Veterinary Orthopedics Webinar on Evolution of Internal Fixation

raviraidurg@gmail.com
CAPT. DR. RAVI RAIDURG
M.V.Sc, PhD (Veterinary Surgery & Radiology)
Associate Professor & Head,
Department of Surgery & Radiology, Veterinary College,
Vinoba Nagar, Shivamogga 577 204, Karnataka, India
Phone: +919449827183, E mail: raviraidurg@gmail.com
EVOLUTION OF INTERNAL FIXATION
IN
VETERINARY ORTHOPAEDICS
1

2
HIMALAYA PPAK
WEBINAR SERIES

S.No Webinar Topics
1 Preoperative planning in Veterinary Orthopaedics
2
Evolution of Internal Fixation in Veterinary
Orthopaedics
3 Methods of fracture repair in Veterinary Orthopaedics
4 Plate Osteosynthesis – Terminologies and Instrumentation
5
Open Reduction and Internal Fixation (ORIF) for long bone
fracture repair in dogs
6
Management of long bone diaphyseal fractures with minimal
invasive plate osteosynthesis (MIPO)in dogs
3
HIMALAYA PPAK
WEBINAR SERIES

Aim : Understand the events in
“Evolution of internal fixation in Veterinary Orthopaedics”
Learning Objectives
At the end of this session you should be able to:
 Explain how “Internal Fixation evolved in Veterinary practice”.
 Enumerate the “Turning points in history which revolutionized
Orthopaedics”
 Understand the genesis of AO & AOVET group
 Recognise and apply AO principles to small animal fracture
management.
 Explain Biological Osteosynthesis (BO) & concept of MIPO
4
EVOLUTION OF INTERNAL FIXATION
IN

S.
No
Topic
Time
(min)
Slides
1 Introduction 10 01-12
2 15
3
204
5
6
30
7
8 10
9 Summary 05 159 – 160
raviraidurg@gmail.com 5
EVOLUTION OF INTERNAL FIXATION IN
SESSION OUTLINE (90 Min)

The Beginnings – 2600 BC
 First description of fracture
management in Ancient
Egypt.
7

HISTORICAL OVERVIEW OF THE FIRST
TECHNIQUES OF OSTEOSYNTHESIS
(1775 to 1985)
 Conservative management (External Coaptation)
 Wiring/Cerclage
 Screw fixation
 Intramedullary nailing
 The external fixator
 Plate and screw osteosynthesis
 Compression plating
 DCP (Dynamic compression plating)
8

Conservative treatment
(External Coaptation)
9

XIX century
Lorenz Böhler (Austria)
 Pioneer of the conservative
treatment.
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 atrophy.
10

Wiring/Cerclage
11

1775
 French manuscript described fixation of bone fragment using iron
wire.
12

1827
Rodgers K
 First internal fixation of a fracture using an iron wire.
 He resected the pseudoarthrosis of the humerus and then
connected the fragments with silver wire
13

1839
Malgaigne
 Treated Flaubert’s fracture of humeral shaft with a
metallic suture.
14

ESF
External Skeletal Fixation
15

400 BC
Hippocrates
 simple external fixator for
fracture of the tibia.
 Device made up of leather
rings that covered the limb.
 Rings were connected to each
other by four rods made of
cherry wood that travelled
from the knee to the ankle.
 The rods were placed laterally
with respect to the ankle, so
not to interfere with the
movement of the ankle and
permitted for an inspection of
the skin
16
External fixator for tibial fracture as applied
by Hippocrates

1839
KEETLEY
(English physician) ESF Long bones
 It was here that Keeley described a
technique where rigid pins were inserted at
the level of the femur and connected to an
external system of splints with the objective
of reducing the incidence of
pseudoarthrosis.
 In the Keeley fixator the pins were made of
plated steel and inserted into the bone
through a mini-incision of the
 skin. The pins were connected to each other
by two horizontal braces and the entire
fixator was covered in iodoform gauze.
17
Keetley’s fixator.

1843
Wutzer
 In Europe, developed principle of ESF but without any
success
 His “screw apparatus” couldn’t provide sufficient stability
to the fracture.
18

1843
Malgaigne
(French physician )
 introduced a device to
treat fractures of the knee-
cap and the olecranon.
19
Malgaigne fixator

1897
Clayton Parkhill (in DENVER)
 This fixator by Parkhill was made up
of four screws of which two were
inserted into the proximal fragment
and two into the distal fragment.
 The screws were connected among
each other with plates and bolts.
 Parkhill used this technique to treat
fractures and pseudoarthrosis of the
tibia.
 In all cases he used supplemental
plaster immobilization toincrease
stability.
 Clayton Parkhill died five years later
of an appendicitisand therefore was
not able to further develop his
technique.
20
Parkhill external fixator

1897
Freeman ( In Colorado)
 Developed an EF system similar to that of Parkhill.
 Specifically, a single pin was inserted both above and
below the fracture. These two pins wereconnected to
each other by metal bars which were covered in wood.
 Furthermore, Freeman developed a trocar in order to
position the pins in the most sterile manner as well as
to protect the soft tissue.Freeman is credited with
inventing a “T handle” for facilitating an easy insertion
of the pins through the skin.
 Moreover, he affirmed that the pins should be inserted
at a certain distance from the fracture and this
insertion should be performed through the skin
incision.
 With this technique, Freeman wrote that he had
successfully treated both the neck of the femur and
pseudoarthrosis of the tibia
21
Freeman fixator

1902
Lambotte
(Belgian physician)
 Applied a unilateral frame in a
systematic manner.
 This fixator was made up of metal pins
that penetrated into the bone and
protruded through the skin.
 The pins were connected to each other
by an external device, that permitted
for the stabilization of the pins and
bone segments.
22
Lambotte’s external fixator

1938
 Hoffman realized that one of the principle
limitations was the necessity for an open
reduction before applying the fixator. For this
fact, he coined the modern Greekterm
“osteosynthesis”, which means“put the bone in
its place”.The Hoffman fixator was composed of
anincorporated universal ball joint connecting the
external ball of the fixator to strong pin-gripping
clamps.
 This universal joint allowed for a reduction of the
fracture in the three planes of space even after
the fixator was applied.Hoffmann published his
technique in 1938 and presented it to the French
Congress of Surgery [13].
 Here it was possible to apply a sliding
compression distraction bar that allowed to apply
the compression at the centre of either the
fracture or the distraction.
23
Hoffmann’s external fixator

1846
 Development in anaesthesia
24

1851
Von Langenbeck
 Successfully improved the ESF apparatus developed
by Wutzer.
25

1858
Hansmann (Hamburg,
Germany)
 Described the first internal
fixation by means of a plate and
percutaneous placed screws.
26

1865
Introduction of
“Principles of
Antisepsis”
by
Jozef Lister.
27

1870
Jozef Lister
 Father of asepsis,
 Used metal wires to fix closed
fractures.
 This technique was adopted by
Trendelenburg in Germany and by Lucas
Championnière in France.
28

1870
Bérenger Féraud (1832-1900).
 Published first book, with the title "Traité de
l’immobilisation directe des fragments osseux
dans les fractures" ("About direct
immobilisation of the bone fragments in
fracture"), where the internal fixation has
been mentioned.
 In this book he described three cases of tibia
fractures, which he treated by cerclage after
conservative treatment failure.
29

1883
Stimson
 First to describe a
method of bone
fixation by using
ivory pegs, fixed in
the medullary canal.
 Ivory pegs were
inserted into the
medullary canal for
non-union.
30

1893
Nicolas Senn
 Used pegs and rods made of animal
bone for intramedullary nailing.
31

W C Roentgen
Discovery of X rays
32
1895(08 Nov 1895)

1895
Sir William Arbuthnot
Lane (1856-1938)
 The first metal plate
used for fractures
fixation (indicated initial
shortcomings such as
corrosion, insufficient
strength, malunion or
nonunion, or a poor
return to function).
33

1895
Sir William Arbuthnot
Lane (1856-1938)
 Published his classic
work about fracture
treatment "The
Operative Treatment
of Fractures" .
 Performed the first
interfragmental
fixation.
34

1897
Clayton Parkhill (Denver, USA)
 In the United States considered as “Father of
external fixation”.
 He presented his device to the American
College of Surgery in 1897, when he was
Professor at the university of Colorado and
Dean of the medical faculty.
 His successful career dramatically ended at
the age of 42 when he died during the
Spanish-American war due to appendicitis
35

1906
Albin Lambotte (1866-1955),
Belgium
 Introduced the term of
osteosynthesis.
 Father of internal fixation.
Introduced the "no touch"
technique, which made surgery
safe.
 His first fixation was the fractured
tibia when he fixed it with the plate,
but corrosion occurred.
36

1912
 Introduction of Alloys
 Sherman introduced his version of internal
fracture fixation plate
37

WWI
 Ernest Hey- Groves
described the first
endomedullary fixation
method as an easy
technique allowing bone
fixation through a very small
skin incision without
additional damage to the
periostium. The fracture
healed without the application
of a plaster cast or traction
device
 He also reported the use of
metallic rods for the treatment
of gunshot wounds.
 Very high infection rate.
38

1916
 Ernest Hey- Groves described the First
textbook on osteosynthesis (textbook: "On
modern method of treating Fractures")
39

1917
 Hoglund of United States reported the
use of autogenous bone as a
intramedulary implant.
 A span of cortex was cut out and then
passed up the medullary cavity across the
fracture site.
40

1926
 Innovation of stainless steel
41

1930’s
Rush brothers
(Rochester, Minnesota,
USA),
Gerhard Küntscher
(Hamburg)
 Independently
developed technique
of “intramedullary
nailing”.
42

Gerhard Kűntscher – 1900-1972
 Gerhard Kűntscher was born in Germany
in 1900.
43

Gerhard Kűntscher - continued
 During development of his “marrow nail” he
conducted studies on cadavers' and animals.
44

 Developed a V-shaped stainless
steel nail that was inserted
antegrade.
 The V-shaped nail was first used in
1940
 By 1947, 105 cases using the V-
shaped nail was performed by
Küntscher and Finnish surgeons.
45

 By late 1940s,
Küntscher had
designed a new nail,
the cloverleaf nail.
46

1944
Introduction of antibiotics
(penicillins) in orthopaedics
47

1945
Eggers
 Introduced Eggers plate
which had two long slots
that allowed the screw
heads to slide and thus
compensate for resorption
of the fragment ends.
 It had structural instability
48

1949
 Robert Danis (1880-1962), Belgium
 Used the term "osteosynthesis”.
 His work "Théorie et pratique de
l’ostéosynthse" had a great influence on
the future German-Swiss AO school.
49

1949
Robert Danis (1880-1962), Belgium
 Described the main principles of internal fixation:
 "In order to be completely satisfactory, internal fixation
must fulfil the following three requirements. (1)
Enablement of immediate, active movement of muscles in
the affected region and the adjacent joints. (2) Complete
restoration of the original shape of bone.(3) Direct union of
the bone fragments without the formation of visible callus"
50

1949
 Danis’ plate (1949) called “coapteur” suppresses
interfragmentary motion and increases stability of
fixation through interfragmentary compression
achieved by tightening the side screw
51

52
1951
First results of ORIF
Maurice Müller
Fribourg, Switzerland
• 75 patients
• stable fixation
• early mobilization
• no complications

Early 1950s
Gavrijl Abramovitch
Ilizarov
(Siberia,USSR)
(1921-1992)
 Developed a circular
fixator, which permitted to
stabilise bone fragments but
also made three-dimensional
reconstructions possible
53

Gavriil A Ilizarov, MD
 Graduated from medical
school in 1944
 Staff surgeon at Hospital for
War Invalids, Western Siberia
 Faced with consequences
(nonunion fractures, bone
defects and osteomyelitis) of
WWII
54

Lack of facilities, equipment and
antibiotics
55

Early 1950s
 Professor Gavril Abramovich Ilizarov was born in
the Caucasus, in the Soviet Union in 1921.
 He was sent, without much orthopedic training, to
look after injured Russian soldiers in
Kurgan,Siberia in the 1950s. With no equipment he
was confronted with crippling conditions of
unhealed, infected, and malaligned fractures.
 With the help of the local bicycle shop he devised
ring external fixators tensioned like the spokes of a
bicycle. With this equipment he achieved healing,
realignment and lengthening to a degree unheard
of elsewhere.
 His Ilizarov apparatus is still used today as one of
the distraction osteogenesis methods.
56

1954
57
1954 published his first article
on Transosseous Osteosynthesis

Gavrijl Abramovitch Ilizarov
(Siberia,USSR)
(1921-1992)
 1967. At this time he successfully treated an
infected, non-union fracture sustained by the
Olympic high jump champion Valery Brumel.
 Professor Ilizarov’s methods were brought
to the west in 1981 by an Italian doctor,
Prof. A. Bianchi-Maiocchi.
 He headed the world’s largest orthopaedic
hospital. This is the Kurgan All-Union
Scientific Centre for Restorative
Orthopaedics and Traumatology.
 Professor Ilizarov continued working in this
field of orthopaedics for 41 years until his
death in 1992 at the age of 71.
58

1958
Bagby and Janes
 Described a plate with specially designed oval holes
to provide interfragmentary compression during screw
tightening
59

Plate and screw osteosynthesis
60

1958 AO/ASIF
(Arbeitsgemeinschaft fur osteosynthesefragen)
Maurice Müller, Martin Allgöwer, Hans Willenegger, Robert
Schneider and Robert Mathys (Switzerland)
 Plate and screw osteosynthesis. A group of Swiss orthopaedic
surgeons formed the Arbeitsgemeinschaft fur
osteosynthesefragen (AO), also known as the Association for the
Study of Internal Fixation (ASIF). The principles for fracture
management developed by the AO group defined the standard of
care for fracture
 They revolutionised internal fixation of fractures developing
techniques that allowed early return to function and
consequently better fracture healing with less fracture
disease.
61

62
1958
AO founded in Biel (Bienne)
November 6, 1958, Hotel Elite
Biel (Bienne), Switzerland

63
1958
Est of AO
AO stands for
Arbeitsgemeinschaft für Osteosynthesefragen
• Before the AO was founded, casting was the mainstay of
treatment for most fractures, routinely resulting in permanent
disability
• The AO commenced systematic investigation of the biology of
bone healing and fracture repair
• As a result, rigid fixation, with plates and screws, and early
mobilization, with implants, became the gold standard in
management of musculoskeletal trauma

64
1958 AO Founders
Arbeitsgemeinschaft für Osteosynthesefragen
Maurice Müller
Zürich
1918−2009
Martin Allgöwer
Chur
1917−2007
Walter Bandi
Interlaken
1912−1997
Robert Schneider
Grosshöchstetten
1912−1990
Hans Willenegger
Liestal
1910−1998

65
1959 AO Principles
Hans Willenegger
Maurice Müller
Martin Allgöwer
Robert Mathys
1 Documentation of all patients
2 Development of implants and instruments
3 Research of fracture healing and tissue cultures
4 Teaching of osteosynthesis techniques

Principles of Bone Plating
Their original goals of fracture repair were to:
 obtain anatomical reduction of fractures
 ensure stable internal fixation that satisfies the
biomechanical requirements of the fracture
 preserve the fracture vascularity by atraumatic technique
 achieve early active pain-free return to function to limit the
development of fracture disease
66

67
1960 1st AO Course in Davos
Participants:
56
7
2
3
1
Maurice Müller teaches femoral nailing in the AO Lab.

68
1961 AO Round hole plate
Maurice Müller
St Gallen, Switzerland

69
1961 AO Compression device
Maurice Müller

70
1963 AO Principles of ORIF
Maurice Müller Martin Allgöwer
Hans Willenegger Robert Schneider
1 Atraumatic surgical technique
2 Anatomical reduction of fracture
3 Stable internal fixation
4 Early active pain free mobilization

72
1963 AO Instrument boxes
Attendance at an official AO
Course was mandatory for
purchasing the six official AO
Instrument boxes.

73
1963 AO Tubular plates
Maurice Müller
Bern, Switzerland
1/2 tubular
1/4 tubular
1/3 tubular

74
1963 Primary bone healing
Hans Willenegger
Liestal
(1910−1998)
Robert Schenk
Basel
(1923−2011)
Fritz Straumann
Waldenburg
(1921−1988)

75
1969
Est of AO VET
 AO VET is one of the four clinical divisions of the AO, the world’s
pre-eminent educator in orthopedics.
 AO VET is an independent nonprofit organization that
represents a global network of surgeons, scientists, and
other professionals highly specialized in veterinary surgery
of the musculoskeletal system.

76
AO VET objectives
 Friendly exchange of experiences in the field of trauma and
orthopedics
 Establishment of principles for the operative and non-operative
treatment of musculoskeletal disorders in animals
 Establishment of courses and other training worldwide
 Experimental and clinical research

78
AO VET
 AOVET educational offerings, delivered in peer-topeer,
interactive learning environments, give veterinarians the
tools necessary to provide high-quality care for orthopedic
cases.
 All AOVET courses teach methods, not products.

79
AO VET
AOVET has established a curriculum-based approach for its
consecutive education offerings:
 Principles courses to introduce the basic principles of fracture
management using renowned AO techniques
 Advanced courses to enable the application of advanced concepts
and techniques for the management of complex fractures
 Master courses to foster and expand specialization and in-depth
knowledge on specific topics

80
1969 AO VET (veterinary)
Dog treated with Kuntscher nail by
H Knoll, J Jenny and
owner H Willenegger

81
1969 Dynamic compression
Martin Allgöwer
Stephan Perren
Max Russenberger
Dynamic Compression Plate
Narrow: DCP 3.5
Broad: DCP 4.5

82
1969 AO Manual
Maurice Müller
Martin Allgöwer
Robert Schneider
Hans Willenegger
1970 Translated from German
into English by
by Joseph Schatzker

Dynamic compression plate
(DCP)
83

1967
Schenk and Willenegger
 both members of a Swiss group of investigators, made
reference to the compression technique advocated by
Bagby and Janes.
 Although this plate was called a Dynamic
compression plate (DCP) only one-time static
compression could be obtained
84

LC-DCP
(LIMITED CONTACT – DYNAMIC COMPRESSION PLATE)
85

The area of possible maximal contact depends on the shape of the
undercuts
(above, conventional DCP; middle, LC-DCP; below, PC-Fix)
1969 Perren S M LC-DCP
86

87
1978
Strain theory of healing
Stephan Perren
Davos, Switzerland
Alexander Boitzy

DCP or LC-DCP
The basic principles of an internal fixation
procedure using a DCP or LC-DCP plate and
screw system (compression method) are
 Direct anatomical reduction and
 stable internal fixation of the fracture
 Wide exposure of the bone is usually
necessary to gain access
88

DCP or LC-DCP
 provide good visibility of the fracture zone to allow reduction and
plate fixation to be performed.
 requires pre-contouring of the plate to match the anatomy of the
bone. The screws are tightened to fix the plate onto the bone,
which then compresses the plate onto the bone. The actual
stability results from the friction between the plate and the bone.
89

Measurements of the plate-bone
contact area of the DCP and LC-DCP
 Field et al. (1997) measured the bone-plate contact area for
both DCPs and LC-DCPs fixed to cadaveric bone and found
“no apparent differences in interface contact area
attributed to bone plate design” .
 This contradicts the assertion by Gautier and Perren
(1992) that the LC-DCP reduces the contact area by 50%
 (Gautier, E. and S. M. Perren (1992). Die limited contact dynamic compression plate
(LCDCP): Biomechanische Forschung als Grundlage des neuen Plattendesigns.
Orthopade. 21:11–23.)
 (Field, J. R., T. C. Hearn and C. B. Caldwellm (1997). Bone plate fixation: an
evaluation of interface contact area and force of the dynamic compression plate
(DCP) and the limited contactdynamic compression plate (LC-DCP) applied to
cadaveric bone. J. Orthop. Trauma. 11:368–373.)
90

Measurements of the plate-bone
contact area of the DCP and LC-DCP
 Jain et al. (1999) measured cortical blood flow with laser
Doppler flowmetry of canine tibias fixed with a DCP or LC-
DCP. They found no difference in cortical blood flow
between the two groups supporting the findings of Field et
al. (1997).
 They also reported on the biomechanical properties of the
tibia and found no difference between the two groups. Jain
et al. (1999) and Kregor et al. (1995) concluded that “the
LC-DCP is not advantageous in fracture healing or
restoration of cortical bone perfusion to devascularized
cortex.
 (Jain, R., N. Podworny, T. M. Hupel, J. Weinberg and E. H. Schemitsch (1999). Influence of
plate design on cortical bone perfusion and fracture healing in canine segmental tibial
fractures. J. Orthop. Trauma. 13:178–86.
 Kregor, P. J., D Senft, D. Parvin, C. Campbell, S. Toomey, C. Parker, T. Gillespy and M. F.
Swiontkowski (1995). Cortical bone perfusion in plated fractured sheep tibiae. J. Orthop. Res.
13(5):715-724.)
91

Biological Osteosynthesis
(1985)
 LC-DCP (Limited Contact - Dynamic compression
plating)
 LCP (Locking Compression Plate)
 Locking head screw
 LCP as conventional DCP (Compression
technique)
 LCP as LISS (Bridging technique)
 LCP (Combination technique)
 LISS (Less Invasive Stabilization System)
 MIPO ( Minimally Invasive Plate Osteosynthesis)
92

Principles of biological
osteosynthesis
The basic principles of biological osteosynthesis include:
 Minimize iatrogenic soft tissue disruption.
 Utilize indirect fracture reduction techniques.
 Provide appropriate stable fixation.
 Promote the early return to limb function
The principles of biological osteosynthesis were developed in order to maximize healing
potential by balancing biology and mechanics in the treatment of fractures.
93

LOCKING COMPRESSION PLATE
(LCP)
94

95
2000 Locking compression
plates
Robert Frigg Bettlach, Switzerland
Michael Wagner Wien, Austria
Robert Schavan Willich Anrath, Germany
Combination
hole
Osteoporotic
bone
Nonunions

Locking Plates are an evolution. . .
. . . of plate fixation
96

Plate Evolution
 DCP
 Dynamic Compression Plate
 LC-DCP
 Limited Contact
Dynamic Compression Plate
 LCP
 Locking Compression Plate
97

How is a Locking Plate Different?
 Conventional plates
depend on friction between
the screw & bone for
stability
 Locking plates & screws
create fixed angles that do
not rely on screw purchase
in bone
Conventional
Screw & Plate
Locked
Screw & Plate
98

Plate Design:
Combination Hole
 “Figure of eight” hole
design
 Locking screws
 Conventional cortex &
cancellous screws
99

 Threaded underside of head
 To thread (lock) into plate hole
 Larger core diameter:
 Increases strength
 Dissipates load over larger area of bone
 Smaller thread pitch:
 Threads not used to generate
compression between plate and bone
Locking Screw Design
Cortex ScrewLocking Screw
100

Locking Screw Design
 Core design:
 Solid and cannulated
 Cannulated screws are inserted over guide wires
for precise placement
101

Screw Head Designs
 Threaded head:
 Locks screw to plate
 Conical head:
 Can be used instead of locking
screws
 Smooth underside fits in round
holes
 Partially threaded -- lags two
fragments together
 Fully threaded -- pulls bone to plate
 Spherical head cortex screw:
 Conventional use
102

Original AO
Principles
 Anatomic reduction
 Stable fixation
 Preservation of blood supply
 Early motion
Do the AO Principles still apply?
103

Locking Plates & Screws
AO Principles
1) Anatomic Reduction:
Locked plate design allows lag screw and
compression plating techniques
2) Stable Internal Fixation:
Locking screws increase stability in osteoporotic
and metaphyseal bone
104

Locking Plates & Screws
3) Preservation of Blood Supply:
 Limited bony contact stabilizes fracture
without plate-to-bone compression
 Tapered tip allows submuscular plate insertion,
decreasing tissue destruction
105

Locking Plates &
Screws
4) Early Active Pain Free Mobilization:
A more stable construct = earlier return to ADL
106

LOCKING
COMPRESSION PLATE
(LCP)
The LCP with combination holes can also be used,
depending on the fracture situation, in either
 a conventional technique (compression principle),
 bridging technique (internal fixator principle), or
 a combination technique (compression and bridging
principles).
107

LOCKING COMPRESSION PLATE (LCP)
(conventional technique (compression principle)
 Ideal indications for this
compression technique are:
 Simple fractures in the
diaphysis and metaphysis (if
precise, “anatomical”
reduction is necessary for the
functional outcome; simple
transverse or oblique
fractures with low soft tissue
compromise) •
 Articular fractures (buttress
plate).
 Delayed or non-union,
osteotomies.
 Complete avascularity of
bone fragments.
Forearm shaft fracture with simple
fracture patterns (AO 22-A3),
stabilised in traditional open
technique, using two LCPs in
compression technique
108

(Bridging technique)
 “pure” internal fixator providing
relative stability by bridging the
fracture zone according to LISS
principles (=bridging
technique)…
Indications
 Multifragmentary fractures in the
diaphysis and metaphysis.
 Open-wedge osteotomies (e.g.,
proximal tibia: TomoFix).
 Periprosthetic fractures.
 Delayed change from external
fixator to definitive internal
fixation.
 Tumor surgery.
Complex distal tibia and fi bula fracture AO
42-C2 with extension into the articular
portion of the ankle join, stabilised with a
long LCP Metaphyseal-plate 3.5/4.5/5.0mm in
a MIPO-technique (minimal invasive plate
osteosynthesis).
109

(combination technique)
 Pilon fracture AO 43-C2
stabilised with a LCP 3.5 for the
tibia in a combination-technique
using
 1) limited open reduction and lag
screw fixation providing
interfragmentary compression
and absolute stability of the
articular portion and
 2) bridging the metadiaphyseal
comminution by a partial MIPO-
technique.
110

LESS INVASIVE STABILIZATION
SYSTEM (LISS)
111

112
1995 LISS
Robert Frigg
Bettlach, Switzerland
Less
Invasive
Stabilization
System
Locking head screws

SYSTEM (LISS)
 for the treatment of
metaphyseal fractures of long
bones.
 The implant consists of a
plate-like device and locking
screws which together act as
an internal fixator.
113

SYSTEM (LISS)
114

MINIMALLY INVASIVE PERCUTANEOUS
PLATE OSTEOSYNTHESIS
(MIPO)
Minimally invasive plate osteosynthesis (MIPO) is a recently described
method of biological internal fixation performed by introducing a bone
plate via small insertional incisions that are made remote to the fracture
site. The plate is slid adjacent to the bone in an epiperiosteal tunnel
connecting the two insertional incisions. Screws are placed in the plate
through the insertional incisions or via additional stab incisions made
over the holes in the plate
115

116
1997 Mini incisions
(MIPO)
Christian Krettek Harald Tscherne
Minimally
Invasive
Plate
Osteosynthesis

MINIMALLY INVASIVE
PERCUTANEOUS PLATE
OSTEOSYNTHESIS
(MIPO)
Advantages
 Reduced operative time
 Lower risk of infection
 Increased rate of callus formation
 Less post operative pain
117

MINIMALLY INVASIVE
PERCUTANEOUS PLATE
OSTEOSYNTHESIS
(MIPO)
Disadvantages
 Technically challenging to learn and master
 Less suitable for simple and articular fracture
that require precise anatomic reduction &
interfragmentary compression
 Access to intraoperative fluoroscopy ( C arm
imaging intensifier) & hence increased amount
of radiation
118

MINIMALLY INVASIVE PERCUTANEOUS PLATE
OSTEOSYNTHESIS
(MIPO)
 Schematic illustrations of the lateral
minimally invasive plate
osteosynthesis approach to the
humerus and percutaneous
insertion of the plate.
 (A) The proximal insertional incision
is prepared by bluntly dissecting
deep to the deltoid and brachialis
muscles.
 (B) The tunnel is extended from
distal to proximal by carefully
inserting long, straight Metzembaum
scissors under the brachialis muscle,
until the tip of the scissors is seen in
the proximal insertional incision.
 (C) The bone plate is inserted
percutaneously in the tunnel.
119

OSTEOSYNTHESIS
(MIPO)
 Schematic illustrations of the
craniomedial minimally invasive plate
radius and percutaneous insertion of
the plate.
(A) The distal insertional incision is
prepared by bluntly dissecting deep
to the tendons of the extensor carpi
radialis and common digital extensor
muscles.
(B) After lateral retraction of the
extensor carpi radialis muscle in the
proximal insertional incision, the
bone plate is inserted
percutaneously from distal-to-
proximal.
120

OSTEOSYNTHESIS
(MIPO)
Schematic illustrations of the lateral
minimally invasive plate osteosynthesis
approach to the femur and percutaneous
insertion of the plate.
(A) The proximal insertional incision is
prepared by bluntly dissecting deep to
the vastus lateralis muscle after
performing an approach to the proximal
femur.
(B) The tunnel is extended from distal-to-
proximal by carefully inserting long,
straight Metzembaum scissors under
the biceps femoris and vastus lateralis
muscles, until the tip of the scissors is
seen through the proximal insertional
incision.
(C) The bone plate is inserted
121

OSTEOSYNTHESIS
(MIPO)
Schematic illustrations of the
medial minimally invasive plate
tibia.
 (A) The proximal insertion
incision is prepared by
sharply dissecting and
retracting the sartorius,
gracilis and semitendinosus
muscles.
 (B) The bone plate is inserted
122

123
2000 AO Plate
technology
1961 Round hole plates Maurice Müller
1963 Tubular plates Maurice Müller
1970 Dynamic compression plates Stephan Perren
1989 Indirect reduction techniques Jeff Mast
1990 Biological fixation Reinhold Ganz
1990 Limited contact (DC) plates Stephan Perren
1993 PC-Fix Stephan Perren
1997 MIPO Christian Krettek
1995 LISS Robert Frigg
2000 Locking compression plates (LCP) Robert Frigg

01
02
03
04
Summary / Take Home Points
Turning points in history, which revolutionized Orthopaedics
12
4
1846
Developments
in
anaesthesia
1865
Principles
of
Antisepsis
Jozef Lister.
1895
Discovery
of X rays
1944
Discovery
of
Penicillins

05
06
07
04
Evolution of Orthopaedics
12
5
1958
Conservative
Method
1958
AO
1985
Biological
Osteosynthesis
1997
MIPO

01
02
04
Evolution of plates
12
6
1969
DCP
Dynamic
Compression
Plate
1994
LC DCP
Limited Contact
Dynamic
Compression
Plate
2001
LCP
Locking
Compression
Plate

01
02
03
04
Evolution of plates
12
7
1969
DCP
Dynamic
Compression
Plate
1994
LC DCP
Limited Contact
Dynamic
Compression
Plate
1985
BO
Biological
Osteosynthesis
2001
LCP
Locking
Compression
Plate

Veterinary Orthopedics Webinar on Evolution of Internal Fixation

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