My
career has spanned not only one half century, but more specifically and
more importantly, the most spectacular half centuryin the history of medicine.
Following World War II, an astonishing confluence of remarkable resources
created a unique environment for progress in medicine that had never occurred
before. These resources included the flowering of scientific capabilities
and personnel in remarkable ways, the influx of massive funding for both
patient care and research and a social environment that placed major emphasis
on medicine in Western Civilization.
The high expectations have not been disappointed. Extraordinary progress has been made in these five decades . more, by far, than during the entire history of medicine prior to that era. And more importantly, the platform or base from which medicine will progress from here will dwarf the successes of the past five decades.
So, too, has the nature of practice of orthopaedics changed drastically. Consider, for a moment, that early in my career, I did the orthopaedic surgery of the first successful human limb replantation (May, 1962) and continued to design techniques and performed all the orthopaedic surgery for the limb replantations at the MGH for years. (19, 20) While this was occurring, I also did the tumor surgery such as the hemipelvectomies for chondrosarcoma, etc. and in addition wrote a book on the management of fracture cases. (21)
During
that same early period, my research work focused on the effects of growth
hormone on skeletal tissues and the interaction of calcium and phosphate
metabolism on skeletal mass, bone turnover and osteoporosis. (1,
6, 7, 8, 11, 15, 17, 18) It was also in that era that we concentrated
our work on the prevention of venous thromboembolic disease.
Think of the width of that experience in musculoskeletal disease. Such a panoply of interests is unheard of today. During that time, I also began to work on new ideas in reconstructive hip surgery, ideas in those days which emphasized ways to improve the surgery of and the results of cup arthroplasty. (2, 9, 12) Now, fast for ward to the present time when our major effort is the decade long project of the development of electron beam, crosslinked, melted ultra high molecular weight polyethylene, with its high potential to revolutionize another type of hip reconstruction, total hip replacement surgery.
The range, depth, scope, and extent of this odyssey is, in major part, a reflection of this remarkable period of time. It is also a reflection of a decision I made from the start of my career to weave research into an academic clinical career. And indeed, it has been varied and fascinating. If you will, permit me to reflect on what I consider to be, perhaps, the three most lasting areas of my activities, those perhaps that are the most influential on the current and future practice of orthopaedics.
Among the most satisfying areas of progress in our work during this half century have been the contributions to the conquest (or near conquest) of fatal pulmonary embolism following major hip surgery in the adult. Consider the fact that in 1959, when I was Chief Resident at the MGH, ignorance was massive in all five major aspects of venous thromboembolic disease (VTED) :
- the nature of the disease,
- its true incidence;
- the ability to diagnose the condition in vivo;
- the prevention of venous thromboembolic disease;
- the treatment
of this condition.
In those days, fatal emboli were considered to be “acts of God” or “ bolts out of the blue ”. The incidence of deep venous thrombosis following surgery of the lower extremities in adults was felt to be about 12%, and this diagnosis was based mainly on the Homan ’s sign! There were no widely used diagnostic tools, no preventative measures and no effective treatment. Along with Ed Salzman and Roman DeSanctis, we did the first study of the use of Coumadin in the prophylaxis against VTED following hip fractures. (3) Imagine, voluntarily using an anticoagulant in elderly patients with a fracture and a large hip wound.
When that proved to be effective, we initiated studies of a similar nature for prevention of VTED following elective hip 8 surgery. (4, 13, 16, 22, 24, 30, 36, 37, 40, 42, 50) This was done to refute the “accumulated wisdom ”of our elders that the unilateral massive swelling of the extremity following cup arthroplasty was “the postoperative swelling of hip surgery. ” The results of this work plus the huge contributions of so many, many outstanding investigators can be estimated in three different forms:
- the adoption of effective prophylaxis is extremely wide and in some areas nearly universal in high risk cases;
- the major discussions about prevention of VTED now are no longer focused on “how ”, “if ”, or “why ”but rather are focused on making choices over the uses of safer and safer and more and more effective modalities of prophylaxis.
- the last fatal pulmonary embolism following hip surgery in a patient of mine was 42 years and 3, 000 cases ago;
The second overarching theme of my work has dealt with concepts, designs, techniques and instruments to further the efficacy of reconstructive surgery of the hip. These efforts ranged from new incisions (5, 10, 23) and new approaches regardless of incision (14, 29, 31, 32) , through many instruments, many implants to innovative concepts. (26-28, 31, 32, 35, 57, 69, 73, 74) We were the first to use a cement gun to deliver bone cement;the use is now world-wide. We designed the first modular acetabular component and the first metal-backed acetabular component. In North America, the vast majority of acetabular components are modular. We did the first femoral head autograft and first femoral head allograft for acetabular augmentation for total hip replacement and designed the first special components for and performed the first total hip replacement on a hip that had a congenital total dislocation. (34, 38, 41, 52, 59, 63, 67, 68) Later on, we developed the hybrid total hip replacement concept, recognized as the state of the art at the last consensus report of the NIH. (51, 75-77, 79) We also developed the Harris Hip Score in 1967. (9, 78)
Our work was active in the design of both cemented and cementless total hip replacement, with special emphasis on improved fixation. Perhaps one of the most lasting efforts in this realm is the work with Jorge Galante that culminated in the design of the hemispherical, porous acetabular component transfixed with screws (or press fit) that has so drastically changed total hip surgery. (43, 49, 62, 67) It has played a major role in solving many of the problems of acetabular revision surgery, has greatly improved acetabular reconstruction surgery in young patients and is now gaining increasing scientific backing as the best acetabular component in primary total hip replacement in the older age group as well. This implant also is very valuable in the “high hip center ”concept (45, 55, 61, 64) and the “Jumbo ”socket concept. (80)
These efforts continue apace with major work now aimed at reducing dislocation, increasing range of motion, and augmenting the quality of life by creating more normal and more anatomic total hip replacement.
Thirdly, a most exciting avenue of research has been the role we played in the identification, definition and hopefully the cure of a world-wide disease. That disease is periprosthetic osteolysis. (25, 33, 39, 44, 46-48, 50, 53, 54, 56, 60)
Many, many excellent investigators have played major roles in this effort. Our particular pathway began with the publication in 1976 of four cases of periprosthetic osteolysis. (25) Many others had seen this affliction, including Charnley, McKee and Willert. Charnley had felt it most likely due to infection but could not identify bacteria. (70) McKee felt it was secondary to the motion of loose components. (71) Willert advanced the idea of the concept of particle migration. (72)
From this small start (the publication of four cases) , for us the next step was work with Steve Goldring and Al Schiller (33, 39) that was the first demonstration that, indeed, the periprosthetic membrane which people had been discarding for over 20 years as “fibrous tissue ”had the capacity to elaborate PGE 2 and collagenase and to resorb bone. All of the work identifying the many cytokines and enzymes involved in the lysis that constitutes periprosthetic osteolysis followed rapidly thereafter.
We also identified the role of this lytic process in acetabular loosening and femoral loosening. (44, 46) Since the submicron particulate debris, primarily particulate ultra high molecular weight polyethylene (UHMWP) generated at the metal to polyethylene articulation, is the offending agent that initiates periprosthetic lysis, we initiated in 1990 a program to see if we could decrease such debris by creating a better articulation for artificial joints.
But, rather than starting our research on materials, we began by inventing a new hip simulator, driven by the belief that without such a device which could quantify the efficacy of any proposed new articulation in terms of reduced wear, any proposed new material would long remain a hypothetical possibility.
The effort to design a better hip simulator also drove us to define, for the first time, the actual pathways that individual points on the femoral head must take inside the hip joint during the gait cycle. (58) Once the hip simulator was established, in collaboration with Professor Ed Merrill at MIT, our group has invented a new material, electron-beam irradiated, melted, highly crosslinked ultra high molecular weight polyethylene. (65, 66, 81). Massive in vitro experiments have shown it to be remarkable, not only in wear resistance and oxidation resistance, but in physical properties as used in an acetabular component. This material has been FDA approved for use in hips and knees. Should it prove to be as effective in vivo as its behavior is in vitro, a new age of total hip replacement will be with us. The duration of success, reduc-tion of complications, decrease in revisions, improvements in functional outcomes, decrease in cost, improved ADL and extended indications would all follow. More importantly, should this material demonstrate long term success, it would close the loop in the story of the world-wide disease of periprosthetic osteolysis. That is to say, periprosthetic osteolys is a man-made disease, never seen before in the history of mankind. It is the direct result of the invention of total joint surgery. If the improved polyethylene works over the long term, this disease may have been fully cycled, that is to say, introduced, identified, defined, explained and cured, all in one generation. Were that to occur, it would be a remarkable feat.
It must be said that in everything I have described there have been many powerful and massive, major contributing forces. These include but are not limited to, the giants in our field who built the platform that made any such effort possible, the large number of remarkably bright, dedicated and inventive colleagues and co-workers who were a constant source of solace, inspiration and renewal throughout the five decades and in particular, the Fellows. As a source of renewal, challenge, excitement and inspiration, the Fellows are unequaled and, almost without question, they are my most impressive legacy. To all these people, I owe an incalculable debt. Many thanks.
