1. Current Orthopaedics (2003) 17, 322--325
2003 Elsevier Ltd. All rights reserved.
c
doi:10.1016/S0268 - 0890(03)00093- 8
ORTHOPAEDIC HISTORY
The evolution of total knee arthroplasty. Part1:
introduction and first steps
A. A. Shetty, A. Tindall, P Ting and F. W Heatley
. .
12 Farington House, 22 Gloucester Street, Pimlico, London SW1V 2DN, UK
KEYWORDS
history; development; knee
arthroplasty/replacement
INTRODUCTION grace, re-emerged and converged in the past. By know-
ing how we have arrived at today’s prostheses, we can
Total knee replacements are now performed routinely better hope to understand future developments and
all over the world. This series of articles provides a evaluate future designs and modifications.
glimpse of the important stages in the development of
the ‘modern’ arthroplasty, giving a historical perspective
on a procedure that has now become a successful stan- EARL DA
Y YS
dard operation. Although most of the arthroplasties and
surgical techniques described here are no longer in use, The Parisian, Jules P’eau (1830 --1898), defined an arthro-
one occasionally still sees patients with such prostheses plasty as ‘the creation of an artificial joint for the purpose of
in situ. restoring motion’. At the turn of the 19th century, ap-
If you had taken an opinion poll amongst the leading proaches to the problem of arthritic joints were idiosyn-
post World War II orthopaedic surgeons, the vast major- cratic and based purely on individual experience with
ity would have doubted whether knee arthroplasty little research or scientific evidence. Although the results
would ever have become a viable operation. A delightful were poor when compared to our ‘modern’ techniques,
story is told about Fairbanks senior, one of the original patient satisfaction could often be surprisingly high. This
‘Bart’s’ surgeons in London. In his latter years, he was was doubtless partly due to the lack of surgical alterna-
afflicted with deafness and his hearing aid was powered tives that were available.
by a large portable battery. Whenever knee replacement In the past, severe degenerative disease of the knee
was mentioned, there would be a loud click as Fairbanks was frequently treated by arthrodesis. The disability re-
turned off the battery to conserve electrical energy and sulting from the loss of movement was clearly sum-
brain power! marised by the first editor of the British Journal of
These articles will not just trace the history but also Bone and Joint Surgery, Sir Reginald Watson-Jones of the
emphasise the principles underpinning this remarkable London Hospital who wrote in 1949: ‘Arthrodesis of
epic that is truly an orthopaedic triumph. The story of the knee joint causes obvious stiffening which cannot be
course is still unfolding and as surgery and technology concealed. No neighboring joint is available to take
advance, so there may be a swing back to concepts that over function and the disability is indeed very great.
seem to have been discarded or sidelined.The emergence I have known patients to say that they would prefer
of the unicondylar replacement is a classic example and amputation and an artificial limb to constant stiffness
also a particular delight to the senior author, who, as of the knee joint. If ever there was an indication for
a registrar was taught the ‘new’ technique by Frank arthroplasty in a weight bearing joint it would be in the
Gunston and later for several years did the bicompart- knee.1 ’
mental Oxford. Sometimes, there is a tendency to Today, most knee replacements are performed for
discard techniques too quickly. We have shown how relief from the symptoms of osteoarthritis, a condition
many ideas and concepts have emerged, fallen from which was poorly understood and often ignored in
the early days of orthopaedic surgery. For example,
Correspondence to: AT at alistair___tindall@hotmail.com in Whitman’s standard ‘Textbook of Orthopaedics’ in

2. THE EVOLUTION OF TOTALKNEE ARTHROPLASTY 323
the 19th century, only one of the 650 pages was devoted As recently as1958 Brown, McGaw and Shaw were using
to osteoarthritis.2 flaps of skin interposed in a similar manner with surpris-
This review describes the development of alternatives ingly good results.11
to knee arthrodesis, with the aim of restoring movement The problems associated with these attempts at joint
whilst still relieving pain and maintaining stability. The reconstruction with soft tissue were shortening, infec-
concept of soft tissue arthroplasty dominated the surgi- tion, an inflammatory response and reankylosis. As a
cal thinking on reconstruction of the knee for the first result, surgeons began to investigate the use of other
third of the 20th century. The middle third was the era materials, including plastic and metal. Vitallium (the
of metal interposition and the large uniaxial metal hinges. Howmedica trademark for cobalt-chrome) was first
Only in the latter third of the century did the principles used by Venables and Stuck in 1938. It had excellent wear
that underlie modern replacement gradually emerge. properties and did not corrode. This heralded a funda-
mental change in technology, whereby the pre-1938 era
of biological implants moved into the post-1938 era
of metallic prostheses and the age of interpositional
INTERPOSITION ARTHROPLASTY arthroplasty gradually faded out. This is an example of
In 1826, Barton attempted one of the first simple resec- metallurgic technology being incorporated into early
tions of an ankylosed joint with some initial success.3 orthopaedic biomaterial design. This process is still
However, the patient later suffered reankylosis and ongoing, with the development of such materials as
shortening of the limb. It must be remembered that in stainless steel 316L, cobalt alloy F75 and titanium alloys.
the early 19th century, arthritis was still very poorly de- In the early 1940s, surgeons were beginning to report
fined and we cannot be sure exactly what disease Barton success with the use of vitallium cups in total hip replace-
was treating. It was not until 35 years later, in 1861, that ments. Willis Campbell12 and Smith-Petersen13 applied
Ferguson reported the first successful case of soft tissue this concept to the knee, and used vitallium plates for
interposition knee arthroplasty in the Medical Times.4 an interpositional arthroplasty. Smith-Petersen’s pros-
Five years after the operation, the patient had, what thesis actually capped the distal femur and was one of
was described as, ‘a useful limb’. This produced much in- the first steps on the way to a distal femoral hemiarthro-
terest and established the fundamental knowledge that plasty Fig. 1. Plastics also came into vogue in the late
interposition of soft tissue and foreign material could 1940s. Samson, using fascia lata interposed between the
prevent ankylosis. bone ends, reported good results in 26 of the 47 patients
Independently, in 1860, the French surgeon Aristide treated.14 Amongst these he mentions three cases where
Verneuil (1823--1895) demonstrated that interposition he used sheets of cellophane instead of fascia lata. All
of soft tissue could prevent reankylosis following resec- three cases failed due to the cellophane being discharged
tion of the temporo-mandibular joint.5 This principle spontaneously, or creating a major tissue reaction. Kuhn
was again adopted four decades later in the early 1900s. and Potter tried nylon,15 whilst Taylor experimented
Surgeons interposed autogenous (and later animal) soft with Fluon. Once again, orthopaedics was flirting with
tissue between the bone ends. John B.Murphy of Chicago biomaterials on an ad hoc basis. Often the honeymoon
(1857--1916) in1910 used medial and lateral autogenous tis- was rather brief! Well-conducted studies into the wear
sue flaps sutured between the joint surfaces to prevent properties were few and far between and did not really
bony ankylosis.6 commence until the age of modern hip replacement in
In 1918 William Stevenson Baer of Johns Hopkins Uni- the 1970s.
versity published a series of 28 cases of interpositional
arthroplasty of the knee.7 He used a piece of pig’s bladder
that he had tanned by soaking in potassium chromate
(cross-linking the collagen fibres). He reported 15 ‘good’
results; a 54% success rate. However, the criteria used
for a good result were not as stringent as those used in
the present day.
In 1920, Putti (one of the giants of early orthopaedics
who first described the developmental nature of hip dys-
plasia in neonates) working at the Rizzoli Institute in
Bologna, reported his results from interposing tensor
fascia lata in the knee.8 Other materials, including pre-
patellar bursae9 were also used to create an interposi-
tional arthroplasty of the damaged joint. In 1928 Albee
published a series of 10 cases where he had interposed
fascia lata and fat, with a ‘good result’ in nine patients.10 Figure 1 The Smith-Petersen femoral hemiarthroplasty.

3. 324 CURRENT ORTHOPAEDICS
TIBIAL HEMI-ARTHROPLASTY the inferior surface in an attempt to increase stability
(Fig. 3).
Themistocles Gluck (1853--1942) (who was the assistant These early attempts at arthroplasty, although simple
to Bernhard Langenbeck) published a paper on ‘Autop- in design and concept, provided the basis for today’s uni-
lasty - Transplantation -Implantation of Foreign Bodies’ compartmental knee replacements. They were able to
in 1894. He described the use of an ivory cup with an in- correct for a valgus or varus deformity with minimal
tramedullary peg inserted into the tibia to produce a bone loss during their implantation. They also kept the
hemi-arthroplasty of the knee.16 soft tissue balance of the knee by not sacrificing the col-
However, apart from the one-off genius of Gluck, the lateral ligaments, a concept whose importance would
concept of tibial replacement did not emerge until the have to be rediscovered for the condylar replacements.
1950s with the advent of the new materials referred to
in the first part of this series. Although they may not
have recognised it at the time, surgeons were starting FEMORAL HEMI-ARTHROPLASTY
to address the problem of fixation. The femur would be
cappedFthe ‘bowler-hat approach’, whilst the tibia The work by Willis Campbell in 1940 using a metallic hip
would be slottedFthe ‘marquetry approach’. The first implant, and the fact that it was well tolerated, started a
of the tibial pioneers was a German surgeon appropri- new era in the use of foreign materials as implants. He re-
ately named Marquardt. In 1950 he reported his results ported the use of a vitallium interposition femoral mould.
using steel,17 and soon de Palma18 was reporting the use Initial results were apparently good but Campbell aban-
of tibial hemi-arthroplasty prostheses made from acrylic. doned the procedure after only four cases.12 As previously
The choice of material reverted back to metals again mentioned, in the 1940s, Smith-Petersen of Boston, Mas-
when in 1966 Macintosh19,20 fromToronto used a metallic sachusetts, USA, the pioneer of hip interposition arthro-
tibial surface implant, (Fig. 2), instead of the acrylic pros- plasty, not surprisingly tried capping the distal end of the
thesis devised by Kier and Murk Jansen of Denmark. femur at the knee. He created a distal femoral mould
Macintosh’s technique is of some interest. He began by made from vitallium as a surface device for the femur
correcting any fixed flexion deformity with serial plas- (Fig. 1) in an attempt to create a femoral hemi-arthro-
ters.When the deformity was too severe, he performed plasty. He employed this on three ankylosed rheumatoid
a posterior capsulotomy as the first step. He removed as knees in the late1940s.13
little bone as possible from the tibial plateaux, taking
care that the medial and lateral collateral ligaments were
preserved, as well as both cruciates. The metallic tibial
blocks were inserted with no bony fixation and relied
on the tension of the collateral ligaments to hold them
in place (the forerunner of ligament balancing). The im-
plants came in various sizes and differing thicknesses
thus enabling varus and valgus deformities to be cor-
rected. He reported on 58 arthroplasties, 51 bilateral
and seven unilateral. The overall results were satisfac-
tory amongst the elderly but rather disappointing in the
younger age group with an active life style. In 1969
Marmor modified the Macintosh tibial plateau by
adding a serrated under-surface and holes round the side
to allow bone in-growth. McKeever added a keel on Figure 3 The Mckeever tibial hemiarthroplasty.
Figure 2 The Macintosh tibal hemiarthroplasty.

4. THE EVOLUTION OF TOTALKNEE ARTHROPLASTY 325
cases, for example Kraft, who had used acrylic (after the
manner of the Judet prostheses in the hip) to replace the
distal femur following resection of a giant cell tumour.
Like the Judet, it had a metal intra-medullary peg, and
like many Judet prostheses the peg snapped after a year.
ACKNOWLEDGEMENTS
We are most grateful to Lucy Sheridan of DePuy,
Professor Peter Walker and Mr. Michael Freeman in
providing some illustrations.
REFERENCES
Figure 4 The Platt condylar cup. 1. Watson-Jones R. Discussion following speed and trout. J Bone
Joint Surg 1949; 31B: 53.
In1952 Rocher used acrylic to cap the distal femur.21 In 2. Whitman R. A Treatise on Orthopaedic Surgery. Philadelphia: Lea
Brothers & Co., 1901; 302--303.
1954, Kraft and Levinthal made a large prosthesis for the 3. Barton J R. On the treatment of anchylosis by the formation of
reconstruction of the entire distal end of the femur after artificial joints. North Am Med Surg J 1827; 3: 279--292.
the resection of a large giant cell tumour.22 4. Ferguson M. Excision of the Knee Joint. Recovery with a false joint
In the mid-1950s, Platt of Manchester produced his and a useful limb. Med Times Gaz 1861; 1: 601.
Condylar Cup (Fig. 4). This was a stainless-steel surface 5. Verneuil A. De Ia creation d’une fausse articulation par section ou
resection partielle de los maxillaire inferieur, comme moyen de
replacement of the femoral side. Like Macintosh, Platt remedier a l’ankylose vraie ou fausse de Ia machoire inferieur.
also used an extensive programme of preoperative phy- Arch Gen Med 1860; 15: 174--195.
siotherapy including serial plasters. The cup was fitted 6. Murphy J B. Arthroplasty of Ankylosed Joints. Trans Am Surg
over, but not fixed to, bone and a synovectomy and pa- Assoc 1913; 31: 67--137.
7. Baer W S. Arthroplasty with the aid of animal membrane. Am
tellectomy were carried out at the same time. Those
J Orthop Surg 1918; 16: 171--199.
knees with cystic degeneration were bone grafted to 8. Putti V. Arthroplasty of the knee joint. J Orthop Surg 1920; 2: 530.
create a solid bed for implantation. In 1969 Platt and 9. Campbell W C. Arthroplasty of the knee. Report of cases.
Pepler23 reported a 10 year follow-up of 62 knees in 55 J Orthop Surg 1921; NS: 3430.
patients, the majority being rheumatoid. Over 50% of 10. Albee F H. Original features in arthroplasty of the knee with
patients achieved 501 of flexion, whilst 20% managed improved prognosis. Surg Gynec Obstet 1928; 47: 312.
11. Brown J E, McGaw W H, Shaw D T. Use of cutis as an interposing
901 or more. Forty-four per cent of patients were pain membrane in arthroplasty of the knee. J Bone Joint Surg 1958; 40A: 103.
free, 23% complained of an occasional ‘twinge’, 10% 12. Campbell W C. Interposition of vitalliun plates in arthroplasties of
re-ankylosed and 20% became infected, of whom two the knee. Am J Surg 1940; NS: 47639.
patients required amputation. 13. Smith-Petersen, quoted in Blundell-Jones C. Arthroplasty of the
knee. Mod Trends Orthop 1972; 8: 210.
The MGH (Massachusetts General Hospital) Femoral
14. Samson J E. Arthroplasties of the knee joint, late result. J Bone
Condylar Replacement was a second generation Smith- Joint Surg 1949; 31B: 50.
Petersen mould with an added intra-medullary stem. 15. Kuhn J G, Potter T A. Nylon arthroplasties of the knee in chronic
Jones, Aufranc and Kermond reported this Boston series arthritis. Surgery Gynec Obstet 1960; 91: 351.
of 78 arthroplasties in 1967 24 Thirty-two (41%) were
. 16. Gluck T. Autoplastik-Transplantation-Implantation von Fremdkor-
good (defined as allowing a normal range of movement), pern. Berl kIm Wschr 1894; 27: 421--427,
17. Marquardt O. Kinegelenksplastik mit VLA Stahiplatte. Z Sch G.
20 (37%) were unsatisfactory, nine (12%) cases were Orthop 1950; 80: 140.
infected and three (4%) subluxed due to instability. 18. de Palma A F. Disease of the knee. Philadelphia: Lippincott.
Fourteen prostheses (20%) had to be removed. 19. MacIntosh D L. Hemiarthroplasty of the knee using a space-
Between 1941 and 1949, 24 papers were published occupying prosthesis for painful varus and valgus deformities.
reporting a total of 896 patients undergoing femoral J Bone Joint Surg (Am) 1958; 40A: 1431.
20. MacIntosh D L. Arthroplasty of the knee. J Bone Joint Surg 1966;
arthroplasty using various materials with overall good 48B: 179.
results in 46% of patients.14 As with tibial hemi-arthro- 21. Rocher. Arthroplastie du genou par tetes femorales en acrylic.
plasty, these femoral prostheses had the advantages of Bordeaux Elit 1952; 1: 48.
minimal loss of bonestock with correction of valgus/ 22. Kraft G L, Levinthal D H. Acrylic prosthesis replacing lower end of
femur for benign giant cell tumour. J Bone Joint Surg 1954; 36A: 368.
varus deformities and intrinsic soft tissue balance, but
23. Platt G, Pepler C. Mould arthroplasty of the knee. J Bone Joint Surg
at the cost of high rates of infection and instability. 1969; 51B: 76.
The use of plastics as a distal femoral replacement does 24. Jones W N, Aufranc O E, Kermond W L. Mould arthroplasty of
not appear to have been very popular.There are isolated the knee. J Bone Joint Surg 1967; 49A: 1022.