December 1999 Bulletin

20th century orthopaedics

The 20th century. It's a remarkable period in the history of orthopaedics. It brought improved patient care and quality of life for millions of people afflicted with musculoskeletal disorders.

Editor's note

This special report is a brief overview of orthopaedics in the 20th century. Space limitations preclude reviewing all the medical advances in orthopaedics or recognizing the valuable contributions by the many orthopaedic surgeons who played a role in improving musculoskeletal care in the last 100 years. The report does not include the socioeconomic forces that have shaped the practice of orthopaedics. It is a glimpse at the profession that improved the lives of millions of people.

Joint replacement, internal fracture fixation, spinal instrumentation, arthroscopy, limb lengthening, orthopaedic oncology are among the many benefits to mankind.

In peacetime and during wars, in shifting economic and political environments, orthopaedic surgeons have persevered to find improved treatments for young and old, for genetic disorders and traumatic injuries, for strains and sprains and malignant bone tumors.

It has been a century of marked contrasts in the development of the profession, says Leonard F. Peltier, MD, an orthopaedic surgeon who has written extensively about the history of the specialty.

In 1741, Nicolas Andry, professor of medicine at the University of Paris, published the first edition of Orthpaedia which presented the art and science of correcting and preventing deformities in children. The bood defined for the first time what has become orthopaedic surgery. He illustrated the volume wiht numerus drawings, including the splinted tree. The concept for the tree comes from the Greek meaning of the word orthopaedic-ortho (straight) and pais (child). Early orthopaedists often used braces and other forms of treatment to make the child "straight".

"In the first half of the century, orthopaedics was a specialty whose primary focus was on children with only a limited role in the treatment of trauma," says Dr. Peltier. "The hospitals for crippled children dealt with poliomyelitis, tuberculosis of bones and joints, hematogenous osteomyelitis and congenital deformities usually see in children over one year old.

"Poliomyelitis has been eliminated by routine prophylaxis. Tuberculosis has been controlled by antibiotics, although tuberculosis may be returning as a problem because of resistant strains and poor public health control. Acute and chronic osteomyelitis has been controlled by the use of antibiotics. Early diagnosis and treatment has greatly improved the care of children with congenital deformities."

In the second half, following World War II, Dr. Peltier observes that "orthopaedic surgeons expanded the treatment of fractures and hand surgery. Reconstructive surgery grew enormously with the development of total joint replacement. The study of biomechanics has been an important development; so has the introduction of nonferrous metals and alloys, plastics and ceramics. The development of orthopaedic oncology and the use of limb sparing procedures and adjuvant therapy has opened a whole new prospect for tumor patients."

As the century comes to a close, a cross section of orthopaedic surgeons also looked back at the progress of the specialty and named the most important advances in orthopaedics in the last 100 years.

Joseph A. Buckwalter, MD, chairman of the Council on Research and Scientific Affairs, puts joint replacement at the top of his list of the most significant advances in the century because of the improved mobility and decreased pain in patients. That's followed by advances in internal and external fixation. He adds the development of polio vaccine; antibiotic treatment of bone and joint infections, including tuberculosis; MRI, imaging of musculoskeletal tissues and structures; and arthroscopy.

In addition to total joint replacement and trauma management, Robert D. D'Ambrosia, MD, 1999 Academy president, casts his vote for arthroscopy and spinal instrumentation. In the area of research, he says the most outstanding advances were bone morphogenetic protein and biomechanics.

Total hip arthroplasty also gets the top spot on the list of Marc F. Swiontkowski, MD, followed by internal fixation of fractures because, he explains, both had a dramatic impact on patient function.

Next, he lists outcomes research as "ordered" by John J. Gartland, MD, 1979 AAOS president, and demonstrated by John E. Wennberg, MD; James N. Weinstein, DO; and others. His list continues with the fracture bracing movement lead by Augusto Sarmiento, MD; total knee arthroplasty; and arthroscopy.

Total hip replacement; internal fixation, the AO method; arthroscopy; and the Ilizarov technique for limb lengthening are nominated by Thomas A. Einhorn, MD.

James D. Heckman, MD, 1998 AAOS president, acknowledges that total joint arthroplasty, fracture fixation and arthroscopy are major steps forward in the 20th century. But, he says, "perhaps the most significant advance that has allowed us to do all these wonderful procedures has been the development of sterile techniques such as laminar flow and others and the use of prophylactic antibiotics. The advent of these techniques opened the door to extensive surgery with large implants with but a trivial risk of infection-the dreaded and still insoluble complication."

Antibiotics heads the list of Dr. Sarmiento, 1991 AAOS president, saying, they "eliminated and/or reduced significantly infections which in the past had been the main killer of people throughout the world. It includes tuberculosis which, at least in our country, has been virtually eliminated."

Next, he lists chemotherapy in the treatment of tumors, followed by advances are imaging technology such as MRI, CT scan and some X-ray modalities; total joint replacement; arthroscopy; spinal instrumentation for scoliosis and other conditions; and closed intramedullary nailing of long bone fractures.

Dr. Gartland and Richard A. Brand, MD, 1997 president of the Orthopaedic Research Society, start their lists of significant advances with total joint arthroplasty because it has allowed dramatic relief and improvement of musculoskeletal function lasting up to several decades. "Among all surgical procedures, it is one of the most successful, by any measure of outcome, and one of the most cost-effective," says Dr. Brand.

Internal fixation has allowed shorter hospitalizations, early return to function and likely reduced the incidence of nonunion in most cases, says Dr. Brand.

Next, he lists limb lengthening and the related osteogenesis which "has provided the opportunity to correct substantial limb length inequalities and minimize the long-term complications, e.g., knee and lumbar spine arthrosis, or nuisance (large shoe lifts). Minimally invasive surgery including arthroscopy also are cited.

"Pharmacological treatment of various sorts of inflammatory arthritis is vastly improved in the past 30 years," Dr. Brand says, and "antibiotics have affected orthopaedics as much as any specialty." However, he warns, "antibiotics are likely overused on a prophylactic as well as therapeutic basis, giving rise to resistant strains of bacteria."

Evidence-based medicine is on his list as a "great advance" as well as patient-based outcomes.

Vernon T. Tolo, MD, points to significant 20th century advances in spinal instrumentation, including the Harrington instrumentation, followed by segmental fixation and rod contouring, segmental fixation using multiple hooks and more recently the use of screws.

Rocco A. Calandruccio, MD, 1977 AAOS president, lists many of the same procedures and treatments named by others, as well as the introduction of new metals like stainless steel, cobalt, titanium; plastics; and new bioabsorable materials. He also lists bone grafts, microvascular hand surgery and improved treatment of traumatized patients.

A major advancement for orthopaedics, says Dr. Calandruccio, was the organization of the American Academy of Orthopaedic Surgeons because of its profound impact on the continuing medical education of orthopaedic surgeons.

Organized in 1933, the Academy provides a vast selection of educational venues-courses, books, monographs, videos, CD-ROMs and an Annual Meeting that is world's largest educational event for orthopaedic surgeons. In 1997, the American Association of Orthopaedic Surgeons was formed to engage in advocacy activities, while the American Academy of Orthopaedic Surgeons continues to provide educational services for the profession.

The Academy has grown from 471 members in 1934 to 23,800 throughout the world; its international educational programs are expanding. More than 1,600 volunteers and 210 full-time staff are actively engaged in the activities of both organizations.

The Future

What's ahead in the coming decades? The orthopaedists are unanimous that the future of orthopaedics will be based in biology.

"This new century should see a slow but incremental application of new treatments, based on the unlocking of our genetic blueprints," says Douglas W. Jackson, MD, 1997 Academy president. "Tissue engineering should enable more 'regenerative-type' biologic repair of musculoskeletal tissues.

"While trauma care and joint replacement will remain a reason for current methodologies of surgical intervention, orthopaedic surgeons of the next century will have more medical treatments and minimally invasive procedures."

Dr. Einhorn calls the coming decades "the age of molecular medicine, a period of more biologic interventions through enhanced treatment of bone and cartilage, using growth factors and gene therapy.

"The focus of the profession will shift from the development of mechanical implants to the restoration of the musculoskeletal system by regeneration. There's nothing wrong with implants, but no matter how well made they are, they are only artificial and they always will be less than ideal."

Dr. Heckman puts it this way: "The movement away from mechanical treatments toward biological treatments as pioneered by Bassett and Brighton and others in the 1960s and more recently by Marshall Urist, MD, will probably have a greater impact on our discipline in the future than even total joint arthroplasty."

Orthopaedic surgery will have some of the earliest clinical successes with gene therapy, predicts Scott D. Boden, MD. He says, "There are several approaches, including our program with the novel LMP-1 gene delivered locally, regionally or systemically to treat local (fracture and spine fusion), regional (osteopenic femur or vertebrae) or systemic (osteoporosis) bone formation needs."

Dr. Boden also expects advances in biomaterials, "particularly bioresorbables, in combination with growth factors, will facilitate tissue engineering of bone and cartilage."

In addition to advances in molecular biology and genetic engineering, Dr. D'Ambrosia expects strides in virtual reality education and Internet education. Dr. Sarmiento expects important developments in chemotherapy for malignant tumors and growth factors to expedite fracture, cartilage and fibrous tissue healing; and Dr. Brand sees future advances in nonbiologic tissue substitutes, such as calcium hydroxyapatite, virtual surgery for training and robotic surgery using principles of haptics for long distance minimally invasive surgery.

If that's the future, what's the vision of the future orthopaedic practitioner? "A new breed of doctors will be practicing orthopaedics by 2013," say authors of an article in the November issue of the Orthopaedic Journal of Thomas Jefferson University, Philadelphia. "These orthopaedists will bring a knowledge of molecular and cellular biology to their patient care efforts. They will understand the molecular mechanisms underlying orthopaedic deformities and diseases and will know how to use molec- cular technology as treatment modalities because they will be practicing molecular orthopaedics."

That's the view of Dr. Gartland; Rocky S. Tuan, PhD; and Edward J. Caterson, co-authors of the article, "Orthopaedics in 2013, a Second Look." They recall the prophesies of Henry J. Mankin, MD, in his 1983 American Orthopaedic Association presidential address, "Orthopaedics in 2013: A Prospection."

Dr. Mankin said future advances in orthopaedics will be based in biology, and in the ability of scientists to understand and alter its basic unit, the cell. As he prophesied, discoveries in cell biology, immunology and cytogenetics have had a profound effect in many areas of medicine. However, these discoveries have not had much of an effect on orthopaedics yet, says Dr. Gartland and his co-authors.

The situation is likely to change rapidly when, says Dr. Gartland, "the huge volume of new information about the roles of genes in normal development and in developmental variation, in aging, in repair and in susceptibility to disease, and in the cause and pathogenesis of musculoskeletal diseases begins to be appreciated clinically. With the work already in progress in molecular and genetic research, it should be possible in the near future to describe the complete sequence of genetic events which are involved in the normal development of the skeleton."

Dr. Gartland points out that more than 20 musculoskekeltal-related diseases have been linked to specific genes or chromosomes, including Duchene muscular distrophy, familial osteoarthritis, Gaucher disease, Marfan Syndrome and osteogenesis imperfecta.

Gene therapy also may play a role in delayed or impaired union. "It now is believed possible that subtle genetic differences between individuals may explain why some patients heal better than others, and why some patients are more predisposed to orthopaedic complications," says Dr Gartland.

One example is the use of bone morphogenetic protein to replace bone lost by orthopaedics or by surgical resection, for accelerating fracture repair and for augmenting spine fusions."

Tissue engineering of cartilage and bone "will move from the laboratory into a useful clinical technique to repair and replace damaged or diseased parts of the musculoskeletal system," he says. "Recombinant bioactive molecules are likely to be developed to replace present bone graft materials.

"A long-range goal of tissue engineering remains the in vivo remodeling of human tissue such as cartilage and bone. Treatment of damaged or diseased articular cartilage in the future is likely to involve the implantation of tissues and cells that respond to local stimuli through growth and differentiation into mature chondrocytes capable of producing extracellular matrix that will integrate into the surrounding tissue."

Mesenchymal stem cells "ultimately will prove to be a better bone substitute than either autologous bone grafts or growth factors such as recombinant bone morphogenetic proteins,'' says Dr. Gartland.

"It is not difficult to imagine the possibility that these multipotential cells, combined with genetic and tissue engineering techniques, soon will be able to produce adult human bone and cartilage as whole joint replacement materials."

Dr. Mankn frightened the audience in 1983 when he said it was possible "joints will live, meaning all the total joint orthopaedists will be put out of business," says Dr. Gartland. His article concludes ". . .it now seems appropriate to upgrade Mankin's 1983 prophesy that 'joints will live in 2013' from a possibility to a strong probability."

Hip arthroplasty

He was a perfectionist, an innovator, a methodical investigator.


That's how Herbert D. Huddleston, MD, describes John Charnley, MD, the orthopaedic surgeon who worked his way through seemingly insurmountable problems, sometimes going down blind alleys, until he developed one of the great medical advances of the century-low-friction hip arthroplasty.

Dr. Huddleston was one of hundreds of American orthopaedists who visited Dr. Charnley at Wrightington Hospital, in Lancashire, U.K. to learn about the procedure. Later, Dr. Huddleston became a partner of Charles Bechtol, MD, who with Mark Coventry, MD, and Mark Lazansky, were among the first American surgeons to use Dr. Charnley's total hip procedure in the United States.

Dr. Charnley's development of the low-friction arthroplasty procedure paved the way for orthopaedist surgeons to bring comfort and restore mobility to millions of people with arthritic joints. It vastly expanded the practice of orthopaedics and an industry of device manufacturers

Hip arthroplasty has been recorded as early as the 1890s and total hip replacement in the 1930s, but the procedures were never really successful in providing long-term relief of pain and restoring mobility to the patient.

"The cart has been put before the horse; the artificial joint has been made and used, and now we are trying to find out how and why it fails,"1 (p. 99) Dr. Charnley said in 1956.

He had been working on the problems of total hip arthroplasty through the 1950s, although he seemed pessimistic about the possibility of a successful arthroplasty ever being devised. As late as 1959 he said, "It is important to realise that factors exist which will for ever limit the scope of arthroplasty of the hip, no matter how we may study and improve the biomedical design. . . . If the head of the femur is replaced by a polished sphere of steel or plastic, surely it is a vain hope to expect an elderly patient to balance securely on the summit of this slippery 'universal joint' if strong muscles do not exist to pull the body into balance. It is an axiom in hip joint surgery that mobility and stability are incompatible. . . ." 1 (pp. 110, 111)

But he persevered. Dr. Charnley introduced frictionless total hip arthroplasty in clinical practice in November 1962. He had overcome the problem of loosening of the prosthesis by reducing the diameter of the ball on the femoral prosthesis to 22.25 mm, thereby reducing friction between the metal prosthesis and the socket of the hip replacement. And, he fixed the prosthesis in the femur with a specially designed mixture of the self-curing acrylic cement used by dentists-polymethylmethacrylate cement.

There were setbacks along the way. Dr. Charnley originally seated the head of the femur prosthesis in a "cup" of Teflon, but after 300 operations and three to four years he found Teflon was unsuitable because it was breaking down and causing adverse tissue reactions.

Chance played a role, too. One day, a young man selling gears made of high molecular weight polyethylene stopped at the hospital. The plastic intrigued an engineer who worked with Dr. Charnley, but it was dismissed by the doctor. However, when tests in his biomechanical laboratory showed that the plastic was highly resistant to wear, Dr. Charnley set about working with the manufacturer to make it suitable use in the hip replacement procedure.

Sometimes overshadowed in the story of Dr. Charnley's accomplishments is the fact that to overcome the deep infection around joint replacement, he developed a clean air enclosure which filtered the air coming into the operating room to remove small bacteria-laden particles. To further reduce the risk of contamination, he developed a ventilated hooded full-body gown to wear in the operating room.

"Bechtol was skeptical about the rumors of what Charnley was doing," says Dr. Huddleston. He initially refused to visit Charnley, but did so reluctantly. "He came back and was so excited that he went back in a month later, this time with a camera," Dr. Huddleston recalls.

Later, Dr. Bechtol, and a host of other orthopaedic surgeons, working with device manufacturers, developed their own designs for prostheses. "It was market driven; everyone thought they had an improvement, but the original configuration is better than anything else," says Dr. Huddleston.

A 1998 review of 261 patients who had 320 Charnley low-friction arthroplasties 20 to 30 years ago (mean 22 years) found 93.9 percent considered the operation a success and 82 percent were pain free. Satisfactory function was achieved in 59 percent of patients and 62 percent had an excellent range of motion.

Using engineering, biological science, surgical skills, ingenuity and perseverance, Dr. Charnley advanced hip arthroplasty. His research in mechanical, material and surgical problems also helped advance joint replacement in the knee and elsewhere.

1. Waugh, W: John Charnley, The Man and the Hip, London, Springer-Verlag 1990.

Bone regeneration

It was one of the most intriguing mysteries in medicine. Why does bone regenerate?

The solution was provided by Marshall R. Urist, MD. His breakthrough research on bone formation through autoinduction opened new and expanding horizons in the biological treatment of bone fractures and defects. It stands as one of the most important contributions to the basic science of orthopaedics in the 20th century.

The story of Dr. Urist is that of a dedicated, tenacious investigator in search of the key to bone regeneration. Other physicians and scientists had studied the phenomenon, but it remained a mystery until his discovery in the early 1960s. It took another 20 years until Dr. Urist's discovery was widely accepted by the scientific community.

His search begins early in his career. "My first interest was aroused during medical school and recounted in the term paper for graduate school at the University of Chicago," says Dr. Urist. He also recalls a book by Rene Leriche, a French surgeon, who wrote about surgery in World War I and speculated about the possibility of bone regeneration.

It was his own experiences in World War II that stimulated Dr. Urist to devote a lifetime of research to finding out what was the responsible for the remarkable ability of bone to repair itself. As an orthopaedic surgeon with Gen. George Patton's tank corps in World War II, he treated many shattered bones and other traumatic injuries. "Thousands of soldiers survived battled-incurred wounds and lived to regenerate very large fractures and missing bone substance," Dr. Urist says. "The opportunities for reconstructive surgery and continuous outcome research were unlimited."

After the war, Dr. Urist returned to the University of Chicago as a postdoctoral research fellow in the Department of Physiology Radioisotope Facility and worked on bone transplants with bone-seeking radioisotopes. In addition to his research, Dr. Urist practiced orthopaedic surgery in Veterans Administration hospitals.

His research efforts shifted to the University of California at Los Angeles Medical School. "We started to research the process from the very beginning of bone growth when the first cells are formed in the embryo," he says. While the research was underway, Dr. Urist became aware of a number of advances in molecular biology that provided clues on the process of regeneration in bone.

Working for the Atomic Energy Commission, Dr. Urist investigated the incorporation of radioactive materials into bones of people exposed to atomic-testing fallout. Searching for possible ways to remove the radioactive materials and remineralize the bone matrix with native materials, Dr. Urist implanted mineral-free matrix into soft tissues of mice and other animals. He found the matrix stimulated the growth of bone including marrow.

After further studies, Dr. Urist concluded that bone morphogenetic protein (BMP) was the key to bone growth.

It had been 10 years of research. "The 'eureka' moment occurred when implants of radioisotope-seeking bone matrix did not remineralize; instead induced heterotopic bone formation replaced the old matrix," says Dr. Urist. "Thus, our contract to remove harmful isotopes was not fulfilled, but a byproduct of the matrix proved to be BMP."

The discovery occurred in 1963 in a military-type Quonset hut at UCLA. In 1965, he published a paper that cells in the matrix stimulated cells at the implant site to become bone and in 1968 he presented preliminary clinical trials of osteoinductive preparations of hydrochloric acid-demineralized bone matrix.

But for the next two decades, Dr. Urist had a hard time convincing other researchers. One orthopaedic surgeon describes the situations: "There was Dr. Urist grinding up cow bones or rabbit bones and extracting BMP which could cause cells to form into cartilage and bone. But no one would believe him."

Dr. Urist says the only way to overcome the skepticism was to enable other researchers to reproduce his finding. He gave free samples of freeze-dried BMP, which he concentrated from developing bone, to practicing orthopaedic surgeons, embryologists and molecular biologists.

In the late 1980s, BMPs were cloned and eventually produced in a recombinant mode. By the early 1990s, scientific papers and exhibits on the use of BMPs were presented at Academy Annual Meetings. In 1997, researchers were reporting 10-year follow-up studies of spinal fusions that had been accomplished with BMP.

Today, at age 86, Dr. Urist is still involved in research, which he says "is sharply focused on BMP treatment of patients with nonhealing bone disorders, both local and systemic. There still are a lot of problems associated with malignant bone that are not understood."

Arthroscopy


Robert W. Jackson, MD, looks through arthroscope and operates through a medial portal.Robert W. Jackson, MD, still remembers his first impression of arthroscopy.

It was 1964 and he was at the University of Tokyo on a fellowship, doing work on cell cultures. He heard that Japanese physicians were looking into knee joints, so he investigated.

"Unbelievable," recalls the man who is credited with bringing arthroscopy to North America.

The arthroscopy procedure was being done by Masaki Watanabe, who had developed a number of arthroscopes, and his colleagues, Hiroshi Ikeuchi and Sakae Takeda. So impressed was Dr. Jackson, that he spent as much time as he could with the men. "They would be teaching me how to use the arthroscope and I would be teaching them English," says Dr. Jackson.

The story of the arthroscope doesn't really start there. Physicians had been trying to develop ways to look into body cavities for centuries. In 1918, Professor Takagi used a cystoscope to look inside a knee. He believed that if he could see inside a knee he could treat a tuberculous knee early and prevent stiffness. A stiff knee was a cultural as well as physical disability in Japan, explains Dr. Jackson.

The first arthroscope was made by Takagi in 1931 and by 1938 he had made 12 models-some with lens and some without. Arthroscopy also was being developed in Germany in the 1930s. World War II stopped the scientific development of arthroscopy and in the 1950s, Watanabe continued where Takagi stopped.

When Dr. Jackson returned to the University of Toronto he started doing arthroscopy and teaching others. He did 25 cases in 1965 and 70 cases in 1966.

The word got around and a number of orthopaedic surgeons-John McGinty, MD; Ward Casscells, MD; John Joyce III, MD, among others-visited him in Toronto. They spread the word in the United States and were pioneers in the field.

Twenty-five people were in the audience at his first Academy instructional course on arthroscopy in 1968, says Dr. Jackson. By the early 1970s, the audiences grew to 200 and 300. Arthroscopy was spreading, and orthopaedists like Lanny Johnson, MD, and others were producing innovations in the
instrument.

Eventually, the use of arthroscopy became more widespread in the United States than Canada. More than 700,000 knee and shoulder arthroscopies are performed in ambulatory settings in the United States annually.

"Orthopaedic surgeons were more aggressive here (in the United States) and could get a higher reimbursement than could Canadian orthopaedists who received $185 a case," says Dr. Jackson.

The International Arthroscopy Association was officially established in 1974; the Arthroscopy Association of North America (AANA) incorporated as a separate entity in 1982. In January 1994, AANA and the Academy opened the Orthopaedic Learning Center in Rosemont, Ill., where they are headquartered. It is recognized as the preeminent surgical skills learning center in the United States.

Eight years ago, Dr. Jackson became chief of orthopaedic surgery at Baylor University Medical Center, Dallas and still does arthroscopy on knees. He estimates he's done about 30,000 cases in his career.

Limb lengthening

They called him the magician of Kurgan.

His name was Gavrill A. Ilizarov, MD, an orthopaedic surgeon in the remote village of Kurgan, Siberia, 1,500 miles from Moscow. They didn't call him a magician because of the card and coin tricks that he performed.

His "magic" was in limb lengthening and correcting limb deformities that amazed physicians throughout the world.

"He was a genius, an original thinker," says Victor Frankel, MD, professor emeritus, Hospital for Joint Diseases, orthopaedic Institute and professor orthopaedic surgery, New York University. Dr. Frankel talks admiringly about the how the young Russian surgeon working in primitive conditions-an operating room heated by a wood fire-revolutionized the procedure of limb lengthening.

Dr. Ilizarov went on to be a prominent surgeon, the head of a 600-bed hospital and by the time he died in 1992, at the age of 71, was one of the most highly decorated citizens in Russia.

In the early 1950s, Dr. Ilizarov developed a circular external fixator for the treatment of fractures. The device is connected to the bone by thin wires and has a variety of plates and rods so that it can be assembled in a variety of ways to move limb segments in any direction, including length, rotation, angulation and translation.

The device was important, but orthopaedists agree that even more important was the concept of distraction that Dr. Ilizarov called tension stress. By cutting only into the cortex bone, leaving marrow cavity intact, and slowly distracting the segments, Dr. Ilizarov showed that bone and tissue can be made to grow.

Dr. Ilizarov was little known until 1967 when he successfully treated the famous Russian Olympic high jumper, Valery Brumel, who had been in a motorcycle accident and suffered open fractures to both legs. Doctors in Moscow could not heal the infected wounds, but Dr. Ilizarov was able to not only avoid amputation, but also enable Brumel to return to sports.

He gained wide recognition in the Soviet Union, treating hundreds of people with limb deformities. The procedure was unknown to the outside world until Dr. Ilizarov successfully treated a famous Italian explorer who had injured his leg and, because of infection, faced the possibility of amputation.

By the 1980s, Italian physicians were using the Ilizarov procedure and word reached orthopaedists in the United States. Dr. Frankel first saw the circular fixator at a medical meeting in Barcelona in 1984 and then went to Italy to learn the technique. In 1985, he brought the Ilizarov apparatus back to the Hospital for Joint Diseases and in November 1986 performed the first operation on an adult in the United States. He used the technique many times and recalls one case in which he lengthened an arm by 6 inches.

Dror Paley, MD, also had learned that the process was being used in Italy. He visited Ilizarov three times-a total of three months-and spent six months with the Italian physicians.

Dr. Paley first used the procedure in 1986 while at the Hospital for Sick Children in Toronto. He began using the procedure in the United States in 1987. Today, he is co-director of the Maryland Center for Limb Lengthening and Reconstruction, Baltimore and has lectured, operated and taught the procedure to orthopaedic surgeons in many countries.

"The importance of the procedure is that it lead to saving limbs and allowing people to walk on two legs," says Dr. Paley.

Back when the fee was $3 . . . and sometimes you got a duck

A lot has changed in the last 50 years since William F. Donaldson Jr., MD, started his career in medicine.

In the 1950s, orthopaedists treated a lot of "post-polio" patients, says Dr. Donaldson, 1975 AAOS president. "They quit developing polio once they got the vaccine," the 78-year-old orthopaedist recalls. "But I used to make rounds during polio season and saw 150 acute polio patients, week-in and week-out and made decisions to move them out of the hospital. First we [orthopaedists] were letting them rest. Rest was a big factor because if you tried to actively exercise people with polio, they tended to get worse.

"In a very short period of time, we closed our polio wards. It must've been in the early 1960s. And for the next 10 to 20 years we were doing all the reconstructive surgery for their [polio victims'] residual paralysis."

Dr. Donaldson remembers when tuberculous bone and joints were common. "At first, we had no medicines to use at all and patients would develop these large abscesses-the worst were around the spine because the bone would be eaten away and collapse and people would become paralyzed from it," he says. "The abscess would drain and they'd get secondarily contaminated with other bacteria.

"We used to have a lot of patients with osteomyolytis back then, too. We didn't have antibiotics then and it destroyed so much of the bone."

Along came penicillin. "I gave my first penicillin shot in 1944 as an intern (at St. Francis General Hospital, Pittsburgh) for someone who had pneumonia," recalls Dr. Donaldson. "We used such small doses because it was so scarce. We treated it like it was gold and we had to decide who should really get it. Doses were 1,000-5,000 units at the most-now they give 100,000s of units."

James F. Richards Jr., MD, who began his practice in 1962 in the rural area of Orlando, Fla., also recalls using penicillin and cortisone. "Those were the drugs that really revolutionized some of the medical care," says the 68-year old orthopaedist.

Dr. Donaldson and Dr. Richards remember when reimbursements and patient relations were a lot different than they are today. "My first year in practice I made $7,200," Dr. Donaldson recalls. "There was a snow storm that year and lots of fractures came in. I earned my entire salary in about two weeks."

Patient visits cost $15, with follow-ups at $5. "Unless you had surgery, then we'd charge a surgical fee, in which case follow-up visit was for free," says Dr. Donaldson. "Traditionally, nobody had ever been turned away because they couldn't pay at the hospital and at the clinic."

Gifts were not uncommon, but "they were not a barter type of thing," says Dr. Donaldson. "If a guy knew I liked golf, I'd get golf balls. Or, I'd get vegetables. I even got a painting from one of my muscular dystrophy patients."

Dr. Richards says a standard office visit was $3 in 1962, and about half the patients were treated for free. He made only $10,000 his first year in practice. "People brought me the bass they caught or the duck they shot," Dr. Richards says. "They'd ask me for the keys to my car and put a load of oranges in it. They felt they were giving me something for the services they received."

Extraordinary effort made 'heroes' of orthopaedics

Henry J. Mankin, MD, has some personal heroes who by extraordinary effort have made a major contribution to the field of orthopaedics. He acknowledges that some may disagree about the value of their contributions, but he offers these heroes for consideration.

The first are Jonas Salk, MD, and Albert Sabin, MD, who developed a vaccine against the polio virus. Because of these physician scientists, orthopaedic surgeons may never see a patient with polio, but he says, "let me tell you, it was a terrifying disease. As orthopaedists, we had to perform hundreds of triple arthrodeses, tendon transfers, shoulder fusions, Lohman procedures, Steindler flexor plasties, hamstring transfers . . . sometimes 20 or more procedures in a single child and still not solving the problems of the short extremities."

His next hero is Selwyn Waksman, MD, who in 1943, "as a result of prodigious effort and in collaboration with Rene Dubois and Oswald Avery. . . treated three patients with tuberculosis with a product of Streptomyces griseus-streptomycin-what a major discovery."

Pathologist Henry Jaffe, MD, is Dr. Mankin's third hero. "His gave us an order to our understanding of bone disease," Dr. Mankin says.

In the diagnostic area, the most important of a long succession of heroes, says Dr. Mankin, is Wilhelm Konrad Roentgen, who a little over a 100 years ago produced the first X-ray image.

His next hero is Paul Randall Harrington, MD. "With a remarkably simple operative procedure he changed the lives of probably by now millions of patients with scoliosis who suffered extraordinarily with frames and casts," says Dr. Mankin.

Marius Smith Peterson, MD, is among Dr. Mankin's other surgical heroes. "In 1917, just a few years out of school, he developed an approach to the hip; in 1931, he and Eddy Cave and Van Gorder devised a nail for neck fractures which is the forerunner of all our modern devices. He osteotomized the spine for ankylosis in 1945 and of greatest importance perhaps, he devised the cup arthroplasty." Otto Aufranc, MD, William Harris and other made it better, he says. Austin T. Moore, MD, approached hip prosthetic implants from the femoral site and was the first to use Vitallium. But the hero who "put it all together" was John Charnley, MD.

The father of the surgical plate was Arbuthnot Lane, MD, says Dr. Mankin. "William O'Neill Sherman, MD, made them better, Glen Eggers, MD, made them slide, but there can't be any doubt that [Martin] Allgower, [Maurice] Müller, [Hans] Willineger and the rest of the great Swiss mechanicians made a quantum leap enormously enhancing our ability to fix fracture, hold osteotomies and immobilize alloimplants."

Historical displays

The next time you are in the Academy building, Rosemont, Ill., take a few minutes to view the exhibits of prostheses, internal fixation devices and arthroscopy instruments mounted in display cases in the first floor corridor adjacent to the Orthopaedic Learning Center.

In 1985, the Committee on the History of Orthopaedic Surgery, chaired by Hugh Smith, MD, prepared an exhibit on the evolution of arthroplasty of the hip. In 1989, the committee, revised, updated and expanded the section, adding contributions of John Charnley, MD, and Maurice Müller, MD. The committee included R.A. Calandruccio, MD, chairman; Robert Graham, MD; Leonard F. Peltier, MD; Lee H. Riley Jr. MD; and Marshall R. Urist, MD.

Other displays also present the evolution of knee arthroplasty, and internal fixation devices for fractures of the proximal femur. The Arthroscopy Association of North America has displays on the development of arthroscopy scopes.


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