Orthopedic (sometimes spelled orthopaedic) surgery is surgery performed by a medical specialist, such as an orthopedist or orthopedic surgeon, trained to deal with problems that develop in the bones, joints, and ligaments of the human body.
Description
The range of treatments done by orthopedists is enormous. It can cover anything from traction to amputation, hand reconstruction to spinal fusion or joint replacements. They also treat broken bones, strains and sprains, and dislocations. Some specific procedures done by orthopedic surgeons are listed as separate entries in this book, including arthroplasty, arthroscopic surgery, bone grafting, fasciotomy, fracture repair, kneecap removal, and traction.
In general orthopedists are attached to a hospital, medical center, trauma center, or free-standing surgical center where they work closely with a surgical team including an anesthesiologist and surgical nurse. Orthopedic surgery can be performed under general, regional, or local anesthesia.
Much of the work of the surgeon involves adding foreign material to the body in the form of screws, wires, pins, tongs, and prosthetics to hold damaged bones in their proper alignment or to replace damaged bone or connective tissue. Great improvements have been made in the development of artificial limbs and joints, and in the materials available to repair damage to bones and connective tissue. As developments occur in the fields of metallurgy and plastics, changes will take place in orthopedic surgery that will allow the surgeon to more nearly duplicate the natural functions of the bones, joints, and ligaments, and to more accurately restore damaged parts to their original range of motion.
Who Performs the Procedure and Where Is It Performed?
Orthopedic surgery is performed by a physician with specialized training in orthopedic surgery. It is most commonly performed in operating room of a hospital. Very minor procedures such as setting a broken bone may be performed in a professional office or an emergency room of a hospital.
Questions to Ask the Doctor
What tests will be performed prior to surgery?
How will the procedure affect daily activities after recovery?
Where will the surgery be performed?
What form of anesthesia will be used?
What will be the resulting appearance and level of function after surgery?
Is the surgeon board certified by the American Academy of Orthopedic Surgeons?
How many similar procedures has the surgeon performed?
What is the surgeon's complication rate?
Definition
Orthopedic (sometimes spelled orthopedic) surgery is an operation performed by a medical specialist such as an orthopedist or orthopedic surgeon, who is trained to assess and treat problems that develop in the bones, joints, and ligaments of the human body.
Purpose
Orthopedic surgery addresses and attempts to correct problems that arise in the skeleton and its attachments, the ligaments and tendons. It may also include some problems of the nervous system, such as those that arise from injury of the spine. These problems can occur at birth, through injury, or as the result of aging. They may be acute, as in an accident or injury, or chronic, as in many problems related to aging.
Orthopedics comes from two Greek words, ortho, meaning straight, and pais, meaning child. Originally, orthopedic surgeons treated skeletal deformities in children, using braces to straighten the child's bones. With the development of anesthesia and an understanding of the importance of aseptic technique in surgery, orthopedic surgeons extended their role to include surgery involving the bones and related nerves and connective tissue.
The terms orthopedic surgeon and orthopedist are used interchangeably today to indicate a medical doctor with special training and certification in orthopedics.
Many orthopedic surgeons maintain a general practice, while some specialize in one particular aspect of orthopedics such as hand surgery, joint replacements, or disorders of the spine. Orthopedists treat both acute and chronic disorders. Some orthopedic surgeons specialize in trauma medicine and can be found in emergency rooms and trauma centers, treating injuries. Others find their work overlapping with plastic surgeons, geriatric specialists, pediatricians, or podiatrists (foot care specialists). A rapidly growing area of orthopedics is sports medicine, and many sports medicine doctors are board certified in orthopedic surgery.
Demographics
The American Academy of Orthopedic Surgeons reports that in 2003, there are 15,853 active fellows, 1,829 resident members, and 2,240 candidate members, for a total of 19,922 orthopedic surgeons in the United States.
Description
The range of treatments provided by orthopedists is extensive. They include procedures such as traction, amputation, hand reconstruction, spinal fusion, and joint replacements. They also treat strains and sprains, broken bones, and dislocations. Some specific procedures performed by orthopedic surgeons are listed as separate entries in this book, including arthroplasty, arthroscopic surgery, bone grafting, fasciotomy, fracture repair, kneecap removal, and traction.
In general, orthopedists are employed by hospitals, medical centers, trauma centers, or free-standing surgical centers where they work closely with a surgical team, including an anesthesiologist and surgical nurse. Orthopedic surgery can be performed under general, regional, or local anesthesia.
Much of the work of an orthopedic surgeon involves adding foreign material to the body in the form of screws, wires, pins, tongs, and prosthetics to hold damaged bones in their proper alignment or to replace damaged bone or connective tissue. Great improvements have been made in the development of artificial limbs and joints, and in the materials available to repair damage to bones and connective tissue. As developments occur in the fields of metallurgy and plastics, changes will take place in orthopedic surgery that will allow surgeons to more nearly duplicate the natural functions of bones, joints, and ligaments, and to more accurately restore damaged parts to their original ranges of motion.
Diagnosis/Preparation
Persons are usually referred to an orthopedic surgeon by a primary care physician, emergency room physician, or other doctor. Prior to any surgery, candidates undergo extensive testing to determine appropriate corrective procedures. Tests may include x rays, computed tomography (CT) scans, magnetic resonance imaging (MRI), myelograms, diagnostic arthroplasty, and blood tests. The orthopedist will determine the history of the disorder and any treatments that were previously tried. A period of rest to the injured part may be recommended before surgery is undertaken.
Surgical candidates undergo standard blood and urine tests before surgery and, for major procedures, may be given an electrocardiogram or other diagnostic tests prior to the operation. Individuals may choose to donate some of their own blood to be held in reserve for their use in major surgery such as knee replacement, during which heavy bleeding is common.
Aftercare
Rehabilitation from orthopedic injuries can require long periods of time. Rehabilitation is usually physically and mentally taxing. Orthopedic surgeons will work closely with physical therapists to ensure that patients receive treatment that will enhance the range of motion and return function to all affected body parts.
Risks
As with any surgery, there is always the risk of excessive bleeding, infection, and allergic reaction to anesthesia. Risks specifically associated with orthopedic surgery include inflammation at the site where foreign materials (pins, prostheses, or wires) are introduced into the body, infection as the result of surgery, and damage to nerves or to the spinal cord.
Normal Results
Thousands of people have successful orthopedic surgery each year to recover from injuries or to restore lost function. The degree of success in individual recoveries depends on an individual's age and general health, the medical problem being treated, and a person's willingness to comply with rehabilitative therapy after the surgery.
Abnormal results from orthopedic surgery include persistent pain, swelling, redness, drainage or bleeding in the surgical area, surgical wound infection resulting in slow healing, and incomplete restoration of pre-surgical function.
Morbidity and Mortality Rates
Mortality from orthopedic surgical procedures is not common. The most common causes for mortality are adverse reactions to anesthetic agents or drugs used to control pain, post-surgical clot formation in the veins, and post-surgical heart attacks or strokes.
Alternatives
For the removal of diseased, non-functional, or non-vital tissue, there is no alternative to orthopedic surgery. Alternatives to orthopedic surgery depend on the condition being treated. Medications, acupuncture, or hypnosis are used to relieve pain. Radiation is an occasional alternative for shrinking growths. Chemotherapy may be used to treat bone cancer. Some foreign bodies may remain in the body without harm.
Bland, K. I., W. G. Cioffi, and M. G. Sarr. Practice of GeneralSurgery. Philadelphia: Saunders, 2001.
Canale, S. T. Campbell's Operative Orthopedics. St. Louis: Mosby, 2003.
Schwartz, S. I., J. E. Fischer, F. C. Spencer, G. T. Shires, and J. M. Daly. Principles of Surgery, 7th Edition. New York: McGraw Hill, 1998.
Townsend, C., K. L. Mattox, R. D. Beauchamp, B. M. Evers, and D. C. Sabiston. Sabiston's Review of Surgery, 3rd Edition. Philadelphia: Saunders, 2001.
Periodicals
Caprini, J. A., J. I. Arcelus, D. Maksimovic, C. J. Glase, J. G. Sarayba, and K. Hathaway. "Thrombosis Prophylaxis in Orthopedic Surgery: Current Clinical Considerations." Journal of the Southern Orthopedic Association 11, no.4 (2002): 190–196.
O'Brien, J. G. "Orthopedic Surgery: A New Frontier." MayoClinic Proceedings 78, no.3 (2003): 275–277.
Ribbans, W. J. "Orthopedic Care in Haemophilia." HospitalMedicine 64, no.2 (2003): 68–69.
Showstack, J. "Improving Quality of Care in Orthopedic Surgery." Arthritis and Rheumatism 48, no.2 (2003): 289–290.
Organizations
American Academy of Orthopedic Surgeons. 6300 North River Road Rosemont, IL 60018-4262. (847) 823-7186 or (800) 346-2267. http://www.aaos.org/wordhtml/home2.htm.
American College of Sports Medicine. 401 West Michigan Street, Indianapolis, IN 46202-3233 (Mailing Address: P.O. Box 1440, Indianapolis, IN 46206-1440). (317) 637-9200, Fax: (317) 634-7817. http://www.acsm.org.
American College of Surgeons. 633 North Saint Claire Street, Chicago, IL 60611. (312) 202-5000. http://www.facs.org/.
American Society for Bone and Mineral Research 2025 M Street, NW, Suite 800, Washington, DC 20036-3309. (202) 367-1161. http://www.asbmr.org/.
Orthopedic Trauma Association. 6300 N. River Road, Suite 727, Rosemont, IL 60018-4226. (847) 698-1631. http://www.ota.org/links.htm.
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, 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.
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 M.D. or D.O. 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:
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:
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 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 2007, the median salary for an
orthopaedic surgeon in the United States is $220,000 and $500,000+ [1].
History
Orthopedic implants to repair fractures to the radius and ulna. Note the visible break in the ulna. (right forearm) Photo: Peter
Battaglia
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.
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[citation needed]. 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[citation needed]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 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 congenitaldislocation 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..
Terminology
Nicholas Andry coined the word "orthopaedics", derived from Greekwords for "correct" or "straight" ("orthos") and
"child" ("paidion"), in 1741, when at the age of 81 he publishedOrthopaedia: or the Art of Correcting and
Preventing Deformities in Children.
In the U.S. 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; see also spelling differences.
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.
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