One Hip Doctor

Sir John Charnley, MD

charnley_b09678_optDue to the omnipresent and disabling nature of arthritis of the hip socket, surgeons have been searching for more than a century to find a satisfactory solution to this debilitating and painful condition. Early attempts to treat arthritic hips included arthrodesis or fusion of the joint, which often relieved the pain but left the patient with a stiff, unusable joint that was better suited to sitting or standing, but rarely both.  Other efforts included osteotomies, nerve division, or joint débridements to remove arthritic spurs, calcium deposits, and irregular cartilage in an attempt to smooth the surfaces of the joint. Early in the last century there was a widespread search for some material that could be used to resurface or even replace the hip. Surgeons tried pig bladder, gold, magnesium, and Pyrex. All met with failure. Surgeons and scientists were unable to find a material that was biocompatible with the body and yet strong enough to withstand the tremendous forces placed on the hip joint.

In 1925, an orthopaedic surgeon, Marius Smith-Petersen, MD, molded a piece of glass into the shape of a hollow hemisphere which could fit over the ball of the hip joint and provide a smooth new surface for movement. charnley_71020001_optWhile proving biocompatible, the glass could not withstand the stress of walking and failed quickly. Undaunted, he pursued other materials for his “mold arthroplasty,” including plastic and stainless steel.  During the 1940s, mold arthroplasty was “state of the art.”

A dramatic improvement was made in 1936 when metallurgists Charles Venable and Walter Stuck manufactured a cobalt-chromium alloy, later named vitallium; it was almost immediately applied to orthopaedics. This new alloy was both very strong and resistant to corrosion, and has continued to be used in various prostheses since that time. While this new metal proved to be a great success, the actual resurfacing technique was found to be less than adequate. It became clear that pain relief was not as predictable as hoped, and hip movement remained limited for many patients. The search for different types of prostheses continued.

charnley_ads3_optIn 1942, orthopaedic pioneer Austin T. Moore, MD, of South Carolina, developed replacements for the entire ball of the hip. These could be used to treat hip fractures and also certain arthritis cases. This type of hip replacement, called hemiarthroplasty, only addressed the problem of the arthritic femoral head (the ball). The diseased acetabulum (hip socket) was not replaced. The prosthesis consisted of a metal stem that was placed into the marrow cavity of the femur, connected in one piece with a metal ball that fit into the hip socket. While very popular in the 1950s, results remained unpredictable and arthritic destruction of the socket persisted. In addition, there was no truly effective method of securing the component to the bone. Large numbers of patients developed pain because of this loosening of the implant. The desired result was still not achieved.

As early as 1938, the Judet brothers of Paris attempted to use an acrylic material to replace arthritic hip surfaces. This acrylic provided a smooth surface, but unfortunately tended to come loose. charnley_ads2_optHowever, the challenge of fixing the socket was solved quickly when surgeons borrowed methylmethacrylate, a dental material, from their dental brethren. A new total solution for the chronic decay of the hip socket was growing near.

In England, a very innovative surgeon, John Charnley, MD, was also attempting to solve these ongoing problems. Boston orthopaedic surgeon, William Harris, MD, remembers Charnley as “the most innovative orthopaedic surgeon ever. He had incredible drive, remarkable persistence, and great imagination.” Charnley built a lab of unparalleled sophistication at an isolated former tuberculosis sanatorium that had been converted to a makeshift hospital at Wrightington, Manchester, England, and it became a wellspring of knowledge for the surgical treatment of arthritis. Perhaps as noteworthy, but often overlooked, it was Dr. John Charnley who developed the concept of laminar air flow to eradicate a systemic infection problem in his hospital. Dr. Charnley aggressively pursued effective methods of replacing both the femoral head and acetabulum of the hip. charnley_71020003_optIn 1958, he proposed replacing the eroded arthritic socket with a Teflon implant, but the Teflon proved to be too soft. “Unwrapping the problem as biological was significant. He realized he needed better materials because submicron particles were causing the problem,” recalls Dr. Harris. Leonard Marmor, MD, recounts that “he went back to all 200 patients and replaced the plastic. He was an extraordinarily motivated man, intensely dedicated, and he had an utter belief in the words of Winston Churchill, ‘Success consists of going from failure to failure without losing enthusiasm.’ He would not let his failure get in his way.”

And he was lucky, too. Marmor remembers, “Charnley was visited by a plastic salesman who understood neither the questions nor the answers that Charnley was discussing with him and Charnley threw him out. But his technician spoke to the salesman and told him he would test the plastic without Charnley’s knowledge. There are probably 10 million replacements today using that material.” This worked wonderfully well. Truly this was the birth of “total hip replacement.”

charnley_Girdlestone.008smaller_optBy 1961, Dr. Charnley was performing the surgery regularly with good results. He further improved the techniques and component designs. Thousands of people were successfully relieved of their hip pain, and the long-term results became very predictable. Recalls Dr. Marmor, “Surgeons would write to him from all over the world and he would schedule them. In the early years, he insisted that he train you personally in his technique so he was sure you got it right. The Queen of England knighted him for his immense contributions.” Today over 238,000 hip replacements are performed annually in the United States using the principles of a low-friction arthroplasty with a polyethylene socket and metal femoral prosthesis. Marmor explains, “The total hip operation is one of the most effective operations ever developed and the bulk of it is his work.”

Photo Credits
Photo of Sir John Charnley, MD, National Library of Medicine
Photo of Wrightington Hospital, courtesy Jules S. Shapiro, MD
Photo of Charnley prosthesis advertisement, courtesy Journal of Bone and Joint Surgery
Photo of an advertisement for Charnley Hip prosthesis, courtesy Journal of Bone and Joint Surgery
Photo of operating room at Wrightington Hospital, courtesy Jules S. Shapiro, MD
Photo of girdlestone hip x-ray, courtesy James Hamilton, MD