M.O.: Since the days of Archimedes, this must be the first time that someone has become famous by having a screw named after him. How did you achieve that?

T.H.: To answer this question, we have to go back to the time when I was a young orthopaedic surgeon in England. There was a very big competition to get a good position. I had come into orthopaedics a little bit late, and I thought, "In order to get somewhere, I need to become an expert." And I started wondering what subject I could become an expert on. Just at this time, I had two or three patients with terrible scaphoid fracture problems. One night, I found myself operating on a fracture dislocation of the scaphoid that was a terrible mess, and I ended up taking it out. And, at the time, nobody really knew what to do with a scaphoid. So I decided to become an expert on the scaphoid; and two weeks later, I had read everything there was on the subject. So I was an expert. This was in the early 70s, and people were getting interested in osteosynthesis, because of the work of the AO and their kits for the fixation of articular fractures. In particular, the AO had developed the concept of fixation and early mobilization. I have always believed in this concept: articular fractures have to be soundly fixed, and patients must be mobilized as soon as possible.

 

M.O.: Where were you at the time?

T.H.: I was training as an orthopaedic surgeon at St. George's Hospital, London. I was working under Alan Apley, who was a very famous English orthopaedic surgeon; he was my teacher, and a big influence on my thinking about "joints must move". I had already learned that one had to decide whether a fracture was stable or unstable, and that if a fracture was unstable, it needed surgery to fix it. I gave my first paper on the scaphoid at the Royal Society of Medicine, and I was awarded a prize. After the next few weeks, I was surprised to see that all the other hospitals in London were sending me their problem scaphoids, even though I was only a junior surgeon. So then I started trying to fix the scaphoids as I said we should. But obviously, it's one thing to say you should fix them, but it's another thing to succeed. And I had some horrible experiences trying to fix them using AO cancellous screws, which was what one was told to use at this time.

 

M.O.: But why did you not go on using pins?

T.H.: Pins are an easy way to fix something, but, of course, they give no compression. Maybe I was a little too fanatic, but in these days we believed that compression was the key for healing, particularly in an intra-articular fracture. When one pins a fracture, there is no compression, and one still has to have a plaster: one has opened the joint and then put a plaster, and that is a bad principle.

In order to improve scaphoid fixation, I did some cadaver work. I soon realized that if I wanted to fix an unstable scaphoid with AO cancellous screws, I needed a jig to compress the fracture and to guide me to put a screw in. So this is where I started working on a jig, with an engineer in the Department of Orthopaedics who made splints. I still have a collection of these jigs, but the problem was that they were all much too big, because the smallest size of jig had to allow an AO cancellous screw with a big 4-mm head to go down it. I managed to use them in a few patients, but it was too difficult. So I came to the conclusion that what was needed was a much smaller implant. I was convinced that it was the screw head that caused all the problems, and that if one could take the head off, one could go down to a diameter of 2 mm. I got there one evening when I was working with the engineer. I said to him, "How about taking the head off the screw?" And he said, "That won't work." So I said, "What about having two threads?" He then said that was a good idea, but there would be no compression, and the fragments would be held apart. I could not accept that; I still liked the idea of a screw without a head. So I was holding it for about an hour, had another pint of beer, and said, "Well, how about making the threads different pitches?" He was silent for about a minute, and then he said, "Fantastic. That's a great idea." We got very excited. We did some mathematical calculations, and we thought it could work.

 

M.O.: Had you already thought of extending this fixation to other joints?

T.H.: Yes, of course. I rapidly realized that this screw could be used quite generally for intra-articular fixation. But I was working on a jig for scaphoid fractures, and, with the new screw, we were able to develop a much smaller jig. In fact, the first jig that was put on the market in England was designed for AO screws, so it was too big, even though a dozen or so were sold. Luckily, I was smart enough to take a patent on the idea of the screw, so the design was protected. That was also the time when I moved to Australia. The thing was that I even though I was becoming an expert on the scaphoid, I had not found a really good job in England. The health system was not good, and there were not many vacancies. Then a senior lectureship in Orthopaedics became available in Australia. I applied and got the job, so I left just in the middle of all this development.

 

M.O.: What was the job in Australia like?

T.H.: To be honest, it was not quite what I had hoped. I was at the University of New South Wales, with Professor Huckstep. He had worked a lot in Kenya, and was known for his nail, a very special design with many perforations. Huckstep was a very interesting man, but I found it difficult to work on my own ideas in his Department. However, at the University of New South Wales, there was a Department of Bioengineering, where they had developed the Dwyer spinal instruments for scoliosis surgery. There I met a young engineering student, Bill Fisher. He was very bright, and I explained my idea to him. He got very excited about the project. I took him in the operating theatre, and we did cadaver studies, which made him feel a bit queasy at first, but he got used to it all quite quickly. We did some big screw trials, and then we decided that we needed to put some screws into scaphoids to see if it was going to work. He took some Steinmann pins home to his garage, where he had a lathe, and he turned these into the first screws. We got them sterilized, and I started putting them in. I put in 25 in the first year. We were also refining the jig, until I got a very delicate and handy instrument. I published my first paper with Bill Fisher. He went on to publish papers in Engineering, and is now head of the Department of Bioengineering in the University.

 

M.O.: Were you happy with your first cases?

T.H.: Absolutely. Also, I believed so much in compression that, even in non-unions, I would just put in my screw, without any bone graft. However, I soon found that for non-unions one had to do more. So I started to develop the technique I have now, which is osteotomy and grafting plus screw fixation. But nothing is absolute in surgery. One of my very first patients had a sclerotic non-union, and I put in a screw, without any graft. He was then lost to follow-up, until five years ago, that is 18 years after the operation. The screw was a bit bent, since it had been made from a steel Steinmann pin, but it was still holding. And he was delighted, because his scaphoid had been stable ever since the operation.

 

M.O.: What did you do after these first cases?

T.H.: I was getting complicated scaphoids sent to me from all over southern Australia, and I soon found myself in a dilemma. The question was whether I should keep these instruments to myself and build my practice, or whether they should be made available on the largest possible scale. This question was soon answered, because, obviously, the product had to be made available. Also, with a patent, one can do it very cheaply for one year, but after that it gets very expensive. To keep it going, one needs some commercial backing. So I had to find a company.

 

M.O.: How did you go about it?

T.H.: The first people I went to was AO, who were having a course in Sydney at this time. So I met all the famous AO guys and explained my idea to them. They appeared to be very interested, and asked for some sample screws to test in the AO laboratory. I had to go to Europe, and used the opportunity to travel to Switzerland. I did not see Maurice Müller, who was the chief of AO at the time; but I met the head of the laboratory. Although they had first told me that my screw was very interesting, they now said that it was not so clever, that I should drop the whole idea. They said they had tried it, and it didn't work, it didn't give enough compression. They advised that I should forget about it.

 

M.O.: Why?

T.H.: I don't know. The AO technicians had a big laboratory, and they claimed that they had measured the compression, and that the concept did not work. I was, of course, very shocked; but, in retrospect, I think that they did not want to develop anything that was not Swiss. After several further visits to firms that were well known at the time, I met someone in Sydney who was head of Zimmer in Australia, and he arranged for me to fly to Warsaw, Indiana, to talk to the Zimmer people. I spent two days there. Everything was beautifully organized. There were six or seven interviews, during which I had to sit down in a little room and explain the whole idea from the beginning to the end. And each person was very nice, and they found my idea interesting, but, as was explained to me later on, none of them was prepared to make a decision on their own about it, because they felt that their jobs might be on the line if the thing didn't work. Next day, there were two more people that I had to meet, and I said, "That's it. I am going to do just one more presentation, and only if every single person who is involved in the decision-making is in the room at the same time." I think that was a bit risky by way of strategy, and my request was not easy to meet. However, they complied. So I gave my presentation in front of all the decision-makers. At the end of the presentation, everyone was shuffling around and scribbling on bits of paper, but nobody would say anything. So I asked each one, "Tell me honestly, what do you think about this idea?" They hummed and hawed quite a bit, but finally they all agreed that the idea looked good. That's how it all started.

 

M.O.: Which year was that?

T.H.: That was in 1976 - five years after I had started working on the idea. So they decided to take over the patent straight away, and then we signed a contract. Because of the distance, I asked that I should be allowed to work in Australia. They accepted that; and it was crucial to our success. The first sets became available in America in 1978.

 

M.O.: The screw was made of titanium?

T.H.: Yes. From the very beginning, I wanted the screw made in titanium, because, as I saw it, it would stay in for the rest of the patient's life. Titanium appeared to me to be more suitable, because stainless steel screws do not really remain stainless, and that could cause problems. However, titanium was a comparatively new material in orthopaedic surgery. It was being used a bit for hip replacements, but nothing was known about its long-term behaviour. Zimmer were not very keen on the idea, perhaps because of the costs involved. Shortly after we had signed the contract, they said, "Look here, we are not going to make the screw out of titanium. We are going to use stainless steel." This is where I made another brink decision. I said, "If the screw is not made out of titanium, it is useless, and the deal is off. It's titanium or nothing." I just had this gut feeling; I had no scientific proof, but I was convinced that titanium was essential.

 

M.O.: Surely you must have been aware of the fact that titanium is not all that easy to machine?

T.H.: Of course - but that was their problem, not mine. I knew it could be done, but that in order to do it, they would need to get new machines. In the end, I won, and so did they, because it was a profitable investment. When the screw was first marketed, they advertised themselves as "the first company that can make this screw in titanium." They were very good the way they introduced the product. Nobody could have a set without having been to a workshop to learn how to use it; and the product was made available only after it had been tested and approved by all the big American centres. The introduction was done very competently. They often asked me to give presentations, and the important thing was that all, absolutely all, the top American hand surgeons had used and endorsed the screw. This was a very healthy start, and it became very successful in America.

 

M.O.: How had you got on in Australia?

T.H.: Settling in Australia had not been easy, perhaps because I was English and had not trained in Australia. At that time, the population of Australia was less than 15 million, and, they obviously had enough orthopaedic surgeons themselves. I had gone there with my family. We went with a very open mind about staying, we wanted to make a life there. We were prepared to adapt ourselves, but we did find that life there was rather different from life in Europe. Also, I had to find a post where I could go on working the way I had in London. Unfortunately, the University job was not very satisfactory. However, at the same time I was able to teach the undergraduates and to train the registrars - something I have always enjoyed doing. In the end, though, I left the University, to go into surgery, which is what I really wanted to do. This was particularly difficult, because every time I went for a job, someone would try to stop me. People thought I was not sufficiently qualified, although I had been doing all this teaching and training of registrars. In the end, I had no choice but to go into private practice. However, it was not that bad, because the other orthopaedic surgeons were very supportive, and sent me most if not all the difficult scaphoids and later the wrists. But it is always difficult to do research without the back-up of an academic institution.

Finally, I was made an "honorary" at Sydney Hospital, the oldest teaching hospital in Sydney. It was a bit like an English hospital, and I was very happy there. I had to work harder, because I was in general orthopaedics and had to do everything. I was doing the first uncemented hips, the first knee arthroscopies in Australia, and a lot of interesting things. At the same time, I continued my clinical work on the scaphoid and on the wrist; I travelled a lot; I gave lectures and did workshops all over the world. Also, my private practice took up a lot of my time, because in the private sector, one has to run everything oneself, whereas the hospital gives one an office and a secretary. Private practice is like running a business - and I had never done this back in England.

 

M.O.: How did your career develop in Australia?

T.H.: I was able, by and by, to specialize entirely in hand and wrist surgery. And in 1986, after a particularly difficult time (when all the orthopaedic surgeons had walked out from the public hospitals in Sydney, because of problems with the administration), I was lucky enough to be able to work in the newly established Hand Surgery Unit at Sydney Hospital, under a general surgeon, Bruce Connolly. He had trained in America, with Bob Carroll, one of the world's first true hand surgeons. Together with another specialist, a plastic surgeon, who had also trained in Louisville, Kentucky, we built up a busy practice, with more and more patients coming from all over Australia, and even from overseas. I was fortunate to be able to pursue my own interest in the wrist. At the same time, I travelled a lot, and was able to meet surgeons from all over the world. It was a very interesting time, and I was also able to set up a hand surgery training programme, which took in junior surgeons from many countries.

However, by then, there were commercial problems. Let me tell you about the one that led to the thing called the Herbert-Whipple screw. Whipple, who was at Richmond, Virginia, was a colleague of Caspari's; he was working with an arthroscopy company, and he wanted to have a cannulated screw.

 

M.O.: Was that a design you had thought of yourself?

T.H.: Of course - the idea was in my patent. I had thought of it from the outset. It was such an obvious idea. Zimmer would never make a small cannulated screw, because they thought it would be too fragile. They had done cannulated screws for the large joints, but never wanted to go into small cannulated screws. Yet, if you look at fractures of the medial malleolus - one of the problems with solid screws is that they have to be removed later on, because the head is always a problem. It would have been so easy to make a headless screw for the medial malleolus, which would be buried in the bone. Anyway, Whipple had asked his arthroscopy company to make a cannulated Herbert screw for use in arthroscopic surgery. One of the features that I had specified in my patent was that the shank, the shaft of the screw, should have a smaller diameter than the threads, which is obvious, because that is where it glides between the compressive parts. So Whipple, with the company's engineers, designed a screw with a shaft that was bigger than the diameter of the threads. It was the only way in which he could break the patent. At the very same time, Zimmer bought the arthroscopy company, and found that they had bought the new screw. They wrote to me to say they were going to phase out Herbert screws and start making Whipple screws. I was very angry then, because the Whipple design had never been tested, and there had been nothing published. Also, nobody had asked me. If they had done, I would have said, "I have been asking you for years to make a cannulated screw, and you haven't done it. Now you have got one, and it is all wrong - its shape, its dimensions are wrong - and you want to go and use it untried and untested." There was some pretty nasty correspondence, but in the end there was quite a good compromise. They got me to meet Terry Whipple, and we discussed it. Terry was quite open that his screw was a copy of mine, and we came to the following agreement: I would go on working on the standard Herbert screw, while he would promote the cannulated screw; he would do all the work on it and write the papers to document the value of his design, while I would put my name on the new screw. But I have to say that I tried it a few times in the scaphoid, and stopped, and I have never used it since. It doesn't work, it's not suitable for that site.

 

M.O.: Since we are on the subject of priority - why is your jig called the Huene guide, rather than the Herbert jig?

T.H.: Well, this is what happened. During the very early days when I was working on the jig, I got a letter from an orthopaedic surgeon in America, Donald Huene, who is a sports medicine doctor in California. He said he was very interested in my jig for the scaphoid; that he was working himself on a scaphoid jig; and that he would like to have one of mine. We ought to get together and talk about it. In actual fact, our concepts were quite different, because my instrument was designed for a volar approach and a headless screw, while his was for use through a lateral incision and a conventional screw. We had some correspondence, and I told him in the end that his jig was not suitable, because I thought that neither the screw with a head nor the lateral approach were useful in the scaphoid. Eventually, the correspondence stopped. And then one day, out of the blue, Zimmer told me that my jig would from now on be known as the Huene guide, and that I had to call it that in my papers and my lectures. The story was that Huene had taken out a patent on his jig, and had sued Zimmer. Although my jig had come first, we were stuck. So Zimmer gave him a lot of money and the right to call it the Huene guide, even though my jig and my technique were completely different. It really hurt me, because all the criticism that ever has been has been about the jig. And Huene has never used it. He wrote to me one day and said he must come and visit me one day, and find out how to put on this thing.

 

M.O.: You never put your patients in a plaster?

T.H.: That has been my basic principle from the beginning: good fixation, and then movement. Of course, early on I thought sometimes that this was not sufficient, and I would tell my patients to be very careful; but I always allowed them to mobilize the wrist. Even after reconstruction with a bone graft, I think there must be early movement, because you have to remodel the bone graft. And - the most important part of all - if you want your fixation to remain good, you must not let it get osteoporotic. If you put it in a cast, you will get osteoporosis very quickly, and then the fixation is not as good. Let me give you an example.

I had a professional cricketer, who had a horrible scaphoid non-union, which had had a previous operation. He had quite a small proximal pole. I managed to reconstruct the scaphoid, with great difficulty, and had problems getting a good stable graft. I decided not to use a cast, but told the guy that he had a fifty-fifty chance that his scaphoid would heal, but that he would have to go very slowly; to wear a splint at all times, except for washing. When I saw him after six weeks, I was very worried. However, the x-rays were fine, it was healing, and the screw was holding its ground, and the scaphoid was well on the way to union. So I told him that he could a bit more now with his wrist; that he could start some very gentle practising. And that's when he said to me, "I have to be honest - I started started playing cricket already three or four weeks ago, and yesterday I was playing in a match." He was in for four hours, and scored 100 runs. Now that was a case where I would not have let him do it. If I had known that he was going do that, I would have put him in a plaster. I had only one case that I can remember, in my whole clinical practice, where there was a failure of fixation in the first few weeks, and he was a cowboy riding rodeo horses, and he fell off and broke the screw. For me, if the fixation is good, then immobilization is contra-indicated.

 

M.O.: Have you never seen any movement around the screw?

T.H.: This can happen; but I think it is the result of fibrous union. For instance, early on I felt strongly that, in fibrous non-union, simple compression would be enough to make the fracture unite. I was wrong, because in 50% of the cases, the outcome was a disaster. That's why I think fibrous union should be bone-grafted.

 

M.O.: Do you prefer a volar or a dorsal approach?

T.H.: I think it all depends on the fracture site. If I have to do a reconstruction, I prefer a volar approach. In fresh fractures, if there is a lot of displacement, I prefer a volar incision, because sometimes there are ligaments inside the fracture, or comminuted fractures that are difficult to control from a dorsal approach. If there is little displacement, I mainly do percutaneous fixation. My principle, which goes back to my early training, is: if I am going to do open reduction and internal fixation, I have to have good exposure, I have to have an anatomical reduction. and I have to have rigid fixation, if need be with a bone graft. However, I love the dorsal approach for proximal scaphoid fractures. Some surgeons would use this approach for all scaphoid fracture patterns, because fixation is more straightforward; but I think that a dorsal incision does not provide full exposure of the scaphoid, which is a major disadvantage.

 

M.O.: Let me ask you another question: avascular necrosis of the scaphoid - does it exist?

T.H.: Certainly it exists - but, as you have probably realized, I am a little bit pedantic about the use of words. 'Avascular' means 'no blood'; and 'necrosis' means 'dead tissue'. With a scaphoid like that, all you can do is put it in the bucket. You cannot reconstruct it, you can't fix it. However, an ischaemic proximal pole - which is common - is hard, white, it's like a piece of cortex. It's ischaemic, but it still has some chance, because it can heal, and you can fix it. So, when Bill Cooney says that you can get avascular necrosis to heal, I say, "Well, show me how. Because I can't."

 

M.O.: Why did you then say good-bye to all that, and leave Australia?

T.H.: To answer that, we shall have to go back to the beginning. I come from Europe, and have always remained attached to the European way of life. In Australia, even at the best of times, I always felt that I was a bit of a stranger on that continent so far from home. I had my family with me in Australia, and the children have stayed down under; but myself and my wife, who is Austrian, were going back to Europe more and more often. And in the end, we decided to buy a house in France. At the same time, I decided to take early retirement in Australia, so as to have more time for my leisure pursuits, such as sailing my boat around the world, studying music, etc. I think that working as a surgeon can keep one from having a normal life, a family life; and I think that one should think about this quite seriously. Life is too short, and there are so many interesting things to do.

 

M.O.: So how do you spend your time?

T.H.: As I was saying, I have lots of interests and hobbies. I play classical music and jazz; I am studying the clarinet; and I belong to a little band, the European Hand Surgeons' Jazz Band. I also have this house in the Var, at Mons, which is a lovely village in the mountains, not far from the sea. I adore the mountains, and I love the sea. Also, when I have the time, I have this property, and I love working on the land. And I am trying to learn the French language, with some difficulty.

 

M.O.: What made you choose France?

T.H.: I chose France because I think that it is probably the best country in the world to live in. I have loved this country since my childhood days, and have always felt at home here. The interesting thing is that, when we look in our family history, we came from France, four or five hundred years ago. The family came from Normandy, so, in a way, I am going back to my roots. On one of my trips to Provence, I discovered this absolutely marvellous place, and said to myself that that was where I would dream to find a house.

 

M.O.: No more surgery, then?

T.H.: I am too young to forget surgery completely. My retirement is a good opportunity to follow ideas that I have, to do more writing, and teaching. I am delighted with the way I have been received by my colleagues in France, in England, and across Europe, all the more so since these friendships have enabled me to keep up with the developments in hand surgery. I am always (or almost always) available to discuss difficult wrists with my colleagues, and to contribute to the teaching of the junior surgeons.

At the same time, I can work on ideas that I did not previously have time to develop. I am currently working on devices with Martin Surgical, a German company that makes a lot of trauma products. In particular, there is an ulnar head prosthesis, which is one of my pet subjects. This is doing well in Europe at present. With Martin's, I have also done Herbert screws, but cannulated ones - the ones the surgeons had always wanted, but which Zimmer had never done. We have a new range, with a high-compression and a normal screw. Bill Fisher and I, after many trials, had arrived at what we thought was an ideal design, and the clinical trials had confirmed our choice. However, we decided to give the surgeons what they wanted: if they want double compression, they can have double compression. So we now have a normal-compression and a high-compression screw. (which is almost twice that of the standard screw). Of course, nowadays, there is no patent, so now it is an open market.

 

M.O.: What would be your message to junior colleagues who dream of being inventors?

T.H.: From my life and work, I have learned three secrets, which I will share: The first one is not to be frightened of change, of doing something different and something new; to keep an open mind; to question everything that one has been taught and everything that one is doing in surgery.

The second one is to have a sound training, because mastery of one's craft will give one the name that one needs to start developing things.

The third, and perhaps the most important one, is to have absolute faith in one's ideas, to be absolutely persevering, not to take No for an answer, and to go on and on.

And I would add: it is never, never easy. Be brave, and good luck - and you will need a lot of luck if you are to be successful.

 

Maîtrise Orthopédique n° 105 - June-July, 2001