Innovation & Evolution in Hip Replacement Surgery: Highlights from the Keggi–Rubin Hip Implant Collection at Yale University
Hip Reconstruction Before Total Hip Replacement
Over two centuries ago, surgeons began to perform exploratory procedures such as hip resection and various interposition grafting techniques that paved the way for modern partial and total hip arthroplasty. In London, 1822, Anthony White removed a young boy’s diseased femoral head, a procedure which became known as joint excision. A more conservative procedure emerged in the 1860s, when surgeon Auguste Verneuil tried inserting soft materials between the femoral head and acetabulum. His goal was to recreate a cushion that would prevent any further joint damage. Many pioneering surgeons adopted Verneuil’s concept with the use of different materials: gold foil, fat, fascia, and even pig bladder. Though their work was unsuccessful, these attempts inspired many succeeding surgeons. In 1891, German surgeon Themistocle Glück performed the first recorded prosthetic hip replacement by excising a diseased femoral head and replacing it with a device made of elephant ivory secured by nickel plated screws. In an era prior to the discovery and routine use of antibiotics, surgical site infection was a common reason for surgical complication and failure.
An osteotomy is the cutting of the bone to realign it to a natural orientation, a procedure which surgeons have used to reposition the hip joint for functional improvement and pain relief. In 1826, the American surgeon John Barton performed the first femoral shaft osteotomy on a sailor with a deformed, stiff, and painful hip. Later, during the mid-20th century, a variety of upper femoral osteotomies were being used to treat arthritic hips. Osteotomies were performed using simple instruments such as the osteotome, curette, and mallet to shape the bone before fixing its new position with plates, pins, and screws. These procedures improved hip pain and function but were unpredictable and unsatisfactory by modern standards.
Vitallium Cup Mould Arthroplasty
Dr. Marius Nygaard Smith-Petersen first devised the concept of cup arthroplasty in Boston, Massachusetts, during the 1920s. After observing membrane growth around shards of glass embedded in a man’s back, Dr. Smith-Petersen believed that glass could stimulate fibrous tissue growth, which could recreate a smooth contact surface at the joint. In 1923, Dr. Smith-Petersen placed a hemisphere of glass over a patient’s damaged femoral head; unsurprisingly, the glass cup shattered and failed. After a serendipitous visit to his dentist, Dr. Smith- Petersen discovered a new cobalt-chrome-molybdenum alloy called Vitallium, which eventually allowed him to produce a far more durable “cup mould prosthesis” that he first implanted in 1938. As a partial hip replacement, this procedure involved the remodeling of both the femoral head and the acetabular socket and ultimately proved to be surprisingly durable, with reports of 46- to 65-year patient follow-ups.
Early Attempts at Prosthetic Hip
Hemiarthroplasty
Anderson Nylon Arthroplasty
In the 1950s, there was a short-lived attempt to replace the femoral head with a nylon prosthesis. Additional nylon discs could be added to adjust the neck length, as shown on this prosthesis. Ultimately, this failed due to rapid wear of the nylon polymer, and a metal version of this implant ultimately became available.
Judet Vitallium Prosthesis
The Judet brothers of Paris developed acrylic hip implants in the late 1940s and innovated a ball-and-stem design to help reduce the incidence of femoral implant loosening. Their metallic prosthesis featured a femoral head that was fixated via a triflange stem driven into the femoral neck, which, unfortunately, did not provide long-term stability.
Austin Moore Prosthesis
In the 1930s, Dr. Austin Moore of South Carolina worked to address the then “unsolved problem” of hip fractures by designing an uncemented femoral hemiarthroplasty prosthesis with a windowed stem, which he inserted into the femoral canal through the posterior (“Southern”) approach. Ultimately, this prosthesis became the first off-the-shelf body part replacement available worldwide. Dr. Moore admired the prosthesis so much that he had the device welded onto the hood of his 1951 Chrysler Imperial convertible!
Thompson Prosthesis
This vitallium femoral implant was designed by Dr. Frederick Thompson of New York and was first implanted in the 1950s. The ball-and-stem concept was similar to the Austin Moore Prosthesis, but Thompson later relied on bone cement to create stable fixation in the femoral canal, which proved to be a more durable implant construct, especially in the weak osteopenic bone of older patients with femoral neck fractures. This implant continues to be used in many parts of the world today.
Case 1 photograph of physical exhibition in Cushing Rotunda, Cushing/Whitney Medical Library- Hip Reconstruction Before Total Hip Replacement