The Continuing Evolution of Bone Surgery

Feb 28, 2021 | Articles

It is all too easy to overlook the fact that bones are just one component of a much more complex assembly known as the musculoskeletal system. That system also contains muscles, tendons, ligaments, and other soft tissues that together or individually perform a surprising range of essential body functions. Consequently, bone surgery can be necessary not only to relieve pain and restore movement but also to maintain the integrity of other vital activities. These include storing some of the body’s essential minerals, producing white blood cells and regulating certain endocrine functions.

While the ribs serve as a means to protect vulnerable internal organs and the spinal vertebrae provide us with flexibility, it is our arms and legs that we tend to value most, for the mobility and agility they provide. In ancient times, long before the modern bone surgery with which we are all familiar, a fractured leg often necessitated amputation to avoid the risk of death due to associated complications. Even during the more enlightened ancient Egyptian and Roman eras, the only successful treatment for fractures was immobilisation and rest. Immobilisation efforts involved using wooden splints or bandages, stiffened with mud or animal blood, to act as a cast. And so, it remained for many centuries.

The next significant advance was probably the invention of the plaster of Paris cast by a Dutch army surgeon in 1851. The first bone surgery was still to come. Aside from treating fractures and dislocated joints, the orthopaedic doctors of the time continued to focus on non-invasive methods to correct skeletal deformities in children, with varying degrees of success. Interestingly, the name of the discipline derives from a pair of Greek words – “orthos” and “paedion”, which translate respectively as “straight” or “correct” and “child”.

While it did not involve bone, the first orthopaedic surgery was a procedure known as percutaneous tenotomy. Performed in the late 1800s, its purpose was to cut a tendon to supplement the effect of bracing and exercise when treating deformities. This minimally-invasive option is still used today as a means to alleviate chronic tendon pain in various joints, including the shoulder, elbow, and ankle.

The event that would initiate the first genuine bone surgery occurred only in 1939 when a German surgeon named Gerhard Küntscher invented an internal fixation device known, appropriately as the Küntscher nail. The nail’s rigid, cloverleaf-shaped cross-section enabled surgeons to secure the individual fragments of a severely fractured bone internally and thus maintain its overall structure during the healing process. Sadly, the German military withheld worldwide access to this groundbreaking technology until its defeat and the end of World War II.

The other big breakthrough in the field of bone surgery was also the brainchild of Gerhard Küntscher and is known as an intramedullary rod. The rod could be inserted into the medullary cavity of long bones such as the femur and secured in place with Küntscher nails. The technique provided healing in far less time than the traditional methods of plaster and traction. The procedure was welcomed by the German high command because it allowed injured German soldiers to return to active duty much sooner than usual. Today, similar nails and rods are still used to repair complex fractures.

Modern bone surgery not only benefits from the development of new biocompatible materials such as titanium, plastics and ceramics, but also from new technologies. Widely touted in orthopaedic circles as the most successful surgical interventions in the history of medicine, partial and total hip and knee replacements (arthroplasty) are now performed routinely. The earliest attempt to replace a diseased hip joint with a prosthesis date back to 1891. However, while the operative technique was successful, the outcome was less so. The prosthetic joint in question was made of ivory and was insufficiently strong to provide lasting service.

Thankfully, materials science has long since solved any problems due to poor durability and biocompatibility. Today arthroplasty represents the pinnacle of achievement in the field of bone surgery, and new, improved materials have led to vast improvements in the longevity of prosthetic joints. Nails, rods and prostheses, however, may not be the ultimate solutions. Advances in the field of tissue culture together with several other emerging new technologies seem to suggest that there will be even more exciting times ahead for orthopaedic patients and their surgeons.