. : You devoted your life to the external fixer?

. : Not, of course, I entirely did not devote my life to the external fixer, but I was interested there since the beginning of the Sixties, at one time when this hardware was used very little. The external fixer is an excellent way of communication between the bone and the external world, favourable with certain measurements. It is what interested us.

We wanted to measure the consolidation of the fractures and we began, in 1965, a study by posing a strain gauge on a bar of fixer of Hoffmann. The strain gauge is a system which makes it possible to measure a deformation. For a given mechanical solicitation, the deformation of the bar is proportional to the consolidation of the fracture: if the bar for an effort given this day, the weight of the member for example, becomes deformed less than the previous week or the two weeks, that means that the fracture progressed in mechanical quality. We developed this system which was, in 1976, the main theme of our thesis.

This search led us to study the mechanics of the external fixer, reserved at the time with the open fractures or the very fractures. This study encouraged us to also use it for simpler fractures. Contrary to the well anchored ideas, external fixing, if it is used according to certain mechanical principles, we could report some to us, is not responsible for delays of consolidation or pseudarthroses. It allows, on the contrary, a fast consolidation, with cal periosteum. We used it at the beginning for diaphyseal fractures of the tibia, then for fractures of the humerus, front armlever, mining area, sometimes of the femur and, since the middle of the years 1970, we used it on the level of the wrist and the hand.

 

. : At the beginning, did you have reproaches to make with the screwed plate and the nail?

. : We do not have any objection against the plate nor against the nail but, simply, they did not make it possible to make the measurements of osseous consolidation which we wish to make. For this reason we came to the external fixing which led us to excellent results. We reported ourselves very quickly that external fixing could be used just as easily that a plate or that any other hardware of fixing.

 

. : There are nevertheless many advantages to use the systems of osteosynthesis interns…

. : Yes, but there are also the partisans of the plaster. There are partisans of the nail, and partisans of the plates and screws. We attended the French school of Blackbird of in 1999 57 when the tendency was with the . We had large discussions with the Swiss school which, at the time, defended the plates. Although in Brussels we are at the school of the primary cal, with Robert , we noted that the plates posed problems, in particular of and bone resorption under the implant. Our intention was to obtain one cal periosteum, and for this reason to build an assembly of which we could control rigidity, which is possible neither with a plate nor with a nail. Various schools represent various tendencies, we decided to develop external fixing.

 

. : You were already sensitive to the problems of rigidity of the assemblies?

. : Yes and not. All at the beginning yes, at the time of our mechanical study of the external fixer. We noted that by changing very little the characteristics of the assembly we improve rigidity considerably, passing from a mobility mailman 50 with a mailman 5. Then, by increasing the component count of the external fixer, as the school of Montpellier will do it later, the gain of rigidity became tiny, passing from a mailman 5 with a mailman 2, but sufficient to prevent the formation.

However, one still discussed very little problems of rigidity at the time. It is only with beginning of the year 70 that we were confronted with the results of the Swiss school and we noted that the results that we obtained with external fixing and the consolidation could be higher than the primary consolidation obtained with plates. It is primarily a comparison external fixings plates which we carried out or more exactly elastic assembly rigid assembly, and its negotiable instrument on the consolidation of the fracture. The result encouraged us to continue the techniques of external fixing, according to the elastic mode.

 

. : Nevertheless the clinical monitoring of an external fixer is more intricate than that of one of osteosynthesis interns…

. : It is possible, but that did not pose any specific problem to us. We considered very early, at the end of the Sixties, the organization of a consultation of follow-up of the patients carrying external fixer, every two weeks. The purpose of it is to control the aspect of the cards and, once a month, the radiological consolidation. This approach enabled us to control the problem very well. In 1974 we began an exploratory study on the tolerance of the cards, which collected 12 or 13 thousand observations, according to a first protocol. This study did not show an main issue related to the application of the cards. In 1983, we changed the protocol of clinical study and we joined together some seven thousand observations of cards. Once again the problems involved in the cards did not appear insurmountable. This study is forwarded in the thesis of Yves , in 1993.

In 1983 also, with the factories csotcina.comedy of Geneva, we carried out an experimental study which led to the realization of new types of implants which are the cards. It is an example of collaboration Industry-University, as to date recommended by the European Community.

We could show that these cards with the mechanical characteristics of cut very improved, involved an significant improvement of the overall clinical result and osseous behavior but not of the infection. It seems that the infection depends more of the patient or the surgeon that card itself. I.e. that there are on the one hand patients who develop in a random way an infection of card, which is discussed very well. In addition certain patients develop an infection of all their cards. It is probably then either about a problem of surgical follow-up, or of a problem of hygiene of the patient.

To summarize, we were interested much in the problem of the cards which requires a specific follow-up, every 15 days or every month, with recommendations with the patients. As a whole two percent of patients require a new hospitalization, for problems of card.

 

. : Are you informed of work on the junction card-skin?

. : Money coatings were tested without, to our knowledge, the results not being significant. Coatings of hydroxyapatite are used, in the animal with perhaps results, but these implants are not largely used in private clinic. We thought of a certain moment with ammoniated derivatives for a coating of card but the studies remained at the experimental stage and were never exploited.

 

. : What do you think of the overall dimension space of the external fixer compared to internal osteosynthesis?

. : It is a problem which challenged us obviously. We on this subject led a study with a psychologist and a nurse. It appears that the patient is worried more by his accident and his fracture that by his external fixer. On the other hand the family, the close relations of the patient are relatively impressed.

Of course, certain patients reject their processing, whatever it is. But they cannot withdraw their nail or their plate. On the other hand they can attack with a plaster or an external fixer.

The weight of the assemblies has an importance which appeared well at the time of a comparative study between conventional Hoffmann and Hoffmann II which is lighter, because built partly out of aluminum and used with carbon bars.

 

. : Certain patients must be inhibited by their aircraft…

. : An early mobilization and hinges of the member are undertaken as soon as possible. It can happen that a patient is very “afraid” of the fractured member and avoids moving it. It is certain that if a leg is not mobilized, if one does not mobilize ankle, if the knee is not mobilized, the venous return, circulation, will be decreased. The damning up will cause a certain acidification of the chamber of fracture. A poor blood circulation can support the delay of consolidation, even a pseudarthrosis. This complication is not specific to external fixing and can be observed with all the systems of processing.

 

. : What do you think of the phenomenon?

. : It is necessary to distinguish the concept of and circular external fixing. I met on several occasions with which I had excellent contacts. Let tell you to me two amusing anecdotes! In 1977, in Budapest, I wished to put a question at the end of a conference of . At once one of the organizers told me: “Mr here he is preferable not to put a question”. Later, to Cuba, in 1986 I raised the arm to put a question and to connect immediately: “Since there is no question, one concludes the meeting”. Nevertheless into private we sympathize.

Mr had the brilliant idea of osteogenesis in distraction, nobody will not dispute it. Many surgeons and researchers believed that the bone only developed forwarded to compressive stresses, under specific mechanical conditions. I believe that it is the first to have shown in an obvious way, in private clinic, that the bone could be formed in distraction. It is a very original contribution but which does not require a circular fixing. We make the same thing with a unilateral framework.

One can think of the fixing “phenomenon” circular as with a phenomenon of mode. Generally the circular external fixer is not often used for nothing if is not to be tied up the patient without, for us, to bring of significant advantage. We do not use circular fixings in the service; we have some in the museum of them.

 

. : Do not be you not a little severe?

. : I know the Russian systems well, almost all circulars. Before the system, one of most known was the fixer of . was circular, is circular, is circular. Besides compared Hoffmann with Rolls-Royce and projected in congress a transparency of itself in Rolls-Royce. Its fixer was compared with robust , with the photograph of an assistant at the wheel.

 

. : Why to have chosen at the beginning Hoffmann?

. : External fixing was practically born in Belgium with Albin , who developed the first external fixer of everyday application, in 1902. When the first meeting on external fixing was organized, in 1965, at the Hospital, the fixer of was still usually used in Belgium. Hoffmann was introduced on our premises only in 1958, the only external fixer “modern” present in Belgium.

 

. : But gradually, other options on external fixing appeared; why did you remain faithful to yours?

. : I am not completely of agreement. Until 1980 there were very few of other options. After 1980 one saw flowering the external fixers, because of the success of Hoffmann. Many of these external fixers were less powerful than the fixer of Hoffmann. I do not see why change, even if there is today, as it is probable, of the fixers equivalent to Hoffmann on the market.

 

. : What allured you in Hoffmann?

. : Its versatility still improved with Hoffmann II. The materials used in conventional Hoffmann were not as powerful as current materials. Hoffmann II allows more freedom, being less limited to the level of the hinges and the vices.

I am of course against the external fixers type, difficult of use in the vicinity of a hinge, which require a prereduction, which is too much bulky and which is very expensive. The fixer of Hoffmann, that it is the old one or the new one, allows any type of assembly, and gives right to the error. If the senior registrar or the intern does not align completely well the fragments in urgency, the following day the reduction can be improved without difficulty. Hoffmann II offers all the degrees of freedom. I do not like at all that my freedom is reduced and I am against the stresses which the hardware will impose to me!

 

. : What brings to you moreover Hoffmann II?

. : It is the continuation of original Hoffmann, which does not amend the design that we have of external fixing, its prolongation by some new possibilities which are pleasant and effective. What one calls the “clicks” particularly facilitated the handling of the bars and the independent cards. Thanks to their ratchet gear by spring, the assemblies are modifiable, without need for complete disassembling. The bars acquired fuller possibilities of movement, the cards are simpler to establish and more powerful, the whole of the assembly is lighter.

 

. : The debate on the rigidity of the syntheses 20 years ago was posed in the same terms as today?

. : It does not seem to me. The rigidity of an assembly is a notion which was introduced by work of Robert and of the Swiss school which sought the primary cal, the appearance of cal periosteum being regarded as a failure. The Swiss school imposed its views for a long time and convinced many people. You must remember that twenty years ago, he was necessary that all is rigid. The surgeons using external fixing, one told: “it must be rigid”, to support the consolidation. From where the use of the “double executives” and assemblies in Swiss country cottage expensive at the school of Montpellier. They appear to us justified neither from a theoretical point of view, neither experimental, nor especially private clinic. One can admit with the rigor of rigidity with a plate which can remain established several years. But the external fixer, it, cannot remain established; it should be removed! We need cal periosteum.

In very rigid situation, all occurs as if the bone did not understand that it is broken. It will be altered at its rate/rhythm, i.e. slowly. In more it will reabsorb because it is requested little mechanically. With the ablation of the external fixer the fracture or will not be badly consolidated. Thus one showed the external fixer to be responsible for pseudarthroses whereas actually it is the surgeon who induced the nonunion by building a too rigid assembly. I am convinced by it after having observed in private clinic and in the literature, on a great number of patients, that the fracture consolidates more quickly under an elastic assembly than with a fixing by plate.

I would like on this subject to insist on the difference that there is between stability and rigidity. Very often the surgeons confuse these two concepts. Stability allows at the time of a reasonable weight-bearing, the hold of the geometry imposed by the surgeon during the reduction of the fracture. It is important, in private clinic, to define the stability of a synthesis which will prevent the collapse of the system at the time of its weight-bearing. The degree of elasticity, the reverse of rigidity, will allow certain microcomputer-movements the chamber of fracture, will stimulate the periosteum and will be at the origin of the cal periosteum.

 

. : When an assembly is too rigid or too rubber band?

. : One cannot quantify desirable elasticity for a chamber of fracture. Empirical concepts, the clinical observation, showed that certain configurations allow the development of one cal periosteum and that other configurations, like the multiple executives or the plates with compression, delay the appearance of the cal. The consolidation being a problem , it is impossible for us to provide for with certainty how it will evolve/move.

 

. : Which is the activity of your service apart from the external fixer?

. : The activity of the service is rather general-purpose and relates to traumatology, the hand surgery, of the rachis, the prosthetic replacements and the pediatric surgery. External fixing represents 10% approximately surgical activity of the service. I.e. we pose 250 fixers a year, in traumatology or csotcina.comedy for certain arthrodeses for example.

 

. : And you, whom do you make particularly?

. : I have in the beginning a formation of general surgery. I made traumatology much. I do far too much administration, but also search, teaching and at the csotcina.comedic level, of the prosthesis, little rachis and little infantile csotcina.comedy.

 

. : Did you make all your career with ?

. : Before being affected at the hospital in 1977, I worked at the hospital, in general surgery, with already a guideline very marked csotcina.comedy-traumatology.

The hospital is the first academic hospital of the Universit3e libre de Bruxelles. It has approximately 900 beds, including 60 beds of csotcina.comedy-traumatology. The hospital of is a young hospital. He was thought about the years 1999 57 and was inaugurated on October 3rd, 1977. Other university hospitals are the hospital, the Saint-Pierre hospital, and the Institute Jules , the center of the tumors of the University. There is in addition a network of nonuniversity hospitals of training course, but cash of the university beds. I will not go further in this attempt at explanation of our Belgian system!

 

. : Thus you have a retreat of approximately 20 years on your activity of traumatology…

. : A little more because we preserved certain files of the hospital, in particular all the files of external fixing, which were posed since the beginning of the Sixties, until 1980.

. : How do you clean the cards of fixers?

. : After installation of the fixer, it is normal to observe a light bleeding which will be decreasing. A flow of clear fluid (serosities) can persist. Into postoperative, one surrounds a dry compress around the cards. It is necessary to supervise the state of the compresses daily, to avoid any hardening which can be responsible for bedsore at the end of a certain time. As soon as the openings of cards are closed, the bath, the shower are authorized just as swimming.

Daily care of cards is essential to avoid any infection; they are carried out once per day. The crusts must be removed to allow the free flow of serosities. If a flow persists a smear will be carried out, for analysis. It is necessary also to clean the metal assembly.

 

. : Where the patients bathe when they have a fixer?

. : In a swimming pool or the sea, any problem. I have a guy who made with his external fixer. I recommend to my patients to wash and dry then the openings of cards with alcohol. No the , not of iodine which can involve skin reactions.