Ultrasound-Guided Proximolateral Approach for Digital Flexor Tendon Sheath Injection in the Horse: A Cadaver Study

Abstract

Objectives The aim of this study was to define a reliable ultrasound-guided proximolateral approach (PLA) for injection of the digital flexor tendon sheath (DFTS) in horses that would be as accurate as the landmark-guided basilar sesamoidean approach (BSA).

Study Design Forty cadaveric limbs with no palpable effusion or DFTS abnormalities were randomly and evenly distributed between one senior (WRR) and one resident clinician (CRH) and between ultrasound-guided PLA and landmark-guided BSA groups. Limbs were injected with contrast, radiographed, and dissected. For each injection, the following was recorded: clinician, order of injection, number of attempts, if contrast was present within the DFTS, and if a structure other than the DFTS was penetrated.

Results The ultrasound-guided PLA resulted in a greater number of successful injections into the DFTS than the landmark-guided BSA (19/20 vs. 16/20, respectively) with significantly fewer attempts (p = 0.03). The ultrasound-guided PLA also resulted in significantly less penetration of the surrounding soft tissue structures compared with the landmark-guided BSA (p = 0.02). Neither clinician experience nor injection number within the series was determined to have an effect on injection outcome.

Conclusions The ultrasound-guided PLA to the DFTS is accurate and technically easy to perform. This approach should be considered for synoviocentesis of the DFTS, particularly in cases in which effusion is not present to reduce soft tissue trauma.

Keywords

horse - digital flexor tendon sheath - ultrasound-guided injection - landmark-guided injection - interventional ultrasound

Author Contribution

All authors contributed to the study conception and design, study execution, data analysis and interpretation and preparation of the manuscript. All authors approved of the final version of the manuscript.

• References

• 1 Fiske-Jackson AR, Barker WH, Eliashar E, Foy K, Smith RK. The use of intrathecal analgesia and contrast radiography as preoperative diagnostic methods for digital flexor tendon sheath pathology. Equine Vet J 2013; 45 (01) 36-40
• 2 Agass R, Dixon J, Fraser B. Computed tomographic contrast tenography of the digital flexor tendon sheath of the equine hindlimb. Vet Radiol Ultrasound 2018; 59 (03) 279-288
• 3 Jordana M, Martens A, Duchateau L. , et al. Distal limb desensitisation following analgesia of the digital flexor tendon sheath in horses using four different techniques. Equine Vet J 2014; 46 (04) 488-493
• 4 Schnabel LV, Fortier LA, McIlwraith CW, Nobert KM, Wayne McIlwraith C, Nobert KM. Therapeutic use of stem cells in horses: which type, how, and when?. Vet J 2013; 197 (03) 570-577
• 5 Ortved KF. Regenerative medicine and rehabilitation for tendinous and ligamentous injuries in sport horses. Vet Clin North Am Equine Pract 2018; 34 (02) 359-373
• 6 Schnabel LV, Boone L, Peroni JF. Regenerative medicine. In: Auer JA, Stick JA, Kummerle JM, Prange T. , eds. Equine Surgery. St. Louis: Elsevier; 2019: 104-122
• 7 Finnoff JT, Hall MM, Adams E. , et al. American Medical Society for Sports Medicine (AMSSM) position statement: interventional musculoskeletal ultrasound in sports medicine. PM R 2015; 7 (02) 151-68.e12
• 8 Nielsen JV, Berg LC, Thoefnert MB, Thomsen PD. Accuracy of ultrasound-guided intra-articular injection of cervical facet joints in horses: a cadaveric study. Equine Vet J 2003; 35 (07) 657-661
• 9 Purefoy Johnson J, Stack JD, Rowan C, Handel I, O'Leary JM. Ultrasound-guided approach to the cervical articular process joints in horses: a validation of the technique in cadavers. Vet Comp Orthop Traumatol 2017; 30 (03) 165-171
• 10 Fuglbjerg V, Nielsen JV, Thomsen PD, Berg LC. Accuracy of ultrasound-guided injections of thoracolumbar articular process joints in horses: a cadaveric study. Equine Vet J 2010; 42 (01) 18-22
• 11 Cousty M, Firidolfi C, Geffroy O, David F. Comparison of medial and lateral ultrasound-guided approaches for periarticular injection of the thoracolumbar intervertebral facet joints in horses. Vet Surg 2011; 40 (04) 494-499
• 12 Nottrott K, De Guio C, Khairoun A, Schramme M. An ultrasound-guided, tendon-sparing, lateral approach to injection of the navicular bursa. Equine Vet J 2017; 49 (05) 655-661
• 13 Denoix JM, Jacquet S. Ultrasound-guided injections of the sacroiliac area in horses. Equine Vet Educ 2008; 20: 203-207
• 14 Schneeweiss W, Puggioni A, David F. Comparison of ultrasound-guided vs. ‘blind’ techniques for intra-synovial injections of the shoulder area in horses: scapulohumeral joint, bicipital and infraspinatus bursae. Equine Vet J 2012; 44 (06) 674-678
• 15 Jordana M, Oosterlinck M, Pille F, Valère A, Martens A. Comparison of four techniques for synoviocentesis of the equine digital flexor tendon sheath: a cadaveric study. Vet Comp Orthop Traumatol 2012; 25 (03) 178-183
• 16 Rocconi RA, Sampson SN. Comparison of basilar and axial sesamoidean approaches for digital flexor tendon sheath synoviocentesis and injection in horses. J Am Vet Med Assoc 2013; 243 (06) 869-873
• 17 Hassel DM, Stover SM, Yarbrough TB, Drake CM, Taylor KT. Palmar-plantar axial sesamoidean approach to the digital flexor tendon sheath in horses. J Am Vet Med Assoc 2000; 217 (09) 1343-1347
• 18 Bassage LH, Ross MW. Diagnostic analgesia. In: Ross MW, Dyson SJ. , eds. Diagnosis and Management of Lameness in the Horse. St Louis: Elsevier Science; 2003: 93-124
• 19 Cauvin ERJ, Smith RKW. Ultrasonography of the fetlock. In: Kidd JA, Lu KG, Frazer ML. , eds. Atlas of Equine Ultrasonography. West Sussex: John Wiley & Sons; 2014: 45-72
• 20 Schramme MC, Smith RKW. Diseases of the digital synovial sheath, palmar annular ligament, and digital annular ligaments. In: Ross MW, Dyson SJ. , eds. Diagnosis and Management of Lameness in the Horse. St Louis: Elsevier Science; 2003: 674-684