DukeMed Alumni News
Winter 2008

Coonrad Led the Way
to Revolutionary Elbow Replacement

by Jim Rogalski

Sometime before his death in 370 BC, Hippocrates wrote this: “He who would become a surgeon should join an army and follow it.”

The horrors of war are profuse, but what Hippocrates saw in them was their value for
large-scale evidence-based medicine, and war’s ability to spur medical breakthroughs.

World War II, for instance, brought us widespread use of blood banks and penicillin, and today’s surgeons use many of the techniques first learned by repairing WWII combat wounds.

Ralph W. Coonrad, MD’47, HS’47-’53, can trace the revolutionary elbow prosthesis he designed to the Korean War, although there would be a 15-year delay until it would make it to the drawing table.

Coonrad was stationed stateside from 1953-’55 at Fort Chaffee, Ark., where he was chief of orthopedic surgery and treated many U.S. soldiers wounded in Korea. One particular Army Captain would provide the inspiration for the future development of the revolutionary Coonrad Elbow.

The Captain’s elbow had been destroyed in combat. Coonrad replaced it with what was then the state-of-the-art elbow prosthesis. But after installing the device and while still at the operating table, Coonrad was dissatisfied. He found its motion too limited and he couldn’t close the skin over the device. “It was a simple hinge device, metal to metal, and poor design,” he says. “With surgical instrumentation, design is everything.”

So Coonrad removed it and meticulously rebuilt the soldier’s elbow, interposing thigh tissue and creating elbow ligaments, a procedure he used widely over the next 15 years, all the while incubating ideas about how to build a better elbow prosthesis. All of the elbow replacements available over that 15-year period had major flaws: They had complications of instability and dislocation, and with most having metal-to-metal articulations, tended to loosen, causing bone disintegration in the upper arm and forearm.

In 1968 Coonrad’s ideas for creating a better elbow germinated and he began working with the Zimmer Company to design a better elbow replacement. In 1972 his first design—a wooden prototype that he built in his garage—was born.

“This new design offered a metal-to-plastic joint articulation and included longer stems that are inserted into the humerus above and the ulna below, which distributes the stress forces,” he says.

The Coonrad Elbow gradually became one of the most widely used elbow replacements in the ‘70s, with the first one implanted by permission to a close friend—Dr. Richard Bryan— at the Mayo Clinic, followed by one implanted by Coonrad a few months later. In 1978 Coonrad modified it to allow a few degrees more looseness in the joint and a longer stems to better distribute the enormous forces that occur at the elbow joint, he says.

Coonrad’s close friend at the Mayo Clinic, Bernard Morrey, MD, whom Coonrad says is known around the globe as “Mr. Elbow,” was using the Coonrad Elbow exclusively, and in 1982 suggested modifying the design by adding a flange in front to add stability and allow more surface for bone growth. He also suggested adding a porous coating, also to give added purchase for bone.

Coonrad and the Zimmer Company loved the ideas and in 1982 the Coonrad Elbow became the Coonrad-Morrey Elbow, and has been the gold standard of elbow replacements ever since. More than 20,000 of them have been used worldwide, and so long as patients follow the protocol of not lifting objects of more than five pounds with the repaired arm, it has been nearly flawless.

Coonrad recently reported 41 consecutive elbow replacements lasting longer than 10 years and has not had to remove a single one. Twenty-one have been functioning for 10-14 years; 10 for 15 to 19 years; and 10 for 20 to 31 years. Of the nearly 1,000 Coonrad-Morrey Elbows the Mayo Clinic has installed, only 12 have needed revisions because of bushing wear.

Here at Duke, where Coonrad was director of Lenox Baker Children’s Hospital for 24 years, and ran a private orthopedic surgery practice, he is revered for his historical contributions to orthopedic surgery and for his humility and integrity.

James Urbaniak, MD’62, HS’62-’69; James Nunley,T’69, MD, HS’75-’79; and L. Scott Levin, T’77, MD, HS’82-’91, have collectively installed more than 300 Coonrad- Morrey Elbows over the past 35 years, and call it a tremendous scientific breakthrough.

“He changed the course of orthopedics with the elbow,” says Nunley, the J. Leonard Goldner Professor and chief of the Division of Orthopedic Surgery, who has installed about 75 Coonrad-Morrey Elbows. “All of the other elbows had tremendous problems.”

Urbaniak, the Virginia Flowers Baker Professor of Orthopedic Surgery, has placed nearly 200 of the elbows into patients who came to Duke from five continents for the treatment. While the elbow has been a major contribution to medicine, Urbaniak says that another important trait about Coonrad is that he “has always been a kind and caring physician, loved by his patients and medical colleagues. They don’t come any better than Ralph.”

Coonrad retired from full-time practice in 1996 when his wife Evelyn, WC’45, MD’49, HS’49-’53, was diagnosed with cancer. She died in 1998. Today at age 84 he is at Duke three mornings a week helping with teaching and rounds at Duke Children’s Hospital.

He also does pre-operative counseling of doctors and staff.

Coonrad has two daughters, Susan, T’77, and Sally, L’86, who live in Durham and Charlottesville, Va., respectively.