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patients with crippling arthritis. Today, young patients present for hip replacement surgery
hoping to restore their quality of life and function.
The hemiarthroplasty of the Judet brothers and the interposition mold arthroplasty of Smith-Petersen gave
surgeons experience with reconstructive hip surgery and stimulated new ideas and directions for improving the
technique and the results. The Judet brothers described their work in 1950 as follows:
“The purpose of this article is to describe a special procedure for arthroplasty of the hip.
The idea of the operation, which we have called ‘resection-reconstruction,’ is excision of
the pathological femoral head and its replacement by an artificial head, made of a
synthetic plastic material, which is firmly fixed to the upper end of the femur. This study is
based on 300 cases, the earliest of which dates back some three and a half years” (192).
The procedure as described in their original article was to gain access to the joint, remove the head of the femur
while preserving the femoral neck, and then pass their prosthesis down the center of the neck, thereby creating
a prosthetic head anchored into the neck. The early results of the surgery were promising, with good pain relief
and improvement in mobility (193). As word spread of these early results, surgeons throughout the world began
adopting the Judet prosthesis as their standard hip arthroplasty technique. In their original paper from 1950, the
Judet brothers reported generally good results with half having excellent function and negligible pain within 2 to 3
months, and the other half having a slower recovery over 6 to 8 months. A follow-up paper in 1952 showed a
similar success rate with good or excellent results in 65% of those undergoing reconstruction for the principle
diagnosis of osteoarthritis. The brothers started writing their book “Resection-Reconstruction of the Hip,” but by
the time the English version was published in 1954, failures had begun to manifest themselves (194).
Judet's hip prosthesis did not follow the concept of low-friction arthroplasty. Nevertheless, this prosthesis
represents an important step in the development of the hip prosthesis currently used.
Themistocles Gluck (195), working in Berlin during the last decade of the 19th century, had demonstrated that
the human body could tolerate large foreign bodies and had designed total knee joints made of ivory, which he
fixed in place with a cement consisting of a mixture of resin and pumice or plaster of Paris. Gluck's work was
based on a long series of animal experiments. His clinical cases were in patients with joints destroyed by
tuberculosis or other serious disease. Gluck (196) was the first researcher to use cement for improved fixation of
both components of an ivory total knee replacement in 1891.
It was not until 1938 that Philip Wiles (197) of London implanted matched acetabular and femoral components
made of stainless steel as hip replacements in six patients with Still disease. The acetabulum was stabilized with
screws and the head component with a stem, side plate, and screws. Then, World War II intervened and after
the war Wiles did not pursue his ideas any further.
With hemiarthroplasties becoming popular for the treatment of intracapsular hip fractures, it was logical to
expand the operation to include an acetabular component. All-metal combinations were introduced by McKee
and Farrar and Ring in England and by Haboush, Urist, and McBride in the United States
(198,199,200,201,202,203,204). Although the use of these prostheses gave surgeons further experience with
what had become known as total hip arthroplasty, the results were not entirely satisfactory because of problems
with loosening of the components and wear between the opposing metal surfaces.
It was John Charnley who led the way in establishing total hip replacement as a useful procedure—one that
could be performed by any well-trained orthopedic surgeon, anywhere in the world. Charnley's method was the
culmination of many years of hard work in the laboratory and in the clinic. Success did not come easily. His life
and work are well presented in the biography by William Waugh (205). His most important intellectual
breakthrough was his concept of the low-friction arthroplasty (206). Previously, all surgeons had substituted
prostheses that were the same size and configuration as normal human anatomy. Charnley greatly reduced the
diameter of the head on the femoral stem to a diameter of 22 mm to improve the frictional torque. Muller et al.
(40) followed suit by introducing a design with a femoral head diameter of 32 mm. Charnley's (207) attention was
called to the possibilities of using methyl methacrylate cement by Leon Wiltsie of Los Angeles, and Charnley
quickly adopted it. After an initial failure with the use of polytetrafluoroethylene (Teflon) as a bearing surface, he
adopted high molecular weight polyethylene, which was satisfactory. With his design, materials, and technique of
the operation in place, the use of the procedure spread quickly everywhere except the United States, where
there was some delay awaiting the approval of the acrylic cement by the Food and Drug Administration. This
time period in the early development of the total hip arthroplasty is highlighted in the “Commentary on the
History of Total Hip Arthroplasty by Dr. William H. Harris” in this chapter.
Charnley (207) was able to popularize the use of methyl methacrylate cement for fixation of total hip prostheses
in the 1950s. Although the chemical composition of the cement has remained the same for many years, there
have been important advances in the cementation technique. Early methods entailed limited, if any, preparation
of the bone bed and femoral canal. Cement was introduced antegrade and little attempt was made at
pressurization with the exception of finger-packing the cement. This technique resulted in poor penetration of the
bone and loosening. An understanding that cement is not a glue, but rather a grout, led to improved techniques.
Fixation is achieved by mechanical interlock rather than adhesion. Contemporary cementation techniques
include cleaning of the endosteal bone with pulsatile lavage, retrograde insertion, and sustained pressurization
to optimize a complete, uniform, interlocking, and reproducible cement mantle. The benefits of these modern
cement techniques have been documented in the Swedish hip registry with very good mid-term and long-term
results (208,209,210,211,212).
Initially, total hip replacement using methyl methacrylate as a bone cement was thought to be a very forgiving
operation. Errors in resecting bone and reaming could be made up by the addition of more cement.
Unfortunately, this led to increased loosening. The operative technique has become more and more exact, and
cementing technique more crucial. Robin Ling pointed out the importance of careful preparation of the bone
surfaces and forcing the cement into the bone by pressure (213,214,215,216). The introduction of low-viscosity
cement improved fixation of arthroplasty components (217,218). William Harris also studied and popularized the
use of improved cementing techniques (219,220).
Charnley (221) was concerned about the fairly high rate of fracture of his first-generation stems. He recognized
the cause being a cantilever bending of a distally well-fixed stem. He found that changing the cross-sectional
geometry and overall dimensions produced a much stiffer stem, leading to different failure mechanisms
(222,223,224). Similar findings along the way showed small changes in the design or finish of the original stems
were associated with substantial effects on their long-term outcomes. Refinements in modern cemented stem
designs that utilize the viscoelastic properties of cement and in conjunction with modern cementing techniques
have delivered excellent mid-term and long-term