Transfixation Casting Research Articles

Modified traveling traction a novel external fixator for provisional stabilization of tibial fractures

External fixators have been used for temporary stabilization as a part of damage control orthopedics. Watson et al in 2000 described “traveling traction”, a simple external fixator for provisional stabilization of pilon fractures. We have tried to analyze the wide applicability of this simple external fixator and its modification (Ez-fix) for provisional stabilization of all tibial fractures: proximal, diaphyseal and distal tibial. This was a 18-month prospective hospital based study in which 91 skeletally mature patients with tibial fractures (proximal, middle, distal 1/3rdand pilon) provisionally stabilized with Ez-fix external fixator application were enrolled. Ez-fix, with one distal femoral/ proximal tibia pin and other calcaneal pin was applied. Posterior splint was given for added stability. The patients were followed up till a definitive fixation or trans-fixation cast was applied. Out of 91 fixators 56 were shaft, 28 proximal and 7 were distal tibial fractures. The average duration in the Ez-fix across all the fracture patterns was 22 days. 71 of the 91 fractures had associated fibula fractures too. 25 Ez-fixes were applied in the ER/ICU. Satisfactory initial reduction in the Ez-fix was achieved in 92% of the proximal, 71% distal and 57% shaft fractures. The place of external fixation did not affect the initial reduction as there were comparable rates of satisfactory reduction in Ez-fixes applied in OT and ER/ICU. There was a significant association between duration and loss of reduction with p-value of

The Effect of Increasing Fracture Site Stiffness on Bone-Pin Interface Stress and Foot Contact Pressure within the Equine Distal Limb Transfixation Cast: A Finite Element Analysis.

The aim of this study was to determine how increasing stiffness of fracture site tissues distal to the pins in an equine distal limb transfixation cast influences stress at the bone-pin interface, within the bones distal to the transcortical pins, and contact pressure between the foot and the cast. A transfixation cast finite element model was used to compare the bone-pin interface stress, pin stress, bone stress distal to the pins and contact pressure between the foot and the cast, using six stiffness values for a composite tissue block representing progressive stages of fracture healing. Increasing stiffness of the composite tissue block resulted in a decrease in the maximum stresses at the bone-pin interface, an increase in stresses distal to the transcortical pins and a decrease in the maximum pin stresses. As the composite tissue block stiffness was increased, contact pressure between the bottom of the composite tissue block and the cast increased and the stress patterns surrounding the pin holes became less focal. The findings of this study illustrate that with good foot to cast contact within a transfixation cast, increases in tissue stiffness due to progressive fracture healing are expected to reduce bone-pin interface stresses, and increase fracture site loading and stress. Increasing the contact pressure between the foot and the cast could reduce transfixation casting complications such as pin loosening, pin hole fracture and poor fracture healing, if these results transfer to ex vivo and in vivo settings.

Finite Element Analysis of Six Transcortical Pin Parameters and Their Effect on Bone-Pin Interface Stresses in the Equine Third Metacarpal Bone.

The objectives of this study were to validate a finite element model of the equine distal limb transfixation cast and to determine the effect of six transcortical pin parameters on bone-pin interface (BPI) stresses in the third metacarpal bone. A transfixation cast finite element model was developed from a computed tomography scan of the third metacarpal bone and modelled pin elements. The model was validated by comparing strain measured around a 6.3-mm transfixation pin in the third metacarpal bone with the finite element model. The pin parameters of diameter, number, location, spacing, orientation and material were evaluated by comparing a variety of pin configurations within the model. Pin diameter and number had the greatest impact on BPI stress. Increasing the diameter and number of pins resulted in lower BPI stresses. Diaphyseal pin location and stainless-steel pins had lower BPI stresses than metaphyseal location and titanium alloy pins, respectively. Offset pin orientation and pin spacing had minimal impact on BPI stresses during axial loading. The results provide evidence that diameter and number are the main pin parameters affecting BPI stress in an equine distal limb transfixation cast. Configurations of various pin size and number may be proposed to reduce BPI stresses and minimize the risk of pin related complications. Further refinement of these models will be required to optimize pin configurations to account for pin hole size and its impact on overall bone strength.

Long‐term outcome of treatment of a squamous cell carcinoma of the foot by amputation of the distal limb in a pony

SummaryThis report describes a rare case of squamous cell carcinoma (SCC) in a 10‐year‐old Shetland pony. The pony was presented for evaluation of a chronic, ulcerating mass of the foot associated with a nonweightbearing lameness of the right forelimb. Foot radiographs revealed an aggressive bone lesion with severe osteolysis of the distal phalanx. Amputation of the digit was performed under general anaesthesia at the level of the metacarpophalangeal joint using a palmar flap technique and a transfixation cast for protection of the stump. Avascular necrosis, infection and dehiscence of the stump occurred 3 weeks later and a second amputation was performed at the level of the proximal third of the third metacarpal bone. Histopathology revealed a squamous cell carcinoma. After healing of the stump, a prosthesis was fitted to the limb for improved ambulation of the pony. Two years after the amputation, telephone follow‐up with the referring veterinarian and the owner, revealed that the pony was healthy and able to go out daily in a paddock with its prosthesis. SCC represents an unusual indication for limb amputation. Successful outcome is rarely reported in horses.

Use of a modified transfixation pin cast for treatment of comminuted phalangeal fractures in horses

To (1) report a modified transfixation pin cast technique, using dorsal recumbency for fracture reduction, distal positioning of the pins in the epiphysis and distal metaphysis, and a hybrid cast, combining plaster of Paris (POP) and fiberglass casting, and (2) report outcome in 11 adult horses. Case series. Adult horses (n = 11) with comminuted phalangeal fractures. Horses were anesthetized and positioned in dorsal recumbency. The phalangeal fracture was reduced by limb traction using a cable attached to the hoof. Screw fixation in lag fashion of fracture fragments was performed when possible. Transfixation casting was performed using two 6.3 mm positive profile centrally threaded pins with the 1st pin placed in the epiphysis of the metacarpus/tarsus at the center of, or slightly proximal to, the condylar fossa and the 2nd one 3-4 cm proximal. A hybrid cast was applied. Forelimbs were involved in 9 horses and the hind limb in 2. Pins were maintained for a minimum of 6 weeks. No pin loosening was observed at the time of removal (6-8 weeks). A pony fractured the distal aspect of the metacarpus at the proximal pin. Nine horses survived (82%); none of the horses developed septic arthritis despite the distal location of the distal pin, close to the fetlock joint. This modified transfixation pin casting technique was associated with good pin longevity and could reduce the risk of secondary pin hole fractures and pin loosening.

Comparison of hydroxyapatite-coated and uncoated pins for transfixation casting in horses

To determine the extent to which a hydroxyapatite coating promotes pin stability in the third metacarpal bone during transfixation casting in horses. 14 adult horses. 7 horses each were assigned to either an uncoated or hydroxyapatite-coated pin group. Three transcortical pins were placed in the third metacarpal bone of each horse and incorporated into a cast for 8 weeks. Insertion and extraction torque were measured, and torque reduction was calculated. Radiography was performed at 0, 4, and 8 weeks. Lameness evaluation was performed at 2, 4, 6, and 8 weeks. Bacteriologic culture of pins and pin holes was performed at pin removal. All horses used casts without major complication throughout the study. Insertion torque was higher in uncoated pins. There was no effect of group on extraction torque. Hydroxyapatite-coated pins had lower torque reduction. Five of 15 hydroxyapatite-coated pins maintained or increased stability, whereas all uncoated pins loosened. Pin hole radiolucency, lameness grades, and positive bacteriologic culture rates were not different between groups. Hydroxyapatite coating increased pin stability within the third metacarpal bone of horses during 8 weeks of transfixation casting but did not improve pin performance on clinical assessments. Clinical use of hydroxyapatite-coated transfixation pins may result in greater pin stability; however, further research is necessary to improve the consistency of pin osteointegration and elucidate whether clinical benefits will ultimately result from this approach in horses.

Transfixation cast technique for arthrodesis of the distal interphalangeal joint of horses

Surgical arthrodesis of the distal interphalangeal (DIP) joint by transfixation casting was used to salvage a three-year-old filly and a yearling filly that were chronically lame because of infection of the DIP joint for breeding. Unlike previously described techniques for arthrodesis of the DIP joint, the technique used did not require insertion of implants across the joint, which may have contributed to the successful outcome.

Facilitated ankylosis of a juvenile, flexurally deformed, open, luxated and infected metacarpophalangeal joint using an alternative approach

SummaryA 4‐day‐old Arabian filly was referred for severe lameness due to a flexurally deformed, open, luxated and infected metacarpophalangeal joint. Arthrodesis was indicated as progressive cartilage destruction and osteomyelitis developed. An alternative arthrodesis technique was employed, which consisted of a loop of cerclage wire running through predrilled holes in a lateromedial direction and dorsal to the central axis of the third metacarpal bone and proximal phalanx, in combination with external coaptation using a half‐limb transfixation cast. Ankylosis was radiographically confirmed after 4 weeks. The foal was discharged from the hospital with a grade 1 out of 5 lameness and a 6–7° valgus deviation of the ankylosed metacarpophalangeal joint. At telephone follow‐up after 18 months, the owner reported persistence of the valgus deviation, soundness at walk, and a slight gait irregularity at trot. The described cerclage wire arthrodesis technique is a relatively simple method for attaining ankylosis that could be considered in similar cases.

A singular case of traumatic total hoof capsule avulsion

SummaryTotal, full thickness hoof wall avulsion is rare in horses. Sometimes complications such as fracture of the distal phalanx, osteomyelitis, septic arthritis and degenerative joint disease have been reported. Limiting motion at the affected site and hoof stabilisation are essential to obtain a good hoof regeneration.This case report reviews the clinical features including diagnostic techniques (radiographic examination and venography) of a Quarter Horse filly presented with a complete and full‐thickness traumatic hoof capsule avulsion complicated by an open fracture of the third phalanx. A transfixation casting technique was performed followed after one month by 2 short limb casts applied for 2 months each. Twenty‐four months after trauma the foot had completely regrown. The dorsal aspect of the hoof wall appears to be remarkably shorter compared to the heels. From a radiographic viewpoint, the lateral aspect of the left hind foot shows diffuse bone remodelling and a deformed distal phalanx.

Evaluation of transfixation casting for treatment of third metacarpal, third metatarsal, and phalangeal fractures in horses: 37 cases (1994–2004)

To evaluate clinical findings, complications, and outcome of horses and foals with third metacarpal, third metatarsal, or phalangeal fractures that were treated with transfixation casting. Retrospective case series. Animals-29 adult horses and 8 foals with fractures of the third metacarpal or metatarsal bone or the proximal or middle phalanx. Medical records were reviewed, and follow-up information was obtained. Data were analyzed by use of logistic regression models for survival, fracture healing, return to intended use, pin loosening, pin hole lysis, and complications associated with pins. In 27 of 35 (77%) horses, the fracture healed and the horse survived, including 10 of 15 third metacarpal or metatarsal bone fractures, 11 of 12 proximal phalanx fractures, and 6 of 8 middle phalanx fractures. Four adult horses sustained a fracture through a pin hole. One horse sustained a pathologic unicortical fracture secondary to a pin hole infec-tion. Increasing body weight, fracture involving 2 joints, nondiaphyseal fracture location, and increasing duration until radiographic union were associated with horses not returning to their intended use. After adjusting for body weight, pin loosening was associated with di-aphyseal pin location, pin hole lysis was associated with number of days with a transfixation cast, and pin complications were associated with hand insertion of pins. Results indicated that transfixation casting can be successful in managing fractures distal to the carpus or tarsus in horses. This technique is most suitable for comminuted fractures of the proximal phalanx but can be used for third metacarpal, third metatarsal, or middle phalanx fractures, with or without internal fixation.

Treatment of long bone fractures in South American camelids: 5 cases

An adult llama and four alpacas were referred with long bone fractures. The llama presented with a closed, comminuted fracture of the right metatarsal bones. Two of the alpacas presented with comminuted fractures of the proximal radius. One fracture was closed and one was open. One alpaca had a closed, comminuted fracture of the distal radius, and the final alpaca had a closed, oblique fracture of the metatarsus. A diagnosis was made in each animal on the basis of clinical examination and radiographs. All fractures were managed by open reduction and internal fixation using selective placement of lag screws and dynamic compression plates. Four animals made uneventful recoveries and no long-term complications were encountered. One alpaca was re-admitted for plate failure and non-union of the fracture 5 weeks after surgery. The plate and screws were removed and a transfixation cast was applied. The fracture healed, however the alpaca showed signs of radial nerve paralysis after the cast was removed. With confinement in a small yard, full function gradually returned to the leg over the ensuing 4 months. Using techniques recommended in other species, South American camelids are suitable candidates for long bone fracture repair using open reduction and internal fixation.

Facilitated ankylosis of the distal interphalangeal joint in a foal

A 3-month-old Quarter Horse colt sustained a penetrating injury over the coronary band on the right forelimb resulting in an articular bone sequestrum and septic arthritis of the distal interphalangeal joint. Despite aggressive treatment for septic arthritis, severe osteoarthritis and ongoing sepsis resulted in persistent lameness. Facilitated ankylosis of the distal interphalangeal joint was performed using a combination of open surgical debridement, placement of an autogenous cancellous bone graft and stabilisation within a transfixation cast. Bony ankylosis of the joint was observed radiographically 7 weeks following surgery. Evaluation of the horse 30 months following surgery revealed complete fusion of the middle and distal phalanges, and the distal sesamoid bone. The horse is pasture sound and is used as a breeding stallion. This report describes the surgical approach and case management employed to achieve facilitated ankylosis as a treatment for unresolved septic arthritis of the distal interphalangeal joint. This is the first report of successful facilitated ankylosis of the distal interphalangeal joint in a foal.

In vitro comparison of transfixation and standard full-limb casts for prevention of displacement of a mid-diaphyseal third metacarpal osteotomy site in horses

To compare transfixation and standard full-limb casts for prevention of in vitro displacement of a mid-diaphyseal third metacarpal osteotomy site in horses. 6 forelimbs from 6 horses euthanatized for reasons not related to the musculoskeletal system. A 30 degrees osteotomy was performed in the mid-diaphysis of the third metacarpal bone. Two 4.5-mm cortical bone screws were placed across the osteotomy site to maintain alignment during casting. Two 6.35-mm Steinmann pins were placed from a lateral-to-medial direction in the distal aspect of the radius. A full-limb cast that incorporated the pins was applied. An extensometer was positioned in the osteotomy site through a window placed in the dorsal aspect of the cast, and after removal of the screws, displacement was recorded while the limb was axially loaded to 5,340 N (1,200 lb). Pins were removed, and the standard full-limb cast was tested in a similar fashion. The transfixation cast significantly reduced displacement across the osteotomy site at 445 N (100 lb), 1,112 N (250 lb), 2,224 N (500 lb), and 4,448 N (1,000 lb), compared with the standard cast. A full-limb transfixation cast provides significantly greater resistance than a standard full-limb cast against axial collapse of a mid-diaphyseal third metacarpal osteotomy site when the bone is placed under axial compression. Placement of full-limb transfixation casts should be considered for the management of unstable fractures of the third metacarpal bone in horses.

In vitro evaluation of four methods of attaching transfixation pins into a fiberglass cast for use in horses

Abstract Objective To compare the axial stability provided by 4 methods of attaching transfixation pins into a fiberglass cast. Design Axial stability of 4 methods of transfixation pin attachment to a fiberglass cast cylinder was determined in vitro. Methods of attachment included simple incorporation of the pins into the cast, placement of a washer and nut on the pin and incorporation into the cast, extension of pins beyond the cast and attachment to a steel halo, and washers within the cast and attachment to a steel halo. Population A model was designed to simulate a transfixation cast applied to the equine metacarpus. 8 identical constructs were present in each of the 4 groups. 6 fiberglass cylinders were also tested to identify the contribution of the cast cylinder to the overall stability of the transfixation cast. Procedure Load-displacement curves were recorded, and a stiffness modulus was calculated for each treatment group and for a simple fiberglass cylinder without transfixation pins. Result and Conclusion There was no significant difference among the 4 methods of attachment. The fiberglass cast material appears to be the major determinant of axial stability. (Am J Vet Res 1996;57:1098–1101)

In vitro comparison of the standard short limb cast and three configurations of short limb transfixation casts in equine forelimbs

Summary Axial stability of equine oblique proximal phalangeal osteotomies with application of the standard short limb cast or 1 of 3 configurations of transfixation casts was determined in vitro. Transfixation cast methods included use of parallel pins, divergent pins, or parallel pins incorporating a metal walking bar. Displacement at the osteotomy was recorded for each limb at 4,448 N. Standard short limb casts provided significantly (P = 0.0002) less axial stability than did any form of transfixation cast. Significant differences were not found between the 3 transfixation casts.