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How Orthopedists Were Selected


Consumers’ Research Council of America has compiled a list of top Orthopedists throughout the United States by utilizing a point value system. This method uses a point value for criteria that we deemed valuable in determining the top Orthopedic professionals.

The criteria that was used and assessed a point value is as follows:

Experience:

Each year the Physician has been in practice

Training:

Education and Continuing Education

Professional Associations:

Membership in Medical Associations

Board Certification:

Completing an approved residency program and passing a rigid examination on that specialty

Simply put, Orthopedists that have accumulated a certain amount of points qualified for the list. This does not mean that doctors that did not accumulate enough points are not good doctors, they merely did not qualify for this list because of the points needed for qualification.

Similar studies have been done with other professions using a survey system. This type of study would ask fellow professionals who they would recommend. We found this method to be more of a popularity contest. For instance, professionals who work in a large office have much more of a chance of being mentioned, as opposed to a professional who has a small private practice. In addition, many professionals have a financial arrangement for back-and-forth referrals. For these reasons, we developed the point value system.

Since this is a subjective call, there is no study that is 100% accurate. As with any profession, there will be some degree of variance in opinion. If you survey 100 patients from a particular physician on their satisfaction, you will undoubtedly hear that some are very satisfied, some moderately satisfied and some dissatisfied. This is really quite normal.

We feel that a point value system takes out the personal and emotional factor and deals with factual criteria. We have made certain assumptions. For example, we feel that more years in practice is better than less years in practice; more education is better than less education, being board certified is better than not being certified, etc.

The Top Orthopedists list that we have compiled is current as of a certain date and other doctors may have qualified since that date. Nonetheless, we feel that the list of Top Orthopedists is a good starting point for you to find a qualified health care specialist.

No fees, donations, sponsorships or advertising are accepted from any individuals, professionals, corporations or associations. This policy is strictly adhered to, ensuring an unbiased selection.


Finding an Orthopedist


Choosing an Orthopedist is an important decision. Thus, our goal is to assist you in making that decision. First of all, when selecting an Orthopedist, you may want to begin your search several different ways:

Ask family, friends, neighbors and/or co-workers.
Contact your local Chamber of Commerce or Better Business Bureau
for reputable Orthopedists.
Contact your city, county or state medial agencies for names of qualified Orthopedists.
Contact and ask for referrals from medical associations. Many are listed in this publication.

We recommend that you interview the Orthopedist and ask the following:

Is your staff friendly and accommodating?

Do you have two waiting rooms, one for sick people and one for healthy people that are just in for check-ups?

Do you take walk-in patients, or is it by appointment only?

What are the procedures if we need a doctor in the middle of the night or on a weekend?

Do you have an associate that covers for you when you are not available?

Do you have more than one office and if so, how is your time divided between offices?

What kind of continuing education do you utilize?

Do you accept phone calls during office hours?

How do you stay current on the latest drugs and prescriptions available, medical testaments and modern concepts?

What types of insurance coverage do you accept?

How do you handle billing? Do you require payment at the time of visit?

Discuss your family medical history and particular problems you are concerned about.

After you have consulted a few Orthopedists you should have a good idea which one you felt most comfortable with and who best answered your questions.


What is an Orthopedist?


Orthopedic Surgery
From Wikipedia, the free encyclopedia:

Orthopedic Surgery or Orthopedics (also spelled Orthopaedics, see below) is the branch of surgery concerned with acute, chronic, traumatic, and overuse injuries and other disorders of the musculoskeletal system. Orthopaedic surgeons address most musculoskeletal ailments including arthritis, trauma and congenital deformities using both surgical and non-surgical means.

The first of the above images is pre-operative and the second image is following a C5 corpectomy and combined anterior and posterior fusion with cage placement and bone grafting. This is one of the conditions treated by Orthopaedic surgeons.

This image shows extensive repair work to the right acetabulum 6 years after it was carried out. Further damage to the joint is visible due to the onset of arthritis.


Training

Orthopedic surgeons are physicians who have completed additional training in Orthopedic surgery after the completion of medical school, either M.D. or D.O. According to the latest Occupational Outlook Handbook (2006-2007) published by the U.S. Department of Labor, between 3-4% of all practicing physicians are Orthopedic surgeons.

In the United States and Canada Orthopedic surgeons (also known as Orthopedists) complete a minimum of 13 years of postsecondary education and clinical training. This training includes obtaining an undergraduate degree, a medical degree or osteopathic degree, and then completing a five-year residency in Orthopedic surgery. The five-year residency consists of one year of general surgery training followed by four years of training in Orthopaedic surgery.

Many Orthopedic surgeons elect to do further subspecialty training in programs known as 'fellowships' after completing their residency training. Fellowship training in an Orthopedic subspecialty is typically one year in duration (sometimes two) and usually has a research component involved with the clinical and operative training. Examples of Orthopedic subspecialty training in the US are:

1. Hand surgery
2. Shoulder and elbow surgery
3. Total joint reconstruction (arthroplasty)
4. Pediatric Orthopedics
5. Foot and ankle surgery (Not to be confused with podiatry)
6. Spine surgery (Also performed by neurosurgeons)
7. Musculoskeletal oncology
8. Surgical sports medicine
9. Orthopaedic trauma

These are also the nine main sub-specialty areas of Orthopaedic surgery.


Hand surgery is the only truly recognized sub-specialty within Orthopaedic surgery. The other sub-specialities are informal concentrations of practice. To be recognized as a hand surgeon, a practitioner must have completed a fellowship and obtained a Certificate of Added Qualifications (CAQ) which requires an additional standardized examination.

Practice

Orthopaedic surgeons address most musculoskeletal ailments including arthritis, trauma and congenital deformities using both surgical and non-surgical means. According to applications for board certification from 1999 to 2003, the top 25 most common procedures (in order) performed by Orthopaedic surgeons are as follows:

  1. Knee arthroscopy and menisectomy
  2. Shoulder arthroscopy and decompression
  3. Carpal tunnel release
  4. Knee arthroscopy and chondroplasty
  5. Removal of support implant
  6. Knee arthroscopy and anterior cruciate ligament reconstruction
  7. Knee replacement
  8. Repair of femoral neck fracture
  9. Repair of trochanteric fracture
10. Débridement of skin/muscle/bone/fracture
11. Knee arthroscopy repair of both menisci
12. Hip replacement
13. Shoulder arthroscopy/distal clavicle excision
14. Repair of rotator cuff tendon
15. Repair fracture of radius (bone)/ulna
16. Laminectomy
17. Repair of ankle fracture (bimalleolar type)
18. Shoulder arthroscopy and débridement
19. Lumbar spinal fusion
20. Repair fracture of the distal part of radius
21. Low back intervertebral disc surgery
22. Incise finger tendon sheath
23. Repair of ankle fracture (fibula)
24. Repair of femoral shaft fracture
25. Repair of trochanteric fracture


Of Orthopaedic surgeons applying for certification with the American Board of Orthopedic Surgery between 1999 to 2003, these were the percentages of surgeons in each specialty area:

General Orthopaedics: 54.8%
Spine surgery: 11.3%
Sports medicine: 10.8%
Hands and upper extremity: 8.7%
Adult reconstructive: 3.9%
Pediatric Orthopaedics: 3.4%
Foot and ankle: 3.1%
Trauma: 2.6%
Musculoskeletal oncology: 1.3%


A typical schedule for a practicing Orthopaedic surgeon involves 50-55 hours of work per week divided among clinic, surgery, various administrative duties and possibly teaching and/or research if in an academic setting.

History

Jean-Andre Venel established the first Orthopedic 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 Orthopedics or the first true Orthopedist in consideration 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 Orthopedic surgery resulted from experiences during wartime. On the battlefields of the Middle Ages the injured were treated with bandages soaked in horses' blood which dried to form a stiff, but unsanitary, 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 thigh bone fractures until the late 1970s 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 Gavril Abramovich Ilizarov in the USSR. He was sent, without much Orthopedic training, to look after injured Russian soldiers in Siberia in the 1950s. 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. His Ilizarov apparatus is still used today.

David L. MacIntosh 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 brought an end to their athletics due to permanent joint instability. Working with injured football players, Dr. MacIntosh 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. The subsequent development of ACL reconstruction surgery has allowed numerous athletes to return to the demands of sports at all levels.

Modern Orthopaedic surgery and musculoskeletal research has sought to make surgery less invasive and to make implanted components better and more durable.


Bone Fracture


Internal and external views of an arm with a compound fracture, both before and after surgery


A bone fracture is a medical condition in which a bone becomes cracked, splintered, or bisected as a result of physical trauma. A bone fracture can also occur as a result of certain medical conditions that weaken the bones, such as osteoporosis or certain types of cancer. A broken bone is not always defined as a fracture, much as a fracture is not always defined as a broken bone. (U.S. Gov't 2005) A broken bone is defined as a complete severing of the bone, as in opposition to a fracture covering any type of crack or break in the bone.

In Orthopaedic medicine, fractures are classified as closed or open (compound) and simple or multi-fragmentary (formerly comminuted).

Closed fractures are those in which the skin is intact, while open (compound) fractures involve wounds that communicate with the fracture and may expose bone to contamination. Open injuries carry an elevated risk of infection; they require antibiotic treatment and usually urgent surgical treatment (debridement). This involves removal of all dirt, contamination, and dead tissue.

Simple fractures are fractures that occur along one line, splitting the bone into two pieces, while multi-fragmentary fractures involve the bone splitting into multiple pieces. A simple, closed fracture is much easier to treat and has a much better prognosis than an open, contaminated fracture. Other considerations in fracture care are displacement (fracture gap) and angulation. If angulation or displacement is large, reduction (manipulation) of the bone may be required and, in adults, frequently requires surgical care. These injuries may take longer to heal than injuries without displacement or angulation.

Another type of bone fracture is a compression fracture. An example of a compression fracture is when the front portion of a vertebra in the spine collapses due to osteoporosis, a medical condition which causes bones to become brittle and susceptible to fracture (with or without trauma).

Other types of fractures are:

Hairline Fracture
Transverse Fracture
Comminuted Fracture


Special considerations for children

In children, whose bones are still developing, there are risks of either a growth plate injury or a greenstick fracture.

A greenstick fracture occurs because the bone is not as brittle as it would be in an adult, and thus does not completely fracture, but rather exhibits bowing without complete disruption of the bone's cortex.

Growth plate injuries require careful treatment and accurate reduction to make sure that the bone continues to grow normally.

Plastic deformation of the bone, in which the bone permanently bends but does not break, is also possible in children. These injuries may require an osteotomy (bone cut) to realign the bone if it is fixed and cannot be realigned by closed methods.

OTA classification (Orthopaedic Trauma Association)

Orthopaedic surgeons have devised an elaborate classification system to describe the injury accurately and guide treatment. There are five parts to the code:

(a) Bone: Description of a fracture starts by naming the bone

(1) Humerus
(2) Radius/Ulna
(3) Femur
(4) Tibia/Fibula
(5) Spine
(6) Pelvis
(24) Carpus
(25) Metacarpals
(26) Phalanx (Hand)
(72) Talus
(73) Calcaneus
(74) Navicular
(75) Cuneiform
(76) Cuboid
(80) LisFranc
(81) Metatarsals
(82) Phalanx (Foot)
(45) Patella
(06) Clavicle
(09) Scapula


(b) Location: the part of the bone involved (e.g. shaft of the femur).

1) proximal
2) diaphyseal
3) distal

  
(c) Type: It is important to note whether the fracture is simple or multifragmentary and whether it is closed or open.

A =simple fracture
B =wedge fracture
C =complex fracture


(d) Group: The geometry of the fracture is also described by terms such as transverse, oblique, spiral, or segmental.

(e) Subgroup: Other features of the fracture are described in terms of displacement, angulation and shortening. A stable fracture is one which is likely to stay in a good (functional) position while it heals; an unstable one is likely to shorten, angulate or rotate before healing and lead to poor function in the long term.

Other classification systems

There are other systems used to classify different types of bone fractures:

"Neer classification" (PMID 9155417): humerus overview eMedicine
"Denis classification": spine GP Notebook
"Seinsheimer's Classification": femur Duke



An avulsion fracture is where the tendon tears away a piece of bone.


Bone Healing


The natural process of healing a fracture starts when the injured bone and surrounding tissues bleed. The blood coagulates to form a blood clot situated between the broken fragments. Within a few days blood vessels grow into the jelly-like matrix of the blood clot. The new blood vessels bring white blood cells to the area, which gradually remove the non-viable material. The blood vessels also bring fibroblasts in the walls of the vessels and these multiply and produce collagen fibers. In this way the blood clot is replaced by a matrix of collagen. Collagen's rubbery consistency allows bone fragments to move only a small amount unless severe or persistent force is applied.

At this stage, some of the fibroblasts begin to lay down bone matrix (calcium hydroxyapatite) in the form of insoluble crystals. This mineralization of the collagen matrix stiffens it and transforms it into bone. In fact, bone is a mineralized collagen matrix; if the mineral is dissolved out of bone, it becomes rubbery. Healing bone callus is on average sufficiently mineralized to show up on X-ray within 6 weeks in adults and less in children. This initial "woven" bone does not have the strong mechanical properties of mature bone. By a process of remodelling, the woven bone is replaced by mature "lamellar" bone. The whole process can take up to 18 months, but in adults the strength of the healing bone is usually 80% of normal by 3 months after the injury.

X-ray of a bone fracture in the process of healing

Several factors can help or hinder the bone healing process. For example, any form of nicotine hinders the process of bone healing, and adequate nutrition (including calcium intake) will help the bone healing process. Weight-bearing stress on bone, after the bone has healed sufficiently to bear the weight, also builds bone strength.


Treatment

First aid for fractures includes stabilizing the break with a splint in order to prevent movement of the injured part, which could sever blood vessels and cause further tissue damage. Waxed cardboard splints are inexpensive, lightweight, waterproof and strong. Compound fractures are treated as open wounds in addition to fractures.

At the hospital, closed fractures are diagnosed by taking an X-ray photograph of the injury.

Since bone healing is a natural process which will most often occur, fracture treatment aims to ensure the best possible function of the injured part after healing. Bone fractures are typically treated by restoring the fractured pieces of bone to their natural positions (if necessary), and maintaining those positions while the bone heals. To this end, a fractured limb is usually immobilized with a plaster or fiberglass cast which holds the bones in position and immobilizes the joints above and below the fracture. In some cases surgical nails, screws, plates and wires are used to hold the fractured bone together more directly.

Occasionally smaller bones, such as toes, may be treated without the cast, by buddy- wrapping them, which serves a similar function to making a cast. By allowing only limited movement, fixation helps preserve anatomical alignment while enabling callus formation, towards the target of achieving union.

Operative methods of treating fractures have their own risks and benefits, but usually surgery is done only if conservative treatment has failed or is very likely to fail. With some fractures such as hip fractures (usually caused by osteoporosis, surgery is offered routinely, because the complications of non-operative treatment include deep vein thrombosis (DVT) and pulmonary embolism, which are more dangerous than surgery. When a joint surface is damaged by a fracture, surgery is also commonly recommended to make an accurate anatomical reduction and restore the smoothness of the joint.

Infection is especially dangerous in bones, due to their limited blood flow. Bone tissue is predominantly extracellular matrix, rather than living cells, and the few blood vessels needed to support this low metabolism are only able to bring a limited number of immune cells to an injury to fight infection. For this reason, open fractures and osteotomies call for very careful antiseptic procedures and prophylactic antibiotics.

Sometimes bones are reinforced with metal, but these fracture implants must be designed and installed with care. Stress shielding occurs when plates or screws carry too large of a portion of the bone's load, causing atrophy. This problem is reduced, but not eliminated, by the use of low-modulus materials, including titanium and its alloys. The heat generated by the friction of installing hardware can easily accumulate and damage bone tissue, reducing the strength of the connections. If dissimilar metals are installed in contact with one another (i.e., a titanium plate with cobalt-chromium alloy or stainless steel screws), galvanic corrosion will result. The metal ions produced can damage the bone locally and may cause systemic effects as well.


The Bone Healing Process


Physiology and process of healing

In the process of fracture healing, several phases of recovery facilitate the proliferation and protection of the areas surrounding fractures and dislocations. The length of the process is relevant to the extent of the injury, and usual margins of two to three weeks are given for the reparation of the majority of upper bodily fractures; anywhere above four weeks given for lower bodily injury.

The process of the entire regeneration of the bone can depend upon the angle of dislocation or fracture, and dislocated bones are generally pushed back into place via relocation with or without anesthetic. While the bone formation usually spans the entire duration of the healing process, in some instances, bone marrow within the fracture having healed two or fewer weeks before the final remodeling phase.

While immobilization and surgery may facilitate healing, a fracture ultimately heals through physiological processes. The healing process is mainly determined by the periosteum (the connective tissue membrane covering the bone). The periosteum is the primary source of precursor cells which develop into chondroblasts and osteoblasts that are essential to the healing of bone. The bone marrow (when present), endosteum, small blood vessels, and fibroblasts are secondary sources.


Phases of fracture healing

There are three phases of fracture healing which are separated into 5 total phases;

1. Reactive Phase
     Fracture and inflammatory phase
     Granulation tissue formation
3. Reparative Phase
     Callus formation
     Lamellar bone deposition
5. Remodeling Phase
     Remodeling to original bone contour

Reactive Phase

After fracture, the first change seen by light and electron microscopy is the presence of blood cells within the tissues which are adjacent to the injury site. Soon after fracture, the blood vessels constrict, stopping any further bleeding. Within a few hours after fracture, the extravascular blood cells, known as a "hematoma", form a blood clot. All of the cells within the blood clot degenerate and die. Some of the cells outside of the blood clot, but adjacent to the injury site, also degenerate and die. Within this same area, the fibroblasts survive and replicate. They form a loose aggregate of cells, interspersed with small blood vessels, known as granulation tissue.


Reparative Phase

Days after fracture, the cells of the periosteum replicate and transform. The periosteal cells proximal to the fracture gap develop into chondroblasts and form hyaline cartilage. The periosteal cells distal to the fracture gap develop into osteoblasts and form woven bone. The fibroblasts within the granulation tissue also develop into chondroblasts and form hyaline cartilage. These two new tissues grow in size until they unite with their counterparts from other pieces of the fracture. This process forms the fracture callus. Eventually, the fracture gap is bridged by the hyaline cartilage and woven bone, restoring some of its original strength.

The next phase is the replacement of the hyaline cartilage and woven bone with "lamellar bone". The replacement process is known as "endochondral ossification" with respect to the hyaline cartilage and "bony substitution" with respect to the woven bone. Substitution of the woven bone with lamellar bone precedes the substitution of the hyaline cartilage with lamellar bone. The lamellar bone begins forming soon after the collagen matrix of either tissue becomes mineralized. At this point, "vascular channels" with many accompanying osteoblasts penetrate the mineralized matrix. The osteoblasts form new lamellar bone upon the recently exposed surface of the mineralized matrix. This new lamellar bone is in the form of "trabecular bone". Eventually, all of the woven bone and cartilage of the original fracture callus is replaced by trabeclular bone, restoring much, if not all, of the bone's original strength.


Remodeling Phase

The remodeling process substitutes the trabecular bone with "compact bone". The trabecular bone is first resorbed by osteoclasts, creating a shallow resorption pit known as a "Howship's lacuna". Then osteoblasts deposit compact bone within the resorption pit. Eventually, the fracture callus is remodelled into a new shape which closely duplicates the bone's original shape and strength.


Other forms and complications

Inadequate bone healing

Inadequate bone healing may predispose to further fractures at the same site, as well pseudarthrosis, undesired mobility in what appears to have become a new joint.

Many factors may contribute to lack of bone healing, including smoking (nicotine is known toxin for bones).


Osseointegration

Osseointegration is the pattern of growth exhibited by bone tissue during assimilation of surgically-implanted devices, prostheses or bone grafts to be used as either replacement parts (e.g., hip) or as anchors (e.g., endosseous dental implants).


Musculoskeletal system


The musculoskeletal system (MSK) is an organ system that gives animals the ability to physically move, by using the muscles and skeletal system. Apart from locomotion, the skeleton also lends support and protects internal organs.


Solid musculoskeletal system


The human musculoskeletal system consists of the human skeleton, made by bones attached to other bones with joints, and skeletal muscle attached to the skeleton, usually by tendons.


Arthroplasty


Arthroplasty (literally "formation of joint") is an operative procedure of Orthopaedic surgery performed for replacing the arthritic or dysfunctional joint surface with something better or remodeling or realigning the joint by osteotomy or some other procedures. Previously, popular form of arthroplasty was interpositional arthroplasty with interposition of some other tissue like skin, muscle or tendon to keep inflammatory surfaces apart or excisional arthroplasty in which the joint surface and bone was removed leaving scar tissue to fill in the gap. Other forms of arthroplasty include resection(al) arthroplasty, resurfacing arthroplasty, mold arthroplasty, cup arthroplasty, silicone replacement arthroplasty, etc. Osteotomy to restore or modify joint congruity is also an arthroplasty.

For the last 45 years the most successful and common form of arthroplasty is the surgical replacement of arthritic or destructive or necrotic joint or joint surface with prosthesis. For example a hip joint that is affected by osteoarthritis may be replaced entirely (total hip arthroplasty) with a prosthetic hip. This would involve replacing both the acetabulum (hip socket) and the head and neck of the femur. The purpose of this procedure is to relieve pain, to restore range of motion and to improve walking ability, thus leading to the improvement of muscle strength.

The use of arthroscopic tools has been particularly important for injured patients. Arthroscopy was pioneered by Dr. Watanabe of Japan to perform minimally invasive cartilage surgery and re-constructions of torn ligaments. Arthroscopy helped patients recover from the surgery in a matter of days, rather than the weeks to months required by conventional, 'open' surgery. Knee arthroscopy is one of the most common operations performed by Orthopedic surgeons today and is often combined with meniscectomy or chondroplasty--both of which are removal of a torn cartilage.


Hip Replacement




In this X-ray, the patient’s right hip (on the left in the photograph) has been replaced, with the “ball” of this ball-and-socket joint replaced by a metal head that is set in the thighbone or femur and the socket replaced by a white plastic cup (clear in this X-ray).

Hip replacement is a medical procedure in which the hip joint is replaced by a synthetic implant. It is the cheapest, safest and most successful form of joint replacement surgery.


History


The earliest recorded attempts at hip replacement (Gluck T, 1891), which were carried out in Germany, used ivory to replace the femoral head (the ball on t In 1960 a Burmese Orthopaedic surgeon, Dr. San Baw (29 June 1922 – 7 December 1984), pioneered the use of ivory hip prostheses to replace ununited fractures of the neck of femur ('hip bones'), when he first used an ivory prosthesis to replace the fractured hip bone of an 83 year old Burmese Buddhist nun, Daw Punya. This was done while Dr San Baw was the chief of Orthopeadic surgery at Mandalay General Hospital in Manadalay, Burma. Dr San Baw used over 300 ivory hip replacements from the 1960s to 1980s. He presented a paper entitled 'Ivory hip replacements for ununited fractures of the neck of femur' at the conference of the British Orthopeadic Association held in London in September 1969. An 88% success rate was discerned in that Dr San Baw's patients ranging from the ages of 24 to 87 were able to walk, squat, ride the bicycle and play football a few weeks after their fractured hip bones were replaced with ivory prostheses. Dr San Baw's use of ivory was, at least in Burma during the 1960s, 1970s and 1980s (before the illicit ivory trade became rampant starting around the early 1990s) cheaper than metal. Moreover, due to the physical, mechanical, chemical, and biological qualities of ivory, it was found that there was a better 'biological bonding' of ivory with the human tissues nearby the ivory prostheses. An extract from Dr San Baw's paper, which he presented at the British Orthopeadic Association's Conference in 1969, is published in Journal of Bone and Joint Surgery (British edition), February 1970.

The modern artificial joint owes much to the work of John Charnley at Wrightington Hospital; his work in the field of tribology resulted in a design that completely replaced the other designs by the 1970s. Charnley's design consisted of 3 parts – (1) a metal (originally Stainless Steel) femoral component, (2) an Ultra high molecular weight polyethylene acetabular component, both of which were fixed to the bone using (3) special bone cement. The replacement joint, which was known as the Low Friction Arthroplasty, was lubricated with synovial fluid. The small femoral head (22.25mm) was chosen for its decreased wear rate however has relatively poor stability (the larger the head of a replacement the less likely it is to dislocate, but the more wear debris produced due to the increased surface area). For over two decades, the Charnley Low Friction Arthroplasty design was the most used system in the world, far surpassing the other available options (like McKee and Ring).



A titanium hip prosthesis, with a ceramic head and polyethylene acetabular cup.



Due to longer living patients and hip replacements being more common, longer term problems have been noticed in the use of polyethylene acetabular cups. The wear debris from these components can cause Osteolysis, and the bond between the femeral component and the femur weakens, and this may require more surgery.

Techniques

There are several different incisions or approaches used to access the hip joint including the posterior (Kocher), anterolateral (Hardinge or Liverpool), and anterior (Smith-Peterson).

The posterior (Kocher) approach accesses the joint through the back, taking Piriformis and Quadratus internis off the lesser trochanter. This approach gives excellent access to the acetabulum and preserves the hip abductors however is supposed to have a higher dislocation rate.

The anterolateral approach is the most commonly used approach as it is also the usual approach for trauma replacements (hemiarthroplasties). The approach requires division of the hip abductors (Gluteus Medius and Minimus) in order to access the joint. The abductors may be lifted up by cutting of the greater trochanter and reapplying it afterwards using cables (as per Charnley), or may be divided at there tendinous portion and repaired using sutures.

In contrast to the posterior approach and lateral approach, the anterior approach uses a natural interval between soft tissue to gain access to the hip joint. The interval is found between the sartorius and tensor fascia latae. The main disadvantages to the anterior approach are that it risks damage to the lateral femoral cutaneous nerve, and it is not widely available to the public because fewer surgeons have been trained in this technique. Dr. Kristaps Keggi has been a pioneer and advocate of this approach for nearly 30 years. More recently, this approach has been advocated by Zimmer. This approach is not commonly used for hip arthroplasty.


Joint Replacement


The modern total hip replacement was pioneered by Sir John Charnley in England in the 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, there have 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 knee replacement was developed by Dr. John Insall and Dr. Chitranjan Ranawat in New York. Uni-compartment knee replacement, in which only one side of an arthritic knee is replaced, is a smaller operation and has become popular recently.

Joint replacements are available for other joints on a limited basis, most notably shoulder, elbow, wrist and ankle.

In recent years, surface replacement of joints, in particular the hip joint, have become more popular amongst younger and more active patients. This type of operation delays the need for the more traditional and less bone-conserving total hip replacement, but carries significant risks of early failure from fracture and bone death.

One of the main problems with joint replacements is wear of the bearing surfaces of components. This can lead to damage to surrounding bone and contribute to eventual failure of the implant. Use of alternative bearing surfaces has increased in recent years, particularly in younger patients, in an attempt to improve the wear characteristics of joint replacement components. These include ceramics and all-metal implants (as opposed to the original metal-on-plastic). The plastic (actually ultra high molecular weight polyethylene) can also been altered in ways that may improve wear characteristics.

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