Ankle Arthrodesis/fusion is the end-stage procedure for the treatment of ankle arthritis. Other options available for treating arthritis of the ankle is Joint Replacement Surgery. So, when selecting between arthrodesis and replacement as the optimum procedure for a patient the important considerations are-
1) Infrastructure: – Well equipped OT and Trained Staff
2) Availability of Implants: – Total Ankle still not available in India even in December 2019.
3) Patient’s expectations after surgery: – Total Ankle tolerated well in urban lifestyle.
4) The longevity of the Implant: – 85% survivorship at 10 years in the best of the series.
In low demand patients and financially sound Individuals, arthroplasty finds favor as the cost of the surgery is above 8000 US$.
On all the above counts’ Fusion/ Arthrodesis scores over Arthroplasty. It has been proven beyond doubt that ankle fusion does not produce a bad walking pattern, while it takes away the pain from an individual whose life is already severely compromised due to painful arthritis of the ankle.
Ankle Arthrodesis can be done by either open or arthroscopic techniques:
1) Open Technique: – For moderate to severe deformities. Healthy skin is mandatory for open procedures. Various approaches used are Anterior, Lateral, Lateral+medial, Medial & Posterior.
2) Arthroscopic Technique: – For mild deformities i.e. less than 15 degrees of varus or valgus tilt in the coronal plane. Preferred in the presence of compromised skin and diabetic patients.
Fixation Methods: – Screws, Anterior Plate, Lateral Plate
Plates are used to achieve more stiffness of arthrodesis especially in the presence of osteoporosis.
Fixation by 3 compression screws is biomechanically similar to that of plate
( Clifford C, Berg S, McCann K, Hutchinson B, A biomechanical comparison of internal fixation techniques for ankle Arthrodesis. The Journal of Foot Ankle Surgery 2013;54:188-191).
Dr. Kamal Dureja.
Head of Foot & Ankle Surgery Unit,
Max Smart Superspeciality Hospital, Saket
Dr. Shantanu Bhardwaj.
Fellow in Foot & Ankle Surgery,
Max Smart Superspeciality Hospital, Saket
Implants removal belongs to the foremost common elective orthopedic procedures in industrial countries. In an often-cited Finnish study, implant removal contributed to almost 30 percent of all planned orthopedic operations, and 15 percent of all operations of the department.
Controversy exists as to the necessity for routine orthopedic implant removal. In children, it can be essential to remove implants early to avoid disturbances to the growing skeleton, to avoid their bony confinement making later removal technically hard or impossible, and to enable for planned reconstructive surgery after skeletal maturation (for example, in case of hip dysplasia).
In adults, pain, the resumption of strenuous activities or contact sports after fracture healing, soft tissue irritation, as well as the demand of patient are typical indications for removal of the implant in clinical practice. Numerous surgeons will remember patients whose intractable, barely explainable local symptoms and complaints resolved rapidly after the procedure. Though, ortho implant removal needs a second surgical procedure in scarred tissue and poses a risk for re-fractures and nerve damage.
Pain can even get worse after implant removal. In a series of 109 femoral nail removals, a rise in pain and discomfort was noted in 4/58 (7 percent) of all patients with, and 10/51 (20 percent) of all patients without pre-operative signs. Similar observations were made in subjects who had experienced open reduction and internal fixation of ankle fractures.
Corrosion, systemic release of nickel, cobalt, and chromium, and it’s presumed allergic, toxic, and even carcinogenic potential have been related to stainless steel implants. Yet, none of these adverse effects had influentially been confirmed in the clinical setting. Orthopedic fixation devices made from titanium alloy are considered less vulnerable to degradation and safe to be retained in situ, but aluminum and titanium had been traced in serum and hair of 16 out of 46 patients after spinal instrumentation as well.
It is best to surmise that decision to remove an Orthopedic implant should be taken in consultation with the Surgeon who can help evaluate the need, effectiveness, and risks of this common procedure in different clinical settings.
A humerus fracture is a break of the humerus bone within the top arm. Symptoms may include pain, swelling, and bruising.
Types for Humerus Fracture
The plating technique is used when indicated for the treatment of a fracture of the shaft of the humerus. Depending upon bone anatomy, a broad heavy-duty plate or a narrow plate is used if the humerus is very thin. The plate may be placed on the dorsal surface of the humerus or the volar side. Screws should engage a minimum of six cortices per the main fragment. When LIFP is used, a narrow, longer plate is preferred.
The Distal Humerus –
For the fixation of intra-articular fractures of the distal humerus, a 3.5/4.0mm distal humerus extra articular plate or a malleable reconstruction plate is useful. A reconstruction plate is placed posteriorly on the lateral column and medially on the medial column for maximum support. In the case of bone loss two plates, one medial and one on the lateral side, are applied.
The Proximal Humerus –
Proximal humerus locking plate-PHLP are pre-contoured and anatomically shaped plate for the proximal humerus. It has five holes in the section abutting the head.
These locking screw holes are in different angles to improve the fixation. The first two holes are slanting at an angle of 95 to the plate and are inclined slightly upwards; these screws ascend in the head. The next row also has two screw holes that at 90° to the plate and at an angle of 50 to one another, spreading out in the head. The fifth hole is an integrated hole and is set at an angle of 90 to the plate. This portion of the plate is bent upwards such that the screw ascends in the head.
Related Post: Post-Operative Care for Humerus Fracture
The proximal section also has several holes of 2 mm diameter through which sutures are passed to repair and stabilize the rotator cuff. These holes serve as placement points for the aiming block. The block sits on the plate to guide the threaded drill sleeve and subsequently the drill bit to the perfect angle of screw insertion in the humerus head. Hence, the use of the aiming block is mandatory while applying for this plate. In the plate segment abutting the shaft, four integrated screws holes are deployed. These are used to apply the placement of conventional or locking screws.
In the case of tibial shaft fractures associated with a displaced intra-articular fracture of the knee and the ankle, plating is the most commonly adopted technique.
The tibial plateau fracture and the tibial pilon fracture require accurate open reduction and fixation. Buttress plating is almost always necessary to support epiphyseal-metaphyseal fragments. Plating with Indirect reduction techniques is used for such fractures.
Narrow plates are used is employed to fix fractures of the tibial diaphysis. For the convenience of the operator, Plates are usually applied on the subcutaneous surface of the tibia. Plates may also be applied on the lateral surface. It is essential to engage six cortices on either side of the fracture.
Eccentric insertion of a screw on each side of the fracture is recommended to compress a tibial diaphyseal fracture. If the plate is placed in a too anterior or too posterior position or there is comminution of either cortex, placement of a single screw in each fragment tends to act as a fulcrum around which the fragments can rotate. To avoid it, instead of one, two eccentric screws are inserted in each fragment, prior to compression. Two screwdrivers are used at the same time to compress the fracture from both sides. This technique is consistent with biological plating as it limits the extent of surgical exposure and avoids the use of plate holding forceps: both factors help in maintaining bone vitality.
LIFP metaphyseal plate for the lower end of the tibia [LCP tibial plate, Synthes, Paoli] is pre-contoured to meet the shape and thickness requirement of the area and mode of application. Its ballet tip renders it easier to a minimally invasive surgical technique. The thinned plate profile especially takes the peculiarities of the metaphyseal area into account and provides easy contouring of the plate. The long hole helps to optimize the fine-tuning of the reduction in the longitudinal axis. The dense net of integrated holes in the thinned plate area of the distal end covering the malleolar region allows a closer insertion of the screws and therefore, provides a higher purchase with better stability.
The integrated holes provide a choice of dynamic compression and angular stability in the implant. The angulation of the two outermost hole units towards the center of the thinned plate allows a closer juxta-articular plate placement. A single smaller hole is provided to facilitate temporary fixation with a K-wire. The undercuts on the surface abutting bone face maintain good vascularization of the periosteum. Plates with similar designs are available for fractures in the metaphyseal areas that reach into the proximal tibia, the proximal and distal shaft of the humerus, fibula, and proximal and distal radius as well as ulna.
Ulna and Radius are two main bones in the forearm. Ulna runs along the outside of the wrist and Radius runs along the inside. A bony projection at the end of the ulna is called the ulnar styloid process.
It fits into the cartilage of the wrist joint and plays an important role in the strength and flexibility of the wrist and forearm. A break of the bone in this area is called an ulnar styloid fracture.
The Symptoms of Fracture:
The main symptom of an ulnar styloid fracture is immediate pain. This type of fracture is usually accompanied by a radius fracture. In such a case, the pain is felt more on the inside of the wrist than near the ulnar styloid process.
Additional symptoms include:
One may also notice the wrist and hand hanging at a different angle than the usual configuration.
Hand and wrist fractures (the latter is basically an ulnar styloid fracture) are mostly caused by an injury sustained while trying to break a fall with an outstretched arm.
Other common causes include:
- Motor Vehicle accidents
- Hard falls
- Sports injuries
Further, osteoporotic conditions can also increase the risk of fractures. Such a condition weakens the bones and makes them brittle. One needs to take extra precautions to avoid bone injuries.
Options to treat broken bones include both with and without surgery.
Mild ulnar styloid fractures often need a basic wrist cast. The doctor may have to realign bones before adding a cast. This process is called reduction and can sometimes be done without an incision (closed reduction).
For severe fractures, which may also involve other nearby bones, one would require surgery. This involves an open reduction: The doctor makes an incision near the fracture and uses the opening to reset the affected bones. Severe breaks may require using metal orthopedic bone screws or pins to keep the bones in place while they heal.
Following an open reduction, a durable cast is needed, which may be made from plaster or fiberglass.
Ankle fracture: Types, Symptoms & Causes
An ankle fracture happens when one or more than one bone that makes up the ankle joint- and probably its ligaments break at or close to the joint.
Every year, 184 persons out of every 100,000 withstand ankle fractures. Emergency rooms witness 1.2 billion visits in 2003 due to ankle fractures alone. This number has been increasing and the broken ankles have been getting more severe in the last few years.
Types of ankle fractures
Ankle fractures can be categorized into 5 main types:
- Lateral malleolus fracture :– The lateral malleolus is the point situated on the outside of the leg where the fibula articulates with the talus. A lateral malleolus fracture is a broken distal fibula.
- Medial malleolus fracture :– A medial malleolus fracture is a tibia fracture analogous to the lateral malleolus fracture of the fibula. It is a fracture of the distal tibia.
- Posterior malleolus fracture :– It is very infrequent that only the posterior malleolus- the actual bony protrusion of the tibia is broken.
- Bimalleolar fracture :– If two ankle bones are fractured, it is known as a bimalleolar fracture. This is usually a combination of a medial malleolus and lateral malleolus fracture. This kind of fracture will lead to an unstable ankle.
- Trimalleolar fractures:– If all 3 of the malleoli (the medial, lateral and posterior) have been broken, it is a trimalleolar fracture. This kind of fracture will lead to a very unstable ankle.
The many common symptoms across all kinds of ankle fractures are:
- Extreme pain in the ankle that may “radiate” out to the foot and knee
- Swelling in the ankle and, sometimes leg
- A problem in walking or complete inability to walk (don’t use this as a test, as it can worsen the injury)
The symptoms of an ankle fracture may be mistaken for the symptoms of other medical situations (sprained ankle, talus fracture, etc.). Ensure you consult a doctor to know if you have an ankle fracture and get the suitable treatment. The treatment may include surgical intervention that requires orthopedic instruments used by the surgeons.
An ankle fracture is an outcome of too much stress being put on any or all the bones of the ankle joint. The causes of the ankle fractures are:
- Ankle twist :– If your foot twists far to the side, turning around your ankle
- Ankle roll :– If your foot rolls up on its side during you are putting substantial weight on it
- A fall or a trip :- If you suddenly lose your balance and awkwardly try to catch yourself with your feet.
- Overextension of the ankle joint :- If you try to swing your foot down too far in a parallel arc with your leg, as a may be ballerina
- Extreme impact :– If the joint sustains a serious blow, as it may if are in an automobile accident or you come down on your feet from a height
Without suitable care and medical intervention, an ankle fracture can lead to arthritis. You have an especially high risk of ultimately getting arthritis if, after the injury, your ankle appears misshapen. If the break is serious, you might see a bone poking out of your skin. If this is the case, you must take immediate medical care, as this kind of ankle fracture can lead to severe infection.
Treatment for Ankle fracture will be decided by the Orthopedic Surgeon after proper examination of the injury using X-ray or CT scan or MRI. He may opt for Surgical Intervention and use of trauma Implants like Malleolar Screws, Wires, Plates and Screws if other options are not effective.
Surgery is followed by planned Post-Operative Care including Physiotherapy so that the patient regains proper movement of the ankle.
Injuries to children leading to fracture of femoral bone are quite common. Non-surgical treatment option has been effective for common Femur Fractures. Selecting treatment methods for femur fractures is dependent on the age of the child since the displacement (separation of the bone ends) that can be accepted depends on the child’s age and even widely displaced fractures have healed in young children.
Usually, cast treatment is adopted for treating Femur fractures in infants and toddlers. A Pavlik harness may be preferred instead of a Spica cast in early infancy.
The rapid growth of bone in young children does not require the bone ends to be perfectly aligned. Over time, the bone remodels to a shape, where it may not be evident that the bone had been injured. Spica casting for about 4 to 6 weeks will be adequate for bone healing in the case of most infants and toddlers.
Spica casting is usually adequate for younger children (Up to the age of 6) to treat a femur fracture. As children get older, the duration of casting may be slightly longer, but the bone still has excellent potential for healing.
For children in the 5 to 7-year age bracket, Orthopedic Surgeon has to make a decision in consultation with the parents for applying the best technique to heal the bone injury. While a Spica cast is a popular option in treating children, a doctor may decide to insert flexible rods inside the bone. The pros and cons must be well understood by the treating Doctor.
In Later Childhood
While there is no clear cutoff for spica casting options becoming less practical, but one must evaluate options with the surgeon. The surgical treatment options commonly adopted for femur fractures are:
- Flexible Rods: A flexible intramedullary nail is the most common treatment option for older children (age 7 – 12). These flexible rods are inserted just above the knee into the medullary canal of the femur bone and easily removed after treatment. The rods do not cross the growth plate. As the rods are not rigid, they cannot support the child. These young children heal very quickly, and the rods do not cause problems.
- External Fixation: External fixationuses a rod outside the patient’s body which is attached to the bone with long pins or screws. The external fixators are often used with open fractures or when the fractured bone is in many pieces (comminuted). Due to good results with the flexible rods, the use of external fixators is limited.
- Standard Rods: In an adult, an Intramedullary rod is the standard treatment for a femur fracture. Once a child’s growth plates have closed, only then this type of rod should be used. Around the ages of 11 to 14, most femur fractures will be treated in the same way as they are treated in an adult.
Above are general approaches for the treatment of common femur fractures but deciding the best treatment option in a situation depends not just on the age but on a number of factors of individual circumstances of the child, which may alter the treatment approach.
Internal Fixator Plates have been used from very early times to fix the bones internally. The locking plates serve to maintain length, rotation, and angulation at the fracture. Initially, there were Sherman plates, which used self-tapping screws. Then came the Broad, Narrow, and Small plates of AO type. They were used with compression devices to give a rigid internal fixation.
There used to be cortex to cortex union with no visible callus formation. To achieve an anatomical reduction extensive dissection was done. The periosteum was stripped mercilessly. At that time the biological treatment concept was not there. The heavy plates were tightened to fix on the bone. The area under the plate lost its periosteal blood supply and became avascular. The stability was produced by the friction between the undersurface of the plate and bone. The avascular bone corroded and the holes in bones for screws got osteonecrosis and loose hence they failed to hold till union quite often.
There was an incidence of sterile sequestrum formation in the avascular bone. The process of fracture union used to get delayed till they were revascularized by creeping substitution. Till then the limb had to be immobilized causing stiffness, weakness, muscle atrophy, joint stiffness (fracture disease).
Next came Dynamic Compression plates (DCP). Which due to its special hole pattern produced compression without a compression device and the concept of extra-periosteal plate came. Still, there was the avascular area under the plate. Which was further reduced by Low Contact Dynamic Compression Plate (LCDCP). Here the avascular area under the plate was less. Care was taken to avoid unnecessary periosteal stripping. Hence the union was quicker and better.
With these principles in mind, the DCP and LCDCP reduced the fracture healing time and there was some callus formation. There was consequent early mobilization and less amount of Fracture disease.
Once the true nature of these events was uncovered, the priorities changed from mechanical stability to biology. The biological internal fixation or bio-buttress fixation is one that makes sense from the biological point of view. Blind, subcutaneous, or submuscular insertion of an implant like a bone plate via a minimal surgical approach to preserve vascularity and fixing it by the newer aiming and stabilizing technologies to achieve elastic flexible fixation is part of this protocol. It took some more time to come with the concept of the internal fixator.
The healing pattern of bone is more natural with visible callus formation, and its strength returns early since live bone heals in a shorter time than creeping substitution of dead bone. The locked internal fixation plates! (LIFE) represents a novel, bio-friendly approach to internal fixation. It resembles a plate, but its biological and mechanical characteristics are different and it functions rather like a fully implanted external fixator, even in its healing pattern. It is known that an external fixator causes the least vascular damage in comparison to intramedullary nailing or conventional plate fixation.
This is the LCP. These plates were custom made for different parts of bones and areas. They were made to tackle even the periarticular fractures. These plates were also slotted in the undersurface to reduce the amount of periosteal damage. The holes had an option of fixation with two types of screws. The first one was a regular cortical or cancellous screw that fixed the plate to the bone in the desired position, the other was a locking option. They have a guide to fix the direction of the screws to the plate.
The holes are having threads as well as on the screw heads so that on tightening the screws it fixed to the plate without producing unnecessary compression of the plate on the bone.
The healing pattern of bone is more natural with visible callus formation, and its strength returns early since live bone heals in a shorter time than creeping substitution of dead bone. The locked internal fixation plates (LIFE) represents a novel, bio-friendly approach to internal fixation. It resembles a plate, but its biological and mechanical characteristics are different and it functions rather like a fully implanted external fixator, even in its healing pattern. I am known that an external fixator causes the least vascular damage in Comparison to intramedullary nailing or conventional plate fixation.
Spinal Implants: Spinal or spine implant systems made of titanium and other materials, utilizing specially designed spinal instrumentation are often used when spinal conditions require surgery. The implants facilitate fusion, correct deformities, and stabilize and strengthen the spine.
Conditions that often require instrumented fusion surgery include slippage of the spine (spondylolisthesis), chronic degenerative disc disease, traumatic fracture, and other painful forms of spinal instability including scoliosis.
Implants for Spine Surgery are made of metals like titanium, titanium alloy, or stainless steel; some are made of non-metallic compounds. These are available in different shapes and sizes to accommodate patients of all gender and ages.
Scientists and surgeons around the world are constantly working to develop and refine implants. In recent years there have been huge advances, including the advent of the hook, rod, and screw systems that enable surgeons to correct spinal deformities 3-dimensionally; the development of special plates and cages that help promote spinal fusion; and the creation of small but strong implants for children.
Types of Spine Implants
There are mostly two common types of spinal implants used in spine surgery given as- Fusion, Non-fusion
Non-fusion: Non-fusion spine implants consist of artificial disks and expandable rods.
Fusion: Fusion spine implants are used during spinal fusion surgery by an orthopaedic surgeon and are often used along with a bone graft. The spinal Fusion implants usually include:
- Rods: Rods are used, along with hooks and screws, to immobilize involved spinal levels, and to contour the spine into correct alignment. One of the original implants used in the spine, the rods are strong, yet have some flexibility so that the surgeon can shape the rod to match the contours of the patient’s spine.
- Pedicle Screws: Deriving its name from pedicles of the spinal vertebrae, these specially designed screws are carefully implanted into the pedicles. Traditionally used in the lumbar spine, with recent advances in technology and technique, surgeons are now using them in the thoracic spine too. Screws provide strong “anchorage” points to which rods can be attached. Rods can then be contoured to correct deformities and to facilitate fusion.
- Hooks: These are used with rods and other implants to anchor them to vertebrae.
- Plates: Plates are mostly used in the cervical spine. Plates are manufactured to conform to the contour of the spine and are held in place by screws set into adjacent vertebrae. When the plate requires adjustment, a contouring tool is used to customize the fit to the patient’s anatomy.
- Cages: These are most often placed between two vertebrae and are called “interbody” cages. Cages are small hollow devices with perforated walls. Bone graft or BMP is often packed into the cage to promote bone growth between the adjacent vertebrae. Cages are used to restore lost disc height resulting from a collapsed disc and to relieve pressure on nerve roots.
Application of Spine Implants
Implants are carefully chosen to ensure the best choice for the specific patient. For example, “low volume” implants are used because they reduce muscle irritation and cause less post-operative pain. For patients who are slim, “low profile” implants not visible through the skin are used. Titanium is the preferred material as it is strong, light, and, unlike stainless steel implants, can be used with MRIs. When suitable, the use of radiolucent materials such as carbon fiber cages is also followed. Carbon-fiber implants cannot be seen on a scan but allow us to see if a bone is forming and fusion is taking place.
Future of Spine or Spinal Implants
Scientists are working on developing bio-resorbable implants. These are used to facilitate fusion. However, after a year or so (when fusion should be complete) the implant is not necessary but is left in the body. Bio-resorbable implants are designed to break down when they come into contact with water (such as body fluids). In a year, most decrease in size by 50% and are completely gone in 2-3 years. Thus the implant is present in the body when it is needed to promote fusion, and then gradually “fades-away” over a 12-36 month period. Though only a few bio-resorbable implants are available, it is hoped that in the future a significant step in this field would take place.
In the past two decades, there have been major breakthroughs in the development of spinal implants. The result is a better treatment option for patients.
Bone Plate uses to treat the bone fragments fracture. A bone, if fractured needs to be properly aligned and stabilized so that it unites and is strong enough to handle the body’s weight and movement. Earlier, Doctors relied on casts and splints from outside the body to support and stabilize the bone. The development of a surgical intervention to internally set and stabilize fractured bones using Implants is now widely practiced.
To treat a fracture, the bone fragments are first repositioned (reduced) into their normal alignment during the surgical procedure. Special implants Viz. plates, screws, nails, and wires hold them together.
Some of the advantages of such an Internal fixation procedure are:
- shorter hospital stays,
- enables patients to return to their normal function faster, and
- reduces the incidence of nonunion (improper healing) and malunion (healing in improper position) of fractured bones.
The implants are made from stainless steel and titanium, which are durable and strong. In the case of joint replacement, these implants can also be made of cobalt and chrome alloy. The Implant material is compatible with the body and rarely causes an allergic reaction.
The most often used implant for internal fixation is Screws. Although it is a simple device, there are various designs depending upon the type of fracture and place of use. Screws of different sizes are used with bones of varying sizes. Screws may be used alone to hold a fracture and is used with plates, rods, or nails. After the bone unites, screws may be either left in place or removed.
Plates hold the broken pieces of bone together and work as an internal splint. Screws are used to fix it to the bone. After healing of the bone is complete, Plates may be left in place or may be removed.
Nails or Rods
Long bones in our body are hollow at its center. Inserting a rod or nail through the hollow center of the bone to hold the bone pieces together is the adopted technique in some fractures of the long bones. Screws at each end of the rod are used to keep the fracture from shortening or rotating and hold the rod in place until the fracture has healed. Rods and screws may be removed after healing is complete or left in the bone. This technique is commonly used to treat fractures in the femur (thighbone) and tibia (shinbone) bone.
Wires are often used to pin the bones back together. They are often used to hold together pieces of bone that are too small to be fixed with screws. In many cases, they are used in conjunction with other forms of internal fixation, but they can be used alone to treat fractures of small bones, such as those found in the hand or foot. Wires are usually removed after a certain amount of time but may be left in permanently for some fractures.
External fixation is often used to hold the bones together temporarily when the skin and muscles have been injured. An external fixator acts as a stabilizing frame to hold the broken bones in the proper position. In an external fixator, metal pins or screws are placed into the bone through small incisions into the skin and muscle. The pins and screws are attached to a frame outside the skin. Because pins are inserted into the bone, external fixators differ from casts and splints which rely solely on external support.
In many cases, external fixation is used as a temporary treatment for fractures. Because they are easily applied, external fixators are often put on when a patient has multiple injuries and is not yet ready for a longer surgery to fix the fracture. An external fixator provides good, temporary stability until the patient is healthy enough for the final surgery.
Other times, an external fixator can be used as the device to stabilize the bone until healing is complete.
There may be some inflammation or, less commonly, infection associated with the use of external fixators. This is typically managed with wound care and/or oral antibiotics.
Sterile conditions and advances in surgical techniques reduce but do not remove, the risk of infection when internal fixation is used. The severity of the fracture, its location, and the medical status of the patient must all be considered.
In addition, no technique is foolproof. The fracture may not heal properly or the plate or rod may break or deform. Although some media attention has focused on the possibility that cancer could develop near a long-term implant, there is little evidence documenting an actual cancer risk and much evidence against that possibility. Orthopedic surgeons are continuing their research to develop improved methods for treating fractures.