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What is Orthopaedic Surgery?

This frequent question embodies other implicit questions. Those who ask this question might be asking “what services can an orthopaedic surgeon offer to my benefit?’ or “what are the qualifications of an orthopaedic surgeon and how is an orthopaedic surgeon constrained to practice within his capacities?”. There is yet another, more oblique, question which is “what can an orthopaedic surgeon find out about me which I may not be aware of?”

 

In attempting a definition the dynamic nature of professional healthcare and orthopaedic surgery needs emphasis.

 

Originally orthopaedic surgeons had little training, and their skills were evolved empirically. The “fathers” of modern orthopaedic surgery were intellectually impoverished by today’s standards. However, orthopaedic surgery evolved, along with other healthcare specialities, to become highly scientific, and well regulated both by the orthopaedic community and by statutory legislation.

 

Currently, in developed urban areas, the science of orthopaedic surgery had diverged into numerous sub-specialities and in there is now no such thing as an “orthopaedic surgeon”. Instead there are at least 12 sub-specialities which include spinal surgery, surgery of the hand, the management of peripheral trauma, paediatric orthopaedic surgery, microsurgery and re-implantation surgery, geriatric orthopaedic surgery and more. Naturally, the more distant the orthopaedic surgeon is from urban centres, so the more generalized he would be expected to be and such “general orthopaedic surgeons” can be exceedingly capable and diverse in their skills.

 

Many of the specialities mentioned can overlap with the fields which have other designations. For example many plastic surgeons are involved in surgery of the hand and neurosurgeons will overlap with orthopaedic surgeons in the management of vertebral pathology. Microsurgery has evolved from a large number of different specialities. The name given to the type of surgeon is probably irrelevant provided that in their ascendency into a super-speciality that individual is appropriately trained. It might matter little whether the individuals with a backgrounds in orthopaedic surgery or neurosurgery, manage vertebral pathology, given that proviso.

 

The foundation treatment of orthopaedic surgeons is one of the general physician. Orthopaedic surgeons are, first and foremost, “doctors”. Thereafter they would train (ideally) as surgeons in the broad sense with capacities in general surgery and other realms such as plastic surgery or neurosurgery. Only after that would the orthopaedic surgeon begin “post-graduate” training in a super speciality, such as those listed. The period of training a super specialist orthopaedic surgeon may well be 15 or more years.

 

Therefore the entrance gate to orthopaedic surgery is selection into a medical school. Because the profession has prestige and expectations of high income, competition to enter a medical school has been exceedingly high. One can therefore expect that these individuals are pre-selected for superior capabilities.

 

Since the attractions of entering healthcare are great, it is to be expected that there would be many “Johnny-come-lately” aspirants. Some of these have not succeeded in gaining admission to formal medical schools or might choose an easier (and cheaper) route. After (sometimes fierce) jostling, these “alternative” practitioners have often succeeded in becoming recognised as “legitimate” health carers. One example is chiropractic and the reader is recommended to explore the origin and evolution of this field.

 

Another parallel with orthopaedic surgery is the overlap between the super speciality of orthopaedic foot and ankle surgery with podiatry.

 

The advantage that the orthopaedic surgeon has over other competitors for healthcare is the training as a general physician. The reason why this is a benefit to the patient is to counter the superficial belief that the treatment of a particular region of the body can be done in isolation of the patient as a whole.

That is wrong. Body-wide illnesses can percolate into every system of the body and a sound knowledge of broad-based general medicine is, many would say, imperative. For example pain in the foot might originate from a brain tumour, an autoimmune disease, a cyst in the spinal cord, a parasitic infection and much more.

 

There are also some curiosities. One might wonder why there has been no attempt by the “parallel” specialities to undertake surgery of the hand. This has happened in surgery of the foot (with the evolution of the podiatrist). Why not the hand?   One reason might be the misconception that the intricacy and the delicacy of the hand are such that it could not be entrusted to anyone other than a fully medically trained super specialist, whereas the foot would be considered a relatively simple arena. This is also fallacious since the complexities and importance of the feet probably exceed that of the hand (or so say those who are trained as super specialists in both hand surgery and foot surgery).

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How does Chiropractic work?

Chiropractic was evolved as an empirical trade by DD Palmer in the late 1800s.  He was a teacher and grocer, who later became a “magnetic healer”.  Nine years later he conceived the idea of chiropractic.  His technique was based on the “adjustment” of bones. Palmer claimed that “a subluxed vertebra… is the cause of 95% of all diseases… the other 5% is caused by displaced joints other than those of the vertebral column“.

After a court case which ruled that chiropractic was a legitimate form of therapy it was marketed as a science and DD Palmer later claimed to be a philosopher.

DD Palmer started a school of chiropractic, perhaps not surprising with his teaching background, which allowed chiropractic to proliferate.  He repeatedly contended that he was not practicing medicine and had been imprisoned for practicing medicine without a licence.  His son took over the school of chiropractic and considered declaring chiropractic a religion (perhaps for the tax benefits available in the USA at that date).

The object of this post is not to give a critical overview of chiropractic.  Instead Paul Ingraham’s excellent commentary at http://saveyourself.ca is recommended.

What is unlikely to be disputed is that chiropractic is a large industry, and clearly there must be client satisfaction for it to survive commercially.

Where patient benefit results a “scientific” explanation might be of secondary importance. However an importance exists in that by an understanding the degree or frequency of benefit might be improved, or extrapolated to other illnesses.

Unfortunately chiropractors have proffered many explanations of their treatment which have little rational support. Often the “explanations” are no more than hollow jargonizing. It seems that a (perhaps the main) reason is to enhance their prestige and credibility as “science based” practitioners. Some claims (such as “correcting leg length inequality”) are fraudulent. Ironically it is this attempt at establishing “credibility” which does most to discredit chiropractic. The chiropractor could be well advised not to explain the reasons why their treatment is beneficial, and simply offer the service, letting it speak by results.

The foundation of chiropractic has been the management of vertebral pain by manipulative treatment, particularly rotary and hyperextension manipulation.  A “successful” manipulation, usually associated with satisfying clicks from the vertebral column, often dramatically lessens pain.

The question becomes “where does the pain come from and why does ‘clicking’ help? ”

In the 1970s I harvested a large number of cadaveric vertebrae. These vertebrae were stereo-radiographed, dissected, and after removal of soft tissue, using the stereo-radiograms, reassembled in the in vivo positions.

One purpose was to familiarize vertebral surgeons (myself included) with the large variation in the anatomy of the vertebral column.

In addition the facet joints anatomy and the mechanics of the facet joints in relation to orientation and instant locus of movement in to each other were explored. From that was extrapolated the relationship to the vectored loads on the intervertebral disc and the inter-segmental locus of movement.

In another study arthrograms were performed on a number of facet joints in these cadaveric spines with the soft tissues intact.  An example is below.

In the context of this paper, the most important finding of this research was the presence of an operculum in the facet joint capsule, which allowed passage through the capsule of a neurovascular bundle, into the intra-articular space.  Also demonstrated were features of the intra-articular fat within the capsule. [A later post will consider the function of the intra-articular fat.]

Much vertebral pain is clearly mechanical (because of its instant onset), and chiropractic (at least in its manipulative therapy guise) must provide a mechanical solution in order to cause the instant relief from pain. Therefore a mechanical sequence must be sought in any explanation of chiropractic benefit.

This paper postulates that the origin of some back pain (and the associated muscular spasm) is that the intra/extra-articular fat became entrapped in the operculum in the capsule.  This could explain the sudden onset of the pain. What the rotary manipulation does is to produce an intra-articular cavitation effect (and hence the click). Cavitation produces sudden changes of pressure within the joint capsule which forces the entrapped fat from its “locked” position in the operculum: Hence the instant relief.

Supporting this hypothesis was the beneficial treatment of “acute lumbar pain” by intra-articular injections of local anaesthetic and cortico steroid into the articular joints under radiological imaging, of which I performed many thousands, in the early 1970s.  The percentage of success was high, usually with an instant relief of pain comparable to that of successful chiropractic.  The long-term results appeared to be better than chiropractic.  A possible explanation for the latter is that the steroid produced an atrophy of the fat and hence less likelihood of future entrapment.  [Whether this atrophy caused some loss of proprioceptive capacity I don’t know, but it was one of my concerns at the time.]

A further benefit was the radiological demonstration of the vertebrae, a necessary precaution often not performed by the chiropractor. As a result of chiropractors missing these primary pathologies, and perhaps excessive forces, a number of patients were paralyzed or died when treated by chiropractic. This acted as a disincentive for some chiropractors who then replaced manipulative management with other techniques, such as “wedging”, or ventured into dietary supplements and other areas in order to continue their trade. Some claim or imply the special capacity to offer “holistic” treatment.

http://www.sciencebase.com/science-blog/how-does-chiropractic-work

 

What is meant by this, and the reason that superiority of chiropractic over other forms of healthcare in this respect is far from clear.

 

[Documentation that injury can follow chiropractic has been requested. Under the search term “Chiropractic causing paralysis” Google provided 155,000 entries.

http://www.medscape.com/viewarticle/726445_2

The papar http://www.ptjournal.org/cgi/content/full/79/1/50 is a comprehensive study.]