External Fixation in Orthopedic Traumatology

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Frontispiece

Raoul Hoffmann in 1922

Photograph courtesy of Dr. Anne-Christine Hoffmann and the Hoffmann Family, Geneva, Switzerland

Hoffmann is external fi xation. This book is in tribute to Dr. Hoffmann, a private practitioner of surgery who worked in Geneva, Switzerland, and in his mature years developed the technique, improved the equipment and established the indications for external skeletal fi xation. Hoffmann actualized fi xateurs. Born in Berlin the son of a Lutheran minister, Hoffmann was brought up in French Geneva and trained fi rst as a theologian and then as a physician. He met his wife Elsa in Sweden and served as a Christian missionary in Kashmir. He raised his family in Tramelan, a small watchmaking town in Swiss Jura. Hoffmann was a doctor, minister, family man and outdoorsman. He reestablished his practice in Geneva where he not only made external fi xation work but also promoted abstinence from drink. Hoffmann lived from 1881–1972, a great man of the last century.

Schwechter EM, Swan KG. Raoul Hoffmann and his external fi xateur. JBJS. 2007;89:672–8.

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David Seligson • Cyril Mauffrey

Craig S. Roberts

Editors

External Fixation in

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ISBN 978-1-4471-2199-2 e-ISBN 978-1-4471-2197-8 DOI 10.1007/978-1-4471-2197-8

Springer London Dordrecht Heidelberg New York British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library Library of Congress Control Number: 2011941601

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Printed on acid-free paper

Springer is part of Springer Science+Business Media (www.springer.com)

Editors

Dr. David Seligson

Department of Orthopaedics University Hospital Louisville Louisville,

KY, USA

seligson@louisville.edu Dr. Cyril Mauffrey

Department of Orthopaedics University Hospital Louisville Louisville,

KY, USA

cmauffrey@yahoo.com

Dr. Craig S. Roberts Department of Orthopaedics University Hospital Louisville Louisville,

KY, USA

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This book is dedicated to family, friends and

all signifi cant others.

David Seligson

I dedicate this book to my parents, my three

daughters Oceane, Manon, Chiara and my

wife Marzia, for all their patience and love.

Cyril Mauffrey

This work goes to my wife Theresa, my

daughter Stephanie and my son John.

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vii

Foreword

The history of external fi xation goes back to the ancient times when Hippocrates in about 400 BC wrote about a simple external fi xator. Hippocrates described a form of external fi xation to splint a fracture of the tibia with the device consisting of closely fi tting proximal and distal Egyptian leather rings connected by four wooden rods from a cornel tree.

Malgaigne in 1840 has been credited with the fi rst use of “pins” when he created a simple metal pin in a leather strap for the percutaneous pin treatment of a tibial fracture.

In the early twentieth century, Lambotte, a Belgian surgeon, designed a device for external fi xation that allowed the placement of pins in any needed direction while the pins were connected to a rod by adjustable clamps.

More recently, several surgeons such as Shanz, Reidel, Stader and Anderson, with their work, have been credited for the evolution of external fi xation design systems. In 1938, it was Dr. Hoffmann from Switzerland, who realized that major improvements were desirable to make the external fi xator more clinically applica-ble. He developed a technique based on closed reduction with guided percutaneous pin placement. One could argue that Hoffmann’s technique represented the fi rst application of minimally invasive orthopedic surgery.

Despite all the good intentions of the surgeons to apply the concept of external fi xator in the clinical setting, during the Second World War, several studies were published describing complications of the technique, including pin infections, pin breakage or loosening, nerve or tendon damage from pin insertion, and loss of reduction. As a result of these reports, external fi xation developed a bad reputation and its popularity declined.

More recently, however, external fi xation underwent many changes allowing for the various previous complications to be addressed. Overall, improvements in fi x-ator confi gurations and the skill and judgment of surgeons led to the current accep-tance of the method.

Nowadays, external fi xation is considered as a valuable clinical treatment option, providing surgeons with the ability to affect the spatial relationship of tissues, both

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viii Foreword

statically and dynamically, utilising minimally invasive techniques. The simplicity and speed of application, the adjustability of the frame confi guration and the mini-mal blood loss with the negligible interference of the blood supply at the cutaneous and osseous levels are some of the advantages of the external fi xation technique.

Currently, external fi xation has many applications in the care of the trauma patient. Open fractures with severe soft tissue injuries and/or massive contamination are ideally suited to this technique. External fi xation is also a versatile salvage tech-nique for the complications arising from extremity trauma. The management of residual fracture deformity, bone loss, and infections are often simplifi ed by exter-nal fi xation. It can also be used as a salvage tool in cases associated with major complications after nailing or plating. It can be applied as a temporarily treatment of long bone fractures in patients with multiple injuries until the physiological state has been optimised so that conversion of the external fi xator to a nailing/plating procedure can be performed. In cases of persisting infection or ongoing problems with soft tissue coverage, external fi xation can be considered as the defi nitive stabi-lisation method in this group of patients. Moreover, in complex periarticular frac-tures, where the concept of damage control for the extremities is applied, external fi xation can span the affected joint, allowing adequate resuscitation of the surround-ing soft tissues, temporarily restoration of the mechanical axis and rotation until defi nitive reconstruction can be performed with open reduction internal fi xation techniques.

The textbook of external fi xation in orthopedic traumatology is a superb volume on the current state of the art. All the anatomical sites of the skeleton where external fi xation can be applied in simple and complex clinical situations are included. All relevant chapters have been prepared by contributors who have a deep understand-ing of the subject.

This book is a testament to the present concepts of application of external fi xa-tion techniques. It will fi nd a special place in the reading rooms of both junior and senior surgeons.

The editors are to be congratulated for putting together a superb textbook on external fi xation for the trauma and orthopedic surgeon.

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ix

Preface

“External fi xation in Orthopedic traumatology” focuses on the use of external fi xa-tion in the acute management of patients with serious orthopedic injuries. The book highlights the indications for external fi xation and provides an evidenced based guide to both the specialist orthopedic surgeon and the trainee. The manuscript is organized in 14 chapters covering the indications and surgical techniques for pelvis, lower limb and upper limb injuries, including detailed illustrations and clinical pho-tographs that will enable the reader to rapidly visualize the structure of the construct and to plan for surgery accordingly. More general topics such as damage control orthopedics, biomechanics of external fi xation and medico-legal considerations sur-rounding the injured patients are also included to provide an overall picture of the Orthopedic trauma patient. The Combined experience of the editors and authors, their involvement in a number of external fi xation system designs and their interna-tional reputation in the fi eld contribute to making this textbook an essential tool that should be available to all orthopedic surgeons dealing with injured patients.

David Seligson Cyril Mauffrey Craig S. Roberts

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xi

Contributors

Dennis Beck , M.D. Orthopaedics Associates , Evansville , IN , USA Charles Daniel Benson, M.D. Department of Orthopedic Surgery, Resident in Orthopedic Surgery, University of Kansas Medical Center , Kansas City, Kansas, USA

Thomas De Coster Division of Trauma, Department of Orthopaedics , University of New Mexico , Albuquerque , NM , USA

Thomas Dienstknecht Department of Orthopaedic Trauma , University of Aachen Medical Center , Aachen , Germany

Paul J. Dougherty Department of Orthopaedics , University of Michigan , Ann Arbor , MI , USA

Peter V. Giannoudis Department of Trauma & Orthopaedic Surgery, School of Medicine , University of Leeds , Leeds , UK

Jessica Heinsen , M.D. Department of Orthopaedics , University Hospital Louisville , Louisville , KY , USA

Kimberly M. Kesling Department of Orthopaedics, Clinical Services , Darnall Army Medical Center , Ft Hood , TX , USA

N. S. Laud , M.D. Department of Orthopaedics , Laud Clinic , Mumbai , Maharashtra , India

Cyril Mauffrey , M.D., FRCS Department of Orthopaedics , University Hospital Louisville , Louisville , KY , USA

Janet Macphaden Department of Orthopaedics , Nurse Practitioner, University Hospital Louisville , Louisville , KY , USA

Alfredo Aybar Montoya , M.D. Department of Orthopaedics, Av. San Felipe , Jesus Maria , Lima 14 , Peru

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xiv Contributors

Hans-Christoph Pape Department of Orthopaedic Trauma , University of Aachen Medical Center , Aachen , Germany

V. Manakavala Perumal , M.D. PWD Road, Chettikulam Junction, Nagercoil , Tamil Nadu , India

Craig S. Roberts , M.D., M.B.A. Department of Orthopaedics , University Hospital Louisville , Louisville , KY , USA

Laura Ruhala , M.D. Department of Engineering , University of Southern Indiana , Evansville , IN , USA

David Seligson , M.D. Department of Orthopaedics , University Hospital Louisville , Louisville , KY , USA

Madhusudhan Yakkanti Department of Orthopaedic Surgery , University Hospital Louisville , Louisville , KY , USA

Jonathan Yerasimides Department of Orthopaedics , University Hospital Louis-ville , LouisLouis-ville , KY , USA

G. Zych Department of Orthopaedic Trauma , University of Miami Leonard M Miller School of Medicine , Miami , FL , USA

External Fixation in Orthopedic Traumatology

Frontispiece

David Seligson • Cyril Mauffrey

Craig S. Roberts

Editors

External Fixation in

This book is dedicated to family, friends and

all signifi cant others.

David Seligson

I dedicate this book to my parents, my three

daughters Oceane, Manon, Chiara and my

wife Marzia, for all their patience and love.

Cyril Mauffrey

This work goes to my wife Theresa, my

daughter Stephanie and my son John.

Foreword

Preface

Contents

Contributors