History of the AO History of the AO History of the AO

history AO

1. AO PRINCIPLES
and
PHILOSOPHY
PROGRESS and EVOLUTION
[1958 -2006]
JESSE B JUPITER MD

2. Objectives: At the end of the
lecture I hope you will understand
•AO principles, their evolution, and how
they relate to fracture surgery today
•Role of surgery in diaphyseal,
metaphyseal, and articular fractures
•Importance of the soft tissues in
fracture surgery

3. In the 1940’s and 1950’s the
incidence of permanent
partial disability was35%
following tibial fractures and
70% following fractures of
the femur
(Swiss Nat. Ins. Co.)

4. Maurice Müller(1 March 1950)
Robert Danis (Bruxelles)
ANATOMIC REDUCTION + RIGID FIXATION
primary healing
soudure autogène

7. Maurice Müller(1951)Fribourg
Martin Allgöwer
Hans Willenegger

8. 1958 Biel,Switzerland;
-The Founding of AO
Arbeitsgemeinschaft für Osteosynthesefragen
•An association of
surgeons devoted to the
study of problems
associated with internal
fixationASIF

9. Goals of the AO founders in 1958:
•anatomical reconstruction
of bone axis & joints
•functional restitution
through early motion
•direct (primary) bone
healingby rigid fixation
•atraumatic surgical
technique
M.Müller M.Allgöwer
H.Willenegger R.Schneider

10. AO
WAS KNOWN AS
ALWAYS OPERATE
ALWAYS OSTEOMYELITIS
YOU MAY BE SURPRISED
BUT IN 1958, THESE WERE
RADICAL THOUGHTS,
AND NOT WIDELY ACCEPTED

11. LIFE IS MOVEMENT
MOVEMENT IS LIFE

12. Full active painfree mobilization
results in a rapid return of
blood supply to both
the bone and soft tissues

13. OVERVIEW
•Goal of internal fixation
is functional recovery!!
•Fracture healing involves
issues of mechanics,
biology, and
biomechanics
•Neither strongest nor
stiffest implant necessary

14. UNDERSTANDING THE WHY
IS THE CLUE TO UNDERSTANDING
CHANGE
CHANGE COULD ONLY OCCUR WITH
•CONTROL OF SEPSIS, ANTIBIOTICS
•IMPROVED CRITICAL CARE, ANAESTHESIA
•BETTER METALURGY
•IMPROVED SOFT TISSUE HANDLING

15. AT THE BEGINNING OF THE
CENTURY, THE TECHNOLOGY
WAS ALREADY AVAILABLE,
BUT RARELY USED

16. THE PIONEERS OF
INTERNAL FIXATION
BOULANGER-FERRARD
MALGAIGNE
HANSMANN
BIRCHER
W. ARBUTHNOT LANE, 1905
ALBIN LAMOTTE, 1907
AND ESPECIALLY

17. LAMBOTTE,
1907

21. The Past
•Sepsis
•Metal corrosion
•Implant
breakage
•Implant bulk
P r o b l e m s

22. CONVENTION WISDOM
1
ST
HALF-20
TH
CENTURY
SEPSIS: THE MAJOR CONCERN
CLOSED METHODS WERE IN FAVOUR

23. THE PIONEERS OF INTERNAL
FIXATION WERE OVERWHELMED BY
THE GREAT MASTERS OF THE
WESTERN WORLD
•LORENZ BOHLER -AUSTRIA
•REGINALD WATSON -JONES -UK
•EDWARD CAVE -USA

24. the SECOND HALF of the CENTURY
DOMINATED
by the
ORIGINAL AO DOCTRINES EARLY
FUNCTIONAL
REHABILITATION

25. WHAT HAS HAPPENED
TO THESE AO PRINCIPLES
IN 2018?
STABLE FIXATION AND EARLY MOTION ARE STILL THE
HALLMARKS,
and CAREFUL SOFT TISSUE HANDLING HAS ASSUMED
INCREASED IMPORTANCE:
THE BIOLOGY/BIOMECHANICAL EQUATION
ANATOMIC REDUCTION STILL REQUIRED FOR
ARTICULAR and FOREARM FRACTURES
AO TEACHING METHODS ARE NOW
THE NORM in TRAINING PROGRAMS

26. the CONCEPT OF ANATOMICAL
REDUCTION
IS STILL VALID FOR:
•ARTICULAR FRACTURES
•SOME LOWER EXTREMITY
METAPHYSEAL FRACTURES
•DIAPHYSIS -the FOREARM

27. SNAPSHOT 2018
the ARTICULAR FRACTURE
•MAINSTAY STILL ANATOMIC
REDUCTION STABLE FIXATION TO
ALLOW EARLY MOTION
•MINIMALLY INVASIVE TECHNIQUES
•BIOLOGIC GLUES vs GRAFTS

28. Multifragmented Diaphyseal fracture
BRIDGING PLATING

29. Dorsal combined fracture
Severe soft tissue injury

30. 5 Months

31. Full function

32. NEW PLATE CONCEPTS:
The LOW CONTACT
CONCEPT

33. SNAPSHOT-2018
•ANOTHER UNSOLVED PROBLEM
•the METAPHYSICAL +/-ARTICULAR
FRACTURES IN OSTEOPOROTIC BONE
•93% OF ALL FRACTURES
COURT-BROWN & McQUEEN EDINBURGH

34. FIXATION IN OSTEOPENIC BONE
LOCKING PLATE : or FIXATEUR INTERNE
REPRESENTS AN ADVANCE
IN THE FIXATION OF SCREWS
IN SOFT BONE

35. LOCKING SCREW CONCEPT
ANGULAR STABILITY

37. SNAPSHOT 2018
the ARTICULAR FRACTURE
•MAINSTAY STILL ANATOMIC
REDUCTION STABLE FIXATION TO
ALLOW EARLY MOTION
•MINIMALLY INVASIVE TECHNIQUES
•BIOLOGIC GLUES vs GRAFTS

38. Arthroscopically assisted dorsal percutaneous scaphoid fixation
the center of the circle is the target point for
insertion of the guidewire into the proximal
pole of the scaphoid
the guidewire is driven dorsal-to-
volar so that it exits at the radial
base of the thumb
fracture reduction is controlled
arthroscopically and drilling
should stop 2mm from the distal
scaphoid cortex
Slade JF, Gutow AP, Geissler WB JBJS 84A, suppl 2:21-36, 2002

39. ABOVE ALL, WE MUST RESPECT
OUR PATIENTS, including
the BIOLOGY:of the WHOLE PERSON,
of the LOCAL TISSUES
the BIOMECHANICS: to achieve stability
allowing early rehabilitation

40. THE NEW CENTURY
ADVANCES WILL BE DRAMATIC
•IMAGING –WILL COMPLETELY
CHANGE OUR DIAGNOSTIC AND
THERAPEUTIC CAPABILITY
•GENETIC –THERAPY –WILL MAKE
CARTILAGE/BONE + OTHER TISSUE
•ROLE OF ARTHROPLASTY IN FRACTURE
CARE WILL CHANGE

41. BUT,TO THE YOUNG SURGEONS
HERE TO-DAY!
DON’T DESPAIR –WE
HAVE NOT RUN OUT OF
PROBLEMS FOR YOU
TO SOLVE

42. AO PRINCIPLES
evolution 1958 -2006
SUMMARY
1)ANATOMIC REDUCTION
· Only where necessary (joint fractures)
-restore anatomy
2) STABLE FIXATION
· Sufficient stability
-absolute
-relative

43. AO PRINCIPLES
evolution 1958 -2006
SUMMARY
3) ATRAUMATIC SURGICAL TECHNIQUE
·Preserve vascularity
·Direct vs. indirect reduction
4) EARLY ACTIVE R.O.M.
·Functional aftercare
·Prevent fracture disease

48. The results of a
poorly conceived and poorly executed
open reduction internal fixation are
always worsethan closed treatment
Professor Hans Robert Willenegger
1911 -1998

49. The objective of fracture treatment
is the restoration of as complete
function as possible with the least
risk to the patientand least anxiety
for the surgeon
Sir Robert Jones, 1913

50. Massachusetts General Hospital
Department of Orthopaedics
Boston, Massachusetts