Digital Flexor Tendon Sheath Research Articles

Identification of surgically-induced longitudinal lesions of the equine deep digital flexor tendon in the digital flexor tendon sheath using contrast-enhanced ultrasonography: an ex-vivo pilot study.

BackgroundLongitudinal tears in the lateral aspect of the deep digital flexor tendon are the most common causes of pain localised to the equine digital flexor tendon sheath. However conventional ultrasonographic techniques provide limited information about acute lesions. Ultrasonographic contrast agents are newly developed materials that have contributed to advancement in human diagnostic imaging. They are currently approved for intravenous use in human and animal models. In this study we described intrathecal use in the horse. This study was undertaken to evaluate the reliability of standard and angle contrast-enhanced ultrasonography to detect and characterize surgically-induced longitudinal lesions in the deep digital flexor tendons.In this pilot study surgically-induced lesions were created in the lateral aspect of the deep digital flexor tendon within the digital flexor tendon sheath in 10 isolated equine limbs to generate a replicable model for naturally occurring lesions. Another 10 specimens were sham operated. All the limbs were examined ultrasonographically before and shortly after the intrasynovial injection of an ultrasound contrast agent containing stabilised microbubbles. The images were blindly evaluated to detect the ability to identify surgically-created lesions. The deep digital flexor tendons were dissected and a series of slices were obtained. The depth of longitudinal defects identified with contrast-enhanced ultrasound scans was compared to the real extent of the lesions measured in the corresponding gross tendon sections.ResultsContrast-enhanced ultrasonography with both angle and standard approach provided a significant higher proportion of correct diagnoses compared to standard and angle contrast ultrasonography (p < 0.01). Contrast-enhanced ultrasonography reliably estimated the depth of surgically-induced longitudinal lesions in the deep digital flexor tendons.ConclusionContrast-enhanced ultrasound of the digital flexor tendon sheath could be an effective tool to detect intrasynovial longitudinal tears of the deep digital flexor tendon, although an in vivo study is required to confirm these results for naturally occurring lesions.

Outcome Following Surgical Treatment of 23 Cases of Primary Plantar/Palmar Annular Ligament Desmopathy: A Retrospective Study

Reasons for performing studyLittle exists in the literature regarding the outcome of endoscopically‐guided desmotomy of the palmar/plantar annular ligament (PAL) where injury to the PAL was the only diagnosis.ObjectivesTo report the return to previous level of exercise in horses treated with endoscopically guided PAL resection in which PAL injury was considered to be the primary condition.Study designRetrospective case series.MethodsMedical records of surgical cases at Donnington Grove Veterinary Surgery between 2005 and 2013 were reviewed. The inclusion criteria were cases that had undergone surgical transection of the palmar/plantar annular ligament under general anaesthesia and endoscopic guidance using a No. 12 scalpel blade where annular ligament injury was the only notable finding at surgery. Follow‐up was obtained by a telephone questionnaire.ResultsTwenty‐three horses were included in the study. Twenty horses were noted to have restriction to passage of the arthroscope within the digital flexor tendon sheath at the time of surgery. Following the initial 3‐month post operative rest period 21 horses were sound. Three horses did not return to their previous level of activity due to unrelated lameness issues and 2 returned to a lower level of competition due to owner preference. Of the remaining 18 horses, 16 returned to their previous level of athletic performance. Two horses had recurrent or persistent lameness associated with the residual PAL desmopathy.ConclusionsIn this case series surgical treatment of primary PAL injury carries a good prognosis (89% return to previous level of exercise) in contrast to a previously reported study (&lt;50% of horses were able to return to athletic function) [1].Ethical animal research: Ethical committee approval not currently required by this congress: retrospective study of clinical records. Explicit owner informed consent for participation in this study was not stated. Sources of funding: None. Competing interests: None.

The role of avian reoviruses in turkey tenosynovitis/arthritis

Turkey arthritis reovirus (TARV) has been isolated from the gastrocnemius tendons and tibiotarsal joint fluid of lame male turkeys >12 weeks old in the Midwest. Two experiments were conducted to compare the pathogenicity in turkeys of three TARVs (TARV-MN2, TARV-MN4 and TARV-O'Neil), one turkey enteric reovirus (TERV strain MN1) and one chicken arthritis reovirus (CARV strain MN1). Two hundred microlitres of virus were inoculated by the oral, intratracheal, or footpad route into 6-day-old poults placed in isolator units. Poults were necropsied at 1 and 4 weeks post infection in Experiment 1, and at 2 and 4 weeks post infection in Experiment 2. Reovirus was detected by reverse transcription-polymerase chain reaction and virus isolation in tendons of TARV-inoculated poults at 1, 2 and 4 weeks post infection. TARV-O'Neil and TARV-MN2 were detected in tendons of sentinal birds at 1 and 4 weeks and 1 week p.i., respectively. In general, TARVs produced lymphocytic tenosynovitis of the gastrocnemius and digital flexor tendon sheaths without inflammation of the tendons proper. In Experiment 1, poults inoculated with TARV-MN2 and TARV-O'Neil had significantly higher gastrocnemius tendon inflammation scores, as determined by histology, than those inoculated with TERV-MN1 or CARV-MN1. In Experiment 2, poults inoculated with TARV-MN2 and TARV-O'Neil had significantly higher gastrocnemius tendon inflammation scores than those inoculated with TARV-MN4 and virus-free medium (negative control group). Koch's postulates was fulfilled when TARV-MN2 and TARV-O'Neil were re-isolated from tendons of poults that had originally been challenged with either of these viruses. Results of these experiments indicate that TARVs have a unique ability to induce gastrocnemius tenosynovitis in turkeys and that administration of TARV-O'Neil through the oral or intratracheal route is a reproducible model to study pathogenesis of TARV infection.

Ultrasonography of the distal limbs in Nellore and Girolando calves 8 to 12months of age.

BackgroundUltrasonography can be used anywhere and allows rapid, noninvasive differentiation of soft tissue structures of the musculoskeletal system. The objectives of this study were to describe the ultrasonographic appearance of the structures of the metacarpo-/metatarsophalangeal and the interphalangeal joints, the appearance of the growth plates of the distal metacarpus/metatarsus and of the proximal phalanx and to measure the cross-sectional dimensions of the DDFT and SDFT in Nellore and Girolando calves eight to 12 months of age.ResultsIn the longitudinal dorsal view the common digital extensor tendon and the digital extensor tendon were depicted as echogenic parallel fiber bundles located directly under the skin. The joint spaces appeared as anechoic interruptions of the hyperechogenic bone surfaces. The normal amount of synovial fluid could not be depicted. The growth plates were seen as anechoic interruptions of the bone surface proximal and distal to the fetlock joint space. In transverse sonograms of the distal palmar/plantar regions, the flexor tendons and branchs of the suspensory ligament were imaged as echogenic structures. The lumen of the digital flexor tendon sheath could not be imaged in these normal cattle. The thin digital distal annular ligament and the reversal of positions of the DDFT and SDFT could be appreciated. No significant differences were found between the cross-sectional measurements of the DDFT and the SDFT from Nellore and Girolando in any age, thoracic/pelvic limbs, right/left sides and lateral/medial digits.ConclusionsThe results of this study establish important ultrasonographic reference data of the normal structures of the distal limbs and the normal dimensions of the flexor tendons in Nellore and Girolando calves for use in clinical practice.

Proximal Digital Annular Ligament Desmotomy in Horses: A Cadaveric Study

Proximal digital annular ligament (PDAL) desmitis occurs in horses for which PDAL desmotomy is the only reported treatment. The presented work aims to develop a technique for safely performing PDAL desmotomy in horses. Twenty hind limbs and 13 forelimbs, harvested from horses dead or euthanized for reasons unrelated to any structure in the pastern region, were used. All horses were free of disease at the level of their PDAL. Proximal digital annular ligament desmotomy was performed using a minimally invasive approach to the digital flexor tendon sheath between the palmar (plantar) annular ligament and the PDAL, using a medial or a lateral access. Limbs were immediately dissected after the procedure to assess the completeness of the PDAL desmotomy and any possible damage to surrounding structures. The PDAL was successfully transected in all limbs except one. Damage to the surrounding tissue included transection of the palmar digital nerve (n = 1), longitudinal tear of the superficial digital flexor tendon (n = 3), and transection of the ligament of the ergot (n = 21). A medial approach was found to be safer than a lateral approach. In conclusion, PDAL desmotomy can be performed in a safe, repeatable, and technically easy way. This is, to our knowledge, the first report of a standardized technique for performing a PDAL desmotomy in the horse.

Weissella confusa septicemia in a foal

Weissella confusa is a Gram-positive bacterium that has been identified in environmental and food samples from around the world. Rare cases of bacteremia in immunocompromised people have been reported. A 2-day-old foal was presented for weakness and suspected sepsis. Blood culture yielded pure growth of a Gram-positive coccobacillus, which was identified as W. confusa through sequencing of the 16S ribosomal DNA. Although the foal initially responded to antimicrobial therapy with ceftiofur and metronidazole, it later developed septic complications of the right tarsocrural joint and right digital flexor tendon sheath and was euthanized. Postmortem examination and histology revealed subcutaneous icterus, severe diffuse interstitial pneumonia, septic synovitis, necrotizing vasculitis with marked thrombosis and hemorrhage in the medial digital vessels of the right hind limb, and ischemic necrosis of the right hind hoof laminae. Gram-positive, coccobacilli were observed in the vascular lesion.

Distal limb desensitisation following analgesia of the digital flexor tendon sheath in horses using four different techniques

Controversy exists about the desensitisation obtained after diagnostic analgesia of the digital flexor tendon sheath (DFTS) during lameness examinations. To determine whether DFTS analgesia results in inadvertent desensitisation of the palmar/plantar digital nerves and whether this depends on the injection technique used. Crossover experimental study. The DFTS of 9 horses were injected with local anaesthetic solution and radiodense contrast medium using one of the following techniques: Proximal (at lateral proximal recess of the DFTS), Axial (axial to the lateral proximal sesamoid bone), Base (at base of the lateral proximal sesamoid bone), and Distal (at palmar/plantar mid-pastern). In total, 72 injections were performed. Skin desensitisation at the heel bulbs was tested with a dynamometer before and at 15, 30, 90 and 120 min after injection. Overall, complete desensitisation of a heel bulb at one or more time points after injection occurred in 22 limbs (30.6%). An additional 7 limbs were partially desensitised. Complete skin desensitisation occurred in 10, 3, 4 and 5 limbs using the Proximal, Axial, Base and Distal techniques respectively. Significant differences between techniques were only found at T30. The probability of skin desensitisation at the heel bulbs was 4 times higher when using the Proximal compared with the Axial and Base techniques in the forelimbs, and 3 times higher compared with the Axial and Distal techniques in the hindlimbs. Skin desensitisation nearly always occurred exclusively on the lateral heel bulb. Bilateral desensitisation only occurred in 5 limbs. Anaesthesia of the palmar/plantar digital nerves with distal limb desensitisation often occurs after DFTS analgesia. A higher chance of desensitisation exists when injecting the proximal DFTS recess. It is advisable to verify skin sensitivity at the heel bulbs after DFTS analgesia to avoid false interpretations about the origin of pain causing lameness.

Comparison of basilar and axial sesamoidean approaches for digital flexor tendon sheath synoviocentesis and injection in horses

To define a method for the basilar sesamoidean approach (BSA) to the digital flexor tendon sheath (DFTS) in horses and compare it with the axial sesamoidean approach (ASA) for DFTS synoviocentesis and injection. Evaluation study. 12 healthy adult mares without evidence of abnormalities related to the lower limbs. Each horse had 1 forelimb and 1 hind limb assigned to each DFTS approach (basilar vs axial, relative to the proximal sesamoid bones) in a Latin square design. The order of horses and of limb injection for each horse was randomly selected. All procedures were performed in standing sedated horses. The number of attempts to place a needle in the DFTS, presence of synovial fluid in the needle hub, time for DFTS injection, and number of accurate injections of sterile contrast material into the DFTS (evaluated by means of radiography) were compared between methods. Median time for injection was significantly shorter for the BSA, compared with the ASA. The median number of times the needle was redirected was also significantly less for the BSA. Odds of obtaining synovial fluid via the BSA were 5.7 times as great as for the ASA (95% confidence interval, 1.2 to 278). Successful injection of contrast material into the DFTS did not differ significantly between the BSA (24/24 limbs) and ASA (23/24). The BSA was a useful method for DFTS synoviocentesis in the forelimbs and hind limbs of standing sedated horses and was superior to the ASA in most aspects. This approach to the DFTS should be considered when DFTS injection or synovial fluid retrieval is desired, particularly in horses with minimal DFTS effusion.

An iatrogenic septic tenosynovitis of the digital flexor tendon sheath after diagnostic anaesthesia in a horse

An iatrogenic septic tenosynovitis of the digital flexor tendon sheath after diagnostic anaesthesia in a horse

Tenosynoviotomy for Sepsis of the Digital Flexor Tendon Sheath in 9 Horses

To describe a tenosynoviotomy technique for treatment of sepsis of the digital flexor tendon sheath (DFTS) in horses and report long-term outcome. Case series. Horses (n = 9). Horses were positioned in lateral recumbency with the affected limb uppermost. A linear incision was made just lateral to the mesotenon beginning 5 cm proximal to the apices of the proximal sesamoid bones, extending 2 cm distal to the bifurcation of the superficial digital flexor tendon (SDFT). The incision was continued through the skin, subcutaneous tissue, palmar/plantar annular ligament, and DFTS. Tenotomy of the distal lateral branch of the SDFT was also performed. The site was thoroughly debrided, lavaged, and packed with gauze and allowed to heal by second intention. Follow-up was obtained via owner telephone interview. Mean surgery time was 32 minutes (range, 10-64 minutes). Systemic antibiotics were administered postoperatively (range, 11-46 days; mean, 23 days). Mean hospitalization was 11 days (range, 0-49 days). Follow-up was available for 7 (70%) horses. One year postoperatively, 5 (71%) horses were serviceable for their intended use, and 2 (29%) had been euthanatized. Of 5 survivors, 3 returned to ridden exercise, 1 was retired as a broodmare, and 1 was a broodmare. All owners were satisfied with the cosmetic appearance of the surgery site. Open drainage via tenosynoviotomy, performed as a salvage procedure, represents a feasible treatment for DFTS sepsis.

Highlights of recent clinically relevant papers

Highlights of recent clinically relevant papers

Tenoscopic Surgical Treatment of Tears of the Manica Flexoria in 53 Horses

To determine typical clinical features associated with tears of the manica flexoria (MF) and prognosis for return to athletic function after surgical resection. Case series. Medical records (January 2001-December 2011) of horses that underwent tenoscopic surgical treatment of MF tears were reviewed and outcome obtained by telephone questionnaire of owners. Fifty three horses (65 MF tears) were treated; 83% were cobs or ponies. Injuries occurred more frequently in hindlimbs (85%) and effusion of the digital flexor tendon sheath was associated with all MF tears. Follow-up (>3 months after surgery) revealed that 42 horses (79%) returned to pre-injury level of ridden exercise, 7 horses returned to a lower level of exercise, 3 remained lame, and 1 was euthanatized. Injury to the MF is most likely to occur in hindlimbs with cobs and ponies overrepresented.

Systemic or intrasynovial medication as singular or as combination treatment in horses with (peri-)synovial pain

Records of lame horses (2004–2007) with (peri-)synovial pain of the metacarpophalangeal joint (MCPJ, n = 53), digital flexor tendon sheath (DFTS, n = 20), and distal interphalangeal joint (DIPJ, n...

The effects of perineural and intrasynovial anaesthesia of the equine foot on subsequent magnetic resonance images

Artefacts caused by regional anaesthesia can influence image interpretation of ultrasonography and nuclear scintigraphy. Perineural and intrasynovial anaesthesia are commonly performed prior to magnetic resonance imaging (MRI); and the effects on MR images, if any, are unknown. To determine if perineural and intrasynovial anaesthesia of structures in the equine foot cause iatrogenic changes detectable with MRI. A baseline MRI examination of both front feet was performed on 15 horses, 2-6 days prior to mepivacaine injection adjacent to the lateral and medial palmar digital nerves, and into the podotrochlear bursa, digital flexor tendon sheath and distal interphalangeal joint of one randomly assigned forelimb. Magnetic resonance imaging was repeated at 24 and 72 h post injection; then qualitative and quantitative assessments of MRI findings were performed. Magnetic resonance imaging findings associated with the palmar digital nerves, podotrochlear bursa and distal interphalangeal joint at 24 and 72 h after mepivacaine injection did not alter significantly from those at baseline. Compared with baseline, a significant increase in synovial fluid volume of the digital flexor tendon sheath was detected with MRI at 24 and 72 h post injection. Perineural anaesthesia of the palmar digital nerves and intrasynovial anaesthesia of the podotrochlear or distal interphalangeal joint did not interfere with the interpretation of MR images acquired at 24 or 72 h after injection. However, intrasynovial anaesthesia of the digital flexor tendon sheath caused an iatrogenic increase in synovial fluid, detectable on MR images for at least 72 h. Although a definite time frame for resolution of digital flexor tendon sheath distension was not determined, we recommend waiting more than 3 days between intrasynovial anaesthesia of the digital flexor tendon sheath and evaluation with MRI.

Injuries to the digital flexor tendon sheath in the horse

The equine digital flexor tendon sheath (DFTS) is frequently localized as a cause of lameness. The DFTS contains, and is associated with, several important anatomic structures including the flexor tendons, manica flexoria and palmar/plantar annular ligament. Correct identification of the structures involved in injury is important, as the treatment and prognosis vary with injury. Diagnostic tenoscopy is the gold standard for diagnosis. The most commonly diagnosed injuries include linear tears of the deep digital flexor tendon, tears of the manica flexoria and palmar/plantar annular ligament desmopathy. Please note: Wiley-Blackwell are not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing material) should be directed to the corresponding author for the article. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

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.

The use of intrathecal analgesia and contrast radiography as preoperative diagnostic methods for digital flexor tendon sheath pathology

The sensitivity of ultrasonography for the diagnosis of manica flexoria (MF) tears within the digital flexor tendon sheath (DFTS) is lower than for diagnosis of marginal tears of the deep digital flexor tendon (DDFT). Additional diagnostic tools would assist in appropriate decision making for either conservative or surgical management. To evaluate the improvement in lameness of horses with MF or DDFT tears following intrathecal analgesia and to assess the sensitivity and specificity of contrast radiography for the diagnosis of these tears. The case records of horses presented to a referral clinic over a 7-year period that underwent intrathecal diagnostic analgesia, or intrathecal analgesia and contrast radiography, of the DFTS with subsequent tenoscopy were examined. Fifty-three limbs had intrathecal diagnostic analgesia performed and 23 contrast tenograms were assessed in horses undergoing DFTS tenoscopy. Horses with DDFT tears were significantly more likely to respond positively to intrathecal diagnostic analgesia than those with MF tears (P = 0.02). Using contrast radiography, tears of the MF were predicted with an overall sensitivity of 96% and specificity of 80%; marginal tears of the DDFT were predicted with an overall sensitivity of 57% and specificity of 84%. The results of intrathecal analgesia of the DFTS in combination with contrast radiography have a high sensitivity for predicting MF tears. The sensitivity of contrast radiography for predicting tears of the DDFT is lower but the specificity remains high. Contrast radiography performed at the same time as intrathecal analgesia provides useful information regarding the presence of MF tears and DDFT tears, which can assist in the decision of whether to manage the lameness conservatively or with tenoscopic evaluation.

Comparison of four techniques for synoviocentesis of the equine digital flexor tendon sheath: A cadaveric study

To compare four different techniques for synoviocentesis of the equine digital flexor tendon sheath (DFTS). Fifteen inexperienced operators performed each of the following injection techniques on two cadaveric limbs: Proximal (at the proximal recess of the DFTS), Axial (axial to the proximal sesamoid bone), Base (at the base of the proximal sesamoid bone), and Distal (at the pastern). The number of attempts needed before the needle was assumed to be correctly positioned into the DFTS was recorded and 10 ml of methylene blue was injected. The limbs were dissected to determine the presence of methylene blue in the DFTS, the distance between the needle entrance point and the lateral palmar or plantar (digital) nerve, the degree of subcutaneous leakage and the distance between the border of the leakage zone and the lateral digital nerve. The Axial (29/30) and Distal (25/30) approaches had the highest numbers of successful injections. The median number of attempts was highest for the Axial approach. The distances from the injection point and from the border of the leakage zone to the lateral digital nerve were longer for Distal and Axial approaches. In the hands of inexperienced operators, the Axial approach was the most successful technique for injection of the equine DFTS. Sparse subcutaneous leakage and larger distance to the nerve when using this technique might decrease the risk of in-advertent palmar or plantar digital nerve desensitisation when performing DFTS analgesia.

Agreement between arterial partial pressure of carbon dioxide and saturation of hemoglobin with oxygen values obtained by direct arterial blood measurements versus noninvasive methods in conscious healthy and ill foals

To determine agreement between indirect measurements of end-tidal partial pressure of carbon dioxide (PetCO(2)) and saturation of hemoglobin with oxygen as measured by pulse oximetry (SpO(2)) with direct measurements of PaCO(2) and calculated saturation of hemoglobin with oxygen in arterial blood (SaO(2)) in conscious healthy and ill foals. Validation study. 10 healthy and 21 ill neonatal foals. Arterial blood gas analysis was performed on healthy and ill foals examined at a veterinary teaching hospital to determine direct measurements of PaCO(2) and PaO(2) along with SaO(2). Concurrently, PetCO(2) was measured with a capnograph inserted into a naris, and SpO(2) was measured with a reflectance probe placed at the base of the tail. Paired values were compared by use of Pearson correlation coefficients, and level of agreement was assessed with the Bland-Altman method. Mean ± SD difference between PaCO(2) and PetCO(2) was 0.1 ± 5.0 mm Hg. There was significant strong correlation (r = 0.779) and good agreement between PaCO(2) and PetCO(2). Mean ± SD difference between SaO(2) and SpO(2) was 2.5 ± 3.5%. There was significant moderate correlation (r = 0.499) and acceptable agreement between SaO(2) and SpO(2). Both PetCO(2) obtained by use of nasal capnography and SpO(2) obtained with a reflectance probe are clinically applicable and accurate indirect methods of estimating and monitoring PaCO(2) and SaO(2) in neonatal foals. Indirect methods should not replace periodic direct measurement of corresponding parameters.

Assessment of the tissue diffusion of anesthetic agent following administration of a low palmar nerve block in horses

To investigate tissue diffusion of anesthetic agent following administration of low palmar nerve blocks (LPBs) in horses. Randomized clinical trial. 12 adult horses. In 9 horses, mepivacaine hydrochloride-iohexol (50:50 dilution) injections were administered bilaterally (2 or 4 mL/site) to affect the medial and lateral palmar and palmar metacarpal nerves (4 sites). Lateral radiographic views of both metacarpal regions were obtained before and at 5, 15, 30, 60, 90, and 120 minutes after block administration; proximal and distal extents of contrast medium (and presumably anesthetic agent) diffusion from palmar and palmar metacarpal injection sites were measured and summed to determine total diffusion. Methylene blue solution was injected in forelimbs of 3 other horses that were subsequently euthanized to determine the potential route of anesthetic agent diffusion to the proximal suspensory ligament region. Mean extents of proximal and total contrast medium diffusion were 4.0 and 6.6 cm, respectively, for the palmar metacarpal nerves and 4.3 and 7.1 cm, respectively, for the palmar nerves. Subtle proximal diffusion secondary to lymphatic drainage was evident in 17 of the 18 limbs. Contrast medium was detected in the metacarpophalangeal joint or within the digital flexor tendon sheath in 8 and 7 limbs, respectively. In the cadaver limbs, methylene blue solution did not extend to the proximal suspensory ligament region. In horses, LPBs resulted in minimal proximal diffusion of anesthetic agent from the injection sites. Limbs should be aseptically prepared prior to LPB administration because inadvertent intrasynovial injection may occur.