Fracture healing is a complex and gradual process that typically proceeds without complications when a suitable mechanical and biological environment is provided.1 Bone can uniquely regain its original properties.2 However, disruption of this process can lead to healing in incorrect anatomical positions, delayed healing, or nonunion.3,4 Such conditions are associated with morbidity, and in severe cases, amputation or euthanasia may be necessary.2 Nonunion is characterized by the formation of fibrous or cartilaginous tissue between the fragments and typically requires surgical intervention for treatment.5,6 These unfavorable conditions in fracture healing are usually attributable to intraoperative technical errors (implant failure or inadequate fracture stability) or chronic infection.7,8 In addition, factors such as advanced age, severe soft tissue injury, multiple trauma, segmental fractures, and contamination can contribute to the development of nonunion.4,6
The FDA defines nonunion as the absence of visible signs of healing at the fracture site for 3 months. However, this time frame varies in the literature.9 In general, nonunion is classified into 2 types: viable and nonviable. Viable nonunions are classified as hypertrophic when excessive bone callus formation occurs and oligotrophic with little or no bone callus formation. Nonviable nonunion is classified as dystrophic, necrotic, defective, and atrophic.10 Clinical examination findings are also crucial for accurate classification.11,12
Treatment of nonunion should be operative.13 Although operative treatment is being planned, factors such as local blood circulation, stability, and the ability of the involved tissues to regenerate must be considered.5 Adequate debridement should be performed to reduce the bacterial load and remove necrotic tissues in the treatment of infective nonunion fractures. The restored fracture should be restabilized with appropriate fixation.7,14
In nonunion treatments, locked plates and interlocking pins are used for bone fixation.15,16 In addition, circular and hybrid external fixator systems can be utilized because of their resistance to shearing, distraction, compression, rotation, and torsional forces.4,17
In contrast, linear external fixator systems are easier to apply and have fewer complications, such as pin tract infections, with reports18 indicating that animals adapt more quickly to these systems. Moreover, linear systems have been successfully applied in a reported case19 of nonunion in a cat.
Therefore, this study aimed to evaluate the clinical and radiological findings of nonunion cases in cats treated with a linear external fixator and to demonstrate the success rate of this system in the effective treatment of such cases.
Methods
Animals
The inclusion criteria for this study included cats of different breeds, various ages, and sexes who had previously undergone plate osteosynthesis or intramedullary pin osteosynthesis in another clinic but did not achieve fracture healing. These cats were diagnosed with nonunion based on clinical and radiographic examinations conducted in the Clinic of Surgery Department of Siirt University Animal Health Practice and Research Hospital between July 2022 and September 2023. To ensure data reliability, all patients were evaluated by a single veterinary surgeon based on the literature.9,12 Written consent was obtained from the patient's owners before the treatment procedures were performed in accordance with the hospital rules.
Preoperative management
A general preoperative examination of the patients was performed, blood parameters were checked (CBC and serum biochemistry panel; Mindray BC-60R Vet; Hasvet), and it was concluded that the patients were healthy. Antibiotics (20 mg/kg ceftriaxone; Unacefin; 0.5 g; Yavuz İlaç) were administered parenterally twice daily for 7 days for prophylaxis. The patients were kept on cage rest until surgery. Patients underwent surgery within 1 to 4 days of admission to the hospital. Before the operations, bilateral radiographs of all cases were taken, the location and shape of the nonunion fracture were determined, and pin application sites were identified accordingly.
Instrumentation
Tasarım-Med company-designed linear fixators (TF-Ers Hand-Wrist Fixator; Figure 1), which are specifically designed for the treatment of delayed healing fractures, manufactured from lightweight alloys but possessing high strength with a capacity of at least 4 Schanz pins, were used as osteosynthesis material. Additionally, 2.5 mm negatively or positively threaded Schanz pins were selected considering the thickness of the cortical bone in the cases. Electric drills, wrenches, soft tissue, and orthopedic sets were used in the procedures.
Picture of the external fixator that was used.
Citation: American Journal of Veterinary Research 86, 3; 10.2460/ajvr.24.11.0350
Retrieved data
The etiology of the fracture, fracture classification, time between initial surgical intervention and revision surgery, osteosynthesis material in the initial and revision surgery, physical examination findings, surgical technique, postoperative complications, healing times, and implant removal times were examined (Table 1). The data were extracted from the medical records of the patients.
Summary of clinical data, nonunion classification, and outcomes in feline fracture cases.
| Case | Signalment (age, sex, breed, body weight) | Etiology | Tissue condition fracture location | Initial method of fracture treatment | Nonunion classificationa | Time from first surgery to second surgery (d) | Second method of fracture treatment | First time to use the limb (d) | First fibrosis callus (d) | Nonunion treatment (d) | Outcome veterinary assessmentb |
|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 6 months old, female, crossbreed, 1.5 kg | High rise | Closed L-tibia diaphyseal transversal | Plate osteosynthesis | Pseudoarthrosis | 164 | ESF (LF, 3 Schanz) + Im-pin | 6 | 20 | 58 | Excellent |
| 2 | 6 months old, female, crossbreed, 2.6 kg | High rise | Opened L-humerus proximal diaphyseal transversal | Im-pin osteosynthesis | Oligotrophic | 165 | ESF (LF, 3 Schanz) | 4 | 26 | 47 | Excellent |
| 3 | 3 years old, female, Scottish Fold, 2.3 kg | High rise | Opened L-tibia diaphyseal transversal | Im-pin osteosynthesis | Oligotrophic | 168 | ESF (LF, 4 Schanz) + Im-pin | 5 | 21 | 71 | Good |
| 4 | 2 years old, female, crossbreed, 2.3 kg | High rise | Closed L-tibia diaphyseal segmental | Im-pin osteosynthesis | Oligotrophic | 157 | ESF (LF, 4 Schanz) | 6 | 18 | 59 | Excellent |
| 5 | 1.5 years old, female, crossbreed, 2.1 kg | High rise | Closed R-tibia distal diaphyseal transversal | Im-pin osteosynthesis | Oligotrophic | 162 | ESF (LF, 3 Schanz) | 3 | 23 | 49 | Excellent |
| 6 | 3 years old, male, Turkish Van, 4.6 kg | Traffic accident | Closed L-humerus segmental diaphyseal oblique | Plate osteosynthesis | Oligotrophic | 162 | ESF (LF, 4 Schanz) + cerclage | 7 | 24 | 68 | Good |
| 7 | 1.5 years old, male, crossbreed, 2 kg | Traffic accident | Closed R-femur proximal diaphyseal transversal | Im-pin osteosynthesis | Oligotrophic | 158 | ESF (LF, 4 Schanz) | 2 | 21 | 52 | Excellent |
| 8 | 1 year old, female, crossbreed, 1.8 kg | Traffic accident | Closed L-femur proximal diaphyseal transversal | Im-pin osteosynthesis | Oligotrophic | 163 | ESF (LF, 4 Schanz) | 2 | 19 | 57 | Excellent |
| 9 | 3 years old, female, Turkish Van, 2.3 kg | Traffic accident | Closed L-humerus distal diaphyseal transversal | Im-pin osteosynthesis | Oligotrophic | 165 | ESF (LF, 3 Schanz) | 4 | 35 | 64 | Good |
| 10 | 2 years old, female, Scottish Fold, 2.4 kg | Traffic accident | Closed R-tibia diaphyseal transversal | Plate osteosynthesis | Pseudoarthrosis | 171 | ESF (LF, 4 Schanz) | 5 | 24 | 53 | Excellent |
ESF = External fixator. Im-pin = Intramedullary pin. L = Left. LF = Linear fixator. R = Right.
Surgical procedure
Cefazolin (Cefazolina Dorom; Teva; 25 mg/kg, IV) was administered 30 min before the operation, and the dose was repeated 90 min later. After shaving and disinfection (4% chlorhexidine + 70% isopropyl alcohol) at the fracture site, anesthesia was induced by IV injection of 4 mg/kg propofol. Anesthesia was maintained using a closed-circuit anesthesia device (SMS 2000 Classic Vent-V) with 2% sevoflurane (Sevoran; Abbott). For tibial fractures, the patient was positioned supine on the operating table with the affected limb hanging. In femoral and humeral fracture cases, patients were positioned laterally with the affected limb on top and treated using the limited incision open reduction external fixation technique.
This method was applied to all cases diagnosed using the different nonunion methods. Fracture fragments were approached craniolaterally in the femur and humerus and craniomedially in the tibia. A limited incision was made just above the fracture line (approx 3 to 5 cm). The implants from previous surgeries were removed. Traditional debridement of the bone ends was performed by removing the fibrous and necrotic tissues using a scissor-like rongeur, creating a flat surface, and reopening the medullary canal with a pin. The fracture fragments were reduced using a thin intramedullary pin (1- to 2-mm-diameter K-pin) covering 33.3% of the medullary canal retrogradely, and the incision was closed using a routine technique. The areas adjacent to the joints and fracture line were identified using fluoroscopy (BJI-1 portable X-ray fluoroscopy instrument). A linear external fixator was applied to the bone to ensure that each fragment received 1 or 2 Schanz pins. In all cases, except for those where 3 Schanz pins were used for all fragments (cases 1, 5, and 9; Figure 2), the intramedullary pins applied for reduction were removed. In case 2, because only 1 Schanz pin could be applied to the proximal fragment, an additional cross-pin was applied to the fracture line (Figure 3). The reduction of the fragments was rechecked using fluoroscopy, necessary adjustments were made, and the surgery was subsequently completed.
Case 1 x-ray images. A—Preoperative anterior-posterior image. B—Postoperative day 1 anterior-posterior image. C—After the removal of fixator anterior-posterior image. D—After the removal of fixator medial-lateral image.
Citation: American Journal of Veterinary Research 86, 3; 10.2460/ajvr.24.11.0350
Case 2 x-ray images. A—Preoperative medial-lateral image. B—Postoperative day 1 medial-lateral image. C—After the removal of fixator medial-lateral image. D—After the removal of fixator anterior-posterior image.
Citation: American Journal of Veterinary Research 86, 3; 10.2460/ajvr.24.11.0350
Follow-up evaluation
The functions of the vascular and muscular structures of the affected extremities were evaluated through comprehensive clinical examinations. In patients diagnosed with open fractures (cases 2 and 3), swab samples were collected from the bone surfaces in the wound area and sent to the laboratory for microbiological analyses.
Until the completion of this procedure (microbiological analyses), 20 mg/kg ceftriaxone (Unacefin; 0.5 g; Yavuz İlaç) was administered parenterally twice daily for 3 days in all cases. In addition, 0.4 mg/kg of tolfenamic acid (Tolfine; Novakim) was administered parenterally once daily for 5 postoperative days to control pain and inflammation. Pin bottoms were cleaned with 10% povidone iodine (Poviiodeks; Kimpa) once daily. In cases of pin bottom infection, pin bottom care was performed twice a day. All patients were hospitalized for appropriate postoperative care until fracture healing was completed and the fixator was removed. This duration was recorded as an average of 57.8 days (between days 47 and 71).
Radiological examinations (FDR Smart X Digital Radiography System; Fujifilm) were conducted weekly until postoperative day 15. Subsequently, anterior-posterior and medial-lateral radiographs of the involved extremities were repeated every 2 to 3 days, depending on the case, until the fixator was removed to accurately determine the significant time interval. In cases where consolidation was completed, the pin holders were loosened under sedation, and the fixator was removed.
Clinical outcome assessment
During the postoperative period, the continuity of the anatomical position and new fractures that may have occurred at the pin insertion and healing levels were evaluated using radiological examinations. In clinical controls, criteria such as limb use, presence of pain and edema, joint functions, and presence of regional muscle and tendon contractures were reviewed. The findings of the cases were graded according to the functional and aesthetic diagnosis described by Rovesti et al20 (Table 2).
Functional and aesthetic grading of patients in the postoperative period.
| Grade | Lameness status | Limb appearance |
|---|---|---|
| Excellent | Normal gait, no lameness or pain | Normal appearance |
| Good | Normal gait, mild lameness in the limb | Normal appearance |
| Fair | Mild to moderate lameness | Appearance not perfect |
| Poor | Limb occasionally used, constant lameness | Abnormal appearance |
Statistical analysis
The average times for initial fibrous callus formation and consolidation completion were recorded as the arithmetic mean, obtained by dividing the total number of days determined for each case by the number of cases.
Results
Patients
This study included 10 cats that had previously undergone unsuccessful osteosynthesis of the relevant limb. Six patients were mongrels, 2 were Scottish Fold, and 2 were Turkish Van cats. The ages of the cats ranged from 6 months to 3 years. Their live weights were 1.5 to 4.6 kg. When the cases were analyzed etiologically, 5 cases occurred due to traffic accidents, and 5 cases occurred due to falling from a height. Five of the included fractures were located in the tibia, 3 in the femur, and 2 in the humerus (Table 1). When the first osteosynthesis operation was examined, intramedullary pins were applied in 7 cats, and plates were applied in 3 cats. Eight cats were diagnosed with oligotrophic nonunion and 2 cats with pseudoarthrosis on clinical and radiologic examinations before revision surgery. The mean period between the 2 operations was 164 days (range, 157 to 171 days).
Follow-up evaluation
At the end of revision surgery, treatment success was achieved in all 10 patients. The first fibrous callus at the fracture line started at an average of 23.1 days (between days 18 and 35), whereas consolidation was completed at an average of 57.8 days (between days 47 and 71) (Table 1). In all the cases, healing was defined as secondary fracture healing. The fixators were removed 1 week after consolidation was completed in all cases (Figures 2 and 3). In 2 cases with open fractures (cases 2 and 3), Staphylococcus haemolyticus (case 2) and Streptococcus canis (case 3) were identified in swab samples through microbiological analysis. Due to resistance of the S haemolyticus isolate to methicillin, cephalosporins, penicillin, gentamicin, enrofloxacin, and ciprofloxacin, treatment was continued with doxycycline (10 mg/kg, IV, twice daily for 5 days). The S canis isolate exhibited resistance to tetracycline, and the patient was treated with enrofloxacin (5 mg/kg, IV, once daily for 5 days).
Postoperative daily clinical examinations did not reveal any complications associated with using a fixator. Edema was observed in only 2 cases (cases 2 and 7) on postoperative day 1. This situation improved on days 2 to 3. All patients started using the relevant limbs within 1 postoperative week, and their gait gradually improved during the healing process.
Pin bottom infection and associated soft tissue infection occurred in 3 cases (cases 2, 7, and 9). In this case, daily care of the pin bottom increased, and the infection was eliminated. An open wound occurred after the operation in 3 cases (cases 2, 6, and 9). The wounds were located lateral to the proximal humerus in case 2 and lateral to the distal condyle of the humerus in cases 6 and 9. The wounds were dressed in a rivanol solution 3 times per day for the first 4 days. Then, the dressing application was continued with a mixture of hydrogel and alginate (Nu-Gel; Systagenix and rifamycin sodium (Rif; Koçak Farma). The wound-healing process was observed for 12 to 19 days. During the treatment process, no complications such as fractures, cracks in the fixator, fractures in the pin, or loosening of the system were observed. However, in 1 case (case 1), slight bending of the Schanz pin was detected; however, no intervention was performed as there was no deterioration in the reduction. No abnormal mobility was detected in the clinical examination of the cases after removal of the fixator, and these findings were supported by radiological examination. The patients were kept in the hospital for approximately 1 more week for clinical follow-up and treatment of lesions following removal of the fixator. After the follow-up period, all patients were in good health, and none showed signs of limping.
Discussion
This study aimed to evaluate the treatment of nonunion in different limbs of cats using linear external fixators. Studies2,4,16,21 involving the use of grafts have shown that the treatment success rate varies between 43% and 100%. Cappelleri et al7 reported that antebrachial and crural septic nonunion fractures in 23 dogs were successfully treated in 20 dogs using circular external skeletal fixation, whereas 3 underwent amputation. They also highlighted that they encountered mild complications in 6 dogs and serious complications in 5 dogs. However, Garnoeva et al19 found that the nonunion of a radial fracture in a cat was successfully treated with a type II external fixator. Reviewing the literature suggests that using more stable external fixator systems (such as circular external fixators) is generally recommended for the treatment of nonunion cases.7 In the present study, however, based on the data presented by Garnoeva et al19 and Gülaydin and Alkan,17 preference was given to the use of linear external fixators and intramedullary pin combinations (cases 1, 2, 5, and 9). Overall, the systems provided sufficient stability, and successful treatment outcomes were achieved in the cases included in the study. No severe complications affecting the healing were observed. However, certain limitations, including the small sample size and the use of weight scales, should be carefully considered when interpreting the findings of this study. Approximately 80% of delayed union and nonunion cases in the treatment of human and veterinary fractures develop owing to faults in the surgical technique.11,22 Surgical technical errors may involve the inadequate consideration of rotational and axial stability when using intramedullary pins, inadequate wire size, or use of pins of inappropriate diameter and in the wrong location when using linear external fixators. Errors such as inadequate plate size, poor plate contour, and screw passage in the fracture line were reported when a plate was used.5 In the present study, 3 cases had inadequate plate sizes, and 7 cases had errors in the size and application of intramedullary pins during the first surgical treatment of the patients. Thus, the cause of nonunion in 10 cases was attributed to errors associated with the surgical technique.
The classification of nonunion fractures is important for their treatment. Some studies7,23 have highlighted that biologically active nonunion fractures can heal without debridement when adequate stability is achieved; besides, debridement is necessary for biologically inactive nonunion fractures to initiate the bone healing process.7,23 However, studies4 also state that debridement is required to expose viable bone for each patient. Debridement can be performed using the traditional or en bloc osteotomy techniques.7 Blaser et al5 stated that they preferred en bloc osteotomy for the treatment of oligotrophic and inactive nonunion fractures and it is a simpler technique to remove all fibrous, cartilaginous, and necrotic tissues within the fracture space than the traditional debridement technique. They also stated that this allowed the application of a compression plate to the bone for fracture stability. Cappellari et al7 used the conventional technique for oligotrophic nonunion fractures and en bloc osteotomy for biologically inactive nonunion fractures and reported that the conventional technique was a less invasive treatment option for the healing of 5 oligotrophic nonunion fractures. In this study, debridement was performed using a flat-tipped (scissor-like) rongeur in all cases. This allowed the conversion of a complex nonunion into a bipartite fracture, allowing simple reduction and alignment, as in en bloc osteotomy. Based on these experiences, debridement is necessary and can be effectively performed using a flat-tipped rongeur because feline extremities have a thinner cortical structure than canine extremities.
In terms of biomechanical properties, the circular external skeletal fixator perfectly resists axial and rotational forces at the fracture site, allowing axial micromovements and stimulating bone calcification.24 It is used in nonunion treatment due to its properties.25–27 Moreover, the circular external skeletal fixator facilitates the filling of bone openings with grafts.4 Dogs can tolerate a 10% to 20% loss of limb length.7,28
Based on the literature,19 linear external fixator and intramedullary pin combinations are preferred for treatment. Additionally, bone lengthening was not performed in the cases presented, as there was no shortening greater than 10% after intraoperative debridement. The cats in this study experienced no stability problems related to fixation in the postoperative period, owing to the effect of the pin combinations. Thus, a linear external fixator, which allows for unilateral use and is easier to apply, can be used in similar cases.
Traditionally, the treatment of nonunion requires autogenous cancellous bone graft to fill fracture gaps caused by incompatible reduction and to promote osteogenesis in potential areas of avascular bone at the fracture line.5 Also, the use of bone grafts has potential disadvantages such as infection, increased surgical time, pain, and postoperative bleeding.29 In a previous study,5 en bloc osteotomy was used; thus, fracture gaps were eliminated, and graft was unnecessary. In the same study, in 10 of 11 dogs, complete healing was achieved without cancellous bone grafts, and dogs without grafts recovered faster.5 The current results support the idea that using grafts is not necessary for biologically active nonunions in cats when smooth bone surfaces are developed.
All patients started using the relevant extremities within 1 postoperative week, and their gait gradually improved during the healing process. This finding is consistent with that in the literature.4,5,7,16,19,30 Bone healing was completed at an average of 57.8 days (between days 47 and 71). This was faster or similar to the results reported in other studies.4,5,7,16,19,21,30
Although external fixators are beneficial in fracture treatment, they can cause complications such as fixator-induced pin and wire loosening, breakage, and fracture at the pin insertion level in the postoperative period.17,20,31,32 During the treatment of nonunions, the most important complications are related to the use of grafts.29 During the treatment process, no complications such as fractures, cracks in the fixator, fractures in the pin, or loosening of the system were encountered. However, in 1 case (case 1), slight bending of the Schanz pin was detected, and no intervention was performed as no deterioration in the reduction was observed. In addition, the debridement method used in the current study eliminates the need for a graft, as it provides flat bone surfaces during block osteotomy. This contributes to fewer complications.
Debridement is believed to be important during the treatment of nonunions. According to the data obtained, the linear external fixation system provided adequate stability in the treatment of nonunion in cats and maintained this stability until bone healing was complete. Observations of the healing periods showed that faster or similar times were achieved than in similar cases. This is considered to be due to the advantages of external fixators.
Acknowledgments
None reported.
Disclosures
The authors have nothing to disclose. No AI-assisted technologies were used in the generation of this manuscript.
Funding
The authors have nothing to disclose.
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