2.1. History of prosthesis surgery

Although major surgical procedures were occasionally performed in the early 1800s, it was not until the introduction of general anaesthesia and antiseptic techniques during the latter half of the nineteenth century that bone and joint surgery could be developed. During the 19^th century, the conditions affecting joints were generally different from those encountered today. Surgeons treated patients with acute and chronic infections, both septic and tuberculous, poliomyelitis and untreated developmental dysplasia of the hip. These conditions often led to joint instability and ankylosis. Fracture treatment was relatively primitive, and non-unions, mal-unions and osteonecrosis of the hip were commonly encountered. Thus, arthroplasty was used to treat patients with numerous conditions, which differed considerably from the contemporary situation, in which the majority of patients suffer from degenerative joint diseases and other forms of arthritis. (Steinberg & Steinberg 2000)

Resection arthroplasty of the hip was first reported in Europe in the early 1800s and became well established by the middle of the 19^th century. This procedure was performed primarily for the treatment of patients with chronic bacterial and tuberculous arthritis. Between 1921 and 1945, G. R. Girdlestone, Professor of Orthopaedic Surgery at Oxford, refined the indications and techniques for resection arthroplasty. This procedure eventually became known as the Girdlestone arthroplasty. The results were thereby improved substantially, and before the development of total hip replacement, Girdlestone pseudoarthrosis was often used as a primary treatment for patients with degenerative arthritis of the hip. (Steinberg & Steinberg 2000)

The era of modern arthroplasty began when Sir John Charnley developed the predecessors of today’s hip replacement during the late 1950s and early 1960s (Steinberg & Steinberg 2000). Hip replacements soon revolutionised the treatment of hip arthritis in elderly patients (Moran & Horton 2000). Modern hip prostheses are modular, which means that the surgeon can modify the different components to suit each patient’s needs. They are made of metal and plastic, and the components can be attached to bone in several ways. In cemented fixation, the prosthesis is secured by polymethylmethacrylate. The fixation of a cementless prosthesis takes place by means of bony ingrowth into a porous coating on the surface of the device. Acetabular components can be press-fit and secured with screws (Kingston & Walsh 2001, Love et al. 2001).

The success with hip replacements led to interest in other joints, particularly the knee. A great variety of knee replacements were produced, and hinged knees caused particular problems. Regardless of how well the hinged components were designed, the basic problem seemed to be that rigidly fixed components with motion in only one plane failed because of the stresses applied to the device to its attachment to bone. Thus, in the 1970s and early 1980s, knee replacement was widely considered to result in a poor outcome. Condylar components were also used. There was controversy, which still continues, concerning the advisability of replacing only one compartment of the knee. Some of the designs were successful, however: these aimed to resurface the joint and to reproduce the knee anatomy with a low-friction joint. The remaining knee ligaments provided stability, allowing some rotational movement. Total knee replacements have undergone a period of convergent evolution, and most implants now adhere to the same basic design principles (Moran & Horton 2000). Nowadays, mobile-bearing prostheses have improved mobility and lessened plastic breakdown compared to the older fixed-bearing models (Love et al. 2001, Scuderi et al. 2001, Steinberg & Steinberg 2000).