Orthopedic
Surgery
History
Early orthopedics
Many developments in
orthopedic surgery have resulted from experiences during wartime. On the battlefields of the Middle Ages, the
injured were treated with bandages soaked in horses' blood, which dried to form
a stiff, if unsanitary, splint.[citation needed]
Originally, the term
orthopedics meant the correcting of musculoskeletal deformities in children. Nicolas Andry, a professor of medicine at the
University of Paris, coined the term in the first textbook written on the
subject in 1741. He advocated the use of exercise, manipulation, and splinting
to treat deformities in children. His book was directed towards parents, and
while some topics would be familiar to orthopedists today, it also included
'excessive sweating of the palms' and freckles.
Jean-André Venel established
the first orthopedic institute in 1780, which was the first hospital dedicated
to the treatment of children's skeletal deformities. He developed the club-foot
shoe for children born with foot deformities and various methods to treat
curvature of the spine.
Advances made in surgical
technique during the 18th century, such as John Hunter's research on tendon
healing and Percival Pott's work on spinal deformity steadily increased the
range of new methods available for effective treatment. Antonius Mathijsen, a
Dutch military surgeon, invented the plaster of Paris cast in 1851. Until the
1890s, though, orthopedics was still a study limited to the correction of
deformity in children. One of the first surgical procedures developed was
percutaneous tenotomy. This involved cutting a tendon, originally the Achilles
tendon, to help treat deformities alongside bracing and exercises. In the late
1800s and first decades of the 1900s, significant controversy arose about
whether orthopedics should include surgical procedures at all.
Modern orthopedics
Examples of people who aided
the development of modern orthopedic surgery were Hugh Owen Thomas, a surgeon
from Wales, and his nephew, Robert Jones. Thomas became interested in orthopedics and
bone-setting at a young age, and after establishing his own practice, went on
to expand the field into the general treatment of fracture and other
musculoskeletal problems. He advocated enforced rest as the best remedy for
fractures and tuberculosis and created the so-called "Thomas splint"
to stabilize a fractured femur and prevent infection. He is also responsible
for numerous other medical innovations that all carry his name: Thomas's collar
to treat tuberculosis of the cervical spine, Thomas's manoeuvre, an orthopedic
investigation for fracture of the hip joint, the Thomas test, a method of detecting
hip deformity by having the patient lying flat in bed, and Thomas's wrench for
reducing fractures, as well as an osteoclast to break and reset bones.
Thomas's work was not fully
appreciated in his own lifetime. Only during the First World War did his
techniques come to be used for injured soldiers on the battlefield. His nephew,
Sir Robert Jones, had already made great advances in orthopedics in his
position as surgeon-superintendent for the construction of the Manchester Ship
Canal in 1888. He was responsible for the injured among the 20,000 workers, and
he organized the first comprehensive accident service in the world, dividing
the 36-mile site into three sections, and establishing a hospital and a string
of first-aid posts in each section. He had the medical personnel trained in
fracture management. He personally
managed 3,000 cases and performed 300 operations in his own hospital. This
position enabled him to learn new techniques and improve the standard of
fracture management. Physicians from around the world came to Jones' clinic to
learn his techniques. Along with Alfred Tubby, Jones founded the British
Orthopedic Society in 1894.
During the First World War,
Jones served as a Territorial Army surgeon. He observed that treatment of
fractures both, at the front and in hospitals at home, was inadequate, and his
efforts led to the introduction of military orthopedic hospitals. He was
appointed Inspector of Military Orthopedics, with responsibility for 30,000
beds. The hospital in Ducane Road, Hammersmith, became the model for both
British and American military orthopedic hospitals. His advocacy of the use of
Thomas splint for the initial treatment of femoral fractures reduced mortality
from compound fractures of the femur from 87% to less than 8% in the period
from 1916 to 1918.
The use of intramedullary
rods to treat fractures of the femur and tibia was pioneered by Gerhard
Küntscher of Germany. This made a noticeable difference to the speed of
recovery of injured German soldiers during World War II and led to more
widespread adoption of intramedullary fixation of fractures in the rest of the
world. Traction was the standard method of treating thigh bone fractures until
the late 1970s, though, when the Harborview Medical Center group in Seattle popularized
intramedullary fixation without opening up the fracture.
X-ray of a hip
replacement
The modern total hip
replacement was pioneered by Sir John Charnley, expert in tribology at
Wrightington Hospital, in England in the 1960s. He found that joint surfaces
could be replaced by implants cemented to the bone. His design consisted of a
stainless steel, one-piece femoral stem and head, and a polyethylene acetabular
component, both of which were fixed to the bone using PMMA (acrylic) bone
cement. For over two decades, the Charnley low-friction arthroplasty and its
derivative designs were the most-used systems in the world. This formed the
basis for all modern hip implants.
The Exeter hip replacement
system (with a slightly different stem geometry) was developed at the same
time. Since Charnley, improvements have been continuous in the design and technique
of joint replacement (arthroplasty) with many contributors, including W. H.
Harris, the son of R. I. Harris, whose team at Harvard pioneered uncemented
arthroplasty techniques with the bone bonding directly to the implant.
Knee replacements, using
similar technology, were started by McIntosh in rheumatoid arthritis patients
and later by Gunston and Marmor for osteoarthritis in the 1970s, developed by
Dr. John Insall in New York using a fixed bearing system, and by Dr. Frederick
Buechel and Dr. Michael Pappas using a mobile bearing system.
External fixation of
fractures was refined by American surgeons during the Vietnam War, but a major
contribution was made by Gavril Abramovich Ilizarov in the USSR. He was sent,
without much orthopedic training, to look after injured Russian soldiers in
Siberia in the 1950s. With no equipment, he was confronted with crippling
conditions of unhealed, infected, and misaligned fractures. With the help of
the local bicycle shop, he devised ring external fixators tensioned like the
spokes of a bicycle. With this equipment, he achieved healing, realignment, and
lengthening to a degree unheard of elsewhere. His Ilizarov apparatus is still
used today as one of the distraction osteogenesis methods.
Modern orthopedic surgery
and musculoskeletal research have sought to make surgery less invasive and to
make implanted components better and more durable. On the other hand, since the
emergence of the opioid epidemic, Orthopedic Surgeons have been identified as
one of the highest prescribers of opioid medications. The future of Orthopedic
Surgery will likely focus on finding ways for the profession to decrease
prescription of opioids while still providing adequate pain control for
patients.
Training
The examples and perspective
in this section deal primarily with the United States and do not represent a
worldwide view of the subject.
In the United States,
orthopedic surgeons have typically completed four years of undergraduate
education and four years of medical school and earned either a Doctor of
Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree. Subsequently,
these medical school graduates undergo residency training in orthopedic
surgery. The five-year residency is a categorical orthopedic surgery training.
Selection for residency
training in orthopedic surgery is very competitive. Roughly 700 physicians
complete orthopedic residency training per year in the United States. About 10%
of current orthopedic surgery residents are women; about 20% are members of
minority groups. Around 20,400 actively practicing orthopedic surgeons and
residents are in the United States. According to the latest Occupational Outlook
Handbook (2011–2012) published by the United States Department of Labor, 3 to
4% of all practicing physicians are orthopedic surgeons.
Many orthopedic surgeons
elect to do further training, or fellowships, after completing their residency
training. Fellowship training in an orthopedic sub-specialty is typically one
year in duration (sometimes two, and sometimes has a research component
involved with the clinical and operative training. Examples of orthopedic
subspecialty training in the United States are:
Hand and upper extremity
Shoulder and elbow
Total joint reconstruction
(arthroplasty)
Pediatric orthopedics
Foot and ankle surgery
Spine surgery
Orthopedic oncologist
Surgical sports medicine
Orthopedic trauma
Hip and Knee surgery
Osseointegration
These specialized areas of
medicine are not exclusive to orthopedic surgery. For example, hand surgery is practiced
by some plastic surgeons, and spine surgery is practiced by most neurosurgeons.
Additionally, some aspects of foot and ankle surgery are also practiced by
board-certified doctors of podiatric medicine (DPM) in the United States. Some
family practice physicians practice sports medicine, but their scope of
practice is nonoperative.
After completion of
specialty residency/registrar training, an orthopedic surgeon is then eligible
for board certification by the American Board of Medical Specialties or the
American Osteopathic Association Bureau of Osteopathic Specialists.
Certification by the American Board of Orthopedic Surgery or the American
Osteopathic Board of Orthopedic Surgery means that the orthopedic surgeon has
met the specified educational, evaluation, and examination requirements of the
board. The process requires successful
completion of a standardized written examination followed by an oral
examination focused on the surgeon's clinical and surgical performance over a
6-month period. In Canada, the certifying organization is the Royal College of
Physicians and Surgeons of Canada; in Australia and New Zealand, it is the
Royal Australasian College of Surgeons.
In the United States,
specialists in hand surgery and orthopedic sports medicine may obtain a
certificate of added qualifications in addition to their board primary
certification by successfully completing a separate standardized examination.
No additional certification process exists for the other subspecialties.
Anterior and lateral view
x-rays of fractured left leg with internal fixation after Practice surgery
According to applications
for board certification from 1999 to 2003, the top 25 most common procedures
(in order) performed by orthopedic surgeons are:
Knee arthroscopy and meniscectomy
Shoulder arthroscopy and
decompression
Carpal tunnel release
Knee arthroscopy and
chondroplasty
Removal of support implant
Knee arthroscopy and
anterior cruciate ligament reconstruction
Knee replacement
Repair of femoral neck
fracture
Repair of trochanteric
fracture
Debridement of
skin/muscle/bone/ fracture
Knee arthroscopy repair of
both menisci
Hip replacement
Shoulder arthroscopy/distal
clavicle excision
Repair of rotator cuff
tendon
Repair fracture of radius
(bone)/ulna
Laminectomy
Repair of ankle fracture
(bimalleolar type)
Shoulder arthroscopy and
debridement
Lumbar spinal fusion
Repair fracture of the
distal part of radius
Low back intervertebral disc
surgery
Incise finger tendon sheath
Repair of ankle fracture
(fibula)
Repair of femoral shaft
fracture
Repair of trochanteric
fracture
A typical schedule for a
practicing orthopedic surgeon involves 50–55 hours of work per week divided
among clinic, surgery, various administrative duties, and possibly teaching
and/or research if in an academic setting. According to the American
Association of Medical Colleges in 2021, the average work week of an orthopedic
surgeon was 57 hours. This is a very low estimation however, as research
derived from a 2013 survey of orthopedic surgeons who self-dentified as
"highly successful" due to their prominent positions in the field
indicated average work weeks of 70 hours or more.
Arthroscopy
Main article: Arthroscopy
The use of arthroscopic
techniques has been particularly important for injured patients. Arthroscopy
was pioneered in the early 1950s by Dr. Masaki Watanabe of Japan to perform
minimally invasive cartilage surgery and reconstructions of torn ligaments.
Arthroscopy allows patients to recover from the surgery in a matter of days,
rather than the weeks to months required by conventional, "open"
surgery; it is a very popular technique. Knee arthroscopy is one of the most
common operations performed by orthopedic surgeons today and is often combined
with meniscectomy or chondroplasty. The majority of upper-extremity outpatient
orthopedic procedures are now performed arthroscopically.
Arthroplasty
Arthroplasty is an
orthopedic surgery where the articular surface of a musculoskeletal joint is
replaced, remodeled, or realigned by osteotomy or some other procedure. It is
an elective procedure that is done to relieve pain and restore function to the
joint after damage by arthritis (rheumasurgery) or some other type of trauma.
As well as the standard total knee replacement surgery, the uni-compartmental knee
replacement, in which only one weight-bearing surface of an arthritic knee is
replaced, is a popular alternative.
Joint replacements are
available for other joints on a variable basis, most notably the hip, shoulder,
elbow, wrist, ankle, spine, and finger joints.
In recent years, surface
replacement of joints, in particular the hip joint, has become more popular
amongst younger and more active patients. This type of operation delays the
need for the more traditional and less bone-conserving total hip replacement,
but carries significant risks of early failure from fracture and bone death.
One of the main problems
with joint replacements is wear of the bearing surfaces of components. This can
lead to damage to the surrounding bone and contribute to eventual failure of
the implant. The use of alternative bearing surfaces has increased in recent
years, particularly in younger patients, in an attempt to improve the wear
characteristics of joint replacement components. These include ceramics and
all-metal implants (as opposed to the original metal-on-plastic). The plastic
chosen is usually ultra-high-molecular-weight polyethylene, which can also be
altered in ways that may improve wear characteristics.
Jan Ricks Jennings, MHA,
LFACHE
Senior Consultant
Senior Management Resources,
LLC
Jan.Jennings@EagleTalons.net
JanJenningBlog.Blogspot.com
412.913.0636 Cell
724,733,9636 Office
