Endoscopy of the Digital Flexor Tendon Sheath in Horses

An arthroscopic procedure for examination of the digital flexor tendons and tendon sheath was developed in 16 equine limbs and 12 horses. Distension of the tendon sheath and insertion of the arthroscope was accomplished through a cul-de-sac on the palmar or plantar surface of the tendon sheath 1 to 2 cm palmar or plantar to the digital neurovascular structures and between the annular ligament and proximal digital annular ligament. A single arthroscope entry point allowed examination of all regions of the tendon sheath cavity and most surfaces of the digital flexor tendons within the sheath. Distal to the fetlock, surgical procedures could be performed through additional entry portals on the lateral, medial, or palmar surfaces of the tendon sheath. The palmar digital vessels and nerves were avoided by palmar placement of the instrument incisions and insertion of a needle before incising the skin. The fetlock canal and proximal regions of the tendon sheath were examined by redirecting the arthroscope. Flexion of the fetlock aided passage of the arthroscope into the proximal tendon sheath regions. Evaluation of the palmar surface of the superficial digital flexor tendon was limited by the midline attachment of the tendon sheath, otherwise the surfaces of the tendons and tendon sheath could be examined with 25 degrees and 70 degrees arthroscopes. The tendon sheath was more tightly invested to the tendons in the proximal regions, limiting the arthroscope movements and second instrument access.     

Anatomical Description of the Presence and Variability of the Digital Manica Flexoria in the Equine Digital Flexor Tendon Sheath

During endoscopy (tenoscopy) of the distal aspect of the equine digital flexor tendon sheath (DFTS), the digital manica flexoria can be visualized connecting the distal branches of the superficial digital flexor tendon. However, this structure has been inconsistently described and variably named in the veterinary literature. The objectives of this study were to describe the presence, configuration and variability of the digital manica flexoria in the equine distal limb. Dissection of 144 equine cadaveric limbs revealed the presence of this structure in all the feet, although different types and conformations were identified. In the forelimbs, a membranous digital manica flexoria predominated (94%; P < 0.001), in particular a synovial bridge type (83%; P < 0.001). In the hindlimbs, a tendinous digital manica flexoria predominated (93%; P < 0.001), in particular the oblique‐crossing of tendinous bundles (61%; P < 0.001). Passage dorsal to the digital manica flexoria towards the distal DFTS was only possible in 22 of the 144 limbs, all forelimbs. Clinicians should be aware of the intra‐ and inter‐individual anatomical variations of the digital manica flexoria to avoid misinterpretation during ultrasonographic and tenoscopic examinations of the DFTS.     

Quantitative Evaluation of Equine Deep Digital Flexor Tendon Morphology using Magnetic Resonance Imaging

Injury of the distal aspect of the deep digital flexor tendon (DDFT) is a recognized cause of lameness, but diagnosis is difficult. This study aimed to improve understanding of DDFT morphology and pathology using retrospective evaluation of magnetic resonance (MR) images. We hypothesized that: (1) The distal aspect of the DDFT in normal horses would have a repeatable proximal/distal pattern and symmetry between limbs and between lobes; (2) DDFT dimensions would be related to bodyweight, navicular bone dimensions and hoof size; (3) this symmetry and pattern would be lost in DDFT injury; and (4) DDFT size would increase with injury. MR images of 64 live horse limbs, 26 with no identified DDFT lesion and 38 with identified DDFT abnormalities, and 19 normal cadaver limbs were analyzed. Using standardized transverse images, measurements of DDFT cross-sectional area, medial-lateral (ML) width and dorsal-palmar depth were obtained at six preselected sites. A uniform distal to proximal shape pattern was identified in all horses. The flattened crescent shape at the insertion changed to a deeper bilobed shape more proximally, with the mid-navicular area having the greatest cross-sectional area. Strong ML (P < 0.0006) and left/right symmetry (P < 0.02) were observed. In addition, there was a strong association between DDFT cross-sectional area and horse weight (P = 0.005) and between DDFT and navicular bone ML width (P = 0.004). Symmetry between sides or between lobes was lost at sites with a unilateral lesion and correlation between horse weight and DDFT cross-sectional area was lost in the presence of lesions. DDFTs with core lesions had a consistent increase in cross-sectional area overall, but other lesion types had no significant increase in size. The shape and symmetry seen in normal tendons could be related to the mechanical demands placed upon individual lobes. The limited increase in cross-sectional area with injury may be explained by the restrictive structures of the hoof, possibly explaining the ongoing pain seen in such lesions.     

Rupture of the Vinculum in Association with Tendon Injury within the Digital Flexor Tendon Sheath in Two Horses

The following report documents an unusual anatomical finding in two cases of aseptic tenosynovitis of the digital flexor tendon sheath. Disruption of the vinculum attachment between the palmar/plantar border of the superficial digital flexor tendon and the adjacent palmar/plantar annular ligament was identified in combination with other tendon pathology within the digital flexor tendon sheath. This tenoscopic finding has not been described previously in the literature.     

Tenoscopic Anatomy of the Equine Carpal Flexor Synovial Sheath

Objective —To describe the tenoscopic anatomy of the carpal sheath of the flexor tendons (carpal sheath) viewed from a lateral approach.
Study Design —Tenoscopic observation of structures within the carpal sheath subsequently confirmed by dissection.
Animals or Sample Population—12 equine cadaveric forelimbs.
Methods —The limbs were positioned lateral side up with the carpus slightly flexed. After distention of the carpal sheath, a portal for the arthroscope was made approximately 3 cm proximal to the distal radial physis and 2.5 cm caudal to the radius between the tendons of the ulnaris lateralis and lateral digital extensor muscles.
Results —A lateral tenoscopic approach was adequate to identify all structures within the carpal sheath. From proximal to distal, structures identified using this approach were the radial head of the deep digital flexor muscle, accessory ligament of the tendon of the superficial digital flexor muscle, distal radial physis, tendons of the superficial and deep digital flexor muscles, accessory carpal bone, antebrachiocarpal and middle carpal joints, and vincula of the tendon of the deep digital flexor muscle.
Conclusions —A lateral tenoscopic approach offered an easy, repeatable entry into the carpal sheath and allowed good observation of all structures within the sheath except for the medial borders of the tendons of the deep and superficial digital flexor muscles.
Clinical Relevance —Applications of a lateral tenoscopic approach to the carpal sheath include diagnostic procedures, lavage and synovial resection for septic tenosynovitis, desmotomy of the accessory ligament of the tendon of the superficial digital flexor muscle for flexural deformity or tendinitis, and removal of osteochondromas from the distal radial metaphysis.     

Desmotomy of the Accessory Ligament of the Superficial Digital Flexor Muscle in Equine Cadaver Limbs

Effects of longitudinal compression before and after transection of the accessory ligament of the superficial digital flexor (SDF) muscle were measured in eight equine cadaver forelimbs. When compression was increased from 890 N to 3115 N, the metacarpophalangeal (MCP) and carpal joints hyperextended 20 degrees and 4 degrees, respectively, and strain in the SDF and deep digital flexor tendons was increased 3.5% and 1.4%, respectively. The accessory ligament did not elongate. Immediately after transection of the accessory ligament at 3115 N load, a 2.8 mm gap formed between the transected ends of the accessory ligament, and the muscle belly of the SDF elongated and moved distad. The MCP joint hyperextended 15.8% further and strain of the SDF tendon increased 11.2% further. These results show that the accessory ligament transferred load in the SDF musculotendinous unit away from the muscle belly and that desmotomy altered this function. Decrease in the MCP joint angle indicated that the accessory ligament contributed to the support of the MCP joint under load. Increase in SDF strain after desmotomy was probably influenced by the change in the moment about the MCP joint and increased length of the SDF musculotendinous unit.     

Survey of the Occurrence of Equine Deep Digital Flexor Tendon Contraction (Clubfoot) in the Main Thoroughbred Breeding Area in Japan

At 114 ranches in the Hidaka District of Hokkaido, a total of 1,118 Thoroughbred foals that were born from January to June 2003 were examined at different times from May to September of the same year to ascertain the occurrence of clubfoot. Clubfoot was seen in a total of 179 foals (16%) at 89 ranches (78%). Also, 124 of the 179 foals (69.3%) had clubfoot of grade II or higher, and it was found that grade I was likely to be overlooked or rapidly advance. In the present study, the occurrence of clubfoot was higher than expected in the investigated region. Hence, it is necessary to establish accurate diagnostic techniques and clubfoot guidelines to minimize the impact.     

Evaluation of an Autologous Tendon Graft Repair Method for Gap Healing of the Deep Digital Flexor Tendon in Horses

A sutured tenorrhaphy technique that incorporated an autologous tendon graft was compared mechanically and histologically with a sutured tenorrhaphy at 6, 12, and 24 weeks after repair. Tenorrhaphy was performed in the forelimb tendon of the deep digital flexor muscle and the graft was taken from the hindlimb tendon of the lateral digital extensor muscle; one forelimb site included the graft, whereas the other forelimb site was not grafted. Tenotomies were made immediately proximal to the insertion of the accessory ligament into the tendon of the deep digital flexor muscle. Grafted and nongrafted tenorrhaphies were sutured with 2 polydioxanone in a modified double locking-loop pattern. Limbs were supported with a bandage and an extended elevated heel shoe that maintained the dorsal hoof wall angle at 70° to 75°; this support was removed at 12 weeks and dorsal hoof wall angle was maintained at 40° to 45° for the remainder of the study. Gap formation (2.5 ±.3 cm) was evident at all tenorrhaphy sites at 3 days on ultrasound examination. In grafted repairs, the breaking stress was increased ( P <.001) between 6 weeks (2.56 ±.44 MPa) and 12 weeks (17.69 ± 7.68 MPa), with grafted tendon having a greater breaking stress than nongrafted tendon (8.77 ± 2.5 MPa; P <.05). No differences in breaking stress were evident at 24 weeks. At 12 weeks, repair tissue in grafted tendon was histologically more mature, had less cellularity, better fibroblast orientation and more homogeneous collagen matrix than nongrafted tendon. Polydioxanone suture was still evident histologically at 24 weeks and was associated with minimal cellular reaction. Incorporation of an autologous tendon graft improved the mechanical properties and histological quality of the repair tissue in equine flexor tenorrhaphies at 12 weeks but not at 24 weeks after repair.     

Treatment of a Cyst-Like Synovial Hernia Associated with the Digital Flexor Tendon Sheath of a 17-Year-Old Pony

The aim of this study is to describe the successful treatment of a synovial hernia associated with the digital flexor tendon sheath (DFTS) in a 17-year-old pony. The pony presented with left forelimb lameness and multiple unusual swellings of the palmar and plantar aspect of the fetlock. The lameness was isolated to a swelling in close proximity to the DFTS of the left forelimb using diagnostic analgesia, and on diagnostic imaging, the swelling was found to be associated with the DFTS. The hernia resolved after percutaneous drainage and intralesional corticosteroids and atropine and pressure bandaging. Reports of synovial hernias in the horse associated with the DFTS are rare. This difference should be considered when presented with cases exhibiting similar clinical signs.     

Desmotomy of the Accessory Ligament of the Deep Digital Flexor Tendon in Horses: An Update

Desmotomy of the accessory ligament of the deep digital flexor tendon is advocated to allow for lengthening of the deep digital flexor musculotendinous unit and axial realignment of the bones of the digit. This procedure has several indications. It can be performed using either the open or the minimally invasive surgical approach. This article describes both surgical approaches. Corrective shoeing before surgery contributes to success in both surgical approaches. The cosmetic results obtained after the minimally invasive procedure are much better as compared with those after the open surgical procedure. The minimally invasive approach compares favorably with results reported after using an open surgical approach and offers the advantages of minimally invasive surgery including reduced incision length, reduced morbidity, and improved cosmetic outcome. The minimally invasive approach may be also performed on the standing sedated horse.     

A Comparison of Repair Methods for Gap Healing in Equine Flexor Tendon

In nine horses (18 forelimbs), a 3 cm section of superficial digital flexor tendon was removed and the tendons were repaired with immobilization for 6 weeks and (1) no suture (n = 6); (2) a double locking loop tenorrhaphy with carbon fiber (n = 6); or (3) a double locking loop tenorrhaphy with size 2 nylon suture (n = 6). Clinical assessment, gross evaluation, morphometry, histology, and mechanical testing were performed on two limbs from each treatment group at weeks 6, 12, and 24. At weeks 6 and 12, the unsutured tissue was less mature than the tissue sutured with nylon. By week 24, the carbon fiber repair had breaking stress (mean, 12.5 M Pa) similar to the unsutured repair (mean, 10.6 M Pa). There was necrosis and a granulomatous foreign body reaction around the carbon fiber. The nylon suture repair had significantly greater strength per unit area (mean breaking stress, 20.4 M Pa) because of a smaller area of repair tissue in the gap (mean, 3.6 cm2). At week 24, the nylon suture repair tissue was the most mature with the least inflammation of the three repair methods. A nylon double locking loop suture was the preferred method for equine flexor tenorrhaphy of a tendon gap because of greater breaking stress, histologic maturity, biocompatibility, and the adequate functional and cosmetic outcome.     

Some Thoughts on Deep Digital Flexor Tenotomy

Deep digital flexor tenotomy is becoming increasingly popular as part of the treatment regimen for laminitis. The rationale for performing a tenotomy is based on the severity of the rotation of the third phalanx (coffin bone) in chronic laminitis cases with the goal of realigning the coffin bone relative to the ground. The procedure is safely performed in the mid-cannon bone and pastern regions. The farrier is an integral member of the treatment team in providing mechanical support to the foot after the surgical procedure.     

Frequency of Penetration of the Digital Flexor Tendon Sheath and Distal Interphalangeal Joint Using a Direct Endoscopic Approach to the Navicular Bursa in Horses

Objective

To evaluate the frequency of inadvertent penetration of the digital flexor tendon sheath (DFTS) and/or distal interphalangeal joint (DIPJ) when using a direct endoscopic approach to the navicular bursa, and to evaluate an alternate direct approach to the navicular bursa.

Study Design

Cadaveric study.

Sample Population

Equine cadaver limbs (n = 40 for direct; n = 12 for alternate approach).

Methods

Four surgeons performed the direct endoscopic approach to the navicular bursa on 10 limbs each. Frequencies of inadvertent synovial penetration and iatrogenic damage were compared between surgeons. Use of an alternate direct approach, adopting a straight parasagittal trajectory, was evaluated by 2 surgeons.

Results

Inadvertent synovial penetration occurred in 45% of limbs (DFTS 37.5%; DIPJ 17.5%; and both structures 10%). Successful bursa entry was achieved on the first attempt in 45% of limbs. Significant variation in frequency of inadvertent synovial penetration was observed between surgeons (range 10–80%). Inadvertent synovial penetration did not occur when using the alternate direct technique. Iatrogenic damage to navicular bone fibrocartilage and/or deep digital flexor tendon occurred in 55% of limbs using the direct endoscopic approach and in 0% of limbs using the alternate direct approach.

Conclusion

Because of the considerable risk of inadvertent penetration of the DFTS and/or the DIPJ when making a direct endoscopic approach to the navicular bursa, it is advisable to investigate for inadvertent penetration when treating navicular bursa sepsis using a direct approach. The alternate direct technique may reduce the risk of inadvertent penetration; however, the view within the bursa may be restricted.     

Healing of Transected Equine Superficial Digital Flexor Tendons With and Without Tenorrhaphy

Healing of transected superficial digital flexor tendons was evaluated mechanically and histologically in eight horses. Tendons sutured with polyglyconate had higher loads at failure than nonsutured tendons at weeks 5 and 9. The tendon stress at failure (force per unit area) was higher in the sutured tendons at week 5 but not at week 9, reflecting the increased size of the scar at week 9. Histologically, scars after tenorrhaphy were consistently more mature than nonsutured tenotomy scars. The mean maturity score for sutured tendons was higher than for nonsutured tendons at weeks 5 and 9. Overall, these data support tenorrhaphy with absorbable suture.