This chapter will cover the evolution of forceps and vacuum-assisted delivery of the foetus in cephalic presentation. The options available before the development of obstetric forceps are briefly reviewed. The invention of the forceps in the early 17th century was followed by their evolution over four centuries with the introduction of the pelvic curve, axis-traction and rotational forceps. The phase of prophylactic forceps delivery will be discussed. The development of vacuum-assisted delivery has evolved over the past 150 years. However, in practical terms, the modern era of vacuum-assisted delivery began with Tage Malmström's vacuum extractor in the early 1950s. The evolution of the modern vacuum extractor with metal, soft and hard plastic cups will be reviewed.

The position of the acetabular cup is a major factor in the long-term outcome of total hip arthroplasty (THA). Malpositioning of the acetabular cup frequently has been reported with the use of a minimally invasive implantation technique. It remains unclear whether the limited visibility or the increased retractor traction and thus tilting of the pelvis during cup implantation is the cause. This study investigated the influence of iatrogenically related pelvic lift using an anterolateral minimally invasive THA technique. In a group of 30 consecutive patients who underwent THA via a minimally invasive anterolateral approach, iatrogenic lifting of the pelvis was measured with a smartphone using a 3-axis accelerometer and compared with patients in a historical age- and sex-matched control group who underwent THA using a transgluteal approach. Postoperatively, the inclination and anteversion of the cup was determined on pelvic radiographs. In the anterolateral group, the pelvis was lifted by a maximum of 6.3° and by an average of 3.9° when the acetabular cup was impacted; no difference was noted compared with the transgluteal group. In contrast, the cups in the anterolateral group showed significantly increased inclination and reduced anteversion. In both techniques, the iatrogenic tilting of the pelvis at the time of cup implantation occurred to a comparable extent. Therefore, the significant differences in postoperative radiographs cannot be attributed to increased retractor traction on exposure of the acetabulum, which means that the limited visibility must be responsible. [Orthopedics. 2017; 40(4):e589-e593.].

In recent years, endoscope-assisted transoral approach for condylar fracture treatment has attracted much attention. However, the surgical approach is technically challenging: the procedure requires specialized instruments and the surgeons experience a steep learning curve. During the transoral endoscopic (TE) approach several instruments are positioned through a narrow oral incision making endoscope maneuvering very difficult. For this reason, the authors changed the entry port of the endoscope from transoral to submandibular area through a small stab incision. The aim of this study is to assess the advantage of using the submandibular endoscopic intraoral approach (SEI).The SEI approach requires intraoral incision for fracture reduction and fixation, and 4 mm size submandibular stab incision for endoscope and traction wires. Fifteen patients with condyle neck and subcondyle fractures were operated under the submandibular approach and 15 patients with the same diagnosis were operated under the standard TE approach.The SEI approach allowed clear visualization of the posterior margin of the ramus and condyle, and the visual axis was parallel to the condyle ramus unit. The TE approach clearly shows the anterior margin of the condyle and the sigmoid notch. The surgical time of the SEI group was 128 minutes and the TE group was 120 minutes (P >0.05). All patients in the TE endoscope group were fixated with the trocar system, but only 2 lower neck fracture patients in the SEI group required a trocar. The other 13 subcondyle fractures were fixated with an angulated screw driver (P <0.05). There were no differences in complication and surgical outcomes.The submandibular endoscopic approach has an advantage of having more space with good visualization, and facilitated the use of an angulated screw driver.

With the advent of locking screws fixation devices, came new problems when removing internal fixation hardware. The objective of this study was to evaluate these problems and their possible solutions. The first problem was screws jamming on the plate, secondary to either initial poor screwing technique (with inadequate placement of the targeting device) or use of excessive force (when screwing in the screws without using the torque-controlling screwdriver). Treatment consists of destroying the screw heads using tungsten drills. The screw bodies can then be extracted using a trephine drill. The second problem involves destruction of the recess of the screw head. It can be secondary to overly forceful screw insertion or risky screw extraction. This can be treated using a specific conical left-turn screwdriver, assuming that the screw/plate thread is still intact. Finally, the screw recess can be filled. The plate itself may be a source of problems when being extracted because the screw holes left free also have been filled. Lever arm maneuvers to raise the fibrous bridges and substantial traction along the axis can be useful. These problems are more frequent with minimally invasive surgery. The consequences of this fixation type's hardware removal surgery are multiple: lengthened operative time, risk of secondary maximally invasive surgery, presence of metallic shavings residues in cases of screw head destruction, and the risk of iterative fracture secondary to trephine drill use. Prevention is thus essential. It is based on rigorous technique in placing the targeting device, drilling, and inserting screws, the systematic use of the torque-controlling screwdriver, and the verification of proper screw position. The locking compression plate (LCP) material is highly effective but its removal should not become challenging.

Obstetric forceps are used to guide fetal movement during delivery, ideally accompanied by active pushing by the mother. Forceps in the form of "tongs" appeared in the 17(th) century, and by the 19(th) century had evolved into forceps with two crossing shafts (Levret, Pajot, Kielland), axis-traction forceps (Tarnier), and forceps with convergent shafts (Démelin, Suzor). Application and traction differ according to the type of instrument, and require extensive training and knowledge of obstetric mechanics. The easiest and most suitable applications are anterior. In transverse application, forceps with convergent shafts or another instrument (spatulas or vacuum extractor) are to be preferred. Certain deliveries can be difficult, and require careful evaluation informed by experience. If the fetus is not progressing after three pulls, this route of delivery should be abandoned.

Based on the analysis of their group of 75 patients treated for the fracture of proximal femur by means of the Gamma nail and on the analysis of data from the literature the authors present a comprehensive list of all complications resulting from this technique: inadequate reduction, -jamming of nail, fracture displacement by nail isertion, perforation of the head, incorrect length of the lag screw, problems with distal locking, fracture of the femoral shaft, rotation of head on the lag screw, rotation of diaphysis on the nail, failure of the healing of the wound and infection, breaking of the nail, non-union, healing in the varus position, aseptic necrosis of the head, incorrect rotational position of the limb, unequal length of lower limbs, problems with the set of instruments, migration of the set screw. Ensuing from the analysis are the main principles of the surgical technique.

This paper proposes a modification of the classical position for shoulder arthroscopy. Two changes are proposed to improve visualization, accentuate pathology, and give better access to the inferior one half to one third of the shoulder joint. The direct lateral position is changed to a semilateral position in which the patient is allowed to rotate 30 to 40 degrees posteriorly, thus putting the shoulder joint on a horizontal plane. This allows for more comfortable arthroscopy and instrumentation. Also, if capsulorrhaphy is desired, better penetration of the scapula is possible since the scapula is vertical; thus, the angle of the approaching staple is less severe. The second change is to apply traction in a plane perpendicular to the long axis of the humerus rather than parallel to it. This modification elevates the humerus out of the glenoid rather than distracts the humerus into a subluxed position. The result accentuates labral pathology and gives a significantly improved view of the inferior one half to one third of the glenoid capsule. This new plane of traction allows excellent visualization with very little traction; thus, the problem of traction neuropraxia has been eliminated.

The author starts by showing that the first forceps were originally designed to handle hot metal in founderies and that the word derived from "formus" (hot) and "capere" (to take). The author, Professor Dumont, tries to trace the history of the development of modern forceps, discussing whether the Arabs or such well known authors of classical works as Roesslin, Raynald, Rueff and Rousset knew of the instrument or whether they just described instruments of destruction. Crainz in 1941 had written an article to discuss whether the early Romans had forceps and came to no firm conclusion. Speert in 1957 said that a live baby had been born earlier than the 17th Century, possibly as early as the 2nd or 3rd century of the Roman empire, i.e. over 300 years before Jesus-Christ, by forceps. The description is given of a bas-relief depicting forceps delivery but no one knows whether the bas-relief is genuine or not. The discovery of the Chamberlen forceps in 1813 at Woodham Mortimer Hall in Essex, England, and the lengthy description of how the Chamberlens kept the secret of the invention of the forceps over several generations is very well described. Then follows the story of Jean Palfyn's "mains de fer" which led later to Levret and his long curved forceps. Returning to England, the authors describes how William Smellie covered his forceps with leather so that the patients should not feel the cold metal or hear the clink of the handles. The author then quotes Dr Slop, who appears in Laurence Sterne's "Tristram Shandy" and who knew the Smellie's forceps. Sacombe was an arch enemy of instrumental delivery. The role of the Dane Saxtorph, and how Antoine Dubois delivered Napoleon's son, the future King of Rome, by forceps, is reviewed. Madame La Chapelle and her work as well as that of Scanzoni, and finally of Simpson who first used anaesthesia after inventing a forceps, continues the history. Great names such as Pajot, Tarnier with his axis-traction forceps and finally Barton, Piper and Kielland with their inventions are all described in this beautiful history of forceps.