Courtesy: Medical Miracles, from Readers Digest 1981.
November.
From the frontiers of science and the far horizons of
personal courage, these stories of medical triumphs and miracles will reaffirm
your faith in the awesome powers of the human spirit. Dramatic victories and
human triumphs.
Selected and edited by the editors of Readers Digest
Maria Gabriella’s carrier as a prima ballerina and teacher
had come to a halt. A hip injury,
followed by arthritis, had left her painfully disabled, and surgery could
provide no lasting relief. Today,
however, pain-free and with her mobility totally restored, she is able to rise
on her toes again in the graceful pirouettes and arabesques of her ballerina
days.
Maria Gambarelli is the beneficiary of a miracle, which has
become routine: the total replacement of the human hip with a smoothly
functioning joint of plastic and metal.
Thanks of the talents of Professor John Charnley, a cheery, 63-year-old
English surgeon who combined profound clinical insight with inspired tinkering
to develop operation, thousands of persons can today walk, dance and live
normally again, free from crippling pain.
Marine’s longtime Senator, Margaret Chase Smith, was saved
from being disabled by replacement of her hips, the right in 1970 and left in
1971. “I have no walking aid, no limp,
no pain, and I have had no medication since the operations. I walk miles; I walk all the time,” she
says. Replacement of actress Katharine
Hepburn’s right hip in Los Angeles in 1973 enabled the famous star to continue
acting in her characteristic, free-striding style. George Halas, who owns the Chicago Bears
football team, suffered from painful, crippling arthritis in both hips. They were replaced when he was in his 70s,
the left in November 1968 and the right in May 1969. He is now a spray 85 and reports no trouble
with his hips.
As these cases attest, total hip replacement—today
successful in better than mine out of ten cases—is a revolution in treatment
comparable in impact to the advent of antibiotics against incestuous diseases.
John Charnley’s triumph stems from a combination of clinical
acumen, uncommon commonsense and a bit of luck.
The natural human hip joint consists of a ball and socket. The head of the long bone of the thigh [the
femur] is a ball. The cartilage-lined
hollow [called the acetabulum] of the hipbone is a socket. Together, the healthy ball and socket work
smoothly under the tremendous workload those bipeds put upon them. But when disease attacks, bone grinds on
bone, and movement becomes excruciating.
For decades, surgeons had attached artificial beads to
femurs, of reshaped and relined sockets.
The assumption was that body fluids lubricated the natural joints and
would do so when bone against bone was replaced by metal against bone or,
later, by plastic against plastic. But
these approaches did not always work.
For a pain-racked patient, the chance of truly effective relief was
little better than 50-50.
Professor Charnley, who in November of 1974 received the
Albert Laser Clinical Medical award for his achievements, began his research
into improving hip surgery at the Manchester Royal Infirmary soon after World
War 2nd. [Later, he was to establish the now world-renowned Center for Hip
Surgery and Wrightington Hospital in nearby wigan]. In 1954, he met a man who had had an acrylic
head fastened to his thighbone. It
worked well, but squeaked so persistently that the man’s wife refused to dine
out with him. Charnley started studying
joint lubrication. He concluded that is
“probably a unique combination of fluid film and the phenomenon called boundary
lubrication—an easy slippage of intrinsically slippery surfaces upon one
another—without any man-made parallel.”
The concept of boundary lubrication led him to construct an
artificial joint that combined a stainless-steel ball with a socket of the new
plastic, polytersfluorethelene [Teflon], and the freest solid then known. These new joints produced phenomenal
results. Patients who had been unable to
walk were suddenly free of pain and had a near-normal range of motion on their
hips.
Elated, Charnley performed some 300 operations. But within a year things began to go
wrong. For patients with the artificial
hips, motion became as painful as it had been with arthritis. Charnley discovered that the relatively soft
Teflon did not remain effective inside the body, because, under the workload of
the weight-bearing joint, it simply wore away much too rapidly to be practical.
These were depressing times for Charnley. His wife, Jill, can remember his sitting
“bolt upright in bed, suddenly awake with the cold idea of an avalanche of
patients with failing hips descending upon him.”
Meanwhile, Charnley had begun to look for a whole new approach,
possibly involving a joint with a sealed bearing. Early in 1962, luck interceded. A salesman came to the laboratory with
samples of a high-density polyethylene, which he said had good wearing
qualities. Charnley, with the Teflon
failure on his mind, told the technician to throw away the samples.
The technician, fortunately, had other ideas. The apparatus they had used for testing the
wear-resistance of Teflon was standing idle, and he put the spurned samples on
it just to see what would happen. To
everyone’s astonishment, after three weeks on the matching the material had not
worn as much as the Teflon he had worn in 24 hours. “If my technician hadn’t disobeyed my orders!”
says Charnley today. “Oh, yes, there is an enormous amount of luck in research!”
The high-density polyethylene had a surface much less
slippery than Teflon, but by another piece of luck had the capacity to be
lubricated by synovial fluid [the natural fluid that bathes the body’s joints],
so that the rub of the metal femur head against the plastic socket was very
smooth indeed. Charnley started using
the new material in November 1962, carefully building into his design an X-ray
marker—metal wire exactly the diameter of the plastic socket, which would
enable him to check the wear. X-ray
images made of a ten-year period, and superimposed over pictures of the joint
when first implanted, show that the average wear has been only 1.5
millimeters. And ten percent of the
artificial joints show no wear at all.
Today the basic Charnley operation [called low-friction
arthroplasty] is available at many major U.S medical centers, and it is
estimated that over 50,000 such operations are being performed annually around
the world. The surgery takes from 50
minutes to about three hours, depending on the difficulty of the individual
case. The surgeon makes a lengthwise
incision alongside the hip and thigh, deftly pulls muscles aside to reveal the
hip, sometimes sawing off the knob on the top of the femur [called the greater
trochanter], to which hip muscles are tacked.
Then he saws off the head of the femur.
On the pelvis side, working with rasps and other stout
tools—an orthopedist has to be half—carpenter—he cleans out and reshapes the
hollow in the hip socket to receive the new plastic socket, which he cements
securely into place with a substance—methyl methacrylate—used by dentists. Next he reams out the marrow shaft below the
cut end of the femur and inserts first the cement, then the long stem of the
steel ball prosthesis. [In this crucial step Charnley was also a pioneer. Other surgeons had used the cement thinly, as
if it was glue, and it had failed to hold.
Charnley slathered it on and packed it in as if he were setting tiles in
grout.] Once both socket and prosthesis
have hardened in the cement, if the surgeon has chosen to sever and trochanter,
he will wire it back into the femur, where it heals itself laid any other
fractured bone.
Four or five days after the operation, the patient is on his
feet, gingerly putting weight on the hue hip.
He is usually discharged from the hospital in two to three weeks. Most patients can abandon even the use of a
cane within three months.
The Charnley operation today dominates the treatment of
severely arthritic hips. Dr. Frank E.
Stinchfield of Columbia’s College of Physicians and Surgeons, whose 1800
total-hip patients have included ballerina Cambarelli and former Senator
Margaret Chase Smith, comments, “Almost every surgeon modifies the operation a
bit. But, basically, we all are using
Charnley’s method. He’s the one who has
perfected the principles. His
contributions are now accepted universally.”
Not every individual with a troublesome hip is a suitable
candidate for hip replacements. To
determine who can be helped, surgeons weigh many complex factors, involving
general health, the soundness of the bone to which the new parts must be
attached, the degree to which other joints are also damaged, the psychological
attitude of the patient. Obesity is a serious
obstacle to successful surgery, and persistent infection in the hip joint is an
almost total barrier. The majority of
patients are 60 or older, but the operation can be done at any age, once growth
is substantially completed. The
operation is also possible when cancer has attacked the hip-joint
area—depending on the condition of the rest of the pelvis and femur.
Consistent success with the hip-replacement operation has
given rise to the popular supposition that getting a new joint for any other
part of the body is simply a matter of browsing through the spare-parts
catalogue and hiring the necessary technicians.
This is not yet the case.
Finger-joint replacements are, of course, a long-established
success. And other spare parts to
replace our aching joints are on the drawing board, in the laboratory and in
early clinical trials [with the knee now getting the highest priority]. But most orthopedists would agree with
Charnley that so far only the hip is “a universal joy.”
