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Cleveland Clinic gained worldwide status with orthopedic leadership and innovation
The department is globally recognized for many clinical and research achievements.
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A combination of strong leadership and innovation in the areas of clinical practice, research and education has steadily propelled the orthopedic department of the Cleveland Clinic to greater recognition regionally, nationally and internationally.
Over time the group, based in Cleveland, carved out an important place for itself in the orthopedic arena by adding a full complement of orthopedic subspecialties, enhancing its research efforts and, in December 2007, establishing the Orthopaedic Rheumatologic Institute, (ORI) to better triage patients presenting with musculoskeletal disorders.
Kenneth E. DeHaven, MD, past president of the American Academy of Orthopaedic Surgeons and former orthopedic resident and staff member at the Cleveland Clinic, told Orthopedics Today that two things about the Cleveland Clinic stand out for him. “One is a total commitment to excellence of patient care. Everything was secondary to providing the very best of patient care. [Second is a] … collaboration and seamless cooperation among the entire clinic staff members concerning patients with multiple diagnoses that is the best I have ever experienced,” he said. “It deserves the recognition it gets as one of the top hospitals in the country.”
Group practice model
In addition to orthopedics, the clinic enjoys a worldwide reputation for advances in cardiovascular health, transplantation and other groundbreaking areas of clinical medicine and research.
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Image: Cleveland Clinic |
Current and former members of the orthopedic department agreed the clinic’s successful group practice model, in which physicians work with year-to-year contracts, has been an asset to their work.
Being associated with a large, well-known institution that emphasized the group practice concept proved beneficial for the orthopedics department, Richard D. Parker, MD, current chairman of orthopedics at the clinic, told Orthopedics Today. “Perhaps one of the biggest milestones for orthopedics is we have been an integral part of the Cleveland Clinic’s group practice, which is a very unique practice model,” he said.
A. Seth Greenwald, DPhil (Oxon), first director of the Cleveland Clinic’s Biomechanics Laboratory and a member of the Orthopedics Today Editorial Board, said, “The intent of the clinic founders particular to the care of patients, the study of their problems, and the education of those that serve them soon became the mantra of the department.
“Everyone at the Cleveland Clinic adheres to the same mission statement: To improve clinical outcome by balancing research and education, with patient care. These principles are embodied in the book To Act as a Unit which tells the story of the Cleveland Clinic.” Greenwald said.
“That is how we define our department, too,” Parker explained. Despite extensive sub-specialization within orthopedics at the clinic today, which did not exist even a few decades ago, together we have a comprehensive product to offer every patient, he said.
Evolving department
In 1922, James A. Dickson, MD, became the first orthopedist to practice at the clinic, serving as department chairman for 32 years.
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The dedication and innovation on the part of a host of orthopedic leaders helped bring the department to its current level of excellence. Through their efforts osteotomies, which constituted the primary arthritis and nonunion treatments for major joints done during Dickson’s era, were replaced with such practices as internal fixation and total joint replacement (TJR).
After World War II orthopedic sub-specialization and TJR surgery began to emerge and forever change the face of orthopedic care. “The Cleveland Clinic was at the forefront of that,” Parker said.
Hand surgery advances
George Phalen, MD, at the clinic, identified the concept of carpal tunnel syndrome (CTS) and devised a test orthopedists still use to diagnose CTS, Parker said. In the early 1950s Phalen also associated CTS with certain occupations.
Today, those in the clinic’s hand section continue to develop less-invasive approaches for CTS and are making advances treating other challenging hand conditions and performing reconstructions for congenital problems, he said.
C. McCollister Evarts, MD, helped foster several orthopedic innovations, including spinal instrumentation and endoscopic spine surgery. In 1970 he performed the first TJR surgery done at the clinic — a metal-on-plastic total hip arthroplasty (THA) that heralded a new era of treating arthritic joints.
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New era
Greenwald said, “The modern era odyssey began in 1970 with the appointment of Evarts as chairman of the orthopedic department and his quest to recruit potential leaders in orthopedic surgery.”
“Evarts was one of the most influential leaders in orthopedic surgery over this period of time,” DeHaven said.
During his term, the clinic established the Biomechanics Laboratory to study problems associated with the rapid rise of hip and knee implant use. Studies contributing to device performance, fixation with acrylic bone cement, biological ongrowth and ingrowth surfaces, and specific implant designs were among its first applied research endeavors.
This included a multi-axial artificial wrist replacement, which was designed, manufactured, patented and eventually used at the clinic, Greenwald said.
The laboratory’s basic research efforts into the pathomechanics of hip joint degeneration were recognized with the Kappa Delta Award from the American Academy of Orthopaedic Surgeons in 1979.
Joint reconstruction
“We were part of the evolution of the technology behind TJR surgery,” Parker said. Lester S. Borden, MD, who joined the clinic in the 1970s, led the way. His engineering background facilitated development of precise TJR instrumentation that enabled procedures to be performed by more orthopedic and general surgeons.
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The clinic received an early FDA permit to use polymethylmethacrylate bone cement before its approval and surgeons progressed from performing THA to total knee arthroplasty.
Among Evarts’ recruits was John A. Bergfeld, MD, who interned at the clinic starting in 1964. In 1972, when Bergfeld was a staff surgeon, H. Royer Collins, MD, who was interested in sports medicine, succeeded Evarts as department chairman. With DeHaven, these men were integral to getting the clinic involved in sports medicine and educating others in this new subspecialty. All three are past presidents of the American Orthopaedic Society for Sports Medicine.
Sports medicine pioneers
“The first well-organized section committed to the practice of orthopedic sports medicine was at the Cleveland Clinic,” Bergfeld said. “We were the forerunner.”
Bergfeld and others worked as team physicians for local high school, collegiate and professional sports teams. Their work with the Cleveland Browns and the Cleveland Cavaliers started in 1976 and 1981, respectively.
“We still have a high profile in sports medicine,” said Bergfeld, who is sports medicine section editor for Orthopedics Today. Sports-related research at the clinic yielded considerable early information about the ACL and posterior cruciate ligament (PCL). The resultant clinical picture of PCL injuries and information on how to reconstruct the PCL is still widely recognized, he noted.
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“The other important development was we were the first clinic to have primary care sports medicine doctors and orthopedic surgeons working together,” Bergfeld said.
In 2000, Joseph P. Iannotti, MD, PhD, was tapped to chair the department. In 2006, Delos T. Cosgrove, MD, Cleveland Clinic chairman and CEO, formed system-wide institutes establishing the ORI. Iannotti was appointed the institute’s inaugural chair whose mission is to help bridge orthopedic clinical and research areas within the clinic and connect them with rheumatologic care.
According to Iannotti, a member of the Orthopedics Today Editorial Board, this was a “programmatic decision from a translational perspective to link the orthopedic department and specific clinicians.” His strategy included recruiting clinicians engaged in translational research and linking them with appropriate basic scientists.
This fairly recent shift in approach to orthopedic research and academic practice represents a monumental effort that has started paying off in terms of innovations in imaging, surgical simulation, limited joint resurfacing, injury prevention and cartilage tissue engineering advances.
“We have made a major paradigm shift in how people view the department as a place where innovative ideas and good quality research originates,” Iannotti told Orthopedics Today.
In 2008, members of the clinic’s orthopedic section saw 136,500 patients and performed 12,250 surgeries. The department is internationally recognized and has “very few weak links. All the subspecialties are strong, along with our research and teaching programs. I think we have all the components of a really excellent department,” Bergfeld said.
For more information:
- John A. Bergfeld, MD, is medical director, Cleveland Clinic Sports Medicine Program. He can be reached at Cleveland Clinic Sports Health, 9500 Euclid Ave., A-41, Cleveland OH 44195; 216-444-2618; e-mail: bergfej@ccf.org.
- Kenneth E. DeHaven, MD, can be reached at University of Rochester Medical Center, Box 665, 601 Elmwood Ave., Rochester, NY 14642-2970; 585-275-2970; e-mail: Kenneth_DeHaven@ URMC.Rochester.edu.
- A. Seth Greenwald, DPhil (Oxon) can be reached at Orthopaedic Research Laboratories, 2310 Superior Ave., East, Cleveland, OH 44114; 216-523-7004; e-mail: seth@orl-inc.com.
- Joseph P. Iannotti, MD, PhD, can be reached at The Cleveland Clinic A-41, 9500 Euclid Ave., Cleveland, OH 44195; 216-445-5151; e-mail: iannotj@ccf.org.
- Richard D. Parker, MD, can be reached at 9500 Euclid Ave., Desk A-41, Cleveland, OH 44125; 216-444-2992; e-mail: parker@ccf.org.