From AAHKS 2016 – A legendary storyteller, Dr. Dorr touches on his organization: Operation Walk and Operation Walk USA, his novels, and a short history of orthopedic medicine.
Dr. Brian Cunningham: Hey, guys. Live from AAHKS here 2016. We’re very fortunate to get a few minutes with one of the real legends in joint replacement surgery, Dr. Larry Dorr.
Dr. Larry Dorr: Thank you.
Cunningham: Thank you for taking a few minutes with us. One of the things that I think is a unique perspective from Dr. Dorr is kind of growing up with joint replacement and really having a historical perspective. One of the things that we talked a lot about at this meeting is patient-reported outcomes and the prevalence and interest that people have. What’s your take on patient-reported outcomes and the role that they should have?
Dorr: I’ve done patient-reported outcomes for most of my career because doing research I use the Harris Hip Score. We had a patient-scored Harris Hip Score, so we had a patient generated-score, so we’ve done it. I’ve learned a few things. One is, you can’t have a very long score sheet because they get bored doing it real fast. All right? If you go in there with five or 10 forms, that’s why that 36-question format we cut down to 12. That’s one thing that they’re going to have to be really aware of with these forms that they’re making them fill out.
Secondly, I think they’re good. I think it’s good for us to know outcomes. You can’t help but learn from patients. We do our assessments so much on whether we have to do a re-operation or we have to do a revision. Whereas, a lot of the patients are not really happy with what they have, but they’re not going to go through another operation, you know? Sometimes those aren’t reported much nor accurately. For instance, Bob Barrack just put a paper out that 10% of patients with total hip replacement have clinical pain. It interferes with their activities, and, yet, most hip replacement scores are 93% of patients are …
Cunningham: Pretty happy.
Dorr: If we’re going to get better and do a better job for our patients, then we really need to know what we’re doing for them and how they perceive outcomes. Lots of times they perceive them differently than we do. They grade them differently than we do, so, yeah, I’m kind of for them.
Cunningham: Okay. Okay. As far as pushing towards getting better outcomes, there’s been a lot of technology. People have done all kinds of things. There’s cement-less total knees. They’ve done dual mobility. There’s been all kinds of technology. As you look back to where we were at the beginning and where we are now, what do think were some of the real big breakthroughs in arthroplasty?
Dorr: Well, the biggest breakthrough we’ve had was highly cross-linked polyethylene. I mean, that changed the game. If you look at everything that was going on with hip replacement and knee replacement and you look at what the talks are at these meetings like we’re see at one now, the talk were dominated by osteolysis and wear and failure mechanisms. We don’t have much failure mechanism now anymore. Our fixation is very good, cemented or non-cemented. Our materials now with highly cross-linked polyethylene are so good we’re not getting revisions for revising somebody just to change their plastic because it’s worn and nor are we getting osteolysis problems that are creating horrendous revisions. They’re just kind of fading away. Now we have more talks on health and economics. They’re kind of boring for me. I still like operating.
Cunningham: Sure. Absolutely.
Dorr: It’s been a dramatic change and, really, the highly cross-linked polyethylene has been the real big change. The biggest change medicine ever had was penicillin.
Dorr: But this is the biggest change in orthopedics since the new technology started in the 60s.
Cunningham: Yeah. Something I think that’s probably more interesting, for me for sure and probably for you, is I know you’ve been a part of quite a bit of philanthropy and outreach and international work. Tell us a little bit about Operation Walk. I know that’s something that near and dear to you.
Dorr: Yes, it is near and dear to me. Operation Walk, it’s a mission organization that goes to foreign countries and operates on poor people. Sometimes we take things for granted in the United States.
Dorr: Things that we don’t realize other people don’t even have. We worry about access for insurance here, but they don’t have access to health care period. At least if you don’t have insurance or you can go to a county hospital, you know?
Dorr: It’s a wonderful organization and the thing I’ve learned about it is that the benefit is just as much for the givers as the takers. It’s just amazing how many doctors, nurses, PA’s, technicians, even volunteers go on these trips and they come back and it’s like they’ve had an epiphany. They realize that unconditional giving changes your soul. You know?
Cunningham: Yeah. Wow.
Dorr: Every time we go on a trip or our group we take two premed students or pre-PT students. Every single one of them has come back and gone into medicine, so that’s the effect it has on you. You go on these trips if you take your whole hospital group, we’ll take our whole hospital group, we just got back from Honduras, for instance. It changes the whole morale in the hospital for a while.
Cunningham: That’s true.
Dorr: Because you get on the elevator and even the house keeper she’ll ask you, “How was your trip to Honduras?” A lot of them are from Central America and they’ll say, “Oh, you know my family lives down there.” But it changes, it’s just like everybody’s uplifted because you know what we do down there? When you operate on somebody that would never ever have a chance to get this in their life unless we did it, not a chance, and you do that and you see the appreciation and you watch somebody walk. Sometimes you see people walk that haven’t walked for two years because they’re just crippled.
There’s some hard operations because some of these are very advanced arthritics, but you see that and it brings tears to people’s eyes. I’ve cried. It brings tears to nurses and hardened doctors and you know what you realize? You realize, “You know what? This is why I went into medicine.” There’s no forms down here, no lawyers. There’s no government going after my practice. I went into medicine to take care of people like this and at least for one week I get to do it. That’s what it is.
Cunningham: How many trips do you think you’ve been on?
Dorr: We’ve been doing it for since 20 years, and so some years we’ve gone on two trips. Some years we’ve only gone on one. In the beginning we’re were only doing one. I don’t know, but we’ve got 16 groups in the United States and two in Canada now. I know that we’ve operated in total with all the groups we’ve operated over 10,000 patients. It has an impact.
Cunningham: That’s amazing.
Dorr: Of course, now there’s Operation Walk USA.
Cunningham: That’s what I heard. I was going to ask you about that. Tell us about the domestic [crosstalk].
Dorr: We do it on poor patients here. There still are patients without insurance here. We do that every time. We started it in LA and we did it for four or five years in LA before it caught on nationally. We tried to get it started earlier, but there were a lot of people afraid of malpractice insurance and trouble, but that’s kind of gone by the board. I think we started doing it the first weekend in December. We wanted to do it between Thanksgiving and Christmas because it’s a giving-
Cunningham: Giving season. Yeah, sure.
Dorr: It’s a giving season, yeah. It still is that way. It’s still usually like the first weekend of December or right around there.
Cunningham: Is it specific locations, LA?
Dorr: No, I think last year there were 25 hospitals all across the country.
Cunningham: Wow. That’s amazing.
Dorr: There were 25 hospitals, maybe 200 surgeons that participated.
Dorr: We had quite a few, yeah. It’s good even here in our own country.
Cunningham: Yeah, that’s fantastic. As you’ve been to AAHKS meeting after AAHKS meeting, what do you think the challenges are that are facing AAHKS as a new president looks to step in sometime in the spring?
Dorr: You know, in a way AAHKS doesn’t have many challenges. Its membership is growing. The bank account’s full and people love the organization and it’s doing what … I founded it with [Chit Ranawat 00:09:47] and the two of us started it out and we had the very first meeting. I ran the slide projector and I think we had 65 people and that was the first meeting. Now you go on to the elevator and you’ve got companies with ads on the elevators.
Cunningham: Where did you guys have the first meeting?
Dorr: I think the very first meeting was here in Dallas. It was at a Hilton Hotel. It’s over by the airport.
Cunningham: Did you guys send out invitations yourself?
Dorr: Yeah. We let the word out, but it grew fairly quickly. I think within five years we had 300. Of course, now we’ve got 3,000. The challenges change. Our challenge in that day was just trying to get it to grow and trying to see whether we were going to be relevant. We’re definitely relevant and we’ve definitely grown. Of course, on the other side now when you get big challenges do change a little bit. Now you start having a lot of sub groups and you’ve got to keep them all happy, you know?
Dorr: Somebody wants something they’re not getting. No, there aren’t that many challenges. God’s been good to this organization so far. We’ve just got to just keep saying our prayers, I think.
Cunningham: There you go.
Dorr: It’s pretty good so far.
Cunningham: Fantastic. I know your time is busy, but just one more question. I know you’re a talented surgeon, philanthropist, also an author [inaudible 00:11:35].
Cunningham: Tell us a little bit about the book.
Dorr: I’ve got two books out and I’ve got one that the agents are looking at now, but the first two are fun for medical people because it’s a history of medicine in the first volume. It’s in novel form, so it makes it fun reading. I didn’t figure anyone wanted to go to bed at night and read data. It follows a Sullivan family and it starts around the Civil War and the first one ends at World War II because medicine didn’t really start becoming medicine until after the turn of the century. If women had a baby in 1895 50% of those babies were dead within a year and a lot of them from diphtheria. Things didn’t change til vaccines really came around and, of course, now you’ve got people worrying about vaccines because they think they’re going to get autistic. Really the first cure in medicine was, in Christmas eve if I remember the year right, it was like in 1892, and it happened in Germany. A doctor gave a baby that had diphtheria vaccine antitoxin and the baby lived. That was the first cure in medicine.
Of course, then antibiotics, everybody was struggling to find an antibiotic in the first 50 years of the 1900’s. Of course, penicillin was found and that changed everything because once they had penicillin then not only could you go to the surgery and operate without having a third of your operations fail from infection. But the other thing that happened in the laboratories is now they could put penicillin into the vials that they were trying to grow viruses in and they couldn’t grow viruses because they could isolate the virus, but then they’d try and grow it to get a culture, to get a vaccine or an antiviral medicine or even just to understand it and it would get overrun by bacteria. So, in 1948 it was at Harvard a researcher named Enders put penicillin in with the polio virus and the polio virus survived and that’s how they were able to develop the polio vaccine. Penicillin allowed all the vaccines for childhood diseases, measles, mumps, polio, et cetera, they couldn’t grow those before because bacteria overran them. So, penicillin hasn’t just been a clinical drug. It’s really helped research, too. That’s the first book.
Then the second book is World War II to 1975 and that’s really when all the big advances have happened in medicine. In fact, I’d have to say that was a period of big revolution and even another thing that happened during that period was the discovery that smoking was such a deleterious habit. In the second book in the story of getting the government to put on the cigarette packages that it’s dangerous to your health. That went on from 1950 to 1962 or three when they did and it was kind of mean.
Like cataract surgery, the surgeon Ridley in Britain who developed the cataract lens which is one of the most successful operations we have. He got the idea because he took care of the pilots in the second World War and the gunshot wounds into the planes. The gunshot would drive the Plexiglas plane window into the pilot’s eyes. He’d operate on the pilots and he saw there was no [real 00:15:42] reaction around the Plexiglas. After the war he went to a company and he said, “Can you make me a lens out of this Plexiglas?” He put the first one in in 1949, and then it’s very interesting. It wasn’t until 1980 it got approved by the FDA here. All those decades there was bickering inside medicine bickering because the biggest guy in ophthalmology in England did not like Ridley, so he blocked it. His big buddy was a professor at Northwestern and that guy blocked it here in the U.S.
Cunningham: There you go.
Dorr: So, in 50’s, 60’s, 70’s there was three decades when people could have had cataract surgery, but the inside politics in medicine kept it from happening. There are some fun things to read about there.
Cunningham: Yeah, that fantastic.
Dorr: It is most of the revolutions happened then. The 60’s just exploded for devices, hips and spine and trauma and all the devices we used. Frankly, since like around 1975 most of the things, at least in orthopedics have been more evolutionary than revolutionary.
Dorr: Heart surgery has had a few things like stents in the late 80’s and things, but we’ve been mostly evolutionary and we still are. Until we get to biological solutions for things like arthritis there really won’t be another big revolution. That’ll probably all happen through gene research. That’s another thing that’s in the second book that’s kind of fun. The DNA sequence was figured out by Watson and Crick in 1953 and Watson was kind of a jerk, but Crick was a very affable guy and everybody loved him.
There was a bar about two blocks down from their lab called the Eagle Pub. It had swinging doors, and the day in February after they knew they’d figured it out that one morning they came in and Watson, he was a smart guy, Watson figured it out. He kind of stole it from Rosalind Franklin. She never got in on the Nobel Prize because she died very young from ovarian cancer, but she’s the one that first saw it. She was the one that really first saw it. Anyway, once they figured it out Crick, he always went to lunch down at the Eagle bar, so he walks down to the Eagle Pub, throws open the doors and says, “I’ve found the secret to life.” He was absolutely sure they’d cure cancer in no time, and, of course, we’re still trying.
Cunningham: Yeah. Wow. [crosstalk].
Dorr: Probably the secrets are our genes, but boy it’s hard for us to decipher the secret.
Cunningham: Yeah. Absolutely.
Dorr: Until that happens I think most things are going to be plodding along.
Cunningham: Okay. Very good. Thank you so much for your time.
Dorr: Yeah. You’re welcome.
Cunningham: We appreciate it. Fantastic.
Dorr: Yeah, no problem.
Cunningham: Thank you very much.