Orthopedic Surgery: A Rationalization story BY: JOSEPH ayinde

Robert Jones: Father of Orthopedic Surgery

Robert Jones, the father of Orthopedic Surgery revolutionized Orthopedic practices during World War , and helped create the specialty of Orthopedic Surgery we have today. Robert Jones attended Liverpool University, where he studied medicine. He later completed his fellowship at "the Royal College of Surgeons of Edinburgh." Robert Jones was assigned as captain to the 1st Western General Hospital in 1914. Jones was immediately raised to the rank of major, with the new job of inspecting the "Western command's" hospitals. After completing hospital inspections in 1914, Jones discovered massive inadequacies in hospitals across the Western Front, motivating him to write a "damning report."(Scotland 165). Sir Alfred Keogh, Director General of Army Services, received this report. Sir Alfred Keogh invited Robert Jones to build an experimental orthopedic unit in Alder Hey, Liverpool, in 1915. The Alder Hey Unit was the first to separate patients with orthopaedic wounds for treatment. The Alder Hey unit began with 250 beds and quickly expanded to 560. Jones was able to open the first Orthopaedic centre in London in March 1916, because of the great success of the Alder Hey unit. Unlike other treatment-only facilities, this one focused on both therapy and rehabilitation a drive to create more efficient outcomes for patients and inevitably physicians as thing reduced the chance for re-injury(Scotland). This center treated orthopedic disorders such as non-union, mal-union, and peripheral nerve damage surgically. The center used therapy in the form of "curative workshops" for recovery. Patients were assigned an occupation to study in these seminars. This both aided in the restoration of physical function and enhanced morale. Soon after Jones' unit debuted, 17 orthopaedic centers opened across the UK. Thirty-four percent of individuals admitted to orthopaedic centers returned to some type of military service a striking more efficient outcome than seen before(Green and DeLee). However, there was pushback to these centers since London-based doctors believed that significant surgical innovation could only take place in London, ultimately there was resistance to the new profession being created as these London surgeons were primarily general surgeons.

Jones was appointed director of Military Orthopaedics by Sir Alfred Keogh in 1916 as a result of his outstanding success in this orthopedic center(Green and DeLee). Keogh was apprehensive because he knew it would be met with hostility from the London Surgeons. Nonetheless, this decision was made under intense pressure from Moynihan, who threatened to leave unless Robert Jones was appointed director of military orthopaedics. Even after his appointment, Jones faced opposition from London surgeons who saw themselves as the core of the surgical establishment, but Moynihan was powerful enough to hold Jones in his position. Jones' primary responsibility as Director of Military Orthopaedics was to deal with formally mishandled orthopaedic wounds(Scotland). When confronted with a large number of these mishandled wounds, his uncle's inventive mentality came in handy. Jones chose to think efficiently. Instead of cotinung to treat wounds that were a result of inefficiency, he was going to create a more predictable form of treatment. Jones was successful in introducing "the Thomas splint."

The Thomas splint was a type of treatment/management for complex femur fractures, which were one of the most common injuries on the Western Front. Prior to its development, the Western Front relied on the "Rifle Splint" developed by the Royal Army Medical Corps comprised of London surgeons(Scotland). This splint did not effectively immobilize fractures. As a result, the injured experienced severe blood loss, preventing them from having potentially life-saving and limb-saving procedures a clear result of the lack of efficiency. This is why Henry Gray, the chief musculoskeletal surgeon on the Western Front, encouraged Jones' to use the Thomas splint, as the Western Front faced a seventy to eighty percent death rate in compound femur fracture procedures(Green and DeLee). Unlike the Rifle splint, the Thomas splint was linked to the groin and ankle with lines knotted under stress around the bottom of the spleen to provide traction. This assisted patients in overcoming thigh muscle spasms and maintaining proper fracture alignment. This reduced movement among bone segments at the fracture site, along with blood loss(Scotland). This led to the majority of patients reaching Casualty clearing stations haemo-dynamically stable and able to undergo major surgery a clearly more efficient outcome than seen before.

American Orthopedic Surgery During WW1

Almost immediately after the United States declared war in April, the British medical service requested that orthopaedic surgeons be deployed to work since Jones was experiencing staffing issues in Britain's orthopaedic centers, which had a total of 20,000 beds(Scotland). Junior medical officers from orthopaedic hospitals were routinely deployed to the Western Front, due to lack of staff. When the United States entered the war in April 1917, American orthopaedic surgeons stepped in to help. Before the war, American surgeons had visited Jones' clinics and operating sessions in Liverpool on a regular basis and appreciated his work, prompting their efficient preparation. Initially, 20 orthopedic physicians led by Joel Goldthwaite arrived in the UK, paid for by the US military and placed at Jones' disposal(Green and DeLee). The unit was known as the First Goldthwaite Unit. At the time, there were already 600,000 men in the United Kingdom who had been handicapped by war injuries, with 65 percent of them having orthopaedic issues and few competent orthopaedic surgeons to treat them These American physicians were not sent to frontline hospitals along France's front lines. Their principal objectives were to develop ways for preventing deformity and restoring function a drive to create more predictability and efficiency in terms of treatments(Scotland).

By July, the surgeons had been sent to military hospitals in a dozen British towns, which had approximately 5,000 beds for orthopaedic care and rehabilitation, all under Sir Robert Jones' direction. In May and June 1917, editorials in The American Journal of Orthopaedic Surgery urged for additional volunteers, and David Silver reiterated this request in his July 1917 AOA Presidential Address(Green and DeLee). Recognizing that the bulk of volunteers would be general surgeons, the Surgeon General developed a 6-week crash course on orthopaedic surgery principles to be taught at several colleges. This was done through the newly formed Department of Military Orthopaedic Surgery, which was directed by Major Elliot G. Brackett of Boston. Predictability and efficiency clearly the goal here as specialization led to physicians facing less surprises through experience, allowing them to implement their formerly successful efficient techniques and methods to treat the patient effectively(Scotland).

On October 9, 11 captains and 32 first lieutenants set ship for Europe as the Second Goldthwaite Unit17, accompanied by 12 specially trained nurses. The majority of these individuals had little to no orthopedic expertise, but they were eager to learn from more senior doctors(Scotland). From this second unit, 11 men were posted as battlefield surgeons to the existing base hospitals in France; the others were scattered among British hospitals to learn from senior surgeons and assist with reconstructive surgery and rehabilitation. A few orthopaedic doctors had been dispatched to the battlefield hospitals in France, but their advent caused considerable animosity and friction at first. The introduction of orthopaedic surgeons was not welcomed by the general surgeons, and they had little regard for these newcomers, showing clear resistance to the changing direction towards specialty in the surgical profession(Green and DeLee). In fact, general surgeons continued to perform surgical procedures, but because they had little, if any, knowledge of orthopaedic principles, the early orthopaedic arrivals served on Splint Teams, which consisted of a young orthopaedic surgeon and two enlisted men who applied dressings and splints after the general surgeons had performed the operative procedures. This quantification allowed for distributed allocation of the workforce. The combination of gruesome trench warfare, antiquated military tactics, and modern killing equipment including large artillery pieces, mortars, and machine guns that resulted in an unfathomable number of casualties. Individually, the few American orthopaedists had limited influence, but as instructors and planners, were crucial. As in these positions they could create and teach more optimal methods more treatment, while also planning more effectively leading to increased predictability. Another aim of surgeons in the Second Goldthwaite Unit was to learn as much as they could from their British colleagues in order to transfer this information on when the AEF got fully engaged in battle(Scotland). To accommodate the massive number of victims, regular treatment methods were devised. The injured troops were transported from the battlefield to a first aid station, where they were treated for shock and readied for transport to a forward base hospital by enlisted personnel skilled in dressings and splints. The original operation was conducted in these hospitals(Scotland).

As soon as patients were stable enough to be relocated, they were brought to hospital sections in the back by special hospital trains outfitted with operating rooms and surgeons. Each train could accommodate 500 stretchers as well as many other soldiers with upper extremity wounds who did not require supine treatment(Green and DeLee). The improved technology of the train allowed for control of the transportation system. Now patients could be transported more effectively. During the Meuse-Argonne Offensive, 26 of these trains were constantly in use, and it is estimated that hospital trains alone transported over 300,000 patients. Closer to the shore were base port hospitals, where orthopaedic doctors decided which patients should be shipped back to the United States(Scotland). The armistice that halted the combat on November 11, 1918, did not mean that the work of American orthopaedic surgeons came to an end. Thousands of injured troops remained in hospitals in France and England, requiring more care and transportation back to the United States due to the initial lack of efficiency of the care-giving system. By mid-1919, all of the American surgeons had been demobilized and returned home(Green and DeLee).

Emergence Of Professional Organizations

The American Orthopaedic Association (AOA) was created in 1887 as the first formally structured organization representing orthopaedic surgery. This group met on a yearly basis to exchange ideas and develop orthopaedic surgery knowledge and science. The AOA founded two committees in 1931 that would eventually change the entire framework of the American orthopedic society. The first committee was tasked with creating a permanent organization that would be more broadly based than the AOA and would not have membership limits such as the AOA. This was the birth of the American Academy of Orthopaedic Surgeons (AAOS), which was established in 1933. A strive to create more predictability through education. The second committee was constituted to look into the formation of an orthopaedic specialist board. In January 1933, the AOA advocated the formation of an orthopaedic certification board comprised of representatives from the AOA, the AAOS, and the American Medical Association's Section of Orthopaedic Surgery (AMA). The American Board of Orthopaedic Surgery's Articles of Incorporation were drafted in February 1934, outlining the organization's goals (ABOS). Soon after, the ABOS established an Examinations Committee, an Eligibility Committee, and a Residency Training Committee to evaluate hospitals and medical schools that were training new surgeons to become orthopaedic surgeons. This was a drive towards exerting control over the new up and coming profession. Credentialization would allowed for physicians to have credibility based on their ability to treat efficiently and effectively, producing predictable outcome.

General Norman Thomas Kirk of the United States Army was the first military doctor to be certified by the American Board of Orthopedic Surgery and a member of the American Academy of Orthopedic Surgeons. He authored thirty scientific papers. As surgeon general, he reformed the United States Army Surgeon General's Office to deal with the tremendous task of World War II. By the conclusion of the war, the medical department had grown to include 47,000 doctors. At the time of the attack on Pearl Harbor, the department had a staff of 1200. During World War II, his leadership promoted the earliest feasible adoption of sound clinical practices for the care of injured soldiers. Again, a drive towards quickness as it was merely quality. The tragedy of war aided the birth of the orthopedic specialty by supplying material, manpower, and, sadly, casualties who needed care. For Orthopedic Surgery, war represents a virtual pandemic. Medicine made improvements in areas such as more optimal organization and training for mass casualty care, as well as more predictable treatment of orthopedic infections and the novel intramedullary fixation method. Many of the twentieth century's most fascinating advancements had their genesis in World War II, demonstrating the educational benefit of war.

External fixation was invented in the 1930s as a means of stabilizing fractures. American victims treated with this approach in a steady atmosphere had positive outcomes throughout the conflict. When compared to alternative treatments for long-bone fractures, the first use of external fixation resulted in a high prevalence of infection a clear sign of inefficiency. The issues were most likely caused by the fact that the external fixation technique was relatively difficult, and few active-duty surgeons were familiar with it, leading to a lack of predictability. As a result, external fixing was discontinued in the United States army for the duration of the war. Gerhard Kuntsner, a German surgeon, created a fracture treatment procedure. During the 1940s, he invented a method for intramedullary nailing of long-bone fractures, which he used throughout the war. While imprisoned, captured Allied pilots witnessed this method while receiving intramedullary nailing for femoral fractures. The treatment of intramedullary nailing was divisive at the time. Because of this controversy, the Office of Scientific Research and Development provided a grant to the National Research Council in 1997 to support clinical research on the intramedullary nail as a treatment for fractures. Investment in research showed to urge to create more control in the treatment system through this new intramedullary technology.

During WW2, around 18,000 men of the United States army lost limbs. The majority of these casualties occurred when the allies arrived in Normandy, France, in June 1994. Based on his experiences in WWI, Colonel Norman Kirk MD (who subsequently became the army's surgeon general) advocated for the early development of amputee clinics to offer consistent and predictable care for the enormous number of amputations that were predicted. Amputee facilities were initially housed in five United States Army general hospitals. This was done in order to pool the resources of doctors, therapists, nurses, and prosthetists. These facilities were in charge of revision surgery, prosthetic fitting, and physical rehabilitation. Two additional centers had to be created within a year since the original five were unable to handle the workload. Concerns were raised, both real and imagined, owing to a lack of skilled workers at these amputee institutions which led to fears rooted in unpredictability and lack of control of the system.

Due to the obvious enormous number of young military members who were amputated in a short period of time, there was a need for improved more efficient prosthetic devices. The national research council committee on prosthetic limbs was funded by the office of scientific research and development. This was an attempt to enhance both the upper and lower limb prostheses that were available at the time. The committee's first aim was to create an acceptable temporary prosthesis that could be mass-produced. A focus on calculability, as mass production was equally as important as the quality of the prosthesis itself. This study resulted in the development of the patellar tendon-healing prosthetic, which is still in use today. Normal walking was the objective of the lower-extremity prosthesis fitting. This effort resulted in a comprehensive knowledge of human movement and the creation of innovative materials for prosthetic application.

Prior to World War II, infected wounds were treated with Henry Gray's delayed primary closure technique. This procedure involves utilizing a wound culture to detect if the wound was ready for closure. Churchill reported a 5% failure rate among 25,000 soft tissue lesions evaluated only on clinical appearance for closure. Another study of this approach found promising outcomes in over 20,000 individuals with open fractures who had delayed primary closure. Lack of drainage, skin redness, foreign material, and the presence of healthy-looking tissue were utilized to decide if closure was suitable based on the clinical appearance of the wound. This method is being used today and was one of the great advances in wound treatment that occurred during WWII. Evaluation upon clinical appearance proved to be a much more effective for of diagnosis with more predictability.

Lower extremities wound mortality rates fell from 7.7 percent in World War I to 2.1 percent in World War II, and upper extremity wound mortality rates fell from 4.1 percent to 1.1 percent. This drop was mostly due to a lower rate of infection. In an early effort to avoid infection of combat wounds, American soldiers were given packets of sulfa powder to sprinkle on them(Doughtery). During the 1930s, sulfa antibiotics were developed as a therapy for infection in both tablet and topical powder form. North African surgeons discovered that this dusting approach could not prevent infection of open wounds and did not serve as a substitute for proper early surgical treatment. Showing their inefficient as surgery would still be needed in the end.

During World War II, penicillin proved a vital contribution in averting the huge infections that afflicted injured military men. Despite the fact that penicillin was discovered in 1929, it took ten years to refine the active component. This made scale manufacture of penicillin problematic, causing widespread usage to be delayed until midway through World War II. This was a clear sign of emphasis put on calculability as the focus was on mass production rather than the quality of the penicillin(Doughtery). In a prospective research, 3407 British soldiers were injured in Normandy in June and July 1944. Penicillin was given to 436 injured troops who were thought to be at higher risk of clostridial infection, while the remaining patients got standard care. Gas-Gangrene developed in none of the penicillin-treated individuals, but in five of the untreated patients. This experiment quantified the efficiency of penicillin as a form of treatment

In 1945, around one-third of the fellows of the American Academy of Orthopedic Surgeons were in active service. These doctors provided medical care in all main foreign theaters of operations as well as in the United States. Their Army obligations honed their leadership abilities early in their careers. Many orthopedic surgeons came from academic backgrounds, and their participation in the military aided in the establishment of protocols to deal with war losses. Protocols were crucial to creating a more controlled system(Doughtery). From 1947 through 1962, 60 percent of the presidents of the American Academy of Orthopedic Surgeons were World War II veterans. This group of combat veterans affected the leadership of American orthopaedic medicine after the war.

Arthroplasty

Total hip replacement, known as Total Hip Arthroplasty, relieves discomfort and improves mobility in a damaged joint, resulting in a significant improvement in quality of life. Sir John Charley's mastery of basic sciences and respect for biomechanics prompted him to doubt the validity of assumptions formed by successful attempts to replace the hip joint with an implant that addressed the damaged acetabulum and femoral head. The McKee-Farrar total hip replacement, which used metal components, had become the most common(Kolundzic). Charnley investigated this prosthesis and concluded that metal-on-metal would cause wear issues. He underlined the advantages of plastic materials, noting the increased efficiency of plastic as compared to metal.

Charnley's procedure included both femoral and acetabular components. The acetabular component was constructed of high-density polyethylene, whereas the femoral component was comprised of a cobalt-chrome alloy. Both components were kept together by acrylic cement, also known as bone cement, which Charnley, his contemporaries, and even future generations thought was a safe and effective stabilizer. As stabilizer that provided more predictability overall. Charnley was well aware that a deep infection following total hip arthroplasty was a big disaster from which a successful recovery was exceedingly difficult(Kolundzic). The use of preventive antibiotics before, during, and after surgery did not prevent the problem. Charnley believed that minimizing contact between pathogenic organisms carried by the surgical team and those present in the operating room air was the most efficient way to prevent infection. He agreed to work on such a project until he was able to build a plastic room that would separate the surgeon and his direct assistance from the rest of the staff. The team would be dressed in specially constructed clothing, and the room's breathing air would not circulate. All tactics geared towards limiting physical interaction with patients geared towards increased control.

The reduction in the number of infections was remarkable, and it served as a model for surgeons all around the world. Its popularity waned over time as a result of encouraging outcomes from simple rigorous adherence to customary safeguards and low traffic in the operating suite. Many people, however, continued to follow Charnley's program and reported better outcomes.

Total hip arthroplasty, which was nearly unknown until a half-century ago, quickly became a standard operation used by many orthopedic surgeons who just loved their patients being impressed by the quick immediate results, which prompted physicians to focus on speed of care just as much as quality of care. It was precisely the rapid success of hip joint endoprosthesis implantation that, in some ways, obscured some hazards involved with the treatment, particularly problems that resulted in a limited artificial joint survival (Kolundzic). THA is a major orthopedic treatment that, like any other surgical procedure, has the risk of complications, one of which is the development of aseptic instability of the implant. The chance of developing this consequence is connected to the extent of hip damage, bone quality, musculature quality and kind of surgery, comorbidities, and, of course, surgeon experience; nonetheless, no surgeon's work is fully free of difficulties. The identification of these parameters helped to provide increased predictability of procedures by minimizing surprises in the form of infections.

Traditionally, research into risk factors for THA aseptic instability has focused on demographic variables (age, gender), biomechanical variables (body mass index), the reason for prothesis implantation), and material properties (cemented, non-cemented, resurfacing) and surgeon skill. Keeping everything in mind, all of these parameters explain just a small portion of the variability in the occurrence of infections during THA, implying that the essential determinants determining whether it will develop in a certain patient are still largely unknown. It is widely held that "patient contingent factors," which are neither demographic or biomechanical in nature, largely impact one's specific "predisposition" to infection development. This was crucial to know as this made room for technology to quantify and track disposition. In the early 1980’s, Dr. Jackson, was recognized as the founding father of The International Arthroscopy Association (IAA) and the Arthroscopy Association of North America (AANA). Jackson recognized the potential use of arthroscopy in the diagnosis and treatment of joint issues and was able to implement it at the American Academy of Orthopaedic Surgeons (AAO) through annual teaching seminars (Kolundzic). Jackson was able to popularize arthroscopy by creating learning "labs" to instruct medical professionals interested in procedures and diseases (AANA website). Overall, Dr. Jackson was able to change the procedures utilized in Orthopedic surgery to treat joint disorders.

Arthroscopy

Jackson's International Arthroscopy Association's mission was to stimulate the creation and distribution of information in the domains of orthopedics and medicine via arthroscopy in order to better the diagnosis and treatment of joint problems(Jackson). The initial idea behind the IAA was to create "chapters" in each developed country, each with its own structure and meetings striving to create more widespread calculability and predictability. The top papers from around the globe would be presented at an IAA meeting conducted in conjunction with SICOT every three years. By the third the IAA membership had grown to more than 200. It was becoming clear that this radical new notion known as "endoscopic surgery" or "minimally invasive surgery," which had been developed by the private sector of medicine and had been generally dismissed as "unlikely to succeed" by the academic community, was indeed something substantial(Jackson). A reduction is invasiveness was simply more efficient, showing the power of the drive towards efficiency Arthroscopy was growing more popular, and new arthroscopic surgery methods were being developed at a rapid pace.

The fifth conference, held in Sydney, Australia in 1987, was an experimental "combined gathering" with the International Society of the Knee (ISK). President McGinty was Jack McGinty. As a result, "combined meetings" of the IAA and the ISK were conducted every two years(Jackson). The Worldwide Society of Arthroscopy, Knee Surgery, and Sports Medicine (ISAKOS) was established as the official English-speaking international organization to represent arthroscopy, knee surgery, and sports medicine(Kolundzic).

By 1982, it was clear that a new form of organization was needed in America to address the educational demands of the rapidly growing number of orthopaedic doctors who practiced arthroscopy. There had to be control exerted over this system. This would largely consist of yearly meetings (rather than the triennial meetings conducted in conjunction with SICOT), instructional courses, and potentially even a journal. The North American chapter of the IAA was formally renamed the "Arthroscopy Association of North America," and all current North American "chapter" members became AANA's "founding members". The new organization would have annual meetings and maintain ties to the IAA while developing its own administrative and financial autonomy(Jackson).

Initially, all instruction was done one-on-one between an instructor, a student, and a patient. Initially, this was made possible via "beam-splitting" devices, which allowed the pupil to see what the instructor was looking at. The issue was that the student, while holding the device and staring down it, would frequently shift the arthroscope slightly away from the field of view that the teacher was attempting to demonstrate, frustrating both of them. This style of teaching was substantially aided by the introduction of flexible teaching attachments (first fiberoptic and subsequently multi-jointed prismatic devices). This technology came to control he system as it provided a more optimum method of learning. Techniques and pathology were soon demonstrated using 35-mm slides and videos(Jackson). Models of the knee constructed of plastic and rubber allowed for early rehearsal of instrument movement inside the joint. Cadaver parts eventually became the gold standard for showing and performing surgical operations. Scientific advances in the discipline were duly documented in the peer-reviewed Arthroscopy: The Journal of Arthroscopic and Related Surgery, which first appeared in 1985.Although the time span is fairly small in historical terms, there is no debate about the influence that arthroscopic surgery has had on the whole range of surgical therapy. Accurate diagnosis, decisive operational therapy with minimum further tissue injury (by keyhole incisions), faster rehabilitation durations, less problems, and more economy are indisputable benefits that are increasingly sought after by all areas of surgery. These were all signs of a more controlled, efficient, calculable, and predictable system(Jackson). The outcomes witnessed in high-profile professional athletes when the concepts of sports medicine were applied through arthroscopic surgery were clearly the incentive and catalyst for this huge revolution in surgery.

Transformation of Certification

The American Board of Specialties issued life-time credentials over its first 50 years. This accreditation was bestowed upon orthopedic surgeons who passed their initial certification exams. This test was divided into three major sections. The first was a written test consisting of one essay question with a time constraint of one hour. The second type of test was an oral examination, which consisted of three sessions with four different examiners on four distinct subjects. Each of these sessions lasted ten to fifteen minutes(Jackson). The final component was a clinical examination that tested the applicants' abilities to evaluate a live patient. The ABOS began producing ten-year time-limited certificates in 1986. That is, every ten years, orthopedic surgeons had to pass the assessment examinations in order to receive a new ten-year certificate. This provided more predictability in terms of quality of care as physicians had to remain proficient through the course of their time practicing. The ABOS member boards decided in 2000 to transition their re-certification programs into the maintenance of certification model.

The certification model's upkeep analyzed applicants based on four major areas of criterion. Professional standing, proof of life-long learning, knowledge evaluations, and practiced improvement through case lists and peer reviews were the initial criteria. Continuing medical education and self-assessment credits were used to get admission to life-long learning. Continuing medical education and self-assessment examinations are examples of evidence of life-long learning(“History of Orthopedic Surgery”). The computer-based re-certification tests for knowledge evaluation. Candidates could take the ABOS web-based longitudinal assessment from any place on their own computer as a substitute for in-person multiple choice tests, however the knowledge evaluation retained the previously used oral examination. Control through technology is evident here has computerized test substituted for written ones. (Mazloom) The ABOS also began collaborating with residency programs to enhance competence measurement for orthopedic surgeons in training(“History of Orthopedic Surgery”). They accomplished this by releasing graduate medical educational resources. These instruments evaluated the surgical skills and professionalism required to become a successful orthopedic surgeon(Cox).