Orthopedic Surgery

Orthopedic surgery (also spelled orthopaedic surgery) is the branch of surgery concerned with the musculoskeletal system, including bones, joints, cartilage, ligaments, tendons, and muscles. It addresses acute trauma, overuse injuries, degenerative conditions such as osteoarthritis, congenital deformities, infections, and tumors. Although the name suggests operations alone, orthopedic care usually begins with non-surgical measures such as bracing, medication, injections, and physical therapy, and surgery is reserved for cases where symptoms persist, function is limited, or a structural problem is unlikely to heal without an operation.

The field matters because musculoskeletal conditions are among the commonest causes of pain and disability worldwide, and their burden grows with population ageing. Its procedures, such as fracture fixation and joint replacement, are among the most widely performed operations in modern medicine. Wartime trauma, notably in World War I, repeatedly accelerated its techniques, and the twentieth century brought implants, imaging, and minimally invasive methods that changed practice.

This entry traces the field from its origins through its core principles: diagnosis, indications for surgery, and the main procedures, including fracture care, arthroplasty, arthroscopy, spine surgery, soft-tissue reconstruction, pediatric and oncologic work, and subspecialties. It then covers implant science, perioperative care, rehabilitation, technology, training, global access, and the unresolved evidence debates surrounding the discipline.

Definition and scope

Orthopedic surgery, also called orthopaedics, is the branch of surgery concerned with conditions involving the musculoskeletal system. The name can be misleading, because the wider specialty is not limited to operations. Some sources define it as a medical specialty that focuses on injuries and diseases of the body's musculoskeletal system, while others frame it as a branch of surgery. The practical distinction is between the operative discipline, which is carried out by surgeons using surgical techniques, and the broader specialty, which also includes treating many musculoskeletal conditions without surgery, using medication, exercise and other rehabilitative or alternative therapies. Orthopedic surgeons therefore work across diagnosis, injection and casting, bracing, rehabilitation, and prevention, not only in the operating room.

The spelling variants reflect regional convention rather than different meanings. One source puts it plainly: there isn't a difference between "orthopaedics" and "orthopedics," at least not in regards to meaning. The longer form retains the æ ligature of its Greek and Latin roots, and in North America the shortened form is widely used. In the United States, the majority of college, university, and residency programmes, and even the American Academy of Orthopaedic Surgeons, still use the spelling with the digraph "ae", though hospitals usually use the shortened form. Elsewhere, in Canada, both spellings are acceptable; "orthopaedics" is the normal spelling in the UK. Usage is therefore a matter of audience and institutional style rather than substance.

Tissues treated

The specialty's domain is the locomotor apparatus as a whole. The core tissues are bones, joints, ligaments, tendons, muscles, and nerves. Each has a distinct role: ligaments are strong bands of connective tissue that hold bones together, while tendons connect muscles to bones, allowing for the transmission of forces and movement, and nerves transmit signals between the brain and muscles, controlling voluntary and involuntary actions. Articular cartilage, which covers the ends of bones within joints, is also central to many of the conditions treated, and the bone itself is treated both as a structural frame and as a living tissue that can fracture, become infected, or develop tumors. Because these tissues function together, a problem in one often affects the others, which is why the specialty treats the system as an integrated whole.

Categories of condition

Orthopedic conditions are commonly grouped by cause. Trauma, including fractures and dislocations, is the most visible category. Other major groups include sports injuries, degenerative diseases, infections, tumors, and congenital disorders. Degeneration is most often represented by osteoarthritis of the hip, knee, and spine, while infections include osteomyelitis and septic arthritis. Congenital conditions range from developmental hip dysplasia to clubfoot. Overuse injuries, such as tendinopathy and stress fractures, are often grouped with sports injuries but have a degenerative or repetitive-loading mechanism. Deformity is a separate concern: orthopedic procedures are often used to correct structural abnormalities or deformities of the musculoskeletal structure, especially the spine and limbs, and the classic example is scoliosis.

The patient population also spans all ages. Once devoted to the care of children with spine and limb deformities, orthopaedists now care for patients of all ages, from newborns with clubfeet to young athletes requiring arthroscopic surgery to older people with arthritis. This breadth is one reason the specialty is divided into subspecialties by body region or patient group, a subject treated in later sections.

Boundaries with non-operative specialties

Orthopedics shares much of its territory with rheumatology and physical medicine and rehabilitation (PM&R). Rheumatology focuses on inflammatory and immune-mediated disease, including rheumatoid arthritis and other autoimmune diseases, and its rehabilitation perspective mainly concerns patients with back pain, soft tissue and age-related musculoskeletal problems. Physical medicine physicians, known as physiatrists, are specialists in the care of neurological and musculoskeletal conditions. In practice, they often work side-by side with orthopaedic surgeons and rheumatologists to care for complex or multi-faceted care plans.

The boundary is therefore one of primary responsibility rather than strict separation, and the same patients move between these services. Conditions such as osteoarthritis, back pain, and osteoporosis are managed by all three groups. Treatment guidelines for these conditions routinely include physical therapy; one review notes that methods of physical therapy and rehabilitation are part of all published guidelines for the management of rheumatoid arthritis, spondyloarthritides, osteoarthritis, osteoporosis, chronic back pain, chronic non-malignant pain and fibromyalgia. Surgical referral is usually decided within this shared pathway, after non-operative options have been tried or found inadequate, which links the definitional question to the later discussion of indications for surgery.

Etymology and early history

The name of the specialty dates to 1741, when the Paris physician and medical professor Nicolas Andry published a treatise on preventing and correcting deformities in children, titled L'orthopédie. He built the word from two Greek elements, orthos ("straight" or "correct") and paidion or paideia (relating to the child). Andry wrote for parents and others who raised children as well as for physicians. His book's frontispiece showed a bent sapling tied to a stake, and this image later became an emblem of orthopaedic associations. The English form "orthopaedics" followed from an English translation of 1743. The spelling "orthopedics" later became standard in American usage, while the "ae" form remains the convention in Britain and much of the Commonwealth.

The practice is far older than the name. The ancient Egyptian Edwin Smith Papyrus, copied around 1600 BCE and probably based on a much older text, describes 48 injury cases with examination, diagnosis and treatment. For fractures of the upper arm it recommends restoring alignment by traction, then binding the limb with linen splints. Its description of manipulating the fracture under the fingers may be among the earliest records of open fracture reduction, and healed fractures in Egyptian skeletal remains suggest that these methods worked to some degree. Early Greek texts in the Hippocratic corpus describe reduction of the humerus in more detail, using linen bandages soaked in a cerate and splints applied after about a week. Late Antique writers such as Paul of Aegina also warned that excessive traction or tight bandaging could cause harm. Across these traditions, the core tools were manipulation, traction, padding, bandaging and splinting, and most treatment was non-operative.

Organized institutions for skeletal deformity appeared only in the late eighteenth century. In 1780, the Swiss surgeon Jean-André Venel, born in Morges in 1740, founded an institute at Orbe in the canton of Vaud, which is generally regarded as the first hospital devoted to the treatment of children's skeletal deformities, particularly spinal curvature. Venel's method had three stages: careful preparation, reduction of the deformity, and measures to prevent relapse. He relied on massage, manipulation, water treatments and mechanical devices, and he also linked treatment to schooling and vocational training. His institute served as a model for many similar institutes founded in Europe after about 1800. Surgery in the modern sense developed more slowly. Subcutaneous tenotomy, the division of a tight tendon, was practised by the French surgeon Dupuytren in 1821, and tenotomy of the Achilles tendon became one of the earliest operations used in the field. In 1851 the Dutch military surgeon Antonius Mathijsen introduced the plaster-of-Paris cast, which became a standard means of immobilization.

Operative bone and joint surgery became practical mainly after three nineteenth-century advances. The introduction of ether and other inhaled anaesthetics in the 1840s made long and painful procedures tolerable and allowed surgeons to work more slowly and precisely. Antisepsis, which Joseph Lister promoted from 1867 using carbolic acid, and later asepsis, which relied on sterilized instruments and clean operating conditions, reduced the risk of wound infection, which had previously made operations on bone and joints very dangerous. Wilhelm Röntgen's discovery of X-rays in 1895 gave surgeons a way to see fractures, dislocations and deformities before and after treatment, a development that transformed diagnosis and planning. Together these advances moved orthopaedics beyond the correction of childhood deformities toward the surgical treatment of injuries and disease in patients of all ages, a shift that had largely taken place by the early twentieth century.

Clinical assessment and diagnosis

Diagnosis rests on the patient's history. Clinicians ask where the pain is, when it began, whether a specific injury preceded it, how it changes with load and rest, and whether there are night pain, fever, weight loss or a history of cancer. These answers determine which examinations and tests follow.

Physical examination

Physical examination plays a central role in orthopedic diagnostics. Inspection comes first and can show swelling, bruising, skin changes or malalignment. Palpation then assesses local warmth, tenderness, muscle bulk and the pulses of the affected part.

Joint motion is measured in degrees at the end points of travel. Movement is tested both as active range, where the patient moves the joint, and as passive range, where the examiner moves it. A marked difference between the two can point toward a structural or neurological cause, and pain within the available range is recorded. Comparison with the opposite limb is usually made.

Gait analysis reveals limps, shortened stance phases and compensatory trunk movements. It can expose hip, knee or spinal problems that are not evident when the patient is lying still. Neurovascular checks involve noting the severity of pain, feeling the skin for temperature abnormalities, assessing discoloration, checking for a pulse, and ensuring proper range of motion. These checks are repeated after fractures and dislocations, because a compromised limb can deteriorate quickly. Focused neurological testing and special provocative tests then target specific ligaments, menisci or nerves.

Imaging

Imaging is usually sequential. Radiographs are usually the first-line investigation, with cross-sectional modalities, magnetic resonance imaging (MRI) and computed tomography (CT), sometimes subsequently indicated, depending on the initial findings.

Plain radiographs are inexpensive and quick, and they can be taken with the patient bearing weight, which matters for alignment assessment. They reveal fractures, bone tumors, infection and developmental deformities such as developmental dysplasia of the hip. They are poor at showing soft tissue, so an ACL tear, meniscal injury, or tendon rupture often appears "normal" on X-ray.

CT reconstructs bone in fine detail. It is chosen when a fracture is hard to see on film, when a fracture involves a joint, or when a surgeon must plan reconstruction. CT scans in Orthopedics are used to evaluate complex fractures of the knee, pelvis, wrist, etc., for surgical planning. They can sometimes detect occult fractures which are not visible on plain x-rays. Its drawbacks are radiation dose and artifact noted on the images around metal orthopedic hardware or total joint prostheses.

MRI is the preferred modality for soft tissue, since it provides excellent imaging of soft tissues including tendons, ligaments, menisci, and muscle. It also can detect changes in the bone marrow that are seen in fractures, bone bruises, infections, or stress reactions. In bone tumors, MRI is the gold standard for local staging. Contrast injected into a joint can help show labral tears, and implants must be screened before scanning.

Ultrasound involves no radiation and can be used at the bedside. It is useful for superficial tendons and soft-tissue masses, and enables real-time image-guided biopsy. Sound waves cannot penetrate bone or gas, so deep and bone-covered regions are beyond its reach. Results also depend on operator skill. Nuclear studies complement these tools: bone scanning is occasionally used to diagnose a fracture, particularly if other tests, such as plain x-rays and computed tomography (CT) or magnetic resonance imaging (MRI), do not reveal the fracture. In tumor work, a whole-body study can survey for additional lesions.

Laboratory testing and biopsy

The ESR and the CRP are usually increased when inflammation is present. However, because inflammation occurs in so many conditions, both the ESR and the CRP levels alone do not establish a diagnosis. In adults with suspected bone infection, ESR and CRP may be elevated, but on the contrary white blood cell counts is often in the normal range. A complete blood count, ESR and CRP form the minimum initial panel. In one analysis, an ESR ≥70 mm/hour is suggestive of osteomyelitis. CRP is often more useful for follow-up of the response to treatment. Blood cultures are drawn when bacteremia is suspected. For bone tumors, the workup adds alkaline phosphatase, lactate dehydrogenase and protein electrophoresis to help exclude infection and metastatic carcinoma.

Definitive diagnosis of bone infection generally requires bone biopsy with histopathology and microbiologic culture, because isolating the organism allows susceptibility testing. Biopsy is also the reference standard for tumors. Core needle sampling is usually preferred, and open biopsy is usually indicated when, after a percutaneous biopsy, the diagnosis is inconclusive or does not correlate with the clinical presentation and radiologic findings. The biopsy site must be planned with the eventual resection in mind, because the needle track is generally excised with the tumor. Errors are not rare: in a series of 597 patients undergoing sarcoma biopsy, the rate of major errors in diagnosis was 13.5%, and the rate of complications was 15.9%. These events occurred more frequent, when the biopsy was performed in a referring institution, rather than in an oncology center.

Classification systems

Classifications standardize how fractures and deformities are described. Examples include the Gustilo–Anderson grading of open fractures, the AO/OTA system for long-bone fractures, Neer's classification of proximal humerus fractures, Garden's classification of femoral neck fractures, the Kellgren–Lawrence grading of osteoarthritis, the Crowe classification of hip dysplasia, and the Lenke system for adolescent scoliosis. Each links a descriptive scheme to a treatment threshold or prognosis, and each provides a shared vocabulary for surgeons, radiologists and registries. Interobserver agreement varies between systems, so classifications are used as guides rather than as sole determinants of treatment.

Non-operative management and indications for surgery

For most musculoskeletal complaints, treatment starts without an operation. Many soft-tissue and degenerative problems improve over time, and surgery carries its own risks, so an operation is usually reserved for patients in whom it is likely to help more than continued conservative care. The decision depends on the diagnosis, its severity, and how much it limits the patient's life.

First-line conservative treatment

Conservative care usually combines several measures. Activity modification and rest reduce loading on an irritated structure. Immobilization with splints, casts, or braces protects acute injuries and can ease painful tendon or joint conditions. Oral analgesics and anti-inflammatory drugs control symptoms, and physiotherapy restores movement and strength. Corticosteroid injections are the most commonly used injection therapy, and their value is mainly short-term. A 2021 guideline on rotator cuff tendinopathy found that steroid injections reduce pain and disability over roughly eight weeks compared with placebo, but did not significantly outperform anaesthetic-only injections at six months or longer. In lateral epicondylalgia, a randomized trial found that patients injected with steroid had worse outcomes at one year than those given placebo, despite early benefit. Research also suggests that the setting of care matters less than the content: an Australian randomized trial found that a physiotherapist could deliver a shoulder injection with outcomes not significantly different from those given by an orthopedic surgeon, at lower cost to the funder.

Criteria for operating

Surgery is generally considered when symptoms persist despite an adequate trial of conservative measures. The main indications are persistent pain that does not respond to treatment, functional limitation that interferes with work or daily activities, and mechanical instability, such as ligament insufficiency or a joint that slips out of alignment. A neurological deficit is a separate and more pressing criterion. Progressive weakness or sensory loss caused by compression of a nerve root or the spinal cord usually prompts earlier intervention, whereas a stable, mild deficit may be monitored. Imaging findings alone rarely determine the choice, because structural abnormalities such as disc herniation or degenerative change are common in people without symptoms. Clinicians therefore correlate imaging with the history and examination before recommending an operation.

Shared decision-making and informed consent

Where surgery and observation are both reasonable, the choice is made jointly with the patient. The clinician explains the expected benefit, the realistic chance of persistent symptoms, the risks of the operation, the recovery period, and the alternative of continued non-operative care, including the option of doing nothing. Informed consent is a process of discussion and understanding, not only a signed form. Patient goals are central: a manual worker, an athlete, and an older adult with the same radiographic findings may reasonably choose differently. Structured decision aids are used in some settings to make the trade-offs explicit. The chosen pathway may also change over time, so a patient who initially chose observation may later opt for surgery if symptoms persist.

Urgent versus elective indications

Elective operations are scheduled after conservative care has been tried, and their timing can be planned around the patient's needs. Some conditions, however, require surgery or other immediate action. The clearest example is the open fracture. Guidelines emphasize early intravenous antibiotics, with a common target of within one hour of arrival, and a 2015 American quality programme recommendation advised starting antibiotics within 60 minutes of presentation. In one study of type III open tibial fractures, infection rates rose as the delay increased, from 6.8% when antibiotics were given within the first hour to 27.9% after 90 minutes. Surgical debridement and stabilization are also time-sensitive, usually within the first 24 hours, although research suggests that antibiotic timing has a greater effect on infection than the timing of surgery. Vascular compromise is another urgent indication: a limb with compromised circulation is reduced and splinted immediately, and urgent vascular repair may be needed. Compartment syndrome, in which pressure within a closed fascial space impairs circulation to muscle and nerve, is present in roughly 9% of open fractures. Its diagnosis is primarily clinical, based on severe pain out of proportion to injury, pain on passive stretch, and altered sensation, and it is treated by fasciotomy. A literature review cited in a recent case report associated delayed fasciotomy beyond 12 hours with higher rates of infection and amputation.

Fracture care and internal fixation

Fracture treatment begins with restoring the alignment and length of the broken bone. In closed reduction, displaced fragments are realigned by manipulation without exposing the break, and the limb is then held in a cast or splint while the bone heals. This approach suits many stable or minimally displaced fractures and is the usual first choice for many fractures in children, whose bones remodel substantially. Open reduction and internal fixation (ORIF) exposes the fracture so that the fragments can be set under direct vision and held with implants. The choice between the two depends on the fracture pattern, the degree of displacement, whether a joint is involved, the condition of the overlying bone and soft tissue, and the patient's general health.

Implants and external fixators

Plates and screws are the most widely used internal implants. Compression plates press fragments together to achieve absolute stability, whereas bridging and locking plates allow a controlled amount of motion across the fracture. Intramedullary nails are rods placed into the marrow canal of long bones, most often the femur and tibia, and they generally require smaller incisions than plating. Rigid fixation provides an environment which promotes primary bone healing, while flexible fixation promotes secondary healing through controlled motion. Plates, screws, and intramedullary nails, as well as external fixation methods, offer varying degrees of stability.

External fixators hold bone with pins placed above and below the fracture, joined by bars outside the skin. Depending on how they are built, they can either carry the full load and protect the fracture from collapse, or share load and allow compression across the fracture surface. Their traditional indication was open fracture management, and their role was later extended to definitive treatment; today they are an integral part of damage control orthopaedics. That approach stems from the observation that definitive fixation of long bones in multiply injured patients can worsen the systemic inflammatory response, the so-called 'second hit', which can contribute to respiratory failure and multiorgan dysfunction. Rapid temporary stabilization is therefore used in physiologically unstable patients. In the 2005 Pakistan earthquake, a retrospective series of 1,145 fracture fixations included 295 external fixations, most of them on the tibia. Although anatomic safe zones exist for pin placement, neurovascular structures may be at risk in severe trauma. One reported case showed iatrogenic superficial femoral artery occlusion caused by kinking of the artery around an external fixator pin.

Biology of fracture healing

Bone differs from most tissues because it is regenerated and pre-fracture tissue properties are largely regained, rather than repaired with a poorly organized scar. Healing is classically divided into two patterns. In primary (direct) healing, the cortices reunite without forming a callus. Osteons cross the fracture line through cutting-cone remodeling, which requires absolute stability between fragments and substantial interfragmentary compression. Secondary (indirect) healing instead relies on a periosteal response, with the fracture gap stabilized by callus formed through endochondral ossification.

Mechanical strain at the fracture site is a central determinant of which pattern occurs. Strains below 2% typically favor primary bone healing, strains of 2–10% encourage secondary union, and strains above 10% predispose to nonunion. Neither pattern is inherently superior: in strict terms of achieving bony union, there is no superiority of primary bone healing over secondary bone healing, merely two different tools tailored for different fracture situations. Both excessively rigid and excessively flexible constructs can impair repair. Healing depends on local biology, including site-specific vascularity, soft-tissue damage, and the availability of osteoprogenitor cells, as well as on systemic factors. Conditions such as diabetes mellitus, compartment syndrome, chronic disease, or a history of smoking can all affect bone healing.

Complications and their management

Nonunion is suspected when progress stalls. Healing should be demonstrated on serial radiographs, with clinical improvement and less pain or tenderness on examination. Warning signs include persistent pain, loss of fracture reduction, hardware failure, and a lack of progressive radiographic healing. In one series of 165 posttraumatic subtalar fusions, the nonunion rate was 13.3%, and smoking and certain screw configurations were associated with higher rates.

Infected nonunion is among the most demanding problems. Management relies on radical debridement, skeletal stabilization, and microbial-specific antibiotics, often supplemented by local antibiotic delivery and, where needed, local or free muscle flaps for soft-tissue coverage. Large defects require complex reconstruction, such as distraction osteogenesis and vascularized bone grafting.

Malunion, or healing in a poor position, usually reflects technical or assessment errors. Deformity may follow operative treatment if reduction or fixation at the time of surgery is inadequate. Near-anatomical reduction with appropriate fixation is the most reliable way to maintain position until union and to reduce malunion and ongoing instability. When malunion does occur, corrective options include osteotomies with plate and screws, external fixation, intramedullary nails, and total knee arthroplasty, among others.

Posttraumatic arthritis can develop even after an apparently successful reduction. Even after anatomic reconstruction, a displaced intra-articular fracture can progress to symptomatic posttraumatic arthritis. Radiographic change does not always correspond to symptoms, and in one study of nonoperatively treated distal radius fractures, radiological signs such as posttraumatic arthritis and malunion did not necessarily produce symptoms. Initial management is usually conservative, including activity modification, anti-inflammatory medication, physical therapy, bracing, and corticosteroid injections. Surgical options for advanced cases include joint realignment, joint fusion, and joint replacement.

Joint replacement (arthroplasty)

Principal procedures

Hip and knee replacement make up most arthroplasty. In the 2025 report of the American Joint Replacement Registry, primary knee replacements accounted for about half of the 4.4 million validated hip and knee cases, and primary hip replacements for about a third. The 2025 AJRR Annual Report captured 4,434,668 validated hip and knee procedures performed between 2012 and 2025 for analysis. The majority of procedures within the AJRR continue to be primary TKA (51%), followed by primary THA (32%). Shoulder replacement is the next most frequent type in national registers, while elbow, wrist and ankle replacements are much rarer. The United Kingdom's National Joint Registry recorded 116,901 hip procedures, 134,652 knee procedures, 9,809 shoulder procedures, 1,347 ankle procedures and 1,056 elbow procedures in its 2025 annual report.

Total replacement resurfaces every articulating surface of the joint, for example the acetabulum and femoral head in the hip, or the femoral, tibial and patellar surfaces in the knee. Partial replacement preserves healthy compartments and ligaments. Hemiarthroplasty replaces only the femoral head, most often after a femoral neck fracture, while unicompartmental knee arthroplasty replaces a single compartment of the knee and hip resurfacing caps the femoral head rather than removing it. In the 2024 American report, hemiarthroplasty made up 3.6% of procedures and partial knee arthroplasty 2.5%. Partial procedures generally involve smaller incisions and a faster early recovery, but they carry a higher risk of conversion to total replacement when the remaining compartments degenerate.

Surgical steps and approaches

A hip replacement begins with exposure of the joint through an approach that is chosen by the surgeon, commonly posterior, anterior or direct lateral, each with its own trade-off between muscle disruption and dislocation risk. The femoral head is removed, the acetabulum is reamed and a cup is seated, and the femoral canal is prepared for a stem that carries a new head. Knee replacement usually proceeds through a medial parapatellar incision, with resection of the distal femur, proximal tibia and posterior patella, followed by placement of metal and polyethylene components. Trial components are used to check limb alignment, leg length, soft-tissue balance and stability before the final implants are fixed with bone cement or by press-fit porous surfaces. Ligament balancing and component alignment are central to the knee's function, and malalignment is a recognized cause of later failure.

Indications and expected outcomes

Advanced osteoarthritis is the most common indication, typically when pain and functional limitation persist despite non-operative care. Inflammatory arthritis such as rheumatoid-arthritis, avascular necrosis of the femoral head and displaced fractures, especially of the femoral neck in older adults, are other indications. Most patients undergoing hip or knee replacement report substantial pain relief and better walking and daily function, although results depend on preoperative health, comorbidity and the rehabilitation that follows. Joint replacement is among the most effective operations for improving quality-of-life in people with end-stage arthritis.

Revision arthroplasty and causes of failure

Revision surgery is longer and more demanding than primary replacement, requiring planning and specialized implants and instruments. Revision surgery is longer and more complex, requires extensive planning, and requires the use of specialized implants and tools to achieve the desired result. The leading causes differ between hip and knee. The most common causes for revisions of THA were aseptic loosening (35.1%), deep infection (18.2%), dislocation/instability (15.9%), and periprosthetic fractures (11.4%). For knees, the most common causes for revisions of TKA were deep infection (21.6%), aseptic loosening (18.3%), instability (14.1%), and pain (10.9%).

Aseptic loosening is the failure of fixation without infection. Wear particles from the bearing surfaces provoke an inflammatory response in surrounding bone, which resorbs bone (osteolysis) and loosens the component. For hip replacement, the risk of aseptic loosening leading to revision total hip arthroplasty is about 1 percent per year. Instability, usually from component malposition or soft-tissue imbalance, dominates early failure, whereas loosening and polyethylene wear dominate later failure. Timing matters: in one single-center series, early revisions had PJI (29.2%) as the leading cause, while aseptic loosening (22.2%) predominated in late revisions.

Periprosthetic joint infection (PJI) is especially difficult to manage. Physical examination, laboratory tests, radiography and joint aspiration used to diagnose prosthesis infection are insensitive and/or nonspecific. Treatment generally combines prolonged antibiotics with exchange arthroplasty performed in one or two stages, whereas aseptic loosening usually requires a single revision. PJI is the second most common cause of implant failure, and projections for the United States anticipated rising infection rates through 2030 as primary volumes grow. Revision outcomes therefore depend heavily on correct diagnosis, which is why infectious-disease expertise and microbiological sampling form part of many revision pathways.

Implant materials and biomechanics

Orthopedic implants must carry body weight and muscle forces while remaining stable inside living bone. Material choice therefore balances strength, stiffness, corrosion resistance, wear behavior, and how well the surface integrates with tissue. Load-bearing components such as femoral stems, plates, and screws are mostly metal, while articulating surfaces may be polymer, ceramic, or metal, depending on the joint and the design.

Metals

Three alloy families dominate. Austenitic stainless steel, commonly grade 316L, was among the first implant metals. It is inexpensive and easy to fabricate, and it still appears in some temporary fixation devices, but it has largely been replaced in long-term joint replacement. Cobalt–chromium alloys, often with molybdenum added, are harder and far more resistant to abrasion, which suits them to femoral heads and other sliding surfaces. Titanium alloys, most often Ti-6Al-4V, are lighter and considerably less stiff than the other two, and they support bone ingrowth well. Their poor abrasion resistance generally rules them out as bearing surfaces, so they are used mainly for stems, cups, and spinal hardware.

Stiffness is the key difference. Cobalt–chromium and stainless steel have elastic moduli roughly in the range of 200 GPa, titanium alloys near 110 GPa, and cortical bone around 15–20 GPa. The mismatch between implant and bone drives several of the biomechanical problems discussed below.

Polymers and ceramics as bearing surfaces

Ultra-high-molecular-weight polyethylene (UHMWPE) became the standard bearing material in joint replacement during the second half of the twentieth century. It is tough and has low friction against metal and ceramic, but sliding generates microscopic debris. Submicron particles migrate into the tissue around the implant, where macrophages engulf them and release inflammatory mediators that activate bone-resorbing cells. This process, called osteolysis, progressively erodes bone around the prosthesis and can cause aseptic loosening. A linear wear rate of about 0.1 mm per year is widely cited as the threshold above which osteolysis tends to appear. Highly cross-linked polyethylene, which is more wear resistant, has reduced the problem: in a small randomized cohort followed for 12 years, osteolysis was markedly less frequent with the cross-linked liners. Younger and more active patients generate more wear cycles, and in one large hip series osteolysis of the pelvis was far more common in patients under 50 than in those over 70.

Ceramics, mainly alumina and zirconia, are very hard, smooth, and generate few particles, so they are used in ceramic-on-ceramic and ceramic-on-polyethylene pairings. Their brittleness and the risk of fracture or noise limit their use. Metal-on-metal bearings, an earlier alternative, are discussed in the section on evidence debates.

Cemented versus cementless fixation

Cemented fixation uses polymethylmethacrylate (PMMA) bone cement, which is mixed from powder and liquid, hardens within minutes, and interlocks with the irregular surface of bone. Cementless fixation relies on a press fit at surgery and then on bone growing into a porous coating, such as titanium beads, sintered mesh, or hydroxyapatite. Cemented femoral stems date to the late 1960s and remained the preferred choice in many countries, notably Scandinavia.

Each method carries trade-offs. Cemented fixation gives immediate stability and is generally less costly, but it takes longer to perform, risks cement implantation syndrome with hypotension and hypoxia, and may age or loosen over time, particularly in younger patients. Cementless fixation is quicker to perform but depends on biological integration, and it has been associated with a higher risk of periprosthetic fracture in some series. Registry findings conflict. Some international registry analyses report higher revision rates for cementless stems, while a large American study of hip replacement after femoral neck fracture found fewer periprosthetic fractures with cement but more early deaths and readmissions. Current practice therefore tends to choose fixation according to bone quality, age, activity level, and fracture type rather than adopting a single method.

Load transfer, stress shielding, and wear debris

Bone remodels in response to the mechanical loads it carries, a principle known as Wolff's law. A stiff implant takes over part of that load, so the surrounding bone experiences lower strain and gradually resorbs. This phenomenon, stress shielding, is well documented around femoral stems and has also been described after knee replacement and tumor prostheses. Its consequences include loss of bone stock, increased risk of periprosthetic fracture, aseptic loosening, and a more difficult revision. Clinical harm is not seen in every patient, however, and finite element studies suggest that material matters more than geometry: metal-backed tibial components produced significant bone loss beneath the baseplate, whereas all-polyethylene components tended to show increased density. Design responses include lower-modulus titanium, more flexible stem geometry, and porous lattice structures that reduce the stiffness contrast.

Wear debris from polyethylene, metal, or ceramic is the second major biomechanical concern. Once debris accumulates in the periprosthetic interface, the inflammatory response described above turns load-bearing bone into a site of resorption, so the implant can loosen even when its mechanical design is sound. Cement and circumferential porous coatings can slow the distal migration of particles, and anti-inflammatory and bisphosphonate medications have been reported to slow the progression of osteolysis, although definitive treatment often requires revision surgery.

Arthroscopy and minimally invasive techniques

Instrument and access

An arthroscope is a slender optical instrument with a light source and camera. It is inserted through a small skin opening, called a portal, so the surgeon can view the inside of a joint on a monitor. Cannulae, which are hollow sleeves, hold each portal open so that probes, shavers, graspers and radiofrequency devices can be introduced beside the scope. Joints are usually distended with sterile fluid to create working space and to clear blood and debris from the field. Triangulation, the practice of using two or more portals so that instruments meet a lesion from different angles, is attributed to the Japanese engineer-surgeon Masaki Watanabe, who also contributed much of the scope design.

Origins

The technique began in Japan. Kenji Takagi, who in 1918 became the first to visualize the knee joint cavity of a cadaver using a cystoscope, and he soon used a modified cystoscope in living patients, mainly to diagnose tuberculous knees. Swiss surgeon Eugen Bircher reported clinical use of arthroscopy in the early 1920s, and the two traditions developed in parallel for some time. Watanabe's work produced the decisive step: the Watanabe No. 21 arthroscope, produced at scale in 1959, which made routine joint examination practical. In 1962 Watanabe performed what is generally regarded as the first arthroscopic partial meniscectomy of the posterior horn of the medial meniscus. Arthroscopy then spread to Western countries during the 1960s and 1970s, with R. W. Jackson in Toronto among those who promoted it there.

Common procedures

Arthroscopy is now used across most large joints, and the knee remains the most frequent site. In the knee, the principal operations are meniscal repair or debridement, partial meniscectomy, cartilage smoothing (chondroplasty), and removal of loose bodies. In the hip, labral repair is widely performed for femoroacetabular impingement (FAI), a mismatch of hip shape that can damage the labrum and cartilage. Outcome series are generally favorable, though with caveats. In one systematic review, at 24-month follow-up, 100% of the patients had returned to sport, and a long-term study reported that the all-cause reoperation rate was 34.4%, and 12.5% of patients progressed to THA. When the labrum cannot be repaired, surgeons may reconstruct it instead. One comparative cohort found a higher risk of conversion to total hip arthroplasty (THA) with labral reconstruction (20% versus 7%) than with primary repair. Shoulder stabilization, rotator cuff work, ankle ligament repair, and elbow and wrist procedures are also routinely arthroscopic.

Advantages, limits, and the learning curve

The main rationale for arthroscopy is reduced tissue trauma. Compared with open surgery, the procedure requires smaller incisions, minimizes soft tissue disruption, and reduces postoperative pain, hospitalization, infection risk, and joint stiffness. These benefits are real but not automatic: they depend on the indication, and some outcomes differ little from those of non-operative care. Arthroscopy also imposes a steep technical learning curve. Surgeons must work in a confined space, interpret a two-dimensional image with limited depth perception, and manage instruments through fixed portals, so skill and case volume strongly influence safety and efficiency. Complications such as nerve or vascular injury, instrument breakage, and fluid extravasation are reported at low rates but remain relevant in training.

Extension to the spine

Minimally invasive principles have been extended to the spine, where percutaneous and endoscopic approaches use small working channels to reach the disc or the lateral recess. These techniques are most often applied to disc herniation that compresses a nerve root, and they aim to limit muscle dissection and bone removal relative to open decompression. Their indications, technical demands and comparative effectiveness are discussed in the spine section and in the evidence debates below.

Spine surgery

Spine surgery covers operations on the vertebral column, the discs between vertebrae, and the neural elements they contain. Most procedures aim to relieve pressure on nerve roots or the spinal cord, to stabilize segments that have become unstable, or to correct abnormal alignment. Degenerative disease is the most common reason for surgery in adults, and the choice of operation depends on which structure is compressed and whether the spine has lost stability.

Degenerative conditions

Disc herniation occurs when the nucleus of an intervertebral disc protrudes and presses on a nerve root or the spinal cord, typically producing leg pain, numbness, or weakness. Spinal stenosis is a narrowing of the spinal canal or the neural foramina, usually from thickened ligaments, facet joint enlargement, and disc degeneration. Degenerative spondylolisthesis is a slippage of one vertebra over the next, caused by degeneration of the facet joints and discs rather than a fracture. These conditions frequently coexist in older patients, and their combination shapes the operative plan. Surgery is generally considered after conservative care such as medication, physiotherapy, and epidural injections has failed to control persistent leg pain, progressive weakness, or disability.

Decompression

Decompressive procedures remove the tissue that compresses neural structures. In a discectomy, the surgeon removes the herniated portion of a disc, usually through a small opening. A laminectomy removes the lamina, the bony roof of the vertebral arch, to widen the spinal canal. Laminotomy and foraminotomy are more limited variants that enlarge only part of the canal or the exit foramen. The goal is to relieve pressure on the nerve root or spinal cord so that symptoms and neurological function can recover. Decompression alone does not address instability, and the risk that a segment will slip or deform after the posterior elements are removed has driven the use of additional stabilization.

Evidence on whether adding fusion improves results remains contested. In a randomized trial of patients with stable degenerative spondylolisthesis, the group receiving fusion had a lower cumulative reoperation rate than the decompression-only group, but the difference in overall disability scores at two years was not statistically significant. A 2023-era meta-analysis of patients with stenosis and neurogenic claudication found no significant difference in reoperation rates between fusion and nonfusion groups, and it suggested that fusion offered limited benefit in stenosis without spondylolisthesis.

Fusion, instrumentation, and motion preservation

Spinal fusion aims to make two or more vertebrae grow into a single solid unit. Surgeons usually place bone graft or graft substitutes between the vertebrae and fix them with pedicle screws joined by rods. Approaches include posterior, transforaminal, anterior, and lateral routes, and each carries different risks to the surrounding muscles, vessels, and nerves. Instrumentation improves the rate of solid fusion but adds cost and operative time.

Lumbar disc arthroplasty was developed to preserve motion at the treated level and reduce the consequences of fusion. In a single-level trial of a total disc replacement against anterior fusion, the arthroplasty group had shorter operating times and hospital stays, and the two groups showed similar patient satisfaction and disability scores over two years. A five-year follow-up of a large investigational device trial reported improved physical function and reduced pain in the arthroplasty group, with heterotopic bone formation rising over time. A systematic review of randomized trials, however, found that many statistically significant results were fragile, meaning that small shifts in event counts could reverse them, and that industry-funded studies tended to be more fragile. Long-term durability and the risk of adjacent-segment disease therefore remain open questions.

Deformity correction and cervical myelopathy

Scoliosis, a lateral curvature of the spine, and kyphosis, an excessive forward curvature, may require surgery when curves progress, cause pain, or threaten lung or neurological function. Correction typically combines release of rigid soft tissues, osteotomy where necessary, and long instrumented fusion, with careful attention to the balance of the spine and the trunk.

Degenerative cervical myelopathy, in which age-related changes in the neck compress the spinal cord, is a distinct indication. Its goals are to decompress the cord and prevent further deterioration. A meta-analysis of ten studies with 517 patients reported that surgery produced a greater recovery rate than conservative care, although post-treatment scores did not differ. Earlier decompression is generally associated with better neurological recovery, and the surgical approach, whether anterior, posterior, or circumferential, is chosen according to the level of compression, alignment, and the surgeon's experience. Posterior laminectomy without fusion has been associated with late postoperative kyphosis in some series, which has encouraged the use of laminoplasty and fixation. Artificial disc replacement in the cervical spine has been reported to preserve motion and to yield better quality-of-life scores than anterior fusion in some reviews.

Ligament, tendon, and soft-tissue reconstruction

Anterior cruciate ligament reconstruction

Reconstruction of the anterior cruciate ligament (ACL) aims to restore anteroposterior and rotatory knee stability. The choice of graft is one of the few adjustable factors that influences the risk of failure. Grafts fall into three groups: autografts taken from the patient's own tissue, allografts taken from a donor, and synthetic grafts. Hamstring tendon autograft is the most commonly used option worldwide, followed by bone–patellar tendon–bone and quadriceps tendon autografts. Each has trade-offs. Hamstring grafts are associated with low donor-site morbidity, but small tendon diameters can compromise graft strength, and patellar tendon grafts are often favored where stability is the priority. Bone–patellar tendon–bone is also the only allograft option that provides bone-to-bone healing at both ends.

Allografts shorten operating time, avoid harvest-site pain, and allow graft size to be matched to the patient. Their disadvantages include a theoretical risk of disease transmission, an immune response, and tissue weakening during sterilization. Irradiated grafts can be weakened further, and allografts tend to incorporate more slowly. The main clinical concern is re-rupture in young, active patients: one comparison of active patients under 25 reported graft rupture in about 9.6% of autografts versus 25.0% of allografts. Health-economic analyses generally conclude that autografts are as effective or slightly better and are more cost-effective, so allografts are usually reserved for revision surgery or for patients in whom autograft harvest is unsuitable. Reported revision rates after primary reconstruction average about 2–10%, rising to as high as 42% in high-level pivoting athletes.

Rotator cuff repair

The rotator cuff is a group of four muscle–tendon units that stabilize the shoulder, and tears are a common cause of shoulder pain. Repair is performed arthroscopically or, less often, through an open incision, typically by reattaching the tendon to the humeral head with suture anchors. Healing is the main limitation. Reported retear rates vary widely depending on the tear size, the imaging method, and the follow-up interval, with estimates ranging from roughly 11% to over 90% for large chronic tears. A 2025 systematic review of 13 studies found an overall retear rate of about 12.5%, and early repair was associated with fewer retears (about 9.9% versus 15.9% when repair was delayed). Known risk factors include older age, diabetes, smoking, muscle fatty infiltration, muscle atrophy, and larger or more retracted tears. Clinical benefit can persist even when a retear is seen on imaging, so imaging findings and patient-reported function do not always match.

When a tendon cannot be repaired, tendon transfer may be used. Donor tendons or muscles with a useful function are rerouted to restore active elbow flexion, shoulder elevation, or grip, most often in brachial plexus injury, tetraplegia, or irreparable posterosuperior cuff tears. Reverse shoulder arthroplasty is an alternative in some older patients with cuff arthropathy.

Achilles tendon repair

The Achilles tendon is the strongest and thickest tendon in the body, and its rupture is increasingly common among active adults. Treatment is either operative (open or percutaneous repair) or nonoperative (casting or functional bracing with early weight-bearing). Historically, surgery was the default because it lowered re-rupture rates, but the gap has narrowed with modern rehabilitation. A 2021 randomized trial in Norway found no difference in the Achilles Tendon Total Rupture Score at 12 months between nonoperative care, open repair, and minimally invasive surgery. Re-ruptures occurred in 6.2% of nonoperative patients compared with 0.6% in each surgical group, while nerve injuries were most common after minimally invasive surgery. Meta-analyses generally confirm that surgery reduces re-rupture risk but increases complications such as wound infection and nerve injury. The choice therefore depends on the patient's activity goals and tolerance of complications.

Muscle injury, nerve repair, and soft-tissue reconstruction

Complete muscle–tendon ruptures, such as those of the quadriceps or pectoralis major, are generally repaired when function is compromised, with the timing of repair influencing the result. Partial strains are managed non-operatively. Peripheral nerve injury is treated according to the nature of the injury. A clean, sharp transection without tension may be repaired directly by suturing the nerve ends. Larger gaps require an interposed nerve graft, commonly a sensory nerve harvested from the leg or forearm. Where the nerve is damaged close to its origin, nerve transfers can redirect a healthy donor nerve to restore function. Nerve regeneration is slow, so early repair is generally preferred for motor recovery. Soft-tissue loss with exposed tendon, bone, or joint is reconstructed with local flaps, skin grafts, or free microvascular tissue transfer, often jointly with plastic and reconstructive surgeons.

Return to sport and rehabilitation

Rehabilitation timelines differ by structure. After ACL reconstruction, return to pivoting sport is typically deferred for many months, and current practice increasingly uses criteria such as limb symmetry in strength and hop testing rather than time alone. After rotator cuff repair, the arm is usually immobilized for several weeks before passive and then active motion is introduced, with heavy lifting and overhead loading delayed for several months. After Achilles repair or nonoperative treatment, early controlled loading is common, and return to sport is usually measured in months. Across all these procedures, rehabilitation and physical therapy protocols, and the patient's occupational and athletic demands, shape the final outcome as much as the surgical technique. Outcomes are also evaluated in randomized controlled trials that compare operative and nonoperative care, which remain relatively few for some of these injuries.

Pediatric and congenital orthopedics

Developmental dysplasia of the hip

Developmental dysplasia of the hip (DDH) covers a spectrum of hip abnormalities, from instability to outright dislocation, that can emerge during embryonic life, infancy, or childhood. Screening relies on clinical examination of the newborn and, for selected infants, ultrasound. Because hips that are dislocated but not yet fixed can deform the socket over time, the aim is to treat early. The Pavlik harness is the standard first-line treatment for infants younger than six months. The device, a fabric brace, holds the baby's hips flexed and gently turned outward. Its use spread from work that Arnold Pavlik began in 1944. In a Southampton cohort of 332 babies with 546 dysplastic hips, the harness failed to reduce 18 hips in 16 patients, and those hips required surgery. Avascular necrosis was noted in 1% of hips treated in the harness. Treatment practice still varies; one UK study notes that treatment consensus is lacking, particularly for well-centred, stable dysplastic hips.

Clubfoot

Congenital clubfoot, a deformity that is relatively common, with an incidence of 1 per 1000 live births, combines hindfoot equinus, midfoot varus, and forefoot supination/adduction. The Ponseti method, developed by Dr. Ignacio Ponseti in the 1950s, uses serial plaster casts applied in sequence to gradually correct the foot, usually followed by a percutaneous Achilles tenotomy. Outcomes depend heavily on the population studied. A systematic review of nine studies reported success rates between 55% and 100%, and relapse rates between 3.2% and 34.2%. A meta-analysis of African institutional studies pooled an overall success rate of 84.8% by participants, with relapse reported in 11.7% of participants. Timing also matters: when treatment begins within the first three weeks after birth, most infants grow up without physical symptoms, pain, or walking dysfunction. Older children fare worse; in one review the lowest success rate, 55%, was seen among children aged two to five years. Feet associated with myelodysplasia show a similar pattern, with an initial success rate of 93%, but a final success of 63% at 4.9 years of follow-up.

Adolescent idiopathic scoliosis

Management of adolescent idiopathic scoliosis depends on curve magnitude and the child's skeletal maturity. Mild curves (under 20°) can be observed, while moderate curves (20°–40°) can be treated with bracing. If curves are not amenable to bracing, surgical intervention is generally recommended. The Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST), a multicenter randomized trial published in 2013, was stopped early because bracing significantly decreased the progression of high-risk curves. Its success rate was 72% for the brace group and 48% for the observation group, and a positive correlation of brace wear time and treatment success was reported. Where curves progress, posterior spinal fusion remains the gold standard, and the timing of fusion is planned around how much growth remains. Surgeons use 3D reconstruction of curves to plan correction when surgery is needed.

Growth, limb-length discrepancy, and neuromuscular deformity

Because children's bones grow, surgical planning depends on how much growth remains. Limb-length discrepancy may be managed by guided growth or epiphysiodesis, which slows the growth of the longer limb, or by lengthening the shorter one. Distraction osteogenesis, popularized by Gavriil Ilizarov in Kurgan, involves cutting the bone, stabilizing it with an external fixator, and separating the fragments slowly so that new bone forms in the gap. This technique is used both for lengthening and for reconstructing deformed or shortened bones. In neuromuscular conditions such as cerebral palsy, spasticity and muscle imbalance can cause hip displacement, equinus, and crouch gait. Management therefore includes hip surveillance, soft-tissue release, tendon transfers, and osteotomies, often guided by instrumented gait analysis.

Family-centered care

Pediatric orthopedic care involves parents or guardians in decisions, and the process of informed consent usually includes both the child and family. Surgeons also consider the child's developmental stage, pain control, the effect of casts or braces on play and schooling, and the need for repeated follow-up through growth. Surgery on growing bones carries particular risks, including growth-plate arrest, leg-length change, and recurrence of deformity, so long-term surveillance into adulthood is often required. Transition from pediatric to adult services is a further part of planning, since many congenital conditions require lifelong monitoring.

Orthopedic oncology and infection

Bone tumors and metastatic lesions

Orthopedic oncology covers primary tumors of bone and soft tissue, along with cancer metastases that reach the skeleton and can weaken bone enough to fracture. Before any resection, clinicians establish how far a lesion extends locally and whether disease has spread elsewhere, typically using cross-sectional imaging such as CT and MRI. The biopsy needs particular planning, because the needle track or incision becomes contaminated and must be excised along with the tumor. For that reason, the biopsy is often performed by the surgeon who will carry out the definitive operation.

Osteosarcoma illustrates the typical pattern. About 2-3% of pediatric cancers are osteosarcomas, the most frequent primary malignant bone tumor in children and young adults. Treatment usually combines chemotherapy given before surgery with a resection, and a further choice must be made between limb-salvage and amputation.

Surgeons now generally regard limb-salvage as the default, keeping amputation for cases in which the tumor recurs locally or the salvage operation develops complications. Outcome data are broadly favorable for salvage. A systematic review and meta-analysis found that five-year overall survival was higher after limb salvage, and that local recurrence, although more frequent in that group, did not alter overall survival. A retrospective pediatric series from Lisbon of 62 patients reported a five-year survival of 38%, with worse results linked to metastatic disease, tumors larger than 8 cm and amputation, while limb-salvage surgery was performed in 59.7% of cases and presented higher mean functional scores (88.4%) compared with AMP (79%). A tertiary-center study from Peshawar reported five-year survival of 83.8% in salvage patients against 62.5% in amputees, and surgical margins were more frequently negative in the LSS group. Amputation carries lasting costs as well, including phantom-limb sensation and dependence on a prosthesis.

After wide resection, the skeletal gap may be bridged with an endoprosthesis or with biological material. Reimplantation of the sterilized autograft with plate and screw fixation is one example, allowing anatomical restoration and limb preservation. Ewing sarcoma is generally managed with systemic chemotherapy combined with local control by surgery or radiotherapy, and radiotherapy is often used when resection would leave unacceptable margins or is not feasible. Metastatic bone disease is managed differently: the goal is usually to prevent or treat pathological fracture and to control pain, with stabilization and radiotherapy chosen according to the site and the prognosis.

Bone and joint infection

Infection in bone (osteomyelitis) and in joints (septic arthritis) demands fast source control as well as antibiotics. Pediatric guidance stresses prompt irrigation and debridement of septic joints, followed by antibiotic therapy for at least two to four weeks. Osteomyelitis without an abscess or a septic joint is more often managed with antibiotics alone.

Duration of therapy has changed over time. The standard treatment for osteomyelitis in adults has been prolonged intravenous courses, typically four to six weeks. Observational studies and some trials have since shown that certain oral agents can substitute for intravenous therapy in selected patients. In children, an early switch to oral antibiotics is common once the child improves, and a total treatment duration of at least three to four weeks for osteomyelitis and two to three weeks for septic arthritis is generally ensured. If inflammatory markers fail to fall, the course is lengthened toward six weeks. In diabetic foot osteomyelitis, international guidelines generally suggest a treatment duration of approximately six weeks, while shorter durations are suggested for those who receive complete surgical debridement or amputation of the infected bone. Infection with methicillin-resistant <i>Staphylococcus aureus</i> is associated with more severe disease that requires more operations, which links the surgical plan to antibiotic resistance and bacterial identity.

Periprosthetic joint infection

Periprosthetic joint infection is among the most serious complications of joint replacement. For acute infection around a well-fixed implant, surgeons often choose debridement, antibiotics and implant retention (DAIR). The procedure combines systemic antibiotic therapy with aggressive surgical debridement, copious irrigation of the operative field, and exchange of all removable modular components. Reported success varies. Outcomes after DAIR for early infection range from 45% to 88%, with better results in cases treated within 30 days and with multidrug-sensitive organisms. Failure has been associated with hematogenous infection, the intensity of the inflammatory response, and the presence of resistant pathogens.

Recommended antibiotic duration after DAIR is long. The 2025 International Consensus Meeting guidelines recommend a minimum 12-week course of targeted antimicrobial therapy following DAIR for optimal infection control. When DAIR fails, or when infection is chronic, the implant is usually removed. A two-stage exchange of the prosthesis is considered the gold standard for treating chronic PJIs. Delays in reaching the joint also matter: empirical oral antibiotics given before deep cultures have been shown to postpone the first debridement, so clinicians generally avoid them until intraoperative samples are obtained.

Hand, foot, ankle, shoulder, and elbow subspecialties

Hand and wrist surgery concentrates tendons, nerves, small joints and fine vascular structures into a small area, so many procedures are performed as short outpatient operations, often under local or regional anesthesia. Trigger finger (medically termed stenosing tenosynovitis) occurs when the tendon sheath surrounding a flexor tendon becomes inflamed and thickened, narrowing the canal through which the tendon must pass. The resulting catching or locking is usually treated first without surgery: an initial corticosteroid injection into the tendon sheath resolves symptoms in a substantial portion of patients. Release surgery is reserved for failed non-operative care, and is a minor outpatient procedure. Carpal tunnel release, which decompresses the median nerve at the wrist, is the other common outpatient hand operation, and a surgeon may combine it with tendon or nerve repair when the injury is more complex.

Dupuytren's contracture is a fibrotic disorder of the palmar fascia. Over time, this tissue thickens and forms fibrous cords that tether the fingers in a flexed position. The ring and small fingers are most often affected, and the condition is typically painless; the main problem is loss of finger extension. Treatment ranges from needle aponeurotomy (breaking the cord with a needle), collagenase injection (an enzyme that dissolves the cord), or surgical fasciectomy for more severe cases. The conditions also interact. A 2023 matched analysis of a United States claims database found that a new Dupuytren diagnosis after trigger finger treatment occurred in 1 in 128 patients overall, 1 in 156 patients treated with steroid injection, and 1 in 126 patients treated with surgical release. Surgical trauma has been proposed as a trigger for disease onset in susceptible people, and the mechanism remains a matter of debate rather than settled causation.

Foot and ankle

Foot and ankle surgery covers fracture fixation, joint reconstruction for arthritis, deformity correction and revision of failed operations. Specialist training reflects this breadth. One fellowship program lists flatfoot and cavovarus reconstruction, hindfoot, midfoot, and ankle arthrodesis, total ankle arthroplasty, Taylor Spatial Frame application, trauma and fracture care, diabetic foot care, including Charcot arthropathy among its core experiences. Surgeons in this field must choose between fusing and replacing a diseased ankle joint, a decision shaped by age, activity level and the joint's remaining mobility. Foot and ankle surgery is also practised by podiatric surgeons, and some programs accept accredited podiatric surgery residency graduates alongside orthopaedic surgeons.

Shoulder

Shoulder problems form the core of shoulder and elbow practice. Shoulder instability is when the shoulder joint slips out of place (dislocates) or feels loose. This is one of the most common conditions treated surgically, especially in active patients and athletes. Instability is usually managed in stages. Atraumatic instability, without a major injury, is generally addressed first with rehabilitation: most often, atraumatic shoulder instability can be managed by restoring the normal strength and coordinated use of the shoulder through a reconditioning program. When surgery is needed, a traumatic dislocation may require repair of the torn labrum, while a loose joint without a single lesion may be tightened by capsular surgery, since usually there is no single lesion that can be repaired. Rotator cuff tears and labral tears are commonly repaired arthroscopically, and frozen shoulder, stiffness and pain that limits how far you can move your arm, is another frequent indication for assessment.

Elbow

Elbow instability usually results from injury to the ligaments on the medial or lateral side of the joint. Its prevalence may be underestimated, and treatment of elbow instability presents a challenge to balance the opposing risks: persistent instability and progressive stiffness. Arthroscopic options include capsular-ligament plication or ligament reattachment using suture anchors. Stiffness is the characteristic complication of elbow surgery. Loss of elbow motion is the most common complication, and residual stiffness more than about a year after injury is usually refractory to bracing and therapy and may require open or arthroscopic release to improve function. For stiffness from primary or post-traumatic arthritis, arthroscopic contracture release, typically combined with in situ decompression of the ulnar nerve, has become the procedure of choice for the majority of elbows in that group. Fracture care follows the same logic: the goal is to restore anatomical congruency of the joint along with reconstruction of involved structures so that movement can begin early without loss of stability. Heterotopic bone formation, which can limit motion, is a further complication that surgeons must anticipate after elbow trauma.

Organization and fellowship training

Within a department, subspecialties are usually organized by body region, and surgeons typically complete general orthopaedic training before pursuing additional specialized training. Fellowships are often one year in length; one foot and ankle program describes itself as a one-year program designed to prepare an orthopaedic surgeon for a career in orthopaedic foot and ankle surgery in either a full-time academic setting or private practice. Fellows gain volume as well as breadth, and one foot and ankle sports medicine fellowship expects that the fellow performs a minimum of 300 surgical cases over the year. Hand surgery and shoulder and elbow surgery are likewise offered as fellowships, with some hand surgery also undertaken by plastic and reconstructive surgeons, so subspecialty boundaries vary by country and by training route.

Rehabilitation and recovery pathways

Prehabilitation before surgery

Prehabilitation, meaning planned exercise, education and psychological support delivered before an operation, is now a routine part of many orthopedic pathways. A pooled analysis of 48 unique trials involving 3570 unique patients found that pre-operative programs improved function, health-related quality of life, muscle strength and back pain compared with usual care. The benefit varies by procedure. For knee replacement candidates, moderate-certainty evidence favoring prehabilitation was reported for function and strength. For lumbar surgery, the strongest signal was a reduction in pre-operative back pain. Some reviews rate the evidence for muscle strength and quality of life after hip replacement as moderate, while others find it inconclusive. Postoperative benefits are less firmly established: the quality of evidence for postoperative outcomes was low to very low, according to the review authors.

Physical therapy before surgery usually targets joint motion, quadriceps and hip strength, and gait, so that the operated limb starts recovery from a better baseline. Programs are often combined with physical therapy sessions supervised in clinic and exercises performed at home.

Early mobilization and weight-bearing

Weight-bearing permissions are set by the procedure, the stability of the fixation or implant, bone quality, and the patient's ability to protect the limb. A fracture held by rigid plates may allow earlier loading than one held by an external fixator, and some arthroplasties permit full weight-bearing within a day of surgery. Tendon and ligament repairs, by contrast, commonly require protected loading for several weeks, and load is increased in stages as radiographic healing and symptoms allow. Protocols are therefore written for each procedure and adjusted to the individual, with the surgeon and therapist revising the timetable at follow-up visits.

Enhanced recovery pathways

The key ERAS components include preoperative optimization, intraoperative stress reduction, and aggressive postoperative mobilization. In orthopedic practice these ideas are built into enhanced recovery after surgery (ERAS) pathways, which replace many traditional habits such as prolonged fasting and bed rest. In hip fracture care, the evidence for ERAS protocols is described as robust, with shorter admissions and fewer delirium and infection events reported.

Analgesia is a central target. Alternative analgesic strategies, such as regional nerve blocks and non-opioid medications, are integrated into these protocols. Typical non-opioid components include NSAIDs and acetaminophen, used alongside regional techniques to reduce reliance on opioids. Whether removing opioids altogether improves recovery is less settled: in orthopaedics, evidence is inconclusive, necessitating further exploration.

Pathway results can be measured in prescribing data. In an analysis of a program across nine Iowa hospitals, mean postoperative opioid prescriptions for orthopedic patients fell by about 45% after ERAS adoption. The same analysis found that orthopaedic patients left about 47% of prescribed opioid doses unused, which suggests that prescribing volumes can still exceed actual need.

Functional outcomes and return to work, daily life, and sport

Recovery is judged through a combination of objective measures (range of motion, strength, gait, walking tests) and validated patient-reported questionnaires covering pain and daily function. Return to work depends largely on occupational demands: sedentary jobs may resume within weeks, while heavy manual labor may require longer and more specific restrictions. Return to daily activities is usually defined by the patient's ability to perform self-care, stairs, and household tasks without assistance.

Return to sport is the most criteria-driven decision. After anterior cruciate ligament reconstruction, the ACL-RSI, a 12-question assessment evaluating emotions, confidence in performance, and risk appraisal, is likely the best measure with regard to return to sports, according to one review. Commonly cited minimum benchmarks include at least nine months post-surgery, at least 90% quadriceps strength symmetry, and at least 90% limb symmetry across hop tests, along with full motion and no pain or instability. Data from a large cohort suggest that the reinjury rate was reduced by 51% for each month RTS was delayed until 9 months after surgery. Current guidance frames readiness as a combination of biological healing, neuromuscular function and psychological readiness. Once cleared, athletes ease back through graded phases, starting with noncontact drills and progressing to unrestricted competition.

Perioperative care and complications

Preoperative assessment and anesthesia

Before an orthopedic operation, the surgical and anesthesia teams assess the patient's heart and lung reserve, bleeding risk, current medications, and frailty. Many centers record a standard physical-status grade and review blood pressure, blood glucose, and anticoagulant use. The choice between general anesthesia and regional techniques, such as spinal or nerve-block anesthesia, depends on the operation, the patient's comorbidities, and the patient's preference. Regional techniques can reduce the need for systemic opioids, but they do not suit every procedure.

Tourniquets

Inflatable cuffs placed on the thigh or upper arm have been in routine use for more than four decades, mainly to improve visualization and cement penetration in joint replacement. In primary total knee arthroplasty, routine full-duration tourniquet use does not reduce venous thromboembolism or transfusion requirements, is associated with early pain and quadriceps dysfunction, and may increase wound morbidity. Rare but serious adverse events, such as compartment syndrome and vascular injury, have also been documented. Because of these trade-offs, surgeons are increasingly testing selective or pressure-limited strategies, which aim to keep the technical benefit while reducing harm. Trial evidence on this question remains mixed, and the optimal approach is still debated.

Thromboembolism and surgical site infection

Venous thromboembolism (VTE) is among the most important medical complications after lower-limb surgery. Recovery after lower-limb large joint arthroplasty carries a heightened thrombotic risk, because the operation affects each component of Virchow's triad. Clinical guidance from the UK's National Institute for Health and Care Excellence treats every patient undergoing hip or knee replacement, or hip fracture surgery, as a candidate for prophylaxis. For most patients undergoing knee or hip arthroplasty, low-molecular-weight heparins, or direct oral anticoagulants such as rivaroxaban or apixaban, are commonly the first agents chosen for the early perioperative period. Prophylaxis is often combined with mechanical measures such as intermittent pneumatic compression. Duration varies: prophylaxis is typically continued for at least 10 to 14 days after major orthopedic surgery, although some recommend extending it to 35 days. After hip fracture repair, some guidelines advise up to 4 to 5 weeks after surgery.

Prevention of surgical site infection relies on sterile technique, skin antisepsis, operating-room environmental controls, and a timed dose of antibiotic prophylaxis given shortly before incision. Deep infection around an implant is especially serious, because bacteria can form biofilm on hardware, which makes eradication harder and may require implant removal. Rising resistance among bacteria adds to the difficulty of treating these infections.

Common complications

Complications after orthopedic surgery fall into several groups. Nerve and vascular injuries can occur during dissection, retraction, or limb positioning. Tourniquet use has been linked to skin blistering, wound hematoma, muscle injury, nerve palsy, postoperative stiffness, deep vein thrombosis, and pulmonary embolism. Joint stiffness, persistent restriction of motion, can follow surgery on both bones and soft tissues. Implant failure may arise from loosening or instability, while fracture nonunion results from impaired healing. Early recognition of compartment syndrome, which requires prompt decompression, is essential because delayed treatment can cause permanent muscle damage.

Patient-reported outcomes and registries

National joint registries record each primary and revision procedure, along with the implant used, and track how long implants survive. With over 2.35 million records, the National Joint Registry of England, Wales and Northern Ireland is the largest arthroplasty registry in the world. The first such registry was established in Sweden: the world's first knee replacement registry began in 1975 as a product of a prospective nationwide knee arthroplasty pilot study. Modern registries also aim to collect patient health-related outcomes alongside surgical data, which allows comparison of national results with those of other countries. Patient-reported outcome measures, typically questionnaires on pain, function, and satisfaction completed before and after surgery, add the patient's perspective to survival data. Registry results are used to compare implant designs and to identify surgeon- or hospital-level variation in performance. A registry-based survivorship estimate for total hip replacement was 93.6% at 20 years, according to a recent meta-analysis.

Technology and digital innovation

Digital tools now touch orthopedic care at several points: intraoperative positioning, the planning of implants and guides, image interpretation, and remote follow-up. Their worth is usually judged in two steps. The first question is whether a technology improves technical precision. The second is whether that precision produces better outcomes for patients, and the second question is still contested.

Computer-assisted navigation and robot-assisted systems are used mainly in arthroplasty, where they help the surgeon position and align components against a preoperative plan. A meta-analysis of randomized trials found that robotic total knee arthroplasty produced significantly lower mechanical alignment outlier rates than conventional surgery, but does not demonstrate superior short to medium-term functional outcomes. The technology also adds time: it is associated with longer operative times. Accuracy data for one commercial platform show a cutting error of less than 0.6° for all coronal and sagittal parameters, with no difference in overall complication rates compared with conventional surgery. Reviewers have noted that the most consistent finding is improved radiographic or technical accuracy, and that a precise reconstruction has limited value if clinical outcomes do not follow. Pooled evidence on early functional recovery is more favorable in some reviews, with one cohort reporting significantly better KSS, WOMAC, OKS, and FJS-12 scores during the early postoperative period. Long-term survival of the implants remains insufficiently studied, so the overall benefit of these systems is still unresolved.

Patient-specific instrumentation and 3D printing form a second strand of innovation. Surgical guides are designed from preoperative CT or MRI data, because 3D printing patient specific, custom devices requires volumetric data acquisition from imaging modalities such as computed tomography (CT) or magnetic resonance imaging (MRI). Such guides fit the individual bone surface and reduce reliance on estimation during cutting and drilling. Their proposed advantages include resection accuracy, mechanical axis alignment, cost-effectiveness, and time economy, yet reviews describe the results as controversial, and long-term outcome data are scarce. The most common use is preoperative planning rather than final implant production in most subspecialties. Printed models of complex acetabular fractures have been shown to improve the inter-rater reliability of complex acetabular fracture classification compared with radiographs and cross-sectional imaging alone. Custom implants have been reported for severe bone loss and paediatric deformity, where anatomy varies widely, and some comparative series report fewer adverse events than off-the-shelf devices, though these series are small.

Machine learning applied to radiographs has shown high diagnostic accuracy, especially for hip fractures, a common injury in older adults. One deep learning model reached an overall binary accuracy for hip fracture detection of 93.7% and a functional subclassification accuracy of 90.8%. A larger study of 40,203 PXRs reported an AUROC of 0.990 on emergency department images, but performance was slightly lower when an implant was present in the radiograph, a practical limitation in patients who already have hardware. In a reader study, the model's area under the curve was higher than that of the five radiologists who were compared. Assistive use appears to help less experienced staff: in a multicenter pediatric study, AI significantly improved junior clinicians' accuracy. A human-algorithm system tested in a clinical setting reported sensitivity, specificity, and accuracy of 97%, 95.7%, and 96.08% for hip fracture detection. Most published figures come from retrospective datasets, so accuracy on images does not by itself establish improved patient care or workflow efficiency. Machine learning models that predict surgical outcomes, such as functional recovery or implant failure, are less mature than fracture-detection tools and need prospective validation.

Telemedicine and wearable sensors are used for follow-up and remote rehabilitation. Video consultations and patient-reported apps allow clinicians to review wound healing, pain, and function between clinic visits, while inertial sensors and activity trackers can record gait, step counts, and movement at home for review by the treating team. Questions remain about the accuracy of consumer devices, the integration of data into electronic records, reimbursement, and the handling of sensitive health information under data privacy rules. Adoption also depends on whether remote monitoring changes clinical decisions, a question that is still being studied.

Training, certification, and workforce

The training pathway

Orthopedic training begins after medical school. Graduates must complete an orthopedic surgical residency, which is typically five years long and centers on common injuries and general techniques. Many programs open with a broad base. The first postgraduate year usually establishes general surgical competence, after which rotations cover trauma, sports medicine, joint reconstruction, spine, pediatrics, hand, foot and ankle, and oncology. Trainees gradually take on more responsibility, and some programs pair each resident with a single attending for an extended period. Mentorship models have residents rotate one-on-one with an attending physician or small group.

Programs also vary in structure. Some embed research time. A Wake Forest pathway, for example, places applicants with a strong research interest for two years in the orthopedic laboratory working toward a PhD, and successful completers are then considered for the five-year residency. At Indiana University, the program runs two tracks, a five-year clinical track and a six-year research track, each with a separate match process and rank list.

Specialization continues after residency. Subspecialty fellowships in areas such as adult reconstruction, sports medicine, hand surgery, and spine typically last one year, while musculoskeletal oncology may take one to two years. Those who wish to subspecialize in orthopedic oncology must complete an additional fellowship phase.

Certification and national models

Certification systems differ by country. In the United States, board certification is administered by the American Board of Orthopaedic Surgery, and eligibility depends on completing an accredited residency. In the United Kingdom, trauma and orthopedic surgery is organized as a structured specialty training program that follows the foundation years after medical graduation. Germany recognizes orthopedics and trauma surgery as a specialist qualification (Facharzt) obtained through a defined period of supervised training. The length, assessment methods, and the balance between clinical service and academic work vary across these systems, so comparisons of training duration between countries require care.

Surgical simulation and cadaveric training

Hands-on skills are developed alongside clinical work. Residency curricula commonly include laboratory sessions. One program describes hands-on courses and cadaveric labs covering anatomic dissections, internal and external fixation, and joint reconstruction. Simulation models and procedural workshops allow trainees to rehearse technically demanding steps before operating on patients. Competency-based education, which ties progression to demonstrated skill rather than elapsed time alone, has shaped how these exercises are assessed, though the evidence on how far simulation transfers to operating-room performance continues to be debated.

Workforce composition and gender

Women remain underrepresented in orthopedic surgery. Although women account for more than half of medical students in the USA, in 2018 only 7.6% of American Academy of Orthopaedic Surgeons members were women. Among clinically active academic surgeons, one study found that 435 of 4,519 (10%) were female, compared with 19% in the AAMC faculty database and 7% of AAOS members. More recent data from US residency programs show a different pattern at the trainee level: there were 1,026 female orthopedic surgery residents, which comprised 23.7% of all orthopedic residents across the United States. Representation among senior faculty is lower, with 11.3% of all operative orthopedic faculty being female.

Recruitment patterns also matter. In a survey of German-speaking students, researchers noted that despite women making up the majority of medical students in Germany, their representation in surgical fields, especially orthopaedics and trauma surgery, remains comparatively low. Evidence from the United States suggests that female applicants have a match rate reflective of their male peers, but significantly fewer females apply to orthopedic surgery. Barriers may appear early; one Saudi study proposed that the potential barriers to female participation are likely present from the beginning of medical education.

Surgeon volume and outcomes

A recurring question in workforce planning is whether experience improves results. A systematic review of orthopedic studies found that higher hospital volume was associated with lower mortality and hip dislocation rates, while higher surgeon volume was associated with lower hip dislocation rates. The reviewers also noted that all other associations were negative or inconclusive. In a single-center ankle fracture study, patients treated by low-volume surgeons took 30% longer to heal radiographically and had greater reoperation rates than those treated by high-volume surgeons. Evidence is not uniform: a retrospective cohort study of cervical disc arthroplasty found that surgeon volume did not have a significant impact on outcomes following CDA. Analyses have also found that there appears to be a continuum rather than a clear-cut threshold between volume and outcome, making it difficult to identify a specific cutoff point. Researchers also caution that the benefits of high-volume work seem to be related more to the doctors performing health care than to the hospital organization or volume.

Global burden and access to care

Scale of demand

Musculoskeletal disorders group more than 150 distinct diagnoses that affect the joints, muscles, bones, ligaments, tendons and spine. Musculoskeletal disorders include more than 150 different conditions affecting joints, muscles, bones, ligaments, tendons, and the spine. Global Burden of Disease estimates place the number of people living with these conditions in 2021 at about 1.69 billion, close to double the 1990 figure. In 2021, the global prevalence of MSDs was estimated at 1,686.56 million cases (95% UI: 1,599.17 to 1,780.15 million), representing a 95% increase from 1990. Their weight in lost healthy years is uneven. Measured in disability-adjusted life years, they make up roughly one-fifteenth of the global total, but about one-fifth in high-income countries. MSDs account for 6.7% of global disability-adjusted life years (DALYs), with this figure rising to 21.3% in high-income countries Projections point to a further rise in absolute case numbers, even as age-standardised rates keep falling. By 2035, the number of MSD cases is projected to rise to 2.161 billion, along with corresponding increases in DALYs and mortality, although ASRs are expected to continue declining.

Demand for specific operations is growing faster in some health systems. In the United States, Medicare-recorded primary knee replacements rose from about 604,000 in 2013 to just over 1.01 million in 2022, and a projection reaches roughly 2.79 million by 2040. The authors of that projection expect this expansion to exceed the growth of national health spending. The annual adjusted primary total knee arthroplasty (TKA) volume increased from 603,704 in 2013 to 1,013,533 in 2022 and is projected to reach 2,793,919 by 2040, and growth in primary TKA and THA is expected to continue and outpace national health expenditure.

Unequal access

The shortfall in surgical access is measured in billions of people. Roughly 5 billion people do not have access to safe, timely surgical and anaesthesia care when needed, and most of them live in the poorest regions of the world. Basic operative care is out of reach for about nine in ten people in low- and lower-middle-income settings. Access is worst in low-income and lower-middle-income countries, where nine of ten people cannot access basic surgical care. The concentration of operations is similarly skewed. Of an estimated 312·9 million surgical procedures undertaken worldwide in 2012, only 6·3% were done in countries comprising the poorest 37·3% of the world's population.

Trauma care shows the gap sharply. The median rate of trauma need was 7361 individuals per 100,000 per year (IQR 6313-9461), whereas the median rate of trauma surgery was 64.8 procedures per 100,000 per year. The median rate of trauma surgery currently performed in the represented LMICs was 20 times less than the Lancet Commission on Global Surgery's benchmark. The commission's estimate of the overall gap is 143 million additional surgical procedures needed in LMICs each year to save lives and prevent disability.

Access to imaging, standard implants and rehabilitation follows similar gradients, although these elements are less often measured in headline statistics. A commentary on the commission's report argued that there is one critical element almost completely omitted: rehabilitation.

Essential surgery, task-sharing and appropriate technology

Essential surgery concentrates on a limited set of operations, including obstetric emergencies, fracture and open-wound care, and treatment of hernia and bowel obstruction, which avert much of the avoidable death and disability. International recognition followed: In 2015, the United Nations decided on a new set of sustainable development goals which for the first time recognized surgery as an integral and necessary component for a functioning health system.

Task-sharing assigns defined procedures, such as closed fracture reduction, splinting and basic wound debridement, to trained non-specialist clinicians working under supervision, while reserving complex reconstruction for specialists. Appropriate technology favours devices that can be sterilised, repaired and used with limited power or imaging, such as traction frames, simple external fixators and locally produced implants, rather than costly systems designed for high-income hospitals.

Financing and cost-effectiveness

Financing is often the decisive barrier. Where patients pay at the point of care, as is common in several low-income countries in Africa and South Asia, user fees make up the bulk of financing mechanisms for surgical and anaesthesia care provided within the public sector and within private for-profit facilities. The 2015 commission also estimated that 33 million people facing catastrophic health expenditure each year result from surgical need.

In high-income systems, the pressure appears on the payment side. In the United States, average inflation-adjusted Medicare reimbursement for primary TKAs decreased by 42 %, from $1888 in 2000 to $1097 in 2019. Cost-effectiveness of common operations depends on volume and patient risk. A simulation built on Medicare data found that knee replacement was good value for older adults across the risk groups examined, but at all risk levels, TKA was more costly and less effective in low-volume centers than in high-volume centers. For a more specific group, a recent analysis reported that knee replacement in patients aged 50 to 65 with a body mass index of 40 or more carried an ICER of $35 200.

The economic scale of these disorders is also large. In 2021, MSDs were responsible for a global VLW of $2099.84 billion, representing 1.41% of global GDP. The same analysis found that the economic burden of MSDs was highest in high-income regions and lowest in sub-Saharan Africa. Because such estimates depend on recorded diagnosis and treatment, the lower figures in poorer regions should not be read as lower need.

Evidence debates and unresolved questions

Arthroscopy for degenerative knee conditions

Arthroscopic partial meniscectomy is one of the most common orthopedic operations, and its benefit was long assumed rather than demonstrated. The FIDELITY trial, run at five orthopedic clinics in Finland, randomized 146 patients aged 35 to 65 with degenerative medial meniscus tears and no knee osteoarthritis to either the real operation or a sham procedure. At 12 months, the surgical group did no better than the sham group on the primary outcomes, which included the Lysholm and WOMET scores and pain after exercise. A later 10-year follow-up of 133 patients found no benefit across outcomes and a suggestion of worse symptoms and disability after surgery. Surgery was also linked to more radiographic osteoarthritis progression (81% versus 70%) and to more high tibial osteotomy or knee replacement (12% versus 4%). Commentators have noted that this is the only one of four placebo-controlled trials of this procedure with 5- or 10-year data.

A meta-analysis of individual patient data from 605 randomized patients, which pooled trials comparing the operation with exercise therapy, corticosteroid injection, or sham surgery, found only a small reduction in knee pain at 24 months, of about two points on a 100-point scale. No clinically relevant difference emerged for overall knee function, quality of life, or mental health. The debate therefore centers less on whether any effect exists and more on whether the small pain benefit justifies the risks, costs, and the common practice of operating on degenerative tears in people with early osteoarthritis. Sham-controlled designs address a methodological problem: surgical trials are difficult to blind, because patients and clinicians usually know whether an operation has taken place, and a placebo operation is one way to preserve blinding.

Spinal fusion and decompression compared with nonoperative care

The Spine Patient Outcomes Research Trial (SPORT) in the United States combined a randomized cohort of 304 patients with an observational cohort of 303 patients who chose their own treatment. Crossover was high: about 40% of randomized patients switched treatment in each direction within one year. Because of this, the investigators reported results according to the treatment actually received. In the lumbar disc herniation arm, the authors could not claim that either surgery or nonoperative care was superior. In the spinal stenosis arm, at eight years 70% of patients randomized to surgery and 52% of those randomized to nonoperative care had undergone an operation. As-treated analyses of the randomized group showed that the early advantage of surgical decompression, seen up to four years, disappeared by years six to eight, whereas the observational group kept a stable surgical advantage. The investigators noted that patients who chose nonoperative care rarely worsened, which made the decision more one of preference and tolerance than of safety. Because patients' preferences and the crossover between groups confound comparisons, the SPORT results illustrate the difficulty of answering the question with randomized design alone.

Implant durability and metal-on-metal bearings

Long-term implant performance remains an open question, particularly for metal-on-metal hip bearings. In 2010 a widely used metal-on-metal design was recalled because its failure rate was about twice the expected level, with loosening and dislocation as the main problems. Aseptic loosening caused by osteolysis is the second leading cause of failure in patients with these bearings, and wear from the metal components releases debris that can provoke a strong immune reaction and soft-tissue damage. The U.S. Food and Drug Administration then required manufacturers to conduct post-market surveillance or withdraw such devices, and metal-on-metal total hips are no longer marketed there. Failures in these bearings are often clinically silent, so imaging surveillance is important; in one cohort of 247 primary metal-on-metal total hips followed for about ten years, MRI detected pseudotumors in roughly a third of hips. Outcomes vary considerably between series. A single-surgeon series reported excellent ten-year survivorship after revision of a recalled large-head design, which illustrates that failure rates depend on design, surgeon, and patient factors. National joint registries, such as the one in Sweden that identified poorly performing products, are the main tool for detecting such differences across populations, and they underpin the case for lifelong surveillance.

Biological and regenerative treatments

Platelet-rich plasma and stem-cell preparations are widely offered for tendon disorders and osteoarthritis, often outside the context of formal trials. The evidence base is limited in several respects: study populations and preparation methods differ widely, outcome measures are inconsistent, many trials are small or short, and blinding and placebo control are difficult to achieve when the product is injected. Regulatory status and oversight also differ between countries, which complicates comparison of results. As a result, the question of whether these treatments produce benefits beyond placebo, and for which patients, remains only partly answered by high-quality evidence.

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153. Limb-salvage surgery offers better five-year survival rate than amputation in patients with limb osteosarcoma treated with neoadjuvant chemotherapy. A systematic review and meta-analysisncbi.nlm.nih.gov
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180. Return to Sports After Anterior Cruciate Ligament Reconstruction - PMCpmc.ncbi.nlm.nih.gov
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194. Accuracy and Outcomes of a Novel Cut-Block Positioning Robotic-Arm Assisted System for Total Knee Arthroplasty: A Systematic Review and Meta-Analysisncbi.nlm.nih.gov
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197. Patient-Specific Orthopaedic Surgery: An Economic Analysis on 3D Printing Devicesjournaloei.scholasticahq.com
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201. Automatic Hip Fracture Identification and Functional Subclassification with Deep Learningdoi.org
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204. Improving pediatric hip fracture detection using deep learning: multicenter validation and clinical reader study - PMCpmc.ncbi.nlm.nih.gov
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210. Orthopaedic Residency Programtuftsmedicine.org
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215. Academic Orthopaedics As a Driver of Gender Diversity in the Orthopaedic Workforce: A Review of 4,519 Orthopaedic Faculty Membersncbi.nlm.nih.gov
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222. Impact of Surgeon Procedural Volume on Outcomes Following Cervical Disc Arthroplasty: A Retrospective Cohort Study - PMCpmc.ncbi.nlm.nih.gov
223. Volume versus Outcomes in Orthopaedic Surgery: A... : Journal of Bone and Joint Surgeryovid.com
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234. What Is the Need for and Access to Trauma Surgery in Low- and Middle-Income Countries? A Scoping Review - PubMedpubmed.ncbi.nlm.nih.gov
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244. 10-Year Data Confirm No Benefit From Arthroscopy for Degenerative Meniscal Tearmedscape.com
245. Arthroscopic Partial Meniscectomy for Degenerative Tear - 10-Year Outcomes.myorthoevidence.com
246. One of the world's most common knee surgeries does not help and may even be harmfulmedicalxpress.com
247. Arthroscopic partial meniscectomy vs non-surgical or sham treatment in patients with MRI-confirmed degenerative meniscus tears: a systematic review and meta-analysis with individual participant data from 605 randomised patients - Osteoarthritis and Cartilageoarsijournal.com
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249. Second SPORT Study Results: Clear Advantage of Surgery for Spinal Stenosis and a Slipped Vertebra - Geisel School of Medicinegeiselmed.dartmouth.edu
250. Commentary on: The role of surgery for treatment of low back pain: Insights from the randomized controlled SPORT trials - PubMedpubmed.ncbi.nlm.nih.gov
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252. Metal-on-Metal Hip Implant Recallsbonesmart.org
253. Outcomes of the Recalled Articular Surface Replacement Metal-on-Metal Hip Implant System: A Systematic Reviewresearchgate.net
254. Failure of Metal-on-Metal Total Hip Arthroplasty: The First Reported Case from the Caribbean and the Need for a National Joint Registry - PMCpmc.ncbi.nlm.nih.gov
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256. The Long-Term Survivorship and Cause of Failure of Metal-on-Metal Total Hip Arthroplastyncbi.nlm.nih.gov
257. Long-term Follow-up on Revisions of a Recalled Large Head Metal-on-metal Hip Prosthesis: A Single Surgeon Series - PMCpmc.ncbi.nlm.nih.gov