Originally published in Medical Grapevine (2008)
For the original article, please click here.
At the time of publishing, Dr Lai Choon Hin was a Senior Consultant Orthopaedic Surgeon and the Director of the Adult Reconstruction Service at Tan Tock Seng Hospital, Singapore. He was also the President of the Singapore Orthopaedic Association, and the ASEAN Arthroplasty Association.
In this article, Dr Lai draws upon his vast experiences in the field explain how it has evolved over the last three decades.
The last 30 years have seen a significant change and evolution of orthopaedic surgery in Singapore.
In the mid eighties, when I began my career in orthopaedic surgery, there was hardly any form of sub-specialisation in orthopaedic surgery. My head of department, the late Prof N Balachandran was an expert in all aspects of orthopaedics from paediatric trauma and congenital problems to adult degenerative conditions. Other consultants in the department were equally adept at treating hand injuries to operating on major spinal deformities. At that time, there were not so many advances. There was less to learn as the types of surgeries were less varied or complicated and so were easier to master. In our training then, we were exposed to all aspects of orthopaedics.
The first sub-speciality to evolve was hand and microvascular surgery. The pioneers of hand surgery in Singapore, Prof P Chacha, Prof Robert Pho and Prof Tan Ser Kiat ushered in the development of microvascular techniques while maintaining their expertise in other aspects of orthopaedics. All the registrars and senior registrars in the department were similarly trained. It was only in the late 80s and early 90s was the Department of Hand Surgery set up in Singapore General Hospital, followed by a similar department in National University Hospital. With that, the training of hand surgeons followed a completely different track from orthopaedic trainees, spending just 6 months in orthopaedic surgery during their 3 to 4 years of traineeship.
When I was applying for the Adult Reconstruction Fellowship at the Mayo Clinic, in the US in 1988, the term "Adult Reconstruction" was unheard of in the local orthopaedic scene. This was an American sub-speciality term and most of my predecessors were trained in the UK.
I remembered that there was much excitement, when Prof N Balachanrdan did the first Insall Burstein I total knee arthroplasty in SGH in 1985. This was followed by the craze of the Isoelastic hip replacement. Hip and knee replacement surgery were rare events then. Practically the whole department, consultants and staff, would be assisting and watching the head of department performing it. Today, primary hip and knee replacement surgeries are routine standard operations done with one to two assistants. Even extensive revision hip and knee replacement surgeries are done in a quiet efficient manner without the excitement and fanfare of the early years.
The most complicated spine surgery then was Harrington Rodding for scoliosis. This usually takes place during school holidays as most of the patients were school students and they needed a long convalescence period. Today, spine surgeons do all sorts of intricate spinal instrumentations with aid of MRI, CT, fluoroscopy and computer navigation daily. Disectomies are done as outpatient procedures.
Presently, children with congenital problems and trauma are mainly seen in KKWCH, and current orthopaedic trainees spend only 3 to 6 months there. As a result, orthopaedic registrars elsewhere have limited experience managing even common children fractures and paediatric problems.
Even the more common bone tumors, like Ewing's sarcoma and osteosarcoma, are rarely seen by the younger surgeons outside of KKWCH.
Today, orthopaedic surgery is subdivided into:
Adult Reconstruction Surgery (dealing with major joint reconstruction of hip, knee, shoulder and elbow) Spine Surgery Hand Surgery
Paediatric Orthopaedics Sports Medicine & Surgery Trauma
Foot and Ankle Surgery
These sub-specialisations are necessary because the field of knowledge is so large and wide, and it is impossible to be an expert in all fields. The skills required of a microsvascular surgeon is vastly different from that of the adult reconstruction surgeon. Sub-specialisation is also crucial for the future development and advancement of orthopaedic surgery in Singapore.
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