36

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: bcdas2002@gmail.com

IRJALS Research Paper

ISSN: 1839-8499

May – 2012 Volume – 1, Issue – 2

Article #05

Scholars

Knowledge is Power

www.setscholars.org

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

40

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).

41

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

44

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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