Orthopedic surgery

Orthopedic surgery
MeSH	D019637

This fracture of the lower cervical vertebrae, known as a "teardrop fracture", is one of the conditions treated by orthopedic surgeons and neurosurgeons.

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 orthopaedic surgery and orthopaedics in British English) is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal trauma, sports injuries, degenerative diseases, infections, tumors, and congenital disorders.

Nicholas Andry coined the word "orthopaedics", derived from Greek words for orthos ("correct", "straight") and paideion ("child"), when he published Orthopaedia: or the Art of Correcting and Preventing Deformities in Children in 1741. Correction of spinal and bony deformities became the cornerstone of orthopedic practice. Today, over 6 months of training is dedicated to the treatment of the pediatric population.

In the United States orthopedics is standard, although the majority of college, university and residency programs, and even the American Academy of Orthopaedic Surgeons, still use the spelling with the Latinate digraph ae. Elsewhere, usage is not uniform; in Canada, both spellings are acceptable; orthopaedics usually prevails in the rest of the Commonwealth, especially in Britain.

Training

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

Selection for residency training in orthopaedic surgery is very competitive. Approximately 700 physicians complete orthopaedic residency training per year in the United States. About 10 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 (2009–2010) published by the United States Department of Labor, between 3–4% of all practicing physicians are orthopaedic surgeons.

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

• Hand surgery
• Shoulder and elbow surgery
• Total joint reconstruction (arthroplasty)
• Pediatric orthopedics
• Foot and ankle surgery
• Spine surgery
• Musculoskeletal oncology
• Surgical sports medicine
• Orthopedic trauma

These specialty areas of medicine are not exclusive to orthopaedic surgery. For example, hand surgery is practiced by some plastic surgeons and spine surgery is practiced by most neurosurgeons. Additionally, foot and ankle surgery is practiced by board-certified Doctors of Podiatric Medicine (D.P.M.) in the United States. Some family practice physicians practice sports medicine; however, their scope of practice is non-operative.

After completion of specialty residency/registrar training, an orthopaedic 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 United States, specialists in hand surgery and sports medicine may obtain a Certificate of Added Qualifications (CAQ) in addition to their board certification by successfully completing a 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 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 debridement
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

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. In 2009, the median salary for an orthopaedic surgeon in the United States was $406,847.

History

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

Jean-Andre Venel established the first orthopaedic 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 orthopaedics or the first true orthopaedist 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 orthopaedic 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 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. 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 orthopaedic 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.

Ruth Jackson became the first female Board-certified Orthopaedic Surgeon in the U.S in 1937. Orthopaedics continues to be a male-dominated field. In 2006, 12.4% of orthopaedics residents were women.

David L. MacIntosh pioneered the first successful surgery for the management of the torn anterior cruciate ligament (ACL) 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 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 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 orthopaedic surgeons today and is often combined with meniscectomy or chondroplasty. The majority of orthopaedic procedures are now performed arthroscopically.

Arthroplasty

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 in New York utilizing a fixed bearing system, and by Dr Frederick Buechel and Dr Michael Pappas utilizing a mobile bearing system.

Uni-compartmental knee replacement, in which only one weight-bearing surface of an arthritic knee is replaced, is an alternative to a total knee replacement in a select patient population.

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

See also

• Bone fracture
• Bone grafting
• Broström procedure
• Computer Assisted Orthopaedic Surgery
• Arbeitsgemeinschaft für Osteosynthesefragen
• Gait analysis
• Halo Brace
• Hand surgery
• Podiatric surgery
• Orthopedic nursing
• Traction
• Partial knee replacement
• Epiphysiodesis
• Reconstructive surgery
• Buddy wrapping
• Anterior cruciate ligament reconstruction
• Tommy John surgery

External links

• American Academy of Orthopaedic Surgeons
• American Osteopathic Academy of Orthopedics
• Arthroscopy Association of North America
• American Orthopaedic Society for Sports Medicine
• Wheeless' Textbook of Orthopaedics
• The International Society of Orthopaedic Surgery and Traumatology
• The Journal of Bone and Joint Surgery, American Volume
• The Journal of Bone and Joint Surgery, British Volume
• Arthroscopy: The Journal of Arthroscopic and Related Surgery