Author Archives: James Hundley, MD

About James Hundley, MD

Dr. Hundley is a retired orthopaedic surgeon and the originator and co-founder of OrthopaedicLIST.com, a resource website for orthopaedic surgeons and related professionals.

Implant Identification: An Opportunity for You to Participate

           Having been in the orthopaedic profession for a long time, I have occasionally been confronted with an implant that I did not recognize and either did not have enough time or was unable to find out what it was.  Who hasn’t seen or heard of a bent femoral rod from trauma?  How about the intramedullary rod that had been in a femur for thirty years and had to be removed for a total knee replacement?  There have been a few knee and hip prostheses that had been implanted at “Elsewhere General” and needed to be revised.

                When I looked for a source that listed implants, I couldn’t find one.  That’s when OrthopaedicList.com was conceived.  It has proved to be immensely popular and useful for finding sources of implants, but we needed more.  You still had to know what you were looking for.  The next evolution brought “X-Ray Identification”.

As orthopaedic surgeons and operating room nurses know only too well, removing implants can be tricky and is not always as easy to do as the x-ray might “suggest”.  Various rods have a variety of cap screws, removal threads, locking screws, etc.  You must have compatible instruments.  If you are revising a total joint replacement implant and don’t need to revise all components, it is essential to know the brand and model of the device.  That way you can match compatible components and preserve that which seems better left in place than removed.

It’s always good to get the operative notes from the original surgery, but too often they don’t describe the implants.  The best source I’ve seen are the implant package labels that the OR nurse affixes to the operating room record, but they are not always available either.

For these reasons, at the suggestion of an orthopaedic professor, we started collecting x-ray images of identified implants on OrthopaedicList.com a few years ago.  Since this is something that will always be evolving and since we wish to provide free access to our colleagues throughout the world, we chose the Internet as our venue.  Our library of implants has grown quite a bit, but to reach its true potential it needs to grow a lot more.  To do so, we need your help.  Why would you wish to go to the trouble?

1. More devices are being implanted in younger as well as older patients.  Many will live into old age.  When the time comes to do something, records may be unavailable, the surgeon may no longer be in practice, the surgeons and product representatives who could  recognize these implants may be gone, and so on.  By going to our library of X-Rays (“Implant Identification“), you have a fighting chance of figuring it out.

2. Please remember that what is familiar to you in your time and locale may very well be unfamiliar to someone else in another place or time.  Thus, we are not just looking for what you consider uncommon, but we’re looking for what you implant in your everyday practice.

3. Some implant companies have their own library of images of their implants, but they are predominantly specific to their implants and not necessarily available to everyone.

4. Privacy rules are making it harder to obtain records, even with signed releases from our patients.  I know about that from experience.

5. The world population is aging and people move around.  There will be more and more people with implants.  Add those and you’ll realize that a growing number will need second surgeries in places different from the original hospitals.

6. The educational benefit has been an unanticipated bonus.  We have word that nurse and technical schools use our images to train their students.  We hear that medical schools in some countries do the same.  We even know of at least one large orthopaedic manufacturer who uses our service to train their new representatives.  Furthermore, surgeons can send their patients to the site to see what various implants look like, including some cases that they have performed.

7. Those who give presentations need illustrations for their slides.  You/they can copy the images from “Implant Identification” for those presentations.

8. You can post “unknowns” yourself in hope that our colleagues will help you identify your inherited, troublesome implants.

So, how does one submit an x-ray?  Go to www.orthopaediclist.com and “roll over” “Implant Identification” on the blue navigation bar near the top of the page.  Click on “Submit an X-Ray”.  The rest should be easy.  If you have problems, please let us know at info@orthopaediclist.com.

Oh, what about HIPPA and patient privacy?  Before submitting images, please crop out any information that may identify the patient.  That way we protect patient privacy.  We have a legal opinion that Implant Identification does NOT violate HIPPA policy.

Thanks for your help.  We’re all in this together to the benefit of our patients.

Dr.  Hundley is a retired orthopaedic surgeon with forty years of experience.  He is the president and a founder of OrthopaedicList.com.

How “Implant Identification” Simplified a Total Hip Revision

by Andrew Walden

Ed Note:  The following article is from an e-mail re´ how using Implant Identification helped in a total hip revision case.  We couldn’t have said it better.  Reprinted with permission of Mr. Walden.

I wanted to inform you of a situation in which your website helped us during a hip revision.  I’m sure you already know how valuable your x-ray registry is and it only continues to get stronger with more additions.

I was doing a case in which the surgeon was revising a prosthesis that had no op report and he couldn’t identify the components.  He was planning on revising the stem and shell and was convinced that they were loose.  However, and I think you know where I’m going with this, the stem was solid and would have required an ETO and lots of time to bang out.  I happened to locate the stem on OrthopaedicLIST and from there we contacted the company’s rep and got head options and liner options.  What could have been a long and very difficult revision turned out to be a head and liner exchange and most likely a better outcome for the patient.

Just to offer some feedback…what might make it easier to locate implants would be to subcategorize even further than just primary hip replacemet.  For example, pressfit vs cement, collar vs collarless, taper vs cylindrical, etc.

There used to be a site called that had a good number of x-rays but it appears to be gone.  Now OrthopaedicLIST and xrayregistry.com are the only x-ray identification sites that I’m aware of and orthopaediclist has a much larger database.

Thanks for the site.  I will continue to help add more x-rays and encourage others to do so as well.

Regards,

Andrew Walden

Andrew Walden is an orthopaedic manufacturer’s representative based in Wilmington, NC, USA.  Click on Implant Identification to see the aforementioned “x-ray registry”.

Nicholas Andry’s Symbolic Tree

by Douglas W. Kiburz, MD

Nicholas Andry    Lyon 1658 – Paris 1742

Nicholas Andry holds an important place in the history of orthopaedics and medicine as it was Andry who first used the word “orthopaedics” in a book published in 1741.  Within the text he illustrated the “crooked tree” which has become the symbol for many orthopaedic organizations around the world.  Although many related agencies have taken to modifying or customizing the tree, the essential design remains.

Andry was born in Lyon in 1658 and started his studies in theology but was drawn to the field of medicine.  In 1697 he defended his thesis:  The Relationship in the Management of Diseases Between the Happiness of the Doctor and the Obedience of the Patient.  He became well known for his stand against the “bleeding barber surgeons” and worked tirelessly to limit their venues.

His fellow faculty members depicted him as “superb, spiteful, confused, scornful, irascible and jealous” as described by R. Kohler in the European Orthopaedics Bulletin.  Andry was creative and prolific in his writings.  In 1700 he wrote his first book in which his explanations earned him the title “Father of Parasitology”.  At the age of 80 he published his famous work L’Orthopedie, a two volume set, in Paris in 1741 and it was translated in Brussels in 1742, London in 1743 and Berlin in 1744.

The book had artistic chapters on external proportions, methods of preventing trunk and spine deformities and had suggestions for physical therapy.  In a section addressing limb deformities, Andry recommended a bent leg be corrected by bandaging it to an iron plate as was commonly done to straighten the crooked trunk of a sapling.  From there came the orthopaedic crooked tree symbol, which has stood the test of time, translation and modernization.

Andry died in Paris at the age of 84 not long after having written his famous volume L’Orthopedie.  Kohler reminds us that Nicholas Andry neither deserves to be scorned nor to be revered.  “He produced fundamental ideas on methods of prevention, the plasticity of the child and the importance of gymnastics” and was known for his astute observations and colorful personality.  Few of Man’s whims or drawings or scribblings have survived to become as internationally recognized as the “Tree of Andry”.

Dr. Kiburz is an orthopaedic surgeon practicing in Sedalia, MO, USA and specializing in foot, ankle, and arthroscopic surgery.  He is also an accomplished sculptor who has produced a beautiful, three-dimensional, copper interpretation of the 1741 Tree of Andry.

Operating Room Nurses = Patient Advocates

by Susan Langlois, R.N.

May 22nd, 2009

       I think that operating room nursing is a specialty that is often overlooked as a legitimate form of nursing because our patients are not perceived as being “in our care” but rather in the care of the surgeon and the anesthesia personnel. Therefore, our role is diminished somehow. In all honesty, that way of thinking shows a lack of awareness of the mind set of OR nurses who see themselves as the ultimate patient advocates for patients who cannot speak for themselves.

In truth, to be capable patient advocates OR nurses need to be forceful team members in that operating room. To do this, we really need a comprehensive knowledge of all aspects of operating room patient care. This includes an understanding of the impact on the patient of the anesthesia care as well as an understanding of the anatomical and physiological effects of the actual surgical procedure being performed. This is especially important in orthopaedic surgery, where, in many cases the surgeon is going to “take it apart and then put it back together”. We want to understand how this is going to be done and the expected outcome and challenges for our patient.  I remember many years ago when non-reamed intramedullary nails were first available. Some surgeons continued to ream anyway. I thought to myself, I must not understand the purpose of this reaming – I had always thought it was so the surgeon could get such a snug fit for that nail that it would not rotate in the canal since, in those days, locking that nail was not an option. So I did an informal study of the surgeons and found out that they continued to ream because that was what they had always done and were just in a learning curve for these new locked nails. I did notice that, over time, these surgeons did stop reaming but the explanation was not as scientific as I was thinking it might be!!!

Susan Langlois, R.N. recently retired from active nursing after forty years as an OR nurse.  She has had a vast experience at several hospitals, starting with a U.S. Army hospital in Fort Benning, GA and ending with the Cape Fear Orthopaedic Center in Wilmington, N.C.  She has been a tremendous resource for OrthopaedicList.com for many years.

 

Graduate Medical Education: Issues and Options

by Frank C. Wilson, MD

March 22nd, 2010

Graduate medical education, still in the process of being born, was not mentioned in Flexner’s 1910 landmark treatise on medical education.  The existence now of 8500 residency programs and 127 specialties and subspecialities would, a century ago, have seemed preposterous.

Movement in GME prior to 1985 was largely academic and specialty specific. Curriculum, accreditation and certification, and duration of training were issues for resolution within the house of medicine.  Since the mid-1980s, influences outside of medicine, fueled by explosive population growth, technologic innovation, and social concerns have become dominant players, threatening the foundations of the educational bridge between student and practitioner.  An expanding and aging population and a panoply of therapeutic options have created overriding problems of access and expense.

Among the major challenges facing contemporary graduate medical education are issues related to teaching and learning, evaluation, professionalism, supervision, research training, funding, and manpower.  This book considers the issues in these areas and offers options for their resolution.

Following are excerpts from a few of these topics:

Teaching and Learning

“The search for ways to improve medical education should include a re-examination of the values underlying the profession.  Values shape the world; they should hold pride of place in the intellectual community and drive the educational enterprise.  Unfortunately the ethos that determined them in the past has been blurred by contravening trends of the present.  Propelled by the explosive escalation of knowledge and technology, too little attention has been given to the humanistic values that should determine their use.”

Professionalism

“Among the core competencies, professionalism is the most critical and among the most difficult to quantify. It is the competency which, possessed in full measure, gives rise to the others.  A professional possesses and maintains a unique body of medical knowledge and uses it to provide effective, safe, compassionate and ethical patient care, including the communication skills necessary to help patients navigate through a complex health care system.”

… “professionalism is founded on the pillars of science and service, upon possession of a specialized body of knowledge and skills, and the obligation to use that expertise to serve others before self.”  … “at the heart of this obligation is ethics, and at the heart of ethics is the welfare of the patient.”

“Professionalism is not just a philosophical ideal, nor can it be marginalized by the need for efficiency or productivity. It should be defined according to its characteristic traits, its cognitive base made clear, and opportunities provided to gain experience in its application to daily medical care.”

Manpower: Supply and Distribution

“With specialty choices determined largely by issues of income and lifestyle, fewer students are choosing careers in primary care.  High-tech specialities offer exciting opportunities for cure; but older patients having chronic conditions, are often more in need of care than cure – for someone to be there to guide them through the complex world of health care and to manage multiple diseases and depression. Despite the fact that most of the problems for which a physician is consulted can be handled by generalists, they have become an endangered species.”

“Medical care for the aged drives and will continue to drive, health care in the U.S. for the foreseeable future. By 2020, some 20% of Americans will be over 65, and people over 85 constitute the most rapidly expanding segment of the population, for which all physicians must be prepared.”

“Population trends must be studied, and planning for anticipated growth closely coordinated with the capacity of the U.S. health care system for expansion.  Since resources are finite, and expansion of the physician pool is very costly and time consuming, joint planning…is essential to meet short- and long- term needs for medical services.”

****

 In his Foreword to the book, David C. Leach, Executive Director Emeritus of the ACGME, said: “This is an important book about this most formative time in a physician’s life, the history of graduate medical education, the key issues that consume present interests of medical educators, and the options that the profession and society have for going forward.  It is timely.  Workforce shortages, financial constraints, new knowledge and technologies, and dramatically changing demographic patterns in society pose challenges.  Changes are needed; will wisdom or reflex actions inform the changes?”

 Dr. Wilson is Kenan Professor and  Chief Emeritus of Orthopaedics at UNC.  He is a past President of the American Orthopaedic Association, the American Board of Orthopaedic Surgery, the Association of Orthopaedic Chairmen and the Thomas Wolfe Society.  He received the Thomas Jefferson Award from UNC, and the Distinguished Clinician-Educator Award from the American Orthopaedic Association.  His book, Graduate Medical Education:  Issues and Options, can be found  on OrthopaedicLIST.com.

Synergistic Effects of Marketing through Service

by James D. Hundley, MD

Saturday, October 24th, 2009

Some doctors think that “being a good doctor” is all that is needed to get patients to come see them. That might work over a long period of time, but unless one is in an extremely under served location, that is not likely to be enough. Patients and referring physicians have to know of you to schedule visits or refer patients to you, so some way of getting the word out is essential to having a busy practice. Even when one is currently busy, complacency could have negative future consequences. Surgeons need a constant flow of new patients to maintain an optimal case load. So, if you agree that marketing is important, how do you best go about it? Do you do it by giving money to a marketing agency or could you do it by giving of yourself?Neither way is inexpensive since giving of oneself takes time away from family, play, and work. On the other hand, when you give of yourself in service, you’re likely to get a lot more back than you invest.

Current wisdom seems to be that marketing one’s practice is best done through paid ads in newspapers, magazines, radio, television, yellow pages, social media and so on. I do not think that that is the best way to get the word out. Anyone can say virtually anything in paid ads, so how is the potential patient supposed to know who he or she is really getting in his or her doctor?

During my over forty years of orthopaedic practice, I had some success with marketing through service and relationships. By this I mean giving of one’s time and talents in a variety of ways. In every case, I tried to be more than just a member of an organization or cause. The more you put in, the more you get back. Here are some examples:

Local Marketing

1. I was able to become the volunteer team physician for a local university. The work was a pleasure and much more extensive than outsiders ever imagined, but when they saw me on the bench at basketball games, many figured that I knew something about sports medicine. The same thing works with high schools and community colleges and the need is great.

2. The Rotary Club was a great way to meet business leaders around town. They tended to call me when they or their families had orthopaedic problems. Their employees often asked their bosses who they went to and followed suit. Not only that.  I enjoyed getting away from the grind and pressure for lunch on a regular basis and befriending a variety of community leaders. The Rotary Club is but one of many civic clubs and organizations that bring you considerably more benefit than you take to them.

3. Church is a great way to meet people. Marketing is clearly not the reason one should join and attend a church, but doing so clearly has earthly benefits.

4. Befriending the nurses in the operating room and on the wards can be a huge benefit. That is not to mean that one cannot demand excellence, something that you must do. All it takes is to treat them with respect and recognize that they bring significant knowledge to the care of your patients. By making them partners, you reward a more positive effort in behalf of your patients and the likelihood that they will both come to see you and send their friends and family, too. Non-medical people often ask those in our profession for suggestions as who to see. If I want to how skilled a particular surgeon is, I ask an OR nurse. If they think you’re a good surgeon and a good person, they are likely to send the people they care about to you. If they dislike you, they’ll guide them elsewhere.

5. By accepting appointment to the local library board, I had a fulfilling service experience and met an entirely different group of people. It doesn’t matter what boards you serve on; it just matters that you serve.

6. By working with the local medical society and ultimately becoming an officer, I met many local physicians whom I probably would have never met. It makes a positive difference to physicians to refer their patients to someone they know and feel that they can trust.

7. Writing articles for the local newspaper makes one an instant expert in the eyes of many readers. Not only does it serve people by sharing your medical information, but no matter the subject of the article, having published it makes many more people know your name and more likely to call you. You can always pay for an ad, but news outlets are often looking for items of interest and happy to accept articles written by doctors.

8. I think that word of mouth is the most powerful marketing tool you can employ. You can’t control it like an ad, of course, but if you consistently treat patients in their best interests and get reasonably good results, you will have unleashed a marketing force that is among the most effective.

Statewide Marketing

1. Working with our state orthopaedic society brought significant benefits to my practice. When someone from my city was injured elsewhere and the orthopaedist who took care of them in some other city sent them to someone they knew (i.e. me) to complete their treatment or follow-up, it enhanced my reputation at home. People talk and tell their friends; and that kind of talk is good.

2. Working (fund-raising in my case) with my medical school and residency program enhanced my reputation at home.When there is friendship and mutual respect between you and a professor of orthopaedics who speaks well of you to patients from your home town, they take note, and they tell their friends.

The above activities will only get more people in your door.Once they get there, it’s up to you to properly take care of them, and that includes way more than surgical competence. Application of the four “A’s” (ability, affability, affordability, and availability) is critical.That applies to their entire experience in your office and the surgery center or hospital.

Let’s face it. Patients generally have no good idea as to an individual surgeon’s abilities. They have powerful perceptions, but they are not likely based on objective data. If you consistently treat patients in their best interests and with respect, they will keep coming back. First, of course, you have to get them to come see you at your office.

So, if you’d like to increase your patient load without spending more money, you might just try marketing through service and relationships. Not only is your practice likely to benefit, but the personal benefits of gratification and personal growth that incur from altruism beyond your daily medical practice may pleasantly surprise you.

Dr. Hundley is a retired orthopaedic surgeon with forty years of experience.He is the president and a founder of OrthopaedicList.com.

Local Antibiotics in Prophylaxis of Surgical Wound Infections

by Laurence E. Dahners, MD

August 22nd, 2009

In 2007 we published an animal study (Yarboro S, Baum E, Dahners L: Locally Administered Antibiotics for Prophylaxis Against Surgical Wound Infection. Journal Bone Joint Surgery 2007 89(5)) documenting that injecting gentamicin into contaminated wounds after closure of the incision results in several orders of magnitude reduction in bacteria counts as opposed to systemic cephalosporins such as are usually given to prophylax against infection. This results in high concentrations in the wound cavity which are not achieved by IV administration and by injecting it after wound closure it is not removed before closure like antibiotic irrigation solutions. It worked significantly better than sustained release pellets at reducing bacterial counts. I have incorporated this into my trauma practice by injecting (80mg gentamicin in 40cc saline, inject enough to fill the wound) a gentamicin solution after the wound is closed and been very pleased with the reduction in the numbers of infections, especially in open fractures. Data that we published in the August 2009 JBJS suggest that systemic cephalosporins and local gentamicin have a large synergistic effect, so I would recommend doing both.

Dr. Dahners is a Professor of Orthopaedic Surgery at the UNC School of Medicine in Chapel Hill, NC, USA.  His clinical focus is on trauma and his research interests are in ligament physiology, ligament healing, ligament growth and contracture, and bone healing and the biomechanics of internal fixation.  You can see his “Pearls” of orthopaedics on OrthopaedicList.com.

Dr. Dahners et al published “Better Prophylaxis Against Surgical Site Infection with Local as Well as System Antibiotics.  An in Vivo Study” in the August 2009 issue of the Journal of Bone and Joint Surgery.

Stopping Healthcare-Associated Infections

by Barbara Dunn

November 14th, 2009

When someone develops an infection at a hospital or other patient care facility that they did not have prior to treatment, this is referred to as a healthcare-associated (sometimes hospital-acquired) infection (HAI).  According to the World Health Organization (WHO), at any point in time, 1.4 million people worldwide suffer from infections acquired in hospitals.

As part of an ongoing commitment to quality care and infection prevention, nationwide doctors and hospitals are partnering with Kimberly-Clark to deliver continuing education programs on healthcare-associated infection (HAI) prevention to staff and management Whether you’re a healthcare professional, patient, or visitor , the most effective way to keep HAIs down to a minimum is to wash your hands or use an alcohol-based sanitizer.

Please view the informational video at this link.

For more information please go to the Not on My Watch campaign.

Barbara Dunn was born in Jersey City, New Jersey, worked as an interior designer in Manhattan, then moved to Hawaii where she worked for a production company before moving to Arlington and reinventing herself as a PR executive.

The Looming Total Joint Replacement Surgeon Shortage

by Scott S. Kelley, MD

Tuesday, November 17th, 2009

The difference between a good total joint and a great total joint replacement is initially small, but over time the difference can be significant.  A good total joint might last 10 years, but a great total joint could last 30 years.  Being a total joint surgeon is a profession with little or no room for error with every single hand movement. The procedures are demanding and the patient population is complex.

Now, imagine this: The number of total joint replacement surgeons in the United States is cut by over 40 percent. The patient’s option for a surgeon is limited due to demographic or insurance restrictions.  This becomes a significant problem if the joint replacement fails because the subsequent surgery is much more complicated; therefore, fewer surgeons are willing to manage the revision.

Unfortunately, this could be the future of total joint replacement surgeons in America. Orthopaedic residents generally are not going into joint replacement fellowships because of this very issue.  We are 50% filled at best, during a time when we need to be increasing in size. Nationally there is a huge number of impending failures looming. Given the current state of our country, this issue is only going to get worse within the next 5-10 years.

The reimbursement for a single joint replacement surgery has been cut by over 65% in the last ten years.  This isn’t an issue for most surgeons currently in practice; however it does limit the amount of resources they can offer patients.  For example, try calling a doctor’s office and getting an actual person on the phone; these cuts affect everything from the number of front desk employees to the quality of care the surgeon is able to provide.

Cuts of over 65% in 10 years are now being followed with further cuts.  Understandably this makes doctors in training nervous.  Performing this surgery is stressful and I’m afraid it just isn’t worth it for younger doctors considering a specialty surgery career, particularly in joint replacement.

While prevention and patient education remains a goal of all healthcare providers, it does not overshadow the current epidemic that is facing our society with respect to osteoarthritis and its surgical treatment options: the reality is that patients will continue to want the best in surgical care from the best providers.

Please click on the following to see a video entitled “Access Denied:  The Approaching Shortage of Specialist Doctors” and use it to educate your patients on the future of specialized care.  Although it’s a bit biased, it does clearly state the facts.

Dr. Kelley, a third generation surgeon, is a graduate of the University of Iowa School of Medicine.  He performed his orthopaedic residency at the Upstate Medical Center in Syracuse, NY and his fellowship in Adult Hip and Knee Reconstruction at the Mayo Clinic in Rochester, MN.  He is a founder of the North Carolina Orthopaedic Clinic in Durham, NC, an affiliate of the Duke Medical Center where he is a Clinical Professor of Orthopaedic Surgery.  He has authored numerous scientific papers, serves as editor of medical journals, and is a member of a number of prestigious medical organizations.

The Quest for Flexible Fixation with Locking Plates

By Michael Bottlang, PhD, Director, Legacy Biometrics Laboratory

Tuesday, January 4th, 2011

A 2004 editorial entitled ‘‘When Evolution Begets Revolution’’ described locking plates as the next great advance in orthopaedic traumatology that was adopted at an unprecedented speed [1]. The editorial concluded with the prudent prediction that ‘‘this wave of enthusiasm will surely be followed with an analysis of the inherent problems, followed by a truer understanding of the role of these implants.” Today, locking plates are recognized for the superior fixation strength of fixed-angle locking screws, particularly for metaphyseal fixation in osteoporotic bone. They furthermore support biological fixation, allowing subcutaneous plating while preserving periosteal perfusion. Hence, they satisfy two out of three principal aspects of fracture fixation, being stable fixation, preservation of biology, and promotion of fracture healing.

The latter aspect of fracture healing is increasingly being recognized as an inherent problem of the current generation of locking plates. If locking plates do not provide a mechanical environment that promotes fracture healing, they become prone to losing the race between healing and fixation failure, leading to late implant breakage and loss of fixation. There is growing evidence from clinical and animal studies that the inherent stiffness of a locked plating construct can suppresses fracture motion to a level that is insufficient to promote fracture healing by callus formation [2-4].

With hindsight, locked bridge plating constructs pose an apparent conundrum: They provide inherently rigid stabilization, yet they should facilitate secondary bone healing that relies on flexible fixation to stimulate callus formation. To resolve this conundrum, we developed a modified locked plating concept, termed Far Cortical Locking (FCL) that enables flexible fixation with locking plates [4,5]. FCL reduces the stiffness of a locked plating construct by means of FCL screws that are fixed in the plate and in the far cortex while retaining a controlled motion envelope in the near cortex of a diaphysis. FCL screws have a flexible shaft with a reduced diameter that can elastically deflect within the near cortex motion envelope. The motion envelope is controlled by the diameter of a collar segment adjacent to the FCL screw head. FCL constructs therefore resemble a monolateral external fixator, the bar of which has been applied close to the bone surface and the pins of which are secured in the far cortex rather than in the near cortex.

A biomechanical study has shown that FCL screws reduce the stiffness of locked plating construct by over 80% while retaining comparable strength [5]. An in vivo study has furthermore shown that FCL constructs reliably yielded bridging of all cortices, causing healed fractures to be 156% stronger than control fractures stabilized with standard locked plating constructs [4]. Most interestingly, standard locked constructs suppressed fracture healing at the cortex under the plate where fracture motion is minimal. A clinical study is currently being conducted to document the effect of FCL screws on healing of supracondylar femur fractures.

The facts that controlled interfragmentary motion can promote fracture healing while absence of motion will suppress callus formation have long been recognized in the external fixator literature, particularly by the landmark studies of Goodship and Kenwright [6] and Claes [7]. As such, the evolution of locked plating towards more flexible fixation is both novel and conservative. If clinical results should support the prior finding on improved healing with FCL, they will likely inspire a variety of implant solutions aimed at providing flexible fixation with locking plates. These solutions will be key for the quest on flexible fixation with locking plates. However, solutions should be supported by evidence on their ability to promote fracture healing while ensuring that flexible fixation is not gained on cost of fixation strength. Such next generation of flexible locking plates will resemble true internal fixators that replicate the biomechanical behavior of external fixators by allowing adequate interfragmentary motion to promote the natural fracture healing cascade via callus formation. It is the hope of the author that this evolution will in turn resolve the misnomer “secondary” bone healing by recognizing the prime importance of this natural healing cascade for the vast majority of fractures.

Dr. Bottlang is the Director of the Legacy Biomechanics Laboratory in Portland, OR, USA. His research is focused on orthopaedic trauma and fracture care. His line of research on FCL was funded by the NIH and has received the Award of Excellence at the 2010 meeting of the American Association of Orthopaedic Surgeons. He holds several patents and has contributed to the development of several devices, including Zimmer “MotionLoc” FCL screws for which he receives royalties.

Note:  Listings of the MotionLoc FCL screws and the NCB Polyaxial Plate can be found on OrthopaedicLIST.com and x-ray examples of plate and screw fixation of fractures can be seen in the OrthopaedicLIST.com Implant Identification section.

[1] Sanders R. When evolution begets revolution. J Orthop Trauma. 2004;18:481-482.

[2] Henderson CE, Bottlang M, Marsh JL, Fitzpatrick DC, Madey SM. Does locked plating of periprosthetic supracondylar femur fractures promote bone healing by callus formation? Iowa Orthop J. 2008;28:73-6.

[3] Lujan TJ, Henderson CE, Madey SM, Fitzpatrick DC, Marsh JL, Bottlang M. Locked plating of distal femur fractures leads to inconsistent and asymmetric callus formation. J Orthop Trauma. 2010;24-3:156-62.

[4]  Bottlang M, Lesser M, Koerber J, Doornink J, von Rechenberg B, Augat P, Fitzpatrick DC, Madey SM, Marsh JL. Far cortical locking can improve healing of fractures stabilized with locking plates. The Journal of bone and joint surgery. 2010;92:1652-1660.

[5] Bottlang M, Doornink J, Fitzpatrick DC, Madey SM. Far Cortical Locking can reduce the stiffness of locked plating constructs while retaining construct strength. J Bone and Joint Surg. 2009; 91(8):1985-1994.

[6] Goodship AE, Kenwright J. The influence of induced micromovement upon the healing of experimental tibial fractures. J Bone Joint Surg Br. 1985;67-4:650-5.

[7] Claes LE, Wilke HJ, Augat P, Rubenacker S, Margevicius KJ. Effect of dynamization on gap healing of diaphyseal fractures under external fixation. Clin Biomech (Bristol, Avon) 1995;10-5:227-34.