Twenty years ago you could recognize trauma surgeons by the circles under their eyes and the fact that they were the only orthopedists doing cases at 3AM. Alas, it was not the most sought-after subspecialty. No longer the stepchild of the field, trauma has found its voice and its strength, and is contributing more to orthopedics than ever before.
Dr. J. Tracy Watson, Fellowship Director and Chief of Orthopaedic Trauma at Saint Louis University in St. Louis, is former President of and currently on the board of directors of the Orthopaedic Trauma Association (OTA). Providing a bit of history, he notes, “Trauma fellowships have become incredibly popular over the last six or seven years. This is in stark contrast to the late ’90s when at one point we had 35 fellowship spots and only about eight qualified applicants. This dearth of manpower issue had evolved because of the old model whereby traumatologists were extraordinarily overworked and underappreciated. In the mid to late ’80s and early ’90s every major hospital had one trauma surgeon; this poor person was inundated with cases all hours of the night and day. Beyond the exhaustion, there was the catch 22 that you were doing lots of cases but were not being properly reimbursed (despite the fact that you were generating substantial revenues for the institution).”
And there was insult to the injury, says Dr. Watson.
To top it off, when you would discuss career advancement with your superiors, the response was inevitably, ‘Well, you haven’t published anything for two years.’ At which point of course the roar from the trauma surgeon would be, ‘That’s because I’ve been in the OR all the time!
Burn out was rampant, and traumatologists would find themselves getting aggravated and disillusioned, a la ‘Hmm, no recognition, insufficient reimbursement, and I’m making everyone else’s life easier.’ It didn’t have the ring of fairness.”
“In fact, almost all trauma surgeons from that era left their first one or two jobs because they felt used and abused. Moving into the mid ’90s the field became more enlightened. As a trauma surgeon at Henry Ford Hospital in Detroit, I am proud that we were some of the first surgeons to demand dedicated orthopedic trauma rooms. My traumatologist colleagues and I were having to contend with accidents from severe ice storms in the early morning. We would have to wait—and make patients wait—until about 10pm just to start our cases.”
So did hospital administrators get teary-eyed for the traumatologists? No, says Dr. Watson…their eyes were opened wide when the traumatologists pointed out to them that they were losing money. “Reimbursements to hospitals were declining, and administrators saw that orthopedic trauma patients were sitting around in the hospital for a couple of days before they could get into the OR. So the hospitals began to figure out that if traumatologists operate on patients in a timely fashion then those ‘no pay’ patients would no longer cost the system money. This applied on the ‘back end’ also…we demonstrated to the hospital that the ‘no pay’ patients spend more time post op if surgery was delayed—meaning that they were costing the system money. Bingo…dedicated orthopedic trauma rooms began to pop up in centers where there were active traumatologists who were willing to push this issue.”
As these working conditions improved, the number of traumatologists also increased, says Dr. Watson. “The trend reversed, and now we have 80 plus fellowship spots per year with over 100 applications; now there is potentially an oversupply, trending towards a sticky problem. You must have a reasonable number of cases in order to obtain sufficient experience to qualify as an expert. There is a concern that we may be diluting caseloads, as well as the possibility that we have too many fellowships. The OTA is now doing a formal match for fellowships—to participate with the OTA in the match the fellowship has to demonstrate certain benchmarks. We are trying to decide whether or not to work through the Accreditation Council for Graduate Medical Education, something that would mean a rigid process as well as a formal and rigorous evaluation of the educational and surgical experience that the fellowships may or may not be offering.”
On the technology front, says Dr. Watson, the need exists to separate the orthopedic wheat from the chaff. “With regard to fracture care, there is a substantial focus on lock plating. We know that these things work, but we don’t fully understand the interplay of the biomechanics. Every Joe and Harriet company has locked plates these days…the issue is how to sort out the good ideas from the bad ideas when we don’t fully comprehend the subtleties of why locked plating works. Another trend is that we are re-examining surgical indications and perhaps slowly returning to more conservative management for common fractures like humeral shafts, ankles etc. Most trauma patients do need surgery—but not all isolated fractures do. It is our responsibility to work out the indications.”
And if Dr. Watson were handed a one million dollar grant? “I would put it towards determining what else we could do for the geriatric trauma patient, as well as the underinsured. There is a gaping hole in the geriatric orthopedic trauma literature…additionally, we need to know what type of functional outcomes are achieved by our underinsured patients. Most trauma centers have a lot of young and old underinsured patients…and their outcomes are much different than those who have sufficient insurance to allow for post op organized rehabilitation, home care and orthotic management.”
Dr. Watson: “The best news—news that affects both surgeons and patients—is that orthopedic trauma is no longer the ugly duckling of the field.”
Dr. Frank Liporace, Associate Professor and Director of Trauma and Reconstructive Fellowship at the University of Medicine & Dentistry of New Jersey, concurs, and gives credit where credit is due. “The fourfold increase in trauma fellowship applicants is to a large extent due to the efforts of the OTA. The organization has made great strides in helping applicants understand that being a traumatologist doesn’t necessarily mean a difficult lifestyle—and that it can be very rewarding. And the fact that a future traumatologist can almost be assured a dedicated orthopedic trauma room is critical. This is true not only because no one wants to do complex cases at 4am but because cases done during the daytime will almost assuredly have more resources on hand.”
As for what has changed in the educational arena, Dr. Liporace says, “In the past few years we have realized that acute, definitive care for large surgeries involving the open reduction of fractures, especially in the areas around the ankle, foot, and knee, may have negative effects. In some cases, the soft tissue does not heal properly, and there is increased risk for infections—particularly in patients with multiple comorbidities. For example, 40 years ago it was suggested that if we ‘attack’ distal tibial fractures within the first six hours then we would have better outcomes. Unfortunately, this approach resulted in more complications as we moved forward in time and the mechanisms of injury became higher energy and got more complex. While high speed car accidents may leave the patient alive, the injuries are more complicated as opposed to 40 years ago.”
Some of the issues they are sorting through involve the impact on soft tissue…others involve the nuances of the inflammatory cycle. Dr. Liporace: “Not only is the bone more catastrophically injured, but the X-ray only shows bone and not soft tissue—so we don’t have the whole picture. It may be that these fractures should be treated with external fixation first (the literature has gone back and forth on this)”
Fortunately, we are deepening our understanding of the inflammatory cycle, the interleukins involved, and the timing of when they appear in the inflammatory cycle. We now know that you must wait at least seven to ten days to operate on someone with a high energy, periarticular injury.
“Otherwise, it’s like you are delivering a second hit with surgery…remember, surgery is in essence a controlled trauma. By taking this approach we are respecting the mechanism of injury.”
“The main thing is to try early on to get the extremity out to the correct length, stabilize it with external fixators, and then wait until the soft tissue has calmed down and any blistering is re-epithelialized. Doing otherwise means that you are strangling the microvasculature. Whether or not you will know to take this approach depends on what types of mechanism of injury are coming into your institution. If you are primarily accustomed to low energy mechanisms of injury then you may not be as familiar with the negative ramifications of treating a high energy injury too early.”
Alas, says Dr. Liporace, the ‘Git r done’ sentiment seems to have crept into orthopedic trauma. “We reached the point where we felt that immediate care of long bones with intramedullary rods should be done post haste. There are studies saying that using intramedullary rods in long bone fractures within 24 hours results in better patient outcomes. However, much of this information has been widely extrapolated to mean, ‘Let’s get it done ASAP.’ The problem is when you put the rods in after the 12 to 24 hour mark you are causing a second hit in the form of a huge inflammatory response (especially if the patient has a closed head injury or visceral injuries).”
On the product side, states Dr. Liporace, there are new technologies making life easier for surgeons and patients alike. “We now have a number of smaller, low profile implants that give us the ability to address peri-articular injuries. In terms of plates and screws, many of these are now precontoured to the surface of the bone, resulting in less soft tissue disruption and less patient discomfort. Facilitating the development of these products are large databases of bone morphology that show not only the average bone morphology but displays variations between males and females and differences between ethnicities, things that allow implants to be more specific to the patient. Also, there are radiolucent handles that we attach to plates that help us control the amount of surgically induced trauma. There are also carbon fiber guides that are stronger than ever, as well as drills with larger flutes that decrease temperature and reduce the risk of osteonecrosis.”
And on the horizon? “While this work is in its infancy, coming down the pike is the ability to have ionized implants, something that would make them more resistant to infection. They might carry time-release antibiotics, growth factors, etc., which is especially important when doing surgeries in high risk area for complications including but not limited to infection and nonunion. These and other new developments are best undertaken with surgeons working closely and appropriately with manufacturers.”
Trauma…no longer in critical condition.
