Efficacy of two reduction methods in conjunction with

3-D–printed patient-specific pin guides for aligning

simulated comminuted tibial fractures in cadaveric dogs
Matthew D. Johnson, DVM, MVSc, DACVS1*; Daniel D. Lewis, DVM, DACVS1; William A. Sutton, BSME2;
Logan M. Scheuermann, DVM1; Christina C. De Armond, DVM, MS1; Stanley E. Kim, BVSc, MS, DACVS1;
Adam H. Biedrzycki, BVSc, PhD, DACVS, DECVS3

1Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL
2Department of Mechanical and Aerospace Engineering, College of Engineering, University of Florida, Gainesville, FL
3Department of Large Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL

*Corresponding author: Dr. Johnson (mdjohnson@ufl.edu)

https://doi.org/10.2460/ajvr.21.12.0215

OBJECTIVE
To assess the feasibility and accuracy of using 2 methods for reduction and alignment of simulated comminuted
diaphyseal tibial fractures in conjunction with 3-D–printed patient-specific pin guides.
SAMPLE
Paired pelvic limbs from 8 skeletally mature dogs weighing 20 to 35 kg.
METHODS
CT images of both tibiae were obtained, and 3-D reconstructions of the tibiae were used to create proximal and distal
patient-specific pin guides. These guides were printed and used to facilitate fracture reduction and alignment in
conjunction with either a 3-D–printed reduction guide or a linear type 1A external fixator. Postreduction CT images
were used to assess the accuracy of pin guide placement and the accuracy of fracture reduction and alignment.
RESULTS
The 3-D–printed guides were applied with acceptable ease. Guides for both groups were placed with minor but
detectable deviations from the planned location (P = .01), but deviations were not significantly different between
groups. Fracture reduction resulted in similar minor but detectable morphological differences from the intact tibiae
(P = .01). In both groups, fracture reduction and alignment were within clinically acceptable parameters for fracture
stabilization by means of minimally invasive plate osteosynthesis.
CLINICAL RELEVANCE
Virtual surgical planning and fabrication of patient-specific 3-D–printed pin guides have the potential to facilitate
fracture reduction and alignment during use of minimally invasive plate osteosynthesis for fracture stabilization.

M inimally invasive plate osteosynthesis (MIPO) is

an emerging treatment modality in small animal
orthopedics.1–5 MIPO uses indirect reduction tech-
niques to align the major fracture segments prior
to implant application. Manual traction, intramed-
ullary pins, external fixators (EFs), and appropriate
plate contouring have been used to facilitate indirect
closed reduction of appendicular long bone fractures
during MIPO in dogs.1,2,6–14 Gaining proficiency in
MIPO can be technically challenging, and the avail-
ability of intraoperative fluoroscopy greatly facilitates
the process.5,15–17
Virtual surgical planning based on CT imaging
and 3-D printing are being used with increasing fre-
quency in both human and small animal orthopedic
surgery.18–32 Virtual modeling affords creative preop-
erative formulation of surgical procedures and allows
for the fabrication of bone models and patient-
specific guides that can be used prior to or during
surgery.33 Guides are designed to conform to specific
topographic features on a bone’s surface, enabling a
precise, congruent fit between the guide and bone.
Fabricated patient-specific guides have been used
as drill, osteotomy, and reduction guides (RGs) to
facilitate and maintain alignment for implant place-
ment.23,27,30,34–37 A recent cadaveric study27 evaluated
the potential use of virtual surgical planning with
application of a printed alignment jig for managing
fractures in dogs. In that study, Lynch and Davies27
used a cadaveric tibial fracture model and developed
a 2-stage surgical process that included placing pins
in the major proximal and distal tibial fracture seg-
ments during an initial surgical procedure. The frac-
tured limbs, with implanted pins, were then imaged

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with CT, and the CT volume data were subsequently
used to virtually reduce and align the fractured tibia.
A reduction jig was developed to articulate the pins
securing the proximal and distal fracture segments
during a virtual surgical planning session. The jig was
then fabricated and applied during a second surgical
procedure to reduce and align the fractured tibia.27
For the present study, we proposed that custom
pin guides fabricated with virtual 3-D renderings of
CT images of intact tibiae could be applied to accu-
rately reduce a simulated comminuted, mid diaphy-
seal tibial fracture. We were specifically interested in
assessing the efficacy of 2 methods of articulating
the attached pin guides to reduce and align the frac-
tured tibiae and postulated that both methods would
yield acceptable fracture alignment. This methodol-
ogy could be used in clinical cases, because guides
could be designed on the basis of a mirror image of
the contralateral, intact tibia, requiring only a single
CT and surgical procedure.
The objective of the study reported here was to
assess the utility and reliability of designing, print-
ing, and applying 3-D–printed patient-specific pin
guides to facilitate reduction and alignment of tibiae
with simulated comminuted, mid diaphyseal frac-
tures. We evaluated 2 reduction systems with regard
to speed and simplicity of application as well as
accuracy of fracture reduction, including the restora-
tion of prefracture tibial length and torsional, frontal
plane, and sagittal plane alignment.
We hypothesized that use of patient-specific
pin guides, regardless of reduction technique, would
restore acceptable anatomic length (discrepancy
of ≤ 5 mm, compared with length of the intact tibia)
and facilitate acceptable fracture reduction (transla-
tion of ≤ 3 mm) and frontal, sagittal, and torsional
alignment (deviations of ≤ 5°, ≤ 10°, and ≤ 5°,
respectively, compared with the intact tibia).7,14,38,39
We further hypothesized that use of a 3-D–printed
RG would result in shorter reduction times with less
difficulty and would yield more accurate reduction
and alignment, compared with manual reduction
with a linear EF.
Materials and Methods
Cadavers of 8 skeletally mature dogs weighing
20 to 35 kg that had been euthanized for reasons
unrelated to the present study were acquired. The
dogs’ tibiae were palpated to screen for normalcy,
and cadavers were included if no palpable abnor-
malities were noted. Cadavers were frozen at –30° C
until imaging could be performed. Cadavers were
thawed prior to CT (Aquilion Prime S computed
tomography scanner; Canon Medical Systems) of
both pelvic limbs. Helical volume data (slice thick-
ness of 0.5 mm and 0.3-mm slice overlap) were
acquired. The bone algorithm was used for all 3-D
reconstructions and analyses.
DICOM files of the CT images of the tibiae
were imported into a proprietary software program
(Mimics; Materialise Medical Imaging Software Suite)
for segmentation and 3-D modeling of anatomic
2
structures, operative planning, and guide design.
The length of each tibia, frontal, and sagittal angu-
lation and degree of tibial torsion were measured
according to methods previously described.40–42 The
cadavers were stored in a –30° C cooler until custom
guides were designed and printed. Each dog’s right
and left pelvic limbs were randomly assigned by coin
toss to an RG and an EF group.
Guide design
All guides were developed on the basis of CT
images of the intact tibiae. These 3-D–rendered
models were assessed for digital imperfections, cor-
rected, and subsequently exported to the propri-
etary software program. Data were then exported
as stereolithography files to a proprietary software
printing program (Insight; Stratasys) to generate
toolpaths for printing of the models. Subsequently,
the 3-D models were printed (Fortus 450mc;
Stratasys) with a T12 tip (0.178-mm layer thickness)
in a biocompatible acrylonitrile butadiene styrene
material, with a final print accuracy of ± 0.127 mm.
Rendered images of the intact tibiae served as the
control for rendered images of the fractured tibiae
following reduction.
The proximal pin guides were designed to con-
form to the topography of the cranial, medial, and
caudal aspects of the proximal portion of the tibia.
The basic pin guide design consisted of 3 compo-
nents: pin sleeves, bridge, and patient-specific base
(Figure 1). Each guide had 2 identical 10-mm cylin-
drical pin sleeves with a 30° divergence; the sleeve
closest to the fracture was oriented perpendicular
to the long axis of the tibia. Divergent pins afforded
greater RG stability while potentially mitigating pin
interference if a plate were to be applied in a clinical
situation. The sleeves were designed to accommo-
date 3.2-mm-diameter partially threaded pins (Dura-
face; IMEX Veterinary Inc). The bridge component
consisted of a 25 X 10 X 20-mm rectangular prism
that incorporated the 2 pin sleeves and contacted
the cranial aspect of the tibia. The base established
contact with the medial and caudal aspects of the
tibia by means of 2 overlapping components con-
sisting of a 25 X 10 X 25-mm rectangular prism on
the medial aspect with a 7-mm-radius sphere and
a 20 X 15 X 7-mm rectangular prism to capture the
caudal tibial contours. Additionally, a hole was placed
in the caudal region of each pin guide base, trans-
verse to the long axis, to accommodate a 1.6-mm
Kirschner wire. Once the desired anatomic location
was determined on the basis of local topography and
the template had sufficient contour and contact with
the desired location, the topography of the tibia was
subtracted by means of Boolean subtraction and a
clearance factor of 0.4 mm from the modular tem-
plate to create a patient-specific fit for each speci-
men. The distal pin guides were designed in a similar
manner, but without the caudal rectangular prism, to
conform to the cranial, medial, and caudal surfaces
in the region of the distal tibial metaphysis. All of the
sleeves were designed to be aligned in the sagittal
plane when applied to the tibia.
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Figure 1—3-D renderings of the right tibia of a dog with external fixator (EF) pin guides in their planned positions
(A–D) and the left tibia of the same dog with reduction guide (RG) pin guides and the RG (gray) in place (E–H). Each
tibia is shown in medial, cranial, lateral, and caudal views. For the cranial view of the left tibia (F), the RG has been
removed to allow visualization of the pin guides.
In the EF group, a type 1A linear EF consisting
of 4 pin clamps and a carbon fiber connecting rod
(SK system; IMEX Veterinary Inc) was applied to the
pins to reduce and align the fractured tibia. The pin
sleeve height was reduced for pin guides in the EF
group so that the connecting rod of the EF would
be positioned at a similar distance from the sagit-
tal tibial mechanical axis as the 3-D printed RG. The
remainder of the pin guide design was identical
(mirror image) to the RG pin guide developed for
that cadaver’s contralateral limb.
In the RG group, a 3-D–printed RG was designed
to be applied to the pin sleeves to align and reduce
the fracture. The printed RG consisted of a bivalved,
2-piece, 10-mm-high X 19-mm-wide rectangular
block with sufficient length to accommodate all 4 pin
sleeves. The RG was designed with 4 mirror-image,
hemicylindrical recesses, created by means of Bool-
ean subtraction, along the RG length at appropriate
locations to secure the pin guide sleeves if the tibia
was optimally aligned. The 2 component halves of
the RG had 3 matching transverse holes to accom-
modate 4.8-mm bolts. Assembling the RG in contact
with the pin sleeves was intended to restore ana-
tomic alignment and length of the fractured tibiae.
The RG was secured to the pin sleeves by placing
wing nuts on the 3 bolts placed through the 2 com-
ponent halves (Figure 1).
Guide application and fracture reduction
For both reduction groups, medial incisions
were made over the proximal and distal aspects of
the tibia to allow the 3-D patient-specific pin guides
to be attached to the respective tibial segments at
the specified locations. Once the pin guides were
congruently placed on the tibia, a medial-to-lateral
1.6-mm Kirschner wire was placed to secure the
guide to the tibia. A 3.2-mm partially threaded
pin was then placed through each of the pin guide
sleeves and seated in the caudal cortex of the tibia.
Pin guides were attached to the intact tibia for ease
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of placement, with minimal assistance needed to
hold the limb.
The time required to place the pin guides was
recorded. Obtaining sufficient exposure for and
ease of placement of the pin guides was subjectively
assessed with a 10-point Likert-type scale: 0 = unable
to achieve proper placement; 5 = guide placement
with moderate soft tissue manipulation; and 10 = able
to place guide easily with minimal extraneous soft
tissue disruption (Supplementary Table S1).
Once the pin guides were secured, an incision
was made over the medial aspect of the mid diaphy-
sis of the tibia. Multiple osteotomies were made in a
consistent pattern to create a simulated comminuted
diaphyseal fracture.10 The fibula was fractured by
angulating the crus through the osteotomy. The inci-
sion was closed in a single layer prior to any attempt
at fracture reduction so that direct visual assessment
of reduction was not possible.
For the RG group, the 3-D–printed RG was
assembled, securing the pin guide sleeves. The bolts
were placed through the holes in the RG, and wing
nuts were applied to the bolts and tightened. For the
EF group, pin clamps were loosely placed on each
of the pins and a connecting rod was advanced, in
a proximal-to-distal direction, through each of the
clamps. Traction was applied to the pes to distract
the fractured tibia to its original length, and the
pins were manually aligned by rotating the pes as
the clamps were tightened to stabilize the reduced
tibia. The pin alignment was visually inspected. If
the proximal and distal pins were not rotationally
aligned, the clamps were loosened, and the reduc-
tion was improved prior to retightening the clamps
(Supplementary Figure S1).
The time required for guide application and
reduction was recorded. A subjective assessment
of the efficiency and simplicity of this process was
recorded on a 10-point Likert-type scale: 0 = unable
to achieve acceptable reduction; 5 = fracture reduc-
tion achieved with marginally acceptable alignment;
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and 10 = fracture reduction readily achieved with
optimal alignment (Supplementary Table S1).
Guide measurements
CT imaging was performed following reduction
of the tibiae. The DICOM images were processed in
the same manner as described for the intact tibia.
Metal suppression was used to reduce metallic arti-
fact, with individual pin placement derived from the
defect created by the pin in each tibia. Pin place-
ment was then measured by virtually replacing the
pin in each 3-D–rendered image to determine the
accuracy of placement of the guides. Absolute val-
ues for distance or degree of deviation were derived
by comparison against the intended virtual position
for each pin. Actual placement measurements were
given positive and negative values (medial vs lateral,
cranial vs caudal, and proximal vs distal) that were
averaged to determine the prevailing direction of
pin deviation in a given plane. Pins were numbered
1 through 4 from proximal to distal. Intact tibiae and
virtual patient-specific pin guides were overlapped
with the proximal and distal segments of the post-
reduction tibiae. Point-to-point registration was
used to accurately align the tibiae
and move the guides without alter-
ing each guide’s planned location
on each tibia.43 Actual pin place-
ment was compared to the virtual
planned location, and differences
were recorded in each plane; angle
deviations were also measured
(Figure 2). All measurements were
performed on the digital images.

Postreduction imaging
and fracture reduction
measurements
Tibial length, translation at the
fracture site, frontal and sagittal
plane angulation, and torsion were
Figure 2—3-D renderings of a tibia with the pin guides in place. Images measured and compared with each
show the planned pin guide placement (pink) and median placement of specimen’s intact values. The fron-
the guides for the RG (orange) and EF (blue) groups (n = 8 tibiae/group). tal plane, proximal and distal joint
The tibia is seen in medial (A), cranial (B), lateral (C), long axis (D; proxi- orientation lines, and mechanical
mal is at the bottom), and transverse plane (E) views. The height of all
pin sleeves was adjusted to be equivalent for ease of visual comparison. axis were defined with previously
described points.40 Joint orienta-
tion lines and the mechanical axis
were created with the use of datum
planes oriented perpendicular to
the frontal plane. The 2-D mechani-
cal medial proximal tibial angle and
mechanical medial distal tibial angle
were measured (Figure 3).
Similarly, with tibiae viewed in
the sagittal plane, points described
by Dismukes et al41 were used to
create the proximal and distal joint
orientation lines and mechanical
axis as datum planes perpendicu-
lar to the sagittal plane. Intact and
postreduction mechanical caudal
proximal tibial angles and mechani-
cal cranial distal tibial angles were
measured (Figure 3).
To measure postreduction
frontal and sagittal plane angula-
tion, the mechanical axis defined
on the intact tibia was transposed
Figure 3—3-D renderings of the tibia of a dog. A—Cranial view of the over the frontal and sagittal postre-
intact tibia showing joint orientation lines and the mechanical axis. duction joint orientation lines. The
B—Postreduction rendering with identical joint orientation lines show- mechanical axis was duplicated and
ing mild deviation of the distal tibia (1.5° valgus). C—Medial view of
the intact tibia showing joint orientation lines and the mechanical axis. oriented to cross the postreduction
D—Postreduction rendering with identical joint orientation lines showing proximal and distal joint orientation
mild deviation of the distal tibia (4.5° recurvatum). lines at the angles measured on the

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intact tibia. Frontal and sagittal angulation was then
determined by measuring the angular difference
between the 2 mechanical axes.
Overall reduction was graded as near anatomic
(deviation of tibial length of ≤ 5 mm, translation of
≤ 3 mm, internal or external torsion and varus or val-
gus angulation of ≤ 5°, and procurvatum or recurva-
tum of ≤ 10°), acceptable (deviation of tibial length
of ≤ 10 mm, translation of > 3 to ≤ 6 mm, internal
or external torsion and varus or valgus angulation of
≤ 10°, and procurvatum or recurvatum of ≤ 20°), or
unacceptable (deviation of tibial length of > 10 mm,
translation of > 6 mm, internal or external torsion
and varus or valgus angulation of > 10°, and procur-
vatum or recurvatum of > 20°).14,38,39
The absolute value of alterations in length,
reduction, or alignment was used to assess the
accuracy of reestablishing the intact tibial morphol-
ogy for comparisons within and between reduction
groups to negate the effects of bidirectional (eg,
medial or lateral and cranial or caudal) variations
between specimens.
Statistical analysis
Data were analyzed with the Wilcoxon signed
rank test. A preliminary power analysis was per-
formed to determine a minimum sample size for this
comparison. Based on estimates of the precision
of CT measurements, a minimum specimen num-
ber of 8 specimens was determined. The provided
parameters were significance level (adjusted for
sidedness) = 0.025, SD of the dependent variable =
4 mm, SD of the independent variable = 6 mm, num-
ber of tibiae = undefined, power = 0.9, and minimal
detectable difference = 1. The variable calculated
was the total number of tibiae. A total of 8 cadavers
were used in this study. The probability was 93% that
the study would detect a relationship between the
independent and dependent variables at a 2-sided
significance level of 0.05 if the true change in the
dependent variables was 1.0-mm/mm change in the
independent variable. This assumed that the SD of
the independent variable was 6 and the standard
deviation of the dependent variable was 4.
Results
Pin guide placement accuracy
Ease of placement of the proximal and distal pin
guide was similar for the 2 reduction groups, with
minor but measurable deviations from the planned
location and orientation. Guide placement in all
3 planes showed small, significant (P = .01) deviations
from the virtual location but was not significantly
different between reduction groups in any plane
(Table 1).
Ease of fracture reduction
Median scores for ease of fracture reduction
were 10 (range, 9 to 10) and 8 (range, 7 to 10) for
the RG and EF groups, respectively; these scores
were significantly (P = .03) different. Median time
to reduce the tibiae was 1.4 minutes (interquartile
[25th to 75th percentile] range, 1.2 to 1.5 minutes)
and 3.0 minutes (interquartile range, 2.3 to 4.4 min-
utes) for the RG and EF groups, respectively; these
times were significantly (P = .02) different. In the EF
group, fracture reduction had to be readjusted in
3 specimens owing to visible torsional malalignment
following initial tightening of the EF clamps.
Fracture reduction accuracy
Fracture reduction accuracy was similar in the
2 reduction groups, with minor but measurable devia-
tions from the intact tibiae (Tables 2 and 3). Fracture
reduction in all 3 planes showed small, significant
(P = .01 or .02) deviations from the intact tibiae,

Table 1—Accuracy of placement for 3-D–printed patient-specific pin guides fabricated from virtual 3-D renderings
of CT images of intact tibiae from cadaveric dogs (n = 8 tibiae/group) and used to facilitate reduction and alignment
(with a reduction guide [RG] or external fixator [EF]) of simulated comminuted diaphyseal tibial fractures.
Proximal pin guide Distal pin guide
Variable RG group EF group RG group EF group
Frontal plane deviation
  Median (IQR) 4.1° (2.1°–5.2°) 5.1° (2.8°–7.4°) 3.2° (1.7°–5.8°) 3.2° (3.0°–4.0°)
  Prevailing direction Proximomedial Proximomedial Distomedial Distomedial
  P valuea < 0.01 < 0.01 < 0.02 < 0.02
  P valueb 0.2 NA 0.6 NA
Transverse plane deviation
  Median (IQR) 2.3° (1.4°–4.4°) 2.8° (1.2°–6.3°) 5.8° (2.1°–10.4°) 6.6° (5.2°–8.2°)
  Prevailing direction Medial Medial Medial Medial
  P valuea 0.01 0.01 0.01 < 0.01
  P valueb 0.4 NA 0.8 NA
Sagittal plane deviation
  Median (IQR) 1.1° (0.7°–3.4°) 2.6° (1.5°–3.8°) 1.4° (1.0°–2.6°) 3.4° (1.2°–4.4°)
  Prevailing direction Proximal Proximal Proximal Proximal
  P valuea < 0.001 < 0.001 < 0.001 < 0.001
  P valueb 0.2 NA 0.06 NA

IQR = Interquartile (25th to 75th percentile) range. NA = Not applicable.

aP value for comparison with virtual location determined on the basis of CT images of intact tibiae.
bP value for comparison with deviation for the EF group.

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Table 2—Accuracy of fracture reduction for tibiae Table 3—Angular and torsional accuracy of fracture
from 8 cadaveric dogs when an RG or EF was used to reduction for tibiae from 8 cadaveric dogs when an RG
facilitate reduction and alignment in conjunction with or EF was used to facilitate reduction and alignment
placement of 3-D–printed patient-specific pin guides in conjunction with placement of 3-D–printed patient-
fabricated from virtual 3-D renderings of CT images of specific pin guides fabricated from virtual 3-D renderings
the intact tibiae. of CT images of the intact tibiae.
Variable RG group EF group Variable RG group EF group
Change in tibial Angular deviation
length (mm) in frontal plane
  Median (IQR) 0.8 (0.1–2.5) 2.3 (0.2–4.8)   Median (IQR) 1.7° (1.4°–4.3°) 2.9° (2.6°–5.2°)
  Prevailing change Increase Decrease  Prevailing change Valgus Valgus
  P valuea 0.02 0.02   P valuea 0.01 0.01
  P valueb 0.3 NA   P valueb 0.6 NA
Mediolateral Angular deviation
translation (mm) in sagittal plane
  Median (IQR) 1.4 (0.7–2.6) 3.2 (2.6–4.3)   Median (IQR) 5.0° (3.5°–6.2°) 5.4° (2.7°–6.6°)
  Prevailing change Medial Medial  Prevailing change Procurvatum Recurvatum
  P valuea 0.01 0.02   P valuea 0.01 0.01
  P valueb 0.09 NA   P valueb 0.3 NA
Craniocaudal Torsional
translation (mm) alignment
  Median (IQR) 0.8 (0.5–1.3) 2.1 (1.5–4.0)   Median (IQR) 3.6° (1.5°–6.4°) 3.5° (1.9°–8.3°)
  Prevailing change Cranial Caudal  Prevailing change Internal rotation Internal rotation
  P valuea 0.01 0.01   P valuea 0.01 0.01
  P valueb 0.01 NA   P valueb 0.3 NA

IQR = Interquartile (25th to 75th percentile) range. NA = Not IQR = Interquartile (25th to 75th percentile) range. NA = Not
applicable. applicable.
aP value for comparison with intact tibiae. aP value for comparison with intact tibiae.
bP value for comparison with deviation for the EF group. bP value for comparison with deviation for the EF group.

but reduction was significantly different between
reduction groups only in craniocaudal translation
(P = .01) and not in tibial length (P = .3) or mediolat-
eral translation (P = .09).
All of the tibiae in the RG group had a < 5-mm
change in length, compared with length of the intact
tibia. In the EF group, 7 tibiae had a < 5-mm change
in length and 1 had a > 5-mm change in length. In
the RG group, 7 tibiae had an increase in length and
1 tibia had a length equal to that of the intact tibia.
In the EF group, 5 tibiae had a decrease in length,
1 tibia had a length equal to that of the intact tibia,
and 2 tibiae had an increase in length. The median
change in tibial length was not significantly (P = .3)
different between reduction groups.
The RG group had 7 tibiae that had ≤ 3 mm of
mediolateral translation and 1 tibia with < 6 mm of
mediolateral translation. In the EF group, 4 tibiae had
≤ 3 mm of mediolateral translation and 4 tibiae had
< 6 mm of translation. The RG group had 6 tibiae with
medial translation and 2 with lateral translation. The
EF group had 5 tibiae with medial translation and
3 with lateral translation. Median absolute mediolat-
eral translation was not significantly (P = .09) differ-
ent between reduction groups.
All tibiae in the RG group had ≤ 3 mm of cranio-
caudal translation. In the EF group, 5 tibiae had ≤ 3 mm
of craniocaudal translation, 2 tibiae had ≤ 6 mm of
craniocaudal translation, and 1 tibia had > 6 mm of
craniocaudal translation. In the RG group, 5 tibiae had
caudal translation and 3 had cranial translation. In the
EF group, 6 tibiae had caudal translation and 2 had
cranial translation. Median absolute craniocaudal
translation was not significantly (P = .01) different
between reduction groups.
In the RG group, the change in frontal plane
angulation was ≤ 5° in 6 tibiae and ≤ 10° in 2 tibiae.
In the EF group, the change in frontal plane angula-
tion was ≤ 5° in 6 tibiae, ≤ 10° in 1 tibia, and > 10°
in 1 tibia. Valgus deviation was present in 6 tibiae
in both reduction groups, and varus deviation was
present in 2. Median absolute change in frontal plane
alignment was not significantly (P = .6) different
between reduction groups.
Sagittal plane angulation was ≤ 10° in all tibiae
in both reduction groups. In the RG group, 4 tibiae
had recurvatum, and 4 tibiae had procurvatum. In
the EF group, 5 tibiae had recurvatum and 3 tibiae
had procurvatum. Median absolute change in sagit-
tal plane alignment was not significantly (P = .3) dif-
ferent between reduction groups.
In the RG group, the change in torsional align-
ment was ≤ 5° in 5 tibiae, ≤ 10° in 2 tibiae, and > 10°
in 1 tibia. In the EF group, the change in torsional
alignment was ≤ 5° in 5 tibiae, ≤ 10° in 1 tibia, and
> 10° in 2 tibiae. Both reduction groups had 5 tib-
iae with external torsion and 3 tibiae with internal
torsion. Median absolute change in torsional align-
ment was not significantly (P = .3) different between
reduction groups.
Discussion
We accepted our first hypothesis that the
use of patient-specific pin guides restored acceptable
anatomic length and facilitated acceptable fracture

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reduction as well as frontal, sagittal, and torsional
alignment. Although both reduction groups had
parameters with statistically significant morphologic
differences from the intact tibia, these discrepan-
cies were minor and within clinically acceptable
standards.7,14,38,39
Ease or time of placement of the pin guides did
not differ significantly between reduction groups,
which was attributed to the similarity in guide
design. Appropriate placement of the proximal pin
guide was inherently easier to gauge at the time of
application because of the irregular topography of
the proximal tibia. Proximal guide placement did,
however, require adequate elevation of the combined
insertion of the sartorius, gracilis, and semitendino-
sus muscles as well as the popliteus and cranial tibial
muscles. Appropriate placement of the distal pin
guide was more difficult to gauge because the dis-
tal tibia is relatively cylindrical and lacks overt pro-
tuberances. Application of a bone-holding forceps
was often required to stabilize both the proximal and
distal pin guides during placement of half-pins. Pin
guide placement was consistently assessed to be
more efficient during the procedure on the second
limb in each cadaver, which was ascribed to acquired
knowledge of the extent of soft tissue dissection
necessary for guide placement.
Although there were statistically significant dif-
ferences between the planned and actual pin guide
placements, these differences were small and did
not prevent clinically acceptable fracture reduction
and alignment. The proximal pin guide was displaced
distally, with the proximal portion displaced medi-
ally, which we ascribed to soft tissue impedance.
Similarly, the distal pin guide tended to be displaced
proximally with the distal portion of the guide dis-
placed medially. Interference by soft tissues was pre-
dictable, and attempts were made in the design of
the guides to minimize impedance. However, design-
ing guides with accommodations for soft tissues can
reduce the specificity of the guide fit.34 Conversely,
improved fit could be attained with greater soft tis-
sue elevation, but this approach is contrary to the
principles of MIPO and could potentiate postopera-
tive morbidity. Pin guides with smaller contact areas
might reduce soft tissue interference and could
potentially improve the accuracy of guide place-
ment, particularly in areas of with unique contours
such as the proximal tibia. Conversely in regions that
lack distinctive topography, such as the distal tibia, a
smaller pin guide contact area might potentiate inac-
curate guide placement. Assessing guide designs
that optimize guide fit warrants further evaluation.
We also accepted our second hypothesis that
application of the 3-D printed RG was faster and
less difficult than application of the EF. Assembly of
the RG was straightforward, simple, and efficient.
Manual reduction with the linear EF also resulted in
greater variability in final alignment, compared with
the fracture reduction obtained with the 3-D–printed
RG. Likert-type scale responses indicated fracture
reduction was easier in the RG group. Subjectively,
application of the 3-D–printed RG was efficient, and
AJVR
the crus appeared to be well aligned in all cadavers.
Although differences between reduction groups were
not found, the interquartile range was larger for the
EF group for all comparisons of fracture reduction,
indicating greater variability within this reduction
group. Application of the EF was only slightly more
cumbersome than application of the RG, requiring
traction of the pes and distal crus with appropriate
torsional alignment. Maintenance of proper align-
ment as the fixation clamps were tightened contrib-
uted to longer reduction times, and adjustment of
the fixator was required in 3 limbs owing to subop-
timal initial torsional alignment. There was consider-
able variability in reduction times in the EF group,
resulting in a large interquartile range, compared
with that for the RG group.
The RG group consistently resulted in full resto-
ration of tibial length, with 7 of 8 specimens actually
being longer than the intact tibia, which was primar-
ily ascribed to the proximal pin guides being placed
distal to their intended location and the distal pin
guides being placed a similar distance proximally.
Application of the RG, which was designed assum-
ing accurate pin guide placement, resulted in slight
lengthening of the tibiae. Pin guide placement was
similar in the EF group, but tibial length restoration
was predicated on traction applied by the investiga-
tors, and there was a net loss of tibial length in that
group. The median increase in length of 0.8 mm in
the RG group represented a 0.5% change in tibial
length. The EF group had median absolute change in
tibial length of 2.3 mm (0.8%), with most tibiae los-
ing length. Quinn et al44 showed that correction of
angular limb deformities that restored limb length to
at least 91% of the length of the contralateral limb,
along with other needed corrections, yielded good
functional results. Franczuszki et al45 reported that
shorting the femur by as much as 20% can be well
tolerated and that the discrepancy in limb length can
be compensated by greater extension of the joints of
the affected limb. Discrepancies in tibial length in the
current study were comparatively minor and unlikely
to affect functional outcomes.
Both reduction groups had minor frontal and
sagittal translations. The EF group had a median
deviation slightly greater than than the 3-mm cut-
off for near anatomic reduction, although 5 of the
8 specimens had deviations ≤ 3 mm, and all discrep-
ancies were considered clinically acceptable. Dis-
crepancies in placement of the pin guides tended to
be medial owing to the presence soft tissues on the
cranial and lateral aspects of the tibia. The resulting
mild translation is likely explained by the proximal pin
guides being slightly more medially placed than the
distal pin guides. Thus, when the RG was applied, the
colinear nature of the planned pin placement would
result in the distal segment being medially displaced,
compared with the proximal segment. Angulation of
the guide during placement could similarly result in
small malalignments at the fracture site.
Assessment of fracture reduction in the fron-
tal plane revealed small valgus deviations in both
groups, but the median absolute change in both
7
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groups was ≤ 5°. Assessment of guide placement
in the frontal plane revealed that the proximal pin
guides tended to be placed in a distomedial orien-
tation, whereas the distal pin guides tended to be
placed in a proximomedial orientation. Colinear pin
alignment resulted in valgus deviation of the frac-
ture segments, although the magnitude of valgus
deviation in both reduction groups was unlikely to
be clinically consequential.
Fracture reduction resulted in minor sagittal
plane angulation, with a clinically acceptable median
deviation of 5° in both groups. We anticipated that
the RG would produce normal tibial alignment, but
comparable alignment was obtained with manual
traction during EF application. Sagittal angula-
tion was equally divided between procurvatum and
recurvatum. Soft tissue interference in pin guide
placement tended to result in displacement that
would promote recurvatum; conversely the angled
pin in each guide tended to lift the guides such that
it would promote procurvatum. Visual inspection
during placement along with the opposing nature
of these tendencies likely contributed to the small
deviations in either direction.
Torsional malalignment is a common outcome
following MIPO.4,14,38,39 Torsional malalignment was
minor in both reduction groups in the present study
(median, 3°) and would be considered clinically
acceptable. Quantitative assessment of torsional
alignment can be a challenge without 3-D imaging,
and the minor deviations from normal noted in these
tibiae may have not been discernible on traditional
postoperative radiographic imaging.
This study has several limitations that prohibit
us from drawing clinical conclusions. We would
assume that soft tissue constraints encountered in
clinical cases would make restoring length and align-
ment much more difficult in a live animal than in a
cadaver. The effects of muscle contraction, soft tis-
sue swelling, and early fibrosis cannot be replicated
in a cadaveric study.10 We would suspect that res-
toration of tibial length in clinical cases would be
more challenging with either reduction technique.
Application of a printed RG might be more chal-
lenging and cumbersome than application of an EF
in a live dog, particularly if surgery was performed
several days after the fracture had been sustained.
We did not apply a plate to definitively stabilize the
simulated fractures because our aim was to evaluate
the efficacy of the indirect reduction techniques in
restoring normal tibial morphology. In clinical cases,
a mirror image of the contralateral tibia could be 3-D
printed and used to accurately precontour a plate for
fracture stabilization.46,47 The medial aspect of the
guide could be removed after application of the RG
or an EF in a clinical situation to allow medial appli-
cation of the plate. An epiperiosteal tunnel could be
developed between the incisions made for pin guide
application to perform MIPO, and application of a
properly contoured plate could be used to further
improve reduction and alignment.1–5,8,9,11,29,30,47 How-
ever, application of a plate and screws would have
produced substantial artifacts on our postreduction
8
CT images, which may have decreased the accu-
racy of our assessments. We assessed reduction
and alignment via CT images and 3-D rendering. CT
measurements of fracture reduction are more pre-
cise and accurate than typical clinical assessments
of fracture reduction obtained with radiographs48
and allowed us to quantify small alterations from
normal tibial morphology that would be unlikely to
have adverse clinical consequences. Acceptable clin-
ical fracture reduction, which has been somewhat
empirically defined in both dogs and humans, allows
some latitude for minor discrepancies in alignment
that would be unlikely to affect functional outcomes.
We applied previously reported acceptable fracture
reduction criteria for minimally invasive fracture sta-
bilization in formulating the grading system used in
our study.7,14,38,39
MIPO is predicated on restoring functional
alignment through the use of indirect reduction
techniques.4,15 Although neither of the assessed
reduction techniques consistently restored normal
tibial morphology, both yielded clinically acceptable
reduction and alignment. Given our encouraging
results, clinical studies to evaluate the feasibility and
efficacy of virtual surgical planning based on a mirror
image of the intact contralateral tibia to design and
fabricate patient-specific guides to facilitate MIPO
for stabilization of tibial fractures seem warranted.
Acknowledgments
This study was supported by University of Florida, Col-
lege of Veterinary Medicine, Small Animal Clinical Sciences
Departmental funds via the 2019 SACS Research Grant
Competition.
The authors declare that there were no conflicts of
interest.
The authors thank Debby Sundstrom for assistance in
preparing images.
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Supplementary Material
Supplementary materials are posted online at the jour-
nal website: avmajournals.avma.org
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