Taylor Neal

Mr. Rhodes

Advanced Placement Language and Composition

23 February 2017

A Career in Orthopedic Surgery

Crash! Mollys mother rushes into the nursery to find her little girl sprawled across the

floor, her crib crushing her bones. She immediately screams to her husband to call 9-1-1. The

ambulance comes and rushes away with Molly and her grief-stricken parents to the nearest

hospital, 20 miles away. Sirens blaring, the ambulance pulls up to the doors of the hospital

where a nurse takes little Molly straight to the surgical wing where an orthopedic specialist will

mend Mollys small, crushed, bones. To fix the bones in such a small body, the surgery requires

perfect precision. The parents sit anxiously in the waiting room for any news about their

daughters condition. After a few tense and stressful hours, news arrives of Mollys successful

surgery. With the procedure finished, the cleaning crew begins the process of sterilizing the

room and the surgeon itself because unlike in the past, a surgical robot helped complete this

surgery. Many children need precision surgery that only a robotic surgeon can perform with a

much higher degree of accuracy. Technology has greatly influenced the field of orthopedics

along with the role and preparation of one aspiring to become an orthopedic surgeon. A career in

orthopedic surgery encompasses completing surgeries to fix broken or deformed musculoskeletal

issues, with updated technology and revised procedures, which can cause stress for the surgeon.

The field of orthopedics has evolved throughout the centuries into a world-renowned

surgical specialty. Its creation traces all the way back to the Enlightenment when a man named
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Nicolas Andry, created the term orthopedics originating from two words in the Greek language,

orthos meaning straight and paideia translating to the education of a child (Bni 45). Andry

also created a symbol, a crooked tree tied to a pole showing how the entire field of orthopedics

prevents deformities from worsening (45). The field of orthopedics took a progressive step when

Jean-Andre Venel, the father of orthopedics, founded the first orthopedic hospital in Switzerland

in 1780 (45). This hospital did not perform surgical procedures, but instead performed

therapeutic treatments and created machines to fix deformities. The field of orthopedics later

evolved into a surgical field near the end of the 19th century (45). An orthopedic surgeon

devotes many years of his / her life to fulfilling the educational requirements.

The educational path to a career as an orthopedic surgeon begins with an undergraduate

degree. In order to fulfill the 8-10 pre-medical course requirements, students aspiring to enter a

career in the medical field tend to major in pre-medicine or a field of science such as biology

(Richardson et al 230). When looking for universities offering a bachelors degree in Biology,

students should consider the University of North Carolina at Chapel Hill (UNC-CH) or

Vanderbilt University. However, UNC-CH and Vanderbilt University both have a low rate of

acceptance, UNC-CH at 28%, and Vanderbilt University only 13% making entry into this field

more challenging (College Search: Supermatch). The one consistent factor families struggle

with involves tuition. For a student who lives in the state of North Carolina, he or she would pay

approximately $19,000 per year to attend UNC-CH (College Search: Supermatch). In

comparison, the same student would pay roughly $58,000 per year to attend Vanderbilt

University, a private school (College Search: Supermatch). Attending UNC-CH would cost a
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student around $40,000 less per year, which after four years accumulates to a total savings of

$120,000. All of this extra money can now go towards paying for medical school.

The most important thing when preparing for medical school involves the Medical

College Admissions Test (MCAT). The recent release of the MCAT2015 improves the selection

process among medical schools (Bingham et al 26). The previous MCAT exams, consisted of

four sections including physical sciences, biological sciences, verbal reasoning, and writing took

4 hours and 20 minutes to complete (25). The MCAT2015 now takes 7 hours and 30 minutes to

complete and consists of interdisciplinary topics, such as biochemistry, to make students use

their knowledge and reasoning skills to tie topics together (25). This creates a more accurate

depiction for medical schools when choosing who they think can do the best in their program

(26). This long testing time can result in discouragement to aspiring orthopedic surgeons.

After taking the MCAT, the next step for students pursuing a career as an orthopedic

surgeon involves choosing the right medical school. When looking for a medical school that

provides high-quality education, one should consider Harvard Medical School, ranked number 1,

and the University of North Carolina School of Medicine (UNC), ranked number 21 (Schools of

Medicine). Both medical schools have very low acceptance rates, Harvard Medical School at

4.1% and UNC at 3.6% (Schools of Medicine). For a student residing in North Carolina, he or

she would pay around $80,000 to attend Harvard Medical School for one year (Harvard

Medical School). The cost to attend UNC for one year would total approximately $50,000,

saving $30,000 per year, $120,000 total over the course of this education (UNC School of

Medicine). Medical school costs a tremendous amount of money so students should start

saving early so when they eventually begin their work they have less debt to pay off.
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The work life of orthopedic surgeons varies day to day. Surgeons have to examine

patients, operate on them, and create a postoperative treatment plan (Tasks and Activities).

Orthopedic surgeons need certain skills such as problem solving, critical thinking, and manual

dexterity, the ability to move ones hands quickly, in order to succeed in fast-pace, life or death

situations (Knowledge and Skills). The schedule of an orthopedic surgeon depends on the

time of year and the types of surgeries performed (Farrell). A typical day for an orthopedic

surgeon may involve arriving to the hospital around six in the morning in order to round, check

on the patients before the hospital cases commence at seven am (Farrell). Most days end around

six at night, but this varies based on the people arriving to the hospital in need of help (Farrell).

The workload normally consists of surgeries in the morning then appointments with patients in

the afternoon. Surgeons schedules vary though, some days they could perform surgeries all day

or they could only have appointments with patients. When holiday breaks arrive, orthopedic

surgeons tend to perform more surgeries because families and children want their operations

scheduled to where they can have time to properly rest and heal (Farrell). Along with all of the

surgeries and appointments a surgeon must complete referrals and other administrative work. A

surgeon can get caught up in all of the work at the hospital, taking time away from ones family.

All surgeons must learn to balance work and family life (Farrell). Orthopedic surgery allows

people to not have to work at a desk all day, but to dive into new exhilarating cases. Surgeons

bring in $443,000 on average per year, creating a great reward after a long day of work

(Sifferlin). Throughout the years, surgeons daily work life transformed with the help of

innovative technologies making procedures more efficient.

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Over the centuries, the field of orthopedics evolved into a distinguished surgical field

through advances in technology. One of the main technological advances in orthopedics

involves 3D printing which has many different uses in the surgical field, one includes anatomical

models that allow surgeons to plan out complex surgeries ahead of time. Creating implants with

the patient-specific dimensions used to take place during the surgery, but with 3D printed

anatomical models, surgeons can shape implants prior to the surgery (Tack et al 9). This results

in a shorter operation and a more accurate fit of the implant, improving patient satisfaction (9).

Another use for 3D printing includes surgical guides which allow surgeons to simulate the

surgery to prepare for the proper incisions (10). Knee surgeons use surgical guides more often

than others due to the patient-specific complexity of knee arthroplasties (10). Surgical guides

increase precision and decrease time spent in the operation room. The addition of 3D printing

proves very beneficial in orthopedic surgery, but not all hospitals can afford this technology.

The complex process of 3D printing takes an extensive amount of time and money. The

3D printing system starts with a 3D computed tomography scan that then goes to the 3D printing

unit (3-D Printing Helps 10). A basic 3D printer takes 10 - 12 hours of data input prior to the

printing (10). Even though the process takes long and grueling hours of work, the end result of

higher surgical accuracy rates makes it worth it for the doctor and the patient. The time to print

depends on the size of the object printed, normally about 24 - 48 hours (10). The material the

printer uses consists of plastic that prints in the shape of a cube, that the surgeon then punches

out to produce the correct shape (10). A basic 3D printer costs around $2,500, a relatively

affordable price considering the expense of most technologies (10). The fees of a 3D printer

rack up with the price of the plastic which costs $30 per spool; a simple object such as a pelvis
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requires half a spool of plastic (11). Even though the process takes hours, it does save time

because the surgeon gets to plan before the operation begins (11). The 3D printing technology

enables surgeons to provide the best medical care to their patients.

Many surgeons use models made by 3D printers, but the field of orthopedics makes

extensive use of this particular development. They find that the model allows them to figure out

hands-on how to fix deformed bones (3-D Printing Helps 10). An example involves a model

of a 3D printed hip. In a case where one surgeon dealt with a deformed hip, he used a 3D printer

to print out an anatomical model of the femoral head and socket of the hip (10). This allowed

him to manipulate the femoral head to determine the precise angles the femoral head would fit

into the socket (10). He could then plan incisions on the model to improve results (10). 3D

printing as a whole has made tremendous impacts on the field of orthopedics providing doctors

with better models customized to each patient.

Another technology that has advanced the field of orthopedic surgery involves robots.

Surgeons now use different types of robots that each have its own purpose to help advance the

surgery. The three main types of robots include active, passive, and semi-active systems

(Mihalko 18). An active system can perform tasks by itself without the aid of a surgeon (18). A

passive system does not perform any tasks but aids the surgeon during the operation (18). The

most common type of system used, the semi-active system, can limit or adjust movements of the

surgical instrument, but overall control lies in the hands of the surgeon (18). Many use

semi-active systems to maintain control of the robotic technology (18). Patients more willingly

allow a robot to perform their operation because technology has embedded itself into every part

of todays society building peoples trust, and making the whole process run smoother.
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One example of a system orthopedic surgeons use includes the Navio robotic system to

aid in partial knee replacements. The Navio system includes a handheld robotic instrument and a

computer system. The surgeon begins by using a wand to take GPS measurements of the

patients knee that feed into the computer (Amazing New Mobility). With the coordinates of

the knee, the computer runs through the individualized surgery and identifies the dimensions

needed to cut out the diseased portion of the knee (Amazing New Mobility). The surgeon can

then check the plans and ask the computer questions about the functioning and flexibility of the

new knee. The computer responds with patient-specific answers allowing the surgeon to

determine if anything needs to change to achieve the best results (Amazing New Mobility).

The surgeon begins to drill within the range the computer provided, and if the surgeon deviates

from the specific coordinates, the Navio handheld instrument will shut down to prevent any

unnecessary harm to the patient (Amazing New Mobility). Once the Navio system removes

the diseased portion of the bone the surgeon can insert a metal implant. This partial knee

replacement system prevents a surgeon from having to perform a total knee replacement

reducing mobility of the patient and resulting in a lower quality of life (Amazing New

Mobility). This robotic invention, one of many, created a new surgical procedure for knee

replacements providing patients with a more satisfactory procedural outcome.

Another robotic system that changed orthopedics for the better includes the orthopedic

drilling robot (ODRO). Hand-drilling, on average, results in an error of 6.1 mm causing blood

vessels and tendons to break (Boiadjiev et al 52). Using the ODRO system provides more

accurate precision, resulting in better medical outcomes (52). This system has two drilling

modes, handily and automatic (53). Handily mode gives the surgeon the option to have it
 Neal 8

function as a normal drill. Automatic on the other hand involves the robotic uses of the system

(53). The automatic mode has two functions, it can either drill through the entire bone, or drill

the set depth the surgeon programs into the system (54). Once the ODRO system drills, the

dimensions of the area penetrated show up on the screen of the computer system (55). This

allows the surgeon to make sure it drilled properly (55). Robotic systems have made a huge

difference in orthopedic surgeries by increasing procedural outcomes and patient satisfaction due

to the more specific measurements that it provides.

Another innovation, stem cells, developed new and improved procedures for orthopedic

surgery. A stem cell can continuously multiply on its own and develop into specialized cells

based on the bodys needs (Bagaria et al 162). Stem cells come from three main sources,

embryos, adults, and umbilical cords (163). Embryonic stem cells come from the blastocyst

stage early in development, and have the ability to divide into any type of cell in the body

making them very special (163). Adult stem cells come from bone marrow, blood, skin, livers,

pancreas, and even eyes within adults. However, these cannot divide into any type of cell, but

only the tissue from which they originated (163). Umbilical cord stem cells come from cord

blood in babies, but have the exact same functions as adult stem cells (163). Orthopedic

surgeons tend to include rare adult stem cells in their studies rather than the other two more

common types (163).

Stem cells have become very popular in studies for the field of orthopedics, but most of

the studies only involve animals. One study on rats involves the use of stem cells in regenerating

the spinal cord. When the spinal cord damages, the neurons no longer have the ability to repair

themselves (Bagaria 164). In this study, surgeons implanted different types of adult stem cells
 Neal 9

into rats with spinal cord injuries. All of the different cells implanted showed improvement in

the movement of the spinal cord (164). The use of stem cells on humans still lies in the future,

but when the field of orthopedics begins to use them for spinal cords, it will lead to better

mobility and increased function for patients (164). Another use of stem cells in orthopedic

surgery involves anterior cruciate ligament (ACL) regeneration procedures. A study tested the

effects of stem cells on ACL regenerations on rabbits, one where a surgeon coated the area with

stem cells (165). The results showed the rabbits with the stem cells had better strength and

stiffness in their ligaments (165). If surgeons used stem cells on humans this could prevent

people from having a weaker knee after surgery and even prevent people from retearing their

ACL.

In orthopedic surgery, bone graft procedures can also benefit from stem cells. Many

people experience bone loss after traumatic accidents and require bone grafts from other parts of

their body. This orthopedic procedure, though common, does not always yield positive results.

Taking bone from other body parts can result in donor site morbidity, healing complications

from the site of retrieval (Lim and Hee 83). An alternative to taking bone involves mesenchymal

cells, which can turn into osteoblasts or /bone cells/, and chondrocytes known as /cartilage cells/

(83). A study performed on people showed that after two months the stem cells integrated into

the bone (83). If surgeons use this application regularly it could prevent unnecessary

complications with bone donor sites. Just like bone grafts, tendons and ligaments result in donor

site morbidity and unnecessary infections. A study on the effects of mesenchymal stem cells on

healing tendons in rabbits produced positive results for the field of orthopedics. Rabbits who

received stem cells showed 87% normal tendon stiffness compared to the 56.4% for those who
 Neal 10

did not (84). If surgeons use stem cells to help repair tendons it would eliminate the need to take

tendons from other parts of the body resulting in less donor site morbidity. Stem cells helped

progress orthopedic surgery providing more creative alternatives to improve healing within the

body.

The field of surgery not only changes with advances in technology but also evolves with

the help of other innovations. Arthroplasty, a replacement of a joint, represents one example of a

procedure that continues to transform. The number of total hip arthroplasties (THA) and total

knee arthroplasties (TKA) completed by orthopedic surgeons increased dramatically in the recent

years. In 2015, the hip and knee implant market totaled around 18.26 billion dollars, and by

2022 it estimates to 34.57 billion dollars because of the aging population of the United States

(Hip and Knee). People choose to have TKAs and THAs for many different reasons, some of

which include lowering pain levels, monetary reimbursement, and mobility of the knee or hip

(Neuprez et al 4). With THAs and TKAs people can return home with an enhanced quality of

life due to lower pain levels and more mobility in their joints.

Hip arthroplasties evolved throughout the centuries to create better fitting joint

replacements. In the 1950s, Moore and Thompson created the original implant, a sphere-shaped

head with a short neck, collar, and a stem coming out the end at a bent angle (Markatos et al

170). In 1960, McKee and Farrar worked together to introduce a stainless steel cup with

teeth-like hinges on top of the round head of the implant, providing better stability (170). Later

that year, Charnley began making implants with acrylic cement to allow for a more desirable

stability with the implant (170). The most recent addition to the implant for the hip took place in

1963 when a surgeon added polyethylene, a plastic to create friction between the implant and the
 Neal 11

hip socket (170). Modifications on the dimensions of the implant took place over time, one of

which included changing the diameter of the head from 40mm to 28mm in order to increase

mobility and decrease the risk of dislocation (170). The evolution of the hip arthroplasty

continues to advance the field of orthopedics allowing patients to receive a more stable and

reliable hip replacement.

Just like the procedure for hip arthroplasties continues to evolve throughout the centuries,

the implant for knee arthroplasties continues to transform through the ages. In the 1950s, Leslie

Shiers and Borje Walldius created the first TKA implant (Markatos et al 172). This original

implant consisted of a metallic piece with hinges that provided stability on all sides of the knee

(172). Unfortunately, this implant did not allow for a wide range of movement, so in 1971 - 73,

Gunston and Coventry both invented implants with more rotation and flexibility (172).

However, these implants loosened too easily so surgeons added polyethylene to create friction,

but unlike the hip replacement, the polyethylene once again allowed too little mobility (172).

After many more failures, a surgeon fitted a flat polyethylene insert into the implant solving the

flexibility and loosening problems (173). With the help of many innovators, arthroplasty

surgeries can now improve the quality of life for many patients. Orthopedic surgeons perform

arthroplasties often, most of the time yielding positive results.

People view orthopedic surgery as a low-risk surgical field therefore they do not expect

many complications. Although orthopedic surgery has a low rate of mortality at .11%, the rate

of complications exceeds the mortality rate immensely (Chikuda et al 3). The rate of major

complications in patients undergoing a common orthopedic surgery averages 4.2% (3). These

rates can increase with different risk factors such as patients age, sex, and comorbidity (3). A
 Neal 12

male patient over 80 years old with a secondary disease such as diabetes has the greatest risk for

complications including mortality (3). Once the surgery concludes, rehabilitation can seem like

a long and tedious process, but focusing and working hard allows the body to properly heal. Bo

Jackson, a baseball player who had two hip surgeries, made a remarkable recovery undergoing

strenuous rehabilitation by performing more than 10,000 push-ups, 15,000 situps and 35,000

repetitions of hip exercises during a five month period (Weaver 73). This hard work during

rehabilitation allowed him to once again play Major League Baseball (73). Unfortunately a

couple of years after returning to sports, Jackson retired because his new hip limited him from

playing to his full potential (Jackson, Bo). With modern hip arthroplasty procedures Jackson

could have healed properly and continued to play sports much longer. Surgeons not only have to

deal with complications during orthopedic surgery, but also prejudices within the field.

Many prejudices against women exist within the field of medicine. Today, women

account for the majority of people in medical school however, females only represent 20% of the

surgical field (Bucknall and Pynsent 89). Orthopedic surgery consists of even more bigotry than

general surgery. In 1998, females only comprised 6.9% of orthopedic surgeons, the second

lowest percentage with cardiothoracic at the bottom (90). The most popular specialities for

women include obstetrics, gynecology, pediatrics, and dermatology (Ng-Sueng et al 11). In a

survey, 76% of females reported they would not pursue a career in orthopaedic surgery due to a

lack of interest and because males dominate the speciality (Bucknall and Pynsent 90). Another

study showed that 34% of females dealt with discrimination in the surgical field, and 64% of

them would no longer choose a career in that field (90). Due to all of the negative attitudes

toward females in surgical fields, especially in orthopedics, females tend to steer clear from those
 Neal 13

specialities. Regardless of gender stereotypes, when it comes to ethical guidelines all medical

students must follow the same rules.

The way doctors treat patients, ethics, plays a large role in the medical field. Doctors

have to learn to communicate and treat patients properly, but most medical schools lack in

educating their doctors on ethical behaviors. A study conducted by the American Academy of

Orthopaedic Surgeons (AAOS) Ethics Committee found that residency programs spent less than

three and a half hours per year on ethical training (Carroll 11). In order to increase the amount of

time and quality put into ethics, the AAOS founded the Resident Ethics Series: Issues and

Scenarios for Discussion and Guidance (11). The questions cover common ethical topics that

can arise in orthopedic surgery and help prepare doctors by engaging them in conversation about

how to respond in these situations (11). The most common ethical issues surgeons come in

contact with include, informed consent, medical error and professionalism (Fard et al 725).

Professionalism by far outweighs the others and includes a wide variety of topics such as

conflicts of interest, doctor - patient relationship, and the doctors relationship with other

surgeons (727). Medical schools need to make sure they teach students ethics properly to

prepare students for different situations they may encounter. Even if doctors follow all of the

instructions to prevent conflicts with patients, they cannot avoid stressful situations within

themselves.

Many doctors experience burnout at some point in time during their career. Orthopedic

surgery mentally, physically, and emotionally drains doctors. Burnout tends to show when

doctors begin their internship and residency years. Before internship only 4% show signs of

depression, but during that year, the rate drives all the way up to 25% from the heavy workload,
 Neal 14

long hours, and low pay (Oaklander 48). Burnout rates among all orthopedic surgeons jumps

even higher ranging from 50-60% compared to general surgeons who range from 30-40% (Arora

et al 512). Burnout can lead to poor judgement, depersonalization, depression, physical

exhaustion, and drug abuse (Arora et al 512). All of these can affect the patient care doctors

provide. A study of 8,000 doctors showed that burnout led to higher rates of a major medical

error (Oaklander 45). Not only does burnout affect patients, but also the doctors life. Around

400 doctors commit suicide every year because they suffer from constant mental distress

(Oaklander 45). The Accreditation Council for Graduate Medical Education made a rule in 2003

that residents could not work more than 80 hours a week, and no longer than 16 hour shifts (48).

Unfortunately this did not help because sleep does not cause burnout on its own (48). These

issues start during internships and continue throughout, so orthopedic surgeons have to learn to

cope with the deaths, workload, and long hours. Doctors deal with mental illnesses such as

depression just like everyone else. When choosing to become an orthopedic surgeon, one must

embrace the job, enjoy helping people, and never solely choose to enter this career because of the

money. The money surgeons receive will never amount to anything if the person does not truly

appreciate his / her career. Surgeons can overcome the time, effort, and stress put into the career

only if they love what they do.

Orthopedic surgeons perform surgeries that incorporate fixing bones, and other

musculoskeletal issues. In the recent decades, the field of orthopedics has improved many

procedures with the help of advanced technology such as robotics and stem cells. The path to

becoming an orthopedic surgeon involves a lot of hard work, but if one loves what they do, then

she can truly succeed.

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 Neal 17

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