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9 September 2000
A
union. cetabular fractures are common in dogs.1–10 For optimal clinical results,
most veterinary surgeons advocate open reduction and internal fixation
■ Interfragmentary Kirschner wires of acetabular fractures unless the complexity of the fracture precludes
can help maintain anatomic anatomic reconstruction of the acetabulum.1–10 Anatomic reduction and rigid in-
reduction of fracture segments ternal fixation must be obtained when stabilizing acetabular fractures to pro-
and enhance the stability of mote primary bone healing and mitigate the development of degenerative joint
repair. disease (DJD).1,2,4,7,10–17
Although numerous methods of internal fixation have been described for sta-
■ PMMA can improve the bilizing acetabular fractures in dogs, bone plating is most commonly used.1–9,11
biomechanic stability of the Several types of plates, including small fragment plates, standard and mini dy-
fixation in part by neutralizing namic compression plates, reconstruction plates, and veterinary acetabular
rotational forces. plates, have been used to stabilize acetabular fractures.1,2,12–14,18–24
Veterinary acetabular plates are curvilinear, stainless-steel plates designed
specifically for stabilizing acetabular fractures in dogs.1,2 Although its curvilinear
shape facilitates molding the implant to conform to the dorsal surface of the ac-
etabulum, precise contouring of these plates can be challenging.20,25–27 Plate ap-
Small Animal/Exotics Compendium September 2000
volume of 2 to 4 ml is gener-
ally sufficient. Because poly-
merization of PMMA is an
exothermic reaction, the ad-
jacent soft tissues—especially
the sciatic nerve—should not
be in direct contact with the
PMMA when this reaction
occurs. When the PMMA
has polymerized, the joint
capsule should be closed and
the greater trochanter can be Figure 3A Figure 3B
reattached using a pin-and- Figure 3—Ventrodorsal (A) and lateral (B) radiographs of a 4-year-old mixed breed dog 18
tension band technique, lag months after surgery to stabilize a left acetabular fracture. Note the mild degenerative joint dis-
screws, or multiple divergent ease and resorption of the femoral neck caused by the fracture and its repair.
Kirschner wires.29
Following surgery, the dog
should be confined for 4 to 8 weeks with exercise re- the protruding wires because of their proximity to the
stricted to short leash walks for the purpose of urina- rectum and urethra. All fractures obtained union by 3
tion and defecation. Serial radiographs should be ob- months and appeared to heal by primary bone union.
tained monthly after surgery to assess healing and Prospective long-term clinical and radiographic eval-
manage postoperative care. Normal activity level may uations (mean ± SD, 347 ± 261 days; median, 380
be resumed gradually after the fracture has achieved ra- days) were satisfactory in 13 of the 14 dogs.30 Ten dogs
diographic union. had no apparent lameness and three had subtle weight-
bearing lameness of the affected limb. The remaining
CLINICAL RESULTS dog had a persistent non–weight-bearing lameness for
The results of acetabular fractures repaired using com- several weeks after surgery. This animal had an ipsilat-
posite fixation were evaluated in 14 dogs.30 Ages of the eral sacral fracture that was not repaired, resulting in
dogs ranged from 4 to 95 months (mean ± standard de- marked dorsomedial rotation of the repaired hemipelvis
viation [SD], 34 ± 25 months; median, 25 months) and luxation of the affected coxofemoral joint eventual-
and body weights ranged from 8 to 39 kg (mean ± SD, ly requiring femoral head and neck excision.
25 ± 6 kg; median, 27 kg). Medical records and radio- Follow-up radiographs (mean ± SD, 347 ± 260 days;
graphs were retrospectively evaluated to determine frac- median, 380 days) revealed no DJD in the affected coxo-
ture location, presence of preexisting DJD, accuracy of femoral joint in 3 dogs, mild disease in 10 dogs, and
fracture reduction, and surgical complications. Prospec- moderate development of disease in 1 dog30 (Figure 3).
tive evaluation of long-term results included subjective The dog with moderate DJD also had a concurrent un-
assessment of lameness, elicitation of pain or crepitus on treated sacral fracture and resultant mild dorsomedial
manipulation of the coxofemoral joint, measurements of rotation of the hemipelvis. Dorsomedial rotation of the
pelvic limb circumference, goniometric measurements acetabulum has been used experimentally as a means of
of coxofemoral joint range of motion, radiographic eval- producing coxofemoral DJD.31 Reduction and stabi-
uation of fracture healing, implant complications, and lization of the concurrent ipsilateral sacral fractures may
the development of DJD. have resulted in a more favorable clinical outcome in
Congruency of the lunate articular surface of the ac- this dog as well as in the dog that developed a coxo-
etabulum was reestablished in all of the fractures; frac- femoral joint luxation after surgery.
ture reduction was considered anatomic in 13 dogs.30 Although decreased limb circumference has been
Craniolateral displacement of the caudal acetabular seg- noted after open reduction and internal fixation of ac-
ment attributed to over-zealous tightening of the reduc- etabular fractures,1 limb circumference in dogs stabi-
tion forceps and prohibited the reduction of one frac- lized with composite fixation did not differ significant-
ture from being considered anatomic.30 ly during final evaluation. A pain response could be
There were few complications following the sur- elicited during coxofemoral joint manipulation in half
geries.30 In four dogs, interfragmentary Kirschner wires of the dogs that had acetabular fractures repaired with
protruded into the pelvic canal. Two of these dogs un- composite fixation; this finding is consistent with other
derwent a second surgery to replace or retract and cut reports of dogs undergoing acetabular fracture stabiliza-
Screw/Wire/PMMA
Composite Fixation
joint was noted in dogs that had acetabular fractures re-
443.8 ± 180.3
200.8 ± 32.2
376.5± 99.2
0.23 ± 0.05a
74.6 ± 9.1
paired with composite fixation. This observation,
which has not been previously reported, was ascribed to
Acetabular Plates
457.8 ± 178.0
209.7 ± 28.2
336.2 ± 85.3
davers compared veterinary acetabular plates and com-
1.06 ± 0.45a
77.2 ± 17.8
Veterinary
posite fixation for the stabilization of uniform central
acetabular osteotomies. In one study,32 hemipelves were
placed in an inverted position and tested in cantilever
bending. The wing of the ilium was embedded in
PMMA while the ischium rested unconstrained on an
aluminum block. In the other study,33 the hemipelves
were placed in an inverted position unconstrained on
Screw/Wire/PMMA
Composite Fixation
aluminum rollers and loaded in a three-point bending
1192 ± 202.7b
136.3 ± 76.5b
0.21 ± 0.25a
fashion. Both studies concluded that the osteotomy re- Results of Composite Fixation Studies
NR
NR
ductions, as evaluated subjectively by visual assessment
and objectively from measurements made from casts of
the acetabulum, were superior in the hemipelves stabi-
lized with composite fixation. Although neither repair
Stubbs and colleagues32
TABLE I
1100.5 ± 331.6b
0.48 ± 0.29a
NR
NR
COMPOSITE FIXATION WITH AND
WITHOUT POLYMETHYLMETHACRYLATE
Polymethylmethacrylate, if contaminated intraopera-
tively, can serve as a nidus of infection,26 and we have
NR
NR
by ventrolateral bending of
the cranial and caudal pelvic
segments at the osteotomy
site. Failure of hemipelves
stabilized without PMMA
occurred by ventrolateral
bending of the cranial and
caudal pelvic segments at the
osteotomy site with pro-
nounced concurrent ventro-
lateral rotation of the cranial
pelvic segment. PMMA im- Figure 4A Figure 4B
proved the mechanical char- Figure 4—(A) Lateral pelvic radiograph taken immediately after surgery to stabilize an acetabular
acteristics of the acetabular fracture. Polymethylmethacrylate was not used in this 5-year-old Yorkshire terrier because of a
fracture fixation, partly by concurrent rectal perforation and concern for enteric bacterial contamination of the bone cement.
neutralizing rotational forces. (B) Lateral radiograph 3 weeks after surgery. Note the loss of reduction and failure of fixation.
The results of this study 34
support the use of PMMA as
a component of composite
fixation when repairing ac-
etabular fractures.
CONTRIBUTION OF
INTERFRAGMENTARY
KIRSCHNER WIRES
Although successful heal-
ing has been reported in
dogs with acetabular frac-
tures stabilized using com-
posite fixation without an
interfragmentary Kirschner
wire,28,30 we believe that the
interfragmentary Kirschner
wire is also an integral com-
ponent of composite fixa-
tion, facilitating initial and
long-term anatomic reduc-
tion. In our experience, the
number of interfragmentary Figure 5—Ventrodorsal radiographs of the four different interfragmentary Kirschner-wire con-
figurations (clockwise from top left: no wires, one wire, multiple divergent wires, two crossing
wires used ranged from zero wires) used in composite fixation of acetabular fractures in dogs.
to three, with highly vari-
able wire orientation30 (Fig-
ure 5). However, the correct placement of one, and par- unaffected by Kirschner-wire placement. Before applying
ticularly multiple, interfragmentary Kirschner wires can the PMMA, the stability of the hemipelves was subjec-
be technically challenging. tively assessed by manual manipulation. This simulated
Another study35 using our central acetabular osteotomy maintaining fracture reduction before application and
model evaluated the contribution of interfragmentary polymerization of the PMMA. All hemipelves were stable
Kirschner wire(s) on anatomic reduction and mechanical when stressed in a dorsal-to-ventral direction because in
properties of composite fixation. Acetabular osteotomies this orientation of loading, the screws and figure-of-eight
were repaired using the screw/wire/PMMA composite fix- wire function as a tension band. When manually stressed
ation with or without one of three Kirschner-wire config- in rotation and ventral-to-dorsal, medial-to-lateral, later-
urations in 32 canine hemipelves (Figure 6). Anatomic re- al-to-medial bending plane, hemipelves secured with one
duction, assessed both subjectively and objectively, was or two Kirschner wires were significantly more stable than
CONCLUSION
Figure 6—Photographs and respective radiographs (insets) of osteotomized hemipelves repaired Acetabular fractures re-
using screw/wire/polymethylmethacrylate composite fixation with four different interfragmen- main a challenge for veteri-
tary Kirschner wire configurations: (A) no wire, (B) one wire, (C) two parallel wires, (D) two nary surgeons. To achieve
crossing wires.35 (From Beaver DP, Lewis DD, Lanz OI, et al: Subjective and objective evalua- primary bone healing and
tion of four interfragmentary Kirschner wire configurations as a component of screw/wire/poly- mitigate the development of
methylmethacrylate composite fixation for the stabilization of acetabular fractures in dogs. DJD, treatment objectives
JAAHA 36:456–462, 2000; reprinted with permission) include accurate anatomic
reduction and rigid internal
fixation. This requires fixa-
tion devices that can be applied with minimal difficul-
ty, facilitate and maintain fracture reduction, and im-
part sufficient strength and mechanical stability to the
repair. Studies have demonstrated that screw/wire/
PMMA composite fixation is a successful repair tech-
nique for acetabular fractures and is associated with few
complications.
ACKNOWLEDGMENT
The authors thank Debby Sundstrom, Department
of Small Animal Clinical Sciences, College of Veteri-
Figure 7—The relative biomechanic differences among four in- nary Medicine, University of Florida, Gainesville, for
terfragmentary Kirschner-wire configurations for augmenta- her technical assistance with this manuscript.
tion of screw/wire/polymethylmethacrylate composite fixation
of hemipelvic acetabular osteotomies: gray bar, no Kirschner
REFERENCES
wires; orange bar, one Kirschner wire; white bar, multiple di- 1. Anson LW, DeYoung DJ, Richardson DC, et al: Clinical
vergent wires; blue bar, two crossing Kirschner wires.35 evaluation of canine acetabular fractures stabilized with an
acetabular plate. Vet Surg 17:200–225, 1988.
2. Braden TD, Prieutt WD: New plate for acetabular fractures:
Technique of application and long-term follow-up evalua-
were those without a Kirschner wire. Biomechanic testing tion. JAVMA 188:1183–1186, 1986.
was performed after PMMA application. Incremental in- 3. Brinker WO, Piermattei DL, Flo GL: Handbook of Small
creases in stiffness, yield load, and maximum load sus- Animal Orthopedics and Fracture Treatment, ed 2. Philadel-
504
11. Henry WB: A method of bone plating for repairing iliac and HOTLINE HEROES
at the NAPCC
acetabular fractures. Compend Contin Educ Pract Vet 7(11): New
Column!
506
924–939, 1985. TOXICOLOGY BRIEF:
Permethrin in Cats
12. Hulse DA, Root CR: Management of acetabular fractures:
508
Long term evaluation. Compend Contin Educ Pract Vet Not Networking?
11(3):189–199, 1980. 12 issues only $38
Join VETTEAM
13. Braden TD, Prieur WD: New plate for acetabular fractures: 518
Get a Handle
Technique of application and long-term follow-up evalua- on HIRING
15. Hulse DA: Pelvic fractures: Conservative and surgical man- Control Center
27. Eaton-Wells RD, Matis U, Robins GM, et al: Pelvic frac- polymethylmethacrylate re-enforcement for acetabular os-
tures, in Whittick WG (ed): Canine, ed 2. Philadelphia, Lea teotomy stabilization in dogs. Vet Surg 28:161–170, 1999.
& Febiger, 1990, pp 387–417. 35. Beaver DP, Lewis DD, Lanz OI, et al: Subjective and objec-
28. Renegar WR, Griffiths RC: The use of methyl methacrylate tive evaluation of four interfragmentary Kirschner wire config-
bone cement in the repair of acetabular fractures. JAAHA urations as a component of screw/wire/polymethylmethacry-
13:582–588, 1977. late composite fixation for the stabilization of acetabular
29. Piermattei DL: An Atlas of Surgical Approaches to the Bones fractures in dogs. JAAHA, accepted for publication, 2000.
and Joints of the Dog and Cat, ed 3. Philadelphia, WB Saun-
ders Co, 1993, pp 240–244.
30. Lewis DD, Stubbs WP, Neuwirth L, et al: Results of screw/ About the Authors
wire/polymethylmethacrylate composite fixation for acetabu-
Drs. Halling, Lewis, and Cross are affiliated with the De-
lar fracture repair in 14 dogs. Vet Surg 26(3):223–234, 1997.
partment of Small Animal Clinical Sciences and the Cen-
31. Inerot S, Heinegaard D, Olsson SE, et al: Proteoglycan alter-
ations during developing experimental osteoarthritis in a ter for Veterinary Sports Medicine, College of Veterinary
novel hip joint model. J Orthop Res 9:658–673, 1991. Medicine, University of Florida, Gainesville. Dr. Lanz is af-
32. Stubbs WP, Lewis DD, Miller GJ, et al: A biomechanical eval- filiated with the Department of Small Animal Clinical Sci-
uation and assessment of reduction for two methods of aceta- ences, Virginia-Maryland Regional College of Veterinary
bular osteotomy fixation in dogs. Vet Surg 27:429–437, 1998. Medicine, Virginia Technical Institute, Blacksburg. Dr.
33. Lanz OI, Lewis DD, Madison JB, Blaeser LL: A biomechan- Beaver is associated with Affiliated Veterinary Specialists,
ical comparison of composite fixation and veterinary aceta- Orange Park, Florida. Dr. Stubbs is affiliated with the
bular plates for stabilization of acetabular osteotomies in
Alameda East Veterinary Hospital, Denver, Colorado.
dogs loaded in three-point bending fashion. Vet Comp Or-
thop Traumatol 11:152–157, 1998. Drs. Lewis, Cross, Lanz, and Stubbs are Diplomates of
34. Lanz OI, Lewis DD, Madison JB, et al: A biomechanical the American College of Veterinary Surgeons.
comparison of screw and wire fixation with and without