1 AO philosophy

The philosophy of the AO (Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixation) has remained consistent and clear, from its inception in 1958 by a visionary group of 13 Swiss colleagues and friends to its status as a worldwide surgical and scientific foundation and community. Advances in basic science and technology, together with growing clinical expertise, have resulted in many changes to the implants, instruments, and techniques used in trauma surgery. However, the basic philosophy of care remains the same today as in 1958 when the AO was founded.

Vision–Excellence in surgical management of trauma and disorders of the musculoskeletal system.

Mission–To foster and to expand a network of healthcare professionals in education, research, development, and clinical investigation to achieve more effective patient care worldwide.

Structure–Medically guided nonprofit organization led by an international group of surgeons specialized in the treatment of trauma.

2 Background

In the first half of the 20th century, fracture management mainly focused on achieving bone union and the prevention of infection. The methods used to treat fractures, mostly by immobilization in casts or traction, inhibited rather than promoted function throughout the healing period ( Fig 1.1-1 ). The important and key concept of the AO was to provide safe open reduction and stable internal fixation of fractures while protecting the soft tissues and allowing early functional rehabilitation.

Long before the establishment of the AO, the importance of operative fixation of fractures had been recognized. Early advocates included Elie and Albin Lambotte ( Fig 1.1-2 ), Robert Danis ( Fig 1.1-3 ), Fritz König, William O′Neill Sherman, William Arbuthnot Lane, Gerhard Küntscher ( Fig 1.1-4 ), Raoul Hoffmann, and Roger Anderson. However, their ideas and innovations were not widely adopted because significant obstacles needed to be overcome. The list of technical, metallurgical, and biological obstacles was formidable; especially the risk of infection that often resulted in amputation.

In addition, peer group skepticism often amounted to real hostility. Innovations, such as stable internal fixation by Albin Lambotte [1], advances in intramedullary nails by Gerhard Küntscher, and the introduction of early motion (albeit in traction) by Lorenz Böhler ( Fig 1.1-5 ) [2], Jean Lucas-Championnière [3] and his disciple George Perkins, were restricted by the inability to reconcile two key concepts within one program of care: effective splinting of the fracture and early, controlled mobility of the joints.

3 The role of the AO

What was needed, and what the AO provided, was a coordinated approach to identify these obstacles, to study the difficulties they caused, and to set about overcoming them. The chosen path was to investigate and understand the relevant biology, to develop appropriate technology and techniques, to document the outcomes and react to the findings, and, through teaching and writing, share whatever was discovered.

This enormous challenge was triggered by an apparently small issue. In the 1940s and 1950s questions were being asked, not least by the Swiss workman′s compensation board insurance company, why it took some fractures 6–12 weeks to heal but 6–12 months for patients to return to work?

Robert Danis, first through his writings and later by a short personal visit, inspired Maurice E Müller and the early AO group including Martin Allgöwer, Robert Schneider, and Hans Willenegger. The essence of Danis’ observation was that healing without callus took place if he used a compression device to impart absolute stability to a perfectly reduced diaphyseal fracture. During healing, the adjacent joints and muscles could be exercised safely and painlessly [4].

Inspired by this concept and driven by a determination to apply it clinically, and establish how and why it worked, Müller and the AO group set in motion a process of surgical innovation, technical development, basic research, and clinical documentation. This progressed as a campaign to improve the functional outcome and minimize the problems and complications of fracture care. The group propagated their message by writing and teaching, and by developing innovative courses to teach their principles and surgical techniques ( Figs 1.1-6 – 7 ). That work continues to this day, involving many specialist groups working for the common goal of improving trauma care worldwide.