We know that 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. This presentation is a brief historical review Mankind's cumulative experience in fracture management which was Started by the Ancient very primitive trials and ended by the presence of Robotic and Telesurgery the so called Remote surgery

1. Fixation of Fractures
Historical Review
Part 2
DR. Fathi Neana , MD
DR> Fakhry & Alrajhy Hospital

2. Unstable and Rigid internal fixation
Unsatisfactory outcome in Both

3. 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)

4. After 1990’s
Biological Osteosynthesis (internal fix)
Research at a cellular level
flourished
Pathophysiology of multiply
injured pt
Concept of systemic
inflammatory response
to trauma.
“second hit” phenomenon.
• Stimulating SIRS
• immunosuppression
• Dec of immunoglobulins ,
interferon
• Anergy
• Delayed hypersensitivity skin-
testing.
• Increased risk of posttraumatic
sepsis

6. Blood Supply to Bone
Arterial
80% endoosteal damaged mostly by
Initial Trauma
20% periosteal damaged by
Surgical Trauma
Venous
100% periosteal damaged by
Surgical Trauma

7. Surgical Trauma
Implant contact
Surgical technique

8. Implant contact

9. Rigid Fixation
in
Transverse or Short
oblique fractures
( stress theory - critical strain )
Elastic Fixation
Any Less Contact
Bridging Device
External fixator
Internal fixator (LCP)
Unreamed I.M.N.

10. REAMED VS. UNREAMED IMN

11. REAMED IMN
MORE RIGID LESS BIOLOGICAL
UNREAMED IMN
LESS RIGID MORE BIOLOGICAL

12. REAMED VS. UNREAMED IMN

13. REAMED IMN IS LIMITED
TO
PSEUDOARTHROSIS
OSTEOPOROTIC BONE
OTHERWISE UNREAMED
IMN
NAILING
IS THE STANDARD METHOD
OF FIXATION FOR LONG
BONES
BUT
UNAPPLICABLE IN MANY
SITUATIONS
WHICH ARE INDICATIONS
FOR
PLATING

14. INDICATIONS FOR PLATING
Articular , Metaphyseal Fractures
Badly comminuted Diaphyseal fractures
Children fractures
Polytrauma with head & chest injury
Presence of prosthesis (thr)
Very narrow or wide medulla
Bowed or deformed long bone

15. DCP (Dynamic Compression Plate)
The Dream (Science Fiction)
Minimal Bone Contact

16. WASHERS
VS.
WAVE PLATE
The Dream (Science Fiction)
Minimal Bone Contact

18. LC DCP
LIMITED CONTACT DYNAMIC COMPRESSION PLATE

19. PC FIX
POINT CONTACT FIXATOR
THE INTERNAL FIXATOR

20. LISS
LESS INVASIVE STABILIZATION SYSTEM

21. LCP
LOCKING COMPRESSION PLATE
DCP PC FIX
LCP

22. LCP
LOCKING COMPRESSION PLATE

23. LCP
LOCKING COMPRESSION PLATE

24. BIOLOGICAL BRIDGE PLATING
LCP ( INTERNAL FIXATOR )
PRE-REDUCTION
4L
LONG PLATE.
LESS SCREWS.
LEAVE SMALL. FIX STRATEGIC FRAGMENTS
LIGAMENTOTAXIS . INDIRECT REDUCTION

25. STRESS THEORY
CRITICAL STRAIN
STRESS CONCENTRATION
RIGID FIXATION
STRESS DISTRIBUTION
ELASTIC FIXATION

26. Surgical technique

27. Open Reduction Condemned
except in
Articular fractures
Forearm fractures

28. CLOSED , INDIRECT
REDUCTION
MINIMAL INVASIVE
MIPPO
LESS INVASIVE
LISS
KEY HOLE SURGERY
(ARTHROSCOPIC)

29. MINIMAL INVASIVE PLATE OSTEOSYNTHESIS
(MIPPO)

30. MINIMAL INVASIVE PLATE OSTEOSYNTHESIS
MIPPO

31. MINIMAL INVASIVE PLATE OSTEOSYNTHESIS
MIPPO

33. Alignment Control
(Closed Indirect Reduction - Minimal invasive – less invasive - Keyhole Surgery)
Length
Angulation
Rotation
Image Intensification
vs.
Computer Assistance

34. Image intensification

35. LENGTH
ANGULATION
Cable Tech
ROTATION

36. 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)

37. Computer Assisted
Orthopedic Surgery
(CAOS)
1- Computer science
2- Space digitization
3- Imaging technology
4- Surgical techniques
Surgical navigation
Robotic assistance

38. Reduction Maneuver Robot
system
Surgical navigation

39. 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)

41. Remote surgery
(Telesurgery)

44. Why Robotic Surgery
A robot is not just a machine
It is an information system with
arms
The robots are actually more
accurate than Human beings
(Robotic Pedicular screws error 0.02% vs 11%
human experts vs 40% learning curve)

45. Total Integration of Surgical Care
Courtesy of Joel Jensen,
SRI International, Menlo Park, CA
Minimally Invasive
& Open Surgery
Pre-operative planning
Surgical Rehearsal
Intra-operative navigation
Remote Surgery
Simulation & Training
Pre-operative Warm-up

46. This presentation was a brief
review of the history of
Mankind's cumulative
experience in Fracture
management
It was Started by the Ancient
very primitive trials and ended
by the presence of Robotic and
Telesurgery