Feasibility of C-arm guided closed intramedullary pinning for the stabilization of canine long bone fractures

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1 Veterinry World, EISSN: Aville t RESEARCH ARTICLE Open Access Fesiility of C-rm guided closed intrmedullry pinning for the stiliztion of cnine long one frctures Anupreet Kur, Ashwni Kumr, Deepesh Kumr, Jitender Mohindroo nd Nrinder Singh Sini Deprtment of Veterinry Surgery nd Rdiology, College of Veterinry Science, Guru Angd Dev Veterinry nd Animl Sciences University, Ludhin , Punj, Indi. Corresponding uthor: Ashwni Kumr, e-mil: drshwnikumr@rediffmil.com, AK: nupreettoor@hotmil.com, DK: vetdeepesh@gmil.com, JM: jmohindroo@yhoo.co.in, NSS: nssini61@rediffmil.com Received: , Revised: , Accepted: , Pulished online: doi: /vetworld How to cite this rticle: Kur A, Kumr A, Kumr D, Mohindroo J, Sini NS (2015) Fesiility of C-rm guided closed intrmedullry pinning for the stiliztion of cnine long one frctures, Veterinry World 8(12): Astrct Aim: To evlute the fesiility of C-rm guided closed intrmedullry pinning (simple Steinmnn nd end threded) techniques for the stiliztion of vrious cnine long one frctures. Mterils nd Methods: The present study ws conducted on 19 dogs with long one frctures which were stilized using simple Steinmnn (Group I; n=6) nd end threded (Group II; n=13) pinning under C-rm guidnce. Signlment, history of trum, clinicl exmintion, nd hemtoiochemicl findings were recorded t the time of presenttion. Rdiogrphy of the ffected lim ws crried out in two views to determine type nd site of the frcture. Tretment of ll the frctures ws ttempted using simple Steinmn nd end threded pinning under the C-rm guidnce. The success nd filure of the closed technique were correlted with ge, site, nd type of frctures. Results: The men ody weight nd ge of the dogs were 18.53±2.18 kg nd 21.58±5.85 months, respectively. Erly presented cses t men dy of 2.84±0.54 were included. Out of 19 cses, it ws possile to plce implnt successfully in 10 cses (success rte 52.63%) only. The remining 9 cses hd serious intropertive complictions like misdirection of the pin fter engging the proximl frgment (n=3), missing the proximl frgment completely, nd formtion of the flse trct (n=6). The mjority of these complictions were ssocited with younger ge nd proximl or distl third olique frctures. High success rte of C-rm guided closed pinning ws oserved in midshft frctures (75%) nd trnsverse frctures (77.78%) in dogs of more thn 1 yer of ge (77.78%). Simple Steinmnn pinning ws etter fesile in closed mnner with high success rte (66.70%) ut lso hd implnt relted complictions. Although, C-rm guided end threded pinning ws less (46.15%) successful, slightly tedious nd time-consuming ut hd etter implnt stility thn tht of simple intrmedullry pinning. Conclusions: From the present study, it ws concluded tht C-rm guided closed pinning is recommended in trnsverse nd midshft frctures of the long ones in dogs older thn 1 yer of ge. Furthermore, there is need to improve trction devices for enhncing the success of C-rm guided intrmedullry pinning in dogs. Keywords: C-rm guided pinning, closed pinning, dog, end threded pin, frcture. Introduction Reduction, retention, nd immoiliztion re the sic principles of frcture mngement. Reduction of long one frctures cn e chieved y closed nd open methods. Reduction y the open method is ssocited with dditionl soft tissue trum, periostel stripping, nd disturnce of hemtom t the site of frcture [1]. Hemtom formtion is necessry stge for the initition of frcture heling [2] s it contins multilinege mesenchyml progenitor cells nd hs the inherent osteogenic potentil [3,4]. Biologicl osteogenesis is recent concept tht involves dequte stiliztion of frcture without interfering physiologicl environment t the site of frcture [5]. It cn e chieved y using C-rm guided closed intrmedullry pinning which is sfe nd widely prcticed procedure [6]. The C-rm guided Copyright: The uthors. This rticle is n open ccess rticle licensed under the terms of the Cretive Commons Attriutin License ( cretive commons.org/licenses/y/2.0) which permits unrestricted use, distriution nd reproduction in ny medium, provided the work is properly cited. closed intrmedullry pinning procedure hs mny dvntges like minimum surgicl wound, less post-opertive cre nd less pinful [6,7]. Bsinger nd Suer [8] opined tht lood supply to the frcture ws preserved, nd there ws miniml disruption of the frcture hemtom in closed frcture stiliztion. Intrmedullry pinning is one of the most common used techniques for the repir of long one frctures. A iomechnicl study on cnine femur indicted etter holding the strength of prtilly threded tipped over the non-threded tipped pins [9]. In nother pper, end threded pinning hs not een reported to e superior over simple Steinmn pins [10]. Simple intrmedullry pinning technique is ssocited with mny implnt relted compliction [11]. Now--dys dynmic frcture fixtion is preferred over rigid fixtion [12]. It ws hypothected tht C-rm guided end threded pinning my provide sufficient stility to frcture with minimum dmge to hemtom ut t the sme time ecuse of the threded portion it my Veterinry World, EISSN:

2 e difficult to plce into medullry cvity in the closed mnner. The present study ws crried out to study the fesiility of C-rm guided simple Steinmn nd end threded intrmedullry pinning techniques for the stiliztion of long one diphysel frctures in dogs. Mterils nd Methods Ethicl pprovl The present study ws duly pproved y the Institutionl Animl Ethicl Committee. Signlment nd history The present clinicl study ws crried out on 19 (13 mle nd 6 femle) dogs, presented to the Deprtment of Veterinry Surgery nd Rdiology with history of lmeness following trum nd exhiiting clinicl signs suggestive of the long one frcture. The men ge nd ody weight of the dogs studied were 21.58±5.85 months (rnge 2-84 months) nd 18.53±5.85 kg (rnge 6-40 kg), respectively. The cses were presented with men of 2.84±0.54 dys (1-9 dys). C linicl exmintion Plption of ffected one ws done to ssess crepittion nd soft tissue swelling. Pre-opertive rdiogrphy in mediolterl nd crniocudl views, hemtology (hemogloin, totl leukocyte count nd differentil leukocyte count) nd serum iochemistry (lkline phosphtse, clcium, nd phosphorus) ws done in ll the cses. Generl condition of the ffected dog ws ssessed from its norml lertness, ility to wlk or stnd on the helthy lims nd stle crdiopulmonry prmeters. Surgicl procedure The prenesthesi for the surgicl procedure comprised utorphenol (0.2 mg/kg), cepromzine (0.05 mg/kg), nd glycopyrolte (0.01 mg/kg) comintion intrmusculrly. Anesthesi ws induced with 5% thiopentone sodium, intrvenously until effect. The following endotrchel intution, ll the ptients were mintined on isoflurne (1.5-2%) with oxygen using the prtil rerething system. For closed reduction nd stiliztion of frctures, smll skin incision ws mde for normogrde pin insertion. Adequte trction ws pplied on the frctured lim under generl nesthesi so s to reduce the frctured frgments (Figures-1 nd -2). To stilize humerus frcture, the pin ws inserted into one oliquely just lterl to the ridge of the greter tuercle. For femur, the greter trochnter ws plpted, nd the pin ws inserted from the trochnteric foss. For tii, it ws inserted t the proximl end of one pproximtely ¼ inch cudomedil to the tiil tuerosity. All the frctures were ttempted to stilize using simple Steinmnn (Group I; n=6) nd end threded (Group II; n=13) intrmedullry pins in closed mnner. A smll (1 cm) skin incision ws mde to locte the pin insertion site. Approximte size of the implnt ws selected occupying more thn 50% of the dimeter of the medullry cnl t isthmus of the long one which ws mesured using computerized rdiogrphy system, preopertively. Using wl, the entry point for pin into the medullry cnl ws creted (Figure-3). Then, the Simple Steinmnn pin ws progressed into the medullry cvity which ws confirmed using C-rm visuliztion. The frctured frgments were toggled y mnipultion. The pin ws further progressed into the distl frgment nd seted dequtely into the distl epiphysis in Group I nimls (Figure-4). In Group II, the simple Steinmnn pin ws withdrwn, nd end threded intrmedullry pin ws inserted into the medullry cvity (Figure-5). The frctures which could not e reduced nd/or stilized y closed technique were further stilized y open method. The rtio of implnt dimeter nd minimum dimeter of the medullry cvity t the isthmus were determined from the post-opertive rdiogrphs. Pos t-opertive cre Animls were given cefotxime t 20 mg/kg twice dy nd meloxicm t 0.2 mg/kg once dy for 5 nd 3 dys, respectively. Modified Roert-Jones Figure-1: Appliction of trction to the forelim with frctured humerus in the nesthetic period prior to surgery. Figure-2: Appliction of trction to the hindlim with frctured femur in the nesthetic period. Veterinry World, EISSN:

3 ndging ws pplied on the operted lim t lest for 2 weeks, nd owner ws dvised to restrict the vigorous ctivity of the niml. Medio-lterl nd crniocudl rdiogrphs were tken t the immedite post-opertive period nd then t 2 weeks nd t 4-8 weeks or whenever the cse ws presented for clinicl nd rdiogrphic ssessment or until the complete frcture heling. Removl of the implnt ws done fter the complete frcture union ws evident. Results nd Discussions The long ones included in the present study were femur (n=10), tii (n=6), nd humerus (n=3). The erly cses of frcture with men ± stndrd error dy of 3.00±0.63 in Group I nd 2.76±0.75 in Group II were included. Mild or no significnt swelling on the frctured lim ws oserved which my e ttriuted to simple frctures nd erly presenttion of the cses. All sites of frctures nmely proximl third (n=6), mid shft (n=8), nd distl third (n=5) were included in the present study (Tle-1). The mjor etiology of frcture ws utomoile ccident (36.8%) followed y fll from height (21.1%), usive (21.1%), stuck in cot (10.5%), nd unknown (10.5%). Similr findings hve een oserved previously [13]. In oth the groups, except the frctured one itself, none of the cse hd ny ssocited skeletl injury. The distl frgment length ws 6.50±2.14 cm in Group I nd 7.71±0.98 cm in Group II. The men hemogloin level in the ffected dogs were norml (9.42±0.62 g/dl) ut neutrophilic (75.94±3.67%) leukocytosis ( ± /μL) ws recorded. Leukocytosis my result from corticosteroid relese due to stress, pin, nesthesi, trum nd surgicl mnipultion [14]. The men vlue of lkline phosphtse, clcium, nd phosphorus ws ±13.42 IU/L, 8.97±0.47 mg/dl nd 4.94±0.34 mg/dl, respectively. In Group I, out of 6 cses closed simple pinning ws successfully done in 4 cses (66.7%). In Group II, 13 cses were ttempted for end threded pinning nd it could e plced successfully in 6 cses only (46.15%). While plcing the end threded in normogrde fshion, the threds of the pin gets entngled with the djoining soft tissue structures nd produces ddition resistnce to progression of the pin into the Tle-1: Frcture site wise success rte of C-rm guided closed intrmedullry pinning. Figure-3: Cretion of entry point of the pin for closed pinning using n wl. Outcome Mid shft (%) Proximl third (%) Distl third (%) Successful 6 (75) 1 (16.67) 3 (60) Unsuccessful 2 (25) 5 (83.33) 2 (40) Totl c d e Figure-4: C-rm guided simple intrmedullry pinning in femur. () Frcture site of femur, () Insertion of pin into the proximl end of femur, (c) Pin t the frcture site of femur, (d) Toggling of the frctured one frgments to reduce the frcture, (e) Advncing the pin into the distl frgment of femur, (f) Seting the pin into the distl frgment. Veterinry World, EISSN: f

4 c d e f Figure-5: C-rm guided end threded intrmedullry pinning in femur. () Insertion of simple Steinmnn pin into the proximl one frgment, () Complete reming of the proximl one frgment using Simple Steinmnn pin, (c) Insertion of end threded intrmedullry pin into the proximl one frgment fter withdrwing out the Simple Steinmnn pin, (d) End threded pin t the frcture site of femur, (e) Toggling of the frctured one frgments to reduce the frcture, (f) Seting the pin into the distl one frgment. medullry cnl. Moreover, end threded pinning requires perfect reduction t the site of frcture efore eing seted properly into distl frctured frgment. But, closed pinning offer limited mnipultion leding to poor reduction t the site of the frcture. These fctors might e the possile resons for reduced success of plcing end threded pin, in the present study. However, the simple Steinmnn pinning ws found etter fesile in closed mnner compred to tht of end threded pinning. In the present study, 9 cses hd intropertive complictions like misdirection of the pin fter engging the proximl frgment (n=3) (Fig ure-6), missing the proximl frgment completely nd formtion of flse trct (n=6) (Figure-7). High success rte of closed pinning ws oserved in midshft frctures (75%) compred to proximl third nd distl third frctures (Tle-1). Similrly, high success rte of closed intrmedullry pinning ws oserved in trnsverse frctures (77.78%) while the high percentge of filure ws oserved in olique frctures (Tle-2). When tking the ge into considertion closed pinning ws more successful in dogs which were more thn 1 yer of ge (77.78%) thn dogs <1 yer of ge (30%) (Tle-3). It ws found tht C-rm guided closed pinning is etter fesile for skeletlly mture dogs s compred to young dogs ecuse well-developed cortex of long ones in dult nimls fcilitte direction of the pin within the medullry cvity. Both structurl nd mteril properties of immture one re considerly different from those of dult one nd re chrcterized y lower strength, nd stiffness, s well s lower yield stress nd elstic modulus [15]. In the present study, using Figure-6: Complictions of C-rm guided pinning: Missing the proximl frgment. () Pin missing the proximl frgment of the one, () Pin missing the proximl frgment of the one gin. Tle-2: Frcture configurtion wise success rte of C-rm guided intrmedullry pinning. Outcome Trnsverse (%) Olique (%) Successful 7 (77.78) 4 (40) Unsuccessful 2 (22.22) 6 (60) Totl 9 10 Tle-3: Age wise success of C-rm guided IM pinning. Outcome <1 yer (%) >1 yer (%) Successful 3 (30) 7 (77.78) Unsuccessful 7 (70) 2 (22.22) Totl 10 9 the closed method, the successful pin plcement could e chieved in 50% frctures of ech long one (Tle-4). Moreover, limited vilility of effective nd specific techniques nd devices for frcture reduction is mjor constrint of minimlly invsive Veterinry World, EISSN:

5 c Figure-7: Complictions of C-rm guided pinning: Misdirection of the pin nd formtion of flse trct. () Pin inserted into the proximl frgment of the one, () Misdirection of the pin out of the cortex of the proximl frgment, (c) Pin entering the sme flse trct on ttempting the pinning multiple times. Tle-4: Bone wise success rte of C-rm guided intrmedullry pinning. Outcome Femur (%) Tii (%) Humerus (%) Successful 5 (50) 3 (50) 2 (66.67) Unsuccessful 5 (50) 3 (50) 1 (33.33) Totl osteosynthesis nd further improvement of the trction devices my improve the success rte of C-rm guided pinning [16]. The men±stndrd error intropertive time ws found to e non-significntly less in Group I (35.00±4.56 min) thn in Group II (41.67±4.77 min) suggesting tht C-rm guided end threded pinning is comprtively more tedious nd tkes more time thn simple intrmedullry pinning. No wound heling relted complictions were seen in ny of the cses. Miniml exposure of internl structures (site of frcture nd djoining soft tissue) to the externl environment could e the prole reson for uneventful recovery of surgicl wounds in nimls of the present study. Similr oservtions hve een reported previously [7,17]. Moreover, the risk of post-opertive infection hs een reported s high s twice for nimls undergoing 90 min procedure compred with those tht hd 60 min procedure [18]. In the present study, out of 10 cses operted successfully y closed intrmedullry pinning, three hd implnt relted complictions. In Group I, one implnt ws dislodged fter 2 weeks nd in nother dog proximl migrtion of pin ws seen [11]. Both the complictions were ttriuted to the hevy weight of the niml; however, stisfctory frcture heling ws seen in these cses. In Group II, no implnt relted compliction ws oserved nd frctures heled uneventfully except one in which implnt ws dislodged fter 5 dys nd owner did not gree for the second surgery. Hence, comprtively few complictions were recorded in Group II which corroortes to the erlier findings tht prtilly threded tipped IM pins provide etter holding strength thn non-threded tipped IM pins [9]. Fully threded intrmedullry pins hve lso een recommended for the repir of long one frctures in dogs nd cts [19,20]. Threded pins hve lso een found to provide etter stility in externl skeletl fixtors [21]. In contrst, nother report did not find ny dvntge of end threded pins over simple Steinmn pins [10]. On long term follow-up 9 out of 10 frctures repired y closed methods heled. In Group I, only one implnt ws removed nd in Group II, 3 implnts were removed. The remining nimls were not presented for implnt removl ut hd stisfctory lim usge nd frcture heling s recorded on telephonic follow-up. Conclusion The following conclusions were drwn from the present study: 1. The C-rm guided closed pinning is recommended in trnsverse nd mid shft long one frctures of the skeletlly mture dogs 2. The C-rm guided closed end threded intrmedullry pinning is tedious ut provides stle immoiliztion of frcture s compred to simple intrmedullry pinning. Authors Contriuti ons AK, designed this clinicl study under the guidnce of Ashwni Kumr, JM nd NSS. Ashwni Kumr, DK, AK, JM nd NSS performed surgicl interventions. AK nd Ashwni Kumr performed post-opertive cre nd follow-up. AK collected dt, nlyzed nd prepred the mnuscript. All the uthors red, revised nd pproved the finl mnuscript. Acknowledgments The uthors re thnkful to the Indin Council of Agriculturl Reserch for providing finncil support in the reserch project ICAR 22 All Indi Network Progrm on Dignostic Imging nd Surgicl Conditions in nimls Competing Interests The uthors declre tht they hve no competing interests. References 1. Johnston, A.L. nd De cmp, C.E. (1999) Externl skeletl fixtion. Vet. Clin. North Am. Smll Anim. Prct., 29(5): Snde, R. (1999) Rdiogrphy of orthopedic trum nd frcture repir. Vet. Clin. North Am. Smll Anim. Prct., Veterinry World, EISSN:

6 29(5): Oe, K., Miw, M., Ski, Y., Lee, S.Y., Kurod, R. nd Kurosk, M. (2007) An in-vitro study demonstrting tht hemtoms found t the site of humn frctures contin progenitor cells with multi linege cpcity. J. Bone Joint Surg. (Br)., 89: Mizuno, K., Mineo, K., Tchin, T., Sumi, M., Mtsur, T. nd Hiroht, K. (1990) The osteogenic potentil of frcture hemtom. Superiostel nd intrmusculr trnsplnttion of the hemtom. J. Bone Joint Surg. (Br)., 72: Dejrdin, L.M., Guoit, L.P. nd Pfeil, D.J.F. (2012) Interlocking nils nd minimlly invsive osteosynthesis. Vet. Clin. North Am Smll Anim. Prct., 42(5): Guiot, L.P. nd Dejrdin, L.M. (2012) Periopertive imging in minimlly invsive osteosynthesis in smll nimls. Vet. Clin. North Am. Smll Anim. Prct., 42(5): Kim, S.E., Hudson, C.C. nd Pozzi, A. (2012) Percutneous pinning for frcture repir in dogs nd cts. Vet. Clin. North Am. Smll Anim. Prct., 42(5): Bsinger, R.R. nd Suer, J.T. (2004) Two techniques for supplementing interlocking nil repir of frctures of the humerus, femur, nd tii: Results in 12 dogs nd cts. Vet. Surg., 33: Ogurtn, Z. (2006) Comprtive holding strength etween prtilly threded tipped nd non threded tipped pins for frcture fixtion in cnine femur: Biomechnicl results. PhD Thesis. University of Selcuk. 10. McLughlin, R. (1999) Internl fixtion: Intrmedullry pins, cerclge wires nd interlocking nils. Vet. Clin. North Am. Smll Anim. Prct., 29(5): Kumr, P. nd Ghlot, T.K. (2013) Clinicl evlution of intrmedullry pinning nd interlocking niling technique for stiliztion of femorl frctures in dogs. J. Anim. Sci. ******** Adv., 3(6): Asif, M.A., Dilipkumr, D., Shivprksh, B.V., Usturge, S.M., Ksrlikr, V.R. nd Ridurg, R. (2011) Clinicl evlution of sttic nd dynmic veterinry intrmedullry interlocking niling technique for femorl frcture repirs in dogs. Indin J. Vet. Surg., 32(2): Rghunth, M., Sing h, M., Ydv, R.K. nd Singh, S.S. (2007) Distriution nd clssifiction of cnine long one frctures. Indin Vet. J. 84: Sstry, G.A. (1998) Veterinry Clinicl Pthology. CBS Pulisher nd Distriutors Pvt. Ltd., Delhi. p Dejrdin, L.M. nd Cssu, J.P. (2008) Femorl frctures in young dogs. AO Vet., 3: Johnson, K.A. nd Dejrdin, L.M. (2011) Minimlly invsive osteosynthesis in non diphysel frcture. Aville from: ppers/070.pdf. [Accessed on ]. 17. Kernek, C.B. nd Perry, A. (1981) Frcture heling in the rt tii: Open medullry pin versus closed medullry pin insertion. Clin. Orthop. Relted Res., 160: Brown, D.C., Conzemius, M.G., Shofer, F. nd Swnn, H. (1997) Epidemiologic evlution of postopertive infections in dogs nd cts. J. Am. Vet. Med. Assoc., 210: Ozsoy, S. (2004), Fixtion of femur, humerus nd tii frctures in cts using intrmedullry threded Steinmnn pins. Vet. Rec., 155(5): Altuntmz, K., Ozsoy, S., Mutlu, Z., Devecioglu, Y. nd Guzel, O. (2012) Use of intrmedullry fully-threded pins in the fixtion of feline nd cnine humerl, femorl nd tiil frctures. Vet. Comp. Orthop. Trum, 25(4): Aron, D.N., Tooms, J.P. nd Hollingsworth, S.C. (1986) Primry tretment of severe frctures y externl skeletl fixtion: Threded pins compred with smooth pin. J. Am. Anim. Hosp. Assoc., 22: Veterinry World, EISSN: