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History of the AO 1958−2008 Kevin Newman

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1 History of the AO 1958−2008 Kevin Newman
St Peter‘s Hospital, Chertsey, Surrey, UK

2 1944 The inspiration for AO Maurice Müller Bern, Switzerland (1918−)
met a former soldier who had received a femoral nailing by Gerhard Küntscher Kiel, Germany (1900−1972) military surgeon Interview with Maurice Müller for Maîtrise Orthopédique (www.maitrise-orthop.com): M.O. When did you become aware of your surgical vocation? M.E.M. From the age of eight, my only ambition was to become a surgeon. I should mention that my father had been a surgeon in the States, but had to give up his career to live in Switzerland, because his wife did not want to move to the USA. At the age of 20, after some psychometric tests, my choice of profession was approved by the experts. They told me that their tests had identified a three-dimensional gift, which could beused to advantage in orthopaedic surgery. After my state medical examinations in 1944 I worked as a locum GP for three weeks. Two patients made a particular impression on me. The gait of the first was normal. He told me he had fractured his femur during the war between Finland and Russia in 1940, and that a German military surgeon named Küntscher had operated on him at the front and inserted a long nail. Less than two weeks later he was walking comfortably with just one stick. At that time, this was amazing. He had only come in to find out where he should go to have his nail removed. The other patient was having trouble walking with a stick. When I suggested that he must be in great pain he replied: “No, I am extremely well. Two years ago I had a Leveuf hip arthroplasty. Before that I had been in excruciating pain both day and night; my hip had seized in a very poor position. It’s true that my hip is now unstable and I can’t walk without a stick, but at least I can move it and it doesn’t hurt. This operation has changed my life.” Two weeks later I had decided to devote my surgical career firstly to fracture fixation and secondly to hip surgery. I was convinced that one of these fields would eventually revolutionise orthopaedic surgery. During the next 15 years, they became the most important aspects of orthopaedics, and my workload increased accordingly. Extract from interview with Maurice E. Müller for Orthopaedics Today in February 2001 with Lee Beadling Shortly after passing his state medical exams in 1944, Müller replaced a general practitioner in Bern for three weeks. There he encountered two cases that would shape his future in medicine and remain with him for six decades. The first was a man who was injured during the conflict between Russia and Finland. The patient told of how a surgeon named Küntscher had inserted a nail into his fractured femur four years prior. “He asked me to take the nail out if it was possible. When I examined him, he was absolutely perfect,” Müller said. “It was so much better than all the femur fractures of people who were treated in Switzerland with immobilization.” The second case was a man who came to Müller and said he had received a Leveuf hip arthroplasty. Although the man still limped badly, the implant had provided him with great pain relief. “I asked him if he was happy and he said that he was as happy as he ever was. Before, he said it was impossible for him to sleep and today he was absolutely perfect,” Müller said. These two men, their stories and satisfaction with their lives are what directed him to fracture fixation and his work with total hip replacement. “I will remember these cases until the end of my life,” he said.

3 1950 The early years Maurice Müller
resident of Liestal, Switzerland (1918−) was on a fellowship in Holland with Cornelis Pieter van Nes Leiden, Netherlands (1897−1972) who advised him to visit Robert Danis in Bruxelles Maurice Müller was appointed Oberarzt (senior registrar) at Liestal Hospital, Switzerland in October 1947 and worked there for 2 years before going to Leiden in The Netherlands as a visiting registrar with Dr van Nes. During this fellowship in Holland he visited Robert Danis in Brussels. Extract from interview with Maurice Müller for Maîtrise Orthopédique (www.maitrise-orthop.com): M.O. Tell us about your training as a surgeon. M.E.M. My career started in Autumn 1944 at the Balgrist Hospital in Zurich. This had 150 beds and was the largest orthopaedic centre in Switzerland. At that time, fractures were not exclusively dealt with by orthopaedic specialists. As for hip operations, in 18 months I saw only half a dozen fusions and about 10 osteotomies of the femur, generally by the Ombredanne technique for upward dislocations. In 1946 I went to Ethiopia for 18 months with a Swiss surgical team. It was there that I really learned to operate. Not on fractures, as these were generally treated by the local healers with wooden splints, as in the days of Confucius. There were some self-styled nurses who used plaster bandages, a treatment which generally led to pressure sores, infection and amputation. After returning to Switzerland, I became senior registrar at Liestal Hospital in October 1947 for two years. At the beginning of 1950 I worked as a visiting registrar at Leyden in Holland with the famous Van Nes, a specialist in hip and back surgery. When I returned to Switzerland I was appointed senior registrar in general surgery at Fribourg and was able to operate on all fractures in the department using the Danis technique. In the Spring of 1951 I came full circle by returning to Balgrist Hospital, in the post of senior registrar for 5 years. Then in 1960 I became consultant at St. Gall, where I was able to set up my school, in a new ultramodern hospital.

4 1950 Compression plating Robert Danis Bruxelles, Belgium (1880−1962)
“Théorie et Pratique de l’Osteosynthèse” coapteur plate for rigid fixation Extract from: Maurice E. Müller. A personal tribute by Joseph Schatzker. AO Dialogue, issue 4, December 2006 “In May of 1950, he (M.E.M.) paid a visit to Robert Danis in Belgium. This would prove to be the most important visit of his life. In Belgium Maurice saw absolute stability achieved with compression, he saw the healing of bone without radiologically evident callus, and above all he saw the benefit of immediate mobilization which led to full functional recovery. What Maurice saw made a huge impression. Many surgeons had come to visit Danis but returned empty handed, blind to all what they had seen. Maurice immediately grasped the full significance of these radically new concepts. The visit to Danis laid the foundation for his future principles of osteosynthesis.” Extract from interview with Maurice Müller for Maîtrise Orthopédique (www.maitrise-orthop.com): M.E.M. During my first period at the Balgrist in 1945 I wrote a thesis on the 25-year outcome of patients with Legg-Calvé-Perthes disease. In Holland I published my first major article in a German orthopaedics journal, concerning the indications for Smith-Petersen cups and Judet prostheses. During that same period I spent a few days with Professor Danis in Brussels, who taught me the principles of stable fixation and painless active mobilisation, starting immediately after the operation. At Fribourg Hospital I was able to demonstrate the advantages of bone fixation followed by good physiotherapy. M.O. You were at that time convinced that fracture sites should be subjected to compression? M.E.M. The compression was to obtain a completely stable construct. Compression of the fracture site was the only technique which gave us a sufficiently firm result. The aim was to allow active mobilisation of joints after all fixation procedures. Perfect immobilisation of the main segments seemed to us to be essential. It is important to understand what is happening at the histological level. If AO/ASIF succeeded, it was because it proved that, where the site is perfectly immobilised, the union which takes place is different from normal osteogenesis, that is, there is healing without formation of a callus. This is also what happens “naturally” in fractures which are stabilised spontaneously by impaction of the fragments, as in certain compression fractures of the vertebral column. There, too, you have primary healing. This type of union is possible only at an absolutely stable site. If there is mobility of more than 5 microns between fragments, there is a risk of non-union. References: 1. Compression osteosynthesis. Muller ME. Z Unfallmed Berufskr Jun 30;49(2):136-41 Compression for “per primam” healing Absence of callus “soudure autogène”

5 1951 First results of ORIF Maurice Müller Fribourg, Switzerland
75 patients stable fixation early mobilization no complications Extract from: Maurice E. Müller. A personal tribute by Joseph Schatzker. AO Dialogue, issue 4, December 2006 “His next appointment came in 1951, when he was placed in charge of trauma care at the University Hospital of Fribourg. For Maurice, this was a golden opportunity. He showed almost reckless courage in testing his evolving new ideas and techniques. He treated 75 patients with absolutely stable internal fixation and immediate functional mobilization. The complication rate was almost nil. At the time, this kind of success was unheard of.”

6 1952 Old army friendships Maurice Müller Robert Schneider
Extract from: Maurice E. Müller. A personal tribute by Joseph Schatzker. AO Dialogue, issue 4, December 2006 “The next year, in 1952 Maurice was appointed senior resident to the orthopedic department of Balgrist in Zürich. Luckily for Maurice, the new head, Professor Francillon was not interested in doing surgery and Maurice had free rein to implement his new and still evolving principles of operative fracture care and reconstructive surgery. It wasn’t long before rumors began to fly about this new “Oberarzt” who was doing miraculous work. Maurice attempted to share his visions with the surgical community. His colleagues sat through two lectures, during which he outlined the basis for his evolving orthopedic philosophy. They thought he was crazy. Something had to change. By the time Maurice reached Balgrist in 1952, he had risen in the army to the rank of officer. During an annual tour of duty he met his old school and rowing buddy Robert Schneider, who by this time was the chief of a small district hospital. Schneider was so impressed with the concepts put forth by his younger orthopedic colleague that he invited Maurice to come to his hospital and operate on difficult trauma problems. Maurice’s astounding operative results impressed Schneider who, in turn, began to introduce Maurice to a number of his friends like Walter Bandi, Walter Schär, Hans Willenegger, and other similar general surgeons. It is important to understand that these general surgeons worked as chiefs of small district hospitals where they were absolute masters. They began to invite Maurice and he began to operate frequently in their hospitals. Soon a group of surgeons began to form, a group of friends linked by their origin in the Canton Bern, by their school friendships and by their professional standing as chiefs in their own hospitals. They stuck proudly together and supported one another and frequently stood in opposition to the conservative and stodgy academic world. As Maurice’s pupils, they were gaining great surgical expertise in trauma care. In time, they became his devoted supporters.”

7 1954 Documenting trauma Lorenz Böhler Wien, Austria (1885−1973)
241,000 trauma x-rays Maurice Müller was aware of the work that Professor Böhler had done between the two world wars in documenting meticulously his trauma cases. He was also aware of the work he had done with the Austrian Workers’ Compensation Board (AUVA) to fund his research, a tactic that the AO Group would later use working with the Swiss National Accident Insurance Fund (Schweizerische UnfallVersicherungsAnstalt or SUVA). Böhler had been instrumental in 1925 in setting up the first hospital in Europe dedicated to Trauma, the Accident Hospital in Wien (Vienna, Austria). Extract from Surgery, Science and Industry by Thomas Schlich: “As with fracture diagnostics, X-ray images were seen as the most objective means of therapy control. In this respect the AO used Böhler as their example. Over the years the Viennese surgeon compiled series of X-rays tracking his patients’ progress. In 1938 he published a study containing three X-rays for each of the 78 femoral neck nailings performed in his clinic. Including other, conventional, photographs, in 1943 his collection comprised 4000 cases with about 20,000 individual pictures.” “In 1954 he had the meticulously recorded case histories of all 78,349 in-patients and 507,772 out-patients as well as the X-rays of 241,000 injuries treated in his Vienna hospital since 1925.” Accident Hospital

8 1956 Five friends, eight more
Müller Willenegger Allgöwer Guggenbühl Ott Patry Brussatis Baumann Hunziker Schneider Bandi René Patry René Patry was born in Geneva on March 14, 1890 into a family of doctors; he was very well educated and cultured, having very broad medical training in Geneva, Strasbourg, St. Gallen, Aarau, and Lucerne; he was head of the clinics at the cantonal hospitals in the latter two cities. From 1931 to 1938 he was district medical advisor to the state insurance company, SUVA, in Geneva, and concurrently was active in various prominent posts at the Cantonal Hospital in Geneva, the largest public hospital in Switzerland. He received his postdoctoral qualification in 1938, became a professor in 1947, and was director of the University Policlinic for Surgery in Geneva from 1948 to He met Maurice Müller at the Balgrist Clinic in Zurich; from 1957, Müller regularly operated in Geneva and brought Patry into the AO. Patry admired Müller very much, but he despised the instrumentation as “quincaillerie” (ironmongery) and hardly ever operated with it. Patry was president of the Swiss Society for Trauma and Occupational Diseases (SGUB) from 1948 to 1955, and of the Swiss Society for Surgery in 1959 and in the first half of 1960; therefore, he was chairing the congress where the AO appeared in public for the first time. René Patry passed away in 1983. Fritz Brussatis Fritz Brussatis was born on April 1, 1919 in Mainz, Germany, and took his medical studies in Berlin and later Vienna, where he passed the state exams and received his Doctorate in He became assistant surgeon at the university neurosurgery clinic in Zurich and in 1952 at the Balgrist Orthopedic University Clinic. There began a productive cooperation with Maurice Müller. In 1954, they published the case of an occipitocervical arthrodesis treated according to an idea from Van Nes. Müller introduced Brussatis to the AO in its preparatory phase as the only non-Swiss member, but by 1958 he had already returned to Germany to take up neurology in Hamburg and orthopedics in Munster, where he completed his postdoctoral training in In 1969 he became director of the Orthopedic University Clinic in Mainz. His scientific interest was directed primarily towards those areas bordering on orthopedics and neurology. In 1977 he became a member of the Board of Directors of AO Germany, and from 1981 to 1982, president of the German Association for Orthopedics and Traumatology. He was also a member of the Scoliosis Research Society. Fritz Brussatis passed away in 1989. August “Urs” Guggenbühl August Guggenbühl was born on November 17, 1918 in Grenchen, Switzerland. He took his medical studies in Geneva, Freiburg and Basel, passed his state exams in 1945, and received his Doctorate in He acquired his surgical training at the Neumünster hospital in Zurich, and in the surgical departments at the Aarau cantonal hospital and Interlaken regional hospital. He was senior registrar from 1949 in the surgical department of the Liestal cantonal hospital, succeeding Maurice Müller, and in 1953 was kept on by Hans Willenegger. From 1957 to 1983 he was chief surgeon at the hospital in Grenchen, where he permitted Robert Mathys to be present at a hip osteotomy performed by Müller in In 1959 Guggenbühl and Willenegger published the first series on operatively-treated distal radius fractures. He was a great friend of animals and worked together with veterinary surgeons. He was a founding member of AO Vet in In 1984, after his retirement, he moved to Dubai to act as AO delegate and he managed a large state trauma clinic there until He trained the local doctors and organized their advanced training in AO hospitals so that they were able to take over the modern management of the clinic in During this period, he also actively participated in various AO courses in the Middle East and in the United Arab Emirates. Today, three founding members of the AO remain to inspire us, including August Guggenbühl, 90 this November: he sends his best regards to the AO community in this special 50th anniversary year! Ernst Baumann Ernst Baumann was born on August 22, 1890, in Langenthal, Switzerland. He pursued medical studies in Basel and Kiel and initially had his own practice in the country in Rothrist. In 1924 he became assistant and then senior physician at the Cantonal Hospital in Aarau, where he worked in obstetrics and gynaecology and trained as a surgeon. From 1928 until 1960 he was chief surgeon at the district hospital in Langenthal; during that time, from 1941 to 1942, he was a surgeon on the Eastern Front. In 1942 he received his post-doctoral qualification in Bern and in 1957 was named Honorary Professor of Surgery by the medical faculty of Bern University. Baumann was Nestor of the Swiss Traumatologists, and his best-known works are those on elbow fractures in children with vertical extension and on pseudarthrosis of the internal malleolus. He developed a self-drilling and self-tapping lag screw with which the early AO screw fixations were performed. He was president of the Swiss and German Society for Trauma and Occupational Diseases (SGUB) from 1955 to 1960 and also president of the Sports Physicians Commission for the National Gymnastics Association. Ernst Baumann passed away on February 1, 1978. Robert Schneider Robert Schneider was born in Biel in 1912, studied medicine in Bern and spent one semester in Paris. In 1937 he began to specialize in general surgery and in 1947 became a senior resident under Professor Lenggenhager. Despite academic leanings, he took the post of surgeon- in-chief in a community hospital in Grosshöchstetten, a rural village near Bern. Shortly after arriving there, I met him and we developed a fraternal relationship, which lasted for 38 years. After meeting four of his surgical friends, I organized for them a course on “Stable Internal Fixation”, in October 1956 at the Balgrist Hospital in Zürich. A year later, we decided to found an “Association for the Operative Treatment of Fractures” –subsequently AO. The six founders adopted the following principles: 1. “Good” is what is good for the patient and satisfies the needs of the surgeon. 2. All procedures to be simple and described in simple terms. 3. Each operatively treated fracture to be documented and evaluated. 4. Documentation to include copies of all x-rays and slides, available to the group. 5. Each failure to be analysed and its cause determined. 6. The results to be statistically analysed. Robert Schneider adhered to these principles throughout his professional career. In 1959 he became the first Chairman of the AO–a post he held for 20 years. His critical self-evaluation, his grasp of complex issues, his ability to unveil links between seemingly unrelated events, and his many discoveries, earned him great respect nationally and internationally. In 1968 he published “The First 10 Years of AO”. A later book “25 Years AO Switzerland” is a treasure house of AO information. Written in German, the book sadly was never translated into English. Some 22 other publications were but a prelude to his major work, a 300-page treatise “The Total Hip Prosthesis, a Biomechanical Concept and Consequences”. Robert Schneider received numerous honours, but he remained, nonetheless, a modest, friendly man. In many countries he was “the father of the AO”. He remained in practice until the time of his sudden death, just as he put in the last skin suture after a hip arthroplasty. Robert Schneider will stay alive in the memory of all those who had the privilege to know him. Walter Schär Walter Schär was born in Langnau in the Emmental region of canton Bern on January 15, He studied medicine in Zurich and passed the state exams there in From 1931 to 1944 he was assistant surgeon in pathology and internal medicine at the Pathology and Anatomy Institute of Zurich University and in the medical department of Schaffhausen Cantonal Hospital. He was also assistant surgeon, and from 1943 senior registrar, at the university surgical clinic in Bern, where Walter Bandi and Robert Schneider worked for him as house officers. From 1944 to 1968 Schär was chief surgeon at the District Hospital in Langnau. Walter Schär belonged to the initial group of Bernese friends introduced to Maurice Müller by Robert Schneider. Müller came to Langnau fairly often as a guest surgeon. Schär was an example of the strong and assertive, but rather quiet Bernese character. He was totally reliable both in technical matters and as a person. He passed away on October 16, 1982. Walter Stähli Walter Stähli was born on October 20, 1911, in Saint-Imier in canton Bern. He studied medicine in Bern and Lausanne and passed the state exams in Bern in 1936, obtaining his Doctorate there in He then trained in surgery at the Solothurn Bürgerspital. He was assistant surgeon at the District Hospital in Biel and the Cantonal Women’s Clinic in Bern as well as assistant medical director at the Solothurn District Hospital. From 1945 to 1981 he was chief surgeon at the Saint-Imier District Hospital, in the French-speaking Bernese Jura valley. From 1964 to 1982 Stähli was a member of the hospital and home commission of canton Bern. Like his friends, Walter Schär and Walter Bandi, Stähli is a good example of the quiet manner of the Bernese, interspersed and lightened by a great sense of humor. For example, on the subject of AO implants and instruments, which he originally received as an AO member for the purposes of testing, he wrote that: “The quality of both the instruments and implants was very good. The village locksmith only had to be called in once” in order to remove an intramedullary nail. Today at 97, Walter Stähli is still full of the AO pioneer spirit and he sends his best regards to the AO community on the occasion of the AO’s 50th anniversary. Interview with Maurice Müller for Maîtrise Orthopédique: “My monograph on osteotomies of the hip appeared in 1957, so that I became well known particularly in the German-speaking countries. I became a Privatdozent at the University of Zurich. In the same year I left the Balgrist to concentrate on the invasive treatment of fractures without postoperative immobilisation. Around thirty surgeons, who were senior consultants in Switzerland, asked me to demonstrate my technique and instrumentation for osteotomies of the hip and the fixation of recent fractures. In this way I got to know Hans Willenegger, consultant at Liestal, Robert Schneider of Grosshöchstetten, and Walter Bandi in Interlaken. After forming a friendship with Martin Allgöwer in Coire (Chür), we decided in November 1958, with a few friends, to set up an Arbeitsgemeinschaft für Osteosynthesefragen (Association for the Study of Internal Fixation), known as AO/ASIF.” Schär Stähli

9 1958 AO founded in Biel (Bienne)
November 6, 1958, Hotel Elite Biel (Bienne), Switzerland The 13 surgeons met in a hotel in Biel, Switzerland and founded the AO, the Arbeitsgemeinschaft für Osteosynthesefragen (working group for the fixation of bone fractures).

10 Arbeitsgemeinschaft für Osteosynthesefragen
1958 AO Founders Arbeitsgemeinschaft für Osteosynthesefragen Maurice Müller Zürich 1918− Extract from: AO Philosophy and Principles of Fracture Management-Its Evolution and Evaluation David L. Helfet, MD, Norbert P. Haas, MD, Joseph Schatzker, MD, Peter Matter, MD, Ruedi Moser, DVM and Beate Hanson, MD, MPH The Journal of Bone and Joint Surgery (American) 85: (2003) The Beginning of AO Switzerland In 1958, a group of Swiss general and orthopaedic surgeons established the AO (Arbeitsgemeinschaft für Osteosynthesefragen), or the Association for the Study of Internal Fixation (ASIF), in an attempt to transform the contemporary treatment of fractures in Switzerland. The five members of the "core group" were Maurice E. Müller, Hans Willenegger, Martin Allgöwer, and two other early members, Robert Schneider and Walter Bandi. The treatment of fractures at that time often included prolonged bed rest in traction and subsequent application of a cast or splint, often resulting in poor functional results and lifelong disability. This early group of Swiss surgeons established, after extensive examination of treatment goals, the principles of complete functional restoration of the injured limb through anatomical reduction and stable fixation, with use of atraumatic surgical techniques, and early mobilization. They decided to develop a system of implants, instruments, and surgical techniques that would allow the reliable treatment of fractures by adhering to the above principles. During this early period, the AO developed a new method involving application of a compression plate and the concept of the lag screw to achieve their goal of rigid internal fixation of fractures. The AO "pioneers" also realized that immobilization resulted in atrophy of the soft tissues, osteoporosis, thinning of articular cartilage, severe joint stiffness, and, at times, causalgic pain. To prevent these complications and to improve the results of fracture treatment, they introduced "functional after-treatment." This concept was based on the observation that when stable fixation of a fracture was achieved surgically, most of the pain was effectively eliminated, which made immediate and full mobilization of the extremity possible. Thus, a much quoted and timeless expression evolved among the members of the AO group: "Life is movement, movement is life. "The demands on this type of operative treatment were great. The reduction had to be anatomic, and the fixation had to be sufficiently strong, stable, and lasting to allow functional use without the risks of hardware failure, delayed union, nonunion, or deformity. Soft-tissue handling was also of paramount importance since infection should not mar the outcome. In close collaboration with two Swiss manufacturing firms, the AO began an intensive period of development to produce comprehensive new sets of instruments and implants for fracture treatment. The instrumentation expanded and included not only plates and screws but also intramedullary nails, external fixators, and special plates (e.g., angled blade-plates), all of which revolutionized the surgeon's ability to manage many injuries and fractures effectively and reliably, utilizing all of the AO principles and methods. Many techniques, implants, and instruments were developed, courses in how to use them were taught, and they were popularized by the "AO Manual," which was published in 1970. Internal fixation of most fractures, especially open fractures, was a revolutionary concept and was contrary to the accepted surgical teaching of the time. The procedure was considered an unnecessary insult and ill advised, with the risks of infection and stiffness outweighing the benefits. Clearly, the AO founders, like all revolutionaries, had to prove that their way was better if it was to be accepted. Martin Allgöwer Chur 1917−2007 Walter Bandi Interlaken 1912−1997 Robert Schneider Grosshöchstetten 1912−1990 Hans Willenegger Liestal 1910−1998

11 1958 Hex-head screw Maurice Müller Zürich, Switzerland (1918−)
Robert Mathys Bettlach, Switzerland (1921−2000) Extract from Interview with Maurice Müller for Maîtrise Orthopédique (www.maitrise-orthop.com): M.O. How did you come to manufacture your own fixation equipment? M.E.M. I noticed in 1951 that Van Nes and Danis were using a number of instruments which they had developed themselves. So, in 1951 I arranged for a number of technicians and small manufacturers to make some spike retractors, a set of chisels and elevators, Schanz screws, twin external fixators, etc. Eventually, a stainless steel importer recommended a very capable technician who had never made surgical instruments before, but who would certainly be able to understand my ideas. This was Mr Mathys, who agreed not to sell my instruments until they had been evaluated for 4 years. I immediately decided to work exclusively with him. This was in April ‘58 and in November of the same year, when the instrumentation had been completed, we founded AO/ASIF, which was to subject the devices to systematic testing for more than 3 years. M.O. How did you manage the financial aspects of the sale of your instruments? M.E.M. In 1958 we decided not to market the equipment. It was sold only from 1963 onwards, that is, after the publication of our first book on fracture fixation according to AO/ASIF principles. Like the founder members of AO/ASIF, all those who wanted to become members of our association had to sign the charter, which required them to keep records of all patients undergoing surgery, and at the same time to waive any remuneration for the current and future equipment. All receipts from the sale of instruments went from the outset into the public company Synthes, which operated as a charity without remuneration of any kind. No dividend was paid and all the money received was to be used in research and education. Synthes was created before anyone had had the opportunity to buy these tools and implants. We initially allowed the hardware to be sold only to those who had attended a theoretical and practical AO/ASIF course. The first of these training events was held in December At that time there was, throughout the world, a wide variety of instruments; and in particular so many different screws that it was necessary to have an incredible range of screwdrivers to hand when an implant was being removed. Our plan was to produce a range of hardware with a basic screw and a basic screwdriver. The rest you know. Our hexagonal socket-head screw was to be used all over the world. M.O. Where did this screw come from? M.E.M. In 1957 I was very fed up with slot-head and cross-head screws. Everyone had difficulty in removing them. I did try Phillips heads, but here again I had problems. The hexagonal socket was used in industry, but only for very large screws. One day, while I was changing a car wheel that had screws of this type, I decided that we could try applying this principle to orthopaedic screws. No-one encouraged me in this project - quite the contrary. Mr Descamps, who was with me in 1960, even told me: “You won’t succeed; the French would never want to use such a specialised screw and one which no-one uses anywhere in the world.” I replied: “Well, my friend, I could certainly convince everyone in Switzerland, and if all the Swiss surgeons are persuaded, the French might like to follow suit.”

12 1959 AO Principles Hans Willenegger Maurice Müller Martin Allgöwer
Robert Mathys Documentation of all patients Development of implants and instruments Research of fracture healing and tissue cultures Teaching of osteosynthesis techniques The 4 principles of documentation, teaching, research, and instrumentation would become the 4 pillars of the AO Foundation in 1984. References: Technique of Internal fixation of Fractures. Müller ME, Allgöwer M, Willenegger H 2. Technik der operativen frakturenbehandlung. Müller ME, Allgöwer M, Willenegger H. 1963:223-31

13 1959 AO Laboratory Davos Martin Allgöwer
Davos, Switzerland (1917−2007) AO Laboratory for Experimental Surgery Forschungsinstitut Obere Strasse Martin Allgöwer was the first director of the AO Laboratory for Experimental Surgery in Davos. The building had previously been a TB clinic and was rented to the founders of AO who each paid 10,000 SFr towards the costs.

14 1959 AO Documentation Maurice Müller Davos, Switzerland (1918−)
Extract from Surgery, Science and Industry by Thomas Schlich: “Like Böhler, the AO used standardised forms in its project. At the beginning of 1959 Müller introduced coloured code sheets for documenting the operation and the check-ups after four and twelve months. He also designed punch cards to which miniature copies of the X-rays could be attached. After discharging an osteosynthesis patient, surgeons were supposed to send the yellow code sheet to the Davos documentation centre first. The information from this sheet to the Davos documentation centre first. The information from this sheet was then used to make two new punch cards, one of which remained in Davos while the other was sent back to the respective surgeon. The surgeons also needed to send along a set of pre- and post-operative X-ray pictures. These were copied and miniaturised and pasted onto the punch cards. Four months later the surgeon saw the patient gain, took two X-rays in different planes, filled in a blue code sheet and sent these, together with his copy of the punch card, to Davos. Again, miniaturised copies were added to the punch card and one copy went back to the surgeon. The same thing happened one year after the operation. Following this third examination the surgeons filled in a red sheet. In the first year after the centre was opened, 1000 cases were registered and 10,000 X-ray copies were made available for analysis.”

15 1960 1st AO Course in Davos Participants: 56 7 2 3 1
2 3 1 December 10th 1960 was the start of the first AO Course in Davos. The guest of honour was Professor Hermann Kraus ( ) from Freiburg in Germany, the first senior surgeon from outside Switzerland to support the AO. The 4 day course was led by Maurice Müller and was held in the AO laboratory. 69 surgeons attended. This photograph shows Maurice Müller (aged 42) demonstrating femoral nailing on cadaveric bone to a group of senior (older) surgeons. Müller always considered himself to be the “nailer” of the AO group and Allgöwer to be the “plater”. Maurice Müller teaches femoral nailing in the AO Lab.

16 1960 AO in Davos

17 1960 AO Faculty in Davos Robert Schneider Walter Ott Walter Schär
Bandi Martin Allgöwer Fritz Brussatis Willy Hunziker August Guggenbühl René Patry Trauffer is the name of a souvenir shop/tea room in Davos. Presumably the baskets in the picture were for bread and pastries. Someone has been airbrushed out of photo (Brussatis?) Who were Fischer, Keller, Bloch? Ernst Baumannn (Fischer) (Keller) Hans Willenegger Maurice Müller Walter Stähli (Bloch)

18 1961 AO TK founded Maurice Müller St Gallen, Switzerland (1918−)
Robert Mathys Bettlach, Switzerland (1921−2000) Extract from: AO Philosophy and Principles of Fracture Management-Its Evolution and Evaluation David L. Helfet, MD, Norbert P. Haas, MD, Joseph Schatzker, MD, Peter Matter, MD, Ruedi Moser, DVM and Beate Hanson, MD, MPH The Journal of Bone and Joint Surgery (American) 85: (2003) Implementation of the AO Philosophy Through the TK-System The development and clinical testing of new instruments and implants and the creation of educational materials for these products are handled within the AO Foundation by a system of medical-technical committees—the TK-System. It consists of several specialty Expert Groups and the core Technical Commission (AOTK). New product ideas are submitted to the relevant Expert Groups of the AO, which are governed by surgeons, as they make up the majority of the members. The Expert Groups provide an open forum of ideas concerning relevant clinical problems and possible solutions. Once these surgeons have identified medical needs, discussed critical characteristics, and defined milestones, the engineers work out the technical solutions. The solutions are discussed, adapted, and tested with respect to the materials and the mechanical, biomechanical, and biological behavior until a final prototype is developed. This process continues until the responsible Expert Group is satisfied with the product and proposes the idea, technique, and implant to the Technical Commission for final approval and release. Only the Technical Commission, which to this point has not been involved in the development, can ultimately approve the devices. It should be emphasized that unpaid medical members in the Expert Groups as well as in the Technical Commission are in the majority to ensure that decision-making is based on medical rather than commercial considerations. It should be noted that all medical product-safety regulatory obligations, such as obtaining the CE-Mark of the European Community or approval of the United States Food and Drug Administration, must be met long before the decision about market release is made by the AO Technical Commission. We believe that this ensures that AO standards are higher than any existing legal requirements worldwide.

19 1961 AO Round hole plate Maurice Müller St Gallen, Switzerland
Interview with Maurice Müller for Maîtrise Orthopédique: M.O. Where did your ideas on fixation originate? M.E.M. I was fairly well steeped in the ideas of Lambotte, Danis and Charnley. When I started, there was no question of carrying out any sort of fixation, which was a dangerous procedure at that time, unless its function could be guaranteed. One of my slogans was: “Life is movement, and movement is life.” The first rule of the group was that immediate and painless mobilisation of the limb must be possible from the day after fixation. Occasionally, casting was allowed, but only when joint mobility had been achieved, that is, after the first 8 to 10 days. With this immediate exercise treatment, the results were generally excellent. We were convinced that postoperative plaster casts were associated with oedema, muscle contractions and joint stiffness, necessitating prolonged physiotherapy to achieve perfect mobility. M.O. In that case, why did you prefer plates to nails? M.E.M. But nails were my first choice. The plates only came later. If you read my book published in 1957, you will see that apart from angled osteotomy plates, there was no mention of any fixation plate. In the treatment of non-union of the leg we used the tension plate; this means that the plate was positioned on the tensile side of the bone. So, for non-union in varus it was placed on the lateral aspect of the tibia. For fractures to the lower extremities, compression between the fragments was achieved by screws, the plate being used only to neutralise the fracture site. Apart form fractures to the forearm, in the emergency treatment of injuries I have never fitted a plate except for neutralisation purposes. I am always amazed to learn that one of the main things which people remember about AO/ASIF is the plate. References: Principes d’ostéosynthèse. Müller ME. Helvetica Chir Acta 1961;28: Verschraubung von tibiafrakturen (plating of tibial fractures). Allgöwer M. Helv Chir Acta 1961;28:214-21

20 1961 AO Compression device Maurice Müller St Gallen, Switzerland

21 1961 2nd AO Course in Davos John Charnley and Martin Allgöwer in the AO Davos Lab. In 1961, the second AO Course in Davos (102 participants), the guests of honour were Michel Postel from Paris and John Charnley ( ) from England (who was invited to talk about the biomechanics of fractures). This photograph shows Charnley, aged 50, listening to Martin Allgöwer ( ), aged 44, in the AO laboratory in Davos. Maurice Müller took the opportunity to show Charnley the early results of his work with hip prostheses as well as internal fixation cases. In 1962, the AO Course was cancelled due to pressure on the AO founders to deliver a manuscript of the AO textbook. In 1963, the 3rd AO Course was held in March and was German-speaking only. The guest of honour was the German traumatologist Heinrich Bürkle de la Camp ( ) from Bochum, who had been critical of internal fixation at the 1958 German Surgical Society congress. In Davos in 1963 he conceded that AO equipment was technically superior to anything made before, especially the Müller compression plate when compared with the Lane plate. The 4th AO Course was in December 1963 and was held in English and French. In 1964, the 79 year old legendary Austrian traumatologist Professor Böhler ( ) was guest of honour at the 5th AO Course in Davos. Extract from Surgery, Science and Industry by Thomas Schlich: “Even Böhler changed his attitude. Though his appraisal of osteosynthesis in the 1963 edition of his textbook (Technik der Knochenbruchbehandlung or Techniques of fracture treatment) was still critical, it did not prevent him from attending the Davos course in 1964 as the guest of honour. Taking the invitation as a sign of respect for his authority, Böhler came with an open mind, ready to let himself be impressed by his young colleagues’ systematic efforts. The AO surgeons, he declared in his speech, had the same objectives he himself was pursuing with his concept of functional treatment, the difference being that they chose a more complicated path to that aim. In his report before the German Surgical Society in the same year, Böhler was full of praise for the AO’s operative technique as well as for its equipment, organisation, documentation and research efforts, all of which he regarded as great progress in bone surgery.” In 1965, the producers Mathys and Straumann were in charge of the organisation of the practical exercises. In 1966, the AO Course was extended from 4 to 5 days. In 1968, the AO Course was divided into a German-speaking section (for 436 surgeons) and an Italian-speaking section (100 surgeons). In 1969, the AO Courses were moved into the newly built Kongress center in Davos. The 1st Advanced Course was held in this year. Foreign AO courses: 1965 Germany 1968 Yugoslavia 1969 Canada, Spain 1970 Austria, USA 1972 Australia, Mexico 1973 England, Italy, East Germany, Israel

22 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 Introductory chapter of the first AO textbook: “We cannot advise too strongly against internal fixation when it is carried out by an inadequately trained surgeon and in the absence of full equipment and sterile operating conditions. Using our methods, enthusiasts who lack self-criticism are much more dangerous than sceptics or outright opponents.” “Osteosynthesis is an exceedingly difficult treatment method, in which half-measures invite great dangers. It requires thorough training, much experience, sound judgment, technical skill and the ability of three-dimensional thinking on the part of the surgeon, who must also have specialised equipment at his disposal. This is why osteosynthesis – despite all its advantages if performed correctly – can never be recommended as a generally applicable standard treatment method.” References: 1. Technique of Internal fixation of Fractures. Müller ME, Allgöwer M, Willenegger H Technik der operativen frakturenbehandlung. Müller ME, Allgöwer M, Willenegger H. 1963:223-31 Review of 1st AO textbook by Richard G Eaton in JBJS Am 1965;47:1293 THE TECHNIQUE OF INTERNAL FIXATION OF FRACTURES. M. E. Muller, M. Allgower, and H. Willenegger. Translated by G. Segmuller. New York, Springer-Verlag, $20.00. Those who would expect this book to be a handbook of surgical techniques are due for a pleasant surprise. Although 142 of its 272 pages are devoted to details of the use of AOl (Association for the Study of Osteosynthesis) internal fixation devices, the book presents an excellent discussion of the rationale of osteosynthesis, including the experimental background and histological evidence of its ultimate objective-primary healing of bone, that is, healing without roentgenographic evidence of callus formation. The authors’ points are well described and clearly illustrated, including the liberal use of roentgenograms to support the effectiveness of the implants. Primary bone healing seems well documented, and the minimum degree of osteoporosis is impressive. Of special interest are the sections dealing with open fractures and the management of infected implantations. No statistics are given on the incidence of sepsis following fixation in closed fractures, but the authors state that they had fewer infections following internal fixation of open fractures than following the same procedure on closed fractures. Although this observation is not uncommon, it seems significant that the insertion of metallic implants in potentially infected wounds has not, in the authors’ hands, brought about any increase in the incidence of infection. Meticulous attention to the handling of tissues and the rigid internal immobilization apparently create optimum conditions for bone and soft-tissue healing. A sound discussion of the management of septic wounds and of the selection of patients with open fractures for internal fixation is included. The message of the book is quite clear ; however, a word of caution is advisable. In the hands of the superb technicians who have developed and repeatedly used this system of ingeniously devised precision implants, remarkable results can be achieved. The AOl compression-plate system may prove to be one of the best means of internal fixation yet devised. However, for the surgeon who by choice or by chance does not use this system frequently and who thus cannot be assured of the technical perfection in reduction and fixation that is required, the technique should be approached with caution. Whatever one’s inclination regarding internal fixation (If fractures, this book will serve as an excellent reference on the general principles and techniques of the operative treatment of fractures. Students and residents will be interested in the extensive bibliography of fracture management which includes references to many of the classic articles. Trauma surgeons at all levels of experience should welcome this concise presentation of the philosophy and use of AOl internal fixation devices. Richard G. Eaton, M.D.

23 1963 AO Plating Photograph is from Technique of Internal Fixation of Fractures, page 150, Fig 157. Review of 1st AO textbook by John Charnley in JBJS Br 1966;48:200-1 Technique of Internal Fixation of Fractures. By M. E. MULLER, M. ALLGOWER and H. WILLENEGGER. With contributions by W. BANDI, H. R. BLOCH, A. MUMENTHALER, R. SCHNEIDER, S. STEINEMANN, F. STRAUMANN and B. G. WEBER. Revised for the English edition by G. SEGMOLLER. 11 x 8 in. Pp. ix+272, with 244 figures. Index Berlin, Heidelberg, New York: Springer-Verlag. Price £7 7s. This work, as the title suggests, is devoted to the technique of using internal fixation in the treatment of fractures and is the product of a group of young Swiss surgeons calling themselves A.O. (Association for Osteosynthesis). The book was written when they had been working together as a group for not very much more than five years. The intellectual vigour inspiring the work shines out from each page. There is no doubt that the book will see future and better editions, and that their teaching will have a far-reaching influence in bone surgery not confined only to the treatment of fractures. In a subject which is so fundamentally controversial as the operative treatment of fractures, there will be many critics; many illustrations in this book could be used to support the view that this book will do more harm than good, as for instance the treatment meted out to the patient in Fig. 157, page 150, even though this result was perfect. But this book is not intended for persons without experience, and surgeons who have the judgment to select and reject will find a real thrill in their first reading of this book. The writers are admirably modest as regards originality and they pay tribute in particular to the genius of the Belgian surgeon Danis, who more than anyone influenced them in their compression technique for the plating of fractures. Nevertheless the value of their contributions to surgical technique is real, as shown by the fact that the work of Danis would have slipped into obscurity had they not recognised its value and taken it several stages further. The shrewdness of their appraisal of technical matters is typified in their specification for the A.O. cortical bone screw ; they have chosen 4.5 millimetres as the external diameter and this should give food for serious thought in Britain in view of the choice of 4 millimetres by the B.S.I. Committee on Bone Screws. The chapter on the basic theory of osseous union is sketchy and obviously biased in favour of operative treatment, but one appreciates that the case for operative treatment would still remain unproved even if the whole of the book were to be devoted to experimental surgery. It is to be hoped that some day they will expand their very superficial references to experimental work on osseous union at present in progress at the Department of Experimental Surgery in Davos. As it stands at the moment this particular chapter has just about as much content of pure truth as the brochure of a drug firm. In the chapters devoted to the instruments and the techniques for individual fractures there is a tendency for statements to seem a little inconsistent in different parts of the book. This is probably the result of the book being the product of more than one mind and also because the various techniques are continuously being developed and improved. Speaking generally I do not think this book gives as good an impression of the work of the A.O. as one gets from a visit to Professor Muller and from knowing the principal personalities concerned. The style of writing is commendably brief and free from padding, but the paragraphs tend to be short and profound statements contained in isolated sentences can easily be overlooked. In techniques advised for individual fractures it is possible that their greatest contribution is the method of handling the Y-shaped supracondylar fracture of the femur. Fractures of the shaft of the tibia, on British standards, are grossly overtreated, especially since many of these injuries are skiing fractures with not very much damage to soft parts. When using intramedullary nails for the tibia Continental surgeons in general seem to have no fears about boring out the medullary canal of a young adult to a diameter of 16 millimetres. This must leave the tibia in the lower third no more than a thin bony shell on the outside of a steel tube, a thought which this reviewer finds horrifying to contemplate. Intracapsular fractures of the neck of the femur, where operative treatment is accepted by the most conservative of surgeons, receives scant attention and this chapter is so superficial that it might have been better to leave it out entirely. John CHARNLEY.

24 1963 AO Instrument boxes Attendance at an official AO Course
was mandatory for purchasing the six official AO Instrument boxes. Robert Mathys produced 20 full sets of the famous 6 boxes which contained all the AO instruments needed for internal fixation of fractures. In 1963, the third AO Course in Davos, the guest of honour was the German traumatologist Heinrich Bürkle de la Camp ( ) who had been critical of internal fixation at the 1958 German Surgical Society congress. In Davos in 1963 he conceded that AO equipment was technically superior to anything made before, especially the Müller compression plate when compared with the Lane plate. He went on to praise the AO at the German Surgical Society the following year. Interview with Maurice Müller for Maîtrise Orthopédique: “The first 13 members of AO/ASIF soon acquired patients who came not only from Switzerland but from other countries, since our surgeons had exceptional implants which were not yet for sale. This, needless to say, infuriated the rest of the surgical community. The definitive hardware was developed in '62, and our first book on fixation was published in 1963. From that time onwards we were unable to monitor the technical expertise of the users of our devices, since anyone could now buy the implants. On the other hand, the question of finance became simpler since, as industry was earning money, it was able to finance research and education.”

25 1963 Teaching nurses Extract from Surgery, Science and Industry by Thomas Schlich: “Being practising surgeons themselves, the AO members knew very well that the introduction of their treatment method stood or fell with the verdict of the operating room nurses. They were therefore eager to give the nurses an important place in their network of control and cooperation. In the second (sic) year of the courses at Davos, a course programme for nurse was developed parallel to those for doctors.” A textbook for Operating Room Personnel (ORPs) was published in 1980: “AO/ASIF Instruments and Implants: A Technical Manual” by Fridolin Sequin and Rigmor Texhammar.

26 1963 AO Tubular plates Maurice Müller Bern, Switzerland 1/2 tubular

27 1963 Primary bone healing Hans Willenegger Fritz Straumann Liestal
(1910−1998) Fritz Straumann Waldenburg (1921−1988) Robert Schenk Basel (1923−) Extract from a Tribute to Hans R. Willenegger, by P. Ochsner in AO Dialogue 1999 Thanks to his initiative, links were forged with Straumann, a metallurgical research institute, who helped to solve problems with the implant material. Out of this collaboration arose the industrial production of Synthes implants and instruments with a scientific background. Parallel to this, H. Willenegger contacted R. Schenk, at that time Professor at the Institute of Anatomy in Basel, who contributed histological knowledge to their experimental work in bone healing. The animal experiments that led to their basic publications, where carried out in the basement of the hospital in Liestal. Osteotomies of the ulnae of dogs were bridged by compression plate osteosynthesis. This then enabled them to demonstrate direct bone healing based on bone remodeling, starting from the adjacent Haversian systems under stable conditions. Later experiments confirmed osseous healing of hypertrophic pseudarthroses by stabilization using only a compression plate and without bone grafting. Soon H. Willenegger realized that by performing an osteosynthesis in a suboptimal way, catastrophic complications could be created. Being willing to help such patients, Liestal became a center for the treatment of posttraumatic osteomyelitis, pseudarthrosis and malunion. References: 1. Zum histologischen bild der sogenannten primärheilung der knochenkompakta nach experimentellen osteotomien am hund. Schenk R, Willenegger H. Experientia 1963;19:593 Morphological findings in primary fracture healing. Schenk R, Willenegger H. Symp. Bio. Hung 1967;7:75 The reaction of cortical bone to compression. Perren SM, Huggler A, Russenberger M, Allgöwer M, Mathys R, Schenk R, Willenegger H, Müller ME. Acta Orthop Scand Suppl. 1969;125:19-21 A method of measuring the change in compression applied to living cortical bone. Perren SM, Huggler A, Russenberger M, Straumann F, Müller ME, Allgöwer M. Acta Orthop Scan Suppl. 1969;125:7-16 Interview with Robert Schenk, in International Bone Research Association (IBRA) Newsletter 2/2007: Robert Schenk: a life’s work for bone biology With its research prize, IBRA honours the pioneer of bone biology, Prof. Robert Schenk, MD, whose work has significantly contributed to the development of the fixation and implantation techniques used today. In this interview, the Professor (emeritus) of the Inselspital Bern (CH) speaks out about interdisciplinary collaboration and crucial moments in research. Prof. Schenk, how did you get interested in bone biology? From early on, I’ve always had a liking for biology. When I commenced my studies in Zurich (CH) in the forties, there was no biological research as we know it today. Thus I studied medicine; however, I wrote my thesis in the field of experimental biology. In 1956, I was appointed to a professorship at the Institute for Anatomy in Basel (CH). At that time, my primary interest was in histology and embryology. It was Hans Willenegger who then introduced me to surgery. Together we gave a lecture on surgical anatomy. Willenegger’s influence contributed to waking my interest in the field of fractures. By the way, the lectures often were very spontaneous. While I was drawing anatomical structures with both hands onto the blackboard, Willenegger demonstrated surgical interventions on the blackboard eraser. What were your most important works at that time? I studied fracture healing under stable conditions and primary wound healing of the cortical bone. The results from that time exhibited a crucial influence on the further advances in osteosynthesis. Willenegger introduced me to Fritz Straumann. This is how the unusual collaboration of the surgeon Willenegger, the metallurgist Straumann and myself as the histologist came about. This was a unique model of interdisciplinary collaboration and, for me, the crucial experience that showed me the way for my future activities. The three of you conducted ground-breaking research work. What factors determine the productiveness of collaborations like yours? That depends on the people involved – and the prevailing culture. Maybe this type of collaboration is only possible in pioneering times, when new fields are emerging. At any rate, some luck is needed for such things to happen and this you can neither bring about by force nor can it be bought. During a one-year sabbatical in New York in 1966, I made my “American educational experience”: openness, fairness and recognition of scientific achievements without any envy. This style, which was limited more or less to the US at that time, has thankfully spread internationally in the meantime. What other fields have you been involved in? It was some time after my return from New York that I moved from Basel to Bern where I worked with Ewald Weibel, a good friend of mine. We were both interested in electron microscopy which opened up completely new dimensions then. Weibel studied the lungs, I investigated the bone, but we used similar methods and had similar aims. Together with my team, I was able to explore mineralization and cellular activities in the bone. Only with the emergence of electron microscopy had the quantitative analysis of tissue regeneration become a possibility. Of course, in the meantime, molecular biological techniques have been introduced to this field. Later, I was involved in developing cement-free methods to replace cement fixation. At that time, it was a new finding that bone and implant can actually grow together and that the surface of the implant plays a major role in this process. Which aspects of bone biology do you perceive as crucial for clinical applications? In classical biomechanics, the relationship between structure and function has been studied for more than 150 years. The structural integration at the implant site is the aim of peri-implant bone healing. This depends on material tolerability, an osteophilic surface, adequate blood supply and primary stability under load. These conditions depend largely on biological factors and have to be taken into consideration in both development and treatment. Robert Schenk’s Curriculum Vitae: 1923 Born in Bussum (NL) 1941 Medical studies in Zurich 1950 Conferral of doctorate 1953 Postdoctoral lecture qualification 1956 Professorship at the University of Basel, research on bone and cartilage histology, bone growth, bone repair, fracture healing, histomorphometry of bone biopsies, pathogenesis and treatment of metabolic bone disease 1964 AO award for histological studies in primary bone healing 1971 Professorship at the University of Bern, research into the fine structural aspects of epiphyseal and articular cartilage, later on orthopaedic and dental implants 1978 Visiting professorship at the Rush Medical College, Chicago Honorary Member of the Canadian Orthopaedic Society 1979 Steindler Award of the American Academy of Orthopaedic Surgery 1983 Associate Editor, Journal of Orthopaedic Research Honoured Professor at the College of Veterinary Medicine, Ohio State University 1988 Professor emeritus, since then independent research activities at the Inselspital Bern 1992 Lorenz Böhler Medal of the Österreichische Gesellschaft für Traumatologie.

28 1965 AO Nailing Maurice Müller Bern, Switzerland References:
Technique of Internal fixation of Fractures. Müller ME, Allgöwer M, Willenegger H Technik der operativen frakturenbehandlung. Müller ME, Allgöwer M, Willenegger H. 1963:223-31

29 1968 High-energy fractures
Martin Allgöwer Basel, Switzerland Thomas Rüedi Chur, Switzerland References: Die intraartikulären Frakturen des distalen Unterschenkelendes. Rüedi Th, Matter P, Allgöwer M. Helv chir Acta 1968;35:556 Fractures of the lower end of the tibia into the ankle-joint. Rüedi Th, Allgöwer M. Injury 1969;1(2):92 Experiences with the dynamic compression plate (DCP) in 418 fresh fractures of the tibial shaft. Rüedi T, Kolbow H, Allgöwer M. Arch Orthop Unfallchir 1975;82(3):247-56

30 1969 AO VET (veterinary) Dog treated with Kuntscher nail by
H Knoll, J Jenny and owner H Willenegger AO VET history The first animal to be treated for repair of a fracture was the dog belonging to Mrs. Willenegger, the wife of the founding member Prof. Hans Willenegger, who performed the surgical intervention himself at the human hospital in Winterthur, Switzerland. The surgeons applied a Küntscher Nail to a short oblique simple femur fracture with good success in 1943. In 1969, 11 years after the AO, AOVET was founded. Due to the fact that animals were an integral part of the research for humans, it was felt that the animals should profit from the same advancements in fracture treatment, which could be made in those 10 years. In the early years human AO surgeons were helping the veterinarians interested in learning the new techniques and together slowly but surely the concepts for the veterinary applications of the Mathys and Strauman implants were developed and the AO principles applied to small- and large animals. The first president of AOVET was Bjiörn von Salis a private practitioner near Zurich who lead the small group of enthusiasts for several years. The pioneers of AOVET included among others, Feri & Geri Kasa, small animal practitioners from Lörrach, Germany (near Basel), Prof. Jacques Jenny, a Swiss veterinarian working at the University of Pennsylvania, Profs. Wade Brinker and Bruce Hohn, both from the USA. The following human surgeons were very active and supported the early veterinary work: A. Guggenbuehl, A. Daetwiller, and Prof. H. Rosen to name only a few. There are many more distinguished veterinary and human surgeons who contributed significantly to the development of veterinary trauma surgery through the years, but space available doesn’t allow mentioning them all. Nevertheless their contributions are greatly appreciated by us who profited from their pioneer spirit.  In 1975 the AOVet Center was established in Waldenburg and initially directed by Dieter Prieur, a German small animal specialist. The AO Vet flourished under the wings of Fritz Straumann who was a devoted animal lover. At the veterinary courses in Davos, Switzerland, an annual honorary lecture is sponsored in his name and supported by his son. In 1992 the AOVet Center was moved to Zürich and is since then directed by J. Auer with the able assistance of Mrs. Monika Gutscher. To continue with the history, in 1983 the fracture classification system for long bone fractures was developed by Maurice Müller and in 1984 AO was transformed into a foundation with the following bodies: Board of Trustees, Academic Council, Board of Directors. AO VET is represented at the board of Trustees by the president and either the president-elect or the past president. J. Auer is a member of the Academic Council. In 2007 AOVET was recognized as one of the four specialties of the AO Foundation: Trauma, Spine, Craniomaxillofacial and VET.

31 1969 Dynamic compression Martin Allgöwer Stephan Perren
Max Russenberger Dynamic Compression Plate Narrow: DCP 3.5 Broad: DCP 4.5 The US Patent for the DCP was filed by Martin Allgöwer, Stephan Perren and Max Russenberger on April 30th 1969 and granted on June 13th 1972. References: 1. A Dynamic Compression Plate. Perren S, Russenberger M, Steinemann S, Müller M, Allgöwer M. Acta Orthop Scandinavica 1969; supplementum 125,:31-41 2. Clinical experience with a new compression plate “DCP”. Allgöwer M, Ehrsam R, Ganz R, Matter P, Perren SM. Acta Orthop Scan Suppl 1969;125:45-61 The Dynamic Compression Plate -- DCP. Allgöwer M, Matter P, Perren SM, Ruedi T. New York, Springer-Verlag 1973. Biomechanics of compression osteosynthesis of the AO. Weber BG, Müller G. Acta Orthop Belg 1971 May;37(6): Experiences with the dynamic compression plate (DCP) in 418 fresh fractures of the tibial shaft. Rüedi T, Kolbow H, Allgöwer M. Arch Orthop Unfallchir 1975;82(3):247-56 Experience with the dynamic compression plate (DCP) in 418 recent fractures of the tibial shaft. Rüedi T, Webb JK, Allgöwer M. Injury 1976;7:252-7

32 1969 AO Manual Maurice Müller Martin Allgöwer Robert Schneider
Hans Willenegger Translated from German into English by by Joseph Schatzker Review of 1st AO Manual by Lewis D Anderson in JBJS Am 1971;53(8):1670 MANUAL OF INTERNAL FIXATION. M. E. Muller, M. Allgower, H. Willenegger. New York, Springer-Verlag, $43.50. This Manual of Internal Fixation is the English translation of a similar manual published in German in I 969. The authors state that the purpose of this manual is to meet the need for a description of the use of the special instruments and techniques designed by the ASIF group. It is not, nor does it purport to be, a cataloging of results achieved by these techniques, but simply a description of the techniques themselves. The underlying aim of all of their operations is to minimize or eliminate the need for external fixation by achieving rigid internal fixation. By so doing, they hope to achieve early return of full function and to prevent the “fracture disease” associated with lengthy external immobilization of fractures. The style of this book is telegraphic and the translation by J. Schatzker is clear and concise. The illustrations and captions are beautifully done. I especially enjoyed the illustrations of principles or operative technique demonstrating various methods of achieving compression such as the lag screw principle and the tension band principle. To many orthopaedic surgeons in this country some of the methods illustrated will appear radical. This is particularly true for the techniques involving diaphyseal fractures of the tibia and comminuted fractures of the distal end of the femur where a great deal of metal is used. There will probably be less disagreement with the methods advocated for articular fractures. In analyzing this manual certain facts must be kept in perspective. First, the instruments and implants described are beautifully designed and beautifully constructed. Second, the ASIF (formerly AO) group of surgeons are excellent technicians and are thoroughly familiar with their equipment and techniques. Third, as stated by the group itself in the preface, “Open treatment of fractures is a valuable but difficult method which involves much responsibility. We cannot advise too strongly against internal fixation if it is carried out by an inadequately trained surgeon, and in the absence of full equipment and sterile operating room conditions. Using our methods, enthusiasts who lack self criticism are much more dangerous than skeptics on outright opponents. We hope therefore that readers will understand our efforts in this direction and that they will pass on any constructive criticism to us.” Taken in this light, this manual is a very valuable addition to the literature. When open reduction is indicated, many of the techniques result in much better fixation than other methods. However, it must be emphasized that the techniques are exacting, conditions of sterility must be extremely rigid, and any surgeon who undertakes these techniques should be experienced. The fact that these techniques exist and have been described in this manual certainly does not mean that they should be attempted by every surgeon treating fractures in every circumstance. Lewis D. Anderson, M.D. Review of 1st AO Manual by J H Hicks in JBJS Br 1971;53:566 Manual of Internal Fixation. Technique Recommended by the AO-Group. By M. E. MULLER, University of Berne; M. ALLGÖWER, University of Basle; and H. WILLENEGGER, Kantonsspital Liesthal. In collaboration with W. BANDI, H. R. BLOCH, A. MUMENTHALER, R. SCHNEIDER, B. G. WEBER and S. WELLER. Translated by J. SCHATZKER. 28 / 20 cm. Pp. ix+297, with 306 figures. Index Berlin-Heidelberg-New York: Springer Verlag. Price DM 158; $43.50. That enthusiastic Swiss organisation, the Arbeitgemeinschaft fur Osteosynthesefragen, starting from scratch, has in the course of little over ten years, advanced the knowledge of fracture behaviour perhaps further than in the previous century. With the publication of the Manual of internal Fixation they give detailed instructions how to put their principle of fixation by compression into practice. There is much to shock the traditionalists, for example, the deliberately leaving open of compound wounds; and there are many opportunities for critics who believe that two plates and fifteen screws automatically mean bad treatment. It all depends upon the manner in which they are applied and, above all, this is a manual of good craftsmanship. Every possible mechanical resource is exploited and the reader is introduced to an armamentarium that will do jobs never before possible. There is, perhaps, some doubt as to whether craftsmanship can be taught. Those surgeons who feel the need to have the book open as they work would probably get better results from conservative methods. But for the man with a little aptitude there is a wealth of good ideas. Greater emphasis could have been placed on the avoidance of brutal engineering that pays no heed to the biology of the living bone. The care, for example, of the soft-tissue attachment is there but not greatly emphasised. It may be more than a coincidence that the non-reactive pseudarthrosis is, according to Müller, becoming more common as open reduction and rigid internal fixation gain wide acceptance. Buried amongst the practical details is a true appreciation of fundamental fracture behaviour. All dogma appears to have been discarded and it is doubtful whether the osteoblast is ever mentioned. Instead we are told exactly which type of pseudarthrosis requires fixation and nothing but fixation for it to unite. Skin necrosis is recognised (but not Per Edwards who described it so clearly). One page and one page only is devoted to sepsis ; perhaps it is unfair to expect more in a manual. It is a book for the specialist but it contains ideas that ought to interest the physiologist and the pathologist for the next decade. - J. H. HICKS References: 1. Manual of internal fixation; technique recommended by the AO-Group. Müller ME, Allgöwer M, Willenegger H. New York Springer 1970.

33 Prof Willenegger presents Prof Böhler with AO book.
1970 AO and Lorenz Böhler Prof Willenegger presents Prof Böhler with AO book. This photograph was taken in 1970 on the occasion of Lorenz Böhler’s 85th birthday. He is seen here being presented with the new AO Manual by the 60 year old Professor Willenegger. Lorenz Böhler ( ). Hans Willenegger ( ).

34 1972 AO International Hans Willenegger
Liestal, Switzerland (1910−1998) 1st president of AOI AOI was founded on November 25th 1972 in Bern. Extract from AO Philosophy and Principles of Fracture Management-Its Evolution and Evaluation David L. Helfet, MD, Norbert P. Haas, MD, Joseph Schatzker, MD, Peter Matter, MD, Ruedi Moser, DVM and Beate Hanson, MD, MPH The Journal of Bone and Joint Surgery (American) 85: (2003) AO International The founders decided that AO instruments and implants would only be provided to interested surgeons, i.e., those who had received formal instruction in the proper application of the devices and had also become knowledgeable about AO principles and techniques. In 1972, AO International was founded to coordinate the teaching programs of the AO group around the world. The premise of the AO was that operative fixation of fractures should become a safe method of treatment with a low prevalence of complications. Operative treatment was never advocated as being the only method of fracture treatment. From the beginning, the AO stressed that indications for surgery were dependent on the surgical environment, the skills of the surgeon and operating team, the personality of the patient, and the injury. Once the decision to operate had been made, it was necessary for the surgeons to have the requisite and complete instrumentation and to use excellent surgical technique according to the established AO principles to maximize the quality of the treatment. Since the first course was taught in Davos in 1960, education was and has remained one of the cornerstones of AO. AO International has a broad base of the most experienced fracture-trauma surgeons worldwide who donate their time and expertise as faculty to maximize the learning experience for course participants. These surgeon educators strive to update and continually improve the educational quality of AO courses. Since 1960, there have been 1665 courses in 122 countries with almost 175,000 participants. The AO group dramatically improved the learning experience by introducing the concept of practical work in laboratories originally with use of cadaver bones and later with plastic bone models. AO International has also funded thousands of international fellowships, providing educational opportunities for residents and practicing surgeons to visit AO Centers and observe AO techniques. Currently, AO is investigating new opportunities for information transfer with use of CD-ROM, interactive video, and several advanced communication techniques. The AO has a long tradition of consistently updating and improving its educational concepts and disseminating this new information throughout the world.

35 1974 1st AO CMF course Joachim Prein Basel, Switzerland

36 1978 Strain theory of healing
Stephan Perren Davos, Switzerland Alexander Boitzy St Gallen, Switzerland References: Cellular differentiation and bone biomechanics during the consolidation of a fracture. Perren SM, Boitzy A. Anatomia Cllinica 1978;1:13-28 Physical and biological aspects of fracture healing with special reference to internal fixation. Perren SM. Clin Orthop 1979;138:175-96 Biomechanics of fracture healing. Perren SM. Can J Surg 1980;23(3):228-32 A radiological and histological analysis of fracture healing using prebending of compression plates. Nunamaker DM, Perren. SM Clin Orthop Rel Res 1979;138:167-74 Role of interfragmentary strain in fracture healing: Ovine model of a healing osteotomy. Cheal EJ, Mansmann KA, Digoia AM, Hayes WC,Perren SM. Journal of Orthopaedic Research 2005;9(1):131-42

37 1981 Biomechanical stability
Bernhard Georg Weber St Gallen, Switzerland (1927−2002) Minimax Fracture Fixation Extracts from an interview with Maîtrise Orthopédique (http://www.maitrise-orthop.com): Bernhard Georg Weber has profoundly influenced Swiss orthopaedics; his many papers have gained him international renown. After a long and busy career, his metal-on-metal prosthesis has put him once again in the forefront of orthopaedic innovation. We went to interview him - and found a grand old man full of youthful enthusiasm. M.O. How did you become Maurice Müller's successor at St. Gall? B.G.W. After training under Prof. Francillon at Zurich University Hospital, I found a post in Prof. Stinchfield's department, in New York. While I was waiting for my United States visa, I decided to tour the main centres of orthopaedic surgery in Europe. When I was in England, I got a telegram from Maurice Müller asking me to come and work with him. I thought, well, perhaps it would be better anyway to work in Switzerland. So I accepted, and spent six and a half years as Maurice Müller's Senior Registrar. Then, when he got the Chair in Berne, I became his successor at the Canton Hospital in St. Gall. M.O. Why did he want you to go to St. Gall? B.G.W. He had met me when I was a house officer and he was Senior Registrar at Balgrist. Then, when he was in private practice, he started sounding out his colleagues in Switzerland to see who had what it took to be his senior registrar at the centre he was going to - St. Gall. By then, I had a reputation as a hard worker and a good sport, someone who could win or lose. That was exactly what Maurice Müller was looking for, to set up "his" orthopaedic centre that was to be a completely new departure in Switzerland. The combination of orthopaedics and traumatology had not been thought of before. The following years showed that this sort of centre is ideal for multiply injured patients and those with single injuries alike; it also proved an ideal pattern for training in conventional orthopaedics. That is because in traumatology, the junior surgeon gets to know the pathophysiology of trauma, and because every orthopaedic operation is in itself a trauma. Also, traumatology offers a much larger surgical material than would pure orthopaedics. In 1960, when the St. Gall hospital was founded, there were only three conventional orthopaedic centres. Today, 35 years later, there are some fifty centres - and it was St. Gall that had provided the impetus for this development. Many orthopaedic surgeons who now head departments - not only in Switzerland but also abroad - did their training in St. Gall. M.O. How did you get on with Maurice Müller? B.G.W. Maurice Müller developed new concepts in all branches of the orthopaedic discipline, which have been influential world-wide. I was incredibly lucky to be able to work in his department as a young registrar. Not only did I benefit from his knowledge, he was also so busy writing up his ideas that I was able to run the centre more or less as I saw fit. I was virtually in control, and able to do my own thing. Maurice Müller checked what we did, but gave us a plenty of scope to do things the way we wanted, provided that his principles for the management of cases were adhered to. Also, whenever we made suggestions that were along his lines, we found him very willing to listen. This provided us with a vast field of activity, and accounts for the large number of papers that came out of that centre. Our scientific output was remarkable not only in terms of quantity, but also because of the high quality of our publications. That sort of thing was unique in the history of Swiss orthopaedics. And it was Maurice Müller who had provided the framework within which all these things could go ahead. M.O. Why did he leave St. Gall? B.G.W. He had ambitions, and he wanted a Chair. Getting a Chair was very, very important to him. Later on, he was also made President of SICOT, and by the end of his career he had reached a level few other orthopaedic surgeons could claim to have risen to. I myself have never been tempted by the honours of academia. There are differences between the two of us that play a role even nowadays. Not a negative role - but what I would call mutual monitoring. He certainly keeps an eye on what I am doing in hip surgery. Fractures did not present a problem, but in hip surgery we were rivals to some extent. However, when he left St. Gall, he wanted his work to go on, and by leaving me in charge he knew that it would be continued by one of his disciples and his friends. M.O. Were you worried that your chief might pinch your ideas? B.G.W. And how! He was a super Chief, but he also saw himself as the lord of the manor. M.O. During your first years as a consultant, what were your main interests? B.G.W. First of all, ankle fractures, a subject on which I wrote a textbook that came out in After that, I became interested in non-union, and wrote about that subject with O. Cech, a colleague in Prague who had spent two years working with us. It was a great textbook on non-union, and is still highly relevant 22 years later. Non-union was classified in terms of the bioactivity of the tissue involved. We knew that the healing chances of non-union depended on two factors: Firstly, union is a function of the viability - i.e. the blood supply - of the fragments. That is something that Robert Judet had also found; and we were able to confirm this fundamental concept. Secondly, union depends on the stabilization of the fragments, so that the ends can knit. This means that there are two problems that need to be controlled – a biological one, and a mechanical one. At the time, surgeons were not sufficiently aware of this dual requirement. We were able to make this point, and thus to contribute to the success of our textbook. M.O. Did you propose any practical solutions? B.G.W. Indeed we did - in fact, we described in our textbook all the possibilities that were of proven value at the time. What we suggested was based upon our experience in the management of 800 cases of non-union, at the Canton Hospital and in Prague. We knew the nature and the natural history of most of the patterns of non-union in our patient material, and were thus able to establish a detailed prognosis for every case. This prognosis was based on the dual assessment of the biological condition at the site of non-union and of the mechanical stabilization that could be provided. When all is said and done, non-union is quite straightforward to treat: It all boils down to knowing the bioactivity at the site, and providing stable fixation. We have also developed several other original techniques, such as internal fixation using a dished metal plate. M.O. Where would that be used? B.G.W. These plates were used in the treatment of femoral non-union that was difficult to manage otherwise. We had many such cases, either after attempts at conservative management or after intramedullary nailing or plating, in particular with segmental fractures. Even where first-class internal fixation with a plate or a nail had been performed, the fragments would sometimes not unite because of the poor biological condition of the bone ends. In these cases, where the hardware would break after a few months, I thought that the plate should be made to bridge the site of non-union, with a graft placed under the bulge of the plate to lie between the plate and the lesion. The practical application of this principle was somewhat empirical, but the success of this procedure was so convincing that we began to manage recent fractures in critical zones with this technique. We then applied the method to limb lengthening, to speed up healing. We applied a dished plate and a graft, and the whole thing healed very quickly. Much faster than with an Ilizarov. With an Ilizarov, lengthening takes a year, whereas with a Wagner followed by a plate-and-graft, it only takes four to five months. M.O. It is not a very well-known technique ... B.G.W. That's because I did not make a huge effort to make it known. I did not want to create a whole range of implants to cater for every conceivable pattern. What I wanted was to obey the laws of biomechanics with a minimum of hardware, but with a hardware that the surgeon in the theatre could adapt to the individual patient's needs. In other words, the surgeon should be able to twist and bend the plates to make them fit the different, and very complex, patient patterns. This policy has been called "Minimax", since it achieves a maximum of effect with a minimum of outlay. M.O. As early as the Sixties, you had realized that there was a difference between a flexible and a rigid plate. B.G.W. Yes. As I was saying, at St. Gall we were a group of young surgeons who were forever discussing and bouncing ideas off each other. Not all of our new ideas were popular with the Chief. Very early on - I think in Alexander Boitzy refused to do anatomical reductions and stable internal fixation of the tibia in certain cases. The fractures concerned were complex multi-fragment patterns, and he disobeyed the house rule which said that such cases should be managed with anatomical reduction and rigid fixation. Boitzy thought it would be enough to link the main distal fragment and the proximal fragment using a subcutaneous plate that did not interfere with the injury zone. That's how biological fixation was born, and Boitzy actually coined the term "biological internal fixation." Thirty years later, this term is still very modern. But when we, the young ones, were talking about "elastic” biological fixation, we were almost branded traitors to the AO/ASIF cause. It is a good example of how things evolve. In surgery, a bad idea does not take long to be recognized as such. After a couple of years, everyone knows it's rubbish. But good ideas take a long time to establish themselves - twenty years is not unheard of. M.O. What were your initial indications for nailing as opposed to plating? B.G.W. To me, nailing always has had very limited indications: fractures of the middle third of the femur or the tibia; either transverse or very short oblique fractures. All other cases would be managed either conservatively, with a Sarmiento plaster, or plated, or given an external fixator. The interlocked nail that now exists is really an unstable intramedullary plate! One might just as well use an external fixator, which would not interfere with the intramedullary blood supply. M.O. Do you think that in femoral fractures an external fixator would give the same results as an interlocked nail? B.G.W. No, it would work better. And it can be done using a unilateral fixator with three upper and three lower pins. I have written a paper on complex femoral fractures managed with an external fixator. The results were remarkably good, and I cannot understand why this technique has encountered so little interest. Everybody wants to use interlocking nails, because they are the "in" ironmongery. M.O. Finally, let us talk about something that is very dear to your heart. B.G.W. After a lifetime trying to master my craft, I find that there is one field that deserves particular attention. I am talking about postgraduate education and training for surgeons, in particular the acquisition of skills. Obviously, one can read textbooks and listen to papers at scientific meetings, and acquire a lot of theoretical knowledge in this way. However, I think that, in postgraduate education, too much emphasis is placed on theory, and too little importance is given to the acquisition of practical skills. M.O. So what do you think should be done? B.G.W. There should be practical courses, provided on a regular basis. M.O. Do you think that surgeons could perfect their skills by working on plastic bones? B.G.W. I am sure they could. That's where training starts. It's like playing the piano. PGE should not be all theory; there must also be practical workshops. M.O. Who should pay for these workshops? B.G.W. The surgeons who attend them. If I wanted to learn to play an instrument, I would need to pay my music teacher. Equally, if I wanted to improve my tennis or my skiing, I would need to take paid lessons. Surgeons should be encouraged to achieve greater mastery over the technical aspects of their craft. The courses could be organized by the surgeons themselves. M.O. Do you not think that such workshops would be a bit artificial? B.G.W. They would be a beginning, a means of learning a new surgical technique - "Learning by doing." The next stage would be a visit from a colleague who is well versed in that technique; and the final stage would be finding someone that puts the instruments into the learner's hands and tells him to get on with it. References: Wave plate osteosynthesis as a salvage procedure. Weber BG. Arch Orthop Trauma Surg 1990;109:330-3 Besondere Osteosynthesetechniken (Special internal fixation techniques). Brunner CF, Weber BG. Heidelberg, Springer-Verlag 1981 Minimal amount of metal Maximum stability

38 Tscherne classification of closed fractures
1983 Soft-tissue injury Harald Tscherne Hannover, Germany References: Die Klassifizierung des Weichteilschadens bei offenen und geschlossenen Frakturen. Tscherne H, Oestern HJ. Unfallheilkunde 1982;85:111-5 Tscherne classification of closed fractures

39 1984 AO Foundation Peter von Rechenberg Thomas Rüedi Peter Matter
Fritz Straumann Robert Mathys Stephan Perren Extract from Surgery, Science and Industry by Thomas Schlich: “On 8th December 1984 the AO Foundation was finally established. Allgöwer, Matter, Müller, Perren, von Rechenberg, Rüedi, Schneider and Willenegger ‘permanently and irrevocably’ contributed to the Foundation all 50 bearer shares of Synthes AG Chur. In addition Robert Mathys gave SFr 400,000 in cash; Fritz Straumann and Hansjörg Wyss each gave SFr 100,000. Synthes AG Chur was not dissolved, but its shares were now owned by the AO Foundation. The purpose of the new Foundation was defined as the support and promotion of the Laboratory for Experimental Surgery in Davos, ‘as well as the advancement of the AO/ASIF concept, and the research, education, and documentation in the field of medicine in Switzerland and abroad connected therewith’. Notary Martin Allgöwer Maurice Müller Robert Schneider Hans Willenegger Hansjörg Wyss

40 1984 Four pillars of AO Martin Allgöwer Basel, Switzerland
1st AO Foundation president Four pillars of cooperation: Documentation Teaching Research Instrumentation

41 1987 AO Classification Maurice Müller Peter Koch Serge Nazarian
“A classification is useful only if it considers the severity of the bone lesion and serves as a basis for treatment and for evaluation of the results.” Extract from: AO Philosophy and Principles of Fracture Management-Its Evolution and Evaluation David L. Helfet, MD, Norbert P. Haas, MD, Joseph Schatzker, MD, Peter Matter, MD, Ruedi Moser, DVM and Beate Hanson, MD, MPH The Journal of Bone and Joint Surgery (American) 85: (2003) AO Documentation As a basic principle, it was always clear to the founders of the AO that operative treatment of fractures would gain acceptance only if substantial improvement in the clinical results could be obtained in multiple centers. Thus, radiographs and complete case histories of their patients were compiled and maintained until fracture-healing was achieved. The cases of these patients from the clinics of all founding members were evaluated systematically. The documentation of more than 150,000 operatively treated fractures over twenty-eight years confirmed the clinical advantages of the AO principles and techniques of fracture care and also created the basis for the AO fracture classification system, which was first described in 1987 by Müller et al. With this unique documentation of fractures, the unified description of the various fracture patterns became possible, and the ability to compare results by fracture type and fixation technique became a reality for the first time References: Classification AO des fractures, les os longs. Müller ME, Koch P, Nazarian S. New York, Springer; 1987 AO Philosophy and Principles of Fracture Management – Its Evolution and Evaluation. Helfet DL et al. JBJS-A 2003;85:

42 1987 Indications for ORIF Joseph Schatzker Marvin Tile Toronto, Canada
Foreword by Maurice E. Müller to 1st edition of The Rationale of Operative Fracture Care : After the publication of the AO book Technique of Internal Fixation of Fractures (Müller, Allgöwer and Willenegger, Springer-Verlag, 1965), the authors decided after considerable discussion amongst themselves and other members of the Swiss AO that the next edition would appear in three volumes. In 1969, the first volume was published (the English edition, Manual of Internal Fixation, appeared in 1970). This was a manual of surgical technique which discussed implants and instruments and in which the problems of internal fixation were presented schematically without radiological illustrations. The second volume was to be a treatise on the biomechanical basis of internal fixation as elucidated by the work done in the laboratory for experimental surgery in Davos. The third volume was planned as the culminating effort based upon the first two volumes, treating the problems of specific fractures and richly illustrated with clinical and radiological examples. It was also to discuss results of treatment, comparing the results obtained with the AO method with other methods. The second and third volumes were never published. The second edition of the AO Manual appeared in It dealt in greater detail with the problems discussed in the first edition, although it still lacked clinical examples and any discussion of indications for surgery. Like the first edition, it was translated into many languages and was well received. Finally, after 22 years, the much discussed and much needed third volume has appeared. Two Canadian surgeons have successfully undertaken the challenging task of filling this gap in the AO literature. Joseph Schatzker and Marvin Tile first came into contact with AO methods of internal fixation in Impressed by the results of the method, they set themselves to learn it in minute detail and before long became masters of the technique and strong exponents of its effectiveness. They appeared often as lecturers and instructors in AO courses in Switzerland, and North America. Their numerous publications and lectures have greatly contributed to the wide acceptance of the operative method of fracture care. Joseph Schatzker translated the first and second editions of the Manual from German into English, and has, in addition to these excellent translations, achieved distinction as a teacher of the AO method. Both he and Marvin Tile participate annually as instructors in the instructional courses at the American Academy of Orthopaedic Surgeons. With their long association with AO techniques and tremendous clinical experience, these two distinguished surgeons were eminently qualified to undertake the monumental task of defining the specific indications for operative fracture care. In this book they present not only their own views but also a synthesis of the thoughts and writings of other AO members. The book is outstanding and far exceeds the goals originally envisaged for the projected third volume. The authors have been careful in choosing examples and the appropriate radiological illustrations to delineate the mechanism of injury, the biomechanical problems, the indications for treatment, and the actual execution of surgical procedures. They always guide the reader to the essence of the problem, clearly emphasizing the principles of fracture treatment, a deductive approach through analysis to the clinical decision. Schatzker and Tile speak of fractures having a “personality”. This “personality” is a key concept requiring careful definition: it includes not only a careful analysis of the fracture and all its soft tissue components, but also a thoughtful assessment of the patient, his or her age, occupation, health, and expectations of treatment, as well as a critical appraisal of the skill of the surgeon and the supporting surgical team and environment. This analysis, combined with the knowledge of what constitutes a reasonable result, allows the authors to formulate a guide to treatment. They also provide useful advice about avoiding technical difficulties and pitfalls, about planning correct postoperative care, and about the treatment of complications which may arise. The book is superbly illustrated with many drawings skillfully employed to clarify and emphasize essential techniques. The style is easy to understand, clear and unambiguous, giving a lucid presentation of complex and difficult concepts. It will certainly become a standard reference work for everyone involved in the treatment of fractures. Berne, July MAURICE E. MÜLLER Toronto, Canada Toronto, Canada

43 1988 Periosteal blood supply (plates)
Stephan Perren Davos, Switzerland Osteoporosis under plate is caused by bone necrosis and not by stress protection Extract from: AO Philosophy and Principles of Fracture Management-Its Evolution and Evaluation David L. Helfet, MD, Norbert P. Haas, MD, Joseph Schatzker, MD, Peter Matter, MD, Ruedi Moser, DVM and Beate Hanson, MD, MPH The Journal of Bone and Joint Surgery (American) 85: (2003) AO Research and AO Development Since research was one of the pillars on which the AO based its success, AO surgeons and scientists actively pursued clinical and laboratory investigations. Implants coupled to bone always participate in load transmission and may cause stress-shielding. The amount of stress-shielding depends on the rigidity of the implant and the coupling between implant and bone. Interestingly, experiments with less rigid plates demonstrated more rather than less porosity. The theory of "stress protection" based on Wolff's law does not explain the early, temporary porosity under the plate, which disappears after four to five months even with the implants still in place. Since re-fractures following plate removal were thought to be due to stress-shielding, plate stiffness attracted the interest of many researchers. The ideal plate was conceived as having the exact same modulus of elasticity as bone, as it was theorized that this would prevent stress-shielding and would make application of a plate more physiological and safer, but this concept was wrong mechanically. Stiffer implants result in more stress-shielding, and less stiff implants result in less, but it is wrong to assume that an implant of the same stiffness as bone produces no stress-shielding. In addition, the mechanical behavior of the coupling element (the screw) must be taken into account. Loosening of the screws would have the same effect as a plate with reduced stiffness. While many scientists continued to investigate the mechanical effects of plates on bone, the AO Research Institute in Davos, Switzerland, instead began to investigate the biological effects and, in particular, the effects of the plates on bone circulation. These investigators were able to show that plates interfered substantially with the blood supply to the underlying bone and caused the underlying cortex to become necrotic. References: 1. Die Limited-Contact-DC-Platte (LC-DCP), Konzept und wissenschaftliche Grundlage. Perren SM, Klaue K, Gautier E. Hefte zu der Unfallchirurg. 1993;230:813-5 2. Effects of plates on cortical bone perfusion. Jacobs RR, Rahn BA, Perren SM. J Trauma 1981;21(2):91-5 Early temporary porosis of bone induced by internal fixation implants. A reaction to necrosis, not to stress protection? Perren SM, Cordey J, Rahn BA, Gautier E, Schneider E. Clin Orthop Relat Res 1988;232:139-51 The reaction of cortical bone to compression. Perren SM, Huggler A, Russenberger M, Allgöwer M, Mathys R, Schenk R, Willenegger H, Müller ME. Acta Orthop Scand Suppl. 1969;125:19-21 A method of measuring the change in compression applied to living cortical bone. Perren SM, Huggler A, Russenberger M, Straumann F, Müller ME, Allgöwer M. Acta Orthop Scan Suppl. 1969;125:7-16 43 43

44 1988 AO Plastic bones Thomas Rüedi Stephan Perren Chur, Switzerland
Davos, Switzerland Open letter from the Chairman of the Board of SYNBONE, Professor Thomas Rüedi: “From the very beginning I was involved in AO fracture treatment. In those days, we used human bones collected from anatomy and pathology departments. With the increase in demand, problems such as safety, preservation and transportation, as well as hygienic and aesthetical issues needed to be addressed.   Stephan Perren had the brilliant idea of a realistic artificial bone and got in touch with the Swiss space industry. They had expertise in producing light-weight foam similar to cancellous bone to fill the ailerons of their rockets. Shortly following the experimental steps the growing need for artificial bones could not be met.   To meet this demand SYNBONE was founded in The first challenge was not only to build a production line providing enough artificial bones, but also to fracture them in a standardized way. The task of fracturing the models was delegated to ARGO in Davos, a private institution enabling handicapped individuals regular employment as well as independent living. Even to this day, this solution is respected and demonstrates continued social responsibility.   Since the beginning, I was privileged to accompany SYNBONE as Chairman of the Board. Concurrent with these exciting start-up years and the ensuing period of growth, AO Education became more and more sophisticated. Today the minimally invasive osteosynthesis (MIO) and computer assisted surgery (CAS) models with soft tissue covering the bone have become standard. Looking back on our first bone model in the 80's and seeing today's models makes me wonder what the models will look like 20 years from now.’ “Synthes bones” = SYNBONE

45 1989 AO Founders reunited Hans Willenegger Robert Schneider
Maurice Müller Peter von Rechenberg Martin Allgöwer Walter Bandi CEO 45

46 1989 AO Alumni Association 56 local chapters in 6 AO Regions in 2008
Europe North America Middle East Asia Pacific The AO Alumni Association (AOAA) was founded on January 5, 1989. This Association will help to attract and hold the interest of leading trauma surgeons. The aims of the AOAA are: To maintain and establish a close relationship between AO faculty members, AO fellows and former participants of AO advanced courses. To further progress in the treatment of disorders in the locomotor system in general, and trauma in particular, by the exchange of experiences and ideas among all members. To foster the establishment of Local Chapters and to encourage local meetings during the various national conventions. Other interested parties (surgeons) related to the worldwide AO effort  Criteria for membership The minimum prerequisites for membership of AOAA are: AO faculty member AO fellow AO advanced course participant (incl. specialty courses) Local Chapters can increase the requirements for admission according to the special situations in their countries.  Benefits for members Information via Newsletters and Internet about activities within the AO and AOAA AO publications, such as the AO Scientific Supplements to Injury, the AO Dialogue, Orthopedic Trauma Direction, the AO Foundation brochure, the Annual Reports of the AO Foundation, etc. are distributed Special AOAA Symposia are organized on a regular basis Access on closed-user-group pages on the Internet Personal AO Alumni address Relevant AO publications and videos can be purchased at a special rate (e.g. at Symposia) Regular meetings during major national and international conventions, e.g., AO courses Davos, AAOS, OTA, DGU, SICOT, etc An AO Alumni certificate is provided Latin America Africa

47 1989 Indirect reduction Jeff Mast Roland Jakob Reinhold Ganz
Foreword by Hans Willenegger to Planning and Reduction Technique in Fracture Surgery: During the past 30 years, the Study Group for the Problems of Osteosynthesis (AO) has made decisive contributions to the development of osteosynthesis as a surgical method. Through close cooperation among specialists in the fields of orthopedic and general surgery, basic research, metallurgy, and technical engineering, with consistently thorough follow-up, it was possible to establish a solid scientific background for osteosynthesis and to standardize this o0perative method, not only for the more obvious applications in fracture treatment, but also in selective orthopedics where hardly any problems relating to bone, such as those with osteotomies can be solved without surgical stabilization. Besides the objective aim, the AO was additionally stimulated by a spirit of open-minded friendship; each member of the group was recruited according to his professional background and position, his skills, and his talent for improvisation. Against this backdrop without even mentioning the schooling program well known throughout the world I should like to add some personal and general comments. This book is written for clinicians, instructing them how to perform osteosynthesis with special reference to plating in all its varieties and in strict accordance with the biomechanical and biological aspects and facts. From this point of view, the chapter on preoperative planning merits particular emphasis. Not only is it conductive to optimal surgery, it will also contribute to self-education and may found a school. Preoperative planning thus appears as a leitmotif throughout the whole book. The theme is illustrated with a number of fascinating details and suggestions concerning fracture repair and the different kinds of osteotomies, always closely linked with further fundamental concepts: minimal disturbance of blood flow, minimal hardware, optimal stability. I perused with special interest the chapter on plate fixation. All plates (straight and angled) were implanted with the patient on a conventional operating table without X-ray control, even in the case of a segmental fracture, shortening, or comminution. For such cases, the AO distractor is the instrument of choice; the reduction can be achieved without external traction, avoiding the need for both the traction table and the technically demanding insertion of an interlocking nail. Following the precepts outlined, the results are convincing, provided that the specific problems of the plate, which is in eccentric position, are taken into consideration. The AO distractor simplifies the reduction of a fracture to be treated by intramedullary nailing. In certain cases, the plate itself can be used as a reduction instrument, for instance by applying the plate first at the proximal part of the fractured bone. This simple and effective procedure is demonstrated in different situations and will be stimulating for anyone familiar with the art of plating. The great importance of any simplification of osteosynthesis should not be underestimated, as it is not only in developing countries that operating rooms may not be adequately equipped. Having discovered this for myself in the course of my travels in various countries, I always carry the AO distractor in my luggage and have often found it useful. In addition to discussing external fixation and the minidistractor, the remaining chapters refer to a number of combinations of internal and external fixation. Finally, the authors describe a remarkable selection of tricks used to adapt the classical AO implants to many different purposes. Every devotee of the art of surgery will especially like this well-illustrated closing chapter. This expertly written and stimulating book is a valuable addition to the orthopedic literature and merits the widest possible distribution. Berne, October Prof. Hans Willenegger, M.D. hon., D.V.M. hon. Extract from: AO Philosophy and Principles of Fracture Management-Its Evolution and Evaluation David L. Helfet, MD, Norbert P. Haas, MD, Joseph Schatzker, MD, Peter Matter, MD, Ruedi Moser, DVM and Beate Hanson, MD, MPH The Journal of Bone and Joint Surgery (American) 85: (2003) With the growing appreciation of the importance of the blood supply of the osseous fragments, the AO has reappraised not only the plate design but also the manner in which bone is reduced and the plate is applied to bone. Classical open reduction relies on direct manipulation and fixation of the broken fragments, which is referred to as direct reduction. This type of reduction results in varying degrees of devitalization of the fracture fragments. To avoid this devitalization, the AO has developed various techniques of indirect reduction. Indirect reduction is accomplished by distraction of the fragments with use of a distractor, an external fixator, a plate, or by traction applied to the limb. Reduction is achieved by so-called ligamentotaxis, which avoids direct manual manipulation of the fragments. References: Planning and reduction technique in fracture surgery. Mast J, Jakob R, Ganz R. New York, Springer-Verlag 1989 New techniques in indirect reduction of long bone fractures. Rüedi TP, Sommer C, Leutenegger A. Clin Orth Relat Res 1998;347:27-34 Technique of using the AO-femoral distractor for femoral intramedullary nailing. Baumgaertel F, Dahlen C, Stilleto R, Gotzen L. J Orthop Trauma 1994;8(4): Intramedullary nailing of acute femoral shaft fractures without a fracture table: Technique of using a femoral distractor. McFerran MA, Johnson KD. J Orthop Trauma 1992;6(3):271-8 Subtrochanteric fractures of the femur. Results of treatment with the 95o condylar plate. Kinast C, Bolhofner BR, Mast JW, Ganz R. Clin Orthop 1989;238:

48 1990 “Bio-logical” fixation
Alexander Boitzy Reinhold Ganz Bern, Switzerland Bern, Switzerland Soft-tissue injury determines the type of fracture fixation. Three stages of tissue damage: Compromised (careful standard fixation possible) Partial degloving (indirect reduction required) Soft tissues destroyed (reconstruction essential) References: Biological internal fixation of fractures. Gerber C, Mast JW, Ganz R. Arch Orthop Trauma Surg 1990;109: Clinical aspects of “bio-logical” plating. Ganz R, Mast J, Weber B, Perren S. Injury 1991;22:4-5 Die biologische Plattenosteosynthese. Gautier E, Ganz R. Zentralbl Chir 1994;119:564-72 Principles of internal fixation. Gautier E, Perren SM, Ganz R. Curr Orthop 1992;6:220-32

49 1990 Endosteal blood supply (nails)
Stephan Perren Davos, Switzerland Extract from: AO Philosophy and Principles of Fracture Management-Its Evolution and Evaluation David L. Helfet, MD, Norbert P. Haas, MD, Joseph Schatzker, MD, Peter Matter, MD, Ruedi Moser, DVM and Beate Hanson, MD, MPH The Journal of Bone and Joint Surgery (American) 85: (2003) Similar studies on intramedullary nailing revealed that reaming and nailing destroyed the inner two-thirds of the cortical blood supply. AO research has subsequently shown a large diminution in the cortical blood supply during reaming. These discoveries heralded a major shift within the AO, with a modification of the techniques and principles of internal fixation. The emphasis shifted away from mechanics and toward preservation of the local biology. References: 1. The biomechanics and biology of internal fixation using plates and nails. Perren SM. Orthopedics 1989;12(1):21-34 The effects of reaming and intramedullary nailing on fracture healing. Kessler SB, Hallfeldt KK, Perrren SM, Schweiberer L. Clin Orthop Relat res 1986;212:18-25 Unreamed tibial nail in tibial shaft fractures with severe soft tissue damage. Initial clinical experiences. Kretek C, Haas N, Schandelmaier P, Frigg R, Tscherne H. Unfallchirurg 1991;94(11):579-87 A new solid unreamed tibial nail for shaft fractures with severe soft tissue injury. Haas N, Krettek C, Schanelmaier P, Frigg r, Tscherne H. Injury 1993;24(1):49-54 Prospective study of union rate of open tibial fractures treated with locked, unreamed intramedullary nails. Bone LB, Kassman S, Stegemann P, France J. J Orthop Trauma 1994;8(1):45-9 Reaming versus non-reaming in medullary nailing: interference with cortical circulation of the canine tibia. Klein MP, Rahn BA, Frigg R, Kessler S, Perren SM. Arch Orthop Trauma Surg 1990;109:314 49 49

50 1990 Small footprint LC-DCP
Stephan Perren Davos, Switzerland Emanuel Gautier Chur, Switzerland L Limited C Contact D Dynamic C Compression P Plate References: The limited contact dynamic compression plate (LC-DCP). Perren SM, Klaue K, Pohler O, Predieri M, Steinemann S, Gautier E. Arch Orthop Trauma Surg 1990;109:304-10 The concept of biological plating using limited contact dynamic compression plate (LC-DCP). Perren SM. Injury 1991;22 suppl 1:1-41 Die Limited-Contact-DC-Platte (LC-DCP), Konzept und wissenschaftliche Grundlage. Perren SM, Klaue K, Gautier E. Hefte zu der Unfallchirurg. 1993;230:813-5 Limited Contact Dynamic Compression Plate (LC-DCP) - biomechanical research as basis to new plate design. Gautier E, Perren SM. Orthopade.1992;21(1):11-23 Effects of plates on cortical bone perfusion. Jacobs RR, Rahn BA, Perren SM. J Trauma 1981;21(2):91-5 Early temporary porosis of bone induced by internal fixation implants. A reaction to necrosis, not to stress protection? Perren SM, Cordey J, Rahn BA, Gautier E, Schneider E. Clin Orthop Relat Res 1988;232:139-51 Klinische Ergebnisse mit der Limited Contact DCP-Platte aus Titan - eine prospektive Studie mit 504 Fällen. Matter P, Schütz M, Bühler M, Ungersböck A, Perren SM. Z Unfallchir Versicherungsmed Berufskr 1994;87(1):6-13 Clinical experience with titanium implants, especially with the limited contact dynamic compression plate system. Matter P, Burch H. Arch Orthop Trauma Surg 1990;109:311-3 The application of the limited contact dynamic compression plate in the upper extremity: an analysis of 114 consecutive cases. McKee MD, Seiler JG, Jupiter JB. Injury 1995;26:661-6

51 1990 Robert Schneider passes away
In Memoriam Robert Schneider, by M.E. Müller for AO Dialogue December 1999: Robert Schneider was born in Biel in 1912, studied medicine in Bern and spent one semester in Paris. In 1937 he began to specialize in general surgery and in 1947 became a senior resident under Professor Lenggenhager. Despite academic leanings, he took the post of surgeon-in-chief in a community hospital in Grosshöchstetten, a rural village near Bern. Shortly after arriving there, I met him and we developed a fraternal relationship, which lasted for 38 years. After meeting four of his surgical friends, I organized for them a course on “Stable Internal Fixation”, in October 1956 at the Balgrist Hospital in Zürich. A year later, we decided to found an “Association for the Operative Treatment of Fractures” – subsequently AO. The six (sic) founders adopted the following principles: 1. “Good” is what is good for the patient and satisfies the needs of the surgeon. 2. All procedures to be simple and described in simple terms. 3. Each operatively treated fracture to be documented and evaluated. 4. Documentation to include copies of all x-rays and slides, available to the group. 5. Each failure to be analysed and its cause determined. 6. The results to be statistically analysed. Robert Schneider adhered to these principles throughout his professional career. In 1959 he became the first Chairman of the AO–a post he held for 20 years. His critical self-evaluation, his grasp of complex issues, his ability to unveil links between seemingly unrelated events, and his many discoveries, earned him great respect nationally and internationally. In 1968 he published “The First 10 Years of AO”. A later book “25 Years AO Switzerland” is a treasure house of AO information. Written in German, the book sadly was never translated into English. Some 22 other publications were but a prelude to his major work, a 300-page treatise “The Total Hip Prosthesis, a Biomechanical Concept and Consequences”. Robert Schneider received numerous honours, but he remained, nonetheless, a modest, friendly man. In many countries he was “the father of the AO”. He remained in practice until the time of his sudden death, just as he put in the last skin suture after a hip arthroplasty. Robert Schneider will stay alive in the memory of all those who had the privilege to know him.

52 1992 AO North America Seen in this photograph taken in Davos Rinerhorn in June 1992: Back row: Jeff Summer-Smith, ?, Keith Mayo, Jeff Mast, Peter Trafton, Andy Burgess, ?, ?, ?, ?, David Helfet, James Gerry Front row: Hans Jörg Wyss, Marvin Tile, Jesse Jupiter, Bruce Mallin, Joel Matta, Howard Rosen, Joseph Schatzker, James Hughes, Larry Bone Ted Hansen (President) Jim Hughes? Steve Olson? Terry Axelrod? Jim Kellam? Steve Schelkun? Keith Mayo? Mark Vrahas? John Wilber? Mike Miranda?

53 1992 AO Center Davos Summer Spring Fall Winter
At a cost of SFr25 million the AO Centre was opened on June 28th 1992. The AO Centre in Davos houses the AO Research Institute, the AO Foundation, the AO International, the AO Documentation Centre and the AO Course Secretariat, and (since 1993) the AO Development Institute. All four pillars of AO, research, documentation, education and instrumentation are now under one roof.

54 1993 Internal fixator PC-Fix
Stephan Perren Slobodan Tepic Davos, Switzerland ???, Switzerland PC-Fix Point Contact Fixator Monocortical locking References: Basic concepts relevant to the design and development of the Point Contact Fixator (PC_Fix). Perren SM, Buchanan JS. Injury 1995;26 Suppl 2:1-4 The biomechanics of the PC-Fix internal fixator. Tepic S, Perren SM. Injury 1995;26 Suppl 2:5-10 Observations concerning the different patterns of bone healing using the Point Contact fixator as a new technique for fracture fixation. Hofer HP, Wildburger R, Szyskowitz R. Injury 2001;32 suppl 2:15-25 The principle of internal fixators applied to diaphyseal forearm fractures using the Point Contact Fixator (PC_Fix): results of 387 fractures of a prospective multicentric study. Haas NP, Hauke C, Schutz M, Kaeaeb MJ, Perren SM. Injury 2001; 32 suppl 2:51-62 Treating forearm fractures using an internal fixator: a prospective study. Fernández Dell’Oca AA, Tepic S, Frigg R, Meisser A, Haas N, Perren SM. Clin Orthop Relat Res 2001;389:

55 1994 AO East Asia Suthorn Bavonratanavech Chiangmai, Thailand
1st president of AOEA Hong Kong Indonesia Malaysia Philippines Singapore South Korea History of AO Asia Pacific (AOAP) The AO was founded in 1958 in Switzerland and its principles of fracture management were propagated to all parts of the world. The dissemination of AO knowledge has expanded under the responsibility of AO International, now called AO Education (AOE), which is one of four main pillars of the AO Foundation beside AO Clinical investigation and Documentation, AO Development and AO Research. The AO principles have helped thousands of surgeons and million of patients in the treatment of musculoskeletal injuries. In the past, Asian surgeons learnt about AO techniques by attending courses in Davos, Switzerland and through visits of guest lecturers from the West in the countries of Asia. The number of AO courses in Asia has sharply increased over the last couple of years because of the availability of Practical Workshop Sets (PWS) in Asia. Apart from developing the teaching activities for orthopedic surgeons, we should not forget that the nurses in the operating rooms who are a part of the operation team need also to be included in the AO teaching activities (ORP courses). Under the AO Presidency of Prof. Marvin Tile from 1992 to 1994 the concept of regionalization was born and AO East Asia (AOEA) was founded in November 1994 under the leadership of Dr. Suthorn Bavonratanavech who also became the first chairman of AOEA. Prof. S.P. Chow, the second chairman spearheaded the growth of scientific activities within AOEA and the third chairman, Dr. G On Tong united the region of AO Asia-Pacific. The Cranio-maxillofacial group, originally a subspecialty within AOEA, became an independent body, called AO Cranio-Maxillofacial Asia in This group is under the chairmanship of Prof. Thiam Chye Lim from Singapore. Major achievements of AOEA at a glimpse were: the first issue of AOEA newsletter in 2000, the launch of the AOEA website in 2001, the formation of the study groups in 2003, the first AOAA-Asian Chapter Symposium in Chiang Mai, Thailand and the formation of the ORP group in 2004, and the first combined regional AO courses in Chiang Mai, Thailand in 2006. It is worthwhile mentioning that the AO Foundation with the help of devoted doctors and our industrial partner Synthes provided support to relief tsunami and earthquake victims in Asia. The countries belonging to AOEA were: Hong Kong, Indonesia, Malaysia, Philippines, Singapore, South Korea, Taiwan (Chinese Taipei) and Thailand. The success of AOEA came from the cooperation and contribution of surgeons in the member countries, the support from the Board of Directors and members of the Academic Council of the AO Foundation. A major step forward happened in 2003, when Japan affiliated with AOEA. In November 2006, the AO trustees of the People’s Republic of China decided to join AOEA, bringing the most populous nation to be part of the group. There was additional momentum at the AO courses in 2006 in Davos with the trustees of Australia and New Zealand agreeing to join the Asian Trauma Group. At that time the chairman of AOEA, Dr. G On Tong, decided to call the new body AO Trauma Asia-Pacific, in short AOTAP. At the Tips for Trainers event in New Delhi in February 2007, another breakthrough happened with the trustees of India accepting the invitation to join AOTAP. In less than six months AO Trauma Asia-Pacific has become a reality and is now representing one of the regions of the AO Foundation. There are three study groups in AOEA, namely hand, soft tissue and minimal invasive. The  latter group published the first book on the subject of minimally invasive plate osteosynthesis (MIPO) in It is the first book in AO Publishing, which does not originate from Europe and North America. Taiwan/Chinese Taipei Thailand

56 1995 LISS Robert Frigg Bettlach, Switzerland Less Invasive
Stabilization System Locking head screws Extract from: AO Philosophy and Principles of Fracture Management-Its Evolution and Evaluation David L. Helfet, MD, Norbert P. Haas, MD, Joseph Schatzker, MD, Peter Matter, MD, Ruedi Moser, DVM and Beate Hanson, MD, MPH The Journal of Bone and Joint Surgery (American) 85: (2003) In metaphyseal regions, minimally invasive plate osteosynthesis has advantages over a conventional open plate-fixation technique. The problem with the use of conventional periarticular plates or angled plates is that their design features do not facilitate percutaneous fixation and hence they require classic open reduction techniques. The Less Invasive Stabilization System has therefore been developed with features that greatly facilitate percutaneous fixation of the plate to the underlying bone, especially in the metaphyseal regions. In this system, the plate is fixed to an insertion device, which acts to guide the insertion of the fixation screws. Furthermore, the Less Invasive Stabilization System also incorporates a "locked internal fixation" system, which allows for unicortical fixation. Another added feature is that the special fixation screws, which lock into the plate, are self-drilling and self-tapping and incorporate radial preload to enhance their cortical fixation. Similarly, the locking compression plate concept offers many advantages for all plate applications but especially for percutaneous techniques, as the use of a "locked" screw in any hole provides stable fixation (unicortical or bicortical), without the need for perfect plate-contouring or additional soft-tissue dissection. The concept combines an angular stable anchorage with traditional compression and is especially suited for fractures in osteoporotic bone. References: 1. Distal femoral fracture fixation utilizing the Less Invasive Stabilization System (L.I.S.S.): the technique and early results. Kregor PJ, Stannard J, Ziowodzki M, Cole PAA, Alonso J. Injury 2001;32 Suppl 3:32-47 2. The development of the distal femur Less Invasive Stabilization System (LISS). Frigg R, Appenzeller A, Christensen R, Frenk A, Gilbert S, Schavan R.Injury 2001;32 Suppl 3:24-31

57 1997 Walter Bandi passes away

58 1997 Mini incisions (MIPO) Christian Krettek Harald Tscherne Minimally
Invasive Plate Osteosynthesis Extract from: AO Philosophy and Principles of Fracture Management-Its Evolution and Evaluation David L. Helfet, MD, Norbert P. Haas, MD, Joseph Schatzker, MD, Peter Matter, MD, Ruedi Moser, DVM and Beate Hanson, MD, MPH The Journal of Bone and Joint Surgery (American) 85: (2003) The techniques of indirect reduction and application of a bridge plate have resulted in the development of the concept of minimally invasive plate osteosynthesis. In this technique, the fracture is first reduced by indirect means. The plate is then slid through a small skin incision, deep to the investing muscle, and, when the plate is in position, it is fixed to the bone with screws inserted percutaneously. This technique of plate fixation mimics intramedullary nailing with the obvious difference that the fixation device, i.e., the plate, lies in an extramedullary position. In metaphyseal regions, minimally invasive plate osteosynthesis has advantages over a conventional open plate-fixation technique. References: Evolution of minimally invasive plate osteosynthesis (MIPO) in the femur. Krettek C, Muller M, Miclau T. Injury 2001;32 Suppl 3:SC32-47 2. Minimally Invasive Plate Osteosynthesis (MIPO), Part I. Krettek C. (editor) Injury 1997;28 Suppl 1 A1-48 Minimally Invasive Plate Osteosynthesis (MIPO), Part II. Krettek C. (editor) Injury 1998;29 Suppl

59 1998 AO Latin America AOLAT Argentina Bolivia Brazil Chile Colombia
Ecuador México Perú Uruguay AO Latin America by Jaime Quintero AO Dialogue 2001 Since the early days the AO group established the so-called founding sections, AO Switzerland, AO Germany, AO Austria, and AO Spain, with distinguished surgeons leading the educational activities in their specific regions. After the establishment of the AO Foundation in 1984 and according to specific regional needs, new sections were formed in different parts of the world, AO North America, AO East Asia, AO United Kingdom, and recently AO Latin America, AOLAT. AOLAT is a “participating entity” of the AO Foundation and shares the same ideals and objectives as the AO Foundation, to improve the care of patients with musculoskeletal injuries, deformities and degenerative diseases in Latin America, through education and research in the principles, practice, and results of operative treatment. Although AOLAT focused its initial interests on long bone trauma, it has spread its wings to other areas such as Polytrauma Care, Spine, Hand, and Maxillofacial surgery. History of AO in Latin America In the late ‘60s and early ‘70s prominent Latin American surgeons started contacts with the core AO Swiss group. From Mexico down to Peru, Chile, Uruguay, Brazil, and Argentina, leading surgeons like José Ortega, Julio Ramos, Hugo Grove, Roberto Masliah, Eduardo Patow, Jose A. da Nova Monteiro, Jose Soares Hungria Filho, Salomon Schachter, and others had to overcome scepticism and strong opposition of the dominant “establishment” who claimed that AO meant “Always Osteomyelitis” and that Internal Fixation was “Infernal Fixation”! During these years the missionary activity of “Hausi” Willenegger was instrumental in spreading the AO gospel and finding the appropriate leaders in every country of Latin America. It would be unfair not to mention also the diligent efforts of Luigi Negri, Joao da Costa, Edwin AO Latin America J. Quintero Kunkler and Emilio Melgar from the former Straumann Institute, who joined Hans Willenegger on many of his trips and who found the active businessmen who could start the difficult and complex commercial activity of distributing Synthes® products. Once established, the AO Foundation and former Latin American AO Trustees José Ortega, Roberto Masliah, Hugo Grove, Salomon Schachter, José Soares Hungria Neto, Karlos Celso de Mesquita, Edgar Nieto, Jaime Quintero, Alberto Fernandez, and Guido Behn started the so-called “Latin American chats” during the AO Trustee meetings. These were chaired initially by Hans Willenegger and later by Diego L. Fernandez and Peter Matter, who, as head of the AO International, started the “regionalisation” project. We thank Peter Matter and former Foundation Presidents who fully supported this project that culminated in 1998 with the founding of AO Latin America. Our gratitude goes to Martin Allgöwer, Marvin Tile, Sigfried Weller, Chris Colton, and Joseph Schatzker. AOLAT Founders AOLAT was officially established in June 1998 during the AO Trustee meeting in Davos, Switzerland, with the following membership: José Hungria Neto (Brazil), Alberto Fernández (Uruguay), Fernando Garcia (México), Fiesky Núñez (Venezuela), Marcelo Somarriva (Chile), Carlos Sancineto (Argentina), Cléber Paccola (Brazil), Gottfried Köberle (Brazil), and Jaime Quintero (Colombia). In 2001, three members joined the AOLAT founding group: J. Franco, new elected trustee from Brazil; M. Figari, new elected trustee from Argentina and coordinator of the Maxillofacial Latin Amercian Committee, LATMESC, and G. Ochoa, from Colombia, as coordinator of the Spine Governing Body for Latin American Educational activities, LASEC. Aims and objectives of AOLAT AOLAT coordinates the educational activities of AO International in Latin America, with emphasis in the organization of AO Courses for surgeons and ORP, seminars, symposia, and AO Educators’ Courses. It also promotes research projects in the region, according to the local needs and resources. One of the key aspects of AOLAT is its close relationship with the AO Alumni Association chapters in Latin America. Former AO Trustees have recently handed over to younger leaders, like J.C. de la Fuente (Mexico), R. Pesantez (Colombia), R. Postigo (Chile) and F. Baldy (Brazil). Recently, new chapters have joined the AOAA worldwide community with capable leaders, like G. Reynoso (Peru), C.l Cabezas (Ecuador) and J. Carrasco (Bolivia). Fiesky Nuñez (Venezuela) and Carlos Sancineto (Argentina) are still the active AO trustees and Presidents of their local AOAA chapters. AOLAT Educational strategy Each year AOLAT sets up the strategy and discusses projects for the following year. The local AOAA chapter then takes full responsibility to prepare and organise the planned activity, with the collaboration of the local Synthes-Stratec representative and the AOLAT office. As an example, if the planned activity is a Principles Course in Peru in 2002, the AOLAT members, together with the area manager of Synthes-Stratec and Claudio Gubser of AO International discuss the date, venue, course chairman, number of participants, course content, and the proposed local and international AOLAT/ AOI faculty. The AOLAT office then sends the proposed draft program, and the course syllabus and guidelines to the national AOAA chairman. In Maxillofacial and Spine Courses the responsibility goes also through the LATMESC and LASEC coordinators and their international educational committees. On request, the AOLAT president and the administrative assistant may also travel to offer additional organisational support. This has proved to be extremely valuable in certain countries where the academic power of the AO Foundation needs to be reinforced. AO Courses in Latin America in 2001 Principles 4 Advanced 7 ORP 4 Hand 2 Maxillofacial 3 Spine 5 Foot and Ankle 2 AOLAT clinics, AOAA 2nd Symposium and Future Projects Three centers in Latin America (Hospital Lomas Verdes, Ciudad de México, Mexico; Clínica Fundación Santa Fe, Bogotá, Colombia; Hospital del Trabajador, Santiago de Chile, Chile) offer AO fellowships to Spanish- and Portuguese-speaking surgeons wanting to improve their knowledge and skills in specific areas of trauma and reconstructive surgery. Recently, the 2nd AOAA Latin American Symposium was held in September, 2001 in Rio das Pedras, which gathered 180 AOAA members, from different countries and varying specialities: the theme was “New Trends in Research, Development and AO Techniques in Musculo-Skeletal Trauma and Reconstructive Surgery”. In 2002 AOLAT will coordinate the 1st Seminar for ORP Faculties, where selected nurses and instrumentists will have the opportunity to improve their educational skills and knowledge of the current AO techniques. Our mission Forty-three years after the founding of AO Switzerland, AOLAT enters the 3rd millennium as a strong, united community of surgical professionals, driven by the same commitment and enthusiasm as the AO founding fathers: to offer the medical community, the health institutions and our patients, scientifically proven and state-of-the-art methods of treating trauma and musculoskeletal disorders, with the benefit of a prompt and painless recovery. Amigos y del mundo: Bienvenidos a AOLAT e Bemvindos ao futuro!

60 1998 Hans Willenegger passes away
Tribute to Hans R. Willenegger, by P. Ochsner in AO Dialogue 1999 January 6, 1910 to December 22, 1998 Shortly, before Christmas, Hans Willenegger passed away after months of progressive illness, during which time he was lovingly cared for by his wife and family. Worldwide many of us will recall a personal souvenir of a direct contact with him, and we shall all be conscious that we have lost a paternal friend. Hans Willenegger spent his youth in the alpine area near Bern, the city where later he studied medicine. He then trained to become a general surgeon with O. Schürch in Winterthur. When Schürch was elected to the chair of surgery at the University of Basel, H. Willenegger was invited to accompany his teacher, and there he was promoted as a lecturer on the subject of blood transfusions. 1953 H. Willenegger was appointed as the head of the Kantonsspital Liestal, a district hospital near Basel, where at the time of his election there was, as yet, no specialization. At the beginning therefore he was responsible for all somatic patients. During the ten following years, specialization evolved and by 1962 he was able to move to a modern hospital building with five individual departments. He proved to be a clinician with an exceptional devotion to his profession and to his patients. He often worked day and night together with his collaborators to care for seriously ill people. From his students he demanded precision work and dedication to the task in hand. If an unexpected bad result of a treatment happened, all collaborators had to analyze the case together in order to learn the relevant lessons and to find a better solution for the future. It was not usual for his trainees to come in for ready praise and, at times, he exhibited certain eccentricities. When assisting an operation as a teacher, he would ensure that no mistakes were made, and was even known to have tapped an errant student’s hand with a clamp. Notwithstanding, Wi - the nickname given to him in the hospital - enjoyed the greatest respect and devotion of all collaborators. H. Rozetter, the administrative director of the hospital characterized his work with the following words: “H. Willenegger has remained the same during his whole career. A medical doctor, who was able to talk to his patients and their relatives in a simple and clear way, in whom all of them had confidence, because they felt there was someone speaking to them who was willing to give his best to cure them of their ills. He represented a person of character, tirelessly fighting against any over-estimation of one’s abilities and who accepted only one claim: the one of faithfully following the path of duty.“ Hans Willenegger - most frequently called in the Bernese way “Hausi” - held one of the five central positions in the founding committee of the AO in The development of AO was outlined in the last AO Dialogue. We do well to focus upon the very personal contribution of H. Willenegger to this institution’s evolution. Having to cope with a wide spectrum of traumatology, he realized early the imperfection of the outcome. He therefore introduced the complete documentation of all osteosyntheses in With great care he analyzed the published work, dealing with different operative methods to improve fracture outcome, in particular the writings of F. König, for whom he had a great respect and admiration. After coming to recognize, through M. E. Müller, the work of A. Lambotte and R. Danis, he quickly realized that a scientific basis for this impressive technical knowledge was lacking. Thanks to his initiative, links were forged with Straumann, a metallurgical research institute, who helped to solve problems with the implant material. Out of this collaboration arose the industrial production of Synthes implants and instruments with a scientific background. Parallel to this, H. Willenegger contacted R. Schenk, at that time Professor at the Institute of Anatomy in Basel, who contributed histological knowledge to their experimental work in bone healing. The animal experiments that led to their basic publications, where carried out in the basement of the hospital in Liestal. Osteotomies of the ulnae of dogs were bridged by compression plate osteosynthesis. This then enabled them to demonstrate direct bone healing based on bone remodeling, starting from the adjacent Haversian systems under stable conditions. Later experiments confirmed osseous healing of hypertrophic pseudarthroses by stabilization using only a compression plate and without bone grafting. Soon H. Willenegger realized that by performing an osteosynthesis in a suboptimal way, catastrophic complications could be created. Being willing to help such patients, Liestal became a center for the treatment of posttraumatic osteomyelitis, pseudarthrosis and malunion. Because of this experience, H. Willenegger initiated the worldwide teaching of the AO principles, becoming the first President of AO International in 1972. This event marked the starting point for many years of global travelling, teaching AO in all five continents. He differentiated several teaching activities: Direct teaching (2) teaching for teachers, enabling future teachers to continue their work of training locally, and (3) selecting adequate people to profit of an AO fellowship for one to four months in an established and recognized AO center, tailored to the needs of the fellow. Countless are the slides that he gave to future AO teachers, carefully and paternally explaining the basic principles underlying each one. B. G. Weber in St. Gallen was supported in his interest in malleolar fractures, and C. Burri in Ulm encouraged in his work on posttraumatic infections. Many others, including the writer of this article, were carefully motivated to work on one of the many problems in traumatology that persisted at that time. As a devoted teacher he was willing to open new possibilities of development to the recipient of his message, without claiming any rights as an initiator. We can honour his memory in no greater way than by doing alike.

61 1999 AO Clinical investigation
Ruedi Moser 1999− Beate Hanson 2003− Extract from: AO Philosophy and Principles of Fracture Management-Its Evolution and Evaluation David L. Helfet, MD, Norbert P. Haas, MD, Joseph Schatzker, MD, Peter Matter, MD, Ruedi Moser, DVM and Beate Hanson, MD, MPH The Journal of Bone and Joint Surgery (American) 85: (2003) To demonstrate the performance of AO techniques and implants, clinical data are required. The collection of the data is the task of the AO Clinical Investigation and Documentation (AOCID) Division, which evolved from AO documentation activity in the beginning of The AOCID is guided by a separate board, which is also governed by surgeons, as they make up a majority of the members. The independent AOCID board serves to separate AO Development from clinical investigations to ensure scientific objectivity. Since the AOCID is endowed with its own budget and its success is measured by publications in non-AO, peer-reviewed journals, commercial influence is minimized if not impossible. Depending on the device, the AOCID board decides whether and what kind of implant-related clinical data are required. The board then supports the principal clinical investigator in the literature review, clinical design, statistical analysis, selection of participating clinics, provision of technical support for documentation, monitoring, evaluation of the results, and preparation of publications. From AO Documentation to AO Clinical Investigation (AOCID): The Future of AOCID and Evidence-Based Medicine Issues The general mission of the "new" AOCID is to provide quality, reputable, and timely research guidance to AO surgeons worldwide who are seeking to conduct studies to answer important clinical questions. To meet its mission, the AOCID has recruited qualified physicians and epidemiologists who are trained in study methodology and study execution. In addition to these in-house experts, the AOCID has established connections and relations with various professionals, institutions, and universities to serve as resources for obtaining competent methodological support, since we believe that this is the cornerstone of quality research for the future. Case studies and case series were paramount in the early days of orthopaedics and in the initial development of the AO. Without them, little progress would have been made. Furthermore, they are still needed when new and innovative techniques and devices are implemented; however, the AOCID acknowledges the lack of evidence that emerges from these studies and is now taking the leadership role in promoting a strong move toward what we are calling evidence-based orthopaedic surgery. The emphasis will be placed on the design and performance of randomized controlled trials, which provide the best evidence and are the most powerful tool in modern clinical research. The AOCID is committed to influencing and supporting AO surgeons and their collaborators so that the aforementioned changes in thinking will extend throughout the orthopaedic community as a whole and will translate into more valid orthopaedic studies that rival those of our colleagues in other areas of medicine who have adapted an evidence-based approach. We believe that the early implementation of these principles is beginning to pay dividends for the AO, for the surgeon, and most importantly for the patient.

62 Surgeon of the 20th century
Professor Maurice E. Müller was named “Surgeon of the 20th Century” by SICOT in 2002 Extract from: Müller’s work revolutionized fracture treatment. AO founder dedicated his life to education, research and the documentation of orthopedics. by Lee Beadling , February 2001 in ORTHOPEDICS TODAY Müller’s fusion of sound philosophy, technique and implants are credited with changing the face of orthopedic surgery. His innovative techniques for fracture fixation spread rapidly because they were systematic and could be easily taught. Prof. Maurice E. Müller is one of a handful of people whose work has so drastically changed the landscape of contemporary orthopedics that it is easy to say that the specialty would not be what it is today without him. “The thing that unquestionably changed surgery in the last 40 years of the last century was the creative genius of Maurice,” said Joseph Schatzker, MD, past president of the AO/ASIF Foundation and former president of the Maurice E. Müller Foundation of North America. “He gave us the techniques of stable internal fixation, which we could employ not only in trauma but also in reconstructive surgery. Maurice conceived of a school of surgery based on sound biologic and biomechanical principles with a marriage between philosophy, technique and implants that revolutionized surgery,” Schatzker added. Müller knew that he wanted to be a surgeon at age 12. In 1938, when he was 20 years old, he passed a dexterity examination which confirmed his earlier desires. “They told me that the best thing for me would be to be a surgeon,” Müller told ORTHOPEDICS TODAY. “The reason is that I had a good three-dimensional thinking which would be good for a doctor of bone and joint.” Early inspiration Shortly after passing his state medical exams in 1944, Müller replaced a general practitioner in Bern for three weeks. There he encountered two cases that would shape his future in medicine and remain with him for six decades. The first was a man who was injured during the conflict between Russia and Finland. The patient told of how a surgeon named Küntscher had inserted a nail into his fractured femur four years prior. “He asked me to take the nail out if it was possible. When I examined him, he was absolutely perfect,” Müller said. “It was so much better than all the femur fractures of people who were treated in Switzerland with immobilization.” The second case was a man who came to Müller and said he had received a Leveuf hip arthroplasty. Although the man still limped badly, the implant had provided him with great pain relief. “I asked him if he was happy and he said that he was as happy as he ever was. Before, he said it was impossible for him to sleep and today he was absolutely perfect,” Müller said. He said these two men, their stories and satisfaction with their lives are what directed him to fracture fixation and his work with total hip replacement. “I will remember these cases until the end of my life,” he said. Introduction to fixation In 1949, Müller took a fellowship with Cornelis Pieter Van Nes in Leiden, The Netherlands. While under the tutelage of the hip and spine surgeon, who was trained by Marius Nygaard Smith-Petersen and Robert Judet, Müller was encouraged to visit Brussels and see the surgeon Robert Danis. Observing Danis, Müller saw for the first time that a stable osteosynthesis could be achieved by compression through the use of interfragmentary lag screws and compression plates. Later that year, Danis published Théorie et Pratique de l’Osteosynthèse and shortly thereafter Müller was appointed senior registrar in general surgery at Fribourg, where he was in charge of all trauma cases. There he performed 75 fixations using Danis’ methods and implants. However, he was unsatisfied with the quality and reliability of the instruments. He realized that for the operative treatment of fractures to be successful, he needed to have dependable implants and instrumentation. He contacted a number of technicians and manufacturers and had custom-made chisels, elevators, screws and fixators fashioned based on the methods he saw in Danis’ workshop. Müller traveled with his instrumentation, performing internal fixation and lecturing on its benefits. He gathered around him a group of friends, including Robert Schneider and Hans Willenegger. He impressed surgeons with his skills in the operating room and then with the unbelievable results he was obtaining with his operative techniques of fixation. At the time, Martin Allgöwer was using hemicerclage wires to fix fractures at his hospital in Chur, which was located near ski slopes and saw its fair share of broken bones. He heard about Müller and asked him to come and demonstrate his surgery. Allgöwer was immediately taken with Müller and the wheels of the machine that would eventually become the Arbeitsgemeinschaft für Osteosynthesefragen (AO) had begun to turn. Müller, Willenegger, Allgöwer, Schneider and nine other friends met in early 1958 in Chur to discuss the concepts and practice of internal fixation. The foundation laid at that meeting led to the formation of the AO in November of that year. The members decided that the focus of the group would be on research, instrumentation, education and documentation. Genius at the helm At the helm of the organization, Müller used his surgical and mechanical genius to address the issue of instrumentation. He forged an alliance with a precision instrument maker, Robert Mathys, who had never made a surgical instrument. Mathys agreed to not sell any of the instruments to anyone beside the AO for at least four years. The AO would use this time to test and improve the instruments before anyone else could use, or more importantly, abuse them. It may seem like a simple concept now, but one of the most important of Müller’s innovations came at this time — the hexagonal recess in the screw head. Prior to the development of this screw, different surgeons used different screws. “Surgeons at that time needed at least six to 10 different screwdrivers for the many different screws they may encounter during surgery,” Müller said. The hexagonal recess in the head allowed for better seating of the screwdriver and reduced the importance of visualization of the screws for their removal. In December 1960, the AO, Robert Mathys and Fritz Straumann, a metallurgical expert who specialized in stainless steel, chartered Synthes AG, a nonprofit organization that would market the AO devices. This alliance, the first of its kind, provided the funding for the AO’s activities. Müller and the other members of AO turned over their royalties for the early instruments, as well as any future developments, to the organization, a unique and generous contribution that continues to this day. The courses Shortly after the founding of Synthes AG, the first AO course was offered and attracted about 90 surgeons from Europe and North America. The only way to acquire the AO instrumentation at that time was to attend the course and demonstrate skill in their utilization. Additionally, surgeons had to vow to keep complete and precise records of all their cases using the devices. These records would be held by the innovative AO documentation center. The courses continued on a yearly basis. In 1963 the first AO manual was released in German, and word of the philosophy, the technique and instrumentation spread. The entire world was not ready, however. Prior to the beginning of the AO courses, Müller was invited to the United States to present his technique and his nearly 10 years of data. Sparsely attended, his presentations were controversial and treated as heresy by the established orthopedic community. In the spring of 1960, after Müller toured North America, editorials began appearing in orthopedic journals, including the Journal of Joint and Bone Surgery, condemning Müller and his principles. In fact, in 1963 a device manufacturer told Müller that it would never make the kinds of instruments he used. “I told them that you will see, that this is the future and if you don’t want to do something for the future, then that is up to you,” Müller said. Opening up to the world Schatzker met Müller in 1965 when he was assigned to be his guide during a trip to Toronto. “I saw a whole new world of orthopedics that was rather foreign to us,” Schatzker recalled. He eventually went to Switzerland on a fellowship and ended up translating the AO manuals to English, which was instrumental in opening up the AO philosophy to the world. Schatzker said Müller was the intellectual engine of the AO pioneers as well as a surgical and commercial genius. “The techniques that Maurice developed not only worked but were developed and designed in such a way that other people could do them. Although the early rules may sound very rigid today or wrong in light of today’s knowledge, they were the first ABCs of internal fixation. “His system consisted of principles, tools and techniques that one could teach. You could go to an AO course, which would convince you that you could do it, go home with the book, which mirrored exactly what was said in the lecture, and then you could apply it. ”Müller’s interest in education continues through the AO. So far the organization has provided training to more than 135,000 surgeons and 85,000 nurses through nearly 2500 courses. It has also organized and financed fellowships for more than 4000 surgeons. The AO Center in Davos now hosts courses at which 1000 surgeons from all over the world can attend at one time. Starting in the early 1950s and continuing through the period of his fracture fixation work with the AO, Müller was also one of the pioneers of hip arthroplasty. In fact, it was he, Charnley and McKee who introduced the total hip concept to the European continent at a meeting in Paris in 1966. He developed his hip in 1961, two years after his good friend Charnley. Although he had not seen Charnley’s total hip, the two were similar in design, with a head diameter of 22 mm. After dislocation problems, Müller increased the size of the head to 32 mm and later developed an advanced stem. As with the concept of internal fixation, Müller was told the “total hip operation would never be performed here,” when he presented his data in 1964 to surgeons in the United States. “Then, only four years later, they told me that things had now changed.” From 1959 to 1963, Charnley and Müller used Teflon, and afterwards polyethylene. The chemical sterilization of polyethylene gave Müller better results than the sterilization with gamma radiation. In fact, Müller has one patient that still has a functional polyethylene/metal hip after 32 years. After 1987, Müller used mostly metal/metal articulation similar to the one used between 1967 and 1970. Müller retired from the AO in 1984 with the founding of the AO/ASIF Foundation. Since then he has been involved in many projects, including the Maurice E. Müller Foundation, which is dedicated to continuing education, research and documentation in the field of orthopedic surgery. He also is an active philanthropist, recently giving a large amount of money to the city of Bern to establish a museum. “There have been many people who sold things for a great deal more money than Maurice, but there are few people who throughout their life have been as generous,” Schatzker said. For the future, Müller believes more emphasis needs to be placed on evidence-based outcome research and surgeon technique and quality of service. He also believes that surgeons must be held more accountable and that the device industry needs to be simplified. “It is not for the needs of the patients that we need so many instruments; it is for the need of the shareholders,” he said.

63 2000 AO Principles of Fracture Management
Thomas Rüedi Liam Murphy Chur, Surrey, Switzerland England AO principles of fracture management (book and CD-ROM). By Thomas P. Ruedi and William M. Murphy. Pp. 864. Review by RM Smith for JBJS Am 2002;84(7):1293 This text, which is the current and massively updated version of the AO manual, describes the philosophy and syllabus behind the AO Principles Course that has been taught since Like the course, it emphasizes the basic principles related to the biology of fractures and fracture-healing and covers preoperative planning, reduction techniques, and surgical techniques. The book essentially provides all of the core content and background information of the AO course in a format that is easy to refer to, allowing for a consolidation of the teaching material. The first three sections cover AO philosophy, decision-making, and specific reduction and fixation techniques; the later sections focus on specific fractures and the general issues associated with injury and fracture complications. The book is superbly organized and well illustrated with clear diagrams and accompanying radiographs. Specific learning points on each page are emphasized in the margin and again in the text, and the use of color to allow text highlighting and cross-referencing is excellent. Each chapter ends with a bibliography that includes key references from the literature and provides a web site address that allows access to additional up-to-date references. The most advanced feature of this book is that it is accompanied by two CD-ROMs that provide the entire book in Adobe Acrobat format. The CD-ROMs also include a large number of teaching videos that can be played by simply clicking on the relevant image in the electronic book. Unfortunately, the video that one wants to view always seems to be on the other CD-ROM. Nevertheless, the CD-ROM version allows easy navigation to different parts of the book and direct access from the bibliography to the appropriate abstract via the Internet. The references, which are accessible on the Internet, are highlighted in blue, and the appropriate Internet connection can be made by simply double-clicking on the reference, which launches the browser and connects directly to the reference on PubMed. At the end of each chapter, there is also a direct link to the AO Publishing web site, where it is hoped that updates to the chapters and additional important references will be published regularly. As a course manual alone, this book is invaluable, but the combination of the book, the CD-ROMs, and the web access makes it one of the most revolutionary and innovative textbooks currently available. It is clear that this form of publishing is going to be more common over the next few years and promises exciting concepts to come. Aside from the technological aspects discussed above, perhaps the most important thing to note is that this is a most informative and readable text. It would be useful as a study aid before or after attending a course and is an excellent source of information on many fracture problems. Overall, it is a superb work that was written by a large number of individually recognized authorities who were brought together by two very experienced editors, and it illustrates the cumulative knowledge of the AO group over a number of years. I strongly recommend this book to anyone involved in orthopaedic traumatology, from the resident to the established specialist. Review by Allen Goodship for JBJS Br 2001;83(6):934 The editors state that this is not a handbook but a text which offers recommendations, supported by clinical guidance, on the principles advocated by the AO organisation. This limits its value as an overall review of the science and clinical management of bone healing. A forward-thinking addition is the provision of CD-ROMs which accompany the book and provide an electronic format that includes many video clips to aid in the understanding of the written text. The initial section contains chapters which provide a background to the science underlying the AO philosophy of the treatment of fractures. The specific biological, materials and engineering sciences are presented in relation to their relevance to bone healing. It is interesting to see how the traditional principles of biomechanics which dominated the early development of the AO approach have now been phased out, with more emphasis being placed on the pathophysiology of bone repair. The integration of biomechanics with biology related to the AO doctrine is not given any detailed discussion. The chapters on implants and materials include reference to exciting new materials and their potential role in the management of fractures. Important consideration has been given to the classification of fractures; this has great relevance to the collation of results from clinical trials. The editors have also emphasised the management of soft tissues in an important chapter. The second section deals with decision-making and planning. This includes an excellent chapter on the patient and injury. With increasing understanding of the biology of bone repair and the development of new implants, it is very important to place emphasis on the treatment of the patient as opposed to the fracture. This section also deals with the clinical issues of soft-tissue trauma. Sections three, four and five are on the application of scientific principles to clinical fracture, using expert authors for particular anatomical areas. There is a particularly good piece on acetabular fractures. The book concludes with general issues and a section on complications. The material covered is extensive and provides an extremely useful test for trainees, scientists and expert clinicians. There is guidance for taking the different areas further in terms of the scientific and clinical literature. Although this is an excellent text to be highly recommended, its purpose is to provide recommendations and guidance on the AO philosophy and principles. Readers in general, and trainees in particular, should also be aware of other, less rigid approaches to the management of patients with fractures. Allen E. Goodship.

64 2000 Howard Rosen passes away
A Special Tribute to Howard Rosen, M.D. ( ) - by Joseph Schatzker Great teachers are born, not made. They are naturally imbued with a passion for their subject, a real care and concern for students, a genuine desire to impart knowledge, and often a theatrical flare, stage presence, sense of timing, and a flare for humor. Howard Rosen was a great teacher and possessed all of these talents. At lectures with a twinkle in his eye and a twitch of his well waxed and groomed mustache he established an immediate rapport with his listeners. He was never at a loss for a good story, an anecdote or joke. Howard never dazzled his audience with audiovisual wizardry, but the X-ray slides of his cases spoke volumes about his technical prowess as a surgeon and demonstrated his very thorough understanding of the biological and biomechanical principles which underpinned his rationale of treatment. His accompanying vignettes of the patients' personal histories also made one realize that each case was not only a surgical challenge but represented a human being for whom he had great empathy. Howard could lecture with equal mastery on any subject relating to trauma but his favorite subjects were the treatment of impossible pseudoarthoroses and bone infection. During the lectures Howard would become so engrossed in his subject and would relive each case in such detail that he often would be just short of finishing when his time was up. We all well remember his good natured plea " Oh, let me show you just one more case before I finish". Although as a lecturer Howard was in great demand, it was during the hands-on practical laboratory exercises where he truly shone. One often saw him at a fracture model surrounded by the table participants who stood totally enraptured. No question was too simple. Howard displayed infinite patience. Despite his seniority he never intimidated and made the most junior residents feel completely at ease. Howard was never too tired to teach and unlike many of his younger colleagues who found table instruction tiring or boring, Howard, even in his later years, always looked forward to be with his "table." One on one contact was Howard's true forte and love. The greatest surgical teachers are usually great surgeons. Howard was an innovative and meticulous surgeon with a quest for absolute perfection. Each step of the procedure was executed with equal care and attention. If at the end of a long case Howard was not absolutely satisfied with the result he would take everything apart and start from scratch. Surgery for Howard did not stop in the operating room. As meticulous as he was at the operating table so was he in the postoperative care. He seemed never in a hurry no matter how late in the day or how tired. Each patient received his care and all his attention. Howard loved his patients and in return was adored by them. Howard Rosen was born in New York City in 1925 and was raised in the Bronx. He graduated magna cum laude from New York University and then attended the NYU School of Medicine. In 1948, Howard began to practice as an orthopedic surgeon in the City of New York joining the staff of the Hospital for Joint Diseases. An illustrious but conventional career was certain but a chance encounter in 1959, at an orthopedic exhibit changed its direction entirely. In 1959 Howard attended the SICOT meeting in New York City and there at an exhibit he caught a glimpse of the young Maurice Müller who was stunning his audience with the demonstration of many cases of fresh fractures and salvaged pseudoarthroses treated by means of absolute stability which he achieved with the help of compression. This was a totally revolutionary form of surgical treatment of musculoskeletal problems. Howard's interest was not only piqued by curiosity and desire to learn this revolutionary and promising technique, but also by his concern for an uncle of a close friend and colleague whose love for tennis had been marred by a recalcitrant pseudoarthrosis of his humerus which failed to heal despite numerous surgical attempts. Howard was so impressed by what he saw that he arranged for the uncle of his friend to be treated in Switzerland by the relatively unknown Professor Müller. The uncle returned without a cast and without any immobilization. The non-union healed soon thereafter. The exhibit at SICOT and the experience with his friend's uncle so fired the imagination of the young Howard that he arranged, entirely on his own, to be the first North American surgeon to attend the first AO course held in Davos, Switzerland in Howard returned armed not only with enthusiasm and new knowledge, but also with a personal investment in the set of the basic AO instruments and implants which he carried to North America in his suitcase. The AO course in 1960 launched the young Howard on a course which led him to become a brilliant traumatologist and a most courageous exponent and pioneer of the AO surgical treatment of fresh fractures and complications such as infection and non-unions. At that time, the surgical world of North America and that of the rest of the world was steeped in conservatism. An aggressive surgical approach to fractures, which would normally have been treated in plaster, was considered almost malpractice. However, Howard was a careful clinical observer who carefully studied the patients he treated. Since the results of this new Swiss method of treatment were superior, Howard became convinced that the theories of the AO were correct and the way of the future. He became a relentless exponent of the AO methods. Now his professional life became very exciting because not only was he able to bring healing to many whose problems were considered insoluble, but his great skill as a teacher allowed him to share this new knowledge with an ever growing number of well established practicing surgeons as well as with the "upcoming" generation of residents and young surgeons. His skills salvaged many complex and difficult fresh fractures. He also showed great surgical genius and inventiveness in his treatment of many abandoned "untreatable" non-unions and infections. Howard became not only a persuasive exponent of the new and revolutionary techniques but also a master at execution and application of all the new principles of biomechanics and surgical techniques. Around 1966, Howard's sphere of surgical interest began to widen. He became interested in the fledgling field of Veterinary Medicine and began to work as a consultant at the Animal Medical Center in New York where he performed surgery on injured race horses and other animals, first with his colleague Jacques Jenny and subsequently with his life long friend Bruce Hohn. In 1973 Howard was elected an Honorary Fellow of the American College of Veterinary Surgeons and the following year, with a small group of his close veterinary colleagues, the founding member of the Veterinary Orthopaedic Society. Howard continued his close association with his Veterinary colleagues throughout his surgical career and was a frequent faculty member of the Veterinary AO courses held in Columbus Ohio. In October, 1973 during the twenty-two day Yom Kippur war in Israel, Howard and his wife Connie ( Constance) left New York to volunteer at the Rebecca Sieff Hospital in Safed, Israel. The hospital, located only ten miles from the front, was inundated with freshly wounded soldiers. Their wounds were not the injuries Howard was accustomed to treat. Missiles created devastating injuries which defied standard approaches. But Howard's skill and ingenuity in the application of the emerging new AO external fixateur saved many limbs which would otherwise have been amputated. Throughout the subsequent busy years of his international career as a surgeon and teacher, Howard and Connie made frequent trips to Israel. On these occasions Howard would teach and perform surgery and renew his ties with the Israeli orthopaedic world and its surgeons. He developed particularly close ties with the Shaare Zedek Hospital in Jerusalem. In 1991 the hospital honored him with the distinguished Rofeh Award, and in the following year bestowed an even much greater honor by renaming the Orthopaedic Department of the Share Zedek hospital the "Professor Howard Rosen M.D. Orthopaedic Institute". At the time of his death when most surgeons would have been long retired, Howard was still the Chief of the Problem Trauma Service at the NYU Hospital for Joint Diseases Orthopaedic Institute in New York. He was also an active attending Orthopaedic Surgeon at the Beth Israel Medical Center in New York, and the Clinical Professor of Orthopaedic Surgery at the NYU School of Medicine/Mount Sinai School of Medicine in New York City. He continued also with great pride and personal satisfaction as the Adjunct Professor of Orthopaedic Surgery at the Ohio State University, Department of Clinical Sciences, in Columbus Ohio. During his very busy international career as surgeon and teacher, Howard published fifteen chapters of medical books and wrote well over fifty-five articles, abstracts and forewords in various medical journals. He chaired, organized and served as faculty for nearly 300 courses and symposia held in the U.S.A. and around the world. He acted as a visiting Professor to orthopaedic departments and universities, lecturing and participating at grand rounds and performing operations almost 100 times from 1973 to the present throughout North America and fourteen other countries. He received many honors and awards. In 1993 the Hospital for Joint Diseases Orthopaedic Institute presented Howard with the Frauenthal Medal awarded each year to the most outstanding member of its faculty. Howard was the first recipient of this great honor. It will be difficult to think of an AO course without Howard. From his early pioneering days Howard worked relentlessly on behalf of the AO. Howard was a member of faculty of every major AO course held in North America, a member of the faculty of every English Basic and Advanced AO course held in Davos since the late 1960's and a faculty member of many AO courses around the world. He served on many committees and was a member at large of the AO International commission. Howard had a great sense of the "AO Family". After having served two terms on the Board of Trustees, in order to ensure his continuing presence at the Trustee Meetings and show the affection and respect in which he was held, the AO Foundation Trustees voted unanimously to make Howard Rosen the first Honorary Member of the Board of Trustees. No mere surgeon could leave the mark that Howard left and imbue so many people with a sense of loss. Howard was a fine and honorable man whose humanity transcended his stature as a surgeon, scientist and teacher. During my last visit to Howard in early June, as he lay dying in hospital, as I was leaving I turned to Howard's nurse and stated that I was a close friend. "But Dr. Schatzker, she replied, "everyone who has been here, and Dr. Rosen has had many, many visitors, said that they were close friends". This remark characterized Howard's special relationship with people. Howard loved people and people loved Howard. He had the unique quality of making everyone feel special and he displayed a great interest in all their personal and professional affairs. Howard especially loved children. He understood them and the things which were important to them. He knew how to talk with them and also had infinite patience to spend time with them. There were times when he made me feel inadequate as a father. While I went skiing Howard, instead of joining us on the hill, took my teenage son Mark, fly fishing. Fishing was one of Howard's passion. However it was not the fishing or catching fish which was important. Howard wanted to spend time with my son. He loved young people and longed for grandchildren. While waiting for his own grandchildren Howard adopted the children of his friends. My three sons who are now grown men always looked upon Dr. Rosen as "Uncle Howard." There was a special bond, a special understanding between Howard and children which was unique. Howard's greatest friend colleague and admirer was his loving wife Connie. We all feel an immense loss and a personal bereavement but the loss felt by Connie and her family is infinitely greater. Connie was Howard's confidant, advisor and his informer of the great world which lay outside the demanding world of surgery. Connie's passion for art, literature and music were shared with enthusiasm by Howard for his interests were anything but narrow. Howard loved his family and always found time in his almost impossible schedule to spend time with Connie, and with his two daughters, Aileen and Terry. His daughters, were his pride and joy who enriched his life by expanding the family circle with husbands and children. After many years of waiting, Howard was rewarded with grandchildren. His joy was immense and he was always ready to show the latest pictures of his passion. It is sad that death robbed Howard of the joy of playing with the twins who were the last grandchildren to be born. However he shared much of his granddaughter, Maya's childhood and did have the great joy to see Isabelle and August born and begin to grow into the loved and loving human beings he would want them to be. We, his surgical friends and colleagues, are deeply saddened and grieve at his passing. His many patients grieve at having lost their doctor and friend. His family mourns the loss of a husband, a father, and a grandfather. The world suffers the lost a unique human being. His like does not come our way frequently. We are the richer for having known him.

65 2000 Robert Mathys passes away
The genius of Robert Mathys Sr by M.E. Müller for AO Dialogue Robert Mathys rose from the ranks of a mechanic to that of a global industrialist and was honoured in academic circles. Who could have predicted that the accidental encounter of a then obscure industrialist with an unknown group of young Swiss surgeons would become the cornerstone of a global surgical revolution of fracture treatment. In Chur, in March 1958, ten Swiss surgeons met to hammer out the goals and guidelines of a new fracture treatment school. Their thesis was that surgery should create sufficiently stable internal fixation of fractures for immediate functional rehabilitation. To realize their goal, this nascent group set out to develop a radically new, surgical armamentarium. I was charged with designing this, being the only member with experience in implant and instrument development. In 1951–1957, I had worked with six different instrument manufacturers, who were all the same. The moment a new device was developed, they wanted to mass produce it and push sales. None had the slightest interest in testing. I sought one who had had no previous contact with surgeons. It was suggested that I contact Robert Mathys of Bettlach, a developer and supplier of fastening devices for the chemical industry. Our first three meetings, in April 1958, told me that Mathys had the skill and vision to make our armamentarium a reality. I gave him the designs of a radical screw, with a new thread and a hex recess in its head, of a compression plate and tension device, as well as a new screwdriver. In less than a week Mathys produced the first prototypes! He then had eight days to consider conditions for a partnership: our activities to be kept secret, each new instrument and implant to undergo testing for 2–4 years before it could go into mass production. Mathys would have no direct contact with other surgeons. He not only accepted all our conditions, but charged only for his material and production costs. He saw reflected in the vision of the AO group his own philanthropic dream. A handshake sealed our agreements. Written contracts came years later! Robert Mathys, the instrument maker In late 1958, he attended an operation and saw me use the prototypes. He was happy that everything worked together. He saw a few shortcomings of our prototypes and within days had improved them. He took great pride and joy in our work and knew that he had made the right decision to put all is resources into the work with our group. He was so productive and creative that I was able, as the group gathered in Biel on the 6th November 1958 to found the AO, to show them all the prototypes that we should be testing. Toward the end of 1960, we planned to hold in Davos our first major educational effort and we nervously awaited participants from Germany and the USA. With logistic genius, on December 11th, Mathys gave us 12 kits, each comprising 4 basic sets, organized according to their use (screwing, plating, intramedullary nailing, and angled blade plate sets). Mathys and coworkers also held an exhibition of all the AO devices available for use by the small group of AO surgeons. Non-AO surgeons would have to wait at least one to two years before they could have these new surgical products. The course was a great success, but this success bred the first major problems. Robert Mathys and the Technical Commission In 1961 the AO established its Technical Commission, to make it possible for other AO surgeons to suggest changes and developments. As the group expanded we established in 1973 the “small TK” to deal with all new developments. The demands on the small TK grew further, but Mathys never yielded and never departed from the principle that no device would go into production without exhaustive testing for the first 2–4 years. New devices still under test were designated “available on special request”. Standard instruments and implants were those described in the AO Manual. By 1982 there were 1,500 instruments and implants. Robert Mathys approved that careful documentation would be made available to the “TK” for its deliberations. Robert Mathys the pilot He became a glider pilot at age 18, and at 22 years he began work for an airline and became a pilot. In the early years of the AO, he would often make a personal drop of badly needed instruments or implants from his plane near a hospital. In 1966 he made a personal flight of 34,000 km through Africa, where he frequently delivered, as gifts to his African friends, badly needed instruments and implants. Robert Mathys the patriarch He had four children. His family now has grown to 24 members. He was not only devoted to his family, but also to his workers. Thus “going public” was something that he could never entertain. Robert Mathys received many accolades in 1996 on the occasion of the 50th anniversary of his firm. Shortly thereafter he developed pulmonary fibrosis, which led to his untimely death on the 19th August 2000.

66 2000 Locking compression plates
Robert Frigg Bettlach, Switzerland Michael Wagner Wien, Austria Robert Schavan Willich Anrath, Germany Combination hole Osteoporotic bone Nonunions Extract from: AO Philosophy and Principles of Fracture Management-Its Evolution and Evaluation David L. Helfet, MD, Norbert P. Haas, MD, Joseph Schatzker, MD, Peter Matter, MD, Ruedi Moser, DVM and Beate Hanson, MD, MPH The Journal of Bone and Joint Surgery (American) 85: (2003) Another added feature is that the special fixation screws, which lock into the plate, are self-drilling and self-tapping and incorporate radial preload to enhance their cortical fixation. Similarly, the locking compression plate concept offers many advantages for all plate applications but especially for percutaneous techniques, as the use of a "locked" screw in any hole provides stable fixation (unicortical or bicortical), without the need for perfect plate-contouring or additional soft-tissue dissection. The concept combines an angular stable anchorage with traditional compression and is especially suited for fractures in osteoporotic bone. References: Evolution and rationale of locked internal fixator technology. Introductory remarks. Injury 2001;suppl 2:3-9 Locking Compression Plate (LCP). An osteosynthesis plate based on the Dynamic Compression Plate and the Point Contact Fixator (PC-Fix). Frigg R. Injury 2001;26 suppl :63-6 Locking Compression Plate (LCP): Ein neuer AO Standard. Wagner M, Frigg R. OP-Journal 2000;16(3): Development of the Locking Compression Plate. Frigg R. Injury 2003 Nov;34 Suppl 2:B6-10. Review. First clinical results of the Locking Compression Plate (LCP). Sommer C, Gautier E, Müller M, Helfet DL, Wagner M. Injury 2003Nov;34 Suppl 2:B43-54

67 2000 AO Plate technology 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 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 Extract from: AO Philosophy and Principles of Fracture Management-Its Evolution and Evaluation David L. Helfet, MD, Norbert P. Haas, MD, Joseph Schatzker, MD, Peter Matter, MD, Ruedi Moser, DVM and Beate Hanson, MD, MPH The Journal of Bone and Joint Surgery (American) 85: (2003) Despite the advances in the techniques of intramedullary nailing, application of a plate has continued to be a very important technique in achieving stable fixation of fractures. The realization that contact of the plate with the underlying cortex led to damage of the cortical blood supply resulted in a redesign of the plate profile. The dynamic compression plate, which succeeded the round-hole plate in 1969, was replaced by the limited-contact dynamic compression plate in the mid-1980s. The limited-contact dynamic compression plate has enjoyed great clinical popularity and success. Further research into the contact of plates with bone led, in 1987, to the development of the point contact fixator. A whole new family of fixation devices has developed from this concept of locked internal fixation. The Less Invasive Stabilization System (LISS) plates or the distal aspect of the femur and the proximal part of the tibia and the whole family of locked compression plates are examples of these devices. Several clinical trials with use of these implants are ongoing.

68 2001 Anatomical plates Preshaped locking plates for MIPO techniques

69 2001 AO Portal on the Internet
The AO Foundation has had an Internet presence since Both technology and the AO have of course made great strides since then. In 2001 it was decided to develop the AO website into a knowledge portal. Content was continually added over the past few years, leading to a website comprised of approximately 12,000 active pages.

70 2002 Hardi Weber passes away
Bernhard Georg Weber Obituary in JBJS Am 2003;85(3):583 Bernhard Georg (Hardi) Weber died suddenly on August 22, 2002, at the age of seventy-five. Born in Basel, Switzerland, on August 7, 1927, Hardi was educated in Basel and earned his medical degree in 1954 from the Universität Basel. He gained firsthand knowledge of medical practice as a country physician and as a ship’s doctor. Hardi received general surgical training in Chur, Münsterlingen, and Bezirksspital Uster, and then orthopaedic surgical training in the University Hospital Balgrist in Zurich and the University Hospital of Berne. He actually contemplated a career change to architecture until his time at the Balgrist Clinic in Zurich, where he recognized that orthopaedics would allow him to combine his interest in medicine and technology with his desire for artistic expression. One can only speculate on the architectural contributions that Hardi might have made if he had switched from medicine to architecture. Hardi already had an attractive contract in his pocket for a position in New York when his good friend Norbert Gschwend of Zurich suggested that he speak with Maurice E. Müller of St. Gallen about a position as part of AO (Arbeitsgemeinschaft für Osteosynthesefragen). Maurice E. Müller and his ideas on fracture care, which were then considered revolutionary, were greatly advanced by the government of St. Gallen when it built the large clinic for orthopaedic surgery in 1959 and named Müller chief of the department. Professor Müller brought Hardi in as his senior registrar—a position he held from 1960 to When Maurice Müller went on to become the Chief of Orthopaedics at the University of Berne in 1967, Hardi Weber succeeded him as chief at St. Gallen, a position that he held until 1986 when he moved his practice to the Klinic am Rosenberg in St. Gallen. Hardi was appointed to the position of Associate Professor of Orthopaedic Surgery at the University of Berne in 1967 and then to Honorary Professor in His special interests in orthopaedic surgery included the hip joint, fractures in patients of all ages, nonunions, and proximal tibial osteotomy for the treatment of varus gonarthrosis. His association with Maurice Müller allowed his innovative mind to grasp the principles of AO and make use of his artistic and mechanical abilities. He was a strong believer in stabilizing long-bone fractures to permit immediate mobilization of the adjacent joints. He stressed this principle of “functional after-treatment” over and over in his teachings on the care of patients with fractures. His creative imagination led to the publication, in 1982, of a book, Special Techniques in Internal Fixation, which he co-authored with Chris F. Brunner. Some of the techniques had been used in the past by others, but many new ideas that went beyond the principles taught in standard AO courses were presented. By the 1970s, the idea that some fractures of nonmature bone might be better managed through the use of internal stabilization was becoming more accepted. In 1980, Hardi coedited the book Treatment of Fractures in Children and Adolescents, which revealed that 16.2% of fractures in children and adolescents at the County Hospital of St. Gallen were treated with internal stabilization. The authors were unable to locate comparative figures in the world literature. Hardi, with coauthor O. Cech, wrote the book Pseudarthrosis: Pathophysiology, Biomechanics, Therapy, Results, which was published in This book became the classic for the surgical treatment of nonunions of the long bones. The illustrations of nonunion types (elephant foot, horse hoof, and oligotrophic) became standard, as manifested by their later inclusion in Campbell’s Operative Orthopaedics. Hardi Weber developed the trunion prosthetic hip implant in the late 1960s. This modular device allowed the prosthetic femoral head to rotate on a rod or dowel-shaped prosthetic neck, which was termed a “trunion.” The femoral component was made of Protasul, a cobalt-chromium alloy, and metallic failure was virtually unknown. Hardi used the anterolateral surgical approach, and his patients did not have dislocations postoperatively. In 1986, Hardi Weber left his position as Chief of the Orthopaedic Department at the County Hospital of St. Gallen to join a group of orthopaedic surgeons, all former registrars of his, who were practicing in St. Gallen and Heiden. Free of administrative chores, he was able to devote his full energy to surgery and research. During this period, he studied the end results associated with the metal-on-metal total hip prosthesis of McKee-Farrar. On the basis of retrieval data, Hardi designed a new metal-on-metal articulation surface with a cobalt-chromium alloy called Metasul. He remained a strong believer in cement fixation of prosthetic components, and thus the metal acetabular articulation was encased in polyethylene for cementing. His design was modified for cementless fixation by Lawrence D. Dorr of Los Angeles, California. In addition to books and chapters in books, Hardi authored or coauthored more than 180 scientific papers. He was a member of many surgical societies, including SICOT (Société Internationale de Chirurgie Orthopédique et de Traumatologie) and the International Hip Society, and he was a founding member of the European Hip Society. He distinguished himself not only as a superb clinician but also as an outstanding teacher, and he was in demand all over the world as a speaker and teacher. Hardi learned to ski at an early age, and he pursued technical competence to the level of championship instructor. He tracked surgical competence with the same level of enthusiasm, as he considered both activities equally important in his life. Later in life, he pursued tennis with an equal amount of dedication and enthusiasm. He also enjoyed mountaineering and windsurfing, and he collected Jaguar automobiles. In his seventh decade, so that he could continue skiing and playing tennis, he underwent a bilateral proximal tibial osteotomy because of varus gonarthrosis. He is survived by his wife, Alice, after forty-eight years of marriage, and by their two daughters, Sabina and Cornelia. During their years together, Hardi and Alice (who is a schoolteacher, gymnast, ski instructor, and art dancer) shared the experience of whitewater rafting in the United States, and they particularly enjoyed American jazz music. Hardi was fully involved in professional activities until his death. His skill as a physician was appreciated by the patients under his personal care, and his teaching enabled patients worldwide to reap the benefit of his knowledge. His subtle wit, although not always apparent in his professional activities, was greatly appreciated by his close friends. He will be greatly missed by many friends and colleagues and by a multitude of grateful students and patients. —T.R.S.

71 2002 StarDrive screws Stephan Perren Davos, Switzerland
New Products from AO Development May 2002: Stardrive™ a new AO screw drive connection Some 40 years ago the AO selected the hexagonally recessed screw drive connection. In comparison to single and cruciate slots, the HEX offers a good lateral guidance that allows “blind” insertion and removal. In comparison to Phillips, the torque transmission is largely independent of axial thrust, which may compromise initially unstable reduction of the fracture fragments. Furthermore, to avoid collision of sequentially inserted plate or lag screws the surgeon knew the inclination of a HEX screw of which only the head protrudes from the bone because the screw driver by necessity aligns with the screw axis. Still, the flats of the HEX screw-driver and -recess are oriented rather tangentially to the force applied. Such torque transmission may strip and results in a tendency to expand the screw head with application of torque. This is the case especially when the screw driver is worn. The new AO Stardrive™ maintains the advantages of the HEX but offers a better resistance to stripping, as the flats are orientated more perpendicularly to the force applied. A further advantage of the new AO Stardrive™ is that the size of the drive connection now conforms to general technical standards.

72 2003 AOSpine is formed John Webb Max Aebi Paul Pavlov
Nottingham, Montreal, Nijmegen, England Canada Netherlands Excerpt from AOSpine Europe history page at website In the late '90s a of group of spine surgeons led by John Webb, Max Aebi, and Paul Pavlov supported by the AO's industrial partners pushed for greater autonomy for the spine surgeons within the AO.  In 2000, the Board of Directors of the AO Foundation, having recognized the special needs and the market dynamics of spine, created an AO Specialty Board for Spine Surgery. The AO Spine Board was given responsibility to grow spine as key competence of the AO Foundation, with a charter to specifically manage and promote the distinctive needs and desires of spine surgeons within the AO. This specialty group has its own governance for its educational, scientific, product development, and administrative issues while remaining in close collaboration and partnership with the Foundation’s other institutes and regions. In the last three years AOSpine has gone from strength to strength and established itself as a widely accepted academic and scientific group in the spine world. As Mike Janssen, Chairman AOSpine International states: “Spine surgery today is increasingly characterized by a merging of specialties. The old walls separating these specialties are being broken down by the shared goal of advancing the field of spine care.” The organization has gone through some structural changes in order to rise to the new challenges of spine surgeons around the globe. The AOSpine International Board provides strategic planning and support to the affiliated AOSpine Regions. Each AOSpine region has their own budget, authority, and the responsibility to drive local activities within the AOSpine International framework. Today AOSpine has a membership of around 8000 surgeons, researchers, and allied spine professionals. AOSpine continues to grow, taking the AO model to a new level by providing new programs, new ideas, and a team committed to spine!

73 2003 Strain theory and LCP Michael Wagner Christoph Sommer
Wien, Austria Chur, Switzerland References: First clinical results of the Locking Compression Plate (LCP). Sommer C, Gautier E, Müller M, Helfet DL, Wagner M. Injury 2003 Nov;34 Suppl 2:B43-54 Development of the Locking Compression Plate. Frigg R. Injury 2003 Nov;34 Suppl 2:B6-10. Review.

74 2004 AO CAS and BrainLAB Christian Krettek Hannover, Germany
C Computer A Aided S Surgery

75 2005 AO Expert nails

76 2006 AO Trauma Asia Pacific AOTAP Australia New Zealand
China Philippines Hong Kong Singapore Indonesia South Korea Japan Taiwan Malaysia Thailand India joins AOTAP in 2007 History of AO Asia Pacific (AOAP) The AO was founded in 1958 in Switzerland and its principles of fracture management were propagated to all parts of the world. The dissemination of AO knowledge has expanded under the responsibility of AO International, now called AO Education (AOE), which is one of four main pillars of the AO Foundation beside AO Clinical investigation and Documentation, AO Development and AO Research. The AO principles have helped thousands of surgeons and million of patients in the treatment of musculoskeletal injuries. In the past, Asian surgeons learnt about AO techniques by attending courses in Davos, Switzerland and through visits of guest lecturers from the West in the countries of Asia. The number of AO courses in Asia has sharply increased over the last couple of years because of the availability of Practical Workshop Sets (PWS) in Asia. Apart from developing the teaching activities for orthopedic surgeons, we should not forget that the nurses in the operating rooms who are a part of the operation team need also to be included in the AO teaching activities (ORP courses). Under the AO Presidency of Prof. Marvin Tile from 1992 to 1994 the concept of regionalization was born and AO East Asia (AOEA) was founded in November 1994 under the leadership of Dr. Suthorn Bavonratanavech who also became the first chairman of AOEA. Prof. S.P. Chow, the second chairman spearheaded the growth of scientific activities within AOEA and the third chairman, Dr. G On Tong united the region of AO Asia-Pacific. The Cranio-maxillofacial group, originally a subspecialty within AOEA, became an independent body, called AO Cranio-Maxillofacial Asia in This group is under the chairmanship of Prof. Thiam Chye Lim from Singapore. Major achievements of AOEA at a glimpse were: the first issue of AOEA newsletter in 2000, the launch of the AOEA website in 2001, the formation of the study groups in 2003, the first AOAA-Asian Chapter Symposium in Chiang Mai, Thailand and the formation of the ORP group in 2004, and the first combined regional AO courses in Chiang Mai, Thailand in It is worthwhile mentioning that the AO Foundation with the help of devoted doctors and our industrial partner Synthes provided support to relief tsunami and earthquake victims in Asia. The countries belonging to AOEA were: Hong Kong, Indonesia, Malaysia, Philippines, Singapore, South Korea, Taiwan (Chinese Taipei) and Thailand. The success of AOEA came from the cooperation and contribution of surgeons in the member countries, the support from the Board of Directors and members of the Academic Council of the AO Foundation. A major step forward happened in 2003, when Japan affiliated with AOEA. In November 2006, the AO trustees of the People’s Republic of China decided to join AOEA, bringing the most populous nation to be part of the group. There was additional momentum at the AO courses in 2006 in Davos with the trustees of Australia and New Zealand agreeing to join the Asian Trauma Group. At that time the chairman of AOEA, Dr. G On Tong, decided to call the new body AO Trauma Asia-Pacific, in short AOTAP.At the Tips for Trainers event in New Delhi in February 2007, another breakthrough happened with the trustees of India accepting the invitation to join AOTAP. In less than six months AO Trauma Asia-Pacific has become a reality and is now representing one of the regions of the AO Foundation. There are three study groups in AOEA, namely hand, soft tissue and minimal invasive. The  latter group published the first book on the subject of minimally invasive plate osteosynthesis (MIPO) in It is the first book in AO Publishing, which does not originate from Europe and North America.

77 2006 AO LCP Manual Michael Wagner Wien, Austria Robert Frigg
Bettlach, Switzerland

78 2006 AO Surgery reference Editors: Chris Colton Peter Trafton
Joseph Schatzker Ernst Raaymakers What is the AO Surgery Reference? The AO Surgery Reference is a huge online repository of surgical knowledge, consisting of more than 7'000 pages. It includes: Hundreds of surgical procedures and approaches described in text and images Surgical decision making made easy with literature evaluated and prepared for quick reference Access to AO course videos Access to hundreds of pages of previously published AO material Who are the authors? The different anatomical segments are being authored by 62 renowned surgeons from 19 countries. All modules were prepared by at least 2 teams from different countries, ensuring not only that the AO principles were adhered to, but putting much weight on the fact that decision making, operating procedures, and hospital standards are different around the world. We took care to describe all modules in a way that they might be useful to surgeons anywhere in the world.

79 2007 AOSpine Manual John Webb Vincent Arlet Max Aebi AO Spine Manual
Principles and techniques (Vol 1) Clinical applications (Vol 2) Max Aebi, Vincent Arlet, and John K Webb are the three editors-in-chief who oversaw the creation and publication of this book along with a team from the AO. More than 80 authors contributed to the manual and the twelve section editors ensured high standards throughout. The two volumes offer the reader a combined total of 1,500 pages and over 3,000 figures. Also included is one DVD-ROM for both volumes. Principles and techniques (Vol 1) relates to the teaching of basic surgical knowledge and surgical techniques at AOSpine courses and acts as a foundation for the application of these principles in clinical practice. It presents basic scientific and technical principles— it provides the reader with the scientific background to understand spine surgery and it teaches how to apply these surgical principles using the instrumentation necessary in a step-by- step manner with exceptional illustrations; some critical steps are explained using sequences from AOSpine teaching videos. Clinical applications (Vol 2) is based on the novel interactive sessions within AOSpine courses and acts as a huge resource of clinical cases with which the readers’ current knowledge on how to treat their patients can be expanded. It presents discussions concerning typical clinical cases. The reader is involved in the development of the rationale of treatment, the indications, the contraindications, the argumentation in favor of a technique or against one, and the outcome. Case examples are outlined with learning points from more than 50 surgeons of which each is a leader in their surgical field. Clips from AOSpine live surgery videos enhance the learning experience.

80 2007 AO Principles of Fracture Management─2nd edition
Thomas Rüedi Chur, Switzerland Richard Buckley Calgary, Canada Christopher Moran Nottingham, England

81 2007 Pediatric classification
Theddy Slongo Bern, Switzerland Laurent Audigé Dübendorf, Switzerland Reference: 1. The AO Pediatric Comprehensive Classification of Long-Bone Fractures (PCCF). Fracture and Dislocation Compendium. Slongo T, Audige L (2007) The AO Pediatric Classification Group.

82 2007 Martin Allgöwer passes away
A tribute to Martin Allgöwer, by Thomas Rüedi in AO Dialogue April 2006: Martin was born in 1917 and had a happy youth with his two older brothers in St. Gallen, Switzerland – at that time the center of the Swiss textile industry. The economic depression in the 1930s hit the family hard, nevertheless Martin was able to attend medical school at Basel University. With the beginning of World War II his studies were frequently interrupted by military services, where he served as captain of the Swiss army medical corps. Finding clinical employment after graduation was difficult in those years, so he started to work in the tissue culture research laboratory of CIBA, one of the big pharmaceutical industries in Basel. Later he continued his studies on human monocytes in the burn unit of Truman Blocker at the Texas Medical Center in Galveston. This research resulted in the inaugural dissertation (PhD) on “The cellular basis of wound repair”, which could be considered as a precursor of today’s stem sells studies. Back in Basel, Martin spent 8 years in the surgical department of the university hospital under Carl Henschen and Rudolf Nissen. One of his teachers in those years was Hans Willenegger who became a great friend. In 1956, Martin Allgöwer was promoted to surgeon-in-chief of the Kantonsspital in Chur, which is situated in the center of one of the best Swiss skiing and mountaineering areas. As his original training was mostly focused on visceral surgery, he was now confronted with many sports injuries, especially fractures. Having suffered from a tibia fracture himself in 1952 that was treated by a cerclage wiring and resulted in considerable shortening and external malrotation, Martin was most enthusiastic to join the group of young Swiss surgeons that gathered in 1958 to form the Arbeitsgemeinschaft für Osteosynthesefragen – “AO” – to improve operative fracture treatment. Realizing the great need for basic research in the field of bone healing, Martin immediately founded the Laboratory for Experimental Surgery in the building of a former laboratory for tuberculosis in Davos. Only two years later, in 1960 the first AO Course was organized in the Davos research lab with 46 active Swiss surgeons and many others who were interested in the new, revolutionary techniques of internal fixation. That was the start of Davos becoming the AO “Mecca”. As a general surgeon, Martin also had great interests in other surgical fields, especially visceral and endocrine surgery as well as in intensive care. He pioneered the proximal selective vagotomy for the treatment of duodenal ulcer, which replaced the more radical Billroth gastric resection in those years. He was similarly involved in parathyroid surgery and headed the Swiss Cancer League from With the increasing incidents of road traffic accidents, open fractures and the management of polytrauma patients became a big issue. Martin Allgöwer was probably one of the first to internally fix open fractures as an emergency and to introduce “early total care” in the management of the multiple-injured patients, who were consequently ventilated for at least 24 hours in one of the first intensive care units in Switzerland. In 1967 Martin Allgöwer was elected as chairman of the Department of Surgery at the Basel University Hospital, a position he held until His many innovative ideas and achievements and the reputation of his school for surgeons and fellows soon spread around the whole world and made Martin one of the most famous surgeons of our time. Innumerable honorary memberships including that of the American College of Surgeons, the American Surgical Association and the Royal College of Surgeons of England may be proof of that. In 1979 Martin was elected President of the ailing Societé Internationale de Chirurgie/International Society of Surgery. Thanks to an enormous personal engagement first as president, then as secretary general, one of the oldest surgical societies was revitalized and is considered today the umbrella of world surgery in general. Besides these international activities Martin was above all a clinical surgeon, a critical researcher and great teacher. In spite of doing surgery himself almost every day and fixing acute fractures also at night, he found the time to assist young residents with great patience during their first hernia repair or with a malleolar fracture, always giving meticulous attention to a gentle soft tissue handling and careful suturing techniques, especially the “Allgöwer stitch”. He personally knew every patient in his department, and was the first to arrive at the hospital and the last to leave. While in Chur his research at the Davos laboratory (headed by Stephan Perren) concentrated on fracture healing, then later in Basel he was intrigued by the studies on burn toxin by his colleague Guido Schönenberger, a subject that is still dear to him today. He wrote many key articles in books and journals as well as lectures and expected his colleagues to do the same. From his surgical department in Basel, more than 20 academic surgeons emerged, all of them receiving attractive hospital appointments. In the AO, besides Maurice E Müller and Hans Willenegger, Martin Allgöwer was always the third important pillar and a key figure. Maurice was the surgical genius and magician, Martin gave the group the scientific background and credibility, while Hans was spreading the AO gospel and philosophy around the world. Realizing that the three of them would not last forever, in 1984 Martin had the great idea of creating the AO Foundation, which was to guarantee continuity. Based on the experiences with the AO fracture courses, in 1986 Martin – together with a few German and Swiss surgeons – initiated again in Davos the first course in Gastroenterologic Surgery with hands-on-exercises on specially prepared gut specimen, which were equally successful and are still offered today. Although his professional interests and activities filled most of his days (and often the nights as well) Martin had other interests such as flying his own two engine airplane, powder snow skiing in Davos or Heliskiing in the Canadian Rocky Mountains as well as listening to classical music. Even after retiring from active surgery and teaching Martin never lost his interest in the AO and its activities. He has probably not yet missed the opening of an AO Course in Davos, sitting in the front row and listening critically to the new developments of fracture treatment, which have revolutionized some of the original AO principles established by the pioneers. As he has always shown interest in innovations – often applying new techniques with enthusiasm himself, he has also been able to accept the recent changes in AO philosophy. This reflects his remarkable mental flexibility in spite of his almost 90 years. Like many others, I have worked closely with Martin and learned a lot from him. I now feel privileged to be able to thank and pay tribute to this outstanding personality and great friend.

83 2008 AO 50th anniversary Professor Maurice Müller on his 90th birthday
March 28, 2008 unveils a plaque in Hotel Elite. Biel (Bienne) Switzerland From the AO website On March 28, 2008, the AO marked its foundation in 1958 by 13 general and orthopedic surgeons by unveiling a commemorative plaque at the Hotel Elite in Biel, Switzerland, where the first meeting of the AO took place. Maurice E Müller, one of the visionary founders of the AO, carried out the unveiling on the same day he celebrated his 90th birthday. 

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85 Transforming Surgery Changing Lives


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