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Paper 2


By J. Charnley*

The design of an artificial hip joint is influenced by the problems of surgical technique in making the implant.
Encouraging results have already attended the use of an elementary design of ball and socket joint with the
rubbing surfaces exposed to tissue fluids. When the surfaces are of identical metals (chrome-cobalt alloy) the
tissue fluids appear to lubricate in some measure; when the ball is of metal and the socket of high molecular
weight polyethylene there appears to be some degree of self-lubrication in the plastic.
The essential problem is whether particles abraded from the rubbing surfaces will cause harmful tissue
reactions over a long period of time. The more resistant the materials are to wear, the less will be the amount
of the abraded material to cause harm. The success of the exposed joint is such that it seems desirable to explore
to the limit this simple solution before seeking new and more complex designs. The exposed bearing has an
additional advantage in permitting subluxation as a safeguard if the hip is violently forced beyond its designed
range; this protects from avulsion the cement bond between the living bone and the implant.
General factors in design are discussed which have developed from practical experience with different types
oftotal prosthesis used in clinical practice. The attempt has been made to concentrate on information obtained
from surgical experience rather than to report laboratory tests which are readily repeatable in engineering

INTRODUCTION alone if the socket is normal and is lined by the natural

FOR THE BENEFIT OF non-surgical participants in this antifriction lining of articular cartilage; a large number of
symposium I shall concentrate on factors in the design of elderly patients who suffer fractures of the neck of the
an artificial hip joint which have developed out of surgical femur fall into this category.
experience; I shall dwell only briefly on those aspects
which can be reproduced in an engineering laboratory.
It is necessary first of all to define what I mean by 'an S C O P E O F THE PROBLEM
artificialhip joint' since this term has been used erroneously Problems in the design of an artificial hip joint are
in the lay press during the last 10 or 15 years. The term essentially development problems since surgical experi-
artificial hip joint should be reserved for a surgical implant ments in the last five years have shown that the feasibility
composed of the two elements of a ball and socket joint. of an artificial hip joint is no longer in doubt. Existing
I n the last 30 or 40 years surgeons have frequently re- designs of artificial hip joint are all capable of giving early
placed either the ball or the socket of the hip joint, but it is results which approximate, often in an astonishing way, to
only in the last 10 years that serious attempts have been the function of a normal hip joint. During the last five or
made to replace both parts of the articulation. It is now six years the total number of operations of this kind which
clear from surgical experience that only limited success have been performed in the British Isles is probably of the
is to be expected by replacing the ball part of the hip joint order of 4000. The question which has yet to be answered
alone if the bony socket is diseased since pain can reside is how long these artificial hip joints will continue to
in the bone of the diseased socket. On the other hand, function without return of the pain and disability for
excellent results can be obtained by replacing the ball part which the operation was originally performed. Experience
The M S . of this paper was received at the Institution on 6thJanuary gives grounds for believing that 10 years of success can be
1967. 2 expected from existing designs and possibly longer, but
* Consultant Orthopaedic Surgeon and Director of Hip Surgery, large numbers have not yet been followed for more than
Centre for Hip Surgery, Wrightington Hospiral, near Wigan,
Lancs. four or five years. The essential problem is the design of
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an artificial hip joint capable of 20 or 30 years of service Another example of impairment of function as a result
without replacement. of a minute amplitude of movement between an implant
and the living bone has been repeatedly observed when
BONDING THE ARTIFICIAL JOINT TO THE comparing the quality of hip arthroplasties, performed by
LIVING BONE slightly different methods, on the right and left hips of the
Mechanical ingenuity in the design of an artificial hip same patient. Two or three years ago I often inserted
joint is frustrated if the implant cannot be rigidly, and artificial sockets in the acetabulum without using cement,
permanently, fixed to living bone. Relative movement by enclosing the plastic socket in a stainless-steel cup and
taking place between the foreign implant and the living pressing this into the bony socket which had been reamed
bone when load is taken on the joint can cause pain and to give an interference fit. This 'press-fit' socket was
defective function. On the other hand, experience has provided with a central spigot to hold alignment of the
shown that if an artificial hip joint can be rigidly bonded central axis. In patients with bilateral hip disease, where
to the living bone, as by means of a quick-setting cement, the press-fit socket was used on one side and the socket on
it is possible to have excellent function even if the design the other side was fixed by means of cement, we found
of the articulation is quite elementary. I n my early experi- almost invariably that the patient would admit to a distinct
ments (I)* with polytetrafluorethylene(p.t.f.e.) (Teflon) as a preference for the side which was cemented, though
socket against a steel femoral head, both parts cemented highly delighted with both hips. The difference between
rigidly to the living bone, excellent function persisted the two sides was usually so slight that it could only be
even though the bearing sustained wear far beyond a degree proved by having the same psychological background to
which, in engineering circles, would constitute total compare the two hips and would not have been detected
failure. I n these cases defective function only made itself by comparing the two types of socket fixation in two dif-
obvious when the metal head actually pierced the socket ferent patients. It should be emphasized that in these
to cause pain by pressing on living bone, or when the head cases the press-fit socket was never 'loose' in the sense of
bored so deeply into the thick-walled socket that the wobbling erratically in its bony bed. I n some press-fit
amplitude of movement was reduced and to exceed this cases which were explored for pain the only movement
reduced range put mechanical leverage on the socket to demonstrable was rotation around the axis of symmetry,
loosen it. but when the socket was changed for a cemented variety
I n my view, endorsed by McKee and Farrar (2), total the pain was cured. It should be emphasized that negative
replacement of the hip joint has only become a practical feedback for a slightly loose socket can impair function
possibility as a result of using self-curing methylmethacry- even if it does not cause frank pain.
late cement. This view is not yet accepted by all surgeons
and attempts are still being made to bond to living bone
with screws or nails. This approach, I believe, is doomed GEOMETRY OF THE ARTIFICIAL H I P JOINT
to failure in the long term, because elastic deformation The range of angular movement in a ball and socket joint
under load leads to fretting movement between the bone is governed by (a)the depth of the socket, in relation to its
and implant, during reversals of loading, because of un- diameter, and (b) the width of the neck in relation to the
even distribution of the load over the bone surface. I n diameter of the ball. Since stability is a very important
this application it is better that the cement should have matter it is probably unwise to consider sockets which are
no adhesive property to wet bone, since this usually less than half the diameter in depth. Generally speaking,
implies chemical reactivity and this almost certainly will since the diameter of the neck of the ball has to be an
render it biologically intolerable. appreciable thickness for purposes of strength, and the
It is still not widely recognized how small the amplitude socket a half-diameter depth for stability, the maximum
of movement between a weight-bearing prosthesis and angular range which can be expected in an artificial hip
living bone need be to cause pain sufficient to render the joint is not much more than 90". This means that the
implant a failure. I have explored a painful artificial hip maximum angular range in any one direction is not much
joint of the metal-to-metal variety to find the amount of more than 45" from the centralized position.
movement between the bone of the pelvis and the cement In the normal human hip joint all the ranges of angular
holding the metal socket so small that at first sight it was movement can be contained within 45" from the neutral
not recognized. The movement. in this instance was position except for the plane of flexion and extension (the
detected by the ability to express blood from the zone of sagittal plane). In young adults flexion range can reach
contact between the cement and the bone, rather than by 140" from the extended position to the position with the
the actual observation of movement which was less than front surface of the thigh pressed against the abdomen.
1 mm. Radiologically there was nothing to suggest move- Even in the elderly adult it would be unwise to plan an
ment between the socket and the bone of the pelvis. artificial hip joint for a range of flexion less than 110"from
Nevertheless, after refashioning the bony bed to receive the fully extended position.
new cement, and replacing a new socket, the patient com- Nature achieves a range of 130-140" of flexion in the
pletely lost her pain and recovered function. hip by tilting the socket in the direction of flexion; and by
* References are given in Appendix 2.1. making the lips of the socket flexible so that the rigid part
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Fig. 2.1. Three-dimensional protractor for estimating range of movement in different designs of
hip prostheses

of the acetabulum has a depth less than half the diameter UNIT CONSTRUCTION OF THE ARTIFICIAL
of the ball. This is difficult to copy in surgery, because HIP JOINT
tilting the socket impairs the design of the joint in the The necessity to provide for subluxation of the joint when
position of maximum load when walking. achieving the extreme ranges of flexion is a bar to any
Using a simple three-dimensional protractor (Fig. 2.1) design based on a stable retention of the ball in the socket
to investigate the range of movement of an artificial hip by mechanical means. The ability to subluxate provides
joint two points of special interest become evident when a very valuable safety device to safeguard the cemented
the socket is fixed in the basic position of 45" (axis directed bonds, especially that between the socket and the bone
downwards and outwards) with no forward or backward of the acetabulum, in the event of a patient sustaining
tilt. accidental violence which forces the joint beyond its
First, the range of 90" of flexion from the fully extended designed range. I n the earliest design of artificial hip joint,
position is obtained by combining 45" of angular movement McKee provided the socket with three metal 'petals'
(limited by impingement of the neck against the rim of the embracing the ball beyond its half diameter to resist
socket) with 45" of rotation in the axis of the femoral neck. dislocation, but it was found that these petals were more
Secondly, in order to pass beyond the 90" of flexion of a nuisance than an aid.
range (i.e. to reach 120") without tilting the socket in this There are obvious attractions in a design in which the
direction, the ball must subluxate a short distance from rubbing surfaces of artificial hip joint could be sealed with
the depth of the socket. a silicone-rubber sleeve, to retain a lubricant or prevent
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the escape of abraded particles worn from the rubbing the socket was made of Teflon (p.t.f.e.). Teflon proved too
surfaces. Whether this can ever be done without limiting soft for continued use and the direction of wear over a
the range of angular movement, and without trapping and period of 2-3 years was estimated in 37 patients.
damaging folds of sleeve at the maximum range of move- Our results showed 10-15" as the most common direc-
ment, is, from my experience, open to grave doubt. A tion of wear, but the study brought out the very remarkable
sealed bearing is more than likely to present problems of fact that in a small proportion of cases the direction of
its own and transfer the problem of survival for 20 to wear could vary from as much as 20" in a positive direction
30 years from wear of the bearing surfaces to the survival (towards the mid-line of the patient) to as much as 25" in
of the flexible sleeve. a negative direction (i.e. in a direction of dislocation away
A completely sealed bearing of unit construction would from the mid-line of the body). A most exhaustive scrutiny
offer very considerable difficulties to the surgeon in the of clinical records associated with these cases showing
manner of insertion. The present system by which work extreme divergence from the norm revealed nothing at all
on the socket is completed and then the work on the ball to offer a satisfactory mechanical explanation. We were
part started, followed by mating the two surfaces as the therefore forced to accept these observations and conclude
last part of the procedure, enables both procedures to be that the design of an artificial hip joint should be such that
carried out under full vision throughout. To insert a joint it is stable for vertical forces in the absence of abductor
designed on unit construction would necessitate fixing the muscle force.
stem of the ball first, and then the cementing in position
of the socket would offer considerable difficulty since not
only would it be difficult to introduce the socket at this SMALL- VERSUS LARGE-DIAMETER BALL
stage in the procedure, but the act of introducing the AND SOCKET
socket would obscure the surgeon's view of the cemented Since the failure of p.t.f.e. as a bearing material in the
area. artificial hip joint, I have accepted some degree of fric-
It would therefore be greatly to the advantage of both tional resistance as unavoidable and consider it important
patient and surgeon to concentrate on improving to the to minimize frictional torque by using the smallest dia-
absolute limit the elementary design of artificial hip joint meter of femoral head which surgical and mechanical
in which the bearing surfaces are exposed to tissue fluids, conditions permit.
and where lubrication is either by means of these fluids or The surgical condition which governs the minimum
in spite of them. size of head is the avoidance of dislocation. A ball of small
diameter has to move only a small distance to escape
completely from the control of the socket compared with a
DIRECTION OF THE RESULTANT FORCE ball of large diameter. If the intrinsic stability of the joint
It is obviously important in changing an artificial hip joint were to reside entirely in the contraction of the muscles, it
to have practical knowledge of the average direction of the is clear there would be a great danger of dislocation in a
principal force on the hip joint in the course of weight- joint with a small-diameter ball when the muscles are
bearing. There have been many theoretical studies of the relaxed or off their guard. Surgical experience leads me to
magnitude and direction of the 'resultant force' in the believe that the stability of an artificial hip joint resides
human hip joint (the resultant of the weight of the body entirely in the fibrous sleeve which develops to form the
and the force of the abductor muscles supporting the pel- capsule round the joint. I have observed this in post-
vis) and, in general, it can be said that the principal force mortem examinations two years and three years after
can be taken as two or three times the weight of the body operation, and possess a cine film demonstrating this. It is
and operates in the hip joint in a direction inclined from a remarkable biological adaptation that the fibrous and
10" to 15" towards the mid-line of the body. This figure ligamentary tissues of the original capsule, often thickened
has recently been confirmed by direct measurements, and abnormal as a result of arthritic disease, can heal
derived from strain gauges in the neck of a prosthetic round the artificial hip joint to produce a structure per-
replacement of the neck of the femur, by Riddell (1966). fectly adapted to the new joint. This is all the more
These observations are of particular interest in that they remarkable when one considers that the diseased femoral
are the first to be obtained in the conditions of a surgical head is very much larger than the miniature steel ball, and
implant in the hip joint which might be different from the voluminous capsule closes down on the small metal
those in the normal hip, since it is possible that the ab- head to form a new capsule which serves all the functions
ductor muscles, which given the direction of the resultant of the normal capsule. My cine film demonstrates how this
force, might not contract with as much power as in the newly formed capsule resisted dislocation under traction
normal hip. in the axis of the neck of the femur, yet at the same time
We have recently had an opportunity for making some the capsule permits over 90" of rotation.
new observations with a direct bearing on this surgical Clinical experience in reducing the size of the ball
approach to the direction of the resultant force to the hip starting at 41 mm, to 28 mm, then to 25 mm, and finally
joint (Elson and Charnley, 1966)by measuring the direction to 22 mm has led me to feel that a ball 22 mm in diameter,
of the track of wear in total prosthetic replacements where compared with the size of a normal femoral head of
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50-47 mm in diameter, is probably the smallest we dare the interests of strength at the junction of the sphere and
use. the neck has been taken inside the contour of the main
Experience with this small-diameter ball is beginning to spherical surface. The range of angular motion depends
suggest a possible advantage over the large ball not en- on the diameter of the neck at its point of junction with
visaged in the original plan based purely on reducing the sphere, and the bending moment on the neck is increased
frictional torque. Since we must accept a minor degree of the further the narrow section of the neck is distant from
subluxation of the femoral head to achieve the last 10" or the centre of the ball; therefore, the best combination is to
20" of flexion, it is possible that the small-diameter ball have the narrowest part of the neck inside the circum-
can permit this subluxation with less force being trans- ference of the ball.
mitted to the socket during that range of movement of the We are at the moment engaged on fatigue tests to decide
thigh which continues after impingement of the neck on the the minimum diameter of neck suitable for the predicted
lip of the socket. A large-diameter ball will probably exert loads. By reducing the diameter of the neck the angular
a greater force on the socket than a small ball because ( a ) range can be increased above 45" from the neutral position
the tension in the capsule produced by stretching is likely or, alternatively, the angular range can be kept at 45" and
to be higher than the smaller stretch produced by the the head sunk deeper than half its diameter in the socket
small ball, and (b) this greater force applied to the rim of a to increase stability against dislocation (Fig. 2.2). Experi-
large socket will be at a greater distance from the centre of ence has shown a great increase of stability against
rotation in a large socket than in a small socket with, dislocation by sinking the centre of the ball 2.4 mm
consequently, a greater turning movement available for below the rim of the socket (i.e. making the depth of the
loosening the cement bond of the socket. socket this amount more than its radius). T o reduce the
I n my original design using a small ball the fixation of diameter of the neck demands a metal which is not only
the socket in the bone of the pelvis was entirely mechanical, stainless but possesses great mechanical strength. For this
being an interference fit assisted with mechanical roughen- reason a forging of stainless steel is preferred to a cast
ing of the surface. By keeping the external diameter of the prosthesis of the otherwise excellent surgical metal
socket as large as possible, and the internal diameter of chr ome-cobalt .
the socket as small as possible (i.e. giving the thickest It will be of interest to engineers studying bones of a
possible wall to the socket), the frictional torque trans- normal skeleton that in arthritic disease the bony aceta-
mitted from the ball to the socket could never reach the bulum is considerably larger than the normal bony socket.
value required to turn the socket against its bed in the With the exception of diseases of the hip based on con-
bone of the pelvis. Since using cement to hold the socket genital malformation of the socket, the acetabulum in
to the pelvis this concept of a maximum difference arthritic disease is wider and deeper than the normal
between the internal and external radii of the socket is acetabulum and very few will fail to contain a hemisphere
perhaps not so important, but I still believe it to be an 50 mm in diameter. This dimension is true for European
attractive feature of design. patients but may not hold for patients in Asia and the Far
There are points of interest in the design of the neck of BEARING MATERIALS
the femoral prosthesis. I n the choice of materials for bearing surfaces of the
I n my present design the radius which is demanded in artificial hip joint there would seem to be no alternative

Fig. 2.2. Different dimensions of femoral neck in relation to range of movement in the socket
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to chrome-cobalt alloy if a metal-to-metal bearing is celerating rate of wear of both parts. In an artificial joint
preferred. Electrolytic action in the internal environment using a plastic bearing one element should be hard and
of the body makes identical metals an absolute require- highly polished, and so be responsible for retaining the
ment. It is a surprising fact in the light of standard geometry of the rubbing surfaces even in the presence of
mechanical practice that chrome-cobalt alloy, working wear at the plastic surface.
against itself, appears to perform in an acceptable fashion
when lubricated by body fluids. It is possible that the P.t.f.e. against stainless steel
success of the McKee-Farrar design may be linked to the My first trials of a steel head against a p.t.f.e. socket used
large diameter of the head, in relation to film lubrication. a stainless-steel ball 41 mm in diameter and the socket
If it were to prove desirable to reduce the size of the head, about 5 mm thick which was an interference fit in the
for reasons of surgical technique, the efficacy of lubrication reamed bone of the pelvis. Friction resistance evidently
might be impaired. There would seem to be little scope for was high because the plastic shell turned with the steel
developments in design of the McKee-Farrar implant ball and wore out against the bone. Reducing the diameter
should the long-term results prove unsatisfactory. of the ball to 28 mm, then to 25 mm and finally to 22 mm,
The actual mode of lubrication of the chrome-cobalt but retaining the external diameter of the plastic socket at
bearing is difficult to understand on the available evidence. 50 mm, overcame the tendency of the socket to turn, but
It is my own feeling that what success this bearing has p.t.f.e. proved to have inadequate wear resistance on the
depends on the triumph of hardness and wear resistance small-diameter head. A 22-mm ball in the hip joint would
over lubrication. wear through 7-10 mm of plastic in 2+3 years.
On this line of thought it is possible that a material even It can be mentioned here that ‘cold flow’ of p.t.f.e. was
harder than chrome-cobalt, such as tungsten carbide, never observed, presumably because the rate of wear of
might be used to resist wear in the absence of lubrication. plastic was greater than the rate of flow. I have a specimen
This concept would make it possible to use a small- of p.t.f.e. which has been under a load of 160 lb through a
diameter ball to avoid high frictional torque, and in- 22-mm steel ball for 5+ years, at room temperature, and
corporate the geometrical attractions I attribute to the no detectable cold flow so far has been observed.
small ball. At the moment there does not seem to be any
available evidence relating to the biological testing of Rate of wear of p.t.f.e. in relation to diameter of ball
tungsten carbide in animal tissues.
In designing a simple ball and socket bearing exposed The increased pressure on the plastic bearing resulting
to the tissue fluids of the body, there is still plenty of from using a small ball is frequently criticized as a source
scope for exploring a bearing of which the socket is made of accelerated wear which might be avoided if the largest
of a wear-resistant plastic. possible ball were to be used. On the clinical evidence the
problem does not seem to be quite so simple. I n the course
of about three years a ball 41 mm in diameter could wear
Plastic bearings as much as 3 mm into a p.t.f.e. socket (Figs 2.3 and 2.4)
There is no future for a bearing composed of plastic and in the same time a ball 22 mm in diameter might wear
rubbing against plastic, if my early experiences with nearly 10 mm. Calculations showed that the volume of
p.t.f.e. (Teflon) are any guide. When the remarkable plastic worn away in both instances is almost the same.
plastic p.t.f.e. first came on to the market it was publicized Since the most serious result of wear in a plastic
that the lowest coefficient of friction occurred when this bearing is tissue reaction to abraded particles of plastic and
material rubbed against itself ( p 0.04). It was suggested not mechanicd failure of the worn bearing, a large ball
that the low frictional resistance of a metal shaft in con- might have no advantage over a small ball on the score of
tact with a p.t.f.e. bearing was the result of the shaft eliminating plastic detritus.
picking up a layer of p.t.f.e. on its surface. In the body
p.t.f.e. behaved very differently from in the laboratory; Filled p.t.f.e.
in the body a tenacious yellow substance appeared which Trials of p.t.f.e. filled with glass fibre to increase resistance
adhered patchily to the rubbing surfaces and seriously im- to wear, and the proprietary material fluorosint (Polypenco),
paired the frictional properties when p.t.f.e. was wearing were all disappointing and offered the first indication that
against itself. This resulted in seizure of the plastic simulated tests of wear must be very carefully scrutinized.
bearing with movement then occurring between the outer All the filled p.t.f.e. materials suffered from surface
surface of the p.t.f.e. implant and the host bone, with the changes when exposed to tissue fluids for a number of
result that the bone eroded through the plastic from the years. The surfaces became slightly ‘pasty’ and could be
outside. This experience makes it necessary to issue a scraped away with a blunt instrument with greater ease
general warning to surgeons that no plastic should ever than could the original product. In the laboratory, lubri-
be used as a bearing surface against bone. Many plastics cated with distilled water, the surface of these filled speci-
(though not acrylic) bearing against bone develop a rough mens of p.t.f.e. took on a high polish and resisted wear
surface suggesting that the plastic has a fibrous molecular better than pure p.t.f.e. by a factor of at least 20. In the
structure, and this ‘felted’ is followed by a rapidly ac- body the surface of the bearing never took on a glaze; it
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Fig. 2.3. 41-mm femoral head prosthesis showing wear of Teflon socket after three years
of service in the body. Socket at right, specimen without wear. Femoral head
positioned in the site before wear

Fig. 2.4. Wear of Teflon socket in contact with 22-mm femoral head pros-
thesis after three years of service in the body. Femoral head positioned in
the site before wear

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remained matt and actually lapped the surface of the metal considered necessary in everydayengineering, might reduce
head, removing in some instances over 0.25 mm of metal the rate of wear of high-density polyethylene.
in two or three years. The resistance to wear of filled
p.t.f.e. in the body was, therefore, no greater than pure FINAL REMARKS
p.t.f.e. It is clear from these clinical experiences that only by
judicious testing in the human body is it likely that we can
get further with this research, and establish the value of
High molecular weight polyethylene in v i m tests designed with the hope of stimulating bio-
Laboratory wear tests of high molecular weight poly- logical conditions in the human subject. It is impossible
ethylene indicate a resistance to wear superior to p.t.f.e. to do this work in a large quadruped, and in any case,
by a factor of at least 500. It is true that this method of periods of time in the region of five years are necessary
wear testing led us astray with the filled varieties of p.t.f.e., before conclusions can be drawn. By selecting patients
but this was the result of chemical action of tissue fluids who are grossly disabled from the original disease, it is
and nothing of this kind has been detected in specimens possible to give spectacular relief from suffering and, at
recovered at post-mortem after three years of service. the same time, collect information which will be of value
We have observed no detectable wear, radiographically, to less severely disabled patients in the future. It cannot
in some 230 patients scrutinized after three years’ service be too strongly emphasized, however, that these surgical
in the body. It would appear from a post-mortem speci- techniques still have not reached a stage when they can
men that bedding-in is just becoming complete at three be used light-heartedly as an alternative to less spectacular
years. methods in younger patients with disability less than total.
It is evident that we need to know much more about the
fundamental nature of wear between plastics and metal A P P E N D I X 2.1
surfaces ‘lubricated’with aqueous liquids. In my laboratory REFERENCES
we are attempting to investigate the influence of surface (I) CHARNLEY,
J. ‘Arthroplasty of the hip-a new operation’,
finish and perfection of sphericity of the metal head on Lancet 1961 (27th May), 1129.
(2) MCKEE,G. K. and WATSON-FARRAR, J. ‘Replacement of
the wear of plastic sockets. We wish to determine whether arthritic hips by the McKee-Farrar prosthesis’, J . Bone
standards of sphericity and polish, higher than are usually Jt. Surg. 1966 48B, 245.

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