Beyond Plates: How Surg'X Interlocking Nails are Advancing Veterinary Orthopaedics

Introduction to Interlocking Nails

Interlocking Nails have emerged as the gold standard for treating long bone fractures in human medicine, thanks to their biological and mechanical advantages over traditional plate fixation methods. These innovative implants are inserted into the intramedullary canal of the bone, a minimally invasive approach that preserves the surrounding soft tissues and vascularity of the periosteum, promoting better healing.

The Interlocking Nail construct offers superior mechanical resistance to compression, bending, and torsional forces, compared to traditional plate or plate-rod constructs, making it particularly well-suited for comminuted fractures where bone fragments are severely displaced or shattered. ILNs are placed neutral to the long axis of the nail-bone construct and, therefore, provide a more homogenous area moment of inertia and are better able to resist bending forces than plates.1 By spanning the length of the bone and being secured with interlocking screws, these nails provide exceptional stability and alignment, facilitating proper bone healing.

In contrast, traditional plate fixation techniques, which require more extensive soft tissue dissection and periosteal stripping, can compromise blood supply and potentially impede the healing process. Additionally, plates are less resistant to bending and torsional forces, rendering them less suitable for highly unstable fracture patterns. It has been shown that intramedullary implants have a more uniform stress distribution due to their central position in the bone.2

Challenges in Veterinary Orthopaedics

Despite being the gold standard for treating long bone fractures in human medicine, Interlocking Nails have not seen widespread adoption in veterinary orthopaedics for dogs and cats. This is primarily due to the technological limitations of the products previously available for the veterinary segment.

The unique anatomical structures and biomechanical demands of quadrupedal animals like dogs and cats posed significant challenges. Traditional Interlocking Nail designs lacked the necessary anatomical curvature to match the natural contours of long bones in these species. This mismatch could lead to improper alignment or a too caudal insertion point, thus damaging the tibial plateau or CrCL insertion.

Furthermore, inadequate distal anchorage and limited locking options of the first generation of veterinary Interlocking Nails restricted the indications and effectiveness of these implants for certain fracture types or locations.

The minimally invasive nature of Interlocking Nails, which is a key advantage in human trauma cases, was also difficult to fully leverage in veterinary procedures due to the difficulty of aiming distally, due to the inaccuracy of the instrumentation used in veterinary medicine (fluoroscopy is systematically used in human medicine), and slack problems with older-generation nails.

Overall, the technological gap between human and veterinary orthopaedic implants hindered the widespread adoption of Interlocking Nails in the treatment of long bone fractures in dogs and cats, despite their potential benefits.

The Surg'X Interlocking Nail System

The Surg'X system represents a significant advancement in veterinary orthopaedics, overcoming the technological limitations of previous interlocking nail products for small animals. By incorporating advanced features from human surgical devices, the Surg'X system offers a comprehensive solution for the treatment of long bone fractures in dogs and cats.

This innovative system introduces several key features that were previously unavailable in the veterinary market.

Anatomical Curvature

The Surg'X Interlocking Nail System features a unique patented curved design, with a radius specifically engineered to match the natural curvature of long bones in dogs and cats. This anatomical curvature offers significant advantages over traditional straight intramedullary nails.

By closely following the bone's natural shape, the Surg'X nail restores the anatomical profile of the limb after fracture repair. This helps maintain proper biomechanics and weight distribution, reducing abnormal stresses that could impede healing or lead to future issues.

Additionally, the curved nail design allows for a more cranial insertion point on the tibia. This strategic placement avoids conflicts with the cranial cruciate ligament insertion, preventing potential disruption or impingement of this crucial stabilising structure in the stifle joint.

The anatomical curvature also enables more distal anchoring of the nail within the femur. This expanded footprint expands the system's indications, making it suitable for a wider range of fracture patterns, including those involving the metaphyseal or even epiphyseal regions near the joints.

Advanced Versatile Locking

The Surg'X system incorporates an advanced angle-stable locking mechanism, providing superior fixation and versatility in treating complex fractures. This locking system allows for multiple screw options, enabling surgeons to customize the construct according to the specific fracture pattern.

One notable feature is the of the Surg'X system is that it offers a 3rd cranio-caudal orthogonal screw. It is possible to: use only 2 orthogonal screws, which can be placed in a small fragment, enabling very proximal or very distal fractures to be treated, or use 3 screws on either or both of the 2 fragments to increase stability and strength.

“One of the new features of the CAS-ILN is the presence of a third locking hole, allowing a third screw to be inserted perpendicular to the others, providing multiple locking options and screw distribution. Overall, 6 different screw distributions were chosen in this study, proving the versatility of this contoured nail.1

The Surg'X system's locking holes are strategically positioned closer to the extremities of the nail. This design innovation expands the range of indications, allowing for effective treatment of metaphyseal and even epiphyseal fractures. Traditionally, such fracture patterns have posed challenges for intramedullary nailing systems, but the Surg'X system overcomes these limitations, offering a comprehensive solution for a wide spectrum of long bone fractures in small animals.

Cannulated Design

The Surg'X Interlocking Nail System features a cannulated design that offers significant advantages during surgery. The cannulation, or hollow centre, allows for guided insertion of the nail using a guide pin. This makes it easier to insert the nail into the distal fragment with a minimally invasive approach.

Moreover, the cannulated design enables intra-operative locking verification. By utilising the cannulation, surgeons can confirm the accurate positioning of the locking screws during the procedure. ?Misplaced screws are one of the most frequent complications with pre-existing nails; this feature enhances surgical precision and reduces the risk of complications associated with improper locking.

The cannulated design streamlines the surgical process, minimising the need for additional imaging or verification steps, this avoids the systematic use of fluoroscopy for distal locking, as in human surgery. It provides surgeons with real-time feedback and control during the critical locking phase, contributing to successful fracture fixation and improved patient outcomes.

Titanium Alloy Material

The Surg'X Interlocking Nail System is made from Ti-6Al-4V ELI (Extra Low Interstitial) titanium alloy, a material renowned for its excellent biocompatibility and high mechanical strength. This alloy's unique properties make it an ideal choice for orthopaedic implants in both human and veterinary medicine.

One of the key advantages of Ti-6Al-4V ELI is its modulus of elasticity, which is closer to that of cortical bone compared to other metallic implant materials. This similarity in elastic modulus helps reduce the phenomenon known as "stress shielding," where the implant bears a disproportionate amount of the load, hindering the bone's ability to carry its natural share of the stress. By allowing better transmission of stresses between the bone fragments, the Surg'X nails promote more effective healing.

In addition to its favourable elastic properties, Ti-6Al-4V ELI offers exceptional biocompatibility, minimising the risk of adverse reactions or rejection by the body. This titanium alloy is highly resistant to corrosion and has a long-standing track record of successful use in medical implants, ensuring safe and reliable performance within the body.

The Surg'X nails also feature coloured anodization, with different colours corresponding to different sizes. This color-coding system enhances ergonomics and ease of use for veterinary surgeons, allowing for quick and accurate identification of the appropriate implant during procedures.

Product Development Process

Surg'X maintains stringent quality standards in product development that are comparable to those used by manufacturers of human surgical implants. Their rigorous multi-phase process involves extensive design, prototyping, and testing to ensure the highest levels of performance and safety.

The development journey begins with a comprehensive definition of user needs, garnering input from Veterinary Surgeons to understand their requirements and challenges. Concept research and computer-aided design then bring these ideas to life, iterating through multiple designs before advancing to prototyping stages.

Prototypes undergo cadaveric testing and rigorous biomechanical evaluations to assess their suitability for the intended applications. This data-driven approach allows for refinements and optimisations before proceeding to industrialisation and pre-production manufacturing phases.

Even after initial production, Surg'X conducts pilot clinical studies, closely monitoring the implants' performance in real-world surgical settings. This meticulous process ensures that each Surg'X product meets the highest standards of quality, safety, and efficacy before being released to the veterinary market.

Veterinary Collaboration

Surg'X understands the importance of involving veterinary experts throughout the product development process. From the initial definition of user needs to clinical evaluation, the company collaborates closely with a team of seven French veterinarians who are specialists in orthopaedic surgery and recognised opinion leaders.

These veterinary surgeons, representing six different veterinary healthcare facilities (public veterinary colleges and private veterinary hospitals), provide invaluable insights from a scientific and clinical perspective. Their expertise is instrumental in evaluating the biomechanical performance, clinical aspects, and ergonomics of Surg'X implants and instrumentation before they are introduced to the market.

By fostering this collaborative approach, Surg'X ensures that its interlocking nail system and other products are developed with a deep understanding of the real-world challenges and requirements faced by veterinary professionals. This commitment to involving clinicians throughout the development process results in solutions that are not only technically advanced but also practical and user-friendly for veterinary surgeons.

Late last year, the Vi Advisory Board attended a bespoke Wetlab at the School of Veterinary Medicine at the University of Nottingham, to evaluate the system, since then, several clinical cases have since been successfully treated by ViAdvisory Board members. Following a recent feline case, Dr Christoph St?rk DVM, DES ChirPA, Dip ECVS, MRCVS said of the system: “Overall, I am very happy with the Surg’X Interlocking Nail System so far”.

Surg'X Training Opportunities

Veterinary Instrumentation is committed to providing comprehensive training opportunities for veterinary professionals on the Surg'X Interlocking Nail system. Following a fully booked wet-lab course in March 2024, Vi are delighted to be hosting a second hands-on course in November this year. The November Surg'X Interlocking Nail Training Course will once again incorporate wet-lab exercises to give attendees practical experience with the system. Feedback from the first training course was incredibly positive, with the average rating of the overall course from attendees at 9.62/10.

The one-day training course will take place on Friday, November 29th, at the prestigious Queens Veterinary School, University of Cambridge. This immersive training program is designed to equip Veterinary Surgeons with the skills and knowledge necessary to effectively utilise the Surg'X Interlocking Nail system in their clinical practice.

During the wet-lab exercises, participants will have the opportunity to work directly with the Surg'X implants and instrumentation under the guidance of experienced instructors. These hands-on sessions will cover various aspects of the Interlocking Nail System, including proper implant selection, surgical techniques, and post-operative management.

By attending this training course, veterinary professionals can gain confidence in using the advanced Surg'X Interlocking Nail system, which offers numerous advantages over traditional orthopaedic implants. The course will provide a comprehensive understanding of the system's unique features, such as its anatomical curvature, advanced locking options, and cannulated design, ensuring optimal patient outcomes.

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References

1.?????? Roels J, Hebrard L, Saban C, Maggiar A, Ragetly G, Leperlier D, Pucheu B, Guillemot A, Viguier E, Gauthier O, Cachon T. Retrospective study of the early clinical experience with a precontoured angle-stable interlocking nail for fracture repair in dogs and cats. Am J Vet Res. 2024 Jan 27:1-10. doi: 10.2460/ajvr.23.09.0207. Epub ahead of print. PMID: 38262138.

2.?????? Deprey J, Blondel M, Saban C, Massenzio M, Gauthier O, Moissonnier P, Viguier E, Cachon T. Mechanical evaluation of a novel angle-stable interlocking nail in a gap fracture model. Vet Surg. 2022 Nov;51(8):1247-1256. doi: 10.1111/vsu.13837. Epub 2022 Jun 8. PMID: 35675144.