Orthopedic surgery or
orthopedics (alternatively spelt orthopaedics), is the branch
of surgery concerned with conditions involving the musculoskeletal
system. Orthopedic surgeons use both surgical and nonsurgical means
to treat musculoskeletal trauma, spine diseases, sports injuries,
degenerative diseases, infections, tumors, and congenital disorders.
Etymology
Nicholas Andry coined the word in
French as orthopédie, derived from the Ancient Greek words ὀρθός
orthos ("correct", "straight") and παιδίον
paidion ("child"), and published Orthopedie
(translated as Orthopædia: Or the Art of Correcting and Preventing
Deformities in Children) in 1741. The word was assimilated into
English as orthopædics; the ligature æ was common in that era for
ae in Greek- and Latin-based words. As the name implies, the
discipline was initially developed with attention to children, but
the correction of spinal and bone deformities in all stages of life
eventually became the cornerstone of orthopedic practice.
Differences in spelling
As with many words derived with the "æ"
ligature, simplification to either "ae" or just
"e" is common, especially in North America. In the US,
the majority of college, university, and residency programmes, and
even the American Academy of Orthopaedic Surgeons, still use the
spelling with the digraph ae, though hospitals usually use the
shortened form. Elsewhere, usage is not uniform; in Canada, both
spellings are acceptable; "orthopaedics" is the
normal spelling in the UK in line with other fields which retain
"ae".
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.
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 of 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.
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
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 sub-specialty 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
sub-specialties.
Practice
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 inter-vertebral 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 identified as "highly
successful" due to their prominent positions in the field
indicated average work weeks of 70 hours or more.
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.
Epidemiology
Between 2001 and 2016, the prevalence
of musculoskeletal procedures drastically increased in the U.S, from
17.9% to 24.2% of all operating-room (OR) procedures performed during
hospital stays.
In a study of hospitalizations in the
United States in 2012, spine and joint procedures were common among
all age groups except infants. Spinal fusion was one of the five most
common OR procedures performed in every age group except infants
younger than 1 year and adults 85 years and older. Laminectomy was
common among adults aged 18–84 years. Knee arthroplasty and hip
replacement were in the top five OR procedures for adults aged 45
years and older.
