Finding a better way: a personal account
A personal reflection on service, independence, and the practical challenges that inspired new approaches to orthopedic care.
Entrepreneurship and innovation in the delivery of Orthopedic care - Dr. Jones' journey - 2025
Milestones leading to orthopedic care entrepreneurship and innovation
My first passion as a lanky kid was Little League baseball. To everyone's surprise I led the league in hitting and pitching. I learned money management delivering Indianapolis Star papers in Columbus, Indiana. My education was prioritized by my parents; both were college business school graduates.
In middle school and high school, barber shop cleaning and larger paper routes paid for my new interest in fixing and selling cars. I managed a boat rental business for a local businessman, continued sports, and led the art club. This period was challenging for our family as my father grappled with a recession and I attended four different high schools. Careers in art, architecture and the work of the surgeons in my family all attracted me. On a church retreat, a kind pastor helped me to recognize the highest reward came from serving others and that it would be a privilege to use my mind and heart to apply science to illness.
In college, an independent study course in biology excited me to reveal the unknown by collecting data from unique ecosystems. In medical school, I landed an assistantship in neurosurgery research and conducted animal surgery and spinal cord microdissections to delineate the chemistry of spasticity during its onset, a condition that challenges rehabilitation after neural injury. A second job paid most of my living expenses, an externship monitoring cardiac tracings for all ICU patients at the general hospital every third night. Eventually, Orthopedics emerged as my best opportunity to rehabilitate people by using my gifts of mechanical ability and motivation, during often lengthy recoveries.
I computer-matched into a postgraduate surgery training program at a high-volume center where I quickly assumed the care of critically ill patients, sleeping only 6 out of 48 hours. Although better prepared for this work than many coming from less clinical medical schools, the lack of teaching inside or outside the operating theater or even a reading list struck me as a warning sign as I transitioned into orthopedics. In addition, that program's leader struggled with impatience and anger management that hindered learning. Several faculty members quietly guided me towards a transfer and helped me with recommendation letters rather than have me opt for a different specialty.
My next orthopedic program had low patient volumes and methods skeptical of aggressive surgical approaches. There was an abundance of teaching about disease courses and their diagnosis. Patients were brought into care conferences to demonstrate unusual physical findings, a powerful tool to novices in the profession. With time, I came to see my unsettled time of learning in orthopedic surgery had provided me with exceptional breadth, balance and with an extra year as administrative chief resident, tremendous surgical experience in all the subspecialties. This fostered my continuing interest in general orthopedics and allowed me to follow an independent career path I considered important to my professional integrity.
My first experience with clinical research was under two senior surgeons in my second training program, exceptional teachers and national leaders, who shared an interest in shoulder fracture outcomes. We queried early computer databases at two centers to identify thousands of patients with fractures I then classified using old x-ray films. We focused on the complex, which were recommended for surgery by all subject experts based at tertiary referral centers. Two years of effort provided live follow-up evaluation of final outcomes for over half the mostly elderly patients afflicted. This study depicted 'persons in the wild' after injury and not merely those selected for referral to specialty shoulder centers because of problems. I hadn't imagined there would be so many challenges to late outcomes clinical research, and this effort grew my expertise for evaluation of outcomes. At its end, our study proved the senior surgeons' hypothesis correct that non-operative care outcomes were satisfactory to elderly patients and provided function suitable to their ages. We were also able to demonstrate that the many surgeries being done initially for complex proximal humerus fractures were unreliable and fraught with complications. Our study did identify some specific fractures and surgical challenges that demanded surgical innovation. Our results were presented to meetings where audiences applauded the work, but we met rejection by journal editors as being overly countercultural. Other studies have confirmed our work, and surgical methods have improved.
Returning to my hometown to practice general orthopedics, and be close to my mother who was near the end of her struggle with cancer, I was welcomed by expert ER physicians who were also missionaries. I quickly grew the busiest practice in this Big Ten University town, where my father worked as an administrator and my mother pursued humanitarian work. My father helped me with my business and we built a specialty office across from the ER with help from his project manager. I learned from so many, yet grew tired of the constant politics amplified by new Medicare initiatives and I longed to study the common elements causing so many patients anguish related to such issues as poor bone formation. Married now, my wife and I agreed that I would accept a fellowship position in research to enable a career as an orthopedic clinical investigator, and that we would evaluate our options for practice locations in the Southeast, closer to my wife's family in North Carolina.
The University of Pennsylvania held the largest Orthopedic lab in the world when I arrived there, yet the winds of funding quickly reversed. I gained excellent guidance and training but often worked outside our lab and taught to defer my tuition. After three years, I had uncovered many novel findings related to micro-vessel cells roles and other contributions in early bone formation. Two years later, while working as trauma faculty in North Carolina, I successfully defended my thesis for my PhD in Anatomy and Structural Biology.
As I pursued a clinician investigator career, I learned first-hand about the many challenges to that role in American medicine. My clinical assignment was at a trauma center 34 miles away from a laboratory, where I'd been promised one day each week to serve as a postdoctoral fellow under longstanding mentors, brilliant growth factor researchers and pediatric endocrinologists. My trauma center was a new project for our university, having real potential and good support from other clinical services on site. However, our team was loosely organized by leaders who had never served in high level trauma centers as we launched an orthopedic trauma center to care for the area's most critically injured patients on an urgent basis. When my grants for my lab work ran out, I didn't try to renew them. Instead, I saw I could turn my innovation to applied research and, with help of academicians and clinicians near my trauma center, we accomplished some landmark work. The first was emulation of forces in calcaneus fracture, notoriously disabling the hindfoot, that led us to develop and patent a repair construct that remains the standard of care for central depression-type fractures. Another was conception of a resorbable hydrogel to improve care for severe wounds discussed more below.
Like most innovators, I was flustered in a bureaucratic system before the information age when loose teamwork led some patient care wanting. I landed in an exciting position at a for-profit hospital nearby, where I could use my sports medicine and joint replacement experience. Unfortunately, innovations in care there was challenged not only by profit motive but also low staff morale. With time, all the local physicians boycotted the hospital due to poor management! I relocated my work base again to a practice with former academic colleagues within the town where our family had built a house. I relearned private practice management from a gifted administrator there, carried out some clinical research, and hung on as my friends in the subspeciality of spine surgery forced out by a takeover of our community hospital, a common phenomenon. I recruited other generalists that kept our practice thriving for a time, including an old friend who was the most active clinical investigator of the region after he found himself squeezed out of his tenured academic position. After a dozen years as practice owner, I began accepting temporary clinical assignments outside our area based on my ability to cover a variety of clinical problems, including ER patients. This type of fill-in practice has occupied me since, offering a look at the various approaches and adaptations to American Medicine by many systems that try to help every patient as best they can, using stretched resources.
My innovative work now continues on four projects. All of these address an unsolved clinical need, with a large medical market for the product. Perhaps our project with the largest market is a one that can prevent wound infection, hydrogels. The need is illustrated best in open fractures, which continue to disable our patients commonly. Chronic infections are a common underlying element, along with vascular, pain and job adjustment issues. Another area where infection has major impact is within wounds having large implants, such as joint replacements. The burden of joint replacement infection (PPI; periprosthetic infection) has grown to the level of being considered a national crisis, due to high levels of suffering and cost.
First conceived while teaching trauma care, I employed hydrogels just coming on the wound care market as bio gels for the prevention of the drying of exposed tissues and the delivery of high doses of antibiotics directly to the injured tissues. The most promising gel was a polysaccharide polymer product being pitched to our wound nurses as a wound absorbent, but it had very limited absorption capacity. The product (Sorbsan, Dow-Hickam) was a fiber pad that was manufactured by dehydrating and compressing alginate fibers, a seaweed-derived abundant polysaccharide. The pad absorbed fluids only until fully rehydrated, which occurred after rewetting in less than a minute, which made the product morph to a pudding-like consistency that could no longer be handled. Initial testing showed this gel bound and released slowly the commonly used antibiotic gentamicin, which had a long history of deposition dosing within large wounds as mixed into bone cement, plaster, or other agents. The manufacturer funded our further work to derive methods for hydration and application to deep wound surfaces quickly. In pre-clinicals and a small IRB-approved clinical study of twelve patients with severe open fractures, the product was found to reduce bacterial counts a hundred-fold and to prevent subsequent deep infection clinically. After reporting our results widely, I was surprised to find little commercial interest but recognized the challenges of its handling properties. More recently, the military asked us to develop it into a hydrogel spray for in-situ gel formation for rapid treatment of multiple severe open fractures in austere environments, and they agreed to fund its development. After a lengthy process of pre-submission, formal invitation and full submission, our project's funding has been withheld by the U.S.'s current austerity plan. We are seeking funding from foundations and early-stage investors.
A shoulder replacement we have developed addresses fixation challenges at the glenoid region of the scapula, or the 'socket' portion, which is one of the chief sources of failure of replacements. Fixation can be especially challenging in cases with bone loss, including those having reoperations for failure of prior fixation of glenoid implants that can leave massive deficits. Our design is patented and favorably compares to existing products. It may also provide a solution to many more problems of shoulder replacement being done now with non-anatomic designs (Reverse Shoulder), opening a new market because it can one day enable anatomic designs for all shoulders needing joint replacement using this new fixation technology.
The final two products which hold my attention now include a new osteotomy device, which may guide limb realignment and provide for immediate weight bearing after surgery. This operation is recommended now rarely, but the actual need is large. The problem is in the lack of a reliable surgical technique. Limb malalignment is an important cause of focal concentration of joint forces that contribute to joint breakdown from arthritis, which affects our increasingly active middle-aged patients. However, existing techniques and the devices used for limb realignment surgery can be unreliable and the recoveries are lengthy, even in the hands of highly skilled and experienced surgeons.
Another innovation I've begun with a team of experts is the reduction of surgical trauma in knee replacement newer technologies, to reduce the scope of the surgery and the period of recovery, which we hypothesize can reduce the incidence of the procedure's most common and often serious complications.