Thank you very much. Good evening, everybody. So today we're going to talk a little bit about the principles of articular fracture management.
And before we start off, I'd just like to acknowledge, Doctor Louis Desjardin. He is, my mentor in orthopaedics and certainly with some of these articular fracture cases, they can be. Very, very tricky, and, having an extra set of hands, is always useful, certainly someone with his experience.
So I just like to acknowledge, his help and also that some of the images that I'm using in this presentation do appear courtesy of him as well. So with articular fractures, what we need to remember, is the most important thing probably is that what we see on the X-ray really is the tip of the iceberg, and there's a huge amount of damage that can occur to other structures besides the obvious damage that we can see to the epiphyseal and the metaphyscial bone. And this includes damage to the articular cartilage, and probably that is the most important aspect that we, under, recognise.
Certainly, we also see damage to the surrounding soft tissues, to the adjacent growth plates in scale to the immature animals, and to the vascular supply as well. So some specific examples of that might include ligament damage, such as cranial cruciate ligament damage, which is relatively commonly seen when we experience femoral condylar fractures. And another one that's often very important and can lead to some fairly disappointing results is damage to the blood supply of the femoral head, which can be associated with growth plate fractures or slipped capital femoral epiphyses, in, in that region.
All this means is that despite adhering to all of the principles of treatment of articular fractures that we're going to talk about today, sometimes we can see some really high morbidity being experienced with these fractures, and maybe it's these additional injuries that explain that. While rigid fixation and anatomic reduction of the articular factors are absolutely critical operative goals, if we're going to do the absolute best for the animal and optimise joint function, reducing progression of arthritis, they do not address the musculoskeletal tissue surrounding the fracture, and those are obviously critical for physiological movement and range of motion. And certainly as we've been progressing, there's a lot of chat about how open approaches to these articular fractures may be contributing to further injury in some cases.
And we are starting to move towards trying to use closed methods of reduction, trying to limit that soft tissue approach, and that may be more effective at limiting further soft tissue trauma and give these animals a better prognosis. And I guess an example of that is if people are listening have treated humeral condylar fractures are very common, commonly experienced lateral humeral condylar fractures. And when you're in surgery and you reduce the fracture, everything feels great, you have a smooth range of motion, you feel like You've got almost 100% flexion and extension, and then you close your soft tissue approach, and all of a sudden you feel like you've got a very limited range of motion.
And certainly that's, that can be pretty disappointing. So trying to use less aggressive soft tissue approaches there is becoming, quite popular. So an example of one of these cases, this is Izzo, and Izzo was a 12 week old German Shepherd puppy who presented for surgical repair of a slipped capital femoral epiphysis.
And this puppy had been run over by a golf cart by the owner, so we had the whole guilt complex going on as well. So we did actually perform a minimally invasive stabilisation, using percutaneous reduction and fixation, and you can see the results of that here. So that's why the pins are quite long because they were actually placed minimally invasively through that small incision.
You can see the three staples. That was the only approach there. And we elected to perform that minimally invasive repair in order to try and prevent further damage to the blood supply.
And, already we knew that having suffered this injury, the prognosis for normal development of the femoral head was probably only fair due to that initial trauma. So we did this repair, and at 2 weeks postoperatively, as you can see here, everything looked to be progressing pretty well. At 4 weeks postoperatively, we saw Izzo back again, and we removed those pins.
And already you can see there's some evidence of progressive change. It is only 4 weeks after the fracture, the angulation of the femoral head certainly appears altered. The fiss is more closed than it appears to be on the other side.
So we were a little concerned, but at this stage ISO was progressing very well clinically, was walking well, no pain or range of motion of the hip, and ISO continued to progress well with no lameness at all, and was seen back for a routine check at 6 months postoperatively due to our concerns. And now we can see dramatic remodelling secondary to the vascular damage that was sustained at the time of the initial trauma. And this continued to progress, at the 18 month follow up, as you can see here.
Now, surprisingly, given the dramatic radiographic signs, ISO was actually only manifesting mild and intermittent lameness, and this could be fairly easily controlled with medical management when necessary. So at the moment, we haven't had to do anything dramatic here, but we need to recognise she may still need. A salvage surgery, for that at some point in the future, whether that's a total hip replacement or a femoral head and neck excision.
Currently, that's not indicated. But you can see, you can get a really disappointing result even when you think you've done everything correctly. So I think, having informed owner consent when we go forward with these injuries and letting them know that despite us doing what we consider to be the best job, we could still end up with complications further down the line.
So the outcome with articular fractures certainly can be elusive, and when working towards a definitive diagnosis, other aspects which may influence the outcome should also be considered. So obviously the degree of comminution is really important. If we see fractures where comminution exists within the articular surface, then they can be really difficult to repair.
You can reduce the osteochondral fragments and stabilise them if possible, if they're large enough, but stair step defects and gaps in the articular cartilage really need to be avoided if we're going to minimise development of osteoarthritis. And in the presence of these very small fragments which can't be stabilised, that prognosis will certainly become much more guarded. It's also important for us to identify whether these fractures may be pathologic fractures.
So stress fractures, as we see in racing greyhounds, for example, or those that are associated with incomplete ossification of the humeral condyle, or potentially bipartite radial carpal bones as well. And the prognosis for uncomplicated healing of these fractures certainly is reduced. So this is a stress fracture here of the central tarsal bone, which also then went on to result in a calcineal fracture.
And although the fracture is acute, the damage which has been going on here is pretty chronic. So the blood supply may be very poor, and the prognosis is certainly likely to be worse than it would be for an acute fracture that's associated with trauma. In the operative picture in the photo here, in the centre, you can see that this is a pathologic fracture of the radial carpal bone here.
And certainly, again, the damage here is chronic, even though the fracture has only just occurred. And I think you can probably appreciate in this photo, the cartilage here has already been damaged. We can see chondromalacia and certainly regardless of how accurately we put that bone back together, this will reduce the prognosis and following repair.
So this video here shows a case of incomplete ossification of the humeral condyle being viewed through arthroscopy. And fractures of the humeral condyles, most commonly of the lateral humeral condyle, as I mentioned earlier, are commonly encountered secondary to this condition. And it is important to recognise this as a pathological fracture.
So we can see on the CT scan here that the bone is very sclerotic and also there is a defect there that's not going to compress nicely when we place our lag screw. So owners do need to be made aware of the poor prognosis for healing here, and generally larger transcondylar screws would be recommended in these cases than when we experience non-pathological fractures, such as in little puppies, for example. And this is because the dog is going to be dependent upon that implant for significantly longer, potentially for the duration of its life.
So instead of starting off with a 2.7 screw, and then changing that to a 3.5 when the, when the 2.7 breaks, and then changing that to a 45 when that 35 screw breaks, maybe just start off with the largest screw you think you can realistically achieve in the first instance.
The upside of these fractures is if we catch them early, normally the degenerative joint disease that is associated with them tends to be minimal, despite the fact that the condition really is by definition chronic. So, as I mentioned at the beginning, articular fractures really can be a surgical challenge, and we do need to try to adhere to certain principles if we're going to give patients the greatest opportunity of maintaining a healthy articular surface with viable hyaline cartilage, normal peri-articular supporting connective tissues, and minimal muscle atrophy and fibrosis. And the principles would include obtaining an accurate diagnosis, instituting early treatment.
Achieving anatomical reduction, providing rigid fixation, preferably with inter fragmentary compression, and also then restoring the functional axis of the limb. And an additional principle which has been added to these in recent years is the use of appropriate post-operative physical rehabilitation. Deviation from these principles will likely lead to a poor outcome characterised by post-traumatic osteoarthritis, some joint fibrosis, muscle atrophy, and in all likelihood, chronic pain.
However, while it's very easy to list those principles, achieving all of them is not always easy. For example, in this particular case that you can see here, when attempting to achieve an accurate diagnosis, it was really difficult. We know we need to fix the articular surface, we know we need to restore the axis of the limb.
But in order to be able to plan that surgical intervention appropriately, we need that definitive diagnosis, including what number of fragments are we dealing with and what size are those fragments. And on these radiographs, you can kind of look at it and think, well, it looks like the lateral epicondyle is fractured. It looks like the electronon is fractured.
Maybe the coronoid is fractured as well. But all of these structures are overlapping, and it's very difficult to make that definitive diagnosis. And for me, looking at the images, they would not be sufficient for me to go on, make a surgical plan and proceed to surgery.
So although we're saying we want to have early treatment wherever possible, certainly we don't want to compromise achieving that accurate diagnosis just to get that patient into surgery quickly. So here is another case example. And I guess, you know, if you're looking at these, you're thinking, well, what would be my diagnosis?
And initially, maybe you think I, I really can't see that much on, on these X-rays. You might have some concern about the lateral trochlear ridge of the talus, but in these views, it is overlain by the calcaneus. So we do need more information here.
So diagnostic imaging of the task is particularly is always challenging because of the degree of superimposition encountered, and it is quite well documented now that CT will give you more information on most of these tarsal injuries than we can get from plain radiographs. However, we don't all have CT available. Certainly, even here, out of hours, it can be difficult for us to get a CT.
So there are simple things that we can do to try and improve that visualisation. You do not necessarily need to have advanced imaging for all of these. So you could start with taking some oblique views, and that gradually is going to reduce the superimposition by the calcaneus, and gradually that will reveal more and more of that lateral trochlear ridge.
Also, we can think about using tangential views as you can see here. So this is one version of a of a tangential views, gives you a skyline view of the, of the trochlear ridges here, and I think you can now appreciate that certainly that lateral trochlear ridge is certainly fractured and it's quite moderately displaced there as well. And so we had some suspicion about that lateral trochlear ridge before, but then when we take this second tangential view, which is the flexed plantaro dorsal view, you can see that there's also a fragment of the talus which is projecting cordially.
So this is actually a much more complicated injury than you may have initially suspected just based on two views of the tarsus. So these oblique and tangential views can be really, really useful, and certainly if you don't have CT, they can be incredibly useful in giving a little bit more information. So, while the diagnosis can often be confirmed with plain radiographs, depending on the anatomic area involved and the complexity of the fracture, anything from oblique or stressed radiographs to advanced imaging using CT or MRI may be required.
As I said, CT can be very useful in achieving a definitive diagnosis and planning surgery if you have it available. So, here you can see on the right side, this is a normal hock, and the traumatised hock is on the left. And on the boxes outlined in green, you can see that there's a comminuted fracture of the lateral trochlear ridge.
And there also is a fissure through the third malleolus, or what we call the caudal malleolus of the tibia. And then if we look at the red slice, we can then see that there is also a longitudinal fracture in the trochlear of the talus. So certainly there's a lot going on in this case, and I think it would have been quite difficult to know all of that information based purely on plain radiographs.
So we can also try stressed views for these guys to reduce superimposition. So here is the case that we were talking about earlier. So in the views on the left, the elbow was flexed, and a gauze bandage was applied to the anti-braium to distract it away from the humerus.
And now we can clearly see the electronon fracture, the medial coronoid process fracture, and the comminuted fracture of the proximal ulnar as well. In the views on the right, the quartocranial view, but with the sling, the sling is a cordocranial view, but the slings were applied to distract the humerus. And you can clearly see there's the lateral epicondylar fracture.
So, certainly very useful to use and very, very simple, very easy to achieve in general practise, no special tools required. So, as we said, CT can be super useful. This was actually one of our technicians who slipped and fell in the hospital.
So, certainly, if you're thinking about fractures that don't actually look like they are articulate to start with on radiography, CT can give you a very different impression of what's going on. So, on the radiographs here in this video is going to go back to repeat it. Self in just a second.
So on the radiographs, you certainly can't see much of a fissure going on, extending down to the joint. So here you go, there is a fissure. It looks like it comes down in close proximity to the joint, but it doesn't actually look like it involves the articular surface at all.
And that's true on both views. So it's close, but you might be thinking, I think I can squeeze a screw in underneath that. Then you look at the CT and very clearly that fissure goes all the way down to the joint surface, and certainly that's going to mean treating this fracture in a very different way.
So the CTs can be very useful. If you don't have CT available, it doesn't mean don't treat these fractures, but maybe just be aware that you may underestimate how far these fissures are progressing and be prepared to surgically explore and be prepared to potentially change your surgical plan, when you actually get into surgery. So, our second principle that we spoke about was using early treatment for these cases.
Sometimes we do get questions about whether we can manage articular fractures without surgery. And non-operative management of articular fractures generally leads to pretty Satisfactory results due to the resultant deformities of varying incidences of delayed union or non-union contracture of the joint, persistent instability of the joint, and certainly post-traumatic osteoarthritis. An early intervention does result in reduced pain, reduced secondary cartilage damage, limited soft tissue contraction, easier fracture reduction, and reduced morbidity as well.
So plenty of reasons to get these cases into surgery sooner. Chronicity of the fracture may well end up limiting treatment options for dogs and often does result in a poorer prognosis postoperatively even if surgery does remain an option. Close reduction of articular fractures with subsequent internal fixation certainly has been described, but it is only recommended for dogs that are treated within 24 to 48 hours of trauma and those that have minimal swelling.
So if we delay treatment, if we delay treating these cases, then we may well take them out of that category and they will not be able to have a closed reduction anymore. Open reduction is generally recommended in patients that are treated more than 48 hours after trauma, or where the fractures are irreducible, either because of swelling or callous formation or muscle contraction. And achieving anatomic oral reduction certainly becomes more difficult as fractures become more chronic.
And the prognosis given to the owner should definitely reflect this and the increased risk for the development of clinically relevant OA. And I'm really speaking from experience here because I have a fracture that just turned up today, which is, an articular fracture of the elbow, which is 2.5 weeks old.
So I am definitely not relishing the, thought of treating that one tomorrow. This case that we can see here, is a similar one. So this condylar fracture was a chronic lesion in a young dog.
So it had been there for 14 days before the dog was referred to us, and this was always going to be very, very challenging. Now, one of the fractures in this case could not be reduced at all. So you can see here on the postoperative views, we did actually just morsalize that to form basically a bone graft, in that area.
And because of the chronicity, because we've had to morsalize that fragment, you can see this is a very tenuous repair, the entire repair hi. On two screws in that distal fragment. So really not very comfortable at all.
Now this is not the recommended treatment. This is not how I would choose to treat an acute fracture here. We have added an IM pin, we have got a plate on the other side to try and protect that repair.
And actually, because we were so worried about this case, we did put it in a carpal flexion bandage, for a couple of weeks just to protect that repair as well. It just goes to show how important it is to see these cases and treat them early, because certainly we would have been able to get a much better result, much better fixation on that lateral side if this fracture had been seen more acutely. And our physical rehabilitation was absolutely imperative for this case, particularly after the use of the carpal flexion bandage.
And as soon as that carpal flexion bandage came off, this case was back and seeing our rehab department twice weekly, to improve range of motion of the carpus and the elbow. And actually, in this case, certainly, I say, I would not recommend it, but at 21 days, you can see that the fracture is healed, it's healed nicely. And the range of motion of this dog's elbow, although restricted, was certainly very functional.
I don't think this is going to cause the dog a major issue. And surprisingly, we actually got a good result with this case, but it certainly was by no means guaranteed. So, the third principle that we mentioned was that of anatomical reduction.
And there's been a lot of research done here, looking at how, how perfect does our reduction need to be, and when do we need to start being really, guarded with our prognosis for owners, depending on what we've been able to achieve. Obviously, the goal of treatment in intra-articular fractures is to obtain complete anatomical restoration of the articular surface with stable internal fixation. And in the presence of articular surface incongruity or persistent joint instability, there will be abnormal loading of the cartilage and the subchondral bone, and that will likely exceed the load bearing capabilities of the hyaline cartilage and lead to progressive cartilage degeneration.
But certainly it is a major unresolved question in trauma, and this remains in people as well as in animals, what degree of step off can they really tolerate at a joint surface, and this is still being investigated today, even though these early studies were performed back in the 1990s. So this was a really interesting study that was performed by Lynas and others in 1993, and they evaluated healing of gondola fractures, medial femoral condylar fractures in rabbits. And they deliberately gave these rabbits either a 0.5 millimetre or a 1 millimetre step off associated with their intra-articular fracture repair.
Now in both groups, the bone healed normally by 12 weeks postoperatively. And in the, in both groups, the articular cartilage did hypertrophy on the lower side of the step. So the cartilage hypertrophy to try and make up the difference between those two surfaces.
But the cartilage only managed to hypertrophy enough to bridge the defect in the group that had a 0.5 millimetre step. So in the ones that had a 1 millimetre step, they had an exposed area of subchondral bone.
And the conclusion made from this study was that ideally, we need to have the step off at the articular surface being less than the articular cartilage thickness in that area. Now, that certainly is a recommendation that has persisted to date. Unfortunately for us, dogs and cats, their articular cartridge tends to be very thin, so that basically means we have a 0.5 to maybe 1 millimetre, gap that we can leave and expect these dogs to actually go on to do well.
So here we can see some pictures from that study. So you see that the articular cartilage hypertrophy is occurring on both of these groups. But certainly in the 1 millimetre group, which is the images that you can see on your right, it hasn't actually bridged that gap.
So between the two, the red arrow head and then the double-ended arrow, you can see that there is an area which is no longer covered by articular cartilage, and that will result in, post-traumatic arthritis progressing. In the 0.5 millimetre group, you can see that the articular cartilage has hypertrophied and has managed to bridge that gap.
So you can see the area where the green arrowhead is that there's complete coverage over that fracture site, despite the fact there was a step left at surgery. So following the study by Linus, it was considered that defect healing probably decreases as the height of the step-off increases, and that higher step-offs will lead to poorer restoration of congruency and so ideally that step off should be less than local articular cartilage thickness. However, there were some studies that went on after that that started to question those results.
So in 1993, again, a group led by LeFO did publish an initial study where they created 3 millimetre defects, similarly in rabbit femoral condyles, and these defects were 5 millimetres deep. In 67% of those cases, they saw osteophytes being developed on the medial aspect of the operated knee as soon as 20 weeks after surgery. So in those cases, with a 5 millimetre deep defect, which was 3 millimetres wide, then we had osteoarthritis progressing very quickly from a very early stage.
They had the femoral and tibial cartilage at the site, was exhibiting fibrillation. It was hypocellular, and it lost saffranin O staining, which is linked to the proteoglycin content of the cartilage. And actually, some areas of cartilage were completely denuded or replaced by a panus formation.
In none of those cases did they manage to restore femoral congruity by cartilage repair. So that defect clearly too big. So the same group went on and did a further study in 1995 when they created slightly smaller defects.
So instead of a 5 millimetre step off, they went with a 2 millimetre step off. And in this group, they did get complete cartilaginous and bony repair, which resulted in closure of that surgical defect and complete restoration of femoral congruity. And there were no differences between the characteristics of the cartilage in these groups, so histologically and biochemically, they were exactly the same between rabbits that had a 2 millimetre step and rabbits that had no step.
So they concluded in that study that actually cartilage and bone do possess the ability to remodel small articular step-offs and restore joint congruity. So a little bit of a difference. So the first set of studies were saying 0.5 millimetres and anything more than that, we're going to have a bad result, whereas this group said, well, maybe a 2 millimetre step is actually OK.
So, in terms of looking again in the tibial plateau in humans, do we really need anatomical reduction? So they actually saw no increase in articular cartilage pressures with step-offs of up to 1.5 millimetres.
So again, agreeing with that second set of studies there, that maybe we can have a slightly larger step without having catastrophic results. Even when they had a 3 millimetre step, the increase in pressure at the articular cartildge was really fairly minimal. And again, so they we're going down a similar route that sensitivity to step off is going to be inversely proportional to cartilage thickness.
So the thicker the cartilage is, the bigger the step you can leave and expect articular cartilage to remodel over that. So, what we can see here is that our results are going to very much depend on which joint we're talking about. In the tibial plateau, and people, they're lucky, they have a huge amount of cartilage, so it's probably more forgiving for us in elbow fractures, for example, a very thin cartilage, likely we have to be more accurate.
So a more recent review of the human literature was performed in 2010, and they looked at intra-articular injuries to multiple joints, so including the distal radius, the acetabulum, the distal femur, and the tibial plateau. And similarly, they concluded different joints and even varying areas within the same joint have diverse tolerances for post-traumatic articulate step off. And in some joints, factors that were only partially related to articular reduction at.
She appeared to be more important in determining the outcome than the articular step off alone. So for example, in the stifle and in fractures similar to the medial femoral condylar fracture that you can see here, joint stability and retention of the meniscus and coronal alignment were actually really important factors to consider and maybe rivalled articular step off for being important prognostic factors. So our veterinary literature also appears to support a multifactorial, multi-factorial aetiology for the development of post-traumatic arthritis.
And we certainly do have some uncertain. How much male reduction is acceptable and to what degree does reduction influence outcome. So there was a study by Cook in 1999, and he looked at 10 dogs postoperatively that had lateral humeral condylar fractures.
So really common for us, so very valid to look at. And in those cases, they did do closed reduction and fixation. There was no open approach there.
And they achieved really good reduction in most of their cases. They said male reduction was 1.5 millimetres or less in all of the dogs, despite the fact that they were treated closed.
However, they did take radiographs at a mean follow-up of about 15 months after surgery, and they did see evidence of osteoarthritis in 6 out of the 9 dogs that they followed up. So really a high percentage of those dogs with osteoarthritis at that time. There was another study that looked at 13 dogs similarly following the same lateral humeral condylar fracture repair, and they reported that 100% of those dogs developed post-traumatic osteoarthritis, regardless of whether or not they achieved anatomical reduction.
So, although it's something important to aim for, it doesn't, avoid arthritis. Hopefully, it reduces the progression. Of arthritis there.
So this is a case that we treated, and you can see that initially, when you look at these radiographs, particularly the craniocaudal view, you might not think this really is an articular fracture. Then, when you look at the medialateral view, there's certainly some concern about that fissure running down through the radius. And when we zoom that image in, you can see definitely there is a step at that articular surface, and this truly is an articular fracture.
So we took this case to surgery, you can see here, that we did achieve what we considered to be anatomical reconstruction. We were using very, very small implants. This is 12 millimetre screw, a 11 1.5 millimetre screw, tension band wire, and then a tea plate to support.
The repair, connecting the articular and metaphycial areas to the diaphysis. So we were very happy with this repair. We felt we did not have a step defect in the joint, and we said, well, he's going to develop arthritis at some point, but hopefully, we've done the best we can for this dog.
And this is a 3-month follow-up picture of that case. And you can see at the moment, there isn't really any evidence of progressive osteoarthritis, but this is definitely a, not any evidence yet. It certainly will progress in the future.
But at the moment, there's no evidence. The implants are stable and the fracture is healing. So we can, even in these very complicated cases, get a good result, but we do need to inform the owners they will have arthritis in the future.
So, after all those studies, where are we at with this is anatomical reduction necessary? Based on the current literature, the recommendation certainly remains to achieve as accurate reconstruction of the articular surface as you possibly can. However, small step defects that are less than the local car sickness may allow local repair mechanisms to restore congruity.
But even if a congruent surface is attained, then post-traumatic osteoarthritis may persist as a cause of continued joint inflammation and continued cartilage degradation. And the precise events that lead to this are very hotly debated, but they likely involve multiple factors including, the congruency of the joint affected, the iatrogenic surgical trauma that is sustained, whether the area affected contributes significantly to load sharing or not, how stable your repair is, any gap and step male reduction, the age of the patient, and also whether or not we get these patients into post-op rehabilitation as well. And the multiple factors affecting outcome do have to be considered, because they may affect your decision-making and your surgical plan.
So the images that you can see here show a fracture of the electronon and also a fracture of the radial head as well. And we have to prioritise these repairs, because it's the the one that we repair first is going to be the one we have the best chance of getting accurate reduction on. So, given that the radial head contributes more to load sharing, we focused on a Achieving perfect reduction of the radial head in the first instance, and this did go on to lead to suboptimal repair of the ular notch in the anineal process.
But the important part of the notch for load sharing is the distal portion and the articulation with the radius, which was reduced well. So if you can't get everything back together perfectly, do consider which might be the most important, which is going to be the least forgiving of having a step defect, and correct that one first. So, yes, definitely anatomical reduction is still necessary, but in some cases, if we do not achieve that, it doesn't necessarily mean we have to go straight for a salvage surgery.
These dogs may still do OK. So this is a case example here. This was a 1.5 year old male neutered Dutch shepherd, and he had his right hind limb run over by a car.
He presented to us non-weight bearing. There was pain on hock manipulation, and there was certainly quite pronounced soft tissues swelling over the area. And these are the plain radiographs that we took.
And again, as you see here, really not a huge amount to see. You can see that there's some soft tissue swelling for sure. You can see that on that medial side there looks to be a small fragment of mineralization that has maybe come from.
Either the, distal tibial malleolus or, maybe from the thallus itself. And you may be thinking, well, maybe this is going to involve a collateral ligament, but based on this, it would be very difficult to know what you were going to do, how you were going to treat this injury. So we went ahead to take some stressed views, and you can see here that quite obviously as soon as you stress this, this hock, that you can see there is a fracture of the medial trochlear ridge of the talus.
And in this situation, you think, well, this looks like I should be able to surgically repair this pretty well. But as we know, certainly we can miss things on plane radiographs, and because we do have CT here, we did go ahead and perform a CT scan. Now, in this situation, it didn't necessarily tell us that there was any additional fragments, but it certainly does give you a bit more information about how big that fragment is in three dimensions.
Is this reducible or not? Can you perfectly reduce it? And what sizes of implant might you need to have in order to be able to complete this job?
So, when we were making a treatment plan for this Dutch shepherd, we had some questions to ask ourselves. So do we think that this case is going to potentially cope with conservative management or non-surgical management? Do we think that we could potentially do a relatively simple surgery such as an excision of that fragment and expect a good outcome?
Or do we want to go down the route of open reduction and internal fixation? If so, we need to decide what approach we're going to use to get in there and give ourselves good visualisation. And we need to think about what implants we're going to use.
Are we going to use K wires or is the fragment large enough to allow us to use a lag screw, or we're going to have to use a position screw, due to the size of the fragments, all of these questions we need to answer before we go in. We suspect there's some damage there to the medial collateral ligaments, certainly the joint stresses abnormally. So we need to think about how we might repair or augment, that, primary repair of that ligament.
And then we need to think about what our postoperative plan for this patient is going to be, what the prognosis is going to be, so that we can talk to the owner about that. So, when we were thinking about that, we thought conservative management, it's an articular fracture, it's not going to heal with conservative management, it would lead to a non-union and a poor outcome. So we decided that that was not going to be a good choice.
Excision, would definitely go on to lead to progressive and probably quite proliferative osteoarthritis. We've all seen osteochondrosis cases of the medial, trochlear ridge, and certainly they tend to develop very proliferative and clinically relevant arthritis very relatively early in life, and this would be a very similar situation. So again, not ideal.
So we retained open reduction internal fixation as our preferred option, with the plan being to achieve a congruent joint, we do know there's certainly very thin cartilage in that area, so we need to be as accurate as we possibly can if we're going to get a good result there. Now, luckily for us, in terms of our approach, the medial collateral ligament is actually already impaired. So we can actually go through the medial collateral ligament because it is ruptured.
And then when we go back in, we can, when we're closing, we can repair that and potentially we're going to be using a bone tunnel, through the malleolus in order to allow us to do that, and also place, potentially prosthetic ligaments there as well. And post-op plan, this is definitely going to require physical rehabilitation to get the best result. So, these are our post-op images, for this case.
And it certainly, this dog is on exploration certainly did have a tear of the medial collateral ligaments, so we used this to our advantage during the approach. And this fracture of the ridge was repaired using 2 1.5 millimetre screws, and they were counter sunk, so they sat below the articular surface there.
The medial collateral ligament was then primarily repaired and stabilised, and we've augmented that with a proline prosthesis that was secured through bone tunnels in the malleolus and the suture screw that you can see there in the talus. And again, just because we happen to have it, and this isn't something you would need to do necessarily, but this is the post-op CT of that patient. We did not charge this to the owners.
It's really for our information to see what kind of a job did we do and what did we achieve. And we can see here that certainly we look, we're pretty happy with the congruity of the joint based on that image, and we're happy with the implant placement, that that's not going to interfere with anything. And these are radiographs of that same case, 3 months postoperatively.
And again, at this stage, we can't see any obvious radiographic evidence of arthritis. Unfortunately, we don't have any further follow-up of this particular case, but there was a similar case that we operated a little, quite recently. It was a slightly more complex fracture.
It was actually a four-piece tar fracture, and that is now. 6 months out from surgery, and we do have follow up to that point. And in that case, we have some minor radiographic arthritis that's there, but clinically, they, the dog is progressing very, very well.
So, I think you can see that, certainly it's, it's preferable to excising the fragment. If we'd excise that fragment at this stage, we would be seeing certainly evidence of arthritis at 3 months and definitely at 6 months post-surgery. Now, having said that, we definitely need to try and achieve anatomical reduction, we saw with our, ISO, our case that we had right at the beginning, that an anatomical reduction can come at a cost.
Certainly, if you're going to need a great big soft tissue approach, then it, we certainly need to think about the cost of achieving anatomical reduction. And this is it was a little dog called Rimshot. He was a mixed breed dog.
He presented to us at 3 months old. You can appreciate all the open faeces here. And obviously, he has a femoral fracture, that's obvious, but he also has a fracture of the tri-radiate growth plate at the acetabula.
And I'm going to show you a CT scan, with a 3D reconstruction in a second, but you can see on these CT images there's obvious separation at the point where the ilium and the isum meet at that acetabular physis. He also has a pubic fracture, probably not very relevant, for the dog at this point. So here's our CT here, and you can see that CT reconstruction can be really useful in order to demonstrate the step off at the articular surface.
I can see that quite nicely here. So, ideally me this articular surface to sit nicely. However, in a young dog, the biological cost of approaching this area to reconstruct this fracture would be really high.
We also have to think that this is very soft bone in this young dog, it's going to have very poor implant holding capability. And so when we put all the, all the kind of considerations together, we decided that we would manage this case non-surgically. So we broke all the rules of articular fracture management.
And this is rimshot at 10 month follow-up. Now you can definitely see that he does have a length discrepancy between the two limbs. You can see outlined in red there that when he stands, the stifle is much more extended on that side, which is the side with the problem.
Even though his feet are in similar positions. So he does have a short limb. It's not affecting him clinically, but certainly he does have that.
He also has a smaller right hip. We can see that radiographically, and certainly, you know, we can't rule out this is going to cause him a problem in the future. However, this is the dog walking at that 10 month follow-up, and you can see that really, if you didn't know something had happened, you probably wouldn't consider this dog to be lame.
You wouldn't think he has a major problem here. We may need to do a total hip replacement in the future, but at this point, very happy with this and considering all of the things that could have gone wrong with an open approach, I think this was probably the right decision for this dog. So, the type of approach for articular fractures does need to be considered carefully before we go to surgery.
We want surgery to be as a traumatic as possible. And some of the traditional surgical approaches to the joints of the dog and cat have been previously reported, and certainly they can be used to treat all articular fractures. But some of these traditional approaches have been reported, such as the trans-electronon osteotomy, for example, while they provide amazing visualisation of that articular surface, they are associated with very high complication rates postoperatively, and I think they're used by fewer and fewer surgeons today.
If we look at the trans-electronal osteotomy, for example, the postoperative complication rate associated purely with the osteotomy itself, nothing to do with the fracture you treated, is 37%. So I think that's actually quite difficult to justify, even if it does allow you to see that articular surface better. So a minimally invasive surgical approach using minimally invasive osteosynthesis techniques can be optimal for a pair of certain articular fractures, particularly those that are minimally displaced, the ones that are simple, so generally only in two pieces, and the ones that are acute and you see them early.
And these limited approaches are gaining acceptance for articular fracture repair. However, they definitely provide poorer visualisation unless they are combined with other imaging techniques. So one option would be using arthroscopy and then placing the implants percutaneously, or you can do a mini arthrotomy and use the arthroscope through that to view your articular fracture.
And even though you're making a very small approach to the joint there, that mini arthrotomy incision is much shorter than, a full arthrotomy incision that would be used to treat articular fractures using traditional open reduction and stabilisation techniques. And you can extend that mini arthrotomy as needed to. Apply implants to stabilise the fracture.
And these techniques using arthroscopy certainly improved the surgeon's view of the articular surface and they result in a more precise. I Yeah. I, I do authors.
Used it a lot for fracture repair. I actually prefer to use fluoroscopy personally. I use that to improve, my spatial orientation and to enable me to assess my fracture alignment and implant position without having to use a scope.
I kind of find if I'm using a scope and I. I'm trying to place implants and I'm trying to position the limb. I feel like I need to be an octopus in in order to do all of those things.
And that's working in a university where I can normally have multiple people help me. I still find that very tricky to manage, fluoroscopy for me, much easier to deal with. So, but treatment of articular factors with arthroscopy or other minimally invasive osteosynthesis techniques do have a significant learning curve, and they do require expensive equipment.
So while they potentially have advantages, it's not going to be suitable for everybody. I do think that, CAMs and fluoroscopy equipment is going to come down in cost over, the next, over the following years. So it may become, more achievable for multiple practises to have this.
However, we do need to bear in mind there's a massive disadvantage to the use of fluoroscopy, and that is the exposure to ionising radiation. So we do need to make sure that you have appropriate protective equipment, and that you'll be only using the number of views that you really need, if you're not using views all the time, using thyroid protectors, lead aprons, radiation attenuation gloves, all those kind of things. So, definitely need to look after our own safety, first.
But as an example, the pictures here show, a little French bulldog that presented with a gondola fracture of the elbow. We've heard a lot about those today. In this case, it's actually a sill, that lateral condylar fracture that we see so frequently.
And this was repaired minimally invasively, and the dog presented, I think about 72 hours after, but we could still move it, it still felt like we could reduce it percutaneously. And that was repaired with a combination of Kwis placed minimally invasively, and that did go on to heal very well. This is a little dog immediately after surgery.
We did place a carpal section bandage just for 5 days. This dog's going to heal very quickly, so I don't think we need to have that on for much longer. And certainly that dog went on to say, to do very well and had, did have some physical rehabilitation to maximise range of motion of the elbow and carpus there.
So, the 4th principle that we mentioned is that of rigid fixation, and this is one that really is not debated. This is something that everyone accepts. We really do need to achieve rigid fixation of these fractures, particularly in adult animals, if we want these things to heal well.
The type of fixation is absolutely critical, and it is important in the mechanism of post-traumatic osteoarthritis development. And this was proven right back in 1990, a study by Francis and Johnson, where they treated the same fracture in multiple different ways and compared the results. So again, it was these femoral condylar fractures.
You can see this is a, a, a popular, model to use. If they did not fix these fractures at all, then at 12 weeks, they saw pronounced osteophytosis and Absolutely no attempt of the fracture to heal at all. If they were fixed, but with no compression, across the fracture site, then at 12 weeks, similarly, they saw osteophytosis and no fracture healing.
So, just fixing these with a screw, but without actually compressing that fractured site, didn't really achieve anything over and above leaving these fractures alone. Mhm. So, bearing that in mind, this was a Labrador that was hit by a car, and he presented to us with a lateral femoral condylar fracture.
And we elected to treat this minimally invasively, we used a position screw and K wires, to treat this. And we did not achieve compression across that fractured site. So these are our follow-up radiographs at 4 weeks, and then at 8 weeks.
So immediately post-op, you can see is on the is is on the left there and then our follow up is as as we go progressively right 4 and 8 weeks. So at 4 weeks, we can see that all of our implants remain in the right place. There's no loss of alignment of the fracture, but there is some seroma formation.
You can see there's some swelling over there, and one of the pins appears to be migrating a little bit. So that may be indicative that we have some instability going on. The fracture gap also appears to be slightly widened when we compare that to our immediately post-op view.
But the dog's progressing very well clinically at this stage, doing great, using the leg really well, and so we have to make a decision, do we want to revise this now, or do we want to wait and see? And as the dog was doing well clinically at this stage, we decided to not do anything. We'll see the dog back in another 4 weeks and see where we're at.
So at 8 weeks post-op, we still haven't lost alignment, but the pin that was migrating before has migrated further. We have some resorption of the fracture edges and absolutely no progression of healing at all. So again, now we have to make some decisions.
And at this stage, I don't know, does anyone else remember Action Man? I feel really old bringing this up. This is my brother's favourite toy, but you have to consider at this point, are you going to be an ostrich?
Are you gonna put your head in the sand, send the dog away, it's doing clinically well, let's just. Hope that it never comes back, or are we going to actually go ahead, revise this and try and get a better result? And maybe looking at the continuing research from the Francis and Johnson study will help us decide.
So back to Johnson's paper, if the femoral condylar fractures in those papers were compressed, then at 12 weeks, there was limited to no osteophytosis. The fragments healed, and there was restoration of the articular cartilage. So in this case, we decided not to be ostriches, and we did go back and perform a revision surgery.
We were able to still do this in a minimally invasive fashion, but we placed a 6.5 millimetre lag screw that was placed in the original trajectory of the previously placed 3.5 millimetre position screw.
We did also place an additional screw to compress that proximal aspect of the fracture. And you can see here, these are our post-op views. There is some additional metal work in there.
That was a cannulated drill bit. We initially tried to place the more proximal screw over one of the K wires that had been in there, but the drill bit broke and had to be left in situ. So this then did go on to heal beautifully well.
The dog did great, but you can see that it is really important to achieve rigid fixation. And also, no matter how tempting it is to start doing minimally invasive surgery, don't do that and then forget about the other principles of articular fracture repair. If you go minimally invasive, you still really need to follow all of the other rules.
Fractures do need to be repaired with interfragmentary compression whenever the size of the fragment will allow you to do so. Sometimes fragments are too small. If you place a lag screw, that's going to cause the fragment to explode.
And in those situations, maybe you can apply the, compression using bone holding forceps and then place the screw in a positional fashion. How exactly you achieve that internal fixation will vary between joints, but really, in our, in our preoperative planning, we need to really try and make sure that we're including in that achieving compression across the joint. So this is another example here.
So this dog was a retired racing greyhound, and he presented with this really nasty fracture affecting the stifle joint. There was some consideration this may have been a possible stress fracture. It's not one that's commonly reported in greyhounds, but we were slightly concerned about the sclerosis of the bone.
It is minimally displaced at this time. The knee itself was stable, there didn't appear to be any cruciate ligament damage. And you can see from these intraoperative pictures, we did look, we found that the cruciate ligament was indeed intact.
There was some mild damage to the caudal cruciate ligament. It was slightly frayed, but it was not transected, so we didn't stabilise that, really. And we used, lag screws to repair that articular surface.
Now what you can see there is it does appear that there's a great big gap in the articular cartilage. So we do actually have reduction of the subchondral bone underneath that. The bone is together, but there was a damaged piece of articular cartilage that had peeled off, so that had to be removed rather than left loose within the joint.
So in this case we were lucky, we did not have any cruciate ligament damage, but do you know if you do have cruciate ligament damage associated with these fractures, then you will also need to repair those in order to protect your primary fracture fixation. So these are the post-op views of that dog, and again, views at 8 weeks postoperatively. And at this stage, the implants are all certainly remaining in the correct positions, no signs of complications, and the fracture is healing very well.
So in this case, this went on to do very well. So moving on to our 5th principle here. So we said that once we've achieved, reconstruction of our articular surface, we also need to restore the functional axis of the limb, and this is absolutely critical.
Anatomical alignment of that functional of the limb will ensure even load distribution. It will promote faster recovery, and it will reduce the development of post-traumatic arthritis as well. Now when we consider the restoration of anatomical alignment, the most important factors to consider are rotation and valgus virus as well.
If we have a deficit in limb length, as we saw earlier with our case example, then often that's very well tolerated, to a degree. And, deficits in pro or retrocovatum also appear to be less critical in terms of the clinical outcome for the patient. So we really need to concentrate on that rotation and the valgus virus and prioritise restoring those.
But in order to restore the functional axis of the limb, we do need a stable repair between the metaphysis and the epiphysis. And this can be done in multiple different ways. So, the restoration of alignment can again be achieved using our traditional open approaches.
It can also be achieved using minimally invasive approaches and indirect reduction techniques with intra-op fluoroscopy being being used where necessary to ensure that appropriate alignment before applying any fixation. Now in patients where there is no comminution, then it certainly is OK to use things like crossed K wires or just lag screws, Steinman pins or modified rush pins can be used as well. So these can all be used, and particularly in younger patients or smaller patients, patients where you think healing is going to occur very quickly.
External fixators have also been used to supplement repairs when necessary, and they can also be used as the primary method of fracture stabilisation, particularly in open fractures or very comminuted ones, but they generally do not allow the creation of inter-fragmentary compression at the articular surface. So for the articular surface, you probably want to be using something else. In larger animals or comminuted fractures, so animals where you perceive healing is likely to be delayed, and certainly a bone plate is going to be preferred for achieving that, restoration of, limb access.
This will achieve more rigid fixation. It will allow an earlier return to limb function. And certainly the locking compression plates, if you have access to those, may have advantages here.
It's not as, critical to accurately contour those. So in difficult anatomic sites like the distal humerus or the distal femur, then that can, be useful. And also they are not as reliant on that screw bone interface, which in soft metaphycele bone can be very helpful to.
There are some special purpose plates that exist for some of these areas, such as the hockey stick plate for distal femoral condylar fractures. And they can be very useful if the dog is of the right shape, for that particular implant. And you can see that we have used that in this, distal femoral fracture, that you can see in the images here.
If you're using older generations of the interlocking nail, where rotational slack remains a significant problem, then they are definitely not recommended for stabilisation of metaphycele or juxtaarticular fractures. So they would not be appropriate for restoring this functional access. However, if you have access to the angle stable interlocking nail, which is the ILO system marketed by biometrics, that can be considered for use in these cases, and that has been proven that because of the absence of slack, we can use that in these cases.
So that may be an option. The exact implant that you select, and the size of that implant will depend on the weight of the patient, the anatomic site we're talking about, and obviously the morphology of the fracture as well. So, principle 6, I say this won't be in the older textbooks, this is more of a recent thing that's been added as a, as a 6th principle, but, this post-operative physical rehabilitation.
So the goal of fixation of articular fractures is to allow range of motion of the affected joint as soon as possible postoperatively so that we can reduce joint stiffness and peri-articular fibrosis. And damage to the articular cartilage, especially in situations where we see larger segments of the articular cartilage being involved, should be protected from heavy weight bearing in the early stages in order to allow for healing. However, a joint motion is absolutely required to maintain joint health, and it does promote healing of injured and articular surfaces.
So our early goals for rehabilitation for any articular or peri-articular fractures include maintaining or improving the joint and segment range of motion, providing pain relief, minimising peria-articular fibrosis, and giving sufficient time for bone healing by allowing progressive loading that will protect against implant failure and augment rather than disrupt bone healing. After sufficient healing has occurred to support partial physiologic loads, then the rehabilitation programme should include exercises to promote muscle and bone strengthening, continued improvement of range of motion, and gradual return to the activities of sport if it's a sporting dog or just daily activity. The physical rehabilitation programme will need to be tailored to the individual patient, the owner and the individual fracture too.
But it may initially include modalities such as pain relief and cryotherapy for the 1st 72 hours. After 72 hours, we continue the analgesia, but cryotherapy is often exchanged for heat therapy, and passive range of motion exercises tend to be started around this time. Gentle weight shifting exercises, maybe some sling assisted walking may also be started at around the same time as well.
And then within 10 to 14 days, we can progress this to leaning exercises, maybe the use of some cavalletti poles, weight shifting on uneven surfaces, and potentially underwater treadmill therapy as well, as long as the incision has healed sufficiently. But we do need to take caution, we need to, limit vigorous movements against the resistance of water until we have evidence of radiographic bone union. I know just discounts you to remember that cats, as you can see here, can tolerate all of these physical rehabilitation as well.
It's not just a dog thing. So we can certainly get cats in the water treadmill and, certain, what should we say, not all cats, but most cats in my hands can be trained to, if not enjoy at least tolerate this kind of physical rehabilitation. So just wanted to kind of have this case as a kind of one of the final things here to talk about.
So as you can see here, this was an incredibly complex fracture. I see a little dog called Roxy. And this fracture involved the trochlear, it involved the condyles.
It had an area of comminution which could not be reconstructed, as you can see, there's a kind of defect there in the femoral condyle. But luckily this was not in a load sharing region. And certainly, when repairing this, you know, you might be having going through your head, goodness, you know, should I really even try or should I go straight to a salvage procedure here?
I'm not sure what the outcome for this is going to be. And while the X-ray looks pretty impressive, you can see from the intraoperative picture, we certainly haven't achieved all of the things we would like to with an articular fracture. So this girl went into, a lot of physical rehabilitation straight after surgery, and you can see here, we, we started with some cryotherapy, then we did some weight shifting, then we did some stairs and some active exercise.
And then this is Roxy at 8 weeks post-surgery. So you can. See, yeah, she does still have a lameness there, but considering the state that that, stifle was in, it's really quite a positive, outcome there.
And so what that says to me is that even when these things appear really intimidating, it certainly can still be worth still having a go at really following all the principles that you can, and the outcome may still be pretty good. So we shouldn't resort to salvage options too soon. However, certainly, if we do end up in a situation where everything else has failed, then we can still resort to those salvage options, either joint replacement, or potentially arthrodesis for certain joints as well.
So in that situation, certainly we do have options, available to us. And at that stage, I can take any questions anyone may have. Karen, that was absolutely fabulous and I think you're selling yourselves as a collective of surgeons and certainly yourself personally in this instance that you are selling yourself very, very short because some of these operations, as I said right in the beginning, I'm very glad that they weren't my joints, but I tell you what, if they were my joints, I would like you to be on the other side of that scalpel because it's absolutely incredible what you guys have achieved in in in some of these fractures.
And that last one with Roxy was just yeah, incredible. 8 weeks later that she's running down there and in fact the problem there was the nurse trying to keep up with her. True.
I, I was quite tickled though about the cats on underwater treadmill and I enjoyed your, your Britishness in in talking about not necessarily enjoying but tolerating the water. That's that's must be quite interesting to to start them off in the water. Absolutely.
I think there's a reason why most people who show those videos have mute on. Yeah, that's great. That's great.
Karen, I, I cannot thank you enough for your time and sharing with us tonight. I think like the, myself, the rest of the audience, are sitting here absolutely gobsmacked with what you've shown us and we don't have any questions coming through at this stage. But I, I really have to say thank you for sharing with us and it, it's really impress.
And lovely to see. I've been a vet for a very long time now. And it's lovely to see the, the steps and advances of, of what 30 years ago we would have just gone, sorry about that, but that leg needs to come off and and now Roxy's running 8 weeks later after what looks like a horrific injury.
-huh. Yeah, I think, I think it's a And if you've got the people that can help you out in those situations, certainly it's not just me. But, having, having the team that can help you out with those things, certainly we can get some good results in in some fairly catastrophic cases.
And I'm, I'm always jealous. I'm a little bit of a closet surgeon, nowhere near in your class, but I, I'm always very, very jealous as to the the toys that you guys get to play with in the Absolutely. Yeah.
Again, working at a university that will support us, we, we, we're very lucky with the toys we can, we can get. We've just had a comment come through from Ian, kind of echoing what I've been saying here and he goes, my God, you either have to be very good or very brave or both. I suspect both and the last option.
But I love the webinar. Thank you. No problem.
Thanks very much. Yeah. To all the guests tonight, thank you for attending.
We really appreciate it. To Karen once again, a really big thank you for your time and that to Dawn in the background, thank you for making it all happen and look seamless. Folks, that's it for another members webinar and Karen, we look forward to having you back at some stage in the future.
Absolutely. Thank you. Have a good evening.