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of the hip rather than an arthroplasty in 1826, his statement
regarding the indications for this procedure could be applied to the operation of hip arthroplasty today.
“I hope I will not be understood as entertaining the belief, that this treatment will be
applicable to, and judicious in, every case of anchylosis. I believe the operation would be
justifiable only under the following circumstances, viz. where the patient's general health
is good, and his constitution is sufficiently strong; where the rigidity is not confined to the
soft parts, but is actually occasioned by a consolidation of the joint; where all the muscles
and tendons that were essential to the ordinary movements of the former joint are sound,
and not incorporated by firm adhesions with the adjacent structure; where the disease
causing the deformity has entirely subsided; where the operation can be performed
through the original point of motion, or so near to it, that the use of most of the tendons
and muscles will not be lost; and, finally, where the deformity, or inconvenience, is such
as will induce the patient to endure the pain, and incur the risks of an operation” (41).
Although in an arthrodesis the purpose of the operation was to create raw cancellous bone surfaces on each
side of the joint and to hold them in rigid apposition, in an arthroplasty the purpose of the operation was to shape
the ends of the bones and to hold the surfaces apart, almost always using some material interposed between the
fragments. A
wide variety of materials was used by different surgeons (Table 1.1). In Chicago, J. B. Murphy (168) developed
procedures for arthroplasty for all of the major joints using a flap of fascia and fat interposed between the
remodeled joint surfaces. The reamers that he designed for shaping the head of the femur and acetabulum were
used for this purpose by orthopedic surgeons for many years. In 1917, William S. Baer (Fig. 1.17) (169), the
founder of the Department of Orthopedics at the Johns Hopkins Medical School, reported on a series of 100
arthroplasties in which he had used chromicized sheets of pig bladder as the interposing membrane. For a short
time, “Baer's membrane” was widely used for arthroplasty. Fascia lata removed from the patient was also used
as an interposing membrane in hip arthroplasty (168,170,171). For the treatment of older children with congenital
dislocations of the hip, Colonna (172) carried out a procedure in which the capsule of the hip joint was used as
an interposing membrane as well as a means to retain the hip in the acetabulum. Kallio (173,174,175), in
Helsinki, had success using the dermal layer of the skin taken from the patient as an interposing membrane in
hip arthroplasty.
Table 1.1 Chronologic Insight to Interposition Materials and Performing Surgeons
Surgeons Year Interposition Material
J. M. Carnochan 1840 Block of wood
A. S. Verneuil 1860 Soft tissue
L. Ollier 1885 Periarticular soft tissue
H. Helferich 1893 Pedicle flap of muscle
J. E. Pean 1894 Thin platinum plate
Foedre 1896 Pig's bladder
J. B. Murphy 1902 Fascia lata
Hofman 1906 Periosteum
Lexer 1908 Fascia
R. Jones 1912 Gold foil
Loewe 1913 Skin
Baer 1919 Chromicized submucosa of pig's bladder
Putti 1920 Fascia lata
From Heybeli N, Mumcu, E. Total hip arthroplasty (history and development). SDU Tip Fakultesi
Dergisi. 1999;6(4):21–27.
Figure 1.17. William S. Baer (1872–1931).
Marius Nygaard Smith-Petersen (176,177,178) of Boston began working on other materials to use for
arthroplasties of the hip in 1923. At first he tried using cups made of glass, which broke; then cups of Bakelite, an
early plastic material that also failed. He achieved success 15 years later with the adoption of cups made of
Vitallium, the first nonreactive metal alloy to be used in orthopedic surgery (117). “Mold arthroplasty,” as Smith-
Petersen called his operation, was carried out through his anterior lateral incision and consisted of a revision of
both the head of the femur and the rim of the acetabulum. Vitallium cups of varying diameter and depth were
used. The operation was followed by a prolonged hospital stay for physical therapy and rehabilitation.
Postoperative rehabilitation progressed much more slowly than at present, with patients being confined to bed
for 3 or more weeks with the legs separated by a pillow. The results were impressive; 82% good or satisfactory
results in 1,000 cases (179,180,181). Smith-Petersen's mold arthroplasty became the method of choice for hip
arthroplasty. John Schwartzmann (182) showed that this operation was particularly useful in patients with
rheumatoid arthritis.
The most sophisticated interposition arthroplasty procedure was devised by Bateman, who developed the bipolar
prosthesis (183,184,185). Like the mold arthroplasty, the bipolar prosthesis provides two surfaces for motion:
The first between a large cup and the acetabulum, the second between a femoral component and a high-density
polyethylene surface inside of the cup. For this hemiarthroplasty, the head and neck of the femur are replaced
with a prosthesis, but the acetabulum is not modified. This type of implant was first introduced in 1974 and has
been carried out in thousands of hips with good results and few postoperative complications. Cemented bipolar
hemiarthroplasty for acute femoral neck fracture is associated with excellent component survivorship in elderly
patients. The rate of complications is generally low, and the arthroplasty provides satisfactory pain relief for the
lifetime of the majority of elderly patients.
While older hemiarthroplasty systems were unipolar arthroplasties that did not offer modularity between the head
and the stem, modern hemiarthroplasty systems offer modularity for both unipolar and bipolar arthroplasties. In
theory, the second articulation in a bipolar arthroplasty would increase the range of motion and decrease wear
on the native acetabulum. The polyethylene may also result in the release of particulate wear debris, which may
lead to osteolysis (186). The functional outcomes of unipolar and bipolar arthroplasties have been found to be
equivalent in a number of studies. Bipolar arthroplasty has a generally higher cost with no significant differences
in terms of estimated blood loss, length of stay, dislocation rate, revision rate, mortality, or infection (187). Table
1.2 shows the results of complications and functional outcomes in four recent randomized prospective studies on
unipolar and bipolar hemiarthroplasties.
Table 1.2 Results of Randomized Prospective Studies on Unipolar and Bipolar
Author Year n Implants Complications
Calder et
al. (188)
1996 250 Cemented Thompson unipolar
Cemented Monk bipolar
No significant
No significant
Cornell et
al. (189)
1998 47 Cemented Osteonics unipolar
Cemented Osteonics bipolar
No significant
No significant
Davison et
al. (190)
2001 280 Cemented Thompson unipolar
Cemented Monk bipolar
No significant
No significant
Raia et al.
2003 115 Cemented premise stem, Centrax
bipolar, Unitrax unipolar
No significant
No significant
From Bhattacharyya T, Koval KJ. Unipolar versus bipolar hemiarthroplasty for femoral neck fractures: Is
there a difference? J Orthop Trauma. 2009;23(6):426–427.
Total Hip Arthroplasty
As discussed above, the first attempt to treat hip arthritis surgically was performed a little over 100 years ago.
The early failure of these endeavors to create an artificial hip, either through poor design, inferior materials, or
mechanical failure, led to subsequent attempts in the 1960s when
we began to see a revolution in the development of total hip arthroplasty implants. Very good long-term results
were found in elderly