Bone Plating in Patients with Type III Osteogenesis Imperfecta: Results and Complications

William J Enright, MD and Kenneth J Noonan, MD

Abstract
The results of bone plating in four children (6 femurs, 2 tibias) with osteogenesis imperfecta type III were analyzed. Average age at time of operation was 44 months. In three of the femurs, multiple platings were performed for a total of 13 bone platings in the eight bones studied. Average time to revision following plating was 27 months. Indications for revision included fracture (6), deformity (3), hardware failure (3), and nonunion (1). Other complications included one case of compartment syndrome. All eight bones were ultimately revised to elongating intramedullary Bailey-Dubow rods. Bone plating in skeletally immature patients with osteogenesis imperfecta does not provide better outcome than elongating rods. Complications from bone plating leading to revision, such as refracture or hardware failure, are higher than in those children managed with elongating rods, as previously reported in the literature.

INTRODUCTION Osteogenesis imperfecta (OI) is a group of inherited disorders caused by defective type I collagen synthesis. Using the Sillence classification, one can determine the type of OI based on clinical, radiographic, and genetic findings.13 Patients with OI can suffer from frequent fractures and deformity of the long bones during development, resulting in impaired ambulation. The goal of orthopedic surgery for OI is twofold: Reduce the incidence of fractures and correct long bone deformity. Contemporary surgical options for deformed bones in OI include osteotomy and stabilization with non-elongating nails (Rush rods, flexible nails), elongating nails (Bailey- Dubow, Frasier-Duval), and bone plating.14,7,8,10,14,15 Elongating rods allow for growth of the bone, thereby decreasing the number of repeat operations. The advantages of elongating rods over fixed intramedullary rods include benefit to growing bones, lower incidence of re-fracture, and longer time to reoperation.4,5,11,12 There is also evidence that suggests that elongating rods used in the femur do not require revision as often as those placed in the tibia.16
At our institution, we have utilized plate fixation for stabilization of osteotomies in young patients with severe OI. Plate fixation was initially appealing in this group of patients given the age of the individuals and the difficulty of placing expandable rods in small bones. In addition, the treating surgeon felt that these rods were too large for the smallest children, thus resulting in stress shielding and bone atrophy. The purpose of this study is to review our experience in this small but select group of patients.
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MATERIALS AND METHODS

This study is a retrospective review of all patients with osteogenesis type III treated with bone plating for correction of deformity or treatment of fracture. All operations were performed by the same pediatric orthopedic surgeon between 1994 and 2001. Inclusion criteria for this study were a diagnosis of type III osteogenesis imperfecta, history of bone plating, and recent clinical follow-up. After review of the medical files of all patients treated for osteogenesis imperfecta at the University of Wisconsin Hospital and Clinics, we were able to find four patients who had undergone at least one bone plating as treatment for fracture or deformity. Clinical records and imaging studies were reviewed. We recorded the indications for initial plating, types of plates and screws used, time to evidence of healing on radiograph, time to revision, indications for revisions, hardware used in revision (plate or rod), number and location of fractures

following each plating, complications including hardware failure, and number of revisions for each bone. Regarding the measurement of time to fracture and time to revision, the authors considered each plating separately. There were cases of sequential platings of the same bone in patients where initial plating was revised with further plating. Initial plating was considered as the start point for this study, and revision with expandable rods was considered the end point.
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RESULTS All four patients were diagnosed with osteogenesis type III using the Sillence classification. 13 There were three males and one female, ranging in age from 14 to 82 months (44.7 months mean age) at the time of surgery. Ages ranged from five to eight years (7.7 years mean age) at last follow-up. The average time from initial plating to final follow-up period was four years.
Thirteen bone platings were performed on eight bones. The eight bones included six femurs and two tibias. Three of the femurs underwent multiple platings before being ultimately revised to Bailey-Dubow rods. Of these three femurs, two were plated twice, and one femur was plated four times for a total of 13 platings. All platings were separate operations. No two bones were plated at the same time. The indications for initial plating of the eight bones included fracture and deformity. Of the six femurs, four were plated because of fracture, and two were plated for correction of deformity. Of the two tibias, one was plated for correction of deformity and the other because of fracture. All eight bones ultimately required revision. Three of the femurs underwent further plating for revision, while the two tibias and three other femurs were revised to Bailey-Dubow rods. Indications for revision included fracture (6), deformity (3), hardware failure (3), and nonunion (1). Rate of fracture following plating was 46% (six fractures). Location of fracture was distal to the plate in two cases, under the plate in two cases, and through the plate in two cases. In the two cases of fracture through the plate, fracture of bone with broken plate was considered the reason for revision and also considered a complication (Figures 1 and and2).2). The average time to revision was 27 months (range 4 to 71 months). The average time from initial plating to final revision with Bailey-Dubow rods was 42 months (range 9 to 89 months) for all bones.

Figure 2

Radiograph showing screw pull-out. Note the proximal and distal cancellous screws have pulled out, allowing the plate to displace from the bone and leading to hardware prominence. The complication rate in these patients was 69.2% (9 plates). The most common complication following plating was screw pull-out. Screw pull-out was seen following plating in five cases. One case involved multiple screws and required revision for stabilization. Two fractures through the plate were seen, and these underwent revision. Bending of two of the plates was observed. Of these nine complications, three instances of hardware failure led to revision: Screw pull-out required revision in one case, and two fractures went through the plate as mentioned above. Complications are listed in Table 1.

TABLE 1

There was one case of compartment syndrome following plating of a tibia, which required fasciotomy. There was one case of nonunion in a femur. This nonunion was noted five months after the initial plating and was revised with bone plating seven months after the initial operation. There were three instances of prominent hardware, one of which was symptomatic.
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DISCUSSION Bone plating is an option in the treatment of fracture and deformity in children with osteogenesis imperfecta. Previous studies in the orthopedic literature report treatment of these patients with intramedullary rods, both fixed and elongating. The benefits of elongating rods over fixed rods have been demonstrated in regard to reduction in the number of operations performed and facilitation of growth.4,5,12 There are no studies, however, examining the results of bone plating in comparison to the results obtained with elongating intramedullary rods.

The purpose of this study was to examine the results of bone plating in patients with osteogenesis imperfecta. Average time to revision following plating was 27 months. This compares quite unfavorably with the five years to revision following placement of Bailey-Dubow rods reported by Luhmann et al.9 It compares more favorably with the average time to revision of 2.5 years following placement of non-elongating rods reported by Marafioti and Westin.10 The most common indication for revision following plating was fracture (6), followed by deformity (3) and hardware failure (3). The complication rate of plating was 69.2%. This rate was slightly higher than the 63.5% complication rate previously reported by Jerosch et al. and significantly higher than the 27% complication rate reported by Marafioti and Westin in their treatment of patients with OI.6,10 Jerosch et al. implanted Bailey-Dubow rods in 107 bones and Kirschner wires in eight bones.6 In their study, the Kirschner wires were implemented because of small bone diameter. The most common complication of Bailey-Dubow rods has been reported to be rod migration.6,7 The most common complication seen after plating was screw pull-out. This seems intuitive given the quality of bone in patients with osteogenesis imperfecta. Not only does the bone quality not allow for purchase of the screws, the bowing of bones may act to further any screw pull-out. Screw pull-out was not a clinical problem in this series unless it was associated with increasing deformity or fracture. The treatment plan for skeletally immature patients with osteogenesis imperfecta must include consideration of growth. The advantage of the elongating rod is that it allows for longitudinal bone growth. The rod does cross the physis, but the diameter of the rod is small enough not to affect growth.2Bone plating does not disturb the physis in most cases, but it does not migrate with growth, thus leaving unsupported bone. Higher revision and failure rates in the bone adjacent to the plate are also most likely due to the sharp disparity in construct rigidity and osteopenic metaphyseal bone. Considering the higher complication rates, shorter length of time to revision, and unknown effect on longitudinal growth, bone plating does not compare favorably to elongating rods in patients with osteogenesis imperfecta. We recommend elongating rods when considering treatment of deformity or fracture in patients with osteogenesis imperfecta.
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Footnotes
Study conducted at University of Wisconsin Hospital and Clinics, Madison, WI Go to:

References 1. Bailey RW. Studies of longitudinal bone growth resulting in an extensible nail. Surg Forum.1963;14:455 458. [PubMed]
2. Bailey RW. Further clinical experience with the extensible nail. Clin Orthop. 1981;159:171176.[PubMed] 3. Bailey RW, Dubow HI. Evolution of. the concept of an extensible nail accommodating to normal longitudinal bone growth: clinical considerations and implications. Clin Orthop. 1981;159:157170.[PubMed] 4. Gamble JG, Strudwick WJ, Rinsky LA, Bleck EE. Complications of intramedullary rods in osteogenesis imperfecta: Bailey-Dubow rods versus nonelongating rods. J Pediatric Ortho.1988;8(6):645649. 5. Harrison WJ, Rankin KC. Osteogenesis imperfecta in Zimbabwe: a comparison between treatment with intramedullary rods of fixed-length and self-expanding rods. J Royal College Surg Edinburgh.1998;43(5):328 332. 6. Jerosch J, Mazzotti I, Tomasevic M. Complications after treatment of patients with osteogenesis imperfecta with a Bailey-Dubow rod. Archives Ortho & Trauma Surg. 1998;117(4-5):240245.

7. Lang-Stevenson AI, Sharrard WJ. Intramedullary rodding with Bailey-Dubow extensible rods in osteogenesis imperfecta: an interim report of results and complications. J Bone Joint Surg Br. 1984;66-B(2):227 232. [PubMed] 8. Li YH, Chow W, Leong JC. The Sofield-Millar operation in osteogenesis imperfecta: a modified technique. J Bone Joint Surg Br. 2000;82-B(1):1116. [PubMed] 9. Luhmann SJ, Sheridan JJ, Capelli AM, Schoenecker PL. Management of lower extremity deformities in osteogenesis imperfecta with extensible intramedullary rod technique: a 20-year experience. J Pediatric Ortho. 1998;18(1):8894. 10. Marafioti RL, Westin GW. Elongating intramedullary rods in the treatment of osteogenesis imperfecta. J Bone Joint Surg Am. 1977;59A(4):467472. [PubMed] 11. Mulpuri K, Joseph B. Intramedullary rodding in osteogenesis imperfecta. J Pediatric Ortho.2000;20(2):267273. 12. Porat S, Heller E, Seidman DS, Meyer S. Functional results of operation in osteogenesis imperfecta: elongating and nonelongating rods. J Pediatric Ortho. 1991;11(2):200203. 13. Sillence D. Osteogenesis imperfecta: an expanding panorama of variants. Clin Orthop. 1982;159:11 25. [PubMed] 14. Sofield HA, Millar EA. Fragmentation, realignment, and intramedullary rod fixation of deformities of the long bones in children. J Bone Joint Surg. 1959;41A:1371. 15. Stockley I, Bell MJ, Sharrard WJ. The role of expanding intramedullary rods in osteogenesis imperfecta. J Bone Joint Surg Br. 1989;71-B(3):422427. [PubMed] 16. Zionts LE, Ebramzadeh E, Stott NS. Complications in the use of the Bailey-Dubow extensible nail.Clin Orthop. 1998;348:186195. [PubMed]

Management Of Femur Fractures With Self-Made Polymethylmethacrylate Plates, Stainless Steel Plates, Intra-Medullar Pins And Interlocking Nails In Dogs

P. Mukherjee1, D. Ghosh1, S. Roy1 and S. Basu2 West Bengal University of Animal and Fishery Sciences, 37, K. B. Sarani, Kolkata-700 037, India. 1. Department of Veterinary Surgery & Radiology. 2 Department of Veterinary Gynaecology and Obstetrics. Corresponding author Dr. Prasenjit Mukherjee Senior Research Fellow Department of Veterinary Surgery and Radiology West Bengal University of Animal and Fishery Sciences, Kolkata- 700 037, India.

SUMMARY

This is a retrospective study of 24 femur diaphyseal transverse fractures stabilized with intra-medullar pinning, steel bone plating, fabricated polymethylmethacrylate (PMMA) plates and intra-medullar interlocking nailing (ILN). Four groups, each including 6 animals, were followed-up for 9 weeks in the perspective of postoperative complications and fracture healing. Routine physical examinations assessed limb function, joint involvement and condition of the operative site. Serum calcium and phosphorus showed no significant change. Full limb function was obtained quicker using fabricated PMMA plates, followed, in the order, by ILN, steel bone plating and intra-medullar pinning. Fabricated PMMA and steel bone plates showed earlier radiographic disappearance of fracture lines and earlier formation of direct bridging callus. The use of fabricated PMMA plates showed promising results for the management of the femur transverse fracture in dogs considering the advantages of lower cost, easy fabrication and actual adaptation to the specific contour of the bone.

Key Words: Bone Plating, Canine, Femur Fracture, Intra-Medullar Interlocking Nailing, Intra-Medullar Pinning, Polymethylmethacrylate Plate.

INTRODUCTION

Among the long bones, the incidence of femur fractures is highest (45.87%) (Gahold et al, 2002) mostly seen in diaphysis and distal metaphysis (Roy et al, 2005). Internal fixation provides mechanical stability to a fractured bone, allowing weight bearing, early use of the limb and rapid healing. The selection of internal fixation is based on mechanical, biologic and clinical parameters associated with each patient and fracture, not just the fracture pattern itself (Aron et al, 1995). Intra-medullar pinning is most widely used because provides axial alignment and resists bending forces but not the shear and rotational forces (Vasseur et al, 1984). Less surgical exposure and dissection is needed to place intra-medullar interlocking nails compared to placement of bone plates. Therefore, the use of intra-medullar interlocking nail may result in preservation of more periosteal vascularity (Heitemeyer et al, 1990), promoting biological osteosynthesis (Reems et al, 2003). Bone plating resists tension, compression, shearing and rotational forces, and depending upon their placement resist bending forces. However, it is a more traumatic procedure (Stiffler, 2004), and demands extreme professional skills to achieve dynamic compression. The present study was carried out to assess the feasibility of using bone plates which contributes to dynamic compression but devoid of some complications like accurate proficiency in contouring plate with bone interface, as well as easy affordability. To this purpose we adopted an extremely versatile thermoplastic polymeric material, polymethylmethacrylate (PMMA), firstly introduced by Charnley (1960), used for decades as "filler" material in total-hip insertion and recently for internal fracture-fixation plates, to more evenly distribute forces over the plate-bone interface, thereby combating premature plate failure (Moursi et al, 2002).

MATERIAL AND METHODS

Aims To evaluate the efficacy of fabricated polymethylmethacrylate (PMMA) plating as a method of internal fixation in canine diaphyseal femur fractures and to compare it with ILN, intra-medullar pinning and steel plating in view of bone healing and complications. Study design The study was conducted on twenty four (24) clinical cases of femur diaphyseal transverse fractures in dogs between the age group 2-5 years of either sex. The cases were randomly divided in to four groups and treated with four internal fixation devices (Gr. AIntramedullary pinning; Gr. B- Bone Plating; Gr. C- Bone plating with fabricated PMMA plates and Gr. D- Intramedullary Interlocking nailing) comprising six animals in each group. Each animal of different groups were subjected to physical (condition of the operative site, assessment of full limb function, affection of joint as per the method described by Branden and Brinker, 1973) (Table I) and radiological examinations (14 mAs; 50Kvp and 90 cm FFD) throughout the study period. The decision for adopting any one of the internal fixation technique following the standard procedures (DeYoung and Probst, 1985; Conzemius and Swainson, 1999 and Raghunath and Singh, 2002) was randomly adopted.

Fabrication of polymethylmethacrylate (PMMA) bone plate For fabrication of PMMA plates of appropriate thickness, two parts polymer of methylmethacrylate powder was mixed with one part of liquid monomer methylmethacrylate . Different sizes of femur from canine cadaver of different body weights were taken as negative cast. Then the PMMA was applied over the lateral side of the femur to achieve 6-8 mm thickness and kept till drying as a cast. The plates then were removed and grounded with sand paper into desired shape and finish and drilled with 3.5 mm drill bit to make six hole plates of different sizes (Fig. 1). Sterilization of fabricated plate was achieved by autoclaving. At the time of surgical intervention, different plates were taken corresponding to the size and body weight similar to patient under the study.

Table: I. Clinical evaluation of functional limb usage Grade Limb use description Nonuse Definition

No functional use of the limb; carries the limb most of the time. Some functional use; will set limb down to stand or walk; carries limb when running; does not bear weight on limb. Functional use of limb; partial weight bearing. Full function for standing, walking, running; full weight bearing.

II

Slight use

III

Limp

IV

Normal

Anaesthesia preoperative preparation and surgical procedure The dogs were pre-anaesthetized with subcutaneous injection of atropine sulphate @ 0.04 mg/kg body weight 15 minutes before the administration of injection xylazine hydrochloride @ 1 mg/kg body weight intramuscularly. After proper sedation, the dogs were placed to the operation table and operation was performed with intraoperative administration of injection ketamine hydrochloride @10 mg/ kg body weight and injection diazepam @ 0.5 mg/ kg body weight intravenously for maintenance of anaesthesia. Preoperatively, operative site was aseptically prepared with routine application of antiseptic solution, scrubbing and painting. Anesthesia was performed using atropine sulphate (0.04 mg/kg), xylazine hydrochloride (1 mg/kg), ketamine hydrochloride (10 mg/ kg) and diazepam (0.5 mg/ kg). The decision for adopting any one of the internal fixation technique following the standard procedures (DeYoung and Probst, 1985; Conzemius and Swainson, 1999 and Raghunath and Singh, 2002) was randomly adopted. Postoperative care Robert-Jones bandage was applied in all the cases postoperatively for 3 days to alleviate movement and the soft tissue swelling. Animals were intramuscularly administered with injection ceftriaxone @ 10 mg/ kg body weight for 7 days and injection meloxicam @ 0.3 mg/kg body weight for 3 days. Post operative dressing was carried out on 3rd, 5th and 7th day and as and when required. Removal of cutaneous sutures was done after complete healing of the wound in 10th postoperative day. The movements of the animals were restricted over the post operative period for 7-10 days. Implants were kept in situ over the entire study period. Statistical analysis The data were analyzed statistically by general linear model with univariate data by Tukey HSD multiple comparison test (Tukey, 1953) using SPSS 10.0 version for windows.

RESULTS

The anaesthetic regimen provided adequate anaesthesia. None of the animals showed untoward complication due to anesthesia and operative procedures.

Physical examination Postoperative physical examination showed marked soft tissue swelling mostly up to 1st week of operation and in some cases extent of swelling persisted little bit more i.e. up to 2nd week in the animals of all four groups. The postoperative results of limb function viz. range of motion of stifle joint and full functional limb usage have been shown in Table II and III. The clinical evaluation of functional limb usage showed a remarkable difference amongst the study groups being earliest in Gr. C.

Table: II. Results of limb function and Range of Motion of the Stifle Joint (ROMSJ)

1st week Gr. A (n= 6) Grade- I: (n=6)

3rd week Grade- II: (n=6)

5th week Grade- II: (n=4) III: (n=2) Grade- II: (n=1) III: (n=5)

7th week Grade- III: (n=6)

9th week Grade- III: (n=4) IV: (n=2) Grade- II: (n= 1) IV: (n= 5)

ROMSJ A5 week: (n=6)

Gr. B (n= 6)

Grade- I: (n=6) Grade- II: (n=2) III: (n=4)

Grade- II: (n=1) IV: (n=5)

A7 week: (n=1)

Gr. C (n= 6)

Grade- I: (n=5) II: (n=1) Grade- I: (n=6)

Grade- II: (n=1) III: (n= 5) Grade- II: (n=1) III: (n=5)

Grade- III: (n=4) IV: (n=2) Grade- II: (n=1) III: (n=4) IV: (n=1)

Grade- IV: (n=6)

Grade- IV: (n=6)

Gr. D (n= 6)

Grade- II: (n=1) IV: (n=5)

Grade- II: (n= 1) IV: (n= 5)

A7 week: (n=1) A9 week: (n=2

A= ankylosis, N=normal, ROMSJ= range of motion of stifle join

Table: III. Mean S.E. of achievement of Grade IV (full functional) limb usage in days Groups Days Gr. A 63.00 0.00 Gr. B 49.00 0.00 Gr. C 44.33 2.95 Gr. D 46.20 2.80 Radiographic findings Radiographically, fabricated polymethylmethacrylate plated animals showed early disappearance of fracture line and formation of direct bridging callus, whereas in intramedullary pinning, animals exhibited formation of excess external callus and more remodeling time. In intramedullary interlocking nailing, though did not show appreciably noticeable excess external callus formation, they took more remodeling time than steel bone plating and fabricated polymethylmethacrylate plating but lesser than intramedullary pinning. The 9th week post operative diagram of femur fracture of dog managed with intramedullary pin showed no radiographic signs of soft tissue swelling, pin migration or distortion. The radiodensity of the callus at the fracture side was uniform to that of cortical bone, suggesting maturation and remodeling. The medullary cavity was noticed reestablished in proximal and distal fragments of the fracture except at the site of union, which still represented the presence of dense callus packing the medullary canal. The remodeling was yet to be completed though, process found to be in advance stage as evidenced by irregularly arranged hypo dense callus at the periphery of the union site (Figure 2). The end stage radiograph at the 9th week of fracture immobilization in group -B, showed intact radiodense stainless steel plate and screws. The fracture gap was completely obliterated and remodeled imparting uniformity in radiographic features to that of proximal and distal bone fragments. The thickness of cortex at the union site was similar to that of normal in transcortical site (Figure 3). After the 9th week of fracture treatment with PMMA plate the radiograph showed presence of plate and all screws in situ without any materialistic abnormalities. The medullary cavity was established with uniformity of diameter throughout the length of bone. The remodeling was completed which was evidenced by

absence of extra callus in the exterior or interior of the cortex at the junctional zone (Figure 4). After 9 weeks of fracture immobilization with ILN in the radiograph, fracture was found completely obliterated with organized callus. The nail and screws were found intact without any distortion, bending or breakage. The medullary canal looked uniform in diameter even at the junctional site to that of proximal and distal fragments (Figure 5).

DISCUSSION

Formation of pre-molded PMMA concave plate was very convenient without much difficulty due to its some inherent biomechanical properties like noncorrosiveness and nonabsorption or degradation of the material within the system (Vcsei and Starlinger, 1982). Marked soft tissue swelling during 1st postoperative week, irrespective of the groups, was due either to the preoperative trauma by the bone fragments and severity of the soft tissue injury during surgery. In group C and B the more duration of perceptible soft tissue swelling was due to more injury inflicted upon the tissue at the time of surgery. Moreover, more number of screw tips which crossed the transcortex might had also resulted more sustained trauma to the muscle mass in comparison to other two groups, where either no screw or less numbers of screws were used. The early ambulation of the affected limbs in the animals treated with PMMA plate in group C, followed by group D (ILN), B (steel plate) and A (intramedullary pinning) were also suggestive of quality of healing in those group in a same order as, weight bearing is considered to be one of the most important gross observable parameter for assessing the quality of fracture healing (Hutzschenreuter et al, 1969). The animals of group A treated with intramedullary pinning showed nonuse of limb for a longer duration (table-II). might have resulted due to the painful swelling of the operated limb which improved in course of time. The more duration of nonuse of the limb by the same animals might be due to incomplete neutralization of the forces as the rotational forces never are neutralized as a result of which slight rotational instability persisted in early phase of fracture healing. Similar to the animals of group A, the femur fracture of dogs immobilized with steel bone plate in group B also showed nonuse of the affected limb during the 1st week of operation which might be due to the inflammatory reaction of tissue at the site. The observation of grade-II and grade-III limb use on 3rd week as well as full functional limb use on 7th week of fracture immobilization indicated the positive correlation of better fracture immobilization and fracture healing with limb use. The use of bone plate for internal immobilization results to rigid fixation, resisting tension, compression, shearing and rotational forces (Stiffler, 2004). The use of PMMA plate for internal fixation of fracture is comparatively a newer concept with variable success (Kallmes and Jensen, 2003). The postoperative physical finding after using PMMA plates for management of femur fracture in the present study should be graded as promising as, such treated dog showed early ambulation, weight bearing and uneventful recovery which obviously might had resulted from optimum rigid fixation and qualitative fracture healing. Femur fractures were treated with interlocking nail as internal fixation device also showed grade- I limb function in first week which suggested the similar grade of tissue trauma to other groups while the surgical intervention was undertaken for fixing the internal fixation device. Subsequently, the dogs showed better grades of limb ambulation which reached to its best i.e. gradeIV, earliest at 5th to 7th postoperative weeks. Intramedullary pinning in long bone in animals undoubtedly results to better fixation stability barring its incapability for resisting the rotational force which can be overcome by using the ILN (Dueland et al, 1999). The addition of screws or bolts increases the ability of the pin to resist the rotational, shearing and compressive forces at the fracture site. The early and full limb ambulation is one of the criteria on the basis of which apparently quality of callus formation and fracture healing can be assessed, was satisfactorily observed in the animals of the Group D treated with ILN. Intramedullary interlocking nailing does not require perfect anatomic fracture reduction of fracture for stability as such fracture with intramedullary interlocking nail undergoes indirect bone healing as interfragmentary load sharing is not usually obtained (Stiffler, 2004). In the instant study, presence of moderate quantities of external bridging callus in group A and D, is indicative of secondary bone healing with stability of fracture. As compression fixation was not attained by interlocking nailing as well as due to prevention of rotational stability of pin by screwing, the exuberant callus formation was not observed which has also been reported by many workers (Wiss et al, 1986 and Brumback et al, 1988). Radiographically, the fracture fragments were found perfectly aligned, retained without any remarkable anomalies in group B and C. The prefabricated concave plate, when used for immobilization of the bone with convex surface, coupled perfectly covering almost 1/3rd of the circumference, which provided very good gripping when fixed with cortical screws in the present study that might be attributed to the reasons for good alignment , retention of fracture fragments in postoperative observation period. In group B, type of periosteal reaction and formation of callus are in conformity of normal bore healing (Dambacher and Ruegsegger, 1994). At all stages of radiography in both the groups , the minimum external

callus formation was observed with quickest symptoms of remodeling. The quality and quantity of fracture callus formation mostly depends on type and accuracy of fracture fixation; more the rigidity and stability in the fixation, minimum is callus formed (Beale, 2004). In the present study, due to rigid fixation, fracture healed by primary union, where direct osteon to osteon union of fragments occured (Stiffler, 2004; Vasseur et al, 1984).

CONCLUSIONS

Based on the above findings it may be concluded that bone plating is considered to be best option than any other immobilization devices but, self fabricated PMMA plate seems promising result in veterinary orthopedic surgery considering its cost, fabrication and facilities for imparting the specific contour of the questioned bone to be repaired, which provide the efficacy of using dynamic compression of fracture healing.

REFERENCES Aron, D.N., Palmer, R.H. and Johnson, A.L., 1995. Biologic strategies and a balanced concept for repair of highly comminuted long bone fractures. Comp. Contin. Educ. Pract. Vet., 17: 35-49. Beale, B., 2004. Orthopedic Clinical Techniques Femur Fracture Repair. Clin. Tech. Small Anim. Pract., 19: 134-150. Branden, T.D. and Brinker, W.D., 1973. Effect of certain internal fixation devices on functional limb usages in dogs. J. Am. Vet. Med. Assoc., 162: 642-646. Brumback, R.J., Uwagie-Ero, S., Lakatos, R.P., Poka, A., Bathon, G.H. and Burgess, A.R., 1988. Intramedullary nailing of femoral shaft fractures. Part II: Fracture-healing with static interlocking fixation. J. Bone Joint Surg. Am., 70 (10):1453-62. Charnley, J., 1960. Anchorage of the femoral head prosthesis to the shaft of the femur. J. Bone Joint Surg., 42: 28. Conzemius, M. and Swainson, S., 1999. Fracture fixation with screws and bone plates. Vet. Clin. North Am. Small Anim. Pract., 29 (5): 1117-1133. DeYoung, D.J. and Probst, C.W., 1985. Methods of fracture fixation. In: Textbook of Small Animal Surgery, W.B. Saunders, Philadelphia, Edn. 1, Slatter, D.H. p 1949-1988. Dueland, R.T., Johnson, K.A., Roe, S.C., Engen, M.H. and Lesser, A.S., 1999. Interlocking nail treatment of diaphyseal long-bone fractures in dogs. J. Am. Vet. Med. Assoc., 214 (1): 59-66. Gahold, B.M., Dhakate, M.S., Patil, S.N., Gawande. P.S. and Kamble, M.V., 2002. Retrospective study of fractures in canines A report of 109 cases. Indian J. Vet. Surg., 23 (2): 129. Heitemeyer, U., Claes, L., Hierholzer, G. and Krber, M., 1990. Significance of postoperative stability of bony reparation of comminuted fractures. Arch. Orthop. Trauma. Surg., 109 (3): 144-149. Hutzschenreuter, R., Perren, S.M., Steinemann, S., Geret, V. and Klebl, M., 1969. Some effects of rigidity of internal fixation on the healing pattern of osteotomies. Injury, 1: 77-81. Kallmes, D.F. and Jensen, M.E., 2003. Percutaneous vertebroplasty. Radiology, 229:2736. Moursi, A.M., Winnard, A.V., Winnard, P.L., Lannutti, J.J. and Seghi, R.R., 2002. Enhanced osteoblast response to a polymethylmethacrylate-hydroxyapatite composite. Biomaterials, 23 (1): 133-144. Raghunath, M. and Singh, S.S., 2002. Intramedullary interlocking nailing (ILN) for long bone fracture fixation in dogs using indigenously designed equipment. Indian J. Vet. Surg., 23 (2): 89-91. Reems, M.R., Beale, B.S. and Hulse, D.A., 2003. Use of a plate-rod construct and principles of biologic osteosynthesis for repair of diaphyseal fractures in dogs and cats: 47 cases (1994-2001). J. Am. Vet. Med. Assoc., 223: 330-335. Roy, S., Samanta, G., Mukherjee, P., Ghosh, D. and De, D., 2005. Occurrence of fracture in dogs in and around Kolkata: A review of 150 cases. In: XXIX Annual Congress of Indian Society for Veterinary Surgery and National Symposium. p 30. Stiffler, K.S., 2004. Internal fixation. Clin. Tech. Small Anim. Pract., 19: 105-113. Tukey, J.W., 1953. The problem of multiple comparisons. Dittoed Manuscript of 396 pages, Department of Statistics, Princeton University. Vasseur, P.B., Paul, H.A. and Crumley, L., 1984. Evaluation of fixation devices for prevention of rotation in transverse fractures of the canine femoral shaft: An in vitro study. Am. J. Vet. Res., 45: 1504-1507. Vcsei, V. and Starlinger, M., 1982. Gentamicin-PMMA bead chains in the treatment of posttraumatic osseous and tissue infections.

Arch. Orthop. Trauma Surg., 99 (4): 259-263. Wiss, D.A., Fleming, C.H., Matta, J.M. and Clark, D., 1986. Comminuted and rotationally unstable fractures of the femur treated with an interlocking nail. Clin. Orthop. Rel. Res., 212: 35-47. Copyright Priory Lodge Eduation Limited 2008 First Published November 2008