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He advocated the use of exercise, manipulation, and splinting to treat deformities in children. His book was directed towards parents, and while some topics would be familiar to orthopedists today, it also included 'excessive sweating of the palms' and freckles.<ref>{{Cite web |vauthors=Meals CG, Meals RA |date=28 July 2021 |veditors=Windle ML, Schraga ED |title=Sugar-Tong Forearm Splinting Technique: Application of Sugar-Tong Splint, Postprocedural Care, Complications |url=https://emedicine.medscape.com/article/80127-technique |access-date=2022-02-26 |work=Medscape |publisher=WebMD LLC}}</ref> [[Jean-André Venel]] established the first orthopedic institute in 1780, which was the first hospital dedicated to the treatment of children's skeletal deformities. He developed the club-foot shoe for children born with foot deformities and various methods to treat curvature of the spine.{{cn|date=November 2023}} Advances made in surgical technique during the 18th century, such as [[John Hunter (surgeon)|John Hunter]]'s research on [[tendon]] healing and [[Percival Pott]]'s work on [[Pott disease|spinal deformity]] steadily increased the range of new methods available for effective treatment. [[Robert Chessher]], a pioneering British orthopedist, invented the double-inclined plane, used to treat lower-body bone fractures, in 1790.<ref>{{Cite journal |last=Valentin |first=Bruno |date=October 1958 |title=Robert Chessher (1750–1831): An English Pioneer in Orthopaedics |journal=Medical History |volume=2 |issue=4 |pages=308–313 |doi=10.1017/s0025727300024054 |issn=0025-7273 |pmc=1034426 |pmid=13599783}}</ref> [[Antonius Mathijsen]], a Dutch military surgeon, invented the [[plaster of Paris]] [[cast (orthopedic)|cast]] in 1851. Until the 1890s, though, orthopedics was still a study limited to the correction of deformity in children. One of the first surgical procedures developed was percutaneous tenotomy. This involved cutting a tendon, originally the Achilles tendon, to help treat deformities alongside bracing and exercises. In the late 1800s and first decades of the 1900s, significant controversy arose about whether orthopedics should include surgical procedures at all.{{cn|date=September 2021}} === Modern orthopedics === [[Image:Hugh Owen Thomas.jpg|thumb|right|[[Hugh Owen Thomas]], a pioneer of modern orthopedic surgery]]Examples of people who aided the development of modern orthopedic surgery were [[Hugh Owen Thomas]], a surgeon from [[Wales]], and his nephew, [[Robert Jones (surgeon)|Robert Jones]].<ref>{{cite journal |vauthors=Beckett D |title=From bonesetters to orthopedic surgeons: a history of the specialty of orthopedics. |journal=Surgical Technologist |date=1999 |volume=31 |pages=6–11 |url=http://www.ast.org/pdf/173.pdf }}</ref> Thomas became interested in orthopedics and [[Bonesetter|bone-setting]] at a young age, and after establishing his own practice, went on to expand the field into the general treatment of fracture and other musculoskeletal problems. He advocated enforced rest as the best remedy for [[bone fracture|fracture]]s and [[tuberculosis]], and created the so-called "Thomas splint" to stabilize a fractured femur and prevent infection. He is also responsible for numerous other medical innovations that all carry his name: Thomas's collar to treat tuberculosis of the cervical spine, Thomas's maneuvere, an orthopedic investigation for fracture of the hip joint, the [[Thomas test]], a method of detecting hip deformity by having the patient lying flat in bed, and Thomas's wrench for reducing fractures, as well as a so-called "osteoclast" implement to break and reset bones.{{cn|date=November 2023}} Thomas's work was not fully appreciated in his own lifetime. Only during the [[First World War]] did his techniques come to be used for injured soldiers on the [[battle]]field. His nephew, Sir Robert Jones, had already made great advances in orthopedics in his position as surgeon-superintendent for the construction of the [[Manchester Ship Canal]] in 1888. He was responsible for the injured among the 20,000 workers, and he organized the first comprehensive accident service in the world, dividing the 36-mile site into three sections, and establishing a hospital and a string of first-aid posts in each section. He had the medical personnel trained in fracture management.<ref>{{cite journal |vauthors=Irving M |title=Care of emergencies in the United Kingdom |journal=[[British Medical Journal]] |volume=283 |issue=6295 |pages=847–849 |date=September 1981 |pmid=6794724 |pmc=1507078 |doi=10.1136/bmj.283.6295.847}}</ref> He personally managed 3,000 cases and performed 300 operations in his own hospital. This position enabled him to learn new techniques and improve the standard of fracture management. Physicians from around the world came to Jones' clinic to learn his techniques. Along with Alfred Tubby, Jones founded the British Orthopedic Society in 1894. During the First World War, Jones served as a [[Territorial Army (United Kingdom)|Territorial Army]] surgeon. He observed that treatment of fractures both, at the front and in hospitals at home, was inadequate, and his efforts led to the introduction of military orthopedic hospitals. He was appointed Inspector of Military Orthopedics, with responsibility for 30,000 beds. The hospital in Ducane Road, [[Hammersmith, London|Hammersmith]], became the model for both British and American military orthopedic hospitals. His advocacy of the use of [[Traction splint|Thomas splint]] for the initial treatment of [[Femur|femoral]] fractures reduced mortality of open fractures of the femur from 87% to less than 8% in the period from 1916 to 1918.<ref name="Welsh Biography Online">{{cite DWB |id=s-JONE-ROB-1857 |title=Jones, Sir Robert, Bart |year=1959 |access-date=2010-12-31 |vauthors=Jones AR}}</ref> The use of [[intramedullary rod]]s to treat fractures of the femur and [[tibia]] was pioneered by [[Gerhard Küntscher]] of Germany. This made a noticeable difference to the speed of recovery of injured German soldiers during [[World War II]] and led to more widespread adoption of intramedullary fixation of fractures in the rest of the world. [[Traction (orthopedics)|Traction]] was the standard method of treating thigh bone fractures until the late 1970s, though, when the [[Harborview Medical Center]] group in Seattle popularized intramedullary fixation without opening up the fracture. [[File:Hip replacement Image 3684-PH.jpg|thumb|left|X-ray of a [[hip replacement]]]] The modern total [[hip replacement]] was pioneered by Sir [[John Charnley]], expert in [[tribology]] at [[Wrightington Hospital]], in England in the 1960s.<ref name="Wroblewski2003">{{cite journal |vauthors=Wroblewski BM |title=Professor Sir John Charnley (1911–1982) |journal=[[Rheumatology (journal)|Rheumatology]] |volume=41 |issue=7 |pages=824–825 |date=July 2002 |pmid=12096235 |doi=10.1093/rheumatology/41.7.824 |publisher=The British Society for Rheumatology via Oxford Journals |doi-access=free}}</ref> He found that joint surfaces could be replaced by implants cemented to the bone. His design consisted of a [[stainless steel]], one-piece femoral stem and head, and a [[polyethylene]] acetabular component, both of which were fixed to the bone using [[Poly(methyl methacrylate)|PMMA]] (acrylic) [[bone cement]]. For over two decades, the Charnley low-friction arthroplasty and its derivative designs were the most-used systems in the world. This formed the basis for all modern hip implants. The [[Exeter]] hip replacement system (with a slightly different stem geometry) was developed at the same time. Since Charnley, improvements have been continuous in the design and technique of [[joint replacement]] (arthroplasty) with many contributors, including W. H. Harris, the son of R. I. Harris, whose team at Harvard pioneered uncemented arthroplasty techniques with the bone bonding directly to the implant. Knee replacements, using similar technology, were started by McIntosh in [[rheumatoid arthritis]] patients and later by Gunston and Marmor for [[osteoarthritis]] in the 1970s, developed by [[John Insall]] in New York using a fixed bearing system, and by Frederick Buechel and Michael Pappas using a mobile bearing system.<ref name="Hamelynck2006">{{cite journal |vauthors=Hamelynck KJ |title=The history of mobile-bearing total knee replacement systems |journal=Orthopedics |volume=29 |issue=9 Suppl |pages=S7-12 |date=September 2006 |pmid=17002140}}</ref> External fixation of fractures was refined by American surgeons during the [[Vietnam War]], but a major contribution was made by [[Gavril Abramovich Ilizarov]] in the [[USSR]]. He was sent, without much orthopedic training, to look after injured Russian soldiers in [[Siberia]] in the 1950s. With no equipment, he was confronted with crippling conditions of unhealed, infected, and misaligned fractures. With the help of the local bicycle shop, he devised ring external [[fixator]]s tensioned like the spokes of a bicycle. With this equipment, he achieved healing, realignment, and [[Distraction osteogenesis|lengthening]] to a degree unheard of elsewhere. His [[Ilizarov apparatus]] is still used today as one of the distraction osteogenesis methods.<ref>{{cite book |title=Limb Lengthening and Reconstruction Surgery |veditors=Rozbruch SR, Ilizarov S |publisher=[[CRC Press]] |year=2006 |isbn=9781420014013 |url=https://books.google.com/books?id=yNTED-6REewC |via=[[Google Books]]}}</ref> Modern orthopedic surgery and musculoskeletal research have sought to make surgery less invasive and to make implanted components better and more durable. On the other hand, since the emergence of the opioid epidemic, orthopedic surgeons have been identified as one of the highest prescribers of opioid medications.<ref>{{cite web |title=Information Statement: Opioid Use, Misuse, and Abuse in Orthopedic Practice |url=https://aaos.org/globalassets/about/bylaws-library/information-statements/1045-opioid-use-misuse-and-abuse-in-practice.pdf |publisher=[[American Academy of Orthopedic Surgeons]] |date=2015}}</ref><ref name = "Armstrong_2020">{{cite journal |vauthors=Armstrong AD, Hassenbein SE, Black S, Hollenbeak CS |title=Risk Factors for Increased Postoperative Pain and Recommended Orderset for Postoperative Analgesic Usage |journal=The Clinical Journal of Pain |volume=36 |issue=11 |pages=845–851 |date=November 2020 |pmid=32889819 |pmc=7671821 |doi=10.1097/AJP.0000000000000876}}</ref> Decreasing prescription of opioids while still providing adequate pain control is a development in orthopedic surgery.<ref name = "Armstrong_2020" /><ref name="pmid27428259">{{cite journal |vauthors=Seangleulur A, Vanasbodeekul P, Prapaitrakool S, Worathongchai S, Anothaisintawee T, McEvoy M, Vendittoli PA, Attia J, Thakkinstian A |display-authors=3 |title=The efficacy of local infiltration analgesia in the early postoperative period after total knee arthroplasty: A systematic review and meta-analysis |journal=[[European Journal of Anaesthesiology]] |volume=33 |issue=11 |pages=816–831 |date=November 2016 |pmid=27428259 |doi=10.1097/EJA.0000000000000516 |s2cid=13813622}}</ref><ref name="pmid27423648">{{cite journal |vauthors=Hansen RN, Pham A, Strassels SA, Balaban S, Wan GJ |title=Comparative Analysis of Length of Stay and Inpatient Costs for Orthopedic Surgery Patients Treated with IV Acetaminophen and IV Opioids vs. IV Opioids Alone for Post-Operative Pain |journal=[[Advances in Therapy]] |volume=33 |issue=9 |pages=1635–1645 |date=September 2016 |pmid=27423648 |pmc=5020121 |doi=10.1007/s12325-016-0368-8}}</ref> </textarea><div 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