The caudal margin of the fragment is elevated with a Hohmann retractor and the medial attachments are sharply transected.
As soon as enough mobility is achieved, the fragment is grasped with heavy bone holding forceps. The fragment is pulled out vigorously, tensing its remaining attachments and allowing them to be cut with a scalpel or sharp elevator.
Finally the fragment is pulled caudolaterally as much as possible to allow the large biceps tendon being transected at its origin at the supraglenoid tubercle.
In a comminuted fracture the fragments are removed one after the other. Ideally, the smaller fragments should first be removed followed by removal of the larger ones.
Resection of an old fracture is significantly more time consuming and difficult than resection of a fresh fracture.
In some cases the fragment has to be divided with an oscillating saw into smaller fragments. These are subsequently removed one after the other.
Be aware that removal of a chronic supraglenoid tubercle fracture is a crude surgical procedure resulting in a huge hole in the shoulder region.
Following removal of the fragment(s), the area is lavaged and the created dead space obliterated as much as possible. It is impressive to appreciate the size of the dead space that is created by the removal of the supraglenoid tubercle. If substantial dead space persists, a closed suction device should be used to prevent development of a postoperative seroma.
Closure of the incision occurs in several layers followed by the application of a stent bandage sutured over the closed skin incision.
The left image shows a multi fragment supraglenoid tubercle fracture. The right shows the same horse after removal of all the fragments.
4. Patient recovery
Recovery from anesthesia
Assisted recovery from anesthesia is recommended. Pool recovery, if available (left) is ideal.
The drain is removed when a significant drop in fluid production occurs.
Antimicrobials and phenylbutazone are administered perioperatively and continued until the there are no clinical signs of seroma formation.
Horses are restricted to stall rest for 60 days to allow time for the dead space to ﬁll with ﬁbrous tissue and the biceps tendon to reattach. A carefully controlled rehabilitation program is important for these horses to regain strength and coordination in their shoulder joints.
Percutaneous stimulation of the shoulder muscles during rehabilitation to minimize muscle atrophy should be considered.
Typically, physical therapy begins with range-of-motion exercises and hand-walking for 5 minutes per day, followed by walking over ground poles and gradual increases in duration of exercise each day. Horses are not usually ready to return to training or to be turned out into a paddock for 6 to 12 months after surgery.