How would you describe orthopaedics?
Orthopaedics is a part of surgery dealing with bones, joints and muscle injuries—essentially, anything to do with what we call the locomotor system: those parts of the body that allow us to move around. You can get orthopaedic spinal surgeons, shoulder surgeons, elbow and hand surgeons, knee surgeons, foot and ankle surgeons, and so on.
What is a fracture?
The easiest way to define a fracture is a broken bone. At one end of the spectrum you can have someone who walks into the surgery with a small stress fracture, at the other end is a bone broken into several pieces with extensive soft tissue damage around the injury.
Are some people more prone to fractures than others?
Yes, they can be. At the extreme end of the spectrum there are inherited diseases which cause osteogenesis imperfecta, better known as brittle bone syndrome. For some people with this condition, they only need to cough to break a bone. Osteoporosis—a condition in which the bones become brittle and fragile—can be the result of poor diet; smoking doesn’t help your bone health, and the same for not getting enough exercise. So there are lifestyle choices involved, but there is also a genetic aspect. Osteoporosis is something that is affected by aging, especially affecting post-menopausal females. If they are seriously osteoporotic they can be treated with medication. The great thing is that your bone density is not set in stone—it is variable throughout your life, so you can do something about it if you choose to.
How has fracture treatment changed in your time?
It has changed significantly through our increased knowledge of the science of bone repair. We now know much more about the biology involved in bone healing, and we have been able to develop ways of influencing that healing process. We are also much more pro-active in our approach—we used to treat fractures by carrying out an open operation to fix the bone, then encasing the area in plaster and waiting. Now we can manage fractures non-operatively, using removable splints or boots. These allow patients to move their muscles a bit, which keeps them healthier. While such equipment was in existence in the past, it was not particularly widely available. That may have been partly due to unit costs, but also a lack of general acceptance of these devices by clinicians.
What was behind that caution?
You have to maintain the stability of the fracture during the healing process. If something shifts and the fracture heals in a poor position the repair won’t be as strong as it could be and—depending on where it is—can end up increasing the risk of things like arthritis. Understanding how these devices worked under different circumstances took time.
What are the biggest problems you encounter?
Some particularly complex fractures can be difficult to fix, but we usually find a solution. Others appear simple, but then fail to heal. That can be because they haven’t had the right stability, or for some reason the biology has not been right. Fractures heal naturally as long as certain conditions are met, but sometimes this does not happen. Then we have to investigate why.
Can you explain what you mean by the ‘biology’ of fracture repair?
There are certain nutrients and minerals that the bone needs in order for it to heal. There are also certain messenger proteins produced in bone marrow that are required for healing. This is what we call the biology of the fracture. Say you have a fracture that is caused by repeated small injuries, like a stress fracture; all you need to do is protect it and it will heal. It already has stability, so if you take the load off the fracture and rest it, the fracture will heal. It already has the right biology. But if you have multiple fragments of bone, where the soft tissue around the injury is badly damaged, it is a very different situation. The blood supply—and therefore nutrient supply—to the injury could be completely shot. Where the biology is significantly damaged, it will need to be improved for you to get the best result. As well as getting the stabilising structures right, getting the biology right is absolutely vital. How would you go about getting the biology right? We have to influence the chemical environment within which the bone sits, which is where bone grafts would usually come into play. Taking a piece of bone from another part of the body and grafting it in place in the location of the fracture brings some of these proteins into the region of the damaged bone. What is exciting now is that, instead of a bone graft, we can instead draw bone marrow from the donor site, mix it with some specialised paste and inject it into the wound to introduce these beneficial proteins into the area.
What areas are you struggling with?
Despite our best efforts, sometimes fractures don’t heal. That can be very frustrating. You do your best, you think you have done a good job and yet they don’t heal—and we simply don’t know why. Whether it is an unknown infection or some aspect of the biology we don’t yet understand, the healing does not happen.
What is the end stage if a fracture does not heal?
The worst case scenario could be an amputation, and that is what happened in the past. But now there are more advanced bone regeneration techniques. It is possible to cut out a section of bone that is infected or dead, shorten the limb, put an external scaffold in the limb and very slowly lengthen the scaffold as bone forms in that gap. This can be quite involved for the patient and they could have to wear the scaffold for 12- 18 months, but that is infinitely better than an amputation. There are degrees of interventions we have available before we get to that horrible end point, which hopefully we avoid.
When would you use this technique?
If a year down the line a fracture has failed to heal we would call that a non-union, and be asking questions about why. Has there been movement within the repair, or is there an issue with the biology? If we have feel it is the biology, we would look at a bone graft, or one of these chemical solutions.
Does technology have a big influence on the field?
Advances in imaging and the software that goes with it have been huge. For example, a CT scan can be translated into a 3D image that we can manipulate on screen for an incredibly detailed view of the damage to the bone and the surrounding tissue. More recently, 3D printing allows us to take these scans and make a model of your fracture. Even with the most complex fractures, you can plan your operation before laying hands on a patient—that has been a great leap forward.
Has this changed the way you conceptualise an operation?
That’s an interesting question. I think the ability to conceptualise in three dimensions is very necessary in the type of operation where you are fixing several pieces of bone, and you need the fixing tools to interact with the bone at precisely the right angles. Previously, I was trying to think in three dimensions anyway, but this technology has certainly aided in that.
What would you say has been the biggest advance in your field?
With regard to fractures, I would say the biggest advance has actually been a change of mind-set. When I started, the paradigm was that you carried out an open operation to repair the fracture. The thinking has moved on from there. Now, we have developed techniques where, for example, if you want to put a stabilising plate on a patient’s tibia you make a small hole above the fracture, slide the plate down along the bone and then use targeting devices to screw it in place. Instead of one big cut you have multiple small ones. It is all about preserving that envelope of tissue around the wound, which is vital for bone healing. That is probably one of the biggest advances, but it has been a stepwise improvement as opposed to a great leap.
If you had a silver bullet, where would you aim it?
I was looking at an orthopaedic journal from 1949 where they talked about what the great leaps forward in the field would be, and one was an injectable paste. There would be no open operation. You would set the fracture, and then inject a paste around it, which would then set and hold everything in place while the fracture healed. That would still be my magic bullet: if you could inject an internal plaster, hold the repair rigid and then give it the right environment to heal.
Is there anything like that in the horizon?
Alas, no. There are injectable pastes available which are aimed at improving the biology. What is really exciting is that we now have genetically engineered substances that we can inject into and around the fracture which mimic those proteins.
What do you like most about your job?
It suits my personality, I like problem-solving and finding solutions. A patient arrives with an issue that is impacting on some aspect of their life, be it work, sport or general mobility. I analyse it, identify the problem and devise a treatment plan. The vast majority of the time it works and they go away happy. That really appeals to me, hearing that they are back to running again, or have taken up a sport they love, or are just living pain free. That gives me real satisfaction.