Orthopedic Review

The early 1900’s can be seen as a great turning point for Orthopedics. The discovery of the X-ray almost marked 1900 and Orthopaedics itself was only now being seen as a true specialty of its own. The British still dominated Orthopaedic developments, but the new world had now reached maturity and there were increasingly more contributions being made by the Americans. The bloom of understanding, with the introduction of the X-ray, was not as dramatic as expected. Instead, the turn of the century was marked by new institutions and associations that sought to mark Orthopaedic Surgery as an individual and growing specialty.

One area where there was an evident surge of new information with the introduction of the X-ray was that of osteochondritis and osteonecrosis. Although the German George Clemens Perthes took the first X-rays of Perthes’ disease in 1898, Perthes’ assistant did not publish these until 1914. IN 1903, Robert Osgood (1873-1956) of Boston first described a lesion of the tibial tubercle occurring during adolescence. This is now known as Osgood-Schlatter’s disease. The German, Albert Hoffa (1859-1907), stressed in his book of 1902, that excision of the femoral head for cases of hip disease should not be routine. He had realised that not all cases of hip disease were tuberculous. Hoffa was interested in scoliosis, but has his name associated with the hypertrophy of the infrapatellar fat pad that is now called Hoffa’s disease. Another German by the name of Georg Axhausen (1877-1960), is noted as the first to use the word aseptic necrosis. It must be stressed that necrotic bone was frequent at this time, for there were no antibiotics, and any study into a non-infectious bone necrosis was innovative. In an article he published in 1910,Axhausen wrote that necrosis occurred at the bone-ends of every fracture, and that this stimulated and was replaced by periosteal proliferation. He also believed that focal necrosis of subchondral bone caused changes in the overlying articular cartilage which lead to arthritis deformans. It was not until the 1950’s that Axhausen’s term of aseptic necrosis was replaced by the term avascular necrosis.

Jacques Calve (1975-1954) of Berck, France, Arthur T. Legg (1874-1939) of Boston, U.S.A. and George Perthes of Tubingen, Germany, are all said to have described Perthes’ disease in 1910. Hence this disease is sometimes referred to as Calve-Legg-Perthes disease. With the help of radiography, Calve realised that some cases of tuberculous hips in children were actually cases of coxa plana. He saw that these rare cases of hip irritability had X-ray evidence of coxa vara, hypertrophy of the femoral head, increased density, fragmentation and flattening of the epiphysis. He noted that the disease was of short clinical duration, had good recovery, did not relapse and was not associated with adenopathy or abscess. Calve also described vertebral osteochondritis with collapse, which he attributed to vascular changes subsequent to trauma (although we now know that eosinophil granuloma is the common cause). Legg had wide interests, but is best known for the eight papers that he published on coxa plana. He included a treatment of traction hip splint and noted the limited degrees of movement.

The early 1900’s was also a time of improvement for spinal surgery. Russell A. Hibbs (1869-1932), was from the New York Orthopaedic Hospital and in 1911, published a report on a technique of spinal fusion that he had developed. Hibbs performed the first spinal fusion for tuberculosis and later performed a similar procedure for scoliosis. Joel Goldthwait (1867-1961) was another of the great Boston orthopaedists. He had a major interest in posture and in 1911, published a laminectomy from L1 to S3 performed on a man who developed bilateral sciatica followed by paraplegia after a lifting strain.

Enough for the history, lets move on the future.
The immediate challenges facing the modern orthopaedic surgeon are : The Human genome Project (sequencing the 23 human chromosomes; due for completion 2003) with the promise of gene therapy, human cloning and bovine prosthetic implants; corporate control of the practice of medicine with surgeons answering to corporate bosses rather than their patients and colleagues; the rise of the Internet with a more efficient interchange of information and the Global Burden of Disease where motor vehicle accidents are going to be the third greatest burden of morbidity by the year 2020. These challenges are there and are somewhat daunting but certainly less frightening than many that faced our proud forebears and teachers. If alive, John Hunter would be in the forefront of these scientific developments and I suspect, chide us for our tardiness in embracing such challenges. In some ways, Orthopaedics has lost its way by producing surgical technicians (surgeons merely content to operate) with not enough commitment to fundamental biomedical research and the protection of their craft.

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