Ex Vivo Assessment of an Ultrasound-Guided Injection Technique of the Navicular Bursa in the Horse

An Alternate Radiographic Guided Technique for Injection of the Equine Navicular Bursa Using a 40 mm (1.5-inch) 20-Gauge Needle: A Pilot Study

Injection of the equine navicular bursa can be technically challenging, and inadvertent penetration of other synovial structures is common using previously described techniques. When injecting the navicular bursa, inadvertent penetration of other synovial structures and hoof configuration can affect success rate, especially when performed by inexperienced operators. The aim of this study is to describe an alternate radiographic guided technique for injection of the equine navicular bursa that consistently avoids penetration of the distal interphalangeal joint using a 40 mm (1.5-inch) 20-gauge needle. This ex vivo pilot study compared the success rate, needle redirection rate, and rate of inadvertent synovial penetration of a novel injection technique for the equine navicular bursa between operators with three differing levels of experience in equine veterinary medicine (1 year, 8 years, >30 years). There was no significant difference in success rate between operators regardless of level of experience or hoof configuration, and inadvertent penetration of other synovial structures was highly unlikely. Thus, using the described technique, injection of the navicular bursa can be performed by individuals of various experience levels in equine veterinary practice, and can be achieved with a high success rate with little chance of inadvertent penetration of other synovial structures regardless of hoof configuration.

Factors affecting successful ultrasound-guided injection into the podotrochlear bursa using a palmarolateral approach

OBJECTIVE

To evaluate potential factors affecting ultrasonographic visibility of the suprasesamoidean region and the success rate of ultrasound-guided injection (USGI) into the podotrochlear bursa (PB).

STUDY DESIGN

Ex vivo, experimental study.

ANIMALS

24 cadaveric forelimbs.

METHODS

The PB was distended with 0, 1, or 2 ml of iodinated contrast material and saline under radiographic guidance. Ultrasonographic visibility of the suprasesamoidean region and PB was graded before and after distention with the limb loaded in three positions (vertical, cranial and caudal). Two operators with different experience levels performed an USGI into the PB with methylene blue (12 limbs each [four limbs with each of three volumes of PB distension]) using a palmarolateral approach and caudal foot placement. Limbs were frozen and sectioned to assess accuracy.

RESULTS

Ultrasonographic visibility scores of the suprasesamoidean region (p = .0081) and PB (p < .0001) were improved using a caudal foot placement. Higher visibility grades of the suprasesamoidean region were associated with higher injection success rate (p = .047). The injection success was 75% (9/12) for the experienced versus 41.6% (5/12) for the less experienced operator (p = .14). PB distension improved visibility during caudal foot placement (p = .013) but not injection success rates (p = .78).

CONCLUSION

Caudal foot placement enhances visibility of the PB and suprasesamoidean region. Limbs with poor visibility of the suprasesamoidean region are more likely to undergo a failed USGI.

CLINICAL SIGNIFICANCE

The lateral USGI approach should be performed only in cases of optimal visibility. The reported success rates support the technical challenge of PB injections.

Comparison Between Ultrasonographic and Standing Magnetic Resonance Imaging Findings in the Podotrochlear Apparatus of Horses With Foot Pain

This prospective study aimed to blindly compare the ultrasonographic and standing magnetic resonance imaging (sMRI) findings in deep digital flexor tendon (DDFT), navicular bone, and navicular bursa in horses with foot pain, positive digital analgesia, and without definitive radiographic diagnosis. Ultrasonography detected more DDFT abnormalities (32/34 feet vs. 27/34 with sMRI) but identified less palmar navicular abnormalities (23/34 feet vs. 30/34 with sMRI). In suprasesamoidean DDFT lesions, which were mainly dorsally located, changes in echogenicity did not correspond to a particular pattern of sMRI signal change. Transcuneal ultrasonography did not allow assessment of morphology and extent of distal DDFT lesions, and sporadically discriminated the affected lobe compared to sMRI. Defects of the palmar compact bone were identified with both modalities except a parasagittal defect, which was only seen at sMRI.

Accuracy of open magnetic resonance imaging for guiding injection of the equine deep digital flexor tendon within the hoof

Lesions of the distal deep digital flexor tendon (DDFT) are frequently diagnosed using MRI in horses with foot pain. Intralesional injection of biologic therapeutics shows promise in tendon healing; however, accurate injection of distal deep digital flexor tendon lesions within the hoof is difficult. The aim of this experimental study was to evaluate accuracy of a technique for injection of the deep digital flexor tendon within the hoof using MRI-guidance, which could be performed in standing patients. We hypothesized that injection of the distal deep digital flexor tendon within the hoof could be accurately guided using open low-field MRI to target either the lateral or medial lobe at a specific location. Ten cadaver limbs were positioned in an open, low-field MRI unit. Each distal deep digital flexor tendon lobe was assigned to have a proximal (adjacent to the proximal aspect of the navicular bursa) or distal (adjacent to the navicular bone) injection. A titanium needle was inserted into each tendon lobe, guided by T1-weighted transverse images acquired simultaneously during injection. Colored dye was injected as a marker and postinjection MRI and gross sections were assessed. The success of injection as evaluated on gross section was 85% (70% proximal, 100% distal). The success of injection as evaluated by MRI was 65% (60% proximal, 70% distal). There was no significant difference between the success of injecting the medial versus lateral lobe. The major limitation of this study was the use of cadaver limbs with normal tendons. The authors conclude that injection of the distal deep digital flexor tendon within the hoof is possible using MRI guidance.

An ultrasound-guided, tendon-sparing, lateral approach to injection of the navicular bursa

BACKGROUND

Navicular disease in the horse often requires injection of the navicular bursa. We have developed an ultrasound-guided, lateral needle approach to navicular bursocentesis, which avoids penetration of the deep digital flexor tendon (DDFT) and the need for radiographic control.

OBJECTIVES

To describe and evaluate the feasibility and efficacy of an ultrasound-guided, lateral bursocentesis technique.

STUDY DESIGN

Cadaveric and in vivo experiments.

METHODS

The navicular bursa in 62 cadaveric forelimbs of 31 horses and in both forelimbs of 26 live horses, positioned with the foot flexed in a navicular block, were submitted to lateral, ultrasound-guided injection of 1.5 ml radiocontrast agent. Lateromedial radiographs were taken to locate the contrast. A second injection of 0.5 ml methylene blue was administered during needle withdrawal in cadaveric limbs to investigate the needle pathway during dissection.

RESULTS

Contrast agent was successfully deposited in the navicular bursa in 104 of 114 (91%) limbs and in the navicular bursa alone in 89 of 114 (78%) limbs. Dissection showed no evidence of penetration of the DDFT in cadaver limbs. Failure to inject the navicular bursa was significantly associated with poor quality of the ultrasound image (P = 0.04) and resulted in aberrant injection of the distal interphalangeal joint in five of 114 (4%) limbs, the peribursal soft tissues in four of 114 (4%) limbs and the digital flexor tendon sheath in one of 114 (0.9%) limbs. Synovial fluid was observed at the needle hub in 58% of live horses.

MAIN LIMITATIONS

It is unknown whether injection results obtained in the limbs of horses without disease can be extrapolated to horses with clinical disease of the podotrochlear apparatus. The localisation of contrast medium on radiographs may not accurately reflect the behaviour of local anaesthetic solution or therapeutic medications injected in the navicular bursa.

CONCLUSIONS

This lateral, ultrasound-guided technique for injecting the navicular bursa is effective, does not penetrate the DDFT and avoids exposure of personnel to radiation.