Orthopedic surgery

Orthopedic surgery or orthopedics (also spelled orthopaedics) is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and non-surgical means to treat musculoskeletal trauma, sports injuries, degenerative diseases, infections, tumors, and congenital conditions.

Nicholas Andry coined the word "orthopaedics", derived from Greek words for orthos ("correct", "straight") and paideia ("rearing" (usually of child)), in 1741, when at the age of 81 he published Orthopaedia: or the Art of Correcting and Preventing Deformities in Children.

In the US the spelling orthopedics is standard, although the majority of university and residency programs, and even the AAOS, still use Andry's spelling. Elsewhere, usage is not uniform; in Canada, both spellings are common; orthopaedics usually prevails in the rest of the Commonwealth, especially in Britain.

Training

In the United States and Canada, orthopedic surgeons have typically completed 4 years of undergraduate education and 4 years of medical school. Subsequently, orthopedic surgeons undergo residency training in orthopedic surgery. The five-year residency consists of one year of general surgery training followed by four years of training in orthopedic surgery.

Selection for residency training in orthopedic surgery is extremely competitive--candidates for orthopedic residencies generally graduate at the top of their medical school classes. Approximately 650 physicians complete orthopedic residency training per year in the US. About 7 percent of current orthopaedic surgery residents are women; about 20 percent are members of minority groups. There are approximately 20,400 actively practicing orthopaedic surgeons and residents in the United States.According to the latest Occupational Outlook Handbook (2006–2007) published by the US Department of Labor, between 3–4% of all practicing physicians are orthopedic surgeons.

Many orthopedic surgeons elect to do further subspecialty training, or 'fellowships', after completing their residency training. Fellowship training in an orthopedic subspeciality is typically one year in duration (sometimes two) and usually has a research component involved with the clinical and operative training. Examples of orthopedic subspecialty training in the US are:

  • Hand surgery (also performed by Plastic and General Surgeons)
  • Shoulder and elbow surgery
  • Total joint reconstruction (arthroplasty)
  • Pediatric orthopedics
  • Foot and ankle surgery (Also performed by podiatric surgeons)
  • Spine surgery
  • Musculoskeletal oncology
  • Surgical sports medicine
  • Orthopedic trauma

After completion of specialty residency/registrar training, an orthopedic surgeon is then eligible for board certification. Certification by the American Board of Orthopaedic Surgery means that the orthopaedic surgeon has met the specified educational, evaluation, and examination requirements of the Board. The process requires successful completion of a standardized written exam followed by an oral exam 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 US, specialists in hand surgery and sports medicine may obtain a Certificate of Added Qualifications (CAQ) in addition to their board certification by successfully completing an separate standardized examination. There is no additional certification process for the other subspecialties.

 

Practice

According to applications for board certification from 1999 to 2003, the top 25 most common procedures (in order) performed by orthopedic surgeons are as follows



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. In 2007, the median salary for an orthopedic surgeon in the United States is $388,784.

 

History

Orthopedic implants to repair fractures to the radius and ulna. Note the visible break in the ulna. (right forearm)

Jean-Andre Venel established the first orthopedic institute in 1780, which was the first hospital dedicated to the treatment of children's skeletal deformities. He is considered by some to be the father of orthopedics or the first true orthopedist in consideration of the establishment of his hospital and for his published methods.

Antonius Mathysen, a Dutch military surgeon, invented the plaster of Paris cast in 1851.

Many developments in orthopedic surgery 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, but unsanitary, splint. Traction and splinting developed during World War I. The use of intramedullary rods to treat fractures of the femur and tibia was pioneered by Dr. Kuntschner 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. However, traction was the standard method of treating thigh bone fractures until the late 1970s when the Harborview Medical Center in Seattle group popularized intramedullary fixation without opening up the fracture. 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 malaligned 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.

David L. MacIntosh pioneered the first successful surgery for the management of the torn anterior cruciate ligament of the knee. This common and serious injury in skiers, field athletes, and dancers invariably brought an end to their athletics due to permanent joint instability. Working with injured football players, Dr. MacIntosh devised a way to re-route viable ligament from adjacent structures to preserve the strong and complex mechanics of the knee joint and restore stability. The subsequent development of ACL reconstruction surgery has allowed numerous athletes to return to the demands of sports at all levels.

Modern orthopaedic surgery and musculoskeletal research has sought to make surgery less invasive and to make implanted components better and more durable.

Additionally, there is currently under development highly promising research involving the regrowth of Anterior Cruciate Ligament Tissue by the use of scaffolding around the Ligament, thereby providing an environment in which the tissue can clot and heal like other areas of the body which are not surrounded by the clot-preventing liquids which surround the major ligiments. This research among others conducted at the Sports Medicine Research Laboratory is still in the Research and Development stage.

 

Arthroscopy

The use of arthroscopic tools has been particularly important for injured patients. Arthroscopy was pioneered in the early 1950's by Dr. Masaki Watanabe of Japan to perform minimally invasive cartilage surgery and re-constructions of torn ligaments. Arthroscopy helped patients recover from the surgery in a matter of days, rather than the weeks to months required by conventional, 'open' surgery. Knee arthroscopy is one of the most common operations performed by orthopedic surgeons today and is often combined with meniscectomy or chondroplasty.

 

Joint replacement

The modern total hip replacement was pioneered by Sir John Charnley in England in the 1960s.He found that joint surfaces could be replaced by metal or high density polyethylene implants cemented to the bone with methyl methacrylate bone cement. Since Charnley, there have been continuous improvements 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 and Dr. Chitranjan Singh Ranawat in New York utilizing a fixed bearing,and by Dr Frederick Buechel and Dr Michael Pappas utilizing a mobile bearing.Uni-compartment knee replacement, in which only one side of an arthritic knee is replaced, is a smaller operation and has become popular recently.

Joint replacements are available for other joints on a limited basis, most notably shoulder, elbow, wrist, ankle, and fingers.

In recent years, surface replacement of joints, in particular the hip joint, have 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 surrounding bone and contribute to eventual failure of the implant. 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 (actually ultra high molecular weight polyethylene) can also be altered in ways that may improve wear characteristics.