1. AO history and philosophy
Published: July 2013
Reviewed: 2019
Reviewer: Piet de Boer
AO Trauma Basic Principles Course

2. Why are you here?

3. You want to be here to ……….
Learn how to fix broken bones

4. So why would you want to hear about history or the AO?

5. Learning objectives
To understand that the AO can help you professionally, personally, and financially
To see how participation will provide for personal and professional growth
If you want to move forward it is useful
to know how you got where you are

6. The AO story
This is a story of a group of surgeons who committed themselves to achieving better outcomes in the treatment of fractures

7. How does the story begin?
Most fractures join without treatment
Bone heals – evolutionary sine qua non
Chris Colton

8. Fractures heal without treatment
Dinosaur fracture 150 million BC
Reindeer fracture 1 million BC
Human fracture 5000 BC

9. Fractures heal without treatment
And that is why doctors have
“successfully” treated
fractures for 5000 years

10. But 70 years ago…
Both nonoperative and operative fracture care were highly unsatisfactory

11. Poor results from nonoperative treatment—prolonged immobilization in plaster
Most disability that occurs following fracture is related to the treatment and not to the pathology…fracture disease
George Perkins 1892–1979

12. Problems of nonoperative treatment—fracture disease
Prolonged immobilization and nonweight bearing results in:
Stiffness
Muscle atrophy
Skin atrophy
Circulatory dysfunction
Fracture disease

13. Poor outcomes from operative treatment
Failure to understand fracture healing and soft tissue rehabilitation
Poor training of junior doctors
Lack of adequate instrumentation
Frequent failures
Operative treatment is worse
than nonoperative treatment

14. Robert Danis (1880–1962)
The late 1940s saw the culmination of the random development of fracture fixation devices starting in the mid-19th century. An eclectic mix of implants from a great variety of surgical "authors", none designed to complement the others. The biology of bone healing had not been investigated scientifically and knowledge was sparse. 
In 1949, a Belgian surgeon, Robert Danis, published a book entitled "Théorie et Pratique de l'Ostéosynthèse". This, his second book on fracture fixation, documented his concepts of early functional rehabilitation following rigid fracture fixation.
Applied plates to fractures to obtain compression and found you could get fracture healing without callus formation—“primary bone union”

15. Interfragmentary compression—Sudure autogene, healing without callus
Danis found that if you compressed a fracture, it healed without callus formation. He described the use of a lag screw to obtain compression as well as a plate with a turn buckle that resulting in axial compression of the fracture.

16. Maurice Müller (1918–2009)
Maurice Müller met Robert Danis in Brussels in 1950
They talked all night
The meeting between Maurice Müller—then a young surgeon—and Danis is well documented. They talked all night and drank Johnny Walker whisky. We do not know how many bottles they drank but Danis inspired Müller who went back to Switzerland and started fixing fractures according to the principles of Danis.

17. Foundation of AO—Biel, November 6,1958
The 13 visionary trauma and orthopedic surgeons met in a hotel in Biel, Switzerland and founded the AO, the Arbeitsgemeinschaft für Osteosynthesefragen (working group for the fixation of bone fractures).
Since then, the AO Principles have revolutionized surgical fracture care for the benefit of millions of patients throughout the world.
“Arbeitsgemeinschaft für Osteosynthesefragen”

18. Original AO Surgical Principles 1958
Anatomical reduction
Rigid fixation
Preservation of soft tissues
Early active mobilization
29-year-old man
AO type C.3
17 weeks postop.
40 weeks postop

19. designs new implant/technique
AO value concept
Clinicians define
clinical problem
Clinicians teach
new technique
Research lab does
basic research
Clinicians test new
implant/technique
Development lab
designs new implant/technique
Manufacturers make
new implant

20. AO organization (1959) Four pillars: Research on fracture healing
Development of implants and instruments
Documentation of all patients
Teaching of osteosynthesis techniques
The four principles of documentation, teaching, research, and instrumentation would become the four pillars of the AO Foundation in 1984.
References:
Müller ME, Allgöwer M, Willenegger H. Technique of Internal fixation of Fractures
2. Müller ME, Allgöwer M, Willenegger H. Technik der operativen frakturenbehandlung. 1963:223-31

21. Research—AO Laboratory Davos (1959)
Martin Allgöwer
Davos, Switzerland (1917−2007)
AO Laboratory
for Experimental
Surgery
Martin Allgöwer was the first director of the AO Laboratory for Experimental Surgery in Davos. The building had previously been a tuberculosis clinic and was rented to the founders of AO who each paid CHF 10,000 towards the costs.

22. AO Laboratory Davos
Stephan Perren–pioneer in understanding mechano-biology
The Strain Theory

23. AO Research Institute Davos (2019)
Basic and translational research
Clinical Priority Programs (eg, infection)
Research grants and fellowships
PEER = Program for Education and Excellence in Research

24. Development—hex-head screw (1958)
Robert Mathys
Bettlach, Switzerland (1921−2000)
Extract from interview with Maurice Müller for Maîtrise Orthopédique (
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.”
Cooperation between surgery and industry

25. AO documentation (1959) Maurice Müller Davos, Switzerland (1918−2009)
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.”

26. AO Clinical Investigations Department 2019
Clinical trials
Health economics
Educating doctors how to become clinical researchers
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.”

27. Education—first AO course in Davos (1960)
Participants: 2 3 1
On December 10, 1960 the first AO course in Davos was held. The guest of honor was Professor Hermann Kraus (1899–1972) from Freiburg, 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”.
Martin Allgöwer teaches Sir John Charnley in the AO Lab

28. AO courses 2018 58,118 participants 832 educational events
22,311 faculty days
8,798 faculty, worldwide
On December 10, 1960 the first AO course in Davos was held. The guest of honor was Professor Hermann Kraus (1899–1972) from Freiburg, 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.

29. AO courses
Knowledge
Attitude
Skills

30. AO courses
Blended learning
eLearning

31. AO Foundation portal www.aofoundation.org

32. AO Surgery Reference

33. AO Trauma STaRT www.aotrauma.org/STaRT
Award-winning learning hub for residents
Supports self-directed learning through case discussions, self-assessment, and access to a large number of AO learning material
Free and simple registration
Now available for PCs, laptops, and iPad
AO Trauma STaRT is a learning hub for orthopedic trauma residents that supports self-directed learning at all stages of their training.
Identification of knowledge gaps through self-assessment options (quizzes, tests)
Interactive case discussions enhance clinical reasoning skills and illustrate the application of basic principles in the clinical setting
Overview of available AO learning material for residents with direct access
All case discussions and self-assessment options are based on defined competencies and learning objectives of the AO Trauma Residents Education Program.
AO Trauma STaRT intends to complement the offerings of certifying bodies and teaching hospitals for residents.
Current available for PCs, laptops, and iPad – NOT available for:
iPhones
Andriod devices

34. iPhone and Android apps AO/OTA Classification and AO Surgery Reference34

35. AO Trauma Orthogeriatrics App Available for smartphones and tablet devices
Authors: Markus Gosch, Katrin Singler, Tobias Roth
Part of the curriculum of the AO Trauma Orthogeriatrics Education Taskforce

36. AO Fellowship Program

37. The AO lifelong-learning path
Responding to the changing needs of practice-based learning of surgeons
Expertise: AO Trauma provides the means for experts to share ideas, build their reputation, increase their visibility, and transmit their knowledge to the next generation of surgeons.
Growing specialization: Educational events and learning resources are invaluable for those wishing to maintain their knowledge base, keep up with the latest advances, or solve specific problems related to setting up practice.
Residency: AO Trauma provides the educational resources to nurture principle education in trauma surgery during the malleable years.
Start of practice: AO Trauma provides the educational resources and support to help overcome the challenges faced by young surgeons at the start of their careers.

38. Success of the AO is based on:
Friendship
Constructive criticism
Share success as well as failure
Interest in R&D
Mutual respect
Cooperation
Teaching and learning
Benefit for the patient is the ultimate goal

39. Take-home messages
The AO can help you professionally, personally, and financially
If you participate, the AO will provide for your personal and professional growth

40. AO Foundation
Philosophies and techniques of treatment will change with time, but the philosophy that we exist to improve the care given to our patients will last forever
The techniques and philosophy of the AO have changes with time. In 50 years time the techniques used and the implants available will be very different to now.
But the concept that the AO Foundation exists to improve the care given to patients was true 50 years ago, is true now, and will be true in 50 years time.