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Mo.'"'t.<o.

l of
EQJ)INE
FIE LD
SURGERY
Mc\~LAC\1 of

ECWINE
FI E LD
SURGERY
David A. Wilson, DVM
Associate Professor, Equine Surgery
Department of Veterinary,Medicine and Surgery
University of Missouri
Columbia, Missouri

Joanne Kramer, DVM


Clinical Assistant Professor, Equine Surgery
Department of Veterinary Medicine and Surgery
University of Missouri
Columbia, Missouri

Gheorghe M. Constantinescu, DVM, PhD., Dr.h.c.


Professpr, Anatomy
DepartrnentofBiomedical Sciences
Ul'liversity of Missouri
Columbia, Missouri
CHAPTER 1
Introduction
David A. Wilson

"Chance favors the prepared mind." and disease. Swelling and trauma can sign ificantly
Louis Pasteur alter the anatomy such that previously well-
understood structures may be difficult to identify
This book is written for practitioners and veteri - and in unexpected locations.
nary students attracted to and interested in equine Once the anatomy is understood, the specific
surgery. Procedures are described and illustrated surgical procedure should be thoroughly reviewed.
that can be performed in the field or basic prac- The surgeon should get in the habit of reviewing
tice settings, require a minimum of additional every procedure prior to performing the surgery to
equipment or assistance, ge nerally take less than I refresh the surgeon's memory of the specifics of th e
hour of anesthesia, and do not involve entering a surgery. Equine practitioners are exposed to a wide
body cavity or joint. Although the procedures range of disorders but do not often see many of
described in this book can be donf in the field by anyone particular disorder. Therefore, it may be
any qualified veterinarian, it is not the intention months or years between specific surgeries, and a
of this book to be the sole source of preparation procedure that was once very familiar may seem
or reference for the new or relatively inexperi- completely foreign after the first skin incision. Sur-
enced equine practitioner. gical procedures should be practiced on cadaver
Performing surgery in the field has the poten- specimens prior to performing them for the first
tial to be very rewarding but also the potential time on a client's animal. Practice surgeries on
to be very unrewarding. If the procedure goes cadaver specimens to review the pertinent normal
acco rding to plan, the experience ca n be great. anatomy, confi rm the landmarks for th e approach,
However, as with many things involving horses, and identify potentially difficult portions of the
there is a seemingly almost unlimited opportunity procedure and to develop familiarity with the
for fail ure. Preparation is the key to minimizing particular instrument needs for the proposed
these opportunities for failure. A thorou gh under- surgery.
standin g of the presenting problem, indicated Practitioners or new graduates wanting to
surgical procedure, relevant anatomy, available become more familiar with these procedures
facilities, equipment, and assistance, client expec- should consider working with or visiting a n expe-
tations, and individual patient characteristics are rienced practitioner. In addition, many continu-
important; these factors must be evaluated when ing education opportunities are available that
considering surgery in the field. provide in-depth reviews of these and similar pro-
With any surgical procedure, it is the responsi- cedures. In particular, the annual meetings of the
bility of the surgeon to be thoroughly familiar American College of Veterinary Surgeons and the
with the pertinent anatomy as well as the poten- American Association of Equine Practitioners are
tial deviations from normal expected in health good sources of current surgical information.

2
Introduction 3

CLIENT COMMUNICATION DECISION FOR SURGERY

Client communication is probably the most The decision to perform surgery on a specific case
important factor in preventing misunderstand- can be difficult. Is the su rgery necessa ry? What are
ings and addressing problems when things do the best- and worst-case scenarios for a present-
not go well. The owner (or trainer) should be ing problem or specific procedure? The decision
inform ed of the options for therapy, costs, prog- is complicated by adding the field scenario into
nosis, potential complications and consequences, the equation. The temperament of th e horse, the
anticipated outcome, and recommendations prior potential surgical environment (i.e., facilities,
to surgery. Ideally, this conversation should be terrain, weather, etc.), the availability of needed
with the person who will actually pay the bill and equipment, the availabil ity of trained assistants,
with the person responsible for the horse's ca re. the expectations of the client, the skill of the
However, in many insta nces in equine practke, surgeon, and the ability to handl e unforeseen
the person paying the bill may not be available. developments aU en ter into the decision. Certainly
Keeping good written notes of conversations many clients have excellent facilities; however,
and estimates and providing written discharge there are other clients with facilities where field
instructions concerning afterca re is essential. Ali surgery may be a greater adventure than anyone
commu nications should be as realistic and honest needs. After considering the factors for a given cir-
as possible. Clients must be warned of the poten- cumstance, the surgeon must decide whether to
tial co mplications and expected outcome. General perform a particular procedure.
complications such as the development of rhab -
domyolysis or colitis seen in horses stressed by
transportation, anesthesia, and surgery should be PATIENT EVALUATION
commu nicated to the owner when appropriate.
The specific complications associated with the A thoro ugh history should be gathered on all
procedure to be performed should also be dis- horses prese nted for elective surgery. Previous
cussed. However, overstating the difficulty of the treatments, responses to treatment, potential ad-
recomm ended surgery or the gravity of the poten- verse reactions to previously administered med-
tial consequences to minimize client expectations ications, and the genetic background (e.g., the
is inappropriate. potential for developing hyperkalemic periodic
paralysis) sho uld all be reviewed.
A thoro ugh physical examinatio n sho uld be
INSURANCE performed, conce ntrating on the rest of the
animal prior to focusing on the potential reason
When contemplating surgery on an insured horse, for surgery. Blood should be submitted for evalu-
the veterinarian should be aware that it is the ation including a complete blood cell count or at
client's responsibility to inform the insurance least a packed cell volume and total protein deter-
company of a pending su rgical procedure, partic- mination prior to the time of the su rgery. Serum
ularly for an elective procedure. which is the case chemistry evaluations are desirable but are not
for most procedures covered in this book. The always necessa ry for elective procedures. If the
veterinarian may choose to co ntact the insurance horse's physical condition or laboratory values
co mpany, but it is the client's responsibility. The are abnormal, elective procedures should be
insurance company will then make a decision postponed .
about whether to cover the an imal for the proce~
dure. These deliberations are between the owner
and the company, but the veterinarian may be PATIENT PREPARATION PRIOR TO SURGERY
drawn into the process when decisions regarding
treatment options, prognosis, and euthanasia are For most elective procedures, feed sho uld be with-
considered. Because of potential conflicts of inter- held about 6 hOllrs prior to surgery. Water should
est, guidelines for those si tuations are available be allowed ad libitum. Withholding feed for up
from the American Association of Equine Prac ti - to 72 hours can be tolerated for elective proce-
tioners Equine Insurance Com mittee. l dures. However, it sho uld be recognized and
4 PRESURGICAL PREPARATION AND ASSESSMENT

communicated to the owner that withh o lding order to be prepared for the unanticipated need
feed will alter gastrointestinal flora and predispose to expand the surgical site.
the horse to colitis. Immediately prior to the operation, the pro-
Tetanus vaccination status of the patient posed surgical site sho uld undergo a surgical
should be assessed and, if necessary, a tetanus scrub consisting of at least 5 minutes' exposure
booster should be administered. If the patient has to either povidone-iodine 7.5% surgical scrub
never received tetanus toxoid and the su rgery is (Betadine surgical scrub ) or chlorhexidine glu-
an elective procedure, the procedure should be conate 4% antimicrobial skin cleanser (Hibiclens;
delayed until appropriate tetanus prophylaxis is Zeneca Pharmaceuticals Inc., Wilmington, Del.).
established. Patients that have not received tetanus The final surgica l preparation consists of alter-
toxoid within the past 6 months, but are on a con- nating 70% alcohol or isotonic saline rinse with
tinu ing immuni zation program, should receive a the surgical scrub using aseptic technique. Rinsing
tetanus booster. with saline or 70% isopropyl alcohol does not make
Prophylactic and therapeutic antibiotics a difference in the antimicrobial effect of povidone-
should be judiciously administered. When indi- iodine; however, alcohol reduces the residual effect
cated, antibiotics should be administered imme- and antiseptic quality of chlorhexidine.'
diately prior to surgery at the correct dosage and
for the correct amount of time but should be dis-
REFERENCES
continued as soon as possible after surgery.
When possible, the surgical site should be
I. American Associatio n of Equine Practitioners: The
clipped (size 40 clipper blades) and prepped veterillary role ill equille insurallce, Lexington, Ky,
before (within 2 hours) induction. Over smooth 2000, AAEP.
areas, the hair may be shaved with a disposable 2. Stashak TS: Selected factors that affect wound
razor. A wide area surrounding the anticipated healing. In Stashak TS, editor: Equine wound mall-
surgery site should be clipped and scrubbed in agement, Philadelphia, 1991, Lea & Febiger.
CHAPTER 2

Surgical Instruments
David A. Wilson

Th is chapter serves as a reference for the various scalpel handle is usually held in a "pencil-gri p"
surgical instruments referred to throughout the fashion to allow for finer motor co ntrol. The No.
book. The equin e surgeon should become famil- 4 handle and its associated blades are used for
iar with the instruments, how they handle, what larger areas where precision is not a major
procedures they should and should not be used concern.
for, and when they should be used. Usi ng the right
instrument at the right time is essential to good
Scissors
surgical technique. Selecting the appropriate
instru ment ensures minimal trauma to tissues Many types of scissors are available depending on
and that the procedure will be performed in the the job to be performed. These include scissors
least amount o f time with the least harm to the designed to cut various types of tissue and scis-
patient. Handling the instruments in practice sors designed to cut suture, wire, or bandage
cadaver or laboratory settings is essential to material. Opera ting scissors are classified accord-
become proficient enough to handle them effec- ing to the shape of the tips, for example, sharp-
tively in surgical situations. sharp, sharp-blu nt, and blun t-blunt (Figure 2-3).
When using the appropriate scissors, the tip of the
scissors is used to cut tissue, the tip or body is used
INSTRUMENTS to cut sutures) and the heel is used to cut wire.
Metzenbaum scissors are relatively delicate and
Scalpel blades used for the No.3 scalpel handle are are made for precise dissection, whereas Mayo
sizes 10, II , 12, and 15 (Figure 2-1). Scalpel blade scissors are made for tissues wi th more substance.
sizes 20, 21, and 22 are made for the No.4 scalpel Mayo and Metzenbaum scissors are available with
handle (Figure 2-2). The No. 10 blade on a No.3 straight or curved blades. The straight blades are
Bard-Parker handle is used for most equine su r- designed for working close to the surface of the
gical procedures. However, the No. 11 and No. 15 wound, and the curved scissors are used for
blades are useful when very precise or small inci- working deeper in the wo und (Figu re 2-4). For
sions are required. The sharp tip on both the No. blunt dissection, the closed tips of the scissors are
II and No. 12 blades is useful for lancing inserted into the tissue and then opened to spread
abscesses. Typically, the scalpel handle is held the tissue. Tissue scissors should not be used to
between the thumb and the third and fourth cut suture or wire.
fingers, with the index finger placed over the back Bandage scissors are designed with angled
of the handle to apply pressure on the blade. blades, and the lower blade has a small " button"
When using the No. II and No. 15 blades, the tip to protect the underlying structures and

5
6 PRESURGICAL PREPARATION AND A SSESSMENT

to allow easy entry under bandage material Needle Holders


(Figu re 2-5) . If bandage scissors are used against
The two primary types of needle holders used in
contaminated wounds, the scissors should be
large animal practice are the Mayo-Hegar and
sterilized after use to prevent transfer of infec-
Olsen-Hegar needle holders (Figu re 2-6). The
tion.
Olsen-Hegar needle ho lders have a suture-cutting
scissors built into the jaws, enabling the surgeon to
cut suture witho ut reaching for the suture-cuttin g
scissors. A variety of other options for needle
holders are available depending on the preference
of the surgeon and the size of needle being held.

Thumb Forceps
Thumb fo rceps are used for graspi ng and holding
tissues (Figure 2-7). Typically, the forceps are
10 11 12 128 15 15C held in a "pencil" grip. Many types are available,
and the selecti on is based on the type of tissue
Figure 2~ 1 Scalpel blades that fit the No.3 Bard- involved. Toothed fo rceps are commo nl y llsed for
Parker handle. (Reprinted with permission from Miltex stabilization of tissue such as skin, fascia , or
Instrument Company, Bethpage, N.Y., 2004. ) muscle wh ile suturing. Theoretically, the presence
of teeth on these forceps makes the grip required
to hold the tissue less forceful than if there were
no teeth, resulting in less tissue trauma. Fo rceps
are often classified based on the number of inter-
locking teeth on each head. For example 1 x 2
indicates there are two teeth on one side of the
fo rceps and one on the other. The higher-number
teeth are generally used for more robust tissues.
, Nontoothed forceps generally have ridges or
grooves on the surface of the tip and are used fo r
,, grasping visceral and serosal or adventitial tissues
as the lack of teeth decreases the likelihood of
puncture.

I )
Hemostatic Forceps
20 Hemostatic forceps are primarily used to clamp
A B
23
" th e ends of vessels to establish hemostasis. Halstead
Figure 2·2 A, Bard-Parker No.4 handle. B, Va rious mosquito force ps are used for clamping smaiJ
shapes of scalpel blades that fit the No.4 scalpel handle. vessels (Figure 2-8, A). Kelly forceps are used fo r
(Reprinted with permiss ion from Miltex Instrument clampi ng larger vessels and as a grasping forceps
Company. Bethpage. N.Y.• 2004. ) to hold tissue or stay sutures for m anip ulation

Figure 2-3 Operating scissors. ( From


Sonsthagen TF: Veterinary illstrllll1ellts alld
equipmel1t: a pocket guide, St Louis, 2006,
Elsevier Inc.)

Sharp/sharp Sharplblunt BlunVbluntSharp/sharp Sharplblunt Blunt/blunt


straight straight straight curved curved curved
Surgicailnstruments 7

A B c A B
Figure 2-4 A. Straight Mayo scissors. S, Curved Figure 2-6 A, Mayo- Hegar needle holders. B, Olsen-
Mayo scisso rs. C, Curved Metze nbaum scissors. Hegar needle holders. (Reprinted wi th permiss ion from
(Reprinted with perm ission from Miltex Instrument Miltex Instrument Company, Bethpage. N.Y., 2004. )
Company. Bethpage. N.Y.• 2004.)

~ "
VI W ••
••
!
Yo
,.
r;; •
2

,
<i!>

A B c
Figure 2-5 Liste r bandage scissors. (From Figure 2-7 Forceps. A. Brown-Adso n force ps. B.
Sonsthagen TF: Veter;'lary imtrulllents and equipment: Tissue forceps. C, Adson fo rceps. (Reprinted with per-
a pocket gil ide, St Louis, 2006, Elsevier Inc. ) mission fro m Miltex Instrument Company, Bethpage,
N.Y.• 2004. )

Figure 2-8 A, Halstead mos- Yo


quito forceps. B, Kelly forceps.
C. Crile fo rceps. (Reprinted with Yo
permissio n from Miltex Instru -
ment Co mpany. Bethpage, N.Y.,
2004.)

A B c
8 PRESU RGICAL PREPARATION AND ASSESSMENT

(F igure 2-8, B). When curved forceps are used, potential for trauma, they should not be used on
they should be applied such that the tip of th e skin or viscera intended to remain with the
forceps is pointing upward. patient. Sponge forceps are used to hold gauze or
other sponges to blot tissues dry from blood or
other fluid during dissection (Figure 2-10).
Grasping Forceps
A variety of forceps with a ratchet device built into
Retractors
the handle are used to grasp. retract, o r stabilize
larger portions of tissue. Allis tissue forceps are Retractors are essential for the display of deep
probably one of the more common grasp illg tissues during an operation. They may be hand-
forceps (F igure 2-9). They have opposing edges held or self-retracting. The retractors work by
with short teeth and relatively long "arms" and are placing a blade in fro nt of tissues that would oth -
used to grasp fasc ia, subcutaneous tissu e, skin. erwise reduce the visibility of the operative field
tendon, etc. Because of their short teeth and (Figures 2-11 to 2-13). Great care must be taken

Figure 2·10 Forester sponge-holding forceps. (From


Figure 2-9 Al lis forceps. (Reprinted with permiss ion
So nsthagen TF: Veterinary iflStrtlmellts alld equipmelll:
from Miltex Instrument Company, Bethpage. N.Y.,
a pocket guide, St Louis. 2006, Elsevier Inc.)
2004. )

i~

Figure 2-11 Finge r-held retracto rs.


A, Senn retractor. B, Mathieu retractor.
C, Meyerding finger retractor with
I various blades for gripping (shown ver-
!
ti cally). D, Fa rabeuf retractor. E, Parker
retracto r. (Reprinted with permiss ion
from Miltex Instrument Company,
Bethpage, N.Y., 2004. )

.....
A B c D E
Surgical Instruments 9

,
••


••

I~ .-

10 o
b B
o c D
Figure 2-12 Hand-held retractors. A, Army-Navy retractor. B, Hohmann retractor wi th two different blades.
C, Meyerding retractor. D, Ribbon maUeable retractor. (Reprinted with permission from Miltex Instrument Company,
Bethpage, N.Y.. 2004.)

to ensure that damage is not caused to the struc- with delicate or heat-sensitive components cannot
tures being retracted. endure such an environment.
Gas sterilization usin g ethylene oxide is used
fo r instruments that may be damaged by the heat
General Pack for Field Surgery of autoclaving. However, ethylene oxide produces
Box 2- J lists the co ntents of a typical general pack noxious fumes that require special venting and
for field surgery. Throughout the remainder of
the book, only the instruments needed in addi-
tion to these are listed in the description of the
procedure.

INSTRUMENT PREPARATION

Most of the procedures described in this book


are classified as "clean" elective surgical proce- A
dures. Therefore, the instruments used should
be wrapped and sterilized. Before sterilizatio n,
instruments are thoroughly cleaned, paying
particular attention to box locks, hinges, and
serrations, and disassembling instruments with
multiple components. Common sterili zatio n
techniques include autoclav ing, gas sterilization,
plasma sterili zation, and cold sterilization. Auto-
c1aving, a technique using moist heat from stea m,
is the sterilization method of choice for preparing
instruments for aseptic surgery. An indicator is
placed in the pack with the instruments and
should be checked by the surgeon to confirm the
sterility of the instruments. The high heat and B
humidity effectively sterilize most instruments, Figure 2-13 Self-retaini ng retractors. A, Weitlaner
but some surgi cal instrum ents and equipment retractors. B, Gelpi retractors.
10 P RESURGICAL PREPARAT ION AND ASSESSM EN T

BOX 2-1 suited for sterilizing heat- and moisture-sensitive


instruments and instruments with sharp edges.
Contents of a Typical General Pack
Major advantages of this technique include a ster-
for Field Surgery
ilization time as short as 55 minut~s and the pro-
4 Towel clamps duction of no toxic residuals requiring aeration to
2 Needle holders (Mayo-Hegar or Olsen-Hegar) com ply with Occupational Safety and Health
I Brown-Adson thumb forceps Administration (OSHA) safety regulations.
I Rat tooth forceps (2 x 3 or I x 2) Cold (chemi cal) sterilization, using a product
2 Straight mosquito forceps (straight or curved)
such as gluta rald ehyde, provides a hi gh level of
2 Kelly forceps (straight or curved)
disinfection but does not achieve sterili za tion.
1 Suture scissors
I Curved Metzenbaum scissors Minimum immersion time for disinfection with
I Curved Mayo scissors glutaraldehyde is approximately 45 minutes. Cold
I Straight Mayo scissors sterilization is commonly used by the large animal
2 Carma It or Oschsner forceps surgeo n for a second or third surge ry of th e day
I NO.3 scalpel handle when other methods of sterili za tion are not avail-
30 Gauze sponges able. Solutions used for cold steriliza tion can be
I Hand towel very irritating to tissues. Therefore, care should be
taken to thoroughly rinse or immerse the instru -
Other Useful Equipment ments in sterile saline before use to avoid
Battery-operated headlight or other light source
potential tissue damage. Specific steriliza tion
Knee pads
protocols can be developed fo r you r practice by
Glue to help hold drapes in place
Ropes to assist in limb positioning consulting furth er references and manufacturers'
Small fold-up camping table on which to place recommendations.1.2
instruments
Towels
REFERENCES

l. Freema n DE: Ster ili zation and antiseptics. In Auer


extensive aeration fo r at least 14 hours before the JA, Stick l A, ed itors: Equine surgery, ed 2, Ph iladel-
piece of equipment can be used again. phia, 1999, WB Saun ders.
Hydrogen peroxide gas plas ma is the latest tech- 2. Sou thwood LL, Baxter GM: Instrument steril ization,
nique for low-temperatu re «50°C), low-mo istu re skin prepa ration , and wo und ma nageme nt, Vet Ciill
sterilization of sensitive surgical products. 1t is N Am Equine Pract 12: 173, 1996.
CHAPTER 3
Wound Closure
David A. Wilson

The princi ples of wound closure are similar


WOUND PREPARATION
whether closing a surgical in cision or a laceration.
Primary closure relies on a clean field, with clean
The objective in wound preparation is to reduce
and viable wound margins and skin edges for
the contamination of a wound and to obtain a
closure. When presented with a naturally occur-
"clean" field. Infection is the most importa nt
ring wound, there are many factors to consid~r,
factor in delaying wound healing. Infections are
but the primary objectives are to preserve the life
classified as primary, in which the contamination
of the patient, to determine the extent of the
occurs at the time of injury, or seco ndary, in
wound, and to prevent or minimize infection.
which the contamination occurs through the
A minor wound should not divert attention
suture line or through other portals (i.e., drai.ns,
from more serious problems, such as hemorrhagic
fistulas).
shock, exhaustion, or cerebral contusion associ-
Before wound preparation, the wou nd should
ated with head injuries. Thus, a quick assess ment
be protected by placing sterile, water-sol uble
of the wo und should be followed by a thorough
lubricating jelly or sterile moist gauze sponges
physical examination and acquisi tion of pertinent
into the wound. A wide area of hair around the
vital signs. After initial stabilization and control of
wound shou ld be clipped. To prevent hair from
bleeding, attention sho uld be directed at deter-
falling into the wound, the hair may be dampened
mining the extent of the wou nd and returning the
with water or lightl y coated with a sterile, water-
patient to a normal functional and cosmetic status
soluble lubricating jelly. Spo nges used to pack the
with the shortest delay possible.
wound should be discarded and replaced by new
Wounds should be thoroughly evaluated to
ones after each stage of preparation. The wound
determine their extent. Wounds over synovial
bed itself should be gently cleansed with antisep-
st ructures such as joints or tendon sheaths are
tic soap and steril e gauze sponges, followed by
common in horses, and the involvement of these
copious lavage to neutralize the detergent base
structures is often unrecognized. Tendons and lig-
of the antiseptic. The clipped area should be
aments, vessels and nerves, and the eyes, sinuses,
scrubbed at least three times with antiseptic soap
thorax, and abdomen are other structures com-
and rinsed between scrubs with sterile 0.9% saline
monly involved in equine wounds. Thinking in
solu tion.
three dimensions and understanding the three-
dimensional anatomy of the involved structures
will help the practitioner to recognize the poten-
Antiseptics for Skin Preparation
t ial extent of the injuries and to better prepare the
owner for th e potential problems associated with The two most commonly used surgical scrubs
the wound. for skin preparation are povidone-iodine and

11
12 PRESURGICAL PREPARATION AND ASSESSMENT

chlorhexidine. Although uncommon, one disad- normal saline or lactated Ringer's solution, meet
vantage of povidone-iodine is a skin reaction, these criteria and are the most commonly used
which seems to be more frequent after clipping, solutions. Tap water is often used initially to
scrubbing, rinsing with 70% alcohol, spraying reduce gross contamination in heavily contami-
with povidone-iodine solution, and bandaging. nated wounds. In these cases, subsequent lavage
Detergent forms of chlorhexidine should not be with sterile isotonic fluid may help restore tissue
used around the eye) because exposure may lead normotonicity and reduce edema.
to corneal edema and bulbous keratopathy.l-J Wound lavage should also be considered for
The mechanical effect of scrubbing the wound closed wounds. The advantages of flushing a
with these antiseptic soaps is helpful in removing closed wound include the dilution and mobiliza-
debris and reducing bacterial concentration at the tion of exudates and the delivery of medication.
wound surface. A marked delay in wound healing The disadvantages are that bacteria can be readily
occu rs if the soap is not thoroughly rinsed from introduced into the wound and dead space may
the wound. Additionally, even though these anti- be created or expanded.
septics are effective, much of the bacterial popu-
lation in the skin resides in protected hair follicles)
sebaceous glands) and crevices in the lipid coat of WOUND DEBRIDEMENT
the superfi cial epithelium.
The goal of debridement is to obtain fresh, clean
wound margins and skin edges for primary closure
WOUND LAVAGE and to remove contaminated tiss ues and foreign
material so that wound healing can progress effi-
Bacteria adhere to the wound surface by an elec- ciently during second-intention healing.
trostatic charge. Lavage cleans the wound of Debridement involves the removal of dead or
debris and reduces the bacterial numbers, inflam- damaged tissue, foreign bodies, and bacteria that
matory mediators, and substances that potentiate compromise local defense mechanisms. Liberal
infection . In addition, lavage stimulates periph- removal of contaminated fascia, fat, and muscle
eral microcirculation through its gentle massag- and careful retenti on of bone, tendons, nerves,
ing action, which may favor the formation of and major vessels are important. Fascia, fat, and
granulation tissue. Lavage is easy to perform, muscle all have excellent blood supply and
requires no special equipment, is cost effective, provide excellent media for the growth of conta-
and is well tolerated by most patients. minating organisms. Although skeletal muscle is
Lavage solutions are most effective when deliv- not replaced, there are usually sufficient remain-
ered by a fluid jet of at least S psi: Pressures of ing muscle fibers or alternative muscle groups
10 to IS psi are approximately SO% effective in available to make up for the loss. Small pieces of
removing substances that potentiate infection and bone that have lost their blood supply should be
adherent bacteria from a wound. s Although this removed.
pressure cannot be achieved by gravity flow or
lavage with a bulb syringe, adequate pulsatile
Surgical Debridement
pressure can be attained by forcefully expressing
lavage solutions from a 35- or 60-mL syringe Surgical debridement may be accompl ished in a
through an IS-gauge needle or by using a spray variety of ways (en bloc, layered, or staged). En
bottle or a WaterPik. The WaterPik delivers 40 to bloc resection is probably the most effective
50mL/min at 10 to 15 psi at the low-intermediate method of surgical debridement but may result in
setting and is effective for heavily contaminated the loss of some viable tissue. With this technique,
wounds. Care must be taken not to drive conta- the entire wound is excised at its niargi ns such
minants deeper into the wound or inadvertently that all wounded and conta minated tissue is
separate loose fascial planes. removed. This method is primarily reserved for
The ideal lavage solution should be sterile, iso- draining tracts and areas where significant tissue
tonic, normothermic, nontoxic, and compatible loss can occur without consequence. With layered
with antibi otic or disinfectant medications that debridement, tissue removal is started at the most
may be added. Isotonic crystalloids, such as superficial tissue layer and is continued into th e

-
Wound Closure 13

depths of the wound. This systematic approach controUed by the inflammatory and debridement
helps to prevent contamination of deeper tissues phases of healing but prior to granulation tissue
with debris from more superficial layers as formation. Delayed primary closure is best used
debridement progresses and preserves viable for contaminated, contused, or swollen wounds
tissue. Staged debridem ent is a method of layered and for those involving a synovial struct ure. It is
debridement that minimizes tissue loss. In most particularly useful in distal limb wounds, where
equine distal limb wounds, where tissue is at a contamination is a frequent problem.
premium, staged debridement is used over a Delayed secondary closure is performed more
number of days to avoid inadvertent removal of than 5 days after injury, once granulation tissue
viable tissue. When performing staged debride- has begun to form . As with delayed primary
ment, the two governing criteria are color and closure, delayed seco ndary closure is used after
attachment. White, tan, black, and green tissues, several days of therape utic care for contaminated
as well as those that are poorly attached, should wounds with co mpromised blood supply. At
be debrided. Tissues that are pink to dark pur- the time of closure, the granulation tissue is
ple and well attached should be left in place. removed to allow apposition of skin edges. This
Non-surgical methods of wound debridement may result in sign ificant dead space o r oozing of
include chemical or enzymatic debridement, laser blood and serum. Drains may be necessa ry to
debridement, bandaging techniques, or biosur- minimize the accumulation of serum within the
gical therapy. These techniques are discussed wound.
elsewhere. 6 Second-intention healing consists of fibrop la-
sia followed by wound co ntraction and epithel ial-
ization. Indications for second-intention healing
WOUND CLOSURE include severe contam ination or infection, con-
siderable skin loss, excessive skin tension that pre-
Priorities during wound closure are to limit in- cludes primary closure, and unavoidable motion
fection or contamination, minimize skin loss, and like that occurring in the pectoral and gluteal
exert th e least amount of tension possible on th e regions. Second-intention healing is best used for
suture line. Ideally, wounds are managed by wounds not over a joint surface, those with an
primary closure. Wounds most amenable to adequate vascu lar supply to the underlying soft
primary closure include those of the head and tissues, and those with sufficient mobile skin to
upper body, flap wounds with a good blood supply, allow wo und contraction.
and recent minimally co ntaminated wounds of the
extremities. Wounds with considerable skin loss, or
severe contamination or infection, sho uld not be SUTURE MATERIAL
closed initially. These may be closed later using
delayed primary or seco ndary closure techniques Suture material selection should be based on the
or allowed to heal by second intention. biologic and physical properties of the suture, the
Primary closure, leading to first-intention wound environment, and the tissue respo nse to
healing, is performed after surgery or soon after the suture (Table 3-1). The characteristics of the
injury. Ideally, primary closure is performed ideal suture include good handling quality; good
during the golden period. The golden period knot security; adequate tensile strength; lack of
relates to the time required for multiplying bacte- allergenic, electrolytic, capillary, or carcinogenic
ria to reach an infective level, considered to be 106 properties; minimal tissue reaction; no adverse
organisms per gram of tissue. Theoretically, this effects on a wound in the presence of infection;
time period is 6 hours. In actuality, this may be easily sterili zed; economical; and absorption soon
longer in clean wounds and considerably sho rter after the suture has served its purpose.
in severely contaminated wou nds. Primary clo- The suture material with the best handling
sure is best used for fresh, minimally contam- characteristics is silk, which, with respect to
inated wounds with a good blood supply without handling, sets the standard by which all other
involvement of vital structures. suture materials a re compared. Generally, the
Delayed primary closure is performed 3 to 5 days braided, multifilament synthetic sutures have
<lfter iniurv when h r of 'nfi ia 1 r
• •
) n m -
-...
"0

"Cm
~

TABLE 3-1
-""
()
>
r
"0
Characteristics of Commonly Used Suture Materials
"~
m

PERCENT
LOSS OF "-~
No. OF o
TENSILE z
THROWS >
STRENGTH z
COMPLETE FOREIGN FOR GOOD SIZE- o
TRADE 14 21 ABSORPTION MODE OF BODY KNOT STRENGTH >
~
~
rn
GENERIC NAME NAME FILAMENT SOURCE DAYS DAYS ( DAYS) DEGRADATION RESPONSE SECURITY* RATIO ~


~

m
Z
-;
Absorbable
Polyglactin 910 Vicrylt Multi Glycolic-lactic acid 35-50 60-80 60-70 Hydrolysis Slight 3 Good to
polymer excellent
Polyglycolic acid Dexon f Multi Glycolic acid 35-60 65-90 120 Hydrolysis Slight 3 Good to
excellent
Polydioxanone PDS lit Mono Polydioxanone 15-25 30-40 180 Hydrolysis Slight 4 Excellent
polymer
Polyglyconate Maxon t Mono Glycolic acid- 30 45 180 Hydrolysis Slight 4 Excellent
polytrimethylene
carbonate
Poliglecaprone 25 Monocrylt Mono Copolymers of 70 100 110 Hydrolysis Slight 5 Excellent
epsilon-
caprolactone
and glycolide
Chromic catgut Multi Submucosa of Variable 90+ Enzymatic Inflammatory 3 Poor
ovine intestine
or serosa of
bovine intestine

Nonabsorbable
Silk Multi Raw silk spun by >80% in Variable Proteolysis Moderate 3 Poor
silk worm 8 days
Polymerized Supramid or Multi Polyamide strands NA NA NA Moderate 5 Good
caprolactum Braunamid enclosed in a
polyamide
sheath
Stainless steel Mono Chromium nickel NA NA NA Inert 2 Excellent
molybdenum
Polyester Mersilene' Multi Synthetic resin NA NA NA Moderate 5 Excellent
polymers
(extruded)
Nylon Ethilon' Mono Polyamide 30% in NA Chemical Minimal 4 Good
filament 2 years degradation
(extruded)
Polypropylene Prolene' Mono Polymerized NA NA NA Minimal 3 Fair to good
polyolefin
hydrocarbons
(extruded)

,. An additio nal throw is recommended for con tinuous patterns.


tEthicon, Inc, Somerville. N.J.
:j:Davis & Geck, Inc, American Cyanamid Co, Manati, Puerto Rico.
NA, not applicable.

~
~
~
0.
n
:.
~
;;;

-'"
16 PRESURGICAL PREPARATION AND A SSESSMENT

ment sutures. Stainless steel has the worst han- with an increased incidence of suture sin us tract
dling properties. formation. 1
The number of throws necessary to secure a
squa re knot vari es with the size and type of suture
material. In general, multifilament sutures have SUTURE PLACEMENT AND PATTERNS
better knot security than do monofilament
sutu res. Stainless steel has the best knot secu ri ty. The placement of sutures affects wound healing.
Also, the smaller the suture, the more secure is Sutures should be placed such that they just
the knot. For example, No. 2-0 polyglycolic acid appose the wound edges. Loosely approximated
suture material has better knot secu rity than does wounds are st ronger at 7, 10, and 21 days after
No. 2 polyglycolic acid suture material. surgery than are wounds tightly secured with
The suture material should be as strong as the sutu res,S possibly because overtightening disrupts
tissue in which it is placed. Skin and fascia are rel- the microvascuJar circulation to the wound edges.
atively strong, whereas fat and muscle are rela- Wound edges weaken over time because of colla-
tively weak. In traumatic wounds, the tissue gen lysis; therefore, sutures should be placed at
immediately surrounding the wound may be least 0.5 em from the margins. Additionally, al-
compromised. Therefore, the wound margins though more sutures improve initial strength,
should be debrided, if possible, to clean healthy the increased number of su tures compromises
tissue and the sutures should be placed back from blood supply to the wound edges and stimulates
the wound margins to ensure that the sutures are an excessive tissue reaction and subseq uentl y
placed in the healthiest tissue. The strength of a increases infection rate. Deep sutures should be
sutu red wound is usually dependent on both the placed only in fascial planes, tendons, and liga-
tissue's ability to hold suture and the tensile ments, because additional deep sutures are gener-
strength of the suture material. With healthy ally ineffective and ca use excessive tissue reaction.
tissue, the initial strength of the sutured wound is The suture pattern also can affect wound
dependent on the strength of the sut ure; however, healing. Although the simple continuous pattern
by 3 to 4 days, the repaired tissue starts to increase is the easiest to apply and provides the most
in strength. uniform support, its design leads to redu ced
All suture materials potentiate infection by microcirculation to the wound margins and a
acting as foreign bodies when placed in contami- single break resuJts in failure of the entire line.
nated wounds. Monofilament su tures are the least Comparatively, a simple interrupted pattern leads
reactive and can withstand wound contamination to less edema, does not exert a negative impact on
better than can multifilament sut ures of the same the microcirculation, and encourages greater
material. Multifilament sutures exhibit capillarity, wound ten sile strength after 5 and 10 days,'
a wicklike action that allows bacteria to move although these positive effects are attenuated at
along the suture strand. Nat ural materials (e.g., later times. 9' 13 The disadvantages of interrupted
catgut, silk, cotton, linen, collagen) are generally patterns compared with conti nuous patterns
considered the most reactive, are weaker, and have include the use of more suture material and
a variable rate of absorption. increased placement time. Interrupted suture pat-
Synthetic absorbable sutures, such as polygly- terns should be used when impaired healing is
colic acid, polyglactin 910, polydioxanone, poly- anticipated and excessive tension is present.
glyconate, and polyglecaprone, have the distinct Simple interrupted suture patterns cause less
advantage of being absorbed at a constant rate by inflammation than vertical mattress and far-near-
hydrolysis. Additionally, m onofilam ent sutures near-far patterns beca use of relatively less suture
are less reactive than twisted or braided materials. material in the incision line and fewer skin
Synthetic nonabsorbable sutures, such as nylon, penetrations.
polypropylene, and polyfilament polyamide, are Suture patterns may be divided based on
generally less reactive than absorbable sutures. whether they are appositional or serve as tension
Polyfilament polyamide has cha racteristics that suture patterns. Simple interrupted, simple con-
make it the least desirable synthetic no nab- tinuous, Ford interlocking, cruciate, and subcuta-
sorbable suture, such as losing 15% to 20% of neous or subcuticular patterns are classified as
its strength when wet and being associated appositional suture patterns (Figures 3-1 to 3-5).
Wound Closure 17

~t;.t~ ~t;..;t _ _

Figure 3-1 Simple interrupted pattern. Figure 3-2 Simple continuous pattern.

Figure 3-3 A and B, Ford interlock-


ing pattern.

The ver tical and horizontal mattress patterns and


the near-far-far-near or far-near-near-far or other
combination suture patterns are classified as
tension su ture patterns (Figures 3-6 to 3-10).
They are often used in conjunction with apposi-
tional suture patterns to combine the benefits of
both (see Figure 3-9) .

Simple Interrupted and Continuous Patterns


The simple interrupted suture pattern provides
secure, anatomic closure with precise suture
tension (see Figure 3-1).lt is easy to apply and the
skin retains the ability to expand between the
~(k,t;..t·<Mo . sutures. The simple continuous suture pattern is
Figure 3-4 Interrupted cruciate pattern. used in tissues that are elastic and are not subject
18 PRESURGICAL PREPARATION AND ASSESSMENT

I
I

Figure 3-7 Continuous hor izontal mattress suture


pattern. Used as a tension suture, slight everting
pattern.

-
~er.v..41,-- - -
Figure 3-5 Subcu taneous pattern illustrating the - -
direction of suture placement in both the beginning
and end of the pattern.

,,
B
A B Figure 3-8 A and B, Interrupted verti cal mattress
~t;;,1>M.­ pattern.
Figure 3-6 A, Interrupted horizontal mattress
pattern. B. Horizontal mattress suture pattern wi th bol-
sters used as a tension suture pattern. tubin g or buttons to act as a tension suture.
Because of the placement of this pattern, the
sut ures have a tendency to reduce the blood
to significa nt tension (see Figure 3-2). It provides supply to the wound edges. The continuous hor-
good apposition and an airtight or watertight seal. izontal mattress pattern provides necessary
Bites in the wound edges are made at right angles tension fo r wound edge approximatio n without
to the edges of the wound. Excess tension causes applying tension to the wound edge itself (see
puckering and strangulation of the skin. Figure 3-7) . It is often used as a tension-relieving
suture for the wound edge.
Horizontal Mattress Pattern
Vertical Mattress Pattern
The interrupted horizontal mattress pattern ca n
be evertin g or appositional depending on the The interrupted vertical mattress pattern can also
depth of suture placement and dista nce from the be everting or appositiona l depending on the
wo und edges (see Figure 3-6) . The pattern is good depth of suture placement and distance from th e
for large skin wounds, for wounds with increased wound edges (see Figure 3-8). It is stro nger in
tension, and in conjunction with pieces of rubber tissues under tension and less compromising to
Wound Closure 19

"
,.
Figure 3~9 A and B, Com-
bined vert ica l mattress tens ion ,
suture and simple interrupted
,,,-:
appositional sut ure patterns.
C, Comb ina tion of ve rtical mat-
tress sutures with bolsters and A v' c
simpl e interru pted apposit ional
sutu res to close incisions under
tens ion.

B
--

Figure 3~ lOA and B, Near-far-far-near


tensio n suture pattern. C and 0 , Far-near-
nea r-fa r tension suture pattern .

A c

B D

blood supply to the wound m argins than inter-


rupted horizontal mattress su tures. The verti cal
Other Tension Patterns
mattress suture pattern can be used for concu r- The nea r-far-far- nea r, fa r- near-near-far, and other
rent closure of skin and subcutis to eliminate dead va ri ati ons are tension suture patterns occasio nally
space. used in eq uin e surgery (see Figure 3- 10). They

I
20 PRESURG ICAL PREPARATION AND ASSESSMENT

have been shown to be excellent tension sutures; use either right or left one-hand ties to take full
however they are time consuming to insert. In one advantage of their utility.
retrospective study, an increased incisional infec-
tion rate was associated with closure of the linea
alba using a near-far-far-near suture pattern. 14 TISSUE ADHESIVES

Various tissue adhesives, such as cyanoacrylates,


Subcutaneous or Subcuticular Patterns
collagen gelati n, and fibrin glue, are used fo r
Subcutaneo us or subcuticular suture patterns are primary wound closure.15,16 Advantages include
used to close the subcutan eous or subcuticular rapid and painless application, hemostatic and
ti ssue prior to skin closure. Subcuticular pattern s bacteriostatic properties, the provision of a
can also be used in place of a typical ski n closure water-resistant protective coating, no need for
pattern (see Figure 3-5). The first part of the suture rem oval, and an acceptable cosmetic
suture pattern is placed by starting approximately result. " It is generally thought that tissue adhe-
8 to 10mm from the apex of the incision in the sives m ay have som e benefits in small incisions or
subcutaneous tissue, d irecting the needle toward wounds in wh ich primary suture closure is indi-
the apex of the incision, and emerging in either cated, whereas larger wo unds are unlikely to
the subcu tis or subcutaneous tissue depending on benefit from tissue adhesives. Wounds healing by
the pattern desired. The second bite of the suture second intention may benefit from tissue adhesive
starts at the apex and emerges approximately 8 to sp rays after a healthy granulation tissue bed has
10mm fro m the apex in the subcutaneous tissue. formed. 16
The knot is then tied and thus is "buried." The
third bite of the suture is superficial to the knot
and closer to the apex of the incision to effectively DEAD SPACE
reinforce burying the knot. The remainder of the
suture pattern is placed somewhat similar to a Dead space allows the seepage and accumulation
co ntin uous horizontal mattress pattern , with the of blood and serum in a warm and moist envi-
needle crossing the incision at right angles or ronment that is ideal for bacterial proliferation,
sligh tly "behind" where the previous suture thus enco uraging infection. Dead space may be
emerged. A knot similar to the start is placed at dealt with by layered wound closure when ade-
the end of the incision. The last two bites start in quate tissue is available, by compression bandages,
the subcutaneous tissue and the needle is directed by drainage, or by suture obliteration,17 although
toward th e apex and somewhat more superficial. the latter may promote wound infection in con-
The last bite sta rts with the needle reversed at the tamin ated wounds. Walking sutures can be used
sam e level of emergence as the previous bite, to advan ce a skin flap over the wound bed at th e
directing the needle toward the subcutaneous same time the dead space is eliminated (Figure
tissue about 8 to 10 mm from the apex. The kn ot 3- 11 ). A stent or tie-over bandage can be used to
is tied and the free end of th e suture is cut. The help obliterate dead space in wounds in which cir-
needle is passed in to the subcutaneous tissue at cumfe rential bandaging is not possible. This type
the level of the knot, emergin g through the skin of bandage protects the wound and may provide
about 10 to 15 mm perp endicular to the incision relief to the primary suture line as well as direct
li ne. The needle and suture are then pulled tight pressure over areas of dead space (see Figure
to help bury the knot, and the suture is cut at the 25-12).
skin level.
Securing sutures is most commo nl y performed
using instrum ent ties. However, every surgeon DRAINS
should be able to use one- and two-hand ti e tech-
niques to secure sutures. The ability to use these Drains are used when a la rge dead space remains
techniques gives the surgeon significant flexibility after suture closure or there is sufficient tissue
to apply secure ligatu res and sutures in various damage so that continued seepage of fluids is
situ ations where the use of instrument ties is expected. Drains can be therape utic to remove
problematic. Ideally, the surgeo n should be able to existin g fluid accumulation or prophylactic to
Wound Closure 21

--
, •

,
- ,-
-'-
"

A B

4Ie~,'P<""'''~>
,

C 0
Figure 3-11 A-D, Use of walking sutures placed in the subcutaneous tissue to close large defects in skin.

Figure 3-12 A, Insertion of the


Jackson-Pratt negative suction drain
using a trocar at a site ventral to the
incision line. B, Jackson-Pratt negative
suction drain in place to provide con-
tinuous suction to remove exudate and
fluid from the incis ion or wound site. A B
Note use of three-way stopcock. 60-mL
syringe. and needle placed through
plunger to maintain suction.

41e"?/<At;, ,"f;,."'"......
_>

ensu re against fluid accumulation. Drains must be the chances of retrograde infection. Drains should
maintained in a sterile environm ent to decrease be sutured proximally and at the exit point.
the chance of secondary infection. They should Drains are classified as active or passive. Active
traverse the wound from a proximal to distal ori- drains are closed suction drains that function by
entation, adjacent to but not directly underlying negative press ure to suction out excess fluid or air
the suture line, and should exit from a sepa rate (Figure 3- 12). Passive drains, including Penrose
incision adjacent to the wound edges to minimize drains or other forms of rubber or polyethylene
22 PRESURGICAL PREPARATION AND ASSESSMENT

,
Figure 3-13 Partial closure of subcutaneous tissue Figure 3-14 Previously repaired pastern laceration
over Penrose drain . Drain sutured in place (arrow) and showi ng evidence of skin necrosis seco ndary to ban ~
exits the site distal to th e incision or wound site to avoid dages applied over tens ion suture supports. Three
the primary incision line. hor izontal mattress sutures had been placed with
polyethylene supports 2 weeks previously.

tubing, function by gravity or pressure differen-


tials (Figure 3-13). The ideal drain is inert, soft,
smooth, nonreactive, and radiopaque. The disad - associated with complications.!8 Rel ief incisions
vantages of drains include the potential introduc- away fr0111 the wound margins can so metimes
tion of bacteria or foreign bodies into the wound, decrease tension. The relief incisions may be
the care involved to maintain patency, and the closed after the primary incision is closed or left
potential irritation and resultant scar tissue and to heal by second intention.
adhesion formation that may occur as the result Tension suture patterns used to reduce the
of a foreign body reaction. Drains should be tension on the primary suture line are placed well
removed after 2 to 3 days, when infection is con- back from the wound margins so that the blood
trolled, or if they are not functioning effectively. supply is not compromised. Once the tension
Ideally, wound drainage is expected to change sutures are in place, the primary incision line is
from an exudate to a transudate, and the quantity sutured to appose the wound edges. Widely placed
is expected to graduaUy diminish to negligible vertical mattress sutures, with or without support
levels during the 2- to 3-day period. using buttons, gauze, or rubber or polyethylene
tubing, are effective in reducing tension on the
primary suture line. Other tension suture patterns
MANAGEMENT OF SKIN TENSION incl ud e horizontal mattress, far-near-near-far,
and far-far- near-near patterns. Tension sutures
Excess tensio n on a primary suture line is l.ikely to with supports are used in regions that cannot be
complicate healing via local ischemia, cutting out effectively bandaged (e.g., upper body, neck),
of sutures, and wound disruption. Methods to whereas no supports are used under bandages or
decrease ten sion on the primary su ture line casts, because pressure on the supports may cause
include undermining the surrounding skin, pro- tissue necrosis (Figure 3-14) . Tension sutu res are
viding relief incisio ns, and the use of tension removed in 4 to 10 days, depending on the
suture patterns. Although excessive undermining appearance of the wound. Staggered removal is
is deleterious, undermining up to 4 cm from the preferred, removing half of the sutures initially
wound edge on distal limb wounds has not been and the remaining half later.
Wound Closure 23

REFERENCES two absorbable suture materials for closure of


jejunal enterotomy incisions in healthy dogs, Vet Q
I. Hamill MB, Osato MS, Wilhelmus KR: Experimen- 23:67, 2001.
tal evaluatio n of chlorhexidine gl ucona te for ocular II. Magee AA. Gal uppo LD: Comparison of incisional
antisepsis, Antimicrobial Agef/ts Chemother 26:793, bursting strength of simple continuous and inver-
1984. ted c ruciate su ture patterns in the equine linea alba,
2. Phinney RD, Mondino BJ, Hofbauer JD, et al: Vet Su'g 28:442, 1999.
Corneal edema related to accidenta1 Hibiclens 12. Van Hoogmoed L, Snyder JR, Stover SM, et a1: In
exposure, Alii J Ophtha/mol 106:210, 1988. vitro biomechanical comparison of the strength
3. Nasser RE: The ocular danger of H ibiclens (chlor- of the linea alba of the llama, using two suture
hexidine), Pfost Recomtr Surg 89:164, 1992. patterns, Am J Vet Res 57:938, 1996.
4. Baxte r GM: Wou nds and wound healing. In 13. We isman DL, Smeak DD, Birchard SJ, et al: Co m -
Colahan PT, Mayhew IG, Merritt AM, Moore lN, parison of a co ntinuo us suture pattern with a
edito rs: Equine medicine alld slIrgery, ed 5, St Louis, simp le interrupted pattern for enteric closure in
1999, Mosby. dogs an d cats: 83 cases (1991-1997), ] Alii Vet Med
5. Stashak TS: Selected factors that affect wound Assoc 21 4:1 507,1999.
healing. In Stashak TS, editor: Eqlline IVOUlld mall- 14. Kobluk eN, Ducharm NC, Lumsden JH , et a1:
agement, Philadel phia, 1991, Lea & Febiger. Factors affecting incisional complication rates asso-
6. Wilson DA: Principles of early wound manage- ciated with colic surgery in horses: 78 cases ( 1983-
ment, Vet elill N Alii Equine Pmct 21:45, 2005. 1985 ). ] Alii Vet Med Assoc 195:639, 1989.
7. Stashak TS: Selection of suture materials a nd suture 15. Blackford J. Shires M, Goble D, et al: The use of
patterns fo r wou nd closure. In Stashak TS, editor: N-butyl cyanoac rylate in the treatment of open leg
Equine wound management, Philadelphia, 1991, Lea wounds in the horse, Proc Am Assoc Equille Pract
& Febiger. 32:349, 1986.
8. Brunius U, Ahre n C: Healing of skin incisions 16. Bello TR: Practical t reatment of body and open leg
during reduced tension of the wound area. A ten- wou nds of horses with bovine collagen, biosyn-
siometric a nd histologic study in the rat, Acta Chir thetic wound d ressing and cyanoacrylate, J Eqllille
Scalld 135:383, 1969. Vet Sci 22: 157, 2002.
9. Fingland RB. Layton Cl, Kennedy GA, et al: A com- 17. Trotter GW: Techniques of wound closure, Vet Clil1
parison of simple con tin uous versus simple in ter- N AII1 Equine Pmct 5:499, 1989.
rupted suture pattern for tracheal anastomosis after 18. Bail ey lV, Jacobs KA: The m esh expansion method
large-segment tracheal resection in dogs, Vet SlIrg of suturing wounds on th e legs of horses, Vet Slirg
24:320, 1995. 12:78,1983.
10. Kirpensteijn 1. Maarschalkerweerd RJ. van der Gaag
I, et al: Comparison of three closure methods and
CHAPTER 4
Emergency Management of the Fracture Patient
Gal Kelmer

INDICATIONS INITIAL EVALUATION AND TREATMENT

Unstable appendicular skeleton fractures. Prompt and proper fracture stabilization in the
horse can make the difference between death and
an athletic future. A horse with a fractured, unsta-
EQUIPMENT ble limb can rapidly induce further trauma that
will markedly decrease the chance fo r successful
Bandaging material includes uniform layered repa ir and survival. The goal of the initial treat-
cotton padding, elastic gauze, elastic adhesive, ment and stabil ization is to prevent further
inelastic tape, and wound dressing materials. trauma. Such trauma may result in eburnation of
Splints can be made from any lightweight rigid fracture ends, further fragmentation and fracture
material. PVC (polyvinyl chloride) pipe, 8 to displacement, damage to neu rovascular struc-
10 cm in diameter and of 4- to 8-mm wall thick- tures, skin penetration leading to an open frac-
ness, sectioned longitudinally into thirds makes ture, and additional soft tissue damage. 1·6
an excellent, inexpensive, readily available splint- Initial assessment of the injured horse inclu-
ing material. The sharp edges of the splint may be des evaluating the systemic condition, specifically
rounded and should be wrapped with tightly hydration status and cardiovascular function, the
taped padding. Other acceptable splinting mate- bone involved, and the stabil ity of the bony
rials include wooden splints,S to 20 cm wide and column, and determining whether the fracture is
10 to 20mm thick, and aluminum or concrete open or closed. Typically, the horse will be sys-
reinforcement rods, 12 to 16 mm in diameter, cut temically stable and will benefit from immediate
to length (Figure 4-1). stabilization of the injured limb. Analgesia and
sedation of the fractured horse are important in
order to relieve anxiety and alleviate pain, thereby
POSITIONING AND PREPARATION minimizing further self-inflicted damage to the
injured limb. Phenylbutazone (4.4 mg/kg N ) is
All emergency fracture stabilization should be beneficial for both its analgesic and anti-inflam-
done with the horse in a standing position while matory properties. Additional analgesia and seda-
providing analgesia and mild to moderate seda- tion can be achieved using detomidine (0.01 to
tion. Recovery from general anesthesia can chal- 0.02 mg/kg NIIM) with or without butorphanol
lenge even an ideal fracture repair by the ap- (0.0 1 to 0.04 mg/kg IM). Use caution when
plication of extreme forces to the horse's limb. administering these sedatives and analgesic agents,
Thus, general anesthesia should be avoided unless so as not to render the horse ataxic. Horses with
absolutely necessary. ! these fractures may be dehydrated and hypo-

24

-
Emergency Management of the Fracture Patient 25

volemic and thus can be profoundly affected by be applied. Splinting can be done well with simple
these agents. If there is skin penetration of the equ ipm ent in field situations when attention is
injured limb, even if distant from the apparent given ~o proper technique. 7,B
fractu re. broad-spectrum antibiotics (e.g., gen- Radiographs can be taken either following
tamicin 6.6 mg/kg IV and potassium penicillin stabilization or later at the referral facility. The
22,000 Ju/kg IV, or gentamicin and procaine basic method of stabilization is a splint applied
penicillin 22,000 IV/kg 1M, or cefazolin II mglkg over a bandage to decrease interfragmentary
IV) should be administered. In a markedly dehy- movement and to significantly alleviate anxiety.
drated horse, administration of aminoglycosides The specific mode of immobilization differs along
(e.g., gentamicin) and nonsteroidal antiinflamma- the limb according to the locally predominant
tory drugs (NSAIDs) (Le., phenylbutazone) should biomechanical forces. Both forelimbs and hind
be postponed until adequate hyd ration is achieved limbs can be divided into the following four func-
via intravenous fluid administration. The horse tional sections. l . s Section 1 is the most distal fore-
should be current on tetanus vaccination . limb or hind limb segment between the coronary
band and the distal quarter of the metacarpus or
metatarsus. Section 2 in the forelimb extends
Limb Stabilization
from distal metacarpus to dista l radius, while in
Immediately after initial assessment o f the patient the hind limb it includes middle and proximal
and the affected limb, external coaptation should metatarsal fractures. Section 3 in the forelimb
comprises diaphyseal and proximal radial frac-
tures, while in the hind limb it includes tarsal
and tibial fractures. Section 4 in the forelimb
- - \
consists of fractures of the ulna, humerus, and
scapula, while in the hind limb it includes proxi-
mal tibial physis and femur fractures . Appropriate
stab ilization techniques for the previously des-
cribed sections of both forelimbs and hind limbs
are described next.

Section 1
The most distal forelimb or hind limb segment
is between the corona ry band and the distal quar-
ter of the metacarpus or metatarsus ( Figure 4-2).
Figure 4-1 Bandaging and splinting equipment. Dorsopalmar or dorsoplantar bending is the prin-

Section 4
Figure 4-2 Dividing the limbs
into four functional sections. Each
section is stabilized in a different 3
technique according to the local gov- Section 3 - - -
erning biomechanical forces.

Section 2 - - -
f- Section 2

Section 1
Section 1 - - - -
26 PRESURGI CAL PREPARATION AND ASSESSMENT

dpal force and is best counteracted by applying Section 2


a dorsal splint-cast combination over a light band- Forelimb fractures, from distal third metacarpus
age extending from the ground to just below the to distal radius, should be stabilized with a Robert
carpus. The bandage is applied with the distal limb Jones bandage applied from the ground to the
straight and the splint applied to align the dorsal humeroradial joint (elbow) (see Figure 4-2). The
cortices. The splint is taped tightly with the carpus bandage should include multiple layers of padd-
held in flexion. The tape material should be ing and each padding layer is tightened with
nonelastic, such as duct tape or white tape to elastic gauze. Padding can be made with rolled or
prevent unwanted motion between the splint and layered cotton. Each padding layer should be
the limb (Figure 4-3). Fiberglass cast material may about 2 to 3 em thick with the total bandaged
be applied over the taped splint to increase rigidity. diameter approximately three times the limb's
In the hind limb, the same principles hold but the diameter. It is crucial that the bandage is uniform
splint is applied to the plantar aspect with ti,e in shape and tight enough to achieve maximum
metatarsophalangeal (fetlock) joint in slight flexion stability and rigidity of the splinted limb while
(Figure 4-4). avoiding excessive focal skin pressure. Palmar and
lateral splints that extend from the ground to the
elbow should be applied. Splints should be taped
as tight as possible over the bandage, using a gen-
erous amount of nonelastic adhesive material
such as duct tape (Figure 4-5).
Middle and proximal third metatarsal fractures
(see Figure 4-2) should be bandaged from the
ground to the level of the stifle. In the hind limb,
the bandage should be less extensive to facilitate
splint application. Plantar and lateral splints
should be applied from the ground to the level of
the calcaneal tuber. The lateral splint may extend
to the level of the stifle for more proximal frac-
tures. Splinting material and application manner
are similar to those previously described (Figure
Figure 4-3 Section 1 forelimb fracture, distal thi rd
4-6) .
metacarpus to distal interphalangeal joint region, sta -
bilized using a dorsal splint-cast combination over a
light bandage.

Figure 4-4 Section 1 hind limb fracture, distal third


metatarsus to distal interphalangeal joint region, stabi- Figure 4-5 Sect ion 2 forelimb fracture, distal radius
lized using a plantar splint-cast combination over a light to distal metacarpal region, stabilized using paJmar and
bandage. lateral splints over a heavy Robert Jones bandage.
Emergency Management of the Fracture Patient 27

Figure 4-6 Section 2 hind limb fracture, third Figure 4-7 Section 3 forelimb, diaphyseal and prox-
metatarsal bone, stabi lized using plantar and lateral imal radial fractu res, stabilized using similar bandage
splints over a moderate Robert Jones bandage. and palmar splin t as for section 2 fractures. Here the
lateral splint is extended to lie against the lateral aspect
of the shoulder and prevent limb abd uction.

Section 3
Diaphyseal and proximal radial fractures should
be stabilized with a Robert Jones bandage aug-
mented with caudal and lateral splints applied as
for section 2 with the exception that the lateral
splin t extends proximally to lie against the lateral
aspect of the shoulder (see Figure 4-2). The prox-
imal extension of the splint is essential because
of minimal soft tissue protection over the medial
aspect of the radius. The splint prevents abduc-
tion of the distal limb and penetratio n of the skin
by the fractured bone ends at the medial aspect of
the fracture line (Figure 4-7). Tarsal and tibial
fractures are especially difficult to immobilize
because of the reciprocal apparatus (see Figure 4-
2). A Robert Jones bandage is applied as for
section 2) but in this case the bandage should
extend to the level of the patella with the splint
preventing slippage. The splint should extend
proximally to lie against the lateral thigh and hip
and prevent skin penetration by fracture bone
ends from limb abduction. Ideally, a lightweight
metal splint or steel concrete reinforcement rod
shaped to the hock and stifle angulations and bent
back upon itself is used as the lateral portion of a
Figure 4·8 Section 3 hind limb, tibia, and tarsal frac-
Schroeder-Thomas splint. Cast material can be tures, stabilized using lateral splint over a moderate
wrapped around the bent rod fo r additional Robert Jones bandage. The splint is made of a speci fi-
strength (Figure 4-8). Alternatively, the splint can cally bent aluminum rod enforced with synthetic cast
be made of a wide (20 em) wooden board (Figure mater ial and extending proximally to lie against the
4-9). In all options, the splint is incorporated into thigh and hip to prevent limb abd uction.
I
28 PRESURGICAL PREPARATION AND ASSESSMENT

Figure 4-9 Section 3 hind limb, tibia, and tarsal frac- Figure 4-10 Section 4 forelimb fractures disabling
tures, stabilized using a lateral splint over a moderate the triceps apparatus such as olecranon fractures. A
Robert Jon es bandage. The spl int is made of a broad caudal splint over a light bandage is applied in order to
wooden board extended proximally to lie against the lock the ca rpus in extens ion and by that aid in control
thigh to prevent limb abduction. and use of the limb.

the coaptation as tightly as possible with liberal cases, initial stabilization of the limb and the
use of inelastic tape. patient and consultation with the nearest surgical
facility will provide the best servi ce to the horse
Section 4 and the client. The horse sho uld be transported in
Fractures of the ulna. humerus, and scapula are a confined area with minimal space for body
unstable as a result of loss of the triceps function , movement and adequate room for head motion
which precludes use of the limb (see Figure 4- and foot placement to aid in balance. A horse with
2). A light bandage from the ground to the elbow an injured forelimb should face backward and a
combin ed with a caudal splint spanning the horse with a hind limb injury should face forward
carpus to lock the carpus in extension will enable so as to prevent additional stress on the injured
weight bearing on a limb affected with an ulnar limb during emergency stops. Providing dist rac-
fracture (Figure 4-10). Splinting cannot aid prox- tion for the ride in the form of a small amount of
imal tibial physeal and femur fract ures (see Figure hay is recommended. 2
4-2). Heavy coaptation may actually cause further
damage by increasing the fulcrum to distract the
fragment and potentiaUy open a closed proximal COMPLICATIONS
tibial fracture.
Improper splinting such as using one thick
padding layer without intermittent tightening
PREPARATION FOR REFERRAL with elastic gauze or a very heavy splint improp-
erly secured to the limb can actually increase the
In most cases, it is advisable to discuss referral and amount of damage to the fractured limb. 4 •s
surgical options with the client only after the
patient is relatively calm and the limb is properly
stabilized. The nearest surgical facility should be EXPECTED OUTCOME
contacted and consulted prior to transporting the
horse. Euthanasia is definitely indicated in certain The prognosis depends on the horse's weight and
situations such as an open comminuted tibial temperament, the specific bone involved and the
fracture in an ad ult size horse.5 However, in most location of the fractu re within the bone, the frac-
Emergency Management of the Fracture Patient 29

ture configuration, and the availability of a well- splint (Figure 4- 11 ). The splint provides a quick
equipped surgical facility. The goal of initial sta - and easily applied support; however, it may
bilization is to ensure that the horse reaches the provide less rigid support than a tightly placed
referral center in the best possible condition, splint-cast combination,l,2
while minimizing additional injuries to soft tissue
and fractured bones during transportation. I ,2,s
COMMENTS

ALTERNATIVE PROCEDURES Joint luxations present similar to traumatic unsta-


ble fractures and warrant immediate stabilization
A commercially available manufactured metal following the same described principles.
splint, "Kimzey Leg Saver" (Kimzey Welding
Works, Woodland, Calif.), provides adequate sta-
bilization for section 1 fractures in both forelimbs REFERENCES
and hind limbs. Care should be taken to ade-
quately cushion the most proximal aspect of the I. Bramlage LR: Current concepts of emergency first
aid treatment and transportation of equine fracture
patients, Camp Cant Educ 5:S564, 1983.
2. Bramlage LR: First aid and transportation of frac-
ture patients. In Nixon AJ, editor: Equine fracture
repair, Philadelphia, 1996, WB Saunders.
3. Young DR, Kobluk CN: Diseases of bone. In Kobluk
CN, Ames TR, Geor R], editors: The horse: diseases
and clinical management, Philadelphia, 1995, WB

I Saunders.
4. Auer JA, Bramlage LR: Emergency care and trans-
portation of the fracture patient. In Colahan PT,
Mayhew IG, Merritt AM, Moore lN, editors: Equine
medicine and SlIrgery, ed 5, St Louis, 1999, Mosby.
5. Bramlage LR: Emergency first aid treatment
and transportation of equine fracture patients. In
Auer lA, Stick JA, editors: Equine surgery, ed 2,
Philadelphia, 1999, WB Saunders.
6. McIlwraith CW, Orsini ]A: Musculoskeletal system.
In Orsini JA, Divers T], editors: MalUml of equine
emergencies: treatment and procedllres, ed 2, Phil-
adelphia, 2003, WB Saunders.
Figure 4·11 An alternative way to stabili ze section 1 7. Walmsley J: Emergency management of fractures in
fractures and luxations is by use of a commercially horses, In Practice 21:122, 1999.
available manufactured metal splint. the "Leg Saver" by 8. Whitton RC: Temporary splinting of fractures. In
Kimzey. (Courtesy Kimzey Welding Works. Woodland, Rose RJ, Hodgson DR, editors: Manual of equille
Calif.) practice, ed 2, Philadelphia, 2000, WB Saunders.
CHAPTER 5
Field Anesthesia
Keith R. Branson

Equine field surgery requires portable anesthesia. antiemetic and antihistaminic effects. The central
This factor makes it difficult to use inhalation sedatio n seen with the phenothiazine tranquiliz-
anesthesia. Fortunately) most of the patients un- ers is due to their antagonism of dopamine at cen-
dergoing surgical procedu res in the field are rela- trally located receptors. In general) increasing the
tively healthy and require minimal supportive dose above tha t needed fo r sedation will only
care while under anesthesia. Adequate) safe anes- result in an increase in duration of tranquilization
thesia is still required) however) because regard- and increased undesirable side effects. I Further
less of your surgical skills) a successful outcome increases in dose m ay even result in excitement.
also requires successful an esthesia. This chapter Acepromazine produces a decrease in arterial
includes a discussion of the physiologic effects of blood pressure caused by a peripheral al-ad reno-
the drugs commonly used for injectable anesthe- receptor antagonism. 2 Because of this a l antago-
sia) how these drugs are used, and a brief discus- nism ) a m ixed adren oreceptor agonist) such as
sion of supportive ca re measures and induction epinephrine) can have a more dramatic hypoten-
methods. In addition, a brief discussion of caudal sive effect since its vasodilatory ~ effects will be
epidural anesthesia an d epidural ca theter place- more pronounced. In addition) acepromazine has
ment is included. an antiarrhythm ic effect on the heart, most likely
from an a-adrenoreceptor antagonism in the
heart. 3,4 Minimal respiratory depression) other
TRANQUILIZERS AND a,-AGONISTS than a slight decrease in the respiratory rate) is
associated with the use of acepromazine alone) and
None of the injectable general anesthetics possess it does decrease the animal's ability to thermoregu-
all the properties needed to produce good anes- late.'" Early reports of priapism and flaccid penile
th esia when used alone. For that reason other paralysis in stallions and geldings given acepro-
drugs are administered in conjunction with the mazine have led to hesitance to use this drug in stal-
general anesthetics. Tranquilizers and a 2-agonists lions and geld ings. 8- lo Some practitioners think
are commonly used for their sedative, analgesic, that acepromazine is still a useful sedative fo r use
and muscle relaxan t properties. in male horses) and if used) it sho uld be adminis-
tered intramuscularly (1M) and at the lowest effec-
tive dose.1l There is a dose-dependent decrease in
Acepromazine
the hematocrit attributed to sequestration of ery-
Acepromazine is the most commonly used mem- throcytes in the spleen. lo.n Acepromazin e is highly
ber of the phenothiazine family of tra nqu ilizers. protein bound and has an elimination half-life of
Members of this group of drugs are known longer than 3 hours.10 It undergoes hepatic m etabo-
for their sedative effects) but they also possess lism to form inactive metabolites.

30
Field Anesthesia 31

When used alone, the dose for acepromazine Lower doses are often used as an analgesic in
ranges from 0.02 to 0.09 mg/kg administered colic patients. The detomidine dose is 0.01 to
intravenously (IV) and 0.03 to 0.05 mg/kg 1M. 0.04 mg/kg IV 01' I M when used alone, and, as
Acepromazine is rarely used alone when sedation with xylazine, lower doses of detomidine ca n be
and chemical restraint for standing surgical proce- used as an analgesic. Detomidine has a longer
dures are desired, since it has no analgesic proper- duration of sedation tha n xylazine (approxi-
ties. In addition, time to onset can be highly mately 45 and 30 minutes, respectivelyL and the
variable and the overall degree of sedation is hard sedation produced lasts lon ger than the analgesia.
to predict. When these agents are used with opioids, the Ur
agonist dose is reduced . These combinations are
discussed in a later section of this chapter.
a,-Agonists
Two other selective u 2 -adrenoreceptor agonists
Xylazin e is one of the most widely used sedative- are used in horses-romifidine and medeto-
analgesics in veterinary medicine. Unfortunately, midine. Both have physiologic effects similar
it also has significant undesirable cardiovascular to xylazine a nd detomidine. 15 ,24 A dose of romm-
effects since it is a nonspecific a-adrenoreceptor dine 0.08 mg/kg IV is equivalent to approximately
agon ist. It was thought that if agents that were 1 mg/kg of xylazine or 0.02 mg/kg of detomidine.
more specific for the centrally located <X2- Detomidine, at least at higher doses, produces
adrenoreceptol's could be developed, the periph- sedation of longer duration than romifid ine
eral effects would be minimized. Detomidine is but romifidine appears to produce slightly less
more specific for o r adrenoreceptors but its car- ataxia. 25,26 Medetomidine is an u 2-agonist ap-
diovascular effects are very similar to those of proved for use in dogs. Its use in horses has
xylazine wh en equipotent doses are compared. been limited, but it appears a dose of 0.0075
The initial response of the peripheral vasculature mg/kg will produce adequate sedation of a
is vasoconstriction. Although there may be differ- duration longer than that normally seen with
el1Ces in the venous and arterial responses, an xylazine but shorter than that seen with detomi-
obv ious increase in peripheral vascular resistance dine .15,27
and an accompanying increase in a rterial blood One advantage of the uragonists is the avail-
pressure occur. l3 · 15 This is especially evident if the ability of spec ific antagonists to reverse their
drug is given intravenously. These agents also have effects. The most commonly used antagonists are
significant central sympatholytic and parasympa- tolazoline, yohimbine, and atipamezole, with tola-
thomimetic effects, which result in a decrease in zoIine being the least specific antagonist for the
cardiac output. A decrease in heart rate occurs uradrenoreceptor and atipamezole being the
both as a result of the central effects and as a most specific. 28 Because of tolazoline's relative
response to th e initial vasoconstriction-indu ced lack of (X2 spec ificity, its use is sometimes associ-
hypertension. l3 · l s In add iti on to bradycardia, atri - ated with significant clinical signs as a result of the
oventricula r conduction disturbances increase antagonism of endogenous adrenergic substances.
following (X2-agonist administration. 14. 16 This group These signs can include diarrhea, abdominal pain,
of drugs routinely causes some decrease in the res- and hypotension caused by vasodHation. 28 The
piratory rate with little effect on PaC02; however, a use of the agonist atipamezole has been evaluated
decrease in Pa02 is routinely observed at the doses as part of a lameness examination after light
needed to produce sedation. 15,16 sedation with detomidine (0.01 mg/kg). 29 Admin-
A transient increase in UriJle output is seen istration of atipamezole reversed most of the
after the administration of u 2-agOnlsts.1 7.18 Concern sedation-related stride changes, but some differ-
exists that ~-agonists, especially xylazine, may ences were still evident. In general, the dose of
cause abortion in pregnant mares, but there is antagonist is determined by the agonist dose and
little evidence of this effect. However, intrauterine the specific agonist used. This relationship is a
pressure is increased after the administration of reflection of the relative affinity the agonist and
most uz-agonists. 19 Both xylazine and detomidine antagonist h ave for the receptors. In general, 4 mg
undergo hepatic metabolism with rapid excretion of tolazoline is needed to adequately reverse 1 mg
of the metabolites in the urine. 20-B of xylazine, an d 10 mg of atipamezole is needed
When used alone, the usual dose for xylazine to reverse 1 mg of detomidine. 28.3o The time inter-
is 0.3 to 1 mg/kg IV and 1 to 2 mg/kg 1M. val since administration of the agonist should also
32 PRESURGICAL PREPARATION AND ASSESSMENT

be considered when determining the dose of tion. 34 A 10% solution of guaifenesin in sterile
antagonist to admin ister. If in doubt, it is certainly water also produces minimal hemolysis. 35 Less
appropriate to titrate the antagonist dose to concentrated solutions are less likely to cause
I produce the desired degree of reversal. phlebitis or thrombus formation. 36 Perivascular
administration of guaifenesin can result in severe
tissue damage. If the solution is allowed to cool
Benzodiazepines
substantially below room temperature, the gua ife-
The benzodiazepines are used primarily for their nesin will precipitate out of the sol ution. It can be
muscle relaxant effects. In add ition, they provide redissolved by warming the solution. Guaifenesin
some sedation, although their sedative effects undergoes hepatic metabolism a nd the metabo-
are minimal in horses. They are also used to lites are excreted in the urine. 37 Accumulation of
treat seizu res. The benzodiazepines functio n by metabolites, such as catechol, can lead to signs of
enhancing the effect of y-aminobutyric acid toxicity, including muscle stiffn ess, tremors, and
(GABA), an inhibitory neurotransmitter. This dyspnea. Guaifenesin is rarely used alone but is
results in sedation by depression of the limbic usually combined with an injectable anesthetic
system and in muscle relaxation by inhibition of agent such as a barbiturate or a dissociative anes-
internuncial neurons within the spinal cord. 11 thetic such as ketamine.
Limited data are available on the physiologic effects
of the benzodiazepines in horses, but the cardio-
vascular effects are minimal in most species. ll •ll •n OPIOIDS
Three benzodiazepines are currently in use in
equine anesthesia diazepam, midazolam, and Opioids are potent analgesics; unfortunately, they
zolazepam. Zolazepam is part of a fixed drug often produce excitement when adm inistered by
product, Telazol (Fort Dodge Animal Health ), themselves to horses. This is especially true of the
which is a combination of zolazepam and tileta- full opioid agonists. The development of opioids
mine, a dissociative anesthetic that is discussed that are agonists at only some opioid receptors has
further in the dissocia tive anesthetic section later mad e the use of opioids in the horse easier and
in this chapter. Diazepam is supplied in a propy- more effective. Opioid receptors are commonly
lene glycol veh icle that makes intramuscular classified as mu ( ~), kappa (K), and delta (0)
injection painful and the rate of absorption from receptors. Mu receptor activation is generally
the injection si te variable. Midazolam is water associated with profound analges ia as well as with
soluble and well absorbed after intramuscular some of the und esirable opioid effects such as
injection. 32 All of the benzodiazepines appear to bradycardia. hypoventilation. and excitement.
undergo hepatic metabolism with the metabolites Kappa receptor activation produces anal gesia that
excreted in the urine. Som e of the m etabolites of is not as intense as that associated with mu recep-
diazepam appear to have a significant pharmaco- tor act ivation but is also associated with fewer
logic effect. 32,33 Because these drugs are rarely used undesirable effects. Delta receptors are primarily
alone, the commonly used doses are included in thought to modulate mu receptor activity and
the later section on anesthetic combinati ons. produce analgesia. In general, the opioids have
minimal cardiovascular and respiratory effects.
Small increases in heart rate, blood pressu re, and
Guaifenesin
cardiac output were observed after full agon ists
Guaifenesin, also known as glyceryl guaiacolate were admi nistered, probably from the excitatory
(GG), is used for its muscle relaxant properties at effects of these drugs in the horses studied. 38 The
the internuncial neurons in the spinal cord. The nonselective full agonists such as morphine and
cardiovascular and respiratory effects of guaifen- fentanyl have a very narrow m argin between the
esin are minimal when the commonJ y recom- analgesic and the excitato ry dose, especially in
m ended clinical doses are used. It is usually pain-free animals. 39 It is important to differenti-
suppli ed as a sterile powder that is dissolved to ate the behavioral effects of opioids in pain-free
form a 5% or 10% solution of guaifenesin. A 5% horses, such as those often used in research
solution is comm only dissolved in a 5% glucose studies, and their effects in clinically painful
solution to minimize hemolysis after administra- horses. In a study of the peri operative use of 1110r-
Field Anesthesia 33

phine in painful horses, minimal behavioral ef- analgesic effect. 48.s1 Some evidence exists that sub-
fects were seen. 40 Kappa agonists such as butor- anesthetic doses produce minimal analgesia. 52 •s4
phanol also produce some excitement but the The cardiovascular effects of ketamine must be
effect is somewhat less than that seen when mu separated into its indirect central effect and its
agon ists such as morphine are administered. 4 1,42 direct peripheral effect. The central effect is an
Butorphanol has been admin istered as a continu- overall increase in sympathetic tone resulting in
ous infusion to maintain analgesia at a loading mild increases in heart rate, arterial blood pres-
dose of 0.018 mglkg IV and then a continuous sure, and cardiac output. It does, however, have a
infusion at 0.0237 mglkglhr'3 Another opioid mild direct depressant effect on myocardial co n-
that has seen limited use in horses, but has many tractiIity.46.55 Little respiratory depression is see n
desirable characteristks, is buprenorphine. When at cl inical doses although a slight increase in res-
combined with detomidine, buprenorphine has piratory rate and decrease in tidal volume are
provided good analgesia and sedation for stand- sometimes observed. Ketamine produces minimal
ing procedures.44 Transdermal delivery systems muscle relaxation. Because of its poor muscle
have provided an additional route of admin- relaxant effects and tonic-clonic limb spasms, it is
istration for opioids. Fentanyl is commonly not used alone in veterinary anesthesia.
adm inistered in this manner (Duragesic; Janssen
Pharmaceutical Products) to a variety of species.
This delivery route has been studied in horses, and
Tiletamine
it was determined that two 10-mg (100 ~glhr) Telazol is a proprietary mixture with equal con-
patches provided plasma levels of fentanyl that centrations of zolazepam, a benzodiazepam, and
should provide analgesia. Eight to IS hours was tiletamine, a dissociative anesthetic. It is distrib-
required to reach peak plasma levels and patches uted as a dry powder that is reconstituted prior to
needed to be replaced at 48-hour intervals to use. Tiletamine is somewhat more potent than
maintain the desired plasma co ncentrations. 45 No ketamine and has a slightly longer duration of
significant undesirable effects were noted in this actio n. Its cardiovascular, respiratory, and anes-
st udy. thetic effects are similar to those of ketamine. S6
Even though Telazol contains a tranquili zer as well
as a dissociative anesthetic, it is not commo nly
INJECTABLE ANESTHETICS used alone in equine anesthesia.

None of the available injectable general anesthet-


ics provide all of the actions of an ideal anesthetic.
Thiopental
Therefore, when used clinically they are almost Thiopental is an ultra-short-acting thiobarbitu-
always combined with other drugs. rate. It produces rapid unconsciousness after
intravenous injection. Recovery is a result of
redistribution of the drug from the brain to other
Ketamine
ti ssues in the body. Initially, the drug is redistrib-
Ketamine is a dissociative anesthetic. Patients uted to muscle and other nonfatty tiss ues with
receiving ketamine appear to be in a cataleptic moderate blood flow. The ultimate site of redis-
state while still maintaining many reflexes. The tributio n is poorly perfused adipose tissue but, at
higher centers, the cereb ral co rtex, are dissociated th e time of recovery from anesthesia, the major-
from somatic input. The site of action of keta- ity of the drug resides in moderately perfused
mine is centrally located N-methyl-D-aspartate tissues. Ultimately, it undergoes hepatic m etabo-
(NMDA) receptors. In addition, some of the lism. If thiopental is adm inistered for prolonged
analgesia produced by ketamine may be due to periods and then discontinued, the primary
interaction with opioid receptors. 46 Ketamin e factors associated with the termination of anes-
undergoes hepatic metabolism with urinary ex- thesia are both redistribution into fat and hepatic
cretion of the metabolites. Some of the metabo- metabolism. These are slower than redistribution
lites have pharmacologic activity.47 The analgesic into moderately perfused tissues. The site of
properties of ketamine are so mewhat controver- action for barbiturates has been shown to be
sial; however, many stucUes show a significant on the GABA receptor. 46 Barbiturates enhance
34 PRESURG ICAL PREPARAT ION AND ASSESSMENT

the inhibitory effect of this neurotransmitter by 2. After the drugs a re administered, they should
decreasing the rate of its dissociation from its be allowed to have an effect. It is important to
receptor and directly increasing the duration of wait 5 to 15 minutes after IV administration
GABA-associated chloride channel ope nin g. It has and 15 to 30 minutes after 1M admi nistration
no analgesic effects at subanesthetic doses. Its car- for the drugs to have their fu ll effect.
diovascular effects are a mild peripheral vasodila- 3. If a tranquilizer or <Xragent alone is not effec-
tion (primarily venous) and a decrease in cardiac tive, it is usually best to add an opioid rather
contractility.46 A concurrent increase in heart rate than to give more of the initial drug.
often occurs. Although thiopental can be used
alone to produce equine anesthesia, the quality of For long procedures, it is sometimes easier to
recovery is poor.57 For this reason, it is commonly administer a continuous infusion of detomidine
used with other agents. rather than to administer additional doses during
the procedure. This is especially useful during
Japaroscopic procedures. After initial sedation
Propofol
with detomidine and butorphanol or detomidine
Propofol is a phenolic compound that is chemi- and bupreno rphine, an infusion of detomidine is
cally unrelated to thiopental, but the clinical and administered at the rate ofO.IIlg/kg/min (0.0001
physiologic effects are very similar. One signifi- mg/kg/min ) ..... A 450-kg horse would therefore
cant difference is the rapid hepatic m etabolism require 27 mg of detomidine/hr. Alternatively, an
of propofol.58 This combinatio n of redistribution initial detomidine infusion rate of 0.6 J.lglkglmin
and rapid metabolism results in rapid recovery can be used. The detomidine infusion rate is then
even after long periods of administration. Cur- decreased by half every 15 minutes. 59 Xylazine can
rently its cost precludes frequent use as an equine also be given by infusion at the rate of 0.55
anesthetic agent, although use may increase in the mg/kg/hr.60 Tn additio n to the infusion, local
future. It is used after premedication with a tran- anesthetics should be used at the su rgery site. Co n-
quilizer. stant infusions are often superior to intermittent
admi nistration in that the quality of sedation is
more uniform and there is usually less ataxia since
STANDING SEDATION AND RESTRAINT the peaks in plasma drug levels are eliminated.
COMBINATIONS

Many minor surgical and diagnostic procedures INJECTABLE GENERAL ANESTHESIA


are done without general anesthesia. In some
cases, a tranquilizer or ~-agon i st alone is ade- There is no ideal general anesthetic; therefore,
quate. In most cases, however, th e combination of combin ations of drugs are used to produce
a tranquilizer o r cx2-ago nist with an opioid pro- general anesthesia. When combining drugs, it is
vides superior seda tion, analgesia, and restraint. important to select drugs that have complemen-
Many combinations are used, and the doses tary effects. In addition, the duration of actio n of
withi n t11ese co mbinations are variable. The the drugs must be considered as welJ as their
attending veterinarian should use his or her judg- undesirable side effects. When the combination of
ment as to the precise dose to use. O ne rule to xylazi ne and ketamine is analyzed, it is evident
rem ember is that you can always give more drug that ketamine provides the anesthesia as well
if needed but it is difficult to remove a d rug from as some a nalgesia but is lacking in muscle relax-
the animal once it has been adm inistered. Table ation and would ca use rough inductions if used
5- 1 lists the commonly used drugs and their alone. The addition of xylazine adds muscle relax-
doses, as welJ as some specific comments. ation as well as more analgesia and sedati on to
It is important to remember that no matter smooth the induction. Thei r durations of action
which drugs are selected to sedate a horse, are complementary as well. Xylazme produces
several other factors are important fo r successful approximately 30 minutes of sedation so the
sedation. recovery from ketami ne is generally smooth but
the sedation after anesthesia is not prolonged. The
I. The horse should be caLn when the drugs are addition of butorphanol or a benzodiazepine adds
ad min istered. more analgesia-sedation or muscle relaxation-
Field Anesthesia 35

TABLE 5-1
Drugs Commonly Used for Standing Sedation in Horses
DOSE ( IN MG/KG) (ALL CAN
DRUG(S) BE GIVEN IV OR 1M) COMMENTS

Single Drugs
Acepromazine 0.04-0.08 1. May cause penile paralysis
2. Variable time to onset
Xylaline 0.3-1 1. Higher doses may cause ataxia
2. Sedation lasts longer than analgesia
3. Approximately 30-minute duration
Detomidine 0.Ql-0.04 1. Higher doses may cause ataxia
2. 60- to 90-minute duration
Romifidine 0.04-0.12 1. May cause less ataxia than xylazine or detomidine
2. 60- to 90-minute duration

Drug Combinations'"
Acepromaline 0.05 1. May cause penile paralysis
Morphine 0.1-0.2 2. Variable time to onset
Acepromazine 0.05 1. May cause penile paralysis
Butorphanol 0.025-0.05 2. Variable time to onset
Xylaline 0.25-1
Butorphanol 0.01-0.05
Detomidine 0005-0.Q2
Butorphanol 0.01-0.05
Detomidine 0.01
Buprenorphine 0.006
Romifidine 0.04-0.08
Butorphanol 0.01-0.05

"Note: Use of the higher doses of both drugs often results in ataxia.

sedation, respectively. Tn addition, if a local an- analgesia and sedation, and will slightly prolong
esthetic can be used to desensitize the surgical the anesthesia. A benzodiazepine can also be
site, the general anesthetic requirements are often administered IV prior to ketamine to enhance
decreased. muscle relaxation . Diazepam or midazolam can
be used at the dose of 0.06 mg/kg. In draft horses,
the doses of the drugs are decreased by 10% to
20%? If the duration of anesthesia needs to be
a,-Agonist-Dissociative Combinations
extended) one half of the original dose of xylazine
Xylazine and ketamine are commonly used and ketamine can be administered together IV.
together for short general anesthesia. Xylazine Detomidine or romifidine can also be used as a
(l.l mg/kg IV) is administered, and then after the preanesthetic prior to ketamine anesthesia. 68. 70
horse is sedate (usually abo ut 5 minutes) keta- The doses used are detomidine (0.02 mg/kg IV),
mine is admi nistered (2.2 to 2.75 mg/kg IV).6l·'" or romifidine (0.08 to 0.12 mg/kg IV), followed by
This will usually provide approximately I 0 minutes ketamine (2 to 2.2 mg/kg IV). Because of the
of light general anesthesia. Mules and donkeys do longer duration of action of these drugs, if addi-
not respond adequately to this combination and tional time is needed, a half dose of ketamine
may not even become recumbent if the lower ket- only should be administered. Butorphanol or a
amine dose is used."·66 Butorphanol (0.02 mg/kg) benzodiazepine co uld also be used with these
can be adm inistered with xylazine to en hance combinations.
), 36 PRESURGICAL PREPARATION AND ASSESSMENT

a ,-Agonists can be combined with Telazol. longed and the horse is unable to get up but does
The a,-agonist should be administered first and not appear sedate, fluids should be administered
Telazol is administered only after th e horse is in an attempt to improve excretion of the drugs
sedate. Xylazine (1.1 mg/kg IV ) can be combined and their metabolites.
with Telazol (1.65 mg/kg IV ) to produce general Detomidine can be used with guaifenesin and
anesthesia of approximately 20 to 30 minutes. 62,7 1 ketamine after indu ction with detomidine and
Alternatively, detomidine can be used. Detomi- ketamine. 76,77 The preparation used contains ket-
dine at doses of 0.02 mg/kg or 0.04 mg/kg IV amine (2 mg/mL) and detomidine (0.02 mg/mL)
followed by Telazol (2 mg/kg IV) produced ap- in 10% guaifenesin administered at approxi-
proximately 25 and 30 minutes of anesthesia, mately 1 mLlkg/hr. If 5% guaifenesin is used, the
respectively." Xylazine (0.44 mg/kg IV ) can be ketarnine and detomidine concentrations should
followed by a mixture ofTelazol dissolved in deto- each be reduced by one half (l mg/mL and 0.01
midine and ketamine to produce recumbency of mg/mL, respectively). The infusion rate for the
approximately 40 minutes" A 500-mg bottle of less concentrated mixture is 2 mLlkg/hr.
Telazol is dissolved in 4 mL of 100 mg/mL keta- Romifidine with guaifenesin and ketamine has
mine and 1 mL of 10 mg/mL detomidine. Three been used as a maintenance anesthetic following
milliliters of the mixture per 450 kg of body induction with romifidine and ketamine. 78 The
weight is th e recommended dose. induction dose is 0.1 mg/kg of romifidine IV fol-
lowed by 2.2 mg/kg of ketamine IV. The mainte-
nance infusion consists of an initial bolus of 50
a,-Agonist-Dissociative-Guaifenesin
mg/kg of guaifenesi n followed by IV infusion of
Combinations
romifidine (0.0825 mg/kg/hr), ketamine (6.6 mg/
The combination of guaifenesin, ketamine, and kg/hr ), and guaifenesin (l00 mg/kg/hr). After 30
xylazine (GKX), or "triple drip:' has been used for minutes, the guaifenesin infusion rate is decreased
many years in equine anesthesia. This combina- 50%.
tion was first described as an induction comb ina-
tion 73 and later as a maintenance anesthetic.?4
Thiopental-Guaifenesin Combinations
When used as a maintenance anesthetic, 0.5
mg/mL of xylazine and 1 or 2 mg/mL of ketamine The use of guaifenesin with thiopental allows the
are added to a 5% solution of. guaifenesin in use of a lower dose of thiopental and usually pro-
dextrose. One liter of 5% guaifenesin would have duces better recovery than the use of thiopental
5 mL of 100 mg/mL xylazine and 10 or 20 mL of alone. Induction is usually preceded by the
100 mg/mL ketamine added. It should always be administration of an ~-agonist such as xylazine
administered through a catheter because extravas- or detomidine. Both thiopental and gua ifenes in
cular guaifenesin can cause severe tissue damage. will cause tissue damage. Therefore, it is essential
In addition, the vein used for administering the this mixture be administered via an indwelling IV
anesthetic should not be occluded so blood can catheter located in a vessel with good blood flow.
flow freely to allow distribution of the drug and A 14-gauge or larger catheter is recommended to
prevent thrombophl ebitis. Triple drip can be used allow the rapid administration of the thiopental-
as an induction agent in horses sedated with guaifenesin mixture. To administer this mixture,
xylaxine. 74 More commonly, however, it is used as 2g of thiopental is added to 1 L of 5% guaifen-
a maintenance anesthetic following induction esin. 64 This mixture is then administered IV as
with xylazine and ketam ine as described earlier in rapidly as possible until the horse is recumbent.
this section. It is infused at a rate that produces To speed induction, 1 additional gram of thiopen-
the desired level of anesthesia, but the mainte- tal can be administered IV as the horse begins to
nance infusion rate is usually 2.2 to 2.75 mLlkg/hr relax. If drug administration is stopped after the
(approximately 1 mLllb/hr)."'·"·" The higher con- horse is recumbent, the duration of anesthesia
centration of ketamine allows slightly slower will be 10 to 20 minutes. Additional anesthesia
infusion rates for longer procedures. This is an time can be produced by continuing the infusion
appropriate anesthetic technique for up to 90 to effect. The typical infusion rate will be approx-
minutes in healthy horses. If the recovery is pro- imately 1.5 mLlkg/min." If more than 1 L of the
longed, tolazoline can be used to antagonize the mixture is to be used, the second liter should only
sedative effects of xylazine. 75 If the recovery is pro- contain 1 g of thiopental (l mg/mL). Total anes-
Field Anesthesia 37

thesia time with this mixture should be limited to eyes with a towel will protect the eyes somewhat
30 minutes or less. After short anesthetic periods, and eliminate visual stimulatio n of the patient.
recovery from this mixture is usually quiet and The surface the horse is placed on should be
uneventful. smooth and can be padded if padding is available.
It is important to minimize the time spent
positioning the patient for sho rt procedu res
MONITORING HORSES WHILE UNDER since limiting anesthesia time usually results in
INJECTABLE GENERAL ANESTHESIA better recovery. Proper positioning of the patient
will limit the potential for myopathi es and
In general, sophisticated monitoring equipment is neuropathies.
not used during field anesthesia. Efforts should be When in lateral recumbency, the lower front
made to ensure adequate circulatory and respira- leg should be pulled as far rostral as possible to
tory function. 79 This can be as simple as palpating eliminate pressure on the brachial plexus and
the pulse, observing chest wall movement, and associated blood vessels. The halter should also be
observing mucous membrane color. Normal removed to prevent facial nerve damage on the
horses will have a pulse rate between 25 and 50 down side. Positioning of the lower hind limb is
beats per minute and a respiratory rate of 6 to 12 not as critical, but it is commonly puUed forward
breaths per minute. as well to decrease pressure on the medial mus-
Anesthetic depth is determined by assessing culature. Both the front and hind upper limbs
the palpebral and corneal reflexes and watching should be suppo rted in a position parallel with
for the presence of nystagmus. Horses under the ground. Horses positioned in dorsal recum-
injectable general anesthesia will appear to be at a bency should have their head and neck positioned
lighter plane of anesthesia than those under in a natural position to ensure a patent airway.
inhalation anesthesia. The corneal and palpebral The legs should be allowed to assume a natural,
reflexes should be present. Also, the character of semi-flexed position. Unless necessary for the pro-
breathing will often change as the depth of anes- ced ure, the hind limbs should not be kept in an
thesia decreases. Commonly, deep "sighs" and extended position.
intermittent breath holding will occur at a light Fluid therapy is not commonly administered
level of anesthesia. Usually, if nystagmus is to equine patients undergoing short field proce-
present, the depth of anesthesia is inadequate dures but is appropriate if indicated. Ally balanced
unless the procedure is almost complete. If anes- crystalloid solution such as 0.9% saline or lactated
thesia is being maintained by an infusion, the rate Ringer's solution can be administered at a rate
of the infusion can be increased if deeper anes- of 5 mL/kglhr to maintain vascular volume and
thesia is needed. When the horse is very light, a promote tissue perfusion. Any significant blood
small bolus (0. 1 to 0.5 mLlkg) of the infusion can loss can be treated by administering 3 mL of crys-
be rapidly administered. During anesthesia with talloid fluid for each milliliter of estimated blood
an (X2-agonist-ciissociative combination, an addi- loss. In healthy animals, this is usually adequate
tional dose of (X2-agonist-dissociative or dissocia- therapy for blood losses of up to 10% of the
tive alone can be administered. The usual dose is blood volume. Ideally any preexisting dehyd ration
half of the induction dose. should be corrected prior to anesthesia. If this is
not possible, the fluid deficit can be replaced while
under anesthesia. The fluid deficit is commonly
SUPPORTIVE CARE FOR HORSES WHILE estimated by multiplying the perceived amount of
UNDER INJECTABLE GENERAL ANESTHESIA dehydration (in percent) and the animal's weight
(in kilograms) to determine the deficit (in liters).
Because patients undergoing surgical procedures A 450-kg animal that is 5% dehydrated would
in the field are usually relatively healthy and need 22.5 L to replace its deficit (0 ..05 x 450 kg =
support facilities are limited, intensive supportive 22.5 L).
care is usually not administered. An ocular lubri- Under field conditions, intubation is not essen-
cant or ocular antibiotic ointment (without tial for the equine patient. It does protect the
steroids) should be placed in both eyes to prevent airway from occlusion and allow mechanical ven-
corneal drying and th ere should be nothing near tilation if needed. It would certainly be beneficial
the eye that could rub on the cornea. Covering the to at least have an endotracheal tube available.
I
I
38 PRESURGICAL PREPARATION AND A SSESSMENT

Oxygen supplementation can easily be done in ideal. The horse should be fitted with the correct
the field using a portable E oxygen tank, regula- size nylon halter and a sturdy lead rope should be
tor, and flowmeter. A full E tank will hold approx- available. If an a z-agonist-dissociative combina-
imately 650 L of oxygen. The oxygen can be tion is used, the horse can easily be induced by one
,I
administered via a nasal insufflation line at a flow person. After administration of the dissociative
rate of 5 to 10LImin. Oxygen can also be supple- agent, the handler maintains control of the head.
mented using an E tank and a demand valve. The Generally, the horse will lean back and the handler
demand valve is attached to an endotracheal tube may have to hold the head down to keep the horse
and can be used in two ways. If the horse is breath- from going over backward. Alternatively, the
ing spontaneously, the demand valve is auto- handler can stand at the shoulder of the horse a nd
maticall y triggered during inspiration and the move the horse in a circle around him. One hand
inspired air is supplemented with oxygen. Alter- should be on the horse's shoulder and the other
natively, if the horse is not breathing well sponta- holding the lead rope close to the horse's head. As
neously, the demand valve can be manually the dissociative agent takes effect, the rear end of
triggered to start the oxygen flow. Once an ade- the horse will usually swing away from the
quate volume has been delivered, which is deter- handler. He or she sho uld be on the side of the
mined by watching the chest excursion, the trigger patient that is to be up once the horse is anes-
is released and the horse passively exhales. The thetized if it is to be positioned in lateral recum-
demand valve must have a high maximum flow bency. As the horse goes down, the handler ca n
and have an adaptor to allow it to be attached to step toward the head and control its fall by
an equine endotracheal tube. Some demand holding onto the lead rope. If a guaifenesin
valves designed for human use do not have an mixture is used for induction, it is difficult to hold
adequate peak flow rate. The flow rate should be the horse and the drug container. A second person
in excess of 150 Llmin. At least one demand valve is needed to manage the drug bottle as the horse
has both the required flow rate and necessary is going down. If several assistants are available,
adaptors for equine use (Eq uine Demand Valve; an alternative method can be used. One person
JD Medical, Phoenix Ariz.). should be at the head holding th e lead rope and a
second person should hold the tail. If the horse is
nervous, the person holding the tail should wait
until the horse is almost ready to go down before
INDUCTION AND RECOVERY FOR
grabbing it, recognizing that the horse may still
INJECTABLE FIELD ANESTHESIA
kick. Two additional assistants are at the horse's
shoulders. As the horse begins to relax, the assis-
Induction
tants on the head and tail pull in opposite direc-
Before administering any anesthetic drugs, a tions and down. The assistants on the shoulders
quick physical examination should be performed. attempt to keep the horse from falling sideways.
Any obvious health problems or injuries should This should allow the horse to go down into a
be brought to the attention of the owner or agent sternal position, and it can then be rolled onto
and their effect on anesthesia discussed. The either side.
risk of anesthetic and surgical complications
should be discussed and made clear to the owner
Recovery
as well. In a comprehensive survey of almost
42,000 equine anesthetic cases, the overall death Recovery after short injectable anesthesia is usu-
rate (excl uding colic surgeries) was 2.4%.80 This ally relatively smooth. If the horse was nervous
included horses that died or were euthanized. If and excited during induction, the recovery may be
only the horses undergoing injectable anesthesia less than optimal. IdeaLly during recovery, the
were evaluated, the death rate dropped to 0.3%. horse will move into a sternal position, wait a few
Although this may seem to be a big positive for minutes, and then stand uneventfully. Covering
injectable anesthesia, one must realize these were the horse's eyes with a towel often will help keep
generally healthy horses undergoing short proce- the horse from trying to get up before it is ready.
dures with anticipated high success rates. In addition, it is important to keep the surround-
A level area free of obstacles should be selected ings as quiet as possible during recovery. A sudden
for the procedure. An open grass-covered area is loud noise may arouse the horse before it is able
Field Anesthesia 39

to stand. If the horse is trying to get up but is joint is located by moving the ta il up and down
unable to remain standing, a small dose of and palpating for flexion. Once the joint has been
xylazine (0.2 to 0.4 mglkg IV) may calm the ani- located, 2 mL of a local anesthetic such as 2% li-
mal and provide a quieter recovery. Some practi- docaine can be injected into the superficial tissues
tioners advocate holding the horse down until it is over the joint. An 18- or 20-gauge 2.5- inch (6.4-
able to get up, and this may be of benefit. It is best em) spinal needle is used to access the epidural
done by kneeling on the horse's neck at the dorsal space. In large or heavily muscled horses, a 3.5-
aspect and holding the head to keep the horse from inch (8.9-cm ) needle may be needed, and in many
swinging it up. Once the horse's attempts to get up horses, a standard 1.5-inch (3.75-cm ) hypodermic
have become more vigorous, the head can be needle will be ad equate (Figure 5-1). The needle
released and the horse allowed to stand. After it is is introduced perpendicular to the skin directly
standing, it is important to try and steady the horse over the center of the space on the midline. As the
to keep it from stumbling around and injuring needle is advanced and the epidural space is
itself. If it is stand ing but very Wlstable, a second entered, a loss of resistance will be felt. If the tip
person holding the tail may be of benefit. of the needle strikes the floor of the canal, it
should be withdrawn slightly. There should be no
resistance to the injection of fluid o r air at this
EPIDURAL ANESTHESIA AND ANALGESIA point. An alternative method of determining
when the epid ural space is entered is called the
Epidural anesthesia is an excellent method of pro- "hangin g drop" technique. After the needle has
viding desensitization to the tail and perineal been advanced through the skin and into the soft
region of the standing horse. Local anesthetics tissue overlying the intervertebral foramen, the
traditionally have been used, but more recently stylet is removed (if present) and a small amount
other drugs such as opioids and ur agonists have of saline or local anesthetic is instilled into the
been used separately or with local anesthetics to hub of the needle. As the tip of the needle pene-
improve the desensitization provided by local an- trates the ligamentum flavum. the fluid runs
esthetics or provide long-term pain control. down the needle into the epidural space and the
fluid in the hub disappears.
Anatomy If repeated epidural injections are to be made,
The spinal cord and meninges usually end in the an epidural catheter can be placed to make this
sacrum. Epidural injections are usually performed more convenient. Several commercial epidural
at the sacrococcygeal or first intercoccygeal joint. catheter kits that are suitable for equine use are
Either location is acceptable, and the injection site available. The needle insertion technique is the
can generally be determined by moving the tail up same as described above but a different needle is
and down and palpating for the most proximal
movable joint. The depth of the soft tissue over
the first intercoccygeal space is 3.5 to 8 cm. Bl The
nerves desensitized by the injection of a local
anesthetic in this area include the caudal and 52
to S5 sacral spinal nerves. These provide nerve
fibers making up the pudendal, middle rectal, and
cau-dal rectal nerves. The S2 nerve also con-
tributes motor innervation to most of the hind
limb, and blockade of this nerve may cause hind
limb ataxia. For this reason, it is important to limit
the volume oflocal anesthetic injected because the
volume injected will determine the rostral extent
of the blockade. Figure 5-1 A sagittal section through the sacrococ-
cygeal region of an equ ine cadaver showing the needle
Technique placement for a caudal epidural injection. The upright
needle is 2.5 inches long and the more caudally inserted
After the hair is clipped, suitably cleaned, and dis- needle is 3.5 inches in length. The horse we ighed
infected, the sacrococcygeal or first intercoccygeal approximately 500 kg when alive.
40 PRESURGICAL PREPARATION AND ASSESSMENT

used. A Touhy needle with a slightly curved tip take up to 20 minutes. The opioid most co m-
allows eas ier placement of the catheter. After monly used for epidural injection is morphine;
the needle is in place, the catheter is advanced the dose usually used is 0.1 mglkg." This dose can
I through the needle and cranially into the epidural provide analgesia without any motor effects for up
space. The opening on the needle should be ori- to 18 hours. Co mmercial preservative-free mor-
ented cranially. and this can be checked while the phine preparatio ns are available that should be
needle is in the animal by observing the notch on used if possible. especially if multiple injections
the hub of the needle. This notch will be over are to be performed. Unfortunately. the currently
the opening at the distal end of the needle. The available preservative-free preparations are so
catheter should be advanced 5 to 10 cm cranially. dilute, the volume required is too large to be prac-
If local anesthetics are to be injected, this d istance tical. When th e more concentrated morphine
should be shorter, only 2 to 4 cm, to prevent an preparations are used, they should be diluted to a
impairment of motor innervation to the hind total volume of 10 mL with 0.9% sterile saline.
limbs. Once the catheter is in place, the needle is Xylazine can be administered epidurally by itself
withdrawn and the injection hub is attached to or with other drugs. It appears to have some weak
the catheter per the manufacturer's instructions. local anesthetic effects that are not reversed by Cl 2 -
The catheter is then secured to the horse, and the antagonists as well as analgesic effects produced
injection hub and site of entry of the catheter by adrenergic receptors in the spinal cord. The
through the skin are covered. It is important to usual dose is 0.17 mglkg" The author often adds
secure the catheter in such a way that prevents I mL of 100 mglmL xylazine to 4 mL of 2% lido-
kinking or accidental removal. The catheter ca ine to be used for caudal epidural injection in a
should be flushed daily if no therapeutic injec- 4S0-kg horse.
tions are performed.

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Field Anesthesia 41

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dine, romifi dine and xylazine. Zentralbl Veter;l1- trated solutions of guaifenesin for eq uine anesth e~
armed A 41:523 , 1994. sia,] Am Vet Med Assoc 176:6 19, 1980.
20. Spyridaki MH, Lyris E, Georgoulakis I, et al: Deter- 36. Herschl MA, Tr im CM, Mahaffey EA: Effects of 5%
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in equine urine for dopi ng analysis, ] Pharm endothelium, Vet SlIrg 21 :494, 1992.
Biollled A,wl 35: 107, 2004. 37. Davis LE, WolffWA: Pharmacokinetics and m etab-
21. Sa lonen }S, Suoli n na EM: Metabolism of deto m i- olism of glyceryl guaiacolate in ponies, Alii ] Vet Res
dine in the rat. I. Co mpar ison of 3H-labell ed 31:469, 1970.
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Metab Pharmacokiflet 13:53, 1988. mon ary effects of narcotic agonists and a partial
22. Salonen JS, Vaha-Vahe T, Vainio 0, et al: Single- agonist in ho rses, Am / Vet Res 39: 1632, 1978.
dose pharmacokinetics of detomidine in the ho rse 39. Amadon RS, Cra ig AH: The actions of morphine
and cow,] Vet PllQrmacol Ther 12:65, 1989. on the horse. Prelim inary studies: diacetyl mor-
23. Mudib AE, Ch ui YC, Young LM , et al: Characteri- phine (heroin), dihydrodesoxymo rph ine-D (deso-
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Metab Dispos 20:840, 1992. 40. Mircica E, Clutton RE, Kyles KW, et a1: Problem s
24. Freeman SL, Bowen 1M, Bettschar t-Wolfensberger associated with perioperative morphine in horses:
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1
42 PRESU RGICAL PR EPARATION AND ASS ESSMENT

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1994. 57. Taylor PM: Th e stress response to anaesthes ia in
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of laparoscopic surger y using a detomidine- 59. W ilson DV, Bohart GV, Eva ns AT, et al: Retrospec-
buprenorphine combination in standing horses, t ive analysis of detomidine infusion for sta nding
Vet Allaestll Allnlg 30:72, 2003. chemical restraint in 5 I horses, Vet Anaesth Analg
45. Maxwell LK , Thomasy SM, 510vis N, et al: Phar- 29:54, 2002.
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sition of ketamine, int Anesthesiol eli" 12:157. anesthetic drug combinatio ns study in ponies, Acta
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48. Rogers R, W ise RG, Pai nter OJ, et al: An investiga- 63. Muir WW, Ska rda RT, Milne OW: Evaluation of
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2004. pa riso n of four drug combinations for total intra-
49. Kapfer S, Alfonsi p, Gu igna rd B. et al: Nefopam and venous anesthesia of horses undergoing surgical
ketamine co mparably enhance postoperative anal- rem oval of an abdominal testis, J Am Vet Med Assoc
gesia. Anesth Allnlg toO: 169, 2005. 217:869, 2000.
50. Ed rich T, Friedrich AD, Eltzsch ig HK, et al: Keta- 65. Matthews NS, Taylor T5, Skrobarcek C L, et al: A
mine for long-term sedat io n and an alges ia of a comparison o f injectable anaesthetic reg imens in
burn patient, Allestlt Analg 99:893, 2004. mules, Eqllille Vet' SlIppl 34, 1992.
51. Ozyalcin NS, Yuce! A, Ca mlica H , et al: Effect of 66. Matthews NS, Taylor TS: Anesthetic management
pre-emptive ketamine on senso ry changes and of donkeys and mules. In Steffey EP, editor: Recellt
postoperative pain after thoracotomy: compariso n advances in allesthetic mallagement of large domes-
of epidural and intramuscular routes, Br , Annesth tic animals, Ithaca, N.Y., 2000, International Veteri-

93:356, 2004. na ry Inform ation Service (www.ivis.org).
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Field Anesthesia 43

70. Taylo r PM , Benn ett Re, Brearley Je, et al: Com - 78. McMurphy RM, Young LE, Marlin Dj, et a1:
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ho rses un dergoing elective surgery, Am J Ve t Res romifidi ne, guaifenes in , and ketamine with an es-
62:359,200!. thesia maintai ned by inhalation of h alotha ne in
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59: 17, 1995. Assoc201:1 187, 1992.
77. van Dijk P: Intraveno us anaesthesia in horses
by gua iphenesin -ketam ine-detomidine infusion:
some effects, Vet Q 16(suppI 2):SI22, 1994.
1MB URGERIES

45
Chapter 6
Periosteal Transection and Elevation
Rick D. Howard

between the common and lateral digital extensor


INDICATIONS tendons, a site with minimal soft tissue overlying
the radius. The surgical approach fo r treatment of
Performed alone for the treatment of angular
tarsal valgus is over the lateral malleolus of the
limb deformities in foals with mild to moderate
tib ia just proximal to the distal tibial physis
deformity or in combination with transphyseal
(Figure 6-2). The vertical skin incision is posi-
bridging for foals with more severe deformities.
tioned either just cranial or caudal to the lateral
Most commonly used for treatment of carpal
digital extensor tendon. The surgical approach for
valgus and tarsal valgus but also for varus or
treatment of metatarsophalangeal or metacar-
valgus deformities of the metacarpophalangeal or
pophalangeal angular limb deformities is on the
metatarsophalangeal joints.
concave side of the limb using an approach just
proximal to the distal physis of the 3rd metacar-
pal bone or the 3rd metatarsal bone. Periosteal
EQUIPMENT transection and elevation to augment growth at
the proximal physis of the first phalanx through
A hooked surgical blade and periosteal elevator. an approach just distal to the proximal physis of
the 1st phalanx may be indicated in certain
cases.
POSITIONING

Dorsal recumbency is preferred for bilateral PROCEDURE


procedures or when performed concurrent with
transphyseal bridging. Lateral recumbency is pre- Periosteal transection and elevation is performed
ferred for unilateral cases or for bilateral cases on the lateral aspect of the limb for treatment of
(with rolling) not requiring concurrent trallsphy- valgus deformities and on the medial aspect of the
seal bridging. limb for the treatment of varus deformities. A 3-
to 4-cm vertical incision is made in the skin and
subcutaneous tissues parallel to the long axis
ANATOMY of the bone beginning I to 2 cm proximal to the
physis and extending proximally. The incision is
The surgical approach for treatment of carpal carried to the level of the periosteum. Curved
valgus is over the distolateral aspect of the radius hemostatic forceps are used to bluntly dissect
just proximal to the distal radial physis (Figure between the periosteum and overlying soft tissues
6-1). The vertical skin incision is positioned extending from the distal aspect of the incision in

46 •
Periosteal Transection and Elevation 47

1-
Site of
surgical ___-1',
approach

Figure 6-3 Occasionally, a rudimentary cartilagi-


nous ulna is noted, which should be transected using a
Figure 6-1 Incision site for periosteal transection No. 10 scalpel blade. When ossified, as is typical in older
on the lateral aspect of the left forelimb between the foals. a segmental ulnar ostectomy should be performed
common (1) and lateral (2) digital extensor tendons •
uSing rongeurs.
sta rting at the level of the distal radial physis and
extending proximal 3 to 4 em.

Figure 6-4 The periosteum is initially transected


alo ng the lateral hemicircumference of the bone. The
periosteum is then incised longitudinally extending
proximally 3 to 4 em from and connecti ng with the hor-
izontal periosteal transection. The resulting paired tri-
I angular shaped flaps of periosteum are elevated with a
periosteal elevator.

Figure 6-2 Incision site for periosteal transection


on the lateral aspect of the left tibia on either side in older foals, a segmental ulnar ostectomy should
(dotted lines) of the lateral digital extensor tendon (1) be performed using rongeurs (Figure 6-3) . The
starting at the level of the dista l tibial physis and extend- periosteum is then incised longitudinally extend-
ing proximal 3 to 4 em.
ing proximally 3 to 4 em from and connecting
with the horizontal periosteal transection. The
the cranial and caudal planes. The subcutaneous resulting paired triangular shaped flaps of per-
tissues and tendons are elevated with curved iosteum are elevated with a periosteal elevator
hemostatic forceps. A No. 12 hooked scalpel blade (Figure 6-4). The subcutaneous tissues are sutured
is used to transect the periosteum along the lateral with absorbable material in a simple continuous
hemicircumference of th e bone. When performed pattern, and th e skin is sutured closed with intra-
for treatment of carpal valgus, the rudimentary dermal sutures or with simple interrupted sutures
cartilaginous ulna should also be transected using of No. 3-0 nonabsorbable monofilament suture
a No. 10 scalpel blade. When ossified, as is typical material. The wound is bandaged routinely.


48 LIMB SURGERIES

tion and elevation using a blind approach through


POSTOPERATIVE CARE
a I-em-length skin incision. Using the blind tech-
nique, th e surgical wounds are allowed to heal by
Postoperative Care second intention under a bandage. The primary
advantages of the technique are the decreased sur-
Bandaging: Postoperatively, the surgical site is gical time and decreased incisional complications.
maintained under a bandage for 10 to 14 days.
Postoperative care is essentially as described for
Suture Removal: If skin sutures are placed, they
should be removed after 10 to 14 days. the open technique for periosteal transection and
Exercise: The foal is strictly confined to a stall for elevation.
10 to 14 days. Exercise restriction is instituted
postoperatively to reduce trauma to the asym-
metrically loaded physis and cuboidal bones and COMMENTS
is considered an essential component of the ther-
apeutic plan during postoperative convalescence. The differential diagnoses for angular limb defor-
The duration and degree of exercise restriction mities in foals include intercarpal or intertarsal
are dependent on the age of the foal and the ligament laxity, crushed carpal or tarsal bones,
severity of the angular limb deformity; however, distal radial or tibial physeal dysplasia, and physeal
strenuous exercise should not be allowed until the
trauma resulting in premature closure of the
angular limb deformity has been corrected.
Other: The hooves should be trimmed to achieve physis. Preoperative radiographs are important to
balance and the foal maintained on a nutritionally confirm the source of the angular limb deformity
balanced diet. and to determine if surgical manipulation of the
growth plate is indicated for treatment of the defor-
mity. Dorsopalm ar (plantar) and lateral medial
radiographic views of the affected area will gener-
EXPECTED OUTCOME ally confirm the source of the angular deformity.
Periosteal transection and elevation is best
The expected degree of correction is proportional indicated for deformities associated with physeal
to the amount of growth expected to occur at the dysplasia. Periosteal transection and elevation
affected physis during the 6 to 8 weeks following requires a functioning physis to be effective. If the
surgery. It is considered that after this amount of physis is crushed, as occurs with Salter-Harris
time no further benefit is derived from periosteal type V or VI fractures, the procedure will not be
transection and elevation. In cases where partial effective because the physis is unable to respond.
but inadequate correction is ach ieved, repeated Angular limb deformities may also be associ-
surgery may be warranted provided adequate ated with the metaphysis or diaphysis of long
growth potential remains. In contrast to the bones; typically the third m etacarpal or metatarsal
transphyseal bridge procedure, overcorrection of bones. These deformities are usually congenital
the angular limb deformity is not a complication and their repair is beyond the scope of this book.
of periosteal transection and elevation. Since its introduction in to equine surgery in
1980, periosteal transection and elevation has
been widely accepted as an effective method for
COMPLICATIONS augmentation of axial limb growth in the treat-
ment of angular limb deformities. 1.2 The effec-
Complications include incomplete correction of tiveness of the procedure has been questioned.
the angular limb deformity, incisional dehiscence, The results of a study on the efficacy of periosteal
and development of arthropathy as sequelae to transection and elevation for the treatment of
the damage induced by asymmetric loading of the experimentally induced carpal valgus indicated
cuboidal bones during weight bearing. foals treated with stall confinement and hoof
trimming alone or with the addition of periosteal
transection and elevation demonstrated a similar
ALTERNATIVE PROCEDURES correction in angular limb deformity.3 Although
the results were significant, it is important to note
An alternative technique to the open technique as that the transphyseal bridge model for carpal
described involves performing periosteal transec- valgus used in that study may be an inadequate

Periosteal Transection and Elevation 49

ld approach through model for naturally occurring carpaJ valgus 2. Auer JA, Martens RJ. Williams EH: Periosteal tran-
Jsing the blind tech- and that extrapolation of the results to naturally section for correction of angular limb deformities in
:e allowed to heal by foals. J Am Vet Med Assoc 181 :459. 1982.
occurring disease may be inappropriate.
3. Read EK, Read MR, Townsend HG, et al: Effect of
ndage. The primary
hemi -circumferential periosteal transection and ele-
re the decreased SUf-
vation in foa ls with experimentally induced angular
lonal complications. REFERENCES limb deformities. ] Am Vet Med Assoc 221 :536,2002.
Ily as described for
teal transection and 1. Auer JA, Martens RJ: Angular limb deformities in
young foals, Proc Am Assoc Equine Pract 26:81, 1980.

limb defor-
or intertarsal
tarsal bones.
pP"tSla, and physeal
closure of the
are important to
limb deformity
ianipullati',In of the
of the defor-
lateral medial
area will gener-
deformi ty.
elevat,,''n is best
with physeal
and elevation
effective. If the
Salter-Harris
will not be
to respond.
also be associ-
of long
or metatarsal

indicated
and hoof

In'''',n'to note
for carpaJ
an inadequate
CHAPTER 7
Transphyseal Bridging
Rick D. Howard

periostea l transection and elevation. Lateral re-


INDICATIONS
cumbency is used for unilateral cases not requir-
ing periosteal transection and elevation .
Transphyseal bridging is performed alone or
in combination w ith periosteal transection and
elevation for the treatment of angular limb de·
ANATOMY
formities associated with the carpus, tarsus, meta-
carpophalan geal, or metatarsophalangeal joints
Regardless of the technique used, transphyseal
in young foals «3 months of age) with severe
bridging requires the placement of an orthopedic
angular limb deformity or in foals with clinically
implant in the epiphysis of the operated bone. The
significant deformity after the potential for rapid
surgeon should become famili ar w ith the size and
growth has passed: 2 months for the distal 3rd
contour of the epiphyses of comm only operated
m etacarpal) 3rd metatarsal, and proximal 1st
bo nes to avoid inadvertent damage to the articu-
phalangeal physes; 4 months for the distal tibial
lar surfaces of the adjacent joint. Because of the
physis; and 6 months for the distal radial physis.'·2
irregular shape and narrow proximal-to-distal
dimension of th e distal tibial epiphysis, radi-
ographic guidance is essential to avoid the risk of
EQUIPMENT errant placement of the implant into the tibio-
tarsal joint. Radiographic confirmation of correct
An AO-ASIF 4.5-mm or 5.5-mm screw set, instru- screw placement is recommended for transphy-
mentation for placement and removal of screws, seal bridging at all locations.
and orthopedic wire are required. Alternatively,
self-tapping screws may be used, reducing the
required orthopedic equipment to a drill, an PROCEDURE
appropriate-size drill bit, screwdriver, self-tapping
screws, and orthopedic wire. Equipment for ob- Transphyseal bridging is performed on the medial
taining intraoperative radiographs is also neces- aspect of the limb for the treatment of valgus
sary. deformities and on the lateral aspect of the limb
for the treatment of varus deformities. Periopera-
tive antibiotics are administered, the foal is anes-
POSITIONING thetized and positioned, and the surgical site is
prepared aseptically fo r surgery. A curvilinear
Dorsal recumbency is preferred for bilateral pro- incision is made in the skin and subcutaneous
cedures or when performed concurrently with tissues oriented along the long axis of the radius

50
Transphyseal Bridging 51

':,L '---- Epiphysis

.,,:[~t;..t'«... .

Figure 7-2 Hypoderm ic needle in position to iden-


tify the distal radial physis . Two screws are placed per-
pendicular to the long axis of the bone approximately
I to 2 em proximal and distal to the physis.

Figure 7-1 A curvili near incision (dotted lille) is


made over the medial aspect of the left distal radial
physis or iented along the long axis of the radius, begin-
ning at the level of the radiocarpal joint and extend in g
toward the diaphysis of the bone for exposure of the
epiphysis, the physis, and 2 to 3 em of the metaphysis .

beginning at the level of the radiocarpal joint and


extending toward the diaphysis of the bone for
exposure of the epiphysis, the physis, and 2 to 3
cm of the metaphysis (Figure 7-1). The soft tissues
are bluntly dissected and retracted. Then 22-gauge
Figure 7-1 A figure of eight wire (IS-gauge o rtho-
I.S-inch needles are placed into the radiocarpal
pedic wire) is placed around the heads of the screws and
joint space and the physis. A I-em incision is
tightened using a wire hvister or pliers.
made with a scalpel through the collateral liga-
ment midway between the needles for placement
of the epiphyseal screw (Figure 7-2). Using radi-
ographic guidance for screw placement and ori-
entation, a 3.2-mm pilot hole is drilled, measured,
and tapped for placement of a 4.5-mm screw. As ~(}.v.,c.,;t~
a general rule, the epiphyseal screw is placed Figure 7-4 A second figure of eight wire is placed
roughly parallel to the physis, except in the distal and ti ghtened as described and the wire tw ists are bent
tibial physis, where a shorter screw is used and the against the bone toward the adjacent joint.
screw mllst be angled from distal to proximal to
avoid entering the tibiotarsal joint. A 40-mm- metaphysis and tightened incompletely. A figure
length cortical screw is inserted into the epiphysis of eight wi re (lS-gauge orthopedic wire ) is placed
and inco mpletely tighten ed. A I-em incision is around the heads of the screws and tightened
made in the periosteum over the metaphysis at a using a wire twister or pliers (Figure 7-3). A
site approximately 2 to 3 cm from the physis. The second figure of eight wire is placed and tightened
periosteum is elevated, and a 4.5-mm 40-mm- as described, and the wire twists are bent against
length co rtical screw is similarly placed in the the bone toward the adjacent joint (Figure 7-4).

52 LIMB SURGERIES

The screws are tightened with a screwdriver until Postoperative Care


the heads are flush with the soft tissues, taking
care not to tighten the screws excessively as this Bandaging: The surgical site is maintained un-
will cause the wires to become dislodged over the der a bandage until skin sutures are removed at
10 to 14 days.
screw heads. Tightening the screws places addi-
Exercise Restrictions: Postoperatively, the foal
tional tension on the figure of eight wires as the should be strictly confined to a stall. Exercise
bevel of the screw head engages the wires. The restriction is instituted postoperatively to reduce
subcutaneous tissues are sutured with absorbable trauma to the asymmetrically loaded physis and
material in a simple continuous pattern, taking cuboidal bones and is considered an essential
care to cover as much of the implant as possible. component of the therapeutic plan during post-
The skin is sutured with simple interrupted sutures operative convalescence. The duration and degree
of No. 3-0 nonabsorbable monofilament suture of exercise restriction are dependent on the age
material. The wound is bandaged routinely, and a of the foal and the severity of the angular limb
thin cotton padded outer wrap is placed to reduce deformity; however, strenuous exercise should not
external trauma to the surgical sites.
be allowed until the angular limb deformity has
been corrected.
Suture Removal: Skin sutures are removed at
10 to 14 days.
other: The hooves should be trimmed to achieve
balance and the foal maintained on a nutritionally
POSTOPERATIVE CARE balanced diet.

An essential component of the postoperative care


is the timely removal of the transphyseal bridge
implants. Client education is a key component of
successful case management. Clients should be
instructed that the implants must be removed EXPECTED OUTCOME
when the deformity has corrected or just prior
to complete correction. In contrast to periosteal The expected amo un t and rate of axial correction
transection and elevation, overcorrection of the are proportional to the growth potential of the
angular limb deformity occurs if timely removal affected physis and are dependent on the age of
of implants is neglected. In cases where bilateral the patient and the physis affected. Typ ically, rapid
transphyseal bridging is performed, the removal correction of the angular limb deformity occurs
of implants may need to be performed on sepa- in young foals) while slower, but steady, correctio n
rate occasions to allow adequate correctio n for is anticipated fo r the older patient.
each limb. Although implant removal may be
achieved in some foals using sedation and local
anesthesia, general anesthesia greatly facilitates
the procedure and is indicated for most cases.
Following routine aseptic preparation, the
position of the screw heads is identified by Swelling, inflammation, and scar tissue formation
probing with a hypodermic needle and a stab inci- at the surgical site of the implants are common
sion is made down to each screw head. A mos- but typically become less apparent once the limb
quito hemostatic forceps is used to retract the soft has straightened and resolve once the implants
tissues while a screwdriver is manipulated and have been removed. The development of infection
firmly seated into the screw head and used to may result in subcutaneous abscess o r skin inci -
remove each screw. A sturdy curved hemostatic sion dehiscence and in some cases necessitates
forceps placed through the stab incision over the premature removal o f the surgical implants. The
metaphyseal screw is used to hook the loops of the most serious potential complication is overcor-
figure of eight wires for extraction by firm trac- rection of the angular limb deformity. The gravity
tion. The skin incisions are sutured and the sur- of this complication should not be underempha-
gical site bandaged for 10 to 14 days until the sized; for example, a mild carpal valgus is typically
sutures are removed. o nly a cosmetic impairment compared with the

,
Transphyseal Bridging 53

potentially severe performance-limiting conse-


quences of a carpal varus deformity that may
result from delayed removal of transphyseal
bridge implants. Timely removal of implants is
essential to reduce the frequency of this compli-
cation.

ALTERNATIVE PROCEDURES

An alternative to the open technique as described


involves performing the surgery through stab
incisions made over the location of each screw
site. 2 The soft tissues between the screw holes are
bluntly undermined with mosquito hemostatic
forceps forming a tunnel for passage of the
figure of eight wires. Postoperative care is as
described for the open technique for transphyseal
bridging.
An alternative to screws and wires for Figure 7-5 Dorsopalmar radiograph of the carpus

I transphyseal bridging is the use of orthopedic


staples, initially described in 1963. 3 Staples have
with a single 4.S-mm cortical bone screw placed across
the distal radial physis as an alternative for transphyseal
bridging.
the advantage of being easier and quicker to
place and have a low complication rate. 4 Two
sizes of staples are commercially available: 22 x screw can be placed distal to proximal or proxi-
22 mm (Zimaloy Epiphyseal Staple; Zimmer, Inc., mal to distal as shown in Figure 7-5.
Warsaw, Ind.) and 29 x 22 mm (Blount E.S.;
Stryker, Kalamazoo, Mich.). Disadvantages of sta-
ples include the lack of compression across the COMMENTS
growth plate in the early postoperative period and
the limited flexibility in placement caused by the The primary advantage of transphyseal bridging
fixed leg length of the staple. compared with periosteal transection and eleva-
Another alternative is the recently described tion is the more consistent response achieved even
tech nique for the placement of a single transphy- in severely deformed or older patients. Unless the
seal screw for transphyseal bridging.s The de- physis is damaged on the side opposite the side
scribed technique involves the placement of a bridged or the physis is too mature to respond,
single fully threaded screw at an oblique angle in correction will occur. The disadvantages of the
lag fashion from the medial malleolus, across the procedure include increased time and cost of
physis and into the metaphysis of the tibia. The the procedure, the increased risk of infection, the
approach to the medial malleolus is via a stab inci- increased likelihood of a less-than-satisfactory
sion and is associated with minimal soft tissue cosmetic appearance, the requirement for more
dissection. Advantages cited for this technique special equipment, the possibility of overcorrec-
include reduced need for soft tissue dissection, tion, and the need for a second surgery to remove
improved cosmetic result, and reduced risk of the implants to avoid overcorrection.
infection. Although the authors indicate they had . The differential diagnoses for angular limb
used th is procedure in the treatment of carpal deformities in foals include intercarpal or inter-
valgus, the current report was limited to treat- tarsal ligament laxity, crushed carpal or tarsal
ment of tarsal valgus in 4- to 12-month-old bones, distal radial or tibial physeal dysplasia, and
horses. In this report of 11 cases, the tarsal valgus physeal trauma resulting in premature closure of
resolved and the cosmetic result was considered the physis. In addition, angular limb deformities
excellent. 5 We have used this method for correc- may also be associated with the metaphysis or dia-
.tion of ca rpal valgus in foals. In the carpus, the physis of long bones, typically the third metacarpal


54 L I MB SU RG ERIES

or meta tarsal bones. These metaphyseal or dia- Transphyseal bridging may also be used in
physeal deformities are usually congenital, and concert with periosteal transection and elevation
th eir repai r is beyond the scope of this book. in foals with severe deformities, as the two proce-
Preoperative radiographs are important to dures are performed on opposite sides of the limb.
I
confi rm the sou rce of the angular limb deformity There is no objective evidence indicating the com-
and to determi ne if su rgical manipulation of the bi nati on results in better or faster co rrection of
growth plate is indicated for treatment of the the deformity.
deformity. Dorsopalmar (plantar) and lateral
medial radiographic views of the affected area
will generally co nfi rm the source of the angula r REFERENCES
deformity.
Transp hyseal bridging requires a functioning I. Fretz PB, Cyubaluk NF, Pharr jW: Quant itative anal-
physis to be effective and is best indicated for ysis of long bo ne growth in the horse, Am f Vet Res
deformities associated with physeal dysplasia. If 45: 1602, 1984.
th e physis is crushed, as occurs in Salter-Harris 2. Auer JA: AnguJar limb deform ities. In Auer lA, Stick
type V or VI fractures, transphyseal bridging will lA, editors: Equine surgery, ed 2, Ph iladelph ia, 1999,
not be effective because of the inability of the con- WB Sau nders.
3. Heinze CD: Epiphyseal stapling, Proc Am Assoc
tralateral side of the physis to respond. If the
Equine Pmct 9:203, 1963.
origin of the deformity is associated with the
4. Hunt Rl: Management of angular deformities, Proc
joint (e.g., crushed carpal bones), transphyseal Am Assoc Equine Pmct 46: 128, 2000.
bridging can cos metically straighten the external 5. Witte S, Tho rpe PE, Hunt RJ, et al: A lag-screw tech-
appearance of the limb, but the internal misalign- nique fo r bridgi ng of the medial aspect of the distal
ment may result in degenerative joint disease and tibial physis in horses. f Am Vet Med Assoc 225: 158 1,
lameness. 2004.


CHAPTER 8
Distal Limb Perfusion
Joanne Kramer

INDICATIONS ANATOMY

Infection of bo ne and soft tiss ues in the distal limb Regional perfu sion delivers anti biotic into th e
(Figure 8- 1). venous system by intraosseous or intravenous
infusion. With pressure, the perfusate distends
the veno us vasculature, allowing the perfusate
to enter tiss ue wi th intact venous vasculatu re.
EQUIPMENT Antibio tics then enter ischemic tissue and exu-
dates via increased hydrostatic pressure in ca p-
A cannulated screw with an approp riately sized il lar ies and diffusio n across a concentra tio n
drill bit and tap or commercially ava ilable gradie nt. ' ,2 During regio nal perfusion , the timing
intraosseo us infusion needles are needed for of anti biotic del ive ry to the tissues is expected to
intraosseous perfusio n (Figu re 8-2) . A 20- to follow a similar pattern to that observed follow-
26-gauge I -in ch catheter is necessary fo r intra- ing co ntrast medium. Shortly after intravenous
venous perfusion. For both techn iques, an injection, contrast is in both th e venous and arter-
Esmarch bandage o r pneumatic tourniquet and ial system s; 15 m inu tes after injection. contrast
the selected anti bio tic diluted in 60 mL of normal has sta rted to d iffuse into adjacent soft ti ssues;
saline are necessary. and 30 minutes after injectio n, contrast is pri-
marily in the adjacent soft tissues' (Figure 8-3).

POSITIONING AND PREPARATION


PROCEDURE
The limb should be clipped and prepared for
Selected Antibiotics
aseptic surgery. Care sho uld be taken to isolate
open, infected sites from th e perfusion entry site. Antibiotics must be approved fo r intravenous
Depending on the nature of the ho rse, the proce- admin istration. Concentration -dependent antib i-
dure can be pe rfo rmed with the horse standing or o ti cs such as ge ntam icin and amikacin are com-
under general anesthesia. For intraosseous perfu- monly used, but other antibiotics may be used as
sion, the initial procedure is often performed well. Ideally, antibioti c choice is guided by culture
under general anesthes ia and follow-up proce- and sensi tivity results. Because such high tissue
du res are perfo rmed standin g. Standing proce- concentratio ns ca n be ach ieved locally with small
dures require sedatio n and regional anesthesia doses of antibiotic, antibiotics that are cost-
above the area to be perfused. prohibitive to use systemically can be used. In

55
56 LIMB SURGERIES

reports, 125 to 1000 mg of am ikacin or gentam-


icin per perfusion has been used .3- 6 For other
antibiotics, the systemic dose o r less is used.

Exsanguination
Exsanguination of blood from the distal limb
is recommended before perfu sion of the tissues.
Placement of the intravenous catheter is easier
before exsanguination. Placement of the bone
screw can be done eas ily before o r after ex-
sanguination. For exsanguination, an Esmarch
bandage is applied to the limb from the hoof to
Figure 8-1 A horse with a chronic distal limb infec-
the distal cannon bone and secured tightly at the
tion.
proximal end to prevent loss o f the perfusate into
the systemic circulation. A pneumatic tourniquet
can also be applied at th e proximal end of the
Esmarch bandage to prevent loss of the perfusate.
After applying the to urniquet or securing the
Esmarch bandage at the proximal end, the distal
po rtion o f the bandage is unwrapped (Figure
8-4). In cases with extensive cellulitis, application
of an Esmarch bandage is not recommended
because of the risk of forcing bacteria from the

Figure 8-2 Cannulated 4-mm scre"1 with a nut and


adapter welded to the head.

A
Figure 8-4 A. A pneumatic tourniquet is applied at
Figure 8-3 Contrast distribution 5 minu tes after the proximal end of the Esmarch bandage to prevent
injection into the palmar digital vein in the distal loss of the perfusate. B. The distal portion of the
pastern region. bandage is then unwrapped.
Distal Limb Perfusion 57

interstitial flu id into the lymphatic system.? In are then glued and taped into place. The selected
these cases, a tourniquet is applied to the distal antibiotic diluted in 60mL of sa lin e is injected
metacarpus w ithout prior Esmarch bandage ap- slowly using a small syringe. Because of the pres-
plication. SUfe needed to deliver the antib iotic, we com-
monly use a three-way stop-cock to allow the
diluted antib iotic to be conveniently delivered
Intravenous Perfusion with a smail syringe (Figure 8-5). The tourniquet
A 20- to 26-gauge I-inch catheter is placed in the is left in place for 30 minutes. After release of the
palmar vei n at the level of or just distal to the tourniquet, the cath eter is removed and press ure
sesamoid bones. The catheter and extension set is applied to the puncture site for seve ral minutes.

Intraosseous Perfusion
A stab incision is made in the proximal portio n o f
the pastern midway between the lateral and dorsal
aspect. An appropriately sized drill bit is used
to create a pilot hole for the cannuJated screw
(Figure 8-6). The hole is tapped and the cannu-
lated screw is placed (Figure 8-7). The selected
ant ibiotic diluted in 60 mL of normal saline is
then slowly injected using a three-way stop-cock
and small syringe. The tourniquet is left in place
fo r 30 minutes. After release of the tourniquet, the
screw is removed and the skin is closed with an
interrupted suture.

POSTOPERATIVE CARE

Postoperative Care
Bandaging: A sterile dressing is placed over the
incision or catheter site and a half limb bandage
is applied.
Exercise Restrictions: Stall rest with limited
activity is advised until the sepsis is resolved.
Medications: Systemic antibiotic therapy is con-
tinued as indicated by the underlying condition.
When the same antibiotic is given systemically as
is used in the perfusion, we omit one systemic
dose of the antibiotic on the day the perfusion is
performed. Tetanus prophylaxis is provided if nec-
essary.
Suture Removal: Skin sutures are removed 12
days postoperatively.
Figure 8-5 A 20- to 26-gauge i-inch catheter is
placed in the pal mar digital vein at the level of or just
distal to the sesamoid bones. The catheter and exten-
EXPECTED OUTCOME
sion set are then gl ued and taped into place. The
selected antib iotic diluted in 60 mL of saline is injected
slowly using a sma ll syri nge. Because of the pressure Synovial structure and bone infections are diffi-
needed to deliver the antibiotic, a three-way stop-cock cult to treat and can have a poor outcome despite
is used to allow the dil uted antibiotic to be delivered aggressive treatment. Regional antibiotic perfu-
with a small syrin ge. sion is an adjunctive therapy in the treatment of
58 LIMB SURGERIES

I' I


Drill bit

Cannulated
screw
Tap ~P"" ,t.:1.,., .

Figure 8-6 A stab incision is made in the proximal portion of the pastern midway between th e lateral and dorsal
aspect. An appropriately sized drill bit is used to create a pilot hole fo r the cannu lated screw.

COMPLICATIONS

Severe tiss ue irritation from the antibiotic perfu-


sion may occur but is rare. Partial thrombosis of
the vein used for perfusion may occu r, especially
if used repeatedly. Complete thrombosis is un-
com mon.

ALTERNATIVE PROCEDURES

Regio nal perfusion can be performed in many


areas of th e limb and has been described in the
tarsus, radius, and carpus. 9,]O lntraosseous perfu-
sion can also be performed with a 14-gauge needle
placed through a 2-mm drill hole or the male end
of a Luer tip extension set placed through a 4-mm
Figure 8-7 lntraosseo us screw placement for perfu - hole, but slight inaccuracies in fit ca n result in
sion of the pastern and coffin joint region. leakage of the perfusion solution. ]]

sepsis and does not replace systemic antibiotic


th erapy, appropriate debridement, lavage, and COMMENTS
drainage. Because regional antibiotic perfusion
ca n achieve high tissue levels of antibiotics in In some st udies, intravenous perfusion techniques
affected sites, it can improve the outcome. In one have resulted in higher tissue levels of antibiotics
stud y, the overall survival rate was 86% when than intraosseo us techniques.4 ,12 Both methods
di stal limb pe rfusion was used in conjunction produce much higher tissue levels than the
with aggressive systemic and local therapy.8 recommended peak serum concentrations. Intra-
Distal limb Perfusion 59

venous perfusion requi res less equipment than 4. Butt TD, Bailey lV, Dowling PM, et al: Compariso n
intraosseo us perfusion but can be diffi cult to of 2 tech niques for region al anti biotic delivery to
perform in limbs with significant swell ing or in the equine forelimb: intraosseous perfusion vs.
veins that have had multiple perfusions. Sites fo r intravenous perfusion, Call Vet I 42:617, 200 I.
5. Mattson 5, Boure L, Pearce 5: Intraosseous gen-
intraosseolls perfusion can be used multiple times
ta micin perfusion of the distal metacarp us in
after th e o riginal hole is drilled.
standing horses, Vet Slirg 33(2): 180, 2004.
Additionally, a stud y co mparing intraarticular 6. Werner LA, Hardy ], Bertone AL: Bone gentamici n
injectio n of gentamicin with regional int raven ~ concentratio n after in tra-articuJa r injection or
ous perfusion of gentamici n in normal horses regional intravenous perfusion in the ho rse, Vet
found the techn iques produced similar bone Stlrg 32(6):559, 2003.
co ncentratio ns and that intraa rticul ar injection 7. O rsini JA, Elce Y, Kraus B: Management of severely
produced greater synovi al fluid concentrations infected wound s in the equine pati ent, Clill Tech Eq
than regional intravenous perfusion. 13 In clinically Pmct 3(2):225,2004.
affected horses, the increased hydrostatic pressure 8. Sa ntsch i EM, Adams SB. Murphey ED: How to
achieved in regional perfusion techniques may perform eq ui ne intraveno us digital perfusion, Proc
Am Assoc Equine Pract 44: 198, 1998.
result in better perfusion of capillaries obstructed
9. Kettner NU, Parker lE, Watro us B1: lntraosseo us
by deb ris or fibrin , but this has not been objec-
regional perfus ion for treatm en t of septic physiti s
tivelyevaluated. in a t\'10 week old foal, J Am Vet Med Assoc
222(3 ):346,2003.
10. Wh itehair KJ. Blevins WE, Fessler JF. et al: Regiona l
REFERENCES perfusion of the carpus for antibiotic delive ry, Vet
SlIrg21 (4):279, 1992.
1. Finste rbush A. Argaman M. Sacks T: Bone and join t II. Richardson OW: Local an ti m icrob ial delivery in
perfusio n of antib iotics in the treatment of exper- equ ine orthopedics, Proc Am CoIl Vet SlIrgeollS Vet
imental sta phylococcal infection in rabbits, I Balle Symp 13: 162,2003.
loint SlIrg 52: 1424, 1970. 12. Scheuch BC, Va n Hoogmoed WD. W ilson JR, et al:
2. Finsterbu sh A, Wei nbu rg H: Venous perfusio n of Comparison of intraosseous or intravenous infu-
the limb with antibiotics for osteomyel itis and sion fo r del ive ry of amikacin sulfate to the tibio-
other ch ronic infecti ons, I Balle loint SlIrg Alii 54: tarsal joint of horses, Am J Vet Res 63(3):374, 2002.
1227,1972. 13. Werner LA. Hardy J. Bertone AL: Bone gentamici n
3. Palm er SE, Hogan PM: How to perform regional concentration after intra-articula r or regio nal in tra-
li mb perfusion in the standing horse, Proc Am Assoc venous perfusion in the horse, Vet SlIrg 32(6}:559,
Eqllille Pmct 45: 124, 1999. 2003.
CHAPTER 9
Mid Metacarpal-Metatarsal Tendon Laceration Repair
Joanne Kramer

imal to the navicular bursa within the hoof


INDICATIONS
capsule. The distal end of the sheath and naviClI-
lar bursa are separated by the transverse lamina.
Treatment of flexor and extensor tendon lacera-
In the mid metacarpal-metatarsal region) the
tions in the metacarpal or metatarsal region that
cross section of the flexor and extensor tendons
do not involve the digital sheath (Figure 9-1 ). Ca re
va ries from flat to circular (Figure 9-3).
of lacerations involving the digital sheath requires
intensive management to treat synovial structure
sepsis and is discussed elsewhere l -3 (Figure 9-2).
ASSESSMENT AND SURGICAL PROCEDURES

EQUIPMENT Stabilization
A brief o bservation of the laceration and limb
Cast material and associated supplies are essentia1. position is made and the need for immediate
Recommended suture materials for tendon repair stabilization is determined. Elevation of the toe
includ e nylon , polydiaxone, and coated Kevlar indicates complete deep digital flexor tendon
(FiberWire, Arthex, Naples, Fla.). Size No.2 or laceration (Figure 9-4), and mild to moderate
larger suture material is used. dropping (hyperextension ) of the fetlock suggests
superficial digital flexor tendon laceration or
partial disruption of the suspensory apparatus
POSITIONING AND PREPARATION (Figure 9-5). Severe hyperextension of the fetlock
suggests transection or complete disruption of
The horse is positioned in lateral recumbency the suspe nsory apparatus (Figure 9-6). Buckling
with the affected limb positioned for access to the forward at the fetlock or difficulty extending
laceration. The circumference of the limb should the distal limb suggests common or long digital
be clipped and prepared asepti cally from at least extensor tendon rupture (Figure 9-7).
the fetlock to the mid carpal/tarsal region. The need for stabilization must be balanced
agai nst the need to determine the extent of the
wound and to offer owners who have eco nomic
ANATOMY concern s a general prognosis before proceeding
with potentially costly procedures. Examination
The proximal extent of the digital tendon sheath of the injury ca n be performed with the limb
is in the distal th ird of the metacarpal-metatarsal held up before stabilization is applied, but often
region. The distal end of the sheath lies just prox- a detailed exam ination is not possible until the

60
Mid Metacarpal-Metatarsal Tendon laceration Repair 61

horse has been placed under anesthesia. Stabiliza-


tion should be applied before induction of anes-
thesia or transport. Flexor tendon lacerations,
whether complete or partial, require Kimzey
splint (Kimzey Welding Works,

Woodland, Calif.)
application or similar support to reduce the
tension on the flexor tendons (Figure 9-8). Exten-
sor tendon lacerations can be stabilized in a
weight-bearing position by incorporating a PVC
or wood splint into the bandage along the dorsal
or palmar-plantar surface of the limb (Figu re
9-9).

Figure 9·1 Flexor tendon laceration in the mid


metacarpal region proximal to the flexor tendon sheath. Synovial Structure Involvement
If the wound is near the digital sheath, involve-
m ent of the sheath can be determined byasepti-
cally inserting a needle into the sheath at a site
distal from the wound and distending the sheath
with sterile saline. Involvement of the sheath is
confirmed if fluid is observed at the wound site.

Vascular Status
Laceration of the digital vein and artery may
accompany flexo r tendon lacerations. In general,
despite significant laceration of the vasculature, it
is rare to have ischemic complications if only one
Figure 9·2 Flexor tendon laceration in the palmar side of the vasculature is transected. Lacerations
pastern region involvin g the flexor tendon sheath. involving both the lateral and medial vasculature

Common digital extensor Long digital extensor


tendon =-___. . . ,. . . tendon--

" i· ..
>, .
..."'
MT III

~;;::=:::==::::~~e"l- Me II
Interosseous mel "" __ II
(suspensory lig.)

Digital
check

A B

Figure 9·3 A, Transverse section through the middle metacarpal region. B, Transverse section through the middle
metatarsal region.
62 LIMB SURGERIES

Figure 9-4 Horse with a complete laceration of the


deep digital flexor tendon. The toe is elevated from the
ground, indicating hyperextens ion of the coffin joint. Figure 9-6 Horse recovering from suspenso ry liga-
ment disruption. Note the fetlock hyperextension.

Figure 9-5 Horse with a partial laceration of the


superficial digital flexor tendon showi ng mild fetlock Figure 9-7 Buckling forward of the fetlock seen with
hyperextension. long digital extensor tendon transection.

risk ischemic compromise to the distal limb but clean transection s with potential for primary
can also heal adequately. Unfortunately, a practi- closure, debridement should be as conservative
cal way of assessing the ab ility of collateral circu- as possible. The wound should be lavaged ex-
lation to provide adequate blood supply in the tensively before, during, and after debridement
future healing period is not available. (Figure 9-10) . If closure is performed, gloves and
instruments are changed after debridement and
before closure.
Wound Debridement and Repair
If the free cut ends of the flexor tendon are
Removal of contaminated and devitalized tissue is cleanly transected and appear hea lthy, primary
performed with layered debridement. In relatively repair should be performed to improve alignment
Mid Metacarpal-Metatarsal Tendon Laceration Repair 63

Figure 9-10 Extensive lavage during the initial stages


of laceration repair.

Figure 9-8 Kimzey splint support for a deep d igital


flexor tendon laceration. An extended elevated heel
shoe has also been placed on the limb for support lization without tendon suturing. If the laceration
during bandage changes. involves greater than 75% of the cross-sectional
area of the tendon, tendon suturing may offer
similar benefits to repair of complete transec-
tions. 6
Many extensor tendon lacerations have a sig-
nificant degloving component and extensive soft
tiss ue trauma, which precludes reconstruction.
With appropriate wound care, these lacerations
can heal by second intention and often have
minimal functional impairment. Fibrosis between
the tendon ends eventually results in a mechani-
cal link between the tendon end s and, in many
cases, return of extensor function of the digit. 6
However, if the wound is amenable to primary
closure and the tendon ends are transected
cleanly, primary tendon repair is preferable.

Suture Patterns for Tendon Laceration Repair


Modified Far-Near-Near-Far Pattern
Figure 9-9 PVC sp lint support for an extensor
This pattern is the simplest pattern to perform,
tendon laceration.
and is best used in flat tendons. The needle is
placed perpendicular to and approximately 1.5 em
from the proximal tendon end for the initial far
and ea rl y strength of the repair.'" If the ends bite. The needle then enters the distal tendon end
of the fl exor tendon are extensively retracted) 0.5 to 1 em from the end for a nea r bite in a posi-
swollen, or discolored or the wound appears to be tion sli ghtly axial to the far bite. It is then looped
significa ntly infected, the area should be debrided back to the proximal end of the tendoll) and a near
and allowed to heal by second intention. In select bite is taken 0.5 to 1 em from the end in the sa me
cases, delayed primary closure can be performed plane as the previous near bite. The suture is then
with or without tendon suturing. All situations brought to the distal end, and a far bite is taken in
require a minimum of 6 weeks of cast or splint the same plane as the initial far bite 1 to 1.5 em
support. Partial flexor tendon lacerations can be from the end. The two far ends are then tied
managed with wound closure and limb immobi- (Figure 9-1 I).
64 LIMB SURGERIES

Figure 9-11 Modified far-nea r-near-far pattern.

Figure 9-13 Three-loop pulley.

angles. The initial loop is placed perpendicular to


the long axis of the tendon in a n ear-far pattern.
The second loop is placed in a plane 60 degrees
relative to the initial loop with bites taken similar
distances apart from each tendon end. The final
loop is placed in a fa r-near pattern 60 degrees
from the second loop (Figure 9-13).

POSTOPERATIVE CARE
Figure 9-12 Modified compound locking loop.
Flexor Tendon Lacerations
No suture pattern or material provides the
Modified Compound Locking Loop strength required for flexor tendon function after
This pattern is strong and works best in flat repair. 4,9,10 Therefore, during the early sta ges of
tendons or ligaments. but it can also be used in tendon healing, the repair must be protected from
round tendons. A superficial transverse bite locks weight-bearing forces with cast application or
around small groups of fibers to decrease pull- other external support. External support should
through of larger vertical bites approximately 2 be provided for a minimum of 6 to 8 weeks fol-
em from the tendon end. The pattern sta rts with lowing repair. After this period, support should be
a superficial transverse bite about 1 em wide. A gradually reduced. An elevated extended heel shoe
vertical bite is then placed through both tendon andlor splint should be provided for the follow-
ends, and a similar transverse bite is taken in the ing 4 to 6 weeks. The optimal extent of heel ele-
opposite tendon end. A vertical bite is then taken vation required has not been determined, but the
from the distal tendon end to the proximal tendon initial hoof angle ach ieved is typically between 65
end and ti ed to the start of the first transverse bite. and 75 degrees. Heel elevation and extension are
A similar but wider locking loop is next placed then gradually reduced over the next 12 weeks to
slightly closer to the tendon ends' (Figure 9-12). adapt the tend on to increasing tension . Som e
Alternatively, both locking loops can be placed as horses require long-term heel extension after
a continuous pattern. 4 flexor tendon transection.
Repair of superficial digital flexor tendons in
Three-Loop Pulley the hind limb may benefit from Kimzey splint
This pattern is strong and has less gap formation application rather than half limb cast application.
than other repair patterns. 8 ,9 It works best on Because hock flexion is normally accompanied by
round tendons such as the deep digital flexor fetlock flexion, tension in the superficial digital
tendo n in the m etacarpal region. The end result is flexor tendon is increased when a horse flexes its
three loops equ ally dividing the cross-sectional hock but is constrained from fetlock flexion by a
area of the tendon and intersecting at 60-degree half limb cast. The Kimzey splint supports the
Mid Metacarpal-Metatarsal Tendon Laceration Repair 65

limb in fetlock flexion. Disadvantages of the tra, excessive granulation tissue, stringhalt ga it,
Kimzey splint include prolonged immobilization and fetlock contracture if the limb is chronically
with the distal limb in flexion and the need flexed because of pain or inadequate extensor
to keep the limb from bearing weight during tendon function. Wound infection, dehiscence,
bandage changes. A full limb cast extending to the sequestrum formation, and excessive granulation
proximal tibia will decrease strain on the superfi- tissue can be managed by local debridement
cial digital flexor tendon during repair by pre- and wou nd therapy. Stringhalt development is
venting hock flexion , but generally, the risk of un co mmo nly see n after wounds in the proximal
complications with a full limb cast is not worth dorsal metatarsal region and may require surge ry
the benefit when repairing superficial digital flexor for treatment. l s Distal limb co ntracture can be
tendon lacerations in the metatarsal region. prevented by monitoring for adequate use of the
lower limb and splinting as needed.
Extensor Tendon Lacerations Co mpli cations of flexor tendon laceratio ns
include dehiscence, wound infection, tend on
In the early phases of extensor tendon healing, a dege neratio n seconda ry to infection, inadeq uate
distal limb splint is recommended to support the repair strength , vascular compromise to the lower
digit in extension. Often, the support of a bandage limb, cast complications, adhesions, contracture,
is sufficient to prevent flexion, as some digital and co ntralateral limb laminitis. Dehiscence and
extension is due to momentum as the limb swings wound complications are managed by debride-
forward. If primary repair is performed, cast or ment and second intention healing. Inadequate
splint support should be provided for a minimum repa ir stre ngth is best prevented and managed by
of 4 weeks. adeq uate limb immobilization and a gradual
decrease in limb support. No direct treatment is
Contralateral Limb Support available for vascular co mpromise. Cast compli-
cations are co mmon but can be minimized by
Suppo rt should be provided for the opposite limb
careful daily monitoring of the cast and cast
to dec rease the risk of contralateral limb lameness,
changes as indicated. Contracture is a complex
reduce edema, and elevate the contralateral limb
problem resulting from prolonged immobiliza-
to a similar height as the casted limb. A support
tion or pain and healing with excessive surround-
bandage and foot elevation are often applied to
ing scar tissue. Flexor tendon lacerations in
the contralateral limb, II In cases of severe injury,
nonsheathed areas are less likely to have this
support to the contralateral limb is essential to
compli cation, and a gradually increasing exe rci se
decrease the chances of contralateral limb lamini-
program improves most cases. Contralateral limb
tis. This ca n be provided in the form of frog and
laminitis is a severe complication. Appropriate
caudal support, heel elevation, and decreased
sup port of the contralateral limb and early aggres-
breakover. Commercial shoes are available and
sive treatment for the primary problem can min-
work well for this purpose (Redden Modified
imize its occurrence. Appropriate treatment for
Ultimate, Nanric Inc., Versailles, Ky.).
co ntralateral limb laminitis includes co rrective
shoeing, deep bedding, stall rest, analgesics a nd ,
EXPECTED OUTCOME ideally, resolution of the primary problem.

With optimal treatment, riding soundness occurs


in approximately 75% of extensor tendon lacera- ALTERNATIVE PROCEDURES
tio ns and 50% of flexo r tendon lacerations. '2 - '4
Return to significant athletic activity has been Annular ligament desmotomy may be indjcated
reported in 23% to 50% of flexor tendon lacera- in some cases if superficial or deep digital
tions 12 · '4 and 71 % of extensor tendon lacerations. '2 flexor tendon swelling is impeded by the annular
ligament. Typically, this is performed several
weeks or even months after the tendon injury. A
COMPLICATIONS limited case report suggests that annular ligament
desmotomy within 1 to 3 days after acute super-
Complications of exte nsor tendon lacerations ficial tendon rupture in racehorses may be
include wound infection, dehiscence, bone seques- beneficial. '6
66 LIMB SURGERIES

8. Adair HS, Gobel DO, Rohrback BW: In vitro com-


COMMENTS pa rison of the locking loop and the three loop
pulley suture techniques in the repair of equ ine
Although the mod ified fa r-near-near-far sut ure flexor tendons, } Equille Vet Sci 9: 186, 1989.
pattern is not as strong as the compound locking 9. Jann HW, Stein LE, Good JK: St rengt h characteris-
loop or three-loop pulley patterns. it is simple to tics and failure modes of locking-loop and three-
perform and does not requ ire extensive exposure loop pulley suture patterns in eq uine tendo ns, Vet
to perform. Placement of the near bites axial to 511rg 19: 18, 1990.
the far bites may decrease sutu re pull-out. It is 10. Loch ner FK, M ilne OW. Mills EJ, et al: In vivo and
most usefuJ for superficial digital flexor tendon in vitro measurement of tendon strain in the horse.
Alii VetJ Res 41:1929, 1980.
and extensor tendon repair.
11. Hendrickson DA, Sto kes M, Wittern C: Use of an
elevated boo t to reduce co ntralateral support limb
complicatio ns secondary to cast appl ication, Proc
REFERENCES Am Assoc Equi1le Pmc 43: 149, 1997.
12. Belknap JK, Baxter GM, Nickels FA: Extensor
I. Bertone AL: Infectious tenosynovitis. Vet Cli,l N tendon laceratio n in horses: 50 cases (1982- 1988),
Am Equille Pmcl 11:163, 1995. J Alii Vet Med Assoc 203:428, 1993.
2. Gaughn EM: Orthopedic wounds tendon and 13. Foland JW, Trotter GW, Stashak C, et al: Trau matic
tendon sheath, Proc Am Coil Vet Surgeolls Vet Symp injuries involving tendons of the dista l limbs in
13: 167,2003. ho rses: a retrospective study of 55 cases, Equine Vet
3. Honnas eM, Schumacher J, Watkins JP, et aJ: Diag- J 23:422, 1991.
nosis and treatment of septic tenosynovitis in 14. Taylo r DS, Pascoe JR, Meagher OM. et al : Digital
horses, Comp COllt Educ 13:301, 199 1. flexor tendon laceratio ns in horses: 50 cases. ( 1975-
4. Bertone AL, Stashak TS, Sm ith FW, et al: A com- 1990), J Am Vet Med Assoc 206:342, 1995.
parison of repair methods for gap healing in equine 15. Crabill MR, Hon nas eM, Taylor DS. et al : String-
flexor tendon, Vet SlIrg 19:254, 1990. halt seco ndary to trauma to the do rsoproxi mal
5. Jann HW, Good JK, Morga n SJ. et al: Healing of region of the metatarsus in ho rses 10 cases ( 1986-
t ransected equ ine superfic ial digital flexor tendo ns 1991 ), J Am Vet Med Assoc 205:867,1994.
with and without tenorrhaphy, Vet SUtg 2 1:40, 16. Mackay-Smith MP: How to surgically treat and
1992. post-operatively rehabilitate acute athletic rupture
6. Bertone AL: Tendon laceratio ns. Vet Clill N Am of su perficial d igital flexor tendon, Proc Am Assoc
Equille Pmct 11 :293,1995. Equine Pract 47:279.200 1.
7. Watkins JP: Treatmen t p rinciples of tendon diso r-
ders. In Auer lA. Stick lA, ed ito rs: Equine surgery,
Philadelph ia, 1999, WB Saund ers.
CHAPTER 10
Annular Ligament Desmotomy
Joanne Kramer

INDICATIONS PROCEDURE

Annular ligament constriction caused by primary Open Te(hnique


annular ligament desmitis (Figure 10-1) and
A 6- to 8-em skin incision is made over the lateral
annular ligament constriction seco ndary to ten-
aspect of the superficial digital flexor tendon
donitis or septic tenosynovitis.
(SDFT) at the level of the palmar annular liga-
ment. The incision is made palmar to the neu-
rovascular bundle and should be just axial to the
EQUIPMENT palmar edge of the sesamo id bone' (see Figure 10-
2). A small incision is made in the proximal
Closed techniques are performed with a Mayo border of the digital sheath or annular ligament,
scisso rs, bistoury knife, or groove director. and a groove director or forceps is passed under
the annular ligament to act as a gu ide for further
transectio n. The incision is continu ed through the
ANATOMY entire proximal annular ligament, being careful
not to damage the underlying tendons (Figure
The palmar-plantar annular ligament attaches on 10-3). The flexor tend ons and exposed sheath
the abaxial surfaces of the proximal sesamoid are examin ed for ad hesions. If present, they are
bones and partially surrounds the tendon sheath resected. The tendon sheath is lavaged as required
blending with its palmar-plantar wall and making by the primary problem.
up the palmar-plantar wall of the fetlock ca nal Subcutaneous tissues are closed with No. 2-0
( Figure 10-2). The proximal and distal extent of absorbable suture in a continuous o r interrupted
the palmar-plantar annular ligament can be esti- pattern. The skin is closed with an interr upted
mated by palpating the apex and base of the pattern.
sesamoid bones.

Closed Te(hnique
POSITIONING AND PREPARATION This is the preferred method if the tendons within
the fetlock ca nal do not need to be exposed. A 2-
The horse is positioned in lateral recumbency. cm incision is mad e through the ski n just proxi-
The circumference of the limb should be mal to the palmar annular ligament. The sheath is
clipped and prepared aseptically from the mid entered through a similar or smaller incision, and
metaca rpus- metatarsus region distally. the distal extent of the annular ligament is defined

67
68 LIMB SURGERIES

by passing a groove director or forceps under


the annular ligament and palpating the distal end
of the ligament (Figure 10-4). Care should be
taken to exclude the proximal digital annular lig-
ament. The annular ligament is then transected by
passing a bistoury knife underneath the ligament
and transecting the ligament (Figure 10-5, A, B)
or by passing the groove director underneath the
ligament to guide a scalpel blade' (Figure 10-5, C).
Care must be taken to not incise the skin if the
bistoury knife is used. Alternatively, the annular
ligament can be transected with scissors. A small
subcutaneous plane is created for I blade of the
scissors, and the annular ligament is transected by
closing the blades of a scissors passed so that one
blade of the scissors is deep to the annular liga-
ment and the other blade superficial to th e liga-
ment in the subcutaneous plane created 2 (Figure
10-6). The tendon sheath can then be lavaged as
requited by the primary problem.
Figure 10-1 Appearance of a limb with const riction If the incision in the proximal tendon sheath is
of the palmar annular ligament.
large, it can be closed with No. 2-0 absorbable
suture. Subcutaneous tissues are closed with No.
2-0 absorbable suture. The skin is closed in an
interrupted pattern.

,
-.

neurovascular
". i .
• J.

bundle ,
(the circle) • •
- DDF tendon


.. • ••
Tendon
sheath

annular lig.
Site of
approach
--.., SDF tendon
~t;.t:~
B
A
Figure 10-2 The palmar-plantar annular ligament attaches on the abaxial surfaces of the proximal sesamoid bones
and partially surrounds the tendon sheath blending with its palmar-plantar wall and making up the palmar-plantar
wall of the fetlock canal. A. Lateral view. B, Cross section.
Annular Ligament Desmotomy 69

Figure 10-4 Entrance into the digital sheath through


a small skin incision proximal to the palmar annular
ligament in a closed annular ligament resection. ArrolVs
~e...,.,.t;;..ta... .
show the approximate proxim al and distal bo rders of
Figure 10-3 Transecti on of the ann ular ligament the pal mar an nular ligament.
using the open technique.

'1
\
\
\

A B c

Figure 10-5 The 3nl1 uJar ligament is transected by A, passing a bistoury kni fe undern eath the ligament, B, ro tat-
ing the bistoury kn ife 90° so that the cutting edge is toward the liga ment, and transecting the ligament, or C, passing
the groove director underneath the ligament to guide a scalpel blade.
70 LIMB SURGERIES

Figure 10-6 The annular ligament can also be I) \ \

transected with scissors. A. A small subcutaneous


plane is created for one blade of the scissors, and .11 '
B, the annu lar ligament is transected by closing
the blades of a scissors passed so that one blade of
the scissors is deep to the annular ligament and
the other blade is superficial to the ligament in the
subcutaneous plane created.

A B

POSTOPERATIVE CARE
Postoperative (are
Bandaging: A sterile dressing is placed over the phenylbutazone therapy is dictated by underlying
incision and a half limb bandage is applied. The tendon damage and the level of lameness present.
initial bandage is changed 24 hours after surgery. Antibiotic therapy is continued in cases with preex-
Subsequent bandage changes are performed at 4- isting infection and in select cases where delayed
to S-day intervals or more frequently if indicated. incisional healing is anticipated.
Bandaging is applied for a minimum of 4 weeks Suture Removal: Skin sutures are removed
regardless of whether the open or closed technique 12 days postoperatively.
is performed. Intrasynovial Medications: Intrasynovial so-
Exercise Restridions: Stall rest is provided for 10 dium hyaluronate is a useful adjunctive therapy
days, after which a gradual increase in daily hand- in cases where adhesions have been transected
walking is important to minimize adhesion forma- or a high level of inflarnmation is present within
tion. In cases without underlying tendon pathology, the sheath. Although sodium hyaluronate has
light daily lunging at a trot or limited small paddock been shown in an experimental adhesion model
turnout may be performed 3 weeks postoperatively. to decrease adhesion formation and increase
Gradual return to work may begin in 6 weeks or as hyaluronic acid content within the digital sheath,'
indicated by the healing of any underlying tendon no products are specifically labeled for digital
• •
InJury. sheath use. The author has used 20 to 40 mg
Medications: Phenylbutazone is administered at of sodium hyaluronate labeled for intraarticular
4.4 mg/kg BID for the initial 24 hours and at use at the time of surgery and 10 to 14 days
2.2 mg/kg BID for an additional 5 days. Further postoperatively.

lesions can also have a good prognosis, but exten-


EXPECTED OUTCOME
sive tendon lesions or significant sheath adhesions
limit future soundness. The prognosis is guarded
After desmotomy, the lower limb profile has
for cases with septic tenosynovitis.
mild to moderate symmetrical enla rgement
resulting from release of the constricting liga-
ment. This decreases over tim e, but it is rare COMPLICATIONS
fo r a completely normal cosmetic appearance to
return. The prognosis for soundness is good for Complications include wo und dehiscence, septic
cases with pr imary constriction or thickening of tenosynovitis, synovial fistula formatio n, and
the annular ligament. Cases with minor tendon adhesions. Complicatio ns are rare following the
Annular Ligament Desmotomy 71

closed technique. The use of the open techniqu e and under ultrasound guidance, creating partial-
increases the risk of complications, but with thickness incisions in the hypoechoi c regions with
appropriate postoperative care and monito rin g, a No. II blade.
co mplications are not co mmon.
Endoscopic Transection
ALTERNATIVE PROCEDURES Endoscopy of the digital sheath with guided
transection of the annular ligame nt has also been
Extrasynovial Transection described 6 -s and offers an improved prognosis for
horses with digital sheath pathology.
Performance of an annular ligament desmotomy
without entering the tendon sheath has been
REFERENCES
described. 4 The technique relies on the presence of
a small extrasynovial space between the SDFT and
1. Adams SB, Fessler JF: Palmar-plantar an nular liga-
the palmar annular ligame nt_ A 2-cm skin incision
ment division. In Adams SB, Fessle r JF, editors: Atlas
is ce ntered between the proximal border of of equifle Sl/rger)', Philadelphia, 2000, WB Sa unders.
the annular ligament and the ergot on palmar or 2. Turner AS, Mcllwraith CW: Sectio ni ng of the
plantar midline. Sharp dissection is continued palmar or plantar annular ligame nt of the fetlock.
through the subcutaneous tissues until the trans- In Turner AS, Mcllwraith CW, editors: Techniques
verse fibers of the annular ligament are identified. ill large allimll( sllrgery, Philadelphia, 1989, Lea &

Ca reful sharp dissection is conti nued through the Febiger.


annular ligament until the division between the 3. Gaughan EM , Nixon AJ, Krook LP, et al: Effects of
annular ligament and longitudinal fibers of sodium hyaluronate on tendon healing and adhe-
th e SDFT is identified through a 5-mm incision sion for mation in horses, Am J Vet Res 52:764, 1991.
4. Hawkins DL, Churchill EA: Extrasynovial
in the annular ligament. Curved Kelly forceps are
palmar/ plantar an nular ligament desmotomy, Proc
directed through the incisio n in the annular liga-
Am Assoc Eqlline Pmc 44:210, 1998.
ment to identify th e dissection plane. The Kelly 5. McGhee JD, White NA, Goodrich LR: Primary
forceps are opened several millimeters and a desm itis of the palmar and plantar annular liga -
No. 15 blade is used to incise the ligament. The ments in horses: 25 cases ( 1990-2003), } Am Vet Med
forceps are advanced distally and then turned and Assoc 226:83, 2005.
advanced proximally to allow complete incision of 6. Fortier LA, Nixon AJ, Ducharme NC, et al: Teno-
the ligament. In most cases, the palmar axial scop ic examination and proximal annular ligament
attachme nt of the flexor sheath to the SDFT on desmotomy for treatment of eq ui ne com plex digital
either side of midlin e can be seen in the surgical sheath tenosynovitis, Vet Surg 28:429, 1999.
7. Nixon AJ, Same AE, Ducharme NG: Endoscopic
field.
assisted annular ligam ent release in horses, Vet Surg
22:501, 1993.
Desmoplasty 8. Wilderjans H, Boussauw S, Madder K, et al:
Tenosynovitis of the digital flexor tendon sheath and
Desmoplasty of the annular ljgament has been annular ligament constriction syndro me ca used by
described in four horses with primary annular lig- longitudinal tears in the deep digital flexor tendon:
ame nt desmitis.s The procedure involves identify- a clinical and surgical report of 17 cases in Warm-
ing hypo echoic lesions in the annular ligament blood horses, Equine Vet} 35:270, 2003.
CHAPTER 11
Lateral Digital Extensor Tenectomy
Joanne Kramer

performed sta nding, local anesthetic is infiltrated


INDICATION
directly over and deep to the distal and proximal
skin incision sites. The lateral aspect of the mid to
Treatment of conventional stringhalt (Figure
distal tibi a and the proximal metatarsal region are
11-1 ).
clipped a nd prepared aseptically.

EQUIPMENT PROCEDURE
Large Carmalt forceps are used for removi ng the A 3~cm incision is made directly over the palpa-
muscJe tendon un it from the proximal incision. ble lateral digital extenso r tendon just proximal to
its junction with the long digital exten sor tendon.
The tendo n is elevated to the level of the incision.
ANATOMY A second lO-cm vertical ski n incision is made
directly over the lateral digital extenso r starting at
The lateral digital extensor muscle of the hind the muscle tendon junction and extending proxi-
limb o ri ginates from the lateral collateral liga ment mally (Figure 11-3, A). Pulling on the isolated
of the stifle and the adjacent region of the tib ia lateral digital extensor tendon in the distal inci-
and fibu la. It proceeds lateral to the long digital sion can be used to guide the exact location of the
exte nso r muscle and enters its tendon sheath in proximal incision. The subcutaneous tissue and
th e groove of th e lateral malleolus of the tibia. In fasciae are incised to expose the lateral digital
th is region, the tendon and sheath are covered by exten sor m uscle belly. Blunt di ssection and large
extensive cru ral fascia and th e distal extensor reti- Carmalt forceps are used to eleva te the muscle to
naculum of the tarsus. Just distal to the tarsus, th e the level of th e incision. A small amount of sharp
lateral digital extensor tendon joins the long and blunt dissection is also used to free restrict-
digi tal extensor tendon (Figure 11-2). ing tiss ue from the muscle tendon unit. The latera l
digital extensor tendon is th en excised in th e distal
incision (Figure 11 -3, B). The entire tendon is
POSITIONING AND PREPARATION then pulled through the proximal incision (Figure
11-3, C). Th is is the most difficult aspect of the
The procedure is performed with the horse under proced ure and is best accomplished by placing
general anesthesia in lateral recumben cy with large forceps underneath the tendon of the lateral
the affected limb up or standing with sedation digital extensor muscle and pulling proximally
and local a nest hesia. When the procedure is and laterally. The muscle is then severed in th e

72
lateral Digital Extensor Tenectomy 73

proximal portion of the incision so that at least 2


cm of muscle is removed (Figure 11-3, DJ. [f nec-
essary, the remaining muscle stump is cauterized
or Qversewn with absorbable suture material in a
Halstead or Cushing pattern. Some surgeo ns
believe the success rate of the surgery increases
with removal of more muscle, and in some cases
recurrence of stringhalt has been treated with
resection of an additional 3 to 4 inches of lateral
digital extensor muscle. 1,2 The crural fasciae are
then closed with a simple interrupted or
simple co ntinuous pattern with No. 0 synthetic
Figure 11-1 Marked hyperflexion of the hock in a absorbable suture material. Closure of the subcu-
horse with a strin ghalt gait. taneous tissue is optional. The skin is closed with
No. 0 suture material in an interrupted or contin-
uous pattern of the surgeon's choice. The distal
incision requires closure of the skin only.

Long digital-
extensor m.

Lateral digital
extensor

B
Tendon of lateral
digital extensor m.
Tendon of long
Long digital
digital extensor m.----l,

Digital
• -
.-:;..
. .
.
~ :" . . .~­
retinaculum ·• •. -
• •
. , '.
.- ---
~

Lateral digital • •
extensor tendon
~ -{.

c
A

Figure 11~2 A, Location of the lateral digital extensor muscle and tendon with cross sections nea r B. the muscle-
tendon junctio ns and C. distal incision site.

I
74 LIMB SURGERIES

A c

B
~_~.1!. ,
o
Figure 11-3 A, A 3-cm incision is made directly over the palpable lateral digital extensor tendon just proximal to
its junction with the long digital extensor tendon (aJ . A second lO-cm ver ti cal skin incision is made directly over the
lateral digital extenso r starting at the muscle-tendon junction and extending proxi mally (b). B, The lateral digital
extenso r tendon is excised in the distal incision. C. The entire tendon is pulled thro ugh the proxima l incision. D, The
muscle is severed in the proximal portion of the incision so that at least 2 em of muscle is removed.

surgery are variable and ca nnot be predicted.


POSTOPERATIVE CARE
Improvement, when present, may occur in the
immediate postoperative period or days to
Postoperative Care
months after the surgery.2
Bandaging: A sterile dressing is placed over the
incisions and a full limb bandage is placed from
the proximal tibia distally. The bandage is changed COMPLICATIONS
as needed every 2 to 4 days and maintained until
the incisions have healed.
Dehiscence of the incision may occur) especially if
Exercise Restridions: Stall rest is required for
2 weeks and followed by small area turnout for 2 a stringhalt gait persists in the early postoperative
weeks. period. Seroma or hematoma formation associ-
Meditations: Phenylbutazone is administered at ated with the stump of the lateral digital extensor
4.4 mg/kg BID for 24 hours. muscle may also occur.
Suture Removal: Skin sutures are removed 12
days postoperatively.
COMMENTS

EXPECTED OUTCOME Stringhalt is a gait abnormality characterized by


exaggerated hyperfl exion of o ne or both hind
Although positive results from the surgery are limbs. Several forms have been described. The
often dramatic and very rewarding) owners Australian, or outbreak, form of stringhalt is bilat-
should be forewarned that the results of the eral, occurs in groups of horses on pasture, and is
lateral Digital Extensor Tenedo y 7S

thought to be ca used by a plant toxin. It has been but the authors have not seen 'diopathic cases
identified in Australia, New Zealand, and Califor- improve without surgery. In horses with stringhalt
nia. 3,4 The Australian form and possibly other seco ndary to dorsal metatarsal trau ma, respon se
forms of stringhalt have been shown to have an to treatment was reported in nin e horses. 6 Of the
underlying neuTopathy.4,S four horses treated with exercise, one resolved,
Conventional, or classic) stringhalt occurs two improved, and one had no change in gait. Of
in individual horses and is typically unilateral. the five horses trea ted surgically, two resolved, two
The majority of conventional stringhalt cases have had gait improvement, and one had no change in
no known initiating factors. Some cases are as- gait.
sociated with trauma to the dorsal proximal
metatarsal region, with the suspected etiologies
being adhesion formation involving the lateral
REFERENCES
digital extensor tendon and altered myotactic
response due to injury,6 Other causes of stringhalt
I. Turner AS, McJlwraith CW: Lateral digital extensor
may be peripheral neuropathy associated with tenotomy. In Turner AS, McIlwraith CW, editors:
neurologic disease such as equine protozoal Techl1iques ill large allima{ surgery, Philadelphia,
myelitis. 5 1989, Lea & Febiger.
In one report, a stringhalt-like gait improved 2. Su llins KE: Lameness. Part X. The tarsus. In Stashak
after local anesthesia of the tarso metatarsal and TS, editor: Adam's lame/less in horses, Philadelphia,
distal intertarsal joints and resolved after intraar- 2002, Lippincott, Will iams and Wilkins.
ticular corticosteroid trea tment. 7 The authors 3. Adams SB, Fessler IF: Lateral digital extensor
have also observed stringhalt-like gaits in horses myotenectomy for stringhalt. In Adams SB, Fessler
with thin soles after trimming and horses with JF, ed itors: Atlas oj equ ine surgery, Philadelphia,
2000, WB Saunders.
hind limb laminitis. These horses have a normal
4. Siocombe RF, Huntington PI, Fr iend SCE, et al:
or significantly inlproved gait on soft footing or
Pathological aspects of Australian stringhalt, Eqllille
after abaxial anesthesia. Vet/24:174,1992.
When a horse is presented with a stringhalt- 5. Va lentine B: Mechanical lameness in the hindlimb.
like gait, a di etary history, neurologic exam, and In Ross MW, Dyson 5J, edito rs: Diag1l0sis a1ld man-
sea rch for identifiable sources of pain should agement oj lame1less i1l the horse, St Louis, 2003, WB
be undertaken and treatment is based on these Saunders.
results if indicated. Surgical treatment is generally 6. Crabill MR, Honnas eM, Taylor OS, et al: Stringhalt
indicated for cases of stringhalt associated with secondary to trauma to the dorso proximal region of
dorsal metatarsal trauma or horses with stringhalt the metatarsus in horses: 10 cases (1986- 1991), J Am
of unknown etiology. One author recommends Vet Med Assoc 205:87,1994.
7. Hebert C, Jahl1 HW: Intra-articular corticosteroid
surgical treatment if th~ gait improves after local
treatment for stringhalt in a Quarter horse a case
anesthetic solution is injected into the lateral
report, J EquinE Vet Sci 14:53, 1994.
digital extenso r muscle.s 8. Bennet SD: Lameness in the American Saddlebred
With th e exception of the stringhalt gait, many and other trotting breeds with collection. In Ross
cases will have an unremarkable history and din- MW, Dyson SJ, editors: Diagnosis and mallage-
ical examination. The improvement in gait after ment of lameness ill the horse, St Louis, 2003, WB
surgery is difficult to predict for individual cases, Sau nders.

,
CHAPTER 12
Medial Patellar Desmotomy
Joanne Kramer

maximal stifle extension the fibrocartilage is ele-


INDICATIONS
vated and rotated over the medial troch lear ridge
of the femur' (Figure 12-2). The patella is released
Horses with persistent upward patellar fixation or
when the patella is rotated laterally and elevated
ho rses with co ntinu ed intermittent upward patel-
sligh tly by the quadriceps to clea r the m edial
lar fixation after appropriate conditioning and
trochlear ridge. The locked and unlocked posi-
maturation have been achieved (Figure 12-1).
tions of the patella are shown in Figures 12-1
throu gh 12-4.

EQUIPMENT

A blunt- tipped bistou ry knife is used to transect PROCEDURE


the medial patellar ligament.
With the limb fully weight bearing and the
stifle extended. a 2-cm vertica l skin incision is
POSITIONING AND PREPARATION made just cranial to the distal part of the medial
patellar ligament (Figure 12-5) . Curved Kelly
Surgery is performed with the horse sta nding. The forceps are advanced under the medi al patellar
limb should be fully weight bearing with the stifle ligament to create a plane of dissection deep to the
extended. The tail sho uld be wrap ped and tied out medial patellar ligament. Keeping close to the
of the surgical field. The medial aspect of the stifle medial patellar ligament and on its distal aspect,
region is clipped and prepared aseptically. Local a bistoury knife or Bard Parker handle with a new
anesthetic is injected subcutaneously cranial and No. 10 blade is advanced under the medial patel-
deep to the m edial patellar ligament. lar ligament with the cutting side facing distal.
When the tip of the blade or bisto ury knife is pal-
pable on the caudal side of the medial patellar lig-
ANATOMY ament, the instrument is rotated 90 deg rees and
the m edial patellar ligamen t is severed (Figure 12-
The medial patellar ligam ent inserts distally in a 6). When the ligament is transected, the stifle will
groove o n the proximal medial aspect of the tibial flex sligh tly. After transection. the apo neurotic
tuberosity and proximally on the medial aspect of insertion of the sarto rius muscle is palpable just
the patella through the para patellar fibrocartilage. caudal to locatio n of the patellar liga ment. 2 -4 The
Upward fixation of the patella occurs if durin g skin is closed with interrupted su tures.

76
Medial Patellar Desmotomy 77

-
.. • - .
-
- -
--- -- . -
- .;"1 ' T
-.. -
Figure 12-1 A horse with upward fixation of the Figure 12-3 Exaggerated flexion of the limb after
patella. Note the extended stifl e and hock and flexed release of the patella.
distal limb.

Cartilaginous process
(parapatellar
fibrocartilage)

-
.. r -- - -

Figure 12-4 Nor mal limb position at the start of the


next stance phase.

Medial
patellar
Figure 12-2 The locking mechanism.

Cartilaginous process
(parapatellar fibrocartilage) ..__--..

Patellar
ligaments: Figure 12-5 Location of the skin incision for
medial---:c-:-
medial patellar desmotomy.
middle==J~tT
lateral-

Incision site ~--


78 LIMB SURGERIES

case selection. 5 Fragmentation of the patella or


middle patellar ligament desmitis may occur in
some horses. If associated with lameness, frag-
mentation of the patella may require arthroscop ic
treatment. 6,7

COMPLICATIONS

Surgical errors are rare but include entrance into


the femoropatellar joint capsule, severance of the
medial femorotibial or middle patellar ligament,
and incomplete transection of the medial patellar
ligament. If a blade is used for transection and is
not securely attached to the handle, it may detach
when being tu rned 90 degrees against the liga-
ment. Medial patellar ligament desmotomy may
predispose horses to distal fragmentation of the
patella from increased stress on the middle patel-
lar ligament. 6,7 A case of apical fracture has also
been reported. s Extensive fibrosis or surgical site
swelling may also develop and usually resolves
with extended rest but rarely results in lameness
or recurrent upward patellar fixation. 9

ALTERNATIVE PROCEDURES

A modification of the procedure performed under


Figure 12~6 Transection of the medial patellar liga- general anesthesia that involves transection of the
ment with a bistoury knife.
aponeurosis of the gracilis and sartorius in addi-
tion to the medial patellar ligament transection
has been described. 1O This procedure may mini-
Postoperative Care mize the risk of recurrent fixa tion.
Medial patellar ligament splitting has been
Bandaging: None is practical or required in this described as an alternative to medial patellar lig-

region. ament desmotomy.ll The procedure induces a
Exercise Restridions: Stall rest with handwalk- localized desmitis and thickenin g of the ligament
ing for 2 weeks followed by small paddock turnout
that theoretically makes locking the patella more
for a minimum of 90 days after the surgery.
Medications: Phenylbutazone is administered at difficult. Using ultrasound guidance, percuta-
4.4 mg/kg BID for 24 hours. neous splitting of the proximal third of the medial
Suture removal: Skin sutures are removed 12 patellar ligament is performed. Advantages of the
days postoperatively. procedure include a reported high success rate
with early return to work after surgery, and
reduced incidence of fragmentation of the patella
and middle patellar ligament desmitis.ll
EXPECTED OUTCOME Injections of counterirritants into the medial
and middle patellar ligaments have been used as
If rested extensively after surgery, most horses a treatment for intermittent upward patellar
have an uneventful recovery and return to their fixation and may work by creating fibrous tissue
intended use. A retrospective study supports a that restricts stretching of the medial patellar
high return to athletic activity with appropriate ligament. 12 ,13
Medial Patellar Desmotomy 79

2. Adams S8, Fessler IF: Medial patellar d esmotomy.


COMMENTS In Adams S8, Fessler JF, editors: Atlas of equine
surgery, Philadelph ia, 2000, WB Saunde rs.
In a horse with upwa rd patellar fixation, th e limb 3. Jansson N: Treatment fo r upward fixat ion of the
is positioned with the stifle and hock held in patella in the horse by m edial patella r des m otomy
extensio n with the distal limb held in partial in dications and co mplications. Equine Pract 18:24,
fl exio n (see Figure 12-1). Release of the lim b often 1996.
occurs w ith a quick and exaggerated flexion (see 4. Walmsley JP: The sti fle. In Ross MW, Dyson 51,
Figu re 12-3) . Three situations have been editors: Diagllosis and mallagemem of lame1less in
described. 2 Persistent fixat ion occu rs wh en th e the horse, Philadelphia, 2003, WB Saunders.
5. Bathe AP, O'Hara LK: A retrospective study of the
patella remains fixed for a prolo nged period of
o utcome of medial patella r ligament desmotomy in
time, o ften req uiring assistance or multipl e
49 horses, Proc Am Assoc Equine Pract 50:476, 2004 .
attempts by th e horse to release the patella. Inter- 6. Gibson K, Mcl lwraith CW, Parks RD, et al:
mittent fixa tion occu rs wh en the patella remai n s Produ cti on of patellar lesions by medial patellar
fixed with the limb held in extension behind the desmotomy in normal horses, Vet Surg 18:466,
horse for several seco nds and then is released 1989.
during a normal step. Momentary fixat io n occurs 7. Mcllwraith CW: Osteochondral fragmentation of
when the patella temporarily fixes, causing a slight the distal aspect of the patella in horses, Equine Vet
delay in the start of protraction and a slightly ]22:157,1990.
exaggerated flexion wh en the limb is released. 8. Riley CB, Yovich JV: Fracture of the apex of the
Conservative therapy should always be patella after med ia l patellar desmo tomy in a horse,
Aust Vet J 68:37, 1991.
attempted before su rgical correction of upward
9. Dyson 51: Patellar injuries. In White NA, Moore TN
patellar fixation. Most cases of intermittent up-
editors: Curreflt techniques ill equine surgery and
ward p atellar fixatio n occur in you ng horses lameness, Philadelph ia, 1998, WB Sa unders.
with poor quadriceps condition or in horses that 10. Wright I: Ligaments associated wi th joints, Vet Ciin
have had a period of exte nded stall rest. Th ese N Am Equille Pract II :249, 1995.
horses o ften respond to an exercise program that 11. Tribnar MA: Medial patellar liga ment sp litting for
increases the strength of the quad riceps and su r- the treatment of upward fixation of the patella in 7
rounding musculature. Cases that a re ca n d id ates equids, Vet Surg 3 1:462, 2002.
for surgery have interm ittent upward patell ar fix- 12. Brown M: The effects of an injection of counterir-
ation despite adequate condi tioning programs or ritant into th e patellar ligament of ponies: applica-
tion to st ifle la meness, J Equine Vet Sci 3: 149, 1983.
have persistent locking that ca nnot be manually
13. van Hoogmoed LM , Agnew DW, Whitcomb MB, et
released or recurs after release.2.4·6,'4
al: Ultrasonograp hic and histologic eval uation of
Although most cases of upward patellar
medial and middle patellar ligaments in exe rcised
fixation are primary, u pwa rd pateUar fixation horses followi ng injections with ethanolamine
ca n occur seco ndary to neurologic disease and to oleate and 2% iod ine in almond oil, Am J Vet Res
stifle pathology an d in horses with coxofemoral 63:738, 2002.
joint luxation. 4,'4.'7 If n ecessa ry, these condition s 14. Sullins KE: Lameness. Part XII. The stifle. In Stashak
should be ruled out before performing surgery. TS, ed itor: Adam's lameness ill horses. Philadelphia.
Because of possible fragmentation of the distal 2002, Lipp incott Williams and Wilkins.
patella and middle patellar ligament desmitis after 15. Black 18: The Western performa nce horse. In Ross
desmotom y, the amount of postop erative rest h as MW, Dyson SJ, editors: Diagllosis and management
been increased. The optim um rest period fo r of lameness ill the horse, Philadelphia, 2003, WB
Saunders.
healing is not know n. C urrent reco mmend atio ns
16. Walmsley 1P: Medial desmotomy for upward fixa-
va ry and include 4 to 6 weeks if no sign s of lame-
tion of the patella, Equine Vet Educ 6: 148, 1994.
n ess are present,S 2 to 3 months,9.'8 2 to 5 months,4
17. Clegg PO, Butson RJ: Treatment of coxofemoral
and 4 to 5 months. 6 joint luxation secondary to upward fixa tion of
the patella in a Shetland pony, Vet Rec 138: 134,
REFERENCES 1996.
18. Latimer FG: Tarsus and stifle. In Hinchcliff KW.
I. Dyce KM, Sack WO, Wensing CJG: The h indlimb Kaneps AI, Geor RJ, editors: Equille sports medicine
of the horse. In Dyce KM, Sack WO, Wen sing CJG, and surgery, New York, 2004, WB Sau nders.
editors: Textbook of veterillary anatomy, Philadel -
phia, 1987, WB Saunders.

1____________________________________________________________________
CHAPTER 13
Distal Check Ligament Desmotomy
Joanne Kramer

INDICATIONS POSITIONING AND PREPARATION

The primary indication for distal check liga- The horse is positioned in lateral recumbency
ment desmotomy is deep digital flexor tendon with the affected limb up. When both limbs are
(DDFT) con tracture with coffin joint contrac- affected, the distal check ligament on the down
ture (Figure 13- 1). It is also occasionally used in side can be approached medially. Alternatively, the
th e treatm ent of metacarpophalangeal fl exural horse may be positioned in dorsal recumbency
deformities and in the treatment of ca udal foot when the condition is bilateral. The ci rcumference
lameness w ith upright hoof wall or pastern con- of the limb should be clipped and prepared asep-
formation. tically fro m the fetlock to the mid carpal region.

EQUIPMENT PROCEDURE

Specialized instruments are not required for A 6-cm skin incisio n is made near the distal end
this su rgery. The foot should be trimmed of the proximal third of the metacarpus over the
and examined for subsolar abscesses. Toe exten- DDFT (Figure 13-5). The ap proach can be per-
sions are ap plied in some cases to protect the formed on the lateral or medial aspect of the limb.
toe and to provide a lever arm during breakover The lateral approach is generally simpler and is
to gradually stretch the DDFT (Figures 13-2 and fa rther from the neurovascular bundle. The sub-
13-3). cutaneous tissues and palmar fascia are in cised,
and the intersection between th e distal check li g-
ament and DDFT is palpated or visualized (Figure
ANATOMY 13-6). The intersection between the DDFT a nd
distal check ligament is usually fou nd best by pal-
The distal check ligament wraps around the pation with fingers or the tip of an instrument.
DDFT on the dorsal and lateral surface of the Occasionally, it ca n be visualized. Because of the
DDFT and often forms a slight C shape aro und C shape of th e distal check ligament) it o ften
the DDFT (Figure 13-4). The palmar vei n, artery, wraps around the DDFT such that the DDFT is
and n erve lie close to the DDFT and distal check deep to the intersection of the superficial digital
ligament (see Figure 13-4). Care should be taken flexor tendon and distal check ligament.
to not exteriorize or transect these with the check Blunt dissection between the distal check liga-
ligament. ment and DDFT with a curved Kelly forceps or

80
Distal Check ligament Desmotomy 81

Figure 13-1 Deep digital flexor tendon contracture in the


left foreli mb.


,. .

Figure 13-2 A toe extension created by setti ng a larger


size shoe forward after trimming.

.-

-. " ~
'

.
--

"

Figure 13-3 A toe extension created with acryli c hoof


material.

-
82 L IMB S URGER IES

Common tendon
sheath of SDF and DDF

Communicating
branch

,--- Interosseous - -
• medius
palmar v.a.
(suspensory lig.)

Lateral palmar v.a. palmar n.


(palmar common
digital v. III) SDF tendon

Lateral palmar n'


Communicating branch

Figure 13~4 Anatomy of the distal check ligament and palmar metacarpus.

Figure 13-5 Location of the ski n


incision for distal check ligament
desmotomy,

\ / Site of
approach

I
Distal Check Ligament Desmotomy 83

DDF
tendon,~
Distal
check j

~ DDFtendon
~ ''<-'- - Distal
check lig.
Figure 13-9 Transection of the distal check liga-
~s.....,t;.:l,u.....-
ment.
Figure 13-6 Ident ificatio n of the intersectio n be-
tween the distal check ligament and DDFT.

Figure 13-7 Intraoperative view of the exteriorized Figure 13-10 Gap for m ation between th e ends of
check ligament. the check liga ment after transection.

After confirming that the check ligame nt has


been exteriorized, the check ligament is transected
-;lG>c.ot;..t(... . with a scalpel blade (Figure 13-9). Comple te tran-
Figure 13-8 Exteriorizat ion of the check ligament sectio n is assessed by careful exami nation of the
with curved forceps. transected ends and the gap between the ends of
the ligament when the foot is extended. A gap of
at least 1 em sho uld be present. and the ends of
Metzenbaum scissors is used to separate the struc- the check ligament should be visualized (Figure
tures and exteriorize the check ligament (F igure 13-10). If intact fibers of the check ligament
13-7), To enable exterioriza tion of the entire remain, these sho uld be transected.
check ligament, it is helpful to dissect bluntly to The palmar fascia and subcutaneous tissues are
the far side of the tendon bundle with th e curved closed with a simple contin uous pattern using No.
tips facing palma r and then rotate the ti p dorsally 2-0 absorbable suture material. The skin is closed
when exteriorizing the check ligament (Figure with a conti nuous or simple interrupted pattern
13-8). using No. 2-0 or No. 3-0 suture material.
84 LIMB SURGERIES

is then gradually lowered over the first postoper-


POSTOPERATIVE CARE
ative week to allow for an adaptation period.

Postoperative Care
Dietary Modification
Bandaging: A sterile dressing is placed over the
incision and a half limb bandage is applied. The Rapid growth should be controlled to the extent
bandage is changed every 3 to 4 days and the possible. Ea rly weaning may be indicated in foals
limb is maintained in a bandage for 3 weeks. of heavy lactating mares. High-energy diets
Exercise Restrictions: Handwalking should be should be avo ided. and there may be some benefit
introduced 5 days postoperatively and the time to limiting feed intake to grass hay only for 30
period of handwalking gradually increased over days.I More commonly, growing weanlings are fed
the following 3 weeks up to 30 to 45 minutes a grass hay or grass-alfalfa mix hay-based diet
twice daily. When controlled exercise is not possi- with concentrate rations of 0.5% body weight for
ble, turnout in a small area is provided. a 60-day period.
Medications: Phenylbutazone is administered at
4.4 mg/kg BID for the initial 24 hours and 2.2
mg/kg BID for an additional 3 days. Continued
phenylbutazone administration at lower doses or EXPECTED OUTCOME
less frequent intervals may be necessary for pain
management. Most horses with DDFT contracture improve dra-
Suture removal: Skin sutures are removed 12 mat ically with distal check ligament desmotomy,
days postoperatively. corrective trimm ing or shoeing, and management
of controllable underlying factors. Younger horses
and those with deformities of less than 90 degrees
Corrective Trimming have the best prognosis. 2 -s The results for treat-
If not done preoperatively. the heels should be ment of metacarpophalangeal deformity vary.2.3,6
trimmed or rasped to lower the hoof angle. In In a single report of selected cases of caudal foot
some cases, toe extensions are used in the post- lameness, results were good.7
operative period to increase tension on the DDFT
during breakover and to protect the toe from

excessive wear. COMPLICATIONS
A large change in hoof angle subsequent to
surgery and corrective trimming may cause sig- Complications include excessive scar tissue for-
nificant postoperative pain and subsequent con- mation and recurreflt contracture. The amount of
tractural reflex. In these cases, the foot can be
trimmed and a temporary heel elevation can be
placed on the foot (Figure 13-1 I). The elevation

-
Figure 13-12 No grou nd contact at the heel in a
Figure 13-11 Temporary heel elevation using acrylic. horse with deep digita l flexor tendon contracture.
Distal Check ligament Desmotomy 8S

scar tissue formed may be partly related to the size desmotomy. II Radiographs are useful for evaluat-
of gap between the ends of the check ligament ing the position and architecture of the third
after transection. Excessive scar tissue formation phalanx.
can be minimized by adequate hemostasis, careful Before proceeding with surgery, the horse
and minimal dissection during surgery, and should be examined for sources of pain that are
appropriate bandaging after surgery. Recurrent contributing to the contracture through a pain
contracture is usually due to inadequate hand- withdrawal reflex. In most cases, sou rces of pain
walking during the recovery period, or persistent are related to physitis or foot pathology and are
pain from uncorrected underlying problems (e.g., treated in conjunction with distal check ligam ent
severe developmental orthopedic disease, reCUf- desmotomy. Rarely, other sources of pain such as
fent toe abscesses). should er osteochondrosis are present and affect
the prognosis.

ALTERNATIVE PROCEDURES
REFERENCES
Ultrasound Guided Transection
1. Owens JM: Abnormal flerion of the corono-pedal
Ultrasound guided transection of the distal check
joint or "contracted tendons" in unweaned foals,
ligament has been described." The technique is
Equine Vet J 7:40, 1975.
technically more difficult than the traditional 2. Adams SB, Santschi EM: Management of congeni-
technique but can be performed with the horse tal and acquired flexural deformities, Proc Am Assoc
standing. Equille Pract 46: 117,2000.
3. Mc1lwraith CW, Fessler IF: Evaluation of inferior
check ligament desmotomy for treatment of
Corrective Trimming and Shoeing acquired flexor tendon contracture in the horse, J
Mild cases of DDFT contracture often respond to Am Vet Med Assoc 172:293, 1978.
4. Stick lA, Nickels FA, Williams MA: Long-term
lowering the heels. The toe then acts as a fulcrum
effects of desmotomy of the accessory ligament of
and the weight of the foal forces the coffin joint
the deep digital flexor muscle in Standardbreds: 23
to extend. 9 In some cases treated co n servatively, cases (1979-1989), J Am Vet Med Assac 200:1131,
lowering the heel alone results in continued pro- 1992.
gression of contracture. This is presumably due to 5. Wagner PC, Grant BD, Kaneps AJ, et al: Long term
pain or damage in the dorsal lamina and third results of desmotomy of the accessory ligament of
phalanx secondary to abnormal weight-bearing the deep digital flexor tendon (distal check liga-
forces. This is particularly true when after trim- ment) in horses, J Am Vet Med Assoc 187:1351,
ming, the heels do not contact the ground during 1985.
normal weight bearing (Figure 13-12). Select 6. Blackwell RB: Response of acquired flexural defor-
cases of this type have been treated without mity of the metacarpophalangeal joint to desmo-
tomy of the inferior check ligament, Proc Am Assoc
surgery by lowering the heel and applying a shoe
Equine Pract 28:107,1982.
with a raised heel. The rational e behind this
7. Turner TA, Rosenstein OS: Inferior check desmo-
approach is that it allows for d ecreased tension on
tomy as a treatment for caudal hoof lameness, Proc
the DDFT while allowing the entire foot to be Am Assac Equine Pract 38: 157, 1992.
trimmed and bear weight normally. to 8. White NA: Ultrasound guided transection of the
accessory ligament of the deep digital flexor muscle
(distal check ligament desmotomy) in horses, Vet
COMMENTS Surg 24:373,1995.
9. Curtis SJ: Farriery in treatment of acquired
flexural deformities and a discussion on apply-
With DDFT contracture, excessive stress on the
ing shoes to young horses, Equine Vet Ed 4: 193,
toe causes widening of the white line, excessive
1992.
wear of the toe, and in some cases remodeling of
10. Redden RF: A method for treating club feet, Proc
the tip of the third phalanx. Before surgery, the Am Assoc Equine Pract 34:321, 1988.
foot should be checked carefully for subsolar 11. Adams SB, Fessler JF: Distal check desmotomy. In
abscesses near the toe. If abscesses are present, Adams SB, Fessler JF, editors: Atlas of equine
treatment is preferred before distal check ligament surgery, Philadel phia, 2000, WB Saunders.
CHAPTER 14
Proximal Check Ligament Desmotomy
Joanne Kramer

and cranial aspect of the superficial digital


INDICATIONS
flexor tendon at the m usculotendinous junction
(Figu res 14-4 and 14-5). From the lateral aspect,
Proximal check ligament desmotomy is used in
th e ligament lies adjacent to the proximal and
the management of metacarpophalangeal flexural
medial aspects of the carpal tendon sheath. From
deformities (Figures 14- 1 an d 14-2) and in the
the medial aspect, the ligament lies adj acent to,
management of superficial digital flexor ten-
an d is fused with, the deep sheet of the flexor reti-
donitis (Figure 14-3) .
naculum. To gain access to the proximal check lig-
ament from the medial aspect, the antebrachial
fascia m ust be incised where it is extended as the
EQUIPMENT superfi cial sheet of the flexor retinaculum. This
exposes the tendon of the flexor carpi radialis
Gelpi or Weitlan er retractors, electrocautery, and muscle, which is retracted caudally to expose the
suction should be available for this procedure. ligament.
The fi bers of the proximal check ligament are
in two layers~superficial and deep.
POSITIONING AND PREPARATION The palmar carpal branch of the proximal
radial artery is the nutrient artery for the superfi -
The horse is positioned in lateral recumbency cial digital flexor tendon (SDFT). It is exposed at
with the affected side down. Bilateral cases are the proximal aspect of the ligament and runs in a
repositioned after one limb is complete. Alterna - distolateral di.rection between the superficial and
tively, dorsal recumbency can be used when the deep layers of the proximal check ligament.
condition is bilateral. Dorsal recumbency has the
advantage of natural hemostasis, but access to
the surgical site is awkward. The circumfe rence of PROCEDURE
the limb should be clipped and prepared asepti-
cally fro m the carpus to the mid radial region. An 8- to l O-cm incisio n is made on the medial
aspect of the limb 1 cm caudal to the radius and
cranial to the cephalic vein. The incision starts 1
ANATOMY em proximal to the level of the distal physis and
extends proximally (see Figure 14-4). The subcu-
The proximal check ligament originates on taneous tissues are incised and electrocautery is
the caudomed ial aspect of the radius, cou rses used as needed to achieve hemostasis. The com-
obliquely, and inserts broadly on the medial municating branch of the proximal rad ial vein

86

••
Proximal Check Ligament Desmotomy 87

Figure 14-1 Moderate superficial digital flexo r ten-


don contracture in both forelimbs. Figure 14-3 Superficial digital flexor tendonitis in
the left forelimb.

Site of
approach

Figure 14-2 Superficial digital flexor tendon con-


tracture with fetlock contracture in the left forelimb.
~~t;.r;~~VI(_

Figure 14-4 Location of the incision for proximal


check ligament desmotomy.
that perforates the antebrachial fascia and joins
the cephalic vein is ligated and transected. The
cephali c vei n is then retracted caudally (Figure 14- 14-7). The proximal check ligament is fused with
6). The superficial sheet of flexor retinaculum and the deep sheet of flexor retinaculum. The fibers of
the anteb rachial fascia are incised to expose the the ligament are generally oriented obliquely and
tendon and distal muscle belly of the flexor carpi can be traced to the distal radius. Palpation and
radialis. Gelpi or Weitlaner retractors are used to blunt dissect ion are used to define the limits of the
retract the flexor carpi radialis caudally (Figure proximal check ligament.
88 LIMB S U RG ERIE S

The palmar carpal branch of the proximal ligament is carefully transected a small amount
radial artery courses through the proximal margin at a time, taking care to avoid vessels coursing
of the check ligament, and other small but deep through the ligament (Figu re 14-8). Visualizing
vessels can be found throughout the ligament. the distal extent of the check ligament may require
When isolated and visualized, the proximal check transecting a small amount of the deep sheet
of the flexor retinaculum. When the excision is
complete, the muscle belly of the radial head of
the deep digital flexor tendon (DDFT) is visible
(Figure 14-9) . The carpal sheath may also be
visible in the distal portion of the incision (Figure
14-10). If the carpal sheath has been incised, the
area should be lavaged liberally. The area is
checked for bleeding before closure.
The incision in the superficial sheet of the
flexor retinaculum is closed with No. 2-0 or No.
o absorbable suture material in a continuous pat-
tern. The subcutaneous tissues are closed with No.
2-0 absorbable suture material. The skin is closed
Figure 14-5 Intraoperative view of the proximal with an interrupted pattern using No. 2-0 suture
check ligament (arrow), material (Figure 14-11 ).

fascia (a)

Deep communicating branch to the


proximal radial v. (b)

Cephalic v. (c)

Superficial of flexor retinaculum


Tendon sheath of flexor carpi
(cut) radialis m.

Tendon
flexor carpi radialis m.

Figure 14-6 Ligation and transection of the communicating branch that perforates the antebrachial fascia. and
incision of the supe rfi cial sheet of retinaculum and tendon sheath of the fl exo r carpi radialis.
Proximal Check Ligament Desmotomy 89

b (cut)

~~t;..tc, ~ .
Figure 14-7 Retraction of the flexor carpi radialis caudally to expose the proximal check ligament fused with the
deep sheet of flexor retinaculum. a, Antebrachial fascia; b, cut end of the deep communicating branch to the proxi-
mal radial vein; c, proximal check ligament; d, tendon of fl exo r ca rpi radialis muscle; e, tendon sheath of flexor carpi
radialis muscle;f, deep sheet of flexor retinaculum; g, supe rficial sheet of flexor retinaculum.

," (cut)

I > Layers of proximal check lig.


~t;..t (, ..

Figure 14-8 Transection of the proximal check ligament. a, Deep communicating branch to the proximal radial
vein; b, proximal radial artery (palmar carpal branch ); c, deep sheet of flexor retinaculum; d, superficial sheet of flexor
retinaculum.

SuperfiCial> L f
ayers 0
proximal
check lig.

c
Carpal
~t;,,£'~

Figure 14-10 The carpal sheath exposed after tran-


section of the proximal check ligament. a, Superficia l
Figure 14-9 Visualization of the muscle belly of the sheet of fl exor retinaculwn; b, deep sheet of flexor reti-
radial head of the deep digital flexor tendon (arrow) naculum; c. proximal radial artery (palmar carpal
after transection of the proximal check ligament. branch).

,

90 LIM B SURGER I ES

Figure 14-11 Closure of the superficial


retinaculum, subcutaneous tissue, and ski n.

POSTOPERATIVE CARE EXPECTED OUTCOME

The prognosis is guarded for mild to moderate


Postoperative care
metacarpophalangeal flexural deformities and
Bandaging: A sterile dressing is placed over the poor for severe deformities.2.3 When performed
incision, and a pressure bandage is applied over for superficial digital flexor tendonitis, the prog-
the incision site. The limb is then bandaged from nosis for a return to racing appears to be improved
the incision site distally. The limb is kept bandaged for racehorses, with Standardbreds showing greater
for 3 weeks and the bandage is changed every 3 improvement. 4. 6
to 4 days. For flexural deformities, polyvinyl chlo-
ride (PVC) splints may be necessary to prevent
the fetlock from buckling forward and to maintain COMPLICATIONS
load on the flexor tendons.
Exercise Restrictions: The horse is stall rested Seroma formation is the most common compli-
for 2 weeks without handwalking and then stall
cation. Seromas should be left to resorb sponta-
rested with handwalking for the following 2 weeks.
Exercise is then gradually increased as indicated neously. Seromas that continue to increase in size
by the primary problem. can be aseptically aspirated or, rarely, treated by
Medications: Phenylbutazone is administered drainage after postoperative days 12 through 14.7
at 4.4 mglkg BID for the initial 24 hours Incisional or carpal sheath infections are possible
and 2.2 mglkg BID for an additional 3 days. Con- but not common. Increased strain on the sus-
tinued phenylbutazone administration at lower pensory ligament after proximal check ligament
doses or less frequent intervals may be necessary desmotomy may predispose to suspensory liga-
for pain management in flexural limb deformities. ment desmititis. 8,9 Horses treated for metacar-
Antibiotics are used preoperatively but generally pophalangeal flexural deformities may not have
not continued in the postoperative period. significant improvement with proximal check lig-
Suture Removal: Skin sutures are removed 12
ament desmotomy alone and may require addi-
days postoperatively.
Other: When contractural deformity is present, tional procedures.
the foot should be trimmed to as normal an angle
as possible. In mild cases, an elevated heel may ALTERNATIVE PROCEDURES
be beneficial to allow lengthening by a gradual
increase in load on the tendon. In severe cases,
In horses with superficial flexor tendon core le-
a vertical bar shoe may be indicated.'
sions, percutaneous tendon splitting may improve
Proximal Check ligament Desmotomy 91

healing by draining hematomas or seromas asso- intact, the majority of the load during weight
ciated with the core lesion and creating a com- bearing is sustained by the tendon from the prox-
munication between the tendon core and the imal check ligament distally. Desmotomy is
peritenon that promotes healing. The procedure thought to allow the muscle to assume a greater
is often performed in conjunction with proximal portion of the load and contribute to the elastic-
check ligam ent desmotomy.7,10 ity of the entire unit. 14 The act ual strain in vitro
Tenoscopically assisted superior check liga- on the SDFT after proximal check ligament
ment desmotomy has also been described and desmotomy increases, but the elongation of the
may offer the advantages of decreased incisional musculotendinous unit also increases during load
complications and operative time,l1 ,12 application. 15 This elo ngation and recruitment of
Flexural limb deformities of the metacar- muscle fibers may allow for increased elasticity in
pophalangeal joi nt will so metimes respond to the musculotendon unit compared with those
inferior check ligament desmotomy alone or that heal without desmotomy. 14
in combination with proximal check ligament
desmotomy. 2,1l Fetlock flexu ral deformities have REFERENCES
also been treated with superficial digital flexor
tenotomy.2
1. Auer ]A: Flexural deformities . In Aller JA, Stick lA,
editors: Equine surgery, ed 2, Philadelphia, 1999,
WB Saunders.
COMMENTS 2. Adams S8, Santsch i EM: Management of congeni-
tal and acquired fl exural deformities, Proc Am Assoc
Proximal check ligament desmotomy is more dif- Equine Pract 46: 117. 2000.
ficult than distal check ligament desmoto my. A 3. Kidd lA, Barr ARS: Flexural deformities in foals,
thorough understanding of the anatomy, careful Equine Vet Edu, 14(6):311,2002.
attention to hemostasis, and strict asepsis are 4. Fulton Ie, Maclean AA, O'Reilly JL, et al: Superior
check ligament desmotomy fo r treatment of super-
important for consistently good res ults.
ficial digital flexor tendonitis in Tho roughbred or
Determining the most appropriate s urgical
Standardbred horses, At/st Vet J 71:233, 1994.
treatment for fetlock flexural deformities can be 5. Hawkin s JF, Ross MW: Transection of the accessory
difficult. For mild cases where the fetlock angle is ligament of the superficial digital flexor muscle for
less than 180 degrees, the limb can be forced into the treatment of superficial digital flexor tendonitis
extension and the superficial and deep digital in Standardbreds: 40 cases (1988- 1992), J Am Vet
fl exor tendons palpated. If the tautest structure is Med Assoc 206(5):674, 1995.
the DDFT, distal check ligament desmotomy may 6. Hogan PM, Bramlage LR: Transection of the acces-
be beneficial. If the tautest structure is the SDFT sory ligam ent of the superficial digital flexor
or th e superficial and deep feel equally taut, prox- tendon for treatment of tendonitis: long term
ima l check ligam ent desmotomy is th en per- results in 61 standardbred racehorses horses ( 1985-
1992 ), Equine Vet J 27(3):22 1, 1995.
formed. In moderate or severe cases where the
7. Adams SB, Fessler JF: Proximal check desmo-
fetlock angle is greater than 180 degrees, both pro-
tomy/Percutaneous tendon splitting. In Adams SB,
cedures are performed. 2 If response is not ade- Fessler JF, editors: Atlas of equine surgery, Philadel-
quate after tran section of both check ligaments, phia, 2000, WB Saunders.
tenotomy of the SDFT is performed. As discussed 8. Alexander GR, Gibso n KT, Day RE: Effects of supe-
previously, severe cases have a poor prognosis for rior check desmotomy on flexor tendon and sus-
correction because of joint capsule and s uspen- pensory ligament strain in equin e cadavers, Vet
sory li gament contracture. These cases are candi- Surg 30:522, 200 I.
dates for fetlock arthrod esis. 9. Gibson KT, Burbd ige H M, Pfeiffer DU: Super-
Several, but not ail, studies suggest that proxi- ficial digital flexor tendonitis in thoroughbred race
mal check ligament desmotomy increases the like- horses: outcome following non-surgical treatment
and superior check desmotomy, Aust Vet J 75:631,
lihood of return to racing after superficial digital
1997.
flexor tendonitis. 4 -6 ,9 The reaso n for improvement
10. Henni nger R, Bramlage L, Schneider R: Shor t term
is not clearly understood but is likely related to the effect of superior check liga ment desmotomy and
functional lengthening of the superficial digital percutaneous tendon splitting as treatment for
flexor musculotendinous unit that occurs after acute tendonitis, Proc Am Assoc Equine Pract
desmotomy. When the prox imal check ligament is 36:539, 1990.
92 LI MB SURGERIES

11. Kretzschm ar BH, Desjardins MR: Clinical evalua- 14. Bramlage LR: Superior check desmotomy as a
tion of 49 tenoscopically assisted superior check treatment for superficial digital flexor tendonitis:
ligament desmotomies in 27 horses, Proc Am Assoc Initial report, Proc Am Assoc Equine Pract 32:365,
Equine Pract 47:484, 2001. 1986.
12. Southwood LL, Stashak TS, Kainer RA: Desmo- 15. Shoemaker RS, Bertone AL, Mohammad LN, et al:
tomy of the accessory ligament of the superficial Desmotomy of the accessory ligament of the super-
digital flexor tendon in the horse with use of a ficial digital flexor muscle in equine cadaver limbs,
tenoscopic approach to the carpal sheath, Vet 5urg Vet SlIrg 20:245, 199L
28:99, 1999.
13. Blackwell RB: Response of acquired flexural defor-
mity of the metacarpophalangeal joint to desmo-
tomy of the inferior check ligamen t, Proc Am Assoc
Equine Pract 28: 107,1982.
CHAPTER 15
Distal Splint Bone Resection
Joanne Kramer

INDICATIONS EQUIPMENT

Fractures in the middle or distal third of the splint A chisel or osteotome, bone rasp. and tourniquet
bones with nonunion , excessive callus, sequestra, are used for this procedure.
or septic osteitis (Figure 15- 1).
ANATOMY

The distal aspect of the splint bone has rudimen-


tary attachm ents to the palmar/plantar fascia and
proximal ligament of the ergot (Figure 15-2). The
interosseous ligament attaches the splint bones to
the third metacarpal-metatarsal bone. In the hind
limb, the dorsal metatarsal artery lies between
metatarsal bones III and IV. The do rsal branch of
the ulnar nerve (lateral) and the palmar meta-
carpal or plantar metatarsal nerves (lateral and
medial) run in the area of the distal end of the
splint bone (see Figure 15-2).

POSITIONING AND PREPARATION

The horse should be placed in lateral recumbency


with the affected splint bone up or in dorsal
recumbency with the affected limb suspended .
The limb should be prepared and draped for full
circum fere ntial access to the entire m etacarpal!
metatarsal region.

PROCEDURE

A vertical incision is made directly over the


Figure 15-1 Mid metatarsal splint bone fracture. affected splint bo ne starting 4 em proximal to the

93
94 LIMB SURGER I ES

Common digital
'",o~ tendon

Lateral
extensor

. ., Interosseous medius m .
(suspensory lig.)

,
Dorsal br.
of ulnar n. - ••••

01 the ergot

Interosseous Ii
Medial palmar a.v.
Distal end of Jig. 01 the
(palmar common
lateral splint bone ergot Lateral palmar a.v.
digital a.v. II)
Palmar Interosseous digital a.v. III)
n. IV medius Medial palmar n.
(suspensory lig.) Lateral palmar n.
Within the digital
tendon sheath

' - , ' ' - -- Distallig. of


the ergot


~t;.e". .. _
Figure 15-2 Anatomy of the distal splint bone.

fracture site and ending 2 cm distal to the distal


aspect of the splint bone. The distal end of the
splint bone is sli ghtly rounded and can usually be
palpated directly. If the region is significantly
swollen, the opposite splint bone can often be pal-
pated and used as a rough estimate of the distal
landmark. The incision is then deepened to the
level of, but not through. the periosteum. In severe
cases, extensive scar tissue is present surrounding
the splint bone. The distal end of the splint bone
is identified and sharp dissection used to free it
from its distal attachment to the palmar fascia and
proximal ligament of the ergot (Figure 15-3). The
end is then grasped with a towel clamp or forceps,
and a curved osteotome or chisel is used to
sever the attachments to the third metacarpal or
Figure 15-3 Freeing the spl int bone from its distal
metatarsal bone (Figure 15-4). Ca re should be
attachments.
taken to avoid damaging the dorsal metatarsal
artery in the pelvic limb, which may be difficult to
identify in cases with extensive fibrous tissue.
In some cases, the distal splint bone and frac-
tured portion can be freed past the fracture site
Distal Splint Bone Resection 95

Figure 15-6 Removing the affected portion of splint


bone.

Figure 15-4 Severing the interosseous ligament


attaching the splint bone to the cannon bo ne.

Figure 15-7 Using a bone rasp to smooth the edge


of the remaining proxi mal spli nt bo ne after excision of
the distal portion.

discolored tissue should be removed. The area is


~t;..t'~
then lavaged. The proximal aspect of the remain-
Figure 15-5 Amputation of the splint bone proxi- ing splint bone is tapered or smoothed with a
mal to the fracture site with an osteotome. bone rasp to avoid leaving any sharp edges (Figure
15-7) .
Bleeding from the region can be controlled
for removal in one unit. The osteotome is used as needed through the use of cautery, hemostat
2 em proximal to the affected area to create appl ication, and occasionally ligation. Although
th e proximal amputation site (Figure 15-5) . The the region is generally very vascular, most bleed-
splint bone and affected portion with its perios- ing can be controlled by postoperative pressure
teum can then be removed as one unit (Figure 15- bandaging. Tourniqu et application facilitates the
6), Other cases may have extensive callus for- procedure.
mation, making removal in one unit from the The subcutaneous tissues are closed with a syn-
distal end difficult. These require removal of the thetic absorbable suture material. If the amount
portion distal to the affected site , creation of th e of dead space is extensive, a Penrose drain can be
proximal amputation site, and further dissection placed before closure of the subcutaneous tissues.
to remove the remaining portion of affected bone. Most cases can be managed without a drain. The
All sequestra, surrounding mineralized tissue, and skin is closed with an interrupted pattern.
96 LI MB SURGERIES

the amputated portion of the splint bone is


POSTOPERATIVE CARE
unlikely but may require additional rest, antiin-
flammatory therapy, and possibly fur ther surgical
Postoperative Care removal.

Bandaging: A sterile dressing is placed over the


incision and a half limb bandage is placed and
changed the day following surgery. An inner pres- ALTERNATIVE PROCEDURES
sure bandage can be placed over the incision site
to control postoperative hemorrhage and swelling. Segmental ostectomy of the affected portion of
If placed, this should be removed the day follow- the splint bone leaving the proximal and distal
ing surgery. The bandage is changed every 2 to 4 segments intact has been described as an alterna-
days for 3 weeks. If a drain has been placed, it tive to resection of the entire splint bone distal to
should be removed within 3 days or sooner if the fracture. Results were good in the 17 cases
drainage is minimal. described. l
Exertise Restridions: Strict stall rest is advised
for the first 10 days followed by stall rest with
handwalking for the following 2 weeks. Return to
activity is then dependent on healing of the site COMMENTS
and the degree of any concurrent suspensory lig-
ament damage. In general, exercise is limited to Minimally displaced fractures will often heal ade-
small-area turnout for at least 2 months postop- quately with conservative management. 2- 4 Frac-
eratively. tures in the proximal third of the splint bone may
Medications: Phenylbutazone is administered at require internal fixation or complete removal of
4.4 mg/kg BID for the initial 24 hours and 2.2 metatarsal bone IV.,·6 Amputation of the splint
mg/kg BID for an additional 3 days. Further anti-
bo ne in the proximal one fou rth of the splint bone
inflammatory use is dependent on concurrent
problems such as suspensory desmitis. Antibiotic potentially destabilizes the remaining portion of
use and duration are dependent on the presence the splint bone and is not recommended without
of infection and ideally guided by culture results. consideration of internal fixation of the rema in-
If a drain is placed, antibiotic therapy should be ing proximal fragment. If the proximal fragme nt
continued 24 hours past removal of the drain. is stable) some open proximal fractures may be
Generally, if debridement is thorough, the need managed by deb ridement without disturbing the
for antibiotic therapy is minimal. proximal or distal seg ment attachments. 2•4,7
Suture Removal: Skin sutures are removed 12 Distal splint bone fractures are often associated
days postoperatively. with hyperextension injuries or suspensory liga-
ment desmitis. 8.9 These conditions should be as-
sessed preoperatively and may dictate postopera-
tive therapy. Fractures in the middle third of the
EXPECTED OUTCOME splint bone are generally a result of trauma and
are more likely to be associated with infecti on or
The prognosis for middle and distal splint bone sequestrum formation.
fract ures is exceUent. The prognosis for proximal
splint bone fractures is variable.
REFERENCES
COMPLICATIONS
1. Jenson PW, Gaughan EM, Lillich JD, et al: Segmen-
Seroma formation may occur especially if a large tal ostectomy of the second and fourth metacarpal
and metatarsa l bones in horses: 17 cases (1993-
amount of dead space was present during closure.
2002),1 AII1 Vet Med Assoc 224(2):271, 2004.
This is generally treated by continued bandaging
2. Adams SB, Fessler JF: Excision of distal splint bone
or, if persistent, by opening the distal end of the fractures. In Adams SB, Fessler JF, editors: Atlas of
incision. Dehiscence of the incision is possible, equine surgery, Philadelphia, 2000, WB Saunde rs.
especiall y if a seroma develops. Generally, this is 3. Dyson SJ; The metacarpal region. In Ross MW,
only partial dehiscence and can be allowed to heal Dyson SJ, editors; Diagllosis and management of
by second intention. Excessive bone reaction nea r lamelless in the horse, St Louis, 2003, WB Sau nders.
Distal Splint Bone Resection 97

4. Jenson PW, Gaughn EM, Lillich JO, et a1: Splint bone 7. Kidd 1: Management of splint bone fractures in the
disorders in horses, Camp COlIl Educfor the Pract Vet horse, In Practice 25(7):388, 2003.
25(5):383,2003. 8. Bukowiecki CF, Bramlage LR, Gabel AA: In vitro
5. Baxter GM, Doran RE. Allen 0: Complete excision strength of the suspenso ry apparatus in trainin g and
of a fractured fourth metatarsal bone in eight horses, resting horses, Vet SlIrg 16(2): 126, 1987.
Vet SLlrg 2 1(4):273, 1992. 9. Verschooten F, Gasthuys F, De Moor A: Distal spl int
6. Peterso n PR, Pascoe JR, Wheat JD: Surgical ma n- bone fractures in the horse: an experimental and
agement of proximal splint bone fractures in the clinical study, Eqllille Vet] 16:532, 1984.
horse, Vet SlIrg 16( 1): 13, 1987.
CHAPTER 16
Deep Digital Flexor Tenotomy
Joanne Kramer

INDICATIONS POSITIONING AND PREPARATION

Severe distal interphalangeal joint contracture or The procedure is most often performed with the
severe laminitis with rotation of the third phalanx horse standing in adult horses with laminitis and
(P3) (Figures 16-] and 16-2). recumbent in foals with severe deep digital flexor
tendon (DDFT) contracture. When performed
with the horse standing, heel wedges are tem-
EQUIPMENT porarily placed on the horse to take tension off the
DDFT during the procedure. A high palmar-
A heel wedge is used during standing procedures. palmar metacarpal nerve block or inverted -U
Modified table knives or malleable retractors are block is performed in the proximal metacarpal
useful when isolating the tendon during transec- region. The limb is clipped circumferentially and
tion ' (Figure 16-3). prepared for aseptic surgery in the mid metacarpal
region. A sterile adhesive drape or short drapes
proximal and distal to the site are used.

Figure 16-1 Severe deep digital flexor tendon Figure 16-2 Lam initis with rotation of the third
co ntracture. phalanx.

98
Deep Digital Flexor Tenotomy 99

flexion. The incision for mid metacarpal deep


ANATOMY
digital flexor tenotomy is located above the prox-
imal extent of the digital flexor tendon sheath and
The heads of the DDFT originate from the medial
is typically below the distal check ligament inser-
epicondyle of the humerus, olecranon, and caudal
tion. At this level. the neurovascular bundles lie
radius and insert as a single tendon on the palmar
directly over and slightly dorsal to the DDFT. Care
surfa ce of the third phalanx. Transecting the
must be taken to not exteriorize or transect these
DDFT eliminates the pull of the deep digital flexor
with the tendon (Figure 16-4).
muscle on the coffin bone, reducing shearing
forces between the dorsal coffin bone and hoof
wall and essentially eliminating coffin joint
PROCEDURE
A 3-cm incision is made over the DDFT in the
middle third of the metacarpus, avoiding the
flexor tendon sheath, which extends proximally to
the level of the second and fourth metacarpal
bones (Figure 16-5). The palmar fascia is incised,
and blunt dissection is used to create a space
between the superficial digital flexor tendon and
the DDFT. A space is then created between the
DDFT and the suspensory ligament (interosseous
medius tendon). The bent knife with the larger
Figure 16-3 Be nt table knives are useful during iso- curvature is slid on the palmar surface of the
lation and transection of the deep digital flexor tendon. DDFT, and the bent knife with the smaller curva-
The curvature of the top instrument is greater than that ture is slid on the dorsal surface of the DDFT until
of the bottom instrument. the instruments overlap (Figure 16-6). Slight

Common digital
extensor tendon

Lateral digital
extensor tendon
. • I,. . •
", '.... ••
... "......
•- -
.

'.
-
• •
- --
~ . •
.'

MC IV MC II

Dorsal br. Interosseous medial m.


ofulnarn. (suspensory lig.)
Medial palmar a.v.
(palmar common
digital a.v. II)
Lateral palmar a.v.
(palmar common
digital a.v. III)
Medial palmar n.
Lateral palmar n.
SDFT

Figure 16-4 Cross sectional anatomy of the deep digital flexor tendo n and mid metacarpal region.
100 LIMB SURGERIES

overlapping of and tension on the instruments


bring the DDFT to, but not out of, th e incision .
The DDFT is then tran sected with a No. JO blade
(Figure 16-7). I f the distal check ligament is
present at the level of the incision, it is isolated
and transected with the DDFT. After transection,
the heel elevation can be removed to check for
adequate gap formation between the tendon ends.
Closure of the subcutaneous tissue is optional.
Closure of the skin is performed with an inter-
rupted apposing or everting pattern using No.
2-0 mon o filam ent suture material.

POSTOPERATIVE CARE

Postoperative Care

i of
Bandaging: A sterile dressing is placed over the
't- a:pproach incision and a half limb bandage is applied. The
limb should remain bandaged for 30 days, and
the bandage is changed every 5 to 7 days or more
frequently if needed.
Exerc:ise Restrictions: Horses with laminitis
should be rested as their condition indicates and
are not allowed significant turnout for a minimum
of 6 months. Foals with contracture can be allowed
turnout in a small area after I week, and the
amount of exercise allowed is gradually increased
Figure 16-5 lncision location for deep digital flexor over the next 60 days. Free choice turnout should
tenotomy. not be allowed for up to 6 rnonths.'
Medications: Phenylbutazone should be admin-
istered for a rninirnum of 5 days.
Suture Removal: Skin sutures are removed 12
days postoperatively.
Other: Continued corrective shoeing is an essen-
tial component of treatment. Surgery should not
be performed without considerations for postop-
erative corredive trimming and shoeing. Prin-
ciples of shoeing to reestablish the normal
relationship between the solar surface of P3 and
the sole following deep digital flexor tenotomy
have been described',' and are essential when
tenotomy is performed as a component of lamini-
tis treatment. Foals with severe fiexural deformi-
ties should be trimmed in a normal fashion. The
need for corrective shoeing in these cases
depends on the amount of release achieved after
tenotomy.

Figure 16-6 Isolation of the deep digital flexor


tendon.

2
Deep Digital Flexor Tenotomy 101

ALTERNATIVE PROCEDURES

Tenotomy at the level of the mid pastern has been


described. 9 The procedure is performed under
general anesthesia. A vertical 3-cm midline in-
cision is made on the palmar aspect of the mid
~e..v, t;;..tl< '1 _ pastern. The incision is continued through the
Figure 16~ 7 Transection of the deep digital flexor subcutaneous tissue and digital flexor tendon
tendon. sheath. Curved forceps are placed under the
tendon, and it is transected with a scal pel. The
incision in the tendon sheath is closed with No.
2-0 absorbable suture. The subcutaneous tissues
EXPECTED OUTCOME are closed with 2-0 absorbable suture and the skin
is closed in an interrupted pattern.
Deep digital flexor tenotomy is a salvage proce-
dure, although some horses may become so und
for athletic activity. The intended goal should be
limited to an improvement in comfort level and
pasture soundness. Severe chronic cases of coffin
joint contracture may have such severe joint The DDFT can be isolated and elevated outside
capsule and surrounding tissue contracture that the incision with curved forceps as has been tra-
limb position may not improve significantly after ditionally described. to During standing surgery,
tenotomy.5,6
we prefer to use the modified table knives
The prognosis for horses with laminitis likely described by Redden because the neurovascular
depends on the condition of P3 and blood supply. structures are easily protected from transection
An improvement in pain, but not survival rate, without having to exteriorize the tendon. Because
has been reported in horses with acute refractory of the anatomic location and peri tendinous
laminitis,7 In selected cases of chronic laminitis, attachments, tenotomy at the level of the pastern
an improved prognosis for survival has been may provide greater release than tenotomy at the
reported. s mid metacarpal level. I I No difference in outcome
has been demonstrated between tlle two tech-
niques, and we prefer mid metacarpal tenotomy
COMPLICATIONS because of the lack of tendon sheath in the mid
m etacarpal region and the more proximal loca-
Incisional dehiscence or drainage is rare. Sever- tion for standing surgery.
ance of the palmar artery, vein, or nerve is possi-
ble and care must be taken that these structures
are not isolated with the DDFT. Pain following
tenotomy in foals with contracture may be signif- REFERENCES
icant because of stretching of the joint capsule and
soft tissue and can be managed with nonsteroidal I. Redden RF: Shoeing the laminitic horse. In Redden
antiinflammatory medication. Occasionally, tem- RF, editor: Understanding laminitis, Lexington,
porary heel elevation is used to allow for a more 1998, The Blood Horse Inc.
gradual change in foot conformation. Hyper- 2. Sullins KE: Standing musculoskeletal surgery. In
Bertone A, editor: Standing surgery in the horse,
extension of the coffin joint may occur and is
Vet Clin N Am Equine Pract 7:687, 199 1.
managed with heel extension and elevation.
3. Nickels FA: Laminitis. In Ross MW, Dyson S1.
Superficial digital flexor tendonitis may result
editors: Diagnosis mId management of lamelless in
from the increased strain on the superficial digital the horse, Philadelphia, 2003, WB Saunders.
flexor tendon. Recurrent infection, abscessation, 4. Redden RF: Shoeing the laminitic horse, Proc Am
and sequestration of P3 are associated with Assoc Equine Pract 43:356, 1997.
chronic pain. If chronic pain persists, flexural 5. Adams SB, Santschi EM: Management of congeni-
deformity of the metacarpophalangeal joint may tal and acquired flexural deformities, Proc-Am Assoc
occur. Equine Pract 46: 117, 2000.

\

102 LIMB SURGER IES

6. Mcllwraith CW, Fessler IF: Evaluation of inferior 9. Allen 0, White NA, Foerner 1F, et al: Surgical
check ligament desmotomy for treatment of management of chronic laminitis in horses: 13
acquired flexor te ndon contracture in the horse, J cases (1983-1985), ] Am Vet Med Assoc 189:1604,
Am Vet Med Assoc 172:293, 1978. 1986.
I
7. Hunt RJ, Allen DA, Baxte r GM, et a1: Mid 10. Adams S8, Fessler JF: Deep digital flexor tenotomy.
metacarpal deep digital flexor tenotomy in the In Adams 5B, Fessler JF, editors: Atlas of eqllille
management of refractory laminitis in horses, Vet surgery. Philadelphia, 2000, WB Saunders.
5urg 20:15,1991. 11. Hunt Rl: Laminitis. In Ross MW, Dyson 5J, editors:
8. Eastman TG, Honnas eM, Hague BA: Deep digital Diagllosis and management of lameness ;n tlte horse,
flexor tenotomy as treatment for chronic laminitis Philadelphia, 2003, WB Saunders.
in horses: 37 cases, Proe Am Assoc Eqllille Pmct
44:265, 1998.
CHAPTER 17
Semitendinosus Tenotomy and Myotomy
Joanne Kramer

the affected limb positioned down. The myotomy


INDICATIONS
procedure is performed with the horse sta nding
with local anesthesia and sedation.
Treatment of gait abnormalities secondary to
fibrosis or ossificat ion of the semitendinosus
muscle (fi brotic myopathy).
PROCEDURE

EQUIPMENT Semitendinosus Tenotomy


Palpation of the proximal medial tibial region
No special equipment is required for tenotomy. A usually reveals the location of the horizontally ori-
blunt-tipped bistoury is useful for the myotomy
ented tendon of insertion. Generally, the tendon
procedure. is about four fingers' width distal to the proximal
tibia. The distal end of the tibial crest can also be
used as a proximal to distal guide. An 8-cl11 verti-
ANATOMY
cal incision is made over the tendon caudal to the
medial saphenous vein. The incision is extended
The semitendinosus muscle originates from the
through the subcutan eo us tissues and the dense
transverse processes of the first and second caudal
crural fascia to expose the tendon. Curved forceps
vertebrae, the sacrosciatic ligament, and the
are passed underneath the tendon, and the tendon
ventral surface of the ischiatic tuberosity. It inserts
is transected (Figure 17-1). The fascial layer is
on the tibial crest, crural fascia proper, and cal-
closed with an interrupted or continuous pattern
caneal tuberosity. The tendon of insertion on the
using synthetic absorbable suture material.
medial aspect of the proximal tibia is transected
The subcutaneous tissue is closed with a continu-
in the tenotomy procedure. The myotomy proce-
ous pattern using synthetic absorbable suture
dure involves transecting muscle fibers at the
material. The skin is closed in an interrupted
distal extent of the fibrotic region and is typically
pattern.
performed on the caudal aspect of the limb just
proximal to the musculotendinous junction.
Semitendinosus Myotomy
POSITIONING AND PREPARATION Infiltration of local anesthetic is performed in
an inverted-U pattern surrounding and distal
The semitendinosus tenotomy procedure is per- to the most taut palpable area of fibrosis . A 6-cm
formed with the horse in lateral recumbency with vertical incision is made over the caudal aspect

103
104 LIMB SURGERIES

Saphenous a. and n.
and medial
saphenous v.
___ Incision line

Tendon of
semitendinosus m. B

A
Figure 17-1 Location (A) and incis ion (B) of the semitendinosus tendon of insertion on the proximal tibia

of the semitendinosus muscle beginning at the


POSTOPERATIVE CARE
distal extent of the fibrosis and extending
distally. Blunt dissection is used to deepen the
incision to the level of palpable fibrosis. A blllnt-
tipped bistoury is used to transect the muscle
or tendon attachments at the distal extent of the Postoperative Care
fibrotic area (Figure 17-2). Taut vertical fibrotic
bands that appear to limit cranial movement Bandaging: If myotomy is performed, the gauze
when the limb is pulled forward by an assistant packing is changed the following day and
are transected.! The horse is then walked several removed in 2 days.
Exercise Restrictions: Stall rest with light hand-
steps to judge the effect of the release. If necessary,
walking is advised for the first 2 weeks, followed
the procedure is repeated until the gait improves by gradually increasing exercise. Full turnout is
or until the entire area distal to the fibrosis has allowed 6 weeks following surgery.
been transected. The incision is lavaged copiously Medications: Phenylbutazone is administered at
with sterile saline and packed with sterile roll 4.4 mg/kg BID for the initial 24 hours and 2.2
gauze. Partial closure of the skin is performed and mg/kg BID for an additional 5 days. Antibiotic
the remainder of the incision is left to heal by therapy is continued until 24 hours after drain or
second intention. Alternatively, a Penrose drain packing removal. Horses should receive a tetanus
can be placed and the incision closed primarily. toxoid booster if it has been longer than 6 months
When other muscles such as the semimembra- since the previous vaccination.
nosus or biceps femoris are involved, a similar Suture Removal: Skin sutures are removed 12
days postoperatively.
myotomy procedure can be performed.
Semitendinosus Tenotomy and Myotomy 105

- - - - - Bistoury
knife

Fibrotic
region

Fibrous
bands

~ 09.........,,~..:t:u...-

Figure 17-2 The use of a bistoury knife to tran sect restr ictive sca r tissue on the distal aspect of the affected

region.

EXPECTED OUTCOME COMPLICATIONS

Reported cases treated with tenotomy have had Dehiscence, seroma formation, and infection are
good results, but only a small number of cases possible but not common if the tenotomy only is
have been reported. 2 ,3 Horses with mild scarring performed. If myotomy is performed, the likeli-
often improve considerably with tenotomy, and hood of these co mpli cations increases. Extensive
the procedure has minimal complications. In the postoperative fibrosis may result in recurrence of
author's opinio n, horses with more severe fibrosis the gait abno rm al ity.
generally require myotomy fo r improvement and
have a higher likelihood of recurrence. In one
report, 75% of horses treated with myotomy had ALTERNATIVE PROCEDURES
75% or greater improvement in gait. At approxi-
mately 2-year follow- up, one th ird of these horses Tra nsect io n of th e semitendinosus muscle's in-
had some recurrence of gait restriction . Some se rtion on the calcaneal tuber has also been
horses with some recu rren ce of restriction were described fo r cases where a taut band is palpable.
able to perform at their intended level. 4 Horses The lim b is protracted during surgery after
with fibrosis confined to the semi tendinosus tenotomy of the tibial insertion. If a taut band
muscle have a better outcome than those with is palpable over the calcaneal tuber insertion, it is
additional fibrosis in the biceps femoris or semi- tra nsected through an incision caudal and distal
membranosus muscles. s In cases where muscles to the first incision. 2•7
other than the semitendin osus are involved, tran- Complete removal of the area of fibrosis and a
section of fibrosis in the involved muscle may be 4-cm portion of tendon has also been described. 8,9
beneficial. 1.6 The procedure can be effective, but a high inci-
106 LIMB SURGERIES

dence of complications probably caused by the REFERENCES


extensive dissection required and large remaining
dead space has been reported. Additionally, recur- I. Irwin DHG, Howell DW: Fibrotic myopathy,
rence in gait restriction secondary to fibrotic hematomas and scar tissue in the gaskin area of the
heali ng is likely. I,1O thoroughbred, J South African Vet Assoc 52:65,
1981.
2. Bramlage LR, Reed SM, Embertson RM: Semi-
COMMENTS tendinosus tenotomy for treatmen t of fibrotic
myopathy in the horse, } Am Vet Med Assoc 186:565,
1985.
Fibrotic myopathy is commonly a result of trauma
3. Pickersgill CH, Kriz N, Malikides N: Surgical t reat-
to the semitendinosus muscle with subsequent ment of semitendinosus fibrotic myopathy in an
inflammation, hematoma formation, and fibrosis endurance horse management, complications
or ossification. Involvement of the semimembra- and ou tcome, Equine Vet Educ 12:242, 2000.
nosus, biceps femoris, and gracilis muscles is also 4. Magee AA, Vatistas NJ: Standi ng semitendinosus
possible. In cases where the inciting injury was myotomy for the t reatment of fibrotic myopathy
observed, the hind limb has been caught cranially in 39 horses, Proc Am Assoc Equine Pract 44:263,
and underneath the horse or slipped forward 1998.
excessively during sLiding stops. It has been 5. Villamandos RG, Santisteban JR, Avila I: Tenotomy
reported after in tramuscular injections. 2.s,1O Two of the tibial insertion of the semitendinosus muscle
of two horses with fibrotic myopathy, Vet Rec
congenital cases and three cases associated with
126:67,1995.
peripheral neuropathy have been reported. 2ol1
6. Dabare iner RM, Schmitz DG, Honnas eM, et al:
The gait associated with fibrotic myopathy is Gracilis muscle injury as a cause of lameness in two
likely caused by an effective shortening of the horses, ] Am Vet Med Assoc 224:1630, 2004.
semitendinosus muscle and adhesions between 7. Adams SB, Fessler JF: Sem itend inosus tenotomy for
the semitendinosus muscle and biceps femoris fibrotic myopathy. In Adams SB, Fessler JF, editors:
or semimembranosus muscles. This functional Atlas of equine surgery, Philadelphia, 2000, WB
shortening limits protraction of the hindlimb and Saunders.
results in the limb being retracted just before 8. Adams OR: Fibrotic myopathy in the hindlegs of
ground contact and contacting the ground in a horses, J Am Vet Med Assoc 139: 1089, 1961.
pronounced vertical slapping motion. The abnor- 9. Sullins KE: Lameness. Part XlII: the femur. In
Stashak TS, editor: Adam's lameness in horses,
mality is most easily observed at a walk. The gait
Philadelphia, 2002, Lippincott, Williams & Wilkins.
restriction appears to be primarily mechanical
10. Turner AS, Trotter GW: Fibrotic myopathy in the
and not directly associated with pain. horse, } Am Vet Med Assoc 184:335, 1984.
II. Valentine BA, Rouselle SD, Sams AE, et al: Dener-
vation atrophy in three horses with fibrotic myopa-
thy, J Am Vet Med Assoc 205:332, 1994.
CHAPTER 18

Palmar-Plantar Digital Neurectomy


Joanne Kramer

surgery is performed, the lateral side of the upper


INDICATIONS forelimb and the medial side of the lower forelimb
are operated on initially. The horse is then rolled
Chronic lameness that improves significantly after
onto the opposite side and th e procedures are
palmar/ plantar digital anesthesia and has not
repeated. Alternatively, the horse can be placed in
improved with alternative treatment options.
dorsal recumbency with the limbs extended or
Typical indications include selected cases of nav-
flexed on the sternum.
icular disease, navicular bone fractures, wing frac-
When possible, surgery time is decreased by
tures of the third phalanx, idiopathic heel pain,
having two surgeons operate simultaneously. The
and palmar-plan tar foot injuries (Figure 18-1).
circumference of the limb should be clipped and
prepared aseptically from the fetlock distally.
EQUIPMENT

Specialized instruments are not required for the ANATOMY


guillotine or Black's method of neurectomy.
Perineural capping requires Gerald or similar The palmar-plantar branch of the palmar-plantar
smooth-tipped forceps (Figure 18-2) . digital neurovascular bundle lies in the space
between the palmar/plantar border of the pastern
and the abaxial border of the deep digital flexor
POSITIONING AND PREPARATION tendon (DDFT). The nerve is just palmar/plantar
to the artery and is found just deep to the liga-
This surgery can be performed with the horse ment of the ergot. The presence of small accessory
standing or under general anesthesia. Maintaining nerve branches varies; when present, they often lie
sterile and atraumatic technique is more difficult palmar/plantar and deep to the ligament of the
during standing surgery because of the proximity ergot.
of the ground and inadvertent limb movement.
Standing surgery is performed with the horse
under sedation with local anesthetic over the PROCEDURE
palmar digital nerves at the level of the sesamoid
bones. Peripheral anesthesia is also beneficial A 3-cm skin incision is made over the abaxial
when the surgery is performed under general border of the DDFT in the mid to distal pastern
anesthesia. region (Figure 18-3, A) . The incision is extended
Horses under general anesthesia are placed in carefully through the subcutaneous tissue. Blunt
lateral or dorsal recumbency. When bilateral dissection is used to isolate the palmar digital

107

Figure 18-2 Gerald forcep s used when performing


perineural capping.

Figure 18-1 Preoperative image of a horse with nav-


icular d isease. Note the typical pointing sta nce of the
left forelim b.

of digital cush ion

A Site of
approach

c
1
.-.--1

.. _, _ _
~Pp- t;;.l,-~

o
Figure 18-1 A, Incision location for pal mar digital neurectomy. B, Location of the palmar digital nerve in relation
to surrounding structures. C, Palpation of longitudinal fibers when the nerve is stretched over a smooth instrument.
OJ Crimped appearan ce of the nerve after it has bee n released. E, Transection of the palma r digital nerve. 1, Palmar
d igital ne rve; 2, palmar digital vein; 3, palmar digital artery; 4, ligament of the ergot.
Palmar-Plantar Digital Neurectomy 109

nerve (Figure 18-3, B) . Identification of the nerve years, the reported soundness rate is 63%. I
is confirmed by its appearance (smooth, white, Reasons for lameness vary and may be directly
and glistening), by the crimped appearance of the related to surgical complications, reinnervation,
nerve after it has been stretched and released, and or secondary lameness in the limb.
by palpating longitudinal fibers when the nerve is
stretched over the smooth portion of an instru-
ment (Figures 18-3, C and D). When isolation of COMPLICATIONS
the nerve is confirmed, a 2- to 3-cm section of the
nerve is freed from the surrounding tissues. The Progression of the underlying problem may occur.
nerve is stretched, and the proximal end is tran- In severe cases of navicular disease, progression
sected sharply with a new blade as proximal as can result in DDFT rupture or navicular bone
possible. The distal portion is then transected fracture. To decrease the incidence of these com-
sharply (Figure 18-3, E). The surgical site is eval- plications, we generally avoid performing neurec-
uated for accessory nerve branches. If identified, tomy in horses with erosion of the flexor cortex of
they are transected in a similar manner. Subcuta- the navicular bone or extremely large medullary
neous closure is optional. The skin is closed with cavity cysts (Figure 18-4). If neurectomy is per-
a continuous or interrupted pattern using No. formed in horses with flexor cortex lesions, the
2-0 suture material. horse should be shod with moderate to significant
heel elevation and activity should be limited. In
all cases of navicular disease, corrective shoeing
POSTOPERATIVE CARE for navicular disease should be continued postop-
eratively.
Postoperative Care Undetected foot abscesses may occur from lack
of sensation, and the foot should be examined
Bandaging: A sterile dressing is placed over the
daily for evidence of puncture. Reinnervation can
incisions, and a limited-pressure bandage is
occur within months of the surgery, and treat-
applied over the incision sites using folded gauze
sponges and 3-inch Elasticon. A half limb bandage ment options are limited to repeat neurectomy
is then applied. The initial bandage is changed 24 at a more proximal location. Neurectomy above
hours after surgery and replaced without the pres- the dorsal branch of the palmar digital nerve
sure bandage. Subsequent bandage changes are is not recommended. Painful neuroma formation
performed at 4- to 5-day intervals or more fre- is somewhat unpredictable. 3 Its occurrence is
quently if indicated. Bandaging is applied for a thought to increase when excessive inflammation
minimum of 3 weeks.
Exercise Restridions: Stall rest is provided
for 4 weeks. After 10 days, handwalking is al-
lowed. After 4 weeks, the horse may resume
normal activity.
Medications: Phenylbutazone is administered at
4.4 mg/kg BID for the first 24 hours and 2.2
mg/kg BID for an additional 5 days.
Suture Removal: Skin sutures are removed 12
days postoperatively.
Other: When performed for navicular disease,
corrective shoeing to decrease the biomechanical
forces on the navicular bone should be continued.
The bottom of the foot should be checked daily
for puncture wounds, or the horse should be shod
with pads.

EXPECTED OUTCOME
Figure 18-4 Horse with large medullary cavity cyst.
Reported soundness rates 1 year after palmar This horse is at increased risk for deep navicular bone
digital neurectomy are 74%1 and 77%.2 After 2 fracture following neurectomy.
110 LI MB SU RG ERIES

occurs. This may be related to performing surgery


too soon after diagnostic anesthesia, traumatic
su rgical technique, excessive postoperative move-
ment, or incisional site problems. Ideall y, su rgery
should not be perfo rmed fo r a minimum of
2 weeks after diagnostic anesthesia of th e palmar
digital nerve. Surgical technique and hand ling of
the nerve should be as atraumatic as possible,
and excessive dissection minimized. Adequate
postoperative rest and proper band aging tech -
niques should be emphasized to the owner. Loss
of th e hoof wall as a res ult of ischemia is a ra re
but possible complication. Reasons for its occ ur-
ren ce are not well und erstood.4 Figure 18-5 Exposure of the palmar digital nerve in
the proximal and distal incisions used in Black's
method of neurecto my.

ALTERNATIVE PROCEDURES

Black's Technique
This method of neurectomy allows for removal of
a longer section of nerve, decreasing the cha nces
of accessory nerve branch innervation to the
region. The proximal nerve endin g may also lie
deeper in the incision, potentially decreasing the
incidence of neuroma formation. 5
A 2-cm skin incisio n is made over the abaxial
border of the DDFT just above the medi al or
lateral cartilage of the third phalanx in the distal
pastern region. The incision is extended carefully
through the subcutaneo us tissue. Blunt dissection
is used to isolate the palmar digital nerve. Identi-
fi cation of the nerve is co nfirmed by crimping of Figure 18-6 The nerve has been transected proxi-
the nerve after it has been stretched and released mally and pulled thro ugh the distal incision in Black's
method of neurectomy.
and palpating longitudinal fibers when th e nerve
is stretched over the smoo th portion of an instru -
ment. Closed Kelly forceps are placed below the
nerve, and tractio n is appl ied to identify the loca-
tion of the nerve in th e proximal pastern region.
A 2-cm incision is made in the proximal pastern
region distal to the base of the proximal sesamoid
bone directly over the nerve being held in trac-
ti on. The nerve is isolated in th is region, and trac-
tion is applied to the proximal and distal ends to
ensure the same nerve is exposed through both
incisions (Figure 18-5). A new scalpel blade is
then used to transect the nerve as proximal as pos-
sible through the upper incision. Traction is
applied to the distal end of the nerve in the distal
incision, and a 6- to 8-cm po rtio n of nerve is
stripped through the incision (Figure 18-6) . The
exposed nerve is then severed as distally as possi- Figure 18-7 Two-day postoperative view of the inci-
ble, and the skin is closed ro utinely (Figure 18-7). sions used in Black's method of neurectomy.
Palmar-Plantar Digital Neurectomy III

Perineural Capping
Perineural capping of the proximal nerve end may
be performed in an attempt to decrease painful
neuroma formation.} Controlled studies with
high case numbers are lacking, but if the tech-
nique can be performed atraumatically it is likely
beneficial. The palmar digital nerve is isolated and
exposed as for the guillo tine technique. The distal
end of the nerve is severed. The end of the prox-
imal nerve is grasped with hemostats, and Gerald
or similar dressing forceps are used to free the
combined epin eurium and perineurium (per-
ineural sleeve) from the nerve (Figure 18-8, A A
and B). After freeing of the perineural sleeve, the
proximal end of the nerve is sharply transected. If
sufficient nerve length is available, two partial
incisions in the nerve can be made before tran-
seeting the nerve. The purpose of these incisions
is to slow axon regeneration and allow increased
time for the perineural capping seal. 3 After nerve
transection) the edge of the perineural sleeve is
grasped and pulled over the nerve (Figure 18-8,
e) . The perineural sleeve is closed with one or two
interrupted sutures using 4-0 absorbable suture.
Subcutaneous and skin closures are routine.
Other techniqu es for neurectomy have been
described, including a method of tunn eling the B
proximal nerve end into bone and the use of a
carbon dioxide laser to perform neurectomy) and
they appear to have good success rates. 6 ,7

COMMENTS

Careful selection of cases should be performed.


Significant improvement in lameness after palmar
digital anesthesia is important, as well as an owner
who understands potential complications and will
provide excellent short- and long-term postoper-
ative management. A variety of techniques for
neurectomy are available, but no single technique C
has proven to be superior. Atraumatic technique Figure 18-8 Perineural capping on a cadaver limb.
and adequate postoperative rest are the essential A. The nerve ending is grasped with hemostats, and
components of all techniques. Although potential smooth-tipped forceps are used to strip the perineural
complications of neurectomy dictate limited use sleeve proximally. B, The perineural sleeve has been
stripped proximally, and the nerve is exposed. C, After
of the procedure) palmar digital neurectomy can
severing the exposed nerve, the nerve ending retracts
offer significant pain relief and return to athletic
proximally within the perineural sleeve. The perineural
function in horses that have not responded to sleeve is then closed with No. 4-0 suture material.
other treatment options.
112 LIMB SURGER I ES

REFERENCES 5. Black J8: Palmar digital neurectomy: an alternative


surgical approach, Proc Am Assoc Equine Pmct
38:429, 1992.
I. Jackman BR, Baxter GM, Doran RE. et al: Palmar
6. Harris JM, Kermedy MA: Modified posterio r digital
digital neurectomy in horses: 57 cases (1984-1990).
neurectomy for management of chronic heel pai n in
Vet Su'g 22:285, 1993.
horses, Proc Am Assoc Equine Pract 45:99, 1999.
2. Matthews S, Dart A, Dowling B: Palmar digital
7. Haugland LM, Collier MA. Panciera RJ. et al: Effect
neurecto my in 24 horses using the guillotine tech-
of C02 lase r neurectomy on n euroma formation
nique, Aust Vet} 81 :402, 2003.
and axonal regeneration. Proc Am Assoc Eqllille Pmct
3. Evans LH: Procedures used to prevent pa inful neu-
39:229, 1993.
romas, Proc Am Assoc Equine Pmct 16: 103. 1970.
4. Taylor TS, Vaugha n IT: Effects of denervation of the
digit of the horse,} Am Vet Med Assoc 177: 1033, 1980.
CHAPTER 19
Cast Application
Joanne Kramer

INDICATIONS CAST APPLICATION

Casts provide mechanical support and physical Preparation


protection for fractures, luxations, and tendon
The li mb should be clean and the foot trimmed
and ligament injuries. Casts also provide physical
normally. A sterile dressing is applied over inci-
protection and soft tissue immobilization for
sions or wounds. A double layer of stockinette is
wounds and are commonly used to facilitate
applied to the region of limb to be cast (Figure 19-
wound healing.
2). The stockinette should conform to the limb
and not be allowed to wrinkle. Orthopedic felt is

applied at the proximal limit of the cast (Figure
EQUIPMENT 19-3).

Fiberglass casting material, cast padding, syn-


thetic stockinette, orthopedic felt, and acrylic are
used (Figure 19-1). A variety of fiberglass casting
material is available. J,2 We commonly use Delta
Limb Positioning and Handling
Lite "S."*
The limb is generally cast in a weight-bearin g
position. Exceptions include flexor tendon lacera-
tions, where the limb may be cast in a slightly
POSITIONING AND PREPARATION
flexed position. The hind limb is often cast in
slight flexion to decrease tension on the superfi- .
Most casts are applied under general anesthesia
cial digital flexor tendon from the reciprocal
with the affected limb uppermost. Stan din g
apparatus when the stifle and hock flex. If traction
application is possible but increases the risk o f a
is required, wires may be placed through the hoof
poorly fitting cast due to movement. Half limb
wall and used with a steel bar to apply traction.
and distal limb casts are put on with the horse
Wires may also be useful to maintain foot posi-
under general anesthesia. Foot casts and some
tion while casting. When handling the limb
forelimb distal limb casts are put on with the
during cast application, the limb should be held
horse standing with the affected limb held up by
only at the foot and above the cast. Pressure o n
an assistant.
the cast m aterial during the cu ring process can
create focal pressure points that lead to cast sores
"Delta-Lite "$"; Johnson & Johnson, Raynham, Mass. o r areas of stress concentratio n.

113
114 LIMB SURGERIES

" ,,
'>

$ ; II!
'" ..

Figure 19-1 Supplies used in cast application. From Figure 19-4 A cast where all layers have cured
left to right, stockinette, orthopedic felt, foam cast simultaneously.
padding, and fiberglass casting material.

Figure 19-2 Applying a double layer of stockinette. Figure 19-5 A cast where individual layers of cast
material have cured separately. The result is a weak cast
prone to break.

water. Specific directions for handling vary with


each manufacturer. Generally, the cast material is
immersed in water at room temperature (68° to
77° F, 20° to 25° C) and squeezed four to five times
while immersed, before application. Cast material
curing time can be slowed slightly by exposing the
material to cooler water for a sho rter time period.
As cast material cures, it stiffens to provide rigid
support. AlI layers of the cast should cure sim ul -
taneously to provide adequate strength. Once cast
application is begun , subsequent layers of cast
Figure 19-3 Orthopedic felt applied at the antici~ tape must be applied rapidly to avoid individual
pated proximal limit of the cast. layers of cast material stiffening before becoming
bonded to the surrounding layers (Figures 19-4
and 19-5).
Handling of Cast Material
The strength of a cast depends on the thickness of
the cast and the bonding between the individual
Application of Cast Material
layers of cast tape. The polyurethane resin i.n the A layer of cast padding is applied before the cast
casting tape starts to cure when immersed in material is applied to ensure even contact between

-
Cast Application 115

Figure 19-6 Foam padding applied before fiberglass Figure 19-7 App lying fiberglass casting material.
casting tape is applied.

the cast and the limb and to protect the skin from
the fiberglass material. A variety of materials are
available for cast padding.1 A water-curable foam
padding>!- is commonly used and appears to de-
crease cast sores' (Figure 19-6). The foam padding
should be set on the limb with only minimal
tension. The cast material should be applied with
only enough tension to avoid wrinkling. Each
turn should be overlapped by half a tape width.
The tension used when applying the cast material
can be increased gradually as the number oflayers
in the cast increases. For most fiberglass cast Figure 19-8 Inco rporation of a heel wedge into the
materials, the horse should be maintained in bottom of the cast. A pa rtial roll of casting tape has been
incorporated into the heel (left) and acrylic applied to
recumbency for 20 minutes after cast application
provide an even weight bearing surface (right).
to allow for curing.

Half Limb Cast strength compared with wider casting tape. Four-
A doubl e layer of stockinette is rolled from the inch-wide cast tape should be used for subsequent
foot to above the carpus or tarsus and held in layers (Figure 19-7). Cast material should be
place with towel clamps. The stockinette should applied with only enough tension to avo id wrin-
fit snugly and be stretched to avoid wrinkles. A 2- kling and with each turn overlapped by half a tape
inch-wide felt strip is then placed over the width. Before the last layer of cast material is
metacarpal-metatarsal bones at the proximal limit applied, the stockinette is folded down and held
of the cast, which should be 2 em distal to the in place by the last cast layer. Ad hesive tape is used
ca rpal or tarsal joint. Custom support foam or to seal the proximal end of the cast. The entire
other cast padding material is applied starting length of cast should be covered in five to eight
proximally and working distally, with special layers of tape.' Generally, five or six rolls of casting
attention paid to adequately cover the coronary tape are used in a half limb cast. Casts providing
band. This is immediately followed by a layer of mechanical support for severe orthopedic injuries
2- to 3-inch-wide casting material. The initial require more layers than do casts providing soft
2- to 3-inch layer allows better contouring of the tissue support for wound healing. A heel wedge
cast material to the limb but has decreased should be placed so that the toe and heel of the
cast are level when the limb is directly under the
horse (Figure 19-8). Acrylic or other durable
"Custom Support Foam; 3M Animal Health Care Prod- material is applied to the bottom of the cast to
ucts, St. Paul, Minn. prevent wear (Figure 19-9).
116 LI MB SURGERIES

Figure 19-9 Applying acrylic to protect the bottom Figure 19-11 A foot cast used to protect hoof wall
of the cast from excess ive wear. injuries or aid in third phalanx fracture stab ilizatio n.

joint dorsally or the proximal sesamoid bones


palmarly or plantarl y.'

Foot Cast
Foot casts terminate just below the coronary band
on the hoof wall (F igure 19- 11 ). They can be used
in the management of hoof wall injuries or coffin
bone fractures. ' Felt padding should be applied to
the heel bulb region. Two-inch casting material is
used to allow for adequate contouring. Acrylic is
placed on the bottom of the cast to decrease wear.

Figure 19-10 Applying a dist.l limb cast.


Bandage Cast
Bandage casts are used when frequent access to
Distal Limb Cast
the limb is desired or as reduced support in the
This cast terminates at the proximal pastern, transition from a traditional half limb cast to ban-
allowi ng fetlock flexion and extension (Figure 19- daging. Two or three pieces of th in sheet cotton
10). Distal limb casts are most commonl y used in are rolled around the limb and secured wi th
the treatment of heel bulb and distal pastern and brown roll gauze. Vetrap* is the n applied. The
coronary band lacerations.5,6 The palmar-plantar foot is included in the wrap for increased immo-
aspect of the cast is slightly shorter tha n the bilizatio n. Orthopedic felt is applied at the proxi-
dorsal aspect of the cast to allow for fetlock exten- mal limit of the cast. Applicati on of custom foa m
sion. Stockin ette is applied and felt padding is support is recommended but optional. The cast is
placed around the proximal aspect of th e first then constructed wi th the desired amount of
phalanx. The limb is cast in a weight-bearing posi- casting tape (generally five or six rolls of 4-inch
tion. Cast padding and 2- or 3-inch cast material casting tape). Acrylic is applied to protect the foo t.
is used to allow for adequate contouring. Acrylic At the first required bandage change, the cast is
is placed on the bottom of the foot to decrease cut with an oscillating saw along the medial and
wear. The heel is not typically elevated. Deter- lateral or dorsal and palmar aspects. The bandage
mining the optimal weight-bearing position of is then changed, and the two halves are reapplied
the fetlock is difficult and is best assessed when and secured with duct tape. s
the cast has cured and the limb is bearing weight.
In some cases, the cast may have to be trimmed *Vetrap; Animal Care Products, 3M Health Care, SI. Paul,
back slightly if it appears to impinge on the fetlock Minn.
Cast Application 117

A modification of this procedure is performed cast Removal


when less immobilization is requ ired or the ban -
In adult horses, casts are generally removed or
dage cast is used as a transition to bandaging alone
replaced with in 4 to 6 weeks. With very careful
after a half limb cast has been removed. The initial
monitoring, an adult horse showing no problems
layer of bandage material described earl ier is
may wear a cast up to 6 to 8 weeks. In young foals,
placed without Vetrap, and a seco nd identical layer
casts should be removed in 10 to 12 days. For
is placed over the initial layer and secured with an
older foals, casts can be left in place for up to 3
elastic wrap. The cast is then constructed without
weeks.
inclusion of the bottom of the foot and bivalved
For orthopedic support, cast application is
at the first bandage change (Figure 19-12, A to C).
often necessary for 8 weeks. For wound support,
cast application is required for 2 to 3 weeks.
POSTOPERATIVE CARE Casts are removed with an oscillating cast
cutter and cast spreaders. The med ial and lateral
Posto erative care sides of the entire length of the cast are cut full
thickness with an oscillating saw (Figure 19-1 4).
Bandaging: A support bandage and foot eleva- The cast spreaders are then inserted in the cut lin e
tion are often applied to the contralateral limb' and the cast pried open (Figure 19-15). The
(Figure 19-13). In cases of severe injury, support
underlying stockinette is then cut, and the cast is
to the contralateral limb is essential to decrease
removed from the limb. When the osc illating saw
the risks of contralateral limb laminitis. This can be
provided in the form of frog and caudal support, has penetrated the depth of the cast, a character-
heel elevation, and decreased breakover. Com- istic "give" is felt. The cast cutters should not be
mercial shoes are available and work well for this dragged back and forth along an area to be cut.
purpose~ Even pressure should be applied without moving
Exercise Restridions: Horses with casts should the saw until the cast has penetrated the depth of
be confined to a stall. After cast removal, exercise the cast. The cast cutters are then removed and
must be gradually increased to avoid overloading reinserted so that the previously cut area is over-
articular cartilage, bone, and soft tissues. The lapping halfway with the next area to be cut. Cast
longer the period of immobilization, the more spreaders should not be inserted until the entire
important and gradual is this reintroduction
length of cast is cut. If the thickness of the cast is
period.
symmetrical and the layers of castin g tape have
*Redden Modified Ultimate; Nanric Inc., Versailles, Ky. cu red in a one-layer cast, removal is straightfor-

A B C
Figure 19-12 A bandage cast used for transition to bandaging after traditional half li mb casting. A, The casting
material is placed over a do uble layer of bandage material. B, At the first desired bandage change, the bandage cast is
split into two halves. C, After the bandage is changed, the halves are supported with duct tape, allowing subsequent
bandage changes to be performed as needed.
118 LIMB SURGERI ES

ward. Special care should be taken over bony the transition between cast support and normal
prominences, joints, and the coronary band, as weight bearin g. Foals often require temporary
these are the areas most likely to be injured with heel extension after cast application because of
the cast cutter. flexor tendon laxity (Figure 19-16).
Bandaging or splint application is indicated
after cast removal to prevent edema and to ease
Cast Monitoring
Casts must be monitored daily for the presence of
heat, discharge, pressure sores, and cracking.
Horses wearing casts should be mo nitored closely
for cha nges in the level of lameness present. Early
cast removal and replacement or reassessment are
indicated immediately if the cast has broken or
the horse has had a significant change in lameness
level.

COMPLICATIONS

Cast sores, disuse osteopenia, articular ca rtilage


Figure 19-13 Bandaging and elevation of the con- softening, joint stiffness, tendon or ligament
tralateral limb. laxity, or breakage of the cast may occur. 2 •4 •1O ,11
Pressure or frictio n sores generally occur at the
proximodorsal aspect of the thi rd metacarpal
bone, the proximoplantar aspect of th e superficial
digital flexor tendon, and the pal mar/plantar
aspect of the sesamoid bones in hal f limb casts
(Figures 19-17 and 19-18). In distal limb casts,
pressure or friction sores are most comm on at the
proximopalmar aspect of the pastern. Foals and
thin-skinned horses are particularly susceptible to
cast sores. The degree of articular ca rtilage
atrophy and disuse osteopenia and laxity is likely
related to the length of cast immobilization and
to the use or lack of use of the limb during the
Figure 19-14 Cast removal using an oscillating saw. casting period. In foals, marked flexor tendon

Figure 19-15 Aft er the entire cast has been split with Figure 19-16 Application of a heel extension to
an oscillating saw. Cast spreade rs are inserted to sepa- provide flexor tendon support in a foa l with tendon
rate the two halves of the cast. laxity secondary to cast application.
Cast Application 119

Figure 19-19 Incorporation of a dorsal-palmar


splint to increase bending strength in a half limb
cast.

A B
ALTERNATIVE PROCEDURES
Figure 19-17 Areas prone to cast sore development
when a half limb cast is worn. Splints
During cast application, longitudinal splints of
cast material can be applied on the dorsal and
palmar aspect of the cast for additional strength.
The splints are applied after several layers of cast
material have been applied, and the final layers of
cast material are used to incorporate the splints
into the cast (Figure 19-19).

Preplaced Fetotomy Wires


Plastic-covered fetotomy wires can be prep laced
on the medial and lateral aspects of the limb
superficial to the cast padding but deep to the
casting tape. The cast is then removed by placing
Figure 19-18 Cast sores on the palmar aspect of the handl es on the wire and using the wire to saw the
fetlock. cast open on each side?

laxity occurs within a short period of time. Prox- COMMENTS


imal sesamoid bone fracture secondary to disuse
osteopenia after hind limb cast application has Casts are only rarely used as the primary stabi-
been reported in two horses.12 Half-limb casts lization method for fractures or luxations. More
ending too low can create stress concentration on often, casting is used as initial first aid stabiliza-
the metacarpal bone and risk fracture, especially tion for the transport of horses with severe
during recovery from anesthesia. orthopedic injuries. For more information on the
Breaking of the cast usually occurs at the level appropriate form of stabilization for specific
of a moveable joint. Breakage is a result of inade- injuries, Chapter 4 on emergency stabilization of
quate cast material strength due to inadequate orthopedic injuries should be consulted.
thickness or inadequate curing (curing of two or The benefits of cast application in wound
more individual layers). Broken casts need to be healing are often overlooked because of a per-
removed immediately and replaced entirely. ceived increase in cost. We have found that the
120 LIMB SURGER IES

cost of frequent bandage changes is often similar 5. Blackford JT, Latimer FG, Wan PY, et al: Treating
to th e cost of initial casting and have had good pastern and foot lacerations with a phalangeal cast,
success with cast application as an aid to wound Proc Am Assoc Equille Pmct 40:97.1994.
h eal ing. To minimize complications, the period of 6. Booth TM, Knottenbelt DC: Distal limb casts
in eq uine wound management. Equine Vet Educ
cast application should be as short as possible. and
11:273.1999.
removal, reassess ment, and replacement should
7. Booth TM, Dart AI. Watkins JP: Equine limb casts:
be performed if there is any question as to the
materials and methods, Camp Can t Educ Pmct Vet
status of the underlying limb. Foals can develop 25:708.2003 .
cast complications quickly because of th eir thin 8. Hogan PM: How to make a bandage cast and indi-
skin, high activity level, and tendency toward cations for its use, Proc Am Assac Equine Pract
severe ligament laxity. 46: I SO. 2000.
9. Hendrickson DA , Stokes M, Wittern C: Use of an
elevated boot to reduce contralateral limb support
REFERENCES complications secondary to cast application, Proc
Am Assoc Equine Pmct 43: 149. 1997.
1. Booth TM, Dart AJ. Watkins JP: Equine limb casts: 10. Richa rdson OW, Clark CC: Effects of shor t- term
materials and methods, Comp Cant Educ Prac Vet cast immobilization on equine articular ca rtilage,
25:701.2003. Am I Vet Res 54:449. 1993.
2. Murray RC, Oebowes RM: Casting techniques. In 11. vanHarreveld PO, Lillich JD, Kawcak CE: Effects
Nixon AI, editor: Equine fracture repair, Philadel- of immobilization followed by remobilization
phia, 1996, WB Saunders. on mineral density, histomorphometri c features
3. Bramlage LR, Embertson RM, Libbey CJ: Resin and formation of the bones of the metacar-
impregnated foam as a cast liner on the distal limb, po phalangeal joint in horses, Am / Vet Res 63:276,
Proc Am Assoc Vet Pract 37:481,1991. 2002.
4. Riggs CM: Indications for and application of limb 12. Malone ED, Anderson BH, Turner TA: Proximal
casts in the mature horse, Equine Vet Educ 9:190, sesamoid bone fracture following cast removal in
1997. two horses, Equine Vet EdriC 9:185,1997.
EAD AND ECK URGERIES

121
CHAPTER 20
Intraoral Wire Fixation of Rostral Mandibular
and Maxillary Fractures
David A. Wilson

lated feed material, and the area surrounding the


INDICATIONS
fracture site is scrubbed with povidone-iodine
soap and rinsed aga in. If a wire will be passed
Fractures of the rostral mandible, maxi lla, and
around the premolars, stab incision sites are
incisive bones that can be repaired with wire and!
clipped and prepared aseptically.
or acrylic. Only fractures that can be readily
repaired with stainless steel wires are discussed.
ANATOMY
EQUIPMENT The primary structures potentially involved in the
repair of these fractures are the maxilla, incisive
Stainless steel wire (16 or 18 ga uge), needle bone, incisive part of the mandible, incisors,
holders or pliers, wire cutters, acrylic, and drill. A canine teeth, mental and infraorbital nerves,
spool speculum or section of PVC tubing placed intermandibular synchondrosis, and permanent
between the cheek teeth improves access to the tooth roots. The permanent incisors, canines, and
oral cavity. Ideally, a nasotracheal tube is also premolars are formed from separate enamel
placed during the surgery to facilitate breathing. organs that are derived from lingual (med ial)
extensions of the dental laminae of the deciduous
teeth. 1 The permanent incisors erupt on the
POSITIONING AND PREPARATION lingual aspect of the deciduous incisors.
The mental nerve emerges from the mental
Simple fractures involving one to three incisors foramen on the rostrolateral aspect of the hori-
can be repaired in the standing, sedated horse zontal ramus, approximately midway between the
with local anesthesia. Mental and infraorbital second premolar and the third incisor. A smaller
nerve blocks provide effective regional anesthesia portion of the mental nerve continues rostral in a
in these cases. Alternatively, local anesthesia can smaller canal along with the vasculature of the
be used. Fractures involving the interdental space lower incisors. 1
are more commonly repaired under general anes-
thesia in either lateral or dorsal recumbency
depending on fracture configuration. Antibiotics PROCEDURE
and nonsteroidal antiinflammatory agents are
administered prior to surgery. Ideally, a naso tra - Var ious methods have been described to repair
cheal tube is placed to protect the airway. The fractures of the rostral mandible and incisive
mouth is rinsed with water to remove accumu- bone.'· " The first step of the surgery is thorough

122


Intraoral Wire Fixation of Rostral Mandibular and Maxillary Fractures 123

debridement of the fracture site. Remaining food to facilitate wire passage between the incisors. The
material, clotted blood, and bone fragments are wires should be app lied tightly by hand and
removed. A bone curette may be used to freshen twisted one or two turns followed by additional
the edges of exposed bone, being ca reful to not twisting using fencing pliers, needle drivers, or the
manipulate or damage exposed, unerupted per- equivalent, being careful not to overtighten the
manent teeth. Completely detached or broken wires and cause wire breakage. When necessary,
teeth should be removed . However, loose decidu- additional stabilization can be achieved by secur-
ous teeth are maintained if possible. These teeth ing the corner incisor(s) to the exposed canine
often survive better than expected and provide if erupted or seco nd or third premolar (Figures
stability, structure, and positioning for future 20-2 and 20-4).
permanent tooth eruption. Fractures involving Incorporating the second premolar into the
alveoli can result in infectious periodontitis and fixation involves placing a tension band wire from
puipitis, necessitating removal of the tooth. 9 the incisors to the second premolar (Figure 20-3).
However, removal of the tooth should be delayed A stab incision is made through the cheek directly
until the fracture heals. over the space between the second and third
Fractures that involve four or fewer incisors premolars. Hemorrhage is minimized by incising
can be repaired with cerclage wire fixation tech - through the skin and using blunt dissection to
niques. As a rule of thumb, wires should engage a separate underlying soft tissues. The buccal
minimum of two teeth as the teeth immediately mucosa is penetrated, and the drill bit with a pro-
adjacent to the fracture will not be very stable. A tective drill guide is positioned between the
minimum of two loops should be used to secure second and third premolars just ventral to the gin-
a fracture fragment . Ideally, there should be gival margin. The drill guide is left in place after
overlap of the wire loops to improve stabilization drilling between the teeth is completed to help
(Figure 20-1). A 14-gauge hypodermic needle thread the wire through the drilled hole. The wire
with or without a 2-mm drill hole can be used to is then pulled through the cheek and directed
guide the stainless steel wire (16 to 18 gauge [I- rostral to be laced through the holes previously
to l.2-mm diameter]) through the interalveolar made between the incisors. The wires spanning the
spaces. In yo ung horses, the 14-guage needle may interdental space are twisted together to increase
be used without prior drilling. The 14-guage compression at the fracture line. After tightening,
needle may also be used as a cannula after drilling the ends of the wi res are bent flat and may be

A B c
"7J.p"...,,!~ .. ( .,.
Figure 20~ 1 A. Using a hypodermic needle as a wire guide to help pass the wire between teeth. B. Second passage
of the wire using the hypodermic needle to help pass the wire. C, Wires in position to repair a rostral mandibular
fracture involving the first and second right incisors in a young horse without canine teeth. Note overlap of w ire
loops, which reinforces the fixation.
124 HEAD AND NECK SURGERI ES

covered with a small amount of acryl ic. In youn g,


rapidly growing horses, both sides of the mandible
should be included in the fixa tion to the prem o-
lars to minimi ze the risk of developing disparate
m andibul ar growth or placi ng undue stress on the
sym physis.
Bilateral fractures in the interdental space with
displacement are often unstable a nd req uire more
than wire fixation. In co mminuted fractures of th e
interdental space, the mandible tends to collapse
when th e wires are ti ghtened. A buttress is needed
to maintain the mandible in position. Acryl ic
reinforcement of intraoral wiring can be used in
B so me of these fractures, res ultin g in a relatively
stable fixation. 12 Ideally, cold curing acrylic should
be used or the acrylic should be lavaged with
saline as the acrylic is curing.
A ~e",._t:...~ <.L.
'" A ten sion band wire is placed from the inciso rs
Figure 20·2 A. Rostral mandib ular fracture involv- to the first or second cheek tooth as previo usly
ing the first left incisor and all three right incisors. described. After the wires are placed, an intraoral
In older ho rses, the canines ca n be used to anchor the splint is made by molding acrylic around the wires
stabilizing sutures. B. Note the "notch" in the cani ne to and conto uri ng it to fit th e m outh from the
help hold the wires in position (arrow). incisors to the second cheek tooth. The wires run

B c
Figure 20-3 A. Positioning of drill th rough cheek between first and second cheek teeth fo r insertion of tension
band wi re for repair of rostral mandibular frac ture. B. Initial wire insertion to repair rostral mandibular fracture

involving the right incisors. In young horses. a 14- or 16-guage needle can be used to insert the wires between teeth.
In older ani mals, a small drill (abo ut 2 mm) can be used to provide a path for the wire. C. Wires in place fo r repa ir
of a rostral ma ndibular fracture involving the right incisors in the absence of can ine teeth. After the wires are tight-
ened, the ti ed ends should be folded over aga inst the gu m to min imize so ft tissue irritatio n. A small amou nt of acryl ic
may be applied over the wire ties to minimize irritation .

....
Intraoral Wire Fixation of Rostral Mandibular and Maxillary Fractures 125

EXPECTED OUTCOME

Rostral fractures usually heal without complica~


tion in 4 to 6 weeks, provided there is adequate
stabilization and permanent tooth buds are not
involved. Fractures involving the interdental space
may require a longer healing period. typically
8 weeks. In most cases, the wires can be removed
in the stand ing horse with minimal sedation.

COMPLICATIONS

Purulent drainage, bone sequestration. septic


osteitis, difficult mastication, unusual incisor
eruption, wire loosening. and fixation failure are
~e __ -;t;~' ............... potential complications. Brachygnathism has also
Figure 20-4 Comparison of techn ique to repair the been reported in three foals following repair of
same fracture as Figure 20-3 showi ng how the fra cture bilateral fractures of the mandible.' In one study,
would be repaired if the cani nes were present. 27% of horses experienced short-term complica-
tions. 5 Fortunately, although short-term compli-
cations may be common, the long-term prognosis
through the acrylic and hold it into place. Addi- for functional and cosmetic outcome is favorable.
tional strength can be gained by wiring the acrylic
to the mandible, incisors, or premolars. In frac-
tures that have minimal displacement or maintain COMMENTS
reduction easily, the acrylic may be formed to the
mouth first, allowed to harden, and then removed Young, curious horses typically incur these frac-
prior to the insertion of wires. This allows tures when they try to free themselves after getting
removal of sharp edges or excessive material with their head or teeth caught. Delay or failure to
a rasp or Dremel tool. Holes are then drilled into repair these fractures may result in malocclusion,
the acrylic splint. and the splint is wired to the tooth loss, osteomyelitis, loss of function, and less
mandible, premolars, and incisors. than optimal cosmesis. 5 Because the oral side of
the mandible and maxilla is the tension surface,
intraoral wire fixation provides strong, effective
POSTOPERATIVE CARE fixation in many fracture configurations.

Postoperative Care
REFERENCES
Medications: Because these fractures are often
open, with significant contamination, broad-spec-
1. Dixon PM: Dental anatomy. In Baker GJ, Easley J,
trum antibiotic therapy should be considered, but
editors: Equ ille dell tis try, London, 1999, WB
it generally is not necessary beyond the first 3 to
Saunders.
5 postoperative days. Nonsteroidal antiinflamma-
2. Murch KM: Repair of bovine and equine mandibu-
tory drugs are typically administered for 1 to 3
lar fractu res, Can Vet J 21:69, 1980.
days. Tetanus prophylaxis should be current.
3. Staton AL: Si mplified wiring procedure for frac-
Other: Horses generally return to a norrnal diet
tured jaw, Pulse 2:9, 1988.
immediately after surgery, but in some cases a
4. DeBowes RM: Fractures of the mandible and
pelleted feed or gruel may be of benefit. The
maxilla. In Nixon AJ. editor: Equine fracture repair,
mouth may be rinsed out at least twice daily for
Philadelphia, 1996, \rVB Saunders.
the first week. Additionally, the horses should not
5. Henninger RW, Beard WL: Rostral mandibular and
be allowed to graze for 2 to 4 weeks, and the
maxillary fractu res: repair by interdental wiring,
wires should be checked daily for breakage.
Proc Am Assoc Equine Pract 43: 136, 1997.
126 HEAD AND NECK SURGER IE S

6. Steenhaut M: Su rgical-treatment of dental prob- 10. Henninger RW, Beard WL, Schneide r RK, et al:
lems and mandibuJar fractures in the horse, Vlaams Fractures of the rostral portion of the mandible
Diergeneeskundig TijdschriJt 67:23, 1998. and maxilla in horses: 89 cases (1979-1997), J Am
7. Martens A, Steenhaul M, Boel K. et al: Conserva - Vet Med Assoc 214:1648,1999.
tive and surgical treatment of mandibular and 11. Adams S8, Fessler JF: Repair of mandibular and
maxillary fractures in 54 horses. Vlaams Dierge- maxillary fra ctures In Adams S8 , Fessler]F editors:
neeskundig Tijdschrift 68: 16. 1999. Atlas oj equine surgery, Philadelphia. 2000. WB
8. Beard WL: The skull. maxilla. and mandible. In Saunders.
Auer JA. Stick lA . editors: Equine surgery, ed 2, 12. Peavey CL. Edwards RB, Escarcega A], el al: Fixa-
Philadelphia, 1999, WB Sa unders. tion technique influences the monotonic properties
9. Crabill MR. Honn<1s CM: Mandibular and maxil - of equine mandibular fracture constructs, Vet Surg
lary fracture osteosynthesis. In Baker G], Easley 32:350, 2003.
J. editors: Eqllille dentistry. London. 1999, WB
Sa unders.


CHAPTER 21
Sinus Trephination
David A. Wilson

approximated by a line from the medial canthus


INDICATIONS
of the eye to the infraorbital canal. This line
should be avoided when creating entrance portals
Sinus trephination can be performed for both
to the sinuses. The location of the sinuses are illus-
diagnostic and therapeutic purposes to confirm
trated in Figures 21-1 through 21-3 and the
the presence of purulent exudate; to obtain sirtus
approximate boundaries of the sinuses are
contents for cytology, biopsy, or culture; and to
described below.'
provide a portal for sinus irrigation or tooth
repulsion. I - 3
Maxillary Sinuses
The dorsal boundary corresponds to a line drawn
EQUIPMENT caudad from the infraorbital foramen parallel to
the facial-crest . The ventral boundary varies with
A Steinmann intramedullary pin of 3/ W or 1/4-inch the age of the horse. The last three or four cheek
diameter or a trephine instrument is used for this tooth roots project into the ventral aspect of the
procedure. maxillary sinus to an extent that var ies with age.
The rostral boundary is at the level of the infraor-
bital foramen, and the caudal border is at the level
POSITIONING AND PREPARATION of the ventral portion of the orbit. The maxillary
sinus is divided into rostral and caudal portions by
The procedure is performed in the standing, an oblique septum, whose lateral margin is com-
sedate horse with local anesthesia. 3-s The trephine monly about 5 cm ca udal to the facial tubercle, but
site is clipped and prepared for surgery. Instilla - can be quite variable (see Figure 21-1). The infra-
tion of local anesthesia should create a skin bleb orbital canal separates the maxillary sinus into a
and infiltrate the underlying periosteum. lateral bony compartment occupied by the roots
of the cheek teeth and a medial compartment
within the ventral concha! sinus.
ANATOMY
Frontal Sinus
Important landmarks for defining the boundaries
of the sinuses and determining entrance portals The frontal sinus is roughly triangular-shaped
include the infraorbital canal, the facial crest, the with the base on midline. The right frontal sinus
facial tubercle, the orbit, and the nasolacrimal is separated from the left sinus by a complete
duct. The course of the nasolacrimal duct can be septum. The rostral limit of the frontal sinus is at

127
.........................
~""- ~- ..... ~---

128 HEAD AND NECK SURGER IES

Infraorbital canal
Nasolacrimal

Rostral maxillary sinus Caudal maxillary sinus

~t;.1. ___
Figure 21-1 Lateral view of skull with bone removed over the frontal and maxillary sinuses. Note position of in fra-
orbital canal an d nasolacri mal duct (dotted lilies).

a point halfway between the infrao rbital foramen


and th e orbit at the approximate level of the fifth
cheek tooth. The ca udal limit is at the level of th e
caudal border of the orbit. The lateral extent is
near the level of the medial canthus. The medial
extent is on midline. In the horse, the dorsa l
conchal sinus has an extensive com munication
with the frontal si nus. and together they are com-
monly referred to as the conchofrontal sinus. The
rostral extent ofthe co ncha! sinu s is at the level of
-+ Conchofrontal th e facial tubercl e.
Sinus
The caudal maxillary and fro ntal sinuses
Infraorbital
canal communicate through a large frontal maxillary
opening and drain into the nasal cav ity through
Caudal maxillary the nasomaxillary opening in th e middle meatus.
\ The rostral maxillary sinus drains into the na sa l
Rostral maxillary
cavity through a separate opening in the middle
sinus
meatus.
Facial
tubercle
PROCEDURE AND PREPARATION
'-- Nasolacri mal
duct Several sites are recommended for sinus trephina-
tion in the horse. The trephine po rtal for the
frontal sinus is 3 to 4 cm caudal to the most rostral
aspect of the frontal sinus and 3 to 4 cm lateral to
midline. The trephine portal for the caudal max-
illary sinus is 1 to 2 cm dorsal to the facial crest
and 7 to 8 cm caudal to the most rostral aspect of
the facial crest. The trephine portal for the cranial
~ Q.,...,t;;;J.;.,..,......, maxillary sinus is J to 2 cm dorsal to the facial
Figure 21-2 Overview of skull with bone re moved crest and 3 to 4 em ca udal to th e facial tubercle.
over the frontal and maxillary sinuses. Note relative As the septum dividing the maxiUary sinuses is
posi ti ons of in fraorbital cana l and nasolacrimal duct variable, these locations are guidelines only.
(dotted lilles). The infraorbital foramen and the levator
nasolabialis and levator labii maxillaris muscles
Sinus Trephination 129

Dorsal conchal
-0,-- Nasolacrimal duct
Dorsal nasal concha Infraorbital canal

Dorsal, middle, and


Ventral nasal ventral nasal meatus

Rostral maxillary

---'; '+----'t Palatine artery

~~d;.vL ,"
Figure 21-3 Transverse section through the skull at level of M2 (between the medial canthus and the facial
tubercle).

Site of penetration are palpable and should be avoided when creating


of intramedullary pin portals for the maxiJJary sinuses.
For diagnostic trephination, a I-em stab
incision is made through the skin and periosteum.
A Steinmann intramedullary pin is used to pene-
trate the bone. The pin should be positioned in
the chuck such that a maximum of 1/ 2 inch of the
pin length is protruding (Figure 21-4). The goal is
Concho-
to penetrate the bone without damaging deeper
frontal siinu'i~ structures. Excess pin length protruding from the
Caudal handle of the pin chuck should be guarded to
maxillary
Sinus
protect the surgeon . This size portal provides
Rostral ~-: access for aspiration or for placement of a lavage
iI catheter, biopsy instruments, or a 4-111111 arthro -
scope for inspection of the sinuses.
Occasionally) there is a need for a larger portal
Facial
into the sinuses. Commercial trephine instru-
crest
ments are available up to 2.5 cm in diameter)
tubercle
which is large enough to allow digital palpation
Figure 21~4 Identification of the limits of potential
trephine sites in the maxillary and frontal sinuses. The
of the sinuses if necessary. A circular incision)
diagonal dotted line is the approximate site of the slightly larger than the size of the trephine. is
septum between the rostral and caudal maxillary made and the skin is discarded. Alternatively) a

sinuses. cross-incision can be made through skin and
periosteum. The four resultant flaps are elevated
,

130 H EAD AND NECK SURG ERIES

from the underlying bone to provide access for the the depth of penetrati on du ring the trephination
trephine instrument. The skin edges are elevated proced ure.
from th e trephine site to avo id binding the soft
tiss ues in the instrument as it is turned. The trocar
po int of the trephine should be extended to prop- ALTERNATIVE PROCEDURES
erly seat the saw blad e. Once the saw blade is
seated, the trocar poi nt should be retracted to Endoscopic examination using arthroscopic
minimize the risk of penetrating any underlyin g equipment allows visualizatio n of the caudal
structures. Oscillatin g rotations are used to cut maxillary and frontal sinuses throu gh a frontal
and ream o ut a circular plug of bone, with care sinus po rtal and of the sphenopalatine sinus
taken to control th e instrumen t as th e cut is thro ugh a ca udal m axillary sinus portaI. 7- \O Th e
nearing completion to avoid damagin g st ructures potential advantages o f end oscopic examination
within the sinus. include the ab ility to o btain a more diagnostic
biopsy, the potential to treat mino r problems, and
the abi lity to visualize a greate r portion of the
POSTOPERATIVE CARE respective sin uses. AJthough m any disorders of
the si nuses can be addressed b y sinus trephinatio n
Postoperative therapy depends on the primary with or without sinus endoscopy, seve ral disor-
problem. Sinus trephination is principally used ders, such as resectio n or treatment o f neoplastic
for diagnostic purposes and sinus irrigation. With and nonneoplasti c growths, may require a
the exceptio n of primary sinusitis, most condi- sin us bone flap surgery to properly address the
tions will require further su rgical therapy once the disorder. 11
primary problem is determined. Portals can
remain open for 10 to 12 days to allow repeated
irrigation or entrance. Mild cellulitis surro unding COMMENTS
th e po rtal site often develops, which can be
managed b y cleaning the site at Jeast daiJy with Specific diseases of th e sinuses include empyema,
moistened ga uze sponges. sin usitis, tumors, and alveola r periostitis. Chronic,
un ilateral purulent nasal discharge is the primary
sign associated with paranasal sinus empyema in
EXPECTED OUTCOME horses. Other clinical signs associated w ith disor-
ders of the si nuses in clude facial swelling and d is-
Even large trephin e holes typically heal without tortion and ocular di scharge.
complicatio n in 3 to 4 weeks. Replacement bone
or fibrous tissue fills the defect. A small depression
is o ften palpable, but not visible, once the hair REFERENCES
grows out. The long-term prognosis d epends on
the primary problem. I. Me rriam ]G: Field sinusoto my in the ma nageme nt
of chronic si nusitis and alveolitis, Proc Am Assoc
Equine Pmct 39:235, 1993.
COMPLICATIONS 2. Worster AA, Hackett RP: Equine sinus endosco py
usi ng a fl exible endoscope: diagnos is and treatment
The most common com plication is hem orrhage. of sinus disease in the standing sedated horse, Proc
The sinus mucosa is extremely vascular, and this Alii Assoc Equille Pmct 45:1 28 1999.
3. Adams SB, Fessler JF: Sinus treph ination. In Ada ms
vasc ularity is increased in inflammatory co ndi -
SB, Fessler JF, editors: Atlas of equil1e surgery.
tions. Generally, direct pressure will control the
Philadelphia, 2000, WB Saunders.
bleeding. Inadvertent penetratio n of structures 4. Ford TS: Standing surgery and procedures of the
within the sinus can result in addition al compli - head, Vet Ciin N Am Equ ille Pmct 7:583, 1991.
cations such as oronasal fistula formation, bone 5. Schumacher J: Stand ing sinus surgery of the horse.
sequestration, hemo rrhage, and death d epending Proe ACVS Vet Sylltp 132,2004.
on th e stru cture penetrated. T hese severe compli - 6. Gerard MP: Applied pa ranasal si nus anato my. Proc,
cations can be virtu ally eliminated by co ntrolling ACVS Vet Sylllp 128, 2004.
Sinus Trephination 131

7. Ohnesorge B, Stadler P: Minimal invasive and 9. Ruggles AJ. Ross MW, Freeman DE: Endoscopic
conventional surgery of progressive ethmoidal examination of nor mal paranasaJ sinuses in horses,
haematomas in horses, Tiemrztliche Praxis Ausgabe Vet SlIrg 20:418, 1991-
Grosstiere Nlltztiere 29:219, 200 I. 10. Ruggles A]. Ross MW, Freeman DE: Endoscopic
8. Ohnesorge B, vonBo rstei M, vonOppen T: Endo- exami nation and treatment of paranasal sinus
scopic therapy of progressive ethmoidal haematomas disease in 16 horses, Vet Surg 22:508, 1993.
in horses via sinus maxillary trepanation: case 11. Hilbert B}, Little CB. Klein K. Thomas 18: Tumours
reports, Pferdeheilkunde 20:316, 2004. of the paranasal sinuses in 16 horses, A I/st Vet J
65:86, 1988.
CHAPTER 22
Tooth Repulsion
David A. Wilson

tion, including the use of a full-mouth speculum


INDICATIONS
with appropriate illumination, and a radiographic
examination are recommended if dental disorders
Repulsion is indicated for cheek teeth that cannot
are suspected. Additionally, ultrasou nd , nuclear
be removed orally, teeth with broken crowns, or
scintigraphy, and co mputed tomog raphy may be
fragmented teeth. '·' Although the techniques
useful to evaluate certain dental disorders. 9
described in this chapter are applicable to the first
five cheek teeth, repulsion in field or suboptimal
conditions is most practical for the rostral cheek EQUIPMENT
teeth. Improved extraction techniques and anes-
thetic protocols have expanded the capability of A dental punch and mallet are used for tooth
oral extraction of affected teeth. Oral extraction is repulsion. A trephine or large bone rongeurs, or a
the preferred method of removal when possible high-speed burr can be used to remove overlying
and practical. J ,5-7
bone to access the tooth roots. Ideally, pre-
Specific indications for tooth removal include operative, intraoperative, and postoperative radi-
retained deciduous teeth, interventional ortho - ographs should be taken to ensure identification
dontics, severe periodontal disease, loose teeth, of the correct tooth, to assess the approach, to
supernumerary teeth, dental impactions, end- evaluate the positioning of the dental punch, and
odontic disease with secondary osteomyelitis, to check the tooth root socket for remaining frag-
severe disease or injury to the dental crown or ments after repulsion.
root, malocclusions, occlusal trauma, neoplasia,
biting discomfort, and sinus disease secondary to
dental disease. s POSITIONING AND PREPARATION
The clinical signs associated with dental disease
are broad and typically include quidding, the The horse should be placed under general anes-
presence of a head tilt while eating, nasal dis- thesia in lateral recumbency with the affected
charge, sinusitis, the presence of a chronic drain- tooth up. If a mandibular tooth is affected, the
ing tract, headshaking, facial pain, excessive horse may be placed in lateral recumbency with
salivation (ptyalism), anorexia or pica, and the the affected tooth up or in dorsal recumbency.
presence of long forage stems or whole grain in
the feces. Additional but less common clinical
signs include facial swelling or distortion, weight ANATOMY
loss, diarrhea, colic, reluctance to start eating, slow
or intermittent eating, difficulty in prehension, Pertinent structures to be aware of when consid-
choke, and epistaxis. s A thorough oral exam ina- ering tooth repulsion include the facial muscles,

132
Tooth Repulsion 133

facial crest, orbit, infraorbital canal, nasolacrimal and caudal maxillary sinuses and their relation-
duct, frontal and cranial and caudal maxillary ship to the cheek teeth. ).
sin uses, facial artery and venous plexus, parotid The upper cheek teeth usually have three
salivary duct. and branches of the facial nerve roots-two small lateral roots) and a larger medial
(Figure 22-1). The alveoli of the second and third root (Figure 22-4). Occasionally four roots are
premolars (teeth numbered six and seven in the present. The lower cheek teeth have two roots
Triadan system) and often the rostral aspect of the (with the exception ofM3, which has three roots),
fourth premolar (tooth 108 or 208 in the Triadan one caudal and one rostral. The reserve crown and
system) are embedded in the maxillary bone.1O roots of the rostral cheek teeth are roughly per-
The three molar tooth roots (9 through 11 in the pendicular. The reserve crown and roots of the
Triadan system) and part of the fourth premolar caudal three cheek teeth are curved caudally.
in younger horses extend to a variable degree into
the maxillary sinus depending on the age of the
horse. In young horses, the large reserve crowns PROCEDURE
virtually fill the sinus, whereas in the old horse
with shorter roots, the sinus becomes fairly large Selection of the surgery site is critical to success-
(Figures 22-2 and 22-3). The caudal aspects of the ful tooth repulsion. The surgery site is based on
fourth premolar and the first molar lie in the the loca tion of the tooth or teeth involved and
rostral maxillary sinus, and the second and third their curvature. The first two or three (depending
molars li e in the caudal maxillary sinus. (See on the age of the horse) maxillary cheek teeth and
Chapter 21 for a discussion on sinus trephination all of the mand ibular teeth are directly accessible,
and for a more detailed description of the rostral but tlle caudal three o r four maxillary cheek teeth

levator anguli ",<U


Malaris ", ..
Parotid gland
Angularis oculi a.v. ,
Zygomatic
Dorsal part of Parotidoauricularis m.
lateral nasal m.
Dorsalis nasi
levator nasolabialis m.
Nasal diverticulum
levator labii
Ventral
masseteric v.
~_- and masseteric
br. a.

Parotid duct

i m.
jugUlar v.
Depressor labii -"set,,, Dorsal and vee,":
inferioris m. '" m. buccal brs. of
Depressor anguli oris m. labial a.
from cutaneous faciei m.
Buccinator . Parotid duct a.v.

Figure 22·1 Lateral view of head with skin removed showing superficial structures.
134 H EAD AND N ECK SURGERIES

~"_ ... .:J. .. __

A B
Figure 22-4 Lateral and ven tral views of mandibu-
Figure 22-2 Radiograph of 8-year-old horse.
lar and maxillary cheek teeth showing differences in
root structu re. A. maxillary tooth with three roots
(some have four roots); B. mandibular tooth with two
roots.

Id eally, radiograph s are taken at various inter-


vals throughout the procedure to ensure accurate
placement of the surgical site, removal of a
minimal amount of bone over the affected tooth,
and accurate placement of the punch. Radi -
ographs provide an accurate method o f placing
the punch along the sagittal plane but not in the
frontal plane. The teeth accessible through the
sinu ses are usually more toward mid lin e than
anticipated (see Figure 21-3). In yo ung horses
with long tooth roots that virtually fili the sinuses,
a trephine site that is very close to the infrao rbital
ca nal will be necessary.
Figure 22-3 Radiograph of 12 -year-old horse.
After the approp riate surgery site has bee n
se lected, a 5-cm skin incision is mad e. The bone
overlyin g the tooth roots is removed with eit her
rongeurs or a trephine (Figure 22-5). The punch
need to be accessed through the maxillary sinus. is sea ted with the mallet, and a hand is pos itio ned
The th ird upper molar is better accessed through in the mouth over the affected tooth to detect
a frontal sinus trephinatio n site to allow position- vi bratio ns fro m the punch. Radiograph s can be
ing of a dental punch through the frontomaxiilary taken at this point to verify accurate place ment
opening in to the ca udal-maxillary sinus II or a and orientation o f the punch. Once it is verifi ed
co mbinatio n of frontal and maxillary trephina- that the tooth being punched is the affected tooth,
tion sites. 12 Occasio nally, a bone flap may be used several hard hits are generally required with the
to provid e greater expos ure to the tooth roots. iJ mallet to loosen the tooth (Figure 22-6). The
Tooth Repulsion 135

that will be resistant to future infection. If t~e plug


does not come out on its own, the horse should
be sedated or anesthetized and the plug removed.
If gauze sponges are used for packing, the sponges
should be replaced every 2 to 3 days.

POSTOPERATIVE CARE

Figure 22-5 Horse in lateral recumbency showing Postoperative Care


trephination of the caudal maxillary sinus.
Exercise Restridions: The horse should be stall
rested for at least 2 weeks with controlled hand
walking only.
Medications: Broad-spectrum antibiotics are
recommended for 3 to 5 days. Further antibiotic
therapy may be indicated if infection of the tissues
surrounding the affected tooth is extensive. Non-
steroidal antiinflammatory drugs are recommen-
ded for 1 to 2 days.
Other: The mouth should be lavaged and the
surgery site cleaned daily. If an acrylic plug or
dental wax was placed at the time of surgery, it
should either be expelled on its own or removed
within 30 days of surgery. Following plug removal,
~e.. .... .:t-,.. .
the surgery site is cleaned at least daily until the
wound is completely filled with granulation tissue.
Figure 22-6 Dental punch in position to repulse the
left second maxillary molar.

EXPECTED OUTCOME
rostral cheek teeth can often be removed intact.
Because of the limited space in the oral cavity, the Owners should be forewarned that although post-
caudal cheek teeth may be too long to remove operative care is not technically difficult, it is
intact. If this is the case, molar cutters or Gigli involved and may be necessary for extended
wire can be used to decrease their length in order periods. Short-term complications are likely, but
to remove them completely. the long-term prognosis for healing is good.
Once removed , the tooth is examined carefully
for missing roots or fragments. The tooth root
socket is thoroughly explored to remove any COMPLICATIONS
residual fragments oftooth or bone. This is a crit-
ical point of the surgery as many of the compli- Complications from this procedure can be
cations associated with this procedure are due to divided into categories that include problems
bone or tooth sequestra. associated with restraint or general anesthesia,
In most cases, the tooth socket is filled with a the extraction itself, wound healing, and long-
plug to prevent packing of feed material in the term complications. 5,15, 16 Complications associated
tooth socket. Plugs can be made of a variety of with the extraction itself include hemorrhage,
materials such as 4 x 4 gauze sponges, acrylic, removal of the wrong tooth, and damage to struc-
dental wax, or other material. 14 Acrylic plugs tures adjacent to the tooth being removed (i.e.,
should be inserted such that they do not extend palatine artery. sinuses, alveolar bone, jaw, adja-
too deep into the socket, to facilitate ease of cent teeth, nasolacrimal duct, parotid salivary
removaL Generally, the socket should remain duct, and facial nerve ).
packed for 2 to 3 weeks to allow formation of a Complications associated with wound healing
good granulation tissue bed in the tooth socket include wound dehiscence or persistent drainage
:

136 HEAD AND NECK SURGERIES

resulting from fistula formation, incomplete tooth


ALTERNATIVE PROCEDURES
removal, bone sequestrum, infected tooth root
socket, packing breakdown, mucous membrane
healing prior to wound granulation, or the pres- Several options exist for treatment of periapical
ence of a foreign body in the wound. Long-term infections in horses. Medical therapy is limited to
complications can be associated with an incorrect the systemic administration of antibiotics and is
initial diagnosis resulting in persistence of the often ineffective. Ideally, the antibiotic therapy is
primary problem, removal of the wrong tooth, or guided by bacterial culture and sensitivity results.
leaving behind a diseased tooth or tumor. In the absence of bacterial culture results, we gen-
Therapy starts with exploration of the tooth erally recommend long-term therapy (30 to 60
root socket under general anesthesia. Generally, a days) of a potentiated sulfonamide. Typically, the
bone or tooth root fragment is identified, and drainage stops or at least diminishes during the
removal typically results in rapid heal ing of the course of therapy, only to return shortly after
surgery site. If bone or root fragments are not the antibiotics are discontinued. One publication
identified, alveolar bone damage may be present. reported successful medical therapy in three of
Because the alveolar bone between cheek teeth is five horses treated medically. 17
relatively thin, damage to the alveolar bone may Occasionally lateral buccotomy and alveolar
expose the root of the adjacent tooth, which may plate removal are indicated for removal of teeth
result in periodontal disease in the adjacent tooth. with damaged crowns or teeth surrounded by
Inadvertent removal or loss of the alveolar sclerotic bone that would make removal by con-
plate can occur as a result of the original inflam- ventional oral extraction or repulsion difficult.!!
matory process or during surgery. Removal of the Additionally, the caudal mandibular cheek teeth
alveolar plate such that the ce ment surface of the may be removed with this technique. 18 Lateral
reserve crown of the adjacent tooth is exposed will buccotomy and alveolar bone plate removal are
result in incomplete healing as granulation tissue more tedious and time consuming than oral
will not adhere to exposed cementum. Similarly, extraction or repulsion and therefore are not
aggressive curettage of the socket can result in practical in field situations. A thorough descrip-
destruction of mesenchymal cells that would have tion of the technique is available elsewhere. SJ 1
contributed to healing of the socket. Generally, Ideally, endodontic th erapy for periapical
these errors will result in the development of infections in horses would allow for the tooth
chronic draining tracts and periodontal disease to remain in place, thus avoiding many of the
with the potential future need for removal of the complications associated with their removal.
affected adjacent tooth. Endodontic therapy requires special surgical
Repulsion of a mandibular tooth may result in skills, knowledge, and equipment and is generally
a fractured mandible if the dental punch is posi- a long general anesthetic procedure. The reported
tioned on the mandible rath er than on the tooth long-term success rates have ranged frol11 44% to
root or if the punch slides off the tooth root and 81 %.1.19,20
this redirection is not recognized by the surgeon. An alternative procedure for periapical infec-
This is a surprisingly easy complication if care is tions of the mandibular teeth has been re-
not taken to correctly position the punch and ported. 9,21 Periapical curettage involves identifying
continually monitor its orientation. Fortunately, the affected area, removing the overlying cortical
unless the mucous membranes have been pene- and cancellous bone, and identifying the affected
trated, these fractures can heal well following alveolus. Using curettage and irrigation. infected
removal of any small bone fragments. material is removed, with care taken to not disturb
Because of the orientation of the cheek teeth, the healthy root. The wounds are then left to heal
gaps created by tooth removal are gradually closed via second intention. Postoperative therapy con-
by movement of the cheek teeth to fill the gap. sists of removing the external serum crusting on
This movement creates another problem that will a daily basis and applying petrolatum to the skin
require continued tooth care for the rest of the around the wound to prevent serum scalding. The
horse's life. Tooth overgrowth can occur at either wounds are not flushed, and postoperative antibi-
the site of tooth removal or the first or last cheek otics and analgesics are recommended but not
tooth of the opposing arcade. required. The success rate has been reported to be
Tooth Repulsion 137

over 75%, but a large number of cases have 4. Gaughan EM: Denta l surgery in horses, Vet Clill N
not been repo rted. 2 1 Those deemed unsuccessful Am Equille Pract 14:381, 1998.
were subsequently treated successfully with tooth 5. Easley J: Equine tooth removal (exodontia).
repulsion. Periapical curettage appears to be a In Baker GJ, Easley J, editors: Equ ine dentistry,
London, 1999, WB Sa unders.
reasonable option for resolving the periapical
6. Tremaine WH: Oral extraction of equine cheek
infection and maintaining the mandibular tooth.
teeth, Equine Vet Educ 16:151, 2004.
7. Lowder MQ: O ral extraction of equine teeth, Camp
Cant Educ Pmct Vet 2 1:11 50,1999.
COMMENTS 8. Knottenbelt DC: The systemic effects of dental
disease. In Baker GJ, Easley J, editors: Equine den-
The difficulty of a nd time required for dental tistry, London, 1999, WB Sau nders.
repulsion vary considerably. Repulsion of the 9. Gibbs C. Dental imag ing. In Baker GJ, Easley
more caudal upper teeth because of their curved J, editors: Equine dentistry, London, 1999, WB
roots and si nus involvement is technically more Saunders Co.
10. Dixon PM: Dental anatomy. In Baker GJ, Easley
difficult and requires addition al surgical time and
intraoperative monitoring and more postopera-
J, editors: Equine Dentistry, London, 1999, WB
Saunders.
tive care. Repulsion of teeth from older horses 11. Lowder MQ: Tooth removal, reduction, and preser-
with shorter reserve crowns is less difficult than vation. In VVhite NA, Moore JM, editors: Currellt
repulsion of teeth from young horses with exten- techniques in equine surgery and lameness, Philadel-

Slve reserve crowns. phia, 1998, WB Saund ers.
Simultaneous or preoperative loosening of the 12. Boutros CP, Koenig JB: A combined frontal
affected tooth with molar spreaders and extrac- and maxillary sinus approach for repulsion of the
tion forceps is beneficial and results in a shorter third maxillary molar in a horse, Catl Vet J 42:286,
and less traumati c repulsion. 2001.
Each tooth is independently and firmly 13. Hahn K, Kohl er L: Removal of upper cheek teeth of
the horse using bone flap technique, muscle trans-
attached to the bony structure (alveolus) by the
position and alveolar closure, Tierarztliche Praxis
periodontal ligament and gingiva. The periodon-
Allsgabe Grosstiere N'ltztiere 30:50, 2002.
tal ligament consists of bundles of connective
14. Trostle 55, Juzwiak J5, 5antschi EM: How to use
tissue fibers that run in various directions from antib iotic impregnated plaster of paris for alveolar
the bone of the socket wall to the cement cover- packing after tooth removal, Proc Am Assoc Equine
ing th e reserve crowns and the tooth roots. The Pract 46: 180, 2000.
gingiva has a mucous m embrane surface with a 15. Lillich JD: Complicatio ns of denta l surgery, Vet
dense internal fibrous attachment to the perios- Clin N Am Equ ine Pmct 14:399, 1998.
teum and the peripheral cement of the tooth. Even 16. Pascoe JR: Complications of dental surgery, Proc
in cases with extensive periodontal disease, there Am Assoc Equine Prnct 37:14 1, 1991.
may be significant remaining gingival or peri- 17. Dixon PM, Tremaine WH, Pickles K, et al: Equi n e
dental disease. Part 4: a long-term study of 400
odontal ligament attachments to make tooth
cases: apical infections of cheek teeth, Equine Vet J
removal difficult, particularly in young horses
32: 182, 2000.
where the reserve crown may be as long as 18. Lane Gl: Equine dental extraction--repulsion vs
8cm. buccotomy: techniques and results. Proceedings
of the 5th Wo rld Veterinary Dental Congress,
Birmingham, 1997.
REFERENCES 19. Lowder MQ: Diseases of the teeth. In Colahan PT,
Mayhew IG , Merritt AM, Moore IN, ed itors: Equine
1. Prichard MA. Hackett RP, Erb HN: Long term medicine and surgery, ed 5, Philadelphia, 1999.
outcome of tooth repulsion in horses. A retrospec- Mosby.
tive study of 61 cases, Ve t 5urg 21: 145,1992. 20. Bake r GJ: Endodontic therapy. In Baker GI, Easley
2. Schumacher J. Ho nnas eM: Dental surgery, Vet J. editors: Equine dentistry. London, 1999, WB
Clill N Am Equine Pract 9:133,1993. Sa unders.
3. Dixon PM: Dental extraction and endodontic tech- 21. Carmalt JL, Barber SM: Periapical curettage: an
n iques in horses, Comp COrl t Edltc Pmct Vet 19:628, alternative su rgical approach to infected mandibu-
1997. lar ch eek teeth in horses, Vet Surg 33:267, 2004.
CHAPTER 23
Tracheotomy
David A. Wilson

INDICATIONS ANATOMY

Indications for tracheotomy are to establish an The paired muscle bellies of the sternomandib-
emergency airway because of an upper airway ularis, sternothyroideus. and sternohyoideus mus-
obstruction, or to relieve nasal or laryngeal cles lie on the ventral aspect of the trachea and are
inflammation. Tracheotomy is a life-saving proce- separated during the approach. The tracheal rings
dure in the face of an upper respiratory obstruc- are spaced closely together, but incision of the
tion. Tracheotomy is also used to "rest" an annular ligament allows enough separation
inflamed upper respiratory tract. Tracheotomy to insert the tracheotomy tube without removal
can also be used as a route for endotracheal intu- of portions of the tracheal ring (F igures 23-1
bation for general anesthesia when nasot racheal through 23-5).
or orotracheal intubation limits access to the sur-
gical field.
PROCEDURE
EQUIPMENT
A 6- to 8-cm ventral midline incision is made
Tracheotomy tube and scalpel blade. between the upper and middle thirds of the neck
in a region where the trachea is easily pal pable. In
cases where a permanent trach eostomy is antici-
POSITIONING AND PREPARATION pated or even a possibility, the tracheotomy site
should be caudal enough to allow space in the
Ideally, a wide area is clipped and routinely pre- cranial third of the neck for the su bsequent tra-
pared for aseptic surgery; however, in emergency cheostomy (F igure 23-6). Long incisions should
sit uations little preparation is dOf\e. The proce- be avoided to improve the "fit" of the tracheotomy
dure is ideally performed standing with the head tube.
extended using local anesthesia. In an emergency The subcutaneous tissues are incised, and the
situation, a variety of positions are used. When paired sternothyrohyoideus muscles are sepa rated
llsed as a route for endotracheal intubation, the on midline. Blunt dissection should be minimized
procedure is often performed in lateral recum- to decrease subcutaneous emphysema and seroma
bency after induction of anesthesia. Light seda- formation. Two tracheal rings in the center of the
tion may be necessary for fractious patients. incision are identified, and a tran sverse stab inci-
Draping is not necessary, but sterile instruments sion is made between the two rings. The stab inci-
and gloves are desirable. sion should completely penetrate the tracheal

138
,----- - - - - - - - - - - -

Paired omohyoideus mm.

Sternohyoideus mm.

sternomandibularis mm.

~roo<>:t,;..!"'--
,*~t........t"(.I.<J .
Figure 23-1 Ventral view of the neck with the skin
removed showi ng cutaneous colli muscles. Figure 23-2 Vent ral view of neck with ski n and cuta-
neous colli mu scles removed.

Paired omohyoideus mm.

Left external jugular


Figure 23-3 Ventral view of the neck with skin and
cutaneous coll i and sterno mandibular is muscles removed.
Paired
sternothyrohyoideus mm.
Paired
sternomandibularis - - \
mm. (cut)
140 HEAD AND NECK SU RGERIES

Atlas (C 1

Longus capitis

Maxillary v.

Common carotid a. - - Esophagus


Sternomandibularis - - - Parotid gland
Sternothyroideus ' - - - - Linguofacial v.
Omohyoideus and __
sternohyoideus mm .
Cutaneous colli m. - - - - Trachea

,*-~t .... ..:t:~

Figure 23-4 Tran sverse section through cervical region at level of C l.

Longus capitus
Sternomandibularis m.

Common carotid

Left external jugular v.


Sternothyroideus mm.
Sternohyoideus mm . - -
Omohoideus m.- -
Cutaneous coll i

~~4-t".....: .

Figure 23-5 Transverse sectio n of the neck at the level of C4.


Tracheotomy 141

but care must be taken to make sure the second


flange of the tube does not dissect subcutaneously.
This complication can be avo ided by careful posi-
tioning and palpation of the tube after placement.
The self-retaining tracheotomy tubes have the
advan tage of not completely relying on the tra-
cheotomy tube for an open airway. Therefore,
if the tube becomes clogged, there rema ins a
residual, albeit compromised, airway. Collapse or
"kinking" of the tube is also avoided with the use
of self-retaining tracheotomy tubes.

Tracheotomy
incision site +- POSTOPERATIVE CARE

Postoperative Care
Tracheotomy Tube Management: Trache-
otomy tubes require almost continuous mon-
'e..<_.-".
fC _ _
itoring and management. The tubes and the
Figure 23-6 Incis ion site fo r tracheotomy. surrounding skin should be cleaned at least daily.
Scrubbing of the tracheotomy site should be
avoided. Exudate and blood clots should be
removed with a dry, sterile sponge, and the skin
surrounding the site should be cleaned. Extra
tubes should be immediately available.
Medications: Broad-spectrum antibiotics and
nonsteroidal antiinflammatory agents are generally
not necessary unless indicated for the treatment
of the underlying problem.
other: After removal of the tracheotomy tube, the
wound is allowed to heal by second intention with
daily cleaning. Cleaning of the wound during
closure is performed at least once daily or as
needed with moistened gauze sponges. Petrola-
tum (Vaseline) is applied to the skin surrounding
the surgery site to prevent scalding from the anti-
cipated drainage. Healing is generally complete in
2 to 3 weeks.

COMPLICATIONS
Figure 23-7 View of the tracheotomy site just pr ior
to inserting self- retaining tracheotomy tube.
Fortunately, in horses there are few complications
mucosa. A stab incision that is too shallow may associated with tracheotomy. Most complications
res ult in separation of the mucosa from the tra - are associated with the primary problem rather
cheal rin g, which will increase bleeding and may than the tracheotomy procedure. However, sub-
lead to granuloma formation. The an nular liga- cu taneous emphysema, hemorrhage, and inflam-
ment is incised from midl ine ] to 2 em in both mation are relatively common. t.} Minimizing soft
directions (a bout one third of the ci rcumference tissue dissection, avoiding separation of the
of the lumen), tracheal mucosa from the ca rtilage rings, and
A tracheotomy tube is then placed (Figure 23- avoiding tracheal ri ng trauma will minimize
7) . We prefer self- retaini ng tracheotomy tubes, these complicati ons. Rare complica tio ns include
142 H EAD AND NEC K SU RGERIES

tracheal stricture, granulomas, chondromas, and 2. Freeman DE: Standing surgery of the neck and
pneumothorax.I -4 thorax, Vet Clin N Am Equille Pract 7:603, 199 1.
3. Adams S8, Fessler JF: Tracheotomy. In Adams S8,
Fessler JF, editors: Atlas of equille surgery. Philadel-
REFERENCES phia, 2000, WB Saunders.
4. Kelly G, Prendergast M, Skelly C, et al: Pneu mot ho-
rax in a horse as a co mplication of tracheoto my,lrish
I. Turner AS, Mcllw raith CW: Tracheostomy. In
Vet J 56: 153. 2003.
Turn er AS, Mcl lwraith CW, editors: Techniques ill
large al/ill/al sllrgery, ed 2, Philadelphia, 1989, Lea &
Febiger.


CHAPTER 24
Tracheostomy
David A. Wilson

aspect of the trachea. The smaller sternothy-


INDICATIONS
roideus inserts on the caudal border and abaxial
surface of the thyroid cartilage, and the larger
Tracheostomy is indicated for any permanent dis-
sternohyoideus continues on to insert on the
order of the larynx and upper trachea in which
basihyoid bone. The paired omohyoideus muscles
airflow is impaired.
originate from the subscapular fascia close to the
shoulder joint and join the sternohyoideus in the
prox.imal third of the neck. The trachea primarily
EQUIPMENT consists of from 48 to 60 hyaline cartilage rings.
These rings are ( -shaped and open dorsally, with
No special equipment is required. Self-retaining the ends connected by the transversely oriented
retractors and Rochester Carma!t forceps or tracheal muscle, l
similar forceps are desirable.

PROCEDURE
POSITIONING AND PREPARATION
Several similar techniques have been described. 2 •4
The surgery can be performed with th e horse A 10- to 12-cm ventral midline incision is made
standing with mild sedation and local anesthesia in the proximal th ird of the neck in a region where
or in dorsal recumbency under general anesthe- the trachea is palpable (Figure 24-1). If a tra-
sia. The head should be extended for either pro- cheotomy has been performed previously, this site
cedure. If the procedure is performed in dorsal should be avoided.
recumbency, care should be taken to position the The cutaneous colli and subcutaneous tissues
neck, head, and body without twisting or torquing are incised, and the paired sternothyrohyoide us
such that the skin incision is directly on midline and omohyoideus muscles are identified. The
when the horse stands. The ventral cervical region right and left sternothyrohyoideus muscles are
is clipped and prepared routinely for aseptic separated on midline and retracted laterally to
surgery. expose a section of three or four tracheal rings.
Sections of the paired sternothyrohyoide us
muscles as well as the most axial portions of the
ANATOMY omohyoideus muscles are clamped with an
angiotribe, straight Rochester-Pean or Rochester-
The paired sternothyrohyoideus muscles originate Carmalt forceps, transected, and excised at the
from manubrium sterni and extend on the ventral proximal and distal extent of the tracheostomy

143
144 HEAD AND NECK SURGERIES

site to minimi ze the tension on the tracheal


mu cosa-skin junction during subsequent closure.
Bleeding is controlled with hemostat application
and or ligation if necessary. Subcutaneous tissue
may be sutured to the peritracheal fascia to
decrease dead space.
A midline and two paramedian incisions are
made 15 mm o n each side of midline in the
exposed tracheal rings (Figures 24-2 and 24-3 ).
Care should be taken to start on midline and to
Tracheostomy avoid incising the mucosa. The rectangular seg-
incision site ments of tracheal cartilage that are created are
carefully dissected free of mucosa. The mucosa is
desensitized with topical application oflocal anes-
thetic solution and incised in a double-Y-pattern.
Stay sutures are placed to ali gn and prevent retrac-
tion of the mucosa. The mucosa is then apposed
to the skin using No. 2-0 PDS and a simple inter-
rupted pattern. Care should be taken to close all
gaps between mucosal edges or between mucosa
Figure 24-1 Incision site for tracheostomy, just
and skin. The remaining skin incision, proximal
caudal to the first tracheal ring.

A
Figure 24-2 Ventral view of the neck illustrat-
ing tracheostomy procedure. A, Dotted lines show-
ing proposed incision lines th ro ugh tracheal
cartilage only. S, After incising through cartilage
and removal of the first fou r tracheal sections.
C, After removal of all tracheal sections. Dotted
line shows proposed double-Y incis ion in tracheal
mucosa. D, Finished tracheostomy showin g tra-
cheal mucosa sutured to skin.
B

c
Tracheostomy 145

and distal to the created stoma, is apposed in an


interrupted pattern.

POSTOPERATIVE CARE

Postoperative Care
ExeKise Restriction: The horse should be con-
fined to a stall for 2 weeks with controlled hand-
walking only.
Medications: Broad-spectrum antibiotics and
nonsteroidal antiinflammatory agents are recom- A
mended for 1 to 2 days.
Suture Removal: The sutures are removed in
10 to 14 days.
Other: The surgery site should be cleaned once
or twice daily until the sutures are removed and
once daily indefinitely.

EXPECTED OUTCOME

Tracheosto my sites generally heal with minimal


complications, but slight dehiscence may occur
and may require additional repair. Owners should
be warned that in some cases it may take as long B
as 4 months for sufficient stoma healing to occ ur Figure 24-3 A, Immediate postoperative appearance
before the required once or twice daily cleaning is of tracheostomy. B, View 3 weeks after surgery.
reduced to maintenance levels. The required long-
term maintenance varies from cleaning o nce
per day to less than on ce per month. Lo ng-term
outcome of tracheostomy is generally favorable. stoma size can be repaired by enlargement of the
In one study, more than 90% of owners were stoma, either by removing the ventral portion of
pleased with the resul ts (F igure 24-3).' additional tracheal rings or by removing greater
portions of muscle to reduce the tension on the
tracheal mucosa-skin suture line. Removal of a
COMPLICATIONS 3 x 6-cm portion of skin over the stoma site to
decrease the chances of functional appositional
The most common complications include partial closure of the stoma site has also been described.)
dehiscence of the tracheal mucosa-skin suture Additionally, sm all elliptical portions of skin m ay
line, excessive inflammation, granulation tissue be taken out of either side of the stoma after it is
formation, stricture, skin growth or apposition created to reduce the chances of functional appo-
over th e tracheostomy site, and coughing. Long- sition. If partial dehiscence occurs, the granula-
term complications include co ughing during tion tissue, if present, should be resected and
exercise, stridor, and exercise-induced dyspnea. 4 sutures placed to reattach the mucosa to skin.
Complications can be reduced if sufficient por- Tracheostomy affects pulmonary defense
tions of the paired sternothyrohyo ideus and por- mechanisms by disruption of the mucociliary
tions o f the omohyoideus muscles are removed, escalator, reduced airway temperature control,
the mucosa-to-ski n suture line is placed with little and altered humidification of inspired gases.
to no tension, and care is taken to place sutures Horses with preexisting pulmonary disease may
sufficiently close together to eliminate all gaps experience an exacerbation of the existing disease
between mucosal edges or between mucosa and res ulting from this reduction in pulmonary
skin. Stricture of the stoma size or insufficient defense mechanisms.5
146 H EAD AND NECK SURGERIE S

REFERENCES 3. McClure SR, Taylor TS, Honnas eM, et al: Perma-


nent tracheostomy in standing horses: technique
and results, Vet Slirg 24:231. 1995.
I. Hare WeD: Equine respira tory system. In Getty R,
4. Rakestraw PC, Eastm an TG, Taylor TS, et al: Long
editor: Sisson alld GrossnulII's The anatomy of the
term outcome of horses undergoing permanent tra-
domestic arlima/s, ed 5, Philadelphia, 1975, WB
cheostomy: 42 cases, Proc Am Assoc Equine Pract
Saunders.
46:111,2000.
2. Shappell KK, Stick lA, Derksen FJ. et al: Permanent
S. Murray JF: Tile normal hlllg: the basis for diagnosis
tracheostomy in Equidae: 47 cases (1981-1986),
and treatmellt of pulmonary disease. ed 2, Ph iladel-
J Am Vet Med Assoc 192:939, 1988.
phia, 1986, WB Saunders.
CHAPTER 25
Surgical Treatment Options for Dorsal
Displacement of the Soft Palate
David A. Wilson

spay hook may be useful for the sternothyroid eus


INDICATIONS
tenectomy procedure. 9 A Ge lpi or Weitlaner
self- retaining retracto r, Allis tissue forceps. lo ng-
Dorsal displacement of the soft palate (DDSP)
handl ed or right-angle scissors, and curved
causes temporary o r intermittent exercise intoler-
sponge forceps are used fo r soft palate resectio n.
ance. A number of factors pote ntially influ ence
An Nd:YAG, CO" or diode laser may be used to
soft palate position, and accordingly a va riety of
transect muscle or to perform the staphylectomy
procedures have been described for the treatment
or photothermoplasty procedures. IO,12.13,17,19
of DDSP. Altering the head position, chan ging
tack, and using a "tongue-tie" or a figure-eight
noseband are a few of the conservative treatment
PREPARATION AND POSITIONING
options that may help horses w ith DDSP and aid
in the diagnosis and determination of the ca use of
Most procedures are best performed with the
the displacement. Various su rgical procedures
horse under general anesthesia in do rsal recum-
have been described to treat DDSP, including
bency and the head extended; however, with ·expe-
sternothyrohyoideus myectomy, sternothyroideus
rience, they ca n be acco mplished in th e standing
tenectomy, staphylectomy, and epiglottic aug-
sedated horse with local anesthesia.
mentation. 1' 13 Var ious co mbinatio ns of the proce-
Staphylectomy procedures require tempo ra ry
dures have also been described ,14. !9 Also, various
access to the lar ynx. This is typically accomplished
laser procedu res to either resect o r ca uterize the
by using intravenous anesthesia. When an endo-
soft palate, and a tie-forwa rd proced ure have been
tracheal tube is used, it is rem oved for the portio n
recently described to address DDSP, IO,!2,13,!7,20
of the procedure requiring access to the larynx.
None of these procedures are very effective for
persistent DDSP because of the likely damage to
in nervat ion of the soft palate and pharynx in
ANATOMY
these cases.
T he sternomandibularis originates from manu -
brium sterni , extends th e entire length of the
EQUIPMENT neck, formin g the ventral border of the jugular
furrow; and inserts on the caudal border of the
Rochester-Carmalt forceps, straight Rochester- ramus of the mandible (see Figures 23-1 through
Pean forceps with lo ngitudinal serrations, an 23-5) . At approximately the mid-ce rvical region,
angiotribe o r a similar instrument, and a Penrose the paired sternomand ibula ris muscle diverges
drain are used for th e myectom y procedu res. A from midline, exposing th e underlying paired

147

148 HEAD AND NECK SURGER IES

Lingual process of ---+r'


basihyoid bone

Basihyoid bone

Thyroid cartilage

Paired
thyrohyoideus mm.

Mandibular inn. Cricothyroid _


membrane
Cricoid cartilage ~
Unguofacial v. --+---"
Parotid gland

Paired
sternothyroideus mm.
Paired omohyoideus mm.
Paired sternohyoideus mm.
Paired sternomandibularis mm. -1-'1=

Figure 25-1 Ventral view of the head and rostral Figure 25-2 Ventral view of the larynx.
neck with the skin and cutaneous colli mu scle removed.

sternothyrohyoideus muscles. The paired ster- long incisio n is made through the anesthetized
nothyrohyoideus muscles originate from manu- skin on th e ventral midline of the neck (Figure
brium sterni and extend on the ventral aspect of 25-3), The level of the caudal portion of the inci-
the trachea. The smalJer sternothyroid eus inserts sion is at the level where the sternomandibularis
on the caudal border and abaxial surface of the diverges from midline, exposing the paired ster-
thyroid cartilage. The larger sternohyoideus nothyrohyoideus muscles, The rostral portion of
muscle inserts on the basihyoid bone and the the incision is at the level of convergence of the
lingual process of the hyoid bone (Figures 25- J omohyoideus and sternohyoideus muscles. At this
and 25-2), The paired omohyoideus muscles orig- mid-cervical region, the sternothyrohyoideus
inate from th e subscapular fascia close to the muscles are well exposed and are relativel y free
shoulder joint and merge with the sternohyoideus from other structures.
in the proximal third of the neck The incision is continued through the subcu-
Important landmarks for the laryngotomy taneous tissue and the cutaneous colli muscle. The
incision include the paired sternohyoideus sternohyoideus muscle is th en exposed and split
muscles overlying the larynx and th e V-shaped longitudinally on midline. The dissection contin-
cricothyroid membrane, which lies between the ues laterall y along the trachea to the lateral
thyroid and cricoid ca rtilages. borders of the sternothyrohyoideus muscles, The
ventral surface of the muscles is then separated
from the cutaneous colli and sternomandibularis
muscles by scissors and blunt fin ger dissection.
PROCEDURE
The dissection should continue until a 5-cm lon-
gitudinal section of the paired muscle is under-
Myectomy and Tenectomy Procedures
mined and separated from th e surrounding
Sternothyrohyoideus Myectomy tissues. The combined sternothyrohyoideus mus-
This procedure can be performed in the standing cles are elevated from the wound and an approx-
patient or under general anesthesia. A 6- to 8-cm- imately 5-cm length of muscle is removed by
Dorsal Displacement of the Soft Palate 149

Rostral

Omohyoideus m.

Sternohyoideus m. -+
Retracted
cut ends of the
sternohyoideus and
sternothyroideus
(smaller) mm.
Incision site for

myectomy

Caudal
Figure 25-4 Intraoperative view of ste rnohyoidec-
tomy and sternothyroidectomy for DDSP.

Figure 25-3 Surgical approach for sternothyrohy-


oideus myectomy.

cross-clamping the muscles with Rochester-


Carmalt, straight Rochester-Pean, or similar forceps.
Mayo scissors, a scalpel blade, or a laser (Nd:YAG
or diode) can be used to cut the muscle and
remove the 5-c01 section of muscle between the
clamps. Electrocautery may also be used, but the
Figure 25-5 Sutured ventral neck inCISion with
electrical stimulation ca uses significant muscle
Penrose drai n in place emerging proximal and distal
contraction. The forceps are then removed from
(arrows) to the primary incision.
the ends of the muscles and the muscles are
allowed to retract, leaving a large area of d ead
space next to the trachea (Figure 25-4 ). Hemor-
rhage is usually negligible, but small bleeders may entire incision may be left to heal by second inten-
be clamped with hemostats. tion. 7 Co mpl ete healing with minimal scar for-
A Penrose drain may be placed and tunneled mation will occur within 2 to 3 weeks.
through stab incisions, rostral and caudal to the
surgical incision (Figure 25-5). A three-layer Sternothyrohyoideus and Omohyoideus
closure consisting of cutaneous colli muscles, sub- Myectomy
cutaneous tissue,.and skin is performed. The cuta- A variation of this procedure involves an in cision
neous colli muscles and subcutaneous tissue are in the prox:imal third of the neck and partial
closed in separate layers using an absorbable myectomy of the omohyoideus muscle (Figure
monofilament suture material with a simple con- 25-6). This procedure involves more dissection
tinuous suture pattern. The skin is closed with than the sternothyrohyoideus myectomy and may
suture and pattern of the surgeon's choice. We be slightly more likely to develop postoperative
typically use No. 2-0 nylon in a Ford's interlock- seromas. The axial portion of the o mohyoideus
ing pattern, or skin staples. Alternatively, the muscles must be transected from their attach-
150 HEAD AND NECK SURGERIES

Sternothyroideus. m.

Sternothyroideus
Omohyoideus m.
Sternohyoideus

Figure 25-8 Close-up view of the sternothyroideus


musculotendinous section showing dotted lines where
resection will occur. Th e omohyoideus muscle is being
Figure 25-6 Intraoperative view of sternohyoidec- retracted.
tomy. sternothyroidectomy. and omohyoidectomy for
DDSP.

Ceratohyoideus m.
Ceratohyoid
,.,.,. Cricoid cartilage
bone ....-Cricothyroid lig.
Figure 25-7 Lateral view of
Lingual process
the larynx illustrating the inser-
of basihyoid bone c:~~
tion of the sternothyroideus on
the thyroid cartilage. Th e omohy-
oideus muscle is being retracted.
of
i of the omohyoideus m.
sternothyroideus m.

ments to the sternohyoideus muscles. This proce- on the caudal edge of the thyroid ca rtilage to
dure is better performed with the patient under ensure that the correct structure is isolated. A spay
general anesthesia because of the more extensive hook may be used to help isolate and exteriorize
dissection. although it ca n be accomplished in the the tendon' (Figu re 25-7). A small vein often lies
standing patient. This procedure has the advan- adjacent to the tendon and should be avoided.
tage of removing all of the caudaJ retractors of the Forceps are placed across the muscular portion of
larynx. the sternothyroideus muscle. The tendon is tran -
sected, and a 2-cm portion of the muscle is
Sternothyroideus Tenectomy and Sternohyoideus removed (Figure 25-8). The omohyoideus is
Myectomy dissected from the sternohyoideus muscle. and a
Another variation of this procedure invol ves a 5-cm section of sternohyoideus is then removed
sternothyroideus tenectomy and sternohyoideus (see Figure 25-6) .
myectomy. A 5-cl11 ventral mid-line skin incision
is made over the larynx and is extended caudally Staphylectomy
to the level of the first tracheal ring. The longitu- A ventral midline laryngotomy is performed at
dinal incision is extended through the paired ster- the level of the cricothyroid membrane. A to-cm
nohyoideus muscles to expose the ventral aspect incision is made starting at the cra nial border
of the larynx, the cricoid cartilage, and the crico- of the thyroid cartilage and extending caudal to
tracheal space. The musculotendinous portion of the first tracheal ring (Figures 25-9 and 25- 10).
the sternothyroideus muscle is located at the level The incisio n is continued through the cutaneous
of the cricoid cartilage. abo ut 3 to 4 cm off coUi muscles and subcutan eo us tissue. The paired
midline. The tendon is followed to its attachment sternohyoideus muscles are identified and sepa-
Dorsal Displacement of the Soft Palate 151

rated longitudinally the length of the incision (see


Figure 25-1). A self-retaining retractor is inserted
between the muscle bellies to expose the fascia
overlying the cricothyroid membrane. Sharp dis-
section is continued through the fascia . A small
vein is often present within the fascia that is tran-
sected. Bleeding is controlled with either hemo-
stats or electrocautery. The exposed cricothyroid
membran e is palpated. The caudal border of the
thyroid cartilage and the cranial border of the
cricoid cartilage are identified. The laryngotomy
inn.
is then perfo rmed by placing the back of the
scalpel blade against th e cricoid cartilage. An
cartilage
oall ventricle initial stab incision is made into the laryngeal
lumen, and the incision is continued rostral to the
center of the thyroid cartilage. The self-retaining
retractors are then repositioned within the larynx.
The laryngeal lumen m ay be swabbed with a
gauze sponge that has been soaked with local
'hP"..,,-/-J.:........ . anesthetic solution (2% mepivacaine).
Figure 25-9 View of the ventral throat region illus- A finger or curved sponge forceps is inserted
trating the relative position of the larynx in relation to into the larynx, over the epiglottis to displace the
the mandible and the laryngeal ventricle in relation to
caudal free edge of the soft palate into the airway.
the cricothyroid membrane.
If freeing the soft palate is difficult, the epiglottis
should be pushed ventral while lifting the head.
This action should displace the epiglottis and free
the caudal edge of the soft palate (Figure 25-11).
The free edge of the soft palate is then grasped
on midline with Allis tissue forceps. The forceps
should grasp approximately 5 to 8 mm of tissue.
The tissue is retracted to provide tension on the
caudal border of the palate. Long-handled or
right-angle scissors are then used to start a cut to
one side of the forceps and directed to the oppo-
site side. The tissue removed should taper to a
point and be about 2 cm in length (Figure 25-12).
The procedure is repeated on the opposite side.
The tissue removed should be crescent shaped:
wide at the center (about 6 to 10 mm) and taper-
Incision site for ing to a point about 2 cm on either side of midline
(Figure 25-12, D). The laryngotomy incision is left
to heal by second intention.

Alternative Staphylectomy Procedures


Other surgeons have recommended removal of a
small notch of tissue at th e caudal midlin e of the
soft palate. 6 For this procedure, Rochester or
equivalent forceps are used to grasp the soft palate
in the center of the caudal border) and Metzen-
baum scissors are used to cut around the tips of
the forceps. The size of tissue removed approxi-
Figure 25-10 Surgical approach for laryngotomy mates an equilateral triangle with each side mea-
.
mClSlon. suring about 8 to 10 mm .


152 H EAD AND NECK SURGER IES

C
Figure 25-11 A, O nce the incision has been made through the cricothyro id me mbrane, self- retai ning retractors
are placed to aid visual ization of the caudal aspect of the larynx. B, The soft palate is elevated from bel ow the ep iglot-
tis and becomes visible within the larynx (arrow) . C, The free edge of the soft palate is then grasped on midline with
Allis tissue fo rceps.

Figure 25-12 A, The free


edge of the soft palate is retracted
caudally. B, Long-handled or
righ t angle scisso rs are used to
sta rt a cut on m idlin e d irected
to the opposite side. The tissue
removed should taper to a poi nt
and be app roximately 2 em in
length. C, The procedure is
B repeated o n the opposite side. D,
The tissue removed should be
wide at the center and taperi ng
a maxim um of 10 mm to a point
approximately 2 em on either
A side of midline.

o
Dorsal Displacement of the Soft Palate 153

Staphylectomy is often used in conjunction


POSTOPERATIVE CARE
with sternothyrohyoideus myectomy. A compos-
ite procedure has been described that includes a
ventriculectomy in addition to myectomy and
Postoperative Care for Myectomy and
partial staphylectomy." Staphylectomy has also
Tenectomy Procedures
been used in conjunctio n with epiglottic aug-
mentation for cases of flaccid epiglottis. 16 Exercise Restrictions: The horse should be
An alternative combination procedure has rested in a stall for at least 1 week with controlled
been described and reviewed that combines a handwalking followed by return to normal exercise
sternothyroideus myectomy, small staphylectomy, over the next 2 to 3 weeks.
and caudal soft palate photothermoplasty.19 The
Medications: Perioperative therapy rnay consist
of antibiotics and nonsteroidal antiinflammatory
procedure is performed through a typicallaryn-
drugs. These generally do not need to be contin-
gotomy approach. Prior to penetrating the ued beyond the first postoperative day unless a
cricothyroid membrane, both caudal margins of drain is in place.
the thyroid cartilage are exposed and the ster- Suture Removal: The sutures are removed in
nothyroideus muscles are transected at their 10 to 14 days.
musculotendino us junctions. The cricothyroid Other: A towel stent or neck bandage may be
membrane is then incised to expose the laryngeal applied over the incision site and maintained for
lumen. The caudal free edge of the soft palate is 2 to 4 days after surgery (Figure 25-(3). The stent
grasped with Allis tissue forceps, and a CO, laser or bandage protects the wound and provides
is used (at a power setting of 35 Wand focused counterpressure to the wound to reduce edema,
hematoma, and seroma formation. The Penrose
spot size of 0.22 mm) to make several lines in a
drain should be removed in 2 to 3 days.
sweeping motion through the oral mucosa o f the
soft palate, parallel to and extending rostral 4 to
5 em from the caudal free margin of the palate.
A small (4 mm x 8 mm ), semicircular section of
tissue is then sha rply resected from the caudal free
margin of the soft palate. The cricothyroid mem-
brane is closed with polyglactin 9 10 in a simple
co ntinuous pattern. The remaining layers are left
to heal by second intention.
Laser ablation of the ca udal aspect of the soft o
palate can also be performed in the standing
sedated horse using the Nd:YAG or diode laser o r
electrocautery with endoscopic visualizatio n in an
attempt to increase the rigidity of the palate. To
perform the procedure effectively, the palate must
be displaced during th e procedure. Maintaining
thi s position can be difficult due to swallowing,
etc., in the conscious horse. 17 :, \
,
,
,, \
Tie-Forward Procedure
A tie-forward procedure has also been described J
in which a suture is placed from th e basihyoid
bone to each wing of th e thyroid cartilage at the i
\lj
insertion site of the sternothyroideus muscle. ll .20 ),"'-
This suture maintains the larynx in a rostral and •
Figure 25-13 Towel stent sutured in position fo r
slightly more dorsal position. Therefore, instead sternohyoideus myectomy, sternothyroideus tenectomy
of preventing caudal retraction of the larynx by fo r either DDSP o r modified ForsseU's procedure. The
means of the myotomy-tenotomy procedures, the stent is applied to protect th e incision and to apply pres-
"tie-fo rward" procedure maintains the larynx in a su re to the incision site to minimize postoperative
fixed cranial position. hematoma or seroma formation.
154 HEAD AND NECK SURGERIES

Postoperative Care for Staphylectomy phagia if too much of the caudal palate is removed
Procedures and granulation tissue at the exposed edge of the
palate.
Exercise Restrictions: The horse should be
rested in a stall with controlled handwalking only
for 2 weeks to allow the inflammation of the soft
palate to subside. The horse may then return to COMMENTS
its normal activity.
Medications: Broad-spectrum antibiotics and DDSP is a common cause of poor performance in
nonsteroidal antiinflammatory drugs are adminis- racehorses. but it also occurs in other types of per-
tered for 2 to 5 days depending on the amount formance horses. particularly those that have
of postoperative drainage and local inflammation. exaggerated flexion at the poll durin g work. DDSP
Suture Removal: Laryngotomy incisions may be is one of the common causes of noise at exercise
left to heal by second intention. and the noise is typ ically characterized as a "gur-
Other: The incision site is cleaned at least once
gling" sound, generally loudest on expiration. It is
daily with moistened sterile sponges. Petrolatum
is applied around the incision to minimize
often a diagnosis by exclusion of other common
scalding. causes of noise at exercise or decreased perfor-
mance. Horses with DDSP often have sign ificant

EXPECTED OUTCOME

The incision should heal completely within 2 to


3 weeks with minimal scarring. Previous reports
have indicated a 50% to 85% chance for return to
normal activity following the various versions of
sternothyrohyo ideus myectomy.2.4,15 The progno-
sis for horses with intermittent dorsal displace-
ment to return to normal activity following
staphylectomy is about 60%.4.1S.16 Combinations
of these procedures have been reported to
improve the prognosis. 15.19 Horses with persistent
DDSP or a hypoplastic epiglottis with DDSP have
A
a poor prognosis. In cases with a hypoplastic
epiglottis. a partial staphylectomy with or without
epiglottic augmentation may be a better surgical
option.

COMPLICATIONS

Following myectomy-tenectomy procedures. the


complications are few but can include seroma or
hematoma formation, incisional infections. and
re Wliting of the severed ends of the muscles
through scar formation. Seromas and hematomas
are best treated by controlling bleeding at the time
of surgery, adequate counterpressure app lied to
the wound postsurgery, and limiting exercise in B
the immediate postoperative period. There may Figure 25-14 A. Endoscopic view of normal equine
be a cosmetic defect at the site of muscle resec- larynx. B. Endoscopic view of equine larynx with dorsal
tion. Staphylectomy complications include dys- displacement of the soft palate.
Dorsal Displacement of the Soft Palate 155

airway compromise during exercise but can 6. Llewe1.lyn H R. Petrowitz AB: Sternothyroideus
recove r quickly when the horse is allowed to m yotomy for the trea tment of dorsal displacement
swallow to replace the palate in the correct posi- of the so ft palate, Proc Am Assoc Equine Pract
tion. During clinical examination, the palate may 43:239,1997.
7. Robertson JT: Dorsal displacement of the soft
not displace unless specific conditions, such as the
palate. In White NA II , Moo re IN, editors: Curre1lt
type of tack used and the head position used
teclllliqlles ;11 equine surgery and lameness. Philadel-
during performa nce, can be dup licated . Un less the ph ia, 1998, WE Sau nders.
specific condi tions are duplicated, the "noise" 8. Holcombe SJ, Ducharme NG: Pha rynx. In Aue r JA,
reported by the owner or trainer will not be noted Stick ]A, editors: Equine surgery. ed 2, Philadelph ia.
and the airway will generall y appear completely 1999, WE Saunde rs.
normal on endoscopic exami nation at rest or after 9. Ada ms SB, Fessler IF: Sternothyrohyoideus
exercise {Figure 25- 14}. Endoscopic examination myectomy. In Adams SB, Fessler JF, ed itors :
while the horse is wo rki ng on a high-speed tread- Atlas of equine sllrgery, Philadelph ia , 2000. WB
mill, ideally with the same tack and head position Sau nde rs.
that exist when the DDSP typically occurs, is fre- 10. JagerHauer K, Lutkefels E. Deegen E, et al: Expe ri-
m en tal study on transendoscop ic laser su rge ry of
quen tly the only way to directly make the diagno-
21 dorsa l d isplacement of the soft palate in horses,
SiS .
Tierarztliche Praxis Ausgabe Grosstiere Nutztiere
DDSP may occur seco nd ary to other airway 3 1:18,2003.
abn or malities that cause turbulent airflow, in- 11. Ducharme NG: Treatment consid erations for
creased negative airway pressure, or to signifi- DDSP, Pro, ACVS Vet Symp 13:2 10, 2003.
cant upper airway inflammat ion. These common 12. Stick JA: Soft palate displacement: treatment
airway abnormali ties include la ryngeal hemiple- o ptions, Proc ACVS Vet Symp 13: 189,2003.
gia, epiglottic entrapment, guttural pouch dis- 13. Tate LP, Swee ney C L, Bowma n KF, et al: Tra nse ndo-
orders, and pharyngeal lymphoid hyperplasia. scopic Nd:YAG laser surgery for treatment of
Therapy to address these potential primary prob- ep iglottal entrapment an d dorsaJ displacemen t
lems is wa rranted before proceeding with any of of the soft palate in the horse. Vet Surg 19:356,
1990.
the surgical options discussed here.
14. O'Rielly JL, Beard WL, Renn TN, et al: Effect of
combined staphylectomy and laryngotomy on
upper airway mechan ics in clin ically normal
horses, Am ] Vet Res 58: 10 18, 1997.
REFERENCES 15. Bo ne nClark G, Bryant ], He rnandez J, e t al:
Sternothyroideu s tenectomy or sternothyroideus
1. Mcllwraith CW, Turner S: Myectomy of the ster- tenectomy with staphylectomy for the trea tm ent of
nohyoid, sternothyroid, a nd omohyo id muscles. In soft palate displacement, Proc Am Assoc Equine
Mcllwraith CW, Turner S, editors: Equine surgery Proct 45:85, 1999.
advallced techniques, Philadelphia, 1987. Lea & 16. Ada m s SB, Fessler JF: Epiglottic augmentation and
Febiger. staphylectom y. In Adams SB, Fessler JF, editors:
2. Harrison rw, Raker CW: Sternothyrohyo ideus Atlas of equine surgery. Ph iladelphia, 2000, W B
myectomy in ho rses: 17 cases (1984-1985), ] Am Sa unde rs.
Vet Med Asso, 193: 1299, 1988. 17. Hogan PM, Palmer SE, Congelosi M: Transendo -
3. Shappell KK, Caron JP, Stick JA, et al: Staphylec- scopic laser cauterization of the so ft palate as an
tomy for treatment of dorsal displacement of the adjunctive treat me nt for dorsal disp lacement in
soft palate in two foals, ] Am Vet Med Assoc the racehorse, Proc Am Assoc Equine Pract 48:228,
195:1395,1989. 2002.
4. Ande rson ]D, Tulleners EP. Joh nston JK, et al: Ster- 18. Barakzai SZ. Johnson VS, Bai rd DH. et al: Assess-
nothyrohyoideus myectomy o r staphylectomy for men t of the efficacy of composite surgery for the
treatment of inte rmittent dorsal displacement of treatmen t of dorsa l displacement of the soft palate
the soft palate in racehorses: 209 cases ( 1986-1991), in a group of 53 racing Thoroughbreds (1990-1996),
] Am Vet Med Assoc 206: 1909, 1995. Eqllifle Vet J 36: 175, 2004.
5. Duncan DW: Retrospective study of 50 Thorough- 19. Sm ith 11. Embertso n RM: Sternothyroide us
bred racehorses subjected to radical myectomy Myotomy, stap hylecto my, and oral caudal soft
surgery for trea tme nt of dorsa l displace me nt of the palate photothermoplasty for treatmen t of dorsal
soft palate, Proc Am Assoc Equil1e Pmct 43:237, displacement of the soft palate in 102 Thorough-
1997. bred racehorses, Vet SlIrg 34:5, 2005.
156 HEAD AND NECK SURGERIES

20. Ducharme NG, H ackett RP, Woodie JB, et al: 21. Parente El, Marti n BB, Tulleners EP. et al. Dorsal
Investigations into the role of the thyrohyo id d isplacement of the soft palate in 92 horses during
muscles in the pathogenesis of dorsa l displacement h igh -speed t readmill exam inati on (I993- 1998),
of the soft palate in horses, Equille Vet J 35:258, Vet Surg 31:507. 2002.
2003 .


CHAPTER 26
Modified Forssell's Operation for Cribbing
David A. Wilson

INDICATIONS POSITIONING AND PREPARATION

The primary ind ication for this procedure is mod- This procedu re is best perfo rmed under general
ificatio n of cribbi ng behavior when nonsurgical anesthesia with the horse in dorsal recumbency
methods fail. and the head extended; however, with experience,
it can be accompli shed in the standing sedated
horse with local anesthesia. Transecting the ster-
nohyoideus at the attachm ent to the hyo id appa-
ratus is difficult in the standing horse. The ventral
EQUIPMENT cervica l region is clipped and prepa red for aseptic
surgery.
Large Rochester-Carmalt, straight Rochester- Pea n
or angiotrib e forceps, and a Penrose drain are
used for this procedure. An Nd:YAG or diode laser
may be used to transect muscle.] PROCEDURE

A 3D-em ventral midline incision is made starting


2 em rostral to the la rynx at the basihyoid bone
and extending caudally (Figure 26-1). The ski n
ANATOMY is retracted laterally, and hemostasis is ach ieved
as needed in the subcutaneous tissue. A plane
The ventral branch of the accessory nerve (CNXl) of dissection is established between the omohy-
is located on the dorsomedial aspect of the ster- oideus and sternomandibularis muscles to expose
nomandibularis and enters the muscle about 5 em the medial as pect of sternomandibularis 5 em
from the musculotendinous junction. The paired caudal muscles to the musculotendinous junction.
sternothyrohyoideus muscles lie on the ventra l The sternomandibularis muscle is gently retracted
aspect of the trachea. The tendon of insertion of a nd rolled sligh tly abaxial to expose the dorsal
the sternothyroideus muscle is on the caudal medial aspect. The nerve can be located by palpa-
border and abaxial su rface of the thyroid cartilage tion of a slight indentation in the musculature
(see Figure 25-2) . The larger stemohyoideus mus- where the nerve enters or by identifying the nerve
cle continues on midline to insert on the basihy- just caudal and ventral to a small arterial branch
oid bone. The paired omohyo ideus muscle merges supplying the sternomandibularis muscle (Figures
with the sternohyoideus muscle in the proximal 26-2 through 26-4). In most cases, a small amount
third of the neck (see Figures 23-2 to 23-5). of fascia will need to be dissected from the ster-

157
158 HEAD AND NECK SURGERIES

Incision site
for modified
Forssell's
procedure

~e._t;C~

Figure 26-3 The sternomandibularis muscle is


retracted laterally exposing the insertion of the ventral
branch of the sp inal accessory nerve. In most cases, a
small amount of fascia covers the nerve and wili need
to be dissected off to expose the nerve.
~f>..--~.:6____

Figure 26-1 Incision site for modified Forssell's pro-


cedure. A 30-cm vent ral midli ne incision starts 2 em
rostral to the larynx at the basihyoid bone and extends
caudally.

~e .......t;;'""J-.........-. ~ e.r....;t;;J;g",~
Figure 26-2 Lateral view of neck illustrating the Figure 26-4 The inse rtion of the spinal accessory
approximate insertio n site of the ventral branch of the nerve is best identified by palpation for a depression on
spinal accessory nerve as it traverses the axial surface of the axial bo rder of the sternomandibulari s muscles.
the sternomandibularis muscles (dotted lilies) prior to
entering the muscle belly approximately 5 em caudal to
the musculotend inous junction.
myectomy and a sternothyroideus tenectomy
nomandibularis muscle to expose the nerve. are then performed as described in Cha pter 25.
Cont raction of the sterno mandibular is muscle Additionally, when performing myectomy for
and flexio n of th e head are observed when the cribbing behavior, a portion of the o mohyoideus
nerve is pinched with hemostats. A 5- to 1O-C111 is removed and the sternohyoideus and omohy-
section of nerve is exposed using blunt dissection oideus are ideally transected rostral to the ventral
and removed (Figure 26-5) . A sternohyoideus aspect of the larynx.
Modified Forssell's Operation for Cribbing 159

Figure 26-5 Once the spinal accessory


ne rve is identified, it can be blu ntly dissected
free from the muscle to expose a 5- to lO-em
section of the nerve to be removed.

Ventral

accessory n.
Sternohyoideus m.

surgery, app lying adequate counterpressure to the


POSTOPERATIVE CARE
wo und postsu rgery, and limiting exercise in the
imm ediate postoperative period. The long-term
consequences of the incisional complications are
Postoperative Care
minimal. These incisions can heal very well by
Exer<ise Restridions: The horse should be second intention if necessary. Therefore, even
confined to a stall for 2 weeks with controlled with complete dehiscence, the inci sions heal with
handwalking only. very little scar formation. A cosmetic defect may
Medications: Phenylbutazone is administered at be present at the site of muscle resection, partic-
4.4 mg/kg BID for the initial 24 hours and 2.2 ularly if the muscles are resected in the mid-
mg/kg BID for an additional 2 days. Broad-spec-
cervical region.
trum antibiotic therapy is indicated until 24 hours
after drain removal.
Suture Removal: Sutures are removed 12 to 14
days after surgery. EXPECTED OUTCOME
Stent Removal: The stent is typically removed
2 days after surgery. Reported success rates using the modified Fors-
Drain Removal: The Penrose drain is removed sell's procedure range from 50% to 100%.1-3.6
2 to 5 days after surgery depending on the Many horses undergoing this procedure show
amount of drainage. various levels of cribbing following surgery. For-
Dther: In the event that hematomas or seromas tunately, most just apply their teeth to a flat object,
occur, they should be managed conservatively.
such as the top of a post or fence, but do not grasp
as they did prior to surgery and do not flex the
neck or make gulping noises as they did prior to
surgery. Success has been attributed to transecting
COMPLICATIONS the sternohyoideus and omohyoideus rostral to
the ventral aspect of the larynx. This success may
The most common complication is failure to occur because the entire insertion of the omohy-
resolve the behavioral abnormaUty.2-8 Factors that oideus is removed. If a more caudal transection is
may help to minimize recurrence of the cribbing performed, it is difficult to include all of the omo-
behavior include excising the muscle belly cran ial hyoideus. Additionally, remaining rostral portions
enough to prevent scar tissue from facilitating of the sternohyoideus muscle may establish some
retraction of the larynx and instituting environ- adherence to the surrounding tissues and regain
mental and behavioral changes. Other complica- some retraction function. Cosmesis is generally
tions include seroma or hematoma formation and very good, particularly if the muscle transections
incisional infections. Seromas and hematomas are are as far proximal and distal as recommended.
best treated by controlling bleeding at the time of Muscle resections in the mid cervical region may


160 HEAD AND NECK SURGERIES

result in visual "steps" on the ventral aspect of the 2. Greet TR: W indsucking treated by myectomy and
neck where the muscle becomes reattached to the neurectomy, Equine Vet J 14:299, 1982.
fascia overl ying the ventral trachea. 3. Turn er AS, White N, Ismay J: Modified Forssell's
operation for crib-biting in the ho rse, J Am Vet Med
Asso, 184:309, 1984.
ALTERNATIVE PROCEDURES 4. Mcllwraith CW, Turner AS: Myectomy of the ster-
nohyoid, sternothyroid, and omohyoid muscles. In
Md lwraith CW, Turner AS: Equine surgery adva1/ced
Nonsurgical methods to modify cribbing behav-
tecillliqlles, Philadelphia, 1987, Lea & Febiger.
ior include moving the horse to a pasture or 5. Fjeldborg I: Results of surgical management of crib-
increasing the frequency of turnout, applying bing by neurectomy and myectomy, Eqllille Pract
noxious agents to the surfaces used for cribbing, 7:34, 1993.
providing the horse with a companion such as 6. Schofield WL, MulvilJe JP: Assessment of the m odi -
another horse, a goat, or a pony, the application fied Forssell's procedure for the treatment of oral
of cribbing straps, the use of electric shock collars, stereotypes in 10 horses. Vet Rec 142:572, 1998.
acupunctu re, J and the use of opioid antagonists in 7. Adams S8: Biology and treatment of specific muscle
an attempt to block the pleasurable sensation d isorders. In Auer JA, Stick JA , editors: Equille
caused by the cribbing and wind-sucking activity.? surgery, ed 2,. Philadelphia, 1999, WB Saunders.
8. Adams SB, Fessler JF: Modified Forssell's operatio n
for cribbing. In Adams SB, Fessler IF, editors:
Atlas of equine surgery, Philadelphia, 2000, WB
REFERENCES Sa unders.
9. Oodam NH, Shuster L, Court MH, et al: Investiga-
I. Delacalle J, Bu rba OJ, Tetens J, et a1: Nd:YAG laser- tio n into the use of narcotic antagonists in the treat-
assisted modified Forssell's procedure for treatment ment of a stereotypic behavior pattern (crib-biting)
of cribbing in horses, Vet SlIrg 31 :111, 2002. in the horse, Am J Vet Res 48:311,1987.
. . . PHTHALMIC URGERIES

161
CHAPTER 27
Nasolacrimal Flush
Laurence E. Galle

or akinesia of the eyelids and nares may facilitate


INDICATIONS
insertion of the catheter.
Catheterization and flushing of the nasolacrimal
duct is indicated to confirm or rule out naso-
ANATOMY
lacrimal obstruction as a cause for epiphora,
muco id, or mucopurulent discharge. Flushing of
The structures of the nasolacrimal system are
the nasolacrimal d uct may also be a therapeutic
divided into secretory and drainage components.
procedure in that it call dislodge sm all foreign
The tearfi lm is a trilamina r fluid secreted by the
bodies or purulent debris that obstruct the flow
lacrimal gland, third eyelid gland, conj unctival
of tea rs through the duct. ! If an obstruction is
goblet cells, and meibomian glands. The tearfilm
diagnosed within the nasolacrimal system, dacry-
is drained from the eye through the dorsal and
ocystorhinography can be performed to deter-
ventral puncta into the dorsal and ventral canali-
mine the anatomic location of th e obstruction
culi (Figure 27-1). T he canaliculi m erge ventro-
by the injection of radiopaque contrast media
medial to the medial canthus and form the
through the catheter. 2
lacrimal sac, a dilation of the proximal n aso-
lacrimal duct that lies with in the lacrimal fossa of
EQUIPMENT the lacrimal bone. The nasolacrimal duct passes
medially through the maxillary bone and contin -
A 5-Fr male urinary catheter or polyethylene ues rostrally through the soft tissues of the nares
tubing is needed for nasolacrimal catheterization. to the opening or orifice of the duct. This opening
A 3-mL syrin ge, %-inch 25-gauge needle, and is located on the floor of the nasal cavity approx-
local anesthetic are needed if local anesthesia or imately 5 to 7 cm from the opening of the nares
akinesia is to be used to facilitate placement of the near the mucocutaneous junction (Figu re 27-2).
catheter. If the cath eter is to be su tured into place, The n asolacrimal duct is approximately 4 to 5 mm
a No. 10 Bard-Parker blade, needle drivers, general in diameter and is narrowed proximally as it
operatin g scissors, and No. 2-0 or No. 3-0 mono- passes through the maxillary bone. l,3·s
filament non absorbab le suture are also needed.

PROCEDURE AND PREPARATION


POSITIONING AND PREPARATION
The openi ng of the nasolacri mal duct is located
Nasolacrimal catheterization is typically per- on the floor of the vestibulum of the nasal cavity,
formed with standing sedation . Local anesthesia and a 5-Fr male urinary catheter is placed into

162
Nasolacrimal Flush 163

~--Dorsal lacrimal punctum

Nasolacrimal sac ----,

'-----Ventrallacrimal
punctum
Nasolacrimal --'-- -
duct

Figure 27-1 Schematic illustrating the anatomy of the dorsal and ventral puncta, nasolacrimal sac, and naso-
lacrimal duct.

the ostium and advanced gently in a retrograde


manner, I Using the ind ex finger, gentle pressure is
/ applied over the opening to «sea!" it around the
ca theter. Patency of the nasolacrimal system can
be tested by injecting 15 to 20 mL of sterile saline
throu gh the catheter. Patency of the dorsal and
ventral puncta at the medial can thu s is individu-
ally determined by alternately applying digital
pressure over each canaliculus.
Alternatively, the nasolacrimal system ca n be
catheterized in an antegrade mann er from the
dorsal punctum. 6 The surgeon sho uld first use
appropriate local anesthesia or akinesia of the
eyelids, topical anesthesia of the co rn ea, and seda-
tion. The catheter is inserted into the dorsal
punct um and is flushed with sterile saline. The
ventral canaliculus should be occluded with
digital pressure to ensu re flushing of the naso-
lacrimal duct to its openin g (Figure 27-3).
The nasolacrimal catheter can also be tem-
porarily sutured in place to provide patency of the
nasolacrimal system while treating an obstruc-
tion. If the surgeon intends to suture the naso-
lacrimal cathete r in place, then local anesthesia of
the dorsal or lateral nasal wall adjacent to the
nares should be injected prior to placing th e tube.
A stab incisio n is then made through the anes-
Figure 27-2 Nasolacrimal punctum in the vest i- thetized area using a No. 10 Bard-Parker scalpel.
bulum. The nasolacrim al catheter is inserted retrograde as
described above and is advanced to the naso-
lacrimal sac. The free end of the catheter is
inserted from inside the nasal cavity through the
164 OPHTHALMIC SURGERIES

Figure 27-1 Catheter placed in the dorsal punctum


demonstra ti ng the use of digital pressure to obstruct ~-'(;."-'''-
the ventral canalicul us.
Figure 27-4 Nasolacrimal catheter sutured in place
to treat nasolacrima l obstruction.

stab incision and exits dorsally or dorsolaterally


along the face. The catheter is sutured in place catheteriza tion. Cath eters that exit the dorsal or
adjacent to the opening of the duct with two ventral puncta and are sutured in place have the
simple-interrupted No. 3-0 monofilament non- potential to rub the cornea and ca use corneal
absorbable sutures. Additional sutures are placed ul ceration. Care should be taken to avoid contact
along the face to secure the catheter7 (Figure of the catheter or sutures/with the cornea.
27-4).

REFERENCES
POSTOPERATIVE CARE
1. Moore C: Eyelid and nasolacrimal disease, Vet Clill
N Alii Equine Pract 8:499, 1992.
Postoperative Care
2. St rubbe D, Gelatt KN: Op hthal m ic examination and
Medications: If obstruction of the nasolacrimal diagnostic procedures. In Gelatt KN, editor: Veteri-
duct is diagnosed, then flush material is submit- nary ophthalmology, ed 3, Philad elphia, 1999, Lip-
ted for bacterial culture and susceptibility, the pincott Williams & Wilkins.
results of which should direct antibiotic use. 3. Cooley PL Normal equine ocular anatomy and eye
Antimicrobial therapy should be continued for at examination, Vet Clin N Alii Equine Pmct 8:427,
least 14 days. 1992.
other: Nasolacrimal catheters that are sutured 4. Carastro SM: Equine ocu lar anatomy and oph- .
in place to maintain patency of the duct during thalmic examination, Vet Clill N Am Equille Pmct
treatment should remain in place for at least 2 to 20:285, 2004.
3 weeks.' Topical antimicrobial therapy should be 5. Sa muelson D: Ophthalmic an atom y. In Gela tt KN ,
continued until the catheter is removed. editor: Veterinary ophthalmology, ed 3, Philadelphia,
1999, Lippincott Williams & Wilkins.
6. Sla tte r D: Lacrimal system. In Slatter D, editor:
Fundamel1tals of veteri1lary ophthalmology, ed 3,
COMPLICATIONS Philadelphia, 2001, WB Saunders.
7. Brook D: Use of a n indwelling nasolacrimal cann ula
Congenital ostium malformation or scarring of for the adm inistration of medication to the eye,
the nasolacrimal duct or puncta may prevent Eqlline Vet] (Suppl ) 2:135, 1983.
CHAPTER 28
Inferomedial Subpalpebral Lavage Tube Placement
Laurence E. Galle

co njunctiva. The palpebral conjunctiva is firmly


INDICATIONS
adherent to the eyelid at the eyelid margin and
becomes loosely attached toward the conjunctival
A sub palpebral lavage tube is indicated to facili-
fornix. In th e ventral aspect of the medial canthus,
tate the administration of topical ophthalmic
the conjunctiva in the fornix: reflects onto the
solutions,l.6
anterior surface of the third eyelid. The conj unc-
tiva of the third eyelid again reflects into a fornix
on its posterior surface before becoming associ-
EQUIPMENT ated with the globe as it becomes the bulbar
conj unctiva' (Figure 28-2). The inferomedial sub-
Needle drivers) general operating scissors. 12- palpebral lavage tube will be positioned such that
ga uge trocar, and one sterile silicone sub palpebral its footplate is in the inferomedial conjunctival
lavage tube device approximately 90 em long with fornix between the ventral eyelid and the third
a I-em-diameter footplate are needed 2.3 (Figure eyelid.'
28-1). The sub palpeb ral lavage tube device may be
purchased from commercial sources or manufac·
tured by the surgeon from appropriate materials. PROCEDURE

The surgeon should ensure patency of the sub-


POSITIONING AND PREPARATION palpebral lavage tube prior to attempting to insert
it into the patient. The tip of a 12-gauge trocar
Subpalpebral lavage tubes can be placed in is directed deep into the conjunctival fornix
sedated patients using appropriate nerve blocks between the ventral eyelid and third eyelid. The
to provide eyelid akinesia and sensory anesthesia index finger is used to guide the trocar and
including topical corneal anesthesia. prevent injury of the globe with the trocar (Figure
28-3). The trocar is advanced through the con-
junctival fornix and through the skin ventral to
ANATOMY the medial ca nthus. A stainless steel thimble may
be used to advance the trocar, and needle drivers
Ventromedial subpalpebrallavage tube placement may be placed adjacent to the exit site of the trocar
requires knowledge of the lower eyelid, medial through the skin to provide counterpressure to
canthus, third eyelid, and orbital rim. The poste· facilitate trocar placement. The free end of the
rior surface of the ventral eyelid is th e palpebral subpalpebral lavage tube is inserted externally

165

[
166 OPHTHALMIC SURGERIES

Figure 28·1 Footplate of lavage tube.

Figure 28-3 Finger guiding trOCilr.

Tarsal conjunctiva
plate ---;- _ev,lIor palpebrae
sup~rioris m.
Cilia
conjunctiva

Tarsal
Semilunar fold
glands --::::::::::: I tertia,
Skin' third eyelid)
Orbicularis
oculi m.

lavage tube
in

~P-A.itO.t-" ,
Figure 28-2 Schematic of eyelid anatomy.

into the trocar from the conjunctival fornix. The


tubing is advanced until it is visualized in the tip
of the trocar and the trocar and tubing are then
advanced through the skin, leaving the subpalpe-
brallavage tube in the ventral eyelid as the trocar
is removed. The surgeon advances the subpalpe- Figure 28-4 Horse's head with lavage tube in place.
bral lavage tube until the circular footplate is
secure aga inst palpebral conjunctiva. Prior to
suturing the lavage tube into place, a 20-gauge
Luer stub adapter with attached injection port is
inserted into the free end of the lavage tube and
patency is again tested by injecting saline or fluo- adjacent to the ipsilateral ea r. These tabs of tape
rescein through the lavage tube. Short strips are then sutured in place using two No. 2-0
of duct tape or porous medical grade tape are monofilament nylon simple interrupted sutures
secured to the lavage tube adjacent to the exit site per tab of tape to secure the lavage tube to the
through th e ventral eyelid, between the eyes, and patient (Figure 28-4).
Inferomedial Subpalpebral Lavage Tube Placement 167

for resuturi ng of tape tabs, and tearing o r break-


POSTOPERATIVE CARE age of the lavage tube system. 3,5 The most fre-
quently reported complications of inferomedial
Postoperative Care lavage systems are displacement of the footplate
fro m the conj unctival fornix (18%) and need for
Protection: Aprotective eye cup is recommended
resuturing of tape tabs (14%).'
to prevent self-trauma and failure of the lavage
tube.
Other: The tube and footplate should be tested
daily for patency; the blunt-tipped Luer adapter is REFERENCES
a common site for failure with leaking of the tube
and may need to be replaced if worn. Tubes 1. Brooks DE: Equ ine ophthalmology. In Gelatt KN,
leaking from sites rostral to the ears will need to editor: Veterinary ophthalmology, ed 3, Ph iladelphia,
be replaced with a new lavage tube. Tape tabs and 1999, Lippincott, Williams & Wilkins.
sutures should be inspected for loosening and 2. Miller TR: Prin ciples of therapeutics, Vet Clin N Am
should be resutured if necessary.'·5 Equille Pract 8:479, 1992.
Medication: Only 0.1 mL of medication is nec- 3. Gi uliano EA, Maggs DJ, Moore CP, et al: Inferom e-
essary for injection through the lavage tube. The dial placement of a single-entry subpalpebral lavage
dose of medication is advanced through the tube for treatment of equine eye disease, Vet Opll-
lavage tube by slowly injecting approximately 1 mL t/In/mo/ 3: 153, 2000.
of air through the tube using a tuberculin syringe.' 4. Frauenfelder H, McJlwraith W: Placement of a sub-
palpebra l catheter in a standing horse, Vet Med Small
Arl;m c/irl 74:724, 1979.
COMPLICATIONS 5. Sweeney CR, Russel l GE: Comp licatio ns assoc iated
wi th use of a one-hole subpalpebrallavage system in
horses: 150 cases (1977-1996), , Am Vet Med Assoc
Ocular complications of subpalpebrallavage tube 2 11 :127 1,1997.
placement include displacement of the footplate 6. Gelatt KN: Postoperative sub palpebra l medicat ions
from the conjunctival fornix, corneal ulceratio n, in horses and dogs, Vet Med 62:1165,1967.
swelling of the ventral eyelid, and loss of the foot- 7. Samuelson D: Ophthalmic anato my. In Gelatt KN,
plate within the eyelid. Nonocula r complicati ons ed itor: Veterillary ophthalmology, ed 3, Philadelphia,
include leakage or loss of the injection port, need 1999, Lippinco tt, Williams & Wilkins.
CHAPTER 29
Eyelid Laceration Repair
Laurence E. Galle

INDICATIONS PROCEDURE AND PREPARATION

Simple traumatic eyelid lacerations can be The surgical site is cleaned of debris with gentle
repaired with simple, multilayer suturing tech- lavage with saline or a 1:50 dilution of povidone-
niques. If, however, defects are excessively large iodine solution. Necrotic tissue is identified and
with significant loss of eyelid tissue from devital- debrided, leaving as much viable eyelid tissue as
ization or necrosis, advanced blepharoplastic tech- possible.J,6 If the laceration involves the lacrimal
niques may be required. 1,2 canaliculus near the medial canthus, then tempo-
rary cannulation of the affected canaliculus prior
EQUIPMENT to suturing is necessary to align the lacerated ends
of the canaliculus during suturing. I.' Subconjunc-
General surgical pack, Derf needle drivers, Bishop- tival co nnective tissue is closed using No. 3-0
Harmon tissue forceps, Stevens tenotomy scisso rs. or No. 4-0 absorbable simple horizontal mattress
sutures. The first sut ure should be placed adjacent
to the eyelid margin to provide optimal eyelid
POSITIONING ma rgin apposition, and subsequent sutures are
placed toward the apex of the incision. Eyelid
Although some minor lacerations may be repaired lacerations should be repaired with a minimum
with standing sedation-an esthesia and appropri- of two suture layers (i.e., subconjunctival sutures
ate local anesthesia-akinesia, general anesthesia and skin sutures); however, excessive tension
with the patient in lateral recumbency is recom- across the laceration or significan tly compro-
mended for most eyelid lacerations. 1.3 mised eyelids may require an additional suture
pattern or a temporary tarsorrhaphy.1 Skin clo-
ANATOMY su re is performed with No. 3-0 monofilam ent
nylon suture. The first skin suture to be placed is
The four major layers of the eyelid, from external a figure-of-eight suture within the eyelid margin
to internal, are skin, orbicularis oculi muscle, to provide optimal eyelid margin apposition 2•3
fibrous tarsal plate, and conjunctiva 4•S (see Figure (Figure 29-1). The remainder of the skin is closed
28-2). in a simple interrupted pattern.

168
Eyelid laceration Repair 169

COMPLICATIONS

The most frequent complication of eyelid lacera-


tion repair is wound dehiscence. This is most
commonly a result of single-layer closure, but it
may also occur as a result of devitalized wound
edges or excessive tension across the surgica l site.
A B If wound dehiscence occurs, a second surgical
repair with debridement and suturing is recom-
mended to prevent eyelid margin defects and
to reduce the potential for corneal abrasion or
ulceration.
Some patients may develop a notch-like defect
of the eyelid. Slich defects, if significant, can cause
abnormal tearfilm distribution, and corneal irri-
tation or ulceration. Minor defects of the eyelid
margin may be left alone if they do not adversely
affect the corneal surface; more significant defects,
C 0 however, require additional blepharoplastic tech-
'ii"-,,, .;t~• ._ niques to correct or remove the defect. These
Figure 29-1 Schematic demonstrating A, B, subcon- eyelid margin defects are most easily prevented by
junctival closure and C, figure-of-eight suture at eyelid two-layer closure and an appropriately placed
margin. D, The reminder of the skin laceration is closed figure-of-eight suture at the eyelid margin.'
in a simple interrupted pattern.

REFERENCES

1. Brooks DE, Wolf D: Ocular trauma in the horse,


POSTOPERATIVE CARE Equille Vet J (Su ppl ) 2:1 41,1983.
2. Millichamp NJ: Ocu lar trauma, Vet Clin N Am
Eqllille Pract 8:521,1992 .
Postoperative Care 3. Moore CP: Eyelid and nasolacrimal disease, Vet Clin
N Am Equine 8:499, 1992.
Medications: Systemic and topical broad-spec-
4. Samuelson D: Ophthalmic anatomy. In Gelatt KN,
trum antibiotics are used initially pending culture
editors: Veterinary ophthalmology, ed 3, Philadel-
and susceptibility of the affected area, and tetanus
phia, 1999, Lippincott, Williams & Wilki ns.
prophylaxis should be given. Appropriate antibi-
5. Cooley PL: Normal equine ocular anatomy and eye
otics are continued for 7 days. Nonsteroidal anti-
exami nation, Vet Clill N Am Equine Pract 8:427,
inflammatory therapy is necessary for a minimum
1992.
of 3 days.
6. Moore CP, Constantinescu GM: Surgery of the
other: Cold compresses should be applied post-
adnexa, Vet c/in N Am Small Allim Pract 27: J0 I J,
operatively to combat inflammation and edema.
1997.
Protedion: Protective eye cups are recom-
2 7. Miller TR: Eyelids. In Auer lA, Stick JA, editors: Equine
mended to prevent self-trauma. ,3
surgery, ed 2, Philadelp hia, 1999, WB Saunders.
CHAPTER 30
Enucleation-Transconjunctival and Transpalpebral
Laurence E. Galle

INDICATIONS PREPARATION AND POSITIONING

Enucleation is indicated when there is minilnaJ or The patient should be placed in lateral recum-
no chance for maintenance of vision and when bency under general anesthesia with the affected
leaving the globe would result in continued eye up.
patient discomfort or leave the patient at risk of
systemic complications. Common indicatio ns
for enucleation include ruptured globes, intraoc- ANATOMY
ular neoplasia, panophthalmitis, and chronic
uveitis or glaucoma. 1,2 It is imperative that the Unlike carnivores, the equine globe is positioned
surgeon consider aU alternatives that might within a completely enclosed bony orbit ( Figure
otherwise retain a comfortable, visual eye prior 30-1 ). Extraocular muscles, vascular supply, fat,
to performing an enucleation. The tran5- fascia, and the optic nerve form the orbital cone
conju nctival approach is preferred for optimal as they co nverge to the posterior aspect of the
cosmesis and minimal need for hemostasis. The orbit. The orbital cone is completely enclosed
transpalpebral approach, with use of a complete within a con nective tissue fascial sheath called
tarsorrhaphy prior to enucleation, is indicated for Tenon's fascia, which merges anteriorly with the
co ntaminated or infectious ocular disorders sclera adjacent to the limbus. The conjunctiva is
where reducing the potential of contaminating firmly attached to the limbus, becomes more
th e orbit with conjunctival microbial flora is elastic and loosely attached as it forms the con-
desired. 3 junctival fornix, a nd reflects onto the posterior
surface of the eyelids where it again becomes
firmly attached at the eyelid margin. The fibrous
tarsal plate of the eyelids is continuous with dense
connective tissue called the orbital septum that
inserts on the orbital rim. 4,5
EQUIPMENT
PROCEDURE
A general surgical pack is appropriate for an en u-
cleation. Additional instrumentation that may
Transconjunctival Enucleation
prove valuable includes suction, electrocautery,
Steven's tenotomy scissors, and Bishop-Harmon A lateral canthotomy is performed with Metzen-
tissue forceps. baum scissors to facilitate exposure of the globe.

170
Enucleation-Trans(onjunctival and Transpalpebral 171

Zygomatic process of
Infratrochlear notch Zygomatic process of
frontal bone
temporal bone
Caudal lacrimal process .,.-
Fossa of lacrimal sac

Z
/

<
I
I
r

• Caudal alar foramen

Temporal process
of zygomatic bone

Figure 30-1 Schematic demonstrating the horse's bony orbi t.

Usi ng delicate toothed forceps, such as Bishop- globe, the optic nerve is isolated and clamped
Harmon tissue forceps. the conjunctiva is gently approximately 4 to 5 mm caudal to the sclera.
grasped adjacent to the limbus and tented, and the Using curved Metzenbaum scissors or enuclea-
conjunctiva is snipped approximately 2 mm from tion scissors, the optic nerve is transected
the limbus with Steven's tenotomy scissors to between th e sclera and the clamp to leave approx-
create an incision. A peritomy (360° conjunctival im atel y 2 to 3 mill of optic nerve attached to the
incision adjacent to the limbus ) is performed enucleated globe. The conjunctiva, third eyelid,
using blunt and sharp dissection with Steven's and third eyelid gland are removed using Met-
tenotomy scisso rs, leaving approximately 2 mm of zenbaum scissors. The eyelid margins are excised
conjunctiva attached to the limbus for grasping fro m the eyelids approximately 4 mm from th e
with forceps for globe manipulation (Figure 30-2, eyelid margin using Mayo scissors. Hemostasis
A and B). The dense fibrous con nective tissue during removal of the conjunctiva and eyelid
attachment of Tenon's fascia is grasped and margins is provided with hemostatic clamps
incised with tenotomy scissors. Tenon's capsule is or electrocautery. The surgical site is closed in
incised near its insertion over its circumference, three layers. A si mple continuous pattern of No.
and the extraocular muscles and fascial attach- 3-0 absorbable suture is used to close the fascia
ments are transected at their insertions using and connective tissue attached to the orbital rim
curved Metzenbaum scissors o r curved Steven's in a manner to create a diaphragm to minimize
tenotomy scisso rs. Avoiding rostral traction of the concavity postoperatively. A simple continuous


172 OPHTHA LM IC SURGERIES

POSTOPERATIVE CARE

Postoperative Care
Protedion: A protective eyecup is used for 1
A week postoperatively to prevent self-trauma.
Medications: Nonsteroidal antiinflammatory
drugs may be used from 3 to 7 days to minimize
associated discomfort and edema.'
B Suture removal: Suture removal is recom~
mended in approximately 14 days.

COMPLICATIONS
c
Patients commonly exhibit significant periorbital
swelling and discomfort for 2 to 3 days postoper-
Figure 30-2 A and B. Schematic demonstrating a
peritomy. C, Schematic demonstrating Allis tissue atively. This can be minimized through appropri-
forceps clamped to the eyelid margins and attached skin ate intraoperative hemostasis and postoperative
to facilitate exposure during dissection for transpalpe- antiinflammatory therapy.) Orbital cysts or
bral enucleation. mucoceles may develop several weeks to months
postoperatively if the conjunctiva is not com-
pattern of No. 3-0 absorbable suture is placed pletely excised. Such cases require surgical explo-
in the subcutaneous tissues. The skin is closed ration and removal of remaining conj unctiva.
with No. 3-0 nylon in a simple interrupted Because the nasolacrimal duct is not ligated and
pattern. 3.6 is usually patent immediately postoperatively, it
is not uncommon to observe serosanguino us dis-
Transpalpebral Enucleation ch arge from the ipsilateral nares postoperatively.
This is not usually a complication but will often
A complete temporary tarsorrhaphy is performed worry an observant client who was not appro-
using No. 2-0 monofilament nylon in a simple priately informed of this possibility prior to
continuous pattern. An elliptical skin incision is discha rge.
made around the palpebral fissure using a scalpel,
leaving approximately 5 mm of skin attached to
the eyelid margin. Allis tissue forceps may be REFERENCES
clamped to the eyelid margins and attached skin
to facilitate exposure during dissection (Figure I. Michau TM, Gilger BC: Cosmetic globe surgery in
30-2, C). Blunt dissection should be used in a pos- the horse, Vet Ciin N Am Equine Pmct 20:467, 2004.
terior direction, being careful not to enter the con- 2. Brooks DE, Wolf D: Ocular trauma in the horse,
junctival cul-de-sacs. Ca udal to the conjunctival Eq"ille Vet] (Suppl ) 2:141,1983.
fornix, blunt dissection should be continued 3. Brooks DE: Orbit. In Auer JA, Stick JA, editors:
toward the sclera until the sclera is exposed. Equille surgery, ed 2, Philadelphia, 1999, WB
Extraocular muscle transection and optic nerve Sau nders.
4. Samuelso n D: Ophthalmic anatomy. In Gelatt KN.
transection should be performed as described in
editor: Veterinary ophthalmology, ed 3, Philadelphia,
the transconjunctival enucleation procedure.
1999, Lippincott, Williams & Wilkins.
Once the optic nerve has been transected, the 5. Cooley PL: Normal equine ocular anatomy and eye
globe and attached conjunctiva, third eyelid, and examinatjon, Vet Ciill N Am Equine Pmc! 8:427,
its gland are removed from the orbit. The surgical 1992.
site is closed in three layers as described for 6. Ramsey OT. Fox DB: Surgery of the orbit, Vet Clill
transconjunctival enucleation. 3,6 N Am Small Allim Pract 27: 1215, 1997 .


CHAPTER 31
Entropion
Laurence E. Galle

or No, 4-0 monofilament nylon or braided silk


INDICATIONS
suture are needed to place temporary tacking
sutures . In addition to these instruments, a No. 15
Equine entropion occurs most commonly in
Bard-Parker scalpel blade on a No, 10 scalpel
neonates secondary to dehydration, septicemia, or
handle and Steven's tenotomy scissors are needed
malnutrition. ]-4 Some breeds, however, may be
to perform a Hotz-Celsus blep haroplasty,
predisposed to congenital entropion or primary
anatomic entropion that is unrelated to systemic
illness. 5 Primary anatomic entropion and entro-
pion that occurs as a complication of system ic PREPARATION AND POSITIONING
illness are often exacerbated by pain and bleph-
arospasm, which results in spastic entropion. Tacking sutures are easily placed in sedated or
Regardless of the etiology, entropion in the anesthetized patients using appropriate local
neonate should be initially managed with tempo- anesthesia-akinesia. Anesthesia or sedation, how-
rary tacking sutures rather than a permanent sur- ever, is often contraindicated in patients with
gical procedure. The usefulness of such everting systemic illnesses that are frequently responsible
sutures is twofold. For spastic entropion, they for entropion, The eyelids of most debilitated
prevent corneal irritation and discomfort resul- neonates can be tacked with only local anesthesia
tant to cilia and hair of the eyelids contacting the and aki nesia, and this is often performed with the
corneal surface, thus breaking the cycle of corneal patients restrained in lateral recumbency. Hotz-
pain and blepharospasm. For secondary entro- Celsus blepharoplasty is also performed with the
pion, the sutures maintain a more normal patient in lateral recumbency with the affected eye
anatomic relationship of the cornea and eyelids upward, but this requires general anesthesia.
while the underlying illnesses are resolved, If
entropion persists after repeated tacking suture
procedures have failed. then a permanent method
ANATOMY
of correction, the Hotz-Celsus blepharoplasty
technique. may be necessary.4
The major layers of the eyelids, from external
to internal, are skin , orbicularis oculi muscle,
fibrous tarsal plate, and conjunctiva. The eyelids
EQUIPMENT are covered with hair to within 2 to 3 mm of the
eyelid margin, and well-developed cilia (eye-
Bishop- Harmon tissue forceps, Derf needle lashes) are on the upper eyelid6 ,' (see Figure
drivers, general operating scissors. and a No. 3-0 28-2),

173
174 OPH TH ALMIC SURGER I ES

B c

D
Figure 31-1 Schematic of Lembert sutures placed in Figure 31-2 Schematic of crescent-shaped skin
eyelid. being removed and "bisecting" method o f suture place-
ment to close Hotz-Celsus blepharoplasty.

3 1-2, A). One corner of the crescent is grasped


PROCEDURE
with Bishop-Harmon forceps, and the crescent of
skin and orbicularis oculi is excised sharply using
Temporary Eyelid Tacking
Steven's tenotomy scissors. Closure of the surgical
Simple interrupted Lembert sutures are placed to site should be with No. 4-0 monofi lament nylon
evert the affected eyelid margin. Lembert sutures or braided silk in a simple interrupted pattern. To
are placed in the eyelid skin such that the most ensure appro priate alignment of the curvil inear
distal portion of the suture is approximately 3 mm incisions, the fi rst suture should be placed in the
from the eyelid margin (Figure 31-1 ). The center of the incision, with subsequent sutures
number of Lembert sutures to be placed will vary placed such that they bisect the area remaining to
by the extent of entropion and the degree of be sutured (Figure 31-2, B to D ).
tension necessary to maintain eyelid eversion, but
a minimum of two or three Lembert sutures
should be placed. POSTOPERATIVE CARE

Hotz-Celsus Blepharoplasty Postoperative Care

The length of affected eyelid margin and amou nt Protedion: A protective eye cup is recom-
mended for either surgical procedure until sutures
of inward rolling are estimated before the patient
are removed to prevent rubbing of the surgical
is anesthetized or local anesthesia is injected. Hair site.
should be clipped and the surgical site prepared Suture Removal: Tacking sutures should be left
for aseptic surgery. The surgeon removes a cres- in place for 7 to 10 days but may "cut through"
cent-shaped strip of skin and underlying orbicu- the skin prior to this time. Hotz-eelsus blepharo-
lar is oculi muscle of the approximate shape and plasty sutures should be removed in 14 days.
size of the area affected by entropion. s An incision
is made through skin and underlying orbicularis
oculi muscle 3 mm from, and parallel to, the COMPLICATIONS
affected eyelid margin, using a No. 15 scalpel
blade. A curvilinear incision is made proximal to, Care should be taken to prevent stiff suture ends
and parallel to, the first incision, joining the ends of monofilament nylon from making contact with
of the two incisions to create a crescent (Figure the cornea as such contact will cause corneal
Entropion 175

irritation and may precipitate corneal ulceration. 2. Koch S, Cowles R, Schmidt G: Ocular disease in the
Overcorrection of entropion by removing too newborn horse: a preliminary report. } Equine 511rg
much tissu e may result in ectropion and exposure 2: 167, 1978.
keratitis. Therefore, the surgeon should err on the 3. Gelatt KN: Congenital and acquired ophthalmic
disease in the foal, Anim Eye Res 1-2: 15, 1993.
side of removing less tissue if any doubt exists as
4. Turner AG: Ocular conditions of neonatal foals, Vet
to the amount of tissue to be removed. Client edu-
Clill N Am Equine Pract 20:429, 2004.
cation about the potential of overcorrectio n or the 5. Munroe G, Barnett K: Congenital ocu lar disease in
need for a second Hotz-Celsus procedure if the foal, Vet Clin N Am Large Anim Pmct 62:519,
undercorrected is imperative. 1984.
6. Cooley PL: Normal equine ocula r anatomy and
eye examination , Vet Clin N Am Equille Pmct 8:427,
1992.
REFERENCES 7. Samuelson D: Oph thalmic anatomy. In: Ge1att KN,
editor: Veterinary opllthalmology, ed 3, Philadelphia,
1. Latimer C, Wyman M, Hamilton J: An ophthalmic 1999, Lippincott, Williams & Wilkins.
survey of the neonatal ho rse, Equine Vet J (Suppl) 8. Moore CP, Constantinescu GM: Surgery of the ad-
2:9, 1983. nexa, Vet Clin N Am S1IIall Anim Pmct 27:101 1,1997.
CHAPTER 32
Nerve Blocks for Ophthalmic Procedures: Lacrimal, Zygomatic,
Infratrochlear, Palpebral, and Supraorbital Nerve Blocks
Laurence E. Galle

INDICATIONS ANATOMY

The indications for the lacrimal, zygomatic. and The lacrimal, zygomatic, infratrochlear, and
infratrochlear nerve blocks are to provide local frontal nerves provide sensory innervation to the
anesthesia to the dorsolateral, ventrolateral, and eyelids of the horse. The lacrimal nerve innerva tes
ventromedial eyelids. These sensory nerve blocks the dorsolateral third of the eyelid, the zygomatic
are primarily used for minor diagnostic or thera- nerve innervates the ventrolateral eyelid, the
peutic procedures such as sub palpebral lavage infratrochlear nerve innervates the medial can-
tube placement, conjunctival biopsy, or eyelid lac- thus and ventromedial aspect of the eyelids,
eration repair. These blocks do not provide aki- and the frontal nerve innervates the dorsomedial
nesia of the eyelids. [· 3 two thirds of the eyelids (Figure 32- 1). The zygo-
The supraorbital nerve block provides sensory matic nerve is a branch of the maxillary branch
anesthesia of the dorsomedial two thirds of the of the trigeminal nerve (CN V), whereas the
eyelid to facilitate examination or minor surgical lacrimal, infra trochlear, and frontal nerves are
procedures. This block does not provide akinesia branches of the ophthalmic branch of the trigem-
of the eyelids.'-3 inal nerve. 1.4 The lacrimal, zygomatic, and
The palpebral nerve block is used to provide infra trochlear nerves exit the orbit from beneath
eyelid akinesia for ophthalmic examination and to the orbital rim adjacent to the areas they inner-
facilitate diagnostic or minor surgical procedures. vate, whereas the frontal nerve exits the orbit with
It does not, however, provide sensory anesthesia the frontal artery and vein through the supraor-
of the eyelids.1-3 bital foramen of the supraorbital process of the
frontal bone.
The palpebral nerve is a bran ch of the auricu-
EQUIPMENT lopalpebral branch of the fac ial nerve (CN VII)
and innervates the orbicularis oculi muscle. The
A 5-mL syringe, 'Is-inch 25-ga uge needle, and 2% palpebral nerve is most easily palpated as it crosses
lidocaine. the dorsal border of the zygomatic arch' (Figure
32-2) .

PREPARATION AND POSITIONING PROCEDURE

These procedures may be performed in restrained The lacrimal nerve block is performed by palpat-
patients but are facilitated by sedation. ing the dorsolateral orbital rim_ Using a 25-gauge

176
Nerve Blocks for Ophthalmic Procedures 177

needle, inject 3 to 5 mL of 2% lidocaine along the


lateral third of the orbital rim. The zygomatic
nerve block is performed in the same manner, but
n. along the ventrolateral third of the orbital rim.
The infratrochlear nerve is blocked by injecting 2
to 3 mL of 2% lidocaine over a notch palpated
Infra-
along the ventromedial aspect of the orbital

trochlear n. nm.
The supraorbital foramen is located by grasp-
ing the rostral and caudal borders of the supraor-
bital process of the frontal bone usi ng the thumb
and middle fingers. Moving the thumb and
middle finger medially as the process widens, the
index finger is used to palpate the depression of
the supraorbital foramen approximately hal fway
Figure 32-1 Schematic demonstrating innervation between the middle finger and thumb. A 25-gauge
of the eyelids by the lacrimal, zygomatic, frontal and needle is passed subcutaneously to the opening of
infratrochlear nerves. the supraorbital foramen or into the supraorbi-

Figure 32-2 Schematic demonstrating palpebral nerve anatomy in relati onship to the zygomatic arch and orbital
rim. F, Frontal; J, infra trochlear; L, lacrimal; Z, zygomatic.

=
178 OPHTHALMIC SURGERIES

tal foramen and 2 to 3 mL of 2% lidocaine are needle within the foramen in fractious patients.
injected. l Surgical exploration to remove the needle is nec-
The palpebral nerve is located by palpation essary if this latter complication occurs.
along the dorsal aspect of the zygomatic arch with
the index finger. A 25-gauge needle is inserted
through the skin adj acent to the nerve as it crosses REFERENCES
the zygomatic arch, and 1 to 5 mL of 2% lidocaine
are injected subcutaneously. The injection si te 1. Strubbe DT. Gelatt KN: Ophthalmic examination
should be gently massaged for 2 to 3 minutes. and diagnostic procedures. In Gelatt KN. editor: Vet-
Resulting eyelid akinesia may last 45 minutes to 1 erinary ophthalmology, ed 3, Philadelphia, 1999, Lip-
hour. I pincott, Williams & Wilkins .
2. Cooley PL: Normal equine ocular anatomy and eye
examination, Vet Clill N Am Equine Pract 8:427,
1992.
COMPLICATIONS 3. Carastro SM: Equine ocular anatomy and oph-
thalmic examination, Vet Clill N AII1 Equine Pract
Inserting the needle directly into the suprao rbital 20:285, 2004.
foramen for frontal nerve block is preferred 4. Samuelson D: Ophthalmic anatomy. In Gelatt KN.
by some clinicians but has the potential hazards editor: Veterinary ophthalmology, ed 3, Philadelphia,
of intravascular injection and breaking off the 1999, Lippincott, Williams & Wilkins.
• . I,~
1
••

CHAPTER 33
Temporary Tarsorrhaphy
Laurence E. Galle

eyelids are composed of skin) muscle, a fibrous


INDICATIONS
tarsal plate, and conjunctiva from the external to
internal su rfaces. The meibomian gla nds are
A temporary tarsorrhaphy is performed to pro-
buried within the distal end of the fibrous con-
vide temporary decreased exposure of the globe,
nective tissue tarsal plate wi th o penings in the
protection of the cornea, or both. ]-3 It is most
eyelid margin. Well-developed cilia (eyelashes) are
often used to protect an ulcerated cornea but may
on the upper eyelid 6 (see Figure 28-2).
also be used to maximize eyelid closure when
excessive corneal exposure is likely (e.g., facial
nerve [eN VII] paralysis- paresis).'"
PROCEDURE

The skin of the dorsal eyelid is grasped with


EQUIPMENT forceps, and a simple horizontal mattress suture
of No. 2-0 or No. 3-0 monofilament nylon is
Derf needle drivers, Bishop-Harmon ophthalmic placed using a curved cutti ng needle. The suture
forceps, and general operating scisso rs are neces- pattern is sta rted 5 mOl from the dorsal eyelid
sary for this procedure. margin, and the needle shouJd be inserted down
to, but not through, the fibrous tarsal plate. The
needle should be advanced such that it exits the
PREPARATION AND POSITIONING eyelid margin slightly anterior to the meibomian
gland orifices. The horizontal mattress su ture
This procedure is most easily performed using crosses the palpebral fissure, is inserted into the
general anesthesia with the patient in lateral ventral eyelid margin slightly anterior to the mei-
recumbency. It can be performed, however, in a bomian gla nd orifices, and sho uld exit the eyelid
standing patient with heavy sedation and appro- skin approximately 5 mm from the eyelid. This
priate nerve blocks to obtain eyelid akinesia and completes half of the mattress sut ure. The hori-
sensory a nesthesia. zonta l mattress suture is completed by placing the
suture from the ventral to dorsal eyelid using the
same depth of Suture placement as in the first half
ANATOMY of the suture placement. The number and spacing
of the hori zontal mattress sutures are determined
A thorough understand in g of eyelid anatomy is by the surgeon. 7.S Stents m ay be used to minimize
imperative for appropriate suture placement in a cutting of the suture into the eyelid. 8 The eyelids
temporary tarsorrhaphy. The major layers of the may be completely closed with this technique, or

179
180 OPHTH ALMIC SURGERIES

only a portion of the palpebral fi ssure may be cornea. Either situation predisposes the patient to
dosed to cover a localized lesion. In either case, corneal ulceration, an d such sutures should be
the sutures are tempora ry. removed or replaced immediately. As noted for
postoperative care, the palpebral fissure may
begin to "gap" as early as 7 days postoperatively;
POSTOPERATIVE CARE tarsorrhaphies that are "gapped" should be
removed or replaced to prevent ulceration.

Postoperative Care
Protedion and Cleaning: The eye should be REFERENCES
covered with a protective eye cup to prevent
rubbing. The cup should be cleaned daily, and the 1. Mille r TR: Principles of therapeutics, Vet Clin N Am
tarsorrhaphy should be inspected for potential Equine 8:479,1992.
complications. 2. And rew SE, Brooks DE, Biros D1, et al: Posterior
Suture Removal: The palpebral fissure will lamellar keratoplasty for treatment of deep stromal
begin to "gap" open to expose the sutures, usually abscesses in nine ho rses, Vet Ophthalmol 3:99, 2000.
in 7 to 10 days. This exposed suture may rub the 3. Brooks DE: Equin e ophth alm ology. In Gelatt KN,
cornea and could lead to corneal ulceration. The ed itor: Veterirlary ophthalmology, ed 3, Philadelphia,
sutures should be removed or replaced when 1999, Lippincott , Williams & Wilkins.
gapping begins to occur. 4. Slatter D, Hanson S, deLahunta A: Neurooph-
tha lmology. In Slatter D, edi tor: Fundamelltals of
veterinary ophthalmology, ed 3, Philadelphia, 2001,
WB Sa unders.
COMPLICATIONS 5. Millicha mp N1: Ocular trauma, Vet Clin N Am
Equine 8:52 1, 1992.
6. Samuelson D: Ophthalmic anatomy. In Gelati KN.
If the mattress sutures are placed too shallow
ed itor: Veterinary ophthalmology. ed 3. Philadelphia.
withi n the eyelid or exit too far an terior to the
1999, Lippincott. Will iams & Wilkins.
m eibomian glands, the inverting nature of the 7. Slatter D: Principles of ophthalmic surgery. In Slatter
suture pattern may ca use the eyelid margins to D, ed ito r: FUrldamentafs of veterillary oplltllalll1 ology,
rub the cornea (i.e., entropion). If the sutures are ed 3, Philadelphia, 2001, WB Saunders.
placed too deep (e.g., thro ugh the conjunctival 8. Miller TR: Eyelids. In Auer 1. Stick J, editors: Equine
surface), the suture material may contact the surgery, ed 2. Philadelphia, 1999, WB Saunde rs.
ALE ROGENITAL
URGERIES

181
CHAPTER 35
Cryptorchid Castration
Joanne Kramer

proper liga ment, the ligament of the tail of the


INDICATIONS
epididymis, and the scrotal ligament (inguinal
extension of the gubernaculum ).1 Cryptorchid
Cryptorchid castration is performed to prevent
surgery is based on the identification of one or
breeding and to modify behavior.
more of these structures and the use of these
structures to locate the retained testicle.
The retained testicle may be within the
EQUIPMENT inguinal ca nal or within the abdomen. Complete
abdominal cryptorchids have the epididymis and
Emasculators are used to crush and sever the testicle with in the abdomen. Incomplete or partial
spermatic cord. White's modified, Serra, and abdominal cryptorchids have the tail of the epi-
Reimer emasculators are commonly used. All ca n didymis within the inguinal canal and the testes
be used effectively; we commonl y use Serra emas- within the abdomen (Figure 35-1). Fo r complete
culators. Sponge forceps can be used to evert the or incomplete abdominal cryptorchids. the prox-
vaginal process. imity of the testicle to the vaginal ri ng varies
depending on the length of the liga ment of the tail
of the epididymis and proper ligament.
POSITIONING AND PREPARATION

Cryptorchid castration is performed with the horse PROCEDURE


in dorsal recumbency under general anesthesia.
The cryptorchid testicle is removed first. A IO-cm
skin incision is made over the superficial inguinal
ANATOMY ring (Figure 35-2). Electrocautery is used if nec-
essary to control subcutaneous bleeding. The
Normal testicular descent involves enlargement depth of the incision is extended by palpating the
and then regression of the gubernaculum, a mes- deep inguinal ring through the subcutaneous
enchymal condensation with in the genital fold tissues and inguinal canal with the index finger of
conn ected to the developing testes. This enla rge- both hands and then spreading the tissues in one
ment of the gubernaculum extends through the layer. Dissecting bluntly is important because of
vaginal ring and inguinal canal and is invaded by the superficial caudal epigas tric vessels that lie
an extension of peritoneal lining forming the lateral to the incision. Dissecting the deeper
vaginal process. During the process of testicular tissues in one layer keeps the surgical field simpler
descent, the gubernaculum differentiates into the and makes it easier to identify the inguinal exten-

196
Cryptorchid Castration 197

A B c >
Figure 35~1 Th ree differen t positions of a retained testicle (cryptorch idism). A. Inguinal retention within the
inguin al canal. B. Incomplete or partial abdominal retention. C. Complete abdominal retention.

Superficial iguinal

>

Figure 35-2 Location of the superficial ingu inal


ring. Straigh t dotted line indicates the cranial border of
Figure 35-4 The inguinal extension of the guber-
the pubis.
naculum (small arrow) has been used to locate the
vaginal process (large arrow) in a cryptorchid.

-
abdominal cryptorchids will have only th e epi-
didymis prese nt in the vaginal tuni c, and with
gentle traction and occasional enlargement of
the vaginal ring, the testicle can be found and
Figure 35-3 Schematic view of the inguinal exten - removed. It is important that the descended tail of
sion of the gubernaculum. the epididymis not be mistaken for a small testi-
cle and removed without removal of the abdom-
inal testicle (Figu res 35-6 and 35-7).
sio n of the gubernaculum or the vaginal process
(Figures 35-3 and 35-4).
Noninvasive Inguinal Approach
[f the testicle is inguinal, it will be identified at
th is point and can be removed using emasculation If the testicle is abdominal, the cranial medial
(Figure 35-5). The vaginal tunic should be opened aspect of the superficial inguinal rin g is searched
to confirm the presence of a testicle. Incomplete for the inguinal extension of the gubernaculwn
198 MALE UROGEN ITAL SURGERIES

A Figure 35-6 The taiJ of the epididymis exposed in an


incomplete abdomi nal crypto rchid .

B
Figure 35-5 A, First view of an inguinal testicle
(arrow). B, An ingu in al t.esticle after exterio rization
Figure 35-7 Afte r iden tifi cation of the tail of the
(arrow).
epididymis in Figu re 35-6, traction on a long proper
ligament resu lted in exteriorizatio n of the abdomi nal
testicle.

(scrotal ligament).2 The ingui nal extension of the


gubernaculum is palpable as a fi brous band such if the inguinal exten sion of the gubern acu lum
tha t when tension is placed on it, it ca n be is not located, the vaginal process can often be
obse rved to descend into the inguinal ca nal. The fo un d by palpat ing a thin co rd like structure in the
size of the inguinal extension of the gubernacu- dep ression of the deep in gu inal ring and by plac ing
lum varies but is generally less than 1 cm. Light a curved sponge forceps in the deep inguin al ri ng
traction on the inguinal extension of the guber- and carefully everting the vagina l process M (Figure
naculum and blunt dissection to loosen tissue 35-8) . Openin g the vaginal process reveals the lig-
aro und the structure in th e inguinal ca nal res ult ament of the tail o f the epididym is, which ca n be
in exposure of the vaginal process (see Figures 35- used to find the epididymis and testicle. In so me
3 and 35-4). The vaginal process is then incised, cases the vaginal rin g must be enla rged to all ow
and the epididymis or liga ment of the tai l of the the testes to be exteriorized. This can be done
epididymis is used to retr ieve the testicle from the manually with a finger or with Metzenbaum

abdomen. SCissors.
Cryptorchid Castration 199

The testicle is removed by emasculation or lig-


ation and transection. Some testicles will not be
able to be exteriorized sufficiently to effectively
apply emasculators and will require ligation. If the
vaginal ring has been opened or is wider than one
process finger width) the superficial inguinal ring should
be closed with No.2 or 3 synthetic absorbable
suture material in an interrupted pattern. Further
of the tait
closure of the subcutaneous tissues and skin is
;$f epididymis
optionaL
~roper fig. of the
tail of the epididymis
Modified Parainguinal Approach
This approach can be used when the location of
. (i"t the testicle is known to be abdominal or when the
<'!'
, Y ' f-: .&-
:J • .o::-_,..... v~·tk'lo>-- noninvasive method has been attempted but the
Figure 35-8 Schematic view of eversion of the vaginal process not located. 5 A lO-cm skin inci-
vaginal ring with sponge forceps sio n is made 2 cm parallel to the medial border of
the superficial inguinal ring beginning 3 to 4 cm
cranial to the cranial extent of the ring (Figure 35-
9, A). A 4-cm incision is made into the aponeu-

Lig. of the tail of

Tail of epididymis

Proper lig. of testis

B
Figure 35-9 Modified para inguinal approach for removing an abdominal testicle. A, Tncision in the aponeurosis
of the external abdominal oblique. B, Schematic view of sweeping the deep inguinal ring for testicular attachments.
C, Closure of the aponeurosis of the external abdominal oblique.
200 MALE U ROGENITAL SURGER IES

rosis of the external abdominal oblique muscle.


EXP~CTED OUTCOME
Th is incision should be 1 to 2 cm medial to the
superficial inguinal ring and centered over the
Cryptorchid castrations vary in the diffic ulty and
cranial aspect of the ring. The index and middle
time required to perform. In general, the time
fi nger are inserted through this incision and
requi red or level of difficulty cannot be pre-
bluntly thro ugh the internal abdominal oblique,
dicted preoperatively. Many inguinal cryptorchids
transverse fascia, and peritoneum and into the
requi re li ttle more than routine castrations. Some
peritoneal cavity. The area of the deep inguinal
abdomi nal cryptorchids require significant time,
ring is swept with the finger for either the epi-
careful exploration, and closure. Best results come
didymis, ductus deferens, proper ligament, or lig-
when the surgeon is prepared fo r either situat ion.
ament of the ta il of the epididymis (Figure 35-9,
B). Once one of these attachments is exteriorized,
traction is used to exteriori ze the testicle fro m the
abdomen. The testicle is removed by emasculation COMPLICATIONS
or ligation and transection.
The aponeurosis of the external abdominal Complications are similar to those discussed for
oblique muscle is closed with No. 2 or 3 synthetic routine castration. When invasive procedures are
absorbable suture material (Figu re 35-9, C). The necessary, the risk of incisional problems and
skin and subcutaneous tissue are closed with No. eventration is greater than for routine castration.
2-0 absorbable synthetic suture material. Addit ionally, if significant tissue trauma and
manipulation occur during explorat ion fo r
abdominal testicles, adhesion formation near the
ingu inal ring may cause colic. Using non invasive
approaches when possible and entering the
POSTOPERATIVE CARE
abdo men through approaches that can be closed
di rectly (e.g., the modified parainguinal incisio n)
decrease the risk of incisional complica tions and
eventration. Rarely, greatly enlarged testicles, ter-
atomas, or cystic testicles are identi fi ed and
Postoperative Care require removal through an enlarged incision.
Monorchidism is rare but possible. If a
Exercise Reslridions: All horses should be stall retained testicle is not identified after a thorough
rested for 24 hours. Further restriction of activity
search, two options are ava ilable. The horse can
depends on the approach used and the antici-
pated incisional healing. Horses that undergo a be referred for further surgery, preferably
noninvasive approach with minimal dilation of the laparoscopy, or the descended testicle can be
vaginal ring can be allowed turnout after the initial removed and hormonal testing carried out to
24 hours of stall rest and can return to use in 2 confirm the absence of testicular tissue.
weeks. When the superficial ring has been closed,
horses should have stall rest for 24 hours followed
by 1 week of handwalking and 2 weeks of small- ALTERNATIVE PROCEDURES
paddock turnout. When the abdomen has been
entered through a limited parainguinal approach,
horses should have stall rest for 24 hours followed Alternati ve procedures for removing cryptorchid
by 3 weeks of small-paddock turnout. testicles include invasive inguinal, suprapubic
Medications: Horses should receive a tetanus paramedian, and flank approaches. The invas ive
toxoid booster if it has been longer than 6 months ingu inal approach involves entering the abdomen
since the previous vaccination. Phenylbutazone th rough the inguinal canal. This procedure ca n
(4.4 mg/kg BID) therapy is provided for 24 hours. extensively disrupt the deep inguinal ring and
Antibiotic therapy is case dependent but typically vaginal ri ng, which cannot be closed directl y.
is given only perioperatively. Therefore, the authors prefer the parainguinal
other: Recently gelded horses should be isolated approach to the invasive inguinal approach.
from mares for a minimum of 2 days and prefer- Suprapubic paramedian laparotomy has been well
ably up to 1 week after castration.
described and is preferred by some authors.6.7


Cryptorchfd Cdstration 20 J

With the exception of laparoscopic approaches, of the ductus deferens entering the canal indicates
cryptorchid castration is not routinely performed the horse is an incomplete abdom inal cryp-
through a flank approach. torchid, is an inguinal crypto rchid, or has a
Laparoscopy is a safe and effective way to iden- descended scrotal testicle. 4 Decision to perform
tify and remove abdominal cryptorchid testicles. diagnostic rectal examination is based on the size
Advantages include performing the procedure and temperament of the horse and the anticipated
through small incisions with secu re closure, ease surgical approach. Bilateral cryptorchidism occurs
of locating the testicle, and the ability to examine in up to 15% of cryptorchid horses. These cases
both sides of the abdomen when the side of the may have inguinal, incomplete abdominal, or
retained testicle is unknown. Disadvantages abdominal retenti on .9
include expense of the equipment and the need to
learn a specialized technique.
REFERENCES

I. Dyce KM, Sack WO, Wens ing C1G: The urogenital


COMMENTS apparatus. In Dyce KM, Sack WO, Wensing CJG,
editors: Textbook of veterillary allatomy, Philadel-
Geldi ngs that present with stallion-like behavior phia, 2002, WB Sau nders.
should have serum testosterone measurements 2. Valdez H, Taylor TS, McLaughlin SA, Martin TM:
before and 30 to 120 minutes after the adminis- Abdom inal crypto rchidectomy in the horse using
tration of at least 6000 IV human chorionic inguinal extensio n of the gubernaculum testis,] Am
gonadotropi n (HCG) intravenously to determine Vet Med Assac 174: litO, 1979.
if testicular tissue is present. Geldings have serum 3. Adams OR: An improved method of diagnosis and
testosterone levels of less than 40 pglml. Cryp- castration of cryptorchid horses, ] Am Vet Med
torchids have serum concentrations of greater Assac 145:439, 1964.
4. Adams SB, Fessler IF: Noninvasive inguinal cry p-
than 100 pg/mL' Horses younger than 18 months
to rchidectomy. In Adams S8, Fessler JF, editors:
or horses tested during winter may respond
Atlas of eqlline surgery, Philadelphia, 2000, WB
poorly to HCG and may need to have an addi- Sau nders.
tional sample tested 24 hours after HCG admin- 5. Wilson OG, Reinertson EL: A modified parain-
istration or be retested when older or during the guinal approach fo r cryptorch idectomy in horses.
spring.9 Previous surgical exploration often makes An eva luation in 107 horses, Vet 5urg 16:1, 1987.
identification of surgical landmarks difficult, and 6. Bladon B: Surgical management of cryptorchidism
whe n the side of cryptorchidism is not known, in the horse, In Practice 24: 126, 2002.
surgery can be prolonged. In these situations, 7. Cox J: A surgica l approach to the cryptorch id
laparoscopic exploration of the abdomen is the horse, III Practice 10:11, 1988.
8. COX JE: Cryptorchid castration . In McKinnon AO,
recommended approach.
Voss lL, editors: Equine reproductioll, Philadelphia,
Left cryptorchid testicles are more likely to be
1993, Lea & Febiger.
abdominal, whereas right cryptorchid testicles are 9. Mueller EPO: Cryp torchidism. In Wolfe OF, Moll
more likely to be inguinal.!O Rectal examination of DH, editors: Large animal Ilrogellital surgery.
the inguinal region may also be useful in deter- Philadelphia, 1999, Williams & Wilkins.
mining the location of the testicle. Horses with 10. Stickle RL, Fessler JF: Retrospective study of 350
abdominal testicles will have a small or indis- cases of equi ne cryptorchidism,] Am Vet Med Assoc
cernible inguinal rin g. A larger ring with evidence 172:343, 1978.
CHAPTER 36
Circumcision
Joanne Kramer

performed when lesions are located anywhere


INDICATIONS
from the internal lamina of the external fold to th e
inner lamina of the preputial fold.
Circumcision is ind icated for removal of neoplas-
tic tiss ue, granulomas. or other masses from the
sheath (Figure 36- 1), It is also indicated for
PROCEDURE
removal of preputial scar tissue that prevents
penile retraction or extension.
Two parallel circum fere ntial incisio ns are made
around the prepuce proximal and distal to the
affected region (Figure 36-3), A plane of dissec-
EQUIPMENT tion is established deeper than the affected tissue
but superficial to the deep fascia of the penis, The
A tourniquet is optional. enti re region between the circumferential inci-
sions is undermined and removed by creating a
longitudinal incisio n between the circumferential
POSITIONING AND PREPARATION incisions (Fig ure 36-4). Subcutaneous vessels m ay
require ligation. If a tourniquet has been used, it
The horse is positioned in dorsal recumbency
under general anesthesia. The penis is exte nded,
and th e prepuce and shaft of penis a re prepared
for aseptic surgery.

ANATOMY

The prepuce has two infoldings, which allow for


retraction of the penis into the preputial cavity.
The first of these infoldings is the external fold of
the prepuce consisting of the external lamina,
preputial ostium, and internal lamina. The
seco nd infolding is the preputial fold consisting
of the outer lamina of the preputial fold, the Figure 36-1 Squamous cell carcino ma involving the
preputial ring, and the inner lamina of the prepuce. Th is lesion was removed successfully by
, , ,
preputial fold (Figure 36-2), Circumcision can be Ci rcumCISion.

202
¥ • " oJ

Circumcision 203

ring Outer

Urethral

Fossa glandis

Preputial
fold
Outer
Preputial lamina
ostium
lamina B
Preputial
ring

preputiallam~i~n~a----- - - -- -- - - - - - - - -
External preputial lamina

Figure 36-2 A, External aspect of the penis and prepuce. S, Median section through the penis inside of the prepuce.

Figure 36-3 Circumferential incisions lIsed for removal of a lesion invo lving the prepuce.
204 MA LE U ROGEN ITAL SURGER IES

Figure 16~4 Intraoperative view before a longitud i-


Figure 36~6 In traoperative view after closure during
nal incision (dotted IiI/e) is crea ted between the hori-
a ci rcu mcisio n procedure.
zontal incisions to complete the removal of a squamous
cell carcino ma les ion du ring ci rcumcision.

POSTOPERATIVE CARE

Postoperative Care
Exercise Restridions: Exercise is limited to
handwalking or small-paddock turnout for 2
weeks. Light daily exercise is important to mini-
mize edema formation. Stallions should be iso-
lated from rna res for 3 to 4 weeks.
Medications: Phenylbutazone is administered at
4.4 mg/kg BID for the initial 24 hours and 2.2
mg/kg BID for an additional 3 days. Antibiotic
therapy is given preoperatively and for 3 to 5 days
Figure 36-5 Multiple-layer closu re after ci rcumci- postoperatively. Horses should receive a tetanus
.
slon. toxoid booster if it has been longer than 6 months
since the previous vaccination.
should be rel eased at th is point and the area Suture Removal: Sutures used are absorbable
checked carefully before closure. Sim ple superfi- but can be removed 12 days postoperatively.
cial resecti ons can be closed in one layer wi th an
interru pted pattern that apposes the remain ing
epithelium . Resection of larger amo unts of
prepuce o r resection s with greater depth need to EXPECTED OUTCOME
be closed in layers usin g short runs of continuous
suture patterns with absorbable suture in the The most co mmon reaso n fo r circumcision is
deeper layers and an interrup ted pattern in the removal of squamous ceU ca rcin oma lesions
epithelium ' (Figures 36-5 and 36-6). Care should invo lvin g the prep uce. If th e extent of neoplasia is
be taken to maintain alignment during closure. limited and confined to the preputial tissues and
Circumcision 205

wide surgical margins are taken, the prognosis for injection in a limited number of cases and has had
survival without recu rrence appears to be good.2 good reported success. 4 •S

COMPLICATIONS REFERENCES

Edema commonly develops and generall y resolves 1. Allen DA: Conditions of the penis and prepuce. In
with time and low-grade exe rcise. Recurrence of Wolfe DF, Moll HD, edito rs: Large allimal urogenital
sq uamous cell carcinoma lesions is possi ble. surgery, Philadelphia, 1999. Williams & Wilkins.
Dehiscence of the incision ca n be managed by 2. Mair TS, Walmsley JP, Phillips Tl: Surgical treatment
second-intenti on healing. but extensive dehis- of 45 horses affected by squamous cell carcinoma of
cence may cause stricture and require further the penis and prepuce, Equine Vet J 32:406, 2000.
3. Palmer SE: Use of lasers in urogenital su rge ry. In
resection.
Wolfe DF, Moll HO, editors: Large animal urogenital
surgery, Philadelphia, 1999, Williams & Wilki ns.
4. Fortier LA, MacHarg MA: Topical use of 5 fluo-
ALTERNATIVE PROCEDURES
rouracil for treatme nt of squamous cell carcinoma
of the external gen italia of horses: 11 cases, J Am Vet
Laser excisio n of neoplastic tissues of the prepuce Med Assoc 295: 1183, 1994.
has been described and has the advantages of 5. Theon AP. Pascoe JR, Meagher DM: Peri-operative
increased hemostasis and ablation of the underl y- intratumoral adm inistration of cisplatin for t reat-
ing tumor bed.) Surgical excision has been com- ment of cutaneous tumors in equids, J Am Vet Med
bi ned with topical 5-fluo rouracil and cisplatin Assoc 205: 1170, 1994.

==
CHAPTER 37
Penile Amputation
Joanne Kramer

nosum penis surrounded by the tunica albuginea


INDICATIONS
is the largest vasc ula r space. The primary blood
vessels (th e dorsal arteries and veins of the penis)
Neoplastic lesions (primarily squamous cell carci-
enco untered in penile amputation a re on the
noma) and other masses involving the shaft of the
dorsal aspect of the penis between th e deep fascia
penis (Figure 37-1), permanen t penile paralysis,
and the tunica albuginea. The veins on the dorsal
paraphimosis, or priapism.
aspect of the penis and the cross-sectional
anatomy of the penis are shown in Figu re 37-2.

EQUIPMENT
PROCEDURE
A tourniquet and urinary catheter are required for
this procedure. WilHam's technique is commonly used and is well
described. ! A triangular skin incision is made on

POSITIONING AND PREPARATION

The horse is positioned in dorsal recumbency


under general anesthesia. The penis is extended
and maintained in extension using gauze or
umbilical tape around th e glans. The penis,
prepuce, and caudal abdomen in the area where
the penis is extended should be prepared for
aseptic surgery. A urinary catheter is placed before
surgery to facilitate identification of the urethra
during surge ry.

ANATOMY

The urethra is located on the most ventral aspect


of the penis and palpable if a urinary ca theter has
been placed. The urethra is surrounded by the Figure 37~1 Extensive melanoma on the distal shaft
corpus spongiosum penis. The corpus caver- of the penis.

206
Penile Amputation 207

Internal
pudendal v.

Obturator

External
pudendal v. m.

Dorsal
A
Bulbospongiosus m.

v. of penis

Cranial v. of
Body of penis penis

\----4---
r------5 ------~·
B
r---------
6 -------+ c

~~~~~,... - - - Dorsal process of glans penis ----'

5
6
D

-«'{ P.->vot;.J:<c, . >

Figure 37-2 A, Anatomy of the penis with transverse sections that extend through the B, glans penis, C, cranial
penis, and D. caudal penis. 1, Retractor penis muscle; 2, bulbospongiosus muscle; 3, ureth ra; 4, corpus spongiosum
penis; 5, alb ugi nea; 6, co rpus cave rnosu m penis.

the ventral aspect of the penis proximal to the the lumen of the urethra (Figure 37·5) . The sides
intended site of amputation (Figures 37·3 and 37· of the urethra are sutured to the skin edges
4). The base of the triangle is distal and about 3 with a simple interrupted pattern using No. 2-0
em wide. The sides of the triangle are 4 to 5 em absorbable monofilament suture material (Figure
long. This incision is continu ed through the sub- 37-6). When the amputation is performed in the
cutaneous tissue. The skin and underlying tissues more proximal portions of the penis, it may be
are discarded. helpful to close the subcutaneous tissue to the
A longitudinal incision is mad e the length of tissue just deep to the urethral mucosa before
the tr ia ngle between the retractor penis muscles, closure of the mucosal epitheli um to the skin.
through the corpus spongiosum penis, and into Closure of this layer decreases tension on the ure-
208 MALE UROGEN ITAL SURGEIUES

Figure 37-6 The sides of the incised urethra are


sutured to the epithelium using an interrupted pattern.
Figure 37-3 Triangular skin incis ion used in
William's technique for amputation.

Figure 37-4 Intraoperative view of the triangular


~r; C.f "~
skin incision used in WilJiam's technique for amputa-
tion. Figure 37-7 The base of the penis is transected so that
the dorsal aspect is slightly longer than the ventral aspect.

Figure 37-5 A longitudinal incision is made into the Figure 37-8 The tunica albuginea is closed to com-
lumen of the urethra. press the corpus cavernosum.

thral mucosa) minimizes dead space) and helps cavernosum to compress the vascula r spaces using
control hemorrhage from the corpus spongio- a simple interrupted pattern with No. 0 or No.1
sum. When this layer is closed) a simple continu- absorbable suture (Figure 37-8). The fi rst suture
ous pattern with absorbable suture material is is placed on midline, and the subsequent sutures
used. bisect the halves (Figure 37-9). The sutures should
The penis is then transected at the base of th e be closely spaced. Generally) seven or eight sutures
tr ia ngle in an oblique manner so that the dorsal are used. Blood loss from the corpus cavernosum
aspect of the penis is slightly longer than the can be extensive) and this seal should be checked
ventral aspect (Figure 37-7). Branches of the carefully after release of the tourniquet.
dorsal artery and veins of the penis are ligated. The subcutaneous tissue deep to the skin is
The tunica albuginea is closed over the corpus closed to the tissue just deep to the urethral
Penile Amputation 209

Figure 17-10 Final ap pearance after performing


William's technique.

Figure 37-9 Intraoperative view of the initial suture


placed to close the corpus cavernosum.

mucosa in a simple continuous pattern with


absorbable suture material. The urethral mucosa
is then closed to the skin at the base of the trian-
gle in a simple interrupted or simple continuous
pattern using No. 2-0 monofilament absorbable
suture material (Figures 37-10 and 37-11).

POSTOPERATIVE CARE

Postoperative Care
Exercise Restrictions: Stall rest with handwalk- Figure 37-11 Intraoperative view of final appear-
ing should be provided for 10 days, followed by ance after performing William's technique.
small-area turnout for 10 days.
Medications: Phenylbutazone is administered at
4.4 mg/kg BID for the initial 24 hours and 2.2
mg/kg BID for an additional 3 days. Antibiotic Recurrence or metastasis of squamous cell carci-
therapy is given perioperatively and for 3 to 5 days noma is a significant problem, and owners should
postoperatively. Horses should receive a tetanus be forewarned of this . Reported survival rates for
toxoid booster if it has been longer than 6 months squamous cell carcinoma include a 60% to 71%
since the previous vaccination. survival rate of longer than 1 year. 2,3 Involvement
Suture Removal: Sutures are absorbable but of the urethra decreases the prognosis; one study
can be removed 12 days postoperatively. shows only a 30% IS-month survival rate when
Other: Amputation is not usually performed on urethral tissue was involved. 2
stallions because of potential incisional problems.
Ideally, stallions should be gelded several weeks
before surgery. If the procedure is performed on
a stallion, exposure to mares should be avoided
COMPLICATIONS
for 4 weeks. Artificial collection will be necessary
when breeding is resumed. Hemorrhage, dehiscence, urethral stricture,
minor swelling, and recurrence or metastasis of
neoplastic lesions are possible. Mild incisional
EXPECTED OUTCOME hemorrhage during urination may be common
during the first 2 to 3 days postoperatively.1.4 Per-
With appropriate hemostasis, complications sistent bleeding or hemorrhage that is dissecting
associated with the surgery are not common. into the incision line should be controlled surgi-
210 MALE UROGEN ITAL SURGERI ES

cally.4 Minor dehiscence of the sut ure line usuall y


COMMENTS
res ults in adequate healing by second intention.
More extensive dehiscence may result in urethral Amputation in the distal portion of the penis is
stri ct ure. Recurrence or metastasis of neoplastic
considerably less co mplicated than in the more
lesions carries a poo r prognosis and requires proximal portions. In the proximal portions, the
further surgery. diameter of the penis is larger and the redundant
tissue of the prepuce must be dealt with, which
increases surgical a nd anestheti c time. In cases of
ALTERNATIVE PROCEDURES squamous cell carcinoma, every attempt must be
made to assess the horse for evidence of metasta-
Alternative techniques for am putation have been sis and to identify small satellite lesions elsewhere
describ ed and include Scott's and Vinsot's tech- on the penis or prepuce. For horses with lesions
niques.l,s In Scott's technique, a full circumferen - too proximal to amputate or requiring preputial
tial incision is made at the intended site of ablation and ingu inal lymph node removal, more
resection. Dissection is carried down to but not involved proced ures have bee n described. 6•s
into the u rethra. Approximately 4 to 6 em of
urethra is freed distal to the site of peniJe ampu-
tatio n. This is the most difficult aspect of the REFERENCES
entire procedure, because the wall of the urethra
is intimately associated with th e corp us spo ngio- I. Schumacher J: The penis and prepuce. In Auer JA,
sum. The vascu lar spaces of the corpus caver- Stick JA, editors: Equille surgery, Philadelp hia, 1999,
nosu m are closed by apposing the tunica WB Sa unde rs.
albuginea with simple interrupted sutures using 2. Howarth S, Lucke VM, Pea rso n H: Squamous cell
No. 0 o r 1 absorbable suture material. The ure- ca rcinoma of the eq uine exte rn al genitalia: a review
thral stump is separated in to three tri angular por- and assessment of pen ile a m putation and urethros-
to my as a surgical lrea tment, Equine Vet J 23:53,
tio ns, folded back, and sutured to the epithelium.'
1991.
Advantages and disadvantages of this technique
3. Mair 1'S, Walm sley JP, Ph ill ips TJ: Surgical treat-
are similar to those for William's technique. me nt of 45 horses affected by squamous cell carci-
With Vinsot's technique, a triangul ar portion noma o f the pen is and prepuce, Equine Vet J 32:406,
of epithelium a nd underl ying tiss ue with the base 2000.
proximal to the apex is removed. A modification 4. Adams S8 , Fessle r 1F: Penile amp uta tion. In Ada m s
of th is procedure performed in standing horses S8 , Fessler JF, ed itors: Atlas of eqlline su rgery,
invo lves making a longitudinal incisio n directly to Philadelphia , 2000, WB Saunde rs.
the ureth ra.' A non absorbab le ci rcum fe rentiallig- 5. Scott EA: A technique for amp uta tion of the equine
atu re is placed around the penis, and the penis is pe nis, J Am Vet Med Assoc 168: 1048, 1976.
tra nsected distal to the ligature. After longitudinal 6. Archer DC, Edwa rds GB: En bloc resection of
the pen is in five geldings, Equine Vet Edllc J 6: 12,
incisio n, the urethral mucosa is sutured to th e
2004.
skin as previously described. The penile stump is
7. Dol es J, Williams JW, Yarbro ugh TB: Penile a m puta-
allowed to heal by second intention. The advan- tion and sheath ablation in the horse, Vet 5urg
tages of this technique are the decreased surgery 30:327,200l.
time a nd the potential to perform the procedu re 8. Markel MD, Wheat JD, Jones K: Gen ital neoplasm s
standing. The disadvantage of this technique is treated by en bloc resection and pen ile retroversion
th e tend en cy for strict ure formation and the in horses: 10 cases (I977- 1986),J Am Vet Med Assoc
potential for inadequate hemostasis. ' 192:396, 1988.
CHAPTER 38
Perineal Urethrotomy in Males
Gal Kelmer

1.5 em in the uret h ral isthmus and penile urethra.


INDICATIONS
The urethralis muscle envelops the pelvic urethra.
The corpus spongiosum penis surrounds the
Treatment of urolithiasis involving the bladder
u rethra, and the bulbospongio511s muscle lies
and urethra, urethral rents causing hemospermia
caudal to the pe lvic urethra and becomes ventral
in stallions and hematuria in geldings, and tem-
to the pen ile u rethra d istally. The symmetrical
porary urine divers io n fo r urethral obstr uctive
retractor penis muscle covers the bu l bospongio ~
lesions, such as hematom a, neoplasia (e.g.) sq ua -
sus and lies beneath the subcutaneous tiss ue at the
mOllS cell ca rcinoma), o r parasitic granuloma
perineal region.
(e.g., habronemiasis ).1.)

EQUIPMENT

A mal e urinary catheter is helpful fo r urethra iden- PROCEDURE


tification during su rgery. When using urethro-
tomy to treat urolithiasis, special equipme nt such A vertical incision starts 4 to 6 cm distal to the
as a custom-made lithotrite may be necessary. anus and extends ventrally for 8 to 10 cm through
the median raphae skin and subcutaneous tissue
(Figure 38-1). The incision should not extend
PREPARATION AND POSITIONING
ventral to the ischium in order to prevent urine
spraying on the limbs and subsequent scald for-
The horse sho uld be standing in stocks with the
mation. The retractor penis muscles are separated
use of systemic sedation and epid ural analge-
on midline and reflected laterally (Figure 38-2) .
sia. An alternative to epidural anesthesia is an
The bulbospongiosus muscle is exposed and
inverted-V block using local anesthetic. Manual
incised. H emorrhage is expected, at this stage,
emptying of feces from the rectum is followed by
and is controlled by applying light press ure using
dipping, tail wrapping, and su rgical preparation
surgical gauze. The incision continues through
of the perineal region.
the corpus spongios um penis and the ureth ral
wall. Urethral lum en entry is verified by visualiz-
ANATOMY ing and palpating the urinary catheter (Figu re
38-3). The catheter helps to prevent both acci-
The male pelvic urethra is about 12 cm long and dental deviation from midline and penetration of
tapers in diameter from 3 em near th e prostate to the cranial urethral wall. 104

211
212 MA LE U ROGENITAL SURGERIES

Figure 38-3 A, Postoperative view of perineal ure-


throtomy in a geldi ng. At the cente r of the incision the
uri nary catheter is visible within the urethral lumen. 8,
Close-u p view of a com pleted perineal urethrostomy.
The second layer of suture is shown depicting simple
Figure 38-1 View of the hi nd quarters of a gelding. interrupted sutu res between the urethral mucosa and
The inter rupted line dep icts the approach for perineal the perineal skin.
urethrotomy.

POSTOPERATIVE CARE

Postoperative Care
Protection and Cleaning: The surgery site
should be kept clean, and petrolatum jelly is applied
to the perineal region and the medial aspect of both
upper hind limbs to prevent urine sCilld.
Medications: Broad-spectrum systemic antibi-
otics and nonsteroidal antiinflammatory medication
such as phenylbutazone are given perioperatively
for 3 to 5 days.
Exercise Restrictions: Stallions need to avoid
sexual activity for 4 to 6 weeks.
Dietary Modifications: Adding salt to the feed,
at 10/0 of the horse's diet, may encourage drink-
~........"t.:;,.1..... -
ing and aid in preventing recurrence of urolithia-
Figure 38-2 Intraoperative view, showing perineal
sis. 5
urethrotomy of a gelding with a uri nary ca theter in other: Hemorrhage should be monitored for the
place. The illustration dep icts the incision thro ugh the
first 24 hours. Dripping of blood from the incision
skin and subcutaneous tissue and between the retrac- and terminal hematuria are expected for up to 2
tor penis muscles. The deep layer shown at the center
weeks postoperatively.
of the incision is the bulbospongiosus muscle.
Perineal Urethrotomy in Males 213

Urethrostomy for perm anent urine diversion is


EXPECTED OUTCOME
created by a two-layer closure over the above
described urethrotomy (see Figure 38-3 B). Ini-
Cystic urolithiasis carries a favorable prognosis,
tially, a hemostatic layer is performed by suturing
but owners should be forewarned about the pos-
the bulbospongiosus muscles and the corpus spon-
sibility of recurrence. 6. 8 Urethral urolithiasis can
giosum penis, using No. 3-0 synthetic absorbable
be treated successfully if diagnosis and treatment
suture, in a simple con tinuous pattern. The
are performed early, thus avoiding urethral
second layer is performed in a simple interrupted
obstruction and bladder rupture. The success of
pattern, using No. 2-0 polypropylene, connecting
urethrotomy for treatment of other urinary
the urethral mucosa to the perineal skin. Meticu-
obstructive lesions depends primarily on the
lous, tensionless apposition of the mucosa to the
nature and extent of the lesion.
skin is crucial to prevent dehiscence and lateral
urine diversion causing scald formation. ],2
COMPLICATIONS Laparocystotomy is an effective method for
cystic calculi removal. The primary disadvantage
Excessive bleeding in the form of a continuous is the need for general anesthesia. The primary
stream of blood warrants intervention. Applica- advantages are reduced trauma to the bladder and
tion of light pressure with gauze or cold packing urethra and decreased recurrence rate from com-
for 10 to 15 minutes is usually sufficient. However, plete calculi removal and the less traumatic nature
if significant bleeding persists, surgical explo- of the procedure.5,9
ration is indicated. If the corpus cavernosum Laparoscopy has also been used for cystic
penis is the so urce of bleeding, suturing the tunica calculi removal. The procedure necessitates
albuginea is indicated for prompt, effective hemo- general anesthesia, special equipment, and expe-
stasis. Urine scald is a common sequel that can rience with the technique. However, it enables
generally be avoided by keeping the distal end of excellent visualization and access to the bladder. II
the incision proximal to the ischial arch . Scald
should be cleansed, and affected areas should be
treated with silver-sulfadiazine cream, zinc-oxide,
COMMENTS
or other nonirritating cream -ointment on a daily
As a treatment for urolithiasis, urethrotomy can
basis. Unilateral urine scald caused by asymmet-
be performed for retrieving small uroliths or
ric urine flow may be eliminated by applying
crushing larger ones using a lithotrite. l Most
sutures at the contralateral side of the urethro-
cystic calculi are large enough that they must be
tomy in an attempt to redirect the urine stream
crushed or broken into smaller pieces to allow
straight caudally. Stricture formation can gener-
removal through a urethrotomy incision. This can
ally be prevented by careful attention to tech-
res ult in a long and somewhat traumatic proce-
nique, making one straight incision of adequate
dure. Other, less traumatic, options for eliminat-
length. Recurrence of urolithiasis may be
ing uroliths via urethrotomy include laser (e.g.,
more common following urethrotomy than with
pulsed-dye) and electrohydraulic lithotripsy.'-'
laparocystotomy due to incomplete fragment
Performing the urethrotomy 24 to 48 hours before
removal. 9 Other reported complications include
lithotripsy may provide for better visualization
rectal or urethral damage, orchitis, peritonitis,
with less hemorrhage. Following calculi fragmen-
incontinence. and bladder rupture. 9
tation, thorough bladder irrigation is indicated
and may be repeated postoperatively to decrease
ALTERNATIVE PROCEDURES recurrence and prevent cystitis.

Urethral rents can be treated by perineal release


REFERENCES
incision. The procedure is identical to that of per-
ineal urethrotomy but avoids entering the ure-
1. van Harreveld PO, Gaughan EM . Lillich JO:
thral lumen. The incision through the corpus
Urethral surgery in horses, Camp Cant Educ Pract
spongiosulll penis presumably provides a tem- Vet 20;739, 1998.
porary alternative route for the blood, while 2. Lillich JO, OeBowes RM: Ureth ra. In Aller JA, Stick
allowing the urethral rent to heal by second JA, ed itors: Eqllille 5l11gery, ed 2, Philadelphia, 1999,
in tention. 3. \0 WB Saunders.
214 MALE UROGENITAL SURGER IES

3. Schumacher J, Schumacher J: Surgical management 7. Judy CEo Galuppo LD: En doscopic-assisted disrup-
of urolithias is in the equine ma le. In Wolfe OF, Moll tion of urinary calculi using a holmium:YAG laser
HO, editors: Large animal urogenital surgery, ed 2, in stand ing horses, Vet Surg 3 1:245, 2002.
Baltimore, 1998, Williams & Wilkins. 8. Eustace RA, Hunt 1M: Electrohydraulic lithotripsy
4. Adams SB, Fessler JF: Perinea l urethrotom y and fo r the treatment of cystic calculi in tvvo geldin gs,
remova l of cystic calculi In Adams SB, Fessler 1F, Equine Vet J 20:221. 1988.
editors: Atlas of equine surgery. Philadelphia, 2000, 9. Laverty S, Pascoe JR, Ling GV, et al: Urolithiasis in
WB Saunders. 68 horses, Vet Surg 2 J :56. 1992.
5. Schumacher J, Schumacher J, Schmitz 0: Macro- 10. Schumacher T, Varner DO, Sch mitz DG, et al:
scopic haematu ria of horses. Equine Vet Edllc 4:255, Urethral defects in geldings with hematuria and
2002. stallions with hemospermia, Vet Surg 24:250, 1995.
6. Howard RD, Pleasant RS, May KA: Pulsed dye laser 11. Ragle CA: Laparoscopic removal of cystic calculi in
lithotripsy: treatment for urolithiasis in 2 geldings. 10 horses. In Fische r AT, editor: Equi1/e diagllostic
J Am Ve t Med Assoc 212:1600.1998. and surgical laparoscopy, Philadelphia, 2002, WB
Saunders.
EMALE ROGENITAL
URGERIES

215
CHAPTER 39
Caslick's Procedure (Vulvoplasty)
John C. Janicek

mare's conformatio n.) To reduce the likelihood of


INDICATION
removing an excessive width of mucosa, thumb
forceps may be used to apply downward tension
Pneumovagina resulting from abnorm al perineal
o n the band of excised mucosa. Excessive mucosal
conformation.
removal results in excessive sca r tissue forma-
tion, makin g future easlick's procedures more
diffi cu lt.,,4
EQUIPMENT Once the mucosa has been excised, the exposed
surfaces are apposed beginning at the dorsal COI11-
No special equipment is required.

POSITIONING AND PREPARATION

The mare is restrained stand ing in a stock or


backed into a stall doorway. The tail is held out of
the way by an assistant or wrapped and tied
forward. Following aseptic preparatio n of the per-
ineal region, local anesthetic ( 15 to 20 mL lIsing a
22-gauge needle) is infiltrated along the vulvar
labial mucocu taneous margin (Figure 39- 1),
Excessive local anesthetic infiltration should be
avoided to prevent distortion of the mucocuta-
neous margins.!

PROCEDURE

Beginning at the level of the ischiatic tuber and


extending to the dorsal commissure, a th in band
of mucosa approximately 3 to 5 mm wide is
excised from each side of the vulva along the '<l r f"J~.c~_
mucocutaneous margin 2 (Figure 39-2). The Figure 39-1 Infiltration oflocal anesthetic along the
exact length of tissue removed depends on the vulvar mucocutaneous ma rgin.

216
(aslick's Procedure (Vulvoplasty) 217

(
\ -
'<jj p...t_l_",~.

Figure 39-4 Additio n of a "breeding stitch" just


distal to the Caslick suture line.
~P"'AI>t...i_
......~
Figure 39-2 Excision of vulvar mucosa along the
mucocutaneous junction using sc issors.

POSTOPERATIVE CARE

Postoperative Care
Medications: Antibiotic and antiinflammatory
therapies are generally not necessary.
I Suture Removal: Sutures should be removed
10 to 14 days after surgery.
other: No exercise restrictions are necessary.
Prior to foaling (3 to 5 days), an episiotomy
should be performed to minimize perineal da-
mage during parturition.

'9 i..._._
f'~f;•.
EXPECTED OUTCOME

Figure 39-3 Apposition of vulvar mucosa usmg a
Resolution of pneumovagina is likely followi ng a
Ford interlocking pattern.
Caslick's procedure in mares with normal to
mildly abnormal perineal conformation. Mares
missure with No. 0 non abso rbable suture using a with moderate to severe abnormal perineal con-
continuous pattern. Simple continuous or Ford formation or persistent pneu movagina may
interlocking patterns are commonly used (Figure require perineal body reconstruction.
39-3). A single "breeding stitch" may also be
placed just distal to the suture line with No. I non-
absorbable suture material using a loose single COMPLICATIONS
interrupted suture to protect the repair during
assisted live cover or artificial insemination Min imal complications are associated with this
(Figure 39-4). The "breeding stitch" should not be procedure; however, dehiscence and suture sinus
so ventral that it prevents urination or assisted live tract development are possible. Excessive ventral
cover breeding. A «breeding stitch" should not closure may result in urovagina. Unpredictable
be placed in mares in wh ich pasture breeding is vulvar tearing may occur if episiotomy is not per-
intended. formed before parturition.
218 FEMALE UROGENITAL SURGERIES

normal conformation. Improving the physical


COMMENTS condition of these mares res ults in improved per~
ineal conformation. With age and repeated foal-
For maximum reproductive function, the dorsal
ings, the vulva lengthens and vulva conformation
commiss ure of the vulva should extend no more
becomes more horizo ntal relative to the pelvic
than 4 to 5 cm dorsal to the ischiatic tuber,
brinl because of general organ and muscle relax-
meaning that approximately two thirds of the
vulvar cleft is below the ischiatic tuber.4 The
ation in the pelvic region. 4 •
vulvar labiae should be oriented vertically with a
cranial-to-caudal slope of no more than 10 de-
grees from vertical. s A distance of more than 4 cm REFERENCES
between the dorsal commissure of the vulva
and the ischiatic tuber and/or an angle of more I. Anasari MM: The Caslick's operation in mares,
than 10 degrees in the declination of the vu lvar Comp Cont Edllc Vet 5:s107, 1983.
labiae is associated with poor perineal conforma- 2. Beard W: Standing urogenital surgery, Vet Clill N Am
tion and increases the likelihood of pneu- Equine Pmct 7:669, 1991.
3. Turner AS, McI lwrath CW: Techniques ill large
movagina. s Variations in perineal conformation
allimai surgery, ed 2, Philadelphia, 1989, Lea &
have many causes, including inherent conforma-
Febiger.
tion, poor physical condition, and age. A flat
4. Trotter GW, McKinnon AO: Surgery for abnormal
croup, elevated tail set, under-developed vulvar vulvar and perineal conformation in the mare, Vet
labiae, and sunken anus all contribute to faulty Clill N Am Equine Pmct 4:389, 1988.
perineal conformation. s Poor physical condition 5. Easley J: External perineal conformation. In McKin-
intensifies the problem and ca n result in abnor- non AO, Voss JL, editors: Equi/le reprodllction,
mal conformation in mares with otherwise Philadelphia, 1993, Lea & Febiger.
CHAPTER 40
Perineal Body Reconstruction (Episioplasty)
John C. Janicek

tissue required to develop a dorsal commissure


INDICATION
that will provide an adequate vaginal seal. The
length required is typically 4 to 6 em. The incision
Pneumovagina or persistent endometritis follow-
is then extended dorsocranially until the cranial
ing easlick's procedure.
portion terminates on the dorsal midline at the
vestibulovaginal junction (Figure 40-1). The tri-
EQUIPMENT angular mucosal flaps are then resected from both
sides of the vestibule. The resultant exposed sub-
No special equipment is required. mucosa forms a right-angled triangle with the
right angle located along the dorsal commissure
of the vulva' (Figure 40-2) .
PREPARATION AND POSITIONING Closure of the ventral vestibular mucosal
margins is performed cranial to caudal with No. 2-
The mare is restrained standing in a stock, and the oabsorbable suture in a simple continuous pattern 2
procedure is performed with either epidural or (Figure 40-3). Deeper submucosal tissues are
local perineal body anesthesia, and sedation if apposed with No. 2-0 absorbable suture using a
necessary. Once anesthesia is confirmed. the tail simple interrupted pattern. Caslick's procedure is
is wrapped and securely retracted. Fecal material is performed to appose the vulvar opening (Figure
removed from the rectum. The perineal region is 40-4).
then rinsed and aseptically prepared. Sterile saline
is used instead of alcohol to remove antiseptic
soaps, because alcohol may cause excessive irrita- POSTOPERATIVE CARE
tion.
Postoperative Care
Exercise Restrictions: Small-paddock turnout
PROCEDURE should be maintained for 14 days.
Medications: Broad-spectrum antibiotics are
Vulvar retraction is maintained with towel clamps administered for 7 to 10 days. A nonsteroidal anti-
or stay sutures positioned lateral to the dorsal inflammatory agent is administered for 3 to 5
vulvar commissure. In this procedure, triangular days.
areas of mucosa are removed from the perineal Suture Removal: Caslick's sutures are removed
body. An incision is made along the vulvar muco - 10 to 14 days after surgery.
cutaneous margin of both labiae beginning at the Other: Sexual rest for 4 to 6 weeks is recom-
dorsal commissure, extending to the desired mended. Prior to foaling (3 to 5 days), an epi-
siotomy should be performed to prevent perineal
ventral limit. I The ventral limit of the incision is
damage during parturition.
subjectively chosen by determining the amount of

219
220 FEMALE UROGENITAL SURGERIES

Figure 40-1 Proposed area of vestibula r


mucosa to be removed (dotted lilies) for
perineal body reco nstruction.

Figure 40-2 Caudolateral view of proposed area of


vestibular mucosa to be removed (dotted lines) for perinea l
body reco nstruction.

Figure 40-3 Cranial-to -cauda l cl osure of


• •
the ven tral vestibular m ucosa margin usmg a
simpl e continuous pattern.
Perineal Body Reconstruction (Episioplasty) 221

moderate to severely abnormal perineal confor-


mation. Occasionally, pneumovagina does not
resolve following Caslick's procedure or perineal
body reconstruction. In these cases, perineal body
transection may be warranted. 2

COMPLICATIONS
.
Minimal complications are associated with this
I procedure; however, dehiscence and suture sinus
tract development are possible. Excessive ventral
closure may result in urovagina. Unpredictable
vulvar tearing may occur if episiotomy is not per-
formed before parturition.

Figure 40-4 easlick's procedure is performed to


ove rsew the submucosal perineal tissues and appose the
vulvar lips. REFERENCES

I. Beard W: Standing urogenital surgery, Vet Clill N Am


EXPECTED OUTCOME Equille Pract 7:669,1991.
2. Trotter GW, McKinnon AO: Surgery for abnormal
Adequate reconstruction of the mare's perineal vulvar and perineal conformation in the mare, Vet
region alleviates pneumovagina in most cases of CliIl N Am Equine Pract 4:389, 1988.
CHAPTER 41
Urethral Extension (Urethroplasty)
John C. Janicek

extending from the urethral orifice to near the


INDICATIONS
mucocutaneous junction so that urine enters the
vagina caudal to the brim of the pelvis. allowing
Urine pooling, urovagina.
gravity to assist in voiding urine. In all techniques,
it is important to place the first suture cran ial to
the urethral orifice to minimize the risk of fistula
EQUIPMENT formation and to appose the dissected tissue
shelves with minimal tension. Adequate visualiza-
Long-handled instruments and a 30-Fr Foley tion is achieved by use of a vaginal spatula posi-
catheter are required. Self-retaining retractors tioned along the dorsal aspect of the vaginal
(vaginal spatula. Balfour. modified Finochietto) lumen along with ventrolateral placement of
and a good light source (floor lamps. headlamp. towel clamps in the vulvar labiae. Retraction may
or fiberoptic lights) are useful but not necessary. also be provided using Balfour or modified
Finochietto retractors.

PREPARATION AND POSITIONING Monin Te(hnique


This technique involves caudal translocation of
The mare is restrained standing in a stock, and
the transverse urethral fold l ,2 and is recom-
surgery is performed following epidural anesthe-
mended only in cases with mild perineal confor-
sia, and sedation if necessary. Once anesthesia is
mational abnormalities. The major limitatio n of
confirm ed, the tail is wrapped and secu rely
this technique is the inability to extend the ure-
retracted. Fecal material is removed from the
tlual opening as far caudally as can be done with
rectum. The perineal region is rinsed, followed
other techniques, which is necessary in mares with
by cleansing of the vaginal lumen with a dilute
moderate to severe perineal conformational
povidine-iodine solu tion. The perineal region is
abnonnalities.
then asepticall y prepared, with care taken to not
The transverse urethral fold is grasped with
use alcohol, as it may cause excessive irritation.
Allis tissue forceps 1 cm abaxial to each side of
midline and retracted approximately 5 cm cau-
dally. The lateral aspect of the transverse urethral
PROCEDURE fold is split horizontally and the incision is
extended along the corresponding ventrolateral
Various repair techniques are described. The goal vaginal wall (Figure 41-1). The transverse urethral
of all techniques is to create a mucosal tunnel fold is sutured to the vaginal floor in the retracted

222
Urethral Extension (Urethroplasty) 223

'\
\

Figure 41-2 A, The right side of the transverse ure-


th ral fold and corresponding ventrolateral vaginal wall
are split horizontally in an interrupted manner. Arrows
indicate the direction of tissue mobilization. The left
Figure 41-1 The transverse urethral fold is caudally side of the transverse urethral fold has been sutured to
retracted. On the right side, an incision has been made the corresponding ventrolateral vaginal wall. B, Close-
through the transverse urethral fold and correspo nding up view of a two-layer closure. The ventral layer is
ventrolateral vaginal wall. On the left side, a dot'ted line apposed using a Connell pattern, and the dorsal layer is
indicates the proposed incision line. apposed using a continuous horizontal mattress
pattern.
position with No. 2-0 absorbable suture using a
two-layer pattern. The ventral layer is apposed right vaginal walls to a point approximately 3 cm
using a Connell pattern, and the dorsal layer is cranial to the vulvar labiae (Figure 41-3). Und er-
apposed using a horizontal mattress pattern mining of the ventral and dorsal mucosal layers is
(Figure 41-2). A simple interrupted suture should performed to decrease tension. The ventral mu-
be placed at the caudalmost aspect of the two cosal layer is closed with No. 2-0 absorbable su-
. ..
InCISions. ture using a Connell pattern, everting the tissue
ventrally (Figure 41-4). Submucosal tissue is
closed with No. 2-0 absorbable suture using a
Brown Technique simple continuous pattern (Figure 41-5). Finally,
This is the most common urethral extension tech- the dorsal mucosal layer is everted dorsally with
nique used. 3 Correction of urovagina in mares No. 2-0 absorbable suture using a continuous
caused by severe perineal conformation abnor- horizontal mattress pattern (Figure 41-6).
malities can be achieved with this technique by
extending the urethral opening far caudally.
Shires Technique
However, mares with vaginal scars or vaginal
mucosa atrophy are not good candidates fo r this Although simple and efficient, this technique 4 is
technique because of increased tissue tensio n. 3 limited in that it may be used only in mares that
A 30-Fr Foley catheter is placed in the urinary have redundant vestibular folds that may be
bladder and the cuff is inflated. The transverse pulled together to form a tunnel without the need
urethral fold is split horizontally, and the mucosal for dissecting and undermining tissue flaps to
incision is extended caudally along the left and form a shelf.'
224 FEMALE UROGENITAL SURGERIES

Figure 41-3 Horizontal splittin g of the transverse Figure 41-5 Submucosal tissue closure using a
urethral fol d and ca udal extension of the vaginal simple continuo us pattern.
mucosa incision (dotted line) alo ng the left and right
vaginal walls.

Figure 41-6 A, Eversion of the dorsal mucosal layer


Figure 41-4 Inversion of the ventral mucosal layer using a continuous horizontal mattress pattern. B, Close-
using a Co nnell pattern. up view of the co mpleted three-layer closure.
Urethral Extension (Urethroplasty) 225

A 30-Fr Foley catheter is placed in the urinary No. 2-0 absorbable suture usi ng a simple contin-
bladder and the cuff is inflated. Before any inci- uous pattern (F igure 41-9) .
sion is made, two lines of the ventral vaginal
mucosa are dorsa ll y everted and su tured over th e
McKinnon Technique
Foley catheter with No. 0 absorbable suture using
an interrupted horizontal mattress pattern, Correction of urovagina in mares caused by severe
leaving adequate mucosa to allow excision and perineal co nformation abnormal ities can be
further suturin g (Figure 41-7). Suture placeme nt accomplished with thi s techni que5 ,6 by providing
is continu ed caudally to approxim ately 2 em a wide, long, and strong urethral extension. This
crani al to the vulva r labiae. The two lines of dor- technique is recommend ed when the urethra
sall y eve rted mucosa are excised to create four opening needs to be extended far caudally and
fresh-cut edges of vagina l mucosa (Figu re 41-8). increased tiss ue ten sio n is present. Minimal tiss ue
These debrided edges are then apposed with ten sion is exerted o n th e completed tunnel. Ini-
tially, a steep learni ng curve for this tech nique is
enco untered, but it can be easily performed with
expe rience. In addition, disruption of th e blood
supply should be avoided during the tissue flap
dissection.
A 3D-Fr Foley ca theter is placed in the u rinary
bladder and the cuff is inflated. The caudal border
of the transverse urethral fold is grasped on
midline with All is tiss ue force ps and retracted
caudally. A hori zo ntal mucosal incision is made 2
to 4 cm cranial to the caudal edge of th e trans-
verse urethral fold extending slightly dorsocau-
dally along the left and right vaginal wal ls (Figure
41-10 ). This incision should end at the vulva r
labia half to two thirds of the di stance between the
vaginal floo r and vaginal roof. The transverse ure-
thral fold and vag inal wall mucosal tissues are
undermi ned so th at the free tiss ue flaps are
Figure 41-7 Do rsal eversion of ventral vaginal reflected ca udall y and axially, respectively. Dis-
mucosa over 30-Fr Foley catheter and sutured using an section of transverse urethral fold tissue should
interrupted horizontal mattress pattern.

Figure 41-8 Excision of dorsally everted vaginal


mucosa, creati ng four fresh-cut edges of vaginal Figure 41-9 Apposition of freshly debrided mucosal
mucosa. edges usi ng a simp le continuous pattern.
226 FEMALE UROGENITAL SURGERIES •

>;t.S~ ;1;.. ~ •
Figure 41-10 Caudal retraction of the transverse
urethral fold allowing an incision to be made into the Figure 41-11 Caudal reflection of the transverse
transverse urethral fold. The proposed incision is urethral fold and axial reflection of the vaginal wall
shown with dotted lines. The incis ion should end at the mucosa after dissection.
vulvar labia half to two thirds of the distance between
the vaginal floor and roof.

allow 3 to 6 em of caudal reflection, while the


vaginal wall tissues are reflected past midline
without tension (Figure 41-11) . The final config-
uration is in the shape of a Y, with the base of the
Y caudaL Beginning at the right cranial junction
of the transverse fold and vaginal wall incision,
reflected tissues are apposed with No. 2-0 ab-
sorbable suture using a Connell pattern, endi ng
at the midpoint of the transverse urethral fold
reflection (Figure 41-12). The second su ture line
is performed on the left side in the same manner,
continuing caudally ending at the caudal edge of
reflected vaginal wall (Figu re 41-13). It is impor-
tant to maintain minimal su ture tension on the
suture line and invert all tissue edges. Exposed
submucosal tissues created dorsally by transverse
fold and vaginal mucosal dissection are allowed to 1¥,S.. ;(~.

heal by second intention. Figure 41-12 The reflected transverse urethral fold
When indicated, a Caslick's procedure is per- and vaginal wall are apposed using a Connell pattern
formed after all urethroplasty techniques. beginning at their cran ial junctions.

Urethral Extension (Urethroplasty) 227

,
dures. 3•S Short-term complications such as dehis-
cence or fistula formation are reported to occur in

11 % to 15% of all described techniques.'" When
, complications arise, subsequent surgeries are essen-
tial to improve the chances for complete healing.
Postoperative conception rates are reported to be
64% to 92% within 1 year postoperatively.3's Recur-
rence of urovagina is uncommon, unless a signifi-
cant change in perineal conformation occurs.

COMPLICATIONS

Suture dehiscence and fistula development along


the suture line are the most common complica-
, tions. Fistula development is most commonly
observed at the junction of the transverse urethral
fold and vaginal wall reflexion. These complica-
tions can be avoided by precise dissection, metic-
ulous suture placement, and reduced tension
on apposed tissues. If a fistula develops, an
attempt to repair the fistula should be pursued to
Figure 41-13 The second suture line begins on the minimize the risk of endometriti s, persistent
opposite side in the same m anner, continuing caudally urovagina, and infertility.
ending at the caudal edge of the vagina walL The com- Leaving the indwelling urinary catheter in
pleted urethral extension is in the shape of a Y, with the
place for longer than 3 days may result in cystitis.
base of the Y pointing caudal.
If cystitis does occur, the catheter is removed, the
urine is cultured, and appropriate antimicrobials
POSTOPERATIVE CARE are administered until bacteria are no longer
isolated .}
Postoperative Care
Exercise Restridions: Small-paddock turnout REFERENCES
should be maintained for 30 days.
Medications: Broad-spectrum antibiotics are
I. Beard W: Standing urogenital surgery, Vet Clill N Am
administered for 7 to 10 days. A nonsteroidal anti-
infiammatory agent is administered for 3 to 5 days. Equine Pmct 7:669,1991.
2. Baird AN: Surgical management of urovagina in the
Catheter Removal: Mares should be monitored
mare, Southwest Vet 38:36,1987.
closely to determine their ability to urinate ade-
3. Brown MP, Colahan PT, Hawkins DL: Urethral
quately. The Foley catheter is removed within 3
extension for treatment of urine pooling in mares, ]
days postoperatively.
Other: The reproductive tract should not be Am Vet Med Assoc 173: 1005, 1978.
4. Shires GM, Kaneps AJ: A practical and simple surgi-
examined for 2 to 4 weeks after surgery, and
cal technique for repair of urine pooling in the mare,
the mare should have 45 to 60 days of sexual
Proc Am Assoc Eqllil'le Pract 32:51, 1986.
rest.
5. McKinnon AO, Belden JO: A urethral extension
technique to correct urine pooling (vesicovaginal
EXPECTED OUTCOME reflux) in mares, J Am Vet Med Assoc 192:647,1988.
6. Easley JK: Diagnosis and treatmen t of vesicovaginal
Primary healing is reported to occur in appro- reflux in the mare, Vet Clin N Am Equine Pmct 4:407,
ximately 85% to 89% of urethroplasty proce- 1988.
CHAPTER 42
Third-Degree Perineal Laceration Repair
John C. Janicek

The preparation solution should be rinsed with


INDICATIONS
sterile saline, not alcohol, as alcohol may cause
excessive irritation.
Dystocia, traumatic breeding, or co nversio n of a
rectovaginal fistula into a third-degree perineal
laceration for subsequen t repair. PROCEDURE

One- and two-stage repair techniques are


EQUIPMENT described. A one-stage repair is preferred;
however, a two -stage repair should be performed
Long handled instruments and monofilament if excessive tension is present during surgery. No
abso rbable suture materials are required. Self- distinct advantage or disadvantage exists between
retaining retractors (Balfour, modified Finochietto) techniques. Principles for all techniques include
and a good light source (floor lamps, headlamp, or initial creatio n of rectal and vaginal shelves,
fiberoptic lights) are useful but not required. minimal tissue tension, and maintaining a soft
manure consistency after surgery. All repair tech-
niques close the defect from cranial to caudal.
PREPARATION AND POSITIONING Modification of the techniques can be performed
based on surgeon preference.
Surgery is delayed for 4 to 6 weeks following the
Towel clamps or retention sutures are posi-
laceration to allow wound contraction and inflam-
tioned along the dorsolateral and ventrolateral
mation to su bside. Delaying surgery for this period
aspects of the laceration to provide exposure. The
allows the wowld edges to strengthen and become
cranial extent of the laceration is extended
clearly defined before repair is attempted. A gruel
approxi mately 3 cm, creating a rectal and vag inal
or pasture diet is fed 3 to 5 days prior to surgery,
shelf. Dissection is continu ed laterally and ca u-
and the mare is fasted 1 day before surgery.
dally along the scar tissue line into the submucosa
The mare is restrained standing in a stock, and
until the tissue flaps created can be apposed on
surgery is performed following epidural anesthe-
midline without tension (Figure 42-1). Both
sia, and sedation if necessary. Once anesthesia is
mucosal su rfaces are dissected 2 cm or more.
confirmed, the tail is wrapped and secu rely
retracted. Fecal material is removed from the
One-Stage Repair
rectum and vagina. The perineal region is rinsed,
followed by cleansing of the rectal and vaginal Goetz Technique
lumens with a dilute povidone-iodine solution. Using No.1 absorbable suture, a six-bite pattern
The perineal region is then aseptically prepared. is used to close the rectovaginal shelf.l The sut ure

228
------------------------------------------------------------...............
Third-Degree Perineal Laceration Repair 229

Figure 42-2 The rectovaginal shelf is closed with a


six-bite pattern. The pattern sho uld begin and end in
the vagi nal lumen without penetrating the rectal
Figure 42-1 Surgical dissection of a third-degree
mucosa.
peri nea l lace ration prior to surgical repair. The recto-
vaginal shelf is reflected with the proposed incis ion line
(dotted lille) show n.

pattern begins with in the vaginal lumen, allow ing


the knot to be sec ured within the vaginal lumen
(Figu re 42-2). Sutures are positioned approxi-
mately 1 em apart; the suture pattern includes the
vaginal mucosa but does not penetrate the rectal
mucosa. The vaginal mucosa is closed over the
newly created rectovaginal shelf with No. 0
abso rbable sut ure usin g a continuous horizontal
mattress pattern. The rectal mucosa is left to heal
by second intention. Closure of the rectova ginal
shelf and vagi nal mucosa sho uld extend to the
cutaneous perineum. Caslick's procedure is th en
performed to appose the vulvar opening.

Modified Goetz Technique


The vag inal mu cosa is inverted into the vaginal
lumen with No. 0 abso rbable suture using a Figure 42-3 The vaginal mucosa is inverted into th e
Co nn ell o r Lembert patter n. 2-4 This suture pattern vaginal lumen using a Connell pattern and the recto -
is continued caudally to reconstru ct the cranial vaginal shelf is closed using a purse-string pattern.
half of the defect and then tied but not cut. Using
No. I absorbable suture, purse-string su tures are shelf is reconstructed, closure of the vaginal
used to close th e rectovaginal shelf (Figure 42-3). mucosa is completed. followed by closure of th e
Sutures are positioned ap proximately 1 cm apart remaining caudal half of the rectovaginal shelf.
and should not pass through the vaginal or rectal The rectal mucosa is everted into the rectal
mucosa. O nce th e cranial half of th e rectovaginal lumen with No. 0 absorbable suture using a

,

230 FEMALE UROGENITAL SURGERIES

Cushing or Lembert pattern (Figure 42-4). continuous pattern ending at the center of the
Closure of the rectovaginal shelf and mucosal sur- shelf. The left side is closed in the same manner.
faces should extend to the cutaneous perineum. A Rectal and vaginal mucosa surfaces should not be
Caslick's procedure is then performed to appose penetrated.
the vulvar opening. Perineal body reconstruction begins at the
caudal edge of the newly formed rectovaginal
Semitransverse Closure Technique shelf and is continued caudally. The first suture
Small marker incisions are made at the ventral incorporates the caudal end of the newly formed
aspect of the perineal body along the left and right rectovaginal shelf and the right and left sides of
mucocutaneous junctions 5 ; these markers will be the perineal body. The dorsal portion of the per-
used as the ventrocaudal points of the triangle ineal body is closed first with No. 2 absorbable
used to construct the perineal body. The scar suture using a Cushing pattern. Incorporation of
tissue mucosal junction along the rectovaginal the rectal, vaginal, or anal mucosa should be
shelf is incised longitudinally and divided in its avoided during closure. The remainder of the
entirety. Rectal and vaginal mucosae are under- perineal tissue is closed with No. 2-0 absorbable
mined approximately 7 to 10 cm from the recto- suture using a simple interrupted pattern.
vaginal shelf. Beginning approximately 4 cm Caslick's procedure is performed to appose the
cranial to the external anal sphincter, a mucosal perineal skin and vulvar opening.
incision is made from the lateral edge of the rec-
tovaginal shelf ventrocaudally toward the original
Two-Stage Repair
marker incision. A triangle-shaped section of
mucosa is excised; the exposed triangular section Aanes Technique
of submucosa will form the perineal body when The vaginal mucosa is inverted into the vaginal
sutured. The center of the rectovaginal shelf is lumen with No. 0 absorbable suture using a
grasped with Allis tissue forceps, pulling the shelf Connell or Lembert pattern. 6,7 This suture pattern
caudally to the cranial border of the proposed is continued caudally to reconstruct the cranial
perineal body. The final configuration is in the half of the defect and then tied but not cut. Using
shape of a Y, with the base of the Y pointing No.1 absorbable suture, purse-string sutures are
caudal. Beginning at the deepest corner on the used to close the rectovaginal shelf (see Figure
right side, the rectovaginal shelf is reconstructed 42-3). Sutures are positioned approximately 1 cm
with No. 2 absorbable suture using a simple apart, avoiding the vaginal and rectal mucosa. If
an excessive amount of tension or dead space is
present, partial tightening of the purse-string
sutures along with sagittally oriented simple inter-
- rupted sutures will help obliterate dead space
(Figure 42-5). Once the cranial half of the recto-
vaginal shelf is reconstructed, closure of the
vaginal mucosa is completed, followed by closure
of the remaining caudal half of the rectovaginal
shelf. Optionally, the rectal mucosa may be
inverted into the rectal lumen with No. 2-0
absorbable suture using a Cushing or Lembert
pattern. Closure of the rectovaginal shelf is COI1-
tinued to the level of the cutaneous perineum.
Closure of the perineal body is performed 3 to
4 weeks after the first surgery if the rectovestibu-
lar shelf is completely healed. If dehiscence occurs
or a fistula is present, the first stage must be
repeated. Local anesthesia of the perineal body or
epidural anesthesia is used. Closure of the per-
/
...._
J1t-_ ;f.•.•. r.-~
ineal body is performed as described in the per-
Figure 42-4 The rectal mucosa is everted into the ineal body reconstruction technique (see Chapter
rectal lumen using a Cushing pattern. 40). A triangular section of the vestibular mucosa
,

, Third-Degree Perineal Laceration Repair 231

A B
Figure 42~5 A, Suture pattern placement in the Figure 42-5 B, To prevent this complication, the
cranial area of a third-degree perineal laceration repair purse-string suture is tied before the ridge starts to
when excessive loss of tissue or thick, inelastic connec- form.
tive tissue is present. When the purse-string suture is
tightened, tension on the connective tissue produces a
transverse ridge in the rectal submucosa that reduces
the diameter and elast icity of the rectum.

D
c "'$i.e- .(_...£(#..,., ,
Figure 42-5 C, Sagittally oriented simple inter- Figure 42-5 D, Tissues are approximated without
rupted sutures are then placed from rectal submucosa excessive tension. Several of these purse-string sutures
to vaginal sub mucosa to obliterate dead space. with their associated simple interrupted sutures may be
necessary in mares that have suffered excessive tissue
loss or that have developed excessive fibrosis.
232 FEMALE UROGEN ITAL SURGERIES

is reflected ventrall y and removed from each side. sorbable suture in a simple continuous pattern
with the triangle apex pointing cranially and the (Figure 42-7). Deep perineal tissues should be
base along the mucocutaneous junction of the apposed with No. 2-0 absorbable suture using a
perineum (Figure 42-6). Closure of the ventral simple interrupted pattern. Perineal ski n is
vestibular mucosaJ margins should be performed apposed with No. 0 nonabsorbable suture using
in a cranial-to-caudal manner with No. 2-0 ab- Ford interlocking pattern (Figure 42-8).

Figure 42-6 A, Proposed area of vestibular


Illllcosa to be removed (dotted lilies) for perineal
body reconstruction. B. Caudolateral view of pro-
posed area of vestibular mucosa to be removed
A (dotted lilies) for perineal body reconstruction.

Figure 42-7 Cranial-to-caudal closure of the


ven tral vestibular mucosa margin using a simple con-
tinuous pattern .

, ,
Third-Degree Perineal laceration Repair 233

such as dehiscence or fistula fo rmation are


reported to occur in 12% to 24% of all surgical
repairs. 2,4,6,7 Subseq uent surgeries are essential
when co mplications arise to improve the chances
for co mplete healing. Conceptio n rates are
reported to be 75% to 92% with in 1 year after
surgery.2.4,6,7 Third-degree lacerations recur in 5%
to 50% of foaling mares due to the inelasticity of
the resultant scar t.issue.2- 4,6.7

COMPLICATIONS

Suture dehiscence and subsequ ent fistula devel-


opment are possible. These complications can be
avoided by precise d issection, adequate tiss ue pur-
chases) and reduced tension on apposed tiss ues.
Fistula formation may result in fa ilure to conceive
due to endomet ritis) pneumovagi na) or contin-
Figure 42-8 Apposition of submucosal perineal ued fecal conta mination of the vaginal lumen.
tissue is shown using a ser ies of simpl e cont inu ous Urovagina may be a conseq uence of th e mare)s
patterns. Casli ck's procedure is performed to oversew natural perineal confo rmatio n or the result of
the subm ucosal perineal tissues and appose the vulvar alterin g the perineal confo rmatio n during a rec-
lips.
tovaginal fist ula repair and can be add ressed with
a urethroplasty procedu re. 2 Mares should be
mo nitored closely during subseq uent foa lings
because the fibrous tiss ue from the repair may
POSTOPERATIVE CARE red uce the elasticity of the birth canal and predis-
pose the mare to additional birthing traum a. 7 As
Postoperative (are the sutures are progressively placed in the caudal
tiss ues) care must be taken to avoid narrowing of
Exercise Restrictions: Sma ll-paddock turnout the rectal lumen) which will predi spose the mare
should be maintained for 30 days. to tenesmus and co nstipatio n.
Medications: Broad-spectrum antibiotics are
administered for 7 to 10 days. A nonsteroidal anti-
infiammatory agent is administered for 3 to 5
days. COMMENTS
Suture Removal: Perineal and Caslick's sutures
should be removed 10 to 14 days after surgery. Epidu ral anesthesia is occasionally insufficient for
Dietary Modifications: Free-choice access to
some rectovaginal procedures. Local anestheti c
grass, a gruel diet, or both should be provided for
techniques have bee n developed to ei ther supple-
30 days, with gradual return to normal diet. Occa-
sionally, mineral oil may be added to the diet to ment or replace epidural anesthesia. The perineal
maintain a soft manure consistency. area can be dese nsitized by infiltrating local anes-
Other: Sexual rest is recommended until the fol- thetic laterally between the rectum and the pelvis.
lowing breeding season. A needle long enough to extend approximately 1
inch cranial of the area to be desensiti zed sho uld
be used. One hand is inserted in to th e rectum and
the needle is inserted through the skin at th e 9 to
EXPECTED OUTCOME 10 o'clock position lateral to the rectum. The
needle is then advanced parallel to the rectum in
Primary healing is reported to occu r in approxi- the loose connective tissue lateral to the rect um.
matel y 75% to 90% of repaired third-degree per- Twenty to 40 mL of local anesthetic are injected
ineal laceratio ns. 2 -7 Short-term co mplicat ions as the needle is withdrawn. The procedure is then
234 FEMALE UROGENITAL SURGERIES

Pudendal n.

Caudal rectal n.

e;" (>,..-.-t;" .1.-"", ____


Figure 42-9 Illustration for performing subsacral anesthesia in the horse. The left hand is placed in the rectum to
identify the ventral sacral foramina and a needle is inserted on midline a third of the distance from the anus to the
base of the tail, directed toward the foramen identified by the left hand.

repeated on the other side at the 2 to 3 o'clock desensitized by this block include the perirectal
position. region, the entire caudal region overlying the
Another technique of subsacral anesthesia has semitend inosus and semimembranosus muscles,
been described. The tail is wrapped and retracted and most of the perineum excluding the vulva and
dorsally. One hand is inserted into the rectum to the area immediately surrounding the vulva. In
locate the sacral promontory. The hand is drawn males, the penis and retractor penis muscles will
back along the sacrum 2 to 3 em from midline to be desensitized. 8
locate the ventral sacral foramina. By counting
back, the third ventral foramen (exit of the
pudendal nerve) is found. The index or middle REFERENCES
finger remains on this point (Figure 42-9) . With
the other hand a needle (LIp to 6 inches in length) I. Beard W: Standing urogenital surgery, Vet c/in N Am
with a short beveled point is inserted on midline Equine Pract 7:669, 1991.
a third of the distance from the anus to the tail 2. Belk nap JK, Nickels FA: A one-stage repair of third-
base, and directed toward the ventral sacral degree perineal lacerations and rectovestibular fistu-
foramen. A syringe is attached to the needle and lae in 17 mares, Vet Surg 21 :378, 1992.
approximately 20 mL of anesthetic solution is 3. Stjck1e RL, Fessler JF, Adams SB: A si ngle-stage tech-
nique for repai r of rectovestibular lacerations in the
injected. The syringe is removed and the needle
mare, Vet SlIrg 8:25, 1979.
withdrawn 5 to 6 em until the point reaches the
4. O'Reilly JL, Maslean AA, Lowis TC: Repair of third-
fou rth sacral foramen (exit of the caudal rectal degree perineal laceration by a modified Goetz tech -
nerve) and 20 mL of anesthetic solution is like- nique in twenty mares, Equille Vet J 10:2, 1998.
wise injected. The entire procedure is repeated on 5. Phillips TN, Foerner JJ: Se mitransverse closu re tech-
the other side so that a total of 80 mL of anaes- nique for repair of perineal lacerations in the mare,
thetic is required. Within 5 to 20 minutes areas Proc Am Assoc Equine Pract 44: 191, 1998.
Third-Degree Perineal l aceration Repair 235

6. Aa nes WA: Surgical man agement of foaling injuries, 8. Popescu P, Paraipan V, Nicolescu V: Anestezia sub-
Vet Clill N Am Equine Pract 4:417, 1988. sacrala 1a taur si la cal. Probleme ZootelJl/ice SI Vet-
7. Co lbern GT, Aanes WA, Stashak TS: Surgical man- erillare Of. 3:46, 1958. In Westhues M, Fritsch R:
ageme nt of perinea l lace rations and rectovestibular Anilllal allaesthesia, Vol. 1, p. 180, Edinburgh and
fi stulae in the m are: a retrospective study of 47 cases, London, 1964, O liver and Boyd. ("Local Anaeste-
] Alii Vet Med Assoc 186:265. 1985. sia" translated from German by A.D.Weaver)
CHAPTER 43
Rectovaginal Fistula Repair
John C. Janicek

is co nfirmed) the tail is wrapped and securel y


INDICATIONS
retracted. Fecal material is removed from the
rectum and vagina. The perineal regio n is rinsed,
Dystocia. traum atic breeding, or unsuccessful
followed by cleansing of the rectu m and vagina
third -degree perineal laceration repair resulting in
with a d ilute povidine-iodine solution. The per-
rectovaginal fistula formation.
ineal reg ion is then aseptically prepared. The
preparatio n solution should be rin sed wi th sterile
saline) not alcoho l) as alcohol may ca use excessive
EQUIPMENT irritation.

Long-handled instrum ents and monofilam ent


absorbable suture materials are required . An SO- PROCEDURE
degree scalpel handle is hel pful for the direct
repa ir technique described. Self-retaining retrac- Va rio us repair tec hn iques are described. Princi-
tors (Balfour, mod ified Finochietto) and a good ples for all techniqu es include complete debride-
light so urce (floor lamps) headlamp, or fiberoptic m ent of th e fistul a margin, minimal tensio n on
lights) are useful but no t required. the repair, and maintaining a soft manu re consis-
tency after su rgery. Modifi cation of the techniques
can be perfo rm ed based on surgeo n preference.
PREPARATION AND POSITIONING
Direct Repair
Surgery is delayed fo r 4 to 6 weeks following
fistula formation to allow wound contraction and Fistulas up to 10 em have been repaired usin g this
inflammation to subside. Delaying surgery for th is techniqu e. I This technique preserves the perineal
period allows the wound edges to strength en and body and anal sphincter) res ulting in good
become clearly defined before repair is attempted. prima ry healing and m inimal swelling and pain
A gruel or pasture diet is red 3 to 5 days prior to after surgery. Complete fistula margin debride-
surgery, and the mare is fasted 1 day before ment, which can be diffi cult in craniall y located
surgery. fistulas) is the major limitation of the direct repair.
The repair can be performed with the horse The anal sp hincter is dilated with self- retaining
standing or under general anesthesia. For stand - retractors o r by placing umbili cal tape through the
ing procedures, the mare is restrained in a stock, anal sphincter 2 cm lateral to each side of dorsal
and surgery is performed folJowing epidural anes- midline and secu ring the tape around the base of
thesia) and sedation if necessary. Once anesthesia th e tail. Towel clamps or retention sutures are

236
Redovaginal Fistula Repair 237

positioned along the ventrolateral aspect of the subm ucosa is apposed tra nsversely with No. 1
sphin cter fo r retraction if self-reta ining retractors absorbable suture using a si mple interrup ted
are not used (Figure 43~ 1). The fistula margin is pattern. The sub mucosal sutures should be pre-
incised circumferentially (Figure 43-2), exposing placed beginning in the lateral aspects of the
the submucosal tissue and incised edges of the fistula and tightened after all sutures have been
rectal and vaginal mucosae (Figure 43~3). Taking preplaced. Care should be taken to avoid purchase
large, closely spaced ( 6~ to 8~ mm ) bites, the of the rectaJ and vaginal mu cosa within these bites
(Figure 43~4). The rectal mucosa is then apposed
transversely with No. 0 absorbable suture using a
continuous horizontal mattress pattern (Figure
43-5), Clos ure of the vagi nal mu cosa is optional.

Schiinfelder Technique
FistuJas up to 6 em have been repaired with this
technique. 2 As long as principles of flap develop-

..

Figure 43-1 Dilation of the anal sphincter using


umbilical tape secured around the base of the tail and ~U;;",";C.••l'4"-
ventrolateral position ing of towel clamps allows good Figure 43-3 Exposure of fresh submucosal tissue
visualization of the rectovaginal fistula. and incised edges of the rectal and vaginal mucosae,

--
v
Figure 43-2 Circumferen tial inci-
sion of the fi stula using an 3D-degree
scalpel handle.
238 FEMALE UROGENITAL SURGERI ES

A B
~~~ ~. ... -

Figure 43-4 A, Preplacement of submucosal suture


pattern in a transverse direction beginning in the
corners of the fistula using a simple interrupted pattern.
B, Sagittal cross section of submucosa suture place-
ment. Avoid penetrating the rectal and vaginal
mucosae.

~~~.l>" -

Figure 43-6 Transverse cross section of a dorsally


based U-shaped vagina l tissue flap originating from the
lateral vaginal waU.

A mm from the fistula margin. Once the flap is


rotated, the vaginal mucosa faces dorsally into the
rectum and its margins should extend at least 2
mm beyond the fistula margin (Figure 43-7). The
flap is circumferentially secured to the edges of
the fistula with No. 0 abso rbable suture using a
B simple interrupted pattern. The rectal mucosa
~~.-~­
sho uld not be penetrated when securing the flap
Figure 43-5 A, Transverse apposition of the rectal
mucosa using a continuous horizontal mattress pattern.
to the fistula margin. Closu re of th e rectal mucosa
B, Sagittal cross section of rectal mucosa suture place- is not required.
ment.
Bemis Technique
ment are respected, this technique avoids exces- This technique ca n be used to repair large fistu-
sive tension on wound closure and minimizes las.'" Ca ud ally located fistulas can be easily and
swelling and pain after surgery. efficiently repaired, leaving the caudal rectum and
Following full-thickness fistula debridement, a anal sphincter intact. The major limitations of this
U-shaped vaginal tissue (mucosa and submucosa) technique are redu ced exposure and difficult
pedicle flap is made from the lateral vaginal wall closure of large cranially located fistulas. Addi-
closest to the fistula (Figure 43-6). The base of the tionally, increased sca r tissue formation in the
flap should be as wide as the fistula and at least perineal region may compromise the elastic
two-thirds the length of the flap. The flap length nature of the dorsal vaginal region.
should provide sufficient length to achieve rota- An 8- to lO-cm transverse perineal incision is
tional transfer to cover the fistula without tension made equidistant from the ventral surface of the
on the flap. The base of the flap should be I to 2 anal sphincter and the dorsal commissure of the


Redovaginal Fistula Repair 239

/
I

Figure 43-7 Transverse cross section of a vagi nal


tissue fla p rotated into position so that the vaginal -.;;.e......l.J' u -
mucosa is facing dorsally and its margins are at least Figure 43-8 Co mplete horizontal dissection
2 mm beyond the fistul a margin. The flap is circu rn - between the ventral surface of the anal sphincter and
ferentially secured to the edges of the fistula using a dorsal com miss ure o f the vulva extendi ng th rough the
simple interrupted pattern. fis tula to create rectal and vaginal shelves. The dotted
lines indicate proposed areas of dissectio n.

vulva. Dissection is continued cranially in a hori-


zo ntal plane through the perineal body and rec- using a continuous horizontal mattress pattern.
tovagi nal shelf, attempting to se parate the fistula The vaginal mucosa is longitudinally or trans-
into two equal-thickness fistulas (rectal and versely ap posed with No. 0 absorbable suture
vagi nal) (Figure 43-8). The rectal and vaginal using a continuous horizontal mattress pattern.
mucosae are circwnferentiaUy dissected approxi-
mately 2 to 3 em from the underlying tissue sur-
Huber Technique
rounding the fistula. Avoiding the rectal mucosa)
the rectal fistula is transversely closed with No.1 This technique is a combination of the Bemis and
absorbable suture using an interrupted Lembert conversion to third-degree laceration techniques
pattern. The sutures are preplaced beginning in that can be used to repair large fistulas. 5.6 Longi-
the lateral aspects of the fistula and tightened after tudinal divi sion of the vaginal shelf provides
all have been prep laced. The vaginal fistula is then exceUent exposure and surgical access for suture
longitudinally closed with No. I absorbable suture placement. Healthy tension -abso rbing rectal
using an interrupted Lembert pattern. The sutures tissues located between the fistula and perineum
are preplaced beginning in the rostral and ca udal are preserved) and broad) generous shelves of
aspects of the fistula and tightened after all have perirectal and perivaginal tissues are created.
been preplaced (Figure 43-9). After both fistulas An 8- to lO-cm transverse perineal incision is
have been closed) the remaining tissue surround- made equidistan t fro m the ventral surface of the
ing and caudal to the fistulas is closed with No. 0 anal sphincter and the dorsal commissure of the
absorbable suture using a simple interru pted vulva. Dissection is continued cranially in a hori-
pattern. The transverse perineal skin incision can zontal plane through the perineal body and rec-
be left to heal by second intention or primarily tovaginal shelf) attempting to separate the fistula
closed with No. 2-0 nonabsorbable suture using a into two equal-thickness fistulas (rectal and
simple interrupted pattern. The rectal mucosa is vaginal) (see Figure 43-8) . The rectal and vaginal
transversely apposed with No. 0 absorbable suture mucosae are circumferentiaUy dissected approxi-
240 FEMALE UROGENiTAL SURGER IES

......
~e-""t.-. t.~~­

Figure 43-10 Appearance of the surgical area afte r


a longitudinal midline incision is made thro ugh the
vaginal shelf.
Figure 43-9 After dissection , the rectal fistula is
transversely closed and the vagi nal fistula is longitudi-
nally closed using an interrupted Lembert pattern.
Su ture preplace ment sho uld begin in the lateral and
cranial aspects, respectively, of each fistula. Submucosal
tissue surround ing and caudal to the fistula is closed
using a simple interrupted pattern. The perineal skin
incision can be left to heal by second intention or pri-
marily closed using a sim ple interrupted pattern.

mately 2 to 3 em from the underlying tissue sur-


rounding the fist ula.
A longitudinal midline incision is made
through the vaginal shelf from the fistul a caudally
to the exterior (Figure 43- 10) . The vaginal mucosa
is inverted toward the vagi nal lumen with No. 0
absorbable suture using a Connell pattern. This
suture pattern is co ntinued ca udally to recon -
struct the cran ial half of the defect and then tied
but no t cu t. If desired, the rectal mucosa is trans-
versely apposed from the vagin al side with No. 0
absorbable suture using a Connell pattern from
the vaginal side. The rectovaginal shelf is closed
with No. 1 absorbable suture using a six-bite
purse-st rin g pattern. Successive bites are taken in Figure 43-11 Vaginal mucosa inversion towards the
the rectal submucosa, lateral perivaginal tissue, vaginal lumen using a Con nell pattern. A six-bite purse-
and vaginal submucosa o n each side with the knot string pattern is lIsed to close and el im inate dead space
ti ed deep to the rectal mucosa (Figure 43-11 ). between the rectal and vaginal shelves.
Redovaginal Fistula Repair 241

Sutu res are positioned approximately 1 em apart,


avoid ing the vaginal and rectal mucosa. O nce the
cran ial half of the rectovaginal shelf is recon-
structed, clos ure of the vaginal mucosa is com-
pleted, foll owed by closure of the remaining
caudal half of the rectovaginal shelf. The trans-
ve rse perineal ski n incision is closed with No. 2-0
nonabso rbable suture usi ng a simple interrupted
pattern . If indicated, easlick's procedure is per-
fo rm ed to appose the vulvar openi ng.

Klug Technique
Fistulas up to 6 em have been repaired using this
technique.7 The KIug technique provides good
vis ualizatio n, a durable and stable closure, and
good first-time healing success rate without dis-
ru pting the in tegr ity of the anal sphincter. Repair-
ing a large fistu la using this techniqu e should be •
attem pted with ca ution. Tiss ue mobilization is A
difficult in large fistula repairs and may requi re an
alternative repair method. Cranially located fist u- , ,

las shouJd not be repaired with this technique )


because of inadequate visualization and limi ted
working room.
B ~Ro/T>V"l~ce~~­
Beginning at th e caudal edge of th e fistula, an
incision approximately 1 cm in depth is made Figure 43-12 A, An incisi on (dotted lilies) approxi -
mately 1 em deep is made through the vaginal mucosa
through the vaginal mucosa and submucosa
and sub mucosa beginnin g at the caudal edge of the
extendi ng ca ud ally to the dorsal co mmiss ure of
fistula and extended to the dorsal commissure of the
the vulva ( Figure 43-12). The vaginal mucosa vu lva. Essentia lly, a second-degree per ineallacera tio l1 is
caudal to the fistula is dissected approxim ately 2 created. B, Sagittal cross section indicating the length
em and ve ntrally reflected. The cranial and la teral and depth of the incis ion (dotted lille) made through
aspects of the fistula are then horizontally split the dorsal vaginal mucosa and sub mucosa.
through the li ne of scar tissue and sepa rated into
rectal and vaginal shelves (Figure 43-13). Dissec-
ti on of the rectal and vaginal shelves sho uld
extend approximately 2 to 3 cm lateral and cranial
to the fi stula. Slight caudal traction is applied to
the cra nial vaginal shelf, and an interrupted vest-
over-pants pattern using No.1 absorbable sutu re
is used to close the fi stula (Figure 43- 14). The
Conversion to Third-Degree Perineal laceration
cranial vaginal shelf provides the ventral layer,
while the caudal rectal shelf provides the dorsal When fistulas have large diameters or are located
layer of the repair. A shelf overlap of at least 2 cm very cranial or if minimal perineal tiss ue is
should be ob tained (Figu re 43-15). The remain- present, co nversion into a third-deg ree perineal
ing vagina l su bmucosa should be apposed with laceration and subsequent repair is often reco m-
No. 0 absorbable suture using a simple inter- mend ed. T hird -degree perineal laceration conver-
rupted pattern. The reflected vaginal mucosa sion is initiated by incising from the caudal
should be apposed with No. 2-0 absorbable suture margin of the fistu la through the perineal ti ssues,
usi ng a con tinuo us horizontal mattress pattern. anal sphincter, and dorsal vulvar commissu re.
The rectal mucosa is allowed to heal by seco nd Repair of third-degree laceratio ns is discussed in
intention. Chapter 42.
242 FEMALE UROGENITAL SURGERIES

A
A

--J

B B

Figure 43 13 A, Followi ng creation of a second-


w
Figure 43 14 A, Vest-over-pants (dotted line) is used
w

degree per ineal laceration , th e dorsal vaginal mucosa to close the fistula. The first two su tures are placed
caudal to the fistula is dissected 2 em and ventrally th rough the cran ial aspect of the vagi nal shelf and the
reflected. B, Sagittal cross section of the ventrally caudal edge of the rectal shelf. B, Sagittal cross section
reflected vaginal mucosa. The dotted title depicts hori- indicating caudal traction of the vaginal shelf so that at
zontal dissection through the cranial and lateral aspects least 2 em of tissue overlap is obtained.
of the fistula, allowing separatio n of the fistu la into
rectal and vaginal shelves.

POSTOPERATIVE CARE
EXPECTED OUTCOME
Postoperative Care
Primary healing is reported to occur in approxi-
Exercise Restrictions: Small-pen turnout should
mately 65% to 100% of repaired rectovaginal
be maintained for 30 days.
fist ulas.l-l O Short-term complications such as de-
Medications: Broad-spectrurn antibiotics are
administered for 7 to 10 days. A nonsteroidal anti- hiscence or fistula formation are reported to occur
infiammatory agent is administered for 3 to 5 days. in 6% to 35% of all surgical repairs. '· 'o Subsequent
Suture Removal: Perineal and Caslick's sutures surgeries are essential when complications arise to
should be removed 10 to 14 days after surgery. improve the chances for complete healing_ Post-
Dietary Modifications: Free-choice access to operative conception rates are reported to be 33%
grass, a gruel diet, or both should be provi