The Greatly-Extended Role Played by the Bone Specialists of Today
Not all doctors aspire to become bone specialists, but for those who may be less interested in a more generalised role, the opportunities for specialisation have never been more numerous. In fact, the past couple of decades have seen the emergence of a number of brand new medical disciplines as the direct result of newly-acquired knowledge relating to human physiology and the disease process, together with some remarkable advances in the technology that is now available to doctors and surgeons.
In the wake of the expanding boundaries of transplant surgery and the development of advanced medical imaging techniques, such as computer-aided tomography and magnetic resonance imaging, the role of bone specialists is one that has undergone considerable change. Much of that change is of comparatively recent origin, but it has seen this specialism achieve parity with those that have been established far longer.
Archaeologists have confirmed that, long before the term orthopaedics was coined during the mid-eighteenth-century, when presented with fractured limbs, the physicians of Ancient Egyptian times fashioned splints from bamboo, reeds, or bark, and padded them with linen to create a comfortable yet tight fit to ensure that the surfaces of the fractured bones would remain in contact and immobile in order to facilitate the healing process and to avoid the risk of deformities. A few centuries later, the work of a Greek surgeon tasked with treating Rome’s gladiators did much to develop a better understanding of the musculoskeletal system while, during that same era, there is evidence of the earliest attempts to create artificial limbs including wooden legs and iron hands. Although not exactly bone specialists, these early pioneers provided the foundations for the reduction of fractures and dislocations, and the design of prostheses upon which others would eventually build.
In addition to their work on fractures and amputations, those early Greek physicians also developed the use of bandages and other forms of binding as a means with which to correct spinal deformities in children – a practice that was later adopted in Europe. In fact, it was this practice that, in 1741, prompted one Nicholas Andry to coin the term orthopaedics, a combination of the Greek words “orthos” and “paidion” meaning straight or correct and child, respectively. Even with the establishment of the world’s first orthopaedic institute, around forty years later, the primary focus of its resident bone specialists remained the treatment of skeletal deformities in children and it was only in 1851 that the first plaster of Paris cast was created.
In the absence of any formal qualification requirements, many laypeople in need of an income set themselves up as so-called bonesetters. The practice began in early Roman times and continued until well into the eighteenth century. They treated fractures and dislocations in their own homes, in local taverns, and in coffee shops, and because they charged less than a licenced physician, some even became lucrative family businesses handed down through the generations.
The change that was destined to establish the future of the medically-qualified bone specialist, however, came with the transition from the non-operative treatments to the use of surgery and began with the introduction, by Joseph Lister, of open reduction and internal fixation (ORIF) for the treatment of patellar fractures. The first use of metal plates, wires, and screws followed soon after and, despite some initial problems arising from infections, poor techniques, and allergies of the metals used, the practice has since been perfected, as has the use of intramedullary nails and rods for the fixation of femoral and other long-bone fractures, aided by the discovery and diagnostic application of X-rays. Today, these techniques are being employed on a daily basis and with great success by orthopaedic surgeons worldwide.
With the establishment of orthopaedics as a specialist discipline, the role of bone specialists began to expand rapidly and the next major breakthrough came with the pioneering work of Sir John Charnley in the 1960s. He designed the first artificial hip joint, consisting of a femoral stem made from stainless steel, which articulated with an acetabular cup made from polythene, both secured to the bone with acrylic cement. For the next 20 years, his prosthesis was adopted worldwide and subsequent modifications to its design, coupled with improved surgical techniques, have served to make arthroplasty one of the most successful surgical interventions ever developed.
Today, elective joint replacements, often using minimally-invasive techniques, account for as much of a bone specialist’s time as the treatment of trauma cases.