Mayo Clinic’s orthopaedic reputation built and strengthened over past century

For nearly a century, orthopaedic surgeons have looked to the Mayo Clinic in Rochester, Minn., U.S.A., as a veritable bench mark for quality clinical outcomes and scientific research in musculoskeletal medicine.

“Mayo was fortunate to offer one of the first independent orthopaedic surgery departments in the country” and pursue orthopaedics as a specialty rather than a division of surgery, said Daniel J. Berry, MD, chair of Mayo’s orthopaedic department since 2005.

Originally consisting of adult reconstruction, hand, orthopaedic oncology and pediatric sections, the orthopaedic department has grown to include spine and sports medicine programs, which is housed in a center that vice chair Michael J. Stuart, MD, helped establish in 1990.

There are 42 orthopaedists in the main clinic in Rochester and about 10 each at expansion offices in Arizona and Florida. Fifty residents are enrolled in a residency program that is expected to expand to about 60, and everyone is involved in the academic process, Berry said. Mayo also offers a full range of orthopaedic fellowships.

Iconic institution

Berry said the department’s goals are the same now as they were at the outset: “To provide outstanding multidisciplinary, subspecialty, clinical capability to manage complex and routine orthopaedic problems coupled with a vigorous and outstanding research program and excellence in orthopaedic education.”

The full-service department remains an integral part of the Mayo Clinic, which is “one of the most iconic medical institutions in the world,” according to Charles Sorbie, MB, ChB, RCS, of Kingston, Canada.

Those who founded the clinic at Mayo chose “outstanding doctors and scientists that have in common an almost Spartan desire for hard work. [They] perform research, which is thoroughly reliable, and while a high proportion is basic, it has immediate or will have a future clinical impact,” said Sorbie, an Orthopaedics Today Europe Editorial Board member.

Hand surgeon Jean Goubau, MD, of Brugge, Belgium, said when he visited Mayo in 1998, he witnessed the high standards of the staff involved in the biomechanics lab and educational programs. Goubau recalled how then-retired Ronald L. Linscheid, MD, organized Mayo’s exchange with the Service d’Orthopédie II and Prof. Yves Allieu from Montpellier, France.

“He fulfilled perfectly the goal of the Mayo brothers … that exchange of views and thoughts were the key for successful medicine and research,” whether it occurred in Minnesota or elsewhere, Goubau said.

A decade later, Goubau is still profoundly affected by his Mayo experience.

“This institution is the best example of dedication to medicine and quality of treatment through well-organized research in order to serve patients efficiently,” he told Orthopaedics Today Europe.

Mayo’s new 245,000-square-foot W. Hall Wendel Jr. Musculoskeletal Center, which opened in May 2008, includes onsite radiograph imaging technology. This provides patients with a one-stop clinical experience never before possible in the Mayo orthopaedic department. Images: Mayo Clinic

Surgeons in charge

Goubau recalled what a Mayo hand surgery consultant told him: “Mayo is so successful because it is run by doctors, but not by any doctor. It is run by surgeons.”

Mayo orthopaedist David G. Lewallen, MD, said, “We are all practicing surgeons and it makes a big difference in our mindset. It allows us to maintain our focus and stay on task. It creates an environment where people can practice medicine in the way we all sort of envisioned we would when were beginning medical school.”

This approach helped build, refine and strengthen the department’s reputation over time, he said.

Mayo’s consistency of vision, which produced unwavering leadership and practically unmatched innovation, originated in 1910 with Mayo Clinic founder William Worrall Mayo, MD. Mayo and sons William J. Mayo, MD, and Charles H. Mayo, MD, established strong roots in the health care arena in mid-America that continue to thrive today, Berry said.

“Two of three recipients of the 1950 Nobel Prize for Medicine discovered corticosteroids at Mayo, and our department took advantage of that to explore their use in musculoskeletal conditions,” he said.

“We climbed on some of our forefathers’ shoulders,” Stuart added.

Leadership mentality

One giant in the department was past chair Mark Coventry, MD, who “popularized and perfected realignment osteotomy, the proximal tibial osteotomy and also performed the first U.S. Food and Drug Administration-approved total hip replacement in the United States,” Stuart said.

Surgeons and residents often gathered to observe surgical cases in the early days at Mayo. The orthopaedic department members intently studied laminar flow systems and all forms of total joint arthroplasty over the years.

He cited Bernard F. Morrey, MD, chairman from 1988 to 1997, as another influential leader whose pioneering biomechanics research and clinical work made him “a well-recognized world expert on the elbow.”

Morrey and three other Mayo orthopaedists served as president of the American Academy of Orthopaedic Surgeons (AAOS): Melvin S. Henderson, MD, an AAOS founder; William H. Bickel, MD; and Edward D. Henderson, MD. Several presidents of the major U.S. orthopaedic specialty societies also hailed from Mayo.

First joint implant registry

Lewallen credited Coventry for his foresight in starting the Mayo joint replacement registry in 1969, the oldest in the world.

Coventry clearly understood how significant this procedure was and the importance of tracking its outcome in patients. “That stroke of genius may have been his biggest contribution to our department. It continues now, many years after his death, and it is the reason anybody’s really heard of us in orthopaedics in the large sense,” Lewallen said.

The registry was transitioned into a database during Morrey’s tenure as chairman and is regularly updated and upgraded.

The registry now includes objective and subjective patient scores among other surgical information. “As our understanding of the implication of different patient activities becomes clearer, our ability to enter that into the database gets assessed,” Morrey said.

Patients’ smoking status, for example, was recently added as a searchable field.

“The database includes 100% of the implants put in here,” he said. Morrey estimated that by Mayo’s 100th anniversary in 2010, the registry will contain data for 100,000 knee, hip, shoulder, elbow and ankle surgeries.

Registry officials disseminate registry data to the international orthopaedic community primarily via a Mayo-published joint replacement arthroplasty textbook and numerous peer-reviewed papers. “Lots of information has been learned from the registry that has helped improve the care we provide patients,” Lewallen noted.

Already this year, Mayo researchers had more than 750 papers published based on the registry, 70% of which concerned hip and knee replacements.

World recognized

Some orthopaedic sections are well-recognized. The department continues to be a leader in adult reconstruction problems and joint replacement development, Berry said.

“We have very active biomechanics, gait analysis and tissue engineering labs that contribute to our ability to help design implants in an innovative manner,” he said.

Pioneering work in elbow, shoulder and musculoskeletal infections also continues at Mayo, he said.

Tumor surgery integrates department and clinic team members’ multidisciplinary strengths so limb-salvaging, life-saving surgery can be performed, Berry explained.

During his stay at the Mayo Clinic, Goubau was mentored by Richard A. Berger, MD, PhD, and said the hand section is respected worldwide.

Sports medicine “involves a multidisciplinary approach where patients are evaluated and treated, whether it’s nonoperative or operative, by our sports medicine staff,” Stuart said.

The study of sports medicine at Mayo started in the early 1980s and includes well-recognized investigations into knee ligament reconstruction, elbow stability and joint biomechanics. Physical examination tests developed by Mayo practitioners include shoulder instability under anesthesia, the elbow hook test, and the moving valgus stress test that Shawn W. O’Driscoll, FRCS, described.

International collaboration

International collaboration remains important at Mayo, according to Berry.

“It enriches the department to hear different ideas from around the world,” he said. “When we develop personal connections with visiting physicians and fellows, this advances orthopaedics in a multitude of new ways that would otherwise be impossible.”

Ties with the Rizzoli Orthopaedic Institute in Bologna Italy; Reinhold Ganz, MD, in Bern, Switzerland; and Christian Gerber, MD, of Zurich’s Balgrist Hospital are among the strongest, Morrey said.

Famous figures from all walks of life have turned to Mayo’s orthopaedic department for care, including prominent business and industry leaders, sports figures, U.S. government officials, heads of state and some of the world’s most recognized spiritual leaders.

But despite its worldwide reputation and various clinical and scientific discoveries, the department still maintains regional practices that seek to deliver optimal care to residents in Minnesota, Florida and Arizona.

“I hope the orthopaedic surgeon of the future doesn’t miss out on the art of medicine and the enjoyment we get from taking care of patients,” Stuart said.

For more information:

• Daniel J Berry, MD, +1-507-284-4204; e-mail: mundt.norma@mayo.edu; David G. Lewallen, MD, +1-507-284-4896; e-mail: lewallen.david@mayo.edu; Bernard F. Morrey, MD, +1-507-284-3659; morrey.bernard@mayo.edu; Michael J. Stuart, MD, +1-507-284-3462; e-mail: stuart.michael@mayo.edu. Drs. Berry, Lewallen, Morrey and Stuart can be reached at 200 1st St. SW, Rochester, MN 55905 U.S.A..
• Jean Goubau, MD, can be reached at Dienst Orthopédie en Traumatologie, AZ St. Jan AV, Ruddershove 10, B-8000 Brugge, Belgium; +32-50-45-21-66; e-mail: jean.goubau@azbrugge.be.
• Charles Sorbie, MB, ChB, RCS can be reached at Queen’s University, Richardson House, 102 Stuart Street, Kingston, Ontario K7L 3N6, Canada; +1-613-533-2661; e-mail: sorbieC@kgh.kari.net.

Reference:

• For more information, go to www.mayoclinic.org.