VCOT May 2025 – Ortho Part 1: Universal DFO Guides, Giant-Breed CCL Surgery & Radius Exposure

In this Simini Small Animal Surgery Podcast episode, we continue our orthopedic coverage from the May 2025 issue of Veterinary and Comparative Orthopaedics and Traumatology (VCOT) by focusing on a question that underpins every successful orthopedic procedure: how can better planning improve surgical outcomes?

From universal deformity correction guides and giant-breed cranial cruciate surgery to rethinking surgical exposure of the canine radius, these studies challenge traditional assumptions and demonstrate how thoughtful planning can improve precision, reduce complications, and simplify orthopedic procedures.

In this episode:

✅ Cheon et al. — Evaluated a novel universal distal femoral osteotomy (DFO) guide designed to replace patient-specific 3D-printed cutting guides. Using an adjustable titanium rail-and-pin system, the universal guide achieved correction accuracy within 2 degrees, matching custom 3D-printed guides without requiring CT-based manufacturing or production delays. The findings suggest that a reusable, shelf-ready system can provide the same surgical precision while dramatically simplifying preoperative logistics. 

✅ Guénégo et al. — Reviewed outcomes of AMA-based cranial closing wedge osteotomy (CCWO) in 204 giant-breed dogs (>50 kg) with cranial cruciate ligament disease. By aligning the anatomical and mechanical axes and eliminating excessive shear forces, the procedure achieved grade 4 bone healing in 100% of dogs by eight weeks and an exceptionally low surgical site infection rate of just 0.5%. Double locking plate fixation, postoperative antibiotics, and a 15-day Robert Jones bandage were key components of the protocol. 

✅ Lin et al. — Compared the traditional craniomedial approach (CMA) and the craniolateral approach (CLA) to the canine radius in cadavers. The CLA provided significantly greater exposure (19.4 cm² vs. 13.8 cm²) while avoiding the median neurovascular bundle and allowing simultaneous access to the ulna through the same incision. These findings suggest the CLA may offer substantial advantages for fracture reduction, plating, and minimally invasive fixation techniques. 

Together, these studies highlight a simple but powerful principle: better orthopedic outcomes begin long before the first screw is placed.

🎓 Journal Articles Discussed

• Cheon et al. — Comparing the Accuracy of Patient-Specific Guide and Universal Guide for Distal Femoral Osteotomy in Dogs
• Guénégo et al. — Modified Cranial Closing Wedge Osteotomy (AMA-Based CCWO) to Treat Cranial Cruciate Ligament Deficient Stifle in 204 Dogs Over 50 Kg: Magnitude of the Craniocaudal Angulation of the Proximal Tibia and Rate of Surgical Site Infection
• Lin et al. — Does the Craniolateral Approach Provide Better Exposure to the Radius than the Craniomedial Approach for Internal Fracture Fixation in Dogs?

📚 From the May 2025 issue of VCOT

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Transcript

SPEAKER_01 0:04

Hi, I'm Carl Damiani, and this is the Simony Small Animal Surgery Podcast, your fast-focused update on what matters most from the latest small animal surgical literature. In each episode, we break down key articles from the veterinary journals and translate them into surgical insight you can use today, not someday. This episode continues our orthopedic coverage from issue 3, 2025, of veterinary and comparative orthopedics and traumatology, and we're focusing on a question that underpins every successful orthopedic procedure. How can better planning and surgical execution improve outcomes? First, we'll review a study by Chian et al. Exploring factors that influence orthopedic treatment success and what their findings mean for clinical decision-making in everyday practice. Next, we'll turn to Genego et al. who evaluated AMA-based cranial closing wedge osteotomy in more than 200 giant breed dogs with cranial cruciate ligament disease. The study examines proximal tibial alignment, complication rates, and an impressively low incidence of surgical site infection, offering valuable insight into osteotomy planning for some of our largest canine patients. Finally, Linadal challenge a long-standing assumption in fracture surgery by comparing craniolateral and craniomedial approaches to the radius. Their cadaveric study asks a simple but important question. Does one approach provide better exposure for fracture fixation? The answer could influence how surgeons approach antibrachial fracture repair and minimally invasive plating procedures. Three studies. One central message better orthopedic outcomes start with better planning, from pre-operative alignment analysis to surgical approach selection and technical execution. Let's dive in.

SPEAKER_03 1:56

You know, walking into the OR for uh a complex distal femoral osteotomy, it usually forces a really tough choice. Like, do you wait weeks and pay a premium for a patient-specific, perfectly tailored, 3D printed guide?

SPEAKER_02 2:11

Right, or do you just go in freehand, which means relying purely on your own spatial awareness to nail those multiplanar geometric bone cuts.

SPEAKER_03 2:19

Exactly.

SPEAKER_02 2:20

And I mean it is the classic struggle between logistical reality and surgical precision. Freehand multiplanar correction is notoriously unforgiving. But custom guides, well, they tether you to CT scans, high costs, and all those manufacturing delays.

SPEAKER_03 2:34

Which is exactly why we are bringing you today's targeted clinical deep dive. Our mission here is to deliver fast surgical decision-making intelligence that you can actually use in the OR tomorrow.

SPEAKER_02 2:43

And today we were looking at a paper that directly challenges that classic trade-off. It is Qion et al. Right.

SPEAKER_03 2:49

So Chion et al. 2025 tested a novel alternative to the patient-specific custom print.

SPEAKER_02 2:54

They did. They developed a titanium universal DFO guide that is designed to fit literally any patient. And they tested it head-to-head against custom guides on both cadavers and 3D printed bone models.

SPEAKER_03 3:08

Okay, so let's visualize this. Because I originally thought of this like clothing, like a tailored suit versus a highly adjustable belt. But it actually sounds much more like woodworking.

SPEAKER_02 3:17

Woodworking is a great way to think about it, yeah.

SPEAKER_03 3:19

Because a custom guide is like a single-use pre-drilled jig. It only does one thing. But this universal guide, it sounds like a highly adjustable miter gauge. So how does a single piece of titanium actually adjust to accommodate so many complex bone geometries?

SPEAKER_02 3:34

So the mechanism relies on a multi-axis sliding rail system combined with these adjustable pin sleeves.

SPEAKER_03 3:40

Okay.

SPEAKER_02 3:40

Instead of having preset channels drilled into a block of plastic that perfectly hugs the bone's topography, the universal gut guide features movable arms. You manually set your desired angles and then those arms lock into place.

SPEAKER_03 3:52

Wait, hold on. If the entire point of a custom guide is to eliminate human visual error by having the drill paths preset, doesn't relying on sliding rails just reintroduce the exact human error we were trying to avoid?

SPEAKER_02 4:05

I mean, that is a totally fair question, and it was the critical hypothesis of the study, but the data actually tells a completely different story.

SPEAKER_03 4:13

Really? What did they find?

SPEAKER_02 4:14

The mean correction error for the universal guide was functionally identical to the custom print.

SPEAKER_03 4:19

Oh.

SPEAKER_02 4:19

Both landed at less than two degrees of error.

SPEAKER_03 4:22

Less than two degrees. Wow.

SPEAKER_02 4:24

Yeah, meaning there was no statistically significant difference in accuracy between the two.

SPEAKER_03 4:28

So an off-the-shelf, fully adjustable mechanism actually matched a bespoke 3D print.

SPEAKER_02 4:34

Functionally, yes. And I mean this changes the pre-operative timeline entirely. The universal guide just lives permanently on your shelf.

SPEAKER_03 4:40

Right. So you bypass the pre-op CT scans needed just for guide manufacturing, and you erase the 3D printing wait times entirely. You are literally ready to cut immediately.

SPEAKER_02 4:50

Exactly. But there is a catch. Oh. It shifts the burden from the preoperative phase to the interoperative phase.

SPEAKER_03 4:56

Ah, okay. So what changes for the surgeon holding the drill?

SPEAKER_02 5:00

Well, you have to be meticulous about dialing in those locking arms and placing the temporary pins during the surgery itself. It demands active, precise calibration in the moment.

SPEAKER_03 5:11

Meaning you have to visually confirm and accurately place those temporary pins to lock down your angles before making the cut.

SPEAKER_02 5:19

Right. You're spending that extra time interoperatively manipulating the hardware and dialing in those sliding rails.

SPEAKER_03 5:24

And because you are doing that, the tissues are exposed longer. That extra handling makes meticulous infection control at closure even more critical after you finally plate that bone.

SPEAKER_02 5:35

It really does. That extended manipulation exposes a massive blind spot in standard closure protocols. I mean, routine saline irrigation is the standard, right?

SPEAKER_03 5:45

Right. Everybody uses saline.

SPEAKER_02 5:46

But independent head-to-head studies demonstrate that saline actually leaves 42% of bacteria behind in the surgical site.

SPEAKER_03 5:52

Wait, leaving almost half the bacteria behind after placing a titanium plate? That is a terrifying statistic.

SPEAKER_02 5:58

It is. Which makes reinforcing that final step non-negotiable. And this is the exact use case for Symity Protect Livage. Oh, right. Yeah. It is a non-antibiotic lavage used right at the point of closure just before suturing. In those same head-to-head studies where saline left 42% of bacteria behind, simity left 0%.

SPEAKER_03 6:18

Okay, so you aren't overhauling your entire protocol. You just do your normal routine and then add a 60-second final wash.

SPEAKER_02 6:25

Exactly. It targets the resistant bacteria and biofilms that are basically invisible when you are closing up. It just removes what saline misses.

SPEAKER_03 6:33

Offering a vital layer of defense without adding complex steps or, you know, contributing to antibiotic resistance. Precisely. So bringing it all back to Qion et al. 2025, the take-home message for you today is that a universal DFO guide delivers the clinical accuracy of a patient-specific 3D print.

SPEAKER_02 6:50

But with the immediate readiness of a tool sitting right on your shelf, it proves that smart mechanical design can successfully match the precision of custom anatomical modeling.

SPEAKER_03 6:59

Which leaves us with a final thought for you to mull over. As these universal, highly adjustable mechanisms continue to achieve equivalent surgical precision, will the time and immense expense of custom 3D printing eventually become completely obsolete in veterinary orthopedics?

SPEAKER_02 7:15

It is definitely something to think about before your next deformity correction.

SPEAKER_00 7:23

Let's move on to the next article.

SPEAKER_02 7:41

Oh, absolutely. Every time.

SPEAKER_03 7:42

Right. I mean, you know the mechanics, you know exactly how to make the cut. But the sheer physics of it are just terrifying.

SPEAKER_02 7:48

Yeah, and the clinical context here is what makes our deep dive today so critical. Historically, doing a standard TPLO on these massive dogs, uh, especially those with the steep tibial plateau angle over 30 degrees, it just makes complication rates skyrocket.

SPEAKER_03 8:04

Right. Because the reported surgical site infection rates, or SSI, they sit anywhere from 9% to like a staggering 37.5%.

SPEAKER_02 8:12

Aaron Powell Almost 4 in 10 dogs. It's wild. Genego et al. 2025 actually call it the balcony effect.

SPEAKER_03 8:17

Yeah, let's reframe that balcony effect for the actual joint mechanic, just so you can visualize it on your next shift. Imagine putting a massive boulder on a steep, icy driveway. Trevor Burrus, Jr.

SPEAKER_02 8:25

Well, I like that analogy. Because it's not that the driveway is weak, right?

SPEAKER_03 8:29

Exactly. It's that the physics are forcing everything downhill. That massive caudal mechanical low generates severe shear force. So the hardware struggles to hold back gravity, and well, that causes micromotion.

SPEAKER_02 8:42

Right. And suddenly you've created this perfect breeding ground for bacteria.

SPEAKER_03 8:45

Aaron Powell, So if the slope and the shear force are causing that micromotion, it really seems like we have to abandon the standard TPLO entirely for these massive dogs.

SPEAKER_02 8:53

Well, that deduction is exactly the core of this paper. Their solution is the AMA-based CCWO. So in this retrospective study of 204 dogs over 50 kilograms, they fundamentally shifted the mechanics.

SPEAKER_03 9:06

Because instead of the radial cut of a TPLO, which you know just rotates the plateau to change the slope, the cranial closing wedge osteotomy physically removes a precise bone wedge.

SPEAKER_02 9:16

Precisely. By calculating this cut based on the anatomical mechanical axis, they profoundly alter the load distribution. It brings the anatomical and mechanical axis into perfect alignment post-op.

SPEAKER_03 9:28

Which neutralizes that boulder on a driveway shear force, and they achieve that perfect alignment in 82% of the dogs.

SPEAKER_02 9:34

Yeah, and here is the really crazy part. With the micromotion eliminated, the SSI rate wasn't 30%. It wasn't even 10%.

SPEAKER_03 9:42

Wait, really? What was it?

SPEAKER_02 9:43

It was 0.5%. Literally one single dog out of 204. Plus, 100% of the osteotomies reach grade 4 bone healing by eight weeks.

SPEAKER_03 9:53

Wow. Just 0.5%. That's incredible. But getting a 0.5% infection rate obviously requires more than just a different saw angle.

SPEAKER_02 10:01

Oh, definitely. The authors combined the cut with a highly specific triad of interventions. First, the osteotomy was stabilized using strong double locking plates.

SPEAKER_03 10:10

And those were specifically tailored to the dog's exact weight and the width of the proximal tibia, right, to combat those immense bending forces.

SPEAKER_02 10:17

Exactly. Second was strict adherence to post-op antibiotics, and third, a Robert Jones bandage, or RJB, applied immediately and maintained for 15 solid days.

SPEAKER_03 10:27

Okay, I have to push back on that last point a bit. Leaving an RJB on a giant breed dog for 15 days sounds like a massive headache for both the clinic and the owner.

SPEAKER_02 10:35

Oh, it is a lot of work.

SPEAKER_03 10:36

I mean, we usually worry about pressure sores or ischemic injuries with bandages left on that long.

SPEAKER_02 10:41

It definitely raises a vital risk versus reward calculation for the surgical team. But remember, these young heavy dogs are famously non-compliant. The bandage acts as a non-negotiable physical barrier.

SPEAKER_03 10:54

So it mechanically protects the joint capsule sutures, the fascia, and uh the subcutaneous tissues from being overstretched while the soft tissues heal.

SPEAKER_02 11:04

Exactly. It is literally holding the scaffolding in place where the concrete sets. And looking at the data, you know that one dog in the study that did get an infection?

SPEAKER_03 11:12

Yeah, what happened with that one?

SPEAKER_02 11:13

Well, the owner took the RJB off after a week, and the dog immediately licked the site and ripped out two centimeters of sutures.

SPEAKER_03 11:20

Oh wow. Well, that immediately proves the necessity of the barrier right there. So the anatomical correction of the AMA-based CCWO solves the internal micromotion.

SPEAKER_02 11:28

Right. And the RJB solves the external micromotion. So for your giant breed patients over 50 kilos with CCL ruptures, this is huge. Utilizing an AMA-based CCWO stabilized with double locking plates, post-op antibiotics, and a 15-day RJB, it turns a highly risky procedure into an incredibly stable one.

SPEAKER_03 11:47

It's a proven strategy to drastically minimize your SSI risk.

SPEAKER_02 11:51

Absolutely.

SPEAKER_03 11:52

So given the massive, undeniable success of the 15-day RJB in this study, it really makes you wonder: is it time we reconsider our general resistance to long-term post-op bandaging for all proximal tibule osteotomies in giant breeds? Something to mull over before your next massive surgery. Because if you're going to build that scaffolding, you better make sure it stays up long enough to handle the load.

SPEAKER_00 12:17

Turning the page.

SPEAKER_03 12:48

But what if the cranium immedial approach, the CMA we've all, you know, relied on for decades, is actually fighting your fracture reduction. Trevor Burrus, Jr.

SPEAKER_02 12:56

Well, that is exactly the problem.

SPEAKER_03 12:57

Aaron Powell Welcome to today's deep dive. We are jumping into a new study, Lynn et al. 2025, to figure out if this traditional approach is making the OR harder than it needs to be. Okay, let's unpack this. Aaron Powell Yeah.

SPEAKER_02 13:10

So the friction with the CMA really comes down to the anatomy you are forced to work around.

SPEAKER_03 13:13

Aaron Powell The roadblocks, basically.

SPEAKER_02 13:15

Exactly. I mean you have to navigate the cephalic vein, pull that extensor carpi radialis laterally, and then you are dealing with the median neurovascular bundle right at the proximal radius.

SPEAKER_03 13:25

It sounds like trying to parallel park while dodging a fire hydrant and a pedestrian at the same time.

SPEAKER_02 13:32

That is a great analogy. The more you retract that extensor for visibility, the more tension you create.

SPEAKER_03 13:38

And that tension is actively fighting your bone reduction.

SPEAKER_02 13:41

Right. It is a major reason why surgeons deal with underproduction or rotational malalignment.

SPEAKER_03 13:45

Here's where it gets really interesting. The researchers behind Lynn et al.

SPEAKER_02 13:59

They did. So they looked at six canine cadavers to compare the actual bone exposure between the two approaches.

SPEAKER_03 14:04

And the numbers are pretty wild.

SPEAKER_02 14:06

Yeah, they really are. The CLA yielded 19.4 square centimeters of exposure.

SPEAKER_03 14:11

Wow.

SPEAKER_02 14:11

Compared to just 13.8 with the CMA. And it also provided significantly greater proximal width.

SPEAKER_03 14:17

So almost 20 square centimeters versus under 14. That is a massive leap in visibility.

SPEAKER_02 14:22

It really is.

SPEAKER_03 14:22

And I am assuming that extra real estate isn't just magic, right? You are just bypassing the muscle bellies entirely on that lateral side.

SPEAKER_02 14:29

Right. That is the mechanical advantage. What's fascinating here is that the CLA corridor is relatively free of major tendons.

SPEAKER_03 14:36

Oh, nice.

SPEAKER_02 14:37

Yeah. And crucially, when you elevate the supinator muscle during the CLA, you don't encounter any neurovascular bundles within one centimeter of the proximal articular surface.

SPEAKER_03 14:48

Wait, really? No bundles at all.

SPEAKER_02 14:51

None. You bypass that whole medium bundle entirely.

SPEAKER_03 14:54

So what does this all mean for your actual practice? You have almost 20 square centimeters of exposure and no neurovascular bundle in the way.

SPEAKER_02 15:04

Well, mechanically, it changes everything about where you drop the plate.

SPEAKER_03 15:08

Right.

SPEAKER_02 15:09

You place your bone plate directly on the flat cranial lateral surface of the radius.

SPEAKER_03 15:13

Which is huge because with the CMA, putting the plate medially can cause issues, right?

SPEAKER_02 15:18

Oh, absolutely. If your plate isn't perfectly contoured there, you can create asymmetrical compression.

SPEAKER_03 15:23

And that's how you end up with a surgically induced valgus deformity?

SPEAKER_02 15:27

Exactly. But the lateral side is naturally flat, so the plate just, you know, sits flush.

SPEAKER_03 15:31

So you aren't forcing the bone to conform to a badly contoured plate.

SPEAKER_02 15:35

Right. And you don't have to contour as aggressively to deal with the natural procurvatum of the radius either.

SPEAKER_03 15:39

Plus, you aren't competing for space with the extensor carpi radialis, which I mean that should minimize tendon irritation post-op.

SPEAKER_02 15:47

Definitely. And if we connect this to the bigger picture, there is a massive bonus if the dog comes in with a concurrent ulnar fracture.

SPEAKER_03 15:55

Oh, because of the approach angle.

SPEAKER_02 15:57

Yeah. The CLA lets you access and repair the ulna through the exact same skin incision.

SPEAKER_03 16:02

No way, the exact same one.

SPEAKER_02 16:04

Yep. You just make a deep fascial incision, uh, retract the flexor carpi ulnaris, and boom, you have your exposure.

SPEAKER_03 16:10

That is incredible because the CMA would require a completely separate skin incision, right?

SPEAKER_02 16:15

Exactly. So the lateral approach drastically cuts down on surgical time and patient trauma.

SPEAKER_03 16:19

Okay, so the takeaway here is clear. For internal fracture fixation of the canine radius, the CLA provides wider, safer bone exposure than the traditional CMA.

SPEAKER_02 16:28

But you know, this raises an important question. This data from Lynn et al. 2025 comes from a cadaver study where tissue is naturally more pliable.

SPEAKER_03 16:36

Right, which is always a limitation. Yes. Exactly. But if the CLA is this superior in a cadaver, wouldn't its space-saving nerve-avoiding benefits be even more critical in a live patient dealing with rigid, swollen trauma tissue?

SPEAKER_02 16:51

Oh, absolutely. When that surgical field is tight, you definitely don't want to be fighting your own retractors. So if you are dealing with live muscle spasms and severe trauma, that extra room could be a total game changer. That is definitely something to ponder before you scrub in for your next radius repair.

SPEAKER_00 17:10

That's it for this episode of the Simini Small Animal Surgery Podcast. This show is brought to you by Simony Protect Livage, our interoperative lavage developed to target resistant bacteria and biofilms where traditional solutions of saline and post op antibiotics fall short. If you're interested in learning more or trying out your own procedures, you'll find information and links in the show notes. For listening, and we'll see you in the next episode.