Many orthopedic surgeons elect to do further training, or fellowships, after completing their residency training. Fellowship training in an orthopedic sub-specialty is typically one year in duration (sometimes two) and sometimes has a research component involved with the clinical and operative training. Examples of orthopedic subspecialty training in the United States are:


These specialized areas of medicine are not exclusive to orthopedic surgery. For example,  hand surgery  is practiced by some  plastic surgeons , and spine surgery is practiced by most  neurosurgeons . Additionally,   foot and ankle surgery  is also practiced by doctors of  podiatric medicine  (DPM) in the United States. Some  family practice  physicians practice  sports medicine , but their scope of practice is nonoperative.


After completion of specialty residency or  registrar  training, an orthopedic surgeon is then eligible for board certification by the  American Board of Medical Specialties  or the  American Osteopathic Association Bureau of Osteopathic Specialists . Certification by the American Board of Orthopedic Surgery or the  American Osteopathic Board of Orthopedic Surgery  means that the orthopedic surgeon has met the specified educational, evaluation, and examination requirements of the board. [ 18 ] [ 19 ]  The process requires successful completion of a standardized written examination followed by an oral examination focused on the surgeon's clinical and surgical performance over a 6-month period. In Canada, the certifying organization is the  Royal College of Physicians and Surgeons of Canada ; in Australia and New Zealand, it is the  Royal Australasian College of Surgeons .


In the United States, specialists in hand surgery and orthopedic sports medicine may obtain a certificate of added qualifications  in addition to their board primary certification by successfully completing a separate standardized examination. No additional certification process exists for the other subspecialties.


According to applications for board certification from 1999 to 2003, the top 25 most common procedures (in order) performed by orthopedic surgeons are: [ 20 ]


A typical schedule for a practicing orthopedic surgeon involves 50–55 hours of work per week divided among clinic, surgery, various administrative duties, and possibly teaching and/or research if in an academic setting. According to the  American Association of Medical Colleges  in 2021, the average work week of an orthopedic surgeon was 57 hours. [ 21 ] [ 22 ]  This is a very low estimation however, as research derived from a 2013 survey of orthopedic surgeons who self identified as "highly successful" due to their prominent positions in the field indicated average work weeks of 70 hours or more. [ 23 ] [ 21 ]


The use of arthroscopic techniques has been particularly important for injured patients.  Arthroscopy  was pioneered in the early 1950s by  Masaki Watanabe  of Japan to perform minimally invasive cartilage surgery and reconstructions of torn ligaments. Arthroscopy allows patients to recover from the surgery in a matter of days, rather than the weeks to months required by conventional, "open" surgery; it is a very popular technique. Knee arthroscopy is one of the most common operations performed by orthopedic surgeons today, and is often combined with meniscectomy or chondroplasty. The majority of upper-extremity outpatient orthopedic procedures are now performed arthroscopically. [ 24 ]


Arthroplasty is an orthopedic surgery where the articular surface of a musculoskeletal joint is replaced, remodeled, or realigned by  osteotomy  or some other procedure. [ 25 ]  It is an elective procedure that is done to relieve pain and restore function to the joint after damage by arthritis ( rheumasurgery ) or some other type of trauma. [ 25 ]  As well as the standard total knee replacement surgery, the unicompartmental knee replacement, in which only one weight-bearing surface of an arthritic knee is replaced, may be performed, [ 25 ]  but it bears a significant risk of revision surgery. [ 26 ]  Joint replacements are used for other joints, most commonly the  hip [ 27 ]  or  shoulder . [ 28 ]


A post-surgical concern with joint replacements is wear of the bearing surfaces of components. [ 29 ]  This can lead to damage to the surrounding bone and contribute to eventual failure of the implant. [ 29 ]  The plastic chosen is usually ultra-high-molecular-weight  polyethylene , which can also be altered in ways that may improve wear characteristics. [ 29 ]  The risk of revision surgery has also been shown to be associated with surgeon volume. [ 28 ] [ 30 ]


Between 2001 and 2016, the prevalence of musculoskeletal procedures drastically increased in the U.S, from 17.9% to 24.2% of all operating-room (OR) procedures performed during hospital stays. [ 31 ]


In a study of hospitalizations in the United States in 2012, spine and joint procedures were common among all age groups except infants. Spinal fusion was one of the five most common OR procedures performed in every age group except infants younger than 1 year and adults 85 years and older. Laminectomy was common among adults aged 18–84 years. Knee arthroplasty and hip replacement were in the top five OR procedures for adults aged 45 years and older. [ 32 ]


Artificial ligaments  are devices used to replace damaged  ligaments . Today, the most common use of artificial ligaments is in  anterior cruciate ligament reconstruction . [ 1 ]  Although  autotransplantation  remains the most common method of ligament reconstruction, numerous materials and structures were developed to optimize the artificial ligament since its creation in the  World War I  era. [ 2 ]  Many modern artificial ligaments are made of synthetic polymers, such as  polyethylene terephthalate . [ 3 ]  Various coatings have been added to improve the biocompatibility of the synthetic polymers. [ 3 ]  Early artificial ligaments developed in the 1980s were ineffective due to material deterioration. [ 4 ]  Currently, the Ligament Advanced Reinforcement System (LARS) artificial ligament has been utilized extensively in clinical applications. [ 5 ]   Tissue engineering  is a growing area of research which aims to regenerate and restore ligament function. [ 2 ]


Artificial ligament research began in the  World War I  era. [ 2 ]  In the first documented case of an artificial ligament in 1914, Dr. Corner utilized a piece of silver filament as synthetic graft to reconstruct a ruptured  anterior cruciate ligament  ( ACL ). [ 2 ]  A ligament made of silk was used to replace an ACL in 1918. [ 2 ]


In the early 1980s, technological progress in chemistry and materials science promoted the development of medically suitable materials. Doctors utilized these synthetic materials in clinical applications. The  Food and Drug Administration  (FDA) approved an artificial ligament made of  Gore-Tex  for use in ACL reconstruction in 1986. [ 6 ]


The design of artificial ligaments in the 1980s consisted of two major parts: a relatively stiff cable or tape, and silicone rubber cylinders on one or both ends. [ 2 ]  The cable or tape was usually made of  polyethylene ,  nylon  or  carbon fiber . The  silicone rubber  cylinder varied in size to fit different sized patients. [ 2 ] [ 7 ] [ 1 ]  Theoretically, the flexibility of the  silicone rubber  would allow some deformation under relatively low loads, and the artificial ligament would stiffen to maintain its shape under higher loads. [ 7 ] [ 1 ]  Practically, this design never achieved its goal to mimic the property of a natural ligament. [ 8 ]  The mechanical performance of the artificial ligaments was inadequate for widespread clinical application. In the long term, performance loss, complications, and failure occurred. [ 8 ]


Material deterioration contributed to the ineffectiveness of early artificial ligaments. [ 4 ]  Issues would occur in the months and years following treatment. [ 2 ] [ 4 ]  J.E. Paulos indicated in a report about  Gore-Tex  usage in  ACL  reconstruction: "Early results of the  Gore-Tex  prosthesis used for  ACL  reconstruction showed low rates of failure. Unfortunately, with extended follow-up, our rate of complications continues to increase. Mechanical failure, effusions, and infections continue to occur". [ 2 ]  At the time, the materials used in artificial ligaments could not sustain adequate mechanical performance. [ 2 ] [ 4 ]  For many of these materials, their mechanical performance diminished in the long-term. [ 1 ] [ 8 ] [ 4 ]


The primary usage of modern artificial ligaments is in  anterior cruciate ligament reconstruction . Many artificial ligaments seek to mimic or exceed the performance of the native  ACL . [ 5 ]  The mechanical performance of an artificial ligament can be characterized by  abrasion  resistance, withstanding flexural and rotational  fatigue , [ 2 ]  and preventing graft slippage or rupture. [ 9 ]  Biocompatibility is important to the performance of the artificial ligament in vivo. [ 3 ]  Biocompatibility is related to new tissue ingrowth, [ 10 ]  fibroblast migration,  osseointegration  of bone, reduction of  inflammation , preventing scar tissue infiltration, and improving hydrophilicity. [ 3 ]  Tissue ingrowth and fibroblast migration have been shown to improve the mechanical strength of the artificial ligament, [ 10 ]  and osseointegration with the surrounding bone can reduce the likelihood of graft slippage. [ 9 ]  Many artificial ligaments are designed to minimize inflammation and scar tissue infiltration because they can hinder the mechanical strength and can cause graft rupture. [ 3 ]  Artificial ligament design strives to improve hydrophilicity because hydrophobicity can trigger the host's natural response to foreign bodies. [ 3 ]


The Ligament Advanced Reinforcement (LARS) is a leading artificial ligament in ACL repair surgery. They are made of  polyethylene terephthalate  (PET). [ 3 ]  They consist of an intraosseous and an intra-articular portion. The intraosseous section consists of longitudinal fibers bounded by a knitted transverse structure. This knitted structure can help prevent deformation and abrasion. [ 5 ] [ 11 ]  The intra-articular portion is made of longitudinal fibers pretwisted at a 90 degree angle. This section is designed to resist fatigue and promote tissue ingrowth. [ 5 ]  Leeds Keio ligaments consist of a  polyester  mesh structure. It seeks to mimic the mechanical properties of the native ACL. The porous nature of the ligament can promote tissue ingrowth which has been shown to improve mechanical properties. [ 5 ]  The PGA Dacron artificial graft consists of 75% braided biodegradable  polyglycolic acid  and 25% permanent  Dacron  thread. [ 11 ]  The Kennedy LAD artificial ligament is made of  polypropylene  ribbons. It is designed to promote tissue ingrowth and the progressive transfer of load onto the new ligament. [ 10 ]


The native ACL of a human has a  tensile strength  on the order of kilonewtons, [ 3 ]  and an elongation at failure of approximately 10%. [ 10 ]  The mechanical properties of the native ACL vary throughout the human population. The strength of a child's ACL tends to be greater than that of an adult. [ 10 ]  PGA Dacron artificial ligaments have an ultimate tensile strength near 3500 N and a mean ultimate elongation of approximately 20%. [ 10 ]  Kennedy LAD ligaments have a tensile strength at failure of approximately 1500 N and an approximate stiffness of 50 N/mm. [ 10 ]  Leeds-Keio artificial ligaments have an ultimate tensile strength near 2000 N and a stiffness around 250 N/mm after tissue ingrowth. [ 10 ]  LARS artificial ligaments have varying mechanical properties depending on the amount of fibers used. A higher gauged ligament will have a greater tensile strength. During testing, a 60 gauge LARS ligament exhibited an ultimate tensile strength of 2500 N while a 120 gauge ligament exhibited a tensile strength of 5600 N. [ 5 ] [ 12 ]  The ingrown tissue has been shown to improve viscoelastic properties and reduce friction. [ 5 ]


Coatings have been added to artificial ligaments to improve their biocompatibility. 58S bioglass and  hydroxyapatite  coatings have been shown to improve osseointegration and cellular activity in vitro and in animal studies [ 3 ]  when deposited onto PET ligaments using the soaking method. [ 2 ] [ 3 ]  Hydroxypropyl cellulose surface treatments have been shown to improve osseointegration for PET ligaments in animal studies. [ 2 ]  Uncoated PET is hydrophobic, so coatings are designed to improve hydrophilicity. [ 3 ]   Hyaluronic acid  coatings can reduce hydrophobicity and have been shown to reduce scar tissue formation and inflammation in vivo. [ 3 ]  Hyaluronic acid and  chitosan  composite coatings can be deposited onto artificial ligament surfaces by the layer-by-layer technique, and they have been shown to enhance new bone formation at the ligament interface in mice. [ 9 ]  The chitosan is used to reduce hydrophobicity and improve osseointegration and mineral deposition, while the hyaluronic acid promotes cell differentiation and growth. [ 9 ]   Poly(sodium styrene sulfonate)  coatings have been shown in animal studies to improve knee functionality and mimicry of the native ACL. [ 2 ] [ 13 ]


The  anterior cruciate ligament  (ACL) is a frequently injured human body structure that may cause secondary damages to the knees, such as meniscal tears and articular cartilage degeneration, without medical treatment.  ACL reconstruction  is a commonly practiced technique for ACL injury, conducted on 30% of patients, which manages to restore stability to the knee structure. [ 2 ] [ 14 ]  Traditional ACL reconstructions uses autografts or allografts which demand a long rehabilitation time and in most cases, develop donor morbidity in the long term. [ 11 ]


The early interests in artificial ligaments led to the implementation of non-human tissue, such as Proplast ligaments made of  Teflon  and carbon fibers and Polyflex made of  polypropylene . [ 10 ] [ 15 ]  The results demonstrated poor resistance to torsion forces. [ 11 ]  Approved by FDA in 1986 and adopted in clinics later,  Gore-Tex  cruciate ligament prosthesis demonstrated low rates of mechanical failure but high rates of rupture in follow-up. [ 16 ]  Gore-Tex was then abandoned in ACL surgery and  Leeds-Keio  (LK) ligament was then adopted. In the later long term follow-up research, LK ligament demonstrated promising performance at first but still showed low stability rates in 2 years and increased degenerative changes compared with their opposite joint in one decade. [ 17 ] [ 18 ]  In the 21st century, the  Ligament Advanced Reinforcement  (LARS) ligament became the most popular artificial ligament on the market.  LARS ligaments not only provide satisfactory outcomes initially but also do not perform differently in at least 2 years. [ 19 ]  LARS ligaments demonstrate higher stability and lower morbidity rate compared to autograft in short-term research and in a 9-year study, LARS ligament showed a 100% survival rate. [ 5 ]  Synthetic ACL grafts always develop creep, fatigue and failure so the demand for synthetic grafts with sufficient supply, satisfactory mechanical properties, and low morbidity rate is essentially high. [ 5 ]  Currently, the LARS ligament is the most comparable to both autografts and other synthetic grafts. [ 5 ]


Complications that commonly occur in the artificial ligaments after the first ten years are breakage, wear debris, synovitis, recurrent instability, osteolysis and chronic effusions. [ 10 ]  Complications do not commonly surface right after the surgery or after a relatively short term, and in a few cases, start to show up after the first ten years. Follow-up research is required to study the performance of certain synthetic materials for artificial ligament and to monitor the health of patients. [ 10 ]  Rupture rates are usually recorded in 2 to 5 years. [ 10 ]


While the future of artificial ligaments is unknown, leading researchers in  tissue engineering  aim to regenerate and repair the ligament to restore normal function. [ 2 ]   ACL tissue engineering will be based on the healing of the  medial collateral ligament  (MCL), since the ACL does not heal naturally. [ 2 ]   A seed cell will be used in tissue engineering for the repair of ACL ligaments. The seed cell must have qualifications such as: easily available, potent to proliferate, and efficient in elaborating a mature extracellular matrix.  Stem cells such as bone marrow-derived  mesenchymal stem cells , adipose-derived stem cells, perivascular stem cells, and human foreskin  fibroblasts  are commonly used in tissue engineering. [ 2 ]


Bone malrotation  refers to the situation that results when a  bone  heals out of rotational alignment from another bone, or part of bone. It often occurs as the result of a  surgical  complication after a  fracture  where  intramedullary nailing (IMN)  occurs, [ 1 ]  especially in the femur and tibial bones, but can also occur genetically at birth. The severity of this complication is often neglected due to its complexity to detect and treat, [ 1 ]  yet if left untreated, bone malrotation can significantly impact regular bodily functioning, and even lead to severe  arthritis . Detection throughout history has become more advanced and accurate, ranging from clinical assessment to  ultrasounds  to CT ( computed tomography ) scans. Treatment can include an  osteotomy , a major surgical procedure where bones are cut and realigned correctly, or compensatory methods, where individuals learn to externally or internally rotate their limb to compensate for the rotation. Further research is currently being examined in this area to reduce occurrences of malrotation, including detailed computer navigation to improve visual accuracy during surgery. [ 2 ]


Bone malrotation predominantly occurs after an injury where a bone is fractured, however malrotation can genetically occur during  foetal development . It usually occurs during a surgery which involves  intramedullary nailing , which is the insertion of metal rods and nails to stabilise bones. Nailing is used as it requires minimal surgical dissection, less disruption of the fracture  hematoma  and allows faster functionality to a patient post-surgery. [ 1 ] [ 3 ]  However, due to the semi-closed nature of IM, it is impossible to correct under direct vision, so there is less rotational control compared to traditional open methods such as plate fixation. [ 3 ]  As a result, in many cases of intramedullary nailing, the bone is misaligned which causes malrotated regrowth. This torsional error is a major problem for femoral and tibial fractures, and occurs in 17 to 35% of patients who receive these surgeries, [ 4 ]  and up to 40% of femur fracture patients. [ 1 ]


Femoral malrotation is the most significant bone malrotation issue, and these errors cause cosmetic problems but can also cause drastic physical problems. [ 4 ]


Historically, bone malrotation occurred due to a lack of adequate treatment measures, where fixation methods such as  traction ,  casting  and non-locked nails provided poor torsional stability. Currently, the utilisation of locked intramedullary nailing, has reduced the occurrence of rotational malalignment during fracture healing, yet femoral malrotation continues to remain very prevalent due to surgeon's inability to reliably restore the pre-injury alignment during operation. [ 1 ]  A high attention to detail is necessary intra-operatively to avoid this complication when locking the intramedullary device. [ 5 ]  The utilisation of both radiological and clinical assessment techniques to compare with an injured limb would also help prevent bone malrotation, however these can be difficult and inexact methods of assessment, which is why complications are so common. [ 1 ]


It is difficult to assess and diagnose the rotational malalignment of a bone after an operation, and many methodologies have been developed.


Clinical assessment and observation  is one methodology, however it is unreliable, and can lead to complications. For femoral or tibial malrotation, many surgeons use the patient's ankle or patella to symmetrically align them with the injured side or to the floor but this method does not consider the position of the proximal fragment and could be moved during reduction attempts. [ 5 ]  In order to measure femoral malalignment, many doctors will compare the internal and external rotation of both hips, while the patient is supine or prone, and a change in a patient's range of movement indicates malrotation. However, while clinical assessment can indicate the direction of malrotation, it often reports inaccurate measurements of the degree of malalignment, so it is unreliable in determining the potential impacts and necessary treatment methods. [ 3 ]


Another diagnosis methodology sometimes utilised are  radiographs ; however, they are unreliable as they require difficult patient positioning to quantify the rotational deformity. [ 5 ]   This difficulty is due to a patient's restriction in movement, as they may exhibit post-traumatic deformities and severe pain. To determine the level of femoral malrotation, with this method, two radiographs of the pelvis and upper legs must be made. Firstly, an anteroposterior (AP) perspective which shows the degree of difference between the femoral neck and femur, and another view where the hips and knees are both flexed to a right angle, which determines antetorsion. Both of these radiographs are utilised to calculate the angle of anteversion of the femoral neck. [ 3 ]


Ultrasounds  can also be used to measure bone malrotation, and are considered highly reliable. The main issue with utilising ultrasound measurement is that it relies largely on the skills of an ultrasound technician, and consequently is not widely used. When measuring femoral malrotation with ultrasounds, a patient's thighs are fixed symmetrically while the degree of rotation of the femoral shaft is measured. This methodology requires exact positioning of a patient to correctly measure any deformity. [ 3 ]


MRI scans  can be utilised and are proven to be reliable and effective at determining malrotation of bones. However, they are not as readily available as CT scanners, and are also time consuming and very expensive. [ 5 ]


The standard bone malrotation detection practice utilised are  computed tomography scans , which are able to exactly quantify the amount of rotational malalignment. [ 5 ]  It is also considered highly reliable and utilised because of its reproducibility. For femoral malrotation, the scan involves doctors measuring the angle between a line through the axis of the femoral neck and a line tangential to the femoral condyles. The angle difference between the uninjured and injured sides determines the degree of malrotation.  An increase in the anteversion of the femoral neck of the injured side denotes internal rotation, and a decrease means external rotation has occurred. Another advantage of CT scans is that patient positioning does not impact the measurement accuracy of femoral torsion, which is unlike radiographs and ultrasounds.  However, inaccurate measurements of malrotation can still occur in CT scans, but are mostly related difficulty in drawing clear and accurate lines along the femoral neck within the image. To avoid this inaccuracy, there needs to be improved accuracy of the line drawn, and this can be fixed by the utilisation of multi-image superimposed projection of the CT images so a more accurate measurement can be drawn. [ 3 ]


Whilst malrotation of a bone can be tolerated for most cases, it can still cause severe impacts on functional outcome for some patients. Whilst tibial fractures are the most common long bone fractures, it is malrotation of the femur which can cause the most significant impacts on regular functioning. [ 6 ]


If untreated, femoral malrotation can cause considerable gait disturbance and abnormal hip joint pressures. [ 2 ]  Malrotation of the femur in the setting of a mid-shaft fracture has an impact on the axis of the entire leg, which shifts the centre of force in the knee away from its neutral position. Consequently, femoral malrotation has significant impacts on the mechanical axis and force vectors within the knee. This can cause pain in the hip and knee, and patients may be limited in their movement, which can impair their function, especially in physically demanding activities such as walking up stairs and running. [ 3 ]  This can impact a person's satisfaction in life, as they may be physically unable to do things they want and need to, such as for laborious work, leisure activities, or raising a family, which can have significant impacts on their psychological health. Femoral malrotation can also cause an abnormally rotated foot, as the angle of a person's foot is directly related to the angle of the femur. [ 7 ]


Another significant long term consequence of femoral malrotation if untreated is  degenerative arthritis  of the hip and knee. [ 3 ]  This joint arthrosis occurs as there is a proven correlation between rotational error, axis deviation and  arthrosis  of the knee and hip joints. However, the severity of the arthrosis is dependent on the percentage of malrotation. [ 4 ]


Whilst most malrotation problems occurred during surgery, patients with 10° or less difference of malrotation compared with the uninjured side rarely complained of any issues. [ 8 ]  However, patients with differences greater than 15° found noticeable issues, and above 30° malrotation difference resulted in serious complaints. [ 5 ]  External femoral malrotation is usually much better tolerated than internal malrotation. [ 1 ]  However, older studies have found that external rotational deformities are more poorly tolerated, [ 9 ]  which shows the need for more research in this area.


There are two main treatment methods; corrective surgery to fix the malrotation, or compensatory methods where patients learn to compensate for any malrotation when walking.


Many people with bone malrotation, such as femoral malrotation are able to functionally tolerate and learn  compensatory methods , such as externally or internally adjusting their limb. Patients will compensate for even considerable rotational malalignment when they are active.  However, femoral malrotation is more difficult to compensate for and maintain with non-operative treatment methods. [ 5 ]  Patients with femoral malrotation of less than 15 degrees give less complaints than those with higher amounts of malalignment, yet many patients are able to tolerate the deformity well. [ 3 ]


In extreme cases, the malalignment can be treated by means of a derotational  osteotomy  which is a major surgical procedure. [ 3 ]  It can be conducted around the existing intramedullary fixtures, but it usually requires a subtrochanteric osteotomy, which is an invasive surgical approach where bone is cut and realigned. As this is a major procedure, it is beneficial if discovered early, before callus has set, and consequently, patients should be assessed for malrotation in the early post-operative period and a CT scan should occur if abnormalities are found. [ 5 ]  Correct measurement of bone malalignment with a CT scan is vital when considering an osteotomies in fixing rotational deformities, as torsional differences below 15 degrees are often easily compensated for with non surgical treatment. [ 3 ]  Revision surgery should be avoided, if not necessary, as implementing femoral nails for a second time leads to higher rates of problems such as infection, nonunion, or nail destabilisation due to overlapping holes for the interlocking screws. [ 10 ]


There is currently limited clinical attention in the area of bone malrotation and research into more accurate methods, likely due to the complexity of the issue. [ 1 ]  Whilst computed tomography scans are useful in determining the degree of bone malrotation after a surgery has occurred, research is being conducted into how to prevent this deformity occurring at all during surgery. CT scans are impractical intraoperatively due to high cost, lack of equipment portability and increased exposure to radiation. [ 10 ]


Consequently, one area being researched is that of  computer navigation,  which could be utilised during these surgeries to avoid malalignment issues.  Computer assisted surgery  (CAS) matches a patient's anatomy with pre or intraoperatively generated fluoroscopic image data, by using camera detected infrared signals. The computer then calculates the positioning of each component and creates a visual of their position on the monitor. As a result, the surgeon can monitor in real time the position of the surgical instruments in relation to the patient's anatomy and conducts the procedure accordingly. [ 11 ]  The surgeon can plan the torsional adjustment and control the fracture reduction and nail insertion on a touchscreen of the navigation module.


Currently, this navigation may add extra time during surgery, so it is sometimes considered unnecessary in an urgent surgery. However, without computer navigation, the risk of bone malrotation is significantly increased. The benefit of computer navigation means that surgeons are able to view more clearly and restore axial alignment, but also ensure the injured limb and matches the alignment and length of the uninjured limb. [ 2 ]  CAS provides increased surgical accuracy and safety for both patients and surgeons, radiation time is reduced, and it utilises minimally invasive techniques which means less tissue damage, improved wound healing, and reduced infections and scarring for patients. [ 11 ]


Dorsal intercalated segment instability  ( DISI ) is a deformity of the  wrist  where the  lunate bone  angulates to the dorsal side of the hand. [ 2 ] [ 3 ]


The main cause of DISI is [ 4 ]  wrist trauma, with or without a fracture:


This  human musculoskeletal system  article is a  stub . You can help Wikipedia by  expanding it .


The  Drehmann sign  describes a clinical test of examining orthopedic patients and is widely used in the functional check of the  hip  joint.
It was first described by Gustav Drehmann (Breslau, 1869–1932). [ 1 ]


The Drehmann sign is positive if an unavoidable passive external rotation of the hip occurs when performing a hip flexion. In addition, an internal rotation of the respective hip joint is either not possible or accompanied by  pain  when forcefully induced. [ 2 ]


The positive Drehmann sign is a typical clinical feature in slipped capital femoral  epiphysis  (SCFE), the  impingement syndrome of the acetabulum-hip ,  or in  osteoarthritis  of the hip joint. [ 3 ]


EOS imaging  is a medical device company based in  Paris, France , that designs, develops, and markets EOSedge and the EOS system, innovative, orthopedic medical imaging systems, associated with several orthopedic solutions along the patient care pathway – from  diagnosis  to post-operative treatments. The EOS platform targets  musculoskeletal disorders  and  orthopedic surgical care  through 2D  X-ray  scans and 3D skeletal models from stereo-radiographic images of patients in a seated or standing position.


The philosophy of EOS imaging surrounds three main principles: reduction of the  radiation  dose emitted by the technology, relevance and manipulability of calculated clinical parameters, and optimization of the patient care workflow. Currently, over 300 EOS systems are installed in medical centers in 51 different countries, including the United States, Japan, Korea, China, and throughout the European Union.


The EOS imaging technology stems from the scientific findings of  Georges Charpak  ( Nobel Prize in Physics , 1992) concerning radiation detection and  particle physics , especially the  multi-wire chamber . [ 1 ]  Since then, physicists, engineers, radiologists, and surgeons have collaborated to transform these findings into a new technology called the EOS system.


EOS imaging began in 1989 as Biospace Med, a medical company founded by Georges Charpak for the development of his detection technology. In 1999, Marie Meynadier became the CEO of Biospace Med; she developed the company's first subsidiary dedicated to imaging solutions for pre-clinical research – the EOS system.


In 2004, hospitals in Paris, France and Brussels, Belgium finished running clinical tests on the EOS prototype, and in 2005, the first fundraising efforts commenced with the company's first venture capital round.


From 2007 to 2011, the company obtained  CE marking  in Europe and  FDA  approval to market the EOS system and the sterEOS 2D/3D workstation in the United States.


The first installations of EOS in European and North American hospitals and clinics occurred from 2008 to 2010. In 2011, the EOS system was being integrated into clinical routines of medical centers in 10 countries, including the United States, Canada, and Australia.


In 2010, Biospace Med changed its name to EOS imaging.


In 2012, EOS imaging entered the  Euronext Paris  stock exchange (name: EOSI) and had its first installation in Asia.


In 2013, EOS acquired the medical company oneFIT Medical (see Acquisition of oneFIT Medical).
In 2014, EOS provided the EOS system in the Vietnam market (Medic - Medic Hoa Hao) through Bluelight.


In 2015, the CFDA certification in China and the NECA designation in Korea were obtained, allowing the company to further expand its market.


In 2016, the company entered into the Latin American market with the signing of its first contract in Brazil.


In 2019, the company launched EOSedge, its new generation imaging system powered by photon-counting technology.


While based in Paris, France, EOS imaging has five other corporate locations in various regions around the world:  Besançon, France ;  St. Paul, Minnesota , US;  Montreal, Quebec , Canada;  Frankfurt, Germany , and in  Singapore .


In 2013, EOS imaging acquired oneFIT Medical (based in Besançon, France), a  medical software  engineering and manufacturing company dedicated to the development of  surgical planning  software for spine, hip, and knee surgeries and patient-specific orthopedic surgical cutting guides. [ 2 ]


EOS imaging platforms—EOSedge and EOS—deliver unique and specific capabilities that are used in conjunction with EOS Advanced Orthopedic Solutions to generate highly accurate 3D representations of patient anatomy and enable a seamless surgical planning experience.


The EOS examination takes place in an upright scanning cabin where the patient can either stand or sit. With a vertically traveling arm supporting two fine X-ray beams perpendicular to one another, the EOS system acquires frontal and lateral, weight-bearing images of the patient in a functional – standing or sitting – position. These biplanar images are then used to create a 3D model of the patient's skeleton.


The ALARA principle (As Low As Reasonably Achievable) represents a movement to “minimize radiation doses and releases of radioactive materials” by minimizing the time of exposure to radiation, increasing the distance between the human body and the radiation source, and using absorber materials to shield the body from  beta particles , X-rays, and  gamma rays . [ 3 ]


EOS imaging aligns itself with this principle, providing reduced exam times and amounts of radiation in comparison with conventional imaging systems. [ 4 ] [ 5 ]  Furthermore, EOS developed a Micro Dose option that further reduced the radiation exposure by 5.5 times compared to a typical low-dose EOS exam protocol, resulting in a nearly negligible radiation dose. [ 6 ]  Additionally, with Flex Dose technology, EOSedge can deliver up to an 80% overall radiation reduction compared to same acquisition without Flex Dose.


Having reduced-radiation options available for patients has become critical in the world of medical imaging as radiation exposure from artificial sources, such as medical imaging, has increased over the last two decades, [ 7 ]  and many patients require multiple examinations throughout the course of their medical treatment.


The sterEOS workstation enables the generation of patient-specific 3D models of the spine and/or lower limbs from weight-bearing low dose or Micro Dose EOS exams. Once the models are created, clinical parameters are automatically calculated and may be exported as a patient report including 2D images and 3D captures. This report is used by physicians for diagnosis, post-operative assessment, and patient follow-up. sterEOS also enables the exportation of 3D anatomical biomarkers for pre-operative planning.


The EOSapps (kneeEOS, hipEOS, and spineEOS) are online, 3D surgical planning solutions based on the weight-bearing EOS images. Frontal and lateral EOS images are uploaded to the EOS Portal, where the EOS 3DServices team prepares the 3D models and dataset and makes the planning case available online. Surgeons can have access to the patient's anatomy information in 3D, with which they can plan and simulate the effect of different implant selections and positions in 3D. spineEOS is used to plan spine surgeries, hipEOS is used for the planning of  total hip arthroplasty , and kneeEOS is geared towards the planning of  total knee arthroplasty .


Foot Levelers  is a foot care, footwear, and whole body health company based in Roanoke, Virginia, and owned by Kent S. Greenawalt.


Foot Levelers began in Iowa, in 1952, by Chiropractor Monte H. Greenawalt. Greenawalt earned his degree from Lincoln Chiropractic College and began to notice a pattern in patients with foot problems—his adjustments did not hold. Dr. Monte referred these patients to a podiatrist, but their problems persisted.


Monte began to experiment with orthotics, and through trial and error, developed a formula based on 16 unique measurements of the foot. Unlike off-the-shelf orthotics or even those made by podiatrists, Monte’s orthotic was designed to support all three arches of the foot, rather than just one. Through Greenawalt's orthotics invention, his patients began to show positive results and his adjustments held longer.


In Foot Levelers multi-decade history, they have served tens of thousands of doctors and millions of patients [ 1 ]  through their patented orthotic technology. [ 2 ]  They have offices in the U.S., Europe, and Australia and serve customers in over 80 countries.


Foot Levelers holds title sponsorship of "America's Toughest Road Marathon", the  Blue Ridge Marathon , since 2012.


Halo-gravity traction  (HGT) is a type of  traction  device utilized to treat spinal deformities such as  scoliosis , [ 1 ] [ 2 ]   congenital  spine deformities,  cervical instability ,  basilar invagination , and  kyphosis . [ 3 ]  It is used prior to surgical treatment to reduce the difficulty of the following surgery and the need for a more dangerous surgery. [ 4 ] [ 5 ] [ 6 ]  The device works by applying weight to the spine in order to stretch and straighten it. Patients are capable of remaining somewhat active using a  wheelchair  or a walker whilst undergoing treatment. Most of the research suggests that HGT is a safe treatment, and it can even improve patients'  nutrition  or  respiratory functioning . However, some patients may experience side effects such as  headaches  or neurological complications.  The halo device itself was invented in the 1960s by doctors working at the  Rancho Los Amigos hospital . [ 7 ] [ 8 ] [ 9 ]  Their work was published in a paper entitled "The Halo: A Spinal Skeletal Traction Fixation Device." [ 10 ]  The clinician  Pierre Stagnara  utilized the device to develop Halo-Gravity traction. [ 11 ] [ 12 ] [ 13 ]


Halo-gravity traction works by straightening and stretching the compressed  spine . [ 14 ] [ 15 ]  It relies on the  viscoelastic  properties of  vertebrae . This means vertebrae can stretch over time. Doctors will apply weight to the spine, and gradually increase it over time, slowly straightening and stretching it. [ 16 ]  Patients undergoing the procedure will typically spend the entire course of the treatment, which is usually three to eight weeks, in a  hospital . Usually, halo-gravity traction is the first step in the treatment plan for a child with severe spinal deformity. Following the procedure, it is common for a surgical operation such as  spinal fusion surgery  to be performed afterward to permanently mend the issue. [ 14 ] [ 17 ]  It is utilized before the operation to reduce the need for a more dangerous surgery and to reduce the risk of damage to the soft  tissues  or  nerves  that surround the spine during the surgery. [ 15 ] [ 18 ] [ 19 ]  In addition, HGT has also been found to reduce the risk of complications during the following surgery. [ 20 ] [ 21 ] [ 22 ]


To perform halo-traction therapy a surgeon will use six to ten small pins to attach a "halo" made of a metal ring to the patient's skull. [ 23 ] [ 24 ] [ 25 ]  Doctors will typically leave one to two centimeters of distance between the halo and the patient's head. It is common for older patients to be given eight pins while younger patients are given 10. Prior to pin placement, some patients may undergo hair removal. It is not required for successful treatment, but it can help to reduce the risk of pin infection from hair getting caught in a pin or  scalp necrosis . [ 7 ]  The pins will be placed into the  forehead   bones  to prevent the head from moving. Pin placement is determined using a  CT scan . The chosen area will be cleaned with  betadine  swabs. Usually, two to three pins are placed in the  frontal  and  occipital  areas. Pins placed on the occipital area will have to be placed one centimeter above and behind the  auricle  of the ear. Pins placed on the  anterior  of the head will likely be placed one centimeter to above the sides of the eyebrow to avert potential damage to the  supraorbital  and the  supratrochlear nerves , and potential  muscle  damage.  Parietal  placements are generally avoided as the skull around this area is generally softer, which risks the pins puncturing the  temporal artery . Typically, the pins will tightened to a  torque  equivalent to the age of the child using a  torque wrench . Adults can withstand tighter torques than children can. [ 26 ]  Whilst this operation is being performed the child will be given general  anesthesia . [ 7 ]  In  infant  children, significantly less torque is required to tighten the pins. This allows for the pins to be placed in more areas than they could be placed in older patients. [ 27 ]


Afterward, the halo will be attached to a  pulley system  which is attached to the patient's bed,  walker , or  wheelchair . [ 28 ]  Spring-type pulleys are typically used as they allow for the patient to self-regulate the weight applied to the pulley, which improves the safety of the device. [ 29 ] : 390   Spring-based HGT devices are also cheaper and easier to build than other methods of construction. [ 30 ]  It is common for patients to begin the procedure with 5-10 pounds of weight on the pulley system. [ 29 ] : 387   Over the next few weeks, clinicians will add weight to the pulley, which will slowly straighten the patient's spine over time. Eventually, a weight greater than 50% of the patient's body weight may be achieved. [ 23 ] [ 31 ]  Doctors will monitor the movements and strength and will take  x-rays  of the patient to track their progress. They will adjust the amount of weight on the pulley system based on the results. All patients will undergo  cranial nerve  testing during the procedure. [ 23 ]  After the spine has reached its optimal position, spinal fusion surgery will be performed on the patient. [ 15 ]


Whilst undergoing the procedure, patients are encouraged to remain as active as possible. Activities such as low-impact play, walking, or standing can all increase the benefits of halo-traction therapy. However, patients are limited to leaving the traction for only a short time span. They can leave for activities such as repositioning, changing clothes, daily medical care,  showering , or using the  toilet .  Baby shampoo  is required to be used for bathing purposes as other shampoos could contain chemicals that react negatively with the metal halo. Patients will be required to utilize a special bed for  sleeping  whilst in the traction. After ending treatment the patient is required to avoid strenuous activities for a few months as their spine and muscles will still need to recover. Some patients may wear an orthopedic vest or a  halo vest . [ 15 ]


Halo-gravity traction has been found to be almost completely safe. [ 29 ] : 385  [ 32 ]  Patients who have undergone the procedure report that they have a greater ability to stand upright, an increased appetite, and an improved  body image . [ 33 ]  It can improve  respiratory  functioning by relieving pressure on the lungs caused by a deformed spine. [ 13 ] [ 34 ] [ 35 ]  Patients often  gain weight  and have improved  nutrition  following HGT. [ 36 ]  This may occur since HGT can correct issues associated with spinal deformities, such as  exercise ,  comorbid   metabolic disorders , and  gastrointestinal  malformations. These issues are associated with malnutrition and low weight, and HGT can lead to weight gain by correcting them. [ 37 ]  When in combination with surgical release, HGT may improve the  flexibility  of the spine and lead to more spinal correction. [ 38 ] [ 39 ]


Patients may experience pain from the pins, which is usually caused by the loosening of the pins. This can be remedied by tightening them. Up to 20% of patients may experience  infections  at the site where the pins were applied. These infections are typically treated with  antibiotics . One rare, but serious complication of the procedure can be the development of intra-cranial  abscesses  due to  septic  contamination of the pin site. [ 13 ]  Some patients experience  headaches  around the area where the pins were applied for a short while after the halo is attached. It is common for patients to recover from this pain in less than 24 hours. [ 29 ] : 384   Halo therapy will leave small  lesions  in the skin when the pins are first removed. Typically, they will turn into  scabs  after a few days. Patients who have undergone the procedure will also have small  scars  on their foreheads. These scars will typically fade over time. [ 15 ]


If the traction that is applied is greater than the tolerable amount, the patient may feel  cervical pain ,  cranial nerve lesions ,  nausea ,  vertigo , [ 40 ]  or  dizziness . These side effects are treated by lowering the level of weight applied. [ 41 ]  Some patients may suffer from  motor paresis  after the application of the device. Typically it is present in patients with preexisting spinal cord abnormalities. [ 29 ] : 389   Generally, HGT does not cause neurological side effects due to the slow progression of traction. The spine adjusts slowly over time, and as a result, consequences are generally limited. Children are less likely than adolescents or adults to experience neurological side effects, due to the softness and flexibility of their spine, as well as their low weight. [ 42 ]


Erb's palsy  has been identified as a rare neurological side effect of HGT. [ 43 ]  One 2006 study published in the journal "Studies in Health Technology and Informatics" found that in extremely rare cases HGT could induce  Erb's palsy , ulnar nerve paralysis, and  median nerve palsy  in cases. In the seven cases identified by the study, all patients had fully recovered within a few months of treatment. The likelihood of developing Erb's palsy due to HGT is associated with the weight of the traction. [ 44 ]  Another study published in the  Journal of Spinal Disorders & Techniques  found that patients may experience Erb's palsy or  sensory loss  during or after treatment. However, none of the patients who had experienced these side effects reported in this study had permanent neurological loss. [ 45 ]


One 2016 clinical study published in  BioMed Research International  found that HGT resulted in reduced bone density among patients with kyphoscoliosis. [ 46 ]  However, little other research has investigated this potential side effect or found any evidence to support this claim. [ 37 ]


Patients with bone conditions such as  fibrous dysplasia  or  osteogenesis imperfecta  may be unsuitable for treatment if the pins are not capable of safely being applied to the bone. [ 29 ] : 385    Osteoporosis  is considered a contraindication that sometimes may prevent treatment,  however, doctors may avert complications by utilizing more pins with a lower torque. [ 40 ]   Absolute contraindications  for halo-gravity traction include the presence of a  stenotic segment , an  intradural or extradural lesion , lesions in the skull by the sites of pin application, [ 12 ]  any lesion or  tumor  by the spine cord, [ 23 ]  severe skull deformity, and  spine instability . [ 12 ]


Most of the research conducted on HGT found that it is mostly a safe, [ 47 ]  reliable, [ 47 ]  and effective treatment. [ 48 ] [ 49 ] [ 50 ]  The average correction rate of HGT has been shown to be 19.4% for  sagittal curves  and 24.1%  coronal  curvature. [ 12 ]  One 2013 study on 33 patients published in the journal  Spine Deformity  found an average correction rate of 33% for coronal curves and 35% for sagittal. [ 51 ]  According to a  cohort study  conducted on 75 subjects investigating the efficacy of Halo traction therapy found an improvement rate of 31% to 66% for the spine. They found a  coronal  curvature improvement of 19.6% for adolescents, and 12% for adults. Kyphosis had improved at a rate of 23.9% for adolescents. Afterward, spinal surgery performed on people who had undergone the procedure had a greater than 50% chance of success. [ 52 ]


One study conducted on 20 patients with either scoliosis, kyphosis, or kyphoscoliosis found that the most improvement occurred within the first 3 weeks of treatment. According to this study, the spinal curve had improved by 63.7% during the first two weeks, which decreased to 24.3% at 3 weeks, and to 15.9% at 4 weeks. [ 38 ]  Other studies have found similar results. One study conducted on 21 patients found that 45% of improvement occurred within the first 3 weeks. [ 53 ]  Another study on 24 patients found that a mean improvement of 82% occurred during the first three weeks. [ 54 ]


Much of the research utilized as evidence of the efficacy of HGT has been criticized for a lack of a  control group  and a small  sample size . [ 55 ]  Some research has suggested that HGT leads to  statistically insignificant  improvement. [ 56 ]   Paul Sponseller, an  Orthopedic surgeon  at  Johns Hopkins University , claims in his study "The use of traction in the treatment of severe spinal deformity" that his research found "no statistically significant difference in main coronal curve correction (62% vs. 59%), operative time, blood loss, and total complication rate (27% vs. 52%)." However, his data did showcase that people who had not undergone HGT required  surgical resection  30% more often. [ 55 ]  In a study on 25 patients with severe spinal deformities who had been treated with spinal surgery, a mean correction of 44 degrees was found in patients who had not undergone HGT prior to the operation, and a mean correction of 52 was found in patients who had been treated with HGT. The researchers concluded that this difference was not statistically significant, and therefore HGT should not be used as the general treatment for these issues, and should be reserved for specific cases. [ 57 ]


Some research suggests that HGT may be less effective than other forms of traction, such as Halo-femoral traction or Halo-pelvic traction. [ 58 ] [ 59 ]  HGT also has been found to require lengthy hospital stays, which many patients dislike about the treatment. [ 60 ]  In the study by Paul Sponsellor, he found that patients who had undergone HGT spent almost twice the amount of time hospitalized as those who had not received the treatment. [ 55 ]  HGT is significantly safer than other forms of traction. It is less likely to produce significant complications such as  blood loss , [ 59 ] [ 61 ]  neurological side effects, and spine stiffness or degeneration. [ 62 ]  HGT also allows patients to remain social and active, whilst other forms of traction severely restrict movement. [ 63 ]  These reasons have led to HGT becoming the standard preoperative treatment for patients with severe spinal deformities. [ 64 ]


The treatment of broken bones and dislocated joints can be traced as far back as the  Ancient Greeks .  Hippocrates  is credited with a method of reduction of a  dislocated shoulder . 16th century Spanish texts talk about the  Aztecs  use of  reduction  of fractures using fir branches. The modern discipline of orthopaedics in trauma care developed during the course of World War I, but it was not until after World War II that orthopaedics became the dominant field treating fractures in much of the world. Today, the discipline encompasses conditions such as bone fractures and bone loss, as well as spinal pathology and joint disease. [ 1 ]


Several volumes of the  Hippocratic Corpus ,  Articulations or On Joints, On Fractures, On the Instruments of Reduction  discuss  Ancient Greek medicine  relating to orthopaedics, [ 2 ]  and  Hippocrates  is credited with a method of reduction of a  dislocated shoulder .


16th century Spanish texts talk about the  Aztecs  use of  reduction  of fractures, as well  intramedullary  fixation using fir branches. [ 3 ]


Peter Lowe  was the first surgeon to use the term  amputation  in his 1597 book  A discourse of the Whole Art of Chirurgerie . [ 4 ]


Nicolas Andry  has been credited with the term 'orthopaedics', taken from the title of his 1741 book  Orthopédie  on childhood deformity correction. [ 5 ]   The frontispiece of the book bore an engraving of a sapling being splinted with a stake, a symbol now referred to as the  Tree of Andry  and adopted by many orthopaedic associations internationally.


In 1768,  Percivall Pott  published his book  Some Few Remarks upon Fractures and Dislocations  following his compound femoral fracture on the use of  splinting  to avoid  amputation . [ 6 ]   Pott's student,  John Hunter , expanded on the knowledge of bone healing.


Around the same time,  Jean-André Venel  published his work  Orthopaedia, or the Art of Preventing and Correcting Deformities in Children , one of the first surgeons to discuss the practical application for treating  congenital deformities .


Even after the  Medical Act 1858 ,  bonesetters  continued to practice unlicensed within England, with one of the last being Evan Thomas. His son,  Hugh Owen Thomas , is considered by many to be the father of modern orthopaedics in the UK, [ 7 ]  with many published works such as  Diseases of the hip, knee and ankle joints (1876), Principles of the treatment of diseased joints (1883), The principles of the treatment of fractures and dislocations (1886), Fractures, dislocations, diseases and deformities of the bones of the trunk and upper extremities (1887) and Fractures, dislocations, deformities and diseases of the lower extremities (1890)' . The use of his  traction splint  during the  First World War  lead to a dramatic reduction in the mortality following  femoral fractures .


Thomas' nephew,  Robert Jones  continued his work, and was the first person to publish on the use of  radiography  in orthopaedics. [ 8 ]


The developing field of orthopaedics was originally focused on deformities in children, and subsequently adults. The involvement of orthopaedics in trauma care developed in the course of World War I, the interwar period, and World War II. [ 9 ]  It was not until after World War II that orthopaedics became the dominant field treating fractures in much of the world.


Later in the 20th century,  John Charnley  pioneered  hip replacement , [ 10 ]  as well as published on the conservative treatment of fractures.


Orthopedic surgery  is the branch of  surgery  concerned with conditions involving the  musculoskeletal system .  Orthopedic surgeons  use both surgical and nonsurgical means to treat  musculoskeletal injuries ,  sports injuries , degenerative diseases, infections,  bone tumours , and  congenital limb deformities .   Trauma surgery  and  traumatology  is a sub-specialty dealing with the operative management of  fractures ,  major trauma  and the multiply-injured patient.


List excludes anatomical terminology covered in  index of anatomy articles .


Abbreviated Injury Scale
-  Acetabular fracture
-  Acheiropodia
-  Achilles tendon rupture
-  Acromioplasty
-  Adamantinoma
-  Adhesive capsulitis of shoulder
-  Advanced trauma life support
-  Ainhum
-  Akin osteotomy
-  Albers-Schonberg disease
-  Albright's hereditary osteodystrophy
-  Allis test
-  ALPSA lesion
-  Amelia (birth defect)
-  American Joint Replacement Registry
-  Amphiarthrosis
-  Andersson lesion
-  Aneurysmal bone cyst
-  Ankle replacement
-  Anterior cruciate ligament injury
-  Anterior cruciate ligament reconstruction
-  Antley–Bixler syndrome
-  Apert syndrome
-  Apley grind test
-  Apley scratch test
-  Apprehension test
-  Arachnodactyly
-  Arm fracture
-  Arthralgia
-  Arthritis
-  Arthrocentesis
-  Arthrodesis
-  Arthrogram
-  Arthrogryposis
-  Arthroplasty
-  Arthroscopy
-  Arthrotomy
-  Articular capsule
-  Articular cartilage repair
-  Astragalectomy
-  Autologous chondrocyte implantation
-  Avascular necrosis
-  Avulsion fracture


Baastrup's sign
-  Baker's cyst
-  Baksi's prosthesis
-  Ballottement
-  Bankart lesion
-  Bankart's fracture
-  Barlow maneuver
-  Barré–Liéou syndrome
-  Barton's fracture
-  Baumann's angle
-  Beals syndrome
-  Bechterew's
-  Bennett's fracture
-  Bifid rib
-  Bimalleolar fracture
-  Blount's disease
-  Blumensaat's line
-  Blunt trauma
-  Bohler's angle
-  Bone cutter
-  Bone cyst
-  Bone density
-  Bone disease
-  Bone fracture
-  Bone fracture healing
-  Bone grafting
-  Bone healing
-  Bone metastases
-  Bone mineral
-  Bone pathology
-  Bone remodeling
-  Bone resorption
-  Bone tumor
-  Bone
-  Bosworth fracture
-  Bouchard's nodes
-  Boutonniere deformity
-  Boxer's fracture
-  Brachydactyly
-  British Orthopaedic Association
-  Brodie abscess
-  Broström procedure
-  Brown tumor
-  Bruck syndrome
-  Brunelli procedure
-  Bryant's traction
-  Buddy wrapping
-  Bumper fracture
-  Bunion
-  Burst fracture


Calcaneal fracture
-  Camurati–Engelmann disease
-  Cancellous bone
-  Cartilage
-  Cartilaginous joint
-  Catel–Manzke syndrome
-  Cenani–Lenz syndactylism
-  Cervical dislocation
-  Cervical fracture
-  Cervical rib
-  Chalkstick fracture
-  Chance fracture
-  Chandler's disease
-  Charnley prosthesis
-  Charnley retractor
-  Chauffeur's fracture
-  Child bone fracture
-  Chondroblast
-  Chondroblastoma
-  Chondrocyte
-  Chondrogenesis
-  Chondromalacia patellae
-  Chondromyxoid fibroma
-  Chondrosarcoma
-  Chopart's fracture-dislocation
-  Clarke's test
-  Clavicle fracture
-  Clay-shoveler fracture
-  Cleidocranial dysostosis
-  Clinodactyly
-  Club foot
-  Clubbed thumb
-  Cobb angle
-  Codman triangle
-  Cole carpenter syndrome
-  Colles' fracture
-  Combined tibia and fibula fracture
-  Compartment syndrome
-  Complex regional pain syndrome
-  Compression fracture
-  Computer-assisted orthopedic surgery
-  Congenital knee dislocation
-  Congenital limb deformities
-  Congenital patellar dislocation
-  Conradi–Hünermann syndrome
-  Coopernail's sign
-  Cortical bone
-  Cotrel–Dubousset instrumentation
-  Coxa valga
-  Coxa vara
-  Cozen's test
-  Crus fracture
-  Crush injury
-  Crush syndrome
-  Cubitus valgus
-  Cubitus varus
-  Cunningham shoulder reduction
-  Currarino syndrome


Danis–Weber classification
-  Darrach's procedure
-  Darrah procedure
-  De Quervain syndrome
-  Denis Browne bar
-  Denis classification
-  Destot's sign
-  Diaphysis
-  Diffuse idiopathic skeletal hyperostosis
-  Discectomy
-  Discoid meniscus
-  Dislocated shoulder
-  Dislocation of hip
-  Displacement (orthopedic surgery)
-  Distal radius fracture
-  Distraction osteogenesis
-  Drawer test
-  Dupuytren's contracture
-  Durkan's test
-  Duverney fracture
-  Dynamic compression plate
-  Dynamic hip screw
-  Dysplasia epiphysealis hemimelica


Early appropriate care
-  Ecchondroma
-  Ectrodactyly
-  Ectromelia
-  Ehlers–Danlos syndrome
-  Eiken syndrome
-  Elbow examination
-  Elbow extension test
-  Ellis–van Creveld syndrome
-  Enchondroma
-  Enchondromatosis
-  Ender's nail
-  Endochondral ossification
-  Endosteum
-  Enthesis
-  Epiphyseal plate
-  Epiphysiodesis
-  Epiphysis
-  Erlenmeyer flask deformity
-  Essex-Lopresti fracture
-  Evans technique
-  Evans-Jensen classification
-  Ewing's sarcoma
-  Exostosis
-  External fixation
-  Extraskeletal chondroma


Fairbank's changes
-  Fairbanks disease
-  Fat embolism
-  Femoral fracture
-  Femoral head ostectomy
-  Fibrocartilage callus
-  Fibrocartilage
-  Fibrosarcoma
-  Fibrous dysplasia of bone
-  Fibrous joint
-  Fibular fracture
-  Ficat classification
-  Finkelstein's test
-  Fixation (surgical)
-  Flat bone
-  Flat feet
-  Flexion teardrop fracture
-  Foot drop
-  Foot fracture
-  Forearm fracture
-  Frankel's sign
-  Freiberg disease
-  Froment's sign
-  Frykman classification


Gaenslen's test
-  Galeazzi fracture
-  Galeazzi test
-  Gamekeeper's thumb
-  Garden classification
-  Garre's sclerosing osteomyelitis
-  Gartland classification
-  Genu recurvatum
-  Genu valgum
-  Genu varum
-  Gerber's test
-  Gerdy's tubercle
-  Geriatric trauma
-  Giant-cell tumor of bone
-  Gigli saw
-  Gilula's Lines
-  Girdlestone's Procedure
-  Gorham's disease
-  Gosselin fracture
-  Greenstick fracture
-  Grosse-Kempf nail
-  Gruen zone
-  Gustilo open fracture classification
-  Guyon's Canal


Haglund's deformity
-  Hajdu–Cheney syndrome
-  Hallux rigidus
-  Hallux valgus
-  Hallux varus
-  Hammer toe
-  Hand deformity
-  Hand fracture
-  Hand of benediction
-  Hand surgery
-  Hangman's fracture
-  Haruguchi classification
-  Hardinge lateral approach to the hip
-  Harrington rod
-  Harris Hip Score
-  Harris lines
-  Harrison's groove
-  Haversian canal
-  Hawkin's classification
-  Hawkins-Kennedy test
-  Heberden's node
-  Hemarthrosis
-  Hematoma
-  Hemimelia
-  Herbert classification
-  Herbert screw
-  Herscovici classification
-  High ankle sprain
-  High tibial osteotomy
-  Hilgenreiner's line
-  Hill–Sachs lesion
-  Hip dysplasia (human)
-  Hip examination
-  Hip fracture
-  Hip replacement
-  Hip resurfacing
-  Hip spica cast
-  Hoffa fracture
-  Holdsworth fracture
-  Holstein–Lewis fracture
-  Hubscher's maneuver
-  Hueter-Volkmann law
-  Human musculoskeletal system
-  Hume fracture
-  Hume fracture
-  Humerus fracture
-  Humphrey's ligament
-  Hyaline cartilage
-  Hydroxylapatite
-  Hyperostosis
-  Hypertrophic pulmonary osteoarthropathy


Ideberg classification
-  Ilizarov apparatus
-  Infantile cortical hyperostosis
-  Injury Severity Score
-  Internal fixation
-  Intervertebral disc annuloplasty
-  Intervertebral disc arthroplasty
-  Intramedullary rod
-  Intramembranous ossification
-  Involucrum
-  Irregular bone
-  Iselin's disease


Jansen's metaphyseal chondrodysplasia
-  Jefferson fracture
-  Jobe's test
-  Joint dislocation
-  Joint locking (symptom)
-  Joint replacement
-  Joint replacement registry
-  Joint stiffness
-  Joint
-  Jones fracture
-  Juvenile osteoporosis


Kanavel's cardinal signs
-  Kapandji score
-  Kashin–Beck disease
-  Keller procedure
-  Kellgren-Lawrence grading scale
-  Khyphoplasty
-  Kienbock's disease
-  Kirschner wire
-  Klein's line
-  Klippel–Feil syndrome
-  Klippel–Trénaunay–Weber syndrome
-  Knee cartilage replacement therapy
-  Knee examination
-  Knee replacement
-  Kniest dysplasia
-  Kocher criteria
-  Kocher manoeuvre
-  Köhler disease
-  Krukenberg procedure
-  Kuntscher nail


Lachman test
-  Larrey's sign
-  Larsen syndrome
-  Lasègue's sign
-  Latarjet procedure
-  Lauge-Hansen classification
-  Legg–Calvé–Perthes syndrome
-  Ligamentous laxity
-  Limb lengthening methods
-  Lisfranc fracture
-  Lisfranc joint
-  Lisfranc ligament
-  List of orthopedic implants
-  Lister's tubercle
-  Lobstein syndrome
-  Loder classification
-  Long bone
-  Loosers zone
-  Lunotriquetral shear test
-  Luxating patella


Madelung's deformity
-  Maffucci syndrome
-  Maisonneuve fracture
-  Major trauma
-  Malgaigne's fracture
-  Malunion
-  March fracture
-  Marfan syndrome
-  Marie-Strümpell disease
-  Marshall syndrome
-  Marshall–Smith syndrome
-  Martin-Gruber Anastomosis
-  Mayfield classification
-  McCune–Albright syndrome
-  McMurray test
-  Medullary cavity
-  Melnick–Needles syndrome
-  Melorheostosis
-  Mesenchymal chondrosarcoma
-  Metaphysis
-  Metatarsophalangeal joint sprain
-  Microfracture surgery
-  Milch classification
-  Mirel's Score
-  Monostotic fibrous dysplasia
-  Monteggia fracture
-  Moore or Southern posterior approach to the hip
-  Moore's fracture
-  Moore's pin
-  Morton's neuroma
-  Morton's toe
-  Mulder's sign
-  Müller AO Classification of fractures
-  Multiple epiphyseal dysplasia
-  Mumford procedure
-  Musculoskeletal injury
-  Myxoid chondrosarcoma


National hip fracture database
-  Neer classification
-  Neer impingement sign
-  Neer's prosthesis
-  Nonossifying fibroma
-  Nonunion
-  Nonunion of fracture
-  Nursemaid's elbow


O'Brien's test
-  Ober's test
-  Oligodactyly
-  Ollier disease
-  Orthopaedic pathology
-  Orthopaedic procedure
-  Orthopedic cast
-  Orthopedic plaster casts
-  Orthopedic plates
-  Orthopedic surgery
-  Orthotics
-  Ortolani test
-  Ortolani test
-  Osgood–Schlatter disease
-  Osseointegration
-  Osseous tissue
-  Ossification center
-  Ossification
-  Ostectomy
-  Osteitis fibrosa cystica
-  Osteitis
-  Osteoarthritis
-  Osteoblast
-  Osteoblastoma
-  Osteochondritis dissecans
-  Osteochondritis
-  Osteochondrodysplasia
-  Osteochondroma
-  Osteochondromatosis
-  Osteochondrosis
-  Osteoclast
-  Osteocyte
-  Osteofibrous dysplasia
-  Osteogenesis imperfecta
-  Osteoid osteoma
-  Osteoid
-  Osteolysis
-  Osteoma
-  Osteomalacia
-  Osteomyelitis
-  Osteon
-  Osteopetrosis
-  Osteophyte
-  Osteoporosis
-  Osteosarcoma
-  Osteosclerosis
-  Osteostimulation
-  Osteotomy


Paget's disease of bone
-  Panner disease
-  Patella alta
-  Patella baja
-  Patella fracture
-  Patellar dislocation
-  Patellar tendon rupture
-  Pathologic fracture
-  Patrick's test
-  Patrick's test
-  Pauwel's angle
-  Pauwel's classification
-  Pectus carinatum
-  Pectus excavatum
-  Pediatric trauma
-  Pelvic fracture
-  Penetrating trauma
-  Perichondrium
-  Periosteal reaction
-  Periosteum
-  Periostitis
-  Perkin's line
-  Perthes Lesion
-  Pes cavus
-  Phalen maneuver
-  Phocomelia
-  Physical therapy
-  Pigeon toe
-  Pigmented villonodular synovitis
-  Pilon fracture
-  Pipkin classification
-  Pipkin fracture-dislocation
-  Pivot-shift test
-  Plafond fracture
-  Polydactyly
-  Polyostotic fibrous dysplasia
-  Polytrauma
-  Ponseti method
-  Porotic hyperostosis
-  Pott's fracture
-  Preiser disease
-  Proteus syndrome
-  Protrusio acetabuli
-  Pseudarthrosis
-  Pulled hamstring
-  Pycnodysostosis
-  Pyogenic osteomyelitis


Quadriceps tendon rupture


Radius fracture
-  Rapadilino syndrome
-  Reduction (orthopedic surgery)
-  Resuscitation
-  Resuscitative thoracotomy
-  Rett syndrome
-  Revised Trauma Score
-  Rib fracture
-  Rickets
-  Rocker bottom foot
-  Rolando fracture
-  Rotationplasty
-  Rotator cuff tear
-  Rowe Score
-  Rubinstein–Taybi syndrome
-  Ruedi-Allgower classification
-  Rush nail


Sacralization of the fifth lumbar vertebra
-  Salter–Harris fracture
-  Sanders classification
-  Sarcoma
-  Scaphoid fracture
-  Scapular fracture
-  Schenck classification
-  Scheuermann's disease
-  Schmorl's nodes
-  Schober's test
-  Schwartz–Jampel syndrome
-  Scoliosis
-  Seddon classification
-  Segond fracture
-  Seidel nail
-  Seinsheimer classification
-  Separated shoulder
-  Sequestrum
-  Sesamoid bone
-  Sesamoiditis
-  Sever's disease
-  Shenton's Line
-  Shepherd's fracture
-  Shin splints
-  Short bone
-  Shoulder examination
-  Shoulder fracture
-  Shoulder replacement
-  Shoulder surgery
-  Silver–Russell syndrome
-  Simmonds' test
-  Skeletal fluorosis
-  SLAP tear
-  Slipped capital femoral epiphysis
-  Slipped Upper Femoral Epiphysis
-  Smith Peterson nail
-  Smith-Petersen anterior approach to the hip
-  Smith's fracture
-  Soft tissue injury
-  Southwick angle
-  Speed's test
-  Spina bifida occulta
-  Spinal curvature
-  Spinal fracture
-  Spinal fusion
-  Spiral fracture
-  Splint (medicine)
-  Spondylolisthesis
-  Sports injury
-  Sprained ankle
-  Sprengel's deformity
-  Steinmann pin
-  Stener lesion
-  Sternal fracture
-  Stieda fracture
-  Straight leg raise
-  Stress fracture
-  Subacromial bursitis
-  Sudeck's atrophy
-  Sulcoplasty
-  Supracondylar fracture
-  Swan neck deformity
-  Swanson prosthesis
-  Swanson's arthroplasty
-  Symphysis
-  Synchondrosis
-  Syndactyly
-  Syndesmosis
-  Synovectomy
-  Synovial fluid
-  Synovial joint


Talipes equinovarus
-  Talwalkar nail
-  Taylor Spatial Frame
-  Tear of meniscus
-  Teisen classification
-  Tendon transfer
-  Tension band wiring
-  Teunissen–Cremers syndrome
-  Thomas test
-  Thompson and Epstein classification
-  Thompson test
-  Thurstan Holland sign
-  Tibia fracture
-  Tibial plateau fracture
-  Tietze syndrome
-  Tile classification
-  Tillaux-Chaput avulsion fracture
-  Tinel sign
-  Toddler's fracture
-  Tommy John surgery
-  Trabecula
-  Traction (orthopedics)
-  Traction splint
-  Trauma center
-  Trauma surgery
-  Trauma team
-  Traumatology
-  Trendelenburg gait
-  Trendelenburg's sign
-  Trethowan's sign
-  Trevor's disease
-  Triage
-  Trimalleolar fracture
-  Triple arthrodesis
-  Tscherne classification
-  Tumoral calcinosis


Ulnar fracture
-  Unhappy triad
-  Unicompartmental knee arthroplasty
-  Upington disease


Valgus deformity
-  Valgus stress test
-  Vancouver classification
-  Varus deformity
-  Vertebral osteomyelitis
-  Villonodular synovitis
-  Volkmann's canals
-  Volkmann's contracture
-  Volkmann avulsion fracture


Waddell's signs
-  Wagstaffe-Le Fort avulsion fracture
-  Wallis–Zieff–Goldblatt syndrome
-  Wassel classification
-  Watson-Jones anterolateral approach to the hip
-  Watson's test
-  Weaver–Dunn procedure
-  Webbed toes
-  Wedge fracture
-  Weil's osteotomy
-  Wilson test
-  Winged scapula
-  Wolff's law
-  WOMAC
-  Wound healing
-  Wrist drop
-  Wrist osteoarthritis


Yergason's test
-  Young-Burgess classification


Zadek's procedure


James H-C. Wang  is a Chinese American orthopedic biomechanist and  academic . Currently, he is a  Professor  at the Departments of  Orthopaedic Surgery ,  Bioengineering , and PM&R at the  University of Pittsburgh . [ 1 ]  In addition, he is a Faculty Member at the  McGowan Institute for Regenerative Medicine . [ 2 ]


Wang is most known for his work on tissue biomechanics,  tissue engineering , and cell  mechanobiology . [ 3 ]


Wang is a Fellow of the International Orthopaedic Research (FIOR), and  American Institute for Medical and Biological Engineering  (AIMBE). [ 4 ]


Wang completed his  Bachelor of Science  in Engineering Mechanics in 1982 and  Master of Science  in Experimental Biomechanics in 1989 from  Tongji University . Later in 1996, he obtained  PhD  in  Bioengineering  from the  University of Cincinnati  in the US. [ 1 ]


In 1982, Wang joined Tongji University as an Assistant Instructor in the Department of Engineering Mechanics. After moving to USA, he finished his PhD at the University of Cincinnati and later completed postdoctoral training in  Biomedical Engineering  at  Johns Hopkins School of Medicine  and  Washington University in St. Louis . After his postdoctoral training, he joined the  University of Pittsburgh  in 1998, where he was  Assistant Professor  at the Department of Orthopaedic Surgery from 1998 to 2005. Subsequently, he held the position of tenured  Associate Professor  at the Department of Orthopaedic Surgery and associate professor at the Departments of Bioengineering,  Mechanical Engineering  and  Materials Science , and PM&R between 2005 and 2012. Since 2012, he has been serving as Professor at the Department of Orthopaedic Surgery and also Professor at the Departments of Bioengineering and PM&R. [ 1 ] [ 2 ]


In 2017, he was appointed  Vice Chair  of Research at the Department of Orthopaedic Surgery at the University of Pittsburgh. Since 2004, he has been the Director of the MechanoBiology Laboratory in the same department. [ 2 ]


At the University of Pittsburgh, Wang has developed a research program in cell mechanobiology, which particularly focuses on the role of tendon cells in the development of  tendinopathy . He has been consistently receiving substantial funding support from  NIH  and  NSF . Additionally, he has been awarded research grants from DOD for several projects that aim to develop practical and clinically actionable strategies for the prevention and treatment of tendinopathy. He has authored numerous publications spanning the areas of tissue biomechanics, tissue engineering, and cell mechanobiology. [ 3 ]


To understand the inflammatory and degenerative responses of tendon due to overuse injury, Wang's group has established a validated animal model of tendinopathy by using mouse treadmill running that mimic human tendinopathy development. Additionally, his work emphasized the role of HMGB1 as a pivotal molecule in mechanically induced tendinopathy and proposed glycyrrhizin and metformin as potential therapeutic agents to inhibit HMGB1 activity, thereby offering preventive and treatment options for tendinopathy. [ 5 ] [ 6 ]


Wang's research team has also worked on the identification and characterization of tendon stem cells (TSCs) in humans, mice, rats, and rabbits. [ 7 ]  Wang's tendon stem cell research has focused on the effects of different mechanical loading conditions on TSC growth and differentiation. [ 8 ]  Focusing on TSCs, his work highlighted the role of  TSC mechanobiology in tendon homeostasis as well as the development of degenerative tendinopathy. [ 8 ] [ 9 ]  His group showed that in normal conditions, the multi-differentiation potential of TSCs allows these stem cells to differentiate into tenocytes; however, under high stress and injurious conditions TSCs can undergo aberrant differentiation into adipocytes, chondrocytes, and osteocytes. Wang's team has established the beneficial effects of modest exercise on tendons via moderate treadmill running by the virtue of its effect in enhancing the function of TSCs resulting in the formation of normal-like tendon tissue at the site of injury. [ 10 ] [ 11 ]  In their examination of treatment options for tendon injuries, [ 12 ]  his group has provided insights into the application of biologics such as PRP [ 13 ]  for the effective treatment of tendon injuries. [ 14 ]


Wang also focuses his research on tissue engineering. His approach to regenerate tendons after injury includes the use of PRP. His group showed that PRP with minimal leukocytes, known as pure-PRP (P-PRP), induces TSC differentiation into active tenocytes. These tenocytes produce abundant collagens, enabling P-PRP to effectively repair tendon injuries. His team demonstrated that the combined application of kartogenin and PRP effectively enhanced the formation of a fibrocartilage region connecting the tendon graft and bone interface, thereby improving the biomechanical strength of the tendon-bone junction. [ 15 ]


The  management of scoliosis  is complex and is determined primarily by the type of scoliosis encountered: syndromic, congenital, neuromuscular, or idiopathic. [ 1 ]  Treatment options for idiopathic scoliosis are determined in part by the severity of the curvature and  skeletal maturity , which together help predict the likelihood of progression. Non-surgical treatment (conservative treatment) should be pro-active with intervention performed early as "Best results were obtained in 10-25 degrees scoliosis which is a good indication to start therapy before more structural changes within the spine establish." [ 2 ]  Treatment options have historically been categorized under the following types:


For adults, treatment usually focuses on relieving any pain, [ 3 ] [ 4 ]  while physiotherapy and braces usually play only a minor role. [ 5 ]


Treatment for idiopathic  scoliosis  also depends upon the severity of the curvature, the spine’s potential for further growth, and the risk that the curvature will progress.


Mild scoliosis (less than 30 degrees deviation) has traditionally been treated through observation only. [ 7 ]  However, the progression of adolescent idiopathic scoliosis has been linked to rapid growth, [ 8 ]  suggesting that observation alone is inadequate as progression can rapidly occur during the pubertal growth spurt. Another study has further shown that the peak rate of growth during puberty can actually be higher in individuals with scoliosis than those without, further exacerbating the issue of rapid worsening of the scoliosis curves. [ 8 ]  Moderately severe scoliosis (30–45 degrees) in a child who is still growing requires bracing. A 2013 study by Weinstein et al. [ 9 ]  found that rigid bracing significantly reduces worsening of curves in the 20-45 degree range and found that 58% of children receiving "observation only" progressed to surgical range. Recent guidelines [ 10 ]  published by the Scientific Society of Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) in 2016 state that “the use of a brace is recommended in patients with evolutive idiopathic scoliosis above 25º during growth” based on a review of current scientific literature. Severe curvatures that rapidly progress may be treated surgically with spinal rod placement. Thus, early detection and early intervention prior to the pubertal growth spurt provides the greatest correction and prevention of progression to surgical range. [ 11 ]  In all cases, early intervention offers the best results. A growing body of scientific research testifies to the efficacy of specialized treatment programs of physical therapy, which may include bracing. [ 12 ]


Physical therapists  and  occupational therapists  help those who have experienced an injury or illness regain or maintain the ability to participate in everyday activities. For those with scoliosis, a physical therapist and/or occupational therapist can provide assistance through assessment, intervention, and ongoing evaluation of the condition. This helps them manage physical symptoms and/or use compensatory techniques so that they can participate in  daily activities  like self-care, productivity, and leisure.


One intervention involves bracing. During the past several decades, a large variety of bracing devices have been developed for the treatment of scoliosis. [ 13 ]  Studies demonstrate that preventing force sideways across a joint by bracing prevents further curvature of the spine in idiopathic scoliosis, [ 14 ]  while other studies have also shown that braces can be used by individuals with scoliosis during physical activities. [ 15 ]  It is important to note that scoliosis is not merely a lateral or sideways deformity, but occurs in three dimensions [ 16 ]  as a rotational component is often present.


Other interventions include postural strategies, such as posture training in sitting, standing, and sleeping positions, and in using positioning supports such as pillows, wedges, rolls, and corsets. [ 17 ]


Adaptive and compensatory strategies are also employed to help facilitate individuals to returning daily activities.


Scoliosis specific exercises have been found to improve treatment outcomes when utilized in addition to bracing and other standards of care. [ 18 ]  Scoliosis specific exercises include methods such as Schroth [ 19 ]  which specifically aim to correct aesthetic differences and strengthened muscles and connective tissue that may have atrophied as a result of scoliosis and asymmetric posture. Schroth exercises and other scoliosis specific exercises should be utilized in conjunction with bracing and other standards of care, [ 20 ]  and be performed under the guidance of a trained professional to ensure the exercises are effective and target the individual's curve pattern so that the correct muscles are strengthened. Strengthening spinal  muscles  is a crucial preventive measure. This is because the muscles in the back are essential when it comes to supporting the  spinal column  and maintaining the spine's proper shape.  Exercises  that will help improve the strength of the muscles in the back include rows and leg and arm extensions. [ 21 ]  Elastic  resistance exercise  may also be able to sustain the progression of  spinal curvature . [ 22 ]  This type of exercise is able to sustain progression by equalizing the strength of the torso muscles found on each side of the body.


Disability caused by scoliosis, as well as physical limitations during recovery from treatment-related surgery, often affects an individual’s ability to perform  self-care  activities. [ 23 ]  One of the first treatments of scoliosis is the attempt to prevent further curvature of the spine. Depending on the size of the curvature, this is typically done in one of three ways: bracing, surgery, or postural positioning through customized cushioning. [ 23 ] [ 24 ] [ 25 ]  Stopping the progression of the scoliosis can prevent the loss of function in many  activities of daily living  by maintaining range of motion, preventing deformity of the rib cage, and reducing pain during activities such as bending or lifting.


Occupational therapists  are often involved in the process of selection and fabrication of customized cushions. These individualized postural supports are used to maintain the current spinal curvature, or they can be adjusted to assist in the correction of the curvature. This type of treatment can help to maintain mobility for a wheelchair user by preventing the deformity of the rib cage and maintaining an active range of motion in the arms. [ 23 ]


For other self-care activities (such as dressing, bathing, grooming, personal hygiene, and feeding), several strategies can be used as a part of  occupational therapy  treatment. Environmental adaptations for bathing could include a bath bench, grab bars installed in the shower area, or a handheld shower nozzle. [ 26 ]   For activities such as dressing and grooming, various assistive devices and strategies can be used to promote independence. An occupational therapist may recommend a long-handled reacher that can be used to assist self-dressing by allowing a person to avoid painful movements such as bending over; a long-handled shoehorn can be used for putting on and removing shoes. Problems with activities such as cutting meat and eating can be addressed by using specialized cutlery, kitchen utensils, or dishes.


Productive activities include paid or  unpaid work , household chores, school, and play. [ 27 ]  Recent studies in healthcare have led to the development of a variety of treatments to assist in the management of scoliosis thereby maximizing productivity for people of all ages.  Assistive technology  has undergone dramatic changes over the past 20 years; the availability and quality of the technology has improved greatly. [ 28 ]  As a result of using assistive technology, functional changes may range from improvements in abilities, performance in daily activities, participation levels, and quality of life. [ 27 ]


A common assistive technology intervention is specialized seating and postural control. For children with poor postural control, a comfortable seating system that provides them with the support needed to maintain a sitting position can be essential for raising their overall level of well-being. [ 29 ]  A child's well-being in a productive sense involves the ability to participate in classroom and play activities. [ 27 ]  Specialized wheelchair seating has been identified as the most common prescription in the management of scoliosis in teenagers with  muscular dystrophy . [ 30 ]


With comfortable wheelchair seating, teenagers are able to participate in classroom activities for longer periods with less fatigue. By tilting the seating position 20° forward (toward the thighs), seating pressure is significantly redistributed, so sitting is more comfortable. If an office worker with scoliosis can sit for longer periods, increased work output is likely to occur and could improve quality of life. Tall, forward-sloping seats or front parts of seats, and when possible with tall desk with the opposite slope, can, in general, reduce pains and the need of bending significantly while working or studying, and that is particularly important with braced, fragile, or tender backs. An open hip angle can benefit the used lung volume and respiration. [ 31 ] [ 32 ]


For those not using a wheelchair, bracing may be used to treat scoliosis. Lifestyle changes are made to compensate for the proper use of spine braces.


Physical symptoms such as chest pains, back pains, shortness of breath, and limited spinal movement can hamper or preclude participation in leisure activities of a physical nature. The occupational therapist's role is to facilitate participation by helping the patient manage these symptoms.


Bracing is a common strategy recommended by an occupational therapist, in particular, for individuals engaging in sports and exercise. [ 15 ]  An OT is responsible for educating an individual on the advantages and disadvantages of different braces, proper ways to wear the brace, and the day-to-day care of the brace.


To help a person manage heart and lung symptoms, such as shortness of breath or chest pains, an occupational therapist can teach the individual energy conservation techniques. [ 26 ]  This includes scheduling routine breaks during the activity, as suitable for the individual. For example, an occupational therapist can recommend that a swimmer take breaks between laps to conserve energy.  Adapting or modifying the exercise or sport is another way a person with scoliosis can do it. [ 26 ]  Adapting the activity may change the difficulty of the sport or exercise. For example, it might mean taking breaks throughout an exercise. If a person with scoliosis is unable to participate in a sport or exercise, an OT can help the individual explore other physical activities that are suitable to his/her interests and capabilities. An occupational therapist and the person with scoliosis can explore enjoyable and meaningful participation in the sport/exercise in another capacity, such as coaching or refereeing.


Bracing is most effective when the patient has bone growth remaining (is skeletally immature) and should aim to both prevent progression of the curve (prevent progression to surgery), as well as reduce the scoliosis curve. Reduction of the curve is important as the natural history of idiopathic scoliosis suggests it can continue to progress at a rate ~1 degree per year in adulthood, [ 33 ]  while the treatment results of bracing have been shown to hold over >15 years. [ 34 ]  In some cases with juveniles, bracing has reduced curves significantly, going from a 40 degrees (of the curve, mentioned in length above.) out of the brace to 18 degrees in it. Braces are sometimes prescribed for adults to relieve pain related to scoliosis. Bracing involves fitting the patient with a device that covers the torso; in some cases, it extends to the neck. The most commonly used brace is a  TLSO , such as a  Cheneau type brace , a  corset -like appliance that fits from armpits to hips and is custom-made from fiberglass or plastic. It is worn upwards of 18–23 hours a day, depending on the doctor's prescription, and applies pressure on the curves in the spine. The effectiveness of the brace depends not only on brace design and  orthotist  skill; patient compliance; and amount of wear per day, but also the "stiffness" of the spine resulting from a shortened spinal cord [ 35 ] [ 36 ]  and/or nerve tension. [ 37 ]  as evidence by the force necessary (mean force ~121 lbs) to physically correct scoliosis during spinal surgery [ 38 ]
The typical use of braces for idiopathic scoliosis is to prevent progression to surgical range as well as reduce the scoliotic curve of the spine as spinal fusion surgery can reduce mobility due to fusion of the vertebrate while potentially increasing pain long term. [ 39 ]  For non-idiopathic scoliosis (ie. neuromuscular, congenital, etc.) and those with additional comorbidities (ie.  Marfans Syndrome ) spinal surgery may be required due to structural changes in the spine.


Indications for Scoliosis Bracing:  Scoliosis professionals determine the proper bracing method for a patient after a complete clinical evaluation. The patient’s growth potential, age, maturity, and scoliosis (Cobb angle, rotation, and sagittal profile) are also considered. Immature patients who present with Cobb angles less than 20 degrees should be closely monitored and proactively treated based on their risk of progression [ 40 ]  as surgery can be prevented with early intervention of conservative treatment. [ 41 ]  Immature patients who present with Cobb angles of 20 degrees to 29 degrees should be braced according to the risk of progression by considering age, Cobb angle increase over a six-month period, Risser sign, and clinical presentation. Immature patients who present with Cobb angles greater than 30 degrees should be braced. However, these are guidelines and not every patient will fit into this table. For example, an immature patient with a 17-degree Cobb angle and significant thoracic rotation or flatback could be considered for nighttime bracing. On the opposite end of the growth spectrum, a 29-degree Cobb angle and a Risser sign three or four might not need to be braced because there is reduced potential for progression. [ 42 ]


Surgery is indicated by the Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) at 45 degrees to 50 degrees [ 10 ]  and by the Scoliosis Research Society (SRS) at a Cobb angle of 45 degrees. [ 43 ]  SOSORT uses the 45-degree to 50-degree threshold as a result of the well-documented, plus or minus five degrees measurement error that can occur while measuring Cobb angles.


Scoliosis braces are usually comfortable for the patient, especially when it is well designed and fit; also after the 7- to 10-day break-in period.  A well fit and functioning scoliosis brace provides comfort when it is supporting the deformity and redirecting the body into a more corrected and normal physiological position. [ 44 ]


The Scoliosis Research Society's recommendations for bracing include curves progressing to larger than 25°, curves presenting between 30 and 45°,  Risser sign  0, 1, or 2 (an X-ray measurement of a pelvic growth area), and less than six months from the onset of menses in girls. [ 45 ]


Progressive scolioses exceeding 25° Cobb angle in the pubertal growth spurt should be treated with a pattern-specific brace like the Chêneau brace and its derivatives, with an average brace-wearing time of 16 hours/day (23 hours/day assures the best possible result).


The latest standard of brace construction is with CAD/CAM technology. With the help of this technology, it has been possible to standardize the pattern-specific brace treatment. Severe mistakes in brace construction are largely ruled out with the help of these systems. This technology also eliminates the need to make a plaster cast for brace construction. The measurements can be taken in any place and are simple (and not comparable to plastering). Available CAD/CAM braces include the Regnier-Chêneau brace, the Rigo-System-Chêneau-brace (RSC brace), the Silicon Valley Brace, and the Gensingen brace; braces can and should be customized to fit the individual's curve pattern and reduce the curve as much as possible as immediate in-brace correction has been shown to be associated with better treatment outcomes. [ 46 ] [ 47 ]  Many patients prefer the "Chêneau light" brace as it has good in-brace corrections reported in international literature and is easier to wear than other braces in use today. [ 48 ] [ 49 ]  However, this brace is not available for all curve patterns.


Prior to 2013 the efficacy of bracing has not been definitively demonstrated in randomised clinical studies, with more limited studies giving inconsistent conclusions. [ 50 ]  In 2013 the Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST) published results establishing benefits of bracing in adolescents with idiopathic scoliosis. In the randomized cohort, 72% in the group instructed to wear a brace for 18 hours per day against 48% in the observation group sustained curve progression to under 50 degrees, the proxy used for not requiring surgery. Additionally results suggested that the more a patient wore the brace, the better the result. [ 51 ] [ 52 ]


In progressive infantile and sometimes juvenile scoliosis, a plaster jacket applied early may be used instead of a brace. It has been proven possible [ 53 ]  to permanently correct cases of infantile idiopathic scoliosis by applying a series of plaster casts (EDF: elongation, derotation, flexion) on a specialized frame under corrective traction, which helps to "mould" the infant's soft bones and work with their growth spurts. This method was pioneered by UK scoliosis specialist Min Mehta. [ 54 ]  EDF casting is now the only clinically known nonsurgical method of complete correction in progressive infantile scoliosis. Complete correction may be obtained for curves less than 50° if the treatment begins before the second year of life. [ 55 ] [ 56 ]


Surgery is usually recommended by orthopedists for curves with a high likelihood of progression (i.e., greater than 45 to 50° of magnitude), curves that would be cosmetically unacceptable as an adult, curves in patients with  spina bifida  and  cerebral palsy  that interfere with sitting and care, and curves that affect physiological functions such as breathing. [ citation needed ]


Surgery for scoliosis is performed by a  surgeon  specializing in spine surgery. For various reasons, [ specify ]  it is usually impossible to completely straighten a scoliotic spine, but in most cases, significant corrections are achieved. [ citation needed ]


The two main types of surgery are:


One or both of these surgical procedures may be needed. The surgery may be done in one or two stages and, on average, takes four to eight hours. A Cochrane review could not draw conclusions on how effective surgical interventions were when compared to non-surgical interventions in patients with adolescent idiopathic scoliosis. [ 57 ]


Spinal fusion  is the most widely performed surgery for scoliosis. In this procedure, bone [either harvested from elsewhere in the body ( autograft ) or from a donor ( allograft )] is  grafted  to the vertebrae so when they heal, they form one solid bone mass and the  vertebral column  becomes rigid. This prevents worsening of the curve, at the expense of some spinal movement. This can be performed from the anterior (front) aspect of the spine by entering the  thoracic  or  abdominal  cavities, or more commonly, performed from the back (posterior). A combination may be used in more severe cases, though the modern pedicle screw system has largely negated the need for this. [ 50 ]


In recent years all-screw systems have become the gold-standard technique for adolescent idiopathic scoliosis.  Pedicle  screws achieve better fixation of the  vertebral column  and have better biomechanical properties than previous techniques, so enabling greater correction of the curve in all planes. [ 50 ]


Pedicle screw-only  posterior spinal fusion  may improve major curve correction at two years among patients with adolescent idiopathic scoliosis (AIS) [ 50 ]  as compared to hybrid instrumentation (proximal hooks with distal pedicle screws) (65% versus 46%) according to a  retrospective, matched-cohort study . [ 58 ]  The prospective cohorts were matched to the retrospective cohorts according to patient age, fusion levels, Lenke curve type, and operative method. The two groups were not significantly different in regard to age, Lenke AIS curve type, or Riser grade. The numbers of fused vertebrae were significantly different (11.7±1.6 for pedicle screw versus 13.0±1.2 for hybrid group). This study's results may be biased due to the pedicle screw group's being analyzed prospectively versus retrospective analysis of the hybrid instrumentation group.


In general, modern spinal fusions have good outcomes with high degrees of correction and low rates of failure and infection. However a systematic review of  PubMed  papers in 2008 concluded "Scoliosis surgery has a varying but high rate of complications", although the non-standardised data on complications was difficult to assess and was incomplete. [ 59 ]  Patients with fused spines and permanent implants tend to have normal lives with unrestricted activities when they are younger; it remains to be seen whether those that have been treated with the newer surgical techniques develop problems as they age. [ 60 ]


A complementary surgical procedure a surgeon may recommend is called thoracoplasty (also called costoplasty). This is a procedure to reduce the rib hump that affects most scoliosis patients with a thoracic curve. A rib hump is evidence of some rotational deformity to the spine. Thoracoplasty may also be performed to obtain bone grafts from the ribs instead of the pelvis, regardless of whether a rib hump is present. Thoracoplasty can be performed as part of a spinal fusion or as a separate surgery, entirely.


Thoracoplasty is the removal (or resection) of typically four to six segments of adjacent ribs that protrude. Each segment is one to two inches long. The surgeon decides which ribs to resect based on either their prominence or their likelihood to be realigned by correction of the curvature alone. The ribs grow back straight.


Thoracoplasty has risks, such as increased pain in the rib area during recovery or reduced pulmonary function (10–15% is typical) following surgery. This impairment can last anywhere from a few months to two years. Because thoracoplasty may lengthen the duration of surgery, patients may also lose more blood or develop complications from the prolonged anesthesia. A more significant, though far less common, risk is the surgeon might inadvertently puncture the pleura, a protective coating over the lungs. This could cause blood or air to drain into the chest cavity,  hemothorax  or  pneumothorax , respectively. [ 61 ]