ORTHOPEDICS—HISTORY AND EVOLUTION
INTRODUCTION
It will be interesting to know that orthopedics was born as a specialty for correcting deformities in children. In 1741 Nicolas Andry (Fig. 1.1) coined the word “orthopaedics”, which was derived from Greek words for “correct” or “straight” (orthos) and “child” (paidion). Both “orthopaedics” and “orthopedics” are accepted spellings and in vogue worldwide. Until the end of 18th century, orthopedics was limited to correction of deformities in children and fracture treatment was largely restricted to traction, splints and bandages.
In 19th century, three landmark discoveries in this surgical field made surgeries safe, painless and enthusiastic. These were development of principles of antisepsis by Sir Joseph Lister (Fig. 1.2), the discovery of ether anesthesia in 1846 by William Morton (1819–1868) and the invention of X-rays by Wilhelm Conrad Roentgen (1845–1923). Discovery of X-rays revolutionized the way of making a diagnosis in orthopedic cases. Another vital contribution which modernized the management of fractures was the invention of plaster of Paris (POP) bandage by Antonius Mathijsen in 1851. Thereafter, in 20th century the World Wars I and II contributed a lot to the development of core orthopedics by producing countless number of patients requiring amputation, debridement, fracture management, tendon surgeries, etc. In fact many great orthopedic surgeons were military surgeons like Sir Robert Jones, Gerhard Küntscher, and Antonius Mathijsen. Today, the scope of orthopedics has extended way beyond fracture fixation and deformity correction and many subspecialty branches have emerged like spine surgery, orthopedic oncology, pediatric orthopedics, sports medicine, reconstructive orthopedics (joint replacement), etc.
SOME ORTHOPEDIC LEGENDS AND THEIR CONTRIBUTION
Galen (129–199 BC): Father of Sports Medicine. He is also credited with describing for the first time the use of longitudinal traction for reduction of overlapping bone fragments.
Nicolas Andry (1658–1742) (Fig. 1.1): He published the first book in orthopedics “L'Orthopedie” in 1741, which conferred him the title of “Father of Orthopedics”. For correction of deformity of tibia he suggested bandaging the limb to an iron plate. His famous engraving (Fig 1.3) of the “crooked tree” published by him in his book soon became the symbol of orthopedics worldwide.
Percival Pott (1714–1788): Pott's fracture. Pott's paraplegia. In 1756, this great English surgeon sustained a broken leg after fall from his horse. It was assumed that he had sustained a bimalleolar fracture so it began to be called Pott's fracture but in reality he had sustained a much serious open fracture of tibia.
Jean-André Venel (1740–1791): He is considered by some as “Father of Orthopedics”. He established the first orthopedics institute in the world in Switzerland.
Hugh Owen Thomas (1834–1891): He devised the popular Thomas splint and Thomas test for flexion deformity of the hip. He is also known as “Father of British Orthopedics”.
James Paget (1814–1899): He was the great English surgeon- cum-pathologist who is best known for his contributions, viz. Paget's disease of bone and Paget's disease of nipple. He popularized the term “Fracture disease” to refer to stiffness that occurs following conservative treatment of fractures. He was also the first to describe “Carpal Tunnel Syndrome” in 1854 although the term was coined by Moersch later in 1938.2
Robert Jones (1857–1933): He was the nephew of great Hugh Owen Thomas. He is known as “Father of Modern Orthopedics”. He described the Jones fracture and the Robert Jones bandage. He published first report of use of X-rays in orthopedics.
Albin Lambotte (1866–1955): Belgian surgeon, coined the term “osteosynthesis” meaning internal fixation and is regarded as the “Father of Modern Internal Fixation”. He also devised the first modern external fixator and was first to describe the use of biodegradable implants.
Martin Kirschner (1879–1942): He contributed the very simple but the very useful “K wire” to orthopedics.
Lorenz Böhler (1885–1973): Father of Trauma Surgery.
Austin Moore (1899–1963): He performed the first metallic hip replacement. He designed the Austin-Moore prosthesis, which is still in use.
Gerhard Küntscher (1900–1972): His biggest contribution to orthopedics was the intramedullary nail which revolutionized the treatment of diaphyseal fractures of long bones.
Reginald Watson-Jones (1902–1972): He devised the Watson- Jones approach (anterolateral approach) to the hip joint. He was the student of Sir Robert Jones. He was the first editor of Journal of Bone and Joint Surgery (British), a popular journal on the subject.
Maurice E. Müller (1918–2009): He was a Swedish surgeon who was instrumental in the development of internal fixation techniques (fixation of fractures with metal implants placed inside the skin). In 1958 he co-founded “Arbeitsgemeinschaft fur Osteosynthesefragen” (German for “Association for the Study of Internal Fixation”, or “AO”, a popular organization that works for improving the standard of patient care in orthopedics.
Paul Randall Harrington (1911–1980): Harrington invented the Harrington rod, a device that is used during corrective surgery for scoliosis.
John Charnley (1911–1982) (Fig. 1.4): Father of Total Hip Arthroplasty. He was the great innovator of the modern total hip replacement and popularized the use of bone cement in total hip replacement.
Gavriil Abramovich Ilizarov (1921–1992): He gave the famous Ilizarov theory that bone would grow if gradually distracted. His work pioneered a new way of treating some of the most difficult cases in orthopedics, viz. infected nonunion, deformity correction and limb lengthening.
Kenji Takagi (1888–1963): Father of Arthroscopy. Takagi, a Japanese surgeon carried out the first successful arthroscopy of a joint (knee).
Masaki Watanabe (1911–1995): Father of Modern Arthroscopy. He performed the first arthroscopic partial meniscectomy.
William Enneking (1926–2014): Father of Orthopedic Oncology. He gave a classification system for bone tumors.
HIGH-YIELD POINTS
- Nicolas Andry is also called as the Father of Parasitology.
- The first intramedullary steel nail was introduced by Gerhard Küntscher. However, first interlocking intramedullary nail was performed by Modney and Bambara in 1953.
- First reamed intramedullary nailing was done by Fischer.
ORTHOPEDIC TERMINOLOGY
Ankylosis (Fig. 1.6A): Fusion of a joint due to a disease that causes abnormal adhesions between two joint surfaces.
Figs 1.6A to C: X-rays of the knee showing (A) Ankylosis; (B) Arthrodesis; and (C) Arthroplasty (knee replacement)
Arthrodesis (Fig. 1.6B): Surgically-induced fusion of two joint surfaces.
Arthroeresis: It refers to an operation carried on a joint to restrict an undue mobility.
Arthrography: X-ray examination of joint after injecting contrast material (now largely been replaced by MRI).
Arthropathy: A disease of a joint.
Arthroplasty (Fig. 1.6C): Replacement of a joint with a prosthesis.
Arthrosis: Degenerative wear and tear of cartilage of the joint (osteoarthritis).
Arthrotomy: A procedure where surgeons cut into the joint (usually to drain pus from the joint).
Calcaneus: Deformity of ankle joint with the foot fixed in dorsiflexion.
Calcification: Deposition of amorphous (powdered/noncrystalline) calcium phosphate.
Cavus: Exaggeration of medial longitudinal arch of the foot.
Clonus: Successive, rhythmic and involuntary muscular contraction and relaxation (pathological hyperreflexia of normal deep tendon reflex). More than 5 beats are significant.
Chemonucleolysis: Injection of chymopapain (a proteolytic enzyme) into disc space to dissolve the disc (as a treatment of prolapsed disc).
Circumduction (Figs 1.7A and B): It is a combination of flexion, extension, abduction and adduction. In this movement, distal end of a limb makes a conical movement and the apex of the cone is at the proximal end of the limb.
Corticotomy: A surgery that involves cutting only the cotex of bone, leaving the meduallary vessels and periosteum intact. The bone may or may not be split into two pieces.
Coxa: Pertaining to the hip.
Cubitus: Pertaining to the elbow.
Dorsum: Upper/back surface of an animal/human (dorsal surface of the hand is the surface opposite the palm).4
Dislocation: Two joint surfaces loosing total contact with each other.
Epiphyseal plate/growth plate or physis: Hyaline cartilage present above the proximal metaphysis and below the distal metaphysis separating metaphysis from epiphysis.
Epiphysiodesis: Surgically-induced fusion of the epiphyseal plate or physis to metaphysis and/or epiphysis.
Equinus: Deformity of ankle joint with foot fixed in plantar flexion.
Extension (Figs 1.8A to F): Movement in sagittal plane, which increases the angle between two body parts.
Eversion (Fig. 1.9): Plantar surface (sole) of foot rotates away from mid-sagittal plane (can be called valgus).
Flexion (Figs 1.8A to F): Movement in sagittal plane, which decreases the angle between two body parts.5
Genu: Pertaining to knee.
Hemarthrosis: Bleeding into the joint space.
Impacted fracture: When fracture fragments are driven into each other.
Interosseous membrane: A fibrous sheath that separates two bones (between two forearm bones or two leg bones).
Inversion (Fig. 1.9): Plantar surface of the foot (sole) rotates toward the mid-sagittal plane (can be called as varus).
Kyphosis: Normal backward convex curvature of spine in thoracic and sacral region.
Laminectomy: Removal of spinal lamina (usually to decompress the spinal cord or nerves).
Lordosis: Normal backward concave curvature of spine in cervical and lumbar region.
Laminotomy: Removal of a part of lamina.
Manus: Pertaining to the wrist.
Myositis: Inflammation of the muscles.
Neurolysis: Interruption of the transmission of nerve signal (usually for pain relief) by application of physical agents (heat or freezing) or chemicals (such as phenol or alcohol) to a nerve.
Neurorraphy: Surgical suturing of a divided nerve.
Open reduction: Reduction of fracture fragments by surgical exposure and under direct vision. In open reduction fracture hematoma is drained.
Opposition (apposition) of thumb (Fig. 1.10): A movement unique to thumb in which thumb rotates around its long- axis and its palmar surface comes in contact with the palmar surface of little finger.
Orthotic: Orthotic is a device that aids/supports a body part and enhances the structural and functional characteristics of the skeletal system.
Ossification: Deposition of crystalline calcium phosphate to form new bone.
Osteoclasis: Surgically-induced fracture of the bone (to correct a bone deformity).
Osteogenesis: Bone formation.
Osteometric devices: Theses are used to measure bone length.
Osteonecrosis: Death of bone tissue.
Osteosynthesis: Stabilization and internal fixation of fracture.
Osteotomy: A surgical procedure in which bone is cut in order to correct deformity.
Plantar surface: Inferior surface of the foot, which comes in contact with the ground.
Plantaris: Equinus that occurs at the forefoot is called plantaris (forefoot fixed in plantarflexion).
Planus: Flattened medial longitudinal arch.
Pronation (Figs 1.11A and B): Rotation of the forearm and hand so that the palm faces downward. Pronation of foot is a combination of eversion, abduction and dorsiflexion.
Prosthesis: An artificial device that replaces a body part.
Recurvatum: Excessive extension deformity of a joint (Genu Recurvatum is hyperextension deformity of knee joint, i.e. knee bends backwards). It is opposite to flexion deformity.
SLAP lesion: Tear of superior labrum in shoulder, from anterior to posterior aspect.
Spondylitis: Inflammation of vertebrae.
Spondylosis: An umbrella term that refers to degenerative changes in the spine, viz. bone spurs, degenerated intervertebral discs, etc.
Spondylolisthesis: Anterior or posterior translation of one segment of spine in relation to the vertebrae below.
Spondylolysis: A defect in pars-interarticularis of vertebral arch. It may progress to spondylolisthesis.
Subluxation: Two joint surfaces loosing partial contact between each other (a partial dislocation).
Supination (Figs 1.11A and B): Rotation of the forearm and hand so that the palm faces upward. Supination of the foot is the combination of inversion, adduction and plantar flexion.
Synovitis: Inflammation of synovium.
Tenodesis: Surgical suturing/anchoring of tendon to bone.
Tenolysis: Surgical release of a tendon from adhesions.
Tenotomy: Surgical division of a tendon.
Tenosynovitis (syn. tenovaginitis): Inflammation of a tendon and its surrounding sheath.
Tendonitis (syn. tendinitis): Inflammation of the tendon (an acute condition usually).
Tendinosis: Degeneration of the tendon's collagen in response to chronic overuse.
Tendinopathy: It is a broad nonspecific term that refers to disorder/disease of a tendon (“pathy” is a greek word meaning disease/disorder).
Valgus*: Term used when limb distal to a joint points away (laterally) from mid-line.
Varus*: Term used when limb distal to a joint points towards (medially) mid-line.
Volar: Pertaining to the palm in hand or the sole in the foot.