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.

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...

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.

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.

Limb reconstruction after high energy trauma.

Limb reconstruction techniques rely on stable external fixation to provide early limb function after major long bone injury. Bone may be generated by callus distraction techniques and internal techniques of moving bone segments used to fill bone defects. Soft tissue defects may be treated by acute shortening, although skin defects will also close spontaneously during bone transport as the leading edge of bone is covered with granulation tissue. External fixation is also used to cross joints permitting rest and repair of the joint. Hinges placed within the bars of the fixation frame may be used to correct deformities in the bone and soft tissue contractures using closed distraction techniques. These techniques are appropriate to metaphyseal fractures and diaphyseal fractures with bone loss. A major advantage is the lack of donor site morbidity, associated with skin flaps and large bone grafts. Acceptance of these techniques is growing whilst the methodology continues to improve. In more complicated cases, specialist training and dedicated hospital units with multidisciplinary support is desirable.

[Bone lengthening. History of the development and field of applications]. / Knogleforlaengelse. Udviklingshistorien og anvendelsesmulighederne.

Leg lengthening has been performed since early in this century. The first successful lengthening was reported in 1905. Leg lengthening evolved from forced lengthening of the bone during anaesthesia, through use of cortical bone grafts, plate and screws to callus distraction (callotasis). Development of external fixators and evolution of biological concepts of bone regeneration has been important. In 1951 Ilizarov developed his apparatus. Ilizarov pioneered the biology of bone and soft-tissue regeneration. He performs a percutaneous subperiosteal corticotomy and waits five to seven days prior to distraction with a rate of 0.25 mm of length four times each day. The method has increased the opportunities in reconstructive bone surgery. The technique is difficult with many problems and obstacles which can be overcome.

Development of the small AO fixator to the current set.

An indirect system to reduce and hold comminuted fractures of the distal radius was developed in the mid 1970's starting with a simple threaded distraction rod and advancing to a versatile system of rods and universal clamps. This system has gained wide acceptance since then and is used for the wrist joint and for other indications in surgery of the hand, the upper limb, the foot and in paediatric orthopaedics.