History of Artificial JointsHistory of Artificial Joints

Copyright 2010. PEER.tamu.edu

Question:

• Do you know anyone that has ever had a joint replacement surgery?

• Many people are now benefitting from joint replacement surgery.

• Pets also benefit from joint replacement surgery!

Hip ReplacementHip Replacement• The hip joint is the largest load

bearing joint. A hip joint is lined with a layer of cartilage that reduces friction and acts as a shock absorber.

• When the bone is exposed to arthritis and injury, this protective layer is damaged, causing extreme pain.

• What are some things that could cause injury to your hip?

Hip Replacement• The search to alleviate pain led surgeons The search to alleviate pain led surgeons

over a century ago to research the over a century ago to research the possibility of hip replacements.possibility of hip replacements.

Early Hip Arthritis Surgery in the Early Hip Arthritis Surgery in the 1800s1800s

• In 1821, Anthony White In 1821, Anthony White of the Westminster of the Westminster Hospital in London, Hospital in London, performed the first performed the first anthroplasty, where an anthroplasty, where an arthritic or joint surface is arthritic or joint surface is replaced. The procedure replaced. The procedure helped with pain and helped with pain and mobility, but failed with mobility, but failed with stability.stability.

Early Hip Arthritis Surgery in the Early Hip Arthritis Surgery in the 1800s1800s

• In 1826, John Rhea Bartonii performed In 1826, John Rhea Bartonii performed the first osteomy, where a bone is cut to the first osteomy, where a bone is cut to shorten, lengthen, or change its shorten, lengthen, or change its alignment. Unfortunately, this alignment. Unfortunately, this procedure had unpredictable results.procedure had unpredictable results.

• Early solutions also included removing Early solutions also included removing calcium deposits and damaged calcium deposits and damaged cartilage. cartilage.

Leading the WayLeading the Way

In 1891, Professor In 1891, Professor Themistocles Glück led the Themistocles Glück led the way in his development of a way in his development of a hip implant fixation. He hip implant fixation. He produced an ivory ball and produced an ivory ball and socket joint that he fixed to socket joint that he fixed to bone with nickel plated screws. bone with nickel plated screws. He also used a mixture of He also used a mixture of plaster of Paris, and powdered plaster of Paris, and powdered pumice with resin for fixation.pumice with resin for fixation.

Glück Introduces New Ideas to Studies

• Glück‘s studies on hip replacements led to greater advancements that were implemented on other joints, including knee joints.

• He was also one of the first to propose implementing joints from corpses and amputated limbs . He proposed the idea by demonstrating in animal experiments that the cavity in the bone for the bone marrow would accept the shaft of the artificial joint if it is stably anchored within it.

Glück Introduces New Ideas to Studies

• GlückGlück was also a pioneer in proposing was also a pioneer in proposing the idea of biocompatibility, which the idea of biocompatibility, which explains how a foreign material placed explains how a foreign material placed in the body must be well tolerated by in the body must be well tolerated by the patient’s body.the patient’s body.

Think Break:

• What were some of the problems with early efforts at joint replacement?

• What were some of the materials used in early joint replacement surgeries?

Greater Advances

• In 1925, a surgeon in Boston, Massachusetts, M.N. Smith-Petersen, M.D., molded a piece of glass into the shape of a hollow hemisphere which could fit over the ball of the hip joint and provide a new smooth surface for movement.

While proving biocompatibility, the glass could not withstand the stress of walking and quickly failed.

Greater Advances

• One concern in prosthetics is using a One concern in prosthetics is using a material that is biocompatible and will material that is biocompatible and will not cause adverse effects once implanted, not cause adverse effects once implanted, an ideaan idea Glück had introduced earlier Glück had introduced earlier. .

• M.N. Smith-Peterson continued his M.N. Smith-Peterson continued his studies and pursued studies and pursued other materials other materials including plastic and stainless steelincluding plastic and stainless steel..

Cobalt-Chromium AlloyCobalt-Chromium Alloy• A dramatic improvement was A dramatic improvement was

made in 1936 when scientists made in 1936 when scientists manufactured a manufactured a cobalt-chromium cobalt-chromium alloy. This new alloy was both alloy. This new alloy was both very strong and resistant to very strong and resistant to corrosioncorrosion, and is still being used , and is still being used today.today.

• While this new metal proved to be a great success, the actual resurfacing technique was not adequate.

What is Hip Resurfacing?

Hip resurfacing involves removing the cartilage from the surface of the femoral head and replacing it with a metal cap. This may save the hip joint for 20 to 30 years.

Finding a solution…Finding a solution…

• In 1938, Dr. Jean Judet and his brother, Dr. Robert Judet, of Paris, attempted to use an acrylic material to replace arthritic hip surfaces. Unfortunately, this material fell short of expectations and tended to fall loose.

Judet acrylic prosthetic design

By this time it became clear that artificial joint material had to be biocompatible and withstand the stresses of the body.

Continuing ResearchContinuing Research• In the 1950s, Frederick R. Thompson and In the 1950s, Frederick R. Thompson and

Austin T. Moore separately developed Austin T. Moore separately developed replacements for the entire ball of the hip. replacements for the entire ball of the hip.

Continuing Research

• Their type of hip replacement replaced Their type of hip replacement replaced the arthritic femoral head (ball), but the arthritic femoral head (ball), but failed to replace the acetabulum (hip failed to replace the acetabulum (hip socket). socket).

• The prosthesis consisted of a metal stem The prosthesis consisted of a metal stem which was placed into the marrow cavity which was placed into the marrow cavity of the femur, connected in one piece with of the femur, connected in one piece with a metal ball which fit into the hip socket.a metal ball which fit into the hip socket.

The Birth of “Total Hip The Birth of “Total Hip Replacement”Replacement”

• In 1958, John Charnley In 1958, John Charnley from England introduced from England introduced the idea of replacing the the idea of replacing the eroded arthritic socket eroded arthritic socket with a Teflon component. with a Teflon component. When this failed he used When this failed he used a polyethylene polymer to a polyethylene polymer to construct the socket.construct the socket.

Charnley replaced Teflon with polyethylene

The Birth of “Total Hip The Birth of “Total Hip Replacement”Replacement”

• To obtain fixation of the polyethylene To obtain fixation of the polyethylene socket as well as the femoral implant to socket as well as the femoral implant to the bone, polymethylmethacrylate was the bone, polymethylmethacrylate was used as a bone cement. used as a bone cement.

• By 1961, Charnley was performing By 1961, Charnley was performing surgery regularly with great results.surgery regularly with great results.

Animal Studies• J. Charnley did not come across his

innovations by pure luck. He became highly interested in animal studies and applied these findings to the design of hip replacement.

• In particular, Charnley did research in the lubrication of animal joints after a patient with a Judet replacement produced a squeak when he moved his hip.

Animal Studies• He studied the work of biologists who studied

lubrication of animal joints. This helped Charnley explain why synovial (joint) fluid served as a lubricant for articular (joint) cartilage, but not for metal on bare bone, nor a lubricant for metal on metal.

Hip Dysplasia in Dogs

The left image is a normal hip. The femur is smooth and round. The ball fits nicely into the socket (acetabulum).

The right image is a abnormal hip. We can see a shallow socket and a short neck attaching the ball to the shaft of the femur.

Normal Hip Abnormal Hip

Hip Dysplasia Treatment

Total hip replacement in canines results in the most normal limb function in large dogs. The objective of this procedure is to replace the cartilage of the acetabulum “socket” with a polyethylene socket, and the femoral head with a metal prosthesis.

Stop and Think:

• What are some good reasons why researchers use animals as subjects in their investigations?

Knee ReplacementKnee Replacement• The healthy knee joint is lined with cartilage. Arthritis The healthy knee joint is lined with cartilage. Arthritis

and injury can cause damage to this protective layer.and injury can cause damage to this protective layer.

The damage of knee joints by arthritis The damage of knee joints by arthritis led to research and development of led to research and development of knee replacements.knee replacements.

Knee ReplacementsKnee Replacements

• Some of the early work began by implanting metal spacers between the bones of the knee. In the 1950s, McKeever and McIntosh attempted this procedure but results were unpredictable.

The study of hip The study of hip replacements led to replacements led to ways to treat knee joints.ways to treat knee joints.

The Beginning of Knee The Beginning of Knee ReplacementsReplacements

During the late 1960's, a During the late 1960's, a Canadian orthopedist, Frank Canadian orthopedist, Frank Gunston, from Sir John Gunston, from Sir John Charnley's Hip Center, Charnley's Hip Center, developed a metal-on-plastic developed a metal-on-plastic knee replacement to be secured knee replacement to be secured to the bone with cement. This to the bone with cement. This was really the first metal and was really the first metal and plastic knee and the first with plastic knee and the first with cement fixation.cement fixation.

Continued AdvancementsContinued Advancements• In 1972, John Insall, M.D., designed what has become In 1972, John Insall, M.D., designed what has become

the prototype for current total knee replacements.the prototype for current total knee replacements.

The prosthesis was The prosthesis was made of three made of three components for components for resurfacing all three resurfacing all three surfaces of the knee -surfaces of the knee -the femur, tibia and the femur, tibia and patella (kneecap). patella (kneecap). Each were fixed with Each were fixed with bone cement and the bone cement and the results were results were outstanding.outstanding.

Leading VendorsLeading Vendors

• Moore’s 1952 model was produced in collaboration Moore’s 1952 model was produced in collaboration with Howmedica Inc., at the time Austenal with Howmedica Inc., at the time Austenal Laboratories, now merged withLaboratories, now merged with Stryker®.Stryker®.

• Stryker® is one of the leading medical device Stryker® is one of the leading medical device companies today. companies today.

• Encore medical is also one of the leading medical Encore medical is also one of the leading medical device companies that led the way in prosthetic hip device companies that led the way in prosthetic hip and knee replacements. and knee replacements.

Stryker Products

3-D Knee

Primary Acetabular Components

Primary Femoral Components

Hip Replacement Systems

Knee Replacement

Joint Replacement TodayJoint Replacement Today

Joint replacements have come a long way Joint replacements have come a long way since their beginning. Every year, more than since their beginning. Every year, more than 600,000 people in the U.S. undergo hip- or 600,000 people in the U.S. undergo hip- or knee-replacement surgery, according to knee-replacement surgery, according to Consumer ReportsConsumer Reports..

New advancements in hip replacement include New advancements in hip replacement include minimally invasive surgery that spares minimally invasive surgery that spares muscle, offering patients a faster recovery.muscle, offering patients a faster recovery.

The Future????

• What can you imagine for the future of Joint Replacement?