Nicholas Andry coined the word in French asorthopédie, derived from theAncient Greek wordsὀρθόςorthos ("correct", "straight") andπαιδίονpaidion ("child"), and publishedOrthopedie (translated asOrthopædia: Or the Art of Correcting and Preventing Deformities in Children[2]) in 1741. The word wasassimilated into English asorthopædics; theligatureæ was common in that era forae in Greek- and Latin-based words. As the name implies, the discipline was initially developed with attention to children, but the correction of spinal and bone deformities in all stages of life eventually became the cornerstone of orthopedic practice.[citation needed]
As with many words derived with the"æ" ligature, simplification to either "ae" or just "e" is common, especially in North America. In the US, the majority of college, university, and residency programmes, and even theAmerican Academy of Orthopaedic Surgeons, still use the spelling with the digraphae, though hospitals usually use the shortened form. Elsewhere, usage is not uniform; in Canada, both spellings are acceptable; "orthopaedics" is the normal spelling in the UK in line with other fields which retain "ae".[citation needed]
Many developments in orthopedic surgery have resulted from experiences during wartime.[3] On the battlefields of theMiddle Ages, the injured were treated with bandages soaked in horses' blood, which dried to form a stiff, if unsanitary, splint.[citation needed]
Originally, the term orthopedics meant the correcting of musculoskeletal deformities in children.[4]Nicolas Andry, a professor of medicine at theUniversity of Paris, coined the term in the first textbook written on the subject in 1741. He advocated the use of exercise, manipulation, and splinting to treat deformities in children. His book was directed towards parents, and while some topics would be familiar to orthopedists today, it also included 'excessive sweating of the palms' and freckles.[5]
Jean-André Venel established the first orthopedic institute in 1780, which was the first hospital dedicated to the treatment of children's skeletal deformities. He developed the club-foot shoe for children born with foot deformities and various methods to treat curvature of the spine.[citation needed]
Advances made in surgical technique during the 18th century, such asJohn Hunter's research ontendon healing andPercival Pott's work onspinal deformity steadily increased the range of new methods available for effective treatment.Robert Chessher, a pioneering British orthopedist, invented the double-inclined plane, used to treat lower-body bone fractures, in 1790.[6]Antonius Mathijsen, a Dutch military surgeon, invented theplaster of Pariscast in 1851. Until the 1890s, though, orthopedics was still a study limited to the correction of deformity in children. One of the first surgical procedures developed was percutaneous tenotomy. This involved cutting a tendon, originally the Achilles tendon, to help treat deformities alongside bracing and exercises. In the late 1800s and first decades of the 1900s, significant controversy arose about whether orthopedics should include surgical procedures at all.[citation needed]
Examples of people who aided the development of modern orthopedic surgery wereHugh Owen Thomas, a surgeon fromWales, and his nephew,Robert Jones.[7] Thomas became interested in orthopedics andbone-setting at a young age, and after establishing his own practice, went on to expand the field into the general treatment of fracture and other musculoskeletal problems. He advocated enforced rest as the best remedy forfractures andtuberculosis, and created the so-called "Thomas splint" to stabilize a fractured femur and prevent infection. He is also responsible for numerous other medical innovations that all carry his name: Thomas's collar to treat tuberculosis of the cervical spine, Thomas's maneuvere, an orthopedic investigation for fracture of the hip joint, theThomas test, a method of detecting hip deformity by having the patient lying flat in bed, and Thomas's wrench for reducing fractures, as well as a so-called "osteoclast" implement to break and reset bones.[citation needed]
Thomas's work was not fully appreciated in his own lifetime. Only during theFirst World War did his techniques come to be used for injured soldiers on thebattlefield. His nephew, Sir Robert Jones, had already made great advances in orthopedics in his position as surgeon-superintendent for the construction of theManchester Ship Canal in 1888. He was responsible for the injured among the 20,000 workers, and he organized the first comprehensive accident service in the world, dividing the 36-mile site into three sections, and establishing a hospital and a string of first-aid posts in each section. He had the medical personnel trained in fracture management.[8] He personally managed 3,000 cases and performed 300 operations in his own hospital. This position enabled him to learn new techniques and improve the standard of fracture management. Physicians from around the world came to Jones' clinic to learn his techniques. Along with Alfred Tubby, Jones founded the British Orthopedic Society in 1894.
During the First World War, Jones served as aTerritorial Army surgeon. He observed that treatment of fractures both, at the front and in hospitals at home, was inadequate, and his efforts led to the introduction of military orthopedic hospitals. He was appointed Inspector of Military Orthopedics, with responsibility for 30,000 beds. The hospital in Ducane Road,Hammersmith, became the model for both British and American military orthopedic hospitals. His advocacy of the use ofThomas splint for the initial treatment offemoral fractures reduced mortality of open fractures of the femur from 87% to less than 8% in the period from 1916 to 1918.[9]
The use ofintramedullary rods to treat fractures of the femur andtibia was pioneered byGerhard Küntscher of Germany. This made a noticeable difference to the speed of recovery of injured German soldiers duringWorld War II and led to more widespread adoption of intramedullary fixation of fractures in the rest of the world.Traction was the standard method of treating thigh bone fractures until the late 1970s, though, when theHarborview Medical Center group in Seattle popularized intramedullary fixation without opening up the fracture.
The modern totalhip replacement was pioneered by SirJohn Charnley, expert intribology atWrightington Hospital, in England in the 1960s.[10] He found that joint surfaces could be replaced by implants cemented to the bone. His design consisted of astainless steel, one-piece femoral stem and head, and apolyethylene acetabular component, both of which were fixed to the bone usingPMMA (acrylic)bone cement. For over two decades, the Charnley low-friction arthroplasty and its derivative designs were the most-used systems in the world. This formed the basis for all modern hip implants.
TheExeter hip replacement system (with a slightly different stem geometry) was developed at the same time. Since Charnley, improvements have been continuous in the design and technique ofjoint 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 inrheumatoid arthritis patients and later by Gunston and Marmor forosteoarthritis in the 1970s, developed byJohn Insall in New York using a fixed bearing system, and by Frederick Buechel and Michael Pappas using a mobile bearing system.[11]
External fixation of fractures was refined by American surgeons during theVietnam War, but a major contribution was made byGavril Abramovich Ilizarov in theUSSR. He was sent, without much orthopedic training, to look after injured Russian soldiers inSiberia in the 1950s. With no equipment, he was confronted with crippling conditions of unhealed, infected, and misaligned fractures. With the help of the local bicycle shop, he devised ring externalfixators tensioned like the spokes of a bicycle. With this equipment, he achieved healing, realignment, andlengthening to a degree unheard of elsewhere. HisIlizarov apparatus is still used today as one of the distraction osteogenesis methods.[12]
Modern orthopedic surgery and musculoskeletal research have sought to make surgery less invasive and to make implanted components better and more durable. On the other hand, since the emergence of the opioid epidemic, orthopedic surgeons have been identified as one of the highest prescribers of opioid medications.[13][14] Decreasing prescription of opioids while still providing adequate pain control is a development in orthopedic surgery.[14][15][16]
This image, taken in September 2006, shows extensive repair work to the rightacetabulum six years after it was carried out (2000). The onset of arthritis, a bone/joint disease, has made further joint damage visible.
In the United States, orthopedic surgeons have typically completed four years of undergraduate education and four years of medical school and earned either aDoctor of Medicine (MD) orDoctor of Osteopathic Medicine (DO) degree. Subsequently, these medical school graduates undergoresidency training in orthopedic surgery. The five-year residency is a categorical orthopedic surgery training.
Selection for residency training in orthopedic surgery is very competitive. Roughly 700 physicians complete orthopedic residency training per year in the United States. About 10% of current orthopedic surgery residents are women; about 20% are members of minority groups. Around 20,400 actively practicing orthopedic surgeons and residents are in the United States.[17] According to the latest Occupational Outlook Handbook (2011–2012) published by theUnited States Department of Labor, 3–4% of all practicing physicians are orthopedic surgeons.
Many orthopedic surgeons elect to do further training, or fellowships, after completing their residency training. Fellowship training in an orthopedic sub-specialty is typically one year in duration (sometimes two) and sometimes has a research component involved with the clinical and operative training. Examples of orthopedic subspecialty training in the United States are:
In the United States, specialists in hand surgery and orthopedic sports medicine may obtain a certificate of added qualifications in addition to their board primary certification by successfully completing a separate standardized examination. No additional certification process exists for the other subspecialties.
Radiography to identify eventualbone fractures after a knee injuryOrthopedic implants to repair fractures to the radius and ulna. Note the visible break in the ulna. (right forearm)Anterior and lateral view x-rays of fractured left leg withinternal fixation after surgery
According to applications for board certification from 1999 to 2003, the top 25 most common procedures (in order) performed by orthopedic surgeons are:[20]
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. According to theAmerican Association of Medical Colleges in 2021, the average work week of an orthopedic surgeon was 57 hours.[21][22] This is a very low estimation however, as research derived from a 2013 survey of orthopedic surgeons who self identified as "highly successful" due to their prominent positions in the field indicated average work weeks of 70 hours or more.[23][21]
The use of arthroscopic techniques has been particularly important for injured patients.Arthroscopy was pioneered in the early 1950s byMasaki Watanabe of Japan to perform minimally invasive cartilage surgery and reconstructions of torn ligaments. Arthroscopy allows patients to recover from the surgery in a matter of days, rather than the weeks to months required by conventional, "open" surgery; it is a very popular technique. Knee arthroscopy is one of the most common operations performed by orthopedic surgeons today, and is often combined with meniscectomy or chondroplasty. The majority of upper-extremity outpatient orthopedic procedures are now performed arthroscopically.[24]
Arthroplasty is an orthopedic surgery where the articular surface of a musculoskeletal joint is replaced, remodeled, or realigned byosteotomy or some other procedure.[25] It is an elective procedure that is done to relieve pain and restore function to the joint after damage by arthritis (rheumasurgery) or some other type of trauma.[25] As well as the standard total knee replacement surgery, the unicompartmental knee replacement, in which only one weight-bearing surface of an arthritic knee is replaced, may be performed,[25] but it bears a significant risk of revision surgery.[26] Joint replacements are used for other joints, most commonly thehip[27] orshoulder.[28]
A post-surgical concern with joint replacements is wear of the bearing surfaces of components.[29] This can lead to damage to the surrounding bone and contribute to eventual failure of the implant.[29] The plastic chosen is usually ultra-high-molecular-weightpolyethylene, which can also be altered in ways that may improve wear characteristics.[29] The risk of revision surgery has also been shown to be associated with surgeon volume.[28][30]
Between 2001 and 2016, the prevalence of musculoskeletal procedures drastically increased in the U.S., from 17.9% to 24.2% of all operating-room (OR) procedures performed during hospital stays.[31]
In a study of hospitalizations in the United States in 2012, spine and joint procedures were common among all age groups except infants. Spinal fusion was one of the five most common OR procedures performed in every age group except infants younger than 1 year and adults 85 years and older. Laminectomy was common among adults aged 18–84 years. Knee arthroplasty and hip replacement were in the top five OR procedures for adults aged 45 years and older.[32]
