In the 1950s, about the same time that John Charnley was perfecting total hip replacement surgery in England (see previous blog posts), American Paul Harrington addressed a vexing spine problem. To understand the problem, consider that a snake slithers along by curving its spine repeatedly from side to side. By comparison, a human’s spine is not as flexible. It can bend a little from left to right but is normally straight when its owner stands tall. If a human spine develops a curve to the side that does not go away when standing at attention, the bend is unbalanced and tends to progress. Untreated, the spine can collapse to the side and cause shortened stature, an unsightly humpback, and in some conditions even compression of the heart and lungs inside a twisted ribcage. A compromised life ensues.
This spinal side-to-side curve is called scoliosis. In the mid 20th century, polio-induced muscle imbalance was the main cause of this debilitating deformity, and orthopedists tried various spine stretching and bracing devices to correct, or at least halt, the deformity’s progression. As you might imagine, gaining adequate control to align the head over the pelvis with a brace consisting of metal struts, leather straps, and horsehair pads proved to be nearly impossible. Comfort was certainly not a priority. Attempts at surgical correction were similarly primitive and tortuous. Illustrated above are two patented, yet unsuccessful attempts to address the problem.
Although not by choice, Paul Harrington happened to be at the right place at the right time to make a difference. He had grown up in Kansas and played on three consecutive championship basketball teams at the University of Kansas. Thereafter he attended medical school and completed orthopedic surgery residency training in Kansas City. On return from overseas duty after World War II, job opportunities were scarce. He found one in Houston that nobody else wanted–surgeon for the polio clinic.
Polio was then epidemic, although its viral cause was unknown, and the Salk vaccine to prevent it was a decade away. Harrington, confronted with a large number of children and teenagers with post-polio scoliosis, went to work with the clinic’s brace makers. They made stainless steel hooks that during surgery Harrington attached to the spine above and below the curved sections. He connected the hooks with a notched rod on the concave side of the curve and ratcheted the spine straight, akin to jacking up a car. Similar hooks, connected with a tensioned cable, helped stabilize the correction on the convex side of the curve. Harrington then fused the portion of the spine that was now spanned by the instrumentation.
After surgery, the patient remained immobile until the fusion solidified. Months of bed rest were followed by several more in a plaster cast or brace that ran from chin to hips. At times a hook dislodged, the rod broke, infection occurred, or the spine did not fuse. Undaunted, Harrington, kept meticulous notes on each patient and gradually perfected the instrumentation, surgical technique, and post-operative regimen. This attention to detail eventually reduced the incidence of complications from 77% initially to zero, where it remained even after several hundred patients.
In 1958, he presented his results to the annual meeting of the American Academy of Orthopaedic Surgeons where his iconoclasm was met with astonishment, skepticism, and derision. A few, however, wanted to try his technique, and Harrington insisted that they first visit him and observe the procedure. Acceptance was gradual. In 1960, Time Magazine reported, “Some ailments seem almost preferable to their cures. A case in point is scoliosis, . . . treatment seems so punishing that [parents] cannot be persuaded to permit it even to save their children from permanent deformity. Last week Houston surgeon Paul Harrington, MD, was winning converts to a new and happier method.”
As with most innovations, more advanced instrumentation has supplanted Harrington’s system in the following decades. These provide better immediate stability and eliminate the need for post-operative bedrest and bracing. The new devices also allow for preservation of the natural front-to-back curves in the spine while correcting the dreaded side-to-side bowing. Although polio has all but disappeared in first-world countries, Harrington’s pioneering work still has purpose for injury-induced spinal instability and for scoliosis from other causes. When seeking work, knowingly or unknowingly, Harrington subscribed to the aphorism, “Go where you are needed,” and his diligence in Houston paid off.
Happy New Year.