Indirect reduction brought surgeons back to basics

The founders of the concept highlighted the importance of preoperative planning and using the fracture implant.

It has been more than a decade now since Planning and Reduction Technique in Fracture Surgery by Jeffrey Mast, MD; Roland Jakob, MD; and Reinhold Ganz, MD, was published. This now- classic work has influenced fully an entire generation of fracture surgeons. The concept of “indirect” reduction helped transform many surgeons from mere carpenters to “kinder and gentler” gardeners of living bone.

The immeasurable contribution of the Arbeitsgemeinschaft Fur Osteosynthesefragen (AO) [or the Association for the Study of Internal Fixation (ASIF)] to the care of patients throughout the world cannot be disputed or, in fact, overemphasized. However, up until this biologic concept was introduced, fracture surgery had tended to drift somewhat toward obsession with anatomic, rigid and exact reduction and fixation of fractures, often at the expense of bone viability. The unfortunate consequences of this, of course, were “ununited” fractures and “ununited” infected fractures.

Back to basics

By introducing the indirect concept, Mast et al brought us back full circle to the understanding and importance of maintaining viability of bone while using the well-loved AO/ASIF implant to achieve “stable” rather than rigid internal fixation.

The fathers of the indirect concept taught us once again the importance of preoperative planning and the use of our actual fracture implant as reduction tools. This, along with important reduction concepts such as focal traction applied via push-pull screws, femoral distracters and external fixators, as well as a virtual plethora of helpful concepts such as composite fixation, have contributed greatly to our understanding of fracture reduction and fixation.

X-ray 1
This 38-year-old male presented with injuries from a gunshot wound to his right femur.

X-ray 2
Application of traction is applied, as shown in the AP radiograph.

Since introduction of this concept, literally hundreds of independent publications on the indirect technique have been reported in the literature. Moreover, just recently, David Helfet, MD, succinctly pointed out at his presidential address to the Orthopaedic Trauma Association that we are continuing to advance in our “biological revolution” with more and more attention being paid to fracture biology looking, of course, for the penultimate technique.

When we get there, as surely we will, our patients and we will always certainly owe a measure of gratitude to those who led the charge.

X-ray 3 X-ray 4
A postop AP radiograph taken of the same patient (left), and the postop, lateral view.
X-ray 5 X-ray 6
Follow-up radiographs show classic low-profile indirect healing.

Author

Brett R. Bolhofner, MD, is director of orthopedic trauma at Bayfront Medical Center in St. Petersburg, Fla.

It has been more than a decade now since Planning and Reduction Technique in Fracture Surgery by Jeffrey Mast, MD; Roland Jakob, MD; and Reinhold Ganz, MD, was published. This now- classic work has influenced fully an entire generation of fracture surgeons. The concept of “indirect” reduction helped transform many surgeons from mere carpenters to “kinder and gentler” gardeners of living bone.

The immeasurable contribution of the Arbeitsgemeinschaft Fur Osteosynthesefragen (AO) [or the Association for the Study of Internal Fixation (ASIF)] to the care of patients throughout the world cannot be disputed or, in fact, overemphasized. However, up until this biologic concept was introduced, fracture surgery had tended to drift somewhat toward obsession with anatomic, rigid and exact reduction and fixation of fractures, often at the expense of bone viability. The unfortunate consequences of this, of course, were “ununited” fractures and “ununited” infected fractures.

Back to basics

By introducing the indirect concept, Mast et al brought us back full circle to the understanding and importance of maintaining viability of bone while using the well-loved AO/ASIF implant to achieve “stable” rather than rigid internal fixation.

The fathers of the indirect concept taught us once again the importance of preoperative planning and the use of our actual fracture implant as reduction tools. This, along with important reduction concepts such as focal traction applied via push-pull screws, femoral distracters and external fixators, as well as a virtual plethora of helpful concepts such as composite fixation, have contributed greatly to our understanding of fracture reduction and fixation.

X-ray 1
This 38-year-old male presented with injuries from a gunshot wound to his right femur.

X-ray 2
Application of traction is applied, as shown in the AP radiograph.

Since introduction of this concept, literally hundreds of independent publications on the indirect technique have been reported in the literature. Moreover, just recently, David Helfet, MD, succinctly pointed out at his presidential address to the Orthopaedic Trauma Association that we are continuing to advance in our “biological revolution” with more and more attention being paid to fracture biology looking, of course, for the penultimate technique.

When we get there, as surely we will, our patients and we will always certainly owe a measure of gratitude to those who led the charge.

X-ray 3 X-ray 4
A postop AP radiograph taken of the same patient (left), and the postop, lateral view.
X-ray 5 X-ray 6
Follow-up radiographs show classic low-profile indirect healing.

Author

Brett R. Bolhofner, MD, is director of orthopedic trauma at Bayfront Medical Center in St. Petersburg, Fla.