Landmarks in Orthopedics: A 20-Year Perspective (Medscape)
Editor’s Note
To commemorate Medscape’s 20th anniversary, we asked Ira H. Kirschenbaum, MD, chairman of the Department of Orthopaedics at Bronx-Lebanon Hospital Center, Bronx, New York, who is also board chairman of Medscape Orthopedics, to sketch in some of the landmark developments in orthopedics over the past 20 years. Here is the big picture, in Dr Kirschenbaum’s perspective.
A Look Back Over Two Decades
Probably the greatest advance in orthopedics in the past two decades has been the way we look at the success or failure of treatment interventions. There has been a shift in focus on what the surgeon views as a success vs what the patient views a success.
In 1995, we thought we knew that when a patient reached certain postsurgical parameters, it was called a success. We have since realized that the patient’s view of satisfaction is more important. In 2015, we talk about “patient-reported outcomes” rather than specific surgical scoring systems. That has been a radical shift.
We have also seen a shift in the focus from looking only at long-term clinical results of surgery to looking at more immediate results. In 2015, we care much more about enhanced, pain-free surgery and rapid recovery. Whether this is an emotional patient satisfaction issue or a practical issue of earlier return to function is unclear, but no doubt it dominates the discussion in a way that it didn’t back in 1995.
In addition, device companies in every orthopedic subspecialty have consolidated. In 1995, the number of major “metal” companies was greater than what we have today. While one can argue that this has brought greater and necessary standardization, it can also be argued that innovation has been hurt by this consolidation.
In 2015, the search for biologics for treatment of joint injuries or diseases over devices has not reached its potential. In 1995, some predicted that the next decades would bring biologic solutions to many orthopedic problems. This has yet to be seen.
Advances in Orthopedic Subspecialties
There have been some more notable surgical changes over the past two decades. In hand surgery, for example, the intervention of distal radial plating as a standard of treatment has allowed early and improved function in radius fractures.
Fracture care has morphed into limited surgical exposure procedures as well. In joint replacement, the appreciation of improved bearing surfaces has been a major advance, increasing the longevity of implants.In shoulder surgery, the incredible advances in surgical repair arthroscopically have pretty much replaced open procedures.
There has been an explosion in fixation devices in spine surgery, although the final chapter on patient outcomes research on this advance has yet to be written.
Advances in wound healing techniques in foot surgery have brought remarkable benefits to patients.
Reimbursement Challenges
We have also appreciated the value of efficient and safe medical-delivery practices. A treatment plan administered in a consistent and sound manner will produce fewer errors and complications.
Once-optional fellowship training has become not only a gold standard for surgical competence but pretty much a necessity.
Problematically, reimbursement for procedures has plummeted while the cost to surgeons to deliver care has increased. Whether this will affect the pace of innovation or the number of residents who choose orthopedics as a specialty remains to be seen.