The upcoming Daily Dilemmas in Trauma course (see sidebar for details) will discuss challenges surgeons are likely to encounter on call. Course directors Paul Tornetta III, MD, FAAOS, and J. Tracy Watson, MD, FAAOS, as well as other distinguished trauma surgeons, will guide participants in strategies and techniques for managing fractures and other orthopaedic injuries.
Two topics the course will address are (a) injuries to the syndesmosis and methods for reduction and (b) controversies in the management of femoral neck fractures. To provide a preview of what course participants will learn about handling such cases, Drs. Tornetta and Watson talked with AAOS Now about their perspectives and tips for achieving successful outcomes.
AAOS Now: How important is it for the syndesmosis to be perfectly reduced?
Dr. Tornetta: Let’s start with the understanding that an anatomic reduction is always the goal. That said, the syndesmosis must be adequately reduced, but it’s likely that it doesn’t have to be anatomically reduced. There are a number of trials that look at functional outcomes versus the displacement, and those trials have shown that somewhere around 2 mm to 3 mm of translation and maybe up to five to eight degrees of rotation do not negatively affect functional outcomes at one to two years. Again, one never shoots for anything but anatomic. We don’t always get there, so it is good to know that every study that has been done has shown the same thing: When you’re well reduced, there’s a good outcome. Interestingly, none of the studies that have evaluated the reduction of the syndesmosis has evaluated length. That is a critical component, particularly for a fibular fracture that is not being fixed or a high fibular fracture associated with syndesmotic disruption. It is a missing piece in the evaluation, and it should be a clear goal to maintain length as well.
Dr. Watson: I agree. The issue is, what do you mean by perfectly reduced, and how far off can your reduction be? If it is close but still off by a minimal amount, then probably, as Dr. Tornetta and the studies have suggested, it’s really not going to make a difference. However, what is the threshold of malreduction that is going to be a real problem for us? I think you need to get it as perfect as you can by whatever means available to you. My feeling is, if you’re there, you might as well make it as perfect as possible, to the extent of performing an open reduction and visually confirming an anatomic reduction.
Do all unstable syndesmoses need to be stabilized?
Dr. Tornetta: Most of us would fix any instability that we find, because we’re worried about late syndesmotic widening, which has no simple solution. However, it does seem that there are some syndesmotic injuries that probably do not require fixation. Additionally, there’s evidence that stress positive SE4 injuries that are taken to the operating room have the same rate of instability of the syndesmosis as displaced SE4 ankle fractures. However, patients with stress positive SE4 injuries treated nonoperatively are allowed to walk at six weeks, and we don’t see late syndesmotic instability. There is probably a spectrum of injury that is not yet completely defined that would suggest that not all syndesmotic injuries require surgery. I think any static syndesmotic widening has to be stabilized, but syndesmotic instability per se, if the ankle can remain reduced during healing, may not require reconstruction. More research needs to be done in this area, but carefully, as there is no evidence that adding a syndesmotic screw in questionable cases causes any problems.
What are the most proven methods for reduction? Do they all have to be opened?
Dr. Watson: I don’t think there’s one specific method that is any better than most. However, if there’s any question, and you’re still unsure of the accuracy of reduction, then I feel you are obligated to actually open the syndesmosis anterolaterally and reduce it under direct vision. This is probably the best way to confirm that you have achieved a good (anatomic) reduction. Whatever technique you feel comfortable with and is reproducible is fine. The bottom line is if you’re unclear about how well your reduction is or how well you’re doing it, then you need to actually open it, evaluate the pathology at the syndesmotic area, and reduce it anatomically.
Dr. Tornetta: I don’t disagree. I think there are a few things we know as far as radiographs are concerned. Again, I would separate this into Weber B and C injuries, at the level of syndesmosis, because I think they are slightly different. For Weber B injuries, once the fibula is fixed, if there is no bump or bolster under the calcaneus that would anteriorly translate the talus, then the syndesmosis is generally lined up. I confirm alignment using a lateral radiograph. It has been shown, as far back as the late 1980s, that a lateral radiograph is a better way to evaluate syndesmotic reduction than the anteroposterior (AP) or mortis view. Not necessarily for length, but if length is restored, using the position of the fibula on the lateral and matching it to the normal ankle is quite effective in confirming the translational reduction.
Femoral neck fractures
For a young person with a displaced femoral neck fracture, how do you reduce and how do you fix?
Dr. Watson: I think most people would say if it’s significantly displaced, you would want it as close to anatomic as you can get. In a study that was never published, with blinded investigators, they produced unstable femoral neck fractures in cadavers. Multiple surgeons then performed a closed reduction, pinned them, and then the reduction was reevaluated and confirmed on X-ray. They then graded their reductions—whether they were adequate or inadequate. The cadaver reductions were then dissected so the researchers could visualize directly the quality of reduction. The results found that if you thought your reduction was inadequate, it probably was, as determined by the post-fixation dissection. If you honestly graded your reduction as reduced and anatomic, the dissections confirmed in most cases that it probably was reduced. By the way, the reductions were actually pretty accurate. The conclusions demonstrated that if the surgeon was honest about the quality of his or her closed reduction, it correlated with the actual open findings. Thus, it may not be necessary to open every unstable fracture in younger patients. However, if it’s significantly displaced, and there is any question, you will open it through whatever approach you are comfortable with. I think if you can get it close to perfect when you are performing closed methodologies, that’s fine, but if it’s off, you probably should perform an open reduction.
Dr. Tornetta: I would agree. I think that if the reduction looks qualitatively good on the AP and lateral views on a fracture table, then I prefer not to open the fracture. If it is off, then I prefer an anterior approach to directly access and reduce the fracture. There are two good ways to fix the fracture once reduced: cannulated screws and fixed angle devices. The randomized FAITH (Fracture Fixation in the Operative Management of Hip Fractures) trial, which assessed these techniques, found no real difference in reoperation or complications as long as basicervical fractures were excluded.
How have you incorporated the findings of the HEALTH (Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty Versus Hemi-Arthroplasty) trial into your practice?
Dr. Watson: That study looked at hemiarthroplasty versus total hip arthroplasty and found that it didn’t really make a difference. However, I think it depends on the age and activity level of the patient. If you have a 65-year-old—which isn’t that far away from me—I’d probably want a total hip in hopes that if I live a lot longer and remain active, I can avoid an acetabular revision down the road, rather than wearing away my acetabulum and requiring a late acetabular revision when I’m not as healthy and less likely to tolerate a revision surgery. I think it depends on the characteristics, activity level, demographics, and comorbidities of each patient. It’s hard to generalize, and they didn’t really go into that much detail in that study to stratify the various patient characteristics. I think the study made a case that for an older, less active individual, a hemiarthroplasty functions just as well as a total hip. I don’t think I would change what I do in my practice, however. I don’t do total hips, but when I have a younger patient, activity- and health-wise, even though they are “elderly,” I have my joint colleagues evaluate them for a possible total hip replacement.
Dr. Tornetta: The study looked at the time to get up and go, pain, and revision rates, and there really wasn’t a difference. The problem is that it’s a relatively short-term study for an arthroplasty trial. Some smaller studies have shown a difference in a younger population. The HEALTH trial is larger and spans a greater age range, so it didn’t show that same difference. The question becomes: Will there be a difference in 10 years? Can you apply these data the same way to an 80-year-old as you can to a 70-year-old? Because people are living longer and are more active. If you’re 65 or 70 years old and you’re going to live 20 years on a hip, that’s potentially a different thing if you have a hemiarthroplasty versus a total hip compared to an 85-year-old household ambulator. I think that the way in which we can apply the trial is to say that there’s stronger evidence now that in an older, less active population, a unipolar arthroplasty or a bipolar is equal to a total hip even in functional outcomes. However, in the younger patient, I don’t yet think that the question is answered. I also defer to my arthroplasty colleagues to have those discussions with patients.
Terry Stanton is the senior science writer for AAOS Now. He can be reached at firstname.lastname@example.org.
Amy Perlmutter is the marketing manager for AAOS. She can be reached at email@example.com.
Craft your experience in Boston
Editor’s note: Based on the latest guidance from the Centers for Disease Control and Prevention for large events and mass gatherings, AAOS and Orthopaedic Trauma Association (OTA) made the difficult decision to cancel this course. The health, safety, and well-being of the AAOS global community is our highest priority. The AAOS and OTA staff, course directors, and faculty are working diligently to plan a virtual course experience to be delivered later this year. Details will be shared as soon as they are available.
Registration is open for the Daily Dilemmas in Trauma course, presented by AAOS and the Orthopaedic Trauma Association (OTA) May 14–16 in Boston.
This unique and highly personalized course, led by Paul Tornetta III, MD, FAAOS, and J. Tracy Watson, MD, FAAOS, places you at the table with top-notch faculty who will bring insights, expertise, pearls, and solutions from institutions nationwide. Programming includes operative and nonoperative fracture-management strategies to help you stay current when taking call.
Lecture topics are attendee-guided. In addition to preselected content, faculty will tailor many topics to address registrant preferences resulting from precourse voting. Early registrants will vote on topics for 10 lectures to create a unique experience covering the popular results.
Course highlights include:
- There will be a low faculty-to-participant ratio and a small-group discussion environment.
- During highly interactive sessions, participants will be able to ask questions and seek advice.
- Participant-guided programming: Nearly half of the course will be structured around attendee-voted topics.
The course will provide attendees with focused instruction for upper- and lower-extremity fractures, as well as sessions on complication management and outcomes. Surgeons should consider bringing their extended care team to Boston, as this course provides an excellent update for physician assistants and nurses on how to get through a night of trauma call.
You’ll return to your practice equipped with appropriate care and treatment options, evaluation techniques, and postoperative strategies for common yet often complex fractures and injury patterns.
To register, visit www.aaos.org/3061A or call 800-626-6726. After registering, be sure to vote on your preferred session topics at aaos.org/3061/vote.