The future of orthopedics

Just as fi ctional stories, such as 1984 by George Orwell and Our Posthuman Future by Francis Fukuyama, have not accurately portrayed the future of the human race, predictions about the future of orthopedics made during past years have seldom become a reality. If the truth be known, most changes occur with progression of existing trends that are improved by a few genuine advances, which most of us can see only by looking back in time, sometimes revealed by startling changes that progress quite rapidly. So then, could anybody have predicted the last 30 years of changes in orthopedics alone? Think back for a moment: Forty years ago children with Perthes disease might have been non-weight bearing for 2 years. Children with scoliosis may have been placed in skeletal traction followed by use of a brace well into adolescence. Adults undergoing spinal fusion and those with spinal fractures were immobilized in a plaster cast extending from neck to pelvis for many months. Orthopedic hospitals had teams of personnel who did nothing but evaluate the mechanics of traction. The inpatient stay for complex fractures was often months. Many fractures were treated without surgical fi xation, and fracture surgery 40 years ago was restricted primarily to the forearm and occasionally the ankle. Intramedullary nailing was an interesting thought but not frequently used. Charnley, in England, had moved forward with an interesting hip replacement, but it had not yet been accepted by the orthopedic community. Orthopedic surgery, much like the other surgical specialties, was under the control of general surgery. The major trends of 40 years ago were decreasing the amount of time in the hospital and stabilizing fractures to allow early mobilization, including the advent of internal fi xation, joint replacement, and arthroscopic surgery. All of these goals were greatly assisted by advances in anesthesia and pain relief for patients. The 40 years between 1968 and 2008 have seen great advances in many areas of orthopedics: internal fi xation of fractures, including intramedullary nailing and plating techniques and devices; joint replacement, including joints other than the hip and knee; arthroscopic surgery, including the development of therapeutic as well as diagnostic applications; minimally invasive techniques; cartilage regeneration; biological implants; and genetic engineering. So then, let us address some initial thoughts about predictions for the future. Certainly, minimally invasive techniques will be developed further, and stays in the hospital will become even shorter. Long hospital admission times will be rare except for patients with multiple trauma and other extensive procedures. Several global issues will have a major infl uence on the future of orthopedics. All over the world, the population shift is from rural to urban settings; it is estimated that within the next 10–15 years 60% of the world’s population will live in urban environments, placing enormous demands on the health care facilities in urban areas and exacerbating the current “trauma-call and emergency-care” crisis. Longer life expectancies mean that people expect a better quality of life for a longer period than ever before — the “baby boomers” aren’t sitting in their rocking chairs. Along with these longer, more active lives come increased bone and joint injuries and chronic musculoskeletal diseases. Approximately 40% of women over the age of 40 years have some form of osteoporosis, and more than 1 million women have vertebral compression fractures. Arthritis is the most common reason for consulting an orthopedist and is the most important medical problem affecting the quality of life in this age group. We can look to the day when the average life expectancy will go from the eighties to well into the nineties and beyond. That is going to generate a large group of patients who are going to require a signifi cant amount of orthopedic care. Offprint requests to: J.H. Beaty Received: November 26, 2008