants is determined with a spinal needle necessary caveats are that fragments should be of sufficie
in a manner similar to that employed in corresponding size and have adequate osseousinfrastructure for placeme
fractures of the third carpal bone. The fracture configuration of a screw and that the process of reconstruction should
will determine the size and number of implants necessary. lesstraumatic than removal. Most chip fractures are repair
Figure 4.93 illustrates a slab fracture of the radial carpal with 2.7 mm AO/ASIF cortex screws although on occasio
bone which was repaired arthroscopically. Sagittal slab these may be sufficiently large for use of 3.5 mm diame1
fractures of the intermediate radial of third carpal bone have screws. The latter may be employed in repair of frontal pIa
been found at arthroscopy; the fractures have been generally fractures of the third carpal bone that extend from its proxin
treated by removing the slab fragment. but in a recent case articular surface (usually the radial facet), to exit with t
with internal fixation with a 2.7 -mm screw. Arthroscopy also dorsal surface of the bone proximal to the carpometacarlj
is the technique of choice for the repair of reconstructable Chip fractures of the dorsodistal margin of the rad
fractures of multiple carpal bones. These involve most carpal bone (Fig. 4.95), dorsoproximal margin of the till
commonly the radial and third carpal bones and the carpal bone and dorsoproximal margin of the radial carl
technique is varied to accommodate the variations of each bone have been repaired using 2.7 mm diameter screv
individual fracture (Fig. 4.94). Such cases should be fitted Delineation of the fracture is performed in a manner simi]
with a sleeve cast for recovery from general anaesthesia and to that describedfor the repair of slabfractures. Most fragmeI
for the immediate post-operative period. Slab fractures of the which are amenable to repair will exit the bone within t.
fourth and intermediate carpal bones have been reported capsular reflection and/or associated intercarpalligamen
(Auer et al 1986). Poor results were achieved after screw This point can be determined, if necessaryby radiographica
fixation with arthrotomy. 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.
Mcllwraith CWoArthroscopic surgery-athletic and developmental
References lesions. Proceedings of the 29th Annual Meeting of the American
Association of Equine Practitioners. 1983.
Auer JA. Watkins JP.White NA. et al. Slabfractures of the fourth and Mcllwraith CW Experiences in diagnostic and surgical arthroscopy
intermediate carpal bones in 5 horses. J Am Vet Med Assoc 1986; in the horse. EquineVetJ1984; 16: 11-19.
188: 595-601. Mcllwraith CWoDiagnostic and surgical arthroscopy in the horse.
Bramlage LR. Surgical diseases of the carpus. Vet Clin North Am 2nd edn. Philadelphia: Lea & Febiger; 1990: 33-84.
(Large Anim Pract) 1983; 5: 261-274. Mcllwraith CWoRadiographically silent injuries in joints: An over-
Convery FR. Akeson WHo Keown GH. The repair of large view and discussion. In Proceedings of 37th Annual Convention
osteochondral defects -an experimental study in horses. Clin American Association of Equine Practitioners. SanFrancisco. CA
Orthop 1972; 82: 253-262. 1991. pp. 785-792.
Dabareiner RM. Sullins KE. Bradley W. Removal of a fracture Mcllwraith CWoTearing of the medial palmar intercarpal ligament
fragment from the palmar aspect of the intermediate carpal bone in the equine midcarpal joint. Equine VetJ 1992; 24: 367-371.
in a horse. J Am Vet Med Assoc 1993; 203: 553-555. Mcllwraith, CWo Arthroscopic surgery for osteochondral chip
DeHaan CEoO'Brien TR. Koblik PD. A radiographic investigation of fragments and other lesions not requiring internal fixation in the
third carpal bone injury in 40 racing Thoroughbreds. Vet Radiol carpal and fetlock joints in the equine athlete: What have we
1987; 28: 88-92. learned in 20 years?Clin Techn Equine Pract 2002; 1: 200-210.
Finerman GAM. Noyce FR (eds): Biology and biomechanics of the Mcllwraith CWoBramlage LR. Surgical treatment of joint disease.In:
traumatized synovial joint: The knee as a model. Rosemount 11: Mcllwraith CW, Trotter GW (eds). joint disease of the horse WE
American Academy of Orthopedic Surgeons. 1992. Saunders; Philadelphia 1996: 292-317.
Firth EC.Deane. GibsonK. et al. Current studies in carpal diseaseand Mcllwraith CW, Fessler]F. Arthroscopy in the diagnosis of equine
function in the horse. Vet Cond Educ. Massey University. New jointdisease.JAm Vet Med Assoc 1978; 172: 263-268.
Zealand 1999; 135: 81-89. Mcllwraith CWoNixon AJ. Joint resurfacing: attempts at repairing
Fischer AT. Stover SM. Sagittal fractures in the third carpal bone in articular cartilage defects. In: Mcllwraith, CW, Trotter GW, (eds)
horses: 12 cases(1977-1985). J Am Vet Med Assoc 1987; 191: Joint disease in the horse. Philadelphia: WB Saunders; 1996:
106-108. 317-334.
Friedman MI. Gallick GS.Brna JA. et al. Chondromalacia of the knee: Mcllwraith CW, Yovich ]v; Martin GS. Arthroscopic surgery for the
a comparison between those treated with and without intra- treatment of osteochondral chip fractures in the equine carpus. ]
articular shaving. Arthroscopy 1987; 3: 131. Am VetMed Assoc 1987; 191: 531-540.
Frisbie DD. Trotter GW. Powers BE. et al. Arthroscopic subchondral Martin GS.Haynes PF,McClure JR. Effect of third carpal slabfracture
plate microfracture technique augments healing of large and repair on racing performance in thoroughbred horses: 31
chondral defects in the radial carpal bone and medial femoral cases(1977-1984). J Am Vet Med Assoc 1988; 193: 107-110.
condyle of horses. Vet Surg 1999; 28: 242-255. Martin GS. Mcllwraith CW Arthroscopic anatomy of the intercarpal
Grant BD. Repair mechanisms of osteochondral defects in equidae: a and radiocarpal joints of the horse. Equine Vet 1985; J17:
comparative study of untreated and X-irradiated defects. 373-376.
Proceedings of the 21st Annual Meeting of the America~ Mitchell N. Shepard N. Healing of articular cartilage in intra-
Association of Equine Practitioners. 1975. pp. 95-114. articular fractures in rabbits. J Bone Joint Surg [Am] 1980; 62:
Howard RD. McIlwraith CWoPowers BE. et al. Long-term fate and 628-634.
effects of atWetic exercise on sternal cartilage autografts used for Ogilvie-Harris DJ. Bauer M.. CoreyP. Prostaglandin inhibition and thE
repair of large osteochondral defects in horses. Am J Vet Res rate of recovery after arthroscopic meniscectomy. A randomized
1994; 55: 1158-1167. double blind prospective study. J Bone Joint Surg (Br) 1985; 67:
Hurtig ME. Fretz PB. Arthroscopic landmarks of the equine carpus. 567-571.
JAmVetMedAssoc 1986; 189: 1314-1321. Phillips TJ. Wright IM. Observations on the anatomy and pathology
Hurtig ME. Fretz PB. Doige CE. Schnurr DL. Effects of lesion sizeand of the palmar intercarpal ligaments in the middle carpal joints 01
location on equine articular cartilage repair. Can J Vet Res 1988; Thoroughbred racehorses. Equine Vet J 1994; 26: 486-491.
52: 137-146. Pool RR. Meagher DM. Pathologic findings and pathogenesis of race.
Johnson 11. Arthroscopic surgery principles and practice. St Louis: track injuries. Vet. Clin North Am Equine Pract 1990; 6: 1-30.
Mosby; 1986. Pritsch M. Horoshovski H. Rarine I. Arthroscopic treatment 01
Kannegieter NJ. Burbidge HM. Correlation between radiographic osteochondral lesions of the talus. J. Bone Joint Surg [Am] 1986
and arthroscopic findings in the equine carpus. Aust Vet J 1990; 68: 862-865.
67: 132-133. Richardson DW. Technique for arthroscopic repair of third carpa
Kannegieter NJ. Colgan SA. The incidence and severity of intercarpal bone slab fractures in the horse. Am Vet Med Assoc 1986; 188
ligament damage in the equine carpus. Aust Vet J 1993; 70: 288-291.
89-91. Richardson DW Proximal surface lesions of the third carpal bone
Kawcak CEoMcIlwraith CWoNorrdin RW. Park RD. Steyn PS. Clinical Proceedings of the 1st Advanced Arthroscopy Course. Coloradc
effects of exercise on subchondral bone of carpal and State University. 1988.
metacarpophalangeal joints in horses. Am J Vet Res 2000; 61: Richardson DW. Arthroscopically assisted repair of articulal
1252-1258. fractures. Clin Techn Equine Pract 2002; 1: 211-217.
Kawcak CE. McIlwraith CWoNorrdin RW. Park RD. JamesSP.The role Riddle WE. Healing of articular cartilage in the horse. J Am Vet Mec
of subchondral bone in joint disease:a review. Equine VetJ 2001; Assoc 1970; 157: 1471-1479.
33: 120-126. Ross MW. Richardson DW. Beroza GA. Subchondral lucency of tht
Lysholm J. Hamberg P. Gillquist J. The correlation between third carpal bone in Standardbreds racehorses: 13 case!
osteoarthrosis as seen on radiographs and on arthroscopy. (1982-1988),J Am Vet Med Assoc 1989; 195: 789-794.
Arthroscopy 1987; 3: 161-165. Schneider RK. Bramlage LR. GabelAA. Barone LM. Kantrowitz BM
Mcilwraith CWo Current concepts in equine degenerative joint Incidence. location and classification of 371 third carpal bont
disease.J Am Vet Med Assoc 1982; 180: 239-250. fractures in 313 horses. Equine Vet J Supp11988; 6: 33-42.
SJ: Arthroscopic surgery: the carpal and fetlock joints. dorsomedial intercarpal ligaments in the midcarpal joint.
-of the 29th Annual Meeting of the American Surg 1997; 26: 359-366.
Association of Equine Practitioners. 1983. Whitton RC. Rose RI. The intercarpal ligaments of the equ
SJ: Intercarpal ligament impingement: a primary cause of midcarpal joint. Part II: The role of the palmar intercar
pathology in the intercarpal joint. In Proceedings of the ligaments in the restraint of dorsal displacement of the proxil
row of carpal bones. Vet Surg 1997; 26: 367-373.
Wilke M. Nixon AI. Malark I. Myhre. G. Fractures of the pair
carpal bone in Standardbreds and Thoroughbreds: 155 cases aspect of the carpal bones in horses: 10 cases (1984-2000
(1977-1084). I Am Vet Med Assoc 1988; 193: 353-358. Am Vet Med Assoc 2001; 219: 801-804.
H, Carlsten I. Retrospective study of subchondral sclerosis Wright IM. Ligaments associated with joints. Vet Clin N Am 19
and lucency in the third carpal bone in Standardbred trotters. 11: 249-291.
Equine Vet I 1999; 31: 500-505. Young DR. Richardson DW. Markel MD. Numamaker [
AM, McIlwraith CW, Powers BE, et al: Morphologic and Mechanical and morphometric analysis of the third carpal bc
biochemical study of sternal cartilage autografts for resurfacing of Thoroughbreds. AmI Vet Res 1991; 52: 402-409.
induced osteochondral defects in horses. AmI Vet Res 1992; 53:1038-1047.
Yovich IV. Trotter GW. McIlwraith CWoNorrdin RW. Effects
, , McCarthy PH, RoseRI. The intercarpal ligaments of the polysulfated glycosaminoglycans on chemical and physi
defects in equine articular cartilage. Am I Vet Res 1987; .
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 Arthroscopic examination of the fetlock joint may be
aspectof the fetlock joint is probably the best equine example indicated specifically as a diagnostic procedure or as part of
of what can be achieved with joint distention. an arthroscopic surgical procedure (McIlwraith 198'4).
The same advantages that have been discussed in the The latter situation is more common, although diagnostic
carpus hold for arthroscopic surgery in the fetlock. The arthroscopy is indicated in cases involving a lameness
indications for arthroscopic surgery in the metacarpo- problem that has been localized to the fetlock but for which
phalangeal and metatarsophalangeal joints include the the radiographic signs are equivocal. The procedure is most
following conditions: valuable if synovial effusion is present or if the area of
1. Osteochondral fragments of the proximal dorsal aspectof lamenesshas been identified as intra-articular on the basis of
the proximal (first) phalanx. a response to intra-articular analgesia and when there has
2. Erosions of articular cartilage and subchondral bone not been a responseto conservative treatment.
disease on the dorsal proximal aspect of the first A complete arthroscopic examination of the metacarpo-
phalanx. phalangeal or metatarsophalangeal joint is not possible.Two
3. Synovial pad fibrotic proliferation (villonodular synovitis) arthroscopic approaches are required to achieve as effective
of the metacarpophalangeal joint. an examination as possible of both the dorsal and palmar
4. Other forms of proliferative synovitis. (plantar) components.
5. Osteochondritis dissecans of the sagittal ridge of the Each diagnostic examination will be described. Because
third metacarpal or metatarsal bones (McIIl/MtIIl). the dorsal approach most commonly is performed on the
6. Osteochondral fragments associated with the proximal metacarpophalangeal joint, it is described for that joint. The
palmar or proximal plantar aspect of the proximal only difference in examination of the metatarsophalangeal
phalanx. joint is that it may be more difficult because of the decreased
7. Removal of apical fragments of the proximal sesamoid ability to maintain extension of the joint. The plantar (palmar)
bone. examination is facilitated by flexion and this is especially
8. Removal of abaxial fragments of the proximal sesamoid convenient in the hilid limb.
bones.
9. Removal of basilar fragments of the proximal sesamoid
bones. Arthroscopic examination of the dorsal
10. Lesions of the intersesamoidean ligament. metacarpophalangeal joint
11. Axial osteitis of the proximal sesamoidbones.
12. Avulsions of the suspensory ligament insertions. This arthroscopic examination ~an be performed with the
13. Subchondral cystic lesions of McIIl. horse in dorsal or lateral recumbency. If lateral recumbency
14. Lesions of the dorsal plicae. is used. the horse should be positioned so that the site for
15. Chondral fractures. arthroscopic entry is up. For the same reason of versatility
16. Fibrous joint capsule tears. mentioned in Chapter 4 with regard to the carpal joint. the
17. Assistance in repair of condylar fractures of the use of dorsal recumbency is preferred. While the leg is being
McIIl/MtIIl and fractures of the proximal phalanx. surgically prepared and draped. it is held by an assistant or is
18. Other selected proximal sesamoid fractures. suspendedin a mechanical device (Fig. 5.1). Draping can be
completed with the fetlock resting back on the elbow or common digital extensor tendon. The outpouching of the
appropriatelysuspendedsothe joint remainsextended. 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
Insertion of the arthroscope joint capsule lateral to the common digital extensor tendon;
The metacarpophalangeal joint is distended with fluid this is penetrated when the lateral portal is created.
(Fig. 5.2) before making the arthroscopic portal. In this joint, The site for the laterally placed arthroscopic portal is in the
distention facilitates the recognition of the correct place for proximolateral quadrant created by distending the joint
the arthroscopic portal and minimizes the risk of iatrogenic maximally (Fig. 5.2). A No. 11 blade is used to incise the skin
trauma to the joint on entry of the arthroscopic sleeve. There and stab through the joint capsule (seeFig. 5.3). The arthro-
are no tendon sheaths to avoid as in the carpus, and the scopic sleevecontaining a conical obturator is then inserted
surgeon does not have to be concerned with exact local- through the joint capsule, initially perpendicular to the skin
ization of structures before distention. and then parallel to the articular surface of Mclll to avoid
Distention is performed by using approximately 35 ml of iatrogenic damage to this area (Fig 5.4). Entry is completed
fluid and inserting a needle across the dorsal aspect of the by advancing the sheath proximad to avoid iatrogenic
proximal sesamoid bone into the palmar pouch of the fetlock damage to the midsagittal ridge of the distal metacarpus (see
(see Fig. 5.2). Adequate distention can be recognized easily Fig. 5.4). The sheath can then be directed distad once over the
with bulging of the joint capsule on either side of the sagittal ridge.
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
If the arthroscopic portal is made in the more proximal from what was previously described in the carpus. However,
dorsal pouch, the sheath can be advanced across the joint in the carpus is unique and the skin incisions for the instrument
a transverse direction without causing damage to the portal are made prior to joint distention and insertion of the
midsagittal ridge of the metacarpus. The position described arthroscope merely to avoid entering an extensor tendon
here for the arthroscopic portal is different than in the sheath. There are no such issues in the fetlock joint, or most
previous edition of this text (McIlwraith 1990a). It represents other joints for that matter. The practice of inserting a needle
a modification initially suggested by Foerner (pers comm to ascertain the ideal position for instrument insertion and
surgical maneuverabilityis commonto all joints other than Withdrawing the tip of the arthroscope further and moving i
the carpus.By making a skin incision with a scalpeland No. across the sagittal ridge laterally (eyepiecemoving medially
11 blade.the surgeoncreatesthe instrument portal through permits inspection of the lateral condyle of the distal meta
the joint capsule(Fig. 5.7). The small egresscannula can carpus as well as the proximal lateral aspect of the proxim~
then be inserted through this portal without the trocar. An phalanx (Fig. 5.12).
arthroscopic examination can then commence. At the The examination just described enables recognitiol
completionof arthroscopy,the skin incisionsonly are closed and characterization of synovial pad fibrotic proliferatiol
(Fig.5.8). (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
Diagnostic arthroscopy of the dorsal osteochondritis dissecans of the midsagittal ridge an
pouch of the fetlock Joint condyles of Mclll, tears of plicae and joint capsule. articula
components of fractures of Mclll and proximal phalanx. an
With slight retraction of the arthroscope and looking across subchondral cystic lesions of Mclll.
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 Arthroscopic examination of the
reflection (Fig. 5.9). At this transition zone,the synovium has palmar or plantar fetlock joint
a flap, or pad. that varies in size, and the surgeon must be
familiar with the normal range (see Fig. 5.9). Synovial pad This examination can be performed with the horse in dorsI
fibrotic proliferation (villonodular synovitis) manifests as an or lateral recumbency, the position varying with th
enlargement of this flap. Apart from the flap, the synovial condition being operated. The authors preferred later!
membrane in the remainder of this dorsal area is non-villous. recumbency when operating on fragments associated wit
The articular surface of the medial condyle and mid- the palmar/plantar aspect of the proximal phalanx in tb
sagittal ridge of McIIl can then be examined by rotating past, but now use dorsal recumbency for all evaluation~
the arthroscope so that the lens is angled distad conditions in the palmar/plantar compartment. While flexio
(Fig. 5.10). The tip of the arthroscope is then moved distad from an assistant is sometimes needed, advantages includ
(eyepiece moving proximad) to inspect the dorsal articular less hemorrhage, convenient operating position for plant~
edge of the proximal medial eminence of the proximal (palmar) chip fragments, as well as sesamoid fragmen1
phalanx (Fig. 5.11). The synovial membrane of the dorsal and the ability to put instrument portals in either medial (
joint capsule is also evaluated during these maneuvers. The lateral pouch.
synovial membrane is notably more villous as one progresses
distad and villi can sometimes obscure the view of the
Insertion of the arthroscope
proximal dorsal rim of the first phalanx. The synovial mem-
brane attaches immediately adjacent to this rim, and use of The joint is prepared for surgery and distended by placing th
instruments (including the egress needle) to allow improved needle in the palmar pouch using the approach described b
inspection of the first phalanx is common practice during Misheff & Stover (1991). With the joint distended, a ski
both diagnostic and surgical arthroscopy in this area. 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 with fragmentation, 140 horses had other lesions in the
Also. it is not considerednecessaryor beneficialto fetlock, comprising 64 with wear lines. 11 with articular
cartilage erosion. 15 with chronic proliferative synovitis. 4
arthroscopy in such a case has been to ascertain with osteochondritis dissecans,and 45 with a combination
.' -of the radiographically apparent mass. If the
of the above lesions. Carpal arthroscopy for the removal of
of the joint is in satisfactory condition. the prog- osteochondral chips was performed concomitantly in 100 of
is still good with an osseous mass remaining in the these horses (Table 2).
Follow-up was available for 286 horses (85.1%): 208
the sizeor numberof fragmentsthat can (73%) returned to their previous use. of which 153 horses
(73.6%) returned to the same level of performance and
undergo surgery. The surgeon must consider 55 (26.4%) returned to performance, but at a lower class; 18
bone being removed. the amount of exposed horses (6.3%) developed another fragment and 60 (21 %) of
bone being left in the joint. and the amount of horses did not return to their previous use. Of the 270
racehorses with follow-up. 196 (72%) returned to racing and
created by the arthroscope or instrument portals. 141 (51.7%) of these raced at the same or a higher level.
rather to the amount of capsular attachment to the 18 (6.6%) of the racehorses developed another fragment and
56 (21.0%) were in the failure category. Of the non-
the joint is flushed with fluid by racehorse group, 12 of 16 (75%) returned and 4 (25%) did
open egress cannula over the site of the defect. not return to their previous use at the same level of
portals are sutured and the leg is bandaged. The performance. The difference of return to previous use between
is maintained for at least 2 weeks after surgery. racehorses and non-racehorses was not significant. The
walking commences after 1 week. With simple fresh overall successrate in horses with fragments only returning
the horses can be put into training after 6-8 weeks. to use was 85.9%; with fragments and other fetlock lesions. it
horses with more extensive involvement, the con- was 75%; with fetlock fragments and carpal arthroscopy con-
time is increased for a variable period up to comitantly. it was 68.6%; and with fragments plus carpal
arthroscopy and other fetlock lesions, it was 80.6%.
after surgery, but some veterinar- In a third study done to examine the longevity of
.As discussedin the section concerning the postoperative careers and quality of performance of 461
.-to the patient's recovery is 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
results with arthroscopic surgery for uncomplicated (Colon et al 2000). It was found that 89% of the horses
(411/461) raced after surgery and 82% (377/461) did so at
fractures are associated with severe capsulitis. wear lines. the same or a higher class; 68% of the horses raced in a
osteoarthritis. or extensive fragmentation of the proximal first stakes or allowance race postoperatively. This paper con-
phalanx. the progn!;)sis decreases accordingly. As with the firmed that the quantity and quality of performance was not
carpus. surgical intervention can still improve the status of diminished after arthroscopic treatment of dorsoproximal
these patients. but communication to owner and trainer is fragments, and that surgical removal of a chip fragment
important to ensure that no one is disappointed. Even with preserved the economic value of a racing Thoroughbred.
suchprecautions. however. some peoplehave short memories. allowing a rapid and successive return to racing at the
The results of arthroscopic surgery in 74 fetlock joints of previous level of racing performance (Colon et al 2000).
63 horses (35 Thoroughbreds and 28 Quarter Horses) over a Horses that raced before and after surgery (258) had an
2-year period were initially reported by Yovich & Mcllwraith average of 8.4 starts (median = 6) before surgery and 13
(1986). Larger numbers have replaced these data. The results (median = 11) after surgery.The averagetime between surgery
of arthroscopic surgery were reported in 1994 in 336 horses and first postoperative start was 189 days (median = 169);
with 572 osteochondral fragments removed from 439 fetlock 87% of the horses racing before surgery (224/258) returned
joints (Kawcak & Mcllwraith 1994). Of these horses. 311 to race at the same or higher class. The average earnings per
were racehorses. including 188 Thoroughbreds. 119 Quarter start after surgery was less than the average earnings before
Horses. 2 Standardbreds. 1 Racing Arabian and 1 racing surgery in 61 % of these horses and greater in 32%.
Appaloosa. There were 25 non-racehorses. A single meta- Colon et al (2000) considered the 11 % postoperative
carpophalangeal joint was operated on in 220 horses. and failure rate to be pessimistic due to various factors. It was
both metacarpophalangeal joints were operated on in 97 noted that horses that did not race after surgery tended to be
horses. a single metacarpophalangeal joint in 17 horses. both older at the time of surgery and had raced more times pre-
metatarsophalangeal joints in one horse and all 4 fetlock operatively. They concluded that the lack of return to racing
joints in one horse. Fragmentation of the proximal phalanx was not related to chip incidence. location or size,as these did
was the only lesion in the fetlock joints of 96 horses. Along not differ between the raced and unraced group. They
carefully measured fragment size and concluded that it did osteochondral fragments on the proximal dorsal rim, an
not affect post-surgical racing prognosis: 48% of the surveyed radiographs are used to make the definitive diagnosis. VI
horses had at least one fragment larger than the mean and have encountered cases in the hind limbs bilaterally an.
87% of these raced after surgery. They concluded that the because of the consistent location of these fracturt
hypothesis that "the smaller the chip fragment, the better the involving both the proximal medial eminence and sagitt
prognosis" was rejected by these findings. However, they groove,a developmental predisposition may be present.
noted that it was not possible in their study to compare post- In the previous edition of this book, the use of rest w~
operative racing performance to arthroscopic visualization of advocated, as these fractures can heal (McIlwraith 1990a
articular cartilage health or associated intra-articular However,since that time, caseshave beenencountered that ill
cartilage lesions. They did point out, appropriately, that not heal and continued to cause clinical signs. The recon
usually the articular cartilage damage is not severe and can mendation now is to provide compression of these fractur!
be managed medically. with 2.7 mm AD/ ASIF cortical screws.
Arthroscopic surgery is performed with the norm.
arthroscopic approach to the dorsal pouch and with tb
Arthroscopic removal of dorsoproximal limbs in extension. Examination of the joint will confirm tb
chip fractures of the proximal phalanx presence of the fracture (Fig. 5.33). Needles are placed t
in standing horses ascertain ideal positioning of the screw and, after a sta
incision is made in the appropriate location, a 2.7 mm hole
This technique has been described and reported in 104 drilled obliquely down through the fracture fragment. Tb
horses (Elce & Richardson 2002). Given skilled technique, it hole is generallyperpendicular to the fracture line. Radiograpl
is feasible to perform arthroscopic surgery in the dorsal are made to confirm appropriate positioning and that tb
aspect of the fetlock in this fashion. However, we would only glide hole is beyond the fracture line. A 2.0 mm hole is cor
recommend it if, for some reason, general anesthesia is some- tinued beyond this. After counter-sinking, a 2.7 mm diamete
how not possible or inconvenient. Throughout this textbook, 36 mm long cortical bone screw is then placed to comprel
the authors recommend surgery under general anesthesia. 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
Erosions of articular cartilage and (see Fig. 5.33); other times, debridement in a comparabl
subchondral bone disease on proximal fashion to a slab fracture is required.
dorsal eminences of proximal phalanx

As seen in the carpus, there is a spectrum of disease on the Treatment of slnovial Rad fibrotic
proximal dorsal aspect of the proximal phalanx ranging from proliferation (vilionodular synovitis)
separation of articular cartilage and loss of articular cartilage
to degenerative disease of the subchondral bone. Previously The condition initially designated as villonodular synoviti
discussed osteochondral fragments are considered to be (Nickels et al19 76) and later describedas chronic proliferativ
pathologic fractures and are the end result of a gradation of synovitis (van Veenendaal& Moffatt 1980, Kannegieter,199C
microdam~ge, microfractures, and cellular death (Kawcak et al is seen in the metacarpophalangeal joint. It involves
2000). This range of lesions occur in the same locations as proliferative response from the synovial pad in the proximc
previously described for osteochondral fragments and the dorsal aspect of the joint and, therefore, the term synovic
surgical management is the same. pad fibrotic proliferation (Dabereiner et al19 9 6) is preferre(
The referring clinical signs are also similar, but radio- The term pigmented villonodular synovitis was originall
graphically there may only be a suspicion of disease.However, used to describe pedunculated growths forming in th
on arthroscopic examination, the various manifestations of synovial linings of tendon sheaths and joint in man Gaffe et c
articular cartilage separation (Fig. 5.32A), articular cartilage 1941). These fibrous masseswere polyp-like formations th.
erosion (Fig 5.32B), and subchondral bone disease(Fig 5.32C originated from the synovial membrane and were often pi~
and D) are encountered. Separated cartilage and bone is mented with hemosiderin. Villonodular synovitis in human:
removed. Defective bone is debrided (larger pieces removed), therefore, should not be confused with enlargement of th
and the area lavaged. The prognosis is comparable to synovial pads of the equine metacarpophalangeal joint.
completely separated osteochondral fragments in this area. Classically,the condition was initially demonstrated wit:
contrast arthrography, and it has been treated successful
with arthrotomy (Nickels et al1976, Haynes 1980). Neithe
Treatment of frontal fractures of contrast arthrography nor arthrotomy is used anymorc
proximal dorsal aspect of the proximal because of the development of ultrasound examination i
phalanx using lag screw fixation diagnosis (Steyn et al1989) and arthroscopic surgery as th
treatment technique. The synovial pad of the metacarp(
Frontal fractures of the dorsal aspectof the proximal phalanx phalangeal joint is a fold (plica) of fibrous connective tissu
occur regularly. The clinical signs are very similar to other located in the proximal recess of the dorsal compartment (
the metacarpophalangeal joint at the joint capsule attach- (Dabareiner et aI1996). All the horses had lameness. joint
ment to Mcill. The synovial pad is normally 2-4 mm in effusion. or both of these clinical signs. associatedwith one or
thickness and tapers to a thin edge at its distal border (White both metacarpophalangeal joints. Bony remodeling and
1990). Its function is unknown, but its structure and location concavity of the distal dorsal aspect of McIII immediately
suggestthat the pad acts as a contact interface or cushion proximal to the metacarpal condyles was identified by radio-
betweenthe proximal dorsal rim of the proximal phalanx and graphy in 71 joints (93%) (Fig. 5.34); 24 joints (32%) had
the dorsal surface of distal third metacarpal bone (Mcill) radiographic evidence of a chip fragment located at the
during full extension of the fetlock joint (White 1990). proximal dorsal aspect of the proximal phalanx. Fifty-four
Repetitive trauma during fast exercise can result in irritation joints (71%) were examined by ultrasound. The mean:t SD
and enlargement of the synovial pad and development of sagittal thickness of the synovial pad was 11.3 :t 2.8 mm.
clinical signs of lameness and chronic joint effusion that (The authors also reported that the synovial pad was
often resolves temporarily with rest and intra-articular considered abnormal if the thickness was greater than 4 mm
medication. There is commonly radiographic evidence of on the sagittal view. the distal margin was rounded. or hypo-
bone remodeling, with a concavity at the distal dorsal aspect echoic regions were observed within the pad.) Seventy-nine
of Mcill, and this is suggestive of synovial pad proliferation percent of the horses had single joint involvement. with equal
(Fig. 5.34A). Ultrasound is now the method of choice to distribution between the right and left forelimb. In addition to
further define this proliferation (Fig. 5.34B). Although this pre-surgical diagnosis of this condition. it is also quite
condition is commonly seenin the racehorse, it has been seen common to encounter thickened and enlarged synovial pads
in other horses not subjected to fast athletic exercise (loSasso at arthroscopic surgery (usually when doing the surgery for
& Honnas 1994), and in the previous edition of this text, a removal of a proximal dorsal fragment from the proximal
contrast-enhanced view of the disease in a mule was phalanx) (Mcllwraith 2002).
presented. The surgical approach used when operating on horses
The medical records, radiographs, and ultrasound with this condition arthroscopically is illustrated in Figure
examinations have been reported in 63 horses with 5.35. The authors in most cases use a single instrument
metacarpophalangeal joint synovial pad proliferation 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
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
8 horsesand systemicnonsteroidalanti-inflammatorymedi- trotters on a radiographic survey (Groendahl19 92) and were
cations were also administeredfor variable periods.Three seen in 34 forelimbs and 14 hind limbs. A fourth condition
(38%)of the medicallytreatedhorsesreturnedto racing and initially described as OCDof the palmar metacarpus (Hornoff
only 1 horseracedbetterthan the pre-injury level. 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.
Treatment of other forms of Osteochondritis dissecans of the distal dorsal aspect of the
proliferative synovitis MclII/MtlII can occur in both metacarpo- and metatarso- !
phalangeal joints, but it is more common in the latter. The.'
Occasionally, forms of proliferative synovitis that are not lesions vary in their radiographic manifestations, from a I
localized to the dorsoproximal aspectof the joint are seen(see subchondral defect to defects associated with fragments;
Chapter 3). Typically, these casespresent as chronic synovitis (Fig. 5.38). In some cases,fragments break away completely
and capsulitis that is non-responsive to symptomatic intra- from the primary lesion and become loose bodies. The
articular or systemic anti-inflammatory treatments. In some presenting clinical signs include synovial effusion of the
cases, diagnostic arthroscopy has revealed proliferated, fetlock joint with or without lameness.The horses are usually
thickened, and enlarged synovial villi in the dorsal yearlings (Yovich et al1986). In most instances, the patients
compartment of the metacarpophalangeal joint (Fig. 5.37). are weanlings to yearlings and quite often are presented for
The treatment has been resection of these villi, and the treatment prior to sale. In some instances, training and
overall results have been good. 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
Treatment of osteochondritis dissecans confirm the presence of lesions associated primarily with the
sagittal ridge of MclII/MtIlI. ;
of the distal dorsal aspect of Mc111/Mt111
in the metacarpopharangeal and For purposes of treatment decision and prognosis, the j
lesions have been divided into three types:
metatarsophalangeal joints
.Type I is that in which a defect or flattening is the
There is a divergence of opinion as to what is considered only visible radiographic lesion
osteochondritis dissecans (OCD)within the fetlock joint and .Type II is that in which fragmentation is associated
also those entities that might be considered to be appropriate with the defect
to include in the term developmentalorthopedic disease .Type III is that in which there is a defect or flattening
(Mcllwraith 1993). It is undisputed that OCD of the dorsal with or without fragmentation plus one or more
aspect of the distal McIII and MtIII is a manifestation of OCD loose bodies.
and this is the condition described below. The condition was Oblique radiographs should be taken as well as dorsopalmar
initially described as OCD of the sagittal ridge of the third (plantar) and lateral/medial radiographs for the purpose
metacarpal and metatarsal bones (McIII/MtIII) (Yovich et al of discerning the medial or lateral condyles of MclII/MtlIl
1985). but this term has been modified after recognition that (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
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
articulation. clinical problems may arise when the horse significant). Only 3/12 cases with erosions or wear lines
engages in athletic activity. present at arthroscopy were successful. whereas 13/16 with
In a series of 42 horses that were operated on with no erosions were successful (p = 0.0029). Probably related to
arthroscopic surgery. there were a few Type I lesions (usually that. there was a significantly inferior result when a defect
operated on as they had not responded to conservative was visible on the condyle on oblique radiographs. When a
treatment or if an individual joint in a horse being treated for defect was visible. 6/13 were successful. whereas if a defect
a Type II or Type ill lesion happened to have a Type I lesion). was not visible. 10/15 were successful (p = 0.0274). Osteo-
Forty-two horses in this series reported included 20 phytes were also negative prognosticators (3/9 with osteo-
Thoroughbreds. 8 Quarter Horses. 7 Arabians. 4 Warmbloods. phytes on the proximal phalanx were successful. whereas
1 Standard bred. 1 Percheron. and 1 Appaloosa (McIlwraith 13/19 with no osteophyteswere successful). I
& Vorhees 1990). Forelimbs were involved in 10 horses. hind It was concluded that surgical management of Type II and '
limbs were involved in 15 and both fore and hind limbs were Type III lesions will allow athletic activity in a fair number of
involved in 17 horses. One fetlock joint was operated in 10 cases. but clinical signs will persist in 25%. Whether the
horses. 2 fetlocks in 17 horses. 3 fetlocks in 1 horse. and surgery will be successfulor not will be affected by the extent
4 fetlocks in 14 horses. Forty-eight cases involved the of the lesions. as evident arthroscopically (and in some
proximal 2 cm of the sagittal ridge. where 11 extended distal instances. radiographically). as well as by the presence of
to this point. In 44 instances. lesions involved the lateral osteophytes.erosions. and wear lines. Since the Mcllwraith &
and/or medial condyles of the metacarpus or metatarsus. Vorhees (1990) paper was published. the first author feelsthe
with or without lesions of the sagittal ridge. success rate has improved further because of earlier
Of the 42 horses operated on. follow-up was obtained in intervention and. particularly with radiographing horses at a
28. eight horses were convalescing and in 6 the follow-up young age to ensure clean joints at yearling sale.
Debridement of subchondral cystic regularity (Nixon 1990, Mcllwraith 1990b). Most horses are
lesions of the third metacarpal bone aged 2 years old or less when clinical signs become apparent
and they usually have a history of recently increased physical
The distal Mclll is one of the less common locations for activity (such as entering athletic training). The diagnosis is
subchondral cystic lesions. but they do occur with relative 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 knife. a banana knife. a narrow bistoury. and an Arthro-
the joint; an assistantmay facilitate this step by LokTMretractable blade. We prefer a broad. flat blade. The
flexion on the joint. After assuring the correct disposable No. 11 blade should not be used because of the
risk of breakage. Electrocautery probes have been used more
portal is made distal to the arthroscopic recently for this dissection (Boure et al1999).
, .5.47). The portal is made so that the The immediate postoperative care is the same as for other
comes across transversely. Often, the fragment arthroscopic procedures in the fetlock joint. A period of
2-3 months rest before training resumes is recommended.
can aid visualization.The fragment There have been two reports of treatment of these osteo-
separatedfrom the soft tissue with a knife and is chondral fragments with follow-up. Whitton & Kannegieter
by using a Ferris-Smithcup rongeur (Fig 5.48). (1994) reported on 21 horses.in which 16 horseshad returned
of this fragment leavesa defect within the joint to racing: 12 horses had improved their performance. while 3
and short-digital sesamoideanligaments,and any horses showed no improvement. and 1 horse was retired for
--
other reasons. Degenerative changes within the fetlock joint
plantar defect in the normal phalanx is were detected at surgery in 8 horses. Four horses were treated
appropriatebut is not usually necessary.Figure conservatively: 1 horse returned to its previous level of
performance temporarily after intra-articular medication.
and Figure 5.50 illustrates medial and lateral 1 horse showed no improvement. and 2 horses were resting
at the time of the report.
condition is one of the few in equine arthroscopic A larger case series of 119 horses (109 Standardbred
for which the use of sharp dissectionis essential. horses)had follow-up in 87 racehorses and 9 non-racehorses
used,including a tenotomy (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 dissection with the flat blade is limited to severing the
from the suspensoryligament using a flat blade. suspensory ligament attachments (see Fig. 5.56C). It is
.blade (Foerner-Scanlanelevator)is used to important that the instrument portal is made appropriately
distad so that the knife can sever the suspensory ligament
the abaxial attachment (seeFig. 5.53). attachments from the abaxial fragment. After removal. the
of the fragment, it is removed with Ferris- bone and cartilage are debrided with a curette. A motorized
(see Fig. 5.53). Soft tissue attachments are resector is used to debride the suspensory ligament tags.
with basket forceps or a motorized resector. The Fragmentation of both the apex and abaxial region of the
debrided with a curette. Fragmentation of apical sesamoid bone can occur concomitantly (Fig. 5.58). The
-more than 1/3 of the articular surface arthroscopic technique for these fragments is the same as for
considered ideal candidates for surgery. Apical removing them independently. Generally. the abaxial
fragments in foals can be treated in the same fragment is removed first. followed by the apical fragments
5.55). (Fig. 5.58B-D).
arthroscopic approach is used for surgery on Basal sesamoid fragments are candidates for arthroscopic
fragments. Case selection can sometimes be a removal when no other pathologic changes are present
in the fetlock joint (at least on radiographs) (Fig. 5.59). A
-~ radiographs (Fig. 5.56) do not clearly reasonable number of fragments are of sufficiently small
an abaxial fracture as articular. then a "skyline" size that their removal does not compromise the distal
'. view should be taken (Palmar 1982).
sesamoidian ligament attachments. The exact size limitations
approach is illustrated in Fig. 5.57. Sharp 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 Therehas also beena report of the use of electrocautery
same class and 5 in a lower class). Four racehorses had probesin arthroscopicremoval of apicalsesamoidfracture
not raced prior to surgery; 2 of these horses raced after fragmentsin 18 Standardbredhorses(Boureet al 1999). The
surgery.and 2 did not race before or after surgery. Compared fracture fragmentswere approachedthrough an ipsilateral
with horses with large fragments. horses with smallfragments (3) or contralateral(15) arthroscopictriangulationtechnique.
returned to racing in the same class more often; Distentionof the joints was achievedusing a 1.5%glycine
however.the differences were not significant. solutionand the suspensoryand intersesamoidianligament
The results of arthroscopic removal of fracture fragments attachmentsto the abaxialand axial margins of the apical
involving a portion of the base of the proximal sesamoidbone fragmentweretransectedusing a hook electrocauteryprobe.
have also been reported (Southwood & Mcilwraith 2000). Subsequently.the palmar (plantar) soft tissue attachments
There were 24 racehorses and 2 non-racehorses. Twelve weretransectedwith a loop electrocauteryprobe.After being
(50%) of the racehorses returned to racing and started in at freed of soft tissue attachments,the apical fragment was
least2 races; 8/14 of horses with Grade I fractures (~ 25% of removed with Ferris-Smith intervertebral disc rongeurs.
the base involved) and 4/10 with Grade n fractures (>25%. Eighteenapical sesamoidfragmentswere removedfrom the
but < 100% of the base involved) had a successfuloutcome; left (8) and right (8) hind limbs and the left (1) and right (1)
10/16 without associated articular disease had successful forelimb. Apical fragments occurred in 15 lateral and 3
outcomes compared with 2/8 with associated articular medial proximal sesamoidbones.It was proposedthat the
disease.However. fragment size and presence of associated electrocauteryprobemade an easyand precisedissectionof
articular disease were not significantly associated with all softtissueattachments;10/14 horsesreturned to racing
outcomes (probably related to the relatively low numbers). It (7/9 horsesthat racedbefore surgeryraced again and 3/5
wasconcluded that horses with a fracture fragment involving horsesthat had not racedbeforesurgeryraced afterwards).
a portion of the base of the bone removed arthroscopically Figure 5.61G illustrates the use of an ArthrexTMelectro-
have a fair prognosis for return to racing. cauteryprobeto removea basalsesamoidbonefragment.
Axial osteitis of the proximal sesamoid Follow-up information was obtained for all horses. All
bones and fraying ofintersesamoidean 5 horses without evidence of sepsisreturned to their previous
ligaments with detachment from use with the median recovery time of 9 months. However,
proximal sesamoid bone one of these horsesremained Grade 1/5 lame and radiographs
obtained 1 year after surgery revealed secondaryosteoarthritis
Casesof this have beenrecognizedand treated arthroscopically. of the affected metacarpophalangeal joint. Two horses were
Arthroscopic surgery in 5 cases (out of 8 seen) has been radiographed 12 months after surgery revealing remodeling
reported (Dabareiner et al2001). Typically. the horses present of the sesamoid bones with a smooth contour to the axial
because of lameness and they mayor may not have synovial margins of the sesamoidbone.
effusion (6/8 in the casesreported by Dabareiner et al2001). Instances of focal bone disease involving the sesamoid
Two cases had diffuse cellulitis and effusion of the digital bones have been encountered elsewhere. The pathogenesisis
flexor tendon synovial sheath. All horses had osteolysis of the unknown, but areas of focal subchondral bone diseaseoccur
axial border of the proximal sesamoid bone on radiographs. and have been treated with debridement of defective tissue
In 5 horses. arthroscopy of the palmar or plantar pouch of all (Fig. 5.63).
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 Arthroscopically assisted repair of
or metatarsophalangeal joint was examined. Damage to the lateral condylar fractures of the distal
intersesamoidian ligament was seen in all horses and Mclll and Mtlll
consisted of discoloration. fraying. and detachment from the
associated proximal sesamoid bone. Osteochondral fragmen- Arthroscopy allows an optimal means of assessing and
tation and osteomalacia involving the axial borders of the repairing lateral condylar fractures. The use of the arthroscope I
proximal sesamoid bone was also seen in all joints. After allows verification of articular alignment as well as ,
debridement, the palmar or plantar pouch of the affected compressionof the fracture and a completediagnostic examin- i
joint communicated with the distal synovial sheath through ation of the joint. With correct technique. even displaced
the disrupted ligament. Figure 5.62 illustrates the radiographic fractures can be accurately reduced and repaired without a ':
and arthroscopic manifestations of such a case. 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.
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
Horses with non-displaced fractures typically have a appeared to be affected by the severity of the injury to the
4-month lay-up period. Screw removal varies between joint, the presence of articular comminution, and the quality
different surgeons but in general. only screws that cross of surgical repair. There were 14/16 horses (87%) treated
tubular corticesneed to be removed.There have beentwo without surgery that raced after a lay-up period.
recentstudieson the prognosisfor lateralcondylarfractures This study was particularly interesting in that 58% of
(Bassage& Richardson1998. Zekaset aI1999). Horseswith complete nondisplaced fractures and 60% of horses with
non-displacedcondylarfractureshavean excellentprognosis complete displaced fractures were able to race post-surgery.
for returning to athletic function. The prognosisfor those The authors concluded that the similar number of horses
with displacedfracturesis poorer. racing in these two groups may indicate that a fracture being
Colon JL, Bramlage LR, Hance SR, Embertson RM. Qualitative and
quantative documentation of the racing performance of 461
Thoroughbred racehorses after arthroscopic removal of dorso-
proximal first phalanx osteochondral fractures (1986-1995).
Equine Vet J 2000; 32:475-481.
Dabareiner RM, Watkins JP, Carter GK, et al. Osteitis of the axial
border of the proximal sesamoid bones in horses: eight case
(1993-1999). J Am Vet Med Assoc 2001; 219: 82-86.
Dabareiner RM, White NA, Sullins KE. Metacarpophalangeal joint
synovial pad fibrotic proliferation in 63 horses. Vet Surg 1996;
25: 199-206.
Dalin G, Sandgren B, Carlsten J. Plantar osteochondral fragments in
the metatarsophalangeal joints in Standardbred trotters; result of
osteochondrosis or trauma? Equine Vet J 1993; 16 (Suppl):
62-65.
Elce y, Richardson DW. Arthroscopic removal of dorsoproximal chip
fractures of the proximal phalanx in standing horses. Vet Surg
2002; 31: 195-200.
Foerner JJ. Osteochondral fragments of the palmar and plantar
aspects of the fetlock joint. Proceedings of the 33rd Annual
Meeting of the American Association of Equine Practitioners,
1987: 739-744.
Fortier LA, Foerner JJ, Nixon AJ. Arthroscopic removal of axial
osteochondral fragments of the plantar/palmar proximal aspect
of the proximal phalanx in horses: 119 cases(1988-1992). J Am
Vet MedAssoc 1995; 206: 71-74.
Groendahl AM. The incidence of bony fragments in osteochondrosis
of the metacarpo- and metatarsophalangeal joints of Standard
bred Trotters. A radiographic study. J Equine Vet Sci 1992; 12:
81-85.
Haynes PF. Diseases of the metacarpophalangeal joint. Vet Clin
North Am (Large Anim Pract) 1980; 2: 37-49.
Hogan PM, McIlwraith CW, Honnas CM, Watkins JP,Bramlage LR.
Surgical treatment of subchondral cystic lesions of the third
metacarpal bone: results in 15 horses (1986-1994). Equine VetJ
1997; 29: 477-482.
Hornof WH, O'Brien TR, Poole RR. Osteochondritis dissecans of the
complete is more of a factor in prognosis than the non- distal metacarpus in the adult racing Thoroughbred horse. Vet
displacement. if care is taken to reduce and fix the fracture Radio11981; 22: 98-106.Jaffe
HL, Lichtenstein 1, Sutro CS.Pigmented villonodular synovitis,
accurately. bursitis, and tenosynovitis. Arch Patho11941: 31: 731-765.
Kannegieter NJ. Chronic proliferative synovitis of the equine
metacarpophalangeal joint. Vet Rec 1990; 127: 8-10.
Kawcak CE, McIlwraith CWo Proximodorsal first phalanx osteo-
References chondral chip fragmentation in 336 horses. Equine Vet J 1994;
26: 392-396.
Barclay VP. Foerner JJ. Phillips TN. Lameness attributable to Kawcak CE, McIlwraith CW, Norrdin RW, Park RD, Steyn PS.
osteochondral fragmentation of the plantar aspect of the Clinical effects of exercise on subchondral bone of carpal and
proximal phalanx in horses: 19 cases (1981-1985). J Am Vet metacarpophalangeal joints in horses. Am J Vet Res 2000; 61:
MedAssoc 1987: 191: 855-857. 1252-1258.
BassageLH. Richardson DW. Longitudinal fractures of the condyles LoSasso MB, Honnas CM. Chronic proliferated synovitis in a horse.
of the third metacarpal and metatarsal bones in racehorses: 224 Equine Pract 1994; 16: 29-32.
cases(1986-1995).J Am VetMed Assoc 1998: 212: 1757-1764., McIlwraith CWoSubchondral cystic lesions (osteochondrosis) in the
Birkeland R. Chip
phalangeal jointfractures of the Acta
of the horse. first phalanx in the metatarso-,.
Radiol (Suppl) 1972; 29: horse. Comp Cont Educ Pract Vet 1982; 4: 2828-291S.
McIlwraith CWoExperience in diagnostic and surgical arthroscoppy
; 73-77. in the horse. Equine Vet J 1984; 16: 11-19.
r Boure L. Marcoux M. Laverty S. Lepage OM. Use of electrocautery
McIlwraith CWoDiagnostic and surgical arthroscopy in the horse,
probes in arthroscopic removal of apical sesamoid fracture 2nd edn. Philadelphia: Lea & Febiger; 1990a.
r. 226-232. in 18 Standardbred horses. Vet Surg 1999; 28:,
fragments McIlwraith CWo Subchondral cystic lesions in the horse -the
indications, methods, and results of surgery. Equine Vet Educ
Bramlage LR. Osteochondrosis -related bone cysts. Proc MEP 1990b: 2: 75-80.
1993; 39: 83-85. McIlwraith CW Osteochondritisdissecansof the metacarpophalangeal
CarlstenJ. Sandgren B. Dalin G. Development of osteochondrosis in and metatarsophalangeal (fetlock) joints. Proceedings 39th
the tarsocrural joint and osteochondral fragments in the fetlock AAEP Convention, 1993: 63-67.
joints of Standard bred Trotters. 1. A radiological survey. Equine McIlwraith CWo Arthroscopic surgery for osteochondral chip
VetJ Supp11993; 16: 42-47. fragments and other lesions not requiring internal fixation in the
carpal and fetlock joints of the equine athlete: What have we Standardbred Trotters. 1. Epidemiology. Equine Vet J Suppl199 3;
learned in 20 years? Clin Tech Equine Pract 2002; 1: 200-210. 16: 31-37.
Mcllwraith CWoVorheesM. Management of osteochondritis dissecans Simon O. Laverty S. Boure L. Marcoux M, Scoke M. Arthroscopic
of the dorsal aspect of the distal metacarpus and metatarsus. excision of osteochondral fragments of the proximoplantar aspect
Proceedings 35th AAEP Annual Convention 1990; 547-550. of the proximal phalanx using electrocautery probes in 23
Meagher DM. Joint sugery in the horse: the selection of surgical Standardbred horses. Vet Surg 2000: 29: 285.
cases and consideration of the alternatives. Proceedings of the Southwood 11. McIlwraith CWoArthroscopic removal of fracture
20th Annual Meeting of the American Association of Equine fragments involving a portion of the base of the proximal
Practitioners. 1974. sesamoid bone in horses: 26 cases (1984-1997). J Am Vet Med
Misheff MM. Stover SM. A comparison of two techniques for Assoc 2000; 217: 236-240.
arthrocentesis of the equine metacarpophalangeal joint. Equine Southwood 11. McIlwraith CW. Trotter GW et al. Arthroscopic
VetJ 1991; 23: 273-276. removal of apical fractures of the proximal sesamoid bone in
Murphy DJ. Nixon AJ. Arthroscopic laser extirpation of metacarpo- horses: 98 cases(1989-1999). Proc AAEP 2000; 46: 100-101.
phalangeal synovial pad proliferation in 11 horses. Equine Vet J Southwood 11. Trotter GW. McIlwraith CWoArthroscopic removal of
2001; 33: 296~301. abaxial fracture fragments of the proximal sesamoid bones in
Nickels FK. Grant BD. Lincoln SD. Villonodular synovitis of the horses: 47 cases(1989-1997). J Am Vet Med Assoc 1998; 213:
equine metacarpophalangeal joint. J Am Vet Med Assoc 1976; 1016-1021.
168:1043-1046. Steyn PF. Schmidt D, Watkins J et al. The sonographic diagnosis of
Nixon AJ. Osteochondrosis and osteochondritis dissecans of the chronic proliferative synovitis in the metacarpophalangeal joint
equine fetlock. Compend Cont Educ Pract Vet 1990; 12: of a horse. Vet Radio11989; 3: 125-138.
1463-1475. van VeenendaalJC. Moffatt RE. Soft tissue massesin the fetlock joint
Nixon AJ. Pool RR. Histologic appearance of axial osteochondral of horses. Aust Vet J 1980; 56: 533-536.
fragments from the proximoplantar/proximopalmar aspect of the White NA. Synovial pad proliferation in the metacarpophalangeal
proximal phalanx in horses. J Am Vet Med Assoc 1995; 207: joint. In: White NA. Moore IN (eds). Current practice of equine
1076-1080. surgery. Philadelphia: Lippincott; 1990: 550-558.
Palmer SE. Radiography of the abaxial surface of the proximal Whitton RC, Kannegieter J. Osteochondral fragmentation of the
sesamoid bones of the horse. J Am Vet Med Assoc 1982; 181: plantar/palmar aspect of the proximal phalanx in racing horses.
264-266 AustVetJ 1994; 71: 318-321.
Pettersson H. Ryden G. Avulsion fractures of the caudoproximal Yovich JA. McIlwraith CWoArthroscopic surgery for osteochondral
extremity of the first phalanx. Equine Vet 1982; 14: 333-335. fractures of the proximal phalanx of the metacarpophalangeal
Raker CWoOrthopedic surgery: errors in surgical evaluation and and metatarsophalangeal (fetlock) joints in horses. J Am Vet Med
management. Proceedings of the 19th Annual Meeting of the Assoc 1986; 188: 273-279.
American Association of Equine Practitioners. 1973. Yovich Jv; McIlwraith CW. Stashak TS. Osteochondritis dissecans of
Raker CW: Calcification of the equine metacarpophalangeal joint the sagittal ridge of the third metacarpal and metatarsal bones in
following removal of chip fractures. Arch Am Coli Vet Surg 1985; horses.JAmVetMedAssoc 1985; 186: 1186-1191.
4: 66-68. Zekas LJ,Bramlage LR. Embertson RM. et al. Results of treatment of
Richardson DW. Arthroscopically assisted repair of articular 145 fractures of the third metacarpal/metatarsal condyles in
fractures. Cl~nTech Equine Pract 2002; 1: 211-217. 135 horses (1986-1994). Equine Vet J 1999; 31: 309-313.
Sandgren B. Dalin G. Carlsten J. Osteochondrosis in the tarsocrural
joint and osteochondral fragments in the fetlock joints in
.has become a most important technique trochlear ridge of the femur. At this location. the patella can
diagnosis as well as for surgery in the femoropatellar be displaced further from the trochlear ridge. which allows
femorotibial joints (Martin & McIlwraith 1985, the sleeveto slide proximally more easily.
.c 1984,Folandetal1992.Nickels&Sande
When the sleeveis positioned to the hilt. the obturator is
, Moustafa et a11987, Lewis 1987, Walmsley 2002, removed and is replaced with the arthroscope. The light cable
al 2003). Diagnostic and surgical arthroscopy 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
of the arthroscope into when the arthroscopic sleeveis situated beneath the patella
femoropatellar joint 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
If both legs are involved, each leg should remain the suprapatellar pouch may be poorly illuminated with low
output light sources.
postoperativefemoralnerveparesisor quadriceps The articular surface of the patella and intertrochlear
Alternatively,the legs may be elevatedand tied groove can be visualized by withdrawing the arthroscope
that tensionis not concentratedon the quadriceps from this position (Fig. 6.5). Specific examination of each area
can be achieved by rotating the arthroscope. The suprapatellar
The skin portal for the arthroscope is located between the pouch disappears from view as the arthroscope is withdrawn
middle and lateral patellar ligament, and halfway between and eventually the tension of the patellar ligaments abruptly
the tibial crest and the distal aspect of the patella (Fig. 6.1). forces the arthroscope out from beneath the patella. At this
This arthroscopic portal allows a complete diagnostic stage. the distal apex of the patella is visualized resting in the
examination of the femoropatellar joint as well as fulfilling all intertrochlear groove (Fig. 6.6). A fringe of villous synovium
needs for observation during surgical manipulations. An usually overhangs the distal margin of the patella.
8-mm stab incision is made through the skin, superficial fascia, Longitudinal defects are often observed in the central part of
and deep fascia into the femoropatellar fat pad (Fig. 6.1B). the intertrochlear groove and apparently are normal.
The sleeve and conical obturator are manipulated through particularly in the more distal regions of the groove.
the stab incision in the skin and fascia and then angled 450 to The medial trochlear ridge and the medial aspect of the
the skin in a proximal direction (Fig. 6.2). The femoropatellar distal patella can be visualized by rotating the arthroscope
joint space is entered by gently manipulating the obturator and directing the angled field of view toward the medial
and arthroscope sleeveunder the patella and over the femoral aspect of the joint (Fig. 6.7). Despite joint distention, thepatella
trocWea. This maneuver may be facilitated by elevation of the and medial trochlear ridge remain in close appositionin
distal limb. If resistance is encountered, the sleeve and this case, in contrast to the same area on the lateraltrochlear
obturator are not forced but are directed more laterally to lie ridge. The medial trochlear ridge is then examined
under the lateral part of the patella facet and over the lateral 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
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.

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 Insertion of the arthroscope into the
smooth and non-villous (seeFig. 6.11), but if becomesquite cranial pouch of the medial
villous distal to this point. The entire length of the lateral femorotibial joint
trochlear ridge is then explored by moving the distal end of
the arthroscope distad and advancing the arthroscope horse is positioned in dorsal recumbency with the leg in
further into the joint as necessary (Figs 6.12 and 6.13). This flexion (approximately 900 at hock and stifle). The leg is
maneuver involves moving the eyepiece of the arthroscope surgically prepared and draped. Three approaches have been
mediad and proximad. The synovial membrane is villous used for diagnostic arthroscopy of the medial femorotibialjoint:
adjacent to the distal one-half of the lateral trochlear ridge cranial (Moustafa et al198 7), lateral (Lewis 1987), and
(Fig 6.12B) and fluid distention is often critical to allow a craniolateral (Nickels & Sande 1982). All approaches provide
clear view of this area. The trochlear ridge is examined until an effective examination of the cranial part of the medial
the synovial reflection of the distal extremity is encountered femorotibial joint. The authors use the first two approaches.
(seeFig. 6.13). In the event of the view being obscured by and they are described. The cranial approach allows more
hypertrophied synovial villi, viewing of a specific area of the consistent examination of the intercondylar (cruciate) area.
trochlear ridges can be improved with gradual flexion. As the On the other hand. the lateral approach leaves a clear area
arthroscope is moved axially from the lateral trochlear ridge. cranially for instrument placement when operating on
the distal aspect of the intertrochlear groove can be medial condylar lesions.
examined. Irregular cartilagenous protuberances and creases Cranial approach. The medial femorotibial joint may
are commonly seenand are considered normal (Fig. 6.14). be distended with sterile fluid through an 18-gauge needle

The
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
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
.in some casesthe lateral femorotibial joints cranial cruciate ligament are also observed. The cranial
ligament of the medial meniscus and the cranial portion of
a window betweenthe respectivefemorotibialjoint 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 femoral condyle and the proximal border of the popliteal
may sometimes (rarely) be noted axially beneath the joint tendon. To view the pouch distal to the popliteal tendon. the
capsule. coursing in a proximodistal direction. 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
Insertion of the arthroscope into the of the more caudal articulation of the joint. It was noted by
caudal compartment of the lateral Trumble et al (1994) that the tendon of the popliteal tendon
femorotibial joint being contiguous with the joint capsule of the caudal pouch
of the lateral femorotibial joint makes arthroscopic explo-
Theseapproachesare basedon the descriptionsof Trumble et al ration of this pouch particularly dillicult.
(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 Normal arthroscopic anatomy of the
made this far caudally. The popliteal tendon divides the caudal compartment of the lateral
caudal lateral femorotibial joint. Distention is performed with femorotibial joint
a spinal needle placed caudal to the collateral ligament. For
examination proximal to the popliteal tendon, the portal is With the proximal arthroscopic portal. it is possible to view
placed 2.5 cm proximal to the tibial plateau and 3 cm caudal the proximal border of the popliteal tendon and the lateral
to the collateral ligament (Fig. 6.29) (Walmsley 2001). femoral condyle (Fig. 6.31). Using the distal portal through
Structures seen through this portal are limited to the lateral the popliteal tendon it is possible to examine the caudal
meniscus, part of the caudal aspect of the lateral medial femoral condyle, and a complete tear of the cranial
, the intra-articular portion of the popliteal
cruciate ligament in 1 case.
but this examination is 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
arthroscopy of clinical in 80 casesof meniscal tears in the horse has been described
in the femorotibial 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
cases of cystic lesions of the medial condyle of the more detail separately.
.1987). Surgical intervention for this condition 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
1987; Turner et a11988. McIlwraith 1995 allow examination of the lateral femorotibial joint in these
1995. 2002). Lewis described the arthroscopic cases. If both cranial and cruciate (and medial collateral)
in 20 cases of unilateral lameness. with a positive ligaments are disrupted, the resulting laxity will allow greater
the medial femoro- visualization of the femorotibial articulations and menisci.
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
Osteochondritis dissecans
3 casesand a partial avulsion/
of the cranial ligament of the medial meniscus was Arthroscopic surgery has emerged as the only surgical tech-
1 case. Examination of the menisci was difficult in all nique to treat osteochondritis dissecans (OCD)in the femoro-
patellar joint. It has replaced arthrotomy eliminating local
and Lewis (1987) noted a lack of ability to adequately
problems with wound healing and reducing the need for rigid
the caudal segments of the meniscus. Lewis also
the use of surgical arthroscopy in 2 cases of tibial postoperative management. The techniques presented sub-
sequently are based on the experience of the authors with
fractures. One of the 2 horses was completely sound
clinical cases of OCD in the femoropatellar joint and the
could resume full function; the other was periodically
follow-up data that have been generated from these cases
mild degree when heavily used. Of the 20 casesin
(Mcllwraith 1984, Mcllwraith & Martin 1984,1985; Martin
revealed articular cartilage
& Mcllwraith 1985. Foland et al1992). Although successful
results can be obtained by using arthrotomy, potential com-
plications include seroma formation. local cellulitis and
nonsteroidalanti-inflammatory agent therapy,
fasciitis, and wound dehiscence (Pascoe et al 1980, 1984;
Trotter et aI1983).
Turner et al (1988) reported the confirmation of cranial
, .injury in 5 cases by the use of femorotibial
A cranial approach with the arthroscope Preoperativeconsiderations
used. Arthroscopic examination revealed the following Preoperative diagnosis of OCD is based on clinical and
disruption of the septum surrounding the radiographic signs. The clinical signs that initially prompt the
ligaments and separating the medial and lateral attention of owners are lameness and/or synovial effusion of
joint compartments; increase in the joint space the femoropatellar joint. The diseaseis not breed-specific,but
with ligamentous laxity; synovitis; and areas of it is a diseaseof young horses. In some instances. however. no
clinical problems are apparent until the horse is in training or
a partial longitudinal tear of the cranial has raced (Mcllwraith & Martin 1985). Lesions that manifest
ligament in 1 case (the horse also had a cranial at this stage are generally less severe. Clinical examination
generally reveals some degree of synovial effusion as a
ligament at its insertion adjacent to the tibial consistent finding. Lameness ranges from nondiscernible
tearing of the cranial attachment of the lateral through subtle gait changes (shortened anterior phase of
the stride, low arc of flight. and unusual flight path with the stifle

included
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 To effectively operate the underside of the patella. an
blade completes entry into the joint. The various instruments instrument portal must be level with or distal to the arthro-
are then inserted through the portal as required (Fig. 6.37). scopic portal and usually 2 cm lateral to the arthroscopic
The various surgical approaches are illustrated in Figures portal (seeFig. 6.40). If this portal is more proximal than the
6.38-6.43. In all instances, we are using the same arthro- arthroscopic portal. the end of the instrument cannot make
scopicportal between the lateral and middle patellar ligament contact with the undersurface of the patella. The portal is
although it is noted that an arthroscopic portal between the made lateral to the middle patellar ligament. depending on
middle and medial patellar ligaments has also been used for the position of the lesion on the patella. To operate on lesions
operations involving lateral trochlear ridge lesions (Bramlage on the distal aspect of the lateral trochlear ridge. the same
perscomm 1987). arthroscopic portal is used as that chosen for the proximal
Lesions on the proximal one-half of the lateral trochlear trochlear ridge. although the arthroscope is directed distad.
ridge are reached through a portal proximolateral to the The instrument portal is made low over the distended
arthroscopic portal (seeFig. 6.38). The instrument may pass femoropatellar joint through or immediately adjacent to the
either lateral to or (usually) through the lateral patellar lateral patellar ligament (Fig. 6.41). For lesions on the distal
ligament when using this portal. If the entry is too far lateral, aspect of the medial trochlear ridge. a distal portal is usually
the instrument cannot be manipulated up and over the made between the middle and medial patellar ligaments
lateral trochlear ridge. Passing the instrument through the (Fig. 6.42). If the lesion on the medial trochlear ridge is
lateral patellar ligament does not seem to be of any located on the trocWear groove (axial) side of the distal medial
consequence. Lesions of the proximal portion of the medial trochlear ridge. however. a medial portal does not always
trochlear ridge are reached by using a portal between the allow the instrument to reach this location. In this instance.
medial and middle patellar ligaments. entering the skin distal a lateral instrument portal. allowing the instrument to pass
to the lesion (Fig. 6.39). 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 commonly occur as raised areas of articular
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. trochlear ridge lesions,with the use of
The probe is useful in defining the limits of an osteochondral portal (Figs6.39, 6.42, 6.45, and 6.47).
or chondral flap as well as for assessingits mobility. The probe
is also used to evaluate any cracking, wrinkling, or fibrillation and on the axial sides of the trochlear ridges. It is
in the articular cartilage. If the cartilage is cracked but firmly common to see OCD lesions on the ~ ~c ,-- ~
attached to subchondral bone, it is not removed. Normal-
appearing articular cartilage is also probed, particularly if is gaugedby inserting a spinalneedle.but generally
radiographs have revealed lesions in the subchondral bone in
that area. If intact cartilage overlies a subchondral defect,the ridge will not allow accessto the lesion.
probe breaking through the articular cartilage into the defect arthroscopeand instrument is depictedin Figure
locates the lesions and the undermined articular cartilage is
then removed. graphs indicate severe intraarticular disease and surgery
The most common form of pathologic change encountered contraindicated (Fig. 6.49)
on arthroscopic examination of osteochondritis dissecans of Primary OCD lesions of the patella are uncommon, "--
the lateral trochlear ridge of the femur is flap formation or they do occur (Fig. 6.51).-
",' Femoropatellar and Femorotibial joints
Wi
,~

.,
for lesions on the trochlear ridges, with removal of feature of osteochondritis dissecans of the femoropatellar
joint. This lack of correlation takes a number of forms: (1)
.In addition to primary osteochondritis cartilaginous change more severe than expected. based on
of the patella. degenerative erosive lesions that the subchondral lesions seen on the radiographs; (2)
cartilaginous lesions on the trochlear ridge or patella where
no subchondral bone changes were radiographically
of cartilage (with bone sometimes) are seen on the detectable; or (3) less severe cartilaginous change than
in association with lateral trochlear ridge OCD expected (usually taking the form of intact articular cartilage
6.51B). The usual site for these patellar lesions is the over radiographically lucent subchondral change). The
-it articulates various radiographic defects observed manifest in a number
the area of osteochondritis dissecans on the lateral of ways during arthroscopic examination. Usually some form
ridge. Histological examination of these buds of of cartilaginous flap or islands of cartilage and a fibrous tissue
in one of the author's (A.J.N.) laboratory suggest 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
Lack of correlation between radiographic lesions and detached articular cartilage. In some instances. intact
pathologic changes found intraoperatively are a cartilage is separated from the bone (seeFigs 6.45 and 6.47).
Osteochondral bodies that have detached from the deepfascia. as occurs with the conventional lateral or medial
primary trochlear ridge lesions can be a challenging surgical instrument portals. As in other joints, the skin alone is
problem. They may be free within the joint or embedded sutured and no healing problems have been observed.
within the synovial membrane and joint capsule. If these It is difficult to make specific recommendations with
bodies are totally free within the joint. the surgeon must regard to how to manage osteochondral massesembeddedin
grasp the fragment carefully without pushing it away and the synovial membrane or in the fibrous joint capsule. For
causing it to float up into the suprapatellar pouch (Fig. 6.52). cases in which the loose body is attached to synovial
Switching off the ingress fluids at this stage can decreasethe membrane but is clearly visible within the joint, removal is
fluid flow and minimize movement of the loose body. Prior indicated and can be performed arthroscopically without
fixation of the loose body with a needle is also of help in this problems. For a less-visibleor less-accessiblelesion, arthrotomy
situation. can be performed and the first author (C.W.M.) has used this
In instances of large fragments. the skin incision is technique in one instance of such a lesion (Mcllwraith &
enlargedto facilitate removal and occasionally the deepfascial Martin 1985). It is questionable if removal of this mass was
incision is also enlarged.However.a proximal instrument portal necessary and the authors favor leaving it alone when it is
abovethe patella into the suprapatellar pouch can be used to embedded within the joint capsule. Formation of osseous
remove large fragments with satisfactory results. A spinal bodies in the soft tissue has occurred postoperatively, and
needleis used to confirm the correct position before incising a similar lesions have been noted on radiographs obtained after
portal through the quadriceps muscle into the suprapatellar arthrotomy (Pascoe et aI1984). Horses with these osseous
pouch. Large fragments are removed more easily through this masses can race, leading to the interpretation that these
portal because they do not have to come through the inelastic animals do not need surgery.
Contraindications for surgery include lateral luxation of such fragments have a rigid bony component, which is rarely
the patella owing to excessive loss of the lateral trochlear present in the equine case. Recently, a technique for using
ridge, and secondary remodeling changes of the patellar PDSOrthosorb@pins has beendescribedby Nixon et al (2004)
identified radiographically (seeFig. 6.49). for fixing large OCD flaps (see Chapter 16). A very select
At the completion of the surgical procedures for osteo- group of OCD lesions are suitable for reattachment. The
chondritis dissecans, the joint is liberally lavaged and cartilage of the flap must be relatively smooth, not calcified,
vacuumed to ensure removal of small debris released at the and have at least some residual attachment to the sur-
time of surgical debridement. A special, larger egresscannula rounding cartilage. The arthroscopic PDSpin kit can then be
has been developed for this purpose. It is 8 mm in diameter used to secure the flap in multiple locations. Reattachment,
and is 20 cm in length. It is inserted until its tip lies within the revitalization, and most, importantly, filling of the sub-
suprapatellar pouch (Fig. 6.53A). The suction tubing can be chondral bone defect occurs within 8-12 weeks of :
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- the rapid return of ,
native is to insert a large diameter cannula into the supra- follow-up radiographs (Fig. 6.54). This compares
patellar pouch through a portal proximal to the patella. with the trochlear ridge defect remaining after
After completion of the procedure and suturing of the ment, particularly for the discerning buyer of
incisions, a sterile loban@ drape is placed over the surgery yearlings. It should be stressed, however, that
site in lieu of a bandage (Fig. 6.53B). OCD flaps of the femoral trochlear ridges do not fit :
Pin fixation of large osteochondritis dissecans fragments guidelines established for reattachment and need to
has been described in man (GuhI1984). Note, however, that debrided.
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.
I
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
Postoperativemanagement follow-up evaluation of larger lesions in elite athletes would
Horses generally receive procaine penicillin and gentamicin be appropriate. As mentioned previously, if lateral luxation of
sulfate perioperatively and phenylbutazone before surgery the patella is present, surgery is contradicted. Limitations for
and for 5 successive days. This regimen is a precaution healing have been described in the medial condyle of the
against any development of interfacial swelling. Most cases femur (Converyet al19 72), but our clinical data support some
are simple to manage. and the horse can be discharged soon form of functional filling of these defects on the trochlear
after surgery. Hand walking commences after 1 week to allow 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


Technique
This condition was mentioned in the second edition of this An arthroscopic examination of the femoropatellar joint is
textbook. It has now been further explained and reported in performed as previously described. The lesion is identified on
the literature (McIlwraith 1990) and its pathogenesis the distal patella and any other changes in the joint are
explained (Gibson & McIlwraith 1991). 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).
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
other options that have beenused. Historically,cancellous long digital extensor tendon as previously described. Examin-
bone grafting has beenused (Kold & Hickman 1984), but ation of the medial femorotibial joint is also performed as
resultswith this techniquethrough arthrotomy at leastwere previously described.
not as goodas simple debridement(White et aI1988). More The characteristic dimple in the articular cartilage over-
recently,somecontrolledwork with cancellousbonegrafting lying the subchondral cystic lesion is visualized (Fig. 6.65)
in experimentallycreated 12.7 mm diameter and 19-mm and the location for the instrument portal is determined by
deepdefectsin the medialfemoral condyle and a 6-month placement of a needle (seeFig. 6.64A). The instrument portal
Femoropatellarand FemorotibialJoints

I'
~
madeusing an 8 mm incision through the skin and hole is conservatively cut back to gain sufficient accessto the
and a stab through the joint capsulewith a No. 11 cystic lesion, but not more than that. More recently, one of
.This portal must be positionedso that the authors (AJN)has beenusing cancellous bone graft in the
site of the lesionperpendicular base of the cystic lesion and adding fibrin with cells on top
the articular surface to enable effective surgical mani- (see Chapter 16). Although drilling of the cystic lesion has
been abandoned because it appeared to be associated with
are removed by using a curette and rongeurs (see enlargement of cysts (Howard et al1995), micro fracture has
In someinstancesa motorizedburr is usedto assist been perfomed in the walls of the cystic lesions and it is a
subjective impression that it is quite useful.
The configurations of the cystic lesions at arthroscopy Following debridement, the joint is lavaged liberally and
and can be multi-loculated. Typically debridement of suction is also applied after this procedure. The skin portals
subchondral tissue continues to normal bone. Because are closed with simple interrupted sutures. Care is taken
during initial debridement of the contents of the cyst to
be a difficult decision.Cartilagethat is overhangingthe remove defective tissue immediately from the joint and to
minimize debris accumulation elsewhere. Debris is released in 11 horses had an osteochondritis dissecans lesion
into the joint. but it generally accumulates in the inter-
condylar area lateral to the medial condyle. A special effort is from the opening of the subchondral cystic lesion. ~
made during lavage and suctioning of the joint to remove all debridement performed by arthroscopy was the only
debris from this area. ment for 37 lesions in 23 horses.
drilling of the defect bed was performed in 23 lesions
18 horses. Complete follow-up information
Postoperative management 39 horses: 22 (56%) horses had a successful result
Perioperatively,the horse receivesprocaine penicillin and 17 (44%) horses had an unsuccessful result.
phenylbutazone. The patient is confined to a stall for
2 months. Hand walking commencesat the time of suture results because of factors not directly attributed to
removal. A minimum of 4 more months pasture rest is subchondral cystic lesion of the medial femoral
recommendedbefore training resumes.Training should (censored analysis), 23 of 31 '
resumeonly if the horseis sound at a trot afterthis time. In result and 8 of 31 (26%) horses had,
the series of casesreported by Lewis. the postoperative Within this group of horses, the prognosis for a
convalescence in casesthat were ultimately successful varied
from 4 to 18 months and averagedapproximately7t months sex, size of ]
(Lewis1987). lesion was drilled, the presence of
with the subchondral cystic lesion, or whether the
enlarged after surgery. Compared
Results Arabians, Quarter Horses had a poorer]
In the series reported by Lewis, complete soundness for Follow-up radiographs were available for 14 horses.
these 14 horses, the subchondral cystic lesion --
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 significantly with drilling of the lesion bed at the time
occasionalmild lamenessin the affectedlimb. Of the remaining surgery.
19 horses, various degrees of residual lameness presented a Lesions were classified on radiographic appearance
problem for athletic use as intended; however, some animals either Type I lesions (10 mm or less in depth.
were used for less stressful activities and were satisfactory in
that respect. In summary, the overall satisfactory outcome for surface of
intended use was 72% (48 of the 67 cases).Of the 19 failures II lesions (more than 10 mm in depth and
for intended use, 11 were from a group of 28 potential race- conical or spherical) (see Fig. 6.61B), or Type ill
horses, producing a 39% failure rate. Eight were from a group (flattened or irregular contours of the subchondral j
of 39 horses intended for other use (cutting, reining, roping, the distal aspect of the medial femoral condyle. 1
and pleasure), representing a 21 % failure rate in these types regression showed a significant association between
of horses. Lewis concluded that several factors could affect types as assessedfrom preoperative radiographs and ~
the prognosis, including age (younger horses in general had a types based on surgical assessment. However, '
better prognosis), unilateral versus bilateral lesions (cases of
bilateral involvement were somewhat less successful),signifi-
cant training or use before surgery (generally decreasedthe in six joints; of the SCL that appeared to be Type I
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 were later determined to be Type I on the basis of
articular surface was associated with a less favorable prog- scopic findings. Of the 15 joints that appeared to ~
nosis), pre-existing degenerative joint disease (poorer prog- three had a Type I SCL.six:
nosis), and intended use (racehorseswere the most difficult to four appearedto be norma
return to intended use).
Howard et al (1995) described the results of arthroscopic attachedto the subchondralbone on palpation
surgery for subchondral cystic lesions in the medial femoral and no surgical treatmentwas done; however.
condyle in 41 horses. There were 17 Quarter Horses, 15 stifle of thesehorsesdid havea surgicallesion.
Arabians, 8 Thoroughbreds, and 1 Holsteiner with 28 (68%) not performedon two of the joints with a SD. Given
of the horses being 1-3 years old. For all horses, the owner's
complaint was mild to moderate hind limb lameness, or an lesional injection of 40 mg of MPA (Depo-Medrol@)to
regime. The latter technique ' -
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 supported by more recent work demonstrating that
surgery. In addition to the subchondral cystic lesion, 13 joints fibroustissueof
cause (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
achieving 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
lesionwas little consequencein defining the prognosis.
Additionally, there were 91 (60.6%) horses with less than
(Howard et al amount of or equal to 15 mm of surface debridement and 59 (39.3%)
surface disrupted by measured horses with greater than 15 mm of surface debridement. Of
at the 1 the 91 horses with 15 mm or less of surface disrupted, over
into two groups: those with lesions that involved 70% started at least one race, whereas only about 30% of the
or less cartilage surface and those with greater 59 horses with greater than 15 mm of cartilage surface
15 mm of disruption. During the period between 1989 involvement started a race. The amount of cartilage surface
150 clinically lame Thoroughbred horses with a affected seemedto be a better predictor of successthan lesion
214 subchondral cystic lesions had surgery. Of the depth.
86 (58%) horses had unilateral lesions and 64 Most recently, one author (C.W.M.) has treated a number
of cases with intralesional injection of corticosteroid
were raced, whereas 77% of the siblings (triamcinolone acetonide) under arthroscopic visualization
whereas 71% of males raced; (Fig. 6.66). In 2-year-old Thoroughbreds, everyone at this
stage has been able to go back into training at 2 months, with
61 % (79) of the horses raced as 3 year oIds, and 51% 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
old, with a range of 6-24 months old (Textor et al 2001).
This condition is relatively uncommon. When it occurs, it is Horses will present with severity of lameness from 0 to 3 and ~
typically present at a young age. In one report of 12 cases,the in all casesthe lameness can be exacerbated by stifle flexion.!
mean age of these horses at presentation was 12.3 months Stifle joint effusion (with pouch undefined) was present in
6 of the 12 horses previously described. In 6 horses, intra- osteophyte formation on the medial aspect of the tibia and
articular anesthesia improved the lameness in 4 horses and femur, and subchondral bone sclerosis.
this was unchanged in 2 horses (these had extensive deep A technique for arthroscopic surgery has been reported
lesions of the lateral tibial condyle). In 6 horses the lesions (Textor et al 2001) and cases arthroscopically approached
were considered to be the result of osteochondrosis and were had lesions located in the cranial third of the tibial plateau. In
solitary lesions involving the lateral tibial condyle without horses with lesions involving the lateral tibial condyle, the
other signs of joint disease(Fig. 6.68). In 5 out of 6 horses in lateral aspectof the femorotibial joint was arthroscoped using
which the lesions were considered to be the result of osteo- a medial portal, as described previously, with the arthroscope
arthritis (OA), there was a well-defined cystic lesion of the inserted between the middle and medial patellar ligaments.
medial condyle of the tibia and signs of mild to marked OA, Lesions would typically be identified cranial and immediately
including remodeling the proximal extremity of the tibia, 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 if the examiner has considerable experience (Cauvin et al
fractured portion through a cranial instrument portal in the 1996). However, arthroscopy is the preferred choice for a
medial femorotibial joint (Mueller et al 1994). One author definitive diagnosis.
has pointed out that if the fracture causes significant Diagnostic arthroscopy of the cranial pouch of the medial
disruption to the surrounding tissues. lag screw fixation is femorotibial joint can be done through a lateral or cranial
preferred (Walmsley 1997). In the case described, fixation portal. The cranial portal will give better overall visualization
was performed using a cranial arthroscopic portal with an of the cruciate ligaments in the intercondylar notch, but both
extra instrument portal in line with the angle of the implant. approaches can be used. A typical partial-thickness tear will
The prognosis in these casesis related to absenceor presence involve the body of the cranial cruciate ligament, rather than
of other injury in the joint. The authors have treated cases the insertion. This is consistent with experimental work that
both by internal fixation and with arthroscopic removal. 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
Injuries to the cruciate ligaments ligament has been reported (Edwards & Nixon 1996, Prades
et al 1989). Caudal cruciate ligament injury has been
Cruciate ligament injury in the horse was initially described described in the literature (Moustafa et al1987), but is un-
by Sanders-Shamis et al (1988) and Prades et al (1989). common. Caudal cruciate injuries observed arthroscopically
Complete rupture of the cranial cruciate ligament in the generally appear as longitudinal shredding of the femoral
horse is catastrophic and it is unusual to examine these cases origin, although radiographic lesions associated with the
arthroscopically (Fig. 6.72). Less severe injuries to cruciate tibial insertion of the caudal cruciate can occasionally be
ligaments can be regularly diagnosed with diagnostic seen. Cranial cruciate injury can vary from hemorrhage on
arthroscopy. It has been pointed out that sometimes strains the synovial membrane covering the cruciate ligaments
and partial ruptures may be diagnosed ultrasonographically or mild fiber disruption to more severe fiber disruption
.Grade III, a severetear of the meniscus and ligament abaxial to the junction of the meniscus and its cranial
that extends beneath the femoral condyle so that the ligament and involved separation of meniscal tissue on either
limits of the tear cannot be seen. side of the tear. The author was also uncertain as to whether
It is less common to see tears of the meniscus in the caudal fraying was symptomatic or associatedwith age and use. This
pouch of either the medial or lateral femorotibial joint, paper served as the hallmark for making meniscal injuries a
although this probably reflects the reduced frequency that recognizable syndrome.
surgeons successfully enter and examine the caudal pouches. A later retrospective study described 80 cases of
For meniscal tears in the cranial portion of the meniscus meniscal tears in horses (Walmsley et al 2003). Inclusion
(medial femorotibial joint), the arthroscope is usually placed criteria were:
through the lateral portal, as visualization is satisfactory and
1. Lameness localized to the femorotibial joint with clinical
it is out of the way of the instrument. Meniscal injuries
confidence (in most cases that involved intra-articular
seen in the horse can be categorized as vertical radial
(transverse) vertical longitudinal, vertical flap or bucket diagnostic analgesia).
2. Diagnostic arthroscopy identifying an abnormality in one
handle, or as horizontal transverse (Fig. 6.74). True bucket
or both of the femorotibial menisci.
handle tears, as seen in man are rare in the horse. A cranial
3. The meniscal injury was considered to be the primary
instrument portal is made and the torn portion removed. This
lesion in the joint.
can be accomplished with a combination of Ferris-Smith
rongeurs, biopsy suction forceps, or motorized equipment The medial meniscus was involved in 60 casesand the lateral
(Figs 6.75-6.77). The aim is to leave a clean edge of healthy in 20 cases.Forty-three tears were Grade I. 20 were Grade
meniscus. One of the authors (A.J.N.)has used intraarticular n, and 17 were Grade Ill. Distention of either or both
suturing of the meniscus in four horses. The meniscal tear the femoropatellar and femorotibial joint was recorded in
should be clean, vertical, and relatively fresh. Suturing can be 31 horses, but in 14 of these, distention was recorded in only
achieved by using flexible needles (Fig. 6.78) (Nitinol, the femoropatellar joint. The relative likelihood of joint
Arthrex Corporation, Florida) to tie mattress sutures through distention was nine times greater among horses with Grade n
the tear, and more complex tears can be sutured with a and III injuries (17/20,13/17), respectively,as compared to
Bankart shoulder repair device (Fig. 6.79) (Arthrex Corpo- horses with Grade I injuries (4/43). The median lameness
ration, Florida) used in an upside-down configuration. Trans- Grade was 3 (on a scale of 5); the response to intra-articular
verse vertical tears can be more difficult to trim or suture, analgesia was positive in 59/65 horses in which it was
since they orientated across the structure of the meniscus performed and, in 45/76 horses in which the information
(Fig. 6.80). Additionally, they occur more commonly in the was recorded, the flexion test worsened the lameness. Radio-
central (medial) to caudomedial portion of the meniscus and graphic abnormalities were seenin 38 horses and increased
can be difficult to even visualize. with severity of lesions. New bone formation on the medial
Similarly, tears of the lateral meniscus will be encountered intercondylar eminence of the tibia occurred in 23 cases
on exploration of the lateral femorotibial joint using the and OA of the femorotibial joint was evident in 18 cases.
portal that starts in the medial femorotibial joint. Access can Mineralization of soft tissue structures was seen in
be a little more difficult with the arthroscopic portal in this six cases.
joint as the long digital tendon and popliteal tendon are both Walmsley et al (2003) used the Outerbridge (1961)
present intra-articularly. Avulsion fracture of the insertion of human grading system for articular cartilage lesions. Lesions
the cranial ligament of the lateral meniscus can cause in the articular cartilage of the medial femoral condyle (MFC)
meniscal instability (see Fig. 6.81). This site is predisposed, or lateral femoral condyle (LFC)were recorded as:
and in one author's opinion (A.J.N.), occurs as frequently as .circumscribed areas of prominent fibrillation less
tears in the lateral meniscal body. than 1.5 cm in diameter, (similar to those graded as
In the initial report of Walmsley (1995), there were Outerbridge Grade 2)
5 horses with a vertical tear in the cranial horn and cranial .generalized fibrillation extending over larger areas,
ligament of the medial meniscus and 2 horses with similar associated with a parent thinning of the articular
injuries in the lateral meniscus. All the lesions had similar cartilage (similar to Outerbridge Grade 3)
characteristics and the tear was about 1 cm from the junction .superficial, mild fibrillation (similar to mild Outer-
of the axial border of the meniscus and the cranial ligament bridge Grade 3)
of the meniscus ligament. In all but one case it was in- .full-thickness lesions of variable size in which the
complete, with much of the torn tissue loosely attached to the subchondral bone could be palpated with a probe
axial part of the meniscus from where it was removed. The (similar to Outerbridge Grade 4)
remaining meniscus abaxial to the tear was displaced .shear lesions or chondral flaps characterized by the
cranially and abaxial and its torn edges were debrided. In presence of torn flaps of articular cartilage
those cases, 3 horses returned to full competition, 1 horse .thickened, softened, enfolded, or fissured articular
was useable for hacking, 2 were convalescing and 1 was lame cartilage (similar to Outerbridge Grade 1, but more
after 1 year. Walmsley (1995) pointed out that these lesions severeand with fissuring)
were quite different from the vertical meniscal tears, which .small (about 3 mm), raised plaques of firm cartilage
occurred in the cranial horn of the meniscus at least 1 cm 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 Other indications for arthroscopic
always examine the caudal portion of the medial femorotibial surgery in caudal pouches
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 the caudal aspectof the femoralcondylesin foals
experience.Vertical longitudinal tears of the medial meniscus examination of the caudal pouches has been
have also been seen(Fig. 6.83). Mineralization of the meniscus (Hance et al 1993). We have also used this approach
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 The caudal compartment of the medial femoral
caudal surface of the femoral condyle. debride free or is quite voluminous and free fragments can be
fibrillated soft portions of the meniscus and suture any
longitudinal tears that are not disintegrated. Manipulation of the instrument portal is vital in reaching the
instruments in the caudal compartment is tedious. particu- and avoiding instruments and the arthroscope
larly since the depth of the damaged meniscus from the skin with each other as they penetrate deeper to
surface is often 6-8 cm. Trimming of caudal horn meniscal free pieces.
tissue is best accomplished with a motorized resector, The caudal portion of the caudal r
particularly the large-format tooth synovial resectors such as
the orbit incisor or Synovator. Removal of mineralization medial femorotibial joint (Fig. 6.85). However,
generally requires an arthroburr. ence of authors, disruption of the insertion of
In common with other species, macerated tears of the (evident radiographically) may not be visible
menisci carry a poor prognosis for return to working sound- arthroscopy. Moreover, the popliteal artery is ~
ness as the loss of fibrocartilagenous meniscal tissue is this ligament and exposure of the caudal cruciate
usually marked. These injuries frequently also extend into the motorized resection of the covering joint capsule would
central inaccessible regions of the meniscus so that removal hazardous. A caudal cruciate ligament avulsion in ;'
of torn tissue often is incomplete. has been defined with imaging (Roseet aI2001).

~
Martin GS. Mcilwraith CWoArthroscopic anatomy of the equine
femoropatellar joint and approaches for treatment of osteo-
chondritis dissecans. Vet Surg 1985; 14: 99-104.
Moustafa MAl. Boero II. Baker GJ. Arthroscopic examination of the
femorotibial joints of horses. Vet Surg 1987; 16: 352-357.
Vet Mueller POE. Allen D. Watson E. Hay C. Arthroscopic removal of a
fragment from an intercondylar eminence fracture of the tibia in
a 2-year-old horse. J Am Vet Med Assoc 1994; 204: 1793-1795.
, Zugang.Teil 1:
11: Nickels FA. SandeR. Radiographic and arthroscopic findings in the
equine stifle. J Am Vet Med Assoc 1982; 181: 918-924.
.BoydJS.etaI. Ultrasonographic
examination Outerbridge R. The etiology of chondromalacia of the patella. JBone
Joint Surg (Br) 1961; 43: 752.
and caudal aspects.Equine Vet J 1996; 28: 285-296. Nixon AJ. Fortier LA. Goodrich LR. Ducharme NG. Arthroscopic re-
Akeson WH. Keown GR. The repair of large osteo- attachment of select OCDlesions using resorbable polydioxanone
chondral defects; an experimental study in horses. Clin Orthop pins. Equine VetJ 200436: 376-383
RelRes 1972; 82: 853-862. Pascoe JR. Wheat }D. Jones KL. A lateral approach to the equine
van Weeren PRoRadiographic development of femoropatellar joint. Vet Surg 1980; 9: 141-144.
osteochondral abnormalities in the hock and stifle of Dutch Pascoe JR. et al: Osteochondral defects of the lateral trocWear
Warmblood foals. from age 1 to 11 months. Equine Vet J 1999; ridge of the distal femur of the horse. Clinical. radiographic. and
(Suppll) 31: 9-15. pathologic examination of results of surgical treatment. Vet Surg
-Nixon. AJ. Avulsion of the cranial cruciate ligament in 1984; 13: 99-110.
a horse. Equine Vet J 1996; 18: 334-336. Prades M. Grant VD. Turner TA. Injuries of the cranial cruciate
ligament and associated structures: summary of clinical. radio-
study of 14 horses. Proceedings 48th AAEP 2002; 249-254. graphic. arthroscopic and pathological findings from 10 horses.
~- -Mcllwraith CWoTrotter GW. Arthroscopic surgery for EquineVetJ 1989; 21: 354-357.
osteochondritis dissecans of the femoropatellar joint. Equine Vet Ray CS. Baxter GM. Mcilwraith CWoet al. Development of sub-
J 1992;24: 419-423. chondral cystic lesions after articular cartilage and subchondral
.-Arthroscopic treatment of osteochondritis dissecans. Clin bone damage in horses. Equine Vet J 1996: 28: 225-232.
Orthop 1984; 167: 65-74. Rich RF. GlissonRR. In vitro mechanical properties and failure mode
et al. Lesions of the caudal of equine (pony) cranial cruciate ligament. Vet Surg 1994; 23:
aspect of the femoral condyles in foals: 20 cases(1980-1990). J 257-265.
Am Vet Med Assoc 1993; 202: 637-646. RosePL. Graham JP.Moore I. Riley CB. Imaging diagnosis -caudal
Arthroscopic surgery for cruciate avulsion in a horse. Vet Radiol Ultrasound 2001; 42:
subchondral cystic lesions of the medial femoral condyle in 414-416.
horses: 41 cases(1988-1991). J Am Vet Med Assoc 1995; 206: Sanders-ShamisM. Bukowiecki CP.Biller DS. Cruciate and collateral
842-850. ligament failure in the equine stifle: 7 cases (1975-1985). J Am
WA, Stick JA, Arnoczky Sp, Nickels FA. The effect of Vet Med Assoc 1988; 193: 573-576.
compacted cancellous bone grafting on the healing of sub- Sandler EA. Bramlage LR. Embertson RM. Ruggles AJ. Frisbie DD.
chondral bone defects on the medial femoral condyle in horses. Correlation of lesion size with racing performance in Thorough-
Vet Surg 2000; 29: 8-16. breds after arthroscopic surgical treatment of subchondral cystic
J. Results of treatment of subchondral bone cysts lesions of the medial femoral condyle: 150 cases (1989-2000).
in the medial condyle of the equine femur with an autogenous Proceedings 48th AAEP. 2002; 255-256.
cancellous bone graft. Equine Vet J 1984; 16: 414, Schneider RK. Jenson P. Moore RM. Evaluation of cartilage
c --A retrospective study of diagnostic and surgical
lesions on the medial femoral condyle as a cause of lameness in
arthroscopy of the equine femorotibial joint. Proceedings of the horses: 11 cases (1988-1994). J Am Vet Med Assoc 1997; 20:
23rd Annual Meeting of the American Association of Equine 1649-1652.
Practitioners, 1987. Soper NJ. Hunter JG. Suturing and knot tying in laparoscopy. Surg
CWoSurgery of the hock. stifle and shoulder. Vet Clin Clin N Am 1992; 72: 1139-1152.
North Am 1983; 5: 333-362. Steinheimer DN. Mcilwraith CWoPark RD. Steyn PF. Comparison of
Experience in diagnostic and surgical arthroscopy radiographic subchondral bone changes with arthroscopic
in the horse. Equine Vet J 1984; 16: 11-19. findings in the equine femoropatellar and femorotibial joints.
-.Treatment of osteochondritis dissecans and A retrospective study of 72 horses. Vet Radiol 1995; 36:
subchondral cystic lesions. Proceedings of Panel on Develop- 478-484.
mental Orthopedic Disease.American Quarter Horse Association, Stick JA. Borg LA. Nickels. Peloso JG. Perau DL. Arthroscopic
Dallas, TX, April 1986; 21-22. removal of an osteochondral fragment from the caudal pouch of
Mcllwraith CWoOsteochondral fragmentation of the distal aspect of the lateral femoral tibial joint in a colt. J Am VetMed Assoc 1992;
the patella in horse. Equine Vet J 1990; 22: 157-163. 200: 1695-1697.
Mcllwraith CW Osteochondritis dissecans of the femoropatellar Textor JA. Nixon AJ. Lumsden J. Ducharme NG. Subchondral cystic
joint. Proceedings 39th Annual Meeting AAEP, 1993: 73-77. lesions of the proximal extremity in horses: 12 cases
Mcllwraith CW, Martin GS. Arthroscopy and arthroscopic surgery in (1983-2000). J Am Vet Med Assoc 2001; 218: 408-413.
horse. ContEduc 1984; 6: S43-553. Trotter CW Mcilwraith CWoNorrdin RW A comparison of two surgical
Mcllwraith CW, Martin, CS. Arthroscopic surgery for the treatment approaches to the equine femoropatellar joint for the treatment of
of osteochondritis dissecans in the equine femoropatellar joint. osteochondritis dissecans. Vet Surg 1983; 12: 30--40.
VetSurg 1985; 14: 105-116. Trumble TN. Stick JA. Arnoczky SP. RosensteinD. Consideration of
Marble GP, Sullins KE. Arthroscopic removal of patellar fracture anatomic and radiographic features of the caudal pouches of the
fragments in horses: 5 cases(1989-1998). J Am Vet Med Assoc femorotibial joints of horses for the purpose of arthroscopy. Am J
2000; 216: 1799-1801. Vet Res1994; 55: 1682-1689.
Turner TA. Nixon AJ. Brown M. Prades MA. Injuries to the anterior Walmsley JP. Fracture of the intercondylar eminence of the tibia
cruciate ligament in sevenhorses(Abstract). VetSurg 1988; 17: 38. treated by arthroscopic internal fixation. Equine Vet J 1997; 29;
Vandekeybus L. Desbrosse F. Perrin R. Intralesional long acting 148-150.
corticosteroids as a treatment for subchondral cystic lesions in Walmsley JP. Arthroscopic surgery of the femorotibial joint. Clin
horses. A Retrospective Study of 22 Cases. Proceedings of the Techn Equine Prac 2002; 1: 226-233.
8th annual scientific meeting of the European College of Walmsley JP.Philips TJ.Townsend HGG. Meniscal tears in horses:an
Veterinary Surgeons 1999 33-34. evaluation of clinical signs and arthroscopic treatment of 80
von Rechenberg B. Guenther H. McIlwraith CWoet al. Fibrous tissue cases.Equine Vet J 2003; 35: 402-406.
of subchondral cystic lesions in horses produce local mediators White NA. Mcllwraith CWoAllen D. Curettage of subchondral bone
and neutral metalloproteinases and cause bone resorption in cysts in medial femoral condyles of the horse. Equine Vet J Suppl
horses. Vet Surg 2000; 29: 420-429. 1988; 6: 120-124.
Walmsley Jp.Vertical tears of the cranial horn of the meniscus and Wyburn RS. Degenerative joint disease in the horse. NZ Vet J 1977;
its cranial ligament in the equine femorotibial joint: 7 casesand 25: 321-322, 335.
their treatment by arthroscopic surgery. Equine Vet J 1995; 27:
20-25.
~

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

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 Examinationcommenceson the lateral
brings different areas of the trochlear ridges into view, can
increase the area of visualization. The corresponding area of and its articulation with the tibia. This view
lateral malleolus (Fig. 7.3). c
the distal tibia from the medial malleolus to the distal inter-
mediate ridge is also visible. Many adult horses also have an visualize the central lateral trochlear ridge (Fig.
opening that allows visualization of the proximal intertarsal further distad, the distal part of the lateral
(talocentral) joint distally. Inspection of the synovial lining of comes into the visual field (Fig. 7.5). In this
the dorsal aspectof the tarsocrural joint can also be performed.
The joint is distended using a needle placed through the of the arthroscope. The view of the arthroscope
dorsomedial pouch with the leg in extension (see Fig. 7.1).
The skin portal is made slightly dorsal to the center of the and the arthroscopeis withdrawn
distended dorsomedial outpouching and just below the oriented in a plantar direction to
palpable distal end of the medial malleolus. and the arthro-
of the trochlear groove of the talus (Fig. '
scopic sleeve and conical obturator are inserted (Fig 7.2).
This position is ideal for visualization within the joint. If the of the trochlear groove is visible further distally
arthroscope is placed more medially, it is difficult to pass the addition. the talocentral (proximal intertarsal) j
arthroscopic sheath over the trochlear ridges of the talus visualized (see Fig.
across the joint. The skin portal is made sufficiently large usually patent in very young foals. A
(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 the talus (Fig. 7.7E).
saphenous vein and the extensor tendons, and this location Further withdrawal of the arthroscope
provides optimal visualization of the deeper region of the rotation, so that the view is proximal and
intermediate ridge. A No. 11 blade is then used to continue visualization of the proximal
the portal through the fibrous capsule. The sleeveand conical ridge and its articulation with the distal tibia (Fig.
obturator are then inserted until contact with the medial side
of the talus is made (Fig. 7.2). The joint is then flexed, the medial malleolus is possible (Fig. 7.9). The
aspects of the medial trochlear ridge can be -
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 allows examination of the medial side of
of the sheath; however. the landmarks (as well as location of dorsomedial pouch (Fig. 7.12).
the saphenous vein) are more easily identified with the limb With this approach. imposition of soft tissue sometimes
in extension. makes examination of the lateral trochlear ridge and other
(Tibiotarsal) Joint

areasof the lateral part of the joint challenging.It requires approaches. Additionally, the planfar aspect of the distal tibia
the end of the arthroscopeto be closeto the lateraltrochlear and the deep digital flexor tendon (DDFT) within its tendon
ridge of the talus along with the use of the instrument to sheath can be seen,but these observations have not provento
retract soft tissue. However,with practice, this becomes be of major clinical relevance. Since the second edition, the
reasonablyeasy. 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
Arthroscopic examination using plantar placing a needle in the center of the plantar pouch which
lateral or plantar medial approaches usually allows adequatedistention. The skin portal is made in
the center of the plantar outpouching with the tarsus flexed
These approaches are used far less commonly. They allow at 90°. The arthroscopic sheath is placed in the joint using
excellent visualization of the remaining (proximal) portions the blunt obturator. The surgeon should be careful to avoid
of the lateral and medial trochlear ridges that are not damaging the trochlear ridges of the talus. Viewing
visualized by using the previously describeddorsal approaches. commences with the hock flexed (Fig. 7.13).
Eachtrochlear ridge is bestevaluated by using an arthroscopic Introduction of the arthroscope through a plantaromedial
approach through the same side (Fig. 7.13). The principal or plantarolateral portal located in the center of the plantar
benefit of using the plantar approaches is allowing examin- pouch puts the arthroscope immediately dorsal to the tarsal
ation of defects in the proximal portion of the trochlear synovial sheath surrounding the DDFT and plantar to the
ridges. the removal of loose bodies in the plantar pouch, and trochlear ridges of the talus. This permits evaluation of the
the treatment of sepsis and osteomyelitis. This approach plantar aspects of the medial and lateral trochlear ridges of
sometimes also is useful to access fractures of the lateral the talus as well as the trochlear groove, the distal tibia
malleolus of the tibia. Virtually all of the synovial lining of (plantar aspect of intermediate ridge) and the articular
the plantar joint pouch can be inspected through use of these 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 Chapter14. Arthroscopyalso permits identification of soft
arthroscope dorsally allows observation of the dorso- tissuelesionssuchastearsof the collateralligaments.within
malleolus cannot be seen. or communicating with the tarsocrural joint. As in otherjoints.
arthroscopyis superiorto radiographicexaminationor
synovialfluid analysisfor diagnosisin the tarsocruraljoint.
By extending the joint more (approximately 120°), the
, and lateral dorsal cul-de-sacs of the joint can be

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 244
Lateral trochlear ridge of the talus 37
Medial malleolus of the tibia 12
Intermediate ridge of the tibia plus the
lateral trochlear ridge (both)
Intermediate ridge plus medial malleolus tion, however, often reveals a gait abnormality, which may
of the tibia (both) relate solely to decreased flexion in the tarsus owing to
Intermediate ridge plus medial trochlear
increased synovial fluid pressure.
ridge of talus
In the 1991 retrospective study of 303 joints in which
Lateral trochlear ridge of the talus and the
medial malleolus of the tibia (both) synovial effusion was recorded, it was the presenting clinical
Medial trochlear ridge of the talus sign in 261 (86.1%). In racehorses, effusion was present in
Lateral and medial trochlear ridges of the 166 joints (81 %) and absent in 39 joints. In non-racehorses,
talus (both) effusion was present in 95 joints (96.9%) and absent in
Total 318 3 joints. The degree of lameness was not recorded con-
sistently, but usually was designated as mild. The exception
From Mcllwraith et a11991.
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.
distal to the level of the arthroscopic portal. The fragment is
L M 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.
findings are consistent with OCD.The axial intra- There was a significantly poorer outcome in racehorses with
portion of the medial malleolus is affected. Such articular cartilage degeneration or erosion (p < 0.05).
must be distinguished from fractures of the medial The synovial effusion resolved in 117/131 racehorse
that typically involve the entire malleolus, ex- joints (89.3%) and in 64/86 non-racehorse joints (74.4%).
The outcome for synovial fluid effusion was significantly
manifestations of OCD in the medial malleolus inferior for lesions of the lateral trochlear ridge of the talus
and medial malleolus of the tibia compared to distal inter-
. mediate ridge lesions. There was no significant relationship
in our experience. the more common situation is the between resolution of effusion and successful performance
, effusion and/or lameness when animals are
outcome.
broken or beginning with race training or racing. More recently, the results of 64 Thoroughbreds and 45
Standardbred horses treated for OCD of the tarsocrural joint
usually confirm the presence of a lesion (Fig. 7.28), 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
A dorsomedial arthroscopic portal is used (Fig. 7.29). The Standardbreds, 22% of those who had surgery raced as
, is extended. A needle is then used to decide on the
2 year olds and 43% raced as 3 year olds, compared with 42%
position for the instrument portal. but because of and 50% of the siblings that raced as 2 year olds and 3 year
positioning of the fragment it needs to be also in the olds respectively. For the Thoroughbreds, 43% of those that
pouch and is axial to the arthroscopic portal had surgery raced as 2 year olds and 78% raced as 3 year olds
7.29). The instrument portal is axial and usually slightly 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 displaced fracture fragments may also occur off the medial
lateral mallelous. the arthroscope can usually be pushed trochlear ridge (Fig. 7.39).
through the traumatic defect. from the dorsal to the plantar Occasionally,fractures amenable to lag screw fixation will
compartments of the joint. Sometimes there will be frag- occur in the talus; these are usually in a sagittal plane
mentation that will hinge on the short collateral ligaments (Fig. 7.40). Small linear fractures have been repaired with
into the plantar pouch or indeed become loose bodies in the one screw, but the cases illustrated in Figure 7.40 required
plantar pouch and these can be retrieved with the arthroscope three cortical screws.
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- Retrieval of fragments from the
graphic localization with needles and/or external dissection talocentral (proximal
down to the fragment. intertarsal) Joint
Fragments will occasionally be seenin the dorsal talocentral
Other intra-articular fractures of the joint. They are often under a plica or a fibrous membrane. The
tarsocrural joint dorsomedial arthroscopic portal is the same for all other
surgery and allows visualization into the talocentral joint
These fractures are relatively uncommon. Figure 7.36-7.39 (Fig. 7AI). A needle is used to decide on optimal placement of
show some examples of cases that may be encountered. the instrument portal. In some cases, a medial instrument
Fractures can occur through the medial malleolus of the tibia portal will be satisfactory, while in most we have used a
and will show different manifestations than medial malleolus lateral instrument portal to retrieve the fragment from under
OCD.There will be an obvious linear fracture line and usually the joint capsule or plica. Exchange of arthroscope and
the fragment is displaced distally (Fig. 7.36). The fragments instrument portals may be useful and in several cases,a third
are removed arthroscopically and prognosis will be related to incision, medial and distal, in the dorsomedial joint pouch
whether the long medial collateral ligament can be left intact. has been required. Resection of the perimeter of the opening
Fragments may occur off the proximal plantar aspect of the between the tarsocrural and talocentral joints is often
medial trocWear ridge (Figs 7.37 and 7.38) and are operated necessary to identify and retrieve loose fragments from the
on using an approach through the plantar pouch. Larger 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 Treatment of proliferative synovitis
Occasionally, severe proliferative synovitis occurs in the
phase and later there may be an irregular abaxial tarsocrural joint, and debridement of some of the tissue
to the malleolus. Ultrasound usually detectsdis- (partial synovectomy) can offer some relief" The authors have
(Fig. 7.42). Arthroscopically,the torn ligamentous used both hand instrumentation or motorized instru-
into the dorsal compartmentand is mentation (the latter is usually better) for debridement in
with a motorizedresector(Fig.7.43). these cases.
Treatment of septic arthritis and septi Reference:
osteomyelitis
Beard WL, Bramlage LR, SchneiderRK. EmbertsonRM. Post-operativ
The use of arthroscopy in the treatment of septic osteomyelit racing performance in Standardbreds and Thoroughbreds wit.
lesions of the talus was mentioned previously. ArthroscoI osteochondrosis of the tarsocrural joint: 109 cases(1984-1990
has also been used to remove fibrin from patients wit JAmVetMedAssoc 1994: 204: 1655-1659.
Bertone AL. McIlwraith CWoJones RL. et al. Comparison of variou
septic arthritis and is considered to emulate the successfl
treatments for experimentally induced equine infectious arthritii
results achieved with arthrotomy (Bertone et aI1987). Tl. AmJ Vet Res 1987: 48: 519-529.
management of sepsis in synovial structures is discussed i Dik KJ. Emerink E. van Weeran PRoRadiographic development (
Chapter 14. 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.
Aftercarl Hoppe F. Radiological investigations of osteochondrosis dissecansi
Standardbred Trotters and Swedish Warmblood horses. Equin
VetJ 1984: 16: 425-429.
Careful maintenance of a bandage postoperatively is critic; Laws EG. Richardson DW. Ross MW. et al. Racing performance i
(Fig. 7.44). As discussed with regard to osteochondrit Standardbreds following conservative and surgical treatment fc
dissecansin the intermediate ridge, routine aftercare involv( tarsocrural osteochondrosis. Equine Vet J 1993: 25: 199-202.
1 month of stall rest with hand walking and then son: McIlwraith CWoSurgery of the hock, stifle and shoulder. Vet Cli
limited exercise before training commences at 2-4 month North Am Large Anim Pract 1983: 5: 333-362.
depending on the amount of disease. In cases of oste( McIlwraith CWoFoerner JJ,Davis DM. Osteochondritis dissecans c
the tarsocrural joint: Results of treatment with arthroscopi
arthritis or septic arthritis, the period of convalescence m8
surgery. Equine Vet J 1991: 23: 155-162.
vary. In cases of proliferative synovitis, anti-inflammatoI McIlwraith CWoFoerner JJ.Diagnostic and surgical arthroscopy 4
therapy is often indicated. Intra-articular corticosteroi the tarsocrural joint. In: McIlwraith CW (ed). Diagnostic an
administration also has been used. 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 surface of the scapula. Collateral and stabilizing support for
in horses and two of the authors' (C.W.M. and the shoulder is derived from periarticular tendons and
experience over 20 years includes only 114 cases, ligaments. Lateral support is provided by the supraspinatus
all but eight of those cases involving osteochondrosis. and infraspinatus tendons of insertion, while medial support
techniques for performing arthroscopic surgery of the is formed by the subscapularis tendon of insertion and a
have been described:a craniolateral approach. 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
shoulder joint immediately caudal to the infraspinatus of the teres minor and deltoideus muscles. Access for the
(Nixon 1987. Bertone & McIlwraith 1987b). In arthroscope and instrument entry is limited to the lateral
the use of arthroscopic surgery for treating osteo- aspects by the close association of the scapula with the
and the results achieved in 11 horses (13 thorax. Finally, the accessible portions of the shoulder are
have been published (Bertone & McIlwraith functionally divided into cranial and caudal regions by the
1987a). (Note: in this discussion osteochondrosis is a collective infraspinatus tendon of insertion.
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- Insertion of the arthroscope
ment by arthrotomy (Schmidt et a11975, Mason & Maclean
1977, DeBowes et al 1982, Nixon et al 1984); however, The horse is positioned in lateral recumbency. with the
extensive soft tissue dissection is necessary and the cranio- affected limb uppermost and unsupported in a slightly
medial aspect of the joint may not be visualized (Nixon et al adducted position. The leg is draped so that traction can be
1984). Other complications include loss of lateral joint stability applied to the limb during surgery. After aseptic preparation
(Schmidt et al 1975) and seroma formation (Nixon et al and draping of a wide sterile field. the appropriate landmark
1984). These complications are not only avoided with for insertion of a spinal needle immediately cranial to the infra-
arthroscopy but also the minimally invasive nature of spinatus tendon and proximal to the notch dividing the greater
arthroscopy provides many of the intraoperative and post- tubercle of the humerus into cranial and caudal components
operative advantage~ seenin other joints. On the other hand, is identified (Fig. 8.1). An 18-gauge. 3-inch spinal needle is
arthroscopy of the shoulder is more technically complex. and inserted at this location at an angle approximately 250 caudal
in adult horses it can be a particular challenge. 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
Surgical Anatomy of solution are then injected to distend the joint (Fig. 8.3).
The spinal needle is removed. and when the craniolateral
the Shoulder approach to the shoulder is selected. a 5-mm vertical skin
incision is made in the same location (if it is not made before
The shoulder is a relatively tightly articulated diarthrodial placement of the spinal needle). For the lateral approach. the
joint. and consists of the rounded articular surface of the skin incision for the arthroscope portal is made 1 cm caudal
humeral head and the depressed concavity of the glenoid 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). a ligament (Fig.8.10). In mature horses,complete examination
With the joint maximally distendedso the glenoid and humeral of the medial and caudomedial aspects of the shoulder joint
head are separated,the tip of the arthroscope is inserted over become more difficult. Additional traction can aid exposure,
the humeral head and under the glenoid toward the medial but accesscan be limited unless erosion and malformation of
side of the joint. The articular surface of the glenoid and/or the humeral head are extensive.
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 Lateral arthroscopic approach
the glenoid and humeral head are inspected as well as the
medial surface of the synovial membrane, which contains a An alternative approach for arthroscopic examination of the
normal plica, devoid of villi, which has beenreferred to as the shoulder joint uses a direct lateral approach (Nixon 1987). In
medial glenohumeral ligament, despite the fact it is not truly 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), The primary indication for diagnostic arthroscopy of the
which can be difficult to examine using the craniolateral shoulder joint is the evaluation and treatment of osteo-
approach. Additionally, it also leavesthe portal cranial to the chondrosis section). Diagnostic arthroscopy is also indicated
infraspinatus tendon available for the egresscannula. In adult when lameness is localized to the shoulder by response to
horses the cranial portal can also provide access for the intra-articular anesthesia but when
surgeon to insert a curved, blunt-tipped forceps across are equivocal. In such cases, fibrillation of the
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 dissecans.the arthroscopic findings do :-
advanced safelyto the medial aspect of the joint (Fig 8.13). A with the radiographic changes. and the diagnostic examin-
third portal. 2-4 cm caudal to the arthroscope entry portal, ation is a critical part of the arthroscopic procedure. Arthro- l
is used as an instrument portal for arthroscopic surgery by scopy is also appropriate in cases of septic arthritis. both for
triangulation. This method of internal distraction precludes evaluating the articular cartilage and for treatment. 1
the need for external traction; however. since it risks Using a probe during diagnostic arthroscopy of the
iatrogenic damage to the cranial aspect of the humeral head, shoulder joint is critical. An instrument portal is necessary
it is generally used only in heavily muscled mature horses. for probe placement. and creation of this portal is describedin
For surgical debridement of most OCD lesions, the younger the next section. The optimal site to insert the probe is
age of the horse and the chronicity of the disease provide ascertained using an I8-gauge. 3-inch spinal needle.
sufficient laxity that fluid distention and axial traction are In addition to defining intra-articular disease entities.
adequate to allow accessto most regions of the articulation. arthroscopy has been used in human patients with shoulder
instability and in assessingcasesof supraspinatustendinitis chondrosis in the shoulder. In many instances,
(Cofield 1983), ruptured biceps tendon, and loose body is evaluated after the elimination of problems in 1
removal Oohnson1986). Such indications have not been limb with the use of nerve blocks.
recognizedin the horse as yet; the horse does not have a The diagnosis of osteochondrosis is confirmed]
glenoidlabrum. 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
Arthroscopic Surgery of the Radiographic signs of osteochondritis dissecans in
Shoulder joint for Treatment humeral head include malformation of the.
flattening and/or undulation of the bone caudally,
of Osteochondrosis
As mentioned previously, non-surgical treatment of osteo- caudal portion of the humeral head, particularly
chondrosis in the equine shoulder has rarely allowed horses physeal junction, may be seen. Occasionally, ( .
to regain athletic capability. Three different arthrotomy development is evident without other radiographic
approaches have been used to treat cases of osteochondrosis osteochondritis dissecans.
in the equine shoulder. Complications of loss of lateral Radiographic abnormalities in the scapula that
considered to relate to osteochondrosis j ,
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 of osteochondritis dissecans, osteochondral
complete visualization of the articulation is not possible with and abnormal flattening of , c .
an arthrotomy incision (Nixon et al1984). Extensive traction 8.16). In most instances, the glenoid cavity develops
is also critical to the performance of the procedure.
Arthroscopy provides advantages over arthrotomy in both border.More chronic shoulder OCDcaseshave
avoiding these complications as well as providing additional
benefits through the minimally invasive approach. It should
be stressed,however, that adequate arthroscopic visualization formation on the caudal aspect of the glenoid. In
instances. however. r ." ,
and surgical manipulation in the equine shoulder joint are
articular ( .-'-
more difficult than in other joints described previously in
this text. 1987a).
Arthrography of the shoulder' .-
The material presented is based on the experience of the
authors, both in evaluating the approaches in cadavers as a technique to diagnose OCD. but more importantly.
well as involvement in 114 clinical cases,including a pre-
viously published series of cases of osteochondrosis with to those that are eroded to the extent that they are
follow-up (Nixon 1986, Bertone & McIlwraith 1987a). salvage (Nixon & Spencer: ' -, --

head and glenoid cavil,


Preoperative considerations that one cartilage surf

Most patients manifest clinical signs before 1 year of age.The prognosis,and can lead to surgery and generallya
age of presentation doesdepend somewhat on the observation outlook(Fig.8.18).
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 Arthroscopic technique
clinical signs include lameness with a shortened cranial
phase of stride. Some horses show resentment to firm digital A thorough exploration of the scapulohumeral joint,
pressure caudal to the infraspinatus tendon. Extension and previously described, is performed as the first step. r
flexion of the shoulder joint is also resented in some cases. exploration involves probing all visible lesions as well
Intra-articular anesthesia of the shoulder joint improves or
eliminates the lameness in most cases. However, when the entry for triangulation during arthroscopic surgery in
shoulder, is illustrated in 1 .-.
articular cartilage over subchondral bone defectsis still intact,
intra-articular local anesthesia may not generate a response. is selected to permit accessto the caudal humeral r
Intra-articular anesthesia is performed by using the same central articular surface of the glenoid. To determine
landmark as previously described for placing the spinal needle location. an I8-gauge spinal needle is inserted about (
during arthroscopy. The absence of these localizing clinical caudal to the infraspinatus tendon and 4 cm distal (-
signs, however, does not rule out the presence of osteo- arthroscopic portal (Fig. 8.20). This location usually f
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
When the needle position is judged to be satisfactory, an their degree is ascertained before any surgical manipulations
8 mm skin incision is made at that location. and a stab are performed (Fig 8.22-8.31).
incision is continued into the muscle mass with the use of a This caudolateral instrument portal is used for debriding
No. 11 or 15 blade (Fig. 8.21). A conical obturator is inserted most lesions. Laterally located defects are easier to operate
along the same path to ensure the presence of a workable than medially placed lesions. Therefore, procedures involving
portal. It is important that fluid pressure be at a minimum at lesions on the medial side of the joint are performed first
this time. When the portal is unobstructed. intermuscular while maximal joint distention can be maintained. and
extravasation of fluid is minimal, although it usually becomes separation of the glenoid and humeral head are achieved.
a problem later during surgery, regardless of the portal size. 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 forceps) can be helpful to enter deep OCDlesions and retrieve
debriding large lesions. The resector works well in the cartilage flaps or debride subchondral bone (Fig. 8.34). At the
debridement of easily accessiblehumeral head lesions. When completion of subchondral bone debridement, the edges of
the defect is deeper within the subchondral bone, however, the defect are debrided with a hand curette and Ferris-Smith
the resector and/or burr may not reach, and a right-angled rongeurs. When intact articular cartilage overlies a sub-
curette is used. Angled motorized resectors (see Chapter 2) chondral defect(a common manifestation with osteochondritis
can be very helpful to accommodate to the curvature of the dissecans in the shoulder), all cartilage superficial to the
humeral head. Similarly, small angled rongeurs (patellar 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 horses were completely sound at a jog within 4 months. Five
horses were atWetically sound and were being shown, ridden,
In some instances. the surgeon may visualize lesions and not
or raced after 5-20 months. A sixth horse was sound when
be able to reach them with the instruments. Theselesions are
beginning race training. A seventh horse was pasture sound
usually located on the caudomedial surface of the humeral
and was to begin race training at the time of the report. An
head of adult horses and become even more difficult to access
eighth horse showed well in halter for 12 months, but
in well-muscled patients. In one series (Bertone & McIlwraith
shoulder lameness returned. This horse was donated, and a
1987a), the problem of inadequate instrument length was
necropsy was performed. The ninth and tenth horses were
encountered in three horses. Debridement of these areas can
not completely sound at 11 months. The eleventh horse
be performed in young horses without difficulty, where traction
improved but remained lame and could not be used for
on the limb opens the joint space and facilitates curettage of
athletic performance.
the medial surfaces. However, the ideal instrument for
Follow-up radiographic assessmentrevealed improvement
reaching medial lesions in larger horses has not been found.
in contour of the humeral head and joint space and more
Long rongeurs are rare, and instruments with somecurvature
even density of the humeral epiphysis and the glenoid of the
are also difficult to find. It is important to advise owners that
scapula in 6 horses. One of these horses showed marked
complete debridement may not be achieved when the horse
improvement in subchondral bone density and surface
weighs 500 kg or more. Large accumulations of subcutaneous
contour of the glenoid cavity. In 2 of the remaining 5 horses,
fluid also contribute to inadequate instrument length, and
the caudal border of the glenoid cavity had remodeled to
periodic application of pressure massageto drive fluid out the
appear more like the contralateral joint. In the fourth of the
skin portals often improves access to remote regions of the
6 horses, radiographs obtained 1 year later showed a sub-
humeral head.
chondral cystic lesion in the scapula (1.5 cm in diameter)
that had not been present previously (Fig. 8.38). However,
Damage to instruments this horse was athletically sound. The contour of the glenoid
articular surface and its caudal border was smoother post-
The instrument portal passes through 6-8 cm of muscle
operatively and the subchondral osteosclerosiswas reduced
before entry into the joint. Manipulation of the instruments
in thickness. In the fifth horse in this group, an osteophyte on
is restricted by this muscle mass. The instrument portal can
the humeral head had enlarged, but improvement was noted
be enlarged, but. in certain instances, the probe or trocar has
in joint contour of both the humeral head and glenoid cavity
been bent when removed.
(Fig. 8.39). Radiographs obtained from one of the two horses
One possible solution to the difficulty sometimes experi-
that improved but were still lame showed no improvement in
enced in maintaining separation of the glenoid and humeral
the glenoid lesion radiographically. In the horse where
head (this distance becomes critical when fluid extravasation
euthanasia was chosen when it deteriorated clinically, the
inhibits distention) is placing the patient in dorsal recumbency.By
humeral epiphysis was severelydistorted with a defect in the
suspending the leg and lowering the table slightly, "gravity
articular surface contour, a subchondral cystic lesion, and a
traction" may provide a less energy-consuming alternative.
small intra-articular fracture of the cranial margin of the
The authors have not tried this technique. The possibility of
glenoid cavity.
damaging the brachial plexus is one potential hazard.
In summary, all 11 horses improved clinically. Soundness
Transient paresthesia in the upper extremities after shoulder
was achieved in 9 horses, and 5 of 11 horses have been used
arthroscopy involving traction was reported in man, andbrachial
athletically. Two horses did not become sound. One of these
plexus strain versus joint accessibility with different
horses was young but had extensive lesions of the glenoid
shoulder positions has been described (Klein et al19 8 7).
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
Results improvement. One horse developed severe degenerative
changes in the joint after being sound for 8 months. It seems
The initial series of 11 horses reported by the authors that considerable healing response can be obtained if surgical
included one postoperativecomplication (Bertone & Mcllwraith treatment occurs in a timely fashion.
1987a): a subcutaneous infection with Actinobacillus sp. Hand curettage was satisfactory for treating most lesions,
produced swelling and drainage from the incision 48 hours but the motorized resectors and burr provided the most
after surgery. The incision and subcutaneous tissues were efficient debridement of articular cartilage and subchondral
opened. flushed. and allowed to heal by second intention. bone in both the scapula and humerus, and it avoided the
Moderate swelling in the shoulder region in all horses. potential difficulties associated with hand curettage.
resulting from leakage of lavage fluid subcutaneously and Osteochondrotic lesions of the humeral head were the easiest
intramuscularly. generally resolved within 7 days. to debride, especially in horses that were yearlings or
None of the horses were more lame postoperatively. and all younger, because they had less muscle mass as well as more
improved clinically from within 2 weeks of the operation flexible periarticular structures. However, the lesions were
until the time of follow-up evaluation. Nine of the 11 horses accessibleeven in older horses when the joint was distracted.
achieved soundness and 8 horses remained sound. Seven 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 Nixon AI. Stashak TS. et al. A muscleseparating
...,
1953; 35-B: 643-649.
Mason TA. Maclean AA. Osteochondrosis dissecans of the head of Vet Surg 1984; 13; 247-256.
the humerus in two foals. Equine Vet J 1977; 9(4): 189-191. Nyack B. Morgan JP. et al. Osteochondrosis of the shoulder
Meagher DM. Pool RR. O'Brien TR. Osteochondritis of the shoulder the horse. Cornell Vet 1981; 71: 149-163.
joint in the horse. Proc Am AssocEquine Prac 1975; 19: 247-256.
Nixon AJ. Diagnostic and operative arthroscopy of the equine osteochondrosis in the horse. Proc 31st Annual Conv
shoulder joint. Vet Surg 1986; 15: 129. 1986.
Schmidt GR. Dueland R. Vaughan JT. .-
Nixon AJ. Diagnostic and surgical arthroscopy of the equine
shoulder joint. Vet Surg 1987; 16: 44-52. the equine shoulder joint. Vet Med/Small An Clin 1975;
Nixon AJ, Spencer CPoArthrography of the equine shoulder joint. 542-547.
Equine VetJ 1990; 22(2): 107-113A.
ER

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
diseases such as osteochondral fragmentation,
articulation essentially divides the elbow to a cranial joint
, or traumatically induced cartilage
pouch, a limited caudal joint pouch, and a large proximo-
caudal joint pouch surrounding the anconeal process.
frequency to warrant techniques for arthro-
surgery of the various pouches of the elbow joint. Approaches to the cranial portion of the elbow joint place
small terminal branches of the radial nerve at risk as they
'humeral condyle or
arborize and terminate in the antebrachial extensor muscle
bellies. The arthroscope entry avoids these branches; how-
a seconddescribingsevenhorses (Hopenet al 1992). ever, instrument accesscranially, through the muscle bellies,
may impact on several small branches of the radial nerve. No
clinical repercussions,including extensor muscle dysfunction,
Other lesions. including osteochondritis dissecans have been recognized. The caudomedial approach to the
.the humeral condyles. may be more appropriately elbow joint penetrates between the muscle bellies of the flexor
carpi radialis and flexor carpi ulnaris, and inadvertent entry
by surgical debridement. Arthroscopic techniques
caudal to the flexor carpi ulnaris places the arthroscope close
access to the cranial portions of the humeral
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
.both condyles and to the anconeal
the ulna using a caudoproximal approach via the the flexor carpi radialis muscle belly places the median nerve
at risk. During the caudomedial approach to the elbow, the
complexity of periarticular neurovascular structures instrument entry often penetrates through the flexor carpi
inherent risks of elbow arthroscopy are well known in ulnaris muscle belly, but also without repercussion. The
(Lynch et al1986, Thomas et al1987, Baker & Jones caudal extremity of this approach also may impact on
1999). and have also been described to a limited extent in the portions of the ulnar nerve. The approach to the olecranon
horse (Nixon 1990). Overall, arthroscopic accessto the cranial pouch of the elbow penetrates the distal terminal portions of
the triceps musculature or tendon of insertion; however, no
regions of the elbow in man and horses is relatively simple.
while the caudal compartments are more challenging, with significant neurovascular structures are at risk using this
increased risk to adjacent neurovascular structures (Nixon approach.
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 Positioning
connected by substantial collateral ligaments. As a result.
distraction of the humeroradial articulation and humeroulnar Positioning for arthroscopy of the elbow is dictated by the site
articulation results in little separation of the articular of surgical disease. Only dorsal recumbency will allow
surfaces and therefore limited accessto regions predisposed simultaneous accessto all three pouches of the elbow joint.
to disease.particularly the proximal surface of the radius. For 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 Fig. 9.1
triangular target area for accessof the arthroscope.If the Arthroscopic technique for access to the cranial pouch of the
entry is made too close to the cranial palpable border of elbow joint. Arthroscope entry is made in the triangle formed
the lateral humeralcondyle.manipulationwithin the cranial by the craniolateral curvature of the lateral condyle of the
humerus, the proximal perimeter of the craniolateral surface
pouch of the elbowbecomesmore difficult. The arthroscope of the radius, and the caudal border of the muscle belly of the
sleeveis inserted across the cranial pouch of the elbow common digital extensor tendon. Instrument entry can be
joint, and the obturator exchangedfor the forward oblique made between the muscle bellies of the common digital
viewing arthroscope(Fig.9.1). The cranialarticular surfaces extensor and extensor carpi radialis muscles.
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; Caudomedial approach
however,it is not essential.Withdrawal of the arthroscope to the elbow joint
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 Dorsal positioning can be used if accessto !
articulation and the lateral collateral ligament. The joint pouches is expected, as previously described.
cranial joint pouch of the elbow is voluminous and easily preparation and draping, the site for arthroscope
examined. identified by systematically palpating from cranial!
An instrument portal can be made cranial to the to identify the medial collateral ligament, the r
arthroscopeentry, afterplacing a 7.5 cm x 18-gaugespinal
needle.This portal usually penetratesbetweenthe ante-
brachial extensormusclebellies,generallywhere a shallow the approximation of flexor carpi radialis and flexor I
division can be palpatedbetweenthe extensorcarpi radialis ulnaris muscle bellies. A needle is inserted to identify
and commondigital extensormuscles.The midcranialregion humeroradial articulation,
should be avoided to minimize potential damage to the articular level and between the muscle bellies of the i-
transversecubital artery. For lesionsinvolving the cranio- carpi radialis and flexor carpi ulnaris is identified.
lateral extremityof the radius or lateralhumeralcondyle.the palpable division between these muscle bellies is i
arthroscopeand instrument entry portal can be exchanged more easily at the mid-radius level, and the
to provide instrument accessto the lateral portions of the tracked proximally to the point 2-3 cm distal to the
articular perimeter.Following completionof the procedure. the humeroradial articulation. The palpable'
fluid is expressedfrom the joint and the skin incisionsclosed
with interrupted sutures. overlying superficial pectoral muscles and
fascia. Insertion of the arthroscope proximal to the level of arthroscopesleeveand obturator(Fig.9.3). The arthroscope
the humeroradial articulation places the ulnar neuro- sleevewith obturator in placeis advancedproximally in an
vascular structures at risk. particularly if a second entry for oblique direction to enter the caudomedialaspect of the
instruments is then made caudal to the flexor carpi ulnaris elbowjoint pouch. Whencartilage or bone are encountered
muscle belly. and joint fluid is returned through the egressoutlets on the
Mter insertion of the needle to the caudomedial aspect of arthroscope sleeve,the conical obturator is replaced by
the joint. the elbow is distended with 60 ml of lactated Ringer's the arthroscope.In many instancesthe arthroscopesleeve
solution and a 5 mm skin incision made for entry of the 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 Fragmentation of the anconeal
The craniolateral portion of the distal humerus,particularly The anconeal process can develop fragmentation
the lateral portion of the humeral condyle,is exposedto manifestation of osteochondrosis, f
external impact injury, which can dislodgeintra-articular
osteochondralfragments(Fig. 9.7). Removalof thesefrag- process using the caudoproximal approach is
mentsis generallysimpleusing the craniolateralarthroscopic simple (Fig. 9.11). Fragment removal can be r
using triangulation i ' '- ,- ;
access.After examination of the remainder of the cranial
aspectsof the elbow joint, the arthroscopeand instrument fragments are rare in this location, and many of
portals are reversed,placing the arthroscopethrough an fragments should be considered trauma-induced. :
complex fractures of the I '
instrument portal approximatelybetweenthe musclebellies
of the extensorcarpi radialis and commondigital extensor.
This leavesthe more lateral portal for rongeur entry for fixation. The open lateral approach to the anconeal
fracture removal. Debridementof the subchondralbed is during plate application to the olecranon f
routine and debriscanbe flushedfrom the joint with a large simple, and arthroscopy can be utilized to i
egresscannula. The extentof articular involvementusually the free fragment either during the plating
definesthe expectedoutcome,although the predisposed area (Fig. 9.11) or at a later time.
for impactfracture is generally2-4 cm in length.

Septic arthritis
Osteochondrosis and osteochondritis
dissecans of the elbow
involved in hematogenous septic processes in foals.
lateral aspect of the joint also has minimal: r .
Osteochondrosis of the elbow usually takes the form of either
OCD flap lesions of the humeral condyles or subchondral and is a common site for kicks from other animals'
cystic lesions of the proximal radius. To date, there are no frequently penetrate the joint through or adjacent to
arthroscopic techniques that will provide accessto the head 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 elbow is subcutaneous fluid accumulation, which can
extensive using the approaches described. Distention I
Arthroscopic exploration and debridement of areas of cartilage visualization should be used in moderation, '
degeneration in osteoarthritis is occasionally warranted.
depending on the extent of osteophytosis in the elbow. The easilyexaminedwith moderatedistention.
Necropsy examination of horses used in the development Hopen LA, Colahan PT,Turner TA, Nixon AJ. Nonsurgical treatment
of arthroscopic approaches to the elbow showed minor areas of cubital subchondral cyst-like lesions in horses: seven cases
of muscle hemorrhage associatedwith instrument entry during (1983-1987). J Am VetMed Assoc 1992; 200: 527-530.
Krijnen MR, Lim L, Willems WI. Arthroscopic treatment of
triangulation (Nixon 1990). The primary concern in elbow
osteochondritis dissecans of the capitellum: report of 5 female
arthroscopy is surgical planning to provide accessto the lesions athletes. Arthroscopy 2003; 19: 210-214.
without the necessity for repositioning the horse. The use of Lynch GJ, Meyers JF, Whipple TL, Caspari RB. Neurovascular
dorsal recumbency can result in difficulty in orientation and anatomy and elbow arthroscopy: inherent risks. Arthroscopy
manipulation. but should be taken into consideration when 1986; 2: 190-197.
all three compartments of the joint need to be examined. 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-
References thickness defects in young patients. Arthroscopy 2003; 19:
222-225.
Poehling GG,Ekman EF.Arthroscopy of the elbow. J Bone Joint Surg
Baker CL Jr. Jones GL. Arthroscopy of the elbow. Am J Sports Med 1994; 76A: 1265-1271.
1999; 27: 251-264. Stashak TS. Diagnosis of lameness. In: Stashak TS (ed.), Adams'
Bertone AL. Mcllwraith CWoPowers BE et al. Subchondral osseous lameness in horses. Philadelphia: Lea and Febiger; 1987:
cystic lesions of the elbow of horses: conservative versus surgical 150-153.
treatment. J Am Vet Med Assoc 1986; 189: 540-546. Thomas MA, Fast A, Shapiro D. Radial nerve damage as a
Hardy J. Marcoux M. Eisenberg H. Osteochondrosis-like lesion of the complication of elbow arthroscopy. Clin Orthop 1987: 130-131.
anconeal process in two horses. J AmVet Med Assoc 1986; 189:
802-803.
The clinical signs associated with clinical hip lameness in
recognize, and the need for arthroscopic evaluation horses vary, depending on whether the derangement is a
diagnostic arthroscopy and result of developmental disease in foals and weanlings,
surgical correction of problems in the hip are trauma to the hip resulting in tearing of the ligament of
rare. They may be in part due to the inherent the head of the femur, degenerative osteoarthritis, or fracture
of isolating problems to the coxofemoral joint, of various portions of the acetabulum (Rose et al 1981,
horses with chronic lameness. Moreover, the Miller & Todhunter 1987, Nixon et al1988). Under the best
associated with surgical therapy often diminish of circumstances, the diagnosis of hip disease is often
for arthroscopic exploration. However, an protracted, leading to osteoarthritis as a common sequela.
awareness of hip joint diseases and the use of When the lamenessis marked, muscle atrophy of the affected
imaging modalities such as nuclear scintigraphy and hind limb is evident in the gluteal and quadriceps mus-
thermography, coupled with increased use of intra-articular culature, facilitating an earlier diagnosis. More obscure
anesthesia, have increased the likelihood of establishing a upper hind limb lameness may take more diligence in the
definitive lameness associated with the coxofemoral joint. A work-up. Diagnostic manipulative tests are useful; however,
logical extension of improved diagnostic capabilities is the use the definitive diagnosisoftenrequires intra-articular anesthesia.
of arthroscopic examination with a view to surgical correction Rectal examination is also recommended, although palpable
of some diseases. Arthrotomy of the hip joint is difficult, enlargements have been recorded in only 50% of acetabular
results in limited exposure of relevant structures, is debilitating fractures (Rutkowski & Richardson 1989). and many other
for the horse and surgeon, and is accompanied by high-wound conditions including OCand OA are not detected using rectal
healing complication rates: given this, it is rarely warranted examination.
for any surgical disease of the hip, other than separation of Nuclear scintigraphy has improved the diagnostic
the proximal femoral capital physis. However, arthroscopy specificity for chronic hind limb lameness. but still lacks the
for diagnostic purposes is feasible, particularly in foals conclusive nature of intra-articular anesthesia. Blocking the
(Honnas et aI1993). hip can be difficult until some familiarity with the surface
Diagnostic arthroscopy has been used to evaluate tearing anatomic landmarks is gained. Later confirmation and
of the ligament at the head of the femur (round ligament), staging of the degree of the hip joint involvement can be
osteoarthritis (qA) , fracture of the acetabulum, and osteo- provided by radiographs. Good-quality radiographs require
chondrosis (DC) in the hip (Nixon 1994). In man, diagnostic general anesthesia.and ventrodorsal and oblique ventrodorsal
arthroscopy of the hip is a useful technique to establish a views for evaluation of the acetabulum and femoral heads.
diagnosis, as well as aid in treatment; it actually altered the Moderate and severe degenerative osteoarthritis, osteochon-
preoperative diagnosis in 53% of 328 patients (Baber et al drosis, osteochondritis dissecans (OCD),and luxation or sub-
1999). Given the preoperative use of computed tomography luxation of the hip are apparent on hip radiographs. Less
(CT) and magnetic resonance imaging (MRI) in man, these obvious hip diseases,such as tearing of the ligament of the
results represent a marked increase in diagnostic usefulness head of the femur and mild osteoarthritis, may not be evident
of arthroscopy. In foals, arthroscopic surgery is particularly on routine radiographs. These lesions may need to be
valuable in the treatment of sepsisinvolving the coxofemoral identified through direct visualization during arthroscopic
joint, and in the treatment of osteochondrosis (Nixon 1994). examination.

.
~
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
Arthroscopy is indicated for the diagnosis of hip joint disease, arthroscope, Karl Storz Endoscopy, Goleta, CA) is useful for
particularly in cases in which radiographs provide little more complete examination in adult horses (Fig. 10.3). The
additional information after a positive intra-articular arthroscope sleeve and conical obturator are inserted
anesthetic response has been obtained and as a therapeutic through the skin and angled 200 ventral and 200 cranially,to
tool for other conditions. Arthroscopic examination of the hip follow the dorsal (proximal) contour of the femoral neck
joint in horses has been described in a limited case series (Fig. 10.1). The lateral portion of the hip joint is penetrated,
(Honnas et al199 3, Nixon 1994). Arthroscopic visualization the obturator removed, and the arthroscope inserted. The
was useful in determining the extent of cartilage damage standard 25 or 300 forward oblique viewing arthroscopes are
associated with fractures of the acetabular rim, in several satisfactory for examination of most regions of the hip joint. iJ
cases where radiographically visible small fractures were A 700 arthroscope is useful but not essential to examine the 1
identified associated with the periphery of the acetabular rim,
in assessingthe degree of tearing of the ligament of the head skin portal, for fluid egress and later instrument access,is
of the femur, and in cases where cartilage defects were made 4-5 cm cranial to the arthroscope portal. using a
evident during examination of horses with hip joint lameness 1 5-cm spinal needle or catheter stylette to define the path for
but no radiographic lesions (Nixon 1994). Intra-articular instrument entry prior to skin incision.
debridement of torn and partially torn ligaments of the head Visualization of the articular surface of the cranial,
of the femur, debridement of OCD of the acetabulum, and lateral, and caudal regions of the hip joint is accomplished
cystic lesions of the femoral head have been described (Nixon with the limb supported in a horizontal position (Fig. 10.4).
1994). Similarly, arthroscopic lavage and synovectomy with Manipulation of the limb into a flexed and extended position
debris removal is a u~eful method for improving the response allows other regions of the femoral head to be viewed. Given
in foals with infectious arthritis of the hip. 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
Surgical technique for a complete examination of the hip. This allows the
arthroscope to be inserted between the femoral head and the
Arthroscopic examination of the hip joint is readily acetabulum. In immature horses, distraction and arthroscope
accomplished in foals and can be performed with some insertion can be accomplished easily and allow examination
difficulty in horses up to 500 kg. In larger horses, exam- of the deeperregions of the joint (Fig. 10.5). In older horses,
ination of the articular structures is less complete; the distraction and increased intra-articular fluid pressures are
procedure is more technically demanding and is associated more important to allow visualization of the femoral head
with more surgical trauma to the articular and periarticular and round ligament of the head of the femur (Fig. 10.6). Joint
structures than encountered during hip arthroscopy in foals. distraction can be provided by axial tension on the limb from
However, hip joint laxity associated with persistent effusion an assistant or by mechanical devices such as a winch
provides a largely unrecognized advantage in adult horses attached to the surgery wall. The torso of the horse must be
with chronic hip disease. With appropriate axial traction on stabilized on the surgery table when distraction techniques
the affected hind limb. the femoral head can be distracted are used. An intraoperative decision can be made as to the
from the acetabulum sufficiently to allow examination of necessity and degree of mechanical distraction. The use of
large portions of the femoral head and acetabulum. surgical assistants is necessary for arthroscopy of the hip
The horse is anesthetized and positioned in lateral joint in adults, primarily to manipulate the limb and to
recumbency with the affected limb uppermost. The entire provide axial distraction when required.
lateral region of the hip and gluteal muscle is draped for Instrument access is generally provided through the
surgery with the affected limb supported but free to be cranial instrument portal after developing a path to the hip
mobilized during surgery. An arthroscope entry portal is joint through the tendinous insertion of the middle gluteal
made at the site that has been previously described for intra- muscle using a conical obturator. The arthroscope and
articular anesthesia (Stashak 1987, Nixon 1994). A skin instrument portals can be exchanged for better examination
incision is made between the cranial and caudal portions of of the caudal acetabular rim. This allows entry for rongeurs 1
the greater trochanter, entering approximately 2 cm proximal and curettes through the original arthroscope portal. which j
to the palpable level of the trochanter (intertrochanteric fossa) can then be directed into the caudal regions of the joint. A j
(Fig. 10.1). This provides arthroscopic access to both the long 6-mm diameter egress cannula (Sontec Instruments. j
cranial and caudal recesses of the hip joint. The joint is Englewood, CO)or a second arthroscope sleeveis suitable for 1
initially distended with 60-80 ml of lactated Ringer's fluid egress after surgical debridement. The use of motorized j
solution administered through a 15-20-cm spinal needle or instruments is possible in small and moderate-sized horses,
th~ stvl~tt~ frQm a 15-cm intravenQUScatheter. The arthro- but use of motoriz~(J ~m1inm~nt ~f!n h~ limitp(J hv thp (Jpnth
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

instruments and motorized equipment need to be inserted to improved lameness in two racehorses.More
the limits of their length. Pressing in on the skin and gluteal
musculature occasionally allows an extra 1-2 cm of effective osteophyte formation is often evident over
length to be garnered from routine surgical instruments. caudal perimeter of the acetabulum (Fig. 10.8).
Long rongeurs and long egress cannulae are useful (Sontec moderate osteoarthritis, most of these osteophytes
Instruments). Most surgical triangulation techniques in the
hip are difficult. Debridement of cartilage lesions of the lesions of the femoral head can be accomplished
femoral head and removal of free bodies and debris within the appropriate manipulation of curettes and rongeurs
cranial and caudal recessesof the joint can be achieved with combination with axial distraction. A moderate
persistence. Lesions in the acetabulum can be more difficult iatrogenic damage to surrounding cartilage is always
to debride. In smaller horses, examination and debridement possibility during debridement of these lesions
of torn portions of the round ligament of the head of the advanced cases of hip joint osteoarthritis can
femur can be achieved. Osteochondrosis cysts of the head of arthroscopy (Fig. 10.9), however, lasting -
the femur and fractures of the caudal acetabular rim are following debridement of fibrillated regions is rare.
particularly difficult to adequately debride.

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

Femoral head cartilage lesions 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 There are no large series of cases to describe the results of
acetabulum may not necessarily represent OCD. but can be diagnostic or surgical arthroscopy for any of the conditions
debrided with long rongeurs. 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
Acetabular chip fractures arthroscopy is also very useful to establish the severity of
cartilage injury in mild and moderate degenerative osteo-
Small fractures of the cranial and caudal perimeter of the
arthritis. Severalcaseshave had focal cartilage injuries which
acetabulum can be removed with rongeurs. More extensive
responded particularly well to local debridement. The
fractures can be removed with some difficulty; however, the
establishment of a more accurate prognosis is also a useful
outcome is rarely satisfactory, due to the resultant instability
benefit of hip arthroscopy.
of the coxofemoral articulation (Fig. 10.13). Most of these
Surgical debridementcan be expectedto improve the
proceduresare tedious and time-consuming due tothe increased
outcome with osteochondrosis and OCD conditions of the
depths of the joint from the skin surface. Insertion of instru-
hip. Improvement in lameness after debridement of OCDflap
ments targeting the acetabular rim also places the sciatic
lesions on the acetabular perimeter and after debridement of
nerve at risk, if the instrument rides over the acetabular rim
subchondral cysts of the femoral head have beenseen.Access
and exits the dorsal (proximal) perimeter of the hip joint.
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.
Infectious arthritis and deeper cysts can be opened to some extent although
debridement is incomplete. In foals and miniature horses,
Arthroscopy provides an effective means for lavage and debridement of fraying and tearing of the ligament of the
debridement of debris from septic hip joints. The voluminous head of the femur can be easily performed, and at least with
cranial and caudal recessesof the hip joint frequently contain incomplete rupture, the results are quite satisfactory.
fibrinous and purulent debris. which can be removed by Removal of frayed ligament fibers and lavage of debris from
large-bore egress cannulae. or retrieved using rongeurs or the joint improve the degree of lameness and minimizes the
motorized resectors. Lavage can also be facilitated by a likelihood of secondary osteoarthritis. Synovectomy of
second instrument entry portal for an egresscannula in the portions of the accessiblesynovial membrane also appears to
caudal recess of the hip joint. Careful insertion of all instru- improve the postoperative response in these cases.Complete
ments into the caudal region of the hip is necessaryto avoid disruption of the ligament of the head of the femur results in
trauma to the sciatic nerve. permanent lameness. and long-term improvement after
arthroscopyhas not beenseen.Theselesionsneed further
stabilization.and techniquesfor hip stabilizationhave not
References
beensuccessful in adult horses. Baber YF, Robinson AH, Villar RN, Is diagnostic arthroscopy of the
The prognosisfor a horsewith hip diseasedependson the hip worthwhile? A prospective review of 328 adults investigated
type of lesion. extent of degenerativeosteoarthritis.and the for hip pain, J Bone Joint Surg (Br) 1999; 81: 600-603.
completenessof lesiondebridement.In somecircumstances Honnas CM, Zamos DT, Ford TS. Arthroscopy of the coxofemoral
hip arthroscopyhas improved the prognosis.whereas in joint of foals. Vet Surg 1993; 22: 115-121.
other casesthe extentof osteoarthritisand cartilagedamage Miller CL, Todhunter R. Acetabular osteochondrosis dissecans in a
has preventeda satisfactoryoutcome.Basedon limited case foal. Cornell Vet 1987; 77: 75-83.
Nixon AJ. Diagnostic and operative arthroscopy of the coxofemoral
experience.arthroscopicdebridementof OCDlesionsin the joint in horses. Vet Surg 23, 377-385.
hip appearsto improvethe prognosis.whereasa diagnosisof Nixon AJ, Adams RM, Teigiand ME. Subchondral cystic lesions
completerupt,ure of the head of the ligament of the femur (osteochondrosis)of the femoral heads in a horse.J Am Vet Med
is a predictor of continued lameness.Synovectomyand Assoc 1988; 192: 360-362.
debridement of portions of incomplete rupture of the Rose JA, Rose EM, Smylie DR. Case history: acetabular
ligament of the head of the femur have been useful in osteochondrosis in a yearling thoroughbred. J Equine Vet Sci
1981; 1: 173-175.
providing lasting improvement in the level of lameness.
Rutkowski JA, Richardson DW. A retrospective study of 100 pelvic
Removalof chip fracturesassociatedwith the acetabularrim fractures in horses. Equine VetJ 1989; 21:256-259.
is possible;however.significant improvementin outcomeis Stashak TS. Diagnosis of lameness. In: Stashak TS (ed.),
evident only with small fragments.Largerlesionsresult in Philadelphia: Lea and Febiger; Adams'lameness in horses. 1987:
destabilizationof the articulation and little long-termbenefit. 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 phalanx (Fig. 11.8). From there the dorsal concave part of
(Fig. 11.5) and the loss of orientation. As in all arthroscopic the articulation of the second phalanx and the convex part of
procedures. the shorter the distance from skin to joint cavity. the articulation of the third phalanx can be visualized. By
the better. rotation and relocation of the tip of the arthroscope. the
The arthroscopic sleeveis introduced and positioned in the lateral and medial rim of the articulation and the attachment
distal interphalangeal joint by the use of a blunt obturator to of the joint capsule and the extensor tendon become visible.
penetrate the fibrous joint capsule (Figs 11.6 and 11.7). Once Hyperflexion. hyperextension. and medial and lateral hoof
the sleeve is in the joint. the obturator is exchanged for the rotation will expose additional. deeper parts. of the articu-
arthroscope. and the camera. light cable. and fluid and gas lation. With this approach. even lateral or medial aspects of
ingress line are attached. The diagnostic arthroscopic the distal articulation of the middle phalanx will become
evaluation can commence from this position. One author GB) visible. By careful withdrawal and positioning the tip of the
prefers gas distention with carbon dioxide. as he considers it arthroscope into a more proximally orientated position. the
superior for all diagnostic and surgical procedures; a parallel dorsal joint capsule and the proximal reflection of the joint
fluid distention line is used for postoperative lavage. Hand capsule can be examined.
instruments such as probes. forceps. rongeurs and cannulas
are introduced through the instrument portal. This is
determined by the use of a hypodermic needle.
Diagnostic arthroscopy of the
palmar/plantar poucf1 of the distal
Normal arthroscoPic anatomy of distal Interphalangeal joint
interphalangeal joint
Indications
The dorsal pouch of the distal interphalangeal joint represents
about 30% of the entire joint. The main landmark for this Forthe palmar/plantar approachthe horsemaybepositioned
part of the joint is always the extensor process of the distal 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 extensor process of the distal phalanx. 'I
these locations. To view these ligaments the tip of the arthro- be securely embedded
...,
in the attachment of the
scope has to be directed distally in between the navicular
bone and the palmar/plantar articulation of the second Their size and outline varies from 2 mm up to 30 mID
phalanx. Hyperflexion causes the navicular bone to move diameter. They can be round with a smooth outline. as
osteochondritis dissecans (OCD) fragments. or in ,. --
away from its contact point with the second phalanx and this
exposesmore of the distal axial parts of the joint cavity. with traumatic fractures they might appear more i
in shape.
A complete set of preoperative radiographs :-
important information about the size and location of
Arthroscopic surgery of the dorsal distal --

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
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).
"cosmetic" in nature. However, we feel that many joints with Narrow cup alligator forceps or low profile rongeurs are
so-called silent fragments develop secondary lesions, such as introduced into the joint and the fragment securely grasped,
proliferative synovitis and articular cartilage damage. rotated (to make sure there are no remaining attachments),
In lame horses, the prognosis for complete recovery is still and removed from the joint cavity. At completion of the
good as long as there are no signs of secondary new bone procedure, the defectcreated by the fragment is debrided and
formation. The earliest signs of secondary osteoarthritis are the joint cavity is lavaged using a 4.5 mm egresscannula.
osteophytes on the dorsal aspect of the middle phalanx and In chronic cases,secondary hypertrophic reaction of the
they are usually most obvious on oblique radiographic views. 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
Arthroscopic technique by the use of a mechanical synovial resector. In chronic
The surgical technique for extensor processfragment removal cases, various stages of cartilage damage become visible.
follows the steps of diagnostic coffin joint arthroscopy Discoloration, fibrillation, and erosion up to full-thickness
described earlier in this text. The instrument portal is loss of cartilage will be in proportion to the duration of the
carefully selected to permit access to the central articular initial disease.Intraoperative radiographs may be necessary
surface. To determine the location of the instrument portal. to ensure that all parts of the fragment are removed.
Postoperativemanagement arthroscopic removal of extensor process
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 component,
that the bandage covers the entire hoof. An elastic. adhesive may develop (Gabel& Bukowieckie 1983).
bandage prevents slippage. Bandages are carefully monitored
and changed until the skin sutures are removed 12 days after another choice but incurs the risk of secondary
the procedure. Horses are confined to a stall for a minimum of failure. The implant at this location is exposedto
12 days and then hand walked daily for 15 minutes. Riding cyclic loading and can break. The obvious
and more intensive training can start 3 to 6 weeks after the
surgery. Antibiotics and phenylbutazone are administered operative time with less incisional exposure,
postoperatively for a period of 3 days. visibility within the joint, and shortened
period.
Problems and complications
The most common problem in dorsal coffin joint arthroscopy
is inadequate visualization. Suitable case selection and Arthroscopic surgery of other
conditions in the ~istal
accurate placement of both arthroscope and instrument joint .
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
Abaxial articular fragments
and/or to close too the coronary band. If a fragment or part Other. intra-articular fragments (seeFigs 11.12 and 11..
of a fragment becomes loose it might be extremely difficult to including osteochondral chip fractures or '
relocate. Loose fragments either disappear further distally in
the joint or move into the proximal pouch of the joint. Re- & McIlwraith 1992, McIlwraith & Goodman
arthroscopy within a few days after the first attempt is an visibility of i
option if the fragment cannot be found. might still be a challenge (Fig. 11.22). The
approach is routine. .
portal site for hand instruments is located either
Results
medial to the extensor tendon. An 18-gauge
Since the first report in 1988 there have only been case
reports published.Boening et al (1990) described 14 of 16 characterized by significant porosity of the bone,
lame horses that recovered full athletic function after 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 latero-medial, and two oblique views using
proximal interphalangeal joint is simple and consists of the radiographic films.
dorsal distal articular cartilage of the proximal phalanx as Following removal of fragments, ---' "---
well as the dorsal rim of the middle phalanx and joint capsule padded bandaging of the surgical site for 1 0 days
attachments (Fig. 11.28). This dorsal proximal rim of the confinement for 2 weeks post-surgery.
middle phalanx is the usual location for osteochondral chip hand-walked for another 2 weeks. The,
fragments (Fig. 11.29 and 11.30). Fragments found at this allowed to train for a period of 6-8 weeks after surgery.
location could possibly result from osteochondrosis. These
fragments usually cause synovitis. which results in local
swelling of the proximal interphalangeal joint and associated Arthroscopy of the
lameness. Intra-articular anesthesia is essential for proper p<?uchof the proximal
diagnosis. To establish the exact location of the operative Joint
site for fragment removal, at least four preoperative
radiographs are required. Size and anatomic location of the So far there are no reports found on arthroscopy of
palmar/plantar pouch of '
fragment may be identified with a dorsopalmar/plantar, a
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 digital flexor tendon sheath(Ragland1968. Dik et a11995.
Fortieretal1999. All are exquisitelysensitive.Surgicaltreat-
Flexor Tendon Sheath ment of these complexcasesis appropriateto debridethe
primary tendondefectand stopthe cycleof annular ligament
constrictionandongoingsheathirritation (Fortieretal1999).
Introduction
The primary indication for tenoscopy of the digital flexor Preoperative assessment
tendon sheath is assessmentand treatment of the various
manifestations of chronic, proliferative, so-called "complex Lamenessoriginating from the digital flexor tendon sheath is
tenosynovitis" of this sheath. Chronic tenosynovitis is a confirmed by intrathecal anesthesia, and should be followed
relatively common problem of the digital flexor tendon sheath, by a thorough ultrasonographic assessment. Particular
particularly in the hind limbs. Most mild and moderate forms attention should focus on the extent of tendonitis of the
of tenosynovitis cause only low-grade lameness and 'can be superficial digital flexor tendon (SDFT)and the deep digital
managed medically. More severe tenosynovitis cases, and flexor tendon (DDFT), since they profoundly affect the
those chronic cases that have disruption of the tendon prognosis and the decision for surgery (Barr et al 1995).
sheath, the various mesotenons. the annular ligament, or the Additionally, ultrasonographic evaluation determines the
flexor tendons themselves,may result in a more profound and thickness of the tendon sheath wall and palmar annular
self-perpetuating cycle of increasing tendon sheath fibrosis ligament, and definesthe number, and lateral or medial attach-
and annular ligament thickening (Fortier et al1999). Teno- ment, of tenosynovial massesthat need to be addressedat the
synovial massesand adhesions can developas a consequence time of surgery (Stanek & Edinger 1990, Dik et al 1991,
(Watrous et al 1987). These latter types of complex Redding 1991). Central core lesions of the flexor tendons can
tenosynovitis not only require surgical intervention but also be treated by injection or stab incision at the time of surgical
generally have a reduced prognosis for good cosmetic out- section of the annular ligament. Linear clefts within the
come and return to complete soundness (Fortier et al1999, DDFT and occasionally the SDFT present special problems in
Wilderjans et al 2003). The duration of symptoms seems repair, with most requiring debridement, and some requiring
particularly relevant to the final outcome of these cases. suture repair (Wright & McMahon 1999). In the authors'
experience ultrasonographic examination is not sensitive in
detecting linear clefts in the tendon structure. Any ultra-
Pathogenesis sonographic suggestion of echolucencies within the surface
one-third of the flexor tendons is highly suspicious, and this
Acute tenosynovitis can result from tearing of various portions region should b'~ carefully assessedduring endoscopic explo-
of the digital flexor tendon sheath, the mesotenons, or linear ration. Additionally, adhesions and soft tissue masses within
tears in the flexor tendons within the sheath. Recalcitrant the tendon sheath, as well as between the SDFT and DDFT,
tenosynovitis and secondary constriction due to the palmar/ need to be removed. Presurgical preparation and draping
plantar annular ligament can then follow acute tenosynovitis must provide accessto both lateral and medial portions of the
(Dik et al19 95). Progressivefibrous thickening of the sheath digital flexor tendon sheath, to allow instrument access to
and the intimately attached annular ligament can compress these tissues for removal or sectioning.
and restrict the free movement of the flexor tendons through
the fetlock canal (Adams 1974, Gerring & Webbon 1984,
Verschooten & Picavet 1986, 1988). The consequences Surgical anatomy
include turgid fluid accumulation within the tendon sheath.
enlarging tenosynovial massesalong the abaxial portions of The digital flexor tendon sheath consists of a parietal and
the flexor tendons, particularly in the proximal portion of the visceral layer that provide the inner lining of the sheath and
digital flexor tendon sheath. and adhesions spanning from the surface layer of the enclosed tendons, respectively. The
the tendons to the dorsal and abaxial parietal layers of the intimal layer is several cell layers thick, and is supported by

CHAPTER
Cut annular ligament

dense subintimal and sheath fibrous layers (Hago et aI1990). The most robust mesotenon extends from the palmar midline
The digital flexor tendon sheath extends from the junction of of the SDFT to the adjacent tendon sheath (Figs 12.2 and
distal and middle thirds of the third metacarpus/metatarsus 12.3). Short thick mesotenons also extend from the proximo-
to the level of the middle phalanx and navicular bone medial and proximolateral margins of the DDFT.The proximal
(Fig. 12.1). The sheath enclosesthe SDFTand DDFT, both of portion of the DDFT is encircled by a complete but thin sleeve
which have mesotenon attachments to the tendon sheath. of the SDFTknown asthemanicaflexoria (seeFigs 12.1-12.3),
which ensures alignment of the tendons during their passage digital flexor tendon sheath, the DDFT has several dorsal and
around the fetlock. The digital flexor tendon sheath has its a single palmar/plantar mesotenon attachment (seeFig. 12.1,
proximal reflection and attachment to the full circumference inset). There is also a small encircling component (the digital
of both the SDFT and DDFT, which forms the proximal manica) of the SDFT (see Fig. 12.1, inset), which stabilizes
endpoint of the sheath cavity. In the distal portions of the 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 the proximal DDFT. Linear clefts i
uses a skin entry portal for the arthroscope on the palmaro/ found at this~vel, which may correspond to ,
plantarolateral aspect of the sheath between the annular stricted region of the fetlock canal when the limb
ligament and proximal digital annular ligament (Fig. 12.5).
Distention of the tendon sheath defines an outpouching at SDFT, paying particular attention to adhesions and
massesdirectly between the flexor tendons (Fig. 12. '; -
this site. A skin incision is made slightly palmar/plantar to
the center of this prominent outpouching, to allow the the arthroscope is withdrawn from I
arthroscope to be directed proximally through the fetlock redirected palmar/plantar to the SDFT, where the
canal, and then to be redirected for examination of the distal mesotenon attachment is evident (seeFig. 12.7).
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 sheath is restricted. In such cases, examination can
need to be slightly larger than normal, so thatthe arthroscope improved by severing the annular ]
sleeve and obturator enter easily. Once the sleeve and phases of the surgical procedure, (
obturator have entered the digital sheath, they are pushed 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
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/
flexor Ienaun ~Il~ltLIl
plantar annular ligament is transected after removal of
LU ItUUW ~llLLY VI lla11U 111"" U111"1'." =1"motorized
resectors for direct accessto synovial massesandadhesions tendon sheath masses. However, if movement through the
fetlock canal is restricted, the annular ligament should bedivided
(Fig. 12.8).
Redirection of the arthroscope into the distal regions ofthe early.
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). "U"~C,"L'VII vI LII'" """"""""",.,,'
Ultimately, the arthroscope can be inserted to the distal limits
annular ligamentThe
of the digital flexor tendon sheath. Generally, proliferativemasses
and adhesions are less prevalent in the distal regions only effective treatment for genuine palmar/plantarannular
of the sheath. ligament constriction is surgical division. A simpleannular
Reversal of the instrument and arthroscope portals allows ligament transection can be accomplished withoutthe
examination of the digital flexor tendon sheath using a need for tenoscopy,but in many cases constriction is part
proximal approach (Fig. 12.10). Instruments can be inserted of a complex tenosynovitis syndrome which requires
through the distal skin portal, allowing further motorized resection of tissues in addition to the annular ligament.
resection of adhesions and masses associated with the Tenoscopically assisted annular ligament transection can be
flexor tendons and tendon sheath distal to the level of accomplished free hand using a variety of right-angled
the fetlock. 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
.eno~~op'~ mu~~"~'"UYU"UU"~~"'" ..u..~~'"..v.. adapted without change to the instrumentation for annular
Open tendon surgery for removal of tenosynovial massesand ligament releasein horses (Nixon et al1993). The advantages
adhesions delays initiation of exercise postoperatively and of tenoscopic annular ligament release include the precision
predisposes to adhesion reformation (Watrous et al 1987, of the cut, the safety of identifying and avoiding vital structures
Nixon 1990b). Tenoscopic examination of the digital flexor such as the manica flexoria and flexor tendons, and the
tendon sheath is preferred, as the minimally invasive approach extensive dissection that can be performed through limited
provides complete access to most of the sheath contents, entry wounds. which provides better wound healing with
permits multiple mass removal, and allows early return to less risk of dehiscence and earlier postoperative exercise
walking in the convalescent period (Nixon 1990c). Large (Nixon et al 1993). Placement of the slotted cannula is
tenosynovial masses can be challenging to remove, and critical to facilitate insertion of the arthroscope and 900
complete assessmentcan be difficult until some of the tissue angled blade. The proximal entry portal should be dorsal in
is resected. Preoperative ultrasonography is used to target the digital flexor tendon sheath and the distal exit portal
and develop a plan for mass removal (Fig. 12.11). Straight plantar/palmar. to allow the arthroscope or blades to clear
(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
the heel-bulbs (Fig. 12.14). Interference of the heel-bulb with punch rongeurs (Dyovac 5.2), and motorized resectors with
the arthroscope and video camera can be frustrating, both side and forward aperture, which are also effective in
particularly in breeds such as Cobbs. trimming down epitenal and tendon fiber damage. The aim
The cannula with obturator in place is inserted from should be a relatively smooth tendon surface. Access to the
proximal to distal using arthroscopic visualization (see region between the DDFT and SDFT may also be required to
Fig. 12.14). The insertion path must be external to the trim linear clefts in the DDFT that extend proximal to the
manica flexoria, or this ring of the SDFTwill be divided along sesamoid,(bones,and this needs an entry through the
with the annular ligament. As the slotted cannula and its proximal portion of the manica flexoria for instrumentation,
ribbed obturator near the distal portal. the tip of the as described earlier.
arthroscope is retracted 5 mm into its sleeve, to create a In some casesthere may be tearing of the manica flexoria.
docking portal for the obturator of the slotted cannula This may result from ongoing pressure within the fetlock
(Fig. 12.15). This is then advanced, pushing the arthroscope canal associated with constriction by the palmar/plantar
and sleeve out of the tendon sheath and allowing the slotted annular ligament, or may arise as primary lesions. Depending
cannula to exit the arthroscopic skin portal. The ribbed on the extent of the tear, the edges of the cleft can be
obturator is then removed from the slotted cannula, and the debrided, or the manica resected in toto using arthroscopic
unsheathed arthroscope inserted to view and confirm scissors, knives or motorized resectors (Fig. 12.18). No
positioning with respect to the flexor tendons, the sesamoid attempt at suture repair has been used. Other pathologic
surface, and the palmar/plantar annular ligament. The slot conditions can develop associated with chronic constriction
in the cannula is then oriented to open directly toward the of the annular ligament, including separation of the palmar
annular ligament (Fig. 12.14D), before the 900 angled blade mesotenon of the SDFT.These areas can be trimmed, and any
is inserted and drawn across the fibers of the annular secondary adhesions resected. The aim of digital flexor
ligament to sever the full thickness of the ligament 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 artery and nerve (Fig. 12.20), which can be compressedin
"carpal flexor tendon sheath" and "carpal canal". The carpal carpal canal syndromes. These are rarely viewed during
canal will be used to describe that subcomponent of the routine carpal sheath tenoscopy because the approach is
carpal sheath bound by the carpal flexor retinaculum, generally from the lateral aspect. The SDFT and DDFT are
spanning from the accessory carpal bone to the carpal closely intertwined during their passage through the carpal
ligament. sheath, and have a common and extensive mesotenon that
Carpal sheath conditions that result in chronic and often exits from the caudomedial aspect of the tendons and
insidious lameness have been increasingly recognized and attaches to the caudal aspect of the carpal sheath (see
examined by exploratory endoscopy (McIlwraith 2002a, Fig. 12.20). This effectively prevents complete examination of
Textor et al 2003, Nixon et al 2004). Many of the clinical the carpal sheath using lateral surgical approaches. Other
components of carpal sheath/carpal canal lameness may be important neurovascular structures that lay outside of the
interrelated. Radial osteochondroma,radial physeal exostoses, carpal sheath (see Fig. 12.18), are relevant in carpal canal
tendonitis or myotendonitis of the proximal portion of the release (Textor et al 2003), and should be avoided in the
digital flexors, and idiopathic carpal tunnel syndromes may tenoscopic dissection. The substance of the carpal flexor
all result in lameness and/or sheath distention. These con- retinaculum forming the carpal canal and the distal extent of
ditions frequently have little to differentiate them based on the proximal check ligament can be seen intruding on the
their clinical appearance. Endoscopic examination is useful medial wall of the carpal sheath in the center and proximal
for assessmentand confirmation of the diagnosis of many of regions, respectively(seeFig. 12.19). Vascular support for the
these syndromes, and can then be followed by definitive SDFTand DDFT is provided through the mesotenon attach-
repair. Arthroscopic approaches to the carpal sheath have ment, the proximal and distal carpal sheath reflections to the
been described (Cauvin et a11997, Southwood et alI998). tendons, the radial head of the DDFT, the proximal check
Removal of radial osteochondroma under arthroscopic ligament attachment to the SDFT,and the entry of vessels
visualization is simple and effective, and eliminates the deep through the myotendinous junctions. The carpal sheath fluid
dissectionnecessarywith open approaches(Squire et al1992, has a similar composition to digital flexor tendon sheath
Southwood et al1997, ter Braake & Rijkenhuizen 2001). fluid. The carpal sheath becomes considerably reduced in
Additionally, many horses have caudally protruding bony diameter distal to the carpal canal (Fig. 12.21), which limits
exostosesassociatedwith the closeddistal physis of the radius the mobility of instruments during tenoscopic examination,
(Nixon et al 2004). These exostosesare considered to result despite the fact the mesotenon is thinner in the distal recessof
from previous physitis and when centrally placed can the sheath.
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- Tenoscopic techniques
tendinous junction of the flexor tendons, and fracture of the
Introduction
accessory carpal bone. Tenoscopic division of the carpal
retinaculum can be used to open the carpal canal and release The role of radiographically evident bony exostoses and
pressure on the digital flexor tendons (Textor et al2003). This osteochondromas in causing damage to the DDFT and carpal
reduces the risk of complications associated with open sheath effusion are well described. and tenoscopic removal
surgery, including persistent swelling, seroma formation, has been curative (Squire et a11992. Southwood et al1997,
wound dehiscence and fistula formation. Mcllwraith 2002a, Nixon etal2004). Carefulultrasonographic
examination of the carpal sheath has also identified soft
tissue lesions within the tendons or carpal sheath. and provides
Surgical anatomy better preoperative information for planning the tenoscopic
access. Casestwith carpal sheath effusion but without an
The carpal sheath is a voluminous synovial cavity that obvious radiologic or ultrasonographic cause are frequently
extendsfrom the levelof the lowermiddlethird of the radius treated initially with a combination of intrathecal NaHA and
to the uppermiddlethird of the metacarpus.It envelopsthe corticosteroids. If lameness and/or distention persists,
SDFTand DDFTand their myotendinousjunctions during diagnostic tenoscopic examination is warranted.
passagethrough the carpal canal. Functionally,the carpal
sheath provides protection and lubrication. and minor
metabolicsupport.to bothtendonsastheytraversethecarpal Diagnostic arthroscopy of the carpal sheath
canal.The parietal and visceralsurfacesof the carpal sheath The authors use variations of the standard proximolateral
are morphologically similar to the digital flexor tendon approach to the carpal sheath as described by Southwood et al
sheath.The carpal sheathis more spaciousproximal to the (1998). This technique allows evaluation of the entire
level of the accessorycarpal bone. where it contains both proximal portion of the carpal sheath, including the carpal
SDFTand DDFTand the radial head of the DDF,coursing canal region, but provides limited access to the metacarpal
from the caudalaspectof the radiusto its aponeurosison the region of the sheath. Insertion of the arthroscope into the
DDFT(Fig. 12.19). The medial side of the SDFTwithin the distal region of the carpal sheath improves examination of
carpal sheathalsohas an intimately attachedmedialpalmar 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 Medial


tendon and lateral. collateral
collateral ligament. ligament

middle carpal
joint

Flexor carpi

Accessorioquartal and .
accessoriometacarpal Medial palmar v.

ligaments
'\ Medial palmar a.,n.
A Lateral palmar a.,v.,n.'

Surgery can be performed with the horse in dorsal carpal sheath immediately cranial to the radial head of the
recumbency, or in lateral recumbency with the affected limb DDFT,but can be more clearly defined by using an instrument
uppermost. Dorsal recumbency is generally preferred by the to probe for the intrusion of the ligament into the sheath (see
authors. It has obvious advantages for bilateral evaluation Fig. 12.23).
and significantly reduces intraoperative hemorrhage. Lateral The arthroscope can then be redirected to more caudal
recumbency facilitates tenoscopy through the distal (meta- regions of the carpal sheath, examining the caudal surface of
carpal) portal and some surgeons find the operating position the DDFT and a small portion of the SDFT (see Fig. 12.23).
to be more comfortable. In both situations, the carpus is The arthroscope can be inserted from the lateral to medial
positioned in slight (approximately 15-20°) flexion. The direction to assess these areas of the SDFT and can be
carpal sheath is distended with 50-60 ml of lactated Ringer's inserted a small distance between the SDFTand DDFT before
solution and the arthroscope entry portal is made laterally, encountering the common mesotenon joining the DDFT and
6-8 cm proximal to the remnant of the radial physis. This SDFT.
allows examination of the carpal sheath, while leaving the Further examination of the craniomedial depths of the
region between the arthroscope entry and the distal physis of carpal sheath reveals the transversely oriented fibers of the
the radius available for instrument entry (Fig. 12.22). carpal flexor retinaculum, forming the medial boundary to
Initial examination from the lateral approach reveals the carpal canal (Fig. 12-24). The proximal and distal limits
the caudal aspect of the radius, and the lateral portion of the of the retinaculum are not as distinct as the intrusion formed
DDFT, which at this level obscures most of the SDFT by the proximal check ligament. The proximal border of the
(Fig. 12.23). The SDFT can be examined later by rolling the retinaculum can be recognized only by the adjacent caudal
DDFT with a probe, but this exposes only small portions of protuberan~ of the physeal scar of the radius. The distal
the tendon; complete examination of the SDFT is difficult border of the retinaculum can be determined by digital
using the lateral approach. The common mesotenon for pressure over the caudomedial portion of the carpal sheath,
the SDFTand DDFT attaches to the caudolateral aspect of the which can easily be indented only beyond this distal margin.
carpal sheath, and effectively prevents examination of the The distal regions of the carpal sheath can be examined
SDFT over its caudal and medial surfaces. In the more distal beyond the level of the carpometacarpal joint, but mobility
regions of the carpal sheath, the SDFT emerges, although distal to this level is restricted. Examination of the most distal
better examination of this tendon is provided through a regions of the carpal sheath can be performed by inserting
palmarolateral portal 4-6 cm distal to the accessory carpal the arthroscope through the palmarolateral surface of the
bone (Cauvin et aI1997). carpal sheath in the proximal metacarpus (Cauvin et al
Maneuvering the arthroscope to examine the more 1997), and viewing proximally. This can be difficult with the
proximal regions of the carpal sheath reveals the radial head horse in dorsal recumbency, but the limb should be draped to
of the DDFT coursing from its aponeurosis on the DDFT allow this portal if needed.The arthroscope portal can also be
cranially to curve and expand into its origin on the caudal made in the palmaromedial surface of the sheath at this level
aspect of the radius (see Fig. 12.23). The proximal check but, with the horse in dorsal recumbency, manipulating the
ligament can also be identified within the medial wall of 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
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
recumbency. Penetration of the thin sheath surrounding the this tendon (Textor et al 2003). The retinaculum is divided
flexor carpi radialis tendon is routine. and is an important with a curved serrated blade or radiofrequency probe. cutting
landmark since it defines the medial endpoint for the proximally from the distal edge until 1 cm beyond the
dissection (Nixon 1990a). Exchange of arthroscope and proximal border of the accessory carpal bone. The carpal
instrument portals is often useful to improve visualization sheath is then probed to ensure there are no thickened
areas containing residual fibers of the carpal retinaculum, 1990b). The procedure is simple. has few risks of wound
either proximally or distally. The flexor carpi radialis tendon healing complications. and can often be added to other pro-
should be visible throughout the entire transected area cedures during the tenoscopic examination and treatment of
(Fig. 12.34). disorders of the carpal sheath contents.
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 Postoperative care
the flexor retinaculum (see Fig. 12.34). The surgeon should
decide whether to continue the dissection through this thin The use of tenoscopic techniques to evaluate the carpal
medial portion of the carpal retinaculum. This is based on the sheath and address specific pathology has minimized wound
degree of relief of the carpal canal, which can be assessedby healing complications. The need for extended wound support
the increased ease of movement of the arthroscope and the by bandaging and limitation of postoperative exercise has
increase in viewable structures within the carpal canal. also been reduced. Return to an active walking program is
Severing the medial portion of the retinaculum can be done rapid, and the extent of layoff from work is then dictated only
safely,since the radial artery is approximately 7 mm caudal by the pathology of the tendons themselves rather than the
to the flexor carpi radialis tenqon. However,the medial palmar surgical approach. Animals are usually given perioperative
vein is only 2-4 mm caudal to this site, and careful dissection antimicrobial,l:lrugs. Intrathecal NaHA (20-40 mg) is
is necessaryto avoid perforating this vessel. commonly usep, both at surgery and 2-3 weeks later. Follow-
In clinical cases,the carpal sheath and flexor retinaculum up intravenous NaHA may also be useful, commencing
have been thickened predominantly on the deep (inner) 4-6 weeks after suture removal. Bandage support should be
portion, forming the visible interior layer of the retinaculum provided to keep the arthroscopic and instrument portals
overlying the flexor carpi radialis tendon. Division of only this covered for the first 5-10 days after surgery. This usually
portion of the retinaculum has been adequate to resolve consists of light bandages, sponges. and adhesive elastic
carpal canal symptoms in two horses in a recent publication bandage. Most horses undergoing tenoscopic procedures of
(Textor et al 2003), and a further seven horses operated the carpal sheath show little lameness beyond the initial day
on since then. However, a larger case series has not been of surgery. Intrathecal anesthetics such as bupivacaine are
published. Secondary carpal canal syndrome, developing as a useful during surgery but generally are unnecessary in the
result of radial physeal exostoses,or myotendonitis and/or control of postoperativepain. Nonsteroidal anti-inflammatory
tendonitis of the contained flexor tendons, may also benefit agents are usually given for 2-3 days after surgery.
from division of the carpal retinaculum, using the same Horses are confined to the stall for the initial 1-2 days after
rationale as described for treating flexor tendonitis within the surgery. and small periods of hand walking are then
confines of the palmar annular ligament at the fetlock (Nixon instituted. A balance is necessary between an early return to
"".,
,';:;'",'

~.:. ,

Flexor retinaculum

Medial palmar a., n.


-a., v., n.

walking exerciseand healing of carpal sheathstructures. five horsesundergoingtenoscopiccarpal canal releasehave


Adhesions associatedwith surgery in the carpal sheath recoveredfrom the lamenessassociatedwith the carpal
appearto berare. sheath region (Textor et al 2003). The prognosisfor SDF
tendonitistreatedby proximal checkligamentdesmotomyis
difficult to determinebecauseof the influencesof ancillary
Results and prognosis treatmentto the tendon,exerciseprotocol,and the amount of
time providedfor convalescence.
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).
Tenoscopy of the Tarsal
These reports suggest exostoses from the physeal remnant Sheath
and osteochondroma arising from the metaphyseal region
present with similar carpal sheath effusion and lameness.
and both resolve with mass removal (Mcllwraith 2002a. Introduction
Nixon et al 2004). Lameness and effusion resolved in all 10
cases reported with radial exostosis (Nixon et al 2004). A The nomenclature surrounding the tarsal sheath and the
series of horses having endoscopicallyassistedcheck ligament DDFThas been through severalchanges. The DDFT has been
division has also been described (Kretzschmar & Desjardins referred to as the flexor hallucis longus and as the flexor digiti I
2001). This procedure was considered minimally invasive tendon. The m()re recent term for the DDFT is the "lateral
and was completed in lesstime than open division. It has also digital flexor tendon". However, the use of DDFT is still
resulted in a renewed interest in the use of proximal check extremely common among surgeons and has been continued
ligament desmotomy for treating SDF tendonitis. However. here for the sake of clarity. Persisting lameness associated
one of the authors (A.J.N.) recommends the procedure with tenosynovitis of the tarsal sheath (thoroughpin) is
should be performed bilaterally in all horses. regardless of relatively common, and can result from trauma to the fibrous
age. since a 6% incidence of bowed tendon in the opposite layers of the tarsal sheath, damage to the mesotenon attach-
limb has been recorded in a recent study (Nixon 2002b). ments of the DDFT within the tarsal sheath, and tendonitis of
The prognosis following repair methods using carpal the DDFT itself (Van Pelt etal1969, Van Pelt 1969, Dik &
sheath tenoscopy largely depends on the original pathology. Merkens 1987. Mcllwraith 2002b). Additionally. the DDFT
Ultrasonographic examination followed by tenoscopic courses over the sustentaculum tali. which can be injured
evaluation and treatment provides critical information for through direct trauma, resulting in bone proliferation and
the prognosis, and the structure and duration of the damage to the flexor tendon as it undergoes directional
convalescent interval. The prognosis following removal of change through the region of the hock (Edwards 1978,
osteochondroma and exostosesof the caudal perimeter of the Dik & Merkens 1987). The tarsal sheath is not invested by
physis of the radius is good to excellent (Held et al 1988. as dense a constrictive flexor retinaculum as the carpal
Squire et al 1992, Southwood et al 1997. ter Braake & sheath. and although "tarsal tunnel syndrome" is possible,it
Rijkenhuizen 2001, Nixon et al 2004). The prognosis is poorly characterized (Van Pelt et a11969. Van Pelt 1969,
following carpal retinacular release is unknown. although
Indications for tarsal sheath tenoscopy include a chronic small vinculae in the proximal recesses of the tarsal
tenosynovitis that is poorly responsive to medical therapy. sheath (Cauvin et al 1999). As the DDFT approaches the
These cases may be improved by debridement of massesand sustentaculum, the tarsal sheath becomes narrowed by the
adhesions spanning from the tarsal sheath parietal lining to flexor retinaculum forming the tarsal tunnel (Fig. 12.37).
the DDFr. Severalother manifestations of chronic tenosynovitis The distal cul-de-sac of the tarsal sheath is narrow and
may be tenoscopically debrided. including tears of the DDFT, slightly better defined on the plantar aspect of the DDFT. This
mineralizing masses within the tarsal sheath. and mineraliz- cul-de-sac contains a synovial fold attached to the DDFT and
ation of the surface and deeperstructures of the DDFT.Removal the dorsomedial sheath wall, which forms a blind dorsomedial
of fragmentation of the sustentaculum tali, and debridement pouch (Fig. 12.38). The lateral extension of the tarsal sheath
and lavage of contaminated or infected tendon sheaths are extends more distal than the medial terminal cul-de-sac, both
also major indications for tenoscopy (MacDonald et al1989. of which can be viewed tenoscopically.The tendon of insertion
Welch et a11990. Santschi et al1997, Cauvin et al1999, of the medial digital flexor tendon (MDFT) (flexor digitorum
Mcllwraith 2002b) longus), which has a separate tendon sheath, conjoins with
the DDFT ilIimidiately distal to the termination of the tarsal
sheath.
Surgical anatomy There are no major neurovascular structures within the
tarsal sheath, but there are several neurovascular bundles
The structures and associationsof the tarsal sheath and associated with its outer fibrous layers that need to be
the enclosedDDFTthroughout its coursearound the hock recognized when making instrument portals. Proximally, the
have beendescribed(Cauvin et al1999). The tarsal sheath divided tibial nerve that has become the medial and lateral
commences6-7 cm proximal to the level of the medial plantar nerves, the medial tarsal artery, and the recurrent
malleolus, and extends approximatelyone fourth of the tarsal vein are located in the caudomedial fibrous layers (see
distance down the third metatarsus (Fig. 12.35). The Fig. 12.36). The recurrent tarsal vein is in a more medial
enclosedDDFThas a continuous mesotenonattachmenton location, and is susceptibleto injury when making instrument
its caudo/plantaromedialmargin, which is relatively thin portals. More distally, at the level of the sustentaculum tali,
and contains obviousfine vasculature(seeFig. 12.35 and the medial and lateral plantar nerves, arteries, and veins are
Fig.12.36). This can limit visualizationof caudaland caudo- located caudally, deep in the fibrous layers of the tarsal
lateral portions of the DDFT,dependingon the position of sheath, but also within the confines of the tarsal flexor
the arthroscopeaccessportal. The DDFTalso has several 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 perforated in several areas if necessary, allowing the
plantar neurovascular structures are positioned along the arthroscope to view the caudal portions of the proximal
plantarolateral perimeter of the termination of the sheath pouch of the tarsal sheath. A separate instrument entry,
and are relatively protected (Fig.12.38). 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
Tenoscopic techniques the predominant lesions, dorsal or plantar, to the mesotenon.
With the arthroscope directed proximally, the DDFT
Diagnostic tenoscopy of the tarsal sheath
and proximal reflection of the tarsal sheath are evident
Several approaches to the tarsal sheath have been described, (Fig. 12.40). The mesotenon and medial and cranial/dorsal
but the preferred arthroscopic entry is a central medial portal surfaces of the DDFTare readily examined. Redirection of the
made 1-2 cm proximal to the sustentaculum tali (Fig. 12.39). arthroscope more distally reveals the DDFT as it curves
This permits visualization of both proximal and distal regions over the sustentaculum tali (Fig. 12.40). Limited portions of
of the sheath (Cauvin et aI1999). Examination and debride- the fibrocartilage surface of the sustentaculum forming the
ment of the visible portions of the DDFT and many areas of support surface for the DDFT can also be examined. The
the sustentaculum tali can be performed using instrument DDFTcan be retracted after a local instrument portal is made,
portals directly over or immediately distal to the sustenta- which improves access to the caudolateral surface of the
culum tali. sustentaculum (Fig. 12.40). The medial extremity of the
The central medial approach can be performed with the sustentaculum is extrasynovial and cannot be viewed
horse in dorsal or lateral recumbency with the limb extended. tenoscopically.lhis area is also the most frequent site for
Hemorrhage is slightly reduced by using dorsal recumbency. bony exostosis.and fragmentation, which may then have to
and a tourniquet is useful for hemorrhage control when be removed using open approaches. Over the sustentaculum
using lateral recumbency, since the affected limb is down. The the tarsal sheath is confined by the tarsal flexor retinaculum,
tarsal sheath is distended with saline if it is not already which stabilizes the DDFT (Fig. 12.40). Redirection of the
markedly enlarged. The voluminous outpouching of the arthroscope allows the DDFTto be viewed as it curves distally
proximomedial aspect of the tarsal sheath is readily palpated. (Fig. 12.41). When the arthroscope entry has been made
A skin incision is made in the distal region of this proximal dorsal to the mesotenon,the sustentaculum and dorsal surface
outpouching. approximately level with the medial malleolus of the DDFTare readily examined. Advancing the arthroscope
of the tibia. The arthroscope sleeveis inserted in a proximal further distally allows examination of the remainder of the
direction to commence the examination in the proximal sustentaculum and the DDFT as it courses toward the distal
region of the tarsal sheath (Fig. 12.39).