Evolution of Indian orthopedics and the legacy of its pioneers

Ancient foundations: Indus Valley civilization and Ayurveda

The origins of orthopedic practices in India can be traced back to the ancient Indus Valley Civilization, which existed around 3300 BC. Within this historical context, the discovery of terracotta figurines bearing signs of healed fractures offers valuable insights into the early methods employed for bone setting and splinting. These archaeological findings shed light on the rudimentary yet noteworthy comprehension of musculoskeletal care prevalent during that particular period.¹ India has a rich history in the field of medicine, with orthopedics being a prominent part of this heritage. The legacy of Indian orthopedics is deeply rooted in ancient wisdom and modern advancements, spanning thousands of years. Dating back to the Harappan civilization, orthopedic surgeons in India have been practising techniques such as reducing fractures and performing therapeutic trepanations for more than 4000 years. Many of the orthopaedic methods used today, such as prosthetics, fracture tables, and rehabilitative physical therapy, were pioneered by Indian physicians.⁷ Despite the presence of modern orthopaedic surgeons, traditional Indian bonesetters continue to play a significant role in treating fractures. While bonesetting practices may have high complication rates, they remain a popular choice among the Indian population due to cultural preferences. In many cases, bonesetters are the primary option for fracture treatment, especially in rural and urban areas where access to modern medical facilities may be limited.⁷

India boasts one of the world’s oldest medical systems, known as ‘Ayurveda.’ This ancient medical system has evolved over thousands of years in India. The term ‘Ayurveda’ derives from the Sanskrit words ‘ayur,’ meaning life, and ‘Veda,’ meaning science or knowledge. Thus, ‘Ayurveda’ refers to the science of life. The Susruta Samhita, a fundamental text believed to have originated around the 6^th century BC, serves as a pivotal source of surgical wisdom. Composed by Susruta, who is highly regarded as the “Father of Indian Surgery,” the Susruta Samhita provides comprehensive insights into diverse surgical techniques, encompassing bone setting, amputations, and even the utilization of rudimentary prosthetics. The exact timeline of Susruta’s existence remains uncertain, with various scholars dating him to around 400 BC. Susruta’s renown stems from his notable compilation known as the Susruta-Samhita, which encompasses a wide range of subjects including surgery, medicine, pathology, anatomy, midwifery, biology, ophthalmology, hygiene, and psychology. He aimed to systematically organize the knowledge and experiences of earlier surgeons, consolidating scattered medical facts into a comprehensive body of lectures and manuscripts.²

Similar to Babylonian, Egyptian, Greek, Arabic, and Western medicine, the origins of Hindu medicine can be traced back to magical and superstitious beliefs, gradually evolving over the centuries. Like in other early societies, ancient Indian civilization imposed physical mutilation as a form of punishment for wrongdoing. Adultery, for instance, was often penalized by the severing of the nose. Susruta is credited with developing techniques for nose reconstruction, and Indian physicians became highly proficient in the art of rhinoplasty. This technique, commonly referred to as a “nose job,” is widely practiced by plastic surgeons today, as many individuals seek to conform to contemporary beauty standards. Jean Filliozat (1906-1982), a French physician with expertise in Sanskrit, Tibetan, and Tamil languages, and known for his significant contributions to the field of Indian medicine, stated that Indian Medicine has had a comparable impact in Asia to that of Greek Medicine in the Western world. He highlighted that Indian Medicine has spread to regions such as Indo-China, Indonesia, Tibet, Central Asia, and even Japan, mirroring the dissemination of Greek Medicine in Europe and the Arab countries. Filliozat also pointed out the close connection between Hindu medicine and religion, which led to its relatively static nature in contrast to the secular approach and global influence of Greek medicine.^8,9

Medieval advancements and colonial influence

During the medieval era, there were notable progressions in the field of medicine. Medical professionals utilized herbal remedies to alleviate pain, devised innovative methods for treating fractures through traction techniques, and created customized splints to enhance the healing process. The arrival of European colonizers in the 18^th and 19^th centuries brought about the introduction of Western medical practices. This era witnessed a gradual transition towards a more scientific approach to orthopedics, placing significant emphasis on the study of anatomy and physiology. Nevertheless, it is imperative to recognize that these Western influences intertwined with pre-existing Indian medical knowledge, resulting in a distinctive amalgamation of medical practices.¹⁰

Orthopedic surgery boasts a lengthy and intricate past. Although the term orthopedics was first coined in the 1700s, the principles of orthopedics were already being developed and utilized during ancient times. The Egyptians continued these practices, detailing methods to identify and treat common orthopedic conditions. Subsequently, the Greeks and Romans delved into the study of medicine in a structured manner, significantly enhancing our knowledge of orthopedic anatomy and surgical procedures. Following a period of stagnation in progress during the Middle Ages, rapid advancements were observed during the Renaissance, which included the documentation of various injuries, enhancements in surgical techniques, and the establishment of orthopedic hospitals. Together, these advancements laid the groundwork for modern orthopedics.¹¹

The 20^th century: The rise of modern orthopedics

The 20^th century marked a paradigm shift for Indian orthopedics. Pioneering surgeons emerged, dedicating their careers to this evolving field. Orthopedics, in particular, witnessed significant progress with the contributions of renowned individuals such as Dr. R.J. Katrak, Dr. B.N. Sinha, Dr. K.S. Grewal, Dr. B. Mukhopadhya, and Dr. A.K. Gupta.¹²

Evolution and journey of the Indian Orthopedic Association (IOA)

The Indian Orthopedic Association (IOA) is the most prominent national organization for orthopedic surgeons globally, representing Indian orthopedic surgeons with a membership of over 15,000 active life members. Established in 1955, the IOA has grown into a dynamic organization encompassing academics, research, and social networking. Over the past seven decades, it has evolved into a robust professional body with 22 State chapters. The IOA continues to expand its membership and other aspects, such as fellowships, Continuing Medical Education (CME) programs, orations, and sub-specialty meetings. Among its notable events is the annual IOACON (IOA Conference), which is highly organized and eagerly awaited in India.⁴

The history and development of the IOA closely resemble that of the British Orthopedic Association (BOA), possibly due to the historical association between India and the United Kingdom (UK). Just as Hugh Owen Thomas, a general surgeon, made significant contributions to orthopedics, the late Dr. M G Kini can be considered a pioneer of Orthopedic surgery in India. Dr. R. J. Katrak (Bombay) was the first surgeon to exclusively focus on orthopedic practice, followed by Dr. N S Narasimha Aiyar (Madras) and Dr. S. R. Chandra (Calcutta). These dedicated individuals worked tirelessly when orthopedic surgery was neither popular nor recognized as a distinct field.⁴

The association owes its establishment to the subsequent generation of young surgeons who received training abroad during or after the Second World War. The idea of forming an association was initially proposed by Dr. B. Mukhopadhaya during the annual conference of the Association of Surgeons of India (ASI) in Vellore in 1952, in a small group meeting with some of the prominent legends like Dr. R. J. Katrak, Dr. B. N. Sinha, Dr. K. S. Grewal, Dr. Mukhopadhaya, and Dr. A. K. Gupta. Many of these stalwarts and legends honoured the IOA through their administrative capabilities by acting as the President [Table 1] and Secretary.¹³

The Amritsar meeting of the ASI in December 1955 marked a significant milestone for Orthopedic surgeons, as their long-awaited dream became a reality. During this meeting, a formal Orthopedic Section was established, complete with elected office bearers. Dr. B. N. Sinha and Dr. Mukhopadhaya were unanimously chosen as the president and secretary of the section, respectively. Over the following years, the activities of the Association gained momentum. Dr. A. K. Talwalkar played a pivotal role in initiating the Johnson & Johnson and the Smith & Nephew traveling fellowships, which provided valuable opportunities for orthopedic surgeons and exposed them to the centres of excellence in India.

Additionally, the Kini Memorial Oration, which commenced in 1958, has been consistently delivered ever since. The Association was privileged to have the esteemed Sir Harry Platt as the inaugural Orator in 1958. The IOA instituted the Silver Jubilee Oration in 1980 and the Golden Jubilee Oration in 2005.⁴

Recognizing the need for a dedicated journal, the members of the Association persevered against significant challenges. In 1967, the first issue of the Indian J. Orthop. was published, with Prof. Prakash Chandra serving as the Editor. This achievement was a testament to the determination and commitment of the Association to advance the field of orthopedics. The desire for independence among IOA members culminated in a resolution passed at the Cuttack Conference of IOA (1986), advocating for a complete separation. This decision was officially endorsed at the Agra conference of the ASI in December 1986, marking the IOA’s newfound independence. Since then, this Association has experienced remarkable growth.⁴

Over the years, the IOA has played a crucial role in establishing Orthopaedic departments and postgraduate education centres across the country. The conferences organized by the Association have significantly contributed to the advancement of scientific methodology and the enhancement of surgical practices. Furthermore, the IOA has actively supported the creation of local Orthopaedic branches in different regions of India. Twenty two regional/state chapters established in different parts of India are making valuable contributions to the overall growth and development of the parent association.

Contribution of some distinguished pioneers and legends of Indian orthopedics

Dr. Puliyur Krishnaswamy (PK) Duraiswami (New Delhi) was a pioneer in the implementation of mobile medical units for underserved rural areas and was a founding member of the esteemed National Academy of Medical Sciences. Dr. Duraiswami gained international recognition for his groundbreaking research on congenital anomalies.¹⁴ His scholarly contributions extended to the publication of numerous academic articles in the field of orthopedics, as well as a comprehensive historical account titled “5000 Years of Orthopaedics in India,” which was featured in a prominent clinical orthopedics research journal. In recognition of his outstanding achievements, the Government of India honoured him with the prestigious Padma Bhushan Award in 1966.¹⁵

Professor B. N. Sinha (Lucknow) advocated for the autonomy of orthopedic units from general surgery and proposed this idea to the ASI. Despite facing strong opposition from fellow members of the Association, he remained determined and ultimately achieved his goal of establishing the first independent orthopedic Surgery Department in India at King George’s Medical College, Lucknow, in 1951. Due to his significant contributions to the field, he is affectionately referred to as the “Father of Indian Orthopaedics.¹⁶

Dr. Karam Singh Grewal (Punjab) made significant contributions to the field of Indian orthopedics, especially the research, which was presented in numerous international and national conferences, and published in national and international journals. He also played a pivotal role in the establishment of the IOA and served as its president from 1959 to 1960.¹⁷

Prof. A. K. Gupta (Kanpur) dedicated his entire life to the well-being of his patients and the advancement of medical education. He was not only a devoted teacher but also a meticulous surgeon and a respected leader in his field. Prof. Gupta possessed an insatiable thirst for knowledge and had an extensive understanding of orthopaedic literature. Prof. Gupta actively contributed to the IOA and held various significant positions within the organization: Secretary (1963-1966), Vice President (1967), and President (1975-76).¹⁸

Professor B. Mukhopadhaya (Patna) was the leading force in proposing and realizing the dream of IOA. He possessed a vast knowledge of orthopedics, excelled in planning and organizing, demonstrated expertise in academia and clinical practice, engaged in meaningful conversations, and had a keen eye for identifying talent.¹⁹

Dr. Pramod Kumar (PK) Sethi (Jaipur) is renowned both domestically and globally for his creation of the “Jaipur Foot,” a cost-effective, long-lasting, adaptable, and waterproof prosthetic foot crafted from easily accessible materials. This innovation has significantly improved the mobility of amputees on rough terrains, enabling them to squat and sit cross-legged with ease. The International Red Cross Committee has widely implemented the Jaipur Foot in Afghanistan and other regions to assist individuals who have undergone amputations.²⁰

Prof. MV Natrajan (Chennai) played a pivotal role in the comprehensive advancement of the field by initiating diploma and master’s degree programs in orthopedics, establishing a school of physiotherapy, and a school of prosthesis and orthotics. Additionally, he formulated the blueprint for the Government Institute of Rehabilitation and Artificial Limb Centre in Madras, as well as the plan for accident services in Tamil Nadu. His textbook, highly regarded among undergraduate students, has undergone seven editions since 1982.

Furthermore, his collaboration with the Medical Research Council of Great Britain, the Tuberculosis Research Centre of the Indian Council of Medical Research, the US Agency for Rehabilitation, and the World Health Organization (WHO) has significantly contributed to the enhanced management of prevalent orthopaedic issues in developing nations.²¹

Prof. Amulya Kumar (AK) Saha (Calcutta) made significant contributions to his original research on the shoulder. He delved into the functional anatomy, anthropology, morphology, and radiology of the shoulder, in addition to conducting electrophysiological studies. Prof. Saha authored monographs on the shoulder, including one that served as a supplement to Acta Orthopaedica Scandinavica and another that was translated into German. His paper on the “Zero position of the shoulder” was recognized as a “classic” in Clinical Orthopaedics and Related Research (CORR) in 1983. Furthermore, he dedicated his efforts to studying recurrent dislocation of the shoulder joint and developing rehabilitation techniques for patients with shoulder paralysis resulting from poliomyelitis. Prof. Saha also introduced his methods for addressing recurrent shoulder dislocations.²²

Dr. Brij Bhushan (BB) Joshi (Mumbai), a distinguished hand surgeon, had a remarkable capacity for innovation and implementation of novel ideas like Joshi’s External Stabilization System (JESS) Fixators. Dr. Joshi’s exceptional dedication, persistence, and resilience solidified his status as a trailblazer in the field of Hand Surgery in India.^23,24

Prof. Varghese Chacko’s (Manipal) enduring contribution lies in the establishment of the inaugural subspecialty-based Orthopedic Department in the nation. Upon his retirement, the Orthopaedic Department at KMC, Manipal, operated as four highly esteemed subspecialty units (Hand Surgery, Pediatric orthopedics, Spine Surgery, and Arthroscopy/Arthroplasty), each led by one of his protégés. Furthermore, Prof. Chacko spearheaded early research on Perthes disease, a prevalent condition along the southwest coast of India, and authored numerous scholarly articles on the topic. Additionally, he successfully founded the first Orthotic and Prosthetic Department, known as the Artificial Limb Centre, in the region.²⁵

Another prominent figure is Dr. K.T. Dholakia (Mumbai), who was a leading force in joint replacement surgery.²⁶ Dr. Surinder Mohan (SM) Tuli’s (Varanasi, and spine New Delhi) pioneering work in the spine and management of tuberculosis, particularly spinal tuberculosis, has had a profound impact on the field. His innovative middle-path regimen has yielded remarkable outcomes, significantly improving the treatment of this devastating disease.^14,17 Professor T.K. Shanmugasundaram (Madras) was a key figure in significant medical research. He served as Principal Investigator and Project Director for two major initiatives: the internationally recognized Madras study of tuberculosis of the spine (a collaboration between India’s ICMR and Great Britain’s MRC, 1976–1987), and both the PL.480 Paraplegia Project and the ICMR Paraplegia Project (1979–1987).²⁷

These legends and pioneers, along with countless others, championed the cause of orthopedics in India. They may also be described as “guru”, as they possessed unique blend of qualities and they aim to empower their students to think critically, develop their insights and ultimately become their spiritual guides [Figure 2].²⁸

Close

Figure 2:

Unique characteristics of Indian orthopedic pioneers.

Export to PPT

The 21st century: A thriving field with a unique landscape

Today, Indian orthopedics is a thriving field with highly skilled professionals and world-class medical facilities. Indian orthopaedic surgeons are at the forefront of technological advancements, embracing minimally invasive surgery, robotic surgery, and computer-aided joint replacement.

Development of subspecialties of orthopedics

More than a dozen National associations of various subspecialties related to orthopaedics are now well-established in India, catering for the interest and development of subspecialties like arthroplasty, arthroscopic surgery and sports medicine, trauma, pediatric orthopaedics, spine surgery, foot and ankle Surgery, hand and microsurgery, shoulder and elbow surgery, musculoskeletal oncology, and rheumatology [Supplementary Material-Annexure 1].

Orthopedic education and training in India

As of now, the data of the National Medical Commission (NMC), India, shows that there are 780 medical colleges in India (https://www.nmc.org) in various states/Union Territories of India, with around 3000 postgraduate (PG) seats every year, and this is likely to go up further in the future.

In India, orthopaedic surgeons encounter a significant disease burden consisting of injury, infective, neoplastic, degenerative, and metabolic conditions at different stages of their natural progression. This burden is further compounded by a unique stage of disease that is unfamiliar in Western countries, where patients often present late with untreated or poorly treated cases, sometimes due to missed diagnoses. In countries with limited healthcare resources, it is imperative to adopt a holistic approach not only in treating these cases but also in seeking evidence-based solutions for the various stages of disease progression. The training of orthopaedic professionals and the provision of orthopaedic services must work in tandem to enhance the overall bone health of the nation. Each country must customize its medical education to address the specific healthcare needs of its population.²⁹

Indian orthopaedic research

Despite having a big pool of qualified Orthopaedic Surgeons in India, the research output is lagging compared to some of the other countries. However, Indian orthopedics has witnessed significant growth in research and publications over the last three decades, from 22 publications in 1996 to 1167 in 2024, with a 53.04 times increase [Figure 3]. There has been an upsurge in Indian publications in various International and National journals.^30-32

Close

Figure 3:

Growth of Indian Publications in orthopedics from 1996 to 2024 (Source: https://www.scimagojr.com/).

Export to PPT

The global ranking of India in publications related to orthopedics and sports medicine is showing a positive trend³³ and has improved from 31 in 1996 to 14 in 2024 [Figure 4]. Among the Asian countries, India ranks 4^th, following China, Japan, and South Korea, during the cumulative period of the last three decades [Supplementary Material-Annexure 2]. Among the eight Southeast Asian countries, India leads the tally of publications in orthopedics.³⁴ The quality of publications of Indian publications has also been evaluated in several bibliometrics studies related to orthopedics as a whole,³⁵ Arthroscopy,³⁶ Arthroplasty,³⁷ Spine,³⁸ and Fractures.³⁹

Close

Figure 4:

Trends of India’s global ranking in orthopedics and sports medicine from 1996 to 2024 (Source: https://www.scimagojr.com/ ).

Export to PPT

Indian Journal of Orthopaedics

The Indian J. Orthop. serves as the official publication of the IOA, with a primary focus on clinical orthopedics and fundamental research. It has gained significant recognition as a highly regarded surgical sub-speciality journal in Southeast Asia, attracting a wide readership. The journal is dedicated to advancing the United Nations’ Sustainable Development Goals, contributing to the overall progress of the field. Since its inception on June 1, 1967, it has been consistently published monthly, providing valuable insights and knowledge to its extensive readership of over 15,000 members of the IOA. The journal’s impact factor for the year 2024 stands at 1.1, and the cite score at 2.0.⁴⁰ The Indian J. Orthop. has undergone a remarkable transformation, evolving from a humble publication to a globally respected platform. Now indexed in major databases like PubMed, Scopus, Embase, and DOAJ, the Indian J. Orthop. has become a cornerstone in advancing orthopedic surgery worldwide.⁴⁰ It serves as a vital forum for orthopedic surgeons and researchers to exchange knowledge, discuss innovative techniques, and stay abreast of the latest developments in the field. The most remarkable tenure of Indian J. Orthop. has been that of Professor Anil Kumar Jain, as due to intense efforts and dedication during this Editorship, it was included in Science Citation Index Expanded (SCIe), Pubmed Central and became an impact factor journal.

In addition to the Indian J. Orthop., now there are around a dozen other Orthopaedic-related journals arising from India, and the majority of them are being published by International publishers and are indexed with major indexing bodies like Directory of Open Access Journals (DOAJ), PubMed, and Scopus [Supplementary Material-Annexure 3]. A bibliometric study has also evaluated the trends of publications in Orthopaedic journals arising from India. Three Indian Orthopaedic Journals, i.e., Indian J. Orthop., Journal of Clinical Orthopaedics and Trauma (JCOT), and Journal of Orthopaedics (JOO), are listed both in the PubMed and Scopus, and JOO has shown growth over the years and has created a niche for themselves in the international medical literature.⁴¹ Furthermore, there are more than a dozen Orthopaedic journals of various State Chapters of the IOA, which are likely to get indexing with the major indexing bodies in the future, thus providing a vast platform for Indian researchers to publish their research.

International affiliations

The IOA is affiliated with several International Orthopaedic Associations like Société Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT), American Academy of Orthopaedic Surgeons (AAOS), British Orthopaedic Association (BOA), British Indian Orthopaedic Society (BIOS), International Society of Arthroscopy, Knee Surgery and Orthopaedics Sports Medicine (ISAKOS), and Asia Pacific Arthroplasty Society (APAS) etc.⁴ In addition, several Orthopaedic surgeons of Indian origin are serving in various parts of the world and are associated with their respective associations and journals. Furthermore, some of them have excelled and outperformed to lead the reputed journals like the Journal of Bone and Joint Surgery-American: Dr Mohit Bhandari ( https://www.jbjs.org/ ), and prestigious International organizations like Société Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT): Dr S Rajasekaran, Dr Ashok Johari, and Mr Vikas Khanduja ( https://www.sicot.org/).

Indian orthopaedic industry

Indian industry has evolved significantly in the last 3-4 decades in most orthopaedic instruments and implant manufacturing. It is now one of the major suppliers of these types of equipment to many parts of the world, especially the developing world, due to its cost-effectiveness and affordability. Significant growth is expected to continue and this sector. It is estimated that the current size of the Indian orthopaedic devices market is around USD 375 million, and it will grow at around 20% every year for the next decade to reach USD 2.5 billion by 2030.⁴² Currently, multinational companies (MNCs) dominate this market with up to 70% market share. The market is split evenly between the joint segment (knee and hip) and the trauma-spine segments, with a higher representation of MNCs in the joint segment, at around 80%. Comparatively, the low-value trauma segment has minimal participation of MNCs, with Indian companies occupying up to 90% of the market share. Several Indian companies are now seeking technology collaborations and are obtaining global approvals, such as the CE marking and USFDA approvals, to signify product and technology sophistication.⁴²