Orthopedic surgery
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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. |
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. Orthopaedic surgeons address most musculoskeletal ailments including arthritis, trauma and congenital deformities using both surgical and non-surgical means.
Orthopedic surgeons are
physicians who have completed additional training in orthopedic surgery after the completion of medical school. 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.
In the United States and Canada orthopedic surgeons (also know as orthopedists) complete a minimum of 13 years of
postsecondary education and clinical training. This training includes obtaining an
undergraduate degree, a medical degree, and then completing a 5-year
residency in orthopedic surgery. The 5-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 subspeciality training in programs known as 'fellowships' after completing their residency training. These fellowships typically last 1-2 years and usually have a
research component involved with the clinical and operative training. Examples of orthopedic subspeciality training are:
#Hand surgery#Shoulder and elbow surgery#Total joint reconstruction (
arthroplasty)#Pelvis and Acetabulum #Pediatric orthopedics#Foot and ankle surgery (Not to be confused with
podiatry)#Spine surgery (Also performed by
neurosurgeons)#Musculoskeletal oncology#Surgical sports medicine#Orthopaedic trauma
These are also the nine main sub-specialty areas of orthopaedic surgery.
Hand surgery is the only truly recognized sub-specialty within orthopaedic surgery. The other sub-specialities are informal concentrations of practice. To be recognized as a hand surgeon, a practitioner must have completed a fellowship and obtained a Certificate of Added Qualifications (CAQ) which requires an additional standardized examination.
Orthopaedic 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:#Knee
arthroscopy and menisectomy#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#Débridement 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 débridement#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
Of orthopaedic 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 orthopaedics: 54.8%
*Spine surgery: 11.3%
*Sports medicine: 10.8%
*Hands and upper extremity: 8.7%
*Adult reconstructive: 3.9%
*Pediatric orthopaedics: 3.4%
*Foot and ankle: 3.1%
*Trauma: 2.6%
*Musculoskeletal oncology: 1.3%
A typical schedule for a practicing orthopaedic 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.
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. Kunchner 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.
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 subsequesnt 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.
The use of
arthroscopic tools has been particularly important for injured patients. Arthroscopy was pioneered by Dr. 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.
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. 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 and ankle.
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 devlops in the spine of some children, which if left untreated leads to undesireable deformity and may progress to cause chronic pain and breathing problems. The treatment of
scoliosis is quite complicated and often invovles 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 have provided a substantial portion of treatment for chidlren with musculoskeletal deformities and diseases.
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.
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.
*
Bone grafting*
Gait analysis*
Halo System*
Hand Surgery*
Traction*
The History of Orthopaedics*
Wheeless' Textbook of Orthopaedics*
The International Society of Orthopaedic Surgery and Traumatology*
American Academy of Orthopaedic Surgeons*
Discussion Forum for Orthopaedic Careers Advice*
Pediatric Orthopaedics
