{"id":606,"date":"2014-09-01T15:30:53","date_gmt":"2014-09-01T15:30:53","guid":{"rendered":"http:\/\/phosdev.com\/todaysveterinarypractice\/?p=606"},"modified":"2022-02-16T15:32:32","modified_gmt":"2022-02-16T15:32:32","slug":"orthopedic-follow-up-evaluations-identifying-complications","status":"publish","type":"post","link":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/orthopedics\/orthopedic-follow-up-evaluations-identifying-complications\/","title":{"rendered":"Orthopedic Follow-Up Evaluations: Identifying Complications"},"content":{"rendered":"<p><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2016\/06\/T1409C09.pdf\"><img decoding=\"async\" class=\"size-full wp-image-9886 alignright\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2011\/07\/pdf_button.png\" alt=\"pdf_button\" width=\"110\" height=\"27\" \/><\/a><\/p>\n<p><em>Duane A. Robinson, DVM, PhD<\/em><\/p>\n<hr \/>\n<p>Orthopedic procedures, whether performed on an elective or urgent\/emergent basis, are common in small animal veterinary patients. In many instances, definitive treatment occurs at a referral center, with postoperative follow-up taking place at the primary care clinic.<\/p>\n<p>During the recovery period, the primary care veterinarian needs to be able to identify complications in order to intervene as soon as possible. This article reviews basic guidelines and provides tools regarding identification of complications that may occur in adult patients recovering from orthopedic procedures.<\/p>\n<h2><span class=\"aquabold\">COMMON ORTHOPEDIC PROCEDURES<\/span><\/h2>\n<p>Stabilization techniques for rupture of the cranial cruciate ligament are undoubtedly one of the most common orthopedic procedures performed on an elective basis; these procedures include:<\/p>\n<ul>\n<li>Tibial plateau leveling osteotomy (TPLO)<\/li>\n<li>Tibial tuberosity advancement (TTA)<\/li>\n<li>Lateral imbrication suture (lateral femoral fabellotibial suture).<\/li>\n<\/ul>\n<p>The TPLO and TTA procedures require an osteotomy and normal bone healing for a successful outcome.<\/p>\n<p>Fracture repairs are a group of orthopedic procedures that are particularly challenging because normal healing is dependent on a multitude of factors. For example:<\/p>\n<ul>\n<li>What was the fracture configuration?<\/li>\n<li>What repair method was used?<\/li>\n<li>What is the patient&#8217;s signalment?<\/li>\n<li>Are any comorbidities present and, if so, will they affect fracture healing?<\/li>\n<\/ul>\n<h2><span class=\"aquabold\">BONE HEALING<\/span><\/h2>\n<p>In veterinary medicine, the majority of fractures heal via stabilization of fracture fragments by development of a callus, followed by endochondral ossification, which results in formation of new bone. More specifically, healing of bone can occur via direct (primary)\u2014divided into gap or contact healing\u2014 or indirect (secondary) bone healing.<sup>1,2<\/sup><\/p>\n<h3><span class=\"Gold\">Direct Bone Healing<\/span><\/h3>\n<p>Clinically, direct (primary) healing occurs via a combination of contact and gap healing,<sup>1<\/sup>and requires rigid internal fixation.<\/p>\n<p><span class=\"bold\">Contact direct<\/span>\u00a0healing describes situations in which:<\/p>\n<ul>\n<li>Fracture\/osteotomy surfaces are in direct contact<\/li>\n<li>Interfragmentary motion is not present<\/li>\n<li>Fragments are usually under compression.<\/li>\n<\/ul>\n<p><strong><span class=\"bold\">Gap direc<\/span>t<\/strong> bone healing occurs when an interfragmentary gap of &lt; 1 mm is present.<\/p>\n<h3><span class=\"Gold\">Indirect Bone Healing<\/span><\/h3>\n<p>Indirect (secondary) bone healing is common in patients with nonreconstructable fracture configurations, in which biologic fixation (biological osteosynthesis) methods are used. These methods minimize the extent to which the fracture site\/callus and its blood supply are approached and disturbed (<strong><span class=\"bold\">Figure 1<\/span><\/strong>). Examples of biologic fixation methods include the use of minimally traumatic surgical approaches (eg, closed alignment using an intramedullary pin), external fixator systems, and cancellous bone grafting.<\/p>\n<div id=\"attachment_3795\" style=\"width: 207px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-1.jpg\"><img fetchpriority=\"high\" decoding=\"async\" aria-describedby=\"caption-attachment-3795\" class=\"wp-image-3795 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-1-197x300.jpg\" alt=\"document\" width=\"197\" height=\"300\" \/><\/a><p id=\"caption-attachment-3795\" class=\"wp-caption-text\">Figure 1. Radiograph of comminuted radius and ulna fracture at time of injury (A) and approximately 8 weeks later, after removal of failed external fixator (B). This fracture is an example of a delayed union; note extensive callus formation. While fracture is not healed, it also provides an excellent example of indirect (secondary) bone healing. Courtesy UC\u2014Davis VMTH<\/p><\/div>\n<p>Under indirect bone-healing conditions, immediately after fracture occurrence, bone union begins by:<\/p>\n<ul>\n<li>Accumulation of blood from periosteal, endosteal, and marrow sources, which forms a fracture hematoma<\/li>\n<li>Development of a soft tissue envelope, which surrounds the fracture site and delivers the needed blood supply to the healing bone until the endosteal, periosteal, and marrow blood supply sources are reestablished.<\/li>\n<\/ul>\n<p>The phase described above is the\u00a0<span class=\"bold\">reactive phase<\/span>, which includes the inflammatory and granulation phases, and it is followed by the\u00a0<span class=\"bold\">reparative<\/span>\u00a0and\u00a0<span class=\"bold\">remodeling phases<\/span>. While the initial phases are relatively short lived, the remodeling phase may continue for years.<sup>1<\/sup><\/p>\n<h3><span class=\"Gold\">Interfragmentary Strain<\/span><\/h3>\n<p>Bone healing is also influenced by<span class=\"italic\">\u00a0interfragmentary strain<\/span>\u2014a measure of the deformation that occurs in the area between fracture ends (<strong><span class=\"bold\">Figure 2<\/span><\/strong>). The smaller the gap between the fragments, the greater the amount of strain that will occur with a given degree of deformation. Bone formation requires low strain levels.<\/p>\n<p>Orthopedic implants (ie, plate and screw, interlocking nail) are designed to decrease the amount of deformation at the fracture ends. Limiting the amount of deformation decreases interfragmentary strain, which is important because, in order for bone formation to occur via gap direct bone healing, the strain in the fracture gap must be less than 2% (<strong><span class=\"bold\">Figure 2<\/span><\/strong>).<sup>1<\/sup><\/p>\n<div id=\"attachment_3796\" style=\"width: 310px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-2.jpg\"><img decoding=\"async\" aria-describedby=\"caption-attachment-3796\" class=\"wp-image-3796 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-2-300x179.jpg\" alt=\"Figure 2\" width=\"300\" height=\"179\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-2-300x179.jpg 300w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-2.jpg 451w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><p id=\"caption-attachment-3796\" class=\"wp-caption-text\">Figure 2. Strain is the change in gap length divided by original gap length. This graphical depiction of strain demonstrates how osteoclastic resorption increases the initial fracture gap and, as a result, decreases interfragmentary strain to a point where bone will form.<\/p><\/div>\n<p>The clinical manifestation of this concept is somewhat counterintuitive. For example, one method by which the body reduces strain is to\u00a0<span class=\"italic\">increase<\/span>\u00a0the original gap length by osteoclastic resorption.<sup>1,2<\/sup>\u00a0Therefore, during an early (ie, 6\u20148 weeks after repair) follow-up radiograph, the fracture gap may be wider than it was initially, but this is considered normal (<strong><span class=\"bold\">Figure 3<\/span><\/strong>). However, if such a gap is noted during subsequent radiographic evaluations, it is considered a complication in healing.<\/p>\n<div id=\"attachment_3797\" style=\"width: 238px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-3.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-3797\" class=\"wp-image-3797 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-3-228x300.jpg\" alt=\"Figure 3\" width=\"228\" height=\"300\" \/><\/a><p id=\"caption-attachment-3797\" class=\"wp-caption-text\">Figure 3. Immediate postoperative radiograph (A) and another radiograph 8 weeks after surgery (B); note that the gap in the ulna (blue arrow) has increased in size, which is normal at this stage of healing.<\/p><\/div>\n<p>As it heals, an unstabilized fracture or a fracture that is being addressed using indirect (secondary) bone healing can decrease strain by both formation of a fracture callus (which stabilizes the fracture and, therefore, decreases deformation) and osteoclastic resorption.<sup>1,2<\/sup><\/p>\n<h2><span class=\"aquabold\">COMPLICATIONS OF BONE HEALING<\/span><\/h2>\n<p>Despite veterinarians&#8217; best efforts, complications occur in bone healing, resulting in increased morbidity for patients and increased economic burden for clients.<sup>3<\/sup>\u00a0Examples of such complications include:<\/p>\n<ul>\n<li>Failure to achieve functional clinical union of fragments (<strong><span class=\"bold\">Tables 1 and 2<\/span><\/strong>)<\/li>\n<li>Osteomyelitis<\/li>\n<li>Bone-implant construct failure (construct can fail due to problems with the implant or bone, or implant attachment to the bone)<\/li>\n<li>Fracture disease (eg, atrophy, stiffness, adhesions).<\/li>\n<\/ul>\n<p>For most orthopedic cases, follow-up clinical evaluations with radiographs are generally recommended\u00a0<strong><span class=\"bold\">6 to 8 weeks after surgery<\/span><\/strong>; further follow-up depends on the specific needs of the patient. However, in situations with precarious fixations or concern regarding client compliance after surgery, radiographs may be required\u00a0<strong><span class=\"bold\">4 weeks after surgery<\/span><\/strong>.<\/p>\n<p><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Screen-Shot-2015-05-14-at-12.10.26-PM.png\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-3943 size-full aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Screen-Shot-2015-05-14-at-12.10.26-PM.png\" alt=\"Screen Shot 2015-05-14 at 12.10.26 PM\" width=\"590\" height=\"1232\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Screen-Shot-2015-05-14-at-12.10.26-PM.png 590w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Screen-Shot-2015-05-14-at-12.10.26-PM-144x300.png 144w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Screen-Shot-2015-05-14-at-12.10.26-PM-490x1024.png 490w\" sizes=\"(max-width: 590px) 100vw, 590px\" \/><\/a><\/p>\n<ol type=\"a\">\n<li class=\"references\">For example, if converting from external fixator to plate, remove all fixator components<\/li>\n<li class=\"references\">Surgery involves (1) opening medullary cavity; (2) en bloc removal of affected bone ends, compression of ends using plate and screw fixation (optimal); (3) autologous and\/or allogeneic bone graft (essential); (4) if available, consider rhBMP-2<\/li>\n<\/ol>\n<p><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Screen-Shot-2015-05-13-at-2.10.46-PM.png\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-3827 size-large aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Screen-Shot-2015-05-13-at-2.10.46-PM-903x1024.png\" alt=\"Screen Shot 2015-05-13 at 2.10.46 PM\" width=\"650\" height=\"737\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Screen-Shot-2015-05-13-at-2.10.46-PM-903x1024.png 903w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Screen-Shot-2015-05-13-at-2.10.46-PM-265x300.png 265w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Screen-Shot-2015-05-13-at-2.10.46-PM-768x871.png 768w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Screen-Shot-2015-05-13-at-2.10.46-PM.png 1062w\" sizes=\"(max-width: 650px) 100vw, 650px\" \/><\/a><\/p>\n<h2><span class=\"aquabold\">DELAYED UNION, NONUNION, &amp; MALUNION<\/span><\/h2>\n<p>These complications (<strong><span class=\"bold\">Tables 1 and 2<\/span><\/strong>) tend to occur when the mechanical and biological environment necessary for bone healing is not optimal.<\/p>\n<p>Biologically, it is essential to minimize disruption of the natural bone healing process by:<\/p>\n<ul>\n<li>Minimizing dissection<\/li>\n<li>Preserving surrounding soft tissue structures<\/li>\n<li>Maintaining the fracture hematoma.<\/li>\n<\/ul>\n<p>From a mechanical point of view, the aim is to provide:<\/p>\n<ul>\n<li>Proper alignment of fracture fragments<\/li>\n<li>Adequate stability at the fracture site such that healing (bone formation) can occur (see\u00a0<span class=\"bold\">Interfragmentary Strain<\/span>).<sup>1<\/sup><\/li>\n<\/ul>\n<p>A mnemonic has been developed to outline fracture assessment (<strong><span class=\"bold\">Table 3<\/span><\/strong>).<\/p>\n<p><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Screen-Shot-2015-05-13-at-2.18.22-PM.png\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-3829 size-large aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Screen-Shot-2015-05-13-at-2.18.22-PM-1024x671.png\" alt=\"Screen Shot 2015-05-13 at 2.18.22 PM\" width=\"650\" height=\"426\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Screen-Shot-2015-05-13-at-2.18.22-PM-1024x671.png 1024w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Screen-Shot-2015-05-13-at-2.18.22-PM-300x197.png 300w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Screen-Shot-2015-05-13-at-2.18.22-PM-768x503.png 768w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Screen-Shot-2015-05-13-at-2.18.22-PM.png 1172w\" sizes=\"(max-width: 650px) 100vw, 650px\" \/><\/a><\/p>\n<h3><span class=\"Gold\">Delayed Union<\/span><\/h3>\n<p>Diagnosis of a delayed union can be challenging; by definition, it is a\u00a0<span class=\"italic\">fracture that has not healed in the typical time frame for a given fracture in a given animal<\/span>.<sup>4,5<\/sup>\u00a0Thus, diagnosis is dependent on the knowledge of what is typical for a particular fracture (<strong><span class=\"bold\">Table 4<\/span><\/strong>).<\/p>\n<p><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Screen-Shot-2015-05-13-at-2.22.18-PM.png\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-3831 size-large aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Screen-Shot-2015-05-13-at-2.22.18-PM-1024x301.png\" alt=\"Screen Shot 2015-05-13 at 2.22.18 PM\" width=\"650\" height=\"191\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Screen-Shot-2015-05-13-at-2.22.18-PM-1024x301.png 1024w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Screen-Shot-2015-05-13-at-2.22.18-PM-300x88.png 300w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Screen-Shot-2015-05-13-at-2.22.18-PM-768x226.png 768w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Screen-Shot-2015-05-13-at-2.22.18-PM.png 1298w\" sizes=\"(max-width: 650px) 100vw, 650px\" \/><\/a><\/p>\n<p><strong><span class=\"bold\">Causes<\/span>.<\/strong> Causes of delayed unions can be classified as mechanical, biologic, or both.<\/p>\n<ul>\n<li><span class=\"italic\">Biologic<\/span>: For osteotomy procedures, such as TPLO or TTA, a delayed union is most often due to biologic causes, such as periosteal damage, infection, and impairment of local blood supply.4,5<\/li>\n<li><span class=\"italic\">Mechanical<\/span>: Mechanical causes relate to excessive fracture gaps when bone is lost during trauma or during surgery, inadequate immobilization or immobilization for an insufficient period of time, or interposition of soft tissue structures between fracture ends (<strong><span class=\"bold\">Figures 1 and 4<\/span><\/strong>).<sup>4,5<\/sup><\/li>\n<\/ul>\n<p><b>Figure 4<\/b>. Radiographs of an open comminuted segmental fracture of the right tibia (<strong>A and B<\/strong>) showing repair with an interlocking nail and screws. Four months postsurgery, fracture had not healed and one screw is bent (*) (<strong>C and D<\/strong>). Five months postsurgery the fracture had healed (<strong>E and F<\/strong>). Courtesy UC\u2014Davis VMTH<\/p>\n<div id=\"attachment_3798\" style=\"width: 106px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-4A.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-3798\" class=\"wp-image-3798 size-full\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-4A.jpg\" alt=\"Figure 4A\" width=\"96\" height=\"300\" \/><\/a><p id=\"caption-attachment-3798\" class=\"wp-caption-text\">Figure 4A<\/p><\/div>\n<div id=\"attachment_3799\" style=\"width: 206px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-4B.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-3799\" class=\"wp-image-3799 size-full\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-4B.jpg\" alt=\"Figure 4B\" width=\"196\" height=\"300\" \/><\/a><p id=\"caption-attachment-3799\" class=\"wp-caption-text\">Figure 4B<\/p><\/div>\n<div id=\"attachment_3800\" style=\"width: 93px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-4C.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-3800\" class=\"wp-image-3800 size-full\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-4C.jpg\" alt=\"Figure 4C\" width=\"83\" height=\"300\" \/><\/a><p id=\"caption-attachment-3800\" class=\"wp-caption-text\">Figure 4C<\/p><\/div>\n<div id=\"attachment_3801\" style=\"width: 172px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-4D.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-3801\" class=\"wp-image-3801 size-full\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-4D.jpg\" alt=\"Figure 4D\" width=\"162\" height=\"300\" \/><\/a><p id=\"caption-attachment-3801\" class=\"wp-caption-text\">Figure 4D<\/p><\/div>\n<div id=\"attachment_3802\" style=\"width: 119px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-4E.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-3802\" class=\"wp-image-3802 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-4E-109x300.jpg\" alt=\"Figure 4E\" width=\"109\" height=\"300\" \/><\/a><p id=\"caption-attachment-3802\" class=\"wp-caption-text\">Figure 4E<\/p><\/div>\n<div id=\"attachment_3803\" style=\"width: 140px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-4F.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-3803\" class=\"wp-image-3803 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-4F-130x300.jpg\" alt=\"Figure 4F\" width=\"130\" height=\"300\" \/><\/a><p id=\"caption-attachment-3803\" class=\"wp-caption-text\">Figure 4F<\/p><\/div>\n<p>Patient comorbidities are also an important consideration: advanced age, concomitant corticosteroid administration, and metabolic disease (eg, hyperadrenocorticism) can play a role in fracture healing.<\/p>\n<p><strong><span class=\"bold\">Evaluation<\/span>.<\/strong> If a fracture or osteotomy is not healing in the expected amount of time, careful evaluation of implant construct and thorough patient evaluation are necessary.<\/p>\n<p>The following findings are consistent with instability, and intervention is usually advised:<\/p>\n<ul>\n<li>Broken implants (<strong><span class=\"bold\">Figures 5 and 6<\/span><\/strong>)<\/li>\n<li>Radiolucency associated with bone\/implant interface (<strong><span class=\"bold\">Figure 7<\/span><\/strong>)<\/li>\n<li>Pain on palpation of the fracture site<\/li>\n<li>Increasing lameness.<\/li>\n<\/ul>\n<p><b>Figure 5.\u00a0<\/b>Open radius\/ulna fracture in dog repaired with hybrid external skeletal fixator combining a ring and linear components: 1 month after repair (<strong>A<\/strong>) and approximately 8 weeks after repair (<strong>B<\/strong>). Note that one of the wires is broken and a portion is missing (*). Courtesy UC\u2014Davis VMTH<\/p>\n<div id=\"attachment_3804\" style=\"width: 122px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-5A.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-3804\" class=\"wp-image-3804 size-full\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-5A.jpg\" alt=\"Figure 5A\" width=\"112\" height=\"300\" \/><\/a><p id=\"caption-attachment-3804\" class=\"wp-caption-text\">Figure 5A<\/p><\/div>\n<div id=\"attachment_3805\" style=\"width: 143px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-5B.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-3805\" class=\"wp-image-3805 size-full\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-5B.jpg\" alt=\"Figure 5B\" width=\"133\" height=\"300\" \/><\/a><p id=\"caption-attachment-3805\" class=\"wp-caption-text\">Figure 5B<\/p><\/div>\n<div id=\"attachment_3806\" style=\"width: 310px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-6.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-3806\" class=\"wp-image-3806 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-6-300x243.jpg\" alt=\"Figure 6\" width=\"300\" height=\"243\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-6-300x243.jpg 300w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-6.jpg 370w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><p id=\"caption-attachment-3806\" class=\"wp-caption-text\">Figure 6. A dog in which a carpal arthrodesis was performed 8 months previously; note the broken screws (*), likely related to excessive mechanical stress associated with this procedure. Courtesy UC\u2014Davis VMTH<\/p><\/div>\n<p><b>Figure 7.\u00a0<\/b>Lateral and craniocaudal radiographs of right humerus of a dog that sustained a humeral fracture 4 months previously. The fracture was repaired with an external fixator, threaded intramedullary pin, and single cerclage wire. The cerclage wire appears to have untwisted and is in the fracture site (<strong>A and B<\/strong>). Particularly in\u00a0<strong>A<\/strong>, an area\/ring of lucency (<strong>arrowhead<\/strong>) is apparent around the transcondylar pin, which is consistent with a loose implant. The significant periosteal reaction on the medial aspect of humeral condyle (*) is likely a result of motion but could also result from infection.<\/p>\n<div id=\"attachment_3807\" style=\"width: 197px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-7A_1.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-3807\" class=\"wp-image-3807 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-7A_1-187x300.jpg\" alt=\"Figure 7A\" width=\"187\" height=\"300\" \/><\/a><p id=\"caption-attachment-3807\" class=\"wp-caption-text\">Figure 7A<\/p><\/div>\n<div id=\"attachment_3809\" style=\"width: 183px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-7B.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-3809\" class=\"wp-image-3809 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-7B-173x300.jpg\" alt=\"Figure 7B\" width=\"173\" height=\"300\" \/><\/a><p id=\"caption-attachment-3809\" class=\"wp-caption-text\">Figure 7B<\/p><\/div>\n<p>A key radiographic finding that<span class=\"italic\">\u00a0differentiates a delayed union from a nonunion<\/span>\u00a0is the absence of sclerotic bone at fracture ends in patients with a delayed union.<\/p>\n<p><strong><span class=\"bold\">Infection<\/span>.<\/strong> The following can be noted if infection is present: excessive periosteal reaction (<strong><span class=\"bold\">Figure 7<\/span><\/strong>), radiolucency associated with implant\/bone interface, draining tracts (<strong><span class=\"bold\">Figure 8<\/span><\/strong>), sudden onset lameness, and pain associated with implant or fracture site.<\/p>\n<p><b>Figure 8<\/b>. Surgical site in dog that has healed from TPLO, demonstrating drainage that could be associated with implant-associated infection.<\/p>\n<p><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-8A.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"size-medium wp-image-3810 aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-8A-225x300.jpg\" alt=\"Figure 8A\" width=\"225\" height=\"300\" \/><\/a> <a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-8B.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"size-medium wp-image-3811 aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-8B-300x225.jpg\" alt=\"Figure 8B\" width=\"300\" height=\"225\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-8B-300x225.jpg 300w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-8B.jpg 400w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><\/p>\n<p>If the construct is otherwise stable, a fracture will heal despite infection. While deep percutaneous aspirates can be valuable in identifying the microbial organism and susceptibility pattern, they must be interpreted carefully because contamination with skin organisms during sampling is common.<\/p>\n<p>While the definitive diagnosis of a delayed union can be difficult, suspicion of an inadequate biologic or mechanical environment warrants prompt intervention.<sup>4<\/sup><\/p>\n<h3><span class=\"Gold\">Nonunion<\/span><\/h3>\n<p>A nonunion is characterized by<span class=\"italic\">\u00a0failure of bone healing, cessation of osteogenic activity at the fracture site, and required surgical intervention\u00a0<\/span>to achieve a functional outcome.<sup>5<\/sup><\/p>\n<p><strong><span class=\"bold\">Classification<\/span>.<\/strong> Nonunions are further divided into:<\/p>\n<ul>\n<li><span class=\"italic\">Viable<\/span>: Hypertrophic, moderately hypertrophic (<strong><span class=\"bold\">Figure 9<\/span><\/strong>), and oligotrophic<\/li>\n<li><span class=\"italic\">Nonviable<\/span>: Dystrophic, necrotic (<strong><span class=\"bold\">Figure 10<\/span><\/strong>), defect, and atrophic (<strong><span class=\"bold\">Figure 11<\/span><\/strong>).<\/li>\n<\/ul>\n<p><b>Figure 9.\u00a0<\/b>Comminuted, with one large fragment, mid diaphyseal fracture of left humerus with proximal, lateral, and cranial displacement of distal fragment (<strong>A<\/strong>); repaired with locking plate and intramedullary pin. Radiographs were taken 6 months postsurgery; note the persistent fracture line, moderate nonbridging callus, and 2 broken screws (most distal screws); moderate hypertrophic nonunion demonstrated (<strong>B<\/strong>). Original repair was revised by debriding fracture site, placing an autograft, and stabilizing with dynamic compression plate.<\/p>\n<div id=\"attachment_3812\" style=\"width: 207px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-9A-1.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-3812\" class=\"wp-image-3812 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-9A-1-197x300.jpg\" alt=\"Figure 9A-1\" width=\"197\" height=\"300\" \/><\/a><p id=\"caption-attachment-3812\" class=\"wp-caption-text\">Figure 9A-1<\/p><\/div>\n<div id=\"attachment_3813\" style=\"width: 212px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-9A-2.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-3813\" class=\"wp-image-3813 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-9A-2-202x300.jpg\" alt=\"Figure 9A-2\" width=\"202\" height=\"300\" \/><\/a><p id=\"caption-attachment-3813\" class=\"wp-caption-text\">Figure 9A-2<\/p><\/div>\n<div id=\"attachment_3814\" style=\"width: 120px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-9B-1.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-3814\" class=\"wp-image-3814 size-full\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-9B-1.jpg\" alt=\"Figure 9B-1\" width=\"110\" height=\"300\" \/><\/a><p id=\"caption-attachment-3814\" class=\"wp-caption-text\">Figure 9B-1<\/p><\/div>\n<div id=\"attachment_3815\" style=\"width: 169px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-9B-2.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-3815\" class=\"wp-image-3815 size-full\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-9B-2.jpg\" alt=\"Figure 9B-2\" width=\"159\" height=\"300\" \/><\/a><p id=\"caption-attachment-3815\" class=\"wp-caption-text\">Figure 9B-2<\/p><\/div>\n<p><b>Figure 10<\/b>. Example of necrotic nonviable nonunion: Radiographs from dog that underwent left TPLO procedure 8 months prior to presentation; dog developed a methicillin-resistant Staphylococcus species infection. The TPLO plate was removed 5 months postsurgery. At this point, dog was nonweight-bearing in left pelvic limb. The proximal tibial fragment was palpably unstable, severe muscle atrophy was present in entire hindlimb, and draining tract was noted along medial aspect of stifle.<\/p>\n<p><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-10A.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-medium wp-image-3817\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-10A-146x300.jpg\" alt=\"Figure 10A\" width=\"146\" height=\"300\" \/><\/a> <a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-10B.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-medium wp-image-3818\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-10B-125x300.jpg\" alt=\"Figure 10B\" width=\"125\" height=\"300\" \/><\/a> <a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-10C.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-medium wp-image-3819\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-10C-125x300.jpg\" alt=\"Figure 10C\" width=\"125\" height=\"300\" \/><\/a><\/p>\n<div class=\"orange-box\">\n<h2><strong><span class=\"Gold\">Case Example:\u00a0<\/span><\/strong><\/h2>\n<p><strong><span class=\"aquabold\">Delayed\/Nonunion Complications<\/span><\/strong><br \/>\n<span class=\"arial\">Delayed\/nonunion complications commonly occur in small\/toy breed dogs with fractures in the distal 1\/3 to &#8216;+ of the radial diaphysis (<strong>Figure 11<\/strong>).<\/span><\/p>\n<p><span class=\"arial\">Morphometric studies have demonstrated a propensity for radial fractures in toy breeds compared with large breed dogs; the radius of toy breed dogs also has a decreased vascular supply compared with that of larger breeds.<sup>6<\/sup>These unique mechanical and biologic properties likely contribute to the high rate (83%) of malalignment or nonunion complications when these fractures are treated with external coaptation alone.<sup>7,8<\/sup><\/span><\/p>\n<p><span class=\"arial\">This emphasizes the need for adequate apposition and rigid fixation (eg, bone plate or external skeletal fixator) with preservation of the blood supply during fracture repair. In essence, a biological approach to the repair is advocated.<\/span><\/p>\n<\/div>\n<div id=\"attachment_3820\" style=\"width: 310px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-11.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-3820\" class=\"wp-image-3820 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-11-300x105.jpg\" alt=\"Figure 11\" width=\"300\" height=\"105\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-11-300x105.jpg 300w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-11.jpg 451w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><p id=\"caption-attachment-3820\" class=\"wp-caption-text\">Figure 11. Example of atrophic nonunion: Note that ulna has virtually disappeared and very little radius is present. Despite stable repair with plate, the biological environment was not sufficient to support healing of this fracture.<\/p><\/div>\n<p>A\u00a0<span class=\"italic\">viable nonunion<\/span>\u00a0often has an adequate blood supply and biologic environment but lacks sufficient mechanical stability, while a\u00a0<span class=\"italic\">nonviable union<\/span>\u00a0is characterized by its avascular and biologically inactive environment.<\/p>\n<p><strong><span class=\"bold\">Additional Causes<\/span>.<\/strong> In addition to impaired blood supply, a nonunion can also occur secondary to:<sup>4<\/sup><\/p>\n<ul>\n<li>Technical failures during the repair (<strong><span class=\"bold\">Figure 7<\/span><\/strong>)<\/li>\n<li>Bone loss as a result of injury or surgery<\/li>\n<li>Devascularization of fragments during surgical approach and dissection<\/li>\n<li>Infection\u00a0<span class=\"bold\">(<strong>Figure 10<\/strong><\/span>)<\/li>\n<li>Instability (eg, mismatch of implant to bone stiffness)<\/li>\n<li>Poor fracture reduction (eg, inappropriate choice of implants) (<strong><span class=\"bold\">Figure 12<\/span><\/strong>)<\/li>\n<li>Neoplasia.<\/li>\n<\/ul>\n<p><b>Figure 12<\/b>. Example of technical error that led to development of nonunion; the pin and cerclage were not sufficient to stabilize this fracture.<\/p>\n<p><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-12B.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-3822 size-medium aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-12B-e1431620703437-225x300.jpg\" alt=\"Figure 12B\" width=\"225\" height=\"300\" \/><\/a> <a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-12A.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-3821 size-medium aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-12A-e1431620734505-225x300.jpg\" alt=\"Figure 12A\" width=\"225\" height=\"300\" \/><\/a><\/p>\n<p><strong><span class=\"bold\">Clinical Signs<\/span>.<\/strong> Clinical signs of a nonunion can be variable, but common signs include:<\/p>\n<ul>\n<li>New, persistent, or worsening lameness<\/li>\n<li>Muscle atrophy and stiffness<\/li>\n<li>Palpable instability<\/li>\n<li>Pain on palpation or with use of the limb.<\/li>\n<\/ul>\n<p><strong><span class=\"bold\">Prevention<\/span>.<\/strong> Prevention of a nonunion is key because treatment can be difficult and nonviable nonunions, in particular, can have a poor to guarded prognosis.<\/p>\n<p><strong><span class=\"bold\">Treatment<\/span>.<\/strong> Successful treatment of a\u00a0<span class=\"italic\">viable nonunion<\/span>\u00a0centers on removal of fibrous tissue in the fracture gap, addition of a graft, and rigid fixation (<span class=\"bold\">Figure 9<\/span>), while a\u00a0<span class=\"italic\">nonviable nonunion<\/span>\u00a0must be approached with the focus on preservation of soft tissue structures; as in all other fractures, rigid fixation is of paramount importance.<sup>4,5<\/sup><\/p>\n<ol>\n<li>Remove, reposition, or replace implants.<\/li>\n<li>Open medullary cavity and remove sclerotic\/atrophic bone ends.<\/li>\n<li>Lavage area to remove any infection\/contamination.<\/li>\n<li>Place a suitable autologous, autogenous, or synthetic graft.<\/li>\n<\/ol>\n<p>Although potentially cost prohibitive, use of recombinant human bone morphogenetic protein 2 (rhBMP-2) can contribute to a successful outcome in cases of nonviable nonunions, and its use has been documented in veterinary medicine.<sup>9<\/sup><\/p>\n<h2><span class=\"aquabold\">OSTEOMYELITIS AND SOFT TISSUE INFECTION<\/span><\/h2>\n<p>Posttraumatic osteomyelitis is not very common in elective orthopedic procedures and fracture repairs.<sup>10<\/sup>\u00a0However, open fractures (<strong><span class=\"bold\">Figures 4 and 5<\/span><\/strong>) are particularly prone to infection, with the risk increasing with severity of injury.<sup>11<\/sup><\/p>\n<h3><span class=\"Gold\">In the Literature<\/span><\/h3>\n<p>Despite our best efforts, infection can occur during elective procedures and, therefore, must be a consideration in postoperative monitoring. The infection rate associated with the TPLO procedure (<strong><span class=\"bold\">Figure 10<\/span><\/strong>) has been reported, at the highest, as 8.4%, but a more recent study identified a rate of 3.8% for superficial or deep surgical site infections (SSI).<sup>12<\/sup>\u00a0While this information does not apply to orthopedic surgical procedures as a whole, it does provide a current and relevant idea of the impact of posttraumatic osteomyelitis.<\/p>\n<p><strong><span class=\"Gold\">Clinical Signs<\/span><\/strong><br \/>\nClinical signs associated with an infection can be variable and will depend on time since surgery. Signs often include:<\/p>\n<ul>\n<li>Inflammation and swelling at the surgery site<\/li>\n<li>Pain on palpation over the implant or fracture site<\/li>\n<li>Draining tracts (<strong><span class=\"bold\">Figure 8<\/span><\/strong>)<\/li>\n<li>New\/worsening or sudden onset lameness.<\/li>\n<\/ul>\n<h3><span class=\"Gold\">Diagnosis<\/span><\/h3>\n<p>The following can be noted if infection is present:<\/p>\n<ul>\n<li>Excessive periosteal reaction (<strong><span class=\"bold\">Figure 7<\/span><\/strong>)<\/li>\n<li>Radiolucency associated with implant\/bone interface.<\/li>\n<\/ul>\n<p>While deep percutaneous aspirates of the infected area can be valuable in identifying the microbial organism and its susceptibility pattern, they must be interpreted carefully because contamination with skin organisms during sampling is common.<\/p>\n<p><em><span class=\"italic\">Staphylococcus<\/span>\u00a0<\/em>species are the most common causative organism. That being said, it is crucial that samples of bone, deep tissue, and representative implants are submitted for culture and susceptibility analysis.<\/p>\n<h3><span class=\"Gold\">Antimicrobial Therapy<\/span><\/h3>\n<p>Infections associated with the incision or surrounding soft tissue can often be treated with antimicrobial drugs and have minimal impact on bone healing, but those associated with an implant or the bone itself are more problematic. However, if the construct is otherwise stable, a fracture will heal despite infection.<\/p>\n<p>Microbial infections involving orthopedic implants often develop a bacterial\u00a0<span class=\"italic\">biofilm<\/span>, which confers resistance to systemic antimicrobial drugs. Thus, eradication of the infection necessitates removal of the implant once healing is complete.<sup>10<\/sup>\u00a0Of similar importance is the removal of any avascular bone and\/or sequestra (<strong><span class=\"bold\">Figure 13<\/span><\/strong>) that may be present.<\/p>\n<p>Antimicrobial therapy should be guided by the results of culture and susceptibility analysis, and should be continued for a minimum of 6 to 8 weeks.<\/p>\n<div id=\"attachment_3947\" style=\"width: 235px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-131.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-3947\" class=\"wp-image-3947 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-131-225x300.jpg\" alt=\"Figure 13\" width=\"225\" height=\"300\" \/><\/a><p id=\"caption-attachment-3947\" class=\"wp-caption-text\">Figure 13. Postoperative TPLO patient that developed an infection and sequestrum (*).<\/p><\/div>\n<h3><span class=\"Gold\">Follow-Up &amp; Prognosis<\/span><\/h3>\n<p>Serial radiographs every 4 to 6 weeks until complete healing and resolution of radiographic signs of infection are advised.<sup>10<\/sup><\/p>\n<p>Prognosis is generally good for normal function unless there is significant soft tissue loss\/involvement or infection is associated with a total joint implant that needs to be removed.<sup>10,11<\/sup><\/p>\n<div class=\"orange-box\">\n<h2><span class=\"Gold\">Common Complications:<\/span>\u00a0<span class=\"aquabold\">Cranial Cruciate Ligament Rupture Surgical Repair<\/span><\/h2>\n<p><span class=\"arial\">With elective procedures, such as TPLO or TTA, long-term complications apparent on radiographs can include, but are not limited to:<sup>14<\/sup><\/span><\/p>\n<ul>\n<li><span class=\"arial\">Fracture of tibial tuberosity<\/span><\/li>\n<li><span class=\"arial\">Screw breakage or loosening<\/span><\/li>\n<li><span class=\"arial\">Patellar fracture (<strong>Figure 9<\/strong>)<\/span><\/li>\n<li><span class=\"arial\">Septic arthritis<\/span><\/li>\n<li><span class=\"arial\">Tibial\/fibular fracture (<strong>Figure 14<\/strong>).\u00a0<\/span><\/li>\n<\/ul>\n<p><span class=\"arial\">The surgical site should be evaluated for draining tracts, swelling and inflammation, and pain associated with palpation of the implant. Postliminary (latent) meniscal tears can occur in either case; therefore, a thorough orthopedic examination should be performed to assess for evidence of meniscal pathology.<sup>14<\/sup><\/span><\/p>\n<p><span class=\"arial\">It is important to note that, after TPLO or TTA procedures, dogs continue to exhibit a positive cranial drawer sign but should not have a positive tibial compression (tibial thrust) test.<\/span><\/p>\n<\/div>\n<h2><span class=\"aquabold\">BONE-IMPLANT CONSTRUCT FAILURE<\/span><\/h2>\n<p>Bone-implant construct failure can occur:<\/p>\n<ul>\n<li><span class=\"aquabold\">With failure at the implant level, such as a broken screw (<strong><span class=\"bold\">Figure 6<\/span><\/strong>) or bent plate<\/span><\/li>\n<li>In association with the bone, such as a tibial tuberosity fracture after TPLO or nonunion (<strong><span class=\"bold\">Figure 14<\/span><\/strong>).<\/li>\n<\/ul>\n<div id=\"attachment_3936\" style=\"width: 235px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-141.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-3936\" class=\"wp-image-3936 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-141-e1431619395922-225x300.jpg\" alt=\"Figure 14\" width=\"225\" height=\"300\" \/><\/a><p id=\"caption-attachment-3936\" class=\"wp-caption-text\">Figure 14. Catastrophic failure of TPLO: Note that screws in proximal fragment have pulled out and a fracture of proximal tibial fragment is present (*). The fibula is also fractured (+), which eliminates its function as an internal splint. This patient may present with an acute nonweight-bearing lameness after an episode of inappropriate activity (eg, dog escaped from house and was running in yard).<\/p><\/div>\n<p>A very small number of these complications are attributed to the implant alone, with the major cause identified as technical errors, including:<\/p>\n<ul>\n<li>Inappropriately sized implants<\/li>\n<li>Inappropriate implant placements<\/li>\n<li>Use of cerclage and intramedullary pin for repair of a transverse long bone fracture (<strong><span class=\"bold\">Figure 12<\/span><\/strong>)<sup>13<\/sup><\/li>\n<li>Poor owner compliance.<\/li>\n<\/ul>\n<h3><span class=\"Gold\">Radiographic Evaluation<\/span><\/h3>\n<p>When evaluating serial follow-up radiographs after fracture fixation, it is generally important to evaluate several criteria:<\/p>\n<ul>\n<li>Evidence of implant loosening or breakage (<strong><span class=\"bold\">Figures 4, 5, and 7<\/span><\/strong>): Breakage may not be obvious and can be obscured on a single radiographic view; thus, orthogonal views are essential. If there is evidence of loosening, assess the position of the implant relative to previous radiographs\u00a0<span class=\"bold\">(<strong>Figure 6 and 14<\/strong><\/span>).<\/li>\n<li>Loss of cortical bone adjacent to the implant(s) or radiolucency: May occur with loosening or infection (<strong><span class=\"bold\">Figures 7 and 10<\/span><\/strong>)<\/li>\n<li>Loss of reduction at fracture site or loss of alignment (<strong><span class=\"bold\">Figure 7<\/span><\/strong>)<\/li>\n<li>Evidence of progression toward normal healing at fracture site: Is there a bridging callus? Do the fracture ends appear more rounded and less distinct?<\/li>\n<\/ul>\n<h3><span class=\"Gold\">Management<\/span><\/h3>\n<p>While some failures require surgical intervention, others can be managed nonsurgically. In general, the greater time since surgery, the less likely bone-implant construct failure will occur. For elective osteotomies, such as TPLO and TTA, once the 6- to 8-week follow-up evaluation is reached, the chance for bone-implant construct failure is quite low.<\/p>\n<h2><span class=\"aquabold\">FRACTURE DISEASE<\/span><\/h2>\n<p>Fracture disease describes any other\u00a0<span class=\"italic\">postoperative complication associated with the initial injury, fracture, or repair<\/span>. Some of the more common issues are:<\/p>\n<ul>\n<li>Muscle atrophy<\/li>\n<li>Joint stiffness<\/li>\n<li>Fracture distal to the implant<\/li>\n<li>Articular cartilage degeneration<\/li>\n<li>Adhesion of muscle to bone\/muscle scarring.<\/li>\n<\/ul>\n<p>Disuse of the affected limb contributes significantly to muscle atrophy, joint stiffness, and osteopenia, which helps emphasize the importance of postoperative physical therapy.<\/p>\n<p>Quadriceps contracture (<strong><span class=\"bold\">Figure 15<\/span><\/strong>) is the most common and severe form of fracture disease in small animal patients. It is of greatest concern in:<\/p>\n<ul>\n<li>Young dogs and cats with femoral fractures<\/li>\n<li>Animals managed with prolonged coaptation with the limb in extension.<\/li>\n<\/ul>\n<div id=\"attachment_3937\" style=\"width: 237px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-151.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-3937\" class=\"wp-image-3937 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/Figure-151-227x300.jpg\" alt=\"document\" width=\"227\" height=\"300\" \/><\/a><p id=\"caption-attachment-3937\" class=\"wp-caption-text\">Figure 15. Dog with quadriceps contracture of right quadriceps muscles; note hyperextended stifle and hock.<\/p><\/div>\n<h3><span class=\"Gold\">Quadriceps Contracture Evaluation<\/span><\/h3>\n<p>During follow-up evaluations, the quadriceps muscles should be palpated for evidence of persistent firmness (permanent contraction); in addition, stifle range of motion should be assessed. Use of a goniometer to measure and record maximal angle of flexion and extension is important for ongoing comparisons.<\/p>\n<p>For the stifle:<sup>15<\/sup><\/p>\n<ul>\n<li>Normal flexion angle is &lt; 45 degrees<\/li>\n<li>Normal extension angle is approximately 162 degrees.<\/li>\n<\/ul>\n<p>In one reported case of quadriceps contracture, a loss of stifle flexion, nonweight-bearing lameness, knuckling, and internal rotation were present 22 days after a second attempt to repair a femur fracture.<sup>16<\/sup>\u00a0Therefore, young dogs (&lt; 12 months) should be evaluated for these signs at 10 to 14 days after surgery; then at 4- and 8-weeks postoperatively.<\/p>\n<h3><span class=\"Gold\">Quadriceps Contracture Prevention<\/span><\/h3>\n<p>Risk for this complication decreases as the fracture heals and improved use of the limb occurs. Prevention is the key because there is no effective treatment; prevention includes:<\/p>\n<ul>\n<li>Atraumatic surgery<\/li>\n<li>Internal fixation<\/li>\n<li>Early mobility<\/li>\n<li>Use of affected limb<\/li>\n<li>Passive range-of-motion exercises.<\/li>\n<\/ul>\n<h2><span class=\"aquabold\">IN SUMMARY<\/span><\/h2>\n<p>Orthopedic procedures are commonly performed in small animal patients, and whether it is an elective procedure or urgent\/emergent fracture repair, follow-up evaluations are critical in reaching a desirable outcome.<\/p>\n<p>Due to the increasing frequency of these procedures, primary care veterinarians are often responsible for follow-up visits. In some cases, the primary veterinarian may be comfortable performing the evaluation, taking radiographs, and interpreting progress, while others prefer to perform the evaluation; then consult the surgeon.<\/p>\n<p>In either case, a team approach between the referral surgeon and primary veterinarian is optimal in order to achieve success in managing patients after an orthopedic procedure has been performed.<\/p>\n<p class=\"arial\">SSI = surgical site infection; TPLO = tibial plateau leveling osteotomy; TTA = tibial tuberosity advancement<\/p>\n<h3 class=\"references\"><strong>Suggested Reading<\/strong><\/h3>\n<p class=\"references\">Johnson AL, Houlton JEF, Vannini R.\u00a0<em>AO Principles of Fracture Management in the Dog and Cat<\/em>. New York City: Thieme Medical Publishers, 2005.<\/p>\n<p>Piermatti DL, Flo GL, DeCamp CE.\u00a0<em>Brinker, Piermatti, and Flo&#8217;s Handbook of Small Animal Orthopedics and Fracture Repair<\/em>, 4th ed. St. Louis: Saunders Elsevier, 2006.<\/p>\n<p>Tobias KM, Johnston SA. Musculoskeletal system.\u00a0<em>Veterinary Surgery: Small Animal<\/em>, Vol 1. St. Louis: Elsevier, 2012.<\/p>\n<hr \/>\n<p class=\"references\"><span class=\"author-bio\"><strong><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/C09_a.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignleft size-full wp-image-6489\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/C09_a.jpg\" alt=\"C09_a\" width=\"100\" height=\"115\" \/><\/a>Duane Robinson,\u00a0<\/strong>DVM, PhD, Diplomate ACVS (Small Animal), is an assistant professor of orthopedic surgery at University of California\u2014Davis School of Veterinary Medicine. He received his DVM from University of Guelph Ontario Veterinary College, and his PhD (infectious disease) from University of Minnesota. He completed a rotating internship in medicine and surgery at Ontario Veterinary College, surgical internship at Affiliated Veterinary Specialists (Orange Park, Florida), research fellowship at Iowa State University Veterinary Orthopaedic Research Laboratory, and surgery residency at University of Minnesota.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Duane A.<\/p>\n","protected":false},"author":1,"featured_media":653,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"iawp_total_views":3562,"footnotes":""},"categories":[368],"tags":[13],"class_list":["post-606","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-september-october-2014","tag-peer-reviewed","clinical_topics-orthopedics","clinical_topics-rehabilitation"],"acf":{"hide_sidebar":false,"hide_sidebar_ad":false,"hide_all_ads":false},"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v24.7 (Yoast SEO v27.3) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>Orthopedic Follow-Up Evaluations: Identifying Complications<\/title>\n<meta name=\"description\" content=\"Complications can occur during the recovery period following an orthopedic procedure. 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