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HISTORY OF SURGERY

Jean-Andre Venel established the first orthopaedic institute in 1780, which was the first hospital dedicated to the treatment of children's skeletal deformities. He is considered by some to be the father of orthopaedics or first true orthopaedist in consideraton of the establishment of his hospital and for his published methods.

Antonius Mathysen, a Dutch military surgeon, invented the plaster of Paris cast in 1851.

Many developments in orthopaedic surgery resulted from experiences during war time. On the battlefields of the Middle Ages the injured were treated with bandages soaked in horses' blood which dried to form a stiff, but insanitary, splint. Traction and splinting developed during World War I. The use of intramedullary rods to treat fractures of the femur and tibia was pioneered by Dr. Kunchner of Germany. This made a noticeable difference to the speed of recovery of injured German soldiers during World War II and led to more widespread adoption of intramedullary fixation of fractures in the rest of the world. However, traction was the standard method of treating thighbone fractures until the late 1970's when the Seattle Harborview group popularized intramedullary fixation without opening up the fracture. External fixation of fractures was refined by American surgeons during the Vietnam War but a major contribution was made by Grigor Ilizarov in the USSR. He was sent, without much orthopaedic training, to look after injured Russian soldiers in Siberia in the 1950's. With no equipment he was confronted with crippling conditions of unhealed, infected and malaligned fractures. With the help of the local bicycle shop he devised ring external fixators tensioned like the spokes of a bicycle. With this equipment he achieved healing, realignment and lengthening to a degree unheard of elsewhere.

Toronto, Canada, was an early center of excellence in orthopedic surgery, renowned for training and creative development since orthopedics was defined as a distinct surgical specialty by the pioneer surgeon Robert I. Harris in the 1950s. Generations of orthopaedic surgeons graduating from the University of Toronto program since have contributed to many of the important achievements in orthopedics that have improved the lives of people with bone and joint injuries and diseases.

One eminent example is the work of David L. MacIntosh, who pioneered the first successful surgery for the management of the torn anterior cruciate ligament of the knee. This common and serious injury in skiers, field athletes, and dancers invariably had brought an end to their pursuits due to permanent joint instability. Working especially with injured football players in his role as sports surgeon for the University of Toronto, he devised a way to re-route viable ligament from adjacent structures to preserve the strong and complex mechanics of the knee joint, and restore stability throughout its range of motion, conferring a fully functional joint. This, for the first time in history, reliably could permit the athlete to return to the demands of (even professional) sport or dance after a period of healing. The two major variants of this repair that MacIntosh developed in the 1960s and 1970s for the torn anterior cruciate ligament still are the operations of choice performed today.

Although there were many precursors, the modern total hip replacement is associated with Sir John Charnley in England (1960s). He found that joint surfaces could be replaced by metal or high density polyethylene implants cemented to the bone with Methyl Methacrylate cement. Since Charnley's time there has been continuous improvements in the design and technique of joint replacement (arthroplasty) with many contributors, including W.H.Harris, the son of R.I.Harris, whose team at Harvard pioneered uncemented arthroplasty techniques with the bone bonding directly to the implant. Knee replacements using similar technology were started by McIntosh in rheumatoid arthritis patients and later by Gunston and Marmor for osteoarthritis in the 1970's. The modern condylar total-knee replacement was developed by Dr. John Insall and Dr. Chitranjan Ranawat in New York. Uni-compartment knee replacement, in which only one compartment of an arthritic knee is replaced, is a smaller operation and has become popular recently. Joint replacements are now available for many other joints notably shoulder, elbow, wrist and ankle. The trend now is to minimally invasive surgery in all forms of orthopaedics. Experimental surgeons are applying the technique to the spine, for slipped disks, and to hand and foot pain problems. Joint replacement surgery (reconstructive surgery) has made an enormous difference to the quality of life for sufferers from joint pain and arthritis.

Some children develop curvature of the spine (scoliosis). If untreated this may progress and result in the "humpback" deformity which leads to lung problems and early death. Scoliosis surgery was revolutionized by Dr. Harrington's introduction of hook rods, which could maintain the straightening of the spine long enough for a bone fusion to develop. Modern techniques and implants are different but the principle remains the same.

Particularly important for injured athletes was the use of arthroscopic tools by Dr. Watanabe of Japan, to perform minimally invasive cartilage surgery and re-constructions of torn ligaments. This advance helped ligament repair patients recover from the surgery in a few hours as day-surgery instead requiring hospitalization, as was the case with open-joint surgery. The commonest operation performed by most orthopaedic surgeons is meniscectomy, or removal of a torn cartilage. In most cases this is done using arthroscopy.

Children have special problems with musculoskeletal conditions and have been a focus of Orthopaedics since Hippocrites. Orthopaedic surgeons treat crippling conditions such as club foot and congenital hip dislocation in infants as well as infections in bones and joints in children of all ages. Broken bones are a special problem in children because they are still growing. The techniques for treating adult fractures have to be modified in children.

Although orthopaedic surgery is remarkably successful in treating pain and restoring function it causes problems in a small proportion of patients. No branch of medicine is exempt from complication (medicine). Infection of bone after surgery and the development of blood clots DVT in limbs injured or operated on, are common enough to be the focus of much interest and research. The reasons (indications) for orthopaedic surgery always have to be carefully considered. An informed appreciation of the risks and benefits of the proposed treatment is essential.