Early Development of Total Hip Replacement (Wellcome Witnesses to Twentieth Century Medicine Vol 29)

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Author: L.A. Reynolds | E.M. Tansey (Editors)

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XXIII

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,ETTIN"UTALLORTHOPAEDICTHEATRESARENOWCLEAN AIRTHEATRES %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 DRAUGHTISACTUALLYDANGEROUS #RAVEN7HENWEWEREDOINGTHISWORKAT7RIGHTINGTON )MADEASLITSAMPLER THATWOULDRUNFORONEHOURANDWEUSEDTOTAKEREADINGSALLTHETIME*OHN #HARNLEYWASOPERATING7ETOOKREADINGSONA INCHCULTUREPLATE SOTHESE COULDBESENTTOTHELAB ANDCHECKWHATBACTERIAWEREONIT;SEE&IGURE=) REMEMBER#HARNLEYPUT*OHN2EADINABAGANDHADHIMWAVEHISARMSABOUT AS THIS GENTLEMAN IN FRONT OF ME WAS DOING AND IF YOU HAD RECENTLY HAD A SHOWER THEBACTERIATHATCAMEOUTWASWORSETHANIFYOUHADNT BECAUSEALLYOUR PORESWEREOPEN $EANE 4HE lRST CLEAN AIR ENCLOSURE OUTSIDE 7RIGHTINGTON WAS SET UP AT THE .UFlELD/RTHOPAEDIC#ENTREIN/XFORD AND)WASRESPONSIBLEFORCOMMISSIONING THIS ENCLOSURE )T WAS ALL VERY SPLENDID4HERE WERE QUITE A LOT OF RUNNING IN PROBLEMS GETTINGITTHEWAYITWASMEANTTOBE BECAUSETHISWASTHElRSTONE OUTSIDE7RIGHTINGTON4HEWEEKAFTERITWASCOMMISSIONED)WROTETO(OWORTH BECAUSEOFINTERESTFROMAFOREIGNVISITOR WHOHADSEENTHESEENCLOSURESINUSE INTHISlRSTWEEKANDLIKEDTHELOOKOFTHEM(EEXPRESSEDINTERESTINPOSSIBLE SUPPLYTOHISCOUNTRYAND)AGREEDTOENQUIREFORHIM)HADALETTERBACK THE SECOND SENTENCE OF WHICH ) WILL NEVER FORGET )T SAID APPROXIMATELY @7E NO LONGERSUPPLYTHE(OWORTH TYPEENCLOSUREASYOURSPECIlCATION ASWECONSIDER 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 HASDEVELOPEDFURTHER)AMCONCERNEDTHATTHEDEVELOPMENTOFCLEAN AIRENCLOSURESHASPRODUCEDSOMEWITHHORIZONTALLAMINARmOW ANDSOMEWITH VERTICALLAMINARmOW BUTTHEBODY EXHAUSTSYSTEMHASDISAPPEARED)THINKTHIS IS ACTUALLY PRODUCING WORSE CONDITIONS WITH THE UNSTERILE SURGEON AND OTHER PEOPLESTANDINGINABEAUTIFULBLASTOFCLEANAIRANDINTERRUPTINGITSmOWOVER THEPATIENT AS2EG%LSONHASJUSTSAID &REEMAN)FYOUHAVEVERTICALDOWNmOWANDTHENYOUHAVETOWORRYABOUTTHE LIGHTINGOFTHEOPERATINGTABLEUNLESSTHEYAREVERYCAREFULLYCLEANED THELIGHTS

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AREASOURCEOFDIRTTHATISBLOWNSTRAIGHTDOWNINTOTHEWOUND SOTHEAIRIS STERILEATTHEROOF BUTITISNTONTHELEVELOFTHEWOUND#OULDYOUASKTHEM -R #HAIRMAN WHATISITTHATWEARETALKINGABOUT7HATISTHEINFECTIONRATENOW INTHE5+!SRETIREDSURGEONS WEHAVENOIDEA )DONTTHINK HAVEWE 7ROBLEWSKIPERCENTOVERYEARS &REEMAN.O NOTYOURS 7ROBLEWSKI/H )SEE $ARRAH4HE(EALTH0ROTECTION!GENCYNOWRUNMANDATORYDATACOLLECTIONON ONEOFTHREEINDICATORSINANYHOSPITALATANYTIMEINNECKOFFEMURFRACTURES TOTALHIPS ORTOTALKNEEREPLACEMENTS$ATAISCOLLECTEDFORTHREEMONTHSnAND THISISMANDATORYGOVERNMENTSURVEILLANCE UNLIKETHE.ATIONAL*OINT2EGISTRY 4HISISHOWINFECTIONRATESAREKNOWN4HERATESAREPUBLISHED ANDEVERYHOSPITAL IN THE COUNTRY HAS TO SUPPLY THE DATA IN ONE OF THOSE THREE INDICATIONS 3O DEPENDINGONWHATINDICATIONSYOUCOLLECTTHEDATAFOR YOUHAVETHEINFECTION RATEFORTHATINDICATORFORTHATHOSPITAL ,ETTIN7HATABOUT.ORWICH $ARRAH4HEINFECTIONRATEFORTOTALHIPREPLACEMENTATTHEMOMENTISUNDER PERCENT4HE(EALTH0ROTECTION!GENCYHASAMANDATORYDATACOLLECTIONFOR ATHREE MONTHPERIOD INANYMONTHS ANDTHEYCOLLECTTHEDATADURINGTHE OPERATIVESTAY ANDUPTOSIXWEEKSPOST OPERATIVELY ,ETTIN)TDIDDROPTOPERCENTATONETIME DIDNTIT IN*OHN#HARNLEYSUNIT 7ROBLEWSKI4HREEMONTHSISNOTLONGENOUGH)FYOUARETALKINGABOUTPATIENTS WITHDEEPINFECTIONAFTERTOTALHIPARTHROPLASTY YOUNEEDABOUTFOURYEARSTO COVERABOUTPERCENTREVISIONSFORDEEPINFECTION$EEPINFECTION GIVENTIME WILLPRESENTITSELF BUTITTAKESLONGERTHANNINEMONTHS ,ETTIN3OWEARETALKINGABOUTREALLYACUTEINFECTIONS THEINCIDENCEOFACUTE INFECTIONWITHINTHETHREEMONTHSOFTHEOPERATIONISPERCENT &REEMAN )F YOU ARE SAYING THAT THE INFECTION RATE IN A VERY GOOD HOSPITAL IS UNDERPERCENT WHICHMEANSITSABOVEPERCENT NEARLYPERCENT WITHIN THREEMONTHS ANDYOUMULTIPLYTHATBYFOURORlVETOGETTHELONG TERMlGURE

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-S #LARE $ARRAH WROTE @&OR *ANUARYn$ECEMBER PER CENT .OTE ON DRAFT TRANSCRIPT *ULY


WEARELOOKINGATSOMETHINGLIKEPERCENT PERCENTINFECTIONRATE INTHE LONGTERM %LSON !LSO THERE IS ANOTHER FACTOR IN THIS THE TEMPORAL SAMPLING OF THREE MONTHS ISTOTALLYINACCURATEBECAUSETHESETHINGSGOINBURSTS7HAT-IKEWAS TRYINGTOSAYWASTHATTHREEMONTHSSAMPLINGISAWORTHLESSMEASUREOFDEEP INFECTION.INETYPERCENTOFDEEPINFECTIONSWILLOCCURDURINGTHElRSTYEAR BUT COULDCOMEINANYOFTHElRSTTHREEMONTHS ANDTHEYTENDTOCOMEINBURSTS 9OUGETBURSTSOFINFECTION LOCALIZEDTOABOUTAWEEK 0ROFESSOR*OHN0ICKSTONE)WASSTRUCKBYTHEACCOUNTOF#HARNLEYOFWORKING INANOLDHOSPITAL INATHEATRETHATWASUSEDBYLOTSOFOTHERPEOPLE)SITTHECASE THATTHEINFECTIONWASMOREOFAPROBLEMAT7RIGHTINGTONTHANITWASATOTHER EARLYCENTRES BEFORECLEAN AIRENCLOSURESSPREAD ,ETTIN)TWASCERTAINLYREGARDEDATTHETIMEASBEINGQUITEHIGH WASNTIT!ND THATWASWHY*OHN#HARNLEYINTRODUCEDTHEGREENHOUSE 0ICKSTONE9ES )KNOWTHATSWHYHEINTRODUCEDTHEGREENHOUSE BUTWEREHIS PROBLEMSPARTICULARLYSEVEREBECAUSEOFWHEREHEWASWORKING ORWASHESIMPLY THElRSTPERSONTOGETTOGRIPSWITHTHESEPROBLEMS 7ROBLEWSKI"ECAUSEOFDIFFERENTSURGEONS;USINGTHESAMETHEATRE= &REEMAN(EWASTHElRSTTOGETTOGRIPSWITHTHEM 0ICKSTONE)MEANTHEPROBLEMSOFBADTHEATRESWEREBYNOMEANSCONlNEDTO 7RIGHTINGTON7ERETHEINFECTIONRATESATOTHEREARLYSITESMUCHTHESAMEAS THEYWEREAT7RIGHTINGTON &REEMAN4HEYWEREMUCHWORSE4HEREWEREBIRDSmYINGAROUND 4UCKER)WOULDLIKETOTOUCHONTHEHISTORICALASPECT)THINKTHATTHECONCEPTS OF@DEEPINFECTIONAND@SUPERlCIALINFECTIONTHEWORDSWEUSETODAY WERENT TERRIBLY WELL DElNED IN THE LATE S +EN -C+EE WOULD SOMETIMES SEE A WOUNDTHATWASDISCHARGING ANDHEWOULDSAYTHATITWASA@REJECTION)DONT THINK WE UNDERSTOOD THEN WHAT WAS GOING ON 3WABS WERE TAKEN AND CAME BACKFROMTHELABORATORYWITHREPORTSOF3TAPHYLOCOCCUSEPIDERMIDIS COAGULASE NEGATIVE3TAPHYLOCOCCUS ORPERHAPSABOWELORGANISM4HELABORATORIESWERE SAYINGTHATTHESEWEREEITHERNORMALSKINmORAORCONTAMINATION

3TAPHYLOCOCCUSEPIDERMIDIS THEMOSTIMPORTANTOFTHECOAGULASENEGATIVESTAPHYLOCOCCI#O.3 CANCAUSE INFECTIONININ DWELLINGMEDICALDEVICES


7E NOW KNOW THAT THESE ORGANISMS ARE AN AWFUL NUISANCE AND IN HINDSIGHT THEYUSUALLYINDICATEDTHEPRESENCEOFADEEPINFECTIONWITHADISCHARGINGSINUS !TTHETIMEWEWERELIVINGWITHAVIEW EMANATINGFROMMANYHIGHLYREGARDED BACTERIOLOGYDEPARTMENTS THATWESHOULDNTTREATINFECTIONUNTILWEHADISOLATED THE ORGANISM 3OME BACTERIOLOGISTS SAID THAT PROPHYLACTIC ANTIBIOTICS WERE TOTALLY OUT OF ORDER ) THINK IT SHOULD GO ON RECORD THAT ORTHOPAEDICS TAUGHT BACTERIOLOGYDEPARTMENTSQUITEABITAROUNDTHELATESANDEARLYS/NE THINGWEHAVENTRECORDEDINOURDISCUSSIONISTHEINTRODUCTIONOF'ENTAMICIN IMPREGNATEDCEMENTFOLLOWINGTHEWORKOF"UCHHOLZ&ORMANYPATIENTSTHIS MADEALOTOFDIFFERENCE ,ETTIN4HATISREALLYGOINGBACKTOOURORIGINALTERMSOFREFERENCE SOTOSPEAK ANDWEHAVEMOVEDONQUITEABIT)THINKPROBABLYTHISWOULDBETHEAPPROPRIATE TIMETOMOVEONTOREVISIONBEFOREWElNALLYWINDUPWITHRESULTSANDFOLLOW UP2EG;%LSON= PERHAPSYOUWOULDLIKETOTALKABOUTREVISION THEMOSTDIFlCULT CAUSEOFWHICHWASINFECTION BUTNODOUBTYOUWILLEMBRACEALLTHEREASONSFOR REVISINGTHINGSANDHOWDIFlCULTITCOULDBEINMEREMORTALSHANDS %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 WORKINGWITH#HARNLEY THATTERRIBLENOISEOFAIRRUSHAGAINSTYOUREARDRUMS) AMTHINKINGOFSUING .OWITSAXIOMATICTHATEVERYHIPWILLWEAROUT BREAK FALLOUT IFTHEPATIENT LIVESLONGENOUGH)AMAMAZEDTHATSOMANYCOLLEAGUESSTILLWILLALLOWPATIENTS TODOWHATEVERTHEYLIKEINTERMSOFPHYSICALACTIVITYYOUSEETHESEGLAMOROUS PHOTOGRAPHS INlLMS OFPEOPLEPLAYINGTENNISORSKIING2ECENTLY)HAVEDONE ASTUDYONTHEACTUALLOADINGOFTHEHIPINCERTAINPOSTURES ANDIFnASTHE3WISS DO THEYALLOWTHEIRPATIENTSTOGOSKIINGnTHELOADTHATYOUCANCALCULATEON THEHIP ISWAYABOVEANYTHING;*OHN=0AULTAUGHTUSABOUTXBODYWEIGHT FORNORMALBRISKWALKING TENTIMESBODYWEIGHT QUITEAPARTFROMANYEXTRA

"UCHHOLZINTRODUCEDTHEUSEOFANTIBIOTIC LOADEDCEMENTIN"UCHHOLZAND%NGELBRECHT 7AHLIGAND"UCHHOLZ 7AHLIGETAL 4AGGARTETAL


DYNAMICCOMPONENT)TISEXTRAORDINARY"UTSOMEBODYSTANDINGWITHTHEIR HIPAT THEINWARDFORCEONTHATHIPISBEYONDBELIEF)CANNOTBELIEVETHAT THEREWILLNOTBEANEEDFORREVISIONINTHEFUTURE ) 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 ALBEITWITHDIFFERENTMATERIALSANDTHELIKE EXCEPTFORTITANIUMAND FOR(!#;HYDROXYAPATITECOATING=7HENTHEHIPESCAPEDFROMTHISCOUNTRY IT WASLARGELYTHEPOLYETHYLENEAGAINSTPOLISHEDMETALTHATWASTHEPOPULARIMAGE 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 TOTHEM REMARKABLYWEKNOWNOTHINGABOUT;THEIRWORK=.OW IFWEFORGET

0ROFESSOR*OHN0AULWROTE@4HE"IOMECHANICS'ROUPATTHE5NIVERSITYOF3TRATHCLYDEWASASKEDBY-R *AMES4ULLOCH"ROWN&2#3TOASSISTINTHEDESIGNOFADEVICEFORlXATIONOFFEMORALNECKFRACTURES!REVIEW OFTHELITERATUREPROVIDEDTHEVALUEOFHIPJOINTFORCEOFTIMESBODYWEIGHTWHENSTANDINGONONELEG ;)NMAN 0AUWELS =ANDTHEINTER SEGMENTFORCESANDMOMENTSATTHEHIPDURINGLEVELWALKING ;"RESLERAND&RANKEL = BUTNOVALUESOFJOINTFORCEINWALKINGHADBEENESTABLISHED7ESETUPAGAIT LABORATORY MANUFACTURINGAFORCEPLATFORMFORGROUND TO FOOTFORCEMEASUREMENTANDARRANGINGTWOMM CINECAMERASVIEWINGFROMTHEFRONTANDTHESIDEOFTHETESTSUBJECTS WHICHALLOWEDDETERMINATIONOFTHE THREE DIMENSIONAL COORDINATES DElNING THE POSITION OF THE PELVIS4HIS ALLOWED US TO CALCULATE THE INTER SEGMENTFORCEANDMOMENTSACTINGBETWEENTHETHIGHANDTHEPELVIS6ALUESOFFORCESINTHERELEVANTMUSCLES WERECALCULATEDBYSELECTIONSFROMTHETWOGROUPSOFEXTENSORMUSCLES TWOGROUPSOFmEXORSANDONEGROUPFOR ABDUCTORSANDONEFORADDUCTORS4HEJOINTFORCEWASTHENCALCULATEDFROMTHEGROUNDFORCEANDTHERELEVANT MUSCLEFORCESATTIMEINTERVALSOFSECONDS4HECALCULATEDJOINTFORCEVALUESWEREFROMTOTIMESBODY WEIGHTAMEANOF 4HETIMESVALUEWASDEVELOPEDBYONESUBJECTWALKINGATMS;METRESSECOND= WITHASTRIDELENGTHOFM4HESESTUDIESSUGGESTTHATTHEHIPJOINTFORCEINWALKINGDEPENDSLARGELYON THEPRODUCTOFBODYWEIGHTANDSTRIDELENGTH*OINTFORCESOFANDTIMESBODYWEIGHTRESPECTIVELY WEREFOUND ANDENTRYORLEAVINGACARATTIMES-R2EG%LSON;PAGE=MUSTBEEXTRAPOLATINGFROMTHE FOREGOINGDATASINCEWEHAVENOTUNDERTAKENTESTSONRUNNERS4ESTSUNDERTAKENONTWOOFTHEPATIENTSWHO HADRECEIVEDTHETELEMETERINGHIPJOINTREPLACEMENTDEVELOPEDBY"ERGMANNETAL; =GAVECURVESOF VARIATIONWITHTIMESIMILARTOTHOSECALCULATEDFROMGAITANALYSISALTHOUGHTHEMAXIMUMVALUESDIFFEREDBY APPROXIMATELYPERCENTONAVERAGE!NIMPORTANTFEATUREOFHIPJOINTLOADINGISTHEDIRECTIONOFTHEJOINT FORCERELATIVETOTHEAXISOFTHEFEMUR)NWALKING THISMAYBEDEGREESINTHEFRONTALPLANEANDDEGREES INTHESAGITTALPLANE4HELATTERGIVESRISETOASTRONGTWISTINGMOMENTBETWEENAFEMORALIMPLANTANDTHESHAFT OFTHEFEMURANDTHEEFFECTWILLBEGREATERINSTAIRNEGOTIATIONANDSPRINTING% MAILTO-RS,OIS2EYNOLDS /CTOBER3EE0AUL -ARKOLFETAL "ERMEAND0AUL 3TANSlELD ETAL 3EEALSOVANDEN"OGERTETAL

3TEPHENSONETAL


INFECTION WHICHISONESOURCEOFLOOSENING)WILLRETURNTOTHISLATER IFTHERES TIME THEMAINSERIOUSPROBLEMISONEOFMECHANICALLOOSENINGnINSTABILITY DISLOCATIONANDIMPINGEMENTnSOMETHINGTHATISOBVIOUSQUICKLY-ECHANICAL LOOSENING SO CALLED ISDUETOOSTEOLYSIS DUETOWHATEVERCAUSEnANDTHATCAN BEABADSURGEON ASHASBEENSHOWNINTHE4RENT2EGIONAL!RTHROPLASTYPANEL /THERWISEITCANSIMPLYBEDUETOPOLYETHYLENEDEBRIS.OW-ICHAEL&REEMAN WASPIVOTALINMYDEVELOPMENTINTHISTRAINOFTHOUGHT ATANILLUSTRIOUSMEETING IN0ARISTHATSHALLBENAMELESS )THINK YEARSAGO-ICHAELGAVEALECTURE WHICHWASUNIQUEINMYEXPERIENCE BECAUSEHEPRODUCEDONESLIDEWHICHWAS A FAILED CEMENTED PROSTHESIS WITH ALL THE CHARACTERISTIC mUFlNESS AND IN THE RADIOLUCENTZONES(ETHENCHALLENGEDTHEAUDIENCETOSAYWHATCOULDBEDONE TOREVISETHIS$UTIFULLY BECAUSE)WASACEMENTER )PUTMYHANDUPANDSAID @)WOULDCEMENTIT3UBSEQUENTLY AFTERTHATBRILLIANTPRESENTATION WHICHYOU ;-ICHAEL&REEMAN=DONTREMEMBER BUTWHICHCHANGEDMYVIEW TOTHEFACT THATREVISIONSURGERYALMOSTCERTAINLYSHOULDENTAILUNCEMENTEDCOMPONENTS UNLESSYOUAREDEALINGWITHSOMEIMPOSSIBLESITUATIONWITHVERY VERYTHINWEAK BONE ORPERHAPSASTOVE TYPEFEMUR ORPERHAPSANACETABULUMTHATSGONERIGHT THROUGH&ORGETTINGINFECTION )THINKTHATNON CEMENTEDREVISIONISPROBABLY GOINGTOBETHEANSWER)FEELSADABOUTIT BECAUSE)HAVEALWAYSBEENACEMENTER BUT)MUSTCONFESSTHATIF)WEREBEGINNINGAGAIN )WOULDBEANUN CEMENTER) WOULDSTILLWANTTOHAVECEMENTAVAILABLE AND)WOULDSTILLWANTTOKNOWHOW TOUSEIT BECAUSEITISAVERYSPECIALTOOL THATHAS )THINK ASPECIALPLACE ) WANT TO PAY TRIBUTE TO (ANS "UCHHOLZ A NAME THAT HAS BEEN MENTIONED "UCHHOLZPRODUCEDAMOSTREMARKABLESERIESOFJOINTREPLACEMENTS THEPRINCIPLES OFWHICHHAVESURVIVED BUTHEALSOINTRODUCEDTHISNAIVECONCEPTOFTHROWING SOMEANTIBIOTICSINTOTHECEMENTANDITWOULDGIVEYOUPROTECTION4HEREISNO DOUBTTHATITDOES7HETHERTHATSAGOODTHING ORWHETHERWESHOULDBEPURISTS ANDRELYONPROPHYLACTICANTIBIOTICSORCLEANAIRORBOTHPREFERABLY ISNOTPARTOF THEARGUMENT)THINK)WILLlNISHBYJUSTSAYINGTHATFAILUREISTERRIBLYIMPORTANT ITSVERYIMPORTANTTHATWEHAVEREVISIONS BECAUSEIFYOUDONTHAVEREVISIONS YOU WOULDNTREALLYKNOWWHICHWASTHEBESTPROSTHESISTOUSE WOULDYOU ,ETTIN"EFOREYOUlNISHINTERMSOFREVISION MAY)ASKWHENTHECONCEPTOF IMMEDIATEREPLACEMENTBEGANINTHISPERIODTHATWEARECONSIDERING)NITIALLY

4HE 4RENT REGISTER WAS ESTABLISHED IN (ARPER ET AL &ENDER ET AL (ASSAN ETAL

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YOUDIDNOTHING YOUBASICALLYLEFTIT;&ROMTHEmOOR!REYOUTALKINGABOUT INFECTION=;9ES= WITHANEXCISIONARTHROPLASTY %LSON 5NTIL "UCHHOLZ INTRODUCED THE ONE STAGE n AND SOMETIMES TWO STAGE nREPLACEMENTWITHANTIBIOTIC LOADEDCEMENT THEMAJORITYOF#HARNLEYSCASES WEREALWAYSCONVERTEDTOAPSEUDOARTHROSIS WHICHWASTHEONLYTHINGTHATCOULD BEDONE)WASPRIVILEGEDTOTREATSOMEOF*OHN#HARNLEYSINFECTIONSTHEREWERE VERY VERY FEW AS YOU MIGHT IMAGINE AND HE DIDNT BELIEVE IN THE "UCHHOLZ TECHNIQUEATlRST ,ETTIN)TWENTAGAINSTTHEACCEPTEDNORMALSURGICALPRINCIPLEDIDNTIT TOPUT FOREIGNMATERIALINTOANINFECTEDAREA %LSON !BSOLUTELY BUT THERE IS NO QUESTION THAT IT WORKS AND IT PROTECTS FOR EXAMPLE INMORSELIZEDGRAFTING IFYOUCHOOSETOGODOWNTHATLINE ,ETTIN7HATWASTHEDATEOFTHAT7HENDIDWESTART %LSON!SFARAS)AMCONCERNED ,ETTIN4HATWASWHAT)WANTEDTOGETDOWN BECAUSETHISWASRATHERABIGTHING WASNTIT %LSON ) THOUGHT IT WAS AND ) DID SOME ANIMAL STUDIES IN THIS COUNTRY AND CHECKEDTHEVARIOUSTHINGSTHAT"UCHHOLZRECOMMENDEDANDITALLSEEMEDTOlT TOGETHER)REMEMBER"UCHHOLZPUTTINGHISHANDONMYSHOULDERANDSAYING @%LSON YOUWILLCOMEANDWORKFORMEIN'ERMANY AND)SAID @.OTONYOUR NELLY!NYWAY)WENTTO'ERMANYFORAYEARn"UCHHOLZHADHISFAULTSnTHERES NOQUESTIONnBUTHEHADCHARISMA ) WILL TELL YOU ONE LITTLE STORY "UCHHOLZ CAME ACROSS JUST AFTER THE WAR MET #HARNLEY WHOWOULDNTTALKTOHIMBECAUSEHEHADASABRESCARONHISFACE #HARNLEYSENTHIMAWAYAGAIN BUT"UCHHOLZCAMEBACKANDBYTHATTIMEWE WEREINTHE2#(HIGH DENSITYPOLYETHYLENEERA;="UCHHOLZASKED #HARNLEY @7HATISTHISSTUFF(EHADALREADYBEENTOSEE-AURICE-ÓLLER AND -AURICEHADGOTTHEMAGICFORMULAFROM#HARNLEY-ÓLLERSAID @/H ITSATRADE SECRETANDWOULDNTTELLHIM#HARNLEYSAIDTO"UCHHOLZ@4HESTUFFWASMADE INYOURCOUNTRY YOUMIGHTASWELLUSEIT MIGHTNTYOU

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,ETTIN)THINKYOUHAVENTTOLDUSYOURCONTRIBUTIONTOTHIS BUTPERHAPS*OHN 2EAD WHOWASALSOAREVISER WILLTELLUSABOUTTHESEEARLYREVISIONTECHNIQUES 2EAD4HEEARLIESTREVISIONTECHNIQUEWASTAKINGEVERYTHINGOUTANDTRYINGTO CURE THE INFECTION AND THEN OFTEN LEAVING THEM AS A 'IRDLESTONE ,ATER WE STARTEDREVISINGTHEM ANDWITHANTIBIOTIC LOADEDCEMENT ,ETTIN)AN3TEPHENHASGONE )THINK BECAUSEHEWOULDPROBABLY WELL 2OBIN ,INGWOULDHAVEALOTTOSAYONTHESUBJECTOFPUTTINGBONEGRAFTSINANDOTHER THINGSINTOINFECTEDSURGICALBEDS %LSON!LAN )THINKWESHOULDDISTINGUISHBETWEENREVISIONFORSTERILELOOSENING ANDFORINFECTION THEYARETWODIFFERENTTHINGS EXCEPTTHATINBOTHTHEENDOSTEAL SURFACEOFTHEFEMURISDAMAGEDVERYQUICKLYITBECOMESSMOOTHANDGLASS LIKE ANDSLIMEY ANDISTOTALLYUNSUITEDFORCEMENTING)SPENTHOURSANDHOURSAND HOURSTRYINGTOCUTGROOVESTOGIVESOMEKEY BUTHOWEVERCAREFULLYYOUDOIT YOU CANNOTMIMICTHEVIRGINRUGOSEENDOSTEALSURFACE/NCETHEFAILUREISRECOGNIZED TOBESUFlCIENTLYPROGRESSIVE REVISIONSHOULDBEDONEASSOONASPOSSIBLE ,ETTIN ) THINK WE WILL HAVE TO PRESS ON (AS ANYBODY ANYTHING ELSE TO SAY +EITH 4UCKER7EHAVENTMENTIONEDANAESTHETISTSANDANAESTHETICS)WONDERIFWE COULD JUSTFORAMOMENT BECAUSETHEYAREQUITEIMPORTANTFROMTHEHISTORICAL PERSPECTIVE)REMEMBERHOWWORRIEDWEWEREWHENCEMENTWASINTRODUCEDTO THEFEMORALCANAL WHEN WITHPRESSURIZATION OCCASIONALLYPATIENTSCOULDDIE 4HEANAESTHETISTSATTHATTIMETRIEDTOGETTHEBLOODPRESSUREUPBECAUSETHEY WEREWORRIEDABOUTITFALLING SOMETHINGOFAREVERSEFROMTODAYSPRACTICE(IP SURGERYHASPROMOTEDSPECIALISTANAESTHETISTSWHONOWUNDERSTANDTHEUSEOF SPINALANAESTHETICS EPIDURALS ETC ANDTHISHASMADEHIPREPLACEMENTALOTSAFER )NTHELATESANDTHROUGHTHESMOSTPATIENTSHADTHREEUNITSOFBLOOD ASAMINIMUMFORAHIPREPLACEMENT BUTWITHTHEADVANCESOFANAESTHESIAAND THE BETTER UNDERSTANDING OF HAEMODYNAMICS NOWADAYS MANY PATIENTS DONT HAVEATRANSFUSION

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0HILLIPS ET AL "UERKLE AND %FTEKHAR /H ET AL 2ANDALL ET AL


,ETTIN9ES MOSTOFYOUPROBABLYREMEMBERTHAT(UGH0HILLIPSAND)ANDMY ANAESTHETISTPUBLISHEDAPAPERINTHE"RITISH-EDICAL*OURNAL"-* nONLYTHE SECONDONE)EVERHADINTHE"-*nANDTHATWASONTHECARDIOVASCULAREFFECTS OFIMPLANTEDACRYLICCEMENT4HISlTSINWITHWHAT)WASSAYINGEARLIERABOUT THISCHAPAT.ORTH(ILL0LASTICS BECAUSEHEPAIDFORATECHNICIAN BUT)AM NOT GOING TO GO INTO THAT ANY FURTHER )T WAS SOMETHING THAT CONCERNED THE $O( WHICHSETUPAWORKINGPARTYONIT BECAUSEPEOPLEWEREGETTINGALARMED ABOUTPATIENTSDYINGWHILEHAVINGMAINLYCEMENTED4HOMPSONSPROSTHESESFOR FRACTURES RATHERTHAN4(27EWONTPURSUETHAT BUTYOUAREQUITERIGHTTHAT THEADVANCESINANAESTHETICSAREVERYIMPORTANT 7EAREGETTINGCLOSETOTIMEANDWEOUGHTJUSTTOTALKABOUTTHERESULTSOFFOLLOW UP AND WE HAVE HEARD HOW DIFlCULT IT IS AND HOW WE HAVENT DONE OUR JOB PROPERLY BUT-ICHAEL7ROBLEWSKICERTAINLYHAS)BEGYOURPARDON 'RAHAM $EANE 3ORRY ) DIDNT MANAGE TO CATCH YOUR EYE #HAIRMAN ON A POINT ON ANAESTHETICS7HEN ) WAS IN /XFORD THIS BUSINESS OF DROP IN BLOOD PRESSURE ASSOCIATEDWITHCEMENTWASBEINGLOOKEDINTO4HEYCAMETOTHECONCLUSIONn) AMALITTLEBITHAZYONTHIS NOTKNOWINGTHEANAESTHETICSIDEnTHATTHEUSEOFA NEUROLEPTIC ANALGESICTYPEOFGENERALANAESTHETICSEEMEDTOAVOIDTHISPARTICULAR PROBLEM !NOTHER ASIDE ASWELL THERE WASANOTHER PARTICULARANAESTHETICPROBLEMWITH THEAIRWAYINJUVENILERHEUMATOIDS-ALCOLM3WANNKNOWSBETTERTHAN)DO AND ALONG WITH MY PREDECESSOR 'EORGE !RDEN THAT OPERATING ON JUVENILE RHEUMATOIDSHIPSINTHEDAYSBEFORETHELARYNGEALMASKWASHAZARDOUS DUETOTHE DREADFULAIRWAYTHEYSOOFTENHADTHATPREVENTEDINTUBATION4HEANAESTHETISTS USEDACLEVERDRUGCALLEDKETAMINE.OW THESIDEEFFECTOFKETAMINE FROMTHE SURGEONSPOINTOFVIEW ISTHATEVERYTHINGCANBLEEDPROFUSELY MAKINGCONTROL OFTHEBLEEDINGDIFlCULT)AMSURE-ALCOLM3WANNWILLPROBABLYADDTOTHIS THATKETAMINEADDEDTOTHEDIFlCULTIESOFSURGERYALREADYCOMPLICATEDBYTHE 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 AIRWAYANDHASMADEALOTOFDIFFERENCETOTHISASPECT

0HILLIPSETAL #HARNLEY 2INGA

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$EANE 'RAHAM n $OWN -AURICE $OWSON $UNCAN n $UFF "ARCLAY )AN $UPONT *OE %DWARDS 3HEILAN£E7ILSON %LSON 2EG n &AULKNER !LEX n &RANK 0ETER &REEMAN -ICHAEL XXVIII n n n n n &URLONG 2ONALD 'EORGE 7ALTER 'IRDLESTONE 'ATHORNE2OBERT 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#


(OWORTH &. n (UNTON -R *ACKSON"URROWSSEE"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

+EITHORTHOPAEDICTECHNICIAN +IAER 3VEN +ING 'EOFF +IRKUP *OHN n n +UNZRU +RISHNA2AVI

2EAD *OHN n 2ING 0ETER XXVI n n

,AW 7!LEXANDER3COTTIE 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 !USTIN4 XXVI -ÓLLER -AURICE .EARY &RANCIS XXVnXXIX n /LDER *OHN n

3AEMANN &) 3CALES *OHN4RACEY 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 3IR2ODNEY n n n n 4AYLOR )AN 4ERRYORTHOPAEDICTECHNICIAN 4HEODOROU "# 4HOMPSON &REDERICK XXVI 4RENTANI # n 4UCKER +EITH n n n


VON"ERGMAN %RNST XXVI 7ATSON &ARRAR *OHN 7ATSON *ONES 3IR2EGINALD 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

+EYTOCOVERPHOTOGRAPHS &RONTCOVER TOPTOBOTTOM -R!LAN,ETTIN#HAIR -R0ETER2ING -RS0HYLLIS(AMPSON -R6ICTOR7HEBLE

"ACKCOVER TOPTOBOTTOM 3IR2ODNEY3WEETNAM ,ADY#HARNLEY -R2EG%LSON -R4RISTRAM#HARNLEY 0ROFESSOR-ICHAEL&REEMAN 0ROFESSOR!LAN3WANSON

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