The prehistory of total joints – Themistocles Gluck and Jules Emile Péan
The changing character of joint ailment
From amputation of limbs to resection of joints – steps on the way to total joints
Joints from ivory, joints from platinum – from Gluck to Péan
1 The changing character of joint ailment
Humanity had always problems with painful and stiff joints, as shown by joint changes on the preserved skeletal remnants of our ancestors. These studies demonstrate that the joint diseases that plagued our ancestors were quite different from the “modern” joint diseases. Moreover, it is a surprising fact that the period of change, when the old joint diseases disappeared and the “modern” diseases took its place, had been very short.
The period of this quick change coincides with the therapeutic revolution that started in the 1930’s with development of the first antibacterial drug Prontosil, the first sulfonamide (Domagk, 1935). Other antibacterial drugs, antibiotics, followed later in the 1940’s and 50’s.
Up to the era of the therapeutic revolution, bacterial joint infection dominated joint diseases panorama. The joint infections, mainly tuberculosis and acute bacterial joint infections befell mainly children and young adolescent people. To make things worse, every bacterial joint infection was a potentially lethal disease. There was no drug that could stop spreading of the bacterial infection from the infected joint to vital organs (brain or lung).
The osteoarthritis, the worn out joint disease, on the other hand, was before the era of therapeutic revolution rather a minor nuisance remarkably well tolerated by the older people.
After the 1950’s the bacterial joint diseases disappeared in the developed countries.
Look at the following Table:
Before 1940 After 1960 Joint diseases leading to joint surgery Joint diseases for total hip replacement Acute bacterial joint infections Primary osteoarthritis Infections through open wounds Secondary osteoarthritis Tuberculosis and syphilis Rheumatoid artritis Rheumatoid arthritis remnants after childhood hip diseases Osteoarthritis
In the left column the Table lists in successive frequency order the joint diseases that destructed joints and might give reason for some operative treatment: the list comes from the first edition of the “Campbell’s Operative Orthopaedics” that appeared in 1936. The first three places are occupied by joint infections. Osteoarthritis of the joints, the joint disease that prevails in our modern society comes not until fifth.
In the right column are diagnoses for total hip replacement operations. The data are adapted from the Swedish National Hip Register for 2000. We see that two first places in this statistics are occupied by osteoarthritis of the hip joints; on the third place comes rheumatoid arthritis. On the other hand, the list does not contain any total hip replacement done for hip joint infection or its remainder.
Paralleling the disappearance of bacterial joint infections there has been a remarkable increase of aged people among the general population in the developed countries.
Why and how the joint infections disappeared in our modern society is not entirely clear. We know only that the development and use of modern antibiotics to treat bacterial infections has not been the only cause of change.
The important fact is that the change from devastating bacterial joint infectons to the more amenable osteoarthrititis as a prevailing joint ailment that occurred after 1950’s was also a necessary prerequisite for the success of modern total joint replacement procedures. Without this change in the joint disease panorama, the total joint surgery would remain a rather small subspecialty of orthopaedic surgery.
2 From amputation of limbs to resection of joints – steps on the way to total joints
The surgical treatment of potentially lethal bacterial joint infections of the period before the therapeutic revolution carried with it important ethical problems. We should remember that in the 19th century, an innocently looking open fracture of the lower leg or a wound through to the joint carried with it a 30% risk of death for the patient.
Similarly, the bacterial joint infections caused in 30% to 80% of all cases sepsis (spread of bacteria through blood into vital organs, such as brain, lung, kidneys) with lethal outcome.
When the infection of a joint developed the surgeons had only one operation method that might save the patient’s life – to amputate the whole extremity together with the infected joint and hope that the patient would survive the surgery. This dilemma applied to chronic infections caused by tuberculosis and syphilitic infections too. Also these joint infections ended often with the patient’s dead. There were no drugs to stop the infection from spreading into the rest of the body. Moreover, there were no methods to mitigate the chock caused by the amputation itself, a quick but brutal surgery as it was necessary in the era without anesthesia, so that even the amputation operation was followed by high death rates.
Picture: From amputation to joint resection to total joint replacement (shoulder joint)
Uppermost picture: Infected shoulder joint (Schematically, infection = red circle in the picture)
Amputation of the whole upper extremity – the whole upper extremity is removed = amputated or exarticulated through the shoulder joint. The infection focus is removed; the whole upper extremity is sacrificed.
Resection = only the upper part of the arm-bone = humerus is removed. The infection focus is removed, but the patient retains the upper extremity; it is hoped that the patient will develop useful function in the rests of the shoulder joint. Insert shows the 19th century illustration of shoulder joint resection; the illustration is probably not unrealistic; in the era before narcosis was known the operation might look as in this picture.
Artificial joints = the space left after removed parts of the shoulder joint is replaced by an artificial joint. The patient retains both the whole upper extremity and the function in the shoulder joint.
From amputation to joint resection to total joint replacement (shoulder joint) Click on the icons for a full size pictures
In the 19th century there appeared a radical surgical innovation – joint resection. Joint resection is an operation that removes a part or a whole of a joint instead of removing the whole extremity. Joint resection was considered by some surgeons as the most genial surgical idea of the 19th century. The operation was developed from the desire to save the patient’s life and his limb too; in modern term we would say that it stemmed from “the desire to improve the quality of patient’s life”.
Of course, our ancestors did not use such modern terms, although they were rather poetic too when demonstrating the advantages of the joint resection operation.
The renowned German surgeon Bernhard von Langenbeck said in 1873: “the surgeon is no longer proud when he sees the rows of amputation stumps he had left behind himself, he sees them rather with sorrow as the witnesses documenting the imperfection of his art”.
To demonstrate the advantages of the joint resection operation professor von Langenbeck presented one of his patients, Lieutenant von Petersburg. This brave soldier of the Prussian army received a shot in his right shoulder joint that splintered the upper part of the right arm- bone (humerus) during the Prussian-Austrian war in 1866. The usual surgical practice in such cases was to amputate the whole right arm to prevent spreading of infection. Professor von Langenbeck removed, however, only the splintered upper part of the right arm-bone – and it healed. The brave soldier retained his right arm in spite of the severe injury.
Picture: Lieutenant with right shoulder resected
The picture shows the brave Lieutenant keeping his sword in his right hand again. Note how the contours of his right shoulder are distorted, the contours of the muscles that move the shoulder joint are lacking. An insert shows the damaged upper part of the arm-bone that professor von Langenbeck removed = resected to save the upper extremity.
I am not certain how much function was left in the shoulder of the brave soldier, probably very little because the muscles that move the shoulder were lacking. But the message of this picture is obvious: This brave Lieutenant will be able to continue his military duties thanks to the new operation – the joint resection.
Lieutenant von Petersburg who had the right shoulder joint resected. (from Blauth 1979)
Not all surgeons subscribed to the new operation method of joint resection in cases of severe joint trauma. The renowned Scottish surgeon James Symes argued that the first and foremost goal of all joint surgery is to save the patient’s life. If the amputation saves nine patient lives out of ten and joint resection only eight, then, argued Syme, the amputation is the method of choice, notwithstanding the quality of patient’s life afterwards.
Compare these decisions of the past on the life and death after joint surgery with today’s discussions on the limits to playing golf after total joint surgery! Obviously, there has been a progress.
3 Joints of ivory and platinum – from Gluck to Péan.
Themistocles Gluck – joints of ivory
It soon became obvious that simple joint resection did not improve the patient’s life too much. The resected joint, or rather what remained of it after the resection, was painful, unstable, in need of sturdy braces.
There were surgeons in the past who had the insight that the free space left after removal = resection of the diseased joint might be filled with an artificial joint, such as the Russian surgeon N. I. Pirogow, who proposed the replacement of a tuberculous knee with an artificial joint made of ivory in 1830.
The first surgeon, however, who replaced not one, but many tuberculous joints by artificial joints made from ivory was the German surgeon Themistocles Gluck.
Picture: Professor Themistocles Gluck (1853 -1942). This very active surgeon had an extraordinary misfortune. He carried not only suture of vessels, but also venous grafts already in the 1880’s, long before the American surgeon Carrel; yet the Nobel price for discovery of arterial suture went in 1912 to just Alexis Carrel.
As the pupil of professor von Langenbeck, working with him at the Berlin’s Surgical Clinic, T. Gluck exerted himself to the utmost to change the contemporary surgery “from being the destructive art to become the reconstructive art”. In this activity he developed artificial total joints, fabricated from ivory. And he implanted them in patients.
His lecture in 1890 on his total joint experiments was presented at the 10th International Medical Congress in Berlin. When it appeared in the printed form the Literature references section contained 117 citations of published papers, 53 of them were Gluck’s own publications.
The German orthopaedic surgeon professor Wessinghage could in 1991 trace totally 14 total joint replacements carried out by Gluck during the 1880's and described in Gluck's publications; five of them were still in function 1891: three total knee replacements, one elbow, and one wrist total replacement. All total joints were made from ivory. For their fixation inside the marrow cavity Gluck often used a special form of very hot "bone cement" that hardened within one minute.
All replacements were done on joints destructed by tuberculous infection. The infection was active, there was no known treatment for the infection, and yet Gluck ventured to carry out resection of the destructed joint and then replace it with an artificial joint made from ivory.
Total knee joint - a modular hinge made from ivory Initially, the state of the patients improved much after replacement surgery because the massive infectious focus was removed. Also the function in the replaced joints returned, and Gluck demonstrated gladly these patients on different surgical meetings. Unfortunately, because there was no available treating for the tuberculosis infection, the infection returned eventually and necessitated removal of the ivory total joint constructions.
Yet, you name any modern development of artificial joints and Gluck already thought of it or realized it. Here are some of them:
Stabile fixation of the artificial joint: Gluck used either contemporary “bone cement” or used cementless fixation for his total joints. Above all, Gluck proclaimed that the total joint must be fixated “iron-steady” to the patient’s skeleton if it should succeed.
Modular construction of artificial joints: Gluck proposed that total joints should be assambled by the surgeon directly at the operation board from modular parts of different sizes.
Stress shielding principle – Gluck declared that the skeleton behaves according to the principle to use the minimum of bone mass just able to bear the load put on it. Therefore, he thought that ivory was the best material for total joints; it is equally light and equally strong as the bone tissue itself. Modern surgeons call this principle “Wolff’s law”.
Gluck proposed that joints taken from corpses and amputated limbs may be used as replacement parts although he himself did not use them. Modern total joint surgery uses the so called allografts (joints and bones from corpses) at revision operations in increasing numbers.
Gluck demonstrated in animal experiments that marrow hole will accept the shaft of the artificial joint if it is stably anchored within it. This is one of the keystones of the modern total joint surgery.
Gluck was the first to develop the idea of biocompatibility – the foreign materials for total joints must be well tolerated by the patient’s body.
His total joint replacement operations were a splendid idea done on wrong patients and at the wrong time. Even in modern times, with the availability of antibiotics to treat the joint tuberculosis, the total joint replacement of joints damaged by previous tuberculosis infection is very difficult. Recent report (Mars 2005) summarized experience with 32 total knee operations done on knees with healed out tuberculosis or other infections. The authors point out that it is a difficult operation with high risk of complications (12.5% in the authors' case) and rather uncertain return of function in the replaced knee joint (Bae 2005).
To Gluck’s defense I must say that he believed that treatment of tuberculosis with Koch’s medicine “Lymphe” would heal the tuberculosis, as did many of his contemporaries, even the new director of the Berlin’s surgical clinic professor von Bergman. The Lymphe was, however, worse than worthless; it increased susceptibility of patients to the tuberculous infection.
After Gluck’s lecture in 1890 there came a severe clash with his chief professor von Bergman, new Head of the Berlin surgical clinic. Behind it was von Bergman's disappointment with the failure of treatment of his own patients with Koch's Lymphe and his disillusionment with all things that may mean progress of surgery. Professor von Bergman forced Gluck to publish a repentant declaration, in which Gluck retracted his results with total joint replacement, his recommendations for the method, his ideas for further development of total joint replacement. He wrote in his open retracting letter that replacement of joints with active tuberculosis was erroneous because the infection recurred. He took all responsibility for this mistake on himself. He then sank into oblivion.
When I read Gluck’s honest, open letter today I always think of another letter, John Charnley's retraction of the results of Teflon total hips. What a difference! (Charnley 1963)
Where Gluck failed was in the choice of materials and in the choice of patients. But these failures were due to the era in which he lived and worked. The modern materials such as Stainless steel, Cobalt chrome and Titanium alloys lay in the distant future. There was, however, one surgeon contemporary with Gluck who recognized the importance of biologically inert metals for manufacture of total joints. And this surgeon was led by Gluck’s ideas.
Jules Emile Péan (1830- 1898) - joints from rubber and platinum
was one of the leading French surgeons. Among his credits was the invention of the hemostat, an instrument (squeezer) used to compress bleeding vessels. In a paper published in 1894, he defended Gluck’s ideas on total joint replacement.
He wrote “We wish particularly to stress today the value of prosthetic apparatus, extolled by Gluck for the past few years, its worth wrongly denied by most surgeons...”
Péan then continued to describe his own patient “almost dying with tuberculosis of the humerus including the shoulder joint… and of difficulties so severe that we bluntly thought there was nothing else to do but disarticulation” (amputation of the whole extremity in the shoulder joint).
But Péan was persuaded by the patient to do resection of the diseased humerus (arm-bone) and replace the removed parts with an artificial joint. “We therefore decided to use a device constructed according to the design of Gluck; we first consulted M. Mathieu, our skillful mechanic … he was able to give us one of Gluck’s pieces. This device was too weak, made of ivory, a substance too easily resorbable, with an articulation too little movable. Péan then asked the dentist, Dr Michaels, to work with him to “design a prosthetic device made of an unalterable material and capable of lending itself to an artificial joint with all its motions”.
Picture: Artificial shoulder joint made of rubber and platinum
Dr Michaels constructed an artificial shoulder joint from hardened rubber and iridescent platinum “with a speed and facility worthy of commendation”. The included illustration demonstrated the first total shoulder joint: the head of the humerus was replaced by a round piece of hardened rubber attached to the stem of platinum; the blurred illustration does not reveal how the stem itself was attached to the shaft of the humerus. The rubber head was attached by a platinum wire to the rests of the shoulder joint socket. Artificial shoulder joint made of rubber and platinum The operation with resection of the destructed upper part of the humerus and replacement with the artificial joint succeeded well, “ since the operation the patient had gained 35 pounds and his health would have been excellent had he not be troubled by recurrence of small abscesses...we had to open this small abscess on 4 different occasions.” The paper does not tell anything about the function in the replaced shoulder joint.
Péan concluded his article with six statements that presaged the era of total joint replacement. The first two stated that
“It is possible to replace an important part of the skeleton and even a joint”
“That this device to be well tolerated should be not only aseptic, but made of non-resorbable material.”
Péan's collaboration with a dental surgeon, doctor Michael, in producing the total joint is the first of many future examples demonstrating that surgery of total joint replacement owes much of its progress to collaboration with dental surgeons.
It took then more than seventy years until Gluck’s and Péan’s ideas materialized. When the right kind of patients with right joint disease (osteoarthritis) were increasing among the general population since 1960’s and demanded efficient treatment and when the total joint devices made from right materials became available, total joint replacement operations spread as a big epidemic through all developed countries.
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References:
Bae DK et al.: Total knee arthroplasty in stiff knees after previous infection. J Bone Joint Surg Br. 2005 Mar;87(3):333-6.
Blauth W, Donner K.: Zur Geschichte der Arthroplastik. Z Orthop 1979; 117: 997-106
Charnley J.: Letter to Editor. Tissue reactions to polytetrafluorethylene. The Lancet. Dec 28;1963:1379
T. Gluck: Referat uber die durch das moderne chirurgische Experiemnt gevonnenen positiven Resultate, betreffend die Naht und den Ersatz von Defecten höherer Gewebe…Langenbecks Arch klin Chir 1891, 41: 187-239
B. von Langenbeck: Uber die Endresultate der Gelenkresektionen im Kriege. Langenbecks Arch klin Chir 1874; 16: 340- 490
J E Péan: Des moyens prosthetiques destines a obtenir la reparation de parties osseuses. Gaz de Hôp Paris 1894: 67: 291-302. Reprinted in Clin Orthop Relat Res 1973; 94: 4 -7
