VCOT September 2025 – Ortho Part 1: Supercutaneous Plating & 3D-Printed HIF Guides

In this Simini Small Animal Surgery Podcast episode, we continue our orthopedic coverage from the September 2025 issue of Veterinary and Comparative Orthopaedics and Traumatology (VCOT) by exploring a common surgical objective: maximizing stability while minimizing surgical trauma.

One study evaluates an innovative fracture fixation strategy that combines the biological advantages of external skeletal fixation with the mechanical benefits of locking plate technology. The second investigates whether 3D-printed patient-specific guides can improve the accuracy and safety of transcondylar screw placement in dogs with humeral intracondylar fissures.

In this episode:

✅ İnal et al. — Evaluated supercutaneous locking plates (SLPs) for the management of non-articular radial, ulnar, and tibial fractures in dogs and cats. Applied externally above the skin using locking screws, SLPs achieved a median healing time of approximately 50 days, with most patients bearing weight within 1–2 days postoperatively. Although 24% of cases developed minor screw-track discharge, no implants required removal and all complications were managed conservatively. The findings suggest SLPs may provide a low-profile alternative to traditional external fixators while preserving fracture biology and minimizing soft tissue disruption. 

✅ Kershaw et al. — Investigated the use of 3D-printed patient-specific guides (PSGs) for transcondylar screw placement in canine humeral intracondylar fissures. Using a novice surgeon model in paired cadaver limbs, PSGs produced significantly more accurate entry and exit points than traditional aiming devices. Most notably, three of seven screws placed with standard aiming devices would have violated the joint, whereas zero articular penetrations occurred with PSG-guided placement. The study highlights the potential for patient-specific technology to improve surgical precision and reduce catastrophic technical errors. 

Together, these studies demonstrate that advances in orthopedic surgery increasingly focus on working smarter rather than working bigger—using technology and biomechanics to achieve safer, more predictable outcomes.

🎓 Journal Articles Discussed

• Inal et al. — Minimally Invasive Radial–Ulnar and Tibial Fracture Management with Supracutaneous Locking Plates in Dogs and Cats
• Kershaw et al. — Patient-specific Guides Improve the Accuracy and Safety of Transcondylar Screw Placement—A Cadaveric Study in the Canine Humerus

📚 From the September 2025 issue of VCOT

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Transcript

SPEAKER_02 0:04

Hi, I'm Carl Damiani, and this is the Simene 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 5, 2025 of Veterinary and Comparative Orthopedics and Traumatology, and we're exploring two studies that focus on one of the most important goals in orthopedic surgery, achieving stability while minimizing surgical trauma. First, we'll look at a clinical study by Inal et al. evaluating supercutaneous locking plates for the management of radial ulnar and tibial fractures in dogs and cats. This minimally invasive technique blends concepts from external skeletal fixation and locking plate technology, offering a potentially less cumbersome alternative for fracture stabilization. We'll examine healing times, complications, and how advanced CT analysis was used to quantify fracture healing throughout the study. Then we turn to Kershaw et al., who investigate the use of three-dimensional printed patient-specific guides for transcondyler screw placement in canine humoral intracondyler fissures. Accurate screw placement in these cases can be technically demanding, and the consequences of error can be significant. This cadaveric study compares patient-specific guides with traditional aiming devices and provides valuable insight into how emerging surgical technologies may improve precision and safety in orthopedic procedures. Two studies, one common theme, improving outcomes through smarter surgical execution, whether it's minimizing soft tissue disruption during fracture repair or enhancing the accuracy of implant placement with patient-specific technology, both papers highlight how advances in technique can help us achieve better, more predictable results for our patients. Let's dive in.

SPEAKER_04 2:11

So when you're managing a complex fracture, you're usually stuck choosing between two evils.

SPEAKER_03 2:17

Right. It's always a trade-off.

SPEAKER_04 2:18

Exactly. I mean you use an external fixator, which preserves the fracture hematoma, but it leaves your patient wearing this like really bulky entanglement prone hardware.

SPEAKER_03 2:30

Aaron Powell Oh, yeah, they catch it on everything. Or, well, you go with traditional internal plating, it's sleek and hidden, sure, but you're stripping the periosteum and just wrecking that crucial biological environment. Trevor Burrus, Jr.

SPEAKER_04 2:40

Right, just to get the metal on the bone. But uh, what if you applied a locking plate above the skin? That is the mission for today's deep dive.

SPEAKER_03 2:49

Aaron Powell Yeah, we're looking at a really fascinating recent prospective study in NAL et al. 2025. They tackled this exact trade-off by taking a locking compression plate and applying it completely outside the body.

SPEAKER_04 3:00

Aaron Powell So a supercutaneous locking plate or SLP, and they evaluated this approach on 33 non-articular radial ulnar and tibial fractures.

SPEAKER_03 3:10

Right. Across 15 dogs and 15 cats. And the clinical results are honestly they're wild. The median fracture healing time was about 50 days.

SPEAKER_04 3:17

Aaron Powell Which is solid on its own, but um the true breakthrough here is the functional recovery. Most of these animals were bearing weight on the affected limb within just one to two days post-op.

SPEAKER_03 3:29

Yeah, one to two days. It's crazy. And the biomechanics behind that early weight bearing are just brilliant.

SPEAKER_04 3:35

Aaron Powell I mean, how does it work compared to the old hardware?

SPEAKER_03 3:37

Aaron Ross Powell Well, traditional fixators rely on pins that connect to a distant heavy bar via clamps, which creates a long lever arm and allows for all this micromotion.

SPEAKER_04 3:47

Right, which you definitely don't want.

SPEAKER_03 3:49

Exactly. But the SLP sits mere millimeters above the skin. The locking screws thread directly into the plate itself.

SPEAKER_04 3:58

Oh wow. So it creates a fixed angle construct.

SPEAKER_03 4:01

Yes, exactly, which minimizes shear forces right at the bone screw interface.

SPEAKER_04 4:06

Yeah.

SPEAKER_03 4:06

That absolute rigidity is why they can walk almost immediately.

SPEAKER_04 4:10

You are basically getting the biological healing of an external fixator, but with the rigidity of a locking plate.

SPEAKER_03 4:15

You get the nail on the head.

SPEAKER_04 4:16

Okay, but let's uh let's unpack this for a second. Anytime you have metal constantly breaking the skin barrier, you're inviting pin side infections. Is that a deal breaker here?

SPEAKER_03 4:24

Well, it is the obvious vulnerability. I mean, the paper did note a 24% minor complication rate for superficial screw track discharge.

SPEAKER_04 4:32

Wait, 24%? Doesn't that persistent drainage threaten the entire construct?

SPEAKER_03 4:37

You would think so, right. But crucially, zero cases actually required implate removal.

SPEAKER_04 4:42

Really? Zero cases.

SPEAKER_03 4:44

Zero. And it really comes down to the physical profile of the hardware. Think about a standard fixator. It's a mess of clamps, sharp edges, exposed threads.

SPEAKER_04 4:53

Oh yeah, they trap all sorts of organic debris and harbor dense biofilms.

SPEAKER_03 4:57

Exactly. But the SLP is literally just a smooth, low-profile plate. A simple wipe with a povidone iodine solution keeps the screw tracks clean.

SPEAKER_04 5:07

Because there is simply nowhere for the gross debris to hide. That makes sense.

SPEAKER_03 5:11

Right. It significantly lowers the barrier to entry for trying this.

SPEAKER_04 5:14

But practically speaking, so what does this all mean for the OR tomorrow? What's the practical technique shift?

SPEAKER_03 5:20

Aaron Powell Well, patient anatomy is going to dictate your approach. The goal is minimally invasive closed reduction. But you know, if you're working on a cat's radius or ulna, their bones are just too small.

SPEAKER_04 5:30

Yeah, way too small for blind placement.

SPEAKER_03 5:32

Aaron Powell Right. So you're almost certainly going to need an open approach to visualize the fracture and align the plate properly.

SPEAKER_04 5:38

Aaron Powell And the authors heavily emphasize that anatomical reality, don't they?

SPEAKER_03 5:42

They do. And to make that fixation hold without compromising the joints, they strongly recommend using polyaxial screws.

SPEAKER_04 5:49

Okay. Polyaxial screws. Why those specifically?

SPEAKER_03 5:52

Aaron Powell Because these screws can be angled up to 10 degrees inside the plate hole. So you can actively direct them to grab the thickest cortical bone.

SPEAKER_04 5:59

Ah, I see. While safely steering clear of hidden fissures or the articular surface.

SPEAKER_03 6:06

Exactly.

SPEAKER_04 6:07

It's essentially like installing external scaffolding on a brick building, but instead of drilling straight in, you can bend the anchors to dodge the building's internal plumbing.

SPEAKER_03 6:16

That's a perfect analogy. You get maximum grip without hitting the pipes.

SPEAKER_04 6:21

But you know, because we are talking about open approaches on small feline bones, managing that exact skin implant interface during closure is critical.

SPEAKER_03 6:29

Oh, absolutely. It is the ultimate failure point for any supercutaneous hardware.

SPEAKER_04 6:34

Right, because you have screws creating an open highway straight to the marrow. If the local tissue environment isn't meticulously managed before you close the skin, you are guaranteeing an infection.

SPEAKER_03 6:45

Yeah. Which is why relying on standard saline to flush the site right before you suture is just a massive blind spot.

SPEAKER_04 6:51

Totally. I mean, independent head-to-head studies show saline leaves 42% of bacteria behind in delicate surgical wounds.

SPEAKER_03 6:58

Aaron Powell Which is way too high when you're leaving hardware bridging sterile bone to the outside world.

SPEAKER_04 7:02

Exactly. That is where Semini Protect Livage is a much better fit for your protocol. It's a non-antibiotic lavage you use right at the point of closure.

SPEAKER_03 7:11

Trevor Burrus And that drops the residual bacteria to 0%. Yeah.

SPEAKER_04 7:14

0%. It doesn't add time to the workflow, it just actively protects that highly vulnerable interface before you throw your final stitches.

SPEAKER_03 7:22

Which ties perfectly back into this study because protecting the biological environment is the entire philosophy behind the SLP.

SPEAKER_04 7:29

Aaron Powell So the primary takeaway from Anal et al. 2025 is that supercutaneous plating is a genuinely viable, low-profile alternative to external fixators.

SPEAKER_03 7:40

Yeah. You preserve the fracture hematoma, gain excellent stability, and basically skip the hardware nightmare.

SPEAKER_04 7:46

Trevor Burrus But you know, it leaves us with this final provocative thought. If we're putting the scaffolding on the outside and these patients are comfortably walking the very next day, it completely forces us to rethink the aftermath. Right. How does this permanently rewrite our standard protocols for post-op pain management and mandatory cage rest? If the hardware is external and the dog feels perfectly fine, do we really need to lock them up for six weeks?

SPEAKER_03 8:12

It's a great question.

SPEAKER_04 8:13

Definitely something to chew on the next time you're reviewing a post-op x-ray.

SPEAKER_00 8:20

Here's another useful insight from the literature.

SPEAKER_04 8:28

You know, there are uh certain procedures that just inherently spike your heart rate in the OR. Like you've got a Spaniel or a French bulldog on the table with a humeral intercondylar fissure, and well, you're prepping to place a transcondylar screw.

SPEAKER_03 8:42

Yeah, that is a highly stressful moment for any surgeon. Right.

SPEAKER_04 8:46

So welcome to today's deep dive. We're abstracting some actionable surgical intelligence from a really interesting recent article, Kershaw et al. 2025. And our mission today is to answer a critical question for your practice. Do 3D printed patient-specific guides actually improve surgical accuracy and safety compared to standard aiming devices?

SPEAKER_03 9:09

Aaron Powell Yeah, it's a vital question, really, because the traditional medial to lateral placement of a transcondylar screw is just technically demanding. I mean the anatomy itself fights you.

SPEAKER_04 9:19

Because of the slope, right? Trevor Burrus, Jr.

SPEAKER_03 9:20

Exactly. The medial epicondyl has this steep sloping geometry. So it makes it incredibly difficult to find a stable purchase point.

SPEAKER_04 9:27

Yeah.

SPEAKER_03 9:28

And the risk of your drill slipping down that slope and violating the articular surface is just a constant threat.

SPEAKER_04 9:33

Aaron Powell Which makes the design of the study so compelling, I think. They took seven pairs of cadaveric canine four limbs, but they deliberately handed the drill to a novice surgeon. Aaron Powell Right.

SPEAKER_03 9:43

A total worst-case scenario stress test.

SPEAKER_04 9:45

Yeah, exactly. So one limb in each pair got a standard commercial aiming device, and the other got a custom 3D printed patient-specific guide or a PSG. Trevor Burrus, Jr.

SPEAKER_03 9:56

And that stress test is exactly why the data is so revealing. A novice drilling a complex sloping condyle with a generic tool is well, it's a recipe for disaster.

SPEAKER_04 10:06

Absolutely.

SPEAKER_03 10:07

But when we look at the outcomes, the PSG group was significantly more accurate for both the entry and exit holes.

SPEAKER_04 10:13

I mean, a novice drilling seven limbs with a generic device sounds sweat-inducing. Tell me the custom guides actually moved the needle on those complication rates.

SPEAKER_03 10:20

Oh, the contract is stark. Three out of the seven screws placed with a standard aiming device would have violated the joint.

SPEAKER_04 10:26

Wait, three out of seven?

SPEAKER_03 10:27

Yeah, nearly half. But zero out of seven screws in the PSG group penetrated the joint. Zero.

SPEAKER_04 10:33

Wow. Three out of seven is nearly a 50% failure rate with the generic tool. That completely changes the risk calculus in the OR.

SPEAKER_03 10:43

He really does.

SPEAKER_04 10:44

Using a standard aiming device on a complex condyle is, I mean, it's like trying to balance a ladder on a boulder.

SPEAKER_03 10:49

That's a great way to put it.

SPEAKER_04 10:50

Right. Without a custom footprint that locks into the bone's exact topography, the drill bit is just going to wander.

SPEAKER_03 10:57

Aaron Powell But let me push back here for a second. Custom guides can't just be a foolproof magic bullet. What is the uh operational catch?

SPEAKER_04 11:06

Well, there is always a catch, right? It comes down to your interoperative technique. There was one instance where the trajectory with the patient-specific guide was actually off-axis.

SPEAKER_03 11:16

Okay. And why was that?

SPEAKER_04 11:17

When the researchers investigated it, they found the surgeon hadn't cleared enough soft tissue off the medial epicondyle.

SPEAKER_03 11:23

Ah, so the attachment of the flexor carbi radialis was still like interposed between the guide and the humerus.

SPEAKER_04 11:29

Precisely. If the guide relies on the exact topography of the bone, any remaining soft tissue essentially distorts that surface map.

SPEAKER_03 11:37

Right. So the fit is compromised. Exactly. The guide couldn't sit completely flush, which means with a PSG, meticulous sharp dissection right down to the bare bone is absolutely mandatory. You have to earn that perfect fit.

SPEAKER_04 11:50

So your surgical technique actually has to shift. You aren't just exposing the bone, you are preparing a highly specific docking station.

SPEAKER_03 11:57

Yes. But compare that required effort to the alternative. The standard aiming device was so ergonomically unstable. Yeah, just to stop the tip from slipping off the lateral condyle, they had to pre-drill a small indentation into the bone just to seed the device.

SPEAKER_04 12:16

Drilling a divot just to use the tool perfectly illustrates the inherent instability of the traditional method.

SPEAKER_03 12:22

Aaron Powell It really does. So the actionable take-home message here is that patient-specific guides offer immense technical superiority and safety for transcondylar screw placement.

SPEAKER_04 12:31

As long as you prep the site. Which leaves you with this to ponder. If 3D printed guides can eliminate joint penetration in the hands of a novice, are we approaching a future where using a generic aiming device for this procedure is considered an unacceptable standard of care? Or will the costs and logistics of 3D printing keep these guides out of everyday veterinary practice?

SPEAKER_01 13:06

That's it for this episode of the Simony Small Animal Surgery Podcast. This show is brought to you by Semini 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.