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 1
DR. Fathi Neana , MD
DR> Fakhry & Alrajhy Hospital

2. 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

4. CUMULATIVE EFFECT OF MANKIND EXPERIENCE
BEFORE 1950’S
STATUS OF EXTERNAL FIXATION.
AFTER 1950 ->> 1958
UNSTABLE INTERNAL FIXATION
1958 – 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 Review
Evolution of Fracture Management
ANCIENT ORTHOPAEDICS
PRIMITIVE MAN
ANCIENT EGYPT
ANCIENT GREECE
THE ROMAN ERA
THE 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

5. Most fractures can be reduced by
closed reduction (Ligamentotaxis)
exceptions include Articular & forearm
fractures

6. 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

7. 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)

8. 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.

9. 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

10. 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.

11. 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.

12. 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.

13. 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)

14. 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

15. 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

16. 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)

17. 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.

18. Abraham Colles
(1773-1843)
• He was the first to tie the subclavian artery
• best known for his description of Colles'
fracture, in 1814

19. 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.

20. Antonius Mathysen
(1805-1878)
Dutch military surgeon
Plaster of paris Bandage
( POP Bandage)
1851

22. 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.

23. GURLT (1862)
Open Reduction is the last resort after
Prolonged failures
Of non-operative treatment
LAURENT (1870)
Primary internal fixation could not
begin
until infection was put under control

24. 1877
Developed the Antiseptic Wound
Treatment
Carbolic Acid
1883
Primary Silver Wiring of patellar
fractures
Report 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)

25. 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.

26. 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.

27. Alexander Fleming
(1881-1955)
Lysozymes
1921
Penicillin
1928
Nobel Prize
1945

28. 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.

29. 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.

30. Hansmann 1886
Fiirst report on Plate fixation
William A. Lane (1856-1938)
No Touch Technique
Book on Operative Fixation 1905
Use of his Plate
1907
Elie Lambotte (1866 - ---)
The term Osteosynthesis
Plate & External clamps
1907
Oneil Sherman (1880-1979)
Town & Gilfillian 1943
Eggers 1948

31. First x-ray
Frau Roentgen Lt. hand
1895
Wilheim Roentgen
(1845-1923)
Nobel Prize for Physics
1901

32. 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.

33. The Modern Era
( 2OTH CENTURY ORTHOPAEDICS )
The discovery of the X-ray
almost marked 1900 and
Orthopaedics itself was only
now being seen as a true
specialty of its own.

34. ROBERT DANIS
THE FATHER OF MODERN PLATE OSTEOSYNTHESIS
1938
FIRST AXIAL COMPRESSION PLATE (COAPTEURS)
1949
THE THEORY AND PRACTICE OF OSTEOSYNTHESIS
RIGID FIXATION - PRIMARY BONE HEALING
(SOUDURE AUTOGENE)

35. HEY-GROVES
1872-1944)
PIONEER WORK ON
INTRAMEDULLARY
FIXATION
PEGS OF
BONE
IVORY
HORNS
SOLID METAL RODS
GERHARD KUNTSCHER
(1900-1972)
FIRST HUMAN IMN
1939

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)

39. Unstable Internal Fixation
Disadvantages of
both
Invasive ( O R I F ) &
Prolonged immobilization
Functional Outcome
Loss of reduction
Fracture disease

40. 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. 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.

42. AO (ASIF) 1958
Functional rehabilitation
Anatomical reduction
Mechanically Stable Fixation
Interfragmentary Compression
No external splints - Early mobilization
Dynamic
Compression
Plate (DCP)
1963 + 1969

43. Gavril Abramovich Ilizarov
(1921-1992)
Circular external fixator
1950
Distraction - Compression

44. AO Principles
Anatomical Reduction
Rigid 0steosynthesis
Absolute Stability

47. Anatomical Reduction
means
Open, Direct,
Subperiosteal
Rigid Fixation
means
Interfragmentary
Compression
Implant - Bone Contact
(Friction)

48. This Mechanically Stable Fixation
Is Mechanically Wrong (stress conc.)

49. Conventional Lateral Plate Osteosynthesis (CLPO)

51. Rigid Osteosynthesis (Internal Fixation)
Mechanically Stable
Early Mobilization
But
Invasive ( O R I F )
More Implant Contact
(Over Fixation)
Biologically Inferior

52. Rigid Osteosynthesis
Is Biologically Inferior
Bone Devascularization
Delayed union
Metal failure
Infection
Repeat interferences

53. Unstable and Rigid internal fixation
Unsatisfactory outcome in Both