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Bulletin UASVM, Veterinary Medicine, 70(2)/2013

Print ISSN 1843-5270; Electronic ISSN 1843-5378

Assessment of Long Bone Fractures Healing Outgoing


Minimally Invasive Plate Osteosynthesis in Dogs

PROTEASA Adelina1*, Roxana DASCĂLU1,


Larisa SCHUSZLER1, Aurel SALA1, Cornel IGNA1
1
Banat University of Agricultural Sciences and Veterinary Medicine from Timisoara, Romania
*
Corresponding author: adelinaproteasa@yahoo.com

Abstract. Biological osteosynthesis, characterized by maximizing the potential of healing by


balancing biology and mechanics in the fracture site is supported by orthopedic techniques which
are basically assisting physiological bone healing process. This paper represents one side of a
complex database that monitors the functional results of biological osteosynthesis in dogs.
Indications of MIPO are considered to be multiple fractures and highly cominutive fractures with
best results regarding time healing when compared with classical technique. Our aim is to compare
MIPO and ORIF in cases of simple fractures. A group of 12 dogs diagnosed with fractures of long
bones (humerus, radius, femur, tibia) and treated by minimally invasive plate osteosynthesis was
assessed every two weeks until healing was X-ray certified. Obtained data were compared with
those achieved by other authors for MIPO, but also already well-known results of ORIF, regarding
healing time, degree of lameness, time of gait regaining and operative time in fact. Our results
indicate a healing time similar to classical techniques, ranging between 30 and 90 days, even if the
literature mentions that minimally invasive techniques promotes bone healing due to local vascular
protection by not opening the fracture site. Although the time healing is rated and the technique
sometimes challenging, reduction of postoperative pain and early gait regaining are still two
important advantages that pleads for MIPO.
Keywords. biological osteosynthesis, MIPO, fracture, long bones, dog.

INTRODUCTION

The main objective of biological osteosynthesis was developed by considering the


advantages of preserving the fracture hematoma and blood reserves (Palmer, 1999 Field and
Tornkvist, 2001 Perren, 2002): maximizing the healing potential by balancing biological and
mechanical function in the fracture site (Schatzker, 1995, Perren, 2002).
Biological osteosynthesis is obtained by applying minimally invasive techniques,
namely percutaneous plate insertion, interlocking nailing, external fixationg or a combination
thereof, and indirect reduction of the fracture (Beale, 2004). Biological osteosynthesis
techniques practically assist the physiological process of bone healing with minimal
intervention in the fracture site (Pradyumna et. al., 2005 cited by Hudson, 2009).
Minimally invasive plate osteosynthesis (MIPO) is the most recent evolution of
biological osteosynthesis because the fracture site is not exposed and the bone fragments are
reduced with indirect reduction techniques (Farouk et al., 1999; Krettek et al., 2001). MIPO
has all the biomechanical advantages of the classic method, the aim of absolute stability being
replaced with a more „elastic”, more flexible fixation that allows micromovements in the
fracture site promotting indirect healing and massive callus formation (Nikolaou et al., 2008).
Fracture healing can occur following two patterns: primary healing or Haversian healing
(characterizes all cases with implants that provide absolute stability) and secondary healing
(enchondral and intramembranous healing) (characterizing cases of non- and semi- rigid/ stiff
implants involving a reaction of the periosteum and the soft tissue) (Moore, 2013).

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MIPO advantages compared with ORIF (Open Reduction Internal Fixation) are
significant and related to the decrease of postoperative septic complications (Helfet et al.,
1997), iatrogenic trauma (Kinast et. al., 1989), postoperative pain (Wagner and Frigg, 2006)
and healing time (Wagner and Frigg, 2006), implying a similar stability to classical
techniques (Blauth et al., 2001).

MATERIALS AND METHODS

The group taken into study was composed of individuals of the species Canis familiaris
diagnosed with simple/ minimum degree of comminution fracture of long bones in the Surgery
Department of the Faculty of Veterinary Medicine fromTimisoara, heterogeneous in terms of
age, weight and race. For pre-, intra-and postoperative imaging we used Siremobil Compact L
(Siemens) for intraoperative control images acquisition and the radiological facility type Multix
Swing (Siemens) (computerized radiography system (CR) Direct View Vista CR (Caresteam)
for image processing and AQS Vet Standalone software (Arzt + Praxis GmbH)).
Assessment of the degree of lameness was done subjectively, taking into account the
characteristics described by Jaeger et al. in 2007 for each grade (0 – no lameness; 1 – barely
disturbed locomotion; 2 - locomotion disturbed but limb(s) still bearing weight; 3 – lameness
with limb(s) not always bearing weight; 4 - no weight bearing on limb(s)).
Stage of healing was assessed by the method of Hammer (1985) cited by Boero
Baroncelli in 2012. Characteristics of the stability of metal implants were interpreted by
analyzing the plate bridging ratio and the plate working length.
Statistical analysis was performed by calculating proportions, mean, standard
deviation and by implementing the Friedman test.

RESULTS AND DISCUSSIONS

The group had a mean age of 35 ± 37 months and weight of 16 ± 9 kg (Table 1).
General inhalation anesthesia involved premedication with acepromazine (0.2 mg / kg) and
ketamine (7 mg / kg), induction with 3-5% isoflurane in oxygen and 1-3% isoflurane
maintenance. In the first 24 hours immediately after surgery, pain was controlled by
administration of butorphanol subcutaneously at a dose of 0.1 mg / kg every 6 hours.

A B
Fig. 1. Patient preparation for MIPO (A). Fixing plate after indirect reduction
of a simple diaphyseal fracture of the humerus (B).

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Preoperative antibiotic therapy has been carried out by administration of amoxicillin
with clavulanic acid (12.5 mg / kg). Implant selection was at surgeons’ discretion (LCP or
LC-DCP). Plate contouring was achieved by the healthy limb. After performing small
incisions („stab” incisions) at the proximal and distal parts of the bone and creating an
epiperiosteal tunnel between the two skin „breaches”, the plate is advanced and screws are
applied at the ends of the plate without having intervened in fracture site.
The indirect reduction of the fracture was assessed by fluoroscopy. Minimum
operating time was 60 minutes, with an average of 79 ± 22 minutes. Most of the time was
designated to the indirect reduction of the fracture. Some authors state that the use of
intramedullary nail or external fixation for fracture reduction decreases operating time and
the time of exposure to X-rays (Babst et al., 2012). Time for solving humeral fractures
using minimally invasive techniques plate was reported at 91.5 minutes and the average
time of 160.3 seconds radiation exposure (Li et al., 2012), and distal femur fractures 70
minutes ranging from 60 to 100 minutes (Nayak et al., 2011).

Tabel 1

General data of the study group

Fracture Operating Healing


Age Weight
ID Gender (after time time
(months) (kg)
AO**) (minute) (zile)
1 14 19,5 M 42A3 65 75
2 120 8 M 32A3 75 105
3 60 5 M 42A3 60 90
4 3 4 F 32A3 60 75
5 12 23 F 42A3 65 300*
6 18 11 F 12A3 110 60
7 86 28 M 32A2 124 210*
8 60 23 M 22A3 95 60
9 24 4 M 42A3 93 60
10 8 26 M 22A2 65 30
11 8 26 M 42A3 55 45
12 12 16 M 12A3 75 60
Mean 35 16 79 66
StDev 37 9 22 21,4
* cases presented complications and were excluded from the study group after 3 months
** AO = Arbeitsgemeinschaft für Osteosynthesefragen

Implants characteristics assessment was done by determining two parameters,


namely the plate bridging ratio (ratio between the plate length and the bone length) and the
plate working length (distance between proximal and distal screw closest to the fracture,
reported to the length of the plate). In this study the plate working length had an average of
56 ± 12% and the plate bridging ratio 73 ± 11%. Locking plates are often used in minimally
invasive techniques aiming to reduce iatrogenic trauma to soft tissues and excessive
devascularisation the fracture site. In case of MIPO, plates act as bridging plates without
interfragmentary compression. In the absence of direct, absolute reduction and of rigid
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interfragmentary compression, these methods guide healing to secondary healing with callus
formation which requires a certain amount of movement in the fracture site. In some recent
studies, authors noted that some implants applied minimally invasive are too rigid and may
lead to non-union (Henderson et al., 2008). Rigidity of the fixation and the grade of motion
in the fracture site are directly related to the plate working length. Torsional rigidity is
inversely proportional to the length of the plate and has bending rigidity is inversely
proportional to the square of the plate working length (Fitzgerald et al., 2002).
Boero Baroncelli in 2012, in a MIPO - ORIF comparative study in dogs, states that the
plate bridging ratio for MIPO was 83.3 ± 5.3% vs. 76.4 ± 10.4% ORIF and the plate working
length showed the following values: MIPO group 56.5 ± 8.8% and 42.3 ± 19.1% ORIF group.
To obtain rapid healing the method of osteosynthesis will vary depending on the
fracture pattern. Hak et al. in 2010 states that simple fractures, when possible, will be treated
by direct reduction and interfragmentary compression. Absolute stability offered by this
method minimizes interfragmentary motion and allows primary healing. In contrast, highly
comminuted fractures are best solved by indirect reduction and bridging fixation. Relative
stability obtained by this method allows micromotion in the fracture site, stimulating callus
formation and secondary bone healing (Hak et al., 2010).

A B C D E

Fig. 2 Simple diaphyseal fracture of the humerus in a cross-breeded.


Preoperatively (A). Immediately postoperatively (B). One month postoperatively (C).
Two months postoperatively (D). Three months postoperatively (E).

In the current study, healing time was 66 ± 21.4 days. A fracture was considered healed
when the fracture line was obliterated and callus had a homogenous bone structure (Figure 2).
Of the 12 cases, two presented complications: delayed union in a case of femur fracture and a
case of screw loosening for a fracture of the tibia. Figure 3 shows the mean healing gradient for
a period of 12 weeks in the 12 patients taking into sudy. Differences within each assessment
were statistically significant (Friedman Test, p <0.05, p = 0.00001). Pozzi in 2013, after
leading a study regarding the radius and ulna, stated that these bone fractures repaired by
minimally invasive techniques have healed significantly faster than those treated by classical
technique. Values were 30 days for MIPO and 64 days for ORIF (Pozzi et al., 2013).

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Tabel 2

General data of metal implants

Distance
Plate
Plate length Bone length between two Plate working
ID bridging
(mm) (mm) closest length (%)
ratio (%)
screws (mm)
1 138 179 77 74 54
2 87 122 71 52 60
3 70 121 58 35 50
4 72 102 71 38 53
5 158 172 92 106 67
6 134 155 86 87 65
7 134 234 57 74 55
8 144 200 72 105 73
9 68 108 63 29 43
10 132 199 66 38 29
11 165 221 75 96 58
12 134 160 84 82 61
Mean 120 164 73 68 56
StDev 35 44 11 28 12

Fracture healing was evaluated by the method suggested by Hammer in 1985 and
quoted by Boero Baroncelli in 2012.

Tabel 3

Healing score system used by Hammer, 1985 cit. de Boero Baroncelli et al., 2012

Grade 1 2 3 4 5
Callus Homogenous Massive Apparent Trace No callus
formation bone bone trabeculae bridging of No bridging formation
structure crossing the of the
the fracture fracture line fracture
line line
Fracture Obliterated Barely Discernible Distinct Distinct
line discernible
Stage of Achieved Achieved Uncertain Not achieved Not
union achieved

In another study conducted on a group of 22 dogs with diaphyseal tibial fractures


repaired using MIPO, noted that there were no statistically significant differences when
compared with ORIF, in terms of time to radiographic union and healing gradient (Boero
Baroncelli et al., 2012). Although MIPO technique offers some advantages, there are few
clinical studies that can certify the difference between healing time of fractures repaired
MIPO and ORIF (Guiot and Dejardin, 2011). Unstable fracture healing is characterized by

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the immediate formation of callus prior to new bone. This type of healing is healing
indirect or secondary. The amount of callus depends on the stability of the fractur e and
increases with the degree of instability (Johnson et al., 2005).

Fig 3. Mean healing gradient during 12 weeks monitoring

Lameness was subjectively evaluated and the results are shown in Figure 4. For data
collected during monitoring, the Friedman Test was implemented to analyze the gradient of
lameness, and the results were statistically significant (p <0.05, p = 0.00001), meaning that
there were important changes in the degree of lameness from week to week, influencing the
time of normal gait regaining.

Fig. 4. Mean of lameness gradient development during 12 weeks monitoring

Gait analysis and the limb capacity to support body weight can be interpreted
objectively only by using the treadmill and force platforms.

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CONCLUSIONS

Minimum operating time was 60 minutes, with an average of 79 ± 22 minutes, most of


the time being designated to the indirect reduction of the fracture.
The plate working length had an average of 56 ± 12% and the plate bridging ratio 73
± 11%, stating that implants stability was similar to that provided by MIPO in cases of
comminutive fractures and to that provided by conventional techniques.
Healing time was 66 ± 21.4 days, similar to ORIF, but increased healing time when
compared to healing time for MIPO in cases of highly comminutive fractures.
Full gait regaing was accomplished in 6 weeks.

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