Veterinary Surgery

26:398-407. 1997

Ex Vivo Biomechanical Comparison of Pin Fixation Techniques

for Canine Distal Femoral Physeal Fractures

Objective-To compare the biomechanical properties of five intramedullary (IM) pin fixation
techniques for Salter-Harris type I fractures of the distal femur in dogs.
Study Design-Randomized, one-way factorial design composed of five treatment groups: (1)
single IM pin, (2) dynamic IM crossed pins, (3) paired convergent pins, (4) crossed pins, and
(5) crossed polyglycolic acid (PGA) rods.
Sample Population -Forty pairs of cadaver canine femurs.
Materials-One femur of each pair was manually fractured and subsequently repaired; the
contralateral intact femur served as its control. Each femur was loaded in torsion until failure
occurred and load-deformation curves were generated.
Results-The crossed-pin technique sustained the greatest load to failure (1 16.8%) followed
by the paired convergent pins (104.8%), dynamic IM pins (90.6%), single IM pin (72.1 %), and
crossed PGA rods (71.9%). Statistically significant differences in strength at failure were detected
between the crossed-pin and single IM pin and the crossed-pin and crossed PGA rod techniques.
All fixation techniques underwent greater deformation (1.5 times as much) and had a lower
stiffness (66% to 75%) compared with the intact controls; however, there was no significant
difference between techniques. Failure in the paired convergent and crossed-pin techniques
occurred by fracture of the bone; failure in the other techniques occurred by distraction at the
fracture site.
Conclusion-The rotational stability of any of the fixation techniques appears to be primarily
determined by the ability to prevent distraction and maintain interdigitation of the physis.
Clinical Relevance- When choosing a particular fixation technique for repair of a distal femoral
physeal fracture, consideration should be given to the technique's relative biomechanical merits.
OCopyright 1997 by The American College of Veterinary Surgeons

F EMORAL FRACTURES are the most common

long bone fractures occurring in dogs.' In imma-
ture animals, the physis is the weakest part of the
growing bone2 and, in dogs, the distal femur is the
most frequently involved site for physeal fractures.
Fractures of the distal femoral physis, the majority
of which are Salter-Harris types I and 11,3-6account
for 37% of all physeal fractures in dogs.3
Various fixation techniques have been described
for the repair of fractures of the distal femoral phy-
sis,' with different advantages being offered in sup-
port of one technique over another. Four currently
recognized techniques include the use of a single
intramedullary (M) pin,7 crossed pins,8 paired con-
vergent pins' and dynamic IM crossed pins (modified
Rush pins)." Although retrospective studies have
provided some clinical evaluation of the individual
techniques, no objective comparison has been made
among these four technique^.^.^.'^‘'^ Biomechanical
studies comparing different techniques for repairing
proximal and mid-diaphyseal fractures of the canine
femur have been reported.I3-'*Similar studies, how-

From the Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada.
Funded by the Ontario Veterinary College Pet Trust. Implants provided by Kirschner Medical Corporation, Timonium, MD.
No reprints available.
Address correspondence to H.R. Sukhiani, DVM, DVSc, Diplomate ACVS, Department of Clinical Studies, Ontario Veterinary
College, University of Guelph, Guelph, Ontario, Canada, N1G 2W1.
OCopyright 1997 by The American College of Veterinary Surgeons
0161-3499/97/2605-0007$3.00/0
398
 SUKHIANI AND HOLMBERG
ever, comparing fixation techniques for distal femo-
ral fractures have not yet been performed.
Recently, absorbable implants have been devel-
oped for use in human and veterinary orthopedics.
After their successful use in experimental animal
studies and human clinical cases, polyglycolic acid
(PGA) rods have been advocated for the repair of
physeal fractures in dogs and cat^.'^-^' From a me-
chanical perspective, an advantage of these absorba-
ble fixation devices is that, as the implants degrade
and their mechanical strength decreases, increasing
loads are gradually shifted from the implant back to
the healing bone. The absorbable property of the
implants obviates the need for implant removal. Al-
though the material strength of the PGA used to
manufacture the rods has been q~antitated,’~.’~ the
structural strength of the rods, when actually used
to stabilize fractures, has not been evaluated.
The purpose of this study is to compare, by means
of mechanical torsional testing, five different pin
fixation methods for Salter-Harris type I fractures of
the distal femoral physis in dogs.
MATERIALS AND METHODS
This project was approved by the Animal Care
Committee of the University of Guelph and adheres
to the guidelines of the Canadian Council on Animal
are.'^
Sample Collection
Forty pairs of femurs were obtained from dead,
skeletally immature dogs. These dogs had been eu-
thanitized after their use in veterinary student surgi-
cal exercise laboratories or were obtained as cadav-
ers from local humane societies where they had been
euthanitized for other reasons. The soft tissue attach-
ments on the bones were carefully dissected away
and the presence of an open distal physis was con-
firmed by observation of a distinct physeal cartilage
line. The length of each femur from the dorsal sur-
face of the femoral capitis to the distal surface of
the condyles was measured. The femurs were indi-
vidually wrapped in paper towels soaked with physi-
ological saline solution and packed as pairs in sealed
plastic bags. Each pair was labeled for later identifi-
cation and stored at -20°C until required for testing.
399
Experimental Design
A randomized one-way factorial design was used,
consisting of five treatment groups with eight pairs
in each group. Each pair was randomly assigned into
one of the five fracture fixation groups: single IM
pin, dynamic IM crossed pins, paired convergent
pins, crossed pins, or crossed PGA rods. One femur
from each pair was further randomly assigned to
undergo fracture fixation, with the contralateral fe-
mur serving as its control, so that an equal number
of left and right femurs underwent fixation within
each group.
Fracture Fixation
Before testing, the bones were thawed at room
temperature and any remaining soft tissues, includ-
ing the periosteum and perichondrium around the
distal physis, were carefully removed. The femur of
each pair that was designated for fracture fixation
was manually fractured at the distal physis to create
a Salter-Harris type I fracture. This was achieved by
gripping the epiphysis with pliers and applying a
manual torsional force. The length and width of the
physis on the metaphyseal side of the fracture was
measured for determination of the approximate
cross-sectional area. After anatomic reduction, the
fracture was repaired using the assigned technique.
Single Intramedullary Pin. A ‘1: (3-mm) diame-
ter trocar tip, nonthreaded Steinmann pin (Kirschner
Medical Corporation, Timonium, MD) was directed
proximally from the intercondylar fossa, up the med-
ullary canal along the caudal cortex, to exit at the
intertrochanteric fossa (Fig l).7926327 The distal sharp
tip was cut off and the pin was withdrawn proximally
until the distal tip was just below the level of the
articular cartilage.
Dynamic ZM Crossed Pins (Modijied Rush Pins).
A 0.062” (1.6-mm) diameter Kirschner wire
(Kirschner Medical Corporation, Timonium, MD)
was inserted in the distal fragment, just cranial to
the tendon of origin of the long digital extensor and
just lateral to the lateral trochlear ridge, at an approx-
imate 15” angle to the sagittal plane of the femur.”
The medial pin was inserted at a corresponding site
on the medial edge of the medial trochlear ridge.
The pins were driven alternately up the femur a few
centimeters at a time, directing the tips proximally
and ensuring that they deflected off the endosteal
400 REPAIR OF DISTAL FEMORAL PHYSEAL FRACTURES

directed so that they would cross each other proximal

to the fracture line and penetrate the opposite cortex.
The distal ends were cut and countersunk below the
level of the bone (Fig 4).
Crossed PGA Rods. Two 1.5-mm diameter
holes were drilled from the lateral and medial con-
dyles in a manner similar to that used for insertion
of the pins in the crossed-pin technique.**Two 1.5-
mm diameter, 60-mm long, self-reinforced PGA rods
(Biofix SR-PGA Rods, Bioscience Ltd, Tampere,
Finland) were then placed into the drilled channels
and, using the applicator setting device, each rod
was gently tapped into the bone. Each rod was fully
seated into the bone and was countersunk distally
(Fig 5). The protruding proximal ends were cut with
a heated scalpel blade.28
After repair of the fractures, the proximal and dis-
tal ends of each femur were embedded in polymeth-
ylmethacrylate (PMMA) (Technovit, Jorgensen
Labs, Loveland, CO) (Fig 6). To ensure a secure
grip of the PMMA to the distal epiphysis, a one-
eighth (3-mm) diameter Steinmann pin was placed

Fig 1. Craniocaudal and lateral radiographic projections

of a single IM pin repair.

surface of the opposite cortex. When the pins were

seated in the proximal metaphysis, the distal ends
were cut and countersunk below the level of the bone
(Fig 2).
Paired Convergent Pins. Two 0.062” (1.6-mm)
diameter Kirschner wires were inserted just lateral
and medial to the trochlea starting as far distal as
possible.’ The pins were directed almost parallel to
the sagittal plane, converging slightly, and pene-
trated the cranial cortex proximal to the fracture line.
The distal ends were cut and countersunk below the
level of the bone (Fig 3).
Crossed Pins. Two 0.062” (1.6-mm) diameter
Kirschner wires were inserted in the lateral and me-
dial condyles in a similar manner to the paired con-
vergent Pins-’” However, the pins were Placed at Fig 2. Craniocaudal and lateral radiographic projections
an approximate 30” angle to the sagittal plane and of a dynamic IM crossed-pin repair.
 SUKHIANI AND HOLMBERG 40 1

upper crosshead mount of a servohydraulic materials

testing machine (MTS Bionics 858, MTS Corpora-
tion, Minneapolis, MN). The distal end was placed
in a vise that was secured to the lower platform
mount of the testing machine. The distal PMMA
block was thereby stabilized laterally within the jaws
of the vise but was under no axial compression and
could freely separate if fracture occurred (Fig 6).
Each femur was externally rotated at the proximal
end at a rate of 10" per second until failure occurred
(eg, fracture of the bone or failure of the fixation
implants). The torsional load (torque in Newton-me-
ters) and rotation (angular deformation in degrees)
were recorded simultaneously at a rate of 100 data
points per second. Load-deformation curves were
generated for each femur from these data. The mode
of failure of each femur was also noted. The four
treatment groups repaired with metal pins were
tested first; the configuration that resulted in the
highest strength at failure was then chosen for repair
using the PGA rods. At all times during handling of
the bones, care was taken to ensure that they re-

Fig 3. Craniocaudal and lateral radiographic projections

of a paired convergent pin repair.

transversely through the condyles, caudal to and not

interfering with the previously placed fixation de-
vices, before embedding in the PMMA. Special care
was taken in embedding the femurs distally to ensure
that the PMMA was not in contact with the fracture
line at any point. The intact, control femur of each
pair was embedded using the same technique. After
embedding, the femurs were individually rewrapped
in saline-soaked towels and refrigerated in sealed
plastic bags.

Mechanical Testing
Before the definitive testing of the 40 pairs of
femurs, as described below, pilot tests were per-
formed with a separate set of seven bones to verify
the appropriate mounting and testing techniques- The Fig 4. Craniocaudal and lateral radiographic projections
proximal PMMA block was firmly clamped in the of a crossed-pin repair.
402 REPAIR OF DISTAL FEMORAL PHYSEAL FRACTURES

Statistical Analysis
To determine if an association existed between
the measured variables (strength, deformation, and
stiffness) and the body weight, femur length, and
physeal cross-sectional area, Pearson correlation co-
efficients were determined. A general linear models
analysis of variance was performed to detect differ-
ences between the treatment groups for each of the
measured variables. When significant differences
were found, the means for each group were com-
pared using a painvise Tukey’s studentized range
test to determine where the differences existed be-
tween groups. A significance level of P < .05 was
used in all statistical analyses (SAS Institute Inc,
SAS Circle, Cary, NC).

Fig 5. Craniocaudal and lateral radiographic projections

of a crossed polyglycolic acid rod repair. Note radiolucency
(arrows) where bone was drilled for insertion of rods.

mained moist and that the control and treated femurs

were subjected to the same changes in temperature
and humidity.

Data Evaluation
Values for load to failure and deformation at fail-
ure were determined from the load-deformation
curve of each bone. The failure point was identified
as the point of maximum load on the torque-defor-
mation curve. Stiffness values (Newton-meter/de-
g e e ) were calculated from the slope of the initial
linear portion of each curve using linear regression
analysis. The strength and deformation at failure and
stiffness for each treated femur were expressed as Fig 6. Testing of a femur in the materials testing machine.
percentages of the corresponding values for the con- Inset shows proximal and distal ends of the femur embedded
trol femur of each pair. in polymethylmethacrylate.
 SUKHIANI AND HOLMBERG
RESULTS
Pilot Testing
Preliminary testing showed that a transverse pin
through the distal epiphysis was necessary to prevent
the femur from slipping out of the PMMA block.
When the femurs were simultaneously loaded in tor-
sion and in axial compression at 40% of the body
weight, failure did not occur through the physis. In-
stead, spiral fractures developed through the meta-
physis and diaphysis. Similarly, when the femurs
were supported at the bottom of the distal PMMA
block so that distraction could not occur, even when
no initial compressive load was placed, compression
developed as the torsional load was applied, causing
metaphyseal and diaphyseal fractures. When the
bones were loaded in torsion only and were allowed
to distract distally, failure consistently occurred by
Salter-Harris type I fractures through the distal phy-
sis.
Strength at Failure
The mean strength at failure of the fixation tech-
niques ranged from 72% to 117% of the intact con-
trols (Fig 7). The mean strength at failure for the
femurs repaired with crossed pins and paired conver-
gent pins was higher than that for their respective
intact controls, whereas the mean failing strength of
bones repaired with the other three techniques was
less than that for their controls (Table 1). The
crossed-pin technique sustained the highest load be-
fore failure, followed by the paired convergent pins,
dynamic IM pins, single IM pin and crossed PGA
rods. Statistically significant differences were found
6 100
Ez 75
0 by slippage of the rods within the drill holes and
0
LL 50
0
25
Single Dynamic Paired Ctussed PGA
IM IM Convergent Rods
Fig 7. Mean strength at failure + SE of the repaired fe-
murs as a percentage of the intact femurs.
403
between the crossed-pin and the single IM pin tech-
niques and the crossed-pin and PGA rod techniques.
Deformation at Failure
The repaired femurs, regardless of technique, un-
derwent greater deformation to failure (approxi-
mately 1.5 times) than the intact controls (Fig 8).
There was no statistically significant difference in
the failing deformation between the five groups (Ta-
ble 1).
StifSness
All treated femurs were less stiff (66% to 75%)
than the intact controls (Fig 9). No statistically sig-
nificant difference was found in the stiffness between
groups (Table 1).
No significant correlation was detected between
any of the above measured variables (strength, defor-
mation, and stiffness) and body weight, femur
length, and physeal cross-sectional area.
Mode of Failure
The intact femurs consistently failed at the distal
physis, creating Salter-Harris type I fractures. Fe-
murs repaired with a single IM pin failed by slippage
and distraction at the fracture site. Distraction of the
fracture occurred as the distal segment was forced
distally by the metaphyseal and epiphyseal protuber-
ances sliding against each other. Failure with the
dynamic IM crossed pins occurred by slippage and
distraction at the fracture site with the occasional
additional fracture through the metaphysis. For the
paired convergent pin technique, failure occurred by
fracture through the metaphy seal bone around the
pins. Femurs repaired with crossed pins fractured
either through the metaphyseal bone around the pins
or by fracture of the metaphyseal or epiphyseal bony
projections. The crossed PGA rod fixations failed
occasional bending and fraying of the implants,
allowing slippage and distraction at the fracture line.
The failed femurs remained distracted and mis-
aligned when the torque was released, except for
those repaired with the dynamic IM crossed-pin
technique. The fractures repaired by this technique
did, in fact, dynamically spring back into alignment,
404 REPAIR OF DISTAL FEMORAL PHYSEAL FRACTURES

Table 1. Mean Strength and Deformation at Failure and Stiffness ? SE of Repaired Femurs as a Percentage of Intact Femurs

Fixation Technique

Measure Single IM Dynamic IM Paired Crossed PGA Rods

Strength at failure 72.1* t 5.1 90.6 % 4.9 104.8 t 12.6 ,116.8*1 t 12.8 71.9t t 8.9
Deformation at failure 176.4 2 38.6 143.2 -c 22.2 155.0 ? 26.5 157.1 2 9.6 154.6 t 37.4
Stiffness 65.9 ? 7.7 72.1 t 5.7 74.6 ? 9.2 71.6 ? 4.7 61.4 t 5.9

* t Values with the same superscript are significantly different from each other ( P < .05).

albeit distracted distally, when the torque was re-
leased.
DISCUSSION
The primary purposes of any internal fixation de-
vice are to maintain alignment of the fragments dur-
ing healing and to transmit loads from one end of
the bone to the other.29 For fractures of the distal
femoral physis in dogs, various pinning techniques
have been developed to achieve these purposes. De-
spite their widespread use in veterinary medicine
compared with plate and screw fixation, there has
been relatively little biomechanical investigation of
orthopedic pin fracture fixation. 16.'7330331
Biomechanical strength testing is a widely ac-
cepted and useful means of evaluating the effective-
ness of orthopedic fixation device^.^'"^ Depending
on the purpose of the investigation, testing may in-
volve application of a static load or a dynamic, cyclic
loading regimen to induce failure. In veterinary or-
thopedics, failure with internal pin fixation rarely
occurs as a result of the material strength limitations
of the fixation device. Failures more commonly stem
from not achieving adequate rigidity, resulting in
instability at the fracture site, despite the presence
of intact implants.31 Static loading to failure was
performed in this study to compare the different im-
plant configurations.
To produce clinically meaningful results, ex vivo
biomechanical testing should attempt to mimic phys-
iological loading conditions. Often, only the primar-
ily acting loads may be applied because bone, in
vivo, is subjected to complex intrinsic and extrinsic
forces.31Salter-Harris type I fractures are typically
produced by shearing and avulsion forces2 and, in
the distal femoral physis, bending forces may also
be important.35 The test system used in this study
does not completely replicate physiological loading
conditions; torsional testing was used in this study
as a means of mimicking shear loads at the distal
femoral p h y ~ i and
s ~ ~because torsional instability is
the most common cause of failure with pin fixation
techniques. I5s3l Torsional loading was shown to be
appropriate for this investigation by the consistent
occurrence of Salter-Harris type I fractures in the
control femurs. Although compression at the fracture
site may occur in vivo as the patient begins bearing
weight postoperatively, simultaneous compression
and torsional loading during the pilot tests resulted
in fractures in the diaphysis rather than at the physis.

200 T 75
4
d5 150
s
I-
z $ 50

'
0
; 100 u
0 25
50 s
0
Sinale Dvnamic Paired Cnssed PGA
IM IM Convergent Rods IM IM convergent RoQ

Fig 8. Mean deformation at failure + SE of the repaired Fig 9. Mean stiffness + SE of the repaired femurs as a
femurs as a percentage of the intact femurs. percentage of the intact femurs.
 SUKHIANI AND HOLMBERG
Factors that affect the results of mechanical tests
on bone were considered in the study design and
testing procedure. The effect of variation between
bones because of differing age, gender, porosity,
mineralization, and geometry was minimized by us-
ing matched pairs of bones. The mechanical proper-
ties of a treated femur were expressed relative to the
those of the contralateral, intact femur from the same
dog. Both members of each pair were treated identi-
cally, aside from the creation and repair of the frac-
tures, to equalize any effect caused by drying, freez-
ing, and t h a ~ i n g . Because
~ ~ - ~ ~ of the viscoelastic
nature of bone (its mechanical properties varying
with the rate of loading), loads were applied at a
consistent rate (10" per ~ e c o n d ) . ~Previous
~ " ~ biome-
chanical studies using canine femurs have used an-
gular rates ranging from 6" to 20" per ~ e c o n d . ~In ~ . ' ~ proved. The double-pin configurations in this study
an experimental study using canine tibias, no sig-
nificant effect was noted on the ultimate strength by
varying the angular rate among 3", 6", or 12" per
second.39 Because bone is an anisotropic material
(its mechanical properties depend on the direction
of loading), the orientation of the torsional load was
standardized by externally rotating each femur at the
proximal end. To minimize the effect of varying
pin sizes, so that pin configuration was the primary
variable whose effect would be evaluated, the diame-
ter of pins used in all double-pin techniques was
standardized (0.062"). The diameter of the pin used
for the single IM pin technique was double (0.125")
that used for the double-pin techniques. The size
chosen for the crossed PGA rod technique (0.059")
was the closest available to the size used for the
double-pin techniques.
The load-deformation curves generated in the test-
ing procedure enabled determination of the strength
and deformation at failure and stiffness. Strength
and stiffness are considered the two most important
mechanical factors in a biologically compatible in-
ternal fixation ~ y s t e r n . ~ ' . ~ ~
The strength at failure of the double metal pin
techniques was found to be higher than that of the
single IM pin or PGA rod techniques. The double-
pin techniques were about as strong or stronger than
the intact femurs; the single IM pin and PGA rod
techniques were about 70% as strong as their intact
counterparts. The single IM pin fixation has been
criticized for having poor torsional load transmission
characteristic^.'^ For resistance to torsional loading, greater accuracy can potentially be achieved in
it is necessary for IM devices to have intimate con-
405
tact with the cortical bone so that shear stresses may
be developed between the implant and bone, and
torque transmitted from one fragment to an~ther.~'
In repairing diaphyseal femoral fractures in dogs,
this IM pin-bone contact (friction) can be improved
by using the largest diameter pin possible or multiple
pins to fill the medullary canal.'5929However, with
distal femoral physeal fractures, the benefits of this
approach are limited by the purchase available for
pins in the small distal fragment.16The use of large
pins would also violate one of the principles of phy-
seal fracture repair, that of minimizing operative
trauma to the physis.'
By using two small pins at different angles relative
to the sagittal plane rather than a single longitudi-
nally oriented pin, torsional stability can be im-
sustained greater loads before failure than the single-
pin technique. The improved strength is attained not
only by using a different pin orientation from that
of the axis of the load but by achieving multiple point
fixation in both the proximal and distal fragments.33
Between the double-pin techniques, the paired con-
vergent pins and crossed pins, which were firmly
embedded in cortical bone proximally, sustained
greater loads to failure than the dynamic IM pin
technique in which the proximal ends were seated
in softer metaphyseal cancellous bone. The dynamic
IM pin technique, however, did display a potential
additional advantage of exerting dynamic pressure
by virtue of three-point fixation of the curved resil-
ient pin^.^,'^ When the torque was released, the distal
fragment was able to spontaneously twist back into
axial alignment without further fracture of the bone
having occurred.
The PGA rods, although placed in the same con-
figuration as the crossed pins, failed at significantly
lower torsional loads. Because the shear strength (as
a material property) of PGA is greater than that of
bone,22-24 failure would be expected to occur by frac-
ture through the bone, like those found with the metal
crossed pins. In evaluating the primary mode of fail-
ure of fractures repaired with the PGA rods, failure
appears to have occurred by slippage of the rods
within the drill holes, allowing distraction at the frac-
ture line. There are two possible explanations for
why the rods may have been able to glide in their
holes. By predrilling the holes for the PGA rods,
placement of the rods, compared with driving metal
406 REPAIR OF DISTAL FEMORAL PHYSEAL FRACTURES
pins. However, because of variation in manufactur-
ing tolerances in the drill bits and the PGA rods, or
if the drilling is inaccurate, a slightly larger drill hole
may result. Also, in comparison with driving a metal
pin into bone, which holds the pin in place by elastic
c o m p r e ~ s i o nthe
, ~ ~PGA rods were placed into pre-
drilled holes and were therefore not afforded the
same compressive fit.
In comparing the modes of failure of the two
strongest techniques (the paired convergent and
crossed pins) with the two weakest techniques (the
single IM pin and crossed PGA rods), the former
failed by fracture of the bone whereas the latter failed
by slippage and distraction at the fracture site. The
strength of any of the fixation techniques may be
primarily derived from the ability to prevent distrac-
tion at the fracture site and maintain interdigitation
of the metaphyseal and epiphyseal protuberances.
Maintaining this interlock, in itself, provides rota-
tional stability. If distraction is prevented, failure
then occurs by fracture of the bone, distinct from
the original fracture. When torque is initially applied,
it is the interlocking projections that sustain the load,
regardless of technique. The similar stiffness values
for the different techniques, determined from the ini-
tial portion of the load-deformation curves, reflect
this phenomenon.
ACKNOWLEDGMENT
The authors thank A.E. Valliant, BSc, for assistance
with the statistical analysis and T.C. Hearn, BSc Hons,
PhD, for assistance with the biomechanical testing.
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