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This fracture of the lower cervical vertebrae, known as a 'teardrop
fracture' is one of the conditions treated by orthopaedic surgeons.
This image, taken in September 2006, shows extensive repair work to the right
acetabulum 6 years after it was carried out (2000). Further damage to the joint is visible due to the onset of arthritis.
Orthopedic surgery or orthopedics (also spelled orthopaedics) is the branch of surgery concerned with inuries to, or conditions involving, the musculoskeletal system. Orthopedic surgeons address most muscle injuries that require surgery, and some are also skilled at dealing with congenital conditions that result in orthopedic deformities, such as spastic cerebral palsy, using both surgical and non-surgical means.
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[citation needed], although the majority of university and residency programs[citation needed], 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 are physicians
who have completed applied training in orthopedic surgery after the
completion of medical school and attainment of the conventional (MD, MBBS, MBChB, etc) or osteopathic (DO)
degree. 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.
Orthopedic surgeons 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 however admit students with as little as two years of previous undergraduate education), either an MD MBBS, MBChB, etc) or osteopathic (DO) degree, 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 orthopedic surgery.
After completion of specialty residency/registrar trainng, an orthopedic surgeon is then eligible for board in the United States. In Canada it leads to eligibility for Certification by and Fellowship of the Royal College of Physicians and Surgeons of Canada. In Australia and New Zealand it leads to eligibility for Fellowship of the Royal Australasian College of Surgeons.
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:
- 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)
- Spinal disk fusions
- Musculoskeletal oncology
- Surgical sports medicine
- 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
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:
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 $388,784.[1]
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.
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.[2] 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 1970s.developed by Dr. John Insall and Dr. Chitranjan Singh Ranawat in New York utilizing a fixed bearing,[3] and by Dr Frederick Buechel and Dr Michael Pappas utilizing a mobile bearing.[4]
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 orthopaedics
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. In the US, specialized hospitals such as the Shriners Hospitals for Children have provided a substantial portion of treatment for children with musculoskeletal deformities and diseases.
References
- Garrett, WE, et al. American Board of Orthopaedic Surgery
Practice of the Orthopaedic Surgeon: Part-II, Certification
Examination. The Journal of Bone and Joint Surgery (American).
2006;88:660-667.
See also
External links
Classical
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