Hip Conditions and Procedures

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Debilitating hip disease is unfortunately not a new problem. But the development of its solution is, on the other hand, a relatively recent accomplishment. Many patients assume that hip replacement surgery is the way this problem was always treated. Today’s total hip replacement is not drastically different than its first successful predecessor, and the procedure is precariously close to being taken as commonplace and risk-free. I thought I would take a moment to review the development of the contemporary hip replacement to arm those considering the surgery with what I hope will be an interesting, and possibly useful, historical review.A joint can become painful and nonfunctional from a number of underlying pathologies, including disease and trauma. Untreated, a joint can ultimately lead to non-use and in the case of weightbearing joints such as the knee or hip, to infirmity and the inability to walk. In part, prolonged recumbency associated with end-stage arthritic disease no doubt contributed to the shorter life span experienced by our own past generations.

The first recorded joint replacement in a human being was performed in the 1880s by Themistocles Gluck, heralded as one of the early pioneers of biomaterials for endoprostheses who fashioned a wood-and-ivory prosthesis for the knee of a 17-year-old girl whose joint had been ravaged by tuberculosis infection. Although the surgery ultimately failed secondary to infection, the improvement in mobility experienced by the young patient underscored the benefit of improved mobility born out of joint replacement. The hunt was on to discover the delicate balance of materials indolent enough to the body’s defense mechanism yet durable enough to endure the repeated cycles of human use to empower surgeons with the ability to make joint replacement a reality.

The turning point would not come for another eighty years, in England when Sir John Charnley,MD was laboring over the fact that his legions of hip patients were recovering magnificently from his surgical approach for hip replacement only to relapse a few short years later when his Teflon coated hips would begin to rapidly disintegrate after a relatively few years of very successful pain relief and improved functionality. His quandary was solved when experiments indicated that the wear properties of polyethylene plastic showed the necessary durability for prolonged ambulation, and the Charnley low-friction total hip arthroplasty was born. The first successful, reproducible total hip arthroplasty was implanted in late 1959. The later publication of the success of his process and follow-up results would lead legions of other surgeons to travel to England to study his techniques and attempt to replicate his outcomes.

In his quest to discover superior biomaterials, Dr. Charnley had also made multiple advances in surgical exposure, sterile technique, implant fixation, and postoperative rehabilitation which were instrumental in the overall success of his new operation. Patients were once again able to reclaim the ability to walk, to escape the rusted claws of persistent pain, and increase their range of motion necessary for even the simplest of hygiene tasks which had been denied them due to their diseased joints.

Dr. Charnley’s discovery heralded a truly new era of advancement in orthopedic surgery, and stands as one of the most enduring milestones of surgical progress. Implant manufacturer Eli Lilly became the sole supplier of the cemented hip prostheses for the Charnley arthroplasty, providing three sizes; Small, Medium and Large. Surgeons the world over were required to travel to Great Britain to study at the elbow of the master in order to be ordained as a purchaser of said implants and begin the steady work of bringing the total hip replacement to disabled patients the world over.

Although many improvements have been made on Dr. Charnley’s original design, he is rightly acknowledged as the Father of the modern hip replacement. Mistakes in design alterations were discovered in tandem with new revelations for success. Modular stem designs and metal-on-metal surfaces offered promises that were eventually found to provide dramatic insight into the reactionary nature of the human body unforeseen in the planning stages when considering metal wear.
It would not be until the 1970s that the superbly brilliant surgeons of the Hospital for Special Services in New York City would successfully translate Dr. Charnley’s cemented metal-on-plastic design in producing a reproducible total condylar knee replacement. Advances soon followed in replacements for other joints, as well as other methods of fixation. The original fixation of the total hip replacement with dental cement as a standard was replaced with the idea of ingrowth surfaces on implants that allowed a patient’s own bone to secure the implant and avoid problems with stress shielding noted after cemented implants.

Implant manufacturers turned away from modular designs in favor of variable morphology of their implants, allowing the surgeon the laterality to fine tune a particular size and type of implant to a patient’s particular anatomy. Different surgical approaches were soon advanced, helping to avoid postoperative limp and reduce the possibility of complications such as dislocation. Time passed; patient outcomes improved, and the rate of early complications declined.

More recently, surgical approach has moved to the forefront as THE reason for improved outcomes. Marketing campaigns and special tables promise shorter operative times and lower complication profiles for a given surgical approach in an effort to secure increasing market shares. Implant manufacturers continue to develop improved designs that offer increased speed of bone growth, decreases in pressure points in host bone, and overall more efficient implantation. Some surgeons would even (rightly) regard their own skill set as pivotal in improved outcomes.

In my humble opinion as a joint replacement surgeon, I feel a combination of the three is most accurately the underpinning for improved patient outcomes. A well performed hip replacement is a good surgery, regardless of the surgeon, the implant, or the surgical approach involved. Certainly, the procedure can be tailored to the patient as an individual and to the strengths of the surgical skill of the operator, but the promise of a good outcome of a poorly performed surgery will be realized to be built on a fictional premise.

Today, patients are faced with a great many choices when physical therapy, medications, lifestyle changes, and other modifiable risk factors have been exhausted. When the pain is no longer bearable, and life can no longer be enjoyed, when a patient can no longer persevere, a well-done hip replacement is a welcome option. I hope that patients will seek to educate themselves on both the risks and benefits of total hip replacement, and make an informed decision on what, and whom, they want to travel with them on this serious, and elective, surgical procedure.


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