So You Want to Be an Orthopaedic Surgeon

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So you want to be an orthopaedic surgeon. You like the idea of fixing broken bones and bro-ing out. Let’s debunk the public perception myths of what it means to be an orthopaedic surgeon, and give it to you straight. This is the reality of orthopaedic surgery.

If you’d like to see what being an orthopaedic surgeon looks like, check out my personal YouTube channel, Kevin Jubbal, M.D., where I do a second series in parallel called a Day in the Life. We’ve already covered orthopaedic surgery and orthopaedic spine surgery.

 

What is Orthopaedic Surgery?

Ortho, coming from Greek orthos, meaning “straight or to correct” and paideia, meaning “rearing of children”, was originally concerned with treating children with skeletal deformities like bow legs or knock knees. In essence, orthopaedic surgery focuses on the musculoskeletal system. This translates to fractures, meaning broken bones, but also surgeries involving tendons, ligaments, and sometimes nerve or vascular injuries.

The sports injuries you see on TV of your favorite athletes, like ACL tears, Achille’s ruptures, or rotator cuff issues are handled by orthopaedic surgeons. But there’s much more to it than that. There are a variety of ways to categorize orthopaedic surgery. You can look at interventions that deal with fractures of bones versus soft tissue ligamentous and tendinous repair. You can look at non-acute versus acute surgery, such as trauma. Outpatient versus inpatient. Arthroscopic minimally invasive versus open surgeries. Adult versus pediatrics. Or regionally, you can look at orthopaedic surgery as spine versus pelvis versus extremities.

 

How to Become an Orthopaedic Surgeon

To become an orthopaedic surgeon, you’ll have to complete a 5-year orthopaedic surgery residency after medical school. A single research year is generally optional and can be pursued by those interested in becoming surgeon scientists.  

In terms of competitiveness, orthopaedic surgery is consistently in the top five, in most recent years being ranked fourth, only behind dermatology, plastic surgery, and neurosurgery. 

To be considered at an orthopaedic surgery program, your Step 1 score and 1 rep max on bench press must exceed 500, otherwise your application will be tossed out. I’m kidding obviously, but only sort of. Orthopaedic surgery candidates are top students, with very high Step 1 and Step 2 scores. The field is highly dominated by men, at approximately 95%. However, that’s changing for the better, and I’ve worked with several talented female orthopaedic surgeons during my training.

Like all surgical residencies, orthopaedic surgery residency will be incredibly taxing. There will be a significant amount of time on inpatient services compared to outpatient, which translates to earlier and longer hours.

 

Sub-Specialties within Orthopaedic Surgery

After completing residency, you can choose to subspecialize further with a fellowship, most of which last 1 year. While there are some general orthopods, over 80% decide to subspecialize, and some even complete two separate fellowships.

Trauma

In trauma, you’ll be dealing with fractures of the long bones of the extremities, such as the femur, tibia, forearm, and humerus, as well as fractures of the pelvis and hip socket. Often times these fractures will be “open” meaning the bone came through the skin and was exposed to the outside world. You’ll often be managing intra-articular fractures at joints such as the elbow, shoulder, knee, and hip. Intra-articular refers to fractures extending into the actual articulating surfaces of the joint.

Many of the patients will have multiple, if not all, extremities injured in some way necessitating planning and coordination of multiple surgeries. You’ll be working side by side with general surgery trauma surgeons, as these patients often have accompanying intra-abdominal and intra-thoracic injuries.

This is the subspecialty for you if you don’t mind irregular and unpredictable hours while on call. You will often see patients on the worst day of their lives but help them recover from debilitating injuries in order to get back to a normal life. The surgeries that you do each day will be diverse and unpredictable, but are often times very rewarding. The pay is not as high compared to other orthopaedic subspecialties because many traumatologists treat uninsured patients and are employed by hospitals instead of being in private practice.

Pediatrics

Of all the subspecialties, pediatric orthopaedic surgery is the most broad, as you’ll be operating on a variety of conditions in patients less than 18 years of age.

Most commonly, this includes trauma since kids love breaking things. But it also includes sports injuries, like ACL tears, spine surgeries to correct scoliosis deformity, and deformity correction of congenital limb defects. You’ll see everything from healthy kids who broke their wrist to kids with multiple congenital syndromes who need multiple procedures throughout their lives.

A great deal of pediatric orthopaedic surgery is nonoperative. This is the subspecialty for orthopods that enjoy a broad scope of practice and have the patience to work with both children and their parents.

Spine

Spine includes surgical interventions to correct spinal deformity, trauma, degenerative disease, and nerve compression.

Spine surgeons are consistently among the highest compensated orthopaedic surgeons. You’ll be dealing with multiple areas of the axial skeleton, operating primarily on the cervical, thoracic, and lumbar spine, and occasionally the sacrum.

There is some overlap between orthopaedic spine surgeons and neurosurgeons – both operate on the spine with similar indications and techniques. However, neurosurgeons will also operate on lesions that affect the actual spinal cord that extend into the dura, which is the outermost layer of the meninges. As an orthopaedic surgeon, you’ll stick just to the bony spine and leave the spinal cord to the neurosurgeons.

Hand

Hand surgery obviously includes the hand, but also the forearm, wrist, and sometimes up to the elbow or higher! Approximately 70% of fellowship-trained hand surgeons first completed an orthopaedic residency, but 25-30% of the time it’s plastic surgeons. General surgeons can train in hand fellowship as well, although it’s quite rare.

This is the subspecialty for the cerebral and intellectual orthopods. It’s the second most competitive fellowship and deals with incredibly complex anatomy. You have to find enjoyment in the nuances and esoteric variations of anatomy and function. Given the complex anatomy, you’ll be doing a lot of micro-surgery, operating under microscopes or using surgical loupes to better visualize the tendons, nerves, vessels, and bones.

The pathology treated is extremely broad. You’ll be dealing with fractures, infections, nerve compression, degenerative disease, overuse injuries, congenital defects, and traumatic amputations of the fingers, wrist, and hand. Hand surgeons also deal with revascularization of amputated digits or limbs with the repair of peripheral nerves.

Hand surgeons also do targeted muscle reinnervation, which is essentially science fiction. This provides patients with traumatic amputations to the upper extremity with the ability to use myoelectric prostheses with more intuitive function. In short, nerves that would have innervated muscles that no longer have function can be rerouted such that a prosthetic limb can perform more complex movements. Magic baby.

For example, the starfish procedure allows for independent digital flexion and extension through a myoelectric prosthesis. Straight craziness.

Foot & Ankle

While hand deals with several bony and soft tissue pathologies, foot and ankle surgery is comprised of mostly bony and only some soft tissue work.

Most of foot and ankle surgery is outpatient, but you’ll still be dealing with very serious pathologies, like post-traumatic arthritis and pain, degenerative pathology, cosmetic surgeries, and lots of trauma ranging from ankle fractures to the notorious calcaneus (or heel) fractures that no other orthopaedic surgeons like to treat. Unfortunately, you’ll also be dealing with diabetic foot infections and stinky feet.

You may be wondering how this compares to podiatry. Podiatry generally deals with more nonoperative treatment of calluses, corns, bunions, and the like. Some would argue that orthopaedic surgeons are better equipped for more complex surgeries as they completed a 5-year residency after medical school learning to fix the entire musculoskeletal system with a 1 year fellowship in foot and ankle surgery.

Tumor

Orthopaedic oncology, also known as ortho tumor, is a tiny specialty, with only a couple hundred trained across the country.

Cardiothoracic surgeons deal with intr-thoracic tumors. General surgeons specializing in oncology deal with primarily intra-abdominal tumors. As an orthopaedic surgeon specializing in tumors, you’ll be dealing with both soft tissue and bony tumors in the extremities, spine, and pelvis. If you are an orthopaedic tumor surgeon you’ll likely work in a major city at a major hospital in coordination with many other cancer doctors, such as medical oncologists, radiology oncologists, surgical oncologists, pathologists, and more.

Sports

Sports is by far the most common fellowship for orthopaedic surgeons, but they treat far more than athletes. While they treat sports-related injuries like tendon and ligament tears, they are also generalists. They deal with ligamentous injuries, tendinous injuries, shoulder and elbow disease, and foot and ankle overuse. Often times their focus is on the knee and shoulder joints, whether it is replacing these joints, called arthroplasty, or treating pathology surgically with the use of a small camera, called arthroscopy. The more serious trauma is reserved for trauma orthopods, but sports orthopods also handle a fair amount of orthopaedic trauma work.

When your favorite athlete tears their meniscus, ACL, or rotator cuff, these are the surgeons to find. These procedures all pay well, but you won’t be as highly compensated as a spine surgeon. And as a sports orthopaedic surgeon, you can work anywhere from the smallest town to the largest city.

Joints (Arthroplasty)

Joints primarily comes down to hip and knee replacements, also known as arthroplasty. Joints surgeons also perform some procedures to help delay hip or knee replacements in younger patients, but the majority of their practice is becoming the best at hip and knee replacements. As a joints surgeon, you’ll also do revision surgeries meaning when something goes wrong with a hip or knee replacement (infection, fracture, loosening), you’ll be the person to go in and remove any implants that need to come out.

This is one of the most competitive fellowships, as the field is highly desirable due to arthroplasty being a predictable lifestyle and hip replacements being one of the most successful surgeries that exist. Patients come in having pain with every step and walk out of the hospital the next day. It is an extremely rewarding field. If you like repetition and becoming really good at a few different procedures, this is the subspecialty for you.

 

What You’ll Love About Orthopaedic Surgery

There’s a lot to love about ortho.

First, you’ll actually be fixing pathologies, rather than just managing them as you do in many other medical specialties. Patients come in with a distinct problem and you have a way of fixing it. Also, orthopaedics usually have good outcomes, with most patients having substantial improvement in their condition after surgery.

Second, the surgeries are fun! Scopes and minimally invasive surgeries are becoming more widespread in all surgical specialties, and while they are great for patients, they aren’t as fun to perform. Orthopaedic surgery still has plenty of open cases with amazing exposure and anatomy to appreciate.

Third, it’s a team sport. The personalities within orthopaedics vary widely from the days of everyone being massive bros. However, the common theme remains that most orthopaedic surgeons are team-players. There is a sense of camaraderie amongst arthropods, and they generally will work hard for each other. At the end of the day, orthopods know how to work hard but also have a good time.

Fourth, you’ll be well compensated. Orthopaedic surgeons are consistently the number 1 or number 2 highest compensated physicians, duking it out with neurosurgeons.

Lastly, you get to focus on a particular system. You won’t have to do much medical management, which is what you spent so much time and effort learning in medical school. Some medical students are disappointed by this, and others consider this a unique benefit. Whether it’s a feature or a bug is for you to decide.

 

What You Won’t Love About Orthopaedic Surgery

As with many surgical specialties, orthopaedic surgery can have challenging hours. That being said, be thankful those long hours are in the emergency department and operating room doing procedures, and not so much in the clinic.

Diversity in the field has historically been lacking, both in gender and background. The field is 95% dominated by men, one of the most skewed of any surgical specialty. The good news is that it’s slowly changing for the better with women making up at least 14% of residents in 2016-17, and that number is growing every year.

For better or worse, it will be difficult to escape the bro stereotype. All personalities are welcome and present, but some dominate.

And lastly, oftentimes it’s not very precise or meticulous. When I was weighing neurosurgery versus orthopaedic surgery versus plastic surgery, it was readily apparent that most of orthopaedic surgery is not as concerned with finesse, precision, and nuance. However, hand and tumor subspecialties within ortho are the big exceptions. Depending on your personality, this can be a good or bad thing.

 

Should You Become an Orthopaedic Surgeon?

How can you decide if orthopaedic surgery is the right field for you?

The stereotype is if you say “dude” frequently, can bench at least 2 plates, and are prone to fist-bumping over handshakes, you may be an orthopaedic surgeon at heart. With that said, anybody can be an orthopaedic surgeon.

If you love musculoskeletal anatomy — meaning bones, nerves, and muscles – then it may be for you. If lots of effort, hammers, drills, scopes, and big incisions aren’t enticing for you, then consider looking elsewhere.

Finally, orthopaedic surgery is a highly competitive specialty, so you’ll need to be willing to work your tail off in medical school. That translates to more than just high board scores, but also playing the research game, being a leader, and crushing your clinical rotations beyond just surgery.

 

Let me know what specialty you’d like me to cover next with a comment!

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