Effect of Fixation Method on Postoperative Complication

Rates After Surgical Stabilization of Lateral Humeral

Condylar Fractures in Dogs
Karen L. Perry1, BVM&S, CertSAS, Diplomate ECVS, Mieghan Bruce1, BVMS, MSc (VetEpi),
Samantha Woods2, MA, VetMB, CertSAS, Clare Davies1, Laura A. Heaps1, BVSc, BSc, and
Gareth I. Arthurs3, MA, VetMB, CertVR, CertSAS, DSAS (Orth)
1
The Royal Veterinary College, Veterinary Clinical Sciences, Services, Hawkshead Lane, North Mymms, United Kingdom ,2 The Royal (Dick)
School of Veterinary Studies, University of Edinburgh, Easter Bush Campus, Midlothian, United Kingdom and 3 Arthurs Orthopaedics, Towcester
Veterinary Clinic, Towcester, United Kingdom

Corresponding Author
Karen L. Perry, BVM&S, CertSAS, Diplomate
ECVS, Queen Mother Hospital for Animals,
The Royal Veterinary College, Hawkshead
Lane, North Mymms, Hatfield, Hertfordshire
AL9 7TA, United Kingdom.
E‐mail: klperry@rvc.ac.uk
Submitted April 2013
Accepted December 2013
DOI:10.1111/j.1532-950X.2014.12276.x
Objectives: To assess the impact of stabilization method on the complication rate after
lateral humeral condylar fracture (LHCF) repair.
Study Design: Retrospective multicenter clinical cohort study.
Animals: Dogs (n ¼ 151) with LHCF.
Methods: Medical records (2004–2012) were reviewed for dogs that had surgical
repair of LHCF. Data retrieved included signalment, cause of fracture, evidence of
incomplete ossification of the humeral condyle, occurrence of postoperative
complications, presence of supracondylar comminution preoperatively, and persistence
of an intracondylar fissure postoperatively. Outcome was assessed based on the most
recent data available and graded as excellent, good, fair, or poor.
Results: LHCF (n ¼ 135) were evaluated in 132 dogs; 61 fractures were stabilized
using a transcondylar screw and supracondylar K‐wire, 13 using a transcondylar screw
and supracondylar screw, and 61 using a transcondylar screw and lateral epicondylar
plate. Major complications were significantly (P ¼.01) more common after
stabilization using a transcondylar screw and supracondylar K‐wire (28%) than in
dogs where a supracondylar screw or lateral epicondylar plate were used (11%). Cases
that had postoperative complications were significantly (P ¼.02) more likely to have a
poor outcome.
Conclusions: LHCF stabilized using a transcondylar screw and supracondylar K‐wire
are more likely to have major complications resulting in a poorer outcome than cases
stabilized using a supracondylar screw or lateral epicondylar plate.

Fractures of the humeral condyle are common1 and are divided
into lateral condylar, medial condylar, and intercondylar
fractures.2 Lateral humeral condylar fractures (LHCF) are
most common, accounting for 34–56% of humeral condylar
fractures.1,3,4 These fractures are intra‐articular and in young
growing animals involve the distal humeral growth plate, most
commonly being classified as Salter–Harris Type IV.5,6
LHCF have been reported in many breeds, with
Spaniels,1,2,7–9 Yorkshire Terriers,10,11 English and French
Bulldogs, Miniature Schnauzers, and Gordon Setters11 being
variably overrepresented in different studies. Most LHCF
occur in skeletally immature animals,2,4,10,12 with a peak
incidence at 4 months,4,10,13,14 but adult dogs can also be
affected.4,7 No consistent gender predisposition has been
reported.4,9
LHCF is commonly traumatic in origin.4,10 A history of
condylar fracture occurring during relatively normal activity
should arouse suspicion of incomplete ossification of the
humeral condyle (IOHC), particularly if the dog is a Spaniel.2
LHCF usually result from upward stress transmitted through
the radius on to the humeral capitulum, which is relatively
weakly supported by the thin lateral supracondylar crest.15
When an excessive loading force is applied, it is thought that
the radial head transmits a proximally directed loading force
onto the humeral capitulum, which results in a shear force at the
intercondylar area through to the supratrochlear foramen and
the lateral supracondylar crest, resulting in its separation.14 As
bone is relatively weak when subjected to shear forces, most
condylar fractures result from minor indirect trauma.7,16,17 The
lateral aspect of the humeral condyle is anatomically offset
laterally with respect to the humeral shaft, which may explain
the increased incidence of lateral over medial humeral condylar
fracture.10

246 Veterinary Surgery 44 (2015) 246–255 © Copyright 2014 by The American College of Veterinary Surgeons
Perry et al. Complications After Lateral Humeral Condylar Fracture

Intra‐articular fractures require anatomic reduction and

rigid fixation if joint function is to be restored.4,18,19 LHCF have
been treated using various methods including transcondylar
screws inserted in lag fashion,13,20,21 pins15 or wire,19 Rush
pins,15 various applications of Kirschner wires (K‐wires),17,22,23
self‐compressing Orthofix pins,24 cannulated screws,25 and
closed reduction with subsequent internal fixation.26 Arguably,
treatment using a transcondylar screw in lag fashion is most
commonly performed and this has been well described.2 A
second point of fixation, in addition to the lag screw, has been
recommended to prevent rotation of the lateral fragment around
the axis of the screw.2,27 In most cases, this is achieved by
passing a K‐wire from distal to the lateral epicondyle, aiming
proximally up the lateral supracondylar crest, across the fracture
and into the humeral diaphysis proximally.2 Plate fixation is not
frequently recommended for lateral or medial condylar
fractures, but is considered superior for treatment of more
complex intercondylar fractures where current treatment Figure 1 Use of a transcondylar screw in lag fashion with 2
recommendations involve reconstruction of the intercondylar supracondylar screws for stabilization of a lateral humeral condylar
fracture using a screw inserted in lag fashion followed by fracture.
reconstruction and fixation of the diaphyseal component using
lag screws, K‐wires, or other fixation prior to protection of the
repair using 1 or 2 bone plates placed along the caudomedial and MATERIALS AND METHODS
caudolateral aspects of the distal humerus.8,28,29
With early stabilization and anatomic reduction, the The databases (January 2004–December 2012) of 3 referral
prognosis for LHCF is generally good,2,4 although more hospitals were searched for dogs that had surgical treatment of
guarded for cases secondary to IOHC.2 However, previous LHCF. Dogs not managed surgically or where postoperative
humeral condylar fracture outcomes in the literature have complication data were not available were excluded. Retrieved
reported that 28–57% of dogs have long‐term pain or lameness data included: breed, sex, age, weight, and cause of fracture.
upon subjective evaluation.1,4,7 Records were analyzed to determine whether there was any
Complications reported after treatment of LHCF include evidence of IOHC and cases were assigned to 1 of the
ongoing lameness, reduced range of motion, elbow arthrosis, categories in Table 1. Evidence of IOHC was classified as
non‐union, fixation failure, seroma formation, and infec- present (categories 2–4) or absent (category 1) to assess an
tion.1,3,4,7,8,30–34 The complication rate varies between 15% association between presence of IOHC and major complica-
and 33%.7,10,16,24,26,35 Several factors have been proposed to tions. According to Sumner‐Smith,37 the distal humeral growth
affect the complication rate including surgical time,35 presence plates fuse between 5 and 8 months; therefore, dogs 8 months
of an intracondylar fracture gap,35 transcondylar screw angle,35 were compared to dogs >8 months to assess whether Salter–
and presence of IOHC.2,26 Harris fractures were associated with higher risk of major
There have been very few comparisons of differing complications.
surgical techniques for treatment of LHCF. Orthofix pins have Additional data retrieved included anesthesia time,
been compared biomechanically to cortical bone screws placed surgical time, perioperative antibiotic usage, postoperative
in lag fashion for treatment of LHCF,36 and differing treatment
methods have been compared using finite element micro-
motion analysis for intercondylar fractures where use of lateral
plate fixation was found to be superior to caudal plate fixation.8
It was our perception that the complication rate after treatment
of LHCF using a transcondylar screw inserted in lag fashion in
association with a supracondylar K‐wire was higher than that
experienced when a transcondylar lag screw was used in
association with a supracondylar screw (Fig 1) or lateral
epicondylar plate (Fig 2). Thus, our purpose was to
retrospectively assess the impact of stabilization method on
the complication rate after LHCF repair. Our hypothesis was
that the complication rate associated with a transcondylar
screw inserted in lag fashion and supracondylar K‐wire fixation
would be higher than that associated with using a lateral
epicondylar plate or supracondylar screw and a transcondylar Figure 2 Use of a transcondylar screw in lag fashion with a lateral
lag screw. epicondylar plate for stabilization of a lateral humeral condylar fracture.

Veterinary Surgery 44 (2015) 246–255 © Copyright 2014 by The American College of Veterinary Surgeons 247
Complications After Lateral Humeral Condylar Fracture
Table 1 Classification Scheme for Evidence of Incomplete Ossification
of the Humeral Condyle
Category Evidence of IOHC
1 No evidence
2 Minimally traumatic fracture etiology
3 Not minimally traumatic, but other evidence of IOHC
noted including:
Sclerotic bone intraoperatively
IOHC previously confirmed in contralateral elbow
IOHC previously confirmed in ipsilateral elbow
4 Both minimally traumatic and other evidence of IOHC
as in category 3
5 Unknown
Cases where there was insufficient information in the
history to come to a conclusion
antibiotic usage, and the fixation method (Table 2) used for
stabilization of the fracture.
Presence of postoperative complications was recorded and
the specific details of the complication noted. Complications
were defined as any undesirable outcome associated with the
surgical procedure and were classified as major (surgical
intervention performed) or minor (managed without surgical
intervention). The presence of postoperative infection was
specifically recorded. As previously described,38,39 a wound
was considered infected when a purulent discharge, abscess, or
sinus and/or 1 or more of the clinical signs of pain and localized
swelling, redness, heat, fever or deep incision spontaneous
dehiscence was identified on physical examination and/or
when an organism was isolated from an aseptically collected
sample by culture and/or a positive cytology study.
For all cases where preoperative and postoperative
radiographs were available (125/135), the radiographs were
reviewed by 1 of 2 board‐certified surgeons. Preoperative
radiographs were assessed for the presence of supracondylar
comminution. Immediate postoperative radiographs were
assessed for presence of a fracture gap in the intercondylar
region, screw core diameter (SD), transcondylar screw
angulation (TSA) relative to a line between the epicondyles
as viewed on a craniocaudal radiographic projection and
condylar width (CW) measured from the lateral epicondyle to
the medial epicondyle (mm). The latter 3 measurements were
made as previously detailed by Morgan et al.35 Screw
diameters and condylar widths were both measured directly
from the radiographs so as to standardize measuring of these
Table 2 Classification of Methods of Internal Fixation for Stabilization of
Lateral Humeral Condylar Fractures
Category Fixation Method
1 Transcondylar screw in lag fashion  washer þ 1 or
more supracondylar K‐wires
2 Transcondylar screw in lag fashion þ 1 or more
supracondylar lag or positional screws  washers
3 Transcondylar lag screw  washers þ lateral
epicondylar plate  additional K‐wires
4 Other internal fixation technique
248 Veterinary Surgery 44 (2015) 246–255 © Copyright 2014 by The American College of Veterinary Surgeons
Perry et al.
Table 3 Classification of Gait Assessment Findings at 1st and Final
Postoperative Assessment
Category Gait Assessment Findings
1 No lameness
2 Mild lameness
3 Moderate to severe lameness
4 Non‐weight bearing lameness
5 Unknown
variables. Also, as previously described,35 the condylar width
to screw core diameter ratio was calculated to normalize
measurements across case sizes. Follow‐up radiographs, from
the latest follow‐up appointment available for each dog, were
assessed for evidence of fracture healing and implant stability.
Postoperative data were recorded including the time at
which the 1st postoperative assessment was performed,
physical examination findings at this 1st postoperative
assessment, radiographic findings during the 1st postoperative
assessment, the time at which the final postoperative
assessment was carried out and physical examination findings
and radiographic findings during this examination. The
physical examination findings during both of these visits
were categorized as detailed in Table 3.
Final outcome was based on the most recent data available
about the dog, and rated as excellent, good, fair, or poor
(Table 4), consistent with a previously reported outcome
evaluation method.40,41
Statistical Analysis
Continuous data were expressed as median values and ranges;
and categorical data were expressed as proportions with 95%
confidence intervals (95% CI). The association between
fixation method and risk of any complication, major
complication, postoperative infection, and between other
variables of interest were estimated using univariate logistic
regression analysis. The relationship between potential
confounding factors and major complications or postoperative
infection were analyzed using univariate logistic regression.
Continuous variables (age, weight, TSA, and CW:SD ratio)
were examined as categorical variables and as multiple
fractional polynomials to determine if there was any evidence
of non‐linearity in the association with major complications or
postoperative infection.37 Variables with a P value <.2 were
Table 4 Clinical Outcome Scale
Clinical Outcome Description of Function
Excellent No lameness, clinically within normal limits
Good Mild lameness noted after extensive
exercise
Fair Mild to moderate intermittent lameness but
consistent weight bearing
Poor Non‐weight bearing lameness
Perry et al.
included in the multivariable logistic regression model to
explore the presence of confounding (a 10% change in odds
ratio [OR] for fixation method) and test biologically meaning-
ful interaction. Anesthesia time was included as an a priori
confounder, and center was included as a fixed effect to account
for the correlated nature of the groups. The fit of the final
models were evaluated with the Hosmer–Lemeshow goodness‐
of‐fit test. Strength of the adjusted association between fixation
method and risk of major complication or risk of postoperative
infection were reported using OR and 95% CI. Statistical
analyses were performed using software (R 2.15.3; R
Development Core Team, 2013, http://www.R‐project.org/).
RESULTS
Of 160 records identified and evaluated, 6 were excluded as
either no surgery was performed (n ¼ 2), an external skeletal
fixator was applied (1), a salvage procedure was performed (1),
the affected forelimb was amputated (1), or the forelimb was
treated with external coaptation (1). Nineteen cases (19 dogs)
were excluded because postoperative records were not
available. LHCF (n ¼ 135) were evaluated in 132 dogs; 3
dogs suffered non‐simultaneous bilateral LHCF and each
humerus was included as a separate case.
Dogs were followed for a median of 7 weeks after surgery
(range, 3–312 weeks). There were 25 breeds represented, with
the Springer Spaniel predominating: 55 Springer Spaniels, 17
Cocker Spaniels, 8 Labradors, 7 Cavalier King Charles
Spaniels, and 4 Staffordshire Bull Terriers. Other breeds
represented by <5 cases were Shih Tzu, Bulldog, Boxer, Jack
Russell Terrier, Yorkshire Terrier, Polish Lowland Sheepdog,
French Bulldog, Rottweiler, Wheaten Terrier, Cairn Terrier,
Labradoodle, Border Collie, Border Terrier, Chihuahua,
Hungarian Vizla, Toy Poodle, West Highland White Terrier,
Clumber Spaniel, and German Shepherd Dog. In 1 case, the
breed was unknown. Eighty‐one (60%) were classified as
Spaniel breeds. There were 69 (51.1%) males and 66 females
(48.9%) included in the analyses. Median age at surgery was
15 months (range, 2–132 months). Sixty‐two dogs were 8
months (45.9%) and 73 (54.1%) were >8 months. Weight
ranged from 1.4 to 37.2 kg (median, 14.3 kg); weight records
were not available for 6 dogs.
Fourteen cases (10.3%) were out walking with no trauma
noted at the time of injury, whereas 48 (35.6%) sustained the
fracture whilst running or playing but again with no overt
inciting trauma. Forty‐one cases (30.1%) had minor trauma
whilst 23 (17.0%) had some form of major trauma and 2 had
chronic fractures for which diagnosis had been delayed and the
inciting cause was unknown. The cause in 7 acutely presented
cases was also unknown.
For evidence of IOHC, minimally traumatic fracture cause
was present in 40 (29.6%) cases. Thirteen cases (9.6%) were
classified as category 3 (Table 1). Thirty‐three (24.4%) were
classified as both minimally traumatic fracture cause and in
category 3. Based on a dichotomous categorization for
evidence of IOHC, 86 (63.7%) dogs had some evidence of
Veterinary Surgery 44 (2015) 246–255 © Copyright 2014 by The American College of Veterinary Surgeons
Complications After Lateral Humeral Condylar Fracture
IOHC (minimally traumatic fracture, sclerotic bone visible
intraoperatively, IOHC previously confirmed in contralateral
elbow, IOHC previously confirmed in ipsilateral elbow or a
combination of these).
Supracondylar comminution was present in 48 (35.6%)
cases, not present in 77 (57.0%), and unknown for 10 (8.4%).
Presence of a fracture gap in the intercondylar region on
immediate postoperative radiographs was visible for 56
(41.5%) dogs, not present for 69 (51.1%) dogs, and unknown
for 10 (7.4%) dogs because of implant superimposition and
suboptimal radiographic positioning. Median TSA was 8.5°
(range, 0–37°). Median transcondylar screw diameter, as
measured from the radiographs, was 2.7 mm (range, 1.5–
4.5 mm) and median condylar width was 32 mm (range, 17–
48 mm). Median condylar width to screw diameter ratio was
11.6 (range, 6.5–17.4). In 125 dogs with radiographic follow‐
up, persistence of the intracondylar fissure was noted in 67
dogs (53.6%), healing of the fissure was documented in 45
dogs (36.0%), and the fissure was considered impossible to
assess radiographically in 13 dogs (10.4%). There was no
evidence of an association between evidence of IOHC and
persistence of the intracondylar fissure (P ¼.43).
Sixty‐one fractures (45.2%) were repaired using a
transcondylar screw and 1 or more supracondylar K‐wires,
13 (9.6%) had a transcondylar screw plus supracondylar screw,
and 61 cases (45.2%) had a transcondylar screw plus a lateral
epicondylar plate. Because of the small number of cases
stabilized using a transcondylar screw and supracondylar
screw, for statistical analysis these groups were combined.
Further details regarding the specific implants used are detailed
in Table S1 (available online). Surgical time was available for
67 cases with a median of 100 minutes (range, 40–320 mi-
nutes). General anesthesia time was available for 111 cases, 9
(8.1%) of which were 60–120 minutes, 42 (37.8%) dogs had an
anesthesia time of 121–180 minutes whilst for 60 (54.1%) dogs
it was >180 minutes. One hundred and twenty‐five (92.6%)
dogs were administered perioperative antibiotics and 53
(39.3%) dogs were administered postoperative antibiotics.
Of the 48 cases that had supracondylar comminution, 21
(43.8%) were stabilized using a transcondylar screw and
supracondylar K‐wire and 27 (56.2%) were stabilized using a
transcondylar screw and supracondylar screw or lateral
epicondylar plate. There was no evidence of an association
between presence of supracondylar comminution and chosen
fixation method (P ¼.74).
Postoperative complications included implant loosening
(n ¼ 14 cases), implant failure (14), infection (19), seroma
formation (6), malunion (1), humeral diaphyseal fracture (1),
and lysis/loss of bone stock around the implants (2). Fifty‐six
cases (41.5%) had a postoperative complication, including 25
(18.5%) that had major complications and surgical interven-
tion. Nine dogs had complications that required surgical
intervention but for various reasons did not have surgery.
Based on the last postoperative examination at a median of
7 weeks postoperatively (range, 3–312 weeks), 67 cases
(49.6%) had an excellent outcome, 28 (20.7%) had a good
outcome, 31 (22.9%) had a fair outcome, and 7 (5.2%) had a
poor outcome. The outcome was unknown for 2 dogs. Dogs
249
Complications After Lateral Humeral Condylar Fracture
that had major complications were more likely to have a poor
outcome (OR: 1.67; 95% CI: 1.08, 2.62; P ¼.02).
Association Between Fixation Method and Postoperative
Complications
Fractures that were stabilized using a transcondylar screw and
supracondylar K‐wire(s) were more likely to have any type
(minor or major) of complication (51%) compared with
fractures stabilized using a transcondylar screw and supra-
condylar screw or lateral epicondylar plate (35%) (OR 2.02;
95% CI: 1.01; 4.09; P ¼.06). Major complications were more
common in dogs with transcondylar screw and K‐wire (28%)
than dogs that had transcondylar screw and supracondylar
screw or lateral epicondylar plate (16%) (OR 3.19; 95% CI:
1.30; 8.41; P ¼.01; Table 5). Fractures that were stabilized
using a transcondylar screw and supracondylar screw or lateral
epicondylar plate were 3 times more likely to develop
postoperative infection than fractures stabilized using a
transcondylar screw and supracondylar K‐wire (OR 3.55;
95% CI: 1.20, 13.07; P ¼.03).
Six of the variables evaluated met the criteria for potential
confounders for the relationship between fixation method and
major complications (Table 6), 5 with P values <.2 on
univariate analysis: age (as a continuous variable), weight (as
an ordered categorical variable), evidence of IOHC, presence
of supracondylar comminution, CW:SD ratio (0–12 or >12);
and anesthesia time (>3 hours) was considered an a priori
confounder (Table 2). Persistence of the intracondylar fissure
was found to be associated with an increased major
complication rate (OR ¼ 4.1; 95% CI: 1.4, 14.9; P ¼.017),
but was not included in the multivariate logistic regression
model as it may have been a result of major complication rather
than the cause. After backwards elimination procedure, weight
(as ordered categorical), supracondylar comminution and CW:
SD ratio (0–12 or >12) remained as confounders, and no
interaction was identified. After adjusting for confounding
factors, stabilization using a transcondylar screw and supra-
condylar K‐wire was associated with higher risk of major
complications (OR ¼ 4.79; 95% CI: 1.14, 23.42; P ¼.04).
There was no indication from the Hosmer–Lemeshow
goodness‐of‐fit test to suggest a poor model fit (P ¼.31).
The interactions between screw size and dog age and
screw size and dog weight were further investigated. As dog
Table 5 Comparison of Complication Rates for Dogs That Had a Transcondylar Screw and K‐Wires or Transcondylar Screw and Supracondylar Screw
or Lateral Epicondylar Plate
Type of complication Fixation Method Number of Dogs
Any complication 1 61
2 75
Major complication 1 61
2 74
Post‐operative infection 1 58
2 72
In this table, fixation method 1 refers to cases stabilized using a transcondylar screw and supracondylar K‐wire(s). Fixation method 2 includes cases
stabilized using a transcondylar screw and supracondylar screw or transcondylar screw and lateral epicondylar plate.
250 Veterinary Surgery 44 (2015) 246–255 © Copyright 2014 by The American College of Veterinary Surgeons
Perry et al.
age increased, so did the size of the transcondylar screw. An
increase in dog age by 1 month increased the mean
transcondylar screw size by 0.013 (95% CI: 0.010, 0.016;
P <.0001). However, when the association between CW:SD
and age was investigated, while CW:SD ratio decreased by
0.0079 when age increased by 1 month, this effect was not
significant (95% CI: 0.017, 0.0015; P ¼.101). When dog
weight increased, so did the size of the transcondylar screw. An
increase in weight by 1 kg increased the mean screw size by
0.077 (95% CI: 0.064, 0.089; P <.0001). However, when the
association between CW:SD and weight was investigated, an
increase in weight by 1 kg increased CW:SD ratio by 0.019 and
the effect was not significant (95% CI: 0.034, 0.072;
P ¼.484).
When investigating the association between fixation
method and postoperative infection, 5 variables met the
criteria for potential confounders, 4 with P values <.2 on
univariate analysis: age (as a continuous variable), weight (as a
continuous variable with quadratic terms), evidence of IOHC,
and supracondylar comminution; anesthesia time was consid-
ered an a priori confounder. Weight was the only confounding
factor after backwards elimination procedure, and no interac-
tion was identified. After adjusting for weight, there was little
evidence to suggest that fractures stabilized using a supra-
condylar screw or lateral epicondylar plate had a higher risk of
postoperative infection than cases where supracondylar K‐
wires were used (OR 1.98; 95% CI: 0.48, 10.44; P ¼.37).
Association Between Complication Rate and Referral Center
A univariate analysis was performed to assess for evidence of
an association between referral center and major complication
rate. Referral centers were assigned numbers from 1 to 3. The
risk of major complications was shown to be significantly
higher at referral center 2, with 11 times the odds of major
complications (OR 11.47; 95% CI: 3.62, 44.61; P ¼.001).
There was little evidence to suggest any difference between
complication rates between centers 1 and 3. Referral center 3
was more likely to use the transcondylar screw and supra-
condylar K‐wire technique; after adjusting for fixation method,
there was no evidence of a significant difference in major
complication rate between these 2 centers (OR 2.2; 95% CI:
0.59, 9.25; P ¼.25).
Referral center was added as a fixed effect to the
multivariable logistic regression model. This was done to
Number (%) With Complications Crude OR 95% CI P‐Value
31 (50.8)
26 (34.7) 0.51 (0.26, 1.02) .06
17 (27.9)
8 (10.8) 0.31 0.11; 0.85 .01
4 (6.9)
15 (20.8) 3.55 1.03; 15.49 .03
Perry et al. Complications After Lateral Humeral Condylar Fracture

Table 6 Baseline Distribution of Risk Factors for Major Complications in LHCF stabilized using a transcondylar screw and supra-
in Dogs With Lateral Humeral Condylar Fractures condylar K‐wire(s) when compared with cases stabilized using
Number (%) a transcondylar screw and supracondylar screw(s) or a
Number With Major 95% transcondylar screw and lateral epicondylar plate. Major
of Dogs Complications Crude OR CI P‐Value complications were seen 5 times more frequently in the
Spaniel breed transcondylar screw and K‐wire(s) group. This concurred with
No 53 8 (15.1) our hypothesis that use of a transcondylar screw inserted in lag
Yes 81 17 (21.0) 1.49 (0.61, 3.94) 0.39 fashion and supracondylar K‐wire would result in a higher
Sex complication rate than when a supracondylar screw or lateral
Male 69 13 (18.8) epicondylar plate were used. Also, dogs that had a major
Female 66 12 (18.1) 0.96 (0.40, 2.29) 0.92
complication were more likely to have a poor outcome.
Age (months)
0–12 66 9 (13.6)
A higher rate of postoperative infection for the latter 2
13–48 25 5 (20.0) 1.58 (0.44; 5.17) 0.46 techniques when compared with the transcondylar screw and
48–96 31 6 (19.4) 1.52 (0.47; 4.68) 0.47 supracondylar K‐wire(s) was found on univariate analysis;
>96 13 5 (38.5) 3.96 (1.01; 14.87) 0.04 however, after adjusting for confounding factors, there was no
Age (category) evidence of association between fixation method and postop-
8 months 62 8 (12.9) erative infection.
>8 months 73 17 (23.3) 2.05 (0.84; 5.39) 0.13
Weight (kg)
The signalment of our dogs is similar to previous report
0 to 10 48 6 (12.5) with a predominance of Spaniel breeds, particularly the
>10 to 20 57 10 (17.5) 1.49 (0.51, 4.70) 0.48 Springer Spaniel,2,4,7–9 and identified causes for fractures also
>20 24 6 (25.0) 2.33 (0.65, 8.44) 0.19 concur with previous work.2,4,10 The overall complication rate,
IOHC 41.5%, is higher than previously reported,7,10,16,24,26,35 and
No 47 5 (10.6) classification of these complications into minor and major
Yes 86 20 (23.3) 2.55 (0.95; 8.11) 0.08
based on a requirement for revision surgery was not done in
Supracondylar comminution
No 77 17 (22.1) these other studies. Based on the data presented in those
Yes 48 6 (8.0) 0.5 (0.17; 1.33) 0.18 studies, our classification method would yield major compli-
Anesthesia time cation rates from 18% to 39% for 3 of these reports,24,26,35 so
3 hours 51 6 (11.8) our major complication compares favorably.
>3 hours 60 11 (18.3) 1.68 (0.59; 5.24) 0.34 We found that stabilization using a transcondylar screw
Presence of intercondylar fracture gap immediately postoperatively
and supracondylar K‐wire(s) resulted in a higher major
No 69 13 (18.8)
Yes 56 9 (16.1) 0.82 (0.32; 2.08) 0.69
complication rate than use of a transcondylar screw and
TSA supracondylar screw or lateral plate. This incidence of major
0–10 72 11 (15.3) complications also affected outcome. Previous explanations
>10–20 45 9 (20.0) 1.39 (0.51, 3.67) 0.51 for the relatively high complication rate encountered after
>20 8 2 (25.0) 1.85 (0.25, 9.31) 0.49 LHCF repair have concentrated on the difficulty in restricting
CW:SD postoperative activity.35 Activity restriction should be a
0–12 79 17 (21.5)
>12 46 5 (10.9) 0.44 (0.14, 1.22) 0.14
problem common to all fixation methods, so this seems an
Persistent intracondylar fissure unlikely explanation for the difference between groups in our
No 45 4 (8.8) study. The use of K‐wires for stabilization of these fractures has
Yes 67 19 (28.8) 4.1 (1.4, 14.9) 0.017 been debated for 2 reasons. K‐wires do not provide the
compression or stability of a screw inserted in lag fashion and
they have been reported to migrate during the healing period,42
causing significant problems in both people43 and animals.44,45
account for the inherent similarities to cases treated at the same Although theoretically the K‐wire in the supracondylar
center compared to dogs treated at different centers. The model position is being used as an anti‐rotational point of fixation,
did not reveal any significant findings. There was no difference the increased complication rate in the transcondylar screw and
in postoperative infection compared to that from center 1, and supracondylar K‐wire group indicates that this fixation method
no difference in terms of fixation method used. Dogs from is inferior to use of a supracondylar screw or lateral epicondylar
center 3 tended to be older than at centers 1 and 2 but not plate. This may be attributable to lower stability offered by the
significantly so, and there was no difference in weights between supracondylar K‐wire. We recommend consideration of an
centers. Centers 2 and 3 were significantly less likely to use alternative treatment option in cases where a supracondylar
postoperative antibiosis than center 1. K‐wire is being proposed to minimize postoperative
complication rates. In our data set, there were insufficient
cases where a transcondylar screw and a supracondylar screw
DISCUSSION were used to allow treatment of this as a separate category for
statistical analysis. However, we considered it appropriate to
We found that both complications overall, and major evaluate these 2 methods together as the use of a supra-
complications requiring revision surgery are more common condylar screw is only appropriate for certain configurations

Veterinary Surgery 44 (2015) 246–255 © Copyright 2014 by The American College of Veterinary Surgeons 251
Complications After Lateral Humeral Condylar Fracture
of LHCF. With the transcondylar screw and K‐wire technique
proving inferior, an alternative for all configurations of LHCF
is necessary, and therefore this grouping is considered to be
clinically relevant.
Both increasing duration of surgery and anesthesia lead to
an increased rate of postoperative wound infection.46,47 We
found no association between duration of anesthesia and
fixation method. This is surprising as placement of a
supracondylar screw or lateral epicondylar plate is more
technically demanding, and it would be expected that surgical
and anesthesia time for these would be increased. Morgan
identified surgical time as a factor significantly associated with
postoperative complications after LHCF repair.35 Surgical
time was not identified as a potential confounder in our study;
however, surgical time was only available for 67/135 dogs
(anesthesia time was available for 111 dogs), and therefore this
could have affected our results. Whereas initially, the
postoperative infection rate appeared to be associated with
fixation method, further statistical analysis revealed dog
weight to be a confounding factor, and once this was
accounted for, fixation method and infection rate were no
longer associated.
Weight was identified as a confounding factor in the
statistical model investigating postoperative infection, with
dogs weighing >10 kg being more likely to develop a
postoperative infection. However, for several reasons, these
data should be interpreted with caution. In this data set, there
was only 1 dog in the 10 kg group that developed
postoperative infection and so the confidence interval is
wide. A substantial number of the dogs with missing data for
the category of postoperative infection were also in the
10 kg group, which may have biased the results. It was also
difficult to separate out the effects of age and weight as these
are highly correlated. Increasing weight has, however, been
previously identified as a risk factor for development of
surgical site infection.48 A further possible explanation for
this increased rate of infection in dogs >10 kg may include an
increased likelihood of dogs of this size having IOHC, which
has also been linked to a high incidence of postoperative
infection.48
Age was identified as a potential confounding factor for
major complications, with dogs <8 months being 4 times less
likely to develop postoperative complications than dogs >8
months. The cut‐off point of 8 months was chosen because this
is age when the distal humeral physes should be completely
fused.37 We were interested in assessing whether Salter–Harris
fractures were associated with a higher or lower risk of major
complications. The key determinant for stationary anchorage
of implants is bone density,49,50 which increases with age in
immature animals.51 Significant correlations have been
identified between pullout strength and bone mineral densi-
ty.51,52 The bone in the younger dogs (<8 months) in our study
would be anticipated to have lower bone mineral density and
therefore implant holding capacity may be compromised
relative to older dogs (>8 months); this fact may have been
expected to increase the complication rate in younger dogs,
which is opposite to our findings. However, dogs <8 months
would also be expected to heal more quickly,53 reducing the
252 Veterinary Surgery 44 (2015) 246–255 © Copyright 2014 by The American College of Veterinary Surgeons
Perry et al.
risk of fatigue failure of implants, which may have been
expected to reduce the complication rate, and it appears that
this was the more clinically relevant effect here. Arguably,
fractures in this younger age bracket may also be less likely to
be secondary to IOHC, which may improve the prognosis for
fracture healing. It is interesting to note that even after this
effect of age had been adjusted for, stabilization with a
transcondylar screw and a K‐wire was still associated with a
higher risk of major complications.
More complex fractures are generally considered to be at
higher risk of complications; however, supracondylar commi-
nution was not identified to have an effect on complication rate
or outcome after LHCF in a previous study by Morgan.35 In
contrast, we found supracondylar comminution appeared to be
protective against risk of major complications. This could be
because of surgeon choice, that is, that surgeons may be more
likely to use a lateral epicondylar plate in cases with
comminution, but this was not evident in the statistical analysis.
Alternatively, supracondylar comminution may be more likely
to be associated with higher trauma, that is, fractures with
comminution would be less likely to be those with IOHC, which
typically fracture with low energy trauma. IOHC fractures have
been reported to have an increased risk of implant failure,
recurrence of lameness, and loss of fracture reduction.2 This
could explain the seemingly protective effect of supracondylar
comminution we documented. In summary, it is important to
appreciate that contrary to expectation, supracondylar commi-
nution should not be associated with a poorer prognosis.
Condylar width to screw core diameter ratio was not
previously identified as having an effect on complication rate
or outcome.35 To minimize complication rates, fractures that
are associated with IOHC are typically stabilized using the
largest transcondylar screw that can be safely accommodated in
the humeral condyle, whereas for other cases, the outer
diameter of the screw should be 30–50% of the diameter of the
condyle at the fracture surface because this reduces the time to
screw failure through cyclic loading.2 In our study, contrary to
expectation, higher CW:SD ratio was identified as a potential
confounder, being protective against major complications. This
contradicts previous recommendations to use the largest screw
possible. The effect may not be significant as the confidence
interval for the odds ratio included 1; however, we consider the
findings worthy of discussion because of the altered direction
of effect noted. An explanation for this is not immediately
evident to us; however, it has long been recognized that our
understanding of the pathogenesis of IOHC is incomplete and
that current treatment methods fail to provide a consistently
acceptable result. We initially postulated that a potential
explanation could be that surgeons may have placed smaller
screws in younger dogs and larger screws in older dogs because
of the perceived greater risk for IOHC, which may have
affected these results. However, upon further analysis, while
transcondylar screw size certainly increased with dog age and
with dog weight as one would expect, CW:SD ratio was not
shown to decrease significantly with age or with weight. This
indicates that surgeons did not choose to place a larger screw in
an older dog when compared to a younger dog of the same size.
Neither did they elect to use larger screws in heavier dogs
Perry et al.
compared to lighter dogs of the same condylar width. These
unexpected results could be seen as indicating that simply
using the largest screw possible in cases of IOHC‐related
fracture is not sufficient, and consideration of the use of a
lateral epicondylar plate or supracondylar screw in addition
may be warranted to minimize complication rates.
We did not demonstrate that suspicion of IOHC was
associated with a higher complication rate or poorer outcome.
However, the statistical model was not designed to confirm or
refute this and it is intrinsically difficult to definitively determine
whether an LHCF has occurred secondary to IOHC. Although
we attempted to address this by using a comprehensive
classification system, the classification remains subjective and
errors in classification in either direction are possible.
A further interesting finding that correlates with previous
suggestions35 is that the persistence of an intracondylar fissure
on follow‐up radiographs was associated with an increase in
major complication rate. It is also interesting to note that
persistence of an intracondylar fissure was not associated with
evidence of IOHC pre‐ or intraoperatively. Persistence of a
fissure was noted in 49.6% of our cases. The distinctive pattern
of fatigue failure in screws placed transcondylarly in cases of
IOHC has been analyzed, and it has been shown that screw
failure likely occurs secondary to intracondylar non‐union
because of ongoing instability.54 Cyclic fatigue stresses because
of ongoing instability can also predispose to implant loosen-
ing35; however, it should be noted that with our data set, it is
difficult to discern cause and effect here for several reasons and,
therefore, this result should be interpreted with caution. Some of
these radiographs were taken at the time that the fixation method
was failing, and some fixation failures occurred within weeks of
the initial surgery when healing of the fissure would not have
been anticipated. Also, there were a lot of cases with unknown
data for this variable (17.0%) and this may have affected our
results. For the cases where complications occurred months to
years postoperatively, persistence of an intracondylar fissure
may well have been a contributing factor. In a previous analysis
of 50 cases of LHCF, TSA was demonstrated to be associated
with presence of an intracondylar fracture gap postoperative-
ly.35 It was postulated that intracondylar fracture gap
postoperatively may be associated with implant failure35;
however, the number of cases was too small to statistically
analyze this. We analyzed data for a correlation between
presence of an intracondylar fracture gap postoperatively and
complications postoperatively and no effect was found.
Despite the fact that a correlation between accuracy of
reduction and long‐term outcome for condylar fractures has not
been shown,55 the surgeon should still aim for accurate
anatomic reduction of intra‐articular fractures and, therefore, an
attempt should continue to be made to angle the transcondylar
screw parallel to the epicondylar line to minimize intracondylar
fracture gap persistence.35 However, our results are useful in
that they assist with providing an accurate prognosis for owners
in terms of expected complication rates should an intracondylar
fracture gap be noted postoperatively.
The risk of major complications was significantly higher
at one referral center. Despite performing multivariate
statistical analysis, no cause for this finding was determined.
Veterinary Surgery 44 (2015) 246–255 © Copyright 2014 by The American College of Veterinary Surgeons
Complications After Lateral Humeral Condylar Fracture
Potential reasons that were not specifically investigated in our
study could include surgeon experience or prevalence of multi‐
resistant bacterial infections, which could lead to a higher
incidence of implant removal; however, without further study
this is speculative.
There are a number of important limitations to our study
design. Our primary aim was to evaluate the association
between fixation method and complication rate and as such, the
statistical model used was designed accordingly. This limited
the investigation of associations between complication rates
and other variables, as they were considered principally as
potential confounding factors.
The retrospective nature of the study introduces numerous
potential sources of error, particularly with regard to the
potential for reporting inaccuracies and the lack of standardi-
zation in pre‐ and postoperative radiographic positioning and
protocol. The effect of this should be reduced by reporting a
large number of cases; however, this necessitated a multicenter
study, which introduced further limitations, including a lack of
standardization in perioperative management. The follow‐up
was only short‐term in some cases and lost in others, both of
which may have resulted in falsely low reported complication
rates. However, as such limitations should affect all fixation
methods similarly, this should not have a major impact on our
findings. It has become standard in the veterinary literature to
classify complications as major and minor based upon whether
revision surgery was performed; however, it is recognized as a
limitation that in a number of cases where revision surgery
would be recommended it is not pursued for various reasons
including but not limited to, owner preference and financial
limitations, which again may falsely lower the major
complication rates reported. In addition, the classification
method used for assessing the presence of IOHC was prone to
error. Furthermore, all fractures were followed up using
radiography alone, and no cases were evaluated during follow‐
up with CT. Errors therefore may have been made during the
classification of whether or not the intracondylar fissure healed
postoperatively. It is recognized that in dogs with apparent
disappearance of the fissure on follow‐up radiographs, a
persistent fissure may be demonstrated on CT examination.2
Despite this limitation, our results show that persistence of the
fissure radiographically appears to worsen the prognosis in
terms of postoperative complications and remains clinically
relevant as most condylar fractures will be followed up using
only radiography. A further limitation resulting from radio-
graphic assessment postoperatively is that implant failure may
have been underdiagnosed as it is recognized that screw failure
is not always evident radiographically.54
We demonstrated a significant difference in major
complication rates between the methods of stabilization for
LHCF repair. Use of a supracondylar screw or lateral
epicondylar plate in conjunction with a transcondylar screw
resulted in a lower major complication rate compared with use
of a K‐wire in the supracondylar position. We also found that a
poorer outcome is statistically more likely after development of
major postoperative complications. Based on these results, it
may be prudent to select the use of supracondylar screw or
lateral epicondylar plate for surgical stabilization of LHCF.
253
Complications After Lateral Humeral Condylar Fracture
Future studies to clarify the effects of age, weight, and
postoperative antibiosis are warranted and studies using CT for
pre‐ and postoperative imaging would be useful in clarifying
the influence of IOHC.
ACKNOWLEDGMENT
We acknowledge the assistance of Professor Chris Lamb for his
assistance in retrieval of the images.
DISCLOSURE
The authors report no financial or other conflicts related to this
report.
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SUPPORTING INFORMATION
Additional Supporting Information may be found in the online
version of this article at the publisher’s website.
Table S1: Details of Implants Used in Each Case (Subdivided
by Fixation and in Ascending Weight Order).
255