Fixation of FracturesHistorical Review

Part 1

DR. Fathi Neana , MDDR> Fakhry & Alrajhy Hospital

The past is our foundation for future developments

We must build upon it so that we too can act as a stable foundation for future

generations

One must be aware of the way Surgeons in the past have contributed to

Orthopaedics

CUMULATIVE EFFECT OF MANKIND EXPERIENCE BEFORE 1950’S STATUS OF EXTERNAL FIXATION. AFTER 1950 ->> 1958 UNSTABLE INTERNAL FIXATION1958 – 196 0 ->> 1990 RIGID INTERNAL FIXATION –ABSOLUTE MECHANICAL

STABILITY (AGGRESSIVE TRAUMATOLOGY)AFTER 1990 BIOLOGICAL OSTEOSYNTHESIS LIMITING SURGICAL

TRAUMA (2ND HIT) 1- LESS INVASIVE SURGICAL TECHNIQUES 2- LIMITED IMPLANT CONTACT

AFTER 2000 COMPUTER-ASSISTED SURGERY (CAS) UTILIZING

ROBOTIC OR IMAGE-GUIDED TECHNOLOGIES REMOTE SURGERY (ALSO KNOWN AS TELESURGERY)

Fixation of Fractures - Historical ReviewEvolution of Fracture Management

ANCIENT ORTHOPAEDICSPRIMITIVE MANANCIENT EGYPTANCIENT GREECETHE ROMAN ERATHE ARAB (ISLAMIC) ERA

THE FOUNDATIONS OF MODERN ORTHOPAEDICS

AFTER THE L2TH CENTURY . EUROPE AWAKE FROM ITS DARK AGES

THE MODERN ERA (2OTH CENTURY ORTHOPAEDICS)

THE DISCOVERY OF THE X-RAY WORLD WAR ONE & TWO

THE 21ST CENTURY

Most fractures can be reduced by closed reduction (Ligamentotaxis)

exceptions include Articular & forearm fractures

The Problem was

How to maintain the reduction till complete union

How to fix or immobilize the reduced fracture

This field rapidly progress after the world war II

Evolution of fracture management• Before 1950’s- status of External Fixation.• After 1950’s - 1958 – Unstable internal fixation• 1958 – 1960 ->> 1990 – Rigid internal fixation –Absolute

mechanical stability (AGGRESSIVE TRAUMATOLOGY)• After 1990’s Biological Osteosynthesis Limiting Surgical

trauma (2nd Hit) 1- less invasive surgical techniques 2- Limited Implant contact

• After 2000 Computer-assisted surgery (CAS) utilizing robotic or image-guided technologies

• Remote surgery (also known as Telesurgery)

Primitive Man

• We can see the effects of no treatment at all, i.e. applying rest by instinct and early motion.

• Crude splint, Amputations of limbs and fingers, and to Trephine the skull.

Ancient Egypt (5000 Years B.C.)

• Splints have been found on mummies and they were made of bamboo, reeds, wood or bark, padded with linen.

• There is also evidence of the use of crutches, with the earliest known record of the use of a crutch coming from a carving made in 2830 BC on the entrance of a portal on Hirkouf's tomb.

Imhotep

Ancient Egypt

• In the papyrus (a book), the examination of peripheral was described.

• In this papyrus, injuries were classified according to their prognosis into three categories: – an ailment which they would treat, – an ailment that they would contend

and – an ailment which they would not treat.

• The papyrus also mentioned many cases and the treatment involved.

Ancient Greece

• Many principles behind conditions and their treatment have been attributed to the Ancient Greeks.

• They could be regarded as the first to use a scientific approach.

• They were also the first to document in detail their history and developments.

Roman Era

• Galen (129-199 BC). "the father of sports medicine". • He gave a good account of the skeleton and the muscles

that move it. • He first recorded a case of cervical ribs. • He described bone destruction, sequestration and

regeneration in osteomyelitis and sometimes performed resection in such cases.

• During this Graeco-Roman period, there were also attempts to provide artificial prostheses.

• It is said that both linen and catgut sutures were used for the procedures.

• Various drills, saws and chisels were also developed during this period.

Arab (Islamic) Era

• Although the Arab practices were regarded as an extension of those of the Greeks, the use of plaster-of Paris in the l0th century was significant.

• With the addition of water to a powder of anhydrous calcium sulphate a hard crystalline material was produced.

Al-Razi (Razes), 841-926 A.D.Ibn-Sina (Avicenna) 980-1037 A.D. Al-Zahrawi (Albucasis) 930-1013 A.D. Ibn al Quffi (630 AH/1233 CE - 685 AH/1286 CE)

Traumatology & orthopedics: Al Zahrawi and al Quffi described treatment of bone and joint trauma. Al Zahrawi wrote about osteomyelitis, amputations, and ostotomies for un-united fractures. Al Zahrawi cautioned against above-knee and above-elbow amputations.

Wound treatment: Famous names in wound treatment were: Ibn Sina, Al Zahrawi, Ibn Rushd, and Al Razi. Al Zahrawi taught the following methods of arresting hemorrhage: digital pressure, tourniquet, sponges, cauterization, hypothermia, and ligation of bleeding vessels by sutures of thread. He also advised against tight bandaging. Al Zahrawi emphasized the importance of cleanliness in wound treatment. Ibn Sina mentioned dry dressing. Al Zahrawi wrote about the drainage of abscesses describing in detail the site and shape of the incision, packing of the wound, excision of the skin edges, use of slow decompression of large cavities, dependent and counter drainage.

Arab (Islamic) Era

It was not until the l2th century that Europe began to awake gradually from

its Dark Ages

Until the l6th century, all developments remained within the shadow of previous

Eras

Percival Pott (1714-1788)

• He is best known for the fracture that bears his name Pott's fracture, as he was the first to give a good description of this ankle fracture.

• Pott's most famous work is on the paraplegia of spinal tuberculosis, where he stressed that the condition was not related to spinal cord compression, but associated with strumous disorders in the lungs. This is known as Pott's paraplegia. (Ibn Sina)

John Hunter (1728-1793)

• His saying Don't Think, try the experiment has inspired generations of modern surgeons

• He described how to assess muscle power in a weak muscle.

• He believed that healing depended on the body's innate power, and that the surgeon's task was to aid this.

• He studied loose bodies in joints, pseudoarthroses and fracture healing.

Abraham Colles (1773-1843)

• He was the first to tie the subclavian artery • best known for his description of Colles'

fracture, in 1814

Hugh Thomas (1834-1891)

• Father of British Orthopaedics. • Hugh Owen Thomas was the eldest of

five sons born to a well-known bonesetter at that time.

• Hugh Owen Thomas could not even work with his father and never held a hospital appointment.

• He treated all his patients at his home. • His practice was so busy that he started

his rounds at five or six in the morning and never left his home for other than professional purposes. Thomas would designate Sunday as his free day and hundreds of patients from the country would surround his house in order to be treated.

• The people of Liverpool knew Thomas as a short and quick man. A man who always wore a black coat buttoned up to the neck and a sailors cap pulled over a damaged eye. A cigarette was also seen constantly in his mouth

• Thomas developed a great number of splints the cervical collar, metatarsal bar, heel wedge and knee splint. Many of these are still in use, such as the Thomas splint.

• He was the first to demonstrate concealed flexion of the hip joint and a way of unmasking this by performing the Thomas Test.

Antonius Mathysen(1805-1878)

Dutch military surgeon Plaster of paris Bandage

( POP Bandage)1851

Problems in Surgery

• Infection was a major problem during surgery.

• People often died after surgery from the infection alone.

• Compound bone fractures almost always ended in death because of infections.

GURLT (1862)

Open Reduction is the last resort afterProlonged failures

Of non-operative treatment

LAURENT (1870)

Primary internal fixation could not begin

until infection was put under control

1877Developed the Antiseptic Wound

TreatmentCarbolic Acid

1883Primary Silver Wiring of patellar

fracturesReport of 7 cases

• Lister is known for the introduction of antisepsis.

• He first applied carbolic acid to a compound fracture in 1965.

• It was soon clear that the practices had had a dramatic effect in reducing in particular abscesses.

• have trialed the application of the Penicillium mould directly to wounds.

• Discovered that carbolic acid prevented infection on compound infections.

• By insisting that everything be kept clean and disinfected, he lowered the death rate in his surgeries.

• He discovered it was not the presence of acid bit

• the absence of germs that mattered in surgery.

Joseph Lister(1827-1912)

The Search for the Etiology of Disease

• Robert Koch discovered that anthrax was caused by bacteria.

• He discovered how to grow bacteria in cultures for study, and how to add stain in order to see them.

• Robert Koch proved that most diseases are caused by a particular bacteria.

• Microbiologist, Robert Koch discovered the tubercle bacillus in 1882 where one in seven deaths in Europe was due to TB.

Louis Pasteur(1822-1895)

• Louis Pasteur dismissed t he “miasmatic” theory of disease. He argued that diseases were caused by germs and so effectively established bacteriology as a science.

• Louis Pasteur discovered that chickens could survive cholera when given a weakened form of the disease.

• He found that an anthrax vaccine could be made by heating the bacteria.

• He discovered rabies was caused by a virus instead of bacteria and then developed a vaccine for humans.

Alexander Fleming(1881-1955)

Lysozymes1921

Penicillin1928

Nobel Prize1945

Mold Becomes A Medical Ally in the Battle Against Bacteria

* Alexander Fleming(1881-1955) discovered penicillin which killed staphylococcal bacteria.

* Florey and Chain isolated the chemical and found that it could be mass-produced, making it more affordable.

* Penicillin was stronger (bacteriocidal) that sulfa(bacteriostatic) and had fewer side effects.

The Advent of Drugs

• Dr. Gerhard Domagk(1895-1964) discovered sulfa drugs.

• This drug became world famous when Dr. Perrin H. Long used sulfa drugs to treat Franklin Roosevelt Jr.

• Sulfa was called a “wonder drug” because it killed bacteria but did not hurt the cells of human tissue.

Hansmann 1886Fiirst report on Plate fixation

William A. Lane (1856-1938)No Touch Technique

Book on Operative Fixation 1905Use of his Plate

1907

Elie Lambotte (1866 - ---)The term OsteosynthesisPlate & External clamps 1907

Oneil Sherman (1880-1979)Town & Gilfillian 1943Eggers 1948

First x-rayFrau Roentgen Lt. hand

1895

Wilheim Roentgen(1845-1923)

Nobel Prize for Physics1901

Technology Reigns Supreme

• William Crookes invented the Crookes’ tube which developed into TV’s and Monitors.

* Wilhelm Roentgen invented the x-ray machine by using the Crookes’ tube.

* Because of its ability to see inside the body, x-ray photography is one of the most important medical discoveries.

The Modern Era( 2OTH CENTURY ORTHOPAEDICS )

The discovery of the X-rayalmost marked 1900 and

Orthopaedics itself was onlynow being seen as a true

specialty of its own.

ROBERT DANISTHE FATHER OF MODERN PLATE OSTEOSYNTHESIS

1938FIRST AXIAL COMPRESSION PLATE (COAPTEURS)

1949THE THEORY AND PRACTICE OF OSTEOSYNTHESIS

RIGID FIXATION - PRIMARY BONE HEALING (SOUDURE AUTOGENE)

HEY-GROVES1872-1944)

PIONEER WORK ONINTRAMEDULLARY

FIXATION

PEGS OFBONEIVORYHORNS

SOLID METAL RODS

GERHARD KUNTSCHER (1900-1972)

FIRST HUMAN IMN1939

Evolution of fracture management• Before 1950’s- status of External Fixation.• After 1950’s - 1958 – Unstable internal fixation• 1958 – 1960 ->> 1990 – Rigid internal fixation –Absolute

mechanical stability (AGGRESSIVE TRAUMATOLOGY)• After 1990’s Biological Osteosynthesis Limiting Surgical

trauma (2nd Hit) 1- less invasive surgical techniques 2- Limited Implant contact

• After 2000 Computer-assisted surgery (CAS) utilizing robotic or image-guided technologies

• Remote surgery (also known as Telesurgery)

Unstable Internal Fixation

Disadvantages of both

Invasive ( O R I F ) &Prolonged immobilization

Functional OutcomeLoss of reductionFracture disease

Evolution of fracture management• Before 1950’s- status of External Fixation.• After 1950’s - 1958 – Unstable internal fixation• 1958 – 1960 ->> 1990 – Rigid internal fixation –

Absolute mechanical stability (AGGRESSIVE TRAUMATOLOGY)

• After 1990’s Biological Osteosynthesis Limiting Surgical trauma (2nd Hit) 1- less invasive surgical techniques 2- Limited Implant contact

• After 2000 Computer-assisted surgery (CAS) utilizing robotic or image-guided technologies

• Remote surgery (also known as Telesurgery)

November 6th 1958

• Maurice Müller,• Hans Willenegger, • Martin Allgöwer and …..

• Formed the AO-ASIF group in view of the poor functional results after non-operative Rx of #

• Early restoration of

function, whether a

patient was being

treated for an isolated

fracture or for multiple

injuries.

AO (ASIF) 1958Functional rehabilitation

Anatomical reductionMechanically Stable Fixation

Interfragmentary CompressionNo external splints - Early mobilization

Dynamic CompressionPlate (DCP)1963 + 1969

Gavril Abramovich Ilizarov(1921-1992)

Circular external fixator1950

Distraction - Compression

AO Principles

Anatomical Reduction

Rigid 0steosynthesis

Absolute Stability

Anatomical Reductionmeans

Open, Direct, Subperiosteal

Rigid Fixationmeans

Interfragmentary Compression

Implant - Bone Contact (Friction)

This Mechanically Stable FixationIs Mechanically Wrong (stress conc.)

Conventional Lateral Plate Osteosynthesis (CLPO)

Rigid Osteosynthesis (Internal Fixation)

Mechanically StableEarly Mobilization

ButInvasive ( O R I F )

More Implant Contact(Over Fixation)

Biologically Inferior

Rigid Osteosynthesis Is Biologically Inferior

Bone Devascularization

Delayed unionMetal failure

InfectionRepeat interferences

Unstable and Rigid internal fixationUnsatisfactory outcome in Both

TO BE CONTINUEDIN PART 2

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