I had the good fortune of assisting and observing Mr MAR FREEMAN operate and he is probably the slickest surgeon I’ve seen. He did his knees in under half an hour. Apart from being a neat and super fast accurate surgeon, he was also a great scientist and designer. His knees are doing well even after 25 years.
His greatest contribution is to knee instrumentation. His original simple instruments form the basis of all subsequent TKR instruments. I’m fortunate to have received a set from Freeman himself, which is probably now a part of history. I’m posting the photos of the set
THESE WILL BE DONATED TO THE IOA ORTHOPAEDIC MUSEUM
The history of Total Hip replacements continued.
More implants from my collection. The Judet Acrylic hip was one of the earliest hips to be implanted. These hips developed an acrylic Squeak and showed rapid wear. Smith Peterson’s Cap was a polished cap for femoral head. McKee Farar was the earliest cemented metal on metal hip. And finally the Ring’s cementless metal on metal hip. A revolutionary concept, far ahead of its time, with surprisingly good long term results in more than 70% of cases. These designs have laid the foundation stones to the modern architecture of arthroplasty.
Today I just realized the pleasures of combining two specialties, art and orthopaedics. Over the past years I have been doing art and was trying to copy the simplified line drawings style of Dr B.D.Chaurasia my beloved teacher and mentor. Today I finished my chapter on tibial non unions in the ILIZAROV BOOK, I’m writing. I decided to draw simple representative line drawings. I allocated fifteen minutes per drawing and did 17 in four hours!! (Its beside the point that I missed my lunch). Here I post my quick drawings along with my nonunion classification. The illustrations are unlabelled, and you have to figure it out for yourself. I promise you, it’ll be fun!!
If the union of a fracture is delayed to such an extent that it will not unite without surgical invention, then it is called a non- union. This definition propounded over the last century has been accepted as the norm. However there are certain grey areas. A delay in consolidation for periods beyond the surgeon’s and patient’s patience is also termed as a non union.
CLASSIFICATION OF NON-UNIONS
Based on the local condition of the fracture, non-unions can broadly be classified into two types, hypertrophic and atrophic non-unions. Either of these may be associated with infection, sequestrum, or deformity.
According to Ilizarov there are two broad types of non-union; a stiff non-union and a mobile non-union. The stiff non-unions are hypertrophic on X-ray and the local vascularity is not compromised. This can be converted into union by eliminating shear stresses and augmenting compression distraction stresses.
A mobile non-union showing atrophy in an X-ray will need a proximal corticotomy for bone stimulation and a compression on the non-union site to lead to consolidation.
Catagni of the ASAMI has evolved a classification based on treatment parameters. His classification is divided into two groups, one classifying the non union situations and the other describing the treatment modalities.
I have simplified Catagni’s classification, and this was published in the earlier edition of my book. Here I attempted to do a functional classification, where the non union type will decide how it would be treated. In this I have divided the non unions into two types, infected and infection free. One is atrophic, two and three hypertrophic and four to six have bone gaps. The Prakash Classification is described here
Type A non unions are those without infection. Here the aim of treatment is fracture union alone.
A1 – Non-infected mobile non union. This needs a corticotomy distraction associated with fracture compression.
A2 – Non-infected stiff hypertrophic non union without deformity. This requires primary distraction followed by compression
A3 – Hypertrophic non-infected non union with deformity. This needs primary distraction and secondary compression along with deformity correction. The deformity can be corrected either with hinges, transverse wires or olive wires.
A4- Non-infective non-union with bone defect of up to 5 cm. This will require a corticotomy, a bifocal expansion followed by compression of the non-union
A5 – Non-infective non-union with bone defect exceeding 5 cm. In this case a corticotomy, bone transport and the fracture compression is needed. Occasionally to accelerate the healing time, a two level corticotomy may be done.
A6 – Non-infected non-union exceeding 10 cm with local scarring. Due to extensive bone loss and local scarring it is not possible to do the bone transport using transverse wires. Here crossed olive wires are used to increase the surface.
Type B non unions are those with infection. The basic principles are essentially the same as with Type A but to eliminate infection, it is best if the fracture site is opened, all the dead and devitalized tissue removed, sequestrectomy performed and the frame applied.
B1 – Infected non-union with atrophy
B2 – Infected non-union with hypertrophy without deformity
B3 – Infected non-union with hypertrophy and deformity
In the above three situations the fracture is exposed, unhealthy bone resected and the two fragments are opposed with compression. Existing deformities are corrected taking minimal bone wedges. The resultant shortening is invariably less than 5 centimeters and a corticotomy distraction produces elongation.
B4 – Infected non-union with bone gap of less than 5 cm
B5 -Infected non-union with bone gap between 5 and 10 cm
B6 – Infected non-union with bone gap exceeding 10 cm.
These are complex problems and tax the ingenuity of most surgeons. Each case has to be individually assessed and specific treatment protocol planned. Judicious use of olive wires, hinges, posts, corticotomy, monofocal distraction, bifocal distraction, and compression are deployed to achieve results. Details of specific applications are covered into respective chapters.
This cemented versus cementless debate has finally made me open up. I apologize in advance for my storybook type of rendering. I also make a disclaimer that I have not done more than two digit cementless hip to date, though I have revised a sizable number.
Four unrelated events happened which stimulated me to write this post. When I resumed orthopaedic practice after a 13 year break, it was natural that my old THR patients would come back to me for follow up. (Of course I took the trouble of writing, calling, locating and getting them back for follow up.). In those times I did a Charnley 22mm head all cemented hips. I found a good number doing really well at two decades. Many of them refused to come to my clinic as they were entirely asymptomatic. The second event happened during the last few days when I suddenly started getting messages from orthopaedic colleagues about my cementation technique, especially surgeons who had attempted removal of femoral components cemented by me and had ended up shattering femurs. In the last seven months, I have revised a few cementless hips, and in two cases I found that the bone had ingrown so well into the stem, that removal left an extremely egg shell femur. One I even cracked and had to wire. And then today happened the fourth event. The post in this group, Anuj propagating cementless acetabular components, and people questioning the value of cement in orthopaedics.
The questions that came to my mind were the following
1, Which lasts longer? Cemented or cementless? Both for femur and acetabulum!!
2, Which is easier to revise?
3, Duration of surgery in both primary and revision, cemented and cementless.
4, Is the use of a cementless joint justified under any condition?? Or the corollary, what are the absolute indications for a cemented joint replacement!
Am I the right man to answer this question? Probably not. But am I the orthopaedic surgeon who has used handled and played with the maximum amount of PMMA acrylic? YES I CERTAINLY AM. A pack of bone cement is 40 grams, and if you have done a thousand joints, you would have probably handled (not actually used; as 60% of cement is wasted), fifty kilograms. The bust sculpture photo attached here is 80 kg. In my life as an artist and sculptor, I have used over 800 kilos of poly methyl metha acralate, and have learnt a lot about its properties. I love cement, its smell and what it does.
Having established my credentials, let me attempt to answer the questions from my point of my point of view, certain EBM5 Anecdotal stuff, but I promise to make it interesting.
There are no conclusive studies to prove that cementless fixation is superior to cemented fixation by analysis of any joint registries in the world. Publications appear to be biased towards the type of implant the author likes more.
Cemented hips have been with us for eleven years longer than cementless, and consequently, to date, individual cases of longest survival are naturally cemented rather than cementless.
Occasionally cementless hips are a little more difficult to revise than cemented ones. Likewise cementation does not significantly add to operative time. I have never seen an anterior thigh pain in a cemented hip. And cemented hips are not always difficult to revise. You need the right cement removal instruments.
Bad cementation technique causes problems. Not cement per se. Let us not be biased towards cement, because it is a foreign body. After all even the prosthesis is!!
The following points about bone cement may help us to understand and use it better. A lot of this information is gathered from non orthopaedic situations where PMMA acrylic resin is used in large quantities.
1,Acrylic cement is not a glue or adhesive. It is more like a filler or grout. Epoxy resins and Polyester resins bind far better than acrylic.
2, Normally polymer powder to monomer liquid ratio is 2:1 w/v, but by modifying this proportion, setting times can be altered dramatically. A 1:1 mix provides prolonged setting time, as does lower room temperature or chilling before mixing.
3, Additives to powder quicken the setting time and also modify setting behaviour quickening the liquid phase, while hardening time remains more or less the same. Consequently Gentamycin loaded cement is less desirable for cementation.
4, A clean dry porous surface allows cement to “get inside” the cancellous areas and anchor holes, allowing a more uniform distribution of stresses and a better grouting, naturally leading to a longer life of the cementation.
These are the tricks I have followed which has helped my cemented to hips last so long that I find no reason to switch over to uncemented hips.
A, Keep surfaces clean and dry. As clean and as dry as possible.
B, Inject liquid cement under pressure. More liquid, greater the pressure, better.
C, Don’t hammer the implant in. Hammering only makes the ductile cement push back the prosthesis. Each blow weakens the grout. Sustained manual pressure is applied on the impactor/ positioner, till elbow and shoulder hurts. This is an important trick!
D, A meticulous removal of all overhanging and loose cement debris is essential to prevent particulate debris wear.
In conclusion, don’t be afraid to use cement, only use it properly. And hope you enjoy the pictures.
From Kodama Yamonoito, to the current knees, Townley, Mcintosh buttons, Freemans genius, Waldius hinges, Shiers PCL sacrifycing, anatomic, and single radius knees. These are some implants from my collection. I’m on the 7th chapter of the book on TKR and am still collecting more specimens and pictures of rare TKR implants. Im sure orthopods will identify all designs if they are keen on knees.
I keep being asked this question frequently. WHAT IS THE ROLE OF ILIZAROV IN CLOSED FRESH FRACTURES? I have excerped from my forthcoming Ilizarov book, the following chapter.
Ilizarov fixator in primary closed fractures:
There are two extremes to the above subject. At one end, are those surgeons who believe that there is no place for Ilizarov in primary treatment of fractures, while at the other end are those who find applications of this system in most fractures. If you are a student or practitioner of this fascinating science and art, you should tread the middle path, just as I do. Ilizarov is not routinely indicated as a primary treatment for closed fractures, but there are certain fractures and injuries that are best managed by application of an Ilizarov fixator.
With my thirty year experience in this system, I have found out that the following fractures really do well with Ilizarov:
1, Comminuted, displaced, or complex (bag of bones) fractures around the wrist.
2, Multi-segmental comminuted fractures of long bones where accurate open reduction is a challenge.
3, Intra-articular fractures around knee
Apart from these, an Ilizarov can be applied to practically every fracture, because it would provide a more comfortable immobilization than a plaster, and match all internal fixation devices in stability and dynamism of immobilization. However compared to the fix and forget approach of plates or nails, as an Ilizarov system needs constant monitoring by the surgeon, and demands compliance of a bulky alien object protruding from the patient’s body, its use should be selective and appropriate.
Comminuted, displaced, or complex fractures around wrist:
The following fractures can be treated with excellent results.
1, Displaced Colle’s fracture.
2, Displaced or unstable Smith’s fracture
3, A dorsal or volar Barton’s fracture
4, Radial styloid fracture with wrist subluxation.
The following radiographs show the various conditions that can be treated with excellent results with Ilizarov methods.
The principles are fairly straightforward. It’s called LIGAMENTOTAXIS and involves transfixing bones on either side of the fracture, and distracting them in the correct direction, until the fracture falls in place. If any additional fragment remains splayed or displaced, it is quite an easy matter to pull it in the correct direction, with an appropriately placed olive wire.
Ligamentotaxis is based on the sound scientific principle that the ligaments that bind the joint are most often stronger than the bones they anchor. Thus dislocations are rarer than fractures in and around joints. Under such situations, with intact ligaments, just pulling apart the fragments should automatically align the fragments.
However the most important aspect of this procedure is to achieve precise and perfect reduction in all three planes. Radiographs are seen only in two dimensions; AP and Lateral. The rotational element has to be usually imagined. It is essential to remember this during placement of pins so that appropriate hinges in all axes, can produce as precise a reduction as desired.
Though each of the above mentioned fracture happens by a different mechanism and produces a different displacement in the three axes, the principles of treatment remain the same. An accurate reduction and stable immobilization.
The Rings should be placed with the following considerations in mind
1, They should not be too close, or too distant from the fracture site. Ideally the two rings should be 10cm proximal or distal to the fracture giving a 20 cm span for the assembly.
2, As far as possible, the two rings should be equidistant from the fracture to allow a balanced application of forces.
3, The hinges are placed at the fracture level and not the joint level, because more than early wrist mobilization, our aim is to get the reduction right in three dimensions and retain it in a stable position for three to four weeks until the fracture becomes stable and sticky.
4, In fresh fractures, the easier method is to first perform a reasonable reduction, even accurate if possible by closed means and then apply the fixator with a full regard to biomechanical positions, so that adjustments can be done when needed.
In all these cases the following points are very important.
1. The limb has to be pulled out to the correct length. One must take accurate pre operative measurements of the opposite limb, and using flexible scales or an autoclaved wire coil and a stiff steel scale, measure the limb intra-operatively, to ensure that it is exactly the same size.
2. It is essential to remember the bony landmarks and the correlation of the joints above and below, to ensure that there is no mal-rotation. For lower limb, an imaginary line starting from the inguinal region at the femoral artery, representing the head of femur, passes over the center of patella, crosses the tibial tuberosity and touches the second toe.
3. In the upper limb, with the wrist in supination and elbow in extension, the elbow is in 6 to 8 degrees valgus, and the two lines of this angle begin from head of humerus proximally, and the second finger and center of wrist distally. These lines join in the middle of the elbow.
4. The proximal ring should lie 7 to 10 cm beyond the upper limit of the fracture, while the distal ring should be an equal distance below the lowest fracture.
5. Hinges should be applied at the joint level, though in the initial stages, these hinges are bolted tight and remain static hinges. After a few weeks when the fracture becomes sticky, mobilization can begin at the hinges gradually.
6. Olive wires are judiciously used to pull together fragments, compress a butterfly, and bring close a displaced obliquity.
7. Additional procedures like corticotomy or bone grafting are seldom needed if a fracture is primarily managed with Ilizarov apparatus.
METAL ON METAL HIP REPLACEMENTS
THE MAGIC OF KEN MCKEE
The following photos from my implant collection show the design and details of the McKee-Farar, cemented metal on metal hips. Though these are no longer used, the surprising fact that quite a few of these hips lasted for twenty-five years plus, lead to the re-emergence of interest in metal on metal hips with larger heads. This post is again Orthopaedic history, about the man and his machine!!!
Ken McKee was born on 5 January 1906 and educated at Chigwell School before winning a scholarship to the Medical School at St Bartholomew’s Hospital. After qualifying he held house surgeon appointments at Bart’s and also at Chailey Heritage, where he was influenced by Elmslie, Higgs and Brockman, and this was the stimulus for his chosen career in orthopaedic surgery. His subsequent training included registrar posts in Sheffield and the Norfolk and Norwich Hospital. He obtained the FRCS in 1934 and joined H A Brittain on the staff as a consultant at the Norfolk and Norwich Hospital in 1939. Orthopedic surgery proved to be a fertile field for a man who was fascinated by all things mechanical. His early interest in taking motorcycles and cars to pieces prepared him for an outstandingly inventive career. He himself admitted that “replacing worn joints was a fairly obvious treatment to me.” Throughout the 1940s and 1950s he pursued his goal of hip replacement with little encouragement from his more conservative and sceptical peers. Their comments of the time were recorded by McKee: “£200 is very expensive for an operation that is doomed to failure” and “prosthetic arthroplasty should be reserved for the over 90s.”
In later years he would often recall, with a twinkle in his eye, the eminent questioner at a Royal Society of Medicine meeting of 1957, who asked “where do you put the grease nipple?” McKee noted but disregarded the hoots of laughter that followed. His first models had been made up in brass in 1940, but he delayed putting his ideas into practice until chrome–cobalt alloys became available. He presented his first cases of total hip replacement in a clinical demonstration at the British Orthopedic Association meeting in Cambridge in 1951. At this time, the management of unilateral hip arthritis was highly controversial.
H.A. Brittain, from whom McKee had remained distant, had published two editions of his book The Architectural Principles of Arthrodesis, and Watson-Jones was another proponent of hip fusion. Indeed, in 1948, McKee had invented his own variant of hip fusion using a lag screw and was pleased that the fixation eliminated the need for plaster of Paris. He continued to be committed to total replacement and in 1953 he visited F.R. Thompson in the USA and adopted the Thompson stem for his femoral component, using this in articulation with his chrome–cobalt cloverleaf socket until 1960. He reported a 50% failure rate of this combination in the short term. McKee’s confidence in total joint replacement was not shared by others: even John Charnley was uncertain as late as 1957 and still advocated hip fusion.
John Charnley first used acrylic cement to fix a femoral prosthesis in 1958, and in 1960 he published his findings in The Journal of Bone and Joint Surgery. This was recognized by McKee as the breakthrough he was looking for. With his registrar, John Watson-Farrar, McKee conceived the metal-on-metal cemented hip joint, but unlike Charnley he did not restrict the use of his invention. Metal debris and impingement were major problems and these were addressed by redesign of the Thompson component and by making the femoral head slightly smaller than the socket to diminish equatorial wear. McKee recognized Charnley’s brilliant scientific and engineering skills but was always concerned about wear of high-density polyethylene and unimpressed by Charnley’s laboratory studies of friction. Ken McKee was pleased to know that orthopedic surgeons and engineers were, in 1991, taking a second look at metal-on-metal articulations. McKee’s mechanical aptitude was not limited to total hip replacement. His interventionist approach to fracture treatment led to the use in 1941 of his own intramedullary nail for femoral fractures; A.R. Hodgson was his registrar at the time. A trifin nail and plate was developed for trochanteric fractures, and an external fixator incorporated in a Thomas splint was his novel way of treating tibial fractures. McKee also favored plate fixation for closed tibial fractures and even some open ones. He reported the use of molded plastic corsets for spinal pain and, in the wake of his hip replacement, he designed hinged prostheses for the elbow and the knee. He even experimented with acrylic cement as a replacement for intervertebral discs.
Ken McKee, though a bold and adventurous surgeon, was a quiet and discreet man, who found public speaking neither easy nor agreeable. His conversation was of cars, golf, skiing and sailing rather than orthopedics. Ken was not an inspiring orator, and did not readily enjoy the challenge. He was a quiet man, full of brilliant ideas, some of which were before their time.
This post is dedicated to Kenneth McKee, one of the fathers of modern hip replacement.
The year was 1988. I had an opportunity of spending a few precious weeks with Professor Maurice Muller. (He even invited me home for dinner!!). I had completed a spell in the revision unit of Wrightington Hospital, the Mecca of hip replacements and Charnley’s area of operation. I was passionate about orthopaedics, mad about biomechanics and keen on learning. Muller and I hit on well and he personally showed me his biomechanical laboratory, his experiments and took me on a conducted tour of Protek factory. (This later helped me to build India’s first joint replacement manufacturing factory in 1992, but that’s incidental).
He told me a lot of things that you would probably not find either in JBJS or Wikepedia. I asked a thousand stupid questions, which he patiently answered, though he was a short tempered surgeon. I assisted him in his private hip operations in a fancy clinic and found his technique a striking contrast from the Wrightington methods. He was a quick surgeon, made large incisions, never bothered about bleeding and did things by eye balling, rather than by instruments. (About Charnley’s techniques, ill narrate in another post).
And here is the story of his hips and their evolution. Impressed by Charnley’s work, Muller visited him in 1960. In those times, Chas F Thackeray, who made Charnley hips were allowed to sell them only to those surgeons who trained in Wrightington and learned the technique. If you bought 50 hips and cups, the instrumentation was free. Muller got his sets, began operating and got spectacular success, except for a small problem. 3 of his first 20 hips dislocated and because of component malposition, had to be revised.
Muller wanted a more forgiving system, and tried to analyze the reasons for dislocation. He finally narrowed it to three factors. The small head size, incorrect stem version, and a varus position of stem. He thus devised a Charnley Muller Hip, with a head size 30mm and a banana stem. Being the scientist he was, he constantly improved and modified his designs, till he got to the straight stem, later copied as CORAIL and now the most popular design in the world. I’m lucky to have original implants of the whole series, which I’m posting below. You will see a Charnley copy, becoming a banana stem for valgus position, an addition of calcar for better version orientation, head sizes moving from 26, 30 and finally to 32. Material moving from Stainless steel, to cobalt chrome to titanium. You will also see that he had already made ceramic heads in 1988.
I DEDICATE THIS POST TO MAURICE MULLER, ONE OF THE FATHERS OF HIP REPLACEMENTS.