- Section I Bas Musculoskeletal Science and its Application 1. Introduction: The Past and the Present BRIEF HISTORICAL BACKGROUND Asa student approaching the twenty-first cen- tury, you live in a tremendously exciting era. As you pursue your studies of the basic sci- ences and of modern clinical medicine or the allied professional fields, you will realize how much of what you are learning has been devel- oped since you were born. This is simply an indication of the recently accelerated acquisi- tion of scientific knowledge. However, as Ci- cero said: “Not to know what happened be- fore one was born is to remain a child.” The history of medicine and surgery deserves your attention not only because itis inspiring but also because it places your pres- ent knowledge in perspective and may even stimulate original thought concerning possi- ble developments of the future. If, after gradu- ation, you choose to study one particular field of medicine or other health care professions in depth you would be wise to delve into the history of that particular field so that you may avoid repeating the errors of the past. ‘The bones of prehistoric humans provide mute testimony of disorders and injuries of “We see so far because we stand on the shoulders of giants” —Sir Isaac Newton the musculoskeletal system, and from the be- ginning caring persons sought ways to allevi- ate the crippling conditions of others. As early as 9000 xc, in the Paleolithic age, supersti- tions were being replaced by rational thinking and caregivers were beginning to use splints for weak limbs and broken bones. In the Neo- lithic age, around 5000 nc, crude amputations of diseased or damaged limbs were already being performed. The Egyptians had devel- oped the concept of the crutch by 2000 nc. Greece replaced Egypt as the center of culture by the fifth century nc and Hippocrates, through his teaching and through his stu- dents, had become the “father of medicine.” In the second century ab, Galen, a Greek phy- sician who moved to Rome, became the foun- der of experimental investigation Throughout the first eighteen centuries ap, knowledge in medicine and surgery ad- vanced slowly, culminating in the significant contributions of England’s John Hunter (1728-1793), who has been revered ever since as the “father of surgical rescarch.”” Under- standably, however, the development and per- formance of major surgical operations had to await the revolutionary nineteenth century 12 Section | Basic Musculoskeletal Science discoveries of general anesthesia by Long and Morton (United States), the bacterial basis of disease by Pasteur (France), antisepsis. by Lister (Scotland), and x-rays by Roentgen (Germany) Progress in the science of medicine and sur- gery in the twentieth century, and more par- ticularly in its second half, has been staggering, in its rapidity. Happily, there is no end in sight for such escalating progression. Indeed thi only one of the factors that makes the study and practice of medicine in general, and or- thopaedic surgery and allied professional fields in particular, so exciting and challenging In the twentieth century, the care of pa- tients with disorders and injuries of the mu: culoskeletal system has evolved through three phases. First was the ‘strap and buckle” phase which various orthopaedic splints, braces, and other types of appliances constituted the predominant form of management. Next came the phase of excessive orthopaedic oper- ations, many of which were based more on inical empiricism than on scientific investiga tion. In the third and current phase, science is rapidly replacing empiricism, as evidenced by the combination of increased experimental laboratory investigations (basic research), aimed at understanding the physiology and pathology of the musculoskeletal system more completely, and both retrospective and pro- spective clinical investigations to study the natural course of disorders and critically evalu- ate the results of various forms of treatment in humans In this scientific phase, the study of clinical problems of the musculoskeletal system has become increasingly stimulating and challeng- ing. The care of patients remains an art, but the art must be based on science. You will gain much knowledge from those who have gone before you, both recently and in the distant past, but you may be assured that there is much more to be discovered and understood. THE SCOPE OF ORTHOPAEDICS Although the history of disorders and injuries of the musculoskeletal system dates back to antiquity, the specialty of orthopaedics as a branch of medicine and surgery is relatively young. In 1741, Nicolas Andry, then Profes- sor of Medicine in Paris, published a book, the English translation of which is Orthopaedia, or the Art of Preventing and Correcting Deformi- ties in Children. He coined the term “ortho- paedia” from orthos (straight or free from de- formity) and pais (child) and expressed the view that most deformities in adults have their origin in childhood (Fig. 1.1). Although the term “orthopaedics” is not entirely satisfac- ya. Pod2. ‘igure 1.1. This “orthopaedic tree” from Nicolas Andry’s eighteenth-century book has become the in: temational symbol of orthopaedic surgery. It illus trates the concept that a crooked young tree—like a deformed young child—can be helped to grow straight by applying appropriate forces.tory, it has persisted for more than two centu- ries and is unlikely to be replaced in your aca- demic lifetime. The present scope of orthopaedics has come to include all ages and is considered to consist of the art and science of prevention, investigation, diagnosis, and treatment of dis- orders and injuries of the musculoskeletal sy' tem by medical, surgical, and physical means—including physiotherapy—as well as the study of musculoskeletal physiology, pa- thology, and other related basic sciences, ‘Thus, the modern, sophisticated orthopae- dic surgeon serves as both physician and sur- geon (as implied by the American synonym “orthopedist”). To provide exemplary total care for patients with certain musculoskeletal disorders or injuries, the orthopaedic specialist must work in close collaboration with medical specialists—including rheumatologists, meta- bolic bone physicians, and rehabilitation phy- sicians (physiatrists) or other surgical special- ists, particularly plastic surgeons and neurosurgeons—as well as health care profes sionals, including physiotherapists, occupa tional therapists, and medical social workers, As a group, musculoskeletal disorders and injuries are remarkably common. Indeed, it has been ascertained from numerous surveys in North America that at least 15% of the total number of patients seen by a primary care, or family physician, suffer from a disorder or in- jury of the musculoskeletal system either with or without some coexistent condition CURRENT TRENDS IN CLINICAL CONDITIONS OF THE MUSCULOSKELETAL SYSTEM Our environment is the scene of continual change, and from decade to decade we see many changes in the nature and frequency of the musculoskeletal disorders and injuries that confront us. Although certain musculoskeletal conditions, such as congenital deformities and bone neoplasms, have remained with us, oth- ers have gradually become less common. New problems have arisen in their place and must receive increasing attention. For example, if you had been a student in the early decades ofthe twentieth century, you would have been taught much about bone and joint tuberculo- Chapter 1 Introduction 3 sis, vitamin deficiencies of bone, and paralytic poliomyelitis. Today, these conditions have been largely brought under control by preven- tion, at least in developed countries. Never- theless, in recent years there has been a resurg- ence of tuberculosis and the appearance of post-polio syndrome. Other conditions, such as acute bone and joint infections, have been partially controlled, but only by the applica- tion of intensive modem antibiotic treatment at the onset of disease. Thus, the current em- phasis in teaching about these conditions must be on early recognition, or diagnosis, of the clinical picture and early treatment. Severe cerebral palsy with its associated par- alytic problems is even more common than before because some infants with this condi- tion, who previously died early in life, now survive and grow up with their problem. The age span of humans has become progressively longer, and as a result the various degenerative conditions, such as degenerative arthritis, now assume greater clinical importance. Likewise, senile weakening of bone (osteoporosis), with its complication of fractures in the elderly, has, become an increasingly important problem. Certain conditions, such as rheumatoid arthri- tis, that in previous decades were treated by medical means alone, have become partially amenable to surgical treatment. The increase in the number of automobiles, combined with their increasing speed, has been responsible in part for the great increase in the number and severity of musculoskeletal injuries—fractures and associated trauma—and in particular for the increasing number of patients who sustain multiple serious injuries involving. several major systems of the body. RECENT ADVANCES In recent decades there has been increasing emphasis on the broad fields of medical epide- miology and statistics relevant to both basic research and clinical investigation, in particu- lar concerning methodology and interpreta- tion of data. Epidemiological methods have led to the development of prospective ran- domized, controlled double-blind investiga- tions and clinical trials, “clinical outcome studies” (patient-derived measures of satisfac- tion), evidence-based medicine (including the4 Section | Basic Musculoskeletal Science cost-effectiveness of various forms of diagno- sis and treatment), and practice guidelines. Such developments are especially important in the current era of medical cost constraints by governments and increasing demands by both governments and the public for more ac- countability by the medical and related profes- sions concerning the delivery of health care. In medical undergraduate education the method of “problem-based learning” is be- coming increasingly popular as is the system of using trained “actors” or “actresses” to simulate patients. Postgraduate education has been enhanced by the establishment of techni- cal (psychomotor) skills workshops and labo- ratories, An important advance in continuing medical education has been “telemedicine,” which provides university-staffed audio and, more recently, audiovisual teaching for phy cians, surgeons, and other health care profes- sionals in their own communities far from the university center. During the past three decades, the dyna- mism of orthopaedics has been demonstrated by many important developments that have had a significant impact on the prevention, diagnosis, and treatment of musculoskeletal disorders and injuries. Preventive orthopae- dics has become a reality through more precise counseling as well as intrauterine detection of certain disorders by amniocentesis. The ad- ministration of folic acid to all pregnant moth- ers has significantly reduced the incidence of spina bifida (a neural tube defect), especially in the offipring of high-risk mothers who have already had a child with spina bifida. Earlier diagnosis of potentially serious orthopaedic disorders, such as congenital dislocation of the hip, has become a reality through the routine examination of all newborns, as has the early detection of scoliosis (curvature of the spine). ‘These initiatives have been proved effective. Noninvasive diagnostic “imaging” of muscu- loskeletal disorders and injuries has been en- hanced by radioactive isotope bone scans (scintigraphy) and ultrasound scans (ultraso- nography) and especially by computed to- mography (CT), both two-dimensional and three-dimensional, as well as by magne! ‘onance imaging (MRI). Endoscopic examina- tion of the interior of large joints, such as the res- knee, ankle, hip, wrist, elbow, and shoulder, is now possible with an arthroscope and even certain intra-articular operations, including removal of loose bodies, repair of torn me- nisci, or reconstruction of an anterior cruciate ligament, can be performed through the ar- throscope (arthroscopic surgery). The discovery by molecular geneticists of the gene responsible for certain diseases—for example, muscular dystrophy—raises the ex- citing prospect of gene therapy through ge- netic engineering for such diseases. In addi- tion, some oncogenes are being found in musculoskeletal tumors. Recent advances in orthopaedic treatment include the following: + Total prosthetic joint replacements for al- most every joint in the extremities and os- teochondral allografts for irreversible ar- thritis + More effective mechanical spinal instrumen- tation for scoliosis * Back education units + Hyperbaric oxygenation for impaired pe- ripheral circulation + Detection and monitoring of increased pressure in various “muscle compartment syndromes” + More effective methods of nonoperative treatment of fractures (cast bracing), opera- tive treatment (AO system of rigid internal fixation), stimulation of delayed fracture healing or even nonunion (electricity), and the biological resurfacing of joints through stimulation of the repair and regeneration of articular cartilage (continuous passive motion; CPM) and other methods + More effective systemic chemotherapy for malignant diseases + Limb salvage operations as attractive alter- natives to amputations for m: mors of the extremities + Steroid injection for simple bone cysts + Resection ofa bony bridge across an epiphy- seal plate + Earlier and more complete surgical corree- tion of severe clubfeet + More appropriate materials for splints and braces (orthoses) and for artificial limbs (prostheses)The method of slow distraction of callus at the site of an osteotomy—the “distraction osteogenesis” technique of Ilizarov—has im- proved the results of surgical limb lengthening and the correction of bony deformities to a remarkable degree. The development of surgery performed under magnification of the operating micro- scope (microsurgery) has made possible the replantation of completely severed digits and limbs and the transfer of free vascularized bone grafts and even vascularized and reinner- vated autogenous muscle grafts. These recent advances, which have greatly enhanced the prevention, diagnosis, and treat- ment of musculoskeletal disorders and inju- ries, are discussed in appropriate chapters of this textbook. Thus, there have been many significant ad- vances in orthopaedics during the past three decades. Nevertheless, there are still numer- ous unsolved problems that will require imagi- native research to provide a solution. Indeed, much remains to be discovered and devel- oped. As Cowper wrote, “Knowledge ii proud that he knows so much; wisdom is humble that he knows no more.” SUGGESTED ADDITIONAL READING Andry N. Orthopaedia: or the art of correcting and preventing deformities in children (facsimile re- production of first edition in English, London, 1743). Philadelphia: JB Lippincott, 1961. Vols. Land 2 Bick EM. Source book of orthopaedics. 2nd ed. Baltimore: Williams & Wilkins, 1948 (facsimile Chapter 1 Introduction 5 reprint of 1948 edition by Hafner Publishing, New York, 1968). Bick EM. Classics of orthopaedics. Philadelphia: JB Lippincott, 1976. Howorth MB. A textbook of orthopaedics. Phila- delphia: WB Saunders, 1952. Keith A. Menders of the maimed. London Froude (1919 limited editions). Philadelphia: JB Lippin- cott, 1951 LeVay D. The history of orthopaedics. An account of the study and practice of orthopaedics from the earliest times to the modern era. Park Ridge, NJ: The Parthenon Publishing Group, 1990. Lister J. On the antiseptic principle in the practice of surgery. Lancet 1867;2:253. Lyons AS, Petrucelli RJ II. Medicine: an illustrated history. New York: Harry N Abrams Publishers, 1978. Mayer L. Orthopaedic surgery in the United States of America. J Bone Joint Surg 1950;32B:461. Osmond-Clarke H. Half a century of orthopaedic progress in orthopaedic surgery. J Bone Surg 1950;32B:620, Peltier LE: Orthopedics: history and iconography. San Francisco: Norman Publishing, 1993. Platt H. The evolution and scope of orthopaedics. In: Clarke JMP, ed. Modern trends in orthopae- dics. Vol 1. London, Butterworth, 1950. Raney RB. Andry and the orthopaedics. J Bone Joint Surg 1949;31A:675-682. Rang M. Anthology of orthopaedics. Edinburgh and London: E & S Livingstone, 1966. Roentgen WK. Ona new kind of ray. Nature 1896; 53:274, 377. Salter RB. Advances in paediatric orthopaedics in North America 1954 to 1987. (The American Orthopaedic Association Centennial Program), J Bone Joint Surg 1987;69A:1265-1267 Sournia J-C. The illustrated history of medicine. London: Harold Starke Publishers, 1992