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SURGICAL MANAGEMENT OF UNSTABLE DIAPHYSEAL TIBIAL FRACTURE WITH CONVENTIONAL DYNAMIC COMPRESSION PLATING (DCP) IN DOGS
B. C. Das*1, S.Thilagar2, S. Ayyappan3, B. Justin William3, Mohd. Shafiuzama3 and A. Arun Prasad3
1Department of Medicine and Surgery, Faculty of Veterinary Medicine, Chittagong Veterinary and Animal
Sciences University, Chittagong-4202, Bangladesh
2Controller of Examinations, Tamilnadu Veterinary and Animal Sciences University, Madhavaram Milk
Colony, Chennai 600 051, India
3Department of Veterinary Surgery and Radiology, Madras Veterinary College (MVC), Chennai 600 007, India.
*Corresponding author’s e-mail: [email protected]
IRJALS Research Paper
ISSN: 1839-8499
May – 2012 Volume – 1, Issue – 2
Article #05
Scholars
Knowledge is Power
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Abstract
Diaphyseal tibial fractures are very common in dogs and would present in a variety in forms. Among all
fracture repair modality, plating is most popular and effective technique for fracture management. The
aim of this study was to evaluate the suitability of commonly used dynamic compressing plating
technique in dogs. Six clinical cases presenting to the Small Animal Orthopaedic Outpatient Unit of
Madras Veterinary College Teaching Hospital, Chennai, Tamilnadu, India were subjected to detailed
orthopaedic and radiographic examination and comprehensive study including lameness grade,
functional outcome, radiograhic evaluation and postoperative complications. The lameness grade was
improved on immediate postoperative day in all cases and the functional outcome was graded as
excellent in three cases (50.0%) and good in two cases (33.3%) and fair in one case (16.7%).
Radiographic evaluation indicated primary healing in five cases. Seroma formation, self-mutilated
wound, plate bending and distal screw exposed were observed on postoperative period.
Keywords: Unstable diaphyseal tibial fracture, dogs, dynamic compression plating, lameness grade,
functional outcome, radiographic evaluation.
Citation: Das B. C. (2012), SURGICAL MANAGEMENT OF UNSTABLE DIAPHYSEAL TIBIAL FRACTURE
WITH CONVENTIONAL DYNAMIC COMPRESSION PLATING (DCP) IN DOGS. IRJALS 1(2): p. 36 – 48.
Received: 13-05-2012 Accepted: 19-05-2012
Copyright: @ 2012 Das BC et al. This is an open access article distributed under the terms of the
Creative Common Attribution 3.0 License.
37
1. Introduction
Tibial fractures account for the third most common type of fracture after femur and radius and ulna [1]
and comprise 21.0 per cent [2] of all long bone fractures. Tibial diaphyseal fractures account for 75.0 per
cent to 81.0 per cent of all tibial fractures[3].
The goal of any fracture treatment is to restore the anatomical shape of the fractured bone to promote
stability of fracture with suitable implants and enable the limb to early ambulation. The fracture repair
techniques using bone plates, external fixators, interlocking nails, intramedullary pins and external
coaptation are currently practiced in the tibial fracture management[4]. Bone plating is commonly used
for tibial fractures and is one of the most popular and successful technique for fracture fixation[5]. The
dynamic compression plate (DCP) is a special implant developed by the AO/ASIF group for compression
and stabilization of the plate to the bone. It has the advantages of producing stable internal fixation, low
incidence of malunion and does not warrant external immobilization, thus allowing immediate movement
of neighboring joints and early ambulation [6].
The objectives of the present study were to evaluate the outcome of conventional dynamic compression
plating technique by clinical and radiological analysis and to study postoperative complications, if any.
2. Materials and Methods
The present study was carried out on 6 clinical cases presenting to the Small Animal Orthopaedic
Outpatient Unit of Madras Veterinary College Teaching Hospital, Chennai, Tamilnadu, India.
Selection of cases
Dogs presented with history and clinical signs suggestive of diaphyseal tibial fractures were subjected to
detailed physical, orthopaedic, radiographic examination to confirm the diagnosis and classify the tibial
fractures. The six cases were of both sexes selected on the basis of fracture patient assessment score
(FPAS) and were free from any concurrent neurologic, metabolic or infectious diseases. Fracture Patient
Assessment Score (FPAS) was followed for preoperative decision making. The assessment was carried
with simple 1-10 scoring system [7]. Fracture Patient Assessment Score considered the mechanical,
biological and clinical factors which influenced fracture healing. In the present study, a lower scale (<4)
indicates an unfavourable prognosis, a middle range (5-7) indicates a guarded prognosis and a higher
scale (>7) indicates a favourable prognosis.
38
Preoperative plan
Preoperative plan was prepared using a small animal preoperative planning guide developed by the
AO/ASIF group using plain radiographs. Preoperative mediolateral radiograph of the contralateral limb
was used to measure the diameter and length of the plate and the craniocaudal view was used to determine
the diameter and length of the screws. The weight of the dog was taken into consideration for plate
selection [8]. A standard orthopaedic set, a general surgical instrumentation set and an AO/ ASIF plate
instrumentation set were used in the study.
Surgical treatment
Dogs were fasted for 12 hours prior to surgery and water was provided until 4 hours prior to
premedication. The dogs were premedicated with atropine sulphate and xylazine hydrochloride at the
dose rate of 0.04 mg/kg and 1.0 mg/kg body weight intramuscular respectively. Anaesthesia was induced
by combination of Ketamine hydrochloride and diazepam at the dose rate of 5 mg/kg and 0.05 mg/kg
body weight intravenous respectively. After intubation, anaesthesia was maintained by 2.0 to 2.5 per cent
isoflurane with 100 per cent oxygen at a standard flow rate. Lactated ringers solution was infused
intravenously at a flow rate of 10 ml/kg/hr during surgery. The affected limb was prepared by clipping
and shaving the area from the stifle joint upto the hock joint and scrubbed with povidone iodine solution
(7.5% w/v). The affected limb was bandaged from digit upto the hock joint. The dog was positioned in
lateral recumbency with the affected limb below and contralateral limb above on the operation table. The
affected limb was bandaged using sterile crepe from digit upto the hock and surgical site draped as per
standard protocol. Surgical site was scrubbed using antiseptic 70.0 per cent alcohol. The tibia was
approached through medial curvilinear incision for standard dynamic compression plating technique [9]
and operation was performed as standard dynamic compression plating technique.
Postoperatively, a Modified Robert Jones bandage was applied from digits upto stifle joint for 7 to 10
days. An Elizabethan collar was applied to prevent disturbance of bandage and protect the surgical site.
Ice packs were applied surrounding the operated site for 15 to 20 minutes four times a day immediately
after surgery through the first 24 hours followed by warm packs for the next 24 hours. Ceftriaxone and
Tazobactam (Intacef-tazo
®) and Meloxicam
(Melonex
®) were administered at the dose rate of 20 mg/kg
and 0.2 mg/kg b. wt intravenously for five and three days respectively. Animals were allowed limited
exercise with short duration leash walk for 4-6 weeks. Passive exercises of the affected limb were
39
performed 2 to 4 times daily during the convalescent period. Sutures were removed on the 10th post
operative day. Parameters studied lameness evaluation, functional outcome, radiologic evaluation and
postoperative complications.
3. Results
Lameness grade
A lameness grade was assigned on the basis of severity of clinical signs on preoperatively and 1st, 7
th, 14
th,
30th and 60
th postoperative day to assess the response to treatment. Weight bearing was graded as
followed by Vasseur et al., [10]. The lameness grade was 5 on pre-operative day (Fig. 1) in all cases and
improved on immediate postoperative day in all cases. Normal weight bearing on all limbs at rest and
walking was noticed in case No. 6 on 7th postoperative day, in case No. 1 and 3 on 14
th postoperative day
( Fig. 2) and in case No. 2, 4 and 5 on 30th postoperative day. The lameness grading are represented in
Table 1.
Functional outcome
Functional outcome was evaluated on the 60th postoperative day and categorized as excellent, good, fair
and poor in all the groups of animals [11]. The assessment was subjective and based on individual
evaluation. The functional limb outcome was graded as excellent in three cases (Fig. 3) (50.0%) and good
in two cases (33.3%) and fair in one case (16.7%) (Table 1).
Radiographic evaluation
The operated limb was radiographed in orthogonal views Radiographs were taken using a Siemens 500
mA, 3 phase, 6 pulse, X-ray generator with a focal film distance of 100 cm using 50 - 60 kVp, 80 mA and
8 to 16mAs.
Radiographic evaluation was assessed on immediate postoperative day based on ‘four A’s (apposition,
alignment and angulation and apparatus) and follow-up radiographs 7th, 14
th, 30
th and 60
th based on ‘six
A’s (apposition, alignment and angulation, apparatus, activity and architecture) [12]. Score for apposition
and alignment (0-3) was given as followed by Cook et al., [13]. On immediate postoperative day, the
fracture apposition and alignment score for all cases was 0 at immediate postoperative day. The
angulation of the bone was normal in all cases. The plate length, size and position was appropriate in all
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cases. Screw length was appropriate in all cases except in case No. 4 where distal cortical screws were
shorter and not placed bicortically. Screw position was appropriate in all cases except in case No. 1 where
one proximal and one distal screw was placed in the fracture fragments. Screw sizes were appropriate in
all cases.
On follow-up radiographs, apposition and alignment of fractured fragments with adequate cortical contact
between fractured fragments were maintained at immediate postoperative day except in case No. 1 and 5,
was not maintained in postoperative period. Regarding angulation, mild valgus was noticed in case No. 1
at 30th and 60
th postoperative day and moderate valgus was noticed in case No. 5 at 14
th, 30
th and 60
th
postoperative day. The plate was in position in case No. 2, 3, 4 and 6. Mild plate bending was noticed in
case No. 1 at 30th and 60
th postoperative day and severe plate bending at the fracture site was noticed in
case No. 5 at 14th, 30
th and 60
th postoperative day and cortical screw position was appropriate in all cases
( Table 2). Radiographic evaluation of activity, clinical union was noticed at 60th postoperative day in
case No. 2 (Fig.4). Evidence of primary bone healing was noticed in all cases except case No. 2 which
showed evidence of secondary bone healing (Table 2). Primary bone healing was evidenced by absent or
minimal external callus and secondary bone healing was evidenced by formation of periosteal callus.
Clinical union was evidenced by closure of fracture gap. Soft tissue swelling at fracture site was noticed
in case No. 2, at 14th postoperative day and case No. 5 at 7
th and 14
th postoperative days. There was
alteration of bone density in case No. 2, which showed synostosis (Fig. 7) between tibia and fibula.
Postoperative complications
Seroma formation was observed at distal tibia in case No. 1, 2 and 5 at 1st postoperative day. Self
mutilated wound was noticed at 7th postoperative day in case No. 5. Mild plate bending was observed in
case No. 1 and severe plate bending ( Fig. 5) was observed in case No. 5 at 14th postoperative day. In case
No. 2, distal three screws were found to be exposed through the skin at 60th postoperative day (Fig 6).
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Fig 1: Non weight bearing lameness grade
V- case No. 3
Fig 2: Normal weight bearing, grade1 at
14th postoperative day-case No.3
Fig 3: Functional outcome-case No. 3
Fig 4. 60th
day PO mediolateral and
craniocaudal radiographs-case No. 2
42
Table 1: Lameness grades and Functional outcome
Case
No.
Lameness grade Functional outcome
Pre-
operative
Post-operative
Day 1 Day 7 Day
14
Day
30
Day
60
Excellent Good Fair Poor
1 5 3 2 1 1 1
- + - -
2 5 4 3 2 1 1
- - + -
3 5 3 2 1 1 1
+ - - -
4 5 4 3 2 1 1
+ - - -
5 5 4 4 3 1 1
- + - -
6 5 2 1 1 1 1
+ - - -
Fig 5:- Severe plate
bending at 14th
postoperative day-case No.
5
Fig 6:- Distal plate and
screws exposed through the
skin at 60th
postoperative
day-case No.2
Fig 7: Mediolateral and
craniocaudal radiographs-
case No. 2 at 105th
postoperative day
43
Table 2: Follow-up radiographic evaluation of apparatus (DCP) apparatus (screw) and activity on day 7, 14, 30 and 60th
day
Case
No.
Apparatus (DCP) Apparatus (screw) Activity
D7 D14 D30 D60 D7 D14 D30 D60 D7 D14 D30 D60
1 IP IP Mild bending Mild bending IP IP IP IP NEBH NEBH PHP PHP
2 IP IP IP IP IP IP IP IP NEBH SHP SHP CU
3 IP IP IP IP IP IP IP IP NEBH NEBH PHP PHP
4 IP IP IP IP IP IP IP IP NEBH NEBH PHP PHP
5 IP
Severe
Bending at
fracture site
Severe
Bending at
fracture site
Severe
Bending at
fracture site
IP IP IP IP NEBH NEBH PHP PHP
6 IP IP IP IP IP IP IP IP NEBH NEBH PHP PHP
IP= In Position, D= Day, NEBH- No evidence of bone healing, PHP- Primary healing progressive, CU- Clinical union, SHP- Secondary healing
progressiv
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4. Discussion
The standard approach to tibia provided adequate exposure with minimal soft tissue and vascular trauma
to the fracture site. This approach also facilitated mobility and reduction of fractured fragments. Similar
approach has been reported previously [1, 9]. However, a lateral surgical approach can be used in some
cases to avoid closing skin directly over a large bone plate [14].
The dynamic compression plate used in this study was a special implant developed by AO group for
compression and stabilization of the fracture. When screws were inserted on either side of fracture gap,
the bone and the plate move longitudinally relative to one another, with the plate under tension, the bone
came under compression and the fracture gap was narrowed. Similar procedure has been reported
previously [15, 16]. Three major factors were taken into consideration for plate application. The plate was
applied on the tension side of the bone to convert tensile forces of eccentrically loaded bone to
compressive forces, contouring the plate to original shape and curve of the bone to bring about adequate
fracture alignment and a minimum of six cortices each be engaged by screws bicortically on either side of
the fracture. Eccentric drill guide provided displacement of plate relative to bone. As the screw was
tightened, adjoining bone fragments created interfragmentary strain. This was in accordance with the
procedure of Brinker (15) who reported that there was one millimeter displacement for 3.5 mm dynamic
compression plate and only two screws could be placed eccentrically on each side of fracture. Generally
plate should be applied on the tension side of the bone. The tibia is ‘S’ or sigmoid in shape. The tension
surface of the proximal tibia is cranial but plates were generally placed in the medial side of the tibia
because of the ease of application due to less muscular coverage. However, it was best to place the plate
on the tension side of the bone or on the convex surface of a bone [7]. This is not possible in tibia where
the plate is generally placed on the medial aspect. In the present study, plate application on medial surface
was found to be effective to counteract the fracture forces like compression, tension, bending, torsion and
shearing forces.
Postoperatively lameness grade showed gradual improvement to normal weight bearing over the period of
study. The lameness grade was carried out in accordance with the protocol developed by Vasseur et al.,
(10). Normal weight bearing on all limbs at rest and when walking which was graded as 1 and this was
attributed to adequate fracture reduction with plate load sharing between implant and bone and minimal
disruption of the soft tissue. In the present study, the lameness grading score is in accordance with the
fundamental principle of AO/ASIF which aims to promote pain free mobility through stable internal
fixation and preservation of vascularity with minimal soft tissue trauma. Complete weight bearing was
45
observed from 2nd
day onwards in all 6 dogs with femur and radial fractures managed using 6 hole and 4
hole DCP respectively [17 ]. Dogs started to bear weight on the operated limb on 7th to 10
th postoperative
day and walked normally without any signs of pain or limping 15 to 20 days after the operation [ 18].
In the present study, all the dogs were evaluated for functional outcome at 60th postoperative day and
categorized as excellent, good, fair and poor based on the classification suggested by Clark (11). 16 cases
(89.0%) had a successful return to function in 22 radius and ulnar fractures treated by bone plate [19].
Return to normal, full function of the injured limb in about 3.5 weeks by bone plating [20]. The full
functional limb usage was with an average of 49 days in six cases of femur diaphyseal transverse
fractures in dogs treated by bone plating [21].
In the present study, radiographic evaluation was carried out pre-operatively, immediate post-operative
day, 7th post-operative day, 14
th post-operative day, 30
th post-operative day and 60
th post-operative day to
assess the status and condition of apposition and alignment, angulation, apparatus (DCP and screw),
activity (the progress of fracture healing) and architecture (soft tissue and bone). This evaluation was in
accordance with Saravanan et al. [22], who reported that radiographically assessed on immediate
postoperative day and subsequently on days 15, 30, 45 and 60 postoperatively for experimentally created
comminuted diaphyseal femoral fractures treated by neutralization bone plating. A fracture reduction and
apposition scoring system based on anatomical reduction [8]. This system was used in the present study.
Quality of the fracture reduction was assessed by alignment of the fragments and present of a shift on the
craniocaudal and lateral projection. For good functional outcome and early limb function, perfect
anatomical reduction was necessary [23]. This finding concurred with the above observations. In the
present study, angulation deformity like valgus was in accordance with Dudley et al. [24].
Clinical union occurs in young animals that healed more rapidly than older animals [8, 25]. Primary
healing was evidenced by absence or minimal external callus formation. In primary healing, initial
resorption at fracture ends increased the fracture gap, reduced inter fragmentary compression and
promoted osteogenesis. This primary healing was in accordance with Rahn et al. (26), who stated that
direct bone healing occurred under conditions of stable injuries or rigid internal fixation, fracture
compression and where there was complete apposition of fracture fragments and there was little or no
bridging / external callus formation, because of no mechanical instability.
In the present study, seroma, self mutilated wound, plate bending, exposed plate and screws through the
skin in the distal tibia were observed during postoperative period. Postoperative seroma may probably be
46
due to more dead space at the fracture site and implant irritation. Plate bending was probably due to
fatigue failure of the plate in the fracture zone and prolonged cyclic loading. This finding was in
agreement with the finding of Sharma et al. [27], who reported plate bending in six cases of femur out of
30 different long bone fracture cases. Fatigue failure was probably due to inadequate postoperative care
and imbalance weight bearing due to craniodorsal hip dislocation in contralateral limb (case No. 5).
Distal plate exposure through the skin might be probably due to tension at distal skin incision site and
insufficient exposure of distal surgical site during plate fixation. Screw loosening and fixation failure,
broken bone plate, nonunion, malunion stress protection were common in conventional dynamic
compression plate [28]. However, these complications were not observed in any cases. Synostosis
formation was in accordance with Morgan and Leighton [29] who also reported synostosis was found in
radius and ulna fracture management.
Conclusion
Standard medial approach was ideally suited for management of unstable diaphyseal tibial fractures using
conventional dynamic compression plating technique. Dynamic compression plate primarily counteracted
compression, tension, torsion and shearing but was not good enough in countering the bending force in
this study. In the present study, conventional dynamic compression plating technique provided good
apposition and alignment of the fracture fragment and early functional outcome.
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