ARTICLE IN PRESS

The Veterinary Journal ■■ (2015) ■■–■■

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The Veterinary Journal

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Personal View

Fracture management in horses: Where have we been and where are

we going?
Jörg A. Auer a,*, David W. Grainger b
a Equine Department, University of Zürich, Winterthurerstrasse 260, Zürich CH8057, Switzerland
b
Department of Pharmaceutics and Pharmaceutical Chemistry, University of Utah, Salt Lake City, UT 84112-5820, USA

A R T I C L E I N F O

Article history:
Accepted 1 June 2015

Keywords:
Horses
Fractures
Internal fixation
Fixation principles

Introduction
Revisiting and reviewing how major equine fractures were
managed only a few decades ago compared to current state-of-the-
art treatments is an interesting and constructive exercise. Sadly (and
unacceptably) too many horses that acquire simple fractures are still
euthanased without trying to save them through surgical interven-
tion. Of course, fracture treatment is expensive (especially if plates
and many screws are involved) so conservative treatment using casts
is still commonly an owner’s elective choice. However, employing
an experienced veterinary surgeon to implant a few screws across
a condylar fracture to get the horse out of the clinic within days
and on to pasture within a few weeks may in fact prove to be more
economical than keeping it in a cast, possibly with additional cast
changes for many weeks. Selecting the surgical intervention option
also considerably reduces the risk for foundering.
This Personal View briefly looks at how internal fracture fixa-
tion in horses started, presents today’s successful techniques and
takes a look at where fracture treatment in horses may go in the
future.
Where have we been?
Fifty years ago fracture management in horses was still in its infancy.
The first attempts were undertaken to fix fractures with metal implants
such as screws and plates. The AO Foundation1 and its veterinary arm,
AOVET,2 had the greatest influence on the progression of equine
fracture management in the second half of the last century and
the beginning of the present one. The acronym ‘AO’ stands for
‘Arbeitsgesellschaft für Osteosynthesefragen’, and the AO organisation,
founded in 1958 by four visionary Swiss surgeons, is now globally
recognised (Rüedi et al., 2007). AOVET was founded in 1968 and found-
ing members quickly adapted fracture treatment techniques developed
for human patients to animals such that many are applied today in daily
practice with great success (Nunamaker, 2000; Houlton and Dunning,
2005; Auer, 2006; Rüedi et al., 2007).
November 1968 witnessed the first documented internal fixa-
tions of a long bone in a horse under experimental conditions (Auer
et al., 2013). After many preliminary trials with human plates applied
to isolated cadaveric horse bones, human plates were applied for
the first time to an osteotomised equine metacarpus III (McIII) in
a live animal. A horse reprieved from a slaughterhouse was
anaesthetised, and a transverse osteotomy performed on McIII
using a special atraumatic, oscillating AO bone saw (Auer et al., 2013).
At that time, Dr. Stephan Perren, Director of the AO Research
Institute, Davos, Switzerland, was assessing the feasibility of
using titanium plates for human fracture management and
implantation of these plates in a horse was therefore a welcome
test. The horse recovered rapidly and, after the bone had healed,
all of the implants were removed (Figs. 1a–c). Metallurgic exami-
nation revealed neither damage nor wear and tear of the removed

Please note that the content in this Personal View article has not been subject
to peer-review. The views expressed in this Personal View are entirely those of the 1 See: https://www.aofoundation.org/Structure/the-ao-foundation/Pages/the

author(s) and do not necessarily reflect those of the editorial team, or Elsevier. -foundation.aspx (accessed 18 May 2015).
* Corresponding author. Tel.: +41 79 4143966. 2
See: https://aovet.aofoundation.org/Structure/Pages/default.aspx (accessed 18
E-mail address: jauer@swissonline.ch (J.A. Auer). May 2015).

http://dx.doi.org/10.1016/j.tvjl.2015.06.002
1090-0233/© 2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Jörg A. Auer, David W. Grainger, Fracture management in horses: Where have we been and where are we going?, The Veterinary Journal (2015),
doi: 10.1016/j.tvjl.2015.06.002
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a b c

Fig. 1. One of the first clinical equine cases treated by B. von Salis with osteosynthesis according to the AO method. (a) Dorsopalmar (left) and lateromedial (right) radio-
graphic views of a nondisplaced, biarticular, sagittal fracture of the proximal phalanx; (b) 14-week postoperative dorsopalmar radiograph of the healed fracture, which was
treated with three inter-fragmentary cortex screws inserted in lag fashion.

implants. The horse spent its remaining life without any observ-
able detrimental effects from the procedure. This successful initial
osteosynthesis paved the way for the success story of internal fix-
ation in horses over the following 50 years.
The proper processes for treating equine fractures have taken
decades to develop. First, techniques for first aid and transport of
a fracture patient to the clinic had to be defined (Fürst, 2012). Then,
improved fracture diagnosis, anaesthesia of the fracture patient (a
very important factor in successful fracture management), the ap-
proach to the fractured bone, principles of internal fixation of long
bones (see below), tissue closure, recovery from anaesthesia (in-
cluding pool recovery), proper post-operative management and
rehabilitation had to be established.
While most equine fractures are treated either by fragment
removal using arthroscopic techniques (articular chip fractures) or
by screw application using a lag technique (simple phalangeal, carpal,
tarsal fractures, condylar fractures of McIII/MtIII, and selected avul-
sion fractures of long bones), only relatively few long bone fractures
were initially treated by internal fixation using plates or other
devices.
The dynamic compression plate (DCP), developed by Allgöwer
et al. (1973), was the first plate to facilitate progression of internal
fixation in young horses. This became the mainstay for equine frac-
ture treatment for many years (Fig. 2). However, studies in human
medicine showed that the DCP caused demineralisation from plate
stress shielding and remodelling osteoporosis under the plate

Fig. 2. Left: Craniocaudal and lateromedial immediate postoperative radiographic views of an open radius fracture treated by means of two staggered 4.5 mm DCPs. Right:
Craniocaudal and lateromedial 8-month follow up radiographic views of the healed fracture following removal of the cranial plate.

Please cite this article in press as: Jörg A. Auer, David W. Grainger, Fracture management in horses: Where have we been and where are we going?, The Veterinary Journal (2015),
doi: 10.1016/j.tvjl.2015.06.002
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J.A. Auer, D.W. Grainger/The Veterinary Journal ■■ (2015) ■■–■■
(Gautier et al., 1984; Perren et al., 1988). Although this has not been
encountered in equine surgery, the issue led to the development
of biologically improved plates, such as the limited contact dynamic
compression plate (LC-DCP) (Gautier et al., 1984; Perren et al., 1988),
and eventually to the locking compression plate (LCP), which remains
the state-of-the-art implant for fixation of long bone fractures in
humans, small animals and horses.
To increase the stability of the fixation derived from friction
between the implants and the host bone, a technique called plate
luting was developed with the aim of achieving a 100% plate–
bone contact by applying bone cement, polymethyl methacrylate
(PMMA), between the plate and the bone (Nunamaker et al., 1986a).
This was achieved after all of the plate screws had been inserted.
The screws were loosened again, the plate lifted off the bone, the
soft bone cement placed underneath it, and the screws re-tightened.
The soft cement filled the oblong plate holes around the screw heads
providing additional support, and making the fixation extremely rigid
(Nunamaker et al., 1986a; Turner et al., 1990).
When only the oblong plate holes were filled with bone cement,
a similar (but smaller) increase in strain protection occured. Plate
luting has been especially useful in repairing bones with anatomi-
cally complex surfaces that make contouring of the plate difficult
(Turner et al., 1991). Plate luting in horses is however different from
the plating practices used in humans and small animals where the
developing vascular necrosis of the bone under the plate may result
in pathological fractures after implant removal (Gautier et al., 1984;
Perren et al., 1988).
Where are we now?
The principles applied presently in long bone fracture treat-
ment in horses include the initial repair of the fracture by means
of one or two 3.5 mm or 4.5 mm cortex screws inserted in lag fashion
across the fracture at a location not occupied by the plates during
surgery. The plate screws are inserted perpendicular relative to the
surface of the bone. If a second plate is used, it is positioned such
as to allow the screw holes of one plate to be located between the
screw holes of the other plate (Bramlage, 1983; Sanders-Shamis and
Bramlage, 1986; Auer and Watkins, 1987; Auer, 2012). This facili-
tates the insertion of all screws for both plates. One of the plates
should be placed at the tension side of the bone, where the plates
are the strongest.
In DCPs and LC-DCPs, every hole in each plate should be filled
with a screw (Bramlage, 1983). Should a hole traverse a fracture line,
a lag technique should be applied by overdrilling the cis-cortex, and
the screw should be directed so that it engages the opposite cortex
distant from the fracture line. The plates should together span the
entire bone. Staggering of the plates is acceptable and should be
applied whenever it is not feasible to apply a plate from the distal
to the proximal end of the metaphysis (Fig. 2), for example, for a
plate applied to the lateral aspect of the radius spanning the entire
bone (due to the craniocaudal bone curvature) the middle plate holes
come to lie behind the bone, where no screws can be inserted. Where
no support can be achieved in a cortex, bone cement may be placed
and the screw implanted while the cement is still soft. After the
cement hardens, the screw will be solidly fixed.
Severely comminuted distal limb fractures are treated with se-
lective screw insertion in conjunction with a transfixation cast
(McClure et al., 1994a, 1994b, 1996, 2000), and has replaced the pre-
viously advocated external skeletal fixation device (Nunamaker et al.,
1986b; Richardson et al., 1987).
The LCP contains plate holes that combine two treatment
methods in one implant, namely, compression plating and inter-
nal fixator techniques (Frigg, 2001; Marti et al., 2001). The LCP was
developed to include the axial loading capabilities of the DCP and
LC-DCP, the decreased plate–bone contact of the LC-DCP and the
Please cite this article in press as: Jörg A. Auer, David W. Grainger, Fracture management in horses: Where have we been and where are we going?, The Veterinary Journal (2015),
doi: 10.1016/j.tvjl.2015.06.002
3
rigidity and stiffness of the less invasive stabilisation system (LISS),
where angle-stable locking head screws were first introduced (Frigg,
2001; Marti et al., 2001). The goals were met by designing a ‘combi-
hole’ where either a standard screw or a locking head screw can
be inserted. It is not necessary to only apply locking head screws
(Wagner and Frigg, 2006). An in vitro study comparing the appli-
cation of two LCPs at right angles relative to each other with identical
constructs using DCPs, LC-DCPs, and the clamp–rod internal fixators
(CRIFs) in 4-point bending showed that implanting two locking head
screws on either side of an oblique saw-cut across the artificial bone
composite (Canevasit) provided significantly increased stiffness to
the construct (Florin et al., 2005). Because the strength of a screw
depends primarily on the core diameter and not thread width, the
thicker core of the locking head screws and the thin threads make
the screw several times stronger than conventional cortex screws
(Tepic and Perren, 1995).
By substituting cortex screws through some holes, costs can be
significantly reduced without jeopardising the construct stability
and stiffness. With no application of a ‘push–pull’ device or stan-
dard cortex screws, both of which press the plate onto the surface
of the bone, a gap of 2 mm will be present between the plate and
the bone after its application. Therefore a basic decision must be
made at the start as to whether the plate must be in close contact
with the bone or not. In horses, it is important to have solid contact
between the bone and the plate to increase friction, which further
stabilises the construct and helps to resist the extreme loading forces
encountered in horses.
Within a short period of time LCP has established itself as the
preferred plate for equine fracture fixation despite its higher costs
– mainly because of the screws (Levine and Richardson, 2007; Ahern
et al., 2013). A recent study comparing 4.5 mm LCPs with 4.5 mm
LC-DCPs confirmed the superior strength and stiffness of the LCP
(Sod et al., 2008a, 2008b).
The increasing popularity of locking plates has resulted in the
manufacture of specially designed 5.5 mm LCPs for equine frac-
ture repair. The plate was tested in an in vitro study against the
4.5 mm LCP (Sod et al., 2010) and the 5.5 mm LCP was found to be
superior in resisting static overload in palmarodorsal 4-point bending
and cyclic fatigue testing. The results were better than those achieved
with the 5.5 mm LC-DCP and these findings established the 5.5 mm
LCP as the ideal equine plate for specific long bone fracture fixa-
tion (specifically, the radius and tibia in adult Warmblood horses)
and arthrodesis of the metacarpo/metatarso-phalangeal joints.
The AOVET expert group, which develops new implants for vet-
erinary applications, has recently implemented another change in
plate design. While the human LCP has bevelled and pointed ends
on both sides, the veterinary LCP has one bevelled and pointed end
but the other side has a rounded end with a stacked combi-hole
through which either a cortex- or a locking head screw can be in-
serted (Figs. 3a, b). The locking head part of the combi-hole is
oriented towards the centre of the plate which allows the surgeon
to position the rounded end at the end of a bone to insert a locking
head screw and so avoid the bevelled end protruding over the joint.
The LCP is presently the ideal plate for the veterinary surgeon
(Fig. 4). It can be applied in the same manner as a DCP with only
cortex screws. Because the plate possesses the same type of un-
dercuts as the LC-DCP, it can be used in the same manner. In other
words, the LCP fulfils all desired implant demands, and by purchas-
ing only LCPs, the number of different plates that must be kept in
stock ready for use can be considerably reduced. LCP pricing is only
slightly higher than either the DCP or the LC-DCP and therefore costs
are not a real problem. So, all that a veterinary surgeon must decide
is whether to apply cortex screws, locking head screws, or a com-
bination thereof.
In selected fractures in young foals, the broad 3.5 mm LCP has
advantages over the narrow 4.5 mm LCP (Fig. 5). The plate
 ARTICLE IN PRESS
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Fig. 3. (a) A veterinary LCP (top) and a human LCP (bottom). The stacked combi hole
can be seen at the left end of the veterinary LCP. (b) The stacked combi hole in a
close up view.
Fig. 4. Application of two LCPs to an oblique midshaft radius fracture. The fracture
was reduced and repaired by means of three 3.5 mm cortex screws applied in lag tech-
nique. An 18-hole broad 5.5 mm veterinary LCP was applied to the cranial-, and a special
18-hole broad, human femoral LCP (slightly curved) was applied to the lateral aspect
of the bone. Note: the slight side-to-side curve of the lateral plate allows the plate to
span the entire length of the bone while facilitating screw insertion through all plate
holes. Also, it would have been better to turn the cranial plate around and place the
bevelled, pointed end of the cranial plate at the distal end of the radius. This would
have resulted in a smoother transition from the distal end of the plate to the bone.
Please cite this article in press as: Jörg A. Auer, David W. Grainger, Fracture management in horses: Where have we been and where are we going?, The Veterinary Journal (2015),
doi: 10.1016/j.tvjl.2015.06.002
Fig. 5. Craniocaudal and lateromedial immediate postoperative radiographic views
of a transverse mid-shaft radius fracture in a 4-day old Warmblood filly, treated with
a single 15-hole broad veterinary 3.5 mm LCP applied to the cranial, tension-side
aspect of the bone. Note: the central hole was left open because it would have pen-
etrated the fracture. By using this plate, seven locking head screws could be inserted
into the distal- and six locking head screws together with a 3.5 mm cortex screw
(most proximal screw) in the proximal main fragment. The plate spans the entire
length of the metaphyses/diaphysis without penetrating the distal and proximal
physes.
cross-section is the same but the combi-holes are smaller and closer
together in the 3.5 mm LCP. Hence, more screws can be implanted
in a broad 3.5 mm LCP than in the 4.5 mm LCP of the same length.
The fact that the combi-holes are smaller makes the 3.5 mm LCP a
stronger plate than the 4.5 mm LCP.
Interlocking intramedullary nails have not established them-
selves in horses, primarily reflecting the lack of commercially
available systems that can withstand the extreme forces exerted upon
the implants when a horse is recovering from surgery and during
the immediate postoperative period. The fact that relatively few frac-
tures (simple, transverse fractures) can be adapted to allow successful
use of these implants does not incentivise medical device compa-
nies to develop reasonably priced interlocking nails for horses.
Another problem is the approach to the bone. The preferred extra-
articular approach can relatively easily be achieved at the proximal
end of the humerus and femur, but other long bones require a
transarticular approach. Various experimental studies in vitro have
shown mixed results compared with different plating techniques, un-
derscoring the fact that interlocking intramedullary nails are (at best)
equal to plates (Fröhlich, 1973; Watkins, 1990; Watkins and Ashman,
1991; McDuffee et al., 1994; Herthel, 1996; Herthel et al., 1996; Nixon
and Watkins, 1996; Fitch et al., 2001; Lopez et al., 2001; Radcliffe et al.,
2001; Galuppo et al., 2002). This may, however, change in the future.
Presently, there is only one system in equine clinical use; it was de-
veloped at Texas A&M University, and has shown good results although
it is not (yet) commercially available (Watkins, 2015). The best results
achieved to date are in foals and younger horses, frequently in com-
bination with unicortically applied LCPs (Watkins, 2015).
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Biological fracture fixation

Recently, biological fracture fixation has become popular in both

human and small animal osteosynthesis (Palmer, 1999; Pozzi et al.,
2013). This technique abandons the dogma of anatomical recon-
struction and accepts proper axial and rotational alignment of the
bone (despite incomplete reconstruction) followed by fixation of the
fracture with strategically placed implants.
Longer plates are used in biological fixation, providing better le-
verage conditions. Screws are inserted through the biomechanically
most important holes, but in this case, not all holes in the plate are
filled with screws. The plates are pre-bent to conform to the shape
of the contralateral intact bone. After distraction of the fractured
bone to its original length and rotational correction of the dispalced
bone fragments, the bone is approached through a small incision
at one end and, after separating the soft tissues from the perios-
teum with a specially designed separator, the plate is slid along the
fractured bone, and fixed with screws implanted through stab in-
cisions. Such minimal fixation can rarely be applied successfully in
horses. However, the principle of minimally invasive implant in-
sertion is undoubtedly applicable and as relevant to the horse as
to other species.
The fact that locking head screws are angle-stable is also a val-
uable asset in fighting fixation breakdown: once screws are locked
solidly in the plate, they do not align to the traction forces poten-
tially applied to the construct as do cortex screws. One must also Fig. 6. High-definition musculoskeletal images taken of a human distal tibia with
consider that it is possible to insert a locking head screw firmly into implants using a GE Revolution CT: 1 volume 120 kV/220 mA/0.5 s rotation. Left: a
the plate even if the screw does not engage any bone; the screw single axial 2-D reconstruction image. Right: a cranial view of the 3-D reconstruc-
tion showing the implants used to repair the human distal tibia and fibula fractures
feels solidly appied, leaving the surgeon with the false impression
in red. Note: no stray radiation is visible. Photo courtesy of GE Corporation.
that the screw is placed into intact bone.

Surgery on the standing horse

Increasingly, surgical procedures are performed with great success
on the standing horse. This trend has also permeated orthopaedic
surgery for techniques such as chip fracture removal, lag screw
fixation of simple fractures and implant removal after a fracture has
healed. This type of ‘local’ surgery, while to some extent increas-
ing the risk of surgical site infection, avoids the need for general
anesthesia and in doing so reduces costs.
Surgical site infections
Surgical site infections are still a significant problem in horses, and
several steps must be implemented to reduce infection risks when treat-
ing long bone fractures in horses. These include: (1) wherever possible
the periosteum must be left in contact with the underlying bone to
ensure blood supply to the bone; (2) plates should be applied in areas
where good muscle coverage is present; (3) effective pre-, peri-, and
post-operative antibiotics must be provided; (4) at the end of surgery,
antibiotic-impregnated polymethymethacrylate (PMMA) beads or strings
of beads should be placed along the plates. Watkins (2015, personal
communication) proposes to fill the unused portion of each combi-
hole in the LCPs with PMMA loaded either with Tobramycin or
Ciprofoxacin (2.5 g/200 g of PMMA). Care must be taken to avoid in-
sertion of PMMA into the drive portion of the screw head because it
prevents screw removal at a later date. (5) While closing the surgical
wound, regional limb perfusion should be applied; (6) simple inter-
rupted or vertical mattress sutures in the skin are the preferred closure
technique, even though it takes longer than the placement of stain-
less steel staples.
Diagnostic imaging
Great advances have been made in different diagnostic imaging
techniques. Already smaller movable computerised tomography (CT)
gantries are available for use in surgery rooms. Surgeons at the New
Bolton Center, University of Pennsylvania, routinely use a CereTom
mobile CT unit (NeuroLogica) before and during management of
complicated fractures, and with great success (D. Richardson,
personal communication). There is no doubt that in 10 years’ time
this type of intraoperative imaging will be as popular as direct
radiography is today. Newer technologies provide clear 3-D recon-
struction CT images of vessels, soft tissue structures, and even bones
containing metal implants (Fig. 6), overcoming many current prob-
lems, and even more refinements continue and evolve to improve
intraoperative surgery management.
Where are we going?
Implants
Despite the fact that locking implants have enabled great ad-
vances in equine fracture management, aspects of their use can still
be improved and validated. In the future, all plates will have the
variable angle LCP (VA-LCP) design, but presently these are only avail-
able in special human plates (Figs. 7a–c). Thinner and stronger plates,
possibly combined with intramedullary transfixation nails, may
improve the biomechanical deficits exhibited by current plates.
Special plates for specific applications (e.g., T- or L-plates for prox-
imal physeal fractures of the tibia) may represent a welcome
improvement.
Biodegradable plates and screws manufactured from either
resorbable polymers (e.g., polylactides-co-glycolides and calcium
phosphate composites with established clinical track records) (Eppley
et al., 2004; Agarwal et al., 2009) or soluble metals (magnesium
alloys; Chaya et al., 2015) can provide significantly increased fix-
ation stability, strength and power. Commercialised currently for
craniomaxillofacial use (e.g., DePuy-Synthes’ CMF Rapid Resorbable
Fixation System) and tested in other orthopaedic fixation applications

Please cite this article in press as: Jörg A. Auer, David W. Grainger, Fracture management in horses: Where have we been and where are we going?, The Veterinary Journal (2015),
doi: 10.1016/j.tvjl.2015.06.002
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a b
Fig. 7. (a) The broad end the volar distal radial variable angle LCP (VA-LCP) demonstrating the angles available to insert screws through the holes; (b) birds-eye view of the
plate hole design. The four ridges between the four holes contain threads, where the screw threads interdigitate with the plate; (c) close-up side-view of the screw head,
depicting its threads on the rounded head and the star drive design for the screwdriver (Synthes).
(Rokkanen et al., 2000), these resorbable implants may become in-
creasingly attractive in certain applications because they need not
be removed.
Foreign body responses are observed with highly and semi-
crystalline resorbable polymer devices (Böstman and Pihlajamäki,
2000) but non-crystalline resorbable polymers [e.g., 85:15 poly(L-
lactide-co-glycolide copolymer)] with improved tissue responses can
lack the mechanical properties required for stable long bone fixa-
tion use. The disadvantage of intrinsically poor radiolucent polymer
plate/screw visualisation in radiographs may be overcome by em-
bedding or coating polymer implants with radio-dense materials,
or perhaps by future innovations in implant diagnostic imaging that
do not require electron density contrast with tissue.
Combination devices are implants designed, approved and imple-
mented clinically for a primary device (i.e., mechnical or structural)
function, but containing an on-board secondary drug delivery or ther-
apeutic property (Wu and Grainger, 2006). Nearly all orthopaedic
combination devices in near-term clinical application are adapta-
tions of existing orthopaedic (largely metallic) devices using drug
delivering coatings. The DePuy-Synthes coated antimicrobial ‘Expert’
tibial nail is a prominent example. Newer orthopaedic implants are
presently under development in both design and preclinical testing
stages (Pioletti et al., 2008) that are actually designed to contain spe-
cific zones or areas where osteoinductive materials can be added
to provide long-term effects for improved and facilitated bone healing
(Neut et al., 2015). Intra-operative processing and customisation of
implants with adhesive-applied matrices or printed drug-releasing
coatings is also feasible as a possible future real-time customisation
strategy for combination devices (Trajkovski et al., 2012).
Fracture healing
Fracture healing in horses is much slower than in humans and
small animals (Schenk and Willenegger, 1963) and so measures to
overcome this problem and facilitate healing are required. During
the last decade, numerous research studies using bone morpho-
genic proteins (Lo et al., 2012; Mehta et al., 2012), and other growth
factors (Nyberg et al., 2015), mesenchymal stem cells (Ma et al.,
2014), and cell signalling molecules (Ito, 2011; Vo et al., 2012) have
sought to accelerate bone healing (Amini et al., 2012); some have
shown promise in various bone models and species, but convinc-
ing medical evidence for a consistent clinical bone regenerative
strategy is still lacking (Kirker-Head, 1995; Jang et al., 2008; Fayaz
et al., 2011; Kloss et al., 2013; Rolim Filho et al., 2013; Ferris et al.,
2014).
Please cite this article in press as: Jörg A. Auer, David W. Grainger, Fracture management in horses: Where have we been and where are we going?, The Veterinary Journal (2015),
doi: 10.1016/j.tvjl.2015.06.002
c
More definitive support for precise dosing, timing, combina-
tions of growth factors, cytokines, and/or stem cells, and implantable
vehicles and methods of delivery will unquestionably contribute to
improved healing designs and outcomes (Santo et al., 2013;
Samorezov and Alsberg, 2015). While bone- and fat-derived stem
cells can be relatively easily and inexpensively harvested and
implanted either autologously or allogenically, standards for as-
sessing their potency and healing potential for bone healing are
presently lacking and clinical results in bone regeneration are un-
convincing (Jones and Yang, 2011; Knight and Hankenson, 2013).
The increasingly diverse advocacy and selection of bone-related
growth factors for bone regeneration are confusing: they are fre-
quently difficult to acquire in clinical grades and quantities, lack many
delivery specifications for therapy, and are generally expensive. This
situation is also likely to change in the future as demand in-
creases and production methods mature, but presently remains a
primary limitation to their clinical use.
Multi-fragment fractures and complex implant management
In the horse, severely comminuted long bone fractures are very
difficult to manage successfully by means of internal and/or exter-
nal fixation. Future developments will contribute new, non-toxic
biodegradable bone rapid-set adhesives to assist in the anatomi-
cal reconstruction of the difficult fracture (Donkerwolcke et al., 1998;
Farrar, 2012).
One prerequisite of such bioadhesive compounds is their ability
to reliably facilitate adherence of bone pieces to each other to form
a stable union, but not to interfere with bone healing itself by pro-
grammed resorption. Bone adhesives currently in use do not yet have
requisite mechanical properties sufficient to endure in vivo long bone
applications. Synthetic adhesives (i.e., various polymeric adhesive
combinations, magnesium phosphate cements, and polymer/
calcium phosphate blends) also commonly exhibit biocompatibility
challenges that result in foreign body reactions, infections, and tissue
necrosis. Testing systems and validation criteria that predict bone
cement clinical success are currently equivocal producing confu-
sion in how best to address current shortcomings (Farrar, 2012). The
application of strategic metallic implants to the fractured bone in
combination with novel bone adhesives that provide solid, me-
chanically robust bonds between fracture ends may produce a real
advancement for treating difficult fracture cases.
Identifying the smaller fragments in a multifragment fracture
ahead of surgery using diagnostic imaging techniques and recon-
structing them to a solid block of osteoconductive material using
 ARTICLE IN PRESS
J.A. Auer, D.W. Grainger/The Veterinary Journal ■■ (2015) ■■–■■
rapid-prototyping technology may turn out to be the first step in
the successful management of severely comminuted long bone frac-
tures. A second step might then involve intraoperative removal of
the identified fragments, insertion of the pre-fabricated recon-
structed bone-like implant block into the vacant space, followed by
applying stabilising implants to form a solid construct. This may seem
utopian today but the chances appear good that such approaches
may one day become a reality in orthopaedic fracture repair.
New, improved and more sophisticated implant designs for bone
repair and regeneration can benefit further from computer-interfaced
fabrication technologies. Current bone repair scaffold demands for im-
proving bone regeneration opportunities are increasingly complex,
considering many fabrication variables. Common design parameters for
implants include matrix architecture, pore sizes, distributions and mor-
phologies, surface properties for osseointegration and matrix degradation
products, mechanical properties, and incorporation of diverse biolog-
ical components (e.g., proteins, cells) with desired controlled variations
of these factors within the implant volume and over duration of im-
plantation. Additionally, the capability to produce patient-specific
implants that fit specific defects or fracture sites, even seeded with the
patient’s own sourced biological materials, is increasingly demanded
(Hutmacher et al., 2004; Reichert et al., 2011).
One currently popular method to duplicate bone and fracture
defects utilises high resolution 3-D printing technology that ex-
ploits automated manufacturing throughput, computer-aided design
and precision, informed by actual patient 3-D imaging data
(Hutmacher et al., 2004; Bose et al., 2013; Ventola, 2014). This
computer-aided and designed (CAD/CAM) fabrication strategy is also
known as additive manufacturing, rapid prototyping, or solid free-
form fabrication technology (Hutmacher et al., 2004; Gross et al.,
2014), and for decades has been used for rapid prototyping in manu-
facturing well away from the biomedical field.
This history has catalysed the rapid entrance and technology use
in the ‘organ printing’ field, including musculoskeletal tissue. Medical
imaging, computational modelling and implant scaffold fabrica-
tion are now readily achieved using rapid prototyping techniques
(Hutmacher et al., 2004; Reichert et al., 2011; Ventola, 2014); CT
scan images of patient-specific bone voids are used to generate a
computer-based 3-D volumetric void model. The in silico model is
then manipulated algorithmically using software and ‘sliced’ into
thin horizontal layers from the total volume. These ‘sliced’ void-
specific data then instruct the 3-D printer to fabricate an implant
scaffold, reconstructed layer by layer from the assembled volume
slices, re-building the actual shape of the void from the computer
model. Such printing technology based on CT images produces
implant replicates from diverse biomaterials and variable com-
plexities to address complex bone defects. Implants can be custom-
made to fit patient-specific voids, with scaffolds and cell constructs
recapitulating complex musculoskeletal shapes, compositions and
mechanics (Hutmacher et al., 2004; Reichert et al., 2011; Ventola,
2014).
Bone 3-D printing implant generation is useful at several levels
of practical orthopaedics. By exploiting CT scan data of a fracture,
3-D printers can rapidly print plastic bone-filling replicates
within about 4 h, providing surgical teams with the precise bony
component and opportunity to practice complex surgical recon-
structions prior to actual patient surgery (Gross et al., 2014). The
3-D printed bone replicate approach is also currently used in or-
thopaedic surgeon training (Hoy, 2013), and specifically in veterinary
surgical training (it was introduced in 2015 at Ohio State Univer-
sity, USA).
Finally, actual biomaterial-based patient-specific solid 3-D printed
implants comprising ceramic, metallic or polymeric biomaterials as
liquid resins or powders are now common. Additionally, 3-D printed
living cells, growth factors, other drugs, and complex material ar-
chitectures can also be fabricated in complex mixtures, eventually
Please cite this article in press as: Jörg A. Auer, David W. Grainger, Fracture management in horses: Where have we been and where are we going?, The Veterinary Journal (2015),
doi: 10.1016/j.tvjl.2015.06.002
7
also intra-operatively in real-time, at sub-millimetre precision for
biologically active implants, allowing customisation, personalisation
and direct implantation into patients (Murphy and Atala, 2014).
Globally, both academic and commercial implant makers have
promised human clinical trials for 3-D printed personalised bone-like
biomaterials in 2015. Patient-specific 3-D printed bone implants now
include the recent 510K regulatory approval from the US Food and
Drug Administration (FDA) for a cranial bone void filler for repair
of neurosurgical burr holes. Structural, mechanical and weight-
bearing bone implant applications require extensive validation in
context.
Overall, the rapid prototyping and 3-D computer-aided implant
fabrication approach has a groundswell of popularity and the tech-
nical benefits of throughput, precision, duplication, capacity, cost,
scaling and customisation. All of these exciting new develop-
ments will, at least in part, find their way into fracture treatment
in horses.
Computer assisted surgery
Computer-assisted orthopaedic surgery has substantial poten-
tial to improve precision in the insertion of implants, but it is
currently very expensive to acquire the necessary hardware and soft-
ware (Andritzky et al., 2005; Rossol et al., 2008). Nevertheless, why
should veterinary orthopaedic surgery not in time follow current
human developments in this as in other fields? Who knows?
Computer-aided surgery may one day become routine practice at
least in specialised equine referral orthopaedic centres.
Specialisation
Because of the costs involved in fracture treatment, the need to
store a large number of different implants at a clinic, the threats
or risks of possible legal exposure for treatment liabilities, and
demands by owners and trainers to restore their injured animals
rapidly to functional use, it is likely that most long bone fractures
in horses will in the future be managed in a few well-equipped or-
thopaedic centres that specialise in this type of surgery. Minor
fractures, such as chip-, simple slab- and lateral condylar frac-
tures will still be treated in regular racetrack- and surgery clinics.
Also, emergency and rescue units will likely be established world-
wide, at least where horse sporting and racing events are held, to
provide first aid and state-of-the-art transport of the fracture patient
to a specialised equine clinic. This type of transport was shown on
live television a few years ago when Barbaro, the Kentucky Derby
winner 2 weeks previously, had broken down at the start of the
Preakness race. A helicopter followed the transport of the horse from
Baltimore to New Bolton Center in Philadelphia.
Equine services at the University of Zürich have also profited from
such a service, producing evidence from results of equine fracture
management in improved outcomes in patients transported by spe-
cialised ambulance services,3 with some horses arriving from as far
away as northern Germany (Fig. 8).
One key factor is the early recognition of impending complica-
tions, such as instability of the construct and infection. Immediate
and appropriate clinical responses to the signs of such complica-
tions are required for best outcomes. Applying appropriate measures
such as repeat surgery using stronger implants or meticulous lavage
and curettage of the surgery site, respectively, and/or implanta-
tion of antibiotic-impregnated PMMA beads may solve the problem
at an early stage, reducing costs of long-term treatment with ex-
pensive antibiotics and other therapies.
3 See: www.gtrd.ch (accessed 18 May 2015).
 ARTICLE IN PRESS
8 J.A. Auer, D.W. Grainger/The Veterinary Journal ■■ (2015) ■■–■■
Fig. 8. State-of-the-art emergency transport vehicle and trailer, equipped with a trolley for pulling recumbent animals into the trailer, video equipment that allow audio-
visual communication between the driver and the technician in the trailer with the patient.
Management of patients
Equine clinicians must learn how to manage orthopaedic pa-
tients better post-operatively. Apart from welfare considerations that
are often self-evident, pain management is a key element following
surgery because it optimises patient comfort, prevents overload-
ing of fixation constructs, especially in the early post-operative
period, and often prevents complications.
Numerous opportunities exist to improve treatment outcomes.
Proper post-operative management and rehabilitation should start
immediately following surgery and throughout the recovery period.
More research and client education must be directed towards ef-
fective rehabilitation procedures to assure that the patient can return
to its normal athletic activity. Unfortunately, equine-oriented or-
thopaedic research depends on a limited number of funding agencies,
such as the Jockey Club, Grayson Foundation, Morris Animal Foun-
dation, regional racing associations, and to some extent the AO
Foundation, where competition for limited resources is fierce. New
institutions and foundations supporting equine research are des-
perately needed to better support innovations, treatment validation
through powered randomised studies, and clinician training in new
techniques.
Conclusions
Fracture management in horses has made great progress in recent
decades. The principles applied today are based on experiences made
by the leaders in fracture management and consolidated during nu-
merous AOVET training courses. Significant clinical problem areas
such as severely comminuted long bone fractures in adult horses
represent current treatment challenges. Present trends are towards
standing procedures, minimally invasive techniques and the use of
advanced real-time imaging techniques during surgical proce-
dures. Because of the high costs and risks of using such devices, only
specialised clinics operated by experts in the field of fracture man-
agement in horses will prevail.
Clearly, not all fractures can be treated successfully so case se-
lection is essential. We anticipate that future changes will occur in
the adjunct fracture management sector, such as in new, im-
proved combination devices and implants that provide bone stability
and also contain designed features specific for loading and release
of bone-healing and osteoconductive agents for local delivery, or
to carry antimicrobial agents and implant features that mitigate
infection.
Please cite this article in press as: Jörg A. Auer, David W. Grainger, Fracture management in horses: Where have we been and where are we going?, The Veterinary Journal (2015),
doi: 10.1016/j.tvjl.2015.06.002
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Please cite this article in press as: Jörg A. Auer, David W. Grainger, Fracture management in horses: Where have we been and where are we going?, The Veterinary Journal (2015),
doi: 10.1016/j.tvjl.2015.06.002