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Raoul Hoffmann and His External Fixator*

By Evan M. Schwechter, MD, and Kenneth G. Swan, MD

A wealth of information exists concern-
ing the biomechanics, indications, and
outcomes associated with the use of the
Hoffmann external fixator. Likewise,
much has been written about the his-
tory of external fixation of fractures.
However, little is known about the fas-
cinating life of one of the major figures
in its development, Raoul Hoffmann.
The purpose of this report is to fill that
void and bring to the attention of those
who use his device, or its variations, the
extraordinary career of this very tal-
ented surgeon.
Born in Berlin to Adolphe and
Aline on April 5, 1881, Raoul Hoffmann
was one of three brothers (René and
Roger were the others). He also had one
sister, Rose. Having received an offer to
serve as the minister of the German-
speaking Lutheran Church in Geneva,
Adolphe moved his family to Switzer-
land when Raoul was six months old.
Only a year later, Adolphe presided over
the church’s celebration of the 400th
anniversary of Martin Luther’s birth1.
Raoul’s mother, a minister’s
daughter, was a well-known Swiss-
French author whose writing focused
especially on issues of interest to women
of her era, including home education,
gender relationships, child education,
women’s rights, and religion2.
While Hoffmann’s early school
years were unremarkable, signs of
intellectual prowess, and a strong work
ethic, were evident2. These traits con-
tributed to Hoffmann’s academic suc-
cess in high school at the College of
Geneva, where he graduated first in his
class in 18993. Hoffmann continued his
education at the University of Geneva,
earning a baccalaureate degree in Let-
ters in 1899 and in Physical and Natu-
ral Sciences in 19024.
Hoffmann then took a short
break from academia and served an ap-
prenticeship as a furniture maker in La
Place du Bourg-de-Four, a charming,
historic square in Geneva’s old city5. He
traveled to Paris in search of more chal-
lenging employment as a furniture
maker but was unsuccessful because of
the fierce job competition in Paris at the
time2,4. This early experience in crafts-
manship, requiring sophisticated man-
ual dexterity and an understanding of
engineering, became the basis for Hoff-
mann’s later work designing and con-
structing his ingenious external fixator.
He abandoned furniture making and
focused on a greater calling that he had
long nurtured—medicine.
Hoffmann began his medical ed-
ucation at the University of Berlin but
soon returned to Geneva, where he
earned a diploma in medical physiology
and anatomy. A young man with eclec-
tic interests, Hoffmann concurrently
studied theology. Considering his reli-
gious upbringing, this was not an un-
usual pursuit. In 1908, he received his
degree in theology from the University
of Geneva after writing his thesis on
Søren Kierkegaard, the nineteenth cen-
tury Danish existentialist philosopher
and theologian4,6. Hoffmann briefly
served apprenticeships as a minister at
churches in Geneva, Switzerland, and
Borinage, Belgium4.
Returning to his medical studies
in 1909, Hoffmann completed an ex-
ternship at the University of Greifswald
in Germany, before again returning to
Geneva to finish medical school. In
1909, he passed both oral and practical
medical board examinations4. Hoff-
mann conducted clinical and anatomi-
cal research at the Institut Pathologique
de Genève, and he wrote his thesis on
Théories Actuelles sur la Neurofibro-
matose et ses Complications (Current
Theories on Neurofibromatosis and its
Complications)7. On January 5, 1911,
the University of Geneva awarded Hoff-
mann a Diploma for a Doctorate in
Medicine (M.D.)8.
Hoffmann interned at the Can-
tonal Hospital of Geneva (Fig. 1) and,
in 1912, pursued further studies at the
London School of Tropical Medicine9.
He interned, again, at Falun Hospital
(Sweden), a well-regarded medical
training institution, as well as the loca-
tion of one of his cousins who was a
surgeon at the hospital2. It was there
that he met his future wife, Elsa Holm-
dahl, a nurse. They were married on
January 10, 1914, in Uppsala, Sweden2.
Several months later, Hoffmann
and his new wife began a Christian
mission in Kashmir. There, he served
as a physician and performed numer-
ous operations during their six-month
stay. His wife fell ill, perhaps related to
a pregnancy, which caused them to re-
turn to Geneva just before the start
of World War I4. Their first child, Len-
nart, was born on February 22, 1915, in
Geneva.
Although Switzerland was a neu-
tral noncombatant in World Wars I and
II, military service was, and remains,

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a
member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial
entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical prac-
tice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

*Read in part at the Annual Spring Meeting of the Medical History Society of New Jersey, Princeton, New Jersey, May 24, 2006.
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mandatory. Hoffmann, an avid out-
doorsman, enlisted in the mountain in-
fantry of the Swiss Army. Somewhat
surprisingly, he chose not to join the
medical corps. Instead, he served in the
infantry, as a first lieutenant, in order be
a more effective leader of the younger,
more impressionable draftees4.
In 1915, Hoffmann brought his
family to Tramelan, a small, rural town
well known for watchmaking, located
in the Bernois Jura, about 100 miles
northeast of Geneva. There, he estab-
lished a clinic in his home, where he
treated a wide variety of patients. He
also made house calls, often for emer-
gency Caesarean sections, usually
performed on the kitchen table!4
Hoffmann’s goal was to build a small
community hospital, but, in 1926, the
town made plans to build a road
through Hoffmann’s house10. He left
with his family for Geneva. During
the twelve years he spent in Tramelan,
Hoffmann and his wife had four more
children, Bertil, Aline, Nils, and Karin,
nicknamed Lily2.
Hoffmann’s interest in long-bone
Fig. 1
Hoffmann as an intern at the Cantonal Hospital of Geneva, 1911-1912. (Printed with permission
of Anne-Christine Hoffmann, MD.)
673
RAOUL HOFFM ANN
fractures may have begun in Tramelan,
considering its location near the ski
slopes. Being one of the few doctors in
this rural area, Hoffmann probably
treated the majority of skiing injuries,
including both open and closed extrem-
ity fractures.
On returning to Geneva in 1928,
Hoffmann established a surgical prac-
tice at 4 Rue Emile-Yung, adjacent to
the Cantonal Hospital of Geneva.
By then, Hoffmann had developed a
solid reputation, and his practice grew
quickly. At the same time, he began pub-
lishing articles and texts on assorted
topics, including a biography of his
mother, Aline Hoffmann11, in 1926, and
a handbook for a successful marriage,
“Une Fois Mariés . . .” Réflexions d’un
Médecin12, in 1928. He also made a pre-
sentation to the Congress of the Swiss
Society of Surgeons, in 1929, on the ef-
fect of arthritis on the knee, “Ménisques
du Genou et Arthrite Déformante.”13
Hoffmann’s practice, in his
Geneva surgical clinic, became increas-
ingly focused on fracture management
and care. This interest resulted from his
AND HIS EXTER NAL FIXATOR
concerns regarding what he considered
to be unnecessary amputations, seem-
ingly routine by military surgeons, for
the treatment of complicated fractures4.
Hoffmann began tinkering with the ex-
ternal fixators of his era, whose short-
comings included the need for open
reduction before fixator application.
He developed his own technique for
fracture fixation, which he termed
“ostéotaxis,” derived from the Greek,
meaning, “to put the bones in place.”10
In 1938, Hoffmann published his new
technique and presented it to the French
Congress of Surgery. Near the end of his
life, in 1969, he was presented with the
Nessim Habif World Prize by the Univer-
sity of Geneva for this important contri-
bution to the field of trauma surgery4.
Hoffmann’s work on his external
fixator would continue throughout his
life, but this was far from his sole inter-
est. He was a fervent temperance advo-
cate and joined the Blue Cross, a Swiss,
Christian organization founded to
promote abstinence from alcohol14.
Hoffmann wrote a series of articles on
alcoholism in 1966 for the journal La
Suisse and later published a pamphlet,
entitled C2H5OH cet Inconnu or, “What
is Unknown about Alcohol,” detailing
the damaging effects of its abuse15.
A dedicated and passionate al-
pinist and mountaineer, Hoffmann
loved the outdoors. Among other activi-
ties, he cross-country skied near Lake
Geneva, climbed Le Cervin (the Mat-
terhorn) multiple times, and climbed
both Mont Blanc and La Pointe Dufour
at the age of seventy-nine. He regularly
took walks throughout the Champel dis-
trict of Geneva, in which he lived, and
often made patient rounds by bicycle4,16.
Hoffmann died on March 19,
1972, at the age of ninety-one, at his
home, 28 Avenue de Champel. He was
buried in the Petit-Saconnex Cemetery
next to his wife, Elsa, who died in
19585,17. He was survived by five children
and nine grandchildren.
Brief Historical Review
of External Fixation
Long before Raoul Hoffmann was even
born, others were making progress in
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the development of external fixation.
Some credit Hippocrates (circa 460 to
380 BC) as the first to describe a primi-
tive, but brilliant, external technique for
achieving fracture reduction. He de-
signed a system with levers bound to
the patient’s extremity. The levers then
folded to maintain stability18.
Taking four rods, made of the cor-
nel tree, of equal length, and of the
thickness of a finger, and of such
length that when bent they will
admit of being adjusted to the
appendages . . . There should be
three sets of rods, or more, one
set a little longer than another,
and another a little shorter and
smaller, so that they may produce
greater or less distention, if re-
quired. If these things be properly
contrived, they should occasion
a proper and equable extension
in a straight line, without giving
any pain to the wound; for the
pressure, if there is any, should be
thrown at the foot and the thigh
[as described for use on a tibial
fracture] . . . And, if thought
proper, there is nothing to pre-
vent the two upper rods from be-
ing fastened to one another19.
After Hippocrates, however, the
concept of external fixation lay fallow
for over 2000 years.
The earliest modern concepts
began in 1840, when Jean-François
Malgaigne invented the pointe métal-
lique, or “metallic point.” Simply a
metallic nail, it was placed through a
semicircular metallic band and was per-
cutaneously nailed into the fracture
fragment. A belt, attached to the metal-
lic band, was tightened around the limb
until the nail had pushed the frag-
ment to the desired reduction, and it
could be left in place to prevent frac-
ture displacement20,21.
In 1843, Malgaigne developed
the griffe métallique, literally and figu-
ratively the “metallic claw.” This device
consisted of opposing pairs of curved
points, each attached to sliding metal
plates, which achieved compression
by means of a turnbuckle-type screw.
674
RAOUL HOFFM ANN
It was a simple closed reduction tech-
nique designed for patellar fractures20,21.
Other investigators, including
Carl Wilhelm Wutzer18, Von Langen-
beck18, James Bolton22, R. Rigaud23, and
L.J.B. Berenger-Feraud23, were instru-
mental in developing early external
fixator prototypes. In 1852, Chassin
modified Malgaigne’s metallic point
and claw for application to the clavicle
to permit correction of anteroposterior
displacements. In 1893, Keetley be-
came the first to use bicortical percu-
taneous pins20.
But it was Clayton Parkhill of
Denver, Colorado, who, in 1897, in-
vented the modern concept of unilateral
external fixation. His bone clamp con-
sisted of four fracture-spanning winged
plates secured by a rigid external plate.
Each plate was bolted to one of two half-
pins proximal, or another two distal, to
the fracture site24. Parkhill reported good
results and few complications20.
Like Parkhill, Albin Lambotte
of Antwerp, Belgium, also utilized two
half-pins proximal and two distal to
the fracture. His pins, however, were,
at least initially, fixed between two
heavy metal plates, making the appara-
tus rigid and inflexible, more suitable
for early limb mobilization. However,
his device, first described in 1902, ne-
cessitated initial, open fracture reduc-
tion and then pin insertion and fixator
placement20,21.
After Lambotte, many others
made significant contributions to the
development of the external fixator.
Notable advancements were made
by Codvilla in 190425, Crile in 191925,
and Conn in 193125. In 1931, Pitkin
and Blackfield developed the first bi-
lateral frame25.
In 1934, Roger Anderson of
Seattle designed a device using transfix-
ation pins that permitted multiplanar
adjustment of fracture fragments23. He
was the first to advocate early weight-
bearing and joint mobilization20,26. In
1937, Otto Stader, a Pennsylvania veter-
inarian, designed a canine external
fixator, dubbed the Stader splint, that
facilitated fracture reduction in two
spatial planes24,26.
AND HIS EXTER NAL FIXATOR
World War II provided a vast
number of fractures caused by various
explosive devices and high-velocity
missiles, in which external fixation
might have played an important role,
especially in facilitating the transport
of the patients who sustained these in-
juries. However, infection and fixator
stability became a concern for military
surgeons who were generally inexperi-
enced in its use. External fixation was
banned by the United States military
because of these concerns27,28.
In the meantime, Raoul Hoff-
mann was developing his unique
external fixator and the innovative
techniques for its application.
Hoffmann’s Technique:
“Ostéotaxis”
Building on the work of others, Hoff-
mann realized that major improve-
ments were essential to make the
external fixator more clinically rele-
vant. He studied Lambotte’s fixator,
which required open reduction of the
fracture29. This added to the tissue
damage already sustained and greatly
increased the chance of infection. Hoff-
mann was eager to avoid these com-
plications. He developed a technique
based on closed reduction with guided
percutaneous pin placement. Hoff-
mann’s technique exemplified the first
application of minimally invasive or-
thopaedic surgery.
Hoffmann’s technique was sim-
ple, yet ingenious. He located long-
bone fracture fragments by “tangen-
tially probing” and “cross probing”
(Fig. 2, A), using percutaneous nee-
dles—techniques that also localized
drill “guide” placement (Fig. 2, B). The
surgeon made at least three drill-holes
through the far cortex and partially
threaded half-pins were inserted. The
surgeon could insert a maximum of
five pins for more frame stiffness. The
pins were available in different lengths
for variations in bone depth. Hoff-
mann used blunt pins in order to avoid
soft-tissue trauma29. He experimented
with these percutaneous pins in rab-
bits at the Institut Pathologique de
Genève and found neither pin tract
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the term “ostéotaxis” to describe this

Fig. 2
A: A cross section demonstrating cross-probing and tangential probing. B: A drill guide with cross-
probed percutaneous needles and three pins inserted into a fracture fragment (tangential nee-
dles not shown). (Reprinted, with permission of John Wiley and Sons on behalf of the BJSS Ltd.,
from: Hoffmann R. “Closed osteosynthesis”, with special reference to war surgery. Acta Chir
Scand. 1942;86:235-66. Copyright 1942, British Journal of Surgery Society Ltd.)
infection nor osteomyelitis10.
Hoffmann also designed strong
clamps, which he called “grips,” made
of two rectangular steel plates held to-
gether with bolts. These bolts com-
pressed the plates around the larger
half-pins fixated in bone. Attached to
each clamp was a “ball-and-socket”
joint. At this point, with one clamp se-
cured on either side of the fracture site,
the fracture was reduced by “direct ex-
ternal manipulation.” A rigid steel bar,
8 mm in diameter, was then placed
through the ball-and-socket joint on
either clamp and was fastened by wing
screws, thereby uniting the clamps29.
Most important, however, was
Hoffmann’s observation that, “This
bar can just as well be put into posi-
tion before the reduction process. Its
presence in no way hinders the action of
reduction” [italics added]29. The ball-
and-socket joints could swivel, thus
permitting the rigid bar and, in fact,
the entire frame to move in continuity
(Fig. 3). This, in essence, was Hoff-
mann’s unique contribution to external
fixation. It allowed the surgeon to com-
plete fracture reduction in three spatial
planes independently. Additionally, sec-
ondary correction was possible until
optimal reduction was achieved, since
only the ball-and-socket joint had to be
slightly loosened, the frame adjusted,
and the joint retightened29. Essentially,
the fracture fragments, whether angu-
lated, displaced, or rotated, could be ac-
curately realigned. Hoffmann coined
Fig. 3
External bar connecting two ball-and-socket joints. (Reprinted, with permission, from: Hoffmann
R. Ostéosynthèse “a minima” par tuteur externe transcutané. Rev Med Suisse Romande. 1941;
60:216-34.)
process. Later modifications permitted
both interfragmentary compression
and distraction30,31.
The clamps described were used
for diaphyseal fractures. For metaphyseal
fractures, Hoffmann designed an analo-
gous mechanism, intended particularly
for use at the greater trochanter, lateral
femoral condyle, anteromedial surface of
the proximal part of the tibia, calcaneus,
and superolateral aspect of the humeral
head. This clamp was star-shaped and
was anchored to the cancellous bone by
means of a central pin (Fig. 4)29.
Hoffmann’s clamps, both straight
and star-shaped, were remarkably ver-
satile. Together, they permitted fracture
stabilization virtually anywhere in the
body. To manage extreme clamp place-
ment angles, Hoffmann designed what
he called “bayonet” connecting bars
that were so shaped. This was particu-
larly important, for example, in avoid-
ing the radial nerve in its course around
the humerus (Fig. 5)29.
The external bars were custom-
ized to meet the patient’s build, and
they were available in differing lengths
and widths. Likewise, Hoffmann de-
signed pins of smaller caliber for the
radius and ulna, or for pediatric long-
bone fractures29.
Keenly aware of the potential
complications of external fixation, Hoff-
mann included various precautions in
his technique. He recognized the impor-
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technique avoided open reduction29.

In 1938, Hoffmann first described
his technique in an article entitled,
“‘Rotules à Os’ pour la ‘Réduction
Dirigée’, Non Sanglante, des Fractures
(‘Ostéotaxis’),”32 which he presented at
the French Congress of Surgery the same
year. He patented his device in Switzer-
land on June 16, 193933, and in France on
January 2, 194034, and later, in 1944, he
described use of his fixator for fractures
of the mandible35. In 1951, he published
a book about the fixator and its ortho-
paedic applications entitled, L’Ostéotaxis,
Ostéosynthèse Transcutanée par Fiches et
Rotules30. In the intervening years, Hoff-
mann would author many more articles
describing his technique, in a variety of
languages, including Danish, Italian, En-
glish, French, and German. Many others
have since modified the Hoffmann exter-
nal fixator, but the core concepts of his
technique have continued in use, even to
this day.

The External Fixator

in Combat Casualty Care
Hoffmann’s experience as a first lieu-
Fig. 4 tenant in the mountain infantry con-
Star-shaped clamp. (Reprinted, with permission of John Wiley and Sons on behalf of the BJSS vinced him that his external fixator
Ltd., from: Hoffmann R. “Closed osteosynthesis”, with special reference to war surgery. Acta was applicable to the care of combat
Chir Scand. 1942;86:235-66. Copyright 1942, British Journal of Surgery Society Ltd.) casualties. It was especially suitable for

tance of preventing pin tract infection

and made skin tension-relieving inci-
sions, if necessary. He placed Xeroform
gauze at the pin sites, and also pre-
scribed sulfanilamide—a precursor
to the sulfonamides. To minimize soft-
tissue injury, he used blunted pins and
drills that were designed to prevent ex-
cessive bone penetration29.
Other advantages of the Hoff-
mann fixator included the ability to
loosen one or more pins in case of in-
fection, without substantially sacrific-
ing fixator stability. Also, the fixator
could be applied for the minimal
amount of time necessary, since the
surgeon only needed to loosen the
ball-and-socket joints to check bone
consolidation. Additionally, unaffected
neighboring joints could remain mo- Fig. 5
bile throughout treatment. But per- Bayonet connecting bar as applied to the humerus. (Reprinted, with permission, from: Hoffmann
haps most importantly, Hoffmann’s R. L’ostéotaxis, ostéosynthèse transcutanée par fiches et rotules. Paris: Éditions GEAD; 1951.)
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complicated closed fractures, open
fractures, comminuted fractures, and
fractures caused by high-velocity mis-
siles. Additionally, external fixation
provided rigid immobilization, par-
ticularly suited for military transpor-
tation29. Unfortunately, although
Hoffmann described his fixator before
World War II, it was never used to treat
soldiers in that war, since it was not
produced commercially until Hoff-
mann’s collaboration with the Jaquet
Frères Company (later renamed Jaquet
Orthopédie) in 1947.
For military use of his external
fixator, Hoffmann slightly modified the
components, in part, because of cost
considerations. Instead of external bars,
Hoffmann devised metal “straps,” in
which basically any piece of metal of the
requisite length could substitute. For
extra stability and utility, the clamps,
in this case, without the ball-and-socket
joint, were also connected by “Bridges
of Wire Reinforced Plaster.”29 This con-
sisted of a “bridge,” made of malleable
iron wire, covered in plaster until ap-
proximately 4 to 6 cm thick29.
During World War II, United
States Navy surgeons used Otto Sta-
der’s fixator, while the United States
Army utilized Roger Anderson’s fix-
ator24,27,36. Both were used guardedly,
however, as a method of fracture fixa-
tion in the United States, especially
within its armed forces, because of a
relatively high rate of complications,
including poor pin fixation, pin tract
infection, and localized osteomyeli-
tis26,27,37. Indeed, the copious purulent
drainage from the pin sites of Ander-
son’s device became so infamous that
it was dubbed “Seattle serum,” after
the city in which he worked. These
complications likely resulted from
surgical inexperience with fixator ap-
plication, rather than inherent fixator
design flaws28.
Despite a growing body of litera-
ture in support of external fixation, es-
pecially from Europe, and especially by
Dr. Hoffmann, enthusiasm for external
fixation remained modest after World
War II. A survey by the Committee
on Fracture and Trauma Surgery of
677
RAOUL HOFFM ANN
the American Academy of Ortho-
paedic Surgeons reported, in 1950, that
only 28% of the responders believed
external fixation had a definite role in
fracture management. The report ad-
monished that only those surgeons with
advanced training, i.e., those who per-
formed such procedures under the su-
pervision of a surgeon who himself had
completed no less than 200 procedures
with external fixation, should utilize the
modality26,37.
From the end of World War II
through the early 1970s, a functional
casting technique, described in the
1960s by Dehne, was the accepted tech-
nique for long-bone fracture manage-
ment37. External fixation was all but
forgotten. Even war wounds, such as
those with massive soft-tissue destruc-
tion encountered during the Korean
(1950-1953) and the Vietnam (1961-
1973) wars, were treated without exter-
nal fixation37. Neither internal nor ex-
ternal fixation of long-bone fractures
caused by high-velocity missiles was
permitted in the combat zone.
The 1970s, however, witnessed
increasing studies in the literature, par-
ticularly from Europe, demonstrating
excellent results with external fixation.
Techniques improved, and variety
increased. The most notable works
included those of Judet in France,
Charnley in England, DeBastiani in
Italy, Vidal in France, Burny in Bel-
gium, and Ilizarov in Russia. As a result,
the United States began to see an up-
surge in the use of external fixation37,
especially in the armed forces38. The
Department of Defense eventually so-
licited frame designs suited for military
application. During the Persian Gulf
war in 1991, the Howmedica Ultra-X
model was purchased and deployed38.
Until that time, external fixation had
not been recommended for military use
since World War II—a span of approxi-
mately forty-six years!
The United States Armed Forces
currently use the Hoffmann-II external
fixator (Stryker, Mahwah, New Jersey),
a modified version of its predecessor.
One cannot help but imagine the pride
of Raoul Hoffmann had he been able to
AND HIS EXTER NAL FIXATOR
witness history’s most powerful army
using his device for the care of its
troops. The Department of Defense
has chosen this model, in particular,
because of its versatility. It is a modular
system, in which components can be
interchanged as a wounded soldier is
transported through the evacuation
chain38. Likewise, combat casualties
with external fixators are significantly
easier to transport39. There are fewer
components to the Hoffmann-II Sterile
Field Kit, facilitating the ease and speed
of application, especially since radiog-
raphy is not necessary38.
Reports from the frontlines in
Operation Iraqi Freedom indicate that
the Hoffmann external fixator has
played a major role in initial fracture
stabilization. Explosive ordnances have
caused massive and complex extremity
injuries, often requiring multiple irriga-
tions and débridements, neurovascular
repair, and soft-tissue coverage in order
to salvage a limb. The Hoffmann-II
Sterile Field Kit, designed for far-forward
application, has been used extensively
in the combat setting to provide rigid,
temporary fracture stabilization. Its
benefits are numerous—including the
ability to apply the fixator easily and
rapidly in the field40. Patients with severe
injuries requiring extensive surgical
management are transported to either
Walter Reed Army Medical Center in
Washington, DC; the National Naval
Medical Center in Bethesda, Maryland;
or the Brooke Army Medical Center in
San Antonio, Texas. Patients often arrive
with fractures stabilized by the same ex-
ternal fixator applied in the field41.
In conclusion, in the history of
external fixation, there is no doubt that
Raoul Hoffmann’s device was one of the
most influential. His is perhaps the first
application of minimally invasive sur-
gery, a modality that drives today’s in-
novative surgical concepts. The unique
beauty of Hoffmann’s device was its
outstanding versatility and modularity,
making it a favorite of many trauma
surgeons. The Armed Forces of the
United States currently include the de-
vice as standard inventory.
Although the most modern uni-
Schwechter_OF.fm Page 678 Friday, February 9, 2007 2:12 PM
THE JOURNAL OF BONE & JOINT SURGER Y · JBJS.ORG
VO L U M E 89-A · N U M B E R 3 · M A RC H 2007
lateral external fixator may incorporate
some advanced modifications, the ba-
sic principles, technique, and indica-
tions for its use were first described by
one of the great surgeons of our time,
Dr. Raoul Hoffmann.
Evan M. Schwechter, MD
Department of Orthopaedic Surgery, Mon-
tefiore Medical Center, Albert Einstein College
of Medicine, 3400 Bainbridge Avenue, 6th
Floor, Bronx, NY 10467. E-mail address:
eschwec@gmail.com
Kenneth G. Swan, MD
Department of Surgery, University of Medi-
cine and Dentistry of New Jersey-New Jersey
Medical School, 185 South Orange Avenue,
G-590, Newark, NJ 07103. E-mail address:
pedretdl@umdnj.edu
doi:10.2106/JBJS.F.01177
References
1. Frerichs M. Evangelical Lutheran Church of
Geneva, Geneva, Switzerland. Personal communi-
cation. 2006 May 26.
2. Hoffmann, A.-C. Personal communication.
Geneva, Switzerland. 2006 May 17.
3. Certificat de Maturité from the Collège de
Genève. Courtesy of Georges Deutsch. Geneva,
Switzerland. 2006 May 18.
4. Chautempes-Hoffmann A. Curriculum vitae of
Monsieur Raoul Hoffmann. Courtesy of Georges
Deutsch. Geneva, Switzerland. 2006 May 18.
5. Hoffmann R. Journal de Genève. 1972 Mar 21.
6. Hoffmann R. Kierkegaard et la certitude re-
ligieuse: esquisse biographique et critique [thesis].
Geneva: J.-H. Jeheber; 1907.
7. Hoffmann R. Contribution anatomique et clinique
a l’etude des théories actuelles sur la neurofibroma-
tose et ses complications [thesis]. Geneva: Institut
Pathologique de Genève; 1910.
678
RAOUL HOFFM ANN
8. Université de Genève Diplome de Docteur en Me-
decine. Courtesy of Georges Deutsch. Geneva, Swit-
zerland. 2006 May 18.
9. Diploma, London School of Tropical Medicine.
Courtesy of Georges Deutsch. Geneva, Switzerland.
2006 May 18.
10. Asche G. Raoul Hoffmann: life and accomplish-
ments. AIOD News. 2005;16:8-9.
11. Hoffmann R. Aline Hoffmann. Geneva: Éditions
Forum; 1926.
12. Hoffmann R. “Une fois mariés…” Réflexions
d’un médecin. Septième éd. Lausanne: Édition La
Concorde; 1928.
13. Hoffmann R. Ménisques du genou et arthrite dé-
formante. Basel: Imprimerie Benno Schwabe; 1929.
14. Le Dr. Raoul Hoffmann a nonante ans. Journal
de Genève. 1971 Apr 6; p 11.
15. Hoffmann R. C2H5OH cet Inconnu. Lausanne:
Editeur SAS; 1966.
16. Le Dr. Raoul Hoffmann a 80 ans. Tribune de
Genève. 1961 Apr 6.
17. Strigini M. Cemetery of Saint-George, City of
Geneva, Switzerland. Personal communication.
2006 Feb 18.
18. Asche G, Roth W, Schroeder L, editors. The
externa fixator: standard indications, operating in-
structions and examples of frame configurations.
Reinbek, Germany: Einhorn-Presse; 2002.
19. The Internet Classics Archive. On fractures.
By Hippocrates, written 400 B.C.E., translated by
Francis Adams. Part 30. http://classics.mit.edu/
Hippocrates/fractur.html. Accessed 2006 Feb 15.
20. Browner BD, Jupiter JB, Levine AM, Trafton
PG. Skeletal trauma: basic science, management,
and reconstruction. 3rd ed. Philadelphia: Saun-
ders; 2003.
21. Mears DC. External skeletal fixation. Baltimore:
Williams and Wilkins; 1983.
22. Beck JD, Swan KG. James Bolton, MD (1812-
1869): reflections on an American surgeon. J Am
Coll Surg. 1999;189:324-9.
23. Vidal J. External fixation. Yesterday, today, and
tomorrow. Clin Orthop Relat Res. 1983;180:7-14.
24. Pettit GD. History of external skeletal fixation.
Vet Clin North Am Small Anim Pract. 1992;22:1-10.
25. Paul GW. The history of external fixation. Clin
Podiatr Med Surg. 2003;20:1-8, v.
26. Green SA. Complications of external skeletal fix-
AND HIS EXTER NAL FIXATOR
ation: causes, prevention, and treatment. Spring-
field, IL: Charles C. Thomas; 1981. History of
external fixation; p 3-11.
27. Brav EA. Military contributions to the develop-
ment of orthopaedic surgery by the Armed Forces,
U.S.A. since World War I. Clin Orthop Relat Res.
1966;44:115-26.
28. Dougherty PJ, Carter PR, Seligson D, Benson
DR, Purvis JM. Orthopaedic surgery advances
resulting from World War II. J Bone Joint Surg Am.
2004;86:176-81.
29. Hoffmann R. “Closed osteosynthesis”, with
special reference to war surgery. Acta Chir Scand.
1942;86:235-66.
30. Hoffmann R. L’ostéotaxis, ostéosynthèse trans-
cutanée par fiches et rotules. Paris: Éditions GEAD;
1951.
31. Hoffmann R. Ostéotaxis, guide technique et clin-
ique. Geneva: Jaquet Frères; 1961.
32. Hoffmann R. “Rotules à os” pour la “réduction
dirigée”, non sanglante, des fractures (“ostéo-
taxis”). Helv Med Acta. 1938;5:844-50.
33. Hoffmann R, inventor. Fixateur pour le traite-
ment des fractures des os. Swiss Confederation
patent number 203544. 1939 Jun 16.
34. Hoffmann R, inventor. Fixateur pour le traite-
ment des fractures des os. French Republic patent
number 851028. 1940 Jan 2.
35. Hoffmann R. Fixateur externe transcutané
pour fractures mandibulaires. Helv Med Acta.
1944;3:521-4.
36. Anderson R. Castless ambulatory method of
treating fractures. 1942. Clin Orthop Relat Res.
2000;375:4-6.
37. Sisk TD. External fixation: Historic review, ad-
vantages, disadvantages, complications, and indi-
cations. Clin Orthop Relat Res. 1983;180:15-22.
38. Bosse MJ, Holmes C, Vossoughi J, Alter D.
Comparison of the Howmedica and Synthes military
external fixation frames. J Orthop Trauma. 1994;
8:119-26.
39. Oreck SL. Orthopaedic surgery in the combat
zone. Mil Med. 1996;161:458-61.
40. Camuso MR. Far-forward fracture stabilization:
external fixation versus splinting. J Am Acad Orthop
Surg. 2006;14(10 Suppl):S118-23.
41. Andersen RC, Frisch HM, Farber GL, Hayda RA.
Definitive treatment of combat casualties at mili-
tary medical centers. J Am Acad Orthop Surg.
2006;14(10 Suppl):S24-31.