doctor checking patient's shoulder

How has orthopedic surgery improved for both doctors and patients?

This article originally appeared on Community Health Magazine. 

Make no bones about it: Since its inception, orthopedic medicine has come a long way. And Bonnie Clendening is among the millions of Americans who have undergone an orthopedic surgery and witnessed its evolution firsthand.

Clendening, 77, had knee replacement surgery last summer and says five years prior, she had difficulty walking, along with pain and swelling in her legs caused by peripheral artery disease and bone-on-bone rubbing in both knees.

“I knew that I needed a knee replacement, but I could not find a surgeon willing to do the surgery because I’m considered a high-risk patient,” says Clendening of Bloomington, Indiana, who’s retired from graduate records work in the speech communications department at Indiana University.

Even though it was just last July, several doctors would not take her case, she says, adding that it seemed strange given that knee replacements have been around since the early 1970s. “But when I connected with a surgeon at the IU Health Hip and Knee Center, he said they would do it,” Clendening says.

The team at the IU Health Hip and Knee Center at Saxony Hospital take on high-risk patients, Clendening says, and they utilize strategies to minimize the infection risk, as well as emphasize patient optimization before surgery, which appealed to her.

“With their help, we decided that the right knee would be done first because it was a bit worse,” she says. “I was really sold when I found out I wouldn’t need to wear compression hose, something I had feared coming into this.”

The beginning

Going back even further, the modern term “orthopedics” was coined in the 1700s, according to the National Center for Biotechnology Information at the National Institutes of Health. And during primitive times is when orthopedic principles were beginning to be developed and used — the Egyptians used these practices, and they described ways of identifying and managing common orthopedic conditions.

The Romans and Greeks subsequently started studying medicine in a systematic manner, and they greatly improved the understanding of orthopedic anatomy and surgical techniques. During the Middle Ages, rapid advancement was noted during the Renaissance, including descriptions of various injuries, improvements in surgical technique, and development of orthopedic hospitals, according to the NCBI. Collectively, these advancements helped pave the way for modern orthopedics.

“Fifty years ago, there were no good options for patients with hip or knee arthritis,” says Dr. Lucian Warth, an orthopedic surgeon at the IU Health Hip and Knee Center at Saxony Hospital in Fishers, Indiana. “Improvements in fixation and bearing surfaces have led even further improved outcomes and longevity, allowing surgeons to help even younger, higher-demand patients without fear that the components would wear out so quickly.”

The scientific and technological advancements in orthopedic medicine have been invaluable throughout the years. Whether it’s smarter implants, a better focus on patient care via smart devices, surgical innovations with enhanced tools or imaging and prosthesis upgrades, vast improvements and changes are continually on the horizon, benefiting both the patient and the doctor.

Evolving practices

Dr. James C. Wittig, chairman of the Department of Orthopedics at Morristown Medical Center in Morristown, New Jersey, says it’s been an “incredible time of innovation” for the orthopedic field over the past few decades.

“We saw the emergence of sophisticated robot and navigation devices that helped us more easily and accurately perform joint replacements and orthopedic oncology (limb-sparing) surgeries, high-quality prosthetics, customized implants and 3-D printing for joints and customized pieces,” Wittig says.

In his field of orthopedic oncology, he says the best way to illustrate this period of innovation is with his specialty field of orthopedic oncology — surgery for sarcomas or bone tumors.

“Years ago, if a patient had one of these, more than half would likely lose the limb with the tumor,” he says. “Because of advancements in imaging, MRI, chemotherapy and better optimization of the patients before the surgery, as well as a commitment across specialties to work together for the best outcome for the patient, it’s incredibly rare now that a patient would lose a limb.”

Over the past 30 years, modern knee replacement surgery has been refined and improved and is now one of the most successful surgical procedures for the treatment of knee arthritis, according to the Cleveland Clinic. Assuming there are no breakthrough preventive treatments for the conditions that lead to total knee arthroplasty, by the year 2030 the American Academy of Orthopaedic Surgeons estimates that about 450,000 total knee arthroplasty procedures will be performed every year. This is a large increase from the 245,000 total knee replacements performed in 1996.

Problems in the muscular skeletal system have always been present, whether it be trauma/injury or disease affecting joints, e.g., arthritis or degenerative conditions, which are still not fully understood, says Dr. Alejandro Badia, a hand and upper extremity orthopedic surgeon at the Badia Hand to Shoulder Center in Doral, Florida.

“Hippocrates himself was actually famous for a particular method of treating a shoulder dislocation, which is a common traumatic injury,” Badia says. “Compared to 50 years ago, the big change is that we now fix many fractures that previously were treated in splints or casts or even traction. At this point, we treat fractures with plates and screws or rods and we get people mobilized sometimes even the same day. So, 50 years ago none of that was possible, while 20 years ago we had much of what we have now.”

One of the most common orthopedic surgeries, joint replacement surgery is always advancing in terms of technology and technique, says Dr. Jesse Anderson, an orthopedic surgeon at Banner University Medical Center in Phoenix.

“The public is aware of joint replacement, but what is not as well understood is that almost every joint in the body can now be replaced,” Badia says. “Some decades ago it was only hips and knees, but now it includes toe joints, finger joints, joints between the vertebrae, cervical and lumbar, can all be replaced. That is a huge change compared to years ago where many times fusions were done, which leads to loss in motion and acceleration of pain in the adjacent joints.”

Another common surgery that’s seeing advancements in the tech and science realm is anterior cruciate ligament injury, or ACL tears, says Dr. Travis Menge, an orthopedic surgeon and sports medicine specialist at Spectrum Health Medical Group in Grand Rapids, Michigan.

“As a sports medicine surgeon, many common injuries I see include ACL tears, rotator cuff injuries and labral tears of the hip,” Menge says. “We have made significant technological advancements in the implants we used to fix these injuries, as well as the surgical techniques to allow less pain and a faster postoperative recovery. For example, I perform ACL reconstructions utilizing a quadriceps tendon graft in a very minimally invasive fashion. This graft has gained significant popularity in the past 10 years compared to more traditional alternatives due to its many advantages, such as smaller incisions, less postoperative pain and more consistent graft size. It truly has been an excellent option for many patients, and the outcomes continue to be excellent.”

Another area that is not new but has become more widespread is arthroscopic surgery, according to Badia. “This is of particular interest for me as the public is well aware of knee and shoulder arthroscopy,” he says. “But at this point almost every joint in the upper extremity can be treated arthroscopically from the wrist, elbow and even the base of the thumb and the joints between the fingers and palm. … They are even treated with a small 1.9 mm arthroscope.”

Biologics, in which surgeons facilitate the body to heal itself, also are catching waves in the orthopedic industry, according to Badia.

“In orthopedics, perhaps the greatest, more recent advance that has yet been fully worked out is the area of orthobiologics, which the public often terms regenerative medicine.” Badia says. “This is allowing or facilitating the body to augment its own healing process, and perhaps in the near future reverse some of the degenerative processes such as osteoarthritis, which is a still-not-understood degeneration of the articular or joint cartilage, which has not been able to be cured up until this time. So that would be basically the use of injecting substances, most of them autologous, or coming from your own body, to treat a variety of conditions.”

Patient perspective

Aside from the surgeon’s point of view, patient optimization before, during and after surgery, as well as more streamlined care delivery models that focus on the patient’s journey from pre-op to post-op recovery are front and center in today’s orthopedic medicine advancements.

According to Warth of Saxony Hospital, pain control, blood loss, longevity and fixation are four areas of advancements that surgeons are and should be focusing on.

“Improved pain control has led to improved patient satisfaction with less narcotic utilization through a multimodal regimen,” he says. “Less narcotic leads to less nausea, less sleepiness, less constipation and less addiction. Patients get up and moving with therapy faster, and subsequently can go home much earlier in a safe manner.”

In particular, hip surgery has made significant strides and grown significantly over the past 10 to 15 years when it comes to pain control, Menge says.

“As we learn more about common injuries of the hip including labral tears and femoral acetabular impingement, we are better able to treat patients with a minimally invasive arthroscopic approach,” Menge says. “In the past, young patients with hip pain that did not respond to conservative treatments such as physical therapy or medications were told to manage the pain as best they could until they wished to proceed with hip replacement surgery. Now, we are better able to identify and treat hip pain in young, active individuals with a comprehensive, literature-guided approach using techniques in arthroscopic hip surgery and joint preservation procedures. We are able to return young patients back to their prior level of activity at a very high rate and allow them to continue living there lives without debilitating hip pain.”

The way screws and plates are inserted is also improving. “Thirty years ago, all implants were cemented in. They were fixed to the bone with high quality cement. This fixation would break down over time but could often be expected to last 15 to 20 years or longer. We have developed cementless ‘press fit’ technol ogy with titanium implants where the bone literally grow onto the components. This type of fixation has the potential to never break down, and subsequently is an excellent option for younger more active patients in both hip and knee replacement,” Warth says.

And in addition to improved fixation, improved bearing surfaces have led to improved longevity of the implants, Warth says.

“The polyethylene (plastic) bearing surfaces for hip and knee replacement have improved dramatically. The wear characteristics of the newer ‘polys’ are much better than the older ‘conventional’ polys,” he says. “With improved fixation of the metal implants to the bone, and improved plastics for the bearing surface, we hope that the implants can last 20 to 30 years or longer potentially. Longer follow-up is needed to prove this, as we have not been using the new polys for 20-30 years, but the midterm 10-15 year follow-up demonstrates significantly improved longevity/wear.”

When it comes to blood loss, 15 to 20 years ago, with hip or knee replacement it was common to require a blood transfusion after surgery, according to Warth. “With the addition of a very safe medication, tranexamic acid, during the operation, blood loss and need for transfusion had decreased dramatically,” he says.

Badia in Doral, Florida, says the advances in the orthopedic field have made incredible strides in relieving people of pain and discomfort because they have affected the joint, by replacing or modifying, which is the most common source of pain in the body and the goal is also to improve mobility.

“So, a joint replacement basically gives a new joint, taking care of all three issues; pain, discomfort and mobility,” he says. “The same goes for arthroscopy but will not replace a joint, but in a minimally invasive way, again can help relieve pain. Also with orthobiologics we are simply injecting into the joint.

Quicker recovery

According to Anderson at Banner University Medical Center in Phoenix, recovery and healing time and surgery duration are “perhaps the biggest change that has occurred in the field of joint replacement in the last five years. When joint replacements were completed in the ’90s, a patient would be in hospital for a week, have major problems with nausea, and often be delayed in resuming normal activity,” he says. “Now with advancements, we have patients walking within hours of surgery, home within a day or two and experiencing far fewer postoperative symptoms.”

These improvements in patient experience are less related to the actions of surgeons and more related to changes in approaches to anesthesia and pain control, he says. “Spinal anesthetic instead of a general anesthetic, nerve blocks instead of opioids, and better combinations of post-operative anti-nausea medications have improved the post operative experience significantly,” he says.

Dr. Jason Weisstein, an orthopedic surgeon and medical director of orthopedics at Modernizing Medicine in Colorado Springs, Colorado, says: “We now use nerve blocks, non-opioid pain control, and better anti-inflammatories that better control pain and allow the patient to begin to move again with less side effects than previous medications,” Weisstein says. “We have made significant advancements in early detection and proper treatment of many musculoskeletal injuries that previously may have gone undetected and led to early joint degeneration or arthritis.”

“For example, hip arthroscopy has been a field within orthopedics that has exploded in popularity over the past 10 to 15 years as a treatment for conditions such as labral tears, impingement, or cartilage injury,” Weisstein adds. “We are now able to diagnose these conditions and treat them with a minimally-invasive arthroscopic approach to better preserve the native hip joint and delay progressive degenerative changes that can lead to early osteoarthritis. This allows patients to continue to lead a healthy, active lifestyle much longer than they previously could have enjoyed.”

Another big advancement in the last 50 years was the development and continuous innovation of total joints, Weisstein says. This has significantly improved the outcome of major trauma injuries and fractures.

“Additionally, surgical instrumentation and techniques have evolved over the last 20 years that created a shift from open surgery to arthroscopic procedures that are minimally invasive and have much shorter recovery times and fewer complications. In the last few years, there have bewwen great strides made in stem cell and cartilage restoration technologies that allow for a biologic reconstruction of orthopedic injuries and joints, which creates a more natural healing response for patients and can prevent or delay the need for total joint replacement,” Weisstein says.

Orthopedic surgeon Wittig in Morristown, New Jersey, says the fact that more focus is being put on patients is a huge advancement and improvement in the field.

“I think the most important advancement in orthopedic medicine right now is actually the work we’re oing before the patient has surgery,” he says. “We’re working across multidisciplinary teams to optimize each patient’s health before their surgery. Whether that’s weight loss, smoking cessation or getting a chronic disease like diabetes under control, ensuring the patient is as healthy as they can be before their surgery has led to more positive patient outcomes and a faster return to a better quality of life.”

Anything orthopedic surgeons do — scientific, robotic, technically — is designed to help optimize patient outcomes, make the procedure safe for the patient, and ultimately give them a better quality of life and range of motion than before they had the surgery, Wittig says.

“The emergence of minimally invasive surgeries, where instruments are inserted through small incisions rather than a more invasive surgery, has led to better outcomes, and patients being able to ambulate shortly after their surgery,” he adds.

Simultaneously, surgeons were often incredibly cautious not to let patients with major surgeries ambulate until they had weeks of rehabilitation, according to Wittig. This often involved days in the hospital, followed by time in a rehabilitation or skilled nursing facility. Now, because of advancements in minimally invasive techniques, pain control, the comfort of physicians performing these surgeries, and more literature supporting early ambulation, patients are encouraged to walk within hours of their surgery, and most are able to go home the next day.

Clendening says after her surgery at Saxony Hospital’s IU Health Hip and Knee Center, she recovered “relatively quickly” and was able to walk with a walker within a few days. She was able to get around pretty well when she was going to rehab, too.

“Now, I can walk without a walker, but I occasionally still use a cane for balance unrelated to my knee,” she says. “I have no regrets and plan to get my other knee replaced soon at the IU Health Hip and Knee Center.”

Many recovery times have been shortened significantly because of better imaging, minimally invasive technology, and more enhanced devices, Wittig says.

“The focus on earlier ambulation has also greatly reduced recovery times,” he says. “Future modifications in joint replacement, materials, mechanical designs will prove beneficial but often take years to develop. While these are some of the most necessary innovations, we need to focus on improving patient-specific factors to continue to optimize outcomes. The field has far from reached its limits in terms of innovation.”

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