Orthopaedic Innovations In My Lifetime

by Phillip Parr, M.D.

I have had the privilege of practicing orthopaedic surgery in the Gainesville community for 34 years. One of the more appealing aspects of orthopaedics has been that we, with rare exceptions, are not involved with life or death situations. However, we are deeply involved in the quality of people’s lives. We have learned how to fix things. We can realign bones and fractures and improve joint and muscle function. We can help athletes get back into competition and help those formerly bound to a wheelchair to walk again.

The majority of today’s routine procedures were not yet conceived, or were in their infancy, during my residency at Shands from 1967 to 1970. The practice of orthopaedic surgery has evolved rapidly during my practice lifetime, largely due to new innovative concepts in surgical techniques, as well as increased understanding of joint mechanics and evolving technology. What follows are several developments in surgical care, all within my practice lifetime, that have helped us better diagnose, define, and treat patients’ orthopaedic problems.

Internal fixation of fractures: When I was a resident in the late 60’s, the common treatment for a fractured femur was to place a steel pin through the leg and place the patient in traction for six to eight weeks in the hospital. Thereafter, the patient was placed in a body cast extending from his chest to his toes for another two to three months. Once the fracture healed, the patient was left with an extended period of rehabilitation to regain motion in his stiffened hip, knee, and ankle joints. Frequently, it took over a year to regain motion and strength.

Fractured tibias were placed in long leg casts, sometimes for over a year. Fractures often went to nonunion, angulated, and then required reconstruction and long-term rehabilitation.

Today, fractures of the long bones, including femoral and tibial fractures, can be fixed internally with rods inserted down the center of the bones to align the fractures anatomically. Patients are hospitalized only a few days and they can start walking and moving their joints almost immediately. Rehabilitation is much more rapid and the final functional results are vastly improved.

Principle of early motion: We were taught as medical students and residents that in order for fractures to heal, the joint above and below the fracture had to be immobilized. We have since learned that long-term immobilization leads to serious damage to the immobilized joints because of lack of circulation of the synovial fluid that nourishes the articular cartilage of the joint. Long immobilization leads to stiffness of the joints, atrophy of the muscles surrounding the joint, and to progressive degenerative changes of the joints later in life. With use of internal fixation and early motion, the joints stay healthy and well nourished. The motion of the joint is not detrimental to fracture healing.

C-arm or fluoroscope: With the C-arm or fluoroscopy, we are able to immediately visualize fracture reductions so that they can be placed in a perfect anatomic position. We can also place guide pins under direct vision into bones that require hardware so we can get perfect placement of the hardware. Prior to development of the fluoroscope, reducing and operating on fractures, such as hip fractures, were surgical nightmares. The guide pins had to be placed blindly, followed by X-rays that had to be taken to the X-ray department for development. The pins frequently had to be replaced three or four times before the position was satisfactory. Now pins can be placed accurately under direct visualization and most fractured hips can be done in less than an hour.

Magnetic Resonance Imaging: The MRI scan has revolutionized virtually every field in medicine. The MRI enables us to see soft tissue structures, such as rotator cuffs within the shoulder joint, meniscal tears within the knee joint, herniated discs and other nerve lesions, as well as all types of soft tissue masses. A MRI scan is completely painless. For those individuals who are claustrophobic, or are too large for the tunnel, open MRI scanners are available. The MRI scanner has been a quantum leap forward in diagnosis of soft tissue problems within the joints and spinal cord area.

Arthroscope: The arthroscope is a long thin tube with a camera attached to it that may be inserted into joints through a very small incision. It was developed in Japan and was not available for use in the United States until the early 70’s. Since then, the arthroscope and other instruments associated with minimally evasive surgery have virtually revolutionized former procedures that required large incisions. Anterior cruciate ligament reconstruction in knees can now be done through three or four tiny holes with virtually no blood loss. Rotator cuff repairs can generally be done through the arthroscope. This leads to much better cosmetic results and quicker return to function since there is only minimal damage to the muscles and soft tissue surrounding the joints.

Joint replacement: When I was a resident, joint replacement was in its infancy. The original hip replacement was developed in England. The first hip replacement in Gainesville, performed outside of the Medical Center, was done in 1972. The first knee replacement was done in late 1972, and the first shoulder replacement was done in 1975 or 1976. I had the privilege to be a part of each of those procedures that are now commonplace and performed almost daily in nearly every hospital in America.

The growth of joint replacements was largely due to the development of Methyl Methacrylate, a cement-like substance that would adhere to bone, thereby stabilizing the prostheses. The ability to replace almost any joint, including hips, knees, shoulders, elbows, wrists, and ankles, has been the single most important development in increasing the quality of life for those individuals whose joints were destroyed by the ravages of inflammatory or degenerative processes. During my residency, we had very little to offer people with severely arthritic joints, other than a wheelchair or a surgical fusion of the joint, which left it stiff. Joint replacements have allowed people, otherwise relegated to life in a wheelchair, a normal and active lifestyle.

Allografts: Allografts are pieces of bone, tendon, or other tissue that have been removed from human tissue donors, shaped and sterilized, and then stored in a tissue bank. Formerly, grafts used for any procedure in the human body had to come from the same individual. This usually required a second incision and increased scarring and morbidity for the patient.

With the development of newer techniques in sterilization, allografts are now safe, and multiple studies have shown that they hold up almost as well as one’s own tissue. Bone grafts can be used to augment spinal fusions or ununited fractures. Tendon grafts can now be used for anterior cruciate ligament reconstruction and other procedures requiring the use of a soft tissue graft.

Increased understanding of the knee: During the mid and late 60’s, we were taught that total meniscectomies could be done with little loss of function and that anterior cruciate ligaments (ACL) were disposable. ACL tears were simply removed. We now know that the ACL is the most important ligament in the knee. We preserve as much meniscus as possible, because we now know a total meniscectomy leads to degenerative changes in the knee 10 to 15 years after surgery. With use of the above principles of internal fixation, early motion, and use of the arthroscope, knee ligaments can be reconstructed very rapidly. The ACL in particular can often be reconstructed in a perfect anatomic position with the use of allografts. Athletes whose careers would have ended with serious knee injuries are now able to return to competition within a few months after knee reconstruction.

Cartilage regeneration: All joints are covered with articular cartilage, which pads and protects the bones. The loss of that cartilage is by definition “arthritis.” Until fairly recently, regenerating articular cartilage was thought to be impossible. We now know that there are techniques to resurface cartilage defects within joints. Articular cartilage cells can be grown in a tissue culture environment, replaced back into a defect in the surface of a joint, and actually regrow to look almost identical to the original articular surface. It is not a technique that works for the degenerative joints, but often works well in young people who have had a traumatic loss of their articular cartilage from athletic injuries. Understanding of articular cartilage regeneration is an ongoing process and will advance the treatment of serious joint injuries.

Our new Gainesville medical office building houses a fluoroscope, a MRI scanner, and digital X-rays, all of which are state of the art. Having this technology in our own office streamlines the clinic process and enhances our ability to care for our patients.