Veterinary Surgery Deep Dive: Equine Ortho — February 2026 Edition

In this episode of the Simini Equine Surgery Podcast, we explore the orthopedic research from the February 2026 issue (Issue 2) of Veterinary Surgery, where three studies showcase how refinements in equine tenoscopic surgery are expanding what surgeons can accomplish through minimally invasive techniques. Together, they highlight a common goal: improving surgical access while preserving critical anatomy and optimizing long-term athletic outcomes. 

From preserving tendon blood supply during manica flexoria resection, to a new tenoscopic treatment for proximal digital annular ligament desmitis, and the development of a medial portal for carpal flexor tendon sheath surgery, these papers demonstrate how thoughtful surgical innovation continues to improve patient care.

In this episode:

✅ Racine et al. presented a refined two-portal tenoscopic technique for resection of torn proximal manica flexoria (MF) while preserving the mesotendons (MTs) of the deep digital flexor tendon. Using a four-step approach—including a novel Kocher-Ochsner clamp twisting technique to detach the remaining areolar tissue—the authors successfully preserved the mesotendons while minimizing iatrogenic trauma. Among 30 horses, 96.4% achieved successful tendon sheath healing, and 75% returned to their previous or higher level of athletic performance. By maintaining the extrinsic vascular supply of the deep digital flexor tendon, this modified approach may improve long-term tendon healing while reducing surgical morbidity. 

✅ Wood et al. described a tenoscopically guided proximal digital annular ligament (PDAL) desmotomy for horses with proximal digital annular ligament desmitis. After validating the technique in 10 cadaver limbs, the procedure was successfully performed in five clinical cases, with four horses returning to their previous level of exercise following surgery. The study also demonstrates that pathologic thickening of the PDAL actually facilitates surgical identification during tenoscopy, while emphasizing the importance of performing a palmar or plantar annular ligament desmotomy first to improve instrument maneuverability and protect the superficial digital flexor tendon. 

✅ Woods et al. investigated the feasibility of creating a medial tenoscopic portal into the equine carpal flexor tendon sheath using contrast-enhanced CT and cadaver specimens. The authors identified a reproducible portal location approximately 5 mm proximal and 32 mm caudal to the distal medial radial physis, providing 120–140° of instrument triangulation when combined with the standard lateral portal. Although superficial flexor carpi radialis tendon impingement occurred during early testing, careful blunt dissection and transillumination from the lateral portal allowed safe placement while preserving major neurovascular structures. The technique offers surgeons improved visualization and access to previously difficult-to-reach lesions within the carpal sheath. 

Together, these studies demonstrate that the future of equine tenoscopy lies not in larger incisions, but in smarter portal placement, preservation of normal anatomy, and continual refinement of minimally invasive surgical techniques.

🎓 Journal Articles Discussed

• Racine et al. — Four-step tenoscopic technique to resect a torn proximal manica flexoria while sparing the mesotendons of the deep digital flexor tendon in 30 horses
• Wood et al. — Tenoscopically guided proximal digital annular ligament desmotomy for the treatment of proximal digital annular ligament desmitis
• Woods et al. — Feasibility of a medial tenoscopic portal in the equine carpal flexor tendon sheath in cadavers

📚 From the February 2026 Issue (Issue 2) of Veterinary Surgery

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Transcript

SPEAKER_01 0:04

Hi, I'm Carl Damiani, and this is the Simony Equine Surgery Podcast, your fast focused update on what matters most from the latest equine surgical literature. In each episode, we break down key articles from the veterinary journals and translate them into surgical insight you can use today, not someday. This episode covers the orthopedic section from the February 2026 issue of veterinary surgery, and we're focusing on three studies that highlight advances in equine tenoscopic surgery, from refining established procedures to developing entirely new surgical approaches. First, we'll look at a study by Racine et al. who present a refined four-step tenoscopic technique for resecting torn proximal manica flexoria while preserving the mesotendons of the deep digital flexor tendon. We'll discuss how this minimally invasive approach may reduce surgical trauma while maintaining tendon blood supply and supporting a successful return to athletic function. Next, we'll review Wood et al. who describe a novel tenoscopically guided proximal digital annular ligament desmotomy for horses with proximal digital annular ligament desmitis. From cadaver validation to successful clinical cases, this paper offers a new minimally invasive option for a condition that's likely been underdiagnosed and undertreated. Finally, we'll cover Woods et al., who investigate the feasibility of creating a medial tenoscopic portal into the equine carpal flexor tendon sheath. Using contrast C, T, and cadaver specimens, the authors identify a safe portal location that could improve visualization, instrument triangulation, and access to challenging pathology during carpal sheath surgery. Three studies. One common theme: refining equine tenoscopic techniques to improve surgical access, reduce complications, and expand what's possible through minimally invasive orthopedic surgery. Let's dive in.

Racine et al. Study: A Refined Four-Step Modified Two-Portal Tenoscopic Approach for Resecting Torn Proximal Manica Flexoria (MF).

SPEAKER_03 2:17

Welcome to today's deep dive. Imagine performing a meticulous resection in a joint space that's, well, so tight it feels like, I don't know, trying to pull weeds without disturbing the delicate root system of an ancient transplanted tree. Right.

SPEAKER_02 2:31

It's virtually impossible.

SPEAKER_03 2:32

Exactly. One slip, and you've severed the exact microvascular structures, keeping the surrounding tissue alive. For veterinary surgeons treating proximal manica flexoria tears, that is well, that's just the daily anatomical peril.

SPEAKER_02 2:48

Aaron Powell Oh, absolutely. Because, you know, we all know that iatrogenic damage to the mesotendons during an MF resection, it really compromises that extrinsic vascularity.

SPEAKER_03 2:57

Right. The blood supply to the flexor tendons.

SPEAKER_02 2:59

Exactly. So the clinical bottleneck has always been well, how do we resect this torn tissue without causing that trauma? And that's where Racine et al. 2026 comes in.

SPEAKER_03 3:09

Right. Their perspective clinical study is exactly what we're dissecting today. They designed this modified two-portal

Athletic Recovery Outcomes: Tracking successful digital flexor tendon sheath healing in 96.4% of cases and an impressive 75% return-to-performance level.

SPEAKER_03 3:14

tenoscopic approach specifically to spare those MTs.

SPEAKER_02 3:17

They did. And the data from the 30 horses in this study is honestly striking. 96.4% of the horses available for long-term follow-up showed successful digital flexor tendon sheath healing.

SPEAKER_03 3:30

Which is a massive win.

SPEAKER_02 3:31

Yeah, and even more critically for the owners, 75%. So that's 21 out of 28 horses, returned to their previous or even higher performance levels.

SPEAKER_03 3:41

Wow, a 75% return to work rate. But wait, I have to push back a little here. Sure. Is that high success rate definitively because they saved the blood supply? Or I mean, is this modified approach just better at aggressively removing the necrotic tissue?

SPEAKER_02 3:57

Aaron Powell Well, it's definitely a bit of both. The mechanics matter, right? Efficient tissue removal clears out the immediate pathology.

SPEAKER_03 4:02

Okay, that makes sense.

SPEAKER_02 4:03

But keeping the MTs intact, that's the critical differentiator here. It actively maintains the physiologic oxygen and nutrient supply. So you are directly optimizing the long-term healing capacity of the deep digital

The Kocher-Osner Twist Extraction: Utilizing non-sharp clamp rotation in step four to cleanly break deep areolar attachments via torsion while leaving microvascular roots untouched.

SPEAKER_02 4:15

flexor tendon.

SPEAKER_03 4:16

Instead of just like cleaning up a tear and hoping for the best.

SPEAKER_02 4:19

Exactly. You're preserving the foundation.

SPEAKER_03 4:20

So how are they actually physically extracting the MF without nicking those roots? Because the scalpel in that highly vascularized area seems like it's just begging for unintended damage.

SPEAKER_02 4:31

Oh, for sure. But they actually avoid sharps entirely for the final extraction. The clinical brilliance is in what the authors call step four.

SPEAKER_03 4:40

Okay, walk me through step four.

SPEAKER_02 4:42

So after they transect the MF attachments to the superficial digital flexor tendon, they take a Kocher Ostner clamp.

SPEAKER_03 4:48

Okay.

SPEAKER_02 4:49

They grasp the freed MF and they just simply rotate it.

SPEAKER_03 4:52

Wait, so they're twirling it like like spaghetti on a fork?

SPEAKER_02 4:55

Yes, exactly like that. You just we rotate the clamp about ten times.

SPEAKER_03 4:58

That is wild.

SPEAKER_02 4:59

Right. And the twisting motion naturally breaks the deep areolar tissue via torsion rather than you know relying on a sharp cut.

SPEAKER_03 5:05

Oh, so it just snaps on its own.

SPEAKER_02 5:07

Yep. Allowing you to extract the tissue while leaving the MTs completely untouched.

SPEAKER_03 5:12

That is a remarkably elegant mechanical solution. But okay, if we are going to these extremes to preserve microvascular health, how are we handling the closure? Because if you introduce a bacterial load right at the finish line.

SPEAKER_02 5:26

It ruins everything.

SPEAKER_03 5:27

Exactly. All that meticulous

Simini Protect Lavage Study: Contrasting standard saline's 42% bacterial remainder with a 60-second surfactant alternative that achieves total biofilm disruption and complete pathogen clearance at closure.

SPEAKER_03 5:28

MT-sparing work is compromised. I mean, saline lavage is standard, but independent studies show it leaves, what, 42% of bacteria behind?

SPEAKER_02 5:37

Yeah, 42%, which is just a massive blind spot.

SPEAKER_03 5:40

Almost half.

SPEAKER_02 5:41

Right. Leaving nearly half the bio burden in a freshly manipulated tendon sheath, it's an unacceptable risk to that vascular network.

SPEAKER_03 5:48

Aaron Powell So what's the alternative then?

SPEAKER_02 5:50

That's why integrating Semini protect lavage at closure is becoming standard alongside these advanced techniques. It's a non-antibiotic lavage that drops that remaining bacterial load down to zero percent.

SPEAKER_03 6:03

Wait, zero percent? How does a non-antibiotic solution actually get to zero where saline fails so drastically?

SPEAKER_02 6:10

It really just comes down to the mechanism of action. Saline just physically flushes the area.

SPEAKER_03 6:14

Right, just washing it out.

SPEAKER_02 6:15

Yeah. Which does absolutely nothing against adhered bacteria or biofilms. But simity protect lavage, it acts by physically lysing the bacterial cell walls.

SPEAKER_03 6:24

Oh, so it breaks them open.

SPEAKER_02 6:25

Exactly. It disrupts the surface tension and actively breaks down the pathogens that saline just washes right past.

SPEAKER_03 6:32

Even the resistance strains.

SPEAKER_02 6:33

Even those. And it does all this in just 60 seconds, so it doesn't disrupt your existing surgical workflow at all.

SPEAKER_03 6:39

Okay, so it actively clears the field rather than just, you know, rincing it, tightening up the closure protocol you're already doing.

SPEAKER_02 6:45

Exactly.

SPEAKER_03 6:46

So bringing this all together, what is the core takeaway for the surgeon listening right now?

SPEAKER_02 6:51

Aaron Ross Powell, I'd say for equine MF tears, adopting this mesotendon sparing two-portal technique preserves the extrinsic tendon blood supply and yields those excellent return to work rates.

SPEAKER_03 7:03

Right.

SPEAKER_02 7:04

And utilizing that Kochra Austiner twist technique, it's just a highly effective, safe way to avoid MT damage during extraction.

SPEAKER_03 7:12

Which is incredible. And it leaves you with something really important to mull over before you scrip in next. If preserving microvascular structures in the MF drastically improves outcomes like this, what other standard orthopedic resections in veterinary surgery might be inadvertently sacrificing long-term healing for short-term access?

SPEAKER_02 7:31

That is the big question. Are there other procedures where we are needlessly severing the roots?

SPEAKER_03 7:36

Exactly. Definitely something to explore. You can find the full article links for a scene it all 2026 in the show notes. Thanks for joining us on this deep dive.

SPEAKER_00 7:48

Continuing with the next published

Wood et al. Study: Novel Tenoscopically Guided Proximal Digital Annular Ligament (PDAL) Desmotomy for Horses.

SPEAKER_00 7:51

study.

SPEAKER_02 7:56

So you are staring at an ultrasound of a thickened pasttern, right? And the lameness is well, it's insidious.

SPEAKER_03 8:03

Yeah, incredibly frustrating to deal with.

SPEAKER_02 8:04

Exactly. For years you might have just, you know, chalked it up as an incidental finding and treated it conservatively. But today, we are applying the Simony style guide to extract pure actionable surgical intelligence from a recent paper, no fluff, just what actually changes tomorrow in the OR.

SPEAKER_03 8:22

Right. So calmly stepping into it, the target today is a paper by

Diagnostic Margins and Pathological Thickening: Utilizing ultrasound metrics (>4–5 mm) to establish primary PDAL desmitis diagnoses, noting how tissue thickening creates a safe surgical margin to shield the SDFT.

SPEAKER_03 8:26

Wood et al. 2026. And the clinical challenge they are addressing is proximal digital annular ligament or uh PDL desmetus.

SPEAKER_02 8:34

Aaron Powell Okay, let's unpack this because why does this specific often overlooked ligament matter right now?

SPEAKER_03 8:39

Aaron Ross Powell Well, historically, PDL desmetus might have just been totally missed, you know, or just seemed incidental. Right. But they show that with ultrasound, if you see a combined thickness greater than four to five millimeters, you are dealing with a primary issue. And they outlined this with a really neat study design. First, they did an ex vivo study on 10 normal cadaver hind limbs to uh to refine the technique.

SPEAKER_02 8:59

Aaron Powell Okay, so starting on cadavers to get the approach down.

SPEAKER_03 9:02

Exactly. And then they followed that up by applying it to five live clinical cases.

SPEAKER_02 9:08

Aaron Powell I mean doing a tendoscopically guided desmotomy on the PDAL sounds um incredibly delicate. It's like trying to release a stuck pressure valve, but the valve is basically glued to the pipe, the pipe being the superficial digital flexor tendon or SDFT. Is it actually safe to cut this without just ruining the SDFT underneath?

SPEAKER_03 9:29

So that is the exact core tension here. Let's look at the clinical punchline from those live cases. Out of the five clinical cases, four of the horses became entirely sound.

SPEAKER_02 9:38

Oh wow, that is huge.

SPEAKER_03 9:40

Yeah, and they fully returned to their previous exercise levels. But I should mention the fifth horse was euthanized at three weeks due to post-operative synovial sepsis.

SPEAKER_02 9:48

Oh man, that is a harsh reminder about post-op care.

SPEAKER_03 9:52

Definitely. It underscores that meticulous aseptic technique is totally non-negotiable, even if the surgery goes well.

SPEAKER_02 9:58

Well, here's where it gets really interesting for me. Looking at the cadaver study, the proximal body of the PDL was never completely transected in those normal cadavers. Like not once.

SPEAKER_03 10:07

Not a single time, yeah. And the reason why that matters is that in normal cadavers, the healthy ligament is just, well, it's too thin.

SPEAKER_02 10:15

Aaron Powell So if you try to force the cut, you end up hitting things you shouldn't.

SPEAKER_03 10:19

Exactly. You risk iatrogenic SDFT damage, which they actually saw in four of the cadavers. But and this is the key in clinical decmatus cases, the pathological thickening actually makes the ligament easier to identify.

SPEAKER_02 10:33

Wait,

Actionable Desmotomy Steps: Performing a palmar/plantar annular ligament desmotomy to secure instrument space and utilizing a midline hypodermic needle guide at the SDFT bifurcation.

SPEAKER_02 10:34

really? So the disease itself creates the surgical margin?

SPEAKER_03 10:37

Yeah. Because it's so thickened, you suddenly have enough tissue to safely define it and cut it without hitting the tendon.

SPEAKER_02 10:44

Aaron Powell Okay, so what does this all mean for the surgeon scrubbing in tomorrow?

SPEAKER_03 10:48

Right. The actionable or our steps. First, you perform a palmar or plantar annular ligament, the pan desal dephame.

SPEAKER_02 10:55

Is that because the fet lock is constricted?

SPEAKER_03 10:57

Actually, no. You are simply doing it to gain maneuverability in the sheath. You just need the room.

SPEAKER_02 11:02

Oh, I see. Just giving your instruments some space.

SPEAKER_03 11:04

Precisely. Then, second step, you use a hypodermic needle at the SDFD bifurcation right on the midline. That needle acts as your midline guide, so you stay on track.

SPEAKER_02 11:13

Okay, got it. And what about the neurovascular bundle? I imagine that's a risk.

SPEAKER_03 11:17

Oh, totally. You have to be aware of the lateral plantar digital nerve and the lateral digital vein. This is especially crucial in like thick-skinned cob types because their percutaneous palpation is pretty impaired.

SPEAKER_02 11:30

So your anatomical awareness has to be absolutely flawless there.

SPEAKER_03 11:33

Exactly. So to wrap up the actionable take-home message here, PDAL dismetus is a significant primary diagnosis, and tenoscopically guided desmotomy is a highly viable restorative treatment.

SPEAKER_02 11:46

It really is. And you know, it makes you wonder think about all those mystery past or lameness cases in your past patient records.

SPEAKER_03 11:53

Oh, for sure.

SPEAKER_02 11:54

I mean, how many of those horses were walking around with this exact pathology just waiting for a tenoscopic desmotomy to fix it? It is definitely something to mull over before you review your next ultrasound.

SPEAKER_00 12:08

Now let's take a look at what the next paper shows us.

Woods et al. Study: Feasibility and Mapping of a Medial Tenoscopic Portal into the Equine Carpal Flexor Tendon Sheath (CFTS).

SPEAKER_03 12:16

So uh picture this. You are staring at the monitor, your instruments are locked in a purely proximal lateral approach to the carpal flexor tendon sheath, and you just you cannot reach that Palmar carpal bone fragment.

SPEAKER_02 12:30

Oh, yeah. The angle simply is not there. Aaron Powell Right.

SPEAKER_03 12:33

And suddenly the limitations of that lateral access are, well, they're glaringly obvious.

SPEAKER_02 12:38

Aaron Powell It is a classic anatomical bottleneck, really. I mean, the traditional lateral portal keeps you safe from major neurovascular structures, sure, but you sacrifice critical medial access to get that safety.

SPEAKER_03 12:50

Because the medial aspect is essentially just uh a tightly packed cable bundle. Exactly. It's like one stray millimeter, and you are nicking the cephalic vein, the CV, or the flexor carpi radialis tendon, the FCR key.

SPEAKER_02 13:02

Right, which is a nightmare.

SPEAKER_03 13:03

Total nightmare. But uh for today's deep dive into Woods at all, 2026, we are looking at a study

Pristine Coordinate Anatomy: Identifying a safe window located 5 mm proximal and 32 mm caudal to the distal medial radial physis (DMRP).

SPEAKER_03 13:09

that actually maps a viable route right through that anatomy. We're talking about exactly how to safely place a medial telescopic portal.

SPEAKER_02 13:16

Yeah, and that is exactly the goal here. Woods and the team, they used 20 cadaver forelimbs and contrast CT to really find a safe entry point. Okay. And they pinpointed a very specific window. It's uh five millimeters proximal and thirty-two millimeters caudal to the palpable distal medial radial physis or the DMRP.

SPEAKER_03 13:36

Wait, hold on. Five by thirty-two millimeters is a pristine coordinate for a cadaver under a CT scanner, right?

SPEAKER_02 13:42

Yeah. On paper, it's perfect.

SPEAKER_03 13:44

Right. But in a live bleeding surgical field, a five millimeter proximal margin is practically non existent. Like if a surgeon's blade shifts even a fraction, aren't they just going to shred the FCRT?

SPEAKER_02 13:55

Well, that was the exact risk they encountered during testing. Honestly. But the highly encouraging data point is that they had zero deep intrathical damage. Like the major deep structures were completely safe.

SPEAKER_03 14:08

Oh, wow.

SPEAKER_02 14:08

However, there is a catch. There was a 35% impingement rate on the FCRT along with uh a 5% hit rate on the

Triangulation and Mechanical Payoff: Unlocking a wide 120-to-140 degree instrument triangulation corridor to dramatically improve egress and visualization of caudal radial lesions.

SPEAKER_02 14:16

cephalic vein.

SPEAKER_03 14:17

Man, a 35% impingement rate on the FCRT guarantees serious post-stop lameness.

SPEAKER_02 14:22

It really does.

SPEAKER_03 14:22

I mean, going in blind on that side isn't just risky, it's reckless. So uh why are we risking this medial portal at all?

SPEAKER_02 14:29

Because of the mechanical payoff. It's huge. When you combine this new medial portal with your standard lateral portal, you achieve an instrument triangulation angle of about 120 to 140 degrees.

SPEAKER_03 14:42

Oh, so you are no longer fighting your own instruments?

SPEAKER_02 14:45

Precisely. You get vastly improved egress and visualization for caudal radial lesions. You suddenly gain access to areas that were previously, you know, deemed inoperable from a purely proximal lateral approach.

SPEAKER_03 14:57

Okay, I see the payoff. It's massive. But mechanically, how do we drop that 35% impingement risk down to zero?

SPEAKER_02 15:04

Aaron Powell So the authors found that placing the portal specifically cranial to the FCRT completely avoids those superficial structures. Oh, really? Yeah, you're essentially slipping into a natural fascial window that bypasses the tendon on

Cranial Dissection and Transillumination Mandates: Dropping complication risks to zero by manually dissecting a natural fascial window cranial to the FCRT using scope-driven light transmission to guide execution.

SPEAKER_02 15:17

the vein entirely.

SPEAKER_03 15:17

Aaron Powell Okay, but how do you find that window without cutting something?

SPEAKER_02 15:20

Aaron Powell Well, to safely locate that cranial window procedurally, you must abandon the blind stab incision. You have to use careful dissection through the skin and the subcutaneous tissue.

SPEAKER_03 15:31

Ah, I see. And if we are abandoning the blind stab, I would assume we use what's already in the joint.

SPEAKER_02 15:35

Yes, exactly.

SPEAKER_03 15:36

Like if you've got a lateral portal established, you can just drive the arsenoscope immediately and use transillumination, right? Spot on. You are effectively shining a high-powered light from the inside out to cast a shadow of the FCRT and CV on the medial tissues. So you can literally see the anatomy you need to avoid.

SPEAKER_02 15:53

That is the exact technique the authors advise. The light exposes the superficial structures from within before you even complete the medial entry.

SPEAKER_03 16:01

That makes so much sense.

SPEAKER_02 16:02

It really does. So for the equine surgeon scrubbing in tomorrow, the main takeaway from Woods at all 2026 is this a medial CFTS portal is highly feasible, five millimeters proximal and 32 millimeters caudal to the DMRP.

SPEAKER_03 16:17

Right.

SPEAKER_02 16:17

It unlocks 120 to 140 degrees of triangulation, provided you use diligent dissection and transillumination to protect the FCRT.

SPEAKER_03 16:26

It is just a massive upgrade in dexterity just by utilizing the tools already in your hand differently. Which, you know, leaves you with this to ponder. If this medial approach becomes standard practice, routinely guided by transillumination or even interoperative ultrasound, how long until we are regularly curing those chronic medial palmar lesions we currently just write off as too difficult to reach.

SPEAKER_00 16:50

That's it for this episode of the Simony Surgery Podcast.

SPEAKER_01 16:53

This show is brought to you by Semini Protect Lavage, our interoperative lavage developed to target resistant bacteria and biofilms where traditional solutions of saline and post op antibiotics fall short. If you're interested in learning more or trying out your own procedures, you'll find information and links in the show notes. For listening, and we'll see you in the next episode.