April 2000 Bulletin

Don’t shun nonsurgical fracture care

Lack of interest in biological solutions could undermine profession

By Augusto Sarmiento, MD

I would like to question whether or not the recent changes that have taken place in the care of fractures have been entirely beneficial, or in some ways harmful to our discipline, and if so, why?

The changes, which have resulted in improved trauma care, were inevitable because technological advances opened new frontiers. However, I submit to you that we have paid a high price to get where we are today. Wittingly or unwittingly, we may have compromised the future viability of our profession. In fact, I will go one step further and say that if we do not address the likely outcome of some trends, orthopaedics will not survive as the high ranking branch of medicine it is today.

The orthopaedist of today, particularly when it comes to the care of fractures, no longer seems to consider the biological foundations of the profession important. This became abundantly clear to me when a resident of ours told me that he was not interested in learning how fractures healed, but simply wanted to know how to fix them. He was speaking eloquently on behalf of his contemporaries.

Our students are taught that anatomical restoration of fractured bones is an absolute necessity; that a complication is a deviation from the normal and cannot and should not be tolerated, no matter how mild and inconsequential. Today, orthopaedic surgeons in most educational programs complete their training not knowing how to treat a fracture without surgery. They have no idea what the natural history of a fracture is. Neither do they know what the outcome of the nonoperative approach to fractures would be or how it would affect function and cosmesis.

During the past few years, I have visited several major trauma centers where all fractures were treated surgically, regardless of the severity of the injury, patient’s age, mechanism of injury or degree of displacement. Based on my close observation of such trends and practices, I believe that we are not educating medical surgeons today, but simply cosmetic surgeons of the skeleton. Skeletal cosmetologists, one might say.

Routine intramedullary nailing of the humerus and internal fixation of distal radial fractures is increasingly performed despite the fact that we know that the overwhelming majority of those fractures can be successfully and inexpensively treated without surgery. An ongoing effort is being made to convince the orthopaedic community that these fractures should almost always be treated surgically.

The majority of educational gatherings rarely, if ever, contain a single lecture that addresses the nonoperative treatment of musculoskeletal conditions. Many consist of training sessions that are devoted totally to the teaching of surgical skills. The biological reasons for the surgical procedures being taught are not discussed or are perfunctorily mentioned. These educational experiences are often conducted, directly or indirectly, by individuals representing the manufacturers of the implants and instrumentation needed to carry out the surgical intervention and obviously financially motivated.

Medical journals publish, almost exclusively, papers that deal with surgical techniques only. Half their pages are devoted to advertising surgical products. It appears that either the editors do not want to accept articles outside the popular surgical field or that the orthopaedists with experience in so-called nonoperative treatments are embarrassed to submit manuscripts that do not follow the trendy pattern.

Territory, long held by orthopaedics, is now shared, if not dominated, by others. In the United States, podiatrists who traditionally provided care only to diseased toe nails and prescribed arch supports are currently performing arthrodeses, internal fixation of fractures of the foot, ankle and leg, arthroscopy, amputations, and total ankle replacement. Neurosurgeons stabilize the spine with plates and screws. Plastic surgeons, in many hospitals and universities, are the hand surgeons and play a major role in the care of soft tissue pathology in open fractures.

Whether for academic or financial reasons, all that these different disciplines had to do to expand their territory was to contact industry in order to learn how to use the required instrumentation. Industry eagerly accommodated their desires as they saw the opportunity to expand their markets.

I suspect that these surgical disciplines came to the conclusion that orthopaedics was no longer a specialty based on a solid body of knowledge, but rather a series of surgical procedures that anyone with a modicum of surgical skill could perform equally as well. There is little doubt that the education of today’s surgeons is structured to satisfy the marketing needs of industry.

Today in the United States there is a group suggesting that the orthopaedist should relegate the nonoperative care of fractures to nonoperating disciplines. This is a naive and counterproductive move. Once other groups are empowered to treat fractures by nonoperative means, they will soon dictate which ones we can treat (continued on p. 50) surgically. Those responsible for financing hospitals and clinicians would welcome and support such a move. They will conclude that the care of fractures without surgery is cheaper.

No one should question that today surgical treatment is the gold standard for the management of many fractures and the one standard against which other treatments must be measured. I, personally, admit that the day might come when all fractures will be best treated by surgical means. Improved surgical materials and imaging technology could make that scenario possible.

In order to accept the eventuality that surgical treatment will one day be applicable to all fractures there are important factors to be considered. The first is that if fracture care consists simply of fixing fractures without the need for a biological background on the part of the treating physicians, it is ludicrous to require the long period of training we have at this time. A much shorter period should suffice.

In economically advanced societies, the scenario of treating all fractures surgically could become a reality within a few years. However, we must accept that parallel to it there will be a major and radical reduction in the financial subsidies to trauma hospitals and to fracture care in general.

There is no question in my mind that some of the reasons for the epidemic of surgery are easy to understand, though difficult to justify. In general, the surgical fixation of fractures is preferred by many because it is easier to carry out and more convenient for the surgeon. It is also more prestigious in the eyes of society and definitely more rewarding financially as the reimbursement for surgery is always higher.

Some might argue that such is the contemporary nature of business and, therefore, appropriate. We should not agree with that premise. Medicine is not a business; it is a profession. Its members, since the days of Hippocrates, have sworn to place the interest of their patients before their own. If society in general and our discipline in particular have come to the conclusion that such a philosophy and such values are outdated then I submit to you that we are in serious trouble.

I hope you will agree with me that these are unpleasant issues that need to be addressed. It is naive to believe that they will resolve spontaneously. It is more likely that they will get much worse. If we do not make an earnest effort to correct the wrongs, our heirs will find themselves in a profession whose traditional foundation and values have collapsed.

I am currently President of the Association for the Rational Treatment of Fractures (ARTOF). ARTOF is not an organization promoting the nonoperative treatment of fractures. Quite to the contrary, it recognizes that the surgical treatment is, in many instances, the gold standard against which other treatments must be measured. It recognizes that there are a number of treatment modalities that have clear indications for their use and seeks to reach a consensus among the orthopaedic community as to the most appropriate treatment for the patient under the circumtances. ARTOF is committed to the preservation of the biological foundations of our profession and wishes to put economic considerations in proper perspective.

ARTOF encourages the medical community to develop treatment protocols, independent of third party payers whose main concern appears to be reduction of health care costs and of industry with its profit driven agenda.

History will tell whether or not we, the representatives of medicine and industry have the wisdom and courage to tackle altruistically the important issues that I have addressed.

Augusto Sarmiento, MD,is emeritus professor and chairman, department of orthopaedics and rehabilitation, University of Miami, and 1991 Past President of the Academy.


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