Orthopedic surgery

Editor-in-Chief: Muqtadeer Aziz Ansari, M.B.B.S.

Associate Editor-In-Chief:

Overview




Orthopedic surgery or orthopedics (also spelled orthopaedics, see below) is the branch of surgery concerned with acute, chronic, traumatic, and overuse injuries and other disorders of the musculoskeletal system. Orthopedic surgeons address most musculoskeletal ailments including arthritis, trauma and congenital deformities using both surgical and non-surgical means.

History


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 consideraton 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 Seattle Harborview 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.

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--both of which are removal of a torn cartilage.

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 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 1970's. The modern knee replacement was developed by Dr. John Insall and Dr. Chitranjan Ranawat in New York utilizing a fixed bearing and 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.

Pediatric orthopedics
The treatment of children with muscoloskeletal problems remains an integral part of modern orthopaedic surgery. Many fractures and injuries occur in children due to their high activity level and unique immature skeleton. Treatment of fractures in children is different than adults due to active growth plates in their bones. Damage to the growth plate can lead to significant problems with later bone growth, and at-risk fractures have to be monitored with care.

The treatment of scoliosis is a mainstay of pediatric orthopaedics. For poorly understood reasons, curvature develops in the spine of some children, which if left untreated leads to undesirable deformity and may progress to cause chronic pain and breathing problems. The treatment of scoliosis is quite complicated and often involves a combination of bracing and surgery.

Children have other unique musculoskeletal conditions that have been a focus of orthopedics since Hippocrates, including conditions such as club foot and congenital dislocation of hip (also known as developmental dysplasia of the hip). In addition, infections in bones and joints (osteomyelitis) in children are common.

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

In the U.S. 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; see also spelling differences.

Training
In the United States and Canada, orthopedic surgeons are physicians who have completed applied training in orthopedic surgery after the completion of medical school and attainment of the allopathic (MD, MBBS, MBChB,etc) or osteohhpathic (DO) degree. According to the latest Occupational Outlook Handbook (2006–2007) published by the U.S. Department of Labor, between 3–4% of all practicing physicians are orthopedic surgeons.

Orthopedic surgeons (also known as orthopedists) complete a minimum of 10 years of postsecondary education and clinical training. In the majority of cases this training includes obtaining an undergraduate degree (a few medical schools will admit students with as little as two years of undergraduate education), an allopathic degree or osteopathic degree (4 years), and then completing a five-year residency in orthopedic surgery. The five-year residency consists of one year of general surgery training followed by four years of training in orthopaedic surgery.

Many orthopedic surgeons elect to do further subspecialty training in programs known as '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:


 * 1) Hand surgery (also performed by Plastic Surgeons)
 * 2) Shoulder and elbow surgery
 * 3) Total joint reconstruction (arthroplasty)
 * 4) Pediatric orthopedics
 * 5) Foot and ankle surgery (Also performed by podiatry)
 * 6) Spine surgery (Also performed by neurosurgeons)
 * 7) Musculoskeletal oncology
 * 8) Surgical sports medicine
 * 9) Orthopedic trauma

These are also the nine main sub-specialty areas of orthopedic surgery.

Hand surgery, and more recently Sports Medicine are the only truly recognized sub-specialties within orthopaedic surgery by the Accredited Council of Graduate Medical Education (ACGME). The other sub-specialities are informal concentrations of practice. To be recognized as a hand surgeon or sports surgeon, a practitioner must have completed an ACGME-accredited fellowship and obtained a Certificate of Added Qualifications (CAQ) which requires an additional standardized examination.

Practice
Orthopedic surgeons address most musculoskeletal ailments including arthritis, trauma and congenital deformities using both surgical and non-surgical means. According to applications for board certification from 1999 to 2003, the top 25 most common procedures (in order) performed by orthopaedic surgeons are as follows:
 * 1) Knee arthroscopy and meniscectomy
 * 2) Shoulder arthroscopy and decompression
 * 3) Carpal tunnel release
 * 4) Knee arthroscopy and chondroplasty
 * 5) Removal of support implant
 * 6) Knee arthroscopy and anterior cruciate ligament reconstruction
 * 7) Knee replacement
 * 8) Repair of femoral neck fracture
 * 9) Repair of trochanteric fracture
 * 10) Debridement of skin/muscle/bone/fracture
 * 11) Knee arthroscopy repair of both menisci
 * 12) Hip replacement
 * 13) Shoulder arthroscopy/distal clavicle excision
 * 14) Repair of rotator cuff tendon
 * 15) Repair fracture of radius (bone)/ulna
 * 16) Laminectomy
 * 17) Repair of ankle fracture (bimalleolar type)
 * 18) Shoulder arthroscopy and débridement
 * 19) Lumbar spinal fusion
 * 20) Repair fracture of the distal part of radius
 * 21) Low back intervertebral disc surgery
 * 22) Incise finger tendon sheath
 * 23) Repair of ankle fracture (fibula)
 * 24) Repair of femoral shaft fracture
 * 25) Repair of trochanteric fracture

Of orthopedic surgeons applying for certification with the American Board of Orthopedic Surgery between 1999 to 2003 these were the percentages of surgeons in each specialty area:
 * General orthopedics: 54.8%
 * Spine surgery: 11.3%
 * Sports medicine: 10.8%
 * Hands and upper extremity: 8.7%
 * Adult reconstructive: 3.9%
 * Pediatric orthopedics: 3.4%
 * Foot and ankle: 3.1%
 * Trauma: 2.6%
 * Musculoskeletal oncology: 1.3%

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 $220,000 and $500,000+.