COMMENTARY

Customizing Care to Enhance Fracture Healing

Interviewer: Lara C. Pullen, PhD; Interviewee: William M. Ricci, MD

Disclosures

November 19, 2019

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Every fractured bone carries a risk of not healing properly, and substantial complications can arise from a nonunion. Medscape spoke with William M. Ricci, MD, an orthopedic surgeon and chief of trauma at Hospital for Special Surgery in New York City, to learn more about customizing the care of patients with simple and complex fractures to maximize healing and minimize complications.

William M. Ricci, MD

Tell us about the newest science and the latest techniques in fracture healing.

In orthopedic trauma, we treat all different types of fractures, and we customize the treatment method to the particular fracture type and the particular patient. One thing that's relatively new is customizing the treatment to a particular subtype of fracture. Every fracture that we treat involves, to some degree, a race between the fracture healing and our implants failing.

It sounds like we would want fractures to heal as much and as quickly as possible, but the implants don't last; they aren't durable. Is that what you're suggesting?

That's exactly right. Every implant we use is designed to hold the fracture properly aligned and steady to allow the body's healing process to occur. It's a common misconception that the metal implants we insert provide all the necessary support to allow normal use of the injured limb. That's just not the case.

The metal we put in is, in a way, like an internal cast. If, for example, we put a cast or a splint on your wrist or ankle, it holds the bone straight and steady while the body does the healing. The metal we implant on the inside acts in a similar way.

If you inappropriately walked on a cast, eventually that cast would wear out, give way, and crumble. Likewise, if the patient inappropriately walks on a metal implant prior to full bone healing, the metal will eventually give way.

I like to use the paperclip analogy: A paperclip is metal, but if you bend it back and forth 100 times, it breaks rather effortlessly. In a similar fashion, if you walk on the metal we use to fix broken bones and stress it innumerable times, the metal will give way. If the body heals in an appropriate timeframe, the bone becomes solid and then when you walk or use the broken limb, the inserted metal is not stressed and won't ever break.

Where does absolute or relative stability come in with all of this?

It gets right to the heart of it. What's new is that we customize the construct to a particular fracture. We refer to some fractures as simple fractures. If a bone breaks in half, we can put those two simple pieces back together nearly perfectly, like pieces of a puzzle, and compress them together. Bones generally like to be compressed together while they are healing. In this scenario (and it's a bit of a simplification), we want the metal fixation to be relatively rigid so that we can effectively compress the two bones. They're tightly bound. We're going to use thicker devices with lots of screws and make our construct relatively rigid. This strategy promotes what we call primary bone healing.

The flipside is a case where the bone is crushed into many pieces. We call that comminution. It's not possible to put such small fragments of bone back together rigidly and compress them. In this case, we use a construct that we call relative stability. We'll span the area that is comminuted and design the construct to allow some micro-motion. Micro-motion is useful because it induces a different biologic pathway for healing called secondary bone healing. If you have a construct that is too stiff or too rigid, you won't get secondary bone healing. The surgeon fine-tunes the construct based on what type of healing process is desired.

Then you choose the implants based on the type of fracture?

To some extent, that's correct. If we want to induce primary bone healing, we're going to create an implant and a construct that is quite rigid. If the fracture is such that primary bone healing is not reasonable or practical, we're going to try to induce secondary bone healing. We would want to create a construct that is not rigid, allows some microscopic motion, and will induce secondary bone healing. Of note, patients can’t detect the micro-motion described. If we mix those two concepts, it doesn't work out too well.

So you have to go down one path or the other?

Right. We sometimes will see a fracture that was fixed, but not appropriately. It is a fixation, where we're not giving the bone the right message. We're giving it a sort of halfway between one or the other message, and those are the fractures that go on to a nonunion and don't heal. If a bone doesn't heal in a timely fashion, then the implants eventually give way and lead to fractured hardware and loss of proper alignment. This is a tough situation.

When choosing the implant, do the materials contribute to the stability, or is it just the structure of the implant?

To some degree, it is the materials. If we're fixing a femur, we're going to use a plate designed to fix it. What's different is how we fasten that plate to the bone. That will dictate whether we're generating a rigid construct or a less rigid one. If we fasten the plate with many screws that are close together, it's relatively rigid. If we fasten it with fewer screws spaced apart, it allows the plate to bend more between the screws, and we will have more micro-motion.

There's some controversy about whether one metal is better than another. We use two different metals for implants: stainless steel and titanium. Titanium is a bit more flexible than stainless steel, but the science behind choosing titanium versus stainless steel is not clear.

Are most of the plates off the shelf? Is there any reason to make custom plates?

In general, they're off the shelf. Ten or 15 years ago, we had a generic plate that was used for multiple applications. The plating systems have evolved substantially, and most of the implant manufacturers have very specifically designed plates for each anatomic area of the body.

Attaining the union of the fracture is one piece of the puzzle; another piece is minimizing the risk for complications. What are you doing to minimize complications?

Infection is the most devastating complication we have when treating fractures. Patients receive antibiotics just before surgery and continue taking them generally for 24 hours after surgery. The data indicate that using antibiotics beyond 24 hours is not helpful.

We also need to be very careful with the soft tissues. We're focused on fixing bone, but bone gets its nourishment in large part from the soft tissues, the muscle that surrounds the bone. If we strip the bone of the muscle, it makes fixing the fracture easier because we have more visualization of the bone, but it's counterproductive to the healing process. We go to great lengths to minimize the amount of trauma to the bone, and to minimize the amount of muscle that we peel off of the bone to maximize the healing potential and minimize complications.

Do you have any suggestions for enhancing the fracture healing process?

We've touched on the main issues that we, as orthopedic traumatologists, deal with on a day-to-day basis. We are focused on customizing the care to each individual patient and fracture.

I do have some suggestions regarding the bone health of patients. We're very interested and astute in making sure that patients are well nourished after they have a fracture. Good nourishment is needed to heal a fracture. We're particularly interested in making sure that patients have normal vitamin D levels. Vitamin D deficiency has been associated with healing problems and nonunion.

There is some controversy about treating patients with nonsteroidal anti-inflammatory drugs (NSAIDs) after a fracture. Some data indicate that NSAIDs can slow down fracture healing, and other, conflicting data indicate that they may not. In my practice, in patients with fractures that are at high risk for nonunion, I like to avoid NSAIDs and use other methods for controlling pain. Inflammation is a necessary and important part of the healing process.

Do calcium supplements make a difference?

Calcium is probably less important, but adding calcium to vitamin D is not an unreasonable practice.

Are there any other things available to accelerate fracture healing?

Some experimental trials are going on. One of my associates at Hospital for Special Surgery, Joseph M. Lane, MD, is doing a study looking at new drugs that might accelerate and facilitate fracture healing, but the data are preliminary at this point.

What about weight bearing? Is that important for the healing process?

That's very customized. For certain fractures, weight bearing is absolutely safe and can augment the fracture healing process; but for other fractures, weight bearing is detrimental. That's why it's so important that we customize the postoperative protocol per patient per fracture.

Lara C. Pullen, PhD, is a medical writer based in the Chicago area.

William M. Ricci, MD, is chief of the orthopedic trauma service at both Hospital for Special Surgery in New York City and at Duke University School of Medicine in North Carolina. He has over 19 years of experience and is nationally and internationally known for his surgical expertise in treating complex fractures and complications of fractures (nonunion, malunion, infection, and osteomyelitis).

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