THE CLASSIC: Interposition of Vitallium Plates in Arthroplasties of the Knee

Willis C. Campbell was born in Jackson, Mississippi, received his M.D. from the University of Virginia in 1904, and after an internship of two years, he went to Memphis where he practiced in anesthesia and pediatrics. He was not very successful in either venture. He became interested in orthopedic surgery and studied in England, Europe, Boston, and New York. In 1909 he returned to Memphis and set up his practice in orthopedic surgery in a downtown office building. In 1911 he organized the Department of Orthopaedic Surgery in the newly located University of Tennessee College of Medicine and became the first professor and chairman, positions he held for 30 years until his death in 1941. In 1921 the Willis C. Campbell Clinic was opened in the university’s medical center. At first it was a one-story building, but later four stories were added that housed a complete hospital. In 1924, Cambell established a residency training program in orthopedic surgery, the first residency program of any kind in Memphis. It provided essentially the same training recommended by the American Board of Orthopaedic Surgery when it was established about ten years later. Graduates from the Campbell Foundation-University of Tennessee residency program now number approximately 230 and are scattered throughout the United States, Canada, and Central and South America. In 1923 he opened a hospital for crippled adults in an old building on Alabama Street that in 1927 was replaced by a new building financed by a Mississippi philanthropist. It was a complete hospital and for many years was financed by donations from the Rotary Clubs of Mississippi, Arkansas, and Tennessee. It was unique in that it was for indigent adults only. Much major reconstructive surgery was performed there and the hospital was an excellent part of the residency training program. In 1931, with substantial help from Campbell, the American Academy of Orthopaedic Surgeons was conceived and established. Campbell was its first president. He was one of only three men to ever be president of both the American Academy of Orthopedic Surgeons and the American Orthopaedic Association. In the mid-1930s, Campbell saw the need for a general textbook on orthopedic surgery, and in 1939 he published the first edition of Campbell’s Operative Orthopaedics. It became known as the “bible of orthopedic surgery” and has been published through seven editions; some editions have been published in Spanish, French, and Italian, and an Asian edition in English is used in the Far East. In addition, Campbell devised many new operations and surgical approaches that bear his name. The reconstruction of a new joint by arthroplasty is a complicated surgical procedure involving the consideration of many factors. The interposition of fascia lata or other materials as a lining of the new joint is only one of several important steps in the operative technique. The interposition of various metals, as gold and silver, between the articular surfaces of an ankylosed joint is by no means a new procedure, having been tried and abandoned over 50 years ago. Smith-Petersen has revived this principle in arthroplasty of the hip joint, employing an entirely different method whereby a non-irritating metal cap is placed over the head of the femur. He first tried various materials for this purpose, as glass and bakelite, but has recently adopted the use of caps made of the alloy vitallium, which was introduced by Dr. Charles Venable. The cap is not fixed in any way to the bone; thus, free play is possible between the cap and the head of the femur, as well as between the cap and the acetabulum. He has employed this method in a small number of cases of bilateral ankylosis as a result of atrophic or rheumatoid arthritis, with excellent results. The procedure was also carried out in one case of ankylosis following a pyogenic infection; sufficient time had not elapsed since this operation to determine the end result. In one patient, Smith-Petersen demonstrated a fibrocartilaginous lining in the new joint following the interposition of the vitallium cap, similar to the evolutionary physiologic changes observed by the author after the use of fascia lata as a lining membrane, reported in the Robert Jones Lecture in 1930. In Smith-Petersen’s cases, however, a longer period of time had elapsed and the evolutionary process had reached a more mature stage at the time of operation than in those of the author; further, a smoother and more normal contour of the interior of the joint was obtained than in the author’s cases, wherein fascia lata had been interposed. Venable has also employed a vitallium cap for lining the joint in arthroplasty of the hip. He fixed the cap by a metal screw, allowing motion only between the cap and acetabulum. These measures have not been tried by a sufficient number of surgeons, nor has a proper length of time elapsed to permit an estimation of their true value, but the results shown by Smith-Petersen warrant further investigation. With this in mind, the author has interposed a vitallium plate in two patients with ankylosis of the knee following acute pyogenic infectious arthritis. The technique of the operation is similar to that described by the author for arthroplasty of the knee wherein fascia lata is used, although slightly less joint space was created than has been customary for the interposition of the membrane. Prior to the operation, the size of the plate was estimated from roentgenograms and constructed to fit over the anterior surface of the lower end of the affected femur. Since the anatomy of the knee joint precludes the interposition of metal without internal fixation, the plate was maintained in position by two posterior triangular flanges hooked into the posterior surface of the condyles, and by one vitallium screw inserted into the anterior surface of the shaft of the femur. In the two cases in which this plate has been interposed, we have been disappointed in the amount of motion obtained. This may perhaps be due to an inadequate joint space. In the future, we plan to enlarge the joint space for interposition of vitallium to equal that of joints which are lined with fascia lata. The proper joint space between the articular surfaces of the femur and tibia is approximately ¾ inch. We are now working on a modification of these plates in order to obtain one which can be more easily removed, if necessary. We are also attempting to model a plate to fit the upper end of the tibia, to be used instead of the plate on the lower end of the femur. Our results following arthroplasty of the knee wherein fascia lata was interposed have been so satisfactory that this material will by no means be discarded until some other substance can be secured which will minimize the operative procedure and provide an even more normal joint. In science, one should possess an open mind, and if the results can be improved by new methods, they should be adopted. It is in this spirit that we are now using vitallium plates in arthroplasty of the knee. A further report will be made after the trial of this metal in a larger number of cases.* CONCLUSIONS The use of vitallium in the reconstruction of a new joint is in the experimental stage, and the ultimate outcome of these cases is at present doubtful. Smith-Petersen’s results in the hip have been encouraging and have led the author to try this method in the knee joint. Sufficient length of time has not elapsed, however, to determine whether or not the interposition of vitallium in the knee will be of permanent value, as the problems connected with arthroplasties in this joint differ materially from those in the hip. A further report will be made on these cases when sufficient time has elapsed to determine the end results. Acknowledgment is made of the services of Dr. Harold B. Boyd, who furnished material aid in the construction of this cap.

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