Austin T. Moore (1899-1963), and Harold Ray Bohlman (1893-) published an original case report in the Recorder of the Columbia Medical Society in South Carolina in 1942, and in the Journal of Bone and Joint Surgery a year later. This was the first known report on metallic hip replacement in a patient. E. M. B. A report of the following case seems justifiable because of its unusualness. After searching the literature, no report of a similar case can be found. The patient was observed over a period of 8 years, and during this time several operations were performed, the last one being the most interesting. The patient, a negro male, aged 46 years, and weighing approximately 250 pounds, was first seen in September 1934. He had non-union of a fracture of the neck of the right femur. The fracture had occurred 15 months previously. He suffered severe pain and walked with difficulty by using crutches. Instead of doing a reconstruction operation, or a bone-grafting operation, it was decided to try to secure union by nailing the fragments together and drilling holes up through the neck and into the head to allow revascularization of the head and the fracture line. The operation was performed, and 3 Moore, adjustable, stainless-steel nails were inserted. 4 days after the operation this large man got up and walked about the ward without permission. He was proud of the fact that he could walk. He wanted to “show-off.” He was cautioned against weight-bearing and overuse of his hip, for it was feared that the fragments would not reunite, but he continued to bear some weight on the injured hip from this time on. The fragments were held well together with the nails, and in spite of weight-bearing solid bony union did result, with no pain and with good function of the hip joint. This case was presented to the Columbia Medical Society of Richland County, South Carolina, December 14, 1942, and has been reported in The Recorder of the Columbia Medical Society, VI, 12, December 1942. It is contrary to the policy of The Journal to reprint material, but, since this publication is not available to many of the readers of The Journal, an exception has been made in this case. (Reprinted here from: Moore, A. T., and Bohlman H. R.: Metal hip joint. A case report, J. Bone Joint Surg. 25:688, 1943.) In February 1936, he began to complain of some pain in the hip. On examination a large cyst was discovered in the upper end of the femur in the region of the greater tro-chanter. On reviewing the original roentgenograms it could now be determined that a small cyst had been present at the time of his injury. This cyst, which had escaped detection previously, had increased in size. Operation was performed, the cyst was curetted, and the cavity was filled with bone chips. Microscopic section revealed the pathology to be a giant-cell tumor. Deep roentgenotherapy was administered, and the maximum dosage was given over a considerable period of time. At the time of this operation, even though a large cystic area was present in the trochanter, it was found that there was solid bony union of the previous fracture through the neck of the femur. The nails were no longer necessary, and so were removed. Improvement occurred following the curetting operation and deep roentgenotherapy, pain was relieved, and the patient got about with more or less normal function of the hip joint. (The authors have motion pictures to demonstrate his condition at that time.) Approximately 2 years later there was a recurrence of pain, and roentgenograms showed further enlargement of the cystic area. Again roentgenotherapy was instituted, and the cyst was curetted. Hemorrhage during the operation was profuse and almost uncontrollable. It was feared that the patient might expire on the table. A large bone-grafting operation was performed by removing approximately 10 inches of the upper end of the right fibula and grafting this across the upper end of the femur and down into the shaft. In addition, numerous bone chips were removed, and the cavity of the cyst was packed with these chips. An uneventful convalescence followed, and soon the patient was up and about, using his hip well, and with no complaint of pain. Approximately 2 years later the cystic degeneration returned, and a pathological fracture occurred. Roentgeno-therapy was again administered, and the fracture was treated by bed rest and skin traction. Union in good position was obtained, and there appeared to be some healing of the tumor region. Later, the tumor again began to increase in size, and on re-examination in September 1940 a large cystic mass approximately the size of a grapefruit was found in the upper end of the femur. The cortex of the bone was very thin, and it was realized that another pathologic fracture would soon occur. By this time, every conservative means of treatment had been exhausted, and the tumor continued to enlarge in spite of every effort to control and eliminate its growth. The question then arose as to whether the limb should be amputated at the hip joint, or whether no treatment should be offered. In the latter event, the patient would have to resign himself to pathologic fracture and very likely malignant degeneration of the tumor, with metastasis and death. Amputation at the hip joint would be a very serious undertaking in so large a patient. In an effort to do something for him, it was decided to resect the entire tumor region and to replace this portion of the bone with a metal appliance made in the form of the natural bone, and having in it various loops through which the various muscles and tendons could be attached, so that some reasonable postoperative function of the hip might be expected. Apparently no one had ever had the opportunity previously to replace such an extensive amount of bone as this case demanded. Calculations were made from roentgenograms of the bone, wax models were fashioned and from these models a mold was made, and a vitallium model of the upper end of the femur was finally produced. The appliance was about 12 inches long. It had a smooth, rounded head to fit into the acetabulum, and there were loops for muscle attachments to the upper end. The lower end of the appliance was fashioned so that it could be slipped over and be bolted to the lower fragment of the femur. One of the authors (H. R. B.) had for some time been interested in metal replacements, and had replaced the head of the femur with vitallium. He supervised the construction of the model. Operation was performed under spinal anaesthesia on September 28, 1940. It was realized that the shock of operation would be severe, and for that reason blood was prepared and administered prior to, during, and after the operation. A long lateral incision was made from the crest of the ilium to just above the knee. The femur was divided in half with a Gigli saw, and the upper portion, including the tumor, was removed by subperiosteal dissection. Great, large blood vessels and blood sinuses, some as large as the little finger, were encountered. Hemorrhage at times was profuse, almost uncontrollable. Many large packs were used. The dissection was continued up underneath the periosteum, the capsule of the hip joint was dissected free, and finally the head was removed from its socket by division of the ligamentum teres. When an attempt was made to fasten the vitallium appliance to the lower end of the femur, it was found that it was too small and would not slip over the bone. The bone had to be reduced in size, and the outer cortex was chiseled away. It developed that this was a serious mistake. Following removal of the hard cortical bone, there was little remaining strength in the soft more cancellous portion, and after the appliance had been slipped over the end of the bone and bolted into place, it was realized that the bone very likely would break as a result of the strong muscle pull. The head of the appliance fitted well into the acetabulum. Passive motion of the hip could be carried out in almost a normal manner. The capsule of the hip joint which had been dissected away was sutured, the muscles and tendon attachments about the trochanteric region were fastened to the appliance by suturing their ends through the metal loops provided. The deep fascia was closed, helping to hold the appliance securely in place, and the soft tissue of the wound was closed in layers without drainage. The limb was suspended in balanced traction in a hinged Thomas splint. The postoperative convalescence was somewhat stormy, but very satisfactory. A few days after the operation it was found that in moving this large muscular limb, the bone had fractured as expected. With this sequestrum of bone separated and lying within the appliance where it could not be nourished by normal blood supply, there developed liquefaction necrosis, and a large amount of fluid accumulated in the deep tissues. It was feared that the entire area would break down with infection, and that the project would fail. 6 weeks following implantation of the appliance, another operation was performed. At this time the necrotic sequestrum of bones was removed. It was most interesting to observe that the soft tissues had adhered to the vitallium appliance so firmly that the periosteum had to be elevated in almost the same fashion that normal periosteum is stripped from normal bone. Following this observation, the authors were encouraged, and hoped that complete healing would take place, and that the appliance would be embedded in a normal bone involucrum. By means of skeletal traction the limb was held in suspension, and the lower fragment of the bone was kept in end-to-end apposition with the vitallium appliance. Healing progressed, and check-up roentgenograms revealed increasing bony union. 5 months after the operation, union was solid, and the patient was allowed to be up and about on crutches, using a long thigh brace with pelvic band and large lacer cuff about the thigh to support the site of the fracture. Very soon, he was bearing full weight on the limb, and there was remarkable freedom from pain. There was voluntary active motion of the hip joint, of approximately 75 per cent of normal. Within 9 months following operation, he walked well without support, and only used a cane for long distances. One year following operation, he not only walked well, but picked up a grown man weighing 215 pounds, and walked about with him. Roentgenograms at this time showed a great mass of new-bone formation, extending from the intertrochanteric region of the femur at the capsular attachment downward, enveloping the vitallium appliance, and solidly uniting it to the lower femoral fragment. The patient continued to improve, and walked well without complaint. Moving pictures made 15 months after operation reveal an excellent functional result. Approximately a year and a half following operation, he began to show clinical evidence of cardiac decompensation. There was some swelling of both hands and feet. An acute cardiac attack developed and he was treated in the hospital over a period of 3 weeks for cardiac failure. He returned to his home and was getting about well when, on June 2, 1942, while sitting on the side of his bed, he toppled forward and expired. Notice was received of his death, and consent for autopsy was obtained. At autopsy, the entire femur and half of the pelvis were removed. A new hip joint with an almost normal appearing capsule and synovial lining were found. The bone specimen was preserved by boiling the bone in soapy water, and drying it in the sun. This specimen shows the extensive involucrum about the vitallium appliance. There was no evidence of recurrence of the giant-cell tumor. The vitallium appeared unaffected by its period of service in the body. It was just as bright and shiny as the day it was inserted and at no point on it was there any evidence of corrosion. This patient was observed and treated over a period of approximately 8 years. An ununited fracture, 15 months' duration, of the femoral neck was cured by drilling and nailing with Moore nails. A giant-cell tumor was treated by roentgenotherapy, curettage, and massive bone graft. After 6 years, when tumor growth could no longer be controlled and pathological fracture had occurred, the upper 1/2 of the femur was resected and replaced successfully with vitallium.
Copyright remains with the authors and publisher.
Austin T. Moore (1899-1963), and Harold Ray Bohlman (1893-) published an original case report in the Recorder of the Columbia Medical Society in South Carolina in 1942, and in the Journal of Bone and Joint Surgery a year later. This was the first known report on metallic hip replacement in a patient. E. M. B. A report of the following case seems justifiable because of its unusualness. After searching the literature, no report of a similar case can be found. The patient was observed over a period of 8 years, and during this time several operations were performed, the last one being the most interesting. The patient, a negro male, aged 46 years, and weighing approximately 250 pounds, was first seen in September 1934. He had non-union of a fracture of the neck of the right femur. The fracture had occurred 15 months previously. He suffered severe pain and walked with difficulty by using crutches. Instead of doing a reconstruction operation, or a bone-grafting operation, it was decided to try to secure union by nailing the fragments together and drilling holes up through the neck and into the head to allow revascularization of the head and the fracture line. The operation was performed, and 3 Moore, adjustable, stainless-steel nails were inserted. 4 days after the operation this large man got up and walked about the ward without permission. He was proud of the fact that he could walk. He wanted to “show-off.” He was cautioned against weight-bearing and overuse of his hip, for it was feared that the fragments would not reunite, but he continued to bear some weight on the injured hip from this time on. The fragments were held well together with the nails, and in spite of weight-bearing solid bony union did result, with no pain and with good function of the hip joint. This case was presented to the Columbia Medical Society of Richland County, South Carolina, December 14, 1942, and has been reported in The Recorder of the Columbia Medical Society, VI, 12, December 1942. It is contrary to the policy of The Journal to reprint material, but, since this publication is not available to many of the readers of The Journal, an exception has been made in this case. (Reprinted here from: Moore, A. T., and Bohlman H. R.: Metal hip joint. A case report, J. Bone Joint Surg. 25:688, 1943.) In February 1936, he began to complain of some pain in the hip. On examination a large cyst was discovered in the upper end of the femur in the region of the greater tro-chanter. On reviewing the original roentgenograms it could now be determined that a small cyst had been present at the time of his injury. This cyst, which had escaped detection previously, had increased in size. Operation was performed, the cyst was curetted, and the cavity was filled with bone chips. Microscopic section revealed the pathology to be a giant-cell tumor. Deep roentgenotherapy was administered, and the maximum dosage was given over a considerable period of time. At the time of this operation, even though a large cystic area was present in the trochanter, it was found that there was solid bony union of the previous fracture through the neck of the femur. The nails were no longer necessary, and so were removed. Improvement occurred following the curetting operation and deep roentgenotherapy, pain was relieved, and the patient got about with more or less normal function of the hip joint. (The authors have motion pictures to demonstrate his condition at that time.) Approximately 2 years later there was a recurrence of pain, and roentgenograms showed further enlargement of the cystic area. Again roentgenotherapy was instituted, and the cyst was curetted. Hemorrhage during the operation was profuse and almost uncontrollable. It was feared that the patient might expire on the table. A large bone-grafting operation was performed by removing approximately 10 inches of the upper end of the right fibula and grafting this across the upper end of the femur and down into the shaft. In addition, numerous bone chips were removed, and the cavity of the cyst was packed with these chips. An uneventful convalescence followed, and soon the patient was up and about, using his hip well, and with no complaint of pain. Approximately 2 years later the cystic degeneration returned, and a pathological fracture occurred. Roentgeno-therapy was again administered, and the fracture was treated by bed rest and skin traction. Union in good position was obtained, and there appeared to be some healing of the tumor region. Later, the tumor again began to increase in size, and on re-examination in September 1940 a large cystic mass approximately the size of a grapefruit was found in the upper end of the femur. The cortex of the bone was very thin, and it was realized that another pathologic fracture would soon occur. By this time, every conservative means of treatment had been exhausted, and the tumor continued to enlarge in spite of every effort to control and eliminate its growth. The question then arose as to whether the limb should be amputated at the hip joint, or whether no treatment should be offered. In the latter event, the patient would have to resign himself to pathologic fracture and very likely malignant degeneration of the tumor, with metastasis and death. Amputation at the hip joint would be a very serious undertaking in so large a patient. In an effort to do something for him, it was decided to resect the entire tumor region and to replace this portion of the bone with a metal appliance made in the form of the natural bone, and having in it various loops through which the various muscles and tendons could be attached, so that some reasonable postoperative function of the hip might be expected. Apparently no one had ever had the opportunity previously to replace such an extensive amount of bone as this case demanded. Calculations were made from roentgenograms of the bone, wax models were fashioned and from these models a mold was made, and a vitallium model of the upper end of the femur was finally produced. The appliance was about 12 inches long. It had a smooth, rounded head to fit into the acetabulum, and there were loops for muscle attachments to the upper end. The lower end of the appliance was fashioned so that it could be slipped over and be bolted to the lower fragment of the femur. One of the authors (H. R. B.) had for some time been interested in metal replacements, and had replaced the head of the femur with vitallium. He supervised the construction of the model. Operation was performed under spinal anaesthesia on September 28, 1940. It was realized that the shock of operation would be severe, and for that reason blood was prepared and administered prior to, during, and after the operation. A long lateral incision was made from the crest of the ilium to just above the knee. The femur was divided in half with a Gigli saw, and the upper portion, including the tumor, was removed by subperiosteal dissection. Great, large blood vessels and blood sinuses, some as large as the little finger, were encountered. Hemorrhage at times was profuse, almost uncontrollable. Many large packs were used. The dissection was continued up underneath the periosteum, the capsule of the hip joint was dissected free, and finally the head was removed from its socket by division of the ligamentum teres. When an attempt was made to fasten the vitallium appliance to the lower end of the femur, it was found that it was too small and would not slip over the bone. The bone had to be reduced in size, and the outer cortex was chiseled away. It developed that this was a serious mistake. Following removal of the hard cortical bone, there was little remaining strength in the soft more cancellous portion, and after the appliance had been slipped over the end of the bone and bolted into place, it was realized that the bone very likely would break as a result of the strong muscle pull. The head of the appliance fitted well into the acetabulum. Passive motion of the hip could be carried out in almost a normal manner. The capsule of the hip joint which had been dissected away was sutured, the muscles and tendon attachments about the trochanteric region were fastened to the appliance by suturing their ends through the metal loops provided. The deep fascia was closed, helping to hold the appliance securely in place, and the soft tissue of the wound was closed in layers without drainage. The limb was suspended in balanced traction in a hinged Thomas splint. The postoperative convalescence was somewhat stormy, but very satisfactory. A few days after the operation it was found that in moving this large muscular limb, the bone had fractured as expected. With this sequestrum of bone separated and lying within the appliance where it could not be nourished by normal blood supply, there developed liquefaction necrosis, and a large amount of fluid accumulated in the deep tissues. It was feared that the entire area would break down with infection, and that the project would fail. 6 weeks following implantation of the appliance, another operation was performed. At this time the necrotic sequestrum of bones was removed. It was most interesting to observe that the soft tissues had adhered to the vitallium appliance so firmly that the periosteum had to be elevated in almost the same fashion that normal periosteum is stripped from normal bone. Following this observation, the authors were encouraged, and hoped that complete healing would take place, and that the appliance would be embedded in a normal bone involucrum. By means of skeletal traction the limb was held in suspension, and the lower fragment of the bone was kept in end-to-end apposition with the vitallium appliance. Healing progressed, and check-up roentgenograms revealed increasing bony union. 5 months after the operation, union was solid, and the patient was allowed to be up and about on crutches, using a long thigh brace with pelvic band and large lacer cuff about the thigh to support the site of the fracture. Very soon, he was bearing full weight on the limb, and there was remarkable freedom from pain. There was voluntary active motion of the hip joint, of approximately 75 per cent of normal. Within 9 months following operation, he walked well without support, and only used a cane for long distances. One year following operation, he not only walked well, but picked up a grown man weighing 215 pounds, and walked about with him. Roentgenograms at this time showed a great mass of new-bone formation, extending from the intertrochanteric region of the femur at the capsular attachment downward, enveloping the vitallium appliance, and solidly uniting it to the lower femoral fragment. The patient continued to improve, and walked well without complaint. Moving pictures made 15 months after operation reveal an excellent functional result. Approximately a year and a half following operation, he began to show clinical evidence of cardiac decompensation. There was some swelling of both hands and feet. An acute cardiac attack developed and he was treated in the hospital over a period of 3 weeks for cardiac failure. He returned to his home and was getting about well when, on June 2, 1942, while sitting on the side of his bed, he toppled forward and expired. Notice was received of his death, and consent for autopsy was obtained. At autopsy, the entire femur and half of the pelvis were removed. A new hip joint with an almost normal appearing capsule and synovial lining were found. The bone specimen was preserved by boiling the bone in soapy water, and drying it in the sun. This specimen shows the extensive involucrum about the vitallium appliance. There was no evidence of recurrence of the giant-cell tumor. The vitallium appeared unaffected by its period of service in the body. It was just as bright and shiny as the day it was inserted and at no point on it was there any evidence of corrosion. This patient was observed and treated over a period of approximately 8 years. An ununited fracture, 15 months' duration, of the femoral neck was cured by drilling and nailing with Moore nails. A giant-cell tumor was treated by roentgenotherapy, curettage, and massive bone graft. After 6 years, when tumor growth could no longer be controlled and pathological fracture had occurred, the upper 1/2 of the femur was resected and replaced successfully with vitallium.
Copyright remains with the authors and publisher.