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AO PRINCIPLES and PHILOSOPHY

AO PRINCIPLES and PHILOSOPHY. PROGRESS and EVOLUTION [1958 - 2006]. JESSE B JUPITER MD. Objectives: At the end of the lecture I hope you will understand. AO principles, their evolution, and how they relate to fracture surgery today

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AO PRINCIPLES and PHILOSOPHY

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

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

  3. In the 1940’s and 1950’s the incidence of permanent partial disability was 35% following tibial fractures and 70% following fractures of the femur (Swiss Nat. Ins. Co.)

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

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

  6. 1958 Biel,Switzerland; - The Founding of AOArbeitsgemeinschaft für Osteosynthesefragen • An association of surgeons devoted to the study of problems associated with internal fixation ASIF

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

  8. YOU MAY BE SURPRISEDBUT IN 1958, THESE WERERADICAL THOUGHTS, AND NOT WIDELY ACCEPTED AOWAS KNOWN AS ALWAYS OPERATEALWAYS OSTEOMYELITIS

  9. LIFE IS MOVEMENT MOVEMENT IS LIFE

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

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

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

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

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

  15. LAMBOTTE, 1907

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

  17. CONVENTION WISDOM1ST HALF-20TH CENTURYSEPSIS : THE MAJOR CONCERN CLOSED METHODS WERE IN FAVOUR

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

  19. the SECOND HALF of the CENTURY DOMINATEDby theORIGINAL AO DOCTRINES EARLY FUNCTIONALREHABILITATION

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

  21. the CONCEPT OF ANATOMICAL REDUCTIONIS STILL VALID FOR: • ARTICULAR FRACTURES • SOME LOWER EXTREMITY METAPHYSEAL FRACTURES • DIAPHYSIS - the FOREARM

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

  23. BRIDGING PLATING Multifragmented Diaphyseal fracture

  24. Dorsal combined fracture Severe soft tissue injury

  25. 5 Months

  26. Full function

  27. NEW PLATE CONCEPTS: The LOW CONTACTCONCEPT

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

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

  30. LOCKING SCREW CONCEPT ANGULAR STABILITY

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

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

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

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

  35. BUT,TO THE YOUNG SURGEONSHERE TO-DAY!DON’T DESPAIR – WEHAVE NOT RUN OUT OF PROBLEMS FOR YOUTO SOLVE

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

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

  38. The results of a poorly conceived and poorly executed open reduction internal fixation are always worse than closed treatment Professor Hans Robert Willenegger1911 - 1998

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

  40. Massachusetts General Hospital Department of Orthopaedics Boston, Massachusetts

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