e I/IZ ISTORIJE

The development of internal fixation- historical

UDK 616.71-001.5-089.23(089)
DOI: 10.2298/ACI1203009L

overview

Since the ancient times, man was faced with the antisepsis (1865), X-rays (1895) and antibiotics (1936,1944). In

i
S problem of fracture treatment, which is first de-
mscribed in the records from ancient Egypt. Ever
since, many treatment methods have been developed, but the
real revolution in the fracture treatment was achieved by
internal fixation. Since it rwas described for the first time, at
the end of the 18th century, this method has continuously
developed, but sterilization, radiographies, anaesthesiology,
antibiotics made this surgery modern and safe. The great
ideas and practical solutions of the new methods were done
by Albin Lambotte, William Arbuthnot Lane, Robert Danis,
William Hey Groves. They lead to the expansion of this
method and truly made the principles for the future AO
school. New methods, biological internal fixation, minimally
invasive procedures, new technologies and devices for
internal fixation are introduced in the surgical practice daily.
Key words: fractures, internal fixation, history of
medicine
INTRODUCTION
the following years, the orthopaedic surgery was dramatically
improved. Radiology became an integral part of bone and joint
surgery. All types of osteosynthesis-devices, i.e. plates
(Hansmann 1886), external fixation (Parkhill 1897) and
intramedul- lary nails (König 1913) were introduced into clinical
prac- tice3,4. Extrenal fixation still remains the usefull device for
treating open fractures, in compression of non-union, or
distraction. But, this is special kinds of external fixation, and this
concept is different to the internal fixation one. Basic
experiments were undertaken, surgical approaches described and
the first textbooks on osteosynthesis published by Hey Groves in
1916 (textbook: "On modern method of treating Fractures")1.
Because of the antiseptic technique, anaesthesia and x-ray,
introduction of alloys in 1912, and innovation of stainless steel
(1926) made real improvement in internal fixation. Afterward,
the real inert material were founded, like titanium.
Beginnings - early stages of fracture treatment. It is generally
considered that the first fixation of the ragments were done by
wire ("cerclage")6. According to the Mal- gaigne, first such

T he term "Osteosynthesis" has origin in Greek words procedure was performed in 1770 in Toulouse in France, by
"osteo", which means "bone" and "synthesis" as Lapujode and Sicre7.
"combining separate materials or elements into a united entity".
Osteosynthesis is a term for surgical techniques to treat fractures
of bone using specially designed metal plates, screws, nails and
other devices which is usually removed after the fracture union.
All these procedures have one aim - to achieve the bone union,
mobility and return to normal function and to avoid
complications associated with conventional methods using plaster
cast or skeletal traction.
Although one of the first description of the fracture ma-
nagement dates from Ancient Egypt (2600 B.C.), the first
description of the real fixation was in the 18th century 1.
Rapid industrialisation in the 1900’s, the appearance of the
first car and road traffic accidents (RTA), World War I resulted
in increased needs for fracture treatment worldwide. At XIX
century, conservative treatment was preferable and the pioneer of
the conservative treatment was the Austrian physician Lorenz
Böhler. His method was based on the reduction of the bone,
immobilization using plaster casts or skeletal traction and early
physical exercises in order to avoid complications such as joint
stiffness and/or muscle atrophy1,2.
Bohler methods were popular because in the first half of the
nineteenth century, surgery was compromised by pain and
infection, which resulted in the lethal outcome in many of the
cases. The possibility of the operative treatment of fractures was
enabled by the four major inventions: anaesthesia (1846), Serbia, Belgrade
 10 The development of internal fixation ACI Vol. LIX

The fixation of bone fragments using an iron wire was

mentioned for the first time in a French manuscript in 1775.
Nevertheless, the first internal fixation of a fracture using an iron
wire was contributed to Kearny Rodgers in 1827, who resected
the pseudoarthrosis of the humerus and than connected the
fragments with silver wire. The use of cerclage wires remained
popular in this period. The father of the well-known French
writer Gustav Flaubert, dr Achille-Cléophas Flaubert, had done
1838 the cerclage of the open fracture of the humerus. Jozef
Lister is not only the father of asepsis, he also used metal wires
to fix even closed fractures since 18708.
This technique was adopted by Trendelenburg in Germany and
by Lucas Championnire in France6. In all those cases,
"osteosynthesis" consisted of an open reduction of the fracture
followed by a very unstable fixation with cerclage wires. (Figure FIGURE 2:
1) HANSMANNS INTERNAL FIXATION OF THE FRACTURES
The first book, where the internal fixation has been mentioned,
spent a lot of time, both in the operating room and his workshop,
was published 1870 with the title "Traité de l’immobilisation
producing his own internal fixation devices and instruments for
directe des fragments osseux dans les fractures" ("About direct
fracture treatment. Afterward he started to use it in the patients.
immobilisation of the bone fragments in fracture") by Bérenger
Lambotte pushed his students to train in the workshop, believing
Féraud (1832-1900). In this book he described the three cases of
that this is an excellent opportunity for the orthopaedic training.
tibia fractures, which he treated by cerclage after conservative
His relationship to students and residents was dedicated 9. In 1905
treatment failure6.
Lambotte begin to use plates. And in 1908 he published the
SCREW FIXATION results of his work of the internal fixation of the 35 femur
fractures. He was known as a very skilled surgeon and he also
The methods of screw fixation was first described by the group play violin. Privately he also made 182 violins. Actually he was
of French surgeons in the case of patients with sternum and hard working person who told the important sentence, before he
olecranon fracture. This was the improvement compared to the died: "the greatest crime a man commits against himself and
fixation with the cerclage. This was the interfrag6mental fixation, humanity is to be inac- tive."9 But he died in poverty at age of 90
which was exactly denoted to the fracture6. years. Beside Lambotte, another doctor who was responsible for
and contributed to the use of internal fixation in the fracture
PLATE FIXATION
treatment was is Scottish surgeon Sir William Arbuthnot Lane
The first fracture fixation with plate had been performed in (1856-1938) (Figure 5). In 1915, Sir William Ar- buthnot Lane
1886 by German surgeon Hansmann5,6. The plate could bend published his classic work about fracture treatment "The
distally under right angle, and after the plate was placed on the Operative Treatment of Fractures" (Figure
bone, it protruding from the skin and this enable its easier
removing. The screws were also similarly designed, they
protruded above the skin in order to make the removing easier
(Figure 2).This was the half way to external fixation.
The man who introduced the term of osteosynthesis and the
father of internal fixation was the Belgian surgeon Albin
Lambotte (1866-1955) (Figure 3). His father was an army
surgeon, and often studied in the dissecting room. Lambotte
became the surgeon in Antwerp in the year 1890 and in 1902 he
started to dealing with fracture treatment. Earlier he faced
cholera, diphtheria, he performed spinal surgery, cerebral
hematoma drainage, treated ostearticular tuberculosis. In 1892 he
introduced the "no touch" technique, which makes surgery safe
(Figure 4). His first fixation was the fractured tibia when he fix it
with the plate, but corrosion occurred. In 1902, he performed
osteosynthesis of the femur. During this period he

FIGURE 1:
FIXATION OF THE FRACTURE BY THE CERCLAGE-THE
EARLY METHOD

(
Br. 3 A.R. Lesic et al. 11

factors-occupation to the structure of skeleton-bone and he

stated: "the form of the skeleton depends upon and varies with
the mechanical relation of the individual to his surroundings." 5
He also introduced "non touch" technique in the orthopaedic
surgery of that time. He was a perfectionist and unsatisfied with
the fracture treatment. Thus Lane in 1883 wrote on fractures,
making conclusion that the open reduction with rigid fixation
was necessary10. That was very brave for that time. Actually he
started the new era in orthopaedic surgery in 1905, he used plates
(Figure 7). Despite the criticism of some colleagues for
"unjustifiable procedure", he continue with his work - operative
treatment of fractures. He treated the nonunion of the neck of the
femur with two long screws from the greater trochanter, through
the neck into the femoral head,
achieving union 5,9.
To obtain reduction and control of the fracture, Lane used two
pairs of bone forceps with long handles, which kept the hands
well away from the wound. No-touch technique was the base of
Lane’s fracture surgery. But, Lane was eccentric, and some
called him dangerous man, because he treated people with bone
tuberculosis and rheumatoid arthritis with illeocolonectomy
because he thought the cause of these diseases was constipation.
This was quite strange, but anyhow he made the basis of fracture
surgery. After he retired he start to promote healthy life, and in
FIGURE 3: 1913 become Sir.9
ALBIN LAMBOTTE (1866-1955) Another famous name in the field of internal fixation is Ernest
William Hey Groves (1872-1944), an English surgeon. Before
the days of the Smith-Petersen nail, he fashioned pins from beef
bone and horns to made fixation of the fractures of the neck of
the femur.
The great contribution to the modern treatment of hip fractures
was given by Austin Talley Moore (1899-1963). Austin Moore
was a pioneer in the use of the femoral- head prosthesis which
enabled many elderly patients a chance to survive.9
OSTEOSYNTHESIS
The term "osteosynthesis" was used by the Belgian surgeon
Robert Danis (1880-1962)8. His work "Théorie et pratique de
l’ostéosynthse" had a great influence on the future German-Swiss
AO school. In the 1949 he described the main principles of
internal fixation: "In order to be completely satisfactory, internal
FIGURE 4: fixation must fulfill the following three requirements. (1)
LAMBOTTE IN THE OPERATING THEATRE Enablement of immediate, active movement of muscles in the
affected region and the adjacent joints. (2) Complete restoration
6).The first interfragmental fixation was done by him and from of the original shape of bone.(3) Direct union of the bone
1892 he treated every fracture with internal fixation. He wrote: fragments without the formation of visible callus"5
"Therefore I decided to treat the bones as one would the broken Pioneers of the surgical treatment of the fractures were Albin
leg of a table or chair. The surfaces were brought into accurate Lambotte, Robert Danis, Fritz Konig, William Lane and Gerhard
apposition, and kept in their normal relationship with lion Küntscher enable the AO school2,11. Actually, the founders of this
forceps. Holes were drilled above and below the forceps, and school only refreshed their ideas and made them more
screws were driven in". (from "A method of treating simple "scientific" in terms of modern language.
oblique fractures of the tibia and fibula more efficient than those AO school is a German- Swiss group who provided a
in common use.", W.Arbuthnot Lane, M.S,1894)5. He qualified systematic approach to the fracture treatment which can be
as a member of the Royal College of Surgeons in 1877, but was reproduced by surgeons all over the world. AO (Ar-
advised to take a London degree in 1881. The following year he beitsgemeinschaft für Osteosynthesefragen, ger.) was
became a Fellow of the Royal College of Surgeons- FRCS. At founded in the 1950s in Switzerland by Maurice Müller,
the beginning he was denoted for the internal medicine, but as he 12
was noticed in dissection room, as an anatomy demonstrator, Martin Allgöwer , Hans Willenegger, Robert Schneider and
where he was recruited for the surgery. Lane performed research many other general and orthopaedic surgeons, engineers and
into the function and he noticed the influence of the mechanical metallurgist. The first one, Maurice Edmond Müller (1918 -
 12 The development of internal fixation ACI Vol. LIX

2009) was a Swiss orthopaedic surgeon who develop internal

fixation techniques. The basic principles, as already mentioned,
refresh the old ideas of anatomical reconstruction of fracture
fragments, stable internal fixation with preservation of the blood
and aim to obtain early active mobilisation of the operated limb
and the patient in order to avoid "fracture disease"
The interfragmental compression, originally described by
Robert Danis, became extremely popular due to the work of the
Swiss AO-group in 1950s. During the time, the disadvantages of
internal fixation became evident, because damage of the muscle,
periost and vascularization with additional plate interfering with
bone blood supply led to anything but the union 13.
The good thing was that those observations led to the
development of the "biological plate osteosynthesis
„14
NEW IDEAS - BIOLOGICAL PLATE OSTEOSYNTHESIS
"Biological plate osteosynthesis" is a new term which was
introduced in 1985 and includes a number of new techniques of
osteosynthesis14,15. The primary aim was to create a plate fixation
without disturbance to the soft tissues and the periosteum. To
achieve this result, the Wave Plate or the Limited Contact
Dynamic Compression Plate (LCDCP) was developed. The LC- FIGURE 6:
DCP is an improvement of the Dynamic Compression Plate LANE’S BOOK PUBLISHED IN 1915
developed by Perren in 1969. Extrenal fixation is still method of
choice for the treatment of open fractures, and fixaterurs with We can quote, in conclusion, the words of Martin All- gower:
rings are suitable for compression or distraction at fracture site. "Looking ahead, we have no monopoly on brilliant new ideas.
Intramedulary nailing is method, primarly reserved for femur and We therefore must remain open and attractive for the younger
tibial fractures, when compression effect can be obtained. But, in generation." (Martin Allgower at the inauguration of the AO
this article the main idea is to present internal fixation. Center, 1992). The internal fixation as well as other kinds of
Stainless steal was replaced by titanium and the design of the fracture treatment is a never ending story.
plate was also changed. Due to the new design, bending of the
plate, the vascularisation of the bone fragments is minimally SUMMARY
destroyed and callus formation is better. Jos od davnina je covek bio suocen sa problemom lecenja
preloma kostiju, o cemu svedoce i prvi zapisi iz starog Egipta. Od
THE FUTURE
tada su razvijane mnogobrojne metode lecenja, ali je revoluciju u
Nowadays, minimally invasive surgery, computer assisted lecenju preloma donela unu- trasnja fiksacija. Od kad je prvi put
surgery, and introduction of new (biological) implants will opisana, krajem 18. veka, ova metoda se neprestano usavrsavala i
certainly find their place in the fracture treatment.16,17 These razvijala.
methods decrease the surgical dissection at the fracture site and
maintain bone perfusion, to enable a "biological internal
fixation.".

FIGURE 5:
SIR WILLIAM ARBUTHNOT LANE (1856-1938)
Br. 3 A.R. Lesic et al. 13

3. Lesic A, Bumbasirevic M, Milosevic I, Zagorac S. Gerhard

Ona je prolazila kroz probleme, sve do razvoja metoda asepse,
radiologije, anestezije, antibiotika koji
su ucinili ovu granu hirurgije
FIGURE 7A:
modernom i bezbednom. Svoju eks-
THE LANE’S PLATES
panziju dozivljava krajem 19. i
FIGURE 7B:
X-RAY PICTURE OF ANKLE FRACTURE am
FIXATION IN 1905
Lane, Robert Danis, William Hey Groves. Oni su postavili
temelje buduce AO skole. Nove metode bioloske unutrasnje
fiksacije, minimalno invaziv- ne hirurgije, novi materijali i
tehnika se stalno uvode u praksu.
Kljucne reci: frakture, unutrasnja fiksacija, istorija
medicine.
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veka 12. Dorothea Liebermann-Meffertln Memoriam: Martin
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Aleksandar R. Lesic1’2, Slavisa Zagorac2, Vesna Bumbasirevic1’3, Marko Z.
Bumbasirevic1’2
1
University of Belgrade, School of Medicine,Belgrade
Clinic for ortopedic surgery and traumatology, Clinical Center of
Serbia, Belgrade
Center for anesthesiology and reanimatology, Clinical Center of