Evolution and generation of implants

1. PRESENTED BY
DR INDRAJITCHAKRABORTY
PGT ORTHOPAEDICS
MODERATOR
DR. GAUTAM MAZUMDER
ASSOCIATE PROFESSOR
DEPARTMENT OF ORTHOPAEDICS
GMCH
EVOLUTION
AND
GENERATIO
N OF
IMPLANTS

2. The Earliest Examples Of Active
Management Of Fracture Was
Discovered In Naga-ed-der In Egypt, By
Professor, G. Eliiot.
1. Compound Fracture Femur In An
Adolescent, Splinted With 4 Longitudinal
Wooden Boards, With Dressing Pad
Containing Blood Pigment Was Found
2. Compound Fracture Of Forearm ,
Treated Similarly But With Dressing Pad
Stained With Blood And Vegetable Fiber

3. BASIC TERMS
IMPLANTS are devices or
tissues that are placed inside
or on the surface of the body
ORTHOSES externally applied
device to correct bio
mechanical alignment
Many implants are prosthesis
intended to replace missing
body parts

4. Metals and implants in Orthopaedics
Early fracture surgery
1. Wire fixation – A.M.I CART
1770s surgeon of the HOTEL DEAU AT
CASTRES
2. Bone suture - 1827 DR
KEARNY RODGERS OF NEW YORK ,
resected pseudo-arthrosis humerus
3. The 1st book published on internal fixation
“traite de immobilization” by
BERENGER feraud

5. Screw fixation
Converting rotational force into linear motion
Started in late 1840s
Cucuel & Rigaud , the French surgeons, described two
cases:
In 1st case , screw was inserted to permit traction on a depressed
fracture of superior part of sternum & elevate the fragment
In 2nd case, he inserted two screws in ulna and olecranon, wired
them together, achieving satisfactory union
Sherman advocated self-tapping, fully threaded vanadium
machine screws

6. Robert Danis proposed 3 key
screw features:
Exterior to Core diameter of
3:2, not 4:3 as is typical of
metal screws
Thread surface area one-
sixth that of metal screws
A buttress thread design to
replace standard V-shaped
threads

8. AO FROM 1960 HAS INVENTED THE
FOLLOWING SCREW TYPES
CANCELLOUS SCREWS
• 1)cannulated and non cannulated
• 2)fully threaded and partially threaded
CORTICAL SCREWS
TAPPING & NON-SELF TAPPING
CORKSCREW TIP (cancellous screw) & Trocar Tip(malleolar screw)
SPECIAL SCREWS
• 1)HERBERT SCREW
• 2)ACUTRAK SCREW SYSTEM

9. screws

11.  MALLEOLAR SCREW:
- smooth shaft
- partially threaded
- trephine tip : no tapping needed
- was designed as lag screw for
malleoli fixation NOW small
cancellous screws preffered
- also used in distal humerus ,
lesser trochanter
- size : 25mm – 75 mm

12.  WASHER :
- flat side: rests on bone
- countersunk side: accepts screw head
- prevents screw from breaking through
thin cortex in metaphysis

13. Locking head screw
• The LHS have a head with a
thread that engages with the
reciprocal thread of the plate
hole.
• a screw-plate device with angular
stability
variable angular stability, which
allows angulating locking screws
within the plate hole to address
specific fracture configurations.

14. • To attach implants to the bone by
compressing them onto the bone
surface
• As the plate hole is larger than the
outside diameter of the
conventional cortex screw and the
screw has good purchase in the
underlying bone, as it is tightened it
compresses the plate to the bony
surface.

15. • To hold two bones in correct
relationship─position screws
Their threads purchase in
both bones and the screws do not
compress the bones together.

16. Bell in 1804 used silver coated steel pins and
noted corrosion in them
Lavert in animal experiment found platinum to
be most inert but too soft for clinical use
Lister was one of the 1st to successfully wire a
fractured patella using silver wire

17. PLATE FIXATION
First by HANSMAN of Hamburg, 1886
Malleable plate, the end being bent through a right angle
to project through the skin
The plate then attached to each fragment by one or more
special screws with long shanks that projected through
the skin for ease of removal
Nickel plated sheet steel
Plate was fixed to bone by ivory pegs to prevent
corrosion and removed 3-4 weeks later

18. ALBIN LAMBOTTE
Father of modern internal fixation
Coined the term Osteosynthesis
Developed not only plates and screws but
external fixation devices similar in principle
to ones in use today
His classical book on surgical treatment of
fractures was published in 1913

20. SIR WILLIAM ARBUTHNOT
LANE
A British surgeon
Devised plates that were made of
stout steel, a high carbon steel
He devised No-touch technique to
prevent wound infections
Used to be brittle and broke at
junction of central bar and 1st hole

21. Performed ORIF in all cases of simple fracture
His attempts at internal fixation of compound fractures were
universally failure, but not a single case of operated simple fracture
became infected
Layton accounts that Lane was using Lister’s antiseptic technique
Everyone wore long mackintoshes upto the neck wet with carbolic or
lysol during surgeries
Layton recorded the PM exploration of a fracture plated by Lane,
which was the first observation of healing without external callus
formation in the presence of internal fixation

22. A) LANE BENT WIRE
B) CORRUGATED STEEL
STAPLES
C) SCHEDE BRUN
PLAIN STEEL
STAPLES
D) LAMBOTTE GOLD
PLATED BONE SPIKES
E) LAMBOTTE SCEWS
FOR FIXATION OF
FRAGMENTS

23. WILLIAM SHERMAN

24. the use of tincture iodine for skin preparation and
the uDescribedse of draping and skin toweling
He wrote in 1905 and illustrated both single and
double plating and the use of intramedullary
screw fixation for fractures of neck of femur
Most screws used at that time were derived from
SHERMAN’s design
Use of corrosion resistant vanadium steel
Sherman improved Lane’s plate to make it
stronger

25. Instruments designed by Sherman

26. Lambotte brothers , Elie and Albin, used
other metals like aluminium, brass,
magnesium and copper plates, as well as
steel coated with gold and silver
Thin, round and tapered at both ends
Curved to fit the curvature of the bone
The total disintegration of the magnesium
plates used with steel screws underlined the
effect of electrical corrosion when two
separate metals were used

30. Trauma Biological Osteosynthesis
and Contemporary Developments
Achieve rigid fixation of
bone fragments without
soft tissue or periosteal
injury
Minimal damage of
vascular supply
Fracture healing is
similar to the closed
treatment of the
fractures with callus
formation
Waving and the limited
contact plates (LC-
DCP)
The Waving is a bent plate ,
whose metallic body is not in
contact with the bone at the
fracture site and the space
allows for the autogenous graft
placement
Used in the multifragmentory
fractures of the femoral
diaphysis, when there is
destruction at the medial cortex

31. THE AO GROUP (ARBEITGEMEINTSCHAFTS
FUR OSTEOSYNTHESEFRAGEN) was formed
in BIEL, SWITZERLAND by 13 surgeons on
November 6th 1958.
Maurice Edmond Müller
Martin Allgöwer
H. Willenegger
Robert Schneider
Walter Bandi

32. Standardized Instrumentation Set (AO, 1958)

33. In 1967, AO group with reference to compression
technique introduced DCP
Low rate of malunion
Stable fixation
No need for external immobilization
Early movements of neighbouring joints.

34. LC-DCP- improvement of DCP (by
PERREN)
Reduce the bone plate contact by
50%
Bending of the implant is easier
Vascularization of the bone edges
is minimally affected
Callus formation is favored
Plate holes have the same formation
as that of the classical DCP and so
interfragmentary compression is
possible

35. Biological fixation led to the invention of
LISS
Internal form of external fixation guided through
a small hole, distal to the fracture site with a
closed introduction of cutting screws
Helps form callus without additional injury and
allows healing by preservation of the blood
supply
Disadvantage- requires skill during the closed
application of the plate and screws
Advantage- simplicity, callus formation and
resistance to infection by direct contact

37. Since 1990, Bioabsorbable nonmetallic
materials became popular
Devices made of PLA (polygalactic acid) or
PGA(Polyglicolic acid ) or a combination of
both(PLGA)
Advantage- 1)progressively absorbed and do not
remain in situ
2)Second operation for removal is avoided
Disadvantage- 1)Reaction of immune system due to
their recognition by the macrophages
2)Inability to support early mobilization

38. Intramedullary fixation
Pioneers of IM Screw fixation for #NoF are Von Langenbeck, Koeing, Cheyne, Lambotte
and Lane
GILLETE used the trans trochanteric approach to perform intracapsular fixation of femoral
neck fractures using intramedullary bone pegs
Curtis used drill bit, as reputedly had Langenback, while Charles Thompson used silver nails
in 1899
Lambotte recorded the use of long intramedullary screw
In the late 19th century, BIRCHER is credited for using intramedullary ivory pegs ,
first used in 1886

39. 1910s
Ernest Hey Groves used massive three
and four flanged intramedullary nails
for fixation of diaphyseal fractures of
femur, humerus and ulna
1920s
Smith Peterson used triffin nail for
intramedullary fixation of sub capital
femur fractures
1940
Use of stout wire and thin solid rods
was recommended by Lambrinudi

40. Developed by Gerhardt Kuntsher
Gripped the endosteal surface of the bone so called
elastic nailing
Originally used V shaped nail
Changed to a nail with a cloverleaf cross section
Greater strength and designed to follow any guide pin
more faithfully
Kuntsher improved on Hey Groves original idea of
round rods by using the clover leaf or V –shaped nails
Kuntsher Nail
HEY-
GROVES
LONG
STEEL
STRUT
1921

41. Advantage of K-Nail over Solid nail
Solid nail will not occupy the full width of the medullary canal in most
places, diameter must be selected to fit the narrowest portion of the canal
K-nail with an elastic cross section will adjust to the constrictions of the
canal.
Bone resorption will soon loosen a solid rod
K-nail with a compressible cross section will expand during bone
resorption

42. Kuntsher also developed-
Interlocking femoral and tibial nails
Intramedullary bone saw for endosteal
osteotomy
Expanding nail for the distal tibia and the
Signal arm nail for trochanteric fractures
Flexible powered intramedullary reamers and
intramedullary nail to provide compression at
the fracture site

45. BURGHARD’S SCREWS
SMITH PETERSEN
CANNULATED TRIFLANGED
NAIL

46. NAILS FOR PROXIMAL FEMORAL FRACTURES

48. SECOND
GENERATION
NAILING

49. Grosse Kempf nail-
semiclosed IL nail
Russell–Taylor nail was the
first closed section interlocking
nail
In 1996, the AO developed
the proximal femoral nail
(PFN) for unstable
peritrochanteric femoral
fractures.

50. THIRD
GENERATION
NAILING

51.  PFNA had lateral
cortex impingement
in Asian patients
 PFNA-II
 flattened lateral
surface
 decreased
mediolateral nail
angle
 decreased proximal
nail diameter

52. FOURTH
GENERATION
NAILING

53. Biodegradable polymers and shape
memory alloys
Biologically active agents, such as
Bone Morphogenic Protein-2 and 7
These new nails could also be
impregnated with slow-release
antibiotics to eliminate infections
especially in open fractures

54. Summary
FIRST
GENERATION
SECOND
GENERATION
THIRD
GENERATION
FOURTH
GENERATION
-Primary splint Locking Screw – Fit anatomical - Surface treatment -
Less Rotational
stability
Improved rotational
stability
Titanium alloy - Telemetry
Longitudinal slot over
entire length
Not Slotted Multi axial screw
fixation – Reaming
Eg- K-nail, V-nail Russel-Taylor Nail
PFN Kempf Nail
PFNA

55. BIOMATERIALS

56. POLYMERS
Polymer biomaterials of the first generation
are-
• Silicone rubber
• PE
• Acrylic resins
• Polyurethanes
• Polypropylene (PP)
• Polymethylmethacrylate (PMMA)
Acrylic bone cements play key role in the
anchorage of prostheses to the surrounding
bone in cemented arthroplasties

57.  Charnley (1960) introduced the self-
polymerizing PMMA bone cement
 Sought idea from dental cements
 Prepolymerized PMMA, an initiator, to
catalyse the polymerization process
 A radiopacifier BaSO4 or ZrO2
 Liquid phase formed by MMA
monomer, an accelerator reagent and a
stabilizer. These components are mixed
into a paste which after the
polymerization of the monomer
hardens and eventually sets

58. ROLE OF CEMENT
Allows the secure fixation of implant to
bone
Transfers load evenly from implant to bone
Maintains the bone stock
Acts as shock absorber
Can be used as a drug delivery system

59. SECOND GENERATION
1980 and 2000
Bioactivity- interaction or effect that
materials exert on cells with the aim of
leading or activating them to specific
responses and behaviours
Bioabsorbable materials’ ability to
undergo a progressive degradation while
new tissue regenerates and heals.

60. METALS
None of the metallic materials used in orthopaedics is
bioactive per se
Coating the surface of the implant with a bioactive
ceramic (HA and BGs)
Chemically modify the surface of the material so as
to
obtain the deposition of a bioactive ceramic in vivo
or
to induce proteins and cell adhesion and other
tissue/material interactions.
Coating methods- Electrophoretic deposition
o Plasma spraying
o Radio frequency or Ionic ray sputtering
o Laser ablation
o Hot isostatic pressure

61. The most common ceramic materials can be
classified as BGs, glass–ceramics and calcium
phosphates (CaPs) both as ceramics and
cements.
Application as bone substitutes started around
the 1970s and have been mainly used as bone
defect fillers

62. THIRD GENERATION
Stimulate specific cellular responses at the molecular
level (Hench & Polak 2002)
Temporary three-dimensional porous structures that
stimulate cells’ invasion, attachment and proliferation,
as well as functionalized surfaces with peptide
sequences that mimic the ECM components so as to
trigger specific cell responses

63. PLA,PGA, PCL and PHB- bone tissue engineering purposes
PLA, collagen and silk- ligament tissue engineering
Combination of PCL and hyaluronic acid- meniscus tissue engineering
Hyaluronic acid, polyglactin, collagen, fibrin, alginates, chondroitin sulphate
photocrosslinked hydrogels and glycosaminoglycans- cartilage and intervertebral
disc (nucleus pulposus) tissue engineering applications
Decalcified (or demineralized) bone matrix (DBM)- alternative to
autografts

64. STEEL
A new mineral chromite discovered in Siberia in 1776
Metal chromium extracted from chromite, posses good resistance to
corrosion
Chromium plating of metallic surface
L GULLIET of France was the first to make alloy system to what
we call stainless steel today
Rustlessness- atleast 13% chromium
The 18-8 Smo- 1st stainless steel to be used satisfactorily as a
surgical implant

65. Stainless steel 316 L
STAINLESS STEEL designated as ASTM(AMERICAN
SOCIETY FOR TESTING AND MATERIALS) F-55,
56(GRADES 316 and 316L) is used extensively for fracture
fixation implants
Type 316L is a iron based alloy
Alloying with chromium generates a protective self regenerating
chromium oxide layer which provides protection against corrosion
Addition of molybdenum decreases the rate of slow passive
dissolution of the chromium oxide layer by upto 1000 times,
molybdenum further protects against pitting corrosion
Nickel imparts corrosion resistance and facilitates the shine
Silicon and Manganese are added to impart smoothness

66. The carbon component increases the strength but the alloy is
undesirable
Type 316L has a very low permissible level of carbon to
minimize this problem
Though it is strong stiff and biocompatible material, 316L
has a slow but finite corrosion rate, concerns therefore prevail
about the long term effect of nickel ion
Thus, stainless steel is best suited for short term implantation
in body as in fracture fixation

67. Stainless steel is frequently used because
Material is cheap
The alloy can be formed using common techniques , and its
mechanical properties can be controlled over a wide range for
strength and ductility
The elastic modulus of steel is 12 times higher than cortical
bone

68. TITANIUM
In the last 30 years, another metal which came into use is
TITANIUM
Total inertness in the body
Chemically inactive
MRI compatibility
Titanium , Vitallium have the fabrication versatilty and
strength of stainless steel and excellent compatibility in
the body

69. Titanium alloys
Titanium is the 9th most abundant element the earth’s crust
The metal becomes rapidly coated with an oxide layer, making
it physiologically inert and resistant to most chemicals
It is used to make orthopaedic implants in two forms
Commercially pure
Variety of alloys
Titanium-aluminium-vanadium alloy (ASTM F-136) is
commonly referred to as Ti6AI4V. This alloy is most
frequently used to manufacture implants

70. Cobalt chromium alloys
The cobalt-chromium-tungsten-nickel
alloys(ASTM F-90) is used for manufacture of
fracture fixation implants
In clinical practice its used to make wire and
internal fixation devices including plates,
intramedullary rods and screws

71. EVOLUTION OF IMPLANT METALS
BONE PEGS - 1500
BRASS WIRE- 1775
IVORY ROD
1890
STEEL PLATE (LANE) 1905
SILVER ROD
1913
STEEL ALLOYS 1926
VITALLIUM (STELLITE) 1929
TITANIUM 1950s
CERAMICS 1970
BIODEGRADABLE 1980

72. External fixation
First documented use in 377 BC by
Hippocrates
Traditionally 1st external fixation device
was ‘pointe metallique’ concieved by
MALAIGNE in 1840
Hemicircular metal arc device that could
be strapped around the limb
In 1843 MALAIGNE also described his
‘griffe metallique’, or metal claw
This claw was also used at that time to fix
fracture of patella

73. Modification put up by
CHASSIN was proposed in
1852 for use on displaced
fracture of CLAVICLE
Parkhill 1894 Threaded pins
and clamp, something that
we use today
Lambotte used self tapping
threaded pins, rod, adjustable
clamps

74. CRILE in 1919
1) Drove a peg into neck of femur via
outerface of greater trochanter
2) A metallic clipper bearing double
points that were driven into the
condyles of the distal femur
3) And an external linking device with a
universal joint at each end capable of
being clamped onto the metal spheres
and also capable itself of extension
via a lengthening screw

75. In 1938, In Switzerland, RAOUL HOFFMAN of
Geneva, developed an improvised version of
external fixation similar to that used today
In 1960, building on the ground work of Hoffman,
Burny and Bourgois started to outline the
biomechanical principles on which external fixation
was based . This led the way to the universal
acceptance of this method of fracture treatment

76. EXTERNAL FIXATORS TODAY
 Type -1 Unilateral Uniplanar
 Type -2 Uniplanar Bilateral.
 Type -3 Classical Bilateral Biplanar.
Delta Unilateral Biplanar
 To increase stability of bone–pin
interface
a)Adequate no. of pins in each
fragments (2 for most bone & 3
for femur)
b)Increase pin pitch (3.5mm)
c)Increase size of pin

77. • UNIVERSAL MINI EXTERNAL
FIXATOR
Micro-motion at fracture Site.
It is bi-lateral
More lighter than traditional
External Fixator.
More ligamentotaxis
Less chance of pin tract
infections.

78. HYBRID EXTERNAL FIXATOR
 Thin wires near joint
 Pins (Schanz Screws) in shaft
 It reduces and fixes the joint surface
 Span the diaphyseal segment without
 Disturbing soft tissues

79. MODULAR EXTERNAL FIXATOR
Allows surgeon to reduce the fracture
by manipulation and to hold the
reduction
Free pin placement allows the surgeon
a)to spread both pins, thereby
increasing frame stiffness
b)to position pins according to the
fracture pattern or soft-tissue
injury
c)to avoid injury to nerves or
vessels.

80. During the 60s Gabril Abramovicg Ilizarov developed his
circular osteosynthesis device
Introduced into the western world by the Italian surgeon
Carlo Mauri, who was successfully treated by Ilazarov for
septic non union of tibia
Ilizarov found that slow and steady distraction of a recently
cut bone (securely stabilized in external fixator) leads to
formation of new bone within the widening gap

81. In 1891, German Professor Themistocles Glück made the
earliest recorded attempts at hip replacement surgery
Help his patients suffering from tuberculosis that caused
damage to their hip joints.
Glück created an implantable hip prosthesis fashioned of
ivory and affixed with nickel-plated screws.
Hip Replacement

82. In 1925, Marius Smith-Petersen an American doctor tested an
implant mold made of glass.
Hollow ball that fit over the femoral head to provide a new
smooth surface for improving hip movement.
Initially successful; however, the glass could not hold up
under the pressures of the joint, led to shattering in the patient.
In 1953, George McKee, an American surgeon began to use a
metal-on-metal prosthesis
-First surgeries where both the ball and
socket were replaced
-Metal pieces and particles broke off due
to wear and tear causing complications

83. The Father of Modern Total Hip Replacement
 Sir John Charnley, an orthopaedic surgeon at the Manchester Royal Infirmary
 In the late 1950s, created a prosthesis inspired by the work of dentists.
 A metal femoral stem, a polyethylene acetabular component and acrylic bone
cement
 Cement’s two main features; its toughness and ability to be used as grout to
improve the fit of the implant.
 Charnley’s design was a low friction solution improving patient movement
post-surgery that solved the squeaking noise heard from other implant
solutions at that time
 Smaller femoral head which reduced implant wear over time improving the
life span and success of the surgery.

84. From Charnley until now...
 Implant designs have improved to offer cementless fixation
– or press-fit fixation
 Larger femoral head sizes to reduce dislocation risk
 Improvements in bearing surface materials – notably the
highly cross-linked polyethylene which further reduced
wear and tear rates.

85. • Moore-Bohlman
Upper Femur (1941)

86. THA PRECURSORS
Moore in 1950 had designed the
implant in such way that it is known
today , with two portals in the
proximal part of the stem , which he
filled with grafts of bone which he
took from the femoral head of the
extracted hip, in order to create a
bridge of bone and thus achieve
desired stability

87. McKee THA, circa 1940
McKee-Farrar Total Hip Prosthesis

89. TKR today
• Majority of TKR today are Condylar replacements
which consist of the following
1. Cobalt chrome alloy femoral component
2. Cobalt chrome alloy or titanium tibial tray
3. UHMWPE tibial bearing component
4. UHMWPE patella component

90. Thank you

91. CLASSIFICATION & MANAGEMENT OF
OPEN FRACTURES & PRINCIPLES OF
EXTERNAL FIXATION , WOUND
MANAGEMENT & RECENT ADVANCES
BY
DR. NILOTPAL SAIKIA
PGT ORTHOPAEDICS, GMCH
MODERATOR: DR. KISHORE HAZARIKA