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Abstract

Case series summary

Four domestic cats treated surgically for complex fractures of the proximal femur were included in this retrospective case series. Medical records from October 2021 to January 2023 were reviewed for cats presenting with high-energy trauma resulting in comminuted proximal femoral fractures. All cats underwent surgical stabilisation using a lateral approach extended by complete release of the vastus lateralis muscle to improve visualisation and access. Follow-up included physical and radiographic evaluation and completion of the Feline Musculoskeletal Pain Index (FMPI). The modified approach facilitated better visualisation and implant placement. The mean surgical time was 76 mins. Bone healing was observed in three cases with available follow-up, with FMPI scores indicating complete recovery. One case required revision surgery. Minor complications were resolved. Two cats died later from unrelated trauma.

Relevance and novel information

Complete release of the vastus lateralis muscle enhanced exposure and facilitated successful treatment of complex proximal femoral fractures in cats without direct approach-related complications. This technique may be beneficial when standard exposure is insufficient in feline proximal femoral fractures.

Keywords

Proximal femoral fracture novel approach vastus release trauma

Introduction

Proximal femoral fractures in cats often pose significant clinical challenges. These fractures typically result from high-energy trauma, such as road traffic accidents or high-rise falls,^1
–4 and frequently involve complex fracture configurations with comminution and possible extension into the femoral head or neck.^5
–7 Visualisation of the fracture zone and reduction of fragments can be difficult because of surrounding soft tissue and muscular attachments.^8
–10 Even a combined craniolateral approach to the hip and lateral approach to the proximal femur with deep gluteal tenotomy may not provide sufficient exposure.^8,9,11 This case series presents a modified approach, which includes complete release of the vastus lateralis muscle to improve exposure during surgery. We describe the surgical technique, outcomes and complications in four cases.

Case series description

Case identification

Medical records from a 16-month period (October 2021 to January 2023) at the small animal clinic in Posthausen, Germany, were reviewed to identify cats with trauma-induced complex proximal femoral fractures that had been surgically repaired using a modified anatomical approach to facilitate surgical access. Data collected included signalment, diagnostics, injury type and severity, treatment details, hospitalisation duration, discharge medications and follow-up findings. All cats underwent emergency evaluation and stabilisation, including orthogonal thoracic and abdominal radiographs, abdominal focused assessment with ultrasonography for trauma (AFAST), and haematologic and biochemical analyses. Once stabilised, surgery was scheduled based on clinical condition, with a minimum delay of 12 h (range 12–72) after trauma. Stabilisation included patient-specific crystalloid infusion, multimodal analgesia and tailored antibiotic therapy. General anaesthesia was induced with intravenous (IV) propofol to effect (Narcofol 10 mg/ml; CP-Pharma Handelsgesellschaft mbH) and maintained with isoflurane in oxygen after endotracheal intubation. Intraoperative monitoring included pulse oximetry, capnography, respiratory rate, temperature, blood pressure and electrocardiogram. Affected limbs were clipped, aseptically prepared and positioned uppermost in lateral recumbency.

Surgical approach

After sterile preparation and draping, a lateral approach to the affected hip joint was performed, including a partial tenotomy of the deep gluteal muscle near its insertion on the greater trochanter. This was combined with a lateral approach to the femoral shaft.^8,9,11

To improve visualisation of the craniolateral subtrochanteric region and the transition from the metaphyseal fragments to the femoral head and trochanteric region, the vastus lateralis muscle was released from its origin at the proximal fifth of the femur. This was achieved using a Number 15 scalpel blade and a periosteal elevator to gently dissect the muscle from its origin along a transverse line down to the lateral lip of the femoral shaft. The muscle was then carefully reflected in a craniodistal direction¹⁰ (Figure 1).

Figure 1

Intraoperative view of a basilar neck/intertrochanteric fracture combined with a comminuted subtrochanteric/proximal diaphyseal fracture of the left femur of case 4 after a craniolateral approach to the hip joint with tenotomy of the deep gluteal muscle and a lateral approach to the femoral shaft. (a) Release of the vastus lateralis muscle at its proximal origin at the proximal fifth of the femur at the transverse line; (b) continuation of the release by separation of the vastus lateralis muscle from its origin along the line of the vastus lateralis and the lateral lip of the femur; (c) the vastus lateralis and deep gluteal muscles retracted and secured with stay sutures and reconstruction of the femoral neck and the proximal shaft fractures with K-wires and cerclage wires; (d) reconstruction of the femoral shaft with a cranially placed 2.0 mm locking plate; (e) reattachment of the vastus lateralis muscle to the proximal femur, with suturing to the proximal part of the 2.0 mm locking plate

Upon completion of the fracture repair, the tendon of the vastus lateralis muscle was reattached to its original location, using appropriate suture material and bone tunnels or the craniolaterally placed implant. The surgical approach was closed routinely with monofilament polydioxanone suture (MonoPlus 2/0; B Braun Vet Care) for muscular coaptation, subcutaneous suturing with monofilament glyconate suture (MonoSyn 3/0; B Braun Vet Care) and intracutaneous closure using MonoSyn 4/0 (B Braun Vet Care) or skin staples (Manipler AZ; B Braun Vet Care). A sterile adhesive wound dressing was applied to all surgical sites. Postoperative orthogonal radiographs were obtained to evaluate implant positioning and alignment. Cats were transferred to recovery and remained hospitalised for 1–3 days to allow continued analgesic and antibiotic therapy. Owners received postoperative care instructions, including strict activity restriction of their cats for 6–8 weeks and prevention of wound interference by using an Elizabethan collar for 14 days.

Regular physical and radiographic follow-up examinations were scheduled at 4–6 and 8–10 weeks postoperatively and on an individual case-by-case basis as needed. Radiographs were reviewed for implant stability and bone healing progression. Orthopaedic assessments included evaluation of lameness, range of motion (ROM) and pain on palpation. For long-term outcome assessment, the Feline Musculoskeletal Pain Index (FMPI) questionnaire was completed by owners either in person or via telephone interview.^12
–15

Results

Between 14 October 2021 and 16 January 2023, four cats with complex proximal femoral fractures were treated with the newly described approach. The mean ± SD surgical time was 76 ± 13 mins. Follow-up data were available for 3/4 cases, with a mean follow-up period of 119 ± 43 days. FMPI scores were collected for these cases. As a result of the small sample size and assuming normal distribution, no statistical analysis was performed. Instead, the individual cases are described separately (Table 1).

Table 1

Patient-specific data

Case	Age/sex/weight (kg)	Breed	Affected side	Fracture type	Implants used	Surgery duration (mins)	Outcome	FMPI score
1	3 years/NM/4.0	ESH	Left	Subtrochanteric/femoral neck/acetabular	Femur: 2.4 mm lateral, 1.7 mm cranial locking plates; acetabulum: 2.4 mm lateral locking plate	60	Wound discharge; complete recovery; died 8 months later in a car accident	80
2	1.5 years/NF/4.2	NFC	Left	Intertrochanteric/subtrochanteric/femoral diaphysis	2.3 mm lag screw; 2.3 mm lateral, 1.7 mm caudal locking plates; K-wires	90	Complete recovery	80
3	7 years/NF/4.0	ESH	Left	Femoral basilar/intertrochanteric/subtrochanteric	2.0 mm lag screw; 2.0 mm lateral,1.7 mm cranial locking plates	75	Unknown	N/A
4	9 months/NM/5.3	ESH	Left	Femoral transcervical/basilar neck/inter- or subtrochanteric	K-wires; tension band; 2.0 mm, 1.7 mm cranial locking plates	80	Seroma formation; complete recovery; died 21 months later in a car accident	80

ESH = European Shorthair; FMPI = Feline Musculoskeletal Pain Index; N/A = not available; NF = neutered female; NFC = Norwegian Forest Cat; NM = neutered male

Case 1

A neutered male European Shorthair (ESH) cat (age 3 years 2 months, weight 4 kg) presented with instability of the left proximal femur after unknown trauma on 14 October 2021. Thoracic radiographs and AFAST were unremarkable. Blood work showed mild hyperglycaemia, elevated alanine transaminase and mild thrombocytopenia. Initial treatment included constant rate infusion (CRI) with lactated Ringer’s solution (4 ml/kg/h, Ringer-Infusionslösung; B Braun Melsungen AG) and methadone (0.2 mg/kg IV, Comfortan 10 mg/ml; Dechra), followed by a fentanyl-ketamine CRI (fentanyl 0.5 µg/kg/h, Fentadon; Dechra and ketamine 0.6 µg/kg/h IV, Ketamine 100 mg/ml; CP-Pharma) and amoxicillin-clavulanic acid (20 mg/kg q8h IV, AmoxiClav Hikma, 1.2 g; Hikma Pharmaceutica). Premedication consisted of midazolam (0.2 mg/kg IV, Midazolam-ratiopharm 5 mg/ml, Ratiopharm) and fentanyl (5 µg/kg IV). Anaesthesia followed standard protocol.

Radiography revealed a comminuted subtrochanteric femoral fracture extending into the medioproximal femoral neck and into the lesser trochanter, together with an oblique fracture of the left acetabulum. Because of gas accumulation in the surrounding soft tissue and a skin wound smaller than 1 cm, the femoral fracture was classified as a grade 1 open fracture.

Initially, the acetabular fracture was reduced, and a nine-hole 2.4 mm locking plate (Eickloxx; Eickemeyer–Medizintechnik für Tierärzte KG) was inserted, spanning from the ilium to the ischium. The femoral fracture was then stabilised with a 15-hole 2.4 mm locking plate placed laterally, extending from the greater trochanter to the distal third of the femur, with three locking screws in both proximal and distal segments. A 12-hole 1.7 mm locking plate was applied cranially, with two screws in the distal femoral neck and one in the distal femoral diaphysis. Surgical time was 60 mins. Postoperative radiography revealed good alignment and anatomical reduction of the acetabular fracture. Satisfactory functional alignment of the left femur was achieved. In the area of the most distal screw of the laterally placed plate, an outbreak fragment of the transcortex could be seen. The cat was discharged on postoperative day 2 with amoxicillin-clavulanic acid (20 mg/kg PO q12h for 5 days) and meloxicam (0.1 mg/kg PO q24h for 10 days). Poor confinement and wound interference following poor owner compliance may have contributed to wound dehiscence 3 weeks postoperatively requiring antibiotics for another 14 days. The 4-week follow-up radiographs showed early evidence of healing of the acetabular fracture but no evidence of femoral fracture healing. Mild lameness (grade I/IV) and muscle atrophy were noted. Because of the persistent absence of bone healing and concerns of non-union, revision surgery was performed 6 weeks postoperatively with debridement of the fracture ends and packing of the fracture gap with autologous corticocancellous bone graft harvested from the corresponding ilial wing. No implant adjustments or tightening of screws were required. At 12 weeks after the initial procedure, radiography confirmed complete acetabular healing and progressive femoral healing. The cat was fully weightbearing, with no lameness, discomfort or restriction in ROM. At 5 months, the cat showed a return to full function without clinical signs of implant-associated pain or ROM limitations. In a follow-up call 33 months after surgery, the owners reported that the cat had died in a subsequent car accident 8 months postoperatively. The retrospective FMPI score was 80, indicating full functional recovery before death.

Case 2

A neutered female Norwegian Forest Cat (age 1.5 years, weight 4.2 kg) was referred on 18 December 2021 after unknown trauma. The cat had a left hindlimb lameness, with a skin wound on the left thigh caused by the initial trauma, which had been treated by the referring veterinarian. Physical examination and thoracic imaging were unremarkable except for a non-weightbearing lameness of the left hindlimb. Sedation was achieved using ketamine (2 mg/kg IM), midazolam (0.2 mg/kg IM) and medetomidine (3 µg/kg IM, Domitor 1 mg/ml; Vetoquinol), followed by anaesthesia induction as per protocol. Radiography revealed a comminuted intertrochanteric to subtrochanteric fracture of the left femur, featuring a longitudinal splitting of the proximal segment and separation of the femoral head fragment. In addition, a proximal diaphyseal fracture with craniodorsal displacement was observed.

Intraoperatively, the split proximal fragments were anatomically apposed using a 2.3 mm cortical screw (Eickloxx) in lag fashion and a 1.0 mm K-wire (Kirschner wire; MarMed). A 12-hole 2.3 mm locking plate (Eickloxx) was applied laterally from the greater trochanter to the mid-diaphysis. Fixation was achieved using one unicortical and one bicortical locking screw, as well as an additional cortical screw in lag fashion at the proximal segment. The distal segment was stabilised with three bicortical locking screws. In addition, a nine-hole 1.7 mm locking plate was placed caudally for reinforcement, with two proximal and two distal locking screws. Satisfactory functional alignment was achieved (Figure 2). The duration of surgery was 90 mins. The cat was discharged the next day with meloxicam for 10 days. Follow-up radiography at 5 and 8 weeks showed active healing. At the final examination, the cat exhibited mild lameness (grade I/IV) and slight discomfort during hip extension and rotation. Cage rest was discontinued and gradual reintroduction of activity was advised. At 3-year follow-up, the cat showed no lameness, pain or ROM limitation. Radiography confirmed complete healing without signs of implant loosening or osteolysis. FMPI score was 80, and the owner reported full functional recovery.

Figure 2

Mediolateral and craniocaudal radiographs of the femur of case 2. (a) Initial radiographs before surgery: comminuted intertrochanteric/subtrochanteric fracture with longitudinal splitting of the proximal femoral segment and isolation of the capital fragment and proximal fracture of the femoral diaphysis with caudodorsal displacement; (b) postoperative radiographs: reconstruction of the fractures described in panel a with a laterally placed 2.3 mm and caudally placed 1.7 mm locking plate, including a single cortical screw placed in lag fashion; (c) radiographs 5 weeks postoperatively showing active bone healing and callus formation; (d) radiographs 9 weeks after surgery showing achievement of complete bone healing

Case 3

A neutered female ESH cat (age 7 years, weight 4.0 kg) presented on 1 December 2022 for emergency evaluation after unknown trauma. After stabilisation with IV methadone and fluid therapy, the cat was hospitalised for cardiovascular monitoring. Thoracic and abdominal imaging, including AFAST, were unremarkable. Laboratory results showed a mild leukocytosis with neutrophilia. The next day, sedation was achieved with ketamine (2 mg/kg IM), midazolam (0.2 mg/kg IM) and medetomidine (3 µg/kg IM), followed by anaesthesia as previously described. Radiography revealed a left basilar neck/intertrochanteric fracture accompanied by a comminuted subtrochanteric/proximal diaphyseal femoral fracture, with cranioproximal displacement of the diaphysis. Surgical repair included a 2.0 mm cortical lag screw (OrthoLine; Arthrex) and antirotation pin for the femoral neck. The proximal femur was stabilised using a lateral 12-hole 2.0 mm locking plate (OrthoLine) and a cranial 10-hole 1.7 mm locking plate (OrthoLine). The 2.0 mm plate was secured using three unicortical screws proximally and three bicortical screws distally. The 1.7 mm plate was fixed with two unicortical screws proximally and two distally. Functional alignment was restored. The duration of surgery was 75 mins. The cat was discharged the next day with a 10-day course of meloxicam. No follow-up data, including radiography and the FMPI questionnaire, were available, as the owners did not return for scheduled follow-up assessments. In a telephone conversation 2 years after the surgery, the owners reported that no wound healing problems or ROM restrictions had been observed.

Case 4

A neutered male ESH cat (age 9 months, weight 5.3 kg) was referred on 16 January 2023 for left hindlimb lameness after unknown trauma. The cat exhibited moderate anaemia and leukocytosis with neutrophilia. Other findings were unremarkable except for a non-weightbearing lameness of the left hindlimb, with severe pain in the hip region and instability of the proximal femur. After stabilisation with fentanyl and ketamine CRI, anaesthesia was induced with methadone and medetomidine. Radiography and CT revealed an oblique transcervical/basilar femoral neck fracture accompanied by an intertrochanteric and comminuted subtrochanteric fracture, including a sagittal splitting from the trochanteric to subtrochanteric region and comminution of the proximal diaphysis. Surgical repair included five 1.0 mm K-wires, two cerclage wires and a pin-and-tension band construct (0.6 mm cerclage wire; MarMed) for femoral neck and trochanteric stabilisation. Two locking plates (2.0 mm and 1.7 mm, OrthoLine) were applied cranially to the femur, with two proximal and two distal locking screws. The alignment of the functional axis was satisfactory. The duration of surgery was 80 mins. The cat was discharged on 18 January with meloxicam for 10 days. Radiography at 4 and 8 weeks confirmed active healing, accompanied by clinical improvement. After the cat returned to normal activity, the formation of a seroma was observed at 16 weeks. As a result of the high suspicion that the seroma could have been caused by soft tissue irritation from the implants, associated with the increased activity, the implants were partially removed. The screws and the plates were removed completely. The pins, the two cerclages and a part of the tension band wire could not be removed completely because of bone in-growth and over-growth. At that time, radiography confirmed full healing, and the cat showed no lameness or ROM restriction.

In a follow-up telephone call at 22 months postoperatively, the owner reported the cat had died 6 weeks previously in a subsequent car accident. The FMPI score was 80, indicating a full orthopaedic recovery before death.

Discussion

This case series demonstrates the feasibility and advantages of complete vastus lateralis muscle release in complex proximal femoral fractures in cats. Improved visualisation enabled precise reduction and implant placement, critical for successful outcomes given the limited bone stock in this region. Despite the invasive nature of this approach, no major complications were directly attributable to the muscle release procedure. However, the extent to which the delayed union in one case was attributable to the more invasive approach, potentially compromising the blood supply to the proximal fragments, is difficult to quantify.

The cases involved highly complex fractures affecting the most proximal compartment of the femur, including the femoral head, neck and trochanteric region, typically characterised by severe comminution. Given the extent and complexity of the fragmentation, a minimally invasive osteosynthesis approach would have been more desirable for optimising fracture biology. However, this was not only technically impracticable but could not allow the necessary adequate visualisation of the proximal femoral structures. Extending the standard approach by dissecting the vastus lateralis muscle significantly improved visualisation of key anatomical landmarks – including the femoral neck, greater trochanter and subtrochanteric region – as has also been described in the human literature.^16,17 This improved exposure greatly, facilitated the anatomical reconstruction of fracture components and allowed the safe, accurate placement of implants. Notably, an inadvertent intra-articular or unstable implant insertion was avoided. Moreover, the mean duration of surgery remained relatively short at 76 mins, possibly mitigating the risks associated with prolonged anaesthesia.¹⁸ Given the invasiveness of the technique, careful atraumatic soft tissue handling remains essential in line with Arbeitsgemeinschaft für Osteosynthesefragen (AO) principles, so as to prevent further soft tissue trauma and preserve regional perfusion.^19
–21

It remains unclear whether dissection-related soft tissue trauma contributed to the initial lack of bone healing in case 1. However, severe initial trauma, fracture complexity and the possible inadequate postoperative immobilisation due to poor owner compliance could also have been contributory factors. The minor complication in case 1, involving a mild wound discharge, was attributed to a superficial wound infection likely caused by self-trauma due to licking. In case 2, the minor complication involving seroma formation was considered secondary to soft tissue irritation due to the implants. In both cases, the issues were successfully managed: the wound discharge in case 1 resolved after prolonged antibiotic therapy, and the seroma in case 2 regressed after partial implant removal. In case 2, because of the fracture configuration with comminution and fissuring of the cranial parts of the trochanteric and subtrochanteric region, cranial implant placement was not possible, and a plate was placed from the caudal side. The mean FMPI score of 80 in 3/4 cases (score in one case was unknown) indicates a full return to normal function and quality of life. The FMPI is a well-established and reliable tool for assessing how well cats cope with orthopaedic conditions and pain, with a maximum score of 80 reflecting a completely normal and pain-free state.^12
–15

This study’s limitations include its retrospective nature and small sample size, which precludes statistical analysis and definitive conclusions. Future studies should employ a prospective design with standardised evaluation intervals and larger cohorts to enable more robust data interpretation and comparative analysis. The bone healing of similar fractures without the vastus release should also be compared to determine the possible effects of the new approach on healing properties.

Conclusions

The release of the vastus lateralis muscle is a valuable addition to surgical approaches for complex proximal femoral fractures in cats. It improves surgical access to the trochanteric and femoral neck regions, facilitates anatomical reconstruction and was not associated with adverse long-term outcomes in this case series.

Footnotes

Acknowledgements

Artificial intelligence programs (ChatGPT and DeepL) were used to improve the language and comprehension of the text.

Accepted: 15 July 2025

Author note

The abstract to this work was presented in a poster presentation at the 24th ESVOT Congress in 2024.

Conflict of interest

PAS works as a consultant for Arthrex. LR declares no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Ethical approval

The work described in this manuscript involved the use of non-experimental (owned or unowned) animals. Established internationally recognised high standards (‘best practice’) of veterinary clinical care for the individual patient were always followed and/or this work involved the use of cadavers. Ethical approval from a committee was therefore not specifically required for publication in JFMS. Although not required, where ethical approval was still obtained, it is stated in the manuscript

Informed consent

Informed consent (verbal or written) was obtained from the owner or legal custodian of all animal(s) described in this work (experimental or non-experimental animals, including cadavers, tissues and samples) for all procedure(s) undertaken (prospective or retrospective studies). For any animals or people individually identifiable within this publication, informed consent (verbal or written) for their use in the publication was obtained from the people involved.

ORCID iD

Linus Rustemeyer

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Complete vastus release to repair complex proximal femoral fractures: description and follow-up in four cats