Watson-Jones ushered in new era of British orthopaedics

British pioneer was gifted surgeon, writer, educator and editor.

Issue: Issue 4 2003

Sir Reginald Watson-Jones ---Born in 1902, Watson-Jones made fracture treatment in his country more systematic and scientific. His textbook, Fractures and Joint Injuries, was published in 1940 and was reprinted 15 times during his lifetime.

Sir Reginald Watson-Jones has been described as the vanguard of the new era of orthopaedics in Britain. He was a well-respected practitioner and educator of modern fracture care. His text on the topic was translated into many languages and remained a standard for several decades.

He was responsible for and was the first editor of the British volume of the Journal of Bone and Joint Surgery (JBJS) and retained that post through four decades. The orthopaedic surgeon for England’s king and queen, Watson-Jones held executive positions in many of the United Kingdom’s royal colleges and surgical societies.

“He was a great communicator, educator and teacher and a very good technical surgeon,” said David L. Hamblen, PhD, FRCS, emeritus professor of orthopaedics at the University of Glasgow in Scotland. Hamblen, who is chairman of the Orthopaedics Today Editorial Advisory Board, was one of the last registrars trained under Watson-Jones before he retired. “He was very stimulating and he had a very dynamic personality. Everyone listened to him.”

In addition to launching the British JBJS, Watson-Jones brought a more systematic and scientific methodology of fracture treatment to a community that was entrenched in the conservative practice of using splintage and nothing more, Hamblen said.

A schoolteacher’s son

Watson-Jones, then simply Reginald Jones, was born in Brighton, England, on March 4, 1902, to a schoolteacher and his wife. An honor student, he acquired an interest in the field of medicine after a bout with typhoid fever.

He graduated from the University of Liverpool in 1922 with a bachelor’s degree in science and went on to receive his medical education at the university’s medical school. He decided to pursue the study of orthopaedics following an operation to remove a hemangioma from his leg; in 1926 he became one of the first surgeons to receive the MCh Orth degree.

Following his education in Liverpool, he continued his training in London, where he met and impressed Sir Robert Jones, eventually becoming his protégé. The elder Jones opened many doors for the young surgeon, including a position as the honorary assistant surgeon in charge of the orthopaedic department and fracture clinic at the Liverpool Royal Infirmary.

Watson-Jones modeled the clinic there in the style of many that came into fashion following World War I. He was an advocate of the conservative treatment methods for fracture treatment, including casting and long-term immobilization.

However, he also realized special circumstances required special treatment modalities, and he later used a modification of the nailing technique for hip fractures made popular by Marius Smith-Petersen, MD, of Boston. Other modifications adopted at the clinic included the use of typed patient records for ease of later reading and follow-up.

Shortly after the start of his orthopaedic career, Reginald Jones adopted his mother’s maiden name and became Reginald Watson-Jones to distinguish himself from the many other Joneses practicing medicine in England at that time, including his mentor. Also, that period saw the beginning of a seemingly inexhaustible writing talent when JBJS accepted his first paper for publication in 1930. He would eventually publish two to three papers every year in numerous journals for decades.

The bible for fracture surgeons

In the late 1920s, his scope widened to include a position as orthopaedic consultant at the Shropshire Orthopaedic Hospital in Oswestry, later known as the Robert Jones and Dame Agnes Hunt Hospital, which he held for nearly 40 years. At that time, surgeons were either poorly compensated for their hospital work or not at all, so a healthy private practice was important for a surgeon’s existence.

Watson-Jones’ excellent surgical abilities, combined with the exposure he received from his hospital appointments, allowed his practice to thrive. He eventually had a Packard limousine with chauffeur, a butler, a personal secretary and an office staff of five, according to his JBJS obituary.

In 1940, he published the first edition of the textbook, which would come to be known simply as “the bible.” Fractures and Joint Injuries was a voluminous work which would eventually be reprinted 15 times during his lifetime and translated into several languages, including Spanish, French, German, Portuguese and Polish. Throughout its publication, Watson-Jones found unique ways to demonstrate his theories and techniques, including acetate and radiographic overlays, question-and-answer formats, and a writing style that was not only instructive but interesting.

Internal fixation as internal suture

Although he did bend his conservative thought to include the use of intramedullary nails, he never adopted the potential they offered for early mobilization. In his book, A History of the British Orthopaedic Association, William Waugh wrote: “Watson-Jones regarded internal fixation of fractures as a form of ‘internal suture’ to be followed by plaster immobilization and he found it hard to accept the more radical approach, which was later introduced in Europe. His book and his ideas were a great contribution to fracture treatment in this country and all over the world. His views were soundly based, but much of what he advocated has now been overtaken by new surgical techniques.”

Hamblen said that although Watson-Jones was interested in contemporary advances in fixation, he did not embrace the entire European philosophy. “He adapted those methods to what he felt was appropriate for what was the British mode of practice. It was a meeting of two philosophies. Even so, it was far more aggressive in terms of operative intervention than the traditional British treatment.”

During World War II, Watson-Jones became a civilian consultant to the Royal Air Force and advocated an aggressive rehabilitation program that returned 95% of the injured airmen to some form of duty. Following the war, he was knighted for his achievements. He was appointed as the orthopaedic surgeon to King George VI and served in that capacity from 1946 to 1952. He then served as orthopaedic surgeon to the Queen Mother from 1952.

Hip arthrodesis

At a time when total hip replacements were rare, experimental and risky, Watson-Jones was a believer in hip arthrodesis as a treatment for advanced unilateral osteoarthritis.

“At the time, the only other options were pseudoarthrosis or osteotomies,” Hamblen said. “There was quite an enthusiasm for osteotomies for osteoarthritis of the hip at that time in England.”

Watson-Jones’ hip procedure, which he described in JBJS in 1956, utilized long Smith-Petersen nails that were placed across the joint. “He would then put them in a hip spica for a long time,” Hamblen said. Watson-Jones’ notes from that era document his instructions of four months and not a day less in a plaster hip spica.

“It is an operation that would be hard to sell to people now. But it worked, particularly in young heavy male manual workers, but for women it was inappropriate. They had to have a normal hip on the other side, a normal knee below it and a normal spine above it for him to be successful with it,” Hamblen said.

British JBJS

Watson-Jones is credited with bringing life to the British version of the JBJS. Initially, deals were attempted that would unite the research and investigations of orthopaedists from both sides of the Atlantic into one journal. However, the inability to resolve issues of funding, hierarchy and publishing schedules, combined with Watson-Jones’ charming manner, resulted in the eventual formation of two independent publications.

“To get this all together required a few years of hard work,” Hamblen said.

Watson-Jones served as editor of the British JBJS from the first issue in 1948, published in the face of a severe post-war paper shortage, until his death in 1972. His office was in the basement of a building that also contained his apartment and his practice. As editor, he was fair and meticulous in his perceptions of meritorious or pretentious writings.

Watson-Jones was as deft with a pen as he was with a surgical blade. His JBJS obituary said that his “writings had not only the essential virtues of clarity, simplicity, precision and brevity, but displayed a splendid style of his own, always recognizable, exciting, stimulating and persuasive.”

Charming disciplinarian

Watson-Jones was an enthusiastic charmer who enjoyed the company of his colleagues, whether they were at the billiard table at Oswestry, a mess hall at a Royal Air Force hospital or his basement office for editorial meetings. “He was definitely a social animal, and I can attest to that,” Hamblen said.

In the operating theater, however, he was all business and a strict disciplinarian, and he expected professionalism from all his staff. “He was an advocate of the ‘no touch’ technique, so you could not get your fingers into the wound or you would get them hammered. He was also strong about having a fairly clean field and not having much blood around. So if you got blood spilled on the drapes, you were in big trouble.”

In fact, Hamblen said, some of the surgeries were so clean that color intraoperative photos in his textbook looked as though they were performed on cadavers because of the bloodless fields. “But in fact it was just because the assistants had to make sure there was no blood.”

Many people who came in contact with Watson-Jones were impressed by his penetrating black eyes that gained him the nickname the “Black Prince.” His skills as a communicator endeared him to his students and patients.

“He was always good at communicating with young people at every level of training,” Hamblen said. “He made the young and inexperienced people feel a part of the proceedings. When he ran conferences he would not just ask the senior men in the front row, he would start with the students in the back row and would ask their opinions on cases. He treated their opinions as importantly as the senior men; he probably really didn’t, but he made you feel that way.”

A lifetime of writing and practice

In addition to the standards he had for his students, he also expected justice from his society. The Times would often be the recipient of the fruits of his fondness for letter writing.

He practiced medicine into his late 60s and maintained the helm of the British JBJS after the usual retirement age. After his death, his staff recalled that he refused to admit he had reached the age of retirement … and nobody dared refer to it.

Throughout his career he held many executive positions in medical societies including president of the British Orthopaedic Association, president of the Orthopaedic Section of the Royal Society of Medicine and vice president of the Royal College of Surgeons.

In 1970, his wife Muriel, of 40 years, died. They had two adopted children. He remarried in 1971, but soon after developed leukemia and then had a stroke. He died in August of 1972.