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SA Orthopaedic Journal

On-line version ISSN 2309-8309
Print version ISSN 1681-150X

SA orthop. j. vol.12 n.1 Centurion Jan. 2013

 

 

Treatment of clavicle fractures: current concepts review

 

 

Reviewer: Dr H Sithebe
Department of Orthopaedic Surgery
Steve Biko Academic Hospital
University of Pretoria
Tel: (012) 354-2851

 

 

Oliver A van der Meijden, MD, Trevor R Gaskill, MD, Peter J Millett, MD, MSc J Shoulder Elbow Surg 2012;21:423-29

Fractures of the clavicle are relatively common, accounting for approximately 2%-5% of fractures in adults and 10%-15% in children. Two-thirds involve the diaphysis with the lateral third comprising of 25% and the medial third the remaining 2-3%.

Historically, the vast majority of diaphyseal fractures have been treated nonoperatively except in cases where definite indications for surgical intervention existed such as open fractures. In the last decade however, there has been a plethora of publications highlighting a far greater level of complications (15%-18% non-unions), and patient dissatisfaction (symptomatic mal-union and loss of shoulder strength). This has subsequently led to a paradigm shift towards acute operative stabilisation of clavicle fractures with an expansion of indications to include amounts of displacement and comminution, and patient activity. Not a lot however is said about the complications of surgical intervention such as infection, neurologic compromise, and refracture after hardware removal.

The value of this article is that it provides a concise yet comprehensive review of the current trends in the treatment of not only midshaft fractures but also, of those involving the medial and lateral ends of the clavicle.

Importantly, it emphasises the fact that treatment of clavicle fractures should not be broadly applied resulting in indiscriminate surgical intervention, but rather it be individualised based on fracture characteristics and patient expectations. This is particularly pertinent in the light that there is still no long term evidence showing superior outcome of surgically treated midshaft fractures.

It certainly has a place in the armamentarium of all orthopaedic registrars in training in grounding their approach and reasoning in the often challenging and sometimes controversial treatment of these fractures.

 


 

Combined procedure of open reduction and shortening of the femur in treatment of congenital dislocation of the hips in older children

 

 

Reviewer: Prof EB Hoffman
Department of Orthopaedic Surgery
University of Cape Town
Tel: (021) 674-2090

 

 

Pedrag Klisic, Ljubisa Jankovic Clin Orthop 1976;119:60-69

With this article Klisic, who was from Belgrade Yugoslavia, introduced the concept of femoral shortening in the management of older patients with DDH to the West. Since the use of femoral shortening the incidence of avascular necrosis has almost disappeared, a more concentric reduction is obtained with a better long-term outcome, and the need for pre-operative traction is eliminated.

They reviewed 60 hips in 47 children. The age at surgery ranged from 5 to 15 years. The average shortening was 2.5 cm (range 1-4.5 cm). The femur was derotated to 0°, and the valgus corrected to 115° neck shaft angle. The acetabular dysplasia was addressed with either a shelf or a Chiari osteotomy, and the iliopsoas was moved proximally on the femur. At a mean follow-up of 7 years (range 5-9 years) 63% had good results.

In a second study by Klisic,1 they reviewed 144 hips (including the 60 hips in the first study) at a longer follow-up with a mean of 13 years (range 9-24 years). Although they felt that the combined procedure had stood the test of time with 62% good results, they showed that older patients had poorer results: <8 years of age had 74% good results, 9 to 10 years 59% and >10 years only 32% good results. This is similar to Salter's findings in his landmark publication:21.5-4 years of age had 93.6% good results, while 4-10 years had only 56,7% good results. But Salter did not do a femoral shortening as his article was published in 1974 and Klisic's in 1976! Currently the watershed for relocating congenital dislocation of the hip, because of poor congruity, is 8 years in unilateral and 6 years in bilateral dislocations.3

Subsequent refinements have made this procedure a sine qua non in the treatment of the child >2 years with DDH. Articles by Wenger et al4,5 describe the current status of the technique and is a must read by surgeons doing this procedure. The pelvic osteotomy can either be a Salter or Dega. They shorten the femur an average of 1.5 cm (0.5-3 cm). There is no valgus of the femoral neck, but increased anteversion and they derotate an average of 33°, but caution against too much derotation which can result in posterior hip dislocation if a Salter pelvic osteotomy is done. If I do a Salter osteotomy I try and avoid derotation.

Wenger et al6 has also successfully used derotational femoral shortening in children <2 years with teratological dislocation.

 

References

1. Klisic P, Jankovic L. Long-term results of combined operative reduction of the hip in children. J Pediatr Orthop 1988;8:532-34.        [ Links ]

2. Salter RB, Dubos JP. The first 15 years' personal experience with innominate osteotomy in the treatment of congenital dislocation and subluxation of the hip. Clin Orthop 1974;98:73-103.        [ Links ]

3. Crawford AH, Mehlman CT, Slovek RW. The fate of untreated developmental dislocation of the hip: long-term follw-up of eleven patients. J Pediatr Orthop 1999;19:641-44.        [ Links ]

4. Galpin RD, Roach JW, Wenger DR, Herring JA, Birch JG. One-stage treatment of congenital dislocation of the hip in older children, including femoral shortening. J Bone Joint Surg(Am) 1989;71-A:734-41.        [ Links ]

5. Weinstein SL, Mubarak SJ, Wenger DR. Developmental hip dysplasia and dislocation. Part II. J Bone Joint Surg(Am) 2003;85-A:2024-35.        [ Links ]

6. Wenger DR, Lee CS, Kolman B. Derotational femoral shortening for developmental dislocation of the hip: special indications and results in the child younger than 2 years. J Pediatr Orthop 1995;15:768-79.        [ Links ]^rND^sKlisic^nP^rND^sJankovic^nL.^rND^sSalter^nRB^rND^sDubos^nJP.^rND^sCrawford^nAH^rND^sMehlman^nCT^rND^sSlovek^nRW.^rND^sGalpin^nRD^rND^sRoach^nJW^rND^sWenger^nDR^rND^sHerring^nJA^rND^sBirch^nJG.^rND^sWeinstein^nSL^rND^sMubarak^nSJ^rND^sWenger^nDR.^rND^sWenger^nDR^rND^sLee^nCS^rND^sKolman^nB.^rND^1A01^nCandice^sLee de Carvalho^rND^1A01^nCandice^sLee de Carvalho^rND^1A01^nCandice^sLee de Carvalho

ETHICS ARTICLE
FOR THE PURPOSE OF INCREASING YOUR CPD POINTS

 

Genetic ownership and sharing

 

 

Candice Lee de Carvalho

MSc (Med) Bioethics and Health Law

 

 


The body is a source of instrumental value to others. It provides organs, tissues, gametic materials and cells that can sometimes have life-saving benefits to patients and benefits to physicians and researchers, in addition.


 

 

For this reason, society has approved (with some debate) the acquisition of these materials in various ways. This may be through gifts and donations, such as of blood, marrow, organs and sperm and through the sale of hair, sperm and blood (Campbell 1992:36). However, what has become a major debate is how DNA can, and if it ought to be commoditised; and how and if individuals can keep their genetic information private, or whether it ought to be shared with all.

The rise of genetic research and information has transformed how scientists study, diagnose and analyse disease. Molecular- level information would have been unthinkable 100 years ago. From the time that Watson and Crick discovered the structure of DNA in 1953, the race was on to discover the genetic code.

This was achieved in 2003 and now the function of every part of the genome is the main concern of those wanting to advance genetic breakthroughs even further.

This revolution in medicine - molecular genetics - has not only transformed the way that diseases are diagnosed, but also how they are treated.

Biotechnological advances in human genome mapping, so-called predictability 'or susceptibility testing, heritage testing, biobanking, pharmacogenomics, reproductive technologies and novel diagnostic techniques have transformed access to genetic information. Along with this accessibility come complicated ethical questions of access to and storage of information, security thereof, privacy, consent and, the focus of this article, ownership.

 

Genetic information

Genetic information broadly refers to all of the currently known genetic data for all living organisms. It can also refer to the genetic composition of one individual and their families.

Many individuals express concern that a positive finding on a genetic screening test will result in discrimination and stigmatisation because they are out of the norm. Another concern raised is that the release of genetic information may result in an individual's loss, for example, of the inability to get insurance, or employment if genetic information crosses into the public domain (Orentlicher 1990: 1005).

Nowadays, genetic information is used not only in the doctor's office, but also beyond. For example, genetic information in a variety of forms is found in courts of law as a way of proving or disproving paternity, determining immigration status, in criminal cases involving genetic materials, by the military for soldier identification purposes and by medical aids and other insurance companies.

Genetic information is seen as different from other biological tissues in that it potentially involves more "broad-ranging features of an individuals' health status" and carries implications for relatives (Skene 2002: 49, Gillet and McKergow 2007: 2094). Within the ambit of health and wellness, genetic information is being used in reproductive and fertility health, disease diagnosis and treatment, epidemiological studies, bioinformatics and pharma-cogenomics.

The complex questions about who ought to benefit and about how individuals, families and communities can be protected against harms are most pressing at this time.

 

Genetic exceptionalism

Despite that the gifting and sale of certain parts of the body has become a (debatably) acceptable practice in some parts of society, such as through organ donation, blood donation, sperm donation, ovum selling, selling of breast milk and the like, there has been an attitude of what is termed "exceptionalism" regarding genetic information. This is most likely due to the 'mystique' around genetics, since the concepts can be highly abstract and difficult to understand, but there also tends to be much suspicion about the nature and power of the contents of genetic information.

 

Some arguments for and against genetic exceptionalism

The arguments for classifying genetic information as exceptional are generally grounded in the belief that genetic information is uniquely sensitive information owing to its "prophetic, predictive, shared and symbolic nature" (McGuire et al. 2008: 500).

The most obvious example of this is that of the genetic relationship between monozygotic twins. Since they share such a high percentage of their genetic makeup, if the one were to discover a deleterious mutation, it would be highly likely that the other twin would have it as well. As familial relationships move further apart (genetically), this probability decreases, but the information may nevertheless be relevant to family members and therefore affect decisions that they make about their healthcare, and in some cases, reproductive choices. This is because an individual receives not only information relating directly to her, but she also receives the genetic history of her family or in some instances, her extended family (husband, mother-in-law, father-inlaw). Thus, the argument goes, genetic information should be considered as exceptional. It has been argued that genetic information thus should be offered to all family members as they have a 'right to know' (O'Neill 2001: 703-704).

On the other hand, it may be argued that genetic information is neither "exceptional nor ethically different from other medical information" (Murray 1997: 63). Murray argues that there are medical issues such as elevated cholesterol or exposure to an infectious disease that perhaps ought to be shared with family members as well.

There may also be an argument for sharing of information for public health benefit and so, the age old tension between individual rights and legitimate public health needs arises.

 

Ownership of genetic information

Since genetics touches so intimately on an individual's life, as does any other health-related information, it is often thought of as falling into a property "paradigm" since individuals tend to think of themselves as proprietors of their genetic material (Andrews 1986: 29; de Witter and ten Have 1997: 51; Gillert and McKergow 2007: 2095; Campbell 1992: 40).

In their discussion on ownership of genetic material and information, de Witte and ten Have (1997) identified a few possible owners:

a) the individual with the particular genome;

b) the scientist or company that discovered the particular genes or nucleotide sequences;

c) humankind in general (as noted in the UNESCO declaration).

I would add another category: a group of people who happen to share an identical set of specific nucleotides for a sequence in question.

In order to discuss the issue of genetic ownership, a deeper debate arises: can a person justifiably make the claim to be owners of themselves?

Despite the strong intuition that a person is the owner of themselves, there is little principled moral argumentation to prove that people are indeed in possession of rights of self-ownership. In spite of this, there are strong legal and legal-ethical arguments that uphold individual liberty, freedom, autonomy and dignity aimed to protect the individual from intrusions on or into her body (bodily integrity).

The philosopher, Immanuel Kant argues that people ought to be treated as ends in themselves (not used). They are ends in themselves because they are rational beings that have inherent worth and dignity. Because of their intrinsic value, they are deserving of respect at all times. This respect is to be applied by a person towards his- or herself as well as towards others.

In applying this respect, some of the principles of individual liberty are protected by this principle of ends. On the other hand, freedoms that constitute an indignity towards self and others, such as commoditisation (selling) of the body, are prohibited by this view.

Kant's views against self-ownership are underpinned by the principle of respect for persons, a privilege of man by way of his humanity. Taylor (2004: 71) explains Kant's position writing, "In MM [Metaphysics of Morals], Kant asserts that someone can be his own master but cannot be the owner of himself (cannot dispose of himself as he pleases) - still less can he dispose of others as he please -since he is accountable to the humanity in his own person."

Since, the principle of self-ownership allows actions such as self-mutilation and suicide and asserts that the individual is the final arbiter over herself; it is against the principle of treating oneself with dignity, according to Kant.

 

 

Robert Nozick (1974), a libertarian who argues for self-ownership, borrows from Kant to argue that as humans with inherent value and dignity we ought to have the right to freedom and from John Locke to argue that we ought to have the right to private property.

Where Kant and Nozick agree is that a person should never be treated merely as a means to an end. On the issue of how a person should treat themselves, Nozick believes that that is a matter of personal liberty and that the person should be able to make their decisions without outside interference - that is, they are self owners and free to choose how they treat themselves. Kant, in fact shares the belief in personal liberty. He sees voluntariness and freedom from interference as essential to autonomy. Where they disagree is on the matter of respecting oneself and what that respect means; that is, what dignity means. Kant believes that people have a duty to respect themselves as much as they do to respect others.

If Kant, who argued for individual freedom, autonomy and choice as well as for respect for humanity, were present in today's world, how would he view ownership of genetic information and the exceptionalism debate? It is difficult to imagine how he would apply these moral principles to sharing, or not sharing information and owning or not owning it.

If we were to create a maxim that said, "One should always offer to disclose one's genetic information to family members or relevant others" I would consider this right and appropriate, and I think Kant would agree as I would be demonstrating my duty to respect myself and for others. It shows Kant's concept of autonomy as the principle of morality.

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