Given that the medical discipline we know as orthopaedics has a history that dates, at least, from the times of ancient Egypt, Greece and Rome, it remained a fairly limited field until the early years of the 20th century. While fractures were treated with varying degrees of success, the primary emphasis was on the correction of skeletal deformities in children. This explains the name of the discipline which was derived by the joining of two Greek words meaning “straight” and “child” respectively. The earliest attempts at joint surgery are hard to trace but were probably restricted to the treatment of dislocations and repairs to the associated soft tissues, namely the muscles, tendons and ligaments, rather than to the articulating surfaces.
This does not mean, however, that there were no early attempts to conduct this type of procedure. In 1891, a German professor named Themistocles Gluck became the first to perform joint surgery in an attempt to replace the head of a femur that had been destroyed by tuberculosis with an artificial one. Although the professor’s surgical technique appears to have been perfectly adequate, however, the benefit to the patient proved to be disappointingly short-lived. His prosthesis had been made from ivory and quickly collapsed once subjected to pressure.
Nevertheless, Gluck’s effort encouraged others of whom some chose to focus on inserting various materials between the damaged articulating surfaces to reduce friction and prevent any further erosion responsible for pain and reduced mobility. In this type of joint surgery, they used skin, pig’s bladder and even pieces of the fascia lata harvested from the patient’s thigh muscles. Needless to say, these proved to be only temporary fixes and researchers continued to explore alternative options.
In 1925, for example, the American surgeon, Marius Smith-Petersen, fashioned a hollow hemisphere from glass which he then used to fit over the damaged head of a femur. Sadly, while glass is certainly a more biocompatible material than ivory, it was simply not strong enough and so his prosthesis also shattered under pressure. Smith-Petersen went on to experiment with stainless steel, which has since become a material of choice for use in joint replacement surgery. In collaboration with a colleague named Philip Wiles, Smith-Petersen performed the first successful total hip replacement or arthroplasty by attaching the steel prosthetic components to the bone with screws and bolts.
Just over half a century later, a British surgeon named Sir John Charnley earned the title of “father of modern total hip arthroplasty” when his design became the model for the prosthetic hip joints in use today. Made up of three components, his prosthesis consisted of a metal stem for insertion into the femoral shaft, a polyethylene cup to be placed in the acetabular fossa, and an acrylic cement to hold them in place. Charnley’s successful design marked the start of a new era in joint surgery.
Much of that success can be attributed to Charnley’s expertise in the field of tribology which includes knowledge of the frictional forces between interacting surfaces and lubrication. The efficiency of his low friction prosthesis prompted research into alternative and even more robust materials including exotic metal alloys, plastics and ceramics. In practice, many of the devices used in partial or total joint replacement surgery, today, combine two or more materials.
Meanwhile, attempts by orthopaedic specialists to replace the damaged parts of a knee joint had been rather less successful and the turning point for knee arthroplasty occurred only in the early ‘70s. While Charnley’s materials proved up to the task, the design for a functional hinge joint required much longer to develop. Today, however, total and partial knee arthroplasty is a routine procedure and recognised as one of the most successful orthopaedic interventions to date.
Not only materials but also surgical instruments have played a major part in the progress of joint surgery. One of the most important of these tools was the arthroscope; an instrument that allows detailed inspection of the interior of a joint without the need to expose it. First used by the Japanese professor, Kenji Takagi, it was initially adopted as a diagnostic tool.
Later developments included a sheath through which a punch biopsy could be inserted and observed with the arthroscope. The subsequent development of miniature knives and scissors that could be introduced via the sheath has since made possible the minimally invasive, arthroscopic joint surgery now widely used for soft tissue repairs, irrigation and even joint replacements.
If you wish to learn more about this specialised field or wish to make an appointment with Dr Jan de Vos, contact us at 012 807 0335 or send an email to admin@drdevos.co.za.