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Vol. 22, No.

9 September 2000

CE Refereed Peer Review

Composite Fixation for


FOCAL POINT
Acetabular Fractures in
★Screw/wire/polymethylmeth-
acrylate (PMMA) composite
fixation has proven to be a
Dogs
successful technique for stabilizing
acetabular fractures in dogs. University of Florida
Krista B. Halling, DVM Daniel D. Lewis, DVM
KEY FACTS Alan R. Cross, DVM Daniel P. Beaver, DVM
Otto I. Lanz, DVM W. Preston Stubbs, DVM
■ Screw/wire/PMMA composite
fixation provides comparable
ABSTRACT: The optimal clinical outcome of acetabular fractures depends on precise anatomic
stability and yields superior
reduction and rigid internal fixation. Although bone plating has traditionally been the most
anatomic reduction compared
commonly used method of stabilizing acetabular fractures in dogs, difficulty contouring the
with veterinary acetabular plates. plate and maintaining adequate fracture reduction has prompted the development of alterna-
tive techniques. A composite fixation technique that uses screws, Kirschner wires, stainless-
■ Strict asepsis must be maintained steel orthopedic wire, and polymethylmethacrylate (PMMA) has been used to stabilize acetab-
when using composite fixation. ular fractures. By achieving accurate anatomic reduction and sufficient biomechanic stability,
screw/wire/PMMA composite fixation has proven successful in repairing acetabular fractures
■ Clinical use of screw/wire/ in dogs. This paper describes the application of and clinical results associated with this tech-
PMMA composite fixation nique. The results of our experimental evaluation of bone plates versus composite fixation,
has been associated with few composite fixation with and without PMMA, and composite fixation with and without ancillary
complications and has enabled Kirschner wires are also discussed.
acetabular fractures to heal by
what appears to be primary bone

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

coxofemoral joint (the gemel-


li and internal obturator
muscles) can also be incised
and reflected caudodorsally
to expose fractures involving
the caudal portion of the ac-
etabulum. The sciatic nerve
should be identified and pro-
tected throughout the proce-
dure. The coxofemoral joint
capsule should be incised to
Figure 1A Figure 1B allow assessment of the re-
duction. The fracture sur-
faces should be debrided. A
separate approach can then
be made to the tuber ischii6
and bone reduction forceps
can be applied to the ischium
to manipulate the caudal ac-
etabular segment and facili-
tate reduction27 (Figure 2A).
When anatomic reduction
is achieved, a Kirschner wire
(1.0-mm diameter for small
Figure 1C Figure 1D dogs, 1.6-mm diameter for
Figure 1—(A) Ventrodorsal radiograph of a central acetabular fracture in a 3-year-old Afghan
large dogs) should be placed
hound. Ventrodorsal (B) and lateral (C) radiographs immediately following fracture stabiliza- across the fracture. If the
tion with composite fixation. (D) Ventrodorsal radiograph obtained 3 months after surgical re- fracture involves the cranial
pair; note that the fracture has nearly achieved radiographic union. or central aspect of the ac-
etabulum, the Kirschner wire
can be inserted at or near the
plication is particularly difficult when fractures involve bony protuberance of the origin of the rectus femoris
the caudal aspect of the acetabulum where the adjoin- muscle in a craniolateral-to-caudomedial direction. The
ing ischial surface has an irregular conformation and Kirschner wire generally must be inserted through the
surgical exposure is limited6,20,24,27; anatomic reduction regional musculature in order to be placed at the appro-
may not be achieved or can be lost as the screws are priate angle to traverse the fracture and avoid penetra-
tightened. tion of the articular cartilage of the coxofemoral joint.
An alternative method for stabilizing acetabular frac- A second Kirschner wire of equal length should be used
tures is screw/wire/polymethylmethacrylate (PMMA) to judge penetration of the fracture segments and to
composite fixation. In 1977, Renegar and Griffiths28 re- avoid having the wire protrude into the pelvic canal. In
ported the use of screws, an encircling 20- or 22-gauge some fractures, multiple wires may be required to in-
stainless-steel orthopedic wire, and PMMA bone ce- crease stability and maintain anatomic reduction.30
ment to stabilize acetabular fractures. In 1992, we be- Large reduction forceps can be placed cranial and cau-
gan using a modification of this technique (Figure 1). dal to the acetabulum in some fractures to maintain re-
This paper describes the screw/wire/PMMA composite duction before, during, and after Kirschner wire place-
fixation and reviews our clinical experiences and experi- ment.30
mental investigations using this technique to repair ac- A bone screw is placed in both the cranial and caudal
etabular fractures. acetabular segments, midway between the dorsolateral
margin of the acetabular rim and the dorsomedial as-
PROCEDURE pect of the pelvis. The screws should be positioned ap-
A dorsal approach to the acetabulum is done via an os- proximately 5 to 7 mm cranial and caudal to the frac-
teotomy of the greater trochanter of the femur.29 The ten- ture, respectively. A line drawn between the two screws
dons of insertion of the external rotator muscles of the should intersect the fracture at a right angle. Screw di-

ACETABULUM ■ SCIATIC NERVE ■ ARTICULAR CARTILAGE ■ BONE SCREW


Compendium September 2000 Small Animal/Exotics

of the drill hole by approxi-


mately 4 mm. The screws
should then be placed such
that the screw heads do not
contact the cis-cortex, there-
by leaving the screw shank
and possibly one or two of
the threads exposed (Figure
2B). Stainless-steel orthope-
dic wire (20 gauge for small
dogs, 18 gauge for larger
Figure 2A Figure 2B dogs) should then be placed
around the screws in a fig-
ure-of-eight pattern. The two
free ends of the wire can be
grasped with a wire twister.
While applying tension to
the instrument, the wire can
be tightened by twisting the
two strands into a braid, there-
by compressing the fracture
(Figure 2C). In fractures that
are difficult to anatomically
reduce, tightening of the fig-
Figure 2C Figure 2D ure-of-eight wire can be used
to facilitate fracture reduc-
tion.30 The braided strands
of wire should be cut, leav-
ing at least three twists.
The exposed implants
should then be covered with
medical-grade PMMA. We
routinely add 1 g of sodium
cefazolin to 20 g of PMMA
powder and mix the PMMA
under vacuum (Figure 2D).
Strict asepsis must be main-
Figure 2E Figure 2F tained throughout the proce-
Figure 2—(A) Acetabular osteotomy model in a canine cadaver hemipelvis, simulating a midac- dure to prevent contamina-
26
etabular fracture. (B) A bone screw was placed in each of the cranial and caudal segments, leav- tion of the PMMA. Rather
ing one or two threads exposed to facilitate placement of the wire and polymethylmethacrylate than applying the entire
(PMMA). (C) Orthopedic wire was applied in a figure-of-eight fashion. Interfragmentary com- mass of bone cement at
pression of the fracture fragments should occur as the wire is twisted. The wire was cut, leaving once, the PMMA should be
three twists. (D) A fume-evacuating bone cement mixer (center) and two brands of PMMA packed in small aliquots un-
bone cement (left and right). (E) Care should be taken to thoroughly pack the PMMA around der and around the implants,
the screws and wire to ensure adequate incorporation of the implants in the cement. (F) The thereby increasing the inter-
repaired osteotomy model, showing anatomic reduction and good coverage of the screw heads
digitation of the PMMA
by the PMMA.
with the implants (Figures
2E and 2F). The PMMA
ameter can vary from 2.0 mm in very small toy breeds should completely cover the implants while avoiding an
to 4.5 mm in giant breeds, but typically 2.7-mm screws excessive amount that could interfere with the cox-
are used in smaller dogs and 3.5-mm screws in larger ofemoral joint or impinge on the sciatic nerve. Depend-
dogs. Screw length should exceed the measured depth ing on the dog’s size, we have found that a total PMMA

ORTHOPEDIC WIRE ■ FIGURE-OF-EIGHT PATTERN ■ BONE CEMENT


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-

EXOTHERMIC REACTION ■ RADIOGRAPHS ■ BONE UNION


Small Animal/Exotics Compendium September 2000

tion using other methods of fixation.1 Pain response


was usually mild and only elicited on full abduction or
extension. Decreased abduction of the coxofemoral

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

Lanz and colleagues33


the intertrochanteric ridge of the femoral neck contact-
ing the mass of PMMA.30

COMPOSITE FIXATION VERSUS BONE PLATING


Two studies32,33 using pelves obtained from canine ca-

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

technique approached the strength or stiffness of intact


hemipelves, strength and stiffness did not differ signifi-

significant differences between intact hemipelves and stabilization techniques.


cantly between hemipelves stabilized with composite
Acetabular Plates

1100.5 ± 331.6b
0.48 ± 0.29a

fixation and the acetabular plate (Table I).32,33 110 ± 51.3b


Veterinary

NR

NR
COMPOSITE FIXATION WITH AND
WITHOUT POLYMETHYLMETHACRYLATE
Polymethylmethacrylate, if contaminated intraopera-
tively, can serve as a nidus of infection,26 and we have

significant differences between stabilization techniques.


experienced this complication in one dog. Thus, omit-
2796 ± 152.9b
267.5 ± 61.9b

ting PMMA as a component of composite fixation


Hemipelves

would reduce the risk of implant infection. Additional-


Intact

PMMA = polymethylmethacrylate; NR = not reported


NR

NR

NR

ly, the possibility of thermal injury to the sciatic nerve


would be eliminated and abduction of the coxofemoral
joint may be improved.
Stabilization of acetabular fractures using screws and
Maximum load sustained (Newton)
Distraction stiffness (Newton/mm)

a figure-of-eight wire without PMMA augmentation


Bending stiffness (Newton/mm)

has been described4,18,25; however, we have experienced


failure of fixation and loss of reduction when PMMA
was omitted (Figure 4). These experiences prompted us
to compare the biomechanic characteristics of interfrag-
Yield point (Newton)
Parameter Evaluated

mentary Kirschner wire, screw, and figure-of-eight wire


Reduction (mm)

fixation with and without PMMA augmentation for


stabilization of acetabular osteotomies in canine cadav-
er pelves.34 Stiffness, yield point, and maximum load
bDenotes
aDenotes

sustained were significantly greater for hemipelves sta-


bilized with composite fixation. Failure of hemipelves
stabilized with composite fixation occurred primarily

HEMIPELVES ■ ILIUM ■ ISCHIUM ■ THERMAL INJURY


Compendium September 2000 Small Animal/Exotics

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

ROTATIONAL FORCES ■ WIRE ORIENTATION ■ ANATOMIC REDUCTION


Small Animal/Exotics Compendium September 2000

tained with the addition of


one and then two Kirschner
wires were observed. These
differences, however, were
not significant, with the ex-
ception that hemipelves re-
paired with two Kirschner
wires had significantly greater
yield loads than did
hemipelves repaired without
Kirschner wires (Figure 7).
The results of this study sup-
port the use of at least one
interfragmentary Kirschner
wire; however, fracture con-
figuration and location may
dictate the number and pat-
tern of interfragmentary
Kirschner wires used in stabi-
lizing a particular fracture.35

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
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Price is in US dollars and is subject to change.
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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

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