Should I be a "Gardener" or a "Carpenter" for this Fracture Repair?

Amy Kapatkin, DVM, Dip ACVS, Assistant Professor of Surgery
University of Pennsylvania, Philadelphia, PA 19104-6010

Orthopedic implant technology and understanding is constantly improving and increasing. Understanding of bone biology, balance between implant stability versus vascular viability is also increasing but some of these ideas may really be opinions of individual surgeons. Balancing these two factors is really the goal of fracture repair. How individual surgeons decide on their fixation method becomes experience with similar fracture situations, ability to reconstruct the fracture versus buttressing the fracture and personal preferences.

Many surgeons are of the belief that decisions on fixation devices should be made on whether or not the fracture is reconstructable versus nonreconstructable. For example, a 2-piece short oblique fracture is one in which complete bony reconstruction can be obtained via pin(s) and wire or bone plating. A fracture that has 10 comminutions will be one in which a buttress type construction will have to be used. This is where some of the controversy occurs. Some surgeons feel strongly that these types of fractures should be repaired with strict "biological osteosynthesis" techniques (the gardener). Other surgeons have shown that using standard AO/ASIF techniques are equally successful in managing these nonreconstructable fractures (the carpenter).

"Biological osteosynthesis" was a term recently used to describe techniques in fracture fixation that consciously make no attempts to rebuild the bony column. Instead, the surgeon aligns the joints, does minimal to no tissue disruption around the fracture, and then chooses a repair method that does not remove the extraosseous blood supply from the bone. Direct (primary) bone healing is not going to occur anyway in a highly comminuted, buttress situation. Very often this technique is done in a closed fashion or something coined "open but do not touch" (OBDNT) approach. Other purported advantages of this technique are it's shorter surgical time and that small fracture gaps are not created. These small gaps have large bony strain that is not contusive for bone formation.

Surgical techniques considered to be more biologic are external skeletal fixators (ESF) with or without a "tie-in" configuration, plate-rod constructs and interlocking nails (IN). Some of these techniques are designed so that the apparatus can be disassembled over time to allow more load- sharing of the implants and the bone as healing occurs. Of course, all implants used must still be rigid constructs or fracture healing will not occur.

The AO/ASIF systems have withstood the test of time of being reliable, rigid fracture fixation apparatuses. Although standard plating techniques require removal of soft tissues under the plate area and large incisions, the true AO/ASIF techniques do not recommend destruction of blood supply to the bone. Dynamic construction plates (DCP) and Limited Contract- Dynamic Construction Plates (LC-DCP) are often used in the plate-rod systems that propose they are being biologic. Standard plating techniques can be used as long as the surgeon accepts a buttress construct and does not try to reconstruct all the small fragments. So although some surgeons feel those using standard AO techniques are not being biologic, the real key to this discussion is how you use the implant versus the implant chosen by the surgeon. It has been shown, that using a plate alone properly in a buttress fashion in gap fractures can be used very successfully.

Methods that can be used by the surgeon to be more biologic in fracture repairs are to help maintain the extraosseous blood supply by careful soft tissues handling, proper use of implants (example- low speed drilling in ESF) and cancellous bone grafting.

This talk with take case examples of different fracture repairs and show why certain techniques were used. Discussion will include whether they were more in the line of being gardener or a carpenter and why some were successful and others were not.