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Jean Judet died a year ago. In him, we lost one of the great pioneers of joint replacement in France. Shortly before his death, he gave an interview to Maîtrise Orthopédique, in which he talked about his pioneering days and the transition to modern orthopaedic surgery.
M.O. : What is the history of the Judet family?
J.J. The Judets were country folk, from Central France. One of my grandfathers was a farmer. He must have been quite a personality, because, without any formal education, he managed to become a county councillor and an MP for his constituency. Above all, he managed to give his four sons an education, which was far from easy in those days, since he was not well off. All his friends used to say to him, "You're mad, you don't know what's going to happen." And he would say, "We shall see." And it all turned out very well, in the end, since my father went on to become a well-known orthopaedic surgeon. He trained at the big teaching hospitals, got his D.Sc., etc. The eldest son stayed at home to run the farm and make a bit of money; the second son got a place at the prestigious École Centrale, but had to give up his studies because he got TB. On the maternal side of the family, my grandfather was a migrant worker. These workers were country people who were so poor that they left the land and went to work in Paris. In the early days, they would walk all the way to the capital; later on, they would go by train. My grandfather worked in the building industry, and did all right financially. He came to own a number of properties in Paris - a bit of a rags-to-riches story.
J.J. : My father went into Medicine - but, you know, I somehow never bothered to find out why a country boy should have chosen this profession. As a student, he was poor as a churchmouse. He had 100 francs a month, to pay for food, lodgings, and clothes. Even in those days, 100 francs did not go very far. He worked very hard, and very fast. He was one of the first to realize that orthopaedic surgery was a discipline in its own right, a distinct branch of Surgery. So he went and specialized in bone surgery. Initially, it was tough going, financially; but by and by, he became well known and he built up a considerable practice. He started out at a public hospital, where he was Dujarier's assistant; thereafter, he went into the private sector. He had a good practice, but was obsessed with the idea that he should publish. His textbook on limb fractures had a very wide audience. Later on, when I was invited to lecture in South America, I found this textbook in the libraries there. After all, French was then still widely spoken in that part of the world.
J.J. : Before the War, a friend said to him, "Why don't you set up your own Clinic - you'll be on your own premises; and, after all, you've got those brilliant sons." The thing is that his two sons, Jean and Robert, had decided to go into medicine and orthopaedic surgery themselves. So the decision was taken to build a Clinic. My father did not have a lot of money, and he had to borrow. A friend of his was an architect, and he did the plans. The site chosen was at Square Desaix, near the old indoor cycle-racing track. We therefore saw a large number of sports injuries, and the work load was staggering. The 40 beds at our centre soon proved insufficient; we also had an outpatient clinic, and an X-ray machine. Then the War broke out. We were very patriotic, and a bit reckless, because we set up, at our centre, a sort of first-aid post for wounded members of the Resistance, who came to us from all over the place. It was a miracle that, of the 40 people working with us, none ever grassed on us to the Gestapo. The wounded were arriving all the time. On one occasion, though, Robert was taken away by the Gestapo, who must have got wind of what was going on somehow.
J.J. : He was 30. They came and took him away. I was at the St. Louis Hospital at the time, where I was in charge of the Department of Orthopaedics. Someone rang me to say, "They've taken away your brother." And I thought, "That's it. We shall never see him again." That evening, Robert came back, and said, "That was tough. They interrogated me all day, but they did not rough me up. The first interrogator was very tough, an absolute bastard; the second one was a bit more relaxed; and the third one sounded as if he couldn't give a damn. When it was all over, this third interrogator, who looked rather older than the others, said to me, 'You can go, you are a free man. There are not many that go free from here.'" The Gestapo place was in the rue des Saussaies, three kilometres or so from our centre. Robert, who had the cheek of the devil, said to the German, "Look here, you've made me waste a whole day. I had an operating list, and lots of patients to look after. So how about a car to get me back to work?" And would you believe it, the German goes and checks if there is still a driver on duty. And Robert was driven back in a Gestapo car. We were extremely lucky.
J.J. : Orthopaedics and traumatology. He treated fractures, non-union, those sort of conditions. We went and helped him when we were in training ourselves. He did internal fixation; he operated on lots of cases of osteomyelitis. Bone disorders were a Cinderella area in surgery at that time; and since my father was interested in these disorders, he got patients coming from all over the country. He had trained under Dujarier, who had been the first to do internal fixation. There were plates available then, but nailing was not yet an option. Nails came in at the time of WWII. Apart from internal fixation, he also used traction, and he casted many patients.
J.J. : He was at Boucicaut. There is a story about him which ought perhaps to be off the record, because it is a bit bawdy, but my father loved it: Dujarier was a man of strong appetites. One afternoon, he felt a bit randy, so he went outside and picked up a "lady", who looked O.K., and took her back to the junior doctors' common room. Dujarier stripped; the lady stripped; and then he saw that she was crawling with crabs. However, there was no turning back - Dujarier grabbed a copy of the daily paper, poked a hole in it, and off they went.
J.J. : I trained with Mr. Houdard at the Lariboisière Hospital. At that time, I was already working on some new ideas, and with Robert I had been to see a Belgian called Lambotte, who had designed an external fixator. So we took up this new device, which was not at all in at that time. People were very much against external fixators. We wrote papers on the subject, although we were only juniors at the time; and Mr. Houdard presented these papers at the Academy of Surgery. We also took an interest in epidural analgesia, which had initially been invented by a German, but which had subsequently fallen into disuse. We used the technique in 40 patients, and Mr. Houdard presented the work at the Academy of Surgery. However, we did not carry on, because we were not anaesthetists; but epidurals had worked all right in our hands. In actual fact, Mr. Houdard got a bit worried about us doing all this. So he asked Sister, who had been with him for a long time, "Are these two doing all right?" And she said, "Absolutely no problems."
J.J. : Yes - observation and reading were habits we acquired as clinical students. And, of course, clinical students then played a much bigger role in patient management than they do nowadays. My time as a junior surgeon was a most rewarding one. I spent some time with Mr. Ombredanne, who befriended me. Also with Proust, the brother of the famous novelist. He had a powerful intellect, but as a surgeon, he was less than great and needed someone to help him. He was always running late. He would start operating at 12 o'clock, and the Anatomy classes we had to teach would start at 1 o'clock. Not a happy situation. Towards the end of my training, I was working with Richard at Berck, and then at the St. Louis hospital in Paris. Richard was an extraordinary character. He was tall and extremely handsome, and always had lots of women running after him. He was an excellent surgeon, but his reports were a bit over-optimistic. I remember a patient who had undergone shoulder surgery. Richard asked him to raise his arm. Abduction was poor. Richard took the patient by the hand and said to me, "Write: abduction - 90°." He then asked the patient if he had gone back to his job. The patient said, "I used to be a lathe operator, but I can't work in that job any more, so I am a security guard at a garage." And Richard said to me, "Write: Gone back to work."
J.J. : That's right. Joint replacement was not an option.
J.J. : Quite often, these patients were just left in bed. Sometimes, a small plaster cast was applied, but that was not well tolerated. Sometimes the patients were put in traction. And sometimes nothing was done at all. It must be said that in the over 60's, a femoral neck fracture was the end, in about half the cases. They were prone to all sorts of complications - UTIs, pulmonary complications, etc.
J.J. : Robert was a few years' my junior, and he started training three years after me. But we always tried to stay together. We did not have the nous to try and go to different centres to get wider exposure.
J.J. : Let me tell you: In '45, just after the War, I had a friend, an ENT specialist, who told me about an extraordinary material that was well tolerated - methyl methacrylate - which he used to reconstruct nasal bridges and orbital rims. This gave me the idea that MMA might be used to resolve our femoral neck fracture problem; I thought that Robert and I might try to replace the femoral head by one made of acrylic. We knew Mr. Delaunay very well; he was in charge of the laboratory at the Pasteur Institute. So we went to see him, and we asked him whether he would perform animal studies to establish how well MMA was tolerated. The results of these studies were favourable, so the project was on. We went out to Belleville, where we had heard of a lathe operator. We found the man in an grotty backyard - however, he was a very skilled lathe operator, and he made us some beautifully accurate acrylic heads, with a stem for insertion into the neck of the femur. I remember that, in those days, we did not have a car, so we cycled all the way to Belleville. Those were the days.
J.J. : Yes. We got the acrylic in blocks from a dealer. However, we also went to industry to have some wear and strength studies done. We had to be a bit careful, because it was rather presumptuous to go and put in these heads just like that. The actual surgery was all right, because we had rehearsed the procedure on cadavers at Clamart. The first implant was inserted in 1946. The patient was a wine merchant from Boulogne, with very disabling OA of the hip. By the eighth day, he was happily walking around, and pain-free; and he was celebrating the successful outcome with copious quantities of Beaujolais. The second case we did was an elderly lady at the Rothschild Hospital. One day, a friend saw me and said, "I have heard about that new device of yours for treating femoral neck fractures. I've got a patient on my ward; perhaps you could come and see her." So I went there, and I saw this little old lady with a broken hip, who was really quite poorly. My colleague said to me, "Look here, we can try your implant quite safely, because if we leave her as she is, she's had it anyway." So we went ahead, and Robert and I did the operation. We used a Smith-Petersen approach, took out the femoral head, and replaced it with our implant.
J.J. : By the fifth day, she was walking. It was like a miracle. The case caused a major sensation. Everybody then came to us, and we were inserting acrylic implants right, left and centre. The procedure became incredibly popular, and we were asked to demonstrate our work in the United States. Charnley's idea of using a bonding agent for stem fixation and of cementing in the cup did not come in until the late Fifties. We had ourselves realized that the acetabulum needed protecting, and had tried prosthetic replacement. We had experimented with preserved skin; then inserted a plastic cup; however, we had not used cement.
J.J. : Yes - but somehow neither Robert nor myself had thought of using it that way. It was staring us in the face, and we didn't see it.
J.J. : I don't know exactly when, but it was shortly after.
J.J. : After three or four years. That's when we saw loosened implants and acetabular wear. But some of the prostheses are still all right. Every now and again, I see patients with such implants in our outpatient clinic. Most of them, however, did wear out. You know, a hip has to withstand a lot of loading. So we found we had to do things differently. At that time, we had designed a metal device that was quite similar to the Austin-Moore endoprosthesis. It did all right, but the acetabular side of the joint was still a worry, and we had not properly resolved that problem. I had designed something that was known as the jockey cap - a plastic shell with a peak that was fixed to the hip bone with a screw. Trouble was that it was rather flimsy.
J.J. : Later on, when the problems of cementing became apparent, Robert and I designed rough-textured implants for press-fitting. We inserted some 5000 of these cementless devices. The demand was incredible, and we were wildly enthusiastic about this design. At first, all was great, because fixation was excellent; however, because of poor control of the metallurgical parameters, we subsequently got into a lot of problems with secondary loosening.
J.J. : We both had ideas. Robert was a very blunt man. When I had had an idea and explained it to him, he would say, "Bullshit." We would not talk about it any further, then next day he would say, "I've thought about that idea of yours over night, and perhaps you have a point." It was a very brotherly way of thinking things through.
J.J. : Jointly - oh yes. For instance, for the joint replacements, I had the ideas, and Robert went and developed and applied them. With the cemented implants, it was Robert who had the idea. He said that there should be a porous metal device that would be press-fitted. The principle was sound, but we were let down by the poor properties of the metal. The idea of quadriceps release in the treatment of extensor mechanism stiffness came from me. That procedure, too, became very popular. In fact, it is one of the few bits of surgery still known as the Judet operation.
J.J. : That's quite a story. I had just given a lecture at the Hospital for Special Surgery in New York. The lecture had gone well, and I was very, very excited. I was walking along one of the corridors afterwards, thinking about all the cases of stiffness that we were seeing in our work, and I thought why don't we release the quadriceps. At the time, there was not much internal fixation being done, and stiff knees were more frequent than they are now. There had been attempts at lengthening the quadriceps, but the results were very poor. I went back to France, and one of my first patients was a Breton racing cyclist, who had been absolutely brilliant before an accident that had left him with a stiff knee. He said to me, "If only I could bend my knee, I could get a job delivering newspapers." So I said to myself, "Let's give it a try." I talked it over with Robert, and with both did the operation, detaching the quadriceps. The flexion obtained was 90°. We could have done better than that, but it was our first case. We were happy, and the patient was able to go and deliver newspapers.
J.J. : Yes. I was head of the Paediatric Orthopaedic Surgery Unit in Mr. Fèvre's department. However, my work was divided between mornings at the public hospital and afternoons at my private clinic.
J.J. : When I had reached retirement age. I went on working at the private clinic, and only stopped doing operations two years ago. There comes a time when one has to stop.
J.J. : I got on very well with Ramadier and with Postel. There were these stories about our rivalry with Merle d'Aubigné, but that was really an exaggeration. Merle d'Aubigné would come to dinner parties at my place. It is true, though, that he was not easy to get on with. At conferences, Robert, who was very quick-witted, would sometimes defeat Merle in a discussion, and that did not go down at all well.
J.J. :I will tell you a secret: We did 30 knee ligament operations of the type that later on came to be known as Lemaire's procedure, and never published on our work. We were simply looking for some means of stabilizing unstable knees; and we thought that what we had come up with was so ordinary it didn't warrant a paper. Yes, we did have lots of ideas. In scoliosis patients, we did a number of successful xenografts.
J.J. : We used foal bone. In order to ensure that the graft material would be sterile, we went to the abattoirs to get fetuses from pregnant mares. The fetus was kept inside its membranes and taken to the operating theatre, where the whole thing was swabbed with iodine and the unborn foal was extracted. The bones were beautiful. Grafts would be cut from the femur, and frozen at -30° C. The technique worked well, but graft incorporation took longer than with autografts. In fact, one had to reckon on twice the time. However, the grafts would take in the end, and we had only one rejection in a total of 80 cases.
J.J. : Because of the time it took, and because you could get aseptic graft material only by finding a pregnant mare that was destined for the slaughterhouse.
J.J. : I used a sterile cable-and-hook system. By pulling on the cable, I was able to obtain reduction. Then the grafts would be wedged in. However, the method was less than satisfactory, and I gave it up as soon as the Harrington rods became available. Truth to tell, we were doing too much, and we were constantly overworked. We could have done better, but we did what we could.
