Hipology, Happology, and POSNA: Presidential Guest Lecture

It is an honor and a privilege to have been invited by POSNA President Rick Schwend to share with you perspectives gained by >40 years as a pediatric orthopaedic surgeon. Every POSNA member is where she/he is because of many factors—especially positive relationships. Many of us feel, as expressed by George Thompson, our 2017 Presidential Guest Lecturer, that we are especially lucky. And we are. When I confronted the great challenge of making these words be of value to you, my peers, I decided that collective wisdom might give me the best chance for success. My first thought was to go to the literature, to see what my predecessors had said. Alas—only 1 of the previous 34 Presidential Guest Lectures had been archived. Sobered but undaunted, I noted that 24 of the 33 previous lecturers were still alive and potentially available for direct consultation. When I reached out to these 24, they uniformly responded with enthusiasm to my e-mail or call, usually within 24 hours. Each gave freely of their precious time, eagerly reflecting not only what they themselves had offered during their lectures, but also offering contemporary insights. These esteemed colleagues, 19 of whom are past national society presidents themselves, uniformly encouraged me. They assured me that despite my reservations, I was positioned to tell a story worth telling. They suggested that my own story would be most compelling. Another common theme strongly emphasized by my esteemed advisors was the importance of strong interpersonal relationships not only to each of them, but also to POSNA as a whole, and to the various populations which POSNA serves. That of course leads me to thank these and other mentors, my family, colleagues, patients and their families, and friends for the positive aspects of who I am. A special privilege for each of us is passing on what we have been given. In my case, that includes conveying to the reader some sense of the orthopaedic and personal wisdom I have received from those people whom you never will meet yourselves. As I worked to lend coherence to my message, I found it helpful to present my experience in terms of people, connections, and ideas that have been important to me. Narrative is powerful in life in general and in medicine in particular. We humans seem to be hard-wired to enjoy stories. These stories seem most gripping if they involve people, connections among people, and the ideas. With this background, and encouraged by my predecessors, let the narrative begin! My first memory is of the chicken coop across the street from our little rented house in Iowa City, where my father began his orthopaedic training in Dr Steindler’s renowned department. Ignacio Ponseti was my dad’s very good friend. Perhaps this brief time planted the seed for my lifelong admiration for the Iowa orthopaedic tradition of deep interest in orthopaedic natural history, patient data collection, and years of practice in a single location. Later, after I grew up in Toledo and went on to Boston for college, medical school, and orthopaedic residency, it was my good fortune to come in close contact with John Hall. A large portion of the subsequent 45 years have been spent working in that same medical center in Boston, though with frequent energizing excursions and distant networking similar to career paths taken by role models in Iowa City (Weinstein), Toronto (Salter), Dallas (Herring), and at home in Boston (Hall). Dr John Hall was my first and most important mentor, as he was to many.1,2 He himself loved to tell stories, perhaps as much as he enjoyed surgery. He also loved his relationships with patient and colleagues. It is largely with him in mind that I reflect in this presentation how the field of hip preservation, the concepts of wellness in us and those we serve, and POSNA, have evolved over my 40 plus years in practice. HIPOLOGY John Hall inspired generations of orthopaedists—including me—to work in pediatric orthopaedics. Most of us pre-baby-boomer nascent pediatric orthopaedists were attracted by the generalist aspects of the specialty at a time when most adult orthopaedists were pursuing body region specialization. Counterbalancing that “macho” do-everything persona was the satisfaction offered by a deep interest in one area. For me, that special interest became the patient with a developmental hip problem. Although Dr Hall is most often remembered surgically for his exploits around the spine, he never lost his love for his hip patients and for solving hip problems with surgery. To be a resident with Dr Hall in Boston in the 1970s, and 1980s, soon after he had come from Toronto, was an exhilarating experience, as Ray Morrissy, Tony Herring, Al Crawford, the Ricks McCarthy and Schwend, and many others can confirm. His great clinical prowess attracted not only pediatric patients but also young adults with a variety of problems with onset in childhood. One learned many lessons from Dr Hall, as many outside the operating room as within it. This very charismatic man, imposing though his presence could be for those of us who knew his greatness, had a striking deep respect for his patients. He always sat down to engage even the youngest, taking care to avoid a dominant posture. A concept very important to Dr Hall, imbued to his trainees, was the primacy of principles over any particular technique, his belief being that techniques would evolve, though solid principles would be much more durable. Another important facet of Dr Hall’s life was his welcoming attitude to visitors and fellows from every corner of the globe. As with Dean MacEwen in Wilmington, he particularly valued close international ties through fellows and colleagues. In 1974, Professor Heinz Wagner, on his first trip to North America, gave a Harvard Orthopaedic Grand Rounds lecture that changed my life.3 The subject was the surgical treatment of complex lower extremity deformities, with an emphasis on hip dysplasia osteotomy surgery.4,5 Dr Hall was deeply impressed, recognizing the presence of another true surgical genius. I leaned forward to whisper to Dr Hall, who was sitting in the front row, that someone should bring such expertise to North America. My very good fortune was that Dr Hall not only agreed with me, but he made possible my dream to be one of those early adopters. Dr Hall and his nephew, John Wedge, who preceded me to Wagner’s clinic in Altdorf, strongly supported my candidacy for an AO Fellowship to Germany, where I spent nearly 6 months with Professor Wagner. I later returned to learn from Professor Wagner on 4 more occasions until his retirement in 1994, creating connections to his staff and to the German-speaking orthopaedic world that remain strong to this day. In the 1970s and 1980s, Heinz Wagner was a fascinating dominant figure in the fields of surgery of the hip and lower extremity deformity. His superb clinical results using his innovative uniaxial long bone fixator,5 complex femoral osteotomies,6 and spherical acetabular osteotomy7 were European state of the art in the days before Ilizarov and Ganz were well known. Professor Wagner’s Wichernhaus Clinic in Altdorf, and later in Rummelsberg was a Mecca for those deeply interested in lower deformity surgery and hip preservation.8 A few Wagner quotes may give some sense of this complex man3: “A failure to plan is a plan to fail.” “Restore function and bone structure will take care of itself.” “The average surgeon is an average surgeon.” Another famous Wagnerism: “Sophisticated operations are for sophisticated patients.” This very wise man was not disrespecting his patients, but rather he was an early adopter of the philosophy that all parties involved in complex treatments needed to be prepared as much as possible—particularly the patient. Robert Poss was a Boston colleague (later Vice Editor of the Journal of Bone and Joint Surgery) who shared my interest in hip osteotomy.9 Bob just preceded me in European fellowships with Professors Erwin Morscher in Basel, Renato Bombelli, and also with Wagner. Bob shared with Dr Hall and me, and with the long list of Americans who came after us to Europe and beyond, a belief in the large positive effects of the crosspollination which came from international exchange. On our return in 1979, Bob and I decided to organize a Boston-based hip and knee osteotomy course, as well as a series of instructional course lectures on hip osteotomy at the annual meeting of the AAOS, Our Harvard Osteotomy Course ran from 1984 through 1994, with national faculties including Dr Coventry from Mayo, Harris and Mankin from Boston, and Wagner, Ganz, Bombelli from Europe. The AAOS Hip Osteotomy Instructional Course Lectures began in 1984 and continue in modified from through the present.10–12 In 1980, we in Boston began to use Wagner’s technique for spherical dial acetabular osteotomies (SAO) to treat high grade dysplasia.13 The technique was virtually identical to the technique for rotational acetabular osteotomy (RAO) which Tagawa had independently developed in Japan.14 By 1991, our concern for acetabular bone viability in cases with previous pelvic surgery led to our replacement of SAO/RAO by periacetabular osteotomy.15 Happy though we were with the PAO corrections, we remained dissatisfied by postoperative frequent abductor dysfunction, which we felt was due to the large Smith-Petersen surgical exposure required for spherical osteotomy, and used by Ganz and colleagues for PAO. Our careful introduction of an abductor-sparing direct anterior approach16 was very satisfying and led to widespread adoption of this modified approach for not only PAO, but also for RAO variants in Asia. This distinctly American advance in the field of hip preservation was an important step in gaining respect for our generation of young (then!!) American hip preservers. As time passed, I and my Children’s Hospital colleagues, as Dr Hall had, found deep enjoyment in seeing how our patients “did” over time—not only orthopaedically, but also more generally in their lives. I have learned at least as much from my patients and their families as I have from my orthopaedic colleagues. I suspect we all have. A natural progression led to my seeing more adult patients-many relatives and friends of patients, and ultimately parents and children of patients. We were fortunate to work in an institution which had a tradition of extending care well into adulthood for developmental/congenital cardiac and G-U conditions as well as orthopaedic deformity. Hipology in Boston got a great boost when Jim Kasser, our truly administratively gifted chief for almost 20 years, took over as Chief of Orthopaedics at Boston Children’s Hospital from Dr Hall in 1994. Jim had the foresight to support the concept of an adolescent and young adult hip unit as a center of excellence for hip-preserving patient care, teaching, and research within a children’s hospital. The special structure of our unit and team, within a very supportive large department, attracted excellent hip team colleagues: Young-Jo Kim, Travis Matheney, Beng Yen—and an incomparable group of Hip Fellows. The momentum gained by our large experience with PAO, and later experience with reconstructive surgery for SCFE and Perthes Disease, was intertwined with and enhanced by very close collaborations with European colleagues in Reinhold Ganz’s unit in Bern and in Germany. In January, 2006, a small group of us—including Professor Reinhold Ganz and a few Swiss colleagues, but mostly American pediatric orthopaedists—Perry Schoenecker and his Washington University colleague, John Clohisy, met at the AO Hip Course in Mammoth, CA, to discuss the formation of a North American study group for hip preservation. From this simple beginning, the Academic Network for Conservational Hip Outcomes Research (ANCHOR Group) arose,17 largely supported over these last 13 years by pediatric and young adult hip surgeons: at TSRH in Dallas (Podeszwa and Sucato), Washington University (Schoenecker, Clohisy; Nepple, Pascual), Beaumont Hospital (Zaltz), University of Colorado and the Hospital for Special Surgery (Sink), Ottawa (Beaule), CHOP (Sankar), and Boston (Kim, Millis, Matheney, Novais, Yen). ANCHOR now comprises 12 centers and >20 surgeons, carrying out prospective studies on a variety of developmental hip conditions.18 Almost concurrently, the very active International Hip Dysplasia Institute, under Chad Price’s guidance, has developed to study infant hip dysplasia in a similar multicenter prospective manner. Hipology has been for me an immensely rewarding discipline in terms of connections with amazing people, both colleagues and patients, and in terms of principles and ideas regarding function at many levels. HAPPOLOGY Happology is my made-up singlet, defined by me, a trained orthopaedist but a practitioner not trained formally trained in wellness, as the study of, and the quest for, multidimensional wellness. Happology for me is best understood in terms of people, connections, and ideas. Wellness of physicians and their families, in addition to wellness in patients,19 has been a major interest of my invitor, POSNA Past President Rick Schwend. It was the timely topic of an immensely popular symposium at the 2018 POSNA Annual Meeting coordinated by my predecessor Presidential Guest Lecturer mentor Michael Goldberg, and Jennifer Weiss among others. Wellness, as the deep goal of the most effective medical care, involves parameters beyond the purely physiological which may not be easily measured. Nevertheless, physiologically attuned though we pediatric orthopaedists are, we are special in our appreciation of the whole patient, the family, and the child’s environment. We naturally understand wellness through the lens of the biopsychosocial model, in which relationships are crucial. Hipology has for me been inseparable from Happology, as so many of my most meaningful relationships have been with fellow hipologists, and with patients with hip problems who have come to me, and have remained in contact over decades. For many of us with special interest in hip conditions, hipology is much more than mastery of hip surgery, though technical mastery is satisfying and essential for those performing complex hip surgery. For me, happology in hipology has come with appreciation for the depth of patient experience beyond the purely physiological. My Happology/Wellness, and I think that of my patients, has improved as I have come to understand and appreciate the multidimensional biopsychosocial parameters that influence function. More generally, more accurate insights usually can be gained from integrating multiple perspectives. That said, directly dealing with complexity as opposed to choosing simple solutions is not something that our brains prefer to do, as Daniel Kahneman, in Thinking Fast and Slow, has vividly pointed out.20 Certainly excellent 3–dimensional (3D) perception and excellent anatomic knowledge are essential for the competent surgeon. 3D information often is better than 2D—and indeed, for the analysis of complex hip conditions, the fourth dimension, of motion, can offer better understanding. Similarly, additional information gained from using the biopsychosocial model, ideally from the patient’s perspective, is very powerful in achieving the best possible outcomes for all concerned—particularly the patient. In the 21st century, a patient-centric model of medical care has emerged which clashes with the traditional physician/medical center-centric model of care. Cardiologist Eric Topol’s interesting book, The Patient Will See You Now,21 views the smart phone as the disruptive innovation which has been associated with turning the physician-dominant paradigm of health care upside down. Topol and others reflect that the wise contemporary physician should move beyond grieving for the good old days when most aspects of medical care revolved around the physician. Rather, we should embrace present reality, with its heavy reliance on technology and with progressive erosion of physician autocracy. Indeed, algorithms and computers may replace some of the traditional physician functions. On the positive side, potential efficiencies of technology can be liberating. Even more important, as both Topol and Bernard Lown have noted, the caring physician can and should have a permanently secure role in providing humanistic compassion, communicative judgment, and empathy. No computer is close to fulfilling this role. POSNA We in POSNA are together today because >40 years ago, a group of active pediatric orthopaedists came together to the Orthopaedic in to in their from the Orthopaedic which had in at the of a true pediatric orthopaedic The was the first home developed for pediatric orthopaedics. The concept of to pediatric orthopaedic was but its including the of only 1 member led directly to the of the by Robert Robert and others who and for the to come together to discuss pediatric orthopaedics. 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