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PMMA Plate for Fixation and Repair of Tibial Fractures - A Study of Six Caprines.

Introduction

Fracture are a resultant of complex injuries and result in break in the continuity of body framework. In animals, fractures are caused by trauma and mechanical forces such as bending, twisting and compression (Adams and Fessler, 1974). Long bone fracture in goats are very common (Singh and Nigam, 1981) and one of the important non-infectious cause of lameness (Mathews, 1999). The economical method for fracture management in goats is application of splints, plaster of paris and fibre cast. However, these techniques have various demerits like mal-union, delayed union and non union (Singh et al., 1984) and other demerits includes large callus formation, weakening of tendons, muscle atrophy (Mbuiki and Byagagaire, 1984), delay in weight bearing, interferes with radiographic evaluation, slippage of plasters, softening of plaster cast and wetting of cast due to faulty management which ultimately leads to hike of expenses because of re-application. With the above facts, alternate method i.e. internal fixation through bone plating with cheap available materials through which plate fabrication is done and provide sufficient stability and provide early weight bearing can be used economically in goats. With the above context, polypropylene mesh impregnated PMMA plates were fabricated for internal fixation in goats.

Material and Methods

The study was conducted on six clinical cases of tibia fracture in goats. The case details of fractures are given in Table 1. The choice of internal immobilisation was to accomplish better fracture reduction and early functional weight bearing in goats. Diagnosis of fracture was made on clinical and radiographic examination. For preparation of plates, iron moulds were fabricated (Fig.1) and that moulds a thin layer of PMMA powder was layered and then polypropylene mesh was added. To the former layer, again powder was added up to 3mm thick and then antibiotic was added to the former layer and PMMA liquid was added as per standard manufacturing protocols. The plate was allowed to set. After setting of plate, it was removed from iron mould and holes were drilled as per standard DCP plate holes. The length of plate was determined through radiograph of contra-lateral limbs. The average length of plate was ranged from 10-14 cm length and with width of 8mm and 3mm thick (Fig. 2). The cost of fabrication of plate was 25 INR for plate and 80 INR for one screw. On an average 6 screws were used during plating. The purpose of addition of polypropylene mesh was to keep the plate fragments at one place even when the plates get broken. Pre-operatively, the animals were given with Meloxicam (Melonex (a)) @ 0.3mg/kg, IM and Intamox (a) (Amoxycillin and Cloxacillin) with 10 mg/kg, IV. The animals were prepared surgically and sedated using Dexmeditomidine @ 2.5[micro]g/kg, IV and followed by Ketamine for induction @ 6mg/kg, IV followed by maintenance on Isoflurane by 1-2 percent. The tibia was approached through medial approach, the fractures were reduced and were stabilised using polypropylene mesh impregnated PMMA plate (Fig. 3). The plate was applied as buttress plate to the fractured fragments. Post-operatively, animals were checked for any implant failure, breakage in plates, oedema, any infection or auto-mutilation. Animals were given post-operatively with anti-inflammatory drugs like Tramadol @ 2mg/ kg b. wt. for two days and then Melonex (a) @ 0.3 mg/ kg b. wt. and antibiotic Intamox (a) @ 10 mg/kg b. wt. for six days. Bamboo splints were applied to animals post-operatively for five days.

The animals were evaluated clinically by weight bearing. The weight bearing in animals were graded as mild (+), moderate (++), good (+++), very good (++++) and no weight bearing (-) on 0, 3rd, 7th, 15th, 30th and 60th post-operative days and for infection, oedema, implant failure and auto-mutilation. The animals were evaluated radiographically for healing of fracture by both the plates on 15th, 30th and 60th post-operative days. On 0 day, the radiographs were taken pre-operatively and post-operatively to confirm type of fracture and proper alignment of fracture postoperatively.

Results and Discussion

The animals were evaluated clinically by weight bearing and radiographic evaluation and for complications

Weight bearing (WB)

On 0 day, all six animals before and after stabilisation with polypropylene mesh impregnated PMMA plate showed no weight bearing. Similar observations were observed on 3rd day. However on 7th day, one animal out of six showed good weight bearing both during standing and walking. However rest of animals showed mild weight bearing (Fig. 4) with hoof touching on the ground during walk whereas animals lifted their leg during standing. On 15th day, four out six animals showed moderate weight bearing (Fig. 5) without any sort of discomfort. One animal showed good weight bearing and one animal showed no weight bearing with limping. On 30th day, all animals showed good weight bearing (Fig. 6) both during walking and standing. Similar observations were noticed on 60th day with animals showing very good weight bearing both during walking and standing. During this study, animals had mild to moderate weight bearing from 7-15 days, while good weight bearing was observed from 30-60 days.

The early weight bearing could be attributed to the good plate fixation to the bones, neutralising all forces acting on the bone and also providing adequate strength and stability to fracture site almost similar to that of steel plates. Similar findings were noticed by Dharmendra (2016) who noticed good weight bearing in goats was observed on 30th day onwards where he used the DCP plate with various bone substitutes. Similarly Yuvraj et al. (2007) who noticed weight bearing in dogs after 8th post-operative weeks where they used Gentamicin impregnated PMMA plates for femoral fracture repair in dogs. And observations were also similar to Mukherjee (2007) who also used PMMA plates for femoral fracture repair in dogs where he observed weight bearing by 45 days.

Radiographic evaluation

Radiographic study in both groups were performed on 0 day, 15th, 30th and 60th day post-operatively.

Pre-operative and immediate post-operative (0 day) radiographs evaluation was done to confirm type of fracture (Fig. 7) and proper placement of plate and screws, apposition and alignment of fracture fragments in the six goats (Fig. 8). On 15th day, slight periosteal reaction was evident at the fractured site (Fig. 9). In one case with tibia fracture had distortion in bone fragments. On 30th post-operative day, more callus formation was noticed on the far cortex side of plate comparatively there was less callus on the near cortex of plate (Fig. 10). Bridging of fracture line was incomplete. The fracture line was clearly evident. On 60th post-operative day, massive callus completely filling the fracture site (Fig. 11) and callus was more smoother and radio-opaque.

The formation callus at the far cortex could be due to more compression of force due to tightening of screws at near cortex and tension at the far cortex resulting in proliferation of osteoblasts at the far cortex side then on the near cortex. The more callus formation at the fracture site may be due to micro movements in fracture fragments resulting in second intention healing of fracture since the PMMA plate was applied similar to that of buttress plating. The findings were similar to that of Shivaprakash and Singh (2003) found more callus formation when used teflon, nylon, cadaver and horn plates in goats and dog due to movements at the fracture site. Similarly, Singh and Sahay (2005) conducted radiographic evaluation of transfixation osteosynthesis for tibial fracture repair in goats. They observed the formation of bigger external callus and delayed initiation of osteogenesis when three pins were used for stabilisation.

Complications

No complications were noticed post-operatively during the study.

Conclusions

The polypropylene mesh impregnated plate can provide sufficient strength and stability to the fracture site which can be evident by weight bearing and radiographic evaluation and is also affordable and feasible for use in internal fixation in goats.

References

Adams, S.B and Fessler, J.F. (1974). Textbook of Large Animal Surgery. 2nd Edn, (Ed.) Oehme, Federick, W. Williams and Wilkins, Baltimore. U.S.A. p. 262-48.

Dharmendra, K. (2016). Efficacy of bone substitutes for fracture healing in Goats. Post Graduate Thesis, Nanaji Deshmukh Veterinary Science University (NDVSU), Jabalpur.

Mathews, J.G. (1999). Lameness in adult goats. Disease of Goat. Blackwell Publishers, p. 66-87.

Mbuiki, S.M. and Byagagaire, S. D. (1984). Full limb casting: A treatment for tibial fracture in calves and goats. Vet. Med. Small Anim. Clinician 82: 1159-62.

Shivaprakash, B.V. and Singh, G.R. (2003). Bone plating with fabricated nylon, teflon, horn, cadever bone and stainless steel plates in dogs and goats. Indian Vet. J. 80: 882-87.

Singh, A.P., Nayer, K.N.M., Chandna, I.S., Chawla, S.K. and Nigam, J.M. (1984). Post-operative complications associated with fracture repair of long bones in bovines, equine and ovine. Indian J. Vet. Surg. 5: 45-47.

Singh, A.P. and Nigam, J.M. (1981). Bone and joint disorders of limb in sheep and goat: a radiographic report. Indain J. Vet. Surg. 2: 62-65.

Singh, H. and Sahay, P.N. (2005). A simplified technique of percutaneous transfixation for tibial fracture in goats. J. Res. Birsa Agri. Univ. 17: 121-24.

Yuvraj, H. D., Kumar, D., Shivaprakash, B.V. and Usturge, S.M., (2007). Comparative evaluation of DCP with PMMA plate for femur and radius fracture in dogs. Indian J. Vet. Surg. 28: 1-5.

Vinit Doijode (1), D. Dilip Kumar (2) and B.V. Shivaprakash (3)

Department of Veterinary Surgery and Radiology

Veterinary College

Karnataka Veterinary, Animal and Fisheries Sciences University (KVAFSU)

Bidar - 585401 (Karnataka)

(1.) Post Graduate Scholar and Corresponding author.

E-mail: doijodevinit@gmail.com

(2.) Professor and Head

(3.) Director of Research

(a -) Brand of Intas Animal Health, Ahmedabad

(a -) Brand of Intas Animal Health, Ahmedabad
Table 1: Fracture type and fixation techniques advocated

Animals  Bone   Fracture type         Fracture
                                      position

1        Tibia  Simple oblique        Mid-shaft
2        Tibia  Simple short oblique  Upper
                                      one-third
3        Tibia  Simple short oblique  Mid-shaft
4        Tibia  Transverse            Mid-shaft
5        Tibia  Simple communited     Distal
                                      one-third
6        Tibia  Simple oblique        Mid-shaft

Animals  Fixation technique

1        8 holed, 10cm PMMA plate with screws
         3 proximal and 4 distal fragments
2        8 holed, 10cm PMMA plate with screws
         2 proximal and 4 distal fragments
3        8 holed, 10cm PMMA plate with screws
         3 proximal and 4 distal fragments
4        8 holed, 10cm PMMA plate with screws
         2 proximal and 3 distal fragments
5        10 holed, 14cm PMMA plate with screws
         5 proximal and 3 distal fragments
6        8 holed, 10 cm PMMA plate with
         screws 3 proximal and 4 distal
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Title Annotation:Clinical Article; poly methylmethacrylate
Author:Doijode, Vinit; Kumar, D. Dilip; Shivaprakash, B.V.
Publication:Intas Polivet
Article Type:Report
Date:Jan 1, 2018
Words:1741
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