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Improve the biology—change the
mechanics
“Callus is like sex— it’s natural, it joins two things
together and it requires a bit of movement”
[A Apley]](https://image.slidesharecdn.com/aophilosophy-160422012235/85/Ao-philosophy-30-320.jpg)
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Ao philosophy
- 1. AOTrauma Principles Course AOprinciples and philosophy 1957–2003 Evolution or revolution? Piet de Boer, UK
- 2. 2 Learning outcomes • Outlinethe AO principles and relate them to fracture surgery today • Describe the importance of the soft tissues in fracture surgery • Discuss the role of surgery in diaphyseal, metaphyseal, and articular fractures
- 3. 3 AO principles andphilosophy—aims and objectives • Problem of fracture disease • Development and evolution of AO principles • Role of fixation in management of fractures • Importance of soft-tissue care
- 4. 4 Ambroise Paré 1510–1520 Usedexternal fixation in 1561
- 5. 5 Clayton Parkhill 1860–1902 •Clinical trial in 1897 using an external fixator • 8 of 9 patients achieved union • Device consisted of four screws fixed with series of plates and bolts
- 6. 6 Albin Lambotte 1886–1956 •Pioneer of documentation • External fixator 1902 • Innovator of stable internal fixation
- 7. 7 George Perkins 1892–1979 •Most disability that occurs following fracture is related to the treatment and not to the pathology…fracture disease • Pioneered a fracture philosophy of which movement was the cornerstone
- 8. 8 Fracture disease Prolonged immobilizationand nonweight-bearing resulted in: • Stiffness • Muscle atrophy • Skin atrophy • Circulatory dysfunction
- 9. 9 Fracture disease • Toprevent fracture disease you must mobilize the affected limb • How do you move the limb but hold the fracture? • Internal fixation of course!
- 10. 10 Prevention of fracturedisease • Before the AO, results of internal and external fixation were usually worse than nonoperative treatment • Internal fixation was usually accompanied by prolonged immobilization
- 11. 11 Robert Danis 1880–1962 •Applied plates to fractures to obtain compression • Discovered primary union could occur without callus formation—“soudure autogène”
- 12. 12 William Arbuthnot Lane1856–1943 • Achieved interfragmentary compression with screws and plates • Originated procedure known as “bone plating”
- 13. 13 “Primary bone union” •Bone healing without callus formation • The “cutter” unit
- 14. 14 Maurice E Mueller1918–2009 • Met Robert Danis in Brussels in 1950 • Between 1950–1956 performed 58 ORIF (open reduction and internal fixation) all of which were documented • 1958 Formation of the AO
- 15. 15 November 6, 1958in Bienne, Switzerland Foundation of the Arbeitsgemeinschaft für Osteosynthesefragen
- 16. 16 Walter Bandi The pioneers RobertSchneider Hans Willenegger Martin AllgoewerMaurice E Mueller
- 17. 17 Original AO principles1958 • Anatomical reduction • Rigid fixation • Preservation of soft tissues • Early active mobilization
- 18. 18 Rigid fixation ofintraarticular fracture— absolute stability
- 19. 19 Documentation • Rueedi andAllgoewer documented 487 consecutive tibial shaft fractures treated by plating • 98% union • 3% sepsis • Superb functional outcomes
- 20. 20 What went wrong? •AO techniques were adopted by the world in the 1970s • Glasgow 30% sepsis, 20% nonunion, treating tibial shaft fractures by plating • St Thomas’ 20% sepsis, 20% nonunion
- 21. 21 What went wrong? •When in doubt read the instructions • Anatomical reduction...Yes • Rigid fixation...Yes please • Preservation of soft tissues...er, no!
- 22. 22 The dangers oftoo much emphasis on biomechanics
- 23. 23 The dangers oftoo much emphasis on biomechanics
- 24. 24 Evolution of AOprinciples—biology, preservation of blood supply • Redesign the plates • Plates devitalize bone by pressure on the periosteum and underlying bone • If you reduce the footprint of the plate you will kill less bone
- 25. 25 Improve the biology―redesignthe plate • Plates devitalize bone by pressure on the periosteum and underlying bone • If you reduce the footprint of the plate you will kill less bone • New concepts favor biological healing (eg; LC-DCP)
- 26.
- 27. 27 LISS (less invasivestabilization system)
- 28. 28 Improve the biology—changethe surgical technique • Open reduction devitalizes the bone • Indirect reduction is more soft-tissue friendly
- 29. 29 Do you needto anatomically reduce the fracture? • Intraarticular fractures need anatomical reduction • Shaft fractures need restoration of length, axis, and rotation for normal function to be restored
- 30. 30 Improve the biology—changethe mechanics “Callus is like sex— it’s natural, it joins two things together and it requires a bit of movement” [A Apley]
- 31. 31 Improve the biology―changethe mechanics If callus is a good way for bones to heal (and it is) then maybe a bit of movement at the fracture site would be a good idea after fixation
- 32. 32 AO principles 1990 •Functional reduction • Stable fixation • Preservation of blood supply • Early active mobilization
- 33. 33 Functional reduction ofmetaphyseal fracture—relative stability using plate
- 34. 34 Functional reduction ofshaft fracture— relative stability using nail
- 35. 35 Evolution of principles1990–2004 • Biology is paramount • Minimal access surgery • Minimally invasive plate osteosynthesis • Image-guided surgery • Arthroscopic-assisted surgery
- 36.
- 37. 37 Indirect reduction—percutaneous fixation ofintraarticular fragment
- 38. 38 Temporary spanning usingan external fixator—functional reduction
- 39.
- 40. 40 Submuscular plating―indirect reduction usingan external fixator
- 41. 41 Bridge plate—MIPO Minimally invasivepercutaneous osteosynthesis
- 42. 42 AO principles 2004 •Preservation of blood supply • Functional reduction • Stable fixation • Early active mobilization
- 43. 43 AO treatment 2004—aspectrum of possibilities • Anatomical reduction with rigid fixation • Functional reduction with stable fixation • Open reduction • Closed reduction • Minimal access surgery All have their roles. This course will teach you them.
- 44. 44 AO principles andphilosophy; aims and objectives: • Problem of fracture disease • Development and evolution of AO principles • Role of fixation in management of fractures • Importance of soft-tissue care Time changes philosophies and treatment techniques but the philosophy of improving patient care will last forever Summary