Dr Borgi

Yes, it is time that heals fractures—not thanks to the surgeon or to this or that method, but thanks to that physiological biomechanics which my admiration would call divine, were I not afraid of being accused of teleology: a periosteal sheath which, even when lifted and torn, is sealed enough to keep the spindle-shaped hematoma pressurized around the break; cells contained in this hematoma transform into osteoblasts in the immobile zones at the ends of the spindle, and into cartilage cells in the still-mobile zone:

This cartilaginous callus is solid enough by its shape to hold the fragments in place, yet supple enough not to tear; then comes the invasion of this cartilage by blood vessels, and its ossification forms a provisional callus—still spindle-shaped, therefore solid, but not yet plastic enough to respond to mechanical stress; eventually, these stresses guide the construction of trabeculae and reconstitute a structure adapted to its function, with resorption of the now-useless part of the provisional callus, and often (especially during growth) a correction of deformity.

This admirable process, which allows a dog to heal from a fracture simply by walking on three legs, should make surgeons more humble and prevent them from calling any visible callus on an X-ray “malunited,” like a keloid scar, and from boasting—through a mechanicist distortion quickly refuted by recurrent fractures—about the perfection of the “autogenous weld” they claim to create under their more or less compressive screwed plate.

Very recently, I was asked to testify in a lawsuit brought by a young woman against her surgeon. At age 23, she had sustained a closed fracture of the femoral shaft. After eleven operations and ten years of indescribable suffering and expenses, she was being offered a high-thigh amputation. This took place in a major center in North America.

I felt justified in replying that there was not enough gold in Fort Knox to compensate the young woman for the loss of the ten most beautiful years of her life and ultimately, of one of her lower limbs.

At the opposite end of the long line of witnesses accusing fracture surgery, I might submit this personal case: in a curious accident, a 21-year-old man sustains two identical fractures on both legs—transverse fractures of the mid-shaft of the tibia and fibula. Both are anatomically reduced, realigned, and immobilized in a cast.

But in one case, the reduction was only possible with a small surgical opening, though no osteosynthesis was performed. On the closed side, the tibia consolidated in fifty days; the open fracture site was still mobile at 120 days and had to be treated with a screw fixation graft, successfully.

This case gave me, nearly forty years ago, a conviction that all subsequent observations have confirmed: opening a fracture site—even without the introduction of foreign bodies, even without infection—creates a handicap that must be offset by a solid and lasting fixation, and justified by real benefits in quality of reduction, patient comfort, and, at best, shorter hospitalization.

To the question posed by a participant at the famous Davos osteosynthesis course—”Which fractures can still be treated without surgery?”—one of the instructors gave a flawless answer:
“All those that heal as well without surgery.”
But sadly, most professors were no longer confident in healing through closed methods, and their students were not about to become so…

Because osteosynthesis techniques are so pleasant, their instruments so fascinating, the perfection of radiographic images so satisfying to show the patient, these methods—vigorously promoted by inventors, manufacturers, and vendors—have spread like wildfire, despite their cost, despite the risks, and far beyond reasonable indications. And those who have embarked down this path will find it very difficult to turn back, because they often lack the knowledge, the equipment, and the confidence necessary for the so-called orthopedic treatment of fractures. This treatment is the safest—but it is also the hardest for the surgeon: instead of being resolved in a single operation, it requires many actions with no prestige, and above all, sustained and prolonged attention—therefore, real organization.