Hip Replacement History – Early Years
This post details hip replacement history.
When the first hip replacements were attempted, surgeries were not total but hemi-arthroplasty or partial hip replacement. The results were unsatisfactory.
1891 – German surgeons used ivory to replace the femoral head for patients whose hip joints were destroyed by tuberculosis
1925 – American surgeon Marius Smith-Petersen created the first mold arthroplasty out of glass. Glass was a biocompatible material, but the implants soon broke and failed. Marius Smith-Petersen and Philip Wiles later trialed stainless steel, which soon became the material of choice for several decades.
1930s – Marius Smith-Petersen and Philip Wiles trialed the stainless steel hip replacement. It was fitted to the bone with bolts and screws at Middlesex Hospital in the UK. The patient records were lost during WWII, but one patient was reported to still have unrevised prosthesis – after 35 years.
1938 – Dr. Jean Judet and Dr. Robert Judet developed a short-stemmed prosthesis using an acrylic material which provided a smooth surface, but it became loose after implantation.
1947 – Charles Scott Venable used the material Vitallium in hip replacement implants. Vitallium was originally used in dental prosthetics. The material caused no pathological changes or electrolysis to the bone.
Hip Replacement History – Partial Hip Replacement Stems
1939 – Frederick Thompson of New York and Austin T. Moore of South Carolina developed implants for the entire femoral stem.
The Thompson Stem fit into the femur with cement but without the use of the acetabulum implant. The implant rotated inside of the natural body socket of the pelvis. However, the cartilage and bone didn’t perform well against the implanted stem and needed eventual revision.
The Austin Moore stem was designed similar to Thompson stem. The device was implanted without cement and had a small hole in the stem where a bone graft was placed during surgery. With the graft, the bone would integrate with the device several weeks after the surgery.
Both the Thompson and Austin Moore type stems are used in partial hip replacements today, mostly for patients with a femur break near the femoral head.
1940 – Harold Bohlman performed the first hip joint replacement using a femoral stem made out of Vitallium. The metal head was held to the stem by a nail.
1953 – British surgeon George McKee performed a metal-on-metal total hip replacement. A trainee of Philip Wiles, the implant was a modified Thompson stem cemented into the neck of the femur. Initially, there was removal of pain, but the implant soon loosened and failed.
History of Hip Replacement – Hip Resurfacing
In hip resurfacing, the cap over the femoral head must be designed to be very thin, and manufacturing this requirement was a challenge.
1925 – Marius Smith-Petersen of the United States tried the first molded arthroplasty – out of glass. The implant was a hollow hemisphere which fit over the femoral head and provided a smooth surface for movement. Glass was a good material the body accepted, but it failed to handle the forces through the hip joint – the glass shattered.
1950 – Sir John Charnley created a resurfaced hip bearing using a Teflon femoral cap and acetabulum. It wore out within two years after implanting.
1960 – 1980 there were many failures to hip resurfacing due to the following:
- Aseptic loosening – due to improper fixation techniques
- Metallosis – creating bone loss and patient organ failure
- Technical errors during implants
- Issues with design and manufacturing
- Improper surgical technique
Hip Replacement History – Polyethylene
Early Polyethylene was a large contributor to the failure of hip resurfacing. Mainly used in the acetabulum component, the material broke-down and contaminated bones due to the chemical interaction of the loose polyethylene. Called osteolysis, the condition weakened the bone and caused implant loosening.
1971 – Freeman and Furuya created a polyethylene femoral component and a metal acetabular component. Excess wear forced them to switch to a metal femoral head and polyethylene acetabulum, reducing but not eliminating the problem.
1978 – The Wagner Resurfacing Arthroplasty in Birmingham used a metal-on-polyethylene bearing. In the next six to seven years, the implants failed 55% of the time due to loosening of the components caused by collapse of the femoral head and failure of the materials used in the implants.
1990 – Introduction of highly crosslinked UHMWPE greatly improved the wear and reduced the osteolysis issues of polyethylene.
Hip Replacement History – Modern Approach
1960s – 1970s – Exeter hip stem was developed in UK and first implanted at Princess Elizabeth Orthopedic Hospital in Exeter, England. The implant was a highly-polished design, significantly reducing friction. The collarless neck allowed leg length adjustment. The Exeter hip stem as a cemented device showed excellent long-term durability.
Early 1960s – British surgeon Sir John Charnley is considered to be the father of the modern total hip replacement due to his significant experiments at Manchester Royal Infirmary and Wrightington Hospital. He showed the larger the femoral head in the prosthesis the greater the friction and failure rates. Smaller femoral heads in implants created greater penetration into the acetabulum but less patient stability.
Charnley’s low friction arthroplasty was identical in principle to prostheses used today. His procedure almost completely replaced other procedures by the 1970s and consisted of three parts: femoral stem, acetabular component, and cement.
- Featured stainless steel femoral head – smaller than other designs
- Reduced wear due to small surface area
- Polyethylene acetabular component
- Acrylic bone cement (used in dentistry)
- Lubricated with synovial fluid (natural fluid produced by the body found in joint areas)
Unfortunately the smaller femoral head dislocated more easily than the larger femoral head.
Hip Replacement History – Charnley Patient Selection
1970 – Charnley suggested total hip replacement was only a good alternative for the elderly and inactive population. He practiced and suggested surgeons delay total hip replacements for those over 65, and never ordered at the first consultation.
For those who did receive total hip replacement under the age of 65, he suggested those patients take part in less activity.
In the 1970s, Peter Ring’s implant for total hip replacement was a cementless, metal-on-metal, self-locking femoral and acetabulum design.
Hip Replacement History – Cement and Cementless Implants
Cemented Hemi-arthroplasty where both femur/stem and acetubulum cemented
- Used for femoral head fracture treatment
- Used for femur fracture treatment
- Stems requires better surgical technique
- Pain in cemented stems is rarely seen
Modern Cementless Procedures
- Non-cemented prosthetics – Good for younger patients
- Helps reduce bone loss
- Helps with any future revision surgery
- Uses a specialize coating call hydroxyapatite
- Permits ingrowth of the bone
- Improves fixation of the prosthesis to the bone
Uncemented Stem – Characteristics
- Stems are more costly with more expensive materials, manufacturing, and elaborate design
- Can cause pain in first 2 years of use as the bone adapts to the placement of the stem
Cemented Stem – Characteristics
- Stems requires better surgical technique
- Pain in cemented stems is rarely seen
Hip Replacement History – Hip Replacement Today
Separate Femoral Head
Newer designs have implants with separate femoral head and stem, helping surgeons better adjust leg length through different designs or length of femoral stem (seating higher or lower into the femoral canal). The design also permits the use of different materials for the femoral head.
Newer implant designs also consist of an acetabulum with a metal shell that mounts to the pelvic socket. For non-cemented procedures, the shell has beading to match the bones pores and permit bonding of the implant to the bone. The design allows the acetabulum location to be adjusted, different than the earlier cemented design. A liner, using one of many different materials, goes inside of the shell. The use of new types of polyethylene improves wear and nearly eliminates the risk of osteolysis.
Hip Replacement History – Materials and Wear
Today, the main issue that doctors and patients confront when choosing implant material revolves around the wear debris that is released into your body from any of the implant materials. Even the materials with the most wear debris (metal ball and polyethylene liners) show up only after 10 to 15 years.
It is important to educate yourself about the various options for hip replacement surgery. Be sure to ask your surgeon whether he or she uses metal-on-polyethylene, metal-on-metal, ceramic-on-polyethylene or ceramic-on-ceramic implants – and why.
Hip Replacement History – Conclusion and Engagement
The technology and techniques used in hip replacement surgeries have changed significantly over the past hundred years. What once was rare and risky is now common and not so risky. The pioneers of hip replacement surgery, and their patients, learned through trial and error to bring hip replacement technology to where it is today. Surgeons no longer deter younger patients who need hip replacements from having surgery. Today, the trend is toward younger patients receiving the surgery due to better techniques and materials.
What are you thoughts and concerns regarding hip transplants?
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Resources Used in This Post
Colorado Hip Resurfacing: History of Hip Resurfacing: The Early Years Total Hip Replacement
PubMed – NCBI: Total Hip Arthroplasty – over 100 years of operative history
Science Direct: Thompson hip hemiarthroplasty: Asymptomatic after 44 years a case report
Stryker: Cemented Stems – Exeter
EMedicine – Medline: Overview, Advantages and Limitations, Indications and Contraindications
Wikipedia, the free encyclopedia: Hip replacement
Dr. Fritz Boettner: Hip Resurfacing Surgery, New York City
The Leone Center for Orthopedic Care: Partial vs. Total Hip Replacement Surgery