External fixation of the lower extremities: Biomechanical perspective and recent innovations.

The concept of supporting fractured long bones externally with mechanical fixation has been evidentially applied for over 2000 years, and since been expanded on in the mid-19th century by percutaneous bone fixation. Surgical techniques, external fixator systems, and materials have made continued progress since. The benefits of traditional external fixation have been enhanced in recent years with the introduction of hexapod-style fixators, innovative configurations, and pin modifications, among other things. It is generally agreed upon that biomechanical testing of advancements in external fixation must be inclusive of transverse or torsional loading to simulate construct behaviour in realistic scenarios. Biomechanical studies indicate that hexapod-style fixators show comparable axial stiffness to Ilizarov-style systems and improved performance under torsional and transverse forces. The addition of configuration elements to fixators, inclusion of certain carbon fibre chemical compositions, and techniques intended to augment ring thickness have also been investigated, in hopes of increasing construct stiffness under loading. Novel external fixators attempt to broaden their applications by rethinking bone mounting mechanisms and either expanding on or simplifying the implementation of 3D bone segment transport for corrective osteotomy. Older and seemingly unconventional fixation techniques are being rediscovered and evolved further in order to increase patient comfort by improving everyday usability. The development of new pin coatings can potentially enhance the pin-bone interface while lowering infection rates typically expected at thicker soft tissue envelopes. Although complication, malunion, and nonunion rates have decreased over the past 50 years, the clinical results of external fixation today can still be optimized. Unsatisfactory healing in the lower extremities has especially been reported at locations such as the distal tibia; however, advancements such as osteoinductive growth hormone treatment may provide improved results. With the current progression of technology and digitization, it is only a matter of time before 'smart', partly-autonomous external fixation systems enter the market. This review article will provide a versatile overview of biomechanically proven fixator configurations and some carefully selected innovative systems and techniques that have emerged or been established in the past two decades.

A Brief History of Limb Lengthening.

In the last 35 years, orthopaedic surgeons have witnessed 3 major advances in the technique of limb lengthening: "distraction osteogenesis" facilitated by Gavriil Ilizarov method and infinitely-adaptable circular fixator with fine-wire bone fragment fixation; the introduction of the "6-strut" computer program-assisted circular fixators to effect complex deformity correction simultaneously; and the development of motorized intramedullary lengthening nails. However, the principles and associated complications of these techniques are on the basis of observations by Codivilla, Putti, and Abbott from as much as 110 years ago. This review notes the contribution of these pioneers in limb lengthening, and the contribution of Thor Heyerdahl principles of tolerance and diversity to the dissemination of Ilizarov principles to the Western world.

The Evolution of Remote-Controlled Intramedullary Lengthening and Compression Nails.

The operative elongation of limbs has long been a goal of orthopaedic surgeons. Indeed, the very first external skeletal fixators, although designed for stabilization of displaced fractures, were also used to overcome the posttrauma shortening that so commonly accompanies fracture deformities.

History of external fixation for treatment of fractures.

Surgery in the first half of the nineteenth century was primarily dominated by pain and fear of lethal infections. Therefore, the absolute majority of fractures and dislocations were treated non-operatively. Development of operative treatment of fractures was influenced by three major inventions: anaesthesia (1846), antisepsis (1865) and X-rays (1895). The first to use external fixation is traditionally considered to be Malgaigne (1843). However, his devices cannot be really considered as external fixation. The external fixation device invented by Lambotte in 1902 is generally thought to be the first "real fixator". In America it was Clayton Parkhill, in 1897, with his "bone clamp" who started the process. Both Parkhill and Lambotte observed that metal pins inserted into bone were tolerated extremely well by the body. Mainly on the basis of their research findings, many external fixation devices have been and are being developed.

Evolution of the Hoffmann Fixators.

Dr. Raoul Hoffmann of Geneva, Switzerland with the collaboration of Henri Jaquet developed the original Hoffmann external fixateur as a system for treating broken bones without necessarily opening a fracture site to reposition the bone ends. This system has evolved to a more flexible, modular concept with input from surgeons and engineers. In this chapter the modifications of the Hoffmann family of fixators are traced and the important steps in the development of the concept and the instrumentation emphasized.

The Balkan beam - Florschütz frame and its use during the Great War.

We remember the military medical practice of Croatian surgeon, Vatroslav Florschütz (1879-1967), known for his invention of the traction frame for repositioning bone fracture fragments of the upper and lower extremities. The method, known as the Balkan frame / beam or Balkan splint, was introduced and published in 1911 and used in war medicine thereafter. The memory of this invention adds to our orthopaedic heritage and sheds light on its creator working under the most demanding war circumstances. On the occasion of the 100th anniversary of the outbreak of World War I, reminiscence of Florschütz's war experience, his orthopaedic innovation and other innovations contributes to our understanding of human efforts to save lives and restore bodily function of the wounded during wars.

[Historical aspects of external fixation and possibilities for the future developement].

External fixation is not such a novel method, but it is interesting to learn its history, countries in which it has developed and the time when it gained full expert acceptance in treating not only fractures but orthopedic disorders, inequalities, and articular arthrodeses. The beginnings of external fixation are associated to the name of Malgaigne, followed by the authors of Western European, German and American school of external fixation. In the U.S.A., this method was accepted as late as in 1950s; being accepted in Russia through Ilizarov. In our country, the method was accepted in 1950s, through the work of Prof. Bumbaireviae and Prof. Raduloviae, who are the founders of modem external fixation in our country.

Recuperación de fijación externa RALCA en el Hospital General Docente de Placetas / Recovery of external obsession RALCA in the Educational General Hospital of Placetas

Los fijadores externos en la cirugía ortopédica y traumatológica constituyen actualmente, junto al sistema de compresión interna (AO), las endoprótesis, las técnicas de microcirugía y artroscopia; los pilares fundamentales donde descansan la gran mayoría de los tratamientos quirúrgicos de la especialidad...

The external fixatives in the orthopedic surgery and traumatológica constitute at present, next to the system of internal compression (AO), the endoprótesis, the techniques of microsurgery and artroscopia; the fundamental pillars where rest the great majority of the surgical processing of the specialty...

Orthodontics in 3 millennia. Chapter 14: surgical adjuncts to orthodontics.

Around 1970, after overcoming obstacles related to anesthesia, infection, and blood supply, orthognathic surgeons come into their own. The history of cleft lip and palate treatment has a much earlier beginning because a deformed infant evokes a strong desire to intervene. Angle's belief that orthodontists can grow bone finally came to fruition with the advent of distraction osteogenesis, which developed from the limb-lengthening procedures of Ilizaroff in Russia. Now distraction osteogenesis has replaced osteotomies in many applications.

Mandibular fractures: Historical perspective.

The principles of the treatment of mandibular fractures have changed recently, although the objective of re-establishing the occlusion and masticatory function remains the same. Splinting of teeth is an old way of immobilising fractures but the advent of modern biomaterials has changed clinical practice towards plating the bone and early restoration of function. We present a brief historical overview of techniques and systems that have been used for stabilisation of mandibular fractures.

From unstable internal fixation to biological osteosynthesis. A historical overview of operative fracture treatment.

The first techniques of operative fracture treatment were developed in the 19th century. In fact, these methods only consisted of an open reduction of the fracture followed by a usually very unstable fixation. This method gave rise to the combination of the disadvantages of the conservative and the operative fracture treatment: the fracture had to be opened with a real risk for (sometimes lethal) infection, the bone healing was disturbed, there was muscular atrophy and joint stiffness. The successes were very rare and catastrophes were often seen. Küntscher's endomedullary rods can be considered as the first useful implants in the treatment of diaphyseal fractures. Reaming of the medullary canal and the development of interlocking nails have enlarged the indications for intramedullary nailing. The classic Dynamic Compression Plates from the seventies were the key to a very rigid fixation, leading to primary bone healing. Nevertheless, the use of strong plates and reamed nails disturbed the vascularisation of the bone fragments, leading to a high infection rate (particularly in open fractures) and delayed union (particularly after plate and screw fixation). These insights lead to the development of the "biological osteosynthesis" : a terminology introduced to indicate a new type of osteosynthesis leading to a sufficiently stable fixation of the bone fragments allowing early mobilisation, but without major disturbance of the vascularisation. The unreamed nail can also be considered as a biological osteosynthesis and in a lot of cases it is the implant of choice for tibial and femoral shaft fractures, especially in polytrauma patients. Finally, some new devices contributing to the principles of biological osteosynthesis like locking plates and the LIS-System are gaining popularity.

The evolution of posterior cervical and occipitocervical fusion and instrumentation.

The past several decades have been the setting for a remarkable evolution of spinal instrumentation technology. The advancements that have been made have allowed previously complex disorders of the cervical spine, the atlantoaxial articulation, and the occipitocervical junction to be managed more effectively with direct methods of internal fixation and arthrodesis. This has resulted in improvements in patient outcomes and fusion success rates. The improved strength of instrumentation constructs allows minimal, if any, external bracing, obviating the need for a halo orthosis in many cases. In this paper the authors review key events that have occurred in neuroimaging, biomechanical testing, and the development of fusion and instrumentation constructs.

The history of external fixation.

Even though external fixation is considered to be a rather "new" trend in orthopedics and traumatology, in fact it has been something used by physicians and surgeons for thousands of years. In the mid 1800's, external fixation would see some substantial growth and evolution, pioneered by physicians and surgeons whose principles are still in use today. Through the 1900's, the indications and usage would continue to expand, not to mention the modernization of the external fixation apparatus. Many surgeons in this era are notable for their work with external fixation, especially Gavriel Ilizarov, considered to be the father of external fixation. Further research and development with external fixation needs to be performed and, with time, will more than likely become fully integrated into modern clinical practice.

External fixation indications and patient selection.

Since its modest beginnings in the mid-nineteenth century, external fixation has seen great changes in its design and application. Once thought of as chiefly a fracture management tool, this modality has found its way into the arenas of corrective osteotomies, Charcot management, limb lengthening, nonunion treatment, and malalignment correction. As external fixation has evolved, great improvements in associated complications have also occurred. This is attributed to evolving frame design, subsequent increased stability, and advances in pin/wire insertion techniques. Paley and Herzenberg describe three factors to consider when evaluating whether to use external or internal fixation [2]. 1. Risk versus benefit of the method used for that specific indication. 2. Surgeon's experience with the specific method. 3. Ability to treat the potential complications of the surgery. The authors agree with these factors but would also include psychological tolerance, compliance with postoperative self-treatment, and personal hygiene. In this article the indications for external fixation were described in terms of pathology and individual patient factors were discussed for the surgeon's consideration. The surgeon must consider the patient's bone quality, age, cognitive ability, psychological tolerance, and compliance level. With these factors kept in mind and evaluated appropriately, the surgeon should be able to select the patient and indications for which external fixation will yield a superior result.

Preoperative reduction of spondylolisthesis.

The treatment of SL, especially in some cases, is mostly surgical. This lesion can be considered an extremely localised kyphosis (only two vertebrae) or a localized (sub-)luxation: at most hearetically pre-operative reduction should represent the first stage of the treatment, also because reduction makes further surgery easier and enables us to obtain the best results. After a glance at the various surgical techniques that have been used in the past, we describe our method of preoperative reduction in case of severe SL, an improvement of Scaglietti's original technique. According to the parameters taken into consideration, spondylolisthesis (SL) of the 4th and, above all, the 5th lumber vertebrae can be considered, especially in severe cases, as kyphosis or displacement (or even dislocation in the case of ptosis). In SL-kyphosis the antero posterior axes of the contiguous vertebral bodies are no longer parallel but tend to over-impose one to the other anteriorly forming an open posterior angle of varying degrees. It is an extremely short kyphosis (only two vertebrae) but from all points of view, even therapeutic, it reflects the characteristics of all types of vertebral kyphosis. SL-subluxation or SL-luxation (ptosis) is characterized by the respectively partial or total loss of normal alignment between the vertebrae involved. This can be explained by the fact that nearly all those who have dealt with the problem of treating SL, especially of L5, always ask themselves beforehand if it is possible and/or opportune to eliminate or improve the condition before surgery. In other words the question of reduction (pre or intraoperative, partial or total) of more or less severe L5 SL is always considered by all authors, even if their conclusions are often in disagreement.

[Fritz König (1866-1952): pioneer of osteosynthesis and his influence on traumatology]. / Fritz König (1866-1952). Wegbereiter der Osteosynthese und seine Einflüsse auf die Unfallheilkunde.

Fritz König (1866-1952) was 1918-1935 ordinary professor of surgery at the University of Wuerzburg. A main interest of his work was the technique and indication of osteosynthesis. Since 1900 he investigated methods (wire suture, intra- and extramedullary splint, external fixator, plate) and materials (ivory, steel; wire, screws). All his life he aimed to standardize the technique of osteosynthesis, to work out and spread clear indications for the surgical treatment of fractures, and to carry his point against the resistance of the social accident insurance caused by bad results of a lot of surgeons. His importance is not based on the invention of a great deal of instruments but on his endeavour for the fundamentals of osteosynthesis.