■ Introduction

John Charnley Remembered: Regaining Our Bearings

THOMAS H. MALLORY, MD, FACS

ohn Charnley, although he leagues, Harry Platt and David period of time in the human dure based on a hip scoring sys- Jdid not originate total hip Lloyd Griffiths. Platt said of body. To this day, it is the gold tem. He assembled a team replacement (THR), is consid- Charnley, who first trained as a standard by which prosthetic approach in the operating ered its basic innovator. Total general surgeon, acquiring innovation is measured.7,8 He room; surgery was disciplined hip replacement is one of the excellent, wide-ranging diag- identified the importance of the and organized with each phase great marvels of modern medi- nostic judgment and operative sterile environment regarding of the operation having signifi- cine. The benefit to the patient, skills, “His roots in the princi- prosthetic infection and the cant steps that were not to be the consistency with which it ples and the unity of surgery contribution of the surgical violated. He maintained strong can be reproduced, its enduring were deep and lasting.”3 team to the contamination discipline controlling every ele- longevity, and the many ideas it Charnley became interested in process.9 Now, 30-year follow- ment of the procedure. stimulates are amazing. John arthritis of the hip and fully up exists for patients who have Charnley’s surgical skills were Charnley’s life and legacy committed himself to that end. undergone low friction arthro- amazing; he had the capacity to speak to today’s orthopedic cul- At the suggestion of Harry plasty. Prosthetic survival rate complete an operation two to ture. He was an individual with Platt, Charnley developed a is approximately 90%.10,11 This three times faster than his col- remarkable dedication, out- hip center at Wigan, near is a significant accomplish- leagues. He proved that it was standing originality, and end- Manchester. The center became ment, proving that an artificial not necessary to use prophylac- less energy. the focus of Charnley’s profes- device subject to prolonged use tic antibiotics if the environ- John Charnley (1911-1982) sional career and his subse- was born in Bury, Lancashire, quent contributions. His con- United Kingdom; he was cept of an artificial joint was Charnley believed that patient care was a trained in orthopedic surgery well studied, including numer- system rather than an individual event; the at the Manchester Royal ous bench studies to determine Infirmary.1-4 He served in the effects of friction, joint quality of this care followed a pathway that World War II with distinction. lubrication, and issues of bio- was predictable and manageable. Following the war, he returned mechanics. The interplay of to Manchester to join his col- these various scientific disci- plines created the hypothesis can have remarkable durability. ment was made ultra-clean with 9 From the Department of that a low-friction prosthetic However, the enormity of the use of laminar air flow. His Orthopedics, The Ohio State device combining the bearing Charnley’s contribution to postoperative care was well- University, Columbus, Ohio. surfaces of metal and plastic process and procedure often is structured with defined clinical Reprint requests: Thomas H. would be effective.5,6 He unrecognized. There was strict pathways. Patients were Mallory, MD, FACS, Joint Implant Surgeons Inc, 720 E Broad St, proved that such a device could indication for surgery; the encouraged to return for evalu- Columbus, OH 43215. be tolerated for an extended patient qualified for the proce- ations at regular intervals. Data

SEPTEMBER 2004 | Volume 27 • Number 9 921 ■ Introduction

were collected in a rigorous sion of a new idea must be gov- pointment, and failures. He REFERENCES manner during an era prior to erned by the existing literature, believed that a patient anticipat- 1. Eftekhar NS. The life and work the computer. The publication tested in the laboratory, subject- ing THR should be aged у60 of John Charnley (August 29, 1911-August 5, 1982). Clin of these have been were a refer- ed to clinical trials, and limited years. If one violated this par- Orthop. 1986; 211:10-22. ence point for all subsequent in application until such time as ticular precept and expanded 2. Older J. A tribute to Sir John THR development.7,8,10,11 efficacy is proven.3 the application of joint replace- Charnley (1911-1982). Clin Charnley was a strict and ment, one would harvest a Orthop. 1986; 211:23-29. demanding teacher. His regis- Patient Care world of revision surgery. As 3. Waugh W. John Charnley: The Man and the Hip. London, trars and fellows proceeded Charnley determined that a John Charnley is remembered, England: Springer-Verlag through a program of gradual patient should follow certain we realize that the mechanical London Limited; 1990. responsibilities, first observing, clinical pathways to meet with solution of THR for the biolog- 4. Wroblewski BM. Professor Sir then assisting, and finally exe- a successful clinical result. The ical problem of arthritis must be John Charnley (1911-1982). Rheumatology (Oxford). 2002; cuting the operation. He would health-care provider, whether a an ongoing evolution. Charnley 41:824-825. not release the use of his pros- nurse, physician, or physical believed that this surgery was 5. Charnley J. Low Friction thesis until the surgeon practi- therapist, was subject to a disci- an integral event in the manage- Arthroplasty of the Hip. Theory and Practice. New York, NY: tioner had spent a period of pline that produced a routine ment of end-stage arthritis of Springer Verlag; 1979. time training under his direc- regimen of care. Changes were the elderly patient. His goal was 6. Charnley J. The classic: arthro- tion. He believed that an unin- not implemented in the patient to seek a pain-free sedentary plasty of the hip: a new opera- formed surgeon was best taught care protocols unless a consen- existence for the patient. This tion. Clin Orthop. 1973; 95:4-8. by his fellow colleagues. Under sus was reached in terms of effi- concept is changing, as we are 7. Charnley J, Cupic Z. The nine and ten year results of the low- his direction, hundreds of cacy. Patient follow-up was becoming a more active society friction arthroplasty of the hip. patients were operated on by a provided in clinics on a regular and subsequently developing Clin Orthop. 1973; 95:9-25. team of surgeons, using meth- basis and evaluated using a hip arthritis of the hip at an earlier 8. Charnley J. The classic: the ods and procedures previously scoring system. This con- age. We recognize that wear of long-term results of low-friction arthroplasty of the hip performed unknown to the orthopedic tributed to data that were later the articulation becomes the as a primary intervention. Clin community. used for clinical studies and ultimate fate of THR. Orthop. 1995; 319:4-15. subsequent publications.5,12,13 Total hip replacement is 9. Charnley J. The classic: a clean- Innovation Charnley believed that patient our heritage primarily because air operating enclosure. Clin Orthop. 1986; 211:4-9. John Charnley’s passion for care was a system rather than of the contributions of John 10. Older J. Charnley low-friction innovation was intense. an individual event; the quality Charnley. His life and legend arthroplasty: a worldwide retro- Initially, he was full of new of this care followed a pathway speak to those currently prac- spective review at 15 to 20 years. J Arthroplasty. 2002; 17:675- approaches, ideas, and attempts that was predictable and man- ticing joint replacement. As 680. to resolve the surgical challenge ageable. Despite his emphasis we consider new technologies, 11. Callaghan JJ, Templeton JE, Liu of THR. However, as he gained on the clinical care of the introduce new materials and SS, et al. Results of Charnley experience he became more patient, his primary focus was methods, explore less invasive total hip arthroplasty at a mini- mum of thirty years. A concise conservative. He believed that on the surgical event and its surgery, robotics and comput- follow-up of a previous report. J as his operative technique execution, as that was the er-driven navigation systems, Bone Joint Surg Am. 2004; reached its maturation point it essence of a successful out- it is well to recall the wisdom 86:690-695. should remain unchanged. Cost come. of John Charnley. As I have 12. Delee JG, Charnley J. Radiological demarcation of of innovation and change, studied his life, I am con- cemented sockets in total hip Charnley believed, would cre- Boundaries vinced he would agree that we replacement. Clin Orthop. 1976; 121:20-32. ate chaos and take the focus John Charnley had well- must keep our science pure 13. Wroblewski BM, Charnley J. away from execution of the pro- defined boundaries for THR. and our application true, if we Radiographic morphology of the cedure. Innovation is the source He thought that if these bound- are to maintain our bearings in osteoarthritic hip. J Bone Joint of new technology but must be aries were violated it would regards to the ongoing evolu- Surg Br. 1982; 64:568-569. well disciplined. The progres- lead to complication, disap- tion of THR.

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