Diagnostic and Surgical Arthroscopy in the Horse - 4th Edition

8/10/2019 Diagnostic and Surgical Arthroscopy in the Horse - 4th Edition

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DIAGNOSTIC ANDSURGICAL

ARTHROSCOPY IN THEHORSE


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DIAGNOSTIC AND SURGICALARTHROSCOPY IN THE HORSE

FOURTH EDITION

C. Wayne McIlwraith, BVSc, PhD, DSc, Dr med vet (h.c. Vienna),

DSc (h.c. Massey), Laurea Dr (h.c. Turin), D vet med (h.c. London), FRCVS,Diplomate ACVS, ECVS & ACVSMR

University Distinguished Professor

Barbara Cox Anthony University Chair in Orthopaedics

Director, Orthopaedic Research Center

Colorado State University

Fort Collins, Colorado

Alan J. Nixon, BVSc, MS, Diplomate ACVS

Professor of Large Animal Surgery

Director, Comparative Orthopaedics Laboratory

College of Veterinary Medicine

Cornell University

Ithaca, New York

Chief Medical Officer, Cornell Ruffian Equine Specialists

Elmont, New York

Ian M. Wright, MA, VetMB, DEO, Diplomate ECVS, MRCVS

Senior Surgeon and Director of Clinical Services

Newmarket Equine Hospital

Newmarket, Suffolk, UK


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DIAGNOSTIC AND SURGICAL ARTHROSCOPY IN THE HORSE ISBN: 978-0-7234-3693-5Copyright 2015, 2005, 1984 by Mosby, an imprint of Elsevier Limited.Copyright 1990 by Lea & Febiger.

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This book and the individual contributions contained in it are protected under copyright by the Publisher(other than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and experiencebroaden our understanding, changes in research methods, professional practices, or medical treatmentmay become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in evaluat-ing and using any information, methods, compounds, or experiments described herein. In using suchinformation or methods they should be mindful of their own safety and the safety of others, includingparties for whom they have a professional responsibility.

With respect to any drug of pharmaceutical products identified, readers are advised to check themost current information provided (i) on procedures featured or (ii) by the manufacturer of eachproduct to be administered, to verify the recommended dose or formula, the method and duration ofadministration, and contraindications. It is the responsibility of the practitioner, relying on his or herown experience and knowledge of the patient, to make diagnoses, to determine dosages and the besttreatment for each individual patient, and to take all appropriate safety precautions.

To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors,assume any liability for any injury and/or damage to persons or property as a matter of productsliability, negligence or otherwise, or from any use or operation of any methods, products, instructions,or ideas contained in the material herein.

Library of Congress Cataloging-in-Publication Data

McIlwraith, C. Wayne, author. Diagnostic and surgical arthroscopy in the horse / C. Wayne McIlwraith,Alan J. Nixon, Ian M. Wright. -- Fourth edition. p. ; cm. Preceded by Diagnostic and surgical arthroscopy in the horse / C. WayneMcIlwraith ... [et al.] ; illustrations, Tom McCracken. 3rd ed. 2005. Includes bibliographical references and index. ISBN 978-0-7234-3693-5 (hardcover : alk. paper) I. Nixon, Alan J., author. II. Wright, Ian M., author. III. Title. [DNLM: 1. Horse Diseases--diagnosis. 2. Joint Diseases--veterinary. 3. Arthroscopy--veterinary.4. Horses--surgery. 5. Joints--surgery. SF 959.J64] SF959.J64 636.10897472059--dc23 2014001016

Vice President and Publisher:Linda DuncanContent Strategy Director:Penny Rudolph

Associate Content Development Specialist:Katie StarkePublishing Services Manager:Jeffrey Patterson

Project Manager:William DroneDesigner:Jessica Williams

Printed in China

Last digit is the print number: 9 8 7 6 5 4 3 2 1
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Preface to Fourth Edition

I

t has been another nine years since the third edition of this text was published and it is now out of print.In that time, there has been continued evolution and development of specific arthroscopic surgery tech-niques, which are now included. While the more simple procedures have remained unchanged, many

of these techniques have been better documented with improved levels of evidence. The latter is critical ifequine veterinarians are to provide current recommendations to clients; while updating the technical aspectsof arthroscopic surgery is important for surgeons, surgical residents and others in training.

In this edition, extensive descriptions of procedures, as well as updating of literature with studies sup-porting their value, have been made. There has been a considerable updating of the illustrations, and for thefirst time, we have added videos of the important procedures. We have also added a new chapter on postop-erative management, adjunctive therapies, and rehabilitation procedures because of increased and improvedinformation on options in these areas. Because we teach advanced arthroscopic surgery courses together inour three locations of work, there has been extensive exchange of information that hopefully provides abalanced consensus.

PREFACE


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Preface to Third Edition

I

t has been 13 years since the second edition of this text was published, and it has long been out of print.In that time, arthroscopy has achieved further widespread use, and there have been many developments.The lapse of 13 years has not been due to any lack of interest on the part of clinicians interested in or

actually doing arthroscopic surgery in the horse. Rather it has been an issue of publisher mergers and theeconomic realities of veterinary texts. The request from Elsevier Limited for me to consider having the thirdedition with them was gratefully received and accepted. In the third edition, we have attempted to provideinformation needed by all equine veterinarians giving recommendations to their clients, while at the sametime preserving the technical teaching required of surgeons practicing arthroscopy, as well as surgical resi-dents and others in training. There has been considerable progress in arthroscopic surgery in the horse sincethe publication of the second edition. I have been fortunate to be able to add as authors three individualswho have made significant contributions to the advancement of arthroscopic surgery: namely, Alan Nixon,Ian Wright, and Josef Boening. The format of the book is to retain the core chapters that were in the secondedition, with considerable updating of all these chapters to include new information, both from the authorspersonal experiences, other colleagues advice and experience, and that available in the literature. We havethen added separate chapters on diagnostic and surgical arthroscopy of the elbow joint, coxofemoral (hip)joint, proximal and distal interphalangeal joints, tenoscopic surgery, bursoscopy, arthroscopic managementof synovial sepsis, arthroscopy of the temporomandibular joint, as well as separate chapters on problemsand complications of diagnostic and surgical arthroscopy and arthroscopic methods for cartilage resurfacing.

I am particularly grateful to Drs. Nixon and Wright for their extensive contributions to the new chaptersand their review and additions to the revised chapters from the second edition, and to Dr. Boening forcontributions to the interphalangeal and temporomandibular joint chapters. As in previous editions, thepresentation of these techniques is augmented greatly by the excellent artwork of Tom McCracken. I amalso indebted to staff at the Gail Holmes Equine Orthopaedic Research Center and Veterinary TeachingHospital, Colorado State University, as well as Equine Medical Center, California for patience and help inacquisition of case material, and Geri Baker for her typing. The book would not have been possible withoutthe initial efforts of Jonathon Gregory, Commissioning Editor, Elsevier Limited and the follow-up work byZo Youd and Joyce Rodenhuis of Elsevier.

PREFACE


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ACKNOWLEDGMENTS

We each have individual acknowledgments to make.C. Wayne McIlwraith is indebted to the staff at the Gail Holmes Equine Orthopaedic Research Center

and Veterinary Teaching Hospital at Colorado State University, to the Equine Medical Center, California for

patients and help in acquisition of case material, and to Lynsey Bosch for typing.Alan Nixon would like to thank the Cornell University surgical operating room staff and radiology techni-cians, at both the Ithaca campus and the Cornell Ruffian Equine Specialists practice in New York City, and toacknowledge Amy Ingham for administrative assistance and manuscript preparation. Additionally, he wouldlike to extend his sincere gratitude to the many surgical residents that provided diligent assistance in surgeryand postoperative care, and to his surgical colleagues in consulting practices for their expert assistance.

Ian Wright would like to thank past and present members of the staff at Newmarket Equine Hospital,whose diagnostic excellence and dedicated clinical care permitted progression of the discipline and conse-quent improvements in patients prognoses. In this respect, particular mention is due to Gaynor Minshall,Matt Smith, and both past and present interns. I am also indebted to Louise Harbidge and Lucy Coleman,who typed numerous drafts and coordinated communication while juggling management of the hospitaloffice.

The book would not have been possible without the initial efforts of Penny Rudolph with Elsevier andKatie Starke with Elsevier, who took over before submission of manuscript and has been a great help in car-rying this project to fruition.

C. Wayne McIlwraith, Fort Collins, Colorado

Alan J. Nixon, Ithaca, New York

Ian M. Wright, Newmarket, UK


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1 Introduction,1

Arthroscopic Surgery in the HorseAdvancesSince 2005, 1

2 Instrumentation,5

Arthroscopes, 5

3 General Technique and DiagnosticArthroscopy,28

General Technique for Arthroscopy, 28Diagnostic Arthroscopy, 31Use of Electrosurgery, Radiofrequency, and

Lasers, 40Arthroscopic Lavage and Debridement, 41Learning Arthroscopic Technique, 41Analgesia for Arthroscopic Surgery, 41

4 Diagnostic and Surgical Arthroscopyof the Carpal Joints,45

Diagnostic Arthroscopy of the Carpal Joints, 45Arthroscopic Surgery for Removal of

Osteochondral Chip Fragments, 53Arthroscopic Surgery for Osteochondral Fragments

in the Palmar Aspect of the Carpal Joints, 80Arthroscopic Surgery for Subchondral Bone

Disease, 86

Arthroscopic Surgery for OsteochondritisDissecans, 92

Arthroscopic Surgery for Subchondral CysticLesions, 92

Arthroscopic Surgery for Treatment of Carpal SlabFractures, 93

Arthroscopic Surgery for Treatment of OtherCarpal Slab Fractures, 107

Arthroscopic Surgery for Treatment of ComplexCarpal Slab Fractures, 107

Arthroscopic Surgery for the Repair (with ScrewFixation) of Carpal Chip Fractures, 108

5 Diagnostic and Surgical Arthroscopyof the Metacarpophalangeal andMetatarsophalangeal Joints,111

Diagnostic Arthroscopy of the Fetlock Joints, 111Arthroscopic Surgery of the Fetlock Joints, 116

6 Diagnostic and Surgical Arthroscopy

of the Femoropatellar and FemorotibialJoints,175

Diagnostic Arthroscopy of the FemoropatellarJoint, 175

Diagnostic Arthroscopy of the FemorotibialJoints, 178

Arthroscopic Surgery of the FemoropatellarJoint, 186

Arthroscopic Surgery of the Medial FemorotibialJoint, 209

7 Diagnostic and Surgical Arthroscopy ofthe Tarsocrural (Tibiotarsal) Joint,243

Diagnostic Arthroscopy of the TarsocruralJoint, 243

Arthroscopic Surgery of the Tarsocrural(Tibiotarsal) Joint, 246

8 Diagnostic and Surgical Arthroscopyof the Scapulohumeral (Shoulder)Joint,273

Surgical Anatomy of the Shoulder, 273Diagnostic Arthroscopy of the Shoulder Joint, 273Arthroscopic Surgery for Other Clinical Entities in

the Shoulder, 287

9 Diagnostic and Surgical Arthroscopyof the Cubital (Elbow) Joint,292

Introduction, 292Anatomy, 292Arthroscopic Approaches to the Elbow Joint, 292Arthroscopic Surgery of the Elbow Joint, 296Complications, 300

10 Diagnostic and Surgical Arthroscopyof the Coxofemoral (Hip) Joint,308

Preoperative Assessment, 308Diagnostic Arthroscopy of the Hip Joint, 308Arthroscopic Surgery of the Hip, 312Results and Prognosis, 314

CONTENTS


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Contentsx

11 Arthroscopic Surgery of the Distal andProximal Interphalangeal Joints,316

Arthroscopy of the Distal InterphalangealJoint, 316

Arthroscopy of the Proximal InterphalangealJoint, 332

12

Tenoscopy,344Digital Flexor Tendon Sheath, 344Tenoscopy of the Carpal Sheath, 359Tenoscopy of the Tarsal Sheath, 373Tenoscopy of the Carpal Extensor Tendon

Sheaths, 382Tenoscopy of the Tarsal Extensor Sheaths, 383

13 Bursoscopy, 387

Calcaneal Bursa, 387Intertubercular (Bicipital) Bursa, 393Podotrochlear (Navicular) Bursa, 396Lesions of the Deep Digital Flexor Tendon, 403Lesions of the Palmar Fibrocartilage and

Subchondral Bone, 404Penetrating Injuries of the Navicular Bursa, 404Acquired Bursae, 406

14 Endoscopic Surgery in theManagement of Contamination andInfection of Joints, Tendon Sheaths,and Bursae,407

Techniques, 408Postoperative Care, 415Postoperative Monitoring, 416

Results and Prognosis, 416

15 Problems and Complications ofDiagnostic and Surgical Arthroscopy,419

Preoperative Problems and Planning, 419Intraoperative Problems, 419Postoperative Complications, 422Conclusion, 424

16

Arthroscopic Methods for CartilageRepair,426

Cartilage Response to Injury, 426Repair Methods, 426

17 Postoperative Management, AdjunctiveTherapies, and RehabilitationProcedures,443

Immediate Postoperative Management, 443Longer-Term Postoperative Management, 443

Index,448


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1

CHAPTER 1

Introduction

ARTHROSCOPIC SURGERY IN THE

HORSEADVANCES SINCE 2005

Since 2005 magnetic resonance imaging (MRI) has becomean important diagnostic technique in equine orthopedics.More specific diagnosis of conditions of soft tissues has ledto further indications for diagnostic and surgical arthroscopy.There are limitations, however, and it has been demonstratedrecently that the use of MRI for precise grading of the artic-ular cartilage in human osteoarthritis (OA) is limited andthat diagnostic arthroscopy remains the gold standard forgrading cartilage damage, for a definitive diagnosis, and fordecisions regarding therapeutic options in patients with OA(von Engelhardt et al, 2012).

Numerous publications have documented the use ofelectrosurgery, radiofrequency, and lasers within equinearthroscopic surgery. Clinical use of electrosurgery in the

metacarpophalangeal and metatarsophalangeal joints forremoval of fragments from the plantar margin of the proxi-mal phalanx and proximal sesamoid bones (Bour et al, 1999;Simon et al, 2004) desmotomy of the accessory ligament ofthe superficial digital flexor tendon (David et al, 2011) havebeen described. Thermal chondroplasty with radiofrequencyenergy (RFE) has been used frequently in humans and pro-duces attractive visual effects, but multiple studies now sug-gest detrimental effects of RFE on articular cartilage (Cooket al, 2004; Lu et al, 2000, 2002) and in another study RFEwas shown to exceed the damage obtained with mechanicaldebridement (Edwards et al, 2008). The use of radiofrequencyprobes for section and resection of soft tissues within joints,tendon sheaths, and bursae have also been described and mayhave a place in selected equine procedures (David et al, 2011;

McCoy and Goodrich, 2011).The use of intraarticular local analgesic agents to reduce

the requirement for systemic anesthetic or analgesic agents, orboth, has emerged. Evidence to support preoperative intraar-ticular administration of a combination of opiate and localanesthetic techniques have been provided in man (Hube et al,2009), but opinions vary (Kalso et al, 2002; Rosseland, 2005).Toxicity of bupivacaine to bovine articular chondrocytes hasbeen demonstrated (Chu et al, 2006), and in a second studybupivacaine, lidocaine or robivacaine were shown to have det-rimental effects on chondrocyte viability in a dose- and dura-tion-dependent manner (Lo et al, 2009). Using preoperativeepidural morphine and detomidine has been reported to bene-fit horses undergoing experimental bilateral stifle arthroscopy(Goodrich et al, 2002).

In the carpus, arthroscopic approaches to the palmar aspectof the equine carpus have been detailed (Cheetham andNixon, 2006), and comparison of magnetic resonance contrastarthrography and the arthroscopic anatomy of the equine pal-mar lateral outpouching of the middle carpal joint has alsobeen described (Getman et al, 2007). Arthroscopically guidedinternal fixation of chip fractures of the carpal bones, whichare of sufficient size and infrastructure, has been reported byWright and Smith (2011). This technique can decrease mor-bidity associated with leaving large articular defects followingremoval.

New information in the metacarpophalangeal and metatar-sophalangeal joints has included quantification of the amountof the articular surfaces of the metacarpal and metatarsal

condyles that could be visualized with distal dorsal and distalpalmar/plantar portals (Vanderperren et al, 2009). Declercqet al (2009) reported on fragmentation of the dorsal marginof the proximal phalanx in young Warmblood horses in whichthe majority underwent surgery for prophylactic reasons or toremove radiologic blemishes, or both. Osteochondral fragmentswithin the dorsal plica have also been reported in Warmbloodhorses (Declercq et al, 2008). Impact fractures of the proximalphalanx in a filly have been described by Cullimore et al (2009)and the authors of this text have also seen similar lesions in thedistal metacarpus.

In the palmar fetlock Byron and Goetz (2007) reporteduse of a 70-degree arthroscope to debride a subchondral bonedefect in the distal palmar medial condyle of a third meta-carpal bone; successful access to such lesions is generally lim-ited. Schnabel et al (2006 and 2007) reported the results of

arthroscopic removal of apical sesamoid fracture fragmentsin Thoroughbred racehorses with a higher success rate inhorses that had raced previously. These authors also showedthat removal when younger than 2 years of age gave com-parable racing success to maternal siblings (Schnabel et al,2007). Kamm et al (2011)evaluated the influence of size andgeometry of apical sesamoid fragments following arthroscopicremoval in Thoroughbreds and found no relationship to rac-ing performance. Because 30% of the branches of insertion ofthe suspensory ligaments are subsynovial in the metacarpo-phalangeal/metatarsophalangeal joints, tears involving theirdorsal surfaces can result in articular deficits and extrusion ofdisrupted ligament fibers into the synovial cavity; it has nowbeen documented that such cases can be successfully treatedwith arthroscopic debridement (Minshall and Wright, 2006).

Further information has been recently published on frac-tures of the metacarpal and metatarsal condyles (Wright andNixon, 2013; Jacklin and Wright, 2013) emphasizing theimportance of articular congruency to outcome. Arthroscopi-cally guided repair of midbody proximal sesamoid bone frac-tures was described, and results were reported by Busscherset al (2008), representing a substantial advance in the manage-ment of uniaxial fractures.

Recent developments in stifle arthroscopy have includedpublication of new and modified techniques, correlation ofimaging modalities, and attempts to refine prognostic guide-lines. In the femoropatellar joint, an arthroscopic approach hasbeen described for the equine suprapatellar pouch (Vinardellet al, 2008). The use of a 10-mm diameter laproscopic cannulain the suprapatellar pouch for easier removal of debris and

loose fragments has also been reported (McNally et al, 2011).Ultrasound has been noted to be a useful adjunct with femo-ropatellar osteochondritis dissecans (OCD) when there is highclinical suspicion but equivocal radiographic findings (Bourzacet al, 2009). A new concept of augmented healing of OCDdefects has been introduced by Sparks et al (2011b), whoused polydioxanone pins to reattach separated osteochon-dral flaps. In the femorotibial joints, arthroscopic approachesinto the caudal medial and lateral compartments have beendescribed byWatts and Nixon (2006)and a detailed compar-ison between ultrasonographic and arthroscopic boundariesof the normal equine femorotibial joints has been reportedby Barrett et al (2012). The potential for false-positive ultra-sonographic diagnoses of meniscal tears was highlighted by


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DIAGNOSTIC AND SURGICAL ARTHROSCOPY IN THE HORSE2

Cohen et al (2009). Alternative techniques for treatment ofsubchondral cystic lesions (SCLs) of the medial femoral con-dyle (MFC) have been described since 2005, including injec-tion of triamcinolone acetonide into the fibrous tissue of SCLsunder arthroscopic guidance (Wallis et al, 2008) and chondro-cytes or mesenchymal stem cells in fibrin glue implantation(Ortved et al, 2012). The classification of osteochondrallesions of the MFC initially reported byWalmsley et al (2003)using the Outerbridge human grading system has been devel-

oped further by Cohen et al (2009). A recent study of softtissue injuries of the femorotibial joint treated with intraar-ticular autologous bone marrowderived mesenchymal stemcells showed that a high percentage of horses were able to goback to work after meniscal injury (Ferris et al, 2013). Lastly,clinical symptoms, treatment, and outcome of meniscal cystsin horses were described for the first time recently (Sparkset al, 2011a).

In the tarsus four cases of SCL of the lateral trochlear ridgeof the talus were treated successfully with intralesional injec-tion of triamcinolone acetonide, simulating the protocol ofWallis et al (2008)on the MFC (Montgomery and Juzwiak,2009). A severe SCL on the proximal medial trochlear ridgeof the talus was treated with osteochondral mosaicplasty inone report (Janicek et al, 2010). Since 2005 there have beentwo descriptions of arthroscopic treatment of fractures of the

lateral malleolus of the tibia (ONeill and Bladon, 2010; Smithand Wright, 2011). Pure soft tissue lesions, including tears ofthe joint capsule and avulsions of the collateral ligaments ofthe tarsocrural joint, have been recently described (Barkeret al, 2013).

Considerable advances have been made in tenoscopicsurgery. In the digital flexor tendon sheath there have beenfurther publications of tenoscopic identification and treat-ment of longitudinal tears of the digital flexor tendons andmanica flexoria by Smith and Wright (2006)and Arensberget al (2011). Although coblation has been reported as a tech-nique for debridement and smoothing of the fibrillated edgesof defects, it was found to have a negative impact on out-come (Arensberg et al, 2011). Primary desmitis of the pal-mar/plantar annular ligament has been more clearly defined

(McGhee et al, 2005; Owen et al, 2008), and McCoy andGoodrich (2011) have described the use of a radiofrequencyprobe for tenoscopically guided desmotomy using the sameapproach as the free-handed hook knife technique.

In the carpal sheath a recent paper by Wright andMinshall (2012a) provided further morphologic informa-tion and results of treatment of osteochondromas. Teno-scopic evaluation of horses with tenosynovitis of the carpalsheath has also led to new diagnoses, including tearing ofthe radial head of the deep digital flexor tendon (DDFT)(Minshall and Wright, 2012b). This information, in turn, haspermitted development of confident ultrasonographic diag-nosis. Caldwell and Waguespack (2011) reported a teno-scopic approach for desmotomy of the accessory ligament ofthe DDFT in horses, illustrating use of synovial cavities for

minimally invasive approaches to perithecal structures. Des-motomy of the accessory ligament of the superficial digitalflexor tendon (proximal check ligament) using a monopo-lar electrosurgical technique has also been reported (Davidet al, 2011). Synoviocoeles associated with the tarsal sheathhave been described by Minshall and Wright (2012a).

Finally, there have been developments with bursoscopyas well.Wright and Minshall (2012b) described intrathecaltearing of the tendinous portions of the calcaneal insertionsof the SDF and disruption of its fibrocartilagenous cap, asso-ciated with lameness and tendon instability, respectively.Endoscopic surgery in the bicipital bursa was used to treatcomplete rupture of the lateral lobe of the biceps brachitendon in one horse (Spadari et al, 2009) and to treat an

SCL involving the bursal margins of the humerus in another(Arnold et al, 2008).

Details of a transthecal approach to the navicular bursa(reported briefly in the third edition) have been provided bySmith et al (2007)and Smith and Wright (2012). This is nowconsidered the standard approach for the evaluation of treat-ment of aseptic bursae, particularly when tearing of the dorsalsurface of the DDFT has been identified by MRI or as a clini-cal differential. Haupt and Caron (2010)compared direct and

transthecal approaches to the navicular bursa.Specific advantages of arthroscopy as a diagnostic andsurgical tool are mentioned throughout this book. Generaladvantages of the technique previously recognized include thefollowing:1. An individual synovial cavity can be examined through a

small (stab) incision and with greater accuracy than waspreviously possible. With the availability of such an atrau-matic technique, numerous lesions and new conditionsthat have not previously been identified by noninvasiveimaging modalities can be recognized.

2. All types of surgical manipulations can be performedunder arthroscopic guidance. The use of this form ofsurgery is less traumatic and less painful, and it providesimmense cosmetic and functional advantages. Surgeryis now possible in situations where previously the risks

(morbidity)-benefits comparison would have precludedintervention. The decreased convalescence time with ear-lier return to work and improved performance is a sig-nificant advance in the management of equine joint andother synovial problems. The need for palliative therapiesis decreased, as is the number of permanently compro-mised joints.The initial optimism and advantages of arthroscopy sug-

gested in the first three editions of this book have been sub-stantiated. Arthroscopy has revolutionized equine orthopedicsand continues to push forward pathobiological understanding,diagnostic accuracy and lesion-specific treatment. Problemshave and will continue to be encountered, but now we knowthat many are avoidable. Although the technique appearsuncomplicated and attractive to the inexperienced surgeon,

some natural dexterity, good three-dimensional anatomicknowledge, and considerable practice are required for thetechnique to be performed well. Experience and good caseselection are of paramount importance, and reiterating a pas-sage from the first edition of this book remains as pertinenttoday:

In 1975, arthroscopy was underused and needless arthrotomieswere performed. The pendulum is now swinging rapidly in theother direction. The current tendency in arthroscopy is towardoveruse. Some surgeons seem to be unable to distinguish between

patients who are good candidates for arthroscopy and those whoare not, and the trend is toward arthroscopy in patients in whomlittle likelihood exists of finding any treatable disorder.

(Casscells 1984).

Three years later, another author stated:of those 9000 North American surgeons and the other surgeonsof the world performing arthroscopy, many are ill-prepared and aretherefore, not treating their patients fairly. Overuse and abuse by a

few is hurting the many surgeons who are contributing to orthope-dic surgery by lowering patients morbidity, decreasing the cost ofhealth care, shortening the necessary time of patients returning to

gainful employment, and adding to the development of a skill thathas made a profound change in the surgical care of the musculo-

skeletal system.(McGinty 1987).

Arthroscopy remains the most sensitive and specific diagnos-tic modality for intrasynovial evaluation in the horse. This is


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Introduction 3

somewhat in contrast to human orthopedics, where arthros-copy is predominately used for surgical interference and muchof its diagnostic function has or is being replaced by MRI andcomputed tomography. Arthroscopy continues to be of greatbenefit in the horse, with increased recognition of soft tis-sue lesions in joints, tendons, sheaths, and bursae. However,as stated earlier, although there are many benefits, it is, andwill remain, technically demanding with a continued need fortraining at multiple levels.

REFERENCES

Arensberg L, Wilderjans H, Simon O, Dewulf J, Boussauw B: Non-septic tenosynovitis of the digital flexor tendon sheath caused bylongitudinal tears in the digital flexor tendons: a retrospective studyof 135 tenoscopic procedures, Equine Vet J43:660668, 2011.

Arnold CE, Chaffin MK, Honnas CM, Walker MA, Heite WK: Diag-nosis and surgical management of a subchondral bone cyst within the intermediate tubercle of the humerus in a horse, Equine VetEduc20:310315, 2008.

Barker WJH, Smith MRW, Minshall GJ, Wright IM: Soft tissue inju-ries of the tarsocrural joint: a retrospective analysis of 30 cases eval-uated arthroscopically, Equine Vet J45:435441, 2013.

Barrett MF, Frisbie DD, McIlwraith CW, Werpy NM: The arthroscopicand ultrasonographic boundaries of the equine femorotibial joints,Equine Vet J44:5763, 2012.

Bour L, Marcoux M, Laverty S, et al.: Use of electrocautery probes in arthroscopic removal of apical sesamoid fracture fragments in 18Standardbred horses, Vet Surg28:226232, 1999.

Bourzac C, Alexander K, Rossier Y, Laverty S: Comparison of radiog-raphy and ultrasonography for the diagnosis of osteochondritis dis-secans in the equine femoropatellar joint, Equine Vet J41:686692,2009.

Busschers E, Richardson DW, Hogan PM, et al.: Surgical repair ofmid-body proximal sesamoid bone fractures in 25 horses, Vet Surg37:771780, 2008.

Byron CR, Goetz TE: Arthroscopic debridement of a palmar thirdmetacarpal condyle subchondral bone injury in Standardbred,Equine Vet Educ19:344347, 2007.

Caldwell FJ, Waguespack RW: Evaluation of a tenoscopic approachfor desmotomy of the accessory ligament of the deep digital flexortendon in horses, Vet Surg40:266271, 2011.

Casscells SW:Arthroscopy: diagnostic and surgical practice, Philadelphia,1984, Lea & Febiger.

Cheetham J, Nixon AJ: Arthroscopic approaches to the palmar aspectof the equine carpus, Vet Surg35:227231, 2006.

Chu CR, Izzo NJ, Papas NE, et al.: In vitro exposure to 0.5% bupi-vacaine is cytotoxic to bovine articular chondrocytes, Arthroscopy22:693699, 2006.

Cohen JM, Richardson DW, McKnight AL, Ross MW, BostonRC: Long-term outcome in 44 horses with stifle lameness afterarthroscopic exploration and debridement, Vet Surg38:543551,2009.

Cook JL, Marberry KM, Kuroki K, et al.: Assessment of cellular,biomechanical, and histological effects of bipolar radiofrequencytreatment of canine articular cartilage, Am J Vet Rec65:604609,2004.

Cullimore AM, Finnie JW, Marmion WJ, Booth TM: Severe lamenessassociated with an impact fracture of the proximal phalanx in a filly,Equine Vet Educ21:247251, 2009.

David F, Laverty S, Marcoux M, Szoke M, Celeste C: Electrosurgicaltenoscopic desmotomy of the accessory ligament of the superficialdigital flexor muscle (proximal check ligament) in horses, Vet Surg40:4653, 2011.

Declercq J, Martens A, Bogaert L, et al.: Osteochondral fragmentationin the synovial pad of the fetlock in Warmblood horses, Vet Surg37:613618, 2008.

Declercq J, Martens A, Maes D, et al.: Dorsoproximal phalanx osteo-chondral fragmentation in 117 Warmblood horses, Vet CompOrthop Traumatol22:16, 2009.

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5

CHAPTER 2

Instrumentation

Alarge selection of instrumentation is available for human

arthroscopic surgery, but much of it is unsuitable andunnecessary for routine equine arthroscopy. Many ofthe operating instruments are expensive, fragile, and manu-factured for a specific task in a specific joint. For equine use alimited amount of equipment is generally essential and appro-priate. From a practical standpoint, numerous versions of handinstruments that perform similar tasks add to the clutter onthe surgery table and to the expense of cleaning and resteril-izing. The descriptions and recommendations in this text arebased on the authors experiences and personal choices, andnumerous substitutions can be made. Obviously, the poten-tial for variation is extreme, and it is necessary to continueto evaluate new instrumentation as it becomes available or asnew arthroscopic procedures are developed. This chapter rep-resents the authors current views on instrumentation.

ARTHROSCOPESThe available arthroscopes vary in outer diameter, workinglength, and in lens angle, which may be straight (0 degrees)or angled from 5 to 110 degrees. Many manufacturers mar-ket 4-mm diameter arthroscopes with 0-, 30-, or 70-degreelens angles and working lengths of 160 to 175 mm. The fieldof view is often 115 degrees or more, leading to their classi-fication as wide-field-of-view arthroscopes. Most manufac-turers produce small arthroscopes, usually 2.7-mm diameterarthroscopes with 30- or 70-degree lens angles; a short 2.7-mmdiameter arthroscope with 30- or 70-degree lens angles;and a 1.9-mm diameter arthroscope with a 30-degree lensangle. Generally, surgeons should choose the largest-diameterarthroscope that can safely be inserted and maneuvered with-out causing damage. Small-diameter arthroscopes with appro-

priate operating instrumentation have been developed for usein human carpal, metatarsophalangeal, and temporomandib-ular joints (Poehling, 1988). However, these are fragile, allowless illumination, and provide a much smaller field of view(90 degrees for a 2.7-mm scope and 75 degrees for a 1.9-mmscope). Small-diameter arthroscopes usually also have ashorter working length (50 to 60 mm) because the excessiveflexibility of a longer instrument increases the risk of breakage(Poehling, 1988). More recently, a complete range of sizes hasalso become available in video arthroscopes, which are cou-pled directly to the video camera. This obviates the need for acoupler and eliminates the potential for fogging between thearthroscope eyepiece and camera (Jackson & Ovadia, 1985).Flexible arthroscopes have also had a period of limited usebut generally failed to provide true flexibility and optical clar-

ity (Takahashi & Yamamoto, 1997). Combined approaches,using a rigid arthroscope for most of the procedure and aflexible arthroscope to access difficult areas of the hip, ankle,or knee in people, have added to the more thorough evalu-ation of these joints (Takahashi & Yamamoto, 1997). Simi-larly, a small-diameter flexible arthroscope inserted throughan 18-gauge needle (see Chapter 7) has been successfullyused in standing stifle diagnostic arthroscopy for several years(Frisbie et al, 2013).

A 4-mm diameter arthroscope with a 25- or 30-degreelens angle fulfills most needs of the equine surgeon(Fig. 2-1). A 4-mm, 70-degree arthroscope can occasionallyprovide improved visualization of specific areas of some jointssuch as the tarsocrural, shoulder, and palmar/plantar aspect

of the metacarpo/tarsophalangeal joints. However, none of

the authors now use a 70-degree arthroscope routinely andbelieve additional portals generally replace the need for a70-degree scope. Figure 2-2 illustrates the different fields ofview of a 25-degree arthroscope and a 70-degree arthroscopein the same position in a tarsocrural joint. Popular choices inan arthroscope for routine equine arthroscopy include the30-degree videoarthroscope and direct-view arthroscopesfrom Smith & NephewDyonicsa (Fig. 2-3), the 30-degreeHopkins II rod lens telescope made by Karl Storz,b andthe 30-degree direct view and videoarthroscopes made byStryker.c Comparable-sized arthroscopes are also availablefrom Linvatec,d Richard Wolf,e Zimmer,f Olympusg (True-View II), Arthrex,hand other companies. The advantages ofthe 25- to 30-degree angled lens are that (1) it provides anincreased field of vision; (2) rotating the arthroscope increasesthe visual field without moving the arthroscope; and (3) the

end of the arthroscope can be placed at some distance fromthe lesions, allowing easier access to the area with instrumentsand minimizing the risk of damaging the arthroscope.

All arthroscopes are used within a protective stainlesssteel cannula, which is also commonly referred to as a sleeveor sheath(Fig. 2-4). For a 4-mm arthroscope the cannula hasa 5- or 6-mm diameter and is connected to the arthroscopethrough a self-locking system that varies among manufactur-ers. The cannula has one or two stopcocks for ingress or egressfluid systems, or both. The second stopcock is useful if thesurgeon uses gas and fluid distention interchangeably duringarthroscopy; otherwise, a cannula with one stopcock offersgreater freedom of movement. A rotating stopcock is criticalto allow the ingress fluid line to be positioned away from thelimb or instruments, or both, as required. The space between

the cannula and arthroscope allows flow of ingress fluid. Somecannulas have a wider diameter (5.8 to 6.0 mm comparedwith 4.5 to 5.0 mm) and have several holes adjacent to theopen end. These so-called high-flow sheaths are useful insome large-joint applications in the horse.

A conical obturator is used for insertion of the cannulain almost all situations. In joints with a thick fibrous capsulethis necessitates puncture of the joint using a stab incisionwith a No. 11 or 15 scalpel blade. In joints with a thin fibrouscapsule, the conical obturator can be used to penetrate thecapsule. Separate sharp trocars for insertion and blunt obtu-rators for intrasynovial positioning before placement of the

aSmith & NephewDyonics, 150 Minuteman Road, Andover, MA

01810. Tel: (978) 749-1000. www.smith-nephew.combKarl Storz Veterinary Endoscopy, 175 Cremona Drive, Goleta, CA

93117. Tel: (800) 955-7832. www.ksvea.comcStryker, 5900 Optical Court, San Jose, CA 95138. Tel: (800) 624-4422.

www.stryker.com/en-us/dLinvatec-Conmed Co, 11355 Concept Blvd., Largo, FL 33773. Tel:

(800) 237-0169. www.conmed.comeRichard Wolf, 353 Corporate Woods Parkway, Vernon Hills, IL 60061.

Tel: (800) 323-1488. www.richardwolfusa.comfZimmer, PO Box 708, 1800 West Center St., Warsaw, IN 46581. Tel:

(800) 348-2759. www.zimmer.comgOlympus America Inc., 3500 Corporate Parkwaycenter Valley, PA

18034. Tel: (800) 848-9024. www.olympusamerica.comhArthrex, Inc. 1370 Creekside Blvd, Naples, FL 34108. Tel: (800)

933-7001. www.arthrex.com


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arthroscope in the cannula are now largely redundant. Illu-mination to the arthroscope is provided by a fiberoptic lightcable from a light source. The cable should be a minimumof 10 and preferably 12 feet (3 to 3.5 meters) long to pro-vide adequate working length across the horse. Connectionsbetween light sources and cables are unique to each manu-facturer, but adapters are available so that cables can be fittedto different light sources.

Light Sources

With the increasing use of extremely light-sensitive videocameras, most small fiberoptic light generators will sufficefor routine arthroscopy. Figure 2-5 depicts a small, porta-ble 175-W LED light projector made by Karl Storz that isinexpensive, has a long bulb life, and is satisfactory for mostarthroscopic examinations. Photographs can be taken withthese light sources using video printers; however, careful con-trol of the white balance of the arthroscope control systemis necessary to avoid yellow and brown tint. A high-intensitylight source (usually with xenon bulbs) is useful to producehigh-quality photographs or video for publication. A lightsource with a flash unit is largely obsolete due to the adventof photographic and video capture systems that have replacedstill photography.

Continuous high-intensity light is useful for videotape and

digital video capture. The sources may be high-intensity tung-sten illumination, xenon arc lamps (100 to 500 W), or mer-cury vapor lamps (McGinty, 1984). The xenon light sourceis still considered premier; however, the replacement bulbsare expensive ($400 to $500). The authors use a Karl StorzXenon Nova cold light fountain with 175- or 300-W lamp(Fig. 2-6), Stryker X8000 300W xenon source, Stryker L9000LED light source (Fig. 2-7), and an Arthrex Synergy combina-tion LED light source/camera control. The xenon bulbs lastfrom 350 to 500 hours, which represents a recurring cost forbusy practices. Recently introduced LED sources have bulblife of up to 17,000 hours, which is a major improvement.

Light sources that automatically adjust the light inten-sity are useful to minimize the need for manual adjustment

A B

Figure 2-1 Standard arthroscope types. A,Panoview arthroscopes (Karl Storz Veterinary Endoscopy): 4-mm out-side diameter 30 degrees (above) and 70 degrees (below). B,Close-up view of angled lens.

25 deg

A B

70 deg

IT

IT

Figure 2-2 Effect of 70-degree arthroscope.Views with A,a 25-degree arthroscope and B,a 70-degree arthroscope ofthe same area of the tarsocrural joint with the tip of the arthroscopes in the same position. IT,Intermediate ridge of tibia.

Figure 2-3 Videoarthroscopes (4 mm, 30 degrees Smith &NephewDyonics), which couple directly to the video cam-era, eliminate fogging, and maintain optical clarity. The regu-

lar forward oblique viewing arthroscopes (top) is also available ina tenoscopy version (bottom), with the field of view angled towardthe light post to facilitate annular ligament transection and otherprocedures where the light cable tends to interfere with the limb.


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Instrumentation 7

of light intensity. Most have a feedback electrical signal from

the camera control to light source for intensity adjustment.The Stryker L9000 light source and the Karl Storz lightsources employ useful intensity feedback control. Most havethe option to use this in an automatic mode or to switch tomanual to override the iris control. Additionally, many newdigital video camera control systems now also compensate forvariation in light intensity, which reduces the need for lightsource intensity changes.

Video Cameras

Diagnostic and surgical arthroscopy should not be performedby direct visualization through the arthroscope. The improvedcomfort of erect body posture, lack of eyepiece contaminationby the surgeons eye, and better depth perception make the

direct viewing approach obsolete. The risks of contaminatingthe surgical field and instruments are obvious. In addition,depth perception and ability to perform fine movements areseverely compromised with the monocular vision of a small

image. Projection of images through a video screen correctsthese deficiencies and allows simultaneous observation of theprocedure by several participants (Jackson & Ovadia, 1985).Additionally, video documentation through still image capture,video recorders, and digital video capture systems (describedlater) provide sound surgical training, client satisfaction, andlegal sense. Lightweight video cameras are attached directlyto the eyepiece of the arthroscope (Fig. 2-8), eliminating theneed for the eye to go to the arthroscope. This also provides amore comfortable operating position because the surgeon canstand up straight and the hands can be placed at any level. It isalso possible for an assistant to hold the camera, which allowsthe surgeon use of both hands to manipulate instruments forfine control or access to difficult sites.

AB

C

Figure 2-4 Arthroscope cannulae vary in locking mechanisms. A variety of 5.8-mm outside diameter (OD)self-locking cannulae made by the same manufacturer for use with a 4-mm OD arthroscope and varying in lockingmechanism from standard rotation (A),bimanual snap-in release (B),or automatic lock-in coupling mechanism (C).Allare inserted with a 4-mm conical obturator. The sharp trocar is rarely used. (Image adapted from Karl Storz.)

Figure 2-5 Storz 175W LED light source provides a versatileilluminator with adjustable outlet to suit most light cables inuse today.(Image courtesy Karl Storz.)

Figure 2-6 Intense xenon light source for large joints. Moreintense xenon light sources such as the Karl Storz Nova 300 W pro-vide ample illumination for most joints. (Image courtesy Karl Storz.)

A

B

Figure 2-7 LED light sources. Cool and powerful LED lightsources such as (A)the Stryker L9000 (500 W) and (B)the ArthrexSynergy HD3 combined LED light source/camera control/storagesystem provide state-of-the-art illumination with extremely longbulb life. (Images courtesy Stryker Endoscopy and Arthrex Inc.)


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Solid-state video cameras are now conveniently small andlight and can be attached directly to videoarthroscopes, elim-inating the coupler and any chance of fogging (Fig. 2-9). Theunited arthroscope and camera can be cold soaked or gassterilized, or both. The solid-state cameras currently availableproduce an image from either one or three chips or, more accu-

rately, closed coupled device (CCD) chips (Whelan & Jackson,1992; Johnson, 2002). These chips produce excellent imagequality. Most modern cameras use digital enhancement of theimage, including motion correction algorithms, but still outputas an analog signal (Johnson, 2002). Fully digital cameras suchas the Stryker 1288 video camera can write directly to a CDor DVD without capture devices and provide a dense 1920 1080p image that requires an upgraded monitor to derive themost benefit from its circuitry. Durable and high image-qualityvideo cameras used by the authors are available from Karl Storz(Image 1 Hub camera), Smith & NephewDyonics (ED-3 andD3 three-chip cameras; HD900 single-chip camera), StrykerEndoscopy (1288 and 1488 three-chip cameras), and Arthrex(Synergy system). Several manufacturers produce autoclavable

cameras (e.g., the Stryker 1188 HD three-chip camera, whichcan be sterilized using the flash autoclave cycle, in addition tomore routine methods). These cameras are well sealed with alaser-welded titanium seal design, making them durable, buthave previously been available only as single-chip devices,reducing the image quality. Availabili

Diagnostic and Surgical Arthroscopy in the Horse - 4th Edition

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