Dr. Emal Wardak MS “ Ortho “ , Dip. SICOT, FAA Country Repräsentative AOFoundation

1. Evolution of fracture surgery and AO Principles Dr. Emal Wardak MS“Ortho“, Dip. SICOT, FAA Country Repräsentative AOFoundation

2. Before 1959, when AOwas founded non-operative as well as operative fracture treatment was unsatisfactory !

3. Nature is most forgiving and tries to unite the bone ends inspite of poor treatment ...but can not prevent mal union and infection or poor functional outcome

4. common goal to improve function by early motion Long „before AO“ several attempts for improve- ment were made by a few great men all over the world, • Non operative: • - Sir Robert Jones 1918 • SirWatson Jones 1955 • Perkins 1960 • Böhler L. 1957 • - others • Operative: • Lambotte 1908 • Danis 1950 • Küntscher 1957 • Smith Petersen 1937 • Mc Laughlin 1954 • Hoffmann 1950 etc

5. Albin Lambotte 1886- 1955 Ingenious pioneer of modern operative fracture treatment incl. soft tissue handling and early postoperative movement

6. Primary bone healing „soudure autogène“ • Robert Danis 1880- 1962 • Interfragmentary compression • lag screws • - compression plate Absolute stability

7. Gerhard Küntscher 1900- 1972 Father of im-nailing later Grosse & Kempf interlocking

8. Malgaigne 1849 First external fixator for patella Raoul Hoffmann 1881-1972 Roger Anderson the most important contributors to external fixation

9. 60 years ago Workmen‘scompensation for openfracturesin Switzerland SUVA 1945 • Disability: • Femur 100% • Tibia 66% • Forearm 56%

10. up to 30% posttraumatic Algodystrophy, Sudecks‘ fracture disease • soft tissue atrophy • diffuse edema • joint stiffness • osteopenia • unexplained pain

11. A Müller Allgöwer Willenegger Schneider AO : Arbeitsgruppe für Osteosynthesefragen 1958 O with nine like-minded, 40 year old Swiss Surgeons decided to create to improve fracture care

12. Formulating the AO Principles Manuscript of Maurice E. Müller • painfree, functional aftercare • (Danis, Lambotte, Böhler) 2)anatomical Reduction (Lambotte, Danis) 3)Absolute stability of Fixation to allow „primary bone healing“ without callus (Danis) 4) Respecting the vascularity of bone and of the soft tissues (Lambotte)

13. „Lag screw principle“ Absolute stability by interfragmentary compression „Fragments do not move under load“

14. Primary or direct fracture healing Direct / primary bone healing without visible external callus Neutralisation plate lag screws Bilat.Tibia fx from skiing 1960 1 y 1y

15. Tibiashaft fx. Chur Dec. 1961 - Apr. 1962 n= 159 skiing injuries* screws plates *consecutive series 99% FU n= 83 n= 76 % % Callusfree fx-healing 60 62 Fixation callus 40 38 Delayed healing 6 2.6 Refracture 2.6 1.3 Infection 0 0 simple torsion fx 2-3 surgeons no ethical commission no evidence needed no medico-legal problems Restitution of function 95 93.3 Compensation for disability 0% 0% M.Allgöwer, Chur

16. Preservation of periosteum • Best soft tissue care • Careful skin suture • with 4-0 Principles of surgical technique 1960 M. Allgöwer • Anatomical reduction by minimal exposure • Interfragmentary compression by lag screw or plate

17. Danger: ORIF: Open Reduction Is Fun Mr. Alan S. Apley Compared to conservative treatment ORIF gave • better functional results • fewer algodystrophies • low complication rate • high acceptance by patients • satisfaction to surgeons

18. almost always avoidable !!!! Catastrophies discredited the AO method • too aggressive indications • too extensive exposures • too little care for bone and soft parts • too heavy / too many implants

19. More metal +compression Appearance of Callus was considered: • as sign of instability • as poor osteosynthesis • as bad surgeon „dead bone sandwich“

20. Almost any fracture can be fixed by a nail In the 80ties & inspite of the overall success theAO is criticized for: • too rigid fixations (plates) • too much emphasis on anatomical • reconstruction of the diaphysis • too little consideration for the soft tissues

21. Interlocking nail ( G-K ) • Rapid healing with callus formation • Early weight bearing • Few complications • High rate of union • More malunions Nailing becomes „state of the art“ for diaphyseal fractures (1980ties)

22. B.D.m 18y, motocycle accident, bilat. Femur fractures, IM nailing as emergency procedure. UFN as splint providing relative stability Preservation of vascularity Axial alignement Relative stability 5 mo postop

23. No different from today!!! 6y Case of Prof. Willenegger from the early 1960 ties Biological fixation Bridegplating

24. Careful planning Biological Osteosynthesis - Indirect reduction technique - Minimally invasive approaches • Bridging fixation devices • providing relative stability • - IM-nail • - Long bridge plate • - External fixator

25. Relative stability by splinting / bridging • Locked nail • Bridgeplate • External fixator • Splints reduce, but do not abolish motion at • fracture focus, allowing active limb movement • without pain • Splints must be • „coupled“ to the • main fragments

26. Regular plates work by pressing plate to bone friction and preload Compression interferes with bone vascularity

27. depends on Locking Head Screws LHS Internal fixator principle: LISS / LCP Perren and Tepic From the external to the internal fixator

28. better purchase than standard screws even in osteoporotic bone !! Locked Internal Fixator/ LISS Anchorage with angular & axial stability

29. 87y old lady, distal femur C1 (PFN in situ) Case of Ch.Sommer postop 2

30. 87y old lady, distal femur C1 (PFN in situ) Case of Ch.Sommer LISS with mini- Invasive technique

31. postop 6 weeks 87y old lady, distal femur C1 (PFN in situ) Case of Ch.Sommer LISS: less invasive stabilization system LHS for better purchase in osteoporotic bone

32. Locking Compression Plate- LCP LHS provide angular stability and prevent the plate of being pressed against bone > better vascularity!! threaded hole > LHS conventional DCP hole Internal fixator principle needs re-thinking of philosophy and surgical technique Wagner & Frigg

33. It‘s the surgeons choice which system to use... ...but mixing within one segment is counterproductive

34. Articular fractures: LCP combining bridging & conventional techniques Ski carving accident, case Dr.Sommer

35. Articular reconstruction with lag screws Bridging of complex meta- physeal fx with internal fixator Articular fractures: LCP combining bridging & conventional techniques

36. postop 6 weeks 4 months 7 months H.F., 46y, pilon 43- C2 Ch.Sommer 50% working after 6 we, 100% after 3 mo (full weightbearing)

37. In summary: For restitution of function we need: • correct axial alignment and rotation • congruent articular surfaces • fracture fixation allowing for: • early motion of limb & patient • undisturbed fracture healing

38. What is „undisturbed“ fx-healing? • healing by „bridging“ callus • due to relative • stability? locked IM-nail or bridge plate (LISS) or external fixation

39. What is „undisturbed“ fx-healing? • direct healing without callus due to absolute stability ? lag screw Compression or Buttress Plates or (LCP)

40. We actually need both forms: „Compression“„Bridging“ absolute stability relative stability simple, diaphyseal e simple, metaphyseale complex, diaphyseal e complex, metaphyseal e articular osteoporosis

41. And never forget: a fracture is a soft tissue injury where the bone happens to be brocken

42. Thank you