This interview was conducted in Switzerland in May 2024.
DR. CHOO, WHAT MADE THIS CASE PARTICULARLY CHALLENGING?
In some ways, this case is not at all unusual. It is a displaced proximal humerus fracture with varus, apex anterior angulation, and anterior translation of the diaphysis in an elderly patient with low-energy trauma. However, these features are what make these fractures so challenging – starting from the decision of which patients would benefit from surgery and who of those should get ORIF versus a reverse shoulder arthroplasty. Part of the difficulty with attempting ORIF is to try to get as anatomic a reduction as possible and stable fixation that will be durable to union, which is significantly harder to do with poor bone quality.
CAN YOU COMMENT ON THE USE OF FIBULAR STRUTS IN PROXIMAL HUMERUS FRACTURES?
This is a technique that was popularized in the United States out of the group from HSS (Hospital for Special Surgery).1 It is a very powerful adjunct in these fractures where bone quality is often poor and impaction can leave a defect in the head. They can be used in varus
patterns where the inferomedial “calcar” is comminuted, valgus-impacted patterns, or even as a reduction aid to provide added stability to a displaced surgical neck fracture. They can be drilled through and give the locking screws another point of fixation with added mechanical advantage. However, there are still many concerns about late conversion to arthroplasty and the difficulty of dealing with these once they have incorporated.
DO YOU THINK THAT THERE IS A POSSIBILITY THAT WE MAY PUSH THE INDICATIONS FOR ORIF COMBINING FIBULAR STRUTS WITH SOLID TUBERCULAR FIXATION?
I think this is a very interesting question that we don’t have an answer for quite yet. Part of the impetus for the use of fibular struts was because we clearly still hadn’t solved the problem of ORIF of proximal humerus fractures with locked plating alone. The benefit of the tubercular arms of the Tamina TF is the multiplanar fixation into the humeral head, which at least theoretically can provide more stability and potentially more durable fixation. If this is true, the need for fibular struts may be diminished, which would be beneficial for a number of reasons, not the least of which is the lack of availability of fibular struts in many parts of the world.
HOW DID YOU FIRST LEARN ABOUT BONEBRIDGE?
I first learned about Bonebridge from my partner here in Houston, Professor Milton L “Chip” Routt. His is a name that obviously needs no introduction, as he is a world-renowned pelvic and acetabular surgeon. To add to the very long list of reasons I am indebted to him, he introduced me to Dr. Christof Gerber and his vision of reducing complexity with Bonebridge.
ALL OUR IMPLANTS ARE DESIGNED WITH THE AIM OF “REDUCING COMPLEXITY” IN ORTHOPAEDIC TRAUMA. IS THAT SOMETHING THAT IMMEDIATELY APPEALED TO YOU?
To be quite frank, I was initially skeptical when I heard of the concept of reducing complexity in orthopaedic trauma. I felt like the push here in the United States was towards more and more complexity – more plates for different anatomic areas, more screw options, more bells and whistles with every new iteration of technology. However, the more time I spent hearing about the concept of the company and its philosophy, the more I see the appeal. Not everyone has the luxury of working in a place like I do, where every company and every implant sits on the shelf, and our nurses and techs do nothing but orthopaedic trauma. There is a certain beauty in streamlining and simplifying the implants, sets, and process of fracture fixation and emphasizing the basic principles.
YOU’RE CURRENTLY HERE IN SWITZERLAND AS PART OF THE BONEBRIDGE TECHNICAL COMMISSION, WHICH YOU JOINED IN 2023. CAN YOU TALK A LITTLE BIT ABOUT HOW THAT COLLABORATION HAS BEEN FOR YOU?
It has been amazing to get to know everyone involved in this group for the last year, and I’m truly grateful for those who have made this opportunity possible. The most rewarding thing about being a part of this group is the exchange of ideas with surgeons on the other side of the Atlantic. Despite differences in training and language, we are both seeing the same problems and have far more in common than I expected. That being said, the fun part is in the slightly differing thought processes and approaches to problems we both see, and I think the discussions around these are enlightening to both sides.
Another very exciting aspect has been finding “kindred spirits” in Switzerland who have practices quite similar to mine. The majority of my practice is dedicated to upper extremity trauma, which is a bit unusual in the US. However, through the Technical Commission I’ve gotten to know a number of surgeons who share that same interest; we’ve already begun the process of sharing ideas and collaborating on projects, which is incredibly cool to see.
WHAT PLACES IN SWITZERLAND HAVE YOU ENJOYED THE MOST SO FAR? ARE THERE ANY PLACES YOU WOULD LIKE TO EXPLORE FURTHER IF YOU HAD A LITTLE MORE TIME?
Before this collaboration I had never been to Switzerland, so visiting the country has been an added bonus. It is a truly beautiful country and I think you guys are probably a bit spoiled by the weather, culture, lakes, and mountains that you get to see every day! The people have also universally been extremely kind and welcoming no matter where we’ve been. Although I’ve gotten to see many parts of the country, I look forward to spending more time on future visits perhaps seeing cities like Bern and Geneva and other parts of the French and Italian-speaking regions of the country. Of course, coming to Switzerland in the winter would also be incredible, and I would love to set foot on the famed Swiss Alps at some point!
WHAT OTHER ADVANCEMENTS IN ORTHOPAEDIC SURGERY HAVE YOU FOUND MOST EXCITING IN RECENT YEARS?
That is such a tough question to answer succinctly. I guess the short answer would be the highly collaborative nature of modern orthopaedic research. I think people are bringing a new level of scientific rigor to questions in orthopaedics, and it’s given us a whole new understanding of how best to answer these questions. Orthopaedic trauma has been at the forefront of this with groups like COTS (Canadian Orthopaedic Trauma Society) and METRC (Major Extremity Trauma Research Consortium) doing large, multicenter, randomized controlled trials on how best to manage common injuries and scenarios. On the flip side, I think there will always be a role for advances in techniques and experience in what we do – that is the art of medicine and surgery that cannot be replaced. For instance, if we only believed the results of randomized controlled trials, we wouldn’t be fixing any proximal humerus fractures!
My longer answer would be that I think technology has and will continue to be the main driver in advancements in orthopaedic surgery in general. Looking back in my (relatively) short career, things like locking plates, highly cross-linking polyethylene, and the reverse shoulder arthroplasty have been major paradigm shifts attributable to technological advances. It’s a fool’s errand trying to predict what will come next, but technologies such as 3D-printing, robotics, artificial intelligence, and even things like CRISPR have the potential to really change how orthopaedics and all of medicine is done in the future. We may all have to learn a very different way to do things, but I hope to be retired by that point!
References:
Gardner MJ, Boraiah S, Helfet DL, Lorich DG. Indirect medial reduction and strut support of proximal humerus fractures using an endosteal implant. J Orthop Trauma. 2008 Mar;22(3):195-200. doi: 10.1097/BOT.0b013e31815b3922. PMID: 18317054.