Orthopedics

ORTHOPEDICS, a term proposed in 1741 by Andry (Nicolas Andry) to designate that medical specialty which deals with the study, prevention, and treatment of permanent deformities of the human body. This term should be recognized as extremely precise and fortunate, since it simultaneously designates both the essence of this discipline and the sphere of its activity. However, despite all its clarity, this term subsequently served as a pretext for the most unscientific interpretations of its meaning, and persons little acquainted with the essence of orthopedics referred this term to the category of such widespread Greco-Latin words, deriving it from the Greek orthos (straight) and the Latin word pes (pedis, foot). Meanwhile, orthopedics is a purely Greek term originating from the adjective orthos (straight) and the verb paideuo (to educate, form, train, raise). Thus, orthopedics is a specialty that deals with the prevention and correction of deformities expressed by all sorts of curvatures of various parts of the body. A permanent curvature is possible only in the presence of a curvature of the hard foundation of a given part of the body, i.e., the skeleton. From this it follows that the sphere of activity of orthopedics is primarily the deformities of the limbs and spine. Since the limbs are working levers (see Leg, Arm) attached to the trunk, the main supporting structure of which serves the spine, the paramount importance of orthopedics in the healthcare of the population, the majority of whom live by physical labor, is quite clear. If the deformities of the indicated areas always to a greater or lesser extent reduce the capacity for physical labor, they additionally usually lead to a significant change in the psyche of patients due to severe moral experiences associated with the awareness of the disfigurement of their bodies. This circumstance often prompts individuals afflicted with deformities to withdraw very early, avoid society and the entertainments existing in it out of fear of becoming an object of ridicule. Therefore, it is often possible to see that individuals afflicted with such physical defects devoted themselves to assiduous and systematic intellectual labor or the service of art. Thus, for example, from history it is known that Socrates, Walter Scott, Byron, Little, and many others, as Hoffa (Hoffer) points out, suffered from various kinds of deformities. At the same time, the indicated moral experiences associated with the oppressive awareness of the existing deformity often laid a heavy imprint on the character of their possessors, generating bitterness in them, fanned by the mocking attitude toward them. The indicated consequences of deformities of the human body were well known to representatives of science from time immemorial; 800 years before Christ in the book Ayur-Veda, Susruta sets forth the theory of the occurrence of congenital deformities and speaks of the usefulness of massage for the body. In the writings of Hippocrates, spinal curvatures, clubfoot, congenital dislocations of the hip, and even spondylitis with retropharyngeal abscesses are spoken of quite expansively. Gymnastics is recommended by Hippocrates for the healthy in order to preserve the normal shape of the body, while for the treatment of deformities he proposes various mechanical devices. Celsus speaks already of active and passive gymnastics, and Soranus in 110 AD points out the frequency of leg curvatures in young Romans on the basis of rickets due to the careless attitude of mothers toward them, allowing them to sit and walk prematurely. Galen also speaks in detail about spondylitis and points out the possibility of treating scoliosis with breathing exercises, singing, and correcting bandaging. To him we also owe the currently existing terms "kyphosis," "lordosis," and "scoliosis." In his works there are also indications of genu valgum. Caelius Aurelianus acquaints us with paralytic deformities, which he proposes to treat with passive gymnastics and splints. At the end of the 3rd century, Atyllus first proposed the treatment of contractures by tenotomy. In the writings of Caesar and Tacitus, there are indications of the doctors' familiarity with amputations and prosthetics. In the works of the Arab physician Albucasis (Albucasem) in 1100, we encounter a detailed description of coxitis and spondylitis under the name of coxarthrocace and spondylarthrocace, and in 1363 Guy de Chauliac comes forward with a proposal for the treatment of fractures by traction. In the darkness of the Middle Ages, the further development of orthopedics relatively stagnated, but already in 1561 Ambroise Paré published a book on congenital deformities with an indication of apparatuses for the treatment of clubfoot. He also first attempts to develop the pathogenesis and therapy of spinal deformities, proposing an orthopedic corset made of perforated sheet metal. Around the same time, the Spanish physician Arceus also successfully used apparatus treatment for clubfoot. In 1614 Fabricius Hildanus worked out the pathoanatomical picture of scoliosis and recommended the treatment of deformities with machines. In this era, the forceful correction of deformities of various kinds by apparatuses and machines generally flourished, among which a cuirass resembling medieval armor, proposed in 1619 by Fabricius ab Aquapendente, deserves attention for its crudeness. However, already in 1660 a new direction appears in the treatment of deformities by gymnastics and supporting apparatuses, as was first proposed by the English physician Glisson. From this time on, the development of pathoanatomical studies of deformities generally begins, as well as the broader application of operative treatment methods. Thus, in 1641 Isaac Minnius first performed the transection of the sternocleidomastoid muscle for torticollis. In connection with the development of knowledge on the pathological anatomy and pathogenesis of deformities, the development of corresponding methods for the treatment of deformities by redressement and the fixation of the results achieved by it begins. Thus, for example, in 1640 Cheselden proposed the treatment of clubfoot with a plaster bandage. The founder of scientific orthopedics should be considered the Frenchman Nicolas Andry, who in 1741 published his work L'orthopedie, ou l'art de prevenir et de corriger dans les enfants les difformites du corps par des moyens a la portee des peres et meres (v. I–II, P., 1741; a series of reprints in French and other languages). He also, as indicated above, proposed the term "orthopedics," which has survived to the present time despite numerous attempts to replace it with other terms. Thus, Delpech in 1828 proposed the term orthomorphia, Bricheteau in 1833 – orthosomatia, and Bigg in 1862 – orthopraxy. However, all these terms do not sufficiently accurately localize the sphere of activity of orthopedics and therefore did not take root, just like the attempt of modern times to call orthopedics orthopedic surgery. Since Andry, the rapid development of orthopedics as a special branch of surgery begins, dealing with the study, prevention, and treatment of permanent deformities of the limbs and spine with special attention to the study of pathogenesis, pathological anatomy, and treatment methods. In 1749 Richter proposed tenotomy of the sternal head of the sternocleidomastoid muscle for the treatment of torticollis, and in 1779 the classical work of the English surgeon Percival Pott on spondylitis appeared in print. By this time we already see an exact identification of the sphere of activity of orthopedics in civilized countries of Europe. The conditions for the normal development of the skeleton, the role of statics, and the close relationship between form and function of both the limbs and the trunk have been precisely established. In this field, great merits belong to Hueter and Volkmann, who created the "pressure theory," and Julius Wolff, the author of the "transformation theory." In connection with the indicated scientific foundations, the further development of both the prevention of deformities and their treatment proceeded. Along this same path went the development of functional, prosthetic, and operative orthopedics, and such important basic methods of orthopedic treatment as massage, gymnastics, physical culture, and correcting measures both bloodless and bloody arose. The established fact of the direct influence of form on function and vice versa indicated the insufficiency of changing only one of these conditions; therefore, at the present time it is recognized by all that only a combined method of treatment can give lasting long-term results. The awareness of the necessity of such a combined surgical and functional treatment had to give birth to the awareness of the necessity of separating orthopedics into an independent special branch of surgery, for the practical implementation of which in life the creation of special medical institutions was required. The founder of the first such orthopedic medical institution is Andre Venel, who created the first orthopedic clinic in his homeland in Switzerland. The results achieved by Venel prompted Heine in 1812 to create a similar institution in Würzburg. A similar institution arose on the idea of Leithof in Lübeck in 1818, and then similar institutions began to open in other cities. In Russia, the first scientific work on orthopedics belongs to N. I. [Vreden]

Following Pirogov, who published in 1840 a very valuable histological study related to the tenotomy of the Achilles tendon, the very first orthopedic medical institution in St. Petersburg was founded by de Roon in 1850. Since then, orthopedics began to be practiced by several prominent representatives of Russian surgery, among whom mention should be made of Reyer, Ratimov, Heydenreich, and Valtukh. A major representative of Russian orthopedics is K. K. Horn, who at the end of the last century opened his clinic in St. Petersburg. The first orthopedic clinic was founded in 1900 by G. I. Turner, who also succeeded in introducing orthopedics into the teaching curriculum of the Military Medical Academy, and in 1906, in St. Petersburg, on the initiative of K. K. Horn, the Orthopedic Institute was founded, the management of which, upon Horn's death, was entrusted to Professor R. R. Vreden. After the October Revolution, a whole series of orthopedic institutes and clinics arose in the USSR in Kiev, Kharkov, Odessa, Kazan, and Saratov. The outstanding scientific activity of a number of prominent representatives of Russian orthopedics (Turner, Käfer, Albrecht, Sitenko, Frumin, Friedland, Fink, Oshman, Tregubov, Timofeev, Krasnobaev, Krause, Schenk, Osten-Sacken, and others) has ensured for Russian orthopedics, over the thirty years of its existence, a prominent place in world scientific orthopedics, with which close unity has been established through special congresses and journals. Orthopedics is in the most favorable position in Ukraine, where there are excellent orthopedic institutes in Kharkov and Kiev, and where systematic teaching of orthopedics is conducted for both physicians and students. In 1926, the Society of Surgeon-Orthopedists arose in Leningrad, an orthopedic subsection was created under the scientific council of the Leningrad Regional Health Department to develop a plan for orthopedic care for the population of the region, a large orthopedic department was also opened in the Karl Marx Hospital, and a permanent assistant professorship in orthopedics was established at the State Institute for the Advanced Training of Physicians. Thus, orthopedics in the USSR is in a period of growth and construction. The isolation of orthopedics into an independent scientific discipline is the result of the development of those special methods that orthopedics uses both for the purpose of research and diagnosis, and for the purpose of treating the diseases belonging to it. For its studies, orthopedics uses the following basic methods: 1) determination of the external appearance of various parts of the trunk and limbs that deviate from the norm in their external appearance, and for a clearer idea of these deviations, a comparative evaluation with the corresponding normal areas of the healthy side is used; 2) measurements of the length and volume of the affected parts; 3) determination of the function of this part and the degree of its impairment; 4) measurement of the angles of curvature; 5) clarification of static conditions; 6) determination of the functional capacity of the muscular apparatus; 7) determination of the state of the central and peripheral nervous system in connection with existing deformations. In combating the indicated deformations of the limbs and spine, which according to the main etiological factors can be subdivided into congenital and acquired as a result of altered static conditions, pathological processes, and traumatic injuries, modern orthopedics possesses a whole series of special scientifically grounded prophylactic measures. These prophylactic measures acquire particular value in ensuring the proper physical development of the younger generation, in preventing or averting the development of occupational deformations in connection with labor processes, and in proper occupational selection in connection with existing data from the musculoskeletal system. Therapeutic measures reduce to general treatment directed against various pathological conditions of the entire organism, and to local treatment of pathological processes and traumatic injuries, as well as to the restoration of normal static conditions. Regarding the treatment of the deformations themselves, orthopedics uses both bloodless and bloody methods aimed at restoring normal form, normal static conditions, and normal function. The group of bloodless methods includes massage, gymnastics, and measures correcting deformations. The latter include redistributive manipulations, fixing bandages, and various orthopedic appliances and devices. Surgical intervention extends to the skin, fascia, muscles, tendons, nerves, and bones, ranging from the simplest operations such as subcutaneous division of tendons and fascia to such complex operations as replacement of bone defects, arthroplasty, and transplantation of tendons and muscles. From all that has been said, it follows that the modern specialist in orthopedics must have a broad general surgical training and possess an extensive stock of knowledge in anatomy, physiology, operative surgery, embryology, neuropathology, and mechanics. In the teaching of orthopedics, massage and other methods of physiotherapy, physical culture, gymnastics, the basics of prosthetics, and practical familiarization with the technique of manufacturing therapeutic orthopedic apparatus and prostheses should be included. Specialists in orthopedics with such training, as a hundred years of experience has already proved, are very valuable scientific and practical workers not only in peacetime, but also in wartime. We cannot yet judge the percentage of orthopedic diseases relative to the healthy population due to the absence of exact statistical data. In any case, the need for orthopedic care among the population is extremely great everywhere, since limbs are most often subjected to all kinds of pathological processes and traumatic injuries. These injuries in peacetime conditions make up 80% of all injuries, rising in wartime to 90%. Thus, in the fight against peacetime and wartime traumatism, the first place in the specificity of work falls to the share of orthopedists. This circumstance prompted the mobilization of all orthopedists during the imperialist war in Western Europe, and in England the position of Army Inspector of Orthopedics was even created, to which such a major authority in the field of orthopedics, Robert Jones, was appointed. No less a role belongs in peacetime to orthopedics, which has among its extensive social tasks the fight against crippling.