Selasa, 14 April 2009

sejarah orthopaedi dunia

 THE MODERN ERA (2OTH CENTURY ORTHOPAEDICS)  
  THE TURN OF THE CENTURY.

The early 1900's can be seen as a great turning point for Orthopaedics. 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.
  
  
Probably the most important figure at the turn of the century was Sir Robert Jones (1855-1933). Robert JonesIndeed many would argue that he was the greatest orthopaedic surgeon that the world had ever seen. It was said that when Jones operated, Time stood still. Jones was a nephew of the great Hugh Owen Thomas and became one of his apprentices in Liverpool. In 1896, Jones published the first report of the clinical use of an X-ray to locate a bullet in a wrist. He founded several associations and Orthopaedic hospitals. Jones wrote several important books such as Injuries of Joints in 1915 and Notes on Military Orthopaedics in 1917. His textbook Orthopaedic Surgery is said to be the first to have dealt systematically with the diagnosis and treatment of fresh fractures. In World War I, Jones headed the orthopaedic section of the British Forces. Jones was an advocate of tendon transplantation, bone grafting, and other conservative, restorative procedures.  
  WORLD WAR ONE.

It must be noted that war has played an important part in Orthopaedic history. Many of our greatest contributors were military surgeons and it is remarkable how much we have learnt about ancient Greek orthopaedics through Homer's description of the Trojan War alone. It is interesting to note that many of the achievements during and after World War I were not related directly to traumatic injuries received at war. However, it can be said that Orthopaedics was definitely seen as a separate specialty after World War I and that this was the first major war where aseptic techniques were saving many more lives than in the past wars.
   

  Jules Tinel (1879-1952), of Rouen and Paris, was a neurologist in the First World War and first described Tinel's sign in 1917. This related to nerve injuries, and on percussion of the nerve below the site of nerve injury, formication was elicited if nerve fibres were degenerating. If this was absent, there was a bad prognosis.  
  
  Paul Budd Magnuson (1884-1968) was an American who assisted in orthopaedic services in World War I and with this and his own practice in the slaughterhouse area Magnussonacquired much experience in trauma. He wrote a textbook called Fractures and in this described complete debridement of the knee joint for osteoarthrosis, including synovitis and other degenerative lesions. This involved the removal of osteophytes and damaged menisci, shaving of the cartilage to the bare bone and if necessary, narrowing of the patella.  
  Following the war, an American by the name of Paul N. Jepson (1893-1949) Jepsoncontinued Volkmann's fine work and reproduced ischaemic contracture in animals. In his paper of 1921, he wrote that ischaemic contractures could be prevented by prompt surgical decompression. In 1927, a Russian called M. J. Arinkin introduced sternal puncture as a diagnostic procedure while working at the Military Medical Clinic in Leningrad. This can be applied in the study of metastatic bone disease.  
 
 
 
  In the chain of great surgeons that followed Hugh Owen Thomas, came Thomas Porter McMurray (1888-1949),McMurray who worked for Robert Jones. McMurray was born in Belfast, but worked in Liverpool. His operative dexterity was renowned, for he could remove an entire meniscus in five minutes and disarticulate a hip in ten minutes! In 1928, McMurray published a paper on internal derangements of the knee. Here he introduced his sign for a torn meniscus, McMurray's sign. An operation was also named after him as McMurray was the first to perform a displacement osteotomy for un-united fractures of the femoral neck and arthrosis of the hip.  
  In 1932, Winthrop Morgan Phelps (1894-) published an important paper on cerebral birth injuries. Here he classified the different types, described the variability in its aetiology and a modern approach to managing these cases. Phelps was the professor of orthopaedic surgery at Yale University and director of the Children's Rehabilitation Centre at Baltimore. He made immense contributions to the management of cerebral palsy and stimulated needed interest in the disorder.

Ricardo Galeazzi (1866-1952) of Milan had great experience in congenital dislocation of the hip and structural scoliosis, but is best known for the forearm fracture that he described in 1934. This is the Galeazzi fracture, which is actually more common than Monteggia's fracture.

WORLD WAR TWO.

The knowledge learnt in fighting World War I helped in treating the casualties of World War II. In the Second World War, there were less amputations performed, there was less gangrene, better measures for fixation of fractures and we must not forget the importance of penicillin (whose effects were discovered by Sir Alexander Fleming in 1928). The Germans needed quick measures to restore their fighters to optimal fighting potential and developed a number of nailing procedures during this period. Together with this the Americans were now making more contributions than ever before.  

  
 One of these Americans was Willis Campbell (1880-1941) William Campbellof Memphis, Tennessee who was the main advocate of interpositional arthroplasty at that time. Campbell used a free autogenous transplant of fascia lata from the thigh in a double layer, the smooth surface facing internally. He aimed not at restoring the original anatomy, but at restoring function. Campbell was also a key figure in bone grafting and performed inlay full thickness grafts for non-union fixed with screws of beef bone.  

  Gerhard Kuntscher (1900-1972) served in the German army during the Second World War and published his Knutsherrevolutionary procedure in the opening months of the war. His work was concerned with the intramedullary nailing of fractures of the shafts of long bones and his name is associated with the nail. Kuntscher was prejudiced academically and was never offered a chair. Martin Kirschner (1879-1942) was from Greifswald, Germany and was also known for his methods of fixation, in particular for the Kirschner or K-wire. He also performed the first successful pulmonary embolectomy.  

  Sir Reginald Watson-Jones (1902-1972) was another famous figure from Liverpool. During World War II, he was among the leading teacher in fracture therapy. Watson-Jones published Fractures and Joint Injuries in 1940, which remained a standard reference for several decades and was translated into many languages.  

  In 1942, Albert J. Schein (1910- ) of New York, published a paper which established Gaucher's disease as a specific and not too rare cause of hip disease. This was very important, as many such cases were being miss-diagnosed as Perthes' disease. Also in 1942, another American, Austin T. MooreAustin Moore (1899-1963) reported and performed the first metallic hip replacement. He had replaced, for the first time, the entire upper portion of the femur with a vitallium prosthesis a foot long. It had a round head, loops for muscle attachments, and a lower end, which slipped over the cut shaft and bolted to it. Over the years, the design of the prosthesis and the procedure improved. Consequently, there is one type of prosthesis called the Austin-Moore, which is still used today.  
  AFTER THE WARS.

In the years following the war, orthopaedic surgeons sought to perfect their treatment of fractures, in particular with the use of metallic pins and wires for fixation. With the introduction of alloys that could be used effectively, there was also a new wave of prostheses, which are developing for treatment of arthritis as well as problematic fractures. Antibiotics have greatly improved and so have our diagnostic devices. 
  
  
  In 1948, Knut Lindblom from Stockholm, published his technique of direct injection of the lumbar intervertebral discs with radio-opaque dye. This reproduced the symptoms if done at the level of the lesion and showed the nature of the rupture.

In 1949, H. Lowry Rush (1879-1965) used pins made of especially hardened stainless steel for treating long bone fractures  

  In 1950, the great Sir John Charnley Charnley(1911-1982) of Manchester wrote a classic book on the non-operative approach to fractures, The Closed Treatment of Common Fractures. Charnley is however renowned as the effective innovator of the total hip replacement. Among other principal contributions was the development of a self-curing acrylic cement to anchor both the femoral replacement and the acetabular cup. Charnley was also interested in joint friction, replacing the Teflon with the use of high-density polyethylene. Many of the total hip replacements that he performed in the 1960's are still sound and serving their patients effectively.  

  As an Australian studying Orthopaedics, it is imperative that I add a great Australian Orthopaedic surgeon who is also a delightful teacher of Orthopaedics. Ronald Lawrie Huckstep (b.1926) graduated from the Middlesex Hospital, London in 1952. He then worked in Kampala, Uganda where he contributed greatly to our understanding of poliomyelitis. There he performed operations to improve the lives of people with severe congenital as well as acquired deformities. Huckstep's ingenuity also led him to develop many splints and other useful devices, as well as new methods for fracture fixation. 
   
  He became Foundation Professor of Traumatic and Orthopaedic Surgery at the University of New South Wales in 1972 and has published five books on typhoid fever, poliomyelitis, trauma and orthopaedics plus a quiz atlas.

The preservation of standards of care and independence of our profession from political and commercial interference is important too. Australia has been fortunate in this regard to have Bruce D. Shepherd, (1932- ). A larger than life Orthopaedic Surgeon who has influenced most of the young orthopods in Sydney, established centres for the care of deaf and spastic children (The Shepherd Centre) and almost single-handedly saved private practice in Australia in the 1980's. 
 




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