Giants of Orthopaedic Surgery: Henry J. Mankin MD

Introduction

Examining the life and career of Henry J. Mankin MD (Fig. 1) reveals a tug-of-war of sorts between the University of Pittsburgh Medical Center (UPMC) and Massachusetts General Hospital (MGH) for the distinction of being the professional home that shaped one of the most-accomplished orthopaedic surgeons of our time. The truth is, Dr. Mankin likely shaped both orthopaedic departments more so than the other way around: a testament to his incredible force of nature as an educator, administrator, clinician, and surgeon.

Fig. 1.

Henry J. Mankin MD

“He was a consummate educator for students, residents, fellows, and practicing orthopaedists,” Mark Gebhardt MD, a friend, former colleague of Dr. Mankin, and Senior Editor at Clinical Orthopaedics and Related Research® said. “He was a researcher who received NIH funding for close to 30 years, which was very unusual at that time. He was an administrator and chairman of the department at MGH for 24 years. And he was a great surgeon/caretaker—his patients loved him.”

What makes Dr. Mankin’s career all-the-more impressive is the fact that he was such a well-rounded orthopaedic surgeon while ostensibly being in two places at once. Although Dr. Mankin worked as faculty at UPMC for only 6 years before moving on to Mt. Sinai in New York, the school treated the fiercely proud Pittsburgh native like an emeritus faculty member for the rest of his career. And Dr. Mankin was never shy about his affinity for his hometown school and alma mater.

“When he was at MGH, Henry knew more about what was going on at the University of Pittsburgh than most of the faculty working at Pittsburgh,” Dr. Gebhardt told CORR. “He always kept in touch and he was always sort of a de facto faculty member there. That’s the special thing about Henry—he managed to make that work.”

Building a Team

Whether in Pittsburgh, New York, or Boston, the orthopaedic department always seemed to be better for it with Dr. Mankin at the helm. Gerald Austen MD, the former Chair of Surgery at MGH who led the search committee that eventually hired Dr. Mankin as Orthopaedist-in-Chief at MGH, told CORR that Dr. Mankin turned a good orthopaedics department at MGH into a great one.

“He did this by attracting a group of really outstanding innovative orthopaedic surgeons.” Dr. Austen said. “He made it great by not only attracting innovators, but great clinicians.”

Upon his hiring, following a stint as Chair at the Hospital for Joint Diseases and Mount Sinai Hospital in New York, Dr. Mankin brought with him to Boston renowned hand surgeon Richard Smith MD, pediatric orthopaedic surgeon Michael G. Ehrlich MD, and Robert L. Leffert MD, who later became Chief of the MGH Department of Rehabilitation Medicine and the MGH Surgical Upper Extremity Rehabilitation Unit [3].

“One of the crucial leadership characteristics that made Henry successful was the focus on others within the team,” Dr. Austen said. “It takes the understanding that creating a team is crucial part of being chief. It’s not about you. It’s about bringing in younger people who are smarter than you and have a great potential.”

Dr. Mankin also championed diversity within his unit. In 2004, the American Academy of Orthopaedic Surgeons (AAOS), awarded him with the AAOS Diversity Award.

In a video that accompanied the award [1], Charles H. Epps MD, former chief of the Division of Orthopedic Surgery at Howard University said that Dr. Mankin was one of the foremost proponents of diversity in orthopaedics.

“Not only has he written about it; not only has he spoken about it—having participated in several symposia on the subject—but he lives and believes what he says about diversity in orthopaedics,” Dr. Epps said.

Challenging Traditional Orthopaedic Concepts

With Dr. Mankin leading the department, the MGH orthopaedics program became one of the best in the country. But beyond his ability to build a team, Dr. Mankin was also considered a world-class researcher of metabolic bone diseases, osteoarthritis, and musculoskeletal oncology (Fig. 2). His ground-breaking research, with long-term NIH funding, sometimes challenged some of the very basic concepts of orthopaedics.

Fig. 2.

Dr. Mankin was considered a world-class researcher of metabolic bone diseases, osteoarthritis, and musculoskeletal oncology. (Published with permission from Massachusetts General Hospital. Photo credit: Jeff Thibault).

“We used to inject steroids into the knee to relieve pain,” Freddie H. Fu MD, Chairman of the Department of Orthopaedic Surgery at the University of Pittsburgh School of Medicine and the UPMC explained. “But he actually warned us that steroids could be harmful to the knee. It may relieve pain, but it doesn’t really help the basic problem of wear and tear. He is way ahead of his time.”

Dr. Mankin authored more than 600 publications on a wide range of topics within pediatric and adult orthopaedics. His most cited paper developed a criteria for the classification of osteoarthritis (OA), which standardized and clarified the clinical definition of OA [2]. He was one of the first to describe cartilage biology in terms of cellular processes. His histologic–histochemical grading system for defects in cartilage (known as the Mankin system) is still used today. And his work in tumor biology is, of course, foundational within the specialty.

The MGH’s strong radiation oncology department developed methods for radiation delivery to patients with sarcomas. Dr. Mankin worked alongside Herman Suit MD, PhD, a giant in cancer care, and Daniel Rosenthal MD, FACR, Vice Chair of Radiology, to develop ideas including heat ablation of tumors, and advanced proton-beam therapy for sarcoma care. Within orthopaedic oncology, Dr Mankin’s biggest contribution included his database collection, as he was one of the first to organize his research in databases.

“Dr. Mankin started keeping databases before the word ‘database’ existed,” Kurt R. Weiss MD, orthopaedic surgical oncologist at the UPMC Hillman Cancer Center in Pittsburgh, PA, USA told CORR. “He could pull up all of the osteoartricular allografts that he had done. And he could do that in 1989 or 1990. That was not normally happening in that time.”

A Surgeon to Admire

Dr. Weiss was able to see Dr. Mankin work from a unique vantage point. A Pittsburgh native himself, Dr. Weiss was diagnosed with osteosarcoma in 1989 when he was 15 years old. After the initial diagnosis, his parents asked anyone with a connection to medicine: What’s osteosarcoma? Where do we go? Who do we see? The answers kept coming back: Talk to Dr. Henry Mankin in Boston.

“Little did we know that he was a Pittsburgher like me,” Weiss told CORR.

Dr. Mankin treated Dr. Weiss and they got to know each other during follow-up visits. Even in a room full of people, Dr. Mankin made Dr. Weiss feel like they were talking one-on-one.

“He always came in with the thundering herd—rounds with Dr. Mankin usually had up to 15 people,” Dr. Weiss said. “But to a 9th grader at the time like myself, it felt like a million people. And yet, he was about the most unpretentious person you would ever meet. In his clinics, people come all over the world to see this guy. Patients are spilling out of the waiting room and down the hall and around the corner of the next hallway. But when you were with him, he didn’t answer his pager, he didn’t talk to other people. You were his universe. You were his world. No one really cared that he was running 60 minutes behind. You knew that when it was your turn, that you were going to get all of his attention and that’s one of the things that I remember most about him.”

As his treatments continued, Dr. Weiss began to admire all of his doctors, including Dr. Mankin.

“I thought, ‘Maybe I should be a physician, too,’” Dr. Weiss recalled. “I am from a family of engineers and figured I would go down a similar path. But people like Henry impacted me so profoundly that it made consider being a physician. And when I finally got into medical school and matched in orthopaedics, Dr. Mankin was so proud that I ended up matching at the University of Pittsburgh.”

Lectures and Legacy

Dr. Mankin greatly influenced his residents and mentors in a variety of ways, but most notably through his now-famous 6:30 AM “Breakfasts with Henry” sessions, where he discussed all aspects of orthopaedics. Harry Rubash MD, who succeeded Dr. Mankin as Chief of the MGH, recalled that these didactic case discussions were always well-populated—even with students and trainees from other services.

Dr. Mankin described teaching as “the highest profession” [3] and found it to be the “most honorable and challenging of tasks” [4]. And while his lectures may have been somewhat out of the ordinary at times, they ultimately secured his reputation as a renowned educator.

One of his most well-known lectures involved steroids injected into the knee. Dr. Mankin was one of the first to note that the cells inside the knee cartilage are very active, and when he lectured about this, he would frantically move his arms up and down to show that these cells are really moving. And when steroids are injected into the knee, they would make the active cells in the cartilage inert. He would show this by getting on the ground on curling himself up into a ball, acting if he was a hibernating bear.

“I was not directly taught by him,” Dr. Fu told CORR. “He taught the people who then taught me. But it still feels like I carry his torch. I still use the lessons from his lectures today.”

Indeed, as an educator and teacher, Dr. Mankin was conscious of the fact that his lessons and lectures would likely be his long-lasting legacy. He often quoted his high school principal, who explained that as teachers, classes come and go, but one’s lectures could live on through his or her students forever [3].

For all of Dr. Mankin’s accomplishments, his foresight into knowing that he will live on through his lectures and former students, many of whom have gone on to do some tremendous things in orthopaedics—in Boston, Pittsburgh, and all over the world—may be his greatest triumph.