Question about removing the plates after tibial fracture surgery

[panteaarman]

Hello,

I live in Iran and facing the problem I'm writing about I need to make sure that what I've been told is a standard vet procedure. It would be very helpful to me and my cat’s life if you can give me any consultations and pieces of advice. I’d really appreciate your time and help. Here’s what happened:
 

Two weeks ago I had my 8 month old -DSH/mixed breed- cat fell from the third floor. I took her to the regular vet, and x-rays were taken which indicated her right leg was broken. Then they prescribed some painkillers and injected antibiotics to her broken leg and told me to bring her the next day as she needed a surgery. The next day the surgeon, initially having doubts about whether doing the operation by the time or waiting a few more days, confirmed the safety of doing the surgery. I've attached the x-rays before surgery and the ones right after it. 

BS1.jpg

• panteaarman
• Nov 30, 2016

           

BS2.jpg

• panteaarman
• Nov 30, 2016

 (Before Surgery)

AS1.jpg

• panteaarman
• Nov 30, 2016

         

AS2.jpg

• panteaarman
• Nov 30, 2016

(After Surgery) 

The surgeon didn’t explain to us what exactly is going to happen during the surgery and only said: “We’ll see.” Anyway we had to trust the surgeon since he’s well-known here and the vet reassured his skill and experience. X-rays were taken right away after the surgery, and as apparent in the pictures they used a plate and wires to fix the fracture. The vet said the surgery was operated very well and leaving the plate in her body for the rest of her life could absolutely cause no further problem. I assume the healing process went ok. She’s eaten (at first day she had only chicken soup) well and has been able to use the litter on her own except the first night after surgery. She didn’t stand on the leg for the first few days and then started to slightly put some pressure on it. I'd add that my cat has been spayed a month before this accident. 

Yesterday, after 14 days we took her to the vet to have the stitches removed. The vet asked me if she uses her leg properly. “Well, she has kind of used her leg but not 'properly'. She's been walking with a limp. She's been trying to get around on her leg but also avoiding to put real pressure on it. She’s not tried to fold the legs under her even once, avoiding this sphinx position she's rather laid stretched out on her sides.” I replied and I know it was a bit long and complicated answer but that’s the way it’s really been. She can jump/climb the bed (of 30 cm height) and she's been running before me whenever I want to give her and her littermate their meals. Though she hasn’t been walking normally and she’s rather limping, which I have thought is probably normal. Although yesterday the vet just looked at her and immediately said bring her next week to remove the plate. When I asked for the precise reason of this, he said the plate brakes her walking! He didn’t see her really walking or anything and examined her still in her place. He said we’d rather reserve sooner since the surgeon is busy next week. I did reserve but I am not sure if it’s the best decision at least for now. I searched the internet for vet advice and articles about bone fractures in cats, they all mentioned that removing the plates will be done at least some months after the surgery if necessary. So I’m going to consult more and acknowledge the goodness of doing so. I am really worried, a little part of me is stressed of going through the whole process of another operation this soon but the other big part of me is so concerned to make a good decision and hopefully the right one for my cat’s quality of life whom I wish to be back to its normal state. I've also uploaded a video  of Patu walking to show how she really walks with a limp. 


One more time, I thank you for giving me your time to read this.

 

[Kieka]

It takes time for a broken bone to heal and a limp to go away. Its been about 9 weeks since my Link broke his lower leg and he still has a limp from it (which is worse later in the day). Link has a pin in his leg and the vet said we'd wait and see on if it ever had to be removed. I've had a cat who broke the upper leg and they left the screws and wire in for the rest of his life. 

I have a basic understand of anatomy and movement from my college days. I don't think the location of the plates would interfere with walking because the joint is lower and to the front of the bone. I'd hold off on any surgery until the surgeon looks at her. Even then I wouldn't do anything unless there is swelling or something to indicate that maybe a muscle or tendon was affected by the plates. 14 days is just not long enough to say that the plates are causing a limp versus just typical healing .

 

[panteaarman]

Thanks a lot sharing your experience with us. I am sure the lack of awareness about the details of the medical procedure and my lack of experience on this problem have upset me just as much, if not more, than the situation itself. I do agree with you, and what me worried sick was not only my cat limping, but rather the vet’s sudden decision to reverse what has been said earlier with no clear explanation. 

We also sought advice from the PetCoach team and the chief vet helpfully explained that the fracture was not repaired with a plate, but with an intramedullary pin (IM) which is a kind of metal rod driven straight down the inside of the femur. She emphasized that this kind of implant should be always removed once healing is complete. She also pointed out three possibilities as to why she’s not using the leg. 1. The fracture site is not truly healed and that healing can take much longer than normal or even may not be fully healed due to the lack of complete reduction. Reduction is as she explained the act of bringing two pieces of bone back together into a tight fit by the surgeon.  2. The pin is pressing on the sciatic nerve which is painful and that removing the pin will help this recover and regain at least partial function. 3. There is infection present at the fracture site. 

She advised me to take more x-rays before taking any action to surgery to see firstly if healing is complete and also consider the possibility of infection. This has been a big help, since I’ve thought they used a plate which most of the time is left in place. 

After all, as you said I’d hold off, talk to the surgeon who is available only on Wednesdays. Till then I'm getting advice from other surgeons and taking more x-rays to back up the right decision. 

 

[Draco]

I agree, second opinions is always a good to get more options and opinions. Sometimes one vet misses something the other vet catches.

Keep  us posted on how she's doing. Speedy recovery!

 

[panteaarman]

 

[Geoffrey]

I am a human doctor, not a vet and it takes up to three months for a human fractured bone to heal, certainly that if the fracture is in a bone that is weight bearing.  I would think that it would take a similar time for a cat's bone to heal although this should be checked by a vet.  The video shows that there is a good deal of atrophy (wasting) of the muscles and that the limp is pronounced, suggesting that it is still painful for the cat to weigh bear - as witnessed by her desire to lie down after attempting to walk. 

I think that removing the intra-medullary splint after only a fortnight is premature - and that you should be guided by the surgeon. 

Incidentally the X-Ray shows that the fracture was of the right femur, not tibia and that the position is good. 

With all good wishes,

Geoffrey

 

[panteaarman]

 
I am a human doctor, not a vet and it takes up to three months for a human fractured bone to heal, certainly that if the fracture is in a bone that is weight bearing.  I would think that it would take a similar time for a cat's bone to heal although this should be checked by a vet.  The video shows that there is a good deal of atrophy (wasting) of the muscles and that the limp is pronounced, suggesting that it is still painful for the cat to weigh bear - as witnessed by her desire to lie down after attempting to walk. 

I think that removing the intra-medullary splint after only a fortnight is premature - and that you should be guided by the surgeon. 

Incidentally the X-Ray shows that the fracture was of the right femur, not tibia and that the position is good. 

With all good wishes,

Geoffrey

Dear Geoffrey!

Thanks a lot for your helpful information. I appreciate taking your time and sharing your knowledge with me and my cat, who would send much trilling to you if possible! 

Do you consider this amount of muscular atrophy unusual or a natural part of healing after surgery? Have you meant that the position is good in x-rays taken after the surgery?

I've had another doctor's suggestion since yesterday who mentioned there is infection present at the fracture site. I have heard quite various opinions about her condition which I assume is always the situation with medical cases. Without more x-rays the possibilities are not certain and confined. Also though the most collective recommendation was that removing the pin at this point is premature, as you said. 

I'm showing you the new x-rays here which will be taken tomorrow.

I've known that nothing about the title of this thread is correct by now! 

 

[panteaarman]

I'd like to add that Patu has been a lot better apparently. Yesterday I let her out of her room for a while (I have to lock her in the room since she attempts to jump on heights in the house and also her littermate, Puree is too playful). She started running and playing with Puree, which made me extremely happy but also a bit freaked out because she needs to rest and not run for at least a month I guess and so, I had to take her back again in her room and try to play with her the way that doesn't encourage her to run and jump. 

 

[Geoffrey]

I reviewed the video again and, not being used to veterinary surgery - and being a physician and not a surgeon -  I forgot that the leg has to be shaved  before operating.

     The large amount of fur that was removed makes the leg appear much thinner than the left one and it is most likely that the wasting is much less than I originally thought.  However the pre-surgery X-Rays show that Patu had a horrifying fracture of the upper third of the shaft of the right femur, with gross displacement of the two broken parts of the femur, one part overlapping the other.  It is probable, (and I write this after my experience with humans, not cats), that there has been considerable muscle damage due to the broken parts of the femur lacerating the muscles of the upper leg.  The amount of damage cannot be seen at this early stage but the post-operative X-ray shows marked soft tissue swelling of the thigh.

Muscle wasting is usually present after such major surgery that Patu has undergone and, in humans, a prolonged period of physiotherapy is necessary.  Cats, on the other hand, being cats, will not pay any attention to a physiotherapist and will insist on giving themselves their own ideas of rehabilitation - and once the bone has healed and the pin removed, will be most successful.   The problem will be to restrain the cat until then, and you appear to be very successful in this.

I could not see any bony infection in the X-Ray, I look forward to seeing the new prints and will comment on these.   The position is the appearance after the fracture has been reduced and this is now straight, otherwise the pin could not have been inserted.

 

With best wishes to you both,

Geoffrey

 

[Geoffrey]

One further point about the post-operative X-Ray.  There appears to be shortening of the right femur compared with the left.  Given the gross displacement of the pre-surgery X-Ray, this is not surprising and the surgeon has obviously done as well as could be expected.  

However, regardless of any other factor, I am sorry but Patu may well end up with a permanent limp due to the shortening.

Best wishes to you and Patu,

Geoffrey

 

[panteaarman]

 
I reviewed the video again and, not being used to veterinary surgery - and being a physician and not a surgeon -  I forgot that the leg has to be shaved  before operating.

     The large amount of fur that was removed makes the leg appear much thinner than the left one and it is most likely that the wasting is much less than I originally thought.  However the pre-surgery X-Rays show that Patu had a horrifying fracture of the upper third of the shaft of the right femur, with gross displacement of the two broken parts of the femur, one part overlapping the other.  It is probable, (and I write this after my experience with humans, not cats), that there has been considerable muscle damage due to the broken parts of the femur lacerating the muscles of the upper leg.  The amount of damage cannot be seen at this early stage but the post-operative X-ray shows marked soft tissue swelling of the thigh.

Muscle wasting is usually present after such major surgery that Patu has undergone and, in humans, a prolonged period of physiotherapy is necessary.  Cats, on the other hand, being cats, will not pay any attention to a physiotherapist and will insist on giving themselves their own ideas of rehabilitation - and once the bone has healed and the pin removed, will be most successful.   The problem will be to restrain the cat until then, and you appear to be very successful in this.

I could not see any bony infection in the X-Ray, I look forward to seeing the new prints and will comment on these.   The position is the appearance after the fracture has been reduced and this is now straight, otherwise the pin could not have been inserted.

 

With best wishes to you both,

Geoffrey

 
One further point about the post-operative X-Ray.  There appears to be shortening of the right femur compared with the left.  Given the gross displacement of the pre-surgery X-Ray, this is not surprising and the surgeon has obviously done as well as could be expected.  

However, regardless of any other factor, I am sorry but Patu may well end up with a permanent limp due to the shortening.

Best wishes to you and Patu,

Geoffrey

Dear Geoffrey,

Thanks a lot for your sincere sharing of information and empathy. Patu and I appreciate your consulting with us. 

I tried to compare both legs by observing and touching the legs and indeed the shaved leg doesn’t appear much thinner than the other one in my understanding. What you suggest about the muscle damage sounds very logical and gives me a better comprehension of what Patu has undergone and consequently of the healing process. Do you think using a splint is necessary in her case? 

I’ve observed the shortening you mentioned. As someone with no skill and knowledge in interpreting the x-rays I had a thought about the possibility of the femurs being not equally aligned by the time the x-rays were taken due to the position of my cat. Does this make sense to you? My own inclination is it might look shorter in this way which is also what I hope it’d be.

I’m going to upload the new x-rays tomorrow and keeping you informed about this.

All the best,

 

[panteaarman]

Today I had these new x-rays taken from a well equipped educational hospital with Patu sedated. I consulted with two surgeons. Both mentioned considerable amount of infection present in soft tissue around right femur and tibia, and emphasized on the importance of removing the pin which should be replaced by a plate in their opinion. The surgeon told me her condition has gotten worse after the surgery and the pin is completely useless, though she added the process of surgery can never be precisely predicted. All in all, the surgeon told me not to rush into the next surgery and also to decide who I’d like to do the next surgery which morally is always the responsibility of the surgeon who firstly did it. 

Antibiotics are prescribed for 2 weeks. [Ceftriaxon and Clindamycin which I should inject into a cannula that'd been inserted into her vein today]

This is also the radiology report:

- Presence large amount of gas bubble in soft tissue region around right femor and tibia. 

- Fracture line is still visible, associated with angulation between fracture fragment. 

- Wire does not involve fragment and is loosed. 

- Tip of pin is within femoro patellar joint. 

- No sign of effective callus formation but presence large amount of palisade and solid preosteal reaction in proximal fraction.

[Diagnosis] : Device loosening and failure (wide fracture line), associated with bony infection (osteomyelitis) and severe soft tissue injury. 

***

Blood work is highly suggested. 

--------

I feel down, angry and guilty, but hope for the best. 

AP.jpg

• panteaarman
• Dec 4, 2016

AP2.jpg

• panteaarman
• Dec 4, 2016

 

[Geoffrey]

Thank you for putting up the second X-Rays, they certainly, and unfortunately, clarify the situation.  I am very sorry for you for this result, the pin is now doing nothing and will have to be removed, but just when will be decided by the new surgeon. 

Don't feel guilty, you have done nothing to blame yourself for.    See how the situation is with the antibiotics and see what the surgeon says. 

With best wishes to you  and to Patu,

Geoffrey

 

[panteaarman]

Hi,

After this message I called the previous surgeon and we met him around 11 p.m. We had a big discussion about her condition. Long story short he took the responsibility of doing any further action. His absolute decision was to remove the pin as soon as possible, letting her to be able to use the leg. We had her sedated again last night around 1 a.m and he removed the pin by pulling it out.

 He also added it's not necessary to give the antibiotics at all since she eats and drinks well and her body has its normal activity. Though he told me I should call him immediately if I see pus oozing from the soft tissue or any kind of liquid on her skin surrounding the area. 

 

[panteaarman]

Ok, I just wanted to let everyone here know Patu is doing a lot better. She walks with a less pronounced limp and she seems to be more relaxed.

She stretches her legs exceptionally every time she gets up! (a lot more than usual) She eats and drinks well. Also she sleeps less and plays more.

The surgeon reiterated that she does not need any antibiotics at all, in contrast to two or three vets I consulted with. The surgeon said we need to give her as much strength as possible to heal and that unnecessary antibiotics would only weaken her and delay the healing. In contrary, other vets thought antibiotics is necessary and would accelerate the healing process. Though, some mentioned the surgeon who did the surgery at first place would understand the general circumstances better. At last, worryingly, I decided not to give her any antibiotics. 

There is still a wire in her leg, which the surgeon said will decide later about its removal. To me, it is a bit concerning because the wire can be felt under the skin. I talked about this to the surgeon and he considered this as normal and told me just to watch for any pus or some sorts of wetness on her skin. Fortunately, there was no sign of it. Tomorrow we'll have new x-rays taken to see how things are and hear the surgeon's word about the wire's removal. Usually, I worry a lot about her hiding all the pain, but I guess I should be also as patient. 

Thanks for your care and sharing.