Recent advances in external skeletal fixation

While the use of external skeletal fixation was once associated with substantial postoperative morbidity, clinical and experimental studies have led to technological advances and modifications in application techniques that have greatly improved the results obtained with this treatment modality. The past decade saw numerous advances in external skeletal fixator implants, components and instrumentation, including improvements in fixation pin design, and the development of new linear external skeletal fixation systems and economical circular external skeletal fixation systems specifically engineered for use in dogs and cats. In addition, a greater understanding of fixator biomechanics and the pathobiology of the bone-fixation pin interface have improved fixator application practices. This article reviews many of the more significant recent advances in external skeletal fixation.     

Tibiotarsal fracture repair in a scarlet macaw using external skeletal fixation

Surgical repair of a fractured tibiotarsus in a scarlet macaw (Ara macao) is described. The forces imposed on the fracture site are discussed and the unique features of avian bone emphasised. Advantages of external skeletal fixation and specific details of the frame construction are highlighted.     

Relative stiffness and stress of type I and type II external fixators: acrylic versus stainless-steel connecting bars--a theoretical approach

OBJECTIVE: To compare the stiffness and pin stresses of three sizes of external fixator systems with stainless-steel and acrylic connecting bars. STUDY DESIGN: Finite element analysis. METHODS: Small, medium, and large external fixator systems of type I and type II configurations were modeled for finite element analysis. Each model was evaluated with a standard stainless-steel and three different diameters of acrylic connecting bar. Displacements and stresses were calculated for the loading modes of axial compression, medio-lateral bending, cranio-caudal bending, and torsion. The location of the pin experiencing maximum stress was determined for all configurations and loading modes. RESULTS: Acrylic column diameters of 9.53 mm for the small external fixator system and 15.9 mm for the medium external fixator system provide equivalent stiffness and maximum pin stresses to those provided by the standard stainless-steel connecting bars (3.2- and 4.8-mm diameter, respectively). The largest diameter acrylic column tested (31.75-mm) produced lower stiffness and higher maximum pin stresses than the standard stainless-steel connecting bar (11.1-mm diameter). CONCLUSIONS: When applying a small or medium external fixator, an acrylic column of 9.53-mm or 15.9-mm diameter, respectively, can be used. For a large external fixator system, an acrylic column of diameter >31.75 mm is required. CLINICAL RELEVANCE: The sizes of acrylic connecting bars for use in small and medium external fixator systems have been determined. Large systems should incorporate the standard stainless-steel connecting bar.     

Bilateral correction of metatarsal rotation in a dog using circular external skeletal fixation

An 8-month-old castrated male Saint Bernard was evaluated for bilateral hind limb lameness. Lameness was ascribed to bilateral metatarsal rotational abnormalities on the basis of the physical examination and radiographic evaluations. Staged, bilateral deformity correction and tarsometatarsal arthrodeses were performed using circular external skeletal fixators. The dog's gait improved following surgery and the fixators were removed 3 (left hind paw) and 4 (right hind paw) months following surgery. Twenty months after the initial surgery, the owner reported that the dog was walking well without apparent lameness. Previous reports suggest that metatarsal rotation is untreatable; however, our results suggest that surgical correction of this deformity can substantially improve limb function in dogs affected with metatarsal rotation.     

骨外固定支架在小动物临床上的应用

骨外固定支架是国外治疗小动物骨折的重要方法之一。目前,国内小动物临床的骨折治疗主要采用内固定、夹板或石膏外固定等方法,而骨外固定支架则少用。其主要原因是人们对骨外固定支架相关知识缺乏足够的认识。因此,本文就骨外固定支架适应症、优点、构成、分类、使用原则,以及应用后的术后护理、并发症处理等作一介绍,以拓宽临床兽医对小动物骨折的治疗思路,提高骨折治疗水平。     

Stifle joint luxation in the cat: treatment using transarticular external skeletal fixation

Extra-articular suturing techniques and transarticular external skeletal fixators were used to repair traumatic luxation of the stifle joint in four cats. Rupture of the cranial cruciate, caudal cruciate and medial collateral ligaments, together with injury to one or both menisci, were the most common injuries observed. The method of stifle repair was successful in all cases, but serious complications occurred when cats with transarticular external fixators were not kept confined indoors. Complications consisted of pin loosening and disruption of the fixator, or fractures through proximal or distal pins. Transarticular external skeletal fixation was considered to be a simple and effective method of maintaining short-term joint stability to allow healing of injured soft tissue structures. The apparatus facilitated early weightbearing and, on removal, allowed for the return of near-normal stifle function. Careful pin insertion and owner compliance in enforcing confinement are essential in minimising complications associated with immobilising the stifle joint using transarticular external skeletal fixation.     

Maxillomandibular external skeletal fixation in five cats with caudal jaw trauma

Five cats with caudal jaw injuries including mandibular ramus fractures, temporomandibular luxation/subluxation and temporal bone fractures were managed with external skeletal fixation to provide open-mouth maxillomandibular fixation. Three of five cats were able to eat orally during the period of fixation, whereas two cats with jaws fixed in a suboptimal position were dependent on oesophagostomy tube nutrition. Fixation was well tolerated and was maintained for 21 to 42 days. All cats were eating normally and had good jaw function at follow-up (mean 39 months, range 7 to 71 months).     

Type I external skeletal fixation of radial fractures in microchiropterans.

An adult male big brown bat (Eptesicus fuscus) and an adult female hoary bat (Lasiurus cinereus) were presented with open transverse middiaphyseal left radial fractures. Initial repair was attempted by intramedullary pinning. When the fractures did not heal, intramedullary pins were removed and type I external skeletal fixators were placed. The fractures healed, and the big brown bat regained normal flight but the hoary bat did not.     

Effect of a supplemental plate on the stiffness of a type I external fixator

OBJECTIVE: To assess the effect of a supplemental plate on the stiffness of a six-pin unilateral external skeletal fixator. STUDY DESIGN: Mechanical testing performed on models. METHODS: Wooden (birch) dowels were used to create five models of a fracture. A commercially available external fixation system was applied to the model with a uniform unilateral six-pin fixator design. The models were mechanically tested with and without a supplemental plate attached to the 2 clamps adjacent to the fracture gap. Testing was conducted in axial loading, medial to lateral bending, and cranial to caudal bending. RESULTS: Results showed a 4.42-fold increase in stiffness in axial load, a 4.23-fold increase in stiffness in medial to lateral bending, and a 1.94-fold increase in stiffness in cranial to caudal bending with the addition of the plate. CONCLUSIONS: The addition of a supplemental plate increases the mechanical stiffness of unilateral fixators. This was especially true in axial load and medial to lateral bending. CLINICAL RELEVANCE: A supplemental plate can be used with unilateral fixators to increase stiffness of the fixator. Conversely, the plate can be removed to decrease stiffness without the removal of fixation pins.     

The use of a circular external skeletal fixation device for the management of long bone osteotomies in large ruminants: an experimental study

The study was undertaken to evaluate the feasibility of a simple, inexpensive model of circular external fixator (CEF) for use in large ruminants. A simple model of CEF frames consisting of four full rings (13-19 cm diameter, 4 cm wide and 4 mm thick with 18-24 holes) connected by threaded rods (8 mm diameter, 10-15 cm long) and nuts was developed using mild (low carbon) steel and were nickel-plated. In the first phase of the study, three male cow calves were utilized to study the feasibility of application of the fixators in the metatarsus, tibia and radius, in reference of adaptation and tolerance by animals. In the second phase, the fixators were tested in osteotomized bones. Six bull calves of 1.5-2 years of age weighing about 200-250 kg were utilized for this purpose. After preparing the area for aseptic surgery, under xylazine (at 0.1 mg/kg, i.m.)-ketamine (i.v. till effect) general anaesthesia, the test bone (metatarsus, radius and tibia in two animals each) was approached through the medial surface and an osteotomy was created with a saw and chisel at the mid-diaphysis. The pre-constructed 4-ring CEF was mounted on the limb around the test bone in such a way that it formed a cylinder with the axis of the limb at the centre. Each ring was then fixed to the bone with a pair of beaded wires (316 SS) of 3.5 mm diameter. During the post-operative period, the animals were observed for any change in behaviour, tolerance of the fixators, the weight bearing on the test limb, the status of the fixator, and the level of reduction of the osteotomy, alignment and healing at different intervals. The fixation of CEF was easier in the metatarsus and radius than in the tibia. The inner ring diameters found adequate for metatarsus, radius and tibia were 13-15 cm, 15-17 cm and 17-19 cm, respectively. The fixators applied to different bones were well-tolerated, and the animals could lay down, stand and walk freely with the fixator without any problems. All the animals showed good weight bearing in the immediate post-operative period. Weight bearing, however, slightly reduced in the inflammatory period and showed improvement after about 4 weeks. Wire tract infection was seen in all the animals, which was more on proximal wire tracts on lateral aspect of limbs. Circular fixators were well-tolerated by all the animals, and there was no breaking/bending of connecting rods, slotted bolts or the rings at any stage of observation. Slight bowing of some wires was noticed in cases of tibia and radius (in phase II) and bending of some wires was noticed from first week in two animals one each in radius and tibia. Bone fragments were well maintained until healing occurred (appearance of bridging periosteal callus) at 60-70 days. The functional results were good in all but one case of tibia, where a mal-union was recorded. From this study, it can be concluded that CEF are well-tolerated by large ruminants and can be used to treat long bone fractures. The fixator assembly using mild steel is sufficiently strong to maintain fracture fixation and is inexpensive. The simple design of the CEF appears to be sufficient to treat simple diaphyseal fractures of the metatarsus and radius. Improvement in the technique of fixation and design-like coupling of linear and circular fixator components into hybrid constructs may help to provide greater rigidity in treating tibial and open long bone fractures.     

Biomechanical evaluation of acrylic external skeletal fixation in dogs and cats.

Acrylic external skeletal fixators (ESF) were compared with Kirschner ESF in biomechanical tests. A 2-cm unilateral acrylic ESF was found to be superior to medium Kirschner ESF in compression and shear loads. Acrylic ESF performed as well as Kirschner ESF in torsion loads. Acrylic ESF were used on 11 dogs and cats for repair of long bone fractures, for arthrodesis, or for immobilization of joints following ligament or tendon surgery. There were no complications associated with the use of acrylic ESF. Acrylic ESF offers the advantage of reduced cost, improved versatility, and simplified application technique when compared with Kirschner ESF.     

Validation of a finite element model of the Kirschner-Ehmer external skeletal fixation system.

OBJECTIVE: To determine the validity of finite element analysis (FEA) as a means of examining biomechanical properties of the Kirschner-Ehmer external skeletal fixation system. SAMPLE POPULATION: 10 paired tibiae harvested from skeletally mature dogs weighing between 30 and 38 kg immediately following euthanasia for reasons unrelated to musculoskeletal disease. PROCEDURE: A gap fracture was created in each bone; fragments were stabilized with 3 frame configurations (type I, type II, and type III), using enhanced-profile threaded pins. Each bone-frame construct was tested, using a materials testing machine in 3 modes of testing: axial compression (AC), mediolateral (ML) bending, and craniocaudal (CC) bending, for a total of 9 tests/bone. The elastic limit of the constructs was not exceeded during testing. Mean stiffness values were determined from load-displacement curves. A finite element model of each construct was created, using three-dimensional elastic beam elements, and stiffness values were calculated, using FEA. Correlations between experimental and FEA data then were determined. RESULTS: Significant differences in stiffness were seen among all 3 constructs in CC bending and AC, with stiffness increasing with construct complexity. No significant difference in ML bending stiffness was seen between type-II and type-III constructs; however, both were significantly stiffer than the type-I constructs. The experimental and FEA stiffness data were strongly correlated (AC, r = 0.994; ML bending, r = 0.998; CC bending, r = 0.985). CONCLUSIONS AND CLINICAL RELEVANCE: Strong correlations among experimental and FEA data indicate that FEA is a valid method of comparing stiffness of Kirschner-Ehmer external skeletal fixation constructs.     

Circular external skeletal fixation stabilization of antebrachial and crural fractures in 25 dogs

Fracture stabilization using circular external skeletal fixation was evaluated in 14 dogs with antebrachial fractures and 11 dogs with crural fractures. Most dogs were consistently weight bearing on the stabilized limb by 3 days following surgery. Although all dogs developed minor wire/pin tract inflammation and eight dogs developed major wire/pin tract inflammation, postoperative lameness was not consistently associated with wire/pin tract complications. Fractures in 23 dogs achieved radiographic union (mean +/- standard deviation [SD], 61 +/- 21 days; median, 57 days) without additional surgery; two dogs required restabilization of their fractures with linear fixators. Twenty of the 21 owners that could be contacted felt their dog had no (n=15) or only a mild (n=5) intermittent lameness at the time of final, long-term (mean +/- SD, 37 +/- 17 months; median, 42 months) assessment.     

Treatment of distal diaphyseal fractures using hybrid external skeletal fixation in three dogs

Stabilisation of distal diaphyseal/metaphyseal fractures or osteotomies of the tibia and the radius is challenging due to the small fragment size, with innovative implants and external skeletal fixation systems described for their management. Hybrid external skeletal fixation is a novel external fixation system for use in small animals. This case series describes the management of distal diaphyseal fractures with IMEX-SK hybrid external skeletal fixation in three canine patients. Fracture healing was achieved in all cases, with frame removal after 5 to 10 weeks. Minimal complications were encountered in two cases. IMEX-SK hybrid external skeletal fixation constructs provide the veterinary surgeon with another option in the management of distal diaphyseal/metaphyseal fractures.     

Middle upper beak fracture in a Red-crowned crane that completely recovered with external skeletal fixation

An adult Red-crowned crane in captivity that had a displaced compound fracture of the middle upper beak caused by an accident was treated by using Type I-a external skeletal fixator (ESF). The ESF that was equipped with a unilateral epoxy putty fixator and with five half-pins was fixed on the premaxilla bone. The crane with the ESF on the beak was able to feed smoothly by itself. The ESF was removed 49 days after the first surgery. Beak malocclusion, which was observed in the latter half period of fixing, spontaneously improved within one month after removal of the ESF. This is the first successful case of repair of an upper beak fracture in a Red-crowned crane.     

A clinical evaluation of pancarpal arthrodesis in nine dogs using circular external skeletal fixation

OBJECTIVE: To report clinical outcome and complications after pancarpal arthrodesis using circular external skeletal fixation (CESF) in dogs. STUDY DESIGN: Retrospective study. ANIMALS: Dogs (n=9) with carpal injury. METHODS: Medical records including radiographs (10 limbs) with underlying severe carpal injury that had pancarpal arthrodesis with CESF were reviewed. Short-term follow-up (>6 months) was obtained by phone interview of owners. RESULTS: Mean weight was 24.5 kg (range, 10.1-69.5 kg). Mean duration until CESF removal was 110.6 days (range, 72-149 days). Complications in all dogs were mild postoperative edema of the distal aspect of the limb and initial mild serous discharge form exit points of CSEF wires. Follow-up (mean, 328 days; range, 190-541 days) was available for 8 dogs. All owners reported limb function and cosmesis as being excellent, and perceived that their animals were pain free. Perception of fixator care difficulty, as reported by owners, varied significantly based on previous splint management experience; owners who had experienced splint management for >1 month found fixator care equal to or easier than splint management. CONCLUSION: Pancarpal arthrodesis with a CESF produces a favorable clinical outcome with high owner acceptance. CLINICAL RELEVANCE: Pancarpal arthrodesis by use of CESF is a clinically applicable technique and may offer advantages over internal fixation with respect to postoperative complications.     

Prognostic factors in treating antebrachial growth deformities with a lengthening procedure using a circular external skeletal fixation system in dogs

OBJECTIVE: To evaluate treatment of antebrachial growth deformities (AGD) with a lengthening procedure using a circular external skeletal fixation (CESF) system and to determine prognostic factors. STUDY DESIGN: Prospective clinical study. ANIMALS: Thirty-four dogs with unilateral AGD. METHODS: Length deficits, angular and rotational deformities, elbow incongruity (EI), osteoarthritis (OA) of the elbow and carpal joint, function, and cosmesis were determined before and after a CESF lengthening procedure. RESULTS: On admission, EI (21 dogs; 62%), OA of the elbow joint (17 dogs; 50%), carpal OA (12 dogs; 35%), and concomitant elbow and carpal OA (5 dogs; 7%) were common findings. Treatment significantly improved function (normal, 20 dogs; 60%) and cosmesis (normal, 22 dogs; 65%). Angular and rotational deformities were almost completely corrected with small remaining length deficits. Elbow and carpal OA increased significantly during the follow-up period. Significant correlations were demonstrated between initial elbow OA and final function (R=0.42, P=.02), initial function and final function (R=0.41, P=.02), and initial ulnar and radial deficit and final cosmesis (R=0.58, P=.0001 and R=0.45, P=.008). CONCLUSIONS: Treatment of AGD by a CESF lengthening procedure was successful despite small remaining length deficits. Initial elbow OA, function, and ulnar and radial length deficits are prognostic factors in the treatment of AGD. CLINICAL RELEVANCE: Initial elbow OA and initial function are prognostic factors in predicting the functional outcome of treatment of AGD with a CESF lengthening procedure in the dog.