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John Howard Moe, MD: An Autobiography Dated to 1977-78 (Editor)
Spine Deformity 3 (2015) 429e435 www.spine-deformity.org
John Howard Moe, MD: An Autobiography Dated to 1977-78 (Editor) The youngest in a family of six children, I was born on a farm a short distance from the town of Grafton, North Dakota, on August 14, 1905. The population of Grafton at that time was about 1,500. It was primarily a community of Norwegian immigrants. My childhood and early youth on the family farm were typical of the times. Schooling was in a one-room schoolhouse a mile away, with an enrollment averaging 10 to 12 students, most of whom were my cousins. I was brought up in a Norwegian-speaking home and could not speak English when I first went to school at the age of six. My parents were immigrants from Norway. My father’s family came across Minnesota in an oxen-drawn covered wagon when he was 12 years old. At the age of 18, he homesteaded and married a girl who had recently emigrated. My early recollection of life on the farm was mainly that of hard work and poverty, since the farm my father had homesteaded was rather poor land. My uncle, after whom I was named, spent a great deal of time holding me in his lap in my infancy. He was a victim of tuberculosis and died when I was about 1 or 2 years old. This was probably the source of my problem with tuberculosis in my early adult life. My schooling in the country school continued until the eighth grade, when I transferred to the public school in Grafton. On finishing the eighth grade, I recall rather vividly that I was selected as a speaker at graduation, giving President Woodrow Wilson’s ‘‘Declaration of War against Germany’’ from memory. The following year, I entered high school in Grafton, and graduated as Salutatorian in 1923. University Days It was time for me to decide what to do with my life. I was not impressed with farming, and upon urging by my mother and my sister, who was a nurse, entered the University of North Dakota in 1923. My parents were able to provide very little money for my University schooling, so I worked at washing pots and pans at a hotel. My bedroom consisted of a cot in a room with a dirt floor in the basement of the hotel, and my only transportation was an old bicycle that was soon stolen. 2212-134X/$ - see front matter http://dx.doi.org/10.1016/j.jspd.2015.07.002
The greatest influence in my life was the encouragement and conversations with my sister, and as a result in my second year as a University student, I decided to take the remaining necessary requirements for what was known as ‘‘pre-medicine.’’ At that time, only 2 years of the ‘‘premed’’ course were necessary, although many of those who became my fellow students in medicine had taken 4 years. During my years at the University of North Dakota, I continued to work full-time to support myself. My job in the hotel lasted for the first 6 months; then I was fortunate to obtain a job waiting tables in the ‘‘Commons,’’ for which I received board. My summer job at the North Dakota Public Health Laboratory worked in well with the career of medicine that I had now chosen. I traveled to various towns throughout the state and was able to start saving money for the years of study ahead. I graduated from the University of North Dakota with the Class of 1927. I returned there in 1968 to be honored with the Sioux Award for Outstanding Alumni Achievement. In the fall of 1927, I was admitted to Northwestern University in Chicago, Illinois, financing myself through school
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loans, personal loans from friends, and working nights. My lifesaver from the standpoint of a job was employment as a ‘‘night doctor’’ at the first-aid station at the Standard Oil plant in Whiting, Indiana. I commuted daily by bus, and this travel time provided adequate time for study en-route to school and on the job, since there was actually very little emergency work for me to do while ‘‘on call.’’ During the time I attended Northwestern University, I accomplished very little other than work and study. I did not do any research nor gain any honors. My grades, however, were satisfactory and I passed into the senior year in 1929 in the upper third of the class. Graduation day came, but interestingly enough, I did not participate in the exercises, in spite of the many sacrifices and hard work involved in obtaining this very important degree. Because of the fact that an MD degree was not granted upon graduation at Northwestern University, I obtained an internship at the Illinois Research and Educational Hospital, a part of the University of Illinois. At the end of the year, I received my MD degree, and have since been considered a member of the Class of 1930. Upon finishing my internship, I was in a quandary as to what field of medicine to go into. Since I had become close friends with a nurse in obstetrics and gynecology, I made plans to go into this specialty. Dr. Hark, associate professor of obstetrics, and his wife were also influential and were good friends of mine. As a result, I almost entered the obstetrical training program. However, my roommate, Dr. Claude Lambert, who was in his final year of general surgery residency at the Research and Educational Hospital, wanted to change to orthopedic surgery under Dr. Henry Bascom Thomas, chief and head of orthopedic surgery at the University of Illinois. He persuaded Dr. Thomas to let me fill in several months in order to hold the place open for him when he returned. It is this position as personal assistant to Dr. Thomas that led me into the field of orthopedic surgery. I know of no one who was a better friend at the time, and over these many years, than Dr. Lambert. At the completion of this period of substitution, however, I was again without tangible direction in my life. Residencies Few residencies were available in 1930, and for lack of funds, I moved from place to place searching. During my internship, I had applied for residencies in surgery at the University of Illinois and the Mayo Clinic in Rochester, Minnesota. The former had no room for me in their program at that time. The Mayo Clinic wrote me about a year later saying that my application had been accepted. By that time, however, I had already accepted a position as assistant surgeon for the Cotton Belt Railroad Hospital in Texarkana. Following the termination of that, I accepted a 6-month residency at Gillette Children’s Hospital in St. Paul, Minnesota. As I reflect on my career
in orthopedic surgery, Gillette Children’s hospital was my first exposure to the field in which I was to specialize in years to come. Dr. Carl Chatterton, then Chief of Staff, invited me to join him in private practice. As July 1931 approached, the depression was at its lowest ebb. Dr. Chatterton was forced to tell me that he could not afford to take anyone on and pay a salary. Again, my career was seemingly at a dead end. I received my California license in 1931, and applied for and received a residency at the San Joaquin General Hospital, on the outskirts of Stockton, California. Although not approved as an ideal residency hospital, I did gain a tremendous amount of training there in general surgery and orthopedics. There were many accident cases, and the Chinese community of Stockton provided a great number of patients who had performed ‘‘hari-kari’’ and needed treatment. It was there that I came to know an orthopedic surgeon on staff, Dr. George Sanderson. He knew of my experience in children’s orthopedics at Gillette Children’s Hospital, and as his assistant I gained a great deal of knowledge of orthopedic surgery, particularly in the treatment of children. In 1972, I returned to San Joaquin as a guest speaker to honor Dr. Sanderson on his retirement. During the summer of 1933, the pulmonary tuberculosis that had plagued my childhood recurred. I had never been examined via sample culture, nor were active tubercle bacilli ever found in my sputum; however, on x-ray, a good-sized apical lung lesion was found. I entered the Brete Hart Sanatorium at Murphy, California, in the Sierra foothills. My recuperation in the hot, dry climate was speedy, and I soon left to spend the latter part of the fall with my sister and her husband in Salt Lake City, Utah, where I fully recovered and was ready for the next chapter of my life to unfold. Early Days of Orthopadic Surgery in Minneapolis and St. Paul While in Salt Lake City, I received a letter from Dr. Carl Chatterton telling me of a vacancy in Minneapolis, Minnesota, following the death of one of his former associates, Dr. Carl Flagstad. I reminded Dr. Chatterton of my inexperience in orthopedic surgery, but he encouraged me to come at once and take over Dr. Flagstad’s office and practice. Furthermore, he told me I would be placed on the staff of Gillette Children’s Hospital, and that he would give me personal preceptorship. With great anticipation, I returned to Minneapolis. Having taken the State Boards in 1932, I received my Minnesota license and began my orthopedic practice in 1933, but financial disaster ensued because of the ever-present depression. Fortunately, Dr. Emil Geist, one of the well-known orthopedic surgeons of the time, was in need of help, and I became his permanent assistant and felt that my career was finally forging forward in the field of orthopedic surgery. When Dr. Geist returned from the American Orthopaedic
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Association Meeting in Washington, DC, in the spring of 1934, he died suddenly of a coronary attack. Salvation from starvation came about through Fairview Hospital in Minneapolis, Minnesota. Through the friendship and recommendation from my good Norwegian friend, Dr. Ivar Sivertsen, the hospital accepted me as a staff orthopedic surgeon and he supplied me with patient referrals, numerous enough to enable me to make a small income, sometimes only a few dollars a month. Meanwhile, Dr. Chatterton loaned me money and put me on the Staff of Gillette Hospital as an operating orthopedic surgeon, with a stipend of $150 per month. In 1936, I was appointed head of orthopedics at Minneapolis General Hospital, now called Hennepin County Medical Center. As a result of a very busy schedule and many patients, my surgical skills developed rather rapidly. I was given an appointment at the University of Minnesota soon thereafter as Clinical Instructor in Orthopaedic Surgery (1934e1936), under Dr. Wallace Cole, Head of the Division of Orthopaedic Surgery. My career and professional life began to progress. From then on, there was sufficient advancement in my status as an orthopedic surgeon, and finally enough income to repay my numerous financial obligations. My first Interest in Spinal Work During the years of my early association from 1934 to 1947 with Gillette State Hospital for Crippled Children (now known as Gillette Specialty Healthcare), I was impressed by the total failure of scoliosis treatment. Patients were routinely fitted with a leather jacket and given suspension traction, occasionally with a spine fusion, nearly always resulting in complete failure. Fusions were done without regard to the curve pattern, and most often were performed at the junction of the two curves. As a result, the patient experienced no improvement in his/her curve, which continued to progress. Prior to his death in 1932, Dr. Carl Flagstad had done spinal fusions on a number of the scoliosis patients at Gillette Hospital. His 50% mortality rate was frightening. This was the era before the blood bank, and no blood was available for transfusions. Blood typing was full of errors. Transfusions were carried out by direct flow from donor to patient, and reactions were severe. With such poor results to report, Dr. Chatterton, Chief of Staff at Gillette Hospital at that time, asked Dr. Flagstad to discontinue doing these fusions. Various Influences in My Scoliosis Work In the fall of 1947, I was privileged to join a small group of outstanding orthopedic surgeons from all parts of the country at the Milwaukee Children’s Hospital in Milwaukee, Wisconsin. The members of the group were Drs. Walter Blount, John Cobb, Leslie Mitchell, George Hammond, George Garceau, Claude Lambert, Marcus Stewart, Charles Roundtree, William Bickell, Rufus Aldridge, George
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Carpenter, and I. At the meeting, one whole day was spent on the subject of scoliosis. Dr. Al Schmidt, who had recently finished training at the Hospital for the Ruptured and Crippled in New York City (now Hospital for Special Surgery), participated freely in the discussions as did Dr. Cobb, who headed the clinic there since 1936. The discussion continued all through the night, and I made lengthy notes on the way home, writing down all I had learned from Drs. Cobb, Garceau, Blount, and Schmidt. After this meeting, I immediately contacted Dr. Chatterton and asked permission to inaugurate a scoliosis service in the hospital under my direction. It was my attempt to develop a more realistic and productive treatment in this much-neglected field in orthopedic surgery. They agreed, and in the late fall of 1947 the Scoliosis Service began under my auspices at Gillette Children’s Hospital. The first patients were admitted later that year, and the first cast correction and spinal fusion done in January 1948. The Social Service Department located many candidates for scoliosis treatment, and in a short time there were 25 to 30 scoliotic patients undergoing evaluation and treatment. During this early period of scoliosis treatment, my main source of information was Dr. John Cobb. I visited him frequently, and watched his cast application and surgical technique. Whenever I experienced problems, I would send him the x-rays and ask his advice. He would respond with long letters, outlining the operation step-by-step. Involvement in Poliomyelitis Surgery Over the Years Between 1934 and the development of the vaccine, there were periodic outbreaks of poliomyelitis, with the last epidemic occurring around 1955e1958. It was during this time that Sister Kenny came to Minneapolis and was treating a large number of poliomyelitis patients, mainly with a rejuvenation of the hot pack treatment and early motion of involved joints. Some good resulted from her treatment but I found that her treatment had no beneficial effect on joint contractures or curvatures of the spine. I did fusions on a large number of poliomyelitis patients of various ages. Infants were held in corrective casts and the Milwaukee braces and Lowman fascial transplants were used freely for abdominal weakness. These did not have any beneficial effect on the curve, which almost routinely required cast correction and fusion. Fusions were done as indicated, many of them in children 5 to 10 years old. Contractures were surgically released prior to fusion. I was deeply involved with the poliomyelitis program and gained much experience in the treatment of collapsing scoliosis. Residual poliomyelitis persisted for many years thereafter, and I learned through knowledge gained at Rancho Los Amigos Hospital how to deal with the respiratory cripples, so that surgical fusion could be safely performed. We still see the late effects of poliomyelitis to some degree, but I have not seen an acute poliomyelitis case for many years in the United States. Poliomyelitis is still a
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problem in Mexico and in the destitute areas of South America. I now have a great deal of exposure to poliomyelitis poorly fused years ago, which have been turned over to me for recorrection. Development of Plaster Cast Techniques At the Scoliosis Service at Gillette Hospital, I was closely following the techniques of Dr. John Cobb. This was a cast that incorporated the entire head, with the Risser principle of wedging correction used until 1952. After visiting Dr. Joseph Risser for 2 weeks and seeing his handmade frame (which was entirely new at the time), I returned to Minneapolis and made a Risser frame out of gas pipe. Thereafter, this technique of cast correction was adopted by me and since then turnbuckle casts have been rarely used. My acquaintance with Dr. Yves Cotrel of Berck-Plage, France, showed me the advantages of a suspension strap placed against the convexity of the curve from an overhead frame. This combined with distraction allowed us to gain better correction, with fewer pressure sores. The cast gradually became an extremely well molded, practically nonpadded cast. On high curves, the neck was included; on lower curves, a torso cast was sufficient. A modified Risser frame with overhead bars was developed and is still in use. Preoperative casting was routinely used for many years, but I have found it unnecessary except in some of the special curves. The first turnbuckle cast correction and spinal fusion in January 1948 at Gillette Hospital was successful in gaining good correction, but better corrections were obtained after the adoption of the Risser-Cotrel technique. Fusions were done in a variety of fashions during my early years at Gillette, but in 1952 I developed an excellent facet fusion technique that has been used ever since. Postoperative immobilization was reduced from 1 year to 7 or 8 months after the adoption of the Harrington rod instrumentation. Postoperative bed rest immobilization was continued for 6 months until I found that with good cast application, we could ambulate these patients immediately after the cast was applied postoperatively, and this is still my method of choice. Development of Instrumentation in Scoliosis In 1960, the first corrective instrument I used, devised by Dr. Paul Harrington of Houston, Texas, was an internal distraction rod held above and below by specially designed hooks. I did not at that time adopt Dr. Harrington’s technique of rod insertion without fusion. Modification of the hooks and later in 1976 my modification of the rod by having the square end fit into a square hole in the hook have proven to be highly beneficial in preventing loss of lumbar lordosis. The Harrington rod has also been found beneficial in partially correcting thoracic lordosis. Very recently, I have rejuvenated the use of the Harrington threaded bar placed subcutaneously
and held by hooks above and below with minimal exposure, thus avoiding subperiosteal stripping. Using external correction with the Milwaukee brace is essential. Dr. Allen Dwyer of Sydney, Australia, made a significant contribution to anterior approach to thoracolumbar and lumbar curves. For the most part and in all collapsing spines, I have found it necessary to use a Harrington rod and fusion posteriorly in addition. We have never used the Dwyer apparatus in thoracic curves. Anterior fusion, which was begun by Dr. Arthur Hodgson in Hong Kong was adopted at my University service in the 1970s. I have gradually come to use it more often when indicated in certain congenital scoliosis and in kyphoscoliosis of neurofibromatosis. Its primary use is in kyphosis. Dr. Klaus Zielke’s (of Tubingen, Germany) modification of the Dwyer apparatus has been adopted in recent years and appears to be beneficial. My own contribution to fusion technique has mainly been the development of a good exposure and facet fusion, and the development of better criteria for selection of the fusion area. The halo hoop has had very limited use in my hands. I have not felt it to be as effective as halo distraction or halopelvic distraction and the halo cast. It is too fraught with complications. The Development of the Milwaukee Brace Since the early inception of the Milwaukee Brace in 1946, I have worked closely with Dr. Walter Blount of Milwaukee, Wisconsin, on its development. Together, we have changed it from an unsightly and unsatisfactory brace to a closely fitting brace, and complications have practically been eliminated. Lately, however, I have found that the Milwaukee brace will often produce a thoracic lordosis and thus have added this aspect as one of the contraindications to its use. The School Screening Program and close observation on many cases has modified my opinion to the use of the brace. I no longer routinely fit a Milwaukee brace to a patient with a 20-degree curve in juvenile or early adolescent years. In many of these cases, the curve does not increase and does not require full treatment. Some patients, however, have a severe rib hump with a small curve, and these require surgical treatment and are not responsive to the brace. I consider the Milwaukee brace as the best orthosis for thoracic and combined thoracic and lumbar curves. The main objection to its universal use has been its use in patients who are too old, too mature, and who have too large a curve. Fifty degrees maximum in adolescents has been used as the dividing line between brace and surgical treatment. In juvenile cases, I use the brace on 50 to 60 degree curves but have not found it useful or satisfactory in large, neglected infantile idiopathic curves. I was among the very first to use plastic in the pelvic girdle of the Milwaukee brace. The first plastic was orthoplast, which was satisfactory but disintegrated in certain patients because of the contents of their perspiration. We have added the plastic brace called the Thoraces-Lumbar-Sacral Orthosis
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or ‘‘TLSO,’’ which is a lower back brace that originated in Boston. It has been proven useful in the treatment of mild curves less than 40 degrees in the lumbar and thoracolumbar region. There is a pad over the lumbar curve convexity, and on the opposite side the plastic extends upward to give a counterforce to the lumbar pad. It does not quite reach the axilla. It is made out of polypropylene, which we have found as the most satisfactory plastic. Many times, it is as good in every way for certain smaller curves as the Milwaukee brace. Concepts of the Posterior Fusion Paralytic spines are of many etiologies, but they all present the same problem. A long, flexible spine must be treated by excellent fusion technique plus a Harrington rod. The Dwyer apparatus is an excellent adjunct to the paralytic spine in the adolescent when used in combination with the posterior fusion and Harrington instrumentation. Using this combination, the pseudoarthrosis rate is reduced to an extremely low percentage. When I reported my first 217 cases of early paralytic scoliosis in 1957, the pseudoarthrosis rate was high in the first 60. Through modification and improved knowledge and in the use of autogenous iliac bone instead of bank bone, the pseudoarthrosis rate declined. The addition of the Dwyer apparatus and interbody fusion when indicated has also improved our statistics. In the early days, we did not recognize pseudoarthrosis as often as we should have, nor did we always repair them: loss of correction was very common. We have found this to be a fault, and now we regularly repair a pseudoarthrosis before loss of correction takes place. Development of the Twin Cities Scoliosis Center As the Scoliosis Service at Gillette Hospital developed and my name became known, I began to see private patients with scoliosis. In 1957, I was asked to become Clinical Professor and Acting Director for the Division of Orthopaedic Surgery at the University of Minnesota, which was later changed to the Department of Orthopaedic Surgery. I continued at the University full-time until 1973. Increasing numbers of private patients were admitted to the University and I headed a scoliosis service paying particular attention to severe cases and respiratory cripples. The Department of Anesthesia developed an excellent respiratory service to help me with this. Because of the difficulty in having good x-rays taken and storing them in a separate section at the university, I began to take more and more scoliosis patients to Fairview Hospital, developing an outpatient department here. By then, I had obtained authority from the School of Medicine to establish an affiliation of Fairview Hospital with the University of Minnesota. The Fairview Hospital cooperated in setting up an excellent facility for outpatient care and surgical treatment
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for me. In 1963, Dr. Robert Winter finished his training with me and went into private practice as a hand surgeon. Dr. William Kane, a Scoliosis Fellow who had obtained his PhD degree, was chosen as the Director of the Resident Education at Fairview and St. Mary’s Hospitals. When he left to take the professorship at Northwestern University, I obtained permission to have Dr. Robert Winter join me in the Scoliosis Service as Associate Professor at the University of Minnesota. His first patients were all referrals from my own new patients. Shortly thereafter, Dr. David Bradford from Dr. Frank Stinchfield’s service at the New York Orthopaedic Hospital came to work with me. He was given an appointment as Associate Professor at the University of Minnesota, developing a deep interest in scoliosis under my tutelage. Dr. Bradford was also my protege, and his first patients were referrals from me. As time went on and more and more patients were seen in the Scoliosis Service at Fairview Hospital, we began to give serious thought to establishing a Twin Cities Scoliosis Center in the new Fairview-St. Mary’s Medical Office Building, which is adjacent to both hospitals and connected to them by skyways. In 1975, the Scoliosis service facilities were moved there and became the Twin Cities Scoliosis Center. The patients being referred to this center have become increasingly severe; mortality and morbidity have been low, but complications of various types have arisen, including emboli during treatment with halo-femoral traction. I am still maintaining an active scoliosis practice. There were a total of 5,885 patients seen in our center in 1976; 1,164 were seen by me. Of these patients, 1,506 were new, 219 of which were mine. We held a total number of 201 clinics; personally, I held 71. There were a total of 439 surgeries done for scoliosis; 102 were performed by me. The members of the Twin Cities Scoliosis Center, of which I am the director are, Dr. Robert B. Winter, Dr. David S. Bradford, and Dr. John E. Lonstein. Dr. Jack K. Mayfield recently joined us after he spent 6 months with us as Fellow in Scoliosis.
The John H. Moe Scoliosis Fund and Fellowship In 1969, the John H. Moe Scoliosis Fund was established as a memorial to my wife, Marguerite. The John H. Moe Scoliosis Fellowship was established in 1971. The first man to finish this service was Edgar Dawson, MD, who is now in Los Angeles, California. Annually we accept two or three Scoliosis Fellows depending on our finances, as it is difficult to provide the adequate salary of $20,000 annually for more than two Fellows at a time. We prefer to have them study scoliosis for a period of 1 year but have accepted 6-month participants. They are intermittently involved in our clinics, and also do a good deal of surgery under staff supervision and temporary licensure.
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International Program The staff members of the Twin Cities Scoliosis Center provide many lectures both in the United States and foreign countries. Beginning in 1960, I have helped establish excellent scoliosis services in Sao Paulo and Rio de Janeiro, Brazil. My attention has recently been concentrated on the Caribbean Islands, Puerto Rico, and the Dominican Republic. I am also helping to set up a scoliosis service in Venezuela under a former scoliosis fellow. My first trip to South America 13 years ago was at the request of CARE-Medico Orthopaedics-Overseas to make a complete survey of facilities in Columbia, Peru, Chile, and Brazil. I was able to establish good teaching facilities in all of these countries except Peru which did not seem to be very interested. The international flavor of our center has continued to flourish. We have visitors from all parts of the world and have had fellows from as far away as Iran, Pakistan, Australia, and South Africa. We have a continuous flow of patients from South and Central America, Iran, Canada, Mexico, Puerto Rico, and a few from Italy. The number of foreign doctors who have stayed here to study for varying periods of time during the last decade or two are in the hundreds. While I was Professor and Director of the Department of Orthopaedic Surgery at the University of Minnesota, I arranged annual 3-day symposia as a part of the Continuation Education Courses in Medical Education. In 1964, I held the first course on scoliosis and at this course it was suggested that we form a Scoliosis Research Society. I served as the president for 3 years.
The Future of Scoliosis Surgery Since the advent of the School Screening Program in Minnesota in 1948, I have learned a great deal about the natural history of idiopathic scoliosis. I have found that a great many small curves in the juvenile years do not progress, and some of them resolve spontaneously. Perhaps in part, this is due to the positioning of the patient at the time the x-ray is taken. In small, flexible curves, it is very easy to produce a small curve in a child who does not stand erect or who might be bearing weight unequally on her or his extremities. Whereas I was originally inclined to consider curves of 20 degrees as candidates for a brace, I now feel that no bracing is requireddwhether it be a Milwaukee brace or a TLSOdif the curve remains flexible. Curves progressing beyond 25 degrees and particularly if they become structural and lose their flexibility should be treated with bracing. Our recent studies of the Milwaukee brace treatment have demonstrated clearly that small curves can nearly always be controlled with a Milwaukee brace or, in the case of the lumbar curve, by the TLSO. It is my hope that with the ever-broadening legislative scope of the US and worldwide school screening programs,
combined with increased knowledge in the minds of pediatricians and general practitioners as well as orthopedic surgeons, far less surgery will be done on teenagers in the future. However, because of a lack of understanding and communication among human beings in the basic fundamentals of scoliosis detection and treatment, there is dim hope that surgical treatment of idiopathic scoliosis will be abolished completely. Furthermore, I recognize the fact that even with adequate bracing, many curves progress from small curves to large curves. Therefore, in idiopathic scoliosis, at least, all we can hope for now is a lessening in numbers of those who require surgery. In regard to congenital scoliosis, I believe that the answer to the prevention of severe curves lies entirely in early detection through screening and early fusion. This requires experienced judgment because not every congenital scoliosis requires a fusion. There is no field of scoliosis more difficult than the treatment of a myelomeningocele patient. Here again, early fusion while the curve is beginning seems to be the best answer. I have had satisfactory results with the use of Harrington instrumentation with the rod placed subcutaneously and a minimal exposure of the spine for hook placement above and below with external protection (ie, instrumentation without fusion). This is probably the answer to the collapsing spine of the neuromuscular type of scoliosis. Where Our Energies as Specialists in Scoliosis Should be Directed This is a continuous challenge and problem. Biochemical studies must be continued, although thus far, they have led us nowhere in idiopathic scoliosis. Genetic studies, like likewise, have been thoroughly explored. Nationalization of the school screening program will help us find the innumerable small idiopathic curves that persist into adulthood without detection. There are too few physicians who wish to learn all of the intricacies of scoliosis; hence, centers such as the Twin Cities Scoliosis Center for the teaching of fellows are greatly needed. The development of the Scoliosis Center here has been an international nucleus for developing similar centers throughout the world. We must all continue to write papers and lecture using all our sources of information of computerization, research, and screening. Our Scoliosis and Other Spinal Deformities Book Drs. Bradford, Winter, and Lonstein, and I of our Twin Cities Scoliosis Center have combined our knowledge and writing abilities to produce a textbook on scoliosis. The name of the book is scoliosis and Other Spinal Deformities. A thorough discussion of the techniques of both anterior and posterior fusions is included. I believe, for instance, that anterior fusion should be done with the assistance of a good thoracic surgeon who will open the chest, expose the spine, and provide the proper follow-up care.
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I cannot help feeling that there are only a very few orthopedic surgeons who have the stamina and ability to tolerate a combined procedure. In our experience, practically all anterior fusions require a posterior fusion. It is only in the realm of a scoliosis center that these procedures can be carried out in concentrated numbers, thus furnishing the ideal stage for an outstanding teaching program. Spreading the Knowledge It is extremely important that those of us who have had vast experience in the surgical and nonoperative treatment of scoliosis should spread the knowledge in every conceivable manner. Surgical, clinical routines and demonstrations should be freely shared. As the centers in various parts of the world develop more widely, it becomes even more imperative that we share our knowledge. In my effort to accomplish this, I spend at least 2 or 3 months out of every year teaching and lecturing nationally and internationally on my surgical and non-operative techniques.
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Some of the positions I held over the years include the following: Member of the Clinical Orthopaedic Society in 1940, president in 1955, and of the Minnesota/Dakota Orthopaedic Society in 1934. My association with the University of Minnesota, Division of Orthopaedic Surgery, began in 1934 and progressed to clinical assistant professor, Division of Orthopaedic Surgery, from 1942 to 1957. Clinical professor and director from 1957 to 1964. Professor and director, Division of Orthopaedic Surgery, 1964e1969. Professor and head, Department of Orthopaedic Surgery, 1969e1974. (Editor’s note: Dr. John Moe retired from the Twin Cities in 1980 and moved to Hilton Head, South Carolina. He died on April 2, 1988, at the age of 82 from complications of a malignant brain tumor.)
John Howard Moe, MD: An Autobiography Dated to 1977-78 (Editor) The youngest in a family of six children, I was born on a farm a short distance from the town of Grafton, North Dakota, on August 14, 1905. The population of Grafton at that time was about 1,500. It was primarily a community of Norwegian immigrants. My childhood and early youth on the family farm were typical of the times. Schooling was in a one-room schoolhouse a mile away, with an enrollment averaging 10 to 12 students, most of whom were my cousins. I was brought up in a Norwegian-speaking home and could not speak English when I first went to school at the age of six. My parents were immigrants from Norway. My father’s family came across Minnesota in an oxen-drawn covered wagon when he was 12 years old. At the age of 18, he homesteaded and married a girl who had recently emigrated. My early recollection of life on the farm was mainly that of hard work and poverty, since the farm my father had homesteaded was rather poor land. My uncle, after whom I was named, spent a great deal of time holding me in his lap in my infancy. He was a victim of tuberculosis and died when I was about 1 or 2 years old. This was probably the source of my problem with tuberculosis in my early adult life. My schooling in the country school continued until the eighth grade, when I transferred to the public school in Grafton. On finishing the eighth grade, I recall rather vividly that I was selected as a speaker at graduation, giving President Woodrow Wilson’s ‘‘Declaration of War against Germany’’ from memory. The following year, I entered high school in Grafton, and graduated as Salutatorian in 1923. University Days It was time for me to decide what to do with my life. I was not impressed with farming, and upon urging by my mother and my sister, who was a nurse, entered the University of North Dakota in 1923. My parents were able to provide very little money for my University schooling, so I worked at washing pots and pans at a hotel. My bedroom consisted of a cot in a room with a dirt floor in the basement of the hotel, and my only transportation was an old bicycle that was soon stolen. 2212-134X/$ - see front matter http://dx.doi.org/10.1016/j.jspd.2015.07.002
The greatest influence in my life was the encouragement and conversations with my sister, and as a result in my second year as a University student, I decided to take the remaining necessary requirements for what was known as ‘‘pre-medicine.’’ At that time, only 2 years of the ‘‘premed’’ course were necessary, although many of those who became my fellow students in medicine had taken 4 years. During my years at the University of North Dakota, I continued to work full-time to support myself. My job in the hotel lasted for the first 6 months; then I was fortunate to obtain a job waiting tables in the ‘‘Commons,’’ for which I received board. My summer job at the North Dakota Public Health Laboratory worked in well with the career of medicine that I had now chosen. I traveled to various towns throughout the state and was able to start saving money for the years of study ahead. I graduated from the University of North Dakota with the Class of 1927. I returned there in 1968 to be honored with the Sioux Award for Outstanding Alumni Achievement. In the fall of 1927, I was admitted to Northwestern University in Chicago, Illinois, financing myself through school
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loans, personal loans from friends, and working nights. My lifesaver from the standpoint of a job was employment as a ‘‘night doctor’’ at the first-aid station at the Standard Oil plant in Whiting, Indiana. I commuted daily by bus, and this travel time provided adequate time for study en-route to school and on the job, since there was actually very little emergency work for me to do while ‘‘on call.’’ During the time I attended Northwestern University, I accomplished very little other than work and study. I did not do any research nor gain any honors. My grades, however, were satisfactory and I passed into the senior year in 1929 in the upper third of the class. Graduation day came, but interestingly enough, I did not participate in the exercises, in spite of the many sacrifices and hard work involved in obtaining this very important degree. Because of the fact that an MD degree was not granted upon graduation at Northwestern University, I obtained an internship at the Illinois Research and Educational Hospital, a part of the University of Illinois. At the end of the year, I received my MD degree, and have since been considered a member of the Class of 1930. Upon finishing my internship, I was in a quandary as to what field of medicine to go into. Since I had become close friends with a nurse in obstetrics and gynecology, I made plans to go into this specialty. Dr. Hark, associate professor of obstetrics, and his wife were also influential and were good friends of mine. As a result, I almost entered the obstetrical training program. However, my roommate, Dr. Claude Lambert, who was in his final year of general surgery residency at the Research and Educational Hospital, wanted to change to orthopedic surgery under Dr. Henry Bascom Thomas, chief and head of orthopedic surgery at the University of Illinois. He persuaded Dr. Thomas to let me fill in several months in order to hold the place open for him when he returned. It is this position as personal assistant to Dr. Thomas that led me into the field of orthopedic surgery. I know of no one who was a better friend at the time, and over these many years, than Dr. Lambert. At the completion of this period of substitution, however, I was again without tangible direction in my life. Residencies Few residencies were available in 1930, and for lack of funds, I moved from place to place searching. During my internship, I had applied for residencies in surgery at the University of Illinois and the Mayo Clinic in Rochester, Minnesota. The former had no room for me in their program at that time. The Mayo Clinic wrote me about a year later saying that my application had been accepted. By that time, however, I had already accepted a position as assistant surgeon for the Cotton Belt Railroad Hospital in Texarkana. Following the termination of that, I accepted a 6-month residency at Gillette Children’s Hospital in St. Paul, Minnesota. As I reflect on my career
in orthopedic surgery, Gillette Children’s hospital was my first exposure to the field in which I was to specialize in years to come. Dr. Carl Chatterton, then Chief of Staff, invited me to join him in private practice. As July 1931 approached, the depression was at its lowest ebb. Dr. Chatterton was forced to tell me that he could not afford to take anyone on and pay a salary. Again, my career was seemingly at a dead end. I received my California license in 1931, and applied for and received a residency at the San Joaquin General Hospital, on the outskirts of Stockton, California. Although not approved as an ideal residency hospital, I did gain a tremendous amount of training there in general surgery and orthopedics. There were many accident cases, and the Chinese community of Stockton provided a great number of patients who had performed ‘‘hari-kari’’ and needed treatment. It was there that I came to know an orthopedic surgeon on staff, Dr. George Sanderson. He knew of my experience in children’s orthopedics at Gillette Children’s Hospital, and as his assistant I gained a great deal of knowledge of orthopedic surgery, particularly in the treatment of children. In 1972, I returned to San Joaquin as a guest speaker to honor Dr. Sanderson on his retirement. During the summer of 1933, the pulmonary tuberculosis that had plagued my childhood recurred. I had never been examined via sample culture, nor were active tubercle bacilli ever found in my sputum; however, on x-ray, a good-sized apical lung lesion was found. I entered the Brete Hart Sanatorium at Murphy, California, in the Sierra foothills. My recuperation in the hot, dry climate was speedy, and I soon left to spend the latter part of the fall with my sister and her husband in Salt Lake City, Utah, where I fully recovered and was ready for the next chapter of my life to unfold. Early Days of Orthopadic Surgery in Minneapolis and St. Paul While in Salt Lake City, I received a letter from Dr. Carl Chatterton telling me of a vacancy in Minneapolis, Minnesota, following the death of one of his former associates, Dr. Carl Flagstad. I reminded Dr. Chatterton of my inexperience in orthopedic surgery, but he encouraged me to come at once and take over Dr. Flagstad’s office and practice. Furthermore, he told me I would be placed on the staff of Gillette Children’s Hospital, and that he would give me personal preceptorship. With great anticipation, I returned to Minneapolis. Having taken the State Boards in 1932, I received my Minnesota license and began my orthopedic practice in 1933, but financial disaster ensued because of the ever-present depression. Fortunately, Dr. Emil Geist, one of the well-known orthopedic surgeons of the time, was in need of help, and I became his permanent assistant and felt that my career was finally forging forward in the field of orthopedic surgery. When Dr. Geist returned from the American Orthopaedic
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Association Meeting in Washington, DC, in the spring of 1934, he died suddenly of a coronary attack. Salvation from starvation came about through Fairview Hospital in Minneapolis, Minnesota. Through the friendship and recommendation from my good Norwegian friend, Dr. Ivar Sivertsen, the hospital accepted me as a staff orthopedic surgeon and he supplied me with patient referrals, numerous enough to enable me to make a small income, sometimes only a few dollars a month. Meanwhile, Dr. Chatterton loaned me money and put me on the Staff of Gillette Hospital as an operating orthopedic surgeon, with a stipend of $150 per month. In 1936, I was appointed head of orthopedics at Minneapolis General Hospital, now called Hennepin County Medical Center. As a result of a very busy schedule and many patients, my surgical skills developed rather rapidly. I was given an appointment at the University of Minnesota soon thereafter as Clinical Instructor in Orthopaedic Surgery (1934e1936), under Dr. Wallace Cole, Head of the Division of Orthopaedic Surgery. My career and professional life began to progress. From then on, there was sufficient advancement in my status as an orthopedic surgeon, and finally enough income to repay my numerous financial obligations. My first Interest in Spinal Work During the years of my early association from 1934 to 1947 with Gillette State Hospital for Crippled Children (now known as Gillette Specialty Healthcare), I was impressed by the total failure of scoliosis treatment. Patients were routinely fitted with a leather jacket and given suspension traction, occasionally with a spine fusion, nearly always resulting in complete failure. Fusions were done without regard to the curve pattern, and most often were performed at the junction of the two curves. As a result, the patient experienced no improvement in his/her curve, which continued to progress. Prior to his death in 1932, Dr. Carl Flagstad had done spinal fusions on a number of the scoliosis patients at Gillette Hospital. His 50% mortality rate was frightening. This was the era before the blood bank, and no blood was available for transfusions. Blood typing was full of errors. Transfusions were carried out by direct flow from donor to patient, and reactions were severe. With such poor results to report, Dr. Chatterton, Chief of Staff at Gillette Hospital at that time, asked Dr. Flagstad to discontinue doing these fusions. Various Influences in My Scoliosis Work In the fall of 1947, I was privileged to join a small group of outstanding orthopedic surgeons from all parts of the country at the Milwaukee Children’s Hospital in Milwaukee, Wisconsin. The members of the group were Drs. Walter Blount, John Cobb, Leslie Mitchell, George Hammond, George Garceau, Claude Lambert, Marcus Stewart, Charles Roundtree, William Bickell, Rufus Aldridge, George
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Carpenter, and I. At the meeting, one whole day was spent on the subject of scoliosis. Dr. Al Schmidt, who had recently finished training at the Hospital for the Ruptured and Crippled in New York City (now Hospital for Special Surgery), participated freely in the discussions as did Dr. Cobb, who headed the clinic there since 1936. The discussion continued all through the night, and I made lengthy notes on the way home, writing down all I had learned from Drs. Cobb, Garceau, Blount, and Schmidt. After this meeting, I immediately contacted Dr. Chatterton and asked permission to inaugurate a scoliosis service in the hospital under my direction. It was my attempt to develop a more realistic and productive treatment in this much-neglected field in orthopedic surgery. They agreed, and in the late fall of 1947 the Scoliosis Service began under my auspices at Gillette Children’s Hospital. The first patients were admitted later that year, and the first cast correction and spinal fusion done in January 1948. The Social Service Department located many candidates for scoliosis treatment, and in a short time there were 25 to 30 scoliotic patients undergoing evaluation and treatment. During this early period of scoliosis treatment, my main source of information was Dr. John Cobb. I visited him frequently, and watched his cast application and surgical technique. Whenever I experienced problems, I would send him the x-rays and ask his advice. He would respond with long letters, outlining the operation step-by-step. Involvement in Poliomyelitis Surgery Over the Years Between 1934 and the development of the vaccine, there were periodic outbreaks of poliomyelitis, with the last epidemic occurring around 1955e1958. It was during this time that Sister Kenny came to Minneapolis and was treating a large number of poliomyelitis patients, mainly with a rejuvenation of the hot pack treatment and early motion of involved joints. Some good resulted from her treatment but I found that her treatment had no beneficial effect on joint contractures or curvatures of the spine. I did fusions on a large number of poliomyelitis patients of various ages. Infants were held in corrective casts and the Milwaukee braces and Lowman fascial transplants were used freely for abdominal weakness. These did not have any beneficial effect on the curve, which almost routinely required cast correction and fusion. Fusions were done as indicated, many of them in children 5 to 10 years old. Contractures were surgically released prior to fusion. I was deeply involved with the poliomyelitis program and gained much experience in the treatment of collapsing scoliosis. Residual poliomyelitis persisted for many years thereafter, and I learned through knowledge gained at Rancho Los Amigos Hospital how to deal with the respiratory cripples, so that surgical fusion could be safely performed. We still see the late effects of poliomyelitis to some degree, but I have not seen an acute poliomyelitis case for many years in the United States. Poliomyelitis is still a
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problem in Mexico and in the destitute areas of South America. I now have a great deal of exposure to poliomyelitis poorly fused years ago, which have been turned over to me for recorrection. Development of Plaster Cast Techniques At the Scoliosis Service at Gillette Hospital, I was closely following the techniques of Dr. John Cobb. This was a cast that incorporated the entire head, with the Risser principle of wedging correction used until 1952. After visiting Dr. Joseph Risser for 2 weeks and seeing his handmade frame (which was entirely new at the time), I returned to Minneapolis and made a Risser frame out of gas pipe. Thereafter, this technique of cast correction was adopted by me and since then turnbuckle casts have been rarely used. My acquaintance with Dr. Yves Cotrel of Berck-Plage, France, showed me the advantages of a suspension strap placed against the convexity of the curve from an overhead frame. This combined with distraction allowed us to gain better correction, with fewer pressure sores. The cast gradually became an extremely well molded, practically nonpadded cast. On high curves, the neck was included; on lower curves, a torso cast was sufficient. A modified Risser frame with overhead bars was developed and is still in use. Preoperative casting was routinely used for many years, but I have found it unnecessary except in some of the special curves. The first turnbuckle cast correction and spinal fusion in January 1948 at Gillette Hospital was successful in gaining good correction, but better corrections were obtained after the adoption of the Risser-Cotrel technique. Fusions were done in a variety of fashions during my early years at Gillette, but in 1952 I developed an excellent facet fusion technique that has been used ever since. Postoperative immobilization was reduced from 1 year to 7 or 8 months after the adoption of the Harrington rod instrumentation. Postoperative bed rest immobilization was continued for 6 months until I found that with good cast application, we could ambulate these patients immediately after the cast was applied postoperatively, and this is still my method of choice. Development of Instrumentation in Scoliosis In 1960, the first corrective instrument I used, devised by Dr. Paul Harrington of Houston, Texas, was an internal distraction rod held above and below by specially designed hooks. I did not at that time adopt Dr. Harrington’s technique of rod insertion without fusion. Modification of the hooks and later in 1976 my modification of the rod by having the square end fit into a square hole in the hook have proven to be highly beneficial in preventing loss of lumbar lordosis. The Harrington rod has also been found beneficial in partially correcting thoracic lordosis. Very recently, I have rejuvenated the use of the Harrington threaded bar placed subcutaneously
and held by hooks above and below with minimal exposure, thus avoiding subperiosteal stripping. Using external correction with the Milwaukee brace is essential. Dr. Allen Dwyer of Sydney, Australia, made a significant contribution to anterior approach to thoracolumbar and lumbar curves. For the most part and in all collapsing spines, I have found it necessary to use a Harrington rod and fusion posteriorly in addition. We have never used the Dwyer apparatus in thoracic curves. Anterior fusion, which was begun by Dr. Arthur Hodgson in Hong Kong was adopted at my University service in the 1970s. I have gradually come to use it more often when indicated in certain congenital scoliosis and in kyphoscoliosis of neurofibromatosis. Its primary use is in kyphosis. Dr. Klaus Zielke’s (of Tubingen, Germany) modification of the Dwyer apparatus has been adopted in recent years and appears to be beneficial. My own contribution to fusion technique has mainly been the development of a good exposure and facet fusion, and the development of better criteria for selection of the fusion area. The halo hoop has had very limited use in my hands. I have not felt it to be as effective as halo distraction or halopelvic distraction and the halo cast. It is too fraught with complications. The Development of the Milwaukee Brace Since the early inception of the Milwaukee Brace in 1946, I have worked closely with Dr. Walter Blount of Milwaukee, Wisconsin, on its development. Together, we have changed it from an unsightly and unsatisfactory brace to a closely fitting brace, and complications have practically been eliminated. Lately, however, I have found that the Milwaukee brace will often produce a thoracic lordosis and thus have added this aspect as one of the contraindications to its use. The School Screening Program and close observation on many cases has modified my opinion to the use of the brace. I no longer routinely fit a Milwaukee brace to a patient with a 20-degree curve in juvenile or early adolescent years. In many of these cases, the curve does not increase and does not require full treatment. Some patients, however, have a severe rib hump with a small curve, and these require surgical treatment and are not responsive to the brace. I consider the Milwaukee brace as the best orthosis for thoracic and combined thoracic and lumbar curves. The main objection to its universal use has been its use in patients who are too old, too mature, and who have too large a curve. Fifty degrees maximum in adolescents has been used as the dividing line between brace and surgical treatment. In juvenile cases, I use the brace on 50 to 60 degree curves but have not found it useful or satisfactory in large, neglected infantile idiopathic curves. I was among the very first to use plastic in the pelvic girdle of the Milwaukee brace. The first plastic was orthoplast, which was satisfactory but disintegrated in certain patients because of the contents of their perspiration. We have added the plastic brace called the Thoraces-Lumbar-Sacral Orthosis
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or ‘‘TLSO,’’ which is a lower back brace that originated in Boston. It has been proven useful in the treatment of mild curves less than 40 degrees in the lumbar and thoracolumbar region. There is a pad over the lumbar curve convexity, and on the opposite side the plastic extends upward to give a counterforce to the lumbar pad. It does not quite reach the axilla. It is made out of polypropylene, which we have found as the most satisfactory plastic. Many times, it is as good in every way for certain smaller curves as the Milwaukee brace. Concepts of the Posterior Fusion Paralytic spines are of many etiologies, but they all present the same problem. A long, flexible spine must be treated by excellent fusion technique plus a Harrington rod. The Dwyer apparatus is an excellent adjunct to the paralytic spine in the adolescent when used in combination with the posterior fusion and Harrington instrumentation. Using this combination, the pseudoarthrosis rate is reduced to an extremely low percentage. When I reported my first 217 cases of early paralytic scoliosis in 1957, the pseudoarthrosis rate was high in the first 60. Through modification and improved knowledge and in the use of autogenous iliac bone instead of bank bone, the pseudoarthrosis rate declined. The addition of the Dwyer apparatus and interbody fusion when indicated has also improved our statistics. In the early days, we did not recognize pseudoarthrosis as often as we should have, nor did we always repair them: loss of correction was very common. We have found this to be a fault, and now we regularly repair a pseudoarthrosis before loss of correction takes place. Development of the Twin Cities Scoliosis Center As the Scoliosis Service at Gillette Hospital developed and my name became known, I began to see private patients with scoliosis. In 1957, I was asked to become Clinical Professor and Acting Director for the Division of Orthopaedic Surgery at the University of Minnesota, which was later changed to the Department of Orthopaedic Surgery. I continued at the University full-time until 1973. Increasing numbers of private patients were admitted to the University and I headed a scoliosis service paying particular attention to severe cases and respiratory cripples. The Department of Anesthesia developed an excellent respiratory service to help me with this. Because of the difficulty in having good x-rays taken and storing them in a separate section at the university, I began to take more and more scoliosis patients to Fairview Hospital, developing an outpatient department here. By then, I had obtained authority from the School of Medicine to establish an affiliation of Fairview Hospital with the University of Minnesota. The Fairview Hospital cooperated in setting up an excellent facility for outpatient care and surgical treatment
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for me. In 1963, Dr. Robert Winter finished his training with me and went into private practice as a hand surgeon. Dr. William Kane, a Scoliosis Fellow who had obtained his PhD degree, was chosen as the Director of the Resident Education at Fairview and St. Mary’s Hospitals. When he left to take the professorship at Northwestern University, I obtained permission to have Dr. Robert Winter join me in the Scoliosis Service as Associate Professor at the University of Minnesota. His first patients were all referrals from my own new patients. Shortly thereafter, Dr. David Bradford from Dr. Frank Stinchfield’s service at the New York Orthopaedic Hospital came to work with me. He was given an appointment as Associate Professor at the University of Minnesota, developing a deep interest in scoliosis under my tutelage. Dr. Bradford was also my protege, and his first patients were referrals from me. As time went on and more and more patients were seen in the Scoliosis Service at Fairview Hospital, we began to give serious thought to establishing a Twin Cities Scoliosis Center in the new Fairview-St. Mary’s Medical Office Building, which is adjacent to both hospitals and connected to them by skyways. In 1975, the Scoliosis service facilities were moved there and became the Twin Cities Scoliosis Center. The patients being referred to this center have become increasingly severe; mortality and morbidity have been low, but complications of various types have arisen, including emboli during treatment with halo-femoral traction. I am still maintaining an active scoliosis practice. There were a total of 5,885 patients seen in our center in 1976; 1,164 were seen by me. Of these patients, 1,506 were new, 219 of which were mine. We held a total number of 201 clinics; personally, I held 71. There were a total of 439 surgeries done for scoliosis; 102 were performed by me. The members of the Twin Cities Scoliosis Center, of which I am the director are, Dr. Robert B. Winter, Dr. David S. Bradford, and Dr. John E. Lonstein. Dr. Jack K. Mayfield recently joined us after he spent 6 months with us as Fellow in Scoliosis.
The John H. Moe Scoliosis Fund and Fellowship In 1969, the John H. Moe Scoliosis Fund was established as a memorial to my wife, Marguerite. The John H. Moe Scoliosis Fellowship was established in 1971. The first man to finish this service was Edgar Dawson, MD, who is now in Los Angeles, California. Annually we accept two or three Scoliosis Fellows depending on our finances, as it is difficult to provide the adequate salary of $20,000 annually for more than two Fellows at a time. We prefer to have them study scoliosis for a period of 1 year but have accepted 6-month participants. They are intermittently involved in our clinics, and also do a good deal of surgery under staff supervision and temporary licensure.
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International Program The staff members of the Twin Cities Scoliosis Center provide many lectures both in the United States and foreign countries. Beginning in 1960, I have helped establish excellent scoliosis services in Sao Paulo and Rio de Janeiro, Brazil. My attention has recently been concentrated on the Caribbean Islands, Puerto Rico, and the Dominican Republic. I am also helping to set up a scoliosis service in Venezuela under a former scoliosis fellow. My first trip to South America 13 years ago was at the request of CARE-Medico Orthopaedics-Overseas to make a complete survey of facilities in Columbia, Peru, Chile, and Brazil. I was able to establish good teaching facilities in all of these countries except Peru which did not seem to be very interested. The international flavor of our center has continued to flourish. We have visitors from all parts of the world and have had fellows from as far away as Iran, Pakistan, Australia, and South Africa. We have a continuous flow of patients from South and Central America, Iran, Canada, Mexico, Puerto Rico, and a few from Italy. The number of foreign doctors who have stayed here to study for varying periods of time during the last decade or two are in the hundreds. While I was Professor and Director of the Department of Orthopaedic Surgery at the University of Minnesota, I arranged annual 3-day symposia as a part of the Continuation Education Courses in Medical Education. In 1964, I held the first course on scoliosis and at this course it was suggested that we form a Scoliosis Research Society. I served as the president for 3 years.
The Future of Scoliosis Surgery Since the advent of the School Screening Program in Minnesota in 1948, I have learned a great deal about the natural history of idiopathic scoliosis. I have found that a great many small curves in the juvenile years do not progress, and some of them resolve spontaneously. Perhaps in part, this is due to the positioning of the patient at the time the x-ray is taken. In small, flexible curves, it is very easy to produce a small curve in a child who does not stand erect or who might be bearing weight unequally on her or his extremities. Whereas I was originally inclined to consider curves of 20 degrees as candidates for a brace, I now feel that no bracing is requireddwhether it be a Milwaukee brace or a TLSOdif the curve remains flexible. Curves progressing beyond 25 degrees and particularly if they become structural and lose their flexibility should be treated with bracing. Our recent studies of the Milwaukee brace treatment have demonstrated clearly that small curves can nearly always be controlled with a Milwaukee brace or, in the case of the lumbar curve, by the TLSO. It is my hope that with the ever-broadening legislative scope of the US and worldwide school screening programs,
combined with increased knowledge in the minds of pediatricians and general practitioners as well as orthopedic surgeons, far less surgery will be done on teenagers in the future. However, because of a lack of understanding and communication among human beings in the basic fundamentals of scoliosis detection and treatment, there is dim hope that surgical treatment of idiopathic scoliosis will be abolished completely. Furthermore, I recognize the fact that even with adequate bracing, many curves progress from small curves to large curves. Therefore, in idiopathic scoliosis, at least, all we can hope for now is a lessening in numbers of those who require surgery. In regard to congenital scoliosis, I believe that the answer to the prevention of severe curves lies entirely in early detection through screening and early fusion. This requires experienced judgment because not every congenital scoliosis requires a fusion. There is no field of scoliosis more difficult than the treatment of a myelomeningocele patient. Here again, early fusion while the curve is beginning seems to be the best answer. I have had satisfactory results with the use of Harrington instrumentation with the rod placed subcutaneously and a minimal exposure of the spine for hook placement above and below with external protection (ie, instrumentation without fusion). This is probably the answer to the collapsing spine of the neuromuscular type of scoliosis. Where Our Energies as Specialists in Scoliosis Should be Directed This is a continuous challenge and problem. Biochemical studies must be continued, although thus far, they have led us nowhere in idiopathic scoliosis. Genetic studies, like likewise, have been thoroughly explored. Nationalization of the school screening program will help us find the innumerable small idiopathic curves that persist into adulthood without detection. There are too few physicians who wish to learn all of the intricacies of scoliosis; hence, centers such as the Twin Cities Scoliosis Center for the teaching of fellows are greatly needed. The development of the Scoliosis Center here has been an international nucleus for developing similar centers throughout the world. We must all continue to write papers and lecture using all our sources of information of computerization, research, and screening. Our Scoliosis and Other Spinal Deformities Book Drs. Bradford, Winter, and Lonstein, and I of our Twin Cities Scoliosis Center have combined our knowledge and writing abilities to produce a textbook on scoliosis. The name of the book is scoliosis and Other Spinal Deformities. A thorough discussion of the techniques of both anterior and posterior fusions is included. I believe, for instance, that anterior fusion should be done with the assistance of a good thoracic surgeon who will open the chest, expose the spine, and provide the proper follow-up care.
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I cannot help feeling that there are only a very few orthopedic surgeons who have the stamina and ability to tolerate a combined procedure. In our experience, practically all anterior fusions require a posterior fusion. It is only in the realm of a scoliosis center that these procedures can be carried out in concentrated numbers, thus furnishing the ideal stage for an outstanding teaching program. Spreading the Knowledge It is extremely important that those of us who have had vast experience in the surgical and nonoperative treatment of scoliosis should spread the knowledge in every conceivable manner. Surgical, clinical routines and demonstrations should be freely shared. As the centers in various parts of the world develop more widely, it becomes even more imperative that we share our knowledge. In my effort to accomplish this, I spend at least 2 or 3 months out of every year teaching and lecturing nationally and internationally on my surgical and non-operative techniques.
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Some of the positions I held over the years include the following: Member of the Clinical Orthopaedic Society in 1940, president in 1955, and of the Minnesota/Dakota Orthopaedic Society in 1934. My association with the University of Minnesota, Division of Orthopaedic Surgery, began in 1934 and progressed to clinical assistant professor, Division of Orthopaedic Surgery, from 1942 to 1957. Clinical professor and director from 1957 to 1964. Professor and director, Division of Orthopaedic Surgery, 1964e1969. Professor and head, Department of Orthopaedic Surgery, 1969e1974. (Editor’s note: Dr. John Moe retired from the Twin Cities in 1980 and moved to Hilton Head, South Carolina. He died on April 2, 1988, at the age of 82 from complications of a malignant brain tumor.)