Details on appropriate preparation and draping for this procedure can be found here.
2. Surgical technique
In lateral recumbency the arthroscope is inserted through the palmar pouch, whereas the instruments are inserted through a separate incision at the level of the fracture plane.
The arthroscope is inserted and the fracture configuration inspected...
... and identified.
The fragment or occasionally fragments are freed from their attachments of the distal sesamoidean ligaments with the help of sharp instruments such a scalpels, special curved small osteotomes or sharp periosteal elevators. Loosening occurs proximally, axially, and abaxially. Once freed up the fragment is grabbed with Ferris-Smith rongeurs and rotated to free up the last attachments and finally removed as a whole. Occasionally the fragment has to be split in half to remove it.
Dependent upon the size of the fragment the instrument incision may have to be enlarged for fragment removal.
The use of an arthrobur to grind down the fragment and remove the debris via suction is not encouraged because only the articular component of the fragment can be visualized.
Debridement and inspection of the fracture bed
Once the fragment is removed, the joint is thoroughly inspected and any remaining debris or any small fragments are emoved. Special attention is given to the ligamentous attachment remains, which are checked for osseous remains attached to them.
It is advisable to take intratroperative radiographs to assure that the entire fragment is removed. Intraoperative fluoroscopy represent another option.
Closure and radiographic control
The joint is thoroughly lavaged, the excess fluid removed from the joint, the arthroscope removed and the incisions closed using routine technique. A sterile pressure bandage is applied to the limb with the horse still on the table.
At the end of the procedure it is advisable to take radiographs while the horse is still on the table to assure that all fragments are removed.
A splint-pressure bandage is applied prior to recovery from anesthesia. In most cases the splint can be left off after a couple of days.
For abaxial fractures, only a pressure bandage is applied.
Extended stall rest and a gradual return to exercise will typically result in a functional fibrous union, however soundness is dependent upon the degree of osteoarthritis that develops. Generally stall rest for 90 days followed by hand walking for 30-60 days is sufficient prior to free exercise.
Healing can be monitored radiographically and ultrasonographically. In some cases new bone formation at the fracture site may be noticed after some weeks, which usually do not cause any problems. The potential for return to the previous activities has to be judged cautiously.