Received: 10 December 2018 Revised: 1 September 2019 Accepted: 21 September 2019

DOI: 10.1111/vsu.13346

ORIGINAL ARTICLE – CLINICAL

Accuracy of three-dimensional printed patient-specific drill

guides for treatment of canine humeral intracondylar
fissure

Tim G. Easter BVMedSci, BVM, BVS, MRCVS |

Alexis Bilmont DVM, DECVS, MRCVS |
Jonathan Pink BSc, BVetMed, CertSAS, DECVS MRCVS |
Bill Oxley MA, VetMB, DSAS(Orth), MRCVS

Willows Referral Service, Solihull, United

Kingdom Abstract
Objective: To determine the accuracy of three-dimensional printed patient-
Correspondence
specific drill guides (3D-PDG) as treatment of humeral intracondylar fissures
Tim Easter, Willows Referral Service,
Solihull, West Midlands B90 4NH, (HIF) in dogs.
England. Study design: Retrospective consecutive case series.
Email: tim.easter@willows.uk.net
Animals: Client-owned dogs with HIF treated with a 5-mm transcondylar
screw (TCS) placed from medial to lateral with a 3D-PDG.
Methods: The proposed TCS entry point and trajectory were planned using
computed tomography (CT) data and computer-aided design software (CAD),
and a 3D-PDG was produced. During surgery the 3D-PDG was used to drill
the pilot hole from medial to lateral; the guide was then removed, the pilot
hole was overdrilled, and a 5-mm TCS was placed. Postoperative CT data were
imported into CAD software, and the entry points, exit points, and trajectories
were compared between the planned and actual screw locations.
Results: Sixteen elbows from 11 dogs were included. Mean (SD) entry point
translation was 1.3 mm (0.64), with all screws entering cranial to the proposed
location. Mean maximum screw angulation was 5.2 (2.10 ), with most screws
directed caudodistal to the desired trajectory. Mean (SD) exit point translation
was 1.8 mm (0.89) from the planned location. There was no intra-articular
screw placement.
Conclusion: Use of a 3D-PDG permitted accurate placement of a mediolateral
5-mm locking TCS within the humeral condyle.
Clinical significance: Three-dimensional printed patient-specific drill guides
should be considered as accurate and consistent for placing TCS for treatment
of HIF in dogs.

Results of this study were presented at the World Veterinary

Orthopaedic Congress; October 4-6, 2018; Barcelona, Spain.

Veterinary Surgery. 2020;49:363–372. wileyonlinelibrary.com/journal/vsu © 2019 The American College of Veterinary Surgeons 363
364
1 | INTRODUCTION
Humeral intracondylar fissures (HIF) can cause lameness
and predispose to humeral condylar fractures in affected
dogs.1-4 Placement of a transcondylar screw (TCS) has been
recommended to mitigate lameness and reduce the risk of
subsequent fracture.2-5 Despite stabilisation of the condyle,
many HIF fail to achieve osseous union.2,3,6 This results in
cyclic loading of the TCS for the lifetime of the animal and
can lead to implant failure.2,3,5-7 To prolong the life of the
implant, it has been suggested that the largest possible TCS
be placed across the humeral condyle.2 In springer and
cocker spaniels, the breeds most commonly diagnosed with
HIF, a 4.5-mm diameter screw is frequently used,2,5,6 which
may occupy 30% to 50% of the proximodistal width of the
condyle at the isthmus.6 This, in conjunction with the irreg-
ular shape of the condyle, can make correct positioning of
the TCS challenging, with intra-articular screw placement
reported in up to 9% of cases.8
A complication rate of 59.5% has been reported for
lateromedial screw placement, including seroma, surgical
site infection, and implant failure.5 As such, mediolateral
screw placement has been suggested to reduce these risks.8
However, this technique is more challenging because the
margin of error is smaller compared with lateromedial
drilling.9 Barnes et al9 determined the optimal drilling line
from the medial to lateral condylar surfaces and found
that deviation from this line by as little as 6.6 in a
proximodistal direction would have resulted in unaccept-
able screw placement in some dogs. Previous reports of
clinical studies, however, have described proximodistal
screw angulations of up to 7.3 and 15 without joint
infringement.6,10
Fluoroscopic guidance and aiming devices have previ-
ously been used to improve accuracy of screw place-
ment.6,10,11 Fluoroscopy units are not widely available,
and fluoroscopy-assisted screw placement is highly oper-
ator dependent, requires multiple exposures, and exposes
theatre staff to repeated doses of ionizing radiation; it can
also be time consuming. Commercial drill guides can be
challenging to position and may slip during drilling.
Computed tomography (CT) allows the acquisition of
three dimensional (3D) images, which can be manipu-
lated as stereolithography (STL) files in computer-aided
design software (CAD). Computer-aided design software
can assist surgical planning and produce, via 3D printing,
patient-specific bone models and guides. In veterinary
medicine, this technology has been used for minimally
invasive fracture stabilization,12 shoulder arthrodesis,13
and the production of 3D printed patient-specific drill
guides (3D-PDG) for vertebral fracture stabilization14 and
placement of vertebral transpedicular screws.15 Patient-
specific drill guides are produced in this way with the
EASTER ET AL.
objective of improving drilling accuracy and reducing
surgical time, benefits that have previously been docu-
mented in human orthopedic surgery.16-19
The objective of this study is to evaluate the accuracy of
3D-PDG for the placement of TCS in clinical cases of HIF
by comparing the screw location and trajectory planned by
CAD with the location and trajectory achieved at surgery.
We hypothesized that TCS placed by using a 3D-PDG
would remain within the confines of the condyle, would
have proximodistal and craniocaudal screw angulations of
less than 5 , and would have no translation in entry point.
Feasibility of the study was hypothesized based on previous
successful use of 3D-PDG at the author's institution in other
locations with similarly narrow safe corridors (the cervical
spine).15
2 | MATERIALS AND METHODS
Medical records were reviewed to identify consecutive cases
of HIF treated by placing a medial to lateral TCS using a 3D-
PDG by a single surgeon at our referral hospital between
February 2016 and March 2018. Dogs with concurrent
humeral condylar fractures or those without preoperative
and postoperative CT were excluded. Data recorded included
age, weight, breed, sex, neuter status, surgically treated limb
(left, right, bilateral), and surgical details including the
implant placed and any intraoperative complications. Dogs
were enrolled with informed owner consent.
2.1 | Imaging
Computed tomography was performed with a helical,
16-slice multidetector unit (GE Brightspeed; General Elec-
tric Medical Systems, Chicago, Illinois) with a 0.625-mm
slice collimation at 120 kVp and 79 mAs. Dogs were posi-
tioned in sternal recumbency with the elbow extended.
Images were reconstructed in bone and soft tissue windows
and reviewed by a board certified radiologist and the attend-
ing surgeon.
2.2 | Three-dimensional printed patient-
specific drill guide creation
Three-dimensional data in the form of DICOM (Digital
Imaging and Communications in Medicine) files were
exported to medical image processing software (OsiriX;
Pixmeo SARL, Geneva, Switzerland), and a surface-rendered
representation of the distal humerus was created by using
software-defined threshold settings for bone. This was
exported as an STL file to CAD software (NetFabb
EASTER ET AL. 365

Professional 7.2; Netfabb GmbH, Parsberg, Germany), and a
3D virtual representation of the humeral condyle was cre-
ated. This virtual model was not modified other than very
mild surface smoothing in some cases. A 5-mm virtual cylin-
der, representing a 5-mm locking screw, was superimposed
within the virtual humeral condyle and reoriented in six
degrees of freedom until it was judged to be optimally posi-
tioned. The key criterion was positioning of the cylinder in a
central position at the isthmus of the condyle; this was facili-
tated by the ability to view the condyle in sagittal cross-sec-
tion. The entry point of the cylinder was adjusted to lie
immediately cranial to the medial epicondyle, and the exit
point was adjusted to lie within the centre of the slight con-
cavity of the lateral aspect of the condyle immediately distal
to the lateral epicondyle (Figure 1A-C). The cylinder was
then resized around its long axis to a diameter of 2.5 mm to
represent the width and trajectory of the initial pilot hole. A
virtual drill guide was created with two key features: a
2.5-mm drill guide sleeve surrounding the virtual cylinder
and, via extrusion of the virtual cortical surface, a base rep-
resenting an inverted representation of the cortical contours
of the cranial, caudal, and proximal aspects of the medial epi-
condyle and approximately 15 mm of the distal, medial
humeral cortex (Figure 1D,E). The base ensured that the
guide could fit only in a single position, thus orientating the
drill sleeve to the planned pilot hole entry point and
trajectory.
Stereolithography files of the distal humerus and drill
guide were exported to proprietary software (Formlabs,
Somerville, Massachusetts) associated with a 3D printer
(Form 2; Formlabs) and printed by using biocompatible,
autoclavable methacrylate photopolymer resin (Dental
SG resin; Formlabs). The 3D printed bone and guide were
then cleaned according to the manufacturers’ instruc-
tions, and the drill guides were over drilled with a
2.5-mm drill bit. All models were steam sterilized.
2.3 | Surgery
Dogs were premedicated with a combination of methadone
(0.2-0.3 mg/kg IM) and acepromazine (0.005-0.02 mg/kg IM)

F I G U R E 1 Orientation of a 5-mm cylinder (representing a 5-mm screw) within a humeral condyle by using computer aided design.
Cranial (A), medial (B), and lateral (C) views. The cylinder was resized to 2.5 mm, and a drill guide was designed with a 2.5-mm drill sleeve
and base plate conforming to the cortical contours of the distomedial humerus. Cranial (D) and medial (E) views
366
or medetomidine (0.01 mg/kg IM). Anaesthesia was induced
with propofol (4 mg/kg IV to effect) and maintained with iso-
flurane in oxygen after endotracheal intubation. All dogs
were administered intravenous cefuroxime (20 mg/kg) and
meloxicam (0.2 mg/kg) perioperatively. Opioid analgesia was
administered throughout surgery as required.
The affected thoracic limb was clipped from the proxi-
mal humerus to the carpus and aseptically prepared. A skin
incision of approximately 25 mm was centred directly over
the medial epicondyle and was continued through the
underlying fascial layers. To allow correct seating of the
guide, the flexor carpi radialis muscle was elevated from
the craniodistal aspect of the medial epicondyle, and loose
connective tissue was mobilized from the caudal aspect of
the epicondyle and more proximal cortex.
The 3D-PDG was applied to the medial condylar sur-
face, and its position of optimal fit was assessed; this was
F I G U R E 2 Craniocaudal view of the preoperative humerus
(gray) and postoperative humerus and transcondylar screw (green)
after superimposition. The screw head, screw tip, and artefact
secondary to the presence of a metallic implant can be seen
EASTER ET AL.
typically obvious because the guide became stable after the
contours of its base engaged with those of the epicondyle
beneath. A 2.5-mm drill bit was carefully aligned with the
guide sleeve, and the pilot hole was drilled. Palpation of
the lateral aspect of the condyle confirmed appropriate
drill exit site. The guide was removed, and the pilot hole
was over drilled using a 3.2-mm and then a 4.3-mm drill
bit. After each hole had been drilled, the elbow was flexed
and extended with the drill bit in situ to monitor for
crepitus or restriction in range of motion indicative of
intra-articular penetration. In most cases, the entry point
of the pilot hole was on the cranial slope of the epicondyle,
and a high-speed burr was used to remove a small margin
of the epicondylar slope such that the screw head was
recessed by 1 to 2 mm so that the underside of the head
was seated flat onto the bone. The depth of the hole was
measured with a depth gauge, and a 5-mm titanium or
stainless steel, self-tapping locking head screw (DePuy
Synthes, Raynham, Massachusetts) was placed. Screw
length was selected to ensure that the cutting flutes pro-
truded from the condyle and that the screw head seated
1 to 2 mm below the tip of the medial epicondyle. The
flexor carpi radialis muscle was sutured using 3 metric
polydioxanone in a locking loop pattern through two
1.1-mm drill holes in the medial epicondyle. Fascial layers
were sutured to minimize dead space, and, after skin clo-
sure, the incision was covered with an adhesive covering
(Primapore, Smith and Nephew, Kingston Upon Hull,
United Kingdom). Postoperative CT images were obtained
by using the same protocol as before surgery.
2.4 | Postoperative care
Analgesia was provided with opioids for the first 12 to
24 hours and nonsteroidal anti-inflammatory drugs for a
minimum of 7 days, unless health concerns precluded
F I G U R E 3 Medial (A) and
lateral (B) views of the right
humeral condyle from a 25-kg
Labrador of the planned (green) and
achieved (blue) screw entry and exit
points
EASTER ET AL. 367

their use. Postoperative cephalexin (20 mg/kg orally,

twice daily for 10 days) was prescribed for most dogs.
Dogs were typically discharged the following day, and
owners were requested to restrict exercise to 10 minutes
of lead walks three times daily for a minimum of
4 weeks. Sutures were removed by the referring veteri-
nary surgeon 10 to 14 days postoperatively. A repeat
examination was recommended at 4 weeks after surgery,
with follow-up radiographs obtained according to clini-
cian and owner preference.

2.5 | Screw translation and trajectory

quantitation

Comparison of the planned and actual screw translations

F I G U R E 4 Direction and magnitude of entry point
translation of the achieved screws (blue circles) relative to the
planned screw (green diamond). The mean translation in entry
point is represented by the yellow square
and trajectories was performed in freely available CAD soft-
ware (MeshMixer; Autodesk; http://www.meshmixer.com/).
A surface-rendered representation of the postoperative
humerus was created and imported into the software as pre-
viously described. The screw was isolated by manipulating
DICOM windowing and imported as a separate STL file
while maintaining its orientation relative to the humerus.

F I G U R E 5 Entry point translation and angular deviation of the achieved screws (blue) relative to the planned screw (green) in a
craniocaudal direction. Mean (±SD) entry point translation and angular deviation are represented by the yellow and red lines, respectively.
The beginnings of the lines represent the screw entry points, and the ends of the lines represent the screw exit points. All values are in
millimetres
368 EASTER ET AL.

After it had been imported, the long axis of the screw was
matched to a small virtual cylinder. This was facilitated by
the ability to view the screw in cross-section and the use of
the screw tip and the centre of the hex-drive concavity as
landmarks. The postoperative humerus and screw cylinder
were superimposed onto the preoperative humerus and
planned cylinder. Superimposition was conducted via an
alignment tool in the software by using an iterative closest
point method (Figure 2).20,21
The points at which the cylinders contacted the medial
and lateral condylar surfaces represented the planned
and actual screws’ entry and exit points, respectively
(Figure 3A,B). The entry point of the planned cylinder
was defined as the origin of a matrix with the planned cyl-
inder trajectory aligned with the X-axis and the medial
supracondylar ridge aligned with the Z-axis. Coordinates
of both ends of both cylinders were obtained, and these
values were used to determine, via trigonomic vector
calculations, the magnitude and direction of entry and exit
point translation and angular deviation of the actual
screw relative to the planned screw. The greatest angula-
tion in an oblique plane was calculated (maximum angular
screw deviation) in addition to the proximodistal and
craniocaudal angulations relative to the aforementioned
axes. Positive Y and Z values represented translation or
angulation in cranial and proximal directions, respectively,
and negative values represented translation or angulation
in caudal and distal directions, respectively.
Finally, the cylinder was resized to 5 mm in diameter,
and the condyle was scrutinized in all planes for evidence
of intra-articular screw penetration. Results are summa-
rized as mean (SD) for entry and exit point translations
and angular deviation.
3 | RESULTS
Eleven dogs, corresponding to 16 elbows, fulfilled the inclu-
sion criteria. Breeds consisted of springer spaniels (4),
cocker spaniels (3), Labrador retrievers (1) and cross bred
dogs (3). There were seven male (2 neutered) and four
female dogs (all neutered). The mean age at surgery was
65.4 months (range, 8-124), and dogs had a mean weight of
20.1 kg (range, 14.2-25). Nine left elbows and seven right
elbows were treated, including five bilaterally treated HIF.
All transcondylar implants were 5-mm locking screws,
and all were placed from medial to lateral. There were
11 titanium and five stainless steel screws. No intraoperative
complications were encountered. Surgeries were performed
by a single board-certified surgeon (B.O.).

F I G U R E 6 Entry point translation and angular deviation of the achieved screws (blue) relative to the planned screw (green) in a
proximodistal direction. Mean (±SD) entry point translation and angular deviation are represented by the yellow and red lines, respectively. The
beginnings of the lines represent the screw entry points, and the ends of the lines represent the screw exit points. All values are in millimetres
EASTER ET AL.
F I G U R E 7 Direction and magnitude of angular deviation of
the achieved screws (blue circles) relative to the planned screw
(green diamond). The mean angular deviation is represented by the
yellow square
F I G U R E 8 Direction and magnitude of exit point translation
of the achieved screws (blue circles) relative to the planned screw
(green diamond). The mean translation in exit point is represented
by the yellow square
Mean (SD) entry point translation was 1.33 mm (0.64).
Translations occurred in a cranioproximal direction in
12 elbows and craniodistal direction in four (Figure 4).
Mean (SD) craniocaudal and proximodistal translations
369
were 1.08 mm (0.61; ie, cranial) and 0.25 mm (0.76; ie,
proximal), respectively (Figures 5 and 6).
Mean (SD) maximum angular screw deviation was
5.23 (2.10 ). Screw trajectories deviated caudodistally in
11 elbows, caudoproximally in three, craniodistally in
two, and cranioproximally in none (Figure 7). Mean
(SD) craniocaudal and proximodistal angular deviations
were − 2.91 (2.54 ; ie, caudal) and − 3.00 (2.83 ; ie, dis-
tal), respectively (Figures 5 and 6).
Mean (SD) exit point translation was 1.80 mm (0.89).
Translations occurred in a caudodistal direction in eight
elbows, craniodistal in six, caudoproximal in one, and
cranioproximal in one (Figure 8). Mean (SD) craniocaudal
and proximodistal translations were − 0.26 mm (1.29; ie,
caudal) and − 1.09 mm (1.05; ie, distal), respectively. All
screws remained within the cortical confines of the
condyle.
4 | DISCUSSION
In our clinical setting, the use of 3D-PDG resulted in accu-
rate TCS placement in dogs with HIF. Screw entry point
was a mean (SD) of 1.33 mm (0.64) from the proposed entry
point with a mean (SD) deviation of 5.23 (2.10 ) from the
proposed screw trajectory. Combined, these resulted in a
mean (SD) translation of 1.8 mm (0.89) from the planned
screw exit point. Most importantly, no screw violated the
cortices of the condyle. Our hypothesis that there would be
no deviation in entry point was rejected, yet our hypotheses
that there would be mean craniocaudal and proximodistal
angulations of less than 5 and no intra-articular screw
placement were accepted. Achieving the correct entry point
and trajectory is essential when placing a large TCS across a
relatively long yet narrow humeral condyle. Inaccurate
placement can lead to intra-articular implant placement
and potentially reduce the longevity of the screw if it is not
placed in the most biomechanically robust location. It is
important that techniques designed to aid placement are,
therefore, accurate and reproducible. Furthermore, no
intra-operative or postoperative complications directly
relating to use of the 3D-PDG were identified.
Proximodistal angulation of TCS placed using fluoro-
scopic guidance and an aiming device has been evaluated
in two previous studies.6,10 Instead of CT and/or CAD,
these studies used radiography to measure angulation, the
accuracy of which is highly dependent on radiographic
positioning and, therefore, more subject to error. Angula-
tion was calculated relative to the epicondylar line rather
than to a planned trajectory; however, it may be assumed
that the planned trajectory in these reports was parallel to
this line. The maximum proximodistal angulations in
these reports were 7.3 (mean, 3.6 ) and 15 (mean, 5 ).6,10
370
Our mean and maximum proximodistal angulation values,
−3.00 (2.83 ) and 6.72 , respectively, are lower than in
these other studies and, importantly, are both below the
mean angulation of 16.2 defined by Barnes et al9 as the
angulation required to remain within the safe corridor of
the condyle. However, one dog in the Barnes et al9 study
had a proximodistal safe corridor of only 6.6 . Two elbows
in our group had angular deviation above this value (6.63
and 6.72 ), so, while intra-articular penetration was not
observed in our cohort, this may still be possible in future
cases. Our mean and maximal craniocaudal angular devia-
tions (−2.91 [2.54 ] and 6.03 , respectively) are also well
below the mean and minimum craniocaudal deviations, as
defined by Barnes et al9, required to remain within the
safe corridor (27.5 and 18 ).9 To the best of the authors’
knowledge, this study is the first in which craniocaudal
screw angulation in the humeral condyle is evaluated. The
previously defined safe corridors were calculated for use
with 4.5-mm screws and use of a common entry point.
Therefore, when a 5-mm diameter implant is used, the
safe corridor may be reduced; however, because entry
points in our study were patient specific, the safe corridors
may be increased as variations in condylar anatomy are
accounted for.
To the best of the authors’ knowledge, this is the first
description of transcondylar placement of a 5-mm
locking screw, which is a larger screw than has previ-
ously been reported. Because many HIF fail to achieve
osseous union,2,6 maximizing the size of the implant
placed within the condyle has been advocated to resist
failure fatigue.2 The core diameter of a 5-mm locking
screw is 34% greater than a 4.5-mm cortical screw,
increasing the area moment of inertia (AMI) by 360%.
Although this AMI (18.4 mm4) remains slightly less than
that of a 4.5-mm shaft screw (20.1 mm4) that has previ-
ously been reported as a TCS,6 shaft screws are incom-
pletely threaded. Because incomplete threading reduces
bone-implant contact, the pull-out strength of this
implant may be reduced, and aseptic screw loosening has
been previously reported.6 While a 5-mm locking screw
has a reduced thread depth relative to a 4.5-mm cortical
screw, the thread pitch is reduced (ie, there are more
threads per unit length), which maintains the surface
area available for bone-implant contact. Because TCS are
subject to shear forces and not axial pull-out, the fric-
tional interface between the implant and the bone are
likely to be of greater importance than thread depth for
screw loosening. Locking screws are placed through a
pilot hole 0.1 mm smaller than the core diameter in con-
trast to cortical screws, which are placed through a pilot
hole 0.1 mm larger than their core diameter. The fric-
tional interface between a locking implant and the bone
is therefore likely to be enhanced, although further study
EASTER ET AL.
comparing screw loosening between locking and cortical
screws in the absence of a bone plate is justified. It is not
known what AMI is required to resist the forces placed
on the screw throughout the lifetime of the dog, and it
was beyond the scope of this study to determine the long-
term outcomes for this particular implant. Finally, it is
possible that the exposed threaded head of the locking
screw could result in irritation to the flexor muscles origi-
nating on the medial epicondyle. However, no mus-
culotendinous irritation or injuries were identified during
this study.
Calculated discrepancies between the planned and
achieved entry points and trajectories may arise from pre-
operative, intraoperative and/or postoperative factors.
Preoperative factors relate predominantly to image acqui-
sition, virtual model creation, and guide production. Less
than perfect fidelity of the virtual to the real condyle may
result from inaccuracies during DICOM acquisition,
image reconstruction, conversion to STL files, and, ulti-
mately, during printing. While the tolerance limit of each
individual step is relatively small, with an increasing
number of steps comes an overall reduction in accu-
racy.22 Intraoperative factors include poor seating of the
guide and deviation from the initial pilot hole during
overdrilling. Poor seating may occur due to incorrect
guide positioning or interposition of soft tissues between
the guide and the bone. Gross guide malpositioning is
considered unlikely because of the highly contoured
nature of the epicondyle resulting in a “snap-on” fit;
however, subtlety altered guide orientation because of
residual soft tissue especially in the region of the flexor
carpi radialis muscle attachment to the epicondyle could
have contributed to the reported trajectory inaccuracies.
Removal of soft tissues from the region of the guide foot-
print is a key surgical step and a potential drawback of
the guide system. An additional possible source of inac-
curacy during guided drilling is the inadvertent applica-
tion of nonaxial pressure, tilting the guide that is not
fixed to the bone. The surgeon must remain aware of the
optimal trajectory and guide position during drilling.
Manual overdrilling of the guided pilot hole is perhaps
the largest potential cause of inaccuracy because this
could widen the pilot hole eccentrically with deviation
from the initial trajectory. All entry point translations
occurred in a cranial direction. This may be indicative of
the drill bit slipping down the slope of the medial epi-
condyle towards the epicondylar fossa. While the drill bit
may slip during formation of the initial guided pilot hole,
it may be more likely that the axis of the hole migrates
during overdrilling after the drill guide is removed.
Because of the cranially directed slope of the medial epi-
condyle, after the guide is removed and the drill bit
enters the pilot hole for overdrilling, it is supposed that
EASTER ET AL.
the bit preferentially engages at the lowest (and most cra-
nial) point of the hole. Overdrilling may then result in
cranial migration of the hole. This was corroborated in a
recent study in which the effect of the accuracy of
sequential drilling with increasing drill bit angulation
was investigated.23 In this study, the greater the angle the
greater the migration of the drill hole start location. This
is also likely due to the sequential drill bits engaging at
one edge of the hole. Additional evidence to support that
entry point deviation occurred after guide removal is pro-
vided in that, in 11 of 16 elbows, the angular deviation
occurred in the opposite direction to the direction of entry
point translation. Nine of 12 screws with cranioproximal
translation deviated caudodistally, and two of four elbows
with craniodistal translation deviated caudoproximally
(only three screws deviated caudoproximally in total).
Consequently, the authors infer that that the pilot hole
was drilled correctly, and, when the entry point migrated
during overdrilling, the drill bit tended to angle back
toward the pilot hole. This pattern of events may also act
to limit the overall deviation in screw location. For exam-
ple, if the entry point is too cranial and proximal then a
trajectory that is too caudal and distal will compensate
(or over compensate) for this translation. This is supported
by the comparison of entry and exit points; despite approx-
imately 5 of angular deviation, there was less than
0.5 mm difference between mean entry and exit point
translations, and, despite most entry point translations
occurring cranioproximally, most exit point translations
occurred caudodistally. In fact, six screws had exit point
translations that were smaller than their entry point trans-
lations (ie, were closer to the planned exit point than
planned entry point).
Drill bit migration may be mitigated in a number of
ways. One possibility would be the use of multiple guides
with increasing channel diameters for overdrilling. This
should prevent preferential hole engagement and result
in more accurate drill entry point location. A three-step
guide template has been previously described whereby
separate guides are produced for determining screw entry
point (which may then be burred flat), pilot hole trajec-
tory, and screw insertion.24 Second, the slope of the epi-
condyle could be avoided as an entry point location
during CAD planning. Third, the surrounding bone could
be flattened by using a burr to reduce the risk of slipping
after the initial pilot hole has been drilled. Finally, a can-
nulated drill bit could be used over a 2.5-mm Kirschner
wire placed by using the guide.
Overdrilling, as opposed to drilling directly with a
4.3-mm bit, was considered necessary for several reasons.
First, in hard bone such as the condyle, the torque gener-
ated by a large drill bit could result in thermal necrosis
of the bone25 and could also potentially result in guide
371
dislodgement and subsequent inaccurate location of the
hole. Second, the use of smaller drill bits allows assess-
ment of the exit point before considerable loss of bone
stock. Should concern about the exit point be appreciated
after formation of the pilot hole, reassessment of guide
seating and guide use can be performed with redrilling of
the pilot hole if required. Potential postoperative inaccu-
racies once again include loss of fidelity associated with
image acquisition and virtual model creation as well as
during superimposition of the preoperative and postoper-
ative humeri. Perfect superimposition of the humeri can
be hampered by the beam hardening artefact associated
with the presence of the implants. Metal artefact reduc-
tion software would have been preferred to improve mea-
surement accuracy further.
Potential disadvantages of using a 3D-PDG include the
requirement for preoperative CT, availability of CAD soft-
ware and 3D printing facilities, and the additional soft tis-
sue dissection required for correct guide placement. To
facilitate guide placement, the flexor carpi radialis muscle
was elevated at its origin on the medial epicondyle and then
reattached by using sutures to bone tunnels in the epi-
condyle. It is unknown whether this part of the procedure
incurs any additional morbidity, although no complications
or reductions in function resulting from this technique were
observed. Careful, limited elevation and subsequent repair
may, in fact, be less traumatic to the muscle than placement
of a screw directly through it, which would otherwise be
required for most screw starting positions. While no clinical
manifestations of muscle injury or dysfunction were noted
during this study, such problems could potentially be noted
in a larger population.
Limitations of this study include its retrospective
nature and lack of a control group for comparison. The
proposed entry point and trajectory were not standard-
ized between elbows and, because of the study's descrip-
tive nature, the reasons for the discrepancy in screw
trajectory and entry point were not identified. No clinical
outcome measures were reported because the primary
purpose of the study was to determine the accuracy of
the guide system. While outcome is partially dictated by
the accuracy of method of screw placement, other novel
factors in this study would also have significant effects on
the final clinical result, such as medial to lateral screw
placement and the use of a 5-mm locking screw. These
confounders would preclude assessment of complications
of the guide system in isolation. In addition, 3D-PDG can
be used to place any size or type of screw and can poten-
tially be used for lateral to medial screw placement. The
accuracy of this technique is therefore the outcome mea-
sure of most clinical relevance, and the versatility of the
system allows clinicians clinical freedom with regard to
implant selection.
372
In conclusion, 3D-PDG allowed accurate placement
of a mediolateral 5-mm transcondylar screw in dogs with
naturally occurring HIF. No screws breached the con-
fines of the condyle, and screws deviated only a mean of
1.3 mm and 1.8 mm from the planned entry and exit
points, respectively. Future research is warranted to com-
pare this technique with conventional methods, includ-
ing the effect on clinical outcome.
CONFLICT OF INTEREST
Bill Oxley designs, produces and sells the guides which
are commercially available. All other authors declare no
conflicts of interest.
ORCID
Tim G. Easter https://orcid.org/0000-0002-7407-5414
Bill Oxley https://orcid.org/0000-0002-2158-7133
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How to cite this article: Easter TG, Bilmont A,
Pink J, Oxley B. Accuracy of three-dimensional
printed patient-specific drill guides for treatment of
canine humeral intracondylar fissure. Veterinary
Surgery. 2020;49:363–372. https://doi.org/10.1111/
vsu.13346