evenmore important, arthroscopic surgery constitute what is and technique.The first arthroscopic surgery was meniscectomy
probably the outstanding achievement in orthopedic surgery in humans, followed by procedures such as patellofemoral
in the past decade" (Casscells1984). While the author of this malalignment, abrasion arthroplasty, shaving for chondro-
statement would probably admit to being biased, it is a malacia, and synovectomy. The advantages of arthroscopic
fair reflection on the success and acceptance of the role of meniscectomy have been well documented and arthrotomy is
arthroscopy in human orthopedics. Although generally now a rarity (Pettrone 1982, McGinty 1987). The manage-
considered a modern surgical procedure, the technique took ment of conditions involving the meniscus is also a good
considerable time to develop. The first endoscopic examin- example of how new conceptshave evolved from the increased
ation of a knee joint was performed in 1918 by ProfessorTakagi diagnostic accuracy afforded by arthroscopy and the potential
at the University of Tokyo (Takagi 1933). Later the technique to re-examine a knee with minimal morbidity Gackson1986).
was pioneered in the United States by Burman and colleagues The most important of these new concepts was probably the
(Burman 1930, Burmanet aI1934). The first practical arthro- preservation of meniscal tissue, which led to the technique of
scopewas developed by Watanabe (a pupil of Takagi) in 1960 partial meniscectomy and then to initial arthroscopic repair
(Watanabe 1960), and he also developedsomebasic principles (Keene et al 1987). The development of more complex
for arthroscopy of the knee. In 1965, his techniques were procedures followed and cruciate repairs are now performed
brought to North American by Robert Jackson of Toronto arthroscopically (Shrock & Jackson 1996). The use of
(Jackson1987). arthroscopy in man now encompassesthe shoulder, elbow,
In the early 1970s, the arthroscope began to achieve real wrist, digital, ankle, hip, and temporomandibular joints
clinical use (Casscells1971, Jackson& Dandy 1972), and the Gohnson 1986). It is the most common orthopedic procedure
first course in arthroscopy of the human knee in the United performed today; current estimates cite approximately 9000
States was given in 1973. The procedure of diagnostic orthopedic surgeons performing arthroscopy in the United
arthroscopy initially met with considerable skepticism within States alone (McGinty 1987).
circles of human orthopedic specialists until its value was Arthroscopy in the horse has gone through a similar
demonstrated in the total evaluation of the knee (Dandy & evolution. In 1949, the human pioneer Watanabe reported
Jackson 1975, Watanabe et a11978, Casscells1980). There- arthroscopy of the equine hock. Large animal arthroscopy
after, arthroscopy became firmly established as a diagnostic was first presented in the German literature in 1973
tool in human orthopedic practice, and these early days have (Knezevic pers com 1984) and appeared in the English
been the subject of reviews by Casscells(1987) and Jackson language in 1975 and 1977 (Smith 1975, Knezevic& Wruhs
(1987); the interested reader is referred to these sources for 1977). Diagnostic arthroscopy of the equine carpus was first
more information. reported in 1974 (Hall & Keeran 1975), but was described
In the middle of the 1970s, arthroscopy moved into the more extensively by McIlwraith & Fesslerin 1978. Reports of
second phase of its development, with the realization of the its use in other joints followed and diagnostic arthroscopy of
potential to perform surgery under arthroscopic visualization the equine stifle joint was reported in 1982 (Nickels & Sande
(O'Connor 1974, 1977, Dandy 1981, Jackson 1983). The 1982).
development of appropriate techniques and suitable instru- As in human orthopedics, use of the arthroscope in horses
mentation followed (Johnson 1977, O'Connor 1977, Dandy extended into surgical practice as technology and techniques
1981). It also became apparent that the therapeutic advan- of triangulation developed. Some surgical manipulations
tages of arthroscopy included not only the surgical procedures under arthroscopic visualization in the horse were mentioned
per se (which can be grouped under the heading of surgical by Knezevic & Wruhs in 1977, but arthrotomy remained the
arthroscopy or arthroscopic surgery) but also the benefits acceptedmeans of completing surgery. The first description of
from joint lavage and lysis of adhesions (Jackson 1974, equine arthroscopic surgery involved the carpus (Ommert
O'Connor 1974). The advantages were low morbidity, early 1981, Valdez et al1983) and further descriptions involved
postoperative movement and reduced hospitalization times. the carpal, fetlock, tarsocrural, and femoropatellar joints
198J). Uescriptions of diagnostic and surgical arthroscopic also led to understanding of the contribution of soft tissue
procedures in the carpal, fetlock. tarsocrural and femoro- lesions to joint disease. In the carpus, tearing of the medial
patellar joints were detailed in textbook form in 1984 palmar intercarpal ligament was first reported by Mcllwraith
(McIlwraith 1984b). At that time, the first author used in 1992 and its implications discussed by Phillips & Wright
arthroscopic surgery as the routine method of joint surgery (1994) and Whitton et al (1997a,b,c).
for virtually all conditions, with the exception of subchondral In the fetlock joints, successrates following arthroscopic
cystic lesions of the medial condyle of the femur. some carpal removal of osteochondral fragments of the palmar/plantar
slab fractures. and fractures of the proximal sesamoidbones. aspect of the proximal phalanx have now been documented
Arthroscopic techniques were subsequently developed and (Foerner et al 1987, Fortier et al 1995), and results for
described in the second edition of the book in 1990 arthroscopic treatment of osteochondritis dissecans of the
(McIlwraith 1990a). The use of arthroscopic surgery in the distal dorsal aspect of the third metacarpal/metatarsal bones
treatment of third carpal slab fractures was reported by have been reported (Mcllwraith & Vorhees 1990). Results of
Richardson in 1986; its use in the treatment of subchondral arthroscopic surgery to treat apical (Southwood & Mcllwraith
cystic lesions in the medial condyle of the femur was docu- unpublished data), abaxial (Southwood et al 1998a), and
mented originally by Lewis in 1987. Techniques for diagnostic basilar (Southwood & Mcllwraith 2000) fragments of the
and surgical arthroscopy of the shoulder were described in sesamoidbones are also available in the literature.
1987 (Bertone & McIlwraith 1987. Bertone et al 1987. Since the last edition, the results of arthroscopic surgery
Nixon 1987). At the time of the second edition, arthroscopy for the treatment of osteochondritis dissecans in the tarso-
had also been performed in the distal interphalangeal. crural joint have been documented (Mcllwraith et al1991)
proximal interphalangeal, and elbow joints. Arthroscopes and the arthroscopic approach and intra-articular anatomy
had also been used in the sinuses and tendon sheaths of the plantar pouch of the joint have also been described
(McIlwraith 1990a). (Zamos et aI1994).
By 1990, arthroscopy in the horse had gone from being a Considerable advances have been made in arthroscopic
diagnostic technique used by a few veterinarians to the surgery of the stille joints. The results of arthroscopic surgery
accepted way of performing joint surgery. Prospective and for the treatment of osteochondritis dissecans of the femoro-
retrospective data substantiated the value of the technique in patellar joint have been reported by Foland et al (1992). The
the treatment of carpal chip fractures (McIlwraith et al19 8 7). syndrome of fragmentation of the distal apex of the patella
fragmentation of the dorsal margin of the proximal phalanx was recognized and its treatment reported (Mcllwraith
(Yovich & McIlwraith 1986). carpal slabfractures (Richardson 1992). The use of arthroscopic surgery for treating certain
1986), osteochondritis dissecans of the femoropatellar joint patellar fractures was discussed in the previous edition
(Martin & McIlwraith 1985a, McIlwraith & Martin 1985), and has since been reported in the literature (Marble &
osteochondritis dissecansof the shoulder (Bertone et alI987). Sullins 2000).
and subchondral cystic lesions of the femur (Lewis 1987). In the femorotibial joints, the use of arthroscopic surgery
During this period. the use of diagnostic arthroscopy led to to treat subchondral cystic lesions of the medial condyle of
the recognition of previously undescribed articular lesions, the femur (Howard et al19 9 5) and proximal tibia (Textor et al
many of which are now also treated using arthroscopic 2001) have been reported. Cartilage lesions of the medial
techniques. femoral condyle have also been described (Schneider et al
Since 1990. there has been further sophistication of 1997). Arthroscopy has allowed great advancesin the recog-
techniques: new ones have been developed and treatment nition and treatment of meniscal tears and cruciate injuries
principles have been changed based on new pathobiologic (Walmsley 1995, 2002; Walmsleyet al2003). It has also been
knowledge and further prospective and retrospective studies used to remove fragments from the intercondylar eminence of
defining the success of various procedures. Many of these the tibia (Mueller et al1994) and allow internal fixation of
recent advances have been recorded in a recent publication another case of intercondylar eminence fracture (Walmsley
(McIlwraith 2002a). For example. there has been further 1997). Techniqueshave also beendevelopedfor diagnostic and
documentation of success rates following arthroscopic surgical arthroscopy of the caudal pouches of the femorotibial
removal of fragments from the dorsoproximal margin of the joints (Stick et al 1992, Hance et al 1993, Trumble et al
proximal phalanx (Kawcak & McIlwraith 1994, Colon et al 1994). In addition, a single cranial arthroscopic approach to
2000). Advances in understanding the pathogenesis of all three joint compartments has been developed by Boening
osteochondral disease and fragmentation in the carpus and (1995) and further reported by Peroni & Stick (2002).
fetlock have also been reported (Kawcak et al 2000. 2001). Diagnostic and surgical arthroscopy of the coxofemoral
which naturally led to progress in diagnosis and treatment. joint has been described (Nixon 1994, Honnas et al1993),
Parameters for the surgical treatment of joint injury have lesions identified and surgical treatments performed. The use
been carefully defined (McIlwraith & Bramlage 1996). of the arthroscope is also no longer confined to the limbs, and
Arthroscopic treatment of fractures in the previously con- the anatomy of the temporomandibular joint has been
sidered inaccessible palmar aspect of the carpus has been described recently (Weller et aI2002).
described (Wilke et al 2001) together with arthroscopy of The use of arthroscopy in assisting repair with internal
the palmar aspect of the distal interphalangeal joint fixation of articular fractures has become routine. This
includes fractures of the metacarpal/metatarsal condyles and previously possible. With the availability of such an a
carpal slabfractures (Richardson2002, Bassage& Richardson traumatic technique. numerous lesions and "new" con-
1998, Zekas et aI1999), Techniques have been described for ditions that are not detected radiographically can be
evaluation and treatment of so-called small joints, such as the recognized.
distal and proximal interphalangeal joints (Boening 2002, 2. All types of surgical manipulations can be performed
Boening et a11990, Vail & McIlwraith 1992, Schneider et al through stab incisions under arthroscopic visualization.
1994), In addition, joints in which lamenessis less commonly The use of this form of surgery is less traumatic, less
encountered. such as the elbow can also be examined painful, and provides immense cosmetic and functional
and treated arthroscopically (Nixon 1990), advantages. Surgical intervention is now possible in
Arthroscopic techniques for cartilage repair have been situations where it would not have been attempted
developed and recently reviewed (McIlwraith & Nixon 1996, previously. The decreasedconvalescencetime with earlier
Nixon 2002b), In general, we have tried to developtechniques return to work and improved performance is a significant
that enhance both the quantity and hyaline characteristics of advance in the management of equine joint problems. The
cartilage repair tissue while using the well-documented need for palliative therapies is decreased,as is the number
advantages of arthroscopic surgery. Techniques include of permanently compromised joints.
cartilage debridement, cartilage reattachment. chondroplasty
and subchondral microfracture (micropicking) (McIlwraith & The initial optimism and advantages of arthroscopy in
Nixon 1996, Frisbie et al1999, Nixon 2002b). equine orthopedic practice suggestedin the first two editions
The use of the arthroscope for evaluation and treatment of of this book have been substantiated. It is now accepted that
tendon sheath problems has been another area of major equine arthroscopic surgery has revolutionized equine ortho-
advancement. The arthroscope has been used to assessand pedics. Problems have and will continue to be encountered,
treat tenosynovitis of the digital flexor tendon sheath, and but we know now that many are avoidable. Although the
techniques for endoscopically assisted annular ligament technique appears uncomplicated and attractive to the
releasehave beendescribed (Nixon 1990b. 2002a. Nixon et al inexperienced surgeon, some natural dexterity, good three-
1993. Fortier et aI1999). Intrathecal longitudinal tears of dimensional anatomical knowledge, and considerablepractice
the digital flexor tendons have also been described by Wright are required for the technique to be performed optimally.
& McMahon (1999) and by Wilderjans et al (2003). The Experience and good case selection are of paramount
arthroscope has also been increasingly useful for carpal sheath importance and reiterating a passagefrom the first edition of
conditions (McIlwraith 2002a. Nixon et a12003, Textor et al this book remains as pertinent today:
2003); arthroscopic approaches have been described by
In 1975. arthroscopywas underused and needlessarthrotomies
Cauvin et al (1997) and Southwood et al (1998b). Removal were performed. The pendulum is now swinging rapidly in the
of radial osteochondromas using arthroscopic visualization other direction. The current tendency in arthroscopy is toward
is a significantly improved technique to open approaches overuse. Some surgeons seems to be unable to distinguish
between patients who are good candidates for arthroscopy and
(Squire et al 1992) and has produced excellent results
thosewho are not. and the trend istoward arthroscopy in patients
(Southwood et al1999, Nixon et al2003, McIlwraith 2002b). in whom little likelihood existsof finding any treatable disorder.
The use of tenoscopic division of the carpal retinaculum to (Casscells1984).
openthe carpal canal has been recently described (Textor et al
2003) and superior check ligament desmotomy is now done Threeyearslater,anotherauthor statedthat
arthroscopically (Southwood et al 1997, Kretz 2001. Tech-
niques for tenoscopy of the tarsal sheath have been described of those 9,000 North American surgeonsand the other surgeons
of the world performing arthroscopy,many are ill-prepared and
by Cauvin et al (1999) and methods of treatment reported by are therefore,not treating their patients fairly, Overuseand abuse
Nixon (2002a). by a few is hurting the many surgeonswho are contributing to
Synovial bursae have also been examined with the orthopedic surgery by lowering patient's morbidity, decreasing
arthroscope. Techniques have been described for arthroscopy the cost of health care, shortening the necessarytime of patients
returning to gainful employment,and adding to the development
for the intertubercular bursa (Adams & Turner 1999), the of a skill that has madea profound change in the surgical care of
calcanealbursa (Ingle-Fehr & Baxter 1998). and the navicular the musculoskeletalsystem. (McGinty 1987).
bursa (Wright et aI1999). To date, reports in the literature
have beendominated by casesof contamination and infection. Arthroscopy remains the most sensitiveand specificdiagnostic
but lesions which explain previously undiagnosed lameness modality for intrasynovial evaluation in the horse. This
referable to these sites have now been identified and treated is somewhat in contrast to human orthopedics, where
endoscopically. arthroscopy predominately is used for surgical interference
Specific advantages of arthroscopy as a diagnostic and much of its diagnostic function has or is being replaced
and surgical tool are mentioned throughout this book. by magnetic resonance imaging (MRI). Arthroscopy has
General advantages of the technique previously recognized continued to be of great benefit in the horse, with increased
include: recognition of soft tissue lesions in joints, tendons, sheaths,
and bursa. However, as stated above, while there are many
1. An individual joint canbeexaminedaccuratelythrough a benefits gained from arthroscopy, it is technically demanding
small (stab)incision and with greateraccuracythan was and the need for training remains.
l'\eTerence~ t!oruer Lf\. NIXon Aj. Uucharme NG. et al. Tenoscopic examinatioI
and proximal annular ligament desmotomy for treatment 0
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Bassage LH II. Richardson DW. Longitudinal fractures of the bone plate rnicrofracture technique augments healing of larg(
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the equine elbow. Vet Surg 1990a; 19: 93-101. Squire KR, Adams SB, Widmer WR, et al. Arthroscopic removal of a
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VetSurg 1990b; 19: 266-271. a horse. J Am Vet Med Assoc 1992; 201: 1216-1218.
Nixon AJ. Diagnostic and operative arthroscopy of the coxofemoral Stick JA, Borg LA, Nickels FA, et al. Arthroscopic removal of osteo-
joint in horses. Vet Surg 1994; 23: 377-385. chondral fragment from the caudal pouch of the lateral femoro-
Nixon AJ. Arthroscopic surgery of the carpal and digital tendon tibial joint in a colt. J Am Vet Assoc 1992; 200: 1695-1697.
sheaths. Clin Tech in Equine Pract 2002a; 1(4): 245-256. Takagi, K. Practical experience using Takagi's arthroscope. Nippon
Nixon AJ. Arthroscopic techniques for cartilage repair. Clin Tech SeikeigekaCakkai Zasshi, 1933; 8: 132.
Equine Pract 2002b; 1(4): 257-269. Textor JA, Nixon AJ, Lumsden J, et al. Subchondral cystic lesions
Nixon AJ. Sams AE. Duchame NG. Endoscopically assisted annular of the proximal extremity of the tibia in horses: 12 cases
ligment release in horses. Vet Surg 1993; 22: 501-507. (1983-2000). J Am Vet Med Assoc 2001; 218: 408-413.
l'extor JA. Nixon AJ. Fortier LA. Tenoscopic release of the equine dorsomedial intercarpal ligaments of the mid-carpal joint. Vet
carpal canal. Vet Surg 2003; 32: 278-284. Surg 1997a; 26: 359-366.
Trumble TN. Stick AJ. Arnoczky SF. et al. Consideration of anatomic Whitton RC. Rose RJ.The intercarpal ligaments of the equine mid-
and radiographic features of the caudal pouches of the carpal joint. Part II: the role of the palmar intercarpal ligaments
femorotibial joints of horses for the purpose of arthroscopy. Am J in the restraint of dorsal displacement of the proximal row of
VetRes 1994; 55: 1682-1689. carpal bones. Vet Surg 1997b; 26: 367-373.
VacekJR. Welch RD. Honnas CM. Arthroscopic approach and intra- Whitton RC. Kannegieter NJ. Rose RJ.The intercarpal ligaments of
articular anatomy of the palmaroproximal and plantaroproximal the equine mid-carpal joint. Part III: clinical observations in 32
aspect of distal interphalangeal joints. Vet Surg 1992; 4: racing horses with mid-carpal joint disease.Vet Surg 1997c; 26:
257-260. 374-381.
Vail TB. Mcllwraith CWoArthroscopic removal of an osteochondral Wilderjans H. BoussawB, Madder K. Simon O. Tenosynovitis of the
--~ "-"" -
fragment from the middle phalanx of a horse. Vet Surg 1992; 4:
269-272.
ValdezH. Richmond J. Wain L. Fackelman G. Operative arthroscopy
in the horse. Equine Pract 1983; 5: 39-42.
Walmsley JP.Vertical tears in the cranial horn of the meniscus and
its cranial ligament in the equine femorotibial joint: 7 casesand
their treatment by arthroscopic surgery. Equine Vet J 1995; 27:
20-25.
Walmsley Jp. Fracture of the intercondylar eminence of the tibia
treated by arthroscopic internal fixation. Equine Vet J 1997; 29:
148-150.
Walmsley JP. Arthroscopic surgery of the femorotibial joint. Clin
Tech Equine Pract 2002; 1: 226-233.
Tokyo:IgakuShoin.1978.
Weller RR, Maieler 1}. Bowen
..Smlth&Nephew-Dyonlcs.150MlnutemanRoad. Andover.MA01810.
Tel: (978) 749-1000. www.smith-nephew.com
.~arIStonVeterlnaryEndoscopy.175 CremonaDrive.Goleta.CA 93117.
Tel: (800) 955-7832. www.ksvea.com
.'Stryker. 5900 OpticalCourt. SanJose.CA95138. Tel: (800) 624-4422.
www.strykerendo.com
.dLlnvatec-Conmed Co. 11311 Concept Blvd.. Largo. FL 33773.
Tel: (800) 237-0169. www.linvatec.com
.'RIchard Wolf. 353 CorporateWoodsParkway. Vernon Hills. IL 60061.
Tel: (847) 913-1113. www.richardwolfusa.com
tarsophalangeal joints. Figure 2.2 illustrates the different .rZlmmer. PO Box 708. 1800 West Center St.. Warsaw. IN 46581.
fields of view of a 250 arthroscope and a 700 arthroscope in Tel: (800) 613-6131. www.zimmer.com
the same position in a tarsocrural joint. Popular choices in an .SOlympus America Inc.. 2 Corporate CenterDrive. Melville. NY 11747.
Tel: (800) 848-9024. www.olympusamerica.com
arthroscope for routine equine arthroscopy include the 300 .hArthrex. 2885 South Horseshoe Drive. Naples. FL 34104.
videoarthroscope and direct view arthroscopes from Smith & Tel: (800) 933-7001. www.arthrex.com
sleeveshave a wider diameter (5.8-6.0 mm
usedto penetratethe
sharp trocars for insertion and blunt
use of extremelylight-sensitivevideo
cold light fountain with 175 or 300-W lamp .'Baxter-Edwards, Baxter Healthcare Corp,OneBaxter Parkway,Deemeld.
-,--,- 2.7),
IL 60015. Tel: (847) 948-2000. www.baxter.com
~
light intensity. Most have a feedback electrical signal from the
camera control to light source for intensity adjustment. The
Dyonics AutoBrite IITM Illuminator, the Stryker X-6000TM
light source, the Baxter-Edwards ReliantTM xenon light
source, and the Karl Storz light source all employ useful
intensity feedbackcontrol. Most have the option to use this in
an automatic mode or to switch to manual to override the iris
control. Additionally, many video camera control systems
now also compensate for variation in light intensity, which
reduces the need for light source intensity changes.
Video cameras
Diagnostic and surgical arthroscopy can be performed by
direct visualization through the arthroscope; however, this is
now rarely practical and is no longer recommended. The risks
of contaminating the surgical field and instruments are
obvious. In addition, depth perception and ability to perform
fine movementsare severelycompromised with the monocular
vision of a small image. Projection of images through a video
screen corrects these deficiencies and allows simultaneous
observation of the procedure by several participants Gackson
& Ovadia 1985). Additionally, video documentation through
still image capture, video recorders, and digital video capture
systems (described later) provide sound surgical training,
client satisfaction, and legal sense.Lightweight video cameras
are attached directly to the eyepiece of the arthroscope
(Fig. 2.8), eliminating the need for the eyeto go to the arthro-
scope. This also provides a more comfortable operating
position since the surgeon can stand up straight, and the
hands can be placed at any level. It is also possible for an
assistant to hold the camera, which allows the surgeon use of
both hands to manipulate instruments for fine control or
accessto difficult sites.
Solid-state video cameras are now conveniently small and
light and can be attached directly to videoarthroscopes,
eliminating the coupler and any chance of fogging (Fig. 2.9).
The united arthroscope and camera can be cold soaked,
and/or gas sterilized. The solid-state cameras currently
available produce an image from either one or three chips, or
more accurately, closed coupled device (CCD)chips (Whelan
&Jackson 1992, Johnson2002). Thesechips produce excellent
image quality. Most modern cameras use digital enhancement
of the image, including motion correction algorithms, but
still output as an analog signal Gohnson 2002). Fully digital
cameras such as the Stryker 988TMvideo camera can write
directly to a CD without capture devices,and provide a dense
950 lines per inch image that requires an upgraded monitor
to derive the most benefit from its circuitry. Durable and high the flash autoclave cycle. in addition to more routine methods.
image-quality video cameras used by the authors are These cameras are well sealed. making them durable. but
available from Karl Storz (Telecom SL camera), Smith & have previously been available only as single-chip devices.
Nephew -Dyonics (ED-3 and D3 three-chip cameras; HD900 reducing the image quality. The authors' preferred method of
single-chip camera), Stryker Endoscopy (888 and 988 three- sterilization is with ethylene oxide gas (see Sterilization of
chip cameras), and Arthrex. Severalmanufacturers produce Equipment). This requires a minimal exposure/ventilation
autoclavable cameras: for example, the Smith & Nephew - time of 12 hours and. therefore. is usually suitable only for
Dyonics 337 three-chip camera, which can be sterilized using the first surgery each day: Cameras for subsequent surgeries
used in human small joint surgery are also frequently
inadequate (Oretorp & Elmersson 1986). The hand pump
allows the surgeon to broadly control the degree of distention
as well as the irrigation flow rate. A relationship between
fluid pressure and fluid extravasation into the soft tissues has
been recognized in man (Morgan 1987); extravasation
occurs at approximately 50 mmHg (Noyes et al 1987).
Control of fluid pressure is therefore desirable.
The most popular system for fluid delivery is now a
sleeve.In countries where ethylene oxide is not motorized pump. Such pumps can provide both high flow
rates and high intra-articular pressures.rThe simplest and
moisture betweenthe arthroscopeand camera favored pump for two of the authors (C.WM. and I.M.W) is
an infusion pumpk, such as the one illustrated in Fig. 2.11.
largely eliminated with cameraswhich have large, Such pumps are relatively inexpensive (Table 2.1) and provide
high flow rates on demand, which is particularly useful for
vents is employed.the problemcan be distention of large synovial spaces (see also Chapter 3), but
automatic control of the pressure is lacking (Bergstrom &
and also by using warm irrigating fluid. Anti- Gillquist 1986, Dolk & Augustini 1989). If an outflow portal
is not open, excessive intra-articular pressures may cause
joint capsule rupture (Morgan 1987). Extravasation of fluid
is also a complication whenever excessive pressures are
irrigation system generated, and compartment syndrome has occurred using
mechanical pressure delivery systemsin man.
polyionic fluid is used for joint distention and The ideal pressure and flow automated pump should be
~ during surgical arthroscopic procedures. The
capable of delivering necessary flow rates on demand, keep
an intravenous set connected to pressure at adequate yet safe levels, and include safety
features such as intra-articular pressure-sensitiveshutdowns
to apply pressure(Fig. 2.10). This method is satis- and alarms (Ogilvie-Harris & Weisleder 1995). Many new
pumps meet these criteria, including pumps made by Arthrex,
is economical and provides distention superior to Stryker Endoscopy,Smith & Nephew -Dyonics, Karl Storz,
feed developedby suspendingthe fluids abovethe
.'3M Orthopedics
Pro :ts Division, 3M Cent. MN
1000. Tel: (888) 364. 77. www.mmm.com
rIossettCrossroad,PO.275.
www.davol.com
No 31
us
120 N/A No Fair
N/A
1.0 No 69 Good
saline is not physiologic and inhibits normal synthesis of
proteoglycans by the chondrocytes of the articular cartilage
(Reagan et al1983). Any matrix depletion of the cartilage
during normal arthroscopic procedures would be minor and
certainly not permanent Gohnson et aI1983), but when the
cost of each fluid is similar, the use of the most physiologic reservoir gas tank, including the Karl Storz and Richard WoU
solution is logical. The results of another study evaluating units (Fig. 2.16). Others, such as those from Unvatec, Stryker,
the acute effects of saline and lactated Ringer's solution on and Directed Energy, use a direct step-down valve system
cellular metabolism demonstrated an acute stress to both from a commercial tank (Fig. 2.17). Arguments have been
chondrocytes and synoviocytes immediately after irrigation advanced for the use of gas insufflation of the joint rather
with both fluids, although this was greater with saline. These than fluid distention during arthroscopy (Eriksson & Sebik
stress patterns (monitored by evaluating relative ATP 1982); the gaseousmedium (carbon dioxide, helium, or nitrous
regeneration) are apparent after 24 hours, appear to oxide) results in a sharper image with higher contrast. As
be returning toward normal by 48 hours, and are not well as being useful for photographs, some evidence exists
significantly different from control values 1 week later. Based that it may offer an increased degree of accuracy in assessing
on these results, protection from full activity during this time cartilage damage in some situations (Eriksson& Sebik 1982).
period was considered advisable (Straehley 1985). In addition, it can prevent synovial villi from interfering with
Gas insufflation has been used routinely in equine arthro- the visual field. However, a pressure-regulating device and a
scopy by two of the authors G.B. and A.J.N.). Several types special system are necessary for gas insufflation. In addition,
of gas insufflators are available. Most have a small internal gas escapes easily after removal of any appreciable mass
portal. Gas emphysema,pneumo-
have been identified as
arthroscopy Gager 1980), and
but many procedures start with liquid distention and only use
gas for short periodsof defined activity, which limits emphysema.
Removal of small particles by suction obviously requires a fluid
medium, and fluid irrigation will also be necessaryat the end of
any procedure for lavageand removal of debris.
At this stage,the authors considerthe use of fluid irrigation
more convenient and experience with the use of fluid can
eliminate many of the problems associated with synovial villi
obstructing visualization. No additional equipment is necessary;
and although the imagesobtained have somewhat lesscontrast
compared with images from gas-filledjoints, superficial dalhage
to the articular cartilage and other lesions are seen more
readily in the form of floating strands. Nonetheless,the addition
of gas may be a necessaryand convenient step in the future if
bone grafting, laser surgery,or fibrin-based cell grafting become
an important feature of arthroscopic surgery.
Egress cannula
An egresscannula (Fig. 2.18) is a necessaryitem for most
arthroscopicprocedures.It has an accompanyinglocking
trocar with either a sharp stylet or conical obturator. The areavailablefrom all arthroscopicinstrumentmanufacturers.
cannula is used to flush fluid through the joint in order to Probesfrom differentmanufacturersvary in length and end
clear blood and debris and optimize visibility. The outer end configuration. The probe end can be round, square or
has a luer attachment through which fluid can be aspirated rectangularand can vary from 3 to 6 mm in length. Longer
or to which a long, flexible egress tube can be attached to tips on the probecan hamperentry to the joint bytangling in
transmit fluid to a bucket on the floor rather than having it the capsule,while smallerprobesare easyto insert but are
spillover the surgical site or equipment. The authors use a 2- more proneto bending.A 3-mmrectangularend probewith
or 3-mmegress cannula (Fig. 2.18a) routinely at the beginning taperedshaftis convenientand durable(seeFig. 2.19). The
of the arthroscopic procedure to flush the joint and to probe handle on probescan vary from a round smoothshaft. to a
and manipulate lesions. A larger diameter (4. 5-mm) cannula rectangular shaft, which is easier to grasp, and to the
(Fig. 2 .18c) can be used at the end of the procedure for additionof a thumb bar for directedapplicationof pressure.
clearing debris. The 3-mm cannula usually is inserted without
the use of the stylet, because a portal has been made with a
blade. A conical obturator (Fig. 2.18d), however, is useful to Forceps
facilitate placement of the larger 4.5-mm cannula at the end Currently. the authors use seven different forceps for
of the procedure. retrieving fragments and trimming lesions (Figs 2.20-2.24).
1. Routine use. The workhorse in most arthroscopy packs is
Hand instruments for the Ferris-Smith intervertebral disc rongeur. For removal
of large fracture fragments and osteochondritis dissecans
arthroscopic surgery
flaps. a pair of Ferris-Smith cup rongeurs with a 7-inch
As mentioned previously, a myriad of instruments are avail- shaft and a straight 4 x 10-rom bite (Scanlan Instruments)
able from arthroscopic equipment manufacturers (Caspari is used. These forceps are better than other types for this
1987, Gross 1993, Ekman & Poehling 1994), most of which purpose. Variation exists with regard to the shape of the
are neither suitable nor necessary for equine arthroscopic jaws on different 4 x 10-rom Ferris-Smith rongeurs. A
surgery. The instruments presented in this section are those narrow-nosed pair made by Sontec (Scanlan) is useful for
used by the authors to perform the procedures described in carpal and proximal phalangeal fragments. They pass
this book. It is accepted that there are alternative, and through the instrument portal easily and are appropriate
possibly better, ways to perform any given task and tech- for small and medium-sized fragments (Fig. 2.20). Another
niques certainly will change. The current list is written with pair of Ferris-Smith rongeurs with a 6 x l2-rom cup is
the philosophy of keeping arthroscopy simple and practical used for larger fragments (Fig. 2.20). A set with the jaw
without compromising standards. A combination of angled up and with a 4 x 10-rom cup are also useful in
specialized arthroscopic instruments and instruments not some tight situations. Some surgeons use a pituitary
designed specifically for arthroscopic surgery is used. rongeur for longer fragments.
2. Small fragments. Also recommended is a pair of straight
Blunt Probe ethmoid rongeurs with a 5-rom bite (Richard Wolf or
Scanlan Instruments). These instruments have a pointed
This standard arthroscopic instrument (Fig. 2.19) is necessary nose and are useful for procedures involving chip fractures
for diagnostic as well as surgical arthroscopy. Suitable probes off the proximal aspectsof the first phalanx (seeChapter 5).
Fig. 2.19
(A) Variety of arthroscopic probes, from
large to small format, and with round.
rectangular and thumb plate handles.
(B) Probe ends vary in shape and size.
~
3. Long-handled forceps. A more verSatIle and longer
alternative to the Ferris-Smith rongeur is the Mcilwraith
arthroscopy rongeur (Fig. 2.21), made by Sontec
Instruments? Pituitary rongeurs are also used by other
arthroscopic surgeons for the same purpose.
4. Tight spaces. A small angled rongeur with slightlJl
pointed tip (Fig. 2.22), often referred to as a patella
rongeur (Sontec or Richard Wolf), is especially useful foI
retrieving small fragments from difficult places, including
.nSontec (formerly Scanlan) Instruments Inc., 7248 Tucson Wa~
Englewood, CO 80112. Tel: (800) 821-7496. www.Sonte.
Instruments.com
the palmar surfaceof the metacarpalcondyleor proximal Elevators and osteotomes
phalanx, the palmar recessesof the midcarpaljoint, and
the underside of the patella. The use of sharp-edged The instruments primarily used for separating fragments
rongeur-typeinstruments is preferredin most situations from parent bone include a small round-end curved periosteal
whenpiecesto beremovedare still attachedby softtissue. elevator or a straight narrow osteotome. Examples include
5. Loose bodies. Loosebodiescanberetrievedwith custom the small (6-mm) round-end SynthesO elevator, the 5-mm
equine loosebody forceps,since most loosebodyforceps Mcllwraith-Scanlan elevato~, and the 4-mm cottle osteotome
availablein catalogsof arthroscopicinstrumentsare not (Scanlan) (Fig. 2.25). An extra small (3-mm) curved Synthes
strong enough. For instance,Zimmerhas takenthe basic elevator is also occasionally useful (Fig. 2.25). A markedly
Ferris-Smithdesignand changedthe endsof the jaws for curved sharp-end periosteal elevator (Fig. 2.26) is useful for
removing apical sesamoid fragments (Foerner elevator;
specificpurposes.
6. Cutting forceps. Basketforcepsare used occasionally Scanlan Instruments; see Chapter 5).
(Fig. 2.23) for removal of cartilaginous flaps of osteo-
chondritisdissecansin the femoropatellarjoint. A narrow, Cutting instruments
modifiedbasketforceps(seeCutting Instruments section)
is useful for severing soft tissue structures such as Numerous cutting instruments are available. Their use is
villonodular pads. limited to certain situations. If sharp severance of structures
7. Broken instrument retrieval. A fragmentforcepswith a is required. special arthroscopic cutting instruments should
malleable shaft is also occasionally useful, but not be used. The authors have used both reusable blades and
essential.Theseforcepsare illustrated in Figure 2.24 and disposable blade systems (Fig. 2.27), made by Karl StOrzb,
are madeby ScanlanInstruments(Sontec).
."Synthes (USA),POBox 1766, 1690 RussellRoad,Paoli, PA 19301. Tel:
(800) 523-0322. www.synthes-chur.ch
.nSontec (formerly Scanlan) Instruments Inc., 7248 Tucson Way,
Englewood.CO80112. Tel: (800) 821-7496. www.SontecInstruments.
com
.~arl Stol"lVeterinaryEndoscopy.175 CremonaDrive. Goleta,CA93117.
Tel: (800) 955-7832. www.ksvea.com
Wolfe, BeaverP,Dyonics, Acufex-Smith & Nephe~, Concept-
Linvatec-Zimmer, and Bard-Parker. Sheathed blades are
also available and eliminate the risk of inadvertent
damage to other structures when introducing the blade
(Fig.2.28).
.nSontec (formerly Scanlan) Instruments Inc.. 7248 Tucson Way.
Englewood.CO80112. Tel: (800) 821-7496. www.SontecInstruments.
com
."Richard Wolf. 353 Corporate WoodsParkway. Vernon Hills. IL 60061.
Tel: (847) 913-1113. www.richardwolfusa.com
."Beaver SurgicalProducts.Becton-Dickinson.BDMedicalSystems.1 Becton
Drive. Franklin Lakes.NJ 07417. Tel: (800) 237-2762. www.bd.com
.qAcufex Microsurgical Inc.. Smith & Nephew. 150 Minuteman Road.
Andover. MA 01810. Tel: (978) 749-1000. www.smith-nephew.com
.
Acquisition of the commonlymarketed hook scissorsis
not recommendedfor equine arthroscopy.The bestscissor-
type cutting instrument available currently is the very
narrow basketforceps (Scanlan-Mcllwraith scissoraction
rongeur)(Fig.2.29).
The authorshavefound little indicationfor the retrograde
or hook knives. other than those availablefor arthroscopic
annular ligament transection(seeChapter13). A menisco-
tome can be useful for breaking down fibrous capsule
attachmentswhen freeing a chip as it makesa cleanercut
than a periostealelevator.
Curettes
Curettes are used for debridement of most osteochondral
defects, including those remaining following removal of
traumatic or developmental fragmentation, evacuation of
subchondral bone cysts, and debridement of foci of infection.
Closed spoon curettes are suitable for most purposes, but
open ring curettes may be preferable for the center of lesions
(Figure 2.30). Straight and angled spoon curettes, either 0 or
00 in size, are generally preferred for routine applications
(Fig. 2.30). A rasp is rarely necessary for smoothing debrided
bone regions in joints, but may be useful for smoothing larger
areas such as after radial osteochondroma removal. These
instruments are available in straight, offset convex and
concave designs from various manufacturers, including
Stainless Manufacturing Incr.
Self-sealing cannulas
The use of self-sealing sleevesor cannulae is a logical answel
to the loss of fluid through instrument portals. Either devict
can be used by screw insertion into the tarsocrural, shoulder
or femoropatellar joints, but they are not useful in the carpu!
.'Stainless Manufacturing In
CO91773.
and fetlock because of the close proximity of joint capsule
and lesion. Disposable self-sealing 4.5-10-mm operating
cannulae are available through several manufacturers
(Arthrex, Dyonics, Richard Wolf, or Acufe~). They are useful
for repeatedly introducing small forceps, hand tools, and
shavers,but in the horse, removal of osteochondral fragments
is the most common procedure, and this can only rarely be
done through such cannulae. A 10-mm (I.D.) threaded self-
sealing disposable cannula with insertion obturator (Clear-
trac; Dyonics -Smith & Nephew) has been useful in shoulder
arthroscopy (Fig. 2.31), otherwise operating cannulae are
still rarely used in equine arthroscopic surgery.
Vacuumattachments
Various instruments, including forceps and curettes, are
available with attachments so that suction can be applied as
they are used. The S.2-mm DyoVac (Fig. 2.32) suction punch
rongeur (Smith & Nephew -Dyonics) is used by one of the
authors (A.J.N.) for minor synovial resection, cartilage and
soft bone removal, or larger soft tissue pad or meniscus
trimming. As such, this versatile rongeur gets more use than
most instruments in routine arthroscopy. Further, it often While motorized equipment should be used only with due
prevents having to set up motorized equipment. Use of consideration to the synovial environment and tissues. these
suction enables instant removal of debris as it forms during instruments are extremely efficient and some surgical
debridement within the joint. However, with the high fluid procedures can only be done effectively with such equipment.
pressures used in equine arthroscopy, suction is often un- Synovial resection. whether performed locally to improve
necessary as free material is often spontaneously flushed out visualization of lesions or therapeutically on a subtotal basis.
through the suction channel. The use of suction during any can only effectively be performed with motorized apparatus.
procedure requires an increased rate of ingress fluid delivery. Similarly, some large areas of osseousdebridement. such as
In general, the authors prefer to perform hand debridement in shoulder or stifle osteochondrosis, become impossible to
without suction, reserving it for use with motorized instru- complete reasonably without such equipment. The basic
ments or to remove debris at the end of surgical procedures. concept of motorized instruments is a rotating blade within a
sheath to which suction can be applied. This pulls soft tissue
Motorized instrumentation into the mouth of the blade and removes debris (Graf and
Clancy 1987). Most currently available systemsare powered
A large assortment of motorized arthroscopic instruments electrically and consist of a control unit attached by an
are available from most of the equipment manufacturers. electrical cord to a motorized handpiece. The latter may be
h & Nephew. 15049-1000. operated by buttons on the handpiece or via a foot pedal to
www.sm the control unit (Fig. 2.33).
Cutting heads or blades for the motorized units can be
divided into three broad groups: (1) blades designed to
remove soft tissues such as synovium, plicae, and ligament
remnants; (2) blades to trim denser soft tissues such as
menisci; and (3) burrs for debriding bone. These blades are
mostly available in disposable forms, although renewed
interest in reusable blades has resulted from the economic
downturn in medical practice. However, even disposable
blades can be cleaned, sterilized and reused for a limited
number of procedures (not recommended by manufacturer).
In the authors' experience, this has been a safe practice.
Generally,"fatigue" damage to the blades occurs at the plastic
attachment to the handpiece or in the drive shaft of curved
synovial resectors.
The authors have experience with the Smith & Nephew -
Dyonics Arthroplasty SystemTM,the Richard Wolf Surgical
Arthro Power System, The Baxter-Edwards system, the
Stryker System, and the Karl Storz meniscotome. Dyonics
developed the original shaver, and the third- and fourth-
generation Dyonics systems (PS3500 and EP-1 shavers), are
still very popular. However,blade availability for these models
is becoming increasingly limited, and many surgeons are
upgrading to the Dyonics Power Mac system, or seeking a
different manufacturer. Current shavers have integrated
suction with hand control of suction intensity. Some
manufacturers such Smith & Nephew -Dyonics and Stryker
also have speed and rotation direction controls on the
handpiece. Rotation speedsup to 8000 rpm and bidirectional
capabilities are useful. The hand units of the Dyonics and
Stryker shavers are relatively heavy compared to Storz, Wolf,
and Baxter shavers, but the heavier units are generally more
powerful. All modern shaver motors can be autoclaved and
most can be flash-autoclaved or cold-sterilized as necessary.
Most shavermotors recognize the blade type that the user has
inserted and controls the motor speedrange accordingly. Foot
control of shaver speed and direction, including oscillation
mode, is standard.
Each manufacturer provides a broad range of disposable
blades,which often come with 6-8 cutting tip designsand with
shaft diameter sizesof 5.5,4.5, or 3.5 mm. Some of thesehave ment, villonodular pad removal, and meniscus and soft bone
a curved shaft 2 cm from the tip to allow greater maneuver- debridement, The round or oval burrs are occasionally used
ability around joints. Additionally, a miniblade range of 2.0 in chronic degenerate joints, although other blades have
and 2.9-mm cutters with a variety of tip ends also are some value in similar situations.
available. Three broad types of disposableblades (which can Modern synovial resector units are much more useful than
be subjected to multiple uses)are available (Fig. 2.34): previous types. Design changes including larger apertures,
higher speeds,narrower diameter drive shafts (easier debris
1. smooth edged resectors, e.g. Dyonics Synovator and full
clearance), spiral flutes down the length of the drive shaft,
radius blades (in 3.5, 4.5, and 5.5 mm diameter sizes)
and application of suction, have all contributed to better soft
2. toothed edged resectors, e.g. Dyonics Orbit Incisor, Incisor
tissue resection and less clogging. The oscillating mode
Plus, RazorCut, Turbotrimmer, and Turbowhisker blades
capability of the motor (the unit switches automatically
(in 3.5, 4.5, and 5.5 mm diameter sizes)
between forward and reverse) facilitates cutting of fibrous
3. burrs, round or oval, e.g. Dyonics Abrader and Notch-
tissues and decreases clogging between the blade and
Blaster in round burrs, and Dyonics Acromionizer,
housing. The speed control is computerized, with a variable
Acromioblaster, and StoneCutter in oval elongated burrs
speedcapacity from 0 to 8000 rpm. High speedsare necessary
(in 2.5, 3.5,4.0, and 5.5 mm sizes).
when using the burr, whereas slower speedsare used with the
The smooth-edged resector blades are appropriate for soft tissue blades.
synovectomy. The toothed-edged resector (for trimming Stocking of all the blade types is unnecessary; most
denser soft tissue) can be used for articular cartilage debride- surgeons developa preference for 1 or 2 soft tissue blades,and
a burr. In the Dyonics range, the authors prefer the 5.5-mm the subject of ongoing debate. investigation. and litigation
full radius blade (#7205307) for villonodular pads and (Lee et al 2002). Given these issues. RF for chondroplasty
menisci, the 4.5-mm rotatable curved orbit incisor should be avoided until further studies define safe settings.
(#7205320) or Incisor Plus (#7205687) for most other soft and the use of RF probes in cutting modes for capsule. check
tissue resection, and the 4.0-mm Acromionizer (oval burr; ligament. or annular ligament transection should use the
#7205326) or 4.0-mm Abrader (round burr; #7205324) for minimal power settings that still achieve the desired effect.
bone debridement (seeFig. 2.34). Recently, a range of dual- and should absolutely avoid cartilage and underlying bone.
use combination tips (Dyonics BoneCutter) have been intro-
duced, which resect both soft tissue and bone. These are
available in synovator and full-radius styles, and minimize Lasers
both inventory and the need to switch blades in surgery.
Use of suction on shavers generally improves cutting Lasershave beenused in arthroscopic procedures for removal
performance. However, attention to the degree of filling of of fibrillated cartilage. synovial proliferation and masses.and
the suction bottle is required to prevent the automatic suction for transection of plical and other adhesive syndromes
shut-off engaging, which can then allow fluid to flow back (Lubbers & Siebert 1997. Janecki et al 1998. Smith &
from non-sterile tubing and couplers at the bottle through Trauner 1999). They have declined in popularity in recent
the sterile patient line and out the shaver into the joint or years due to the continued high cost of the units and concern
onto the sterile field. It has been recognized as a potential risk over thermal damage to the cartilage and underlying bone
in the use of shavers for some time (Bacarese-Hamilton et al (Atik&Tali 1999. Sclamberg & Vangsness2002). Lasertypes
1991), and it is particularly likely to happen when the fluid include COpNd:YAG. Ho:YAG. and excimer wavelengths. The
ingressruns out at that same moment, removing the positive use of CO2lasers has diminished. while Ho:YAG and excimer
pressureforcing joint fluid into the suction line. Prevention lasers have persisted (Roth & Nixon 1991. Smith & Trauner
requires suction to be maintained on the tubing at all times, 1999. Doyle-Jones et al 2002). Laser capsule shrinkage for
or at the very least ensuring the joint is pressurized during shoulder and knee disorders and laser-assisted partial
suction bottle exchange. meniscectomy remain the primary use in man (Lubbers &
Siebert 1997. Smith & Trauner 1999). Laser chondroplasty
has been controversial and. despite an excellent appearance
Electrosurgical and following lasersculpting. later cartilage necrosisand mounting
radiofrequency devices researchevidence suggestthe use of laser for cartilage debride-
ment is dangerous unless extreme care in power settings and
Considerableinterest and concurrent concern surrounds the methods of application are employed Ganecki et al 1998.
use of radiofrequency (electrosurgical) devices for cartilage Sclamberg & Vangsness2002; Atik et al2003).
and synovial soft tissue procedures (Polousky et al 2000, Laser-assisted arthrodesis of the distal tarsal joints
Medveckyet al2001, Lu et al2001, Lee et al2002; Sherk et al provides a minimally invasive method for cartilage debride-
2002). Radiofrequency (RF) devices utilize extremely high- ment and articular desensitization (Hague & Guccione
frequency alternating current (e.g. 330 kHz compared to the 2000). Eventual distal intertarsal and tarsometatarsal joint
60 Hz of regular alternating current), which passes to the arthrodesis can develop;however. resolution of the symptoms
tissue at the applicator tip and then through the body to exit of bone spavin do not necessarily require radiographically
at a wide grounding plate, essentially as for all electrosurgical defined obliteration of these joints.
units. The cutting and vaporizing capability depends on the
power and waveform settings. High power settings and low
voltage tends to cut, while low power settings at relatively
Still photography
high voltage denatures and coagulates tissues (Sherk et al
Historically,still photographicimageshave beenrecordedon
2002). Used in the liquid environment of the joint, both of
35-mm film using a camerawith a quick mount adaptorto
these modes have found a place for excision of tissue (plica,
the arthroscope. However,this is time consuming, risks
adhesions,villonodular masses),or denaturation of cartilage
contaminating the surgical field, and is extremely light
(cartilage sculpting or chondroplasty). Radiofrequency
sensitive.A practical alternative is to use a digital camera
devicesused in a cutting mode, at the lowest settings that will
such as a Nikon Coolpix 4500 fitted with an endoscope
still cut plica, ligament, menisci, or masses,seemto be safe if
the probe is directed away from cartilage and does not dwell
adaptor,e.g. Karl Storzrapid coupling adaptor (Fig. 2.35).
Imagesare viewedon a screenon the back of the camera,
on bone (Polousky et al 2000, Lee et al 2002). Similarly,
storedon a memorycard,and may be downloadedlater to a
thermal capsular shrinkage using low power settings has
computerfor imageadjustmentand archiving.
many proponents and seems relatively low risk (Medvecky et
al 2001). However, RF devices used for thermal chondro-
plasty at recommended settings penetrate to the subchondral Video documentation
bone and cause chondrocyte death (Lu et al 2000, 2001). -
Despite the apparent smoothness of cartilage after RF Capture of video clips as analog video on a ~-inch VCR i:
chondroplasty, the later necrosis can be devastating, and is simple and cost-effective for case documentation. It does not
however, provide duplicate copies to provide the owner or
trainer with surgical documentation, nor does it provide easy
accessto an individual caseburied in the middle of a 120-min
video tape. Review of a video and subsequent image capture capture the image (often by clicking a button on the video
for still printing is also very time consuming and does not camera), and store and arrange the images during the
lend itself well to the flow of information to the client. How- surgery. A 3.5 x 5 or 6 x 8-inch print is produced when a
ever, video and s-video formatted VCRs have become very preset number of images have been accumulated to memory.
cheap, and are better than no documentation. Further, simple The print quality (300 dpi) from a high end, digitally
video digitizing programs, such as Windows MoviemakerTM enhanced, 3-chip camera can be photographic quality
(Microsoft), iMovieTM (Apple), VideoStudio 6TM (ULead (Brown 1989). The authors have used the Sony Mavigraph
Systems), or Pinnacle Studio Version 7TM(Pinnacle Systems UP-5600MD, Mavigraph UP-5200MD and the Mavigraph
Inc), all provide a means to capture video from !-inch tapes as
UP2900 color video printers. The UP-5600MD provides
digital video (e.g. MPEG format) or as digital still images (e.g. excellent image quality at approximately $1 per page. These
JPEGformat) that can then be stored electronically or printed units sell for $4,000-$6,000. More economical storage can
out for several cents an image on a color ink-jet printer. be provided from small devices such as the Sony MavicapTM
Additionally, digital video clips can be edited, trimmed, electronic capture and storage device. This stores images on
spliced, and assembled into an annotated presentation floppy disks, which can then be printed on an office computer
using these programs. Other capture systems using Hi8
and inexpensive color ink-jet printer.
video capture have been described and for a complete review Complete digital capture and storage devices for arthro-
of arthroscopic image documentation, the reader is
scopic use are manufactured by Karl Storz, Stryker, and
directed to a recent review which provides an in-depth Dyonics. All three units are expensive, but store both digital
comparison of systems, cabling, connectors, and output still images (TIFF format-with Storz AIDA and JPEGformats
devices (Frisbie 2002). with others) and digital video clips (MPEGI or 2), with the
touch of a button on the camera head. The Stryker SDCPro
2TMand the Storz AIDA are the more sophisticated units in
Digital ima~e capture and the field of digital storage devices (Figs 2.37 and 2.38). The
storage devices units have touch screen patient input, and image editing for
still image output. Image printing can be done in the surgery
Arthroscopic image printing and storage has undergone by attaching an inexpensive HP deskjet printer, while still and
significantimprovementalong with the electronicrevolution video images are also savedon the system's hard drive. At the
of the previous decade.The simplesttechnique for image completion of each case,the files are savedon CD or DVD. The
documentationis electroniccapture and printing on a dye software in the unit provides versatile settings that allow
sublimation printer (Brown 1989. Johnson2002). Self- extensive customization of image capture and compression,
contained units such as the SonyMavigraphS(Fig. 2.36). image editing, output styles, text addition, and internet
.'Sony Electronics, 1 Sony Drive, Park Ridge, NJ 07656. Tel: access. Retail prices range from $12,000 to $16,000. The
(201) 930-1000. www.sonystyle.com Smith & Nephew -Dyonics Vision 625 Digital Capture
materials may deteriorate from thermal shock; various
materials expand and contract at different rates in response
to the rapid temperature changes in a steam autoclave. Some
manufacturers sell autoclavable arthroscopes, which provide
a more durable arthroscope for steam sterilization. Gas
sterilization with ethylene oxide is effective and safe, but it is
not always available, is time consuming and does not allow
multiple procedures in a day using a single set of
instruments.
Consequently, the use of a 2% solution of activated
dialdehyde (Cidex@,Surgikos Inc:) was developedas an agent
for cold sterilization procedures. Cidex Plus@ has a 30-day
shelf life after reconstitution, compared to the 14-day span of
Cidex@,which provides cost savings for frequent users. The
safety and effectiveness of Cidex has been documented in
12,505 human arthroscopic procedures (Johnson et al
1982). A 0.4% infection rate was noted in this series. The
arthroscope and surgical instruments are soaked for a
minimum of 10 minutes. It has been stated that more than
30 minutes of soaking can be damaging to the lens system of
the arthroscope (Minkoff 1977). Glutaraldehyde polymerizes
on standing. When this occurs, crystals can form and cause
clouding of arthroscope lenses.
The surgeon or assistant should be double gloved and
removes the instruments from the Cidex and places them in a
(Fig. 2.39) providesmany similar featuresto the sterile tray. The instruments are washed with sterile water or
saline (Fig. 2.40) and transferred to the surgery table where
be via zip disk or CD drive. and the they are dried after the surgeon's outer gloves are removed.
$9,700 to $12,000. Ancillary instruments (towel clamps, scalpel handle, needle
holder, and thumb forceps) can be previously autoclaved
within the tray, which is then used for washing the soaked
of equipment instruments. Rinsing of the equipment must be done with
care to avoid damage to the camera and arthroscope from
steam autoclaving shortens the useful life of an sharp-edged hand tools.
by causing deterioration of the adhesives
the major lenses. Seals and bonding between .'SurgikosInc.. POBox 90130, Arlington, TX 76004. Tel: (817)465-3141
accumulates, stopcocks and other moving parts cease to
function smoothly. Surfactant-containing solutions can also
erode epoxy and other thermal plastics. From personal
experience, severe damage resulted when soaking a camera
in such a solution. Another recommendation is that plastic
basins be used to soak instruments (McDonald 1984). These
basins reduce electrolytic corrosion, which can occur when
metal instruments are soaked in metal pans.
The question of the potential for Cidexto cause a chemical
reaction in joints was addressed in the literature (Harner
1988). Results of studies in rabbits showed that Cidex
induced a diffuse synovial inflammation when present intra-
articularly at concentrations of 10 ppm or greater. The
degree of synovial inflammation is proportional to the
concentration of Cidex. At 1000 ppm, chondrolysis occurs.
When using a single-rinse basin, the concentration of Cidex
in the rinse basin is 100-300 ppm; if the same rinse solution
is used, the concentration can be 1000 ppm by the fifth
procedure. Clearly, fresh-rinse solutions should be used for
each procedure. A double rinse reduces the Cidex concen-
tration in the second rinse to the order of 1 ppm. Mter
irrigation of the joint with 1 liter of saline, however, the
intra-articular concentration of Cidex is less than 1 ppm,
regardless of the rinse technique (Harner 1988).
Toxicity and safety issueshave reduced the use of Cidex in
many practices. An effective and less toxic alternative is the
peracetic acid SterisTMsystemU,which uses a liquid peracetic
acid (35%), acetic acid (40%), hydrogen peroxide (6.5%), and
sulfuric acid (1 %) soak,followed by a water rinse, for a total of
4 cyclesin a closed system,to provide sterile and virtually dry
equipment for arthroscopy (Fig. 2.41). Each sterilizing run
has a chemical indicator strip (min 1500 ppm) included to
verify the sterility of the instruments. The disadvantages are
the cost of the unit, and the process requires 30 minutes
rather than 10 minutes to complete,so emergency sterilization
for a dropped instrument still requires Cidex.
In many parts of Europe, the use of Cidex is no longer
permitted. A safe alternative is MedDisTM instrument
disinfectantV, which relies on halogenated tertiary amines,
hexamethylene biquanide hydrochloride, ethyl alcohol,
dodecyclamine, and sulfonic acid to sterilize instruments.
The 2% dialdehyde solution is properly classified as a This solution is diluted to 5%, and is then bactericidal,
disinfectant. The chemical is considered bactericidal in fungicidal, and virucidal after a 10-minute exposure, and
10 minutes, destroying all bacteria, including Myobacterium, tuberculocidal and sporicidal within 30 minutes. Shelf life
tuberculosis, Pseudomonas aeruginosa, and viruses. It is after activation is 14 days. It also has safety advantages in
sporicidal in 10 hours and therefore is considered a sterilizing that it is non-irritant, non-fuming, non-corrosive, and has no
agent after use for 10 hours Uohnson et al1982). reported effects on metal or glassendoscopecomponents.
A number of glutaraldehyde-based disinfecting solutions
are available. Use of a solution that does not contain a
surfactant is recommended (Cidex-activated dialdehyde Surgical assistants
solution does not contain a surfactant). Surfactants may leave
a residue, causing stiffening of moving parts and potential Becauseof the unique instrument requirements and the need
electrosurgical malfunction. Because surfactants lower the to have a smooth sequential system during the operation,
surface tension of the disinfection solution, the disinfectant scrub nurses or technicians participating in operative
can penetrate small cracks and crevices. This penetration arthroscopy must be especially trained. It cannot be
creates a rinsing problem, because high surface tension .USteris 20. SterisCorp, 5960 ReisleyRoad.Mentor. OR44060. Tel: (800]
prevents water from entering the cracks and crevices and 548-4873. www.steris.com
removing the disinfectant. As this disinfectant residue ."Medichemlnternational. POBox 237, SevenOaks. Kent TNI 5 02J. UK
minimal or extensivedraping by
vary from simple reuseablecloth
.
~
villi becoming thicker and denser as the disease text, is that of synovectomy; its use in man was described by
Highgenboten in 1982. It is frequently used in the horse to
the use of arthroscopy, new conditions can be facilitate the diagnostic process by allowing examination
Structures that are normal but have not of an otherwise obscure region. Synovectomy is greatly
facilitated by improved soft tissue blades for motorized units
dorsomedial intercarpal ligament in the midcarpal (see Chapter 2).
Arthroscopic synovectomy has been performed in human
.This hemophiliac patients (Casscells1987, Limbird & Dennis 1987).
often overlies a communication between the femoro- It reduced the frequency of bleeds and, with continuous
joint and the medial femorotibial joint. In man. passive motion, arthroscopic synovectomy resulted in good
" (contributing to symptomatology of the
postoperative motion (Limbird & Dennis 1987), and has been
a new clinical entity with the shown more recently to be cost-effective in treating hemo-
of arthroscopy. This condition is not common and philiac patients (Tamurian et al 2002). Results of another
assessment must be made to exclude other causes of study in man suggest intra-articular release of adhesions is
Levesque 1984). The most commonly efficacious in the management of arthrofibrosis of the knee
clinical situation is that of medial patellar plica (chronic stiffnessof the knee) subsequentto previous operative
plica (Richmond & procedures (Parisien 1988). Local synovectomy has been
1983, Nottage et al1983). A direct blow, repeated used in human knees where hypertrophy of the synovium in
or nonspecific synovitis may be the inciting event the anteromedial aspect of the joint following trauma has
to fibrosis and hypertrophy of the synovial plica. caused mild chondromalacic change on the medial femoral
occur as the plica bowstrings over the medial condyle and knee pain. Arthroscopic debridement of this
the femur. Secondary chondromalacia may also pathologic tissue significantly improves symptoms (Chow et
The authors still consider acquired plica-associated al2002). Equivalent indications may be found in the horse.
a normal Figure 3.16 illustrates hemarthrosis and the biopsy of a piece
structure is best exemplified in the horse by of synovial membrane.
and fibrosis of the dorsal synovial pad of the Potentially, clinicians could use synovectomy to treat
3.15). equine conditions involving chronic synovitis. However,
experimental work in the horse has questioned the beneficial
effects of synovectomy: Studies by Jones et al (1993, 1994)
and Theoret et al (1994) have reported that arthroscopic
Arthroscopic synovectomy synovectomy in equine joint tissues has short-lived reversible
changes on standard synovial fluid characteristics and
The remainder of this book deals in large part with clinical lameness. Both team of investigators reported that
arthroscopic surgery to correct various conditions of the regeneration of the synovial membrane was not apparent by
joint. One procedure that has been performed relatively little 30 days after arthroscopic synovectomy Gones et al1994)
in any equine joint. and is not addressed elsewhere in this and incomplete by 120 days (Theoret et al 1994). These
the mechanical and laser techniques were performed. Horses
were evaluated at 1. 3. and 6 months. Villous regeneration
did not occur in any horses after surgical synovectomy. All
synovial membranes healed with a fibrous subintima and less
populated intima. The CO2laser was capable of performing a
more superficial synovectomy than that achieved with
mechanical synovectomy using a motorized arthroscopic
synovial resector. The authors also cQncluded that
mechanical or CO2laser synovectomy could be performed in
the horse. but additional evaluation was needed before the
physiologic significance of the lack of villous regeneration
is known.
The authors of this textbook are concerned about capsular
defects and fibrosis following synovectomy. We recommend
localized synovial resection to improve visualization. but
caution against using more generalized synovial resection as
a therapeutic measure. at least in traumatic joint disease.The
use of the resector for eliminating fibrin in infected joints is
another issue and is discussedin Chapter 14. Hemarthrosis of
the synovial membrane is seencommonly in the carpal canal
in association with radial osteochondroma and may be
occasionally seenin joints. Acute hemarthrosis is commonly
seenin the early stage of severejoint injury as also occurs in
man (Butler & Andrews 1988).
Arthroscopyhasenabledveterinariansto diagnoseotherwise
unrecognized lesions of the medial palmar intercarpal
(Mcllwraith 1992) (Fig.3.17; seealso Chapter4) and cranial
cruciate (Walmsley 2002), meniscal (Walmsley 2002)
ligamentsand femorotibialmenisci(WalmsleyetaI2003).
Arthroscopic lavage
and debridement
Electrosurgery using high-frequency (HF) equipment The usefulnessof lavage in traumatic arthritis had been
(described in Chapter 2) has been used in both human and claimed prior to arthroscopic surgery becoming routine
equine arthroscopy. One of the authors G.B.)has used it quite (Norrie 1975). The adjunctive lavage that goes with
extensively in the horse. In humans. in addition to surgery on arthroscopicsurgeryhas alwaysbeenconsideredbeneficial.
the synovial membrane and joint capsules,most arthroscopic althoughthereis no clear documentationof this effect.How-
meniscal surgeries are routinely done with the electroknife by ever,the benefit of partial thickness chondrectomywhere
at least one group (Kramer et al1992). When using such there is cartilage fibrillation or minor exfoliation is more
3.31). The use of such debridement along books, attending seminars, and viewing video recordings.
, C C but controlled
"Hands on" training and practice, however, is essential.
Instruction and practice on cadavers is the most common
of the rabbit patella with no evidence of way veterinary clinicians have improved their skills before
in either the superficially or deeply shaved areas embarking on clinical cases.Animal cadavers have also been
--& Shephard 1987). Ultrastructural studies after used in the training for arthroscopy in humans (Voto et al
cartilage shavings question knee regeneration 1986); however, artificial models have also been used
Schmid 1987). A successfully.More recently, there has been some development
of equine artificial bones with joint capsules, but at present,
trial of arthroscopic surgery for osteoarthritis cadaver material is inexpensive and readily available.
knee in humans caused considerablecontroversy An interesting prospect for the future is the development
2002). The authors concludedthat the out- of computer-based simulations of arthroscopic surgery
for training and testing of arthroscopic skills (Medical
Simulations. Inc.. Williamstown. MA). Use of simulators will
increase particularly in learning human arthroscopic
techniques. There will probably be lessuse in the horse where
lavage and debridement of osteoarthritic cadaver material is still more available.
based on the severity of degeneration, continues to
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methods for large animal surgeons. Vet Surg 1997; 26: 382-385.
Mcllwraith CW; FesslerJF. Arthroscopy in the diagnosis of equine
Williamson DM, Copeland SA. Suturing arthroscopy wounds: brief
joint disease.J Am Vet Med Assoc 1978; 172: 263-268. report. J Bone Joint Surg (Br) 1988; 70: 146.
middle carpal (intercarpal) or ante-
surgical procedures and initially served
portal for eachjoint. Using two dorsal
,/
./
'"/'
Fig. 4.2
Distal radial carpal bone (R). (A) Diagram of arthroscope
position and visual field. (8) Arthroscopic view; 2. Second carp,
bone; 3,Third carpal bone L, medial palmar intercarpal ligamer
4, fourth carpal bone. I, Intermediate carpal bone; U, ulnar
carpal bone; CD, common digital extensor tendon; ECR,
extensor carpi radialis tendon.
Fig.4.3 Fig.4.4
Junction of the radial and intermediate carpal bones. Second carpal bone (2) and the medial aspect of the third car~
(A) Diagram of arthroscope position and visual field. Dorsal bone (3). (A) Diagram of arthroscope position and visual fie
(B) and palmar (C) arthroscopic views. R, radial carpal bone; (B) Arthroscopic view. (C) A more palmar view of the third
I, intermediate carpal bone; medial palmar intercarpal ligament. carpal bone. including the fossa at the medial palmar aspect I
the junction of the second (2) and third (3) carpal bones as
well as the medial palmar intercarpal ligament (L). Also note
the median ridge of the third carpal bone dividing radial and
intPrmprJi"tPf"rpt.
joints
R
A' -
Fig.4.T
Ulnar (U) and intermediate (I) carpal bones. (A) Diagram of a~roscope position and visual field. (8) Arthroscopic view.
Intermediate facet of the third (3) carpal bone.
Fig. 4.8
Distal articular surface of the intermediate carpal bone (I). (A)
Diagram of arthroscope position and visual field. (B and C)
Arthroscopic views. Note the edge of the radial carpal bone
(R) and synovial plica (P) between intermediate and radial
carpal bones. $, synovial membrane.
--
1111_i,
A
with a closed egress needle (A) and a probe (B) to evaluate the mobility of a carpal chip fragment
sIgnmCarn), oelore II ISremovea ~seeng, ':I:.L.L.). l'ems-~
arthroscopic rongeurs are most commonly employed. j
size is chosen to enclose the fragment as complete
possibleto minimize loss,as this is brought through the
capsule, subcutis, or skin (see Fig. 4.22). Rongeurs w
jaw size of 4 x 10 mm are suitable for most fragmen1
locations. Tearing a fragment loose from its soft t
attachment by twisting the forceps may not seeI
aesthetically pleasing or relate well to basic sur
principles, as sharp severance of the attachments, I:
minimizes the risk of creating a free-floating fragment.
If attachments at the fracture line are strong all(
fragment cannot be displaced with initial probing, a :
Synthes or Mcllwraith-Scanlan elevator is used to sep
the chip from the parent bone (seeFig. 4.23). Also, whe
chip has considerable fibrous capsular insertions, as typ
occurs with fragmentation of the distal lateral radius
elevator or a fixed blade arthroscopy knife can also be us
separate these attachments before removal of the frag
with forceps.
Although rarely necessary,when a chip is long-star
and bony reattachment is developing or has develope
osteotome may be used to free the fragment from the p,
bone. The osteotome is positioned through the instru
portal and is placed in the old fracture line by the sur
using arthroscopic visualization. An assistant strike:
osteotome according to the surgeon's direction. A I
osteotome or an elevator and hammering is preferred
sharp osteotome by some surgeons as it is thought to b
likely to make a new fracture line through normal bon
Foerner pers comm 1984).
In many cases of chronic fragmentation, Ferris-5
rongeurs are used to remove the fragments directly wi1
prior separation. This usually works well, but attemr
remove normal bone in this fashion may break the pin lir
of the forcep blades. If there is extensive bone prolifer.
the use of a motorized burr for debridement of lesions c:
are included in subsequentsections,but the generalrule is considered, but such indications are rare, and the val
that for a fragment on the medial side of the joint, the surgery in such casesis always questionable.
arthroscope passes through the lateral portal and the Once fragments are removed, the defect is debrided.
instrumentsenterthrough a medialportal. Forlesionson the step is discussedin detail later and is usually performed
lateral side of the joint, the arthroscopeis placedthrough a rongeurs and curettes (Fig. 4.24). Other osseous defect:
medial portal and instrumentsthrough a lateralportal. may be debrided at this time. Kissing lesions are evalu
The basicprotocolfor surgeryof all carpal fragmentation but when they are of partial thickness, they usually ar
is similar. A diagnosticarthroscopicexaminationis always debrided.
performedfirst. The egressis openedto flush the joint if The joint is then flushed by opening the egress car
visualizationis lessthan optimal. Whenthe view is clear,the and manipulating the tip in the area of the lesion (Fig. 4
egressis closedand can then be used to palpate areas of The egress can also be used to rub off small tags of carl
fragmentation(seeFig.4.21A). Alternatively,a probecanbe and bone. Placement of the larger, 4.5-mm egress car
used (seeFig. 4.21B), but the egressworks well for pre- should follow, to remove larger fragments (Fig. 4.25). Su
liminary palpationand savesan extra instrumentpassage. may be appliedto this cannula, but it is not routinely perfo
The egresscannula is then removedand the instrument in the carpus. Lavage should continue until the joi
portal through the joint capsuleusually closes,at leastuntil macroscopically cleared of debris. Occasionally, a frag
the time that a larger instrument (which increasesthe migrates away from the fracture site and is either free flo
diameterof the portal) is used.If the fragmentis freshand or attached to synovial membrane (Fig. 4.26). In such (
mobile on palpation,immediateinsertionof graspingforceps it is removed with forceps.
is appropriate.The fragmentis grasped,and the forcepsare At the completion of irrigation of the joint, the porta
rotatedto freethe chip of softtissueattachments(if theseare closed by using skin sutures only (Fig. 4.27). The incisior
Arthroscopic Surgery for Removal of Osteochondral Chip Fragmel
Fig. 4.25
Arthroscopic view of flushing debris from central area of middle carpal joint. (A) External view. (8) Arthroscopic view.
Fig. 4.26
Free fragment in the joint (A) and adhered to synovial membrane (8).
covered with a sterile nonadhesive dressing and adhesive
gauze, before an elastic or padded bandage is applied
(Fig,4.28).
The size of fragments that can be removed arthro-
scopically has no limit. The skin incision has to be extended in
some instances but additional incising of the joint capsule is
not usually required. Failure to lengthen the skin incision can
result in the fragment being lost or trapped in the subcutis. In
exceptional cases,a single absorbable suture may be placed
in the joint capsule after removal of a particularly large
fragment.
Postoperative or intraoperative radiographs to ensure grasped. Any soft tissue attachments to the fragment ill
removal of all fragments are recommended. Although it is severed while the fragment is held with forceps or a tOW
important that no loose fragments remain in the joint, some clamp. Occasionally, insertion of the arthroscope int
osseous densities in the radiographs may not be candidates subcutaneous pockets. with either no or little fluid flow, ca
for removal. In addition, osteophytes away from the articular assistin location of fragments.
margin and within the joint capsule (or enthesophytes)are of
less concern. For any fragment or spur completely buried
within the joint capsule, dissection out of the capsule is
Specific sites of carpal chip
unnecessary and is excessively traumatic. The surgeon
should be certain that such fragments are indeed outside the
fragmentation and their treatment
joint cavity and it is important to recognize that one should
Dorsodistal radial carpal bone
treat the patient rather than the radiograph. Veterinarians
involved in obtaining follow-up radiographs of arthroscopic The dorsodistal aspect of the radial carpal bone is the mo
surgery patients should also be aware of this principle before common site for carpal fragmentation. It is the easie
proclaiming to the client or the trainer that "a chip has been operative site in the carpus, but has the greatest range I
left in the joint." pathologic change seen at arthroscopy relative to what
If radiographs reveal evidence of a fragment remaining in seen on radiographs. The arthroscope is placed through tl
the joint, further arthroscopic examination is performed. lateral portal with the lens-angled proximad and the instrl
When a fragment has lodged subcutaneously, the area is ments are brought through the medial portal (Fig. 4.29
palpated and swept with a pair of hemostats. When the Fragmentation can occur anywhere along the distal dors
fragment is located, it is brought to the skin incision, and margin of the radial carpal bone.
and flexed lateromedialviews and dorsolateral-
Fig. 4.38
Arthroscopic views before (A) and after (8 and C)
debridement of bone loss from distal radial carpal bone.
There is bone loss along the entire width of the radial carpal
bone.
in other locations in the middle carpal joint
frequently in the center of the joint and are 10
the extensor carpi radialis tendon. In additiol
capsule is closer to the articular margin than is tI
the radial and intermediate carpal bones. Becal
factors, joint distention may not be as effective
clear visualization of the fragment. Also, the cb
at this site may extend beyond the attachment
capsule.
In a paper published on the incidence, lo(
classification of 371 third carpal bone fractures in
incomplete fractures of the radial facet occurred i
large proximal chip fractures of the radial facet (
140 cases, small proximal chip fractures of the]
occurred in 18 cases, medial corner fractures 0
13 cases, frontal plane slab fractures of the rad
39 cases,large frontal plane fractures involving 1
and intermediate facets occurred in 35 cases,fract
intermediate facet occurred in 13 cases, and s~
fractures of the third carpal bone occurred i:
(Schneider et alI988).
The most useful preoperative radiographs i
Fig. 4.41
Diagram of positioning of arthroscope and instrument during
operations involving a distal intermediate carpal bone chip
fragment.
Fig. 4.42
Arthroscopic views of fragments of distal intermediate carpal bone (radiographs of these fragments are in Fig. 4.40). (A-B) Small
fragment in left carpus (C-F) Large fragment in right carpus. continued
Fig. 4.43
Fragment on distal intermediate carpal bone found during
diagnostic arthroscopy for removal of a fragment on distal rad
carpal bone. The fragment is on the most-medial margin of thE
distal intermediate carpal bone and in this case was removed I
a medial instrument portal.
Dorsoproximal radial carpal bone The amount of cartilaginous damage associat
these chips is variable. and the prognosis varies aCC
The technique for operating on fragmentation at this site is Although marked erosion of the proximal surfacI
illustrated in Figure 4.49. Thesefractures are usually identified radial carpal bone can occur there, it is a su
preoperatively with standing and flexed lateromedial and impression that the antebrachiocarpal joint appea
dorsolateral-palmaromedial oblique DLPMO radiographs. As more forgiving than the middle carpal joint in hor
with other sites,the size of lesions can vary widely (Figs 4.50 similar degrees of loss from the proximal versus 11
and 4.51). The arthroscope is placed through a lateral portal articular surfaces of the radial carpal bone.
and the instrument enters through a medial portal. The
fragments can usually be well visualized and often are
relatively small (see Fig. 4.50), although significant loss of
bone occurs occasionally (seeFig 4.51).
Proximal intermediate carpal bone
With the standard medial portal, instruments must The technique for operating on chip fractures at th
approach the lesion almost end-on, and manipulation can be illustrated in Figure 4.53. Standing and flexed later
more difficult than on the distal aspect of the radial carpal (LM) and/or dorsomedial-palmarolateral oblique (:
bone. Repeated manipulation tends to cause subcutaneous radiographs (Fig. 4.54) are most useful in ide
extravasation and the medial aspectof the antebrachiocarpal fragmentation of the proximal intermediate carp;
joint is also narrower than other locations. Occasionally, a These fragments can be small, distinct and easily]
lateral arthroscopic portal can be used (Fig. 4.52). (Fig. 4.54), but. often. they are large and extend a c
QO Diagnostic and Surgical Arthroscopy of the Carpal joints
Fig. 4.48
Arthroscopic views of a partial slab fragment of the third carpal bone. (A and B) Surface defect at proximal-distal length of the
fragment respectively. (C) At removal of the fragment. (D) At debridement.
Fig. 4.49
(A) Diagram of positioning of arthroscope and instrument during operations involving a chip fracture off the proximal aspect of\
the radial carpal bone. (B) Making instrument portal.
§;7 Diagnostic and Surgical Arthroscopy of the Carpal Joints
Fig. 4.51
Radiograph (A) and arthroscopic views (8 and C) of large displaced chronic fragment from the dorsoproximal margin of the rad
carpal bone.
Fig. 4.52
(A and B) Fragmentation of the proximal radial carpal bone encountered during removal of a proximal intermediate carpal bon
fragment and being removed using a lateral instrument portal.
abledistance into the joint capsule attachments (Fig. 4.55). In in the carpal joints. Often the fragments
such cases. prior separation of capsular attachments in radiodensity, loss of infrastructure,
addition to separation at the fracture line is recommended. new bone formation. Occasionally, the
Occasionally, a chronic chip or the spur associated with it radiographic views do not demonstrate a
might have an intracapsular portion. In these cases, the event, a skyline (DPrDDiO) view of the
intra-articular portion is removed with rongeurs or a burr as recommended (Fig. 4.56B).
far as the capsular reflection only. Postoperative radiographs The technique for operating on chip fractures of the dorso-
often do not appear as satisfactory as following fragment lateral margin of the distal radius is illustrated in Figure 4.57.
removal. Nonetheless, this is considered preferable to the The arthroscope is inserted through the medial portal and
capsular trauma necessaryto remove intracapsular fragments instruments are passed through the lateral portal. The
and/or new bone. As with fragments in other locations, a position of the fragments necessitates that instruments are
relatively small fragment may be associatedwith considerable directed distad so that their shafts lie at an angle close to the
loss of articular cartilage. dorsal aspect of the carpus. The fragments are usually large
(;?;1 cm wide), with the most proximal portion attached to the
Proximal ulnar carpal bone fibrous joint capsule. These fractures are also commonly
comminuted with a wedge-shaped osteochondral fragment
Fragments at this site are rare. To perform arthroscopic palmar to the largest dorsal fragment.
surgeryfor this lesion,the arthroscopeis placedmediallyand The size of the fragment can be assessed reasonably
instruments enterthrough the lateralportal. accurately from preoperative radiographs. Damage is usually
limited to the defect created by the fragments. only and
Lateral aspect of the distal radius cartilage loss does not usually extend peripheral to the defect
(Figs 4.58 and 4.59). The arthroscopic appearance depends
These fragments are usually best demonstrated on a on the age of the fragments. In many such cases the dorsal
dorsomedial-palmarolateral (DMPW)radiographicprojection fragment appears to be acute and the palmar wedge shaped
(Fig.4.56A). Theycan be displaced,non-displaced, singleor fragment appears to be longer standing. In acute fragmen-
multiple,and frequentlyare larger than fragmentselsewhere tation there is usually hemorrhage within the fracture. When
8§ Diagnostic and Surgical Arthroscopy of the Carpal joints
Fig. 4.57
Diagram (A) and external view (B) of arthroscope and instrument during operations involving a chip fracture off the distal lateral
radius.
Fig. 4.58
Arthroscopic view of relatively small distal lateral radius fragment of a right carpus prior to removal (A), at elevation (8), at
removal with Ferris-Smith rongeurs (C), and after removal and debridement (D).
: fragments, the larger fragment is usually bony proliferation proximal to the defects within the fibrol
superficial fragments, and a deep search is joint capsule is common, and should be left alone. Debridl
in these cases. With fractures of long-standing, ment follows the basic principles outlined previously, but mc
, include areas of capsular tearing. This should be perform(
carefully and in a conservative manner in order to limit tl:
Before retrieval, large fragments are elevated (Fig. 4.59) potential for traumatizing the adjacent tendon sheath and 1
attachments severed with a periosteal elevator. avoid further capsulitis.
cup rongeurs are used to remove fragments. When these fractures are of long duration, the fractul
usually necessary to twist the rongeurs after grasping line may be obscured and the fragment is usually recognize
fragment to ensure that the fragment is free of attach- by the presence of articular erosions and irregularities.
ments before making an attempt to pull it through the joint Despite their size, the prognosis for chip fractures of th
capsule. Enlargement of the skin incision is commonly distal lateral radius is good. This is generally considered to b
necessary to bring these fragments out through the skin. the result of different biomechanical influences and becaus
Figure 4.60 depicts a chronic distal lateral radius fragment the remaining articular surface is usually not damaged to an
that was associated with osteochondral diseaseperipheral to great degree compared to other sites of carpal fragmentatior
the fracture. Damage is rarely more extensive that that noted
here, unless the lesion is chronic and mobile. Removal of
Medial aspect of the distal radius
large fragments that extend proximally into the capsular
reflection can result in penetration of the synovial sheath Fragmentation at this site is best demonstrated in
of the extensor carpi radialis or common digital extensor dorsolateral-palmaromedial oblique (DLPMO) radiograpl
tendon. (Fig. 4.61). The technique for removing fracture fragment
Mter removal of the fragment, the depths of the defectare from the medial aspect of the distal radius is illustrated il
carefully explored to find any remaining fragments. Some Figure 4.62. The arthroscope is placed through the latera
portal and the instruments through the medial portal. A
with distal lateral radius fragments, the instruments ar
angled rather flatly against the knee and directed proximac
These fragments are similar to their lateral counterparts il
that the surface damage is usually localized to the area of th
fragment. However. smaller fragments are more commol
medially but large ones can occur (Fig. 4.63). Methods (
surgical removal are the same as those described for later~
radius fragments. but sometimes on the most medial portio]
of the bone. accesswith forceps is more difficult than laterall:
The surface manifestation of these fragments varies like dist~
lateral chips. and the use of the curette may be necessary fo
chronic lesions (Fig. 4.64). Removal of very large dist~
medial radius fragments can potentially cause trauma to th
extensor carpi radialis tendon shealth with consequeIJ
synovial herniation (Fig. 4.65).
Diagnostic and Surgical Arthroscopy of the
Removal of osteophytes or spurs
The removal of spurs or osteophytes is appropriate if
have fractured off or if their interposition into the joint]
them likely candidates for later fracture. Figure
it is demonstrates spurs that were removed. These spurs n
removed with Ferris-Smith rongeurs. curettage, an ostec
on first, as subcutaneous fluid extravasation is more likely to or burr.
occur in the antebrachiocarpal joint. The loss of irrigating Most spurs that are visible radiographically ar
fluid after creation of a large instrument portal means that candidates for removal. In many instances the experi
the surgeon will need to switch to the opposite side of the surgeon can predict whether an attempt at removing (
joint to operate on a chip on the other side, and insert the is appropriate by examining the radiographs. As a gt
arthroscope into a relatively non-distended joint. If time has rule. however, the surgeon should maintain an open
, between the two entries, some blood may be in the
and examine the spur at the time of arthroscopic su
which can be cleared by irrigation. The bleeding is This statement is not to say that every carpus with a Spl
from a previously debrided subchondral bone candidate for arthroscopic surgery. As experienced clini
and occurs after loss of joint distention. With joint know, many small spurs noted in 2-year-old horses are I
and irrigation, subchondral bleeding is usually evidence of previous synovitis and capsulitis. and are
current clinical importance.
Articular cartilage and bone The amount of articular surface loss should be documente
deBeneration in association with carpal on surgical notes and may be recorded by way of a drawin
chip fractures (Fig. 4.68). Significant bone loss causes loss of cubodi~
congruency (Fig. 4.67F and G).
The presence of articular cartilage degeneration associated More subtle degreesof cartilage damage have been define
with carpal chip fragments and the debridement of degenerate and graded in man (Pritsch et al 1986) and the recent~
cartilage were mentioned previously, although this problem defined ICRS grading system (Cartilage Injury EvaluatioJ
deserves specific attention. For convenience, four grades of System 2002) is gaining acceptance. These classification
articular surface damage, as evaluated arthroscopic ally, have should not be confused with the system just described
been made (Mcllwraith et al 1987) and are illustrated in Although a more detailed breakdown of damage may b,
Figure 4.67: appropriate for guiding treatment. it may have limited ValUI
in defining prognosis.
1. Minimal fibrillation or fragmentation at the edge of the
defect left by the fragment, extending no more than 5 mm
from the fracture line (Fig. 4.67 A and B). Debridement of defects after chip
2. Articular cartilage degeneration extending more than fracture removal
5 mm back from the defectand including up to 30% of the
articular surface of that bone (Fig. 4.67C and D). A discussion of the rationale for debridement after fragmeni
3. Loss of 50% or more of the articular cartilage from the removal necessitates a brief review of current knowledg(
affected carpal bone (Fig. 4.67E). regarding healing of tissues. particularly articular cartilage
4. Significant loss of subchondral bone (usually distal radial These considerations are also important with regard tc
carpal bone lesions) (Fig. 4.67F and G). postoperative management and convalescent time. Tradition.
Erosion and Chips
Proximal
carpal row
Right
Distal
carpal row
r
Partial thickness
kissing lession
and debridement.
ally, repair of articular cartilage has been considered in two defects curetted experimentally were covered with
situations: (1) superficial defects that do not penetrate the full granulation tissue 1 month later. This tissue underwentmetap
thickness of the articular cartilage, and (2) full-thickness change to form fibrocartilage by 2 months and
defects, which extend to subchondral bone. Superficial imperfect hyaline cartilage by 6 months. In another carpal
defectsin equine articular cartilage do not heal, whereas full- study, Grant (1975) noted that the defectsfilled with a deeper
thickness defects heal through formation of granulation layer of immature hyaline cartilage and a more superficial
tissue and its subsequent metaplasia (Riddle 1970). layer of fibrocartilage. Synovial adhesions were also present.
In studies involving the horse, the nature of the replace- The repair most closely resembled the adjacent normal
ment tissue in the full-thickness defect varied between hyaline cartilage when there were few synovial adhesions. If
investigators. In one study, the authors noted that whereas synovial adhesions were significant. the defects filled with a
3 mm, full-thickness defects were repaired satisfactorily at 3 more primitive fibrocartilage and fibrous tissue. The authors
months, defects of 9 mm in diameter were not completely therefore concluded that proximity of the lesion to the
replaced at 9 months (Convery et aI1972). The repair tissue synovial membrane was potentially an advantage to healing.
was a variable mixture of fibrous tissue, fibrocartilage, hyper- Hurtig et al (1988) created large (15 mm square) and
cellular cartilage, and (occasionally) bone, whereas another small (5 mm square) full-thickness lesions in weightbearing
--
.
investigator reported complete healing of both 4 mm and 8
mmdiameter, full-thickness defects (Grant 1975). In a classic
study on the carpus, Riddle (1970) demonstrated that full-
thickness
and nonweightbearing areas of the antebrachiocarpal,
middle carpal, and femoropatellar joints. Repair had occurred
in most small defects at the end of 9 months by a combination
of matrix flow and extrinsic repair mechanisms, although or fragmented cartilage is removed. This protocol is base
elaboration of matrix proteoglycans was not complete at this the belief that loose cartilage is irritating and may detach
time. Better healing occurred in small weightbearing lesions its prospects of healing onto bone are virtually nil. Par
when compared to large or nonweightbearing lesions. thickness erosion adjacent to a full-thickness defect is
Synovial and perichondrial pannus interfered with healing subjected to curettage if the cartilage that remarn
of osteochondral defects that were adjacent to the cranial attached solidly to the bone. Full-thickness defects
rim of the third carpal bone. Large lesions had good repair at debrided to the level of subchondral bone. Any soft defe
2.5 months postoperatively; however, by 5 months, clefts bone is also removed.
between the reparative tissue and subchondral bone were In summary, based on both research evidence and ~
common. Later, the clefts became undermined flaps of fibrous we have observed, the authors feel that a conser Vi
tissue that were disrupted by normal biomechanical forces, approach when it comes to debridement of fibrillatiol
resulting in exposed subchondral bone. thinning of articular cartilage should be taken. In 0
Grant (1975) also found no correlation between increased instances, when cartilage is separated and may appear
healing time and improved tissue quality in full-thickness thickness, the calcified cartilage layer may still be pre~
defects; defects at 54 and 67 weeks contained more fibro- Failure to remove the calcified cartilage layer will cause
cartilage and less hyaline cartilage than defects at 42 and healing response. With experience, one can recognize
47 weeks. Work in other species also has revealed hyaline difference between the calcified cartilage and the:
cartilage at early stages of healing. There is therefore indirect chondral bone (Frisbie et al 2001, unpublished data). ,
evidence that, at 4 months. defects in the articular cartilage debridement of subchondral bone, in an adult animal,
have reached the limit of healing capacity and. by 12 months. relatively straightforward to recognize defective, gran
the replacement tissue has begun to degenerate. (and often necrotic) bone and distinguish it from S
More recent work in the first author's (C.W.M.) laboratory healthy subchondral bone. The distinction is more difficu
comparing normal healing in full-thickness defects at 4 and the young animal, where the subchondral bone is quite
12 months has demonstrated that the percentage of Type II In contrast, when the subchondral bone of a carpal defe
collagen will progressively increase from 0% at 4 months to hard and sclerotic, the use of subchondral microfracture
80% at 12 months. The hexosamine level is about half the aid accessto stem cells and growth factors in the cancel
amount in normal cartilage at 4 months. and slightly less bone and has been used in clinical cases (Frisbie et al 2(
than the 4 month level at 12 months (Vachon et al 1992, unpublished data).
Howard et aI1994). The current state of articular cartilage Deepor extensive debridement using motorized equipn
healing has been reviewed (Mcllwraith & Nixon 1996) and is is unnecessary in most cases.If debridement extends be}
now the subject of a separate chapter in this textbook. the level of attachment of the joint capsule, it can resu
The authors have also had the opportunity to operate bn a increased capsulitis and bone proliferation. In relating S
number of carpal joints for the second time after the animals of these ideasto follow-up management, if the actual matc
have raced and have observed that the healing of defects that fills fresh, localized chip fragments is not of m
varies (Fig. 4.69). In repair areas subjected to histologic concern and the area of the defect is small, then, if 0
analysis, fibrous tissue predominated. For all experimental sources of irritation have been removed, atWetic func
studies in which cartilage healing in some form was demon- should be limited only by soft tissue healing. For this rea
strated, these joints were never subjected to the continual horses with acute fragmentation and with minimal evid(
exercise and trauma of a racehorse. Since the authors of long-standing adaptive failure can return to training i
question how much functional healing occurs, debridement 6-8 weeks.
of partial-thickness defects is not performed. Cartilage is When the lesions are more severe, the limitation
aneural and how much trouble many partial-thickness defects cartilage healing are more significant. If the area ofcarti
cause is questionable. Commonly, these defects are kissing erosion is larger, then some form of healing is required,
lesions in association with fragments, and the best treatment the importance of intact subchondral bone support
is to remove the initiating cause, i.e. the fragment. Whether effective articular cartilage healing is relevant. De
more than fibrous tissue will fill the defectsis unclear, and one mination of the conditions that are necessary or optir
should therefore be conservative in creating further defects or healing requires further investigation. At present, the aut!
enlarging ones already present. The results of a study in man assume that extra time is required when subchondral hea
involving follow-up arthroscopy of patients treated for is necessaryto restore a weightbearing surface. However,
chondromalacia of the knee with or without cartilaginous time requirements and physical factors for bone healinJ
shaving supports a conservative approach to management of Grade 4 lesions have yet to be determined. In chronic, con
partial-thickness defects. The conclusions were that only cated cases, a minimum of 4-6 months rest is curre
loosely hanging articular cartilage should be shaved, and recommended.
that softened, non-loose, fissured articular cartilage should With the possible exception of infected joints I
be spared (Friedman et aI1987). Chapter 14), therapeutic synovial resection with the
The authors also adopt a relatively conservative approach of motorized equipment is not recommended. Locali
with regard to debridement of deeper defects that remain synovectomy is only performed occasionally to facili'
after fragment removal. Rough edgesor adjacent undermined visualization.
management certain prognoses.The first author (C.W.M.) has had pleasiJ
results with horses that have had multiple chip fragments
as many as four carpal joints along with chronic chan~
However, selection should be applied with regard to bo
5 daysto decreasepain. reducesynovitis.and facilitate horses and clients. In general. a better result can be expect
.Resultsof a double-blind.randomized with a horse that has proven racing ability and an owner th
understands the prognosis.
Follow-up information on the first 1000 carpal joir
less operated on by the first author (C.WM.) has provided objecti
(;'synovitis. and less effusion postope~atively(6gilvie~Harris et information to give clients regarding prognosis (McDwraith et
r
al1985). They also had more rapid return of movement and 1987). Arthroscopic surgery was effective in removing'
quadriceps function, and their return to work and sport was osteochondral fragments as well as treating other lesior
significantly faster. The administration of antimicrobial There were no casesof intra-articular infection and fewoth
drugs is a matter of individual surgeon preference. complications. The overall functional ability and cosmel
Based on current knowledge of cartilage healing. it is appearance of the limbs were excellent.
subjectively recommended that exercise be avoided for the Post-surgical follow-up information was obtained for 44
first week after surgery to enable the blood clot to organize racehorses. After surgery, 303 (68.1 %) raced at a level equ
andto allow granulation tissueto commenceformation. Passive to or better than the pre-injury level, 49 (11.0%) hc
flexion and hand walking begin after 7 days and the level of decreasedperformance or still had problems referable to tl
exerciseis then progressivelyincreasedin line with the severity carpus. 23 (5.2%) were retired without returning to trainin
of articular compromise. In horses with simple. fresh frag- 28 (6.3%) sustained another chip fracture. 32 (7.2%) develop
ments (Grade 1 lesions), training may begin at 6 weeks. As other problems. and 10 (2.2%) sustained collapsing sIc
the damage in the joint increases. the convalescent time fractures while racing. When horses were separated into fO
should be appropriately increased. Horses with Grade 2 categories of articular damage. the performance in the t\\
cartilage loss should have a minimum of 3-months rest; with most severely affected groups was significantly inferior. Or
Grade 3 and 4 lesions the horses should have 4-6-months hundred thirty-three of 187 horses with Grade 1 dama~
rest. Rehabilitation protocols including underwater treadmill (71.1 %),108 of 144 with Grade 2 damage (75.0%), 41 of 7
or swimming may be recommended if available. with Grade 3 damage (53.2%). and 20 of 37 horses wil
Postoperative use of hyaluronan (HA) and polysulfated Grade 4 damage (54.1 %) returned to racing at a level equ,
glycosaminoglycans (PSGAGs)is variably favored by different to or better than the pre-injury level. The successrate in casl
clinicians. The authors do not consider HA a necessary or with Grade 1 and Grade 2 lesions was significantly greatc
consistent part of the postoperative routine. In most cases. than that in caseswith Grade 3 and Grade 4 lesions. The dal
the synovial HA levels are expectedto return to normal in the from racing Quarter Horses and racing Thoroughbreds we)
convalescentperiod. If the articular damage at the time of divided. In 277 Quarter Horses, 81 of 112 (72.3%) wit
surgery is of relatively low grade. then most cases resolve Grade 1 lesions, 72 of 96 (75.0%) with Grade 2 lesions. 26 c
after a single treatment. PSGAG (Adequan@)is administered 46 (56.5%) with Grade 3 lesions. and 13 of 23 (56.5%) wit
when there is significant articular cartilage degeneration and Grade 4 lesions returned to racing successfully. In 16
exposure of subchondral bone. Although there may be little Thoroughbreds. 51 of 73 (69.9%) with Grade-1 lesions. 3
effecton defect healing. ongoing cartilage degeneration may of 47 (76.6%) with Grade 2 lesions, 14 of 30 (46.7%) wit
beinhibited (McIlwraith 1982. Yovich et al1987). Clinically. Grade 3 lesions. and 7 of 14 (50%) with Grade 4 lesior
a good response to PSGAG treatment is seen in the cases returned to racing successfully.Thesedata demonstrate a leI
with severe articular cartilage damage. An initial intra- favorable prognosis for horses with severe damage but als
articular injection of Adequan@ (250 mg with 0.5 ml that many horses can still come back and race successfully.
Amikacin sulfate) is recommended followed by weekly has been observed subjectively that. in more severe cases.
intramuscular injections of 500 mg. Corticosteroid therapy shorter racing career can be anticipated due to recurrer
after arthroscopic surgery is only recommended when there
carpal problems, including refragmentation.
is severe. persistent synovitis. Overall, arthroscopic surgery In five Quarter Horses used for roping, barrel racing. (
as a therapeutic procedure is best followed by rest and rodeo, all but one with a Grade 3 lesion returned to successf
physical therapy (controlled exercise). performance. The pleasure and hunter horses had successf
results in all six cases (one Grade 1, two Grade 2, thre
Grade 3. and one Grade 4 lesions). The results of surger
Case selection, prognosis, and results were also assessedin relation to the location of lesions. anI
horses with a single site (or the same site bilaterally) involve
Although fragments of all ages and size are amenable to were included (Table 4.2).
arthroscopic surgery, not all horses are good surgical In racing Quarter Horses. the prognosis associated wit]
candidates. Here, accurate communication with owners and involvement of the third carpal bone was significantly wors
trainers is important to preserve the reputation of the than lesions in other sites. In Thoroughbreds, third Carpc
technique before embarking on chronic cases with less and radial carpal bone lesions had the poorest prognoses. ]
I relative to the joint involved, 63.3% of Sincethe publication of thesedata 15 years ago. ther
Horses and 66.2% of Thoroughbreds with middle havebeena numberof changesin clinicalpracticesthat maJ
carpal joint involvement returned to racing. For the influencefuture results.Theseinclude:
antebrachiocarpal joint. 82.7% of Quarter Horses and
1. Earlier intervention and thereforea higher percentageoj
65.5% of Thoroughbreds returned to racing successfully. If
Grades1 and 2 lesionsbeingpresentedfor surgery.
both middle carpal and antebrachiocarpal joints were
2. Attemptsto enhanceosteochondralhealing (Chapter16),
involved. 64.7% of Quarter Horses and 64.7% of Thorough-
including subchondralmicrofracture.
breds returned to racing.
3. More aggressive postoperative protocols, including
medicationand physiotherapy.
recognized advantages of
surgery, there was no disruption of the
Fig.4.83
Diagram (A) and external views (B and C) of drilling 4.5 mm diameter hole in a frontal plane slab fracture of the third carpal bonE
Arthroscopic for Treatment of Carpal
fixation.Thesemay involvepairs of 4.5 mm or 3.5 mm or a also be beneficial at this point. The total convalescent pert
combination of screw sizes (Fig. 4.89). Slab fractures is usually approximately 6 months.
involvingonly the intermediatefacetof the third carpalbone With appropriate screw placement, complications a
should be approachedusing dorsomedialarthroscopyand uncommon. A further fracture extending to the screw and/t
dorsolateralinstrument portals. Theseusually are repaired creation of a chip fracture at this site has beenrecogniz(
with a single 3.5 mm screw(Fig.4.90). there is good clinical or radiological evidenceim
implants in lamenesslocalizing to the middle carr
joint, screws are not removed.
Postoperative management
Routinely padded dressings are used in the immediate Results
postoperative period but in horses with large unstable
fractures use of a sleeve cast in recovery from general In the series of 23 horses with third carpal slab fractul
anesthesia and in the immediate postoperative period reported by Richardson (1986),17 had a 6-month or lon~
is appropriate. Most animals are confined to a stall for follow-up interval. Ten of the 17 horses returned successfu
2-4 weeks and this is followed by a 6-8 week period of racing; 1 horse was training soundly, and trained well b
increasing amounts of walking exercise. Flexion exercise is retired because of other injuries. One horse was unalt
encouraged immediately after surgery and should continue return to training because of injury that had occurr
until a full and unrestricted range of flexion consistently is simultaneously with the slab fracture, 2 did not recover w
obtained. At the end of the walking period. progressive enough to train, and 1 was lost to follow-up. At the time
increase in exercise is permitted and this may involve writing, 6 horses had less than a 6-month follow-up periodw
Fig. 4.85
Diagram (A), external view of screw placement (B) and radiograph confirming appropriate screw placement (C) in repair of fronta
plane slab fracture of the third carpal bone.
111_lli~
Fig.4.91
Radiographs (A and B) and arthroscopic view (C) of sagittal
fracture of the third carpal bone. A needle has been inserted
to ascertain position of implant placement.
ance of each carpus was reported as good. with only a small surgically removed. and 18 were treated conservatively.
swelling over the screw (Richardson 1986). Horses with the 82 Thoroughbreds with a third carpal fractures. 46 w
displaced slab fractures have a poorer prognosis for return to repaired with screws. 21 had the fragment removed. and
racing than do those animals with undisplaced slabfractures. received rest only. The effect of treatment on outcome was ]
because the latter are associated with more severedamage to significantly different. Fracture characteristics did]
the joint surfaces (Bramlage 1983). This situation remains significantly affect outcome. but did influence treatm,
the same whether treatment involves arthroscopy or selection. In Standardbreds. 77% if the horses raced aJ
arthrotomy. Similarly. the prognosis worsens when loss of the injury: in Thoroughbreds. 65% raced. Earnings per st
wedge of cartilage and bone at the proximal articular surface declined in each breed. but the decline was more pronoun
leaves a large defect after fixation (Bramlage 1983). in Thoroughbreds (Stephens et alI988).
There have been two other retrospective studies published In a second study of 31 cases of racing Thoroughbr
on third carpal slab fractures and their repair. However,these with third carpal slab fractures. all cases were trea
did not generally involve arthroscopic surgery and care surgically. Twenty-one (67.6%) horses raced at Ie
should be taken in extrapolating results. In one paper, the once after recovery from the surgery: In 11 claiming hor:
caserecords and radiographs of 155 horses with third carpal the claiming value decreased from a mean of $13.900 t
bone slab fractures were reviewed (72 Thoroughbreds and 61 mean of $6.500, the mean finish position was 5.8 :t 3
Standardbreds) (Stephens et al 1988). Of 73 fractures in before injury and 5.6 :t 3.30 after surgery (Martin e1
Standardbreds, 37 were repaired by screw fixation. 18 were 1988).
Treatment of Other Carpal
Slab Fractures
Slab fractures of other carpal bones are uncommon but also
can be assessed.reduced, and repaired under arthroscopic
guidance. Frontal plane slab fractures of the radial carpal Arthroscopic repair of large chip fractures can, in SO
bone are assessed arthroscopically through dorsolateral instances be an alternative to removal. This is based on tl
portals in both middle carpal and antebrachiocarpal joints. premise that reconstruction of articular surfaces is preferal
Fracture margins are marked with percutaneous needlesand to creation of a large osseous defect (Grade 4 lesion). TI
the trajectory of implants is determined with a spinal needle necessary caveats are that fragments should be of sufficie
in a manner similar to that employed in corresponding size and have adequate osseousinfrastructure for placeme
fractures of the third carpal bone. The fracture configuration of a screw and that the process of reconstruction should
will determine the size and number of implants necessary. lesstraumatic than removal. Most chip fractures are repair
Figure 4.93 illustrates a slab fracture of the radial carpal with 2.7 mm AO/ASIF cortex screws although on occasio
bone which was repaired arthroscopically. Sagittal slab these may be sufficiently large for use of 3.5 mm diame1
fractures of the intermediate radial of third carpal bone have screws. The latter may be employed in repair of frontal pIa
been found at arthroscopy; the fractures have been generally fractures of the third carpal bone that extend from its proxin
treated by removing the slab fragment. but in a recent case articular surface (usually the radial facet), to exit with t
with internal fixation with a 2.7 -mm screw. Arthroscopy also dorsal surface of the bone proximal to the carpometacarlj
is the technique of choice for the repair of reconstructable Chip fractures of the dorsodistal margin of the rad
fractures of multiple carpal bones. These involve most carpal bone (Fig. 4.95), dorsoproximal margin of the till
commonly the radial and third carpal bones and the carpal bone and dorsoproximal margin of the radial carl
technique is varied to accommodate the variations of each bone have been repaired using 2.7 mm diameter screv
individual fracture (Fig. 4.94). Such cases should be fitted Delineation of the fracture is performed in a manner simi]
with a sleeve cast for recovery from general anaesthesia and to that describedfor the repair of slabfractures. Most fragmeI
for the immediate post-operative period. Slab fractures of the which are amenable to repair will exit the bone within t.
fourth and intermediate carpal bones have been reported capsular reflection and/or associated intercarpalligamen
(Auer et al 1986). Poor results were achieved after screw This point can be determined, if necessaryby radiographica
fixation with arthrotomy. guided needle placement. The position for screw placemel
in most instances is within the synovial cavity and therefc
the drilling process and insertion of implants can
performed under direct arthroscopic visualisation. Healing
repaired carpal chip fractures has been documented but,
date there have been no published results.
Mcllwraith CWoArthroscopic surgery-athletic and developmental
References lesions. Proceedings of the 29th Annual Meeting of the American
Association of Equine Practitioners. 1983.
Auer JA. Watkins JP.White NA. et al. Slabfractures of the fourth and Mcllwraith CW Experiences in diagnostic and surgical arthroscopy
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188: 595-601. Mcllwraith CWoDiagnostic and surgical arthroscopy in the horse.
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(Large Anim Pract) 1983; 5: 261-274. Mcllwraith CWoRadiographically silent injuries in joints: An over-
Convery FR. Akeson WHo Keown GH. The repair of large view and discussion. In Proceedings of 37th Annual Convention
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Dabareiner RM. Sullins KE. Bradley W. Removal of a fracture Mcllwraith CWoTearing of the medial palmar intercarpal ligament
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in a horse. J Am Vet Med Assoc 1993; 203: 553-555. Mcllwraith, CWo Arthroscopic surgery for osteochondral chip
DeHaan CEoO'Brien TR. Koblik PD. A radiographic investigation of fragments and other lesions not requiring internal fixation in the
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traumatized synovial joint: The knee as a model. Rosemount 11: Mcllwraith CW, Trotter GW (eds). joint disease of the horse WE
American Academy of Orthopedic Surgeons. 1992. Saunders; Philadelphia 1996: 292-317.
Firth EC.Deane. GibsonK. et al. Current studies in carpal diseaseand Mcllwraith CW, Fessler]F. Arthroscopy in the diagnosis of equine
function in the horse. Vet Cond Educ. Massey University. New jointdisease.JAm Vet Med Assoc 1978; 172: 263-268.
Zealand 1999; 135: 81-89. Mcllwraith CWoNixon AJ. Joint resurfacing: attempts at repairing
Fischer AT. Stover SM. Sagittal fractures in the third carpal bone in articular cartilage defects. In: Mcllwraith, CW, Trotter GW, (eds)
horses: 12 cases(1977-1985). J Am Vet Med Assoc 1987; 191: Joint disease in the horse. Philadelphia: WB Saunders; 1996:
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Friedman MI. Gallick GS.Brna JA. et al. Chondromalacia of the knee: Mcllwraith CW, Yovich ]v; Martin GS. Arthroscopic surgery for the
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articular shaving. Arthroscopy 1987; 3: 131. Am VetMed Assoc 1987; 191: 531-540.
Frisbie DD. Trotter GW. Powers BE. et al. Arthroscopic subchondral Martin GS.Haynes PF,McClure JR. Effect of third carpal slabfracture
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Howard RD. McIlwraith CWoPowers BE. et al. Long-term fate and 628-634.
effects of atWetic exercise on sternal cartilage autografts used for Ogilvie-Harris DJ. Bauer M.. CoreyP. Prostaglandin inhibition and thE
repair of large osteochondral defects in horses. Am J Vet Res rate of recovery after arthroscopic meniscectomy. A randomized
1994; 55: 1158-1167. double blind prospective study. J Bone Joint Surg (Br) 1985; 67:
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JAmVetMedAssoc 1986; 189: 1314-1321. Phillips TJ. Wright IM. Observations on the anatomy and pathology
Hurtig ME. Fretz PB. Doige CE. Schnurr DL. Effects of lesion sizeand of the palmar intercarpal ligaments in the middle carpal joints 01
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52: 137-146. Pool RR. Meagher DM. Pathologic findings and pathogenesis of race.
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89-91. Richardson DW Proximal surface lesions of the third carpal bone
Kawcak CEoMcIlwraith CWoNorrdin RW. Park RD. Steyn PS. Clinical Proceedings of the 1st Advanced Arthroscopy Course. Coloradc
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33: 120-126. Ross MW. Richardson DW. Beroza GA. Subchondral lucency of tht
Lysholm J. Hamberg P. Gillquist J. The correlation between third carpal bone in Standardbreds racehorses: 13 case!
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Arthroscopy 1987; 3: 161-165. Schneider RK. Bramlage LR. GabelAA. Barone LM. Kantrowitz BM
Mcilwraith CWo Current concepts in equine degenerative joint Incidence. location and classification of 371 third carpal bont
disease.J Am Vet Med Assoc 1982; 180: 239-250. fractures in 313 horses. Equine Vet J Supp11988; 6: 33-42.
SJ: Arthroscopic surgery: the carpal and fetlock joints. dorsomedial intercarpal ligaments in the midcarpal joint.
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Association of Equine Practitioners. 1983. Whitton RC. Rose RI. The intercarpal ligaments of the equ
SJ: Intercarpal ligament impingement: a primary cause of midcarpal joint. Part II: The role of the palmar intercar
pathology in the intercarpal joint. In Proceedings of the ligaments in the restraint of dorsal displacement of the proxil
row of carpal bones. Vet Surg 1997; 26: 367-373.
Wilke M. Nixon AI. Malark I. Myhre. G. Fractures of the pair
carpal bone in Standardbreds and Thoroughbreds: 155 cases aspect of the carpal bones in horses: 10 cases (1984-2000
(1977-1084). I Am Vet Med Assoc 1988; 193: 353-358. Am Vet Med Assoc 2001; 219: 801-804.
H, Carlsten I. Retrospective study of subchondral sclerosis Wright IM. Ligaments associated with joints. Vet Clin N Am 19
and lucency in the third carpal bone in Standardbred trotters. 11: 249-291.
Equine Vet I 1999; 31: 500-505. Young DR. Richardson DW. Markel MD. Numamaker [
AM, McIlwraith CW, Powers BE, et al: Morphologic and Mechanical and morphometric analysis of the third carpal bc
biochemical study of sternal cartilage autografts for resurfacing of Thoroughbreds. AmI Vet Res 1991; 52: 402-409.
induced osteochondral defects in horses. AmI Vet Res 1992; 53:1038-1047.
Yovich IV. Trotter GW. McIlwraith CWoNorrdin RW. Effects
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equine midcarpal joint, Part I: The anatomy of the palmar and 1414.
Arthroscopy has proven to be a most valuable technique in
the metacarpophalangeal and metatarsophalangeal (fetlock)
joints. Its original use was principally, in arthroscopic surgery
in the dorsal aspect of the joint but then extended into the
palmar/plantar aspect. Arthroscopic surgery in the dorsal Arthroscopic examination of the fetlock joint may be
aspectof the fetlock joint is probably the best equine example indicated specifically as a diagnostic procedure or as part of
of what can be achieved with joint distention. an arthroscopic surgical procedure (McIlwraith 198'4).
The same advantages that have been discussed in the The latter situation is more common, although diagnostic
carpus hold for arthroscopic surgery in the fetlock. The arthroscopy is indicated in cases involving a lameness
indications for arthroscopic surgery in the metacarpo- problem that has been localized to the fetlock but for which
phalangeal and metatarsophalangeal joints include the the radiographic signs are equivocal. The procedure is most
following conditions: valuable if synovial effusion is present or if the area of
1. Osteochondral fragments of the proximal dorsal aspectof lamenesshas been identified as intra-articular on the basis of
the proximal (first) phalanx. a response to intra-articular analgesia and when there has
2. Erosions of articular cartilage and subchondral bone not been a responseto conservative treatment.
disease on the dorsal proximal aspect of the first A complete arthroscopic examination of the metacarpo-
phalanx. phalangeal or metatarsophalangeal joint is not possible.Two
3. Synovial pad fibrotic proliferation (villonodular synovitis) arthroscopic approaches are required to achieve as effective
of the metacarpophalangeal joint. an examination as possible of both the dorsal and palmar
4. Other forms of proliferative synovitis. (plantar) components.
5. Osteochondritis dissecans of the sagittal ridge of the Each diagnostic examination will be described. Because
third metacarpal or metatarsal bones (McIIl/MtIIl). the dorsal approach most commonly is performed on the
6. Osteochondral fragments associated with the proximal metacarpophalangeal joint, it is described for that joint. The
palmar or proximal plantar aspect of the proximal only difference in examination of the metatarsophalangeal
phalanx. joint is that it may be more difficult because of the decreased
7. Removal of apical fragments of the proximal sesamoid ability to maintain extension of the joint. The plantar (palmar)
bone. examination is facilitated by flexion and this is especially
8. Removal of abaxial fragments of the proximal sesamoid convenient in the hilid limb.
bones.
9. Removal of basilar fragments of the proximal sesamoid
bones. Arthroscopic examination of the dorsal
10. Lesions of the intersesamoidean ligament. metacarpophalangeal joint
11. Axial osteitis of the proximal sesamoidbones.
12. Avulsions of the suspensory ligament insertions. This arthroscopic examination ~an be performed with the
13. Subchondral cystic lesions of McIIl. horse in dorsal or lateral recumbency. If lateral recumbency
14. Lesions of the dorsal plicae. is used. the horse should be positioned so that the site for
15. Chondral fractures. arthroscopic entry is up. For the same reason of versatility
16. Fibrous joint capsule tears. mentioned in Chapter 4 with regard to the carpal joint. the
17. Assistance in repair of condylar fractures of the use of dorsal recumbency is preferred. While the leg is being
McIIl/MtIIl and fractures of the proximal phalanx. surgically prepared and draped. it is held by an assistant or is
18. Other selected proximal sesamoid fractures. suspendedin a mechanical device (Fig. 5.1). Draping can be
completed with the fetlock resting back on the elbow or common digital extensor tendon. The outpouching of the
appropriatelysuspendedsothe joint remainsextended. distended joint is more prominent lateral to the common
digital extensor than it is medial to it, despite the insertion of
the lateral digital extensor tendon, which ramifies over the
Insertion of the arthroscope joint capsule lateral to the common digital extensor tendon;
The metacarpophalangeal joint is distended with fluid this is penetrated when the lateral portal is created.
(Fig. 5.2) before making the arthroscopic portal. In this joint, The site for the laterally placed arthroscopic portal is in the
distention facilitates the recognition of the correct place for proximolateral quadrant created by distending the joint
the arthroscopic portal and minimizes the risk of iatrogenic maximally (Fig. 5.2). A No. 11 blade is used to incise the skin
trauma to the joint on entry of the arthroscopic sleeve. There and stab through the joint capsule (seeFig. 5.3). The arthro-
are no tendon sheaths to avoid as in the carpus, and the scopic sleevecontaining a conical obturator is then inserted
surgeon does not have to be concerned with exact local- through the joint capsule, initially perpendicular to the skin
ization of structures before distention. and then parallel to the articular surface of Mclll to avoid
Distention is performed by using approximately 35 ml of iatrogenic damage to this area (Fig 5.4). Entry is completed
fluid and inserting a needle across the dorsal aspect of the by advancing the sheath proximad to avoid iatrogenic
proximal sesamoid bone into the palmar pouch of the fetlock damage to the midsagittal ridge of the distal metacarpus (see
(see Fig. 5.2). Adequate distention can be recognized easily Fig. 5.4). The sheath can then be directed distad once over the
with bulging of the joint capsule on either side of the sagittal ridge.
1984), in that by taking the portal more proximad, it was
possible to better visualize the proximal lateral aspect of the
proximal phalanx.
When the arthroscopic sleeve is inserted so that its tip
touches the medial capsule, the arthroscope is inserted and
the examination can begin. It is easy to enter the sub-
cutaneous tissue plane when inserting the arthroscopic
sleeve in the dorsal aspect of the fetlock, and care is
warranted during both the joint distention step as well as
with insertion of the arthroscopic sleeve to avoid this
problem. The authors prefer to use this proximal arthroscopic
portal in the metacarpophalangeal joint to avoid iatrogenic
damage to the midsagittal ridge of the metacarpus and to
provide the best overall view of the dorsal aspect of this joint.
A more distal portal along the dorsal margin of the metacar-
pophalangeal joint immediately proximal to the proximal
phalanx, however,can provide convenient visualization of the
proximal border of the first phalanx.
As in the carpus, creation of an instrument portal and
insertion of an egresscannula or probe are the next steps. A
useful measure is to insert a needle at the proposed instru-
ment portal location to check if such a site is appropriate
(Figs 5.5 & 5.6). The use of aI needle to ascertain ideal
positioning for the instrument portal represents a departure
If the arthroscopic portal is made in the more proximal from what was previously described in the carpus. However,
dorsal pouch, the sheath can be advanced across the joint in the carpus is unique and the skin incisions for the instrument
a transverse direction without causing damage to the portal are made prior to joint distention and insertion of the
midsagittal ridge of the metacarpus. The position described arthroscope merely to avoid entering an extensor tendon
here for the arthroscopic portal is different than in the sheath. There are no such issues in the fetlock joint, or most
previous edition of this text (McIlwraith 1990a). It represents other joints for that matter. The practice of inserting a needle
a modification initially suggested by Foerner (pers comm to ascertain the ideal position for instrument insertion and
surgical maneuverabilityis commonto all joints other than Withdrawing the tip of the arthroscope further and moving i
the carpus.By making a skin incision with a scalpeland No. across the sagittal ridge laterally (eyepiecemoving medially
11 blade.the surgeoncreatesthe instrument portal through permits inspection of the lateral condyle of the distal meta
the joint capsule(Fig. 5.7). The small egresscannula can carpus as well as the proximal lateral aspect of the proxim~
then be inserted through this portal without the trocar. An phalanx (Fig. 5.12).
arthroscopic examination can then commence. At the The examination just described enables recognitiol
completionof arthroscopy,the skin incisionsonly are closed and characterization of synovial pad fibrotic proliferatiol
(Fig.5.8). (villonodular synovitis), other forms of synovitis, fragment
off the proximal dorsal aspect of the proximal phalanx, wea
lines and erosions on the distal articular surface of Mcll
Diagnostic arthroscopy of the dorsal osteochondritis dissecans of the midsagittal ridge an
pouch of the fetlock Joint condyles of Mclll, tears of plicae and joint capsule. articula
components of fractures of Mclll and proximal phalanx. an
With slight retraction of the arthroscope and looking across subchondral cystic lesions of Mclll.
the joint. the first area visualized is the proximal portion of
the dorsal joint proximal to the articular cartilage of the
distal metacarpus, where the synovial membrane forms a Arthroscopic examination of the
reflection (Fig. 5.9). At this transition zone,the synovium has palmar or plantar fetlock joint
a flap, or pad. that varies in size, and the surgeon must be
familiar with the normal range (see Fig. 5.9). Synovial pad This examination can be performed with the horse in dorsI
fibrotic proliferation (villonodular synovitis) manifests as an or lateral recumbency, the position varying with th
enlargement of this flap. Apart from the flap, the synovial condition being operated. The authors preferred later!
membrane in the remainder of this dorsal area is non-villous. recumbency when operating on fragments associated wit
The articular surface of the medial condyle and mid- the palmar/plantar aspect of the proximal phalanx in tb
sagittal ridge of McIIl can then be examined by rotating past, but now use dorsal recumbency for all evaluation~
the arthroscope so that the lens is angled distad conditions in the palmar/plantar compartment. While flexio
(Fig. 5.10). The tip of the arthroscope is then moved distad from an assistant is sometimes needed, advantages includ
(eyepiece moving proximad) to inspect the dorsal articular less hemorrhage, convenient operating position for plant~
edge of the proximal medial eminence of the proximal (palmar) chip fragments, as well as sesamoid fragmen1
phalanx (Fig. 5.11). The synovial membrane of the dorsal and the ability to put instrument portals in either medial (
joint capsule is also evaluated during these maneuvers. The lateral pouch.
synovial membrane is notably more villous as one progresses
distad and villi can sometimes obscure the view of the
Insertion of the arthroscope
proximal dorsal rim of the first phalanx. The synovial mem-
brane attaches immediately adjacent to this rim, and use of The joint is prepared for surgery and distended by placing th
instruments (including the egress needle) to allow improved needle in the palmar pouch using the approach described b
inspection of the first phalanx is common practice during Misheff & Stover (1991). With the joint distended, a ski
both diagnostic and surgical arthroscopy in this area. incision is made with a No. 11 blade in the proximal part (
the bulging capsule (Fig. 5.13). The arthroscopic sheath and
conical obturator are inserted perpendicular to the skin
initially, and then are directed distad (Fig. 5.14). The fetlock is
in 30-450 flexion at this time to facilitate passage between
the distal metacarpus/metatarsus and the proximal sesamoid
bones. The degree of flexion is controlled by an assistant and
the flexion angle varies depending on the area being
examined (for instance, increased flexion is used to bring the
proximal palmar aspect of the proximal phalanx into view).
in
Metacarpophalangeal and Metatarsophalangeal joints
Fig. 5.21
Removal of a small chip fragment (arrow) off the proximal
dorsal medial eminence of the proximal phalanx. (A and B)
Lateral-medial and DLPMO radiographs. C, Arthroscopic
views before (C), during elevation (D), during removal with
Ferris-Smith rongeurs (E), curetting defect. continued
If a fragment is present on the proximal lateral
, it is removed first. A lateral instrument portal is
5.25).
Sometimes the fragment can be recognized only as
a roughening of the proximal phalanx. Occasionally,the chipis
embedded in the joint capsule, and this situation can berec
if the fragment projects into the joint; otherwise,
such a density will probably not be found, and the final
diagnosis of a capsular mass is based on the absence of a
fragment on arthroscopic examination despite its presence
on radiographs. Finally, fragments may already be totally free
within the joint (Fig 5.26).
The grasping forceps commonly used to remove the
fragments are Ferris-Smith intervertebral cup rongeurs
(Fig. 5.21E). Low-profile 4 x 10 mm Ferris-Smith rongeurs
have the ideal combination of strength and ability to access
the fragment. As in the carpus, the use of forceps that can
enclose the fragment minimizes the risk of leaving fragments
in the joint. Twisting of the instrument to ensure breakdown
of soft tissue attachments is carried out before withdrawal of
the fragment.
The surgical manipulations to remove the fragment
will depend on the arthroscopic features described above. A
10 x 4 mm Ferris-Smith low-profile rongeur forceps is used to
remove a totally free chip. If a fragment is small, fresh, and
has minor soft tissue attachments as ascertained by palpation
with the egress cannula direct removal with forceps is also
appropriate. For all chips with significant attachments, the
fragment is initially freed by using a periosteal elevator. For
chips that have a strong fibrous union, the elevator is used to
pry the fragment off the bone. The elevator can also be used
to break down capsular attachments to the dorsal aspect of
the fragment. A curette is useful for more strongly attached
fragments. Because of suspected sensitivity of the dorso-
proximal area of the fetlock joint, the surgeon should limit
removal when it has fibrous joint capsule attached to it
(Fig. 5.30 and 5.31).
If a fracture line extends distad deep into the capsular
attachment area and it is not displaced, surgical removal is
not indicated. Fixation with a small fragment screw is
sometimes indicated (seebelow).
After removal of the fragment, the defect remaining is
inspected (see Figs 5.21, 5.22 and 5.30), as is the nearby
area of dorsal capsule, to ensure that no fragments remain.
This latter inspection must involve palpation as well as
fragment can be moved easily and is attached only at the visualization, as the fragments can merge into the capsule.
synovial membrane reflection. Displacement of the fragment The defect commonly has some tags or raised edges of
facilitates identification and removal. Figure 5.21 illustrates cartilage that can be removed with a pair of ethmoid or
the sequence of events in removing a fresh fragment, 2 x 10 mm Ferris-Smith rongeurs (the pointed nose enables
including elevation. removal with Ferris-Smith rongeurs, these forceps to enter the narrow areas where the fragment
curetting of the defect. removal of small pieces with ethmoid was removed). Alternatively, a curette may be used. Debride-
forceps, and lavage. In other cases the cartilage over the ment of the bone is done carefully with a small (2-0) curette
fragment is intact and elevation is required to define with care taken not to cause damage to the fibrous joint
the fragment. With larger fragments, the attachments of the capsule (Figs 5.31).
fragment at the joint capsule may well be more extensive Variable degrees of articular cartilage damage on the
(Fig. 5.22). With mor~ chronic chips. the fragments tend to distal metacarpal or metatarsal condylar surface may be
be more rounded (Fig. 5.23). Some fragments have deep noted. In many cases,no damage is apparent, but varying
attachments in the joint capsule and require more separation degrees of wearline formation are apparent in some cases
(proximal Fig. 5.24). In some cases.the dorsoproximal rim of (Fig. 5.31C) and full-thickness erosion may be seen in other
the first phalanx may only show a defect on lateromedial cases (Fig. 5.3ID). When these lesions are more severe,the
radiographs. but an oblique radiograph will show a small prognosis is not as favorable (Kawcak & McIlwraith 1994).
fragment.
Unlessa capsular mass projectsinto the joint. it is not with fragmentation, 140 horses had other lesions in the
Also. it is not considerednecessaryor beneficialto fetlock, comprising 64 with wear lines. 11 with articular
cartilage erosion. 15 with chronic proliferative synovitis. 4
arthroscopy in such a case has been to ascertain with osteochondritis dissecans,and 45 with a combination
.' -of the radiographically apparent mass. If the
of the above lesions. Carpal arthroscopy for the removal of
of the joint is in satisfactory condition. the prog- osteochondral chips was performed concomitantly in 100 of
is still good with an osseous mass remaining in the these horses (Table 2).
Follow-up was available for 286 horses (85.1%): 208
the sizeor numberof fragmentsthat can (73%) returned to their previous use. of which 153 horses
(73.6%) returned to the same level of performance and
undergo surgery. The surgeon must consider 55 (26.4%) returned to performance, but at a lower class; 18
bone being removed. the amount of exposed horses (6.3%) developed another fragment and 60 (21 %) of
bone being left in the joint. and the amount of horses did not return to their previous use. Of the 270
racehorses with follow-up. 196 (72%) returned to racing and
created by the arthroscope or instrument portals. 141 (51.7%) of these raced at the same or a higher level.
rather to the amount of capsular attachment to the 18 (6.6%) of the racehorses developed another fragment and
56 (21.0%) were in the failure category. Of the non-
the joint is flushed with fluid by racehorse group, 12 of 16 (75%) returned and 4 (25%) did
open egress cannula over the site of the defect. not return to their previous use at the same level of
portals are sutured and the leg is bandaged. The performance. The difference of return to previous use between
is maintained for at least 2 weeks after surgery. racehorses and non-racehorses was not significant. The
walking commences after 1 week. With simple fresh overall successrate in horses with fragments only returning
the horses can be put into training after 6-8 weeks. to use was 85.9%; with fragments and other fetlock lesions. it
horses with more extensive involvement, the con- was 75%; with fetlock fragments and carpal arthroscopy con-
time is increased for a variable period up to comitantly. it was 68.6%; and with fragments plus carpal
arthroscopy and other fetlock lesions, it was 80.6%.
after surgery, but some veterinar- In a third study done to examine the longevity of
.As discussedin the section concerning the postoperative careers and quality of performance of 461
.-to the patient's recovery is Thoroughbred racehorses after arthroscopic removal of
dorsoproximal osteochondral fragments from the proximal
phalanx. 659 chip fragments were removed arthroscopically
from 574 joints and 461 horses presented for lameness or
decreased performance attributable to the chip fractures
results with arthroscopic surgery for uncomplicated (Colon et al 2000). It was found that 89% of the horses
(411/461) raced after surgery and 82% (377/461) did so at
fractures are associated with severe capsulitis. wear lines. the same or a higher class; 68% of the horses raced in a
osteoarthritis. or extensive fragmentation of the proximal first stakes or allowance race postoperatively. This paper con-
phalanx. the progn!;)sis decreases accordingly. As with the firmed that the quantity and quality of performance was not
carpus. surgical intervention can still improve the status of diminished after arthroscopic treatment of dorsoproximal
these patients. but communication to owner and trainer is fragments, and that surgical removal of a chip fragment
important to ensure that no one is disappointed. Even with preserved the economic value of a racing Thoroughbred.
suchprecautions. however. some peoplehave short memories. allowing a rapid and successive return to racing at the
The results of arthroscopic surgery in 74 fetlock joints of previous level of racing performance (Colon et al 2000).
63 horses (35 Thoroughbreds and 28 Quarter Horses) over a Horses that raced before and after surgery (258) had an
2-year period were initially reported by Yovich & Mcllwraith average of 8.4 starts (median = 6) before surgery and 13
(1986). Larger numbers have replaced these data. The results (median = 11) after surgery.The averagetime between surgery
of arthroscopic surgery were reported in 1994 in 336 horses and first postoperative start was 189 days (median = 169);
with 572 osteochondral fragments removed from 439 fetlock 87% of the horses racing before surgery (224/258) returned
joints (Kawcak & Mcllwraith 1994). Of these horses. 311 to race at the same or higher class. The average earnings per
were racehorses. including 188 Thoroughbreds. 119 Quarter start after surgery was less than the average earnings before
Horses. 2 Standardbreds. 1 Racing Arabian and 1 racing surgery in 61 % of these horses and greater in 32%.
Appaloosa. There were 25 non-racehorses. A single meta- Colon et al (2000) considered the 11 % postoperative
carpophalangeal joint was operated on in 220 horses. and failure rate to be pessimistic due to various factors. It was
both metacarpophalangeal joints were operated on in 97 noted that horses that did not race after surgery tended to be
horses. a single metacarpophalangeal joint in 17 horses. both older at the time of surgery and had raced more times pre-
metatarsophalangeal joints in one horse and all 4 fetlock operatively. They concluded that the lack of return to racing
joints in one horse. Fragmentation of the proximal phalanx was not related to chip incidence. location or size,as these did
was the only lesion in the fetlock joints of 96 horses. Along not differ between the raced and unraced group. They
carefully measured fragment size and concluded that it did osteochondral fragments on the proximal dorsal rim, an
not affect post-surgical racing prognosis: 48% of the surveyed radiographs are used to make the definitive diagnosis. VI
horses had at least one fragment larger than the mean and have encountered cases in the hind limbs bilaterally an.
87% of these raced after surgery. They concluded that the because of the consistent location of these fracturt
hypothesis that "the smaller the chip fragment, the better the involving both the proximal medial eminence and sagitt
prognosis" was rejected by these findings. However, they groove,a developmental predisposition may be present.
noted that it was not possible in their study to compare post- In the previous edition of this book, the use of rest w~
operative racing performance to arthroscopic visualization of advocated, as these fractures can heal (McIlwraith 1990a
articular cartilage health or associated intra-articular However,since that time, caseshave beenencountered that ill
cartilage lesions. They did point out, appropriately, that not heal and continued to cause clinical signs. The recon
usually the articular cartilage damage is not severe and can mendation now is to provide compression of these fractur!
be managed medically. with 2.7 mm AD/ ASIF cortical screws.
Arthroscopic surgery is performed with the norm.
arthroscopic approach to the dorsal pouch and with tb
Arthroscopic removal of dorsoproximal limbs in extension. Examination of the joint will confirm tb
chip fractures of the proximal phalanx presence of the fracture (Fig. 5.33). Needles are placed t
in standing horses ascertain ideal positioning of the screw and, after a sta
incision is made in the appropriate location, a 2.7 mm hole
This technique has been described and reported in 104 drilled obliquely down through the fracture fragment. Tb
horses (Elce & Richardson 2002). Given skilled technique, it hole is generallyperpendicular to the fracture line. Radiograpl
is feasible to perform arthroscopic surgery in the dorsal are made to confirm appropriate positioning and that tb
aspect of the fetlock in this fashion. However, we would only glide hole is beyond the fracture line. A 2.0 mm hole is cor
recommend it if, for some reason, general anesthesia is some- tinued beyond this. After counter-sinking, a 2.7 mm diamete
how not possible or inconvenient. Throughout this textbook, 36 mm long cortical bone screw is then placed to comprel
the authors recommend surgery under general anesthesia. the fracture. Debridement is then performed in the fractur
line, if appropriate. The manifestations at the fracture lin
will vary and sometimes no bone is required to be remove
Erosions of articular cartilage and (see Fig. 5.33); other times, debridement in a comparabl
subchondral bone disease on proximal fashion to a slab fracture is required.
dorsal eminences of proximal phalanx
As seen in the carpus, there is a spectrum of disease on the Treatment of slnovial Rad fibrotic
proximal dorsal aspect of the proximal phalanx ranging from proliferation (vilionodular synovitis)
separation of articular cartilage and loss of articular cartilage
to degenerative disease of the subchondral bone. Previously The condition initially designated as villonodular synoviti
discussed osteochondral fragments are considered to be (Nickels et al19 76) and later describedas chronic proliferativ
pathologic fractures and are the end result of a gradation of synovitis (van Veenendaal& Moffatt 1980, Kannegieter,199C
microdam~ge, microfractures, and cellular death (Kawcak et al is seen in the metacarpophalangeal joint. It involves
2000). This range of lesions occur in the same locations as proliferative response from the synovial pad in the proximc
previously described for osteochondral fragments and the dorsal aspect of the joint and, therefore, the term synovic
surgical management is the same. pad fibrotic proliferation (Dabereiner et al19 9 6) is preferre(
The referring clinical signs are also similar, but radio- The term pigmented villonodular synovitis was originall
graphically there may only be a suspicion of disease.However, used to describe pedunculated growths forming in th
on arthroscopic examination, the various manifestations of synovial linings of tendon sheaths and joint in man Gaffe et c
articular cartilage separation (Fig. 5.32A), articular cartilage 1941). These fibrous masseswere polyp-like formations th.
erosion (Fig 5.32B), and subchondral bone disease(Fig 5.32C originated from the synovial membrane and were often pi~
and D) are encountered. Separated cartilage and bone is mented with hemosiderin. Villonodular synovitis in human:
removed. Defective bone is debrided (larger pieces removed), therefore, should not be confused with enlargement of th
and the area lavaged. The prognosis is comparable to synovial pads of the equine metacarpophalangeal joint.
completely separated osteochondral fragments in this area. Classically,the condition was initially demonstrated wit:
contrast arthrography, and it has been treated successful
with arthrotomy (Nickels et al1976, Haynes 1980). Neithe
Treatment of frontal fractures of contrast arthrography nor arthrotomy is used anymorc
proximal dorsal aspect of the proximal because of the development of ultrasound examination i
phalanx using lag screw fixation diagnosis (Steyn et al1989) and arthroscopic surgery as th
treatment technique. The synovial pad of the metacarp(
Frontal fractures of the dorsal aspectof the proximal phalanx phalangeal joint is a fold (plica) of fibrous connective tissu
occur regularly. The clinical signs are very similar to other located in the proximal recess of the dorsal compartment (
the metacarpophalangeal joint at the joint capsule attach- (Dabareiner et aI1996). All the horses had lameness. joint
ment to Mcill. The synovial pad is normally 2-4 mm in effusion. or both of these clinical signs. associatedwith one or
thickness and tapers to a thin edge at its distal border (White both metacarpophalangeal joints. Bony remodeling and
1990). Its function is unknown, but its structure and location concavity of the distal dorsal aspect of McIII immediately
suggestthat the pad acts as a contact interface or cushion proximal to the metacarpal condyles was identified by radio-
betweenthe proximal dorsal rim of the proximal phalanx and graphy in 71 joints (93%) (Fig. 5.34); 24 joints (32%) had
the dorsal surface of distal third metacarpal bone (Mcill) radiographic evidence of a chip fragment located at the
during full extension of the fetlock joint (White 1990). proximal dorsal aspect of the proximal phalanx. Fifty-four
Repetitive trauma during fast exercise can result in irritation joints (71%) were examined by ultrasound. The mean:t SD
and enlargement of the synovial pad and development of sagittal thickness of the synovial pad was 11.3 :t 2.8 mm.
clinical signs of lameness and chronic joint effusion that (The authors also reported that the synovial pad was
often resolves temporarily with rest and intra-articular considered abnormal if the thickness was greater than 4 mm
medication. There is commonly radiographic evidence of on the sagittal view. the distal margin was rounded. or hypo-
bone remodeling, with a concavity at the distal dorsal aspect echoic regions were observed within the pad.) Seventy-nine
of Mcill, and this is suggestive of synovial pad proliferation percent of the horses had single joint involvement. with equal
(Fig. 5.34A). Ultrasound is now the method of choice to distribution between the right and left forelimb. In addition to
further define this proliferation (Fig. 5.34B). Although this pre-surgical diagnosis of this condition. it is also quite
condition is commonly seenin the racehorse, it has been seen common to encounter thickened and enlarged synovial pads
in other horses not subjected to fast athletic exercise (loSasso at arthroscopic surgery (usually when doing the surgery for
& Honnas 1994), and in the previous edition of this text, a removal of a proximal dorsal fragment from the proximal
contrast-enhanced view of the disease in a mule was phalanx) (Mcllwraith 2002).
presented. The surgical approach used when operating on horses
The medical records, radiographs, and ultrasound with this condition arthroscopically is illustrated in Figure
examinations have been reported in 63 horses with 5.35. The authors in most cases use a single instrument
metacarpophalangeal joint synovial pad proliferation approach. A two-instrument approach has also beendescribed
sometimes be noted when the indication for arthroscopic
surgery was originally the removal of fragments. Conversely.
fragments may be encountered off the proximal dorsal aspect
of the proximal phalanx at the time of arthroscopic surgery
for removal of a proliferated pad when the fragments
were not visible with pre-surgical radiographs. Obviously,
a complete examination of the dorsal pouch is done with any
of these arthroscopic procedures and lesions appropriately
dealt with.
In a report of 68 joints in 55 horses treated by arthroscopic
surgery, 60 joints (88%) had debridement of chondral or
osteochondral fragmentation from the dorsal surface of the
distal metacarpus beneath the synovial pad (more frequently
done than by us) and 30 joints (44%) had a bone fragment
removed from the medial or lateral proximal dorsal eminence
of the proximal phalanx (Dabareiner et alI996).
Arthroscopic laser extirpation of metacarpophalangeal
synovial pad proliferation has been described in 11 horses
(Murphy and Nixon 2001). Elevenclinical caseswere operated
on in this fashion and followed up. All were treated by intra-
articular laser extirpation using either CO2 or an Nd:YAG
laser with arthroscopic guidance. Mean synovial pad
thickness, measured ultrasonographically, was 9 Inm, and 7
(64%) of the horses had radiographic evidence of remodeling
of the dorsal cortex of distal McIIl; 3 horses (27%) had con-
current dorsal proximal fractures of the proximal phalanx.
All 11 horses returned to training within 90 days of surgery
without recurrence of the lesion. Nine horses (82%) sustained
race training and apparently improved their performance
(Mcllwraith 1990a. 2002). With the arthroscope in the lateral following surgery based on follow-up conversation with the
portal. the instrument portal is made medially. Dabareiner et al owners. The use of the CO2 laser requires gas distention of
(1996) considered excision of a portion of the synovial pad to the joint. The authors cited advantages with the laser tech-
be necessary if it was enlarged and inelastic when probed nique that included their ability to be used arthroscopically,
during surgery or if hard nodules could be felt within the pad. better visualization of the joint, better access to lesions on
The mass can sometimesbe torn off by using grasping forceps both sides of the sagittal ridge, reduced convalescence time,
that have a cutting edge(Fig. 5.36A and B). Alternatively, the and better cosmetic and functional results. However, with our
mass can be severed at its base by using a flat knife (Fig. current abilities at conventional arthroscopic surgery, it is
5.36C and D) (see Chapter 2). Disposable scalpel blades questionable if these advantages exist anymore.
should not be used because they may break within the joint. Postoperative management in casesinvolving proliferative
After severing the base. the proliferated pad is removed with synovitis treated arthroscopically is the same as for those
Ferris-Smith rongeurs (Fig. 5.36E) and the base trimmed involving chip fragments of the proximal phalanx. Horses
with basket forceps or a motorized resector. Proliferation of that have synovial pad proliferation without articular
the synovial pad is more common medially than laterally cartilage loss or proximal phalangeal fragments can return to
and. consequently. surgery often involves removal of the racing in 8 weeks, whereas horses with more extensive
medial portion alone. However, examination should be made cartilage damage or more significant proximal dorsal frag-
to ensure that there is not similar proliferation in the lateral mentation of the proximal phalanx should get 3-4 months
portion. If there is. the arthroscope is placed medially and the before training is resumed.
instrument laterally to remove the lateral portion. In one Follow-up on 50/55 horses was obtained for the previously
report in the literature. complete or partial excision of both cited study of Dabareiner et al (1996): 43 (86%) horses that
medial and lateral synovial pads was achieved in 42/68 joints had surgery returned to racing, with 34 (68%) racing at an
(Dabareiner et al1996). The medial synovial pad only was equivalent or better level than before surgery. Horses that
excised or trimmed in 21 joints and 5 joints had removal returned to racing, at a similar or equal level of performance
limited to the lateral pad. were significantly younger than horses returning at a lower
Once the pad is removed, there may be some full-thickness level or not racing. In contrast, the same authors reported
erosion with minor debris where debridement is indicated 8 horses (8 joints) with synovial pad proliferation and
(Fig. 5.36F). More commonly. the bone is left alone. but if remodeling of the distal dorsal aspect of McIIl being treated
there are any elevated cartilage tags. these are trimmed. As medically at the owner's request. Intra-articular sodium
has been previously noted. enlarged. thickened pads will hyaluronate was administered intermittently in these
Arthroscopic Surgery of the Fetlock Joints
the diseaseprocess commonly extends onto the condyles of
MclII and MtlII (Mcilwraith & Vorhees 1990). These cases
were evaluated and treated on the basis of having clinical
signs; the problem was assessedin 65 horses (Mcilwraith &
Vorhees 1990). In one radiographic study, OCD changes on
the dorsal aspect of the sagittal ridge of MclII or MtIII was
seen in 118/753 yearling Standardbred trotters with 61
forelimbs and 147 hind limbs affected (GroendahI1992).
Fragments from the proximal palmar/plantar margin of
the proximal phalanx have also been reported as osteochon-
drosis (Foerner 1987, Nixon 1990), but it is not now generally
accepted that osteochondrosis is the pathogenesis. The
treatment of this condition is described later in this chapter.
The third condition described as OCD are proximal dorsal
fragments of the proximal phalanx in young horses. While
these fragments, at least in racehorses, have long been
consideredto be traumatic in origin, there is evidence some of
these fragments having an osteochondrosis basis, at least
when they present in yearlings. The treatment of these con-
ditions is also described in this chapter. Dorsal bony
fragments in the metacarpo- and metatarsophalangeal joints
were diagnosed in 36 (4.8%) of 753 yearling Standardbred
8 horsesand systemicnonsteroidalanti-inflammatorymedi- trotters on a radiographic survey (Groendahl19 92) and were
cations were also administeredfor variable periods.Three seen in 34 forelimbs and 14 hind limbs. A fourth condition
(38%)of the medicallytreatedhorsesreturnedto racing and initially described as OCDof the palmar metacarpus (Hornoff
only 1 horseracedbetterthan the pre-injury level. et a11981) is now accepted to be a traumatic entity and not
a syndrome of osteochondrosis. It will not be considered
further here, as it is not an arthroscopic surgical condition.
Treatment of other forms of Osteochondritis dissecans of the distal dorsal aspect of the
proliferative synovitis MclII/MtlII can occur in both metacarpo- and metatarso- !
phalangeal joints, but it is more common in the latter. The.'
Occasionally, forms of proliferative synovitis that are not lesions vary in their radiographic manifestations, from a I
localized to the dorsoproximal aspectof the joint are seen(see subchondral defect to defects associated with fragments;
Chapter 3). Typically, these casespresent as chronic synovitis (Fig. 5.38). In some cases,fragments break away completely
and capsulitis that is non-responsive to symptomatic intra- from the primary lesion and become loose bodies. The
articular or systemic anti-inflammatory treatments. In some presenting clinical signs include synovial effusion of the
cases, diagnostic arthroscopy has revealed proliferated, fetlock joint with or without lameness.The horses are usually
thickened, and enlarged synovial villi in the dorsal yearlings (Yovich et al1986). In most instances, the patients
compartment of the metacarpophalangeal joint (Fig. 5.37). are weanlings to yearlings and quite often are presented for
The treatment has been resection of these villi, and the treatment prior to sale. In some instances, training and
overall results have been good. racing may have occurred before the symptomsdevelop.
Although the degree of lameness varies, a positive response
to a fetlock flexion test is usually elicited, and radiographs i
Treatment of osteochondritis dissecans confirm the presence of lesions associated primarily with the
sagittal ridge of MclII/MtIlI. ;
of the distal dorsal aspect of Mc111/Mt111
in the metacarpopharangeal and For purposes of treatment decision and prognosis, the j
lesions have been divided into three types:
metatarsophalangeal joints
.Type I is that in which a defect or flattening is the
There is a divergence of opinion as to what is considered only visible radiographic lesion
osteochondritis dissecans (OCD)within the fetlock joint and .Type II is that in which fragmentation is associated
also those entities that might be considered to be appropriate with the defect
to include in the term developmentalorthopedic disease .Type III is that in which there is a defect or flattening
(Mcllwraith 1993). It is undisputed that OCD of the dorsal with or without fragmentation plus one or more
aspect of the distal McIII and MtIII is a manifestation of OCD loose bodies.
and this is the condition described below. The condition was Oblique radiographs should be taken as well as dorsopalmar
initially described as OCD of the sagittal ridge of the third (plantar) and lateral/medial radiographs for the purpose
metacarpal and metatarsal bones (McIII/MtIII) (Yovich et al of discerning the medial or lateral condyles of MclII/MtlIl
1985). but this term has been modified after recognition that (Mcilwraith & Vorhees 1990). Based on an initial study
Fig. 5.38
Examples of the radiographic appearance of osteochondritis
dissecans (OCD) of the fetlock joint (A) Type I OCD of the
midsagittal ridge of the metatarsophalangeal joint. (B) Type II
OCD. (C) Type III OCD.
Yovich et al19 85), it was felt that Type II and Type III OCDesions
should be treated surgically and many Type I lesionsrvould
resolve, In a second study of 15 cases with Type Iesions
that were treated conservatively, 12 resolved clinicallymd
8 of these showed remodeling of the lesions with
mprovement on radiographic examination (Mcilwraith &torhees
1990), In 3 casesthe clinical signs persisted: in 2 of
hese, the radiographs showed no ch~nge and the horses
:ventually underwent surgery, whereas, in the other case,the
:linical and radiographic signs progressedand the horse was
lot operated on,
In 8 cases of Type II lesions where owners requested:onservative
management, 2 eventually underwent surgery)ecause
of the persistent clinical signs, Clinical signs)ersisted
in 5 others, but surgery was not performed, The
:linical signs improved in only 1 horse, In most of these casesrvhere
clinical signs persisted, the fragmentation also)rogressed
radiographically. It was also clear in this study
:hat clinical signs of effusion may appear before definitive:adiographic
changes. Progression of someType I lesions wasloted:
such casesdo not develop osseous fragmentation, but:he
lesions progress to become larger defects, particularly on:he
condyles (seen on oblique view radiographs). Some cases
Jf Type II lesions improved radiographically. These were
~enerallycaseswith small fragments that fused to the parent-Jone
such that a spur resulted.
Based on the above knowledge, arthroscopic surgery is;onsidered
the appropriate treatment if fragments are
~resent (Type II and III lesions). In other cases in which a
lefect only is detectable radiographically, the decision for
;urgery is based on the degree of clinical signs, the size and
ocation of the defect, and the planned use of the horse.
The arthroscopic approach is the same as that forragments
off the proximodorsal aspect of the proximal
Jhalanx or synovial pad proliferation, using a proximally or
listally placed instrument portal, depending on the location
Jf the fragment or loose body (seeFig. 5.39). When operating
In metatarsophalangeal joints, an effort must be made tolchieve
complete extension. In some cases,the OCD lesionllanifests
as a defect within the sagittal ridge (Fig. 5. 40A and
B),and curettage is performed. More commonly, osteochondralragments
may be within the defect or have loose attach-llents
to the area (Fig. 5.40C-E). In these cases,the fragment
s removed and any defective articular cartilage is debrided:Fig.
5.40F). Loosefragments are located and removed (usually
with Ferris-Smith rongeurs). As mentioned previously,Ilndermined (Fig. 5.43B). But in most instances. there will be a rounded
cartilage may extend medial and lateral from the fragment (Fig. 5.43C and D). Rarely,extensive fragmentation
,agittal ridge of McIlI and MtlII, and it must also be debrided.JCDmay be present (Fig. 5.43E-G).
can also occur on the metacarpal or metatarsal condyles:Fig. Aftercare in these casesis the same as for a chip fragment
5.41). Type III lesions are treated with fragment removalmd off the proximal dorsal aspectof the proximal phalanx. Many
debridement (Fig. 5.42). of these horses are young and therefore have long periods for
Diseaseand fragmentation of the proximal dorsal aspectofthe convalescencebefore being put into training.
proximal phalanx typical of OCDis seenquite commonlyIn The prognosis is based on the appearance of the joint
young horses. The radiographic manifestations are of a during surgery as well as on the age of the horse. If there is
,mall fragment on the proximal dorsal aspect of the proximal no other damage or only a minimally sized defect in the
phalanx (Fig. 5.43). The arthroscopic manifestations can sagittal ridge, the prognosis is good. Follow-up data reveal
vary, as illustrated in Figure 5.43. In some instances, there that when extensive lesions extend medial or laterad from the
will be a flap with diseasedbone underneath, typical of OCD sagittal ridge or distad to involve the loaded area of the
was unavailable. Surgery was successfulin 16 (57.1 %) of the
28 cases and 12 were unsuccessful (42.8%). Of the 12
unsuccessful cases. 7 were still considered to have a problem
in the fetlock joint (25%): 3 were unsuccessful for other
reasons; 1 was unsuccessful for unidentified reasons but was
considered to be normal in the fetlock joint; and 1 horse died.
The successrate was also found to be related to other factors.
There was a trend for the successrate to be higher for surgery
in hind limbs compared to forelimbs. On the one hand. in the
forelimbs only 2 cases were successful and 6 were un-
successful.whereas in the hind limb 7 were successfuland 3
were unsuccessful. When both fore and hind limbs were
involved. there were 7 successesand 3 failures. Type III
lesions had 4 successesand 4 failures. whereas Type II lesions
had 10 successesand 4 failures (difference not statistically
articulation. clinical problems may arise when the horse significant). Only 3/12 cases with erosions or wear lines
engages in athletic activity. present at arthroscopy were successful. whereas 13/16 with
In a series of 42 horses that were operated on with no erosions were successful (p = 0.0029). Probably related to
arthroscopic surgery. there were a few Type I lesions (usually that. there was a significantly inferior result when a defect
operated on as they had not responded to conservative was visible on the condyle on oblique radiographs. When a
treatment or if an individual joint in a horse being treated for defect was visible. 6/13 were successful. whereas if a defect
a Type II or Type ill lesion happened to have a Type I lesion). was not visible. 10/15 were successful (p = 0.0274). Osteo-
Forty-two horses in this series reported included 20 phytes were also negative prognosticators (3/9 with osteo-
Thoroughbreds. 8 Quarter Horses. 7 Arabians. 4 Warmbloods. phytes on the proximal phalanx were successful. whereas
1 Standard bred. 1 Percheron. and 1 Appaloosa (McIlwraith 13/19 with no osteophyteswere successful). I
& Vorhees 1990). Forelimbs were involved in 10 horses. hind It was concluded that surgical management of Type II and '
limbs were involved in 15 and both fore and hind limbs were Type III lesions will allow athletic activity in a fair number of
involved in 17 horses. One fetlock joint was operated in 10 cases. but clinical signs will persist in 25%. Whether the
horses. 2 fetlocks in 17 horses. 3 fetlocks in 1 horse. and surgery will be successfulor not will be affected by the extent
4 fetlocks in 14 horses. Forty-eight cases involved the of the lesions. as evident arthroscopically (and in some
proximal 2 cm of the sagittal ridge. where 11 extended distal instances. radiographically). as well as by the presence of
to this point. In 44 instances. lesions involved the lateral osteophytes.erosions. and wear lines. Since the Mcllwraith &
and/or medial condyles of the metacarpus or metatarsus. Vorhees (1990) paper was published. the first author feelsthe
with or without lesions of the sagittal ridge. success rate has improved further because of earlier
Of the 42 horses operated on. follow-up was obtained in intervention and. particularly with radiographing horses at a
28. eight horses were convalescing and in 6 the follow-up young age to ensure clean joints at yearling sale.
Debridement of subchondral cystic regularity (Nixon 1990, Mcllwraith 1990b). Most horses are
lesions of the third metacarpal bone aged 2 years old or less when clinical signs become apparent
and they usually have a history of recently increased physical
The distal Mclll is one of the less common locations for activity (such as entering athletic training). The diagnosis is
subchondral cystic lesions. but they do occur with relative confirmed with radiographs (Fig. 5.44A and B). As with most
subchondral cystic lesions. they occur in a location subject to
maximal weightbearing during the support phase of the
stride. Once a cystic lesion becomes clinically apparent. the
prognosis for athletic soundness is variable and appears to
be dependent on several factors. including the anatomic
location of the lesion. the presence of any associated
degenerative changes in the joint and the treatment regime
(surgical or conservative) chosen (Bramlage 1993).
Prior to the use of arthroscopic surgery. most caseswere
managed conservatively and empirically and with limited
success (Mcllwraith 1982). If conservative therapy was not
successful. a dorsal arthrotomy was recommended surgically
to debride the lesion and this technique has been more
recently replaced by arthroscopic surgery. The technique is
less invasive and provides the advantage of clear visual
assessmentof the articular surfaces of the joint.
The arthroscopic approach depends on the location of the
cystic lesion. The majority of lesions are on the medial
condyle of the distal metacarpus. in which case the arthro-
scopeand the instrument are both placed medially (Fig. 5.45).
In order to expose the opening of the subchondral cystic
lesion. flexion is required. and so having the arthroscope on
the same side obviates the potential problem that flexion
creates (sagittal ridge interfering with the arthroscopic
position). The arthroscope is placed laterally for a cystic lesion
on the lateral condyle or the sagittal ridge. With flexion. the
opening of the cystic lesion can be visualized (Fig. 5.44). A
needle is used to ascertain the ideal position for debridement;
this tends to be distal and axial over the cystic lesion. The
cystic lesion is then debrided with a curette and pieces
removed with forceps. The cartilaginous edges are trimmed
and debris removed by flushing. Drilling of the cystic lesion is
no longer performed.
A 4-6-month lay-up period is recommended with these
cases.The initial 2 months involve stall confinement with a
program of hand walking. A seriesof caseshave beenreported
(Hogan et al1997) and serve as a basis for prognosis. Sub-
chondral cystic lesions (SCLs) in the distal McIIl were
surgically treated in 15 horses. The median age at presen-
tation was 18 months (range 10 months to 12 years) with
lOllS horses less than 2 years old. The SCLswere confined to
the front limbs in all cases. with two horses having bilateral
lesions. Lesions were isolated to the medial condyle of McIIl
in 13 I 15 horses; a cystic lesion occurred in the lateral condyle
in 1 horse and in the sagittal ridge in another. One horse with
bilateral lesions had an additional cystic lesion located in the
right medial femoral condyle. Fourteen of 15 horses had a
history of moderate lameness attributable to the metacarpo-
phalangeal joint; the lesion was an incidental finding in
1 horse. Duration of lameness ranged from 4 weeks to
8 months and was either acute in onset or occurred inter-
mittently and was associated with exercise. Fetlock flexion
significantly exacerbated the lameness in all cases. Synovial
effusion was absent in 8 (53 %) of cases.
Cystic lesions were curetted arthroscopic ally in 12 horses.
and through a dorsal pouch arthrotomy in 3 horses.
Concurrent osteostixis of the cystic cavity was performed in 7
of the horses. 12/15 horses (80%) were sound for intended
usefollowing surgery. 2 horses did not regain soundnessand result of fracture rather than a manifestation of osteo-
follow-up information was unavailable in 1 horse. The total chondrosis.
period of follow-up was 1-6 years. Follow-up radiograph The principal radiological sign is that of a fragment
examinations were available for 9 horses. Mild periarticular located between the base of the sesamoid bone and the
osteophyte formation and enthesophyte formation at the proximal aspectof the proximal phalanx; it is usually halfway
dorsal joint capsular attachments was present in 5 of the between the sagittal groove and the lateral or medial
9 horses.Bony infIlling of the cystic lesion was detectable in eminence of the first phalanx and is not always associated
8 horsesand enlargement of the cystic cavity was observed in with a defined defect on the first phalanx. Although initially
1 horse. Based on this study, it would appear that surgical the condition was considered peculiar to the Standardbred
treatment of SCLs in the distal McIlI should result in a (Pettersson & Ryden 1982), cases occur in Thoroughbreds
favorableoutcome for athletic use (Hogan et al1997). and the condition is reasonably common in Warmblood
breeds.
Typically, the horses will be admitted with a history of
Removal of axial osteochondral lameness. Lameness at examination will be mild and.
fragments of the proximal commonly, the history is that of subtle lameness reported by
palmar or plantar aspect of the the trainer and manifested at high speed as a rough gait or
proximal phalanx break in stride (Fortier et al199 5). In one series of casesof 82
horses receiving lameness examination at admission. 17
These fragments, described as Type 1 osteochondral frag- (21 %) horses had slight to moderate positive results on hind
ments of the palmar-plantar aspect of the fetlock joint limb flexion. Synovial effusion of the metatarsophalangeal or
(Foerner 1987), were initially reported as chip fractures metacarpophalangeal joint was reported in 19/119 (16%) of
(Birkeland 1987) and avulsion fractures (Pettersson& Ryden horses; 155/164 (95%) fragments were in the metatarso-
1982). Since that time, Foerner (1987) suggested that this phalangeal and 9/164 (5%) involved the metacarpophalangeal
condition is another manifestation of osteochondrosis based joints. The medial plantar eminence of the proximal phalanx
on its incidence and age of occurrence of the fragments. was the location of 114/164 (70%) fragments. Bilateral frag-
However,more recent publications have argued for a traumatic ments were observed in 21 (18%) horses. whereas 15 (13%)
etiology.Hind limb fetlock joints with plantar osteochondral horses had concurrent medial and lateral lesions within the
fragments were collected from 21 horses (17 Standardbred same joint. Standardbred racehorses represented 109 (92%)
trotters, 4 Swedish Warmblood riding horses) and the of those affected (Fortier et al 1995). In another series of
morphology of the osteochondral fragments in adjacent 26 cases.23 of the horses were racing Standard breds and 3
tissues studied by dissection, high-resolution radiography, were racing Thoroughbreds (Whitton & Kannegieter 1994).
andhistology (DaIin et al 1993). The fragments were attachedto The most common reason for presentation in this series was
the short s~samoidian ligaments and had a smoothcartilage an inability to run straight at high speeds. Only 8 horses
coverin'g on the surface facing the joint cavity. presented for lameness. although on examination, 19 were
Histologydid not show any evidence of osteochondrosis. Theauthors lame. A positive flexion test was recorded in 90% of affected
suggested that plantar osteochondral fragments arethe fetlock joints and effusion was present in 48%.
result of an outwardly rotated hind limb axis and sub- To be considered a surgical candidate, the patient must
sequent point loading in the medial fetlock area. Repeated have demonstrable lameness referable to the fetlock, in
high tension loads in the short sesamoideanligaments maycause addition to a radiographically demonstrable fragment
fragments of tissue with osteogenicproperties to avulse (Fig. 5.46). The fragment can be identified on the lateral and
from the proximal phalanx into the ligament, later forming flexed lateral views. Dorsoplantar radiographs taken with the
osteochondralfragments. This pathogenesisdoes not accountror fetlock flexed have also beenrecommended (Birkeland 1972),
lateral fragments, which also occur occasionally. Other but the authors have not used this technique. For optimal
work by the same authors had shown that plantar osteo-chondral definition of the location of the lesion. however, a special
fragments most often occur in the hind limbs andare oblique view with the tube at a 300 angle distad is useful
more frequently in the medial part of the joint (Sandgren (Fig. 5.46B). Both oblique views are essential as lesions can
~t al 1993). It has also been demonstrated that thesefragments be biaxial.
develop early in life and are often possibleto detect Non-surgical treatment usually lowers the horse's
~yradiography before 3 months (Carlsten et aI1993). performance (Barclay et al 198 7). Arthroscopic surgery is
A second study had beendone on osteochondral fragmentsrom now the standard technique. Dorsal or lateral recumbency
the axial proximoplantar/proximopalmar region of the can be used. The authors prefer dorsal recumbency as the
?roximal phalanx in 38 joints in 30 horses: 28/30% of thelorses instrument portal can conveniently be made laterally or
were Standardbreds and 28/30 had a low-gradeameness. medially. However. some flexion of the joint from an assistant
All but one of the horses had hind limb involve-Dent.may be required. If the surgery is done in lateral recumbency,
Of 143 fragments removed, 71% involved the medial the side where the fragment is located should be up and the
lspect of the joint and had to be dissected from a covering of:ynovial
arthroscope and instrument approaches will be made from
tissue (Nixon & Pool 1995). The histologic appear- the same side. The arthroscope is placed in the plantar orpalmar
Lncein these cases suggested that these fragments were a joint pouch. as previously described. after distending
\
The arthroscopeis positionedto visualizethe distal knife. a banana knife. a narrow bistoury. and an Arthro-
the joint; an assistantmay facilitate this step by LokTMretractable blade. We prefer a broad. flat blade. The
flexion on the joint. After assuring the correct disposable No. 11 blade should not be used because of the
risk of breakage. Electrocautery probes have been used more
portal is made distal to the arthroscopic recently for this dissection (Boure et al1999).
, .5.47). The portal is made so that the The immediate postoperative care is the same as for other
comes across transversely. Often, the fragment arthroscopic procedures in the fetlock joint. A period of
2-3 months rest before training resumes is recommended.
can aid visualization.The fragment There have been two reports of treatment of these osteo-
separatedfrom the soft tissue with a knife and is chondral fragments with follow-up. Whitton & Kannegieter
by using a Ferris-Smithcup rongeur (Fig 5.48). (1994) reported on 21 horses.in which 16 horseshad returned
of this fragment leavesa defect within the joint to racing: 12 horses had improved their performance. while 3
and short-digital sesamoideanligaments,and any horses showed no improvement. and 1 horse was retired for
--
other reasons. Degenerative changes within the fetlock joint
plantar defect in the normal phalanx is were detected at surgery in 8 horses. Four horses were treated
appropriatebut is not usually necessary.Figure conservatively: 1 horse returned to its previous level of
performance temporarily after intra-articular medication.
and Figure 5.50 illustrates medial and lateral 1 horse showed no improvement. and 2 horses were resting
at the time of the report.
condition is one of the few in equine arthroscopic A larger case series of 119 horses (109 Standardbred
for which the use of sharp dissectionis essential. horses)had follow-up in 87 racehorses and 9 non-racehorses
used,including a tenotomy (96). In 55/87 (63%) racehorses and 100% of 9 non-
racehorses,performance returned to preoperative levels aft
surgery. Fragment numbers or distribution and concurre
OCD of the distal intermediate ridge of the tibia or tars
osteoarthritis were not significantly associatedwith outcom
Abnormal surgical findings, consisting of articular cartila:
fibrillation or synovial proliferation, were significant
(p <0.001) associated with adverse outcome: these findin
were documented in 31 % of the 32 horses without success
outcome and only 2% of the 55 horses with successfulou
come (Fortier et al1995).
Arthroscopic excision of these fragments has bel
describedin 23 Standardbred racehorsesusing electrocaute
probes (Simon et al 2000). A 1.5% glycine solution in i
Arthropump was used to maintain joint dissectio
Transection was performed using loop probes alone (
alternatively, with hook electrocautery probes to dissect tI
fragment free prior to Ferris-Smith rongeur removal. Thirt
five fragments in 28 joints were removed from either the 11
or the right hind limb in 23 Standardbred racehorses. Six hi
biaxial fragmentation. An ipsilateral (n = 9) or contralater
(n = 26) triangulation approach was used. The autho
concluded that the loops and probes can be safely used
excise osteochondral fragments of the plantar proxim
phalanx. They considered dissection using electrocaute
probes to be more precise and easier to perform than tI
previously described sharp dissection technique. No folIo,
up was given. It has since been recognized that glycine is n
necessary for this procedure.
The
Diagnostic Arthroscopy of the Femorotibial joints
Femoropatellar and Femorotibial joints
Fig. 6.5
Patella (P) and trochlear groove (T), with arthroscope under
the patella, at the level of the proximal trochlear groove. (A)
Diagram of visual field (circle). (B) Arthroscopic view.
Femoropatellar
andFemorotibial
Joints
.,
inserted cranially, but the first author (C.W.M.) generally finds
this unnecessary. For the cranial approach, a skin incision is
made and continued through the fascia between the middle
and medial patellar ligament about 2 cm proximal to the tibial
crest. The arthroscopic sleevecontaining the conical obturator
is then inserted through the fat pad in a slightly proximad,
caudad, and axial direction until it penetrates the medial
femorotibial joint capsule (Fig. 6.15). Entry into the joint is
confirmed by observation of the joint features or egressof fluid
on removal of the conical obturator (if joint is predistended).
The arthroscope is then inserted and the examination can
begin (Fig. 6.16).
Lateral approach. The site of the arthroscopic portal
is caudal to the lateral patellar ligament, cranial to the long
digital extensor tendon, and 2 cm proximal to the tibial spine
(Lewis 1987) (Fig. 6.17). The arthroscopic cannula with
conical obturator in place is then directed medially and
slightly caudad to penetrate the synovial membrane in the
lateral aspect of the medial femorotibial joint (Fig. 6.18A).
The obturator is removed and the arthroscope is inserted.
After checking that the arthroscope is in the cranial
compartment (Fig. 6.18B), the joint is distended, and the
examination begins (Fig. 6.19).
Medial
and Femorotibial joints
Normal arthroscopic anatomy of cranial cruciate ligament can be seen axially under
median septum (Fig. 6.28). A small area of 1-,
the cranial compartment of the
lateral femorotibial joint visible axial to these structures.
.: ~, Lateral
"'/
condyle
Medial
condyle
;z::
Lateral
Medial I
approach
if/!
P
Popliteal
tendon i
!i
I
i
!
2002).
IW;;,
of the pouch and the outline of the caudal cruciate ligament femoral condyle and the proximal border of the popliteal
may sometimes (rarely) be noted axially beneath the joint tendon. To view the pouch distal to the popliteal tendon. the
capsule. coursing in a proximodistal direction. portal is located at the level of the tibial plateau. 1.5 cm
caudal to the lateral collateral ligament. and the arthroscope
is placed through the popliteal tendon to allow examination
Insertion of the arthroscope into the of the more caudal articulation of the joint. It was noted by
caudal compartment of the lateral Trumble et al (1994) that the tendon of the popliteal tendon
femorotibial joint being contiguous with the joint capsule of the caudal pouch
of the lateral femorotibial joint makes arthroscopic explo-
Theseapproachesare basedon the descriptionsof Trumble et al ration of this pouch particularly dillicult.
(1994), Hance et al (1993), and Stick et al (1992). It is
important to be aware that the peroneal nerve lies 7 cm caudal
to the lateral collateral ligament and so no portal should be Normal arthroscopic anatomy of the
made this far caudally. The popliteal tendon divides the caudal compartment of the lateral
caudal lateral femorotibial joint. Distention is performed with femorotibial joint
a spinal needle placed caudal to the collateral ligament. For
examination proximal to the popliteal tendon, the portal is With the proximal arthroscopic portal. it is possible to view
placed 2.5 cm proximal to the tibial plateau and 3 cm caudal the proximal border of the popliteal tendon and the lateral
to the collateral ligament (Fig. 6.29) (Walmsley 2001). femoral condyle (Fig. 6.31). Using the distal portal through
Structures seen through this portal are limited to the lateral the popliteal tendon it is possible to examine the caudal
meniscus, part of the caudal aspect of the lateral medial femoral condyle, and a complete tear of the cranial
, the intra-articular portion of the popliteal
cruciate ligament in 1 case.
but this examination is More recently, the use of arthroscopy to both diagnose and
treat vertical tears of the cranial horn of the meniscus and
the cranial ligament of the meniscus has been described
(Walmsley 1995). The most recent use of arthroscopic surgery
arthroscopy of clinical in 80 casesof meniscal tears in the horse has been described
in the femorotibial by Walmsley et al (2 003). Schneideret al (199 7) also described
the use of medial femorotibial arthroscopy to evaluatecartilage
lesions on the medial femoral condyle as a cause of equine
lameness in 11 cases.These conditions will be discussed in
cases of cystic lesions of the medial condyle of the more detail separately.
.1987). Surgical intervention for this condition As noted previously, the septum separating the lateral and
medial femorotibial joint compartments is commonly
disrupted in association with cruciate ligament injury; a
cranial approach to the medial femorotibial joint will also
1987; Turner et a11988. McIlwraith 1995 allow examination of the lateral femorotibial joint in these
1995. 2002). Lewis described the arthroscopic cases. If both cranial and cruciate (and medial collateral)
in 20 cases of unilateral lameness. with a positive ligaments are disrupted, the resulting laxity will allow greater
the medial femoro- visualization of the femorotibial articulations and menisci.
but without major radiographic abnormalities. A
.was abnormality of the articular surface of
distal weightbearing portion of the medial femoral
abnormalities included fibrillation of the articular
partial- to full-thickness erosion, sometimes
and, in some cases,
cartilage flaps. Abnormalities of the medial
were evident in 9 cases,including mild to marked
and degeneration of the proximal surface. A
Osteochondritis dissecans
3 casesand a partial avulsion/
of the cranial ligament of the medial meniscus was Arthroscopic surgery has emerged as the only surgical tech-
1 case. Examination of the menisci was difficult in all nique to treat osteochondritis dissecans (OCD)in the femoro-
patellar joint. It has replaced arthrotomy eliminating local
and Lewis (1987) noted a lack of ability to adequately
problems with wound healing and reducing the need for rigid
the caudal segments of the meniscus. Lewis also
the use of surgical arthroscopy in 2 cases of tibial postoperative management. The techniques presented sub-
sequently are based on the experience of the authors with
fractures. One of the 2 horses was completely sound
clinical cases of OCD in the femoropatellar joint and the
could resume full function; the other was periodically
follow-up data that have been generated from these cases
mild degree when heavily used. Of the 20 casesin
(Mcllwraith 1984, Mcllwraith & Martin 1984,1985; Martin
revealed articular cartilage
& Mcllwraith 1985. Foland et al1992). Although successful
results can be obtained by using arthrotomy, potential com-
plications include seroma formation. local cellulitis and
nonsteroidalanti-inflammatory agent therapy,
fasciitis, and wound dehiscence (Pascoe et al 1980, 1984;
Trotter et aI1983).
Turner et al (1988) reported the confirmation of cranial
, .injury in 5 cases by the use of femorotibial
A cranial approach with the arthroscope Preoperativeconsiderations
used. Arthroscopic examination revealed the following Preoperative diagnosis of OCD is based on clinical and
disruption of the septum surrounding the radiographic signs. The clinical signs that initially prompt the
ligaments and separating the medial and lateral attention of owners are lameness and/or synovial effusion of
joint compartments; increase in the joint space the femoropatellar joint. The diseaseis not breed-specific,but
with ligamentous laxity; synovitis; and areas of it is a diseaseof young horses. In some instances. however. no
clinical problems are apparent until the horse is in training or
a partial longitudinal tear of the cranial has raced (Mcllwraith & Martin 1985). Lesions that manifest
ligament in 1 case (the horse also had a cranial at this stage are generally less severe. Clinical examination
generally reveals some degree of synovial effusion as a
ligament at its insertion adjacent to the tibial consistent finding. Lameness ranges from nondiscernible
tearing of the cranial attachment of the lateral through subtle gait changes (shortened anterior phase of
the stride, low arc of flight. and unusual flight path with the stifle
included
rotated outward and the hock inward) to obvious lameness
with a stiff gait and difficulty in getting up. Animals may have
difficulty in trotting with a preference to canter or "bunny-
hop" is common.
The radiographic manifestations of the disease vary.
Lesions most commonly occur on the lateral trochlear ridge
but are also seen on the medial trochlear ridge of the femur
and/or on the patella (Table 6.1). The lesions in turn may be
localized to a small area or be distributed along the entire
length of the trochlear ridge. The most common radiographic
manifestation of OCDis a defect (with or without discernible
fragments) on the lateral trochlear ridge of the femur
(Fig.6.32). Defectscan be describedas concave (seeFig. 6.32),
flattened (Fig. 6.33), cystic, or undetermined. Lesions on the
medial trochlear ridge usually manifest as a concave defect
(when evident radiographically), but often are not visible on
radiographs (due to a normal subchondral bone contour)
(Fig. 6.34). Lesions can also be observed (less frequently) in
various parts of the patella and manifest as some form of
subchondral defect (Fig. 6.35).
For many years the authors recommended arthroscopic
surgery for all casesof osteochondritis dissecans,particularly
if an athletic career is planned. However, the study by
McIntosh & Mcllwraith (1993) shows that, with conservative
management (stall or pen confinement for 60 days). then a trainer request for the problem to be assured of correction
number of femoropatellar OCDcases can heal. Based on this also leads to early surgical treatment. Persistence of synovial
study. if defects are less than 2 cm long and less than 5 mm effusion is always an indication for surgery. When the
deepand there is no obvious mineralization or fragmentation severity of the changes is too severe, surgery is not recom-
of the flap on radiographs. conservative therapy is a viable mended. A direct comparative study was done comparing
option. It has also been pointed out by Dik et al (1999) that radiographic and arthroscopic findings in the femoropatellar
up to age 8 months it is possible for radiographic lesions on joint (Steinheimer et al 1995). It is rare to find an arthro-
the femoral trochlear ridges to resolve. In a longitudinal study scopic lesion less severe than the radiographic insinuation.
of Dutch Warmblood foals, radiographed at 1 month old and On the other hand, it is common to find more pathologic
subsequently at 4-week intervals, the mid-region of the lateral change at arthroscopic surgery than predicted by radio-
femoral trocWear ridge becameradiographically abnormal from graphs.
3 to 4 months old. Subsequent progression of radiographic
abnormalities was usually followed by regression and
resolution. with the appearance returning to normal at Technique
8 months old in most cases. At 5 months old. 20% of the A number of different instrument portals are used to perform
stifles were abnormal radiographically, but at 11 months old surgery at various locations in the femoropatellar joint.
this percentage had decreasedto 3%. Normal and abnormal Previously, six different triangulation approaches were used
appearances were permanent from 8 months old (Dik 1999). to operate on the various lesions of osteochondritis dissecans
The authors currently recommend that all lesions greater in the femoropatellar joint and were discussed in the second
than 2 cm in length or 5 mm in depth. or any lesion that edition of this text. However, exact sites for instrument entry
contains osseous densities in the presence of synovial do not need to be rigidly fixed. Rather, the use of an I8-gauge
effusion. be treated with arthroscopic surgery. In some of the disposable spinal needle is now recommended to ascertain
cases that can potentially heal conservatively. owner or the ideal location for an instrument portal (Fig. 6.36). In all
cases,a l-cm incision is made through the skin and super-
ficial and deep fascia, and using a stab incision with a No. 11 To effectively operate the underside of the patella. an
blade completes entry into the joint. The various instruments instrument portal must be level with or distal to the arthro-
are then inserted through the portal as required (Fig. 6.37). scopic portal and usually 2 cm lateral to the arthroscopic
The various surgical approaches are illustrated in Figures portal (seeFig. 6.40). If this portal is more proximal than the
6.38-6.43. In all instances, we are using the same arthro- arthroscopic portal. the end of the instrument cannot make
scopicportal between the lateral and middle patellar ligament contact with the undersurface of the patella. The portal is
although it is noted that an arthroscopic portal between the made lateral to the middle patellar ligament. depending on
middle and medial patellar ligaments has also been used for the position of the lesion on the patella. To operate on lesions
operations involving lateral trochlear ridge lesions (Bramlage on the distal aspect of the lateral trochlear ridge. the same
perscomm 1987). arthroscopic portal is used as that chosen for the proximal
Lesions on the proximal one-half of the lateral trochlear trochlear ridge. although the arthroscope is directed distad.
ridge are reached through a portal proximolateral to the The instrument portal is made low over the distended
arthroscopic portal (seeFig. 6.38). The instrument may pass femoropatellar joint through or immediately adjacent to the
either lateral to or (usually) through the lateral patellar lateral patellar ligament (Fig. 6.41). For lesions on the distal
ligament when using this portal. If the entry is too far lateral, aspect of the medial trochlear ridge. a distal portal is usually
the instrument cannot be manipulated up and over the made between the middle and medial patellar ligaments
lateral trochlear ridge. Passing the instrument through the (Fig. 6.42). If the lesion on the medial trochlear ridge is
lateral patellar ligament does not seem to be of any located on the trocWear groove (axial) side of the distal medial
consequence. Lesions of the proximal portion of the medial trochlear ridge. however. a medial portal does not always
trochlear ridge are reached by using a portal between the allow the instrument to reach this location. In this instance.
medial and middle patellar ligaments. entering the skin distal a lateral instrument portal. allowing the instrument to pass
to the lesion (Fig. 6.39). under the middle patellar ligament. is necessary (Fig. 6.43).
fragmentation within the articular cartilage and sub-
Figs
between 6.45-Fig.
normal 6.47).
and pathologic
Curettage bone. allows better
mined,unattachedarticular cartilageremains.
Manipulations of the surgical instruments vary, but a commonly occur as raised areas of articular
sequential protocol is generally followed. A number of cases
are used to demonstrate the manipulations (Figs 6.44-6.48).
In all cases,the lesions are initially evaluated with a probe. trochlear ridge lesions,with the use of
The probe is useful in defining the limits of an osteochondral portal (Figs6.39, 6.42, 6.45, and 6.47).
or chondral flap as well as for assessingits mobility. The probe
is also used to evaluate any cracking, wrinkling, or fibrillation and on the axial sides of the trochlear ridges. It is
in the articular cartilage. If the cartilage is cracked but firmly common to see OCD lesions on the ~ ~c ,-- ~
attached to subchondral bone, it is not removed. Normal-
appearing articular cartilage is also probed, particularly if is gaugedby inserting a spinalneedle.but generally
radiographs have revealed lesions in the subchondral bone in
that area. If intact cartilage overlies a subchondral defect,the ridge will not allow accessto the lesion.
probe breaking through the articular cartilage into the defect arthroscopeand instrument is depictedin Figure
locates the lesions and the undermined articular cartilage is
then removed. graphs indicate severe intraarticular disease and surgery
The most common form of pathologic change encountered contraindicated (Fig. 6.49)
on arthroscopic examination of osteochondritis dissecans of Primary OCD lesions of the patella are uncommon, "--
the lateral trochlear ridge of the femur is flap formation or they do occur (Fig. 6.51).-
",' Femoropatellar and Femorotibial joints
Wi
,~
.,
for lesions on the trochlear ridges, with removal of feature of osteochondritis dissecans of the femoropatellar
joint. This lack of correlation takes a number of forms: (1)
.In addition to primary osteochondritis cartilaginous change more severe than expected. based on
of the patella. degenerative erosive lesions that the subchondral lesions seen on the radiographs; (2)
cartilaginous lesions on the trochlear ridge or patella where
no subchondral bone changes were radiographically
of cartilage (with bone sometimes) are seen on the detectable; or (3) less severe cartilaginous change than
in association with lateral trochlear ridge OCD expected (usually taking the form of intact articular cartilage
6.51B). The usual site for these patellar lesions is the over radiographically lucent subchondral change). The
-it articulates various radiographic defects observed manifest in a number
the area of osteochondritis dissecans on the lateral of ways during arthroscopic examination. Usually some form
ridge. Histological examination of these buds of of cartilaginous flap or islands of cartilage and a fibrous tissue
in one of the author's (A.J.N.) laboratory suggest stroma are present within a concave defect (seeFigs 6.44 and
6.45); other casesinvolve a dimple-type defect or an area of
cartilage fibrillation or loss with or without undermined or
Lack of correlation between radiographic lesions and detached articular cartilage. In some instances. intact
pathologic changes found intraoperatively are a cartilage is separated from the bone (seeFigs 6.45 and 6.47).
Osteochondral bodies that have detached from the deepfascia. as occurs with the conventional lateral or medial
primary trochlear ridge lesions can be a challenging surgical instrument portals. As in other joints, the skin alone is
problem. They may be free within the joint or embedded sutured and no healing problems have been observed.
within the synovial membrane and joint capsule. If these It is difficult to make specific recommendations with
bodies are totally free within the joint. the surgeon must regard to how to manage osteochondral massesembeddedin
grasp the fragment carefully without pushing it away and the synovial membrane or in the fibrous joint capsule. For
causing it to float up into the suprapatellar pouch (Fig. 6.52). cases in which the loose body is attached to synovial
Switching off the ingress fluids at this stage can decreasethe membrane but is clearly visible within the joint, removal is
fluid flow and minimize movement of the loose body. Prior indicated and can be performed arthroscopically without
fixation of the loose body with a needle is also of help in this problems. For a less-visibleor less-accessiblelesion, arthrotomy
situation. can be performed and the first author (C.W.M.) has used this
In instances of large fragments. the skin incision is technique in one instance of such a lesion (Mcllwraith &
enlargedto facilitate removal and occasionally the deepfascial Martin 1985). It is questionable if removal of this mass was
incision is also enlarged.However.a proximal instrument portal necessary and the authors favor leaving it alone when it is
abovethe patella into the suprapatellar pouch can be used to embedded within the joint capsule. Formation of osseous
remove large fragments with satisfactory results. A spinal bodies in the soft tissue has occurred postoperatively, and
needleis used to confirm the correct position before incising a similar lesions have been noted on radiographs obtained after
portal through the quadriceps muscle into the suprapatellar arthrotomy (Pascoe et aI1984). Horses with these osseous
pouch. Large fragments are removed more easily through this masses can race, leading to the interpretation that these
portal because they do not have to come through the inelastic animals do not need surgery.
Contraindications for surgery include lateral luxation of such fragments have a rigid bony component, which is rarely
the patella owing to excessive loss of the lateral trochlear present in the equine case. Recently, a technique for using
ridge, and secondary remodeling changes of the patellar PDSOrthosorb@pins has beendescribedby Nixon et al (2004)
identified radiographically (seeFig. 6.49). for fixing large OCD flaps (see Chapter 16). A very select
At the completion of the surgical procedures for osteo- group of OCD lesions are suitable for reattachment. The
chondritis dissecans, the joint is liberally lavaged and cartilage of the flap must be relatively smooth, not calcified,
vacuumed to ensure removal of small debris released at the and have at least some residual attachment to the sur-
time of surgical debridement. A special, larger egresscannula rounding cartilage. The arthroscopic PDSpin kit can then be
has been developed for this purpose. It is 8 mm in diameter used to secure the flap in multiple locations. Reattachment,
and is 20 cm in length. It is inserted until its tip lies within the revitalization, and most, importantly, filling of the sub-
suprapatellar pouch (Fig. 6.53A). The suction tubing can be chondral bone defect occurs within 8-12 weeks of :
applied directly to the end. A motorized fluid system is critical
in flushing this joint. Use of this specialegresscannula at the
end of the procedure is most appropriate, because the debris
collects in the suprapatellar pouch and an instrument of
large diameter is necessary to allow its removal. An alter- the rapid return of ,
native is to insert a large diameter cannula into the supra- follow-up radiographs (Fig. 6.54). This compares
patellar pouch through a portal proximal to the patella. with the trochlear ridge defect remaining after
After completion of the procedure and suturing of the ment, particularly for the discerning buyer of
incisions, a sterile loban@ drape is placed over the surgery yearlings. It should be stressed, however, that
site in lieu of a bandage (Fig. 6.53B). OCD flaps of the femoral trochlear ridges do not fit :
Pin fixation of large osteochondritis dissecans fragments guidelines established for reattachment and need to
has been described in man (GuhI1984). Note, however, that debrided.
some clot organization within the defect. After this time, it is
theorised that exercise will facilitate modulation of the tissue
within the defect toward some form of fibrocartilage. On the
basis of follow-up results, the horse can return to light
training 3 to 4 months postoperatively,depending of the age
of the animal.
I
ResultsThe
results of arthroscopic surgery performed in the first
40 cases of osteochondritis dissecans involving 24 horses
were reported by McIlwraith & Martin (1985). More recently,we
published the results of arthroscopic surgery for the treat-
ment of OCD in 250 femoropatellar joints in 161 horses
(Foland et al 1992). There were 82 Thoroughbreds, 39
Quarter Horses, 16 Arabians, Warmbloods, and 15 others of
various breeds. There were 53 females and 108 males: 22
horses were less than 1 year old at the time of surgery, 68
were yearlings, 36 were 2 year olds, 21 were 3 year olds, and
14 were either 4 years old or older: 91 had bilateral
involvement and 70 had unilateral disease.
Follow-up information was obtained on 134 horses,
including 79 racehorses and 55 non-racehorses. Eighty-six
(64%) of these 134 horses returned to their intended use, 9
(7%) were in training at the time of publication, 21 (16%)
were unsuccessful, and 18 (13 %) were unsuccessful due to
other defined reasons. Horses with Grade I lesions (less than
2 cm in length) had a significantly higher successrate (78%)
than did horses with Grade II (2-4 cm) or Grade III (greater
than 4 cm) lesions (63% and 54% successrates respectively).
A significantly higher successrate was also noted for horses
operated on as 3 year olds compared with the remainder of
the study population. A significantly lower successrate was
noted for yearlings than for the remainder of the population.
There was no significant difference as related to gender
involved, racehorse vs non-racehorse, lesion location, uni-
lateral vs bilateral involvement, presenceor absenceof patellar
or trochlear groove lesions, or presence or absence of loose
bodies.
Although a permanent clinical cure would likely be anti-
cipated with this surgery in most cases,the nature of healing
within the defects is less certain. On the basis of long-term
follow-up radiographs obtained in horses that are sound, it
seemsirregular contours in the subchondral bone frequently
persist. After debridement, defects presumably fill with fibrous
tissue or fibrocartilage, but this supposition is based on
minimal amounts of follow-up necropsy data (Pascoe et al
1984) or second-look arthroscopy (Fig. 6.55). Whatever the
tissue that fills the defect, it seems to provide satisfactory
stroma for articulation. No lateral trochlear ridge lesion is
necessarilytoo big to negate surgery but more detailed
Postoperativemanagement follow-up evaluation of larger lesions in elite athletes would
Horses generally receive procaine penicillin and gentamicin be appropriate. As mentioned previously, if lateral luxation of
sulfate perioperatively and phenylbutazone before surgery the patella is present, surgery is contradicted. Limitations for
and for 5 successive days. This regimen is a precaution healing have been described in the medial condyle of the
against any development of interfacial swelling. Most cases femur (Converyet al19 72), but our clinical data support some
are simple to manage. and the horse can be discharged soon form of functional filling of these defects on the trochlear
after surgery. Hand walking commences after 1 week to allow ridges.
The condition is characterized by osteochondral fragmen-
tation of the distal aspectof the patella. In the initial report of
15 horses, the problem was unilateral in 6 horses and
bilateral in 9 and occurred in 8 Quarter Horses, 3 Thorough-
breds, 2 American Saddlebreds, 1 American Paint and 1
Warmblood/Thoroughbred cross. A previous medial patellar
desmotomy had been performed on 12 of the 15 horses.
The condition manifests as hind limb lameness and
stiffness ranging from mild to severe. There is fibrous
thickening in the stifle area in all cases associated with
previous medial patellar desmotomy (the fibrosis is centered
over the desmotomy site) and synovial effusion is normally
present and recognizable if the fibrosis is not too extensive.
The radiographic changes include bony fragmentation,
spurring (with or without an associated subchondral defect),
subchondral roughening, and subchondral lysis of the distal
aspect of the patella (Fig. 6.56).
The treatment is arthroscopic surgery. In the initial series
the lesions at arthroscopy varied from flaking, fissuring,
undermining, or fragmentation of the articular cartilage to
fragmentation and/or lysis of the bone at the distal aspectof
the patella (Fig. 6.57). The subchondral bone was involved in
all cases that had a previous medial patellar desmotomy. Of
the 12 horses that had a previous medial patellar desmotomy,
8 horses became sound for their intended use, 1 horse was
sold in training without problems, 1 horse was in early
training without problems at the time of publication, 1 horse
never improved and 1 horse was in convalescence. Of the
three cases that did not have a medial patellar desmotomy,
2 horses performed their intended use, but 1 horse was un-
The healing potential of horses that have undergone satisfactory. In these instances, there was no severe bone
operations at 2-3 years of age may be less than that of involvement. It is possible that such cases are equivalent to
younger aniJIlals. Fortunately. these older horses typically the chondromalacia syndrome described by Adams (1974).
have smaller defects. complete resurfacing of which may not
be as critical for athletic function. Our published data for
3 year olds supports this conclusion (Foland et alI992).
Preoperativeconsiderations
A common question from clients regarding surgery for The history in these cases usually involves the development of
OCD of the stifles is what is the likelihood of having more hind limb lameness referable to the stifle, usually after medial
lesions develop or will the problem developin other joints? Of patellar desmotomy. In most instances, the specific indication
the 161 horses operated on for femoropatellar OCD.12 under- for the medial patellar desmotomy is unknown (performed by
went concurrent surgery for other lesions as well as femoro- other veterinarians). Subsequent to desmotomy, a gonitis
patellar arthroscopy (Foland et aI1992). Five of these horses develops and persists. Femoropatellar effusion may be present
had OCDlesions in both metatarsophalangeal joints. 4 horses in addition to pericapsular fibrosis. The lameness is typically
had OCD of the tarsocrural joint. 2 horses had subchondral obvious at the trot but is observable commonly at the walk.
cystic lesions of the medial femoral condyle. and 1 horse had Radiographs of the femoropatellar joint reveal either a defect
OCDof a scapulohumeral joint. In other words. the likelihood in the bone at the distal aspect of the patella or bony
of lesions developing elsewhere is low. Also. the more recent fragmentation (usually associated with an observable defect)
work by van Weeren & Barneveld (1999) shows that if a of the distal aspect of the patella (see Fig. 6.56). On the basis
horse is operated on at 11 months of age or older. there of a lack of clinical improvement as well as the presence of
is no likelihood of additional lesion development in the radiographic lesions in these cases, arthroscopic surgery is
Instruments may include a banana blade, which follow-up data are available in 67 (Lewis 1987). This
elevator, Ferris-Smith rongeurs, and motorized abrader. latter technique was then adoptedby the first author andrepo
In occasional instances,a fracture of the medial patellarfibrocartilage in the secondedition of this text.
without osseousinvolvement may be seen(Fig.
6..e0).
A retrospectivestudy of five performancehorses withpatellarPreoperative considerationsThe
fracturestreatedwith arthroscopicremovalhas beenreported typical clinical sign is lamenessin one or both hind limbs
(Marble & Sullins 2000). Four of five horseshadfractures
at a trot. In some horses, lameness is subtle and is noticeable
of the medial aspectof the patella and one horsehadonly during riding. Historically, some of these horses can bein
a fracture of the lateral aspect. Arthroscopy wasperformed training for considerable periods of time, with clinical signsman
in the femoropatellar joint using techniquesdescribed only after a certain amount of work has beendone
previously.There were no complicationswith the Most horses swing the leg medially and the lamenessisacce
joint or the arthroscopicportal incisions. Recoveryperiodsranged when trotting in a circle with the affected leginsid
from 3 to 5 months. All horsesrecoveredcompletely Medial femorotibial analgesia localizes the lesion but aresp
from surgeryand performedat the sameor a higher levelof can also be obtained with femoropatellar blockade.
competitionasbeforearthroscopy. Any change in the external appearance of the stifle isminim
Mild distention of the femorotibial joint may be
seenin more chronic cases.It is more common to seefemoro-pate
effusion (Howard et al1995).
The lesion is apparent radiographically. Both flexed lateraland
caudocranial views (Figs 6.61 and 6.62) are useful to
ascertain the location and sizeof the lesion. The typical lesionis
round or oval with a defect at the articular surface ofvary
size (seeFig 6.61). Such lesions may be bilateral. In
lesions of the medialcondyle other cases,a small flattened or concave defect (seeFig 6.62)
of the femur may be present. Most commonly, the latter lesion is seen inthe
stifle opposite to one manifesting lameness and exhibitinga
For 8 years,the first author (C.W.M.)treated subchondralcystic
large cystic lesion or as an incidental finding on pre-purchaseradio
lesions of the femorotibialjoint using a femorotibial of yearlings. Although surgical debridement ofcysti
arthrotomy with goodresults (Mcilwraith 1983. White et al lesions is being described here, there are a number of
Cystic
1988).
evaluation period showed that healing was similar in grafted
and ungrafted defectsin the equine medial femoral condyle at
6 months Uackson et al 2000). This suggested that surgical
debridement alone rather than adjunctive bone grafting of
cystic lesions is the treatment of choice.
The development of subchondral cystic lesions has been
associatedwith osteochondrosis and trauma. Whereas osteo-
chondrosis was initially consideredthe exclusivepathogenesis.
observations of cystic enlargement after surgery prompted
further investigation into the pathogenesis of these lesions
and to reasons why they may potentially expand. Work in the
first author's (C.W.M.) laboratory (Ray et a11996), showed
that it was possible to consistently produce (5/6 cases)
subchondral cystic lesions by creating a 5 mm diameter, 3 mm
deep defect in the subchondral bone at the central
weightbearing portion of the medial condyle of the femur.
Other work then revealed that the fibrous tissue of
subchondral cystic lesions (removed surgically) released
nitric oxide, PGEz,and neutral metalloproteases into culture
media after in vitro culturing. It was also shown that
conditioned media of the cultured tissue was capable of
recruiting osteoclasts and increasing their activity (von
Rechenberg et al 2000). It was therefore felt that fibrous
tissue could play an active role in the pathologic processesof
bone resorption occurring in the subchondral cystic lesions
and may be partially responsible for the slow healing rate and
expansion of these lesions. For this reason, the first author
(C.W.M.) has in recent years injected corticosteroids at the
time of surgical debridement. Recentreports by Sandler et al
(2002) suggest that simple debridement still has a high
success rate. On the other hand, reports of arthroscopic
intralesional injection of corticosteroids (Vandekeybus et al
1999) have prompted evaluation of this technique and this
will also be described.
Technique
The authors have previously used a cranial arthroscopic portal
between the middle and lateral ligaments with a cranial
instrument portal medial to the arthroscopic portal initially.
The technique developed by Lewis (1987) is superior,
however, and is now routinely used by the author. This latter
technique is described here (Figs 6.63 and 6.64).
The procedure is performed with the horse under general
anesthesia in dorsal recumbency. The leg is flexed such that
the stifle and hock are approximately at 900 angles. Stabilizing
the leg in this position is recommended. The medial
femorotibial joint can be distended with irrigating solution,
but for experienced surgeons, this is generally not necessary
and the arthroscope is inserted through the lateral portal
between the lateral patellar ligament and the origin of the
other options that have beenused. Historically,cancellous long digital extensor tendon as previously described. Examin-
bone grafting has beenused (Kold & Hickman 1984), but ation of the medial femorotibial joint is also performed as
resultswith this techniquethrough arthrotomy at leastwere previously described.
not as goodas simple debridement(White et aI1988). More The characteristic dimple in the articular cartilage over-
recently,somecontrolledwork with cancellousbonegrafting lying the subchondral cystic lesion is visualized (Fig. 6.65)
in experimentallycreated 12.7 mm diameter and 19-mm and the location for the instrument portal is determined by
deepdefectsin the medialfemoral condyle and a 6-month placement of a needle (seeFig. 6.64A). The instrument portal
Femoropatellarand FemorotibialJoints
I'
~
madeusing an 8 mm incision through the skin and hole is conservatively cut back to gain sufficient accessto the
and a stab through the joint capsulewith a No. 11 cystic lesion, but not more than that. More recently, one of
.This portal must be positionedso that the authors (AJN)has beenusing cancellous bone graft in the
site of the lesionperpendicular base of the cystic lesion and adding fibrin with cells on top
the articular surface to enable effective surgical mani- (see Chapter 16). Although drilling of the cystic lesion has
been abandoned because it appeared to be associated with
are removed by using a curette and rongeurs (see enlargement of cysts (Howard et al1995), micro fracture has
In someinstancesa motorizedburr is usedto assist been perfomed in the walls of the cystic lesions and it is a
subjective impression that it is quite useful.
The configurations of the cystic lesions at arthroscopy Following debridement, the joint is lavaged liberally and
and can be multi-loculated. Typically debridement of suction is also applied after this procedure. The skin portals
subchondral tissue continues to normal bone. Because are closed with simple interrupted sutures. Care is taken
during initial debridement of the contents of the cyst to
be a difficult decision.Cartilagethat is overhangingthe remove defective tissue immediately from the joint and to
minimize debris accumulation elsewhere. Debris is released in 11 horses had an osteochondritis dissecans lesion
into the joint. but it generally accumulates in the inter-
condylar area lateral to the medial condyle. A special effort is from the opening of the subchondral cystic lesion. ~
made during lavage and suctioning of the joint to remove all debridement performed by arthroscopy was the only
debris from this area. ment for 37 lesions in 23 horses.
drilling of the defect bed was performed in 23 lesions
18 horses. Complete follow-up information
Postoperative management 39 horses: 22 (56%) horses had a successful result
Perioperatively,the horse receivesprocaine penicillin and 17 (44%) horses had an unsuccessful result.
phenylbutazone. The patient is confined to a stall for
2 months. Hand walking commencesat the time of suture results because of factors not directly attributed to
removal. A minimum of 4 more months pasture rest is subchondral cystic lesion of the medial femoral
recommendedbefore training resumes.Training should (censored analysis), 23 of 31 '
resumeonly if the horseis sound at a trot afterthis time. In result and 8 of 31 (26%) horses had,
the series of casesreported by Lewis. the postoperative Within this group of horses, the prognosis for a
convalescence in casesthat were ultimately successful varied
from 4 to 18 months and averagedapproximately7t months sex, size of ]
(Lewis1987). lesion was drilled, the presence of
with the subchondral cystic lesion, or whether the
enlarged after surgery. Compared
Results Arabians, Quarter Horses had a poorer]
In the series reported by Lewis, complete soundness for Follow-up radiographs were available for 14 horses.
these 14 horses, the subchondral cystic lesion --
intended use was achieved in 34 of the 67 cases based on
follow-up information from the owners. In addition, 14 horses
were sound enough that they were used as intended, despite significantly with drilling of the lesion bed at the time
occasionalmild lamenessin the affectedlimb. Of the remaining surgery.
19 horses, various degrees of residual lameness presented a Lesions were classified on radiographic appearance
problem for athletic use as intended; however, some animals either Type I lesions (10 mm or less in depth.
were used for less stressful activities and were satisfactory in
that respect. In summary, the overall satisfactory outcome for surface of
intended use was 72% (48 of the 67 cases).Of the 19 failures II lesions (more than 10 mm in depth and
for intended use, 11 were from a group of 28 potential race- conical or spherical) (see Fig. 6.61B), or Type ill
horses, producing a 39% failure rate. Eight were from a group (flattened or irregular contours of the subchondral j
of 39 horses intended for other use (cutting, reining, roping, the distal aspect of the medial femoral condyle. 1
and pleasure), representing a 21 % failure rate in these types regression showed a significant association between
of horses. Lewis concluded that several factors could affect types as assessedfrom preoperative radiographs and ~
the prognosis, including age (younger horses in general had a types based on surgical assessment. However, '
better prognosis), unilateral versus bilateral lesions (cases of
bilateral involvement were somewhat less successful),signifi-
cant training or use before surgery (generally decreasedthe in six joints; of the SCL that appeared to be Type I
prognosis), previous administration of intra-articular medi-
cation (subjectively, the author thought prior corticosteroid
injection was detrimental to the ultimate outcome), radio-
graphic appearance (the broader opening of the cyst at the were later determined to be Type I on the basis of
articular surface was associated with a less favorable prog- scopic findings. Of the 15 joints that appeared to ~
nosis), pre-existing degenerative joint disease (poorer prog- three had a Type I SCL.six:
nosis), and intended use (racehorseswere the most difficult to four appearedto be norma
return to intended use).
Howard et al (1995) described the results of arthroscopic attachedto the subchondralbone on palpation
surgery for subchondral cystic lesions in the medial femoral and no surgical treatmentwas done; however.
condyle in 41 horses. There were 17 Quarter Horses, 15 stifle of thesehorsesdid havea surgicallesion.
Arabians, 8 Thoroughbreds, and 1 Holsteiner with 28 (68%) not performedon two of the joints with a SD. Given
of the horses being 1-3 years old. For all horses, the owner's
complaint was mild to moderate hind limb lameness, or an lesional injection of 40 mg of MPA (Depo-Medrol@)to
regime. The latter technique ' -
altered gait. Bilateral radiographic abnormalities of the medial
femoral condyle were detected in 27 horses. Nineteen of the
27 horses had lesions identified bilaterally at arthroscopic supported by more recent work demonstrating that
surgery. In addition to the subchondral cystic lesion, 13 joints fibroustissueof
cause (55) of the horses raced as 4 year olds. The number of starts
and average earnings per start for the horses that had been
operated on were less than their maternal siblings for their
2- and 3-year-old racing careers, but were similar to their
achieving siblings for the 4-year-old racing year. Of the 49 horses with
Type I lesions, 34 (69.3%) horses started a race in their career,
whereas 62 (61.3%) horses with Type II lesions started. This
indicated that radiographically assessedlesion depth was of
lesionwas little consequencein defining the prognosis.
Additionally, there were 91 (60.6%) horses with less than
(Howard et al amount of or equal to 15 mm of surface debridement and 59 (39.3%)
surface disrupted by measured horses with greater than 15 mm of surface debridement. Of
at the 1 the 91 horses with 15 mm or less of surface disrupted, over
into two groups: those with lesions that involved 70% started at least one race, whereas only about 30% of the
or less cartilage surface and those with greater 59 horses with greater than 15 mm of cartilage surface
15 mm of disruption. During the period between 1989 involvement started a race. The amount of cartilage surface
150 clinically lame Thoroughbred horses with a affected seemedto be a better predictor of successthan lesion
214 subchondral cystic lesions had surgery. Of the depth.
86 (58%) horses had unilateral lesions and 64 Most recently, one author (C.W.M.) has treated a number
of cases with intralesional injection of corticosteroid
were raced, whereas 77% of the siblings (triamcinolone acetonide) under arthroscopic visualization
whereas 71% of males raced; (Fig. 6.66). In 2-year-old Thoroughbreds, everyone at this
stage has been able to go back into training at 2 months, with
61 % (79) of the horses raced as 3 year oIds, and 51% already some increased density in their cystic lesions. The
results are very preliminary. The technique's rationale is
basedon the findings of von Rechenberget al (2000). It is
possiblethat this technique offers an ability to return the
athlete to racing more quickly than arthroscopicdebride-
mentdoes.
Horizontal transverse
Of the horses with radiographic technique (Sopera & Hunter 1992) with No.3 polYglactin
more were lame 910 (Vicryl).
follow-up as compared to those that did not have a Meniscal tears, particularly the longitudinal tears
75% vs 10/34 described by Walmsley et al (2003) as Gradeill, can progress
.In the series of cases by Walmsley et al (2003), into the mid-portion and even the caudal horn of the
I lesions were not debrided, but consideration was meniscus. Any meniscal tear where the abaxial (medial) and
to suturing. It was not considered practical in most caudal termination cannot be discerned needs to be explored
but one Grade III lesion was sutured using the further by examination through the caudal joint pouch of
of the laparoscopic extracorporeal knotting the femorotibial joint. Discrete tears of the caudal horn of the
medial meniscus can also occur (Fig. 6.82). The authors now Other indications for arthroscopic
always examine the caudal portion of the medial femorotibial surgery in caudal pouches
joint. even if a tear in the cranial horn appears contained.
The medial meniscus is predominately affected; the lateral
meniscus caudal horn has been involved only once in our the caudal aspectof the femoralcondylesin foals
experience.Vertical longitudinal tears of the medial meniscus examination of the caudal pouches has been
have also been seen(Fig. 6.83). Mineralization of the meniscus (Hance et al 1993). We have also used this approach
is a late-stage development (Fig. 6.84) and frequently signals
chronic meniscal tearing. Surgical aims in mineralized cases
should be to trim all protruding portions that impact on the The caudal compartment of the medial femoral
caudal surface of the femoral condyle. debride free or is quite voluminous and free fragments can be
fibrillated soft portions of the meniscus and suture any
longitudinal tears that are not disintegrated. Manipulation of the instrument portal is vital in reaching the
instruments in the caudal compartment is tedious. particu- and avoiding instruments and the arthroscope
larly since the depth of the damaged meniscus from the skin with each other as they penetrate deeper to
surface is often 6-8 cm. Trimming of caudal horn meniscal free pieces.
tissue is best accomplished with a motorized resector, The caudal portion of the caudal r
particularly the large-format tooth synovial resectors such as
the orbit incisor or Synovator. Removal of mineralization medial femorotibial joint (Fig. 6.85). However,
generally requires an arthroburr. ence of authors, disruption of the insertion of
In common with other species, macerated tears of the (evident radiographically) may not be visible
menisci carry a poor prognosis for return to working sound- arthroscopy. Moreover, the popliteal artery is ~
ness as the loss of fibrocartilagenous meniscal tissue is this ligament and exposure of the caudal cruciate
usually marked. These injuries frequently also extend into the motorized resection of the covering joint capsule would
central inaccessible regions of the meniscus so that removal hazardous. A caudal cruciate ligament avulsion in ;'
of torn tissue often is incomplete. has been defined with imaging (Roseet aI2001).
~
Martin GS. Mcilwraith CWoArthroscopic anatomy of the equine
femoropatellar joint and approaches for treatment of osteo-
chondritis dissecans. Vet Surg 1985; 14: 99-104.
Moustafa MAl. Boero II. Baker GJ. Arthroscopic examination of the
femorotibial joints of horses. Vet Surg 1987; 16: 352-357.
Vet Mueller POE. Allen D. Watson E. Hay C. Arthroscopic removal of a
fragment from an intercondylar eminence fracture of the tibia in
a 2-year-old horse. J Am Vet Med Assoc 1994; 204: 1793-1795.
, Zugang.Teil 1:
11: Nickels FA. SandeR. Radiographic and arthroscopic findings in the
equine stifle. J Am Vet Med Assoc 1982; 181: 918-924.
.BoydJS.etaI. Ultrasonographic
examination Outerbridge R. The etiology of chondromalacia of the patella. JBone
Joint Surg (Br) 1961; 43: 752.
and caudal aspects.Equine Vet J 1996; 28: 285-296. Nixon AJ. Fortier LA. Goodrich LR. Ducharme NG. Arthroscopic re-
Akeson WH. Keown GR. The repair of large osteo- attachment of select OCDlesions using resorbable polydioxanone
chondral defects; an experimental study in horses. Clin Orthop pins. Equine VetJ 200436: 376-383
RelRes 1972; 82: 853-862. Pascoe JR. Wheat }D. Jones KL. A lateral approach to the equine
van Weeren PRoRadiographic development of femoropatellar joint. Vet Surg 1980; 9: 141-144.
osteochondral abnormalities in the hock and stifle of Dutch Pascoe JR. et al: Osteochondral defects of the lateral trocWear
Warmblood foals. from age 1 to 11 months. Equine Vet J 1999; ridge of the distal femur of the horse. Clinical. radiographic. and
(Suppll) 31: 9-15. pathologic examination of results of surgical treatment. Vet Surg
-Nixon. AJ. Avulsion of the cranial cruciate ligament in 1984; 13: 99-110.
a horse. Equine Vet J 1996; 18: 334-336. Prades M. Grant VD. Turner TA. Injuries of the cranial cruciate
ligament and associated structures: summary of clinical. radio-
study of 14 horses. Proceedings 48th AAEP 2002; 249-254. graphic. arthroscopic and pathological findings from 10 horses.
~- -Mcllwraith CWoTrotter GW. Arthroscopic surgery for EquineVetJ 1989; 21: 354-357.
osteochondritis dissecans of the femoropatellar joint. Equine Vet Ray CS. Baxter GM. Mcilwraith CWoet al. Development of sub-
J 1992;24: 419-423. chondral cystic lesions after articular cartilage and subchondral
.-Arthroscopic treatment of osteochondritis dissecans. Clin bone damage in horses. Equine Vet J 1996: 28: 225-232.
Orthop 1984; 167: 65-74. Rich RF. GlissonRR. In vitro mechanical properties and failure mode
et al. Lesions of the caudal of equine (pony) cranial cruciate ligament. Vet Surg 1994; 23:
aspect of the femoral condyles in foals: 20 cases(1980-1990). J 257-265.
Am Vet Med Assoc 1993; 202: 637-646. RosePL. Graham JP.Moore I. Riley CB. Imaging diagnosis -caudal
Arthroscopic surgery for cruciate avulsion in a horse. Vet Radiol Ultrasound 2001; 42:
subchondral cystic lesions of the medial femoral condyle in 414-416.
horses: 41 cases(1988-1991). J Am Vet Med Assoc 1995; 206: Sanders-ShamisM. Bukowiecki CP.Biller DS. Cruciate and collateral
842-850. ligament failure in the equine stifle: 7 cases (1975-1985). J Am
WA, Stick JA, Arnoczky Sp, Nickels FA. The effect of Vet Med Assoc 1988; 193: 573-576.
compacted cancellous bone grafting on the healing of sub- Sandler EA. Bramlage LR. Embertson RM. Ruggles AJ. Frisbie DD.
chondral bone defects on the medial femoral condyle in horses. Correlation of lesion size with racing performance in Thorough-
Vet Surg 2000; 29: 8-16. breds after arthroscopic surgical treatment of subchondral cystic
J. Results of treatment of subchondral bone cysts lesions of the medial femoral condyle: 150 cases (1989-2000).
in the medial condyle of the equine femur with an autogenous Proceedings 48th AAEP. 2002; 255-256.
cancellous bone graft. Equine Vet J 1984; 16: 414, Schneider RK. Jenson P. Moore RM. Evaluation of cartilage
c --A retrospective study of diagnostic and surgical
lesions on the medial femoral condyle as a cause of lameness in
arthroscopy of the equine femorotibial joint. Proceedings of the horses: 11 cases (1988-1994). J Am Vet Med Assoc 1997; 20:
23rd Annual Meeting of the American Association of Equine 1649-1652.
Practitioners, 1987. Soper NJ. Hunter JG. Suturing and knot tying in laparoscopy. Surg
CWoSurgery of the hock. stifle and shoulder. Vet Clin Clin N Am 1992; 72: 1139-1152.
North Am 1983; 5: 333-362. Steinheimer DN. Mcilwraith CWoPark RD. Steyn PF. Comparison of
Experience in diagnostic and surgical arthroscopy radiographic subchondral bone changes with arthroscopic
in the horse. Equine Vet J 1984; 16: 11-19. findings in the equine femoropatellar and femorotibial joints.
-.Treatment of osteochondritis dissecans and A retrospective study of 72 horses. Vet Radiol 1995; 36:
subchondral cystic lesions. Proceedings of Panel on Develop- 478-484.
mental Orthopedic Disease.American Quarter Horse Association, Stick JA. Borg LA. Nickels. Peloso JG. Perau DL. Arthroscopic
Dallas, TX, April 1986; 21-22. removal of an osteochondral fragment from the caudal pouch of
Mcllwraith CWoOsteochondral fragmentation of the distal aspect of the lateral femoral tibial joint in a colt. J Am VetMed Assoc 1992;
the patella in horse. Equine Vet J 1990; 22: 157-163. 200: 1695-1697.
Mcllwraith CW Osteochondritis dissecans of the femoropatellar Textor JA. Nixon AJ. Lumsden J. Ducharme NG. Subchondral cystic
joint. Proceedings 39th Annual Meeting AAEP, 1993: 73-77. lesions of the proximal extremity in horses: 12 cases
Mcllwraith CW, Martin GS. Arthroscopy and arthroscopic surgery in (1983-2000). J Am Vet Med Assoc 2001; 218: 408-413.
horse. ContEduc 1984; 6: S43-553. Trotter CW Mcilwraith CWoNorrdin RW A comparison of two surgical
Mcllwraith CW, Martin, CS. Arthroscopic surgery for the treatment approaches to the equine femoropatellar joint for the treatment of
of osteochondritis dissecans in the equine femoropatellar joint. osteochondritis dissecans. Vet Surg 1983; 12: 30--40.
VetSurg 1985; 14: 105-116. Trumble TN. Stick JA. Arnoczky SP. RosensteinD. Consideration of
Marble GP, Sullins KE. Arthroscopic removal of patellar fracture anatomic and radiographic features of the caudal pouches of the
fragments in horses: 5 cases(1989-1998). J Am Vet Med Assoc femorotibial joints of horses for the purpose of arthroscopy. Am J
2000; 216: 1799-1801. Vet Res1994; 55: 1682-1689.
Turner TA. Nixon AJ. Brown M. Prades MA. Injuries to the anterior Walmsley JP. Fracture of the intercondylar eminence of the tibia
cruciate ligament in sevenhorses(Abstract). VetSurg 1988; 17: 38. treated by arthroscopic internal fixation. Equine Vet J 1997; 29;
Vandekeybus L. Desbrosse F. Perrin R. Intralesional long acting 148-150.
corticosteroids as a treatment for subchondral cystic lesions in Walmsley JP. Arthroscopic surgery of the femorotibial joint. Clin
horses. A Retrospective Study of 22 Cases. Proceedings of the Techn Equine Prac 2002; 1: 226-233.
8th annual scientific meeting of the European College of Walmsley JP.Philips TJ.Townsend HGG. Meniscal tears in horses:an
Veterinary Surgeons 1999 33-34. evaluation of clinical signs and arthroscopic treatment of 80
von Rechenberg B. Guenther H. McIlwraith CWoet al. Fibrous tissue cases.Equine Vet J 2003; 35: 402-406.
of subchondral cystic lesions in horses produce local mediators White NA. Mcllwraith CWoAllen D. Curettage of subchondral bone
and neutral metalloproteinases and cause bone resorption in cysts in medial femoral condyles of the horse. Equine Vet J Suppl
horses. Vet Surg 2000; 29: 420-429. 1988; 6: 120-124.
Walmsley Jp.Vertical tears of the cranial horn of the meniscus and Wyburn RS. Degenerative joint disease in the horse. NZ Vet J 1977;
its cranial ligament in the equine femorotibial joint: 7 casesand 25: 321-322, 335.
their treatment by arthroscopic surgery. Equine Vet J 1995; 27:
20-25.
~
tarsocrural (tibiotarsal) joint has proven highly The tarsocrural joints are shaved on both sides of the joint.
both diagnosticand surgical arthroscopy.The The draping system includes an adhesive barrier and
impermeable drapes (Fig. 7.1). The joint is distended before
the other joints, new discoveries have caused making the skin incisions. The skin incisions for the
in the indications for diagnostic arthroscopy as arthroscopic and instrument approaches are located to the
as an increase in the spectrum of surgical conditions sides of the group of extensor tendons on the dorsal aspect of
tarsocrural joint. For instance, before the use of the joint (the long digital extensor, the peroneus tertius, and
surgical intervention was not considered the cranialis tibialis tendons). These structures are col-
a tarsocrural joint manifesting effusion and/ lectively referred to in the remainder of the text as the
unless it had a radiographic lesion. Now we extensor tendons. As a general principle, all portals are made
that not all cases of tarsocrural OCD, for instance, close to (approximately 1 cm from) the extensor tendons to
radiographically. Although this finding further maximum visualization.
the limitations of radiographs, it does, however,
to define and treat cases of "idiopathic synovitis"
undefined. In addition, Arthroscopic examination using a
other joints, OCD can be treated conveniently with dorsomedlal approach
and the same advantages exist.
The dorsomedial approach is used most commonly. If the
arthroscopic portal is made close to the cranialis tibialis and
peroneus tertius tendons. a large portion of the dorsal aspect
of the joint can be seen. The approach provides excellent
visualization of the cranial or dorsal compartment of the
tarsocrural joint. including the trochlear ridges and trochlear
diagnostic arthroscopy in the tarsocrural
dorsal and plantar. The dorsal approach
a dorsomedial (craniomedial) arthroscopic portal.
approach involves a plantarolateral or plantaro
arthroscopic portal. Most arthroscopic cases involve
, ,. In the previous
.
groove of the talus. Flexing and extending the joint, which Examinationcommenceson the lateral
brings different areas of the trochlear ridges into view, can
increase the area of visualization. The corresponding area of and its articulation with the tibia. This view
lateral malleolus (Fig. 7.3). c
the distal tibia from the medial malleolus to the distal inter-
mediate ridge is also visible. Many adult horses also have an visualize the central lateral trochlear ridge (Fig.
opening that allows visualization of the proximal intertarsal further distad, the distal part of the lateral
(talocentral) joint distally. Inspection of the synovial lining of comes into the visual field (Fig. 7.5). In this
the dorsal aspectof the tarsocrural joint can also be performed.
The joint is distended using a needle placed through the of the arthroscope. The view of the arthroscope
dorsomedial pouch with the leg in extension (see Fig. 7.1).
The skin portal is made slightly dorsal to the center of the and the arthroscopeis withdrawn
distended dorsomedial outpouching and just below the oriented in a plantar direction to
palpable distal end of the medial malleolus. and the arthro-
of the trochlear groove of the talus (Fig. '
scopic sleeve and conical obturator are inserted (Fig 7.2).
This position is ideal for visualization within the joint. If the of the trochlear groove is visible further distally
arthroscope is placed more medially, it is difficult to pass the addition. the talocentral (proximal intertarsal) j
arthroscopic sheath over the trochlear ridges of the talus visualized (see Fig.
across the joint. The skin portal is made sufficiently large usually patent in very young foals. A
(8-10 mm) to ensure that the saphenous vein is not directly
beneath the incision and to avoid its penetration. In many
horses, the arthroscope portal can be made between the the talus (Fig. 7.7E).
saphenous vein and the extensor tendons, and this location Further withdrawal of the arthroscope
provides optimal visualization of the deeper region of the rotation, so that the view is proximal and
intermediate ridge. A No. 11 blade is then used to continue visualization of the proximal
the portal through the fibrous capsule. The sleeveand conical ridge and its articulation with the distal tibia (Fig.
obturator are then inserted until contact with the medial side
of the talus is made (Fig. 7.2). The joint is then flexed, the medial malleolus is possible (Fig. 7.9). The
aspects of the medial trochlear ridge can be -
enabling the arthroscopic sleeveand obturator to pass across
the joint, over the top of the trochlear ridges. and beneath
the extensor tendons (this maneuver is impossible in an
extended joint).
The arthroscopic portal can also be made with the joint
flexed, eliminating the need to flex the joint during placement allows examination of the medial side of
of the sheath; however. the landmarks (as well as location of dorsomedial pouch (Fig. 7.12).
the saphenous vein) are more easily identified with the limb With this approach. imposition of soft tissue sometimes
in extension. makes examination of the lateral trochlear ridge and other
(Tibiotarsal) Joint
areasof the lateral part of the joint challenging.It requires approaches. Additionally, the planfar aspect of the distal tibia
the end of the arthroscopeto be closeto the lateraltrochlear and the deep digital flexor tendon (DDFT) within its tendon
ridge of the talus along with the use of the instrument to sheath can be seen,but these observations have not provento
retract soft tissue. However,with practice, this becomes be of major clinical relevance. Since the second edition, the
reasonablyeasy. approach to the plantar pouch has been reported in the
refereed literature (Zamos et al 1994). Joint distention is
critical for the plantar lateral approach, and is done by
Arthroscopic examination using plantar placing a needle in the center of the plantar pouch which
lateral or plantar medial approaches usually allows adequatedistention. The skin portal is made in
the center of the plantar outpouching with the tarsus flexed
These approaches are used far less commonly. They allow at 90°. The arthroscopic sheath is placed in the joint using
excellent visualization of the remaining (proximal) portions the blunt obturator. The surgeon should be careful to avoid
of the lateral and medial trochlear ridges that are not damaging the trochlear ridges of the talus. Viewing
visualized by using the previously describeddorsal approaches. commences with the hock flexed (Fig. 7.13).
Eachtrochlear ridge is bestevaluated by using an arthroscopic Introduction of the arthroscope through a plantaromedial
approach through the same side (Fig. 7.13). The principal or plantarolateral portal located in the center of the plantar
benefit of using the plantar approaches is allowing examin- pouch puts the arthroscope immediately dorsal to the tarsal
ation of defects in the proximal portion of the trochlear synovial sheath surrounding the DDFT and plantar to the
ridges. the removal of loose bodies in the plantar pouch, and trochlear ridges of the talus. This permits evaluation of the
the treatment of sepsis and osteomyelitis. This approach plantar aspects of the medial and lateral trochlear ridges of
sometimes also is useful to access fractures of the lateral the talus as well as the trochlear groove, the distal tibia
malleolus of the tibia. Virtually all of the synovial lining of (plantar aspect of intermediate ridge) and the articular
the plantar joint pouch can be inspected through use of these portion of the tendon sheath containing the DDFT (see
7.13). Througha plantarolateralarthroscopicportal. the spavin) is noted in the young horse, even when the radio-
c -
graphic signs are negative. In addition, arthroscopy is an
and the lateral malleolus can also be observed if excellent means by which to evaluate the joint in a case of
., ., , Withdrawing the arthro-
severe synovitis, suspected
The general aspects of
discussed in Chapter 3. Septic
young horse can be evaluated and
If a plantaromedial arthroscopic portal is used, directing Chapter14. Arthroscopyalso permits identification of soft
arthroscope dorsally allows observation of the dorso- tissuelesionssuchastearsof the collateralligaments.within
malleolus cannot be seen. or communicating with the tarsocrural joint. As in otherjoints.
arthroscopyis superiorto radiographicexaminationor
synovialfluid analysisfor diagnosisin the tarsocruraljoint.
By extending the joint more (approximately 120°), the
, and lateral dorsal cul-de-sacs of the joint can be
arthroscopy of the
joint
Arthroscopic surgery has proven to be an excellent tool in the
The most common indication for arthroscopyin the tarso- tarsocrural joint and is indicated for the following conditions;
crural joint is for the surgical treatment of OCD.In some 1. Osteochondritis dissecansof the distal intermediate ridge
instances. however. OCD is .and
dissecans of the lateral and medial
examination.For this
3.
~
2.
4. Osteochondritisdissecansof the medial malleolus of
the tibia.
5. Removalof lateralmalleolarfragments.
6. Debridementof septiclesionsof the trochlear ridges of
the talus.
7. Removalof fibrin in septicarthritis.
8. Treatmentof someforms of proliferativesynovitis.
9. Traumaticlesionsand osteoarthritis.includingdiagnostic
arthroscopyin casesof lamenessand hemarthrosis.
10. Intra-articular fracturesof the tarsocruraljoint.
11. Retrieval of fragments from the talocentral (proximal
intertarsaljoint).
12. Tears/avulsionsof the collateralligaments.13.
Tears/avulsionof the joint capsule.
Osteochondritis dissecans of
the tarsocrural joint
.,
Once the fragment is elevated. an appropriately sized pair of
grasping forceps is introduced and the fragment is grasped
(Fig. 7.17). The grasping forceps are then rotated to break As with all other OCD lesions, thearthroscopic
down any remaining soft tissue attachments and withdrawn. manifestations in c -~ .
.""
As discussed in Chapter 4. the forceps should enclose the
fragment. In many instances in the tarsocrural joint. how-
ever. due to the large size of fragments this is not always
possible.as in the caseillustrated in Fig. 7.18. As the fragment but an osteochondritis dissecans flap was found.
is pulled through the joint capsule. fluid flow is again stopped that
crural in joint
the case
had illustrated
an effusion in but
Fig. no
;
These
allow debridement of trochlear groove cystic lesions. Some
lesions can be quite deep,despite minor radiographic abnor-
malities (Fig. 7.34). Flexion of the joint after insertion of the
arthroscope is used to exposethe cyst entry. Needle insertion
then guides the instrument portal.
.,
Tears and avulsions of the collateral
ligaments of the tarsocrural joint
.
The arthroscopecannula and conical obturator are then
inserted through the joint capsulein the samedirection as
the I8-gauge spinal needleunder the infraspinatustendon
toward the caudal aspectof the joint (Fig. 8.4). Entry into
the joint is confirmed by removing the obturator and
observinga flow of fluid from the cannula.The arthroscope
is then placed within the cannula. and the diagnostic
arthroscopic evaluation can commencefrom this position
(Fig.8.5).
Most patients manifest clinical signs before 1 year of age.The prognosis,and can lead to surgery and generallya
age of presentation doesdepend somewhat on the observation outlook(Fig.8.18).
skills of the owners. In some cases,a recent history of lameness
may be described.Contracted conformation of the feetsignifies
more accurately the duration of a problem. Preoperative Arthroscopic technique
clinical signs include lameness with a shortened cranial
phase of stride. Some horses show resentment to firm digital A thorough exploration of the scapulohumeral joint,
pressure caudal to the infraspinatus tendon. Extension and previously described, is performed as the first step. r
flexion of the shoulder joint is also resented in some cases. exploration involves probing all visible lesions as well
Intra-articular anesthesia of the shoulder joint improves or
eliminates the lameness in most cases. However, when the entry for triangulation during arthroscopic surgery in
shoulder, is illustrated in 1 .-.
articular cartilage over subchondral bone defectsis still intact,
intra-articular local anesthesia may not generate a response. is selected to permit accessto the caudal humeral r
Intra-articular anesthesia is performed by using the same central articular surface of the glenoid. To determine
landmark as previously described for placing the spinal needle location. an I8-gauge spinal needle is inserted about (
during arthroscopy. The absence of these localizing clinical caudal to the infraspinatus tendon and 4 cm distal (-
signs, however, does not rule out the presence of osteo- arthroscopic portal (Fig. 8.20). This location usually f
The shoulder is one of the few sites where screw-in self-
sealing cannulae are useful to prevent massive subcutaneous
fluid accumulation. They limit the size of instrument entry,
and so must be at least 7 mm internal diameter to be useful
(described in Chapter 2). A blunt probe is initially passed
through the instrument portal to evaluate the lesions in thejoint.
to palpate the articular cartilage peripheral to the
defects,and to explore the extent of the undermined cartilage
in osteochondritis dissecanslesions as well as the openings of
subchondral cystic lesions. The presence of all lesions and
When the needle position is judged to be satisfactory, an their degree is ascertained before any surgical manipulations
8 mm skin incision is made at that location. and a stab are performed (Fig 8.22-8.31).
incision is continued into the muscle mass with the use of a This caudolateral instrument portal is used for debriding
No. 11 or 15 blade (Fig. 8.21). A conical obturator is inserted most lesions. Laterally located defects are easier to operate
along the same path to ensure the presence of a workable than medially placed lesions. Therefore, procedures involving
portal. It is important that fluid pressure be at a minimum at lesions on the medial side of the joint are performed first
this time. When the portal is unobstructed. intermuscular while maximal joint distention can be maintained. and
extravasation of fluid is minimal, although it usually becomes separation of the glenoid and humeral head are achieved.
a problem later during surgery, regardless of the portal size. Adjunctive traction is also sometimes necessary at this stage
as well. Surgical intervention on laterally placed lesions is still
possible later. when joint distention has decreased.
Humeral head defects (see Figs 8.23 and 8.24) are
debrided initially with a hand curette or periosteal elevator;
large pieces of cartilage are removed by using Ferris-Smith
~
rongeurs (Fig. 8.32). A motorized resector can be used for forceps) can be helpful to enter deep OCDlesions and retrieve
debriding large lesions. The resector works well in the cartilage flaps or debride subchondral bone (Fig. 8.34). At the
debridement of easily accessiblehumeral head lesions. When completion of subchondral bone debridement, the edges of
the defect is deeper within the subchondral bone, however, the defect are debrided with a hand curette and Ferris-Smith
the resector and/or burr may not reach, and a right-angled rongeurs. When intact articular cartilage overlies a sub-
curette is used. Angled motorized resectors (see Chapter 2) chondral defect(a common manifestation with osteochondritis
can be very helpful to accommodate to the curvature of the dissecans in the shoulder), all cartilage superficial to the
humeral head. Similarly, small angled rongeurs (patellar defect is removed and the defect beneath is debrided. Figures
8.30 and 8.31 depict defects on the humeral head after
debridement.
Similarly, articular cartilage fissures,areas of erosion, cyst-
like lesions, and detached articular cartilage in the glenoid
(Figs. 8.25-8.29) are debrided and removed by using Ferris-
Smith disk rongeurs, patellar forceps, curettes (both straight
and angled) and occasionally the motorized resector or burr.
The concave shape of the glenoid sometimes makes
accessibility with the straight resector blade difficult. An
angled resector and the right-angled curette are particularly
useful for debriding extensive lesions and deep lesions.
Osteochondral fragments are rare in the shoulder.
In some cases,an additional cranial incision or exchange
of the arthroscope and instrument portals is needed to gain
instrument accessto the cranial aspect of the joint (Figs 8.35
and 8.36). Alternatively, using the lateral arthroscope entry
technique, the arthroscope remains caudal to the infraspinatus
tendon, leaving the existing portal cranial to the infra-
spinatus tendon free for rongeurs or curettes, which replace
any egress cannula that have been placed during the initial
phase of surgery. Instrument entry through the cranial portal
allows removal of free osteochondral fragments from the
cranial cul-de-sac of the joint or access to lesions of the
humeral head that extend more cranial than normal
(Fig. 8.37).
At the completion of the procedure, the joint is lavaged by
using a large-bore (4.5 mm) egress cannula through the
instrument portal (Fig. 8.33). Suction is usually applied at
some stage to ensure removal of debris. As discussed in
a focal subchondralcystic lesionmay alsobe noted.
the cyst(Fig.8.25).
Postoperative management
Antibiotics are administered perioperatively and for 2 days i
postoperatively.Phenylbutazone is administered on the day of j
the operation and for the successive 3-5 days. Horses are
confined to a stall for 10 days, at which time hand walking
commences. We usually start with hand walking for
5 minutes per day, with incremental increases of 5 minutes
each week to 30 minutes per day. Horses are then turned out
for periods of 4-12 months before forced exercisebegins.
Articular fracture
Arthroscopic Surgery for fractures of the glenoid and portions of the perimeter ofthe
Other Clinical Entities humeral head can lead to severe lameness, and requireremoval
of fragments to improve the outcome. Fragmentation
in the Shoulder of the cranial or caudal glenoid rim can be removed
arthroscopically, while larger fractures generally require
compression by lag screw insertion. Extensive craniocaudallyoriented
Osteoarthritis fractures of the glenoid cavity, which extend
proximally to involve the neck of the scapula, may require
The authors have been involved in sevencasesin which the both arthroscopic debridement and small fragment removal,
horse was considered to have degenerative articular cartilage and then screw compression. These types of fracture can
lesions of the humeral head that differed from the typical appear normal in lateromedial radiographs, largely because
of the minimal craniocaudal displacement of the fracture.
Septic arthritis/osteomyelitis
and weanlings are predisposed to septic physitis andosteomy
which can seeda joint and necessitate furtherdebridem
Routine arthroscopy of the shoulder for
fibrinectomy and removal of inspissated debris is required for
resolution in advanced cases.Lateral or cranial arthroscopic
approaches provide visualization of the joint surfaces
sufficient to allow debridement of synovial membrane andcartilage
The large caudal and cranial cul-de-sacs need
particularly aggressivelavage and manual fibrin removal toreduce
the bacterial load. Debridement of deeper lesionsinvolving
cartilage and subchondral bone may occasionallybe
necessary (Fig. 8.40). Placing ingress drains for antibiotic
delivery can also improve the outcome. Additional detail isprovided
in Chapter 14.
References
cases
Some
Foals
Bertone
Landells JW. The bone cysts of osteoarthritis. J Bone Joint Surg Br Nixon AI. Stashak TS. et al. A muscleseparating
...,
1953; 35-B: 643-649.
Mason TA. Maclean AA. Osteochondrosis dissecans of the head of Vet Surg 1984; 13; 247-256.
the humerus in two foals. Equine Vet J 1977; 9(4): 189-191. Nyack B. Morgan JP. et al. Osteochondrosis of the shoulder
Meagher DM. Pool RR. O'Brien TR. Osteochondritis of the shoulder the horse. Cornell Vet 1981; 71: 149-163.
joint in the horse. Proc Am AssocEquine Prac 1975; 19: 247-256.
Nixon AJ. Diagnostic and operative arthroscopy of the equine osteochondrosis in the horse. Proc 31st Annual Conv
shoulder joint. Vet Surg 1986; 15: 129. 1986.
Schmidt GR. Dueland R. Vaughan JT. .-
Nixon AJ. Diagnostic and surgical arthroscopy of the equine
shoulder joint. Vet Surg 1987; 16: 44-52. the equine shoulder joint. Vet Med/Small An Clin 1975;
Nixon AJ, Spencer CPoArthrography of the equine shoulder joint. 542-547.
Equine VetJ 1990; 22(2): 107-113A.
ER
Septic arthritis
Osteochondrosis and osteochondritis
dissecans of the elbow
involved in hematogenous septic processes in foals.
lateral aspect of the joint also has minimal: r .
Osteochondrosis of the elbow usually takes the form of either
OCD flap lesions of the humeral condyles or subchondral and is a common site for kicks from other animals'
cystic lesions of the proximal radius. To date, there are no frequently penetrate the joint through or adjacent to
arthroscopic techniques that will provide accessto the head lateral collateral ligament. Lavage and flushing of
compartments of the elbow joint represents minimal therapy
for septic arthritis (see Chapter 14). Recalcitrant casesneed
arthroscopic exploration, using debridement of inspissated
and fibrinous material, and partial synovectomy of
proliferative regions. Arthroscopic exploration also allows
evaluation of the cartilage surfaces of the humerus and ulna,
and debridement of any areas that have developed separation
from the subchondral bone. The accessto the cranial pouch prominent regions for osteophyte formation include
of the elbow joint is relatively simple using the craniolateral cranial aspect of 1
approach and, similarly, accessto the proximal caudal joint
pouch can be provided using the caudoproximal approach.
Both can be accomplished with the patient in lateral lavage and chondroplasty for arthritis are questionable
recumbency. The necessity to enter the smaller joint pouch review in Chapter 17); ]
associated with the caudomedial arthroscopic approach is matic relief may be provided for severalyears.
questionable. Most areas of the joint can be adequatelylavaged
and inspissated material removed from the more voluminous
cranial and caudoproximal pouches. Drains can be instilled
or antibiotic repository devices placed in either or both of the
cranial or caudoproximal pouches. The outcome for synovial
sepsisis described in Chapter 14, and is generally dictated by Despite the complexity of the elbow articulation and
the extent of osteomyelitis in the subchondral bone. proximity to important neurovascular structures. (
.
~
to penetrate the joint of horses less than j
instruments and motorized equipment need to be inserted to improved lameness in two racehorses.More
the limits of their length. Pressing in on the skin and gluteal
musculature occasionally allows an extra 1-2 cm of effective osteophyte formation is often evident over
length to be garnered from routine surgical instruments. caudal perimeter of the acetabulum (Fig. 10.8).
Long rongeurs and long egress cannulae are useful (Sontec moderate osteoarthritis, most of these osteophytes
Instruments). Most surgical triangulation techniques in the
hip are difficult. Debridement of cartilage lesions of the lesions of the femoral head can be accomplished
femoral head and removal of free bodies and debris within the appropriate manipulation of curettes and rongeurs
cranial and caudal recessesof the joint can be achieved with combination with axial distraction. A moderate
persistence. Lesions in the acetabulum can be more difficult iatrogenic damage to surrounding cartilage is always
to debride. In smaller horses, examination and debridement possibility during debridement of these lesions
of torn portions of the round ligament of the head of the advanced cases of hip joint osteoarthritis can
femur can be achieved. Osteochondrosis cysts of the head of arthroscopy (Fig. 10.9), however, lasting -
the femur and fractures of the caudal acetabular rim are following debridement of fibrillated regions is rare.
particularly difficult to adequately debride.
Femoral head cartilage lesions of this ligament can occur, and the outlook even
debridement is guarded (Fig. 10.10). Tearing in -
hreeds. nHrtif'111Hrlv miniHt11re horses f'Hn he Hdp,
in those cases with incomplete rupture of the ligament
(Nixon 1994). Manipulation of biopsy punch rongeurs
and motorized equipment is necessary for
debridement of the visible portions of the
accessory ligament of the head of 1
difficult to visualize. and lesions in this
recognized.
Osteochondrosis and
dissecans
General considerations
The author's G.B.)technique of diagnostic and surgical use of
the arthroscope in the dorsal aspect of the distal interpha-
langeal joint (DIP) was first described in 1990 (Boening et al
1990). The arthroscopic technique and long-term results in
Indications
Indications for coffin joint arthroscopyinclude diagnostic
inspectionof thedorsalpouchor of thepalmar/plantarpouch
of the joint, removalof osteochondralfragmentsor avulsion
fragments,removal of osteophytes(Bramlage1988), syno-
vectomy,debridementand joint lavage.The most common
indication in the dorsal distal interphalangealjoint is the
removal of fragmentsof the extensorprocessof the distal
phalanx(Fig. 11.3).
offers a more easy contralateral instrumental approach distal interphalangeal joint, the limited maneuverability
(Boening et al1990, Mcllwraith, 1990a).
The use of fluoroscopy for anatomic orientation is helpful. in the coffin joint will be closed after completion of
ination and/or surgery' .-, .
Under such visualization, the insertion of the arthroscope,
insertion of hand instruments, and the identification of the Sterile bandaging incorporating the entire hoof is
fragment's side can be achieved. In the palmar/plantar pouch value. The risk of
of the coffin joint (seeFigs 11.1 and 11.2) fragment removal and secondary joint infection is directly correlated
is the most common indication for arthroscopic surgery improper bandaging. If loose bandages expose i'
(Brommer et al 2001). These fragments are either free
floating and OCDin origin or embeddedin the joint capsule or even loss of the patient from joint infection might result. The
ligaments. Lesions that are the result of secondary bone bandages should be changed every second day until primary
metaplasia can be detected in these areas. In such cases their healing of the skin incisions is achieved.
appearance seems to be flattish and generally accompanied
by signs of degenerative joint disease.A further indication for
Normal arthroscoPic anatomy -palmarol
palmar/plantar coffin joint arthroscopy is debridement of cystic
lesions at the proximal rim of the navicular bone (Zierz etal plantaroproximal aspect
2000). The technique can be combined with cancellous bone The midsagittal ridge of the dorsal articular border of the
grafts, in which CO2gas distention of the joint is required navicular bone is the first structure to identify (Fig. 11.11).
"
-~I
-
1.,1~:
,.1
~
DDF
I~
.~
.'(',.
..J~/
interphalangeal joint for treatment of plantar view are standard; slightly oblique views can
extensor process fragments helpful in casesof an abaxial fragment. ( --~-
(CT)images may -~
Indications of the damage, and, finally, arthroscopic accessibility. -
After arthroscopic identification the fragment
The most common indication for arthroscopy of the dorsal
1
distal interphalangeal joint is the removal of fragments of the with a periosteal elevator and removed from the joint by
of small cup rongeurs. Most of the fragments.
Preoperative considerations
\,,~ 11J
l,f;
'-1
II~: I II,\
*.
(1985), they drilled out bone cysts in the navicular bone of 5
'I
horses.The arthroscopic approach was according to Vaceket al I'
(1992). After the insertion and positioning of the arthroscope,
V1. 11
they created a contralateral portal for a 4.5 mm drill and
~J
sleeve. The cyst was identified and subsequently drilled
through diagonally. As soon as the drill reached the cyst,
there was a significant loss in drill resistance. All 5 horses
were Warmbloods from 6 to 16 years of age (3 show jumpers,
1 dressage,and 1 pleasure horse). Horse 1 was re-operated
9 months after the first surgery; 7 months after the second
surgery there was significant progress in bone remodeling at
the cyst site. Horse 2 was considered to be completely healed
and was back in work 5 months after the surgery. Horse 3 Fig. 11.27
became sound and went back into training after 12 weeks. Diagram of arthroscope position in the dorsal pouch of the
There are no reports on the outcome of horses 4 and 5. This proximal interphalange359al joint. CD, Common digital
report is contrary to experiences with drilling cysts in the extensor tendon.
medial femoral condyle, where progression of cyst enlarge-
ment after drilling has been observed.
Arthroscopy of the dorsal pouch of the
proximal interphalangeal joint
Limited spacein the dorsal pouch makes accurate location of
arthroscopic portals critical. The limb should be fixed in
maximal extension and placement of the obturator and
arthroscopic cannula into the joint is facilitated by distending
Reports of arthroscopy of the proximal interphalangeal joint the joint with fluid from the palmar/plantar aspect
are rare in the equine veterinary literature (Mcllwraith (Fig. 11.26). The cannula should be inserted along the dorsal
1990b, Schneider et al1994). One report describes a single proximal margin of the middle phalanx to the center of thejoint.
case and the second a group of 3 Standardbred racehorses Ideally. the arthroscopic portal is in the distal aspects ofthe
where osteochondral fragments were removed from the dorsal pouch (Fig. 11.27). Placement too far proximallylimits
dorsal aspect of the proximal interphalangeal joint. In the the ability to view the entire dorsal joint space. Optimal
latter study, after arthroscopic removal of the fragments from placement results in sufficient space in the joint to allowfragments
the dorsal proximal interphalangeal joint, all 3 horsesreturned to be removed safely. Small alligator-cup, or lowprofile
to training and raced successfully. Ferris-Smith rongeurs are recommended because of
III
({{~:
~t;:'"
:f!/lv
1):~
space limitation. The intra-articular anatomy of the dorsal latero-medial, and two oblique views using
proximal interphalangeal joint is simple and consists of the radiographic films.
dorsal distal articular cartilage of the proximal phalanx as Following removal of fragments, ---' "---
well as the dorsal rim of the middle phalanx and joint capsule padded bandaging of the surgical site for 1 0 days
attachments (Fig. 11.28). This dorsal proximal rim of the confinement for 2 weeks post-surgery.
middle phalanx is the usual location for osteochondral chip hand-walked for another 2 weeks. The,
fragments (Fig. 11.29 and 11.30). Fragments found at this allowed to train for a period of 6-8 weeks after surgery.
location could possibly result from osteochondrosis. These
fragments usually cause synovitis. which results in local
swelling of the proximal interphalangeal joint and associated Arthroscopy of the
lameness. Intra-articular anesthesia is essential for proper p<?uchof the proximal
diagnosis. To establish the exact location of the operative Joint
site for fragment removal, at least four preoperative
radiographs are required. Size and anatomic location of the So far there are no reports found on arthroscopy of
palmar/plantar pouch of '
fragment may be identified with a dorsopalmar/plantar, a
in the literature. Although fragmentsoccur in the palmar/
plantar aspectof the pastern,it has beensuggestedthat the
capsularand ligamentousattachmentslimit entry into the
central part of the joint (McIlwraith 1990).
Fragments located in the axial palmar/plantar pouch
are found occasionally on pre-purchase examination
(Fig. 11.31). Thesecasesoften show only Grade1 lameness
and insignificant clinical signs like joint distention and
positiveflexiontest;someare without anylameness.
Fragments.that are located abaxialand which originate
from the proximal lateral or medial rim of the middle
, \iI\!'
~~
DDF
f~
"
"
,
.
~
J
2 cm proximal to the margin of the distal condyle of
proximal phalanx (Fig. 11.26), close to the
/- plantar margin, the obturator and cannula
the palmar/plantar pouch aiming axially (Fig. 11.33
11.34). The axial palmar/plantar pouch is quite
(Fig. 11.35), r
}
.1
after surgery. In this case the fragment could be visualized
arthroscopically in between the distal condyles of I
proximal phalanx. but was inaccessible.
References
the 1st Advanced Arthroscopic Surgery Course, I
University,1988.
Boening
-
KJ. Contact-Arthro-Microscopy and synovial
Annual ECVSScientificMeeting,
--
Konstanz,1995: 71-72.
of osteochondral
joint of the pelvic limbs in three horses. JAVMA
79-82.
Story MR. Bramlage LR. Arthroscopic debridement of
bone cysts in the distal phalanx of 11 horses :--
EquineVetJ2004; 36: 356-360.
articular anatomy
aspects of distal interphalangeal joints. Vet Surg 1992;
257-260.
Vail TB. McIlwraith CWoArthroscopic removal of ' C
fragment from the middle phalanx of a horse. ~
269-272.
Wagner PC. Modransky PD. Gavin PRoGrant BD.
..-
1985; 88:425-431.
ZieI"lJ. Schad D. GiersemehlK. Chirurgische Moglichkeiten
Versorgung von Strahlbeinzystensowie Strukturdefekten
Strahlbein.pferdeheilkunde2000; 16:171-176.
CHAPTER
Cut annular ligament
dense subintimal and sheath fibrous layers (Hago et aI1990). The most robust mesotenon extends from the palmar midline
The digital flexor tendon sheath extends from the junction of of the SDFT to the adjacent tendon sheath (Figs 12.2 and
distal and middle thirds of the third metacarpus/metatarsus 12.3). Short thick mesotenons also extend from the proximo-
to the level of the middle phalanx and navicular bone medial and proximolateral margins of the DDFT.The proximal
(Fig. 12.1). The sheath enclosesthe SDFTand DDFT, both of portion of the DDFT is encircled by a complete but thin sleeve
which have mesotenon attachments to the tendon sheath. of the SDFTknown asthemanicaflexoria (seeFigs 12.1-12.3),
which ensures alignment of the tendons during their passage digital flexor tendon sheath, the DDFT has several dorsal and
around the fetlock. The digital flexor tendon sheath has its a single palmar/plantar mesotenon attachment (seeFig. 12.1,
proximal reflection and attachment to the full circumference inset). There is also a small encircling component (the digital
of both the SDFT and DDFT, which forms the proximal manica) of the SDFT (see Fig. 12.1, inset), which stabilizes
endpoint of the sheath cavity. In the distal portions of the the SDFT against the DDFT during the final path toward
Proximal phalanx
4 ~..~ ,-'
,~~.J"~("
'".~
.,:,r"';' ~'
Lateral oblique
sesamoidean
~~.
r;,"', ~.
f..~i~
.Medialoblique,
sesamoidean
ligament
Straight -
sesamoidean
ligament
Vinculae
of digital sheath
Digital sheath wall
tendon insertion (Nixon 1990c, Redding 1991 1993). The gentlyin a proximodorsaldirection
SDFTcan be seento bifurcate and exit the digital flexor tendon
sheath in the region of the distal portion of the proximal dorsal recessesof the sheath (see Fig. 12.5). High
phalanx (Fig. 12.4). Vascular supply to the flexor tendons is
derived through the mesotenon and digital sheath reflections. wall of a fibrosed tendon:
Synovial fluid from the tendon sheath has a similar com- the initial phases of digital flexor tendon sheath
position to that from joints, with slightly reduced hyaluronic allowing time for the tissues to expand and
acid content (Malark et aI1991). hemorrhage and synovial fluid to 1 ' ,
through severalneedles.
instrument entry is made in the dorsolateral region of the surgical examination and treatment of complex cases.
proxinlal cul-de-sac of the digital flexor tendon sheath (see tourniquet is ]
Fig. 12.5). This is defined by needle entry followed by scalpel ment of a septic digital flexor tendon sheath.
incision. The entry to the digital flexor tendon sheath should lateral skin entry then provides
be palmar to the neurovascular bundle, to avoid damage to
these structures. Preoperative placement of a tourniquet is motorizedresectors.As resectionof
routine and is a useful means to limit hemorrhage from skin
entries, adhesion and mass removal sites, and the annular medial
layer of entry
1_- can
---~---be made ~---
to the proximal portion of 1
ligament division. particularly if this is done early in the
J '
Postoperative care
Sodium hyaluronan (NaHA; 20-40 mg) is frequently injected
into the tendon sheath at the time of wound closure.
Researchin horses and smaller experimental animals indicates
NaHA reduces the formation and reformation of tendon
adhesions in the sheath area and enhances intrinsic tendon
healing (Weiss et al1986, Amiel et al1989, Gaughan et al.
1991, Moro-oka et al 2000). Additionally, intrathecal local
anesthetic installation provides good postoperative pain
control. The use of long-acting anesthetic agents such as
bupivacaine provides 4-6 hours of postoperative analgesia. A
firm bandage is also applied, not only to provide a sterile
environment but also to add counterpressure that provides
additional comfort to the operated limb. The bandage is
usually maintained for 3-4 weeks after surgery.
Antibiotics such as potassium or procaine penicillin are
commenced prior to surgery and continued for 1 or 2 days
~
postoperatively. Surgery around the bulb of the heel and the
distal portion of the digital sheath can be difficult to establish
and maintain a sterile field, particularly around the ergot,
and antimicrobial drugs are a useful precaution. Longer-term injection of NaHA is recommended 2
pain control is provided with nonsteroidal anti-inflammatory Injection of the digital flexor tendon sheath is
agents such as phenylbutazone (4.4 mg/kg orally), which is
usually administered for 7-10 days after surgery to minimize
tissue inflammation and swelling. intravenous NaHA (Legend,Bayer Corp, Animal
Hand walking for increasing periods commences 2-3 days ShawneeMission,KS)may alsobe useful.
after surgery:Long periods of walking exerciseare particularly Return to work'
helpful if tendon adhesions were present at surgery. A secondary tendonitis, which frequently delays return
compromise between incisional healing and the beneficial exercisefor 6-12 months.
affects of early exercise is usually reached on a case-by-case
basis. Use of mechanical walkers, swimming, and passive ultrasonographic examination is useful to evaluate
responseof the flexor tendons. particularly where linear
tendontearsweretrimmed or corelesionswereinjectedwith
growth factors or NaHA at the time of palmar/plantar
annular ligamenttransection.
-\ -Medial
Palmar carpal' palmar a.,n.
ligament Medial palmar v.
Radial a.
Carpal flexor
retinaculum
A "Lateral palmar v.
Mesotenon MEDIAL
LATERAL
.
~
Extensor carpi
Common digital radialis tendon
extensor tendon \
middle carpal
joint
Flexor carpi
Accessorioquartal and .
accessoriometacarpal Medial palmar v.
ligaments
'\ Medial palmar a.,n.
A Lateral palmar a.,v.,n.'
Surgery can be performed with the horse in dorsal carpal sheath immediately cranial to the radial head of the
recumbency, or in lateral recumbency with the affected limb DDFT,but can be more clearly defined by using an instrument
uppermost. Dorsal recumbency is generally preferred by the to probe for the intrusion of the ligament into the sheath (see
authors. It has obvious advantages for bilateral evaluation Fig. 12.23).
and significantly reduces intraoperative hemorrhage. Lateral The arthroscope can then be redirected to more caudal
recumbency facilitates tenoscopy through the distal (meta- regions of the carpal sheath, examining the caudal surface of
carpal) portal and some surgeons find the operating position the DDFT and a small portion of the SDFT (see Fig. 12.23).
to be more comfortable. In both situations, the carpus is The arthroscope can be inserted from the lateral to medial
positioned in slight (approximately 15-20°) flexion. The direction to assess these areas of the SDFT and can be
carpal sheath is distended with 50-60 ml of lactated Ringer's inserted a small distance between the SDFTand DDFT before
solution and the arthroscope entry portal is made laterally, encountering the common mesotenon joining the DDFT and
6-8 cm proximal to the remnant of the radial physis. This SDFT.
allows examination of the carpal sheath, while leaving the Further examination of the craniomedial depths of the
region between the arthroscope entry and the distal physis of carpal sheath reveals the transversely oriented fibers of the
the radius available for instrument entry (Fig. 12.22). carpal flexor retinaculum, forming the medial boundary to
Initial examination from the lateral approach reveals the carpal canal (Fig. 12-24). The proximal and distal limits
the caudal aspect of the radius, and the lateral portion of the of the retinaculum are not as distinct as the intrusion formed
DDFT, which at this level obscures most of the SDFT by the proximal check ligament. The proximal border of the
(Fig. 12.23). The SDFT can be examined later by rolling the retinaculum can be recognized only by the adjacent caudal
DDFT with a probe, but this exposes only small portions of protuberan~ of the physeal scar of the radius. The distal
the tendon; complete examination of the SDFT is difficult border of the retinaculum can be determined by digital
using the lateral approach. The common mesotenon for pressure over the caudomedial portion of the carpal sheath,
the SDFTand DDFT attaches to the caudolateral aspect of the which can easily be indented only beyond this distal margin.
carpal sheath, and effectively prevents examination of the The distal regions of the carpal sheath can be examined
SDFT over its caudal and medial surfaces. In the more distal beyond the level of the carpometacarpal joint, but mobility
regions of the carpal sheath, the SDFT emerges, although distal to this level is restricted. Examination of the most distal
better examination of this tendon is provided through a regions of the carpal sheath can be performed by inserting
palmarolateral portal 4-6 cm distal to the accessory carpal the arthroscope through the palmarolateral surface of the
bone (Cauvin et aI1997). carpal sheath in the proximal metacarpus (Cauvin et al
Maneuvering the arthroscope to examine the more 1997), and viewing proximally. This can be difficult with the
proximal regions of the carpal sheath reveals the radial head horse in dorsal recumbency, but the limb should be draped to
of the DDFT coursing from its aponeurosis on the DDFT allow this portal if needed.The arthroscope portal can also be
cranially to curve and expand into its origin on the caudal made in the palmaromedial surface of the sheath at this level
aspect of the radius (see Fig. 12.23). The proximal check but, with the horse in dorsal recumbency, manipulating the
ligament can also be identified within the medial wall of the arthroscope becomes even more difficult.
~
Removal of radial osteochondroma
Radial osteochondromas originating on the caudal portion of
the radial metaphysis penetrate a variable distance into the
carpal sheath (Fig. 12.25). They are usually lateral and can
be easily identified arthroscopically. An 18-gauge spinal
needle is used to identify an appropriate instrument portal
directly over the mass (Squire et al 1992). An osteotome
(4 rom Cottle) is used to separate the osteochondroma from
the caudal aspectto the radius. The osteochondroma is then
retrieved using large rongeurs, and the bony bed smoothed
using a curette, bone rasp, or motorized burr. Secondary
damage to the DDFT may require debridement with biopsy
rongeurs or motorized apparatus. Finally, debris is flushed
from the sheath before routine skin closure.
One of the principal advantages of tenoscopy compared to
open surgery for removal of osteochondroma is the ability to
assessand treat tendon lesions, which also allows for a more
accurate prognosis. Fibrosis and thickening of the carpal
sheath secondary to osteochondroma is common, and an
assessmentof the degree of resultant carpal canal stenosis
can also be obtained tenoscopically. If there is evidence of
carpal canal constriction, which can be subjectively deter-
mined by the limitation to arthroscope movement through
the carpal canal, release of the carpal flexor retinaculum can
also be accomplished (see later description).
~.:. ,
Flexor retinaculum
Dorsal
metatarsal-
artery Till
Lateral digital
extensor tendon
TIV
'\,,~\
\\\ \
Long plantar ~
ligament
Lateral plantar a.,v.,n. Chestnut
A Tarsal sheath
cavity
the tarsal sheath medially, and has to be avoided. The lateral perforated in several areas if necessary, allowing the
plantar neurovascular structures are positioned along the arthroscope to view the caudal portions of the proximal
plantarolateral perimeter of the termination of the sheath pouch of the tarsal sheath. A separate instrument entry,
and are relatively protected (Fig.12.38). directly over lesions,is preferred for easeof triangulation. The
dorsomedial or plantaromedial arthroscope entry incision
into the sheath is positioned largely based on the location of
Tenoscopic techniques the predominant lesions, dorsal or plantar, to the mesotenon.
With the arthroscope directed proximally, the DDFT
Diagnostic tenoscopy of the tarsal sheath
and proximal reflection of the tarsal sheath are evident
Several approaches to the tarsal sheath have been described, (Fig. 12.40). The mesotenon and medial and cranial/dorsal
but the preferred arthroscopic entry is a central medial portal surfaces of the DDFTare readily examined. Redirection of the
made 1-2 cm proximal to the sustentaculum tali (Fig. 12.39). arthroscope more distally reveals the DDFT as it curves
This permits visualization of both proximal and distal regions over the sustentaculum tali (Fig. 12.40). Limited portions of
of the sheath (Cauvin et aI1999). Examination and debride- the fibrocartilage surface of the sustentaculum forming the
ment of the visible portions of the DDFT and many areas of support surface for the DDFT can also be examined. The
the sustentaculum tali can be performed using instrument DDFTcan be retracted after a local instrument portal is made,
portals directly over or immediately distal to the sustenta- which improves access to the caudolateral surface of the
culum tali. sustentaculum (Fig. 12.40). The medial extremity of the
The central medial approach can be performed with the sustentaculum is extrasynovial and cannot be viewed
horse in dorsal or lateral recumbency with the limb extended. tenoscopically.lhis area is also the most frequent site for
Hemorrhage is slightly reduced by using dorsal recumbency. bony exostosis.and fragmentation, which may then have to
and a tourniquet is useful for hemorrhage control when be removed using open approaches. Over the sustentaculum
using lateral recumbency, since the affected limb is down. The the tarsal sheath is confined by the tarsal flexor retinaculum,
tarsal sheath is distended with saline if it is not already which stabilizes the DDFT (Fig. 12.40). Redirection of the
markedly enlarged. The voluminous outpouching of the arthroscope allows the DDFTto be viewed as it curves distally
proximomedial aspect of the tarsal sheath is readily palpated. (Fig. 12.41). When the arthroscope entry has been made
A skin incision is made in the distal region of this proximal dorsal to the mesotenon,the sustentaculum and dorsal surface
outpouching. approximately level with the medial malleolus of the DDFTare readily examined. Advancing the arthroscope
of the tibia. The arthroscope sleeveis inserted in a proximal further distally allows examination of the remainder of the
direction to commence the examination in the proximal sustentaculum and the DDFT as it courses toward the distal
region of the tarsal sheath (Fig. 12.39). The mesotenon of termination of the sheath. The medial mesotenon is thicker
the DDFT originates from the caudal/plantaromedial border and somewhat compressed within the tarsal canal (Fig.
of the DDFT and provides a barrier to complete examination 12.41), and to facilitate examination of the distal regions of
of the caudal and medial portions of the tarsal sheath the DDFT and sustentaculum, sequential entry both dorsal
(Fig. 12.35). However,this layer is relatively thin. and can be and plantar to the mesotenon allows complete assessmentof
~~~.'\::\..~.::==::::::::::::~,/s(""
Tibia
\\
Medial malleolus "'"
of tibia
.; DDFT
Medial trochlear
ridge of talus
Sustentaculum
It
tali
Calcaneus
'/
,,/
// i~
~.
t"'\
\
the DDFT surfaces and the weightbearing surfaces of the Tenosynovial mass and adhesion resection
sustentaculum. ~
A distomedial approach to the tarsal sheath is less Ultrasonogr~phic evaluation of cases with chronic tarsal
frequently necessary (Fig. 12.42). The retinaculum of the sheath distention frequently reveals tenosynovial masses
tarsal sheath is more dense distally, and the chestnut provides within the sheath (Fig. 12.43). Further inflammation and
a problem for sterile skin preparation. However, examination advancing fibrosis of the tarsal sheath restrict the free range
of this area is occasionally necessary,and a skin incision can of motion of the DDFTwithin the tarsal sheath. Mineralization
be made 1-2 cm proximal to the level of the chestnut over is a late complication of chronic disease, and can involve
the medial aspect of the distended tarsal sheath (Fig. 12.42). portions of the mesotenon as well as the surface layers of the
The DDFT can then be seen as it courses over the distal DDFT(Fig. 12.44). Removal of most tenosynovial massescan
portions of the sustentaculum tali. Surgical procedures in be accomplished using the central medial approach to the
the distal limits of the tarsal sheath are more difficult, due to tarsal sheath (Fig. 12.45). After a thorough examination, an
the small volume of the tarsal sheath at this level and the 18-gauge 7.5 cm spinal needle is used to define the most
overlying retinaculum. Additionally, the converging MDFT appropriate portal for mass removal. The neurovascular
and check (accessory) ligament immediately distal to the structures caudal/plantar to the tarsal sheath can be avoided
tarsal sheath narrow the sheath as the distal limits are by penetration with arthroscope and instruments immediately
approached. adjacent to the cranial-caudal midline, allowing entry either
~
""
~
~
side of the mesotenon. This provides accessfor mass removal lesions and are more common in the tarsal sheath than the
and debridement of the medial surfaces of the DDFT equivalent syndromes in the carpal sheath. Radiographically
(Fig. 12.45). Massescan involve the inner layers of the tarsal evident mine~lization of the DDFT can be differentiated from
sheath, or become more pendulous and float between the mineralizatiqn in the mesotenon and sheath by comparing its
DDFT and the tarsal sheath lining (Fig. 12.46). With chronic position on extended and flexed radiographs. Motorized
disease, the tarsal sheath can become quite thick, and resection of massesand surface proliferation of the DDFT can
examination of the sheath contents can be slow and tedious. be associated with hemorrhage. Tourniquet application
High ingress fluid pressure frequently results in subcutaneous proximal to the tarsal sheath may be helpful, but most
fluid accumulation, making the surgical exploration more hemorrhage is controlled by the pressure of the ingress fluid.
difficult. A gradual increase in the areas available for examin- Distention with gas is an alternative if bleeding continues to
ation can be accomplished using motorized resection of hamper the diagnostic examination and further massremoval.
proliferative synovium. Masses can be removed with scissors Mineralization can extend down to the terminal portions
and rongeurs, biopsy punch rongeurs, motorized resection of the tarsal sheath, and a second arthroscope and/or instru-
(Fig. 12.47), or radiofrequency probes, depending on the ment entry in the distal medial recess of the sheath may be
density of the masses. Large masses and mineralized areas required. After removal of masses,the sheath is flushed prior
may need a second instrument portal to allow the mass to be to routine skin closure. Intrathecal administration of NaHA
stabilized prior to transection at its base. Mineralized masses may be helpful in reducing reformation of tendon sheath
generally result from dystrophic mineralization of chronic adhesions.
Debridement of the sustentaculumtali Postoperative care
The sustentaculum tali is prone to trauma over its plantaro-
medial aspect, resulting in bone proliferation within or Wound healing complications associated with tenoscopic
adjacent to the insertion of the retinaculum on the calcaneus. evaluation of ;he tarsal sheath are generally minimal.
Some wounds also cause contamination or infection of the Exercise can b~ initiated 2-4 days after surgery, depending on
tarsal sheath. The most medial areas of bone proliferation are the degree of lameness.Horses respond to tenoscopic surgery
beyond the medial extremity of the tarsal sheath. Resectionof of the tarsal sheath differently, and some can be quite lame
accessibleproliferative bone, and debridement of the DDFT- postoperatively.This can be controlled at the time of surgery
bearing surfaces of the sustentaculum, can be accomplished by intrathecal deposition of bupivacaine at the time of closure,
using the central medial arthroscope entry, with instrument while postoperative pain relief is provided with nonsteroidal
portals made directly over the sustentaculum. Alternatively, anti-inflammatory agents. More severe reactions to surgery
and sometimes additionally, the distomedial portal (Figure or the primary disease can be treated using epidurally
12.42), is required for arthroscope entry, to allow complete administered morphine and detomidine. Horses with disease
examination of the medial edges of the sustentaculum and processes involving the sustentaculum tali frequently also
the lateral perimeter of the tarsal tunnel as it curves have damage to the dorsal surface of the DDFT, and are
proximally. Fragmented or infected foci in the sustentaculum more lame than horses with tarsal sheath tenosynovitis.
can be removed and/or debrided using hand instruments. Additionally, follow-up medication to the tarsal sheath is
Further details concerning the principles of treating more likely to be necessary,and includes intrathecal NaHA
contaminated or infected lesions are provided in Chapter 15. and follow-up intravenous NaHA. Repeat ultrasonographic
examination is also useful in these cases to assessreturn of
tenosynovial masses,and to evaluate tendon healing.
Clinical application
Lesions identified and treated endoscopically include
osteolytic lesions in the calcaneal tuber. tearing of the
retinacular insertionsof the sdf tendon.tendonitisof the sdf
tendon.traumatic fragmentationof the calcaneus,contam-
ination through openwounds,and puncturesand infection.
ridgesin its dorsalsurface:asthe sdf tendonapproachesthe
calcaneusand becomeswider in a mediolateralplane.these
Osteolytic lesions of the calcaneal tuber
are replaced by an amorphous fibrocartilaginous surface
(Fig. 13.7). However.obliquelyangledfibresare identifiable. Regions of osteolysis in the calcaneal tuber have been
extending mediallyand laterally from the sdf tendonto the reported by Ingle-Fehr & Baxter (1998) and Bassage et al
abaxial margins of the calcaneus:theseare the medial and (2000). Affected animals present with distention of the
lateral retinacular insertions of the sdf tendon (Fig. 13.8). calcaneal bursa and lameness that is responsiveto intrathecal
Fibrocartilagealsocoversthe apexof the calcanealtuberand local analgesia. Radiographs demonstrate radiolucencies in
the proximal plantar margin and/or apex of the calcaneal may be hemorrhage at the site but torn fibrils are discernible
tuber (Fig. 13.10). Ultrasonography confirms distention of the (Fig. 13.11). Tearing and herniation of disrupted tendon
calcaneal bursa and may also reveal disruption of the proximal fibrils is generally more obvious in long-standing cases
plantar margin of the calcaneus and irregular echogenicity of (Fig. 13.12A). Removal of torn fibrils and debridement of the
the adjacent insertion of gastrocnemius. At endoscopy,there parent tendon is performed with a motorized synovial resector
may be discoloration of the calcaneal fibrocartilage with soft, (Fig. 13.12B). Casestreated in this manner have returned to
crumbling, and apparently degeneratebone exposedby use of soundness.
a blunt probe. Removal of the degenerate bone and debride-
ment has resulted in return to soundness but the number of
cases is small and thus confident prognostication is difficult. Traumatic fragmentation of the calcaneus
The etiology of such lesions is unknown. Previous authors E.xternal trauma, usually as a result of falls or kicks from
have tentatively suggestedthat these may be avulsion injuries other horses, ~ay result in intrathecal fragmentation of the
of the plantar ligament (Ingle-Fehr & Baxter 1998), or of calcaneal tuber. These may be open or closed. Most fractures
gastrocnemius (Bassage et aI2000). are identified radiographically and, when the apex of the
calcaneus is involved. flexed plantaroproximal-plantarodistal
Tearing of the retinacular insertions of the oblique (skyline) projections are most useful.
Endoscopyshould be performed with ipsilateral arthroscope
superficial digital flexor tendon
and instrument portals. When accompanied by wounds, the
Tearing of the medial (most commonly) or lateral retinacular surgeon should look diligently for the presence of hair and
insertions of the sdf tendon has been associated with foreign material. Fragments are removed with appropriately
contralateral luxation or subluxation of the tendon from the sized arthroscopic rongeurs and the fracture bed debrided
apex of the calcaneal tuber (Sullins 2002). Partial tears of with curettes. In some instances foreign material may be
the retinaculi have beenidentified on endoscopic examination embeddedin bone. Lesions should be debrided using the same
of the calcaneal bursa in animals with lameness, which principles as applied with osteochondral fragmentation in
localizes to a distended calcaneal bursa. A tentative diagnosis diarthrodial joints but fibrocartilagenous margins always
may be obtained ultrasonographically, but a definitive appear less sharply demarcated than their hyaline counter-
diagnosis is obtained endoscopically. In acute lesions there parts (seeFig. 14.9).
capsules and an intervening fat pad. '
the humerus bears three tubercles: lateral
(lesser),and ~ intermediate tuberosity (tubercle). The over-
lying tendon is bilobed and indented markedly by the inter-
mediate tuberosity. The medial lobe is slightly larger than its
lateral counterpart. A tendinous band envelops the tendon
and bursa in the region of the humeral tuberosities. Over the
humeral tuberosities the biceps tendon is partly cartilaginous
and presents a smooth fibrocartilaginous bursal surface. The
I ntertubercular (Bicipital) musculotendinous junction of biceps brachii lies in the distal
portion of the bursa. which terminates just proximal to the
Bursa deltoid tuberosity of the humerus.
Endoscopic anatomy
Proximal to the humeral tuberosities the bursal synovium is
villous and covers the supraglenoid tuberosity of the scapula,
the origin of biceps brachii, and the voluminous bursal recess
cranial to the scapulohumeral joint. At this level, the proximal
portion of the biceps brachii tendon has visible fiber orientation Fig. 13.15
(Fig. 13.17). Withdrawing the arthroscope provides visualiza- Distal endoscopic approach to the bicipital bursa; D = deltoid
tuberosity of humerus; B = tendon of origin of biceps brachii;
tion of the lateral tuberosity and abaxial side of the inter-
S = supraglenoid tubercle of the scapula; J = scapulohumeral
mediate tuberosity of the humerus. These and the overlying
biceps brachii tendon are covered with smooth fibrocartilage joint.
(Fig. 13.18). The tight interdigitation of the tendon and the
cranial surface of the humerus precludes evaluation of the
medial tubercle and axial side of the intermediate tubercle of
the humerus from this arthroscopic position. Abaxial to the
lateral margin of the lateral tubercle of the humerus there is
a cover of fine synovial villi through which tendinous bands
from pectoralis ascendens are seen perpendicular and
attaching to the lateral tuberosity. With further withdrawal
of the arthroscope. a synovial plica is visible at the lateral
margin of the intertubercular groove (Fig. 13.19). At this level
the arthroscope can be insinuated between the biceps brachii
tendon and fibrocartilagenous surface of the humerus as
far axial only as the intermediate tubercle (Fig. 13.20).
Approaching its distal margin the fibrocartilage is slightly
irregular (Fig. 13.21). Beyond this point the cranial surface of
the humerus and biceps brachii tendon and musculotendi-
nous junction are covered by villous synovium (Fig. 13.22).
In the distal recess it is possible to visualize also a small area
of the fibrocartilage medial to the intermediate tubercle (Fig.
13.22) and to push the arthroscope axially to obtain limited
visualization of the distal medial lobe of the tendon. Utilizing
a proximolateral arthroscopic portal. the most proximal
margin of the intermediate tubercle and a small portion of
the medial lobe of the tendon can be visualized (Fig. 13.23).
Clinical application
intrathecal fragmentation of the supraglenoid tubercle of the
Endoscopy of the bicipital bursa has been used in the scapula and lateral tuberosity of the humerus together with
investigation of lameness referable to this site and to treat contaminated and infected bursae.
Traumatic bicipital bursitis
adhesions to the bicipital tendon. The extensive nature of the
Booth (1999) reported a horse with lameness.localizingto lesions precluded treatment but endoscopy was considered
the bicipital bursa. that was accompaniedby radiologicand diagnostically useful. The authors have seenloss of humeral
ultrasonographicabnormalities. Endoscopyrevealedwide- fibrocartilage with fibrillation of the adjacent bicipital tendon
spread loss of fibrocartilage from the humerus. with (Fig. 13.24) and rupture of the lateral wall of the bursa in
horseswith lamenesslocalizingto this site.Thesecaseshave
.~,.. ,
I OJ..
.
Podotrochlear (Navicular)
Bursa
The dorsal margins of the navicular bursa are, from distal to
proximal, the impar ligament, the palmar/plantar surface of
the navicular bone, the navicular suspensory ligaments, and
the intervening T ligament. The latter is thin and consists of
little more than the fibrous capsules of the distal inter- ~
phalangeal joint, digital flexor tendon sheath, and navicular
bursa. The dorsal surface of the deep digital flexor (ddf)
tendon forms the palmar/plantar margin of the bursa. and Rossignol & Perrin (2003), permits the most compre-
hensive evaluation of the bursa. A 5-mm skin incision is made
proximal to the collateral cartilage on the abaxial margin of
Technique the ddf tendon, palmar/plantar to the digital neurovascular
bundle. The arthroscope cannula with a conical obturator is
Endoscopic evaluation of the navicular bursa is performed then introduced through the skin wound and advanced
with the distal limb joints in a slightly flexed position. The distally and axially, dorsal to the ddf tendon to enter the
horse may be in either dorsal or lateral recumbency. Dorsal bursa at approximately the midpoint of the middle phalanx
recumbency facilitates triangulation and use of medial and (Fig. 13.25). As the bursa is entered, there is usually a loss of
lateral arthroscope and instrument portals. whereas lateral resistance to advancement of the cannula and the obturator
recumbency is favored for investigation and treatment of is then withdrawn and replaced by the arthroscope.
solar penetrations. The technique described originally by An instrument portal can be created using a similar
Wright et al (1999). and subsequently by Cruz et al (2001) technique on the contralateral side of the limb following a
trajectory established by prior insertion of a 1.2 x 90-mm ligament (Fig. 13.27). A slight withdrawal of the arthroscope
(18 g x 3.5-inch) stiletted needle. will allow evaluation of the sagittal ridge of the navicular
Using the above technique, the trajectory of the arthro- bone and the adjacent surface of the ddf tendon. The
scopic cannula is proximodorsal to distopalmar/plantar. If palmar/plantar surface of the navicular bone is covered by
the trajectory is too dorsal, then it is likely that the arthro- relatively homogeneous fibrocartilage. although in some
scopic sleeve will pass through the T ligament and into the animals there is a shallow indentation (sometimes termed a
palmar/plantar compartment of the distal interphalangeal synovial fossa) in the sagittal ridge where the overlying
joint. In such circumstances, the sleeveshould be withdrawn fibrocartilage is thinner. The dorsal surface of the ddf tendon
and realigned to a more palmar/plantar direction before it is is indented to varying degrees for the sagittal ridge of the
advanced again distally. This approach to the navicular bursa navicular bone (Fig. 13.28). In someanimals the dorsal surface
may also result in penetration of the digital flexor tendon of the ddf tendon presents a relatively homogeneous surface,
sheath. In this event the arthroscope may be positioned whereas in others there is evidence of a longitudinally
dorsal to the ddf tendon at the distal reflection of the sheath oriented fiber pattern. Movement of the arthroscope medially
wall before the arthroscope is withdrawn and replaced once and laterally peRmitsevaluation of the abaxial margins of the
again with a conical obturator. Advancement of the cannula bursa. This is ~nerally easieston the side contralateral to the
in the trajectory described above along the dorsal surface of arthroscope but with rotation of the lens can be achieved also
the ddf tendon, will usually result in successfulentry into the on the ipsilateral side. At the margins there are plical
navicular bursa. It is also possible to enter the digital flexor reflections between the ddf tendon and the abaxial margins
tendon sheath, electively pass the arthroscope distally dorsal of the navicular bone (Fig. 13.29). If the arthroscope is then
to the ddf tendon and, then, use cutting instruments to create returned to an axial position and withdrawn slightly further,
portals on the dorsal and palmar/plantar sides of the this will visualize the proximal margin of the navicular bone
T ligament into the distal interphalangeal joint and navicular and reflection of the T ligament from this site (Fig. 13.30).
bursa, respectively (Fig. 13.26). Abaxially, this thickens to blend imperceptibly into the
insertions of the suspensory ligaments of the navicular
bone. Further proximally, the bursal reflection from the ddf
Endoscopic anatomy tendon, suspensory, and T ligaments is covered by villous
synovium (see Fig. 13.30). Proximal to the navicular bone.
Evaluation of the bursa usually commences distally. Here. the dorsal surface of the dill tendon has a recognizable
villous synovium reflects off the ddf tendon and impar fiber pattern.
date.thereareinadequatenumbersto assess
the potential for
endoscopicsurgeryto enhancecasemanagement.
Clinical
debridement of contaminated and infected tissues may
approachedin a conventionalmanner.
At the end of the procedures, arthroscopic
instrument skin portals are closedroutinely. Unless
undermining of laminar tissues, solar wounds
dressing.
The resu~ of 10 of 16 (Wright et al1999) and 15 of 27
(Wright 20P2) animals being sound and returning to their
pre-injury useis significantlybetter than with opensurgical
techniques (Richardsonet al 1986, Steckel et al 1989,
Honnaset al199 5). Thereis also greaterpain relief,reduced
postoperativenursing and medicalrequirementsand fewer
complicationswith endoscopictreatment.
Diagnostic endoscopy
Endoscopy of the navicular bursa may provide useful
information in the evaluation of lameness localizing to this
area but, as yet, its use has been limited. Lesions identified
have included fragmentation of the distal margin of the bone
(Fig. 13.35), tearing of the impar ligament (Dyson 2002) and
ddf tendon (Fig. 13.36), and disruptionof the fibrocartilage
of the bone and ddf tendon (Fig. 13.37). However,the
number of diagnosticexaminationsperformedis small and
clinically correlativestudiesare lacking.
References
AdamsMN. Turner TA. Endoscopyof the intertubercular bursa in
horses.J Am VetMedAssoc1999; 214: 221-225.
BassageIJI ll. Garcia-Lopez J. Gurrid EM. Osteolyticlesionsof the
tuber calcaneiin two horses.J Am VetMed Assoc2000; 217:
710-716.
BoothTM. Lamenessassociatedwith the bicipitalbursa in an Arab
stallion. VetRec1999; 145: 194-198.
BradleyDM. DillinghamMF. Bursoscopyof the trochantericbursa.
Arthroscopy1998; 14: 884-887.
CruzAM. Pharr JW. BaileyJV.BarberSM. FretzPB. Podotrochlear
bursa endoscopyin the horse:a cadaverstudy. VetSurg 2001;
30: 539-545.
DysonSf. In: Diagnosisand managementof lamenessin the horse.
RossMW and DysonSJ(eds).Philadelphia:WBSaunders;2002:
286-299.
Ellmann H. Arthroscopic subacromialdecompression:analysis of
one to three yearresults.Arthroscopy1987; 3: 173-181. Kerr DR. Carpenter CW: Arthroscopic resection of olecranon and
Honnas CM. CrabillMR. MackieJT.YarbroughTB. SchumacherJ. prepatellar bursae. Arthroscopy 1990; 6: 86-88.
Use of autogenouscancellousbone grafting in the treatmentof Klein WK. Endoscopy of the deep infrapatellar bursa. Arthroscopy
septic navicular bursitis and distal sesamoidosteomyelitisin 1996; 12: 127-131.
horses.J Am VetMedAss1995; 206: 1191-1194. wvy HI. Gardner.Lenmak 1J.Arthroscopic subacromial decompression
Ingie-FehrIE. Baxter GM. Endoscopyof the calcanealbursa in in the treatment of full-thickness rotator cuff tears. Arthroscopy
horses.VetSurg 1998; 27: 561-567. 1991; 7: 8-13.
Kaalund S. BreddamM. KristensenG. Endoscopicresectionof the Muller F .ScWeimbeutel und Sebnenscheidendes Pferdes. Arch wiss
septicprepatellarbursa. Arthroscopy1998; 14: 757-758. pracktTierheiIk 1936; 70: 351-370.
~ Ogilvie-Harris DJ, Gilbart M. Endoscopic bursal resection: Tl
surface in patients with subacromial impingement syndrom
olecranon bursa and prepatellar bursa. Arthroscopy 2000; 1 Arthroscopy 2002; 18: 16-20.
249-253. Sullins KE. In: Stashak TS (ed.),Adams'lameness in horses, 5th ed
Ottaway CW, Worden AN. Bursae and tendon sheaths of the hor~ Philadelphia: Lippincott, Williams & Wilkins 2002: 974-976.
Vet Rec 1940; 52: 477-483. Tudor RA, Bowman KF, Redding WR, Tomlinson JC. EndoscoJ;
Richardson GL, O'Brien TR, Pascoe JR, Meagher DM. Punctu treatment of suspected infectious intertubercular bursitis in
wounds of the navicular bursa in 38 horses: a retrospective stuc horse. J Am VetMed Assoc 1998; 213: 1584-1585.
VetSurg 1986; 15: 156-160. van Dijk CN, van Dyk GE , Scholten PE, Karte NP. EndoscOJ;
Rossignol F, Perrin R. Tenoscopy of the navicular bursa: endosco!; calcaneoplasty AmJ Sports Med 2001; 29: 185-189.
approach and anatomy. J Equine Vet Sci 2003; 23: 258-265. Wright IM, Phillips TJ, Walmsley JP. Endoscopy of the navicul
Steckel RR, FesslerIF, Huston LC. Deep puncture wounds of tI bursa: a new technique for the treatment of contaminated aJ
equine hoof: a review of 50 cases.Proc Am Assoc Equine Pra septic bursae. Equine Vet 1999; 31: 5-11.
1989; 35: 167. Wright IM. Endoscopy in the management of puncture wounds
Suenaga N, Minami A, Kimitaka F, Kaneda K. The correlatu the foot. Proc Eur Coli Vet Surg 2002; 11: 107-108.
betweenbursoscopic and histologic findings of the acromion und
Established infection frequently results in the production
Introduction of an intrasynovial fibrinocellular conglomerate (pannus).
This may cover foreign material and devitalized tissue. and
Diarthrodial joints, tendon sheaths, and bursae are closed act as a nidus for bacterial multiplication; it is rich in inflam-
spaces with a similar mesenchymal synovial lining that matory cells. degradative enzymes and radicals. It is also a
produces and maintains a selective physical, cellular, and barrier to synovial membrane diffusion. thus compromising
biochemical environment. The principles of synovial contam- further intrasynovial nutrition and limiting access for
ination and infection are similar for each of these cavities. circulating antimicrobial drugs. The quantity and nature of
Contamination results from the introduction of micro- pannus appears to be dependent on the type and number
organisms and can occur through openwounds or self-sealing of infecting organisms. and its production is also enhanced
punctures, by hematogenous spread, local extension of a by the presence of foreign material. Its presence has been
perisynovial infection, or iatrogenically. Open wounds and associatedwith increasing duration of clinical signs. presence
self-sealing punctures may also introduce foreign material. of osteochondral lesions. and presence of osteomyelitis
Infection follows when the microorganisms reproduce and (Wright et aI2003).
colonize the synovial cavity. The principal potentiating The objectives in treating contamination and infection are
factors for establishing infection are considered to be the similar for all synovial structures: removal of foreign material.
presence of foreign material and/or devitalized tissue, the debridement of contaminated/infected and devitalized tissue.
nature and number of contaminating organisms, and elimination of microorganisms.removal of destructiveenzymes
immunologic compromise, particularly in young animals. and radicals. promotion of tissue healing. and restoration of
Following colonization of the synovium, a combination of a normal synovial environment. A number of techniques have
bacterial pathogenicity and host-immune response lead to been described which include use of drains Gackman et al
the release of a variety of enzymes and free radicals, which 1989). through and through lavage (Koch 1979). open surgery
result in massive inflammation and ultimately destruction of (Rose& Love 1979. Honnas et al1991a. Bertone et al1992.
the tissues in the synovial cavity. The acute inflammatory Schneider et,.al 1992a. Baxter 1996). and endoscopy
response following inoculation of microorganisms is charac- (Mcllwraith ],983. Bertone et a11992. Wright et al1999.
terized by a rapid influx of inflammatory cells, predominately 2003. Frees et al 2002). Variations of these techniques have
neutrophils (Bertone & Mcllwraith 1987). A plethora of also been described. These include open surgery followed by
destructive enzymes have been detected in synovial fluid from insertion of closed suction (Mcllwraith 1983) or open passive
infected joints, including collagenase, caseinase, lysozyme, (Santschi et a11997) drains or by open drainage (Bertone et al
elastase,cathepsin G, and gelatinase (Palmer & Bertone 1994, 1992. Schneider et al 1992a) and endoscopy followed by
Spiers et al 1994). These appear to originate both from closed suction drainage (Rosset al1991. LaPointe etal1992).
invading neutrophils and activated synoviocytes. Together fenestrated drains (Honnas et al1991b). or creation of an
with other inflammatory mediators, such as eicosanoids, open draining wound (Bertone 1999).
interleukins, and tumor necrosis factor (Bertone et al1993) In treating joint infection in man. arthroscopy is con-
and the disturbed synovial environment in joints, these sideredto offer severaladvantagesover lavage and arthrotomy.
trigger production of degradative enzymes by chondrocytes including improved visualization. identification of foreign
(such as stromelysin, aggrecanase,collagenase,and gelatinase). material and infected or devitalized tissue. and access to a
There also is reduced proteoglycan synthesis (Palmer & larger area of synovial surfaces(Dory & Wantelet 1985. Jackson
Bertone 1994). 1985. Parisien & Shaffer 1990). Arthroscopy is reported to
ensure an efficiently evaluated, cleaned, debrided,
decompressedjoint with minimal morbidity,
Foreign material
In the presence of open wounds or self-sealing punctures, the
surgeon should be aware of the potential presence of foreign
material within the synovial cavity. Frees et al (2002) found
intrasynovial foreign material in 4/20 (20%) of tenoscopically
investigated wounds involving the digital flexor tendon
sheath, whereas Wright et al (2003) documented foreign
material in 41 of 95 (43%) horses with wounds or punctures
into synovial cavities which were investigated endoscopically.
In the latter series, foreign material was predicted pre-
operatively in only 15% of animals (Fig. 14.7). The majority
are free floating but the foreign material may also be
adherent to pannus or synovium, embeddedin osteochondral
lesions or foun~in penetrating soft tissues.The most common
contaminantsure hair and wood (Fig. 14.8A). An association
has been demonstrated in man between the presence of
foreign material and the development of infected synovitis
following penetrating wounds (Reginato et alI990). Foreign
material acts as a nidus for infection and causesphysical and
biochemical irritation within the synovial environment.
Large pieces may be removed with Ferris-Smith rongeurs
(Fig. 14.8B), small pieces by a motorized synovial resector,
and if embeddedin bone, curettes may be necessary.
~
least partial synovial resection. The authors' preference in (Bertone et al 1987a. Baird et al 1990) and this should
motorized resectors, for safety and efficiency, is an enclosed, be delivered by a pump system capable of rates in excess of
serrated blade. This is used in a to-and-fro oscillating mode 500 ml/minute. It is important to move the arthroscope. and
with suction applied to draw material into the blade. Angled thus the fluid ingress. repeatedly to all parts of the cavity in
blades are also available and can be useful in some areas. order to produce effectivelavage.The surgeon should be aware
It is suggestedthat synovium may harbor bacteria, sequester of all synovial sulci as. without individual attention. fluids
inflammatory cells, release potent inflammatory mediators, will frequently flow over or past pockets of debris in these
and be a source of immunologic components of inflammation sites.This is particularly important in tendon sheaths. where.
(Riegels-Nielson & Jensen 1984, Riegels-Nielson et aI1991). in addition to moving around the tendons. the arthroscope
Synovectomy has therefore been proposed to be of benefit in should be insinuated betweenthese structures. The mechanical
treating infected arthritis (Rosset al1991, Bertone et al1992) action of flushing removes small. free-floating debris. debulks
although some surgeons consIder its use should be limited microorganisms. and reduces the load of destructive radicals
(Parisien & Shaffer 1990). The authors generally remove and enzymes. Lavage is also thought to raise the pH from the
contaminated/infected synovium that is adjacent to wounds acidic environment produced by infective processes. This
and punctures. More extensive resection is performed in the in turn imprDKesthe action of several antimicrobial drugs.
presence of marked pannus deposits, which are usually including aInil1ogiycosides(Mcllwraith 1983). Effectivelavage
associatedwith long-standing infective processes.Regeneration invariably requires multiple ingress and egress portals. In
of normal villous synovium does not occur following animals with wounds or punctures. these may also serve as
synovectomy (Theoret et al1996, Doyle-Jones et al 2002), instrument and egressportals (Fig. 14.12).
but the clinical implication of this and potential compromise Potential additives to lavage fluid include antimicrobial
compared to the benefits of synovectomy have not been drugs. antiseptics. dimethyl sulfoxide. and fibrinolytics. Anti-
determined. microbial preparations used by the authors include a combi-
nation of sodiumbenzylpenicillin (2.5 x 106 ill) with gentamicin
sulfate (250 mg). or alternatively ceftiofur sodium (500 mg).
Lavage amikacin sulfate (500 mg). or enrofloxacin (500 mg). added
to the final liter of lavage fluid. There is no objective evidence
Lavage is visually directed, high pressure, and should be to support the use of antimicrobial drugs in this manner.
performed thoroughly until all areas of the synovial cavity although administration of an aqueous antimicrobial on
are visibly clean (Gaughan 1994, Thiery 1989, Smith 1986). completion of lavage has been suggested to be of benefit
The fluid of choice is sterile buffered polyionic solution (Nixon 1990). Antiseptic solutions appear to offer no
benefits have been documented, but deleterious
equine cartilage matrix metabolism have been
(Matthews et al 1998. Smith et al 2000), J
the use of fibrinolytics have been mentioned in the human
literature (Jackson 1985), but they are uncommonly
employed in veterinary medicine, With the advent of
endoscopic removal of fibrinoid deposits, their use largely
appears superfluous.
Wound management
Arthroscope and instrument portals are closed routinely.
Traumatic wounds are debrided or (preferably) excised to a
clean/ contaminated state and then if possible these also are
closed. This is based on the premise that endoscopic surgery
can thorou~y cleanse synovial cavities and that a closed
wound minj,mizesthe risk of further and/or secondary conta-
mination or infection. These principles contrast with those of
others in the literature (Gibson et al 1989, Schneider et al
1992a, Baxter 1996) who advocate open management of
infected synovial cavities in order to maintain decompression.
Such alternatives include closed suction drainage (Ross et al
1991, LaPointe et a11992), fenestrated drains (Honnas et al
1991b), or creation of an open draining wound (Bertone
1999), techniques which the authors also advocate in cases
of chronic infection. Solar punctures are debrided, dressed,
advantages over buffered polyionic solution (Bertone et al and managed as open wounds. Traumatic wounds elsewhere
1986) and, evenin dilute concentrations may produce synovial in which soft tissue loss precludes closure should be debrided
irritation (Bertone et al1986, Wilson et aI1994). Dimethyl as rigorously as if closure was to be effected. The wound is
sulfoxide has been recommended as part of the final lavage then dressed and the limb immobilized while second
(Bertone 1996,1999, Frees et al2002). Its efficacy has not intention healing ensues.
constructinga RobertJonesbandage).Commercial.tailored
elasticizedbandagesare effectiveon the carpus and tarsus.
whereas in the proximal limb stent bandages may be
oversewn.
Table 15.1 Horses with diagnosis of inflammation of the temporomandibular joint (TMJ) (1996-2000)
Slight chronic Scintigraphy: left TMJ hot Chronic, diffuse Improved, but still irregular
headshaking. behaviourai spot +, ultrasound: proliferative synovitis headshaking
problems distended joint filling
Case 4 Chronic swelling, right Scintigraphy: right hot Significant traumatic Sound,no symptoms after
Warmblood, joint capsule after colic spot +++, ultrasound: synovitis and 6 weeks
distended joint, increased proliferation of villi +++
6-year-old,gelding,
showjumper thickness joint capsule
Case 5 Significant back Scintigraphy: right hot Subtotal, transverse, Sound and back to full
Warmblood, problems, compression spot ++++, ultrasound: axial rupture of articular work after 4 months
9-year-old mare pain right TMJ, bilateral thickened joint capsule disk, secondary mechanical
dressage teeth abnormalities synovitis, free floating
bony fragment, small size
Cartilage debridement
Some form of cartilage debridement is common during
arthroscopic surgery. As a simple rule, fibrous interpositional
,,'
tissue or exposed loose bone should be removed from full-
thickness defects. Debridement should continue down to
firm, normal appearing, subchondral bone plate. Maintaining
as much subchondral bone as possible keeps the bone and rounds the potential advantagesof debriding partial-thickness
overlying cartilage repair tissue contoured to the normal cartilage defects down to subchondral bone. in efforts to
congruency of the opposing joint surface, thereby enhancing encourage new cartilage formation from subchondral bone
the chance of healing cartilage tissue persistence. However, cellular and growth factor elements (Baumgaertner etal1990.
the remaining bone must be viable. Crumbly, brownish bone Hubbard 1996). Consensus appears to favor not debriding
should always be removed by debridement, using either hand partial-thickness fibrillated cartilage, but rather leaving it
instruments or motorized equipment (Fig. 17.1). At least for attached to the calcified cartilage and underlying bone
the carpus, the amount of residual bone after debridement is (Mcllwraith 1990). Partial-thickness defects have been
an important parameter in determining the prognosis for shown to remain physically unchanged for at least 2 years
return to athletic activity (McIlwraith et al19 8 7, McIlwraith (Mankin 1982). Conversely, some symptomatic benefit for
1990). Several studies indicate the advantage of removal of several months can be derived from chondroplasty of the
full-thickness fibrillated cartilage. However, more debate sur- obviously fibrillated portion of partial-thickness defects,
Repair Methods
which is described in more detail later (Thompson 1975, while leaving perpendicular cartilage defectwalls (Fig. 17.2).
Kim et al 1991). In summary. chondroplasty reduces the A controlled study in dogs indicated the benefit of perpen-
possibility of damaged cartilage leaching degraded cartilage dicular cartilage walls following debridement, compared to
matrix fragments, including collagen, proteoglycan, and beveled edges,which tended to increase the overall dimension
cellular components to the synovial fluid. where they of the healing defect (Rudd et al198 7).
increase synovitis and concurrent lameness (Thompson Exposed subchondral surfaces can be smoothed either
1975). with hand tools, which include curettes, rasps,and rongeurs,
Full-thickness cartilage lesions are debrided to removeresidualor with motorized burrs. Several types of burr heads are
portions of the calcified cartilage layer, which tends available, varying from spherical to oval acromioplasty or
to retard the development of well-attached cartilage repairtissue notchplasty blades, which have an elongated profile for
from the subchondral bone and surrounding cartilage.The maximum bone removal effect (seeChapter 2). Hand tools are
most appropriate tools for cartilage debridement include generally preferred to avoid excessivebone loss; however, for
a seriesof spoonand ring curettes that allow adequateremovalof large areas of irregular hard bone, a burr may expedite the
residual fibrous areas attached to the subchondral bone procedure and provide a better end result. Since the need for
substantialbone removalis low. an inventoryof a singleburr
type is recommended.
Chondroplasty
Resection of the protruding surface strands of partial-
thickness cartilage fibrillation has been promoted as a
mechanism to reduce cartilage-derived detritus entering the
synovial environment (Thompson 1975. Childers & Ellwood
1979. Kim et al1991. Altman et al1992). Motorized synovial
abraders are used to smooth the surface of the more seriously
damaged cartilage. The residual cartilage then presents a
more uniform non-clefted surface, which may be more
durable and incites less synovitis than the large surface area
presented by multiple strands of fibrillated cartilage. The
concept seems simple. but there is a paucity of evidence
documenting any discrete benefit. either in reducing synovial
levelsof fragmentedproteoglycan and collagen or in abrogating
the symptoms of synovitis. Despite this, the technique has
empirical benefits and has been used in equine arthroscopy
for trimming extensive areas of partial-thickness fibrillated
cartilage. The most frequent site for application in the horse is
the stifle (Fig. 17.3). TrocWear ridge OCD in mature horses
(>3 years) is often accompanied by fibrillation of the sur-
rounding cartilage and the patella. Chondroplasty has been
used to trim these areas to smooth articular cartilage and
seems to reduce the incidence of persistent effusion when
these horses re-enter competition. No controlled clinical or
experimental data support chondroplasty in the horse. so its
use remains controversial. It may be preferable to doing
nothing. but the resection depth should only involve the
fibrillated surface and not be aggressively pursued down to
the subchondral bone, since the ensuing repair tissue rarely
has the hyaline characteristics of the original deep cartilage
layers that were resected.
Chondroplasty cannot be efficiently performed without
sharp motorized abraders. Disposable cutting heads are
recommended. Attached suction is also helpful in drawing
and holding the cartilage fronds into the shaver blades. A
"whisker" technique is used to avoid penetration of the intact
deeperlayers of cartilage. Benefits in man have beendescribed worked satisfactorily on large flaps in the fetlock, hock and
for months to years after chondroplasty; however. as much as stifle, where undulating OCDcartilage has been salvaged by
6 months symptomatic relief has also been attributed to pinning to th~ underlying bone (Nixon et al 2003a). The
synovial washout using a saline lavage (Hubbf1rd 1996). intervening fi~rosis between cartilage and bony defect should
be removed if the procedure can be performed without
disturbing remaining perimeter attachment. A 1.2 rom K-wire
Cartilage reattachment
is then used to drill through the cartilage flap and into the
Some cartilage flaps in the stifle. hock, and fetlock can be underlying bone (Fig. 17AA). With changes in the degree of
potentially salvagedand reattached (Nixon etal2003a). While flexion of the joint, multiple K-wire perforations can be made,
not common, an OCDcartilage flap that is relatively smooth all perpendicular to the surface. The soft tissues are protected
and has not detached on its entire perimeter can be elevated by insertion of the K-wire through an arthroscopic guide
and the underlying necrotic cartilage and marrow fibrosis cannula. The kit also contains five 40 rom long x 1.3 rom
debrided. The flap can then be replaced and secured with diameter pins, each of which can be cut in half to provide two
polydioxanone (PDS) pins (OrthoSorb, Ethicon-Johnson & pins approximately 20 rom in length. Except in cases with
Johnson) (Fig. 17.4), or PLLA tacks (Chondral darts, Arthrex. extremely deep subchondral defects. these pins adequately
Naples, FL). Importantly, the OCD flap must be worth secure the OCD flap. For deeper lesions, pins can be cut
reattaching, which requires a smooth congruous surface, longer. up to the entire 40 rom pin. After carefully drilling the
minimal fibrillation, and some perimeter continuity. This has K-wire to end 1 rom short of the anticipated pin length. the
PDS pin is inserted down the cannula and pushed into place Use of the multi-shot chondral dart system (Arthrex,
using the obturator (seeFig. 17.4B). Approximately 1 mm of Naples, FL) for simultaneous multiple anchoring with bidi-
pin is left protruding from the surface of the cartilage so it can rectional barbed pins is being explored, and appears a satis-
be flattened level with the articular surface to make a securing factory alternative to PDS pins. Rapid resolution of effusion
head to the PDS pin. Any excess pin can be removed with and subchondral bone lysis on radiographs is a consistent
a biopsy punch rongeur or other severing rongeur (see feature (Fig. 17.5), and reformation of the subchondral
Fig. 17AC). Multiple pins are inserted approximately 10 mm contour was complete in all but 2 of 16 joints in 12 horses
apart so that the entire cartilage flap is securely reattached to (Nixon et aI2003a). This compares favorably to debridement
the subchondral bone. As few as 2 and as many as 10 PDS of OCDlesions,which generallyleavesa depressedsubchondral
pins have been inserted (Nixon et al 2003a). bone plate at the lesion site. Eleven of the 12 horses were not
cartilage repair. It is simple and inexpensive. However, in a
controlled study using arthrotomy approaches, it did not
provide superior healing in defects on the equine third carpal
bone (Vachon et aI1986). Similarly, it did not benefit healing
of partial-thickness cartilage defects in the same third carpal
bone model (Shamis et al1989).
Subchondral bone forage or drilling was introduced into
human arthroscopy in the 1960s (Pridie 1959, InsalI1974).
Since then it has been frequently used to improve cartilage
quality following chondromalacia of the patella (Childers &
Ellwood 1979). Historically, the most frequent site for
subchondral bone forage in the horse was the sclerotic rim
associatedwith subchondral cystic lesions (Mcllwraith 1983,
White etal1988). The use of this technique has diminished, as
reports of cyst enlargement subsequent to forage have been
published (Howard et al 1995), and surgeons have found
difficulty in arthroscopically making drill holes that are
perpendicular to a defect. The technique has largely been
replaced by microfracture.
Microfrocture
The use of microfracture. or micropick as it has been referred
to in equine arthroscopy, has many of the advantages
associated with forage, including focal penetration of the
dense subchondral plate to expose defects to the benefits of
cellular and growth factor influx, as well as improving
anchorage of the new tissue to the underlying subchondral
bone and to some extent the surrounding cartilage (Rodrigo
et al 1994, Frisbie et al 1999, Breinan et al 2000). The
simplicity of microfracture comes from the use of a tapered
awl (Unvatec, Largo, FL; Arthrex, Naples, FL), instead of a
parallel-sided twist drill. Using the awl abrogates the need for
powered instrumentation to perforate the subchondral bone.
giving additional control over the placement of the
perforation, and also allowing the formation of a tapered entry
to the subchondral marrow spaces.The microfracture awls
should penetratethe subchondral bone deepenough (2-4 mm)
to provide ready access to the marrow spaces, thereby
maximizing cellular and anabolic growth factor delivery
(Fig. 17.6). The microfracture awl also tends to make a crater
in the subchondral bone. which may playa role in better
attachment of, the cartilage repair tissue (Lee et al 2000).
Microfracture, 'holes are generally placed 3-5 mm apart and
cover the entire debrided area in a cartilage lesion (see
Fig. 17.6). It is also important to microfracture the sub-
chondral bone on the perimeter of the cartilage lesion to
encourage new tissue at the junction of repair tissue and
lame, and it appearedthat reattachment was a valuable residual cartilage. The technique has become popular in
option to salvage the dissectedhyaline cartilage flap in human arthroscopy (Rodrigo et a11994, Blevins et a11998,
selectedcases. Steadman et al2001. 2002), and is now frequently compared
to chondrocyte transplantation as one of the two most
frequently employed techniques to improve cartilage healing.
Forage One experimental study in the horse documented improve-
Forageor subchondralbonedrilling has beenexploredin the ments in the quantity of tissue and the hyaline quality of the
horse.Therationaleis to perforatethe subchondralboneand cartilage (collagen type n content) at 4 and 12 months after
allow entry of subchondralmarrow elements.vasculature. micro fracture of full-thickness cartilage defects (Frisbie et al
and growth factors to the defect,which then contribute to 1999). Improvements in early gene expression of cartilage
specificmarkers were evident within 8 weeks of microfracture Abrasion arthroplasty
(Frisbie et aI2003).
The technique clearly has advantages over forage and Abrasion arthroplasty uses a motorized burr to resect a
transplantation methods, including ease of application using uniform layer of residual cartilage and eburnated subchondral
arthroscopy, use of a simple hand tool. the relative economies bone Gohnson 1986. 2001). Eburnated bone is often charac-
of the equipment required, the simplicity and minimal terized by a surface layer of non-viable bone Gohnson2001).
planning required to use the technique. and the apparent which forms a barrier to effective cartilage repair. Abrasion
increase in cartilage repair tissue that deve~ps after the arthroplasty. a.it was originally conceived Gohnson 1986).
procedure. ... removes this superficial layer of dead subchondral plate.
Results of microfracture in equine clinical syndromes thereby exposing vascular tufts from the deeper marrow
have not been published. However, individual experiences spaces. In addition. it provides access to a viable pool of
with micro fracture have included focal and severe cartilage marrow-derived stem cells that could participate in cartilage
defects on the carpal bones, femoral condyles and trochlear repair. Use of motorized equipment is necessary due to the
ridges. proximal sesamoidsand distal metacarpal/metatarsal sclerosis associated with subchondral bone eburnation. The
condyles, and the trochlear ridges of the talus (seeFig. 17.6). result is a coalescing group of fibrocartilaginous tissue tufts
Anecdotal evidence of improved cartilage healing has Gohnson 1986. 1991. Menche et al1996). Although. it has
been derived from the use of microfracture at each of these been used to a limited extent. particularly for areas of
sites. Further case numbers and comparative studies are eburnation of the trochlear ridges of the talus. widespread
required before a definitive recommendation can be made experience with this technique in horses is lacking. and there
for its use. Of the available local manipulative procedures are no published reports documenting other possible sites for
that follow debridement of cartilage lesions, microfracture abrasion arthroplasty. The utility of arthroplasty has been
appears to have the most benefit with the least cost and reduced by the introduction of marrow stimulating tech-
niques such as micro fracture. which perforate the sub-
complexity.
chondral bone plate at multiple sites over eburnated or for focal cartilage injury in the knee has been reported
debridedcartilageregionsand allow reformationof cartilage (Niedermann et a1198S, O'DriscoII1998, 1999). On balance,
repair tissue while still maintaining the subchondralplate the disadvantage of an arthrotomy for insertion of periosteal
contour. grafts in man is not outweighed by the potential benefits in
hyaline cartilage. Additionally, in an equine study, periosteal
transplants to the stifle occasionally induced vascularization
Spong;al;zat;on
of the healing cartilage, which led to exuberant tissue and
Spongialization can be considered an extension of abrasion mineralization in the repair, both of which were detrimental
arthroplasty. since extensive areas of the subchondral bone to the formation of durable hyaline cartilage (Nixon et al
plate and overlying cartilage are removed (Ficat et aI1979). 2002, unpublished data).
Resection extends through the subchondral bone. essentially In other equine studies, autogenous periosteal transfer to
exposing the defect to the marrow spaces that then parti- the radial carpal bone provided no additional advantage to
cipate in cartilage repair. Given the benefitsto maintaining sub- defects healing spontaneously (Vachon et a11991a, 1991b).
chondral bone architecture. we do not consider there is any Moreover, there was a tendency for synovial pannus and
indication for the use of spongialization in equine arthroscopy. adhesions to overwhelm the healing defects (Vachon et al
1991b). In other research studies, the application of auto-
genous periosteal grafts as a mechanism to secure autogenous
Transplantation procedures chondrocyte grafts in full-thickness cartilage defectsprovided
better cartilage repair than periosteal graft alone (Breinan et
In mature horses most debriding and marrow stimulatory
al 1997), and is probably the only widespread clinical
techniques result in fibrocartilage formation with modestbio-
application of periosteal grafts in cartilage repair in man
mechanical capabilities. The use of supplemental free cells.
(Brittberg et al 1994). In horses, there are no reports of
various vehicles containing cells. or entire tissues such as
successful clinical application of periosteal grafting in
periosteum or cartilage grafts have been advocatedto improve
the modest impact that these local manipulative procedures cartilage repair.
have on both the quality and quantity of cartilage repair
tissue. Transplantation procedures can be classifiedaccording Perichondrium
to the origin of transplanted tissue: (1) periosteal trans-
Severalresearchgroups have studied the use of perichondrium
plantation. (2) perichondrial transplantation. (3) autogenous
rather than periosteum for improved cartilage repair (Ohlsen
cartilage (articular. sternal. or auricular) transplantation.
& Widenfalk 1983. Kwan et al 1989. Coutts et al 1992.
(4) osteochondral transplantation. (5) chondrocyte trans-
Bruns eta11992. Ritsilaet a11994. Bouwmeester etaI2002).
plantation. and (6) pluripotent stem cell transplantation.
While these tissues behave similarly to periosteum. various
There is a considerable body of literature that describesthe
investigators considered they were more programmed toward
potential advantages derived from transplantation of whole
a chondrocyte lineage. and should hold special benefits for
tissues. The disadvantages with these methods and the tissues
cartilage repair. In a study comparing free grafts of perichon-
they transfer predominantly hinges on the limited application
drium to periosteumimplanted in equinejoints. perichondrium
by arthroscopic means. Arthrotomy is required for insertion
did not produce significant cartilage (Vachon et al 1989).
of periosteum. perichondrium. intact cartilage. and osteo-
Perichondrial grafting holds few benefits over other techniques.
chondral grafts. Similarly. tissue-engineeredcartilage analoges
and is rarely mentioned in clinical applications in horses or
such as chondrocytes cultured on collagen. polygiycolic acid
man (Ritsila et a11994. Bouwmeester et aI2002).
(PGA). or PGA/polylactic acid (PGA/PLA). or newer synthetic
materials such as hyaluronan membranes. are also difficult or
impossible to implant arthroscopically. This serious practical OsteochondralGrafts
limitation has tempered interest in using thesrimplants. ~
The use of o~teochondral autograft and allograft has been
through several periods of clinical interest. Originally,
Periosteum autogenous osteochondral shell grafts were favored because
Autogenous periosteal transplants have improved the of the secure attachment to the recipient bed afforded by the
quality of repair tissue in various animal models (Rubak bony portion of the graft. The overlying cartilage was well
1982, O'Driscoll & Salter 1984, 1986, Hulse et al 1986, attached at its base since it was harvested as an osteo-
O'Driscoll et a11986, Moran et aI1992). Moreover, high- chondral composite, and the graft also had minimal gapping
quality hyaline cartilage was produced when transplantation at the cartilage perimeter. However. research and clinical
was combined with the use of continuous passive motion in evaluations were tempered by the limited availability of auto-
rabbits. Subsequent application in man has been limited to genous osteochondral graft and the donor site morbidity. Few
carefully selected cases over the last 10 years (Niedermann et al sites in man or animals can sacrifice considerable areas of a
1985, O'Driscoll 1999). However, the surgery is extensive joint for donation as osteochondral grafts. The use of allo-
and includes harvest of tibial periosteum and arthrotomy for graft osteochondral shell grafts was designed to overcome
suture attachment of the periosteal flaps to irregular-shaped these limitations. Several investigators have found utility in
lesions in the human knee. Application of periosteal grafts the use of fresh osteochondral hemiarthroplasty shell allografts
created widespread instability and joint pain (Meyers et al
--
articular cartilage biopsies are harvested arthroscopically
1989, Ghazavi et al1997, Chu et a11999. Aubin et a12001. from minimally weightbearing regions of the injured knee,
Gross et al 2002). However, it should be stressed that these
propagated ex vivo in cell culture, and later implanted under
are not dowels but entire femoral condyle shell grafts. an autogenous periosteal tissue patch (Brittberg et al1994).
The immunogenicity with allografts, particularly the
The indications for the procedure include previously failed
osseous component is also of concern (Elves & Zervas 1974,
surgery, large lesions, and minimal secondary osteoarthriti~
Strong et al1996). (Brittberg et al 2001, King et al 2002). These indications
More recently. mosaicplasty. using autogenous osteochondral include extensive focal defects and osteochondritis dissecans
dowel grafts. has become popular (Hangody et al1997. 1998.
(Robert & Bahuaud 1999, Peterson et al 2000,2002). The
2001a, Jakob et al 2002). This technique has recently been delivery of cells requires an arthrotomy, and the harvest and
arthroscopically performed in the human knee. and involves suture attachment of a periosteal patch is tedious and tech-
harvest of osteochondral dowels from less weightbearing
nically demanding. Both factors complicate the surgery as
regions of the same joint, and insertion of these dowels to well as the postoperative course. There are still several un-
reconstruct a relatively congruous joint surface (Hangody et al resolved questions, including the ideal number of chondro-
1998. 2001a). Considerable research data support the clinical cytes to transplant and most particularly the role of the
application of osteochondral dowel grafting. The technique periosteum in the technique. The periosteum has been shown
has been used successfully in the horse (Bodo et al 2000).
by others to contribute to cartilage healing (O'Driscoll1999).
Other investigations of autogenous and allograft osteochondral
One study compared chondrocyte transplantation secured
dowel transfer in horses have yielded mixed results (Hurtig with a periosteal patch to defects treated with periosteal
1988. Hurtig et al2001). The technical difficulties associated patches without chondrocyte implantation, and found no
with careful graft harvesting and the precision and crafting
difference between the healing tissue after a year (Breinan
needed for heterotopic graft insertion in the recipient bed have et al19 97). Clinical outcome in multiple studies in man have
detracted from wider clinical application (Pearce et aI2001).
reported good to excellent results, with 80-90% return to
Additionally. empty spaces that naturally form between pain-free function for femoral condyle defects and slightly
inserted osteochondral dowels heal poorly and allow synovial lower successrates for lesions on the patella (Minas 1998,
fluid entry to the bone tunnels of adjacent dowels.
2001, Richardson Evans et al1999, Minas & Peterson 1999,
Several instrument systems are available for the harvest Peterson etal2000, 2002. Minas & Chiu 2000, Brittberg et al
and implantation of osteochondral dowels in man and animals.
2001, Lindahl et al 2001). Long-term studies are becoming
These include the mosaicplasty system (Acufex -Smith & available for patients treated with autogenous chondrocyte
Nephew. Andover. MA). the osteochondral autograft transfer repair, one of which shows that 84% of patients had a
system (OATS -Arthrex. Naples. FL), and the consistent osteo- successful outcome from 2 to 9 years after the procedure
chondral repair system (COR -Innovasive), that have been
(Richardson et al1999, Peterson et al2000, 2002, Brittberg
marketed for use in man. Frequently. "mosaicplasty" is used et al2001, Minas 2001).
as an umbrella term for all of these techniques, despite its In horses,chondrocyte implantation techniques have been
trademark use for the Acufex -Smith & Nephew instrumen:' examined in a variety of matrix carrier vehicles (Hendrickson
tation. The benefits of autogenous osteochondral dowel transfer et al1994, Sams & Nixon 1995, Fortier et aI2002a). Initial
include immediate weightbearing capabilities. relatively good research trials indicated the significant effect of chondrocyte
integration of the bony portion of the dowel. and the long-
implantation using a fibrin vehicle (Hendrickson et aI1994).
term data available from clinical trials (Hangody et al2001b,
Subsequent methods to enhance the matrix vehicle, using
Mendicino et al 2001. Jakob et al 2002). In horses. the
tissue-engineering approaches with collagen matrix scaffolds,
arthroscopic application of osteochondral dowel transfer is did not provide a satisfactory improvement in repair (Sams &
cumbersome. harvest of the osteochondral plugs can be Nixon 1995, Sams et al 1995). The addition of anabolic
challenging due to the optical aberrations associated with growth factors was initiated to bolster the matrix elaborated
arthroscopic viewing, and insertion of the osteochondral
by transplanted chondrocytes. Initial studies used vehicles
dowels can be technically demanding. Until the technical
containing growth factors, but no cells, with the expectation
difficulties associated with dowel insertion can be further that a repositofH of a growth factor would enhance repair
minimized. widespread use in horses is likely i~ be limited. tissue from pluclpotent cells arising from the subchondral bed
Experimental work suggests mosaicplasty techniques also (Nixon et aI1999). Insulin-like growth factor-1 (IGF-1) has
become more difficult in mature horses (Bodo et al 2001). been extensivelyevaluated for its effect on chondrocyte activity
Despite this. a case report of mosaicplasty for repair of a (Luyten et al1988, Nixon et al 1998, Fortier et al 1999),
subchondral bone cyst of the medial femoral condyle in a
although other growth factors have also been found to
horse has been published (Bodo et aI2000).
stimulate proliferation, migration, matrix synthesis, and dif-
ferentiation. Many of these growth factors, including basic
fibroblast growth factor,transforming growth factor-g (TGF-g),
Chondrocyte transplantation
and epidermal growth factor, induce beneficial effects to
Autogenous chondrocyte implantation is one of the few FDA- cartilage healing (Mankin et al1991, van den Berg 1995,
approved tissue engineering techniques to treat articular Trippel et al1996, O'Connor et al2000). Local treatment of
ubiquitous matrix that further isolates them from the host
immune response. Comparison of studies in the horse clearly
documented the benefits of allograft cells compared to defects
without cells (Hendrickson et a11994). Allograft chondrocyte
persistence has also been assessedin horses, using a marker
of male cells (the SRY gene) to track the survival of male
allograft transplants in female recipients (Ostrander et al
2001, Hidaka et al 2003). This polymerase chain reaction-
based assayindicated persistence of equine allograft cells at
8 months, ranging from 0 to 28% (Hidaka et al 2003). Most
assaysof the persistence of allograft cells in more vascularized
locations indicate rapid cell loss Oackson & Simon 2002).
Despite cell loss, enhanced repair can be induced, either by
the initial impact of the allograft cells, or the later enhanced
elaboration of paracrine growth factors and matrix that may
improve the quality of cartilage repair. Clearly, however, an
autogenous cell would be an advantage. Recent studies in the
horse, using autogenous chondrocytes seededonto a collagen
membrane and inserted via arthrotomy, have yielded en-
couraging results (Frisbie 2003, unpublished data). Use of
bone marrow-derived pluripotent mesenchymal stem cells
(MSCS)is one solution to the limited availability of predeter-
mined chondrocytes.
medial
osteochondraldisease2. 44 middlecarpaland antebrachiocarpal proximal check desmotomy 389
osteochondralerosion43 joints. arthroscopicexamination57 proximal check ligament 386.390
osteochondralfragments60.65.147.453 palmarolateraloutpouching59 proximal dorsal aspect of proximal
palmar aspectof carpaljoints 99-100 pannus phalanx. removal of osteochondral
proximal dorsalaspectof proximal depositsin scapulohumeraljoint 432 fragments from 136-52
phalanx 136-52 formation 37 proximal dorsal eminences of proximal
proximalpalmar or plantar aspectof removal430 phalanx 152
proximal phalanx167-72 partial thicknesschondrectomy44-5 proximal dorsomedial eminence of
osteochondralgrafts462-3 patella202-4. 208 proximal phalanx 146.153
osteochondralhealing99 articular surface230 proximal intermediate carpal bone 78. 82-4
osteochondritisdissecans(OCD)2. 16. 18. fractures245-6 proximal interphalangeal joints 359-64
105.223-42.269.315.466 fragmentation242-5 arthroscopy of dorsal pouch 359-60
cartilage flap re-attachment459 postoperativemanagement245 arthroscopy of palmar/plantar pouch
chronic lesions237 preoperativeconsiderations242 360-4
debridement335 results245 avulsion fracture of abaxial distal
distal dorsal aspectin technique242-5 condyle of first phalanx 361
metacarpophalangeal and osteochondritisdissecans(OCD)227. osteochondritis dissecans (OCD)361
metatarsophalangeal joints 158-62 238 position of arthroscope for
distal intermediateridge of tibia 281-6 secondaryremodeling238 palmar/plantar pouch 362
distal interphalangealjoints 354 patellaforceps18 removal of palmar middle phalanx
distribution of lesions224 patellarongeur 17-18 osteochondral fragmentation from
elbowjoint 332 patellofemoralarticulation36 axial midline of palmar pouch 364
glenoid315.318 pathologicplicaein man 39 proximal intertarsal joint (PIT) 274
hip joint 344-6 penicillin 436.452 proximal phalangeal fracture 144
humeral head318 periarticularosteophytes60 proximal phalanx 2. 133-5. 139
humerus 315 periarticular swelling29 dorsomedial eminence 148
lateral trocWearridge224-6. 460 periarticular tissues59 dorsoproximal chip fractures 152
medialhumeral condyle335 perichondriumfor improvedcartilage fragmentation of plantaroproximal
medialmalleolus293-4 repair462 articular surface 449
patella227 periosteumtransplantation462 frontal fractures 152. 154
postoperativemanagement241 perisynovialstructures lateral eminence 147
preoperativeconsiderations223-6 iatrogenicdamage450 multiple fragments associated with
proximalinterphalangealjoints 361 injury 448 lateral plantar process 171
results241-2 petechiationof villi 37. 429 osteochondral fragments of proximal
shoulderjoint 319 phenylbutazone97. 322 palmar or plantar aspect 167-72
surgical treatment279 photography23 proximal dorsal aspectof. removal of
tarsocrural (tibiotarsal)joint 269. 280 plica-associated disease39 osteochondral fragments from
technique226-40 pluripotent mesenchymalstemcell 136-52
osteochondroma. tenoscopicremoval393 transplantation464 proximal dorsal eminences of 152
osteochondrosis pneumoperitoneum15 proximal dorsal fragments of 139
arthroscopictechnique314-22 pneumoscrotum15 proximal dorsomedial aspect 143
elbowjoint 332 polymethylmethacrylate (PMMA)beads435 proximal dorsomedial eminence of 146.
glenoid324 poplitealtendon222 153
hip joint 344-6 post-antibioticeffect(PAE)436 proximodorsal aspect 147
humeralhead324 post-arthroscopicirrigation and closure35 proximal radial carpal bone 54. 82
preoperativeconsiderations314 postoperative care436 proximal radius. capitular fovea of 334
shoulderjoint 314-25 pos~operative complications451-4 t proximal sesamoid bones
postoperativeeffusion448 ' apical-abaxial fragmentation 181
osteomyelitis325
osteophytes92-3 postoperative
monitoring 437 axial osteitis 186
osteotome18. 62. 385 preoperativeevaluation31 removal of fragments 172-85
preoperativepreparation31 proximal third carpal bone 43
pressurebandaging28-9 proximal ulnar carpal bone 85
p pressuremanagementsystems28-9 Pseudomonas aeruginosa26
pain and pain relief401. 454 probeuse 16 pumps 11-14. 34
palmar carpalligament(PCL)385 in diagnosticarthroscopy35 punctate erosions 41
palmar intercarpalligaments.tearing in medialpalmar intercarpalligament
104-5 37
R
palmar osteochondralwedge87 proliferativesynovialvilli 449
palmar/plantar annular ligament. proliferativesynovitis158. 305 radial carpal bone 42, 57, 66, 69, 71,
transection371-4 proximalarticular surface53-4 80-1,92,95,98-9,106,108
palmar pouch intermediatecarpalbone 56 large fragment off dorso distal margin
fetlockjoint 135-6 proximal aspectof intermediatecarpal 125
metacarpophalangeal joint 136 bone83 slab fracture 123-4
radial osteochondroma 40
osteoarthritis325 caudalpouches264
removal of 385
osteochondritisdissecans(OCD)319 current status58-9
radial physeal exostoses,removal of 385-8
osteochondrosis 314-25
radiofrequency devices 23 femoropatellarjoint 223-46
placementof arthroscope322 limb suspendedfor 32
radiofrequency energy (RFE)44 postoperativemanagement322 medialfemorotibialjoint 246-64
radiography problemsand complications322
postoperative 36,119,125 post-surgicalfollow-upinformation97
radiographand positivecontrast
preoperative 36,119,125 postoperativemanagement97. 115
arthrogram 316 postoperativeprotocol 102
radius resultsof surgicalarthroscopy323-5
distal articular surface of 55, 57 preoperativeinformation60
septicjoint 325 preoperativeplanning III
distal epiphysis of 56
specificindicationsand techniquefor principle of 34-5
dorsodistal articular surface of 58
diagnosticarthroscopy312 problemsand complications59. 447-54
Richard Wolf Surgical Arthro Power
surgicalanatomy307 prognosis97
System 22
triangulation 317.322 relevantpathobiology60
Ringer's solution 442 seealsoscapulohumeraljoint
rongeurs 16-18, 20-1, 62, 321
removalof osteochondralchip
skinabscesses 452
seealso Ferris-Smith fragments58-99
skin incision 32.35.48.64.89.282 results97.115-22
suturing 35 shoulderjoint 314-25
5 skinportals.closure132 seealsospecificapplications
skinsutures.complicationrate 448
scalpel blade 32.35 surgicalassistants26-7
slabfracturesseecarpalslabfractures
Scanlan-Mcllwraith scissor-action suspensory ligament tags resection with
slottedcannula 376-7
rongeurs 20 synovial resector 179
smallfragments16-17 sustentaculumtali. debridement401
scapulohumeraljoint 307-26 Smith& NephewDyonicsArthroplasty
caudal aspect 309 suturesinuses452
System22 sutures35
cranial aspect 311 smoothedgedresectors22
exploration 314 synovectomy 39-40. 96
sodiumbenzylpenicillin435-6. 452 capsulardefectsand fibrosisfollowing
lateral aspect 310 softtissuemineralization453
medial aspect 312 40
spinalneedle282.307-8.314.317.322. carbondioxidelaser40
pannus deposits in 432 340
seealso shoulder joint effecton articular cartilagein equine
spongialization462 joints 40
sclerosis of third carpal bone 100
spooncurettes20 equinejoint tissues39
self-sealing cannula 20-1 spurs92-3
septic arthritis 306. 325 human hemophiliacpatients39
stemcelltransplantation464
diagnosis 37 mechanical40
sterilization10-11. 25-7 synovial449-51. 3649
elbow joint 332-4 stifle joints 2
septic osteomyelitis 306 synovialbursae3
StorzAIDA digitalimagecaptureand intrathecal endoscopy 409
septic physitis 325 storagedevice25
sesamoid bone 137-9. 367
Strykerarthroscopypump14 synovial diverticulum 218
basal fragment of 183
StrykerSDCPro 2 digital videoand still synovial effusion 280
fracture 172. 180
imagestorageand printing system25 synoviall1ap 133
fragmentation of 185 StrykerSystem22
shavers 22 synoviall1uid
subchondralbone42 bloody or brown 65-6
suction use on 23 disease100--4.152-3
sheath insertion 32-3 debris in 36
drilling 460 synovial fold 39
sheathed blades 19 subchondralcyst2.108-9.164-7.254-6.
sheathed knife system 20 synovial fossa 273-4
467-9 :0, synovial membrane 36-7, -
shoulderjoint
§libchondrallucency104 205, 220, 273-4
arthroscopic surgery 31~25 subchondralmicrofracture99
caudal aspect 313 biopsy 37
subfascialcellulitis452 dorsal pouch 158
damage to instruments 323 suction
diagnostic arthroscopy 307-14 applications21
difficulty in reaching potential lesions evaluation 36-9
use on shavers23 hemarthrosis of 40
323 sulcusmuscularis218
final position of arthroscope within proliferation 39.158
superficialdigital flexortendon (SDFT)
38. resection of 170
sheath 309
fluid extravasation 322 365-8.371-4.378-80.384.386. synovial pattern 37
388.413-14 synovial proliferation 37.
insertion of arthroscope 307-8
supraglenoidtubercle.fragmentation419
insertion of arthroscopic sheath and
suprapatellarpouch201 40
obturator 309
surgicalarthroscopy44 synovialresection96
lateral approach 309-12
advantagesof 58-9 synovialresectorunits 22
medial aspect 313 basictechniques35
normal arthroscopic anatomy 308-9 caseselection97 infection427-39
synovial villi 38. 49 intra-articular fractures299
morphologic features 36 osteochondritis dissecans(OCD)
280. 296
obstruction of view by 449-51 results291-4
synovitis plantarlateral or plantar medial
changes in 37 approaches278-9
evaluation 36-9 positioningof arthroscope270
experimentally induced 37 puncturewound in dorsolateralaspect
forms 37 428
post-operative 452 surgicalarthroscopy279-306 290-1
proliferation and thickening of synovial aftercare306
villi 38 tearsand avulsionsof collateral extremity254-6
ligaments305
tarsus.fracture of proximalplantar aspect tight spaces17
T of medialtrochlearridge 300-1 toothededgedresectors22
talocentraljoint temporomandibularjoint (TMJ)441-5 transillumination36
fragmentsdislodgedfrom medial arthroscopicapproach442-3
trochlearridgeand entered articular disk442
dorsomedialpouch304 bone scintigraphy441 traumatic joint disease37. 40
retrieval of fragments299 clinicalresults444-5 triamcinoloneacetonide253
talus diagnosisof inflammation444 triangulation 1
centralmedial trocWearridge 277 discotemporalcompartment441-2 elbowjoint 336
dewdroplesionsat distal aspectof medialpenetrationof joint capsule444 principle of 34-5
medial trocWearridge 292 overview441 shoulderjoint 317.322
distalmedial trocWearridge277 preoperativeconsiderations441-2 trochleargroove202-3.211
distaltrocWeargroove274 proximal compartment443
lateraltrochlearridge 272 ultrasoundimage442 U
lateral trochlearridgeand distaltibia ventral discomandibulararticulation
ulnar carpalbone52. 85
junction 271 441
medialtrocWearridge273-4, 276, 278 ulnar fracture.mid-shaft336
tendonlinear clefts374-6
and distaltibia and medialmalleolus ultrastructuralstudies45
tendonsheath
junction 275 problems3
osteochondritisdissecans(OCD) seealsoextensortendonsheath V
286-91 tenoscopy365-408 vacuumattachments21
osteomyelitisof dorsodistallateral carpalsheath379-93 vasculaturechanges37
trocWearridge434 diagnostic368-71 VCRs 24
sagittalfracture 303 digital flexortendonsheath365-79 videocameras10-11
subchondralcystic lesionof trochlear extensortendonsheath403-7 video documentation10. 23-4
groove294-5,297 massremoval/adhesiontransection videorecorders10
wearlines on medialtrochlearridge295 371 lightweight single-chipor three-chip10
tarsal sheath resultsand prognosis393 videoarthroscopes 8. 11
centromedialapproach398 tarsal sheath3.393-402 videotape9. 24
cross-sectionalspecimen396-7 techniques368-76. 380-91. 397-401 villi
diagnostictenoscopy397-8 tenosynovialmasses398-400. 403 metaplasia36
distal aspect401 and adhesions371 necrosis33
distal region400, 404 tenosynovitis petechiation37.429
inflammation402 acute 365 1'$ proliferativesynovial449
medialaspect395 chronic 365 synovial36. 38.49.449-51
nomenclature393 complex365 visualization47
postoperativecare 401-2 thermal chondroplasty44 villonodular synovitis152-8
proximal region396. 399 third carpalbone43.78-80.97.102 villous regeneration40
surgicalanatomy395-7 bone density104 villous synovialmembrane210. 219
sustentaculumlevel396 lag screwfixation of slabfractures viruses26
tenoscopy393-402 110-15
resultsand prognosisof tenoscopy sagittalfracture 121-2 W
402 sclerosisof 100
tenosynovitis402 slabfracture 109-10.112.114-16. wearlines 42, 44
wound healingcomplications401 wounds
118-20.124
tarsal tunnel 395 third metacarpalbone healingcomplications401
tarsal tunnel syndrome393 debridementof subchondralcystic management434-5
tarsocruraljoint 269-306 lesions164-7 postoperativecare436-7
diagnosticarthroscopy269-79 subchondralcystin medialcondyle468
dorsomedialapproach269-79 tibia 218 X
insertion of arthroscopicsleeve270 distalintermediateridge273 xenonlight sources9-10