Furlong’s designs for hip prostheses advanced fixation

The British pioneer introduced the first hydroxyapatite-coated implant and bridged the gap between the European continent and the English-speaking world.

Ronald John Furlong's Services as a surgeon in World War II fostered a lifelong interest in biomechanics and bone healing.

Ronald John Furlong, FRCS, was a pioneer whose work in the clinical application of antibiotics and the development of hydroxyapatite-coated ceramic hip prostheses earned him the respect of clinicians and patients alike.

Known as Ronnie to his friends, Furlong was not motivated by desires of personal greatness. Rather, it was the longing to improve the human condition that sparked his imagination and roused his innovative genius.

In eulogizing his friend and colleague, Michael Edgar, FRCS, consultant orthopaedic surgeon at Middlesex Hospital in Middlesex, England, said Furlong possessed rich gifts of personality and intellect. “We give thanks for those gifts, which he used to improve and enrich the lot of many.”

Persuasive power

Edgar said Furlong had a verbal talent honed in part by his love for and knowledge of the King James Version of the Bible.

“His manner of speaking had certain aspects in common with its text: succinctness, eloquence, authority and a sometimes consumed depth of meaning. Coded statements were often betrayed by a twinkle of the eye and a provocative smile,” Edgar said.

A testament to the persuasive power of Furlong’s communicative skills is the story of how he talked his way into the medical school at St. Thomas’ Hospital at the age of 16.

“The dean, of course, didn’t have a hope,” said his long-time friend Fredrick W. Heatley, FRCS. “As far as I can work out, that was the only interview in his life that Ronnie ever attended. He appointed himself to Rowley Bristow as his houseman at a garden party. Mr. Bristow didn’t have a hope either.”

In 1931, he qualified as surgeon at the age of 22, and the next year he won the Cheselden Medal in anatomy and surgery. He passed his exams for Fellowship of the Royal College of Surgeons at 25. At St. Thomas, he had an opportunity to work under such greats as Bristow and Sir Max Page. His clinical interests at the time included the treatment of tuberculosis, bone deformity and hand surgery.

Papal blessing

When Great Britain entered World War II, Furlong volunteered with the Royal Medical Corps. His service took him from North Africa to Italy and Egypt. It was during his service in Northern Italy that he became familiar with Sir Alexander Fleming and his early work with antibiotics for wound care. Furlong’s compassion led him to become involved with the civilian population. His efforts earned him a special blessing from Pope Pius XII. He left military service with the rank of brigadier, the youngest surgeon to obtain that rank at the time.

Henri E. Houben, MD, of Antwerp, Belgium, a Furlong protégé and current trustee of the Furlong Research Foundation, recalled: “During his wartime, especially in Northern Italy, he was confronted with that wide gap between the potentials offered by modern science on one hand and the immense social impact of trauma on the other hand. That experience, with the ever-present genuine social commitment to bring better [conditions] to those who needed it most, was the dynamo driving him to improve on this situation.”

Enduring legacy

Houben said Furlong was one of the first British orthopaedists to examine a German soldier with a fractured femur treated with an intramedullary rod.

“Because this system was unknown in Britain, the war department at that time instructed Colonel Furlong to collect as much information about the femoral nail, which by then was identifiable as a Küntscher nail,” he said.

Through the assistance of Lorenz Böhler in Vienna, Furlong tracked down Küntscher in Kiel and learned his technique. He brought this information and a supply of the rods back to the United Kingdom and convinced the British medical corps to apply the technology, which is still in use today.

Houben told Orthopaedics Today that Furlong’s interest in biomechanics and bone healing also took shape during the war. While treating fractures with plates and screws, Furlong would notice that soft tissue would form between the bone and the foreign material as a form of rejection. “His burning desire was to find a solution to this problem,” Houben said.

Furlong also used the knowledge and experience he gained during wartime as the basis of the popular text Injuries of the Hand, published in 1957.

Clinical career

At war’s end, Furlong was appointed to orthopaedic consultant at St. Thomas Hospital. However, before taking the appointment, he traveled back to mainland Europe and eventually to the United States to study the developments of such pioneers as Willis Campbell, Vitorio Putti, Fredrick Albee, Sterling Bunnell and Oscar Scaglietti.

For many that knew him, the hallmark of Furlong’s clinical career was his commitment to patient care. “He taught me how to handle patients, to give a full clinical examination with charisma and a warm interest,” Houben said. “‘Give them the best of clinical tradition with modern quality treatment,’ he used to say.”

Heatley added, “I can remember one of my first ward rounds with Ronald. With the elderly, he had this art … he would sit and hold their hands. [It was] a touch of medicine that sadly is not always in evidence these days.”

Larger-than-life character

Furlong also left lasting impressions as an orthopaedic educator. “He was a larger-than-life character with very high standards and an intolerance of anything shoddy,” Edgar said. “Certainly he had an excellent sense of humor, but he could be abrupt with it. For a junior member of staff that he felt worthy of support, he would go to endless efforts to encourage and promote them, even with an invitation to dine at the Athenaeum to discuss plans. On the other hand, a weak houseman or registrar in his unit could be condemned.”

Houben said, “We would hang onto his words like magnets, waiting for the next. He was a superb teacher and he had a big mind that matched his physical presence. He stood two meters-plus tall and had the bulk to match. When he came through the door, you couldn’t see the door anymore.”

A new phase

Just as in the theater where the second act holds much of the drama and excitement, Furlong’s lasting contribution to the orthopaedic community — the design and implantation of the world’s first hydroxyapatite (HA)-coated prosthesis — actually occurred during the second phase of his long and memorable career.

In the late 1960s, Furlong, then director of the orthopaedic department of St. Thomas’s, desired to introduce hip replacement surgery into their practice. He was opposed to using the Charnley and McKee prostheses because of his concerns over the design of the devices as well as the surgical technique of the Charnley hip, which required the removal of the top of the trochanter. Furlong decided that the Müller total hip prosthesis would be the better choice, even though it was unavailable to the British market.

He would eventually voice concern about the “Müller banana,” as he called it, due to the biomechanical properties of its curved shape. This led to his 1979 design of one of the first straight-stemmed hip prostheses, the Furlong Modular, which boasted a design that received worldwide attention when it was chosen for use bilaterally in Britain’s Queen Elizabeth, the Queen Mother. Legend has it that Furlong’s concept of a straight stem was inspired by studying the effectiveness of a conical glass stopper in a wine decanter.

An orthopaedic bridge

In order to study the biomechanics of the hip, Furlong wanted to speak with Freidrich Pauwels of Aachen, Germany, who was the primary authority in the field at the time. However, Pauwels did not speak English. To overcome the language barrier, Furlong took German lessons before his morning appointments for several months. After learning the language, he went to Aachen and formed an alliance with Pauwels that resulted in not only a better understanding of biomechanics, but also an agreement to translate Pauwels’ and other classic German biomechanical texts into English with the collaboration of Paul Maquet, MD, of Belgium.

“Ronald became for the orthopaedic world a bridge builder between the [European] continent and the English-speaking world,” Heatley said. “Once the bridge was built, there was a platform for communication and discussion with other Central European professors.”

The birth of JRI

Since the Müller prosthesis was not yet available in the United Kingdom, Furlong had to make trips to Switzerland and return with a carload of contraband implants for St. Thomas Hospital. To facilitate a better importation arrangement, he and his wife Eileen formed Joint Replacement Instrumentation (JRI) Ltd. in 1970 as a method of legally importing the devices and eventually have the devices cast in England.

Heatley joked that the formation of JRI was perhaps due, in part, to the subtle pressure only a mother-in-law can exert.

“He would harness his Mercedes and he, Eileen and the mother-in-law would go to Switzerland. Owing to the size of the Mercedes, the mother-in-law would have to sit on contraband hip prostheses on the way back through customs. She didn’t mind too much if her son-in-law spent time in jail, but she was not going to,” he said.

HA coating

As the first generation of hip arthroplasty patients closed in on a decade of postoperative follow-up, it was clear that fixation was becoming a problem. Furlong knew that something had to be done to increase the potential for cementless fixation.

As fate would have it, Friedrich Osborn of Bonn, Germany, an expert in hydroxyapatite, was looking to partner with an orthopaedist knowledgeable in biomechanics to investigate use of the material on an orthopaedic implant.

The collaboration between Osborn and Furlong resulted in the first implantation of an HA-coated hip in 1985. The Furlong product line would eventually include ceramics, denser coatings of HA and a proprietary coating called Supravit. In 1993, JRI received the Queen’s Award for Technological Achievement for his innovations.

Later years

In 1988, he founded the Furlong Research Foundation with the mission of furthering work on prostheses with exhaustive scientific research, evaluation and dissemination of knowledge. The foundation keeps close records and data on recipients of Furlong implants and provides postsurgical information for patients.

Even in his final days, Furlong’s thoughts were on surgery and care. In memorializing his friend, Houben said, “Only two days before he died, he told me he could not stop thinking about new surgical techniques. ‘In my mind,’ he said, ‘I go over every surgical step as if I am still in the theatre,’ knowing very well that he would never be able to do so.”

One of his former patients summed up her experience in a letter, which was read at his memorial. “For myself like so many others, we owe the gift to walk without pain, to lead a normal life and in my case still keep up with my grandchildren and be so proud to say, ‘I have a Furlong hip and wear my silver brooch with pride.’”