Surgeons look to bust trauma myths

In trauma medicine, decisions are made quickly. Surgeons rely on their knowledge, training, and experience to choose the appropriate course of treatment. But what if some of that decision-making is based not on evidence and proof but on myth? A panel of trauma surgeons took on that question Friday as they assumed the role of “Mythbusters.”

Intra-articular fracture myths
Robert F. Ostrum, MD,
examined the following notions surrounding intra-articular fractures:

  • Myth 1: Severe intra-articular fractures should be treated in minimal fashion to leave bone stock for later surgery.
  • Myth 2: Patients with these fractures will require a later reconstructive procedure regardless of treatment.
  • Myth 3: Surgical intervention in comminuted intra-articular fractures has a high complication rate and may leave the patient with no good salvage plan or with infection.

In tibial plateau fractures, he noted, a common expectation is that the patient will ultimately need a total knee arthroplasty (TKA), so the injury is addressed with a midline incision and double plating. “This is bad thinking that will lead to bad results,” Dr. Ostrum said. In one series of almost 14,000 TKAs, just 0.0045 percent were subsequent to tibial plateau fractures.

“The articular reduction may not be as important as mechanical alignment and stability,” he continued. “As much as we think these patients with severe fractures are going to get bad arthritis, less than 7 percent actually do. Waiting for soft tissues to resolve and then making two small incisions for double plating is more effective than the previously used long midline incision early on.”

In pilon fractures, he said, fracture grade and quality of reduction correlate with the final result, so that comminution is a significant factor. Posttraumatic arthritis in ankle fractures is much more common than in the knee, Dr. Ostrum noted. As with the knee, the two-stage technique of external fixation followed by open reduction and internal fixation (ORIF) seems preferred.

Dr. Ostrum discussed the bone stock question as it applies to calcaneus fracture. Wound problems with these fractures are much more common with a nonsurgical approach and Maryland and AOFAS scores are considerably higher in ankles treated with surgery.

“So the question is, are you better off leaving them alone and doing a late fusion, or fixing them and doing a late fusion? Nonsurgical treatment just to have bone stock for the calcaneous is not a good idea.”

Although separating the variables of severity of injury and the quality of articular reduction is difficult, “these patients do deserve a legitimate attempt to try to get their injury reduced,” he concluded.

Treating calcaneous and proximal tibia fractures
Paul Tornetta III, MD,
addressed a second set of myths, namely:

  • Myth 1: Nonsurgical treatment of calcaneous fractures equals surgical care.
  • Myth 2: Proximal tibia fractures should not be nailed.

Potential advantages of surgery for calcaneous fractures include tuberosity alignment, subtalar congruence, and a restored width for shoe wear. Disadvantages include wound complications and scarring about the tendons. In addition, risk factors for complications—such as smoking, insulin-dependent diabetes, and open fractures—must be considered.

“These are significant risks with the extended lateral approach,” Dr. Tornetta said. Accurate evaluation of surgical outcomes is complicated by the absence or presence of workers’ compensation.

“Nonsurgical management can be reasonable for smokers older than 40 years of age, noncompliant patients, workers compensation patients, and sedentary older patients,” Dr. Tornetta said. The limited number of comparative studies show no difference in pain or general health outcome measures between surgical and nonsurgical treatment. Surgery, however, results in fewer fusions, an earlier plateau period, an earlier return to work, and—for women in particular—restoration of height and width to facilitate shoe wear.

“You are going to get your best and your worst results from surgical management,” he said, “and nonsurgical management is going to be some sort of a bell curve.” The ideal surgical candidate is a young female patient who is active, nonsmoking, nondiabetic, compliant, and willing to accept the risk of a poor result.

Dr. Tornetta noted that nailing proximal tibia fractures has the advantage of decreased infection and of load sharing, while plating offers alignment (theoretically) and intra-articular extension.

“Proximal tibial fractures are hard to nail. However, if you get the perfect portal, the proper trajectory, do nailing in extension, and use blocking screws, the myth is clearly busted.”

Amputation myth
Robert A. Probe, MD,
tackled a “myth” regarding amputation:

  • Myth: Limb salvage is the preferred method for mangling injuries to the lower extremity.

Although salvage is an option in many more cases, measures to avoid amputation may have become extreme or harmful to the long-term benefit of the patient.

In weighing decisions whether to amputate, physicians can turn to reported experience and outcomes and to decision-making tools. Sometimes the decision of whether to amputate is “very easy,” Dr. Probe said. When it is not, scoring systems have been used. But “as much as we would like to have objective data that help make a comfortable decision on the night of injury, that’s proven not to be the case.”

One long-held belief has been dismissed: that if a patient has an insensate plantar foot, the patient probably does not need that limb.

Given current technologies and social strategies, said Dr. Probe, results for amputation and reconstruction are comparable. Current guidelines provide support for which limbs may be saved but not for which limbs should be amputated. Given the poor outcomes for both treatment options, continued efforts should be given to improved treatment strategies and technologies. Nonmedical factors should be an integral part of future strategies to optimize functional outcomes.

Disclosures: Dr. Ostrum—AONA, Synthes; Dr. Tornetta—Smith & Nephew,Wolters Kluwer Health, Lippincott Williams & Wilkins; Dr. Probe—Stryker, Synthes.

Prepared by Terry Stanton, senior science writer for AAOS Now.