The Solution to Weak Knees: A History of the Total Knee Replacement

Nick Brule is a third year student at Grinnell College majoring in Biological Chemistry. Post Grinnell he plans to attend medical school. He is also a member of the men’s soccer team at Grinnell and enjoys solving Rubik’s cubes in his free time.

The total knee replacement is one of the great developments within medicine in the last century. It has allowed people with life-altering osteoarthritis of the knee to return to an active, pain free lifestyle. The total knee replacement was preceded by advancements throughout the history of medicine such as anesthesia and sterile technique. Many of the advancements made with the total knee replacement specifically have been changes in hardware to allow the knee to function in a natural manner. These changes have stemmed from complications with the early knee replacements that needed solutions. This is consistent with how medicine as a whole has progressed. Many developments in medicine have come from treatment that has failed and needed to be changed. The history of the total knee replacement is an example of such a medical development that has developed over time, and produced an effective and life changing treatment through clinical application and reflective analysis.

Surgery as a whole can be traced back to the Roman era when the famous physician Claudius Galen practiced medicine. Galen became a famous physician due to his ability to cure gladiators. He healed lacerations and occasionally straightened broken bones caused from fights. However, Galen was also an academic who studied the anatomy of hogs to gain a better understanding of human anatomy. Ultimately, Galen developed the four humor theory which proposed that bodies consist of four humors: blood, yellow bile, phlegm and black bile. This theory persisted until the mid-1800s when anatomical theory arose.

After the rise of the anatomical era, many surgical advancements occurred that made the development of the total knee replacement possible. One of those advancements was the development of anesthesia. A dentist in Boston named William Morton discovered the sedative properties of ether during 1846. [1] Ether was able to sedate patients for an extended period of time which allowed surgeons to perform painless surgery. This advancement made surgery easier for the surgeon and allowed for longer, more complex procedures. Shortly after, James Simpson discovered the sedative properties of chloroform which became widely used because it was easier to administer than ether. Another advancement was the development of germ theory in the mid-1800s. Physicians were able to prevent infection and the spread of disease simply by washing their hands and using proper sterile techniques.

Besides the major medical and surgical advancements, there were other developments that eventually led to the development of the total knee replacement. The major development was the development of specialization within surgery. During the late 1800s to early 1900s medical knowledge was expanding quickly. This led to specialization within medicine, allowing for more specific skill sets and even greater medical knowledge. One of the specializations that was recognized during that time period was Orthopedics. It was recognized within surgery as a specialty in 1895 and the American Association of Orthopedic Surgeons was established ten years later in 1905. [2] Orthopedics was originally spelled “Orthopaedics” from its Latin roots “orthos” and “paidios”, meaning “straight” and “children” respectively. In the past, some physicians would perform surgery to fix deformed children who had irregular bone structure, giving them knowledge of how to fix fractures and other musculoskeletal complications. Therefore, it was a natural progression to the contemporary field of orthopedics which focuses on bones.

Since orthopedics specializes in bones, it is the specialty tasked with treating bone disease such as osteoarthritis. The total knee replacement is one of the solutions to advanced osteoarthritis of the knee which is defined as the degradation or narrowing of the tibiofemoral joint space. The concept of the total knee replacement was developed around 1880 by a man named Thermestocles Gluck. He proposed an ivory implant that would be cemented to the bone in the knee. Gluck’s ivory implants were ineffective and often resulted in terrible infection however, his idea was novel for the time as it was not until 80 years later that the total knee replacement started to become further developed. It is likely that few developments were made in knee replacement technology during that time period for a couple of reasons. One is the knee is a complex, mechanical unit within the human body. Its movement and weight bearing capabilities are difficult to re-engineer using external materials. Another reason is people were not living long enough for knee replacements to be in high demand. Osteoarthritis typically develops as a result of damage to the knee that occurs over time. However, if people are not living long enough for that damage to accumulate to the point of arthritis then there is no need for a knee replacement. This follows with the advancements in medicine as a whole. As medical knowledge expanded through the early 1900s, physicians were able to cure more diseases and increase the life expectancy of the typical person. With this increased life expectancy came new diseases and conditions such as osteoarthritis. This created the need for a total knee replacement.

The first total knee replacement hardware was developed in 1951. [3] This type of joint was used in knee replacement surgery until around 1970. In the 1970s two approaches to the knee replacement were developed, both that used hardware to resurface the tibiofemoral joint using metal alloy caps and polyethylene inserts to replace the meniscus. The first approach developed in 1970 was the anatomical approach designed by Dr. Sumiki Yamamoto and is named the Duocondylar knee replacement. This approach sought to maintain as much of the normal joint anatomy as possible by retaining the anterior and posterior cruciate ligaments. The other approach was the functional approach developed in 1973 at the Hospital for Special Surgery of New York named the Total Condylar knee replacement. The total condylar “tried to simplify the knee biomechanics by removing both cruciate ligaments” [4].

Both of these approaches had complications. The issue with the anatomical Duocondylar approach was with the function and stability of the ligaments in the knee. Retaining the ligaments allows for natural knee anatomy, but the procedure alters the original knee bone structure which can cause complications with knee durability. The Total Condylar avoided this issue by removing the cruciate ligaments completely. This approach also led to complications, however, as patients did not have full range of motion in their replaced knee. These complications led to further advancement in knee replacement hardware creating the mobile bearing (MB) knee. The MB knee introduced the concept of low contact stress (LCS) which aimed to reduce the amount of weight bearing stress on the polyethylene insert. The MB knee also allowed for greater knee flexion and allowed for axial rotation giving the replaced knee overall more natural movement.

The MB was also not without its complications. During the 1980s around 30% of patients had a complication involving the patella-femoral joint. [5] This led to a debate whether the articulating surface of the patella needed to be replaced and how to do so. It also led to the development of a groove that allowed for easier sliding of the patella and prevented dislocation. Another complication that remains unsolved in current medicine is the life span of the polyethylene insert. The insert for the average knee replacement only lasts approximately 15 years before the material begins to be compromised from wear. However, despite these complications, the MB knee overall has proven to be a success for patients and allows for close to natural movement.

A more recent phenomenon that has developed with knee replacements is the need for bilateral knee replacement. Physicians recently have studied the effects of performing bilateral knee replacements and when they experience complications. Physicians originally thought that younger patients would be better suited to tolerate bilateral knee replacements than more elderly patients, however, the study showed no decline in complications for younger patients. [6] This led physicians to question other aspects of health that may contribute to more risk factors for younger patients such as higher rates of obesity. The complications of the bilateral knee replacement are still an area of study for the knee replacement and likely to become more prominent when risks become more minimized.

The total knee replacement is one medicine’s great achievements as it has allowed for many people with osteoarthritis to live a more active and pain free life. The procedure has been developed by the advancements of medicine through history such as anesthesia. However, the knee replacement is similar to many advancements in medicine as it has been developed through science and engineering, but also through trial and error. That will likely hold true for future advancements to come with the knee replacement and medicine as a whole. Physicians and researchers will have the knowledge to propose a treatment, but the only way to understand the effects is to view the results of the treatment. Therefore, while a procedure such as the total knee replacement seems close to an exact science, future advancements may not be clear. It will take more reflective analysis to determine if the contemporary total knee replacement is the best treatment for osteoarthritis.

Notes:

[1] Richard Hollingham, Blood and Guts: A History of Surgery. New York: St. Martin’s Press, 2008. 61-64.

[2] American Academy of Orthopaedic Surgeons. “Seventy-Five Years of Orthopaedic Surgery.” http://www.aaos75.org/history/

[3] Ibid.

[4] Luca Amendola, Domenico Tigani, Matteo Fosco, and Dante Dallari, History of Condylar Total Knee Arthroplasty, Intech, 2012.

[5] Ibid. 2012.

[6] Memtsoudis, Stavros, M.D., PhD. “Inventing the Modern Total Knee Replacement” Discovery to Recovery (2013): 2, 6.

Further Reading

A.S. Ranawat, A.S. Ranawat, C.S. Ranawat, “The History of Total Knee Arthroplasty” in The Knee Joint: Surgical Techniques and Strategies, edited by Michael Bonnin, Annunziato Amendola, Johan Bellemans, Steven MacDonald, and Jacques Ménétrey 699-707. Paris: Springer-Verlag France, 2012.

Rihard Trebše and Anže Mihelič. “Joint Replacement: Historical Overview” in Infected Total Joint Arthroplasty. London: Springer-Verlag, 2012.

Ponseti, Ignacio V. “History of Orthopedic Surgery” The Iowa Orthopedic Journal 11 (1991): 59-64.