Curative surgical treatment

We have just seen what was used yesterday. A few surgeons – justly – continue to use this stable material which has proved its excellent efficacy.

Most traumatology surgeons have started using another type of equipment, screw-plates. Since bone loss, linked to osteoporosis, weakens the neck of the femur, they prefer to embed the two largest fragments one into the other. They do not attempt to stabilise the secondary fragments, nor do they bother about replenishing the lost bone which, in the neck of the femur was definitively compressed by the fall, leaving a hole which is even bigger when the osteoporosis is advanced.

This classic surgical equipment is therefore designed to hold the two main fragments of a fractured femoral neck in the right position. It consists of two metal parts: the first (cephalic screw) is screwed into the head of the femur; the second (screw-plate) is screwed to the body of the bone. These are held together by the gun. This is welded to the plate at an angle of 130° equivalent to that of the femoral neck.

Although the great advantage of this equipment is to avoid exceptional cases of migration outside the head, its major disadvantage is that you cannot control the degree of penetration of the fragments into each other. A minimum penetration of 10 mm would not have any great consequence but the same does not apply if it reaches 15 or 20 mm and sometimes more.

To stabilise a complex fracture (more than two fragments), all the pieces of broken bone must be reconstructed and held together. This stabilisation takes place in two stages.

How to restore the anatomy of a complex fracture: current technique: screw plate and cables

Initially, the type of fracture must be defined by analysing the main and secondary lines.

see following article
Y. Cirotteau Boyd H.B. and Griffin L.L. classification :
A refinement proposal. Eur J Orthop Surg Traumatol (2002) 12 : 152-157

For further information: modified classification of osteoporotic trochanter fractures (available in french only)

Secondly, the main fracture must be reduced (joining fragments 1 and 2) as well as secondary lines. This can be done using a stabilised screw plate to hold the main fracture line and cables to maintain the secondaries.

In addition to the fact that limping in these cases is inevitable for a long time, a state of spinal column imbalance will also be inevitable in the medium or long term. We can always convince ourselves that this is not very important for someone at the end of their life, but this is not our opinion. And for a younger person (60-65 years old) I'm not certain he or she would agree.
For older people, how can we accept the idea of further reducing their falling muscular strength, which they need in order to stand up, walk and/or go up and down stairs? This is not a serious approach.

It seems quite legitimate and justified, if there are secondary fractures as well as the main two fracture fragments, to treat them with the same amount of attention. This is the intention of the cables. It may be necessary to fix the greater or lesser trochanter or both. Here are a few examples.

Fractured hip (front view)
Main line and greater trochanter

Consolidated hip (front view)

Consolidated hip (side view)
Consolidation of main line
and greater trochanter

Fractured hip (front view)
Main line and greater trochanter

Post-operative (front view)
Stabilisation of main line
and greater trochanter

Post-operative (side view)

Fractured hip (front view)
Main line and greater and lesser trochanter

Immediately post-operative (front view)
Stabilisation of main line and both trochanters

Fractured hip (front view)
Main line and greater and lesser trochanter (two fragments)

Consolidated hip (front view)

For further information... the surgical technique (available in french only)

What is the benefit to the patient?

In the immediate there is a distinct reduction in pain. It is curious to note that although all traumatologists agree that the best antalgic (treatment against pain), in cases of fracture, is firstly immobilisation, yet, as soon as femoral neck fractures are concerned, they "forget" this basic principle!

Nevertheless, since time immemorial, fractured members were immobilised by splints: then plaster and resin were invented, osteosynthesis (fixing with metal components consisting of screws, nails, plates etc.).
The more stable the fracture – the more the pieces are prevented from moving with respect to each other – the less painful it is. It is clear that the better the assembly fixes the broken pieces and holds them together, the more stable it is from a purely mechanical viewpoint.

If we take the example of a chair with a broken leg, it is easy to imagine that you can only sit on it if
the leg is solid. To obtain this you can use glue, plugs, screws or nails. Sometimes, it's true, it's better to make a new leg. Alas, this is not possible for us!
In the same way that we would not hesitate to sit on a strong chair, so the patient who is not in pain and feels stable will not hesitate to put his weight on the broken leg. Everyone knows that it's impossible to ask an elderly person to hop on the one reliable leg.

This is the all-or-nothing law. There is no choice. Either you fix it all or you fix a little and, in this case, it's as if nothing is fixed. Incidentally, leaving a 75 or 80 year old person in bed for 6 weeks is a confession of impotence. Everything must be done for the person suffering the fracture to be on his feet as quickly as possible. Fractures in the elderly should no longer be a source of fear for the patient or the trauma surgeon.

What happens several weeks later?

Putting weight on a bone is essential for its good health. Astronauts who remain in space for a long time, suffer from skeletal disorders – among others. Bones need to bear weight if they are to remain in good health. If you can put weight on a repaired bone it will be in the best condition for healing.
If it is also provided with the elements necessary for its good health, it will consolidate twice as fast (in 50% of cases) or in two months (in 75% of cases) i.e. 1/3 less time than with classic treatment, the average duration of which is three and sometimes four months.

At present, the classic treatment consists of only treating the main line, neglecting secondary lines when they are present and totally ignoring the cause.
Does this mean we are not interested in caring for the elderly? Those responsible for the "Bone and Joint Decade" meet in huge intercontinental palaces, have Royal, Papal and Republican patrons, discourse on the possibility of holding the next conference – if possible – on some far-flung isle.

If you are curious enough to attend a few conferences, you see, immediately on arriving, gigantic panels displaying the name of some product or other which is said to be excellent against bone loss. Trauma surgeons will soon be out of a job. Thank goodness it's not here yet – in so far as there are still surgeons! That's another story.

Without getting into a stupid argument, we must acknowledge that these huge events do make you smile a bit. It would be interesting to ask a member of the audience what he remembers from a speech made by a speaker certain of the essential role played by some kind of ribosome on the dextrorotatory version of an alkylated aromatic molecule in the presence of a tartric acid bound to transgenic messenger RNA! You will have understood that this miserable conference had no other purpose than to show how the mean level of basic medicine – such as traumatology – cannot follow such high-flown science. Only a few initiates of the inner circle are capable of following what is hidden behind these formulae. I want to spare the brave reader who has followed me this far. All this to say: "what about the broken patient?"

All this is also good if – as we saw above – there is some bony support (the rails) and the wagons (the vessels) to transport the drugs (Replacement hormones and diphosphonates) and workers (bone cells) to the right place so that they can work together. We shall not go into more intracellular detail because we are discussing surgical osteoporosis here.

We shall simply say that one reaches a stage where – old age being a shipwreck – it seems that everything has been said but there is still a captain on board – for how long? That's another problem.
He must make sure that all breaches in the hull (the container) are filled by using biomaterial (in this case natural coral) then, he will rebuild the bridge and passageways – if necessary (the content: the broken pieces). What captain would agree to sail a boat only half repaired? What wise man would risk his life on such a frail craft? Don't our little grannies deserve more than a half-repaired boat?

Must we ask the fearful question of whether we really want to do something for our "old folks"? How charming it is to see the solicitude of our elected representative for old people before the elections. And when they break a hip, when it's too hot, who will go and see them? Who looks after them? Hospital emergency departments, charity organisations and, if there are still any around, trauma surgeons. The whole problem is to know whether or not they have the financial and technical resources to do the job properly.

For charity organisations the question doesn't arise because they are wonderful volunteers. I pay tribute to them here. Alas, without denying the exceptional qualities of their good hearts – devotion, compassion, availability, generosity – they don't give good service to the State which relies on them to attenuate its inadequacies. Since it intends to manage Health – Soviet fashion – it should take charge with the same advantages for everyone. Post-war French Medicine was the best in the World. Today it is in the process of becoming one of the worst, due to lack of resources (like England and the Eastern Bloc) in spite of the recent appreciation – inaccurate – by certain leftist ministers. We are not yet talking about the professional quality of those providing this care.

Casualty staff are complaining loudly and their voices are beginning to be heard. They must continue. They must demand more premises, greater competence in their physicians, more rest for these girls and boys who are overworked and literally exhausted after a night on duty.

In the opinion of traumatologists, it is the State. Since 1968, the situation in public hospitals, with a few exceptions, has deteriorated dramatically. The A.R.H (Agence Rιgionale d'Hospitalisation – Regional hospitalisation agency) – the director holding the rank of superprefect – has full power to close hospital beds throughout the land according to criteria which he alone can define! When the decision is made there is nothing to be done. Unless the population, fed up with penalising decisions, decides, as they did in Millau – to take peaceful action and use the Media to voice their complaints. Bravo.

In conclusion:

Curative surgical treatment of a fracture caused by osteoporosis should be treated with the greatest care by all health partners: traumatologists and social partners. Traumatologists should pay more attention to rebuilding the bone as a whole. Social partners should provide them with the resources to do so.

A new philosophy is not always easy to admit. Once again it is good to remember that when it concerns the well-being of a large number, the whole group benefits.

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