Download Orthopedic Practice and Surgery

Orthopedic Practice and Surgery
by Michael A. Ellis, M.D.
1988, 2010
Modern orthopedics can be defined as the medical discipline that deals with problems of bones, joints,
and muscles. The specialty of orthopedics originally evolved to help crippled children—to correct their
deformities, to make them straight. The word orthopedic literally means “straight child” from the Greek
words orthos (straight) and pais (child). One of the most interesting facets of orthopedics is that it is a
medical discipline subject to great change—change for the better, which is why I find the practice of
orthopedics exciting and enjoyable.
An orthopedic physician who sees ambulatory patients or outpatients in the office will recommend
surgery only about 1 in 20 times. This average increases, of course, for the orthopedist whose caseload
require urgent procedures for trauma, infections, or tumors. In a general orthopedic practice, approximately
one-half of surgical patients require emergency surgery for trauma, infections, or tumors. The rest are cases
in which surgery is done electively, after nonsurgical approaches to the problem are unsuccessful.
Treatment of Children
A general orthopedist, whose training is about 20 percent in pediatric orthopedics, frequently
encounters children with orthopedic difficulties. The worst of these is noticeable right at birth and often
includes such problems as clubfoot and congenital dislocation of the hip. In addition, birth trauma may
result in orthopedic complications, particularly fractured clavicles.
Babies with fractures require little treatment. Their blood circulation is so efficient that one can almost
see the healing process taking place. For instance, collar bone fractures occur frequently at birth but heal
within 4 or 5 days, and without the use of an immobilizer. Unfortunately, our blood circulation gets
steadily worse from the day of birth until we die, so that a fracture requiring only a few days to heal in a
child may take 6-8 weeks to heal in an adult.
Tradition once mandated that a child with clubfoot (a condition in which the foot is bent downward
and inward) would receive no treatment until walking age. Frankly, the rationale for this was the blind
hope that the foot would improve on its own. Even as recently as the 1980s, treatment of clubfoot was
delayed until the child was a year old, requiring an average of four operations between ages 1 and 15 years.
Usually these attempts were unsuccessful, leaving the patient with a fused foot that would not bend
normally.
Today it is recognized that surgical intervention for clubfoot should be carried out at an early age. By
the time the infant is 3 months old, the physician is able to assess whether cast technique or nonsurgical
methods will be effective in the treatment of clubfoot. If nonsurgical treatment is unsuccessful by age 3
months, surgery is carried out. The procedure is not performed on the newborn because the stress of
anesthesia and surgery is considered detrimental and is better tolerated when the infant is older.
Orthopedics, The SUM Program Advanced Medical Transcription Unit, 2nd ed.
Health Professions Institute
www.hpisum.com
The trend in orthopedic treatment includes not only earlier operations but also far more aggressive
surgical techniques. For instance, clubfoot used to be treated with two separate operations—one to correct
the downwardness and one to correct the inwardness, at ages one and two, respectively. And it would take
one year beyond that before results were apparent. Today both procedures are performed during one
operation, and the results are usually excellent. If good position is maintained after surgery with casting,
the chances are 90 percent that the clubfoot will grow as a normal foot, albeit several sizes smaller than the
opposite, unaffected foot. This smallness does not reflect failure of surgical treatment; it is rather that the
same birth defect that caused the clubfoot produces other abnormalities in the same leg. Thus, a clubfoot
that has been surgically corrected will look a bit different from a normal foot.
Children with a congenital discrepancy in leg length present an entirely different challenge to the
orthopedic surgeon. In the past, the usual method of leg length equalization was time-consuming,
debilitating, and required frequent hospitalization that often necessitated withdrawing the child from
school for approximately 2 years. The surgery consisted of shortening the longer leg by cutting a segment
out of it. Or, if the child was still growing, staples were placed across the epiphyseal growth plate to slow
the growth of that leg until the legs equalized in length. These procedures were arduous and fraught with
complications, including interruption of the blood or nerve supply to the leg. The surgery was so
debilitating that it was performed only when leg length discrepancy was severe enough that amputation
was the only alternative. And today, when tallness is considered a positive rather than a negative social
trait, physicians cannot convince a child or the child’s parents to consider leg shortening surgery.
A Russian physician by the name of Ilizarov (eh-liz’arov) developed a most innovative method of leg
lengthening. It involves inserting metallic pins through the leg above and below the area to be lengthened,
creating a surgical fracture, and then stretching the healing fracture apart. As the fracture heals, the soft
new bone is literally stretched, and huge differences in leg length—up to several inches—can be corrected.
There are none of the complications that were so prevalent with previous procedures. The Ilizarov
technique represents a genuine advancement in orthopedic practice and is now standard practice in the
western hemisphere.
Future pediatric orthopedic innovations will likely include in-utero surgery to correct congenital
malformations and deformities. Although we can’t currently treat these conditions (today’s instruments are
too large to fit into the womb), this technology is up and coming and definitely on the horizon of
orthopedic surgery. And further down the road is genetic manipulation that will totally prevent congenital
abnormalities from developing at all.
The Elderly Orthopedic Patient
The orthopedic physician sees many elderly patients who develop age-related injuries and conditions.
Yet surprisingly, most of these people not only survive surgery but recover as well. An elderly person in
good general and mental health, with prospects for living 5 or more years, is a candidate to undergo even
an arduous orthopedic procedure. The average age of elderly patients in my practice is 77, and there are
many who are over 100 years of age!
Orthopedics, The SUM Program Advanced Medical Transcription Unit, 2nd ed.
Health Professions Institute
www.hpisum.com
Some years ago a 94-year-old lady who lives on a small farm came to see me because she fell off her
roof while she was trying to repair it to keep the rain off her and her 30 cats. She had broken her hip in the
fall and required an artificial hip. She did very well after surgery, except that she complained of back pain
and insisted that her back was broken. A back x-ray was taken, but her bones were so arthritic that it was
impossible to detect a fracture. Our medical opinion was that her pain was due to severe arthritis, and I said
to her, “You’re awfully old—94—your back ought to hurt! But there are no fractures on the x-ray, and
your back pain is probably caused by arthritis.” Her reply was, “Oh no, Dr. Sonny” (her name for me, since
I was just 38 at the time), “I know my back is broken.” Three months later we took a followup x-ray, and
there was the fracture! At age 94, she went on to heal the back fracture as well as the artificial hip. She is
now 106 years old and comes to see me occasionally, saying that she’s still around and doing well, and
reminds me, “I want you to know that I fixed that roof!”
The most prevalent surgical problem of the aged is that of stress fractures due to osteoporosis (thin and
brittle bones). Older people, especially women, are not accustomed to falling; they do not employ their
bodies in an agile way to prevent fractures when they fall. Complications and fractures resulting from falls
are a fact of life for the aging person, especially the woman with osteoporosis.
A fallacy often repeated is that patients with osteoporotic fractures heal slowly. In actual fact, their
fractures heal nearly as rapidly as those of a 30-year-old; the rate of healing for both is about the same. It is
the quality of healing that is different. While the young patient heals with strong bone, the osteoporotic
patient heals with bone of poor quality.
If one added up all of the factors that deal with the strength of bone and the determination of
osteoporosis—the amount of calcium in the body, protein in the diet, dietary substrates and bonemaking
materials, hormones that promote bone formation—and weighed them against exercise alone, the scale
would tip more than 90 percent in favor of exercise. In my studied opinion, lack of exercise is the vastly
underrated factor in osteoporosis.
If you inspect the lifestyle of the average woman with osteoporosis, you will discover that she walks
less than one-half mile per day and does little lifting. Axial stress upon the bony skeleton—the loading of
vertical weight—is very important in keeping bones strong. Bedridden people develop osteoporosis. Even
a 15-year-old, who is metabolically superior and has a high calcium intake, will develop severe
osteoporosis within a month if all physical activity suddenly ceases (from paralysis, for example).
In addition to osteoporosis and fractures, elderly patients present with a wide variety of other
orthopedic problems. Degenerative arthritis of the joints is a common presenting complaint of the elderly.
In the mid-1950s, older people with hip fractures were simply put to bed—and nearly every person died
within three months from pneumonia or other complications of forced bed rest, including the mental
disorientation that older people experience when they are subjected to major stress.
Today, the ultimate orthopedic solution is to replace the joint, and joint replacement surgery has
evolved to the point where hip, knee, elbow, and wrist joints can be replaced with quite satisfactory results.
Even very elderly patients opt for joint replacement surgery when the prospect of regaining mobility and
independence is offered. The death rate in orthopedic surgery of the elderly is surprisingly low—about 2
percent, which is actually comparable to the risk from a stroke or coronary. These statistics support the
opinion that aggressive treatment for severe orthopedic problems is better than marginal treatment or no
treatment.
Orthopedics, The SUM Program Advanced Medical Transcription Unit, 2nd ed.
Health Professions Institute
www.hpisum.com
Total hip replacement. When artificial hip surgery first came into vogue, there was only one brand of
prosthesis from which to choose. Invented by Dr. Charnley of England, the artificial hip was manufactured
of stainless steel in Switzerland. Today there are many choices in hip prostheses, and the best ones are
made of titanium rather than stainless steel. Titanium is durable, lighter, and its flexibility is more like that
of real bone. (A metal apparatus that is rigid and cannot deflect will work its way loose or break the bone.)
Ceramic and plastic prostheses are also available.
Great controversy currently rages regarding the use of cemented hip prostheses versus press-fit
prostheses. The press-fit prosthesis fits very snugly into the bone, within 1/1000 of an inch, and requires no
cement. With the use of a porous-coated press-fit prosthesis with fine pores—on the order of 100 to 400
microns—the patient’s own bone grows into the pores, resulting in true biologic bonding that is not
dependent upon cement. This is currently favored, and I believe it is a better process since a biologic bond
does not have the inclination of cement to crack and ultimately fail.
Most prostheses are placed within the cavity of a bone, and the orthopedist must make the patient’s
bone fit the prosthesis. However, computerized bone cavity and thigh measurements using CT imaging
now enables custom-fit prostheses to be designed to fit the prosthesis to the bone—a prosthesis with a
custom fit that will last many years longer than earlier types of prostheses.
Other Orthopedic Diseases
Hemophilia. Why would a hemophiliac be under the care of an orthopedic surgeon? Blood contains
enzymes that break down cartilage and impair the generation of lubricating material by the synovium. By
the age of 5, a hemophiliac child will have experienced thousands of bleeds into the joints, leading to
destruction of the joints by the late teen years or early adulthood. The high-motion and weightbearing
joints are the first to degenerate, beginning with the knees and usually followed by elbows, ankles, and
hips. As the joints become deformed and contracted, the patient is left with only partial movement and
characteristic body posture—walking on the toes with knees, elbows, and hips bent.
Osteogenesis imperfecta. More rare than hemophilia, osteogenesis imperfecta is a genetically
transmitted disease of collagenous tissue that leads to fractures and disfigurement early in life. Patients
with osteogenesis imperfecta are said to have “blue eyes and brittle bones.” Collagen tissue in the eye is so
deficient that light is able to penetrate the sclerae, revealing underlying blue veins, and thus the whites of
the eyes appear blue. These patients have so many fractures that their bones often curve and shorten by the
time they are young adults.
Treatment for osteogenesis imperfecta requires intramedullary rodding with multiple osteotomies—in
lay terms, a shish kebab operation. The curved bone is re-broken in multiple places, a rod is inserted down
the middle, and the bones are allowed to heal in a straightened position.
Ollier’s disease. Ollier’s disease is a rare hereditary disorder in which there is defective conversion of
cartilage within bones during childhood. Bones become weakened and are subject to frequent fracturing,
and there may be visible lumps of cartilage that interfere with joint fusion. A child with this condition may
have dozens of these lumpy tumors, and, unfortunately, surgical removal is not a practical consideration.
Orthopedics, The SUM Program Advanced Medical Transcription Unit, 2nd ed.
Health Professions Institute
www.hpisum.com
Orthopedic Specialties and Related Disciplines
Sports medicine. Sports medicine is simply good medicine applied to people who play sports. That it
has become a subspecialty is inappropriate, I believe, since there are no new or different treatments offered
to the sports individual that are not offered to any other orthopedic patient. When I was the team physician
for the Baltimore Bullets, a professional basketball team, I used the same medical treatment for the
professional athletes as I did for my nonathlete patients. The basic difference lay not in the treatment but
rather in the patient. The athlete is usually in better overall physical condition, is more motivated in getting
through treatment, and in setting posttreatment goals.
Podiatry. Podiatrists are trained in the mechanics of performing operative procedures on the foot, but
they do not have any formal surgical training. I believe that podiatrists have a valid role as paramedical
people with medical training in foot anatomy, and that they offer services that other medical disciplines do
not provide adequately or optimally. For instance, when an older patient with diabetes develops corns or
calluses that need treatment, the podiatrist is an appropriate caregiver. However, I do not believe that
podiatrists are fully capable of surgically treating diseases involving the foot. Surgery requires detailed
technique based on an extensive background of medical knowledge, and no part of the body should be
approached on a purely mechanical basis. I believe that the role of the podiatrist should be essentially
nonsurgical.
Neurosurgery. In nonmetropolitan areas, spinal surgery frequently falls under the care of the
orthopedist. Conversely, in larger hospitals and medical centers, neurosurgeons characteristically do all
spinal surgery except for fusions and fracture repairs. I personally do fracture repairs with rods and grafts,
and do spinal fusions on those patients who have deteriorating disk disease. I leave the actual treatment of
nerves and nerve roots to the neurosurgeons.
Pediatric orthopedics. Orthopedic surgeons who are interested in pediatric orthopedics take an extra
year or two of specialized training. I believe that pediatric orthopedics is a valid subspecialty and warrants
extra training. After all, doing major reconstructive surgery on a foot that is only 2 inches in length is a
great deal different than operating on a foot that is 10 inches long.
Orthopedics is an exciting medical and surgical specialty in an era of evolution. It is a discipline which
offers much more today than it did 20 years ago, and 20 years from now will offer much more than it can
today. For me, that is exciting to contemplate.
Orthopedics, The SUM Program Advanced Medical Transcription Unit, 2nd ed.
Health Professions Institute
www.hpisum.com