This article is more than 5 years old. Information may no longer be current.
Putti linked trauma and orthopaedics in Europe
Italian pioneer took orthopaedists from glorified barbers to respected surgeons.
At the time of his death more than 60 years ago, Vittorio Putti was described as one of the best orthopaedists of all time. His legacy touches so many aspects of contemporary orthopaedics that in this era of subspecialization, it is almost difficult to imagine an individual having such a wide-ranging impact.
He helped usher the newborn specialty into the 20th century and established revolutionary practices and procedures in both spine and hip surgery as well as fracture treatment. In addition, he envisioned musculoskeletal trauma as being a part of orthopaedics, was a pioneer in the use of radiology, was instrumental in the formation of orthopaedic specialty societies and was one of the first to suggest the sharing of information and ideas across national as well as ideological borders.
Putti was born into a wealthy and distinguished family in 1880 in the ancient city of Bologna, Italy. He was truly a product of the marriage of science and the arts: his father was a surgeon at the Ospedale Maggiore, and his mother was the sister of Enrico Panzacchi, a romantic era poet. His family’s position and affluence enhanced Putti’s youth. Through his uncle, he met many prominent social and artistic personalities; by his father’s influence, he was introduced to some of the leading scientists and physicians of the time.
Early guidance and Il Rizzoli
|
Putti received his medical degree from the University of Bologna in 1903. Not long afterward, Alessandro Codivilla, the director of the newly established Instituto Ortopedico Rizzoli and the man considered to be the founder of modern orthopaedics in Italy, became his mentor. Legend has it that Codivilla had to work hard to persuade the promising young physician to study orthopaedics, since at that time in Europe orthopaedists were thought of as little more than glorified barbers.
The Instituto Ortopedico Rizzoli, or Il Rizzoli, was set up by surgeon Francesco Rizzoli in an old monastery he purchased with the inheritance he received from his father. Rizzoli was despondent over the lack of proper treatment of congenital defects and deforming diseases such as tuberculosis and poliomyelitis, as well as the resulting deformities they caused. The institute, one of the first hospitals established especially for the treatment of orthopaedic and trauma maladies, soon became well known and respected.
In 1912, Codivilla died and Putti succeeded him as director of the institute and as professor of orthopaedics. Two years later he formed the Officine Rizzoli, which was the first appliance workshop in Europe specifically created to produce orthopaedic prostheses and surgical instruments. Through this shop, Putti oversaw the production of many wooden prostheses for the disabled veterans from World War I and the osteotono, an early externally fixed leg lengthener.
Shortly after taking the helm of Il Rizzoli, Putti fashioned it into one of the leading bone and joint centers in the world. Visiting surgeons from the United States wrote to colleagues that Putti’s clinic surpassed all others in terms of “organization, technique and efficiency.”
Hip advances
Most agree that Putti’s greatest contribution to orthopaedics was his work in congenital hip dysplasia. According to Paolo Gallinaro, MD, immediate past president of the European Federation of National Associations of Orthopaedics and Traumatology (EFORT), Putti’s discovery of the “Putti’s triad,” the three radiologic criteria to diagnose a congenital dysplasia of the hip, is a hallmark of his career.
Putti was a key advocate of the early diagnosis and treatment of congenital hip displacement, which was not a popular viewpoint in the 1920s. To further his point, he produced an anatomic atlas of the pathology of the condition, as well as a 1929 article in the Journal of Bone and Joint Surgery and a 1935 award-winning text on the subject. He expanded the work of Codivilla by perfecting an abduction pillow for the treatment of congenital hip dysplasia.
In a 1929 joint meeting of the British and American orthopaedic associations, he made a prophetic address. “Let me emphasize that to improve the results of the treatment of congenital dislocation, one must lower the age limit for beginning treatment,” Putti said. “But to render this possible, it is necessary for parents to learn to bring their children for medical examination early, [so] that the doctors shall be able to make the diagnosis in time. That will certainly occur in the future and with suitable propaganda and with better orthopaedic training for the medical profession.”
Scoliosis research
Putti also made strides in early spine surgery. His interest in the pathologic history of sciatic pain led him to publish two influential papers on the topic, the first appearing in The Lancet in 1927 and the second in a local Bologna journal in 1936.
In his writing, presentations and educating, Putti proposed that mechanical or skeletal changes in the spine resulted in sciatic pain. This opposed the contemporary view that the pain was the result of a “nerve disease.” Putti used x-rays to prove his point and doing so, established the first radiologic institute in Italy. For years afterward, his x-ray images of the spine were considered the standard.
Although history credits Boston’s Mixter and Barr with the pioneering of disc prolapse surgery, Putti had accidentally “discovered” disc herniation as a cause of sciatica nearly a year before the Americans’ publication. “Putti operated on a sequestered disc prolapse well before Mixter and Barr’s 1934 publication,” Gallinaro said. “He sent the specimen to Prof. Erdheim in Vienna, (a leading pathologist of the era), thinking it was a tumor. Erdheim answered, ‘If you say you found this tissue free in the canal, I can’t say that this is disc, but it still seems to me that it is disc.’’’
Gallinaro said that unfortunately Putti did not follow up with his discovery. “He did not make the next logical step to realize that he had discovered the true pathology of the so-called ‘vertebral sciatica’ and, therefore, the credit of course went to Mixter and Barr.”
Putti also had great influence on fracture treatment and care. His 10 rules for fracture treatment, published posthumously, put forth principles still used in contemporary care, including current concepts on the biologics of fracture healing. He also did innovative work and reporting on joint arthroplasty, bone tumors and traumatology, and helped introduce the Putti-Platt repair for recurrent dislocation of the shoulder.
Trauma merger
Gallinaro said Putti’s contributions in merging trauma with orthopaedic surgery are also a lasting legacy. “Thanks to him, musculoskeletal trauma was included into the practice of orthopaedics. Following his proposal at a meeting in Bologna just before World War II, the name of the international society, the Société Internationale de Chirurgie Orthopédique (SICO) was changed to SICOT, adding traumatology.”
Putti died of a massive heart attack in 1940 while on duty at Il Rizzoli. In his many obituaries, he was called a renaissance man, a master of orthopaedics, a humanist, a pragmatist, open and gracious to all and having a lifelong curiosity of medicine and healing. The New England Journal of Medicine honored his achievements by claiming he built the “most noted bone and joint center in the world.”
Perhaps his greatest homage came from those he inspired. In 1980, Robert Merle d’Aubigné, MD, the famous French orthopaedic pioneer, told an audience in Palermo that it was visiting Putti in the 1930s that led him to become an orthopaedist.