Physicians Perspective

Orthopedics: Looking Back and Forward

I have long found the evolution of medicine a fascinating study. Prior to attending medical school, in fact, I attended public health school to study medical ethics and the history of medicine. It’s a history full of scientific innovation, and it testifies admirably to physicians’ indomitable drive to improve the human lot and relieve suffering.

Specifically in orthopaedics, we’ve come a long way since the Middle Ages, when, for instance, improvised splints were fashioned using bandages soaked in horse blood. Along with techniques like the bleeding of patients and the application of leeches, many such surprising and unsettling practices took place throughout the early years of medicine.

Like all medical specialties, orthopaedics has its own illustrious history of discovery, invention and progress. Perhaps surprising to some, orthopaedics began as a medical specialty focused on the treatment and correction of deformities in children. The word orthopaedics itself was coined in the mid-18th century from two Greek words: orthos, meaning “correct,” and paidion, meaning “child.” Only gradually did it evolve into a specialty aimed at treating spinal and bone deformities in people at all stages of life.

Nicholas Andry, the University of Paris professor who coined the term, advocated the use of exercise, manipulation and splinting to correct childhood deformities. Later, in 1780, Jean-André Venel established the first orthopaedic hospital dedicated to the treatment of children’s skeletal deformities. A true pioneer in orthopaedics, Venel developed a clubfoot shoe for children born with foot deformities, as well as various methods to treat curvature of the spine.

An Advancing Specialty

Orthopaedics continued to advance throughout the 19th century. Research on tendon healing increased the scope of new methods available for effective treatment. One of the first orthopaedic surgical procedures to be developed, which is still in use today, was percutaneous tenotomy, the cutting of a tendon to treat deformities, in conjunction with bracing and exercises. Another important step came in 1851 with the invention of the plaster of Paris cast. Even with these developments, however, orthopaedics was still somewhat focused on the correction of deformities in children during the latter part of the century.

This focus on children began to change in part thanks to Hugh Owen Thomas, a Welsh surgeon who helped to modernize orthopaedic surgery. Becoming interested in the practice of “bone setting,” Thomas expanded the field to include the treatment of fractures and other musculoskeletal issues in adults. Among his contributions, he advocated rest as a treatment for fractures; created the Thomas splint to stabilize femur fractures; and aided in the creation of other orthopaedic tools, such as the Thomas wrench for fracture reduction and an osteoclast to break and reset bones.

20th-Century Developments

The British Orthopaedic Society was established in 1894, setting the stage for further advances. During World War I, fracture care improved greatly, especially with the introduction of military orthopaedic hospitals. Quite notably, mortality associated with compound fractures decreased from 87 percent to less than 8 percent during the war-torn years of 1916-1918.

World War II brought further innovations in orthopaedics. Gerhard Küntscher of Germany introduced the use of intramedullary rods to treat femoral and tibial fractures in German soldiers. These devices were placed centrally in long bones to speed recovery, in many cases allowing soldiers to return to fighting status in just a few weeks. While this innovation eventually led to greater use of intramedullary fixation and mobilization, worldwide awareness of the practice didn’t occur until after peace was declared, as wounded prisoners of war returned to their home countries with what were essentially steel nails in their legs.

The 20th century also saw refinements in external fixation techniques, which involve the use of rods and other devices attached to the outside of a fractured limb to keep it in place during the healing process. The concept was not a new one; it was described by Hippocrates in 400 BC as a method for treating tibia fractures. However, it was Soviet physician Gavriil Abramovich Ilizarov who, in the 1950s, made a key discovery in this area. While developing an external ring fixator system, Ilizarov realized that by preserving the periosteal covering around a severed bone, he could separate two halves of the bone slightly and fix them in place, and then new bone would grow to fill the gap. Armed with his innovations, he was able to achieve healing, realignment and lengthening in his patients. The Ilizarov apparatus is still used today for limb lengthening and to correct deformities.

The Current Orthopaedic Scene

In addition to utilizing historical techniques, modern orthopaedics has evolved to include various subspecialties that utilize new technologies—including new implants, such as those used in total ankle replacements, and minimally invasive procedures like ankle arthroscopy—to treat various ankle conditions.

Contemporary orthopaedics also encompasses the correction of deformities, including congenital conditions like clubfoot, as well as acquired foot deformities, such as those that can lead to bunion and hammertoe surgery. Treatment of tendon and other sports-related injuries are also included within the scope of contemporary practice. Fracture management continues to be a cornerstone of the field.

Orthopaedic foot and ankle surgery, my area of specialization, is just one of the subspecialties relying on the principles of historical orthopaedic practice. This is true even for the newer technique of total ankle replacement, which I’m proud to bring to Sentara Martha Jefferson Hospital. As with total hip or knee replacement, total ankle replacement relies on the use of metal and plastic components to treat painful arthritis and maintain ankle joint mobility. During the replacement surgery, the worn end of the tibia (the shin bone) and the upper portion of the talus (a bone in the ankle) are resurfaced with metal components, and then a plastic component is inserted between them to achieve motion.

New technologies also allow orthopaedic foot and ankle surgeons to perform surgeries, such as Achilles tendon repair and bunion correction, more efficiently, focusing on early mobilization. Advances in radiologic imaging also help to push the field forward, essentially allowing for customized surgery with regard to total ankle replacement, ensuring a more precise placement of the metal and plastic components that replace the worn, arthritic bone surfaces.

While techniques like these would have seemed extraordinary to Andry, Venel and other pioneers in the field, it is upon the fruits of their efforts—along with those of many innovative orthopaedic surgeons—that modern practice has developed. Combined with new research, our collective body of experience allows today’s practitioners to continue to set the stage for further advances in orthopaedics and provide the best possible outcomes for patients.

Meet Dr. Crystal Dickson

Crystal M. Dickson, MD, attended Cornell University in New York, where she earned her Bachelor of Science degree in human biology, health and society. She then graduated from Columbia University Mailman School of Public Health in New York, where she received her Master of Public Health degree in the history and ethics of public health and medicine. She earned her MD degree from the Medical College of Virginia at Virginia Commonwealth University in Richmond. She then completed her residency in orthopaedic surgery at St. Luke’s University Hospital in Bethlehem, Pa., and a fellowship in orthopaedic foot and ankle surgery at the University of Pennsylvania.

Dr. Dickson specializes in the treatment of tendon and ligament disorders, bunion and forefoot deformity correction, ankle and foot arthritis, ankle and foot reconstructive surgery, ankle arthroscopy, and ankle and foot trauma.

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