Iowa and Eugene, Oregon, Orthopaedics

Abstract

Over the last 50 years, the commitment of orthopaedic surgeons to basic and clinical research and evaluation of treatment outcomes has made possible remarkable improvements in the care of people with injuries and diseases of the limbs and spine. A group of Oregon orthopaedic surgeons has had an important role in these advances, especially in the orthopaedic specialties of sports medicine and hip reconstruction. Since Don Slocum (Iowa Orthopaedic Resident, 1934-1937), started practice in Eugene, Oregon, in 1939, three orthopaedic surgeons, Denny Collis, Craig Mohler and Paul Watson, who received their orthopaedic residency education at the University of Iowa, and three orthopaedic surgeons, Stan James, Tom Wuest and Dan Fitzpatrick, who received their undergraduate, medical school and orthopaedic residency education at the University of Iowa, have joined the group Dr. Slocum founded. These individuals, and their partners, established and have maintained a successful growing practice that serves the people of the Willamette valley, but in addition, they have made important contributions to the advancement of orthopaedics.

INTRODUCTION

University of Iowa Orthopaedics and Orthopedic Healthcare Northwest, in Eugene and Springfield, Oregon, have long enjoyed a strong connection. For more than half a century, both groups have recognized the importance of expertise in orthopaedic specialties and a commitment to improving patient care through research and critical evaluation of outcomes. The connection has grown stronger since Don Slocum (Iowa Orthopaedic Resident, about 1934-1937), established his practice in Eugene, Oregon, in 1939. Since then, six orthopaedic surgeons, Stan James, Denny Collis, Craig Mohler, Tom Wuest, Paul Watson and Dan Fitzpatrick, who received their medical education, or orthopaedic residency education, or both, from The University of Iowa have joined Orthopaedic Healthcare Northwest. Ken Singer, another member of Orthopedic Healthcare Northwest, was born and raised in Sac City Iowa; and, Arthur Steindler³ (1878-1959), the founder of University of Iowa Orthopaedics, treated Ken for a knee injury.

DON SLOCUM

Don Slocum spent two years as an orthopaedic resident at The University of Iowa with Arthur Steindler in the late 1930s and then another two years with Willis Campbell at the Campbell Clinic in Memphis, Tennessee. In his last year at the Campbell Clinic, Don decided to establish a practice in Eugene, Oregon, a small university town in Oregon's Willamette Valley, partially because his wife, Margann, was from the area. Willis Campbell wanted Don to stay at the Campbell Clinic and advised him that if he went to Eugene, no one would ever hear of him again. Willis Campbell's leadership of the Campbell Clinic confirms his ability to direct an orthopaedic program, but, examination of the major contributions to Orthopaedics in the 20th Century, shows that he underestimated Don Slocum.

Figure 1.

Don Slocum

When Don opened his office in Eugene in 1939, the city had a population of about 30,000 people clustered along the banks of the Willamette River. During World War II, Don left Eugene to serve in the military for six years. He spent some of his service time at Walter Reed Medical Center in Washington, D.C., where he wrote An Atlas of Amputations⁴³. Don asked Arthur Steindler review the book for him, particularly the chapter on gait; Dr. Steindler immediately recognized the importance and value of the book. As Steindler predicted, Slocum's An Atlas of Amputations became the definitive reference of its time and continues to rank among the texts that advanced orthopaedic practice. Following World War II, Don returned to Eugene and recruited a group of talented orthopaedic surgeons, including Howard Molter, Don Moore, Bob Larson and Jim Degge to join his practice.

Initially Don practiced general orthopaedics, but he became interested in the care of athletes when his son Tom suffered a knee injury while playing high school football in 1958. An exploratory operation on Tom's knee revealed an impacted tibial plateau fracture. This experience led Don to study the limited medical literature concerning the treatment of athletic injuries. The paucity of basic and clinical research on sports injuries and improving physical per formance convinced him that many athletes failed to return to their pre-injury level of physical activity because surgeons lacked expertise in the treatment of sports related injuries: an observation that made him focus more of his study and practice on athletic injuries. His clinical skill attracted the attention of Oregon coaches and athletes and within a short time he was providing all of the orthopaedic care for intercollegiate athletes at the University of Oregon and Oregon State.

Stimulated by challenges of trying to help athletes regain their ability to compete following injuries, Don began investigating the mechanisms of sports injuries and analyzing human movement to restore or improve physical performance^44–46. Bill Bowerman, the internationally recognized Oregon track coach, shared Don's interest in studying human performance and in particular running gait⁴⁶. Based on films of runners they concluded that a more upright posture could increase speed as compared with accepted approach of leaning the trunk forward. The upright running posture became a trade mark of the Oregon runners coached by Bowerman; and, in 1960, Otis Davis, an Oregon runner using the upright style, won the Olympic gold medal for the 400 meters. Don Slocum was among the first to investigate the relationships between symptoms of joint dysfunction and ligamentous laxity detectable by physical examination, and his studies of the roles of knee ligaments in stabilizing the joint while allowing normal motion were critical in advancing the diagnosis and treatment of knee injuries^8,34,47–52.

Along with several other orthopaedists, including Don O'Donahue, Jack Hughston, Jim Nicholas and Bob Larson, Don Slocum helped establish the American Orthopaedic Society for Sports Medicine. As a result of his clinical expertise, research and contributions to national professional organizations, he is recognized as one of the founders of the specialty of sports medicine. He was also a founding member of the Hand Society, making him one of the few individuals to have a role in establishing two orthopaedic specialties.

STAN JAMES

In the early 1960s, Charles Tipton, an accomplished Professor of Exercise Science at the University of Iowa, began studying the effects of exercise on ligaments and ligament healing^2,36,55–60. At that time, orthopaedists believed that ligament tears should be treated with at least six weeks of rigid immobilization⁷. Based on the results of his work on other tissues, Professor Tipton suspected that the orthopaedic surgeons were wrong. To test the hypothesis that early physical activity promoted ligament healing, Professor Tipton needed someone who could skillfully transect dog medial collateral ligaments, repair the ligaments and apply a cast. Stan James (UI 1953 B.A., 1962 M.D., 1967 Orthopaedic Resident) volunteered to help with the project and spent two years performing the animal surgery. To compare the effects of immobilization with activity he applied casts to half of the limbs and maintained the casts for six weeks. Professor Tipton tested the mechanical properties of the ligaments treated with immobilization and with activity; Stan, with help from Dr. Ponseti, and Victor and Angela Pedrini (scientists studying connective tissue biochemistry with Dr. Ponseti), analyzed the collagen content of the ligaments. They found that activity increased intact and repaired ligament strength, collagen concentration and collagen fibril diameter⁵⁷, an observation that contradicted established concepts of ligament healing and called into question accepted clinical practice. Professor Tipton must have been impressed with Stan's work; he subsequently worked with two other orthopaedists, Gerald Laros and Reginald Cooper⁴ on a study of the effect of limb immobilization on ligament insertions³⁶.

During his residency, Stan learned of Don Slocum's practice in Eugene and Don's interest in sports medicine. He visited Eugene in 1965 and two weeks later received a contract, a document that he quickly signed and returned. Because of a need for a hand surgeon between Portland and San Francisco, Don contacted Adrian Flatt, the founder of hand surgery at the University of Iowa⁶, and asked him to provide Stan with further intensive training in hand surgery. Dr. Flatt taught many generations of talented residents at the University of Iowa, but he remembers Stan as an exceptionally capable and mature surgeon²⁶.

Stan arrived in Eugene in the summer of 1967, and started practice as a hand surgeon. Although Don Slocum encouraged Stan to develop a hand surgery practice, he was intrigued by Stan's work on ligament healing and he included Stan in his studies of athletes⁴⁶. When Don learned that his friend Jack Hughston had been appointed the program chairman of a sports medicine conference sponsored by the American Academy of Orthopaedic Surgeons, Don advised Jack to include Stan's work on ligaments in the conference. Jack responded that such a "highfalutin" paper might be of interest. After Stan presented his findings, Marcus Stuart, an orthopaedist from the Campbell Clinic commented politely: "Young man, that was a very erudite paper²⁹." The new orthopaedic specialty of sports medicine was not ready to accept that an observation based on basic research, including biomechanical testing and collagen chemistry, should change entrenched beliefs and practices, and, for the next few years, presentations and discussions of ligament reconstruction and treatment of ligament tears continued to focus on the appropriate angle and duration of knee immobilization. Only after another decade had passed did the concepts that prolonged immobilization of a joint causes tissue damage and that early controlled activity promotes healing become widely accepted⁷.

Shortly after starting practice, Stan received an academic appointment in the Department of Exercise and Movement Science at the University of Oregon and began a series of clinical studies in sports medicine. Although he continued to practice hand surgery, his experience with University of Oregon athletes increased his interest in sports medicine, in particular, sports related injuries of the knee and injuries in runners. Don Slocum supported Stan's interest in sports medicine and they worked together on studies of knee ligaments^{33–35,47,50–52}. Don also introduced Stan to Bill Bowerman. The relationship with Coach Bowerman allowed Stan to conduct a series of investigations of running gait and injuries in runners that helped form the foundation of improved treatment of track athletes ^{1,30–32,46,54}. In the late 1970s, Stan reoriented his practice toward knee surgery so that he could spend more time working with athletes and investigating sports injuries. In the 1980s, his studies of the patellofemoral joint led Orthopaedists to appreciate the complexity of the clinical disorders of this articulation^9,10. Stan's expertise rapidly earned him an international reputation and led many of the world's greatest runners to select him as their physician. He also worked with the founders of the Nike Company, including Phil Knight, to develop a research program and improve the design of running shoes. Stan attributes his life-long interest in research, development of orthopaedic specialization and academic orthopaedics to his education at the University of Iowa, and to the encouragement and support of Don Slocum²⁹. Stan remembers Don as one of the most stimulating people he has encountered in his career and their clinical and academic collaborations have had a substantial impact as demonstrated by their multiple often cited publications^{27,33–35,37,46,47,50–53}.

DENNY COLLIS

In 1970, Denny Collis (UI 1970 Orthopaedic Resident) joined the group and rapidly established a large and successful practice dedicated to the treatment of patients with hip arthritis. During his residency, Denny worked with Dr. Ponseti⁴¹ to define the natural history of idiopathic scoliosis. Their 1969 publication, Long Term Follow-up of Patients with Scoliosis not Treated Surgically²², stands as one of the most important in clarifying the natural history of spinal curvatures and as an example of the critical importance of long term follow up of patients with musculoskeletal disorders. In Eugene, Denny continued traditions established by Don Slocum and Stan James in producing important clinical research^{11–17,19–21,23–25,28,39,42}. He established a computer database for the evaluation of the results of treatment of hip disease in 1970¹⁸, well in advance of similar efforts in large institutions and has maintained this data base since then. Denny has authored or coauthored numerous papers analyzing the outcomes of hip surgery^{11–17,19–21,23–25,28,39,42} including work with Dick Johnston and John Callaghan^19,39. Denny's many contributions to hip surgery were recognized by his peers when he was elected president of the Hip Society for 1996-97. Denny's selfless activities and commitment to research that advanced orthopaedic practice are exemplified by his service on the board of directors of the Orthopaedic Research and Education Foundation (OREF) for eight years, including his service as chairman of the board from 1996-99 and his generous support of this foundation. In addition, to honor Dr. Ponseti and ensure continuing excellence in pediatric orthopaedics at the University of Iowa, Denny served as co-chairman of the campaign to endow the Ignacio Ponseti Chair of Orthopaedics at the University of Iowa, a position now held by Stuart Weinstein⁵.

CRAIG MOHLER

In 1989, while performing a knee operation with John Albright, Craig Mohler (UI 1991 Orthopaedic Resident) heard Dr. Albright ask for a "Slocum" retractor. Shortly thereafter, Dr. Ponseti mentioned the scholarly contributions of Stan James and Denny Collis. In the next year, while relaxing in Dr. Cooper's ⁴ prosthetic clinic with Don Shurr (an expert on orthotics and prosthetics who has educated generations of orthopaedic residents), Craig, like many residents before and after him, listened with rapt attention to stories of Don's legendary career as a Hawkeye football player. One of those stories includes the reconstruction of Don's knee performed by Stan James when Don was a freshman, an operation that, despite Stan's great skill, only could restore Don to his former level of speed and agility. John Callaghan further increased Craig's interest in Orthopedic Healthcare Northwest when he described an elite group of orthopaedists in Eugene who divided their time between practicing the highest quality of orthopaedics, clinical research and exercising. A meeting with Denny Collis at the 1991 American Academy of Orthopaedic Surgeons and two visits to Eugene convinced Craig that the career opportunity in Eugene was exceptional. In 1992, Craig joined the group after finishing a fellowship in joint reconstruction at Rush Medical Center in Chicago. Denny Collis welcomed and encouraged Craig's interest in joint replacement and clinical research^20,21,39,40.

TOM WUEST

In 1991, Dr. Ponseti told Denny Collis that another Iowa Resident, Tom Wuest (UI 1981 B.S., 1987 M.D., 1992 Orthopaedic Resident), would be a great addition to the Eugene group. An interview convinced the group that Dr. Ponseti was correct. Following his residency, Tom and his wife Megan moved to Stoke-on-Trent, UK, where Tom worked with Professor John Templeton at the North Staffordshire Royal Infirmary. From Stoke-on-Trent the Wuests moved to Eugene; a community that he reports has the most attractive feature of Iowa City, a strong University in a relatively small town. About half of Tom's practice is general orthopaedics except for joint reconstruction and spine surgery, the other half is devoted to musculoskeletal trauma. His specific interests include pelvic, acetabular, calcaneal, pilon and plateau fractures^38,61. He serves as Secretary/Treasurer, Finance Committee Chairman and recruiting coordinator for the group. Megan works as a family therapist with the county juvenile detention center and their children Veronika and Samuel attend a French Immersion school. Tom and Megan note that their neighborhood in Eugene resembles Manville Heights in Iowa City, without tornados, snow, sleet and freezing rain. Tom enjoys the academic orientation, professionalism, clinical skill and camaraderie of the Orthopaedic Healthcare Northwest group, and he appreciates the "Iowa Influence"-critical thinking, technical skill, long-term follow-up of patients, and emphasis on non-operative as well as operative treatment.

PAUL WATSON

When Paul Watson (UI 1999 Orthopaedic Resident) looked for a practice opportunity, he identified only one private practice group that valued academic work as well has clinical expertise. He found that the partners in Orthopedic Healthcare Northwest enjoyed working together and helped new members to develop their own interests. A long tradition of excellence maintained by people who work well together and support each other has been important to Paul in selecting places for his education and work. This explains why he chose McGill University for Medical School, the University of Iowa for his residency and Orthopaedic Healthcare Northwest for his work. His decision to attend Harvard as an undergraduate is the only deviation from this pattern. Since Paul joined Orthopaedic Healthcare Northwest, his experience has been everything he expected and more. Although he has a special interest in shoulder surgery, he enjoys every aspect of orthopaedic practice including joint replacement and hand, foot, ankle, tumor and pediatric surgery. Paul has been able to arrange his schedule so that he has free time to spend with his family: he works four days a week and has dinner with his family almost every night, and Eugene has proven to be an ideal place to raise his family.

Figure 3.

Paul Watson and Dan Fitzpatrick at the Wuests' home in Eugene, Oregon (2002)

DAN FITZPATRICK

Last year, Dan Fitzpatrick (UI 1991 B.S.E, 1993 M.S., 1997 M.D., 2002 Orthopaedic Resident) joined the group. During his residency, Dan took advantage of his background in engineering and the facilities and expertise of the University of Iowa Orthopaedic Biomechanics Laboratory to conduct an investigation of ankle joint articular surface incongruities that won an American Orthopaedic Association resident research award. As he was considering his career direction after residency, Dan was attracted by the rich clinical and academic traditions of the Orthopaedic Healthcare Northwest group. During their first visit to Oregon, Dan and his wife Denise immediately recognized that Eugene offered great professional and personal opportunities and a warm and welcoming social life. Dan now finds himself very busy and enjoys being part of the great orthopaedic tradition in Eugene and Springfield. He is planning to pursue several research projects.

CONCLUSION

Since Don Slocum moved to Oregon in 1939, the population of Eugene has grown to more than 140,000, the group he founded has thrived and become a model of a private practice that has made sustained and substantive academic contributions, and the Iowa influence on orthopaedics in the Willamette Valley has become more pronounced. The members of the Orthopedic Healthcare Northwest group with an Iowa connection feel that their strong clinical practice, support for research and success in conducting clinical research stem from the principles and values established by Don Slocum and further developed by Stan James and Denny Collis. The group represents not only the highest standards of clinical practice, but demonstrates that a group of committed orthopaedic surgeons can make important contributions to advancing the specialty through development of specialized care, evaluation of the outcomes of their treatments and research.

Figure 2.

Jody Buckwalter and Denny Collis in front of the Oregon Duck's Football Facility in Eugene, Oregon (2002).