The Eastern Orthopaedic Association is very fortunate to have its twenty-sixth Annual Meeting in Rome. Rome! The very word brings vivid images to the mind. There is the grandeur of Imperial Rome with the Colosseum and the Forum. Christian Rome and its importance are exemplified by Saint Peter's and the Vatican. Renaissance Rome is noted for its masterpieces of art.
Along with Florence and Venice, Rome cradled the Renaissance. No one person is more associated with the art of this period than Michelangelo. When thinking about my Presidential Address, I was certainly influenced by the fact that the meeting was in Rome.
I have now practiced for enough years to have some perspective on the history of orthopaedic surgery. In my opinion, I have been fortunate to live through a period that represents the true rebirth, or renaissance, of orthopaedic surgery. Thus, my subject for today: the Renaissance revisited.
When I was a medical student in the early 1960's, orthopaedics was very limited. The fourth edition of Campbell's Operative Orthopaedics, copyright 1963, had one chapter on fractures, one on malunited fractures, and one on delayed unions and non-unions of fractures. In a similar fashion, traumatic affections of joints and miscellaneous affections of joints each were given one chapter. The discussion on poliomyelitis covered almost as many pages as the primary treatment of fractures. During that time, at the University of Pennsylvania, fracture treatment was divided between orthopaedic surgery and general surgery. Few adult reconstructive procedures were being done. Cup arthroplasty for hips was a notable exception. Other than this, resection arthroplasty and arthrodesis were more common procedures for chronic degenerative osteoarthrosis. Infection was also a major concern. The first clinically important resistance of any organism (coagulase-positive Staphylococcus aureus) to penicillin developed and struck fear in the hearts of surgeons.
While awaiting to start my orthopaedic residency, I was informed that there were only five books and two journals that I needed to purchase or to which I should subscribe. The books were Campbell's Operative Orthopaedics, Watson-Jones's Fractures and Joint Injuries, Ferguson's Orthopaedic Surgery in Infancy and Childhood, Orthopedic Diseases by Aegerter and Kirkpatrick, and Jaffe's Tumors and Tumorous Conditions of the Bones and Joints. The two journals were The Journal of Bone and Joint Surgery and Clinical Orthopaedics and Related Research.
I was told that the knowledge obtained from these books and journals would allow one to become a creditable orthopaedic surgeon.
In the mid to late 1960's, the orthopaedic world began to change just as the art world changed during the Renaissance. Dr. Salk and Dr. Sabin had provided for the end of the polio epidemic, and the attention of the orthopaedic surgeon was directed to other problems. New antibiotics were found that allowed more operative intervention for the treatment of orthopaedic problems.
Michelangelo, whose creations I have chosen to exemplify the art of the Renaissance, distinguished himself in multiple artistic areas. The beautiful sculptures of David and the Pietà rank with the best ever. The architectural majesty of St. Peter's is rivaled by few edifices in the world. Perhaps his finest contribution was the Sistine chapel. The frescoes in the Sistine chapel are considered by many to be the most outstanding paintings ever created.
In a similar fashion, a number of orthopaedic surgeons contributed many concepts to the orthopaedic renaissance. My own mentor, Professor Albert Ferguson, is an outstanding example. He wrote the classic textbook, Orthopaedic Surgery in Infancy and Childhood, and, in addition, wrote extensively on valgus osteotomy for the treatment of osteoarthrosis of the hip. He was also very interested in the treatment of congenital dislocation of the hip and helped to repopularize the Ludloff approach for this purpose. Dr. Ferguson made many other contributions to improve the treatment of trauma and of athletic injuries. He was active in the laboratory investigation of the use of metals for implantation in humans. He was one of a number of renaissance orthopaedic surgeons.
However, perhaps the man most credited with what might be considered the renaissance in orthopaedics was Sir John Charnley. He was first known to me in my orthopaedic residency for his book The Closed Treatment of Common Fractures. This, I might add, was a source of much agony for me as a resident. While my teachers kept insisting that both-bone fractures of the forearm could be reduced and maintained with the correctly applied cast, I had much difficulty with this. However, it was Dr. Charnley's prosthesis for hip replacement with the use of methylmethacrylate that paved the way for a whole new era in joint replacement and the end of untold suffering by patients.
The era of the specialist in orthopaedic surgery arrived. Fellowships began. New journals appeared, including Trauma, Foot and Ankle, and Sports Medicine. The list began to grow rapidly. Reconstructive surgery spread to the knee, elbow, wrist, fingers, and shoulders. Only the ankle appeared to be resistant. Fracture care improved with the use of the image intensifier, the AO system of internal fixation, intramedullary rods, and external fixation. Arthroscopy opened up many new treatment possibilities. Computed tomography scanning and magnetic resonance imaging improved diagnosis. There began to be superspecialists in fields such as pediatric orthopaedics, the spine, and orthopaedic oncology. The orthopaedic world, like the art world in Renaissance Italy, had no limits. This period, in my opinion, lasted from the early 1970's until approximately 1990.
Political changes and economic considerations dimmed the Renaissance in Italy. The Turks captured Constantinople; America was discovered; and, in the sixteenth century, France and Spain fought for domination of Italy. In a similar fashion, new forces entered into the orthopaedic world.
Managed care, cost-effectiveness, and FDA approval were terms that seemed to limit the expansion of our knowledge and put severe restraints on the manner in which we cared for our patients. No longer were the simple concepts of risk-benefit for an operation and for optimum patient care enough. Cost had to be considered when deciding treatment options and diagnostic techniques. Cost also had to be considered when choosing the best implant or prosthesis. Perhaps the most onerous to me was the change of the phrase doctor-patient to provider-consumer and its implication for the relationship that we have with our patients. These new considerations have changed the orthopaedic world rapidly in the last five years.
Is our renaissance over? That is a question that the future will have to answer. The approach to the care of our patients and to our practice is changing dramatically. Many of us wish that we could return to the time of ten to twenty years ago when it was possible that the orthopaedic renaissance was at its height. This will not happen. The changes will continue in health-care delivery, financing, and regulation.
Rather than lament this change, we must accept it. Take solace in the knowledge that the art world continued. Just as the Baroque followed the Renaissance, Bernini added to the St. Peter's of Michelangelo, and later artists provided us with outstanding creations, major progress will continue to be made in orthopaedics. Existing technology will be refined. New fields such as genetic engineering and the development of new bone-replacement materials are expanding. New techniques and devices will be created. There is a great future for orthopaedic progress.
As a result of our changing role in the health-care-delivery system, we will more frequently find ourselves providers in a managed-care system that is dictated by practice guidelines and to which patients' access will be more often limited by gatekeepers. We will be forced to consider cost thoroughly before ordering diagnostic studies and treatment options for our patients. It would be easy to bemoan our current status. However, rather than feeling sorry for ourselves, those of us who have practiced through this time should be thankful for the opportunity to have participated in the renaissance. More importantly, all of us who have lived through this age should realize that we are now more prepared to provide our patients with much better care than we were able to give in the mid-1960's. Henry Mankin, in a recent address, implied that there is almost no procedure that he is currently doing with the same technique that he used when he finished his formal training. This is probably true for all of us who have practiced orthopaedics for the last twenty-five years.
The future will be great. The satisfaction of being able to practice a vocation that allows an individual to personally affect the life of others will remain. There are few professions in which one can have such a direct impact on the quality of life of another human being. This is why we are orthopaedic surgeons.
In conclusion, most of us should be very thankful that we were able to participate in a remarkable time in orthopaedic surgery. Our patients today receive much better care as a result. The care will continue to improve, despite the restraints that we now face. The bottom line is the satisfaction that we get from taking care of individuals. This was true before the renaissance and during the renaissance, and it will remain that way in the future.
†Moshassuck Medical Center, 1 Randall Square, Suite 208, Providence, Rhode Island 02904.