Augusto Sarmiento and Loren L. Latta pp. 411 New Delhi: Jaypee Brothers Medical Publishing, 2010 ISBN: 978-81-8448-907-1
Gus Sarmiento and Loren Latta have compiled a very readable book on the management of fractures without the use of internal fixation. One might describe it as their own Festschrift to a lifetime's philosophy, championed by Dr Sarmiento. He has been steadfastly supported by Dr Latta, the Director of Orthopaedic Research at the University of Miami, where he has, perhaps rather unsung in the past, provided scientific evidence in a laboratory replete with engineering rigour. Any discipline needs iconoclasts and philosophers and Trauma and Orthopaedics are no exceptions. We are properly influenced by thinkers such as Watson Jones, Charnley, and McKibbin; now Sarmiento and Latta have added persuasively about the nature of fracture healing and how this should influence how we should manage broken bones. All of them remind us that we are meant to be inquisitive, influenced by evidence, open minded and holistic - indeed physicians who happen to practice orthopaedic surgery.
One of their simplest demonstrations is an experiment reprised, quite justifiably in this book, fondly known as the "hot dog" test of stiffness of a cylinder of meat wrapped around a broomstick. The preparation is then compressed without a wrapping, and repeated with the meat first enclosed in simple brown paper and then with thermoplastic. The wrapping confers stiffness to the construct - proving (as with Clinton's "it's the economy, stupid") that "it's the strain, stupid" when it comes to the mechanics of fracture healing. This elegant demonstration shows the power of engineers and clinicians working together. This rich partnership between an inquisitive and thoughtful clinician and a clear-thinking engineer concentrates, inevitably, on the mechanical aspects of healing. Readers should not look to the text to help them understand the cellular and humeral factors; this can be found elsewhere.
This book asks us to remember that fracture healing is a powerful product of evolution, and we tinker with it at our peril. They show that with selected fractures we are better harnessing these ill-understood forces rather than literally pushing them aside in our rush to get a quick fix. The authors' appeal that Trauma surgeons must avoid becoming "cosmetic surgeons of bone" is memorable.
The book is well laid out and lavishly illustrated with selected, if time honoured, radiographs. Every chapter is provided with experimental evidence so that the basic principles of non-operative management have been honed and revised; the associated literature review is extensive. This is a book for surgeons who want to see all viewpoints and not to rely on the maxim that Alan Apley was so fond of teasing us with - "fixation is fun". Sarmiento persuades us to put our heads as well as our hands into gear, appreciating that every fracture is a unique problem to be solved.
This book belongs with Charnley's own monograph on the "Closed Treatment of Fractures" and gems such as Henry's "Extensile Exposure" which go well beyond the cookbook approach and remind us of the richness of our heritage and the need to develop philosophies based on evidence beyond commercial advertising.
D. I. Rowley