Injury, Int. J.

Care Injured 46 S3 (2015) S3–S6

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Injury
j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i n j u r y

Evolution of the Hoffmann Fixators

David Seligson*
Chief of Orthopedics, University of Louisville Hospital, Louisville, KY, United States

KEYWORDS ABSTRACT

History Dr. Raoul Hoffmann of Geneva, Switzerland with the collaboration of Henri Jaquet developed the
External fixation original Hoffmann external fixateur as a system for treating broken bones without necessarily opening
Hoffmann a fracture site to reposition the bone ends. This system has evolved to a more flexible, modular concept
with input from surgeons and engineers. In this chapter the modifications of the Hoffmann family of
fixators are traced and the important steps in the development of the concept and the instrumentation
emphasized.
© 2015 Elsevier Ltd. All rights reserved.

Hoffmann original
In his youth, Raoul Hoffmann worked with his brother as an
apprentice carpenter in the Place de Bourg-de-Four in the old
section of Geneva. Hoffmann had qualifications in theology and
medicine from the University of Geneva and was a line officer
(not a medical officer) in the Swiss Alpine patrol where, being a
Swiss citizen, he reported periodically for obligatory duty. When
he set up practice in general surgery in the Village of Tramelan
in the Jura, Hoffmann doubtless treated ski fractures of the tibia.
By the 1930s external skeletal fixation was an established, if
special, technique. Fixators were linear constructs. The fracture
site was opened, the bone repositioned, a fixator applied and the
skin closed. Skin wounds, particularly wounds over subcutaneous
bones, can be problematic. Raoul Hoffmann, who moved back to
Geneva with his private surgical practice because the government
built a road through his house, became interested in solving the
problem of fracture reposition without opening the fracture site.
Hoffmann was a gentleman, a tennis player and also a religious
thinker. He had a famous ironic smile.
Hoffmann was concerned about the problems of infection
at the bone-pin junction. Parkhill and Lambotte had surface
treated their pins to prevent skin reactions. Hoffmann conducted
research in rabbits. Finally he found a manufacturer in Biel who
could make a tempered stainless steel pin that was sharp enough
to penetrate bone without causing too much heat [1]. The story
is told that on the night before his presentation of his fixator
to the Surgical Society, he obtained a bone from the pathology
department, made a fracture and mounted a fixator on the bone
* Corresponding author at: Chief of Orthopedics, University of Louisville
Hospital, 530 South Jackson Street, Louisville, Kentucky 40202 USA.
E-mail address: david.seligson@louisville.edu (D. Seligson).
to show at the meeting. By morning all that was left was the
external fixator as his dog had finished off the bone.
The thrust of Hoffmann’s report to the Swiss Surgical Society
in 1938 was the invention of a fixator for controlled reduction
of fractures with a closed (in contrast to an open) technique.
Raoul Hoffmann applied for a Swiss Patent on 6 April 1938. The
Patent for his «Fixateur pour le traitement des fractures des
os» was awarded on 15 March 1939. This was a difficult time
that coincided with the rise of National Socialism in Germany.
Switzerland remained neutral with a closely controlled border
with Germany. Hoffmann broke his leg in an accident and
apparently continued to bicycle to work in an external fixator
until the tibia healed [2]. Custom devices were manufactured for
Hoffmann (Figure 1, the Hoffmann ‘key’). Ullrich in nearby Ulm,
Germany, refused to make the clamps because he thought that
the market for them would be too small [1,3]. In 1947 a shop
was set up in Geneva by the new engineering graduates Henri
and Georges Jaquet for the manufacture of medical devices that
required ‘mechanics and/or electronics.’ In 1948 Jaquet Frères
began to make Hoffmann Fixators with an improved design
using two plates and a wing nut to give more secure fixation of
the pin holding the clamp to the connecting rod. The original
components were fabricated in stainless steel with a grooved
Bakelite surface to hold the pins (Figure 2). The pins were
manufactured in tempered stainless steel. Parts were made one-
at-a-time on machine-lathes and finished and controlled by
hand. The basic components were ball-joints, rods, a hand brace
for inserting the pins, guides and a skin lance [1]. Hoffmann’s
essential innovation was the bone handle, in French rotule. The
concept was to create a solid anchorage in bone by placing two
or three pins along the axis of the bone and fixing these pins in
a pin-holding clamp. One grip was proximal and one was distal
to the fracture to enable manipulation of the bone for fracture

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S4 D. Seligson / Injury, Int. J. Care Injured 46 S3 (2015) S3–S6
Fig. 1. The ‘key’ from Hoffmann’s early fixator – much like the key to a church gate.
Courtesy Dr. Anne-Christine Hoffmann and Dr. Richard Stern, University Hospital,
Geneva, Switzerland.
Fig. 2. The Ball Joint Rod in stainless steel with Bakelite pin holders was the
workhorse of the original Hoffmann.
reduction. In Hoffmann’s original system the position of the
bone was localised with a pin guide. The position of the guide
was facilitated by fine pins that centre the guide on the bone.
In addition to the concept of percutaneous bone anchorage,
Hoffmann added the requirement that the device allowed for
adjustment of bone position after surgery [4,5]. Hoffmann
conceived a temporary external fixation for war surgery by
connecting pin groups with plaster of Paris [6]. The Hoffmann
Fixator was used in the district (Canton) Hospital in Frauenfeld,
which is in Thurgau near Zurich where Hoffmann assisted Dr.
Isler. When the Chief of Surgery at Frauenfeld changed in 1965,
the AO-Tubular System was substituted, and all the Hoffmann
equipment was returned to a disappointed Raoul Hoffmann,
who by this time was 84 years old [3]. Hoffmann’s fixator was
used by Prof. Jacques Vidal in Montpellier for the treatment
of difficult fracture problems. Vidal emphasised that the rigid
frames promoted fracture healing by providing good stability
[7]. The quadrilateral frame developed by Vidal and his student
Jose Adrey (Figure 3) was widely demonstrated at International
Symposia sponsored by the Hoffmann manufacturers [8]. As the
business grew, the plant was managed by Georges Eduard A.
Deutsch, a precise, small man with a noticeable limp who chain-
smoked strong cigarettes with a cigarette holder. His engineer,
Marcel Wagenknecht, was a bachelor who lived with his mother
and grew roses.
Hoffmann II - Plan-les-Ouates
By 1972, to respond to increased demand in the United States,
Jaquet Frères opened a new plant near la Paraille in Geneva. Jaquet
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Fig. 3. The Vidal-Adrey frame provided great rigidity at a fracture site. Courtesy
Mitchell Orthopedics Supply, Louisville, Kentucky.
Orthopédie was acquired by Howmedica, a division of Pfizer, in
1980. This improved the marketing of original Hoffmann frames
in the US. In 1982 a new plant was opened in Plan-les-Ouates, an
industrial zone in Geneva. By 1995 only 2% of Hoffmann fixators
were sold in Switzerland, the sales were divided with 46% in
Europe, 33% in the US, 17% in the Far East and 4% in Canada and
South America.
The Vidal-Adrey approach delegated external fixation to
the solution of complex, slow-healing and infected fractures
with rigid often cumbersome frames. As early as 1988, there
was a reaction to this approach by both Asche in Freudenstadt
and Burney in Illkirch, who suggested the evolution of simpler
components that could be used more flexibly and in closed
fractures. In 1989, Asche, Court-Brown, Poka and Seligson met in
Rochester, New York to review Asche’s experience in 29 patients
with new, more modular components for external fixation [9].
Priorities included reducing the number of clamps and providing
a more versatile multi-pin clamp, and emphasising the use of a
rod-coupling as a pin holder. In the original Hoffmann, pin inserts
for 3 and 4 mm half pins could be placed in the articulation
coupling to turn it into a pin-holding clamp. However, the
coupling had to be slid onto the connecting rod prior to clamping
the rod in the frame. In the Hoffmann II (Figure 4), the pin-to-bar
clamp could be snapped onto a bar even though the bar was fully
locked in a frame. This feature became the ‘clique fantastique.’
The Hoffmann II project was managed by John Kalblein
of Howmedica. The physician advisory group included Andy
Burgess, Franz Burny, Ekki O. Karaharju and Gregory Zych in
addition to Asche, Court-Brown, Poka and Seligson. Loren Latta
participated since the mechanical testing was conducted in his
laboratory in Miami. The group met over the years in places like
Glen Eagles in Scotland, Paris, Grenada, Garmisch-Partenkirchen
and Geneva. The leading engineer for the original Hoffmann,
Marcel Wagenknecht retired and was replaced by the energetic
and thorough Jacques Mata.
Each winter, Gernot Asche led a fracture symposium in
Freudenstadt. As new parts became available they were in-
corporated in the workshops of the Freudenstäter Courses. The
Hoffmann II manufactured in the Howmedica Factory in Plan-
les-Ouates was brought out as a complete system in 1995.
The external fixation field by this time included large pin
distractors for bone lengthening, such as the Wagner Device, small
wire frames based on traction bows, like the Ilizarov fixators,
and mobile joint-spanning frames, for example, the Volkov-
 D. Seligson et al. / Injury, Int. J. Care Injured 46 S3 (2015) S3–S6
Fig. 4. The Hoffmann II in a multiply injured patient. The frame permits modular
construction by allowing the addition of bars, pins and clamps, as needed.
Oganesyan fixator. Howmedica introduced the Monotube, the
Monticelli-Spinelli ring frame, the Tenxor and a Dynamic Joint
distractor combining these frame concepts with the fixation pins
and clamps of the original Hoffmann and the Hoffmann II. In
most clinics, Hoffmann II frames were less in use as a device for
the treatment of closed uncomplicated fractures than they were
devices to be brought out for the complicated open fracture or
for use in the combat zone. In an attempt to satisfy the combat
need, Howmedica developed a sterile-packed disposable frame
for use by the military (the Ultra-X). This project was abandoned
when the frame did not pass tests for uses for which it was not
intended [10].
Hoffmann 3 – Selzach
On December 4, 1998, the Stryker Corporation of Kalamazoo,
Michigan, acquired Howmedica, the owner of Jaquet Orthopédie,
which manufactured the Hoffmann II fixators. Just as the
International Hoffmann Symposia had introduced the Original
Hoffmann, annual courses and workshops in Freudenstadt,
Germany provided a platform for advances in external fixation
with the Hoffmann II. Stryker had purchased in 1996 the
Osteo Group with its major manufacturing plant in Selzach,
Switzerland. Osteo was a manufacturer of nails, plates and
fixators as well as prostheses. In 2004, with the acquisition of
Howmedica, Stryker moved the manufacture of external fixators
to the plant in Selzach. To meet the requirements of active
trauma practice, modifications were made in the materials
for the connecting rods to make them MRI compatible. Again
the pressure of competition in the market dictated a further,
more comprehensive, upgrade of the Hoffmann platform.
Considerations were larger diameter connecting rods, reusability,
reduction in the inventory of connectors, prepackaged fracture-
specific modules, and interconnectivity with the Hoffmann II
and Hoffmann Compact systems.
The change in corporate structure brought about a different
process for design of the new fixator. Albin Lambotte, a Belgian,
was an expert woodworker who made violins, violas and cellos.
He made models of his devices in wood for manufacturers to use
for fabrication [11]. The image from the past of Albin Lambotte
coming to the machine shop of Collin in Paris, taking off his
jacket and sitting down to make a part to his own liking has
now metamorphosed into a corporate document ‘chartering’
the Hoffmann 3. In a large business entity at risk for shutdown
by regulatory agencies, many more hands have to view and
shape the process of making new parts. Marketing must assess
the need, engineers prepare the drawings, legal must file the
appropriate documentation, and compliance has to oversee the
process. Traumatologists are now ‘consultants’: they are asked
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S5
Fig. 5. The Hoffmann 3: Interchangeable connectors accept 5, 8, and 11 mm
bars and 4, 5 or 6 mm pins. The connectors can be added or removed without
disassembling the frame. Courtesy Stryker Corp.
whether or not the new designs are safe and effective, attractive
and potentially useful.
An early idea (2008) from the new Hoffmann plant was a
disposable, MRI-safe frame for orthopaedic trauma. This fixator
made of polymers was modular, had large 15 mm diameter
aluminium connecting bars, and could not be reused because it
was supplied in sterile packaging and would melt if autoclaved.
As the agenda for an entirely new system evolved, this ‘Hoffmann
Xpress’ was not widely marketed or supplied.
The earthquake on 12 January 2010 in Port-au-Prince, Haiti
created a catastrophic number of patients with unstable skeletal
injuries. Temporary external skeletal fixation as originally
proposed by Hoffmann was used widely in this theatre for
‘damage control.’ The morning after the quake, the Israel Defence
Force set up a hospital. The Israelis and others used a large
tube (11 mm) sterile packaged external fixator for earthquake
causalities [12]. Although external fixation was widely applied
by various national groups following the disaster in Haiti, there
was no systematic plan for definitive skeletal repair after the
initial damage control application of external fixation. Many of
the hastily applied frames did not enable early functional activity.
The US Military did not advocate external fixation for clinical
use in the Second World War even though several systems were
available. The thinking was that improperly applied frames
would cause damage. After the Haitian disaster and requirements
for military deployments at a distance, interest returned in the
use of a prepackaged, simple, large frame fixator for natural
catastrophes and military deployments. The Hoffmann 3 was
designed in Selzach as a frame with interchangeable bars, a
minimum of connectors, and simple instrumentation for field
use (Figure 5). The Hoffmann 3 design engineers working for
the manufacturer made sketches, produced prototypes and
then brought their new devices to surgeons not for input, but
rather for what was called ‘validation.’ In the US Drs. Andrew
Burgess, Gregory Osgood and David Seligson assembled fixators
in cadaver laboratories to prove or validate the designs. The next
step was the submission of a 510k (approval based on preexisting
design concepts) to the Food and Drug Administration on 27 July
2012 with the final agency clearance granted on 24 October 2012
(within the 90 day allowed window). Since its introduction, the
Hoffmann 3 system has been shown to be successful particularly
as a ‘damage control’ frame for patients with significant
polytrauma. The connecting rods are MRI conditional, which is
an important new requirement as patients with severe injuries
are more likely to survive compared with in the past and are
therefore more likely to require repeat advanced imaging.
Conclusion
The design of the Hoffmann family of external fixators began
as a surgeon-driven concept and has recently been shaped
not only by industry, but also by marketing and regulatory
S6 D. Seligson / Injury, Int. J. Care Injured 46 S3 (2015) S3–S6
requirements. In our era, new or innovative changes must pass
not only company censors, but also governmental regulators. The
costs are immense.
As we move forward in the first half of the twenty-first century
we have to ask whether we are making progress or actually
regressing in our understanding of the tremendous potential for
the use of large pin Hoffmann-style external fixation for skeletal
trauma. Hoffmann external fixation, when properly understood,
may reduce pain and incapacity, shorten hospitalisation, control
costs and preserve the vitality of the musculoskeletal apparatus.
Conflict of Interest Statement
David Seligson is a paid consultant for Stryker - there are no
other conflicts of interest
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