Clinical and research pioneers molded Massachusetts General Hospital’s orthopedic surgery history

Marius N. Smith-Petersen, MD, was department chief and an arthroplasty innovator. Ernest A. Codman, MD, developed the concept of tracking patient outcomes.

Like many famous orthopedic departments, Massachusetts General Hospital’s in Boston got its unofficial start from humble beginnings when a handful of surgeons including Joel E. Goldthwait, MD, John B. Brown, MD, and Henry J. Bigelow, MD, organized themselves and became proficient at treating the musculoskeletal needs of local children and adults with poliomyelitis or tuberculosis.

The third-oldest general hospital in the United States, Massachusetts General Hospital (MGH) was established in 1811. In 1899, Goldthwait began his work to further orthopedics as a specialty in the United Kingdom and United States. He established the hospital’s outpatient orthopedic site on Boston’s Fruit Street in 1903. Once it became an independent service, Goldthwait served as its first chief of orthopedics from 1904 to 1911, with Robert Bayley Osgood, MD, as his first assistant.

The first MGH orthopedic ward, Ward I, which opened Nov. 6, 1907, is considered the first U.S. center to offer orthopedic treatment to adults. It also housed the first MGH fracture clinic.

Outcomes emphasized

Tracking, registering and reporting treatment medical outcomes has roots at MGH, according to William H. Harris, MD, who developed the widely used outcomes database, the Harris Hip Score, at MGH in 1969. In 1934, Ernest Amory Codman, an MGH staff surgeon, was ahead of his time as “the first person in North America to articulate and detail the necessity for detailed outcomes follow-up,” Harris said. Codman was also among the first American radiologists.

A benign bone tumor and range of motion exercises now carry Codman’s name, as do the MGH Codman Center for Clinical Effectiveness in Surgery and a most prestigious award recognizing the use of outcome measures given by the Joint Commission on Accreditation of Healthcare Organizations.

Codman’s text published in 1934, The Shoulder, is a classic treatise, James H. Herndon, MD, said.

A portrait of MGH orthopedic pioneer William H. Harris, MD, painted by Warren and Lucia Prosperi was recently unveiled. Pictured in front of the painting are (from left) Henrik Malchau, MD, PhD, co-director of the Harris Orthopaedic Laboratory; Andrew Freiberg, MD, chief of the MGH Adult Reconstructive Surgery Service; William H. Harris, MD; Or-hun Muratoglu, PhD, co-director of the Harris Orthopaedic Laboratory; and Harry E. Rubash, MD, chief of Orthopaedic Surgery. Image: Massachusetts General Hospital

Famous leaders

The history of orthopedic surgery at MGH was molded by now-famous surgeons and leaders, their discoveries and innovations, including early department chiefs Elliot G. Brackett, MD, 1911 to 1918, an American Orthopaedic Association (AOA) president, and Mark H. Rogers, MD, chief from 1918 to 1919 and 1922 to 1923.

Also an AOA president, Osgood was chief from 1919 to 1922. “He was famous for Osgood Schlatter’s disease and for his work during World War I. He was a major leader in national orthopedics,” Herndon told Orthopedics Today.

Herndon chaired the Partner’s Department of Orthopaedics in 1998 involving MGH and Brigham and Women’s Hospital and was the 2003 American Academy of Orthopaedic Surgeons (AAOS) president. “There are a lot of greats in the Harvard system over the last 200 years. Our residency education was really started at Children’s Hospital Boston,” noted Herndon, who is writing the history of orthopedic surgery at Harvard Medical School (HMS), the department’s academic affiliate.

Past staff members have served as editors of the Journal of Bone and Joint Surgery or its predicate publication, including Brackett, Rogers, Thornton Brown, MD, Paul H. Curtiss, Jr., MD, and 1998 AAOS president James D. Heckman, MD.

Arthroplasty innovations

“MGH orthopedics has contributed immensely to all fields of orthopedics, but the area that stands out in my mind is surgery of the hip,” said AAOS president John J. Callaghan, MD.

“It started with Marius N. Smith-Petersen, MD, developing his anterior approach to the hip, as well as a nail for fracture and cup arthroplasty for arthritis. Otto Aufranc, MD, Bill Harris and colleagues took it to a new level with long-term study and basic investigation in virtually all aspects of hip replacement, most recently with landmark improvement in bearing surface technology, which was the Achilles heel of an otherwise remarkably successful operation,” he said.

Smith-Petersen was appointed MGH chief of orthopedics in 1929. Today his name is recognized worldwide for his hip nail and “mold” hip arthroplasty, two remarkable advances when he developed them. Smith-Petersen is also known for his “bloodless” approach to the hip and the MGH femoral condylar mold arthroplasty, a Vitallium metal alloy knee implant he devised.

An outstanding clinician, Herndon said Smith-Petersen, 1943 AAOS president, originated a distal radius excision procedure used to treat wrist problems and the concept of spinal osteotomy, performing spine-straightening osteotomies to treat ankylosing spondylitis.

“I would say he is the most innovative orthopedic surgeon of the Western Hemisphere,” said Harris, a pioneer in his own right who joined the department 53 years ago and was chief of the arthroplasty service from 1975 to 2001. He considers Sir John Charnley the most innovative orthopedic surgeon of all time, but said early MGH arthroplasty developments were so notable that Charnley visited the institution after World War II.

Continual discoveries

Next on Harris’ list of top MGH leaders was Joseph S. Barr, MD, who succeeded Smith-Petersen and was AAOS president in 1951. Barr contributed to a better understanding of the role of the intervertebral disc in the origins of sciatica and lumbar spine pain. “It was his work that played such an important role in defining the pathology of the IVD,” Harris said, describing Barr’s candor, intellectual curiosity and integrity as important.

Barr fostered a work environment that emphasized innovation, he said.

In later years Smith-Petersen’s total joint implants were eventually modified by Aufranc and others inside and outside the department.

“Aufranc was the leading hip surgeon in the country, taking over for Smith-Petersen; a master technician and an absolute genius in relating to patients. He had a massive understanding of rehabilitation,” said Harris, who practiced with Aufranc many years.

In 1931, Marius N. Smith-Petersen, MD, MGH orthopedic chief 1929 to 1946, developed a metal cup used in partial hip replacement and later devised a tri-flanged hip fracture nail, among several other achievements.

Otto E. Aufranc, MD, who was mentored by Smith-Petersen, mastered cup arthroplasty and improved on his mentor’s earlier design. He designed some surgical instruments still used today. Images: Massachusetts General Hospital Archives and Special Collections

Orthopedic registers

Melvin J. Glimcher, MD, chief from 1965 to 1970 and the first tenured professor at HMS, established the MGH hand clinic and the lab that Henry J. Mankin, MD, who succeeded him as department chief in 1972, eventually took over. Trained at Massachusetts Institute of Technology, Glimcher started the first bone molecular lab in the country and was the first Edith M. Ashley Professor, HMS.

Mankin, chief of orthopedic oncology from 1972 to 2000, is known for his cartilage research, Herndon said. “He also added a new clinical specialty of excellence here, developing what is now a large musculoskeletal tumor surgery program.”

More recently, department members championed orthopedic registries for improving implant design and patient care. Henrik Malchau, MD, PhD, co-director of the Harris Orthopaedic Laboratory at MGH, used his experience with the Swedish National Total Hip Arthroplasty Registry to establish the MGH total hip and knee arthroplasty register, which paved the way for other departmental registers, like the computer- based trauma data register.

Time line

These accomplishments and others — from founding the MGH bone bank in 1971 to Herndon’s first use of gene therapy in orthopedics in 1996 — are depicted on a timeline compiled by Harry E. Rubash, MD, department chief since 1998 and the Edith M. Ashley Professor, HMS.

Rubash recently told Orthopedics Today, “Our patient care, teaching and research are extraordinary. Our team just got back from Haiti. We believe very strongly we not only care for people locally, but for people in need throughout the world through our fellows, residents and surgeons. We are truly involved in developing the global care of the orthopedic patient.”

Achievements represented on the timeline that Rubash considers major are the first use of ether anesthesia in 1846 at MGH, the first brace shop in 1908, the first fracture clinic in 1917, when Harris established the Annual Arthroplasty Course in 1970 — the longest running Harvard CME course, and Harris’ research leading to the first implantation of highly crosslinked polyethylene in 1999, among others.

Prior to 1900, some early orthopedic surgeons at Massachusetts General Hospital were among the first to treat adults, as well as children, afflicted with poliomyelitis or tuberculosis.

Innovators

“Through the contributions made in the Harris Orthopaedic Laboratory, we have been innovators and inventors of the whole field of crosslinked polyethylene. It is an example of how being participants in the largest hospital-based research program in the country has fostered a unique mix of basic research and clinical care,” said Rubash, a fellow at MGH in the 1980s.

He said what distinguishes us from others and gives the orthopedic clinicians and researchers here the ability to lead is that everyone is involved in devising solutions to patient-based problems and bringing them to the bedside. “We desire to be the ones developing the techniques that others will utilize to take care of patients,” Rubash said.

Education commitment

Many areas that are strong today were established or expanded under Glimcher and Mankin, such as the hand surgery and trauma services, pediatrics, rehabilitation, cartilage and tumor research and the residency program. Rubash sees those, and joint arthroplasty, as leading areas in the future.

MGH’s relationship with HMS has been critical to training orthopedic surgeons in Boston. “The HMS used to be based on the MGH campus so there has been, since the inception, an enormously close relationship between MGH and HMS,” Rubash noted.

Better than ever

Growth and innovation have aided the department’s progress. After Rubash became chief, for example, the faculty tripled in size. “We have leaders in every subspecialty,” Rubash said.

There are nine major laboratories, including the newest which are dedicated to foot and ankle and shoulder research. A lab focusing on fracture healing and bone vascularization just opened. Some key research areas involve analyzing 3-D joint kinematics with robotic testing systems and studying tissue engineering. Work using stems cells to form bone and increase the blood supply to bone may eventually be used in patients with Perthes’ disease or avascular necrosis.

Mankin told Orthopedics Today, “The MGH remains one of the leading institutions for health care in the country. I’m very proud to be a part of that.

“It’s an amazing facility and orthopedics has remained an important part of the organization. They are a well-considered organization for patient care, research and especially, in my opinion, education.” – by Susan M. Rapp

References:

• Rowe CR. Lest we forget. William L. Bauhan Publishers, Dublin, N.H. 1996.
• http://www.massgeneral.org/ortho

• John J. Callaghan, MD can be reached at University of Iowa Health Care, 200 Hawkins Drive, Iowa City, IA 52242; 319-356-3110; e-mail: john-callaghan@uiowa.edu.
• William H. Harris, MD, can be reached at MGH-HOBBL, 55 Fruit St., GRJ 1126, Boston, MA 02114; 617-726-3866.
• James H. Herndon, MD, can be reached at 55 Fruit St., White 542, Boston, MA 02114; 617-726-5117; e-mail: jherndon@partners.org.
• Henry J. Mankin, MD, can be reached at Orthopaedics-Gray 604, 55 Fruit St., Boston, MA 02114; 617-726-2735; e-mail: hmankin@partners.org.
• Harry E. Rubash, MD, can be reached at 55 Fruit St., Yawkey Center for Outpatient Care, Suite 3700, Boston, MA 02114; 617-726-5231; e-mail: hrubash@partners.org.