Earliest known textbook of orthopedics
Amputations, setting of bones and primitive casts for treating fractures predate recorded history. The surgical specialty of orthopædics owes its name to Nicholas Andry (1658-1742), a French physician whose 1741 textbook Orthopædia*: Correcting and Preventing Deformities in Children reflected the field’s then current focus on children with spinal and pedal (clubfoot) defects. With time, orthopaedics’ reach extended to adults with joint diseases, and musculoskeletal defects of all ilk and location. The battlefield provided a laboratory in which early progress in orthopaedics was made, for example, military surgeon Antonius Mathijsen’s 1851 invention of Plaster of Paris casts, which helped gel orthopædics’ emphasis on bone deformities and fractures.
*From Greek, orthos (correct), paidion (child), see top image
Dr Hugh Owen Thomas (1834-1891), a Welshman, is the widely acknowledged father of orthopedic surgery who made many contributions to medicine and orthopædics in a relatively short life*. The latter half of the 19th century and early 20th saw a series of sea changes that led to the ushering in of modern medicine, of which orthopædics was a major beneficiary. The first change was the development of anesthesia to sleep patients, making surgery less barbaric. The second innovation was British surgeon, Joseph Lister’s, use of carbolic acid to prevent sepsis, based on the work of Louis Pasteur. The final revolution was the development of diagnostic radiology. Modern orthopædics was not far in the future.
*Thomas’s oeuvre included an array of devices, including the Thomas splint, Thomas collar (for tuberculosis of the cervical spine), the Thomas heel to correct varus deformity of the foot, and the Thomas test for identifying hip deformities, treatises on medical diseases of joints; fractures and dislocations of the trunk and upper extremities; fractures and dislocations of the lower extremities; and fractures of the mandible, among other works. Thomas’s work was not fully appreciated in his lifetime. His work was later recognized through his nephew Sir Robert Jones, whose application of the Thomas splint reduced the mortality of compound fractures from 87% to less than 8% during the Great War (1916-1918).
before and after of hip with degenerative joint disease
Simplistically, orthopædics has followed two tracks: elective and non-elective. Non-elective orthopædic surgery is “messy”…think MASH…and is caused by car crashes, war, mass disasters, and terrorist acts, to mention the major causes of emergency orthopædics. Many aspects of trauma orthopædics are “modern”, but the injuries themselves are not. Developed regions have the advantages of air evacuation of the injured, well-stocked blood banks, reliable telecommunication, backup surgical teams and health centers to provide surge capacity*. The injuries are not “modern” and may still lead to amputations and loss of functional capacity.
*Compare this to the hospitals in Afghanistan, Somalia and Syria
Modern orthopaedics is primarily an elective field which replaces hips and knees with joint failure due to osteoarthritis (see bottom image), less often due to rheumatoid arthritis, avascular necrosis, traumatic arthritis and a host of etceteras. The modern joint is largely the brainchild of Sir John Charnley, whose design consisted of 3 components:
• Stainless steel one-piece femoral stem and head
• Polyethylene (originally Teflon) acetabular component, both of which were fixed to the bone using
• PMMA (acrylic) bone cement
Joint replacements are the most commonly performed orthopædic procedure in the USA, with nearly 700,000 knees and 310,000 hips being replaced in 2010. The average cost for hip replacement in the US was $40K (2012) vs $7,700 to $12,000 in Europe.
Orthopædic surgeons have a 5-6 year residency and fellowship, earn ± $535,000 and pay an average of $175,000 in malpractice premiums on Long Island, NY (the most expensive area of New York State) and $30,000 in western New York State (the least expensive area).