Dr. Jaimo Ahn, Gehring Professor of Orthopaedic Surgery at the University of Michigan, answers four questions on clavicle fractures, among other things.

[Related information can be found in the Orthopaedia chapter on clavicle fractures.]

Orthopaedia: You reported a study showing that there were thousands of fractures in the United States among the elderly while dog walking. Does your work imply that the elderly should give up dog walking?

Jaimo Ahn: Yes, I reported that there are many fractures related to dog walking, but at the same time I encourage my patients to love their dogs and enjoy walks with them often. Our furry friends enrich life in so many ways. Dog-walking might be dangerous. Well, so is life. Driving cars has risks and drinking wine has risks, but neither I nor society at large is ready to completely abstain from, let alone ban, either of them! More to the point, in the case of dog-walking, there are not just pleasure-benefits, but health-benefits as well.

I am just a bone expert, but I think physicians of all specialties agree on the following schema: lying down is less healthful than sitting; sitting is less healthful than standing; and standing is less healthful than walking. I would add that dog-walking is better still. That’s because dog-walking provides an opportunity for both weight-bearing in the legs and spine and resistance training for the arms. So is dog-walking associated with some risks? My research shows that it is. On the other hand, my experience and that of physicians of all specialties teaches that the risks of avoiding dog-walking are probably greater.

Orthopaedia: For many years, clavicle fractures were treated non-operatively. Recently, clavicle fracture surgery has become popular. Can you suggest a general rule when a fracture (of any bone) needs surgery?

Jaimo Ahn: At times, the need for surgery is obvious: a broken femur poking through the skin is just asking to be fixed. At other times (such as some clavicle fractures, as you suggest) it’s not so clear. In those cases, I ask, “Is the patient miserable?” And, “Can I safely make them less miserable with a surgical operation?”

For me, this paradigm is simple, yet loaded with complexity and nuance. The decision, from the surgeon’s perspective, is easy in that it is all about what the patient wants: operate if the patient wants surgery and avoid surgery if not. On the other hand, determining what the patient wants can be very hard. To start, I must teach the patient about all treatment options and their risks and benefits–the patient’s preference only counts if they are adequately informed and knowledgeable. Moreover, finding out what even informed and knowledgeable patients really want and need can be tricky. A retiree with a 50% displaced mid-shaft clavicle who can’t sleep or who can’t perform simple hygiene might need surgery just as much as an NFL player who has to get back on the field.

In turn, I have to know what’s bothering my patients, and they have to know what is likely to get much better, or get better much faster, with operative treatment. Preference-based decisions are not about numbers, angles or classifications. Surgery should be offered when it can relieve misery and fulfill reasonable desires. As a community, orthopaedic surgeons have to be just as good at identifying indicated surgical cases as they are at performing the procedures once the surgery is indicated. That’s key if we are going to help our patients achieve their goals.

Orthopaedia: Fractures heal by turning on a biological program very similar to bone growth. Yet as far as we know, this never goes on too far and becomes cancer. Why?

Jaimo Ahn: “There is a fracture, I need to fix it” might be what an orthopaedic avatar says, but the body is saying “There is a fracture, I need to grow it.” The regulatory mechanisms that control this growth, however, are unknown. Indeed, this is one of the great mysteries of human biology.
Bone is really the only tissue that routinely heals with pure regeneration. Further, it does this by creating a neoplasm (definition: “new growth”) all the while never transforming into a cancer (definition: “out of control growth”). This retained control is even more amazing when you consider that moments before the injury, bone is one of the most mitotically quiescent tissues—not doing much cell division and proliferation at all. Within hours of trauma, though, bone becomes home to one of the most proliferative, oncogene-mitogen-morphogen driven processes in the body–a nearly instantaneous response to a mechanical event. Typically, perfect control despite accelerated activation is astonishingly rare. (I know that when I am roused from sleep and rushed to the hospital that I am most liable to forget my phone or ID card, for example.)

Solving this riddle of regulation may help us better understand (and control, or maybe even cure) cancer. The human body is trying to teach us a lesson. I wonder if there is anyone, especially among the young and smart, up for the challenge of unravelling it.

Orthopaedia: You have done a lot of orthopaedic work in Africa and have brought some American expertise there. What lessons have you brought home from Africa that can be used in the United States?

Jaimo Ahn: I have taken two education-service trips to Africa: one to Gaborone, Botswana, and another to Antananarivo, Madagascar. On these trips. education had three facets. First, local surgeons welcomed my expertise to learn practical techniques that could directly benefit their patients. Second, I aimed to teach these surgeons effective teaching methods, so the knowledge would be passed on and retained throughout their community. Third, there was reciprocal education – my learning from the very people I came to teach.

In this latter realm, I discovered alternative methods for performing procedures without relying on advanced, 21st-century American equipment (e.g., how to repair a fracture without fluoroscopy). Additionally, I gained invaluable insights into the resilience of the human body and spirit. I witnessed the resourcefulness of individuals living with fractures and deformities, and the power of family, social support systems, and positive mindsets in overcoming post-surgical recovery challenges. This is not to imply that Americans are weak or ungrateful. Far from it. Rather, it is to say that American healthcare providers should continuously strive to instill even greater resilience and positivity in our patients. If I am able to keep these lessons in mind –all the while distracted by advanced, 21st-century American equipment– I can thank my service trips in Africa.