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%!2,9 $%6%,/0-%.4 /& 4/4!, ()0 2%0,!#%-%.4 4HE TRANSCRIPT OF A 7ITNESS 3EMINAR HELD BY THE 7ELLCOME 4RUST #ENTRE FOR THE (ISTORY OF -EDICINE AT 5#, ,ONDON ON -ARCH %DITED BY , ! 2EYNOLDS AND % - 4ANSEY
6OLUME
¥4HE 4RUSTEE OF THE 7ELLCOME 4RUST ,ONDON &IRST PUBLISHED BY THE 7ELLCOME 4RUST #ENTRE FOR THE (ISTORY OF -EDICINE AT 5#, 4HE 7ELLCOME 4RUST #ENTRE FOR THE (ISTORY OF -EDICINE AT 5#, IS FUNDED BY THE 7ELLCOME 4RUST WHICH IS A REGISTERED CHARITY NO )3".
!LL VOLUMES ARE FREELY AVAILABLE ONLINE FOLLOWING THE LINKS TO 0UBLICATIONS7ELLCOME 7ITNESSES AT WWWUCLACUKHISTMED
4ECHNOLOGY 4RANSFER IN "RITAIN4HE CASE OF MONOCLONAL ANTIBODIES 3ELF AND .ON 3ELF ! HISTORY OF AUTOIMMUNITY %NDOGENOUS /PIATES 4HE #OMMITTEE ON 3AFETY OF $RUGS s -AKING THE (UMAN "ODY 4RANSPARENT 4HE IMPACT OF .-2 AND -2) 2ESEARCH IN 'ENERAL 0RACTICE $RUGS IN 0SYCHIATRIC 0RACTICE 4HE -2# #OMMON #OLD 5NIT s %ARLY (EART 4RANSPLANT 3URGERY IN THE 5+ s (AEMOPHILIA 2ECENT HISTORY OF CLINICAL MANAGEMENT s ,OOKING AT THE 5NBORN (ISTORICAL ASPECTS OF OBSTETRIC ULTRASOUND s 0OST 0ENICILLIN !NTIBIOTICS &ROM ACCEPTANCE TO RESISTANCE s #LINICAL 2ESEARCH IN "RITAIN n s )NTESTINAL !BSORPTION s /RIGINS OF .EONATAL )NTENSIVE #ARE IN THE 5+ s "RITISH #ONTRIBUTIONS TO -EDICAL 2ESEARCH AND %DUCATION IN !FRICA AFTER THE 3ECOND 7ORLD 7AR s #HILDHOOD !STHMA AND "EYOND s -ATERNAL #ARE s 0OPULATION BASED 2ESEARCH IN 3OUTH 7ALES4HE -2# 0NEUMOCONIOSIS 2ESEARCH 5NIT AND THE -2# %PIDEMIOLOGY 5NIT s 0EPTIC 5LCER 2ISE AND FALL s ,EUKAEMIA s 4HE -2# !PPLIED 0SYCHOLOGY 5NIT s 'ENETIC 4ESTING s &OOT AND -OUTH $ISEASE 4HE OUTBREAK AND ITS AFTERMATH s %NVIRONMENTAL 4OXICOLOGY4 HE LEGACY OF 3ILENT 3PRING s #YSTIC &IBROSIS s )NNOVATION IN 0AIN -ANAGEMENT s 4HE 2HESUS &ACTOR AND $ISEASE 0REVENTION s 4HE 2ECENT (ISTORY OF 0LATELETS IN 4HROMBOSIS AND /THER $ISORDERS s 3HORT COURSE #HEMOTHERAPY FOR 4UBERCULOSIS s 0RENATAL #ORTICOSTEROIDS FOR 2EDUCING -ORBIDITY AND -ORTALITY AFTER 0RETERM "IRTH s 0UBLIC (EALTH IN THE S AND S $ECLINE AND RISE s #HOLESTEROL !THEROSCLEROSIS AND #ORONARY $ISEASE IN THE 5+ n s $EVELOPMENT OF 0HYSICS !PPLIED TO -EDICINE IN THE 5+ n s %ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT
#/.4%.43 )LLUSTRATIONS AND CREDITS
V
!BBREVIATIONS
IX
7ITNESS 3EMINARS -EETINGS AND PUBLICATIONS !CKNOWLEDGEMENTS % - 4ANSEY AND , ! 2EYNOLDS )NTRODUCTION &RANCIS .EARY AND *OHN 0ICKSTONE 4RANSCRIPT %DITED BY , ! 2EYNOLDS AND % - 4ANSEY !PPENDIX .OTES ON MATERIALS BY 0ROFESSOR !LAN 3WANSON !PPENDIX 3URGICAL IMPLANT MATERIAL STANDARDS BY -R 6ICTOR 7HEBLE
XI
XXV
!PPENDIX 3ELECTED PROSTHETIC HIPS
2EFERENCES
"IOGRAPHICAL NOTES
'LOSSARY
)NDEX
),,5342!4)/.3 !.$ #2%$)43 &IGURE &IGURE &IGURE &IGURE &IGURE
&IGURE
&IGURE
&IGURE
&IGURE &IGURE &IGURE
3ITE OF A TOTAL HIP TRANSPLANT )LLUSTRATION PROVIDED BY -S #LARE $ARRAH
-R 0HILIP 7ILES &2#3 C )LLUSTRATION PROVIDED BY 3IR 2ODNEY 3WEETNAM
8 RAY OF 7ILES HIP C S )LLUSTRATION PROVIDED BY 3IR 2ODNEY 3WEETNAM
#HARNLEY 04&% DOUBLE CUP IMPLANT C )LLUSTRATION PROVIDED BY THE *OHN #HARNLEY 4RUST
4HE 2ING TOTAL HIP REPLACEMENT 8 RAY OF 4(2 IN POSITION )LLUSTRATION PROVIDED BY -R 0ETER 2ING
+EN -C+EE WITH HIS TOTAL HIP REPLACEMENT SYSTEM 2EPRODUCED BY PERMISSION OF Ú%ASTERN %VENING .EWS 4HE PHOTOGRAPH APPEARED IN A $EREK *AMES COLUMN @(ONOUR FOR MOST DESERVING DOCTOR .OVEMBER
0OST OPERATIVE 8 RAY OF THE -C+EE ARTIlCIAL JOINT )LLUSTRATION PROVIDED BY THE *OHN #HARNLEY 4RUST
(AWLEY ORTHOPAEDIC TABLE SHOWING A NON STERILE ASSISTANT CONTROLLING THE LEG )LLUSTRATION PROVIDED BY -R *OHN +IRKUP
0ROFESSOR 3IR *OHN #HARNLEY &2#3 &23 2EPRODUCED BY PERMISSION OF ,ADY #HARNLEY
-R (ARRY #RAVEN )LLUSTRATION PROVIDED BY -R (ARRY #RAVEN
3TAINLESS STEEL 3MITH 0ETERSEN CUP CM DIAMETER X CM C $ONATED BY -R 6ICTOR 7HEBLE
V
&IGURE
&IGURE
&IGURE
&IGURE
&IGURE &IGURE
&IGURE
&IGURE
&IGURE &IGURE &IGURE
VI
#HARNLEYS ORIGINAL GREENHOUSE CLEAN AIR ENCLOSURE )LLUSTRATION PROVIDED BY THE *OHN #HARNLEY 4RUST
&ILTERS AND MASKS &ROM 4HE 4IMES .OVEMBER )LLUSTRATION PROVIDED AND ANNOTATED BY -R *OHN 2EAD
,OOKING DOWN ON TO THE GREENHOUSE ROOF SHOWING THREE CLOTH INFUSER BAGS INmATED WITH CLEAN AIR )LLUSTRATION PROVIDED BY -R (ARRY #RAVEN
4HE #HARNLEY LOW FRICTION ARTHROPLASTY IN USE FROM .OVEMBER )LLUSTRATION PROVIDED BY THE *OHN #HARNLEY 4RUST
-R @'INGER 7ILSON )LLUSTRATION PROVIDED BY -R -ICHAEL 7ILSON
0RINCIPAL STAGES IN THE DESIGN AND DEVELOPMENT OF THE 3TANMORE PROSTHESIS n )LLUSTRATION PROVIDED BY -RS 0HYLLIS (AMPSON
)#,( RESURFACING ARTHROPLASTY DONE BILATERALLY C )LLUSTRATION PROVIDED BY 0ROFESSOR -ICHAEL &REEMAN
0ROFESSOR *OHN 3CALES DESIGNER OF THE 3TANMORE HIP C 2EPRODUCED BY PERMISSION OF -RS 0HYLLIS (AMPSON
4HE %XETER STEM C 2EPRODUCED BY PERMISSION OF 0ROFESSOR 2OBIN ,ING
3TILLS DISEASE n JUVENILE CHRONIC ARTHRITIS 2EPRODUCED BY PERMISSION OF THE 7ELLCOME 0HOTO ,IBRARY
! #HARNLEY ACETABULAR REAMER )LLUSTRATION PROVIDED BY THE *OHN #HARNLEY 4RUST
&IGURE
&IGURE &IGURE
&IGURE
4ABLE
3URGICAL APPROACHES USED IN TOTAL HIP REPLACEMENT !NTEROLATERAL INCISION DIRECT LATERAL INCISION LATERAL INCISION AND THE MODERN MINIMALLY INVASIVE INCISION $RAWN BY -R +EVIN (ARDINGE
(OWORTH PUBLICITY LITERATURE C )LLUSTRATION PROVIDED BY THE *OHN #HARNLEY 4RUST
#ASELLA SLIT SAMPLER !)2 AS USED IN THE CLEAN AIR ENCLOSURE )LLUSTRATION PROVIDED BY (OWORTH !IRTECH ,TD
4WO 0ETRI DISHES FROM A SLIT SAMPLER WITH A ROTATION TIME OF MINUTES C )LLUSTRATION PROVIDED BY -R (ARRY #RAVEN
3URVIVAL RATES OF #HARNLEY 3TANMORE AND %XETER 4(2 %XTRACTED FROM -ALCHAU ET AL 4ABLE
VII
!PPENDIX 3ELECTED PROSTHETIC HIPS
7ILES )LLUSTRATION PROVIDED BY 3IR 2ODNEY 3WEETNAM
3MITH 0ETERSEN 2EPRODUCED BY PERMISSION OF THE 7ELLCOME 4RUST
*UDET 2EPRODUCED BY PERMISSION OF THE 7ELLCOME 4RUST
-OORE )LLUSTRATION PROVIDED BY THE *OHN #HARNLEY 4RUST
4HOMPSON )LLUSTRATION PROVIDED BY THE *OHN #HARNLEY 4RUST
-C+EE )LLUSTRATIONS PROVIDED BY THE *OHN #HARNLEY 4RUST
#HARNLEY AnC THE *OHN #HARNLEY 2ESEARCH )NSTITUTE 7RIGHTINGTON (OSPITAL D THE *OHN #HARNLEY 4RUST
3TANMORE A -R -ICHAEL 7ILSON BnC -R !LAN ,ETTIN D 7ELLCOME 4RUST
n
2ING )LLUSTRATION PROVIDED BY -R 0ETER 2ING
n
%XETER )LLUSTRATIONS PROVIDED BY THE %XETER (IP 5NIT
n
)#,( )LLUSTRATION PROVIDED BY 0ROFESSOR -ICHAEL &REEMAN
-C-INN )LLUSTRATION PROVIDED BY -R *OSEPH $ANIEL -C-INN #ENTRE
n n n
n
VIII
!BBREVIATIONS "/!
"RITISH /RTHOPAEDIC !SSOCIATION
"/3'
"RITISH /RTHOPAEDIC 3TUDY 'ROUP
"3)
"RITISH 3TANDARDS )NSTITUTION
#%.
#OMIT£ %UROP£EN DE .ORMALISATION THE %UROPEAN #OMMITTEE FOR 3TANDARDIZATION "RUSSELS "ELGIUM AT WWWCENORMBE
$O(
$EPARTMENT OF (EALTH
&$!
53 &OOD AND $RUG !DMINISTRATION
(!#
HYDROXYAPATITE COATING
($0
HIGH DENSITY POLYETHYLENE
)3/
)NTERATIONAL /RGANIZATION FOR 3TANDARDIZATION 'ENÞVE 3WITZERLAND AT WWWISOORGISOEN#ATALOGUE,IST0AGE #ATALOGUE,IST
,&!
LOW FRICTION ARTHROPLASTY
-#!
-EDICINES #ONTROL !GENCY
-$!
-EDICAL $EVICES !GENCY
-(2!
-EDICINES AND (EALTHCARE 0RODUCTS 2EGULATORY !GENCY
-2#
-EDICAL 2ESEARCH #OUNCIL
.(3
.ATIONAL (EALTH 3ERVICE
.)#%
.ATIONAL )NSTITUTE FOR #LINICAL %XCELLENCE
.*2
.ATIONAL *OINT 2EGISTRY FOR %NGLAND AND 7ALES
0--!
POLYMETHYLMETHACRYLATE
04&%
POLYTETRAmUOROETHYLENE
2./(
2OYAL .ATIONAL /RTHOPAEDIC (OSPITAL 3TANMORE -IDDLESEX AT WWWRNOHNHSUKABOUT?THE?2./(
IX
4(!
TOTAL HIP ARTHROPLASTY
4(2
TOTAL HIP REPLACEMENT
5(-70% ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE 5-)34
X
NIVERSITY OF -ANCHESTER )NSTITUTE OF 4ECHNOLOGY WHICH MERGED 5 WITH THE 6ICTORIA 5NIVERSITY OF -ANCHESTER TO BECOME THE 5NIVERSITY OF -ANCHESTER IN
7)4.%33 3%-).!23 -%%4).'3 !.$ 05",)#!4)/.3 )N THE 7ELLCOME 4RUST CREATED A (ISTORY OF 4WENTIETH #ENTURY -EDICINE 'ROUP ASSOCIATED WITH THE !CADEMIC 5NIT OF THE 7ELLCOME )NSTITUTE FOR THE (ISTORY OF -EDICINE TO BRING TOGETHER CLINICIANS SCIENTISTS HISTORIANS AND OTHERS INTERESTED IN CONTEMPORARY MEDICAL HISTORY !MONG A NUMBER OF OTHER INITIATIVES THE FORMAT OF 7ITNESS 3EMINARS USED BY THE )NSTITUTE OF #ONTEMPORARY "RITISH (ISTORY TO ADDRESS ISSUES OF RECENT POLITICAL HISTORY WAS ADOPTED TO PROMOTE INTERACTION BETWEEN THESE DIFFERENT GROUPS TO EMPHASIZE THE POTENTIAL BENElTS OF WORKING JOINTLY AND TO ENCOURAGE THE CREATION AND DEPOSIT OF ARCHIVAL SOURCES FOR PRESENT AND FUTURE USE )N *UNE THE 'OVERNORS OF THE 7ELLCOME 4RUST DECIDED THAT IT WOULD BE APPROPRIATE FOR THE !CADEMIC 5NIT TO ENJOY A MORE FORMAL ACADEMIC AFlLIATION AND TURNED THE 5NIT INTO THE 7ELLCOME 4RUST #ENTRE FOR THE (ISTORY OF -EDICINE AT 5#, FROM /CTOBER 4HE 7ELLCOME 4RUST CONTINUES TO FUND THE 7ITNESS 3EMINAR PROGRAMME VIA ITS SUPPORT FOR THE #ENTRE 4HE 7ITNESS 3EMINAR IS A PARTICULARLY SPECIALIZED FORM OF ORAL HISTORY WHERE SEVERAL PEOPLE ASSOCIATED WITH A PARTICULAR SET OF CIRCUMSTANCES OR EVENTS ARE INVITED TO COME TOGETHER TO DISCUSS DEBATE AND AGREE OR DISAGREE ABOUT THEIR MEMORIES 4O DATE THE (ISTORY OF 4WENTIETH #ENTURY -EDICINE 'ROUP HAS HELD SUCH MEETINGS MOST OF WHICH HAVE BEEN PUBLISHED AS LISTED ON PAGES XVnXXIII 3UBJECTS ARE USUALLY PROPOSED BY OR THROUGH MEMBERS OF THE 0ROGRAMME #OMMITTEE OF THE 'ROUP WHICH INCLUDES PROFESSIONAL HISTORIANS OF MEDICINE PRACTICING SCIENTISTS AND CLINICIANS AND ONCE AN APPROPRIATE TOPIC HAS BEEN AGREED SUITABLE PARTICIPANTS ARE IDENTIlED AND INVITED 4HIS INEVITABLY LEADS TO FURTHER CONTACTS AND MORE SUGGESTIONS OF PEOPLE TO INVITE !S THE ORGANIZATION OF THE MEETING PROGRESSES A mEXIBLE OUTLINE PLAN FOR THE MEETING IS DEVISED USUALLY WITH ASSISTANCE FROM THE MEETINGS CHAIRMAN AND SOME PARTICIPANTS ARE INVITED TO @SET THE BALL ROLLING ON PARTICULAR THEMES BY SPEAKING FOR A SHORT PERIOD TO INITIATE AND STIMULATE FURTHER DISCUSSION
4HE FOLLOWING TEXT ALSO APPEARS IN THE @)NTRODUCTION TO RECENT VOLUMES OF 7ELLCOME 7ITNESSES TO 4WENTIETH #ENTURY -EDICINE PUBLISHED BY THE 7ELLCOME 4RUST AND THE 7ELLCOME 4RUST #ENTRE FOR THE (ISTORY OF -EDICINE AT 5#,
XI
%ACH MEETING IS FULLY RECORDED THE TAPES ARE TRANSCRIBED AND THE UNEDITED TRANSCRIPT IS IMMEDIATELY SENT TO EVERY PARTICIPANT %ACH IS ASKED TO CHECK HIS OR HER OWN CONTRIBUTIONS AND TO PROVIDE BRIEF BIOGRAPHICAL DETAILS 4HE EDITORS TURN THE TRANSCRIPT INTO READABLE TEXT AND PARTICIPANTS MINOR CORRECTIONS AND COMMENTS ARE INCORPORATED INTO THAT TEXT WHILE BIOGRAPHICAL AND BIBLIOGRAPHICAL DETAILS ARE ADDED AS FOOTNOTES AS ARE MORE SUBSTANTIAL COMMENTS AND ADDITIONAL MATERIAL PROVIDED BY PARTICIPANTS 4HE lNAL SCRIPTS ARE THEN SENT TO EVERY CONTRIBUTOR ACCOMPANIED BY FORMS ASSIGNING COPYRIGHT TO THE 7ELLCOME 4RUST #OPIES OF ALL ADDITIONAL CORRESPONDENCE RECEIVED DURING THE EDITORIAL PROCESS ARE DEPOSITED WITH THE RECORDS OF EACH MEETING IN !RCHIVES AND -ANUSCRIPTS 7ELLCOME ,IBRARY ,ONDON !S WITH ALL OUR MEETINGS WE HOPE THAT EVEN IF THE PRECISE DETAILS OF SOME OF THE TECHNICAL SECTIONS ARE NOT CLEAR TO THE NON SPECIALIST THE SENSE AND SIGNIlCANCE OF THE EVENTS WILL BE UNDERSTANDABLE /UR AIM IS FOR THE VOLUMES THAT EMERGE FROM THESE MEETINGS TO INFORM THOSE WITH A GENERAL INTEREST IN THE HISTORY OF MODERN MEDICINE AND MEDICAL SCIENCE TO PROVIDE HISTORIANS WITH NEW INSIGHTS FRESH MATERIAL FOR STUDY AND FURTHER THEMES FOR RESEARCH AND TO EMPHASIZE TO THE PARTICIPANTS THAT EVENTS OF THE RECENT PAST OF THEIR OWN WORKING LIVES ARE OF PROPER AND NECESSARY CONCERN TO HISTORIANS -EMBERS OF THE 0ROGRAMME #OMMITTEE OF THE (ISTORY OF 4WENTIETH #ENTURY -EDICINE 'ROUP n $R 4ILLI 4ANSEY n 2EADER IN (ISTORY OF -ODERN -EDICAL 3CIENCES 7ELLCOME 4RUST #ENTRE FOR THE (ISTORY OF -EDICINE AT 5#, 74#(- AND #HAIR 3IR #HRISTOPHER "OOTH n 74#(- FORMER $IRECTOR #LINICAL 2ESEARCH #ENTRE .ORTHWICK 0ARK (OSPITAL ,ONDON $R 2OBERT "UD n 0RINCIPAL #URATOR OF -EDICINE AND -ANAGER OF %LECTRONIC #ONTENT 3CIENCE -USEUM ,ONDON $R $APHNE #HRISTIE n 3ENIOR 2ESEARCH !SSISTANT 74#(- AND /RGANIZING 3ECRETARY $R *OHN &ORD n 2ETIRED 'ENERAL 0RACTITIONER 4ONBRIDGE 0ROFESSOR -ARK *ACKSON n #ENTRE FOR -EDICAL (ISTORY %XETER o
0ROFESSOR )AN -C$ONALD n 74#(- FORMER 0ROFESSOR OF .EUROLOGY )NSTITUTE OF .EUROLOGY ,ONDON $R (ELGA 3ATZINGER n 2EADER IN (ISTORY OF 4WENTIETH #ENTURY "IOMEDICINE 74#(0ROFESSOR ,AWRENCE 7EAVER n 0ROFESSOR OF #HILD (EALTH 5NIVERSITY OF 'LASGOW AND #ONSULTANT 0AEDIATRICIAN IN THE 2OYAL (OSPITAL FOR 3ICK #HILDREN 'LASGOW $IED $ECEMBER
o
XII
!#+./7,%$'%-%.43 @4OTAL HIP REPLACEMENT WAS SUGGESTED AS A SUITABLE TOPIC FOR A 7ITNESS 3EMINAR BY $R &RANCIS .EARY AND -R +RISHNA 2AVI +UNZRU WHO ASSISTED US IN PLANNING THE MEETING 7E ARE VERY GRATEFUL TO THEM FOR THEIR INPUT AND TO -R !LAN ,ETTIN FOR HIS EXCELLENT CHAIRING OF THE OCCASION 7E ARE PARTICULARLY GRATEFUL TO $R &RANCIS .EARY AND 0ROFESSOR *OHN 0ICKSTONE FOR WRITING SUCH A USEFUL )NTRODUCTION TO THESE PUBLISHED PROCEEDINGS AND TO 0ROFESSOR #HRISTOPHER #OLTON AND $R #AROLE 2EEVES WHO READ THROUGH EARLIER DRAFTS OF THE TRANSCRIPT AND OFFERED HELPFUL COMMENTS AND ADVICE /UR ADDITIONAL THANKS GO TO 0ROFESSOR !LAN 3WANSON -R 6ICTOR 7HEBLE AND -R *EFFREY (ALLETT 0RESIDENT OF THE )3/ 4# #OMMITTEE FOR THEIR HELP PREPARING THE APPENDICES FOR PUBLICATION 7E CONSULTED THOSE INVOLVED WITH THE EARLY DEVELOPMENT OF THE #HARNLEY %XETER )#,( -C+EE -C-INN 2ING AND 3TANMORE PROSTHESES WHO APPROVED THE DETAILS IN !PPENDIX AND SUGGESTED OTHER CHANGES 7E THANK THE CONTRIBUTORS AND 0ROFESSOR #OLTON FOR THEIR HELP WITH THE 'LOSSARY AND -R 0AUL "EVERLEY !RCHIVE 0UBLICATIONS .ORWICH 0ROFESSOR -ICHAEL 7ROBLEWSKI -R 0AUL 3INEY AND -S 0ATRICIA &LEMING *OHN #HARNLEY 2ESEARCH )NSTITUTE 7RIGHTINGTON (OSPITAL -R *OHN 4IMPERLEY %XETER (IP #ENTRE 0ROFESSOR *OHN 0AUL $R 0AUL 5NWIN 3TANMORE )MPLANTS 7ORLDWIDE ,TD #ENTRE FOR "IOMEDICAL %NGINEERING 5#, -R #HRIS #ARTER 7ELLCOME 4RUST -EDICAL 0HOTO ,IBRARY ,ONDON AND -R "HAVIK 3AMANI ACTING MANAGER #OMPUTER ,EARNING #ENTRE 7HIPPS #ROSS -EDICAL %DUCATION #ENTRE FOR THEIR ASSISTANCE &OR PERMISSION TO REPRODUCE THE IMAGES INCLUDED HERE WE THANK ,ADY #HARNLEY THE *OHN #HARNLEY 4RUST -R (ARRY #RAVEN -R *OSEPH $ANIEL OF THE -C-INN #ENTRE -S #LARE $ARRAH THE %ASTERN %VENING .EWS 0ROFESSOR -ICHAEL &REEMAN -RS 0HYLLIS (AMPSON -R +EVIN (ARDINGE (OWORTH !IRTECH ,TD THE *OURNAL OF "ONE AND *OINT 3URGERY -R *OHN +IRKUP -R 2AVI +UNZRU -R !LAN ,ETTIN 0ROFESSOR 2OBIN ,ING $R &RANCIS .EARY -R *OHN 2EAD -R 0ETER 2ING 3IR 2ODNEY 3WEETNAM THE 7ELLCOME 0HOTO ,IBRARY -R 6ICTOR 7HEBLE AND -R -ICHAEL 7ILSON !S WITH ALL OUR MEETINGS WE DEPEND A GREAT DEAL ON OUR COLLEAGUES AT THE 7ELLCOME 4RUST TO ENSURE THEIR SMOOTH RUNNING THE !UDIOVISUAL $EPARTMENT THE -EDICAL 0HOTOGRAPHIC ,IBRARY AND THE 7ELLCOME ,IBRARY -R !KIO -ORISHIMA WHO HAS SUPERVISED THE DESIGN AND PRODUCTION OF THIS VOLUME OUR INDEXER -S ,IZA &URNIVAL AND OUR READERS -S &IONA 0LOWMAN AND -R 3IMON
XIII
2EYNOLDS -RS *AQUI #ARTER IS OUR TRANSCRIBER AND -RS 7ENDY +UTNER AND $R $APHNE #HRISTIE ASSIST US IN RUNNING THE MEETINGS &INALLY WE THANK THE 7ELLCOME 4RUST FOR SUPPORTING THIS PROGRAMME 4ILLI 4ANSEY ,OIS 2EYNOLDS 7ELLCOME 4RUST #ENTRE FOR THE (ISTORY OF -EDICINE AT 5#,
XIV
()34/29 /& 47%.4)%4( #%.4529 -%$)#).% 7)4.%33 3%-).!23 n
-ONOCLONAL ANTIBODIES
4HE EARLY HISTORY OF RENAL TRANSPLANTATION
0NEUMOCONIOSIS OF COAL WORKERS
3ELF AND NON SELF ! HISTORY OF AUTOIMMUNITY
!SHES TO ASHES 4HE HISTORY OF SMOKING AND HEALTH
/RAL CONTRACEPTIVES
%NDOGENOUS OPIATES
#OMMITTEE ON 3AFETY OF $RUGS
-AKING THE BODY MORE TRANSPARENT 4HE IMPACT OF NUCLEAR MAGNETIC RESONANCE AND MAGNETIC RESONANCE IMAGING
2ESEARCH IN GENERAL PRACTICE
$RUGS IN PSYCHIATRIC PRACTICE
4HE -2# #OMMON #OLD 5NIT
4HE lRST HEART TRANSPLANT IN THE 5+
(AEMOPHILIA 2ECENT HISTORY OF CLINICAL MANAGEMENT
/BSTETRIC ULTRASOUND (ISTORICAL PERSPECTIVES
0OST PENICILLIN ANTIBIOTICS
#LINICAL RESEARCH IN "RITAIN n
XV
XVI
)NTESTINAL ABSORPTION
4HE -2# %PIDEMIOLOGY 5NIT 3OUTH 7ALES
.EONATAL INTENSIVE CARE
"RITISH CONTRIBUTIONS TO MEDICINE IN !FRICA AFTER THE 3ECOND 7ORLD 7AR
#HILDHOOD ASTHMA AND BEYOND
0EPTIC ULCER 2ISE AND FALL
-ATERNAL CARE
,EUKAEMIA
4HE -2# !PPLIED 0SYCHOLOGY 5NIT
'ENETIC TESTING
&OOT AND MOUTH DISEASE 4HE OUTBREAK AND ITS AFTERMATH
%NVIRONMENTAL TOXICOLOGY 4HE LEGACY OF 3ILENT 3PRING
#YSTIC lBROSIS
)NNOVATION IN PAIN MANAGEMENT
4HROMBOLYSIS
"EYOND THE ASYLUM !NTI PSYCHIATRY AND CARE IN THE COMMUNITY
4HE 2HESUS FACTOR AND DISEASE PREVENTION
0LATELETS IN THROMBOSIS AND OTHER DISORDERS
3HORT COURSE CHEMOTHERAPY FOR TUBERCULOSIS
0RENATAL CORTICOSTEROIDS FOR REDUCING MORBIDITY AND MORTALITY ASSOCIATED WITH PRETERM BIRTH
0UBLIC HEALTH IN THE S AND S $ECLINE AND RISE
4HE HISTORY OF CHOLESTEROL ATHEROSCLEROSIS AND CORONARY DISEASE n
$EVELOPMENT OF PHYSICS APPLIED TO MEDICINE IN THE 5+ n
%ARLY DEVELOPMENT OF TOTAL HIP REPLACEMENT
4HE DISCOVERY USE AND IMPACT OF PLATINUM SALTS AS CHEMOTHERAPY AGENTS FOR CANCER
-EDICAL ETHICS EDUCATION IN "RITAIN n
3UPERBUGS AND SUPERDRUGS 4HE HISTORY OF -23!
#LINICAL PHARMACOLOGY IN THE 5+ C n
4HE RESURGENCE OF BREAST FEEDING n
$.! lNGERPRINTING &ROM DISCOVERY TO DATABASE
4HE DEVELOPMENT OF SPORTS MEDICINE IN TWENTIETH CENTURY "RITAIN
XVII
05",)3(%$ -%%4).'3 @x&EW BOOKS ARE SO INTELLECTUALLY STIMULATING OR UPLIFTING *OURNAL OF THE 2OYAL 3OCIETY OF -EDICINE n REVIEW OF VOLS AND @x4HIS IS ORAL HISTORY AT ITS BESTxALL THE VOLUMES MAKE COMPULSIVE READINGxTHEY ARE PRIMARILY IMPORTANT HISTORICAL RECORDS "RITISH -EDICAL *OURNAL REVIEW OF THE SERIES 4ECHNOLOGY TRANSFER IN "RITAIN 4HE CASE OF MONOCLONAL ANTIBODIES 3ELF AND NON SELF ! HISTORY OF AUTOIMMUNITY %NDOGENOUS OPIATES 4HE #OMMITTEE ON 3AFETY OF $RUGS )N 4ANSEY % - #ATTERALL 0 0 #HRISTIE $ ! 7ILLHOFT 3 6 2EYNOLDS , ! EDS 7ELLCOME 7ITNESSES TO 4WENTIETH #ENTURY -EDICINE 6OLUME ,ONDON 4HE 7ELLCOME 4RUST PP )3". -AKING THE HUMAN BODY TRANSPARENT 4HE IMPACT OF .-2 AND -2) 2ESEARCH IN GENERAL PRACTICE $RUGS IN PSYCHIATRIC PRACTICE 4HE -2# #OMMON #OLD 5NIT )N 4ANSEY % - #HRISTIE $ ! 2EYNOLDS , ! EDS 7ELLCOME 7ITNESSES TO 4WENTIETH #ENTURY -EDICINE 6OLUME ,ONDON 4HE 7ELLCOME 4RUST PP )3". %ARLY HEART TRANSPLANT SURGERY IN THE 5+ )N 4ANSEY % - 2EYNOLDS , ! EDS 7ELLCOME 7ITNESSES TO 4WENTIETH #ENTURY -EDICINE 6OLUME ,ONDON 4HE 7ELLCOME 4RUST PP )3". (AEMOPHILIA 2ECENT HISTORY OF CLINICAL MANAGEMENT )N 4ANSEY % - #HRISTIE $ ! EDS 7ELLCOME 7ITNESSES TO 4WENTIETH #ENTURY -EDICINE 6OLUME ,ONDON 4HE 7ELLCOME 4RUST PP )3". ,OOKING AT THE UNBORN (ISTORICAL ASPECTS OF OBSTETRIC ULTRASOUND )N 4ANSEY % - #HRISTIE $ ! EDS 7ELLCOME 7ITNESSES TO 4WENTIETH #ENTURY -EDICINE 6OLUME ,ONDON 4HE 7ELLCOME 4RUST PP )3".
XVIII
0OST PENICILLIN ANTIBIOTICS &ROM ACCEPTANCE TO RESISTANCE )N 4ANSEY % - 2EYNOLDS , ! EDS 7ELLCOME 7ITNESSES TO 4WENTIETH #ENTURY -EDICINE 6OLUME ,ONDON 4HE 7ELLCOME 4RUST PP )3". #LINICAL RESEARCH IN "RITAIN n )N 2EYNOLDS , ! 4ANSEY % - EDS 7ELLCOME 7ITNESSES TO 4WENTIETH #ENTURY -EDICINE 6OLUME ,ONDON 4HE 7ELLCOME 4RUST PP )3". )NTESTINAL ABSORPTION )N #HRISTIE $ ! 4ANSEY % - EDS 7ELLCOME 7ITNESSES TO 4WENTIETH #ENTURY -EDICINE 6OLUME ,ONDON 4HE 7ELLCOME 4RUST PP )3". .EONATAL INTENSIVE CARE )N #HRISTIE $ ! 4ANSEY % - EDS 7ELLCOME 7ITNESSES TO 4WENTIETH #ENTURY -EDICINE 6OLUME ,ONDON 4HE 7ELLCOME 4RUST #ENTRE FOR THE (ISTORY OF -EDICINE AT 5#, PP )3". "RITISH CONTRIBUTIONS TO MEDICAL RESEARCH AND EDUCATION IN !FRICA AFTER THE 3ECOND 7ORLD 7AR )N 2EYNOLDS , ! 4ANSEY % - EDS 7ELLCOME 7ITNESSES TO 4WENTIETH #ENTURY -EDICINE 6OLUME ,ONDON 4HE 7ELLCOME 4RUST #ENTRE FOR THE (ISTORY OF -EDICINE AT 5#, PP )3". 8 #HILDHOOD ASTHMA AND BEYOND )N 2EYNOLDS , ! 4ANSEY % - EDS 7ELLCOME 7ITNESSES TO 4WENTIETH #ENTURY -EDICINE 6OLUME ,ONDON 4HE 7ELLCOME 4RUST #ENTRE FOR THE (ISTORY OF -EDICINE AT 5#, PP )3". -ATERNAL CARE )N #HRISTIE $ ! 4ANSEY % - EDS 7ELLCOME 7ITNESSES TO 4WENTIETH #ENTURY -EDICINE 6OLUME ,ONDON 4HE 7ELLCOME 4RUST #ENTRE FOR THE (ISTORY OF -EDICINE AT 5#, PP )3". 0OPULATION BASED RESEARCH IN SOUTH 7ALES 4HE -2# 0NEUMOCONIOSIS 2ESEARCH 5NIT AND THE -2# %PIDEMIOLOGY 5NIT )N .ESS ! 2 2EYNOLDS , ! 4ANSEY % - EDS 7ELLCOME 7ITNESSES TO 4WENTIETH #ENTURY -EDICINE 6OLUME ,ONDON 4HE 7ELLCOME 4RUST #ENTRE FOR THE (ISTORY OF -EDICINE AT 5#, PP )3".
XIX
0EPTIC ULCER 2ISE AND FALL )N #HRISTIE $ ! 4ANSEY % - EDS 7ELLCOME 7ITNESSES TO 4WENTIETH #ENTURY -EDICINE 6OLUME ,ONDON 4HE 7ELLCOME 4RUST #ENTRE FOR THE (ISTORY OF -EDICINE AT 5#, PP )3". ,EUKAEMIA )N #HRISTIE $ ! 4ANSEY % - EDS 7ELLCOME 7ITNESSES TO 4WENTIETH #ENTURY -EDICINE 6OLUME ,ONDON 4HE 7ELLCOME 4RUST #ENTRE FOR THE (ISTORY OF -EDICINE AT 5#, PP )3". 4HE -2# !PPLIED 0SYCHOLOGY 5NIT )N 2EYNOLDS , ! 4ANSEY % - EDS 7ELLCOME 7ITNESSES TO 4WENTIETH #ENTURY -EDICINE 6OLUME ,ONDON 4HE 7ELLCOME 4RUST #ENTRE FOR THE (ISTORY OF -EDICINE AT 5#, PP )3". 'ENETIC TESTING )N #HRISTIE $ ! 4ANSEY % - EDS 7ELLCOME 7ITNESSES TO 4WENTIETH #ENTURY -EDICINE 6OLUME ,ONDON 4HE 7ELLCOME 4RUST #ENTRE FOR THE (ISTORY OF -EDICINE AT 5#, PP )3". 8 &OOT AND MOUTH DISEASE 4HE OUTBREAK AND ITS AFTERMATH )N 2EYNOLDS , ! 4ANSEY % - EDS 7ELLCOME 7ITNESSES TO 4WENTIETH #ENTURY -EDICINE 6OLUME ,ONDON 4HE 7ELLCOME 4RUST #ENTRE FOR THE (ISTORY OF -EDICINE AT 5#, PP )3". %NVIRONMENTAL TOXICOLOGY 4HE LEGACY OF 3ILENT 3PRING )N #HRISTIE $ ! 4ANSEY % - EDS 7ELLCOME 7ITNESSES TO 4WENTIETH #ENTURY -EDICINE 6OLUME ,ONDON 4HE 7ELLCOME 4RUST #ENTRE FOR THE (ISTORY OF -EDICINE AT 5#, PP )3". #YSTIC lBROSIS )N #HRISTIE $ ! 4ANSEY % - EDS 7ELLCOME 7ITNESSES TO 4WENTIETH #ENTURY -EDICINE 6OLUME ,ONDON 4HE 7ELLCOME 4RUST #ENTRE FOR THE (ISTORY OF -EDICINE AT 5#, PP )3". )NNOVATION IN PAIN MANAGEMENT )N 2EYNOLDS , ! 4ANSEY % - EDS 7ELLCOME 7ITNESSES TO 4WENTIETH #ENTURY -EDICINE 6OLUME ,ONDON 4HE 7ELLCOME 4RUST #ENTRE FOR THE (ISTORY OF -EDICINE AT 5#, PP )3".
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4HE 2HESUS FACTOR AND DISEASE PREVENTION )N :ALLEN $ 4 #HRISTIE $ ! 4ANSEY % - EDS 7ELLCOME 7ITNESSES TO 4WENTIETH #ENTURY -EDICINE 6OLUME ,ONDON 4HE 7ELLCOME 4RUST #ENTRE FOR THE (ISTORY OF -EDICINE AT 5#, PP )3". 4HE RECENT HISTORY OF PLATELETS IN THROMBOSIS AND OTHER DISORDERS )N 2EYNOLDS , ! 4ANSEY % - EDS 7ELLCOME 7ITNESSES TO 4WENTIETH #ENTURY -EDICINE 6OLUME ,ONDON 4HE 7ELLCOME 4RUST #ENTRE FOR THE (ISTORY OF -EDICINE AT 5#, PP )3". 3HORT COURSE CHEMOTHERAPY FOR TUBERCULOSIS )N #HRISTIE $ ! 4ANSEY % - EDS 7ELLCOME 7ITNESSES TO 4WENTIETH #ENTURY -EDICINE 6OLUME ,ONDON 4HE 7ELLCOME 4RUST #ENTRE FOR THE (ISTORY OF -EDICINE AT 5#, PP )3". 0RENATAL CORTICOSTEROIDS FOR REDUCING MORBIDITY AND MORTALITY AFTER PRETERM BIRTH )N 2EYNOLDS , ! 4ANSEY % - EDS 7ELLCOME 7ITNESSES TO 4WENTIETH #ENTURY -EDICINE 6OLUME ,ONDON 4HE 7ELLCOME 4RUST #ENTRE FOR THE (ISTORY OF -EDICINE AT 5#, PP )3". 0UBLIC HEALTH IN THE S AND S $ECLINE AND RISE )N "ERRIDGE 6 #HRISTIE $ ! 4ANSEY % - EDS 7ELLCOME 7ITNESSES TO 4WENTIETH #ENTURY -EDICINE 6OLUME ,ONDON 4HE 7ELLCOME 4RUST #ENTRE FOR THE (ISTORY OF -EDICINE AT 5#, PP )3". #HOLESTEROL ATHEROSCLEROSIS AND CORONARY DISEASE IN THE 5+ n )N 2EYNOLDS , ! 4ANSEY % - EDS 7ELLCOME 7ITNESSES TO 4WENTIETH #ENTURY -EDICINE 6OLUME ,ONDON 4HE 7ELLCOME 4RUST #ENTRE FOR THE (ISTORY OF -EDICINE AT 5#, PP )3". $EVELOPMENT OF PHYSICS APPLIED TO MEDICINE IN THE 5+ n )N #HRISTIE $ ! 4ANSEY % - EDS 7ELLCOME 7ITNESSES TO 4WENTIETH #ENTURY -EDICINE 6OLUME 4HE 7ELLCOME 4RUST #ENTRE FOR THE (ISTORY OF -EDICINE AT 5#, PP )3". %ARLY DEVELOPMENT OF TOTAL HIP REPLACEMENT )N 2EYNOLDS , ! 4ANSEY % - EDS 7ELLCOME 7ITNESSES TO 4WENTIETH #ENTURY -EDICINE 6OLUME ,ONDON 4HE 7ELLCOME 4RUST #ENTRE FOR THE (ISTORY OF -EDICINE AT 5#, 4HIS VOLUME )3".
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4HE DISCOVERY USE AND IMPACT OF PLATINUM SALTS AS CHEMOTHERAPY AGENTS FOR CANCER )N #HRISTIE $ ! 4ANSEY % - EDS 7ELLCOME 7ITNESSES TO 4WENTIETH #ENTURY -EDICINE 6OLUME ,ONDON 4HE 7ELLCOME 4RUST #ENTRE FOR THE (ISTORY OF -EDICINE AT 5#, )N PRESS )3". (ARD COPIES OF VOLUMES n ARE NOW AVAILABLE FOR FREE WHILE STOCKS LAST 7E WOULD BE HAPPY TO SEND COMPLETE SETS TO LIBRARIES IN DEVELOPING OR RESTRUCTURING COUNTRIES !VAILABLE FROM $R #AROLE 2EEVES AT CREEVES UCLACUK !LL VOLUMES ARE FREELY AVAILABLE ONLINE AT WWWUCLACUKHISTMED PUBLICATIONSWELLCOME WITNESSESINDEXHTML OR BY FOLLOWING THE LINKS TO 0UBLICATIONS7ELLCOME 7ITNESSES AT WWWUCLACUKHISTMED ! HARD COPY OF VOLUMES n CAN BE ORDERED FROM WWWAMAZONCOUK WWWAMAZONCOM AND ALL GOOD BOOKSELLERS FOR a PLUS POSTAGE USING THE )3".
/THER PUBLICATIONS 4ECHNOLOGY TRANSFER IN "RITAIN 4HE CASE OF MONOCLONAL ANTIBODIES 4ANSEY % - #ATTERALL 0 0 #ONTEMPORARY 2ECORD n -ONOCLONAL ANTIBODIES ! WITNESS SEMINAR ON CONTEMPORARY MEDICAL HISTORY 4ANSEY % - #ATTERALL 0 0 -EDICAL (ISTORY n #HRONIC PULMONARY DISEASE IN 3OUTH 7ALES COALMINES !N EYE WITNESS ACCOUNT OF THE -2# SURVEYS n 0 $!RCY (ART EDITED AND ANNOTATED BY % - 4ANSEY 3OCIAL (ISTORY OF -EDICINE n !SHES TO !SHES n 4HE HISTORY OF SMOKING AND HEALTH ,OCK 3 0 2EYNOLDS , ! 4ANSEY % - EDS !MSTERDAM 2ODOPI "6 PP )3". (m HARDBACK 2EPRINTED
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7ITNESSING MEDICAL HISTORY !N INTERVIEW WITH $R 2OSEMARY "IGGS 0ROFESSOR #HRISTINE ,EE AND $R #HARLES 2IZZA INTERVIEWERS (AEMOPHILIA n 7ITNESSING THE 7ITNESSES 0ITFALLS AND POTENTIALS OF THE 7ITNESS 3EMINAR IN TWENTIETH CENTURY MEDICINE "Y % - 4ANSEY )N $OEL 2 3ODERQVIST 4 EDS 7RITING 2ECENT 3CIENCE 4HE HISTORIOGRAPHY OF CONTEMPORARY SCIENCE TECHNOLOGY AND MEDICINE ,ONDON 2OUTLEDGE n
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).42/$5#4)/. 4HIS 7ITNESS 3EMINAR ADDS AN IMPORTANT ORAL HISTORY STUDY TO THE MANY ACCOUNTS OF MEDICAL INNOVATION THAT HAVE APPEARED OVER THE PAST YEARS 4HIS INTEREST IN INNOVATIONS AMONG HISTORIANS ECONOMISTS SOCIOLOGISTS AND THE GENERAL PUBLIC CAN BE EXPLAINED BY BOTH THE REMARKABLE SUCCESSES AND THE RISING COSTS OF MEDICAL TECHNOLOGIES AND DRUGS -ANY RECENT STUDIES HAVE FOCUSED ON THE POLITICAL SOCIAL AND ECONOMIC CONTEXTS AS MUCH AS ON THE TECHNOLOGIES THEMSELVES )N RECONSTRUCTING THESE CONTEXTS THE RECOLLECTIONS OF THE PIONEERS ARE INVALUABLE IF NOT ALWAYS INDUBITABLE )N THIS 7ITNESS 3EMINAR SOME OF THE SURVIVING ACTORS INVOLVED IN THE EARLY DEVELOPMENT OF TOTAL HIP REPLACEMENT 4(2 ASSEMBLED TO DISCUSS THEIR CONTRIBUTIONS AND RECOLLECTIONS 4HE RESULTING TRANSCRIPT PROVIDES AN INSIGHT INTO THE CREATION OF A NEW MEDICAL TECHNOLOGY IN MID TWENTIETH CENTURY "RITAIN 4HE 4(2 OPERATION HAS BEEN SEEN AS A LANDMARK IN TWENTIETH CENTURY SURGERY 3INCE THE EARLY S IT HAS PLAYED AN IMPORTANT ROLE IN ALLEVIATING PAIN AND RESTORING MOBILITY TO MILLIONS OF PEOPLE SUFFERING FROM ARTHRITIC JOINTS 4ODAY ABOUT HIPS ARE REPLACED IN %NGLAND AND 7ALES EACH YEAR BY THE .(3 AND MANY MORE OPERATIONS ARE CARRIED OUT IN PRIVATE HOSPITALS 4(2 HAS BECOME ONE OF THE MOST COMMONLY PERFORMED ELECTIVE SURGICAL PROCEDURES WORLDWIDE )TS DEVELOPMENT WAS ASSOCIATED WITH INNOVATION IN MATERIALS INSTRUMENTS TECHNIQUES AND OPERATIVE PROCEDURES LATER ADAPTED TO TREAT OTHER JOINTS AND APPLIED ACROSS A RANGE OF SURGICAL SPECIALTIES (IP REPLACEMENT BECAME A mAGSHIP OPERATION AND HELPED TO RAISE THE STATUS OF "RITISH ORTHOPAEDIC SURGERY 4HE SUCCESS OF 4(2 WAS NOT THE RESULT OF ONE SINGLE BREAKTHROUGH )TS ORIGINS LAY IN THE INTERPOSITIONAL AND HEMI ARTHROPLASTIES DEVELOPED BETWEEN AND IN %UROPE AND THE 53 4HE EVOLUTION OF PROCEDURES FOR PUTTING MATERIALS BETWEEN THE ARTICULATING SURFACES OR FOR REPLACING ONE SIDE OF THE HIP JOINT LED
3EE 0ICKSTONE ED ,WY ED ,AWRENCE ED 3TANTON ED 7EBSTER ED 4IMMERMANN AND !NDERSON EDS
.ATIONAL !UDIT /FlCE
&OR A LONG TERM ANALYSIS OF WHAT MADE ORTHOPAEDIC SURGERY VIABLE FROM ITS FOUNDATION IN THE FOLK MEDICINE TRADITIONS OF BONE SETTING IN THE EIGHTEENTH CENTURY TO RESEARCH BASED PRACTICES AND ORGANIZED MEDICAL SERVICES IN THE TWENTIETH CENTURY SEE 0ICKSTONE n
XXV
TO MATERIALS DESIGNS AND SURGICAL TECHNIQUES THAT PROVED CRUCIAL TO ITS SUCCESS (OWEVER 4(2 WAS PRIMARILY A "RITISH INNOVATION ONE THAT STARTED TO TAKE OFF IN THE LATE S UNDER THE .(3 BUT MAINLY IN DISTRICT GENERAL HOSPITALS RATHER THAN IN TEACHING HOSPITALS )T WAS CREATED IN HOSPITAL UNITS AT .ORWICH 7RIGHTINGTON NEAR 7IGAN 3TANMORE 2EDHILL AND LATER %XETER 4HE STORY BEGINS WITH THE PIONEERING OPERATIONS OF 0HILIP 7ILES AT THE -IDDLESEX (OSPITAL IN THE LATE S IT CONTINUES THROUGH THE LATER WORK OF HIS REGISTRAR ' +ENNETH -C+EE AT THE .ORFOLK AND .ORWICH (OSPITAL AND INCLUDES THE PROGRAMMES AT THE OTHER CENTRES LED BY *OHN #HARNLEY 7RIGHTINGTON *OHN 3CALES AND @'INGER 7ILSON 3TANMORE 0ETER 2ING 2EDHILL AND 2OBIN ,ING AND #LIVE ,EE %XETER 4HE AIM OF THE 7ITNESS 3EMINAR WAS TO REVEAL SOME OF THE PERSONAL STORIES AND RELATIONSHIPS BEHIND THE PUBLISHED ACCOUNTS 4HOUGH MANY OF THE EARLY INNOVATORS ARE NO LONGER WITH US THEIR TALES LIVE ON THROUGH THE REMINISCENCES OF THEIR TRAINEES AND SOME OF THE NURSES SURGEONS ENGINEERS AND MANUFACTURERS WHO WERE INVOLVED WITH THE ORIGINAL CENTRES AND WITH LATER DEVELOPMENTS WHO SPOKE AT THIS MEETING 4HE TRANSCRIPT SHOWS EARLY 4(2 AS CLASSIC "RITISH POSTWAR SCIENCE CHARACTERIZED BY IMPROVISATION INGENUITY LONG HOURS AND LOW BUDGETS "UT BY THE S 4(2S WERE TAKEN UP ACROSS THE 7ESTERN WORLD AND BY THE S THE "RITISH COMPANIES HAD BECOME ATTRACTIVE ACQUISITIONS FOR HEALTHCARE CORPORATIONS 4HE GLOBAL MARKET IS NOW DOMINATED BY A HANDFUL OF MULTINATIONAL
)N THE 53 FOR INSTANCE $R -ARIUS 3MITH 0ETERSEN EXPERIMENTED WITH A NUMBER OF MATERIALS IN THE S INCLUDING GLASS AND 0YREX FOR HIS INTERPOSITIONAL CUP ARTHROPLASTY UNTIL HE HAD SOME SUCCESS WITH 6ITALLIUM® A CHROMEnCOBALT ALLOY ;SEE &IGURE AND !PPENDIX = 4HIS ALLOY WAS USED BY $RS &RED 4HOMPSON AND !USTIN -OORE FOR THEIR HEMI ARTHROPLASTIES TO REPLACE THE HEAD OF THE FEMUR IN THE EARLY S 4HESE PROSTHESES HAD AN ADVANTAGE OVER EARLIER HEMI ARTHROPLASTIES lXED WITH PLATES AND SCREWS ON THE OUTSIDE OF THE FEMUR BECAUSE THEIR STEMS WHICH WENT DOWN THE MEDULLARY CANAL WERE MORE STABLE 4HEY WERE ALSO MUCH MORE RELIABLE THAN THE ACRYLIC POLYETHYLENE HEMI ARTHROPLASTY DEVELOPED BY THE *UDET BROTHERS IN &RANCE IN THE LATE S WHICH ONLY HAD A SMALL STEM 3EE NOTE AND !PPENDIX PAGES n
&OR DETAILED HISTORIES OF 4(2 AND ITS PRECURSORS FROM THE POINT OF VIEW OF THE DEVELOPMENT OF MATERIALS SEE 0ARSONS AND 7ALKER n &OR A CHRONOLOGICAL HISTORY BASED AROUND SOLUTIONS SEE 3CALES n &OR A MORE RECENT HISTORICAL OVERVIEW SEE +LENERMAN n
4HERMISTOKLES 'LÓCK n REPLACED A NUMBER OF TUBERCULOSIS DAMAGED JOINTS WITH IVORY PROSTHESES WHICH WERE lXED WITH A BONE GLUE COMPOSED OF COLOPHONY OR ROSIN PUMICE POWDER AND PLASTER OF 0ARIS IN THE S 4HESE MAY HAVE INCLUDED AN IVORY TOTAL HIP REPLACEMENT BUT HIS WORK WAS DISCREDITED WHEN HE WAS FORCED TO RETRACT HIS RESULTS AFTER AN ARGUMENT WITH 0ROFESSOR %RNST VON "ERGMAN n HIS BOSS AND HEAD OF THE "ERLIN SURGICAL CLINIC 3EE 'LÓCK 3EE ALSO WWWTOTALJOINTSINFO0REHISTORY? 'LUCK0EANHTM VISITED .OVEMBER
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COMPANIES MOSTLY BASED IN THE 53 SOME OF WHICH ARE ASSOCIATED WITH THE PHARMACEUTICAL GIANTS 4HE EARLY DEVELOPMENT OF 4(2 WAS A @COTTAGE INDUSTRY IN WHICH SURGEONn INVENTORS WITH A KNOWLEDGE OF ENGINEERING PRINCIPLES WORKED WITH CRAFT BASED TECHNICIANS UNIVERSITY DEPARTMENTS AND SMALL SURGICAL INSTRUMENT MANUFACTURERS &OR INSTANCE IN THE LATE S *OHN #HARNLEY EMPLOYED THE TECHNICIAN (ARRY #RAVEN TO WORK FROM THE WORKSHOP AT #HARNLEYS HOME MAKING 4EmON® ACETABULAR CUPS AND lNISHING FORGED STAINLESS STEEL FEMORAL PROSTHESES ON A LATHE 4HESE WOULD BE STERILIZED IN FORMALDEHYDE OVERNIGHT READY FOR OPERATING THE NEXT DAY #HARNLEY HAD LIAISED WITH THE %NGINEERING $EPARTMENT AT 5-)34 OVER MATERIALS FOR THE PROSTHESIS AND WITH THE 6ICTORIA 5NIVERSITY OF -ANCHESTER $ENTAL 3CHOOL OVER THE PINK ACRYLIC DENTAL CEMENT THAT HE USED TO lX HIS PROSTHESES IN PLACE SEE PAGES AND (E WORKED WITH THE ,EEDS BASED SURGICAL INSTRUMENT COMPANY #HAS & 4HACKRAY TO FORGE HIS FEMORAL PROSTHESIS AND BY THEY WERE MASS PRODUCING HIS PROSTHESIS AT THEIR FACTORY 4HROUGHOUT THE S #HARNLEY ALSO WORKED WITH ANOTHER LOCAL COMPANY TO DEVELOP A CLEAN AIR OPERATING THEATRE ENVIRONMENT TO REDUCE POST OPERATIVE INFECTIONS WHICH WERE RUINING NEARLY PER CENT OF HIS HIP REPLACEMENT OPERATIONS 4HIS "OLTON BASED COMPANY (OWORTH !IR #ONDITIONING HAD BEEN DEVELOPING CLEAN AIR ENVIRONMENTS FOR COTTON MILLS AND BREWERIES SINCE THE LATE NINETEENTH CENTURY AND ADAPTED THEIR TECHNOLOGIES TO #HARNLEYS NEEDS 4HIS USE OF LOCAL COMPANIES AND EXPERTISE WAS A FEATURE OF ALL OF THE lVE EARLY 4(2 CENTRES "UT EACH LEADING SURGEON USED THE PARTICULAR SURGICAL APPROACH HE HAD LEARNED FOR EARLIER HIP OPERATIONS INCLUDING TUMOURS FRACTURED NECKS OF FEMUR ETC ;SEE &IGURE = 4HEIR CHOICE OF MATERIALS ALSO VARIED CONSIDERABLY STAINLESS STEEL COBALTnCHROME ALLOY 4EmON® AND HIGH DENSITY POLYETHYLENE AS DID THE PROSTHESIS DESIGN FEMORAL HEAD SIZE AND NECK STEM AND CUP GEOMETRY
&OR AN ACCOUNT OF #HARNLEYS RESEARCH INCLUDING THE EARLY SETUP FOR MANUFACTURING PROSTHESES BY HAND SEE 7AUGH n 3EE ALSO NOTE PAGE
&OR THE 4HACKRAY COMPANYS RELATIONSHIP WITH #HARNLEY SEE 7AINWRIGHT n ESPECIALLY #HAPTERS AND
3EE (OWORTH AND 7HYTE n ESPECIALLY #HAPTER
)T IS INTERESTING TO NOTE THEIR INGENUITY IN ADAPTING MATERIALS AND EXISTING TECHNOLOGIES FROM THE AIRCRAFT DENTAL PROSTHETIC AND SURGICAL INSTRUMENT INDUSTRIES TO THEIR PURPOSES &OR EXAMPLE MANY OF THE EARLY BIOMECHANICAL ENGINEERS CAME FROM THE AIRCRAFT INDUSTRY WHICH WAS A RICH SOURCE OF RESEARCH ON CORROSION RESISTANT MATERIALS AND THE USE OF CHROMEnCOBALT ALLOYS AND ACRYLIC CEMENT WAS WELL ESTABLISHED IN DENTAL PROSTHETICS 3EE 0ROFESSORS 3WANSON ON PAGES n AND $OWSON ON PAGES n
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AND THE METHODS OF lXATION SCREWS OR NAILS ACRYLIC CEMENT AND BONE IN GROWTH 4HESE LOCAL VARIATIONS LED TO A PLETHORA OF DEBATES ABOUT THE BEST MODE OF 4(2 THE ARGUMENTS CONTINUED AT FORMAL MEETINGS AND IN MORE INFORMAL SETTINGS LIKE THE ANNUAL ORTHOPAEDIC SKIING TRIP TO THE !LPS 4HIS TRANSCRIPT IS ALSO A TESTAMENT TO WHY THESE DEBATES CONTINUE TO THE PRESENT DAY AND TO THE SHIFTING CONCERNS ABOUT THE BODYS REACTIONS TO MATERIALS AND CEMENT WHICH MADE CERTAIN COMBINATIONS OF MATERIALS AND lXATION METHODS MORE ATTRACTIVE AT PARTICULAR STAGES IN THE DEVELOPMENT OF 4(2 &OR INSTANCE CONCERNS ABOUT THE EFFECT OF THE DEBRIS PRODUCED BY METAL ON METAL ARTICULATIONS PROMOTED A GENERAL SHIFT IN THE EARLY S TO CEMENTED METAL ON PLASTIC HIPS ESPECIALLY AFTER THE VERY GOOD EARLY RESULTS WITH THE #HARNLEY PROSTHESIS "UT TOWARDS THE END OF THAT DECADE NEW WORRIES ABOUT THE BIOCOMPATIBILITY OF THE CEMENT AND THE EFFECT OF POLYETHYLENE WEAR PARTICLES LED TO A RESURGENCE OF METAL ON METAL COMBINATIONS ,ATER PROBLEMS WITH THE lXATION OF METAL ON METAL COMPONENTS ESPECIALLY THOSE USING NEW BIOACTIVE COATING METHODS LIKE HYDROXYAPATITE MADE METAL ON PLASTIC ATTRACTIVE AGAIN AND IN THE S MORE ACCURATE MACHINING TECHNIQUES CREATED THE POSSIBILITY OF OBTAINING GOOD RESULTS FROM METAL ON METAL HIP RESURFACING &OR OVER YEARS NOW THE DEBATES HAVE CONTINUED PARTLY BECAUSE OF CONTINUAL NOVELTIES BUT ALSO BECAUSE THE RESULTS ARE HARD TO PREDICT AND CAN ONLY BE JUDGED OVER n YEARS 3HORT TERM STUDIES CAN ONLY PICK UP SERIOUS FAILURES AND RECORDS OF LONG TERM PERFORMANCE ARE LESS COMPLETE THAN THEY MIGHT HAVE BEEN 4HE TRANSCRIPT SHOWS HOW PROPOSALS TO CREATE A "RITISH REGISTER OF HIP IMPLANTS IN THE S CAME TO LITTLE 4HE SEMINAR PARTICIPANTS ALSO CONSIDERED THE ATTEMPTS TO IMPOSE STANDARDS ON THE DESIGN AND MANUFACTURE OF HIP PROSTHESES 4HE S AND S SAW LITTLE CONSENSUS IN THE COMMITTEES SET UP IN "RITAIN AND %UROPE 3TANDARDIZATION AND REGULATION IN "RITAIN CAME MUCH LATER THAN IN THE 53 THE -EDICAL $EVICES
&OR A DESCRIPTION OF THE "RITISH /RTHOPAEDIC 3KI 'ROUP SEE 7AUGH n )TS NAME WAS LATER CHANGED TO 3TUDY 'ROUP "3/' AND IS USED THROUGHOUT THE TRANSCRIPT
(IP RESURFACING WAS ATTEMPTED BY #HARNLEY IN THE LATE S WITH A 04&% DOUBLE CUP SEE &IGURE AND &REEMAN IN THE EARLY S WITH A METAL ON POLYETHYLENE COMBINATION SEE &IGURE 4HERE WERE EARLY FAILURES BUT THE "IRMINGHAM METAL ON METAL HIP RESURFACING DEVELOPED IN THE S SEE !PPENDIX PAGE WAS WIDELY COPIED AND RESURFACING IS NOW A COMMON OPERATION FOR YOUNGER PATIENTS SEE PAGE
&OR INSTANCE THE RECOMMENDATIONS OF THE $O( )MPLANT !DVISORY 'ROUP ;SEE PAGES n AND 3WEETNAM = !LTHOUGH HIP REGISTERS WERE SET UP IN 3CANDINAVIA IN THE PERIOD THE 3WEDISH .ATIONAL (IP !RTHROPLASTY 2EGISTER HAD BEGUN COLLECTING AND ANALYSING DATA ABOUT ALL PRIMARY TOTAL HIP REPLACEMENTS AND RE OPERATIONS AND REVISIONS OF HIP IMPLANTS IN WHILE THE .ORWEGIAN !RTHROPLASTY 2EGISTER WAS STARTED IN
XXVIII
!GENCY -$! WAS NOT FORMED UNTIL THE S AND IT WAS THEN MERGED WITH THE -EDICINES #ONTROL !GENCY -#! IN TO FORM THE -EDICINES AND (EALTHCARE PRODUCTS 2EGULATORY !GENCY -(2! )N THE EARLY PERIOD OF 4(2 IN THE 5+ AS COVERED BY THIS SEMINAR SINGLE CENTRE FOLLOW UP STUDIES WERE THE BEST DATA AVAILABLE 2EGIONAL REGISTERS BEGAN TO APPEAR IN "RITAIN IN THE S AND IN !PRIL THE .ATIONAL *OINT 2EGISTRY FOR %NGLAND AND 7ALES .*2 WAS SET UP 2ECENTLY AS IN SOME OTHER COUNTRIES THE .ATIONAL )NSTITUTE FOR #LINICAL %XCELLENCE .)#% HAS PRODUCED STUDIES OF THE COST EFFECTIVENESS OF PROSTHESES BASED ON LONG TERM FOLLOW UP STUDIES 4HESE STUDIES CLEARLY SHOW THAT THE MOST COMMON AND MOST RELIABLE OF THE MODELS USED IN "RITAIN ARE CLOSELY RELATED TO THE #HARNLEY DESIGNS OF THE S 4(2 MATERIALS AND TECHNIQUES CAME TO BE ADAPTED FOR A GREATER RANGE OF TYPES OF PATIENT AND FOR THE REPLACEMENT OF OTHER JOINTS THEY PROVED TO BE THE BASIS OF A HUGE GLOBAL INDUSTRY THAT NOW HAS MANY OF THE CHARACTERISTICS OF THE PHARMACEUTICAL BUSINESS INCLUDING @ME TOO MODELS AND HUGE AMOUNTS OF MONEY SPENT TO SECURE @SURGEON LOYALTY )T IS A FAR CRY FROM THE "RITISH PIONEERS OF THE S AND S WHO WORKED IN THE .(3 LED THE COLLABORATIONS WITH ENGINEERS AND COMPANIES AND ACHIEVED LONG LASTING RESULTS WITH REMARKABLE ECONOMY 4O THEM MILLIONS OF OLDER AND SOME YOUNGER PEOPLE NOW OWE SUBSTANTIAL ENHANCEMENTS IN THEIR QUALITY OF LIFE 4HIS TRANSCRIPT WILL SERVE AS A PERMANENT RECORD OF THE EARLY DEVELOPMENTS AND WE ARE MOST GRATEFUL TO ALL WHO TOOK PART &RANCIS .EARY AND *OHN 0ICKSTONE #ENTRE FOR THE (ISTORY OF 3CIENCE 4ECHNOLOGY AND -EDICINE 5NIVERSITY OF -ANCHESTER
3EE THEIR WEBSITE AT WWWMHRAGOVUK VISITED .OVEMBER
4HE LATEST .*2 REPORT FOR RECORDS PER CENT OF THE HIP AND KNEE OPERATIONS PERFORMED IN %NGLAND AND 7ALES AND CAN BE VIEWED AT WWWNJRCENTREORGUK0UBLIC00%HOMEPAGEHTM VISITED $ECEMBER
&OR INSTANCE .)#% n 3EE WWWNICEORGUKPAGEASPX O FOR LATER GUIDELINES TO THE .(3 AND FOR PATIENTS FREELY AVAILABLE VISITED .OVEMBER
XXIX
%!2,9 $%6%,/0-%.4 /& 4/4!, ()0 2%0,!#%-%.4 4HE TRANSCRIPT OF A 7ITNESS 3EMINAR HELD BY THE 7ELLCOME 4RUST #ENTRE FOR THE (ISTORY OF -EDICINE AT 5#, ,ONDON ON -ARCH %DITED BY , ! 2EYNOLDS AND % - 4ANSEY
%!2,9 $%6%,/0-%.4 /& 4/4!, ()0 2%0,!#%-%.4 0ARTICIPANTS 0ROFESSOR 3IR #HRISTOPHER "OOTH ,ADY #HARNLEY -R 4RISTRAM #HARNLEY -R (ARRY #RAVENo -S #LARE $ARRAH -R 'RAHAM $EANE 0ROFESSOR $UNCAN $OWSON -RS 3HEILA %DWARDS -R 2EG %LSON $R !LEX &AULKNER 0ROFESSOR -ICHAEL &REEMAN -RS 0HYLLIS (AMPSON -R +EVIN (ARDINGE -R -IKE (EYWOOD 7ADDINGTON -R 'EOFF +ING -R *OHN +IRKUP
-R +RISHNA 2AVI +UNZRU -ISS "ETTY ,EE -R !LAN ,ETTIN #HAIR $R &RANCIS .EARY -R *OHN /LDER 0ROFESSOR *OHN 0ICKSTONE -R *OHN 2EAD -R 0ETER 2ING -R )AN 3TEPHEN -R -ALCOLM 3WANN 0ROFESSOR !LAN 3WANSON 3IR 2ODNEY 3WEETNAM -R +EITH 4UCKER -R 6ICTOR 7HEBLE -R -ICHAEL 7ILSON 0ROFESSOR " -ICHAEL 7ROBLEWSKI
!MONG THOSE ATTENDING THE MEETING -RS *AN 3HERWOOD 0ROFESSOR *OHN 7ALKER 3MITH -R .IGEL 7HEBLE !POLOGIES INCLUDE -R 2ON !NSELL -R &RANK "ROWN -R *OHN #HALLIS -R 3IMON #HAPLIN -R #HRIS &AUX 0ROFESSOR *OHN &ISHER -R 'RAHAM 'IE -R "ARRY (INVES -R &RANK (ORAN $R - & ,ECLERC $R #LIVE ,EE -R )AN ,ESLIE 0ROFESSOR 2OBIN ,ING 0ROFESSOR !RCHIE -ALCOLM -R $EREK -C-INN 0ROFESSOR #OLIN .ORMAND 0ROFESSOR *OHN 0AUL -R *AMES 3COTT $R *EAN 3MELLIE -R 2ICHARD 4ODD -R 2OGER 6ICKERS -R * . 'INGER 7ILSONp $IED &EBRUARY
o
$IED -ARCH
p
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$R $APHNE #HRISTIE 7E ARE VERY GRATEFUL TO OUR ADVISERS 2AVI +UNZRU AND &RANCIS .EARY FOR THEIR HELP WITH THE ORGANIZATION OF THE MEETING AND ) AM PARTICULARLY GRATEFUL TO !LAN ,ETTIN WHO HAS KINDLY AGREED TO CHAIR THE MEETING THIS AFTERNOON 3O WITHOUT FURTHER ADO ) WILL PASS YOU OVER TO THE #HAIRMAN -R !LAN ,ETTIN 4HANK YOU VERY MUCH 4HESE 7ITNESS 3EMINARS HAVE BEEN GOING SINCE )T STRIKES ME THAT PERHAPS IT IS ABOUT YEARS TOO LATE FOR ONE ON TOTAL HIP REPLACEMENT ;4(2 ALSO KNOWN AS TOTAL HIP ARTHROPLASTY 4(! SEE &IGURE = BECAUSE IF ONE HAD BEEN HELD YEARS AGO THE MODERN INNOVATORS WOULD HAVE BEEN HERE IN PERSON )N FACT ONE OR TWO ARE HERE ) AM LOOKING STRAIGHT AT 0ETER 2ING ) THINK THE CONCEPT OF THIS MEETING STARTED WITH 2AVI +UNZRU WHO HAS BECOME VERY INTERESTED IN MEDICAL HISTORY SINCE RETIRING AS A #ONSULTANT /RTHOPAEDIC 3URGEON AND &RANCIS .EARY AND HIS BOSS *OHN 0ICKSTONE WHO IS A PROFESSOR OF MEDICAL HISTORY AT THE 5NIVERSITY OF -ANCHESTER ) THINK MOST PEOPLE WOULD KNOW THAT THE IDEA OF REPLACING DISEASED AND DAMAGED JOINTS BY ARTIlCIAL IMPLANTS WAS NOT NEW IN THE S WHEN *OHN #HARNLEY AND +EN -C+EE AND OTHERS REALLY PUT JOINT REPLACEMENT ON THE MAP 0EOPLE TRIED IN THE NINETEENTH CENTURY IN THE GREAT EXPLOSION OF SURGICAL KNOWLEDGE AND EFFORT AT THE END OF THAT CENTURY BUT FOR ALL INTENTS AND PURPOSES WE WILL BE TALKING ABOUT THE SECOND HALF OF THE TWENTIETH CENTURY A PERIOD WHICH BEGAN WITH *OHN #HARNLEY AND +EN -C+EE AND PERHAPS ENDED YEARS LATER WITH -ICHAEL &REEMAN AND THE DOUBLE CUP %VERYTHING SINCE THEN HAS BEEN A VARIATION ON A THEME AND WHAT WE REALLY WANT IN THE ABSENCE OF THOSE EARLY INNOVATORS IS FOR THE PEOPLE HERE WHO HAVE BEEN ASKED TO COME BECAUSE THEY WORKED WITH OR FOR THOSE PIONEERS TO REMINISCE AND TO TELL US WHAT HAPPENED !LTHOUGH ) SAID THAT IT REALLY STARTED WITH -C+EE AND #HARNLEY ) THINK PERHAPS WE SHOULD PAY SOME TRIBUTE TO 0HILIP 7ILES ;&IGURE = WHO AS ) UNDERSTAND IT DID THE lRST TOTAL HIP REPLACEMENT IN ;SEE !PPENDIX PAGE = 3IR 2ODNEY 3WEETNAM WAS 0HILIP 7ILES HOUSEMAN REGISTRAR AND SUCCEEDED HIM AT THE -IDDLESEX (OSPITAL ,ONDON ) THOUGHT IT WOULD BE APPROPRIATE IF 3IR 2ODNEY STARTED THE BALL ROLLING )F EVERYBODY IN THIS ROOM SPEAKS THEY ARE
"IOGRAPHICAL NOTES APPEAR ON PAGES n
&OR THE BACKGROUND TO THE 7ITNESS 3EMINAR AS AN HISTORICAL TOOL SEE PAGES XInXXIII
4HE )MPERIAL #OLLEGE ,ONDON (OSPITAL )#,( HIP REPLACEMENT SEE &IGURE 3EE ALSO "RIGITTE AND %ARL 0ADGETT ET AL 0ARKER AND 'URUSAMY
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT
&IGURE 4HE DISARTICULATED HIP JOINT THE SITE OF A TOTAL HIP REPLACEMENT , THE HEAD OF THE FEMUR 2 THE ACETABULUM PART OF THE PELVIS
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ONLY GOING TO BE ABLE TO DO SO FOR FOUR MINUTES EACH SO WE DONT REALLY WANT ANYONE SPEAKING FOR LONGER THAN FOUR MINUTES AT A TIME ANYWAY /F COURSE THERE SHOULDNT BE ANY UNDUE CONSTRAINTS BUT ) DO BEG YOU NOT TO TAKE THE mOOR FOR TOO LONG 2ODNEY ) AM SURE YOU WILL SET A TREMENDOUS EXAMPLE TO EVERYONE BY TELLING US ABOUT 0HILIP 7ILES CONTRIBUTION 3IR 2ODNEY 3WEETNAM 9ES AND ) WILL DO IT IN THREE AND HALF MINUTES 4HANK YOU VERY MUCH AND THANK YOU FOR ASKING ME 9OU MADE IT SOUND AS THOUGH THERE WAS A DEGREE OF NEPOTISM #HAIRMAN 9ES ) WAS 0HILIP 7ILES HOUSEMAN AND ) DID INDEED SUCCEED HIM ALTHOUGH ) WASNT HIS REGISTRAR ) WANT TO DRAW EVERYBODYS ATTENTION TO THE PIONEER WORK THAT MY EX CHIEF AND PREDECESSOR ;SEE &IGURE = DID AND TO THAT END ON YOUR CHAIRS IS A COPY OF A PAPER IN THE "RITISH *OURNAL OF 3URGERY THAT HE WROTE IN DESCRIBING HIS lRST ATTEMPT AT A TOTAL HIP REPLACEMENT ARTHROPLASTY 9OU WILL SEE THAT IN THE RIGHT HAND COLUMN ON THE lRST PAGE HE DESCRIBES WHAT ) BELIEVE TO BE THE lRST TOTAL HIP REPLACEMENT ;IN THE 5+= IN AT THE -IDDLESEX (OSPITAL REPLACING THE SOCKET AND THE FEMORAL COMPONENT
&IGURE -R 0HILIP 7ILES &2#3 C
7ILES 3EE !PPENDIX PAGE
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&IGURE 8 RAY OF 7ILES HIP C S
(E DESCRIBES ANIMAL EXPERIMENTATION AND LATER THE INSERTION OF SIX OF THESE PROSTHESES INTO PATIENTS (E ALSO GOES ON TO SAY THAT HE HAD NO ADEQUATE FOLLOW UP AS THE WAR INTERVENED AND OF THE SIX PATIENTS HE ONLY KNEW OF ONE LATER 4HAT ONE PATIENT BECAME MY PATIENT WHEN ) SUCCEEDED HIM IN 4HAT PATIENT HAD A PAINFUL STIFF BUT SLIGHTLY MOBILE HIP WHICH WAS THE SITE OF ONE OF 7ILES SIX TOTAL JOINT REPLACEMENTS ) REMOVED THE ARTIlCIAL JOINT AND IF ) REMEMBER CORRECTLY ARTHRODESED THE HIP n ) MAY HAVE DONE A 'IRDLESTONE ) CANT REMEMBER "UT THE PROSTHESIS IS NOW IN THE ARCHIVES OF THE "RITISH /RTHOPAEDIC !SSOCIATION "/! ON LOAN TO THE (UNTERIAN -USEUM AT THE 2OYAL #OLLEGE OF 3URGEONS 4HIS lRST ATTEMPT AT TOTAL HIP REPLACEMENT HAD SOME SIMILARITY TO THE PRESENT DAY SO CALLED @SURFACE REPLACEMENT ;SEE !PPENDIX PAGE = )N MY TIME 0HILIP 7ILES WAS A MODEST MAN YOULL SEE THAT IN HIS PAPER HE MAKES RELATIVELY SHORT REFERENCE TO THIS MAJOR CONTRIBUTION IN HIP SURGERY WORLDWIDE n SIX CASES HE DISMISSES IT GOES ON TO DESCRIBE ALL THE OTHER OPERATIONS
! 'IRDLESTONE OPERATION IS A RESECTION ARTHROPLASTY OF THE HIP REMOVING THE HEAD AND NECK OF THE FEMUR WHICH USUALLY LEAVES THE PATIENT WITH A PAIN FREE HIP 4HE FEMUR IS LEFT LOOSE ALLOWING SOME MOVEMENT BETWEEN IT AND THE ACETABULUM PELVIS n A @PSEUDOARTHROSIS OR FALSE JOINT 3EE THE 'LOSSARY PAGE
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&IGURE #HARNLEY 04&% DOUBLE CUP IMPLANT C
,ETTIN ) SUPPOSE HAVING SAID THAT VERY FEW OF THE ORIGINATORS ARE LEFT 0ETER 2ING IS HERE 0ETER ) DONT KNOW WHETHER YOU COULD PERHAPS TELL US THE SEQUENCE OF EVENTS 7AS IT -C+EE WHO PRODUCED THE lRST TOTAL HIP REPLACEMENT OR WAS IT *OHN #HARNLEY OR WAS IT EVEN YOU ) KNOW IT WASNT THE 3TANMORE -R 0ETER 2ING .O IT CERTAINLY WASNT ME ) WAS A REGISTRAR AT THE TIME WHEN *OHN #HARNLEY WAS WORKING WITH 04&% ;POLYTETRAmUOROETHYLENE 4EmON® &LUON® = AND LATER ) BECAME A CONSULTANT AT 2EDHILL AND WENT TO A MEETING TWO OR THREE YEARS LATER AT WHICH BOTH -C+EE AND #HARNLEY WERE PRESENT ONE DEMONSTRATING THE METAL ON PLASTIC HIP AND THE OTHER THE METAL ON METAL
-C+EE PRODUCED AN ALL METAL PROTOTYPE REPLACEMENT JOINT IN ALTHOUGH HIS RESULTS WERE NOT PUBLISHED UNTIL ;-C+EE = THE *UDET BROTHERS INSERTED A PERSPEX FEMORAL HEAD IN ;*UDET AND *UDET = AND THE #HARNLEY HIP WAS THE lRST TOTAL HIP REPLACEMENT SYSTEM TO BE ADOPTED WORLDWIDE &OREMAN 0ECK 3EE !PPENDIX PAGES n FOR ILLUSTRATIONS OF THE CUPS AND STEMS MENTIONED IN THIS TRANSCRIPT AND THE MATERIALS USED
4EmON® IS THE TRADE NAME FOR A FAMILY OF 04&% RESINS PRODUCED BY $U0ONT 7ILMINGTON $ELAWARE 53! #HARNLEYS ACETABULAR AND FEMORAL COMPONENTS WERE MADE FROM &LUON® RESIN PRODUCED BY )MPERIAL #HEMICAL )NDUSTRIES )#) IN THE 5+ #HARNLEY DESCRIBES THE MATERIAL ILLUSTRATED IN &IGURE AS POLYTEF -ANY PARTICIPANTS CALLED THIS 4EmON® DURING THE MEETING WHICH HAS BEEN REPLACED IN THE TEXT WITH THE MORE ACCURATE TERM 04&% 3EE ,I AND "URSTEIN
3EE NOTE
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)T OCCURRED TO ME THAT THEY WERE BOTH MAKING A RATHER SIMPLE JOB DIFlCULT BY USING BONE CEMENT WHICH WAS A RELATIVELY UNTRIED MATERIAL AT THAT TIME !ND SINCE WE HAD A PROSTHESIS AT THAT TIME -OORES WHICH GAVE A REASONABLE RESULT CERTAINLY IN THE TREATMENT OF FRACTURES OF THE HIP JOINT IF ONE COULD MATCH THAT TO SOME SORT OF CUP THAT WAS lXED lRMLY YOU MIGHT AVOID THE USE OF BONE CEMENT ;SEE &IGURE = ) HAD SPENT TWO OR THREE YEARS DEMONSTRATING ANATOMY BEFORE THAT AND ONE OF THE AREAS THAT WAS QUITE OBVIOUS TO AN ANATOMIST WAS THE ILEOPUBIC BAR OF BONE !ND AS AN ORTHOPAEDIC SURGEON ) BECAME FAMILIAR WITH THIS IN DOING ARTHRODESIS BECAUSE ONE ATTEMPTED TO GET THE TRIlN NAIL UP THE
&IGURE 4HE 2ING TOTAL HIP REPLACEMENT 8 RAY OF 4(2 IN POSITION
#HARNLEY DESCRIBES THE PROPERTIES OF POLYMETHYLMETHACRYLATE 0--! THE SELF CURING BONE CEMENT @0--! FOR ORTHOPAEDIC USAGE FOR EXAMPLE #-7 ;SEE !PPENDIX = IS PACKAGED AS TWO COMPONENTS ML OF LIQUID AND G OF POWDER 4HE LIQUID CONTAINS THE 0--! MONOMER STABILIZER AND ACTIVATOR 4HE POWDER CONTAINS THE POLYMER A RADIO OPAQUE SUBSTANCE AND POLYMERIZATION INITIATORS 7HEN ADDED TOGETHER AND MIXED POLYMERIZATION OCCURS !T lRST THE CEMENT IS A RELATIVELY LOW VISCOSITY GLISTENING PASTE 4HE VISCOSITY OF THE PREPARATION STEADILY INCREASES AND THE SURFACE BECOMES DULL 4HE RAPID lNAL PHASE OF POLYMERIZATION IS ASSOCIATED WITH AN EXOTHERMIC REACTION 4HE MATERIAL THEN BECOMES A SOLID RESIN 7HEN USED IN LARGE VOLUMES A BULK STATE 0--! BEHAVES IN A DIFFERENT WAY FROM THE THIN MANTLE SEEN IN PROSTHETIC lXATION -C#ASKIE ET AL 3EE ALSO #HARNLEY AND NOTE
3EE !PPENDIX PAGE
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ILEOPUBIC BAR OF BONE FOR SECURE lXATION )T SEEMED THEREFORE THAT IF YOU COULD LOCATE A CUP WITH A LONG SCREW THREAD UP THE ILEOPUBIC BAR OF THE BONE YOU COULD HOPE FOR A REASONABLY SOUND METHOD OF lXATION )F YOU ALSO GOT A CUP THAT WAS ORIENTATED MORE OR LESS DIRECTLY AND CERTAINLY UNIFORMLY AND MATCHED THAT TO A FEMORAL COMPONENT AND YOU HAD A TOTAL HIP REPLACEMENT ;SEE &IGURE = &OR THE DEVELOPMENT OF THAT ) AM VERY INDEBTED TO -AURICE $OWN WHO PUT THE RESOURCES OF HIS lRM AT MY DISPOSAL AND HELPED ME IN ITS DEVELOPMENT AS HE DID FOR A NUMBER OF ORTHOPAEDIC SURGEONS ,ETTIN %SSENTIALLY WHAT YOU WERE DEVELOPING WAS AN UNCEMENTED IMPLANT BECAUSE YOU DIDNT FEEL THAT CEMENT WAS THE WAY FORWARD WAS THAT THE ESSENCE OF YOUR CONTRIBUTION .OW OBVIOUSLY WE HAVE ASKED ONE OR TWO PEOPLE ALONG WHO WERE ASSOCIATED WITH THE EARLY DEVELOPMENT INCLUDING *OHN +IRKUP WHO WORKED AS A JUNIOR WITH -C+EE ;&IGURE = 0ERHAPS YOU COULD TELL US *OHN WHAT WENT ON WAY BACK IN THE EARLY DAYS
&IGURE +EN -C+EE WITH HIS TOTAL HIP REPLACEMENT SYSTEM 2EPRODUCED BY PERMISSION OF THE ¥%ASTERN %VENING .EWS
-R -AURICE $OWN /"% WAS #HAIRMAN AND -ANAGING $IRECTOR OF THE SMALL MEDICAL EQUIPMENT lRM $OWNS 3URGICAL ,TD -ITCHAM 3URREY THAT MANUFACTURED AND MARKETED THE 2ING 4(2 FROM -R 0ETER 2ING WROTE @-AURICE $OWN REMAINED UNTIL THE lRM WAS EVENTUALLY TAKEN OVER BY 3MITHS )NDUSTRIES IN THE MID S ALTHOUGH IT CONTINUED TO MANUFACTURE MY IMPLANTS AND CONTINUED THE TRADING NAME OF $OWNS FOR MANY YEARS AFTER THAT ,ETTER TO -RS ,OIS 2EYNOLDS /CTOBER
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT
-R *OHN +IRKUP ) HAD THE PRIVILEGE OF BEING THERE WITH +EN -C+EE FROM TO SIX MONTHS AS A SENIOR HOUSE OFlCER 3(/ AND MONTHS AS A REGISTRAR AND THE THING THAT STRUCK ME WAS THAT HE WAS NOT JUST AN ORTHOPAEDIC SURGEON OF MECHANICAL BENT BUT HE WAS A GENERAL ORTHOPAEDIST WITH HIS CLINICS FULL OF INTERESTING MATERIAL A FACT THAT CONVERTED ME TO ORTHOPAEDIC SURGERY "UT THERE WAS NO DOUBT THAT HE WAS INTERESTED IN HIPS PERHAPS BECAUSE HIS CLINICS WERE FULL OF FARMERS AND FARM WORKERS WHO WERE OTHERWISE VERY lT EXCEPT FOR AN ARTHRITIC HIP OR AN ARTHRITIC KNEE OR BOTH !ND THIS WAS ONE OF THE THINGS THAT MOTIVATED HIM TOWARDS THAT PARTICULAR lELD OF SURGERY WHICH HE STARTED IN YOU MAY REMEMBER 4HE lRST HIP IN STAINLESS STEEL WAS UNSATISFACTORY AS WAS THE SECOND THE THIRD IN THE ALLOY OF CHROME AND COBALT LASTED SOME THREE YEARS 7HEN ) ARRIVED IN HE WAS STARTING WHAT HE CALLED -ARK HIPS COMPRISING METAL TO METAL CHROMEnCOBALT WITH A mANGED ACETABULUM IN THE CENTRE OF WHICH WERE THREE HOLES WITH THREE SCREWS ) THOUGHT THIS WAS RATHER UNSATISFACTORY BUT ANYWAY THE OPERATION WORKED ;FOR AN 8 RAY OF A LATER VERSION SEE &IGURE =
&IGURE 0OST OPERATIVE 8 RAY OF THE -C+EE ARTIlCIAL JOINT
-C+EE
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&IGURE (AWLEY ORTHOPAEDIC TABLE SHOWING A NON STERILE ASSISTANT CONTROLLING THE LEG
)T WAS INTERESTING /NE DAY HE SAID @7E ARE REPLACING A HIP TOMORROW AND AS ) WAS A BIT LATE GETTING TO THE THEATRE THAT MORNING ) SAW HIM GOING UP THE STEPS RUBBING SOMETHING ON THE BACK OF HIS RIGHT BUTTOCK AND THEN SAW THIS WAS A PROSTHESIS (E SAID @9ES WE MUST ENSURE THAT WE HAVE COMPLETE SLIPPERINESS ITS VERY IMPORTANT THAT WE REDUCE THE FRICTION )T WAS THE HIP BALL HE HAD POLISHED IN HIS WORKSHOP THE NIGHT BEFORE !NYWAY THE FACT IS THAT THIS SOMEWHAT ODD OPERATION APPEARED TO WORK 9OU HAD TO HAVE THE PATIENT ON A (AWLEY TABLE ;&IGURE = AND &RANK THE ORTHOPAEDIC TECHNICIAN WAS CALLED UPON TO MOVE THE LEG AS NECESSARY AT THE RELEVANT MOMENT 4HE PATIENT REMAINED IN BED FOR TEN OR DAYS UNTIL THE WOUND WAS HEALED AND STAYED IN HOSPITAL FOR MAYBE THREE OR FOUR WEEKS &OR MANY PATIENTS THIS SURGERY SUCCEEDED ) SAW THEM AT FOLLOW UP AND MOST WERE VERY PLEASED (OWEVER -C+EE WAS ONLY DOING SOMETHING LIKE TEN A YEAR !ND THEN IN OF COURSE HE WAS CONVERTED TO THE USE OF CEMENT ,ETTIN 4HAT LEADS US ON VERY NICELY ) SUPPOSE TO *OHN 2EAD 4HERE ARE SEVERAL PEOPLE HERE NOT LEAST ,ADY #HARNLEY WHO WERE ASSOCIATED WITH 3IR *OHN ;#HARNLEY= /F COURSE *OHN YOU WERE WORKING FOR HIM FAIRLY EARLY ON 7HAT ARE YOUR RECOLLECTIONS ) THINK ITS QUITE CLEAR THAT 3IR *OHN INTRODUCED CEMENT INTO THE OPERATION
3EE &IGURE FOR AN EXAMPLE OF A (AWLEY TABLE
-C+EE AND 7ATSON &ARRAR
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&IGURE 0ROFESSOR 3IR *OHN #HARNLEY &2#3 &23
-R *OHN 2EAD ) ARRIVED AT 7RIGHTINGTON IN HAVING PREVIOUSLY DONE THREE YEARS AS A REGISTRAR AT 3UNDERLAND /RTHOPAEDIC AND !CCIDENT (OSPITAL "EFORE MY ARRIVAL *OHN #HARNLEY ;&IGURE = HAD BEEN WORKING ON HIS ARTIlCIAL HIP USING A 04&% SOCKET AND A STAINLESS STEEL FEMORAL HEAD !CTUALLY THE lRST ONE HE PRODUCED WAS A DOUBLE 04&% CUP ;SEE &IGURE = WHICH WAS A FAILURE AND AFTER THAT HE MOVED ON TO USING A METAL FEMORAL HEAD !ND THE INITIAL RESULTS OF THAT HAD BEEN QUITE GOOD BUT THERE WERE SEVERAL PROBLEMS /NE WAS THAT WITHIN A YEAR 04&% WAS BEGINNING TO SHOW SIGNS OF WEAR AND THE OTHER WAS THAT HE HAD A HIGH INFECTION RATE BECAUSE AT HIS UNIT AT 7RIGHTINGTON HED BEEN ALLOCATED ) THINK TEN THEATRE HOURS ALTOGETHER BUT THE THEATRE WAS VERY BASIC n IT DIDNT HAVE A RECOGNIZABLE VENTILATING SYSTEM WAS USED BY ALL SORTS OF PEOPLE AT ALL SORTS OF TIMES AND IT HAD A HIGH INFECTION RATE WHICH ) THINK WAS ABOUT PER CENT
0ROFESSOR -IKE 7ROBLEWSKI WROTE @#HARNLEY GAVE THIS PHOTO AUTOGRAPHED TO HIS PAST 2ESIDENTS .OTE ON DRAFT TRANSCRIPT /CTOBER
4HE #ENTRE FOR (IP 3URGERY AT 7RIGHTINGTON (OSPITAL NEAR -ANCHESTER
#HARNLEY AND %FTEKHAR #HARNLEY
0ROFESSOR -IKE 7ROBLEWSKI WROTE @4HE INFECTION RATE BEFORE CLEAN AIR ENCLOSURE WAS PER CENT .OTE ON DRAFT TRANSCRIPT *UNE 3EE #HARNLEY AND %FTEKHAR ALSO &IGURES AND
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"EFORE ) ARRIVED HE STARTED DESIGNING HIS GREENHOUSE TO PRODUCE HIS OWN FRESH AIR INmOW FROM OUTSIDE AND (ARRY #RAVEN ;&IGURE = WHO IS HERE TODAY BUILT THE ENCLOSURE IN HIS WORKSHOP -Y lRST THEATRE LIST WAS WITH THIS GREENHOUSE BEING USED FOR THE lRST TIME WHICH WAS QUITE SOMETHING ) AM SURE YOU HAVE ALL SEEN PICTURES OF IT FROM TIME TO TIME ;&IGURES AND = )T ONLY TOOK THE PATIENTS BODY 4HE ANAESTHETIST WAS KEPT OUTSIDE BECAUSE HE WAS DIRTY ANYWAY BUT WE HAD WINDOWS AT THE SIDE SO THAT OTHER PEOPLE COULD LOOK IN AND SEE WHAT WAS GOING ON ,ETTIN /NE OF THE TOPICS THAT WE WANT TO GET TO IS INFECTION AND THE QUESTION OF THE GREENHOUSE MIGHT BE BETTER DISCUSSED THEN 7AS THAT YOUR MAIN RECOLLECTION 7HAT ABOUT THE CEMENT 7AS THAT INTRODUCED IN YOUR TIME OR BEFORE 2EAD ! LITTLE BEFORE ) THINK AND THE CEMENT THAT WE USED INITIALLY STILL HAD THE PINK DENTAL DYE IN IT WHICH WAS QUITE USEFUL ACTUALLY BECAUSE YOU COULD SEE WHERE IT WAS GOING QUITE WELL ,ETTIN -R #RAVEN WOULD YOU LIKE TO COMMENT ON THOSE EARLY TIMES
&IGURE (ARRY #RAVEN
!NONYMOUS ,OWBURY AND ,IDWELL *OHNSTON "INTCLIFFE
-R *OHN 2EAD WROTE @$ENTAL ACRYLIC WITH A PINK DYE TO MATCH THE GUMS .OTE ON DRAFT TRANSCRIPT *ULY
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-R (ARRY #RAVEN 3PEAKING OF THE CEMENT ) THINK WE STARTED USING IT ABOUT 4HIS WAS WHEN WE WERE STILL ON WITH THE 04&% AND THEN WE WENT ON TO OTHER STUFF CALLED &LUOROSINT® n FUNNY NAME AND FUNNY MIXTURE n AND WE DIDNT DO VERY MANY WITH THAT "UT ) DESIGNED ANOTHER HIP WHICH ) THOUGHT WAS A THREE DIMENSIONAL HIP WHERE YOU HAD A 3MITH 0ETERSEN CUP ;&IGURE = AND A PLASTIC SOCKET PUT INSIDE IT CEMENTED IN WITH THE ACRYLIC CEMENT AND THEN YOU GOT THE MAIN HEAD OF THE PROSTHESIS GOING INTO THE MAIN ($0 SOCKET ) THOUGHT IF THERES ANY MOVEMENT YOUD GET THREE MOVEMENTS WHICH COULD HELP THE LIFE OF THE HIP SOCKET !PPARENTLY THIS WASNT SO ALTHOUGH SOME OF THE CHAPS AT 7RIGHTINGTON n +IRK (OUSTON WAS ONE n LOVED DOING THESE AFTER WE HAD GONE ON TO THE HIGH DENSITY POLYETHYLENE ($0 *OHN #HARNLEY SAID TO HIM @) DONT WANT YOU TO DO THOSE ) WANT YOU TO DO RESEARCH ON THEM "UT +IRK (OUSTON STILL INSISTED ON DOING THEM
&IGURE 3TAINLESS STEEL 3MITH 0ETERSEN CUP CM DIAMETER X CM C
#HARNLEY USED &LUOROSINT® A MICA REINFORCED 4EmON® FOR THE CUPS 4HE REPLACEMENT 5(-70% ;(OECHST /BERHAUSEN 'ERMANY= HAD BEEN USED IN THE %UROPEAN TEXTILE INDUSTRY IN THE S FOR IMPACT BEARINGS OF MECHANICAL LOOMS #HARNLEYS lRST 5(-70% SOCKET LABELLED 2#( WAS IMPLANTED IN .OVEMBER ;'OMEZ AND -ORCUENDE B #HARNLEY n &IGURE = 0ROFESSOR -IKE 7ROBLEWSKI WROTE @4HE 0RESS &IT CUP WAS USED FROM TO WERE IMPLANTED )T WAS NOT USED AFTER 4HE LONGEST SURVIVING WELL FUNCTIONING PRESS lT IS IN A PATIENT AGED AT THE TIME OF SURGERY (E HAS NOW COMPLETED YEARS OF CLINICAL SUCCESS 4HIS IS THE LONGEST SURVIVING WELL FUNCTIONING 4(! .OTE ON DRAFT TRANSCRIPT /CTOBER &REEMAN ET AL 3WANSON AND %VARTS 3EE ALSO 3EMLITSCH AND 7ILLERT
3MITH 0ETERSEN "ERNTSEN AND "ERTELSEN
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7ITH REGARD TO THE GREENHOUSE ;SEE &IGURE = IT WAS BUILT IN AND THIS WAS DONE AS *OHN ;2EAD= SAID BECAUSE THINGS WERENT STERILE ) MANAGED TO GET A LITTLE VENTILATION UNIT WHICH WAS PUT OUTSIDE THE ENCLOSURE AND WE HAD THE GREENHOUSE ;SEE ALSO &IGURE = *OHN #HARNLEY USED TO COME FOR ME ON A 3UNDAY AND SAY @#AN YOU COME DOWN FOR HALF AN HOUR AND IT WOULD LAST ALL DAY 7E WOULD DO SMOKE TESTS IN THE THEATRE ALL KINDS OF TESTS TO SEE WHERE THE AIR WAS GOING !ND WE ENDED UP WITH TWO BAGS INSIDE IT WHICH WERE lLTERS BUT THE UNIT ) GOT HAD SIX lLTERS INSIDE IT WITH TWO MICRON lLTERS ;SEE &IGURE = AND FROM THEN ON THE INFECTION RATE SEEMED TO DROP 4HE PEOPLE WHO HAD LENT ME THE STERILE UNIT WHICH WAS OUTSIDE THE VENTILATION PLANT WAS THE lRM OF (OWORTHS )T WAS A FRIEND OF *OHN #HARNLEY WHO PUT ME ON TO THEM 4HE CHIEF ENGINEER A -R 0OULTON CAME OUT AND ) SHOWED HIM WHAT ) WANTED AND HE LENT ME THIS VENTILATION PLANT AND THEN HE PHONED ME AND ASKED FOR -R (OWORTH TO COME !ND IT WAS A BIT OF A LAUGH REALLY (E CAME IN AN % TYPE *AG n YOU NEEDED
&IGURE #HARNLEYS ORIGINAL GREENHOUSE CLEAN AIR ENCLOSURE
#HARNLEYS GREENHOUSE SUCCEEDED IN REDUCING THE SEPSIS RATE IN 4(2 OPERATIONS FROM PER CENT IN TO PER CENT IN ,OWBURY AND ,IDWELL 3EE ALSO !NONYMOUS (OWORTH "ERG ET AL
-R & . (OWORTH REPRESENTED HIS AIR lLTRATION lRM (OWORTH 3URGICAIR FROM "OLTON ,ANCASHIRE ;ESTABLISHED IN KNOWN AS (OWORTH !IRTECH ,TD IN = THAT HAD ORIGINALLY DESIGNED lLTERS FOR BREWERS AND PHARMACEUTICAL MANUFACTURERS TO REMOVE PARTICLES OR BACTERIA FROM THE AIR 3EE 3COTTISH 3OCIETY FOR #ONTAMINATION #ONTROL 3# A AND B IN PARTICULAR A n FOR PHOTOGRAPHS OF THE GREENHOUSE AND A LATER UNDATED COMMERCIALLY AVAILABLE MODEL ;SC MECHGLAACUK= 3EE ALSO PAGE
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A SHOE HORN TO GET IN n AND HE INTRODUCED HIMSELF TO ME AND ) TOOK HIM IN THEATRE GOT HIM GOWNED UP AND SAID @9OU CAN WATCH THE OPERATIONS THROUGH THE WINDOWS (E LOOKED THROUGH THE WINDOWS AND COLLAPSED ON THE mOOR IT TOOK THREE OF US TO DRAG HIM OUT !ND THEN THE HIP SUCCESS RATE IMPROVED AND WE OR RATHER ) GOT THE ($0 FROM 7EST 'ERMANY THROUGH A SALES TECHNICIAN WHO CAME ) ASKED IF HE COULD GIVE ME A PIECE n HE WAS TRYING TO SELL THINGS n AS ) WANTED TO PUT IT UNDER TEST ) HAD BUILT A TEST RIG FOR TESTING ALL THE MATERIALS WE COULD GET ON A mAT SURFACE AND HE SENT ME A PIECE ) GOT ALL THE INFORMATION ON IT AS WELL FROM 7EST 'ERMANY AND ) TESTED IT *OHN ;#HARNLEY= WAS GOING AWAY TO :URICH ) THINK IT WAS FOR ABOUT THREE WEEKS AND HE CAME IN AND SAID @7HAT ARE YOU TESTING ) REPLIED @0OLYETHYLENE @4HROW THE BLOODY STUFF AWAY HE SAID @ITS NO GOOD !NYWAY ) CARRIED ON TESTING IT AND WHEN HE CAME BACK HE ASKED WHAT ) WAS TESTING AND ) SAID @4HE STUFF YOU TOLD ME TO THROW AWAY (E ASKED FOR MY GRAPH BECAUSE ) DID A GRAPH OF EVERYTHING ) DID @7ELL ) SAID @THERES YOUR GRAPH A STRAIGHT LINE ALL AROUND THE ROOM AND FROM MY lGURES ) HAVE CALCULATED THAT IT WOULD LAST YEARS ) DONT KNOW WHAT THE RECORD IS AT THE MOMENT WITH REGARD TO HIP JOINTS BUT ON A mAT SURFACE ) GOT YEARS WORK OUT OF IT ,ETTIN ,ADY #HARNLEY DO YOU HAVE ANY RECOLLECTIONS ) AM SURE YOU HAVE LOTS OF RECOLLECTIONS ,ADY #HARNLEY ) CERTAINLY DONT WANT TO HOLD THE mOOR FOR ANY LENGTH OF TIME PARTLY BECAUSE ) AM HAVING GREAT DIFlCULTY IN SPEAKING TODAY WITH A PECULIAR THROAT "UT YES OF COURSE ) HAVE VERY MANY MARVELLOUS MEMORIES AND ) MUST SAY THAT IT WAS (ARRY #RAVENS PERSISTENCE IN DOING WHAT HE SHOULDNT HAVE DONE TO PUT THIS PIECE OF HIGH DENSITY POLYETHYLENE ON THE WEAR TESTING MACHINE THAT HE HAD MADE AT THE HOSPITAL AGAINST *OHNS WISHES WHICH OF COURSE EVENTUALLY WAS THE GREAT BREAKTHROUGH THAT *OHN HAD BEEN LOOKING FOR
#HARNLEY
3EE FOR EXAMPLE 7ROBLEWSKI 0ROFESSOR -IKE 7ROBLEWSKI WROTE @) HAVE AN ORIGINAL SPECIMEN FROM .OTE ON DRAFT TRANSCRIPT *UNE
&OR A REMARK ON -R (ARRY #RAVENS TESTING OF THE ($0 SAMPLES AND A FULL DISCUSSION OF THE PROGRESSION FROM A LARGE DIAMETER MM 4HOMPSON OR !USTIN -OORE PROSTHESIS TO THE #HARNLEY LOW FRICTION ARTHROPLASTY USING THE MM HEAD SEE #HARNLEY n %ARLY PROSTHESES WERE TESTED ON HAND MADE WEAR TEST MACHINES -ODERN TESTING EQUIPMENT CAN BE SEEN AT WWWDURACUKCBMEFACILITIES VISITED 3EPTEMBER
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&IGURE &ILTERS AND MASKS CUTTING INFECTION RATES &ROM 4HE 4IMES .OVEMBER 0ROVIDED AND ANNOTATED BY -R *OHN 2EAD
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&IGURE ,OOKING DOWN ON TO THE GREENHOUSE ROOF SHOWING THREE CLOTH INFUSER BAGS INmATED WITH CLEAN AIR
&IGURE 4HE #HARNLEY LOW FRICTION ARTHROPLASTY IN USE FROM .OVEMBER HAVING A THICK SOCKET OF 5(-70% WITH DEEP EXTERNAL SERRATIONS AND A SMALL FEMORAL HEAD ON THE mAT BACK PROSTHESIS
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!T THAT TIME *OHN WAS EXTREMELY DESPONDENT (E HAD A GREAT MANY PATIENTS WHO INITIALLY HAD DONE INCREDIBLY WELL WITH THE 04&% AND WHEN THE 04&% CUPS BEGAN TO WEAR HE HAD NIGHTMARES )N FACT ) KNOW IT IS WELL DOCUMENTED THAT HE USED TO WAKE UP AT ABOUT OCLOCK IN THE MORNING AND ) WOULD SEE HIM WITH HIS HEAD IN HIS HANDS SAYING @) DONT KNOW WHAT ) AM GOING TO DO WITH ALL THE PATIENTS THAT ARE GOING WRONG "UT OF COURSE WHEN ($0 CAME AND WAS PROVED TO BE A VERY HARD WEARING MATERIAL HE WAS ABLE TO OPERATE ON ALL THE PATIENTS WHO HAD HAD 04&% AND OF COURSE THAT WAS THE START OF THE GREAT BREAKTHROUGH IN HIP REPLACEMENT ;&IGURE = ) COULD GO ON ALL AFTERNOON BUT ) SHALL HAPPILY HAND OVER TO SOMEBODY ELSE ,ETTIN 4HANK YOU VERY MUCH FOR THOSE RECOLLECTIONS .OW ) KNOW THAT THE 3TANMORE TOTAL HIP REPLACEMENT CAME A BIT AFTER THE -C+EE AND THE #HARNLEY 7E HAVENT REALLY DECIDED WHICH CAME lRST BUT WEVE DECIDED THAT 7ILES REALLY HAS PRECEDENCE IN THE INTRODUCTION OF TOTAL HIP REPLACEMENT ) DO KNOW THAT 3TANMORE CAME A BIT LATER 5NFORTUNATELY @'INGER 7ILSON ;&IGURE = WHO WAS DUE TO TALK ABOUT THE EARLY 3TANMORE EXPERIENCE PASSED AWAY A COUPLE OF WEEKS AGO BUT HIS DAUGHTER AND SON ARE BOTH HERE ) DONT KNOW IF THEY WOULD LIKE TO SAY ANYTHING -RS 3HEILA %DWARDS 7E CAN ONLY TELL YOU SILLY STORIES HAVING LIVED WITH THE 3TANMORE THROUGH OUR FORMATIVE YEARS ) KNOW NOTHING REALLY PRACTICAL ABOUT IT ) THINK 0HYLLIS ;(AMPSON= WILL BE ABLE TO TELL YOU MUCH MORE ABOUT IT THAN ) CAN 7E DO HAVE RECOLLECTIONS OF MOTHERS TABLESPOONS GOING MISSING FROM THE KITCHEN DRAWER TO BE USED AS SOME SORT OF REAMER OR BATTERED INTO SOME SHAPE HE NEEDED 4HERE WAS ANOTHER GHASTLY STORY ABOUT SOMETHING EXPLODING IN THEATRE AND LEAVING BALL BEARINGS ALL OVER THE THEATRE mOOR 7E ARE NOT QUITE SURE WHAT THAT WAS 7E ARE GRATEFUL THAT YOU HAVE INVITED US HERE TODAY TO STAND UP FOR HIM
$UFF "ARCLAY ET AL 3CALES AND 7ILSON 7ILSON AND 3CALES
3EE /WEN -R -ICHAEL 7ILSON WROTE @(E INSERTED THE lRST 3TANMORE TOTAL HIP ON !PRIL WITH *OHN 3CALES AND AFTERWARDS INITIATED THE "ONE 4UMOUR 2EGISTRY (E DESCRIBED 7ILSONS OPERATION FOR HALLUX VALGUS BUT GAINED MEDIA ATTENTION FROM HIS DESCRIPTIONS OF h7INKLE 0ICKERS $ISEASEv AND h4HE "ATTERED "UTTOCKv )VE JUST CHECKED MY &ATHERS DIARY FOR !PRIL (E WROTE h$ID OUR lRST 3CALESn 7ILSON PROSTHESIS )T WENT VERY WELL n TOOK ABOUT THREE HOURS BUT THIS WAS MAINLY BECAUSE WE WENT VERY SLOWLY AND TOOK LOTS OF PHOTOS ) CAN HARDLY BELIEVE IT WAS SO EASY .OW IT DEPENDS UPON HEALING AND REHABv % MAIL TO -RS ,OIS 2EYNOLDS /CTOBER
3EE NOTE 3EE ALSO AN EXAMPLE OF A REAMER IN &IGURE PAGE
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,ETTIN ) THINK WE ARE PROBABLY COMING TO THE END OF THIS INITIAL TOPIC AND AS ) BELIEVE ) SAID WE THOUGHT THAT PERHAPS THE lNAL INNOVATION IF YOU LIKE WAS THE DOUBLE CUP %VERYTHING SINCE THEN HAS BEEN A VARIATION ON A THEME 4HE CONVENTIONAL TOTAL JOINT REPLACEMENT HAS HAD FOR EXAMPLE HYDROXYAPATITE SURFACES AND VARIOUS OTHER MODIlCATIONS BUT ESSENTIALLY THE BASIC DESIGN REMAINS THE SAME "UT THE DOUBLE CUP ) THINK IS OBVIOUSLY SOMETHING QUITE DIFFERENT -ICHAEL ;&REEMAN= WOULD YOU LIKE TO SAY WHY AND HOW YOU CAME TO DO IT AND WHY $EREK -C-INNS RESURFACING ARTHROPLASTY SEEMED TO WORK AND YOURS DIDNT 0ROFESSOR -ICHAEL &REEMAN 4HE CONCEPT OF A TWO PART RESURFACING ARTHROPLASTY ) DARE SAY CAME FROM A NUMBER OF PEOPLE BUT THE REASON IT CAME TO ME WAS MADE UP OF TWO THINGS ONE WAS THAT THE EARLY RESULTS OF CONVENTIONAL 4(2 ) WONT GO INTO DETAILS WERE NOT ABSOLUTELY WONDERFUL TECHNICALLY AND THERE WERE SOME PARTICULARLY DRAMATIC FAILURES ON THE FEMORAL SIDE IN THE HANDS OF BOTH MY COLLEAGUES AND MYSELF )T SEEMED A PITY TO TREAT A DISEASE THAT WAS ONLY A FEW MILLIMETRES THICK ON THE FEMORAL SIDE WITH AN OPERATION THAT ENDED WITH APPROXIMATELY ONE THIRD OF THE FEMUR BEING SEVERELY DAMAGED 4HAT WAS ONE FACTOR 4HE OTHER WAS THAT ONE OF MY SENIOR COLLEAGUES 3COTTIE ,AW HAD A VERY LARGE EXPERIENCE OF SINGLE CUP ARTHROPLASTY HAVING BEEN IN THE 53 IN
&IGURE -R @'INGER 7ILSON C
$EREK -C-INN REINTRODUCED THE DOUBLE CUP OR @RESURFACING ARTHROPLASTY WITH HIS OWN DESIGN AT THE 2OYAL /RTHOPAEDIC (OSPITAL "IRMINGHAM IN -C-INN ET AL 3EE ALSO NOTE AND !PPENDIX PAGE
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&IGURE 0RINCIPAL STAGES IN THE DESIGN AND DEVELOPMENT OF THE 3TANMORE PROSTHESIS n .OTE THAT THE lRST FOUR MODELS WERE DOUBLE WITH THE BASE SECURED TO THE ACETABULUM AND THE INNER CUP ROTATING INSIDE
"OSTON AFTER THE WAR AND IT WAS A VERY SMALL STEP TO THINK THAT YOU COULD CEMENT THE METAL COMPONENT TO THE FEMUR AND A POLYETHYLENE SOCKET TO THE ACETABULUM 4HE MAN WHO ACTUALLY DESIGNED THE ;)#,( DOUBLE CUP= IMPLANT IS !LAN 3WANSON WHO IS SITTING NEXT TO ME ) WAS THE SURGICAL HALF AND TOGETHER WE WERE AT )MPERIAL #OLLEGE 4HE REASON IT FAILED APART FROM THE FACT THAT ) LIKE MANY OTHERS DIDNT KNOW WHAT WE WERE DOING SURGICALLY WAS AS ) NOW REALIZE THAT THE POLYETHYLENE CUP ARTICULATING WITH A LARGE HEAD AS *OHN #HARNLEY SAID WAS A PARTICULAR RISK "UT IN RETROSPECT ) THINK MUCH MORE IMPORTANT WAS THE FACT THAT IT WAS GAMMA IRRADIATED IN AIR AND THUS ALTHOUGH IT STARTED OUT AS ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE ;5(-70%= BY THE TIME IT WAS IMPLANTED INTO THE PATIENT THE CHAIN LENGTHS HAD USUALLY BEEN REDUCED AND THE WEAR RATE WENT UP THROUGH THE ROOF ) DONT KNOW WHETHER YOU WANT ME TO COMMENT ON COBALTnCHROME ON COBALTnCHROME ) WILL DO IF YOU WISH !NOTHER PIECE OF 0ROFESSOR 3WANSONS WORK WAS THE DESIGN n ) DONT KNOW WHETHER IT WAS THE lRST n OF ONE OF THE EARLIEST HIP AND KNEE SIMULATORS IN WHICH HE RAN COBALTnCHROME AGAINST COBALTnCHROME AND METAL AGAINST POLYETHYLENE )N ) PUT IN MY lRST RESURFACING ARTHROPLASTY ! MAN CALLED 4RENTANI AT THE
4HE )#,( DOUBLE CUP WAS IMPLANTED USING A THIN LAYER OF 0--! IN FOLLOWING TWO YEARS OF LABORATORY INVESTIGATION 4HE PROSTHESIS USED ON THE lRST HIPS HAD A ($0 FEMORAL COMPONENT AND A STAINLESS STEEL ACETABULAR COMPONENT &ROM THE ACETABULAR COMPONENT WAS OF ($0 WITH A COBALTn CHROME FEMORAL COMPONENT AS IN &IGURE AND !PPENDIX PAGE &REEMAN ET AL &REEMAN B &REEMAN ET AL
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2IZZOLI )NSTITUTE IN "OLOGNA HAD PUT ONE IN A FEW MONTHS EARLIER !BOUT THAT TIME !LAN ;3WANSON= WAS DOING THIS WORK AND WE RETAINED THE DEBRIS FROM COBALTnCHROME AND THAT WAS IMPLANTED INTO RATS 4HE RESULTS WERE PUBLISHED IN THE *OURNAL ;*OURNAL OF "ONE AND *OINT 3URGERY= 4HE FACT IS THAT COBALTnCHROME ON COBALTnCHROME IS A PERFECTLY SATISFACTORY MATERIAL MECHANICALLY IF PROPERLY MANUFACTURED 7E NOW KNOW HOW TO DO THAT "UT WHETHER ITS GOING TO BE BIOLOGICALLY SATISFACTORY IS A COMPLETELY OPEN QUESTION AND SINCE !LANS WORK WITH MYSELF AND A MAN CALLED *OHN (EATH ON THE IMPLANTATION CONSEQUENCES OF THE DEBRIS THERES BEEN A LOT OF WORK TO DO WITH COBALT AND CHROMIUM IN THE AREA OF $.! AND FERTILITY WHICH IS QUITE UNKNOWN TO ORTHOPAEDIC SURGEONS 3O WE AWAIT THAT WITH SOME INTEREST ,ETTIN 4HAT LEADS VERY NICELY ON TO WHAT WE ARE GOING TO ASK 0ROFESSOR !LAN 3WANSON TO SPEAK ABOUT BUT BEFORE WE DO THAT IS THERE ANYONE WHO WISHES TO MAKE ANY COMMENTS ABOUT THESE IMPLANTS BEFORE WE MOVE AWAY REALLY FROM THIS VERY HISTORICAL PART -R +EVIN (ARDINGE *UST TO MENTION THAT THE CEMENT WAS INTRODUCED BY *OHN #HARNLEY TO lX THE 4HOMPSON PROSTHESIS AND HE FOUND THAT WITH HIS EXPOSURE IT WOULD REDUCE THE MOVEMENT OF THE STEM BY SOME FOLD SO IT WAS A PARALLEL DEVELOPMENT 7HEN THE DOUBLE CUP 04&% FAILED HE THEN ABANDONED THE
0ALTRINIERI AND 4RENTANI 4RENTANI AND /LMI 4RENTANI AND 6ACCARINO
3WANSON ET AL
&REEMAN ET AL A AND B
4HOMPSON 3EE !PPENDIX PAGE
-R *OHN /LDER WROTE @) AM CONCERNED ABOUT THE PRECISE DETAIL OF #HARNLEYS USE OF CEMENT BOTH IN THE COMMENTS MADE BY (ARDINGE AND OTHERS 4HE HISTORY OF ACRYLIC CEMENT BEGAN WITH ITS lRST SYNTHESIS IN BUT IT WAS NOT USED IN THE HUMAN BODY UNTIL AND THEN ONLY AS A DENTURE BASE MATERIAL )N THE EARLY S 3VEN +IAER OF #OPENHAGEN ;+IAER = AND %DWARD (ABOUSH OF .EW 9ORK ;(ABOUSH = USED SELF CURING METHYLMETHACRYLATE IN HIP SURGERY 4HEY USED AS DID +EN -C+EE IN .ORWICH AND -AURICE -ÓLLER IN 3WITZERLAND LATER SMALL AMOUNTS AS A SEATING COMPOUND BENEATH THE COLLAR OF THE FEMORAL PROSTHESIS TO ALLOW IT TO SETTLE OVER A PERFECT SURFACE AREA 6ERY LITTLE CEMENT WAS PLACED DOWN THE MEDULLARY CANAL )N THE LATE S #HARNLEY WAS LOOKING FOR A SUBSTANCE HE COULD USE TO SUPPORT THE CUP AND FEMORAL PROSTHESIS IN BONE (E WENT TO SEE $ENNIS 3MITH A LECTURER IN DENTAL MATERIALS IN CHARGE OF THE MATERIAL LABORATORY OF THE 4URNER $ENTAL 3CHOOL -ANCHESTER WHO TOOK SOME PINK SELF CURING ACRYLIC OFF THE SHELF AND SUGGESTED HE USE IT AS A lLLER #HARNLEYS GREAT CONTRIBUTION AS A RESULT OF THIS VISIT WAS THE FORMULATION AND ELUCIDATION OF THE PRINCIPLE OF USING LARGE AMOUNTS OF ACRYLIC AS A lLLER OR GROUT #HARNLEYS OBSERVATIONS LED TO HIS THIRD MONOGRAPH !CRYLIC #EMENT IN /RTHOPAEDIC 3URGERY A CLASSIC ON THE SUBJECT .OTE ON DRAFT TRANSCRIPT *ULY 3EE /LDER #HARNLEY 3EE ALSO NOTE AND !PPENDIX PAGE WHICH SHOWS THE 4HOMPSON PROSTHESIS SECURED BY CEMENT
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&IGURE )#,( RESURFACING ARTHROPLASTY DONE BILATERALLY C
PLASTIC ON THE FEMUR AND SWITCHED TO USING A 4HOMPSON PROSTHESIS WITH A 04&% CUP AND THEN HE FOUND THAT THEY WERE WEARING OUT 4HE LOW FRICTION PRINCIPLE CAME ABOUT THROUGH SERENDIPITY WHEN HE TRIED TO INCREASE THE AMOUNT OF PLASTIC IN THE CUP TO EXTEND THE WEAR AND HE EVENTUALLY ENDED UP USING A INCH STAINLESS STEEL BAR WHICH BECAME THE MM LOW FRICTION HEAD 3O THE LOW FRICTION CONCEPT WAS FOUND AS A RESULT OF OBSERVATION IN TRYING TO PROLONG THE LIFE OF THE IMPLANT 4HE OTHER THING ) WOULD LIKE TO SAY IS THAT *OHN #HARNLEY MENTIONED TO ME THAT HE HAD DONE OF THESE HIP REPLACEMENTS USING 04&% AND THEY WERE ALL STARTING TO FAIL AND IT WAS A VERY UNCOMFORTABLE TIME FOR HIM )F HE HAD BEEN A SURGEON WORKING IN THE 53 HIS BACK WOULD HAVE BEEN NAILED TO THE WALL !NYWAY WHAT HE FOUND WAS THAT THE PATIENTS WERE STILL TURNING UP AT THE CLINIC
0ROFESSOR -IKE 7ROBLEWSKI WROTE @,OW FRICTIONAL TORQUE WAS NOT A QUESTION OF hSERENDIPITYv IT IS A WELL KNOWN AND ACCEPTED ENGINEERING PRINCIPLE &ROM THE PROPERTY OF MATERIALS TO LOW FRICTIONAL TORQUE THE PRINCIPLE OF THE DESIGN WAS #HARNLEYS APPLICATION OF MECHANICAL FACTORS TO HIP REPLACEMENT !LL THIS IS WELL DOCUMENTED ;#HARNLEY = 3ERENDIPITY IS CERTAINLY NOT THE WORD TO USE IN THIS CONTEXT #HARNLEY DID USE THE TERM IN A BROADER SENSE .OTES ON DRAFT TRANSCRIPT *UNE AND /CTOBER 3EE NOTE AND FOR AN EXAMPLE OF CUP WEAR SEE ALSO &IGURE
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SAYING @7E KNOW THE OPERATION ONLY LASTS FOR THREE YEARS BUT WE ARE HAVING SUCH BAD PAIN CAN YOU NOT DO SOMETHING BECAUSE *OHN #HARNLEYS INDICATION FOR A HIP REPLACEMENT WAS THE PATIENTS OVERALL CONDITION WOULD BE IMPROVED BY A PSEUDOARTHROSIS A 'IRDLESTONE OPERATION 3O WHEN THEY HAD ALL THE IMPLANT MATERIAL TAKEN OUT THESE PATIENTS WERE STILL BETTER OFF THAN THEY HAD BEEN PRE OPERATIVELY ) THINK THAT SHOULD BE RECORDED -ISS "ETTY ,EE )T WAS A PLEASURE AND A PRIVILEGE TO WORK FOR THE LATE -R ' + +EN -C+EE !S A STAFF NURSE AND WARD SISTER ON THE MALE ORTHOPAEDIC BLOCK OF THE .ORFOLK AND .ORWICH (OSPITAL FROM TO ) OBSERVED -R -C+EES PIONEERING WORK ON TOTAL HIP REPLACEMENT SURGERY WHICH HE HAD COMMENCED PRIOR TO (E HAD FREQUENT MEETINGS WITH A -R (UNTON WHO OWNED A SMALL ENGINEERING lRM IN .ORWICH 4OGETHER THEY DESIGNED PROTOTYPES THAT SURGICAL INSTRUMENT MAKERS COULD THEN PROVIDE IN THE NEW INERT METALS !T THAT TIME -R -C+EE HAD TREATED ARTHRITIC HIPS SURGICALLY WITH LAG SCREW ARTHRODESES WHEREAS HIS COLLEAGUES THE LATE -R ( ! "RITTAIN AND -R 2 # (OWARD FAVOURED THE 6 TYPE ARTHRODESIS (OWEVER IN THE EARLY S -R (OWARD HAD TREATED TWO MALE PATIENTS SUFFERING FROM ANKYLOSING SPONDYLITIS WITH CUP ARTHROPLASTIES LATER BOTH THE PATIENTS HAD TOTAL HIP REPLACEMENTS $ESPITE RECEIVING LITTLE ENCOURAGEMENT FROM THE ESTABLISHMENT -R -C+EE SELF FUNDED ALL HIS EARLY RESEARCH OFlCIAL FUNDING CAME ONLY LATER "Y THE LATE S A NUMBER OF TOTAL HIP REPLACEMENTS HAD BEEN CARRIED OUT SUCCESSFULLY !FTER REMOVING THE HEAD OF THE FEMUR A CURVED STEM PROSTHESIS WAS INSERTED INTO THE MEDULLARY CAVITY ABOVE THE TROCHANTERS THE CUP BEING lXED INTO THE ACETABULUM WITH A SCREW 3UBSEQUENTLY A NEW METAL CUP WAS USED WITH SMALL PROJECTIONS ON THE OUTER SIDE OF THE CUP WHICH WOULD lX INTO THE DENTAL CEMENT THEN USED TO LINE THE ACETABULUM -R -C+EE WAS VERY PARTICULAR ABOUT THE POSITIONING OF PATIENTS AND RELIED UPON THE LATE &RANK "AKER THEN THEATRE ORDERLY AND LATER TECHNICIAN TO DO THIS )N FACT HE WAS RELUCTANT TO OPERATE IF &RANK WAS UNAVAILABLE )N THE S -R *OHN 7ATSON &ARRAR JOINED -R -C+EE AS HIS REGISTRAR LATER BECOMING THE FOURTH CONSULTANT 4OGETHER THEY DEVISED THE -C+EEn&ARRAR HIP JOINT !S A COMMITTED #HRISTIAN -R -C+EE SAW THE ALLEVIATION OF PAIN AND SUFFERING IN OTHERS AS HIS MISSION IN LIFE )T WAS TO THIS END THAT HE WAS A PIONEER IN TOTAL HIP REPLACEMENT SURGERY
3EE NOTE
! MEMOIR PREPARED BY -ISS ,EE IN *ULY @0OSTWAR DEVELOPMENT OF THE /RTHOPAEDIC $EPARTMENT OF THE .ORFOLK AND .ORWICH (OSPITAL WILL BE DEPOSITED ALONG WITH THE TAPES AND OTHER RECORDS OF THE MEETING IN !RCHIVES AND -ANUSCRIPTS 7ELLCOME ,IBRARY ,ONDON
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&REEMAN 4HIS IS A QUESTION TO THE GROUP n IS IT TRUE THAT THERE WAS A "/! MEETING IN -ANCHESTER OR SOMEWHERE THEREABOUTS AT A TIME WHEN *OHN ;#HARNLEY= WAS DOING ARTHRODESIS AND SO THIS STORY GOES +EN -C+EE CAME WITH SOME OF HIS PATIENTS *OHN ;#HARNLEY= SAW THE PATIENTS AND SAID @4HATS THE WAY FORWARD THUS STARTED REPLACEMENT INSTEAD OF ARTHRODESIS )S THAT TRUE OR IS THAT RUBBISH (ARDINGE 4HE "/! MEETING WAS IN -ANCHESTER IN ) THINK THE TRUTH IS THAT *OHN #HARNLEY WAS SHOWING HIS CEMENT lXATION OF THE STEM OF A 4HOMPSON PROSTHESIS IN A FRACTURE OF THE FEMUR AND THAT WAS THE lRST TIME THAT +EN -C+EE HAD SEEN THE USE OF CEMENT IN -ANCHESTER IN ,ETTIN ) CAN CERTAINLY REMEMBER +EN -C+EE SHOWING HIS PATIENTS AT THE "/! MEETING IN .ORWICH WHEN IN THOSE DAYS WE HAD A CLINICAL MEETING ON &RIDAY AFTERNOON (E PRODUCED THESE ELDERLY LADIES WITH THEIR DRESSES TUCKED IN THEIR KNICKERS AND ) THINK THAT WAS THE LAST TIME THERE WAS EVER A CLINICAL MEETING AT THE "/! 4HAT WAS ABOUT OR +IRKUP -AY ) MAKE A POINT ABOUT CEMENT 7E HAVE FORGOTTEN %DWARD (ABOUSH ) AM TALKING ABOUT CEMENT AND TOTAL HIPS IN (ABOUSH WAS USING CEMENT METHYLMETHACRYLATE "UT OF COURSE HE WAS APPLYING IT AS A COLLAR AROUND THE BONE TO SUPPORT THE PROSTHESIS AND THIS FAILED 4HE OTHER POINT RAISED WAS @WHO WAS DOING TOTAL HIPS lRST ) THINK -C+EE AND (ABOUSH ARE THE SIGNIlCANT PIONEERS IN THE SENSE THAT THEY WERE USING METAL TO METAL AND (ABOUSH TRIED TO USE CEMENT
3EE -C+EE
3EE 0ROCEEDINGS "/! 3PRING -EETING -ANCHESTER n !PRIL ;*OURNAL OF "ONE AND *OINT 3URGERY " FREELY AVAILABLE ONLINE AT WWWJBJSORGUKARCHIVE VISITED .OVEMBER = WHERE #HARNLEY DISCUSSED HIS NEW FORM OF LOW FRICTION HIP ARTHROPLASTY AND -C+EE REPORTED THAT THE FAILURES OF HIS SIMILAR OPERATION INVOLVED LOOSENING BUT THE USE OF CEMENT WAS @A GREAT ADVANCE ! CLINICAL MEETING WAS ALSO HELD AT THE -ANCHESTER 2OYAL )NlRMARY WITH A CLINICAL DEMONSTRATION AT 7RIGHTINGTON
0ROFESSOR -IKE 7ROBLEWSKI WROTE @4HE LAST CLINICAL MEETING OF THE "/! UNLESS THERE WERE LATER ONES TOOK PLACE n 3EPTEMBER THE -ANCHESTER MEETING /NE SESSION WAS IN 7RIGHTINGTON (OSPITAL WITH A PRESENTATION OF A GROUP OF PATIENTS WITH THE LONGEST FOLLOW UP #HARNLEY DIED IN !UGUST ) PRESENTED THE PATIENTS IN 3EPTEMBER WHILE 4RISTRAM #HARNLEY DID THE lLMING 4HE RECORD IS AVAILABLE ;7AUGH n= .OTE ON DRAFT TRANSCRIPT *UNE 3EE ALSO 0ROCEEDINGS AND 2EPORTS *OURNAL OF "ONE AND *OINT 3URGERY " ;FREELY AVAILABLE ONLINE AT WWWJBJSORGUKARCHIVE= ON THE !UTUMN -EETING OF THE "/! AT -ANCHESTER WITH A MEMORIAL SERVICE FOR 3IR *OHN #HARNLEY ON 3EPTEMBER
(ABOUSH
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#RAVEN )T WENT IN THE ACETABULUM *OHN #HARNLEY USED THE CEMENT AND THERE WAS A HUE AND CRY ABOUT IT PEOPLE DIDNT WANT IT 7HAT IS HE USING CEMENT FOR 0EOPLE DIDNT WANT THIS AND AS +EVIN ;(ARDINGE= SAID THE lRST TIME IT WAS USED AT 7RIGHTINGTON IT WAS THE ;UNCEMENTED= !USTIN -OORE PROSTHESIS 4HIS CHAP CAME IN AN STONE MAN WHO HAD BEEN TO SEVERAL CONSULTANTS THEY DIDNT KNOW WHAT WAS WRONG WITH HIM AND ) WAS IN THEATRE WITH *OHN #HARNLEY WHEN THEY DID THE OPERATION ) DONT KNOW WHETHER *OHN 2EAD WAS THERE OR NOT BUT WHEN THEY OPENED HIM UP THE PROSTHESIS WAS WAGGING ABOUT IN THE MEDULLARY CANAL AND THAT WAS THE lRST TIME THAT *OHN USED THE CEMENT AT 7RIGHTINGTON !ND THEN WHEN -C+EE STARTED WITH HIS HIP WHERE ) SAY THEY WERE SPIKED -C+EE GOT THE CEMENT THROUGH #HARNLEY AND STARTED CEMENTING HIS SOCKETS ,ETTIN ) THINK WE MUST MOVE ON BECAUSE WE HAVE TOUCHED ON THE MATERIALS AND HOW THE INITIAL MATERIALS WERE NOT VERY GOOD WE HAVE TALKED ABOUT CONlGURATION AND -ICHAEL &REEMAN HAS ALSO MENTIONED THE BIOLOGICAL SIDE OF IT ) THINK ITS TIME WE BROUGHT IN THE ENGINEERS 0ROFESSOR !LAN 3WANSON ) WOULD LIKE YOU TO TALK ABOUT HOW THE ENGINEERS BECAME INVOLVED IN THIS AND THE IMPORTANCE OF THE MATERIALS AND THE DESIGN AND SO ON 0ROFESSOR !LAN 3WANSON ) HAVE BEEN TRYING TO THINK BACK YEARS AS NO DOUBT OTHER PEOPLE HAVE &IFTY YEARS AGO ) WAS EMPLOYED AT A VERY JUNIOR LEVEL IN THE MAKING OF AEROPLANES IN A LABORATORY IN "RISTOL THAT DEALT WITH MATERIALS AND ONE OF THE JOBS ) HAD WAS TO WRITE UP THE RESULTS OF A LONG CONTINUING PROGRAMME ON THE CORROSION OF SO CALLED STAINLESS STEEL ) CAN ASSURE YOU THAT WHEN YOU EXPOSE IT TO SALTWATER AND AIR IT GOES A LOVELY RED COLOUR 4HE FACT IS OF COURSE THAT WHAT IS COLLOQUIALLY KNOWN AS STAINLESS STEEL IS ALWAYS CORROSION RESISTING STEEL ON THE SPECIlCATIONS NOT QUITE THE SAME THING (OWEVER BACK OR MORE YEARS AGO WHAT ) SHALL NEVERTHELESS CALL STAINLESS STEEL n IRON WITH CARBON AND LOTS OF CHROMIUM AND NICKEL n HAD BEEN AROUND SINCE AND WAS WELL KNOWN FOR ITS CORROSION RESISTING PROPERTIES GOOD FOR CHEMICAL APPARATUS FOOD HANDLING APPARATUS AND ALL THAT AND OF COURSE IMPLANTS IF ONLY FOR FRACTURE lXATION )T WAS KNOWN TO BE VERY TRICKY STUFF INDEED IF YOU TRIED TO WELD IT WHICH WAS NOT NORMALLY A CONSIDERATION )F LIKE #HARNLEY YOU HAD A SOLID HEAD ON THE FEMORAL PROSTHESIS YOU DIDNT THINK ABOUT MAKING A HOLLOW
4HE !USTIN -OORE METAL HIP PROSTHESIS WAS INTRODUCED IN AS THE lRST 6ITALLIUM PROSTHESIS TO REPLACE THE UPPER PORTION OF THE FEMUR ;-OORE = 4HE MOST COMMONLY USED TREATMENT OF A DISPLACED FEMORAL NECK FRACTURE HAS BEEN THE UNCEMENTED HEMI ARTHROPLASTY AND THE CEMENTED 4HOMPSON ALTHOUGH NOT ENTIRELY SATISFACTORY 3EE 3CALES 7EINRAUCH ET AL
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HEAD AND WELDING TWO BITS TOGETHER )T WAS ALSO A BIT DODGY IN CONTACT WITH ITSELF )N GENERAL ENGINEERING THERE WAS A PROHIBITION ON THE USE OF STAINLESS STEEL NUTS AGAINST STAINLESS STEEL BOLTS FOR EXAMPLE !ND THEREFORE STAINLESS STEEL FOR BOTH COMPONENTS OF A HIP PROSTHESIS IS NOT ) THINK SOMETHING THAT ANY ENGINEER WOULD HAVE RECOMMENDED 4HERE WERE ALSO COBALTnCHROMIUM BASED ALLOYS WHICH HAD BEEN AROUND IN DENTISTRY SINCE THE S AND THERE HAD BEEN SOME CROSS FERTILIZATION OR LATERAL THINKING BETWEEN ORTHOPAEDIC SURGEONS AND DENTISTS WHICH HAD MADE PEOPLE REALIZE THAT THEY ARE ON THE WHOLE AT LEAST AS CORROSION RESISTANT AS THE STEEL PERHAPS MORE SO AND SOMEBODY DISCOVERED ) KNOW NOT WHO OR WHERE OR WHEN THAT YOU COULD PUT COBALTnCHROMIUM ALLOYS AGAINST THEMSELVES AS A BEARING PAIR WITHOUT A DISASTER 4ITANIUM WAS MORE OR LESS EXOTIC 'OING BACK TO MY DAYS OF MAKING AEROPLANES ) REMEMBER WE WERE DOING TESTS ON TITANIUM ALLOYS FOR HIGH SPEED AEROPLANES AND IT WAS FABULOUSLY EXPENSIVE FABULOUSLY DIFlCULT TO DO ANYTHING WITH AND THEREFORE ONLY OF USE IN MILITARY APPLICATIONS WHERE IN THOSE DAYS MONEY WAS NO OBJECT 4HAT HAS CHANGED OF COURSE AND TITANIUM ALLOYS ARE NOW VERY RESPECTABLE ALTHOUGH NOT GOOD IN GENERAL AS BEARING MATERIALS )F WE TURN TO PLASTICS BACK IN THE LATE S AND EARLY S THERE WAS NOTHING LIKE THE RANGE OF PLASTICS WE HAVE NOW AND NOTHING LIKE THE UNDERSTANDING (ENCE POLYETHYLENE WAS POLYETHYLENE AND ONLY LATER DID THE HIGH DENSITY AND THE HIGH MOLECULAR WEIGHT CHARACTERISTICS BEGIN TO BE DISTINGUISHED AND ONLY LATER DID WE MOVE ON TO 5(-70% WITH ITS EXTRA WEAR RESISTANCE 04&% WAS KNOWN THEN AS A SLIPPERY PLASTIC AND ONE CAN UNDERSTAND WHY #HARNLEY OR ANYBODY ELSE MIGHT HAVE THOUGHT IT ATTRACTIVE AS A BEARING MATERIAL AGAINST STEEL ALTHOUGH AS WE ALL KNOW THERE WERE DIFlCULTIES AND POLYETHYLENE IF THE RIGHT KIND TURNED OUT TO BE BETTER )F WE TURN TO CERAMICS WHICH ) KNOW WERE NOT IN USE THEN BUT HAD BEEN ACTUALLY THOUGHT ABOUT AND TRIED EARLIER ) THINK FOR SOME INTERPOSITION CUPS WAY BACK THE POINT ABOUT CERAMICS IS THAT YOU CAN MAKE A MUCH lNER SURFACE lNISH THAN WITH METALS WHICH OUGHT TO LEAD TO LOWER WEAR !NOTHER GOOD THING IN THEIR FAVOUR IF YOU ARE THINKING OF A BEARING IS THAT UNLIKE CORROSION RESISTANT STEELS WHICH DEPEND FOR THEIR CORROSION RESISTANCE ON AN OXIDE lLM THAT IS LIKELY TO BE RUBBED OFF IN A BEARING AND HAS TO BE CONTINUOUSLY REFORMED THERE ARE OTHER TROUBLES AS PEOPLE HERE KNOW ABOUT THE HEADS OF SCREWS IN lXATION PLATES CERAMICS ARE THE SAME STUFF THROUGHOUT AND SO YOU DONT HAVE TO WORRY ABOUT
#ONlRMATION FROM CLINICAL EXPERIENCE IS PROVIDED BY (OWIE ET AL &ISHER ET AL
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THE WEAR RATE DRAMATICALLY INCREASING BECAUSE YOU RUBBED OFF THE PROTECTIVE SURFACE lLM 4HEY ARE ALSO MORE WETTABLE IN GENERAL BY AQUEOUS SOLUTIONS THAN METALS AND THEREFORE THAT COMMENDS THEM ALSO AS BEARING MATERIALS "UT OF COURSE THEY ARE BRITTLE LESS SO NOW THAN THEY USED TO BE BECAUSE AS WITH THE ALLOYS AND THE POLYMERS OVER YEARS PEOPLE HAVE LEARNED A GREAT DEAL ABOUT HOW TO MAKE AND PROCESS THEM "UT THEY ARE STILL RATHER MORE BRITTLE THAN MOST METALS THAT WOULD BE USED AND ) THEREFORE DO HAVE DOUBTS ABOUT CERAMIC HEADS BEING PUT ON A CONICAL STUB ON A METALLIC FEMORAL STEM ,ETTIN 7E HAVE ANOTHER VERY EMINENT ENGINEER HERE $UNCAN $OWSON WOULD YOU LIKE TO SAY SOMETHING ABOUT THE DESIGN 4HERE ARE LOTS OF VARIATIONS OF THE SHAPE OF THE STEM AND SO ON AND WE PERHAPS SHOULD HAVE MENTIONED ) SUPPOSE 2OBIN ,INGS CONTRIBUTION 5NFORTUNATELY 2OBIN IS UNWELL AND COULDNT BE HERE BUT WE MIGHT MENTION IT )T SEEMS THAT THERE WERE LOTS OF DIFFERENT DESIGNS OF STEM BUT DID IT REALLY MATTER 0ROFESSOR $UNCAN $OWSON )T WAS INTERESTING TO HEAR !LAN 3WANSON SPEAK BECAUSE LIKE HIM ) WAS WORKING IN THE AIRCRAFT INDUSTRY BEFORE RETURNING TO THE ACADEMIC WORLD ) HAD STARTED SOME RESEARCH ON THE WEAR CHARACTERISTICS OF CERTAIN POLYMERS INCLUDING POLYETHYLENE FOR THE DEFENCE INDUSTRY PARTICULARLY FOR MILITARY AIRCRAFT 4HE INDUSTRY REQUIRED A BEARING MATERIAL THAT WOULD OPERATE IN VERY STRANGE ENVIRONMENTS AND PARTICULARLY NOT BE AFFECTED BY THE PRESENCE OF WATER AND HIGH HUMIDITY ) WAS DOING THAT WORK EARLY IN THE S WHEN ) lRST MET *OHN #HARNLEY !FTER HIS TRAUMA WITH 04&% #HARNLEY WAS SEEKING AN ALTERNATIVE POLYMER AND WE HAVE HEARD THE FASCINATING STORY ABOUT HOW THE ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE CAME TO HIS ATTENTION (E MUST HAVE HEARD AND ) KNOW NOT HOW OF THE RESEARCH CONTRACT THAT WE HAD AT THAT TIME WITH THE -INISTRY OF $EFENCE AS HE CAME OVER TO ,EEDS TO SEE SOME OF THE EXPERIMENTAL WORK THAT WE WERE DOING 4HIS WAS AFTER HE HAD STARTED TO USE POLYETHYLENE AND HE BECAME FASCINATED WITH OUR TRIBOLOGICAL STUDIES /NE OF MY LASTING IMPRESSIONS OF *OHN #HARNLEY IS THAT HE WAS A JOLLY GOOD ENGINEER (E WANTED TO UNDERSTAND THE ENGINEERING AND THE PHYSICAL PRINCIPLES BY WHICH THESE DIFFERENT COMBINATIONS OF MATERIAL AND DIFFERENT BEARING CONlGURATIONS WOULD WORK 3INCE THAT lRST CONTACT WE HAD VERY FREQUENT AND STIMULATING EXCHANGE VISITS MYSELF TO 7RIGHTINGTON AND *OHN TO ,EEDS
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#HARNLEY A
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)T IS INTERESTING THAT THE WORD SERENDIPITY HAS BEEN USED ABOUT HIM SELECTING THE INCH MM DIAMETER FEMORAL HEAD 7HEN IN SUBSEQUENT YEARS ) INVITED A COLLEAGUE OF MINE -ICHAEL ,ONGlELD TO DO A MATHEMATICAL ANALYSIS OF THIS HE AND *OHN #HARNLEY WORKED TOGETHER AND IT WAS RELATIVELY EASY TO SHOW THAT THE OPTIMUM HEAD DIAMETER SHOULD BE PER CENT OF THAT OF THE OUTSIDE DIAMETER OF THE CUP FOR MAXIMUM WEAR LIFE AND THAT COMES OUT OF COURSE AT ABOUT nMM #HARNLEYS MM WAS lNE SO WHETHER WE DElNE THAT AS SERENDIPITY OR NOT ) DONT KNOW BUT IT WAS VERY CLOSE TO THE OPTIMUM DIAMETER AS FAR AS WEAR LIFE WAS CONCERNED "UT WASNT THAT A QUESTION OF MANUFACTURING ;&ROM THE mOOR 9ES= ) THINK THE DIAMETER WAS CONVENIENT FOR STANDARD MATERIAL BUT #HARNLEY CLEARLY PRESENTED HIS SELECTION IN TERMS OF TWO SOUND BIOMECHANICS PRINCIPLES (E WAS RIGHTLY OBSESSED AT THE TIME WITH REDUCING THE FRICTIONAL TORQUE AND THIS CAN BE ACHIEVED BY A SELECTING ACCEPTABLE MATERIALS WITH THE LOWEST COEFlCIENT OF FRICTION AND B BY MINIMIZING THE TORQUE ARM OR HEAD DIAMETER -C+EE ) THINK WAS A BIT MORE INTERESTED AT THAT TIME IN THE WEAR STORY RATHER THAN THE FRICTION STORY BUT *OHN #HARNLEY WANTED TO MINIMIZE FRICTION AND MINIMIZE THE FRICTIONAL TORQUE 4HERE ARE TWO WAYS THAT YOU CAN DO THAT /NE IS TO MINIMIZE THE COEFlCIENT OF FRICTION BETWEEN THE SLIDING COMPONENTS AND 04&% WAS THE POLYMER WITH THE LOWEST KNOWN COEFlCIENT OF FRICTION SO HE NATURALLY USED 04&% INITIALLY "UT SECONDLY IN ORDER TO MINIMIZE THE FRICTIONAL TORQUE YOU NEED TO USE THE SMALLEST ACCEPTABLE DIAMETER AND HE ADOPTED INCH OR MM (IS BIOMECHANICS WAS JOLLY GOOD 4HAT WAS HOW ) lRST CAME INTO CONTACT WITH HIM AND SINCE THAT TIME WE HAVE SEEN THE STORY UNFOLD AND AS !LAN 3WANSON MENTIONED DIFFERENT AND MUCH IMPROVED MATERIALS BOTH FOR FEMORAL HEADS AND ACETABULAR CUPS HAVE SUBSEQUENTLY BEEN INTRODUCED 4HE CERAMIC STORY HAS ALSO BEEN FASCINATING )T IS INTERESTING THAT AT THE PRESENT TIME THE CURRENT RANGE OF TOUGHENED CERAMICS IS EXTREMELY GOOD 4HEY ARE GOOD AS BEARING MATERIALS BUT ALSO EXHIBIT VERY LITTLE FRACTURE POTENTIAL 4HE METALS ARE GREATLY IMPROVED AND THE MANUFACTURING PROCEDURES ARE ALSO IMPROVED )N THE PAST WE HAVE TALKED VERY MUCH ABOUT THE ALTERNATIVE MATERIAL COMBINATIONS SUCH AS METAL ON POLYMER OR INDEED OF METAL ON METAL .OW THERE IS A WHOLE GALAXY OF POSSIBILITIES METAL ON METAL CERAMIC ON CERAMIC METAL ON CERAMIC
#HARNLEY ET AL ,ATER WORK ON WEAR INCLUDES 'ELLER ET AL
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METAL ON POLYMERS CERAMIC ON POLYMERS AND MANY OF THESE ARE BEING VERY ACTIVELY DEVELOPED AT THE PRESENT TIME )T WOULD BE INTERESTING TO MEET AGAIN IN ANOTHER YEARS TO SEE WHICH COMES THROUGH AS BEING THE BEST COMBINATION ,ETTIN 7E HAVE TALKED A BIT ABOUT WEAR AND ) THINK WE RATHER NEGLECTED *OHN 3CALES AND THE 3TANMORE 4(2 ) THINK MY RECOLLECTIONS OF THE ORIGINAL 3TANMORE WAS THAT THERE WAS A CUP THAT WAS lXED TO THE ACETABULUM WITH NAILS n WE HAD A GUN WHICH lRED THESE NAILS n AND THEN ANOTHER CUP WHICH ACTUALLY SLOTTED INTO THAT ) THINK FROM THE WEAR POINT OF VIEW HE ;3CALES= WAS VERY MUCH INVOLVED 4HERE WAS AN ENGINEER )AN $UFF "ARCLAY WHO WAS SECONDED FROM "RITISH 0ETROLEUM AND HE DESIGNED ) THINK THE lRST TOTAL HIP SIMULATOR #HARNLEY SENT HIS PROSTHESIS DOWN TO 3TANMORE TO BE TESTED 4HERE WAS A WHOLE ROW OF THESE THINGS WORKING DAY AND NIGHT ALL AROUND THE ROOM CHUGGING AWAY LUBRICATED WITH BOVINE SERUM TO DETERMINE THE WEAR PROPERTIES OF THE JOINT COMPONENTS 7E OUGHT TO MENTION THE CUSTOM MADE PROSTHESES AND ) THINK *OHN 3CALES ;&IGURE = WAS PROBABLY THE lRST TO DEVELOP CUSTOM MADE PROSTHESES PARTICULARLY WITH REGARD TO THE TREATMENT OF TUMOURS /F COURSE 'INGER 7ILSON WAS VERY MUCH INVOLVED WITH THE TREATMENT OF TUMOURS AS ) WAS WITH THE KNEE RATHER THAN THE HIP BUT ) THINK THAT HIS CONTRIBUTION TO CUSTOM MADE PROSTHESES SHOULD BE RECORDED .OW IT IS VERY EASY TO DO ) DONT THINK 2ON !NSELL IS HERE IS HE ;.O= 3WEETNAM -AY ) JUST SAY THAT YOU ARE ABSOLUTELY RIGHT ) THINK THAT *OHN 3CALES WAS THE PRIME MOVER IN THIS PARTICULAR lELD BUT WE SHOULDNT FORGET THAT HE DID IT IN COLLABORATION WITH (AROLD *ACKSON "URROWS THE "ARTS #ONSULTANT ) THINK THE MAJOR STEP BETWEEN 7ILES ORIGINAL CONCEPT OF A TOTAL JOINT REPLACEMENT AND SUBSEQUENT SUCCESS WAS ENTIRELY DUE TO TWO THINGS CEMENT AND NEW MATERIALS SUCH AS COBALTnCHROME ALLOY AND HIGH DENSITY POLYETHYLENE )T WAS THE DEVELOPMENT OF CEMENT THAT LATER ALLOWED THE STEM OF THE FEMORAL COMPONENT TO BE lXED WITHIN THE MEDULLARY CAVITY OF THE FEMUR 7ILES USED STAINLESS STEEL WHICH WE HAVE HEARD FROM 0ROFESSOR 3WANSON WAS DOOMED TO FAILURE 7ILES USED NO CEMENT USUALLY BOLTING HIS PROSTHESIS ON THE FEMUR WHICH WAS DOOMED TO FAILURE 3O ) THINK IT IS THOSE TWO FACTORS n THE NEW MATERIALS AND THE lXATION
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-R 2ON !NSELL WAS UNABLE TO ATTEND THE MEETING (E HAD BEEN INVOLVED WITH THE EARLY DEVELOPMENT OF THE 3TANMORE ARTIlCIAL JOINT AND WAS IN CHARGE OF THE DESIGN OFlCE AT THE $EPARTMENT OF "IOMEDICAL %NGINEERING 2./( 3TANMORE
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&IGURE 0ROFESSOR *OHN 3CALES C
BY CEMENT n THAT CHANGED THE WHOLE SPECTRUM OF TOTAL JOINT REPLACEMENT AFTER 7ILES BRILLIANT AND ORIGINAL CONCEPT FAILED BECAUSE THE SUITABLE MATERIALS HAD NOT EMERGED IN HIS DAY ,ETTIN *OHN 3CALES OF COURSE ORIGINALLY BOLTED IN THE PROSTHESES AND ) THINK ONE OF THEM REPLACING THE DISTAL FEMUR AND KNEE JOINT LASTED FOR YEARS -R )AN 3TEPHEN ) WILL SPEAK ON BEHALF OF 2OBIN ,ING WHO SENDS HIS APOLOGIES BECAUSE HE IS UNWELL ) SPEAK AS A DISCIPLE OF THE ORIGINATOR BECAUSE ) ARRIVED IN %XETER IN ABOUT SIX YEARS AFTER THE lRST %XETER PROSTHESIS WAS IMPLANTED ) THINK 2OBINS GREAT CONTRIBUTIONS WERE lRSTLY THE STEM GEOMETRY WITH THE DEVELOPMENT OF THE DOUBLE TAPERED STRAIGHT STEM AND SECONDLY THE IMPROVED CEMENTING TECHNIQUE THAT RESULTED IN GREATLY IMPROVED lXATION AS 2ODNEY HAS BEEN SAYING
3CALES ET AL
4HE ORIGINAL %XETER (IP %.* WAS AVAILABLE FOR USE IN CLINICAL PRACTICE FROM AUTUMN 3EE &IGURE AND !PPENDIX PAGE
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)T IS MY RECOLLECTION THAT WE AS REGISTRARS WERE ENCOURAGED TO BE METICULOUS ABOUT OUR CEMENTING TECHNIQUE DURING THE OPERATION 4HE DEVELOPMENT OF THE STRAIGHT STEM DOUBLE TAPER COMBINED WITH IMPROVED CEMENTING TECHNIQUE TURNED OUT BY SERENDIPITY TO HAVE MANY ADVANTAGES THAT WERE NOT ENVISAGED AT THE TIME THE %XETER HIP WAS DESIGNED ,ETTIN !RE THERE ANY MORE COMMENTS ANYONE WOULD LIKE TO MAKE ON THIS -ALCOLM 3WANN DID CHILDREN PRESENT PARTICULAR PROBLEMS WHICH REQUIRED ATTENTION ) EXPECT YOU HAD MOST EXPERIENCE DEALING WITH CHILDREN WITH JUVENILE RHEUMATOID ARTHRITIS -R -ALCOLM 3WANN 7E WERE CERTAINLY VERY MUCH IN TOUCH WITH 3TANMORE ABOUT CHILDREN WITH JUVENILE CHRONIC ARTHRITIS ) WAS PERSUADED BY THE LATE "ARBARA !NSELL WHO MANY OF YOU WILL REMEMBER WAS A RHEUMATOLOGIST AT THE
&IGURE 4HE %XETER STEM C
!NSELL AND 3WANN
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-2# #ENTRE FOR 2HEUMATIC $ISEASES 4APLOW -AIDENHEAD WHO THOUGHT WE SHOULD BE ABLE TO HELP THESE CHILDREN WITH THEIR HIP PROBLEMS 7E ARE TALKING ABOUT CHILDREN OF TO YEARS OF AGE AND OVER BUT THEY WERE ALL CONlNED TO WHEELCHAIRS WITH DESTROYED HIPS AND THEY COULD NO LONGER MANAGE THE PAIN 7E FELT SOMETHING SHOULD BE DONE 3O WE WERE FACED WITH THIS PROBLEM OF LARGELY CUSTOM MADE PROSTHESES FOR THEM BECAUSE THEY HAD SMALL SKELETONS #HILDREN WITH JUVENILE ARTHRITIS ARE NOT JUST SMALL BUT THEY ARE SMALLER THAN SMALL THEY ARE MINUTE 'RAHAM $EANE SAW THESE AS WELL 4HEY HAVE ALL SORTS OF PROBLEMS BONE PROBLEMS HYPERVASCULARITY ANATOMICAL DEVIATIONS A LOT OF ANTEVERSION SO WE DID HAVE TO CALL ON HELP FROM THE CUSTOM MADE PROSTHESIS PEOPLE 7E DID GET A LOT OF HELP PARTICULARLY FROM 3TANMORE AND *OHN 3CALES /F COURSE MEASURING AT THAT TIME WAS VERY DIFlCULT THERE WAS NONE OF THE TECHNOLOGY OF TODAY YOU MERELY HAD TO TAKE AN 8 RAY WITH THE ARTIlCIAL HIP PROSTHESIS HELD ALONGSIDE THE PATIENT JUDGE THAT THE MAGNIlCATION WAS ROUGHLY THE SAME AND THEN SEND OFF THE 8 RAY TO 3TANMORE /FTEN WE WERE HELD ON TENTERHOOKS BECAUSE THERE WERE A LOT OF TELEPHONE CALLS AS TO WHEN IT WAS GOING TO BE READY AND ) CAN RECALL IT WAS PRETTY WELL WHEN THE PATIENT WAS ON THE TABLE A MOTORCYCLIST WOULD ARRIVE FROM 3TANMORE WITH THE PROSTHESIS IN HIS POCKET AND YOU HOPED THAT IT WOULD lT &ORTUNATELY MOSTLY IT DID ) WONT GO INTO DETAILS OF THE NUMBERS AND SO ON ,ETTIN 9OU MENTIONED MANUFACTURERS /F COURSE THE MANUFACTURERS WERE VERY IMPORTANT AND 0HYLLIS (AMPSON IS HERE 7ELL 0HYLLIS ) AM NOT QUITE SURE WHAT YOUR ROLE WITH THE MANUFACTURERS EXACTLY WAS WITH :IMMER /RTHOPAEDIC AND OF COURSE AS AN INTERMEDIARY WITH 3TANMORE "UT ) THINK WE SHOULD ALSO MENTION THAT *OHN #HARNLEY OF COURSE HAD AN ARRANGEMENT WITH 4HACKRAYS WHEREBY THEY WOULD NOT SUPPLY A #HARNLEY REPLACEMENT UNLESS THE SURGEON HAD ACTUALLY SPENT THREE DAYS AT 7RIGHTINGTON IN THE TENT AND LEARNED HOW TO DO THE OPERATION ) IN MY TIME DID EXACTLY THAT BUT ) DONT KNOW HOW LONG THAT LASTED HOW LONG 4HACKRAYS KEPT THAT GOING -ICHAEL 7ROBLEWSKI YOU HAVE GOT A COMMENT ON THAT 0ROFESSOR -ICHAEL 7ROBLEWSKI )T WAS THE SECOND HALF OF 3IR *OHN #HARNLEY INFORMED PAST 2ESIDENTS OF THE #ENTRE FOR (IP 3URGERY AT 7RIGHTINGTON (OSPITAL
!RDEN ET AL
#HARLES & 4HACKRAY ,TD OF ,EEDS MANUFACTURED THE #HARNLEY PROSTHESIS FROM UNTIL WHEN 4HACKRAYS WAS ACQUIRED BY $E0UY NOW A *OHNSON *OHNSON SUBSIDIARY 3EE &OREMAN 0ECK n 3EE ALSO NOTE AND 'LOSSARY PAGE n
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&IGURE 3TILLS DISEASE n JUVENILE CHRONIC ARTHRITIS n IN PLUMP MALE TWINS 4HE BOY ON THE LEFT HAS 3TILLS WHICH SHOWS IN HIS POSTURE
BY LETTER SAYING THAT HIP COMPONENTS GENERALLY WERE BEING MADE AVAILABLE UNDER PRESSURE FROM THE MANUFACTURERS ,ETTIN 4HERE YOU ARE PRESSURE FROM MANUFACTURERS 0HYLLIS WHAT ABOUT THAT (OW MUCH INmUENCE REALLY DID YOU HAVE OR DID THE MANUFACTURERS HAVE 9OU HELD THE SURGEONS TO RANSOM ) THINK -RS 0HYLLIS (AMPSON .O ) DONT THINK THATS TRUE AT ALL ) DONT THINK WE HELD THE SURGEONS TO RANSOM 7E ;:IMMER /RTHOPAEDIC= WERENT REALLY CONNECTED
0ROFESSOR -IKE 7ROBLEWSKI WROTE @)T WAS THE FACTS ARE THAT THE #HARNLEY PROSTHESIS WAS NOT PATENTED #HARNLEY TOOK NO ROYALTIES a STERLING FROM THE SALE OF EACH HIP PROSTHESIS WAS PUT INTO RESEARCH #HARNLEY INSISTED ON KEEPING THE COST LOW BECAUSE h4HE .(3 HAS TO PAY FOR ITv 4HE STEM COST a AND THE CUP a /THER MANUFACTURERS WERE PRODUCING AND COPYING THE #HARNLEY PROSTHESIS 4HE MANUFACTURER 4HACKRAY WAS CONSTRAINED BOTH BY PRICE AND SALES HENCE THE PRESSURE FROM THE MANUFACTURER TO MAKE THE #HARNLEY PROSTHESIS FREELY AVAILABLE .OTE ON DRAFT TRANSCRIPT *UNE ! HISTORY OF 3MITH .EPHEW SUGGESTS THAT THE SOCKET WAS SOLD FOR a AND THE FEMORAL PROSTHESIS FOR a IN WITH 4HACKRAY PAYING a TO THE 7RIGHTINGTON RESEARCH FUND FOR EVERY PROSTHESIS SOLD 4HACKRAY HAD SOLE MANUFACTURING RIGHTS WHILE 7RIGHTINGTON RETAINED CONTROL OVER QUALITY &OREMAN 0ECK
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WITH ANY TOTAL JOINTS UNTIL ABOUT WHEN *OHN 3CALES PHONED US OUT OF THE BLUE ONE DAY ASKING IF WE WOULD BE WILLING TO MAKE 3TANMORE TOTAL JOINTS -Y MANAGING DIRECTOR AT THAT TIME WAS $OUGLAS $AVIDSON WHO WOULD NOT UNDER ANY CIRCUMSTANCES MAKE A TOTAL JOINT "UT LUCKILY JUST AFTER THAT HE WENT TO #ANADA AND THE DECISION BECAME MINE ) DECIDED THAT WE WERE GOING INTO TOTAL JOINTS WITH THE 3TANMORE RANGE 7E STARTED OFF HAVING THEM MADE BY $ELORO 3TELLITE AND THEN WE SET UP OUR OWN COMPANY -ETALLO -EDICAL IN 3WINDON IN ) DONT THINK WE HELD THE SURGEONS TO RANSOM IT WAS REALLY *OHN 3CALES WHO WAS HOLDING US TO RANSOM BECAUSE WE HAD TO PROMISE NOT TO MAKE ANY OTHER PROSTHESES APART FROM THE 3TANMORE RANGE FOR AT LEAST TWO YEARS WHICH WE DID AND WE KEPT TO THAT )T WENT VERY WELL AND WE STARTED BY MANUFACTURING THE METAL ON METAL TYPE ;SEE &IGURE ON PAGE = ) THINK WE WERE THE lRST COMPANY TO MAKE VACUUM CAST IMPLANTS WHICH MEANT THAT THEY WERE CLEANER HOPEFULLY THAN MAKING THEM AIR CAST AND THE lRST ONE WAS INSERTED IN BY 'INGER 7ILSON ) BELIEVE THE MAJORITY OF METAL TO METAL ARE STILL GOING VERY STRONGLY 0RIOR TO OUR OWN MANUFACTURE THE JOINTS WERE MADE BY $ELORO 3TELLITE AND ) BELIEVE *ACKSON "URROWS WAS THE lRST TO INSERT ONE OF THESE IN ,ETTIN 7HAT ABOUT THE "RITISH 3TANDARDS FOR IMPLANTS 6IC 7HEBLE IS HERE $O YOU THINK THAT "RITISH 3TANDARDS PLAYED AN IMPORTANT PART IN THIS (OW SOON DID THEY REALLY COME INTO HAVING A STANDARD -R 6ICTOR 7HEBLE "RITISH 3TANDARDS FOR CLINICAL MATERIALS THEMSELVES STARTED OUT AS A TECHNICAL COMMITTEE IN AND THIS WAS CHAIRED IN THE lRST PLACE BY 'EOFFREY "LUNDELL *ONES "UT BY THERE WAS CONSIDERABLE INTEREST FROM THE 'OVERNMENT THE $EPARTMENT OF (EALTH $O( AND THE CORRESPONDING 3COTTISH ORGANIZATIONS 3O AN INTERNATIONAL COMMITTEE WAS SET UP AND MET IN ,ONDON AT THE "RITISH 3TANDARDS )NSTITUTION "3) HEADQUARTERS 4HIS WAS A SPECIAL MEETING CALLED BY "ERNARD "LOCH OF !USTRALIA WHO SUGGESTED THAT PERHAPS THIS SHOULD BE FOCUSED ON INTERNATIONAL STANDARDS PROBLEMS AND IN FACT THERE WAS NO OTHER COMMITTEE EXISTING AT THE TIME "ERNARD "LOCH PERSUADED PEOPLE FROM
3EE NOTE
"URROWS
&OR A DETAILED TIMELINE OF THE "RITISH 3TANDARDS )NSTITUTION SEE WWWBSI GLOBALCOM.EWS(ISTORYINDEX XALTER VISITED *ULY 3EE ALSO !PPENDIX PAGES n AND 3CALES
"LOCH
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VARIOUS COUNTRIES TO COME AND THE lRST MEETING TOOK PLACE IN ,ONDON n -ARCH 4HIS HAD REPRESENTATION FROM VARIOUS OTHER ORGANIZATIONS SUCH AS THE )NTERNATIONAL &EDERATION OF 3URGICAL #OLLEGES AND ALSO FROM THE VARIOUS GOVERNMENTS OF COURSE BECAUSE THEY WERE INTERESTED IN THE FACT THAT THEY WERE STARTING TO SUPPLY PROSTHESES FOR USE IN THEIR HOSPITALS )T WENT ON FROM THERE ) ONLY GOT INTO STANDARDS MAKING A LITTLE BIT AFTER THAT BECAUSE *OHN 3CALES RANG TO ASK ME IF ) WOULD JOIN THE COMMITTEE AND ) WAS ON IT FROM UNTIL ) HAVE ACTUALLY HAD A LOT OF EXPERIENCE OF ALL THESE COMMITTEES .OW AS FAR AS DISTRIBUTION IS CONCERNED ) AM ONLY GOING TO TALK ABOUT *OHN 3CALES COMMITTEE n HE WAS CHAIRMAN OF THE HIP REPLACEMENT COMMITTEE n AND HE HAD MANY DIFlCULTIES WITH THE DIFFERENT PEOPLE FROM ALL OVER THE WORLD IN ARGUING WHAT COULD AND COULDNT BE DONE !T MEETING AFTER MEETING THESE ARGUMENTS OCCURRED AND EVENTUALLY IT GOT TO THE POINT WHERE HE THREATENED TO RESIGN !T THAT POINT THEY DECIDED THAT THEY HAD BETTER JUST KEEP HIM BECAUSE HE KNEW MORE ABOUT THE WHOLE SUBJECT THAN THEY DID 5NFORTUNATELY HE WAS NOT ABLE TO BE PRESENT AT THE TH ANNIVERSARY MEETING OF THE )3/ 4ECHNICAL #OMMITTEE IN 3INGAPORE IN WHEN HE WOULD HAVE BEEN AWARDED THE SPECIAL GOLD AWARD FROM THIS COMMITTEE BECAUSE OF HIS YEARS OF SERVICE ,ETTIN ) THINK YOU DESERVE A MEDAL FOR STAYING ON IT FOR SO LONG )T WAS THE WORST COMMITTEE THAT ) HAVE EVER BEEN ON AND )VE BEEN ON A GOOD MANY ) THINK YOU WERE REPRESENTING THE "/! AND ) WAS REPRESENTING THE #OLLEGE OF 3URGEONS 0HYLLIS YOU MAY REMEMBER n THIS IS VERY PERTINENT TO THE #HARNLEY CUP 7E SPENT A WHOLE AFTERNOON ARGUING THE DIFFERENCE BETWEEN A BEVEL AND A CHAMFER !ND ) DONT KNOW WHAT THE ANSWER WAS *OHN 0AUL n WHO WAS DUE TO BE HERE BUT HAS HAD HIS KNEES REPLACED AND COULDNT WALK ALL THE WAY FROM 'LASGOW n TRIED TO EXPLAIN )T WAS A TERRIBLE MEETING @7AS THE EDGE OF THE CUP BEVELLED OR WAS IT CHAMFERED 4HIS WENT ON AND ON !NOTHER QUESTION ) CAN REMEMBER WAS @(OW FAR SHOULD THE EYE BE FROM THE END OF A +ÓNTSCHER NAIL ) ADMIRE YOU 6IC FOR STAYING ON IT FOR SO MANY YEARS
"LOCH AND (ASTINGS
3EE !PPENDIX PAGES n
-R 6ICTOR 7HEBLE WROTE @*OHN 3CALES WAS A FOUNDER MEMBER OF THE )3/4# ) UNDERSTAND FROM 0HYLLIS (AMPSON THAT *OHN DID RECEIVE HIS TH ANNIVERSARY AWARD PRIVATELY LATER IN .OTE ON DRAFT TRANSCRIPT /CTOBER
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7HEBLE -AY ) JUST COMMENT ON THE NAIL 4HAT WAS A SMALL GROUP OF RATHER OLD PROFESSORS FROM &RANCE BACKED UP BY OTHER MEMBERS FROM 'ERMANY WHO COULD NOT AGREE THAT THE HOLE AT THE END OF A +ÓNTSCHER NAIL HAD TO BE A CERTAIN SIZE NOT A WHOLE SERIES OF SIZES %ACH COUNTRY WANTED ITS OWN PARTICULAR SIZE OF HOLE IN THE NAIL SO THAT ITS OWN HOOK WOULD lT 4HE ARGUMENT CONTINUED UNTIL ) MANAGED TO PERSUADE THEM AFTER TWO HOURS SITTING ON A STAIRCASE IN HEATED DISCUSSION WITH THESE EIGHT PEOPLE THAT ONLY ONE HOLE WAS NEEDED SO IF THE LARGEST HOOK WOULD lT SO WOULD THE SMALLEST ,ETTIN 4HIS "3) COMMITTEE DOESNT EXIST ANY MORE DOES IT 7HEBLE )T DOES IT IS STILL AN ACTIVE PART OF THE "3) ,ETTIN 7HAT ABOUT THE -EDICAL $EVICES !GENCY $IDNT THAT TAKE OVER FROM THE "3) ;&ROM THE mOOR .O IT IS NOT THE SAME= /H +EITH ) DIDNT SEE YOU ARRIVE ) AM SORRY ABOUT THAT 7OULD YOU LIKE TO SAY SOMETHING ABOUT THE -EDICAL $EVICES !GENCY -R +EITH 4UCKER 4HE -EDICAL $EVICES !GENCY -$! DOES NOT EXIST ANY MORE AS IT HAS BEEN AMALGAMATED INTO THE -EDICINES AND (EALTHCARE 0RODUCTS 2EGULATORY !GENCY -(2! 9OU ASKED ME TO TALK A LITTLE ABOUT REGULATIONS -Y INTRODUCTION TO ORTHOPAEDICS WAS WITH +EN -C+EE AND *OHN 7ATSON &ARRAR IN THE LATE S AND SO ) LEARNED ABOUT THE THINGS THAT YOU HAVE BEEN TALKING ABOUT TODAY RINGING POLAR BEARING AND SO FORTH ) MET !LAN #HAPPELL A FACIO MAXILLARY SURGEON IN .ORWICH WHO RECOMMENDED PUTTING THE STUDS ON THE BACK OF A -C+EEn&ARRAR CUP ) REMEMBER THOSE TIMES VERY WELL AND THEY WERE VERY INFORMATIVE YEARS FOR ME GIVEN WHAT ) HAVE BEEN DOING SINCE THEN 4HE PROSTHESES IN THOSE DAYS WERE MATCHED THE SOCKET AND THE STEM CAME AS A PAIR 4HIS SOMETIMES PROVED TO BE A PROBLEM DURING A REVISION 4HEY ;-C+EE AND 7ATSON &ARRAR= WERE GREAT PEOPLE TO WORK FOR AND THEIR PROSTHESES DID SPLENDIDLY WELL 4HEY WERE AMAZINGLY ENTHUSIASTIC PEOPLE WHO COMMANDED GREAT ADMIRATION AND SOMETIMES BEWILDERMENT +EN -C+EES PRAYER SESSION AT THE BEGINNING OF EACH WARD ROUND OFTEN IN THE MIDDLE OF A LARGE WARD WAS SOMETIMES A DAUNTING PROSPECT TO ME AS A YOUNG 3ENIOR (OUSE /FlCER ) TOOK OVER -C+EES lRM AS A #ONSULTANT IN AND IT WAS IN THE S WHEN YOU ;,ETTIN= SECONDED ME FROM THE #OUNCIL OF THE "/! TO THE -$! 4HE -$! NOW THE -(2! HAS DEVELOPED CONSIDERABLY AND PERHAPS YOU SAW ME AS SOMETHING OF A POACHER TURNED GAMEKEEPER
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)T WAS JUST BEFORE THAT TIME THAT A %UROPEAN $IRECTIVE HAD COME ALONG WHICH DIRECTED THAT ALL HIP REPLACEMENTS WOULD HAVE TO HAVE A #% MARK !S YOU KNOW #% MARKINGS ARE GRADED AND HIP REPLACEMENTS WERE TYPE " 3USANNE ,UDGATE HEADED THE -$! ABLY ASSISTED BY !NDY #ROSBIE AND *OHN (OPPER "Y ALL KNEE AND HIP REPLACEMENTS HAD TO HAVE THE #% MARK TO CONFORM WITH THE %UROPEAN $IRECTIVES /NE THING THAT WE IMMEDIATELY REALIZED WAS THAT MANUFACTURERS COULD GET A #% MARK A YEAR AFTER THE INTRODUCTION OF A NEW JOINT 4HUS PROVIDED THE JOINTS SURVIVED A YEAR THEY GOT THEIR #% MARK AND THAT LADIES AND GENTLEMEN WAS HOW IT WAS IN 4HERE WAS NO POST MARKET SURVEILLANCE AND WE WERE TOLD THAT IF WE WANTED TO GET INTO POST MARKET SURVEILLANCE WE SHOULD HAVE TO TURN OVER A %UROPEAN $IRECTIVE FROM THE %UROPEAN #OMMISSION WHICH SOUNDED QUITE A FORMIDABLE THING TO DO EVEN FOR ORTHOPAEDIC SURGEONS 2EALISTICALLY WE GOT NO FURTHER AND IN FACT NOT AS FAR AS *OHN #HARNLEY )T IS ON RECORD THAT *OHN #HARNLEY WANTED TO HAVE SOME SORT OF JOINT REGISTRY RIGHT AT THE VERY BEGINNING AND IT WAS OF COURSE AT #HARNLEYS INSTIGATION THAT SURGEONS COULD NOT ACQUIRE THE TOOLS TO PUT IN #HARNLEY HIP REPLACEMENTS WITHOUT GOING TO 7RIGHTINGTON TO LEARN HOW )T IS ALSO INTERESTING TO ME THAT +EN -C+EE AND *OHN 7ATSON &ARRAR ALTHOUGH THEY STARTED DOING @LARGE VOLUME HIP REPLACEMENTS IN DID NOT PUBLISH UNTIL THEY HAD lVE YEARS DATA )N THEIR WORDS @TO SEE HOW THEY WENT .OWADAYS IT IS POSSIBLE TO PUT THINGS IN TO THE MARKET MORE QUICKLY
4HE LETTERS #% ARE THE ABBREVIATION OF THE &RENCH PHRASE #ONFORMIT£ %UROP£ENE OR %UROPEAN #ONFORMITY &OR DETAILS SEE NOTE
3IR *OHN #HARNLEY WROTE IN @3ERIOUS CONSIDERATION SHOULD BE GIVEN TO ESTABLISHING A CENTRAL REGISTRY TO KEEP A lNGER ON THE PULSE OF TOTAL IMPLANT SURGERY ON A NATION WIDE BASIS 3URGEONS SHOULD NOT BE PERMITTED TO PERFORM TOTAL HIP IMPLANT WORK ESPECIALLY THOSE INVOLVING THE USE OF CEMENT UNLESS PREPARED TO HAVE WEEKLY RETURNS MADE OF THE OPERATIONS AS THEY ARE PERFORMED AND THEREAFTER TO HAVE PATIENTS QUESTIONED ANNUALLY BY CIRCULAR FROM THE REGISTRY 7RIGHTINGTON (OSPIAL )NTERNAL 0UBLICATION NO ;SEE WWWBITECICCOMEVENTS0ORTER 7HATDO#LINICAL/UTCOMESTELL USPDF VISITED .OVEMBER = *ONES 4HE .ATIONAL *OINT 2EGISTRY FOR %NGLAND AND 7ALES WAS ESTABLISHED IN REPLACING THE 4RENT AND .ORTH 7EST REGIONAL REGISTERS AND ITS lRST ANNUAL REPORT DATED 3EPTEMBER IS FREELY AVAILABLE FROM WWWNJRCENTREORGUKDOCUMENTSREPORTSPARTPDF VISITED *ULY
0ROFESSOR -IKE 7ROBLEWSKI WROTE @4HE #HARNLEY HIP REPLACEMENT INSTRUMENTS WERE ALWAYS FREELY AVAILABLE ;TO SURGEONS WHO HAD TRAINED WITH #HARNLEY= 4O QUOTE 3IR *OHN #HARNLEY h4HEY COULD BE USED FOR OTHER OPERATIONS AS WELL AS HIP REPLACEMENTv 4HIS HIP PROSTHESIS WAS NOT AVAILABLE UNTIL THE SECOND HALF OF .OTE ON DRAFT TRANSCRIPT *UNE 3EE &IGURE
-C+EE AND 7ATSON &ARRAR
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&IGURE ! #HARNLEY ACETABULAR REAMER
,ETTIN 7AS THAT ABOUT THE TIME OF THAT "/! MEETING IN .ORWICH -IKE &REEMAN WAS ASKING ME WHAT YEAR THAT WAS 4UCKER 4HE "/! MEETING IN .ORWICH WAS IN BUT THE MEETING YOU ARE REFERRING TO WAS ACTUALLY AT THE 2OYAL 3OCIETY OF -EDICINE IN THE S ,ETTIN ) THINK WE HAVE COVERED QUITE A LOT OF GROUND 9OU WERE TALKING ABOUT REGISTERS AND REGULATIONS AND ) THINK 2ODNEY AND -IKE YOU WERE BOTH QUITE KEEN ON THAT WAY BACK ) SEEM TO REMEMBER THAT WAS ANOTHER COMMITTEE THAT ) WAS ON BUT IT CAME TO NOTHING 3WEETNAM 9OU ARE ABSOLUTELY RIGHT IT CAME TO NOTHING /N YOUR SEATS IS A COPY OF A PAPER THE ONLY PAPER THAT ) HAVE EVER WRITTEN THAT ) THINK WAS OF ANY VALUE AND IT CONCERNS A SCHEME WHICH OUR COMMITTEE PROPOSED ;,ETTIN 7AS THAT A "/! COMMITTEE = .O IT WAS A $O( COMMITTEE CALLED THE !DVISORY 'ROUP ON /RTHOPAEDIC )MPLANTS AND THE REPORT OF THAT GROUP IS ON YOUR CHAIR DATED -AY ) WAS CHAIRMAN -ICHAEL &REEMAN WAS A MEMBER AND AFTER A LOT OF
3EE NOTE
-C+EE 3EE ALSO NOTE
3WEETNAM 4HIS REPORT SUGGESTED A @RECOMMENDED LIST OF ARTIlCIAL JOINTS CONSIDERED BY THE !DVISORY 'ROUP TO DEMONSTRATE ADEQUATE QUALITY CONTROL DURING MANUFACTURE THE USE OF SUITABLE MATERIALS AND OF ACCEPTABLE DESIGN )T WAS ALSO MENTIONED IN THE RECENT REVIEW BY &AULKNER ET AL n WHICH NOTED THE GENERALLY POOR METHODOLOGICAL QUALITY OF THE STUDIES CONSIDERED AND THAT THE RESULTS FOR DIFFERENT TYPES OF PROSTHESES SHOULD BE TREATED AS ESTIMATES ALTHOUGH THERE WERE GOOD RESULTS AT TEN YEARS GIVEN RELATIVELY POOR EVIDENCE FOR THE %XETER ,UBINUS )0 #HARNLEY (OWSE AND 3TANMORE
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DISCUSSION WE CAME UP WITH A SCHEME WHICH WOULD ) LIKE TO THINK HAVE SPARED US A LOT OF THE DISASTERS THAT HAVE OCCURRED IN FAULTY JOINT REPLACEMENTS INSERTED THEREAFTER ) REPEAT THE DATE A SCHEME PUT FORWARD BY OUR COMMITTEE ACCEPTED BY THE "/! ACCEPTED BY THE $O( INDEED ALL THE PROFESSIONAL BODIES ACCEPTED IT )F IT HAD GONE INTO PLACE THERE WOULD HAVE BEEN A SURVEILLANCE SCHEME WITH A RECOMMENDED LIST OF PROSTHESES EACH PROSTHESIS EACH NEW DESIGN WOULD HAVE BEEN MONITORED ) REPEAT THE DATE n !CCEPTED BY THE $O( AND THE WHOLE PROFESSION IT NEVER GOT OFF THE GROUND -Y BELIEF AND HERE ) AM GOING TO COME INTO CONmICT WITH ANOTHER MEMBER IN THE AUDIENCE IS THAT IT NEVER GOT OFF THE GROUND BECAUSE OF THE IMPLANT @INDUSTRY .OW 0HYLLIS WILL TELL ME WHETHER THAT IS RIGHT OR NOT BUT ) AM TOLD THAT SOMEONE IN A SENIOR POSITION IN THE INDUSTRY AT THAT TIME MANAGED TO PERSUADE THE $O( NOT TO PROGRESS THIS SCHEME !ND ) WOULD COMMEND THIS PAPER TO YOU WHICH WAS QUITE LARGELY DEPENDENT ON THE WORK OF -ICHAEL &REEMAN ) HAVE TO SAY ,ETTIN ) THOUGHT HE WAS THE VERY IMPORTANT CHAP 0HYLLIS ARE YOU GOING TO RESPOND TO THAT BARB (AMPSON ) REALLY DONT THINK IT HAS ANYTHING TO DO WITH THE TRADE AT ALL 3IR 2ODNEY ) THINK WE HAD MANY PROBLEMS ,ETS BE FAIR -R 2ONALD &URLONG WAS NEVER ON ANY COMMITTEE NOT "3) NO "/! MEETINGS NONE OF THEM ) REALLY DONT THINK IT WAS THE TRADE WHO STOPPED THE SCHEME
0ROFESSOR -IKE 7ROBLEWSKI WROTE @#HARNLEY KEPT DETAILED RECORDS ON PUNCH CARDS 7ITH THE INTRODUCTION OF COMPUTERS ) HAD THE INFORMATION TRANSFERRED TO A VERY DETAILED DATABASE WHICH IS UPDATED AFTER EVERY VISIT AND OPERATION 4HIS HAS FORMED THE BASIS OF THE *OHN #HARNLEY 2ESEARCH )NSTITUTE A REGISTERED CHARITY WITH CLOSE TO RECORDS FROM .OVEMBER ONWARDS .OTE ON DRAFT TRANSCRIPT *UNE
-R -IKE (EYWOOD 7ADDINGTON WROTE @) FULLY AGREE WITH 3IR 2ODNEY 3WEETNAM THAT IT WAS A DISASTER IN TERMS OF PROPER SURVEILLANCE SEE ALSO PAGE 4HE ONLY LOCAL CONTRIBUTION ) MADE WAS TO ENSURE A REGULAR FOLLOW UP OF OUR OWN HIP REPLACEMENTS #HARNLEY PROSTHESIS THROUGH POSTERIOR APPROACH AND RAN A SPECIAL HIP CLINIC TO ACHIEVE THIS USING THE SAME METHODS OF HIP SCORING AND ANALYSIS AS THAT USED AT 7RIGHTINGTON FOR lVE YEARS ON AN ANNUAL BASIS AND THEN AT lVE YEAR INTERVALS 4HESE RESULTS FORMED THE BASIS OF A SUCCESSFUL THESIS SUBMITTED FOR THE -3C IN /RTHOPAEDICS AT THE 5NIVERSITY OF ,ONDON BY -R 3 ' !TRAH &2#! IN AND WERE ALSO THE SUBJECT OF A PAPER GIVEN BY -R *OHN $OWELL AT THE "/3' IN ! NATION WIDE REGISTER WOULD OF COURSE HAVE BEEN FAR PREFERABLE .OTE ON DRAFT TRANSCRIPT /CTOBER
3IR 2ODNEY 3WEETNAM WROTE @2ONALD &URLONG WAS HEAD OF A VERY SUCCESSFUL HIP IMPLANT MANUFACTURING COMPANY .OTE ON DRAFT TRANSCRIPT *UNE &URLONGS *OINT 2EPLACEMENT )NSTRUMENTATION LATER *2) ,TD BECAME THE SOLE LICENCEE IMPORTING -ÓLLER COMPONENTS FROM LATER CASTING THE COMPONENTS IN TITANIUM ALLOY IN THE 5+ AT THEIR 3HEFlELD SITE 3EE DETAILS AT WWWJRI LTDCOUK VISITED *UNE
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&REEMAN )T WAS A GOOD SCHEME EVERYBODY APPARENTLY AGREED BUT IT DID NOT APPEAR (ISTORICALLY ) WOULD BE VERY INTERESTED TO KNOW WHY NOT ,ETTIN "UT WASNT IT A QUESTION THAT IT WAS LIMITING THE IMPLANTS THAT YOU AND 2ODNEY WOULD HAVE ALLOWED ) SEEM TO REMEMBER THAT THE 3TANMORE KNEE WOULD HAVE BEEN BANNED ) THINK THERE WAS A PERCEPTION THAT IT WOULD HAVE BEEN VERY RESTRICTIVE 3WEETNAM ) AM SORRY BUT IT HAD THE OVERWHELMING SUPPORT OF THE WHOLE PROFESSION INCLUDING THE "/! AND THERE WAS NO JUSTIlCATION FOR NOT GOING AHEAD WITH IT 4HE $O( AGREED IT THEY ASKED ME TO WRITE THIS PAPER IN A PUBLICATION CALLED (EALTH 4RENDS WHICH ) DID QUOTING THE $O(S ACCEPTANCE )T DID NOT GET OFF THE GROUND AND MY UNDERSTANDING WAS THAT IT WAS DUE TO POWERFUL VOICES WITHIN n ) DONT KNOW WHETHER THEY WERE MEMBERS OF THE COMMITTEE OR NOT n THE 3URGICAL 4RADES !SSOCIATION &REEMAN ) THINK 2ODNEY AND ) ARE BOTH SPECULATING THAT THIS WAS A SCHEME TO WHICH YOU COULD HARDLY OBJECT IN PUBLIC SO ALL THE BODIES SAID @/H WELL DONE AND THEN WENT OUT TO THE LOO AND SAID @#HRIST !S INDIVIDUALS WE ARE NOT GOING TO MAKE ANY MONEY IF THIS COMES OFF SO WE MUST STOP IT "UT THAT IS MY GUESS ;&ROM THE mOOR 9ES ) WAS IN THE LOO AT THE TIME= 7ROBLEWSKI -R 0ETER &RANK #ONSULTANT /RTHOPAEDIC 3URGEON FROM -ANCHESTER AND ) WERE APPROACHED BY THE $O( AND WE HAD SEVERAL MEETINGS ON THE SUBJECT 4HE OBJECT OF THE EXERCISE WAS TO HAVE A 2EGISTER NOW INCORRECTLY CALLED A 2EGISTRY TO PUT ON RECORD lRST ALL TOTAL HIPS AS WELL AS HEMI ARTHROPLASTIES 4HE PROJECT WAS OBVIOUSLY IMPOSSIBLE FOR THE TWO OF US TO DO ) SUGGESTED THAT WE COULD PROBABLY SET UP ONE LOCALLY AS A PILOT SCHEME TO SEE WHETHER THIS WAS GOING TO BE A WORKING PROPOSITION ) SUGGESTED THAT TO SET IT UP FROM SCRATCH WOULD COST a 4HAT WAS THE LAST TIME ) HEARD FROM THE $O(
3WEETNAM 3IR 2ODNEY 3WEETNAM WROTE @4HE OUTCOME WAS THAT THERE WAS NO FURTHER ACTION WHATSOEVER EXCEPT THAT THE $O( DID INTRODUCE CERTAIN CONTROLS OF MATERIALS AND MANUFACTURE WHICH THEY CALLED THEIR 'OLD 3TANDARDS BUT NEVER ANY CLINICAL DATA OR FOLLOW UP SURVEILLANCE WHATSOEVER 4HE $O( WERE SIMPLY TOO WEAK TO GRASP THE NETTLE OF hSURVEILLANCEv AND THE ONLY EXPLANATION ) HAVE FOR THIS IS THAT THEY WERE NOT PREPARED TO STAND UP TO THE hINDUSTRYv !LL THE MEDICAL PROFESSIONAL BODIES SUPPORTED THE SCHEME BUT ONLY THE $O( HAD THE POWER TO INTRODUCE IT .OTE ON DRAFT TRANSCRIPT /CTOBER
-RS 0HYLLIS (AMPSON WROTE @) WAS NEVER ADVISED THAT THE 3TANMORE KNEE SHOULD BE BANNED &OR WHAT REASON .OTE ON DRAFT TRANSCRIPT /CTOBER
0ROFESSOR -IKE 7ROBLEWSKI WROTE @-Y HANDWRITTEN NOTES OF THE MEETING ARE DATED *ULY .OTE ON DRAFT TRANSCRIPT /CTOBER
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,ETTIN ) THINK IT HAS PROVED A VERY INTERESTING DISCUSSION WHICH PERHAPS CAME A BIT AFTER THE HISTORICAL PART BUT NEVERTHELESS ) THINK IT IS IMPORTANT THAT IT HAS BEEN REPORTED +EVIN YOU WANT TO SAY A BIT MORE (ARDINGE &OR THE HISTORICAL RECORD WHEN 3TANMORE STARTED MAKING THEIR HIP REPLACEMENT THEY DID APPROACH *OHN #HARNLEY TO SEE IF THEY WOULD BE ABLE TO MARKET THE 3TANMOREn#HARNLEY *OHN #HARNLEY WASNT TOO KEEN ON THIS AND HE SUGGESTED THAT THEY SHOULD MARKET THE 3TANLEYn#HARNMORE 7HEBLE 4HERE WAS AN ATTEMPT AT ONE TIME TO DO EXACTLY THAT INTERNATIONALLY TO GET A STANDARD WHERE YOU COULD CONTROL SOME OF THESE THINGS BUT IT NEVER CAME TO ANYTHING AT ALL /F COURSE NONE OF THE COMPANIES WAS INTERESTED ,ETTIN )T WAS DIFlCULT ENOUGH GETTING THE STANDARDS THROUGH FOR THE METAL WASNT IT !NOTHER THING THAT ) CAN REMEMBER IN THAT "3) COMMITTEE WAS THAT THE 3WISS MATERIALS WERE VERY MUCH WORSE THAN THE "RITISH MATERIALS THE !MERICANS SOMEWHERE IN BETWEEN AND WE COULDNT AGREE A STANDARD ) THINK THE 3WISS WERE STILL USING OLD RAILWAY LINES 4HEY HAD BOUGHT UP THE "URMA RAILWAY AND WERE MANUFACTURING THE PROSTHESES OUT OF OLD RAILWAY LINES 7E COULDNT GET AN AGREEMENT NEVER MIND AN AGREEMENT ON THE DESIGN OF PROSTHESES WE COULDNT GET ONE ON THE MATERIALS THAT THEY WERE MADE FROM )T WAS A VERY BORING COMMITTEE ) THINK WE HAVE TALKED ABOUT REGULATION AND IT DOESNT SEEM AS THOUGH THE MANUFACTURERS REALLY HAMPERED THE ORTHOPAEDIC SURGEONS IF 0HYLLIS IS TO BE BELIEVED 4HEY DIDNT SAY @9OU CANT MAKE IT LIKE THIS THEY lTTED IN WITH WHATEVER DESIGNS THE SURGEONS PRODUCED (AMPSON 3OMETIMES ONE HAD A NOTE ON THE BACK OF AN ENVELOPE OR A CIGARETTE BOX SAYING @#AN YOU MAKE THIS 9OU HAD TO GO ALONG WITH THE SURGEON UP TO A POINT BUT USUALLY SOME MODIlCATION HAD TO BE MADE WITH THE SURGEONS APPROVAL ,ETTIN !RE THERE ANY OTHER POINTS ON THE DESIGN OR THE MATERIALS -ICHAEL ;&REEMAN= MENTIONED THE TERRIBLE FRIGHT THAT HAPPENED WHEN HE PUT ALL THIS WEAR MATERIAL INTO RATS AND EVERY LUMP THAT APPEARED IN A PATIENT THAT HAD HAD A HIP REPLACEMENT WAS THOUGHT TO BE A TUMOUR ;SEE PAGE = "UT -ICHAEL IS THERE ANY MORE YOU WOULD LIKE TO SAY ON THAT /R !LAN ;3WANSON= FOR THAT MATTER &REEMAN ) AM SURE EVERYBODY KNOWS !LAN ;3WANSON= KNEW BECAUSE HE WROTE IT IN A BOOK THAT WE EDITED AND ) HAVE JUST WHISPERED TO ASK HIM IF HE WOULD CARE TO REPEAT WHAT HE SAID IN THE BOOK AND HE SAYS HE CANT REMEMBER WRITING
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IT 3O ) HAVE TO ASK THE AUDIENCE 4HE POINT IS IF YOU GAMMA IRRADIATE IN AIR YOU CROSS LINK THE CHAINS WHICH MAY BE GOOD MECHANICALLY BUT IN OXYGEN YOU ALSO SPLIT THE CHAINS SO THAT STRICTLY THE MATERIAL IS NO LONGER 5(-70% &OR A LONG PERIOD WE GAMMA IRRADIATED IN AIR AT A TIME WHEN THE ATOMIC INDUSTRY KNEW PERFECTLY WELL WHAT WOULD HAPPEN IN PRINCIPLE IF YOU IRRADIATED POLYMERS IN AIR ! LOT OF THE WEAR PROBLEMS THAT ) THINK WE HIT IN THE MIDDLE PERIOD AFTER THE PERIOD YOU ARE TALKING ABOUT #HAIRMAN WERE DUE TO THAT -Y QUESTION IS CAN THE EARLY 7RIGHTINGTON PEOPLE TELL US HOW THE POLYETHYLENE CUP WAS STERILIZED TO BEGIN WITH 3ECONDLY WHEN GAMMA IRRADIATION WAS INTRODUCED WHETHER CONSIDERATION WAS GIVEN TO THE DOWNSIDE MECHANICAL CONSEQUENCES ) SHOULD SAY THAT )VE WHISPERED TO *OHN 2EAD AND HE SAYS HE CANT REMEMBER BUT MAYBE -IKE 7ROBLEWSKI OR SOMEBODY ELSE CAN 7HY DID WE GAMMA IRRADIATE IN AIR WITHOUT KNOWING WHAT WE WERE DOING 7ROBLEWSKI 5NTIL -ARCH THE CUPS WERE MACHINE WASHED SOAKED IN FORMALDEHYDE WASHED AGAIN AND THEN IMPLANTED &ROM -ARCH ONWARDS THE MANUFACTURE WAS TRANSFERRED TO 4HACKRAYS IN ,EEDS AND IT IS AT THAT STAGE THAT THEY WERE GAMMA IRRADIATED 4UCKER 6ERY BRIEmY FOLLOWING ON FROM WHAT -ICHAEL WAS SAYING ) THINK ONE OF THE IMPORTANT PARTS OF THE HISTORY CERTAINLY AS FAR AS ) AM CONCERNED WAS IN THE MID S WHEN -ICHAEL PUBLISHED HIS PAPER SHOWING THAT ALLERGY TO METAL IONS OR WHAT WAS THOUGHT TO BE ALLERGIC REACTION WHICH HE ALLUDED TO BEFORE ) THINK PROBABLY lNISHED OFF THE METAL TO METAL ARGUMENT CERTAINLY FOR QUITE A WHILE 0ERHAPS IT WAS THE EARLY S -ICHAEL WHEN YOU SHOWED THE ACETABULAR COMPONENTS ON METAL TO METAL PROSTHESES GOING IN TO THE PELVIS )F YOU CANT REMEMBER ) CAN &REEMAN ) DONT WANT TO GET INTO MINUTIAE ) DID PUBLISH ON THAT SUBJECT BUT ) WASNT THE lRST TO PUBLISH ON THE ISSUE OF WHETHER COBALTnCHROMIUM WAS IN THE HAIR URINE AND SO ON 4HAT WASNT ACTUALLY THE POINT ) WAS MAKING WHICH WAS
0ROFESSOR !LAN 3WANSON WROTE @0ROFESSOR &REEMAN CREDITS ME WITH TOO MUCH )N THE BOOK REFERRED TO ;3WANSON AND &REEMAN = ) MENTION THE DEGRADATION OF MECHANICAL PROPERTIES CAUSED BY IRRADIATION BUT NOT THE DIFFERENCE BETWEEN IRRADIATION IN AIR AND IN VACUO .OTE ON DRAFT TRANSCRIPT *UNE
3HEN AND $UMBLETON "LACK "ESONG ET AL
%VANS ET AL "ENSON ET AL %LVES ET AL ,ALOR ET AL
(EATH ET AL
&OR EXAMPLE #OLEMAN ET AL
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WHY DID WE STERILIZE BY GAMMA IRRADIATION IN AIR 7AS IT THAT NOBODY KNEW ANY BETTER 7HY WAS IT ) MEAN LOOKING BACK IT WAS AN INCREDIBLE THING TO DO -R +RISHNA 2AVI +UNZRU ! BIT OF AN ANECDOTE ON A TOTALLY DIFFERENT SUBJECT ) WAS -ALCOLM 3WANNS AND 'EORGE !RDENS SENIOR REGISTRAR AND ) REMEMBER 'EORGE !RDEN TRYING TO PUT ONE OF THOSE CUSTOM MADE PROSTHESES INTO A CHILD AND IT JUST WOULDNT lT 4HE REASON SIMPLY WAS THAT THE STEM WAS TOO LONG AND WE HAD TO GET A CARBORUNDUM DISC TO CUT THE STEM OFF IN THE THEATRE 7E HAD TO lND THE ENGINEER lRST n ) THINK HE HAD GONE HOME 7E LIVED THROUGH RATHER INTERESTING TIMES ,ETTIN ) THINK )AN 3TEPHEN TOUCHED ON THE PRESSURIZATION OF CEMENT BECAUSE THAT WAS SOMETHING THAT PROBABLY CAME ABOUT IN THIS PERIOD THAT WE ARE TALKING ABOUT #ERTAINLY *OHN 3CALES WAS PRESSURIZING THE MASSIVE IMPLANTS IN HUMANS AND HE HAD A GUN WHICH HE GOT FROM $E (AVILLAND n ITS FUNNY HOW THE AIRCRAFT INDUSTRY IS MENTIONED AGAIN n WHICH WORKED OFF AN OXYGEN CYLINDER AND IT WAS REALLY QUITE A FEARSOME THING AND ) HAD A CERTAIN AMOUNT OF EXPERIENCE ;WITH IT= JUST AFTER ) GOT ON THE STAFF AT "ARTS )T WAS A PATIENT WITH A TUMOUR OF THE UPPER END OF THE HUMERUS AND *OHN MIGHT HAVE BEEN POSSIBLY ONE OF THE EARLIEST ) DONT KNOW TO REAM ;SCRAPE WITH A REAMER SEE &IGURE = THE MEDULLARY CAVITY (E BROUGHT HIS OWN REAMERS WITH HIM WHICH ) THINK HE PROBABLY GOT FROM THE IRONMONGERS AND WHEN HE GOT TO REAMING THE HUMERUS ) HAD EXPOSED HE SAID @9OU HAD BETTER LET ME DO THIS ITS A BIT TRICKY AND SO HE REAMED THE SHAFT OF THE HUMERUS 4HEN IT CAME TO PUTTING IN THE CEMENT AND HE SAID @9OU HAD BETTER LET ME DO THIS THIS IS A BIT TRICKY AND MY HOUSE SURGEON WHO WAS HOLDING THE ARM THEN SAID @$OES IT MATTER SIR BUT THE ELBOWS SWELLING *OHN HAD OBVIOUSLY DRILLED THROUGH INTO THE ELBOW JOINT AND THE CEMENT WAS GOING INTO THE JOINT (E SAID @7HAT ARE WE GOING TO DO NOW 3O ) SAID @7ELL PUT THAT PROSTHESIS IN AS FAST AS WE CAN 7E PUT THE PROSTHESIS IN AND THEN WE TOOK A PLUG OF CEMENT OUT FROM THE ELBOW JOINT *OHN WAS IN AT THE CRACK OF DAWN THE NEXT MORNING TO SEE THIS PATIENT WHO HAD NOTHING WORSE THAN A TRANSIENT ULNAR NERVE PALSY ;DUE TO COMPRESSION OF THE NERVES=
3EE NOTE
-R -ICHAEL 7ILSON WROTE @!S ) REMEMBER THE HAMMERDRILL WAS ONE OF 3CALES INVENTIONS n A PNEUMATIC PERCUSSION HAMMER WHICH RELIED ON BALL BEARINGS TO PROVIDE THE PERCUSSION ELEMENT ) DONT THINK IT LASTED BEYOND THE (EATH 2OBINSON STAGE AS THE BALL BEARINGS WOULD PERIODICALLY FALL OUT ALL OVER THE THEATRE mOOR AND HAVE TO BE RETRIEVED % MAIL TO -RS ,OIS 2EYNOLDS .OVEMBER
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-R 4RISTRAM #HARNLEY /N THE QUESTION OF STERILIZATION ) CERTAINLY REMEMBER IN THE EARLY S AND -IKE 7ROBLEWSKI CAN PROBABLY CONlRM THIS BUT 4HACKRAY WERE VACUUM PACKING THE CUPS BEFORE STERILIZATION &REEMAN ) AM VERY SORRY BECAUSE 4HACKRAYS WERE DOING IT IN THE S OR NOT UNTIL THE EARLY S SOMEWHERE THERE 3O CAN ) ASK 0HYLLIS WHY DID THE REST OF INDUSTRY GO ON GAMMA IRRADIATING IN AIR (AMPSON ) AM TERRIBLY SORRY ) HAVE NO IDEA &REEMAN "UT THEY WERE VACUUM PACKED AND THEN STERILIZED 3O THEY WERE STERILIZED IN A VACUUM ;&ROM THE mOOR 7ELL= 7HAT DO YOU MEAN @WELL 4HEY WERE STERILIZED IN A VACUUM 2ING -IKE &REEMAN HAS MENTIONED THE POSSIBLE TOXICITY OF THE METAL ON METAL BEARING AND ) THINK HISTORICALLY ITS IMPORTANT TO RECORD THIS &OR THAT AND PERHAPS FOR OTHER REASONS +EN -C+EE TURNED TO METAL ON PLASTIC IN OR AROUND AND ) DID THE SAME THING 2EPORTS OF TOXICITY MOSTLY IF THE IMPLANTS WERE MADE OUT OF COBALT CAME FROM *OHN 3CALES AND FROM -IKE &REEMAN AND THE METAL ON PLASTIC JOINTS SEEMED TO BE GIVING RATHER BETTER EARLY RESULTS )N SPITE OF THE POSSIBILITY THAT METAL IONS ARE HAZARDOUS ONE WAY OR ANOTHER THERE HAS BEEN A RESURGENCE OF METAL ON METAL JOINTS 0ERHAPS PROGRESS IS CIRCULAR ,ETTIN ) THINK 0ROFESSOR 3WANSON MADE THIS POINT EARLIER THAT IT WAS A QUESTION OF THE PURITY IN THE MANUFACTURE OF THE METALS WHICH IS SO MUCH BETTER NOW 0ERHAPS THAT CONNECTS UP WITH THE 3WISS RAILWAY LINES ) THINK WE SHOULD MOVE ON TO THE QUESTION OF THE OPERATION %ACH OF THE EARLY PIONEERS SEEMED TO ADOPT A DIFFERENT TECHNIQUE #HARNLEY AS WE ALL KNOW TOOK OFF THE TROCHANTER WHICH
-RS 0HYLLIS (AMPSON WROTE @7HEN ) LEFT SCHOOL ) WENT TO WORK AT THE ,ONDON 3PLINT #OMPANY WHICH WAS OWNED BY AN !MERICAN -R & ) 3AEMANN )N HE SOLD THE COMPANY AND DECIDED TO START A MANUFACTURING UNIT ;:IMMER /RTHOPAEDIC ,TD= 4HE PLACE HE EVENTUALLY CHOSE WAS IN "RIDGEND 3OUTH 7ALES )N OR THEREABOUTS THE -ANAGING $IRECTOR OF THE COMPANY DECIDED TO LIVE IN #ANADA HENCE MY PROMOTION TO -$ 7HEN -R 3AEMANN DIED HIS HEIRS DECIDED TO SELL THE COMPANY TO "IOMET ;NOW "IOMET -ERCK= ) STAYED WITH THEM FOR A SHORT WHILE AND THEN DECIDED TO RETIRE IN 5NFORTUNATELY WHEN "IOMET BOUGHT THE COMPANY THEY CLOSED AND DISMANTLED THE ,ONDON OFlCE AND THE MANUFACTURING UNIT IN 3WINDON WHERE THE TOTAL JOINTS WERE MADE !LL OF THE HISTORY OF THE COMPANIES WAS DESTROYED ,ETTER TO -RS ,OIS 2EYNOLDS *UNE -R 2AVI +UNZRU WROTE @:IMMER BOUGHT THE 3WINDON WORKS FROM THE lRM $ELORO 3TELLITE WHO HAD BEEN MAKING HIP PARTS THERE FOR MANY YEARS .OTE ON DRAFT TRANSCRIPT /CTOBER 3EE ALSO PAGES n
#OLEMAN ET AL (EATH ET AL
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B A C D
D AC B
&IGURE 3URGICAL APPROACHES USED IN TOTAL HIP REPLACEMENT , TO 2 A ANTEROLATERAL INCISION B DIRECT LATERAL INCISION C LATERAL OR POSTERIOR INCISION AND D MODERN MINIMALLY INVASIVE INCISION $RAWN BY -R +EVIN (ARDINGE
) THINK HE TRIED TO RATIONALIZE BUT THOSE OF US IN THE SOUTH PERHAPS WERE MORE USED TO A POSTERIOR APPROACH +EVIN ;(ARDINGE= YOU DEVELOPED AN APPROACH OF YOUR OWN "UT PERHAPS WE SHOULD START OFF WITH -IKE 7ADDINGTON AND +EN -C+EES APPROACH TO THE HIP WHICH WAS AN ANTERIOR APPROACH ;SEE THE ANTEROLATERAL INCISION IN &IGURE = WASNT IT 7E HAVE GOT SOME lLM LATER BOTH OF -C+EE AND #HARNLEY BUT ) THINK WE WILL PUT THOSE ON DURING TEATIME SO THAT PEOPLE CAN HAVE A LOOK WHILE THEY ARE DRINKING A CUP OF TEA
(ARDINGE &OR A MORE RECENT EVALUATION SEE "ARRACK AND "UTLER
4HE lLM OF +EN -C+EE OPERATING DIGITIZED ON $6$ AND A DIGITAL COPY OF THE SILENT lLM OF *OHN #HARNLEYS OPERATION WILL BE DEPOSITED ALONG WITH THE TAPES AND OTHER RECORDS OF THE MEETING IN !RCHIVES AND -ANUSCRIPTS 7ELLCOME ,IBRARY ,ONDON
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-R -IKE (EYWOOD 7ADDINGTON 2EFERENCE HAS BEEN MADE TO SERENDIPITY AND ) HAVE TO ADMIT THAT MY PROFESSIONAL CAREER WAS LARGELY BASED ON SERENDIPITY RATHER THAN ON ANY STRUCTURAL PLANNING /NE OF THE BEST EXAMPLES OF THAT IS REALLY HOW ) GOT TO MEET +EN -C+EE 7HILE WORKING AS SENIOR REGISTRAR FOR THE LATE (ERBERT 3EDDON AT THE 2./( ) WAS SUMMONED TO HIS OFlCE WHICH AS YOU REMEMBER #HAIRMAN WAS SLIGHTLY PREFERABLE TO BEING INVITED TO HIS ROSE GARDEN (E SAID THAT HE WISHED ME TO GO TO .ORWICH TO ACT AS THE LATE )AN 4AYLORS LOCUM THERE WHILE HE CARRIED OUT A STINT AT +ANO .IGERIA !S A RESULT ) SPENT FOUR MONTHS AT THE .ORFOLK AND .ORWICH (OSPITAL FROM 3EPTEMBER TO *ANUARY 4HERE WAS ANOTHER ITEM ON THE AGENDA BECAUSE AS ) THINK YOU MAY TESTIFY THERE WAS SOME SCEPTICISM AMONGST THE STAFF AT THE 2OYAL .ATIONAL /RTHOPAEDIC (OSPITAL 2./( AT 3TANMORE ABOUT THE REAL MERITS OF WHAT WAS GOING ON BOTH IN 7RIGHTINGTON AND IN .ORWICH FROM *ACKSON "URROWS IN PARTICULAR 3O MY INSTRUCTIONS WERE TO REPORT BACK ON THE -C+EE HIP @7ADDINGTON GET THIS VERY CLEAR DOES THE .ORWICH HIP WORK AND WILL IT LAST !NYWAY ) WENT UP THERE AND EVERYBODY AT .ORWICH WAS EXTREMELY KIND TO ME NOBODY MORE SO THAN )AN 4AYLOR WITH WHOM ) STAYED BEFORE HE DEPARTED FOR .IGERIA *OHN 7ATSON &ARRAR AND +EN -C+EE TOOK ME THROUGH THE OPERATION ) EXPLAINED THAT ) WAS BEING PRESSED TO REPORT BACK TO THE 2./( AND ASKED IF ) COULD MAKE THE lLM ;SHOWN DURING THE MEETINGS TEA BREAK= BECAUSE ) FELT THAT IF ) COULDNT SHOW -C+EE HIMSELF PERFORMING THE OPERATION IT MIGHT BE THOUGHT THAT ) WAS INTRODUCING MY OWN MODIlCATIONS WHEN ) RETURNED TO 3TANMORE
-R -ICHAEL 7ILSON WROTE @#ONCERNING 3IR (ERBERT 3EDDONS ROSE GARDEN MY FATHER ;@'INGER 7ILSON= WROTE THE FOLLOWING FOR HIS SPEECH TO THE 3EDDON #ENTENARY WHICH WOULD HAVE BEEN AROUND *ULY h4HE MERE MENTION OF A VISIT TO THE 2OSE 'ARDEN WAS SUFlCIENT TO PUT THE FEAR OF 'OD INTO ANY REGISTRAR IN TRAINING FOR THEY KNEW IT COULD BE A PRELUDE TO BEING GENTLY MOVED ON !S A CONSULTANT ) WAS NEVER SUMMONED THERE FOR AS ) HAVE ALREADY EXPLAINED (*3 ;3IR (ERBERT 3EDDON= HAD OTHER METHODS OF DEALING WITH RECALCITRANT JUNIOR COLLEAGUES "UT *43 ;*OHN 3CALES= SEEMS TO HAVE BEEN A FAIRLY REGULAR ATTENDER (IS EXPERIENCES ARE WORTH RECORDING AND ) QUOTE h!S WE PROGESSED THROUGH THE GARDEN ENGAGED IN ERUDITE DISCUSSION EVERY NOW AND THEN (*3 WOULD STOP BEND FORWARD PICK A WEED FROM THE LAWN AND THEN CONTINUE HIS POINT 4HIS METHOD OF PROGRESSION COULD BE SOMEWHAT DISCONCERTING TO A NERVOUS VISITORv % MAIL TO -RS ,OIS 2EYNOLDS /CTOBER
-R !LAN ,ETTIN WROTE @(*3 ASKED ME AS HIS &IRST !SSISTANT TO lND LOCUMS FOR CONSULTANTS GOING TO +ANO .OTE ON DRAFT TRANSCRIPT .OVEMBER
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"UT YOU ARE QUITE RIGHT ) SHOULD ADD THAT ) WAS VERY PRIVILEGED TO KNOW +EN -C+EE VERY WELL FOR A LONG TIME HE USED TO COME DOWN AND STAY WITH US WHEN HE OPERATED FROM TIME TO TIME AT THE %SSEX .UFlELD (OSPITAL "RENTWOOD AFTER HIS RETIREMENT FROM THE .(3 ) ALSO WENT ON A REGULAR BASIS TO THE WELL KNOWN ANNUAL MEETINGS OF THE "RITISH /RTHOPAEDIC 3TUDY 'ROUP "/3' AT :URS !USTRIA ATTENDED BY BOTH -C+EE AND #HARNLEY 4HERE WAS A LOT OF FREE AND INFORMAL DISCUSSION THROUGH THE S FROM BOTH OF THEM FROM WHICH ) LEARNT A LOT 9OU ARE QUITE RIGHT THAT BOTH #HARNLEY AND -C+EE HAD AN ALMOST DOCTRINAL ATTITUDE TO THEIR SURGICAL APPROACH -C+EES WAS THE ANTEROLATERAL APPROACH THE 7ATSON *ONES APPROACH AND OF COURSE #HARNLEY INSISTED ON A LATERAL APPROACH WITH TROCHANTERIC OSTEOTOMY #HARNLEY TOLD ME LATER THAT +EVIN (ARDINGE WOULD BE ALLOWED TO DO THINGS HIS WAY IF HE ;#HARNLEY= NEEDED THE OPERATION HIMSELF (OWEVER THE lLM SHOWS THE OPERATION AS PERFORMED BY -C+EE SO ) THINK IT CAN SPEAK FOR ITSELF ,ETTIN 4HE GREAT PROBLEM WITH THAT APPROACH WAS THE CHAP UNDER THE SHEETS ;THE TECHNICIAN WHO MANIPULATED THE LEG AS REQUIRED BY THE SURGEON= WASNT IT (EYWOOD 7ADDINGTON 9ES AND AS YOU KNOW WE HAD OUR 4ERRY ;A TECHNICIAN= AND ) THINK THEY HAD THEIR +EITH ;A TECHNICIAN= n ) CANT REMEMBER HIS NAME n AT .ORWICH ) HAVE TO SAY THAT THAT PART OF THE TECHNIQUE WAS ONE THING THAT ) GAVE UP WHEN ) GOT MY OWN CONSULTANTS JOB AND ADOPTED THE POSTERIOR APPROACH FOR WHICH ) MAKE NO APOLOGIES ,ETTIN -IKE ;7ROBLEWSKI= DID YOU CONTINUE TO REMOVE THE GREATER TROCHANTER THROUGHOUT YOUR WORKING LIFE
-R -IKE (EYWOOD 7ADDINGTON WROTE @-UCH OF THE CONVERSATION AT THE "RITISH /RTHOPAEDIC 3TUDY 'ROUP MEETINGS WAS INFORMAL BUT THERE EXIST MINUTES OF THE SCIENTIlC PAPERS GIVEN WHICH INCLUDED REGULAR CONTRIBUTION THROUGH THE S FROM BOTH -C+EE AND #HARNLEY ON THEIR EVOLVING VIEWS ON THE DEVELOPMENT OF THE ARTIlCIAL HIP JOINT AND RELATED MATTERS 4HE PROCEEDINGS ARE PUBLISHED ANNUALLY BUT HAVE A PRIVATE CIRCULATION TO MEMBERS BUT CAN BE MADE AVAILABLE TO ANYONE PROPERLY INTERESTED WHO APPROACHES THE SECRETARY AT PRESENT -R 4IM -ORLEY 4HEIR SCIENTIlC VALIDITY IS UNDOUBTED .OTE ON DRAFT TRANSCRIPT /CTOBER
4HE ANTERIOR SURGICAL APPROACH TO THE TOTAL HIP REPLACEMENT IS ONE OF THE OLDEST DEVELOPED IN THE S BY "OSTON SURGEON -ARIUS 3MITH 0ETERSEN LATER MODIlED BY "RITISH SURGEON 3IR 2EGINALD 7ATSON *ONES BOTH OF WHOM USED THIS APPROACH TO REPAIR FRACTURES OF THE FEMORAL NECK 3EE 3MITH 0ETERSEN 7ATSON *ONES #HARNLEY B 3EE ANTEROLATERAL INCISION ILLUSTRATED IN &IGURE
*OLLES AND "OGOCH
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7ROBLEWSKI -R #HAIRMAN MAY ) CORRECT YOU )T IS NOT MERELY A QUESTION OF THE TROCHANTERIC OSTEOTOMY IF WE READ #HARNLEYS DESCRIPTION OF THE METHOD OF EXPOSURE IT WAS QUITE PURPOSEFUL ALL TO DO WITH THE MECHANICS OF THE HIP JOINT 4O MEDIALIZE THE CUP REDUCING THE MEDIAL LEVER WHILE INCREASING THE LATERAL LEVER BY MOVING THE TROCHANTER LATERALLY 7E NOW HAVE EVIDENCE TO SUPPORT THAT MEDIALIZED CUPS WEAR LESS CUPS SUPPORTED ON THE RIM WEAR MORE )T IS NOT MERELY THE QUESTION OF EXPOSURE )N FACT IN LATER YEARS 3IR *OHN #HARNLEY USED TO SAY THAT HE DID NOT CHARGE HIS PRIVATE PATIENTS TO DO A HIP REPLACEMENT HE CHARGED THEM FOR REATTACHING THE TROCHANTER ;,AUGHTER= CLEARLY EMPHASIZING THE BENElT OF THE RECONlGURING OF THE HIP JOINT MECHANICS 4HE ANSWER TO YOUR ORIGINAL QUESTION IS YES n UNTIL MONTHS AGO WHEN ) RETIRED FROM CLINICAL PRACTICE ,ETTIN 9OU HAVE LEARNED BETTER SINCE 7ROBLEWSKI 4HATS A MATTER OF OPINION ,ETTIN 4HE PERCEPTION IN THE SOUTH WAS THAT THIS WAS THE WAY THAT THE -ANCHESTER SURGEONS APPROACHED THE HIP THAT 3IR (ARRY 0LATT DID IT THIS WAY AND HIS PUPIL *OHN #HARNLEY DID IT THIS WAY /F COURSE SURGEONS IN THE SOUTH DIDNT APPROACH THE HIP BY TAKING OFF THE TROCHANTER AND THAT WHAT YOU SAID WAS REALLY AN EFFORT TO RATIONALIZE THE APPROACH WHICH WAS THE -ANCHESTER WAY .OW WE HAVE SOME ENGINEERS HERE AND ) WONDER WHETHER THEY WOULD GO ALONG WITH THE THESIS THAT -IKE 7ROBLEWSKI HAS PUT FORWARD -R 'RAHAM $EANE ) AM ONLY HALF ENGINEER ;HAS AN ENGINEERING QUALIlCATION= BUT WHAT CAME TO MIND IS A RECOLLECTION OF ANOTHER GREAT MAN %DGAR 3OMERVILLE WHOSE REGISTRAR ) WAS IN ) REMEMBER WHEN WE WERE DOING #HARNLEY HIP REPLACEMENTS %DGAR 3OMERVILLE WAS IN CONmICT WITH MANY OF HIS COLLEAGUES BECAUSE HE WOULD NOT TAKE OFF THE TROCHANTER ) REMEMBER WE WERE HAVING A PROBLEM WITH A HIP REPLACEMENT AND %DGAR 3OMERVILLE SAID @) HAD BETTER PHONE MY FRIEND *OHN TO SEE WHATS WRONG (E PHONED *OHN #HARNLEY AND OF COURSE YOU ONLY HEAR ONE SIDE OF THE CONVERSATION (E WOULD BE HOLDING THE 8 RAY IN
#HARNLEY AND &ERREIRA #HARNLEYS TECHNIQUE FOR TRANSPLANTATION OF THE GREATER TROCHANTER IS REPRESENTED THERE IN &IGURES n
7ROBLEWSKI ET AL ; 4ABLE = SUGGEST THAT THE MEDIALIZED CUP POSITION CONTRIBUTED TO BOTH THE LOW AND HIGH WEAR GROUPS WITH A P VALUE OF 3EE ALSO FOR EXAMPLE 0ERKA ET AL
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HIS HAND AND HE WOULD DESCRIBE IT ALL THEN CAME THE OBVIOUS PAUSE AND QUITE CLEARLY THE QUESTION THAT CAME BACK FROM *OHN #HARNLEY WAS @$ID YOU TAKE THE TROCHANTER OFF AND %DGAR 3OMERVILLE WOULD REPLY @/F COURSE NOT ) NEVER TAKE THE TROCHANTER OFF 4HE END OF THE CONVERSATION WAS ALWAYS @9OU KNOW WHY YOU ARE HAVING A PROBLEM THEN ,ETTIN "UT THAT WAS A QUESTION OF HIS APPROACH NOT THE MECHANICAL NOTION WHICH ) WAS HOPING THE ENGINEERS MIGHT HAVE $EANE 4HE MECHANICAL NOTION IS CERTAINLY TRUE THE PRACTICALITIES OF IT WERE DIFFERENT !NOTHER RECOLLECTION OF MINE WAS FROM A VISIT TO 7RIGHTINGTON /NE THING THAT ALWAYS PUZZLED ME WAS THAT THE LABORATORY WHICH HAD ALL THE VARIOUS TEST RIGS THERE WERE MORE TEST RIGS ON HOW TO REATTACH THE GREATER TROCHANTER THAN FOR ANYTHING ELSE 4HAT ALWAYS CONCERNED ME %VERYTHING ELSE WAS A SINGLE TECHNIQUE BUT FROM A PRACTICAL POINT OF VIEW THE TROCHANTER WAS OBVIOUSLY CAUSING QUITE A BIT OF TROUBLE ,ETTIN 4HAT REMINDS ME OF A "/! MEETING WHEN *OHN #HARNLEY WAS READING A PAPER ) THINK ON HIS LATEST TECHNIQUE FOR lXING THE GREATER TROCHANTER BACK WHICH ) AM SURE -IKE 7ROBLEWSKI MUST ADMIT DID SOMETIMES PROVE TO BE DIFlCULT AND A SENIOR REGISTRAR BY THE NAME OF #HRIS #OLTON GOT UP AND WAS
3EE NOTE 0ROFESSOR -IKE 7ROBLEWSKI WROTE @4HE HISTORY OF TROCHANTERIC OSTEOTOMY IN 4(! IS WELL DOCUMENTED ;7ROBLEWSKI n= .OTE ON DRAFT TRANSCRIPT *UNE
0ROFESSOR -IKE 7ROBLEWSKI WROTE @6ISITORS TO 3IR *OHN #HARNLEY -ICHAEL &REEMAN -AY !LAN 3WANSON -AY +EN -C+EE !UGUST !LAN ,ETTIN !PRIL *OHN 3CALES -AY h'INGERv 7ILSON -AY 3IR 2OBERT *ONES ,IVERPOOL VISITED 7RIGHTINGTON (OSPITAL ON /CTOBER .OTE ON DRAFT TRANSCRIPT *UNE ! COPY OF A PAGE FROM OF THE 7RIGHTINGTON (OSPITALS VISITORS REGISTER WILL BE DEPOSITED ALONG WITH OTHER RECORDS OF THIS MEETING IN !RCHIVES AND -ANUSCRIPTS 7ELLCOME ,IBRARY ,ONDON -R -IKE 7ILSON WROTE @)VE CHECKED MY FATHERS DIARY FOR -AY WHEN HE WENT UP TO 7RIGHTINGTON ) ENCLOSE THE FOLLOWING EXTRACTS hTH -AY 7ENT UP TO VISIT *OHN #HARNLEY TODAY DRIVEN BY *OHN 3CALES ;*OHN WAS NOTORIOUS FOR HIS DRIVING TECHNIQUE= *UST AFTER DOING MPH DOWN A HILL WE HAD A mAT TYREv hTH -AY 5SUAL SIX ARTHROPLASTIES IN THE DAY ! FEW MORE NEW GIMMICKS (E ;*OHN #HARNLEY= HAS A GOOD WAY OF BRINGING THE FAT TOGETHER WITH TENSION SUTURES AND SPONGE PROTECTORS FOR THE SKIN AND A VERY NEAT WAY OF USING THE STOCKINETTE AS A DRESSINGv % MAIL TO -RS ,OIS 2EYNOLDS /CTOBER
3EE NOTE &OR DETAILS OF THE DIFFERENT APPROACHES TO THE TROCHANTER SEE LINKS FROM WWWWHEELESSONLINE COMORTHOMODIlED?HARDINGE?ANTEROLATERAL?APPROACH?TO?THE?HIP VISITED *ULY
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GREETED IN ABSOLUTE SILENCE WHEN HE SAID @7HY DO YOU WANT TO MAKE AN EASY OPERATION DIFlCULT 4HERE WAS ABSOLUTE SILENCE 3WEETNAM 4HE LAST FEW CONTRIBUTIONS ) THINK ARE PRETTY FUNDAMENTAL 7HAT IS THIS BUSINESS OF REMOVING THE GREATER TROCHANTER ) WENT TO SEE 3IR *OHN OPERATE AND ) CAME BACK TO ,ONDON AND ) DID HIS OPERATION AND ) ALWAYS TOOK THE GREATER TROCHANTER OFF ) WENT TO GREAT PAINS TO PUT THE GREATER TROCHANTER BACK EXACTLY WHERE IT HAD COME FROM BECAUSE THAT IS WHAT ) THOUGHT ) HAD BEEN TAUGHT .OW ) HAVE SEEN SPECIMENS FROM ) THINK HIS TEST RIG TESTING THE METHODS OF lXATION AND IT LOOKS TO ME AS THOUGH IT WAS DONE IN THE WAY ) DID IT THAT THE GREATER TROCHANTER WAS PUT ON EXACTLY FROM WHERE IT CAME .OW WE HEAR THAT ITS FUNDAMENTAL THAT THE GREATER TROCHANTER IS PUT SOMEWHERE ELSE ) WOULD LIKE TO HAVE THIS SORTED OUT ) BELIEVE THERE IS A MYTH OUT THERE ABOUT ANY SIGNIlCANT SHIFT IN ITS POSITION ,ETTIN !LAN 3WANSON IS GOING TO SORT IT OUT FOR YOU 3WANSON ) WILL SAY NOTHING ABOUT THE PROBLEMS OF REATTACHING THE GREATER TROCHANTER BUT ) MUST SAY AS AN ENGINEER ) WAS MOST IMPRESSED WHEN ) READ AND RE READ #HARNLEYS ACCOUNT OF THE OPERATION BECAUSE IT DID SEEM TO ME THAT HE WAS DESIGNING A PROCESS OF WHICH THE PROSTHESIS WAS PART AND THE IDEA OF ACCEPTING THAT THE CENTRE OF GRAVITY OF THE BODY IS WHERE IT IS MOVING THE CENTRE OF THE HIP JOINT CLOSER TO THAT TO DECREASE THAT MEDIAL MOMENT ARM AND INCREASING THE LATERAL MOMENT ARM OF THE ABDUCTOR MUSCLES BY MOVING THE GREATER TROCHANTER LATERALLY WHERE YOU REATTACH IT THEREBY REDUCING THE TOTAL LEVEL OF FORCE ON THE HIP JOINT )T MADE EXCELLENT MECHANICAL SENSE 7HETHER IT MAKES BETTER SENSE SURGICALLY OR NOT ) AM NOT COMPETENT TO SAY BUT ) WAS
0ROFESSOR #HRISTOPHER #OLTON WROTE @) RECALL THAT AT A "/! MEETING AT THE 2OYAL &ESTIVAL (ALL n CANT RECALL THE YEAR n THERE WAS A PAPER BY #HARNLEY ON TROCHANTERIC OSTEOTOMY lXATION ) RECALL COMMENTING THAT ALL THESE METHODS OF lXATION WERE lNE AND DANDY BUT THAT IT WAS NOT NECESSARY TO TAKE OFF THE GREATER TROCHANTER IN THE lRST PLACE ) THINK ) COMPLIMENTED HIM ON lNDING AN ELEGANT SOLUTION FOR A PROBLEM OF HIS OWN CREATION 4HAT WENT DOWN LIKE A PORK CHOP AT A BAR MITZVAH n NO WONDER MY CAREER ALMOST SANK WITHOUT TRACE ) DO RECALL -ICHAEL &REEMAN AGREEING WITH ME PUBLICLY % MAIL TO -RS ,OIS 2EYNOLDS /CTOBER 4HE "/! MEETING AT THE 2OYAL &ESTIVAL (ALL WAS HELD n 3EPTEMBER % MAIL FROM $AVID !DAMS #HIEF %XECUTIVE "/! /CTOBER 3EE 0ROCEEDINGS AND 2EPORTS ;*OURNAL OF "ONE AND *OINT 3URGERY &EBRUARY = FREELY AVAILABLE AT WWWJBJSORGUKCGIISSUE?PDFFRONTMATTER?PDF "PDF VISITED .OVEMBER
#HARNLEY AND &ERREIRA 3EE DISCUSSION ON PAGE
#HARNLEY
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IMPRESSED BY WHAT ) SUPPOSE THESE DAYS WOULD BE CALLED HOLISTIC THINKING RATHER THAN @,ETS JUST DESIGN A PROSTHESIS ,ETTIN 4HATS VERY INTERESTING $UNCAN $OWSON YOU HAD BEEN GOING TO SAY MUCH THE SAME ) THINK 9OU WERE SHAKING YOUR HEAD IN THE AFlRMATIVE $OWSON 9ES ) CANNOT MAKE ANY COMMENTS ON THE SURGICAL ASPECTS OF THIS BUT ) AGREE WITH !LAN AND ) HAVE ENJOYED THE LAST FEW MINUTES OF THE DISCUSSION &REEMAN #AN ) SLIGHTLY ENDORSE 2ODNEYS POINT AND READ INTO THE RECORD THE FACT THAT ) THINK THAT THE lRST PERSON TO DO #HARNLEYS OPERATION OUTSIDE 7RIGHTINGTON WAS *OHN 2EAD AT THE ,ONDON ;(OSPITAL= ) AM NOT SURE IF THATS TRUE ) WONDER IF ANYONE CAN IMPROVE ON THAT RECOLLECTION OF MINE !ND THEN TO JUST MAKE A BRIEF CONTRIBUTION TO THE @WHERE DO YOU PUT THINGS ISSUE ) QUITE SEE !LANS POINT THAT ITS A PROCESS AND ITS A RATIONAL PROCESS BUT ) MUST SAY AS A SURGEON ) FEAR ) HAD THE SAME PROBLEMS AS 2ODNEY THAT ) COULDNT ACTUALLY PUT THE TROCHANTER ANYWHERE ELSE EVEN IF ) HAD WANTED TO AND THE IDEA OF MEDIALIZING IT A LOT HAS OCCASIONALLY LED TO THE ODD PROBLEM THAT ) SEEM TO HAVE SEEN BECAUSE YOU HAVE ONLY GOT A MILLIMETRE OR TWO THAT YOU CAN REASONABLY GO HAVENT YOU 7ROBLEWSKI 3ORRY TO TAKE UP SO MUCH TIME ) REFER THOSE UNBELIEVERS TO THE 3WEDISH (IP 2EGISTER TO HAVE A LOOK FOR THEMSELVES AT THE RESULTS ACCORDING TO THE EXPOSURE "UT THE THING THAT FASCINATES ME IS THAT DISCUSSIONS OFTEN END UP ON THE OPINIONS OF TROCHANTERIC OSTEOTOMY ) HAVE NEVER EVER HEARD ANYBODY WHO ADVOCATES TROCHANTERIC OSTEOTOMY ARGUING AGAINST ANOTHER EXPOSURE ) GET THE FEELING THAT THOSE WHO DIDNT HAVE THE PROPER EXPOSURE SOMEHOW FEEL GUILTY THAT THEY ARE MISSING SOMETHING !M ) CORRECT -R *OHN /LDER ) JUST SPEAK AS ONE SURGEON FROM THE SOUTH OF %NGLAND WHO DOES THE CLASSICAL #HARNLEY LOW FRICTION ARTHROPLASTY WITH A TROCHANTERIC OSTEOTOMY !ND WITH MY FOUR AND A HALF YEARS WORKING AS AN ASSISTANT AND COLLEAGUE WITH 3IR *OHN AND FOLLOWING HIS VERY ACCURATE AND DETAILED EXPLANATION TO ME OF HIS THEORY ) VERY MUCH SUPPORT WHAT WAS SAID BY OUR TWO ENGINEERS 3WANSON
,OCATED AT THE 3AHLGRENSKA 5NIVERSITY (OSPITAL 3AHLGRENSKA 'TEBORG THE 3WEDISH NATIONWIDE STUDY HAS BEEN COLLECTING AND ANALYSING DATA PROVIDED ON A VOLUNTARY BASIS ON ALL PRIMARY TOTAL HIP REPLACEMENTS AND REVISIONS PERFORMED SINCE 0ROFESSOR 0ETER (ERBERTS AND !SSOCIATE 0ROFESSOR (ENRIK -ALCHAU DIRECT THE STUDY SUPERVISED BY A BOARD ELECTED BY THE 3WEDISH /RTHOPAEDIC !SSOCIATION 3EE -ALCHAU &OR FURTHER DETAILS SEE WWWJRUORTHOPGUSE VISITED *UNE 4HE "RITISH DEBATE FAVOURING A NATIONAL HIP REGISTRY SUGGESTED THAT OVER TIME THE 3WEDISH REGISTRY REDUCED THE RANGE OF DIFFERENT PROSTHESES IMPLANTED RESULTING IN LOWER REVISION RATES AND IMPROVED SURGICAL TECHNIQUE *ONES
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AND $OWSON TOGETHER WITH 7ROBLEWSKI ) WAS VERY IMPRESSED WITH #HARNLEYS ENGINEERING ARGUMENTS 4HE TROCHANTERIC OSTEOTOMY ) HAVE DONE THROUGHOUT MY CAREER AND NEVER HAD ANY MAJOR PROBLEMS n WELL EVERYBODY HAS THE OCCASIONAL PROBLEM n BUT ) FOUND IT SUCCESSFUL AND YOU DO NEED IT 2EPLYING TO 3IR 2ODNEY IT IS CORRECT THAT YOU DONT PUT THE TROCHANTER BACK EXACTLY WHERE YOU GOT IT FROM THATS PART OF #HARNLEYS CONCEPT ,ETTIN ) SUPPOSE AT THE END OF THE DAY THERE IS LITTLE DIFFERENCE BETWEEN THE PATIENTS WHO HAVE HAD THEIR TROCHANTERS REMOVED AND STUCK BACK LOWER DOWN AND THOSE WHO HAVE NOT ) WOULD BE VERY SURPRISED IF THERE WAS ANY CLINICAL EVIDENCE THAT THE FUNCTIONAL RESULT WAS ANY BETTER $OES ANYBODY KNOW 3TEPHEN )T IS MY RECOLLECTION AND INDEED IN HIS HISTORY OF THE %XETER HIP 2OBIN ,ING HAS WRITTEN THAT HE CONSIDERED THE OFFSET OF THE STEM TO BE VERY IMPORTANT 4HE ORIGINAL MM OFFSET WAS TO INCREASE THE ABDUCTOR POWER BY INCREASING THE LEVER ARM THIS IS ANOTHER WAY OF ACHIEVING THE SAME EFFECT !NOTHER PART OF THE RATIONALE IN THE DESIGN OF THE %XETER HIP WAS THAT IT WAS SPECIlCALLY TO BE IMPLANTED THROUGH THE POSTERIOR APPROACH WHICH WAS COMMONLY USED IN THE SOUTH OF %NGLAND AT THE TIME ;SEE &IGURE = (ARDINGE ) INTRODUCED THE DIRECT LATERAL APPROACH BECAUSE ) HAD SEEN A LOT OF PROBLEMS WITH THE 4OBIN TROCHANTERIC OSTEOTOMY EVEN IF YOU HAVE BEEN TRYING TO RESTORE IT IN THE PROPER POSITION IT WOULD FRAGMENT n THE BONE WAS DISEASED OR WHATEVER n OR THE WIRES WOULD FRACTURE 4HE THING ) THINK PEOPLE ARE MISSING IS THAT YOU NEED TO RESTORE 3HENTONS LINE -OVEMENT OF THE TROCHANTER DISTALLY OR MOVING IT LATERALLY OR GETTING SUPPOSED IMPROVED LEVERAGE BY RE PLACEMENT OF THE TROCHANTER IN SOME EXOTIC POSITION IS A MYTH 4HE FUNDAMENTAL AIM IS TO RESTORE 3HENTONS LINE THATS WHAT YOU DO ,ETTIN )S 7ROBLEWSKI GOING TO SPEAK TO YOU AFTER THIS (ARDINGE ) DONT KNOW YOU JUST HAVE TO HAVE QUITE AN OPEN VIEW 4HE ANTERIOR APPROACH THE 7ATSON *ONES APPROACH ) LOOK UPON AS THE CAT BURGLARS APPROACH TO THE HIP 4HE POSTERIOR APPROACH ) LOOK UPON AS THE TRADEMANS ENTRANCE TO THE HIP JOINT 9OU MUST HAVE THE PATIENT LYING IN THE SUPINE POSITION TO BE ABLE TO PLACE THE IMPLANTS CORRECTLY 3O YOU NEED TROCHANTERIC OSTEOTOMY IF
,ING n
3EE 'LOSSARY PAGE
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT
THERES AN ANATOMICAL DEFORMITY AROUND THE HIP ) WILL BE THE lRST TO SAY THAT YOU MUST USE A TROCHANTERIC OSTEOTOMY IF THERES SOME ABNORMALITY IN THIS CASE BUT IF THIS WAS A PERFECTLY STRAIGHTFORWARD ANATOMICAL CASE THEN WHY TAKE THE TROCHANTER OFF ,ETTIN ) THINK THAT WAS THE POINT THAT #HRIS #OLTON WAS MAKING ALL THOSE YEARS AGO +EITH WHAT APPROACH DO YOU USE ) OUGHT TO KNOW BECAUSE YOU RECENTLY REPLACED MY HIP 4UCKER 9ES YOU SHOULD ) CONTINUE USING +EN -C+EES APPROACH WITH SOME MODIlCATIONS +EN ALWAYS THOUGHT THAT THE ANTEROLATERAL APPROACH WOULD CAUSE FEWER DISLOCATIONS ,ETTIN "UT ITS NOT +EVIN (ARDINGES APPROACH 4UCKER !LAN WHEN DID THE LONG POSTERIOR LIP COME IN FROM 7RIGHTINGTON "ECAUSE ) THINK THATS PART OF THE HISTORY ,ETTIN ) CANT ANSWER THAT 7HAT ABOUT -IKE 7ROBLEWSKI 7ROBLEWSKI 4HE LONG POSTERIOR WALL #HARNLEY CUP WAS INTRODUCED IN )T WAS BROUGHT IN TO PACIFY SOME 53 ORTHOPAEDIC SURGEONS WHO WERE WORRIED ABOUT THE DISLOCATION OF THE HIP )N FACT FOR THE RECORD IF ) MAY LOOKING AT PRIMARY ,&!S OVER THE PAST YEARS THERE WERE ONLY REVISIONS FOR DISLOCATION PER CENT 4UCKER !LAN IF ) COULD JUST GO BACK TO THE QUESTION ABOUT DISLOCATION WHICH WE HAVENT DISCUSSED IN A BIG WAY $ISLOCATION HAS BEEN PART OF THE HISTORY OF HIP REPLACEMENT AND FORMED A LOT OF THE DISCUSSION IN THE LAST YEARS )T HAS BEEN PERCEIVED THAT THE POSTERIOR APPROACH IS THE ONE WITH THE GREATER DISLOCATION RATE COMPARED WITH THE ANTEROLATERAL APPROACH ,ETTIN 7E INTEND TO HAVE AS FAR AS ) CAN MAKE IT HAPPEN A SECTION AFTER TEA ON COMPLICATIONS AND DISLOCATION WOULD BE ONE OF THEM BUT THERES NO REASON WHY WE CANT PURSUE THAT PARTICULAR TOPIC NOW &OR THE RECORD WE HAVE GOT THE REASON FOR PEOPLE ADOPTING DIFFERENT APPROACHES +EVIN HAS EXPLAINED QUITE CLEARLY WHY HE THINKS HIS APPROACH IS SATISFACTORY -IKE 7ROBLEWSKI HAS FOCUSED ON THE WELL KNOWN #HARNLEY APPROACH AND ITS VERY INTERESTING THAT THE ENGINEERS HAVE
3EE 'LOSSARY PAGE 3EE ALSO &IGURE PAGE
3EE NOTE
(IGUCHI ET AL
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ACTUALLY SAID @4HIS IS SENSIBLE ALTHOUGH ) THINK THE EXPERIENCE OF SOME SURGEONS IS THAT IT MAKES AN EASY OPERATION DIFlCULT "UT ITS INTERESTING THAT WE HAVE GOT IT FOR THE RECORDS BECAUSE THERE WAS A CONSIDERABLE DEBATE EARLY ON ) DONT KNOW WHETHER WE HAVE ANY CURRENT SURGEONS HERE EVERYBODY IS RETIRED EXCEPT +EITH ;4UCKER= WHO IS THE ONLY ONE HERE STILL DOING JOINT REPLACEMENTS 4HE MORE PRECISE DETAILS OF THE APPROACHES PERHAPS ITS MY FAULT THAT WE PUT BACK THE SHOWING OF THE lLM BECAUSE ) THOUGHT THAT YOU WOULD ALL HAVE A LOT MORE TO SAY BUT YOU HAVE ALL BEEN TERRIBLY GOOD AND NOBODY HAS SPOKEN FOR MORE THAN FOUR MINUTES AND NOT EVERYBODY HAS SPOKEN "EFORE WE GO TO TEA ARE THERE ANY OTHER PEOPLE WHO WANT TO COME INTO THE DISCUSSION ON ANY OF THE ASPECTS -R 'EOFF +ING ) WAS QUITE UNSURE WHY ) WAS INVITED TO THIS MEETING TO BE AMONG THE ORTHOPAEDIC GREAT AND GOOD OF THE COUNTRY AND IT NOW OCCURS TO ME THAT ) AM SOMETHING OF A LIVING FOSSIL )N ) HAD A ROAD TRAFlC ACCIDENT AND WAS ADMITTED TO THE .ORFOLK AND .ORWICH (OSPITAL UNDER +EN -C+EE AND AT THE TIME *OHN 7ATSON &ARRAR WAS HIS SENIOR REGISTRAR (E PUT A +ÓNTSCHER NAIL IN MY LEFT FEMUR WHICH ) STILL HAVE 3OME lVE YEARS LATER ) WAS WORKING AS A TECHNICIAN IN THE ORTHOPAEDIC THEATRE WITH +EN -C+EE AND *OHN 7ATSON &ARRAR 4HERE ARE TWO THINGS THAT ) CAN RECALL ONE MAY BE SLIGHTLY APOCRYPHAL ABOUT THE DESIGN OF THE -C+EE HIP (E DIDNT JUST TURN TO ENGINEERING HE ALSO TURNED TO TENTH AND ELEVENTH CENTURY ARCHITECTURE (E COPIED THE mYING BUTTRESSES OF .ORWICH #ATHEDRAL FOR THE SHAPE OF THE STEM OF HIS PROSTHESIS ;SEE &IGURE PAGE = ) WAS ALSO A @&RANK AT ONE STAGE IN THAT ) WAS UNDER THE COVERS MANIPULATING THE HIP $URING PART OF MY CAREER ) ALSO REMEMBER THAT 7ATSON &ARRAR HAD A UNIQUE OPERATING FACILITY IN THAT HE HAD VERY STRANGE LITTLE lNGERS WITH WHICH HE COULD POKE THE CEMENT DOWN THE FEMORAL STEM 4O CONTINUE MY TIMELINE AS A BIT OF AN ANTIQUE ) ACTUALLY HAD A HIP REPLACEMENT IN -AY ;= THROUGH THE POSTERIOR APPROACH DESPITE THE FACT IT WAS DONE IN .ORWICH ) THINK IT WAS THE "IRMINGHAM RESURFACING NOTHING TOO SERIOUS
! DIGITAL COPY OF THE SILENT lLM SHOWN ON -ARCH WILL BE DEPOSITED ALONG WITH THE OTHER RECORDS OF THE MEETING IN !RCHIVES AND -ANUSCRIPTS 7ELLCOME ,IBRARY ,ONDON
! +ÓNTSCHER NAIL OR INTRAMEDULLARY ROD WAS IN FREQUENT USE UNTIL THE S AND IS A HOLLOW ROD OF VARYING LENGTHS AND DIAMETERS SECURED TO THE MEDULLA 3EE 'LOSSARY PAGES n
0ROFESSOR -IKE 7ROBLEWSKI WROTE @4HE mYING BUTTRESS WAS THE BASIS OF EXTRA ARTICULAR .ORWICH HIP ARTHRODESIS ;"RITTAIN ,ANGSTON = .OTE ON DRAFT TRANSCRIPT *UNE
3EE !PPENDIX PAGE
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,ETTIN ) DID ASK -IKE &REEMAN WHY HIS DOUBLE CUP WASNT AWFULLY WELL RECEIVED WHEREAS -C-INNS SEEMED TO BE ) HEAR -C-INN SOLD HIS lRM FOR a MILLION ) DONT KNOW WHETHER THATS TRUE OR NOT &REEMAN 9ES ) AM AFRAID ) DIDNT SELL ANYTHING FOR a MILLION BUT THERE YOU ARE 4HE OPERATION OF RESURFACING WITH POLYETHYLENE FAILED IN EVERYBODYS HANDS ) THINK INCLUDING DRAMATICALLY IN MY OWN AND ) THINK THAT WAS MAINLY BECAUSE OF THE PRODUCTION OF POLYETHYLENE DEBRIS PLUS A LEVEL OF SURGICAL EXPERIENCE WHICH WASNT WHAT IT IS NOW 4HE POLYETHYLENE DEBRIS ) THINK WAS PARTLY DUE TO THE SIZE OF THE HEAD n A POINT THAT #HARNLEY MADE TO ME AND HE WAS ABSOLUTELY RIGHT n BUT ) SUSPECT OVERWHELMINGLY THAT THE POLYETHYLENE WAS NOT 5(-70% BECAUSE IT HAD BEEN STERILIZED BY GAMMA IRRADIATION IN AIR AND THAT THIS WAS THE SIGNIlCANT FACT $EREK -C-INNS OPERATION IS PLAINLY A SUCCESS AND IT HAS THE GREAT ATTRACTION THAT A COBALTnCHROME ACETABULUM IS THINNER SO YOU GET MORE SPACE FOR THE TWO COMPONENTS 4HE ENGINEERING AS !LAN HAS SAID HAS IMPROVED SO THE THING WORKS FROM A MECHANICAL POINT OF VIEW ) HAVE TO SAY THAT ) DONT THINK WE KNOW WHAT THE LONG TERM EFFECTS WILL BE IN YOUNGER PEOPLE OF PERSISTENTLY ELEVATED COBALT AND CHROME LEVELS IN THE BLOOD )T IS NOW KNOWN THAT THOSE IONS OF ALL THE TRANSITIONAL METALS ARE $.! SPLITTERS WHICH THEY SHARE WITH 8 RAYS AND IF YOU TALK TO THE FERTILITY DOCTORS THEY ARE A LITTLE BIT CONCERNED ABOUT IT SO WE ARE GOING DOWN INTO AN AGE GROUP WHERE THIS IS POTENTIALLY A PROBLEM 7HETHER IT WILL BE GOODNESS ONLY KNOWS "UT ) THINK THAT ANSWERS YOUR QUESTION #HAIRMAN DOESNT IT ,ETTIN ) THINK SO )T REMINDS ME OF A QUESTION THAT ) WAS GOING TO PUT EARLIER ABOUT PATENTING THESE DEVICES ) THINK ,ADY #HARNLEY THAT *OHN NEVER PATENTED THE ORIGINAL HIP JOINT ;.O= BUT HE DID SUBSEQUENTLY ;9ES= !ND WHAT ABOUT +EN -C+EE $OES ANYBODY KNOW WHETHER HE DID
-IDLAND -EDICAL 4ECHNOLOGIES ,TD NOW TRADES AS 3MITH .EPHEW "ROMSGROVE ,TD
&REEMAN ET AL #AMERON AND &REEMAN &REEMAN AND "ROWN &REEMAN A ;)SSUE OF #LINICAL /RTHOPAEDICS AND 2ELATED 2ESEARCH CONTAINS ARTICLES BY ALL THE SURGEONS WHO HAD DEVELOPED RESURFACING ARTHROPLASTIES= &REEMAN ET AL &REEMAN AND "RADLEY ,EVACK ET AL (ERNANDEZ 6AQUERO #OTELLA ET AL
-C-INN ET AL 3EE ALSO -C-INN AND $ANIEL $ANIEL ET AL -C-INN ET AL -C-INN 'RIGORIS ET AL 2OBERTS ET AL
#OBB AND 3CHMALZREID
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(EYWOOD 7ADDINGTON *UST A COUPLE OF POINTS THERE ) DONT THINK HE EVER PATENTED IT THAT ) AM AWARE OF "UT HE DID MAKE SEVERAL THINGS CLEAR TO ME DURING THE S AT A MEETING OF THE "/! ) THINK IN /XFORD /NE POINT ABOUT METAL SENSITIVITY HE DID NOT ACCEPT THAT THAT WAS A PROBLEM ) DONT MEAN IN THE LONGER TERM THAT -IKE &REEMAN WAS REFERRING TO ) DONT THINK HE DIRECTLY COMMENTED ON THAT BUT AS FAR AS ACTUAL METAL SENSITIVITY COBALT AND CHROME SENSITIVITY HE DISMISSED THIS AS A PROBLEM 4HE OTHER THING THAT ) THINK IS IMPORTANT TO SAY IS THAT HIS PAPER IN THE DElNITIVE PAPER PAID TRIBUTE TO *OHN #HARNLEY FOR THE INTRODUCTION OF METHYLMETHACRYLATE AND ALSO TO *OHN 3CALES FOR ADVISING -C+EE THAT CHROMEnCOBALT WAS THE IDEAL METAL TO BE USED 0ROFESSOR 3IR #HRISTOPHER "OOTH ) AM A COMPLETE OUTSIDER BUT LISTENING TO THIS DISCUSSION AS A HISTORIAN OF THE TWENTIETH CENTURY ONE HAS TO WONDER WHETHER YOU ARE GIVING THE IMPRESSION THAT THIS WAS ALL HAPPENING IN AN INTERNATIONAL VACUUM 7HAT IS EXTRAORDINARY ABOUT MEDICAL EQUIPMENT AND PROSTHESES AND SO ON IS THAT THE 53 MANUFACTURERS ALMOST ALWAYS MOVED IN ON ANYBODYS INVENTION TOOK THEM OVER AND THEN THE 53 MANUFACTURERS BECOME THE PEOPLE THAT DID IT )S THAT WHAT HAPPENED HERE /R WAS IT PRESERVED IN %NGLAND ,ETTIN ) THINK ) MIGHT BE ABLE TO THROW SOME LIGHT ON THIS BECAUSE THE CEMENT n AT LEAST ) THINK THAT 3IMPLEX # WAS THE ORIGINAL BONE CEMENT n WAS MANUFACTURED IN A BACK STREET IN 3TAMFORD (ILL IN ,ONDON AND THE OWNER OF THE lRM WAS AN !MERICAN WHO HAPPENED TO BE A PATIENT OF MINE WHICH IS HOW ) KNOW THE STORY SOON AFTER ) GOT ON THE STAFF AT "ARTS !ND THERE ARE PEOPLE HERE WHO WILL KNOW MUCH MORE ABOUT THE COMPOSITION BUT THERE WERE INHIBITORS IN THE COMPOUNDS THAT HAD TO BE MIXED TOGETHER AND THIS COMPANY .ORTH (ILL 0LASTICS IT WAS CALLED HAD THE PATENT ON THESE INHIBITORS AND THE 53 &$! 5NITED 3TATES &OOD AND $RUG !DMINISTRATION WOULD NOT GRANT PERMISSION FOR THE CEMENT TO BE USED 3O THE !MERICANS FELL QUITE BEHIND AND THE PATIENTS WERE COMING OVER TO THIS COUNTRY FOR HIP REPLACEMENTS *ILL #HARNLEY IS SHAKING HER HEAD
-R -IKE (EYWOOD 7ADDINGTON WROTE @)T WAS A "/! MEETING WHICH ) THINK WAS IN /XFORD AT WHICH THE QUESTION OF LATE POSSIBLY NEOPLASTIC EFFECTS OF POLYETHYLENE DEBRIS WAS DISCUSSED .OTE ON DRAFT TRANSCRIPT *UNE
-C+EE AND 7ATSON &ARRAR
0HILLIPS ET AL
)N .ORTH (ILL 0LASTICS WERE LOCATED AT 'RAYLING 2OAD ,ONDON . ;-C+EE AND 7ATSON &ARRAR = 3EE 0HILLIPS ET AL FOR DISCUSSION OF ITS CARDIOVASCULAR EFFECTS &OR THE PROPERTIES OF ACRYLIC BONE CEMENT SEE NOTE
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT
4HIS IRRITATED THE !MERICANS NO END AND ) THINK THE lRST PERSON ACTUALLY TO DO A TOTAL HIP REPLACEMENT IN THE 53 WAS (ARLAN !MSTUTZ WHO HAD WORKED FOR A YEAR AT THE 2./( ;3TANMORE= AND WENT BACK TO SPECIAL SURGERY IN .EW 9ORK WITH A -C+EE PROSTHESIS IN HIS POCKET ALONG WITH SOME CEMENT AND THE &$! GAVE HIM PERMISSION TO DO A ONE OFF OPERATION IN )N THE END OF COURSE THE !MERICANS BOUGHT OUT THIS COMPANY BUT THE OWNER KNEW THAT IF HE GAVE THE FORMULA TO THE 53 &$! IT WOULD BE LEAKED AND HE COULD NOT AFFORD TO DEFEND HIS PATENT AGAINST THE BIG !MERICAN COMPANIES (ARDINGE 4HE SURGEONS WHO HAD BEEN TO "RITAIN TO TRAIN LIKE (ARLAN !MSTUTZ AND *OE $UPONT WENT BACK TO THE 53 AND THEY HAD A LICENCE TO USE THE CEMENT ON A LIMITED BASIS *OE $UPONT WHO WORKED AT 7RIGHTINGTON WENT BACK TO 0HOENIX !RIZONA AND HAD PATIENTS UNDER TREATMENT PRE OPERATIVE ASSESSMENT OPERATED AND IN REHABILITATION (E WAS IN THE BIG TIME (E HAD AN OVERDRAFT WHEN HE WENT BACK TO 0HOENIX AND LATER HE SENT A #HRISTMAS CARD TO A CHAP HE KNEW 7ALTER 'EORGE ALSO FROM 0HOENIX WHICH SAID @#OME QUICKLY 7ALTER THE END IS NOT IN SIGHT 3O THIS WAS ANSWERING THE !MERICAN DREAM 4ALKING ABOUT PATENTS THE OTHER THING THAT HAPPENED IN WAS THAT THE lRM #HARLES "ECHTOL DISCOVERED THAT THE #HARNLEY IMPLANT WAS NOT PATENTED SO THATS WHEN THEY BROUGHT OUT THE #HARNLEY TYPE SO IT WAS AVAILABLE TO 53 ORTHOPAEDIC SURGEONS IN THEIR TECHNICAL STAND 4HATS WHEN *OHN #HARNLEY REALIZED HE COULD NO LONGER CONTROL IT (E HAD BEEN VERY PROPER AND TRIED TO CONTROL IT 3O AFTER THAT IT WAS THROWN OPEN AND YOU COULD GET THE INSTRUMENTS AND START OPERATING ,ETTIN #OULD YOU SAY ANYTHING ABOUT THE MANUFACTURERS POINT OF VIEW 0HYLLIS BECAUSE ) SUPPOSE THEY DIDNT WANT TO MANUFACTURE STUFF THAT WAS GOING TO BE COPIED (AMPSON 4HATS QUITE RIGHT TOO *OHN 3CALES HAD ALL THE 3TANMORE IMPLANTS PATENTED BY THE .ATIONAL 2ESEARCH $EVELOPMENT #ORPORATION .2$# AND ANYBODY WHO WANTED TO MAKE 3TANMORE PROSTHESES HAD TO GO TO *OHN 3CALES AT 2./( 3TANMORE AND NOBODY ELSE MADE THEM UNTIL THE LICENCES LAPSED "Y THIS TIME OUR COMPANY HAD BEEN SOLD TO "IOMET :IMMER /RTHOPAEDIC USED TO PAY ROYALTIES TO THE .2$# AND PART OF THE TOTAL AMOUNT WENT BACK TO THE 2./(
&OR DETAILS OF #HARNLEYS DEVELOPMENT WORK SEE 'OMEZ AND -ORCUENDE A AND B 3EE ALSO &OREMAN 0ECK $ORR ET AL "ECHTOL
3EE NOTE
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,ETTIN )T DIDNT GO TO THE INDIVIDUAL AS IT WOULD NOW $OWSON #HAIRMAN JUST ONE OR TWO BRIEF COMMENTS 9OU MENTIONED EARLIER AND REFERENCE HAS BEEN MADE IN THE DISCUSSION TO A NUMBER OF SIGNIlCANT MEETINGS OF THE "/! AND OTHER ORGANIZATIONS ) WOULD LIKE TO REMIND PEOPLE THAT IN THE ENGINEERING lELD A JOINT MEETING BETWEEN THE )NSTITUTION OF -ECHANICAL %NGINEERS )-ECH% AND THE "/! WAS HELD IN ) THINK THAT THIS WAS A LANDMARK IN MANY WAYS AND *OHN #HARNLEY WAS ON THE PLANNING COMMITTEE OF FOUR PEOPLE AS WAS *OHN 3CALES THEY WERE THE TWO REPRESENTATIVES FROM THE "/! 7HEN ) LOOK THROUGH THE LIST OF CONTRIBUTORS IT READS LIKE A 7HOS 7HO OF JOINT REPLACEMENT HISTORY ON BOTH THE ENGINEERING AND ON THE SURGICAL SIDE -IKE &REEMAN RAISED A POINT EARLIER AS DID ) THINK !LAN 3WANSON WHICH MADE ME WONDER ABOUT THE WAY IN WHICH POLYETHYLENE REPLACED 04&% SINCE IT APPEARED THAT THERE WAS SOME KNOWLEDGE AVAILABLE AT THAT TIME OF THE ILL EFFECTS OF RADIATION )T WAS A DIFFERENT ERA OF INFORMATION TECHNOLOGY "ECAUSE IN THE SAME WAY AS WHEN *OHN #HARNLEY WAS INTRODUCING 04&% ENGINEERS KNEW VERY WELL THAT IT WAS A TERRIBLE MATERIAL FOR WEAR )T HAD THE LOWEST KNOWN COEFlCIENT OF FRICTION FOR MAN MADE MATERIALS BUT MANUFACTURERS STEERED AWAY FROM IT AS A BEARING MATERIAL IN BULK FORM ) COULD NEVER UNDERSTAND QUITE WHAT PERSUADED *OHN TO GO DOWN THAT ROUTE 04&% NEARLY ALWAYS HAD TO BE STRENGTHENED AS A BEARING MATERIAL FOR HIGH LOADS )T HAD TO BE IMPREGNATED INTO METAL OR INVOLVED IN SOME OTHER WAY TO BE AN EFFECTIVE BEARING MATERIAL ) THINK THIS POINT WAS IMPORTANT AT THAT STAGE ALONGSIDE THE IRRADIATION ISSUE !ND lNALLY JUST TO SAY SOMETHING ABOUT THE DISCUSSION OF SURFACE REPLACEMENT JOINTS WHICH SEEM TO BE ATTRACTING SO MUCH ATTENTION AT THE PRESENT STAGE IN METAL ON METAL FORM &ROM THE ENGINEERING POINT OF VIEW IT IS VERY INTERESTING THAT THEY WOULD ALL HAVE DIFlCULTY WITH SMALL DIAMETERS BECAUSE UP TO ABOUT MM OR MM DIAMETER THEY ARE ALWAYS RUBBING ONE MATERIAL ON THE OTHER ALL THE TIME THEY ARE RUBBING BEARINGS 7HEN YOU GO TO A LARGER DIAMETER MM AND CERTAINLY UP TO MM OR SO THEN YOU START TO GET SOME VERY IMPORTANT CONTRIBUTIONS TO LOAD SUPPORT FROM THE LUBRICATION WHICH YOU DO NOT GET AT LOWER DIAMETERS 4HIS IS HAVING A BIG EFFECT ON THE RESURGENCE OF INTEREST IN A LARGE DIAMETER METAL ON METAL AND B RESURFACING APPROACHES -UCH OF THE CURRENT WORK IS AS YET THEORETICAL AND EXPERIMENTAL AND HAS OF COURSE TO BE SUBSTANTIATED IN PRACTICE /NE OF THE DIFlCULTIES IS THAT WE ARE GOING TO HAVE TO WAIT SO VERY LONG BEFORE WE SEE THE OUTCOME OF CLINICAL PERFORMANCE OF THESE VERY LOW WEAR RATE JOINT REPLACEMENTS
3EE NOTE AND DISCUSSION ON PAGES AND
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT
3WEETNAM ) WANTED TO GIVE 3IR #HRISTOPHER ;"OOTH= AN ANSWER TO HIS QUESTION (E ASKED WHETHER ALL THIS WORK WAS BEING CARRIED OUT IN AN INTERNATIONAL VACUUM ,ET US GO FORTH FROM THIS MEETING KNOWING THAT IT WAS 4HIS WAS A "RITISH INNOVATIVE IDEA n "RITISH SURGEONS MATERIALS SCIENTISTS ENGINEERS n CONCEIVED THE PRACTICAL CONCEPT OF TOTAL HIP REPLACEMENT 7HAT YOU ARE TALKING ABOUT n WHY IT ;CONTROL OF THE INDUSTRY= EVENTUALLY MOVED TO THE 53 LATER n OCCURS AFTER THE EVENTS THAT WE ARE CONSIDERING TODAY 4HIS WAS A "RITISH INITIATIVE CARRIED FORWARD WITH GREAT SUCCESS 3O THAT IS THE ANSWER "OOTH 4HANK YOU VERY MUCH &REEMAN ) AM VERY MOVED BY 2ODNEYS VIEW BUT ) DO NOT THINK WE SHOULD ABSOLUTELY IGNORE THE CONTRIBUTION OF OTHERS )M NOT QUITE SURE WHAT THIS MEETING TODAY IS ABOUT 5+ JOINT REPLACEMENT OR HIP REPLACEMENT ,ETTIN "ASICALLY IT IS TOTAL HIP REPLACEMENT 5+ )T IS REALLY 2ODNEYS VIEW OF LIFE ) THINK &REEMAN )T IS PERFECTLY ALL RIGHT THAT WE MENTION -AURICE -ÓLLER AND SOME OF THESE OTHER PEOPLE ;9ES= 4HE SECOND QUESTION IS THAT ALTHOUGH WE ARE WONDERFUL TO HAVE INVENTED THIS ;TOTAL HIP REPLACEMENT= WE MADE A TERRIBLE INDUSTRIAL DISASTER !S AN INDUSTRY IT IS ENTIRELY DOMINATED BY THE 53 ) WONDER WHETHER ANYONE WOULD LIKE TO COMMENT ON THAT PART OF THE SUBJECT ,ETTIN ) DONT KNOW )T IS CERTAINLY DOMINATED BY THE 53 THERE IS ONLY ONE "RITISH COMPANY NOW IN THE BUSINESS AND THAT IS 3MITH AND .EPHEW ISNT IT -INUSCULE "OOTH "UT THEY ARE ONLY JOKINGLY %NGLISH )TS THE BUSINESS REALLY n THE ONLY ONES IN THE BUSINESS ARE !MERICANS
$R &RANCIS .EARY WROTE @)T WAS REALLY MANUFACTURING CONTROL THAT MOVED TO THE 53 WHEN THE SMALL 5+ COMPANIES WERE MOSTLY BOUGHT OUT BY THE 53 GIANTS :IMMER $E0UY LATER *OHNSON *OHNSON "IOMET (OWMEDICA LATER 3TRYKER (OWMEDICA AND 3MITH AND .EPHEW WHICH RETAINS A "RITISH CONNECTION % MAIL TO -RS ,OIS 2EYNOLDS /CTOBER
-AURICE -ÓLLER OF "ERN INTRODUCED A FEMORAL PROSTHESIS THAT HAD A HIGH RATE OF STEM BREAKAGES AND WAS FABRICATED FROM CAST COBALTnCHROME ALLOY WITH A CURVED SHAPE -ÓLLERS LATER STEM HAD A MM HEAD AND WAS CALLED THE #HARNLEY -ÓLLER PROSTHESIS +LENERMAN 3EE ALSO 3CHMALZRIED ET AL
&OREMAN 0ECK
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,ETTIN "UT THEY CANT GET THE &$! TO APPROVE THE -C-INN ) DONT WANT TO GET INTO THAT BUT 3MITH AND .EPHEWS HEAD OFlCE IS IN THE 5+ BUT THE REAL ACTION IS IN THE 53 +IRKUP )N THE DISPOSABLE SURGICAL BLADE WAS INTRODUCED IN THE 53 7HEN THE PATENT RAN OUT IN OR THEREABOUTS 3WANN -ORTON OF 3HEFlELD TOOK IT OVER !ND NOW 3WANN -ORTON IS WORLDWIDE THE BIGGEST MANUFACTURER OF BLADES EVEN SUPPLYING LARGE AREAS OF THE 53 (EYWOOD 7ADDINGTON )N RESPONSE TO THE COMMENTS ON THE "RITISH CONTRIBUTION ) HAVE TO SAY THAT WITH THE RECENT PROGRESS SINCE THEN IN LITIGATION AND POLITICS ) VERY MUCH DOUBT WHETHER #HARNLEY AND -C+EE WOULD HAVE SUCCEEDED IN THIS DAY AND AGE IN THEIR ENDEAVOURS IT TOOK SO LONG 7E OWE A GREAT DEAL NOT ONLY TO THEIR TENACITY BUT TO THE POLITICAL AND SOCIAL SIDE OF THE PREVAILING CLIMATE +UNZRU ! QUESTION CONCERNS THE APPROACH TO CHILDRENS HIPS BECAUSE MANY OF THEM WERE QUITE DEFORMED 'EORGE !RDEN ALWAYS TOOK OFF THE TROCHANTER TO DO HIS HIP REPLACEMENTS HIS CUSTOM BUILT HIPS BUT YOU ;3WANN= DIDNT 7OULD YOU LIKE TO TALK ABOUT YOUR APPROACH PLEASE 3WANN 4HE APPROACH ) USED TO THESE HIPS WHICH WERE ALL ANATOMICALLY DEFORMED VARIED BUT WAS BASICALLY THE LATERAL APPROACH 4HAT WAS MY FAVOURITE /CCASIONALLY IT WAS NECESSARY TO REMOVE THE TROCHANTER JUST FROM THE TECHNICAL APPROACH POINT OF VIEW NOT FROM ANY OTHER REASON JUST TO GET AT THE JOINT ,ETTIN 7ELL STOP NOW FOR TEA ) HOPE THE lLMS AND VIDEOS WILL BE READY TO VIEW AT YOUR LEISURE 4HANK YOU YOUVE ALL BEEN VERY GOOD &RANCIS .EARY WILL START THE POST TEA SESSION FROM A HISTORICAL POINT OF VIEW $R &RANCIS .EARY ) WANTED TO SAY A BIT ABOUT THE ROOTS OF THE PROPOSAL OF THIS SEMINAR AND THE RESEARCH WE HAVE BEEN DOING IN -ANCHESTER BECAUSE SOME OF THE PEOPLE HERE MIGHT BE INTERESTED IN SOME OF ITS PRODUCTS 4HIS PROJECT WAS LED BY 0ROFESSOR *OHN 0ICKSTONE AND WAS CALLED @)NNOVATION !SSESSMENT AND (IP 0ROSTHESIS 7E LOOKED AT THE WORK OF 3IR *OHN #HARNLEY ESPECIALLY HIS RELATIONSHIP WITH 4HACKRAY BUT ALSO THE DEVELOPMENT OF THE CLEAN AIR OPERATING
-R !LAN ,ETTIN WROTE @) BELIEVE THAT THE -C-INN HAS SINCE BEEN APPROVED BY THE &$! .OTE ON DRAFT TRANSCRIPT .OVEMBER
3WANN -ORTON FOUNDED IN 3HEFlELD IN MANUFACTURES SURGICAL BLADES SCALPELS AND HANDLES 3EE WWWSWANN MORTONCOM VISITED *UNE
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SYSTEM AND THE RELATIONSHIP WITH (OWORTH !IR #ONDITIONING 7E ALSO CONSIDERED TWO WIDER ISSUES AND THESE WERE PARTICULARLY RELEVANT TO THIS SEMINAR TODAY THE EARLY LOCAL DEVELOPMENT OF 4(2 IN THE lVE CENTRES THAT WE HAVE BEEN DISCUSSING /NE OTHER ISSUE WHICH WE MAY MOVE ON TO LATER ON PERHAPS IS THE ISSUE WE HAVE ALLUDED TO WHY SO MANY DESIGNS OF HIP REPLACEMENTS ARE NOW AVAILABLE AND WHY NOT ONE WON OUT OVER THE YEARS THAT TOTAL HIP REPLACEMENT HAS BEEN AVAILABLE 7HY ARE THERE SO MANY DIFFERENT PROSTHESES ON THE MARKET 6ERY QUICKLY TURNING TO THE BOOK ON THE HISTORY OF HIP REPLACEMENT WRITTEN WITH MY COLLEAGUES *ULIE !NDERSON AND *OHN 0ICKSTONE WHICH WILL BE AVAILABLE NEXT YEAR ) BELIEVE AND A SERIES OF JOURNAL ARTICLES "UT MORE TOPICALLY THERES A NEW EXHIBITION WHICH ) HAVE DONE WITH 3IMON #HAPLIN AT THE 2OYAL #OLLEGE OF 3URGEONS CALLED @(IP (ISTORIES AND WHAT IT DOES IS IT LOOKS AT THE #HARNLEY HIP FROM THE PERSPECTIVE OF THE NURSE THE ENGINEER THE SURGEON THE PATIENT AND THE MANUFACTURER AND LOOKS AT ITS DEVELOPMENT 4HATS ON THE SECOND mOOR OF THE 2OYAL #OLLEGE OF 3URGEONS (UNTERIAN -USEUM IN THE TEMPORARY GALLERY CALLED THE 1VIST 'ALLERY !ND THE OTHER THING THAT ) JUST WANTED BRIEmY TO SAY IS THAT WE ARE ALSO DEVELOPING A PATIENT INFORMATION CENTRE AT 7RIGHTINGTON (OSPITAL WHICH WILL OPEN AT THE END OF THE MONTH ;-ARCH = AND HAS BEEN GENEROUSLY SUPPORTED BY THE *OHN #HARNLEY 4RUST )T WILL USE HISTORY TO EXPLAIN THE RISKS BENElTS AND UNKNOWNS OF JOINT REPLACEMENT SURGERY AND TAKE THE PATIENT FROM INITIAL REFERRAL TO THE HOSPITAL RIGHT THE WAY THROUGH TO SURGERY AND RECOVERY !ND THE PLAN IS TO ALSO OPEN A NEW #HARNLEY -USEUM AT 7RIGHTINGTON SOMETIME LATER IN THE SUMMER ,ETTIN 4HANK YOU VERY MUCH &RANCIS /NE OF THE THEMES OF RESEARCH THAT 3IR #HRISTOPHER ;"OOTH= MENTIONED TO ME OVER TEA WAS THAT THESE INNOVATIONS IN ORTHOPAEDICS AND PROBABLY IN OTHER lELDS TOO HAVE COME NOT FROM ACADEMIC CENTRES BUT FROM PART TIME .(3 CONSULTANTS WORKING IN $ISTRICT 'ENERAL (OSPITALS ) SUPPOSE THIS IS NOT QUITE TRUE OF THE 2OYAL .ATIONAL /RTHOPAEDIC (OSPITAL 2./( AT 3TANMORE ALTHOUGH MANY PEOPLE WOULD REGARD IT AS A
&OR THE BACKGROUND OF THE (OWORTH lRM SEE NOTE
$EVELOPMENT OF THE TOTAL HIP REPLACMENT BEGAN IN .ORWICH BETWEEN n 3TANMORE 7RIGHTINGTON 2EDHILL AND %XETER 3EE NOTE
3EE !NDERSON ET AL FORTHCOMING !NDERSON 0ICKSTONE -ETCALFE AND 0ICKSTONE &OR DETAILS OF THE -ANCHESTER HIP PROJECT SEE WWWYORKACUKRESIHTPROJECTSLHTM VISITED -AY
&OR DETAILS OF THE EXHIBITION SEE WWWHEROACUKUKCULTURE???SPORTARCHIVESRADICAL?SURGERYCFM VISITED *ANUARY
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GENERAL HOSPITAL ) KNOW IT DID HAVE PRETENSIONS AT ONE TIME OF BEING AN ACADEMIC CENTRE BUT ) THINK THIS IS INTERESTING ISNT IT 3IR #HRISTOPHER FELT THAT THIS WAS CERTAINLY SOMETHING THAT SHOULD BE PART OF THE RECORD "UT HAVING SAID THAT ) THINK THE NEXT TOPIC THAT WE PUT DOWN ON PAPER WAS THE QUESTION OF COMPLICATIONS BECAUSE OF COURSE NO OPERATION IN SPITE OF WHAT ONE MIGHT HOPE IS EVER GOING TO BE FREE OF COMPLICATIONS AND ) SUPPOSE WE DID MENTION EARLIER THE QUESTION OF DISLOCATION 4HAT IN SOME WAYS ) THINK GOES WITH THE OPERATIVE TECHNIQUE AND WE MIGHT GO ON TO THAT IN A BIT 4HE lRST THING THAT WE SHOULD ADDRESS IS THE QUESTION OF MECHANICAL FAILURE WHICH WAS SOMETHING THAT HAPPENED EARLY ON BUT PERHAPS AS A RESULT OF THE "3) CONTROLS IS NOT AS COMMON AS IT ONCE WAS 7HAT ABOUT THE ENGINEERS !LAN WOULD YOU LIKE TO SAY ANYTHING ABOUT MECHANICAL FAILURE AND THE DESIGN 7AS THE DESIGN RESPONSIBLE PERHAPS OR WAS IT A QUESTION OF MANUFACTURING OR WHAT 3WANSON ) COULD SAY A LOT OR LITTLE ) SHOULD PREFER THE LATTER AND NO DOUBT YOU WILL TOO ) SUSPECT THAT MOST OF THE MECHANICAL FAILURES IN THE SENSE OF THE THING BREAKING WERE DUE TO THE MANUFACTURE OF THE METAL COMPONENTS ) THINK NOWADAYS PEOPLE JUST DONT MAKE COBALT CHROMIUM ALLOYS WITH THE KIND OF SEGREGATION OF ALLOY ELEMENTS TO GRAIN BOUNDARIES WHICH DID HAPPEN YEARS AGO 4HE COMPOSITION OF THE SO CALLED STAINLESS STEEL HAS BEEN RElNED ENORMOUSLY OVER THE YEARS AND AGAIN THINGS ARE ADDED OR CARBON CONTENTS GET LOWER AND SO ON AND SO FORTH !LL SORTS OF THINGS HAVE BEEN DONE TO REDUCE THE SUSCEPTIBILITY TO CREVICE CORROSION FOR EXAMPLE SO ) STRONGLY SUSPECT THAT WE SHOULD NOW SEE FAR FAR FEWER BREAKAGES OF THE COMPONENTS MAINLY BECAUSE OF ATTENTION TO MANUFACTURE )TS STILL POSSIBLE FOR THE SURGEON TO PUT THE THING IN LESS THAN THE OPTIMUM ALIGNMENT FOR EXAMPLE WHICH MIGHT HAVE AN EFFECT ON CUP MIGRATION AND ALL SORTS OF THINGS "UT ) STRONGLY SUSPECT THAT ATTENTION TO THE METAL ALLOYS AND THE MANUFACTURING THEREOF IS WHAT REALLY HAS MADE THE DIFFERENCE !ND WHILE ) AM SPEAKING ) WOULD LIKE TO MENTION ANOTHER POINT 4HE THING THAT WOULD IMPRESS ME MOST IS LONG TERM COMPARISONS OF DIFFERENT PROCEDURES /F COURSE AS SOON AS ) START TO SAY THIS EVERYBODY ELSE HERE KNOWS AT LEAST AS WELL AS ) DO THAT ONE CANT COMPARE ONE PROCEDURE AGAINST ANOTHER BECAUSE TOO MANY VARIABLES ARE INVOLVED !ND SO AS AN ENGINEER ) AM REPEATEDLY FRUSTRATED IF ANYBODY ASKS ME AS THEY SOMETIMES DO @) AM GOING TO HOSPITAL TO HAVE MY HIP REPLACED WHAT DO YOU RECOMMEND ) HAVE TO SAY @) AM SORRY THE DATA AS FAR AS ) KNOW DOES NOT EXIST WHERE ONE COULD SEPARATE THE EFFECT OF THE PROSTHESES DESIGNS PROSTHESES MATERIALS THE SURGEONS TECHNIQUE THE PATIENT SELECTION AND SO ON AND SO FORTH !ND ) FULLY REALIZE THAT IT WOULD BE AN ENORMOUS TASK BUT IT SEEMS TO ME THAT THERE
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IS AN ENORMOUS GAP IN THE KNOWLEDGE WE HAVE AVAILABLE THAT WOULD SHED LIGHT ON WHAT TO DO !NY ENGINEER CAN LOOK AT ANY PROSTHESIS AND THINK OF A REASON WHY IT MIGHT FAIL BUT WHAT REALLY MATTERS IS HOW OFTEN IT DOES FAIL AND WHEN ,ETTIN ) THINK WE ARE COMING TO THAT CERTAINLY WHEN WE TALK ABOUT RESULTS AND FOLLOW UP 4HAT IS SOMETHING WHICH ONE SHOULD BE ABLE TO ANSWER AND ) THINK THERE HAS BEEN A MOVE FORWARD AND ) KNOW IT DOES SEEM THAT THREE OR FOUR PROSTHESES SEEM TO HAVE BEEN GOING FOR A SUFlCIENTLY LONG TIME WITH SUFlCIENT NUMBERS TO BE ABLE TO MAKE SOME ASSESSMENT 7ROBLEWSKI -AY ) MAKE A COMMENT FOR THE RECORD "ETWEEN AND n THE BEGINNING OF THE #HARNLEY ,&! n WERE CARRIED OUT AT 7RIGHTINGTON (OSPITAL 4HERE WAS NOT A SINGLE REVISION FOR A LOOSE CUP A LOOSE OR FRACTURED STEM SIX YEARS OPERATIONS 4HE lRST FRACTURED STEM APPEARED IN 4HE MAIN PROBLEM WAS A LOSS OR LACK OF PROXIMAL STEM SUPPORT AND BENDING TORSION ! LOOSE STEM FOLLOWED AND lNALLY WEAR AND LOOSENING OF THE CUP 3O NO PROBLEMS IN SIX YEARS AND OPERATIONS 4HE INFORMATION WE HAVE AVAILABLE HAS PASSED YEARS NOW AND IT MAKES FASCINATING READING "UT TO SAY THAT INFORMATION IS NOT AVAILABLE IS INCORRECT 3ECONDLY MY DEAR SIR IF YOU ARE WORRIED PICK YOURSELF A GOOD SURGEON /LDER *UST TO PICK UP YOU WERE ASKING ABOUT COMPLICATIONS IN THE EARLY DAYS ) HAVE BEEN REVIEWING #HARNLEYS LOW FRICTION ARTHROPLASTIES AS PERFORMED BY #HARNLEY HIMSELF FROM n THAT IS NEARLY ,&!S AND SOME PATIENTS ARE STILL ALIVE AND ) STILL SEE THEM )N THAT SERIES THERE HAS BEEN PER CENT WITH FRACTURES OF THE STEM OF THE FEMORAL COMPONENT -ICHAEL 7ROBLEWSKI HAS BIGGER lGURES AND HAS LOOKED AT THIS IN GREATER DEPTH /F THE PER CENT OF FRACTURES n SOME OF THEM EVEN FRACTURED YEARS AFTER #HARNLEY PUT THEM IN n BUT ) AM TOLD THAT SINCE WHEN THE MANUFACTURERS STARTED USING /RTRON THERE HASNT BEEN A SINGLE FRACTURE OF THE FEMORAL STEM 4HAT IS AN INDICATION OF A TECHNICAL COMPLICATION ASSOCIATED NOT ENTIRELY AS -ICHAEL PERHAPS SUGGESTS ON THE LOADING BUT ) THINK IT WAS ALSO A REmECTION OF THE NATURE OF THE METAL THAT WAS BEING USED BY #HARNLEY
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#HARNLEY A AND B $ECOULX /LSSON ET AL 7ROBLEWSKI 0ACHECO ET AL
/RTRON IS THE BRAND NAME USED BY $E0UY )NTERNATIONAL ,TD ,EEDS FOR )3/ STAINLESS STEEL 3EE !PPENDIX FOR EARLY )3/ STANDARDS
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,ETTIN 3O THE MATERIALS ARE OBVIOUSLY VERY IMPORTANT 3TEPHEN !S MANY OF YOU WILL KNOW BUT FOR THE RECORD IN THE EARLY %XETER EXPERIENCE THERE WERE A SERIES OF BOTH STEM AND NECK BREAKAGES DUE TO MANUFACTURING ERRORS &IRSTLY THE MATERIAL USED IN THE STEM AND LATER OVERMACHINING OF THE NECK LED TO FATIGUE FAILURE ) WOULD SUPPORT THE CONTENTION OF THE ENGINEERS THIS IS A FEATURE OF THE MANUFACTURING PROCESS ,ETTIN 7ILL THE "3) OVERCOME THIS WILL STANDARDS COVER SO THAT THIS SHOULDNT HAPPEN IN THE FUTURE 7HEBLE 4HERE HAD BEEN WORK DONE ON THIS SUBJECT FOR THE "3) COMMITTEE )T WAS ENDURANCE TESTING TO SEE WHAT WAS HAPPENING TO PROSTHESES UNDER LOAD 4HE RIGS USED EXAMINED TWO PROBLEMS THE EFFECTS OF TORSION APPLIED TO THE PROSTHESIS WHEN UNDER VARYING LOAD AND EXTENDED TIME AND THE EFFECTS OF VARIOUS LOADS WHEN APPLIED DIRECTLY TO THE BALL OF THE PROSTHESIS WITH THE NECK UNSUPPORTED BUT THE STEM lRMLY lXED 4HESE TESTS WERE CONTINUED FOR LONG PERIODS OF TIME BUT AS FAR AS ) AM AWARE THEY NEVER RESULTED IN THE WRITING OF A STANDARD FOR TESTS OF THIS TYPE ,ETTIN "UT THE MANUFACTURERS TEST THEM ALL NOW 4HEY ARE TESTED IN BATCHES PRESUMABLY 0HYLLIS NOT INDIVIDUALLY (AMPSON /UR MANUFACTURED ITEMS WERE SENT WEEKLY TO 3TANMORE FOR CHECKING BEFORE WE WERE ALLOWED TO HAVE THEM BACK REPACK AND STERILIZE AND THEN SELL THEM ,ETTIN $OES ANYBODY KNOW WHETHER EVERY INDIVIDUAL IMPLANT IS TESTED AGAINST THESE STANDARDS OR JUST BATCHES (AMPSON 4HERES NO @YOU MUST CHECK RECURRENCE 4HAT DOESNT COME INTO IT 7E AGREED BECAUSE THATS WHAT *OHN 3CALES WANTED AND WE THOUGHT IT WAS A GOOD THING BUT ) THINK NOW THIS DOESNT HAPPEN ) REALLY DONT BELIEVE THAT EVERY COMPANY TESTS BATCHES OF PROSTHESES 3WANSON /N THIS QUESTION OF TESTING #HAIRMAN ONE CAN MEASURE EACH INDIVIDUAL PROSTHETIC COMPONENT FOR EXAMPLE ONE CAN DO THE SURFACE lNISH BUT WHEN IT COMES TO FATIGUE TESTING OR CORROSION TESTING IT CAN ONLY BE DONE ON A SAMPLE BASIS AND THERE ARE WELL KNOWN TECHNIQUES IN INDUSTRIES WHERE THESE THINGS MATTER LIKE AEROPLANES WHICH ) USED TO BE IN WHERE THERE ARE IMMENSE PROCEDURES ALL LAID DOWN ABOUT THE FREQUENCY OF SAMPLING AND WHAT YOU DO IF ONE ISNT QUITE RIGHT AND SO ON ) THINK WE SHOULD UNDERSTAND THAT WITH JOINT
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PROSTHESES AS WITH CARS AND AEROPLANES AND EVERYTHING ELSE WE ARE PUTTING OUR FAITH IN STATISTICIANS (AMPSON 4HATS PROBABLY TRUE TO A GREAT EXTENT "UT WE ALSO HAD AN AGREEMENT WITH 3TANMORE THAT WE WOULD KEEP SAMPLES OF ALL THE MATERIALS USED UP TO SEVEN YEARS SO THAT IF 3TANMORE FOUND A HIP PROSTHESIS ON THEIR TEST MACHINE THAT WASNT WORKING PROPERLY OR IT BROKE OR WHATEVER WE HAD TO GO THROUGH THE WHOLE OF THE NUMBERING SYSTEM AND CLEAR EVERY PROSTHESIS OUT OF STOCK AND CHECK THROUGH THE MATERIALS OF THE SAMPLES WE KEPT ,ETTIN "UT ) AM RIGHT IN CONCLUDING THAT ALTHOUGH WE HAVE THESE STANDARDS THERE IS NO OBLIGATION ON THE MANUFACTURERS TO MEET THESE STANDARDS 4HIS IS A VERY UNSATISFACTORY STATE OF AFFAIRS ISNT IT 2ODNEY 3WEETNAM 9ES BUT IT MAY HAVE CHANGED NOW ,ETTIN !T LEAST ) KNOW THAT YOU AGREE WITH ME ANYWAY 9ES SO MECHANICAL FAILURE IS THERE ANYTHING THAT YOU WOULD LIKE TO SAY $UNCAN ABOUT MECHANICAL FAILURE $OWSON 4HE ONLY ADDITIONAL THING ) WOULD SAY IS THAT A LOT OF THE IMPLANT PERFORMANCE CHARACTERISTICS WHICH YOU MAY WISH TO KNOW DO NOT READILY EMERGE FROM STANDARD SIMULATOR TESTS )F YOU ARE GOING TO EVALUATE WHETHER OR NOT A GIVEN TOTAL HIP REPLACEMENT IS SATISFACTORY FROM THE POINT OF VIEW OF WEAR IT MAY BE NECESSARY TO SPEND SIX MONTHS ON A SIMULATOR FOR EACH IMPLANT DESIGN AND THIS IS BOTH RESTRICTIVE AND EXPENSIVE 9OU HAVE TO RELY ON STATISTICAL METHODS FOR BOTH LABORATORY AND CLINICAL EVALUATIONS SOONER OR LATER &EW CURRENT SIMULATORS REPLICATE THE DAILY CYCLES OF LOADS AND MOTIONS TO WHICH IMPLANTS ARE EXPOSED IN VIVO &REEMAN ! POINT OF ORDER #HAIRMAN UNDER MECHANICAL FAILURE DO YOU INCLUDE WEAR /R ARE YOU JUST TALKING ABOUT FRACTURE 9OU ARE ONLY TALKING ABOUT ONE OF THE TWO COMPONENTS ,ETTIN ) WAS GOING TO TALK ABOUT WEAR NEXT IF THATS ALL RIGHT ) WAS ACTUALLY GOING TO SAY THAT A DElNITION OF A STATISTICIAN IS A CHAP WHO WHEN YOU ASK HIM HOW HIS WIFE IS HE SAYS @#OMPARED WITH WHOM ;,AUGHTER= 0ERHAPS WE SHOULD MOVE ON TO WEAR 7OULD YOU START THE BALL ROLLING -ICHAEL
3EE NOTE
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&REEMAN ) WOULD LIKE TO KNOW FROM THE REGULATORS WHO WE HAVE HERE WHAT THE REQUIREMENTS ARE FOR THE POLYETHYLENE COMPONENT ARE THEY SCRUTINIZED IN ANY WAY ON A BATCH BASIS BEFORE THEY GO OUT 7OULD IT BE POSSIBLE FOR EXAMPLE TO KNOW HOW MUCH OXYGEN THEY HAD IN THEM HOW CROSS LINKED THEY WERE ETC !ND IT HAS BEEN SAID ) BELIEVE THAT WEAR WAS THE MAJOR PROBLEM ) WONDER WHETHER WE AGREE AS HISTORIANS LOOKING BACK THAT THE MAJOR PROBLEM WAS DUE TO THE FACT NOT THAT THE HIGH DENSITY POLYETHYLENE POLYMER COMPONENTS WERE POLYETHYLENE BUT BECAUSE WITH SOME EXCEPTIONS THEY WERE GAMMA IRRADIATED IN AIR THEY CAME TO THE MARKET TO A CERTAIN EXTENT AS ACTUALLY A LOW MOLECULAR WEIGHT POLYETHYLENE !RE WE SCRUTINIZING THE POLYETHYLENE (AVE WE MADE A MISTAKE IN THE PAST ,ETTIN ) DONT KNOW 0HYLLIS WERE YOU SCRUTINIZING THE POLYETHYLENE (AMPSON .O WE WERENT 7E USED TO VISIT THE MANUFACTURERS IN 'ERMANY EVERY SIX MONTHS TO ENSURE THAT WE KNEW WHAT THEY WERE DOING BUT OF COURSE THEY REPEATEDLY CHANGED THE FORMULA WITHOUT TELLING ANYBODY SO YOU COULDNT REALLY CHECK THE POLYETHYLENE AT ALL &ROM THE mOOR 3O YOU HAD NO IDEA WHAT THIS STUFF WAS (AMPSON .O -S #LARE $ARRAH ) AM SORRY THERE IS NOBODY HERE FROM INDUSTRY TODAY BUT ) THINK IN THEIR DEFENCE THEY DO COMPLY WITH VERY STRINGENT %UROPEAN STANDARDS AND NOW CERTAINLY WITH THE )3/ 1UITE WHAT THEY ALL MEAN IS A BIT OF A MYSTERY TO ME BUT ) THINK WE SHOULD BE A LITTLE CAREFUL TO SAY THAT THEY ARE NOT COMPLYING 4UCKER -AY ) CONlRM THAT )F YOU ASK THE SO CALLED EXPERTS THEY WILL SAY THAT THERE ARE %UROPEAN STANDARDS FOR PRETTY WELL EVERYTHING INCLUDING SURFACE lNISH HIGH DENSITY POLYETHYLENE ETC ;SEE !PPENDIX = #OMPANIES WILL DECLARE THEIR STANDARDS AND IF YOU CHALLENGE THEM THEY WILL SAY THAT THEY HAVE QUALITY CONTROL AND THAT THEY ARE MANUFACTURING TO THE STANDARD &ROM WHAT ) HAVE GLEANED STANDARDS ARE QUITE LAX 4AKE SURFACE lNISH FOR EXAMPLE PARTICULARLY ON ($0 ACETABULAE THE RANGE OFFERED BY %UROPEAN $IRECTIVES IS QUITE WIDE
)3/ IS A GENERIC NAME GIVEN TO A GROUP OF STANDARDS DEVELOPED BY THE "RITISH 3TANDARDS )NSTITUTION THAT PROVIDE A QUALITY MANAGEMENT SYSTEM FRAMEWORK TO ENSURE CONSISTENCY AND IMPROVEMENT OF WORKING PRACTICES )T CLAIMS TO BE THE MOST COMMONLY USED INTERNATIONAL STANDARD FOR AN EFFECTIVE QUALITY MANAGEMENT 3EE WWWBSI EMEACOM1UALITY/VERVIEW7HATIS)3/XALTER VISITED .OVEMBER
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,ETTIN 4HERES CERTAINLY NO OBLIGATION FOR THE STANDARDS TO BE MET BUT IF ITS NOT MET AND THERE WAS SOME PROBLEM THEN OF COURSE LITIGATION COMPENSATION WOULD BE MULTIPLIED CONSIDERABLY ) WOULD IMAGINE 4UCKER 4HEY HAVE TO OBEY THE %UROPEAN STANDARD ,ETTIN "UT WE DONT KNOW HOW CAREFULLY THEY TEST THEIR PRODUCTS "UT THAT WOULD BE IN THEIR CONTRACT 3WANSON ! VERY BRIEF POINT ) DONT THINK ONE SHOULD SHELTER TOO CONlDENTLY BEHIND THE )3/ SERIES -Y FRIENDS WHO ARE STILL ACTIVE IN ENGINEERING INDUSTRY TELL ME THIS IS MORE ABOUT THE lRMS GENERAL PROCEDURES AND THE INTEGRITY OF ITS lLING SYSTEM THAN ABOUT ACTUALLY LOOKING AT THE PRODUCT ) COULD TELL YOU A HORROR STORY ABOUT A BUS THAT WAS FALLING TO PIECES RUN BY A COMPANY THAT IS ACCREDITED TO )3/ BUT ) WONT 7ROBLEWSKI ) THINK ) WOULD LIKE TO ASK 0ROFESSOR 3WANSON A QUESTION 9OU HAVE DONE SOME WORK WITH "ARRY 7EIGHTMAN ON THE QUALITY OF THE HIGH MOLECULAR WEIGHT POLYETHYLENE EXAMINING EXPLANTED #HARNLEY CUPS WITH A FOLLOW UP OF YEARS 0ERHAPS YOU WOULD BE KIND ENOUGH TO REMIND US WHAT THE RESULTS WERE 3WANSON ) KNOW ) AM GETTING OLD AND MY MEMORY IS FAILING ) HAVE NO MEMORY WHATEVER OF MYSELF OR "ARRY 7EIGHTMAN HANDLING AN EXPLANTED #HARNLEY CUP ) THINK YOU MAY MEAN 0ROFESSOR $OWSON 7ROBLEWSKI .O THE TWO OF YOU ;7EIGHTMAN AND 3WANSON= LOOKED AT WEAR AND DEGRADATION EXAMINING THE WORN AND THE UNWORN PARTS OF THE CUP MATCHING SPECIMENS AND TESTING THEM FOR WEAR CHARACTERISTICS 4HE CONCLUSION WAS THAT THERE WAS NO EVIDENCE OF BATCH TO BATCH VARIATION OR DEGRADATION OF THE MATERIAL IN THE HUMAN BODY 3WANSON ) SUPPOSE ) HAD BETTER GO HOME AND LOOK UP MY OWN PUBLICATION LIST ) AM SORRY ) HAVE NO MEMORY AT ALL OF THIS ,ETTIN !NYBODY ELSE 7E ARE STILL ON THE SUBJECT OF WEAR $R !LEX &AULKNER 3ORRY NOT QUITE ON THE SUBJECT OF WEAR BUT WE SHOULDNT LEAVE THE TOPIC OF STANDARDS WITHOUT MENTIONING THAT HIP IMPLANTS HAVE JUST IN BEEN RECLASSIlED UNDER %UROPEAN $IRECTIVES AS A GRADE RATHER THAN
7EIGHTMAN ET AL
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A GRADE " DEVICE WHICH MEANS THAT CLINICAL EVIDENCE WILL BE REQUIRED FOR NEW PROSTHESES IN ALL CASES WHICH HASNT BEEN THE CASE BEFORE ,ETTIN 9ES THERE ARE OBVIOUSLY VERY GREAT DIFlCULTIES FROM AN ORTHOPAEDIC POINT OF VIEW WE ONLY REALLY KNOW WHEN THEY GO WRONG AND THAT IS AFTER A PERIOD OF TIME OFTEN AND THESE DIRECTIVES THEY END AFTER A YEAR OR SOMETHING DONT THEY +EITH 9OU ONLY HAVE TO PROVIDE ONE YEAR OF FOLLOW UP OR SOMETHING 4UCKER 4HAT IS THE CASE WITH THE #% MARK BUT FORTUNATELY IN THIS COUNTRY WE HAVE NOW MANAGED TO LOOP THE POLITICAL PROBLEMS OF @POST MARKET SURVEILLANCE AND WE HAVE .ATIONAL )NSTITUTE FOR (EALTH AND #LINICAL %XCELLENCE .)#% GUIDELINES .)#% COMMISSIONED THE .(3 0URCHASING AND 3UPPLY !GENCY TO SET UP THE /RTHOPAEDIC $ATA %VALUATION 0ANEL /$%0 WHICH IS RUN BY !NDY 3MALLWOOD WITH MYSELF AS #HAIRMAN 4HIS MEANS FOR A PRODUCT TO BE SOLD IN THE 5+ THE IMPLANT HAS TO HAVE A RATING 4HUS POST MARKET SURVEILLANCE IS STILL NOT AROUND AS SUCH BUT IF A MANUFACTURER WISHES TO SELL AN IMPLANT TO A PRIVATE HOSPITAL IN THE 5+ OR INTO THE .(3 THE IMPLANT MUST HAVE A BENCHMARK 4HE IDEAL BENCHMARK IS ! WHICH THE #HARNLEY THE %XETER AND THE 3TANMORE TOGETHER WITH QUITE A FEW OVERSEAS AND NEWER PROSTHESES HAVE ACQUIRED )F YOU DEVELOP A NEW PRODUCT YOU GO INTO PRE ENTRY WHICH IS NOT A BENCHMARK AND THEN MOVE THROUGH THE THREE lVE AND SEVEN YEAR BENCHMARKS BEFORE ACQUIRING A ! $URING THE PROGRESSION TO ! THE COMPANY WILL HAVE TO COLLECT DATA ON ITS IMPLANT AND SATISFY THE /$%0 CRITERIA 4HUS WE HAVE LOOPED THE %UROPEAN NUISANCE OF NOT ALLOWING POST MARKET SURVEILLANCE BY HAVING THIS FACILITY 4HE /$%0 PANEL WORKS CLOSELY WITH THE .ATIONAL *OINT 2EGISTRY AND THE IDEA IS TO CATCH OUT PROSTHESES WHICH DONT WORK -ICHAEL ;7ROBLEWSKI= ) KNOW YOU ARE
$R !LEX &AULKNER WROTE @%UROPEAN #OMMISSION $IRECTIVE %# OF !UGUST ON THE RECLASSIlCATION OF HIP KNEE AND SHOULDER JOINT REPLACEMENTS IN THE FRAMEWORK OF #OUNCIL $IRECTIVE %%# CONCERNING MEDICAL DEVICES /FlCIAL *OURNAL OF THE %UROPEAN 5NION !UGUST ,n % MAIL TO -RS ,OIS 2EYNOLDS /CTOBER
&OR FURTHER DETAILS SEE WWWPASANHSUKMEDICALORTHOPAEDICSODEPDATABASE VISITED !UGUST SEE ALSO .)#%
3EE !PPENDIX PAGES n
4HE .ATIONAL *OINT 2EGISTRY WAS LAUNCHED IN !PRIL 4HE CONTRACT TO ESTABLISH IT WAS AWARDED TO !%! 4ECHNOLOGY IN 3EPTEMBER MANAGED BY A 3TEERING #OMMITTEE CHAIRED BY "ILL $ARLING #"% AND VICE CHAIRED BY 0ROFESSOR 0AUL 'REGG THEN 0RESIDENT OF THE "/! ;$O( 0RESS 2ELEASE = .ORTHGATE )NFORMATION 3OLUTIONS TOOK OVER THE MANAGEMENT OF THE CONTRACT FROM !PRIL &OR FURTHER DETAILS SEE THE $O( WEBSITE AT WWWDHGOVUK(OMEFSEN VISITED .OVEMBER
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THINKING THAT WE HAVE A LONG WAY TO GO AND ) AM SURE YOU ARE QUITE RIGHT BUT ) THINK WE ARE GETTING A BIT FURTHER FORWARD ,ETTIN 4HIS IS BRINGING US UP TO DATE BUT HISTORICALLY WE ARE GOING ON IN A MINUTE TO FOLLOW UP AND ) MEAN THIS IS REALLY ALL WE HAVE AT THE MOMENT IS LONG TERM FOLLOW UP ISNT IT 7E HAVENT REALLY GOT AWAY FROM WEAR $OWSON *UST A COMMENT ON THAT #HAIRMAN 4HE TYPICAL WEAR RATE IN VOLUMETRIC TERMS IS OF COURSE GENERALLY RELATED TO THE POLYETHYLENE THE 5(-70% WHICH IS PERHAPS TO CUBIC MILLIMETRES A YEAR )F YOU NOW MOVE TO A WELL DESIGNED METAL ON METAL IMPLANT n AND ONE REASON FOR THIS BEING DONE IS TO MINIMIZE THE WEAR VOLUME BECAUSE OF THE OSTEOLYSIS ;BONE LOSS= PROBLEM WITH POLYETHYLENE WEAR DEBRIS n THEN THE WEAR IN THE lRST YEAR OR TWO MIGHT BE OR CUBIC MILLIMETRES AND THEREAFTER LESS THAN ONE TENTH OF A CUBIC MILLIMETRE PER YEAR 4HE QUESTION IS RELATED NOT TO JUST THE VOLUME OF WEAR BUT THE NATURE OF THE WEAR DEBRIS !ND ALTHOUGH THE WEAR RATE OF THE METAL ON METAL IS SO MUCH LOWER n IMPRESSIVELY LOWER THAN THAT OF THE POLYETHYLENE FROM THE METAL ON POLYMER CONlGURATION n THE SIZE OF THE METALLIC PARTICLES OF THE METAL ON METAL JOINT WEAR DEBRIS IS SO VERY SMALL THAT THERE ARE SEVERAL TIMES AS MANY METALLIC WEAR PARTICLES AS THERE ARE POLYETHYLENE PARTICLES GENERATED EACH YEAR !ND THE QUESTION IS WHAT DO THESE PARTICLES DO IN TERMS OF BIOLOGICAL REACTION AND THE JURY SEEMS TO BE OUT ON THIS AS ) THINK -IKE &REEMAN WAS SAYING EARLIER 4HERE MAY BE CAUSE FOR CONCERN SUPERlCIALLY BUT WE ARE AWAITING THE HARD EVIDENCE ,ETTIN 4HIS REALLY DOES BRING US ON TO THE REAL PROBLEM OF WEAR &ROM AN ORDINARY LAYMANS POINT OF VIEW THE RECIPIENT OF THE HIP REPLACEMENT IS CONCERNED WHETHER
-R +EITH 4UCKER WROTE @-Y RECOLLECTION IS THAT IN SPITE OF PROVISIONAL RECOMMENDATIONS BY #HARNLEY AND LATER ON BY -R 2OBIN ,ING IN THE MID S THE $O( WOULD NOT HEED OUR SUGGESTION OF A HIP REGISTRY 7HEN ) JOINED THE -$! -(2! THERE SEEMED TO BE COMPLETE OPPOSITION TO THE IDEA OF A REGISTRY )T WAS THE .ATIONAL !UDIT /FlCE ; = THAT RECOMMENDED A HIP REGISTRY IN THEIR REPORT ON THE #APITAL HIP REPLACEMENT DEBACLE 4HIS WAS IN THE MID S WHEN .)#% ALSO SUPPORTED THE CONCEPT OF A HIP REGISTRY 4O MANY OF US IT WAS SAD THAT THE $O(S ATTITUDE TOWARDS A HIP REGISTRY WAS SO NEGATIVE FOR SO LONG )T STATED IN THE #APITAL HIP REGISTRY REPORT THAT A HIP REGISTRY HAD BEEN IN PLACE AT THE TIME OF THE INTRODUCTION OF THE #APITAL HIP ;SEE NOTE = THE PROBLEMS MAY WELL NOT HAVE OCCURRED OR AT LEAST HAVE BEEN LESS WIDESPREAD &AX TO -RS ,OIS 2EYNOLDS .OVEMBER 3EE .ATIONAL !UDIT /FlCE WHICH NOTES THAT BY THIS TIME PER CENT OF HIP REPLACEMENTS USED PROSTHESES WITHOUT ADEQUATE EVIDENCE OF EFFECTIVENESS AND IN ORTHOPAEDIC CONSULTANTS PRIORITIZED PATIENTS ON THE BASIS OF THE NEED TO MEET WAITING LIST TARGETS
3EE THE SPECIAL ISSUE ON THE DEVELOPMENT OF MONOLITHIC AND SURFACE REPLACEMENT METAL ON METAL HIP REPLACEMENTS IN THE 0ROCEEDINGS OF THE )NSTITUTION OF -ECHANICAL %NGINEERS 0ART ( *OURNAL OF %NGINEERING IN -EDICINE ;(= n 3EE ALSO 7ILLERT ET AL 7ILLERT AND 3EMLITSCH
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IT WILL WEAR OUT "UT THAT ISNT REALLY THE PROBLEM 4HE PROBLEM IS AS YOU HAVE HIGHLIGHTED THE EFFECTS OF THE PRODUCTS OF WEAR AND THIS IS NOT REALLY NEW THIS IS OLD ISNT IT 9OU WERE POINTING OUT IN THAT lRST HISTORICAL PERIOD THAT WE ARE SUPPOSED TO BE CONSIDERING n ) DONT KNOW WHETHER WE HAVE EXCEEDED OUR BRIEF IN TALKING ABOUT CURRENT ISSUES n -ICHAEL &REEMAN WAS TALKING ABOUT THE EFFECT ON THE $.! 9OUR ORIGINAL PAPER -ICHAEL AS FAR AS ) REMEMBER WAS ON THE CARCINOGENIC EFFECTS OF THE WEAR PRODUCTS )T WAS HIS PAPER NOT YOURS ;&ROM THE mOOR 9OU SHARED IT &REEMAN 9ES & ;&REEMAN= COMES BEFORE 3 ;3WANSON= IN THOSE TITLES= "UT THIS WAS KNOWN IN THE PERIOD THAT WE ARE TALKING ABOUT THE S S S &REEMAN -AY WE READ THE NAME (ANS 7ILLERT INTO THE RECORD ) KNOW HE IS NOT %NGLISH HE WAS 'ERMAN AND WORKED IN 3WITZERLAND BUT HE PUT THE PARTICLE PATHOLOGY BUSINESS ON THE MAP IN THE EARLY S 3O ITS NOT NEW AND WE COULD HAVE REDUCED THE WEAR RATE n ) DONT WANT TO HARP ON THIS n BY UNDERSTANDING THE EFFECTS OF IRRADIATION ON THE POLYETHYLENE )T IS NOT ONLY THAT THE MANUFACTURERS KEPT MAKING DIFFERENT STUFF ;POLYETHYLENE= AND SUPPLYING IT TO THE IMPLANT MAKERS BUT THE IMPLANT MAKERS THEN STERILIZED IT AND SENT IT OFF IN BATCHES TO BE GAMMA IRRADIATED IN AIR ,ETTIN !ND THEN LEFT IT ON THE SHELVES FOR SEVERAL MONTHS &REEMAN !ND THEN LEFT IT ON THE SHELF BUT EVERYBODY WAS DOING IT 7E WERE COLLECTIVELY IGNORANT OF THE PHYSICAL CONSEQUENCES OF DOING THAT TO POLYETHYLENE AND -IKE 7ROBLEWSKI AND $UNCAN KNOW MUCH MORE ABOUT THIS THAN ) DO BUT IT WAS A MAJOR PROBLEM THAT HAS BEEN HIDDEN UNDER THE CARPET BECAUSE THE MEDICOnLEGAL CONSEQUENCES OF TAKING IT OUT FROM UNDER THE CARPET DONT BEAR THINKING ABOUT 7ROBLEWSKI !LTHOUGH WHAT YOU SAY -IKE ;&REEMAN= IS PARTLY CORRECT THERE IS ANOTHER ISSUE 4HE MAIN PROBLEM OF CUP LOOSENING IS PENETRATION RESTRICTING ANGULAR MOVEMENT BY IMPINGEMENT )F YOU PUT OFF THE MOMENT OF IMPINGEMENT BY REDUCING THE DIAMETER OF THE NECK AS IT IS POSSIBLE TO DO WITH THE #HARNLEY STEM IN /RTRON FROM MM TO MM YOU INCREASE THE RANGE OF MOVEMENT BY 9OU DO NOT GENERATE ANY FEWER WEAR PARTICLES "UT OVER THE YEARS THAT IT HAS TAKEN ME TO DO THIS STUDY THERE IS A REDUCTION IN THE FAILURE OF CUP
3WANSON ET AL
3EE FOR EXAMPLE 7ILLERT 3EMLITSCH ET AL 3EMLITSCH AND 7ILLERT
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lXATION OF PER CENT 3O ALTHOUGH THE VOLUME OF PLASTIC SHED INTO THE TISSUES HAS INCREASED THE INCIDENCE OF CUP LOOSENING RADIOLOGICALLY AND ON REVISION HAS BEEN REDUCED BY PER CENT ) HAVE SPENT SOME TIME WITH 0ROFESSOR (ANS 7ILLERT OF 'OTTINGEN LOOKING THROUGH HIS HISTOLOGY SLIDES ) HAVE HISTOLOGY SLIDES WITH 04&% SHOWING CALCIlCATION AND NEW BONE FORMATION 0ROFESSOR 7ILLERT ACCEPTS THE EVIDENCE AS A HEALING PROCESS 7E DO NOT KNOW THE FULL STORY 7E CANNOT PUT IT ALL DOWN TO JUST WEAR PARTICLES AND TISSUE REACTION TO WEAR PARTICLES 4HAT IS NOT THE FULL STORY ,ETTIN ) THINK THIS REALLY BRINGS US ON TO THE QUESTION OF LOOSENING DOESNT IT AND REALLY THIS IS WHAT YOU ARE SAYING 4HERES NOT JUST ONE CAUSE OF LOOSENING AND PERHAPS WE SHOULD EXPLORE THAT NOW 9OU ARE SUGGESTING IN FACT THAT ITS OPERATIVE FAULT THAT CAN LEAD TO LOOSENING 7ROBLEWSKI 4HERE ARE TWO PROBLEMS ONE IS FAILURE OF GEOMETRY AND WE CALL IT ARTHRITIS AND FOR THAT WE DO HIP REPLACEMENT AND THE SECOND PROBLEM WE @CREATE IS lXATION OF COMPONENTS ) WONDER HOW MANY COMMON OR GARDEN ORTHOPAEDIC SURGEONS ACTUALLY KNOW TO WHAT LOADS THE HIP JOINT IS SUBJECTED 4HE "3) WOULD NOT ACCEPT lVE TIMES BODY WEIGHT AS A STANDARD FOR TESTING FEMORAL COMPONENTS (EYWOOD 7ADDINGTON #OULD ) BE ENLIGHTENED ON THAT ,ETTIN 7HOS GOING TO ENLIGHTEN YOU &REEMAN 4HE ANSWER IS NO ) DONT HAVE ANY EVIDENCE AND ) DONT THINK THERE IS ANY EVIDENCE -IKE !S FAR AS ) KNOW THERE ARE A SERIES OF WELL FOUNDED THEORETICAL ANXIETIES BUT ITS A BIT LIKE SMOKING IT TAKES A LOT OF YEARS AND ) WOULD BE VERY SURPRISED IF THE THEORETICAL ANXIETIES MANIFESTED THEMSELVES IN A POPULATION OF PEOPLE OVER THE AGE OF 4HEY MIGHT DO BUT ) WOULD BE VERY SURPRISED AND CERTAINLY THE FERTILITY ANXIETIES ON THE WHOLE ) SHOULDNT THINK WOULD AT THAT AGE AT LEAST ) HOPE TO 'OD THEY WOULDNT BUT ITS WHEN YOU GET THE YOUNGER PEOPLE BEING HIT BY A LIFETIME OF RAISED COBALT AND CHROMIUM THEN IT MIGHT BE DIFFERENT -IGHT MIGHT NOT ) DONT KNOW BUT ITS AN ISSUE 7HILE ) AM ON THIS ISSUE ) ENTIRELY AGREE WITH -IKE 7ROBLEWSKI OBVIOUSLY THAT THE IMPINGEMENT ISSUE OF THE LIP OF THE ACETABULUM IS A BIG THING AND YOU ASKED ME WHY RESURFACING ARTHROPLASTY FAILED AND THAT IS ONE REASON n THE HEADnNECK RATIO
7ROBLEWSKI ET AL
3EE NOTE
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT
IS ALL WRONG n AND IF YOU PUT IN A CUP YOU CAN HARDLY MOVE IT AT ALL BEFORE SOMETHING BANGS ON SOMETHING ELSE ,ETTIN $ESIGN FAULT 7ROBLEWSKI -AYBE WE SHOULD ASK A DIFFERENT QUESTION TO ANSWER THE PROBLEM OF TISSUE REACTION TO VARIOUS METALS -AYBE WE SHOULD ASK WHAT ARE THE RECOMMENDED BLOOD LEVELS FOR THESE METALS ,ETTIN ) DONT KNOW IF ANYBODY KNOWS 3WEETNAM 4HE ANSWER IS AS -ICHAEL &REEMAN HAS SAID THAT NOBODY KNOWS AND WILL NOT KNOW FOR VERY MANY YEARS BECAUSE THIS IS A LONG TERM POTENTIAL WORRY "UT ) THINK THE MESSAGE THAT SHOULD GO FROM THIS GROUP OF PEOPLE WHO HAVE EXPERIENCE OF THE DEVELOPMENT OF HIP REPLACEMENT OVER THE LAST YEARS OR SO IS THAT WE IN ARE STILL VERY CONCERNED ABOUT THE ABSENCE OF CLEAR SURVEILLANCE OF NEW PROSTHESES AND NEW TECHNIQUES PARTICULARLY LARGE HEAD METAL ON METAL AND THE FEARS n THE THEORETICAL FEARS n THAT WE ALL KNOW MAY OR MAY NOT AS -ICHAEL ;&REEMAN= HAS SAID LEAD TO SERIOUS COMPLICATIONS AT THE END OF THE ROAD ) THINK THAT IS THE MESSAGE THAT WE SHOULD BE GIVING ) LIKE TO THINK THAT SOMEBODY MAY BE LISTENING 7E SHOULD SAY THAT WE AS A GROUP ARE WORRIED ABOUT THE FUTURE THE LACK OF SURVEILLANCE AND THE LONG TERM EFFECTS OF RELEASED METAL IONS PARTICULARLY IN THOSE HAVING METAL ON METAL IMPLANTS AT AN EARLY AGE 4HATS MY PROPOSITION BUT MAYBE PEOPLE DONT AGREE ,ETTIN )T WILL BE RECORDED 2ODNEY 7HAT DO WE THINK THE MAIN REASON IS IN EVERYDAY PRACTICE FOR LOOSENING $O WE THINK IT IS MALPOSITION OF THE COMPONENTS IN OTHER WORDS BAD OPERATIVE TECHNIQUES )S IT BAD CEMENTING TECHNIQUES OR IS IT THESE TERRIBLE WEAR PARTICLES 7HATS THE FEELING ABOUT THIS 7HAT IS THE MOST SIGNIlCANT CAUSE OF LOOSENING $OES ANYBODY KNOW 7ROBLEWSKI ) AM VERY FORTUNATE BECAUSE ) HAVE ACCESS TO INFORMATION GOING BACK TO .OVEMBER )F THE FAILURE OCCURS IN THE lRST SIX YEARS IE LOOSENING OF THE CUP OR LOOSENING OF THE STEM IN ABSENCE OF INFECTION THE PROBLEM IS ALMOST ALWAYS TECHNICAL &ROM THEN ONWARDS IT IS WEAR OF THE CUP AND LOOSENING OF THE CUP !FTER TO YEARS ON THE FEMORAL SIDE IT IS PROXIMAL STRAIN SHIELDING ,ETTIN ) THINK EVERYBODY KNOWS THAT YOU HAVE GOT VERY CAREFUL FOLLOW UP AT 7RIGHTINGTON $OES ANYBODY ELSE HAVE A COMMENT 7HAT ABOUT )AN 3TEPHEN FOR 2OBIN ,ING (E VERY CAREFULLY FOLLOWS UP ALL HIS PATIENTS AS ) UNDERSTAND IT
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT
3TEPHEN 9ES INDEED THE FOLLOW UP HAS BEEN METICULOUS AND HE FEELS THAT HE HAS OVERCOME THE PROBLEM OF STEM LOOSENING BY THE COMBINATION OF STEM GEOMETRY AND CEMENTING TECHNOLOGY DUE TO THE BEHAVIOUR OF THE DOUBLE TAPER STRAIGHT POLISHED STEM WHICH IS SELF TIGHTENING AND SELF ADJUSTING UNDER LOAD ,ETTIN (AVE YOU ANY COMMENT ON THAT -ICHAEL 7ROBLEWSKI ) QUITE AGREE WITH )AN ) THINK WE HAVE GOT TO LOOK ON THE FEMORAL SIDE 4HE DESIGN AND THE SURGICAL TECHNIQUE MUST EMPLOY THE COMMON ENGINEERING PRINCIPLES THAT OF MALE AND FEMALE TAPERS ENGAGING UNDER LOAD &OR THAT SYSTEM TO BECOME LOAD BEARING THERE MUST BE A SLIP 4HAT SLIP MUST BE OF THE STEM WITHIN THE CEMENT MANTLE 4HE QUESTION NOW CONCERNS THE STEM DESIGN SURFACE lNISH AND THE SURGICAL TECHNIQUE 4HE PROBLEM FROM THEN ONWARDS IS BENDING TORSION 7E PROJECT OURSELVES WHILE WALKING UPWARDS AND FORWARDS NOT JUST FORWARDS SO THE ROTATION IS DOWNWARDS AND BACKWARDS )T IS THE PROXIMAL STEM SUPPORT WHICH IS IMPORTANT SO ) ENTIRELY AGREE WITH )AN ,ETTIN !NY OTHER COMMENTS ON THE QUESTION OF LOOSENING OF HOW WE CAN MINIMIZE IT ) SUPPOSE WE WILL NEVER PREVENT IT &REEMAN -AY ) SUPPORT 2ODNEY 3WEETNAM ON THE ISSUE OF SURVEILLANCE BECAUSE HERE WE ARE A BUNCH OF OLD MEN LOOKING BACK AT THE S AND S WE HAVE OR YEARS OF EXPERIENCE OF THIS AND ACTUALLY #HAIRMAN WE CANT ANSWER YOUR QUESTION WHICH IS WHY DO THESE DAMN THINGS FAIL 4HE 3WEDES CAN !PPARENTLY WE ARE SUPPOSED TO CONlNE OURSELVES TO THE 5+ BUT THE 3WEDES HAVE GOT A REASONABLE DATA SYSTEM IN 3WEDEN WHICH ENABLES THEM TO ANSWER YOUR QUESTION BUT WE DONT KNOW THE ANSWER ,ETTIN 7HAT IS THEIR ANSWER &REEMAN 4HERES A THING CALLED THE 3WEDISH HIP SURVEY WHICH ) SUPPOSE DEPENDS ON THE PERSONALITY OF 3WEDEN AND ITS SIZE AND THE POPULATION AND ONE THING AND ANOTHER "UT UNLESS WE HAVE SUCH A THING HERE AND ) ACTUALLY CANT IMAGINE HOW WE WOULD EVER GET IT INTO OPERATION )F WE HAVE THIS MEETING IN YEARS TIME WE STILL COULDNT ANSWER YOUR QUESTION
!HNFELT ET AL -ALCHAU !LL FAILURES AFTER TOTAL HIP ARTHROPLASTY IN 3WEDEN HAVE BEEN RECORDED SINCE USING MEDICAL RECORDS FROM EVERY IMPLANT AND REVISION WHICH WERE DOCUMENTED AND COMPUTER ANALYZED
-ALCHAU
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT
)MPLANT CUP STEM
0ERIOD
.O OF IMPLANTS YEAR SURVIVAL
YEAR SURVIVIAL
%XETER MIXED
n
#HARNLEY
n
3TANMORE
n
%XETER MATT
n
4ABLE 3URVIVAL RATES OF #HARNLEY 3TANMORE AND %XETER 4(2 %XTRACTED FROM THE 3WEDISH 4OTAL (IP 2EPLACEMENT 2EGISTER OF HIPS IMPLANTED BETWEEN n ARRANGED BY YEAR SURVIVAL RATE -ALCHAU ET AL 4ABLE
&IGURE (OWORTH PUBLICITY LITERATURE ON THE INmUENCE OF THE CLEAN AIR ENCLOSURE THE INSIDE OF THE ENCLOSURE IS SHOWN HERE AND THE SURGEONS FULL BODY EXHAUST SUIT C
4HE %XETER STEMS WERE POLISHED FROM n MATT n POLISHED MONOLITHIC n AND MODULAR POLISHED %XETER 5NIVERSAL FROM ON 4HE DATA SHOWN HERE BETWEEN n HAS BOTH MATT AND POLISHED STEMS
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT
/LDER 4HIS IS A COMMENT BECAUSE ) DONT HAVE AN ANSWER "UT WE ARE NOW LOOKING AT WHAT ) FEEL IS THE VERY GUTS OF THE LONGEVITY OF A PROSTHESIS THE INTERFACE BETWEEN THE PROSTHESIS n WHATEVER IT IS n AND THE PATIENTS TISSUE 4HE INTERFACE IS A COMBINATION OF A MECHANICAL AND A BIOLOGICAL RELATIONSHIP MECHANICAL IN TERMS OF THE PROSTHESIS THAT HAS BEEN PUT IN AND THE METHOD OF THE ENTRY OF THAT PROSTHESIS CHOSEN BY THE SURGEON !ND THEN THERE IS THE BIOLOGICAL RELATIONSHIP HOW THE BODY REACTS AT THAT INTERFACE BECAUSE OF WHAT HAS BEEN PUT IN MECHANICALLY )SNT IT TRUE THAT IN THOSE VERY FEW MOMENTS THAT THE SURGEON PUTS THE PROSTHESIS IN BOTH HE AND THE PATIENT ARE GOING TO GOVERN THE LONGEVITY OF THE PROSTHESIS 3O THERE IS A VERY IMPORTANT MECHANICAL ASPECT /NE OF *OHN #HARNLEYS FAVOURITE SAYINGS WAS @-ECHANICAL PROCESS IS FAR MORE IMPORTANT THAN METALLURGY /F COURSE THE COMPOSITION OF THE PROSTHESIS IS IMPORTANT BUT IT IS THIS COMBINATION OF MECHANICAL AND BIOLOGICAL BEHAVIOUR AT THE INTERFACE THAT IS GOING TO DETERMINE WHETHER THAT PROSTHESIS LASTS ONE YEAR OR OR YEARS 4HE FACTORS THAT AFFECT THAT ARE VERY MULTI FACTORIAL AND AS -ICHAEL &REEMAN AND -ICHAEL 7ROBLEWSKI HAVE SAID WE STILL HAVENT GOT THE ANSWER ,ETTIN !LL THESE THINGS WERE KNOWN IN THIS PERIOD THAT WE ARE SUPPOSED TO BE DISCUSSING THE SECOND HALF OF THE TWENTIETH CENTURY AND EVEN EARLIER 7E STILL DONT KNOW THE ANSWER 7E ARE SUPPOSED TO BE DISCUSSING THE EARLY DEVELOPMENT AND ) SUPPOSE WE HAVE DRIFTED A BIT FROM THAT BUT THESE PROBLEMS WERE KNOWN AND THEY HAVENT BEEN RESOLVED 7HAT ABOUT INFECTION 4HAT WAS CERTAINLY KNOWN AND WHO WAS IT SOMEBODY SAID *OHN #HARNLEYS ORIGINAL INFECTION RATE WAS SOMETHING LIKE PER CENT ;&ROM THE mOOR .EARLY PER CENT= ;3EE &IGURE = 7E HAVE HEARD A BIT ABOUT THE GREENHOUSE AND THIS WAS A VERY BIG THING AT ONE STAGE WASNT IT 4HE $O( WAS VERY MUCH CONCERNED WHETHER THE COST OF INTRODUCING BUILDING OR PUTTING CLEAN AIR THEATRES INTO HOSPITALS AND ALL THE REST OF IT WAS COST EFFECTIVE 4HIS WAS A VERY BIG THING AND ) THINK THERE WAS A STUDY BY THE -2# OF WHERE THE INFECTION CAME FROM AND TO MY RECOLLECTION A CHAP CAME TO THE "/! AND TOLD US THAT IT ALL EMANATED FROM THE PERINEUM OF THE SURGEONS AND THE NURSES AND THE IMMEDIATE CONSEQUENCES OF THAT WAS THAT NURSES NO LONGER WORE DRESSES IN THEATRES BUT WORE TROUSERS )T DIDNT SEEM TO ME THAT THAT STOPPED THE APPROPRIATELY OFFENDING BACTERIA FROM DESCENDING THE TROUSER LEG !ND ) THOUGHT ) WOULD CARRY THIS TO ITS CONCLUSION AND ) WENT TO THE THEATRE ONE DAY AND TIED STRING AROUND MY TROUSERS JUST BELOW THE KNEE WHICH LOOKED RATHER LIKE THOSE PICTURES YOU SEE OF LABOURERS IN THE lELDS IN
$(33 AND -2# *OINT 7ORKING 0ARTY
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT
THE NINETEENTH CENTURY AND IT CAUSED CONSIDERABLE HILARITY AMONG THE THEATRE STAFF BUT THE NEXT DAY MY ANAESTHETIST WENT ONE BETTER AND CAME IN WEARING CYCLE CLIPS ON HIS TROUSERS ) SUPPOSE THE CLEAN AIR THEATRE AND THE EXHAUST TUBES WERE REALLY ELIMINATING EXPIRED AIR WHICH THE -2# STUDY AS ) UNDERSTAND IT DEMONSTRATED WAS NOT A GREAT SOURCE OF BACTERIA 7ROBLEWSKI 5P CURRENTS SKIN SCALES THOSE ARE ALSO IMPORTANT NOT JUST EXHALED AIR ,ETTIN .O BUT THE -2# STUDY AS ) UNDERSTAND IT SHOWED ;THAT THE SOURCE OF THE BACTERIA= WAS OVERWHELMINGLY FROM THE PERINEUM $OES NOBODY REMEMBER ;-UCH LAUGHTER= 7HO WAS THE CHAP AT THE "/! WHO GAVE THE TALK WAS IT ,OWRIE OR ,OURIE &REEMAN ) HAVE NOTHING TO CONTRIBUTE EXCEPT THAT SKIN SCALES AND THE PERINEUM ARE RELEVANT BUT NOT THE END OF THE STORY 3WEETNAM -AY ) JUST RAISE ONE POINT ) KEEP ON HARKING BACK TO THIS BUSINESS OF SOMEBODY READING THIS DISCUSSION IN OR YEARS TIME AND ) THINK ONE OF THE THINGS THAT WE OUGHT TO DISCUSS IS THE QUESTION OF THE RELEVANCE OF CLEAN AIR .OW WE ALL ACCEPTED AS GOSPEL THAT CLEAN AIR IS RESPONSIBLE FOR THE REDUCTION OF SEPSIS )S THAT SO !T THE SAME TIME THAT CLEAN AIR WAS INTRODUCED PROPHYLACTIC ANTIBIOTICS WERE ALSO INTRODUCED AND BECAME WIDESPREAD AND THAT WAS THE RECOGNIZED FALLACY OF THE STUDY OF THAT TIME INTO THE EFlCACY OF CLEAN AIR 3O HAS THE DROP IN INFECTION IN TOTAL HIP REPLACEMENTS BEEN DUE TO CLEAN AIR WHICH IS WIDELY USED AT VAST EXPENSE OR PROPHYLACTIC ANTIBIOTICS ) DONT KNOW THE ANSWER MAYBE SOMEBODY ELSE DOES ,ETTIN $IDNT THE -2# DO A MULTI CENTRE TRIAL WHICH INCLUDED 3WEDEN AND THEY COULDNT GET ENOUGH PATIENTS TO MAKE ANY SIGNIlCANT CONCLUSIONS
,IDWELL ET AL 4HIS IS THE lRST REPORT ON THE -2# STUDY OF ULTRACLEAN AIR IN HOSPITALS IN %NGLAND 3COTLAND AND 3WEDEN n 4HE YEAR FOLLOW UP STUDY OF OPERATIONS ON HIPS AND KNEES APPEARS IN ,IDWELL ET AL
4ED ,OWBURY 3EE ,IDWELL ET AL ,OWBURY AND ,IDWELL ,IDWELL ET AL
3EE NOTE $ISCUSSION OF CLEAN AIR VERSUS ANTIBIOTICS CONTINUED THROUGHOUT THE PERIOD &OR EXAMPLE A LETTER TO THE "-* BY THE AUTHORS OF THE -2# STUDY ;,IDWELL ET AL = POINTED OUT POSSIBLE MISLEADING CONCLUSIONS DRAWN BY $R 0 $ -EERS EDITORIAL WAS PRINTED ALONG WITH -EERS REPLY ;-EERS A AND B = &REELY AVAILABLE AT 0UB -ED SEE GATEWAY AT WWWNCBINLMNIHGOVENTREZQUERYFCGI $" PUBMED VISITED .OVEMBER
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3WEETNAM 4HAT IS MY POINT IT WAS DONE BUT NOT ;DIRECTLY= BY THE -2# !CTUALLY IT WAS INCONCLUSIVE BY SCIENTIlC STANDARDS BECAUSE OF THE INTRODUCTION OF ANTIBIOTICS AT THE SAME TIME )NDEED THE AUTHORS ADMITTED IN THEIR ABSTRACT THAT @THE DESIGN OF THE STUDY DID NOT INCLUDE A STRICTLY CONTROLLED TEST OF THE EFFECT OF PROPHYLACTIC ANTIBIOTICS ,ETTIN "UT THEY EVALUATED THE ANTIBIOTICS IN THAT STUDY PURELY AND SIMPLY -Y RECOLLECTION IS THAT IT WAS AN IMPROVEMENT OF TEN TIMES 3WEETNAM ) AM ONLY TALKING ABOUT CLEAN AIR ITS VALUE IS LIKELY BUT NOT ENTIRELY PROVEN 4HERE WAS CRITICISM OF THE TRIAL IN THE CORRESPONDENCE COLUMNS OF THE "RITISH -EDICAL *OURNAL "-* LATER
&IGURE #ASELLA SLIT SAMPLER !)2 USED IN THE CLEAN AIR ENCLOSURE ORIGINALLY DEVELOPED BY THE -EDICAL 2ESEARCH #OUNCIL 3EE "OURDILLON ET AL
,OWBURY AND ,IDWELL ,IDWELL ET AL 3EE NOTE
,IDWELL ET AL
4HE NUMBER OF PATIENTS BEING OPERATED ON IN ALL CONDITIONS WHO DID NOT RECEIVE ANTIBIOTICS AND WHOSE IMPLANT HAD NO SEPSIS WAS PER CENT COMPARED TO PER CENT OF THOSE RECEIVING ANTIBIOTICS mUCLOXACILLIN ,IDWELL ET AL 4ABLE )6 3EE ALSO (ILL ET AL 4AGGART ET AL
-EERS A 3EE NOTE
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT
&IGURE 4WO 0ETRI DISHES FROM A SLIT SAMPLER WITH A ROTATION TIME OF MINUTES C "ACTERIA GROWN FROM AIR SAMPLED , INSIDE ENCLOSURE 2 OUTSIDE ENCLOSURE
,ADY #HARNLEY )F MY MEMORY SERVES ME RIGHT ) REMEMBER VERY MUCH THAT WHEN THAT STUDY CAME OUT *OHN WAS ABSOLUTELY DELIGHTED THAT IT WAS AGREEING WITH HIS lGURES THAT CLEAN AIR MADE A POTENTIAL DIFFERENCE TO INFECTION !ND ) WOULD ALSO LIKE TO REMIND PEOPLE THAT HE DEVELOPED THE BODY EXHAUST SYSTEM WHICH HE FOUND TREMENDOUSLY BENElCIAL ) AM AFRAID ) THINK IT HAS GONE OUT OF FASHION BUT IT DID HAVE AN ENORMOUS EFFECT ON THE RESULTS OF INFECTION AT 7RIGHTINGTON ,ETTIN )T WAS VERY COMFORTABLE IN THE SENSE THAT YOU HAD NICE AIR ,ADY #HARNLEY (E ALWAYS SAID IT WAS LIKE OPERATING ON TOP OF A MOUNTAIN -R 2EG %LSON 4HE -2# TRIAL SHOWED CONCLUSIVELY AS FAR AS ) AM CONCERNED THAT THERE WAS A SUMMATION BETWEEN THE EFFECTS OF SYSTEMIC ANTIBIOTICS AND CLEAN AIR !T 7RIGHTINGTON THE INFECTION RATE FELL STEEPLY WITH THE INTRODUCTION OF THE CLEAN AIR ENCLOSURE AND WITHOUT SYSTEMIC ANTIBIOTICS 4HERE IS NO DOUBT THAT IF FOR EXAMPLE YOU STAND OVER A 0ETRI DISH IN A CLEAN AIR ENCLOSURE AND YOU WAVE YOUR ARMS ABOUT IN A STERILE DOWN DRAUGHT YOU WILL GET ;BACTERIAL= CULTURES
&OR A DISCUSSION OF THE RECENT DECLINE OF DISCIPLINE IN OPERATING THEATRES SEE 3# A AND B
"OURDILLON ET AL "LOWERS AND #REW ,IDWELL AND 7ILLIAMS (UGHES 4HE INCIDENCE OF INFECTION IN HIP REPLACEMENT SURGERY FROM THE -2# TRIAL WAS LESS THAN PER CENT IN ,IDWELL ET AL 3EE NOTE 3EE ALSO ,IDWELL
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT
,ETTIN "UT ALL ORTHOPAEDIC THEATRES ARE NOW CLEAN AIR THEATRES %LSON )N THE MAJORITY OF CASES REPLACEMENTS ARE DONE IN CLEAN AIR "UT YOU SEE ILLOGICALLY SOME SURGEONS OPERATE WITHOUT A HOOD ONLY A CAP AND THE DOWN DRAUGHT IS ACTUALLY DANGEROUS #RAVEN 7HEN WE WERE DOING THIS WORK AT 7RIGHTINGTON ) MADE A SLIT SAMPLER THAT WOULD RUN FOR ONE HOUR AND WE USED TO TAKE READINGS ALL THE TIME *OHN #HARNLEY WAS OPERATING 7E TOOK READINGS ON A INCH CULTURE PLATE SO THESE COULD BE SENT TO THE LAB AND CHECK WHAT BACTERIA WERE ON IT ;SEE &IGURE = ) REMEMBER #HARNLEY PUT *OHN 2EAD IN A BAG AND HAD HIM WAVE HIS ARMS ABOUT AS THIS GENTLEMAN IN FRONT OF ME WAS DOING AND IF YOU HAD RECENTLY HAD A SHOWER THE BACTERIA THAT CAME OUT WAS WORSE THAN IF YOU HADNT BECAUSE ALL YOUR PORES WERE OPEN $EANE 4HE lRST CLEAN AIR ENCLOSURE OUTSIDE 7RIGHTINGTON WAS SET UP AT THE .UFlELD /RTHOPAEDIC #ENTRE IN /XFORD AND ) WAS RESPONSIBLE FOR COMMISSIONING THIS ENCLOSURE )T WAS ALL VERY SPLENDID 4HERE WERE QUITE A LOT OF RUNNING IN PROBLEMS GETTING IT THE WAY IT WAS MEANT TO BE BECAUSE THIS WAS THE lRST ONE OUTSIDE 7RIGHTINGTON 4HE WEEK AFTER IT WAS COMMISSIONED ) WROTE TO (OWORTH BECAUSE OF INTEREST FROM A FOREIGN VISITOR WHO HAD SEEN THESE ENCLOSURES IN USE IN THIS lRST WEEK AND LIKED THE LOOK OF THEM (E EXPRESSED INTEREST IN POSSIBLE SUPPLY TO HIS COUNTRY AND ) AGREED TO ENQUIRE FOR HIM ) HAD A LETTER BACK THE SECOND SENTENCE OF WHICH ) WILL NEVER FORGET )T SAID APPROXIMATELY @7E NO LONGER SUPPLY THE (OWORTH TYPE ENCLOSURE AS YOUR SPECIlCATION AS WE CONSIDER IT TOO COSTLY FOR PUBLICLY OWNED HOSPITALS ) STILL HAVE THAT LETTER 3INCE THAT TIME THE EXCELLENT CONCEPT OF CLEAN AIR THEATRES INCLUDING THE BODY EXHAUST SYSTEM HAS DEVELOPED FURTHER ) AM CONCERNED THAT THE DEVELOPMENT OF CLEAN AIR ENCLOSURES HAS PRODUCED SOME WITH HORIZONTAL LAMINAR mOW AND SOME WITH VERTICAL LAMINAR mOW BUT THE BODY EXHAUST SYSTEM HAS DISAPPEARED ) THINK THIS IS ACTUALLY PRODUCING WORSE CONDITIONS WITH THE UNSTERILE SURGEON AND OTHER PEOPLE STANDING IN A BEAUTIFUL BLAST OF CLEAN AIR AND INTERRUPTING ITS mOW OVER THE PATIENT AS 2EG %LSON HAS JUST SAID &REEMAN )F YOU HAVE VERTICAL DOWNmOW AND THEN YOU HAVE TO WORRY ABOUT THE LIGHTING OF THE OPERATING TABLE UNLESS THEY ARE VERY CAREFULLY CLEANED THE LIGHTS
7HILE AT THE .UFlELD /RTHOPAEDIC #ENTRE -R 'RAHAM $EANE UNDERTOOK RESEARCH ON HORIZONTAL LAMINAR AIR mOW PHOTOGRAPHING THE AIR mOW OVER THE OPERATING TABLE AND SURGICAL TEAM 4HE RESULTS WERE NOT PUBLISHED &OR A DISCUSSION OF THE RECENT DECLINE OF DISCIPLINE IN OPERATING THEATRES SEE THE 3COTTISH 3OCIETY FOR #ONTAMINATION #ONTROL 3#
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT
ARE A SOURCE OF DIRT THAT IS BLOWN STRAIGHT DOWN INTO THE WOUND SO THE AIR IS STERILE AT THE ROOF BUT IT ISNT ON THE LEVEL OF THE WOUND #OULD YOU ASK THEM -R #HAIRMAN WHAT IS IT THAT WE ARE TALKING ABOUT 7HAT IS THE INFECTION RATE NOW IN THE 5+ !S RETIRED SURGEONS WE HAVE NO IDEA ) DONT THINK HAVE WE 7ROBLEWSKI PER CENT OVER YEARS &REEMAN .O NOT YOURS 7ROBLEWSKI /H ) SEE $ARRAH 4HE (EALTH 0ROTECTION !GENCY NOW RUN MANDATORY DATA COLLECTION ON ONE OF THREE INDICATORS IN ANY HOSPITAL AT ANY TIME IN NECK OF FEMUR FRACTURES TOTAL HIPS OR TOTAL KNEE REPLACEMENTS $ATA IS COLLECTED FOR THREE MONTHS n AND THIS IS MANDATORY GOVERNMENT SURVEILLANCE UNLIKE THE .ATIONAL *OINT 2EGISTRY 4HIS IS HOW INFECTION RATES ARE KNOWN 4HE RATES ARE PUBLISHED AND EVERY HOSPITAL IN THE COUNTRY HAS TO SUPPLY THE DATA IN ONE OF THOSE THREE INDICATIONS 3O DEPENDING ON WHAT INDICATIONS YOU COLLECT THE DATA FOR YOU HAVE THE INFECTION RATE FOR THAT INDICATOR FOR THAT HOSPITAL ,ETTIN 7HAT ABOUT .ORWICH $ARRAH 4HE INFECTION RATE FOR TOTAL HIP REPLACEMENT AT THE MOMENT IS UNDER PER CENT 4HE (EALTH 0ROTECTION !GENCY HAS A MANDATORY DATA COLLECTION FOR A THREE MONTH PERIOD IN ANY MONTHS AND THEY COLLECT THE DATA DURING THE OPERATIVE STAY AND UP TO SIX WEEKS POST OPERATIVELY ,ETTIN )T DID DROP TO PER CENT AT ONE TIME DIDNT IT IN *OHN #HARNLEYS UNIT 7ROBLEWSKI 4HREE MONTHS IS NOT LONG ENOUGH )F YOU ARE TALKING ABOUT PATIENTS WITH DEEP INFECTION AFTER TOTAL HIP ARTHROPLASTY YOU NEED ABOUT FOUR YEARS TO COVER ABOUT PER CENT REVISIONS FOR DEEP INFECTION $EEP INFECTION GIVEN TIME WILL PRESENT ITSELF BUT IT TAKES LONGER THAN NINE MONTHS ,ETTIN 3O WE ARE TALKING ABOUT REALLY ACUTE INFECTIONS THE INCIDENCE OF ACUTE INFECTION WITHIN THE THREE MONTHS OF THE OPERATION IS PER CENT &REEMAN )F YOU ARE SAYING THAT THE INFECTION RATE IN A VERY GOOD HOSPITAL IS UNDER PER CENT WHICH MEANS ITS ABOVE PER CENT NEARLY PER CENT WITHIN THREE MONTHS AND YOU MULTIPLY THAT BY FOUR OR lVE TO GET THE LONG TERM lGURE
3EE NOTE
-S #LARE $ARRAH WROTE @&OR *ANUARYn$ECEMBER PER CENT .OTE ON DRAFT TRANSCRIPT *ULY
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT
WE ARE LOOKING AT SOMETHING LIKE PER CENT PER CENT INFECTION RATE IN THE LONG TERM %LSON !LSO THERE IS ANOTHER FACTOR IN THIS THE TEMPORAL SAMPLING OF THREE MONTHS IS TOTALLY INACCURATE BECAUSE THESE THINGS GO IN BURSTS 7HAT -IKE WAS TRYING TO SAY WAS THAT THREE MONTHS SAMPLING IS A WORTHLESS MEASURE OF DEEP INFECTION .INETY PER CENT OF DEEP INFECTIONS WILL OCCUR DURING THE lRST YEAR BUT COULD COME IN ANY OF THE lRST THREE MONTHS AND THEY TEND TO COME IN BURSTS 9OU GET BURSTS OF INFECTION LOCALIZED TO ABOUT A WEEK 0ROFESSOR *OHN 0ICKSTONE ) WAS STRUCK BY THE ACCOUNT OF #HARNLEY OF WORKING IN AN OLD HOSPITAL IN A THEATRE THAT WAS USED BY LOTS OF OTHER PEOPLE )S IT THE CASE THAT THE INFECTION WAS MORE OF A PROBLEM AT 7RIGHTINGTON THAN IT WAS AT OTHER EARLY CENTRES BEFORE CLEAN AIR ENCLOSURES SPREAD ,ETTIN )T WAS CERTAINLY REGARDED AT THE TIME AS BEING QUITE HIGH WASNT IT !ND THAT WAS WHY *OHN #HARNLEY INTRODUCED THE GREENHOUSE 0ICKSTONE 9ES ) KNOW THATS WHY HE INTRODUCED THE GREENHOUSE BUT WERE HIS PROBLEMS PARTICULARLY SEVERE BECAUSE OF WHERE HE WAS WORKING OR WAS HE SIMPLY THE lRST PERSON TO GET TO GRIPS WITH THESE PROBLEMS 7ROBLEWSKI "ECAUSE OF DIFFERENT SURGEONS ;USING THE SAME THEATRE= &REEMAN (E WAS THE lRST TO GET TO GRIPS WITH THEM 0ICKSTONE ) MEAN THE PROBLEMS OF BAD THEATRES WERE BY NO MEANS CONlNED TO 7RIGHTINGTON 7ERE THE INFECTION RATES AT OTHER EARLY SITES MUCH THE SAME AS THEY WERE AT 7RIGHTINGTON &REEMAN 4HEY WERE MUCH WORSE 4HERE WERE BIRDS mYING AROUND 4UCKER ) WOULD LIKE TO TOUCH ON THE HISTORICAL ASPECT ) THINK THAT THE CONCEPTS OF @DEEP INFECTION AND @SUPERlCIAL INFECTION THE WORDS WE USE TODAY WERENT TERRIBLY WELL DElNED IN THE LATE S +EN -C+EE WOULD SOMETIMES SEE A WOUND THAT WAS DISCHARGING AND HE WOULD SAY THAT IT WAS A @REJECTION ) DONT THINK WE UNDERSTOOD THEN WHAT WAS GOING ON 3WABS WERE TAKEN AND CAME BACK FROM THE LABORATORY WITH REPORTS OF 3TAPHYLOCOCCUS EPIDERMIDIS COAGULASE NEGATIVE 3TAPHYLOCOCCUS OR PERHAPS A BOWEL ORGANISM 4HE LABORATORIES WERE SAYING THAT THESE WERE EITHER NORMAL SKIN mORA OR CONTAMINATION
3TAPHYLOCOCCUS EPIDERMIDIS THE MOST IMPORTANT OF THE COAGULASE NEGATIVE STAPHYLOCOCCI #O.3 CAN CAUSE INFECTION IN IN DWELLING MEDICAL DEVICES
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7E NOW KNOW THAT THESE ORGANISMS ARE AN AWFUL NUISANCE AND IN HINDSIGHT THEY USUALLY INDICATED THE PRESENCE OF A DEEP INFECTION WITH A DISCHARGING SINUS !T THE TIME WE WERE LIVING WITH A VIEW EMANATING FROM MANY HIGHLY REGARDED BACTERIOLOGY DEPARTMENTS THAT WE SHOULDNT TREAT INFECTION UNTIL WE HAD ISOLATED THE ORGANISM 3OME BACTERIOLOGISTS SAID THAT PROPHYLACTIC ANTIBIOTICS WERE TOTALLY OUT OF ORDER ) THINK IT SHOULD GO ON RECORD THAT ORTHOPAEDICS TAUGHT BACTERIOLOGY DEPARTMENTS QUITE A BIT AROUND THE LATE S AND EARLY S /NE THING WE HAVENT RECORDED IN OUR DISCUSSION IS THE INTRODUCTION OF 'ENTAMICIN IMPREGNATED CEMENT FOLLOWING THE WORK OF "UCHHOLZ &OR MANY PATIENTS THIS MADE A LOT OF DIFFERENCE ,ETTIN 4HAT IS REALLY GOING BACK TO OUR ORIGINAL TERMS OF REFERENCE SO TO SPEAK AND WE HAVE MOVED ON QUITE A BIT ) THINK PROBABLY THIS WOULD BE THE APPROPRIATE TIME TO MOVE ON TO REVISION BEFORE WE lNALLY WIND UP WITH RESULTS AND FOLLOW UP 2EG ;%LSON= PERHAPS YOU WOULD LIKE TO TALK ABOUT REVISION THE MOST DIFlCULT CAUSE OF WHICH WAS INFECTION BUT NO DOUBT YOU WILL EMBRACE ALL THE REASONS FOR REVISING THINGS AND HOW DIFlCULT IT COULD BE IN MERE MORTALS HANDS %LSON ) WONDERED WHAT TO SAY ON THE TRAIN COMING DOWN AND ) AM STILL WONDERING NOW ) HAVE PROBABLY DONE AS MANY REVISION HIPS AND PROBABLY KNEES AS ANYBODY ELSE IN THE ROOM ) HAVE INDUSTRIAL DEAFNESS AS A RESULT OF WORKING WITH #HARNLEY THAT TERRIBLE NOISE OF AIR RUSH AGAINST YOUR EARDRUMS ) AM THINKING OF SUING .OW ITS AXIOMATIC THAT EVERY HIP WILL WEAR OUT BREAK FALL OUT IF THE PATIENT LIVES LONG ENOUGH ) AM AMAZED THAT SO MANY COLLEAGUES STILL WILL ALLOW PATIENTS TO DO WHATEVER THEY LIKE IN TERMS OF PHYSICAL ACTIVITY YOU SEE THESE GLAMOROUS PHOTOGRAPHS IN lLMS OF PEOPLE PLAYING TENNIS OR SKIING 2ECENTLY ) HAVE DONE A STUDY ON THE ACTUAL LOADING OF THE HIP IN CERTAIN POSTURES AND IF n AS THE 3WISS DO THEY ALLOW THEIR PATIENTS TO GO SKIING n THE LOAD THAT YOU CAN CALCULATE ON THE HIP IS WAY ABOVE ANYTHING ;*OHN= 0AUL TAUGHT US ABOUT X BODYWEIGHT FOR NORMAL BRISK WALKING TEN TIMES BODY WEIGHT QUITE APART FROM ANY EXTRA
"UCHHOLZ INTRODUCED THE USE OF ANTIBIOTIC LOADED CEMENT IN "UCHHOLZ AND %NGELBRECHT 7AHLIG AND "UCHHOLZ 7AHLIG ET AL 4AGGART ET AL
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DYNAMIC COMPONENT )T IS EXTRAORDINARY "UT SOMEBODY STANDING WITH THEIR HIP AT THE INWARD FORCE ON THAT HIP IS BEYOND BELIEF ) CANNOT BELIEVE THAT THERE WILL NOT BE A NEED FOR REVISION IN THE FUTURE ) CAME ON TO THE SCENE AT A TIME OF OPERATING RELATIVELY SPEAKING ) HAD THE BENElTS OF THE %NGLISH TRIO 2ING #HARNLEY AND -C+EE 4HEY HAD ALL THE INGREDIENTS ALBEIT WITH DIFFERENT MATERIALS AND THE LIKE EXCEPT FOR TITANIUM AND FOR (!# ;HYDROXYAPATITE COATING= 7HEN THE HIP ESCAPED FROM THIS COUNTRY IT WAS LARGELY THE POLYETHYLENE AGAINST POLISHED METAL THAT WAS THE POPULAR IMAGE AND ONCE IT WAS RELEASED ESPECIALLY IN THE 53 BECAUSE OF THE CRUDE METHOD OF OPERATING WITHOUT EVEN THE INSTRUCTION THAT PEOPLE ;SURGEONS= WOULD GET FROM 7RIGHTINGTON THERE WAS A VAST FAILURE RATE "UT IT WAS ALSO HAPPENING IN THIS COUNTRY PROPORTIONALLY THE SAME ) SUSPECT !LONGSIDE THIS THERE WAS A LOT OF DEVELOPMENT ACTIVITY ON THE #ONTINENT ALTHOUGH WE LIVE NEXT DOOR TO THEM REMARKABLY WE KNOW NOTHING ABOUT ;THEIR WORK= .OW IF WE FORGET
0ROFESSOR *OHN 0AUL WROTE @4HE "IOMECHANICS 'ROUP AT THE 5NIVERSITY OF 3TRATHCLYDE WAS ASKED BY -R *AMES 4ULLOCH "ROWN &2#3 TO ASSIST IN THE DESIGN OF A DEVICE FOR lXATION OF FEMORAL NECK FRACTURES ! REVIEW OF THE LITERATURE PROVIDED THE VALUE OF HIP JOINT FORCE OF TIMES BODY WEIGHT WHEN STANDING ON ONE LEG ;)NMAN 0AUWELS = AND THE INTER SEGMENT FORCES AND MOMENTS AT THE HIP DURING LEVEL WALKING ;"RESLER AND &RANKEL = BUT NO VALUES OF JOINT FORCE IN WALKING HAD BEEN ESTABLISHED 7E SET UP A GAIT LABORATORY MANUFACTURING A FORCE PLATFORM FOR GROUND TO FOOT FORCE MEASUREMENT AND ARRANGING TWO MM CINE CAMERAS VIEWING FROM THE FRONT AND THE SIDE OF THE TEST SUBJECTS WHICH ALLOWED DETERMINATION OF THE THREE DIMENSIONAL COORDINATES DElNING THE POSITION OF THE PELVIS 4HIS ALLOWED US TO CALCULATE THE INTER SEGMENT FORCE AND MOMENTS ACTING BETWEEN THE THIGH AND THE PELVIS 6ALUES OF FORCES IN THE RELEVANT MUSCLES WERE CALCULATED BY SELECTIONS FROM THE TWO GROUPS OF EXTENSOR MUSCLES TWO GROUPS OF mEXORS AND ONE GROUP FOR ABDUCTORS AND ONE FOR ADDUCTORS 4HE JOINT FORCE WAS THEN CALCULATED FROM THE GROUND FORCE AND THE RELEVANT MUSCLE FORCES AT TIME INTERVALS OF SECONDS 4HE CALCULATED JOINT FORCE VALUES WERE FROM TO TIMES BODY WEIGHT A MEAN OF 4HE TIMES VALUE WAS DEVELOPED BY ONE SUBJECT WALKING AT MS ;METRESSECOND= WITH A STRIDE LENGTH OF M 4HESE STUDIES SUGGEST THAT THE HIP JOINT FORCE IN WALKING DEPENDS LARGELY ON THE PRODUCT OF BODY WEIGHT AND STRIDE LENGTH *OINT FORCES OF AND TIMES BODY WEIGHT RESPECTIVELY WERE FOUND AND ENTRY OR LEAVING A CAR AT TIMES -R 2EG %LSON ;PAGE = MUST BE EXTRAPOLATING FROM THE FOREGOING DATA SINCE WE HAVE NOT UNDERTAKEN TESTS ON RUNNERS 4ESTS UNDERTAKEN ON TWO OF THE PATIENTS WHO HAD RECEIVED THE TELEMETERING HIP JOINT REPLACEMENT DEVELOPED BY "ERGMANN ET AL ; = GAVE CURVES OF VARIATION WITH TIME SIMILAR TO THOSE CALCULATED FROM GAIT ANALYSIS ALTHOUGH THE MAXIMUM VALUES DIFFERED BY APPROXIMATELY PER CENT ON AVERAGE !N IMPORTANT FEATURE OF HIP JOINT LOADING IS THE DIRECTION OF THE JOINT FORCE RELATIVE TO THE AXIS OF THE FEMUR )N WALKING THIS MAY BE DEGREES IN THE FRONTAL PLANE AND DEGREES IN THE SAGITTAL PLANE 4HE LATTER GIVES RISE TO A STRONG TWISTING MOMENT BETWEEN A FEMORAL IMPLANT AND THE SHAFT OF THE FEMUR AND THE EFFECT WILL BE GREATER IN STAIR NEGOTIATION AND SPRINTING % MAIL TO -RS ,OIS 2EYNOLDS /CTOBER 3EE 0AUL -ARKOLF ET AL "ERME AND 0AUL 3TANSlELD ET AL 3EE ALSO VAN DEN "OGERT ET AL
3TEPHENSON ET AL
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INFECTION WHICH IS ONE SOURCE OF LOOSENING ) WILL RETURN TO THIS LATER IF THERES TIME THE MAIN SERIOUS PROBLEM IS ONE OF MECHANICAL LOOSENING n INSTABILITY DISLOCATION AND IMPINGEMENT n SOMETHING THAT IS OBVIOUS QUICKLY -ECHANICAL LOOSENING SO CALLED IS DUE TO OSTEOLYSIS DUE TO WHATEVER CAUSE n AND THAT CAN BE A BAD SURGEON AS HAS BEEN SHOWN IN THE 4RENT 2EGIONAL !RTHROPLASTY PANEL /THERWISE IT CAN SIMPLY BE DUE TO POLYETHYLENE DEBRIS .OW -ICHAEL &REEMAN WAS PIVOTAL IN MY DEVELOPMENT IN THIS TRAIN OF THOUGHT AT AN ILLUSTRIOUS MEETING IN 0ARIS THAT SHALL BE NAMELESS ) THINK YEARS AGO -ICHAEL GAVE A LECTURE WHICH WAS UNIQUE IN MY EXPERIENCE BECAUSE HE PRODUCED ONE SLIDE WHICH WAS A FAILED CEMENTED PROSTHESIS WITH ALL THE CHARACTERISTIC mUFlNESS AND IN THE RADIOLUCENT ZONES (E THEN CHALLENGED THE AUDIENCE TO SAY WHAT COULD BE DONE TO REVISE THIS $UTIFULLY BECAUSE ) WAS A CEMENTER ) PUT MY HAND UP AND SAID @) WOULD CEMENT IT 3UBSEQUENTLY AFTER THAT BRILLIANT PRESENTATION WHICH YOU ;-ICHAEL &REEMAN= DONT REMEMBER BUT WHICH CHANGED MY VIEW TO THE FACT THAT REVISION SURGERY ALMOST CERTAINLY SHOULD ENTAIL UNCEMENTED COMPONENTS UNLESS YOU ARE DEALING WITH SOME IMPOSSIBLE SITUATION WITH VERY VERY THIN WEAK BONE OR PERHAPS A STOVE TYPE FEMUR OR PERHAPS AN ACETABULUM THATS GONE RIGHT THROUGH &ORGETTING INFECTION ) THINK THAT NON CEMENTED REVISION IS PROBABLY GOING TO BE THE ANSWER ) FEEL SAD ABOUT IT BECAUSE ) HAVE ALWAYS BEEN A CEMENTER BUT ) MUST CONFESS THAT IF ) WERE BEGINNING AGAIN ) WOULD BE AN UN CEMENTER ) WOULD STILL WANT TO HAVE CEMENT AVAILABLE AND ) WOULD STILL WANT TO KNOW HOW TO USE IT BECAUSE IT IS A VERY SPECIAL TOOL THAT HAS ) THINK A SPECIAL PLACE ) WANT TO PAY TRIBUTE TO (ANS "UCHHOLZ A NAME THAT HAS BEEN MENTIONED "UCHHOLZ PRODUCED A MOST REMARKABLE SERIES OF JOINT REPLACEMENTS THE PRINCIPLES OF WHICH HAVE SURVIVED BUT HE ALSO INTRODUCED THIS NAIVE CONCEPT OF THROWING SOME ANTIBIOTICS INTO THE CEMENT AND IT WOULD GIVE YOU PROTECTION 4HERE IS NO DOUBT THAT IT DOES 7HETHER THATS A GOOD THING OR WHETHER WE SHOULD BE PURISTS AND RELY ON PROPHYLACTIC ANTIBIOTICS OR CLEAN AIR OR BOTH PREFERABLY IS NOT PART OF THE ARGUMENT ) THINK ) WILL lNISH BY JUST SAYING THAT FAILURE IS TERRIBLY IMPORTANT ITS VERY IMPORTANT THAT WE HAVE REVISIONS BECAUSE IF YOU DONT HAVE REVISIONS YOU WOULDNT REALLY KNOW WHICH WAS THE BEST PROSTHESIS TO USE WOULD YOU ,ETTIN "EFORE YOU lNISH IN TERMS OF REVISION MAY ) ASK WHEN THE CONCEPT OF IMMEDIATE REPLACEMENT BEGAN IN THIS PERIOD THAT WE ARE CONSIDERING )NITIALLY
4HE 4RENT REGISTER WAS ESTABLISHED IN (ARPER ET AL &ENDER ET AL (ASSAN ET AL
! RADIOLUCENT ZONE IN AN 8 RAY PERMITS THE PASSAGE OF 8 RAYS UNLIKE ONE THAT IS RADIO OPAQUE
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YOU DID NOTHING YOU BASICALLY LEFT IT ;&ROM THE mOOR !RE YOU TALKING ABOUT INFECTION = ;9ES= WITH AN EXCISION ARTHROPLASTY %LSON 5NTIL "UCHHOLZ INTRODUCED THE ONE STAGE n AND SOMETIMES TWO STAGE n REPLACEMENT WITH ANTIBIOTIC LOADED CEMENT THE MAJORITY OF #HARNLEYS CASES WERE ALWAYS CONVERTED TO A PSEUDOARTHROSIS WHICH WAS THE ONLY THING THAT COULD BE DONE ) WAS PRIVILEGED TO TREAT SOME OF *OHN #HARNLEYS INFECTIONS THERE WERE VERY VERY FEW AS YOU MIGHT IMAGINE AND HE DIDNT BELIEVE IN THE "UCHHOLZ TECHNIQUE AT lRST ,ETTIN )T WENT AGAINST THE ACCEPTED NORMAL SURGICAL PRINCIPLE DIDNT IT TO PUT FOREIGN MATERIAL INTO AN INFECTED AREA %LSON !BSOLUTELY BUT THERE IS NO QUESTION THAT IT WORKS AND IT PROTECTS FOR EXAMPLE IN MORSELIZED GRAFTING IF YOU CHOOSE TO GO DOWN THAT LINE ,ETTIN 7HAT WAS THE DATE OF THAT 7HEN DID WE START %LSON !S FAR AS ) AM CONCERNED ,ETTIN 4HAT WAS WHAT ) WANTED TO GET DOWN BECAUSE THIS WAS RATHER A BIG THING WASNT IT %LSON ) THOUGHT IT WAS AND ) DID SOME ANIMAL STUDIES IN THIS COUNTRY AND CHECKED THE VARIOUS THINGS THAT "UCHHOLZ RECOMMENDED AND IT ALL SEEMED TO lT TOGETHER ) REMEMBER "UCHHOLZ PUTTING HIS HAND ON MY SHOULDER AND SAYING @%LSON YOU WILL COME AND WORK FOR ME IN 'ERMANY AND ) SAID @.OT ON YOUR NELLY !NYWAY ) WENT TO 'ERMANY FOR A YEAR n "UCHHOLZ HAD HIS FAULTS n THERES NO QUESTION n BUT HE HAD CHARISMA ) WILL TELL YOU ONE LITTLE STORY "UCHHOLZ CAME ACROSS JUST AFTER THE WAR MET #HARNLEY WHO WOULDNT TALK TO HIM BECAUSE HE HAD A SABRE SCAR ON HIS FACE #HARNLEY SENT HIM AWAY AGAIN BUT "UCHHOLZ CAME BACK AND BY THAT TIME WE WERE IN THE 2#( HIGH DENSITY POLYETHYLENE ERA ;= "UCHHOLZ ASKED #HARNLEY @7HAT IS THIS STUFF (E HAD ALREADY BEEN TO SEE -AURICE -ÓLLER AND -AURICE HAD GOT THE MAGIC FORMULA FROM #HARNLEY -ÓLLER SAID @/H ITS A TRADE SECRET AND WOULDNT TELL HIM #HARNLEY SAID TO "UCHHOLZ @4HE STUFF WAS MADE IN YOUR COUNTRY YOU MIGHT AS WELL USE IT MIGHTNT YOU
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%LSON ET AL A AND B
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,ETTIN ) THINK YOU HAVENT TOLD US YOUR CONTRIBUTION TO THIS BUT PERHAPS *OHN 2EAD WHO WAS ALSO A REVISER WILL TELL US ABOUT THESE EARLY REVISION TECHNIQUES 2EAD 4HE EARLIEST REVISION TECHNIQUE WAS TAKING EVERYTHING OUT AND TRYING TO CURE THE INFECTION AND THEN OFTEN LEAVING THEM AS A 'IRDLESTONE ,ATER WE STARTED REVISING THEM AND WITH ANTIBIOTIC LOADED CEMENT ,ETTIN )AN 3TEPHEN HAS GONE ) THINK BECAUSE HE WOULD PROBABLY WELL 2OBIN ,ING WOULD HAVE A LOT TO SAY ON THE SUBJECT OF PUTTING BONE GRAFTS IN AND OTHER THINGS INTO INFECTED SURGICAL BEDS %LSON !LAN ) THINK WE SHOULD DISTINGUISH BETWEEN REVISION FOR STERILE LOOSENING AND FOR INFECTION THEY ARE TWO DIFFERENT THINGS EXCEPT THAT IN BOTH THE ENDOSTEAL SURFACE OF THE FEMUR IS DAMAGED VERY QUICKLY IT BECOMES SMOOTH AND GLASS LIKE AND SLIMEY AND IS TOTALLY UNSUITED FOR CEMENTING ) SPENT HOURS AND HOURS AND HOURS TRYING TO CUT GROOVES TO GIVE SOME KEY BUT HOWEVER CAREFULLY YOU DO IT YOU CANNOT MIMIC THE VIRGIN RUGOSE ENDOSTEAL SURFACE /NCE THE FAILURE IS RECOGNIZED TO BE SUFlCIENTLY PROGRESSIVE REVISION SHOULD BE DONE AS SOON AS POSSIBLE ,ETTIN ) THINK WE WILL HAVE TO PRESS ON (AS ANYBODY ANYTHING ELSE TO SAY +EITH 4UCKER 7E HAVENT MENTIONED ANAESTHETISTS AND ANAESTHETICS ) WONDER IF WE COULD JUST FOR A MOMENT BECAUSE THEY ARE QUITE IMPORTANT FROM THE HISTORICAL PERSPECTIVE ) REMEMBER HOW WORRIED WE WERE WHEN CEMENT WAS INTRODUCED TO THE FEMORAL CANAL WHEN WITH PRESSURIZATION OCCASIONALLY PATIENTS COULD DIE 4HE ANAESTHETISTS AT THAT TIME TRIED TO GET THE BLOOD PRESSURE UP BECAUSE THEY WERE WORRIED ABOUT IT FALLING SOMETHING OF A REVERSE FROM TODAYS PRACTICE (IP SURGERY HAS PROMOTED SPECIALIST ANAESTHETISTS WHO NOW UNDERSTAND THE USE OF SPINAL ANAESTHETICS EPIDURALS ETC AND THIS HAS MADE HIP REPLACEMENT A LOT SAFER )N THE LATE S AND THROUGH THE S MOST PATIENTS HAD THREE UNITS OF BLOOD AS A MINIMUM FOR A HIP REPLACEMENT BUT WITH THE ADVANCES OF ANAESTHESIA AND THE BETTER UNDERSTANDING OF HAEMODYNAMICS NOWADAYS MANY PATIENTS DONT HAVE A TRANSFUSION
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(ALLIDAY ET AL
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0HILLIPS ET AL "UERKLE AND %FTEKHAR /H ET AL 2ANDALL ET AL
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,ETTIN 9ES MOST OF YOU PROBABLY REMEMBER THAT (UGH 0HILLIPS AND ) AND MY ANAESTHETIST PUBLISHED A PAPER IN THE "RITISH -EDICAL *OURNAL "-* n ONLY THE SECOND ONE ) EVER HAD IN THE "-* n AND THAT WAS ON THE CARDIOVASCULAR EFFECTS OF IMPLANTED ACRYLIC CEMENT 4HIS lTS IN WITH WHAT ) WAS SAYING EARLIER ABOUT THIS CHAP AT .ORTH (ILL 0LASTICS BECAUSE HE PAID FOR A TECHNICIAN BUT ) AM NOT GOING TO GO INTO THAT ANY FURTHER )T WAS SOMETHING THAT CONCERNED THE $O( WHICH SET UP A WORKING PARTY ON IT BECAUSE PEOPLE WERE GETTING ALARMED ABOUT PATIENTS DYING WHILE HAVING MAINLY CEMENTED 4HOMPSONS PROSTHESES FOR FRACTURES RATHER THAN 4(2 7E WONT PURSUE THAT BUT YOU ARE QUITE RIGHT THAT THE ADVANCES IN ANAESTHETICS ARE VERY IMPORTANT 7E ARE GETTING CLOSE TO TIME AND WE OUGHT JUST TO TALK ABOUT THE RESULTS OF FOLLOW UP AND WE HAVE HEARD HOW DIFlCULT IT IS AND HOW WE HAVENT DONE OUR JOB PROPERLY BUT -ICHAEL 7ROBLEWSKI CERTAINLY HAS ) BEG YOUR PARDON 'RAHAM $EANE 3ORRY ) DIDNT MANAGE TO CATCH YOUR EYE #HAIRMAN ON A POINT ON ANAESTHETICS 7HEN ) WAS IN /XFORD THIS BUSINESS OF DROP IN BLOOD PRESSURE ASSOCIATED WITH CEMENT WAS BEING LOOKED INTO 4HEY CAME TO THE CONCLUSION n ) AM A LITTLE BIT HAZY ON THIS NOT KNOWING THE ANAESTHETIC SIDE n THAT THE USE OF A NEUROLEPTIC ANALGESIC TYPE OF GENERAL ANAESTHETIC SEEMED TO AVOID THIS PARTICULAR PROBLEM !NOTHER ASIDE AS WELL THERE WAS ANOTHER PARTICULAR ANAESTHETIC PROBLEM WITH THE AIRWAY IN JUVENILE RHEUMATOIDS -ALCOLM 3WANN KNOWS BETTER THAN ) DO AND ALONG WITH MY PREDECESSOR 'EORGE !RDEN THAT OPERATING ON JUVENILE RHEUMATOIDS HIPS IN THE DAYS BEFORE THE LARYNGEAL MASK WAS HAZARDOUS DUE TO THE DREADFUL AIRWAY THEY SO OFTEN HAD THAT PREVENTED INTUBATION 4HE ANAESTHETISTS USED A CLEVER DRUG CALLED KETAMINE .OW THE SIDE EFFECT OF KETAMINE FROM THE SURGEONS POINT OF VIEW IS THAT EVERYTHING CAN BLEED PROFUSELY MAKING CONTROL OF THE BLEEDING DIFlCULT ) AM SURE -ALCOLM 3WANN WILL PROBABLY ADD TO THIS THAT KETAMINE ADDED TO THE DIFlCULTIES OF SURGERY ALREADY COMPLICATED BY THE DISTORTED ANATOMY OF THESE CHILDREN (OWEVER KETAMINE MADE IT POSSIBLE TO PERFORM SURGERY SAFELY )T HAS NOW GONE OUT OF USE WITH THE DEVELOPMENT OF NEWER TECHNIQUES SUCH AS THE LARYNGEAL MASK THAT CAN DEAL WITH THE DIFlCULT AIRWAY AND HAS MADE A LOT OF DIFFERENCE TO THIS ASPECT
0HILLIPS ET AL #HARNLEY 2ING A
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,ETTIN !M ) RIGHT IN THINKING THAT AT .ORWICH YOU HAVE A PRETTY COMPREHENSIVE FOLLOW UP OF -C+EES REPLACEMENTS 7HOS GOING TO ANSWER THAT +EITH OR YOUR FOLLOW UP LADY #LARE $ARRAH 4UCKER )N THE "RITISH (IP 3OCIETY INVITED PRACTITIONERS WHO WORK WITH HIP SURGEONS TO COME TO OUR ANNUAL SCIENTIlC MEETING )T WAS RECOGNIZED THAT THERE WERE MANY PEOPLE UP AND DOWN THE COUNTRY HELPING WITH THE EVALUATION OF HIP REPLACEMENTS AND THE MANAGEMENT OF PATIENTS POST OPERATIVELY !FTER THE MEETING THE !RTHROPLASTY #ARE 0RACTITIONERS !SSOCIATION WAS BORN THROUGH THE EFFORTS OF #LARE $ARRAH HERE AND HER COLLEAGUES 4HUS THROUGH HIP REPLACEMENT ANOTHER STEP FORWARD HAS BEEN MADE IN THE CARE AND LONG TERM FOLLOW UP OF HIP REPLACEMENTS $ARRAH &OR THOSE OF YOU WHO DONT KNOW ) HAVE BEEN EMPLOYED AT .ORWICH FOR THE LAST TEN YEARS AND BEEN INVOLVED IN WHAT WE CALL OUR JOINT REPLACEMENT FOLLOW UP PROGRAMME SO WE ARE KEEPING AN EYE ON ALL OF OUR IMPLANTS IN .ORWICH SOME OF THEM VERY HISTORICAL AND SOME ARE MORE RECENT 7E HAVE JUST FOUNDED THE !RTHROPLASTY #ARE 0RACTITIONERS !SSOCIATION WHO ARE MAINLY PHYSIOTHERAPISTS AND NURSES WORKING WITH ORTHOPAEDIC SURGEONS AROUND THE COUNTRY COLLECTING DATA SO ) HOPE THAT THE TIDE HAS TURNED AND THAT WITH THE .ATIONAL *OINT 2EGISTER DOING ITS BIT AS WELL THAT WE ARE ACTUALLY GOING TO HAVE BETTER OUTCOME DATA IN THE NEXT TEN OR YEARS ,ETTIN 7HAT ABOUT -C+EES EARLY RESULTS -ICHAEL 7ROBLEWSKI CAN GO BACK TO #HARNLEYS RESULTS WITH ALMOST CONTINUOUS RECORDS FROM THE BEGINNING AS ) UNDERSTAND IT #AN YOU DO THAT WITH -C+EE OR NOT ;4UCKER .O= 7E CANT REALLY HAVE A COMPARISON OF THE LONG TERM RESULTS FROM METAL ON METAL AND THE METAL ON PLASTIC (EYWOOD 7ADDINGTON #HAIRMAN AS PART OF MY PREPARATION FOR THIS MEETING ) REVIEWED MY OWN @AUDIT AS ) LIKE TO CALL IT OF THE EARLY -C+EE REPLACEMENTS TO COMPARE THEM WITH EACH OTHER AND WITH MY OWN WHILE ) STILL DID THESE OPERATIONS ) ALSO TRIED TO TAKE ACCOUNT OF ANY MODIlCATIONS INTRODUCED )
#LARE $ARRAH .ORWICH *ILL 0OPE ,IVERPOOL *USTINE 'REAVES #LYDEBANK #ATHY *ENKINS /XFORD *UDITH ,EARMONT AND -ORAG 4RAYNER %DINBURGH ,INDSAY 3MITH 7ESTON SUPER -ARE "ARBARA 3ELVON 3HEFlELD TOGETHER WITH -ALCOLM "INNS AND 'ORDON "ANNISTER WERE INVOLVED IN THIS INITIATIVE &OR BACKGROUND DETAILS SEE WWWBRITISHHIPSOCIETYCOM.EWSLETTER3EPTDOC VISITED !UGUST
7ILSON ET AL 0ATTERSON AND "ROWN
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OBTAINED INFORMATION FORMALLY AND WAS PRIVY TO THOSE MINUTED AT THE MEETING IN !USTRIA EVERY YEAR UNTIL ABOUT !MONG THESE WERE PAPERS BY -C+EE HIMSELF GIVING HIS YEAR AND YEAR FOLLOW UPS OF HIS OWN HIPS AND BY #HRISTOPHER 0ARTRIDGE FROM 7ORTHING 4HERE WAS ALSO A PAPER BY $ANDY AND 4HEODOROU COMPRISING A RESTROSPECTIVE REVIEW OF -C+EE HIP REPLACEMENTS PERFORMED IN .ORWICH BETWEEN n /NE IN OF THESE REQUIRED REVISION AT SOME STAGE ) ALSO ENTERED INTO INFORMAL CORRESPONDENCE WITH COLLEAGUES ) KNEW TO BE PERFORMING THIS OPERATION &ROM ALL THIS EVIDENCE ) CAME TO THE CONCLUSION THAT THE OVERALL RESULTS WERE REMARKABLY SIMILAR IRRESPECTIVE OF WHETHER THE SURGEONS CONCERNED HAD RECEIVED FORMAL TRAINING IN .ORWICH OR NOT AND INDEPENDENTLY OF ANY MINOR MODIlCATION TO THE TECHNIQUE THAT THEY MAY HAVE INTRODUCED AND IRRESPECTIVE OF THE @LEARNING CURVE 4HERE WAS ABOUT PER CENT TO PER CENT PATIENT SATISFACTION RATE UP TO lVE YEARS AND AN ULTIMATE PER CENT TO PER CENT REVISION RATE OVERALL !S ONE WOULD EXPECT MOST OF THE EARLY REVISIONS WERE DUE TO SURGICAL ERROR RATHER THAN INHERENT DEFECT 7ROBLEWSKI 7HEN WE TALK ABOUT LONG TERM RESULTS AND LONG NOT BEING DElNED THERE IS ONE THING THAT ) DONT THINK THAT ANYBODY n ) DONT ONLY MEAN HERE BUT ANYWHERE n HAS ACTUALLY REALIZED THAT LONG TERM RESULTS CAN ONLY BE ACHIEVED IN YOUNG PATIENTS 3O WHEN WE TALK ABOUT LONG TERM RESULTS THEY ARE RESULTS IN YOUNG PATIENTS ,ET ME GIVE YOU A BIT OF INFORMATION IF ) MAY )F WE ASSUME THAT ALL THE PATIENTS ARE OPERATED ON DAY ONE AS WE DO FOR SURVIVORSHIP ANALYSIS FOR EVERY YEAR OF FOLLOW UP THE MEAN AGE OF PATIENTS AT PRIMARY SURGERY THOSE THAT ARE STILL ATTENDING DECLINES BY EIGHT MONTHS 3O TO GET A YEAR FOLLOW UP THAT PATIENT AT THE TIME OF SURGERY MUST HAVE BEEN ABOUT 3O IT IS NOT JUST LONG TERM RESULTS BUT LONG TERM RESULTS IN YOUNG PATIENTS 3O WHEN WE HEAR THAT A NEW DESIGN OR MATERIAL ESPECIALLY METAL ON METAL IS SUITABLE FOR YOUNG PATIENTS THE QUESTION IS @(AVE YOU GOT LONG TERM FOLLOW UP ,ONG TERM FOLLOW UPS ARE RESULTS IN YOUNG PATIENTS
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-C+EE -C+EE AND #HEN
$ANDY AND 4HEODOROU ! RETROSPECTIVE REVIEW OF -C+EEn&ARRAR PROSTHESES INSERTED IN .ORWICH FROM *ANUARY TO $ECEMBER
&OR #HARNLEY SURVIVORSHIP ANALYSIS SEE 7ROBLEWSKI ET AL FOR THE 3TANMORE SEE $OBBS 3URVIVORSHIP WAS DETERMINED FROM MODIlED LIFE TABLES ACCORDING TO !RMITAGE n
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,ETTIN 7HAT ABOUT YOUR FOLLOW UPS OF THE EARLY #HARNLEY REPLACEMENTS 7ROBLEWSKI 4HOSE THAT ARE ALIVE 9OU SEE ORIGINALLY THE PATIENTS MEAN AGE WAS AND THAT HAS BASICALLY REMAINED UNCHANGED 7E HAVE EARLY RESULTS 4HE LONGEST FOLLOW UP WE AT 7RIGHTINGTON HAVE IS YEARS AND GOING STRONG ,ETTIN "UT IN TERMS OF THE PROPORTIONS OF THOSE EARLY ONES 7ROBLEWSKI )T IS AGE HOW OLD THOSE PATIENTS WERE AT THE TIME OF SURGERY ,ETTIN "UT IN TERMS OF THE SURVIVAL ANALYSIS WHICH TAKES THAT INTO CONSIDERATION AS YOU HAVE ALREADY SAID HOW DOES THAT COMPARE WITH -C+EE 7ROBLEWSKI ) DONT KNOW WHAT THE -C+EE RESULTS ARE BUT IF WE LOOK AT PATIENTS WITH RHEUMATOID ARTHRITIS A MEAN AGE OF YEARS AT THE TIME OF SURGERY AND ALL UNDER THE AGE OF BY THE YEAR FOLLOW UP THE PATIENT DIES BEFORE REVISION BECOMES INDICATED THE ARTHROPLASTY OUTLASTS THE PATIENT 4UCKER ) WANT TO POINT OUT FOR THE HISTORICAL RECORD THAT TODAYS MEETING HAS REINFORCED AND ADDED TO WHAT HAS BEEN HAPPENING OVER THE PAST YEARS (IP SURGEONS HAVE BEEN DEDICATED TO KEEPING RECORDS AND EVERYTHING WE HAVE BEEN TALKING ABOUT TODAY BEARS WITNESS TO THIS /UT OF HIP REPLACEMENT HAS COME THE *OURNAL OF !RTHROPLASTY WHICH -IKE &REEMAN HAS RUN SO WELL ;AS %UROPEAN %DITOR TO = AND ENDLESS ARTICLES IN THE *"*3 *OURNAL OF "ONE AND *OINT 3URGERY 4HIS IS PART OF OUR HISTORY BUT IT HAS STIMULATED ORTHOPAEDIC SURGEONS TO LOOK EVEN MORE CRITICALLY AT WHAT THEY DO AND CONTINUE TO DO ,ETTIN ) AM GOING TO ASK 0ETER 2ING IF HE WOULD LIKE THE LAST WORD (E ALMOST HAD THE lRST ONE AND HASNT REALLY SAID A GREAT DEAL ALTHOUGH HE HAS LIVED THROUGH ALL OF THIS 7HAT ABOUT YOUR OWN RESULTS 0ETER 2ING 4HE RESULTS WHICH ) HAVE HAD FALL INTO TWO GROUPS )F YOU USE UNCEMENTED METAL ON METAL IMPLANTS YOU CAN GET A YEAR SURVIVORSHIP OF PER CENT )F YOU USE UNCEMENTED METAL ON PLASTIC ITS MUCH LESS GOOD ) DONT KNOW WHAT
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0ROFESSOR -IKE 7ROBLEWSKI WROTE @7ITH SURVIVORSHIP ANALYSIS THE END POINT CAN BE TAKEN EITHER AS REVISION OR THE PATIENTS DEATH )N YOUNG PATIENTS WITH RHEUMATOID ARTHRITIS hEND POINT REVISIONv GIVES HIGHER SURVIVORSHIP THAN hEND POINT DEATHv .OTE ON DRAFT TRANSCRIPT /CTOBER
(UNGERFORD
4HE *"*3 HAS BEEN PUBLISHED AS SEPARATE !MERICAN AND "RITISH JOURNALS SINCE DISTINGUISHED BY THE APPROPRIATE MARK ! OR "
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT
YEARS IS BUT EVEN AT TO YEARS YOU ARE LOOKING AT TO PER CENT OF FAILURES AND THE DIFFERENCE BETWEEN THE TWO IS CLEARLY THE EFFECT OF POLYETHYLENE DEBRIS UPON THE INTERFACE BOTH ON THE OUTSIDE OF THE CUP AND ON THE FEMORAL SIDE /F THE METAL ON METAL DEBRIS WHICH WE HAVE SEEN THERE HAVE BEEN THREE OR FOUR EXAMPLES OF AGGREGATES OF METAL FORMING CYSTS NEAR THE JOINT BUT THAT IS NO MORE THAN THREE OR FOUR IN SOME PATIENTS 7E HAVE LOOKED AT THE INTERFACE BETWEEN THE IMPLANT AND BONE IN LOOSENING IMPLANTS AND CERTAINLY YOU GET METAL DEBRIS DOWN THERE BUT YOU DO NOT SEEM TO GET A REACTION AT THAT POINT 3O THERE MAY BE SOME PROBLEMS WITH THE LONG TERM EFFECTS OF METAL BUT THE SURVIVORSHIP DOES LOOK QUITE GOOD 4HE OTHER THING THAT STRIKES ME HAVING LISTENED TO THIS IS THAT ) OPERATED FOR MOST OF MY TIME WITHIN A THEATRE THAT WAS ALSO USED BY A GYNAECOLOGICAL TEAM AND OCCASIONALLY FOR A GENERAL SURGICAL EMERGENCY 7E USED A HORIZONTAL LAMINAR AIR mOW SYSTEM NO EXHAUSTS OR ANYTHING LIKE THAT AND THE ADVANTAGE OF YOUR HORIZONTAL SYSTEM IS THAT YOU CAN STERILIZE ALL YOUR IMPLEMENTS AND APART FROM THE IMPLANTS YOU HAVE GOT EVERYTHING READY THERE EVERYTHING FOR THE ACTUAL REPLACEMENT EVERYTHING FOR BREAKING THE FEMUR WHEN YOU PUT THE IMPLANT IN TOO TIGHTLY AND THAT HAS A GREAT ADVANTAGE AND IT SEEMED TO US TO BE BETTER THAN THE VERTICAL SYSTEM !ND AS FAR AS INFECTION WAS CONCERNED WE WERE ABLE TO DO METAL ON METAL IMPLANTS WITHOUT ANYTHING OTHER THAN SUPERlCIAL INFECTION 3O ) THINK WHEN PEOPLE TALK ABOUT THE INFECTION RATE IN TOTAL HIP REPLACEMENT ITS GOT TO BE ASSOCIATED WITH THE STATEMENT THAT THESE ARE IMPLANTS THAT ARE CEMENTED INTO POSITION AND ) DO THINK THERE IS A DIFFERENCE -OST PEOPLE WITH UNCEMENTED IMPLANTS DONT LOOK UPON INFECTION AS A MAJOR PROBLEM 3WEETNAM -AY ) JUST BRIEmY ASK ONE QUESTION !LL OF US HERE HAVE THE ACCUMULATED EXPERIENCE OF WITNESSING THE DEVELOPMENT OF HIP SURGERY 7E HAVE LIVED THROUGH A MOST EXCITING TIME IN SURGERY AND IN FACT ) THINK WE HAVE BEEN DISCUSSING ONE OF THE GREATEST ADVANCES IN SURGERY EVER 7E HAVE MADE SOME MISTAKES ALONG THE WAY ) AM SURE AND ) JUST WONDER WHETHER THERE IS ANY VIEW THAT WE OUGHT TO GIVE TO THOSE PEOPLE WHO MAY BE READING THIS IN MANY YEARS
'ODSIFF ET AL 3EE ALSO &ITZPATRICK ET AL 4HIS REVIEW FOUND THE MOST FAVOURABLE PROSTHESES IN TERMS OF REVISION RATES AT THAT TIME WERE THE %XETER THE ,UBINUS )0 A 'ERMAN PROSTHESIS AND THE #HARNLEY
3ALVATI ET AL
2ING
2ING "ERTIN ET AL
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT
TIME AS TO HOW THOSE MISTAKES MIGHT BE AVOIDED IN THE FUTURE AND PARTICULARLY WHAT THE MISTAKES WERE ) THINK ITS QUITE IMPORTANT LOOKING BACK OVER YEARS OF A NEW SURGICAL PROCEDURE TO NOTE THAT IT WAS A TRIUMPH IN THE END FOR THE VAST MAJORITY OF PATIENTS BUT A FAILURE FOR SOME LESS FORTUNATE WHO WERE IN RECEIPT OF LESS THAN PERFECT PROSTHESES ,ETTIN ) HAVE TRIED TO GET PEOPLE TO SAY WHAT THEY THINK WERE THE CAUSES OF HIP FAILURE AND ) DIDNT REALLY HAVE A GREAT DEAL OF SUCCESS IN PINNING DOWN PEOPLE AS TO WHETHER IT WAS TECHNICAL ) THINK *OHN /LDER PROBABLY SUMMED IT ALL UP BY SAYING THAT IT WAS A MIXTURE OF ALL THESE THINGS ) DONT KNOW WHETHER YOU FEEL THAT YOU CAN DO ANY BETTER 3WEETNAM ) ONLY ASKED THE QUESTION BECAUSE ) KNEW THE ANSWER 4HE ANSWER IS THAT WE HAVE FAILED MISERABLY IN SURVEILLANCE ) MEAN WE HAVE BEEN WATCHING A NEW PROCEDURE DEVELOP OVER MAYBE YEARS AND WE ARE STILL ASKING QUESTIONS THAT WE CANT ANSWER BECAUSE WE DO NOT HAVE THE CORRECT SURVEILLANCE PROCEDURES IN PLACE AND ) THINK PERSONALLY THATS THE MESSAGE FOR THE FUTURE &REEMAN -AY ) ADD SOMETHING TO THAT ) TOTALLY AGREE AND ALTHOUGH THERE IS NO CONVINCING EVIDENCE ) DONT THINK THAT NEW IMPLANTS ARE ANY BETTER 3O IT MAY BE TRUE THAT WE ARE MOVING FORWARDS BUT ) AM NOT SURE THAT WE HAVE EVIDENCE THAT WE ARE MOVING FORWARDS SINCE THE OPENING PERIOD THAT YOU DESCRIBED #HAIRMAN -R -ICHAEL 7ILSON #OULD ) JUST SAY ) AM EXTREMELY HAPPY TO BE HERE TODAY IN THIS AUGUST COMPANY AND ONE OF THE THINGS THAT MY FATHER ;@'INGER 7ILSON= WAS VERY KEEN ON WAS TO TAKE NOTES METICULOUS NOTES AND WE HAVE A CELLAR FULL OF PATIENTS RECORDS WHICH HE REFERRED TO OCCASIONALLY IF ANYONE RANG UP (E COULD lND THEM WITHIN ABOUT A MATTER OF MINUTES THROUGH AN EXTRAORDINARY CROSS lLING INDEX THAT ) NEVER REALLY UNDERSTOOD MYSELF "UT THAT WAS ONE OF HIS GREAT THINGS THAT THINGS SHOULD BE WRITTEN DOWN AND NOTED PARTICULARLY 4HE OTHER THING WAS THAT ) THINK PART OF THE REASON THAT *OHN 3CALES DEALT EXCLUSIVELY WITH
&OR EXAMPLE IN THE $O( ISSUED A (AZARD 7ARNING .OTICE ;(.= DUE TO @POOR SHORT TERM PERFORMANCE OF THE FEMORAL COMPONENT TO HOSPITALS TO RECALL AND REVIEW ALL PATIENTS WHO RECEIVED A - #APITAL (IP IMPLANT BETWEEN n WHEN THE DEVICE WAS DISCONTINUED LESS THAN PER CENT OF 5+ HIP REPLACEMENT OPERATIONS OVER THAT PERIOD ! FUND ESTABLISHED BY - (EALTHCARE PAID FOR CLINICAL REVIEW AND REVISION IF NEEDED FOR THESE PATIENTS WHICH CLOSED IN LEAVING FURTHER CARE TO THE .(3 3EE WWWDHGOVUK0UBLICATIONS!ND3TATISTICS0RESS2ELEASES0RESS2ELEASES.OTICESFSEN #/.4%.4? )$ CHK !-'"!) AND WWWDHGOVUKASSET2OOTPDF VISITED .OVEMBER .ATIONAL !UDIT /FlCE
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT
0HYLLIS COMPANY WAS THAT THEY WANTED TO CUT DOWN ON ANY VARIABLES SO THAT THE QUALITY OF THE MATERIALS THEY RECEIVED WASNT IN QUESTION AND OBVIOUSLY THAT HELPS WITH THE ANALYSIS OF DATA LATER ON ,ETTIN ) THINK WE HAVE TO BRING THINGS TO A CONCLUSION $OWSON 4HE DISCUSSION BRINGS TO MIND ONE OF 7INSTON #HURCHILLS OBSERVATIONS @3UCCESS IS NEVER lNAL ,ETTIN 4HANK YOU VERY MUCH EVERYONE FOR KEEPING VERY MUCH TO TIME AND ) HOPE THAT THE 7ELLCOME 4RUSTS (ISTORY OF 4WENTIETH #ENTURY -EDICINE 'ROUP HAVE WHAT THEY WANTED 7E HAVE DRIFTED AWAY FROM HISTORY ) AM AFRAID AND COME UP TO THE PRESENT TIME BUT THERE WE ARE THATS THE WAY IT WENT 9OU WANTED A FREE AND EASY DISCUSSION #HRISTIE !BSOLUTELY ) WANT TO THANK YOU ALL FOR PARTICIPATING IN THIS AFTERNOONS SEMINAR AND ALSO TO THANK !LAN ,ETTIN FOR HIS EXCELLENT CHAIRING OF THIS OCCASION
%NRIGHT ED
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n !PPENDIX
!PPENDIX .OTES ON -ATERIALS BY 0ROFESSOR !LAN 3WANSON -ETALLIC !LLOYS #ORROSION RESISTING STEEL STAINLESS STEEL
)RON &E PLUS A SMALL PERCENTAGE OF CARBON # AND ABOUT PER CENT CHROMIUM #R AND PER CENT NICKEL .I $RIVEN LARGELY BY THE NEEDS OF JOINT REPLACEMENT BOTH THE COMPOSITION AND THE MANUFACTURE OF THE SURGICAL GRADES HAVE BEEN RElNED UNTIL THEY ARE NOW VERY DIFFERENT FROM THE GENERAL PURPOSE ALLOYS FROM WHICH THEY ARE DERIVED WITH MANY OTHER CONSTITUENTS TO IMPROVE RESISTANCE TO FATIGUE AND CORROSION )TS STRENGTH VARIES ACCORDING TO WHETHER IT IS ANNEALED OR COLDWORKED
#OBALTnCHROMIUM ALLOYS
#OBALT #O WITH A SUBSTANTIAL PERCENTAGE OF CHROMIUM #R AND SMALLER QUANTITIES OF OTHER ELEMENTS (IGHLY RESISTANT TO WEAR AND CORROSION FOR EXAMPLE AS HARD FACINGS IN EARTH MOVING MACHINERY AND USED BY DENTISTS BECAUSE OF THEIR SUITABILITY FOR PRECISION INVESTMENT CASTING AND THEIR CORROSION RESISTANCE &IFTY YEARS AGO AND PROBABLY IS STILL THE ONLY ALLOY TYPE THAT CAN BE SERIOUSLY CONSIDERED FOR BOTH SURFACES OF ONE BEARING .OBODY HAS YET PRODUCED OR DISCOVERED ANOTHER MATERIAL OR IF THEY HAVE IT IS IMPOSSIBLY EXPENSIVE
4ITANIUM ALLOYS
4ITANIUM 4I IS LIGHTER THAN STEEL OR COBALT AND HAS GOOD CORROSION RESISTANCE BUT IT AND ITS ALLOYS WERE VERY EXPENSIVE YEARS AGO AND VERY DIFlCULT TO MANUFACTURE 4ITANIUM ALLOYS RETAIN THEIR STRENGTH AND STIFFNESS TO HIGHER TEMPERATURES THAN DO ALUMINIUM ALLOYS SO THEY ARE USED FOR AIRCRAFT THAT mY FAST ENOUGH SIGNIlCANTLY SUPERSONIC TO UNDERGO SIGNIlCANT KINETIC HEATING 4HE NEEDS OF THE AEROSPACE INDUSTRY HAD LED TO DEVELOPMENT WHICH MADE IT PRACTICAL AND AN ALLOY WITH SOME ALUMINIUM AND VANADIUM IN IT WAS BEING USED FOR FEMORAL PROSTHESES BY 4HE 3TANDARD WAS REVISED AND REPUBLISHED IN
!DDITIONAL INFORMATION PROVIDED BY -R 2AVI +UNZRU AND -R 6ICTOR 7HEBLE
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n !PPENDIX
0OLYMERS 0OLYMETHYLMETHACRYLATE 0--! 0ERSPEX 0LEXIGLASS
5SED AS A SOLID MATERIAL BY THE *UDET BROTHERS FOR FEMORAL HEADS ;*UDET AND *UDET SEE ALSO !PPENDIX = BUT HAS BEEN A MAJOR FACTOR IN HIP REPLACEMENT SINCE C 5SED AS THE MONOMER WITH AN ACCELERATOR AND INSERTED BETWEEN PROSTHESIS AND BONE AND ALLOWED TO POLYMERIZE IN SITU IT TAKES ABOUT MINUTES TO FORM BONE CEMENT 4WO PROPRIETARY BRANDS OF 0--! WERE USED IN THE 5+ #-7 AND 3IMPLEX ;.ORTH (ILL 0LASTICS= ESSENTIALLY THE SAME CHEMICALLY BUT DIFFERENT IN DETAIL #HARNLEY USED #-7 3EE NOTE
0OLYTETRAmUORETHYLENE 04&% ,OW FRICTION BUT NOT PARTICULARLY WEAR RESISTANT 3EE &IGURE &LUON 4EmON 0OLYETHYLENE 5(-70% ($0
4OOK OVER FROM 04&% IN AS THE MATERIAL OF CHOICE FOR THE PLASTIC ELEMENT OF A METAL ON PLASTIC BEARING IN HIP REPLACEMENT &RICTION IS HIGHER THAN WITH 04&% BUT STILL MUCH LOWER THAN METAL ON METAL AND THE MECHANICAL PROPERTIES ARE BETTER LEADING TO BETTER WEAR RESISTANCE 7IDELY USED OUTSIDE ORTHOPAEDICS BUT THE NEEDS OF JOINT REPLACEMENT HAVE DRIVEN DEVELOPMENTS TO OBTAIN BETTER WEAR PERFORMANCE PARTICULARLY BY INCREASING THE LENGTH OF THE MOLECULAR CHAINS TO GIVE ULTRA HIGH MOLECULAR WEIGHT AND HIGH DENSITY VERSIONS !S WITH ALL POLYMERS THE ADDITIVES THAT ARE USUAL FOR NON SURGICAL PURPOSES lLLERS COLOURS LUBRICANTS MUST BE STRICTLY CONTROLLED OR ELIMINATED
#ERAMICS
!LUMINA ALUMINIUM OXIDE
,IKE MOST METALLIC OXIDES THIS CERAMIC IS HARD AND CAPABLE OF BEING lNISHED TO A VERY HIGH POLISH WITH SUITABLE MACHINERY )T IS FOUND IN LESS RElNED FORMS IN GENERAL ENGINEERING WHERE ITS BRITTLENESS IS ACCEPTABLE BUT THE ORTHOPAEDIC FORM IS LESS BRITTLE AND MORE HOMOGENEOUS PERMITTING BETTER SURFACE lNISH AND LOWER WEAR RATES
:IRCONIA ZIRCONIUM OXIDE
/NE OF MANY OTHER CERAMICS THAT ARE POTENTIALLY USEFUL TO ORTHOPAEDICS AND HAS BEEN USED AS AN ALLOYING CONSTITUENT WITH ALUMINA
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n !PPENDIX
!PPENDIX 3URGICAL IMPLANT MATERIAL STANDARDS nS BY -R 6ICTOR 7HEBLE *UNE 4HERE WERE A FEW "RITISH STANDARDS AVAILABLE FOR MATERIALS USED IN MAKING PROSTHESES IN n AND STANDARDIZATION WORK WAS JUST BEGINNING IN THIS lELD POSSIBLY ALSO IN OTHER COUNTRIES 4HERE WERE NO GENERALLY ACCEPTED )NTERNATIONAL 3TANDARDS AT THAT TIME 4HE "RITISH 3TANDARD FOR WROUGHT STAINLESS STEEL "3 WAS ONLY MADE REDUNDANT WHEN SUITABLE )NTERNATIONAL 3TANDARDS WERE lNALLY DEVELOPED 4HE lRST GROUP OF THESE WERE PUBLISHED IN AND INCLUDED STAINLESS STEELS AND CHROMEnCOBALT ALLOYS FOLLOWED BY TITANIUM AND TITANIUM ALLOYS IN THOUGH WORK AT THE INTERNATIONAL LEVEL ON MANY OF THE OTHER METALLIC MATERIALS HAD COMMENCED IN !T THE BEGINNING IT WAS A BIT OF A @FREE FOR ALL THOUGH THE "RITISH WERE WORKING TOWARDS STANDARDIZATION OF OTHER MATERIALS AND THERE WAS STANDARDIZATION ACTIVITY IN &RANCE 'ERMANY 3WITZERLAND AND THE 53! .EW MATERIALS WERE BEING SUGGESTED FROM TIME TO TIME BUT THEY WERE NOT ALWAYS ACCEPTED FOR 3TANDARDIZATION 4HE INAUGURAL MEETING OF THE )3/ 4ECHNICAL #OMMITTEE ;)3/4#= TOOK PLACE IN ,ONDON IN AND A START WAS MADE AT A MEETING IN 0FORZHEIM 'ERMANY IN THE FOLLOWING YEAR !T THE SECOND MEETING IN #OPENHAGEN 3WEDEN IN DISCUSSION TOOK PLACE ON THE STANDARDIZATION OF SUCH MATTERS AS MATERIALS FOR IMPLANTS ! TASK GROUP AT THAT CONFERENCE WAS SET UP TO LOOK AT QUALITY CONTROL AS THIS WAS THE BEGINNING OF THE SYSTEM OF MAKING INTERNATIONAL STANDARDS FOR BONE AND JOINT REPLACEMENTS 4HE LARGE NUMBER OF RELEVANT )3/ STANDARDS THAT SUBSEQUENTLY APPEARED HAS BEEN INCREASED FURTHER AS A RESULT OF THE %UROPEAN 5NION %5 SETTING UP THEIR #%. STANDARDS ORGANIZATION -OST OF THE #%. STANDARDS ARE THE SAME IN ESSENCE AS THOSE PRODUCED BY )3/ BECAUSE THEY ARE GENERALLY WRITTEN BY THE SAME DELEGATES 4HE ONLY SERIOUS DIFFERENCE BETWEEN )3/ AND #%. STANDARDS IS THE LEGAL REQUIREMENT FOR COMPLIANCE WITH #%. STANDARDS THROUGHOUT THE %5 )3/ STANDARDS ARE NOT LEGALLY BINDING IN ALL THE WORLD BUT THEY ARE ACCEPTED IN MOST OF THE COUNTRIES INVOLVED IN IMPLANT MANUFACTURE AND COMPANIES WHO MAKE IMPLANTS DO HAVE TO BE CAREFUL HOW THEY PRODUCE THEIR PRODUCTS 3UCH STANDARDS ARE NOT AS RIGID AS THEY WOULD BE
3CALES DESCRIBES THE EARLY WORK OF THE "RITISH 3TANDARDS #OMMITTEE 3'# UNDER THE CHAIRMANSHIP OF -R .ORMAN #APENER AND THE CREATION OF "3 THE BASIC REQUIREMENTS FOR METAL SURGICAL IMPLANTS TWIST DRILLS AND SCREWDRIVERS 3EE ALSO #APENER "RITISH 3TANDARDS )NSTITUTION "3 COVERED STAINLESS STEEL AND "3 COBALT CHROMIUM ALLOYS
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n !PPENDIX
IF THEY WERE LEGALLY BINDING BUT PERHAPS THEY DO CONSTITUTE THE BEST AVAILABLE METHOD OF QUALITY CONTROL THAT IS ACCEPTABLE BY MANUFACTURERS ON A WORLDWIDE BASIS ) MUST EMPHASIZE HOWEVER THAT THE #%. STANDARDS DO HAVE LEGAL STATUS IN THE %5 ) HAVE NO RECORD OF OTHER RELEVANT "RITISH 3TANDARD NUMBERS BEFORE BUT THERE WERE MANY HEATED DISCUSSIONS IN THE "3) AND )3/ MEETINGS ON THE SUBJECT OF MATERIALS BETWEEN AND -ATERIALS SUPPLIED TO MANUFACTURERS IN %NGLAND DURING THE S WOULD HAVE BEEN MADE TO SUCH "RITISH 3TANDARDS AS EXISTED ) DOUBT WHETHER THERE WERE "RITISH 3TANDARDS ON OTHER MATERIALS THAN STAINLESS STEEL )T IS MORE LIKELY THAT VARIOUS FORMULAE FOR CHROMEnCOBALT ALLOYS WERE BEING USED BY DIFFERENT MANUFACTURERS AND PROBABLY THE SAME SITUATION APPLIED WITH OTHER MATERIALS LIKE TITANIUM AND THE TITANIUM ALLOYS 4HE @$)3 IN THE STANDARDS NUMBERING SYSTEM MEANS A $RAFT )NTERNATIONAL 3TANDARD THAT IS NOT YET FULLY APPROVED !LL )NTERNATIONAL 3TANDARDS ARE BROUGHT TO ATTENTION EVERY lVE YEARS AND IF NECESSARY THEY ARE THEN REVISED BUT MORE OFTEN ARE ACCEPTED FOR A FURTHER lVE YEAR PERIOD !34- 3TANDARDS ARE !MERICAN IN ORIGIN AND ARE ALSO REVISED IN THE SAME WAY 3OME OF THESE EVENTUALLY BECOME )3/ 3TANDARDS AFTER REVISION 4HE )NTERNATIONAL /RGANIZATION FOR 3TANDARDIZATION )3/ PRODUCES 3TANDARDS FOR METALLIC MATERIALS THAT ARE GENERALLY ACCEPTABLE WORLDWIDE )F THERE IS A NEED TO QUOTE THE COMPOSITIONS OF THESE MATERIALS THE DETAILS CAN BE OBTAINED FROM THE )3/ #ENTRAL 3ECRETARIAT AT 2UE DE 6AREMBE #ASE POSTALE #( 'ENÞVE 3WITZERLAND 4EL OR THE 3ALES $EPARTMENT CATALOGUE AVAILABLE AT WWWISOORGISOEN#ATALOGUE,IST0AGE #ATALOGUE,IST VISITED *ULY
3EE FOR EXAMPLE "3 %. .ON ACTIVE SURGICAL IMPLANTS JOINT REPLACEMENT IMPLANTS PARTICULAR REQUIREMENTS 4HE INTERNATIONAL EQUIVALENT IS %. WHICH COVERS IMPLANTS SURGICAL JOINTS ANATOMY ORTHOPAEDIC EQUIPMENT PROSTHETIC DEVICES PERFORMANCE LIFE DURABILITY SURFACE TEXTURE MARKING INSPECTION STERILIZATION HYGIENE INSTRUCTIONS FOR USE COMPATIBILITY METALS ALLOYS NON METALS AND MEDICAL EQUIPMENT 3TANDARDS THAT APPLY ARE )3/ )3/ )3/ )3/ )3/ )3/ )3/ )3/ )3/ )3/ )3/ )3/ )3/ )3/ )3/ )3/ )3/ )3/ )3/ )3/ )3/ )3/ )3/ )3/ )3/ )3/ )3/$)3 )3/ )3/42 )3/42 )3/ )3/ "3 "3 "3 "3 "3 !34- & !34- & !34- & !34- & !34- & !34- & !34- & !34- & !34- & !34- & .& 3 %%# %. )3/ )3/ )3/
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n !PPENDIX
2ELEVANT STANDARDS FOR SURGICAL IMPLANTS DURING THE PERIOD n A -ETALLIC MATERIALS 0ART 7ROUGHT STAINLESS STEEL "RITISH 3TANDARD "3
)3/$)3 n
0ART 5NALLOYED TITANIUM 2EVISED
)3/n
0ART 7ROUGHT TITANIUM ALUMINIUM VANADIUM ALLOY 2EVISED
)3/n
0ART #OBALTnCHROMIUMnMOLYBDENUM CASTING ALLOY 2EVISED
)3/n
0ART 7ROUGHT COBALTnCHROMIUMnTUNGSTENnNICKEL ALLOY 2EVISED
)3/n
0ART 7ROUGHT COBALTnNICKELnCHROMIUMnMOLYBDENUM ALLOY 2EVISED
)3/n
0ART &ORGEABLE AND COLD FORMED COBALTnCHROMIUMnNICKEL MOLYBDENUMnIRON ALLOY
)3/n
0ART 7ROUGHT COBALTnNICKELnCHROMIUMnMOLYBDENUMn TUNGSTENnIRON ALLOY 2EVISED
)3/n
0ART 7ROUGHT HIGH NITROGEN STAINLESS STEEL 2EVISED
)3/n
0ART 7ROUGHT TITANIUM ALUMINIUM nIRON ALLOY 2EVISED
)3/n
0ART 7ROUGHT TITANIUM ALUMINIUM NIOBIUM ALLOY
)3/n
0ART 7ROUGHT COBALTnCHROMIUMnMOLYBDENUM ALLOY
)3/n
B /THER MATERIALS )MPLANTS FOR SURGERY n ACRYLIC RESIN CEMENTS
)3/
5LTRA HIGH -OLECULAR 7EIGHT 0OLYETHYLENE 5(-70% 0ART 0OWDER FORM
)3/n
5LTRA HIGH -OLECULAR 7EIGHT 0OLYETHYLENE 5(-70% 0ART -OULDED FORM
)3/n
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n !PPENDIX
&OR EXAMPLE COMPOSITION OF SELECTED STANDARDS 3TANDARDS
%LEMENT CARBON # CHROMIUM #R COBALT #O
)3/ )3/ )3/ #O #R .I 7 #O #R -O #O #R .I -O &E
IRON &E
MANGANESE -N
MOLYBDENUM -O
NICKEL .I
SILICON 3I
TUNGSTEN 7
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n !PPENDIX
!PPENDIX 3ELECTED PROSTHETIC HIPS 7ILES ACETABULAR CUP AND RESURFACE OF HEAD OF THE FEMUR -R 0HILIP 7ILES 4HE ,ONDON (OSPITAL 5+ 3INGLE BOLT ON FEMORAL COMPONENT STAINLESS STEEL 3EE 7ILES 3EE ALSO &IGURE 3MITH 0ETERSEN MOULD $R -ARIUS 3MITH 0ETERSEN 53 6ITALLIUM MOULD COBALTnCHROMIUMn MOLYBDENUM ALLOY ARTHROPLASTY INTERPOSED BETWEEN REFASHIONED SURFACES OF ACETABULUM AND HEAD OF THE FEMUR 3EE 3MITH 0ETERSEN !LSO APPEARS AS &IGURE
*UDET BROTHERS ACRYLIC FEMUR HEAD REPLACEMENT LATE S $RS *EAN AND 2OBERT *UDET &RANCE !CRYLIC SHORT STEM MUSHROOM SHAPE @RESECTION RECONSTRUCTION OF THE FEMUR HEAD WITH STEM DESIGNED TO PASS THROUGH TO THE NECK OF THE FEMUR 3EE *UDET AND *UDET !N ADVERTISEMENT FROM IS REPRODUCED IN 4ENNENT AND %ASTWOOD
&OR ADVERTISEMENTS OF VARIOUS PROSTHESES AVAILABLE FOR EXAMPLE IN SEE WWWJBJSORGUKCGIISSUE? PDFBACKMATTER?PDF "PDF VISITED $ECEMBER
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n !PPENDIX
-OORE INTRAMEDULLARY ENDOPROSTHESIS S n $R !USTIN -OORE 53 ,ATER MODEL OF -OORE 6ITALLIUM PROSTHESIS TAPERED STEM AND COLLAR UNCEMENTED 3EE -OORE AND "OHLMAN
4HOMPSON INTRAMEDULLARY PROSTHESIS n $R &REDERICK 4HOMPSON 53 #URVED SOLID 6ITALLIUM STEM LARGE HEAD CEMENTED )NTRODUCED IN THE 53 IN 3EE 4HOMPSON
-C+EE TOTAL HIP REPLACEMENT n -R +ENNETH -C+EE .ORFOLK AND .ORWICH (OSPITAL 5+ 6ITALLIUM PROSTHESIS WITH VARIOUS CUP MODELS FROM -ANUFACTURED BY $OWN "ROTHERS ,TD ,ONDON LATER (UNTON %NGINEERING .ORWICH 3EE -C+EE -C+EE AND 7ATSON &ARRAR 3EE ALSO &IGURES AND
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n !PPENDIX
#HARNLEY LOW FRICTION ARTHROPLASTY n 3IR *OHN #HARNLEY 7RIGHTINGTON (OSPITAL NR 7IGAN 5+
A
B
C
A , TO 2 4HOMPSON PROSTHESIS WITH A 04&% CUP ,OW FRICTIONAL TORQUE MM DIAMETER FEMORAL HEAD AND 04&% CUP WITH MAXIMUM EXTERNAL DIAMETER MM DIAMETER FEMORAL HEAD WITH 04&% CUP B , TO 2 MODELS n ORIGINAL mAT BACK * STAINLESS STEEL STEM WITH A POLISHED lNISH ROUND BACK #HARNLEY STEM WITH A VAQUASHEEN lNISH ROUND BACK #HARNLEY STEM WITH A mANGE #HARNLEY STEM /RTRON AND !LUMINA #ERAMIC HEAD C , TO 2 ORIGINAL #HARNLEY CUP PRESSURE INJECTION mANGE ADDED TO THE CUP TO IMPROVE ACETABULAR lXATION /GEE mANGE ADDED TO THE CUP TO STABILIZE ACETABULAR lXATION BY ENHANCING CEMENT PRESSURIZATION D 4HE /RTRON -ANUFACTURED BY 4HACKRAY n $U0UY FROM 3EE #HARNLEY 3EE ALSO &IGURES AND
D
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n !PPENDIX
3TANMORE TOTAL HIP REPLACEMENT n -R *OHN 3CALES )NSTITUTE OF /RTHOPAEDICS 2./( 3TANMORE 5+
A
A , TO 2 n -ARK n COBALTn CHROME ON COBALTnCHROME STEM AND CUP S COBALTnCHROME ON PLASTIC STEM AND CUP B 3TANMORE RANGE WITH VARIOUS DIAMETER HEADS AND FEMORAL COMPONENTS OF VARIOUS LENGTHS C S
B
C
C 3TANMORE CERAMIC HEAD !LIVIUM A VACUUM CAST COBALT BASE ALLOY STEM AND POLYETHYLENE CUPS C S D 3TANMORE MATT STEMS BOTTOM TO TOP -K MM HEAD !LIVIUM STANDARD STEM C MID S "IOMET MM HEAD STRAIGHT STEM C MID S !LIVIUM STEM MM HEAD C MID S -ANUFACTURED BY :IMMER /RTHOPAEDIC ,TD TO "IOMET FROM
D
3EE $UFF "ARCLAY ET AL 3CALES AND 7ILSON 7ILSON AND 3CALES 3EE ALSO &IGURE
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n !PPENDIX
2ING TOTAL HIP REPLACEMENT n -R 0ETER 2ING 2EDHILL 'ROUP OF (OSPITALS 5+ 5NCEMENTED METAL ON METAL IMPLANT IN COBALTnCHROME WITH SINGLE PELVIC COMPONENT AND THREE SIZES OF FEMORAL STEM -ANUFACTURED BY $OWNS 3URGICAL ,TD -ITCHAM 3URREY 3EE 2ING 3EE ALSO &IGURE
%XETER TOTAL HIP REPLACEMENT n 0ROFESSOR 2OBIN ,ING 0RINCESS %LIZABETH /RTHOPAEDIC (OSPITAL %XETER 5+ $R #LIVE ,EE 5NIVERSITY OF %XETER 5+ A )N CLINICAL PRACTICE FROM AUTUMN IN POLISHED STAINLESS STEEL %.* WITH A HEAD SIZE OF MM CEMENTED WITH ACRYLIC BONE CEMENT AND IN TWO SIZES STANDARD AND LIGHTWEIGHT 4HE CUP WAS MADE FROM HIGH DENSITY POLYETHYLENE IN THREE SIZES NOT ILLUSTRATED A
B
B 5NIVERSAL %XETER STEM MODULAR POLISHED n -ANUFACTURED BY ,ONDON 3PLINT #OMPANY NOW 3TRYKER (OWMEDICA /STEONICS 3EE ,EE AND ,ING ,ING 3EE ALSO &IGURE
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n !PPENDIX
)#,( DOUBLE CUP OR RESURFACING ARTHROPLASTY PROSTHESIS n 0ROFESSOR -ICHAEL &REEMAN )MPERIAL #OLLEGE AND 4HE ,ONDON (OSPITAL 5+ 0ROFESSOR !LAN 3WANSON )MPERIAL #OLLEGE 5+ ! THINLY CEMENTED ($0 PROSTHESIS WITH A STAINLESS STEEL ACETABULAR CUP lRST IMPLANTED IN ! SPECIALLY DESIGNED REAMER SHAPED THE FEMORAL HEAD UNTIL IT lTTED INTO THE PROSTHESIS &ROM THE PROSTHESIS WAS OF COBALTnCHROME WITH AN ($0 ACETABULAR COMPONENT ,EFT IS AN 8 RAY OF A BILATERAL IMPLANTATION C WHICH IS TAKEN FROM &IGURE -ANUFACTURED BY 0ROTEK !' -àNSINGEN "ERNE 3WITZERLAND 3EE &REEMAN ET AL 3EE ALSO &IGURE
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2EFERENCES !HNFELT , (ERBERTS 0 -ALCHAU ( !NDERSSON ' " * 0ROGNOSIS OF TOTAL HIP REPLACEMENT ! 3WEDISH MULTICENTER STUDY OF REVISIONS !CTA /RTHOPAEDICA 3CANDINAVICA n !NDERSON * 'REENHOUSES AND BODY SUITS THE CHALLENGE TO KNOWLEDGE IN EARLY HIP REPLACEMENT SURGERY n )N 4IMMERMANN # !NDERSON * EDS $EVICES AND $ESIGNS -EDICAL TECHNOLOGIES IN HISTORICAL PERSPECTIVE (OUNDMILLS 0ALGRAVE -ACMILLAN n !NDERSON * .EARY & 0ICKSTONE * 6 FORTHCOMING 3URGEONS -ANUFACTURERS AND 0ATIENTS ! 4RANSATLANTIC (ISTORY OF THE 4OTAL (IP 2EPLACEMENT "ASINGSTOKE 0ALGRAVE !NONYMOUS #UTTING GERM RISKS DURING OPERATIONS 4HE 4IMES .OVEMBER !NONYMOUS 4HE #HARNLEYn(OWORTH ULTRA CLEAN AIR UNIT .URSING -IRROR AND -IDWIVES *OURNAL n !NONYMOUS (AROLD *ACKSON "URROWS ,IVES OF THE &ELLOWS OF THE 2OYAL #OLLEGE OF 3URGEONS OF %NGLAND n n !NSELL " - #HRONIC !RTHRITIS IN #HILDHOOD #HELMSFORD 'RAVES -EDICAL !UDIOVISUAL ,IBRARY ; SLIDES ORIGINAL SLIDES SEEM TO HAVE BEEN DESTROYED IN = !NSELL " - 3WANN - 4HE MANAGEMENT OF CHRONIC ARTHRITIS OF CHILDREN *OURNAL OF "ONE AND *OINT 3URGERY " n !NSELL " - "YWATERS % ' 3PENCER 0 % 4YLER * 0 ,OOKING "ACK n 4HE #ANADIAN 2ED #ROSS -EMORIAL (OSPITAL #LIVEDEN 4APLOW %NGLAND "UCKINGHAMSHIRE ;PRIVATELY PUBLISHED BY= "ARBARA - !NSELL !RDEN ' 0 4AYLOR ! 2 !NSELL " - 4OTAL HIP REPLACEMENT USING THE -C+EE &ARRAR PROSTHESIS )N RHEUMATOID ARTHRITIS 3TILLS DISEASE AND ANKYLOSING SPONDYLITIS !NNALS OF THE 2HEUMATIC $ISEASES n !RMITAGE 0 3TATISTICAL -ETHODS IN -EDICAL 2ESEARCH /XFORD "LACKWELL "ARRACK 2 , "UTLER 2 ! #URRENT STATUS OF TROCHANTERIC REATTACHMENT IN COMPLEX TOTAL HIP ARTHROPLASTY #LINICAL /RTHOPAEDICS AND 2ELATED 2ESEARCH n
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"ECHTOL # / 4HE BIOMECHANICS OF THE EPIPHYSEAL LINES AS A GUIDE TO DESIGN CONSIDERATIONS FOR THE ATTACHMENT OF PROSTHESIS TO THE MUSCULO SKELETAL SYSTEM *OURNAL OF "IOMEDICAL -ATERIALS 2ESEARCH n "ENSON - + 'OODWIN 0 ' "ROSTOFF * -ETAL SENSITIVITY IN PATIENTS WITH JOINT REPLACEMENT ARTHROPLASTIES "RITISH -EDICAL *OURNAL n "ERG - "ERGMAN " 2 (OBORN * 5LTRAVIOLET RADIATION COMPARED TO AN ULTRA CLEAN AIR ENCLOSURE #OMPARISON OF AIR BACTERIA COUNTS IN OPERATING ROOMS *OURNAL OF "ONE AND *OINT 3URGERY " n "ERGMANN ' 'RAICHEN & 2OHLMANN ! (IP JOINT LOADING DURING WALKING AND RUNNING MEASURED IN TWO PATIENTS *OURNAL OF "IOMECHANICS n "ERME . 0AUL * 0 ,OAD ACTIONS TRANSMITTED BY IMPLANTS *OURNAL OF "IOMECHANICAL %NGINEERING n "ERNTSEN ! "ERTELSEN ! 0RELIMINARY EXPERIENCE WITH 3MITH 0ETERSENS HIP CUP ARTHROPLASTY !CTA /RTHOPAEDICA 3CANDINAVICA n "ERTIN + # &REEMAN - ! 2 -ORSCHER % /ERI ! 2ING 0 ! #EMENTLESS ACETABULAR REPLACEMENT USING A PEGGED POLYETHYLENE PROSTHESIS !RCHIVES OF /RTHOPAEDIC AND 4RAUMA 3URGERY n "ESONG ! ! 4IPPER * , )NGHAM % 3TONE - ( 7ROBLEWSKI " - &ISHER * 1UANTITATIVE COMPARISON OF WEAR DEBRIS FROM 5(-70% THAT HAS AND HAS NOT BEEN STERILIZED BY GAMMA IRRADIATION *OURNAL OF "ONE AND *OINT 3URGERY " n "INTCLIFFE ) 7 %FFECTS OF USING A #HARNLEYn(OWORTH ENCLOSURE IN A DISTRICT GENERAL HOSPITAL *OURNAL OF THE 2OYAL 3OCIETY OF -EDICINE n "LACK * 4HE FUTURE OF POLYETHYLENE *OURNAL OF "ONE AND *OINT 3URGERY " n "LOCH " "ONDING OF FRACTURES BY PLASTIC ADHESIVES PRELIMINARY REPORT *OURNAL OF "ONE AND *OINT 3URGERY " n "LOCH " (ASTINGS ' 7 0LASTICS -ATERIALS IN 3URGERY ND EDN 3PRINGlELD ), #HARLES # 4HOMAS "LOWERS 2 #REW " 6ENTILATION OF OPERATING THEATRES *OURNAL OF (YGIENE n
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"URROWS ( * 0ROSTHESES FOR ARTHRITIC HIPS *OURNAL OF "ONE AND *OINT 3URGERY " n "URROWS ( * 7ILSON * . 3CALES * 4 %XCISION OF TUMOURS OF HUMERUS AND FEMUR WITH RESTORATION BY INTERNAL PROSTHESES *OURNAL OF "ONE AND *OINT 3URGERY " n #AMERON ( 5 &REEMAN - ! 2 3URFACE REPLACEMENT ARTHROPLASTY OF THE HIP *OURNAL OF "ONE AND *OINT 3URGERY " n #APENER . %DITORIALS AND ANNOTATIONS SURGICAL IMPLANTS *OURNAL OF "ONE AND *OINT 3URGERY " n #HARNLEY * A 4HE #LOSED 4REATMENT OF #OMMON &RACTURES %DINBURGH % 3 ,IVINGSTONE ;TH EDN #AMBRIDGE #AMBRIDGE 5NIVERSITY 0RESS = #HARNLEY * B -ETHOD OF INSERTING THE 3MITH 0ETERSEN GUIDE WIRE *OURNAL OF "ONE AND *OINT 3URGERY " n #HARNLEY * #OMPRESSION !RTHRODESIS %DINBURGH % 3 ,IVINGSTONE #HARNLEY * 3URGERY OF THE HIP JOINT "RITISH -EDICAL *OURNAL I n #HARNLEY * !RTHROPLASTY OF THE HIP n A NEW OPERATION ,ANCET I #HARNLEY * 4HE BONDING OF PROSTHESES TO BONE BY CEMENT *OURNAL OF "ONE AND *OINT 3URGERY " n #HARNLEY * ! BIOMECHANICAL ANALYSIS OF THE USE OF CEMENT TO ANCHOR THE FEMORAL HEAD PROSTHESIS *OURNAL OF "ONE AND *OINT 3URGERY " n #HARNLEY * A 5SING 4EmON IN ARTHROPLASTY OF THE HIP JOINT *OURNAL OF "ONE AND *OINT 3URGERY ! #HARNLEY * B 4HE HEALING OF HUMAN FRACTURES IN CONTACT WITH SELF CURING ACRYLIC CEMENT #LINICAL /RTHOPAEDICS AND 2ELATED 2ESEARCH n #HARNLEY * !CRYLIC #EMENT IN /RTHOPAEDIC 3URGERY %DINBURGH ,IVINGSTONE #HARNLEY * 0OST /PERATIVE )NFECTION AFTER 4OTAL (IP 2EPLACEMENT WITH 3PECIAL 2EFERENCE TO !IR #ONTAMINATION IN THE /PERATING 2OOM )NTERNAL 0UBLICATION .O 7IGAN #ENTRE FOR (IP 3URGERY 7RIGHTINGTON (OSPITAL
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3COTTISH 3OCIETY FOR #ONTAMINATION #ONTROL 3# A ,AMINAR mOW IN HOSPITALS A (OSPITALS 3IR *OHN #HARNLEY 3# #LEANROOM -ONITOR n &REELY AVAILABLE AT WWWSCCOUKMONITORTCMPDF VISITED /CTOBER 3# B ,AMINAR mOW IN HOSPITALS B ,AMINAR &LOW /2S 3# #LEANROOM -ONITOR n &REELY AVAILABLE AT WWWSCCOUKMONITOR TCMPDF VISITED /CTOBER 3EDDON ( * 0ERIPHERAL NERVE INJURIES IN 'REAT "RITAIN DURING 7ORLD 7AR )) A REVIEW !RCHIVES OF .EUROLOGY AND 0SYCHIATRY n 3EDDON ( * )N MEMORIAM 0HILIP 7ILES *OURNAL OF "ONE AND *OINT 3URGERY " n 3EDDON ( * 3CALES * 4 ! POLYTHENE SUBSTITUTE FOR THE UPPER TWO THIRDS OF THE SHAFT OF THE FEMUR ,ANCET II 3EMLITSCH - 7ILLERT ( ' #LINICAL WEAR BEHAVIOUR OF ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE CUPS PAIRED WITH METAL AND CERAMIC BALL HEADS IN COMPARISON TO METAL ON METAL PAIRINGS OF HIP JOINT REPLACEMENTS 0ROCEEDINGS OF THE )NSTITUTION OF -ECHANICAL %NGINEERS 0ART ( *OURNAL OF %NGINEERING IN -EDICINE n 3EMLITSCH - ,EHMANN - 7EBER ( $OERRE % 7ILLERT ( ' .EW PROSPECTS FOR A PROLONGED FUNCTIONAL LIFE SPAN OF ARTIlCIAL HIP JOINTS BY USING THE MATERIAL COMBINATION POLYETHYLENEALUMINIUM OXIDE CERAMINMETAL *OURNAL OF "IOMEDICAL -ATERIALS 2ESEARCH n 3HEN # $UMBLETON * ( 4HE FRICTION AND WEAR BEHAVIOUR OF IRRADIATED VERY HIGH MOLECULAR WEIGHT POLYETHYLENE 7EAR n 3MITH 0ETERSEN - . !RTHROPLASTY OF THE HIP A NEW METHOD *OURNAL OF "ONE AND *OINT 3URGERY n 3OMERVILLE % 7 $ISPLACEMENT OF THE (IP IN #HILDHOOD !ETIOLOGY MANAGEMENT AND SEQUELAE "ERLIN .EW 9ORK .9 3PRINGER 6ERLAG 3TANSlELD " 7 .ICOL ! # 0AUL * 0 +ELLY ) ' 'RAICHEN & "ERGMANN ' $IRECT COMPARISON OF CALCULATED HIP JOINT CONTACT FORCES WITH THOSE MEASURED USING INSTRUMENTED IMPLANTS !N EVALUATION OF A THREE DIMENSIONAL MATHEMATICAL MODEL OF THE LOWER LIMB *OURNAL OF "IOMECHANICS n
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n 2EFERENCES
3TANTON * ED )NNOVATIONS IN (EALTH AND -EDICINE $IFFUSION AND RESISTANCE IN THE 4WENTIETH #ENTURY 2OUTLEDGE 3TUDIES IN THE 3OCIAL (ISTORY OF -EDICINE ,ONDON AND .EW 9ORK .9 2OUTLEDGE 3TEPHENSON 0 + &REEMAN - ! 2 2EVELL 0 ! 'ERMAIN * 4UKE - 0IRIE # * 4HE EFFECT OF HYDROXYAPATITE COATING ON INGROWTH OF BONE INTO CAVITIES IN AN IMPLANT *OURNAL OF !RTHROPLASTY n 3WANSON 2 , %VARTS # - $UAL LOCK TOTAL HIP ARTHROPLASTY ! PRELIMINARY EXPERIENCE #LINICAL /RTHOPAEDICS AND 2ELATED 2ESEARCH n 3WANSON 3 ! 6 &REEMAN - ! 2 4HE 3CIENTIlC "ASIS OF 4OTAL *OINT 2EPLACEMENT ,ONDON 0ITMAN -EDICAL 3WANSON 3 ! 6 &REEMAN - ! 2 (EATH * # ,ABORATORY TESTS ON TOTAL JOINT REPLACEMENT PROSTHESES *OURNAL OF "ONE AND *OINT 3URGERY " n 3WEETNAM $ 2 ! SURVEILLANCE SCHEME WITH @2ECOMMENDED ,IST OF ARTIlCIAL JOINTS (EALTH 4RENDS n 4AGGART 4 +ERRY 2 - .ORMAN 0 3TOCKLEY ) 4HE USE OF VANCOMYCIN IMPREGNATED CEMENT BEADS IN THE MANAGEMENT OF INFECTION OF PROSTHETIC JOINTS *OURNAL OF "ONE AND *OINT 3URGERY " n 4ENNENT 4 $ %ASTWOOD $ - 3URVIVAL OF THE *UDET HIP PROSTHESIS *OURNAL OF THE 2OYAL 3OCIETY OF -EDICINE n 4HOMPSON & 2 6ITALLIUM INTRAMEDULLARY HIP PROSTHESIS PRELIMINARY REPORT .EW 9ORK 3TATE *OURNAL OF -EDICINE n 4HOMPSON & 2 !N ESSAY ON THE DEVELOPMENT OF ARTHROPLASTY OF THE HIP #LINICAL /RTHOPAEDICS AND 2ELATED 2ESEARCH n 4IMMERMANN # !NDERSON * EDS $EVICES AND $ESIGNS -EDICAL TECHNOLOGIES IN HISTORICAL PERSPECTIVE (OUNDMILLS 0ALGRAVE -ACMILLAN 4RENTANI # /LMI 2 ;4HERAPEUTIC TRENDS IN ASEPTIC NECROSIS OF THE FEMORAL HEAD IN ADULTS= )TALIAN ,A #HIRURGIA DEGLI /RGANI DI -OVIMENTO n 4RENTANI # 6ACCARINO & 4HE 0ALTRINIERIn4RENTANI HIP JOINT RESURFACE ARTHROPLASTY #LINICAL /RTHOPAEDICS AND 2ELATED 2ESEARCH n
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n 2EFERENCES
6ENABLE # 3 3TUCK 7 ' #LINICAL USES OF 6ITALLIUM !NNALS OF 3URGERY n 7AHLIG ( "UCHHOLZ ( 7 ;%XPERIMENTAL AND CLINICAL STUDIES ON THE RELEASE OF GENTAMICIN FROM BONE CEMENT= 'ERMAN $ER #HIRURG :EITSCHRIFT FÓR ALLE 'EBIETE DER OPERATIVEN -EDIZEN n 7AHLIG ( $INGELDEIN % "UCHHOLZ ( 7 "UCHHOLZ - "ACHMANN & 0HARMACOKINETIC STUDY OF GENTAMICIN LOADED CEMENT IN TOTAL HIP REPLACEMENTS #OMPARATIVE EFFECTS OF VARYING DOSAGE *OURNAL OF "ONE AND *OINT 3URGERY " n 7AINWRIGHT 0 /PPOSITE THE )NlRMARY ! HISTORY OF THE 4HACKRAY COMPANY n ,EEDS -EDICAL -USEUM 7ALKER 0 3 (UMAN *OINTS AND 4HEIR !RTIlCIAL 2EPLACEMENTS 3PRINGlELD ), #HARLES # 4HOMAS 0UBLISHER 7ATSON *ONES 2 &RACTURES OF THE NECK OF THE FEMUR "RITISH *OURNAL OF 3URGERY n 7ATSON *ONES 3IR 2EGINALD &RACTURES AND *OINT )NJURIES VOL &IFTH AND SIXTH EDN EDITED BY 7ILSON * . %DINBURGH .EW 9ORK .9 #HURCHILL ,IVINGSTONE 7AUGH 7 *OHN #HARNLEY 4HE MAN AND THE HIP ,ONDON 3PRINGER 6ERLAG 7EBSTER ! ED .EW 4ECHNOLOGIES IN (EALTH #ARE #HALLENGE CHANGE AND INNOVATION "ASINGSTOKE 0ALGRAVE 7EIGHTMAN " 3WANSON 3 ! 6 )SAAC ' ( 7ROBLEWSKI " - 0OLYETHYLENE WEAR FROM RETRIEVED ACETABULAR CUPS *OURNAL OF "ONE AND *OINT 3URGERY " n 7EINRAUCH 0 # , -OORE 7 2 3HOOTER $ 2 7ILKINSON - 0 2 "ONRATH % - $EDY . * -C-ENIMAN 4 * *ABUR - + ! 7HITEHOUSE 3 , #RAWFORD 2 7 %ARLY PROSTHETIC COMPLICATIONS AFTER UNIPOLAR HEMIARTHROPLASTY !.: *OURNAL OF 3URGERY n 7HEBLE 6 ( $ESIGN VALIDATION THROUGH CLINICAL TESTING IN VAN 'RUTING # 7 $ ED -EDICAL $EVICES )NTERNATIONAL PERSPECTIVES ON HEALTH AND SAFETY !MSTERDAM %LSEVIER n
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n 2EFERENCES
7HYTE 7 #LEANROOM 4ECHNOLOGY &UNDAMENTALS OF DESIGN TESTING AND OPERATION .EW 9ORK .9 *OHN 7ILEY 3ONS 7ILES 0 4HE SURGERY OF THE OSTEO ARTHRITIC HIP "RITISH *OURNAL OF 3URGERY n 7ILES 0 3WEETNAM 2 %SSENTIALS OF /RTHOPAEDICS TH EDN ,ONDON #HURCHILL 7ILLERT ( ' 2EACTIONS OF THE ARTICULAR CAPSULE TO WEAR PRODUCTS OF ARTIlCIAL JOINT PROSTHESES *OURNAL OF "IOMEDICAL -ATERIALS 2ESEARCH n 7ILLERT ( ' 3EMLITSCH - 4ISSUE REACTIONS TO PLASTIC AND METALLIC WEAR PRODUCTS OF JOINT ENDOPROSTHESES )N 'SCHWEND . $EBRUNNER ( 5 EDS 4OTAL (IP 0ROSTHESIS "ERN ( (UBER n 7ILLERT ( ' ,UDWIG * 3EMLITSCH - 2EACTION OF BONE TO METHACRYLATE AFTER HIP ARTHROPLASTY A LONG TERM GROSS LIGHT MICROSCOPIC AND SCANNING ELECTRON MICROSCOPIC STUDY *OURNAL OF "ONE AND *OINT 3URGERY ! n 7ILSON * . 3ARCOMA OF THE UPPER END OF THE lBULA SIMULATING OSTEOMYELITIS "RITISH *OURNAL OF 3URGERY n 7ILSON * . 0ROSTHETIC REPLACEMENT OF LONG BONE FOR TUMOUR TWO CASES 0ROCEEDINGS OF THE 2OYAL 3OCIETY OF -EDICINE n 7ILSON * . 3CALES * 4 4HE 3TANMORE METAL ON METAL TOTAL HIP PROSTHESIS USING A THREE PIN TYPE CUP ! FOLLOW UP OF ARTHROPLASTIES OVER NINE YEARS #LINICAL /RTHOPAEDICS AND 2ELATED 2ESEARCH n 7ILSON 0 $ *R !MSTUTZ ( # #ZERNIECKI ! 3ALVATI % ! -ENDES $ ' 4OTAL HIP REPLACEMENT WITH lXATION BY ACRYLIC CEMENT ! PRELIMINARY STUDY OF CONSECUTIVE -C+EE &ARRAR PROSTHETIC REPLACEMENTS *OURNAL OF "ONE AND *OINT 3URGERY ! n 7ROBLEWSKI " - #HARNLEY LOW FRICTION ARTHROPLASTY 2EVIEW OF THE PAST PRESENT STATUS AND PROSPECTS FOR THE FUTURE #LINICAL /RTHOPAEDICS AND 2ELATED 2ESEARCH n 7ROBLEWSKI " - 2EVISION 3URGERY IN 4OTAL (IP !RTHROPLASTY ,ONDON .EW 9ORK .9 3PRINGER 6ERLAG
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n 2EFERENCES
7ROBLEWSKI " - 7EAR OF THE HIGH DENSITY POLYETHYLENE SOCKET IN TOTAL HIP ARTHROPLASTY AND ITS ROLE IN ENDOSTEAL CAVITATION 0ROCEEDINGS OF THE )NSTITUTION OF -ECHANICAL %NGINEERS 0ART ( *OURNAL OF %NGINEERING IN -EDICINE n 7ROBLEWSKI " - 0ROFESSOR 3IR *OHN #HARNLEY n 2HEUMATOLOGY n 7ROBLEWSKI " - 3INEY 0 $ &LEMING 0 ! #HARNLEY LOW FRICTIONAL TORQUE ARTHROPLASTY IN PATIENTS UNDER THE AGE OF YEARS &OLLOW UP TO YEARS *OURNAL OF "ONE AND *OINT 3URGERY " n 7ROBLEWSKI " - 3INEY 0 $ &LEMING 0 ! 7EAR OF THE CUP IN THE #HARNLEY ,&! IN THE YOUNG PATIENT *OURNAL OF "ONE AND *OINT 3URGERY " n 7ROBLEWSKI " - 2AUT 6 6 3INEY 0 $ %VANS ! 2 !N INTRAPELVIC POLYTETRAmUOROETHYLENE GRANULOMA /RTHOPAEDICS )NTERNATIONAL EDN n
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n "IOGRAPHICAL NOTES
"IOGRAPHICAL NOTES
3IR #HRISTOPHER "OOTH +T &2#0 B TRAINED AS A GASTROENTEROLOGIST AND WAS 0ROFESSOR OF -EDICINE AT THE 2OYAL 0OSTGRADUATE -EDICAL 3CHOOL (AMMERSMITH (OSPITAL ,ONDON FROM TO AND $IRECTOR OF THE -EDICAL 2ESEARCH #OUNCILS #LINICAL 2ESEARCH #ENTRE .ORTHWICK 0ARK (OSPITAL (ARROW FROM TO (E WAS THE lRST #ONVENOR OF THE 7ELLCOME 4RUSTS (ISTORY OF 4WENTIETH #ENTURY -EDICINE 'ROUP FROM TO AND (ARVEIAN ,IBRARIAN AT THE 2OYAL #OLLEGE OF 0HYSICIANS FROM TO -R (AROLD *ACKSON "URROWS #"% &2#3 ,2#0 n SON OF (AROLD "URROWS &2#3 TRAINED AT 3T "ARTHOLOMEWS (OSPITAL ,ONDON WHERE HE HAD HOUSE DUTIES RETURNING TO #AMBRIDGE ON A "EAVERBROOK 2ESEARCH 3CHOLARSHIP FROM THE 2OYAL #OLLEGE OF 3URGEONS TO STUDY TISSUE CULTURE AND LATER AT THE 2OCKEFELLER )NSTITUTE .EW 9ORK .9 (E WAS APPOINTED SURGICAL REGISTRAR AT THE 2./( IN AND CHIEF ASSISTANT IN THE ORTHOPAEDIC DEPARTMENT AT "ARTS FROM n AND
ASSISTANT ORTHOPAEDIC SURGEON FROM TO (E WAS 3URGEON #OMMANDER IN THE 2OYAL .AVY 6OLUNTEER 2ESERVE DURING THE WAR AND WAS AN ACTIVE CIVILIAN CONSULTANT SURGEON TO THE 2OYAL .AVY FROM n (E RETURNED TO "ARTS AS ORTHOPAEDIC SURGEON FROM n AND WAS A LECTURER IN ORTHOPAEDICS THERE (E WAS $EAN OF THE )NSTITUTE OF /RTHOPAEDICS AT THE "RITISH 0OSTGRADUATE -EDICAL &EDERATION 5NIVERSITY OF ,ONDON FROM n AND n HONORARY ORTHOPAEDIC SURGEON TO THE .ATIONAL (OSPITAL FOR $ISEASES OF THE .ERVOUS 3YSTEM AND A CONSULTANT ADVISER TO THE -INISTRY OF (EALTH AND #HAIRMAN OF THEIR 3TANDING !DVISORY #OMMITTEE ON !RTIlCIAL ,IMBS (E WAS 0RESIDENT OF THE /RTHOPAEDIC 3ECTION OF THE 2OYAL 3OCIETY OF -EDICINE 0RESIDENT OF THE "/! IN n AND ASSISTANT EDITOR THEN DEPUTY EDITOR OF THE *OURNAL OF "ONE AND *OINT 3URGERY UNTIL 3EE !NONYMOUS
#ONTRIBUTORS ARE ASKED TO SUPPLY DETAILS OTHER ENTRIES ARE COMPILED FROM CONVENTIONAL BIOGRAPHICAL SOURCES
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n "IOGRAPHICAL NOTES
,ADY *ILL #HARNLEY 7IFE OF 3IR *OHN #HARNLEY 0ROFESSOR 3IR *OHN #HARNLEY +T #"% $3C &2#3 &23 n ORTHOPAEDIC SURGEON INVENTED THE LOW FRICTION HIP REPLACEMENT IN THE EARLY S (E SERVED IN THE 2OYAL !RMY -EDICAL #ORPS AT $UNKIRK AND IN #AIRO AND WAS APPOINTED ASSISTANT ORTHOPAEDIC SURGEON -ANCHESTER 2OYAL )NlRMARY LATER #ONSULTANT /RTHOPAEDIC 3URGEON AT 7RIGHTINGTON (OSPITAL NEAR 7IGAN ,ANCASHIRE FROM TO (E ESTABLISHED AND BECAME THE lRST DIRECTOR OF THE #ENTRE FOR (IP 3URGERY 7RIGHTINGTON (OSPITAL IN (E WAS 0ROFESSOR OF /RTHOPAEDIC 3URGERY AT THE 5NIVERSITY OF -ANCHESTER FROM TO LATER %MERITUS (IS MANY HONOURS AND AWARDS INCLUDE THE HONORARY FELLOWSHIP OF "/! AND THE ,ISTER -EDAL OF THE 2OYAL #OLLEGE OF 3URGEONS &OLLOWING HIS DEATH IN ,ADY #HARNLEY ESTABLISHED THE *OHN #HARNLEY 4RUST WHICH SUPPORTS THE *OHN #HARNLEY 2ESEARCH )NSTITUTE 3EE #HARNLEY 3EE ALSO 7ROBLEWSKI AND &IGURE -R 4RISTRAM #HARNLEY 3ON OF 3IR *OHN #HARNLEY
0ROFESSOR #HRISTOPHER #OLTON -" &2#3 &2#3%D B TRAINED AT 3T 4HOMAS (OSPITAL 5NIVERSITY OF ,ONDON (E WAS #ONSULTANT IN /RTHOPAEDIC AND !CCIDENT 3URGERY .OTTINGHAM 5NIVERSITY (OSPITAL FROM n AND 3PECIAL 0ROFESSOR IN /RTHOPAEDIC AND !CCIDENT 3URGERY &ACULTY OF -EDICINE 5NIVERSITY OF .OTTINGHAM FROM UNTIL HIS RETIREMENT FROM THE .(3 IN LATER %MERITUS (E HAS BEEN A MEMBER OF THE "/! SINCE ITS 0RESIDENT IN AND A MEMBER OF THE %DITORIAL "OARD OF THE *OURNAL OF "ONE AND *OINT 3URGERY IN n AND (E IS NOW AN INDEPENDENT SPECIALIST IN CLINICAL AND MEDICOnLEGAL PRACTICE -R (ARRY #RAVEN n STARTED HIS APPRENTICESHIP IN ENGINEERING AT 7ALKER "ROTHERS 7IGAN ,TD ENGINEERS AND MINING MACHINERY MANUFACTURERS IN WHERE HE WORKED UNTIL (E JOINED THE -ETAL "OX #OMPANY ,TD AS A MANAGEMENT TRAINEE UNTIL WHEN HE BECAME #HIEF 2ESEARCH 4ECHNICIAN FOR -R *OHN #HARNLEY AT 7RIGHTINGTON (OSPITAL NEAR 7IGAN 4HERE HE DESIGNED AND BUILT MANY COMPONENTS USED BY ORTHOPAEDIC SURGEONS (E MOVED TO ,IVERPOOL 5NIVERSITY IN TO SET UP THE "IO %NGINEERING $EPARTMENT TESTING THE LOADING OF BONE FRACTURES CHECKED
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n "IOGRAPHICAL NOTES
BY 8 RAYS )N HE WENT TO THE 'ROOTE 3CHUUR (OSPITAL #APE 4OWN 3OUTH !FRICA RETURNING TO THE 5+ TO BECOME WORKS MANAGER AT 3URGICAL )MPLANT %NGINEERING 3)% IN UNTIL IT CLOSED THE FOLLOWING YEAR (E STARTED HIS OWN BUSINESS MAKING JOINTS FOR HOSPITALS UNTIL HE RETIRED IN DUE TO ILL HEALTH 3EE &IGURE -S #LARE $ARRAH 2'. $IP3CI B TRAINED AS A NURSE AT 3T "ARTHOLOMEWS (OSPITAL ,ONDON FROM n AND HAS BEEN #LINICAL 2ESEARCH -ANAGER AT THE )NSTITUTE OF /RTHOPAEDICS .ORFOLK AND .ORWICH 5NIVERSITY (OSPITAL .ORWICH SINCE 3HE CONDUCTS THE JOINT REVIEW PROGRAMME TO PROVIDE LONG TERM SURVEILLANCE OF HIP AND KNEE REPLACEMENTS 3HE IS A FOUNDER MEMBER OF THE !RTHROPLASTY #ARE 0RACTITIONERS !SSOCIATION -R 'RAHAM $EANE -" -3C &2#3 B ORTHOPAEDIC SURGEON GRADUATED IN BIOMECHANICS IN WAS APPOINTED ,ECTURER IN /RTHOPAEDICS TO THE 5NIVERSITY OF /XFORD IN AND #ONSULTANT TO THE /XFORD /RTHOPAEDIC %NGINEERING #ENTRE IN AT THE .UFlELD /RTHOPAEDIC #ENTRE (E MOVED TO (EATHERWOOD AND 7EXHAM 0ARK (OSPITALS ;FORMERLY THE 7INDSOR 'ROUP OF (OSPITALS= IN UNTIL
HIS RETIREMENT IN (IS MAJOR INTERESTS AND PUBLICATIONS HAVE BEEN IN BIOMECHANICS ORTHOTICS AND TOTAL JOINT REPLACEMENTS PARTICULARLY THE KNEE (E HAS DESIGNED SURGICAL DEVICES INCLUDING TWO KNEE JOINT PROSTHESES (E WAS 6ICE #HAIRMAN OF THE #OURT OF %XAMINERS AND 3ENIOR %XAMINER AT THE 2OYAL #OLLEGE OF 3URGEONS OF %NGLAND IN 0ROFESSOR $UNCAN $OWSON #"% 0H$ $3C &%NG &23 B WAS 2ESEARCH %NGINEER AT 3IR 7 ' !RMSTRONG 7HITWORTH !IRCRAFT #O FROM TO THEN ,ECTURER IN -ECHANICAL %NGINEERING IN LATER 3ENIOR ,ECTURER 2EADER AND 0ROFESSOR OF %NGINEERING &LUID -ECHANICS AND 4RIBOLOGY AT THE 5NIVERSITY OF ,EEDS FROM UNTIL HIS RETIREMENT IN (E SERVED AS (EAD OF $EPARTMENT OF -ECHANICAL %NGINEERING n $EAN FOR )NTERNATIONAL 2ELATIONS n AND 0RO 6ICE #HANCELLOR n (E WAS 0RESIDENT OF THE )NSTITUTION OF -ECHANICAL %NGINEERS n A &OREIGN -EMBER 2OYAL 3WEDISH !CADEMY AND CO FOUNDER WITH 0ROFESSOR 6ERNA 7RIGHT OF THE ,EEDS "IO %NGINEERING 'ROUP FOR THE 3TUDY OF (UMAN *OINTS IN AND THE #ENTRE FOR 3TUDIES IN -EDICAL %NGINEERING IN 3EE $OWSON AND 7RIGHT
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n "IOGRAPHICAL NOTES
-RS 3HEILA %DWARDS B N£E 7ILSON @'INGER 7ILSONS DAUGHTER -R 2EG %LSON &2#3 B QUALIlED AT #AMBRIDGE IN HAVING DONE CLINICAL WORK AT THE ,ONDON (OSPITAL 3UBSEQUENTLY HE TRAINED AS AN ORTHOPAEDIC TRAUMA SURGEON AND WAS APPOINTED TO THE .ORTHERN 'ENERAL (OSPITAL IN 3HEFlELD IN IN CHARGE OF THE TRAUMA SERVICE THERE !S A RESULT OF A DELAY IN REBUILDING IN 3HEFlELD HE REVERTED TO JOINT REPLACEMENT SURGERY AND IN WORKED AT THE %NDO+LINIK IN (AMBURG ALMOST STAYING THERE PERMANENTLY (E RETURNED TO 3HEFlELD WHERE A UNIT WAS ESTABLISHED DEALING WITH REVISION SURGERY ESPECIALLY INFECTED CASES (E HAS BEEN 0RESIDENT OF THE %UROPEAN (IP 3OCIETY AND OF THE "RITISH (IP 3OCIETY AND WAS A FOUNDER OF THE #AVENDISH (IP &ELLOWSHIP 4RUST $R !LEX &AULKNER -! 0H$ B MEDICAL AND HEALTHCARE SOCIOLOGIST RESEARCHES AND WRITES ABOUT NEW MEDICAL TECHNOLOGIES IN THE CONTEXT OF HEALTHCARE SYSTEMS AND HEALTH POLICY (E WAS APPOINTED TO THE $EPARTMENT OF 3OCIAL -EDICINE AT THE 5NIVERSITY OF "RISTOL FROM TO AND HAS BEEN AT #ARDIFF 5NIVERSITYS 3CHOOL
OF 3OCIAL 3CIENCES SINCE (E LED A @SYSTEMATIC REVIEW OF THE PERFORMANCE OF TOTAL HIP REPLACEMENTS IN 3EE &AULKNER ET AL &AULKNER +ENT AND &AULKNER 0ROFESSOR -ICHAEL &REEMAN &2#3 B TRAINED AT THE ,ONDON (OSPITAL !LONG WITH !LAN 3WANSON HE WAS CO FOUNDER OF THE "IOMECHANICS 5NIT )MPERIAL #OLLEGE ,ONDON IN APPOINTED #ONSULTANT /RTHOPAEDIC 3URGEON AT THE ,ONDON (OSPITAL FROM UNTIL HIS RETIREMENT IN AND 2ESEARCH &ELLOW AT )MPERIAL #OLLEGE ,ONDON FROM UNTIL (E HAS BEEN (ONORARY #ONSULTANT 2OYAL (OSPITALS .(3 4RUST SINCE (E ORIGINATED NEW SURGICAL PROCEDURES FOR RECONSTRUCTION AND REPLACEMENT ARTHRITIC HIP KNEE ANKLE AND FOOT JOINTS (E WAS 0RESIDENT OF THE )NTERNATIONAL (IP 3OCIETY FROM TO THE "RITISH (IP 3OCIETY FROM TO AND THE "/! FROM TO 3EE &REEMAN ED 3WANSON AND &REEMAN EDS -RS 0HYLLIS (AMPSON B STARTED WORK AT THE ,ONDON 3PLINT #OMPANY IN MOVING IN TO WORK FOR :IMMER /RTHOPAEDIC ,TD :/, "RIDGEND 3OUTH 7ALES AS NON
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n "IOGRAPHICAL NOTES
EXECUTIVE DIRECTOR 3HE RETURNED TO ,ONDON IN TO START :/,S SALES OFlCE WAS PROMOTED TO 3ALES -ANAGER IN $IRECTOR OF 3ALES IN AND -ANAGING $IRECTOR IN :/, WAS SOLD TO "IOMET IN ON THE DEATH OF THE OWNER AND -RS (AMPSON RETIRED IN -R +EVIN (ARDINGE &2#3 B QUALIlED AT ,IVERPOOL AND HELD HOUSE AND REGISTRAR POSTS AT THE ,IVERPOOL 2OYAL )NlRMARY (E WAS APPOINTED #ONSULTANT /RTHOPEDIC 3URGEON AT THE -ANCHESTER 2OYAL )NlRMARY n AND HAS BEEN #ONSULTANT /RTHOPEDIC 3URGEON AT THE 7RIGHTINGTON (OSPITAL 7IGAN SINCE (ONORARY ,ECTURER IN /RTHOPEDICS AT THE 5NIVERSITY OF -ANCHESTER SINCE AND (UNTERIAN 0ROFESSOR AT THE 2OYAL 3OCIETY OF 3URGEONS OF %NGLAND SINCE -R -IKE (EYWOOD 7ADDINGTON -! &2#3 B QUALIlED AT #AMBRIDGE TRAINED AT %XETER 3TANMORE AND 'REAT /RMOND 3TREET (OSPITAL ,ONDON AND SERVED WITH THE 2OYAL !IR &ORCE (E WAS #ONSULTANT IN /RTHOPAEDIC AND 4RAUMATIC 3URGERY TO -ID %SSEX AND .ORTH %SSEX (EALTH !UTHORITIES FROM TO AND (ONORARY /RTHOPAEDIC #ONSULTANT SINCE (E IS A &OUNDER -EMBER OF THE "RITISH (IP 3OCIETY AND THE
"RITISH /RTHOPAEDIC 3PORTS 4RAUMA !SSOCIATION A PAST 0RESIDENT OF THE /RTHOPAEDIC 3ECTION OF THE 2OYAL 3OCIETY OF -EDICINE A 3ENIOR &ELLOW OF THE "/! AND IS /RTHOPAEDIC 3URGEON TO %SSEX #OUNTY #RICKET #LUB -R 'EOFF +ING B HAD MULTIPLE FRACTURES FOLLOWING AN ACCIDENT INVOLVING A LORRY IN THE TREATMENT OF WHICH RESULTED IN HIS INTEREST IN THE HEALTH SERVICE (E WORKED IN THE .(3 FOR YEARS INITIALLY AS A TECHNICIAN IN THE ORTHOPAEDIC THEATRES IN THE .ORFOLK AND .ORWICH (OSPITALS WHERE THE -C+EE AND THE -C+EEn&ARRAR HIP JOINT REPLACEMENTS WERE DEVELOPED ,ATTERLY HE WAS A GENERAL MANAGER IN THE .(3 BEFORE RETIRING IN AND HAD A HIP REPLACEMENT THE "IRMINGHAM RE SURFACING DOUBLE CUP TYPE SUITABLE FOR USE IN THE @YOUNGER PATIENT IN -R *OHN +IRKUP &2#3 $(-3! B ORTHOPAEDIC SURGEON AND SURGICAL HISTORIAN QUALIlED AT 3T -ARYS (OSPITAL ,ONDON IN AND AFTER SERVICE IN THE 2OYAL .AVY WORKED WITH +ENNETH -C+EE AT THE .ORFOLK AND .ORWICH (OSPITAL FROM TO *OHN #HARNLEY IN AND AT THE "ATH AND 7ESSEX /RTHOPAEDIC (OSPITAL FROM TO BECOMING
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n "IOGRAPHICAL NOTES
#ONSULTANT /RTHOPAEDIC 3URGEON TO THE "ATH #LINICAL !REA FROM UNTIL (E INTRODUCED AN ANKLE JOINT REPLACEMENT IN (E WAS A 5+ 4RAVELLING 3CHOLAR AND (ONORARY !RCHIVIST TO THE "/! n 0RESIDENT OF THE "RITISH /RTHOPAEDIC &OOT 3URGICAL 3OCIETY "RATTSTROM ,ECTURER TO THE 3WEDISH 3OCIETY FOR 2HEUMATOID 3URGERY AND 6ICARY ,ECTURER 3IR !RTHUR +EITH -EDALLIST AT THE 2OYAL #OLLEGE OF 3URGEONS OF %NGLAND AND (ONORARY #URATOR OF THE (ISTORICAL )NSTRUMENT #OLLECTION THERE SINCE -R + - . 2AVI +UNZRU -3 &2#3 $(-3! B WAS #ONSULTANT /RTHOPAEDIC 3URGEON AT 7HIPPS #ROSS 5NIVERSITY (OSPITAL ,ONDON FROM UNTIL HIS RETIREMENT IN LATER %MERITUS #ONSULTANT AND -EDICAL (ISTORIAN 4HE lNAL PART OF HIS TRAINING AS 3ENIOR 2EGISTRAR INCLUDED WORKING WITH !RDEN !NSELL -AUDSLEY AND 3WANN ON JOINT REPLACEMENT INCLUDING CHILDRENS JOINTS AT THE 7INDSOR 'ROUP OF (OSPITALS (E IS CURRENT 0RESIDENT OF THE (ISTORY OF -EDICINE 3ECTION OF THE 2OYAL 3OCIETY OF -EDICINE AND 6ICE 0RESIDENT OF THE -EDICAL 3OCIETY OF ,ONDON n 0AST 0RESIDENT OF THE (UNTERIAN 3OCIETY CURRENTLY CO #URATOR OF ITS COLLECTION AND 0AST 0RESIDENT OF
THE "RITISH /RTHOPAEDIC &OOT AND !NKLE 3URGERY 3OCIETY -R 7 !LEXANDER 3COTTIE ,AW /"% -$ ,2#0 &2#3 n QUALIlED AT THE ,ONDON (OSPITAL IN WITH JUNIOR APPOINTMENTS IN ORTHOPAEDIC SURGERY THERE FOLLOWED BY WAR SERVICE IN THE 2!-# RECEIVING THE /"% FOR HIS MILITARY SERVICE (E RETURNED TO THE ,ONDON (OSPITAL AS CONSULTANT ORTHOPAEDIC SURGEON IN LATER CONSULTANT TO THE 2OYAL -ASONIC (OSPITAL AND THE )TALIAN (OSPITAL ,ONDON AND ASSOCIATE SURGEON TO THE 2OBERT *ONES AND !GNES (UNT (OSPITAL /SWESTRY (E SPENT THE YEAR OF WITH 3MITH 0ETERSEN AT THE -ASSACHUSETTS 'ENERAL (OSPITAL "OSTON LEARNING ABOUT CUP ARTHROPLASTY WHICH HE INTRODUCED ON HIS RETURN TO ,ONDON IN (E WAS 0RESIDENT OF THE /RTHOPAEDIC 3ECTION OF THE 2OYAL 3OCIETY OF -EDICINE -ISS "ETTY ,EE 2'. B TRAINED IN NURSING AT -ILE %ND (OSPITAL ,ONDON IN BECAME A STAFF NURSE IN THE MALE ORTHOPAEDIC WARD .ORFOLK AND .ORWICH (OSPITAL .ORWICH FROM TO A WARD SISTER FROM TO AND WAS APPOINTED TO THE TEACHING STAFF OF THE "ROADLAND 3CHOOL OF .URSING .ORWICH FROM UNTIL HER
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n "IOGRAPHICAL NOTES
RETIREMENT IN INCLUDING WORK ON THE 2#. TEACHING COURSE 3HE WAS -R -C+EES STAFF NURSE AND WARD SISTER FROM UNTIL -R !LAN ,ETTIN -3 &2#3 B QUALIlED AT 5NIVERSITY #OLLEGE (OSPITAL ,ONDON RECEIVED HIS ORTHOPAEDIC TRAINING AT THE 2./( AND BECAME LECTURER AND lRST ASSISTANT TO 3IR (UBERT 3EDDON AT THE )NSTITUTE OF /RTHOPAEDICS (E WAS #ONSULTANT /RTHOPAEDIC 3URGEON AT 3T "ARTHOLOMEWS (OSPITAL ,ONDON FROM TO AND THE 2OYAL .ATIONAL /RTHOPAEDIC (OSPITAL 3TANMORE FROM TO (E COLLABORATED WITH *OHN 3CALES AT THE )NSTITUTE OF /RTHOPAEDICS 5NIVERSITY OF ,ONDON IN THE DEVELOPMENT AND INTRODUCTION OF THE 3TANMORE RANGE OF ARTIlCIAL JOINTS AND WAS RESPONSIBLE FOR THE lRST TOTAL SHOULDER REPLACEMENT IN THE WORLD IN (E WAS 0RESIDENT OF THE "/! n AND 6ICE 0RESIDENT OF THE 2OYAL #OLLEGE OF 3URGEONS n 0ROFESSOR 2OBIN ,ING /"% (ON&2#3%D &2#3 B CO ORIGINATOR OF THE %XETER (IP WAS EDUCATED IN "RITISH #OLUMBIA /XFORD 5NIVERSITY AND 3T -ARYS (OSPITAL ,ONDON (E WAS APPOINTED #ONSULTANT (ONORARY ,ECTURER IN THE $EPARTMENT OF /RTHOPAEDIC
3URGERY OF THE 5NIVERSITY OF %DINBURGH TO #ONSULTANT /RTHOPAEDIC 3URGEON AT THE 2OYAL )NlRMARY OF %DINBURGH AND THE 0RINCESS -ARGARET 2OSE /RTHOPAEDIC (OSPITAL %DINBURGH TO AND MOVED TO THE 0RINCESS %LIZABETH /RTHOPAEDIC #ENTRE %XETER $EVON AS #ONSULTANT /RTHOPAEDIC 3URGEON IN UNTIL WHICH CULMINATED IN THE IMPLANTATION OF THE lRST %XETER (IP IN THE AUTUMN OF (E SET UP A SYSTEM TO ALLOW THE PROSPECTIVE GATHERING OF ALL DATA ON HIP ARTHROPLASTIES FROM THAT TIME (E HAS BEEN 0RESIDENT OF THE "RITISH /RTHOPAEDIC 2ESEARCH 3OCIETY THE "/! THE "RITISH (IP 3OCIETY AND THE )NTERNATIONAL (IP 3OCIETY -R +EN -C+EE #"% &2#3 n THE lRST TO REPLACE A HIP JOINT IN BY A REPRODUCIBLE METHOD THAT OTHERS COULD USE QUALIlED AT 3T "ARTHOLOMEWS (OSPITAL ,ONDON AND TRAINED IN ORTHOPAEDIC SURGERY AT #HAILEY (ERITAGE (OSPITAL ,EWES %AST 3USSEX UNDER 2EGINALD #HEYNE %LMSLIE n 3YDNEY ,IMBREY (IGGS n AND 3AM "ROCKMAN n (E WAS /RTHOPAEDIC 2EGISTRAR AT .ORFOLK AND .ORWICH (OSPITAL FROM TO AND #ONSULTANT /RTHOPAEDIC 3URGEON THERE FROM TO
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n "IOGRAPHICAL NOTES
$R !USTIN 4 -OORE -$ n 53 ORTHOPAEDIC SURGEON PERFORMED AND REPORTED THE lRST METALLIC HIP HEMI ARTHROPLASTY SURGERY IN (IS ORIGINAL HEAD AND STEM WAS MADE OF THE METAL VITALLIUM ABOUT INCHES LONG AND WAS BOLTED TO THE CUT END OF THE FEMORAL SHAFT A LATER VERSION THE !USTIN -OORE IS STILL USED TODAY FOR FRACTURES OF THE FEMORAL NECK 3EE -OORE AND "OHLMAN $R &RANCIS .EARY 0H$ B IS A RESEARCH ASSOCIATE IN THE #ENTRE FOR THE (ISTORY OF 3CIENCE 4ECHNOLOGY AND -EDICINE AT THE 5NIVERSITY OF -ANCHESTER (IS RECENT RESEARCH HAS BEEN CONCERNED WITH THE HISTORY OF TWENTIETH CENTURY MEDICAL TECHNOLOGIES AND HE HAS CURATED EXHIBITIONS ON JOINT REPLACEMENT AT THE 2OYAL #OLLEGE OF 3URGEONS OF %NGLAND AND AT 7RIGHTINGTON (OSPITAL NEAR 7IGAN IN -R *OHN /LDER &2#3%D &2#3 B QUALIlED AT 'UYS (OSPITAL ,ONDON AND DID HIS ORTHOPAEDIC TRAINING IN "RISTOL (E WAS A 3ENIOR #LINICAL 2ESEARCH &ELLOW 4ORONTO #ANADA BEFORE BEING APPOINTED #ONSULTANT /RTHOPAEDIC 3URGEON AT THE 2OYAL 3URREY #OUNTY (OSPITAL 'UILDFORD 3URREY FROM TO (E WAS A PUPIL ASSISTANT
AND COLLEAGUE OF 3IR *OHN #HARNLEY FROM TO AT THE +ING %DWARD 6)) (OSPITAL -IDHURST 7EST 3USSEX WHERE HE REMAINED UNTIL FOLLOWING THE CLOSURE OF THE HOSPITAL (E HAS BEEN #LINICAL !NATOMIST AT +INGS #OLLEGE ,ONDON -EDICAL 3CHOOL 'UYS #AMPUS ,ONDON SINCE (E CONTINUES A SPECIAL INTEREST IN PRIMARY AND REVISION HIP REPLACEMENT SURGERY AND CONTINUES TO REVIEW THE LONG TERM RESULTS OF THE ,&! 3EE /LDER 0ROFESSOR *OHN 0AUL B WAS APPOINTED IN TO THE $EPARTMENT OF -ECHANICAL %NGINEERING OF THE INSTITUTION THAT WAS TO BECOME THE 5NIVERSITY OF 3TRATHCLYDE 'LASGOW (E BECAME 3ENIOR ,ECTURER IN "IOENGINEERING IN RECEIVED A PERSONAL CHAIR IN AND BECAME 0ROFESSOR AND (EAD OF THE "IOENGINEERING 5NIT IN %MERITUS ON HIS RETIREMENT IN A POSITION WHICH HE STILL HOLDS (E HAS BEEN #HAIRMAN OF THE )NTERNATIONAL 3TANDARDS /RGANIZATION 3UB COMMITTEE ON "ONE AND *OINT 2EPLACEMENTS SINCE 0ROFESSOR *OHN 0ICKSTONE 0H$ B TRAINED IN BIOMEDICAL SCIENCES AND IN HISTORY AND PHILOSOPHY OF SCIENCE 3INCE HE HAS WORKED IN -ANCHESTER WHERE HE FOUNDED THE 7ELLCOME
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n "IOGRAPHICAL NOTES
5NIT AND THE #ENTRE FOR THE (ISTORY OF 3CIENCE 4ECHNOLOGY AND -EDICINE AT THE 5NIVERSITY OF -ANCHESTER 3INCE HE HAS BEEN THE 7ELLCOME 2ESEARCH 0ROFESSOR AT THE #ENTRE (IS PRESENT PROJECTS INCLUDE RECENT HISTORIES OF CANCER THE ARTIlCIAL HIP AND THE .(3 IN -ANCHESTER (E ALSO WRITES ON THE HISTORICAL SOCIOLOGY OF THE HISTORY OF SCIENCE TECHNOLOGY AND MEDICINE 3EE 0ICKSTONE #OOTER AND 0ICKSTONE EDS -R *OHN 2EAD &2#3%D QUALIlED AT 5NIVERSITY #OLLEGE (OSPITAL ,ONDON AND SPENT THREE YEARS IN THE 2OYAL !RMY -EDICAL #ORPS AS A #LINICAL /FlCER IN SURGERY AT THE "RITISH -ILITARY (OSPITAL AND 'ENERAL (OSPITALS IN (ONG +ONG (E WAS APPOINTED 2EGISTRAR AT THE 3UNDERLAND /RTHOPAEDIC AND !CCIDENT (OSPITAL LATER REGISTRAR TO *OHN #HARNLEY AT HIS NEW #ENTRE FOR (IP 3URGERY AT 7RIGHTINGTON (OSPITAL AND SENIOR REGISTRAR AT THE ,ONDON (OSPITAL (E WAS #ONSULTANT /RTHOPAEDIC 3URGEON TO THE (ARLOW (ERTFORD AND (ARLOW (OSPITALS LATER 7ELWYN 'ARDEN #ITY (OSPITAL CONTINUING HIS SPECIAL INTEREST IN PRIMARY AND REVISION HIP JOINT REPLACEMENT SURGERY
-R 0ETER 2ING -3 &2#3 B WAS #ONSULTING /RTHOPAEDIC 3URGEON TO THE 2EDHILL 3URREY GROUP OF HOSPITALS AND 3URGEON IN #HARGE OF THE *OINT 2EPLACEMENT 5NIT $ORKING (OSPITAL FROM TO 0ROFESSOR *OHN 4RACEY 3CALES /"% n DESIGNER OF THE 3TANMORE HIP WAS LECTURER THEN READER AT THE )NSTITUTE OF /RTHOPAEDICS 2OYAL .ATIONAL /RTHOPAEDIC (OSPITAL 2./( ,ONDON AND 3TANMORE FROM TO $URING THIS TIME HE DEVELOPED AIRSTRIP DRESSINGS (E WAS APPOINTED 0ROFESSOR OF "IOMECHANICAL %NGINEERING IN THE 5NIVERSITY OF ,ONDON IN UNTIL HIS RETIREMENT IN LATER %MERITUS (E STARTED THE BIOMEDICAL ENGINEERING DEPARTMENT AT THE 2./( THE )NSTITUTE OF /RTHOPAEDICS PART OF THE 5NIVERSITY OF ,ONDON (E DESIGNED THE 3TANMORE RANGE OF TOTAL JOINTS FOR HIPS WITH THE ASSISTANCE OF !LAN ,ETTIN KNEES SHOULDERS AND ELBOWS (E WAS HONORARY DIRECTOR OF RESEARCH AT THE 2!&4 2ESTORATION OF !PPEARANCE AND &UNCTION 4RUST )NSTITUTE FOR 0LASTIC 3URGERY AT -OUNT 6ERNON (OSPITAL .ORTHWOOD ,ONDON WHERE HE PRODUCED A LOW AIR LOSS MATTRESS TO PREVENT PRESSURE SORES BASED ON THE REVERSE PRINCIPLE OF THE HOVERCRAFT
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n "IOGRAPHICAL NOTES
3EE (AMPSON WWWRAFT ACUKCOMMONJTSHTML VISITED !UGUST 3EE ALSO +ENEDI ET AL EDS AND &IGURE 3IR (ERBERT 3EDDON +T #-' $- &2#3 n WAS 2ESIDENT 3URGEON AT THE COUNTRY BRANCH ;3TANMORE -IDDLESEX= OF THE 2./( FROM TO AND .UFlELD 0ROFESSOR OF /RTHOPAEDIC 3URGERY 5NIVERSITY OF /XFORD FROM TO (E WAS APPOINTED $IRECTOR OF 3TUDIES AT THE )NSTITUTE OF /RTHOPAEDICS 5NIVERSITY OF ,ONDON A JOINT APPOINTMENT BETWEEN THE 2./( AND THE )NSTITUTE FROM TO AND WAS 0ROFESSOR OF /RTHOPAEDICS THERE FROM UNTIL HIS RETIREMENT IN (E WAS A MEMBER OF THE -EDICAL 2ESEARCH #OUNCIL FROM n AND WAS INTERESTED IN !FRICAN AND TROPICAL MEDICAL PROBLEMS 3EE 3EDDON AND 3CALES 3EDDON .ICHOLSON AND 3EDDON 0ARSONS AND 3EDDON -R %DGAR 7ILLIAM 3OMERVILLE -" &2#3%D n QUALIlED IN AND SERVED IN THE 2OYAL !IR &ORCE UNTIL HE WAS DEMOBILIZED IN (E WAS #ONSULTANT 3URGEON AT THE 7INGlELD -ORRIS (OSPITAL /XFORD RENAMED THE .UFlELD /RTHOPAEDIC #ENTRE IN /XFORD UNTIL HIS RETIREMENT
IN SPECIALIZING IN THE TREATMENT OF CHILDRENS DEFORMITIES AND THE PATHOLOGY AND TREATMENT OF CONGENITAL DISLOCATION OF THE HIP (E WAS %DITORIAL 3ECRETARY AND THEN 6ICE 0RESIDENT OF THE "/! 0RESIDENT OF THE /RTHOPAEDIC 3ECTION OF THE 2OYAL 3OCIETY OF -EDICINE THE "RITISH /RTHOPAEDIC 2ESEARCH 3OCIETY AND THE !"# /RTHOPAEDIC #LUB 3EE 'IRDLESTONE AND 3OMERVILLE AND 3OMERVILLE -R )AN " - 3TEPHEN -" &2#3 B TRAINED AT #AMBRIDGE "RISTOL %XETER AND -ONTREAL #ANADA WAS #ONSULTANT IN /RTHOPAEDIC AND 4RAUMA 3URGERY %AST +ENT (OSPITALS FROM TO AND #LINICAL $IRECTOR 4RAUMA AND /RTHOPAEDIC 3URGERY TO AND HAS BEEN AN INDEPENDENT CONSULTANT ORTHOPAEDIC FOOT AND ANKLE SURGEON -ARGATE +ENT SINCE (E IS 0AST 0RESIDENT OF THE /RTHOPAEDIC 3ECTION 2OYAL 3OCIETY OF -EDICINE !RCHIVIST OF THE "/! AND MEMBER OF THE %XPERT 7ITNESS )NSTITUTE -R -ALCOLM 3WANN &2#3 B WAS #ONSULTANT /RTHOPAEDIC 3URGEON TO THE 7INDSOR 'ROUP OF (OSPITALS FROM UNTIL HIS RETIREMENT IN (IS SPECIAL INTEREST IS IN PAEDIATRIC ORTHOPAEDICS AND HE WORKED CLOSELY
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n "IOGRAPHICAL NOTES
WITH 0ROFESSOR "ARBARA !NSELL THE 0AEDIATRIC 2HEUMATOLOGIST AND LATER ESTABLISHED A SURGICAL SERVICE FOR PATIENTS WITH JUVENILE CHRONIC ARTHRITIS AT THE #ANADIAN 2ED #ROSS (OSPITAL AT 4APLOW 3EE !NSELL ET AL 0ROFESSOR !LAN 3WANSON 0H$ $3C &2%NG &)-ECH% B GRADUATED IN MECHANICAL ENGINEERING FROM )MPERIAL #OLLEGE ,ONDON IN (E WORKED IN ENGINEERING LABORATORIES AT "RISTOL !IRCRAFT n WAS APPOINTED ,ECTURER IN -ECHANICAL %NGINEERING )MPERIAL #OLLEGE IN 2EADER IN "IOMECHANICS AND 0ROFESSOR OF "IOMECHANICS FROM UNTIL HIS RETIREMENT IN 7ITH -ICHAEL &REEMAN HE FOUNDED THE "IOMECHANICS 5NIT AT )MPERIAL #OLLEGE IN WHERE WORK WAS DONE ON THE MECHANICAL PROPERTIES OF BONE AND ARTICULAR CARTILAGE INTERNAL lXATION DEVICES AND JOINT REPLACEMENTS 3IR 2ODNEY 3WEETNAM +#6/ #"% &2#3 &2#3%D B WAS #ONSULTANT /RTHOPAEDIC 3URGEON TO THE -IDDLESEX (OSPITAL AND 5NIVERSITY #OLLEGE (OSPITAL ,ONDON FROM TO LATER %MERITUS (E SERVED AS #ONSULTANT !DVISER IN /RTHOPAEDIC 3URGERY TO THE $EPARTMENT OF (EALTH n
/RTHOPAEDIC 3URGEON TO THE 1UEEN n 0RESIDENT OF THE "/! 0RESIDENT OF THE 2OYAL #OLLEGE OF 3URGEONS OF %NGLAND n AND A &ELLOW OF 5#, 3EE 7ILES AND 3WEETNAM AND (UGHES AND 3WEETNAM EDS -R +EITH 4UCKER -" &2#3 B WAS 3ENIOR (OUSE /FlCER TO +EN -C+EE IN 3ENIOR 2EGISTRAR AT 3T "ARTHOLOMEWS (OSPITAL ,ONDON 3URGICAL 4RAINING 0ROGRAMME IN /RTHOPAEDICS INCLUDING 3ENIOR 2EGISTRARSHIPS TO -ESSRS ,ETTIN 2EAD 0HILLIPS 7ATSON &ARRAR 4AYLOR 7ILSON AND +EMP FROM TO (E HAS BEEN #ONSULTANT /RTHOPAEDIC 3URGEON .ORFOLK AND .ORWICH 5NIVERSITY (OSPITAL .ORWICH SINCE (E IS A FOUNDER MEMBER OF THE "RITISH (IP 3OCIETY AND HAS BEEN (ONORARY 3ECRETARY n AND 6ICE 0RESIDENT n AND WILL SERVE AS 0RESIDENT IN ELECTED A MEMBER OF THE 3TEERING #OMMITTEE OF THE .ATIONAL *OINT 2EGISTRY IN #HAIRMAN OF THE /RTHOPAEDIC $ATA %VALUATION 0ANEL /$%0 SINCE AND "/! REPRESENTATIVE TO THE -$!-(2! SINCE
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n "IOGRAPHICAL NOTES
3IR 2EGINALD 7ATSON *ONES +T &2#3 (ON&2#3%D n QUALIlED AND TRAINED AT ,IVERPOOL 5NIVERSITY AND LATER HELD LECTURESHIPS AND DEMONSTRATORSHIPS IN ANATOMY PHYSIOLOGY AND PHYSIOTHERAPY THERE (E WAS RESIDENT HOUSE SURGEON AT THE 2./( AND CLINICAL ASSISTANT AT 'REAT /RMOND 3TREET (OSPITAL FOR #HILDREN RETURNING TO ,IVERPOOL IN AS SENIOR SURGICAL TUTOR AND REGISTRAR AT THE 2OYAL )NlRMARY WHERE HE WAS LATER AN ORTHOPAEDIC SURGEON (E ORGANIZED THE 2OYAL !IR &ORCES ORTHOPAEDIC SERVICES DURING THE WAR WAS (ON #ONSULTANT LATER $IRECTOR OF THE /RTHOPAEDIC AND !CCIDENT $EPARTMENT ,ONDON (OSPITAL FROM ORTHOPAEDIC SURGEON TO +ING 'EORGE 6) TO AND TO THE 1UEEN FROM (E WAS THE lRST "RITISH %DITOR *OURNAL OF "ONE AND *OINT 3URGERY FROM 0RESIDENT "/! n 3ENIOR 6ICE 0RESIDENT 2OYAL #OLLEGE OF 3URGEONS OF %NGLAND n -EMBER OF THE #OURT OF %XAMINERS OF THE 2#3 AND (UNTERIAN /RATOR AND 0RESIDENT OF THE /RTHOPAEDIC 3ECTION OF THE 2OYAL 3OCIETY OF -EDICINE -R 6ICTOR ( 7HEBLE &2#3%D B QUALIlED AT /XFORD AND TRAINED AT +INGS #OLLEGE (OSPITAL -EDICAL 3CHOOL ,ONDON AND SERVED AS A MEMBER
OF THE "APTIST -ISSIONARY 3OCIETY IN THE "ELGIAN #ONGO &OLLOWING A SERIOUS ILLNESS IN !FRICA HE WAS 2EGISTRAR AND 3ENIOR 2EGISTRAR AT -ANlELD /RTHOPAEDIC (OSPITAL .ORTHAMPTON (E WAS APPOINTED #ONSULTANT /RTHOPAEDIC 3URGEON AT !SHTON UNDER ,YNE 'ENERAL (OSPITAL NEAR -ANCHESTER FROM TO (E WAS A 6ISITING &ELLOW AND ,ECTURER AT THE 5NIVERSITY OF 3ALFORD UNDERTOOK RESEARCH AT 5-)34 WITH $R *AN 3KORECKI AND HAD CLOSE TIES WITH 0ROFESSOR 'ARTH (ASTINGS AT THE "IOMEDICAL %NGINEERING 5NIT 3TAFFORDSHIRE 0OLYTECHNIC 3TOKE ON 4RENT ;NOW 3TAFFORDSHIRE 5NIVERSITY= (E HAS BEEN A MEMBER AND FREQUENTLY #HAIRMAN OF MANY NATIONAL AND INTERNATIONAL COMMITTEES CONCERNED WITH THE STANDARDIZATION OF SURGICAL IMPLANTS FROM TO REPRESENTING THE "/! AND SUBSEQUENTLY THE 2OYAL #OLLEGE OF 3URGEONS OF %NGLAND 3EE 7HEBLE -R 0HILIP 7ILES &2#3 n SERVED IN THE !RMY AND THE 2OYAL &LYING #ORPS JOINED HIS FATHER IN THE #ITY OF ,ONDON AND CAME TO MEDICINE LATE A MATURE STUDENT AT THE -IDDLESEX (OSPITAL ,ONDON (E BECAME A #ONSULTANT THERE AT AGE (E SERVED IN THE -IDDLE %AST AND )NDIA IN THE 3ECOND 7ORLD 7AR BECOMING A BRIGADIER 2ETIRING EARLY
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n "IOGRAPHICAL NOTES
HE MOVED TO *AMAICA BECOMING #HAIRMAN OF THE 3CIENTIlC 2ESEARCH #OUNCIL AND ENCOURAGED THE GROWTH OF THE MEDICAL SCHOOL (IS TEXTBOOK ON ORTHOPAEDICS RAN TO FOUR EDITIONS AND SEVERAL REPRINTINGS (E WAS THE TREASURER TO THE "RITISH EDITION OF THE *OURNAL OF "ONE AND *OINT 3URGERY BECAME 0RESIDENT OF THE "/! 3EE 3EDDON -R *AMES .OEL 'INGER 7ILSON /"% #H- &2#3 n CO DESIGNER WITH *OHN 3CALES OF THE 3TANMORE (IP 3YSTEM QUALIlED AT "IRMINGHAM JOINING THE 2OYAL !RMY -EDICAL #ORPS IN WITH THE ST !IRBORNE $IVISION IN %UROPE AND .ORWAY (E WAS /RTHOPAEDIC 2EGISTRAR AT 2OBERT *ONES AND !GNES (UNT /RTHOPAEDIC (OSPITAL /SWESTRY n THEN #ONSULTANT AT #ARDIFF 2OYAL )NlRMARY AND "/! 4RAVELLING &ELLOW TO THE 53! IN (E WAS #ONSULTANT /RTHOPAEDIC 3URGEON AND A $IRECTOR OF THE !CCIDENT 3ERVICE AT THE 2./( ,ONDON AND 3TANMORE FROM n AND !SSISTANT $IRECTOR OF 0OSTGRADUATE 4RAINING AT 2./( FROM n #LINICAL 4EACHER AT THE )NSTITUTE OF /RTHOPAEDICS 5NIVERSITY OF ,ONDON AND #ONSULTANT /RTHOPAEDIC 3URGEON TO THE .ATIONAL (OSPITAL FOR .ERVOUS $ISEASES 1UEEN 3QUARE ,ONDON FROM n (E WORKED EXTENSIVELY IN THE 4HIRD 7ORLD DEVELOPING ORTHOPAEDIC
TRAINING PROGRAMMES EVEN AFTER RETIREMENT AND SERVED AS 0ROFESSOR OF /RTHOPAEDICS AT !DDIS !BABA 5NIVERSITY %THIOPIA IN (E WAS A FOUNDING MEMBER OF 7ORLD /RTHOPAEDIC #ONCERN 7/# AND EDITED THE 7/# .EWSLETTER FOR OVER A DECADE IN HIS RETIREMENT 0RESIDENT OF THE /RTHOPAEDIC 3ECTION OF THE 2OYAL 3OCIETY OF -EDICINE LATER (ONORARY MEMBER %DITORIAL 3ECRETARY OF THE "/! n AND 6ICE #HAIRMAN OF THE )-0!#4 &OUNDATION n 3EE 7ATSON *ONES /WEN -R -ICHAEL 7ILSON -! 'LASGOW B @'INGER 7ILSONS SON 0ROFESSOR " -ICHAEL 7ROBLEWSKI &2#3%D B TRAINED AT ,EEDS -EDICAL 3CHOOL AND AFTER POSTS AT ,EEDS -ANCHESTER /SWESTRY 7RIGHTINGTON AND "IRMINGHAM HE WAS APPOINTED #ONSULTANT /RTHOPAEDIC 3URGEON AT THE #ENTRE FOR (IP 3URGERY 7RIGHTINGTON (OSPITAL ,ANCASHIRE FROM TO (E WAS ALSO %XTERNAL 0ROFESSOR OF /RTHOPAEDIC "IOMECHANICS AT THE 5NIVERSITY OF ,EEDS IN (E HELPED TO ESTABLISH THE *OHN #HARNLEY 2ESEARCH )NSTITUTE AND #HARITABLE 4RUST IN WHICH HAS FUNDED #LINICAL 2ESEARCH &ELLOWS n 3EE 7ROBLEWSKI
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n 'LOSSARY
'LOSSARY
ARTHRODESIS OF THE HIP 4HE SURGICAL FUSION OF THE FEMUR THIGH BONE TO THE PELVIS IN WHICH THE HIP JOINT SURFACES ARE SURGICALLY REMOVED AND THE DENUDED JOINT SURFACES PRESSED TOGETHER AND lXED WITH SPECIAL PLATES AND SCREWS !LSO KNOWN AS FUSION ARTHROPLASTY 3URGICAL REPLACEMENT OF ALL OR PART OF THE HIP JOINT WITH AN ARTIlCIAL DEVICE TO DECREASE THE FRICTION AND WEAR BETWEEN THE FEMORAL HEAD PROSTHESIS AND THE CARTILAGE OF THE ACETABULUM OR ITS PROSTHETIC LINING -ETAL POLYETHYLENE AND CERAMIC OR COMBINATIONS HAVE BEEN USED BONE CEMENT SELF HARDENING ! CEMENT WHICH HARDENS WHEN ITS COMPONENTS ARE MIXED TOGETHER .O EXTERNAL PHYSICAL AGENCY SUCH AS HEAT OR 56 LIGHT IS NEEDED TO INITIATE THE HARDENING PROCESS )N IMPLANT SURGERY THE HARDENING PROCESS IS USUALLY ONE OF POLYMERIZATION "IRMINGHAM RESURFACING ARTHROPLASTY "3! ! METAL ON METAL PROSTHESIS INTRODUCED IN BY $EREK -C-INN "IRMINGHAM .UFlELD
(OSPITAL AND MANUFACTURED BY -IDLAND -EDICAL 4ECHNOLOGIES ,TD WHICH COVERS THE HIP JOINT SURFACES WITH ACCURATELY MACHINED LARGE HEADED METAL PROSTHESES INSTEAD OF REPLACING THEM 4HE ACETABULAR COMPONENT IS lXED WITH A HYDROXYAPATITE COATING WHILE THE FEMORAL COMPONENT IS CEMENTED IN PLACE 3EE -C-INN ET AL !PPENDIX PAGE "RITISH (IP 3OCIETY -ICHAEL &REEMAN 2OBIN ,ING AND (UGH 0HILLIPS FOUNDED THE (IP 3OCIETY IN AN AFlLIATE OF THE "/! 0HILLIPS WAS INVOLVED IN THE INCEPTION OF THE .ATIONAL *OINT 2EGISTER THE #APITAL HIP ENQUIRY AND WROTE THE lRST EDITION OF 4HE 'UIDE TO "EST 0RACTICE IN (IP 3URGERY PUBLISHED BY THE "(3 IN #% MARKING OR %# MARK 4HE LETTERS #% ARE THE ABBREVIATION OF &RENCH PHRASE #ONFORMIT£ %UROP£ENE OR %UROPEAN #ONFORMITY )NITIALLY THE TERM WAS @%# -ARK REPLACED BY @#% -ARKING IN BY %UROPEAN $IRECTIVE %%# ! PRODUCT WITH THIS MARK HAS A MANUFACTURERS DECLARATION THAT THE PRODUCT COMPLIES WITH THE
4ERMS IN BOLD APPEAR IN THE 'LOSSARY AS SEPARATE ENTRIES
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n 'LOSSARY
ESSENTIAL REQUIREMENTS OF THE RELEVANT %UROPEAN HEALTH SAFETY AND ENVIRONMENTAL PROTECTION LEGISLATION AND CONFORMS TO %UROPEAN PRODUCT DIRECTIVES &OR FURTHER DETAILS SEE WWWDTI GOVUKINNOVATIONSTRDCEMARK PAGEHTML VISITED 3EPTEMBER COBALTnCHROMIUM #On#R ALLOYS ! FAMILY OF ALLOYS WITH COBALT AS THE MAIN CONSTITUENT USED IN GENERAL ENGINEERING FOR RESISTANCE TO WEAR AND CORROSION AND IN DENTISTRY AND ORTHOPAEDICS CORROSION ! REACTION BETWEEN THE SURFACE OF A METAL OR ALLOY AND THE SURROUNDING MEDIUM AIR LIQUID OR BOTH 4HE RESULTING METALLIC OXIDES CHLORIDES ETC MAY REMAIN lRMLY ATTACHED OR MAY READILY DETACH WHICH MAKES THE ALLOY UNSUITABLE FOR IMPLANTS WHEREAS THE FORMER CHARACTERISTIC MAKES CERTAIN ALLOYS IDEAL FOR USE AS IMPLANTS ENDOSTEAL SURFACE OF THE FEMUR 4HE INNER SURFACE OF THE BONE AROUND THE MARROW CAVITY %XETER HIP 4HE ORIGINAL MADE IN %.* STEEL ;"3 'RADE 3 AUSTENITIC NON MAGNETIC OFFERS HIGH RESISTANCE TO CORROSION= WAS AVAILABLE FOR USE IN CLINICAL PRACTICE FROM AUTUMN MANUFACTURED BY THE ,ONDON
3PLINT #OMPANY NOW (OWMEDICA 5+ ,TD IN POLISHED STAINLESS STEEL WITH A HEAD SIZE OF MM CEMENTED WITH ACRYLIC BONE CEMENT AND IN TWO SIZES STANDARD AND LIGHTWEIGHT 4HE CUP WAS MADE FROM HIGH DENSITY POLYETHYLENE IN THREE SIZES 3EE ,ING n 3EE ALSO WWWEXETERHIP COUKEX?PAG?REDIRECT ABOUT USHTM VISITED *UNE AND &IGURE &LUOROSINT ! PROPRIETARY PLASTIC MIXTURE WHERE SYNTHETICALLY MANUFACTURED MICA IS CHEMICALLY LINKED TO POLYTETRAmUOROETHYLENE 04&% RESULTING IN PROPERTIES NOT NORMALLY ATTAINABLE IN REINFORCED 04&% 'IRDLESTONE ! RESECTION ARTHROPLASTY OF THE HIP WHERE THE RESECTED PART OF THE BALL OR HEAD OF THE THIGH BONE FEMUR AND THE REST OF THE FEMUR IS LEFT LOOSE ALLOWING SOME MOVEMENT BETWEEN THE FEMUR AND HIP ACETABULUM 4HE MUSCLE AND SOFT TISSUES INCLUDING THE SCAR OF THE PREVIOUS OPERATIONS INFECTION OR INmAMMATION PREVENT THE FEMUR RIDING UP A GREAT DEAL PAST THE HIP BONE SOCKET 4HE LEG SHORTENING CAN BE SEVERAL INCHES 4HE MOVEMENT OF THE PSEUDOARTHROSIS ALLOWS THE PATIENT TO SIT MORE EASILY IN A CHAIR THAN WITH A FUSED HIP 3EE THE CLASSIC ARTICLE BY 0ROFESSOR 'ATHORNE
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n 'LOSSARY
2OBERT 'IRDLESTONE n THE lRST .UFlELD 0ROFESSOR OF /RTHOPAEDIC SURGERY AT THE 5NIVERSITY OF /XFORD WHO DEVISED THIS TREATMENT FOR TUBERCULOSIS OF THE HIP AND LATER HAS BEEN USED IN SEVERE OSTEOARTHRITIS AND MORE RECENTLY AS A LAST RESORT FOR FAILED TOTAL HIP REPLACEMENTS THAT COULD NOT BE REVISED 'IRDLESTONE
STARTED IN TO COORDINATE AND UNIFY INDUSTRIAL STANDARDS 4HE ABBREVIATION )3/ IS BASED ON THE 'REEK ISOS MEANING @EQUAL
HYDROXYAPATITE COATING (!# ! BIOACTIVE MATERIAL APPLIED TO UNCEMENTED PROSTHESIS TO ENCOURAGE THE BONDING OF THE BONE TO SECURE THE IMPLANT
*OURNAL OF "ONE AND *OINT 3URGERY *"*3 /RIGINATED AS THE 4RANSACTIONS OF THE !MERICAN /RTHOPEDIC !SSOCIATION AND VOL CONTAINED THE PROCEEDINGS OF THE MEETINGS OF AND 6OLUME OF THE 4RANSACTIONS IS ALSO VOL OF THE !MERICAN *OURNAL OF /RTHOPEDIC 3URGERY )T BECAME THE OFlCIAL PUBLICATION OF THE "RITISH /RTHOPAEDIC !SSOCIATION IN AND THE NAME CHANGED TO THE *OURNAL OF /RTHOPAEDIC 3URGERY VOL NEW SERIES WITH THE PRESENT TITLE THE *OURNAL OF "ONE AND *OINT 3URGERY ADOPTED IN )N THE ! !MERICAN AND " "RITISH VOLUMES WERE ESTABLISHED WHILE THE !MERICAN /RTHOPEDIC !SSOCIATION REMAINED THE OWNER UNTIL AN INDEPENDENT NON PROlT CORPORATION WAS CREATED
)NTERNATIONAL /RGANIZATION FOR 3TANDARDIZATION )3/ !N INTERNATIONAL NON GOVERNMENTAL ORGANIZATION THAT BEGAN AS THE )NTERNATIONAL %LECTROTECHNICAL #OMMISSION )%# IN LATER THE )NTERNATIONAL &EDERATION OF THE .ATIONAL 3TANDARDIZING !SSOCIATIONS )3! n ! NEW POSTWAR ORGANIZATION THE )3/
+àNTSCHER NAIL OR INTRAMEDULLARY ROD ! HOLLOW ROD OF VARYING LENGTHS AND DIAMETERS SECURED TO THE MEDULLA THE HOLLOW CAVITY INSIDE THE FEMUR WHICH WAS IN FREQUENT USE UNTIL THE S .AMED AFTER 'ERHARD +ÓNTSCHER A 'ERMAN SURGEON WHO USED IT 3OME ATTRIBUTE ITS USE TO EXPLAIN WHY 'ERMAN SOLDIERS IN THE
HEMI ARTHROPLASTY 3URGICAL REPLACEMENT OF ONLY THE HEAD OF THE FEMUR )T IS OFTEN CALLED AN !USTIN -OORE OR 4HOMPSON ! BIPOLAR HEMI ARTHROPLASTY USES A FEMORAL PROSTHESIS WITH AN ARTICULATING ACETABULAR PART BUT NOT lXED TO THE ACETABULUM HIGH DENSITY POLYETHYLENE ($0 3EE ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE 5(-70%
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n 'LOSSARY
3ECOND 7ORLD 7AR WERE BACK IN ACTION A FEW MONTHS AFTER FRACTURED FEMURS WHEREAS THE !LLIED SOLDIERS WERE BACK IN TRACTION LAMINAR ULTRACLEAN AIR mOW SYSTEMS 5NIDIRECTIONAL CLEAN AIR SYSTEMS FOR SURGICAL THEATRES THAT BECAME WIDELY USED IN THE S DESIGNED FOR AIR CHANGES PER HOUR RE CIRCULATING THE AIR THROUGH lLTERS AND mOWING HORIZONTALLY THROUGH A WALL MODULE OR DOWNWARDS FROM AN AIR INLET OVERHEAD 4HESE SYSTEMS LED TO VERY LOW NUMBERS OF AIRBORNE BACTERIA 3EE ,OWBURY AND ,IDWELL SEE ALSO NOTE LOW FRICTIONAL ARTHROPLASTY 3IR *OHN #HARNLEYS OPERATION FOR TOTAL HIP REPLACEMENT AVAILABLE FROM CEMENTED USING lNGER PACKING 3EE #HARNLEY MEDIALIZED CUPS !CETABULAR PROSTHESIS INSERTED DEEPLY MORSELIZED GRAFT ! CANCELLAUS BONE GRAFT IMPACTED INTO THE PROXIMAL FEMUR 4HE BONE IS USUALLY TAKEN FROM THE FEMORAL HEAD IN A PRIMARY REPLACEMENT AND THE PROXIMAL FEMUR IF IT IS A REVISION 4HE BONE IS CHOPPED INTO CHIPS USING A BONE MILL AND USED AS A GRAFT ! CADAVER GRAFT IS USED IF AN ALLOGRAFT IS NOT AVAILABLE
/RTRON ! COBALTnCHROMIUM ALLOY ORIGINALLY DEVELOPED BY +RUPP IN 'ERMANY FOR DENTAL IMPLANTS AND HAS EXCELLENT CORROSION RESISTANCE !DOPTED BY $E0UY FOR USE IN THE #HARNLEY PROSTHESIS AFTER OSTEOLYSIS 4HE DISSOLUTION OF BONE THROUGH DISEASE COMMONLY DUE TO INFECTION OR BY LOSS OF BLOOD SUPPLY TO THE BONE AND A COMMON CAUSE OF LOOSENING A MAJOR FAILURE IN TOTAL HIP REPLACEMENT POLYETHYLENE ! POLYMER OF ETHYLENE #( WIDELY USED FOR BUCKETS (IGHER LEVELS OF POLYMERIZATION ALLOW CLOSER PACKING OF THE MOLECULES WITH FEWER VOIDS AND THE RESULTING HIGH OR ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE HAS IMPROVED WEAR RESISTANCE POLYMETHYLMETHACRYLATE CEMENT -ADE BY MIXING A POWDER POLYMETHYLMETHACRYLATE PLUS AN ACTIVATOR WITH A mUID METHYLMETHACRYLATE PLUS AN INHIBITOR IN A BOWL WITH A SPOON AND SPATULA 4HE MIXTURE BECOMES CREAMY AND THEN DOUGHY !FTER THREE TO FOUR MINUTES IT BEGINS TO SET AND AS IT DOES SO IT BECOMES HOT PRODUCING A CHARACTERISTIC SMELL 4HE MATERIAL HAVING BECOME VISCOUS IS PLASTIC THEN ELASTIC BEFORE BECOMING SOLID
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n 'LOSSARY
POLYTETRAmUOROETHYLENE 04&% ! THERMOPLASTIC DISCOVERED UNEXPECTEDLY IN WHEN A CYLINDER STORED UNDER PRESSURE WAS CUT OPEN )T BECAME AVAILABLE COMMERCIALLY IN THE 53 AND THE 5+ IN )T IS RESISTANT TO HIGH AND LOW TEMPERATURES HAS LOW LOSS DIELECTRIC PROPERTIES OVER A WIDE FREQUENCY RANGE A CHEMICAL INERTNESS AND ANTI STICK PROPERTIES WHICH LED TO ITS EARLY USE IN THE AEROSPACE INDUSTRY AND AS NON STICK COOKWARE 4EmON® PANS WERE lRST SOLD AT #HRISTMAS AND PLUMBERS THREAD TAPE 3EE WWW PLASTIQUARIANCOMPTFEHTM VISITED *UNE PROXIMAL STRESS SHIELDING 4HIS OCCURS WHEN THE STIFF PROXIMAL END OF A FEMORAL PROSTHESIS TRANSMITS MOST OF THE LOAD BETWEEN THE HIP JOINT AND THE FEMORAL SHAFT AND THE SURROUNDING BONE BEING SUBJECTED TO ABNORMALLY LOW STRESSES IS RESORBED OVER TIME BY THE NORMAL REMODELLING PROCESS WHICH RESPONDS TO STRESS LEVELS AMONG OTHER THINGS 2./( SEE 2OYAL .ATIONAL /RTHOPAEDIC (OSPITAL RADIOLUCENTRADIO OPAQUE ! RADIOLUCENT ZONE IN AN 8 RAY PERMITS THE PASSAGE OF 8 RAYS UNLIKE ONE THAT IS RADIO OPAQUE
RASP OR BROACH !N INSTRUMENT USED FOR CLEARING THE FEMORAL CANAL REAMER ! BURR LIKE INSTRUMENT USED DURING THE HIP REPLACEMENT OPERATION TO REMOVE ARTHRITIC BONE FROM THE ACETABULUM BY RASPING OR TO SHAPE THE MEDULLARY CANAL !N ACETABULAR REAMER IS HEMISPHERICAL THE FEMORAL IS STRAIGHT TAPERED OR PIN SHAPED 3EE &IGURE 2OYAL .ATIONAL /RTHOPAEDIC (OSPITAL 2./( 3TANMORE 2./( WAS RECOGNIZED BY THE 5NIVERSITY OF ,ONDON IN AS A POSTGRADUATE TEACHING HOSPITAL AND THE )NSTITUTE OF /RTHOPAEDICS AND -USCULOSKELETAL 3CIENCE )/-3 WAS FOUNDED THERE INITIALLY LOCATED IN 'REAT 0ORTLAND 3TREET ,ONDON "Y MOST OF THE FACILITIES HAD MOVED TO 3TANMORE -IDDLESEX CALLED THE COUNTRY BRANCH OF THE HOSPITAL ! UNIT LOOKING INTO RESEARCH ON PLASTICS BEGAN IN RENAMED "IOMECHANICS AND 3URGICAL -ATERIALS IN LATER "IOMEDICAL %NGINEERING AND LED BY 0ROFESSOR *OHN 3CALES BRINGING TOGETHER THE VARIOUS APPLICATIONS OF ENGINEERING TO ORTHOPAEDIC PROBLEMS 3TANMORE )MPLANTS 7ORLDWIDE 3)7 WAS FORMED FOR THE MANUFACTURE OF SPECIALIZED PROSTHETIC IMPLANTS WHICH BECAME A LIMITED COMPANY IN !
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n 'LOSSARY
COLLECTION OF RADIOGRAPHS HAS BEEN HELD IN THE 7ELLCOME -USEUM OF /RTHOPAEDICS AND THE 2ADIOLOGICAL $EPARTMENT FOR THE -USEUM OF /RTHOPAEDIC 2ADIOLOGY SUPPORTED BY a OF GRANTS FROM THE 7ELLCOME 4RUST TO ADAPT AND EQUIP ROOMS AT 'REAT 0ORTLAND 3TREET AND OPENED BY 3IR (ENRY $ALE IN 3EE #HOLMELEY SELF CURING ACRYLIC BONE CEMENT SEE POLYMETHYLMETHACRYLATE CEMENT 3HENTONS LINE ! RADIOGRAPHIC CURVED LINE FORMED BY THE TOP OF THE OBTURATOR FORAMEN AND THE INNER SIDE OF THE NECK OF THE FEMUR USED TO DETERMINE THE RELATIONSHIP OF THE HEAD OF THE FEMUR TO THE ACETABULUM !LSO KNOWN AS THE -£NARD 3HENTON -AKKAS LINE AFTER %DWARD 7ARREN (INE 3HENTON 3EE 2ENNER SLIT SAMPLER !N INSTRUMENT WHICH SUCKS AIR THROUGH A NARROW SLIT ONTO THE SURFACE OF A CULTURE MEDIUM ROTATED SLOWLY JUST BELOW THE SLIT 3EE "OURDILLON ET AL AND &IGURE 3TAPHYLOCOCCUS EPIDERMIDIS ! GRAM POSITIVE PATHOGENIC BACTERIUM COMMON IN MEDICAL DEVICE ASSOCIATED INFECTIONS 3 EPIDERMIDIS NORMALLY LIVES ON THE SKIN AND ONLY CAUSES INFECTION IF
INTRODUCED AROUND A FOREIGN BODY SUCH AS AN IMPLANT 3EE WWWEBI ACUKCANGENOMESGENOMES HTML HTTPWWWEBIACUKCAN GENOMESBACTERIA3TAPHYLOCOCCUS? EPIDERMIDISHTML VISITED !UGUST 3TANMORE SEE 2OYAL .ATIONAL /RTHOPAEDIC (OSPITAL 3TANMORE HIP 4HE ORIGINAL 3TANMORE PROSTHESIS WAS AVAILABLE FROM SPRING 3EE &IGURE AND !PPENDIX PAGE SURVIVORSHIP ANALYSIS ! STATISTICAL METHOD THAT LOOKS AT THE FREQUENCY OF REVISION OF A PROSTHESIS BY THE NUMBER OF YEARS OF CLINICAL IMPLANTATION TAKING INTO CONSIDERATION THE LOSS OF PATIENTS AT FOLLOW UP DUE TO DEATH AND OTHER FACTORS 4EmON 4HE TRADE NAME FOR A FAMILY OF 04&% RESINS PRODUCED BY $U0ONT 7ILMINGTON $ELAWARE 53! 4HACKRAYS #HARLES & 4HACKRAY ,TD OF ,EEDS STARTED AS RETAIL PHARMACISTS IN DIVERSIFYING INTO SURGICAL EQUIPMENT AND ORTHOPAEDICS IN 4HEY MANUFACTURED THE #HARNLEY PROSTHESIS FROM UNTIL WHEN 4HACKRAYS WAS ACQUIRED BY $E0UY THE 53 SUBSIDIARY OF A
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n 'LOSSARY
PRIVATE 'ERMAN lRM "OEHRINGER -ANNHEIM IN TAKEN OVER BY *OHNSON *OHNSON 4HE #HARNLEY TOTAL HIP REPLACEMENT IS CURRENTLY MANUFACTURED UNDER THE NAME OF $E0UY )NTERNATIONAL 3EE WWW JNJGATEWAYCOMHOMEJHTML LOC ' "%.'PAGE VIEW#ONTENTCONT ENT)D BBBABC VISITED /CTOBER 4HE 4HACKRAY -USEUM ,EEDS WAS ESTABLISHED IN A FORMER WORKHOUSE BUILDING OF THE 3T *AMESS (OSPITAL ,EEDS BY 0AUL 4HACKRAY A FORMER DIRECTOR AND MAJOR SHAREHOLDER IN 4HACKRAYS IN INITIALLY AS AN ARCHIVE OF THE COMPANY TITANIUM 4I ! LIGHT METAL WITH HIGH RESISTANCE TO CORROSION 3INCE THE +ROLL PROCESS WAS DEVELOPED IN IT CAN BE MADE IN CONSIDERABLE QUANTITIES MOSTLY USED BY THE AIRCRAFT INDUSTRY THE CHEMICAL INDUSTRY AND FOR MEDICAL APPLICATIONS TOTAL HIP REPLACEMENT 4HE SURGICAL REPLACEMENT OF THE HEAD OF THE FEMUR AND THE ACETABULUM WITH MANUFACTURED COMPONENTS TRIBOLOGY 4HE STUDY OF MECHANISMS OF FRICTION LUBRICATION AND WEAR OF INTERACTING SURFACES THAT ARE IN RELATIVE MOTION 3EE $OWSON ED
TROCHANTERIC OSTEOTOMY !N OPERATION TO CUT THE GREATER TROCHANTER WITH ALL ITS MUSCLES ATTACHED FROM THE FEMUR TO EXPOSE THE HIP JOINT OR TO ALTER ITS MECHANICS 3EE 7ROBLEWSKI n ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE 5(-70% ! POLYMER USED IN ORTHOPAEDICS THAT IS CLASSIlED AS A LINEAR HOMOPOLYMER FORMED FROM ETHYLENE #( 4HE DENSELY PACKED AND CURLED MOLECULAR CHAINS GIVE IT GOOD WEAR CHARACTERISTICS )RRADIATION FOR STERILIZATION SHOULD BE IN A VACUUM OTHERWISE THE CHAINS OF THE MOLECULES UNRAVEL )T HAS BEEN USED IN HIP REPLACEMENT SINCE WHEN #HARNLEY USED IT FOR ITS LOW FRICTION AND HIGH WEAR RESISTANCE PROPERTIES FOR HIS METAL ON PLASTIC HIP JOINT 3INCE THEN IT HAS BEEN USED IN A LARGE RANGE OF JOINT REPLACEMENTS FOR THE HIP KNEE ANKLE ELBOW AND SHOULDER 6ITALLIUM ! TRADEMARKED ALLOY OF PER CENT COBALT PER CENT CHROMIUM AND PER CENT MOLYBDENUM USED FOR PROSTHESES IMPLANTS AND INSTRUMENTS SINCE 3EE 6ENABLE AND 3TUCK
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n )NDEX
)NDEX 3UBJECT ACETABULAR CUPS lXATION n LOOSENING n MATERIALS MEDIALIZATION STANDARDS WEAR n SEE ALSO #HARNLEY CUPS ACETABULAR REAMER ACRYLIC SEE METHYLMETHACRYLATE POLYMETHYLMETHACRYLATE ADVERTISEMENTS !DVISORY 'ROUP ON /RTHOPAEDIC )MPLANTS SEE $EPARTMENT OF (EALTH AIR SEE CLEAN AIR #ASELLA SLIT SAMPLER AIRCRAFT INDUSTRY XXVII SEE ALSO DE (AVILLAND !IRCRAFT #O ,TD "RISTOL !EROPLANE #OMPANY ,TD ALLERGY METAL !LUMINA CERAMIC ALUMINIUM OXIDE ANAESTHESIA n ANAESTHETISTS ANIMAL EXPERIMENTS ANKYLOSING SPONDYLITIS ANTEROLATERAL ANTERIOR 7ATSON *ONES APPROACH n ANTIBIOTIC IMPREGNATED CEMENT SEE ALSO GENTAMICIN IMPREGNATED CEMENT ANTIBIOTICS PROPHYLACTIC n APPROACHES TO TOTAL HIP REPLACEMENT SURGICAL SEE ANTEROLATERAL LATERAL POSTERIOR
ARTHRITIS JUVENILE CHRONIC n RHEUMATOID ARTHRODESIS HIP n ARTHROPLASTY !RTHROPLASTY #ARE 0RACTITIONERS !SSOCIATION !USTIN -OORE PROSTHESIS SEE -OORE INTRAMEDULLARY ENDOPROSTHESIS BACTERIAL CULTURES BALL BEARINGS "ARTS 3T "ARTHOLOMEWS (OSPITAL ,ONDON BENCHMARKS SEE /RTHOPAEDIC $ATA %VALUATION 0ANEL /$%0 "(3 SEE "RITISH (IP 3OCIETY BIOLOGICAL EFFECTS OF IMPLANTS XXVIII n BIOMECHANICS "IOMET ,TD NOW "IOMET -ERCK ,TD 3WINDON "IRMINGHAM RESURFACING ARTHROPLASTY SEE -C-INN "IRMINGHAM RESURFACING ARTHROPLASTY BLOOD PRESSURE BLOOD TRANSFUSION "-* SEE "RITISH -EDICAL *OURNAL "/! SEE "RITISH /RTHOPAEDIC !SSOCIATION BODY EXHAUST SYSTEM SEE ALSO CLEAN AIR ENCLOSURE BONE CEMENT XXVIII SEE ALSO #-7 3IMPLEX ANTIBIOTIC IMPREGNATED APPLICATION TECHNIQUE n CARDIOVASCULAR EFFECTS n
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n )NDEX
DENTAL PINK XXVII INTRODUCTION n n n n PATENTS n PRESSURIZATION PROPERTIES REVISION SURGERY SELF CURING ACRYLIC 0--! STANDARDS USE BY -C+EE BONE GRAFTS MORSELIZED "/3' SEE "RITISH /RTHOPAEDIC 3TUDY 'ROUP BOVINE SERUM "RISTOL !EROPLANE #OMPANY ,TD LATER "RISTOL !IRCRAFT ,TD AND PART OF "RITISH !IRCRAFT #ORPORATION FROM "RISTOL "RITISH (IP 3OCIETY "(3 "RITISH *OURNAL OF 3URGERY "RITISH -EDICAL *OURNAL "-* "RITISH /RTHOPAEDIC !SSOCIATION "/! ARCHIVES IMPLANT SURVEILLANCE SCHEME MEETINGS n REPRESENTATION "RITISH /RTHOPAEDIC 3KI 'ROUP XXVIII "RITISH /RTHOPAEDIC 3TUDY 'ROUP "/3' XXVIII "RITISH 3TANDARDS )NSTITUTION "3) "RITISH 3TANDARDS n n BROACH SEE ALSO RASP "3) SEE "RITISH 3TANDARDS )NSTITUTION #APITAL HIP IMPLANT CARCINOGENIC EFFECTS OF WEAR DEBRIS SEE ALSO $.! DAMAGE
#ASELLA SLIT SAMPLER #% MARK %# KITE MARK n n CEMENT SEE BONE CEMENT #%. STANDARDS SEE #OMIT£ %UROP£EN DE .ORMALISATION #ENTRE FOR (IP 3URGERY 7RIGHTINGTON SEE 7RIGHTINGTON (OSPITAL CERAMICS n n #HARLES & 4HACKRAY ,TD SEE 4HACKRAYS #HARNLEY ACETABULAR REAMER #HARNLEY LOW FRICTION ARTHROPLASTY ,&! COMPLICATIONS CUPS &LUOROSINT® LOOSENING n 0RESS &IT 04&% n 2#( GRADE 5(-70% 5(-70% n CHAMFERBEVEL ILLUSTRATIONS LONG POSTERIOR WALL STERILIZATION WEAR n EXHIBITION lLM SILENT INSTRUMENTS PROSTHESIS #HARNLEY HIP XXVIII BENCHMARK CONTROLS ON SUPPLY n COSTS DESIGN n n ILLUSTRATIONS MANUFACTURE XXVII PATENTS n WEAR TEST RESULTS AND FOLLOW UP SURGICAL TECHNIQUE n n
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n )NDEX
#HARNLEY -USEUM 7RIGHTINGTON #HARNLEY 04&% DOUBLE CUP IMPLANT n #HARNLEYn-ÓLLER PROSTHESIS CHILDREN HIP REPLACEMENT IN n CHROMEnCOBALT ALLOYS SEE COBALTn CHROMIUM ALLOYS CLEAN AIR n AIR SLIT SAMPLERS #HARNLEYS GREENHOUSE XXVII n n EFlCACY n lLTERS INFECTION RATES BEFORE LAMINAR n PUBLICITY MATERIAL COBALTnCHROMIUM #On#R ALLOYS BIOLOGICAL EFFECTS DURABILITY )#,( IMPLANTS n -C+EE PROSTHESIS STANDARDS SEE ALSO 6ITALLIUM® #OMIT£ %UROP£EN DE .ORMALISATION #%. THE %UROPEAN #OMMITTEE FOR 3TANDARDIZATION "RUSSELS "ELGIUM #%. STANDARDS n LEGALLY BINDING IN %# COMPLICATIONS n #ONFORMIT£ %UROP£ENE OR %UROPEAN #ONFORMITY #% MARK %# KITE MARK n n CORROSION COSTS #HARNLEY PROSTHESIS #-7 BONE CEMENT CUPS ACETABULAR SEE ACETABULAR CUPS CUSTOM MADE PROSTHESES
DE (AVILLAND !IRCRAFT #O ,TD (ATlELD A DIVISION OF (AWKER 3IDDELEY !VIATION FROM DEFENCE INDUSTRY SEE ALSO AIRCRAFT INDUSTRY $ELORO 3TELLITE 3WINDON DENTAL CEMENT XXVII DENTISTRY XXVII $EPARTMENT OF (EALTH $O( !DVISORY 'ROUP ON /RTHOPAEDIC )MPLANTS $EPARTMENT OF (EALTH n $E0UY )NTERNATIONAL ,TD LATER *OHNSON *OHNSON n SEE ALSO 4HACKRAYS DESIGN PROSTHESIS XXVIInXXVIII n n IMPACT ON LONGEVITY IMPACT ON WEAR n VARIATIONS DIAMETER FEMORAL HEAD PROSTHESIS $)3 STANDARDS SEE $RAFT )NTERNATIONAL 3TANDARDS DISLOCATION PROSTHETIC HIPS DISTRICT GENERAL HOSPITALS XXVI n $.! DAMAGE DOUBLE CUP ARTHROPLASTY )#,( SEE )MPERIAL #OLLEGE ,ONDON (OSPITAL )#,( DOUBLE CUP OR RESURFACING ARTHROPLASTY PROSTHESIS $OWN "ROTHERS ,TD LATER $OWNS 3URGICAL ,TD $OWNS 3URGICAL ,TD -ITCHAM 3URREY $RAFT )NTERNATIONAL 3TANDARDS $)3 $U0ONT #OMPANY 7ILMINGTON $%
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n )NDEX
%# KITE MARK SEE #ONFORMIT£ %UROP£ENE OR %UROPEAN #ONFORMITY #% MARK %# SEE %UROPEAN #OUNCIL ENDOSTEAL SURFACE FEMUR ENGINEERING PRINCIPLES n n ENGINEERS LIAISON WITH XXVII n n %SSEX .UFlELD (OSPITAL "RENTWOOD %UROPEAN #OUNCIL FORMERLY %UROPEAN 5NION $IRECTIVES n %UROPEAN #OMMITTEE FOR 3TANDARDIZATION "RUSSELS "ELGIUM #%. STANDARDS n EXCISION ARTHROPLASTY %XETER XXVI %XETER HIP PROSTHESIS n BENCHMARK MECHANICAL FAILURES RESULTS AND FOLLOW UP &$! SEE &OOD AND $RUG !DMINISTRATION FEMORAL COMPONENTS PROSTHETIC CEMENTED DESIGN n LOADING LOOSENING MATERIALS n n MECHANICAL FAILURE n UNCEMENTED n FEMUR ENDOSTEAL SURFACE FRACTURES FERTILITY lLMS 4(2 OPERATION SEE ALSO #HARNLEY -C+EE
lLTERS SEE CLEAN AIR lXATION METHODS PROSTHESIS TO BONE XXVIII n n &LUON® SEE ALSO )#) &LUOROSINT® SEE ALSO #HARNLEY ,&! FOLLOW UP n n n SEE ALSO POST MARKETING SURVEILLANCE RESULTS &OOD AND $RUG !DMINISTRATION &$! 53! n FORCES HIP JOINT n FORMALDEHYDE STERILIZATION OF IMPLANTS XXVII FRACTURES FEMORAL PROSTHESES n HIPFEMUR FRICTION MINIMIZING FRICTIONAL TORQUE &URLONGS *OINT 2EPLACEMENT )NSTRUMENTATION LATER *2) ,TD GAIT LABORATORY 5NIVERSITY OF 3TRATHCLYDE GAMMA IRRADIATION IN AIR n IN A VACUUM GENTAMICIN IMPREGNATED CEMENT 'ERMANY 'IRDLESTONE ARTHROPLASTY n GREENHOUSE #HARNLEYS XXVII n n SEE ALSO CLEAN AIR mOW SYSTEMS (!# SEE HYDROXYAPATITE COATING (AWLEY ORTHOPAEDIC TABLE ($0 SEE ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE 5(-70% (EALTH 0ROTECTION !GENCY (EALTH 4RENDS
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n )NDEX
HEMI ARTHROPLASTY XXVnXXVI HIGH DENSITY POLYETHYLENE ($0 SEE ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE 5(-70% HIP FRACTURES @(IP (ISTORIES EXHIBITION 2OYAL #OLLEGE OF 3URGEONS OF %NGLAND ,ONDON HIP JOINT ANATOMY FORCES LOADS n SURGICAL INCISIONS (OECHST /BERHAUSEN 'ERMANY (OWMEDICA LATER 3TRYKER (OWMEDICA /STEONICS ,ONDON (OWORTH !IR #ONDITIONING ORIGINALLY (OWORTH 3URGICAIR AND LATER (OWORTH !IRTECH ,TD "OLTON XXVII n (UNTERIAN -USEUM 2OYAL #OLLEGE OF 3URGEONS ,ONDON HYDROXYAPATITE COATING (!# XXVIII )#) SEE )MPERIAL #HEMICAL )NDUSTRIES ,TD )#,( SEE )MPERIAL #OLLEGE ,ONDON (OSPITAL )-ECH% SEE )NSTITUTION OF -ECHANICAL %NGINEERS )MPERIAL #HEMICAL )NDUSTRIES )#) ,ONDON )MPERIAL #OLLEGE ,ONDON (OSPITAL )#,( DOUBLE CUP OR RESURFACING ARTHROPLASTY PROSTHESIS n INFECTIONS n #HARNLEYS EARLY OPERATIONS DEEP
PREVENTION n n n RATES n REVISION SURGERY SOURCES n SUPERlCIAL ACUTE @)NNOVATION !SSESSMENT AND (IP 0ROSTHESIS PROJECT 5NIVERSITY OF -ANCHESTER n )NSTITUTION OF -ECHANICAL %NGINEERS )-ECH% )NTERNATIONAL &EDERATION OF 3URGICAL #OLLEGES )NTERNATIONAL /RGANIZATION FOR 3TANDARDIZATION )3/ SEE ALSO "RITISH 3TANDARDS )NSTITUTION CHAMFERBEVEL STANDARDS n n 4ECHNICAL #OMMITTEE )3/ 4# n )3/ INTERPOSITIONAL ARTHROPLASTY XXVnXXVI INTRAMEDULLARY ROD n SEE ALSO +ÓNTSCHER NAIL IRRADIATION SEE GAMMA IRRADIATION )3/ SEE )NTERNATIONAL /RGANIZATION FOR 3TANDARDIZATION )3/ IVORY PROSTHESES XXVI *OHN #HARNLEY 2ESEARCH )NSTITUTE 7RIGHTINGTON (OSPITAL NR 7IGAN *OHN #HARNLEY 4RUST *OURNAL OF !RTHROPLASTY *OURNAL OF "ONE AND *OINT 3URGERY *"*3 *2) ,TD FORMERLY &URLONGS *OINT 2EPLACEMENT )NSTRUMENTATION
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n )NDEX
*UDET BROTHERS FEMORAL HEAD PROSTHESIS XXVI JUVENILE CHRONIC RHEUMATOID ARTHRITIS 3TILLS DISEASE n +ANO .IGERIA KETAMINE +ÓNTSCHER NAIL n n LAMINAR CLEAN AIR mOW SYSTEMS n LARYNGEAL MASK AIRWAY LATERAL SURGICAL APPROACH ,EEDS XXVII ,&! SEE #HARNLEY LOW FRICTION ARTHROPLASTY LOCAL DEVELOPMENT HIP PROSTHESES XXVII n ,ONDON (OSPITAL NOW 2OYAL ,ONDON (OSPITAL ,ONDON ,ONDON 3PLINT #OMPANY LOOSENING n n LOW FRICTIONAL ARTHROPLASTY SEE #HARNLEY LOW FRICTION ARTHROPLASTY LOW FRICTIONAL TORQUE -#! SEE -EDICINES #ONTROL !GENCY -C+EE -C+EEn&ARRAR PROSTHESIS n DESIGN lLM OF -C+EE OPERATING lRST USE ILLUSTRATION MATERIALS RESULTS AND FOLLOW UP n SURGICAL TECHNIQUE USE IN 53
-C-INN "IRMINGHAM RESURFACING ARTHROPLASTY n -ANCHESTER n -ANCHESTER 5NIVERSITY SEE 5NIVERSITY OF -ANCHESTER MANUFACTURERS XXVInXXVII XXIX n n 53 DOMINATION n ATTITUDE TO SURVEILLANCE SCHEME COMPLIANCE WITH STANDARDS n IMPLANT TESTING n SEE ALSO #HARNLEY 2./( 3TANMORE MANUFACTURING EARLY #HARNLEY PROSTHESES XXVII PROBLEMS MASKS SURGICAL MATERIALS IMPLANT XXVII n n n DURABILITY n EARLY EXPERIMENTS XXVI MINIMIZING FRICTION SHIFTS IN XXVIII n STANDARDS n TESTING SEE ALSO #HARNLEY ,&! 3TANMORE 4(2 SEE ALSO SPECIlC MATERIALS !PPENDIX -#! SEE -EDICINES #ONTROL !GENCY -$! SEE -EDICAL $EVICES !GENCY MECHANICAL FAILURES n MECHANICS n n MEDIALIZED CUPS -EDICAL $EVICES !GENCY -$! LATER -EDICINES AND (EALTHCARE PRODUCTS 2EGULATORY !GENCY -(2! XXVIIInXXIX n -EDICAL 2ESEARCH #OUNCIL -2# #ENTRE FOR 2HEUMATIC $ISEASES 4APLOW
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n )NDEX
SLIT SAMPLER STUDIES ON CLEAN AIR n -EDICINES AND (EALTHCARE PRODUCTS 2EGULATORY !GENCY -(2! SEE -EDICAL $EVICES !GENCY -$! -EDICINES #ONTROL !GENCY -#! XXIX METAL MATERIALS ALLOYS n MECHANICAL FAILURE n STANDARDS TOXICITY WEAR PARTICLES XXVIII SEE ALSO COBALTnCHROMIUM ALLOYS STAINLESS STEEL -ETALLO -EDICAL 3WINDON METAL ON METAL PROSTHESES XXVIII EARLY DEVELOPMENT n RESULTS n WEAR XXVIII METAL ON PLASTIC PROSTHESES XXVIII EARLY DEVELOPMENT RESULTS n METHYLMETHACRYLATE SEE ALSO POLYMETHYLMETHACRYLATE 0--! -(2! SEE -EDICAL $EVICES !GENCY -IDDLESEX (OSPITAL ,ONDON XXVI -IDLAND -EDICAL 4ECHNOLOGIES ,TD MOLYBDENUM -OORE INTRAMEDULLARY ENDOPROSTHESIS MORSELIZED GRAFTING -2# SEE -EDICAL 2ESEARCH #OUNCIL -ÓLLER FEMORAL PROSTHESIS NAIL lXATION .ATIONAL (EALTH 3ERVICE .(3 0URCHASING AND 3UPPLY !GENCY
.ATIONAL )NSTITUTE FOR #LINICAL %XCELLENCE .)#% XXIX .ATIONAL *OINT 2EGISTRY FOR %NGLAND AND 7ALES .*2 XXIX n .ATIONAL 2ESEARCH $EVELOPMENT #ORPORATION .2$# .(3 SEE .ATIONAL (EALTH 3ERVICE .)#% SEE .ATIONAL )NSTITUTE FOR #LINICAL %XCELLENCE .*2 SEE .ATIONAL *OINT 2EGISTRY FOR %NGLAND AND 7ALES .ORFOLK AND .ORWICH (OSPITAL XXVI n "/! CLINICAL MEETING SURGICAL RESULTS .ORTH (ILL 0LASTICS ,ONDON n .ORWICH XXVI .ORWICH #ATHEDRAL .2$# SEE .ATIONAL 2ESEARCH $EVELOPMENT #ORPORATION .UFlELD /RTHOPAEDIC #ENTRE /XFORD NURSES /$%0 SEE /RTHOPAEDIC $ATA %VALUATION 0ANEL /RTHOPAEDIC $ATA %VALUATION 0ANEL /$%0 BENCHMARKS /RTRON /RTRON OSTEOLYSIS /XFORD PATENTS n PATIENT SATISFACTION PHYSICAL ACTIVITY PHYSIOTHERAPISTS PLASTICS SEE ALSO POLYETHYLENE POLYTETRAmUOROETHYLENE 0--! SEE POLYMETHYLMETHACRYLATE
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n )NDEX
POLYETHYLENE ULTRA HIGH MOLECULAR WEIGHT SEE ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE WEAR PARTICLES XXVIII POLYMETHYLMETHACRYLATE 0--! SEE ALSO BONE CEMENT METHYLMETHACRYLATE POLYTETRAmUOROETHYLENE 04&% 4EmON® n #HARNLEY DOUBLE CUP IMPLANT SEE #HARNLEY 04&% DOUBLE CUP IMPLANT #HARNLEY SOCKETS PHYSICAL PROPERTIES WEAR n POSTERIOR APPROACH POST MARKETING SURVEILLANCE n n SEE ALSO FOLLOW UP 0RESS &IT CUPS #HARNLEY 0ROTEK !' 3WITZERLAND PROXIMAL STRAIN STRESS SHIELDING PSEUDOARTHROSIS HIP SEE ALSO 'IRDLESTONE ARTHROPLASTY 04&% SEE POLYTETRAmUOROETHYLENE QUALITY CONTROL n n n RADIATION STERILIZATION SEE GAMMA IRRADIATION RADIOLUCENTRADIO OPAQUE RASP RATS REAMERS RECOMMENDED LIST OF IMPLANTS PROPOSED n RECORD KEEPING 2EDHILL XXVI SEE ALSO 2ING PROSTHESIS REGISTER REGISTRY OF HIP IMPLANTS
XXVIII XXIX SEE ALSO .ATIONAL *OINT 2EGISTRY FOR %NGLAND AND 7ALES 4RENT 2EGIONAL !RTHROPLASTY REGISTER 3WEDISH 4OTAL (IP 2EPLACEMENT 2EGISTER REGULATION XXVIIInXXIX n n RESULTS SURGICAL n SEE ALSO FOLLOW UP POST MARKETING SURVEILLANCE RESURFACING ARTHROPLASTY SEE )MPERIAL #OLLEGE ,ONDON (OSPITAL )#,( DOUBLE CUP OR RESURFACING ARTHROPLASTY PROSTHESIS -C-INN "IRMINGHAM RESURFACING ARTHROPLASTY REVISION n RHEUMATOID ARTHRITIS JUVENILE SEE JUVENILE CHRONIC ARTHRITIS 2ING PROSTHESIS n n 2IZZOLI )NSTITUTE "OLOGNA 2./( SEE 2OYAL .ATIONAL /RTHOPAEDIC (OSPITAL ROSE GARDEN (ERBERT 3EDDONS 2OYAL #OLLEGE OF 3URGEONS OF %NGLAND ,ONDON 2OYAL .ATIONAL /RTHOPAEDIC (OSPITAL 2./( 3TANMORE XXVI n CUSTOM MADE PROSTHESES IMPLANT TESTING PATENTS 2OYAL 3OCIETY OF -EDICINE ,ONDON ROYALTY PAYMENTS n 3CALESn7ILSON HIP SEE 3TANMORE HIP SCREW lXATION SERENDIPITY 3HENTONS LINE 3IMPLEX BONE CEMENT
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n )NDEX
SIMULATORS SEE ALSO TEST MACHINES SEE ALSO TESTING SKI TRIPS ANNUAL ORTHOPAEDIC XXVIII SLIT SAMPLERS 3MITH .EPHEW ,ONDON n 3MITH .EPHEW "ROMSGROVE ,TD 3MITH 0ETERSEN PROSTHESIS 3MITHS )NDUSTRIES 3T "ARTHOLOMEWS (OSPITAL ,ONDON "ARTS STAINLESS STEEL MECHANICAL FAILURE PROSTHESES USING n STANDARDS STANDARDS OF COMPOSITION AND MANUFACTURING XXVIIInXXIX n n SEE ALSO "3) )3/ MATERIALS n TESTING FOR COMPLIANCE WITH n STANDING HIP JOINT FORCE 3TANMORE SEE 2OYAL .ATIONAL /RTHOPAEDIC (OSPITAL 2./( 3TANMORE 3TANMORE 3CALES HIP BENCHMARK lRST lXATION ILLUSTRATIONS MANUFACTURE RESULTS WEAR TEST 3TANMORE KNEE 3TAPHYLOCOCCUS COAGULASE NEGATIVE 3TAPHYLOCOCCUS EPIDERMIDIS n STEEL CORROSION RESISTING SEE STAINLESS STEEL STERILIZATION FORMALDEHYDE XXVII GAMMA IRRADIATION SEE GAMMA IRRADIATION
3TILLS DISEASE SEE JUVENILE CHRONIC ARTHRITIS SURGICAL APPROACHES XXVII n SURGICAL BLADES DISPOSABLE SURGICAL TECHNIQUES n n 3URGICAL 4RADES !SSOCIATION SURVEILLANCE INFECTION RATES POST MARKETING SEE POST MARKETING SURVEILLANCE SURVIVORSHIP ANALYSIS 3WANN -ORTON 3HEFlELD 3WEDISH 4OTAL (IP 2EPLACEMENT 2EGISTER 3WITZERLAND TECHNICIANS ORTHOPAEDIC 4EmON® SEE ALSO POLYTETRAmUOROETHYLENE TEST MACHINES n 4HACKRAYS #HARLES & 4HACKRAY ,TD ,EEDS XXVII n n IMPLANT STERILIZATION SUPPLY CONTROLS SEE ALSO $E0UY )NTERNATIONAL ,TD 4HOMPSON INTRAMEDULLARY PROSTHESIS n 4(2 SEE TOTAL HIP REPLACEMENT - (EALTHCARE "RACKNELL TITANIUM AND ALLOYS 4OBIN TROCHANTERIC OSTEOTOMY SEE ALSO TROCHANTERIC OSTEOTOMY TOTAL HIP ARTHROPLASTY 4(! SEE TOTAL HIP REPLACEMENT TOTAL HIP REPLACEMENT 4(2 XXVn XXVII lRST OPERATION n NUMBERS OF OPERATIONS XXV
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n )NDEX
4RENT 2EGIONAL !RTHROPLASTY REGISTER TRIBOLOGY TRIlN NAIL n TROCHANTERIC OSTEOTOMY n n TUMOURS 4URNER $ENTAL 3CHOOL 5NIVERSITY OF -ANCHESTER XXVII 5(-70% SEE ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE ULNAR NERVE PALSY ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE 5(-70% HIGH DENSITY POLYETHYLENE ($0 #HARNLEY CUPS SEE UNDER #HARNLEY CUPS GAMMA IRRADIATION IN AIR n )#,( DOUBLE CUP INTRODUCTION n QUALITY CONTROL n 2#( STANDARDS WEAR n 5-)34 SEE 5NIVERSITY OF -ANCHESTER 5NIVERSITY OF -ANCHESTER XXVII n UNCEMENTED IMPLANTS n 5NITED 3TATES 53 XXVI XXVIIInXXIX n n n VACUUM CAST IMPLANTS VACUUM PACKING VENTILATION SYSTEMS SEE CLEAN AIR mOW SYSTEMS 6ICTORIA 5NIVERSITY OF -ANCHESTER SEE 5NIVERSITY OF -ANCHESTER SINCE
6ICTORIA 5NIVERSITY OF -ANCHESTER $ENTAL 3CHOOL SEE 4URNER $ENTAL 3CHOOL 5NIVERSITY OF -ANCHESTER 6ITALLIUM® XXVI WALKING HIP JOINT FORCE n 7ATSON *ONES APPROACH SEE ANTEROLATERAL APPROACH WEAR n n IRRADIATED 5(-70% METAL ON METAL IMPLANTS XXVIII 04&% CUPS n TESTING 7ILES PROSTHESIS 7RIGHTINGTON (OSPITAL NEAR 7IGAN XXVI "/! CLINICAL MEETING BODY EXHAUST SUITS BONE CEMENT CLEAN AIR ENCLOSURE SEE ALSO GREENHOUSE #HARNLEYS INFECTION RATES LABORATORY PROSTHESIS STERILIZATION 04&% USE RESULTS AND FOLLOW UP TRAINING PROVISION n 53 SURGEON AT VISITORS SEE ALSO #HARNLEY LOW FRICTION ARTHROPLASTY 8 RAYS n :IMMER /RTHOPAEDIC ,TD n -ETALLO -EDICAL :IRCONIA CERAMIC ZIRCONIUM OXIDE
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n )NDEX
)NDEX .AMES "IOGRAPHICAL NOTES APPEAR IN BOLD
!MSTUTZ (ARLAN !NDERSON *ULIE !NSELL "ARBARA n !NSELL 2ON !RDEN 'EORGE "AKER &RANK "ECHTOL #HARLES "LOCH "ERNARD n "OOTH 3IR #HRISTOPHER n "RITTAIN ( ! "ROWN *AMES 4ULLOCH "UCHHOLZ (ANS "URROWS (AROLD *ACKSON #HAPLIN 3IMON #HAPPELL !LAN #HARNLEY ,ADY *ILL #HARNLEY 3IR *OHN XXVII XXVIII n n n n n n n n n n #HARNLEY 4RISTRAM #HURCHILL 2T (ON 3IR 7INSTON #OLTON #HRIS n #RAVEN (ARRY XXVII n n #ROSBIE !NDY $ANDY $AVID * $ARLING "ILL $ARRAH #LARE $AVIDSON $OUGLAS
$EANE 'RAHAM n $OWN -AURICE $OWSON $UNCAN n $UFF "ARCLAY )AN $UPONT *OE %DWARDS 3HEILA N£E 7ILSON %LSON 2EG n &AULKNER !LEX n &RANK 0ETER &REEMAN -ICHAEL XXVIII n n n n n &URLONG 2ONALD 'EORGE 7ALTER 'IRDLESTONE 'ATHORNE 2OBERT n 'LÓCK 4HERMISTOKLES XXVI 'REGG 0AUL (ABOUSH %DWARD (AMPSON 0HYLLIS n n (ARDINGE +EVIN n n (EATH *OHN (EYWOOD 7ADDINGTON -IKE n n (OPPER *OHN (OUSTON +IRK (OWARD 2 #
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n )NDEX
(OWORTH & . n (UNTON -R *ACKSON "URROWS SEE "URROWS (AROLD *ACKSON *ONES 'EOFFREY "LUNDELL *UDET *EAN XXVI *UDET 2OBERT XXVI
0ARTRIDGE #HRISTOPHER 0AUL *OHN n 0HILIPS (UGH 0ICKSTONE *OHN XXVnXXIX n 0LATT 3IR (ARRY 0OULTON -R
+EITH ORTHOPAEDIC TECHNICIAN +IAER 3VEN +ING 'EOFF +IRKUP *OHN n n +UNZRU +RISHNA 2AVI
2EAD *OHN n 2ING 0ETER XXVI n n
,AW 7 !LEXANDER 3COTTIE n ,EE "ETTY n ,EE #LIVE XXVI ,ETTIN !LAN n n n n n n n n n ,ING 2OBIN XXVI n n ,ONGlELD -ICHAEL ,OWBURY % * , 4ED ,UDGATE 3USANNE -C+EE +EN XXVI n n n -C-INN $EREK -OORE !USTIN 4 XXVI -ÓLLER -AURICE .EARY &RANCIS XXVnXXIX n /LDER *OHN n
3AEMANN & ) 3CALES *OHN 4RACEY XXVI n n 3EDDON 3IR (ERBERT 3MALLWOOD !NDY 3MITH $ENNIS 3MITH 0ETERSEN -ARIUS XXVI 3OMERVILLE %DGAR n 3TEPHEN )AN n 3WANN -ALCOLM n n 3WANSON !LAN n n n n n n 3WEETNAM 3IR 2ODNEY n n n n 4AYLOR )AN 4ERRY ORTHOPAEDIC TECHNICIAN 4HEODOROU " # 4HOMPSON &REDERICK XXVI 4RENTANI # n 4UCKER +EITH n n n
%ARLY $EVELOPMENT OF 4OTAL (IP 2EPLACEMENT n )NDEX
VON "ERGMAN %RNST XXVI 7ATSON &ARRAR *OHN 7ATSON *ONES 3IR 2EGINALD 7EIGHTMAN "ARRY 7HEBLE 6ICTOR n n 7ILES 0HILIP XXVI n n n 7ILLERT (ANS 7ILSON *AMES .OEL 'INGER XXVI 7ILSON -ICHAEL n 7ROBLEWSKI " -ICHAEL n n n
+EY TO COVER PHOTOGRAPHS &RONT COVER TOP TO BOTTOM -R !LAN ,ETTIN #HAIR -R 0ETER 2ING -RS 0HYLLIS (AMPSON -R 6ICTOR 7HEBLE
"ACK COVER TOP TO BOTTOM 3IR 2ODNEY 3WEETNAM ,ADY #HARNLEY -R 2EG %LSON -R 4RISTRAM #HARNLEY 0ROFESSOR -ICHAEL &REEMAN 0ROFESSOR !LAN 3WANSON
