Orthopaedics like all other branches of medicine is likely make tremendous scientific progress in the new millennium. The extent of this progress will depend on how we have done in last 1000 years. I feel it is important in a discussion of this nature to separate orthopaedic surgery from orthopaedic surgeons. Progress in orthopaedic surgery need not necessarily mean progress of the orthopaedic surgeon or for that matter the medical profession. As an orthopaedic surgeon we have to deal with many issues such as taking care of all the patients who come our way; balancing our responsibilities to our patients and our families; fighting with the administration in the interest of good patient care and for our own economic well-being; and trying to keep up with advances in orthopaedics in order to stay, both competent as well as competitive. Unlike my generation you must deal with a host of health-care delivery systems, need to have a business acumen that rivals that of a corporate CEO and increasingly you require knowledge of coding that should qualify you as medical-records librarian. Before long you may become convinced unfortunately that medicine is really a business and not a profession. The essence of professionalism in medicine is the willingness of the physician to value the patient’s welfare above his or her own and to provide care when necessary without remuneration or at personal inconvenience. It is unselfish attention to the welfare of others and advancement of our patient interests that earns the public’s respect and trust. These in turn have caused the public to support the autonomy of medical practice, including the privilege of self-regulation. However, this trust has begun to erode. Financial return and economic security are important to all of us. But if and when the commercial ethic in medicine becomes so predominant that it is perceived by the society as greed replacing altruism, we will certainly face loss of autonomy and the ability to self-regulate. I believe that we are nearing that point when society will view medicine as a trade rather than as a profession and we will be treated accordingly. Looking to the roots of western medicine, Hippocrates (466 to 370 BC) is recognized as the father of modern medicine. However the earliest mention seems to be in the Indian literature, the Rig Veda, the oldest book of Veda period (1500–99 BC) when the use of artificial leg as well as artificial eyes and teeth were recorded. Before the 20th Century, the practice of medicine employed little science and was mostly an art. Yet despite this its practitioners were held in the highest esteem. 100 years ago, a physician had few tools with which to work except those of compassion and caring. However, during this century a technological explosion has led to spectacular advances in medicine and as a consequence physicians are infinitely better equipped to bring good health-care to their patients. Our orthopaedic roots date back to 1743 when Nicholas Andre unveiled his splinted crooked tree. However, it was not until the use of plaster of Paris 100 years later that we moved out of the splint age. Modern fracture management rapidly accelerated during and after World War I with Sir Robert Jones espousing the principles of Hugh Owen Thomas. This was followed by the impact of World War II and subsequent war has led great advance in the management of musculoskeletal trauma. Operative practice however came into its own with the introduction of modern anesthesia by William Morton a dentist in 1846, sterility by courtesy of Joseph Lister in 1876 and antibiotics from Alexander Fleming in 1945. These advances made the outcome of surgery more predictable and the practice of orthopaedics, in particular expanded exponentially as operative risks decreased substantially. New methodologies involving joint replacement, arthroscopy, spinal instrumentation and reconstruction following trauma were all developed in the latter part of this century. Last 30 years has sen the rapid changes in technology and it may be a good time to pause and think where all are going and take an account of our games and losses.
Most important thing is “orthopaedic education” both at undergraduate and postgraduate level and continuing education. We must re emphasize that orthopaedic surgery means total care of the musculoskeletal system both conservative and operative. Most of us are interested in operative care because it is lucrative, and as Graham Apley use to say “Surgery in Fun” but 80% of our patients need conservative treatment. Scientific basis of our conservative treatment is appealing and is no better than the alternatives medicine providers. No wonders so many of our patients are now moving to “sinseh” and other providers, with dubious repetition. Emphasizes in our residency is operative treatment and the residents enjoy it. Our continuation education if you may call it “Education” is sponsored one-way or other by multinational is mainly technology oriented to promote a particular product. This is not difficult to understand. These multinational are listed companies and it is not surprising that their motive is to make profit for their shareholders. Unfortunately I feel we are being caught and deviated from our goal of education and professionalism. Type of education we are getting and type of education we need is quite different. What we need is an orthopaedic specialist with compassion but what we are becoming is a high-grade technician. More emphasizes must be placed both at undergraduate and postgraduate level to have a better understanding of the biology of healing of the musculoskeletal system. We must emphasize on the conservative treatment and put it on a more scientific basis. We can no longer dismiss the alternatives as being substandard or even dangerous. We must therefore offer appropriate non-operative alternatives to our patients. If we do not adjust to this reality, we will be relegated to secondary status and will be called up only when operative intervention is a last resort. We are not just surgeons but we are physicians also lastly we may have gained in technology but may have lost in compassion. Medicine is both a science and art and even balance is necessary to provide good medical care. I am sure we will progress in the science of medicines but I hope we will not lose the art of medical practice. For future we must keep abreast with the new technological advances but should not forget the patient care is more than a technical achievement. As Ambre Pare said “we the physician treat the patient He cures them”.
In a prospective study of 14 patients undergoing total hip replacement we have used dual-energy X-ray absorptiometry (DEXA) to investigate remodelling of the bone around two different designs of cementless femoral prosthesis. The bone mineral density (BMD) was measured at 12-weekly intervals for a year. Eight patients (group A) had a stiff, collarless implant and six (group B) a flexible isoelastic implant. Patients in group A showed a decrease in BMD from 14 weeks after operation. By 12 months, the mean loss in BMD was 27%, both medially and laterally to the proximal part of the implant. Those in group B showed an overall increase in BMD which reached a mean of 12.6% on the lateral side of the distal portion of the implant. Our results support the current concepts of the effects of stem stiffness and flexibility on periprosthetic remodelling.
Six normal cadaver lower limbs were mounted on a specially designed loading apparatus. Wires were used to simulate the five muscle bellies of the quadriceps, the ratio of their tensions having been determined from that of the anatomical cross-sectional areas of the muscles. A three-camera system was used to track the patella during knee movements from flexion to extension. The patellofemoral contact area was determined by pressure-sensitive film. The limb was loaded with and without tension on the wire which simulated the oblique part of the vastus medialis (VMO). Absence of VMO tension caused the patella to displace laterally (4.2 mm) and increased the load on the lateral patellar facet throughout the range of knee motion. When the tension on the wire simulating vastus lateralis was reduced by 40% to simulate the effect of a lateral release procedure, the abnormal kinematics caused by the absent VMO returned to normal.
Four different experiments were performed to study the healing of a large, non-vascularised, diaphyseal, bone segment in adult cats. In the first experiment, a 4 cm segment of tibia with its periosteum was excised and replaced in its bed. The other experiments were similar, except that in the second, the periosteum of the segment was removed, in the third its medullary canal was blocked with a Silastic rod, and in the last group the segment was isolated from its muscle bed by a Silastic sheet. The reparative processes were quantified by estimating the resorption index, the cortical new bone formation index, the callus encasement index, and the osteocyte count. Bone resorption and apposition occurred in the segment even when the periosteum was absent or the medullary canal was blocked, with osseous union at both ends by eight to 12 weeks, provided the segment was not isolated from its muscle bed. Thus, the muscle bed played a significant role in these reparative processes.
The joint surfaces of 60 hips obtained from the cadavers of elderly Asians were studied to determine the incidence, the grade and the distribution of both non-progressive (age-related) and progressive degenerative changes. It was observed that in the Asian population of 40 to 90 years of age, non-progressive changes were common, being seen in 66% of the acetabular specimens and 50% of the femoral heads. Only one specimen of the 60 showed unexplained progressive degenerative change. We conclude that primary osteoarthritis of the hip is rare in Asians.
Experience with thirty-eight Asian children and adolescents who presented with either stiffness of the knee, genu recurvatum, habitual dislocation of the patella or congenital lateral dislocation of the patella showed that all those disorders were manifestations of contracture of the extensor mechanism, which fell into two groups according to the components involved. In Group I the main components affected were in the midline of the limb, namely rectus femoris and vastus intermedius; these patients presented with varying degrees of stiffness of the knee, or worse, with genu recurvatum. In Group II the main components involved were lateral to the midline of the limb, namely vastus lateralis and the ilio-tibial band; these patients presented with habitual dislocation of the patella, or worse, congenital lateral dislocation of the patella. In both groups untreated patients developed secondary adaptive changes such as subluxation of the tibia or marked genu valgum which made operative procedures more formidable and less effective. Release of the contracture should therefore be performed as early as possible.
