Weekend Interview: New Bolton surgeons

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The veterinarians talk like it’s routine, or at least common, to slice into a horse’s shoulder, move muscles and nerves, find bone fragments, drop those fragments in a cup and put everything back together again.

The rest of us, can just wonder what it’s like. Though Dr. David Levine and Dr. Mike Ross can try to explain it. I interviewed Levine and Ross for an article about injured steeplechase horse Mandola, who broke his left shoulder in a fall at Saratoga last summer. In hopes of giving the horse a life of retirement (at least), owners Arthur and Staci Hancock and co-owner/trainer Jonathan Sheppard opted for treatment.

Levine, Ross and a team at the University of Pennsylvania’s New Bolton Center large animal hospital did the rest.

In conversations with Levine and Ross, we looked at X-rays, a skeleton model and the actual bone fragments, but I don’t think I’ll ever quite grasp it. See the feature story here, but there was plenty of leftover material.

Did you see the injury occur?
Levine (Mandola’s regular veterinarian): I was watching online and of course I was like ‘Oh no.’ He came back (from Saratoga) and I looked at him. We worried about a bunch of things – his shoulder, his knee . . .

What was the injury?
Levine: He fractured the front of the scapula that makes up the shoulder joint. It’s a bone called the superglenoid tubercle. He had big fragments, but a lot of them and they weren’t able to be reconstructed and put back together.

Why choose surgery?
Levine:
We were talking back and forth about the prognosis and what the options were for him – surgery, doing nothing, euthanasia. It was going to be a challenging bit of surgery. It was going to take two hours.

Ross: With a piece involving the joint and all those pieces you can’t repair, you just figure you’re best to get them out. A missing piece is better than a piece that’s wobbling in the joint. What we would have done if there was one single fragment was try to repair (with screws and a plate or plates) without cutting the tendon, that’s the best of both worlds. In this horse, a repair – even if it was a simple fracture – a repair would have been very challenging because you can’t do it with minimally invasive techniques. There’s no practical way to do it. You’re dealing with a wound that’s five or six inches deep and other incisions to get your drill bits and things in there. It’s challenging, but it could have been done. In this case, there were too many pieces to do that. The only option was to leave them and hope for the best or do what we wound up doing. Surgery maximizes chances of healing.

What was the goal?
Levine:
They wanted to save the horse, they wanted to use the horse if they could, and what could we do to potentially improve the outcome for this horse. A lot of it comes down to money, which is a shame but it’s a reality. To have an owner that decides not to collect on insurance, and go forward with a challenging surgery knowing they might have a pasture ornament at the end because they like the horse – that’s nice, that’s good for us. That makes our job easier.

Describe the process.
Ross: There’s usually something in the way that you’ve got to preserve. There’s a huge nerve right here. The super-scapular nerve. The most important thing on our mind is that nerve.

Levine: You make an incision and come straight around. It’s a big, curved incision. You see the bones here (on a desktop skeleton model) and it looks easy, but it’s a long way in there. The first thing we did in surgery was find the nerve. Isolated it, and moved it out of the way. It’s as wide as your index finger. It’s a huge nerve and it’s right where we wanted to be.

Ross: You have to cut the (biceps brachia) tendon off the bone while saving as much of it as you can and then get the fragments out.

Levine: Then it’s a matter of closing all the layers back up.

How important is recovery?
Levine: You cross your fingers. We have a good anesthesia team, but you’re never out of the woods until they’re up.

Ross: As David said, we were holding our breath a little bit and reserving a call to the owners after surgery until he stood up. It’s a general anesthetic procedure, which you worry about, but the stability of the shoulder joint was a concern too. It wasn’t really disrupted by the surgery, but it was disrupted by the injury.

Did you use the recovery pool?
Ross: No. One problem with the pool is the shoulder is right against the raft. The pool/raft recovery system is a cost/benefit decision. If the horse has a catastrophic recovery we’ll forever say, ‘Why didn’t we use the pool?’ But it’s not a routine thing. It’s labor intensive, it’s costly and it’s not necessarily a slam dunk that the horse is going to recover well. Weighing all the factors, we thought it was reasonable to let the horse recover in a recovery stall. He had a padded matt, a tail rope and a head rope.

What did New Bolton learn from Mandola?

Levine: Students come in and think we can fix anything after a horse like that.

Ross: The good thing about New Bolton Center is we’re a group of people. It’s like a think tank for the betterment of horses or horse healthcare. Together, we’ve developed experience in managing things like this. I admit that sometimes your next case is based on what you’ve done in the last case. ‘Oh my gosh, that didn’t work. You better try something else.’ To us, and I’m looking at Barbaro and the dramatic and massive amount of information and experience all of us gained even though I wasn’t that involved in it. From that experience allowed to us by the Jacksons (Barbaro’s owners/breeders) we learned so much. We’re learning all the time.