Department of Orthopaedics & Traumatology

The University of Hong Kong, Queen Mary Hospital

First of all, I wish to express my cordial congratulations on the 50th Anniversary of the Department of Orthopaedics & Traumatology, formerly the Department of Orthopaedic Surgery, at the University of Hong Kong. Since its official foundation in 1961, the Department has always been one of the most brilliant and globally influential institutions in orthopaedic surgery. All the staff and alumni must be very proud of the Department for its glorious history and of themselves for their contribution to its development.
In its 60-year history including the preparatory 10 years, as all of you here know, the Department has had 4 heads ― namely, Prof. Arthur R Hodgson, Prof. Arthur CMC Yau, Prof. John CY Leong and the current head, Prof. Keith DK Luk.
During the 60 years, the population of Hong Kong expanded by 3.2 times from 2.2 to 7.1 million. GDP per capita increased by more than 100 times from only 2,000 HK$ in 1961 to recent 250,000HK$.
Personally, I came to Hong Kong for the first time in 1974. I clearly remember news papers, on a day, reported the surrender of a Japanese Intelligence Officer on Lubang Island in the Philippines.
I could come to Hong Kong because I had luckily met Prof. Yau two years before in Kobe, when I was learning Harrington instrumentation from Dr. Hiroshi Kumon. Prof. Yau was my mentor indeed who opened a door to a fruitful life as a spine surgeon before me. I have heard from Prof. Luk that originally Prof. Yau should deliver this lecture. Unfortunately, it became impossible.
Then, I was nominated as his replacement, maybe because I have visited the department almost every year and I know both the older and younger generations of staff and alumni. This lecture will evaluate the achievements of the Department and present my views on how the Department should do for the future. In addition, I should be grateful if I would be allowed to a little describe what I owe to the department.
This talk is based on what I have observed or heard and what the Department has published in journals. Further, I have read these history books of the Department and the Hong Kong College of Orthopaedic Surgeons.
In 1951, two years after the establishment of People's Republic of China and one year after the beginning of the Korean War,
Dr. Hodgson was recruited by Prof. Stock of the Department of Surgery, from Norwich, England, as Chief of its Orthopaedics and Trauma Unit.
Hong Kong in the 1950s had two major diseases of the bone and joint, i.e., tuberculosis, in particular TB spine, and poliomyelitis, which caused paralysis or deformities or both.
As for TB spine, curettage of the focus through costotransversectomy by Vincent or Ménard in France and excision of the disease through an extraperitoneal approach and strut bone grafting by Prof. Ito at Kyoto University in Japan all seemed to have failed.
After the advent of antibiotics and anti-TB drugs, however, Capener in UK started his lateral rhachotomy approach removing a pedicle or pedicles from behind to decompress the spinal cord.
At the same time, the spine started to be approached from front for degenerative conditions, for example the cervical spine by Cloward and Smith in USA, and the lumbar spine by Lane in UK and Harmon in USA.
The number of staff at the start of the Orthopaedic Unit was only 3. Dr. SF Lam, who was a houseman, clearly described later the Wednesday Lunch Clinical Meeting held on a day in 1953. At the Meeting, he presented a patient with TB spine, who became the first case of the "Hong Kong Operation."
Dr. Hodgson and Professor Stock published a revolutionary paper on the anterior eradication of the focus of TB spine and fusion in the British Journal of Surgery in 1956. The paper made Prof. Hodgson internationally famous and it remains a classic.
Because of Dr. Hodgson's tremendous achievements, the Department of Orthopaedic Surgery was created with him as founding professor in 1961. He started to be invited abroad for lectures.
Discussing with several leading orthopaedic professors in the East and Southeast Asia and being supported by them, he founded the Western Pacific Orthopaedic Association in 1962. Regarding Japan, he visited Kyushu University in Fukuoka, our University in Sendai and some others in 1962. When listening to his lecture at Kyushu University, a young doctor, Dr. Yoshiharu Takemitsu, now Emeritus Professor, present here was so impressed that he decided to come to Hong Kong next year.
Prof. Hodgson and his colleagues developed the procedures of anterior approach to the spine at every level from C1-2 to L5-S1. This is the transoral approach.
This is a case of a giant cell tumor we had more than 20 years ago. The tumor had destroyed the C2 body and odontoid process and expanded to the C2 lamina. Currently, most lesions at this level are managed from behind alone. However, the transoral approach should be mandatory in cases like this.
As for the lumbosacral region, every spine surgeon must master the anterior approach called Hodgson approach. Ligature and division of the iliolumbar and ascending lumbar veins facilitates the retraction of the common iliac vein to the other side.
This is an approach performed for anterior fusion by me 35 years ago. The whole L5 body was totally exposed.
This is a case of L5 and S1 TB spine I treated.
The whole TB lesion was excised and an iliac strut was grafted between L4 and S2 bodies.
Of course, it had been supplemented with posterior spine fusion before hand.
Total spondylectomy from behind alone developed by Prof. Tomita at Kanazawa University in Japan is being popularized for malignant tumors. However, the lumbosacral tumors still need the Hodgson approach for en bloc corpectomy as this case of a GCT at L5 we had.
Those anterior approaches to the spine at all levels of the spine were the fruits of their anatomical studies with cadavers, like Prof. Digby did. Prof. Digby was a professor of anatomy and a professor of surgery at the University of Hong Kong at the same time. I like his anterior approach by removing the 12th rib to the mid-lumbar spine.
These days, the surgical indication for TB spine is much narrower than at the time of Prof. Hodgson. It is mainly restricted to Pott's paralysis.
Developed countries like Japan are facing the problems of aging society. This is our current surgery for Pott's paralysis in the elderly, i.e., one-stage lateral rhachotomy and posterior fusion supplemented with the compression hooks and rod system.
The length of Prof. Yau's headship was only 5 years. However, Prof. Yau, who had got a title of professor, virtually lead the Department in the last few years of Prof. Hodgson's tenure, when Prof. Hodgson was winding down toward his retirement.
In the 1960s, posterior instrumentation by Dr. Harrington and anterior instrumentation by Dr. Dwyer marked a new epoch in spine surgery.
Prof. Yau introduced those two procedures to Hong Kong and then he developed the halo-pelvic traction, applied it to severe post-TB and post-polio spinal deformities and completed the most reliable scheme at that time.
As for the halo-pelvic traction, in fact, Dewald and Ray had started it earlier at the University of Illinois. In Hong Kong, Dr. O'Brien from Australia most contributed to its development.
I suppose most of the orthopaedic doctors here, even spine surgeons, may not have inserted a pelvic pin to the iliac wing as this slide shows.
As a result, many papers on halo-pelvic traction were published from Hong Kong.
Look at this picture of so many children with a halo-pelvic and you can easily understand Hong Kong was the most advanced center for correction of spinal deformities in the world at that time.
As the number of cases increased, they experienced varieties of complications. This is a case of traction injuries of the abducent and hypoglossal nerves I experienced in 1975.
In order to reduce the complications, they conducted a study on viscoelastic behavior of the deformed spine under distraction, which was the first one of real biomechanics at the Department.
With the halo-pelvic apparatus, severe spinal deformities such as post-TB kyphosis were first corrected by day-by-day gradual distraction, anterior and posterior ligamentous releases or osteotomy, and spinal fusion. The corrections obtained were miracles indeed. However, it needed a 3- or 4-stage surgery and took nearly or more than a year from application to removal of the apparatus.
The Hong Kong anterior spine surgery was naturally applied to lumbar degenerative intervertebral discs,
and then the porous titanium mesh block was introduced as a substitute for a strut bone graft. It was the forerunner of the present day anterior cages. Here I would say that till the end of Prof. Yau's time, anterior surgery for the lumbar degenerative spine had become an unobjectionable doctrine in Hong Kong. And I regret to say that the doctrine thereafter may have prevented spine surgeons from decompressive surgery from behind and minimized their contribution to the clarification of the pathomechanism of lumbar radiculopathy and the development of new surgical procedures.
To observe Prof. Yau perform anterior spine surgery with such precision and grace, every one tended to think that it is easy and could be done the same. But it was not true of ordinary spine surgeons like me. Therefore, since I left Hong Kong after my first stay, it had been my strategy for the development of new surgical procedures that spine surgery should be reproducible by surgeons who have achieved a certain level of skill.
These are letters from Prof. Yau answering my questions regarding hemivertebra excision.
This first case of hemivertebra excision of mine through a combine anterior and posterior approach was performed in 1977, 34 years ago.
Subsequently, I applied the technique to wedge osteotomy of the normal vertebra. This is a case of L2 hemivertebra with a rigid lumbar secondary curve.
At the same time as hemivertebra excision, the lowest lumbar vertebra was osteotomized from behind to balance the spine.
Then I started to remove the hemivertebra from behind alone. Around 1990, spine-shortening had become one of my strategies in the development of spinal surgery procedures
Naturally, the vertebral osteotomy technique from behind was applied to correction of kyphosis. This is a two-level wedge resection and shortening at the thoracolumbar level.
This is a tow-level wedge resection for lumbar degenerative kyphosis.
This is a shortening for osteoporotic fracture having caused paralysis.
The spine-shortening was applied also to fresh burst fractures.
Finally, spine-shortening was applied to reduction of tension of the tethered cord. You can see the reduction of the size of the lipoma on pre- and postop MR images.
Prof. Leong took over the headship at the very early age of 38 and headed the Department for a record 23 years. Among many occurrences in his age, the transition of sovereignty to China in 1997 and SARS in 2003 were the greatest.
In terms of spinal surgical techniques, the ages of Prof. Hodgson and Prof. Yau, that is, the preparatory 10 years and the first 20 years of the Department corresponded to an era of new surgical techniques. Till the end of the age of Prof. Yau, it had become harder to originate a new surgical technique. This is transpedicular decancellation osteotomy they did earliest in the world, much earlier than eggshell procedure by Heinig and transpedicular decancellation osteotomy by Thomsen, which is now more commonly referred to as pedicle subtraction osteotomy.
Prof. Leong started to concentrated on the sophistication of the surgical techniques the Department developed. Prof. Leong is rather a man of administration. Responding to the changes of disease pattern from infection to degenerative conditions or trauma, he introduced basic science research, especially biomechanics. The study on the iliolumbar ligament was a unique and comprehensive one, as I like this kind of study.
The fulcrum bending radiography reported in 1997 was one of the major achievements in the management of scoliosis in Prof. Leong's age. Subsequently, many other papers on this subject followed. The papers were frequently cited. As a result, it is now the standard prediction method of surgical correction of idiopathic scoliosis.
For example, we in Sendai, used to use x-ray under Cotrel traction. There is not much difference in correction between the side bending and Cotrel traction in this case.
However, the fulcrum bending radiograph predicted well the correction in the same case.
Because of his scientific achievement proved by more than 200 full papers in the top journals and his fame highest in the world, Professor Leong was elected as an Academician of the Chinese Academy of Science in 2001, the first clinician in Hong Kong to receive the honor. Further, he was just recently conferred the degree of Doctor of Science, honoris causa by the University of Hong Kong.
Prof. Chow, who was originally a spine surgeon, was sent to UK and USA by Prof Yau in 1976 and 1977. A few months after his return, he succeeded in thumb replantation. His skill is proved by his experimental repair of blood vessels of 0.15 mm in diameter that is still a world record. He has trained many fellows and coworkers and established a very reliable hand service system covering about 10,000 cases per year.
With the recent changing spectrum of pathologies from injuries to degenerative and inflammatory conditions, he started to develop his own novel design of finger joint implants about 10 years ago.
Being a Pro-Vice-Chancellor, he is now looking forward to favorable results of its clinical trial.
Prof. Luk inherited a grown number of staff and an expanded facilities from Prof. Leong, his predecessor, at the end of 2003, 8 years ago.
In order to promote orthopaedic sub-specialization following the international trend, he soon reformed the scheme of clinical service, from 3 teams to 8 subspecialty divisions, creating a new sub-specialty, general orthopaedics.
At the same time, he strengthened basic researches in genetics, biomaterials and tissue engineering. Orthopaedic Research Centre founded by his predecessor, Prof. Leong, was further enforced in terms of its staff,
And facilities.
In addition, collaboration has been multiplied with many regional and international centers of excellence. Allogeneic intervertebral disc transplantation is the world's first study with Navy General Hospital in Beijing. It is the best example of the fruits of collaboration.
As Prof. Luk talked in details this morning, I will little touch upon it using his slides. After removal of a cervical intervertebral disc together with its supra- and subjacent endplates and subchondral bone, a preserved fresh allograft is snugly put into the space.
It is very interesting that the disc implanted maintain the mobility even after 10 years.
The Department now has the next generation of leaders. One is Prof. Kenneth Cheung. He is multi-talented at clinical study and basic sciences research such as genetics and genomics and is President-elect of the Hong Kong College of orthopaedic Surgeons. This paper on Schmorl node of the lumbar spine, analyzing about 2500 cohorts with MRI, instructed by him won an ISSLS Prize, a prize of the International Society for the Study of the Lumbar Spine last year.
Prof. KY Chiu is a hip and knee joint surgeon. He has published many papers on implants and surgical techniques mainly from the viewpoint of the racial uniqueness among the Southern Chinese.
This is a titanium alloy porous-coated femoral component designed for the Chinese by Dr. David Fang. Recently, Prof. Chiu and his colleagues reported bone ingrowth and stem survival of 100% after the follow-up of about 10 years on average.
The Department has produced numerous leaders such as deans of the faculty and pro vice-chancellors of the University of Hong Kong.
Presidents of HKOA and HKCOS in orange colour,
President of the Hong Kong Medical Association and President of the Hong Kong Academy of Medicine,
Presidents of WPOA and SICOT,
And Editor-in-Chiefs of JWPOA, the official Journal of WPOA and J Orthopaedic Surgery, the official Journal of APOA.
Now, I would like to present my view on how the Department should do for the future. It should be learning from the past: how they considered and what they did, analyzing the present: the medical care demands and the trends in science, and creating the future: new strategies and tactics.
Lastly, I wish the Department of Orthopaedics & Traumatology, the University of Hong Kong would continuously be a brilliant star guiding us to a glorious future of orthopaedic surgery as the brilliant star guided the magi to the cradle of the infant in ancient times.
Lastly, I wish the Department of Orthopaedics & Traumatology, the University of Hong Kong would continuously be a brilliant star guiding us to a glorious future of orthopaedic surgery as the brilliant star guided the magi to the cradle of the infant in ancient times.

 

Delivered by

Kokubun

Prof Shoichi Kokubun, MD

Professor Emeritus of Tokoku University

Sendai, Japan

on 20 August 2011