Surgery, Science and Industry: A Revolution in Fracture Care, 1950s-1990s

Surgery, Science and Industry A Revolution in Fracture Care, 1950s–1990s Thomas Schlich Surgery, Science and Industry...

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Surgery, Science and Industry A Revolution in Fracture Care, 1950s–1990s

Thomas Schlich

Surgery, Science and Industry

Science, Technology and Medicine in Modern History General Editor: John V. Pickstone, Centre for the History of Science, Technology and Medicine, University of Manchester, England (www.man.ac.uk/CHSTM) One purpose of historical writing is to illuminate the present. At the start of the third millennium, science, technology and medicine are enormously important, yet their development is little studied. The reasons for this failure are as obvious as they are regrettable. Education in many countries, not least in Britain, draws deep divisions between the sciences and the humanities. Men and women who have been trained in science have too often been trained away from history, or from any sustained reflection on how societies work. Those educated in historical or social studies have usually learned so little of science that they remain thereafter suspicious, overawed, or both. Such a diagnosis is by no means novel, nor is it particularly original to suggest that good historical studies of science may be peculiarly important for understanding our present. Indeed this series could be seen as extending research undertaken over the last halfcentury. But much of that work has treated science, technology and medicine separately; this series aims to draw them together, partly because the three activities have become ever more intertwined. This breadth of focus and the stress on the relationships of knowledge and practice are particularly appropriate in a series which will concentrate on modern history and on industrial societies. Furthermore, while much of the existing historical scholarship is on American topics, this series aims to be international, encouraging studies on European material. The intention is to present science, technology and medicine as aspects of modern culture, analysing their economic, social and political aspects, but not neglecting the expert content which tends to distance them from other aspects of history. The books will investigate the uses and consequences of technical knowledge, and how it was shaped within particular economic, social and political structures. Such analyses should contribute to discussions of present dilemmas and to assessments of policy. ‘Science’ no longer appears to us as a triumphant agent of Enlightenment, breaking the shackles of tradition, enabling command over nature. But neither is it to be seen as merely oppressive and dangerous. Judgement requires information and careful analysis, just as intelligent policy-making requires a community of discourse between men and women trained in technical specialities and those who are not. This series is intended to supply analysis and to stimulate debate. Opinions will vary between authors; we claim only that the books are based on searching historical study of topics which are important, not least because they cut across conventional academic boundaries. They should appeal not just to historians, nor just to scientists, engineers and doctors, but to all who share the view that science, technology and medicine are far too important to be left out of history.

Titles include: Roberta E. Bivins ACUPUNCTURE, EXPERTISE AND CROSS-CULTURAL MEDICINE Roger Cooter SURGERY AND SOCIETY IN PEACE AND WAR Orthopaedics and the Organization of Modern Medicine, 1880–1948 David Edgerton ENGLAND AND THE AEROPLANE An Essay on a Militant and Technological Nation Jean-Paul Gaudillière and Ilana Löwy (editors) THE INVISIBLE INDUSTRIALIST Manufacture and the Construction of Scientific Knowledge Thomas Schlich SURGERY, SCIENCE AND INDUSTRY A Revolution in Fracture Care, 1950s–1990s Crosbie Smith and Jon Agar (editors) MAKING SPACE FOR SCIENCE Territorial Themes in the Shaping of Knowledge

Science, Technology and Medicine in Modern History Series Standing Order ISBN 0–333–71492–X hardcover Series Standing Order ISBN 0–333–80340–X paperback (outside North America only) You can receive future titles in this series as they are published by placing a standing order. Please contact your bookseller or, in case of difficulty, write to us at the address below with your name and address, the title of the series and one of the ISBNs quoted above. Customer Services Department, Macmillan Distribution Ltd, Houndmills, Basingstoke, Hampshire RG21 6XS, England

Surgery, Science and Industry A Revolution in Fracture Care, 1950s–1990s Thomas Schlich

© Thomas Schlich 2002 All rights reserved. No reproduction, copy or transmission of this publication may be made without written permission. No paragraph of this publication may be reproduced, copied or transmitted save with written permission or in accordance with the provisions of the Copyright, Designs and Patents Act 1988, or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1P 9HE. Any person who does any unauthorised act in relation to this publication may be liable to criminal prosecution and civil claims for damages. The author has asserted his right to be identified as the author of this work in accordance with the Copyright, Designs and Patents Act 1988. First published 2002 by PALGRAVE MACMILLAN Houndmills, Basingstoke, Hampshire RG21 6XS and 175 Fifth Avenue, New York, N.Y. 10010 Companies and representatives throughout the world PALGRAVE MACMILLAN is the new global academic imprint of St Martin’s Press LLC Scholarly and Reference Division and Palgrave Macmillan Ltd (formerly Macmillan Press Ltd). ISBN 0–333–99305–5 hardback This book is printed on paper suitable for recycling and made from fully managed and sustained forest sources. A catalogue record for this book is available from the British Library. A catalogue record is available from the Library of Congress 10 11

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Printed and bound in Great Britain by Antony Rowe Ltd, Chippenham and Eastbourne

Contents

List of Figures Foreword by Ulrich Tröhler Acknowledgements Introduction: The AO

Part I 1 2 3 4 5 6

1

Setting Up a Network, 1950s–1970s

Dealing with Broken Bones 9 Starting the Network 28 A Symbiosis of Surgery, Science and Industry 46 ‘Tacit Knowledge’: Education and Training on a Face-to-Face Basis 65 Science and Surgery: Bones in the Laboratory 86 The Science of Surgery: Clinical Research 110

Part II 7 8 9 10 11

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Coping with Success, 1970s–1990s

Acceptance: The AO becomes Mainstream Optimised Control: The AO’s Success in East Germany The Long Road to Success: The AO in the US Redefining Osteosynthesis: Another Revolution in Fracture Care Control and Cooperation on a Global Scale: AO International and AO Foundation

Part III

141 169 180 196 218

Conclusion

Conclusion: Surgery, Science and Industry in Modern Medicine

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Notes Bibliography Index

260 310 337

List of Figures

1. Systematic conservative treatment. Lorenz Böhler, Technik der Knochenbruchbehandlung im Frieden und im Kriege (9th to 11th revised and augmented edition), Maudrich, Wien, 1943, vol. 1, p. 193. Reproduced courtesy of Wilhelm Maudrich Verlag, Vienna. 2. Nailing of the hip. Lorenz Böhler and Wilhelm Jeschke, Operative Behandlung der Schenkelhalsbrüche und Schenkelhalspseudarthrosen und ihre Ergebnisse, Maudrich, Wien, 1938, pp. 124–5. Reproduced courtesy of Wilhelm Maudrich Verlag, Vienna. 3. Compression device. M.E. Müller, M. Allgöwer and H. Willenegger, Manual der Osteosynthese. AO-Technik, Springer, Berlin, 1969, p. 31. Reproduced courtesy of M.E. Müller and Springer Verlag, Berlin. 4. X-rays, osteosynthesis. M.E. Müller, M. Allgöwer and H. Willenegger, Technik der operativen Frakturenbehandlung, Springer, Berlin, 1963, p. 91. Reproduced courtesy of M.E. Müller and Springer Verlag, Berlin. 5. Instruments box. M.E. Müller, M. Allgöwer and H. Willenegger, Technik der operativen Frakturenbehandlung, Springer, Berlin, 1963, p. 80. Reproduced courtesy of M.E. Müller and Springer Verlag, Berlin. 6. Corroded hip nails. Lorenz Böhler, Technik der Knochenbruchbehandlung im Frieden und im Kriege (9th to 11th revised and augmented edition), Maudrich, Wien, 1943, vol. 2, p. 940. Reproduced courtesy of Wilhelm Maudrich Verlag, Vienna. 7. Faculty of the first AO course. Reproduced courtesy of the AO Foundation, Davos. 8. Operating Room Personnel course. Reproduced courtesy of the AO Foundation, Davos. 9. Hans Willenegger presents the AO Manual to Lorenz Böhler. Photograph reproduced courtesy of the AO Foundation, Davos. 10. AO fellowships. The statical data were kindly provided by Isabella Badrutt, AO-International, Davos. The chart was produced by Tobias Katzer, Institute for the History of Medicine, Freiburg.

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List of Figures

11. Perren’s experiment. M.E. Müller, M. Allgöwer and H. Willenegger, Manual der Osteosynthese. AO-Technik, Springer, Berlin, 1969, p. 9. Reproduced courtesy of M.E. Müller and Springer Verlag, Berlin. 12. Primary bone healing. M.E. Müller, M. Allgöwer and H. Willenegger, Manual der Osteosynthese. AO-Technik, Springer, Berlin 1969, p. 8. Reproduced courtesy of M.E. Müller and Springer Verlag, Berlin. 13. AO classification. M.E. Müller, S. Nazarian, P. Koch and J. Schatzker, The Comprehensive Classification of Fractures of Long Bones, Springer, Berlin, Heidelberg, etc., 1990, p. 13. Reproduced courtesy of M.E. Müller and Springer Verlag, Berlin. 14. The diaphyseal fracture types. M.E. Müller, S. Nazarian, P. Koch and J. Schatzker, The Comprehensive Classification of Fractures of Long Bones, Springer, Berlin, Heidelberg, etc., 1990, p. 15. Reproduced courtesy of M.E. Müller and Springer Verlag, Berlin. 15. AO documentation card. M.E. Müller, M. Allgöwer and H. Willenegger, Technik der operativen Frakturenbehandlung, Springer, Berlin, 1963, p. 27. Reproduced courtesy of M.E. Müller and Springer Verlag, Berlin. 16. Conservative fracture treatment. Cartoon by Otto Soglow, The New Yorker, 1939. Reproduced courtesy of Condé Last Rights and Permissions. 17. AO cooperation. Reproduced courtesy of Urs Heim. 18. Tension band principle. M.E. Müller, M. Allgöwer and H. Willenegger, Manual der Osteosynthese. AO-Technik, Springer, Berlin, 1969, p. 33. Reproduced courtesy of M.E. Müller and Springer Verlag, Berlin. 19. DCP. M. Allgöwer, L. Kinzl, P. Matter, S.M. Perren and T. Rüedi, Die Dynamische Kompressionsplatte DCP, Springer, Berlin, 1973, pp. 26–7. Reproduced courtesy of Springer Verlag, Berlin. 20. Hans Willenegger. Photograph reproduced courtesy of the AO Foundation, Davos. 21. AO Foundation 1984. Diagram reproduced courtesy of the AO Foundation, Davos. 22. AO Foundation expenditures. Chart reproduced courtesy of the AO Foundation, Davos. 23. AO Alumni Association members. The statistical data were kindly provided by Esther Stoop, AO International, Davos. The chart was produced by Tobias Katzer, Institute for the History of Medicine, Freiburg.

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Foreword

Interdependent collaboration between clinical medicine, laboratory science and industry is an increasingly prominent feature of post-World War II health care. The AO, an abbreviation originally standing for the Swiss Arbeitsgemeinschaft für Osteosynthesefragen founded in 1958, that is, the Association for the Study of Internal Fixation of Fractures (ASIF) as this worldwide organisation is now termed, seems to fit this development. From around 1960, the AO promoted the systematically organised treatment of a great variety of fractures with its own industrially produced and marketed plates, screws and instruments. Today, the AO system represents a sort of international gold standard. Albeit not new in the 1950s, many variants of such treatments before the AO had more often than not been considered as being a haphazard ‘injury superaddit to an injury’. Thus, the obvious questions are: How, where and why did this true revolution in fracture care come about? Was it ubiquitous and simultaneous? How is it to be explained in personal biographical, sociocultural and even political perspectives? How were unavoidable errors and opposition dealt with? Deeply rooted in their cultural soil, the less than half a dozen founders certainly had far-reaching visions; they also had complementary capabilities which made them strong as an association, and they were altruistically generous in financial matters. Yet, is this sufficient to explain the AO as a mutual win–win merger for surgical practitioners, laboratory scientists and producers alike for the benefit of patients? Are there similarities with developments in other (medical) fields? What are, in brief, the general and specific reasons for the AO’s incontestable success? These historical questions and answers have a bearing for our current and future practices. Thus, reading the AO’s history, chapter after chapter, as written by a young historian, is an exciting privilege for one who has known, as I have, the AO’s first 25 years fairly well from personal experiences as a student, scientist – and patient. When the truly engaging author opens new vistas, describes and analyses entire pictures, and solves some of the riddles involving the past 15 years of AO history, he is constantly leading one to understand its benevolent founders, their successors, and indeed parts of one’s own life, in an often unexpected context. At last, the changes that have transpired in medical culture over the past 40 years become tangible. A core issue is the evidence deemed sufficient to warrant changes: What criteria were needed for an innovation to be considered ‘better’ than a timehonoured treatment – and by whom? The answers are at times surprising. What makes for fascinating reading immediately raises further questions as viii

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to whether or in what respect our contemporary criteria are different, and, if (not) so, why. Two examples: the highly lauded physiological and pathophysiological concepts of bone formation and repair emerge to have played the role of satisfying the academic need for scientifically explaining the empirical success of osteosynthesis ex post rather than as a basis for specific techniques. And with all the clinical, statistical and laboratory evidence at hand to show and explain the excellent chance-to-risk ratio of operative fracture treatment, its success in daily practice has depended on human factors: the personal contact with colleagues, motivating and to some extent even controlling them within ‘the AO family’, and, above all, the trustworthiness of its protagonists have been essential. Such personal qualities and seemingly old-fashioned virtues are, those with surgery, science and industry careers should bear in mind, indispensable complements to the quest for naked, quantified, objective standards; a pursuit that is rightly stressed in our times. Indeed, the book makes its case on how the AO used both facts and virtues to cope with its own success and the partly self-induced developments in this emerging trilateral field. It is certainly worth reflecting upon whether this model might work in the future and elsewhere. Well founded standards are to be strived for, certainly, in surgery as well as in history, but they are not enough to make patients – or readers – happy. Thanks to both his professional skills as a historian and his empathy when treating the apparently hitherto unique AO phenomenon, Thomas Schlich will succeed in making many readers and, perhaps, via the surgeons amongst them, many a patient happy. Ulrich Tröhler, MD, PhD, FRCP(Edin.) Professor of Medical History University of Freiburg/Germany March 2002

Acknowledgements

The research project which led to the production of this book was conducted at the Institute for the History of Medicine at the University of Freiburg, Germany. I wish to thank its director, Ulrich Tröhler, for giving me the chance to work on it. Thanks to his credibilility and standing as a scholar, the Arbeitsgemeinschaft für Osteosynthesefragen (AO) decided to entrust the project to the Freiburg Institute. Professor Tröhler not only saw to the financial basis and provided me with the necessary infrastructure, but also accompanied the research in all its stages with sympathy and advice. I thank the AO Foundation for funding the research project. As president of AO International and later of the AO Foundation, Peter Matter was instrumental in initiating the project and convincing his fellow AO members that such a historical study would be worth the expense. He guaranteed independent research, helped me to obtain access to source material and to get in touch with sources. Though he never tried to influence the content of the study, his lively interest helped to sustain my efforts and deliver the book somewhere between what historians would call a tight schedule and surgeons would deem as an acceptable time-frame. Furthermore, he provided me with a pleasant working environment in his AO International office in Davos, whose staff, above all the chief secretary Ursula Loeliger, did everything to make me feel welcome. During the last year of research and writing I have been a Heisenberg Fellow of the German Research Council (DFG). It is an honour for me to thank the DFG for enabling me to finish the work under such favourable conditions. If readers are able to understand my arguments, it is due to the help of Allison Felmy and Alexis Heede, who tried to make the best of my attempt to tell this story in a foreign language. Allison Felmy corrected many linguistic faults and improved the logic and coherence of the text. In long and lively discussions Alexis Heede resisted my sloppiness in finding the best possible solution for expressing a particular thought. In her extraordinary commitment she has done much more for the book than I was able to compensate. For comments on the contents of my study I am particularly endebted to Urs Heim, former president of AO-International. While working on his recently published book The AO Phenomenon (Bern 2001), he generously shared his experiences and source material with me. He also gave me a leg up by inviting me to participate in the meetings of early AO members, which he organised in Bern in 1997. Most importantly, he read all the chapters critically and corrected a number of mistakes. x

Acknowledgements

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Similarly, almost all chapters were read by the one person who has perhaps the best inside knowledge of the AO’s history, Margrit Jaques-Baumann. She has had many different roles in the AO, among them writing the minutes of the meetings of the AO’s decision-making bodies. With her keen sense for detail she rectified misunderstandings and corrected specific AO terminology. In addition, she gave me much information on important details and put me in contact with interesting witnesses. I am deeply indebted to all the people who were prepared to share their experiences with me in interviews, many of whom also helped to make other source material available: Martin Allgöwer, Suthorn Bavonratanavech, HansUlrich Buff, Urs Heim, James Hughes, Margrit Jaques-Baumann, Eugen Kuner, Max Landolt, Robert Mathys Sr, Peter Matter, Regula Matthisson, Maurice E. Müller, Stephan Perren, Berton Rahn, Howard Rosen, Jörg Rehn, Eberhard Sander, Augusto Sarmiento, Joseph Schatzker, Robert Schenk, Elisabeth Spicher, Marvin Tile, Emanuel Trojan, Bernhard G. Weber, Siegfried Weller. At different stages of the project, I also had the opportunity to discuss parts of the manuscript with many people. Martin Allgöwer, Rainer Egle, Jim Gerry, Eugen Kuner, Maurice E. Müller, Stephan Perren, Eberhard Sander, Rudolf Szyszkowitz and Emanuel Trojan all contributed their wisdom and criticism specifically concerning the AO. Julie Anderson, Silke Bellanger, Alberto Cambrosio, Hans-Georg Hofer, Martin Lengwiler, Andreas Lösch, Sybilla Nikolow, Sibylle Obrecht, John Pickstone, Lutz Sauerteig and Ulrich Tröhler added their historical, sociological and anthropological expertise to help the project. Isabella Badrutt gave me information on the development of fellowships. Claudio Gubser helped me out with data on AO courses for surgeons. Giovannina Jost provided me with data about Operating Room Personnel courses, and Esther Stoop helped me with statistics on the AO Alumni. Urs Jann not only gave me invaluable information on the AO Foundation but also, with his business competency, was instrumental in getting the publishing process on track. Tobias Katzer supported the project by creating some of the diagrams. Peter Schmid designed a cover image that aptly embodies the various aspects of the AO’s history. Richard Danz helped me to keep the book’s language understandable for readers from neither a medical nor a historical environment.

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Introduction: The AO

Having traversed the zone of deciduous trees, the narrow-gauge railway made its adventurous ascent into the high mountains, winding past charming villages and through forests of firs intersected by spectacular high alpine vistas. Finally Davos lay ahead of me, a small Swiss holiday resort, radiant in the late afternoon sun, 4800 feet above sea level, complete with a lake and a Grand Hotel – but also with a high-tech modern research centre for bone surgery. The centre was my reason for visiting Davos. It is the headquarters of an organisation called AO/ASIF (Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixation and Fractures) which is credited throughout the world for having revolutionised the treatment of bone fractures. The AO was also the subject of my newest historical research project. It is mainly through the activities of the AO that one of the most frequently used methods of operative fracture treatment has become part of surgical routine practice. Today we are used to the fact that a surgical operation is frequently the preferred choice of treatment when someone has an accident and breaks a bone. The surgeon performing the operation will be able to ground his1 procedures on well established scientific facts. Having had special training, he will employ high-quality instruments and implants provided by specialised industrial manufacturers. The surgeon will open up the fracture site and fix the fracture with metal implants, like screws and plates, so that the patient can move the affected limb during the healing process. This technique is called ‘osteosynthesis’ or ‘internal fixation’. Most probably the technique used, its scientific basis, the instruments and plates, as well as the surgeon’s training, all come from the AO. Like every medical doctor, I too had heard about this organisation during my time at medical school. While visiting a surgery lecture in the mid-1980s, I had listened as our professor enthusiastically explained the AO’s importance for his field. Later I experienced the impact of his words while taking the centralised medical exams, for which it was necessary to memorise the AO’s techniques and fracture classification. At that time osteosynthesis seemed so natural a procedure, I never would have guessed that less than 30 years earlier it had caused a scandal when the AO, then just a small Swiss association of 1

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surgeons, set out to introduce the operative treatment of broken bones with plates and screws as a standard treatment. In the late 1950s the majority of experts held that osteosynthesis would not work, since its principles contradicted the basic laws of bone healing. Moreover, opening a closed fracture in order to insert plates and screws was seen as a high-risk operation that could possibly result in the amputation of the fractured limb or even the death of the patient. Also, bone surgery was generally not popular among surgeons due to the exceptional level of surgical skill and competence required. As osteosynthesis started becoming a standard procedure worldwide, both proponents and critics attributed its successful introduction to the activities of the AO. Strikingly, within only two decades the association had developed into a multinational enterprise with thousands of members and associates worldwide. The AO was not, however, just another medical association; not only did the AO surgeons cooperate with industry, as others were doing at the time, they even created their own industrial firms as needed. Nor did they simply work with scientists, they also established their own research facilities. In order to assure that their technique and equipment would be used properly, they organised a programme of hands-on instruction courses. The AO training courses, which were then a novel idea, are now a must for any aspiring traumatologist or orthopaedic surgeon. The AO textbooks have also become bestsellers available in all major languages, and the sale of AO instruments and implants yields a substantial economic profit. Sales in 2001 reached SFr1 billion (about US$600 million). The main questions of my book ask how that was possible. How could such a difficult, risky and, upon its introduction, even scientifically unsound technique as osteosynthesis become a standard procedure throughout the world? And what was so special about the AO that enabled it to succeed at introducing a previously rejected technique? Trying to answer these questions puts me simultaneously in a position to examine the development of general aspects of modern medicine in the second half of the twentieth century. By tracing the specific connections between surgery, science and industry, it will be possible to identify the special values associated with the science-based, highly efficient way of treating bodily ills as represented by the AO, thereby determining its place in modern culture and society. To account for the development of modern scientific medicine, historians have brought forward a range of possible explanations. Factors like the increase in knowledge, technological progress, changes in social structure, organisational innovation and new institutions, economic developments, health politics and changes in culture have all been attributed a role. Studying the history of the AO allows me to contribute to these discussions: by examining a particular technique in modern high-tech medicine, I can look at all of these dimensions simultaneously and see how they interact. The case of the AO technique is especially suitable for such a comprehensive approach since it was introduced by a circumscribed group of doctors, scientists and


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manufacturers who produced a wealth of printed and archival source material covering the various dimensions relevant for understanding the technique’s successful establishment. These resources, which are usually hard to come by for historians of recent events,2 have served as the primary basis for my study. I also conducted interviews with the AO’s founders, executives, manufacturers, customers – and critics3 – and consulted published books and articles available on the topic4 to reconstruct and understand the rise of the AO and its technique. That the AO’s success depended on more than the creative development of a surgical technique had already become obvious on my first visit to the AO headquarters in Davos in the summer of 1997. It was this journey that called to mind the introductory passage of Thomas Mann’s novel Magic Mountain, which is set in Davos and which so accurately reflects the impressions of a first-time visitor to this special place that I could not resist paraphrasing it in the first lines of this introduction. But besides the features described in Mann’s novel there are other spectacular things to discover in Davos, such as the AO Centre. Nested among pastures and fir woods, it is a modern high-tech research centre complete with laboratories, animal stables, an excellent scientific library, the latest in computer and media technology, and an international staff of scientists and surgeons from all over the world. On my guided tour I was shown the departments for basic research, clinical research, development and education. All this, and much more as I later learned, was financed by the royalties paid to the association by the manufacturers for permission to make and sell the AO instruments and implants. But regardless of its wealth, my informants have taken pains to explain, the AO has never been a business company. In the interviews I held subsequent to my visit, the AO’s proponents called it, like Greenpeace, a non-profit organisation fighting for a better world, whereas its critics chose to compare it with the Mafia. Others saw the AO above all as a hallmark of quality – the Mercedes-Benz of fracture care. Aside from the organisation’s complex relationships with these different groups of people, the AO itself underwent restructuring in the course of its history. I learned that in 1984 the AO had become a foundation. The AO Foundation, in turn, received its funds from the non-profit shareholders’ company Synthes AG Chur, which had been established back in 1960 as a sort of holding company for all copyrights of the AO equipment. On the other hand, the original Swiss AO, that is, the surgeons’ association, still existed, as did the AO’s German and Austrian branches and various regional entities, not to mention the umbrella organisation known as AO International. Since all these structures had been established in answer to particular challenges, there was much to make a historian curious. My curiosity grew once I started meeting witnesses involved in the AO’s history. The AO members and associates saw themselves as belonging to a great family. When speaking German, surgeons addressed each other with

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the familiar Du instead of the formal Sie, even across boundaries of prestige and hierarchy. The four principle founding members were called ‘fathers’ and their portraits were displayed in the centre’s lecture hall. Characteristic for the AO, a familial spirit was diligently cultivated and reinforced by commemorative meetings. There was no interviewee who did not refer to the AO as a circle of friends. Nevertheless, it became clear that in the same way as opinions on the AO’s identity and future course varied, so did the views on certain issues concerning its past, as in every family each member has their own perspective of the group’s common history.5 Of particular interest were my interviews with critics of the AO, which helped me immensely in seeing the AO’s position within modern medicine on a more general level. As the inclusion of non-AO members may indicate, my objective is more than to provide a family history. My historical analysis of the AO’s case also aims at contributing a clearer picture of the type of medicine we have today to facilitate a better understanding of how it came into being. Accordingly, the various chapters always include a discussion of the AO before the background of the general development of medicine. The concluding chapter will bring all these general points together to show that statements concerning a particular medical technique and those about general trends in medicine are actually intertwined. The structure of the book Part I (Setting Up a Network, 1950s–1970s) shows how the AO made osteosynthesis successful by creating its own specific network. Chapter 1 delineates the process by which broken bones came to be viewed as a technical problem belonging to the domain of surgery and analyses why osteosynthesis had never before been accepted by the surgical community on a large scale. In Chapter 2 I describe how the AO was able to spread its technology by taking up the specific cultural pattern of the fraternity; here I put special emphasis on the general problem of making a locally rooted technology universally applicable. The genesis of the peculiar structure of interdependencies among surgeons, scientists and manufacturers connected with the AO, aptly called a ‘symbiosis’ by some of those involved, is the subject of Chapter 3. Chapter 4 deals with the AO’s quandary of making its technology generally available without losing control over its use. To solve this problem the AO started offering its programme of hands-on instruction courses, which became very popular among surgeons worldwide. In describing this part of the AO’s activities I look particularly at how the problems of tacit knowledge and standardisation were treated. In Chapter 5 I show how the AO’s scientists used laboratory research to reverse general scientific opinion in their favour and create a positive feedback effect between science and business. This chapter highlights what the case of


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osteosynthesis and the AO can teach us about the relationship between laboratory and clinic in modern medicine. Chapter 6 traces the multilayered, complex debate on the validity of studies performed to judge the merits of different types of fracture treatment. It further analyses the AO’s success in changing the perception of risk in a direction that permitted the spread of its treatment method and how this change simultaneously strengthened the AO’s credibility and authority. The scientific disputes on systematic documentation and outcome assessment provide an excellent basis for characterising the societal implications of the different types of rationality prevailing in twentieth-century medicine. Part II (Coping with Success, 1970s–1990s) deals with the AO’s efforts to preserve its network under changing conditions. In Chapter 7 I analyse how a consensus in favour of the AO eventually emerged, first in central Europe and later on in the rest of the world. I look at how the AO propagated its technology within the surgical profession, how it organised marketing and sales, and how patients influenced the successful spread of osteosynthesis. As it turns out, the mechanisms accounting for acceptance of the AO technology reflect how new ideas or technologies become generally accepted in modern, consumer-oriented societies. Noticeable differences in the diffusion of the AO technique in different national contexts provide a striking example of how the context of culture and society determine the speed and degree of spread of even such an apparently culture-independent technology as fixing broken bones. This is illustrated by comparing two highly contrasting settings in Chapters 8 and 9: socialist East Germany, where the AO was very successful early on, and the US, where it was not accepted until the 1980s. In these chapters the importance of control and surveillance in the expansion of technological networks becomes apparent. Chapter 10 surveys the radical changes undergone in the field of operative fracture care, the AO’s role in them, and the consequences these changes had on such a large and sophisticated network like the AO. Chapter 11 focuses on the problems of maintaining control and organising cooperation once the AO had become a huge international organisation. Part III comprises a concluding chapter in which I come back to my leading questions and explicate what we have learned about modern medicine by pursuing them.


Part I Setting up a Network, 1950s–1970s


1

Dealing with Broken Bones

Fixing broken bones seems an obvious thing to do, and it is no surprise that fracture treatment is among the most ancient medical techniques for which we have evidence. But setting up a systematic organisation of sophisticated operative fracture care is an altogether different issue. Particular social, cultural and economic conditions had to come together in order for the AO to be able to establish its network in the late 1950s. These conditions came about as a result of developments made over the previous 100 years. In the first part of this chapter I outline how bone fractures came to be seen as a technical problem of high societal relevance needing to be fixed by a technically oriented sort of surgery as offered by the AO. Considering that accidents were the most common cause of fractures,1 I will start by discussing how the general perception of accidents changed during the course of the nineteenth and early twentieth centuries, so that they came to be seen as falling under the responsibility of the medical profession. I first analyse traffic accidents as a striking example of a process I call ‘naturalisation’2 and then briefly turn to domestic and sports accidents before moving on to accidents at work. The latter are of special significance to this study because of their role in the creation of accident insurance, which in turn laid the foundation for the establishment of systematic fracture care. The second part of the chapter gives an outline of the development of fracture treatment with special emphasis being placed on earlier attempts at osteosynthesis and the reasons why it had not then been accepted on a large scale. The naturalisation of accidents: traffic accidents When problems are conceived of as belonging to the realm of medical competence they are in some way or other interpreted as naturally occurring phenomena. Accident injuries were assigned to the domain of medicine by interpreting them as natural and, at least to a certain extent, inevitable. As long as accidents were associated with divine intervention, culpability, 9

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ignorance or political power, they were seen as a problem for religion, law, education or politics. Only once they had been detached from such connotations did accidents become a problem to be solved by surgical means. Traffic accidents are a case in point. Starting in the 1930s, the increase in accidents on the road served as a powerful argument in support of fracture care, and in the 1950s they became the most common cause of fractures mentioned in surgical case histories.3 By that time, automobile traffic had become a mass phenomenon in all industrialised countries. Though casualties were generally seen as a serious problem, they were nonetheless considered part of everyday life. Whereas in late nineteenth-century England, for instance, anti-motorist attitudes had been common enough to influence legislation, now even an increase of casualties no longer challenged the basic acceptance of the motor car.4 But even without abolishing automobiles, there were still a number of other approaches to prevent accidents or, at least, to mitigate their effects. Speed limits were an obvious remedy for traffic accidents, and whenever they were introduced the number of casualties dropped, only to rise sharply again when the limits were lifted. 5 Driver training, street safety propaganda, punishment for drunk driving and changes in the design of motor cars were also discussed as a means of enhancing road safety. Their effectiveness, however, depended on the degree of enforcement or compliance. The implementation of such measures was further complicated by the fact that they touched upon sensitive political and social issues such as individual rights, not to mention the potential threat to the automobile industry.6 Despite efforts at preventing accidents in the first place, a certain number of casualties were tolerated as inevitable. Surgeons portrayed the technology that had enabled speed as a Pandora’s box for the twentieth century, and they called the traffic dilemma part of humanity’s contemporary existential crisis.7 From this perspective automobile accidents resembled natural events and, as such, were no longer regarded as the consequence of particular political decisions that could be revised if necessary. Surgery and accident naturalisation Although trauma surgeons were usually emphatic about promoting accident prevention,8 their very existence paradoxically helped to rationalise the toleration of traffic casualties. In some instances this inherent tension became apparent. In an article published in 1938 the German fracture specialist Martin Kirschner bemoaned the rapidly growing numbers of bone fractures through road accidents, but he also vehemently opposed the introduction of speed limits for automobiles. Speed limits, he argued, were inconsistent with the principle of modern traffic, which, as he put it, was ‘at the basis of our societal relationships, our wealth, our industry, our agriculture, our military defence, our international standing, in short, of our entire civilisation and culture’. For him, road accidents were not only ‘essentially natural events’


11

but also ‘the eggs that must be broken to make the omelettes’. 9 With this Kirschner articulated the basic compromise made by modern, industrialised societies to promote damage prevention only up to a certain point and thereafter to invest in damage repair instead. The difficulty lay in determining where this breakpoint should be, since it would have to balance the interests of various groups and would vary according to time and national context. The political, non-natural character of any such compromise has been formulated cogently in William Plowden’s work on the history of motor cars and politics in Britain:10 There must be a trade-off between levels of casualties and levels of investment in better roads, or motorway crash barriers, or rubber street furniture, and where the cut-off point should come must be a more or less arbitrary decision. A thousand road casualties may not be acceptable to a civilised society. But why should half of that number be any more acceptable? In order to be able to compromise at all, he writes, ‘Any community must in practice accept some level of road casualties as tolerable, in the same way it accepts, however reluctantly, some levels of crime or kidney disease.’ Plowden’s reference to kidney disease is particularly instructive for understanding how accidents were likened to diseases so that specialised fracture care could be developed to take care of them. Even though it was clear for many that in theory the most effective and cheapest way to save lives was prevention, the only realistic option seemed to be the improvement of trauma surgery. 11 In other words, surgical innovation had to keep up with the continuous increase in the number and severity of injuries from road accidents. Demanding better trauma care, in turn, contributed to naturalising accidents. By focusing on emergency services, historians Roger Cooter and Bill Luckin observed, ‘domestic and street accidents, in particular, are “naturalised” or rendered politically benign’, resulting in, as they warn, ‘a loss of both political and historical insight’.12 Our modern, naturalised notion of accidents and the form of trauma care associated with it are connected to a particular phase in history. Take for example its ‘key words’: most of them, such as ‘accidents’, ‘ambulance’, ‘casualties’, ‘emergencies’ and ‘first aid’ did not acquire their present-day meanings until the late nineteenth century.13 Created in the same time period, the German term for trauma surgery, Unfallchirurgie (literally, ‘accident surgery’) implies that this field of specialisation is concerned with those cases of injury that occur ‘by accident’, that is, naturally, without intent and even without a proper cause, and thus essentially uncontrollably.14 In the context of surgery, those accidents defying prevention came to be seen as a particular sort of naturally occurring disease. According to this view

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an accident, be it a ‘work accident, traffic catastrophe or sports injury’, strikes a previously healthy person at random without any meaningful connection to society or the person affected.15 The consequences of such disease-like occurrences now belonged to medicine’s sphere of responsibility, with surgeons setting out to fight the ‘modern monstrous disease of trauma’ and stem the ‘ever increasing epidemic of trauma’.16 In the same respect society also came to tolerate sports accidents, and health insurance even often paid for their treatment. Here, too, surgery was the beneficiary of naturalisation. With the rise in public enthusiasm for sports, the fields of sports medicine and sports traumatology were established as subspecialties. More specifically, and of particular relevance to the AO’s creation in Switzerland, in the 1950s patients with ski fractures started to fill the surgical wards in winter sport resorts. Specific fracture forms caused by skiing accidents even spawned various specialised surgical books and articles.17 Interestingly, even domestic accidents underwent a process of naturalisation. In this respect Cooter and Luckin rightly point out that the very use of the term ‘domestic’ for such events ‘reinforces a consensus that such mishaps are less preventable than industrial injuries (hence more “natural”)’.18 Occupational accidents and insurance In the nineteenth century workers’ accidents and their repercussions were seen as a pressing problem.19 Here, naturalisation went hand in hand with the emergence of accident insurance, one of several specific elements of the modern social security system. Like modern medicine in general, the rise of modern fracture care was closely associated with the creation of social insurance institutions in western industrialised countries. 20 Whereas the introduction of health insurance affected all medical services, accident insurance was specifically associated with fracture care.21 By the early twentieth century virtually every industrialised country in Europe and North America had instituted some form of accident insurance for industrial workers. Its introduction entailed a radical turning away from previous judicial principles. Putting aside the previously central assumption of personal liability and responsibility in order to follow the new principle of accountability without culpability, an accident came to be defined as an ‘occurrence stripped of intention and wrong-doing’.22 Provision for accident victims could now be regulated regardless of blame. More concretely, workers were now entitled to damages without having to sue the factory owner for negligence. In this way, accidents at work (but also at home or on the street) were seen as ‘natural risks’ and made subject to ‘risk management’ through insurance plans based on the idea of statistical calculability of hazards.23 Here, too, naturalisation opened the doors for surgeons. With no one at fault, and even without a predictable and controllable cause, work accidents could easily be interpreted as diseases. This change in status meant that it was up to the appropriate medical experts to treat them.24 Thus surgeons


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were given the task of dealing with the consequences of those accidents that could not be prevented by existing safety measures. In the US, for instance, the years just before World War I saw the organisation of the first comprehensive programme for the treatment of industrial accidents within a single company, the US Steel Corporation (formerly Carnegie Works) in Pittsburgh, Pennsylvania. And with its director William O’Neill Sherman pioneering osteosynthesis, the company accident hospital soon became renowned for the quality of its trauma care.25 But the main supporters of trauma surgery were the accident insurance companies. Having to balance their expenditures for disability pensions with income earned through members’ fees, the companies had a vital interest in calculating the long-term costs of accidents. In the first half of the twentieth century, insurance companies in various countries started to collect extensive statistical material to evaluate the economic impact of accidents. 26 Inadvertently, this statistical documentation promoted naturalisation. As Cooter and Luckin postulate in their book on accidents in history, through the increased use of statistics, man-made industrial accidents in particular were increasingly seen as part of the expected and ‘normal’ flow and structure of everyday social life ... [A]lthough the volume of accidents became well-known and the accidentcausing potential of certain technologies and labour processes recognised, the extent of such injuries and fatalities could be reckoned a part of the ‘natural order’ of industrial society.27 Naturalisation, then, was not necessarily in conflict with accident prevention. With the rise of statistics, preventability, like predictability, became part of the semantics of the term. Accidents were seen as occurring by chance, and thereby uncontrollably, but in principle they could be prevented – up to a certain point and depending on what safety measures were considered practicable.28 In all sorts of accidents there is always a limit to prevention. Theoretically one could prohibit skiing, make car driving illegal and spend unlimited amounts of money to make the workplace and the home safer. But, in fact, no really radical proposals ever made it off the ground. Instead a compromise emerged, representing a temporary balance of conflicting aims and interests. This compromise included tolerating a certain number of accidents as inevitable, so that they could then be handled like naturally occurring diseases and assigned to the surgeons to heal. The medicalisation of accident insurance In the interwar period, traumatological units were being established in different countries.29 The context of the AO’s later emergence, however, was the system of fracture care in the German-speaking countries, dominated by the public accident insurance companies. The primary purpose of accident

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insurance had been to provide accident victims with financial assistance during recovery and in cases of permanent disability. Initially accidents were less a medical than a financial problem,30 but in order to decide whether accident victims were entitled to receive benefits, the insurance companies had to determine the degree of their disability. As the resulting reports detailed the damage done by the accident, the course of treatment, and its end result, they provided an excellent source of information about the effectiveness of medical treatment. What is more, they also threw the deficiencies of existing fracture care into sharp relief, so insurance companies had adequate reason to fear that any further increase in the number or severity of accidents would exhaust their means to pay the disability pensions. In reaction, they resolved to extend their realm of competence beyond provision of pensions and moved into organising and financing medical treatment. In late nineteenthcentury Germany, accident insurance companies founded their own specialised trauma care hospitals for workers and gradually acquired control over the whole course of treatment of work accident injuries.31 Since compensation for long-term disability fell under the liability of accident insurance, the companies in charge of this branch of the social security system had a concrete material interest in using the best available fracture treatment from the start, thereby improving the chances of occupational rehabilitation. For this purpose they began cooperating with specialised surgeons and soon became the main supporters of specialised traumatology. The best example of the benefits surgeons could reap from this kind of cooperation is the case of the Austrian Lorenz Böhler. Since in Austria, even after World War I, no specialised trauma facilities had yet been established, Böhler took the initiative and persuaded the centralised Austrian accident insurance company to provide him with his own accident hospital in 1925. Located in Vienna but not affiliated with the university, Böhler’s hospital subsequently became the world’s leading centre for fracture care. Throughout the twentieth century insurance companies continued to support traumatologists and fracture specialists, among them, as we will see, the early AO surgeons. By supporting fracture care, insurance companies also came to control the surgeons’ practice. Surgeons now had to account for their actions to a group of lay people, and they had to do it in a form that complied with the conventions of bookkeeping, that is, in an objectivised statistical way. They had to draw up tables and curves with concrete numbers and percentages that could be translated into costs and benefits. Now surgeons’ performance was statistically measured in terms of the economic savings resulting from the prevention of long-term disability.32 Economics: ‘It pays to treat fractures well’ Even trauma surgeons themselves tended to use economic arguments to achieve better conditions for fracture care. By calculating how much they


15

could save by instituting better facilities, Böhler had been able to convince the Austrian accident insurance company to give him an accident hospital. Using the insurance company’s own statistical material, he forecasted a reduction in pension payments and treatment costs of anywhere between one-third and two-thirds.33 Böhler’s calculations turned out to be correct and in 1935 the leading British fracture expert, Ernest Hey-Groves, applauded him for demonstrating ‘that the proper treatment of fractures is not only a scientific problem or philanthropic duty, but also a business proposition. In other words, it pays to treat fractures well’.34 Throughout the twentieth century economics remained a key argument for supporting traumatology. Surgeons justified their demands for better means of fracture care by calculating the possible advantages for the national economy and by calling attention to the individual patient’s financial disadvantage from long convalescence periods and permanent disability. Comparative studies on different methods of fracture care regularly included a section on long-term costs due to absence from work and expense for pensions, and typical reports of successful treatments concluded with the patient’s return to work.35 In 1983 an American traumatologist pointed out that trauma was the principal cause of death among Americans between the ages of 1 and 38, and for each death due to trauma there were at least two cases of permanent disability. At that time the total annual cost of accident trauma, including wages, medical expenses and indirect work losses came to about US$50 billion.36 The ‘Cinderella of modern surgery’ Despite its venerable origins, fracture treatment was not always at the forefront of surgical interest. In the view of those few surgeons active in the area early on, fracture care was repeatedly portrayed as ‘the Cinderella of modern surgery’.37 Since accidents were primarily the lot of the working class, accident victims were traditionally not an attractive clientele for surgeons.38 Paradoxically this tendency was reinforced by the progress of surgery. Now that surgeons were gaining access to areas of the body that had never been within their reach before, other fields of surgery were becoming much more attractive. According to Böhler, accident insurance came just at a time when most surgeons had lost interest in injuries.39 Trauma surgery was pushed into the background and fracture care became unpopular, often delegated to the youngest staff members. Fracture specialists deplored the fact that both fellow surgeons and the public at large failed to see the importance of improving fracture treatment. This drain of interest was accompanied by a lack of financing, so that by the early twentieth century, fracture care lagged behind general surgery in teaching, research, specialisation and institutionalisation.40 As Cooter writes, accidents first had to be ‘discovered’ as a worthwhile object of medical interest before trauma surgery could vie with other surgical specialities.41

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The development of accident insurance, which brought with it new technical means of treatment, gradually started to restore surgical interest in fracture care during the course of the first half of the twentieth century. The two world wars with their great number of injured soldiers further promoted interest in fracture care, while at the same time providing favourable conditions for its reorganisation. Systematic fracture care was now seen as a practicable solution to a relevant problem, deserving the allocation of material and intellectual resources; in short, a ‘demand’ for sophisticated fracture care emerged.42 It was not clear, however, how this demand should best be met. This will be the subject of the second part of this chapter. Conservative fracture treatment The technical problem of treating broken bones was dealt with by a number of different approaches, including now obsolete concepts such as bone glue and massage of the affected limb.43 Generally, two basic types of treatment were distinguished: ‘conservative’ techniques, such as the plaster cast and skeletal traction, which did not require surgical operation, and operative fracture treatment using osteosynthesis. Traditionally, broken bones were treated by realigning the fracture ends and fastening the affected limb with some sort of splint until healing occurred. The plaster cast, which was introduced in mid-nineteenth century was considered a viable and convenient way to treat fractures and rapidly superseded most other treatment methods. Fixation in a plaster cast allowed the bone to heal, but the price of immobilisation was high: joints became stiff, muscles wasted away, and sometimes the whole organism was adversely affected.44 These problems were addressed by Lorenz Böhler, who in the 1920s became the most influential authority in the field of fracture treatment. He had developed the systematic approach he later used in his own hospital in a military unit behind the front line where conditions had allowed him to impose a great measure of control and discipline on patients and personnel.45 Böhler’s system of ‘functional’ fracture care was based on three principles: rejoining, immobilisation and active exercise. That meant that the displaced bone fragments had to be rejoined properly, using skeletal traction if necessary. Then the reduction had to be maintained, which meant that the fracture had to be kept from moving. Immobilisation was achieved most often by means of a skin-tight plaster of Paris dressing, sometimes by continuous traction, and occasionally by internal fixation. During the period of fracture immobilisation active exercise of the entire body except for the immobilised portion was mandatory. The success of Böhler’s system depended on the correct application of the plaster dressings. When his method was adopted but his high standards ignored, complications and failures were frequent. To avoid such failures, Böhler subjected his staff to strict supervision, putting them through comprehensive training and requiring extensive


17

outcome documentation. Böhler’s efficient organisation and tight control of procedures were widely admired and emulated. In terms of technique, Böhler generally favoured the conservative approach, though later becoming one of the first to adopt the triflanged nail for hip fractures and intramedullary nailing for femoral shaft fractures.46 Besides the plaster cast, skeletal traction was the principal means of immobilising fractures within the concept of functional fracture care. It consisted in pulling the affected limb in a direction that led to the realignment of the broken bone and then keeping up the traction by means of some device, usually with the help of weights. Applying traction to a broken limb was a time-honoured technique for treating fractures. In its sophisticated form, as developed in the early twentieth century, traction treatment allowed the patient to maintain the function of adjacent joints and muscles by exercise while at the same time retaining the bone’s fragments in their proper position.47 At an intermediate position between conservative and operative methods lay the technique of external fixation. In external fixation screws or bolts are inserted into the bone fragments through the skin and connected to a fixing device (the fixateur externe) outside the body, mostly some sort of rod. Though the principle had already been applied sporadically in the past, the typical form of the device first came into use in the 1890s. It is interesting to note that most surgeons working with osteosynthesis have also developed some form of external fixation as an alternative.48 Rationalisation and standardisation It was the systematic introduction of conservative treatment methods that formed the context of a new degree of standardisation and rationalisation in fracture care. Far from being a novelty at the time, efforts to standardise surgical techniques went back to the nineteenth century when surgeons were extending their realm of treatment to ever more body regions.49 In fact, standardisation was a general trend in modern society: In industry for instance, the vast increases in the size and scale of enterprises called for ever more structure, uniformity and efficiency. This tendency was also evident in medicine; applying order, uniformity and expertise in medical management was part of a wider movement of rationalisation in the late nineteenth century which, as Roger Cooter has written, ‘gained ground wherever greater complexity, waste and inefficiency appeared to threaten’.50 In post-World War I Britain, orthopaedic surgeon Harry Platt had carried over ‘into civilian practice the main wartime lessons of effective fracture treatment’. He segregated patients according to their fracture type, secured their continuous treatment and appropriate aftercare, and had the process supervised by experts. Like the AO later on, Platt also set a great deal by detailed record-keeping.51 Fracture experts were pioneers in systematising medicine; in the British

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context, Cooter holds, the fracture issue changed the outlook on medicine as a whole, indicating and contributing to ‘crucial changes in the division of labour and in the diffusion of ideas on economy, efficiency and expertise’.52

Figure 1 Systematic conservative fracture treatment: the so-called ‘femur room’ in Lorenz Böhler’s military hospital in Bozen during World War I.

Standardisation of procedures was also central to Böhler and his school. His so-called ‘Schema-F-Philosophie’ was, as the surgeon himself asserted, the secret to his success. As head surgeon Böhler tried to gain control over the application of his techniques by typifying and standardising every detail. Under the conditions of World War I he had been able to achieve an enormous degree of standardisation, which he then sought to transfer to postwar Vienna when he set up his accident hospital. To make things easier, he derived all procedures from a few simple rules. All devices had standardised measures and were thus compatible and interchangeable. Böhler also divided his fracture cases into groups, putting all those patients with a certain kind of fracture in the same room. There they were treated in exactly the same manner. Period photographs of hospital rooms with rows of similarly bandaged young men give an impression of the quasi military atmosphere of his hospital.53 Böhler himself explicitly likened his organisational principles ‘to the progress of rationalisation that in recent years has rendered industry, transport and agriculture more efficient’. By means of subdivision of labour, ‘parts of medical treatment were simplified – thereby suited to mass


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application – and greater efficiency achieved’.54 All this, however, did not yet apply to operative fracture care. The beginnings of osteosynthesis Over the years, surgeons have turned to operative forms of fracture treatment mainly for two reasons: first, in particular cases, such as femoral neck fractures, open reduction and internal fixation was the only effective treatment; and second, for some surgeons osteosynthesis seemed to hold the promise of better treatment results in terms of anatomical and functional restoration. The oldest form of osteosynthesis consisted in connecting the fragments of a broken bone with metal wire, either by sewing them (wire suture) or tying them together with circular wire (cerclage). Anecdotal testimony of the use of wire and ivory pegs in patients with open fractures or non-unions dates back to the late eighteenth century, but prior to the introduction of antisepsis and asepsis such operations would have been too risky to play a major role in routine surgical practice. The first book devoted to internal fixation of fractures was published in 1870. Its author, the surgeon-in-chief of the French navy, L.J.B. BérengerFéraud, recommended the use of internal fixation only for open fractures, which are prone to infection anyway, and for non-unions, which could not be successfully treated otherwise. Around this time internal fixation started to become safer thanks to Joseph Lister’s antiseptic system of wound treatment. Antisepsis is the copious use of disinfectants during the operation to prevent wound infection. In 1883 Lister himself reported of his successful use of wire sutures on some specific fractures, mostly of the knee cap.55 Protected by antisepsis and later asepsis, which was based on scrupulously preventing all contact of the wound with anything which was not sterilised, a number of surgeons tried different procedures of open reduction and internal fixation. But for the majority of surgeons and the scientific authorities the danger of infection by far outweighed any possible benefit from the operation.56 Nevertheless, in the period before World War I osteosynthesis started attracting the interest of surgeons in the German-speaking countries and soon also in France, Belgium, Britain and America.57 Improving fracture care was on the surgeons’ agenda because of new findings stemming from two recent innovations. X-ray diagnostics and the insurance companies’ serial examinations of fracture patients had revealed serious deficiencies in the contemporary conservative and operative methods of fracture treatment.58 In England the operative approach found its most influential spokesman in the famous surgeon William Arbuthnot Lane at Guy’s Hospital in London. Lane deduced his fracture treatment method from his general philosophy about the relationship between movement and skeletal structure. In 1909 he invented his famous Lane plate, which became his preferred fixing device, as he described it in his second osteosynthesis book from 1914. Lane plates

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became standard equipment in many hospitals, and pictures of the different versions available could be found in all relevant surgical textbooks. But in the field of fracture treatment fame was not equivalent with acceptance. In fact, many of these books only mentioned Lane’s technique in order to warn against it. The reason was the difficulty of reproducing the success Lane himself achieved with the technique. He was fastidious with every technical detail, using a sophisticated ‘no touch’ method to avoid infection of the fracture site, whereas others who sought to follow the great master often worked less meticulously. Consequently their results were less favourable and catastrophes due to bone infection were frequent.59 The other eminent proponent of osteosynthesis in the early twentieth century was Albin Lambotte in Belgium. Like Lane he also used a special ‘no touch’ technique and was admired for the fact that his white cotton gloves remained spotless even after a complicated operation. As with Lane’s technique, Lambotte’s methods were not easily replicated. Lambotte published two books about his experience regarding osteosynthesis in 1907 and 1913. It was in the subtitle of his first book that the term ‘osteosynthesis’ first appeared.60 Lane’s and Lambotte’s most important contemporary for the spread of osteosynthesis in the US was William O’Neill Sherman in Pittsburgh. Sherman favoured the use of steel plates with screws because they were easy to apply and allowed anatomical reduction of the fractures, but he was unsatisfied with the quality of the implants. As surgeon to the Carnegie Steel Company he was in an ideal position to investigate different metal alloys and use them to manufacture appliances designed according to engineering principles. In 1912, six years after Henry Ford had discovered that vanadium steel was suited for use in his Model-T cars, Sherman reported on bone plates made of this alloy that could be bent without breaking. Combining them with selftapping screws of the same material which had a grip four times stronger than the usual wood screws and could be manufactured to fit exactly in the plates’ holes, he had created a set of perfectly standardised implants. Sherman’s work represented a new sensibility for the material and design of osteosynthesis equipment, and in 1914 his plates were recommended for use by the Fracture Committee of the American College of Surgeons.61 Lane’s successor as the leading British figure in operative fracture treatment was Ernest W. Hey-Groves in Bristol. In his 1914 article on operative fracture treatment, which was based on numerous animal experiments and extensive clinical data, he criticised the surgical profession for its conservativeness and scepticism as a whole despite the progress being made in the techniques of osteosynthesis.62 After World War I the phase of creative and experimental optimism following the introduction of antisepsis and asepsis was terminated by a general return to closed methods of fracture treatment. Especially metal plates and screws fell into disfavour. This was the age of the high priests of plaster


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cast and traction treatment, such as Böhler and his influential Liverpool counterpart Reginald Watson-Jones. Like Böhler, Watson-Jones advocated non-operative fracture treatment and criticised the liberal application of osteosynthesis, which he limited to very few indications.63 When interest in osteosynthesis resurged in the late 1930s, there were basically three areas in which new developments occurred: the treatment of hip fractures, intramedullary fixation of long bones, and the use of pressure in plate fixation.64 The first standard treatments: nailing of hip fractures and long bones Fractures of the neck of the femur were a longstanding unresolved problem for surgeons. The most problematic cases of this common fracture form were those in which the break ran through the medial, intracapsular part of the femoral neck. For mechanical reasons these fractures could not be stabilised without internal fixation. Attempts at fixing them by means of bolts, screws or nails made of metal, ivory or bone date back to the mid-nineteenth century, but these techniques did not make it into the standard surgical repertoire.65 The first generally accepted technique for fixing femoral neck fractures was developed by Marius Nygaard Smith-Petersen in Boston in 1925. By modifying the devices that were available at the time, he created a special nail shaped like a ‘Y’ in cross-section. This ‘triflanged’ nail allowed stable fixation of the head of the femur without overly disturbing blood supply. The stability obtained with the Smith-Petersen nail made post-operative immobilisation obsolete so that functional exercises with the fractured limb could be started early on. Smith-Petersen published the favourable results obtained with his technique in 1931 and, according to contemporary commentators, restored surgeons’ trust in the nailing technique for hip fractures. The Smith-Petersen nail became the prototype for various similar devices. Böhler, for instance, initially used nails he had obtained directly from Boston but later modified the design. By 1940 nailing of the femoral neck was generally acknowledged as a regular treatment method.66 The second method of internal fixation to become established was intramedullary nailing, or the fixing fractures of the shaft of long bones by inserting some stabilising device into their medullary canal (the interior cavity of long bones containing the bone marrow). The idea was not new; as early as the second half of the nineteenth century surgeons had reported on their attempts to apply different sorts of rods or nails made of metal, bone, or ivory for this purpose.67 But it was not until the 1930s that a viable and standardised method of intramedullary nailing was developed. Its creator was the German surgeon Gerhard Küntscher. Küntscher aimed at restoring the original anatomical shape of the broken bone and making it stable enough for immediate exercise. His model was the technique of nailing femoral neck fractures which he interpreted as a special case of intramedullary nailing.

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Figure 2

Nailing of the hip as documented by Lorenz Böhler in 1938.


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The mechanical principle of Küntscher’s technique consisted in stabilising the fracture site by propping up the nail against the interior walls of the medullary canal. Like Smith-Petersen, Küntscher used a triflanged nail that provided rotation stability through pressure against the walls of the bone. Because of its triflanged shape the nail did not fill out the whole canal and the pressure on the inner lining of the medullary canal was restricted to three long but very narrow strips. Thus blood supply was much better preserved than with the usual rods and nails. Moreover, there was no need to open the fracture site itself since the nail was inserted through a separate approach at the far end of the bone shaft. At the German Surgeons Congress in 1940 Küntscher reported on the results of twelve cases of fracture of the femur treated with his method.68 Despite initial scepticism the Küntscher technique became generally accepted and in the course of World War II was adopted by the German army.69 After the war, English-speaking surgeons first encountered the Küntscher nail in former prisoners of war whose fractures had been operated on by the Germans. In 1945 Time reported such a case, and in their 1947 textbook the American authors Venable and Stuck printed an X-ray of a Küntscher nail and described it as an ‘intramedullary steel splint used by German surgeons in treatment of fracture of the femur in an American prisoner of war’.70 By the early 1950s intramedullary nailing of the femur had also been established as a standard treatment in the English-speaking world, but its application to other bones was just as controversial as in the German- and French-speaking countries.71 Compression plates By mid-century, plates were still in use. The most significant change here was that new plate systems were designed with the aim of applying pressure to the fracture site. There were a number of designs, some of them based on the concept of dynamic pressure. The American surgeon George W.N. Eggers used a device that consisted of a slotted plate, fixed with screws which were tightened sufficiently to secure the plate’s position but loosely enough to allow them to slide in the plate, permitting compression by muscular contraction and bearing weight. Other surgeons saw it as a problem that in these systems compression could not be controlled, so they built plates that allowed them to fix the amount of pressure applied to the fracture. In 1956 George W. Bagby of the Mayo Clinic introduced a compression plate system based on the combination of oval screw holes with specially shaped screwheads. The screws were built so that fastening them caused the plate to shift slightly, thereby producing compression at the fracture site.72 A few years earlier in Brussels, Robert Danis had invented a static compression plate system. It consisted of a steel plate, called the coapteur, which had a built-in mechanism to put pressure on the fracture with the help of an additional screw. Danis’ coapteur simultaneously provided powerful immobilisation and axial compression that could be exactly adjusted and

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permanently preserved. In his 1949 book Théorie et pratique de l’ostéosynthèse the Belgian surgeon determined three results to be achieved by osteosynthesis: first, sufficient stability to allow immediate mobilisation and activity of the muscles in the region and in the neighbouring joints; second, the restoration of the bone in its original form; third, the union of the bone fragments without the usual formation of extra bone tissue (callus) – a form of bone healing he called ‘soudure autogène’ and which was later propagated by the AO as ‘primary bone healing’.73 Besides the risk of infection, lack of stability was the main objection raised by those who criticised the use of osteosynthesis.74 Osteosynthesis proponents like Lambotte and Danis stressed that their fixation techniques must be applied in such a way that the bone could become robust enough to allow post-operative exercise; additional immobilisation with a plaster cast, they stressed, robbed the technique of its advantages, leaving only the drawbacks.75 The failure of most surgeons to ensure the stability necessary for exercise treatment was one of the reasons for the widespread rejection of internal fixation. Often the screws and plates only held the fragments in place while immobilisation was provided by a splint or plaster cast. In 1957 WatsonJones rejected the term ‘internal fixation’ since he held that osteosynthesis never led to stability, but only to correct positioning of the fragments.76 In the late 1950s, use of plate osteosynthesis was declining, ‘principally because in general, intramedullary nailing has shown to be more effective in obtaining the desired end-result’, a US surgeon wrote in 1959.77 At that time, the pendulum of general opinion had swung back against operative treatment. With the exception of intramedullary and femoral neck nailing, osteosynthesis had no place in the standard repertoire of fracture care.78 In the mid-1950s Böhler in Austria and Watson-Jones in England as the leading authorities in fracture treatment had taken conservative treatment to a level of sophistication that could hardly be surpassed. Both recommended internal fixation only for the few cases which could not be managed by other means. A technique of masters It is striking how the initial enthusiasm for a new osteosynthesis method regularly gave way to disillusionment once it became apparent that its widespread use by surgeons lacking adequate training led to spectacular failures.79 From the beginning, osteosynthesis was seen as a difficult technique. At the turn of the century both Lane and Lambotte pointed out the necessity of a thorough command of their methods and of aseptic surgery in general. They knew that their technique’s reputation depended on its competent application. Lane wrote in 1912 that there was ‘nothing wrong with the principle’ of the operation he was describing, though it was ‘very liable to fall into disrepute because of the incapacity of the operator’.80 Bad results were a very serious problem in a field in which the outcome of a treatment was obvious to anyone: unlike other areas in surgery, evidence of incompetence


25

in orthopaedics was ‘visible and enduring – a single case of malunion having the potential to ruin a surgeon’s reputation’, as Roger Cooter wrote.81 Also in 1912 a commission appointed by the British Medical Association judged operative fracture treatment to be beneficial in principle, insisting, however, that it was ‘not a method to be undertaken except by those who have constant practice and experience in such surgical procedures’. 82 Similarly, an American expert who had surveyed 34,753 compensation files for the Aetna Life Insurance Company wrote in 1927 that it was ‘questionable if open bone surgery should ever be done except by highly trained men, with highly trained assistants, in highly trained hospitals; otherwise disaster is likely to result’.83 The German surgeon Fritz Steinmann assumed in 1927 that internal fixation would never become the method of choice because the technique was too difficult, the requirements for asepsis too strict and the risks too high.84 In the 1929 edition of his textbook Böhler considered the introduction of internal fixation the most disastrous development in fracture treatment and blamed it for the death of thousands and permanent disability of even more. According to his estimate, only very few surgeons were able to use osteosynthesis successfully on a regular basis.85 In defence of the operative approach, the German surgeon Fritz König argued that hundreds of failures through incorrect surgery could not refute the positive proof provided by a few perfect results. Using an argument that was typical for osteosynthesis advocates, he asserted that many surgeons rejected internal fixation simply because they were not able to master the technique.86 Many commentators also emphasised the indispensability of complete high-quality equipment. ‘If competent assistance or adequate equipment is not accessible’, the Americans Venable and Stuck cautioned in 1947, ‘it is better that the operation be left undone than be done poorly.’87 But generally, the main emphasis was on procedural rather than material quality problems. ‘If you have a poor surgeon, you can give him the best apparatus in the world, and he will still get a high percentage of failures’, the authors of an American study concluded in 1954.88 Böhler, too, saw the availability of high quality equipment as part of the problem. In his opinion the danger was great at, as he called them, ‘hypermodern’ (übermodern) hospitals where high standard technical equipment was the rule. No one, he argued, was capable of acquiring the knowledge and skill required to use all the various equipment many hospitals had to offer, including those for Lane’s and Lambotte’s osteosynthesis methods. But once the instruments were made available, they would be used, even if the users lacked the experience of a Lane or a Lambotte. The use of the equipment resulted in a rise of mortality rates, he wrote, which would only drop again when the complicated special instruments were put aside.89 It was not unusual for surgeons who had invented or improved a device to attribute its subsequent failure in the hands of others to the users’ lack of

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experience. Reacting to complaints about his modified version of the Küntscher nail, the German surgeon Kurt Herzog asked his colleagues to suspend judgement on his nail until a sufficient number of surgeons had become proficient in using it. Seen from this perspective, it was only justifiable to condemn a new technique of operative fracture treatment if the results under optimum conditions – in a specialised department with traumatologically trained surgeons – proved to be less satisfactory in the long run than those by conservative treatment. Indeed, this had been the case with Böhler’s experiments using lower leg intramedullary nailing.90 The general problem of deficient surgical skill and competence also affected the reception of the original Küntscher nail. Although the technique had initially shown favourable results and appeared to be free of risk, after 1943 many surgeons started reporting ever more cases of failure. Serious bone infection, amputation and even death after application of the nail induced some colleagues to argue that the method had been propagated too quickly. Küntscher saw the problem and warned that medullary nailing should only be performed by surgeons who possessed the complete equipment and the necessary training.91 In reaction to harsh criticism directed against his plate system, Danis in 1956 rejected any responsibility for the poor results reported by those who used his technique with haphazardly composed equipment, insufficient training and less than serious preparation. Here more than in other areas of surgery, he emphasised, asepsis, in particular, had to be extremely stringent.92 During the first half of the twentieth century osteosynthesis was considered unsuitable for large-scale use. Surgeons like Danis were regarded as isolated artists whose results were hardly reproducible by anybody else.93 Though the advantages of well performed internal fixation were obvious even to its critics, the risks associated with its use by the average surgeon were often considered unacceptable.94 But it was not easy to be sure about the real cause of failure or success as long as it was not clear in detail how surgeons had treated their cases. Lack of standardisation impeded not only the widespread use of osteosynthesis techniques but also their adequate assessment. A US surgeon counted no fewer than 62 different methods of internal fixation in 1934. And with the exception of intramedullary nailing, the lack of a coherent system continued into the 1950s: indications were inconsistent, ideas on bone fracture healing were vague and often contradictory, and the available instruments were little tested.95 By contrast, conservative fracture treatment was firmly established as an acknowledged field of surgical activity. Accidents, the main source of fractures, were seen as disease-like events whose consequences had to be dealt with by surgery. A foundation for financing fracture care also existed. Among others, Böhler had demonstrated the need for a system of sophisticated fracture care


27

and he had also illustrated how this demand could be met by instituting the quasi-industrial use of systematic and standardised practices. Most of the treatment methods Böhler employed were non-operative. In operative fracture care nothing like the Böhler school existed. Among the surgeons who saw a need to systematise the previous haphazard efforts at operative fracture care were those who founded the AO in 1958.

2

Starting the Network

On 6 November 1958, 13 surgeons from different hospitals in Switzerland met in Bienne to found an association for promoting the systematic treatment of bone fractures. Together they set out to introduce a particular system of fracture care using internal fixation and early functional exercise. The idea was to do this as a close-knit group. All members of the group, which was given the name AO (Arbeitsgemeinschaft für Osteosynthesefragen – Association for the Study of Osteosynthesis) would use the same standardised technique and equipment and keep in close contact, sharing their experiences so that they could learn from each other. In this chapter I will focus on the specific character of the group, trace it back to its origins and examine the role it played in spreading the AO technique. The roots The idea of building such a group had been around for some time. Maurice Müller in particular had been looking for an organisational base for the systematic introduction of operative fracture care since the early 1950s.1 The young orthopaedic surgeon (born 1918) had had a special interest in osteosynthesis early on and had spent the largest part of his orthopaedic training at the famous Zürich University orthopaedics clinic, the Balgrist. A charity foundation established in 1912 for the care of disabled children, the Balgrist first became affiliated with the university in 1945. In its new institutional setting the clinic continued to focus on the care and education of the disabled, while surgery remained on the periphery. In 1944/45, Müller would spend 18 months there training as an orthopaedic surgeon. In light of the Balgrist’s non-active, non-operative approach to treating disabilities, Müller found that the conditions for helping patients were, in his words, ‘dreadful’. After Müller left the Balgrist he spent the year 1946/47 in Ethiopia as a general surgeon, an experience he would later describe as crucial for the course of his future career as an innovative surgeon. Upon his return from Africa he 28


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took up a two-year position as a senior surgeon at the Kantonsspital in Liestal near Basel. Since the department was headed by a Böhler adherent, Müller received training in Böhler’s systematic approach. In 1949 Müller was well on his way to expanding his treatment repertoire, but after the two-year contract at Liestal ended, he was stuck without a job. Making the best of the situation, he travelled extensively and visited hospitals throughout Europe, ever eager to take up new surgical ideas and techniques. In 1950 one of his journeys took the ambitious young man to Brussels, and to Robert Danis, who showed Müller how to achieve absolute stability of fractures by applying pressure through the use of screws and the coapteur. There Müller also learned of the phenomenon Danis called soudure autogène, by which bones heal without the formation of callus (additional bone tissue). Müller was deeply impressed and adopted the treatment principles set up by his older colleague. As he later remembered, he was amazed how Danis’ technique allowed the post-operative mobilisation of patients and admired the way the Belgian meticulously recorded the course of every case he treated. But he also realised that Danis had no pupils to spread the technique and that he did no research. When Müller was put in charge of trauma care later that same year at the Bürgerspital in Fribourg near Bern, he started applying and modifying Danis’ technique, performing and recording 72 osteosynthesis operations during his stay. In the following year Müller returned to the Balgrist, where he was to spend the next five years. In 1952 he qualified as a surgical consultant and became senior orthopaedic surgeon (Oberarzt). The Balgrist was one of only two orthopaedic university hospitals in Switzerland (the other being in Lausanne). Though accident victims were not within its purview and surgery was still peripheral, the institution was nevertheless a busy place offering a wealth of difficult and challenging cases for an ambitious and innovative surgeon. Furthermore, under the hospital’s new head, Max René Francillon (1899–1983), the young orthopaedic surgeon had the freedom to apply his unusual methods and the implants he had developed. In addition to introducing new sorts of surgical interventions, Müller also systematised operations and post-operative care. Müller’s operative success during his stay at the Balgrist earned him an excellent reputation as a hip surgeon. At that time he started his activities as a visiting surgeon. Every Saturday he would pack his special instruments and implants and go to operate on trauma patients who had been prepared for him in other hospitals. Concluding his training as an orthopaedics consultant in 1956, Müller then went on to qualify as a university teacher in 1957.2 In the same year he left the Balgrist. Despite his growing reputation he was kept on a low salary and was not allowed to accept additional fees from private patients. So he resigned his post and from September 1957 to October 1960 was busy operating in more than 70 different Swiss hospitals, travelling around with a big bag containing his special equipment. Making a living as an itinerant

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surgeon was absolutely unique. But the activity not only provided Müller with fame and a better income (during his first week he earned the equivalent of two years’ salary at his old position), it also gave him the opportunity to demonstrate his ideas and techniques to numerous colleagues, among whom some later joined forces to found the AO. Müller was very much a visionary, but not everybody was prepared to believe in his visions. When he first began propagating his ideas of systematic fracture care, the surgical and orthopaedic establishment did not take him seriously. This might be due in part to his youth and the fact that Müller was not as adroit in presenting his techniques as in inventing and using them. A further reason was his unusual combination of interest in both general surgery and orthopaedic surgery which caused problems of disciplinary affiliation. For this reason it was important for Müller to gather a group of colleagues around him who were interested in his innovative ideas and believed in their potential. This group came together by personal acquaintance. The first contact was with Robert Schneider (1912–1990), who had grown up in the same Bienne district as Müller. During high school (Gymnasium) they had been on the same rowing team at the Bienne Seeklub, with Müller as helmsman and Schneider as oarsman. They met again in 1952 while serving in the Swiss army. The Swiss army was (and still is) a militia army, consisting of citizens who do one extended period of national service, after which they are then called upon periodically for reserve duty exercises. Doctors in the rank of officer, such as Müller and Schneider in their time, first go through a special promotion service programme, upon completion of which their military obligation consists of attending an annual course lasting three and a half weeks.3 With his blond hair and strong, tall physique Schneider looked Germanic, while Müller, who was six years his junior, was rather of the Mediterranean type, dark, short and agile. At that time Schneider was an experienced general surgeon. Müller was a prospective orthopaedic consultant with a penchant for innovation. He had already caused some commotion with his new and unconventional style of surgery and with the self-assurance with which he at times ignored the military hierarchy. Emblematically, Müller enjoyed entertaining his comrades with conjuring tricks showing off his superior manual dexterity in public. Schneider was at first a bit sceptical about his old acquaintance’s surgical competence, but before long an opportunity arose for Müller to prove his special expertise. Following their lively discussions on surgical problems, Schneider presented Müller with a particularly difficult case to operate on. Müller went to Schneider’s hospital in Grosshöchstetten near Bern and mastered the operation brilliantly, thus gaining the respect and friendship of the older surgeon. Both men stayed in close professional and personal contact in the following years. By 1956 they had worked more than 100 days of army reserve duty together, and it was through Robert Schneider that Müller made contact with six of the later AO founding members.


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The fact that a number of later AO members had known one another from the military gave their relationships a special character: having been snowed in together during a military exercise was a much firmer basis for cooperation than the occasional contact offered by medical congresses, as described by a member who had had that experience.4 Many of the surgeons who later became AO members already knew each other from other contexts. Personal ties from school, university, clubs and the military were an important and typical element of social and political life among the educated Swiss. Traditionally, they were acquainted through the officer ranks of the military or student fraternities and maintained a network of informal personal relationships.5 Through Schneider’s recommendations, Müller was regularly called to other hospitals in the region too. He often went to nearby Interlaken, where Walter Bandi (1912–1997), Schneider’s good friend from student fraternity days, was in charge of the surgical department. All of these surgeons were impressed by the results Müller achieved with his new techniques. A few of them even maintained regular contact with each other. As they were all from the Bern region, the core group of the later AO was very much a Bernese affair, which is more significant than an outside observer might expect: in Switzerland territorial origins still have great significance,6 and even within the German-speaking territories there are strong regional affiliations. Inhabitants of the rural and conservative Bern region, for instance, have a strong feeling of their separateness from other Swiss regions and urban centres such as Zürich or Basel. The communal spirit prevailing in the early AO and its assertiveness against outside criticism owed much to the specific regional identity of its members. This attitude can also be attributed to the specific medical milieu within which Müller enrolled the early group of collaborators. It was based on the peculiar structure of Swiss hospital organisation. The origins of this structure go back to the first two decades of the twentieth century when all over the country local authorities founded small to medium-sized public hospitals. At the medium-sized hospitals, head surgeons were in charge of small departments, typically assisted by a single intern who lived on the premises. The head surgeons were usually broadly qualified with years of practical experience behind them. This made them well respected and proud autocrats each within his own small realm. Most of them were acquainted, with their acquaintances in many cases going back to their university and military days, and many, especially those within the canton of Bern, considered themselves to be friends. This class of surgeons kept at a distance from the professors of the university hospitals, preferring instead to form their own professional network parallel to academic surgery.7 Thus the AO did not arise in any of the surgical centres but rather on the surgical periphery. Nor did it include any of the established leaders in the field of fracture care. Most of the original AO members were general surgeons who had, initially, little experience in fracture treatment; only two were

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orthopaedic surgeons, one of them being Müller. A renowned specialist for difficult orthopaedic operations, Müller was the group’s expert on bones and muscles, sinews and joints, so the others were prepared to follow his lead. Soon another Bernese would enter the circle through Schneider’s mediation. This time it was Hans Willenegger (1910–1998), who was already an experienced trauma surgeon when he invited Müller to Liestal near Basel in 1955. He had worked as a senior surgeon at the university department in Basel since 1948 which he had temporarily headed following its director’s unexpected death in 1950. In 1953 Willenegger became head surgeon at the Kantonsspital in Liestal, where Müller had interned a few years earlier. Willenegger had become familiar with osteosynthesis during his internship at Otto Schürch’s department in Winterthur, which its critics considered rather too supportive of osteosynthesis. Like Müller, Willenegger pleaded for meticulous case documentation and had even shown the way by publishing a large number of well documented cases himself. He was a committed surgical teacher and had a strong interest in basic science. On the basis of his earlier experience, it took no great leap of faith for the Liestal head surgeon to adopt the osteosynthesis methods suggested by Müller. After seeing the benefits of stable osteosynthesis on Müller’s second visit to Liestal, Willenegger adopted the Danis coapteur for lower arm fractures.8 In October 1956, just after he had returned from a journey to Böhler’s clinic in Vienna, Maurice Müller brought together his five friends for a three-day instruction course on stable osteosynthesis. Assembled at the Balgrist, the group now pondered the thought of creating an equivalent of the Böhler school devoted to operative fracture treatment. When they met on the evening after Müller’s Habilitation lecture in Zürich on 5 December 1957, they agreed to call their group AO, short for Association pour l’Ostéosynthèse.9 A few months earlier, Müller had also started communicating with Martin Allgöwer (born 1917), who would later play a pivotal role in the AO’s organisation. In late September 1957 Allgöwer had asked his friend Willenegger for advice on a particularly difficult hip problem. Willenegger recommended a look at Müller’s recently published monograph on osteotomies of the upper femur and suggested contacting Müller about the case. Trusting his friend’s opinion, Allgöwer invited the author to Chur, located in the Canton of Grisons in south-east Switzerland, in order to perform the operation, where he once more proved his exceptional surgical talent. Afterwards as the two surgeons were discussing the fracture cases seen at the Chur department, Müller explained to the general surgeon the benefits of stable osteosynthesis and post-operative mobilisation. Allgöwer had been hardly concerned with fracture treatment before he was appointed head surgeon of the Kantonsspital in Chur in 1956. But fractures were becoming increasingly important to him in his new environment in south-eastern Switzerland, as its was surrounded by the Alps with their


33

numerous skiing resorts. A fine winter weekend would bring 30–40 fracture patients into his hospital ward. The problem was that he needed to get them all out again by the following weekend, when the situation was likely to repeat itself.10 So Allgöwer was pleased to hear of a method that could help expedite the treatment process. Quick to see the potential in Müller’s ideas, Allgöwer took up his recommendation to use the special bone screw designed by the Swiss Ernst Baumann for tibia fractures. Just four weeks later, the Chur Kantonsspital was full of patients with screws in their bones undergoing systematic post-operative mobilisation. Eager to continue learning the relevant techniques from Müller, Allgöwer invited him to operate on a regular basis at Chur.11 Originally from St Gallen, Allgöwer was one of the first group members from outside the Bern region.12 His specific professional contribution was his expertise in plastic surgery and his focus on soft tissue surgery.13 But also, and perhaps more importantly, he contributed his rhetorical and social talents to the emerging group. A born leader, Allgöwer instilled trust and confidence in patients as well as in colleagues. Whereas Müller – wiry and agile, often charming, but also capricious in his moods – conveyed the impression of a lively genius, Allgöwer, who was tall, fair, graceful, eloquent and conciliatory, was described as a perfect man of the world. During his training as a surgeon in Basel Allgöwer had functioned as the assistants’ speaker and had stood up to the newly appointed head surgeon Schürch for harassing his subordinates (at the time, Willenegger was also in Basel, as he had followed Schürch as part of his staff from Winterthur). Allgöwer had a marked sense for team work, and visitors to his Chur department reported on his team’s open and positive atmosphere reminiscent of American surgical institutions. In many respects, Allgöwer was the group’s only real match for the dominating Müller, and he rapidly became their other leader. Allgöwer’s work in laboratory science made him see its importance as a basis for surgical innovation. After his medical exams in 1942 he had spent two years in a tissue culture laboratory of the Basel pharmaceutical company, Ciba; and when he started his surgical training at the Basel Kantonsspital in 1945, he was granted his own laboratory to continue his research. After the confrontation with Schürch, Allgöwer was sent to the US to participate in a ten-month research project organised by Hans Willenegger with funding from three Basel foundations. Going abroad for research was quite unusual for Swiss surgeons at that time. Happy for the opportunity to experience American lab procedures, Allgöwer worked mainly on burns injuries in the laboratories of the research department at the University of Texas Medical School in Galveston. When he came back in 1952, Schürch had died and Willenegger had become the temporary head of the department. Allgöwer continued his surgical career and in 1953 submitted his post-doctoral Habilitation thesis entitled ‘The cellular basis of wound repair’. In 1956 he moved to Chur, where he then met Müller.

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In a way, Allgöwer’s recruitment turned the original arrangement of master and followers into a potential group. In the spring of 1958 Allgöwer and Müller invited fourteen surgeons to Chur for a workshop during 15–17 March. Eleven of them turned up, and they formed the group that was to become the AO. Maurice Müller gave the introductory presentation on the principles of osteosynthesis, followed by presentations from Allgöwer, Willenegger, Bandi and Schneider, who would long remain the AO’s principal spokesmen. The theoretical sessions were rounded off by practical exercises with cadaver bones in the basement of the Kantonsspital.14 The ‘AO philosophy’ At the meeting in March 1958 Maurice Müller announced the three main objectives of osteosynthesis treatment: restoration of the original anatomical shape of the broken bone to make normal function possible; functional rehabilitation by active exercise of adjacent muscles and joints after the operation; and ‘primary healing’ of the fracture without the formation of callus.15 These were the basic constituents of the ensemble of theories, practices and tools that became particular to the AO and which the AO’s doctors, scientists and producers liked to call the ‘AO philosophy’. Other parts of the specific AO approach included systematic case documentation and standardisation of techniques and devices. The reason Müller gave for setting up this programme was the unsatifactory state of fracture care at that time. Long-term immobilisation in the course of conservative treatment and insufficient pain-killing frequently caused irreversible secondary damage in fracture patients. Breaking a bone often led to long-term disability, even if the bone itself had healed. In the mid-1950s the Swiss state accident insurance company, SUVA, paid disability pensions to 40 per cent of its patients with lower leg fractures because of permanent damage.16 One of the most dreaded complications was fracture disease. In fracture disease, the bone of the affected limb loses its substance (osteoporosis), muscles waste away, and fibrous tissue forms in the joints and the spaces between the muscles, finally leading to permanent reduction in the range of movement.17 This complication, Müller claimed, could be prevented by the combination of effective fixation with post-operative exercise. The aim of all the measures he suggested was perfect functional reconstitution. It was not so much the question of bone healing that was at issue, but rather the quality of healing with regard to long-term function of the injured limb.18 This was not a new idea. As mentioned in Chapter 1, trauma rehabilitation had been a primary issue in surgery at least since the interwar period. 19 Functional reconstitution was the primary aim pursued by Lorenz Böhler with mostly conservative means and by Robert Danis with his technique of compression osteosynthesis. Müller asserted that by following Danis in adding operative treatment to the arsenal of surgical techniques the AO could accomplish what Böhler had aimed to do with his approach.20


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Müller had also adopted his three main objectives – anatomical reconstruction, functional rehabilitation, primary bone healing – from Danis,21 and he used the same words Danis had used in his 1949 book when demanding that in order to make post-operative functional treatment possible, the fracture site had to be turned into an absolutely stable block.22 Maintance of this stability during the healing process could be achieved by applying pressure to the fracture using intramedullary nails, screws or compression plates. Such a ‘functionally stable osteosynthesis’ made additional external fixation unnecessary. Free of pain and unhindered by plaster casts or traction devices, patients were able to actively move their muscles and joints.23 Even though the AO surgeons were not the first to eschew the plaster cast, complete abandonment of the method of immobilisation after the operation was a radical step at the time.24 It is evident that in setting up its philosophy, the AO adopted and improved on existing concepts. So the AO surgeons did not claim priority for their ideas and techniques, but rather included themselves in a long line of tradition, thus adding to the legitimacy of their radical propositions.25 What was new, however, was the way the AO organised the controlled application of its technique in a close-knit group of well trained experts. The way to create this sort of group was by using a special mode of organisation available in Swiss culture, the fraternity, which could easily be combined with the ideals of surgery as a science endorsed by the AO founders. A surgeons’ fraternity The surgeons’ next meeting took place on 6 November 1958 and was devoted formally to establishing the AO as a surgeons’ association. Though an association for the promotion of a particular medical treatment was without precedent in the country, the step of organising one’s common interests as a registered society is very common in the German-speaking countries which have numerous clubs for all kinds of purposes, and even small cities have a range of societies – from rabbit breeding associations to football clubs. If they fulfil particular requirements as to their purpose and organisation, payments made to these associations are tax free. They are all subject to the same set of legal regulations. They require the adoption of formal statutes, democratic legitimation of their management, set rules for the recruitment of new members and public control of financial dealings. For the later AO surgeons, the idea to give their efforts such an organisational basis was thus in no way strange, especially as they were planning a number of common research and educational activities which needed to be organised and paid for. Thus at the following meeting in Zürich in March 1959, three new members were elected and Allgöwer reported on the simultaneous opening of the research laboratory and the AO documentation centre in Davos. At the following meeting in November of the same year, the AO statutes were discussed. Though de facto the AO had already been founded in 1958,

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the legal process still required setting up statutes and electing an executive committee. The AO’s establishment as a registered society in accord with article 60 of the Swiss code of civil law was prepared with the help of a lawyer. The members unanimously elected a committee: Maurice Müller became secretary and Martin Allgöwer treasurer; Robert Schneider, a Bernese, seemed to be the natural choice for the official spokesman or president. 26 Significantly, the AO avoided the usual designation Vorsitzender, or president, choosing instead the somewhat unusual title of Obmann, which lays stress on the function as a spokesman. The choice emphasised the non-hierarchical character of the office and attributed only a circumscribed function to its holder. The Obmann’s tasks included preparation of the group’s meetings and congresses, writing the annual reports and representation of the group in public. As a group, the executive committee held no separate sessions, nor was there a separate committee’s table during the AO meetings, where the officers instead took their seats among the other members in the room.27 The AO statutes reflected the group’s origin in the milieu of autonomous head surgeons at small and medium-sized hospitals, requiring that all members had to be in an independent professional position.28 Taking place each spring and autumn, the regular AO meetings were seen as the basis for the association’s existence and coherence. As the AO’s innovative drive applied as much to the organisational aspects of fracture care as to its technical and scientific basis, meetings consisted of an administrative and a scientific session. The sessions provided an institutionalised forum where negotiation was possible between the surgeons, and later also the manufacturers and basic scientists, so that they could discuss their problems and attend to their respective interests while simultaneously keeping an eye on each other.29 Exchange and coherence was helped by the special character of the AO as a confederation, and more specifically, a fraternity. Being firmly rooted in Swiss collective mythology, the cultural motif of the confederation (Bund) shaped Swiss social life on all levels. The right of citizens to freely form associations was seen as the most important organising principle of Swiss society. The main values embedded in the idea of the confederation were liberty, equality, unity and loyalty. While leaving much room for interpretation, these collective values pervaded the lively culture of Switzerland’s numerous clubs, organisations and societies.30 The AO was also based on this principle and functioned by mobilising the moral and emotional powers inherent in the common ideal. Taking on the confederation pattern was not a question of deliberate strategy. In an environment pervaded by the Bund theme, it simply was the natural thing to do. The early AO was thus a typical fraternity in the sense of the German term Männerbund,31 that is, an institutionalised corporation of men with life-long participation in the group (women were excluded, but their exclusion was also a result of their virtual non-existence in the surgical community at the


37

time). While all the early AO members would be familiar with fraternity culture, some of them would even have made contact earlier in other fraternal contexts such as the Bienne rowing club, the military, or college societies. Schneider and Bandi, for example, had been in the same fraternity at college which had given them the opportunity to establish their close friendship within a framework of ritualised conviviality, and an institutionalised apprenticeship pattern in which Schneider acted as Bandi’s mentor. Müller’s student fraternity had also provided him with a field in which to practise his organisational talents. He had had a leading role and had been in charge of organising the fraternity’s parties. Socialising rituals, formalised acts of male bonding and competition, group solidarity, the copious use of patrilineal metaphors (Müller, Allgöwer, Schneider and Willenegger were called the ‘founding fathers’) and ample opportunities for building friendships were elements the AO shared with other fraternity-type organisations.32 The social principle of the early AO was a very traditional type of relationship that encouraged face-to-face interaction between members. But at the same time the AO was a distinctively modern association of medical experts whose aim was to promote a scientific approach to surgery. This apparent discrepancy points to a more general issue underlying the group’s structure: As historian of science Steven Shapin puts it, the importance of face-to-face interaction for modern science is often underestimated. It was premodern society, and thus the received view, that ‘managed its affairs in a face-to-face mode’. Here, people ‘were able to draw upon the resources of familiarity ... Knowledge circulated within a system of everyday recognitions’ so that ‘premodern society looked truth in the face’. By contrast, ‘the modern condition permits no such effective resort to familiarity and personal virtue in deciding upon the truth and falsity of knowledge claims’. Instead trust is being placed in abstract institutions and systems, such as the university or the medical profession.33 The example of the AO, however, does demonstrate the importance of the face-to-face dimension in modern science and technology. Particularly in its beginning stages, the AO was indeed a face-to-face community; its organising principle was personal familiarity, and relationships took place primarily on a personal level instead of through the proceedings of an anonymous institution. This principle remained the guideline during the AO’s subsequent expansion, though, as will be described in detail below, it was a guideline that would become increasingly difficult to apply.34 The AO was a close-knit community in which the boundaries between private and public realms were blurred. AO meetings were considered a sort of private event: when in 1971 the surgeons were deciding whether to publish the minutes of their meetings, one member opposed the plan by arguing that the purpose of the AO meetings was to provide the members with a ‘private circle’ where they could discuss issues that they did not yet want to make public; publication of the meetings’ minutes would, then, represent a violation of this boundary.35 The mixing of private and professional life to

38


create trust was typical for fraternal associations and for Swiss club culture in general. Conviviality was another trust-building factor, which explains why celebrations and banquets were as common in the AO as they were in Swiss shooting clubs.36 The official AO meetings, which the members hosted in turn, were followed by an invitation to the home of the respective host. Banquets and long evenings in front of an open fire belonged to the specific AO culture of friendship. Ski racing competitions among members also became a regular feature of the AO culture. Already the very first prefoundation meeting in March 1958 included a ski trip that gave Müller and Allgöwer yet another opportunity to lock horns and, ultimately, to reaffirm their equality.37 In subsequent years the AO surgeons from the various hospitals maintained a tradition of meeting up once a year on the slopes, forming teams and racing against each other. According to Robert Schneider in one of the annual reports, these competitions functioned as an outlet for rivalry and aggression that had built up among the surgeons during the previous year.38 Even though relationships between surgeons are often marked by sentiments of personal and professional rivalry, the AO surgeons were anxious to curb these tendencies within their own ranks. They wanted to test the various techniques of osteosynthesis ‘regardless of questions of prestige’, as it is stated in their textbook.39 For this the values of Swiss fraternity culture, as embodied in the traditional code of behaviour of the shooting clubs, came in handy: in the shooting clubs everybody lined up in formation to shoot, and after the round of shots the prize-winning rifleman would stand apart from the rest of the group for one short moment before promptly stepping back into the line.40 In the opinion of the AO surgeons, too much competition would disrupt the free and rational exchange of data. Harmony was a central element of the group’s self-image as well as its presentation towards others. At the congress of the German Surgical Society in 1963 Müller emphasised the benefit of open discussions ‘free of envy and vanity’ among the AO surgeons with their various, often contrasting, backgrounds and different degrees of surgical skill and experience.41 The minutes of the AO meetings reflect a friendly, basically goal-oriented atmosphere. They report of surgeons bringing along their patients’ X-ray pictures to discuss their experiences and problems under the benevolent, fatherly leadership of the founders. There were no ballots at the meetings, all decisions were made in consensus. This non-confrontative style, which is also typical of Swiss politics in general, must not be taken for the absence of power differences or a sign of constant agreement: differences of opinion were argued out among the leading members before the meetings, and there was never any serious doubt about who was in control during the first decades of the AO.42 Thus the AO leaders were able to utilise the cultural pattern of the fraternity for organising a group of loyal followers with which they could try out their


39

own treatment method in a rural or small city environment without the help or, if necessary even against the will of the conservative Swiss medical elite at the universities. Seen from this perspective the egalitarianism and democratic spirit of the fraternity-type group helped the leading AO surgeons to appropriate some of the university surgeons’ influence and power. Whatever the background, the cooperative atmosphere within the association – later called the ‘AO spirit’ – was apparently unique at the time. Early observers noted the contrast with the authoritarian style that traditionally pervaded surgery, especially in the German-speaking world: At a time when it was normal for junior surgeons in hospitals to be humiliated by the head surgeon in front of the whole team, the AO discussed cases of failure on a technical level, without personal degradation.43 This contrast reflects a more general cultural difference between Switzerland and its German-speaking neighbours: Austrians and Germans were much more prepared to subject themselves to authority than the Swiss. Both countries had a tradition of authoritarian government with widespread popular support. Swiss culture with its strong anti-bureaucratic tendencies did not permit such open display of government power and authority. Accordingly, the emphasis on personal respect and dignity among members, integration and consensus, all integral elements to the Swiss club culture, were what gave the AO its distinctive character.44 The differences in style had significant effects on the efficiency of spreading new techniques. Lorenz Böhler for instance tried to maintain control over the use of his techniques by dealing with his subordinates in the authoritarian manner typical of the military. But his habit of intimidating the surgeons who assisted him simultaneously undermined the patriarch’s efforts at control. In fact, when his assistants made mistakes or difficulties arose, they preferred to conceal them in order to evade Böhler’s rough treatment. This explains why young surgeons who had experienced Böhler’s style were particularly struck by the pleasant and liberal atmosphere within the AO. Here they felt no need to conceal anything from the others.45 Control was voluntary and thus much easier to achieve. The friendly environment and its positive effects on control were also noted by surgeons outside of the AO. According to a comment by two German authors in 1963, psychological factors normally impaired scientific exchange: surgeons worried that their own results compared poorly with those achieved by colleagues, and they built up an inner resistance to letting others participate in their experience. Such psychological constraints, the authors stated, did not apply to the AO.46 The AO members’ non-authoritarian manner of exchange was not only part of Swiss club culture, it was also integral to the particular model of scientific medicine endorsed by the AO. This model stressed democracy and equality among colleagues and de-emphasised personal authority. Surgery was seen as a science and could be mastered by any surgeon. Even the most junior colleagues were allowed to criticise their elders. The opposite view was

40


the widespread notion that surgery was more an art than a science and that it depended on the personal skill and experience of particular authorities in the field.47 This view was favoured by some of the AO’s critics such as the Zürich University head surgeon Hans-Ulrich Buff, a well educated, upperclass grandseigneur. For Buff, the idea of equality was problematic. The fact that most of the AO members were provincial and, in his eyes, mediocre surgeons demonstrated the AO’s inability to provide high-quality fracture treatment.48 As will be discussed in more detail in Chapters 4 and 6, for the AO, however, inclusion and equal treatment of ‘average’ surgeons were part and parcel of their project. The group’s special character was laid down in the AO statutes that were officially adopted in 1960. Their first article stated that the aim of the AO was the study of problems of fracture treatment, experimental research in this field and the exchange of experience in practical and scientific matters. Modelled after the relevant regulations of the Swiss civil code, the statutes declare the members’ assembly to be the highest decision-making body. Regular attendance of all members at AO meetings was taken very seriously, especially in the early years. Members were required to respect the treatment principles developed by the AO ‘as far as possible’. They were not, however, obliged to the exclusive use of AO instruments. Deviating from the Swiss association rule, admission of new members had to be decided unanimously, thus enforcing consensual decisions on that crucial topic, though during the whole history of the AO there was only one case in which the admission of a candidate failed because of a member’s veto. Obviously, expansion was to be carried out in a careful, planned and harmonious manner. Friendship among members was also formally stipulated: In compliance with article 12, members had to commit themselves to a collegial and friendly attitude towards each other, so that each individual member can rely on the collegial support of all members. Practical and scientific progress in the area of operative fracture treatment achieved by individual members must be made accessible to all AO members. Members should strive to support each other where possible.49 These regulations point to the potential of conflict within the group. The atmosphere of companionship within the ‘AO family’ made the group special for its members.50 And they strove to project this distinctive quality as part of their public image. ‘In the present age of the atom it is hardly possible to do research on one’s own’, Maurice Müller wrote in 1963. ‘Real progress’ was only possible through joint planning and joint research. But, as he continued, ‘the main benefit of the AO [lay in] the deep friendship’ between AO surgeons. And, he added with some enthusiasm,


41

How pleasant it is always to be able to ask someone for advice! And in case of serious failure – from which no surgeon is spared – one finds in the bosom of the community not only understanding but also the means to overcome the worst difficulties. Thus – besides the professional gain – it is above all the human aspects of the AO which we could not do without.51 The sense of community was enhanced by the fact that the AO surgeons initially contributed private money to the group’s research programme. On founding the association each member paid 500 francs for the establishment of the Davos laboratory, which was a large sum of money at that time. They also contributed money at the later meetings, the pay-in slip being considered the association’s ballot paper. In 1960 Allgöwer asked the AO members to redirect payments they had received from colleagues for their osteosynthesis activities and all other unexpected surplus to the Davos ‘collecting tank’.52 In exchange the AO members gained access to and instruction in an attractive treatment technique, as I will discuss in Chapter 4. The AO laboratory So part of the rationale in founding a formal association was the establishment of a commmonly financed laboratory. The laboratory was set up in order to provide the AO technique with a scientific foundation. Among the early AO members, it was above all Hans Willenegger and Martin Allgöwer who were interested in experimental science. As will be described in Chapter 5, Willenegger would be the first of the AO surgeons to become actively involved in laboratory research on fracture treatment by establishing the contact with Robert Schenk in the anatomy department at the University of Basel. The idea to set up the AO laboratory, however, goes back to Allgöwer, who had gathered extensive laboratory experience in the US during the early 1950s. Following his appointment to the post of head surgeon in Chur, Allgöwer had been looking for regional facilities to continue his laboratory research53 when he heard of the availability of existing laboratory space in Davos. Situated in a high alpine valley 1600 metres above sea level, the little town was a traditional venue for tuberculosis sanatoria such as the one described in Thomas Mann’s famous novel The Magic Mountain. Davos also had a research institute that had been founded in 1922 to house medical and meteorological research groups. The medical facilities were mostly used for autopsies of tuberculosis victims, several hundred being performed each year. With the advent of new chemical and surgical treatment methods for tuberculosis, however, in the early 1950s, sanatorium treatment became obsolete. Many of the sanatoria were converted into hotels and the local pathology facilities were abandoned in 1958 until a new occupant could be found. When Allgöwer came to inspect the premises later that year, the only person he could find was a janitor assigned to monitor the temperature and keep the building from freezing. The empty rooms still contained the marble

42


dissection tables, which could, as Allgöwer saw it, be reused as operation tables for animal experiments. Aside from these old rooms, which were amenable to conversion into laboratories, there was also a new annexe with a lecture hall of 60 seats. The Canton of Grisons was offering financial incentives to anyone whose plans coincided with the facilities’ original purpose of research. The facilities’ owner, the Swiss Research Institute for High Mountain Climate and Medicine (Forschungsinstitut für Hochgebirgsklima und Medizin), was prepared to let the AO use them free of charge provided it took over their maintenance. The AO reopened the institute in June 1959, accommodating both its Laboratory for Experimental Surgery and the Research Institute for High Mountain Climate and Medicine.54 Chapter 5 will analyse in detail how the AO surgeons and scientists convinced their colleagues of the validity of their groups’ tenets. AO documentation But laboratory science was only part of the AO’s scientific ambitions. The group had been founded to enable the exchange of clinical experience among surgeons using the new technique. Part of the exchange was informal and took place in discussions at the regular AO meetings.55 However, one of the AO’s central objectives right from the start had been the systematic and formalised documentation and collection of data. Some of the AO founders were already familiar with documentation when they formed the organisation. As described earlier, Maurice Müller had always set great store in recording and analysing the fracture cases he had treated, and when Hans Willenegger spoke about operative fracture care in 1955 he could refer back to the 2040 cases that had been recorded in Winterthur and Basel.56 The AO understood its documentation project to be a collective enterprise. Attempts to transcend the limitations of the individual researcher by systematically studying standardised medical treatments go back to the 1930s and 1940s. For fracture treatment Böhler is a prime example. In 1957 he recommended to his European colleagues that they orient their studies on the American model and combine cases from several hospitals.57 The AO surgeons pursued a similar line of reasoning since it was obvious that each of them alone had too few cases for statistical analysis. A side effect of the decentralised structure of this country’s health care system, Swiss doctors working independently were not able to comply with internationally valid standards in clinical research.58 What the Swiss could do, however, as Böhler had suggested, was to start collaborating with a number of hospitals. The AO provided the necessary infrastructure to establish a network of resources and personnel to collect and evaluate data. AO documentation thus resembled a large collaborative clinical trial. Accordingly, the AO members resolved in their founding assembly to document and later re-examine all fractures treated along the newly established guidelines. The obligation of AO members to document cases and


43

make their records available to the other members gave each participant the chance to monitor his own results and compare them with those of others. Thereby reliable statistics could be established and the limits of the new techniques evaluated. The research ideal of openness and public accountability embodied in such a procedure was very much in accord with the AO’s democratic, egalitarian style of discussion and exchange.59 Together the AO surgeons would be able to achieve something they could not achieve alone: they could spread the AO technique in a controlled way. To do this, the individuals involved had to be kept in line with general policy, treatment methods had to be applied correctly, cases had to be recorded and the records made accessible to all. The required discipline was accomplished through the AO members’ voluntary commitment to their fraternity-type association, which was more efficient than openly authoritarian methods. As sociologists of science Susan Leigh Star and James Griesemer have claimed, to achieve collaboration, the allies one has recruited must be disciplined, but not ‘overly-disciplined’.60 What it means to over-discipline, however, depends on the context. In Switzerland of the late 1950s and early 1960s the organisational principle of the fraternity enabled the AO to reach a degree of discipline and coordination that allowed it to introduce new and complex surgical procedures in disseminated regional hospitals that would normally have been reserved for large academic centres.61 In the central European context of the late 1950s, the AO’s style of collaboration was seen as liberal. But when the same system was later transferred to North America, the surgeons there considered it bureaucratic and, ironically, too authoritarian. 62 Making local skill and knowledge universal: standardisation and its limits One of the central challenges in introducing the new procedures was maintaining standardisation. The aim of making the AO technique universally valid and applicable required standardisation.63 As sociologist of science Marc Berg explains, universality is not a characteristic of a method itself but a possible consequence of extending the method’s reach by bringing discipline into a whole array of local practices.64 As shown in Chapter 1, Lane, Danis and Lambotte failed to make their locally created methods universally applicable. Because these individuals could not ensure that their techniques were used correctly by others, most surgeons rejected osteosynthesis as a viable treatment. Since propagation of osteosynthesis by single expert surgeons seemed to have proved impracticable, the AO surgeons pursued another strategy: they built up a controlled network of practitioners working in different places but all using the same technique. The AO attempted to uphold standardisation of procedures in its own ranks not only by holding regular meetings so that practices could be discussed but also by maintaining a system of strict documentation.65 Instruction sheets, textbooks and courses were additional means of standardisation. Standardisation was to be the key that secured the effective spread of the AO technique. But stan-

44


dardisation is also a key element in the modern tendency towards abstract, institutionalised ‘system trust’, as mentioned above. Within the AO, standardisation was facilitated, paradoxically, by setting up personal, face-to-face relationships. But even there standardisation was not perfect. In spreading to other places, techniques inevitably change. Medical historian Joel D. Howell has described how, when certain medical technologies were introduced in early twentieth-century America, local cultures of application arose. He found that ‘despite the best efforts at standardising clinical care’, these local cultures ‘informed ... the practice of medicine at a micro level’.66 Such tendencies were to be opposed by formalising procedures and improving surveillance. Of course, the success of such efforts is limited, though, as Berg expounds, not in any pre-set way: limits of ‘formalisability’ constitute a moving frontier, a place of struggle for control, and any shift involves an exponential increase of work.67 The early AO records are evidence of such processes. A retrospective study carried out by Urs Heim has shown considerable variations in the way the AO technique was used by the individual AO members in their respective local hospitals.68 Each hospital had its own style of using the technique, varying for instance the choice of particular techniques for particular sorts of fractures. These differences did not necessarily make the application of the AO techniques incorrect. AO member Bernhard G. Weber compared the variations to the denominations within Christianity: It was like in the Christian religions, where there are Catholics, different types of protestants, and even sects. In the same way we had different schools within the AO, for instance Allgöwer’s school in Basel, which was different from Willenegger’s school and even more so from the St Gallen AO.69 Such variations do not constitute examples of failed standardisation, but instances of the convergence process described by Berg. Variations may have occurred inadvertently. But some surgeons were ‘dissidents’ in that they deliberately altered the rules they had received from the AO leaders. The staff of St Gallen, for instance, were proud of their own local style. This newly established clinic of orthopaedic surgery was Müller’s first chief position after his phase as an itinerary surgeon and before he became professor and head orthopaedic surgeon at Bern University Hospital in 1967. In St Gallen, Müller assembled a staff of committed and talented orthopaedic surgeons. Among them was Bernhard G. Weber, who underwent his training in orthopaedics at the Balgrist when Müller was a senior surgeon there. Weber remembers that the St Gallen surgeons consciously defied the style of osteosynthesis propagated by the grand master because they found it was too mechanical and violated biological conditions (thus, as Weber asserts, they anticipated an attitude towards osteosynthesis that would later become official AO policy). Weber became Müller’s successor as head of the orthopaedic


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surgery unit in St Gallen, and he was proud of being known as a rebel against Müller’s authority.70 He had a reputation for being a surgical artist in his own right and later even co-authored a book on how the AO techniques could be varied for individual cases, for which he chose a fitting quote from Eugène Ionesco as its motto: ‘Et surtout il n’y pas de culture sans liberté.’71 Outside observers also noticed the heterogeneity within the AO. An American commentator mentioned in 1967 that the Germans and the surgeons in Müller’s unit liked to use intramedullary nails whereas Allgöwer’s group preferred plates.72 In 1979 an AO surgeon explained to his American readership the variations within the AO group concerning the ‘assessment and treatment’ of a certain kind of thigh fracture.73 Contemporaries like Weber and Heim assert that in reality there were more differences among the AO ‘schools’ inside Switzerland than readily apparent. Especially at the larger centres, individual styles of the AO technique evolved. They constituted, as Weber described it, particular cultures of understanding, practising and teaching osteosynthesis. Young surgeons who were socialised in such a culture retained their specific style and, like colonists who bring their dialect with them to their new home, so these surgeons passed on their methods when they transferred to other hospitals. This is why one can find typical St Gallen- or Bern-style surgeons in the US.74 But the spread of the AO technique to other nations often entailed even further adaptations: in Austria, for instance, even those surgeons who embraced the AO methods continued to stick to some of the tenets Böhler had propagated and were more cautious about opening up the fracture site, preferring instead to apply closed methods of nailing.75 In sum, the emergence of local AO styles might be seen as part of the successful spread of the technique. The AO technique proved to be resilient enough to survive such variations. Also, the basic tenets of the AO philosophy, which AO members and adherents felt they shared, served as common rallying points.76 Another issue common to all those who were involved in the AO was its specific equipment, which was at the centre of the symbiotic relationship between AO surgeons, scientists and manufacturers, as will be analysed in the next chapter.

3

A Symbiosis of Surgery, Science and Industry

The preceding chapter examined how the AO network enabled a special type of communication among surgeons. But even more remarkable, as this chapter shows, was the interactive exchange it created between science and industry. This unique form of cooperation, which has aptly been called a symbiosis by those involved, was centred on the production and marketing of the AO equipment. I have therefore thought it appropriate to begin with a historical outline of the general problems concerning the materials used in osteosynthesis, in reaction to which the AO set about developing its own instruments and implants. I will then explain how the specific type of symbiosis between the AO’s manufacturers, surgeons and scientists came about and what it consisted of, placing special emphasis on the balance of interests and power inherent in that special arrangement. At the end of the chapter I will describe the basically sceptical reaction of the surgical world to the AO upon its first public appearance, which set the terms for the AO’s ensuing attempts at self-defence. The issue of osteosynthesis material Even a virtuoso, the AO surgeons wrote in their 1963 textbook, cannot hope for perfect results in surgery unless he has the appropriate instruments.1 As much as the early AO emphasised the individual surgeon’s skill and knowledge as a prerequisite for successful osteosynthesis operations, it also recognised the significance of having the right equipment. In the early stages of osteosynthesis, surgeons tended to use whatever material they had at hand. They employed biological materials such as bone, ivory and horn in the hope that these would eventually be assimilated by the body. But they also tried iron, gold, silver and platinum, often in combination. Many surgeons bought nails, screws, pins and plates in general 46


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hardware stores, but these materials often corroded and broke or caused tissue reaction. Such attempts increased awareness of the need for appropriate materials. In the later nineteenth and early twentieth centuries numerous articles and books described the influence of metals on bone healing and on body tissues in general. Scientists performed laboratory studies that showed the adverse effects of electrolytic phenomena resulting from the combination of different metals within live tissue.2 From the 1920s on, the search for suitable materials focused on iron compounds, such as the vanadium steel alloy introduced by the surgeon William O’Neill Sherman in 1912. New varieties of stainless steel, which the industry was in the process of developing at that time, would prove to be essential for the introduction of Gerhard Küntscher’s intramedullary nailing procedure.3 Despite the improvements in science and metallurgy, osteosynthesis equipment remained poor in quality. The lack of standardised material was still considered the primary reason for the technique’s bad reputation.4 One of the main complaints was directed at the instruments’ makers for their failure to provide a system of compatible instruments and implants. Besides compatibility, another longstanding cause of trouble was the lack of quality control of instruments and implants used in bone surgery.5 William Arbuthnot Lane, for instance, was made responsible for failures caused by the poor quality of some of the ‘Lane plates’ on the market, though he could not control the quality of the plates sold under his name, as he regretted in 1912.6 Whenever osteosynthesis implants went into mass production, their quality seemed to become less reliable. William Sherman demanded a ‘guarantee from the sales agent, so as to make sure that the plate is made of proper material and thoroughly tested’. His plates had fallen into disrepute when imitation Sherman vanadium steel plates made of inferior alloys had led to disasters caused by corrosion and breakage.7 In 1931 the US Bureau of Standards introduced a commercial standard covering the manufacture and sale of steel bone plates and screws to be used for the operative treatment of fractures. Plates and screws conforming to the specifications of these standards were packaged in sealed envelopes that bore a recognisable label.8 Buying instruments and implants was a matter of trust, and surgeons had good reason to be suspicious of their instrument suppliers. When Böhler introduced femoral neck nailing in the 1930s, using nails obtained from various suppliers, he soon noticed corrosion damage in the X-ray pictures. Analysis of specimens revealed considerable variance in the metal used as well as in the quality of workmanship.9 In their 1947 osteosynthesis textbook the Americans Venable and Stuck stressed that, being unable to perform chemical tests to determine the composition of the material himself, the individual surgeon ‘was at the mercy of the salesman’ concerning the composition of the implants he bought. They demanded supervision and

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standardisation of implant quality to make it ‘impossible for instrument makers to supply surgeons with inferior alloys or with improperly manufactured plates and screws’.10 In 1958 the Munich orthopaedist Lange expressed his doubts about the manufacturers’ declarations concerning osteosynthesis materials. He had observed recurrent failure of the implants he had used, so he commissioned a chemical analysis which confirmed his suspicions: of 50 samples, less than 10 per cent had the correct steel composition. He demanded that the materials be checked frequently and that the manufacturers be made responsible for their quality claims.11 In order to have good material, surgeons were often forced to make it themselves. Albin Lambotte, for instance, was said to be as accomplished in instrument making as he was in surgery. Sometimes surgeons worked together with engineers, just as Gerhard Küntscher had done with the technician Ernst Pohl in developing his intramedullary nail. Others, like Küntscher’s colleague Richard Maatz, even had the double qualification of surgeon and engineer.12 Impressed by Danis’ collaboration with the manufacturer Simal on his 1950 visit, Maurice Müller began to create his own devices in the next year. He started with a new type of screwdriver and in the subsequent years tested and modified existing devices and also designed a number of new instruments. During this time he formed his plan to create a complete new set of osteosynthesis equipment.13 At the AO group’s first assembly in March 1958 Müller demonstrated the necessity for new instruments to his friends. Together they tested the available osteosynthesis equipment on cadaver bones. On the conclusion that the quality of existing instruments was dubious in terms of both mechanics and metallurgy, they agreed with Müller that the only way to improve treatment by osteosynthesis would be to offer their own comprehensive set of instruments and implants. The instruments should be simple in design and easy to use, and all implants made of the same biocompatible metal. As it had been his idea, Müller was put in charge of developing the AO equipment.14 Creation of the AO equipment On 8 April 1958 Müller met with Robert Mathys.15 The young engineer had been recommended to him by the director of the Notz steel company of his native town of Bienne, who was a close acquaintance of Müller’s sister. Müller had been in contact with six different manufacturers before, but he had not been happy with many of them. To his regret, their main interest had been putting the new instruments and implants on the market immediately. They had not been enthusiastic about having a trial period before making the material generally available. Mathys was different. When the two men first met, he owned a small metal processing factory with 14 employees. He was an engineer trained in producing clockwork mechanisms for watches and earned his money as a supplier for larger industrial firms building instruments


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for planes in the region between Basel and Bern. A middle-class craftsman with a high respect for academically trained doctors, he felt honoured by the surgeon’s visit, admiring the new Citroen car in which Müller drove up to his small Bettlach workshop. This attitude set the terms for the collaboration of manufacturers and surgeons within the AO. Müller had chosen Mathys because he had never produced surgical instruments before and was prepared to forsake quick profits in favour of the future gains promised by Müller. Mathys was paid for his work and for the material used for making the instruments, but he was not allowed to sell them himself. Instead, everything the two collaborators developed was to be Müller’s property and had to be delivered to his sister, Violette Moraz-Müller in Bienne, who was in charge of distribution and marketing. Provided everything went well, Müller prophesied, Mathys would do business worth millions of francs within four years. His circumspection as to the commercial aspects of the collaboration shows that Müller was no novice in business matters. With a family background in the Bienne watch-making industry, he had founded his first small company with his cousin when he was 19 years old. To test Mathys’ performance Müller showed him the drafts of a new screw for use in solid cortical bone featuring a flat head with a recessed hexagonal hole (like an Allen screw) to fit their hexagonal screwdriver. Eight days later Mathys had a prototype ready. Müller’s second request was a tap to match the screw’s thread and a screwdriver for the hexagonal screw heads. The surgeon was struck by the way Mathys intuitively grasped the essence of surgical problems and immediately made useful suggestions for their solution. After all, Mathys was only a tool maker without prior surgical experience. To give him an even better idea of what the instruments were for, Müller invited the engineer to the hospital in nearby Grenchen, where he regularly operated with the house surgeon August Guggenbühl, a member of the AO group. Mathys was very enthusiastic about his new field of activity and spent much time and effort in developing the AO instruments. Within six months he and Müller created the basic elements of the equipment, which was then officially adopted as the AO basic set at the foundation assembly on 6 November 1958.16 Its core element was the cortex screw. Its thread was so fashioned that the ratio between metal and bone after screwing it into the bone was one part metal to five parts bone, reflecting the difference in stability of both materials. In addition, the surfaces of the thread were almost at right angles to the pressure they were exposed to. This afforded optimal support for the screw. The hexagonal screw head allowed the screwdriver to transfer force to the screw without applying vertical pressure. As opposed to most of the screws used for osteosynthesis at the time, the AO cortex screw was not self-tapping but required the pre-tapping of a matching threaded hole into the bone. For this, a sharp tap, often powered by an air pressure drill, was used. This procedure, Müller and Mathys claimed, would prevent the microscopic damage usually done to the cortical bone in the process of self-

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tapping. Another screw was designed for cancellous bone. Its thread was broader in order to give it enough hold within the much softer cancellous bone tissue. A range of different-sized plates was also conceived. In February 1959 the new AO tension device was ready. It allowed the temporary application of pressure of 30–40 kg on the bone fragments before they were fixed with a plate and screws. The procedure was as follows. First, the surgeon drills a screw hole within one centimetre from the fracture. Then he reduces the fracture and screws the plate down with a cortical screw. While holding the reduction with a clamp he drills another hole in the other bone fragment (a). This hole is used to fix the tension device after hooking it into the end hole of the plate. The device is slightly tightened with a Kardan key (b). Then the rest of the screws are inserted into the first fragment (c). When the screw of the tension device is turned the fragments are brought under considerable inter-fragmental compression (d). After checking the reduction again, the remaining screws are inserted (e). At the end, the tension device is removed and a screw is inserted through the end hole of the plate (f).17 Müller first presented the tension device at the AO meeting in March 1959.

(a)

(b)

(c)

(d)

(e)

(f)

Figure 3 Use of Maurice E. Müller’s compression device as described in the AO Manual (for more information see text).


(a)

(b)

(c)

(d)

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(e)

Figure 4 An X-ray series of the osteosynthesis treatment of a lower leg fracture as shown in the first AO textbook of 1963. Figures (a) and (b) show the state of the bones before treatment. X-ray (c) was taken during the operation, and (d) and (e) 31 weeks afterwards.

What made the AO equipment outstanding was its standardisation. In the 1950s innumerable screws and plates made of various materials were on the market. Surgeons used those materials that happened to be available to them. They were lucky if their screws, plates and taps matched to some extent.18 Typically, when a surgeon asked his operating room nurse for a screwdriver he was given a handful of different models and had to try each one of them until he found one that fit the particular screws he was using. 19 Müller postulated standardisation as one of the AO’s central principles. On the one hand, standardisation meant that all AO instruments and implants were compatible with each other. But it also meant that the AO surgeons all used identical instruments and implants and applied basically the same surgical procedures. This enabled them to compare their individual experiences and the results they obtained.20 In this sense standardisation was a prerequisite for making surgical action controllable. A novel idea at the time, the AO sold its instruments and implants not as single pieces but only as complete boxed sets for immediate use in specific applications, thereby applying a principle to surgery that was usually employed for tools in car repair shops. In 1963 the AO equipment was offered in six sterilisable boxes made of aluminium. For easy recognition they had different colours. The box system was intended as a remedy for surgeons’ inadequate provision for operating on bones. According to the frequent

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complaints published in the surgical journals at that time, surgeons often failed to notice the lack of an essential item until during the operation. The sale of complete sets was meant to eliminate this potential source of failure in osteosynthesis. In a sense, this policy was part of the AO’s attempts to control the application of their equipment.21

Figure 5 The instruments box for the AO compression plate as shown in the first AO textbook of 1963.

Compliance with standardisation was even built into the very design of the hardware: as the screw heads were made to fit the special hexagonal AO screwdriver, the AO equipment could not be mixed with non-AO material. Another effect was that once a hospital had started to introduce the AO system it was difficult to switch to one of the competing manufacturers.22 The AO sets were thus an early – and literal – example of the increasing use of uniformly ‘packaged’ technologies that arose in the 1960s and 1970s. Medical technologies were rationalised and practices ‘pre-disciplined’ by the use of standardised instructions and protocols.23 The creation of the AO instrument sets was an important part of the trend towards standardisation and constituted a very elegant form of supporting and disciplining the user. During the first four years of the AO’s existence control was also enhanced by restricting availability of the equipment to a few selected surgeons.24 Most of them were either AO members or personally known to the group through their participation in the instruction courses.25


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The reaction of the surgical world On 17 May 1960 the AO presented its concept for the first time to a surgical audience. The Swiss Surgical Society had set aside the last part of the first day of their congress in Geneva for four ten-minute talks by Müller, Allgöwer, Willenegger and Schneider. In preparation, Maurice Müller had sent a letter to all AO surgeons asking them to prepare themselves diligently for the event. They were to analyse all cases treated according to AO principles and send the X-ray pictures to Davos. It was necessary to have data concerning the total number of cases as well as the number of failures, so that those who had patients with dissatisfactory results could then bring the pictures needing analysis to their next regular spring meeting in March preceding the Geneva conference. The March meeting also gave the designated speakers the opportunity to rehearse their presentations before the assembly of AO members.26 The presentations at Geneva caused such a stir that the Society scheduled a special session to be held in Bern on 24 November of the same year. On that day the lecture theatre was packed. Over 300 surgeons were in attendance at this second presentation where Müller would speak for 30 minutes on the principles of osteosynthesis. Next to go to the podium was Hans-Ulrich Buff, who at that time was still head surgeon at Solothurn (and was soon to be appointed full professor and head of one of the surgical departments at the Zürich University Hospital in 1961). Buff had a critical stance towards osteosynthesis and the AO, so his talk about general treatment of lower leg fractures was meant as a counterweight to the AO surgeons’ contributions. After him, Walter Bandi spoke about the use of bone screws for tibia fractures. Bandi was standing in for Allgöwer, who was ill. Robert Schneider then expounded the technique of intramedullary nailing of the tibia, after which Hans Willenegger closed the presentation by reporting on the results obtained with this technique. The AO’s presentations caused heated discussions. The atmosphere was belligerent. In particular, Buff, Karl Lenggenhager (chair of the surgery clinic in Bern since 1940) and Max Geiser (senior surgeon of the orthopaedic department at Bern University) drew their sabres against the AO. Excitement was such that part of the last presentation was drowned in the noise of the individual discussions going on in the audience.27 As Müller wrote in 1963, the AO surgeons were surprised that their efforts to test methods of osteosynthesis within the circle of a few surgeons had created so much agitation and elicited so much incomprehension. He was appalled that hardly two years after the AO’s foundation its members were depicted as dangerous sectarians and propagandists.28 In hindsight, so much resistance to a technique that turned out to be useful might seem irrational or at least based on vested interest. As medical historian Joel Howell observed,

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Any change, any introduction of a new technology threatens the status quo; what one group gains in power and prestige, another group loses. As new technologies become accepted, people who once based their expertise on skill and experience obtained without the new technologies find their contributions devalued.29 This might be true to a certain extent, but at the time, caution was very sensible; the early AO critics had good reason for scepticism, considering what they knew about previous efforts to make osteosynthesis a standard treatment.30 Even Allgöwer raised the question of how the AO’s suggestions could attract serious interest after so much negative experience with previous osteosynthesis methods.31 Surgical techniques are particularly susceptible to critique. As opposed to other medical measures, negative effects of surgery are directly visible and can easily be attributed to the surgical intervention. 32 Osteosynthesis was controversial from its very beginnings, and in this case the controversy was intensified by the fact that alternative methods of fracture treatment already existed.33 At the time the AO was founded, scepticism about osteosynthesis had reached a high point in the German-speaking countries. All the scientific authorities in fracture care were against it. Böhler, for instance, excepted only nailing of the neck and the shaft of the femur from his negative verdict.34 At the 1958 congress of the German Surgical Society the eminent German traumatologist Heinrich Bürkle de la Camp joined Böhler in deploring the exaggerated use of osteosynthesis.35 In particular, the use of plates and screws was criticised at that time. Danis’ compression osteosynthesis was mostly rejected, his book judged to be dangerous.36 As reflected by the main theme of the congress of the German Orthopaedic Society in 1958 – ‘Dangers and Mistakes in Osteosynthesis’ – the focus of discussion was on the worst expected outcomes in using the technique. Most contributors to this congress were eager to warn against osteosynthesis, and the few proponents who attended had a hard time defending themselves.37 The same wary attitude shaped the opinions given in the textbooks during the first years of the AO.38 According to a survey the Munich orthopaedist Lange had performed among 25 large hospitals in seven European countries, only intramedullary nailing of the femur was generally accepted and judged to be relatively safe. All other techniques were mostly rejected.39 ‘Real progress’: technical efficiency In the 1950s insufficient stability had been identified as a main source of failure in osteosynthesis. 40 The existing techniques had not been very trustworthy in this regard. For many surgeons, osteosynthesis served merely to realign bone fragments; it was not expected to provide enough rigid fixation to allow active movement of the limb. In 1953 Bürkle de la Camp, who was then director of the accident hospital Bergmannsheil in Bochum


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and editor of a leading German traumatology textbook, stated that it would never be possible to fix a fracture perfectly. In England, John Charnley wrote in 1957 that further improvement in the techniques of internal fixation could not be expected.41 In the late 1950s and early 1960s the most popular osteosynthesis techniques were intramedullary nailing, wiring and cerclage. The use of plates (without compression) was common in the English-speaking world, but was increasingly superseded by intramedullary nailing. Germanspeaking surgeons (most of whom had never heard of compression osteosynthesis) warned against plate fixation because of its lack of stability.42 In this context it was crucial for the AO to convince other surgeons that its technique did in fact provide sufficient stability. This was not too difficult, since the AO instruments and implants were perceived as a great technical progress by those who tested them. Being craftsmen themselves, many surgeons were enthusiastic once they held a piece of the solidly and neatly crafted AO equipment in their hands. 43 Hermann Krauss, head of the university clinic in Freiburg, Germany, recommended the AO technique in his preface to the first AO textbook in 196344 because the dangers associated with osteosynthesis had been greatly reduced by the AO’s recent progress in the creation of improved metal implants and their innovation in operative technique and post-operative treatment. Typically even surgeons who were basically opposed to the AO strongly applauded the AO method’s technical efficiency. 45 Bürkle de la Camp conceded the AO equipment’s technical superiority; even though he had never been a friend of screws or plates, he said in 1963, the AO technique was something altogether different, its compression plate incomparable to the Lane plate.46 Symbiosis It is clear, then, that technical efficiency and its acknowledgement by other surgeons were important factors for the AO’s acceptance. The high level of technical efficiency had been reached by taking up certain elements of existing techniques, such as Danis’ compression osteosynthesis, developing them further and combining them in a systematic way. Through Mathys, Müller was able to obtain industrially produced instruments exactly as he wanted them. This was the beginning of a unique collaboration between surgery and industry.47 After starting his cooperation with Müller, Mathys devoted himself enthusiastically to the development of the new instruments and implants. He built prototypes and delivered them to Müller’s sister to be distributed to the AO surgeons for use in surgical practice. Though Mathys got paid for the time and material spent for making the prototypes, by 1960 he had accumulated a debt of SFr300,000. As he later recalled, all his financial means had gone into the development of the equipment.48 He had bought new tool-making machines on credit and also delivered 20 sets of AO instruments for use at the first AO course in 1960. The deficit worried not

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only Mathys but also his bank. In reaction, Müller went to see the banker in Bienne and assured him that Mathys would be able to repay his debts once he had started production on a larger scale. His descent from a notable Bienne industrialist family as well as his emerging renown as a surgeon helped Müller to convince the bank to extend Mathys’ credit. But there was an additional problem. Mathys started to get the impression that the AO group might release him as their producer and take someone else instead. He had been criticised by the surgeons because of problems with the quality of the metal he had used to make the instruments during the early, almost feverish phase of production. His efforts to get a grip on these problems by bringing in an expert he knew had failed. As a consequence, the AO surgeons chose another expert. Through his contacts at Basel University Hans Willenegger got in touch with Reinhard Straumann, an honorary professor at the Technical University of Stuttgart and a specialist in metallurgical problems within the context of the Swiss watch-making industry. Reinhard Straumann had become famous by inventing special alloys for use in the manufacture of balance springs in watches. He had his own institute for metallurgic research in Waldenburg, one of the traditional venues of the Swiss watch-making industry, situated in a valley of the Jura mountains near Basel. The Straumann Institute had the necessary laboratory facilities to carry out metallurgical analyses and had already been involved in medical studies at the time when they were contacted by the AO, so they accepted Willenegger’s offer to collaborate. Straumann’s son Fritz, who headed the research department in Waldenburg, was put in charge of the collaboration with the AO. In 1960 he was invited to the first AO course in Davos as a ‘passive participant’ and subsequently started to work regularly for the AO, often in cooperation with the AO laboratory in Davos.49 In 1960 it became evident that the AO needed to reorganise its economic basis. If they wished to continue working with Mathys, they had to offer him some sort of contractual security. They also needed to establish a reliable source of funding for their education and research activities.50 To meet both these objectives, the AO devised a special arrangement. In December 1960, on the eve of the first AO course, the four leading AO members, Maurice Müller, Martin Allgöwer, Robert Schneider, and Hans Willenegger, created the new legal and economic basis for the AO’s activities and founded a jointstock company called Synthes AG Chur. Since among the AO surgeons only Müller had any prior experience in business, Allgöwer brought in his tax consultant Peter von Rechenberg to help with the technicalities of establishing the company.51 Its purpose, as regulated in the first paragraph of the statutes, was ‘the trade with and the support of the development of medical instruments’. Von Rechenberg was made chairman and provided the group of surgeons with the necessary legal, economic and administrative know-how.52


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This increasing professionalism was accompanied by a few formal changes. For instance, it was now required that minutes be taken at AO meetings and in committee sessions. Nevertheless, things continued to be handled in a rather casual manner. Even though the Synthes statutes mentioned a general shareholders assembly, such an assembly was never convened. Instead decisions continued to be made informally between the shareholders, most often simply by telephone. Synthes had a starting capital of SFr50,000, divided into 50 shares of 1000 francs each. Of these, Müller held 14, Allgöwer 11, Willenegger and Schneider 12 each, while von Rechenberg had one share. Thus, with 28 per cent of the shares in his hands, Müller needed the support of only one of the others to gain controlling interest. Up to then, he had also been the sole patentee of the instruments and implants he had designed with Mathys. Once Synthes came into existence, he handed over his patents without remuneration. This principle was made standard policy and regulated in special contracts stipulating that all future intellectual property rights of the special instruments and implants developed by AO surgeons or the manufacturers for use in bone surgery would also be transferred to Synthes AG Chur free of charge.53 As the holder of the copyrights, Synthes AG Chur was able to grant Mathys and Straumann the right of exclusive production and marketing of the AO equipment. In exchange, the two producers allowed the company to control the prices, the sales organisation, and the design of product labelling, catalogues and any other material used for commercial purposes. Most significantly, the manufacturers were required to pay royalties to Synthes AG Chur in exchange for the input from AO research and development and the privilege to sell products under the Synthes label. In addition, Straumann committed himself to paying SFr30,000 per year to the documentation centre and Mathys SFr15,000.54 In the beginning the royalties were fixed at 15 per cent of the Swiss retail price but over time they were lowered and at present they amount to a few per cent of the sales price. Since the shareholders did not derive any income from their shares, whose value was fixed to the nominal value, Synthes could be classified as a non-profit organisation. All the payments from the producers went exclusively into the AO’s scientific and educational activities. Most of it was used for the running of the laboratory for basic research and the documentation centre to collect and evaluate the results of the AO method. Through this arrangement, Schneider explained, ‘everybody who has to pay for an AO implant supports further progress’.55 Dividing up the world The final contract between Synthes AG Chur and the equipment producers Mathys and Straumann was signed only after a lengthy period of negotiations among the various parties involved. 56 Since March 1961 Mathys had discontinued his delivery of prototypes. He had also refused to hand over

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the construction documents to Straumann. In the end, Mathys was prepared to cooperate with Synthes and the Straumann Institute, but only on a new basis. He demanded compensation for setting up the special machinery needed for producing the instruments and charged the AO SFr47,600 for special preparation and SFr174,977 for construction expenses. The choice now was either to break with Mathys and pay him an appropriate compensation or to continue cooperation on a new legal and financial basis.57 The surgeons decided for the latter and charged both Mathys and Straumann with the production and marketing of Synthes products. Once the AO had engaged the two producers, it became a matter of priority to balance their claims and interests. In order to negotiate a compromise, they met on neutral ground. In fact, their meeting place was a restaurant at the train station of the small city of Olten, halfway between Bettlach and Waldenburg, the seats of the two companies. It was here that Mathys and Straumann literally divided up the world between them. In order to do it fairly, they drew lots to determine who would be in charge of which sales areas. Among other territories, Straumann got Switzerland, England, Scandinavia and the Americas, while Mathys got Austria, France, Africa and Asia. West Germany was considered so important that they decided to divide the country into two sales areas. On a map they drew a line dividing the country into a southern and a northern part roughly equal in size. Mathys was allotted northern Germany, and Straumann got the south. Both of them signed the copy of the map, which was then entrusted to Synthes.58 In a later round of allocations in 1965, each of the producers got an equal share of sales to the West German army. In addition, Mathys got East Germany, Romania and Bulgaria as his sales areas, while Straumann received the sales rights for Czechoslovakia, Poland and Hungary.59 In the original agreement the producers obligated themselves to close collaboration and mutual support in order to ensure constant and uniform supply to all sales areas. As Straumann had not yet built up sufficient production capacities to meet the demand in his sales areas, he had to buy additional materials from Mathys, thereby becoming Mathys’ principal customer. Due to this new source of income, Mathys could make up his financial leeway and buy raw materials, machines and so forth to overcome his debts. 60 The Straumann Institute continued to take on most of the materials research and examine all cases of corrosion and breakage presented to the AO.61 The worldwide division of interests only became relevant later on. Meanwhile, the pressure to release the instruments had increased. Allgöwer recalled that colleagues accused the AO surgeons of ‘monopolising the system’ for their own benefit.62 Reluctantly the AO surgeons conceded to the demands and in 1962 made their equipment generally available, thus entering a new phase of development which raised new issues concerning control and business.63


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Control Surgeons’ control over their equipment’s design and production was a fundamental principle of the arrangement between the AO, Synthes and Mathys and Straumann. One of the basic rules Müller had introduced when he laid out the concept of the AO in 1958 was the observation of strict quality standards concerning the osteosynthesis equipment.64 All the AO instruments and implants were put through several trial stages by the AO surgeons before becoming generally available. Initially, testing consisted of case documentation and a more or less informal exchange of experience. Some of the surgeons were given the instruments and implants so they could try them out and report on their performance. But in 1964 a systematic formalised testing procedure was instituted. Control over testing and power of decision over the introduction of new instruments or implants lay with the surgeons, not the producers. This power was executed through the Technical Commission (Technische Kommission, or TK), established in November 1961.65 Providing a forum to negotiate the different interests involved, the TK became the centre of power within the arrangement of AO, Synthes and the producers. In the beginning it was a rather informal group consisting of the main AO founders, Mathys and Straumann. The commission convened at least four times a year. Its president and undisputed leader was Maurice Müller. Decisions were made by majority vote and were binding for all members.

Figure 6

Corroded hip nails as shown in Lorenz Böhler’s textbook of 1943.

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The first session on 16 December 1961 was comprised of Allgöwer, Müller, Schneider, Mathys, Straumann, two of Straumann’s employees (Vogt and Karpf) and Moraz-Müller. From 1963 on, von Rechenberg was charged with the administrative chairmanship, whereas Müller remained chairman for technical matters. In practice, the TK controlled all the prerogatives Synthes had over the producers. The TK also supervised the Synthes catalogues and commercial material and made sure that the products offered were identical with those described in the AO textbooks. Only instruments and implants that were approved by the TK were allowed to be sold. At its quarterly meetings, the Commission regulated the range of products to be offered by the producers, fixed the profit margins and negotiated the amount of royalties to be paid to Synthes.66 This arrangement gave the surgeons the power to influence the development of equipment according to their specific needs and interests. This is important because the interests of surgeons or scientists are generally not identical with producers’ interests.67 The surgeons aimed primarily at introducing an attractive new way to treat fractures: to achieve this, they worked with scientists, who for their part were interested in producing new scientific knowledge. By contrast, the two producers were primarily responsible for the survival of their firms. It was not their job to provide fracture treatment or produce scientific knowledge. These different and sometimes contradicting aims and interests were to be balanced by the system of agreements that constituted the AO/Synthes symbiosis. The minutes of the TK sessions show that it was clearly the surgeons, above all Maurice Müller, who were most influential. For instance, decisions on the introduction of new instruments and implants were made not with regard to expected sales but based on their surgical usefulness. At times, the TK even prohibited the manufacturers from putting certain products on the market.68 Mutual benefit The fact that the surgeons and manufacturers had basically different interests should not be taken to mean that they always disagreed. In fact, Mathys supported the surgeons’ strategy of not yielding to market pressures because he saw that maintaining long-term credibility with the purchasers rather than pursuing short-term profits would bring him greater earnings in the long run.69 In any case, the producers were not in a bad position. The structure of their relationship with the AO gave them a number of invaluable advantages over their competitors. Normally, innovation involves considerable risks. A firm can never be sure whether a new product will actually be used and bought. And in order for the emerging product to be accepted, it must be adapted to the criteria and preferences of the users, which requires first-hand knowledge of their needs.70 This prerequisite is particularly significant for the medical instruments market, where competition takes place on the basis of


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performance and adaptation to the users’ needs. Therefore, innovative instrument companies have as one of their main objectives establishing contact with their potential customers to find out what they want. Seen from this perspective, the AO symbiosis of producers and users was an ideal way for Mathys and Straumann to reduce uncertainty about new products. The AO equipment was in continuous development.71 In the first three years development was in Müller’s hands, then other surgeons also started to make suggestions for new instruments and implants. The producers also put their ideas up for discussion. At the TK sessions suggestions were assessed and either rejected or chosen to be further pursued. Apart from the TK, which provided the structural opportunity to let the users’ needs influence the range and shape of the AO products, the biannual meetings of the growing AO group provided a second channel of exchange between surgeons and producers. These meetings were a forum for the surgeons to voice their wishes or complaints concerning the equipment and for the producers to give an account of the state of affairs with regard to the production of new items. So the AO was doubly successful at institutionalising the feedback between users and makers of instruments. Such a system of feedback was something other manufacturers had tried to establish but rarely achieved.72 The producers had an additional benefit from this means of organisation. As Stuart Blume observed in his study on medical innovation, the devices industry generally ‘depends very much upon the clinical reports attesting to the (superior) performance of their particular product’.73 Reporting on clinical performance was also institutionalised within the AO, who saw it as one of their main objectives to conduct and publish studies about the performance of their devices. Contact between colleagues was, in fact, part of an informal division of labour within the AO: the doctors stayed in touch with other doctors while the producers kept in contact with the hospital administrators and the nurses.74 The producers were well aware of the fact that the offprints of these scientific papers, which AO surgeons passed on to their colleagues, were the best conceivable form of advertisement, as Mathys said in 1978.75 The AO surgeons’ conference presentations, their papers and their books all had a favourable effect on sales. The AO courses were a particularly good means of promotion: the producers exhibited their products at the courses and took orders directly from the participants. In the end, they obtained six months’ business as a result of the courses.76 With its structure of heterogeneous but interdependent elements, the AO was a special model in answer to the problem of how to integrate and regulate business, science and medical practice. In the arrangement of surgeons, scientists and manufacturers associated with the AO, various participants worked together. Each of them could pursue their own interests while at the same time contributing to the overall enterprise. Money was exchanged for

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ideas and access to the market, instrument prototypes were given in exchange for control rights, and so on.77 The AO can be seen as a special instance of a more general pattern of collaboration between medicine, science and industry. Though close relationships among scientists, clinicians and industrialists can be traced back to the second half of the nineteenth century, they acquired their significance for mainstream academic research and clinical practice only after World War II and especially in the 1960s and 1970s, when awareness of the so-called biomedical-industrial complex was growing. In her study on cancer immunotherapy, Ilana Löwy characterises this collaboration as a ‘dense, closely-knit network of cognitive, psychological, social, and political interests’, in which ‘members of distinct social groups coexist in a symbiotic relationship based on mutual legitimisation’.78 Therapeutic innovations coming out of such co-operations articulate the multiple interests involved.79 One of the recurrent issues of this form of cooperation concerns the possible conflicts of interest between business and medical ethics. Business and ethics It is telling that the AO founders never wanted to make the association itself into a commercial firm. The AO remained a purely medical, fraternity-type organisation whose aims were the study of fracture treatment, experimental research and exchange of information among colleagues.80 But the fact that the principal founders of the medical association were the same people who later founded and ran the Synthes AG Chur accounts for the peculiar double identity inherent in the AO/Synthes organisation. The surgeons saw this as an ethical problem and tried to keep the identities separate: ‘If a group effort creates an income, it also creates ethical problems for the surgeons involved’, Allgöwer wrote later, pointing out that they had not anticipated their instruments to create ‘more than modest profit’, only enough to keep the research unit and documentation centre going.81 With this, Allgöwer addressed a recurring problem of modern medicine. Many new drugs, including insulin and penicillin, had become generally available only because of the business interest of a pharmaceutical firm. Sometimes scientists and doctors had participated in the profit in one form or another, for instance when the firm supported their research. But doctors and scientists are not supposed to pursue commercial profit. The ethics of the medical profession require that doctors’ private economic interests remain separate from their medical interests. Doctors are supposed to be ‘primarily interested in medical progress, as immanently defined and controlled by the profession’, sociologist Ulrich Beck explains.82 Consequently, as medical historian Harry Marks observes in his study on post-World War II American medicine, profit-making institutions were regarded ‘as operating on the edges, if not outside, the boundaries of science’.83 In order not to compromise their credibility and moral integrity as doctors and scientists the AO surgeons were


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eager to ensure (and to make known among colleagues) that none of Synthes’ profits ran into their own pockets. The strict rule was that ‘any income created by the instruments would be reinvested into research and documentation’, Allgöwer stressed in a 1978 article, concluding that ‘thus the AO organisation (ASIF) has remained strictly non-commercial’ and that the surgeons involved had no material interest, but were only decision-makers.84 But the AO surgeons derived other sorts of benefit from the AO, worth their investment in time, energy and even money. Besides providing them with the social, emotional and intellectual benefits of fraternity life, membership in the AO enabled the surgeons to offer better fracture care, earning them popularity with patients and increasing their career chances.85 They were able to build up a reputation in their field. Surgeons like Müller and Allgöwer quickly attracted patients from all over the world who came to their hospitals for treatment. Other AO members also profited from their popularity among patients, but on a smaller scale.86 Furthermore, their AO membership afforded them, in Allgöwer’s words, the ‘great privilege to have money available for research and travelling’, which was ‘distributed without red tape’.87 This was quite attractive because these funds could be fed into the ‘cycle of credibility’ as described by Bruno Latour and Steve Woolgar as a model for the mechanisms of scientific knowledge production. Reputation and credibility, the two sociologists hold, function as currency in an ‘economy of science’: credibility provides access to research facilities, and the facilities enable scientists to produce research results and establish new scientific facts. These in turn add to the scientists’ credibility, which is needed to start the cycle once again on a higher level.88 Surgeons with academic ambitions did not aim at getting money out of the AO. For them, involvement in the AO was a way to obtain research resources as well as prestige. The AO surgeons did of course appreciate the commercial success of the Synthes products. It provided them with a constant flow of research funds. While in the beginning the AO members did not spend much time thinking about business and its potential conflicts with ethics, with growing success, they did have to consider their position more carefully. The TK minutes show how the surgeons reflected on their role as doctors, for instance urging one another not to yield to market pressure.89 The role conflict arose early on in the context of the Voka affair. In 1963, Synthes was challenged by a competing manufacturing company called Voka (later renamed Osteo).90 Voka had been founded by two former employees of Straumann and Mathys – Vogt and Karpf, hence the abbreviation – who used their insider knowledge to make copies of the AO instruments. The basic principles were identical, and the sketches given in the Voka catalogues resembled those in the AO textbook. Since they had almost no expenses for research and development, Voka was able to sell their products at a lower price.

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The danger for the AO was that surgeons could now use the AO courses to get their training but later buy the cheaper Voka instruments. Understandably, this caused some excitement among the AO community. At first the surgeons planned to send letters to all their colleagues to warn them of the cheap Voka copies. In the subsequent hearings conducted against Voka for patent violation, some AO surgeons served as expert witnesses. But soon the surgeons started to question their commitment to Synthes. Taking such an active role in support of a commercial company seemed to be incompatible with their role as doctors. Being surgeons themselves, they felt that the popularity of the AO among their colleagues had much to do with their professional and scientific credibility, which could be jeopardised by excessive business involvement. Based on these considerations, they decided to refrain from sending the warning letter to their colleagues. Instead the AO producers launched a conventional advertising campaign in surgical journals – conventional in the sense that the advertising was conducted without the help of the AO surgeons – to emphasise the special value of the original equipment in comparison with cheaper copies. In the discussions around the Voka case the AO surgeons came to the conclusion that they had better means at their disposal than legal or commercial campaigns to maintain Synthes’ leading market position. In Müller’s opinion, lawsuits for patent infringements were futile anyway. The original AO instruments would keep their market position, he asserted, as long as the AO maintained its good name and its leadership in research and development. Similarly, von Rechenberg advised against competition in the field of commerce and recommended emphasising the special character of the AO/Synthes as a non-commercial, science-oriented organisation. Lawsuits would only be a secondary strategy for deterring any further unfair competition. As a result of such considerations the AO continued to resort only occasionally to legal action against copyright infringement and unfair competition, but put its main emphasis on winning the users’ trust by research, education and quality control. 91 This was not an easy task, considering that the AO’s treatment methods were still regarded as scandalous by many surgeons. Thus surrounded by critics, the AO’s starting position was relatively difficult. I will analyse the arguments of the AO’s opponents in more detail in a later chapter, where I look at the AO’s gradual acceptance in central Europe. But before that, I want to examine the AO’s main strategies for making their technique safe and efficient and winning their colleagues’ trust and assent. The following three chapters give detailed accounts of the AO’s commitment in the fields of user education, and laboratory and clinical research.

4

‘Tacit Knowledge’: Education and Training on a Face-to-Face Basis

For decades the AO’s programme of user education has been famous among surgeons and was ultimately a major asset in winning general acceptance for the AO technique. However, the main motivation behind the AO’s educational efforts was the desire to see its technique correctly applied. 1 Well aware of the fact that in the past mistakes in osteosynthesis had led to catastrophes and caused the method to fall into disrepute, the AO surgeons thought it necessary to assume responsibility for training those who would make use of their equipment. This was part of their general attempt at controlling the spread of their technique. Building on the discussion of the previous chapters including the control and standardisation of new medical techniques, I use this chapter to demonstrate that the transmission of surgical skill entailed particular challenges due to its special character of ‘tacit knowledge’. After describing how the AO dealt with these challenges by establishing its course programme, I will discuss how the courses influenced the AO’s acceptance and encouraged the commercial success of Synthes, and how they were perceived by followers and critics. Moving on to an analysis of other means developed by the AO to spread knowledge about its technique, among which the most influential were writing textbooks, giving multimedia presentations and establishing a fellowship programme, I will conclude with a discussion on the limits of standardisation and control in spreading new techniques. Dangerous enthusiasm In the late 1950s the AO was not alone in recognising that the successful introduction of osteosynthesis techniques on a broad scale would require securing their correct use. Critics warned against circulating the instruments without simultaneously spreading the necessary skills and knowledge.2 And 65

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while proponents also expressed the need for caution when performing osteosynthesis, they focused on defending the viability of existing techniques that had fallen into disrepute due to surgical mistakes.3 The AO surgeons emphasised from the start that even though their methods worked in principle, success in the individual case depended utterly on their correct application: ‘Training, experience and command of the appropriate surgical technique’ were therefore indispensable.4 After opening the market to the general surgical public, the AO surgeons felt uneasy about the sudden popularity of their instruments because they understood the severity of the risks involved in using the instruments with insufficient training.5 About a year after the AO equipment had become generally available, Müller, Allgöwer and Willenegger published the first AO textbook. In its introductory chapter they cautioned against over-enthusiasm: We cannot advise too strongly against internal fixation when it is carried out by an inadequately trained surgeon and in the absence of full equipment and sterile operating room conditions. Using our methods, enthusiasts who lack self-criticism are much more dangerous than sceptics or outright opponents.6 They reiterated this warning in the subsequent textbooks, knowing perfectly well that spreading the method without simultaneously spreading the pertinent skills and knowledge was dangerous not only for the patients but also for the AO’s reputation. The basic challenge for the AO was to make the outcome of its technique reproducible for other practitioners. In this respect surgery is like experimental science. An experimental observation becomes valid if it can be repeated elsewhere by other scientists. In the same way, the viability of a therapeutic technique depends on its replicability by different physicians working independently of one another. In both fields, it is difficult to achieve and requires a lot of energy and money.7 To make a procedure replicable – be it experimental or surgical – one must make sure that everyone performs it in the same way.8 The results of surgical techniques, however, have to be replicable on a much larger scale than those of scientific experiments. Thousands of surgeons have to be able to obtain the same positive results as the techniques’ inventors, and a single failure can ruin the reputation of a treatment method. Surgical techniques therefore have to be standardised and taught to the prospective users. This was the guiding principle underlying the AO system of face-to-face education, but it was not unique to the AO. Standardised instruction was an important element of contemporary efforts to transform medicine from a personal art into an objective science. Therapeutic action was to become as controllable as a good laboratory experiment.9

Education and Training on a Face-to-Face Basis

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Surgery and tacit knowledge Whereas it is possible to pick up theory by reading, surgical skills can only be acquired through hands-on practice. Especially in the context of bone surgery, surgical competence has often been compared to craftsmanship. Albin Lambotte described the transmission of the ability to use his osteosynthesis techniques in terms of an apprenticeship. He claimed that even the most detailed description could not replace a practical demonstration in the operating room and he recommended practising on cadaver bones.10 In the same vein, the British surgeon Ernest Hey-Groves saw operative fracture treatment as ‘in one sense the work of a carpenter, which can never be properly carried out without the education and training of a carpenter’, and he recommended that ‘if everyone who practised these operations had a preliminary six months in a carpenter’s shop, and then performed on a sufficient number of broken bones of dead people to ensure technical skill, we should hear less than we do of operative failures’.11 Spreading the competence necessary to repair bones with plates and screws seemed to be a tricky business. The success rate of any given fixing technique dropped dramatically the moment it became available for general use. The author of a textbook on the use of implants in surgery suspected that those who invented the technique possibly paid much more attention to important details than later, routine users. During the development phase of an implant inventors are confronted with a host of problems and must acquire detailed knowledge to solve them, but they do not normally pass on this knowledge to later users.12 The phenomenon described by these surgeons has been called ‘local’, ‘personal’ or ‘tacit’ knowledge by sociologists and historians. Tacit knowledge, according to its definition by Harry Collins, is ‘our ability to perform skills without being able to articulate how to do them’. The standard example is the skill involved in riding a bicycle.13 However, its non-verbal character does not prevent tacit knowledge from becoming part of conscious practice and hence subject to negotiation, discussion, reconstruction and teaching.14 Conceived of as knowledge of the body rather than of the mind, surgical skill becomes manifest in certain gestures or series of gestures the surgeon performs in a particular way, while he is very much guided by his sense of touch, which even the most sophisticated instructions cannot provide.15 This was an attitude shared by all the surgeons who were involved in the introduction of osteosynthesis and it shaped the way they tried to spread their techniques. They understood that in order to acquire skill in performing osteosynthesis a person needed to meet someone who could pass it on, so they would have appreciated Michael Polanyi’s characterisation of tacit knowledge: ‘By watching the master and emulating his efforts in the presence of his example, the apprentice unconsciously picks up the rules of the art, including those which are not explicitly known to the master himself.’16 The

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AO had several ways of bringing masters and apprentices together. One of them was by organising instruction courses. The AO courses The first AO course took place in December 1960. The venue chosen for the four-day event was the AO laboratory premises at Davos which had begun operating the previous year. Supervised by Maurice Müller, the AO laboratory staff organised the course, while the manufacturers provided a complete set of instruments and implants for participants’ use during the practical exercises. The principle was that small groups of surgeons, guided by a more experienced table instructor, should practise applying the AO plates and screws on cadaver bones.17 By organising special training courses the AO could promulgate its specific know-how beyond the immediate circle of the AO members themselves. To encourage participation, the AO leaders specifically invited friends and acquaintances, but they also sent letters to a number of clinics whose staff might be interested. Demand was high. Instead of the 25 persons they had anticipated, 69 active participants turned up for the course. Most participants were Swiss, but there were also seven Germans, three Americans, two Austrians, and one person from France.18 The idea behind the AO’s hands-on courses had originated with Maurice Müller. He had tried out this type of instruction a few years earlier by hosting a similar instruction event at the Balgrist hospital for some of the later AO founding members. The most important model for the AO’s teaching programme was Lorenz Böhler’s system of standardised surgical instruction. Böhler had started using military principles of drill and discipline during World War I and then carried them over into the organisation of his famous traumatological hospital in Vienna.19 But whereas Böhler had concentrated his teaching efforts on the surgeons at his own hospital, the AO took on the task of teaching colleagues all over the world. In addition, Müller had seen the benefits of using parts of human corpses for instructional purposes while attending a session on hand surgery that had been organised by Marc Iselin in Nanterre near Paris just a few months prior to the first AO course. There, similar to Müller’s method, practical exercises were performed on cadaver hands. But Iselin’s course was special in that practical instructions were also transmitted by television monitors, an idea that Müller would later adopt for the AO courses.20 The second AO course took place in 1961. In the face of their colleagues’ unbroken interest – this time 102 had registered – the organisers began to worry about their ability to uphold the principle of individual hands-on instruction. In 1962 the course was cancelled since the AO surgeons were busy preparing their first textbook. In answer to the great demand resulting from the previous year’s cancellation, two courses were organised in 1963, one in March that was conducted in German, and the other scheduled for


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Figure 7 The faculty of the first AO course in Davos in 1960: fourth from left, Robert Schneider; fifth from left, Hans Willenegger; sitting in the basket, Maurice E. Müller; second from right, Martin Allgöwer.

December to be held in English and French. At that time the courses were not meant to become regular events. Because of the amount of work involved, the AO surgeons planned to stop the programme after 1963. However, they then decided to keep the courses going on a preliminary basis, expecting that the availability of the textbook and the more widespread adoption of the instruments after the introductory phase would make this form of institutionalised instruction obsolete.21 The opposite happened. Not only did the courses continue to be offered, but they were also expanded and became even more popular. In 1965 the producers Mathys and Straumann became more involved in the technical aspects of course organisation and were put in charge of maintenance and transport of the exercise instruments. In 1966 the course was extended to five days.22 The 1968 course was divided into a German language section with 436 participants and an Italian section with 100 participants. Organisers, instructors, auxiliary personnel and ‘ladies’, as the surgeons’ spouses were called, made up another 297 persons. The course instructors were put up in six Davos hotels. Moving the whole event into the newly built Davos conference centre in 1969 marked a new order of magnitude. In that year the AO offered its first course for advanced students. This was the start of a supplementary programme of specialised courses on specific aspects of the AO

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technique such as surgery of the hip or the spine, or later of hands and feet using special implants. The 1971 Davos course included five different sections, that is, one basic and one advanced course, each with an English and a French version, and an additional veterinary course.23 The first AO course outside Switzerland was held in Freiburg, Germany, in spring 1965.24 Other foreign courses took place in Yugoslavia (1968), Canada and Spain (1969), Austria and the US (1970), Australia and Mexico (1972), East Germany, England, Israel, Italy (1973), and in 28 other countries from 1974 to 1982.25 Demand for instruction seemed insatiable. The AO was being inundated with requests from all quarters.26 Though ever more surgeons had attended courses and were collecting experience in applying the technique, the need for information did not abate, Schneider stated in 1972, adding that the AO had a worldwide monopoly of instruction in osteosynthesis techniques.27 By 1998, 31,927 surgeons had participated in 67 courses in Davos and an additional 125,081 in courses taking place in 66 different countries.28 Today, all-year-round planning is necessary to coordinate the courses, contact the faculty and prepare the material: 60 workshop tables, 6500 sets of instruments, 8000 artificial bones and 40 tons of material with an estimated value of SFr55 million.29 The AO’s organisational form of teaching became a model for others to emulate. In the 1970s other providers of bone surgery equipment started offering similar courses.30 Noticing the emergence of competition, the AO surgeons were reluctant to publish their complete instruction material because they thought it would facilitate imitation of their course programme and jeopardise the unique position the AO had in that field.31 But not all such attempts can be interpreted as imitations of the AO’s model. The establishment of instruction courses was a way of solving the generally perceived problem of regulating the use of new devices. In England, for instance, John Charnley required that those interested in purchasing his hip prosthesis first be taught how to use it at his Centre for Hip Surgery in Wrightington. In 1979 he also started a programme of courses on hip prosthesis operations at Oswestry.32 The AO courses were widely seen as an answer to the urgent problem of securing the competence of osteosynthesis instrument users, as operative treatment still seemed to be at a critical juncture.33 For the AO, teaching became a central element of its activities. The group’s instructional activities were a major argument for keeping the AO in existence even when its original aim of establishing efficient operative fracture care had been achieved.34 Also, the AO’s teaching activities were an important asset for winning over its critics. Bürkle de la Camp, for instance was converted after having attended the Davos course in 1963. An outspoken sceptic beforehand, after the visit he said he would join the AO himself if he were younger, and he praised the AO publicly at the next meeting of the German Surgical Society.35 It was part of the AO’s strategy to invite authorities in their field to the Davos courses as


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guests of honour. Their first guest was Hermann Krauss from Freiburg, the eminent German supporter of the AO. In 1961 Michel Postel of Paris and John Charnley were invited; in 1963, Bürkle de la Camp; and in the following year, Lorenz Böhler, the grand old man of fracture therapy and critic of osteosynthesis. Despite his general reservations, Böhler was impressed by the course. He was a perfectionist when it came to organisation and standardisation in teaching, so it was an honour for Robert Schneider to hear Böhler praise the AO. In his words, he had never attended a course that had been so well organised.36 Besides their courses, the AO tried to reach users by offering fracture symposia. Starting in 1965 with a symposium in Mainz, Germany, these events did not include practical exercises and were therefore much easier to organise than the courses.37 The most expensive variety of user education measures were the workshops established in the 1980s in a number of clinics outside Switzerland. Furnished with a full set of practice instruments, these workshops functioned like a permanent AO instruction course.38 The AO course programme was widely appreciated and earned the AO respect and credibility. Basically, the idea that surgical competence was tacit knowledge was perceived as bad news for the AO and its efforts at spreading a new surgical technique. However, the AO was able to convince the other surgeons that this obstacle could be overcome by thoroughly standardising the relevant surgical procedures and teaching them in practical courses. If, as was generally held, tacit knowledge needed to be transmitted personally from an accomplished master to a pupil, the AO was able to provide the masters. In the end, the AO even benefited from the fact that surgical skill was seen as tacit knowledge, since the AO courses offered the means to acquire it. This made them indispensable and greatly enhanced the AO’s prestige. And, as critics were eager to point out, it was also good for business. Hardware plus software When the AO surgeons started their courses they did not aim at promoting the sale of their instruments; on the contrary, they were rather wary of promoting any further dissemination of their technique for fear of losing control over its use. Yet the training courses turned out to be an excellent means of advertising the Synthes products. This positive side effect was recognised by the manufacturers early on, so whenever the surgeons considered curtailing the course programme, it was the producers who stressed its importance.39 Their interest in continuing the course programme further benefited the AO surgeons, thereby strengthening the symbiosis between them. Because the courses functioned as ‘propaganda for the sale of the instruments’, the surgeons could expect the producers to support them.40 Nonetheless they insisted on planning the course programme according to the users’ needs for instruction rather than the requirements of product promotion.41

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The courses abroad, of course, had the effect of advertising the high quality of AO implants and instruments outside Switzerland. When the AO discussed discontinuing their foreign courses for reasons of efficiency and suggested concentrating all teaching activities in Davos instead, the producers again saw a strategic advantage for their business. Such a retreat to Switzerland, they successfully argued, would give foreign competitors the unique chance to fill the resulting gaps with their own teaching courses and to win over the surgeons to their products.42 The development programme presented in 1977 by Hansjörg Wyss, the president of the AO’s newly established American production and distribution company, Synthes USA, included as one of three main points the requirement to hold at least one advanced and two basic courses annually in the US.43 As the courses were meant to prepare surgeons to use AO instruments, it was logical that the AO discontinued its course programme in countries prohibiting the import of its products.44 In the same vein, instruments and implants from other firms were excluded from presentation at the AO courses and in the instruction videos: ‘It is not our job to advertise someone else’s products’, Mathys admonished in 1977.45 But the promotional effect did not automatically translate into business success. Austrian surgeons, Mathys complained in 1965, often attended the AO courses but bought the competitor’s instruments afterwards.46 Nonetheless, the instruction courses were a chief asset for Synthes in its competition with other instrument suppliers.47 As Straumann said in 1972, the AO not only offered the hardware for operative fracture care, it also provided the software.48 When Allgöwer reported in 1970 that sales of Synthes material rose sharply as a result of the AO’s first course in the US, he was clearly arguing in favour of continuing that course programme. But he was quick to reiterate that ‘business considerations, of course, should not be the primary motivation’ behind the AO’s support of any course programme. 49 Still, that did not prevent critics from accusing the AO of commercialism. In their eyes the courses were simply a clever promotion trick. They found it difficult to believe in any other motives. In 1965 Schneider addressed this problem in his opening speech at the first foreign AO course in Freiburg. The AO surgeons did not promote operating on fractures which would heal peacefully under conservative treatment, he assured those attending, and emphasised that it was not their goal to subject patients to the dangers of an operation in order to charge higher rates.50 Especially in the American context the AO had to be very careful in this respect. According to an American critic in 1970, the courses seduced young surgeons into using the AO method although they lacked the necessary skill and knowledge.51 In reaction to such criticism the AO surgeons explained to their American colleagues their symbiotic arrangements with the producers and stressed that they themselves did not derive any profits from the sale of their instruments. Their aim in offering


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courses was ‘not the propagation of internal fixation of fractures, but to prepare the surgeon for the time when he/she must use such an approach’.52 Standardised visualisation In order to fulfil its function of standardising surgical work, the instruction itself had to be standardised. Teachers, for instance, had to keep to a certain curriculum and place emphasis on important aspects. All this was difficult to oversee, and the more the course programme expanded, the more difficult the maintenance of standardisation became. One strategy for solving this problem was to standardise the teaching material. For teaching surgical procedures, visual aids are of particular importance. A surgeon, Böhler remarked in 1929, can learn more from images than from long talks; appropriately, his textbook contained numerous photographs and drawings.53 Along the same lines the AO equipped its books with a great number of images that could also function as instructional aids in courses and presentations. In fact, in 1969 they made sequences of slides from the images and offered them to surgeons to incorporate into their teaching. As a side effect to its systematic collection of X-ray pictures, the AO documentation centre also had an abundant reservoir of photographic material for similar use. From the early 1970s on, the AO International (AOI), a special organisation that will be discussed in more detail later on, was in charge of providing standardised teaching material. Presided over by Hans Willenegger, the new organisation edited and distributed slide series together with the relevant teaching texts, thereby linking standardised images to standardised verbal instruction. Between 1975 and 1995 the AOI headquarters delivered 62,000 slides to clinics all over the world.54 Another stage of standardisation was achieved by using moving images. Lorenz Böhler had started using teaching films in the 1920s. 55 The AO produced its first films in 1961, and from 1966 on films became a regular feature of the AO courses. In the 1970s several AO instruction films were even awarded prizes.56 The upcoming video technology would further contribute to uniformity in teaching. In the late 1960s the great variety in instruction received by the participants from their respective table instructors was considered a problem. In 1969 the situation was rectified by introducing new media technology. Using two black and white video cameras and a rented monitor system, the course organisers could now transmit the procedures shown at one of the tables live to the participants at the other tables. In 1974 they switched to colour video.57 The use of novel means of communication contributed to the positive image of the AO technique as a modern and efficient treatment method.58 As visual instruction is relatively independent of language, supplementing the courses with videos also turned out to benefit instruction in countries where the language barrier made communication difficult. The first AO course in Yugoslavia in 1968 suffered from language problems, since no Slovenian

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or Serbo-Croatian terminology existed for the AO methods and instruments, nor could anyone describe the mechanical principles for stabilising fractures in that language. Here, the AO instruction films proved to be an ideal means of instruction. After watching the relevant film, which had been produced by the St Gallen AO member Bernhard G. Weber, the Yugoslav surgeons understood – tacitly – the principles of the AO technique.59 Plastic bones with standard fractures In the early years of the AO programme, courses were conducted using bones from human cadavers, which meant that the lessons presented not only a technical but also an olfactory challenge. While the unusual smell was part and parcel of the course, it became a problem wherever the AO was sharing space with other people. At one of the first American courses, which took place in the conference rooms of a hotel, the peculiar smell emanating from the AO’s rooms and spreading into the lobby brought the surgeons into serious conflict with the hotel’s management. According to the anecdotes circulating among the early AO members, procurement and transport of the human body parts was not always easy either.60 With the size of the courses steadily increasing, human bones were becoming a scarce commodity. In 1968, organisation of the upcoming course was encumbered by the lack of bones. Due to such difficulties the AO subsequently extended their search for bones to the Far East, but this was an uneasy solution.61 They therefore considered substituting plastic models for human bones.62 Artificial bones for instructional purposes had first been developed in the US in the early 1970s, and American orthopaedists had already been using them when the AO took up the idea. In the late 1970s the AO started to make their own plastic bones for the AO courses. Like instruments and implants, the bones were produced under the Synthes label and distributed only by the AO producers. Their association with the AO made it necessary to control the bones’ circulation, since their use in courses not organised by the AO would give these courses the appearance of official AO authorisation. Later, the AO’s artificial bones were produced and marketed separately under the name of ‘Synbone’.63 With the use of bone models arose the question of appropriate representation. Artificial bones did not faithfully represent all the relevant aspects of their natural counterparts when broken and repaired.64 The problem of representation became even more acute when the AO shifted emphasis from the mechanical aspects to the biology of bone healing in the 1980s. Consequently, course exercises on naked plastic bones appeared to be a bit out of place.65 But with regard to standardisation, the use of artificial bones was advantageous. As opposed to natural bone (besides not smelling), the plastic material easily lent itself to producing identical standard fractures.66 The effects of the AO’s thoroughgoing standardisation of teaching can still be observed at any AO course. Generally, practical instruction begins by the


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numerous participants simultaneously opening the little plastic bags on their tables that contain plastic bones with uniform fractures. They then use identical instruments and implants according to the instruction given on the video screens in order to achieve the same high degree of fixation. Nurses’ instruction Being practising surgeons themselves, the AO members knew very well that the introduction of their treatment method stood or fell with the verdict of the operating room nurses. They were therefore eager to give the nurses an important place in their network of control and cooperation. In the second year of the courses at Davos, a course programme for nurses was developed parallel to those for doctors. By 1983, 40 courses with 2828 participants had been organised in Switzerland and an additional 250 courses in 29 other countries with a total of 23,296 participants.67 In addition a special textbook for operation room personnel was published.68

Figure 8

First AO Operating Room Personnel course in Davos in 1962.

Difficulties arose whenever the nurses were not included in the instruction network. In 1982 a German AO surgeon reported back from his visit to several American hospitals that they had complete sets of AO instruments and implants but were unable to employ them appropriately because the operating room nurses had no idea how to use and care for the material. Nurses needed to learn not only how to use the instruments but also how to clean and store them. Negligence at this stage posed another potential danger for the AO

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network: if the instruments were not kept in good shape, failures could occur that would discredit the AO method as a whole.69 It was therefore absolutely essential to include nurses in the AO network, as leaving a gap at this point would have endangered the rest of the network. In addition, the courses were a welcome opportunity for establishing relationships of mutual trust between surgeons and their operating room personnel.70 A recipe book for replication The significance of the written word in making the AO technique known and accepted was obvious from the beginning. The AO systematically published articles to influence the scientific discourse and, using Synthes funds, distributed large numbers of separate prints among their colleagues.71 But it was equally important to influence the way the AO technique was described and taught on the textbook level, since omitting that field from their purview would cause problems in different respects. Obviously, it was not useful to leave the textbook writing to those authors who warned against the AO. But perhaps even more detrimental were inaccurate instructions by non-AO surgeons which would lead to incorrect use of the instruments.72 The best way of controlling written instruction was by the publication of a special AO textbook. Such a book would not only present the AO method in a positive context, but it would also contribute significantly to standardising the relevant knowledge concerning osteosynthesis and make it more accessible. Written instruction had always been a feature of the AO’s educational activities. Müller had written his first instructional texts in 1951 to introduce Danis’ techniques at the Fribourg Bürgerspital. He also wrote the instruction sheets (Merkblätter) for internal use in the clinics.73 These sheets, which were discussed regularly at the early AO meetings, now became the basis for the AO textbook. In part, the book was a collective effort of all AO members. In the summer of 1962, the AO assembly was devoted to preparing the book. At that stage the main objectives were to decide what to include in the book and how to systematise and coordinate the various subjects. In the process the orally transmitted AO knowledge was given its canonical written form. The text version was very useful since in its oral form the AO teachings varied with each teacher – a situation that had prompted Allgöwer to complain in 1962 that eminent AO members contradicted each other in their speeches ex cathedra.74 In 1963, five years after the AO had been founded, the Technik der operativen Frakturbehandlung (Technique of Internal Fixation of Fractures) was published. Hermann Krauss of Freiburg wrote the preface. Being the first full professor and surgical authority to support the AO in its early days, Krauss was an appropriate choice. Though it was conceived of as an instruction manual, the Technik also explained the theoretical basis of the AO method in some detail and included an extensive list of relevant literature. Appended to the


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instructional part was a large section of X-ray images showing tibia fractures treated with AO screws and plates. These images were based on material collected by the AO documentation centre.75 Reading the book was, of course, only part of the instruction required for the successful use of the AO technique. As emphasised in its introductory chapter, while the Technik did explain how to achieve good results with the osteosynthesis technique, the necessary practical skills would have to be acquired by the surgeons themselves.76 In 1965 a special AO assembly was convened in order to prepare a second edition of the textbook. Again, the occasion was used to coordinate and reevaluate the AO teachings, so that the new book would function as ‘a touchstone and a honestone’ for the AO dogma, as Schneider wrote. Unifying and redirecting the ‘divergent exegesis of the AO’s basic principles’ required that everything, from the chief principles down to the smallest details of each image, be subjected to scrutiny.77 Since the authors had planned a complete revision in the light of current developments in research and the 14,000 osteosynthesis cases collected by the AO documentation centre, the new Technik would be a long time coming. But by 1967 the first edition was sold out and there was a great demand to replace it. Therefore the AO decided for the temporary solution of publishing only a technical manual. In fact, this type of concise working book complied exactly with many surgeons’ needs at that time.78 The new book, called the Manual der Osteosynthese (Manual of Internal Fixation), was published in 1969. Written in telegram style, it was essentially an expanded version of the instruction sheets currently being used at the AO courses. As opposed to the Technik the Manual contained almost no X-ray pictures. For didactic reasons all of the 683 images included in the book were drawings, often in schematic form. There were few references to research literature, and for more detailed descriptions of the instruments the reader was referred to the Synthes catalogue.79 The AO Manual was similar to the textbook Böhler had published to explain his own methods – Böhler’s cookbook, as it was often called because of the clear and simple directives it contained. Its last edition was published in 1963, the year of the first edition of the AO’s Technik.80 Like manuals in experimental science, the AO Manual was an effort to standardise and transmit the knowledge necessary for the successful replication of a procedure – in the AO’s case, for the successful replication of the ‘experiment’ of osteosynthesis. Its objective was to put surgeons all over the world in a position to obtain consistent results and make the AO method as universal as an accepted scientific fact. In its aims and structure the AO Manual resembled standardised clinical protocols, which were gaining in importance at the time for clinical research. This was the time when, as Marc Berg explains, ‘medical practice became defined as the logical and sequential (i.e. protocol-like) execution of the steps of scientific method’. The publication

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and subsequent popularity of the Manual can thus be seen as another part of the contemporary trend towards redefining medical (and surgical) practice as scientific practice.81

Figure 9 Hans Willenegger presents the new AO Manual to Lorenz Böhler in 1970 on his 85th birthday.

The second, revised edition of the Manual was published in 1977, again as the result of extensive discussions at the AO meetings,82 and a third edition came out in 1992. Meanwhile, a veritable programme of textbooks were being created to satisfy the demands for more specialised instruction. Besides the Manual for the surgeons and the Instrumentation for the nurses, textbooks were published on various aspects and special sections of the AO technique. In 1966, Bernhard G. Weber from St Gallen published a work on fractures of the ankle; an instruction manual on osteosynthesis of hands and feet by Urs Heim and K.M. Pfeiffer came out in 1972; and as I mentioned in Chapter 2, C.F. Brunner and B.G. Weber published a book in 1981 on ‘special techniques of osteosynthesis’. Their goal was to spell out some elements of the ‘personal knowledge’ they had acquired over the years with the AO method in order to put other experienced surgeons in a position to depart in a creative way from the Manual’s strictly standardised instructions.83 In 1965 the Technik was translated into English by the AO surgeon Gottfried Segmüller, who had spent some time in the US, with some help from an English colleague and friend of Allgöwer, Richard Batten. Although little was changed, the extensive documentation on internal fixation of tibia fractures


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was dropped. As correctly assumed by the AO’s American business partners at that time, Smith, Kline & French, this part of the book was likely to provoke a scandal among Americans for whom operations on the tibia were taboo. Shortly after the Manual was published, Joseph Schatzker wrote a translation that first circulated as a typescript and was officially brought out in book form by Springer in 1970. Schatzker’s biography predestined him to be a mediator between the Old and the New World. An emigrant from Poland to North America after World War II, he spoke fluent Polish, German and English. He also belonged to the early American adherents of the AO technique and had spent much time with Maurice Müller in 1967/68. He was thus perhaps the only individual who had both the necessary language skills and a firm grasp of the AO technique to make an accurate translation of the AO teachings.84 The Manual was also translated into a number of other languages. The following list gives an overview of the Manual’s translations and their respective publishers: Italian: 1969 (Springer) Japanese: 1969 (Springer) English: 1970 (Springer) French: 1970 (Masson & Cie., Paris) Spanish: 1975 (ed. Cientifico Medica, Barcelona) Serbo-Croatian: 1981 (Jugoslavenska Medicinska Naklada) Chinese: 1983 (Springer) Russian: 1996 (Springer) Altogether, by the year 2000 close to 110,000 AO textbooks had been distributed.85 AO ‘apprentices’ Despite the important function of the AO textbooks in user instruction, personal experience was still seen as the basis for spreading the AO technique. Even better than attending a course, a visit to an AO surgeon to assist him in the operating room was an excellent way of obtaining the necessary tacit knowledge. This method of spreading competence was institutionalised in 1968 when the AO established a foundation to support young surgeons with scholarships. In October 1969 the first scholarship financed a training visit in Switzerland for two British surgeons, and in 1970 the way was paid for two American colleagues to attend a symposium in Davos. Initially, most fellowships were awarded for international visits – often, for instance, for an American surgeon to spend a certain period of time in a Swiss AO hospital. While fellows were expected to stay at least eight weeks, their visits were limited to a maximum of three months due to restrictions by the Swiss immigration authorities. Once a particular country had a generation of

Fellowships 250

240 228 210

200

225 210 207

216

217

1996

1998

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229

193

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150

142

136 121

80

111 100

137 141 120

109

97 86 78

50 50 35

0 1971–1974

1976

1978

1980

1982

1984

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1988 Year

Figure 10

Number of AO fellowships, 1971–2000.

1990

1992

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2000


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surgeons proficient in the AO technique, the fellowship programme was altered to promote international exchange. 86 As the fellowships were considered an investment in the controlled and successful spread of the AO technique, the recipients were expected to follow up their visits by using AO equipment. Willenegger sought to ensure that the funds were not ‘wasted’ on educating colleagues who would later refuse to commit themselves to the AO method, some of whom, as Müller remarked, took advantage of their fellowships for the sole purpose of spending a holiday in Switzerland. To check on whether the money was well invested or not, former AO fellows were sent questionnaires to ask them about their use of AO products.87 Organisation and surveillance of the scholarship programme was a task assigned to the AO International, that is, to its president, Hans Willenegger. Having initiated the programme, Willenegger was given the job of deciding on individual admissions and assignments to particular hospitals. The candidates were carefully selected. As a rule, Willenegger awarded scholarships only to candidates who had completed or were about to complete their training as consultants in surgery, had attended an AO basic course, and either were using AO instruments or planned to do so in the future. Willenegger later kept up close personal contact with each of the AO fellows. By 1983 the AO had awarded 949 scholarships in 74 countries on all five continents. By the 1990s the scholarship programme comprised around 200 surgeons per year.88 The fellowship programme was an institutionalised way of continuing the AO’s original manner of network extension on a personal level. Often fellowships laid the foundation for lifelong friendships between the host and visiting surgeons. Most of the fellows became loyal and trustworthy AO supporters in their own countries. For the extension of the AO network the fellowships were therefore more important than the courses, even if the latter did more to popularise the AO.89 Personal knowledge and trust ‘Transfer of skill-like knowledge is capricious. Skill-like knowledge travels best (or only) through accomplished practitioners.’90 Harry Collins’ claim for tacit knowledge in science was also of relevance to surgery. Accordingly the best way to circulate such ‘incorporated’ surgical knowledge is to circulate the practitioners,91 which is exactly how the AO initially spread its own technique. It was Maurice Müller’s activity as an itinerant surgeon in the late 1950s that eventually led to the foundation of the group. But aside from the opportunity to convey skill and knowledge, these visits made it possible to establish personal relationships of trust and credibility between the surgeons. Trust, in fact, was the precondition for creating the initial group and would be essential for the AO’s later expansion. It is a general fact that knowledge can only be accepted from trustworthy sources, so its transmission goes hand in hand with the establishment of trust between teachers and pupils. But it

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was needed on both sides. Not only did the newly recruited surgeons want to be sure about the trustworthiness of their AO teachers, but the AO surgeons also wanted to make sure that their equipment was in the hands of people who could be trusted to use it in a competent and responsible manner. According to Allgöwer, the desire to entrust the new equipment only to colleagues who had shown themselves to be competent and reliable had been the chief motivation for establishing the AO courses.92 The personal contacts were also highly valued by its recipients. 93 The readiness of prominent AO surgeons to build up personal relationships with their colleagues was a valuable asset in their struggle against critics and competitors. The fact that with the delivery of its products the AO also ‘delivered’ personal contacts was, according to Willenegger, its outstanding advantage. Being fully aware of this, the manufacturers regularly arranged for Willenegger to visit those hospitals they thought to be most important and provided him with the necessary addresses and background information to set up contacts.94 There was, however, no need for the AO surgeons to be obtrusive. American hospitals and university centres, for instance, started to turn to Synthes USA to have AO surgeons as visiting professors or invite ‘guest speakers from Switzerland’ for their clinical rounds. In the 1970s demand far exceeded the personal capacity of the AO group, even though its members travelled a lot and Willenegger had even devoted himself to the task in retirement.95 Keeping in line with their idea of a fraternal network, the AO sent out reliable and experienced surgeons, like Hans Willenegger or Walter Bandi, to all regions of the world to give lectures, provide hands-on instruction on artificial bones, and accompany the host surgeons on ward rounds, frequently even joining them in the operating room. In a 1976 letter to the American champion of conservative fracture treatment, Augusto Sarmiento, Willenegger wrote (in his rather shaky English): In general I take about 1,000 slides with me, so I can speak and discuss about all scientific and clinical problems of osteosynthesis we are dealing with. Also I shall be ready to assist in operations ... Many operative details and tricks can much better be brought about by such a way.96 In light of the bidirectional need for trust and credibility in the network, the surgeons’ visits aimed both at winning their hosts’ trust and at finding partners for the AO surgeons to confide in. While visiting a particular region, the AO surgeons registered the technical and staff conditions of the local hospitals as well as the surgical competence of their hosts. They assessed whether their colleagues made competent decisions on the use of operative or conservative treatment, judged their surgical and organisational skills, the quality of their asepsis (the reports mostly include a note on the rate of wound


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infection), and the overall social atmosphere of the host institution. Scientific competence and reputation among colleagues were additional criteria.97 Of critical importance to the AO surgeons, a positive evaluation of the moral integrity of all potential partners was a prerequisite to extending the network. In communist East Germany, for instance, they noted the surgeons’ attitude towards the regime, and those surgeons identified as ‘Party careerists’ by their East German friends were regarded with suspicion. Similarly, when the AO surgeons discussed establishing an American offshoot in 1970, their local colleagues warned them against including certain individuals in the network’s inner group. Knowing that the best way to come to a moral assessment was also by personal acquaintance, the AO sent out its messengers to have a critical look at potential partners. 98 As a matter of course, the internal reports resulting from such journeys included, next to the technical judgements, character assessments of the other surgeons. The vocabulary used was sometimes quite outspoken and included such characterisations as ‘suspicious’, ‘difficult with coloured people’ (meaning racist), ‘neurotic’ or suffering from an ‘inferiority complex’.99 Their dependence on trustworthy partners explains the AO surgeons’ caution concerning rapid expansion. In 1970 Schneider spoke in favour of requiring the AO’s international expansion to start, as it had done in Switzerland, with a small, close-knit and easily controllable core group to whom they would then pass on the technique via personal relationships, that is, in a ‘snowball system’ of ‘private conversation’. This was the only way to prove the new partners’ technical and scientific competence and to assess their attitudes concerning the symbiotic relationship with Synthes.100 The AO surgeons thus continued to apply their tried and tested policy of establishing face-to-face acquaintances and relationships of personal trust that had been so successful in the Swiss context. Limits of control In the beginning, the AO surgeons had thought they could relax their control efforts once their technique was generally established as a standard therapy. They expected the AO courses, and even the association itself, to become obsolete in the long run. But experience would teach them otherwise. Because tacit knowledge is invisible, it is particularly difficult to control. One cannot see if it has been successfully transmitted,101 which is why it was often impossible to notice a surgeon’s lack of competence in applying the AO technique until it was too late. As a result, cases of non-unions and infections continued to threaten the AO with discredit. ‘Unfortunately,’ Müller complained in 1971, ‘we have to realise that despite the Manual and despite the courses, elementary mistakes continue to occur.’ From the Synthes sales statistics the TK was able to conclude that the implants were often used incorrectly – for instance, when certain plates made for use in only rare occasions sold very well.102

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Monitoring competence became more difficult as the AO expanded. Surveillance had been comparably easy as long as use of the AO instruments was restricted to colleagues personally acquainted with the AO surgeons. Expansion across national boundaries often held particular risks not seen within the homogeneous Swiss context. When the AO technique was introduced in West Germany, the failure rate increased sharply. In reaction, the AO surgeons tried to curb their German colleagues’ enthusiasm until they could figure out what had gone wrong. For the same reason the Davos course that year focused on the dangers of operative fracture treatment.103 Even more serious problems arose when the AO method started to spread to the US. As I will later describe in more detail, in the United States the AO was widely rejected until the 1980s, mainly because of the poor results due to incorrect application of AO implants.104 As all methods of knowledge transmission have their limits, it was clear that reading the AO Manual was not all it took to become proficient in the technique. The tacit dimension of the knowledge necessary for successful replication was unable to be translated completely into book form. But attendance at an AO course did not guarantee good operative results either. Generally the profit gained from a basic course depended very much on the amount of prior individual experience with osteosynthesis. For inexperienced surgeons, the risk of failure was very high.105 There were many instances of poorly performed operations by surgeons who had previously attended a course.106 Surgeons often did not realise, Willenegger warned in 1978, that osteosynthesis, like any other surgical technique, required assiduous training. Often, as he put it, participants would return from an AO course and without any further training set out to perform a difficult osteosynthesis operation.107 This was exactly what happened when an American outcome study in 1976 found that the AO equipment was widely bought in the US but often used incorrectly. Consequently, the overall results in patients treated with the AO technique were considerably poorer than the results of conservative treatment. The authors of the study criticised the AO surgeons for the false feeling of security their instruction courses had instilled in the participants, who would depart believing erroneously that they had mastered the technique. The courses, they concluded, dangerously seduced young surgeons into operative treatment.108 Correct use of treatment methods was a general issue in medicine, and at times it seemed to be a utopian goal. In his 1970 annual report Robert Schneider quoted a psychiatrist who had complained about his difficulties in making his colleagues carry out a simple dosage system in drug therapy. Schneider remarked: How much more optimistic are we to believe that our implants will be used all over the world in compliance with our ideas. Understanding the biomechanical situation in a broken bone is arguably a greater intellectual


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achievement than following a dosage system. This is why we must adhere to our role as teachers, warners and researchers.109 Seen in that way, the impossibility of perfect control was the very raison d’être of the AO. The influence of user education For proponents and critics alike, the instruction measures offered by the AO were seen as an adequate answer to the widely perceived problem of securing surgical skill and knowledge. The influence of the AO instruction programme on the acceptance and popularity of their methods and materials was enormous. The courses, fellowships, textbooks, videotapes and visits were crucial for establishing the AO’s credibility within the surgical world.110 It was generally believed that spreading surgical competence was a difficult task. As described in this chapter, surgeons knew that learning how to apply osteosynthesis techniques was not like transferring data from instructor to user, but entailed rather a change in the person of the user. It is a kind of active enculturation of the user who has to collect information on principles and rules while also acquiring tacit knowledge, skill and a ‘feeling’ for the method. By making this basic problem one of their central concerns, the AO surgeons gained the credibility and trust that finally enabled them to extend their network all over the world. The measure of their success obviously depended not so much on the real effect of the instruction programme, which is necessarily limited and difficult to ascertain, but on the reassurance that the problem was taken seriously. Standardised instruction is a strategy to reduce insecurity; a strategy that, despite its limits, is a powerful means of persuasion, providing a feeling of security that made acceptance of the new technique possible.

5

Science and Surgery: Bones in the Laboratory

‘From today’s perspective the crucial contributions of basic science, above all the elucidation of the healing processes of bone, to the AO’s reputation throughout the world are evident to us all.’ 1 This judgement by Robert Schneider is typical for the role the association attributes to laboratory research in its own success story. Both commentators within the AO and their non-member counterparts have stressed the importance of experimental studies for winning over other surgeons. The tenets underlying the ‘AO philosophy’ were relatively simple: anatomical reconstruction, rigid fixation with compression osteosynthesis, post-operative functional treatment, primary bone healing. But the fact that some of these tenets were far from being generally acknowledged made laboratory research so important for the acceptance of the AO technique. Furthermore, as long as its biological foundation remained indeterminate, all failures occurring with the technique could be interpreted as proof of its basic impracticability. If the biological foundation of a technique is flawed, John Charnley rightly noted, no technical improvement whatsoever could make it viable.2 But the reverse, claimed Robert Danis in reference to his technique of compression osteosynthesis, was also true. If used correctly, procedures and devices based on true biological knowledge would unfailingly lead to practical success.3 On a more general level, laboratory science was important because modern medicine demands that any new system of treatment be predicated upon experimentally derived knowledge. ‘Science’, Stuart Blume writes in his sociological investigation of technology in medicine, ‘is crucial to the ideology of modern medicine, and must demonstrably provide the discoveries on which new technologies can be based.’ 4 Although Charnley and Danis disagreed concerning compression osteosynthesis, both referred to basic 86

Bones in the Laboratory

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science to substantiate their arguments. Objective, scientifically produced knowledge was seen as the foundation for transforming medicine from a more or less erratic art into a science with clear and unambiguous rules. Though, as John Harley Warner has shown, science meant many different things in the course of medical history, ever since the nineteenth-century ‘laboratory revolution in medicine’, it was above all the laboratory-based experimental sciences that were called upon to supply an epistemic and practical alternative to the traditional medical logic of individual experience and judgement. According to the scientific approach, the basic laws governing the functions of a biological organism were also the basis of good medical practice. Consequently, the knowledge necessary for successful treatment was no longer expected to come from the bedside but from the laboratory.5 This change in perspective also affected surgery. In the course of the nineteenth century, animal experiments were added to case reports and case series to supplement the methodological repertoire of surgical research. 6 Laboratory research also had its place in the field of osteosynthesis, where surgeons tested various techniques and implant materials in animals.7 By the 1950s laboratory investigations on osteosynthesis had become so common that innovations in that field were hard to introduce without some underpinning from the laboratory. 8 Claims of the usefulness of a new technique remained mere ‘theory’ as long as they were ‘supported only by clinical observations’, 9 Eggers wrote with regard to his technique of compression osteosynthesis. Medical historian Roger Cooter has identified the late 1950s as the main period when orthopaedics started to ‘take on the hues of science’ and orthopaedic surgeons to invest increasingly in basic research. Adopting a new image based on the authority of science, they now sought to present anatomical and physiological knowledge as the basis of good orthopaedic practice. According to Cooter’s investigations, only 15 per cent of the papers published in 1940 in the Journal of Bone and Joint Surgery were concerned with ‘investigative research’, whereas in 1959 the number was closer to 50 per cent.10 The turn towards basic science was partially a reaction to its former neglect. Prominent fracture surgeons, such as Reginald Watson-Jones, had rejected the laboratory as a valid source of knowledge relevant for their speciality.11 Lorenz Böhler ridiculed those colleagues of his who saw true science mainly in studying dogs and rabbits, as he put it. For him science was primarily clinical research.12 The Zürich head surgeon and AO opponent Hans-Ulrich Buff inveighed against the increasing weight of experimental science in academic surgery. In an age, he scoffed, in which hens were induced to lay more eggs with the help of science, top athletes were trained scientifically and even politics was a science, most people subscribed to the erroneous notion that medicine must also become a science.13 Other surgeons who opposed such anti-scientific tendencies in fracture treatment admitted, however, that dealing with broken bones indeed tended

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to seduce practitioners to a crudely mechanical style of thinking. 14 In particular, surgeons using osteosynthesis were often depicted as craftsmen who were ignorant of their trade’s scientific dimension.15 As the example of Albin Lambotte illustrates, the roots of osteosynthesis lay indeed in the culture of improvisational tinkering and artisanship. Lambotte had been an outstanding craftsman. He not only made his own surgical instruments but was also an excellent violin-maker. Making fun of colleagues who ‘fiddled about with test tubes’ or ‘had their eyes glued to the eyepiece of a microscope’, he had no interest in experimental science. 16 According to Allgöwer’s estimate, osteosynthesis pioneers often compensated for their negligence of the scientific aspect of their techniques with an ‘instinctive’ sense of biomechanics like Lambotte, or like Danis with an analytical competence, which enabled him to formulate physically sound and biologically correct basic principles.17 Contrary to the ideology of modern medicine, the AO techniques were not based on scientific discoveries. Nor were the instruments and implants created by Müller and Mathys the product of laboratory research but of the ingenious application of the art of engineering. But the disputes about the AO technique and its biological basis as well as the growing general importance of basic science in fracture treatment did induce some AO surgeons to take up their own experimental research. The relevant field of inquiry was biomechanics, which had emerged earlier in the twentieth century.18 The discussion mainly revolved around two subjects: first, the question as to whether compression was good or bad for fracture healing; second, whether the phenomenon called ‘primary bone healing’ actually existed. In my analysis of these discussions I have refrained from judging the correctness or falsity of the ideas. Rather it is my aim to examine how these ideas were created and justified, how they were received by different audiences and how they functioned, as some sociologists of science would put it, both as ‘institutionalised resources for effecting co-ordinated action’19 within the AO and as a means of convincing the surgical public of the viability of the AO’s techniques. After an examination of the disputes over compression osteosynthesis and primary bone healing I will consider the relationship between clinical phenomena and their laboratory models and discuss how basic science and clinical medicine influence each other. Compression The effect of mechanical forces on bone formation and fracture healing had been the subject of scientific investigation since the second half of the nineteenth century, when the frequently cited Wolff’s law was formulated for the first time. In 1892 the surgeon Julius Wolff advanced the hypothesis that living bone was able to adapt its inner structure and shape to the forces exerted upon it. How the bone looked depended on the degree and direction of these forces. Wolff’s considerations were seen as part of a more general


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biological approach developed earlier by the biologist Wilhelm Roux. Claiming that the body was governed by the ‘use it or lose it’ principle, Roux explained that the configuration of all bodily structures was a response to their use: organs, muscles and bones would grow stronger if used intensively and get weaker with disuse. In the 1930s this biomechanical approach was applied to practical surgery by the orthopaedic surgeon Friedrich Pauwels in Aachen, Germany. Pauwels tried to explain the biological processes involved in bone healing by considering the relations between mechanical forces and biology on the level of the individual bone cells. In this context he interpreted the nailing of femoral neck fractures in terms of biomechanics and discussed how the bone fragments had to be arranged to get the best results. Pauwels saw his own work as an early contribution to an important field still needing further research. Accordingly Roux, Wolff and Pauwels came to be regarded by later investigators as the founders of biomechanics. Proponents of osteosynthesis in particular often invoked the biomechanical tradition and its principles in support of their methods. When Müller presented the fundamentals of osteosynthesis to the group in 1958, he stressed that the compliance of bone structure to its function followed exact mathematical principles. Understanding the causal relationship between the behaviour of bone cells and variations in traction and pressure led researchers to theorise that surgeons could best aid the biological processes of bone healing by optimising the physical conditions of a fracture in accordance with the laws of biomechanics.20 One such strategy called for the application of pressure at the area of breakage. In the 1930s a few surgeons had found that fragments of cancellous bone could be induced to fuse by pressing them together, but the first general acknowledgement of this fact by the surgical world came in 1948 after John Charnley had published the favourable results of a technique he had developed to produce the surgical fusion of a joint (arthrodesis). Charnley confirmed his clinical observations by taking biopsies from the relevant portion of patients’ bones: the histological examination of these samples showed that the cancellous bone had fused completely with almost zero callus formation.21 Whereas Charnley based his study on clinical experience, others examined the effect of compression osteosynthesis on laboratory animals. George W.N. Eggers and his colleagues at the University of Texas at Galveston found that a certain amount of what they called ‘physiological’ pressure was ideal for bone healing: less pressure would result in slow and incomplete healing, while more pressure induced necrosis of the fracture ends. These results were confirmed by Zachary B. Friedenberg and George French of Philadelphia who used a special measuring device to determine the amount of pressure applied.22 Despite such positive results, by the 1950s there were still only few surgeons willing to advocate the use of pressure in fracture treatment.23 One

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of them was Robert Danis. For him, any osteosynthesis technique that did not guarantee sufficient and permanent interfragmentary pressure was questionable, just as success using his own technique, the coapteur, depended on the right quantity of compression at the fracture site.24 Another pioneer risking compression osteosynthesis at that time was Maurice Müller. He had adopted both Charnley’s arthrodesis technique and Danis’ coapteur, which he later modified to develop the AO technique.25 However, general opinion held that any form of rigid fixation, with or without compression, would impede fracture healing. Underlying the rejection of this technique was the theory that the breakage killed bone cells at the fracture ends, creating a zone of dead bone tissue that would gradually be replaced by newly formed living bone. Rigid fixation, then, would block the normal approximation of the bone ends during the absorption process, and the resulting gap would delay or even prevent the union of the fractured bone. To avoid gapping, Eggers and other surgeons created various types of dynamic fixation plates. Instead of holes corresponding to the diameters of the screws, these plates had slots so that the forces of muscular traction and load-bearing could work to press the fracture ends together.26 The Küntscher nail was also seen as an effective fixation technique to enable contact between bone ends while the necrotic tissue was being absorbed.27 For the most influential authorities of fracture treatment at the time, Böhler and Watson-Jones, necrosis of the fracture ends was the most significant argument against employing internal fixation. To begin with, Watson-Jones assumed that forced compression was pathogenic and would lead to the absorption rather than to the formation of bone tissue. Basing his argument on purely mechanical considerations, he held that compression osteosynthesis violated the physiological laws of bone healing.28 Many surgeons joined Watson-Jones in assuming that using pressure would lead to additional necrosis of the fracture ends and that the resulting gap would inevitably produce instability and increase the risk of non-union.29 Most surgeons were swayed by the idea that necrosis and absorption impeded healing, so they continued to reject bone plates in favour of nailing techniques and conservative treatment;30 nonetheless, the consensus was that the issue still lacked a satisfactory explanation and so should be made the subject of further experimental research.31 The AO had good reason to take on that task and defend the concept of compression osteosynthesis against its numerous critics. At that time it was a concept shared in one way or another by all participants in the emerging AO network. In the language of interactionist sociology, compression osteosynthesis functioned as a ‘boundary object’ for coordinating the work of the various surgeons, scientists and manufacturers involved with the AO across the boundaries of their respective social worlds.32 If its viability could be proved, the technique would be a further asset in the AO’s efforts to expand their existing network of collaborators.


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Responding to the criticism, Müller emphasised the principal difference between the effects of constant pressure, which supported bone healing, and intermittent pressure, which led to the absorption of bone. The undesirable effect of osteolysis was due not to the method itself but to the incomplete immobilisation of the bone fragments, which disturbed the continuity of pressure. Even microscopic movements were enough to cause loss of bone tissue in the affected area.33 At first the AO did not have much experimental evidence of their own to underpin this view. 34 In the 1963 AO textbook Müller pointed to work in progress by the AO surgeon Hans Willenegger, the engineer Fritz Straumann and the anatomist Robert Schenk.35 As a model for compression osteosynthesis in human patients the three AO scientists used sheep. The experiment involved cutting through the whole diameter of the ovine long bone and carrying out an internal fixation with a compression plate. To find out whether the applied pressure would decrease as the result of bone end necrosis they needed a measuring device.36 Taking advantage of pressure-dependent changes in the magnetic characteristics of nickel, they developed a gauge plate for the treatment of the experimental osteotomies. With this appliance they were able to determine the amount of interfragmentary pressure by placing the operated extremity in a magnetic coil and comparing the measurement with a calibrated curve. The technique was fully developed by 1962.37 However, various technical and surgical problems made it necessary to replace the measuring equipment with a more efficient and reliable gauge plate on the basis of a modified AO compression plate. The new device had been developed by Stephan Perren together with the engineer Max Russenberger. It included a strain gauge compartment in the centre of the plate between the two middle screw holes and allowed the continuous measurement of longitudinal stress on the plate within a living animal. Not only could the course of pressure alterations now be determined throughout the entire healing process, but it also became possible to control the amount of pressure applied in the first place. Within this arrangement even a small loss of bone substance due to pressure necrosis would instantly result in a measurable decrease in pressure. But as no such decrease was registered, the researchers assumed that no resorption caused by necrosis had occurred. The only thing they did observe was a gradual loss of pressure over a period of some weeks. But since the same phenomenon was also registered in the plates that had been applied as a control to non-osteotomised bone, it could be interpreted as reflecting the normal process of bone remodelling. This meant that the healing process in bone treated with the AO compression plate was equivalent to the remodelling processes normal bone was undergoing constantly. The researchers thus concluded that no instability-induced necrosis occurred with the AO method. Even the application of very high static pressure did not result in the slightest absorption of fragment ends; an

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observation, Perren noted, that was so much in contradiction with everyday rationality that it was hard for many surgeons to believe.

(a)

(b)

(c)

(d)

Figure 11 Perren’s biomechanical experiment: (a) plate with strain gauges; (b) applying the plate to a bone; (c) application to the tibia of a sheep; (d) standard curve from dozens of measurements, showing a gradual decrease of pressure in the course of four months.

To make the line of argument complete, the researchers also investigated when and how bone absorption actually occurred in internal fixation. They found that non-rigid fixation, modelled with bendable plates, resulted in resorption at the fragment ends and marked callus formation. By contrast, the use of rigid plates in the control group did not lead to resorption, and callus formation was minimal. Obviously, they concluded, resorption was induced by the effect of momentary loss of preload; in other words, by micro-


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movement. This also explained why circumscribed bone loss of the fracture ends was very common when the customary methods of fracture treatment were used, but did not occur with rigid fixation achieved by compression osteosynthesis. So-called pressure necrosis was nothing other than the result of insufficient fixation. Accordingly, Willenegger, Perren and Schenk redefined the phenomenon in 1971 as ‘mechanically induced bone resorption (formerly erroneously called pressure necrosis)’.38 Thanks to the results of their laboratory research the AO now had effective arguments at their disposal to defend their view and dominate the discourse. In a 1965 discussion Müller confronted the AO opponent Buff, who did not believe in the benefit of compression. He was now able to refute Buff’s criticism with a reference to ‘exact experiments’ that had repudiated the necrosis theory. Declaring the laboratory the arena for any further disputes, he asserted that ‘only counter-experiments and not ex cathedra claims’ could prove the falsity of the AO’s view.39 By the end of the 1960s compression osteosynthesis had gained wide acceptance. According to the AO, its justification was based on clinical experience with thousands of successfully treated cases as well as on experimental results.40 As a sign of the general acceptance among surgeons on both sides of the Atlantic, the leading American textbook on orthopaedic surgery, Campbell’s Operative Orthopaedics, largely adopted the AO’s concept in its 1971 edition, the old view being presented as mere theory: Theoretically the amount of compression exerted across a fracture by a compression plate might cause necrosis of the ends of the fragments. However, from a practical standpoint we have not seen necrosis in either our experimental studies or our patients; furthermore it has not been reported by the AO group. The fact that the AO is presented as a reliable witness is evidence of the prestige and credibility it had acquired by then.41 The AO laboratory Much of the AO’s research on compression osteosynthesis had been performed at its Laboratory for Experimental Surgery in Davos, described in Chapter 2. Established in 1959, the laboratory would increase in importance over the next couple of decades as the AO sought to provide a scientific foundation for its technique and so to win the trust of the surgical world. In the first decade of its existence, the laboratory underwent a number of major organisational and structural changes. Right from the start, the facilities were also home to the AO Documentation Centre for the collection of clinical data. Charged with managing both tasks, the initial labour force consisted of one laboratory worker, one photographer, one animal keeper, two laboratory assistants and one part-time secretary. By 1967 there were 25 employees, eight of whom were academics, and among them two foreigners.42

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In the early period from 1959 to 1963 Allgöwer was director. Spending two days a week in Davos on a regular basis, he maintained research projects on wound healing, shock, and burn injuries. In 1960 a tissue culture laboratory was set up. In 1960/61 the research programme on pressure measurement of osteosynthesis in sheep was started.43 In 1963 when physiologist Herbert Fleisch was appointed director, he further expanded the laboratory by establishing a work group to study calcium metabolism and the regulation of biological calcification, which was his special area of interest.44 In 1967 the successful careers of some AO members changed conditions so dramatically that the laboratory’s future was at stake. When Allgöwer was appointed chair of general surgery in Basel he took the burn injury and shock groups with him. Müller was made chair of orthopaedic surgery at the University of Bern, where he established a new documentation centre. At the same time Fleisch was appointed chair of pathophysiology, also at Bern; with support from the AO he established a new pathophysiological institute and transferred the calcification group to the same university building where Müller had installed the new AO Documentation Centre. In the light of these changes, after which only the 13 members of the groups on biomechanics and wound healing were still in Davos, it was unclear whether the AO should maintain the facilities at all.45 Meanwhile, however, the laboratory and the courses had given the Davos location a positive symbolic value for the AO’s identity, which, as Allgöwer, Schneider and Fleisch argued, should not be given up without thorough consideration. For these reasons plans were made to keep up the laboratory for the next two years and then decide on its ultimate fate. Finally Stephan Perren, who had joined the laboratory staff back in 1964 from Allgöwer’s department in the Chur hospital, was appointed the new head. As his interests focused on fracture healing, the laboratory’s research now had a much more immediate bearing on the AO’s concerns. It included research on implant materials and their respective biocompatibility, the biomechanical effects of different shapes and sizes of implants, and the process of bone healing under different conditions. This was the third thematic move of the Davos laboratory: under Allgöwer’s directorship from 1958 to 1962 the focus had been on polytrauma, treatment of haemorrhagic shock, pathophysiology of burn injuries and the cellular basis of wound repair; the subsequent period under Herbert Fleisch was mostly devoted to the biochemical aspects of bone formation and resorption. Now the main area of study was biological change in bone structure through the influence of physical forces. On the basis of a favourable assessment of Perren’s research, the AO finally decided to continue and even expand its Davos activities. When in 1969 the Fourth International Congress of the European Society for Experimental Surgery was held in Davos, the laboratory was presented to a larger audience of experts, and in 1973 its buildings were complemented by a new animal house.46


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Like its staff, the AO laboratory’s budget also reflects its varied history. Starting with SFr50,000 in the first year, it increased to SFr500,000 when Fleisch joined in 1963 and had grown to SFr980,000 four years later. After the departure of the various groups to Basel and Bern the sum decreased to SFr500,000 in 1969, but it gradually regained its height, amounting to SFr800,000 in 1970 and SFr930,000 in 1971.47 Legally the AO laboratory was organised as a private foundation for the support of basic and applied research. To get the laboratory up and running, Allgöwer had donated SFr10,000. Funding thereafter was subsidised by the AO members through yearly contributions in the range of a few hundred francs each. Various insurance companies and pharmaceutical firms also functioned as outside sponsors. According to its plans of supporting the reinstatement of research at the Davos facilities, the Canton of Grisons contributed SFr10,000 per year. Grants from the American National Institutes of Health and the Swiss National Foundation also played an important role. But despite these various contributions the laboratory’s financial situation remained precarious during the first years of its existence. The tide turned with the involvement of Synthes AG Chur after completion of its contracts with the AO the producers in 1962. According to Stephan Perren’s account the laboratory’s funding up to 1971 came from the following sources: 60 per cent from Synthes AG Chur, 18 per cent from the Swiss National Foundation, 12 per cent from the foreign pharmaceutical industry, 6 per cent from the American National Institutes of Health, 2 per cent from electricity companies (for research on electricity injuries), 1.5 per cent from the domestic pharmaceutical industry, and 0.7 per cent from the Canton of Grisons.48 Despite the decisive role of the producers in funding the research facilities, control remained with the AO surgeons. In September 1971, for instance, when the question arose whether the producers should also be able to commission research tasks to the AO scientists, they stipulated that – in order to uphold the supremacy of medical rationality over commercial considerations – only the AO’s Technical Commission and the trustees of the laboratory foundation were entitled to decide on the laboratory’s research agenda.49 Besides its emphasis on Davos the AO also supported external research on subjects relevant to its techniques.50 The AO surgeons were always proud of the fact that their research efforts were not dependent on the state or on universities. Because of its symbiotic relationship between scientists, surgeons and producers and its feedback mechanism between research and business, the AO’s system of research funding serves as an example of the ‘alliance between laboratory, clinics, and industry’ and the development of ‘new institutional structures’ parallel to the traditional university-based research facilities that have been described by historians of medicine for the second half of the twentieth century.51

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Primary bone healing: the traditional callus revisited In addition to the issues connected with compression osteosynthesis, the early AO’s laboratory research focused on the phenomenon called ‘primary bone healing’. The possibility of bone healing with minimal or even no callus formation stood in remarkable opposition to the received knowledge of the time that gave callus a central role in the process of fracture repair. The idea can be traced back to the early twentieth century. Lambotte remarked in 1907 that bone was unlike other tissues in its ability to heal without visible scarification. In 1914 Lane described a similar phenomenon, which he called fracture healing by first intention as opposed to healing by secondary intention.52 In the same period Bernhard Bardenheuer propagated his nonoperative traction treatment for fractures because it enabled the bone to heal with very little callus, thus restoring continuity in the fastest way possible, namely per primam intentionem (‘by primary intention’; that is, healing as intended, without complications). 53 Interest in this type of bone healing was not restricted to surgeons. In 1937 the Budapest anatomist Stefan Krompecher described a phenomenon that soon came to be regarded as the equivalent to primary bone healing on the tissue level. With the help of newly developed chemical methods for visualising and identifying different types of tissue, he investigated the effect of different mechanical conditions on bone healing in laboratory animals. Under mechanically neutral conditions – that is, without the influence of either pressure or traction – the anatomist observed ‘direct’ bone formation. This ‘primary angiogenic bone formation’, as he called it, resulted in homogeneous bone substance. From his observations Krompecher concluded that surgeons were able to induce the desired type of healing process by creating the respective physical conditions in their treatment methods.54 Krompecher’s findings were frequently cited in the relevant literature, though to a much greater degree in the German-speaking world than in English-language publications.55 Friedrich Pauwels, for instance, integrated Krompecher’s observations into his account of bone healing. Mechanical instability, he claimed, prevented the bone from immediately employing its most stable construction element, the cytoosteon. Instead, the healing process initially aimed at achieving stability by building up a preliminary scaffolding in the form of cartilaginous or fibrous callus.56 But the surgeon whose advocacy of primary bone healing directly influenced the concepts of the later AO was Robert Danis. He claimed that optimal internal fixation would reduce callus formation until it was no longer visible. In disagreement with common surgical opinion, Danis believed that visible callus was a pathological phenomenon indicating the use of imperfect treatment methods. For him, the notion that callus formation was indispensable for bone healing was just as erroneous as thinking that skin regeneration was contingent upon secondary scar formation.57


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The terminology used to describe the phenomenon of callus-free bone healing varied. The term ‘primary bone healing’ had been created in analogy to the primary healing of skin which is characterised by a swift and uncomplicated process with minimal scar tissue. The term ‘secondary healing’ was used in this context to indicate a disrupted course of healing, most often caused by a gap between the wound margins or by infection. It resulted in delayed, incomplete restoration and extensive scarification. Bardenheuer evoked this analogy by comparing the occurrence of callus in bone with the formation of scars in soft tissue. In both cases a surplus of new tissue reflected non-optimal healing conditions, caused by insufficient contact between the bone ends in fractures and poor adaptation of the wound margins or wound infection in soft tissue injuries. Danis, who spoke of soudure autogène or soudure per primam, saw the lack of callus in primary bone healing as equivalent to the almost invisibly fine scars that could be achieved by closing skin wounds with an intracutaneous suture. Along the same lines, authors writing in English often used the term ‘first intention healing’.58 As noted, however, by some contemporaries, among them Küntscher and Müller, the analogy was misleading. The secondary healing of a skin injury was an altogether different phenomenon than bone healing with callus formation. Used correctly, the term ‘secondary bone healing’ would have described a delayed healing process that was complicated by bone infection or non-union. The word ‘secondary’ implied the occurrence of some abnormality, whereas its logical counterpart ‘primary’ would refer to a normal, undisturbed course of healing. Speaking of primary bone healing thus implied a redefinition of what was ‘normal’. The very term ‘primary healing’ implies successful, normal healing ‘as intended’ by the surgeon as well as the requirement to avoid ‘secondary’ healing. Müller therefore later avoided the term, using ‘direct ossification’ instead.59 Despite such criticism the name ‘primary bone healing’ stuck, becoming a trademark of the AO system. Primary bone healing was so important for the early AO because the group had connected its own fate to the concept. Like compression osteosynthesis, this type of healing had become a boundary object for the surgeons, technicians and scientists involved in the AO network and helped them to focus and coordinate their efforts despite their differences in origin and background. Early on, Müller had presented healing per primam as one of the AO’s central concerns. ‘So-called per primam ossification’ was the mark of flawless stability and evidence of the high quality of the technique and its application, he said in March 1958. ‘Any surplus of callus’ was considered ‘evidence of a disturbance of the fracture site’, making it necessary to find out what had gone wrong.60 There was much at stake with the concept of primary bone healing, especially as it was also a focal point of those who opposed the AO and its osteosynthesis techniques. As Schneider later recalled, most surgeons still denied the possibility of bone healing without the ‘traditional callus’ when

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the AO first presented its system to the surgical public.61 Some critics doubted the existence of primary bone healing; others, its usefulness. Charnley, for instance, not only rejected the use of compression osteosynthesis in cortical bone, he also interpreted the lack of callus observed in connection with this method of treatment as a deficiency. Callus, he held, was nature’s ‘own internal fixation’ in the process of cortical bone healing, ‘a highly specialised natural process’ that immobilised the fragments so that they could grow together. Lack of callus was not the result of good immobilisation but the consequence of stripping the bone ends of their outer layer, the periosteum, during the operation so that they were no longer able to produce callus. It was only this surgical disruption of the natural course of bone healing that made artificial immobilisation necessary at all. In the 1950s and 1960s the leading authorities taught that because the bone ends were dead, the fracture gap could never be bridged directly but only via the callus formed by the outer or inner layers of vascular connective tissue enveloping the bones (periosteal or endosteal callus). In order to understand contemporary doubts about the existence of callusfree bone healing, it is worth having a closer look at the work of one of the AO’s Swiss opponents, Max Geiser of the University Clinic for Orthopaedic Surgery and Traumatology in Bern. In his opinion, the very idea of primary bone healing arose only because of the faulty imaging medium used by the majority of experimenters. According to Geiser, the only means by which to reveal the actual processes of bone healing was microscopic examination of the tissues involved. In order to prove his point, Geiser experimented with rabbits. After artificially fracturing the animals’ bones, he examined the different stages of the healing process. To determine how the involved components – endosteum, periosteum and cortical bone – contributed to the healing process, he selectively blocked the activity of each one. He found that healing always started with the formation of callus from the endosteal or periosteal tissues and that cortical bone never contributed to these processes, the fracture ends being necrotic over a distance of several millimetres. While the fracture site was protected mechanically by the newly formed callus, the dead bone ends were gradually replaced by living bone tissue. If this was the normal manner of bone repair, the quality of artificial fracture stabilisation was only of minor consequence. So Geiser used cerclage in his rabbits without giving a thought to the fact that this was a non-rigid fixation technique. For him no degree of stability whatsoever would induce the bone to heal directly from one cortical fracture end to the other, as claimed by Danis and the AO. Bone healing without callus formation was an artefact resulting from the disturbance of the natural healing process: in the course of applying their plates, surgeons had damaged the periosteum and thus inhibited callus formation. The resulting delay in bone healing was masked by the use of fixation devices that maintained stability and created


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the illusion of an undisturbed course of healing. Only gradually would the necrotic tissue in the fracture gap be replaced by new bone.62 Thus for sceptics like Geiser and Charnley, primary bone healing was nothing else than the absence of callus, indicating a deficiency caused by overzealous surgeons. The very definition of primary bone healing was based on the absence of something; it was a negative finding. In light of this criticism, it became an urgent necessity for the AO to come up with a positive description of primary bone healing.63 The existing description was to be supplemented by an additional, different technique of representation – a representational strategy that philosophers of science today call ‘triangulation’. The appropriate technique to achieve triangulation in that context was histology, the visualisation of microscopic tissue structure that Geiser and others had used. Advocates and critics agreed that only the microscope would be able to reveal what was ‘behind’ the absence of callus in the X-ray.64 Xrays were generally considered only indirect evidence of what really happened in bone healing. Histology, by contrast, seemed to be a direct way of gaining knowledge, comparable to seeing the healing process with one’s own eyes. This view can only be explained by cultural convention. In fact histology, if anything, is even more indirect and subject to human agency. By their very nature, histological images stand at the end of a very long and elaborate chain of procedures. Producing a histological image starts with choosing and removing a specimen from some organism, often within the highly artificial setting of a complicated animal experiment. Then the specimen has to be stained, the choice of dye determining which structures become visible in the preparation. Microscopic examination involves choosing a suitable section of the whole specimen which will then be photographed. From the resulting pictures the ‘best’ is chosen for presentation in a scientific paper.65 Despite its artificiality, histology was seen as ‘revealing’ the processes occurring at the fracture site.66 The AO’s proof of primary bone healing When the AO started pursuing this approach in the early 1960s, histology was an accepted method of investigating bone healing. Among others, Krompecher, Pauwels, Bagby, Charnley and Geiser had based their arguments on histological evidence.67 But no one had as yet demonstrated what primary bone healing looked like on the microscopic level. Never had anyone been able to show a healing process that originated from the fractured cortical bone.68 Proponents of compression osteosynthesis like the AO surgeons, however, attributed the failure to observe primary healing to the fact that other investigators had been unable to achieve rigid enough fixation.69 So if anyone was capable of proving its existence it was the AO surgeons, who had the means to achieve the necessary degree of stability.70 For this they had to collaborate with scientists. In the late 1950s Hans Willenegger, who taught at the University of Basel, got in touch with the

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anatomist Robert Schenk. Schenk, who was in Basel at the time, possessed the necessary know-how to examine the process of bone healing using histology. The timing for such an investigation was propitious. The increased interest in health problems caused by radiation in the context of the Cold War had made the subject of bone tissue turnover a popular area of study. As a result, new marker techniques for demonstrating the restructuring of bone were now also available. For the purpose of carrying out their experiments, Schenk and Willenegger were granted access to the ‘dog farm’ owned by the Basel pharmaceutical company Hoffmann-La Roche. Thus equipped, the researchers first made osteotomies of the radius and fixed them with AO compression plates. Then they examined the regeneration of cortical bone at the osteotomy site. 71 Histology showed minor periosteal and endosteal bone formation, a sign that these mechanisms of bone repair had been involved in the healing process. The osteotomy itself, however, had been fused mainly through ossification originating in the cells and blood vessels inside the Haversian canals of the cortical bone ends (the Haversian canals, also called the Haversian system, are the basic structural elements responsible for normal regeneration and growth processes in bone). For those portions of the osteotomy where the bone ends were in close approximation, Schenk and Willenegger described a healing process they would later call ‘contact healing’. It was started by cells specialised in bone resorption. Their osteoclastic activity created a resorption canal in which bone-producing osteoblasts settled, filling it up with lamellar bone. This process of simultaneous resorption and formation of bone resulted in longitudinal osteons that directly connected the fracture ends. On close examination, however, this direct repair process proved to be a very rare occurrence. On the microscopic level it was observed that close contact between the fracture ends was the exception rather than the rule. Because Schenk and Willenegger had used a rigid plate for their experiment, the bone was pressed together on one side of the osteotomy, whereas the greater part of the cross-section showed a small gap. Here they found what they called ‘gap healing’. The void between the fracture ends was filled by fibrous bone tissue originating from capillaries and cells that had grown into it. Most of these capillaries came from the endosteal or periosteal tissue, some of them from the cortical bone. Once the gap had been bridged by fibrous bone, a second step began in which osteons were able to grow into the gap and replace it by lamellar bone tissue in the manner described for contact healing. Thus, Schenk and Willenegger had found that the clinical phenomenon of primary bone healing consisted histologically of two different types of bone repair: one was the direct restitution by contact healing, the other was the two-stage process of gap healing. The investigations by Schenk and Willenegger provided evidence that under optimum conditions, cortical bone contributed actively to bone healing. According to their description, the agents of this active contribution


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were the perivascular cells within the Haversian canals, which were transformed respectively into bone-reducing osteoclasts and bone-producing osteoblasts through stimulation from the injury. Schenk and Willenegger called this phenomenon ‘fracture healing by intracanular osteogenesis’. The mechanism was all the more remarkable as it is identical to what happens in bones anyway. Normal, uninjured living bone is constantly being restructured by osteoclasts and osteoblasts originating from the Haversian system and incessantly producing new osteons. Within this context the researchers’ additional finding that the fracture ends were in fact necrotic did not reduce the persuasiveness of their argument. According to Schenk and Willenegger, necrosis was not caused by the application of pressure, as many critics of compression osteosynthesis had claimed, but by the fracture or osteotomy itself. When a bone was cut or broken, local blood vessels were also destroyed, disconnecting the fracture ends from their blood supply. During the healing process the resulting dead bone substance was gradually broken down by osteoclasts which created absorption canals following the direction and shape of the original osteons. In the next step ‘secondary’ osteons started growing from the cortical bone ends into the canals. After six weeks the necrotic areas were usually full of the new osteons, which connected the two fracture ends like dowels. In this manner all necrotic residue was gradually replaced by new bone substance. During the entire healing process described by Schenk and Willenegger, no additional callus is formed either from connective tissue or from cartilage or from fibrous bone. Instead, the original cortical structure is restored with high-quality lamellar bone tissue. These mechanisms, which are the same ones occurring in physiological bone restructuring processes, lead to a fusion that almost looks as if the bone had never been broken. It was easy to see these observations as the histological equivalent to the radiological diagnosis of primary bone healing.72 But in the course of its experimental reproduction and histological elucidation the original phenomenon had been modified. In a strict sense, the original idea of direct reconstruction only applied to those portions of the bone diameter which underwent contact healing. Even under the optimum conditions of a relatively smooth osteotomy, as opposed to a more or less irregular fracture, contact healing only involved a minimal part of the fracture site. Also, the critics’ view that the bone ends underwent necrosis had proved to be true.73 Yet the identification of clinical primary bone healing with the more complicated histological facts established by Schenk and Willenegger was convincing enough to find general acceptance as proof of the phenomenon’s existence. Crucially, none of their findings spoke against the application of rigid compression osteosynthesis, so even the modified concept of primary bone healing was still a good reason to recommend the AO technique.74 American experimenters who failed to find Schenk’s and Willenegger’s ‘cortex-to-cortex healing’ attributed this to the fact that their osteotomies,

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which had been made with a standard Gigli saw, were not as smooth and regular as those the Swiss produced with their fine micrometer saw. In their rough osteotomy surfaces there were fewer areas of direct contact between the two fragments than in the smooth micrometer saw cuts. This implied, however, that in a ‘normal’ fracture, in which arguably even fewer such areas existed, there may be no direct contact at all and thus no contact healing. The American surgeons did not elaborate on that point. Obviously, the subtleties of histology were relatively irrelevant, as long as the analysis under the microscope confirmed that the treatment results with compression osteosynthesis were excellent.75 The concept of primary bone healing was resilient enough to accommodate such differences. As is typical for well functioning boundary objects, it allowed interpretations in its understanding without losing its function as a common rallying point. The concept kept its attractiveness even when its practical importance was further restricted. The authors of a 1971 article, among them Willenegger and Schenk, wrote that ‘it would be wrong to believe that with stable osteosynthesis one could only find corticogeneous healing in the sense of contact or gap healing’. In most cases additional periosteal and endosteal bone apposition could also be detected. But this was of no practical relevance for the restoration of the bone’s solidity. Since the categories were not particularly clear-cut to begin with, it was difficult to apply them to clinical observations: between ‘nearly ideal callus-free healing as seen in the X-ray on the one hand and callus formation on the other, various intermediary states can be found’, so that ‘from a practical point of view’, even cases in which some callus was visible in the X-ray could still be included in the group displaying primary bone healing. In everyday practice, the authors warned their readers, callus-free ossification should not be enforced at any price. Callus was not a bad thing per se, callus-free healing merely indicated that osteosynthesis had been carried out in an optimal way.76 Now that the whole issue had turned out to be more complicated than expected, the AO surgeons tended to use the concept more judiciously. In their 1969 Manual they define ‘so-called per primam healing’ as ‘direct osseous healing without radiologically visible periosteal or endosteal callus formation’, which is the ‘sign of a flawless stabilisation under favourable circulatory conditions’.77 Schenk and Willenegger were able to refine their observations. Using the antibiotic substance tetracycline as a marker for newly formed bone tissue, they traced the chronological course of the restructuring processes they had described before. They also determined the necessary conditions for the different types of healing more precisely found that the usual share of gap healing made up between 60 and 80 per cent of the fracture’s total surface area.78 By chance, Schenk even had the opportunity to confirm the results of the earlier animal experiments in an adult human patient who had died of unrelated cause three months after internal fixation.79

(a)

(b’)

(b’’)

(c)

(d) Figure 12 Simplified illustration of primary bone healing as shown in the AO Manual of 1969: (a) near the plate the fracture ends are in close contact whereas there is a gap at the side opposite the plate; (b) state on the microscopic level after eight days: the narrow fracture gap b’ is as yet unchanged; the wider gap b’’ has already been filled in by blood vessels and osteoblasts producing bone substance; (c) after eight to ten weeks the narrow gap shows revascularisation origination exclusively from the end of the Haversian canals; the wider gap is also being revascularised by the same type of blood vessels; (d) the magnification of a newly formed vessel shows how processes of bone resorption and formation follow each other: osteoclasts (a) at the top of the canal remove necrotic bone (e) opening up a route for the vessel itself (b) and the bone producing osteoblasts (c) which accompany it.

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Finally, in 1969 AO scientist Berton Rahn was able to complete the AO’s line of argument by showing that primary bone healing could also be observed in rabbits. It was with experiments using this animal species that Max Geiser had sought to refute the AO’s views a few years earlier. Until Rahn’s work, the AO had been unsuccessful in its efforts to answer Geiser’s claims. But when Rahn took on the task, he had at his disposal the AO’s new ‘dynamic compression plate’ (DCP) in miniature. By producing primary healing in a rabbit, he proved that Geiser had failed to see this phenomenon only because he had not achieved sufficient stability.80 In the 1970s primary bone healing had become a generally accepted scientific fact. Widely considered the ‘most rapid course to full bony restoration’,81 it had been ‘demonstrated in the rat, dog, horse, rabbit and man’82 by AO scientists and increasingly also by others who replicated their findings.83 In a successful triangulation, the results of laboratory research and clinical observations reinforced each other.84 Primary bone healing was now a robust, yet flexible boundary object. Even the AO’s opponents could no longer discuss it away and had to admit that ‘one can scarcely quarrel with the theory of compression as revealed by the research presented in Davos’, as one American surgeon reluctantly admitted. He found it hard for ‘us older surgeons’ to believe that callus, the traditionally favourable sign of healing, was now an indicator of poor fixation, but ‘these tenets are well argued and presented by their proponents, and the scientific evidence seems to indicate that they are correct’.85 Laboratory experiments as models of clinical reality In the discussions on both compression osteosynthesis and primary bone healing, experimental evidence was used as an effective means of persuasion. Drawing its effectiveness from the recognition of laboratory experiments as valid models of clinical reality, this type of evidence could only be achieved by methods that were impossible in a clinical setting: ‘For obvious reasons’, Charnley wrote in 1953, clinical observations were problematic because they ‘cannot be repeated on the human subject as frequently as would be necessary to satisfy the demands of a controlled experiment’.86 Replication and control are the main advantages of laboratory science. The laboratory is a place built with the aim of allowing the researcher to control natural phenomena, such as life processes in the case of physiology, or processes of healing in the case of experimental surgery. If all the factors influencing a given process are controlled, one of them can be varied selectively. The phenomenon following this deliberate variation can then plausibly be taken for its causal consequence. Such a strategy was also applicable to the study of fracture healing. As noted by two American researchers in 1954, observations made in the clinical context were shaped by ‘so many variables [that] even at the end of such a study, a true picture would be hard to obtain’; their preferred environment was


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the laboratory, where it was possible to obtain ‘a more accurate comparison of the rate of healing, as well as of the incidence of complications’.87 But even in the laboratory, controlling all the conditions of bone healing ‘presented almost insurmountable difficulties’, Eggers had noted in 1949.88 The evaluation of techniques of fracture treatment was considered ‘complex, even in animal models’, because of the difficulties involved in the ‘standardisation of the experimental technique’.89 Like any laboratory model experimental fracture models had to be standardisable.90 That meant, for instance, that artificial bone defects had to be very similar if the experiment aimed at comparing different treatment methods.91 In order to obtain comparability of artificial fractures Küntscher used a special osteoclast;92 others produced osteotomies with a Gigli saw93 or a hydraulic press permitting ‘precise application of force’.94 Schenk and Willenegger also preferred creating uniform osteotomies to producing relatively variable artificial fractures.95 As it was also advisable to standardise the side effects of the different fixation techniques, ‘utmost care was taken to ensure that the surgical procedure, amount of periosteal stripping, and method of creating the fracture were uniform’, the authors of one study asserted.96 Uniformity and comparability was achieved, however, only at the price of decreased representativeness. Osteotomies were clearly not exactly the same as fractures.97 Like Schenk and Willenegger, most investigators worried that osteotomies differed too much in their reaction to treatment measures from real fractures. Fractured bone displayed many more irregular breakage areas than the cuts the AO investigators had deliberately made in their experiments.98 They were thus easier to stabilise, but they also showed less contact healing but more gap healing. Some surgeons considered them more difficult to treat because the saws used to make osteotomies produced an additional thermal necrosis of the fracture ends that would not occur in real fractures.99 We can see here a basic problem of laboratory science: in order to achieve maximum control by the experimenter, the examined phenomenon has to be simplified as far as possible, but too much simplification endangers the model function of the experiment and raises the question of whether its results were actually ‘transposable to the human patient’ in a clinical setting.100 In investigations on bone healing, the artificial fracture produced in the animal is meant to be a ‘fracture model’ representing a ‘naturally’ occurring fracture in the human.101 But this relationship is not predetermined; rather, it is subject to evaluation.102 Like the artificial injuries, the treatment procedures used in the laboratory also had to be comparable to those of the clinic. Schenk and Willenegger stressed that they had chosen a procedure for their experimental animals that corresponded as closely as possible to compression osteosynthesis used on human patients.103 Here, comparability depended very much on scale. The different dimensions of the animals had to be considered when, for

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instance, choosing a plate for investigating the fixation of the broken femur in a dog model.104 But even when the relation between the dimension of bones and implants was correct, differences in absolute size remained a problem. Hey-Groves had questioned the validity of observations made in animal experiments because the plates used were much shorter than those used in humans.105 In the 1880s Senn had noted that nailing the neck of the femur was considerably more difficult in the small animals he used in his experiments than in human patients.106 For experiments with the AO plate the scientists had to choose large breeds of dogs to ensure secure support of the plate on the bones.107 Physics also varied with the size of the species being treated. In compression osteosynthesis the pressure on the osteotomy of a dog was four times as high as in the human because of its smaller crosssection.108 As mentioned above, it took until 1969 for the AO to develop devices that were simultaneously small enough and effective enough to produce primary bone healing in rabbits.109 The Davos laboratory’s favourite experimental animals were sheep, because they were easy to maintain in the rural mountainous landscape and could be slaughtered after the experiments. Their size also made them good models for testing treatment methods that were to be used in humans.110 Laboratory and clinic In the preceding passages I have traced the dilemma between the need for experimental science to model a more complex reality and, at the same time, to enable control over the phenomena it examines. As discussed in this chapter, these problems were solved in a way that led to a general recognition of the AO’s views about bone healing. Reconciling the functions of reality modelling and control had been a precondition to drawing support from the laboratory. But to achieve consensus on their arguments, the AO scientists and surgeons could also refer to a specific concept prevalent in modern medicine that was defined by the relationship between the laboratory and the clinic. According to this concept of scientific medicine, the facts found in the laboratory formed the basis of clinical action. Doctors learned basic science principles, which they then ‘applied’ to patient care.111 Also, in bone surgery ‘a knowledge of the anatomic and physiological factors involved in the healing of a fracture’ was considered ‘essential to intelligent treatment, especially in treatment by open methods’.112 The common aim of laboratory science and scientific surgery was the replicability of results. In the laboratory, observations become stable, and thus real, if they can be replicated. Similarly, a novel surgical technique becomes viable once it can be successfully repeated by different surgeons on different patients. As in the laboratory, replication in the clinical setting requires the control of numerous variables. The aim of scientific medicine, as already formulated by Claude Bernard in 1865, is to make real world phenomena as controllable and predictable as laboratory phenomena. Along these lines, the surgeon Sándor Pernyész had advised his


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colleagues in the 1930s to work in accordance with the biological laws determined by Krompecher. Observance of these laws would ensure predictability and controllability of their treatment results.113 Predictable success was also the AO’s explicit aim as expressed in the Manual: ‘Once a surgical procedure has been developed so far that success and failure are predictable, i.e. that with due diligence success can almost always be achieved, the procedure can be called reliable.’114 The AO scientists defined their task as elucidating the basic natural laws that enabled the surgeons to be successful.115 But though their contributions were essential in defending the AO techniques, they had not been the basis for developing these techniques, which had already existed before any animal experiments were performed. It was the surgeons’ conviction of the benefit of compression osteosynthesis and of the existence of primary bone healing that brought these topics to the scientists’ agenda. Experimental science only provided retrospective justification. It was an effective way of making the AO technique plausible and accepted among other surgeons:116 ‘Rarely’, one surgeon from outside the AO noted, ‘had a method been subjected to such diligent theoretical and experimental tests before it was made generally available.’117 However, the AO technique, like most therapeutic techniques, was not a product of scientific research. Even though the ideology of modern medicine demanded that new technologies be based on scientific discoveries, this was rarely the case. Historically, science and technology evolved separately and often maintained only loose ties: ‘New scientific knowledge does not necessarily yield technological applications, and conversely, practical solutions to concrete problems may be developed without appropriate scientific understanding of the underlying phenomena’, medical historian Ilana Löwy states, illustrating her point with the example of aspirin, which had been used to control inflammation and reduce fever for a hundred years before scientists developed an explanation for the physiological effect of salicylic acid.118 To be sure, medical technology and laboratory science depend on each other, but their relationship is of a different character than that implied by linear science-application models.119 It is a mutual dependence in which, as Löwy put it, biomedical research and clinical practice have provided legitimacy for each other. While physicians base their claim of effectiveness upon scientific knowledge, biomedical scientists justify their research in terms of its potential contribution to the solution of major health problems.120 The AO scientists based their raison d’être on the needs of the clinicians: According to Perren, the AO laboratory’s research was ‘at no time a goal in itself, but always relied heavily upon the input of the AO group and thereby

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contributed basically to the clinical activities’.121 The special relationship of science and clinical medicine within the AO network was part of a more general historical development described by medical historian Charles Rosenberg, a development in which the context of application (clinical medicine) ‘and the context of knowledge production and reproduction (research and teaching) have generated an intricate and historically determined relationship, one that has had enormous ultimate impact not only in the realm of markets and institutions but inevitably on that of “basic sciences” as well’.122 The bidirectional influence of science and medical practice points to an even more general fact; namely, that it was the cultural power of science rather than its technical power that often served as the main resource for the support of medical innovation. Cultural power refers to the ability to provide plausible explanations within a particular cultural context. In a way, this cultural power even encompassed the technical aspects, since, in the words of Sturdy and Cooter, ‘technical values must themselves be understood as a form of cultural value’.123 The cultural power of science and technology is a very conspicuous factor in the AO’s successful spread. But still, fracture care was neither a mere technology nor a science, but a part of medical practice so that the cultural power of experimental science was limited by clinical rationality. Even scientists like Perren and Rahn warned that laboratory results were not directly transferable to clinical practice: We would like to point to the fact that the indication and contraindication of a certain fracture treatment practically never are based on experimental data alone. Internal fixation is not done because of nice histology or amusing values of physical or biologic properties of bone but because of clinical functional results ... Experimental research will help to find the mechanisms of unwanted reactions and will therefore be important; still, one should not overemphasise experimental data, especially if they are not related to clinical reality.124 Others had much more fundamental reservations associated with their criticism of the whole scientific approach. Despite his interest in experimental science and the technical character of his version of surgery, Charnley was one of those surgeons who were suspicious of the intellectual dominance of laboratory science. He warned against setting too much trust in highly specialised research techniques, such as electron microscopy, at the expense of common sense.125 In Charnley’s view, ‘attempts to control the conditions of the fracture by using experimental animals have yielded nothing of importance compared with what we have learned “the hard way” by developing operative techniques on the human subject’.126 In the preface of his 1953 book on arthrodesis he remarked that ‘a few observations on the human are often of more value than a large series of experiments in animals,


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especially if a few observations illuminate, and are consistent with, a considerable operative experience’.127 When Eggers presented the experimental results obtained with his contact plate in 1948, not everyone in the audience was convinced of their relevance. One surgeon said in the subsequent discussion, It is difficult to discuss a new instrument of this kind, because of the lack of criteria by which to judge it. We cannot look to the experimental laboratory to furnish enough evidence to evaluate the importance of the various factors which seem to be of significance in the process of osteogenesis at the fracture line. And he demanded: If, for example, Dr. Eggers were to submit a consecutive series of one hundred cases, analysed from the point of view of the patient’s return to his former occupation, time of structural union, incidence of non-union, delayed union, and foreign body reaction, we would then hope to evaluate this new and promising method.128 This evaluation will be the subject of the next chapter, which focuses on clinical research on fracture treatment, its preconditions and limits as well as its relation to the various concepts of medical knowledge and practice prevalent in the second half of the twentieth century.

6

The Science of Surgery: Clinical Research

As described in the previous chapter, the AO performed laboratory studies in order to create a scientific basis for its technique. At the same time it was also investigating questions of practical applicability in a clinical setting. In this chapter I begin by looking at the general ideas and values underlying clinical research during the AO’s early years and determine the organisation’s place in this context. I then examine the clinical studies on the usefulness of osteosynthesis and analyse how they were assessed and discussed in a way that finally led to the general acceptance of the AO technique. This analysis then leads to a discussion of various general subjects, among them the function of classification and standardisation in clinical research, the perception and assessment of therapeutic risk, and the limits of the statistical approach in clinical research. I then move on to describe the difficult process of establishing and maintaining AO documentation. After explaining the effect that the AO’s documentation efforts had on its acceptance in the surgical world, I look at the AO’s scientific approach to surgery within the larger context of twentiethcentury controversies over the different views on medical rationality and their social and ethical repercussions. With this I hope to demonstrate that the scientific approach to medicine is not simply a universally valid and value-free attitude, but that it is also based on a selective world view which emphasises particular norms and values while backgrounding others. As opposed to other parts of this book in which I have focused primarily on the localised, contingent character of the described developments, here I try to broaden the focus of my study and highlight a few of the general problems that seemed to confront the surgeons in the second half of the twentieth century. Their discussions on the documentation and standardisation of diagnostics, treatment and results as well the assessment of 110

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therapeutic risks are of interest because they provided the context in which the AO’s systematic efforts in these fields became plausible and attractive to many surgeons. It was principally from these discussions that the AO’s osteosynthesis technique emerged as a success. Clinical research in trauma surgery The AO was founded at the beginning of what historian Harry Marks calls ‘the statistical era of clinical medicine’. At that time a considerable tradition of therapy control existed in medicine. Starting in the 1940s, the use of statistics had become obligatory in many areas of medical research.1 But if it may be said, as some historians do claim, that thinking statistically helped to give twentieth-century culture its special character, then medicine must be seen as part of a more general modern trend.2 For specific reasons some fields of knowledge were particularly liable to adopt quantitative rigour. Theodore Porter attributes this to their vulnerability to the suspicions of outsiders. For this reason, he holds, statistics was seized upon most readily by those disciplines which were conceived of as weak within the scientific hierarchy, such as psychology – and clinical research.3 In a similar vein, other historians and sociologists have identified the statistical movement as a response to increasing demands for accountability when the introduction of new, costly and potentially dangerous technologies necessitated criteria for their evaluation. In particular, the growing visibility and increasing public funding of medical care and research after World War II led to a more pronounced need for justification. One way of responding to that need was to obtain objectivity and universality through statistical methods.4 Ulrich Tröhler has shown that earlier in the century this condition also applied to operative surgery. Surgeons tried to allay public apprehension about their new treatment methods by documenting and analysing the results of their operations.5 New methods of fracture treatment had a particularly strong need for justification since they were always assessed against the background of existing techniques. Another reason why quantification and statistics were so prevalent in fracture care was their close association with accident insurance. Accounting, insurance and applied economics have been determined as the prototypes for quantification in science in general.6 As described in Chapter 1, specialised traumatology had even emerged in connection with accident insurance, the companies having a vital interest in documenting treatment results. According to Lorenz Böhler it was only because of the Austrian state insurance company’s statistics that surgeons even knew about the long-term results of their efforts.7 Regarding the British context, historians Steve Sturdy and Roger Cooter have explored how the rise of scientific management in medicine, particularly in surgery, led to the increase of both diagnostic categorisation and therapeutic standardisation. This tendency had its origin in corporate business and large-scale industry, which hospital managers both served and

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emulated, and is evidenced in orthopaedic surgeon Harry Platt’s introduction of detailed record-keeping into fracture care during the interwar period. In the first half of the twentieth century, American hospitals were also applying systems for managing information from business and administration in surgery.8 It is therefore not surprising that documentation, often with great numbers of cases and extensive follow-up, was quite common in operative fracture treatment around the time of the AO’s founding.9 Surgery as a science Interest in documentation and statistics increased in the twentieth century in response to the contemporary reconceptualisation of medical practice as a scientific activity. The project of making medicine a science was not limited to creating medical knowledge in the laboratory.10 Proponents of this approach felt that even if the individual doctor did not notice it, patient care was always a kind of experiment. Practising medicine was a research activity to which the same principles should be applied as to other experimental research.11 Aspirations to rationalise medical practice became manifest after World War II in extensive outcome studies with increasingly strict criteria. The provision of databases derived from such studies was aimed at putting the doctors’ therapeutic decisions on a firm foundation.12 As Harry Marks writes regarding the 1950s and 1960s, ‘clinical researchers aspired to the conditions of the laboratory experiment, where ideally the factors that affected the outcomes were both known and manipulable’.13 Medical practice was to be made analysable in a new and thorough way. The individual steps of the ‘experiment’ of therapy – ‘the definition of the starting point, the planning of the intervention, the observation of the outcome, and so forth’ – would now have to be ‘discerned and judged’.14 Attempts to give medical practice a rational basis by transforming it from an art into a science are quite frequent in medical history. The most influential example in modern times is the ideal of rational medical practice as proposed by the nineteenth-century physiologist Claude Bernard. Bernard aimed at first achieving complete control of the workings of the organism in the laboratory and then transferring this control to the clinical setting. This concept of ‘experimental medicine’, as it was called, would prove very appealing to subsequent generations of doctors.15 Historically, advocates of the type of experimental medicine promoted by Bernard often stood in opposition to those who pursued a statistical approach to medical practice. From his deterministic standpoint Bernard himself rejected clinical statistics because they could not provide the same degree of certainty achievable by the knowledge of the natural laws that governed life processes. Operating on the level of populations, statistical considerations resulted in probabilities, whereas experimental science established causal relationships by focusing on the deterministic laws of physiology.

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Thus, experimentalism and clinical statistics presented two different strategies for making medical practice scientific. Despite their basic differences, both approaches were not necessarily mutually exclusive. The statistical method was frequently used for assessing the significance of the results obtained in large series of laboratory experiments. Conversely, scientifically inclined clinicians often interpreted the results they found in their clinical statistics as the expression of some deterministic physiological phenomenon of the individual patients. Seen in this way, ‘the patient had become a mass of quantifiable data, and generalisations over a population ... had become data analysis’.16 In the various clinical contexts, the two approaches occurred either as alternatives or in combination with each other. From the beginning, however, both strategies of making medicine a science were opposed by those doctors who insisted on subordinating any scientific knowledge to clinical reasoning. Within this third kind of medical rationality scientific approaches to medical practice entailed the danger of doctors ignoring the individual character of medical diagnosis and therapy and thereby underestimating the complexity of clinical reality. As will be pointed out later in this chapter, some of the AO’s most vociferous critics made this attitude their point of departure in attacking the AO project of introducing a science-based and standardised system of fracture treatment. In general, however, surgery was especially suited to be redefined as a scientific activity, since, in the words of medical historian Christopher Lawrence, in surgery the fiction that medicine had nothing to do with politics reached its purest expression. Surgical intervention could be represented as the inevitable, scientific solution to disease, in comparison to which the alternative solutions seemed inferior.17 Experimentalism was thus an appropriate approach for surgeons. Like the scientific experiment, surgical intervention also aimed at controlling life phenomena. Osteosynthesis pioneer Robert Danis thought that in the same way as the laws of nature determined the result of an experiment, success of an osteosynthesis operation was guaranteed as long as the basic laws of bone healing were respected. He made every effort to give his surgical operations the character of well performed experiments.18 This notion of surgery was also advocated by the AO surgeons who formulated their aims in the language of laboratory science. They defined their research activities not as an effort to propagate osteosynthesis but as a scientific project aiming to ‘prove or disprove’ the ‘hypothesis’ that its principles allowed successful fracture treatment. 19 Fracture care, they proposed, should no longer be ‘empirical’ but ‘rational’. The AO’s explicit goal was to ‘increase reliability and reproducibility of good results by the

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average trauma surgeon’, like a well devised and well performed laboratory experiment.20 With therapeutic intervention being looked upon as a research activity, the boundaries between medicine and science blurred. Comparison and classification In fracture treatment, as in many other areas of medicine, new treatment techniques were introduced to replace existing therapeutic methods, so the foremost objective of outcome studies was to compare old and new treatments. However, it was not easy to render fracture types, treatment procedures and results comparable to each other. 21 At the outset, each individual case is unique with respect to all of these parameters. To achieve comparability, case reports have to be simplified and standardised; 22 but ‘fractures come in infinite variations’, as two US surgeons complained in 1979, making ‘classification difficult, patterned therapy the exception and artistic license the rule’.23 As different kinds of fractures demanded different kinds of treatment and posed different degrees of difficulty, surgeons had to form categories for similar types of fractures. Besides the type of bone affected, the location of the fracture was crucial. Fractures of the tibia required a different course of action depending on whether they affected the top end (tibial plateau), the lower end (ankle), or the shaft (diaphysis). For fixation, it was important to distinguish those fractures in which mechanical forces worked against stabilisation – for instance, by drawing the fragments apart – from those in which gravitation or muscle traction aided stabilisation. Another variable to be taken into account was the additional injury of nearby soft tissue. The cause of the fracture, its aetiology, was also deemed important by some researchers. A Swedish group classified aetiologies into ‘low-energy indirect violence’, ‘lowenergy direct violence’ and ‘high-energy direct violence’; the last group being the most difficult to treat.24 Probably due to the visual and tactile orientation of professionals in the field, language was often seen to be inadequate for describing fractures in an objective and standardised way. Images did better: ‘The use of diagrammatic representation of the fracture classification system is essential’, a 1979 article on tibial plateau fractures claimed, ‘for as the classification schemes vary, so do the adjectives to describe them.’ If used at all, language had to be standardised: the adjectives, so the statement continues, ‘are in need of standardisation to allow for comparisons. For example, the definition of “minimally displaced” varies or is unspecified by various authors.’25 Among the various ways of producing images, objectivity was in particular ascribed to photography. Because photographic images are created chemically without the direct involvement of a human draftsman they are generally regarded as objective representations of reality. As such they can be easily reproduced, disseminated and compared with each other. 26 In fracture care, X-ray photographs were used to document the state of a fracture before and after

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treatment. Often, as a 1979 study on trochanteric fractures of the femur showed, the surgeons’ subjective judgements were ‘refuted by subsequent objective analysis such as that of radiographs’.27 On the other hand, X-ray images were frowned upon by a great many surgeons. Sceptics favoured diagnostic acumen on the part of the individual surgeon over the objectivising powers of an X-ray machine and admonished their colleagues to treat the patient, not the X-ray picture. Typically, such critics were also wary of the AO’s systematic approach.28 Either way, fracture classification was neither uniform nor static, making comparison difficult. Authors often created their own specific classification as needed. Some surgeons did at least refer to the classification of preceding studies in order to enable comparison.29 Alterations in classification were brought about by new diagnostic techniques, such as X-ray tomography,30 or by conceptual change. When, in the 1970s, for instance, the biology of fracture healing was considered more important than mechanical conditions, the degree of soft tissue damage was recorded in more detail.31 The basic problem was to decide which information had to be included. It was very difficult to guess in advance which factors would be needed for later analysis. Failure to include certain types of information could seriously diminish the value of a study. For instance, the benefit of the 1912 study on operative fracture care by the British Medical Association was limited by the fact that classification as to the exact type of fracture was not possible.32 On the other hand, too much, and too detailed information made analysis impossible. The more parameters researchers took into account, the fewer cases they could attribute to the respective categories so that the numbers of cases in each group were too low to be statistically relevant. 33 Charnley regretted in 1957 that in clinical practice ‘there are so many variables (comminution, sepsis, mechanical details of the operation, blood supply, level of fracture, different observers, etc.) that a series of two hundred cases, which is a large series, for any one operator, is soon reduced to statistical insignificance.’34 Given the need for selection and simplification, the way in which studies were planned and structured predetermined much of their outcome. The choice of cases, their classification, the selection of information to be included or omitted, had a decisive influence on a study’s result. In the field of osteosynthesis, the problem of case selection was of particular relevance because often the most difficult and severe fractures were treated with internal fixation whereas simple and uncomplicated cases received a conservative therapy. Conditions such as multiple trauma, old age, or the need for intensive care were major indications for internal fixation since it facilitated the general care of this type of patient. In addition, many osteosynthesis operations were performed only after non-operative treatment had failed.35 Proponents of osteosynthesis demanded that any evaluation of treatment methods must account for such a preselection of difficult cases.36 As can be

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seen from this example, the way in which cases were described and classified contributed much to a study’s result. It was thus advisable for the AO surgeons not to leave this task to others but to contribute actively to fracture classification. Over the years AO surgeons had made several attempts to classify particular types of fractures. Bernhard G. Weber in 1966 suggested a classification of ankle fractures that would help to determine when to operate and when to treat conservatively. His classification (Weber A, B, C) has become widely accepted and today belongs to the standard teaching every medical student receives.37 Since no unified scheme existed in the medical literature, the AO surgeons saw the need for creating a complete classification of fractures. In 1977 a group around Maurice Müller set about doing it, intending their system to be general enough to be used by the whole AO group. It was to be based on the work of surgeons such as Bernhard Weber and Urs Heim, on the accumulated case histories of the AO Documentation Centre and on experience with a preliminary system. The result was a new principle of documentation that was officially adopted by the AO in 1986. Taking Carl von Linné’s classification of plant and animal species as a model, a combination of hierarchical terms was used. All fractures were codified using two numbers, one letter and two additional numbers. In addition to the exact localisation of the fracture, the code reflects the degree of morphological complexity, severity, the difficulty of treatment and the prognosis of the respective fracture. The first two numbers stand for the affected bone. The femur, for instance, is represented by the number 3. The second number represents the segment; for example, 2 for the middle (diaphysis) part of that bone. Thus 32 stands for a fracture of the femur diaphysis. A letter is added to signify the type of fracture: in the case of the diaphysis of the femur, A means a simple fracture, B a wedge, and C a complex fracture. Each of the three types is then further subdivided into three groups, and each of these into three subgroups, by using two more numbers. A1, for instance, designates a simple spiral fracture, and A1.2 a simple spiral fracture in the middle zone of the diaphysis. The complete formula for our example, then, would be 32 A1.2 – a simple spiral fracture in the middle zone of the diaphysis of the femur. Employing a combination of numbers and a letter for coding facilitates the use of data processing systems for analysis.38 The AO classification has been widely adopted as part of the specialised medical language. The instruction booklets, which have been published in a number of languages, are among the most widely used texts in any surgical department’s library. The next logical step after selecting and documenting cases according to uniform principles was to standardise treatment. As analysed in Chapter 4, standardisation of procedures was the prerequisite for the replicability of results. But uniform treatment was also necessary for effective outcome

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Figure 13 AO classification of diaphyseal fractures: after identifying the location of the fracture by using a number code, the fractures are assigned to one of the three types A, B, or C, and then to a particular group and subgroup.

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Figure 14 The diaphyseal fracture types. Fractures of long bones are either simple or multifragmentary: type A represents simple fractures with two fragments; type B and C represent the two types of multifragmentary fractures: type B represents fractures with a wedge fragment, type C complex fractures.

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analysis. Knowledge of differences in treatment could help to explain phenomena that initially seemed paradoxical. In 1953 Gerhard Küntscher found statistically consistent evidence for and against the use of intramedullary nailing of the tibia. The discrepancy could be resolved by considering differences in the execution of the technique, Küntscher explained, the poor outcomes resulting from instability caused by flawed technical procedure.39 Correct causal attribution was very important for the valid analysis of a technique: ‘One single failure that can be put down to the method and not to faulty execution’, the AO surgeons claimed in their Manual, ‘must lead to an alteration of the method.’40 Like Böhler, the AO stressed that a technique could only be correctly evaluated for its usefulness if tested under optimum technical conditions by expert staff.41 Results: what is a success? Of equal importance as the classification of fractures and standardisation of procedures was the definition of the target point, that is, the treatment result. Here, too, researchers regretted that ‘the criteria used to evaluate the results differ so much that close comparisons are virtually impossible’. 42 Like the descriptions of fractures and treatment, so the documentation of results had to be standardised in order to rid their assessment of the contingencies and idiosyncrasies of place and person and thus achieve universal validity. This was attempted early on. In 1912 the Surgical Section of the British Medical Association published a study of 2940 fracture cases and their long-term results, among them 208 operatively treated cases. To achieve comparability, the special committee organised to examine the patients used standardised protocols.43 Information was derived from different types of sources. Statements made by patients were usually regarded with some scepticism. According to a later study conducted by AO surgeons, many patients ‘seem to get used to their post-injury status and do not feel disabled’, even if the treatment has resulted in limiting the range of motion of the affected body part.44 ‘Subjective considerations such as pain or patient opinion are difficult to quantitate and even more difficult to standardise’, two American AO adherents noted, concluding that this sort of information does ‘not provide meaningful measures of comparison’.45 As with fracture diagnostics, X-ray images were seen as the most objective means of therapy control. 46 In this respect the AO used Böhler as their example. Over the years the Viennese surgeon complied series of X-rays tracking his patients’ progress. In 1938 he published a study containing three X-rays for each of the 78 femoral neck nailings performed in his clinic. Including other, conventional, photographs, in 1943 his collection comprised 4000 cases with about 20,000 individual pictures.47 Most scientific articles on fracture treatment included a number of X-ray pictures. Early osteosynthesis advocates such as Lane and Lambotte regarded

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radiographs as incontrovertible evidence of the superiority of operative versus conservative fracture treatment.48 Osteosynthesis opponents liked to publish X-rays of catastrophically failed osteosynthesis operations as a visible warning against the method: ‘Pictures speak better than words’, German orthopaedist Lange said when he demonstrated the consequences of using poor-quality osteosynthesis material in 1958.49 Much debate revolved around the question of when a bone can be considered healed. There was no consensus on this point, nor on the exact definitions of delayed union and non-union. In their assessments most authors combined X-ray pictures, clinical tests and the patients’ ability to use the affected limb.50 But, as Müller had emphasised already in 1960, the AO’s main issue was not getting the bones to heal, as that goal had already been reached by the customary methods anyway, but rather making good, longterm function of the affected limbs possible.51 To check how the affected limb functioned, special tests would be performed after the healing process had finished. Different systems were in use for evaluating joint movement, muscular strength and freedom from pain.52 Typically, good results enabled patients to pursue their normal activities, including their original occupation or even sports (and military service in Switzerland!); pain and stiffness, on the other hand, were evidence of poor results and qualified patients for disability pensions.53 Opinions varied as to how much anatomical malalignment or functional restriction was acceptable: For the AO, even the slightest anatomical anomaly signified poor treatment. Advocates of conservative treatment like Max Geiser and Augusto Sarmiento criticised this attitude. They thought exact anatomical restoration was often unnecessary for regaining normal function of a limb; even poor ‘radiographic’ results usually did not preclude good clinical function in the long run. These surgeons also tended to tolerate minor functional impairment in exchange for avoiding the risks of an operation.54 The stricter the criteria applied for checking treatment results, the better osteosynthesis compared with the customary conservative treatment methods.55 So the AO had a vital interest in designing and performing outcome controls themselves in accordance with their strict standards.56 To provide evidence of the claim that the AO technique resulted in better longterm function, it was necessary to locate and examine patients 10 or 15 years after treatment. To produce convincing studies all patients had to be included, since incompleteness in follow-up could easily lead to biased results. But often those patients with poor results did not return questionnaires and ‘tended to be uncooperative or resistant and hostile when they were finally located’, the author of a special article on this problem explained. If the investigator succumbs ‘to the temptation to exclude these difficult-to-locate patients from his analysis’, he continued, ‘he will obviously reach misleading conclusions’.57 One AO surgeon even travelled to Italy and Spain to obtain a 100 per cent follow-up of 214 compound fractures.58

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My examination of the discussions surrounding the classification of cases, the standardisation of treatment procedures and the evaluation of therapeutic outcome has shown that clinical research on the usefulness of osteosynthesis was a complex, multilayered process, the result of which depended on decisions made by the researchers when setting up and performing their studies. It is easy to see that the results of any clinical investigation necessarily represent an artificial reality, though in a different way than the results of laboratory research. Consequently the AO’s success cannot simply be explained by the superiority of its technique or the truth of its knowledge. A better understanding can be gained from considering the AO’s activities as processes that simultaneously constructed the ‘text’ and ‘context’ of their technique: in order to make it ‘the right tool for the job’, the AO surgeons not only had to construct the tools, they also had to define the job and explain why it was the right technique to use. 59 The discussion on the risks of osteosynthesis is a case in point. Risk The main argument against the use of osteosynthesis was the risk of complications. Typically, critics questioned whether the superiority of osteosynthesis was ‘so substantial that the risk inherent in an open procedure is fully justified’.60 As a rule, risk and safety are major issues in the acceptance of medical innovations.61 This topic is of particular interest for new operative treatments, since in surgery the causal relationship between doctors’ actions and their (possibly fatal) consequences are closer and more obvious than in drug therapy or dietetics.62 From an anthropological perspective, Mary Douglas and Aaron Wildavsky have described how risk perception and assessment is always a matter of focusing on some facts while omitting others; particular criteria for evaluation are selected and responsibility is attributed in a specific way that depends very much on the worldview and interests of those involved.63 Seen from this perspective, the testing of novel treatments and the way in which such tests are documented and analysed are part of a struggle to define risk. Even though the results of documentation and analysis are normally presented as if they were value-neutral and purely matter of fact, statements about risk always contain implicit premises with regard to moral and social values. Indeed, risk assessment is based on particular choices that cannot follow from empirical observations alone but require an ethical underpinning.64 The AO surgeons never denied the dangers of osteosynthesis. Their open acknowledgement was a sign to surgeons outside the organisation that the AO was ‘sincerely concerned about solving the problem’,65 and it earned them much credibility in the field. There were various complications associated with osteosynthesis. Some were directly related to the operation itself, others were thought to develop as a result of it. Critics arguing against the method of treatment typically cited complications occurring during the

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recovery phase, such as delayed union, non-union of the bone ends, bone infection, and an increased susceptibility to refracture after routine removal of the implants. Osteosynthesis proponents, among them the AO, employed two lines of defence to deal with these worries. The first was to demonstrate that if complications occurred, they could be controlled. For instance, in a report in 1966, Müller described how non-unions could be operated on again and successfully healed by compression osteosynthesis. ‘It is our experience that non-union of a long bone is no longer a major catastrophe’; as he saw it, the real dangers to be feared were those caused by non-operative treatment and prolonged immobilisation, namely ‘joint stiffness, circulatory disorders or deformity of the bone’.66 By demonstrating, furthermore, that the cause of the complications lay in errors of application by the surgeon and not in the technique itself,67 the AO could redirect the discourse to focus on the technique’s benefits. Both these strategies can also be seen in the disputes about the most significant type of complication, bone infection. From the beginning and throughout the discussions on osteosynthesis, the risk of infection and its devastating consequences was the main argument against widespread use of the method. Particularly in operative treatment of closed fractures, infection was seen as a direct consequence of the surgeon’s actions. By operating, the surgeon turned a closed fracture into an open wound and created a means of entry for infectious agents. As the AO surgeons wrote in their 1963 textbook, even one instance of bone infection per 1000 cases would be a major tragedy that would have a negative impact on their method’s reputation. Fully aware that the problem of bone infection would determine the fate of osteosynthesis, they stressed the need to deal with it.68 Although it was not directly their aim, the AO’s emphasis on the manageability of infection led to a change in the discourse on osteosynthesis: attention was diverted away from the procedural risks and redirected to the surgeons’ ability to control the outcome of the treatment. As Allgöwer wrote in 1971, ‘Once an infection has become manifest a clear strategy of procedure can prevent a catastrophe.’69 The real catastrophe was not infection as such, but the inadequate treatment of it. Even before the AO, it had been obvious that the complication rate in osteosynthesis was closely associated with the skill of the individual surgeon.70 The AO, however, placed special emphasis on this point. The introductory chapter of the AO’s textbook states: Not every surgeon will achieve equally good results with osteosynthesis. Therefore, we are concerned that everyone should critically check the fractures he has operated upon, not only in order to see the limits of the method in his hands, but also to note his personal limits.71

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The cause of poor results was to be sought in the incompetence of the individual surgeon and not in the method. The AO surgeons were able to underpin their view with data. In their studies they found that the rate of infection varied between 2 per cent and 20 per cent, and that the percentage fell with growing ‘aseptic and atraumatic discipline’ on the part of the surgical team. Statistics further revealed a close correlation between low infection rates and the individual surgeon’s extent of experience.72 As a consequence, infection no longer appeared to be a side effect of opening up the fracture site or a direct result in the treatment of open fractures; instead, it had become ‘the most important factor over which the treating physician has any influence’.73 In order to verify the crucial role of surgical skill and experience, outcome studies on the AO technique frequently included an assessment of the competence of the surgeons who performed osteosynthesis operations. 74 Sometimes X-rays taken before and after the intervention were used as a basis for retrospectively assessing the quality of the fixation.75 There are a number of common mistakes typically mentioned in the studies. One of them was insufficient stabilisation by internal fixation, with compensation via the use of a plaster cast. In this way ‘the worst of both techniques is combined’, and the surgeon exposes the patient ‘to the risks of infection and added tissue trauma as well as the risks of joint stiffness, muscle atrophy, disuse osteoporosis and vascular dysfunction’.76 Insufficient preoperative planning, misplacement of plates and screws, using the wrong length of plates, incomplete anatomical reconstruction of bone or articular surfaces were all further instances of poor surgery mentioned in the studies.77 But standards for correct treatment varied. The same procedure could be judged as being either correct or faulty. For the AO surgeons it was therefore crucial that their own very high standards were applied. In their view, any failure to achieve exact anatomical reconstitution or sufficient interfragmental compression counted as a mistake.78 So besides infection, many other complications could be attributed to the individual surgeon, to his incorrect choice of treatment methods and to his poor technique, or to inappropriate postoperative treatment.79 The risks of osteosynthesis now appeared in a quite different light. The issue was no longer that osteosynthesis was a risky operation; it was now seen as a difficult operation. By speaking about the subject in a different way, the proponents of osteosynthesis had restructured reality. As early as 1966, AO secretary Robert Schneider wrote in his annual report: ‘The time has come that a catastrophe after osteosynthesis is no longer attributed to the method as such but to the surgeon, his incorrect indication and his poor technique.’80 However, the logic of blaming the individual surgeon for failures did not go unchallenged. John Charnley thought that for biological reasons internal fixation would always lead to a certain number of failures.81 In a 1982 review of Brunner and Weber’s Special Techniques of Internal Fixation an

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American surgeon sarcastically commented on the circularity of the AO’s line of argument: The authors conclude that ‘the success or failure of internal fixation reflects an understanding or misunderstanding of this concept, as well as pure technical proficiency or the lack of it, on the part of the surgeon.’ The book seems to be rooted more in belief than in science.82 By and large, however, the propositions made by the proponents of osteosynthesis were accepted by the surgical public. Their line of argument fitted well with the general tendency at the time to defend medical procedures, arrangements and structures by conceptualising the individual health care worker as a central source of trouble in medical practice. 83 The shift in discourse had an additional effect: failures no longer discredited the AO as the organisation advocating osteosynthesis. Instead, since the underlying cause of the failures was now seen as surgical incompetence, the AO’s position as a group of competent experts in the field became stronger, not to mention the fact that the AO offered surgeons the means to become competent themselves by studying the textbooks or attending courses. From the perspective of the organisation itself failures could in principle be prevented. The only thing surgeons had to do was to follow the instructions given by the AO precisely and to use its standardised instruments and implants. The AO now had good reason to increase its activities, to improve documentation, to set up additional courses, and so on. On a more general level, sociologist Ulrich Beck describes this as the ‘transformation of failures and risks into chances for expansion of science and technology’.84 Standardisation, quantification, calculation As described in Chapter 2, the AO set out to register the cases treated with its method in its Davos documentation centre. But collecting data was one thing. Its standardisation, storage and analysis, however, comprised an additional set of problems, and the more successful the collection of data, the more serious these problems became. Before I turn to the AO’s strategy to tackle this challenge, I will explore the general situation by looking at the activities of the AO surgeons’ declared model, Lorenz Böhler. In 1954 he had the meticulously recorded case histories of all 78,349 in-patients and 507,772 out-patients as well as the X-rays of 241,000 injuries treated in his Vienna hospital since 1925. To manage a collection of this magnitude, he found it necessary to simplify the process of recording data by using Herman Hollerith’s punch-card method.85 First used in 1890 to tabulate the United States Census, the Hollerith system combined punched cards with a counting and sorting device to ‘read’ them for certain features. The tabulating machine was an important early step in the development of digital computers and made Hollerith, an inventor from Buffalo, New York, famous. Where the

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accurate compilation of mass statistical information was needed fast, Hollerith’s punched cards were used. Government entities and organisations, such as health departments, quickly became accustomed to encoding data in this way.86 When Böhler became interested in the system in the mid-1950s, he was fortunate to be on good terms with the director of the General Accident Insurance Company (AUVA) in Vienna. The AUVA had been using a Hollerith system since 1948 and in 1954 allowed Böhler access to the machine and personnel. The first task to be tackled was the analysis of 1130 closed lower leg fractures treated between 1925 and 1950. Böhler differentiated 80 variables including each patient’s age, sex and occupation, the type of accident heading to the fracture, the fracture’s shape and the condition of the wound. The mechanical computation method also gave rise to a new degree of confidence. Now, Böhler asserted, he could prove the usefulness of his treatment method with ‘mathematical certainty’.87 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 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 again, 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 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.88 Practical problems In practice, documentation proved to be much more difficult than expected. A complete register of all cases treated with the AO technique would have required enormous amounts of work and money. Problems were manifold. For example, surgeons found the data sheets difficult and time-consuming to fill in. They were also wary of sending their X-rays to Davos because the pictures were often returned only after a considerable delay.89 Even if the AO members could be induced to document and report their cases to the centre, the material still had to be stored and analysed in a useful manner. It became clear that a systematic analysis of several thousand cases could not be accomplished by simple mechanical means.90

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Figure 15 AO documentation card as shown in the first AO textbook of 1963. The miniaturised X-rays show an ankle fracture before and after the operation and four and twelve months later.

In early 1963, in an effort to take advantage of modern electronic data processing systems, the AO started cooperating with two experts, one a physician and mathematician and the other a programmer. The experts recommended a new diagnostic code, new code sheets and new punch cards, but the advantages were dubious. By 1965, 10,000 osteosynthesis cases had been collected, but the data could neither be made available in a useful form nor analysed appropriately. The AO surgeons were thoroughly disappointed. On one occasion, after a meeting with experts in Liestal in 1965, Robert Schneider reported that he had heard ‘much about homogeneity and homogenisation, about hard and soft data’, but he had understood little. In his opinion, the experts had created expectations they could not live up to.91 After they failed to deliver any useable analysis within the two following years the AO terminated cooperation. It was a bitter defeat, Schneider admitted, in the face of so great an investment of effort, time and money.92 In 1967 AO transformed the documentation project into a foundation. Müller, who had been in charge since 1962, became the foundation’s president. In the belief that a new start could bring about the intended aims, Müller transferred the project to Bern and hired a new staff of qualified personnel. Seeing that he had to offer the AO surgeons some sort of immediate benefit for their support, Müller officially invited them to Bern to take advantage of the AO’s huge collection of X-ray pictures.93

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To facilitate the individual surgeons’ participation, a new, simplified code sheet was introduced in 1968. In addition, Müller promised to return X-ray pictures within two weeks of receipt. The purchase of a second LogEtronic machine in the following year increased the processing capacity to 500 pictures per day. The centre was now in possession of 16,000 punch cards containing the most significant data of each case, including diagnosis, fracture localisation, operation, complications, result, and up to eight X-ray copies.94 However, implementing the ambitious documentation project continued to be difficult. Even though no fewer than six revisions of the code sheets had been carried out since the centre’s inception, new sheets were introduced in 1970. In the new forms each item would be marked by a single pencil stroke, facilitating handling and enabling mechanical reading.95 But when the new sheets were actually tested, the familiar problems recurred. Mistakes and slips of the pen were frequent.96 Since it was clear that the centre depended on the surgeons’ voluntary participation for the documentation project to work, the AO started remunerating them for their efforts and expenses. Ten francs were paid for sending the first code sheet and the X-rays, and 29 francs for the other sheets. Müller calculated that each documented case cost the AO 500 francs, amounting to 500,000 francs each year.97 A particularly difficult point was the long-term documentation of the healing and rehabilitation process. It was difficult to get hold of the patients for the one-year re-examination. They also had to be compensated for their journey and lost work-time so that sometimes the costs for a single case ran into the hundreds of francs. Those patients who were unable to come were sent questionnaires. However, the response rate to the first 2000 questionnaires was only 50 per cent. Various attempts to improve the results by modifying the sheets or introducing a new reading system brought little success.98 Each step in processing the materials was a potential source of error. Numerous mistakes occurred, for instance, during the data transferral from the sheets to the punch cards, so that the AO surgeons deemed it necessary to demand tighter surveillance of that process in 1974.99 Despite further modifications and collaboration with the centralised computer system of the University of Bern, analysing the collected materials and making them available for surgeons continued to be a problem. 100 In a retrospective evaluation from 1983, Maurice Müller regretted the high percentage of incorrectly or incompletely documented cases because they precluded any effective application of these efforts. But he was unwilling to abandon what he called the ‘AO founders’ utopian goals’ to record and analyse all cases treated with the AO technique and make the results available to all participants.101 But at that time a more fundamental problem had come to the fore that concerned the basic limits inherent in retrospective case studies. No amount of efficient data storage, analysis and retrieval could alter the fact that it was simply not possible to foresee which aspects of a particular case would be

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perceived as necessary once the parameters of the retrospective study had been determined. As the AO surgeons admitted in 1979, the downside of defining studies after the process of data collection had ended was that ‘many complex questions ... frequently have to be answered indirectly or with the aid of other sources of information such as the radiographs of the case’.102 Prospective studies, by contrast, examined circumscribed problems according to explicit preset criteria. Determining the reproducible criteria for diagnosis, treatment, and evaluation of end results before the study started made this approach effective. By the late 1970s, prospective studies had become the new standard of excellence in clinical research.103 In the field of fracture treatment, retrospective studies were criticised for the large number of uncontrolled variables they contained, their lack of standardisation, and the bias in attributing patients to certain treatment methods. As two American AO proponents asserted in 1979, only the prospective approach would yield ‘meaningful data’ and create enough light to ‘penetrate the muddy therapeutic waters that swirl around what constitutes the best treatment of ... fractures’.104 The problems encountered in the AO’s documentation project are in no way particular to the AO. Rather they reflect a basic conflict arising from the fact that clinical research always represents a compromise between ambitious aims and practical realities. This point has been made by Harry Marks in the context of his history of clinical research in twentieth-century America. ‘Any clinical trial involves a complex process of social negotiation over intellectual ends and practical means’, Marks wrote, pointing out that any researcher has to decide, which issues can I reasonably address with these colleagues, these institutions, these patients, and these funding levels? What data gathering procedures must I have (to resolve my doubts, satisfy my standards, convince my colleagues, and further my career), and which are dispensable?105 There always remains ‘a gap between the world of methodological dicta and the social realities in clinical research’. Even the simplest clinical trial, the most elementary documentation is ‘the product of a negotiated social order, replete with decisions – some contested, some not – and with unexamined assumptions’.106 Clinical studies are thus always a biased extract of the real world. According to Steven Epstein, quoting an AIDS researcher from California: The real world cannot be reproduced in a clinical study, all one can do is try to define things in such a way that some interpretable data can be gained in which the bias is sufficiently limited so that the study is meaningful and applicable to other situations.107

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Reorientation The ambitious plans of documenting all cases treated by AO surgeons with AO methods remained utopian. The incompleteness of available information raised the question of how representative the recorded cases were. Since the total numbers of cases was unknown, the data did not even allow to determine what fraction the existing data represented. Even less was known about their bias, for instance, through exclusion of poor cases. Despite the fact that these basic problems could not be solved by technical means, the AO Documentation Centre’s technical equipment was constantly renewed in correspondence to the latest developments in computer technology.108 By 1986 the centre had collected documentation relating to 175,000 cases. During the preceding five years alone, 42,000 fractures had been documented. One-third of these cases, however, could not be used for analysis because the X-rays had not been sent to Bern. Another third was not fully useable because of the lack of follow-up examinations. So only 10,000–15,000 cases could be used at all. In addition, as Müller pointed out, only about half of the cases had been treated according to the rules given in the AO Manual, so that in the end only about 10 per cent of all cases represented the correctly applied AO technique. In light of these disappointing data even Müller raised the question of whether it was worth the effort to continue this expensive strategy of documentation.109 The AO’s original approach of comprehensive collection of retrospective case data did no longer fit in with the contemporary standards of clinical research. Now, more circumscribed, problem-oriented and prospective studies were demanded, if possible with a control group and randomised attribution of the different treatment methods to the individual patients. So by the mid1980s, it had become increasingly clear that the AO had to change its basic strategy in that regard. The AO surgeons were very familiar with contemporary standards: In the 1970s Müller and others had suggested to supplement AO Documentation by prospective studies, and by the 1980s, many AO surgeons were already performing this type of clinical research.110 So it was only appropriate that Müller planned a reorientation and decentralisation of the AO documentation efforts in 1987.111 Subsequent events, however, hindered him from carrying out these plans himself. Because of conflicts he had with the AO Foundation leadership (described in Chapter 11), after 29 years Müller stepped down from his directorship of AO Documentation in 1988. He was replaced by Peter Matter who became the new chairman of the board of the Documentation Centre and President of the AO Documentation Commission.112 Müller’s retirement from AO Documentation also entailed a major change in the whole institutional arrangement. In 1961 Müller had also established a documentation system for hip prostheses parallel to the AO’s fracture treatment documentation. Using the same basic approach, both projects were

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united when the AO Documentation Centre moved to Bern in 1967. Now, the two systems were separated again. The Hip Documentation Centre became an element of the newly established Maurice E. Müller Centre for Postgraduate Education and Documentation. Müller himself now concentrated on developing a sophisticated programme for evaluation of outcome studies in orthopaedic surgery, the International Documentation and Evaluation System (IDES), and took on the post of chairman of the Presidential Commission for Documentation and Evaluation of the Société International de Chirurgie Orthopédique et de Traumatologie (SICOT) (the International Society of Orthopaedic Surgery and Truamatology).113 The AO’s trauma documentation moved into another location in Bern. With the change in leadership, the general strategy of the AO Documentation Centre also changed. The general function of the centre was seen mainly as support of clinical research. The new concept of decentralised documentation meant that clinics using the AO equipment were supported in their own efforts at documentation in general and at performing prospective studies in particular.114 In 1992 the centre moved into the new AO Centre in Davos. By then 14 prospective studies were underway. 115 In 1998 the centre was renamed the Department of AO Clinical Investigation and Documentation and restructured to have three subunits: a Monitoring Group had the tasks of performing its own independent clinical studies and drawing up protocols to be used for clinical studies in accordance with current legislation and international guidelines; the Technical Support Group was made responsible for the development of specific databases for clinical research and offered its specialist services to all interested institutions; a Consulting Group was formed of specialists for advice in statistics, epidemiology, legal aspects and ethics. After another restructuring in 2000 the unit was renamed the AO Clinical Investigation Department.116 To sum up, one can say that as the result of a gradual development over two decades, the emphasis of the AO Documentation group has shifted from the initial aim of documenting all cases treated in the AO network to assisting others in performing their own clinical research. Positive effects of AO documentation Even though the AO failed to achieve their original goal of comprehensive and complete documentation, they did derive various benefits from what they had collected. For starters, the data constituted a vast repository of clinical experience. As Müller pointed out, by 1983 130,000 fractures had been documented; 80,000 of them were complete with code sheets and X-ray pictures. In the first 25 years of the centre’s existence 550,000 photographic copies of X-ray pictures and 60,000 slides had been produced. From 1980 to 1983 alone, the collection had helped to answer more than 300 complex questions and had provided the basis for more than 40 publications or dissertations.117

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As the first public presentation of the AO technique illustrates, the documentation project had been an integral part of the AO’s public image from the start.118 In preparation for the AO’s appearance before the Swiss Surgical Society in 1960, Müller called upon all AO members to record as completely as possible all the tibia fractures they had treated with osteosynthesis. To be successful at the meeting, he wrote, the AO would need ‘convincing arguments’. In the presentations and the ensuing articles, documentation indeed played a central role. Schneider presented the results of 246 intramedullary nailings, Allgöwer spoke on 400 cases of tibia fractures treated with bone screws, and Willenegger discussed 118 cases of ankle fractures. All presentations included exact quantitative data of results and suitable X-ray pictures. The material had been collected from various AO members and was proudly presented as the product of their collective effort. In his contribution, Müller stressed that the AO members themselves had at first been sceptical about their method and had only been convinced of its value by the results of their documentation. The data demonstrated, he asserted, the kind of results one could hope for if the AO technique was diligently applied. As he would also do on several later occasions, Müller visualised the principles of the AO documentation by reproducing pictures of the punch cards in his article.119 Collective clinical research was also highlighted in the first AO textbook of 1963, which contained more than 40 pages presenting 188 completely documented cases of tibia fractures. According to its preface, the book’s guidelines on open fracture treatment had been ‘extracted during five years of experience with more than 4000 operated and documented fractures’. Only by systematically checking their treatment methods, the authors remarked, had they learned to assess them correctly and become aware of their mistakes.120 Outside the group, the AO documentation efforts were viewed as exemplary and earned the AO surgeons much credit among their colleagues. In the 1965 German Handbook of Traumatology, the Bochum traumatologist and Bürkle de la Camp’s successor, Jörg Rehn, praised the group for their systematic attempts at giving account of their treatment results among themselves and to the surgical public.121 To their own astonishment, this positive effect on the AO surgeons’ image was not impeded by the problems they had with analysing their material. In 1966 Robert Schneider noted that their method had been generally accepted even though they had as yet not managed to present the definitive results of their documentation project. Apparently, he concluded, the immediate evidence of the clinical success had been enough to convince his colleagues. 122 So the way systematic documentation contributed to the method’s general acceptance was not primarily by furnishing proof of its usefulness. For this, the immediate results obtained with the technique were already very effective. The main benefit of documentation for the AO’s recognition among surgeons was the creation of a broad base of trust and credibility. For that

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reason, documentation was made a central element of the AO’s selfpresentation to the surgical public. It was with reference to this favourable effect that the AO surgeons convinced their producers to support the centre.123 To reinforce the idea, the 1969 AO Manual described documentation as the ‘backbone’ of the AO method;124 and when the AO surgeons had the chance to present their project to a larger American readership in 1979, they emphasised their documentation activities and characterised them as a ‘massive, collaborative effort of surgeons interested in evaluating their results’.125 The fact that AO documentation contributed to the technique’s acceptance not so much by furnishing direct evidence of its usefulness but by enhancing the AO’s general credibility illustrates a more general point concerning the function of quantitative and statistical methods in medicine. As numerous historical and sociological studies have demonstrated, even the most sophisticated clinical trials cannot enforce consensus. Results of clinical studies are necessarily subject to considerable interpretative flexibility, even though interpretation is often rendered invisible by using quantitative arguments. Evelleen Richards has found in her study on randomised controlled clinical trials that even this highly sophisticated form of research cannot offer definite solutions to disputes over contentious therapies or technologies.126 According to Theodore Porter, statistical techniques ‘work mainly as social technologies ... The advances of statistics in medicine must be understood as responses to problems of trust.’127 From this viewpoint, the acceptance or rejection of new treatment methods must then be explained as the outcome of multilateral struggles for credibility, as Stephen Epstein has found in his sociological examination of clinical trials on AIDS therapy.128 In the case of the AO technique, the fact that research was being done at all was enough to establish credibility. The actual results of the research were only of secondary importance, considering that the average surgeon had too little time in his schedule to read and evaluate research reports anyway. Then again, the AO’s line of argument was not successful with all surgeons. For those who did not share certain basic premises on the nature of medicine, the blanket reduction of risk to impersonal statistics was anything but self-evident. Divergent rationalities According to the science-based concept of surgery embraced by the AO, surgical risk could be managed by collecting outcome data and using them as a basis for balancing potential benefits against potential dangers. Risk could be calculated and justified and thus posed no real challenge to osteosynthesis. But for a number of osteosynthesis opponents the potential benefits of such a treatment would never outweigh the possible harm to the individual patient in the case of complications. Critics emphasised that statistical data never predicted the outcome of the individual case nor appropriately

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represented the individual tragedy of complication for the patients affected.129 The disagreement over osteosynthesis is an instance of the general observation made by Ulrich Beck that risk assessment is always the outcome of ‘a quarrel of competing, contrasting or overlapping claims to rationality’. According to Beck, rationality emerges in social processes, and it is the historian’s task to find out how rationality becomes ‘accepted, defined, redefined, acquired and lost’.130 In his rejection of statistical rationality, AO opponent Hans-Ulrich Buff even went so far as to deny statistics any practical value at all. In a 1971 article Buff thought it legitimate to express his opinions on treatment methods based solely on his ‘personal experience and impressions of thirty years of practice’, abstaining from ‘giving any figures, statistical arrangements and comparisons’.131 Though not many surgeons would have agreed with such an extreme standpoint, surgery was often considered a particularly difficult field for the use of sophisticated methods of clinical research like randomised clinical trials, because ‘every patient presented a unique challenge, every surgeon had different skills, and each operation could utilise a bewildering range of procedures’.132 This also applied to fracture treatment and orthopaedic surgery. In 1939 Willis Campbell questioned whether any ‘classification of orthopaedic affections can be entirely satisfactory’. There were ‘so many factors involved in any one condition that a survey of end results can be of only questionable value unless the minute details of each case are considered’.133 Another Swiss AO critic, Max Geiser, even doubted that objective assessment was possible at all. For him, the character and location of the fracture, the blood supply of the affected area, the condition of the bone before the fracture, and the technical details in performing the treatment varied so much that setting up reliable comparative statistics was impossible.134 Comparability was also a problem of controlled clinical trials despite randomisation, replication, and unbiased assessment of results.135 ‘Even if all future studies were both complete and standardised,’ two American surgeons wrote in 1979, ‘comparisons between results obtained with different methods at different institutions still would be inaccurate’ because of the many variables involved.136 Even the most advanced methods of clinical research cannot refute this sort of resistance on principle. Statistical reasoning fails to convince those who do not appreciate the generalised type of information it yields. Such fundamental differences in worldviews were part of an ‘ethical clash’ identified by historians of medicine in the twentieth century between those doctors who endorsed ‘professional values centred on the individual’ and others who advocated ‘the statistical necessity of taking averages’.137 Its critics charged scientific medicine with neglecting the individual character of medical problems, and it is easy to see how they got this idea: If patient care is viewed as a controlled, reproducible experiment, treatment procedures must be standardised like laboratory procedures and treatment results handled in the

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manner of experimentally derived data. This means that, as in experimental science, a few precisely defined parameters are put into focus and measured in a way that makes them comparable. At the same time, the differences between the individual cases must be played down. As a consequence, the similarities of body parts and their injuries are emphasised and the particularities of the patients’ individual problems are backgrounded.138 Those surgeons who opposed the de-individualising aspects of the scientific approach to surgery were often also wary of the AO’s systematic application of treatment methods and stressed that each injury was unique and should be treated in an individual way.139 In a typical statement, British surgeon Ernest Alexander Nicoll argued that it was not justifiable to operate on a hundred patients in order to catch those five patients who would actually benefit from osteosynthesis: ‘That would be equivalent to sending 100 people to prison because five of them might be criminals.’ 140 Arthur Hübner explained in his textbook of 1948 that the rules of fracture treatment must never be used in a schematic way. Their application was an art and required much diligence and practice on the part of the surgeon. For successful treatment, the choice of which method to use was less important than the individual surgeon’s experience and personal attitude.141 These surgeons, who preferred to call medicine an ‘art’ rather than a ‘science’, rejected the idea that medical decisions are based on universal scientific principles, seeing them instead as fundamentally personal and individual.142 In his study on early twentieth-century American medicine, Joel Howell found a general ‘deep-seated cultural bias in favour of an individual clinician’s judgement’, as he puts it, ‘a fundamental belief that individual clinicians make decisions using information and modes of analysis which simply cannot be captured by any set of formal rules or procedures’.143 Critics warned that medical practice governed by this sort of standardised procedure would turn medical treatment into a mere technology to be performed by ‘unthinking physicians’. In their view, the art of medicine required diligence, experience, skill, individual attention, sound clinical judgement, and common sense – all instances of tacit knowledge, that could not be passed on in an explicit and systematic manner but had to be acquired through individual experience.144 Much of the disagreement around the AO concept had its roots in these conflicting world views. Concerning instruction, critics typically rejected the AO’s efforts at systematic training and emphasised the personal, tacit dimension of surgical and diagnostic skill which could not be learned from a manual or a course. On the field of treatment, they opposed the AO’s aim of systematisation and standardisation as it prevented the surgeons from dealing with patients on an individual basis. Buff, for instance, criticised the AO for doing everything systematically and ignoring the circumstances of the individual case.145 Similarly, for Geiser such an approach constituted an instance of inappropriate ‘absolutism’ or ‘schematism’. The choice of treatment had to be made individually, according to the type and location

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of the fracture, but also to the patient’s personality, age, occupation, bodily and mental health, not to mention the hospital’s apparative and hygienic conditions and the surgeon’s familiarity with the treatment methods. Apart from bone biology, functional anatomy and pathology, the decision should also be informed by ‘a good dose of common sense’.146 In the same vein, Nicoll blamed the AO for their ‘totalitarian approach’. In a sideswipe at the AO courses he remarked that the ‘high degree of clinical judgement’ necessary for individual fracture care was ‘harder to acquire, or to impart, than technical virtuosity in the operating theatre’.147 Even though the AO surgeons did stress the individual character of each case as well as the individual nature of surgical activities,148 it was clear that they placed more trust in explicit instruction than in individual judgement: surgeons must not rely on intuition but on clear and tested rules, Allgöwer stated in a typical comment on the treatment of bone infection.149 Both sides knew that the AO’s strategy of making surgery a science was part of a current trend. Allgöwer himself drew a parallel between the new way to treat fractures and the modern Zeitgeist with its accelerated lifestyle.150 But while the AO surgeons were in favour of modern life, their critics took a more conservative stance. Buff castigated modern man’s exaggerated belief in science and technology, calling it Wissenschaftsaberglaube – ‘scientific superstition’. Medicine is often described as a combination of art and science, he argued, and for the misled adherents of modern science, medical progress consisted in the steady increase of the scientific portion.151 Similarly, Geiser characterised the image of cool technological elegance associated with osteosynthesis as seductive,152 and John Charnley warned of the ‘superficial impression of precision presented by operative techniques’, and their appearance of ‘modernity’.153 Charnley was also suspicious of the modern scientific means of gaining knowledge and their apparent plausibility. He complained of the ‘tendency to imagine that serious research can now-adays only come out of the laboratory’. Upon reflecting that ‘today our credulity lies in the accuracy which we attribute to our special research tools, such as the electron microscope’, he emphasised the danger of forgetting that ‘sight and touch together make the greatest clinical faculty of all, namely, common sense’.154 Authority and power Apart from conceptual and practical considerations, opposition to making surgery a science had a social dimension. The two models of medical practice also implied different roles for the practitioners with different attributions of authority and power.155 If surgery is a science, then every surgeon can be taught the necessary skills to achieve good treatment results. Scientific surgery thus embodied the democratic ideal of expertise.156 As a form of knowledge, Deborah Gordon writes, ‘clinical science is characteristically explicit, universal, abstract and public’. Criteria for practice can be scrutinised and

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judged by ‘peers, junior physicians, external agencies, and patients’. The mechanical application of established procedures measured by objective standards of scientific integrity was to replace personal discretion and trust in the judgement and integrity of the experienced clinician.157 In a scientific framework, clinical skill and knowledge are attainable independent of the surgeon’s personality. Anyone who adheres to the rules can achieve good operative results. Expertise thus becomes a depersonalised ‘technique to be mastered’ instead of personal ‘experience to be amassed’.158 If surgery is an art, however, hierarchy and personal authority are of central importance. According to Buff, good medical practice depends on the doctor’s personality and is not achievable simply by receiving the right kind of instruction.159 From this perspective, medical expertise can only be passed on by ‘apprenticeship, oral culture, and the case method’. Being ‘implicit, ineffable and tacit, clinical knowledge is less open to public scrutiny and outside surveillance’. It is easy to imagine how such a concept ‘supports a hierarchy based on expertise’.160 Generally speaking, ‘becoming scientific’ was a successful strategy for medicine as a profession on its way to social and cultural dominance. On the individual level, however, this strategy also endangered the doctor’s personal authority. For this reason there was always a counter-current within the medical profession with the aim of protecting the individual practitioner’s autonomy by declaring medicine an ‘inexplicable art’.161 Belonging to that counter-current, many AO opponents considered the organisation’s concept of expertise a threat to their professional autonomy. For Buff the AO’s concept reduced the individual doctor’s role to that of a mediator between the patient, on one side, and the AO as a central agency that issues the directions for treatment, on the other. But this, he argued, was detrimental to good medical practice, which consisted in the interpretation of medical knowledge in the context of the individual case, something that depended on the surgeon’s autonomy and his mature and morally sound character.162 Many AO critics also considered the surgeon’s authority threatened by the popularity of osteosynthesis among patients. Charnley, for instance, called on the academically trained doctor’s awareness of his superiority as a means to resist such pressure from outside the profession: ‘Learned professions must guard against the insidious danger of being influenced by advertisements of the popular press’, he wrote, complaining that sound biological facts never have publicity value, but unfortunately methods which are unsound often possess news value because they appeal to a public which understands mechanical engineering but not surgery. The thinking surgeon cannot share his patient’s pleasure in a perfect radiological reduction.163

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According to Buff, the learned surgeon’s strong personality was the best antidote for fads like osteosynthesis. In order to develop the necessary strength of character, doctors must avoid technical over-specialisation. Instead they should acquire a broad general education in the sense of the German term Bildung which includes the meaning of character formation. This would provide them with a basis of personal freedom and autonomy to withstand pressure from patients and resist the popular error of seeing medicine as a science-driven enterprise. Despite the popularity of osteosynthesis, in most cases conservative treatment is best for the patient, Buff believed, and it is the surgeon’s foremost task to use his authority to guide misled patients through the lengthy process of conservative treatment. Moral integrity and a stable personality enable him to protect his patients’ interests and earn the trust placed in him. All this Buff saw threatened by a subversive tendency towards mechanisation and teamwork that he attributed to the worldwide increase of American cultural hegemony embodied by the industrialist Henry Ford.164 According to Buff’s line of argument, good medicine required the framework of a liberal profession, in which a doctor could assume responsibility for his actions as a free human being. Only an autonomous doctor is able to resist the trends of growing dehumanisation and depersonalisation of medical care and stem himself against the cost explosion in modern medicine. For Buff, medicine as a free profession was one of the most important but also one of the last strongholds of European civilisation. With this position the Zürich professor was a rather radical but nonetheless typical exponent of the modern tradition of defending, in the words of Sturdy and Cooter, the ‘individualised’ against the ‘administrative’ way of knowing.165 It is obvious that both concepts of medicine embody particular values and specific ideas about the doctor’s role in society. Importantly, the scientific view of medicine endorsed by the AO is as much a partial view of reality as its artistic counterpart. As Deborah Gordon explains: Although scientific rationality is assumed to be unbiased it too is a particular approach to reality, albeit a particularly powerful one, that is as committed to a particular set of values as any other approach. The demand for precision and predictability, the hallmarks of science, are not neutral because certain specific measurements are selected for while other types of information are rendered unimportant or irrelevant.166


Part II Coping with Success, 1970s–1990s


7

Acceptance: The AO becomes Mainstream

Starting out in 1958 as a small local association of surgeons with a special interest in an unorthodox treatment method, it took the AO only two decades to become a global player in fracture treatment. This chapter examines the process of acceptance of the AO technique and the concurrent geographic spread of the AO organisation. Building on the previous chapters on instrument design and production, user education, laboratory science and clinical research, I first look at the gradual change in the AO’s evaluation among surgeons in central Europe. I then elucidate the role patients played in the group’s success and characterise the place they came to occupy within the AO’s network of cooperation and control. The second half of the chapter focuses on the AO’s geographic spread, beginning with an analysis of the specific manner in which the AO established itself in Switzerland’s neighbouring countries, West Germany and Austria. After a survey of the AO’s broader expansion I address some of the specific local and national factors confronting the AO surgeons as they set about propagating their technique in more culturally distant countries. These considerations will serve as the foundation for a systematic analysis of the AO’s international success in Chapters 8 and 9. AO – always operate? In the early 1960s the AO technique gradually became accepted by surgeons outside the AO, its growing popularity leading to the release of the instruments and implants in 1962 for general sale. Contemporary criticism of a prevailing ‘trend towards open reduction and rigid internal fixation’ is indirect evidence of the attraction the approach must have held for the rankand-file surgeons at the time.1 Osteosynthesis had apparently become so attractive that critics like Max Geiser warned of the inversion of the usual 141

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decision process: many surgeons, he complained, no longer deliberated over whether operative treatment was necessary, but asked instead in which cases an operation was not allowed.2 In order to check what they considered to be a general overestimation of the effectiveness of operative fracture care, the organisation of German-speaking orthopaedic surgeons devoted its 1959 conference to a discussion on the dangers and mistakes of osteosynthesis.3 As the conference’s theme implies, scepticism had been generated by the observation that failures in osteosynthesis operations were on the rise. Traumatologists were also taking note of the tendency: between 1958 and 1960, leading German traumatologist Heinrich Bürkle de la Camp had seen a steep increase of non-unions and bone infections due to failed osteosynthesis operations. As head surgeon of a large trauma centre, to which all the failed cases of other hospitals were referred for a last attempt at treatment, he was in a good position to testify. Accordingly, he admonished his colleagues to attend to all the preconditions for successful osteosynthesis: adequate knowledge and experience to assess whether an operation was indicated, perfect mastery of the technique, strictest asepsis, and a complete set of highquality equipment. In this context Bürkle mentioned the AO surgeons for the first time and praised their comprehensive concept. But he also urged them to be circumspect with indication.4 Indication was undeniably a central issue in the osteosynthesis debate at the time. Critics accused advocates of exclusively promoting operative fracture care to the point of jeopardising patient recovery, while advocates faulted critics for persisting in conservative treatment despite the good results being shown with osteosynthesis. Attacks against the AO surgeons typically referred to their too liberal use of operative techniques;5 as Allgöwer recalled, they had the reputation of being an ‘aggressive group of surgeons’ who were ‘far too knife-happy’, with their critics foreboding ‘a bitter end’. 6 AO, they sneered, was the abbreviation for alles operieren (always operate). Such criticism was often combined with accusations of avarice.7 In one such indictment from 1966, an article in the magazine Der Skifahrer (The Skier) entitled ‘The Skier’s legs under the Knife’ warned of ‘greedy osteosynthesising Swiss surgeons’.8 From the beginning the AO surgeons were keen to repudiate these charges. In 1960 Müller told the Congress of Swiss Surgeons that it had never been his intention to promote any particular method of treatment.9 The same tone prevails in the AO’s 1963 textbook. Early in the book the authors emphasise that: Osteosynthesis is an exceedingly difficult treatment method, in which halfmeasures invite great dangers. It requires thorough training, much experience, sound judgement, technical skill and the ability of threedimensional thinking on the part of the surgeon, who must also have specialised equipment at his disposal. This is why osteosynthesis – despite

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all its advantages if performed correctly – can never be recommended as a generally applicable standard treatment method.10 The AO surgeons continued to reject the overzealous use of operative methods into the 1970s and 1980s. However, the AO surgeons also challenged the logic of first treating all fractures conservatively and then switching to osteosynthesis only if the initial approach had failed.11 Furthermore, there was no longer any need for the fatalistic attitude prevailing with regard to the treatment of certain types of fracture: fractures, the AO claimed, which were previously judged to be ‘not amenable to surgery’ could now be operated on with success, employing ‘the modern concept of fracture treatment by means of open, anatomical reconstruction, stable internal fixation and functional aftercare’.12 In deciding whether to operate or to treat conservatively, the best way to proceed, the AO reasoned, was by careful and precise indication. In 1966 Schneider named extended soft tissue injuries, paralysis, old age, reconstruction of joints and non-union as imperative indications for osteosynthesis.13 He also mentioned multiple trauma as a special indication which was growing in significance. Because of improved first aid measures, many polytraumatised accident victims no longer died at the accident site but stayed alive long enough to reach the trauma units. Due to the multiplicity of critical injuries, all of which had to be taken care of simultaneously, internal fixation was the only way to treat the fractures without impeding intensive care with cumbersome plaster casts and traction devices.14 Growing recognition of the AO technique is signified by the fact that the focus of the discussion shifted from considering whether osteosynthesis was beneficial at all to the question of its indication. Another sign was the change of opinion of authorities like Bürkle de la Camp. After accepting an invitation to be the guest of honour at the 1963 Davos course, he assured his hosts that he would have participated in their endeavour, were he younger, and subsequently took to praising the AO publicly.15 Gradual recognition is also reflected in the standard textbooks. In 1963 the German Handbook of Traumatology listed a number of fracture types in which internal fixation was superior to conservative treatment without, however, mentioning the AO. Two years later, the third volume of the handbook included a chapter on the lower leg and the foot written by the AO adherent Jörg Rehn, who described the AO technique and its principles in extenso, defined primary bone healing as a rational goal, and recommended the AO compression plate for use in lower leg shaft fractures.16 Even Böhler changed his attitude. Though his appraisal of osteosynthesis in the 1963 edition of his textbook was still critical, it did not prevent him from attending the Davos course in 1964 as the guest of honour. Taking the invitation as a sign of respect for his authority, Böhler came with an open mind, ready to let himself be impressed by his young colleagues’ systematic

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efforts. The AO surgeons, he declared in his speech, had the same objectives he himself was pursuing with his concept of functional treatment, the difference being that they chose a more complicated path to that aim. In his report before the German Surgical Society in the same year, Böhler was full of praise for the AO’s operative technique as well as for its equipment, organisation, documentation and research efforts, all of which he regarded as great progress in bone surgery.17 Sporadic opposition did persist for a long time, encouraged by reports on unfavourable outcomes, such as a dissertation from an assistant doctor stationed at the Saarbrücken university hospital on a series of cases treated between 1963 and 1966.18 But general opinion in Switzerland and other central European countries continued to shift towards acceptance of the AO and osteosynthesis. As early as 1964 Allgöwer noted that the AO had aroused a wave of enthusiasm for internal fixation. It was a development, he remarked, which the AO surgeons themselves viewed with mixed feelings.19 Even the usual demonstrations of disapproval about X-rays showing metal in bones had abated, an observation that Schneider interpreted as a sign of growing acceptance of the AO’s ideas at home and abroad.20 A typical marker signifying the general acceptance of a new idea is when any remaining opposition appears irrational to most people in the field. For the AO this point had been reached in 1969. In a statement on the new status of their method, Schneider recalled the great resistance, in spite of which the AO had achieved its present position. Whatever opposition remained, he concluded, had to do with feelings of personal animosity and not with serious points of science.21 This sort of switch is a sure sign of the successful establishment of a technique: for most surgeons it was now completely plausible and rational to use the AO technique. Whoever continued to oppose it was seen as being guided by purely emotional motives. Accordingly, in the early 1970s the general consensus within the Germanspeaking surgical community was that modern surgical treatment was unimaginable without osteosynthesis.22 Proponents and critics acknowledged the AO’s crucial role in the general acceptance of operative fracture care and noted the striking speed with which the AO instruments and procedures had spread.23 Trust and credibility But how can the process of acceptance be explained? To begin with, osteosynthesis had an image of modernity and efficiency that made it attractive to many surgeons. As shown in the preceding chapters, this was exactly one of the points sceptics like Charnley, Buff and Geiser found problematic about the operative approach. Then, as now, surgeons normally solved medical problems by operating; they were unaccustomed to the relatively passive attitude required in conservative fracture care.24 Accordingly, critics noted that many surgeons preferred operative fracture care not because they thought


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it was better for their patients but because they found it more convenient to operate than to supervise a lengthy healing process using conservative treatment methods. These critics also pointed to the higher prestige and financial gain associated with operative treatment as compared to unprestigious, poorly-paid conservative measures.25

Figure 16 Conservative fracture care ridiculed. Cartoon by Otto Soglow, The New Yorker, 1939.

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Of course, regardless of questions concerning prestige and salary, a working principle of all doctors is to aim at good treatment results. And, as demonstrated in previous chapters, many surgeons were convinced that osteosynthesis treatment made it possible to avoid the side effects of immobilising treatment methods, thus yielding better long-term results for their patients. But despite all these motivations, osteosynthesis never became a standard therapy until the AO made it their goal. As shown in Chapter 1, the general attitude had long been that the method was too difficult and too risky to be used on a routine basis. Only when the AO came up with a controlled and comprehensive system did that situation change. The AO’s comprehensive approach consisted of several elements. One of them was technology. The attractiveness of good instruments and implants cannot be overestimated and is most evident in the way surgeons vividly compared their first exposure to the equipment with childhood memories: The Austrian Harald Tscherne described his feelings as similar to those of a child in front of a glittering Christmas tree, whereas his countryman Rudolf Szyszkowitz was reminded of the fun he had experienced as a little boy with his Meteor metal construction kit.26 Technical perfection was obviously a strong asset with surgeons whose daily experience included their utter dependence on good instruments. But as we have seen in the preceding chapters, other elements were just as important: the AO’s attendance to user education, provision of a scientific basis for its techniques and establishment of a system of clinical evaluation won them the trust of surgeons who were not in the organisation and who, in most cases, were the people who decided on the purchase of the equipment for their units. As a consequence of the symbiosis of surgeons and manufacturers the AO accomplished in many regards exactly what other surgeons had been demanding for decades. The early purchasers saw it as a crucial advantage of the AO over the previous suppliers that it offered everything a surgeon needed in one ‘package’: the AO programme included standardised and fully compatible sets of instruments and implants which had undergone stringent quality controls, textbooks, and training courses as well as a scientific basis.27 Also, significantly, the AO ‘package’ was offered not by businessmen but by fellow surgeons, who took considerable care to keep it that way and make it known among their colleagues that the AO was not a commercial company.28 The in-house system of quality control, the facilities to conduct basic research and clinical outcome studies, gave the surgeons a feeling of safety when using AO/Synthes products, which explains why AO products started to sell so well even before the AO’s research results came out, as Robert Schneider remarked with some astonishment in 1966.29 However, as shown in Chapters 5 and 6, research results could also be used to fend off critics. Laboratory research enabled the AO to put forward its own theory of bone healing and to present it as a plausible scientific foundation


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Figure 17 AO cooperation symbolised as a building with four pillars (drawn by Klaus Oberli after an idea by Urs Heim).

for the propagated methods of osteosynthesis, and clinical outcome studies allowed it to redirect the discussion on the risk and safety of bone surgery in such a way that osteosynthesis became an acceptable option on a wide scale. As the scientific activities were financed by selling AO products and commercial success automatically led to an increase in research funds, the overall effect was a circle of positive feedback. Once the feedback effect had begun, it was relatively easy to maintain and enhance. The symbiotic relationship between surgery, science and industry resulted in a sort of economic perpetuum mobile.30 Income from instrument sales went into research and development, which in turn helped to maintain the AO’s position in the surgical community.

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The AO was also successful in arguing from an economic perspective. When Willenegger wrote to the insurance companies for support of the AO laboratory and documentation centre in 1960, he could refer to statistics demonstrating the profitable effects of exact reposition of bone fragments in terms of compensation and pension payments.31 The AO’s economic argumentation had the desired effect on the Swiss Accident Insurance Agency (SUVA), which took a great interest in the AO’s work. When the AO surgeons presented their new technique to the surgical public in November 1960 in Bern, at their side they had Dr Baur, a SUVA representative who had prepared a presentation on the benefits of the use of the AO technique on lower leg fractures.32 The AO and SUVA stayed in close contact, and representatives of insurance companies took part in the AO courses as ‘passive participants’.33 Savings in pension payments, avoidance of disability and reduction of hospitalisation time were also used as a measure of the AO’s success by Allgöwer and Willenegger in their presentations in Bern and later in the AO textbooks.34 In discussions on the pricing of implants it was quite convenient to be able to balance the implant expenses against the money saved through high-quality fracture care.35 Even when the rapid increase in health care costs was discussed in the 1980s, the AO was still able to point to the net savings achieved by using its technique.36 Mainstream Meanwhile, some of the AO surgeons had started climbing the academic ladder. Originally none of them had a high rank in the university hierarchy. As discussed in Chapter 2, the AO arose within the Swiss milieu of nonacademic surgeons, and apart from Willenegger, who was appointed Associate Professor (Extraordinarius) in 1958, the highest ranking among them were the Privatdozenten Müller and Allgöwer. The first full professor to become an AO member in 1961 was a German, Hermann Krauss from Freiburg, whose support was highly valued as the AO’s eventual ‘breakthrough on the university level’.37 But before long Müller and Allgöwer also reached that level. In 1960 Maurice Müller’s itinerant activity came to an end when he was appointed head of the newly built Orthopaedic-Traumatological Clinic in St Gallen. Comprising 200 beds, it was much larger than any other traumatological unit in the country. With his double qualification as general surgeon and orthopaedic surgeon Müller was the appropriate choice for heading the clinic, the first Swiss institution of its kind. It developed into a Mecca for patients and surgeons from all over the world, and Müller himself became a celebrity. Thus it was only logical that he would be appointed to the even more prestigious post of full professor and head surgeon at the University of Bern’s Orthopaedic Clinic only three years later. As the university had promised to accommodate his unit in new buildings, Müller stayed in St Gallen until 1967; until that time, when the facilities in Bern were completed, Müller would spend only one day per week at his new place of work.38 In


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the summer of 1966 Allgöwer became full professor and director of the Surgical Clinic at the University of Basel. There he initiated the reorganisation of the surgical clinic and gave the different subspecialties a semi-autonomous department status. Allgöwer and Müller became two of the most prominent surgeons of their time. Their pupils became the leaders in orthopaedic surgery and general surgery in Switzerland and beyond. By 1966 the AO had definitely entered the milieu of academic surgery. On the one hand, the growing number of professors and even full professors in its ranks was a visible sign of the AO’s acceptance within the medical establishment.39 On the other hand, this development was viewed with mixed feelings by the AO’s original core of head surgeons of small Swiss hospitals. ‘The AO is pleased about the success and warmly congratulates’, Robert Schneider commented on the rapid rise of his fellow AO founders; continuing, however, in a more sceptical tone, that the organisation’s other members wondered whether Müller and Allgöwer’s new tasks would prevent them from committing an adequate portion of their time and energy to the AO.40 From this perspective the university appeared like a competitor vying with the organisation for the attention of its most eminent members. Despite the growing significance of the AO, most of the original members did not pursue a university career. Even Hans Willenegger and Robert Schneider, who were the most prominent AO surgeons besides Allgöwer and Müller, did not reach the higher academic ranks. Willenegger had become associate professor in Basel in 1958 and later he was given a personal full professorship. Schneider received an honorary professor’s title in 1977 from the University of Mainz and Walter Bandi received the same from Bern in 1978.41 Nevertheless, in their role as AO leaders Schneider and particularly Willenegger acquired worldwide fame. They were sought-after speakers and belonged to the core group of prominent AO surgeons whose acquaintance was high on the list of foreign colleagues attending the Davos courses. As a parallel institution to the university system, the AO was apparently able to build up its prestige relatively independent of the traditional university structures.42 As a result of their continual accumulation of fame, by the late 1960s the AO had made the transition from being a group of outsiders to becoming a mainstream phenomenon. The surest sign of this altered perception was the career-boosting effect that membership in the AO now had for surgeons. Many of those who were made head surgeons in the German-speaking countries, and later in other countries too, had had an advantage precisely because they belonged to the AO.43 As the most visible sign of its overwhelming prestige in the organisation’s home country, the AO was awarded the Marcel Benoist Prize in November 1988 – the oldest and most prestigious scientific award in Switzerland, often called the Swiss Nobel Prize.44 With growing success the AO equipment became so sought after that demand regularly exceeded all forecasts. Even though the AO producers continuously extended their production capacities and a third producer was

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added to satisfy the North American market alone, files are full of complaints about shortages of instruments and implants. Until the 1980s there was no change in the situation.45 Lack of original AO material forced many users to supplement their equipment with competitors’ products, which in turn jeopardised both standardisation and quality control.46 The producers profited from the AO’s success and thus were able to extend their business. A look at the development of Robert Mathys’ company illustrates this point. To be able to meet demand, Mathys extended his manufacturing facilities in 1963, then again in 1966, and started a large-scale refurbishment of his factory in 1968/69. Concurrently he had increased his staff from 16 to 31 in 1963, and to 84 in 1970.47 In 1982 Mathys had 322 employees in Switzerland and 70 abroad, while the Institut Straumann had 184 plus 89 abroad, and Synthes USA had 183 employees in North America. The AO organisation employed 58 more, so that the whole network had more than 900 employees in all.48 Patients Acquisition of prestige and credibility among fellow surgeons is only part of the story of how the AO became mainstream. In what follows I examine the patients’ role in the rise of the AO. To begin with, the spread of the AO technique did not always occur by reason of one surgeon contacting another. Often it was the patients treated with the method who mediated between surgeons. This was possible because of the particular circumstances of the holiday accidents. As it happened, much of the early publicity regarding osteosynthesis came about because visitors to Switzerland’s ski resorts had fractured a limb while on the slopes. As the operations were performed by AO surgeons, the fractures were treated using osteosynthesis. Following the operations, of course, the tourists returned to their homes in Germany, France, the Netherlands or other countries, where they necessarily consulted their local surgeons regarding post-operative treatment. These surgeons were often puzzled about what to do with a patient who had no plaster cast but metal implants instead. In an effort to avoid incorrect post-operative treatment, the Swiss surgeons took care to familiarise their holiday patients with osteosynthesis by preparing special, detailed leaflets. The result was that the patients were then often better informed about these issues than their surgeons back home. The surgeons’ reaction varied, with some of them antagonistic to the point of actually removing the implants; others considered it an interference with their therapeutic autonomy to receive a pamphlet from their patients with detailed instructions on proper post-operative care. But many others were impressed and became curious or even genuinely interested in the new technique they had unintentionally encountered. Often these surgeons got in touch with their Swiss colleagues and asked for further information on


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how to treat their patients. Thus treatment of common patients constituted a route of contact between the AO surgeons and their foreign colleagues.49 But patients’ demands were also a more direct incentive for surgical interest in the AO technique. Although, in principle, decisions on the acceptance or rejection of medical innovations are made primarily by the medical community, patients do have a certain influence: as sociologist Eliot Freidson points out, medicine is an ‘impure’ social form – a profession with a lay clientele coexisting with a community of peers. 50 This means that in medicine, demand for a certain procedure or product can emerge on different levels. On one of these levels the surgeons, in their role as ‘users’, either buy the AO products themselves or induce the hospital administration to make them available. But on another level, they act as providers of a treatment using instruments and implants on patients. In order to achieve the desired results, the patients must cooperate. On this level, then, patients’ wishes and apprehensions have to be taken into account when speaking about demand for medical technology. Many publications on fracture surgery discuss the needs of patients and use them as an argument in favour of certain treatment methods. Early in the twentieth century William Arbuthnot Lane in England and Albin Lambotte in Belgium both claimed that it was above all their working-class patients who depended on their full working capacity who would benefit most from the anatomically and functionally perfect reconstitution achievable by osteosynthesis. 51 Similarly, Hermann Matti from Bern demanded in 1918 that doctors should consider the individual patients’ requirements when choosing a treatment method: for labourers, military officers, athletes and all patients who needed complete restitution of normal anatomical conditions, he recommended osteosynthesis.52 His colleague and countryman Fritz Steinmann recommended osteosynthesis for those patients who were unwilling to undergo lengthy traction treatment in the hospital, insisting instead on going home early.53 By the 1950s proponents and critics of osteosynthesis generally agreed that patients normally preferred operative treatment to the lengthy procedures of conservative treatment methods. In line with this tendency, AO surgeons were able to report on their positive image as being more active, modern and innovative than others who had not adopted the AO approach, leading many patients to come to their hospital units rather than to the clinics of their more conservative colleagues.54 Popularity among patients was thus a useful argument in favour of the AO technique, and AO surgeons took advantage of it – for instance, when trying to convince their American colleagues to switch over to the AO’s approach.55 In the US surgeons were perceptive to this kind of argument because, as four American surgeons noted in 1983 in connection with the AO technique, patients were ‘becoming increasingly more knowledgeable about the benefits available today through the field of medicine’. As a result, physicians were being confronted ‘more than ever

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with expectations and demands for a full functional recovery following traumatic injuries’.56 Such a line of argument was anathema to most osteosynthesis critics. They typically endorsed a paternalistic notion of the patient–doctor relationship and warned against giving in to demands made by patients who lacked the insight necessary for a rational choice. For them, a patient’s request was clearly not an appropriate criterion for the surgeon’s choice of treatment. Charnley, for instance, advocated a clear leadership position for the doctor when he wrote in 1957: ‘In Britain the tradition by which the patient usually puts himself in the hands of his surgeon without question, and usually without wishing to see his radiographs, makes it easy for the surgeon to practise conservative methods.’ But it was not always easy for the surgeon to act in his patient’s best interest, since ‘one of the greatest difficulties in the treatment of fractures is the subtle pressure, a sort of snobbery or blackmail, put on the surgeon by the necessity for being completely “up to date”’.57 The general tendency among patients was clear: they were often not prepared to accept conservative treatment – those who had a fracture type for which conservative treatment was the method of choice often resisted and wanted to be operated on like other patients.58 ‘Thirty years ago’, the Zürich AO opponent Buff complained in 1971, ‘it was difficult to convince a patient that an operation was necessary’: today, he continued, a detailed explanation was needed if the surgeon wanted to abstain from surgical intervention. According to Buff, there were two reasons explaining the poor image of nonoperative fracture care. One reason was the outdated or even ridiculous impression, often caricatured, which conservative methods such as traction treatment made on many patients; the other was modern man’s increasing impatience – a rare species now, he complained, were those who after a ski accident looked forward to spending three weeks in a sunny, balconied room in a spa, their broken limb supported by a calcaneus traction device. The hurried modern lifestyle and the urge for immediate action with visible results also affected fracture care and encouraged the use of operative procedures.59 It is because of these ‘paramedical’ aspects that conservative treatment had largely been abandoned, Buff concluded from his culturally conservative standpoint, which, as analysed in Chapter 6, was a typical reaction from most AO opponents. Normally surgeons had no trouble obtaining their patients’ consent for osteosynthesis. Despite the occasional expression of certain treatment preferences, during the time of the AO’s expansion the patient–doctor relationship was dominated by the paternalistic model and the majority of patients usually accepted the doctor’s recommendations anyway. As a result, patients were usually more concerned about their surgeons’ ability to choose the right treatment and carry it out in a competent manner than about the pros and cons of the different treatment techniques in general.60


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But the role of the patients in making osteosynthesis successful involved more than demand and consent. As opposed to many other types of therapy, the results of osteosynthesis depended crucially on the patients’ behaviour. Poor patient compliance figured prominently among the reasons given for cases of failure, a close second behind surgical incompetence, as discussed in Chapter 6. Surgeons’ concern about patients who spoiled their efforts was a recurrent theme in medical writing: In 1886 Bircher ascribed a particularly dissatisfying result of fixing a tibia fracture with an intramedullary rod to the incompliance of his patient, whom he characterised as an undernourished, alcohol-addicted tramp.61 Patients often tended to overestimate the strain their injured limbs were able to tolerate since neither pain nor a plaster cast reminded them of the fact that their bone had not yet healed.62 The quick return to mobility allowed patients to be discharged earlier. Their absence from the hospitals made it difficult to prevent them from pursuing their usual occupations, be it playing the piano, washing dishes or even doing more heavy work.63 Many patients chose to return to full activity right away, despite warnings by their doctors: of a group of US Army soldiers willing to risk the potential consequences, ‘one patient continued his professional boxing career and others pursued activities such as surfing, parachute jumping, football, and motorcycle riding’.64 This meant that the surgeon had to consider the character of the patients when choosing how to treat their fractures. Osteosynthesis patients had to be sufficiently willing and competent enough to understand and follow the surgeon’s orders.65 Certain types of patients seemed unreliable in this regard: ‘Very elderly patients’, it was emphasised in one report, ‘generally disregard the instructions and commence full weight-bearing immediately.’66 Apart from the very elderly, surgeons tended to exclude other patient groups from such a difficult treatment: psychiatric patients, ‘asocial elements’ – that is, patients with deviant behaviour – and above all alcoholics were often mentioned in the list of unsafe osteosynthesis candidates.67 Some authors suggested supervision by a physiotherapist or external stabilisation as a remedy for these dilemmas. Weber, for instance, recommended applying a – mechanically unnecessary – plaster cast for ankle fractures just to remind patients that their stabilised fractures were not yet healed. 68 In general, however, the best guarantee came from refusing to treat ‘untrustworthy’ and ‘unreliable’ patients with osteosynthesis.69 As one textbook stated: ‘If the patient is not dependable or co-operative, closed methods of treatment may be the wiser course.’70 The degree of damage a patient’s unreliability could do to the AO’s reputation is nicely encapsulated in the story of one of Peter Matter’s patients, a medical student whose tibia fracture had been treated with osteosynthesis. Against the surgeon’s advice the young man started moving about as if his leg had never been broken. He left the hospital early and, despite considerable

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difficulties accommodating his crutches on the vehicle, rode home from Chur to Zürich on his motorbike. He never used his crutches, so it was to be expected that sooner or later he would fall and injure himself. What happened was that he fell on the stairs of the lecture theatre at the University of Zürich during a lecture held by the most outspoken AO opponent in Switzerland, Hans-Ulrich Buff, and refractured his tibia. For Buff this incident was, of course, a confirmation of his scepticism. Very much to Matter’s chagrin, the story became a regular feature of Buff’s lectures.71 This story shows that it was not only the patient’s trust in the doctor that determined the choice of treatment, but also, conversely, the doctor’s trust in the patient. The network of control and cooperation that was so typical for the AO had to include not only the surgeons, scientists and manufacturers but also the patients, who, like the other elements, also had to be checked for their reliability. This is further evidence of the multidirectional character of the trust and credibility necessary for building up and maintaining the AO network. The ‘epidemic’ spread Like any technique or theory, the AO technology and its theoretical basis were first created locally; they became universally viable only after being accepted in other places. The acceptance of the AO technique among surgeons, scientists and patients was simultaneously a process of geographic spreading, and the AO’s growth from a small Swiss association into a powerful multinational enterprise was a central feature of its success story. This process can be observed from the very beginning. Early on the AO surgeons got in touch with colleagues outside Switzerland, for instance when leading AO members went abroad to present their new technique. In September 1960 Maurice Müller gave several talks and organised an exhibition at the International Society of Orthopaedic Surgery and Traumatology (Société International de Chirurgie Orthopédique et de Traumatologie – SICOT) conference in New York.72 In one of his annual reports Robert Schneider characterised the year 1963 by the continuous spread of the AO’s ideas through the increased presentational activities of prominent AO members abroad.73 However, foreigners were also making their way to Switzerland. In the spring of 1960 foreign guests from West Germany, Austria and the US were present at the AO symposium. And from the early 1960s on, Germans and Americans were also becoming AO members.74 As described in Chapter 4, even the early Davos courses were heavily frequented by foreigners, and soon French and English were made official course languages. Leading surgeons from other countries were regularly invited to the courses as guests of honour – the guest list reading like an international Who’s Who of fracture care.75 Other foreign visitors went directly to the AO surgeons’ hospitals to study the new technique, particularly to Müller’s St Gallen clinic and Allgöwer’s surgical unit in Chur. To organise the stream of visitors the St Gallen clinic


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established a schedule dividing them into groups and assigning them to certain weeks and days.76 In the years to come the AO’s swift geographic spread made it necessary to establish an international umbrella organisation for coordinating and controlling the activities in the various countries. For that purpose the AO International (AOI) was founded in 1972. Its first president, Hans Willenegger, functioned as a trustworthy and tireless emissary, making the AOI an effective missionary-like service that considerably enhanced the AO’s worldwide impact, especially outside the European continent. The reasons for founding the AOI and the underlying concept of that organisation will be discussed in Chapter 11, but it will be useful if it is preceded by a more detailed account of the AO’s process of growth beyond the Swiss borders. The AO’s geographic spread started in the neighbouring German-speaking countries. Despite their relative cultural closeness to Switzerland, the pattern of dissemination there differed considerably from the Swiss fraternity model. In the following I will describe how the AO spread first to West Germany and Austria and then to other countries. Though it is not possible to give a detailed report of how the AO technique was taken up in all the different parts of the world, I will present a brief survey of its spread to other countries and discuss some of the factors accounting for the differences in how it was accepted. A more in-depth discussion of this subject will be undertaken in the next two chapters using the exemplary cases of East Germany and the US. West Germany In the AO’s early period the most important area of spread was the Federal Republic of Germany, Switzerland’s neighbour in the north. The first contacts were made with the surgery department at the University of Freiburg in Breisgau in the south-west corner of the country. They began in March 1960 when Müller and Willenegger travelled to Freiburg to give a presentation at a traumatology conference, chaired by the University Clinic’s head surgeon, Hermann Krauss. The two Swiss doctors were so successful in raising the interest of their German colleagues that Krauss sent his intern Leo Koslowski to attend the AO meeting in Interlaken in the spring of 1960. He himself came to the AO symposium in Davos in the summer of the same year accompanied by another of his interns, Siegfried Weller. Invited as an honorary guest, Krauss was one of seven Germans to attend the first AO course in December of that year. In the following year he became an AO member. In fact, Krauss was the first full professor to join, which made his membership an important early step toward professional acknowledgement of the organisation.77 It was through these efforts that Freiburg became the first German clinic to use the AO technique. Subsequently the number of osteosynthesis operations performed at the Freiburg Surgical Clinic increased from 177 in 1959/60 to 1261 in 1967/68.78 Before the AO products became generally

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available, however, provision of instruments and implants constituted a major problem. Since he had participated in the first AO course and belonged to those surgeons in Freiburg who actually applied the AO system, Siegfried Weller took on the role of intermediary between the AO and the University Clinic. He participated in all AO meetings and had the delicate task of carrying instruments, implants and X-rays across the border.79 This was, of course, not a satisfactory state of affairs, so when the producers had determined their respective sales areas in 1963, Straumann established a south German subsidiary in Freiburg. As mentioned in Chapter 4, Freiburg was also the venue of the first foreign AO course, organised by Weller and Koslowski in 1965.80 The University Clinic in Freiburg was also the starting point for the German AO network, as its surgeons gradually left to take positions elsewhere, where they subsequently established the AO method. The first of them was Jörg Rehn, who in 1962 was named head surgeon of one of the leading German traumatological institutions, the Bochum accident clinic, or Bergmannsheil. Formerly under the leadership of Bürkle de la Camp, the Bergmannsheil was a hospital run by the Berufsgenossenschaft – an accident insurance company for professional associations. Rehn became an important supporter for the AO in Germany. In 1963 Mathys chose Bochum as the seat of his new subsidiary for northern Germany, and in 1970 a programme of regular AO courses was initiated at the Bergmannsheil.81 In 1963 another surgeon from Freiburg, Fritz Kümmerle, was appointed full professor and head surgeon in Mainz. He took Carl-Heinz Schweikert with him and put him in charge of the local traumatology unit. Schweikert advanced the AO’s cause by introducing its technique and, in 1965, by instituting the Mainz Traumatological Symposia, which came to be an important forum for the AO in Germany.82 Another Freiburg surgeon, Leo Koslowski, brought the AO technique to the University of Tübingen, where he became full professor of surgery in 1968.83 Siegfried Weller, who in 1967 had even become a member of the Swiss AO and the TK, also went to Tübingen in 1969, when he was appointed head of the local accident clinic of the Berufsgenossenschaft.84 Another early German contact was Fritz Brussatis. Originally from Göttingen, he had gone to Switzerland in the early 1950s to train as an orthopaedic surgeon and got to know Müller during his stay at the Balgrist. Through this chance meeting, Brussatis would become the only foreigner among the AO’s founding members. In 1969 Brussatis was appointed full professor and director of the University Hospital of Orthopaedic Surgery in Mainz.85 With Kümmerle, Schweikert and Brussatis, Mainz was an important node in the West German AO network. The first Mainz Traumatological Symposium in 1965 attested to the growing German interest in the AO: instead of the 50 participants they expected, 250 surgeons came to the


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event.86 Spurred on by such manifest interest in their organisation, the German surgeons started talking about the idea of organising a German AO group.87 But in 1969 the German AO was still negotiating its constitution. Koslowski, the initiator of the German AO, stated at the Swiss AO meeting in November 1969 that the Swiss model was difficult to emulate in the German context because of the great variety of interests among potential members in that country. Also, a centralised structure of documentation after the Swiss example would be extremely difficult to establish with such a large and heterogeneous constituency. Instead, he noted, the Germans were now primarily aiming at systematically teaching the AO technique and its rules of indication.88 For their part, the Swiss AO were anxious to maintain a certain degree of control over the German offshoot. They wanted to make sure that the German colleagues respected the AO’s treatment principles, but they were also anxious to ensure that the symbiotic character of the relationship between surgery, science and industry was maintained in the German context. Whereas younger German surgeons were looking for close ties to the Swiss AO, other more prominent German colleagues aspired to a more independent status. But, as Schneider emphasised in 1970, independence would not be tolerated if it meant that a group bearing the name AO acted against the AO’s principles and collaborated with companies other than Synthes.89 Despite all these difficulties, on 19 November 1970, 22 leading surgeons and orthopaedic surgeons officially founded a German AO in Frankfurt. The German AO rapidly grew in number and prestige; many general and orthopaedic surgeons applied for membership and, despite a restrictive admission policy, in 1996 the association comprised 100 regular members.90 Even though the AO technique initially encountered as much opposition in West Germany as in Switzerland, eventually the tide turned, and the use of osteosynthesis spread ‘like an epidemic’ throughout the country. 91 The AO evidently played a crucial role in that spread and consequently dominated the market – in 1970 the head of the Straumann branch in Freiburg estimated that Synthes met between two-thirds and three-quarters of the West German demand for osteosynthesis material.92 The pattern of spread of the AO technique there, however, differed from the Swiss model. As described in Chapter 2, in Switzerland the skill and knowledge necessary to master the technique were passed on through a network of autonomous surgeons at small to medium-sized hospitals. In West Germany, by contrast, the AO established itself on the level of academic surgery. Its technique was introduced by the surgeons at the top of the university hierarchy, even when they themselves, like Krauss, chose not to use it. Following a very traditional manner of spreading surgical knowledge, the AO method was transmitted via pupils of certain surgical ‘schools’. Starting in Freiburg, it was taken to Bochum, Mainz and Tübingen when Rehn, Schweikert, Koslowski and Weller obtained leading positions at the

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clinics there. The same process repeated itself when these surgeons educated their pupils in turn.93 This means that in West Germany the AO was able to make use of the academic hierarchy to get established. By contrast to Switzerland, the West German AO never comprised an egalitarian-minded group alongside academic surgery. The Swiss tradition of fraternal egalitarianism did not catch on in the authoritarian surgical world north of the border. Krauss, for instance, was a pupil of Ferdinand Sauerbruch, and, like his famous teacher, he too had the habit of addressing his inferiors by the informal Du as a sign of his authority, while requiring of them that they show their subordinance by using the more formal Herr Professor and Sie94 (as is still customary in today’s German grammar schools). Krauss alone decided on the choice of treatment methods to be used. He was the one who ordered Koslowski to attend the AO meeting in Interlaken in 1960 and who sent Weller to the Davos AO course in the same year. In this respect, Krauss was a typical example of the German university head surgeon. Some of these surgeons started tolerating their younger colleagues’ interest in the AO, or even supported it; but they did not normally take up the AO method themselves, leaving it instead to the next generation to figure out how to bring the AO to Germany. It was also this younger generation of surgeons who struggled for the emancipation of traumatology to make it an autonomous subdiscipline within surgery, thereby adding another specific dimension to the AO’s spread in their country. As opposed to most parts of the world, in the German-speaking countries fractures were traditionally treated not by orthopaedic surgeons but by general surgeons. As discussed in Chapter 1, the new specialised field of traumatology emerged when accident insurance companies in Germany, Austria and Switzerland started supporting the formation of special centres of excellence for the treatment of accident victims within the discipline of general surgery. Lorenz Böhler, with his hospital established by the public Austrian Accident Insurance Company (AUVA), was arguably the most influential, but by no means the only example. In West Germany the insurance companies of the Berufsgenossenschaften, who were responsible for the compensation of work accidents, established eight specialist accident hospitals for their purposes, among them the traditional Bergmannsheil in Bochum. The Berufsgenossenschaften also saw to it that all cases of occupational accidents underwent a regulated procedure of diagnosis and treatment performed by general surgeons who had obtained special training. The more serious cases, such as fractures, were often relegated to these special accident hospitals. So, in West Germany traumatological competence was developed within the community of general surgeons. Parallel to this development, traumatology was also gradually being instituted at the German university hospitals in the 1960s and 1970s, often with a special department and a separate professorship. In Freiburg, for instance, Weller had started to concentrate fracture cases in certain wards


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and thus prepared for its subspecialisation on an informal level. Krauss’ retirement then prompted discussions about the future organisation of the Surgical University Hospital that resulted in the establishment of the first autonomous Department of Traumatology at a German university in 1968. After Weller’s temporary directorship, another AO proponent, Eugen Kuner, headed the unit from 1969 to 1997.95 When Weller was named director of the Tübingen Berufsgenossenschaft hospital, he pursued a different professionalisation strategy. First he shifted the hospital’s focus from rehabilitation to acute fracture care, then he began collaborating with the University of Tübingen, which in 1979 resulted in a full professorship of traumatology for himself as the head of the Berufsgenossenschaft hospital. This arrangement, called the ‘Tübingen model’, was emulated throughout Germany. At the same time, the professionalisation of traumatology at the university hospitals continued. Of particular importance was the establishment of the first completely autonomous trauma clinic at the University of Hannover in 1970. The fact that the directorship and the chair were given to the Austrian AO surgeon Harald Tscherne highlights the crucial role the AO played in the professionalisation process of traumatology in German-speaking countries. The professionalisation of traumatology in West Germany went hand in hand with the rise of the AO and was mostly driven by AO proponents. Before the 1970s, fracture treatment in the larger non-specialised hospitals was in the hands of younger surgeons, who had been delegated to that task by the university hospitals’ head surgeons. Novelties like the AO technique were thus taken up by the younger generation of surgeons, who not only adopted the new technique but also used their newly acquired competence to further their careers in the new subspecialty of traumatology. The simultaneous processes of the spread of the AO technique and the professionalisation of traumatology supported each other, so that adopting the AO system became part of the successful professionalisation strategy of trauma surgeons. This was possible because the AO provided the new subspecialty with a specific technical approach, a special body of knowledge, a systematic education, and a system of quality assurance. Osteosynthesis became, in a way, the emblematic technique of traumatology, and in the late 1960s proficiency in the AO technique was a prerequisite for a career in traumatology. Perhaps most importantly, however, the character of the German AO as a club – which by contrast to Switzerland was located firmly inside the arena of academic surgery – provided the ambitious young trauma surgeons with an organisational basis for coordinating and focusing their efforts. Accordingly, they came to be viewed by other surgeons as the traumatology ‘Mafia’, as Weller remembers. As a symbol of the establishment and growing prestige of the subspecialty, traumatologist and AO surgeon Siegfried Weller received the highest possible honour in German surgery when he was elected president of the German Surgical Society in 1982.96

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Austria In many regards the AO’s situation in Austria was similar to that in West Germany,97 the significant difference being that a single doctor, in the person of Lorenz Böhler (the ‘pope of traumatology’), dominated fracture therapy here more than in any other country. Similar to the German Berufsgenossenschaften, the public Austrian Accident Insurance Company had established a network of special accident units throughout the country. The first Austrian Accident Clinic was opened in Graz in 1919. The second institution of this type, Böhler’s clinic in the Webergasse in Vienna, opened in 1925. Böhler was world famous for having revolutionised fracture care with a highly efficient and demonstrably successful system of conservative treatment, and his systematic way of organising care was later emulated by the AO. This was why the AO surgeons sought contact with their Austrian colleagues early on. In 1958 Maurice Müller travelled to Vienna to present his operative system of fracture care at the two local trauma hospitals (Unfallkrankenhaus – UKH) of the Austrian Accident Insurance Company, Lorenz Böhler’s UKH Wien XX in the Webergasse and the UKH Wien XII in the Meidling district, headed by Otto Russe. But his Austrian colleagues received Müller with much scepticism, expecting nothing extraordinary to come from Switzerland, where traumatology was, they thought, relatively underdeveloped. Despite general scepticism, some young Austrians were interested enough in the new Swiss organisation to attend the first AO courses in the early 1960s. Among them was Lorenz Böhler’s son, Jörg, who had first met Müller and Willenegger at the Freiburg Traumatology Conference in 1960 and had registered for the AO spring meeting in the same year. Exemplifying the fact that the spread of the AO had much to do with the rise of a new generation of fracture experts, Jörg Böhler was one of the first Austrian surgeons to adopt the AO methods in his accident unit, first in Linz, and from 1972 onwards in the newly founded Lorenz Böhler Hospital in Vienna. Austrian surgeons became regulars in Davos. Between 1960 and 1969, 70 Austrians had attended AO courses; by 1982, the number had jumped to 228; and in 1994 the total was 572. The most important connection to Austria, however, came about by way of West Germany. Harald Tscherne, at that time a junior surgeon at the University of Graz, became a devoted AO proponent after he visited Rehn at Bergmannsheil in 1963. Upon his return he gave an enthusiastic report to the Graz University head surgeon, Franz Spath. As it happened, Spath had independently become acquainted with Maurice Müller while on the search for a competent orthopaedic surgeon to treat his youngest daughter’s hip problems. In order to check the surgeon’s skills, Spath decided to spend his summer holidays in 1964 at Müller’s clinic in St Gallen. What he saw there was enough to convince him not only of Müller’s surgical capabilities but also of the usefulness of the AO technique.


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Spath subsequently delegated Tscherne to St Gallen for surveillance of his daughter’s hip operation – and to receive instruction on the AO technique. Having concluded his training period with Müller, Tscherne then attended the AO course in Davos. In 1965 he returned to Graz, where he was given the green light to officially introduce the AO system at the University Clinic. Within the first three and a half years, 957 osteosynthesis operations were performed. The rapid success spurred many of Tscherne’s colleagues to attend St Gallen for instruction. Back in Graz with increased competence, they formed a team using the AO technique systematically and with much success. Their way of establishing its systematic use differed from the Swiss model. As in Germany, the go-ahead to introduce the AO technique came from the head surgeon, who generally was not involved in fracture care but who nonetheless set the course for spreading knowledge of the necessary skills. The actual task of introduction was delegated to younger colleagues, who transmitted the skills hierarchically. Similar to Freiburg in the German context, Graz became the breeding ground of the Austrian AO. But interest in the AO was not restricted to Graz. Individual surgeons such as Jörg Böhler were also starting to use the technique at various clinics and hospitals elsewhere in the country. In Vienna, for instance, Emanuel Trojan of the Trauma Hospital in the district of Meidling had been impressed by Müller’s presentation there in 1958. In 1963 he visited the Swiss AO leader in St Gallen, attended an AO course, and then incorporated the AO system into his repertoire in Vienna. When he moved to the Surgical University Clinic in 1966, he took up the task of introducing the technique there. Despite Böhler’s dominant position, Austria belonged to the AO’s initial area of expansion. The positive development culminated in the founding of an Austrian AO group in 1969 – the first AO subsidiary outside Switzerland. Founded on Spath’s initiative, it was officially established in Graz on the occasion of the tenth anniversary of the Austrian Surgical Society. In September of the following year, 122 surgeons participated in the first Austrian AO course, which had been organised chiefly by the Graz University staff in Bad Gleichenberg, a traditional spa south-east of Graz. This course became a regular and quite popular event, and in 1972 a nurses’ course was also added to the annual programme. As in Germany, the AO’s rise in Austria also helped to professionalise traumatology as an autonomous subspecialty. The introduction of sophisticated and potentially dangerous new fixation techniques requiring a much higher level of mastery than that of an average general surgeon had made specialisation in traumatology necessary. But in the Austrian context the AO’s supporting role was restricted to the university context, while the trauma hospitals of the Austrian Accident Insurance Company were dominated by Böhler’s pupils. This type of surgeon had already done much for the acknowledgement of traumatology by systematically introducing post-operative

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functional treatment. Being masters of conservative fracture care, however, they often remained sceptical towards the AO’s operative approach. It was therefore no coincidence that in Austria the AO technique was first adopted at the university hospitals’ fracture departments, first in Graz, then in Vienna and Innsbruck. The young university surgeons were independent of the old school traumatologists and free to turn to operative treatment methods. Moreover, the AO method was doubly attractive: it not only provided this group of surgeons with an effective means of emancipating themselves from the superiority of the Böhler-style traumatologists, as in Germany, but it also helped them to establish autonomous traumatological units within the academic environment of general surgery clinics. By 1991 Austria had 56 independent accident units or clinics with a total of 4500 beds. Almost all of them were headed by members of the Austrian AO. Thus in the end, the AO came to dominate Austrian traumatology in the same way as in Switzerland or Germany. Nonetheless, it was still possible for a long time to distinguish the specific style of those fracture surgeons who came from the Graz school and who were more radical in adopting the AO principles than the others who maintained more of Böhler’s conservative style of fracture care. In sum, Austria was one of the AO’s first and most important strongholds outside Switzerland whose impact affected the whole German-speaking surgical community. Beyond the German-speaking neighbours Before turning to some of the specific problems in a number of other countries and finally coming to the in-depth analysis of the two examples of East Germany and the US, it will be useful to give an overview of the AO’s worldwide spread. Early interest in the AO was not restricted to the Germanspeaking countries. Very early, in fact, Switzerland’s neighbouring countries to the south became involved, and in February 1966 the numerous Italian surgeons who had attended an AO course by that time officially founded the Club Italiano degli Amici dell’AO. In the same year the club’s leading members edited an Italian version of the AO textbook and began publishing an AO Bulletin.98 French surgeons did not start seriously cooperating with the AO until the 1980s. The Swiss AO surgeons attributed this to the marked individualism prevalent in the French surgical environment. It seemed the French had no sense of the kind of fraternity cultivated by their German-speaking Swiss neighbours.99 In Belgium, however, where a local tradition of osteosynthesis existed, interest was great. In 1963 the Belgian surgeon E. van der Elst characterised the AO surgeons as worthy successors to his countrymen and osteosynthesis pioneers Albin Lambotte and Robert Danis. In 1977 a Belgian section was added to the AO International.100 Personal ties to Britain reach back to the early 1960s when Richard Lindsay Batten, head of the trauma unit at Birmingham Hospital, visited Maurice


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Müller in St Gallen to be instructed in the AO technique. Batten admired the AO system and enthusiastically introduced it in Birmingham. In 1966 he was appointed ‘corresponding’ member of the AO. Through his mediation, several young English surgeons were able to take part in the AO fellowship programme from its beginnings in the late 1960s. Because of the strong local tradition of conservative surgery, however, the AO only gradually became accepted in the UK.101 The Scandinavian countries proved to be a very fertile ground for the AO. Surgeons at the University of Uppsala in Sweden, for instance, introduced the AO technique in 1965 after having read about it in scientific papers. In the early 1970s they themselves were in a position to publish the positive results of their application of the technique in American journals.102 In 1975 a Norwegian section was admitted to the AO International.103 In Spain an Associación Española para el estudio de la Osteosíntesis was founded in 1971, Synthes Hispania was established in 1974, and a Spanish section was admitted to the AO International in 1975.104 Israel came in contact with the AO mainly via American surgeons. Some Jewish Americans, such as Howard Rosen in New York, committed themselves to supporting the AO’s efforts there as well.105 Contact with the Arabian countries started in 1982. 106 The AO branched out to Latin America during the 1970s and 1980s, and in 1976 a Mexican section was admitted to the AO International.107 Though it is not possible to enumerate all connections to the various countries, a measure for assessing this process is the AO course activities outside Switzerland. As the AO was careful not to waste its resources, courses were offered only in countries where demonstrable demand existed. Therefore, the organisation of a course in a particular country reflects the existence of real interest there. In the following table the left column shows the first year of an AO course taking place in the country or countries listed in the right column. It is important to note that these dates serve only to mark the beginning of a regular course programme in the respective countries, with subsequent courses in the same countries not being shown.108 Year

Country

1965 1968 1969 1970 1972 1973 1974 1975 1976 1977

West Germany Yugoslavia Canada Austria, USA Australia, Mexico East Germany, England, Israel, Italy Spain Brazil, Chile, Norway Finland, South Africa, Sweden, Hungary Egypt, Ecuador, Indonesia,

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1978 1979 1980 1981 1982 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994

Curaçao, Denmark, India, Kenya, Uruguay Argentina, New Zealand, Peru, Tunisia, Venezuela Costa Rica, the Netherlands, Nigeria, Portugal Bolivia, Morocco Colombia, Libya Greece, Singapore Pakistan, Saudi Arabia, Turkey South Korea, Oman Japan, Kuwait, Taiwan Cuba, Malaysia Bahrain, China, USSR Iraq, Thailand Cyprus, Iran Romania France Panama, Russia, Slovenia

After 1994, courses were organised in Ireland, Ghana, the Ivory Coast, Bulgaria, Poland, Lebanon, Paraguay, Jordan, Latvia, the Czech Republic, Syria, Uganda, Croatia, the Philippines and Bosnia.109 Despite this development the main instructional event was still the annual course in Davos. It was so popular among surgeons all over that world that by 1982 a total of 13,491 persons had participated, only 1527 of whom were Swiss.110 Other surgeons came for longer periods and joined the fellowship programme. Bringing surgeons from all over the world into the AO core countries of Switzerland, Germany and Austria, and later into other countries as well, the fellowships contributed vastly to the AO’s internationalisation. Like the courses, the fellowship programme grew enormously over the years: while it provided 86 fellowships in its first three years, 1971–73, by 1996 over 3000 fellows had taken part.111 Part of the expansion process also concerned the provision of instruments and implants in other parts of the world, so the establishment of producers’ subsidiaries is an additional measure of the AO’s growth outside Switzerland. After being assigned to their respective sales areas in 1963, Mathys and Straumann started establishing sales offices abroad. Mathys opened subsidiaries in Germany (the northern part) and Austria (1963), Belgium (1964), Italy (1965), Australia (1972), India and South Africa (1978), Singapore (1979), New Zealand (1986), Malaysia and Hong Kong (1989), Russia (1992), Japan (1994), South Korea (1996), Taiwan and France (1997), and most recently the Netherlands and China (1998). In addition to his original factory in Bettlach, Switzerland, Mathys set up production plants in Salzburg, Austria, and in Delhi, India. In 1997 Mathys had 16 branches and worked with more than 50 marketing companies. The firm had more than 1100 employees worldwide, of whom 500 were working outside Switzerland.112 In 1988 the


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Straumann Institute decided to set up a factory in Latin America in order to make Synthes products more readily available to surgeons there.113 At present, Straumann’s successor company Stratec has subsidiaries and distribution offices in Argentina, Bolivia, Brazil, Chile, Colombia, the Czech Republic, Denmark, Ecuador, Finland, Germany (the southern part), Great Britain, Greece, Hungary, Ireland, Mexico, Norway, Paraguay, Peru, Poland, Portugal, Spain, Sweden and Venezuela.114 As will be described in Chapter 9, the sole supplier for the North American market is Synthes USA. In 1984 Robert Mathys estimated Synthes’ market share in Europe as follows: Germany, 80 per cent; Belgium, 70 per cent; France, 50 per cent; Italy, 10 per cent; and Austria, 90 per cent.115 Local and national contingencies During the expansion of their organisation the AO surgeons were confronted with conditions that were quite different from those they had known in their home countries. They discovered that the controlled expansion of their technology depended on a host of cultural, social and political factors, many of which they had not expected. Looking back on their experience in 1983, Willenegger and Bandi stressed that the AO constantly had to adapt its strategy to the conditions prevailing in the different countries and even in different regions within the same country. Such conditions, they noted, included institutional circumstances, such as the policy pursued by university or hospital administrators, as well as individual contingencies, like the attitude of the surgeons they dealt with.116 Usually, local surgeons already had a way of dealing with fractures when they encountered the AO. As mentioned above, Böhler’s successful system of mainly conservative treatment was predominant in Austria. Fracture care in the English-speaking world was similarly dominated by Watson-Jones’ conservative approach. Commonwealth countries like Australia, Malaysia or Singapore were directly influenced by British surgery, whereas in most other countries the British influence was mediated by American surgery – which, however, had also based its conservative approach on the British system.117 On their contact journeys the AO surgeons came to know, and sometimes even to appreciate, locally or nationally prevalent treatment methods. In the Soviet Union, for instance, surgeons were reluctant to adopt the AO’s operative approach because they were quite satisfied with the special external fixator system developed by their Siberian colleague Gavriil A. Ilizarov. Ilizarov’s technique was so popular that commentators spoke of ‘Ilizaromania’,118 and its prestige contributed to the Russian surgeons’ national pride. It was not only in Russia that the Swiss had to be careful not to react insensitively to such feelings when they suggested replacing local treatment methods with something from abroad. This was a critical point in general. Moreover, in their function as messengers of a new technique they had to respect the priority of local practitioners and their specific traditions. Local

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practitioners could be general surgeons, as in Germany, or orthopaedic surgeons, as in North America; but they could also be traditional bone setters and Buddhist monks, as in Thailand. Here the AO surgeons had to come to terms with these folk practitioners. In the end, Suthorn Bavonratanavech has noted, the traditional bone setters developed a rationality that allowed them to refer their difficult cases to the western-style hospitals to be treated with the AO method, while they themselves continued to treat more conventional cases with their own methods.119 In less developed countries of Asia, Africa or South America, the medical infrastructure comprised a special problem. Osteosynthesis depends on very strict asepsis, which can only be guaranteed in operating rooms that are built and equipped appropriately – a condition that cannot be taken for granted even in Europe and North America.120 So it was to be expected that in poorer countries the AO technique could only be made available in particular clinics where access was restricted to a wealthy minority who could afford to pay for proper maintenance. In India, for instance, the AO’s Asian starting point in the 1970s, it was private hospitals that started using the AO method.121 But there was another – political – circumstance preventing the AO system from proceeding as usual: the policy of economic autonomy pursued by the Indian government not only blocked the importation of Coca-Cola, it also made the import of Synthes products impossible. Consequently Mathys started a small production plant in Delhi.122 The importance of the symbiotic relationship of AO and Synthes and its special non-profit character was hard to convey in almost all countries. The fact that Synthes AG Chur received royalties from the sales of the instruments and gave them to the AO caused much suspicion, giving rise to the impression that the AO was simply another money-making ploy.123 Furthermore, the collective nature of the AO group itself was difficult to replicate outside the Swiss cultural context. In the US, for instance, the AO instruments were initially known as ‘Müller’s instruments’, and Japanese surgeons tended to identify the whole organisation with Maurice Müller. Adjustments also had to be made not just in India but elsewhere to allow for differences in the political system. Besides the GDR, which will be discussed in the following chapter, the Soviet Union was another such case. Contacts with the USSR started in 1971 when Willenegger visited the central Soviet institution for traumatology and orthopaedics in Moscow. But despite considerable efforts on the AO’s part, including several invitations to attend the Davos course free of charge, closer connections were not made until the end of the decade, when a Russian delegation came to visit AO institutions in Switzerland. The difficulties were at least partially due to the fact that the Swiss were not familiar with the political restrictions existing in that country. So they did not know that in many instances they had to begin by informing government officials of their interests, meaning that invitations to an AO course abroad had to be given through the foreign ministry and not addressed


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to individual surgeons. Also, the wording of the letters was crucial if they were to be taken seriously. The situation changed with Mikhail Gorbachev’s reforms in the 1980s and the subsequent dissolution of the Soviet Union. The changes in the political and economic system made it much easier to build up relationships with local surgeons. In the 1980s Willenegger visited the country and made new connections; in 1986 an AO symposium took place in Moscow, where in 1989 a first AO course was finally organised. Russian surgeons also came into contact with the AO technique by being offered fellowships in Switzerland, and in 1993 Mathys even opened a subsidiary in the Russian capital.124 The sort of difficulties the AO encountered in the Soviet Union were not political in a narrow sense, but they did have to do with the culture generated by the socialist political system. Cultural differences had a definite impact on the acceptance process in the USSR, but they played an even more important role in East Asia. Japan, for instance, turned out to be an extremely difficult environment for the AO to gain a foothold. On the one hand, there was much interest among Japanese colleagues; such tendencies were encouraged by traditional ties between Japanese and German medicine – there were even pupils of Pauwels in Japan. But the inflexible hierarchical structure of Japanese health care organisation with its ‘feudal’ cultural heritage, made it necessary first to convince the old men at the top before anyone else in the structure could start to use the AO equipment. And they were not easy to convince: many remained overtly hostile to the AO until the 1990s. As a consequence, younger Japanese surgeons who were interested, and who had attended an AO course or had acquired their skill and knowledge as AO fellows, were not allowed to use the technique at home. Such cultural restrictions perplexed the European and American AO surgeons, who often found their Japanese colleagues to be introverted, suspicious and touchy.125 The code of honour in Japan also hindered the AO’s usual procedure of using surgeons from one hospital or clinic, who had already been trained in the AO technique, to transmit the necessary skills by instructing groups of their colleagues from other institutions. This problem affected other East Asian countries as well. In Europe and America the AO had often started by introducing its technique to a very limited circle of surgeons, sometimes within a single hospital, as in Freiburg. In Thailand, however, it was important not to give the impression of supporting only one hospital, as it would have struck the resident surgeons as preferential treatment over other hospitals and thus blocked the adoption of the AO technique. There, as in Japan, the AO also encountered a general unwillingness to appear ignorant before colleagues of other institutions; the situation was exacerbated when it would have meant being taught by a younger colleague from another hospital, which would have been perceived as damaging to one’s honour and authority. So the way to proceed in Thailand was by assembling a group of interested surgeons from various institutions. A special osteosynthesis

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subcommittee was founded within the Thai Orthopaedic Association and charged with organising the AO’s training and visiting activities. 126 For figuring out effective ways of cultural adaptation the AO surgeons depended on allies who were able to inform them of the subtleties of the local medical hierarchy. Such differences in the social order often also account for differences in the way the AO technique was spread. A steep hierarchy was not always as detrimental for the AO as it had been in East Asia. In some countries, such as the US or Britain, it was precisely the relative lack of hierarchy that made it difficult to achieve a greater impact. Here, the large degree of professional independence meant that the AO had to convince all the surgeons on an individual basis, whereas in West Germany it was sufficient to win over the head surgeons.127 This survey of the peculiarities of the AO’s development in various national contexts shows that even though the AO surgeons were actively spreading their technique, the success of their project depended on the local contingencies of social, cultural, political and economic conditions – and on their personal contacts within the countries. Willenegger and Bandi confirm these observations in their retrospective claim that the spread of the AO had not been a predetermined development but was crucially shaped by the spontaneity of personal and scientific contacts.128 But contingency is only part of the explanation of the different levels of success the AO surgeons experienced when they tried to propagate their technique. Judging from the history of osteosynthesis in general, the extent of control that the AO group exerted over the use of its technique and materials seems to have been a crucial factor for the success of the AO technique in different countries. To further assess the significance of control for the spread of the AO technique I will take a closer look at two countries, the US and the former East German socialist state, the German Democratic Republic. In both countries the extent of control varied in comparison with each other as well as with Switzerland. These two countries also differed significantly with regard to the AO’s local success. In the US the AO method was initially rejected, and it took a long time before the AO could gain a foothold in American clinics. This will be the subject of Chapter 9. In the GDR, which I will focus on directly in the next chapter, the AO technique was accepted early on and has sometimes been deemed to have been even more successful than in Switzerland.

8

Optimised Control: The AO’s Success in East Germany

After World War II, two states with competing political systems were established in Germany. In the west the Federal Republic of Germany quickly became integrated into the capitalist world, in the east the German Democratic Republic (GDR) was founded upon a socialist system and became a member of the eastern bloc. Initially, trauma surgeons in East and West Germany had been able to stay in contact. But with the GDR’s increasing dissociation from the West, culminating in the construction of the Berlin Wall in August 1961, the opportunities for professional communication dissolved. Behind the wall the field of traumatology developed separately, thereby creating unique conditions for the reception of the AO technology.1 The organisation of health care in socialist East Germany In the GDR constitution, preservation and restoration of citizens’ health was officially defined as a government task. 2 Health care was organised and funded by the state, most institutions were run by the government, and the majority of health care providers were state employees. Free and equal availability of quality health care services was the basic goal and centralised rational planning the way to reach it. Health care resources were to be allocated methodically and rationally from the top down and, if necessary, against the will of those concerned. The whole health care system was organised in a strict hierarchy: guidelines and directives were issued by the superior political or administrative authorities, who then delegated the task of implementing them to their inferiors. The Minister of Health at the top received his directives directly from the Central Committee of the SED, the East German Communist Party; the employees at the hospitals and clinics were situated at the bottom of the hierarchy. An intermediate level was formed by the different specialist 169

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associations, such as the Surgeons’ Association. The specialist associations were in charge of health care planning and research management. They decided which research topics were to be pursued, assigned them to particular institutions, allocated the necessary funds and subsequently evaluated the research work. They also organised specialist training, selected the doctors to send to conferences abroad, supervised the publishing activities of their members and decided on the appointment of senior health care officials, including head surgeons. The specialist associations served as umbrella organisations for the particular subspecialty divisions (Sektionen), such as the Traumatology Division (Sektion für Traumatologie), and for the work groups (Arbeitsgruppen), which were established as needed to study specific problems. Even though the associations, divisions and work groups did not form the top of the hierarchy, their influence and power was considerable, as is often the case. In practice, supervision from above is necessarily limited, so there is much scope for decision-making in the lower echelons. Introduction of the AO technique in the GDR In the GDR, as in other industrialised countries, fracture care was ascribed an important function because of the growing numbers of accident victims through ‘increasing traffic density, growing industrialisation, and the rise of popular and competitive sports’.3 And, as in other countries, osteosynthesis was recommended as an economically sensible way of treating fractures.4 This treatment method had already been the subject of research in the GDR before the AO came along.5 But until the early 1960s most GDR surgeons did not know that anything like the AO existed. Then in 1964 the foremost representative of East German traumatology, Franz Mörl, was invited to attend the AO course in Davos.6 Mörl, who was in his sixties, passed the invitation on to his younger colleague Eberhard Sander. Sander was then a senior surgeon (Oberarzt) at the university hospital in Halle with a specialisation in traumatology. His post-doctoral Habilitation thesis had dealt with the electrogenetic effect of metal osteosynthesis. In 1960 he had taken over Peter F. Matzen’s position as director of the orthopaedic department in Halle, since Matzen had been appointed chair of orthopaedics at Leipzig. He converted the unit into the GDR’s first traumatology department and regularly worked with Küntscher nails7 and with devices for femoral neck osteosynthesis. His experience in the field thus made him the obvious candidate to attend such a course.8 The journey to Davos was the young surgeon’s first educational trip abroad. He was as much impressed by the teaching methods he experienced at the AO course as by the technique of compression osteosynthesis itself.9 Back home, Sander maintained and reinforced his Swiss contacts. In 1965 he invited Martin Allgöwer to give a talk at the GDR traumatologists’ conference; in 1966 he spent two months with Allgöwer as a visiting fellow in Chur.10

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In 1968 Sander founded a working group for operative fracture treatment. The group comprised 22 members and was part of the Traumatology Division of the GDR Surgeons’ Association.11 On 13 December 1968 the statutes for the Working Group for Operative Fracture Treatment of the GDR were officially adopted, having been modelled on the statutes of other GDR working groups.12 As opposed to the Swiss AO, which was a completely private organisation, the East German working groups were firmly integrated into the official health care hierarchy. According to the 1972 figures, there were 61 specialist associations in existence, these being further subdivided into 124 regional associations and 300 working groups. Starting in the 1960s, the working groups had been established for relevant areas of study. Coincidentally, they bore the same German name, Arbeitsgemeinschaft, as the AO (Arbeitsgemeinschaft für Osteosynthesefragen).13 In analogy to the Swiss AO, the Working Group’s list of tasks encompassed research, instruction, documentation and exchange of experience. But the Group was also assigned responsibilities within the organisation of the GDR health care system: prediction and planning of the development of their field, nationwide management of operative fracture care, promulgation of indication guidelines for methods of fracture treatment and publication of outcome studies. Remarkably, its official assignments explicitly granted it a say in the appointment of surgeons in the relevant departments, and, what is even more noteworthy, put it in charge of the distribution of osteosynthesis equipment. This effectively authorised the Working Group to select which surgeons would be given access to the AO instruments.14 Instruction and documentation The founding of the Working Group was celebrated in Halle in October 1968 on the occasion of the first course on operative fracture care. The course marked the inception of an instruction programme following the example of the Swiss AO. Chaired and organised by Sander, the programme included annual instruction courses for surgeons and nurses and, starting in 1979, scientific symposia. The first course was attended by 25 hand-picked surgeons, but the number would soon increase rapidly as osteosynthesis became more popular. With the AO’s help, the GDR courses were able to reach the technical standards of western countries, very much to the astonishment of the younger GDR surgeons, who were not used to seeing such up-to-date technical facilities. Until 1990, Sander had organised 23 educational events, including ten nurses’ courses. But demand for education always exceeded supply. Red tape and economic constraints made it exceedingly difficult to organise AO courses under the conditions of socialism; Sander had to get the bureaucratic gears turning two years in advance in order to obtain such items as visas for foreign speakers, official permission to import instruction material, and authorities’ approval of the programme leaflets. The general scarcity of resources, including even hotel beds, was a constant source of frustration for the hosts.15

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In accordance with AO principles, the East German surgeons also considered outcome documentation a viable means of exerting control over the use of AO technology. The approach fitted in well with official GDR policy; in the late 1960s and early 1970s, one of the government’s declared aims was the installation of modern information and documentation systems at all health care institutions. Documentation of treatments and their results was part of the official agenda of the East German medical associations.16 As a basic principle, it is fair to say that the paternalistic attitude of the socialist state towards its citizens provided the ideal conditions for systematic registration and documentation of all sorts of activities; and in fact, the GDR did install a number of mass monitoring and registration programmes, such as a complete cancer register and thoroughgoing vaccination campaigns of the type that western health authorities could only dream of.17 The East German AO documentation headquarters was established in Halle and began operating on 1 January 1969. Taking their commitment very seriously, the East German AO surgeons were adamant in denying group membership to anyone not willing to contribute to their documentation project.18 In 1976, the East German AO surgeons were able to present a fouryear study of 4850 documented osteosynthesis operations carried out by 27 hospitals and traumatology departments.19 The excellence of East German AO documentation did not fail to impress foreign visitors like Willenegger, and in 1974 Sander was able to report to the Swiss AO about the East German AO documentation as a ‘smoothly running institution’.20 Scarcity and control: allocation of the instruments Things did not run so smoothly, however, with regard to instrument supply. After his 1964 visit to Davos, Sander made every effort to get a complete set of AO equipment imported, but it proved to be very difficult. The AO instruments were simply too expensive. It took several attempts and the support of influential officials including the president of the Surgeons’ Association to gain permission to buy the AO material. In 1966 Sander’s department in Halle became the first East German institution to be furnished with a complete set of instruments.21 A short time later, Sander went to the Foreign Ministry and proposed the importation of AO equipment on a regular basis. With support from some high-ranking colleagues, Sander’s proposal was successful and in 1967 he was allowed to travel to Switzerland, where he visited Mathys’ headquarters in Bettlach and ordered ten sets of instruments. These were shipped in 1968 to the GDR Foreign Ministry, who passed them on to Sander and gave him a free hand to distribute the material as he saw fit. As Sander later recalled, the low number of available instruments forced him to make a strict selection. In order to secure equal access to health care facilities, as was required by the GDR constitution, Sander attempted a geographically uniform distribution of the AO material. But further consideration was given to the degree of traumatological specialisation at the respective


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institutions. The first to be supplied were the medical schools at universities and academies as well as some larger district hospitals. Slowly, more equipment was bought. Starting with 10 sets in 1968, by 1974 the number had risen to 41; and by 1979, 74 traumatological institutions had been supplied with AO material. In total, 157 complete sets of equipment were delivered to East Germany.22 Regarding the method of distribution, Sander later wrote: ‘Such a procedure would have been unthinkable under free-market conditions! But what else could we do, considering the restricted number [of instruments and implants]?’23 The quality control that was in fact achieved by the selective distribution of instruments was thus a side effect of scarcity rather than the result of a deliberate policy. As Sander acknowledged: ‘What was definitely positive and offered considerable advantages in terms of co-operation was that we had a proper grasp of the situation! And we tried to do the allocation in a sensible way.’24 As proven by similar examples in other fields of medicine, shortage of material makes it much easier to supervise and regulate its use. 25 Sander’s selective allocation policy fit in well with the general concept of health care in the GDR. A 1985 memorandum by the SED is evidence of the state’s conscious effort to concentrate resources within a few centres of expertise. It comprises an appeal to party organisations within the health care institutions to make sure that resources be used in an appropriate way and in accordance with official health care policy, and more specifically, that new technical devices should be provided only if indispensable for high-quality and effective medical care, and only to institutions with the physical and human resources needed to achieve the technology’s full effectiveness within a short time. This meant that speciality equipment would only be entrusted to surgeons who knew how to use it, irrespective of their geographical distribution.26 Recognising the benefit of controlled allocation, the East German AO surgeons worried whenever distribution eluded their control, as was the case with surgeons employed by sport clubs. Typical for socialist countries, competitive athletics had a very high standing in official GDR politics. Their prestige gave the sport clubs access to their own sources of foreign currency. This was a rare privilege that was essential for buying products from abroad. A similar advantage was reserved for some highly industrialised areas such as Bitterfeld or the Berlin region, where the industrial health care institutions had enough foreign currency to buy instruments directly from the manufacturers and so could circumvent central distribution. Sander first learned of these irregular channels for obtaining AO material when these surgeons turned up at the AO courses. According to the East German AO surgeons’ estimate, the rise of complication rates after the introduction of the AO equipment was largely attributable to ‘institutions that had not been equipped officially and completely’ with the AO instruments.27 So even within the East German context, it was not easy in all

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respects to oversee the use of their technology, and any lack of control seemed to have negative effects.28 Despite the general enthusiasm in the new technique, decisions to apply osteosynthesis were made rather restrictively.29 The East German surgeon Mörl warned in his 1968 textbook, as the Swiss AO surgeons had previously warned in their manuals, that surgical incompetence and inadequate equipment in the implementation of osteosynthesis methods would inevitably lead to failure. According to Mörl, surgeons having ample experience in the technical procedure and in decision-making and the institutions providing them with appropriate tools of the highest quality were necessary conditions for success. 30 Similarly, in 1969, another GDR textbook made the liberal application of osteosynthesis treatment contingent upon longstanding surgical experience and the availability of a suitable set of instruments and implants. The AO technology in particular, the author cautioned, required ‘extensive education, much experience, proper judgement, technical skill ... not to mention the material resources for the costly AO instrument sets’.31 Scarcity of materials While the lack of materials in the GDR health care system was beneficial for the AO’s efforts at control, it did hamper progress in other respects. Shortages were prevalent on all levels, including large medical machinery, drugs and even bandages. With the separation from West Germany, the East German territories had lost almost all sources of such medical materials. The fact that this problem was never really solved was a constant source of frustration for health care workers.32 There was also no established means of obtaining the relevant literature or teaching materials. The AOI files are full of requests by East German surgeons for books, catalogues and scientific articles or a certain piece of equipment not available in their country.33 Despite the indirect beneficial effects of scarcity on surgical standards, the spread of AO technology in East Germany was impeded by the lack of equipment. The AO surgeons knew in 1970 that the eastern bloc states generally tended to protect their own production of medical devices by prohibiting the import of AO material as soon as they were able to copy the instruments and implants themselves. 34 But domestic production was difficult, and the quality of the instruments and implants suffered due to the lack of technical know-how and appropriate raw materials.35 So the GDR had to continue importing. In 1972 the Mathys representative for the GDR reported that most of the important East German hospitals were now equipped with AO instruments. Furthermore, the only type of material imported for osteosynthesis purposes was the AO equipment, which meant that the AO possessed a de facto monopoly.36 One must bear in mind that Mathys had only one customer in


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the GDR, namely the state. In March 1974 Mathys signed sales contracts worth SFr2.1 million, thereby effectively excluding American and West German competitors from the East German market. The company had had to make considerable price concessions because, as one representative reported, ‘news about the availability of cheap copies had spread on the other side of the Wall, too’. But the sales volume was such that this was no great loss, and further deals were expected, anyway, in autumn of the same year.37 Surprisingly, however, in 1982 orders for AO material came to a complete halt. What had happened? For decades the GDR had depended on importing certain raw materials, such as crude oil, and goods, including AO implants, without being able to export an equal amount of domestic products. This imbalance had led to a chronic shortage of foreign currency. In the early 1980s the situation had became so precarious that the authorities were forced to implement drastic economy measures. During the early stages of the crisis the GDR had started cutting back its purchases of AO equipment. Then in 1982, after foreign credits from all other countries had run out, the GDR struck a deal with West Germany: in exchange for certain political concessions, West Germany would grant the GDR a loan on goods worth DM1 billion, which was more than US$0.5 billion dollars at the time. The stipulation was that the GDR buy only West German products. As the AO material was Swiss, it was naturally excluded from the deal. In no time, Synthes’ West German competitor Aesculap took advantage of the situation: offering its products at reduced prices, they started to push Synthes out of the East German market. At the same time, the GDR was forced to supplement the imports with domestic production of osteosynthesis equipment. By order of the Ministry, surgeons were obliged to buy specific materials from a factory in Thuringia. In order to quash the surgeons’ desire for AO instruments, the Ministry of Health decreed that Synthes should be excluded from all conference exhibitions. Mathys’ sales director Werner Christinat advised the Swiss AO surgeons to refrain from any harsh reactions to their official rejection. He reminded them that despite the apparently bleak outlook at present, they still had the East German AO surgeons as allies.38 The AOI took Christinat’s advice to maintain links with the GDR, and its patience paid off. As early as the autumn of 1982 Willenegger heard that even the East German authorities in charge of importing regretted the restrictions on osteosynthesis equipment. The inferior quality of the East German products was obvious. When Willenegger attended an AO workshop in Frankfurt on the Oder in 1983, he was not able to demonstrate the principle of axial interfragmentary compression on a model because the implant plates from domestic production were too soft. In October of the same year he stated that even the most fervent Party members wished to return to the AO equipment and keep up professional contacts with the AOI. Sure that these people would support any attempts at resuming importation

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of the AO instruments, Willenegger wrote in his report that a decision on the matter was now in the hands of the highest political authorities.39 Willenegger gave his account a few days after Mathys had again received a considerable order from the GDR. To win back some of the East German market, Mathys had been anxious to offer the lowest prices and the easiest terms of payment possible. At the end of 1984, the upper echelons of the GDR hierarchy had arrived at the conviction that a certain quantity of surgical material should indeed be imported on a regular basis, but only the sort of material the domestic producers could not provide at all or only at inferior quality. With this, Synthes was back in business. In 1985 Willenegger informed Maurice Müller that, thanks to the assistance of the East German AO members, it had been possible to deliver SFr700,000 worth of material.40 This episode shows two things. First, it is evidence of how popular the AO and its technology were among GDR surgeons; this applies equally to the technique and the devices as to the AO’s specific concept of professional cooperation. Second, it proves that it was in fact possible for the East German medical profession, if it was determined enough, to have its claims accepted by the state authorities. Political interference The GDR authorities regarded the high quality and easy accessibility of health care as one of the obvious advantages of socialism over capitalism. This made the health care sector a politically sensitive field and a potential target for political intervention. As such it was a possible arena of confrontation between the medical profession and the state: in fact, doctors and government authorities did not always agree on health care policy or on personnel decisions. However, political interference in health care was not as strong or as persistent as in other areas of society. The degree of political pressure depended very much on local and personal contingencies. Basically, the medical profession had a relatively strong position vis-à-vis state and party authorities; this gave it the power to decide on medical matters according to professional criteria. Even though scientific work was subject to official planning, its quality was evaluated according to internal scientific standards and not in terms of political criteria.41 Thus the East German AO surgeons were largely able to pursue their own policy without much interference from the political authorities.42 Nevertheless, there is an air of conspiracy about the AOI’s GDR files. There are records of private meetings between Willenegger and Sander or other GDR surgeons in which issues were raised that differed from those raised in official exchanges. There is also an unofficial travel report that an East German visitor to Switzerland had written to the AO before returning to his country – back home he had written a different, official travel report for the GDR authorities. It was a well known fact that Sander’s telephone line was tapped and his letters were intercepted. The Swiss AO surgeons knew that the Party


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officials had certain reservations towards Sander, who was not a Party member himself. According to the information gathered by the AOI, a number of appointments to eminent posts in the field of traumatology had been made on the grounds of the candidates’ Party loyalty instead of their professional qualifications.43 All this was unofficial information, often picked up in private meetings under quasi-conspirative conditions. There are specific reasons why the GDR surgeons’ efforts at international cooperation with the AOI caused some irritation among state officials. Socialist ideology essentially presumed that in the capitalist system science was governed by the economic interests of large companies and, accordingly, that scientists in the west were required to subordinate their professional ethics to capitalist profit interests. By contrast, socialist scientists could apply themselves to serving the interests of the people.44 So it is not surprising that a symbiosis of surgery and industry, as represented by the AO, could not easily be established across the boundaries of political and economic systems. The AO had to be aware of political sensibilities, so all contracts were controlled first for ‘capitalistic phrases’ and passages that would compromise the prestige and the sense of independence of the German Democratic Republic.45 Professional isolation To the astonishment of the Swiss surgeons, even the highest ranking representatives of East German surgery could not leave the country without special permission. Travel restrictions were the source of much discontent among doctors in the GDR. There was a specific background to this problem that is contrary to official explanations: when the GDR had closed its western borders in 1961, it was not because of fear of an attack from the west. The true reason was the increasing outflow of people during the gradual implementation of the socialist political and economic system. Even after the borders had been closed, thousands of GDR citizens found a way to cross the border, risking their lives to escape to the prosperous and liberal west. The country suffered under the steady population drain, with several sectors being particularly affected. The GDR health care system was one of them, as thousands of well-trained doctors had fled to West Germany where they could enjoy greater professional freedom and a higher standard of living. Thus it was only logical that the general travel restrictions also applied to doctors who wished to attend conferences or training courses abroad.46 The procedure for sending representatives to foreign conferences was initiated by the medical associations who sent their recommendations to the authorities. Those who got permission to leave the country were assigned to official delegations and were sent as a group to the respective conferences.47 The authorities’ concern that doctors might not return from a visit abroad overshadowed all contacts with foreign colleagues. Willenegger had known about this through his contacts in East Germany, and he was anxious to

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assure the president of the GDR Surgeons Association that the AO would take care to prevent such incidences.48 In response to this promise, a number of GDR surgeons were regularly allowed to go to Switzerland for conferences, courses or fellowships at AO hospitals. Starting in the early 1970s, four to five East Germans usually participated in the Davos courses. By 1987, a total of about one hundred GDR surgeons had attended a course in Davos.49 ‘An extraordinarily fertile soil for the AO principles’: success of the AO technique in the GDR The AO was indeed successful in the GDR. The very name ‘AO’ soon came to stand for excellent quality, Sander wrote in retrospect, and even small district hospitals in the countryside made every effort to be able to work according to the AO principles. Altogether, the AO had an increasingly broad impact on fracture treatment in East Germany, and the favourable operative results achieved by using its technique and technology helped to increase the public recognition of East German surgeons.50 From the late 1960s on, the AO technique had enjoyed an excellent reputation among GDR surgeons, and osteosynthesis was regarded as an enormous step forward in the treatment of bone fractures.51 In his 1968 textbook on traumatology Mörl asserted that after the setbacks and failures of earlier decades, operative fracture treatment had recently experienced a tremendous increase, due primarily to the activities of the AO.52 Demand for AO courses was also enormous: the number of applicants invariably exceeded the number of available spaces in the courses.53 As another sign of success, those surgeons associated with the AO started being appointed to important positions, even if they were not active in the SED. In 1973, for instance, Eberhard Sander was appointed chair of general surgery in Halle.54 East German AO surgeons knew that they fared very well in international comparison,55 but external commentators also found their work outstanding. As the Swiss surgeon and later AOI president Urs Heim declared after a visit to the GDR in 1972, ‘never before have we seen such a precise application [of the technique]; their systematic approach is admirable’.56 In his Annual Report of 1972/73, AO Obmann Robert Schneider stated that the GDR seemed to provide an extraordinarily fertile soil for the realising of AO principles, especially when viewed in contrast to the AO’s difficult situation in the US.57 Hans Willenegger, who was then AOI president, repeatedly stressed the GDR’s high standards of organisation and competence in traumatology.58 In 1990, on the occasion of the planned merger of the East and West German AO divisions, Urs Heim wrote a letter to Sander confirming once again the particularly high quality of work that had been done in the GDR. This, Heim rightly supposed, was due to the scarcity of instruments, which had forced the East German AO surgeons to take particular care in equipping only qualified colleagues with AO materials – this step further strengthened the chances for their correct use.59


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By reason of the shortage of AO equipment, the need for its careful distribution allowed the East German AO surgeons to exert an unparalleled degree of control over the use of the instruments. Therefore the beneficial effects of facilitated control obviously outweighed the negative effects of the socialist system. The scarcity of materials also meant that the number of osteosynthesis operations performed in the GDR was lower than in many other countries, but at the same time the results were better and complications were less frequent, so that the East German AO was able to maintain an excellent reputation. The AO story in East Germany shows that the principle of control was integral for the successful expansion of the AO, a conclusion that will be borne out by a comparison with the complicated process of acceptance experienced in the US.

9

The Long Road to Success: The AO in the US

The initial conditions for a successful spread of the AO technique to the United States seemed to be favourable. From the outset, the AO was in close contact with American surgeons. Irvin Leinbach of Florida became an AO member in 1960;1 Howard Rosen of New York City and Herbert Sandick of Massachusetts attended the first Davos course that December.2 In the same year, Maurice Müller participated in a SICOT (Société Internationale de Chirurgie Orthopédique et de Traumatologie) conference in New York City where he had his own exhibition on compression osteosynthesis in nonunion of fractures.3 In the following years Müller made several journeys to the US to demonstrate his compression plate. As a consequence, groups of surgeons in Memphis, Tennessee, Boston, New York and Los Angeles decided to buy the AO instrument sets and try them out.4 In 1963 the fracture care chapter of the eminent textbook Campbell’s Operative Orthopaedics provided a description and a photograph of the so-called ‘Müller plate’, and in 1965 the Journal of Bone and Joint Surgery (JBJS), the leading American journal in orthopaedic surgery, presented a detailed description of the AO equipment and technique.5 Thus by the mid-1960s quite a few American surgeons had heard of the AO method. If it failed to spread, which is what initially happened, it was not for lack of available information. There are additional reasons why one might have expected the AO technique swiftly to become widespread in the US. From the 1950s to the late 1970s the medical sector of the world’s leading economic nation underwent an unprecedented expansion. Paramount to the expansion of medical care was the growth of medical technology. This included not only the building of new hospitals and clinics but also the introduction of new therapeutic and diagnostic techniques and devices. The general growth of the medical sector facilitated the establishment of specialist and subspecial180

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ist disciplines, such as traumatology and orthopaedic surgery. For the most part, health care provision was obtained through privately run institutions, which meant that the organisation and financing of health care followed market principles. In sum, conditions for technical innovation in medicine were favourable in the US at the time.6 Furthermore, fracture care was considered an important issue. As in other industrialised countries, the ‘modern monstrous disease of trauma’ (a term that testifies to the naturalisation of accidents) aroused the attention of the medical profession as well as the general public of the US. According to statistics from 1970, 11 million people were injured in the US each year, and about 1.3 million were hospitalised with musculoskeletal injuries. In the 1970s such statistics provided good arguments for establishing a number of publicly sponsored trauma centres which combined special competence in patient care with basic research. At the same time, the emphasis of surgical attention shifted away from merely avoiding accidental death to preventing subsequent disability of the survivors.7 All this was very much in accord with the AO’s aims. It is thus surprising to see that the AO technique did not become widespread in the US before the mid-1980s. For an explanation, one must go back to the time before the AO surgeons started to contact their American colleagues. ‘Keep the closed fracture closed’: the rejection of operative fracture treatment in the US Basically the AO’s starting position in the US was the same as in Europe. Like their European colleagues, the leading US surgeons had been reluctant to take up techniques of operative fracture care.8 Even though by the 1940s some American surgeons had in fact adopted European methods of osteosynthesis or even developed their own techniques, operative treatment of fresh fractures remained a controversial issue.9 Until the 1960s the conservative English system was standard, and the popular textbook by the osteosynthesis opponent Reginald Watson-Jones was the bible of fracture treatment.10 According to general opinion, surgical intervention in fractures caused infections and obstructed bone healing.11 Even surgeons who had themselves developed new devices for osteosynthesis, like George W. Bagby, the inventor of the Bagby plate, exercised strict restraint in applying them.12 In 1960 the president of the American Orthopaedic Association, John R. Moore, made a passionate speech against operating on fractures and concluded by saying: ‘Keep the closed fracture closed.’ In his speech he explained that the ‘very satisfactory concept of the closed fracture and its treatment was rudely shattered by the sudden realisation that the trend, since World War II, had been decided toward open reduction’, thereby producing a ‘slow but steady stream of tragedies secondary to open reduction of closed fractures of the long bones ...’ as he had witnessed at his clinic.13 It was thus only logical that textbooks normally advised against the use of osteosynthe-

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sis. The same 1963 edition of Campbell’s Operative Orthopaedics, which mentioned the AO technique for the first time, also cautioned against using internal fixation too frequently and related a widely shared opinion in stating that the ‘early enthusiastic use’ of osteosynthesis ‘for too many fractures’ had ‘reflected discredit upon the method’.14 The reservations about osteosynthesis in general also applied to the AO technique in particular. The AO was seen as advocating an aggressive approach, the abbreviation seen as standing for ‘Always Operate’. 15 The English translation of the first AO textbook under the title Technique of Internal Fixation of Fractures received a friendly but cautious review in the American edition of the JBJS: In the hands of the superb technicians who have developed and repeatedly used this system of ingeniously devised precision implants, remarkable results can be achieved ... However, for the surgeon who by choice or chance does not use this system frequently and who cannot be assured of the technical perfection in reduction and fixation that is required, the technique should be applied with caution.16 Similarly, in the following years a number of American papers identified misapplication of osteosynthesis as one of the main reasons for disastrous complications in fracture treatment in general. These papers concluded that, since only very few surgeons had mastered the technique, operative treatment could not be recommended as standard procedure.17 ‘The dark side of Davos’: criticism of the AO technique in the US The American traumatologists discussed the AO compression plate extensively at their association’s Annual Session in 1966. Even though they valued the AO technique highly in principle, they also underlined the dangers of its widespread use in the US: ‘This form of treatment is invading our country and we have to use it with great care’, one surgeon warned in the discussion, thus emphasising that the AO technique was alien to the American surgical environment. The problem was securing accurate replication of the procedure within the new context. As another surgeon pointed out, if the American surgeons failed to follow ‘the principles of what the originators of the technique really would do and really have described’, the technique would not be successful.18 In 1970 (a time when the AO technique was standard treatment in Europe) a special editorial appeared in the Journal of Trauma on the ‘fad’ of AO osteosynthesis. As a result of the AO group’s ‘almost feverish activity’, the author wrote, ‘the theory of the compression internal fixation of fractures has ... taken on a rather unfortunate widespread popularity ...’. In his view, the high quality of the AO technology made it all the more dangerous. The AO had created

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a serious problem in the development of their technique, due primarily to the excellency of their surgery and the precision of their instruments. They are master surgeons who have spent years in developing their technique. They have perfected a beautiful set of instruments, and use them with great skill. As a result, every young surgeon interested in fracture treatment becomes intrigued with the instruments and wishes to try them out immediately in his own hospital. This, then, is the problem. The beginner can no more hope quickly to emulate the work of these surgeons than a week-end skier can successfully duplicate the efforts of a champion Olympic skier.19 Some of the published papers indicate how American surgeons, lacking a supporting network, learned to apply the AO implants in the correct way only slowly and by trial and error. Only after treating a certain number of patients incorrectly did these surgeons dare to use the AO technique as described in the manual. Because there was no forum to discuss their technical mistakes, some of these surgeons continued to apply more traditional treatments, such as plaster casts, as a supplement to internal fixation, until they had gained enough confidence in the AO method to rely on the implants alone.20 This was very different from the process of adopting the method in Switzerland, where the surgeons worked within a network of surveillance which put them under pressure but also gave them the confidence to apply the technique according to the principles established by Müller. The AO was again attacked at the Chicago Orthopaedic Society meeting in 1976. A paper entitled ‘The Dark Side of Davos’ presented the retrospective assessment of 122 cases of diaphyseal tibia fracture treated during a period of four years. The AO technique had been performed on 36 patients; among these, bone infection had frequently occurred, and 11 per cent had remained permanently disabled. On these grounds, the authors strongly advised against the AO treatment method. And again it was the incorrect application of the technique that had caused the poor outcomes. In many cases the AO’s central tenet of producing rigid fixation that allowed the patient post-operative exercise had been ignored. ‘Contrary to Swiss teaching’, the authors pointed out, the patients treated with the AO technique had spent an average period of 164.5 days with a plaster cast on. And in only 21 of the 36 cases was interfragmentary compression attempted at all. According to the authors, ‘the Swiss system of instrumentation, particularly the aura surrounding the pretapped screws, gives the surgeon a false sense of security in his ability to reduce and rigidly fix complicated fractures’. The AO courses even strengthened this false sense of security: all the serious mistakes described in the paper had been made by surgeons ‘trained in the Swiss technique’, which meant that they had at least attended a course. Accordingly, the paper was not meant as ‘an indictment of the Swiss technique’ per se, the authors wrote, but ‘in certain ways ... as an indictment of the Swiss educational methods’.21

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These critics thus explicitly accused the AO of failing to build up an effective network of instruction, quality control and surveillance. Network-building So, here I am back in New York with the instruments. I’m a young guy. I’m in practice, as you know, only seven years. I have these instruments. They’re so pretty. I sit on the floor. There’s no literature. There’s nobody to talk to. I wouldn’t dare put it in a human being ... .22 This is how Howard Rosen described the peculiar situation in which he found himself after having returned from the first AO course in 1960. It exemplifies what it meant to have the instruments but not the network of support. Remarkably, things turned out well in Rosen’s case, and he came to be one of the most competent American AO surgeons.23 Born in 1927, Rosen was a young orthopaedic surgeon of Jewish background, very much a self-made man, who had struggled for the opportunity to study medicine (which at that time had not been easy due to the quota system limiting the numbers of Jewish students admitted to medical schools) and then set up a practice in New York in 1952. He had heard of the AO technique almost by accident. A colleague and friend of Rosen’s, Herbert Sandick, had an uncle named Paul who suffered from a non-union of the left lower humerus. No one in the US had been able to help him. In September 1960 Maurice Müller came to the SICOT conference in New York to give his presentation on the newly developed AO system: Rosen and Sandick went to show Müller the uncle’s Xray pictures and the Swiss surgeon consented to operate on him in Switzerland. He even predicted that the patient would be playing tennis within four weeks after the operation. Shortly thereafter, the older gentleman went to Switzerland to have Müller operate on him. He came back with an AO plate in his upper arm, and Rosen was charged with the follow-up in the US. The young surgeon was so impressed with the success of the operation that he made the journey to Europe himself in order to attend the Davos course in December 1960. Rosen and his friend Sandick were the only Americans to attend this first AO course. They invested the money to buy full sets of AO instruments, weighing 70 kg, which they transported home in eight boxes. But lacking the AO network, Rosen found himself in the situation quoted above. Like a train without tracks, even the best instruments were useless without the relevant network. Several options were available: one of them was never to use the instruments, like Sandick did; another option was to go ahead and actively join the network, which was what Rosen did. In order to ‘learn what to do with these instruments’, as he put it, he regularly visited Maurice Müller in St Gallen during the next few years. Back home in New York, he started to use the technique on cadavers first before trying it on a living patient. This way he became an excellent AO surgeon. There were a number of other

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American surgeons who also spent extended periods in Switzerland in order to acquire the skills and knowledge necessary for the successful application of the AO technique.24 But many US surgeons had to cope more or less alone in everyday practice once they had returned from the courses. The Swiss AO was well aware that the spread of AO equipment without the simultaneous extension of the AO network of control and surveillance was causing serious problems. In 1973 AO Obmann Robert Schneider criticised the unrestricted sale of their instruments in the US. Contrary to the usual strategy of the AO, the material had been made widely available before a small group of selected and well trained surgeons had established a local culture of controlled and standardised use of the technique. As a consequence, Schneider complained, the AO instruments were often simply added to the existing surgical equipment, which made their systematic application nearly impossible. This undermined the AO’s central principle of standardised use. The resulting failures had so damaged the AO’s reputation, Schneider emphasised, that even those American surgeons who were in principle sympathetic toward the AO had turned against it.25 American surgeons told Hans Willenegger that because of the lack of systematic operative training, young surgeons indeed often performed difficult bone operations such as osteosynthesis completely on their own, with no more preparation than having attended a course and read a book on the operation.26 According to Canadian AO surgeon Marvin Tile, there was ‘very little quality control’ in the US public hospitals where the trauma cases were treated by the ‘junior junior junior surgeons’.27 Adapting the kind of network-building that had worked so well in central Europe to the American context therefore proved to be very difficult. Robert Schneider suggested replicating the Swiss success by building a small, closely knit and easily controllable group of surgeons. This group would then function as a catalyst by handing down the technique to increasingly greater numbers of surgeons. But the Swiss AO surgeons did not know how to set up such a group, since they felt incapable of assessing the American situation; the sheer size of the country made it difficult to gain a comprehensive view, and they did not know who among the American surgeons was trustworthy and strong enough to represent the AO’s interests. Müller doubted whether the approach that had been successful in Switzerland could be transferred to the US. The country was ‘slightly larger than Switzerland’, he quipped at a 1970 TK meeting, and in the large urban centres the impact of a small course to start the sort of expansion Schneider had proposed would be zero. 28 Nonetheless, the AO made several attempts in the 1970s to build up a network in the US. In late 1970, the distributor for Synthes products in the USA, Smith Kline & French, drew up a list of possible candidates for establishing an American AO branch. In 1971, Allgöwer expected that an AO group composed of top American surgeons would be created once the AOI statutes were installed, and two years later he cautioned that the projected American AO

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must not consist of unknown outsiders. In 1977, the AO was still planning the establishment of its American branch scheduled to take place in the following year.29 There were specific reasons why an American AOI section could not be instituted. These had to do with differences in mentality. The American surgeons insisted on their freedom to disregard instructions from Switzerland. Even straightforward American AO supporters were very reluctant to subject themselves to surveillance by their Swiss colleagues, which in turn aroused the suspicion of the Swiss surgeons, who were not familiar with such an attitude.30 One of the reasons for this reluctance may lie in the fact that the American surgeons were less familiar with the kind of fraternity culture that had made it relatively easy for the Swiss to subject themselves to group surveillance. The American AO surgeons considered the Swiss AO dogmatic and domineering. They especially resented the Swiss stance of making the assignment of funds contingent on their controllability. In their view, a formal constitution and an official agreement with the Swiss AO would have been too rigid. They would rather continue their activities in ‘a loose system of teaching’, believing that the ‘common goal of teaching and loving AO’ was all that was necessary to keep them together. This attitude made them resist the Swiss attempts at establishing a ‘close-knit group’ after the Swiss example with strong ties to the Swiss headquarters.31 Synthes USA Meanwhile, the business part of the network had also been extended to North America. The AO surgeons considered marketing to be particularly difficult in the US because of the strong competition.32 For the distribution and marketing of their products in the US, the AO initially collaborated with the well established drug company Smith, Kline & French (SKF). The company, which had a small department for other medical products such as instruments, had made an excellent impression on the AO surgeons.33 In 1968 the AO had to abandon its name and logo in the US as a result of legal action instituted by American Optical. As it turned out, this company had already adopted the abbreviation ‘AO’ for its market and was unwilling to share it with the Swiss company. Therefore, the AO changed its abbreviation for the American market to ASIF (Association for the Study of Internal Fixation).34 In 1968 SKF transferred the sale of AO instruments to their subsidiary firm Surel Inc. in Philadelphia, and transferred again in 1971 to a newly formed division, Smith Kline Surgical Specialities. 35 In the early 1970s the AO surgeons were becoming increasingly worried about their cooperation with SKF. They resented their dependence on an American pharmaceutical firm and contemplated building up their own distributing company. In 1974 they ended their partnership with SKF and launched their own sales organisation for the American market under the name Synthes Ltd, subsequently called Synthes USA, in Wayne, Pennsylvania.36

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Originally, North America belonged to Straumann’s sales area, but he was having difficulty supplying the market. Even though the slow acceptance of the AO technique entailed a relatively low demand for AO instruments in the US, those who actually wanted to buy AO equipment could not always get it. This was a significant problem in a country where competition was stronger than in Europe. 37 As early as 1964, SKF had complained about exceedingly long terms of delivery, and in 1966 Müller remarked on the insufficient capacity of the Swiss producers for the American and British markets.38 When, in 1972, Straumann was unable to meet the American demand for the newly developed DCP plate, the need for a new strategy became obvious.39 A problem of another sort was the relative lack of familiarity of the Swiss surgeons with conditions in the US. They were not familiar with the mindset, nor were they initially able to grasp the geographical dimensions of a business market incomparable with those of central Europe. For instance, Joseph Schatzker had to explain to Maurice Müller that North American business representatives needed cars in order to fulfil their duties.40 The situation changed when, in 1977, Hansjörg Wyss entered Synthes USA. Born and raised in Bern, Wyss had a degree in engineering from the Technical University in Zürich (ETH) and graduated from Harvard Business School in 1965. In 1969 he became marketing director of Monsanto’s European textile fibre operation, located in Brussels, which was suffering at the time due to the rise of the Far Eastern textile industry. He became acquainted with Martin Allgöwer in 1974 through their common interest in aviation: Wyss brought over a used airplane Allgöwer had bought in America. Because of difficulties with the American executive staff of the new distribution company, Allgöwer was on the lookout for someone to handle the American AO business. In Wyss he saw the skills he was looking for, and so, not long after their chance encounter, he asked Wyss to become a consultant to the Synthes operation in North America. Wyss became company president and shareholder in June 1977. Assessing the situation, he advised the company’s board that it must do three things: first, build an American manufacturing unit to alleviate the back-order situation and control the cost of goods; second, establish at least one advanced and two basic courses annually in North America with the provision of adequate European faculty; and third, rapidly expand the sales organisation to cover the huge geographical area of the American market.41 Soon the Swiss AO surgeons were hearing that the ‘new AO program of instrument marketing and the dropping of Smith, Kline & French’ was welcomed by the American surgeons, who highly appreciated the improvement in service and availability of the AO equipment.42 Willenegger noted in 1975 that the establishment of a separate sales organisation for the country was very beneficial for the AO’s image there and helped him to free the AO from the odium of commercialism.43

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However, the problem of insufficient supply had not yet been solved. In September 1977, Wyss judged the situation to be disastrous. Demand was much higher than expected, and Synthes USA did not have a single complete set of equipment left. As Wyss later wrote to Willenegger, it took a lot of effort to regain the customers that they lost due to the difficulties in supplying the materials.44 In 1979 Wyss carried out his plan to start production for the North American market. He built a new plant in Monument, Colorado, where conditions were favourable (agreeable climate, no labour unions, tax-free loans), the first business in a new industrial park on a street that was named Synthes Avenue. Having his own production facilities, Wyss was able to keep more of the sales profits, which he could then reinvest.45 Distrust: the AO as part of the ‘medical-industrial complex’ The business side of the AO network caused specific problems for the AO’s acceptance in the US. In sharp contrast to its own self-image, the AO was often viewed in the US as a sales organisation that propagated the indiscriminate use of its instruments. The AO surgeons were suspected of using the whole system for financial gain, and their osteosynthesis plate was disparagingly referred to as the ‘money-maker plate’.46 The Americans found it hard to believe that the Swiss AO surgeons did not profit financially from the sales of their instruments. It therefore became the AO’s foremost mission in the US to refute the accusation of being commercialist. In order to gain trust and credibility for the AO as a non-profit professional organisation, Hans Willenegger made extensive journeys to the US in the mid- and late 1970s.47 For his missions, Willenegger insisted on getting in touch with his US colleagues personally, ‘directly from doctor to doctor’ and keeping the Synthes company in the background.48 In the letters he wrote in advance to introduce himself to the surgeons, Willenegger asked his American colleagues not to ‘misunderstand’ the fact that a Synthes representative had suggested his visit to their clinic, since, as he wrote, ‘our AO/ASIF organisation is characterised by a close co-operation between orthopaedic and general surgeons and our producers’. Under these conditions, however, his visit should not be interpreted as an attempt to propagate operative fracture treatment per se.49 Willenegger usually presented the AO as ‘a medical organisation which has primarily nothing to do with business’. As opposed to its competitors, who were copying the AO’s instruments and implants and were exclusively interested in business, the AO needed business only to finance its activities in research and teaching, he explained. 50 Willenegger’s ‘enlightenment campaigns’ were deemed to have been successful in replacing the AO’s image as a ‘business affair’ with the more appropriate image of a ‘self-supporting organisation’.51 But even in the 1980s, the AO was often held to be a business company in the US, and the AO surgeons still felt they had to clear up this misunderstanding.52

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The patient–doctor relationship Some of the factors that slowed the AO’s spread in the US can be attributed to the patient clientele and their specific relationship with their doctors. The AO surgeons believed that American patients in general had lower expectations as to the functional results of fracture treatment than their European counterparts. Americans, they thought, were normally content with the outcomes that could be achieved by conservative means.53 Another influencing factor was the range of trauma types in the US, which was quite different from Switzerland, where clean and easily mended skiing fractures were common. By contrast, many US hospitals had a high rate of gunshot wounds, which were difficult to operate on, especially as the victims were often brought to the hospital 12–36 hours after the injury had occurred.54 In particular, those clinics responsible for health care provision in poor urban areas simply did not have the time and staff necessary for operative fracture care. According to Willenegger, the Los Angeles County Hospital, run by Augusto Sarmiento, had 20–30 cases of lower leg fractures per week, and it was utterly impossible to treat them all by operating. These patients did not demand anatomical and functional perfection anyway, Willenegger was told, and they were often uneducated or unwilling to cooperate in post-operative treatment.55 Lack of compliance on the part of American patients was generally one of the reasons given to explain the difficulty in transferring the AO technique to America.56 The effect of these patient-related factors was aggravated by the specific legal situation found in the US. Surgeons were alarmed by the legal consequences expected in cases of post-operative complications. The reason, as sociologists have noted, was the loss of legitimacy and credibility of the medical profession in American society at that time. According to Paul Starr, from the 1970s onward it was generally believed that ‘patients needed protection, especially in relation to medical research and the use of experimental techniques’.57 From the perspective of the surgeons, the US had developed into a litigious society in which new ideas were difficult to apply.58 The first US surgeons to use the AO method had taken a huge risk, and, as could be expected within the context of their actions, the fear of malpractice suits was a common subject in the conversations between American surgeons and their Swiss AO colleagues. Consequently, for many American surgeons, the potential anatomical and functional deficiencies resulting from non-operative treatment paled to insignificance beside the risk of being sued for post-operative complications.59 This problem, however, was only relevant as long as the AO technique was considered new and unusual. As soon as it was generally accepted as a standard method, its application involved no special legal risk for the surgeons. On the contrary, they could be accused of negligence if they failed to apply a technique considered to be the ‘community standard’.60

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The growing popularity of the AO in the US: ‘the dominoes begin to fall’ By the 1980s, the AO technique had become popular in the US, but the process of acceptance had, of course, started earlier. The AO and its technique had become the target of so much criticism in the 1960s and 1970s because of its obvious attractiveness and gradually increasing popularity among American surgeons. Many of the early users of the AO technique had built a reputation upon the feats they could accomplish with the new equipment. Just returned from his training period in Switzerland, Joseph Schatzker asked his Toronto colleagues to send him all the non-union cases they could not handle. His unusually high healing rates subsequently earned him much admiration. Similarly, Howard Rosen came to be known as ‘this young guy with this magic plate’ and was invited to treat difficult non-union cases all over New York, New Jersey and Connecticut. 61 And though American surgeons often warned of a more widespread application of the AO technique because it required so much surgical skill, they did not fail to report their own successful use of it.62 There were some signs of a more general early interest. In 1965, the SKF representative in charge of AO product distribution told the TK that American surgeons were basically wary of any innovations, an attitude that made it very difficult to sell novel instruments on the American market. But, he continued, the AO technique had aroused some interest among young surgeons; 3000 of them had reacted to an advertisement in the JBJS and were subsequently supplied with SKF catalogues.63 One of the AO’s main assets for winning the respect of its American colleagues was the high quality of its equipment (which, to a certain extent, however, was vitiated by the fact that the AO instruments were two to three times more expensive than competing products64). Critics and supporters alike praised the ‘fine engineering of the instruments, the rigidity of the plates, the firm seating of the screws, and the intimate approximation of fragments after compression’.65 This impression was enhanced by the positive image of Swiss precision work, which the AO could easily use to its advantage, especially since Americans often referred to the AO technique as the ‘Swiss’ method.66 Like their European colleagues, American surgeons were impressed by the AO’s systematic approach, encompassing the technical and biological basis as well as the technique, post-operative care and outcome documentation. Before that time, ‘everybody had picked out individual fractures and operated on them’ – the AO had ‘the first complete view of the problem of fractures in a holistic way’, recalled James Hughes, one of the early American followers of the AO.67 The 1971 edition of Campbell’s Operative Orthopaedics declared that the use of plates and screws in fractures of the long bone shaft had become commonplace.68 And even though, according to Maurice Müller’s estimate, the JBJS was normally not very sympathetic to the AO,69 in 1972 the journal gave the Davos group the opportunity to present its laboratory evidence for

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primary bone healing70 and published a number of favourable clinical studies on the AO technique.71 Most reports also now stressed that the newly developed AO system was superior to any of the older methods of osteosynthesis. Before, the Swiss AO leaders had always seen it as a major problem that general opinion in the US did not differentiate between the AO technique and other, less useful methods of osteosynthesis.72 Another reason for satisfaction was that studies now distinguished between the technique as such and the quality of its application by the individual surgeon in their assessments, so that the failures that still occurred were attributable to the incompetence of the surgeons instead of the imperfection of the technique. The general thrust of the argument was that if surgeons attempted osteosynthesis, they should use the best available materials and technique – the AO’s – and apply it in the appropriate way, that is, by following the AO’s instructions.73 One factor that enabled controlled spread was the establishment of an American course programme. In the early years, American surgeons went to Davos to learn how to use the instruments. From 1960 to 1975, 1116 Americans attended the Davos courses.74 Strangely enough, the first regular AO instruction courses in the US were offered by veterinarians. It began when the veterinary surgeons Jacques Jenny and Bruce Hohn had decided to treat animals with the AO technique. Hohn had contacted Howard Rosen after having seen his poster exhibition and persuaded him to share his technical knowledge so that he could apply the AO system to dogs and horses. In 1969, Hohn moved to the Ohio State University’s School of Veterinary Medicine, where he organised annual AO courses for veterinary surgeons from 1970 onwards. Howard Rosen, who continued to support Hohn, later became a full professor in the Ohio State University Veterinary section, a founder of the Veterinary Orthopaedics Society and an honorary fellow of the American College of Veterinary Surgeons (all the while continuing with his work on human patients at a New York clinic). 75 Subsequently the veterinarians convinced the orthopaedic surgeon at Ohio State University to support a human section for the course so that for the next three years the veterinary courses at the university had ‘human sections’ in addition to their sections for dogs and horses – ‘humine, equine and canine’, as Rosen jovially put it.76 Further attempts at installing a course programme in the US were made simultaneously in other cities. From the mid-1970s onward, AO courses in North America were held on a regular basis.77 Particularly after 1978, the American AO manufacturer Synthes USA made every effort to establish training programmes, including courses, workshops, fellowships and permanent training facilities in some cities. By 1983, a sufficient number of US surgeons had acquired enough training to serve as course instructors, so that the Americans could become independent of the European faculty. By that time, American surgeons had come to hold such a high opinion of the

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AO courses that they made them a requirement for many of their resident surgeons’ training programmes.78 Even more important than the courses was the AO’s fellowship programme. It had allowed a number of American surgeons to spend extended periods of time in Switzerland and learn the technique directly from the Swiss AO surgeons. Back home in the US they could then pass on their skills to their colleagues, thus initiating local cultures of using the AO technique in a controlled way. Finally they were able to start their own North American fellowship programme. Therefore, by around 1980 the earlier efforts of AO surgeons had finally paid off and, as James Hughes describes it in retrospect, ‘the dominoes began to fall and everybody lined up in a proper way’.79 In 1979 an entire issue of the US journal Clinical Orthopaedics and Related Research was devoted to the AO technique, marking a milestone in that country’s reception of the AO. This not only provided the Swiss AO surgeons and their American proponents with a forum in which to present the AO’s aims and principles in detail, but it also gave them the opportunity to reiterate their warning against incorrect application of their technique.80 The 1980 edition of Campbell’s Operative Orthopaedics presented the AO’s principles definitively as state of the art.81 A similar stance was taken in a number of American papers published in the early 1980s. This included the adoption of the AO’s view that only properly executed osteosynthesis operations should be taken as the basis for evaluating the method, and the conscious effort to follow the AO’s instructions to the letter.82 The use of the AO technique by the US army is additional evidence of its status as a standard treatment.83 A visiting AO surgeon from Germany reported in 1980 that the younger generation of surgeons now used the AO technique with a high level of sophistication.84 According to a 1982 report, the initial debates ‘by rabid proponents and opponents of the method’ were now seen as largely irrational.85 AO surgeons who went to the US now saw a vivid interest in the AO, its techniques and its ‘philosophy’.86 In 1983 Wyss told the Swiss AO surgeons that osteosynthesis operations were now being performed frequently in the US. While many specialist groups and university departments were still sceptical about osteosynthesis, an appreciable shift in opinion had occurred during the previous five years. As Wyss put it, doctors were ‘hungry’ to learn good techniques and keen to attend courses, and many of the conservative head surgeons were either retiring or renouncing their unfavourable judgements.87 By the late 1990s the AO system was the undisputed ‘standard of care for fractures’ in the US.88 This development was reflected in Synthes USA’s business situation. In the Annual Report of the AO group of 1980, business in the US was still described as highly unsatisfactory. In 1984 a rapid increase in sales was noted by Wyss, and when the new company headquarters were inaugurated in 1986, Allgöwer called Synthes USA the leading US company in the field of surgical trauma.89

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Meanwhile, Wyss had bought the shares back from the original shareholders.90 By the late 1990s, more than 50 per cent of the total royalties paid to Synthes AG Chur were coming from North America.91 In the 1980s and 1990s, Synthes USA, initially by far the smallest of the Synthes producers, grew rapidly to exceed the two other producers combined.92 In 1992 the AO North America (AONA) was established as the first of a number of regional AO associations, which meant a change in the AO’s previous more centralist policy. The relative independence can be seen by the fact that the AONA organises and coordinates education but also has its own research funding and fellowship programmes.93 A comparative perspective The AO had finally managed to convince the majority of American surgeons of their system. In the 1980s and 1990s an increasing number of surgeons had gained sufficient competence in using the AO technique and helped to circulate it among their colleagues. While in other countries the AO had been able to build up a network for the controlled transmission of skill and knowledge very rapidly, under the specific cultural and economic conditions of the US it took more than two decades. Both the US and the GDR seemed to offer favourable initial conditions for introducing the AO technique. On a general level, the rising number of accident victims in both countries provided good reason for demanding highquality fracture care.94 Similarly, there was little difference in the AO’s ability to contact young, innovative surgeons early on, thus affording the Swiss surgeons the opportunity to win over a new generation of colleagues. However, despite these similarities AO surgeons met very different challenges in the US and the GDR when promoting their technique. In the GDR, against considerable economic obstacles, the AO method was rapidly introduced, though in limited quantities, and was applied very successfully. Against the background of the East German state pursuing a policy of tight, centralised control of the health care system, the East German AO section was part of the official health care administration and as such was endowed with the means to oversee the application of the AO technique by individual surgeons. Paradoxically, scarcity further facilitated control. Since the AO equipment was very expensive, the economic conditions of state socialism restricted access to it. The instruments were not freely available, but were bought and distributed by central agencies. Effectively one surgeon was in charge of the distribution of almost all the AO equipment in the country. He was able to select those colleagues he knew would make good use of the material and who were prepared to undergo prior intensive training. The socialist system did, however, pose a number of problems to the extension of the AO network: travelling was quite restricted, foreign books and journals were hardly available, and the rationale of communist politics often threatened to prevail over the rationality of surgery, for instance when

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important positions within the health care system were assigned according to political loyalty instead of expert competence. But in the end the beneficial effects of scarcity and the central concentration of power apparently outweighed the negative effects of the communist system. The opposite was the case in the US, where the AO equipment was freely available but used by surgeons who were not familiar with the technique. The application of the AO system of osteosynthesis by incompetent surgeons led to poor results in bone healing and a high rate of complications. As a consequence, osteosynthesis in general, and the AO technology in particular, acquired a bad reputation and was largely rejected by the scientific authorities in the field. The critical point was that in the US context it was very difficult for the AO to oversee the application of its technology. As opposed to their European colleagues, US surgeons were not willing to subject themselves voluntarily to surveillance. Even those American surgeons who did become foreign members of the AO did not tolerate the attempts of the Swiss AO surgeons to monitor their use of the technique. While in Switzerland and East Germany control and surveillance concerned the surgeons’ skills at an early stage in the process of promoting the technique, in the American context it was only the treatment results that were subjected to critical scrutiny. For osteosynthesis, control at such a late stage of expansion proved to be impracticable and an obstacle for its more generalised use. Comparative examination thus underlines the general thesis that control of the materials and aptitude in their application was the key to the successful introduction of osteosynthesis by the AO, as opposed to previous less successful efforts. The AO introduced a new measure of control in different respects and on a number of different levels, and this was the crucial factor for the AO’s success in general. Comparison draws attention to the importance of power and control for understanding why certain innovations spread successfully in certain contexts or not. This is not to say that all modern science and medicine depends on control as much as bone surgery. Nor does it mean that control is always the crucial factor for success. The GDR was obviously not the world’s leading nation in science and medicine in general, nor was the US a country in which medical techniques generally failed. But the paradoxical case of a modern, highly sophisticated technique that worked well in a relatively poor socialist country but failed to work in the world’s wealthiest and scientifically most advanced nation directs attention to the more general fact that even such an apparently mechanical and culture-independent technique as osteosynthesis is highly culture-sensitive. In the three countries examined here, the very same technique fared very differently. In Switzerland the cultural pattern of fraternity provided the opportunity for its controlled application, thus keeping the numbers of failures relatively low. In the GDR, the policy of tight centralised state control over health care providers accomplished the same objective with even more efficiency. By contrast, the free market conditions

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of the American health care system made control, and thus consistent success, extremely difficult. As comparative studies can show, the successful introduction of any medical technology depends utterly on the cultural, political and economic environment in which it is being performed. But it is not clear in advance which of the environmental factors are beneficial or detrimental for a particular technique to succeed.

10

Redefining Osteosynthesis: Another Revolution in Fracture Care

It seems that we would benefit from starting again from where we are now with the enthusiasm of four decades ago, but based on new insight and understanding.1 As evident from this statement made by the surgeon and scientist Stephan Perren in 1999, more than 40 years after the AO had revolutionised fracture treatment, another revolution in fracture care was underway. In this chapter I describe the modifications the AO philosophy and technology underwent once it had been accepted on a larger scale. I also look at the problems these changes entailed with regard to the adaptation of the large and sophisticated network of research, marketing and user instruction the AO had built up. The reason for these problems lay in the thoroughgoing success of the AO’s first revolution fracture care, which had made its original technique the dominant standard treatment, even in the US.2 By the late 1970s, osteosynthesis was widely perceived as ‘safe, scientific, and predictable ... based on a firm foundation of biomechanical and clinical data’.3 This remained so for the rest of the century. But the osteosynthesis technique of the 1970s was not the same technique the AO endorsed in the year 2000. In certain respects, theory and practice of the field had been completely overturned. The AO participated in these changes mostly in an active manner, but sometimes in a more reactive mode. In any case, the association emerged from all these changes as the undisputed leader of the field, both intellectually and commercially. Revision of the AO philosophy The presuppositions and tenets that made up the AO philosophy were first modified in the 1960s when the AO surgeons started to use more precise biomechanical terms for describing the various effects of plates and screws. In 196

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its 1969 Manual the AO group no longer dwelled on the plates’ compressive function. Static compression of simple transverse fractures, it stated, was only one possible effect of using its compression plate. As the most common function they named neutralisation. A plate intended for neutralisation transmits all torsional and bending forces from the proximal to the distal fragments and thus prevents these forces from acting on the fracture surfaces. Under certain conditions another similar support function was intended: buttressing. But the AO plate could also be used in a more dynamic way, now described in terms of the so-called ‘tension band principle’ first developed by Friedrich Pauwels. According to this principle, a plate which is applied to the side of the bone that is subjected to tension forces transforms these forces into pressure. The pressure in turn contributes to the fracture site’s stability, an effect that is enhanced by increasing the tension through loading of the bone structure.4

Figure 18

Tension band principle as visualised in the AO Manual of 1969.

However, the first major challenge to the AO philosophy came with the observation that the sections of cortical bone covered by the plate become thinner and tend to break after the routine removal of the implant. Concerned about what this would mean for their treatment principles,5 AO surgeons and scientists studied the phenomenon to find its origins. Soon, the main line of argument concentrated on a concept called ‘stress protection’. On the grounds of the ‘use it or lose it’ principle embodied in Wolff’s law, surgeons thought that the metal plate protected the living bone

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from the stress it needed as a stimulant for normal growth. In proportion to the degree of relief, the ‘idle bone’, as Allgöwer called it, thus lost substance.6 The discussion on the subject was seen as heralding a new, more biologically oriented phase in the development of the AO philosophy.7 Stress protection became a much discussed topic in the 1970s, within and outside the AO.8 The new concept influenced surgeon’s ideas about rigid fixation. While stress at the fracture site had previously been regarded as an impediment of the healing process, its role now seemed more ambiguous: ‘There is a balance in fracture healing between induction of bone formation by motions ... on the one hand, and motion-related strain conditions that prevent the differentiation of connective tissues into bone, on the other hand’,9 AO scientists Rahn and Perren stated. But it was by no means clear which technique could be used to solve this quandary.10 Even more detailed descriptions of the phenomenon did not lead to a solution11 until Perren proposed an alternative explanation. Considering all known facts, he had come to the conviction that even though stress protection and osteoporosis occurred simultaneously, the one was not the cause of the other. Rather, the observed weakening of plated bone was caused by a disturbance in the local blood supply beneath the plate.12 With the help of new labelling techniques for investigating blood flow and bone formation, researchers found that the pattern of the remodelling processes beneath the plates seemed to mirror vascular changes rather than the effect of stress relief.13 The new emphasis on blood supply was part of a more general shift of focus in fracture treatment from mechanics to biology. Historically, the interest in biology can be seen as the start of the last phase of a three-step development in modern fracture treatment: During the first, conservative phase, doctors aimed above all at repositioning and stabilising the fragments using non-operative means such as plaster casts and traction. The second, mechanical phase was characterised by enforcing anatomically exact reposition using operative means and rigid fixation with metal implants. This was followed by a third phase, in which interest was focused on the biological aspects of bone healing.14 Disregard of biology in favour of mechanics was one of the traditional arguments brought forward against the use of osteosynthesis.15 While the AO still concentrated on mechanical rigidity, other investigators had already started to emphasise the importance of biological factors.16 Only in the 1970s did the AO surgeons gradually integrate this type of consideration into their original philosophy. It was a sign of such influence that in 1971 Willenegger and other AO members characterised bone healing as ‘biophysically induced reaction of the living bone’, the success of which depended not only on physical forces but also on sufficient blood supply.17 Such thoughts were not completely alien to the group. Some AO members, among them Allgöwer, had always put special emphasis on these aspects.


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Being a general surgeon, famous for the atraumatic skin suture technique that bears his name, he stressed that the diligent closure of skin is as important for a successful osteosynthesis operation as the stabilisation of the bone.18 With his interest in soft tissue, Allgöwer was in tune with the general opinion of the time. Textbook chapters and articles on osteosynthesis show how, in the course of the 1970s, soft tissue injuries were taken more seriously in the treatment and prognosis of bone fractures.19 In a 1975 American textbook, fracture was even defined as ‘a soft tissue injury complicated by a break in the bone’, which meant that ‘the most important single factor in the management of fractures is the treatment of the overlying soft tissues’.20 In this context the procedure of compression osteosynthesis was increasingly viewed as unnatural and its aim of primary bone healing as questionable – first outside the AO,21 but then also within the group. In 1971 AO surgeons warned against trying to enforce callus-free healing.22 At an AO meeting in 1973 Perren formulated his, as he called them, ‘heretical’ ideas about primary bone healing, stating that it made no difference for the surgeon how a fractured bone heals as long as it becomes solid, with or without callus.23 With this the AO surgeon was not too far off from the line of argument the AO’s critics had always pursued. Primary bone healing finally lost its special status within the AO philosophy.24 The terms used for redescribing the phenomenon even resembled those of AO opponents 30 years before: ‘Whenever bone fractures occur, the bone ends become necrotic’, Joseph Schatzker stated in 1995, and he explained that ‘when these necrotic bone ends are brought under interfragmental compression and conditions of absolute stability ... the bone does not recognise that it is broken, and therefore all the events which we associate with bone healing, such as the appearance of callus and resorption, are absent’. Instead, the Haversian system continued its normal remodelling processes, though at an accelerated rate due to the presence of necrotic bone. Thus, as Schatzker concludes, ‘the phenomenon described as “primary bone healing” would be more correctly regarded not as healing but as the accelerated Haversian remodelling of dead cortex’.25 The changes in theory were accompanied by changes in practice. With the re-evaluation of primary bone healing, it became easy for critics to denounce the use of compression plates: No one believed any longer that ‘patients whose tibias were plated were able to return to athletic activities sooner than their counterparts’ treated with conservative methods, an article stated in 1998, and ‘plated tibias require longer periods of time for sufficient healing to take place and permit strenuous activities’.26 Instead of plating, other techniques such as intramedullary nailing gained in popularity. Below I sketch out some of the technological changes that went hand in hand with these conceptual transformations.

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‘More intelligent and better osteosyntheses’: technological change In 1969 Schneider formulated his response to the described changes by calling for a reorientation to achieve ‘more intelligent and better osteosyntheses’.27 In fact, the AO’s techniques and materials underwent certain modifications over the years.28 One such early change in the use of AO technology affected double plating, that is the application of two plates to treat one fracture. This procedure was abandoned in the early 1960s because it had led to a higher rate of refractures.29 Besides such modifications of procedure, new hardware was also developed.30 The potential for innovation in that regard was built into the AO’s structure, with the surgeons taking part in improving techniques and devices and the TK functioning as a control authority. AO members actively participated in the design of new implants, which were then presented to the TK and the other AO members to be discussed and tested.31 In this way a gap in the range of available AO products was closed by developing small fragment instruments and implants. They were needed for fixing small fragments of larger bones, but also for treating fractures of the hands and feet. In 1972 two AO small fragment sets were made generally available, and a manual for their use was published.32 According to Allgöwer, the AO’s system of constant innovation worked so well that by 1978 numerous developments had come from systematic tests of various implants on dead bone as well as on living bone in experimental osteotomies in the rabbit, the rat, the dog and the sheep. What had started as a basic set of instruments and implants of about 200 items, is today an armentarium of some 1,400 items.33 The most significant addition to the AO equipment at that time was the Dynamic Compression Plate (DCP). DCP Designed during the early 1960s by Stephan Perren and first introduced at the end of the decade, the DCP was to become in many ways the heart of the AO system for internal fixation. The AO surgeons had noticed that their round hole plate was susceptible to undergoing corrosion in the patient’s body. They found that even very small deviations in the screws’ position in their holes when they were applied to the bone led to circumscribed zones of increased contact and possible attrition. These were the places where corrosion could occur. The new DCP plate and screw system was so designed that the shape of the holes would not only tolerate such small deviations but would also give the surgeon the option of deliberately angling the screws in different directions, providing greater flexibility to the internal fixation procedure. In addition, the DCP’s specially shaped holes engaged the screw in such a way as to self-compress the fracture without the need for an external tension device.34 The DCP was dynamic insofar as the design allowed slight


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passive movements of the screws within their holes in the direction of the fracture line, resulting in an increase of pressure.35 This flexibility turned out to be a major advantage over the AO’s conventional round-hole plate. As a study of 1972 revealed, the performance of the traditional plate was hampered by an astonishing phenomenon. In this experiment, 36 experienced surgeons applied an AO round-hole compression plate to a fractured bone. As usual, in a first step the pressure device was used to create compression. Then one by one the screws were applied to fix the plate to the bone. At the end of the process, when all screws had been fixed, the pressure achieved was measured by a pressure gauge. Surprisingly, more than half of the attempts did not result in any pressure at all or had even created distraction of the fragments. Moreover, the results seemed to be independent of the individual surgeon’s skill and experience. It was obviously a matter of pure chance whether pressure was accomplished or not. Apparently what had happened was that the initial compression had been undone through imperceptible eccentricies of the screws’ positions in the holes. Subsequent adaptation, however, was impossible because those screws that had already been inserted were locked in their round holes. With the DCP, the shape of the holes prevented any such locking effect so that each additional screw that was applied added to the compression at the fracture line. Consequently, the compression that could be measured after applying the DCP showed no such variety between cases. The DCP turned out to be ‘foolproof’ in that regard.36 As long as stress protection was an issue, the DCP’s dynamic characteristics were also seen as a possible answer to that problem. Even after applying the DCP, the fracture ends could in principle move towards each other under muscular forces or weight bearing, thus allowing the transmission of these forces to the bone cortex.37 Stress protection was also supposed be controlled by manufacturing the new type of plate with less rigid titanium instead of the customary steel. In order both to give surgeons a choice and to be able to distinguish the effects of the change in material from those in the change of design, the DCP was produced in both steel and titanium.38 The new plate went through the AO’s usual testing procedures. In 1966 the development phase had been finished and the design was patented. The device had undergone technical trials, and experiments in tissue culture and animals and was ready for testing on humans in selected hospitals. Already the first consecutive series of 60 tibial fractures showed promising results. From January 1966 to October 1970 424 titanium plates were implanted and no negative effects from the material were reported. In 1970 the DCP was made available for all AO members and those surgeons who regularly attended AO conferences. In 1971 a DCP set was included in the standard AO product range.39 The DCP became indispensable for developing new fields of AO activities such as veterinary surgery of small animals, small fragment osteosynthesis

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Figure 19 Use of the DCP: after realigning the bone ends and adjusting the plate, the plate is fixed by a screw fastened in the larger fragment near the fracture line (16a). The next screw is inserted into the other bone fragment with the help of a special drill guide in a slightly eccentric position. As a result, the process of tightening the screw makes the screw head engage with the plate hole in such a way that the bone fragment moves relative to the plate and thus produces pressure in the fracture gap (16b). The other screws are then applied to fix the plate in this position (16c).

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and maxillofacial surgery. Manufactured in different sizes, it proved to be a reliable tool for experimental science and made it possible, among other things, to prove that primary bone healing also existed in rabbits.40 The new plate was also received very well in the rest of the surgical world and became one of the Synthes licensees’ best-selling items. Soon standard textbooks described it as the successor of the regular AO plate for most fracture types.41 The DCP finally replaced most of the other self-compressing plates, and from the mid-1970s it was regularly mentioned as part of the standard armamentarium of bone surgery.42 An ‘illegitimate child’? The dynamic hip screw By contrast, the Dynamic Hip Screw (DHS) was a device the AO included in its system only after being pressured by other surgeons. First described by Gerhard Küntscher’s instrument designer Ernst Pohl, the DHS principle was based on a sliding screw implant, consisting of two major parts. A widediameter lag screw is inserted into the femoral head, and a side plate with a barrel at a set angle is attached to the femoral shaft. Weight bearing and muscle activity cause the screw shaft to slide through the barrel, resulting in impaction of the fracture surfaces and stability. The design was published in the 1950s and subsequently gained much popularity, particularly in the US. The reason the Swiss AO surgeons were initially reluctant to introduce the technique was that they already had angled blade plates for use in fractures of the upper end of the femur (trochanteric fractures), for which the DHS was also intended. In their opinion, the popularity of the DHS principle was not sufficient reason to include it in the AO system. Stressing the fact that the AO’s product policy should not be determined by market pressures but by medical considerations, they decided that the DHS principle was not necessary. The argument that the DHS was much easier to apply than the angled blade technique was interpreted by AO surgeons as evidence of their colleagues’ inferior skills in hip surgery. This haughty attitude did not, however, pay off. The DHS was not only easy to apply, its use also led to shorter operation times and lower complication rates. In addition, other firms like Osteo, Richards, and Zimmer had started offering hip screw systems and threatened to lure surgeons away from the AO. Finally, the AO gave in to the pressure and one of Straumann’s designers developed an AO DHS system together with groups of surgeons in Seattle and Basel. When the device was brought out in 1979, Allgöwer was still uncertain as to whether it was a ‘legitimate or illegitimate child of the AO’. The DHS proved to be very useful in any case and became a success, both in medical and in commercial terms.43 Medullary nailing Another field in which the AO reacted to general developments rather than initiating change itself was medullary nailing. From the beginning the AO surgeons had integrated the technique into their system 44 and had even


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developed their own variation of the Küntscher nail featuring an inner thread at the upper end to facilitate insertion and removal. 45 It was generally acknowledged that the AO’s special contribution to osteosynthesis technology was compression osteosynthesis rather than intramedullary nailing, which had been introduced by Küntscher more than a decade earlier. Accordingly, the 1963 AO textbook refers readers to Küntscher’s works for more details on nailing techniques. The group favoured the compression plate and the absolute stability it afforded as an easier and less risky approach to operative fracture care.46 With the biological turn in osteosynthesis, however, intramedullary nailing became extremely popular. Nails came to be regarded as providing strong, though not rigid, fixation for tubular bones with less biological disturbance than plates. Disturbance was lower because nailing did not interfere with the fracture site itself, but provided a bridging fixation. 47 In particular, the introduction of the locked nail extended the technique’s area of indication. In locked nailing, so-called transfixation screws or bolts are inserted transversally through the bone at both ends of the nail once it has been placed inside the bone’s medullary canal. A nail that is fixed in this way is able to withstand torsional moments and axial loading much better than the standard unlocked nail. It can also be used to treat more proximal and distal fractures and master more complex and unstable situations than its unlocked counterpart.48 Therefore, the locked intramedullary nail became the ‘choice implant for the fixation of diaphyseal fractures’.49 However, the AO missed that important development and for a long time failed to include a locked nail system in their equipment.50 The subject had been discussed early on at a TK session in 1977. Though Stephan Perren explicitly warned his fellow TK members not to bypass this significant innovation, the TK decided against the locked nail.51 The principle on which the locking nail technique was based did not fit in with the AO’s policy of emphasising rigid fixation. Such a device, the TK members thought, was not suitable for inclusion in the AO equipment because it would not provide stability by creating close contact between fragments.52 When the principle of locked nailing gained general acceptance within the surgical community, other providers, such as Kempf and Grosse in France and Russell and Taylor in the US, rapidly became market leaders in that field.53 The AO lost part of its market share of medullary nails in general because it did not offer a locked nail system,54 and the gap in the AO product range also endangered standardisation. An American surgeon, for instance, complained about the AO’s conservative policy which forced him to buy locked nails from other providers, even though he otherwise used only AO material.55 Finally, after repeated demands by Perren, Allgöwer, the American producer Hansjörg Wyss and others, an AO working group for the introduction of the locked nail was founded in the early 1980s; prototypes were made, tested and

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evaluated, and an AO locked nail was produced. The device enjoyed such immediate popularity that the first batches rapidly sold out.56 A similar ambiguity characterised the AO’s attitude towards external fixation which was already an established form of fracture treatment at the time when the AO was founded; nonetheless it was later integrated into the AO equipment.57 Maxillofacial and spine surgery Some specialist areas of osteosynthesis came to operate relatively independently of the general field of fracture care; above all, maxillofacial and spine surgery – areas in which technical development acquired a special dynamics, reflected in the special subunits of the AO organisation. Specialists in maxillofacial surgery became familiar with the AO’s system from their general or orthopaedic colleagues. The first local instances of applying the AO technique emerged in Basel and Freiburg.58 In 1975 the first AO maxillofacial equipment was made generally available, and in 1976 a special set of maxillofacial instruments and implants was produced. The further development of the AO concept in the field led to a comprehensive approach to craniofacial surgery in the fields of traumatology, tumour and reconstructive surgery.59 Later the development of maxillofacial AO techniques and equipment gathered momentum in the US. In 1984, Synthes USA even set up a new division called Synthes Maxillofacial.60 In the 1980s and 1990s the field underwent a rapid development in operation techniques, instruments and implants as well as computer-assisted pre-operative planning.61 Spinal surgery became another dynamic area of development within the AO. Even though vertebral fractures were discussed among AO surgeons in the 1970s,62 it was not until 1981 that the first spinal course was organised as a subunit of the Davos course. Its organiser was Fritz Magerl, a surgeon from the Graz AO school who had transferred to St Gallen.63 The AO surgeons and producers were at first a bit reluctant to spend much time and money on specialised instruction in spinal surgery, since, given the low number of specialists that existed at that time, they did not expect spinal instruments and implants to sell well. Spinal instruments, they thought, would never become mass articles; to have them in the programme was more a question of prestige than of commercial considerations.64 However, by the mid-1980s the subject had given rise to a new dynamic subspecialty within surgery. Its members were now able to operate successfully on a variety of conditions that had not been amenable to effective treatment before.65 In 1991 Synthes Spine was officially launched as a company in the US. The initial product line consisted of items developed and manufactured by the AO sister companies in Europe, and imported by Synthes Spine for sale in the US. One product in particular was destined for star status, the Cervical Spine Locking Plate. Easy and safe to use, this system became the standard of care for this


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treatment. In 1994 the Universal Spine System was introduced, which comprised a hook, rod and screw concept used for many surgical indications including scoliosis, fracture and degenerative back problems.66 ‘To save for usefulness and breeding many a valuable horse or dog’: veterinary surgery Veterinary surgeons also adopted the AO principles. Experience gained in the laboratory through experiments on animals could also be used for treating injured animal patients. As early as 1914 William Hey-Groves wrote that ‘as a side issue’, his studies would provide ‘a perfectly efficient method of treating the broken bones of animals’, so as ‘to save for usefulness and breeding many a valuable horse or dog’.67 Similarly, Gerhard Küntscher, who had first tried his nailing technique on dogs, suggested using the same method as a therapeutic measure for these animals and subsequently intramedullary nailing achieved some popularity among veterinary surgeons.68 In the second half of the twentieth century, there were enough animal owners prepared to spend money on surgical treatment for their pets or horses, to enable some veterinarians to take up the necessary technologies. One of these was the AO system, which was adapted for animals by a number of veterinary surgeons.69 At the AO spring meeting in May 1969 veterinary surgeon Björn von Salis gave a presentation about the use of the AO technique in his field. He had developed a horse ambulance for use during race competitions. It was equipped with everything needed to start fracture treatment directly on site. On this occasion von Salis also announced plans to found a veterinary branch of the AO.70 It was to be established by a group of veterinary surgeons who held weekly meetings at the Straumann Institute in Waldenburg. On 31 August 1969 the AO Vet branch was officially founded. It had 30 members from Switzerland, the US, Germany and Sweden. A first veterinary course in Bettlach was planned for January 1970. Later, regular instruction units for the treatment of small and large animals were included in the Davos courses.71 Also in 1970, a special instrument set for small animals was put on the market. It was developed by a special group organised in 1969 at the Straumann Institute for the purpose of finding better treatment devices in small animal surgery.72 The producer, Fritz Straumann, was a committed supporter of the AO’s veterinary branch. The AO Vet was founded in his institute in Waldenburg, its office was set up there, and in 1976 it became the seat of the newly established AO Veterinary Centre. But Straumann also supported research at universities in other countries, above all at the Ohio State University in Columbus, where he endowed the ‘Straumann Laboratory for Surgical Research’.73 Here lay the other, American, root of the AO Vet. Starting in 1965 veterinary surgeons Bruce Hohn, Jacques Jenny and the American AO adherent Howard Rosen applied the AO technique to animals. Following their participation in 1969 in a human AO course in Davos, they started to organise annual courses in AO techniques for animals at the Ohio

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State University School of Veterinary Medicine, where Bruce Hohn had become professor of orthopaedic surgery.74 As a result of their activities, in 1976 all 22 university veterinary schools in the US were equipped with AO material.75 In 1979 the AO Vet was accepted as a section of the AO International.76 The regular reports given at AO meetings reflect the steadily growing interest of the veterinary community in the AO technique.77 Conservative treatment The AO’s worldwide success also influenced the development of conservative fracture treatment. As the authors of a textbook chapter remarked in 1993, the operative approach had come to dominate ‘the treatment of musculoskeletal trauma to such an extent that residents today have far less training in the principles of closed management’.78 Whereas in the 1950s and 1960s proponents of osteosynthesis had had to defend their approach, in the 1980s and 1990s it was the use of conservative techniques that was in need of legitimation. Nonetheless, the development of conservative fracture care had not come to a standstill, and even though the AO was not active in that field, AO surgeons watched these developments with interest and adopted those methods they found worthwhile. The most interesting new method of closed treatment was a special brace technique developed by the American surgeon Augusto Sarmiento in the late 1960s and early 1970s for lower leg fractures. Prefabricated from light synthetic materials, the Sarmiento brace left the joints free, and even though it enabled the patient’s early mobilisation, fixation was not meant to be rigid. Rather, ‘functional fracture bracing’, as the technique was also called, was ‘based on the belief that motion at the fracture site is the single most important factor that enhances osteogenesis’. 79 In accord with the new biological orientation in fracture care, Sarmiento tried to avoid disturbing the natural processes of fracture healing. No attempts were made to immobilise the fragments themselves, and the abundant callus that formed in the process of healing was seen as highly desirable. The Sarmiento technique was widely accepted. By 1985 Bernhard G. Weber estimated that it was practised as widely as the AO method.80 Its proponents claimed that many fractures could be successfully managed by non-operative means ‘in a rather inexpensive fashion’, ‘with a lower complication rate and with very acceptable cosmetic and functional outcomes’. 81 But the new bracing method was also praised by surgeons who normally used the AO technique. When Weber heard about the new method he sent one of his interns to be instructed by Sarmiento and then introduced the technique at his St Gallen clinic. There, other AO surgeons learned how to use the Sarmiento brace. According to Allgöwer, the technique was similar to the AO’s method in its functional approach while avoiding the need for an operation. He interpreted its emergence as a positive consequence of the opposition against the AO’s operative approach.82


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Biologisation: ‘from carpentry to gardening’ During the 1980s and 1990s fracture surgeons’ shift of interest from mechanics to biology became even more marked. Whereas in the 1980s surgeons had focused on soft tissue biology, by the 1990s they regarded the biology of the bone itself as ‘the real determinant of outcome’. 83 To characterise the contemporary change in fracture care concepts an American textbook of operative orthopaedics in 1993 cited Gathorne Robert Girdlestone who, 60 years before, had foreseen the future of orthopaedics moving from ‘carpentry to gardening’.84 ‘While for many years’, Perren wrote in 1991, ‘the surgeon would strive to obtain maximum stability of fixation, it is now considered better to trade some stability for the preservation of an optimal biological reaction.’85 Complications were now attributed to a disturbance in bone biology or vascularity rather than to a lack of stability.86 Instead of instability, ‘mechanistic thinking and technique’ was seen as the root of ‘most failures’ in fracture treatment.87 Bone healing proved to show an ‘astonishing tolerance to limited and elastic instability’, and as long as bone biology was well preserved some instability seemed even to be beneficial for the healing process.88 In the words of an AO opponent, many surgeons now believed that ‘rigidly immobilised diaphyseal fractures heal, not because they were immobilised, but in spite of the immobilisation’.89 The new attitude also led to an even more critical stance towards primary bone healing under rigid fixation. As the new AO textbook of 2000 stated, it was now ‘difficult to understand why a stable fixed fracture would heal at all’. Apparently, the authors assumed, the dead bone tissue at the fracture ends induced ‘internal remodelling of the bone which eventually crosses the fracture line and thus repairs the fracture’.90 The remodelling process was interpreted as the way in which the body gradually replaced the bone tissue destroyed by fracture and operative treatment. Since remodelling was extremely slow and vulnerable, here absolute stability was needed. This made interfragmentary compression the treatment of choice for fractures with extensive damage to blood supply. Living and well supplied bone, by contrast, needed only relative stability, since it was capable of overcoming motion and bringing about stability by the formation of callus.91 In reaction to the growing significance attributed to soft tissue conditions and blood supply in fracture healing, a concept called ‘biological plating’ evolved. Concerning the reconstruction of the original shape of the bone, surgeons recognised that the customary practice of directly manipulating bone fragments was a major cause of their devitalisation. To avoid it, they began to use indirect reduction techniques developed for closed fracture treatment that allowed the reconstruction of the anatomical shape of the affected body parts without opening them up and handling them directly.92 As for fixation, techniques varied. Whereas in the 1960s and 1970s the AO’s principles of internal fixation had been the same for articular fractures

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and fractures of the diaphysis, now both types of fractures were treated differently. Only fractures involving end segments, such as articular fractures and fractures of certain bones such as the forearm, required anatomical reduction and absolute stability for union and regeneration of articular cartilage, achieved with screw fixation and plating. Shaft fractures, by contrast, required only relative stability with restoration of length, axial alignment and rotation for union and for the full return of function. Multiple fractures in particular needed no correct reduction of the fracture gaps or stability of the whole fracture site. The tolerance of more flexible fixation in complex fractures could be explained by Stephan Perren’s and Jacques Cordey’s strain theory which claimed that multifragmentary fractures can absorb greater deformation with less interfragmentary strain than simple fractures.93 Flexible fixation was not only tolerated, it was even preferred and seen as a means of stimulating callus formation and thereby accelerating fracture healing.94 On the basis of these considerations the locked intramedullary nail became the most important device for treating multifragmentary fractures.95 A similar concept stood behind bridge plating, a type of fixation in which the zone of fragmentation is bridged with a plate fixed to the proximal and distal main fragments outside the zone of injury to maintain length, rotation and axial alignment. Like intramedullary nailing, bridge plating achieves a splinting effect without absolute stability, leading to rapid union by callus formation.96 Along the lines of biological osteosynthesis, in 1991 the AO introduced a modified version of the DCP, the Limited Contact DCP (LC-DCP). The undersurface of this plate has grooves designed to reduce contact with the bone to only 50 per cent of the total area of the plate, leaving room for small blood vessels and callus formation.97 A further development in that direction was the Point Contact Fixator (PC-Fix), presented in 1995. The PC-Fix has even less bone contact and can be understood functionally as a completely implanted external fixator. Due to the avoidance of bone necrosis, the PCFix reduces the risk of infection and reduces healing time from 18 months with conventional plates to some 3 months. The surgery itself takes about 15–20 minutes less. Since the PC-Fix can only be used in certain parts of the bone, another system based on the same principle called the ‘less invasive stabilisation system’ (LISS) has been developed.98 In the late 1990s peri-operative damage was even further decreased by minimally invasive procedures of implant application, in which fixing devices were brought to the fracture site by way of very small often indirect approaches so that plating became ‘a semi-closed technique’.99 In sum, these changes in technology as well as the alterations of theory amount to another revolution in fracture care in which the AO participated. While the first such revolution was associated with the formation of the AO, the second revolution took place when the AO had already established its network of research, development, manufacturing and education. As we have


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seen in the cases of the DHS and locked nailing, it was not always easy to accommodate the changes. Below, I will look at how the AO defined their role in the ongoing revolution in fracture care and how they discussed the problem of adapting their network to innovation. These discussions were partly fuelled by the ever increasing competition from other firms who either copied AO instruments or developed devices of their own. The AO’s attitude to these issues will be the focus of the last part of this chapter. Accommodating the network It is difficult to assess the AO’s exact role in the changes that occurred on the conceptual level. What is clear is that the AO scientists actively contributed to the turn towards biological osteosynthesis, so that the group was able to preserve its leading position in the field, even as the foundations of its original philosophy started to crumble. The AO’s pioneering role in introducing new fracture treatment technology was unequivocal in its early period. Even though the surgeons had not invented the principles of rigid fixation, compression osteosynthesis and functional post-operative treatment, it was due to their systematic and well organised efforts that these procedures became widespread. However, once its original technique had become well established, the AO’s attitude towards innovation became ambiguous. Also, other approaches in fracture care, such as intramedullary nailing and external fixation, which were older than the original AO philosophy, remained outside their centre of interest. Thus, though the group pioneered some new technologies, for instance the DCP, their acknowledgement of other important innovations such as the hip screw and the locked nail came rather late. Despite its institutionalised procedures for regulating technical innovation, the AO showed a tendency towards conservatism. For one thing, as we have seen in the cases of the hip screw and the locked nail, the surgeons were determined not to give in to the forces of the market. They wanted to develop their product range according to purely medical considerations as determined by the TK.100 Moreover, they were convinced that their system was already very good. Each new idea was automatically measured against those principles and techniques which had brought the group so much success. The surgeons were emotionally committed to their technique, and the wish to modify it was met with ambivalence. The emotional dimension shows itself, for instance, in the way Robert Schneider described technical alterations in his 1971 Annual Report. For him, the TK’s decision to modify the shape of the screw head was tantamount to an act of heresy.101 In a 1992 commentary Stephan Perren ascribed the conservative tendencies in the AO to the prevalent surgical mentality. His suggestion to include locked nailing in the AO system had been turned down in 1977 ‘by the clinicians’ even though scientific considerations had clearly indicated its usefulness. Similarly, the widespread use of the DCP ‘was retarded by some resistance

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within the AO group for about ten years’.102 Now, he thought, the same attitude was showing itself with regard to using titanium as a new material for its implants. ‘The researcher and the constructor of new devices will have to win over the experienced surgeon again and again, who tends to fear a change away from what he believed to be the best’,103 he concluded. Perren’s assessment was basically correct. Understandably, practitioners were much more wary about technical change than scientists and developers. Once a surgeon had mastered a technique that enabled him to achieve reliable results, it was difficult to awake new enthusiasm for a replacement technique. As a consequence, doctors tended to be, as Müller remarked in 1973, basically conservative people.104 The fact that the AO system was so comprehensive, systematic and userfriendly also resulted in a certain inertia. Thus, for instance, the arrangement of instruments and implants in sets required rearranging the instruments cases whenever new instruments and implants were added,105 at the risk of confusing the users.106 Avoiding confusion and bringing surgeons and nurses up to date required additional effort. It proved necessary to send Synthes representatives to the hospitals regularly in order to check whether obsolete instruments and implants had been replaced and new devices had been integrated in a useful way.107 Moreover, the introduction of new instruments and implants seemed to threaten the standardisation and internal compatibility of the AO equipment. When the TK discussed including DCPs made from titanium in its sets in 1967, Müller even suggested founding a separate association for promoting the new material, so as to avoid mixing the old and new systems.108 Though Müller’s proposal was turned down, the discussion illustrates the basic difficulties of accommodating new elements into an established system, a problem that is also evident from the difficulties that arose when the surgeons tried to integrate new elements into the well established network of user education and instruction. Teaching change I got to be a Senior Resident By staying up at night Fixing all types of fractures In a way I thought was right. Using techniques I thought Were condoned by the AO, But now they tell me rigid fixation Is not the way to go! The first two verses of ‘A Resident’s Lament’ by an anonymous resident at the Sturbridge AO Residents’ Course in January 1993109 address the reper-


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cussions that conceptual and technical change had on user education. A functioning, routinised, large-scale instruction system like the AO’s is inherently conservative and functions as an impediment to spreading new concepts. It was one thing to accept new concepts, but it was a completely different thing to include them in the teaching programme. When the new biological approach to osteosynthesis was presented at an AO meeting in 1989, the question from one of the members of how these principles were to be taught in the courses and incorporated in the AO Manual ‘remained unanswered’, as it is noted in the minutes of the meeting. 110 A younger generation of surgeons saw the inflexibility of teaching in AO courses and textbooks as being responsible for ‘the slow progress toward improved tissue handling’. In particular, the practice of using bare plastic bones for practical instruction did not fit in with the new ideas about the importance of blood supply and soft tissues.111 Another serious problem resulting from conceptual innovation was how to present the changes to the surgical public without losing credibility and authority. In the medical instruments industry, ‘too radical innovations’ not only threatened established markets but also undermined the position of the acknowledged experts in the respective fields, as sociologist Stuart Blume has observed.112 Conceptual change provided an opportunity to attack the AO which was not missed by its opponents. ‘It did not take long for the orthopaedic community’, one AO critic wrote in a 1998 textbook, ‘to realise that the foundation on which the AO philosophy had been built – rigid fixation and interfragmentary compression – was flawed.’113 It was not the AO’s policy to deny having been wrong. Part of its credibility derived from that openness. Thus, in his speech at the opening ceremony of the Davos AO Centre in 1992, Martin Allgöwer stated that the AO surgeons ‘should not be ashamed of learning from others’. Referring to the previous emphasis on rigid fixation, he went on to admit that ‘many mistakes often took a frustratingly long time to be corrected, but they were finally remedied’.114 On the other hand, there was no need to interpret past shortcomings as failures. They could be seen in a positive manner as ‘items open to evolutionary improvement’, as Perren wrote in 1991.115 Such an evolutionary perspective allowed the emphasis to be placed on continuity, as Joseph Schatzker and Marvin Tile did in their 1996 textbook when they wrote that ‘the initial goals of the AO – the improvement of fracture care with emphasis on the return of full function’ had remained the same. Major changes, however, had occurred in ‘principles, techniques and implants’.116 Schatzker stressed this point later in the AO Principles of Fracture Management published in 2000, explaining that ‘the philosophy of the AO group has remained consistent and clear, from its inception by a small group of friends and colleagues in 1958 to its current status as a world-wide surgical and scientific foundation’. By philosophy he meant ‘the proper management of

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the fracture within the environment of the patient’. Seen in this way, the biological revolution in fracture care was not so radical after all. Since the ‘AO principles relating to anatomy, stability, biology, and mobilisation still stand as fundamentals’, only ‘how they have been expressed, interpreted, and applied over the past 40 years has gradually changed in response to the knowledge and understanding emerging from scientific studies and clinical observation.’117 Another option consisted in defining the revolution as a permanent state, as David Helfet did in his foreword to the textbook, where he declared that ‘the revolution continues even today – the principles remain the same, but the methods have evolved, as clearly they should’.118 ‘Imitation is the sincerest flattering’:119 originals and copies A policy of constant innovation also made a lot of sense from a business perspective. For instance, once all competitors had copies of the AO roundhole plate on offer, it was in fact advantageous to come up with the DCP as a new product to replace it.120 From the beginning, the AO was confronted with other companies’ efforts to copy its successful products. Some of them openly advertised their products as cheaper versions of the original AO material.121 As described in Chapter 3, two former employees of Straumann founded a rival company, Voka, later renamed Osteo, with the declared aim of offering cheaper copies of AO products. According to a report given at a TK session in 1970, one of the founders passed himself off as a designer of AO instruments and characterised the Osteo equipment as an advanced version of the AO instruments.122 Other providers went even further: in 1974 a competitor tried to register its brand name, Synthos, which was an obvious attempt to profit from a confusion with the Synthes name. However, Synthes AG Chur successfully prevented the registration by legal means. Some manufacturers imitated the AO and Synthes logos on their products; others pretended to produce their instruments and implants under the Synthes licence; others still simply used ‘AO’ as a generic name for their material.123 Usually copies were offered at lower prices than the originals and some competitors pursued an aggressive market strategy. Thus in 1970 Osteo not only offered a 25 per cent reduction on all current orders for surgeons in Sweden but was even prepared to replace all AO material at their hospitals with Osteo products free of charge.124 However, the TK had decided in 1963 not to participate in price wars: it had come to the conclusion that even relatively high prices did not impede sales as long as the AO products remained superior to others125 – and it was right. According to Stuart Blume’s sociological study on the medical instruments industry, competition in this market typically takes place on the basis of performance, not prices.126 Also, the association’s commitment to research, development and user instruction made it plausible and acceptable for many purchasers that its products were more expensive than those of other, less committed providers.127 Eventually,


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the AO’s prices became a worldwide reference point for other suppliers, who tended to offer their products 10–20 per cent cheaper.128 The main problem the AO had with competitors was not so much the danger of losing business – most of the time demand was higher than supply anyway; what the AO worried about most was losing control over the quality of the material that was sold for performing its osteosynthesis methods. The AO knew that it was seen as responsible for any failures that occurred in the use of techniques recommended and described by the AO, even if they had been performed with low-quality non-AO materials. The fact that the original AO instruments and implants were better than their copies was an advantage only as long as originals and copies were not confused. It was thus important to identify the original AO material down to each single screw with a brand mark and make it generally known that the originals were only available through Synthes AO producers’ sales organisation.129 There were thus enough reasons for the AO to keep an eye on competitors and their attempts at imitating AO instruments.130 The most effective means for countering this type of competition was the credibility and good image the AO had among its colleagues. Seen from this perspective, the fact that the instruments and implants were so widely copied could also be interpreted as an indication of the high esteem they enjoyed. Being copied even seemed to enhance their popularity. Each advertisement in which competitors offered cheaper versions of the AO equipment increased the demand for the originals, Robert Mathys noted in a discussion; and Maurice Müller added that the more the AO instruments were copied, the more the originals were also bought.131 Another strategy against imitations was patenting. The AO patented many of its instruments and implants, such as the DCP, and were sometimes able to force their competitors to remove a copy from the market. But, as noted in Chapter 3, this strategy was only of secondary importance, since legal action was costly, difficult, and unreliable in its result.132 One of the problems in taking up legal proceedings was the relative character of original and copy. Sometimes a very minor modification was enough difference for a device to be seen not as a copy but as a development. To the indignation of the TK members, Osteo declared its slightly modified AO copies to be improved versions of the original products.133 American manufacturers, in particular, had few scruples about imitating AO materials down to the smallest detail.134 Zimmer, for instance, copied 85 AO products, but stated that their similarity to the AO items was not the result of deliberately copying them but was dictated by their purpose.135 On the other hand, even the AO’s instruments and implants themselves had been designed after the model of existing devices. As the AO surgeons freely admitted, their whole range of equipment was based on principles invented by Danis, Charnley and Küntscher, though the AO version of the respective instruments always differed in some basic respect from the original.136 The only AO implant that was completely new was the angled blade plate for hip

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fractures. Designed in a special U-shaped profile, it was the only such plate that was able to ensure stability of the angle after application to the bone. But even here, other, less effective precursors had existed.137 In order to remain at the forefront of the field it was inevitable that the AO surgeons systematically studied the products offered by other firms and occasionally took an instrument or implant as inspiration for the creation of a new AO product.138 As other manufacturers did the same, there was a continuous flow of ideas from the AO to its competitors and vice versa. All osteosynthesis devices, whether they were brought out by the AO or other providers, emerged within this field of exchange. Whether a device was conceived as a novelty with an autonomous identity, as opposed to a mere copy, depended on the context, and, as in the case of patent infringement litigation, on the results of negotiations.139 ‘Stolen priorities’ As we have seen, for various reasons real novelties were hard to establish in the AO network. Perhaps the most effective brake on innovative tendencies was the AO’s principle of careful quality assurance. The lengthy control procedures strained the patience of surgeons and manufacturers alike. In 1969 Schneider regretted the delay in bringing the DCP onto the market. Even though the AO had been the first to start developing such a plate, he complained, others had been faster in bringing out the end product. Just as competitors were starting to distribute their first specimens, the AO needed another four years of testing before its device would become available.140 In November 1970 von Rechenberg considered the situation to be precarious, with Osteo promoting its new plate and Synthes still unable to sell the plate.141 In fact, as Perren reported in 1973, Osteo’s new self-compression plate met with enormous success in Germany.142 This experience led von Rechenberg and Mathys to complain about the time the AO was losing in protracted approval procedures and endless discussions.143 Willenegger even warned his colleagues in 1976 that they should not think exclusively in terms of science when they discussed the AO product range, but should consider business as well.144 In 1980 Allgöwer found it hard to believe that the AO had become so large and bureaucratic that a decision about a new device could sometimes take up to two years.145 Such long periods of gestation also posed problems for the producers, who wanted to know in advance which raw materials and machines they needed to start manufacturing a new item.146 While the claim to offer only products of proven quality put the brakes on the AO’s innovative drive, it was exactly the image of reliability that was the AO’s major advantage over other providers.147 So despite occasional bouts of impatience, surgeons, scientists and producers saw no need to worry about being overtaken by their competitors, as long as the quality standards remained high.148 Their conservatism was even a source of pride for the AO, as can be seen from Robert Mathys’ exaggerating statement in 1970 that the


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AO equipment had been fully introduced by 1960 and that it underwent only minor changes in later decades.149 Even the design of the AO instruments was deliberately conservative, so as to suggest reliability.150 As another characteristic feature of the health care market working in the AO’s favour, ‘purchasers tend to play safe’ writes Blume, ‘and stick to known and trusted suppliers’.151 The purchasers’ trust in the high quality of AO products was the group’s trump card on the instruments market, an advantage that was enhanced by the credibility gained by the AO’s scientific activities. These were assets none of their competitors possessed.152 The AO retained its high quality reputation and leading position in the field even in the face of intensified competition in the 1980s. Competition grew more intense not only on the basis of lower prices but also as the speed of technological advances and new product introductions increased. Mergers and alliances led to multinational and global industries, while other companies became strong competitors by specialising in specific market sectors such as spine or maxillofacial surgery. As a result, better informed customers had a greater choice of devices from increasingly focused companies.153 The special relationship between surgery, science and industry realised in the AO/Synthes symbiosis proved to be a crucial advantage in many regards. But the structures of this symbiotic arrangement had to be adapted to the immense growth of the enterprise resulting from its success and to accommodate itself to changes in the environment. The next chapter will be devoted to the most significant elements of the adaptation process the AO underwent in the last three decades of the twentieth century, with the result that the AO’s technique and philosophy changed and the AO reshaped itself.

11

Control and Cooperation on a Global Scale: AO International and the AO Foundation

As acceptance of its technique grew, the AO itself transformed from a small group of surgical dissidents into a powerful organisation within the medical establishment. Since the group’s identity had been shaped by its continual fight against outside resistance, its raison d’être became more difficult to define when resistance finally abated. Before this background Obmann Robert Schneider diagnosed a crisis in the mid-1960s: using a military metaphor he likened the AO to a raiding party which had reached its aim and being robbed of a clear objective, was now threatened by dissolution.1 Employing the same sort of imagery in 1969, he remarked that even though a victory was normally followed by immediate demobilisation of the troops, the AO surgeons were only too aware that they could not demobilise their forces. The complication rates in connection with the use of osteosynthesis were evidence of the persistent difficulties hindering the correct application of the AO technique.2 ‘The tasks which stand before us are immense’, Willenegger noted in a similar assessment in 1977, and he guessed that it would take one or two generations of surgeons before the application of osteosynthesis would reach the quality standards that existed for other surgical techniques. ‘There is no other field in surgery which has so much fallow land’, he concluded, ‘therefore we must motivate the young generation to work with us in the AO.’3 Clearly, the AO remained indispensable in the long run, but the way the group organised itself had to be adapted to its growth and global impact. In chronological order, I will first describe the efforts to reorganise the AO activities on an international level in the early 1970s and later come to the organisation of an international AO foundation in the 1980s. 218

AO International and the AO Foundation

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Vulnerability of standardisation At the core of the early ideas about reorganising the AO group was the worry about standardisation. The problem was crucial since the ability to standardise osteosynthesis had been one of the conditions of the AO’s success. In order to remain successful, this achievement had to be maintained, even when the technique spread to other countries. As Willenegger once put it, the AO’s successful adaptation to other national contexts depended on maintaining its ‘common instrument language’.4 What this meant in practice was made clear by Schneider in his 1972 Annual Report in which he asserted that it was in the patients’ utmost interest that screws and intramedullary nails could be removed in the same manner everywhere. 5 Since violations of standards jeopardised the stability of the network, the AO leaders were adamant on this point. Thus Robert Schneider was upset when he came across a non-AO compatible (artfremde) screw while performing an operation in Bienne in 1971. At the next AO meeting he complained bitterly about this breach of standardisation which threatened to throw bone surgeons back into the state of confusion that prevailed when the AO had first set out to introduce order in the field.6 Causes of de-standardisation were manifold. The employment of additional providers in times of increasing demand, for instance, entailed the risk of losing control over the uniformity of instruments. This was seen as the reason for the awkward situation that occurred during the demonstration of the AO technique in Freiburg, Germany, in 1966 when Schneider had to work with an incompatible screwdriver. In the same TK session at which Schneider reported this incident, Müller presented four different screws that had all been passed off as identical AO screws.7 Competitors were another potential source of de-standardisation. Osteo, for instance, not only advertised its products in the US as being ‘Swiss-made’ but also claimed that they could be used together with Synthes material.8 As a result, many American fracture care units mixed the systems. When Willenegger discovered this on his travels, the AO considered taking legal action against the company.9 But as other providers’ copies became nearly perfect, the AO’s aversions against mixing systems became difficult to justify. In 1979 even the official German authority for testing materials, the Materialprüfungsanstalt in Stuttgart, declared that instruments made by AO’s competitor Aesculap could be mixed with Synthes products without problems. In the TK session in which the issue was discussed, Straumann explained that it was never advisable to mix two different systems, not so much because of differences in the metals but because of variations in their mechanics and dimensions. But he also admitted that users, if forced to buy products from other providers because Synthes materials were in short supply, would soon notice that not much would happen if the systems were mixed.10

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Standardisation of instruments was linked to standardisation of procedures. Too great a variety of equipment would also endanger its correct and standardised application.11 During his visit to an American fracture unit a German AO surgeon was struck by the operative incompetence of his colleagues, which he attributed to the diversity of instruments used there.12 In addition, procedural standardisation was also threatened by the emergence of local styles in osteosynthesis. As discussed in Chapter 2, such variations are an inevitable part of the appropriation of any technique and, instead of speaking simply of success or failure of standardisation, it is more useful to speak of a convergence process in which the technique and its local environment adapt to each other. But it is also clear that the tolerance of local adaptation of the AO technique had its limits. If deviation from the standard procedure went so far as to diminish the success rate of the treatment, standardisation had indeed failed. Such deviations could be seen even among AO members, some of whom failed to observe the basic rules of the AO philosophy and routinely applied plaster casts after osteosynthesis, as was reported in the late 1960s. Similarly, Allgöwer later noted an astonishing variability of post-operative treatment among AO members and admonished them to keep to the approved rules. So even in the inner circle only constant surveillance ensured treatment standards,13 and beyond the immediate AO circle, maintenance of procedural standardisation was still more difficult. Whenever a new stage of spreading was reached, an increase in complications and failures due to technical mistakes could be observed.14 The reason was that application of the AO’s highly sophisticated instruments without respecting the basic rules of their use led to more cases of delayed healing and non-union than doing without them, as Müller warned in 1971.15 As discussed in Chapter 4 and demonstrated in the case of the US in Chapter 9, reading the textbooks and attending an AO course was clearly not enough to guarantee successful use of the system in an environment where application was not controlled by experienced colleagues who were also able to transmit the tacit dimension of the AO technique. In the late 1960s and early 1970s the AO surgeons felt an increasing need to provide this sort of surveillance and instruction in a more organised manner. They had reason to fear losing control over the rapidly growing group of AO adherents all over the world. Spontaneous AO subsidiaries Geographical expansion confronted the AO with the problem of control in a new way. In 1966, the founding of an informal Italian AO subsidiary – the Club Italiano degli Amici dell’AO – made the AO worry about how to control the activities of such spontaneously forming groups. Among other things, the observation that the Italian Club’s newsletter contained a number of errors made them aware of the importance of a well coordinated information


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policy.16 The spontaneous character of the establishment of national AO groups can be seen by the fact that three years later Schneider was surprised to hear about plans to establish a German AO. 17 Similarly, leading AO surgeons learned about the establishment of an Austrian AO only after the fact. To his astonishment, the Swiss AO’s Obmann Robert Schneider had not even been invited to the foundation ceremony. What was even more worrying, the new subsidiary’s statutes had been drafted without consulting the Swiss AO, who had to ask its Austrian colleagues to send it a copy.18 At that time control was beginning to slip away from the AO leaders at all quarters. In January 1968 von Rechenberg complained that Mathys had concluded an arrangement with the Italian AO without consulting Synthes AG Chur or the Swiss AO. Such contracts, he demanded, must first be checked by the TK in order to maintain a uniform policy.19 Developments in Spain even threatened the symbiotic arrangement on which the AO was based. In 1971 the TK learned that Spanish surgeons had not only founded their own AO but had also established their own instruments company. Only by reacting swiftly and offering the Spanish colleagues their support for development and documentation could the Swiss prevent them from starting their own production. But the ‘Spanish problem’, as it was called at the time, had not yet been solved. In 1973 the Spanish AO surgeons again deviated from AO policy and started collaborating with another producer who promised them a greater share of the sales profits. In order to prevent such a step, the TK charged Straumann, whose sales area included Spain, with opening a Spanish subsidiary. A local Synthes branch would improve both supply and control. Another means by which to stabilise the link with Spanish colleagues was the organisation of a large-scale AO congress in Madrid in April 1974. The congress was attended by prominent AO leaders and helped to convince the Spanish colleagues of the fact that cooperation with Straumann’s newly established Synthes España and the Swiss AO was worth more than the money offered by some other producer, as Schneider commented.20 As similar problems were reported from other countries such as West Germany, the US and Yugoslavia,21 this was a strategy also to be followed in other contexts. In 1966 von Rechenberg warned of the chaos that would ensue if subsidiaries ‘under the name of AOX’ started propagating their own concepts and products.22 Since using the same instruments and implants was the very basis of cooperation within the AO, product policy had to remain with the TK and Synthes. But in order to maintain control and standardisation, it was not only important to ensure the TK’s power over design and production;23 foreign AO surgeons also had to be prevented from developing products with firms other than Synthes,24 or, as von Rechenberg warned, even establishing their own competitor companies.25 This was seen as a danger when the establishment of a German AO was discussed in 1969. Schneider made it clear that complete independence of the new group from the Swiss AO was unthinkable.

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It could not be tolerated, he asserted, that a foreign group bearing the name AO collaborated with other companies, such as Osteo. 26 These sorts of concerns demonstrate that the uncontrolled creation of AO groups endangered not only the standardisation of the AO technique but also the AO’s special model of symbiosis with industry.27 AO International All these considerations made it increasingly clear that the Swiss AO had to take the initiative if it wanted to avoid the dissolution of the group. ‘We are threatened by a development crisis’, Schneider pointed out in 1970. The question was how to proceed. Accepting all the foreign surgeons into the Swiss AO was no viable solution. This would have completely altered the AO’s character as a face-to-face community and impeded its function of mutual support and control. Rather, Schneider suggested, the AO should maintain the policy that had made it successful in the Swiss context, and organise groups which would be kept relatively small and controllable. 28 First, interested surgeons should be bound to the Swiss AO by a contract and thus form a core group to which gradually more and more members could be added. To ensure control from the very start, the initiative to create such groups must never be left to surgeons outside the AO, von Rechenberg pointed out to his fellow TK members in 1970. He urged them to become involved as soon as they heard of any plans to establish new AO subsidiaries.29 However, individual vigilance and commitment was not enough. The AO leaders quickly noticed that they needed a special institution to fulfil this task. They planned to establish an international organisation under the control of the Swiss AO, to be called AO International (AOI). All groups who called themselves AO would be required to become members of the AOI, thus putting the central AOI office in a position to monitor their formation.30 Besides using the AO’s name, such groups could profit from AOI membership by participating in the education network and receive support for documentation and basic research. In exchange, they subjected their activities to the AOI’s and TK’s surveillance.31 The AOI would coordinate, standardise and monitor user instruction in the various countries.32 Concerning clinical research, the individual AOI member groups, or sections, were expected to establish their own local documentation to coordinate with the Swiss AO Documentation Centre,33 so that clinical studies would be performed in a standardised but decentralised manner. Most basic research, by contrast, was to be done at the AO Laboratory in Davos, which provided research opportunities for scientists from various countries. In addition, laboratory research projects in other institutions were to be supported in the same way the Swiss National Foundation supported such projects.34 This meant that the funds Synthes AG Chur received from the producers’ royalties were not split up strictly according to the sales in the individual countries but were instead collected by the AO and then allocated to individual projects.35


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The plans for setting up the AOI caused heated discussions within the Swiss AO group.36 Among the rank-and-file AO surgeons in Switzerland the internationalisation plans did not meet with immediate approval. It was a time when the Swiss anxieties about immigration and land sales to foreigners were encompassed in the phrase Ausverkauf der Heimat, ‘selling out the fatherland’, an expression the sceptics among the AO surgeons used for formulating their resistance against opening up the AO to outsiders. In order to maintain Swiss control and power they thought it wiser to expand the existing Swiss organisation and not to establish an umbrella organisation. It took the AO leaders some effort to convince members of the usefulness of the new concept, but after a short delay the plans finally got underway.37 The official AOI founding session took place on 25 November 1972 in Bern. Sections from Germany, Italy, Austria, Switzerland and Spain were legally represented.38 The AOI was conceived as an umbrella organisation for national AO chapters to be established in various countries. Each of these chapters or sections had to include at least six general or orthopaedic surgeons active in the field of bone surgery. The AOI’s aims were the same as those defined for the Swiss AO. Member groups were expected to keep up scientific exchange among AO surgeons. In their research efforts they were obliged to cooperate with the AO Laboratory and the AO Documentation Centre. Congresses or courses under the name of AO were required to be organised and coordinated with the board of the AOI. Approval of AO instruments and implants remained with the TK. Personal gain from instrument sales was excluded. Any income must be used for science, education or humanitarian purposes. The AOI’s highest decision-making body was the Delegates’ Assembly, to which each section contributed three delegates and which was to convene at least every two years to decide on matters of research funding in coordination with the AO Laboratory in Davos and the AO Documentation Centre in Bern.39 The most important posts were given to Swiss AO members. Hans Willenegger was appointed president. Being secretary of the Swiss AO, Maurice Müller became ex officio secretary of the AOI. The Austrian Hans Brücke was made treasurer, the Italian A. Bianchi-Maiocchi and the German Siegfried Weller became additional committee members.40 Despite including foreign board members, the AOI was firmly in the hands of the Swiss AO surgeons, and it remained so, even though the original intention had been to allow for more international participation by appointing a new president from a different country every two years.41 The next step was admitting the national sections. At the Delegates’ Assembly of 1973 the groups from Switzerland, Germany and Austria were officially appointed members of the AOI. Acceptance of the Italian and Spanish groups was postponed, since they were still considered too large and not organised in the required manner.42 In 1975 the Spaniards were admitted together with a Norwegian section. Sections from Mexico and East Germany

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followed in 1976, and in 1977 a Belgian section was established. In 1979 the veterinary subsidiary of the AO, the AO Vet, became a member of the AOI. In addition, 13 surgeons from countries without national sections were named ‘individual’ AOI members.43 Eventually, however, the original concept of the AOI failed. In practice, the Norwegian, Belgian, Italian and Mexican sections never really became established. The Belgian section did not work because no university surgeons were interested in participating. The Italian group was in the hands of only three surgeons who failed to reorganise it for AOI membership. Further plans for the Mexican section were abandoned at the moment when its high-profile president went into retirement. 44 Therefore the idea of holding regular assembly meetings had to be shelved. It was simply not possible to get three delegates of each section to meet. As a consequence, everybody was glad that Willenegger looked after the AOI’s business, even though his single-handed leadership meant that the AOI statutes were ignored. In the late 1970s Willenegger abandoned the concept of establishing formal sections and advocated the formation of more informal local groups who kept close contact with the AOI office. As he realised, the original plan was also impracticable because of the rapid global spread of the AO technique. In 1982 the AOI had established relations with 80 different countries; in 40 of which the relationship was very close. According to the original concept, for all these countries special sections would have to be founded and administered. This was not only impracticable but, as Willenegger recognised, by then also unnecessary.45 The AOI – a service organisation Under Willenegger’s presidency the AOI developed into a service organisation for user education. At a TK session in 1976 Schneider defined the AOI’s tasks as the distribution of texts, the provision of a collection of standard lectures and slides, the surveillance of all AO course programmes, and the running of the courses.46 Control of education was indeed an extremely important task to take on. In the early 1970s, coordination of the AO courses in the various countries was so deficient that, in one instance, the German AO was not aware that an advanced AO course was taking place in the country. So in December 1973 the TK officially assigned the AOI the task of coordinating the AO course programme. All courses must be organised in collaboration with the AOI, Müller demanded in 1974, ‘and at every AO course in which our instruments are used, at least one AO member must be present. The producers always have to inform Professor Willenegger’ about their course plans, he emphasised.47 As Allgöwer noted in the following year, the AO had good reason to believe that ‘the courses are slipping from our grasp while still bearing our name’. More and more universities were planning to hold their own AO courses, he reported, and with the growing popularity of the AO technique, keeping up


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standards in teaching became more difficult. Accordingly, standardisation of teaching – upholding the unité de doctrine, as he termed it – was one of Willenegger’s central concerns.48 There were various problems. Sometimes course organisers chose teachers the AO did not approve of, and in other instances they used instruments or implants that had become obsolete.49 In 1978 Müller complained that at the course he had just visited in England, instructors had contradicted each other; some of the teachers not even having read the AO Manual.50 As seen in this example, maintaining the quality of education also involved the provision of competent teaching staff, so that the recruitment, surveillance and distribution of course faculty was another important task to be fulfilled by the AOI.51 The courses were supplemented by other instruction measures. For basic instruction in small groups, local workshops with AO training equipment were established in selected hospitals. Initiated in the early 1980s, by 1990 the programme comprised 84 such workshops in 31 countries.52 The best long-term effects in terms of education, but also in terms of surgeons’ future commitment to the AO, were achieved by the fellowship programme described in Chapter 4. By 1983 the AOI had become, as Willenegger described it, a ‘worldwide centre for training and contacts ... with the task of transmitting research results, surgical technique and clinical experience’.53 Besides these regular and formalised ways of getting in contact with colleagues, the AOI also organised additional contact trips. Delegations of AO surgeons were sent to other countries in order to demonstrate the AO technique to local colleagues and build up personal relationships with them.54 They often held so-called AO seminars, instruction courses of only one and a half days’ duration without practical exercises. The AOI’s most valuable asset in that respect was Hans Willenegger himself. As the ‘AO Ambassador’ he shaped the organisation’s activities according to his personal style. Even before his retirement from active surgery in Liestal in 1975, he had started his travelling extensively on behalf of the AOI. And even after having officially handed over to Martin Allgöwer in 1984 he continued spreading the AO gospel all over the world. During his time in office he visited 244 cities in 123 countries and was involved in hundreds of instructional courses and workshops. By 1990 Willenegger had travelled 1.25 million km by plane, some 32 circumnavigations of the planet. He became acquainted with literally thousands of surgeons worldwide and, thanks to his magnificent ability to remember names and faces, was able to address them all by their correct names. On his journeys, Willenegger held presentations, joined the rounds to see patients and assisted his colleagues in the operating room. A dedicated and extremely popular surgical teacher, he transmitted the necessary skill and knowledge for use of the AO system not by operating himself but by assisting his hosts with almost infinite patience. As a person, he possessed a type of rustic charm which was appreciated by junior surgeons as well as heads of state. Deeply rooted in the Swiss way of life, he was nevertheless interested

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Figure 20

Hans Willenegger teaching in Budapest 1976.

in other cultures. All this made him the ideal person to create the trust and credibility the AO needed in order to expand its network.55 Willenegger’s mission included not only technical instruction but also encompassed explaining the AO’s special character to his foreign colleagues. He was anxious to resolve the usual misunderstandings about the aims of


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the AO and explained time and again that the association was not a business, that its members did not personally gain financially from it, and that they did not promote the sole use of osteosynthesis.56 This last aspect of his activities was also aimed at the AO’s own foreign members and followers, bringing them in line with official AO policy. Thus the reason why Willenegger went to all these countries in person was not only to create trust in others, but also to find out whom the AO could put its trust in, checking foreign surgeons as to their suitability for collaboration. As detailed in Chapter 4, the AOI files are full of dossiers on individual surgeons, which include evaluations of surgeons’ technical skills and their character. According to Willenegger himself, he wanted to identify the best surgeons in the various countries, in intellectual, medical and human terms, and to build up a basis of mutual trust.57 Plans for reorganisation The problem of replacing the old AO leadership with people from a younger generation was addressed in the 1960s, but it took quite a long time for any plans in that direction actually to be put into action. On a theoretical level, the leading AO surgeons had agreed as early as 1968 to call in suitable persons to become shareholders and members of Synthes AG Chur and to work with them in the TK. They wanted to select candidates who occupied a leading position in the field of osteosynthesis and were able to develop it further.58 Even though the issue of rejuvenating the leadership was frequently brought up,59 the changing of the guard did not take place until the mid1980s. During the 1970s, the younger AO surgeons, being busy developing their hospital units, did not have much time to spare. The older leaders, for their part, wanted to solve the AO’s current problems of international reorganisation first, before passing leadership on.60 So when Schneider gave up his position as Obmann in 1978, which he had held for 20 years, he was not succeeded by a younger surgeon but by Martin Allgöwer, who held this office until 1982, when he was replaced by his pupil, Peter Matter.61 In November 1983 von Rechenberg wrote that the AO was still working on handing over Synthes AG Chur to the succeeding generation of surgeons. 62 What von Rechenberg was referring to specifically was the ongoing project of basing the whole AO network on a foundation. By the mid-1970s the AO’s overall structure seemed to be increasingly inappropriate for the challenges the group was now confronted with. The establishment of the AOI, which had become an educational service institution instead of an umbrella organisation, had not solved the problem. From the beginning, management had been based on a gentleman’s agreement among a handful of decision-makers. The personal opinions of a select few had been the basis for the AO’s policy. The whole network, including its scientific and its commercial elements, was thus run by consensus in an informal – and basically unprofessional – way. In practice,

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decisions were more or less determined by Maurice Müller, who occupied a central position in the whole arrangement. This had worked well because of Müller’s well developed intuition and his feeling for the general opinion within the small and close-knit group. Now, however, many surgeons felt the need for a more formalised and more democratic way of running the AO.63 If they wanted to prevent the eventual dissolution of the network the AO leaders had to find new ways of accommodating the various goals and interests of those involved. In 1975 a committee of leading AO members for the first time suggested the establishment of a foundation. Such a structural basis would enable between 50 and 60 surgeons to participate in decisionmaking, they argued. Furthermore, it would keep the doctors in a representative position and would also be advantageous in terms of taxes. The main problem was the possible inflexibility of such a construction in terms of business policy, which could endanger the AO’s survival – especially if the producers’ interests were not sufficiently represented. The industrial partners’ complete dependence on doctors, who had no special business competence and some of whom might even cooperate with other firms too, seemed to carry a certain risk. Therefore, a special management committee was to be created as a counterweight. This committee would run the day-today business and would be able to react swiftly in times of crisis.64 During the next few years the AO leaders held several meetings to discuss the restructuring schemes. They considered how to include younger people and colleagues from other countries, yet without immediately abandoning control. An important issue in that regard was the future way of distributing funds from the producers’ royalty payments. These made up considerable sums of money: as Allgöwer pointed out, by 1979 the AO had invested a royalty income of some SFr32 million in education and research, the major part of which had been earmarked for the research laboratory at Davos and the Documentation Centre at Bern. Further research money had gone to other institutions in Switzerland and Germany, and to an increasing degree also to countries outside Europe as well as to fellowships from and to Switzerland.65 When the discussion process had still not resulted in concrete plans by 1982, some foreign AO surgeons, above all the West Germans, started to get impatient. The West German AO surgeons had done much for the AO technique’s worldwide spread and had come to play a central role for the AO’s international reputation. Despite their significant contribution to the AO’s success they were still unable to participate in fundamental decision-making on technical innovation, research funding and education. Pointing out that the Swiss arbitrary management was also a violation of the AOI’s existing statutes and regulations, they suggested reorganising the AOI to become the true umbrella organisation it had originally been intended to be.66 The AO Foundation However, the Swiss AO surgeons had other plans. At this time, the founding members and shareholders of Synthes AG Chur had taken the first concrete step


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in strengthening the influence of the younger generation by distributing some of their shares to younger Swiss AO surgeons. As a consequence, Peter Matter, Thomas Rüedi and Stephan Perren now also possessed Synthes AG shares.67 On 8 December 1984 the AO Foundation was finally established. Allgöwer, Matter, Müller, Perren, von Rechenberg, Rüedi, Schneider and Willenegger ‘permanently and irrevocably’ contributed to the Foundation all 50 bearer shares of Synthes AG Chur. In addition Robert Mathys gave SFr400,000 in cash; Fritz Straumann and Hansjörg Wyss each gave SFr100,000. Synthes AG Chur was not dissolved, but its shares were now owned by the AO Foundation. The purpose of the new Foundation was defined as the support and promotion of the Laboratory for Experimental Surgery in Davos, ‘as well as the advancement of the AO/ASIF concept, and the research, education, and documentation in the field of medicine in Switzerland and abroad connected therewith’.68 As the governing body of the AO Foundation the founders appointed a Board of Trustees. Though they had initially considered a body of ten to twelve trustees, in the end it comprised around 80 active members, almost all of them surgeons. The high number was due to the desire to include a representative number of surgeons from different countries involved in the AO network. Among the first 82 Trustees that assembled for the first time in 1985, 25 were Swiss, 14 were West German, 14 were American, 5 were Austrian, 4 came from the UK, and the rest were from 16 other countries.69 Swiss influence, however, remained strong, since members of the Swiss AO occupied the key positions within the AO Foundation and its various commissions.70 To ensure the constant rejuvenation of the Board, appointment of the initial members was limited to three, five or seven years, with the possibility of re-election for another four years. New members were to be elected by the Board itself, on the basis of nominations by the Foundation’s Business Council.71 The Board of Trustees, which holds regular annual meetings in different places, was conceived of as a large ‘brain trust’ to determine and monitor the Foundation’s long-term policy concerning the overall direction of research and teaching and the corresponding allocation of funds. Accordingly, its powers include the approval of the budget and financial statements of the Foundation and of the institutions supported by the Foundation, acceptance of the Annual Report of the Foundation and of the scientific reports, and the establishment of the scientific goals for the coming year. Besides the election of its own new members, it also elects the Foundation’s Executive Committee and the chairmen and members of the various institutions supported by the Foundation, again on the basis of nominations by the Business Council.72 If the Board of Trustees is the Foundation’s legislative arm, then the Executive Committee is its government. On behalf of the Board of Trustees, it attends to the strategic and mid-range planning in scientific and medical

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Figure 21 1984.

Structure of the AO Foundation, according to a booklet of

matters. It represents the Foundation to the public, conducts the meetings of the Board of Trustees, and submits proposals for establishing the scientific goals for the coming years as well as the budget and the financial statements of the Foundations and the institutions supported by it, to the Board of Trustees for its approval. The 15 members of the Executive Committee are appointed by resolution of the Board of Trustees upon recommendation of the Business Council. The Executive Committee consists of the Chairman of the Board of Trustees, the President of the AOI, the Chairmen of the Technical Commission and of the Commissions for Education, Documentation, and Research, as well as three additional members. In 1995 the Executive Committee was renamed the Academic Council. 73 Since 1986 the Foundation’s management has been reinforced by a General Manager, Urs Jann, who was appointed by the Business Council.74


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The Business Council (renamed the Board of Directors in 1989) is the second centre of power in the Foundation’s management besides the Board of Trustees.75 It has the task of securing the material basis of the Foundation by taking care of the commercial aspects of AO policy and flexibly organising everyday management. The Business Council consists of up to five physicians. Importantly, they are supplemented by one representative (usually the chief executive) each from the three manufacturers, Mathys, Straumann and Synthes USA. In order to give the producers enough influence to attend to their interests and thus secure the economic basis of the network, they were granted a special right in addition to their legal vote: as stipulated by the Foundation Charter’s Bylaws, resolutions of the Business Council are approved by a simple majority of the members present. In cases where all three producers vote against a particular resolution, the item must be rediscussed. This construction represents a balance between two different and possibly conflicting objectives: the regulations should ensure, in the words of the official Foundation brochure, on the one hand, that ‘the professional decisions regarding medical concepts and ideas will not be dominated by commercial issues. On the other hand, the structure allows for direct input from the medical market place reflecting the true needs of AO surgeons in the field’.76 The Business Council elects its own new members and has established its own rules of procedure. The importance placed on the Business Council can be seen by the fact that in cases of doubt, the powers of the Business Council take precedence even over those of the Board of Trustees. Among the Council’s far-reaching competencies is the right to nominate members to the Executive Committee and the Board of Trustees as well as the chairmen and members of the institutions supported by the Foundation. The influence of the Business Council is based on its power to exercise autonomously the voting rights and other rights connected with the Foundation’s shares in Synthes AG Chur. This also includes the autonomous supervision of the activities, finances and management of Synthes AG Chur and the determination of the financial resources which Synthes AG Chur may make available to the Foundation every year. As a consequence, the Business Council is in fact in charge of the AO’s funding. The Foundation started operating fully after the first meeting of the Board of Trustees held in Davos in October 1985. Its first president was Martin Allgöwer, who remained in office until 1992. 77 The AO also continued to grow in terms of money spent on research and education. From 1960 to 1984, SFr88.5 million had been spent.78 Slowly the old generation of AO founders retired from actively determining the Foundation’s policy. A major change was marked by Maurice Müller’s resignation from the Board of Directors in 1989. This was the last step in a series of divergences Müller had with his AO colleagues. He had not been particularly happy with the restructuring from the start. In particular he

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resented the involvement of the producers in the Business Council/Board of Directors. For him this form of participation meant an abandonment of the AO’s original ethical guideline of the priority of medical concerns over business considerations. His apprehension about the producers’ influence was exacerbated after a disagreement with Hansjörg Wyss over the role of documentation for the AO product policy in September 1988. In the context of this conflict Müller wanted to insert a clause in the Foundation Charter to the effect that producers can never be president of the Business Council. To his surprise, among the Council members only Robert Schneider supported his move. Müller saw this as a defeat and the occasion to resign.79 Globalisation and regionalisation In 1992 the torch was definitively passed on to the younger generation. The transition was marked by Allgöwer’s retirement as President of the AO Foundation and the succession of a Canadian surgeon, Marvin Tile from Toronto. From then on, the presidency would be passed on every two years to leading AO surgeons from different countries. Also in 1992 the members of the Foundation’s Executive Committee were replaced by younger AO surgeons from abroad.80 Under Tile’s presidency a regionalisation scheme was put forward to supplement the existing national associations – AO Switzerland, AO Germany, AO Spain and AO Austria – by other regionally centred organisations. Legally, these groups were still sections of the AOI, which now, however, was a subsidiary of the AO Foundation.81 The first new regional organisation was AO North America (AONA), established in June 1992. Two years later the AO East Asia (AOEA) was founded by surgeons from Hong Kong, Indonesia, Malaysia, Singapore, South Korea, Taiwan and Thailand. The AO Latin America (AOLAT) was founded in 1998 and the AO United Kingdom (AOUK) in 2000.82 One of the AO’s most successful measures in reaction to increasing globalisation was the introduction of a special organisation for maintaining contacts with and between former AO Fellows, the AO Alumni Association (AOAA).83 Since actual membership in the national and regional AO organisations was strictly limited to relatively few leading surgeons, another form of participation for the large number of interested and committed surgeons was required. The idea for an organisation on the level of fellows did not originate with the AO leadership but came from former AO Fellows in North America. First conceived in 1987, the formal establishment of the AOAA was officially announced in 1989. At the first General Assembly in 1990, the AOAA already had 500 members, 300 of which were based in North America. Besides former AO fellows, the Alumni Association also welcomed AO course faculty members and participants of AO Advanced Courses as members. Membership was meant to provide those interested in the AO philosophy with the opportunity to keep in touch with the AO group through regular

233 Figure 22

Expenditures of the AO Foundation, 1985–2000, SFr millions.

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mailings of the AO Dialogue magazine and newsletters, as well as social gatherings during meetings and courses. By October 2000 the AOAA had 31 local chapters with 2297 members from 86 countries. Initiatives such as regionalisation and the establishment of national or regional alumni chapters were supported as part of the efforts to maintain the family spirit which was so typical of the early AO, and which was increasingly endangered by the network’s global growth. In part perhaps due to these new organisational forms, many surgeons involved in the worldwide AO activities express a strong commitment to the AO’s cause. Apparently the special community spirit surgeons can experience in the AO continues to be a major asset of the group in comparison with other surgical associations or medical instrument companies. Another element of the positive image which sets the AO apart from other associations is its Swiss roots. This part of the AO image was symbolised by the decision to set up the general AO headquarters in a high alpine setting in Davos, the AO Centre, the opening of which constituted another turning point in the more recent history of the AO. Members 2500

2297 1942

2000

2051

2144

1738 1545 1500 1202 916

1000

435

500

537

623

149 0 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Year Figure 23

Members of the AO Alumni Association, 1989–2000

The AO Centre The idea for building the AO Centre emerged from the considerations concerning the future of the AO Laboratory in Davos. After 25 years, during which the AO scientists had shared the facilities of the Villa Fontana with the medical division of the traditional Davos Research Institute, the building


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had become too small for the now more than 60 scientists. Renting an additional building had provided only temporary relief. One option to remedy the situation was to invest in extending the old buildings, which were, however, not owned by the AO. Therefore the Board of Trustees chose the other option and in 1987 decided to build a new AO-owned laboratory building. The decision also included allotting a yearly amount of support to run this laboratory on a larger scale than before, an investment which also meant a centralisation of the AO’s research efforts, precluding additional major commitments towards establishing new research facilities elsewhere.84 The trustees also had to consider the question of whether the new laboratory should also be located in Davos, far away from any universities or airports. Some AO surgeons, such as Maurice Müller, favoured a closer connection to existing research facilities at some university. Others even suggested going to the US. However, the Board of Trustees decided that the AO Research Institute should not ‘belong’ to any particular university but should be an autonomous research nucleus, entertaining relationships with a number of universities. Davos, with its symbolic value for the AO, was seen as an ideal place for undisturbed thinking and research in beautiful surroundings.85 The Board also decided to build more than just a new research laboratory. They planned to establish an AO centre, which would house under one roof all the existing AO institutions. The centre would include the AO Research Institute, the AO Foundation itself, the AOI, the AO Course Secretariat and the AO Documentation Centre. So three of the AO’s supporting ‘pillars’ – research, documentation and education – would be accommodated in the centre. A representation of the fourth pillar – instrumentation – was added when in 1993 the Research Institute’s former section for the development of prototypes was transformed into a self-sufficient AO Development Institute with over 30 employees under Stephan Perren’s directorship. Devoted to the improvement of trauma treatment techniques and the development of new and improved equipment, its activities overlapped with that of the Research Institute, thus providing the opportunity for close collaboration between the two departments.86 The new centre’s architecture was designed with the need for close cooperation between the different departments in mind. Combining a modern and flexible design with traditional Swiss architectural elements, it fits in well with the surroundings of the plot of land outside Davos the AO bought for that purpose in 1989. For this, a plebiscite of the Davos citizens had been necessary in order to obtain a special permit to use what was originally pasture for building a research institute. After some complications – for instance, a change in the design for geological reasons and an increase in cost from SFr18 million to SFr25 million – the building was finally opened officially on 28 June 1992.87

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Keeping to the traditional Davos location, while at the same time building an ultra-modern, internationally oriented centre of research and administration, was a shrewd step to take. The centre indeed functions as a symbol of the AO’s identity in a changing world. Its unusual venue symbolises the group’s Swiss roots and its exceptional character. At the same time the centre is a visible demonstration of scientific and financial autonomy, independent of any university in any particular country. In its internal architecture it embodies the AO’s feat of having united surgery, science and industry for the development and controlled spread of a highly innovative and sophisticated concept of fracture care. With this the AO is in certain respects an exception, but, as I will point out in the concluding chapter, it also represents some of the principal trends in the development of medicine in the second half of the twentieth century.

Part III Conclusion


Conclusion: Surgery, Science and Industry in Modern Medicine

As I stated in the introduction, my purpose in studying the history of the AO was twofold. By investigating the way a single technique, in this case osteosynthesis, was transformed from its pre-AO state of peripheral significance to a technique that redefined the standard in fracture care, I hoped to gain insight into the general development of medicine in the second half of the twentieth century. At the same time, I expected that a reconsideration of the modern medical context in broader terms would clarify the conditions necessary for the success of a particular technique. While I have tried to regard both aspects at each step in my analysis, my goal in this concluding chapter is to bring the main points together and highlight their reciprocity. Technological change in medicine For understanding how medicine became what it is today, success stories like that of the AO are of particular interest. It is by reason of their success that innovations are able to change medical practice. This seems simple enough and may tempt the present-day observer to assume that the manifest success of an artefact or a technique can be explained simply by its intrinsic usefulness and practicability and that no further explanatory work is needed. But that assumption is false. It is precisely the conditions of success that have to be explained.1 The precondition for the emergence and spread of any successful medical technology is that it has a societal function. Osteosynthesis could be developed only in a context in which trauma surgery and specifically fracture care were judged important enough to invest considerable sums of money in their development. This aspect should not be taken for granted. Traumatology became important as part of the societal compromise to tolerate the occurrence of a certain rate of traffic, industry and sports accidents provided that sufficient health care facilities were available to the victims. By offering a technological solution to this political problem, surgeons 239

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certainly participated in developing the compromise, but they were not the determining force behind it. Their responsibility lay in responding to a task appointed by society. This example shows the extent to which fracture care was woven into the fabric of modern society. Or, to put it differently, the ‘content’ and the context of modern fracture care technologies developed together, and both were constituents of more general developments, so that medical technology must be treated as another element in the social, political and economic history of medicine and society in general.2 This does not mean that technical efficiency was irrelevant in the case of osteosynthesis. Surgery is a technology of control. Its essence is to subject the living material of the patient’s body to the surgeon’s will. 3 The AO technology was able to enhance surgeons’ control by fixing the fragments of broken bones in a way that allowed them to heal exactly in the right position. Technical efficiency made the AO instruments very attractive and was indeed a crucial factor for the AO’s success. A group like the AO would have failed 30 years earlier because the technical abilities necessary to realise their aims did not yet exist. On the other hand, the availability of useful technology was not enough to make osteosynthesis successful. With the exception of the nailing of hip fractures and intramedullary nailing, osteosynthesis was not used in routine practice until the AO started propagating its method in the 1950s and 1960s. Before the AO’s involvement, most attempts to spread osteosynthesis techniques had failed because their proponents had been unable to achieve and prove their reliability and safety on a large scale. This shows that the widespread use of a technique is not simply evidence of its inherent superiority but the result of much work to make it effective, useful and practicable. One of the measures that made osteosynthesis reliable was the standardisation and quality controls the AO introduced for its instruments and implants. Another element was the group’s systematic effort to change the context of its use. The AO technique was based largely on a method earlier proposed by Robert Danis. But since Danis had not developed a system to improve the conditions of its use, other surgeons could not reproduce his results and subsequently rejected his method. The AO modified Danis’ principles only slightly, but took it as its special task to control the spread of the technology. It created structures not only to check the material but also to survey its application and to support surgeons in acquiring the necessary skills to succeed. In this respect, the AO was acting in accordance with the comprehensive definition of technology proposed in recent science and technology studies.4 According to this definition, the word ‘technology’ has three layers of meaning. First, there is the basic, physical level of technology; in our case this involves the instruments and implants. Second, technology is viewed as an activity, a means to accomplish a specific goal; that is, the operative procedure of osteosynthesis can be called a specific technology of fracture

Conclusion: Science and Industry in Modern Medicine

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treatment. Finally, technology is what people know: having the instruments and starting to use them on fractures was not enough for the successful introduction of osteosynthesis; its users also had to know how to apply the tools and the techniques within their sphere of activity. The spread of knowledge, know-how and practical skills associated with the technology of osteosynthesis were of crucial importance for its success. Historians’ traditional focus on the invention of medical technology often leads them to overlook the most important points in understanding technological change in medicine. Seeing change as technology-driven makes modern medicine appear to be the result of natural and inevitable developments. From this point of view, technology seems as if it were ‘some kind of autonomous, self-defining force’.5 If, however, the perspective is broadened to include the actual process of the spread of osteosynthesis, including its initial failure in this respect, then ‘discovery’ and ‘invention’ reveal themselves as complex processes which cannot easily be separated from the introduction of a novel idea or artefact into a social or economic system, a process often called ‘innovation’.6 It is worth looking beyond the simple development of tools to examine how instruments were used, how access was regulated and controlled, what skills and resources were needed to operate them and what meaning they were given, because it shows how the technology’s use was shaped by its local context and, conversely, how it influenced the local surgical environment as well as medical practice and knowledge on a wider scale.7 The introduction of a technology like osteosynthesis is thus best described not as a single event but as a process during which the context as well as the technology itself may change. Similarly, the sharp distinction between the phases of invention, innovation and diffusion, which is so typical of economic models of innovation, should be avoided because it simplifies this complex process of acceptance.8 Osteosynthesis became broadly accepted not immediately after its invention but only after both the context and the technology itself were altered considerably. Medical innovation as network-building As the AO’s success could not be explained by either the inherent superiority of the technology or the contextual conditions alone, it was necessary to find another explanatory model that transcended these categories. Here it was helpful to apply the network metaphor as used in science and technology studies. The people introducing the instruments and implants could not restrict themselves to design and manufacture; they also had to consider the relationship between artefacts and social, economic, political and scientific factors. As John Law has written in his description of another technological innovation, ‘innovators are network builders’.9 When considered in this way, the introduction of the AO technique emerges as the building of a complex network of specific practices, actors and objects linked to different localities.10

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First, there are the people, that is, surgeons, scientists, manufacturers, and patients: the AO technique did not exist independently of those who used it, and the AO philosophy was only true as long as there were surgeons, scientists and patients acting in accordance with it. Then come the theories and models, and, finally, the materials used in surgical and research practice as well as other resources such as funds. Many of these elements were connected and influenced each other, despite their varied origin from the contexts of surgery, laboratory science or business.11 John Law further describes the elements of such a network as often ‘difficult to tame or difficult to hold in place’. For this reason, ‘vigilance and surveillance have to be maintained, or else the elements will fall out of line and the network will start to crumble’.12 This also holds true for the AO. Control was necessary to ensure that techniques were performed in the proper way, devices were produced to a reliable quality, and theories were understood as intended. Depending on its context, ‘control’ can emphasise either the aspect of exerting power or the aspect of monitoring, checking and supervising. For instance, in an act of self-control the surgeons committed themselves to using strictly standardised equipment in accordance with specific rules laid down by the AO. Each application of the technique was monitored by the AO Documentation Centre, and the production and marketing of the AO equipment by the manufacturers was supervised by a technical commission. Control over conveying skills and imparting knowledge to the individual surgeons was enhanced by standardised instruction courses and textbooks. But as the case of the AO equally shows, control could not be imposed without the collaboration of those subjected to it. Thus words like ‘surveillance’, ‘discipline’ and ‘control’ describe only one aspect of the AO network. One cannot understand its success without also considering the collaborative side of network-building. Cooperation in such a network is only possible if the participants are allowed at least a certain degree of autonomy to pursue their particular interests and develop ‘flexible, heterogeneous economies of information and materials’.13 This sort of relationship between the different elements of the network can best be described by the terms ‘communication’, ‘exchange’ and ‘negotiation’. The AO brought together a large number of different types of participants in its network, allowing each of them to pursue their own interests while at the same time contributing to the overall enterprise. Medical technology and cultural patterns Medical or scientific networks never form in a cultural vacuum. Their type and even their very existence depend on the availability of cultural patterns for building up interpersonal relationships. The interaction of the initial participants of the AO network was shaped by the cultural environment of its local origin in the region of Bern in Switzerland. The AO started as a small


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group of friends, to which new members were added through personal acquaintance. All the initial members belonged to a specific medical milieu. They were head surgeons of the small to medium-sized public hospitals scattered throughout the country. Communication succeeded by means of a separate professional network that existed parallel to – but deliberately distanced from – academic surgery. Their contacts had been favoured by the typical networking among the Swiss educated classes, whose personal ties from school, university, clubs and the military were an important element of Swiss social and political life. The most effective factor, however, for creating the sort of network that enabled the controlled spread of osteosynthesis was the adoption of the cultural pattern of fraternity. An institutionalised corporation of men embodying the Swiss cultural motif of the confederation and its values of liberty, equality, unity and loyalty, the AO was a typical fraternity. As such it was able to mobilise the emotional and moral power inherent in this concept. Like membership in other fraternal organisations, such as shooting clubs or college societies, the AO experience included socialising rituals, formalised acts of male bonding and competition, group solidarity, the copious use of patrilineal metaphors (‘founding fathers’), and ample opportunities for building friendships. Since the boundaries between private and professional life were blurred, AO surgeons viewed fellow members not just as colleagues but also as friends. On the basis of this ‘AO spirit’, the individual surgeons were prepared to subject their surgical practice to surveillance by the group, which was the key to enabling the controlled spread of the AO technique. The social principle guiding the AO was face-to-face interaction between members, which is a type of relationship usually attributed to premodern societies. The AO’s example, however, supports the view that personal familiarity and trust are also fundamental principles for organising relationships among experts in modern science and medicine. These principles are of particular relevance for groups like the AO, with its symbiosis of surgery, science and industry. As Ilana Löwy states, it is exactly such ‘relations across professional and disciplinary boundaries and of interactions between heterogeneous professional groups’ that are central ‘to the understanding of the growth of modern medicine and the biomedical sciences’.14 In this general context, the AO can be viewed as a particular case for the emergence of the so-called biomedical-industrial complex, in which doctors, scientists and industrialists work together to attain their respective goals.15 The agreements, contracts and institutions of the AO network accommodated different interests, but they granted the leading role to the surgeons so that they could pursue their aims according to their specific needs and interests. This concentration of power in the hands of the surgeons arose out of their decision to collaborate with small but growing companies outside of the established medical devices business. It is the methodological advantage of historiography, as opposed to sociology or economics, that one

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can see how the forming of this type of collaborative partnership is not necessarily the consequence of a consciously pursued strategy or the result of an automatic trend. The special arrangement that made up the AO symbiosis was the outcome of contingent events and the chance meeting of particular personalities. Surgery, science, and industry in symbiosis Despite, or even because of, the surgeons’ position of power, the manufacturers derived massive benefits from the symbiosis. The direct contact with potential users and buyers of their products gave them an invaluable advantage over their competitors, especially as they were in a market in which competition took place on the basis of adaptation to the users’ needs.16 This sort of feedback process between users and manufacturers, which many other providers would have liked to establish, was a common feature of the AO symbiosis. The special form of cooperation reduced the producers’ risk concerning investments in new products to a minimum. In addition, surgeons’ activities, such as scientific publications, courses, conference attendance and contacts with other surgeons turned out to be an effective means of product promotion, which, again, was something other companies could only dream of. Seen from a sociological perspective, the AO symbiosis resulted in an effective feedback system of symbolic and monetary capital.17 For the surgeons involved, the AO was not a business company but an alliance for the purpose of improving fracture care whose aims were incompatible with business considerations. But it was also clear that the AO depended on the producers’ commercial success to reach its own medical goal. Whenever doctors and scientists participated in the profits of selling drugs or other products, they found themselves in inner conflict with their roles as representatives of their patients’ interests and disinterested pursuers of truth. The AO’s answer to the problem was to prohibit any private financial gain through the organisation. But while direct profit-making was strictly forbidden, surgeons did derive indirect benefits from working with the AO: the group not only offered them the chance to obtain money for research and travelling; it also provided them with a very useful, attractive treatment method that made them popular among patients and thus enhanced their career prospects. With its complex structure of different yet interdependent elements, the AO was a special model of integrating and regulating commerce, science and medical practice. Though an organisation like the AO could not force consensus of the different spheres of business and medical care, it could provide a forum for negotiating interests and finding mechanisms for compromise. This is much more than either a normal medical association or a medical device company is able to achieve. In the language of interactionist sociology, the success of the AO concept was due to a great deal of collective work done at the intersection of different


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social worlds with varied concerns. 18 From this perspective, a successful therapeutic innovation like the AO technique can be seen as an efficient articulation of the multiple interests of clinicians, basic scientists, industrialists, health administrators and patients.19 But interactionism also points to the fact that different social groups can only cooperate and reconcile their multiple viewpoints if they communicate using common key concepts and techniques.20 In the case of the AO, collective efforts were based on a particular concept of fracture care. Within this overall concept, a variety of elements could be described; among them the theory of primary bone healing, the practices of compression osteosynthesis and post-operative exercise and, on the level of materials, a standardised set of instruments and implants. These elements were common to all those engaged in the AO and functioned as a means to direct their action toward common goals. Because of their character of crossing the boundaries between social worlds, sociologists Susan Leigh Star and James Griesemer have called such entities ‘boundary objects’.21 Boundary objects hold different meanings for different participants within their respective contexts. This is also true for the AO’s boundary objects; for instance, the implants. For the surgeons the AO implants were tools which allowed them to fasten bone fragments; for the patients they were temporary body parts enabling them to move without pain; for the scientists the implants were either the objects of inquiry or a part of their experimental set-up; for the manufacturers, instruments and implants were the products they made and sold. It was this flexibility in meaning that made cooperation possible at all. In reconciling these different meanings, it was hoped that the interests of each party would to be served to a certain degree, so that a network of surgeons, patients, manufacturers and scientists could be established and managed. This task lay at the basis of much of the AO’s structures, such as the surgeons’ association itself, Synthes AG Chur, the three producer firms, the commissions and all the written and unwritten regulations and contracts that ruled the relationships between them. It also shaped the AO in its support of research, in organising courses and publishing textbooks as well as its various efforts to maintain control and cooperation within the AO network.22 Over and above creating adequate conditions for the successful introduction of their method, the AO needed to manage its network in such a way that allowed stability and flexibility at the same time. To maintain the usefulness of their surgical technique, the validity of their scientific knowledge and the commercial success of their products, the AO set up special mechanisms for controlled innovation. The result was a kind of controlled development programme that institutionalised the cooperation between network participants in improving and inventing equipment. So, clearly the AO accepted the fact that it would have to rearrange parts of its large, sophisticated network from time to time if it wanted to keep up with changes in the

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theoretical principles of fracture care and osteosynthesis techniques as well as advances made in the manufacture of instruments and implants. In practice, this meant that the equipment had to be modified, textbook chapters had to be rewritten, and courses had to be reorganised – all of which had to be done without disrupting the comprehensive AO system and without compromising the AO’s credibility as a medical and scientific authority. The need to maintain the network explains why the AO sometimes showed a certain tendency towards conservatism. The rate of innovation also constituted a potential point of conflict between business interests, which demanded speedy innovation, and medical interests, which were more oriented towards strict but time-consuming quality control. In the end, however, the emphasis on proven quality turned out to be a good marketing strategy and added to the positive image of the AO instruments and implants. Controlled expansion Promoting the AO technique beyond its place of origin, first inside Switzerland and later to other countries and continents, meant turning a local phenomenon into a universal phenomenon. Looking back on the failures of its predecessors, the AO realised that the universal application of its method could only be achieved by exerting control in various ways. One central point was to make sure that the technique was applied in the correct way by standardising the surgical procedures. Procedural standardisation is a characteristic of those fields of modern medicine in which the mass application of a treatment method and thus its universal applicability depend on compliance to a certain sequence of actions. But, as the case of the AO technique shows, standardisation could be achieved only up to a certain point. In order to remain practicable in different contexts, the AO technique had to be flexible enough for local cultures of application to emerge. Since any technique inevitably changes when it is applied in specific local contexts, sociologist Marc Berg suggests speaking not of the success or failure of standardisation, but of a ‘convergence’, a mutual adaptation of technique and context that makes successful spread possible.23 Of course, tolerance to such local adaptation has its limits: if deviation from the standard procedure goes so far as to noticeably diminish the success rate of the treatment, then it is appropriate to speak of failed standardisation. The spread of the AO technique was thus more than the passive transfer of instruments, knowledge and skills. There was also a specific surgical subculture transmitted, which involved the active adaptation of the environment with regard to all three layers of technology described above. These layers of technology were not strictly separated. Structural characteristics of the materials, for instance, had an impact on the behaviour of the users: already the fact that the AO equipment was sold only in sets was an instance of ‘pre-disciplining’ the users, a strategy that was to become more


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widespread in modern medicine when other uniform, ‘packaged’ technologies were created.24 User guidance was also the objective of the AO’s educational programme. A traditional form of standardised teaching were the AO textbooks, above all the AO Manual which provided a ‘cookbook’ form of instruction. Such attempts at standardising medical practice fitted in with other contemporary efforts, as exemplified by the protocols in clinical research. But surgical skill could not be acquired by reading books alone. Surgical knowledge is generally perceived as tacit knowledge, which cannot be rendered completely into verbal instructions but also has to be conveyed by practical means. Accordingly, hands-on courses for doctors and nurses were the core element of the AO’s instruction efforts. They became very popular, functioning as a primary asset in making the technique accepted, and later served as a model for a number of other attempts at user education in surgery. Here again, standardisation was a principal strategy to ensure controlled spread. The means to achieve uniform instruction included centrally created and distributed slide series, videotapes and the use of plastic bones with prefabricated uniform fractures. A related approach to the spreading of skills and know-how was the AO’s fellowship programme. It turned out to be extremely useful since it not only transferred skills but also functioned as another means of building up trust relationships between surgical teachers and pupils. These relationships then became important resources for the controlled expansion of the AO technique on a global scale. This is not surprising, since from the very start the only reliable way to extend the AO network was via personal contacts; it also remained the most important expansion strategy for the AO. The primary effect of personal contact was to create trust and credibility with surgeons outside the AO, but just as important was the reverse function of finding partners the AO surgeons could put their trust in. This is why the AO’s investigation of potential partners abroad was not restricted to their surgical and scientific abilities but also took into consideration their character and moral standing; in short, their trustworthiness. So when the AO sent out its representatives to foreign countries, they always had the twofold agenda of satisfying the bidirectional need for trust and credibility. Patients also belonged to the interpersonal network of trust relationships that formed the basis of the AO’s success. For example, foreigners on holiday in Switzerland who suffered skiing accidents which required treatment for broken bones played an important role in extending knowledge of the AO technique to other countries – when they returned home, their doctors were informed of the treatment they had received. In general, patients mostly preferred operative treatment to the lengthy procedures of conservative treatment methods, and surgeons who adopted the AO approach became popular in turn. The popularity of these surgeons contributed very much to the demand for AO equipment among other surgeons in their circle.

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As the outcome of osteosynthesis treatment also depended on patient compliance, surgeons avoided operating on persons they deemed unsuitable, such as alcoholics. It is evidence of the multidirectional character of the trust necessary for building up and maintaining a network like the AO’s that patients also had to be checked for their reliability before they were allowed to join. This is the more noteworthy as the reciprocal character of trust relationships in modern medicine is often overlooked in discussions on the patient–doctor relationship. Equally, the whole personal dimension is often underestimated. Rationalisation, standardisation and control are seen as part of a modern societal change that goes hand in hand with growing anonymity and depersonalisation. By contrast, the case of the AO shows that personal relationships and face-to-face communication still remained crucial. Within such networks the allegedly premodern world of familiarity, personal interaction and virtue are far from being lost. The story about the modern condition that points to anonymity and system trust has to be supplemented by a second story that identifies persisting patterns of traditional familiarity and trust in known persons, as historian of science Steven Shapin has claimed.25 It is difficult to imagine how such personal ties could not form the basis of important trust relationships not only in modern medicine and science, but also in industry, business and politics. Of course, trust in anonymous systems and institutions is necessary if the modern world is to function, but it has to be complemented by the more traditional model of face-to-face relationships. The power of science I: the clinic and the laboratory The AO technique is an instance of modern, science-based medicine. Though it can mean different things, the term ‘science-based’ often relates to a basis in laboratory science. Ever since the ‘laboratory revolution in medicine’, which took place in the nineteenth century, medical measures have required a basis in laboratory discoveries. In the course of this re-evaluation the desire emerged to use objective, scientifically produced knowledge to transform medicine from a more or less erratic ‘art’ based on the logic of individual experience and judgement into a ‘science’ with clear and unambiguous rules.26 At the time of the AO’s founding, this concept was generally acknowledged in surgery. The problem with the AO technique was that it was designed contrary to the ideology of modern medicine, insofar as it was based not on scientific discoveries but on the ingenious application of practical surgery and the art of engineering. According to contemporary knowledge, the technique proposed by the AO could not function because it contradicted the basic laws of bone healing. Convincing the general surgical public that its technique complied with the laws of nature was thus another prerequisite to creating an appropriate context for the technique’s use.


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Supported by the income from royalties received from the producers, AO surgeons and scientists were in fact able to alter general opinion in their favour and to provide their technique with a scientific basis. Laboratory research enabled them to put forward their preferred theory of bone healing and to present it as a plausible scientific foundation for the propagated methods of osteosynthesis. This was also an important step for vindicating the group’s boundary objects, such as compression osteosynthesis and primary bone healing, thereby further enhancing the group’s coherence. Even though the AO’s basic tenets turned out to be much more complex and unclear than expected, they still functioned as a common base. They helped to stabilise the network to such a degree that it was capable of surviving even in the following decades when the tenets would turn out to be wrong or insignificant. The AO scientists were able to achieve all this by applying the principle of medical laboratory research. According to this principle, two main objectives had to be fulfilled. First, the conditions in the laboratory had to be sufficiently simplified to achieve a degree of control over life phenomena that allowed the scientists clear empirical observations and plausible causal explanations. At the same time, however, experimental conditions needed to remain convincing representations of clinical reality. Whether both these conflicting aims were indeed accomplished was the subject of critical discussions among researchers, and it was the result of a consensus in the relevant community that the scientific basis of the AO technique became generally acknowledged. Concerning the mutual dependence of medical technology and science, the case of the AO illustrates that this relationship does not need to follow the linear model, in which scientific facts are first discovered and then applied in a practical context. In actuality, this relationship is often much more complex. Historically, the contexts of knowledge production in science and the context of application in clinical medicine do not have the clear-cut and unidirectional character normally assumed. 27 Both sides stimulate and provide legitimacy for each other. Also, science imparts more to medical practice than mere informational or technical power; it also has a cultural power that serves as an important resource to the introduction and spread of certain treatment methods. What this means can be seen by reconsidering the function of fracture care in modern societies: as opposed to accident prevention, osteosynthesis is a purely technical way of dealing with the risk of industry, traffic or sports accidents. It is a scientific approach that defines accidents as a technical problem, as opposed to seeing them as a legal or political problem. This concentration on technology effectively represents a special kind of cultural value that is enhanced by medicine’s orientation toward science.28 In describing this general cultural phenomenon, one could even go so far as to claim, with Marc Berg, that the world of medicine was remade ‘not because of science, but through a logic of efficiency that science could be mobilised to confirm’.29 In fact, standardisation and control are

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characteristics of a modern industrial approach to medical care, an approach which enables division of labour and efficient high-quality treatment of a high number of patients. The power of science II: ‘trust in numbers’30 The logic of efficiency was also at the heart of another strategy of making medicine a science, namely clinical research. At the time when the AO emerged, quantitative clinical research was already a widespread alternative to the sole dependence on laboratory science, and statistical thinking was becoming part and parcel of modern scientific medicine. Surgeons had adopted quantitative forms of therapy control early on because operative surgery was in particular need of justification.31 In the case of fracture surgery, traditional ties with accident insurance companies further contributed to the prevalence of quantification and statistics. As a consequence of thorough documentation and analysis of medical practice, patient care came to appear like a kind of experiment, and practising medicine became a research activity bound by the same principles that applied to other experimental research.32 In clinical research, the deterministic approach of experimental science converged with the probabilistic approach of statistics, for instance, when AO surgeons interpreted the results of clinical studies as the expression of some deterministic physiological process taking place on the level of the individual patient. From the beginning, the AO embraced clinical research and established an ambitious programme of documenting and analysing all cases treated by AO surgeons. This programme fit in with contemporary tendencies to perform joint clinical research projects in order to collect more cases and thus obtain a more reliable basis of evaluation. Like laboratory research, clinical research was also based on specific fundamental principles. In order to render clinical experience quantifiable and calculable, clinicians had to simplify, objectivise and standardise reality. Like laboratory experiments, clinical studies necessarily represent an artificial reality, depending very much on decisions made while setting up and performing the studies. The exact means of classification and simplification of clinical reality had a crucial influence on the results of the studies. By performing the research themselves, the AO could include all parameters which it deemed important. The AO technique compared much better to non-operative treatment methods, for instance, when studies included longterm rehabilitation results. Therefore, the AO’s extraordinary commitment to clinical research was an important factor for the publication of ever more clinical data in favour of their method. By participating in the construction of this artificial reality, the AO succeeded in making its technique ‘the right tool for the job’ because it specified the job and the parameters for measuring ‘rightness’.33 As this example indicates, judging a new technique to be useful and efficient depends on the criteria of usefulness and efficiency that are valid at


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the time when the issue is being debated. That means that the criteria are variable and that notions of rationality and efficiency are disseminated together with the technique developed in accordance with them; in other words, the content and the context of techniques evolve in conjunction.34 An important part of the change in context affected the perception and assessment of the risks associated with osteosynthesis. Here, clinical outcome studies allowed the AO to redirect the discourse in a way that made its technique an acceptable option for routine use. The AO never denied the risks inherent in its technique. On the contrary, the awareness of risk was an important part of its policy to protect the technique by trying to restrict its use to well trained surgeons. In order to further defuse the risk discourse, the AO surgeons did two things. First, they made it clear that complications, should they occur, could be controlled by the users. And second, they redirected the attribution of responsibility for unfavourable results by demonstrating that failures occurring with their method were not attributable to the method itself but to its faulty application. As a result, osteosynthesis was seen more as a difficult rather than a risky procedure. This fits in with a tendency in modern medicine to defend medical procedures, arrangements and structures by conceiving the individual health care worker as the central source of trouble in medical practice.35 The shift in the risk discourse on the AO technique illustrates another general modern phenomenon, described by sociologist Ulrich Beck as the transformation of failures and risks into chances for expansion of science and technology.36 After the shift, failures no longer discredited the AO but, rather, strengthened their position as a group of experts who possessed the means of preventing them. Thus, the case of the AO impressively demonstrates that risk evaluation is always based on particular choices made with regard to moral and societal values, and that cannot follow from empirical observations alone.37 Despite never reaching its original goal of complete documentation and evaluation, the AO documentation project contributed considerably to the AO’s success in a number of ways. Perhaps the most significant effect resulted from the transparency and frankness it symbolised for many surgeons.38 It was by reason of the project’s existence that a basis of trust and credibility could be established between the AO and users of the AO method. The trustcreating effect also explains why the technique was accepted by many surgeons, to the astonishment of the AO surgeons themselves, even before any concrete research results had come out. Obviously the actual research results were not as important for creating trust among surgeons as their knowing that research was being done at all. This is not an exception. As sociologists of science have observed in other cases, expert technical information is often assessed on the basis of the trustworthiness of its origin rather than on an understanding and evaluation of the information itself.

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Moreover, the need to accept an increasing amount of information on the basis of trust has been identified as a hallmark of modernity, since no individual would be able to handle the amount of specialised knowledge required to understand all the technologies we encounter in everyday life, such as the workings of an aeroplane or the scientific background of a medical treatment.39 In sum, the AO’s scientific activities contributed very much to its success. Since these activities were financed by the producers’ royalties, commercial success automatically led to an increase in research funds resulting in a circle of positive feedback so that the symbiosis of surgery, science and industry led to a sort of scientific-economic perpetuum mobile. Resistance: an alternative view of medicine However, the AO’s line of argument did not convince everybody: a number of surgeons opposed the new technology. Viewed retrospectively, opposition against a successful technical development is often considered to be irrational. Opponents are seen to have been led astray through conservatism or jealousy or some other irrational motive.40 Accordingly, immediately after the AO technique had gained general acceptance, all remaining resistance was attributed to emotional, non-scientific motives. For the historian, however, the reasons for not using a particular technology – even one which ultimately proved to be as successful as osteosynthesis – provide important insights into the process by which communities make decisions on how to practise medicine. ‘Understanding the process may make it clear what choices were available to those who wished to use new technology without assuming that the choices that were made were somehow natural or inevitable’, as historian of medicine Joel Howell notes.41 An important and historically interesting line of argument against the AO came from those surgeons who rejected the aim of making surgery a science, since for them, surgery, like medicine in general, was above all an art. Instead of experimentalism and statistics with their deterministic or probabilistic approaches, they endorsed a different, clinical rationality that was based on contextualisation and individualisation. This traditional clinical approach had lost much of its original clout when laboratory and statistical sciences were gaining influence in the course of the nineteenth and twentieth centuries. Some AO opponents even denied statistics any practical value for surgery. Though this was only a tiny minority among surgeons, it was not so unusual to consider surgery a particularly difficult field for the use of sophisticated methods of clinical research. In surgery the uniqueness of every single patient and each therapeutic intervention are more evident than in other fields, as are the differences in skill of the individual doctor.42 Even the most advanced methods of clinical research fail to convince those who do not appreciate the generalised type of information they yield. On this basis, for instance, critics rejected the AO’s strategy of risk management. Statistical data, they


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argued, would never predict the outcome of the individual case at hand, nor could they appropriately represent the tragedy a complication meant for the affected patient. So risk assessment can indeed be seen as the outcome of a quarrel of competing, contrasting or overlapping claims to rationality, as Ulrich Beck noted.43 The discussions on the AO’s scientific approach to surgery can be seen as an instance of a more general conflict historians have identified in twentiethcentury medicine, namely the ethical clash between those doctors who endorsed ‘professional values centred on the individual’ and others who advocated the ‘statistical necessity of taking averages’.44 Those surgeons who preferred to call medicine an art rather than a science warned against the ‘unthinking physician’ and stressed that medical decisions were fundamentally personal and individual.45 Their unwillingness to reduce the practice of medicine to a set of formal rules also led critics to reject the AO’s systematic training programme. In their view, the course system was just another instance of the modern tendency toward over-specialisation. The courses, they warned, only imparted decontextualised skills and disregarded the tacit dimension of surgical and diagnostic skill necessary for being a good surgeon. In the same vein they also criticised the AO’s efforts at systematic and standardised treatment, which they considered a ‘totalitarian’ approach preventing surgeons from dealing with patients on an individual basis. This sort of criticism was often combined with the warning against a typically modern overestimation of science vis-àvis common sense. The opposition to making surgery a science also had a social dimension, since the two models of medical practice implied different attributions of authority and power to practitioners. Seeing surgery as an explicit, universal and public science embodied a democratic and egalitarian ideal of expertise. According to this ideal, surgery could be mastered by anyone who adhered to the rules.46 However, for those who saw surgery as an art, surgical skill was personal and not easily communicable. Within that concept, personal experience and the authority that followed from it were of central importance. This also meant that clinical expertise was less open to public scrutiny and outside surveillance, so that the individual practitioner had a high degree of autonomy, which would be threatened by a predominance of science. Even though becoming scientific was a successful strategy of medicine as a profession on its way to social and cultural dominance, on the individual level this strategy endangered the doctor’s personal authority. The danger of losing their professional autonomy led a number of doctors to resist the idea of making medicine a science and instead to initiate an important countercurrent to the general trend during the twentieth century.47 It was against such a background that AO critics rejected the group’s concept of scientific and standardised surgery. They feared that it would reduce the individual doctor’s role to that of a mere technician who

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mechanically applied standard treatments to the detriment of good patient care. Their role model was the learned surgeon, whose strong, autonomous personality could withstand such fads as osteosynthesis and who would use his authority to guide patients towards what was best for them, even if the patients themselves erroneously favoured osteosynthesis. So the rejection of making surgery a science as proposed by the AO was not irrational: it simply represented a different strategy for achieving good patient care and an appropriate social position for the medical profession. The scientific view of medicine endorsed by the AO is thus as much a partial perspective on reality as its artistic counterpart. As with any view it is committed to a particular set of values, selecting particular kinds of information, favouring specific strategies of practice and including a special attribution of authority while rendering alternative concepts unimportant, irrelevant or even irrational.48 Acceptance: AO as a brand name On the whole, however, the image of modernity and efficiency associated with osteosynthesis was quite attractive to practitioners of fracture care who, as surgeons, were happy to apply their operative skills whenever it seemed the best option. Critics even think that many surgeons have come to prefer operative treatment because they find it more convenient to operate than to supervise a lengthy healing process using conservative methods, all the more so because operative treatment is more prestigious and lucrative than the unprestigious, poorly paid conservative measures.49 However, the rise of osteosynthesis shows that many surgeons were convinced of its benefits over immobilising treatment methods and considered it a good way to achieve long-term rehabilitation for their patients. Before the AO introduced their controlled and comprehensive system, these surgeons had shied away from operative fracture care because it was too difficult and too risky for routine use. For them, the AO’s programme was an answer to their needs and problems. Thus a general condition for the acceptance of a new technique was fulfilled: a problem existed, to which the AO’s technique was the solution.50 But the process of the AO’s acceptance also shows, as historians of technology have claimed, that in order to ‘close a technological “controversy”, one need not solve the problems in the common sense of that word. The key point is whether the relevant social groups see the problem as being solved.’51 The feeling that the AO had solved a longstanding problem in fracture care can be attributed to various elements of the AO system. One such element is the sophisticated and comprehensive surgical equipment. The fact that the material was developed by AO surgeons who saw to its reliability by subjecting it to strict quality control was seen as a positive point to surgeons who were well aware of their utter dependence on good instruments. In addition, the AO’s attendance to user education, the provision of a scientific


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basis for its techniques, and its systematic clinical evaluation helped to win surgeons’ trust. Deficiencies in all of these points had been perceived as a problem before the AO had been established. So with its specific symbiosis between surgeons and manufacturers, the AO offered exactly what many colleagues had demanded for decades; and they offered it in a ‘package’, so to speak, comprising not only the equipment but also user education and the scientific underpinning. Without deliberately planning it, the AO surgeons had created a brand name with a specific high-quality image, such as the quality-assured image of Mercedes-Benz in the automobile sector. Surgeons could feel safe when opting for the AO. This feeling was even enhanced by the AO’s credibility as a non-profit organisation of colleagues. Thus the AO’s success is another piece of evidence for the general claim that acceptance or rejection of new treatment methods are the outcome of multilateral struggles for credibility.52 Transcultural expansion For its expansion the AO used the specific professional structures and cultural patterns existing in the different countries. This way of proceeding was not the result of a deliberate strategy but rather the outcome of adaptation processes, usually assisted or even carried out by local surgeons. As it turned out, the fraternity culture was so specific to the Swiss environment that it could not be exported without considerable adaptations. Similarly, the concept of symbiosis with industry and the non-profit character of the AO itself were difficult to convey to colleagues abroad. The first countries to which the AO surgeons brought their concept were West Germany and Austria. Even though the surgeons there also spoke German and introducing the technique to these culturally close neighbours was comparably easy, the manner of expansion differed considerably from that in Switzerland. In West Germany the AO did not start as an egalitarian group of nonacademic surgeons at the surgical periphery. Instead, the technique was initially adopted by the head of one university hospital and was spread through the traditional pathways in the German-speaking world. Following the traditional pattern of the surgical school, it was first passed on within the university hierarchy and then introduced to other hospitals when the members of the school became head surgeons there. In this way expansion also occurred in a controlled way. In the West German context the AO technique acquired additional attractiveness by serving as a crystallisation point for the professionalisation of German trauma surgery as an autonomous subspecialty. During the expansion of their organisation to other more distant countries the AO surgeons discovered that the controlled spread of their technology depended on a host of cultural, social and political factors and required recurrent adaptations of their policy. For instance, they had to come to terms with the different local traditions of fracture care and different sorts of practitioners, ranging from orthopaedic surgeons in Britain, conservative

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traumatologists in Austria and adherents of Gavriel Ilizarov’s external fixator in Russia, to bone setters and Buddhist monks in Thailand. The economic conditions in poor, underdeveloped countries posed special challenges, as did the political bureaucracy in Soviet Russia and the feudal cultural heritage in some East Asian countries. The effects of structural conditions often varied: while on the one hand the inflexibility of the medical hierarchy in Asia was an obstacle for the transmission of the AO technique, the relative lack of hierarchy in the North American context also made it difficult to spread the technique, since the surgeons there had to be convinced on an individual basis. The contrast between the AO’s fate in socialist East Germany and in the US demonstrates to what extent the success of even such an apparently cultureindependent technology as repairing bones with screws and plates depended on the cultural, social and political context. In East Germany the AO was part of the official health care administration. Also, AO products were a rare commodity and were centrally distributed, so that East German AO surgeons were in a position to restrict their use only to colleagues who were prepared to undergo training and surveillance. As a consequence, the technique was used with very good results and only few complications, thereby earning itself an extremely positive public image. The effect of government policy and scarcity had resulted in a controlled spread of the technique and thus substituted the effects of the Swiss fraternity pattern. In the US, AO instruments and implants were freely available. Often they were bought and used by surgeons who lacked the necessary skills and knowledge. For decades US surgeons were not prepared to subject themselves to the surveillance of their Swiss AO colleagues, nor was it possible to organise a close-knit AO community following the Swiss example. As a consequence of complications and poor results that followed from the uncontrolled use of the technique, the AO acquired a very bad reputation that did not abate until the 1980s, when the technique was finally acknowledged in the US. Maintaining control turned out to be an open-ended task. Contrary to their initial expectations, the AO surgeons could not relax their surveillance once the technique was more established. The situation became particularly precarious when, in the late 1960s and early 1970s, AO subsidiaries sprang up in different countries and threatened to elude the Swiss AO surgeons’ control. Some foreign groups who called themselves AO even started to propagate their own instruments or initiated collaboration with other manufacturers under conditions different from those of the AO/Synthes symbiosis. Such problems needed an immediate response since they endangered the whole network, but the AO was able to adapt its structures accordingly. When the AO’s size transcended that of a face-to-face community, many of the functions that had been fulfilled by personal interaction had to be formalised and transferred to newly created institutions. In order to accommodate the various goals and interests of those involved, more


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transparent and participatory mechanisms for decision-making were established in the mid-1980s when the AO was reorganised as a Foundation. However, the basic balance of medical and business interests was preserved and even more formally regulated in the Foundation’s statutes and bylaws and built into the new institutional structures. The AO even succeeded in retaining the special atmosphere of friendship derived from the Swiss fraternity model, so that the ‘AO spirit’ continues today to be a very effective asset in enhancing its attractiveness among surgeons worldwide. Progress? Was it good that the AO was so successful? Was medicine the better for it? As relevant as such an estimation may be for doctors and patients confronted with choosing a form of treatment, it is not the historian’s primary task to answer these kinds of questions, but rather to collect and discuss the opinions of various historical actors and to examine how and why a particular technique came to be regarded as a good way and for many surgeons the best way, to treat bone fractures.53 Here it is again useful to study the reactions of the opponents because it was they who made explicit the implicit choices of accepting this particular technology. They point to the fact that making operative care the standard treatment makes medicine more expensive. Even if, as osteosynthesis proponents correctly claim, the overall savings through better rehabilitation compensate for the additional cost, the widespread use of osteosynthesis diverts the flow of money from compensation payments to operative treatment. This is a choice that makes much sense, but it is still a choice, and it clearly enhances the trend towards technological solutions to social problems, as mentioned at the beginning of this conclusion. The critical argument according to which many fracture patients today are treated surgically even though their condition would not require it, points to the modern preference to apply too much technology rather than to risk poor treatment results with conservative therapy; again a choice that is rational but not without alternatives. The rise of osteosynthesis supports the general trend of providing technical solutions so that other possible ways to deal with these problems – for instance, political, legal and moral approaches – are backgrounded. This is not to say that such a development is bad, but it surely changes the way we think and live.54 Independent of whether one likes the increase of technology in medicine or not, its further rise is limited by economy. This is most visible in the less developed countries, where the global spread of the AO has reached its limits. The experience of being confined by socioeconomic conditions has stimulated the AO surgeons to consider such basic problems, for which purpose they even established a special committee. But the problem is a general one which

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goes far beyond fracture care, and which also threatens richer countries, where the medico-industrial complex has expanded to such a degree that health care exhausts an ever growing portion of the wealth of these countries. However, the economic dimension is only part of the picture. It is again critics who point out how the success of the AO system also contributed to changing the face of modern medicine. Doctors indeed tend to become more technically perfect and more specialised. Simultaneously, they are normally less interested in individualisation and contextualisation. This does not mean, however, that doctors impose this view on patients. As the AO case shows, most patients expect their doctors to deliver this kind of technologically efficient medicine and thus contribute themselves to the increased emphasis of medical care on the provision of high-tech services. This does not mean that these trends follow some preordained course. Tendencies like rationalisation and standardisation cannot simply be ascribed to the effect of general trends, as it is rather the general trends that follow from the requirements of concrete challenges, such as trying to spread a sophisticated technology or trying to defend it against criticism. Of course, defence was the more effective the more it was based on the generally accepted ideology of the time, that is on science. But there is nothing automatic in this development. Therefore it is difficult to determine the role the AO had in forming modern medicine or to say whether it is paradigmatic for medicine in the second half of the twentieth century. Though the AO indeed embodies many typical characteristics of modern medicine, it is also unique in its own way. Thus the special arrangement between industry and medicine in the AO offers one way of regulating the often conflicting interests of these two fields. To be sure, it is an attractive arrangement because of the predominance of medical considerations vis-à-vis business. But one cannot easily recommend the AO symbiosis as a model to be emulated by others who do not have the same history. The other reason why one cannot say that the AO is paradigmatic for modern medicine is that there is not simply one modern medicine. Modern science and medicine are too varied, their relationships too undetermined to make such a general assessment.55 Even modern ‘scientific medicine’ is a rather multifarious entity, 56 so that one can even speak of a number of different cultures of modern medicine. On a very general level, the example of osteosynthesis and the AO makes it clear that the development of modern medicine into its present form was neither inevitable nor natural, but rather ‘that there were in fact choices to be made’; more specifically, looking at a single technique can be useful in identifying ‘what past choices have been made and what the effects of those choices have been’.57 The conclusion that even a successful medical technology is the result of specific choices made by human beings gives


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us a general insight into the nature of contemporary medicine, namely that it is the consequence of past decisions and not of a quasi-natural tendency towards progress and improvement. Understanding this basic condition facilitates a critical evaluation of the technical, societal and cultural choices that are implicit in the various kinds of modern medicine we have today.

Notes

Introduction 1. Even today almost all fracture surgeons are male. 2. Cf. Söderqvist 1997b, p. 4. 3. On oral history and its pitfalls, see for example Thompson 1988; Söderqvist 1997b, pp. 7–8; de Chadarevian 1997, pp. 55–61. 4. On the value of articles and books as sources, see Marks 1993, p. 1593 and Holmes 1981, p. 64. 5. It is important to note at this point that my project on the history of the AO was financed by the AO Foundation. The study was conducted as a research project at the Institute for the History of Medicine at the University of Freiburg in Germany. The AO gave me unrestricted access to the existing archival material and to witnesses and at no time obstructed my freedom of interpretation of the material. For a critical view on commissioned history see Cantor 1992.

Chapter 1 1. The steady increase of accidents through industrialisation, increase of traffic and rising popularity of sports was frequently noted by fracture specialists and often used as justification for their demanding more resources: see for example König 1931, p. 1; Böhler 1943, vol. 2, p. 1509; Burwell and Charnley 1964, p. 405; Frank and Zitter 1971, p. 12; Olerud and Karlström 1972a, pp. 8–9; Rüedi et al. 1975, p. 252; Clancey and Hansen 1978, p. 119; van der Griend et al. 1986, p. 430. 2. Cooter and Luckin 1997b, pp. 1–12. 3. König 1931, p. 1; Pettavel 1955, pp. 435, 442–6; Böhler 1958, pp. 179–80; Clarke et al. 1959a, p. 1; Badger 1959a, p. 130; Seiffert and Fiegler 1963, pp. 216–19; Burwell and Charnley 1964, p. 405; Stewart et al. 1966, p. 786; McNeur 1970, p. 58; Rüedi and Lüscher 1979, p. 74; Burri et al. 1979, p. 84; Rittmann et al. 1979, p. 132. On the growing awareness of the problem of traffic accidents and the bone fractures caused by them in interwar Britain, see Cooter 1993b, p. 189. 4. For Britain see for example Plowden 1971, pp. 21–59; for the US, Eastman 1984. 5. For example, in the US after World War II, Eastman 1984, pp. 94–5. The effect was particularly striking in West Germany where, after the wartime speed limit had been lifted in 1953, the severity of injuries increased, decreasing again when the limit was reintroduced in 1957 (Gögler 1962, pp. 14–26). 6. Plowden 1971, pp. 245, 258–9, 271; Trunkey 1983, pp. 21–2. 7. Seiffert and Fiegler 1963, p. 223. 8. Böhler 1958, pp. 179–80. From the 1940s into the 1960s the eminent German surgeon K.H. Bauer repeatedly demanded speed limits and other preventive measures (see Gögler 1962, p. 15). 9. Kirschner 1938, pp. 199–200. 10. Plowden 1971, pp. 389–90. 11. Trunkey 1983, p. 24. 12. Cooter and Luckin 1997b, p. 7. 260

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13. Cf. Cooter 1997, p. 128. 14. On the social construction of the category of ‘accident’ in general, see Green 1997. 15. Lorenz 1955, p. 55. 16. Quotations from Gaston 1975; Allgöwer 1978, pp. 1072–3. Trunkey 1983, p. 20, calls trauma ‘the neglected disease of modern society’. 17. On sports medicine in Germany, see Hertel 1997, pp. 313–14; on skiing and surgery, see Allgöwer 1961, p. 222; Rehn 1965, p. 507; Allgöwer 1978, p. 1071. 18. Cooter and Luckin 1997b, p. 7. 19. See for example, for Britain, Bartip and Burman 1983. Public and medical attention to accidents in the workplace had even started earlier than interest in traffic, sports or household accidents (Böhler 1958, pp. 179–80); also Volkmann 1963, p. 127. 20. For a succinct general survey, see Bynum 1994, pp. 196–202 with more literature on pp. 248–9. Specifically on Germany, France, Britain, Austria and Switzerland, see Köhler and Zacher 1981; for Switzerland, France and Sweden, see Immergut 1992, for Germany, see for example Ritter 1998, pp. 37–52; on US health insurance, see Numbers 1982; Fox 1986. 21. The following account of accident insurance and occupational health is based on Quentin 1963; Köhler and Zacher 1981; Ritter 1983, pp. 11–13, 30–2, 85–86; Hentschel 1983, pp. 13–14, 28–9, 123–44, 191–4; Bartip and Burman 1983; Weindling 1985; Gritzer and Arluke 1985, p. 40; Bartip 1987; Immergut 1992; Cooter 1993b, pp. 82–104; Milles 1997; Sellers 1997, pp. 24–43; Ritter 1998, pp. 27–37; Povacz 2000. 22. Figlio 1985, p. 186. 23. Cf. Milles 1997, pp. 183–9. 24. Cf. the similar argument by Milles 1993b, p. 24. 25. Cooter 1993b, p. 141. 26. On the difficulties of verifying the economic consequences of accidents in general, see for example Böhler 1943, vol. 2, p. 1484. On the statistical material collected by accident insurance companies, see Gray 1928; Böhler 1943, vol. 2, pp. 1499–503; Povacz 2000, pp. 408–15. 27. Cooter and Luckin 1997b, pp. 3, 5. 28. Cooter and Luckin 1997b, pp. 1–12; Green 1997, p. 51; on the insurance companies’ interest in prevention, see for example Hey-Groves 1914, p. 434; Volkmann 1963, p, 126; Hentschel 1983, pp. 192–4. 29. See for example, for Britain, Cooter 1993b, pp. 180–98. 30. Cooter 1993b, pp. 79–81. Cooter notes that the medical profession did originally not play a major role in making accidents socially and politically visible. Accidents had to be brought into focus by others, such as the insurance companies, before any strategies for professionalising the field of traumatology could be articulated. 31. The passages on accident insurance are based on Gray 1928, p. 27 (US). On Germany and Austria, see Böhler 1943, vol. 2, pp. 1509, 1534–42; Lorenz 1955, pp. 29–41; Quentin 1963, pp. 4–5; Hentschel 1983, pp. 123–4; Oestern and Probst 1997, pp. 29–32; Weller 1997, p. 153; Povacz 2000, p. 409. Böhler’s clinic was recommended as a model for many other countries, among them Britain (Cooter 1993b, pp. 191, 205). Cooter points out that the existence of accident insurance schemes did not automatically lead to support for fracture care. Depending on circumstances, economic motives of the insurance companies could account

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32.

33. 34. 35.

36. 37. 38. 39. 40.

41.

42. 43.

44. 45. 46. 47. 48.

49. 50. 51. 52. 53. 54.


either for the presence or, as in Britain in the 1920s, the absence of provision for special fracture services (Cooter 1993b, pp. 147–51). Steinmann 1907, pp. 1–3, 939; Matti 1918, p. vi; Gray 1928, p. 27; König 1931, pp. 1–3; Oestern and Probst 1997, p. 17. On the roots of statistics in bookkeeping, see Porter 1995, pp. 193–216. For more details see Chapter 6. Böhler 1943, vol. 2, pp. 1448, 1502; Lorenz 1955, pp. 5, 36; Böhler 1958; Lehne 1991, pp. 62–86. Quoted in Peltier 1990, p. 52; Cooter 1993b, p. 192. Steinmann 1907, p. 938; Bardenheuer and Grässner 1912, p. 1540; Charnley 1957, p. viii; Ender et al. 1957, pp. 86–8; Krösl 1957, p. 194; Cooter 1993b, pp. 6–10, 85. Trunkey 1983, p. 20. Allgöwer 1978. See also Böhler 1943, vol. 2, p. 1510; Clarke et al. 1959b, p. 1; and from a historical perspective, Cooter 1993b, pp. 81, 206. Cooter 1993b, pp. 84–104. Böhler 1943, vol. 2, pp. 1534–5. Matti 1918, p. vi; Steinmann 1919, p. 2; Lorenz 1955, p. 10; Böhler 1958, pp. 181–7 (with numerous references to other surgeons’ statements on the subject); Bürkle de la Camp 1961, p. 101; Campbell 1963; pp. xiii–xiv; Allgöwer 1978, pp. 1071, 1091; Trunkey 1983, p. 20; Shires 1989, p. 169; Kuner 1997, pp. 135–6. Cooter ascribes the process of discovery to a whole range of various social and economic changes in the course of the nineteenth and twentieth centuries. In this process, professionalisation efforts were one factor among others. Cooter 1993c, pp. 85–8; Cooter 1997, pp. 127, 180–98. This is one instance of how central the definition of ‘demand’ (and ‘risk’) is in the introduction of new medical procedures; cf. Beck 1986, p. 289. As general surveys, see Peltier 1990 and Povacz 2000, pp. 123–230. For the state of the art before World War I, see Bardenheuer and Grässner 1912; Lambotte 1912; Lane 1912; Lucas-Championière 1912; Steinmann 1912; for bone glue see Hedri 1931, p. 145. Hey-Groves 1914, p. 518; Steinmann 1919, p. 1; Böhler 1943, vol. 2, p. 1511; Peltier 1990, pp. 62–84; Povacz 2000, pp. 123–9. On the effect of war conditions see Schlich 1996; on war and medicine more generally see Cooter 1993a. Böhler 1929, pp. 1–29; Böhler 1943, vol. 1, pp. 3–18, 148–55; vol. 2, pp. 887–952 and vol. 3; Böhler 1957a; Peltier 1990, pp. 51–2, 78–79; Lehne 1991. Steinmann 1907, p. 938; Steinmann 1912; Bardenheuer and Grässner 1912; HeyGroves 1914, p. 519; Povacz 2000, pp. 155–9. Lambotte 1907, pp. 59–67; Lambotte 1913, pp. 71–84; Hey-Groves 1914, pp. 437–9, 516–17; Matti 1918, pp. 334–7; König 1931, pp. 56–62; Danis 1932, pp. 21–4; Peltier 1990, pp. 181–96; Colton 1992, p. 23. Tröhler 1991, p. 90. Cooter 1993b, pp. 92–3. Ibid., p. 183. Ibid., p. 181. Böhler 1929, pp. 1–52; Lehne 1991, pp. 53–64. Cooter 1993b, p. 191.

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55. Lister 1883; Mumford 1934, p. 194; Venable and Stuck 1947, pp. 3–6; Deyerle and Bowers 1962; Peltier 1990, pp. 114–19; Colton 1992, p. 13; Povacz 2000, pp. 68–74, 132–9. On Lister, see Lawrence and Dixey 1992. 56. Hansmann 1886; Peltier 1990, pp. 119–22; König 1931, pp. 4–5; König 1952, pp. 238–44; Lange 1959, p. 416. 57. Matti 1918, pp. 311–12; Peltier 1990, pp. 119–22. 58. See for example Povacz 2000, pp. 142–8. 59. Lane 1893; Lane 1905a; Lane 1905b; Lane 1909; Lane 1912; Mumford 1934, p. 196; Böhler 1943, vol. 2, p. 1495; Williams 1973, pp. 5–6; Peltier 1990, pp. 122–3. 60. Lambotte 1907; Lambotte 1912; Lambotte 1913; Société Belge de Chirurgie Orthopédique et de Traumatologie 1971. 61. Sherman 1912; Venable and Stuck 1947, pp. 46–7. 62. Hey-Groves 1914 (cited statement on p. 435); Williams 1973, p. 8; Peltier 1990, pp. 128–9; Povacz 200, pp. 175–80. 63. Venable and Stuck 1947, pp. 20, 200; Watson-Jones 1957 (Watson Jones was a protégé of the major British orthopaedist Robert Jones); Peltier 1990, pp. 53, 133, 187. 64. Peltier 1990, p. 133. 65. Von Langenbeck 1878; Senn 1883; Senn 1889; Böhler 1943, vol. 2, p. 887; Frank and Zitter 1971, p. 7; Williams 1973, p. 11; Peltier 1990, pp. 133–4. 66. Smith-Petersen et al. 1931; Pauwels 1935, pp. 60–74; Böhler and Jeschke 1938, p. 31; Küntscher 1940b, p. 6; Putti 1942, p. 30; Böhler 1943, vol. 2, pp. 887–8; Venable and Stuck 1947, p. 138. 67. Bircher 1886; Peltier 1990, pp. 142–7; Kuner 1999. 68. Küntscher 1940a; Küntscher 1940b, Discussion on the 64th conference of the German Surgical Association, in Zentralblatt für Chirurgie 67 1940, p. 825; Küntscher 1940c; Küntscher and Maatz 1945; Lange 1959, p. 416; Kreuz 1959, p. 538; Bürkle de la Camp 1961, p. 96; Peltier 1990, pp. 147–50. 69. For the following passage see Küntscher 1953, p. 217. Pettavel 1955, p. 436; Watson-Jones 1957, p. 202; Krösl 1957, p. 181; Lange 1959; Böhler 1963; Peltier 1990, pp. 147–50; Heim 1994, p. 26; Povacz 2000, pp. 195–201. 70. Venable and Stuck 1947, p. 83. 71. Lange 1959, p. 419; Gögler 1962, p. 59; Maurer and Lechner 1963, p. 509; Peltier 1990, pp. 147–50; Colton 1992, pp. 24–5; Heim 1994, p. 26; Povacz 2000, pp. 216–19. 72. Hübner 1948, p. 28; Peterson and Reeder 1950; Abel 1952; Reynolds and Key 1954; Bagby and Janes 1958, p. 762; Eggers and Roosth 1959; Robinson 1978, p. 381; Peltier 1990, p. 1253. For a good survey of the different kinds of compression plates, see Bagby 1977. 73. Danis 1932; Danis 1949, pp. 7–19, 94–9; Danis 1956. 74. Steinmann 1919, p. 12; Venable and Stuck 1947, pp. 84–96. 75. Lambotte 1913, p. 47; Danis 1949, pp. 7–8, 14. 76. Watson-Jones 1957, pp. vi, 199. 77. Hampton and Fitts 1959, p. 14. 78. Lange 1959, p. 416. 79. Allgöwer 1964, p. 424. 80. Lane 1912, p. 1532; similarly: Lane 1905b, pp. 137–8; Lambotte 1907, p. 9; Lambotte 1912, p. 1531; Lambotte 1913, p. 4; Société Belge de Chirurgie Orthopédique et de Traumatologie 1971, p. 33; Peltier 1990, pp. 119, 123.

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81. Cooter 1993b, p. 183. 82. British Medical Association 1912, p. 1505; see also Peltier 1990, p. 132. Similar commissions in the US in 1921, 1932 and 1941 came to the same conclusion: Peltier 1990, pp. 132–3; Venable and Stuck 1947, pp. 199, 213. 83. Gray 1928, p. 37. 84. Steinmann 1919, p. 12. 85. Böhler 1929, p. 50. Böhler excepted the hip nail and the Küntscher nail from this general judgement. 86. König 1931, pp. 4–5, 80; König 1952, pp. 243–4; Sherman’s opinion as cited in Venable and Stuck 1947, p. 32. 87. Venable and Stuck 1947, p. 96. See also Mumford 1934, p. 200; Danis 1949, p. 6; Rehn 1953, p. 237; Danis 1956, pp. 740–1. 88. Reynolds and Key 1954, p. 616. 89. Böhler 1943, vol. 1, p. 154; Böhler 1943, vol. 2, p. 1515; see also Böhler 1953, p. 198. 90. Krösl 1957, p. 205; Herzog 1959a, pp. 447, 537; Lange 1959, p. 419. 91. Küntscher and Maatz 1945, pp. 3, 18; Küntscher 1953, p. 217; Lange 1959, p. 416. 92. Danis 1949; Rehn 1953, p. 237; Danis 1956, pp. 740–1. 93. This was also the retrospective assessment by later surgeons such as Williams (1973, p. 13), Robinson (1978, p. 367) and Allgöwer (1978, p. 1072). 94. Nicole 1947, pp. 5–6; Watson-Jones 1957, pp. 187–8. 95. Mumford 1934, p. 197; Heim 1994, p. 28.

Chapter 2 1. My biographical account of Müller draws on Müller 1955a; Müller 1955b; Schneider 1969, pp. 5–10; Müller in Rüttimann n.d., pp. 40–4, 56–7; Gschwend in Rüttiman n.d., pp. 57–60; Schatzker 1998; Schneider 1983, pp. 9–10; M.E. Müller: Robert Schneider 1912–90, (MEM) 1999; Heim 2001, pp. 29–34, 42–6; interviews with M.E. Müller, Bern, 23 March 1999 and 6 December 2000, and Max Landolt, Davos, 10 November 1997. On the Balgrist and its tradition see Rüttimann 1984; Böni 2000. 2. Müller qualified as a Privatdozent at the University of Zürich, which in Germanspeaking countries is acquired through a procedure called Habilitation requiring among other things the writing of a thesis. In Switzerland, Germany and Austria this title is the prerequisite for appointment to a professorship. 3. Heim 2001, p. 30. 4. Personal communication, Max Landolt, Davos, 11 March 1998. 5. König 1998, pp. 48–9, 85–92; Hettling 1998b, pp. 237–8. On Swiss student fraternities and their role in social and political life, see Blattmann 1998b. 6. Cf. König 1998. 7. Heim 2001, pp. 29–30. 8. Lüdi et al. 1952; Willenegger 1953; Böhler 1953, p. 190; Willenegger 1959; Herzog 1959b, p. 537; Willenegger and Roth 1962; Maurer and Lechner 1963, p. 508; Heim 2001, pp. 32, 50–3; interview with M.E. Müller, Berne, 23 March 1999. 9. M.E. Müller: Robert Schneider 1912–90, (MEM) 1999; Heim 2001, p. 32; interview with M.E. Müller, Bern, 23 March 1999. 10. Interview with Eugen Kuner, Umkirch, 20 July 1998, who worked with Allgöwer. 11. Müller and Allgöwer 1958; Schneider 1969, p. 5; Schneider 1983, p. 10; interviews with M. Allgöwer, Davos, 17 December 1997; M.E. Müller, Bern, 23 March 1999.

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12. Allgöwer 1956; Heim 2001, pp. 53–5; interview with M. Allgöwer, Davos, 17 December 1997. When Allgöwer joined the group in the 1950s, two other nonBernese surgeons (Patry and Brussatis) also joined. 13. Allgöwer later became a household name in the medical world not because of his involvement with the AO but because he invented a special technique for sewing skin wounds with minimal scarring. 14. Schneider 1969, pp. 5–6; Schneider 1983, pp. 6–10. 15. Callus is additional bone tissue that normally forms at the fracture site in bone healing and which was considered a necessary phenomenon by most surgeons; for the early AO, healing without callus formation was a mark of perfect bone healing. 16. Allgöwer 1978, p. 1071; Allgöwer and Spiegel 1979, p. 26. 17. Müller 1958, particularly pp. 6–7; Müller 1961; Müller et al. 1963b, pp. 8–20; Allgöwer 1978, p. 1071. 18. Müller 1961, p. 198. 19. Cooter 1993b, pp. 199–217. 20. Müller 1958, pp. 6–7; see also Müller 1961. 21. Danis 1949, pp. 7–19; Müller 1958, p. 7. 22. Danis 1949, p. 10; Müller 1958, pp. 7–8; Müller 1961, p. 200; Müller et al. 1963b, p. 8. Similar demands were made by English-speaking surgeons at the time: see for example Hicks 1959, p. 196; Burwell and Charnley 1964, p. 414, with more references to literature on the subject. 23. Müller 1958, pp. 7–8; Müller 1961, pp. 201–3; Müller et al. 1963b, pp. 6–8. For more details of post-operative treatment see for example Müller et al. 1963b, p. 24; Müller et al. 1969, pp. 94–7. 24. See for example the recommendation to use a plaster cast after osteosynthesis by Lange 1959, p. 444. This was also reported from the English-speaking countries – see Burwell and Charnley 1964, p. 418. 25. Müller 1961, pp. 199; Allgöwer 1961, p. 214; Müller et al. 1963b, p. 1; Allgöwer 1978, p. 1072. On gaining legitimacy in surgery by creating a lineage of predecessors see Schlich 1995. 26. Schneider 1969, p. 7. See also AO statutes, 19 March 1960. The committee was re-elected for example in 1968, AO 3–4 May 1968, pp. 2–3. On Schneider see Heim 2001, pp. 48–9. 27. Heim 2001, pp. 65–6. 28. AO statutes, 19 March 1960, article 3. 29. On such institutions, cf. Star and Griesemer 1989, p. 411. 30. These patterns were of course part of middle-class culture in all western countries. But we are here concerned with their specific Swiss form as condition for the creation of the AO. Cf. Hettling 1998a; Hettling 1998b, p. 232; Hettling 1998c, pp. 110–12. 31. I thank Sibylle Obrecht, being Swiss and who, with the due cultural sensitivity of a cultural anthropologist, has made me aware of this character of the early AO. On fraternities and their significance for Swiss political, cultural and social life from a feminist perspective see Blattmann and Meier 1998. 32. Hettling 1998c, pp. 111–12. 33. Shapin 1994, p. 410. 34. See Chapter 10. 35. AO 7 May 1971, admin. session, p. 2.

266


36. On face-to-face communities in science see Shapin 1994, p. 305; on building trust in science see Porter 1995, p. 226. On Swiss clubs see Hettling 1998b; Hettling 1998c, pp. 108–10. 37. Heim 2001, p. 35. 38. AO 6 April 1974, admin. session, appendix 1: annual report 1972/73, p. 2. 39. Müller et al. 1963a, p. 808. 40. Hettling 1998c, p. 108. 41. Müller et al. 1963a, p. 816. 42. Heim 2001, pp. 65–6. 43. Interview Eugen Kuner, Umkirch, 20 July 1998, who stressed the AO’s open discussion atmosphere as opposed to the usual authoritarian style in German surgery. 44. Cf. König 1998; on clubs, see Hettling 1998b, pp. 231–2; Blattmann 1998a. The AO used the specific Swiss egalitarian tradition, ‘the voluntary joining together of independent ... men according to the old Swiss tradition’. 45. Interview with Max Landolt, Davos, 10 November 1997, who had been with Böhler in Vienna and later joined the AO. On Böhler’s way of creating discipline, see also Lehne 1991, pp. 101–14. The contrast of the AO’s liberal atmosphere with the general style of leadership in surgery was discussed in interview with Eugen Kuner, Umkirch, 20 July 1998. 46. Griesser and Schoen 1963, pp. 827–8. 47. Cf. Gordon 1988, p. 259. 48. Interview with Hans-Ulrich Buff, Zürich, 31 March 1999. 49. AO statutes, 19 March 1960. For the procedure of admitting new members see the minutes of the administrative sessions. See also Schneider 1969, pp. 7–8; interview with M. Müller, Bern, 6 December 2000. 50. See for example Schneider 1969, p. 15; AO 28–29 April 1967, Annual Report 1966, p. 1; AO 9–10 May 1969, annual report 1968, p. 1; H. Willenegger: typewritten report ‘What is AO?’, 3 February 1976, box ‘Prof. Willenegger Kontaktreisen’ 1976; letter from H. Willenegger to Bruce A. Mallin, Phoenix, AZ, 2 July 1980, USA 1; Schneider 1983, pp. 9–10. 51. Müller et al. 1963a, pp. 816–17. 52. Schneider 1969, p. 7; Schneider 1983, p. 49; letter from Allgöwer to the members, facsimile in Schneider 1983, p. 29; interview with M. Allgöwer, Davos, 17 December 1997. 53. Schneider 1983, p. 10; interviews with Peter Matter, Davos, 17 November 1997, Martin Allgöwer, Davos, 17 December 1997. Allgöwer’s study of 1956 is evidence of his early interest in experimental science. 54. Allgöwer 1962, p. 176; Heim 2001, pp. 36–7; interview with Martin Allgöwer, Davos, 17 December 1997. There is an interesting parallel with the centre for hip surgery founded by John Charnley in Wrightington in the late 1950s. The centre, which included facilities for operations and research, was also set up in a former tuberculosis sanatorium with biochemical laboratories and workshops (see Waugh 1990, pp. 113–38). At that time the re-dedication of tuberculosis institutions to orthopaedic surgery seems to have been a widespread phenomenon. 55. AO 21–22 November 1969, pp. 10–11; AO 8–9 May 1979, p. 47. Sometimes surveys among AO members about a specific subject were formalised, as in the case of the use of antibiotics, by sending out a questionnaire (TK 24 March and 8 May 1970, p. 5; AO 21–22 November 1969, pp. 10–11).

Notes

267

56. Schneider 1983, p. 11; see also Willenegger 1953. 57. Krotscheck 1957, p. 5; see also Nicoll 1974, p. 147. 58. AO Laboratory annual report 1959/60, p. 6. On the history of the collaborative approach in general see Marks 1997, pp. 3, 57. 59. AO statutes, 19 March 1960, articles 1 and 3; Müller 1983a, p. 252. On statistics and the ideal of openness, see Porter 1995, p. 204. 60. Star and Griesemer 1989, p. 407. 61. Cf. Berg 1997, p. 177, on clinical protocols. 62. Interviews with Joseph Schatzker, Davos, 16 December 1998, and Howard Rosen, Davos, 16 December 1998. See also Chapter 9. 63. See, among others, Cambrosio and Keating 1995; Berg 1997. 64. Berg 1997, p. 167. 65. This point will be analysed in more detail in Chapter 6. 66. Howell 1995, p. 235. 67. Berg 1997; see for example pp. 113, 166–7. 68. Heim 1998. I am most grateful to Urs Heim for making his fascinating study available to me. 69. Interview with B.G. Weber, St Gallen, 10 June 1999; interviews with Max Landolt, Davos, 10 November 1997, and Peter Matter, Davos, 17 November 1997, who speaks of different ‘signatures’ of the various hospitals’ units. 70. Interview with B.G. Weber, St Gallen, 10 June 1999. On the St Gallen team, see Heim 2001, pp. 46–8. 71. Brunner and Weber 1981, p. vi (‘And above all, there is no culture without liberty’). 72. Gerald W. Shaftan, contribution to discussion, published in JT 7 (1967), p. 226. 73. On trochanteric fractures see Ganz et al. 1979, p. 33. 74. Interview with B.G. Weber, St Gallen, 10 June 1999. 75. Povacz 2000, p. 212. 76. Star and Griesemer (1989) would call them ‘boundary objects’.

Chapter 3 1. Müller et al. 1963b, pp. 7–8. 2. Von Baeyer 1909; Orsós 1925; Mumford 1934, pp. 197–200; Venable and Stuck 1947, pp. 3–76; Nicole 1947, pp. 5–20; Watson-Jones 1957, pp. 205–14; Ferguson 1959, pp. 2–3; Williams 1973, pp. 5–10; Robinson 1978, p. 366; Peltier 1990, pp. 154–61. 3. Sherman 1912; Böhler and Jeschke 1938, p. iii; Leventhal 1951; Watson-Jones 1957, p. 202; Ferguson 1959, pp. 10–12; Williams 1973, p. 10; Robinson 1978, pp. 370–82; Peltier 1990, pp. 154–61. 4. See for example Lambotte 1907, pp. 26–7; Danis 1932, p. 11; Nicole 1947; Lange 1959, pp. 427–34; Hicks 1959, p. 198; Hampton and Fitts 1959, p. 8; Bürkle de la Camp 1961, p. 94; Peltier 1990, p. 152. 5. Mumford 1934, pp. 197–200; Venable and Stuck 1947, pp. 3–76; Nicole 1947, pp. 5–20; Watson-Jones 1957, pp. 205–14; Danis 1949, p. 45; Report by the US Office of the Surgeon General of 1950, quoted in Peltier 1990, p. 152; Frank and Zitter 1971, p. 12. 6. Lane 1912, p. 1532. 7. Sherman 1912, p. 632; Venable and Stuck 1947, p. 47; Williams 1973, p. 15. 8. Venable and Stuck 1947, pp. 198–9. 9. Böhler and Jeschke 1938, p. 32.

268


10. Venable and Stuck 1947, pp. 52, 204. 11. Lange 1959, pp. 431–4. 12. Lambotte 1907, pp. 27–38; Danis 1932, p. 11; Danis 1949, p. 45; Verbrugge 1955, pp. 390–3 (on Lambotte); Bürkle de la Camp 1961, p. 96; Bechtol et al. 1959, p. v; Waugh 1990, pp. 41–9 (on Charnley); Kuner 1999, pp. 34–7 (on Küntscher). 13. Müller 1956; Müller 1958, p. 7; Schneider 1969, p. 6; Schneider 1983, p. 9. 14. Heim 2001, pp. 35–6. 15. On the relationship of Müller and Mathys and their joint development of the AO equipment see Schneider 1969, pp. 6–7; AO 9–10 May 1969, pp. 10–13; AO 8–9 May 1970, pp. 1–5; Schneider 1983, pp. 9, 56; excerpts of the letter from Müller to Mathys of 22 February 1960, in Schneider 1983, p. 27; letter from Mathys to Müller on the occasion of Müller’s 75th birthday (no date given) (MEM); Müller 1996, p. 161; Müller 2001. Also, interviews with R. Mathys, Bettlach, 27 January 1999; M. Müller, Bern, 15 March 1999, 6 December 2000. 16. The following account of the AO instruments and implants and their development is based on Müller et al. 1963b, pp. 12–16, 22, 44–57; Wagner 1963/64, p. 30; Schneider 1969, pp. 6–11; Schneider 1983, p. 6. For the list of instruments and implants, Müller 1983b, pp. 257–9. Also Schatzker 1998, p. 9; interviews with R. Mathys, Bettlach, 27 January 1999; M. Müller, Bern, 15 March 1999. 17. Müller et al. 1979, p. 54. 18. Schneider 1969, p. 6; Schneider 1983, p. 5. 19. Interview with R. Mathys, Bettlach, 27 January 1999. 20. Müller 1958, p. 7; Müller 1961, p. 198; Schneider 1969, p. 15. In an earlier attempt at standardisation Sherman had made standardised plates and screws (Sherman 1912, p. 631). The general lack of standardisation had marred the comparison of the results of different techniques attempted by the British Medical Association in 1912 (BMA 1912, p. 1526). 21. Danis 1949, pp. 30, 44–7; Bürkle de la Camp 1961, pp. 87, 99–101; Synthes instruments catalogue of 1 January 1962, facsimile in Schneider 1983, pp. 43–6; Maurer and Lechner 1963, p. 505; Müller et al. 1963b, pp. 7, 76–82; Schatzker 1998, p. 9; interviews with R. Mathys, Bettlach, 27 January 1999. Interview M. Müller, Bern, 15 March 1999. The AO surgeons stuck to their policy even when their competitors on the market threatened to copy the AO instruments if the AO did not start the sale of single pieces (TK 9 May 1964, p. 10). 22. From the user’s perspective their incompatibility was a disadvantage of the AO instruments, see Bagby 1977, p. 629. 23. Berg 1997, p. 97. 24. For the following passages on the sales restrictions and their abandonment see Müller et al. 1963a, pp. 809–10; Schneider 1969, pp. 8–13; AO 8/9 May 1970, pp. 3–4; Müller 1983b, p. 256. For a facsimile of the first AO instruments catalogue see Schneider 1983, pp. 43–6. 25. In modern history of medicine there are similar instances of initial shortage of new medical products helping the control over its use. When penicillin was first used in the US after World War II the drug was supplied to a handful of ‘experienced investigators’ who had agreed to work under the direction and supervision of the director of a special cooperative investigation (Marks 1997, pp. 106–13). 26. See Schneider 1983, pp. 26–7; letter by Müller, facsimile in Schneider 1983, p. 26.

Notes

269

27. Schneider 1969, pp. 8–10; cf. letters between Schneider and the president of the Swiss Surgical Society, A.M. Fehr, of 1960, printed in facsimile in Schneider 1983, pp. 33–6. The presentations were later published: see Müller 1961; Schneider 1961; Allgöwer 1961; Willenegger 1961. On Buff Largiadèr 2000, pp. 400–2; interview with H.-U. Buff, Zürich, 31 March 1999; on Lenggenhager see Killian 1980, pp. 403–4. 28. Müller et al. 1963a, p. 809. 29. Howell 1995, p. 233. 30. On the historian’s task to take critics of a successful medical technology serious see for example Howell 1995, p. 233; Lachmund 1997, p. 21; Marks 1997, p. 199. 31. Allgöwer 1964, p. 424. 32. Elkeles 1996, p. 68. 33. See for example Hey-Groves 1914, p. 335; Matti 1918, p. 311; Steinmann 1919, pp. 6–22; see also Chapter 1. 34. Böhler based his verdict on extensive statistical material. See Böhler 1957a; Ender et al. 1957, pp. 66–9; Zrubecky 1957, pp. 93, 175; Krösl 1957, p. 204; Jahna and Scharizer 1959, p. 486. 35. After Lange 1959, p. 417; Bürkle de la Camp and Schwaiger 1963–65; Rehn 1983, p. 340. 36. After Rehn 1953 (who himself was a supporter of Danis), p. 236, and Danis 1956, p. 740. 37. German Orthopaedic Society 1959, pp. 425–538. 38. See for example Maurer and Lechner 1963, p. 505. 39. Lange 1959, pp. 417–19. 40. Lane 1909, p. 350; Steinmann 1919, p. 10; Hey-Groves 1914, pp. 513–16; Danis 1949, pp. 100–5; Petersen and Reeder 1950 (with numerous references on the problem). 41. Bürkle de la Camp 1953, pp. 167–8; Charnley 1957, p. 16. 42. See for example the contributions to the session on dangers and mistakes in osteosynthesis treatment, organised by the German Orthopaedic Society in 1958 (German Orthopaedic Society 1959, pp. 414–538) – only one participant mentioned compression osteosynthesis (Hepp 1959, p. 535). See also Badger 1959a, p. 128; Bürkle de la Camp 1961, pp. 94–5; Maurer and Lechner 1963, pp. 507–16; Burwell and Charney 1964, p. 412. 43. Personal communication from Beat Rüttimann, 13 November 1999. 44. Müller et al. 1963b, p. v. 45. This is particularly conspicuous for the American context (Anderson 1965, p. 207; Wickstrom et al. 1967, p. 215; Brian Hopkinson, contribution to the general discussion, JT 7 (1967), pp. 224–5; Wade 1970, pp. 513–14; Dodge and Cady 1972, p. 1167). In addition the AO proponents stressed that the technically efficient AO techniques had to be distinguished from earlier similar techniques (Olerud 1972, pp. 1015, 1030; Laros and Spiegel 1979, p. 10; Schatzker and Lambert 1979, p. 82; Mize et al. 1982, p. 871). 46. Quoted in Schneider 1983, p. 52. 47. The term ‘symbiosis’ was mentioned in a number of interviews with those who were involved in the AO. It was also used with regard to the relationship between radiologists and their trusted suppliers: see Blume 1992, pp. 254, 260–1. 48. AO 8–9 May 1970, p. 3. On this and the following passages, information based on interviews with R. Mathys, Bettlach, 27 January 1999; M. Müller, Bern, 23 March 1999, 6 December 2000.

270


49. Schneider 1969, pp. 9–11; AO 9–10 May 1969, appendices 12–14; AO 8–9 May 1970, p. 3; letter on metallurgical problems from Mathys to the physicist Dr. Werner Müller, Grenchen, of 19 September 1960, facsimile in Schneider 1983, p. 31; Stamm 1985. See also Paul Gisin, contribution to Festschrift Straumann 1985, pp. 13–16; Heim 2001, pp. 71–2. In his 2001 obituary M.E. Müller wrote that the concession work together with Straumann ‘did not come easily for the strong-willed and independent-minded Robert Mathys’ (Müller 2001, p. 3). 50. Schatzker 1998, p. 10. 51. For my account in the following passages of the founding, character and function of Synthes, see the official charter on the foundation of the Synthes AG Chur, 10 December 1960 (MEM); statutes of the Synthes AG Chur, 10 December 1960 (MEM); entry in the Schweizerisches Handelsamtsblatt of 23 December 1960, No. 301–3685; Schneider 1983, pp. 246; von Rechenberg 1983; also based on interviews with R. Mathys, Bettlach, 27 January 1999, and M. Müller, Bern, 23 March 1999. 52. Among the AO surgeons only Müller had any prior experience in business (see above, p. 49). 53. Swiss patents of 1 September 1959 (MEM); contract between M. Müller and Synthes AG, 10 December 1960 (MEM); contracts between AO and Synthes, 10 December 1960 and 10 December 1966; contracts between Synthes, Straumann and Mathys, 21 November 1963 and 9 April 1969 (MEM). The arrangement explicitly excluded instruments for hip prostheses which were dealt with by Müller in a separate organisation. 54. Contracts between Synthes AG Chur, Straumann and Mathys, 21 November 1963 and 9 April 1969 (MEM). 55. Schneider 1969, pp. 10–11. 56. Mathys’ deep-seated suspicion was evident in the author’s interview with him and the statements of others about him (interviews with R. Mathys, Bettlach, 27 January 1999, M. Müller, 6 December 2000; personal communication, U. Heim, 6 December 2000). 57. Synthes AG, minutes of the session of 22 June 1961 in Zürich. This seems to be one of the rare occasions (perhaps the only one?) of the AO leaders acting in their capacity as Synthes shareholders. The document has been preserved in a file containing unrelated documents at the AO centre in Davos. 58. Contract between Synthes AG Chur, Straumann and Mathys, 21 November 1963 (MEM); report by R. Mathys, AO 8–9 May 1970, pp. 3–4; interview with R. Mathys, Bettlach, 27 January 1999. 59. TK 23 January 1965, pp. 13–14. 60. TK 19 December 1962; TK 21 November 1963; contract between Synthes AG Chur, Straumann and Mathys, 21 November 1963 (MEM); Schneider 1969, p. 12; report by R. Mathys, AO 8–9 May 1970, pp. 3–4. 61. Schneider 1969, pp. 12–13; see also the TK minutes. 62. Allgöwer 1978, p. 1081. 63. Two years later the sales office and the stocks were moved to the Straumann headquarters in Waldenburg (Ms Moraz-Müller was about to re-marry and Switzerland had been allotted to Straumann’s sales area). 64. Müller 1958, p. 7. 65. On the TK, see the TK’s minutes, starting in 1961; contracts between Synthes, Straumann and Mathys, 21 November 1963 and 9 April 1969 (MEM); Schneider 1969, p. 11; Müller 1983b, p. 256; Schatzker 1998, pp. 9–10. Early on, the

Notes

66. 67. 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85.

86. 87. 88. 89. 90.

91.

271

surgeons had noticed the necessity of one person deciding on the instruments’ design – during their conflict with Mathys they reproached the technician for altering the instruments without prior permission (Synthes AG, Zürich, session of 22 June 1961). See for example TK 20 August 1963, p. 9; TK 21 November 1963, p. 5; TK 22 May 1965, pp. 13, 16; TK 21 June 1967, pp. 10–11. On this point in general see Blume 1992, p. 60. See for example TK 9 May 1964, p. 10; TK 26 November 1977, p. 6. Interviews with R. Mathys, Bettlach, 27 January 1999, M. Müller, Bern, 23 March 1999. KTK 7 July 1978, p. 8. Blume 1992, p. 62. As a principle, the costs of development were borne by the producers. See minutes of the AO meetings; Blume 1992, pp. 234–5. Blume 1992, p. 260. TK 3 February 1977, p. 3. KTK 7 July 1978, p. 2. Interview with M. Müller, Bern, 6 December 2000. For more on this aspect of the AO courses, see the next chapter on the AO education programme. For a sociological perspective on this kind of collaboration, cf. Star and Griesemer 1989, p. 413. Löwy 1996, p. 161. Ibid., pp. 161–2. Schneider 1969, pp. 10–11. Allgöwer 1978, p. 1082. Beck 1986, p. 341. Marks 1997, p. 234. Allgöwer 1978, p. 1082. On the mechanisms of indirect benefit from medical and scientific activities in general see for example Beck 1986, p. 341. On indirect benefit for the AO surgeons (among much other evidence), interview with J. Schatzker, Davos, 16 December 1998. Interview with M. Müller, Bern, 6 December 2000. Allgöwer 1978, p. 1082. Latour and Woolgar 1979, pp. 187–233. TK 19 June 1976, p. 6 (Allgöwer); TK 26 November 1977, p. 7 (Bandi); TK 3 February 1978, p. 8 (Bandi and Müller); TK 22 September 1978 (Weber), p. 10. On this episode, TK 9 May 1964, pp. 3–5; TK 15 July 1964, p. 11; TK 23 January 1965, pp. 3–4; TK 22 May 1965, pp. 18–19; Schneider 1969, p. 13; interview with R. Mathys, Bettlach, 27 January 1999. For the discussion, see TK 22 May 1965, pp. 18–19. For further instances of legal action see for example TK 14 June 1974, p. 7; TK 4 April 1975, p. 7; TK 21 June 1975, p. 9; TK 2 April 1976, p. 12. For more on copies, also from the AO’s side, see Chapter 10.

Chapter 4 1. See Müller et al. 1963a, p. 810; Schneider 1969, p. 16. 2. Watson-Jones 1957, pp. 188–226. 3. Kirschner 1938, pp. 281–2; Danis 1956; Grundmann 1959, p. 524; Hampton and Fitts 1959, p. vi. 4. Müller 1961, p. 201; quotation from Willenegger 1961, p. 239.

272


5. Allgöwer 1964, p. 424. 6. Müller et al. 1963b, p. vi; Müller et al. 1969, p. v. Quotation from the preface of the English translation (Müller et al. 1970, p. v). 7. Collins 1992. 8. On the reduction of uncertainty by standardising and control see Porter 1995, p. 228. On the difficulty of propagating methods see Star and Griesemer 1989, p. 407. 9. Berg 1997, p. 25. 10. Lambotte 1913, p. 83; Verbrugge 1955, pp. 390–3. 11. Hey-Groves 1914, pp. 435–6. 12. Williams 1973, p. 15. 13. Quotation from Collins 1992, p. 56. See also Polanyi 1966, pp. 3–25. 14. Cambrosio and Keating 1995, pp. 45–79. 15. Cf. Polanyi 1958, pp. 49–65 (quotation p. 54); Polanyi 1966, pp. 3–25; Hirschauer 1991, pp. 289–97. In connection with the AO courses see Perren 1999. 16. Polanyi 1958, p. 53. 17. Berg 1997, pp. 1–37. 18. In addition there were 15 organisational helpers, 7 journalists and insurance company representatives, and a number of other people who were not active trauma surgeons (personal communication, Urs Heim, 23 March 2001). List of participants of the Davos courses 1960–68 (AOI, Davos); Schneider 1969, p. 10; Stamm 1985, pp. 25–6. 19. Lorenz 1955, pp. 22, 48; interview with Maurice Müller, Bern, 23 February 1999. 20. Interview with Urs Heim, Bern, 21 November 1997; Heim 2001, p. 76. On Iselin’s course see also Verdan 1985, p. 14. 21. TK 20 August 1963, p. 7; similarly TK 17–18 April 1964, p. 3. Annual Report of the AO Laboratory 1959/60, p. 6; 1960/61, p. 5; 1962/63, p. 4; 1963/64, p. 3. 22. AO 28–29 April 1967, Annual Report 1966, p. 4; 3–4 May 1968, Annual Report 1967, p. 4; Annual Report of the AO laboratory 1968/69, p. 16. 23. AO 22–23 November 1968, p. 4; AO 9–10 May 1969, Annual Report 1968, pp. 4–5; AO 9–10 May 1969, p. 6; AO 8–9 May 1970, p. 32; AO 26–27 November 1971, admin. session, p. 7. 24. AO 29–30 April 1966, Annual Report 1965, p. 4; Schneider 1969, p. 14. 25. Cf. the table in Schneider 1983, pp. 260–1. 26. AO 22–23 November 1968, p. 4; AO 8–9 May 1970, Annual Report 1969, p. 3; AO 6 April 1973, admin. session, Annual Report 1972/73, p. 1; AO 3 May 1974, admin. session, Annual Report 1973/74, p. 8. 27. AO 28–30 April 1972, admin. session, Annual Report 1971/72, p. 1. 28. Dialogue 12, 2 (December 1998), p. 7. In 1983 it had been 13,491 surgeons in Davos and 20,242 elsewhere (Willenegger and Bandi 1983, p. 274). 29. (25 September 2001). 30. In his reflections the British Straumann representative, J. Pinsent, wrote that ‘several companies, also some Academic institutions, having witnessed the success of the AO education programme, invested heavily in this activity’ (Dialogue 10, 2 (December 1997), p. 11). Howmedica of Kiel started a regular course on the use of their medullary nailing system in Strasbourg in 1976 (Kuner 1999, p. 38, letter from E.H. Kuner to the author, 2 August 1999). 31. KTK 7 July 1978, p. 2. 32. Waugh 1990, pp. 35, 185–90. 33. Maurer and Lechner 1963, p. 505; Groh 1968, p. 14.

Notes

273

34. AO 7 May 1971, admin. session, Annual Report 1970, p. 2. 35. Schneider 1969, p. 12; see also Bürkle de la Camp 1963/64, pp. 47–8. 36. Schneider 1969, p. 13. A list of all guests of honour up to 1982 can be found in Schneider 1983, pp. 264–5. 37. Schneider 1983, p. 32. Urs Heim, personal communication, 23 March 2001. 38. Urs Heim, personal communication, 23 March 2001. 39. TK 20 August 1963, p. 7; TK 24 January 1969, p. 15. 40. TK 17–18 April 1964, p. 3; TK 24 March and 8 May 1970, p. 64. 41. AO 28–29 April 1967, Annual Report 1966, p. 4. 42. Letter from Madl to Straumann and Mathys, 17 January 1969, attached to TK 24 April 1969; TK 24 March and 8 May 1970, p. 29; AO 8–9 May 1970, Annual Report 1969, p. 5. 43. Fragments 7, 5 (August 1987), p. 2. 44. AO 6 April 1973, admin. session, Annual Report 1972/73, p. 4. 45. Quotation from TK 16 Sept. 1977, p. 3; decision not to demonstrate rush pins at US courses from TK 21 June 1975, p. 4; videos from TK 1 July 1978, p. 3. 46. TK 22 May 1965, p. 17; TK 27 May 1977, p. 3. 47. TK 4 April 1975, p. 6; Letter from Charles J. Gudas, Chicago, to James E. Gerry, 14 December 1990 (USA 4). 48. TK 24 November 1972, p. 6. 49. AO 8–9 May 1970, p. 32. 50. Reprinted in Schneider 1983, p. 52. 51. Wade 1970, p. 513. 52. Quotation from Allgöwer and Spiegel 1979, p. 28; Allgöwer 1978, p. 1081; warning against commercialism from TK 27 May 1977, p. 2; critical aspects from Latta et al. 1998, p. 237. 53. Böhler 1929, p. vi. 54. Interview with Elisabeth Spicher, Basel, 10 June 1998. Ms Spicher, who was in charge of making, editing and distributing the slides, kindly provided the author with a photocopy of one series of slides with the accompanying text. 55. Böhler 1943, vol. 2, p. 1583. 56. AO 17–18 April 1964, p. 3; AO 28–29 April, Annual Report 1966, p. 4; AO 9–10 May 1969, p. 5.; TK 14 June 1974, p. 10; TK 21 June 1975, p. 12; personal communication, Urs Heim, 23 March 2001. 57. TK 4 July 1969, pp. 11–12; TK 25 October 1969, p. 8; TK 8 February 1974, p. 10; Schneider 1983, p .57; Perren 1999. 58. AO 8–9 May 1970, p. 32. 59. AO 9–10 May 1969, Annual Report 1968, p. 5. 60. Interviews with Max Landolt, Davos, 10 November 1997, Siegfried Weller, Davos, 16 December 1997; on the American course, personal communication, James E. Gerry, Davos, 3 February 2001. 61. TK 27 January 1968, p. 9; Perren 1999. 62. At first, the use of plastic bones was only considered for the nurses’ course, as they only had to learn when to use which instrument, later also for the doctors’ AO course (TK 27 January 1968, p. 15; TK 24 March and 8 May 1970, pp. 64–5). 63. TK 20 February 1976, p. 6; H. Willenegger, notes on a conversation with H.J. Wyss in Lauenen, 14 April 1981 (USA 4). Synbone AG in Filisur was an indepedent shareholder company, but most of its shares were owned by Synthes AG Chur. The company started production in 1989 (Dialogue 3, 1 (June 1990),

274

64.

65. 66. 67.

68. 69.

70.

71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83.

84. 85. 86.

87.


p. 8). Synbone moved to Malans in 1987 (Dialogue 19, 2 (December 1997), p. 6; Perren 1999). TK 24 March and 8 May 1970, p. 66. The same problem arises in laboratory science where the phenomenon produced and observed in the laboratory is to stand for another phenomenon outside the laboratory: an artificial fracture in an animal stands for, or ‘represents’ an accidental fracture in a human patient. See also Chapter 5. Perren 1999. Interview with Max Landolt, Davos, 10 November 1997; Perren 1999. Invitation by M. Allgöwer, 13 December 1961, reprinted in Schneider 1983, p. 42; AO 3–4 May 1968, Annual Report 1967, p. 4; AO 7 May 1971, admin. session, Annual Report 1970, p. 4; AO 28–30 April 1970, admin. session, Annual Report 1971/72, p. 6; Willenegger and Bandi 1983, p. 274. By 1993 the number of ORP courses was 726 in 47 different countries, with 59,568 participants (Dialogue 6, 1 (June 1993), p. 17). Séquin and Texhammar 1980; TK 4 July 1969, p. 15; TK 4 May 1979, p. 4. Letter from B. Friedrich, Bremen, to H. Willenegger, 6 April 1982 (USA 2); letter from H. Willenegger to H.J. Wyss, 23 August 1984 (USA 3); TK 16 September 1977, p. 6. TK 23 January 1965, p. 17; TK 10 December 1966, p. 6; TK 24 January 1968. p. 5; AO 7 May 1971, admin. session, Annual Report 1970, p. 4; TK 28 April 1972, p. 2. See for example TK 24 November 1972, p. 12. H. Willenegger, notes on experience in the USA, 12 July 1976 (USA 1). Heim 2001, pp. 32, 64. Schneider 1969, pp. 11–12. Müller et al. 1963b; for more detail on the involvement of the documentation centre, see Annual Report of the AO laboratory 1962/63, p. 3. Müller et al. 1963b, p. 8. AO 29–30 April 1966, Annual Report 1965, p. 3. TK 15 July 1964, p. 2; Müller et al. 1969, p. v. Müller et al. 1969, p. v; Annual Report of the AO laboratory 1968/69, p. 15; AO 8–9 May 1970, p. 54. Böhler 1929; Lehne 1991, p. 90; Povacz 2000, p. 171. Berg 1997, p. 53. On tacit knowledge and manuals in science see Cambrosio and Keating 1995, pp. 45–79. AO 6 April 1973, admin. session, p. 9; AO 23 November 1974, scientific session, pp. 7–10. Brunner and Weber 1981. The book was a manifestation of the consciousness of having developed a particular local style of the AO method, described in the preceding chapter. Interview with Joseph Schatzker, Davos, 16 December 1998. On the tibia documentation, interview with Martin Allgöwer, Davos, 17 December 1997. Rüedi and Murphy 2000b, p. xi. AO 9–10 May 1969, Annual Report 1968, p. 6; TK 22 November 1968, p. 16; TK 25 October 1969, p. 9; TK 14 November 1970, p. 16. H. Willenegger, notes on conversation with H.J. Wyss and M. Allgöwer, 29 July 1981 (USA 1). AO 3 May 1974, admin. session, pp. 9, 12; letter from H. Willenegger to S.T. Hansen, Seattle, 18 August 1980 (USA 2); H. Willenegger, notes on conversation with H.J. Wyss in Lauenen, 17 April 1981, (USA 2); H. Willenegger, notes on

Notes

88. 89. 90. 91. 92. 93.

94.

95.

96.

97. 98. 99.

100. 101. 102. 103. 104. 105. 106. 107. 108. 109. 110.

275

telephone conversation with H.J. Wyss and M. Allgöwer, 29 July 1981 (USA 1); letter from James E. Gerry to H. Willenegger, 1 September 1963 (USA 2). Willenegger and Bandi 1983, p. 276; Urs Heim, personal communication, 23 March 2001. Urs Heim, personal communication, 23 March 2001. Collins 1992, p. 73. For science, see Cambrosio and Keating 1995. They wanted to make sure of giving their instruments ‘zu treuen Händen’ (the closest English translation is ‘in trusted hands’) (Allgöwer 1964, p. 424). See for example the letter from Prof. Dr P.F. Matzen, Leipzig, to H. Willenegger, 18 Dec 1978, GDR 1975–1980; letter Prof. Dr G. Langer, Eisenberg, GDR, to H. Willenegger, 20 October 1987 (AOI, Davos). Quotation – letter from H. Willenegger to M. Jaques-Baumann, 3 July 1975 (USA 3). Letter A. Scott Kerr, Synthes USA, to all company representatives, 18 June 1975; letter from A. Scott Kerr to M. Jaques-Baumann 3 July 1975 (USA 1). Also Willenegger and Bandi 1983, p. 276. Letter from H. Willenegger to M. Jaques-Baumann, 23 July 1975 (USA 1); H. Willenegger, memorandum about courses on hand surgery in the US from 1983 (n.d.) (USA 2); letter from J.E. Gerry to M. Jaques-Baumann, 28 January 1983 (USA 2). Quotation – letter from H. Willenegger to A. Sarmiento, 23 December 1975 (AOI, Davos) box: ‘Prof. Willenegger Kontaktreisen 1976’. There are numerous handwritten operation protocols in this box; cf. also the reports by Willenegger and others in USA 1. See numerous reports in USA 1 and in the AO centre’s files on other countries. Report by W. Bandi on the hospital in Jackson, MS, 18 November 1980 (USA 1). For example handwritten notes by H. Willenegger, box: ‘Prof. Willenegger Kontaktreisen’, AO centre; TK 24 March and 8 May 1970, p. 21; Willenegger’s report on his journey to the GDR, 8–15 September 1983, GDR 1981 to end 1987 (AOI, Davos). On the moral dimension of knowledge transfer see Shapin 1994. TK 24 March and 8 May 1970, pp. 21–3. On experimental knowledge, see Collins 1992, p. 74. Quotation from AO 26–27 November 1971, scientific session, p. 5. See also Schneider 1969, pp. 14–15. Plates from TK 23 April 1971, p. 7. AO 29–30 April 1966, Annual Report 1965, p. 5; AO 28–29 April 1967, Annual Report 1966, pp. 3–4; interview with Jörg Rehn, Denzlingen, 5 February 1999. See Chapter 9. Willenegger and Bandi 1983, p. 275. See for exmaple Groh 1968, p. 45. H. Willenegger, Annual Report 1977, pp. 2–3 (AOI, Davos). B.R. Cahill and R.E. Palmer ‘Dark Side of Davos’, unpublished typescript, October 1976 (USA 1). AO 7 May 1971, admin. session, Annual Report 1970, p. 1. This is also stressed by those people whose trust the AO aimed at acquiring at the time; interview with the German surgeon Jörg Rehn, Denzlingen, 5 February 1999.

Chapter 5 1. Schneider 1983, p. 49. Similarly AO 29–30 April 1966, Annual Report 1965, p. 2. 2. Charnley 1957, p. 1.

276


3. Danis 1949, p. 6. 4. Blume 1992, p. 261. 5. Cunningham and Williams 1992; Pickstone 1993, pp. 449–52; Warner 1995; Löwy 1996, pp. 15–18; Marks 1997, pp. 1–2; Berg 1997; Sturdy and Cooter 1998, pp. 447–9. 6. Jones 2000, p. 529. 7. Senn 1883; Senn 1889; Hey-Groves 1914; Venable and Stuck 1947, p. 24; Cooter 1993b, p. 235. 8. See for example Leriche and Policard 1918; Mumford 1934, p. 198; Küntscher 1940b, pp. 9–10; Küntscher 1940c; Nicole 1947; Reynolds and Key 1954. Bagby was surprised that Danis had not indicated in his publications whether he had made preliminary experiments to test his technique (Bagby 1977, p. 627). See also Williams 1973, p. 8; Moore 1960, p. 872; Geiser 1963, p. 100. For surveys see Venable and Stuck 1947, pp. 24–31; Bassett 1962, pp. 1217–19; Ferguson 1959, pp. 2–12; Tröhler and Maehle 1991; Peltier 1990, pp. 128, 154–61. 9. Eggers et al. 1951, p. 469. 10. Cooter 1993b, pp. 234–7. 11. Willenegger, Report ‘What is AO?’, 3 February 1976, Prof. Willenegger, Kontaktreisen 1976 (AOI, Davos). 12. Lehne 1991, p. 99. 13. Buff 1975, p. 187. 14. Campbell 1963, pp. xiii–xiv; Gögler 1962, p. 59. 15. According to Danis 1956, p. 740. See also Watson-Jones 1957, pp. 187–226; Charnley 1957, p. vii. 16. Verbrugge 1955, p. 399. 17. Allgöwer 1978, p. 1072. 18. Perren and Rahn (1978), p. 130) defined the term as referring to the ‘mutual interrelation of mechanical conditions and biologic reactions’. 19. Shapin 1992, p. 356. 20. Pauwels 1935; Pauwels 1941; Nicole 1947, p. 8; Eggers et al. 1949; Friedenberg and French 1952, p. 743; Danis 1956; Müller 1958, p. 8; Allgöwer 1961, p. 214; Willenegger 1961, p. 255; Bassett 1962, pp. 1217–19; Schenk and Willenegger 1964, pp. 441–2; Müller et al. 1969a, p. 32; Perren and Rahn 1978. 21. Key 1932; Charnley and Baker 1952; Charnley 1953; Reynolds and Key 1954, pp. 578–9; Charnley 1957; Geiser 1963, p. 2; Bagby 1977, p. 625. 22. Egger 1948; Eggers et al. 1949; Friedenberg and French 1952; Charnley 1953, p. 14; Bagby 1977, pp. 625–6. 23. For the German-speaking countries, see Abel 1952; Wittmoser 1953; Rehn 1953. 24. Danis 1949, pp. 10, 15–19; Danis 1956, p. 741. 25. Müller 1955b, pp. 482–3; Müller 1956, p. 137; Müller et al. 1963b, p. 10. 26. Eggers 1948; Reynolds and Key 1954, pp. 580–1; Hampton and Fitts 1959, pp. 5, 14–16; Eggers and Roosth 1959; Burwell and Charnley 1964, p. 416. 27. See for example Pettavel 1955, p. 438. 28. Böhler 1953, p. 198; Bürkle de la Camp 1953, p. 172; Watson-Jones 1957, pp. v, 205, 223–5; Hicks 1959, p. 211; Jahna and Scharizer 1959, p. 486. 29. This objection was mentioned and rejected in Müller et al. 1963b, p. 13. 30. Bürkle de la Camp 1961, pp. 94–5; Müller 1961, p. 201. For the English-speaking countries see Blockey 1964, p. 518. Müller et al. 1963b, p. 10, wrote that compression principle for stablising fractures was unknown in the Germanspeaking countries and only scarcely known in the English-speaking world.

Notes

277

31. For the German-speaking countries, see Hepp 1959, p. 536. On the general opinion in the English-speaking world, see Burwell and Charnley 1964, p. 417. 32. Star and Griesemer 1989; Löwy 1996, p. 248. 33. Müller 1955b, p. 482; Müller 1958, p. 8; Müller et al. 1963b, p. 10. 34. There were some supportive results from other investigators (Reynolds and Key 1954, pp. 583–6; see also Key 1932). 35. Müller et al. 1963b, pp. 10–11. 36. Devices for measuring the pressure applied to a fracture had been developed by others before. Friedenberg and French at the Department of Orthopaedic Surgery at the University of Pennsylvania, for instance, had controlled and monitored compression between fragments of their laboratory animals with the help of a calibrated apparatus containing a spring (Friedenberg and French 1952). See also Schenk and Willenegger 1964, pp. 442–4; Schneider 1983, p. 50. 37. Willenegger et al. 1962, pp. 850–2. 38. Hutzschenreuter et al. 1969; Willenegger et al. 1971, pp. 246–8; Allgöwer 1978, p. 1074; Perren 1979, pp. 178–81, 187. 39. AO 29–30 April 1966, Annual Report 1965, p. 3. 40. Perren et al. 1969c, p. 31; Perren and Allgöwer 1976, p. 61; Allgöwer and Spiegel 1979, p. 27. 41. Crenshaw 1971, pp. 478–83 (quote at p. 483). The acceptance is even more clear in the 1980 edition of the textbook (see Edmonson and Crenshaw 1980, p. 527). 42. AO Laboratory Annual Report 1959/60, p. 8; AO 28–29 April 1967, p. 3; Schneider 1969, pp. 7–9. 43. AO Laboratory Annual Reports; Allgöwer 1962, pp. 176–8; Schneider 1969, pp. 11–12; Perren 1972, pp. 34–5. 44. AO Laboratory Annual Reports; Schneider 1969, p. 12; Perren 1972, pp. 34–5. 45. AO Laboratory Annual Reports; AO 17–18 November 1967, p. 4; Schneider 1969, p. 15; Perren 1972, pp. 34–5. 46. AO 17–18 November 1967, p. 4; AO 3–4 May 1968, Annual Report 1967, p. 1; AO 9–10 May 1969, Annual Report 1968, p. 2 and supplements 5 and 12; AO 7–8 May 1971, scientific session, pp. 7–11; AO 6 April 1973, admin. session, Annual Report 1972/73, p. 1; Perren 1992a, pp. 3–4; interview with Stephan Perren, Davos, 3 December 1998. 47. Perren 1972, p. 35. 48. AO Laboratory Annual Reports from 1959/60; Schneider 1969, pp. 7–9; Perren 1972, pp. 34–5; Schneider 1983, p. 49. 49. TK 4 December 1971, p. 19. 50. In addition, research on the AO technique and its biological and mechanical aspects was also done independently of the AO, for instance at the Campbell Clinic in Memphis, TN, funded by the US Public Health Service. Cf. Anderson 1965, p. 191. 51. Löwy 1996, p. 161. 52. Lambotte 1907, p. 19. I have cited Lane from Bagby and Janes 1958, p. 572, as it was not possible to obtain a copy of Lane’s 1914 book. 53. Bardenheuer and Grässner 1917, p. 8. 54. Krompecher 1937. 55. Pauwels 1941, pp. 65–7; Nicole 1947, p. 8; Bürkle de la Camp 1953, pp. 166–7: Schenk and Willenegger 1964, p. 442. Geiser (1963, p. 2) noted that Krompecher was less well known by English-speaking surgeons and scientists.

278


56. Pauwels 1941, p. 82. This view was then adopted by other surgeons. See for example Putti 1942, p. 56; Bürkle de la Camp 1953, p. 167. 57. Danis 1949, pp. 8–9. There was an autonomous reception of Danis’ ideas of compression osteosynthesis and primary bone healing by English-speaking surgeons, independently of the AO. See for example Bagby and Janes 1958, p. 762; Badger 1959b, p. 140; Hicks 1959, p. 203; Hicks 1961, pp. 683–4; Blockey 1964, pp. 518–19; Burwell and Charnley 1964, p. 418; Hicks 1969, p. 73; Burwell 1971, p. 263. 58. Bardenheuer and Grässner 1917, p. 8; Danis 1956, p. 742; Charnley 1957, p. 12; Bagby and Janes 1958, p. 762; Blockey 1964, p. 527; Burwell 1971, p. 263. 59. Küntscher 1964, p. 452; Müller 1971, p. 1144; interview with M.E. Müller, Bern, 23 February 1999. 60. Quotation from Müller 1958, p. 7; see also Allgöwer 1961, p. 219; Müller et al. 1963b, pp. 6–7, 14–15; Wieser 1964, p. 440; Schenk and Willenegger 1964, p. 440; Allgöwer 1964, p. 427. 61. Schneider 1969, p. 10. 62. Geiser 1961; Geiser 1963, pp. 2–4, 25–40, 48, 65–6, 73–4, 86. 63. Müller et al. 1963b, p. 14; see also Hicks 1959, p. 204; Wieser 1964. 64. Müller et al. 1963b, p. 14; Geiser 1963, p. v. 65. Cf. Schlich 2000. 66. Rittmann and Perren 1974, p. 69; Allgöwer 1978, p. 1074; Perren 1979, p. 189. 67. Allgöwer et al. 1963/64, pp. 2–3, 10; Willenegger et al. 1962, pp. 846–7; Müller et al. 1969, p. 10; Perren and Rahn 1978, p. 122. 68. Charnley 1957, p. 16; Schneider 1983, p. 49. 69. Hicks 1959, p. 187; Willenegger et al. 1962, p. 849. 70. Early on, the AO had collaborated with Andrew Bassett, a scientist at the Orthopaedic Research Laboratories of Columbia University. His experimental observations were seen as important arguments for the AO’s view. Bassett had shown that fibroblast developed directly to become bone cells in vitro. According to his in vivo experiments, a bone defect could be healed with cells coming directly from the bone ends without the participation of periosteal and endosteal tissue (AO Laboratory Annual Report 1959/60, pp. 7–8; Bassett and Herrmann 1961; Bassett et al. 1961; Bassett 1962, pp. 1217, 1232; Willenegger et al. 1962, pp. 846–7; Allgöwer et al. 1963/64, pp. 4, 8; Schenk and Willenegger 1963, p. 593. 71. AO Laboratory Annual Report 1962/63, p. 5; Schneider 1983, p. 10; interview with Robert Schenk, Bern, 18 May 1999. 72. Schenk and Willenegger 1963, pp. 593–5; Schenk and Willenegger 1964, pp. 442–51; Willenegger et al. 1971, pp. 245–8; Schenk 1998, p. 60; interview with Robert Schenk, Bern, 18 May 1999. 73. Müller et al. 1963b, p. 13; Schneider 1969, p. 16. For later reappraisals of these experiments as proving the existence of primary bone healing, see Perren and Rahn 1978, p. 119; Perren 1979, pp. 184–5. As evidence of acceptance see Rehn’s handbook contribution of 1965, p. 510, and the American review of the AO textbook by Eaton 1965. 74. Anderson 1965, pp. 2201–6. 75. Ibid.; Anderson et al. 1975, p. 295. 76. Willenegger et al. 1971, pp. 246–9. 77. Müller et al. 1969, p. 8. 78. Schenk and Willenegger 1964, pp. 450–1; AO Laboratory Annual Report 1963/64, p. 4; Willenegger et al. 1971, p. 245; Schenk and Willenegger 1977, p. 156.

Notes

279

79. Allgöwer et al. 1969, p. 45; Willenegger et al. 1971, p. 245. 80. AO Laboratory Annual Report 1968/69, p. 6; Rahn et al. 1971, p. 786; Perren and Rahn 1978, p. 119. 81. Rhinelander 1974, pp. 59–60. 82. Allgöwer and Spiegel 1979, p. 27. 83. Rhinelander 1974, p. 58; Rand et al. 1981, p. 434. 84. Cf. Löwy 1996, p. 256. 85. Wade 1970, p. 514. 86. Charnley 1953, pp. v–vi. 87. Reynolds and Key 1954, p. 578. 88. Eggers et al. 1949, p. 693. 89. Barron et al. 1977, pp. 376, 384. 90. Laboratory-based methods of investigation were ‘developed primarily as a means of generating standardised knowledge of ill health and its treatment’ (Sturdy and Cooter 1998, p. 446). 91. Ainsworth and Wright 1948, p. 48; Galeazzi 1972, p. 30; Barron et al. 1977, p. 376; Schenk 1998, p. 73. 92. Küntscher 1940c, p. 266. 93. Anderson 1965, p. 193. 94. Rhinelander 1974, p. 44. Rand et al. (1981, p. 427) complained that ‘studies comparing different types of internal fixation in a single animal with standardised fractures’ were very rare. 95. Schenk and Willenegger 1964, p. 442. 96. Barron et al. 1977, p. 376. 97. AO 8–9 May 1970, pp. 20–2. 98. Schenk and Willenegger 1977, p. 159. 99. Rhinelander 1974, p. 48. 100. Reynolds and Key 1949, p. 578. 101. Schenk and Willenegger 1963, p. 593. 102. Shapin 1995, pp. 261–6 on metonomy and induction. For animal models in medicine see Bynum 1990. 103. Schenk and Willenegger 1964, p. 442. 104. Uhthoff and Dubuc 1971, p. 165. 105. Hey-Groves 1914, p. 436. 106. Senn 1883, p. 333; Anderson 1965, p. 207. 107. Wickstrom et al. 1967, p. 211. 108. Ibid., p. 212. 109. Geiser himself regretted that he could not afford to use larger animals which would have made it easier to examine the early stages of bone healing with rigid fixation, as he noted (Geiser 1963, p. 5). See also Willenegger et al. 1962, p. 846; AO Laboratory Annual Report 1968/69, p. 6. 110. But size was not everything. Whereas Küntscher claimed in 1940 regarding his dog experiments that fracture healing was basically the same in humans and animals, Geiser noted in 1963 that this was doubted by many authors. At that time it was generally held that fracture healing in frogs and lizards was very different from humans, but the processes in mammals could be used to assess how human bones healed (Geiser 1963, p. 3). Robert Schenk was not sure if experiments on sheep were in all aspects useful for elucidating bone healing processes in man, especially as far as calcium metabolism was involved. The reason is that sheep are herbivorous, therefore their bone metabolism differs

280

111. 112. 113. 114. 115. 116. 117. 118. 119. 120. 121. 122. 123. 124. 125. 126. 127. 128.


from that of humans in important respects so that Schenk preferred animal models from pigs and dogs, whose metabolic characteristics were closer to conditions in humans (interview with Robert Schenk, Bern, 18 May 1999). Gordon 1988, p. 259. Crenshaw 1971, p. 477. Pernyész 1937. Müller et al. 1969, p. 16; Bernard 1957. On the subject more generally see Collins 1992. Willenegger et al. 1971, p. 241; Perren and Allgöwer 1976, p. 61; interview with Berton Rahn, Davos, 6 July 1999. AO 28–30 April 1972, Annual Report 1971/72, p. 6. Quotation from Zorn et al. 1969, p. 264. For the inside perspective see Allgöwer and Spiegel 1979, p. 27. Löwy 1996, p. 160. Blume 1992, p. 262. Löwy 1996, p. 15; see also p. 10. Perren 1992a, p. 4. Rosenberg 1988, p. 568. Sturdy and Cooter 1998, p. 449; Blume 1992, p. 17; Howell 1995, p. 2. Perren and Rahn 1978, p. 133; similarly Perren 1979, p. 175. Charnley 1968, p. vii. Charnley 1957, p. 1. Charnley 1953, p. vi. Eggers 1948; communication by Dr Arthur G. Davis, pp. 51–2.

Chapter 6 1. 2. 3. 4. 5.

6.

7.

8. 9. 10. 11. 12. 13. 14.

Marks 1997 (quote, p. 129); see also Porter 1995; Tröhler 2000. Girgerenzer et al. 1989, p. 235. Porter 1995, pp. 199–202. Gordon 1988, p. 262; Berg 1997, p. 40; Tröhler 2000. Tröhler 1991, p. 90. See also Howell 1995, p. 66, who writes that in early twentieth-century American hospitals the new system of documentation ‘allowed and encouraged the rise of surgery’. Griesser and Schoen (1963, p. 824) recommended that surgeons adopt the methods of population and social statistics. On insurance and probabilistic models see Girgerenzer et al. 1989, p. 255. On administrative cultures and medicine see Porter 1995, pp. xi, 193–216; Howell 1995, pp. 30–68. Böhler 1929; Böhler 1943, vol. 1, p. 152, vol. 2, pp. 1484, 1582; Zrubecky 1957, p. 161; Krösl 1957, p. 193; Jahna and Scharizer 1959, p. 484: Lehne 1991, pp. 60–100. Cooter 1993b, p. 183; Sturdy and Cooter 1998, pp. 421–30. For the US see Howell 1995, pp. 30–68. See for example Danis 1949, pp. 25–6; Pettavel 1955, Eggers and Roosth 1959; Tröhler 1984, pp. 82–96; Waugh 1990, p. 137; Tröhler 1991, p. 103. Marks 1997, p. 2. Berg 1995, p. 449; Berg 1997, p. 22. Cf. Berg 1995; Berg 1997. Marks 1997, p. 120. Berg 1995, p. 460.

Notes

281

15. Bernard 1957; Schlich 1998, pp. 222–40. It is important to note that ‘experimental’ here does not refer to insecurity of outcome, as when it is said that a treatment has not yet become routine but is still ‘experimental’ (see for example Fox and Swazey 1992). On the contrary, ‘experimental medicine’ in Bernard’s sense denotes complete control and predictability of treatment results. 16. Matthews 1995, p. 85. On the early history of the various scientific approaches to medicine and their clinical critics see ibid., pp. 62–85. 17. Lawrence 1992a, p. 32. 18. Danis 1949, pp. 5–6. 19. Allgöwer 1978, p. 1073. 20. Quotation from Allgöwer 1978, p. 1073. See also Danis 1949, p. 6; Allgöwer 1962, p. 178; Müller 1966, p. 90; Müller et al. 1969, p. 16; Rüedi and Allgöwer 1979, p. 105. 21. See for example BMA 1912; Hey-Groves 1914, pp. 520–1; Charnley 1957, p. 1; Koller 1963, p. 805; Buff 1971, p. 1193; Anderson et al. 1975, p. 287; van der Linden and Larsson 1979, p. 876; Laros and Spiegel 1979, p. 19. 22. Porter 1995, p. 206; Berg 1997, p. 23. 23. Laros and Spiegel 1979, p. 2. 24. Olerud and Karlström 1972a, p. 40; see also Schatzker et al. 1974, p. 113; van der Linden and Larsson 1979, p. 874; Chapman and Mahoney 1979, p. 120. On the fact that ski injuries are easier to treat by operative means than other injuries, see Crenshaw 1971, p. 522; Rüedi and Allgöwer 1979, p. 109. 25. Laros and Spiegel 1979, p. 13. 26. See Schlich 2000. 27. Ganz et al. 1979, p. 37. 28. Badger 1959a, p. 123; Stewart et al. 1966, p. 800; Buff 1971, p. 1194. However, it must be noted that later, when the AO started to value biological considerations over mechanics, AO surgeons also warned against reducing patients to their X-ray pictures. See for example Allgöwer 1971, pp. 1128–9; Laros and Spiegel 1979, pp. 16, 18. On scepticism about roentgenography in general see Howell 1995, p. 108. 29. See for example Olerud 1972, p. 1015. Mize et al. 1982, pp. 871–2 used the 1967 classification of Neer et al., whereas Giles et al. (1982, p. 864), rejected that classification and chose another one instead. 30. Laros and Spiegel 1979, p. 13. 31. See for example Burwell 1971, p. 258; Clancey and Hansen 1978, p. 120. 32. BMA 1912, p. 1507; AO 3–4 May 1968, pp. 5–6; AO 7–8 April 1973, p. 12. 33. Nicoll 1974, p. 147. 34. Charnley 1957, p. 1. 35. See for example König 1931, p. 14; Pettavel 1955, p. 438; Rehn 1965, pp. 511–12; Laros and Spiegel 1979, p. 19; Burri et al. 1979, p. 90; Giles et al. 1982, p. 865; Stern et al. 1984, p. 684; van der Griend et al. 1986, pp. 430–3. 36. Schatzker and Lambert 1979, p. 80. 37. Weber 1966; Müller et al. 1977, pp. 288–9; Schaffer and Manoli 1987, p. 597. 38. Müller 1981; Müller 1983a, pp. 253–4; Müller et al. 1990. 39. Küntscher 1953, pp. 217–18. On that subject see also BMA 1912, p. 1526; Blockey 1964, p. 519; Anderson et al. 1975, p. 287; Clancey and Hansen 1978, p. 118; Laros and Spiegel 1979, pp. 2, 7; van der Griend et al. 1986, p. 430. On the view that procedural standardisation was the sine qua non for the full development of medicine as a science see Berg 1995, pp. 415, 460; Berg 1997, p. 25.

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40. Müller 1969, p. 16. Taken from a different perspective, a British proponent of rigid fixation wrote in 1964: ‘It is unreasonable to condemn a procedure when it is uncertain whether it is the procedure or its technical execution that is being judged’ (Blockey 1964, p. 519). See also Danis 1956, p. 762; Berkin and Marshall 1972, p. 1112. Similarly, on coronary artery bypass grafting see Jones 2000, p. 523. 41. See Krösl 1957, p. 205. 42. Anderson et al. 1975, p. 287. 43. BMA 1912. 44. Rüedi and Allgöwer 1979, p. 109; see also Danis 1949, p. 26. 45. Laros and Spiegel 1979, p. 14. 46. Willenegger 1971, p. 322. Howell (1995, p. 110) found in his early twentiethcentury US material the opinion that roentgenograms could ‘tell the truth, even when the patient could (or would) not’. 47. Böhler and Jeschke 1938, pp. 101–201; Böhler 1943, vol. 2, p. 1582. 48. Lane 1905a, pp. 46, 97; Lambotte 1912; Lane 1912; Lambotte 1913, p. 4. 49. Watson-Jones 1957, p. 217; Lange 1959, pp. 426, 436. 50. Charnley 1953, p. 19; Crenshaw 1963, pp. 619–22; Blockey 1964, p. 518; Murray et al. 1964, p. 1045; Brashear 1965, p. 174; Nicoll 1974, p. 149; Anderson et al. 1975, p. 292; Clancey and Hansen 1978, p. 120; van der Linden and Larsson 1979, p. 874. 51. Müller 1961, p. 198. Similarly, see Allgöwer 1964, p. 426; Willenegger 1971, p. 322; Schatzker 1974, p. 220. 52. Blockey 1964, pp. 524–5; Stewart et al. 1966, p. 797; Naiman et al. 1970, p. 212; Tauber et al. 1971, p. 323; Müller et al. 1971, p. 329; Olerud 1972, pp. 1025–30; Schatzker et al. 1974, p. 114; Rüedi et al. 1975, pp. 243–4; Laros and Spiegel 1979, p. 10; Schatzker and Lambert 1979, p. 78; Grace and Eversmann 1980, pp. 434–5; Mize et al. 1982, p. 873. 53. Murray et al. 1964, p. 1064; Rüedi et al. 1975, p. 254; Rüedi and Lüscher 1979, p. 75; Rittmann et al. 1979, p. 136. 54. Geiser 1963, pp. 89–90; Groh 1968, pp. 57–8; Buff 1971, p. 1194; Nicoll 1974, pp. 147–50; Laros and Spiegel 1979, pp. 14–18; interview with A. Sarmiento, Zürich, 15 February 2001. 55. See for example Lambotte 1907, pp. 5–6; Danis 1949, pp. 25–6; Müller 1961, p. 198; Allgöwer 1961, p. 222; Willenegger 1961, p. 225; Burwell and Charnley 1964, p. 409; Nicoll 1974, p. 146; Schatzker et al. 1974, p. 127; van der Linden and Larsson 1979, pp. 876–7. 56. Generally whoever designs the forms for documentation gets to control what will be recorded, Howell 1995, pp. 130–1. 57. Chung 1971, p. 1448; similarly Ganz et al. 1979, p. 37. 58. Allgöwer 1978, p. 1086. 59. Clarke and Fujimura 1992, p. 5. On standards of evidence see also Epstein 1996, p. 37. 60. Quotation from Bagby 1977, p. 630. See also Pettavel 1955, p. 458; Maurer and Lechner 1963, p. 505; Buff 1971, p. 1194; Berkin and Marshall 1972, p. 1112; Nicoll 1974, p. 151; Bagby 1977, p. 630; van der Linden and Larsson 1979, pp. 876–7; Laros and Spiegel 1979, p. 6. 61. See for example Fox and Swazey 1992, p. 9.

Notes

283

62. Liebenau 1983, p. 82; Elkeles 1996, p. 68. On the importance of causal attribution in risk discussions see Beck 1986, p. 83. On the pressure of justification on surgery resulting from this view in the early twentieth century see Tröhler 1991, p. 90. 63. Douglas and Wildavsky 1982. 64. Beck 1986, p. 292. See also ibid., pp. 62, 76–7, 95, 289; Girgerenzer et al. 1989, p. 266. On the normative and political character of all therapeutical evaluation and risk assessment see Richards 1988. 65. Wade 1970, p. 515. 66. Müller 1966, p. 91; Olerud and Karlström 1972a, pp. 43–4; Olerud and Karlström, 1972b. 67. For non-unions see for example Schatzker and Lambert 1979, p. 82. 68. Müller et al. 1963b, p. 21. The subject was frequently discussed and taken very seriously: see Lambotte 1907, p. 12; Hampton and Fitts 1959, p. 32; Maurer and Lechner 1963, p. 505; Blockey 1964, p. 527; Allgöwer 1964, p. 430; Rehn 1965, p. 510; Groh 1968, pp. 77–8; Zorn et al. 1969, p. 264; Wade 1970, p. 514; Allgöwer 1971, p. 1130; Crenshaw 1971, p. 478; Rockwood and Green 1975, p. 74; van der Linden and Larsson 1979, p. 877; Allgöwer and Spiegel 1979, p. 28; Laros and Spiegel 1979, p. 10; Giles et al. 1982, p. 869; Mize et al. 1982, p. 877; Stern et al. 1984, p. 644. 69. Allgöwer 1971, p. 1131. Similarly Olerud 1972, p. 1031; Olerud and Karlström 1972a, p. 42; Allgöwer 1978, p. 1074; Allgöwer and Spiegel 1979, pp. 27–8. 70. See for example Pettavel 1955, p. 453. 71. Müller et al. 1963b, p. 7 (my translation). Similarly: Laros and Spiegel 1979, p. 3; Schatzker and Lambert 1979, p. 82. 72. Müller et al. 1963b, p. 7; AO 22–23 November 1968; AO 7–8 May 1971, scientific session, pp. 14–15, 27; Allgöwer 1971, pp. 1130–1; AO 28–30 April 1972, scientific session, p. 15; AO 16–17 November 1973, admin. session, pp. 2–7, scientific session, p. 12; Rüedi et al. 1975, p. 256; Allgöwer and Spiegel 1979, p. 28; Burri et al. 1979, p. 92. 73. Clancey and Hansen 1978, p. 120. 74. Olerud and Karlström 1972a, p. 15. See also Müller et al. 1971, pp. 329, 337; Dodge and Cady 1972, p. 1167; Anderson et al. 1975, p. 295; Burri et al. 1979, pp. 84–93; van der Linden and Larsson 1979, p. 873; Rüedi and Allgöwer 1979, pp. 109–10; Laros and Spiegel 1979, p. 12; Ganz et al. 1979, p. 38. 75. Burwell and Charnley 1964, p. 420; Burri et al. 1979, p. 91; Laros and Spiegel 1979, p. 81. 76. Laros and Spiegel 1979, p. 3. See also Hicks 1959, p. 210; Burwell and Charnley 1964, p. 407; Blockey 1964, p. 519. 77. Naiman et al. 1970, pp. 212–15; Olerud and Karlström 1972a, pp. 41–2; Rüedi and Allgöwer 1979, p. 105; Ganz et al. 1979, p. 37. 78. See for example Schatzker and Lambert 1979, p. 81; Grace and Eversmann 1980, p. 435. 79. Müller 1961, p. 201; Allgöwer 1978, p. 1091; Allgöwer and Spiegel 1979, p. 28; Laros and Spiegel 1979, p. 10; van der Griend et al. 1986, p. 433. In the same way, plate breakage was attributed to the individual surgeon’s incorrect application rather than to inadequacies of the material used. The AO was by no means isolated with this attitude: it was a generally accepted fact that an inaccurately placed plate, being for instance subjected to bending forces instead of traction forces, was bound to break sooner or later. Plate damages were the outward sign of abnormal mechanical strain caused by mistakes in application. Similarly,

284

80. 81. 82. 83. 84. 85. 86.

87. 88.

89. 90. 91. 92. 93.

94.

95. 96.

97. 98.

99. 100.


problems in bone healing were no longer attributed to the toxic effects of metal but to incorrect application of the implants (Nicole 1947; Bürkle de la Camp 1961, p. 62; Maurer and Lechner 1963, p. 506; Cohen 1964, p. 421; Müller et al. 1969, pp. 102–3; Müller 1971, pp. 1144–51; Rüedi et al. 1975, p. 255; Perren and Allgöwer 1976, p. 63). This principle also guided the AO’s handling of grievances concerning alleged material deficiencies in AO implants. Straumann noted in 1978 that 99 per cent of breakages were due to technical mistakes made by the surgeons who used the implants (KTK 7 July 1978, p. 4; see also AO 9–10 May 1969, supplements 12–15, TK 2 April 1976, p. 13). AO 29–30 April 1966, Annual Report 1965, p. 1. Charnley 1957, p. 1. Allen 1982, p. 797. Cf. Berg 1997, pp. 173–4. Beck 1986, p. 260 (my translation). Lorenz 1955, p. 50. (9 October 2001), ‘The Story of Herman Hollerith’s tabulating machine system’. Howell (1995, pp. 40–2, 66) is another instance showing the importation of methods and tools from business into health care. Quotation from Böhler 1957b, p. 2. See also Böhler 1953, p. 196; Krotscheck 1957, pp. 8–9. AO Laboratory Annual Report 1959/60, p. 5; 1962/63, p. 3; Müller et al. 1963a, pp. 810–11; Müller et al. 1963b, p. 26; Perren and Rahn 1978, p. 126; Müller 1983a, p. 252; Schatzker 1998, p. 10. Müller et al. 1963a, pp. 811–17; Müller et al. 1963b, p. 7; AO Laboratory Annual Report 1965, p. 3; Schneider 1969, p. 7; AO 8–9 May 1970, p. 10. For this and the following passages, see AO Laboratory Annual Report 1963/64, p. 3; 1965, p. 3; Schneider 1969, pp. 14–15; Müller 1983a, p. 252. AO 29–30 April 1966, Annual Report 1965, p. 2. AO 29–30 April 1966, p. 4; AO 28–29 April 1967, Annual Report 1966, p. 5; AO 17–18 November 1967, p. 3; AO 3–4 May 1968, p. 5; Müller 1983a, p. 252. AO 28–29 April 1967, p. 4; AO 17–18 November 1967, p. 4; AO 3–4 May 1968, pp. 1–2; AO 3–4 May 1968, Annual Report 1967, pp. 4–5; Schneider 1969, p. 12; Müller 1983a, p. 252. AO 17–18 November 1967, pp. 4, 10–11; AO 22–23 November 1968, pp. 2–3; AO 9–10 May 1969, pp. 4–5; ibid., Annual Report 1968, p. 2; AO Laboratory Annual Report 1968/69, p. 15. AO 8–9 May 1970, pp. 10–16. AO 26–27 November 1971, admin. session, pp. 1–2; scientific session, p. 1; AO 28–30 April 1972, scientific session, pp. 10–11; AO 6 April 1973, admin. session, p. 4; AO 16 November 1973, admin. session, pp. 11–12. AO 6 April 1973, admin. session, pp. 4–7; AO 3 May 1974, p. 9. AO 28–30 April 1972, scientific session, p. 11; ibid., supplement 1, Annual Report 1972/73, p. 6; ibid., scientific session, p. 11; AO 6 April 1973, admin. session, pp. 4, 7; AO 3–4 May 1974, admin. session, pp. 5–6; AO 22 November 1974, admin. session, p. 5; Müller 1983a, p. 253. AO 3 May 1974, admin. session, p. 8. AO 6 April 1973, admin. session, p. 5; AO 19 November 1973, admin. session, p. 7; AO 3–4 May 1974, admin. session, pp. 4–5; AO 22 November 1974, admin. session, p. 6; Müller 1983a, pp. 253–5.

Notes

285

101. Müller 1983a, pp. 354–5 (quote, p. 255). 102. Ganz et al. 1979, p. 37. For earlier discussions on the difficulties of codification see for example AO 3–4 May 1968, pp. 5–6. On problems of analysis see for example AO 8–9 May 1970, p. 15. In 1971 the AO established a committee to ascertain which facts should be included in AO documentation (AO 7–8 May 1971, admin. session, p. 5). 103. Porter 1995, p. 199; Berg 1995, p. 441; Marks 1997, pp. 132–248; Jones 2000, pp. 505, 518. 104. Laros and Spiegel 1979, p. 19. See also Anderson et al. 1975, p. 287; Allgöwer 1978, p. 1090; Burri et al. 1979, pp. 84–5; Grace and Eversmann 1980, p. 434. In ‘randomised’ clinical studies, cases even had to be attributed to the specific therapy groups at random in order to avoid bias. Real randomisation was, however, rarely performed in fracture studies, since it was often too obvious whether a certain fracture form needed an operation, so that chance attribution of treatment methods would have been unethical. 105. Marks 1997, p. 196. 106. Marks 1997, pp. 124–5; see also Löwy 1996, p. 50. 107. Epstein 1996, p. 34. 108. On the technical development see the regular report on AO documentation at the AO meeting: for example AO 23–24 April 1982, admin. session, pp. 6–14; AO 11–12 November 1983, admin. session, p. 6; AO 3 May 1986, scientific session, p. 7. 109. AO 3 May 1986, scientific session, pp. 3–7. 110. Minutes of the AOI Delegates Assembly, 10 December 1977, p. 8; AO 29–30 April 1983, admin. session, pp. 15–20. 111. AO 1 May 1987, admin. session, p. 6. 112. AO 29 April 1988, admin. session, p. 7; AO 29 April 1989, admin. session, p. 1; minutes of the 9th meeting of the AO Documentation Commission, 23 June 1988 (MEM), pp. 2–6. 113. AO 29 April 1988, admin. session, pp. 7–8; minutes of the 9th meeting of the AO Documentation Commission, 23 June 1988 (MEM), pp. 2–6; brochure ‘The Maurice E. Müller Foundation’ 1991, pp. 16–17; ibid. 1998, pp. 9–11; Schatzker 1998, p. 12. 114. AO 29 April 1988, admin. session, p. 7; AO 29 April 1989, admin. session, p. 1; minutes of the 9th meeting of the AO Documentation Commission, 23 June 1988 (MEM), pp. 2–6. 115. Dialogue 5, Issue 2 (December 1992), p. 17; Dialogue 6, 1 (June 1993), p. 18; brochure ‘AO – 40 Years of Service to Patients’ (AOD). 116. By 1998 the centre had over 200,000 fracture case records in store with 1.2 million X-rays (Dialogue 11, 1 (June 1998), p. 4; Moser 2000; Murphy and Leu 2000, p. 46). 117. Müller 1983a, p. 253. For the use of AO documentation material see for example AO 8–9 May 1970, p. 57 (study of all ankle fracture operations performed in Liestal, 1958–66). For later use in publications see for example Ganz et al. 1979, p. 31. 118. In 1964 Allgöwer declared that the AO’s documentation efforts had to be strengthened to counter the resistance that was forming against the AO in Switzerland and Germany (Schneider 1969, p. 13). Similarly, when the AO tried to defend itself against American critics in the mid-1970s, the good results of

286

119.

120. 121. 122. 123. 124. 125. 126. 127. 128.

129.

130. 131. 132. 133. 134. 135. 136. 137. 138. 139. 140.

141. 142.


418 well documented tibia fracture operations were considered ‘ammunition’ for that purpose (letter James E. Gerry to M. Allgöwer, 13 October 1976 (USA 1)). See Müller 1961, especially pp. 199, 204–5; Schneider 1961; Allgöwer 1961; Willenegger 1961. Examples of later uses of the punch cards to illustrate AO documentation can be found in Müller 1963b, p. 27 and Müller et al. 1969, pp. 16–17. See also Schneider 1969, pp. 7–11. Müller’s letter is reproduced in Schneider 1983, p. 26. Müller et al. 1963b, pp. vi, 7, 25, 125–65. Rehn 1965, p. 507. See also Griesser and Schoen 1963, pp. 827–8; Crenshaw 1971, p. 477; Stürmer 1997, p. 119. AO 29–30 April 1966, Annual Report 1965, p. 2. On disputes about direct clinical evidence versus systematic trial see Jones 2000. TK 20 August 1963, p. 8. Müller et al. 1969, p. 16. Allgöwer and Spiegel 1979, p. 27. Richards 1988, p. 686. Porter 1995, pp. 208–9. See also ibid., p. 8; Epstein 1996, p. 33; Jones 2000, pp. 507, 527. Epstein 1996, p. 37. Similarly, David Jones has found for coronary artery bypass grafting that ‘for many physicians, the fact that trials had been conducted was as important as the findings themselves’ (Jones 2000, p. 536). This fits in well with the general observation that perception and assessment of risks are generally based more on the credibility of relevant institutions and their representatives than on understanding the technical information itself (Wynne 1995, p. 377). Once credibility has been achieved, mechanical objectivity becomes less urgent anyway (Porter 1995, p. 214). Gögler (1962, p. 58) cites the eminent Heidelberg surgeon K.H. Bauer who noted that one grave failure could not be balanced by 50 excellent results. Geiser (1963, pp. 96–7) speaks of one osteomyelitis against 99 excellent cases. See also Groh 1968, pp. 79–80. The limits of statistical statements for evaluating the individual case were also acknowledged by the AO surgeons: see for instance Allgöwer’s preface to Rittmann and Perren 1974, p. v. Beck 1986, p. 79 (my translation). Buff 1971, p. 1193. Jones 2000, p. 523. Campbell 1963, pp. xiii–xiv. Geiser 1963, pp. 87–8. On the problem in general see Löwy 1996, pp. 48–54. Van der Linden and Larsson 1979, pp. 874–5, 877. Ibid., p. 876. Gigerenzer et al. 1989, p. 261. See also Löwy 1996, pp. 48–54. Cf. Howell 1995, p. 131; Löwy 1996, p. 50. Badger 1959a, p. 123. Nicoll 1974, p. 149. Nicoll was a general surgeon who had founded a specialised fracture and rehabilitation centre (similar to Böhler’s) in the 1930s in Nottinghamshire (see Cooter 1993b, pp. 208–11). Hübner 1948, pp. 2, 22–3, 27, 30. Howell 1995, p. 245. However, ‘the symbols “art” and “science” have been large protective shields in medicine, hiding much that is not very scientific or artful’ (Gordon 1988, p. 258). The term ‘science’ can have different meanings in the first place. In the same way that medical practice has many faces, so does its ‘scientific

Notes

143. 144. 145. 146. 147. 148. 149. 150. 151. 152. 153.

154. 155. 156. 157. 158.

159. 160. 161.

162. 163. 164.

165. 166.

nature’ (Berg 1995, p. 458). Some AO critics who advocated individualisation claimed that their approach was the one that was truly scientific (Nicoll 1974, p. 150). Howell 1995, p. 246. Marks 1993, p. 159; Berg 1995, p. 442. On the medical diagnostician’s skill as tacit knowledge see Polanyi 1973, p. 54. See also Chapter 4. Buff 1975, p. 186; interview with H.U. Buff, Zürich, 31 March 1999. Geiser 1963, pp. 87–97. Nicoll 1974, p. 144. Allgöwer 1978, p. 1091; Allgöwer and Spiegel 1979, p. 28. Preface to Rittmann and Perren 1974, p. v. Allgöwer 1964, p. 425. Buff 1975, pp. 186–91. Geiser 1963, p. 95. Charnley 1957, p. vii. Charnley was, however, the leading light of a new generation in post-World War II British orthopaedics which was operative and scientifically oriented and keen to abandon the conservative, holistic philosophy that had dominated the field (Cooter 1993, p. 238). Perhaps one has to consider here the background of Charnley’s longstanding dispute over internal fixation with William Gissane of the Birmingham Accident Hospital: see Waugh 1990, pp. 57–60, 68–71. Quoted from Waugh 1990, p. 71. See also Charnley 1968, p. vii. Sturdy and Cooter 1998, p. 447. Girgerenzer et al. 1989, p. 265; Porter 1995, p. 204. Gordon 1988, pp. 259–60. See also Girgerenzer et al. 1989, p. 236, for the general tendency, and Marks 1997, p. 3, for medicine. See Gigerenzer et al. 1989, p. 265, with regard to the statistical mode of thinking. In a similar way, ‘any vestiges of personalized judgement from the assessment of the effect of drugs’ were to be eliminated with the introduction of the clinical trial in drug therapy (Sturdy and Cooter 1998, p. 446). Buff 1975, p. 186. Gordon 1988, pp. 259–60. On the gentleman doctor of late Victorian Britain see Lawrence 1985. In interwar Britain see Lawrence 1998. On anti-specialist tendencies in British orthopaedics see Cooter 1993b, pp. 245–7. On the conflicting approaches to medicine between 1870 and 1950 see Sturdy and Cooter 1998, pp. 435–9. For the 1970s see Gordon 1988, pp. 257–9. Buff 1975, p. 186; interview with H.U. Buff, Zürich, 31 January 1999. Charnley 1957, p. viii. Buff 1971, p. 1195; Buff 1975, pp. 186–95; interview with H.U. Buff, Zürich, 31 March 1999. Cf. the similar arguments of doctors in interwar Britain in Lawrence 1998, pp. 104–6. Sturdy and Cooter 1998, pp. 435–9. Gordon 1988, p. 283.

Chapter 7 1. 2. 3. 4.

287

Badger 1959a, p. 127; similarly Charnley 1957, p. vii. Geiser 1963, p. 95. See Chapter 3; Lange 1959, p. 415. Bürkle de la Camp 1961, p. 99; see also Rehn 1965, p. 510.

288


5. Bürkle de la Camp 1961, pp. 87, 99; Rehn 1965, p. 510; Tscherne 1971, pp. 1136–7. 6. Allgöwer 1978, p. 1081. 7. See Nicoll 1974, p. 144, Schneider 1983, pp. 52–4. Interviews with Max Landolt, Davos, 10 November 1997. H.-U. Buff, Zürich, 31 March 1999. 8. Schneider 1969, p. 14. 9. Müller 1961, p. 203. 10. Müller et al. 1963b, p. 7. 11. See for example Rehn 1965, p. 512; Allgöwer and Spiegel 1979, p. 28; Willenegger and Bandi 1983, p. 272. 12. Quotation from Rüedi and Allgöwer 1979, p. 105. 13. AO 29–30 April 1966, Annual Report 1965, p. 1. 14. Interview with Siegfried Weller, Davos, 16 December 1997. 15. Schneider 1969, p. 12. For public praise, see for example his contribution to the discussion in LAC 305 (1963/64), pp. 47–8 (see Bürkle de la Camp 1963/64); Rehn 1965, pp. 507–14. 16. Maurer and Lechner 1963, p. 504; Rehn 1965, pp. 507–14. 17. Böhler 1963, p. 248. On his Davos visit see Schneider 1969, p. 13 and Schneider 1983, p. 52. For his report at the congress, see LAC 308 (1964), p. 457. 18. Groh 1968. In this series almost half of the cases treated with the AO technique had a bad or even catastrophic outcome. 19. Allgöwer 1964, p. 424. 20. AO 29–30 April 1966, Annual Report 1965, p. 1. 21. Schneider 1969, p. 16. 22. LAC 329 (1971), p. 1171; Schneider 1971, p. 89. 23. Zorn et al. 1969, p. 264; Uhthoff and Dubuc 1971, p. 165; Crenshaw 1971, p. 477; Nicoll 1974, pp. 144, 151; Rockwood and Green 1975, p. 54; Burri et al. 1979, p. 85; Edmonson and Crenshaw 1980, p. 518; Rand et al. 1981, p. 427. 24. Interview Max Landolt, Davos, 10 November 1997. 25. Latta et al. 1998, p. 237; interviews with Hans-Ulrich Buff, Zürich, 31 March 1999; Augusto Sarmiento, Zürich, 15 February 2001. 26. Tscherne 1994, p. 47; Szyszkowitz 1994b, p. 106. 27. Interviews with Siegfried Weller, Davos, 16 December 1997, Jörg Rehn, Denzlingen, 5 February 1999. This was also reported by the UK Synthes representative J. Pinsent (Dialogue 10, 2 (1997), p. 1). On the importance of safety see also Szyszkowitz 1994b, p. 124. 28. See for example AO 26–27 November 1971, pp. 2–3. 29. AO 29–30 April 1966, Annual Report 1965, p. 2. 30. Rolf Soiron, Some Comments in Pioneering in Academia, Symposium in Honour of Maurice E. Müller, 3 April 1998, p. 1 (MEM). 31. Letter from H. Willenegger to Dir. W. Zaug, Berner Allgemeine, 13 May 1960, facsimile in Schneider 1983, p. 40; letter of thanks from H. Willenegger to the Swiss accident insurance company SUVA, 16 November 1963, facsimile in Schneider 1983, p. 51. 32. Schneider 1969, pp. 7–10. 33. Schneider 1969, p. 10. 34. Allgöwer 1961, p. 221; Willenegger 1961, p. 226; Müller et al. 1963b, p. 7; Müller et al. 1969, p. 1. 35. TK 22 September 1978, p. 2. 36. Morscher 1985.

Notes

289

37. Schneider 1969, p. 10; Schneider 1983, p. 28; facsimile of a letter by Krauss to Schneider, 1 September 1960, in Schneider 1983, p. 29. On the start of the contact with Freiburg see in detail Kuner 1997, pp. 138–9. 38. Schneider 1969, pp. 9–12; Müller 1981, p. 8; Heim 2001, pp. 45–6. Also in 1967, Müller founded Protek AG, a company for the sale of prostheses and instruments manufactured by Mathys and Sulzer. Müller had started to develop hip prosthesis in 1960 following the pioneering work of John Charnley, and worked together with Robert Mathys who manufactured the first prosthetic implants in 1960. In 1966 Müller started working with Sulzer. The royalties and the profits of Protek AG were given for research, education and documentation purposes and distributed through the Protek Foundation. In 1974 this foundation was renamed and established as the Maurice E. Müller Foundation for Continuing Education, Research and Documentation in Orthopaedic Surgery. In 1989 Protek AG became a subsidiary of Sulzer Medica, and in 1996 it was incorporated into Sulzer Orthopaedics (Maurice E. Müller Foundation 1998, pp. 9–11). 39. AO 28–29 April 1967, Annual Report 1966, p 1; AO 3–4 May 1967, Annual Report 1967, p. 1; Schneider 1969, pp. 15–16. 40. AO 28–29 April 1967, Annual Report 1966, p. 1. 41. TK 27 May 1977, p. 1. On Schneider in more detail see M.E. Müller: Robert Schneider 1912–90 (MEM). 42. AO 8–9 May 1970, p. 37; AO 7 May 1971, admin. session, supplement 2, Annual Report 1970, p. 1. 43. Interviews with Max Landolt, Davos, 10 November 1997, Eugen Kuner, Umkirch, 20 July 1998. 44. Marcel-Benoist-Preis (n.d.). On the history of the prize see Stuber and Kraut 1995. 45. TK 9 May 1964, p. 11; TK 15 July 1964, p. 8; TK 10 February 1966, p. 4; AO 28–29 April 1967, pp. 3–4; KTK 25 July 1977, p. 2; KTK 16 September 1977, p. 2; KTK 26 January 1979, p. 5; KTK 9 March 1979, p. 5; KTK 14 April 1979, p. 3; KTK 10 April 1981, p. 7; KTK 2 March 1984, p. 9. 46. AO 17–18 November 1967, p. 5; AO 28–30 April 1972, Annual Report 1971/72, p. 1. 47. AO 8–9 May 1970, p. 5; von Rechenberg 1983, p. 270; Heim 2001, Chapter 3, p. 27. 48. AO 19–20 November 1982, admin. session, p. 7. 49. AO 22 November 1974, admin. session, p. 3; interviews with Peter Matter, Davos, 17 November 1997, Howard Rosen, Davos, 16 December 1997. 50. Epstein 1996, p. 23. 51. Lane 1909, pp. 345–6. For Lambotte, see Heim 1994, p. 24. 52. Matti 1918, p. 314. 53. Steinmann 1919, p. 14. 54. Allgöwer 1964, p. 425. In retrospect: Schatzker 1998, pp. 8, 11; interviews with Max Landolt, Davos, 10 November 1997, Peter Matter, Davos, 17 November 1997. 55. Hans Willenegger, Notes on my experience in the US, 12 July 1976 (USA 1). 56. Knudsen et al. 1983, p. 145. 57. Charnley 1957, p. viii; similarly Moore 1960, p. 873. 58. Interview with Siegfried Weller, Davos, 16 December 1997. 59. Buff 1971, p. 1195. 60. Interviews with Max Landolt, Davos, 10 November 1997, Peter Matter, Davos, 17 November 1997, Emanuel Trojan, Davos, 15 December 1997. This confirms

290

61. 62. 63. 64. 65.

66. 67.

68.

69. 70.

71. 72. 73. 74.

75. 76. 77.

78. 79. 80. 81. 82. 83. 84. 85. 86. 87. 88.


Ulrich Beck’s theory that it is basically the medical experts’ definition and description of risk which forms the population’s views about the acceptability of risks (Beck 1986, pp. 76–7, 87). Bircher 1886, p. 413. See for example Badger 1959b, p. 142; Hicks 1961, p. 687. Hicks 1961, p. 683; Brian Hopkinson, discussion, in JT 7 (1967), pp. 224–5. Grace and Eversmann 1980. For fracture treatment in general see Steinmann 1907, p. 938; Böhler 1958, p. 180. For osteosynthesis AO 8–9 May 1970, appendix 5, p. 6; Berkin and Marshall 1972, p. 1112; Rosen 1979, p. 160. Ganz et al. 1979, p. 33. Lambotte 1907, p. 12; Badger 1959a, p. 125; Murray et al. 1964, pp. 1045–6; Tscherne 1971, p. 1139; Olerud and Karlström 1972a, pp. 38–9; AO 4 May 1974, scientific session, pp. 15, 27; Rüedi et al. 1975, p. 254; Rosen 1979, p. 160. Weber 1966, pp. 48–9; see also Olerud 1972, p. 1019; Olerud and Karlström 1972a, pp. 38, 42; Anderson et al. 1975, p. 291. Also, interview with Emanuel Trojan, Davos, 15 December 1997. For ‘untrustworthy’ see Murray et al. 1964, p. 1046. For ‘unreliable’ see Clancey and Hansen 1978, p. 119. Edmonson and Cranshaw 1980, p. 509. Others, however, stated that ‘in some respects, nonoperative treatment demands more patient compliance than many operative treatments’ (Latta et al. 1998, p. 261). Interview with Peter Matter, Davos, 17 November 1997. Schneider 1969, pp. 9–10. Ibid., p. 12. Founding member Fritz Brussatis was German and went back to Germany as early as 1958; the American Irvin Leinbach was admitted in 1960; the German Hermann Krauss in 1961 (Schneider 1969, pp. 8, 52; Schneider 1983, p. 141). Schneider 1983, pp. 264–5. Schneider 1969, p. 12; Schneider 1983, p. 11. Müller et al. 1963b, p. v; Schneider 1969, pp. 8–9; Schneider 1983, pp. 28, 32; Kuner 1994, pp. 41–4; Heim 2001, Chapter 4, pp. 8–9, 20–1; interview with Siegfried Weller, Davos, 16 December 1997. Kuner 1994, pp. 44–5. Schneider 1983, p. 32; Kuner 1994, p. 44; interview with Siegfried Weller, Davos, 16 December 1997. TK 21 November 1963, p. 2; Kuner 1994, p. 44; interview with Siegfried Weller, Davos, 16 December 1997. Rehn 1953, pp. 234–5; Rehn 1965; Rehn 1983, pp. 109–94; interview with Jörg Rehn, Denzlingen, 5 February 1999; Povacz 2000, p. 209. Heim 2001, Chapter 5, p. 6. Ibid. Kuner 1994, pp. 44–5; Heim 2001, Chapter 5, p. 6–7; interview with Siegfried Weller, Davos, 16 December 1997. Schneider 1969, p. 15; Heim 2001, Chapter 3, p. 23. AO 29–30 April 1966, Annual Report 1965, p. 5; Schneider 1969, p. 14; Schneider 1983, p. 32. AO 28–29 April 1967, Annual Report 1966, p. 1; AO 17–18 November 1967, p. 2; AO 3–4 May 1968, Annual Report 1967, p. 3; TK 27 January 1968, p. 13. AO 21–22 November 1969, p. 3.

Notes

291

89. TK 25 October 1969, p. 8; AO 8–9 May 1970, Annual Report 1969, p. 6; TK 24 March and 8 May 1979, pp. 19–22. 90. Kuner 1997, pp. 141–2. 91. Interviews with Peter Matter, Davos, 17 November 1997; Eugen Kuner, Umkirch, 20 July 1998. 92. TK 24 March and 8 May 1970, p. 26. 93. Interview with Jörg Rehn, Denzlingen, 5 February 1999. 94. Interview with Siegfried Weller, Davos, 16 December 1997. 95. Kuner 1994, pp. 45–6; interview with Siegfried Weller, Davos, 16 December 1997. 96. Interviews with Siegfried Weller, Davos, 16 December 1997, Eugen Kuner, Umkirch, 20 July 1998. On the history of traumatology see Oestern and Probst 1997. 97. The passage on Austria is based on Spath and Tscherne 1968; Beck 1994; Brücke 1994; Feischl 1994; Mathys 1994; Müller 1994; Szyszkowitz 1994a; Tscherne 1994; Szyszkowitz 1995; Povacz 2000, pp. 210–12; interview with Emanuel Trojan, Davos, 15 December 1997; letter from Rudolf Szyszkowitz to the author, 21 August 2001. I thank Prof. Trojan and Prof. Szyszkowitz for their comments and the material they made available to me. 98. AO 29–30 April 1966, Annual Report 1965, p. 4; AO 28–29 April 1967, Annual Report 1966, p. 1; Schneider 1969, p. 14; minutes of the assembly of delegates, AOI 6 January 1975, pp. 3–4; Willenegger and Bandi 1983, p. 273. 99. AO 25–26 April 1980, admin. session, p. 10; AO 21–22 November 1980, admin. session, p. 12. 100. Van der Elst 1963; minutes of the assembly of delegates, AOI 10 December 1977, p. 2. 101. Brian Hopkinson, discussion, in JT 7 (1967), pp. 224–5; TK 25 December 1969, p. 9; Schneider 1969, p. 15. 102. See for example Olerud and Karlström 1972a, pp. 1–2; Olerud and Karlström 1972b. 103. Minutes of the assembly of delegates, AOI 6 January 1975, pp. 5–6. 104. Willenegger and Bandi 1983, p. 273; TK 4 April 1975, p. 10; minutes of the assembly of delegates, AOI 6 January 1975, pp. 4–5; Dialogue 12, 2 (1998), p. 14. 105. TK 5 May 1973, p. 8; TK 8 December 1973, p. 9; interview with Howard Rosen, Davos, 16 December 1997. 106. AO 19–20 November 1982, admin. session, p. 21. 107. Minutes of the assembly of delegates, AOI 4 April 1976, pp. 3–4. 108. Schneider 1983, pp. 260–1; different folders in AOI. Later dates kindly provided by Claudio Gubser, 3 August 2001. 109. The respective years for Operating Room Personnel (ORP) courses are as follows. 1963: Switzerland; 1965: Germany; 1967: France; 1972: Austria, Italy, Sweden; 1974: Spain, United Kingdom; 1975: USA; 1977: Brazil, Chile, Finland, Hungary; 1978: Australia, Bolivia, Ecuador, the Netherlands, Netherland Antilles, South Africa; 1979: Denmark, New Zealand, Norway; 1980: Egypt, Ireland, Israel, Yugoslavia; 1981: Canada; 1982: Portugal; 1983: India, Uruguay; 1984: Namibia, Singapore; 1985: Malaysia, Taiwan, Thailand; 1986: Oman; 1987: Hong Kong, Indonesia; 1988: Colombia, Cuba, Greece, Mexico; 1989: South Korea; 1991: Iran, Japan; 1992: Peru, Russia; 1993: Czech Republic, Pakistan; 1994: Saudi Arabia, Slovenia, Venezuela; 1995: Argentina, Bahrain, Tanzania; 1996: Croatia; 1997: China, North Korea; 1998: Jordan, Paraguay; 1999: Kenya, Kuwait, Poland; 2000: Cyprus. Information kindly provided by Giovannina Jost, 27 Sept. 2001.

292


110. Schneider 1983, pp. 262–3. 111. Willenegger 1989, p. 202; Dialogue 9, 2 (December 1996), p. 9. 112. Interview with Robert Mathys, Bettlach, 27 January 1999. Dates kindly provided by Regula Haag, Mathys Medical, 5 September 2001. 113. AO Foundation Annual Report 1987/88, p. 16. 114. , 7 August 2001. 115. KTK 2 March 1984, p. 9. 116. Willenegger and Bandi 1983, p. 276. 117. Interview with Suthorn Bavonratanavech, Davos, 16 December 1998. 118. Memorandum ‘Traumatology in the USSR’ (no author given), 10 December 1975; letter from Charles Müller to Protek headquarters, 29 May 1978, AOI folder USSR; Ilizarov 1982; interview with Emanuel Trojan, Davos, 15 December 1997. 119. Interview with Suthorn Bavonratanavech, Davos, 16 December 1998. 120. Interview with Robert Mathys, Bettlach, 27 January 1999. 121. Interview with Siegfried Weller, Davos, 16 December 1997. 122. TK 27 May 1977, p. 2; TK 16 September 1977, p. 3. 123. For the GDR see Chapter 8; for the US see Chapter 9; on Norway, personal communication from K. Stromsoe, Bad Ragaz, Austria, 28 June 2001, TK 22 May 1965, p. 17; on Australia and Israel, letter from H. Willenegger to M. JaquesBaumann, 27 July 1975 (USA 1). 124. Memorandum ‘Traumatology in the USSR’, anonymous, 10 December 1975; Note, ‘important contact addresses for the USSR’, anonymous, no date given; letter M.V. Volkov to H. Willenegger, 31 October 1978 – all AOI folder USSR. Report by E. Trojan: AO-Russian Connections, 10 January 1995; note from P. Matter to E. Trojan, 8 September 1997 – these documents were kindly made available to me by Professor Trojan. Numerous Russian hospitals have taken up the AO technique, regular AO courses and symposia are being organised and a Russian AO Alumni chapter was founded in 2000 (letter from Emanuel Trojan to the author, 4 September 2001). 125. TK 10 February 1966, p. 5. See letter from Hideaki Yokoi to Anthony E. Timms, 21 February 1990 and other documents in AOI folder Japan; interview with Siegfried Weller, Davos, 16 December 1997. 126. Interview with Suthorn Bavonratanavech, Davos, 16 December 1998. 127. Interviews with Peter Matter, Davos, 17 November 1997, Suthorn Bavonratanavech, Davos, 16 December 1998. 128. Willenegger and Bandi 1983, pp. 276–7.

Chapter 8 1. Probst 1997, p. 49; Hildebrandt, G.: Sektion der AO-International, Entwicklung und aktueller Stand, typescript for a speech held in Halle on 21 December 1987, from the personal papers of E. Sander generously made available to me. These personal papers will subsequently be quoted as ESA, this paper as ‘Hildebrandt 1987’. 2. My account of the GDR health care system is based on Sozialismus 1968, pp. 76–80; Rohland and Spaar 1973, pp. 181–94, 205–10; Winter 1974, pp. 13–24; Pritzel 1978, pp. 29–34, 102–4; Ruban 1981, pp. 177–90; Mecklinger 1994, p. 63; Ernst 1997, p. 334. 3. Brückner 1969, preface.

Notes

293

4. Uebermuth 1975, p. 206. On economic considerations and the loss of working capacity due to illness and disability in the GDR health care system in general see Müller 1997, p. 247. 5. Uebermuth 1975, p. 206. 6. Hildebrandt 1987, p. 2. 7. For details on this technique see Chapter 1. 8. Autobiographical report by E. Sander 1999, ESA (subsequently quoted as ‘Sander 1999’); E. Sander: Concluding report on my term of office as chairman of the GDR section of the AO International, 26 September 1990, AO archives (in the following, quoted as ‘Sander 1990’). I also used information from the interview with E. Sander, Halle, 8 April 1999, and from subsequent letters. If not stated otherwise, the archival material is located at the AO archives, Davos, files ‘DDR 1975–1980’, ‘DDR 1981–1987’ and ‘DDR 1988–1992’. 9. Sander 1999, p. 2. 10. H. Willenegger and R. Schneider: On the occasion of Professor Sander’s 65th birthday, typescript, 1987. 11. E. Sander: Reasons for the usefulness of the acceptance of our work group for operative fracture care into the AO International, typescript, 17 October 1974 (in the following quoted as ‘Sander 1974’). See also Willenegger and Schneider 1987; Sander 1990; Sander 1999, p. 2. 12. ‘Arbeitsordnung der Arbeitsgemeinschaft für operative Knochenbruchbehandlung in der Sektion Traumatologie der Gesellschaft für Chirurgie der DDR’, 13 December 1968 (ESA). 13. Rohland and Spaar 1973, pp. 108, 123, 303; Winter 1974, p. 196. 14. Arbeitsordnung 1968; Hildebrandt 1987; Sander 1999. 15. Sander 1974; Willenegger and Schneider 1987; Sander 1990; Sander 1999. 16. Rohland and Spaar 1973, p. 187; see also Sozialismus 1968, pp. 87–8. 17. Müller 1997, p. 269. 18. They even turned down propositions from the Swiss AO surgeons to include certain colleagues who had not yet joined the documentation project. See letter from E. Sander to H. Willenegger, 26 August 1976. 19. Arbeitsordnung 1968 (ESA), p. 3; letter from H. Meyer to H. Willenegger, 5 September 1973; Sander 1974; letter from E. Sander to H. Willenegger, 3 January 1980; Hildebrandt 1987, pp. 2–4; Sander 1990. 20. Sander 1974. 21. Hildebrandt 1987, p. 1. 22. Sander 1999, p. 5. The final number also takes into account the sets supplied to orthopaedic surgeons in the GDR. 23. Sander 1999, pp. 4–5. 24. Ibid., pp. 5–6. Sander explained his policy also in interview with the author, Halle, on 8 April 1999. 25. Other examples include the introduction of the antibiotic drug streptomycin in the 1940s in the US: see Marks 1997, pp. 121–6. 26. Aktuelle Probleme 1985, p. 33; see also Uebermuth 1975, pp. 207–8. 27. Hildebrandt 1987, pp. 2–3; also interview with E. Sander, Halle, 8 April 1999. 28. Hildebrandt 1987, p. 3. 29. As stated by Sander in retrospect (Sander 1999, p. 4). 30. Mörl 1968, p. 155. 31. Brückner 1969, pp. 51, 60.

294


32. Pritzel 1977, pp. 90–8; Ruban 1981, p. 47; Mecklinger 1994, p. 64; Spaar 1996, p. 54. 33. AO archives, Davos, files ‘DDR 1975–1980’, ‘DDR 1981–1987’ and ‘DDR 1988–1992’. 34. TK 14 November 1970, p. 3. 35. Letter from M. Madl to H. Willenegger, 14 September 1972. 36. TK 24 November 1972, p. 14. 37. Letter from M. Madl to H. Willenegger, 29 March 1974. 38. Report by Werner Christinat on his conversation with E. Sander on 6 June 1982; report by H. Willenegger on the Second Symposium of the GDR Section of the AOI in Potsdam, 4–6 October 1983. 39. Reports by H. Willenegger on conversations with H. Sander and W. Senst on 14 December 1982, on his GDR trip, 8–15 September 1983, and on the Second Symposium of the GDR section of the AOI in Potsdam, 4–6 October 1983. 40. Reports by H. Willenegger on conversations with H. Sander and W. Senst on 14 December 1982, on his GDR trip, 8–15 September 1983, and on the Second Symposium of the GDR section of the AOI in Potsdam, 4–6 October 1983; memo by H. Willenegger, 29 January 1985; letter from H. Willenegger to M. Müller, 3 July 1983. 41. Spaar 1994b, p. 59; Mecklinger 1994, p. 65; Ernst 1997, pp. 265–335; Müller 1997, pp. 253, 262. 42. Sander 1999, pp. 5–6. 43. See, among other documents in the files, letters from M. Madl to H. Willenegger, 20 March 1975, H. Willenegger to E. Sander, 11 December 1974; reports by H. Willenegger on conversations with H. Sander and W. Senst, 14 December 1982, on the Second Symposium of the GDR Section of the AOI in Potsdam, 4–6 October 1983; letter from H. Willenegger to S. Perren, 30 June 1983; note from H. Willenegger in preparation for his GDR journey, information obtained from Dr Otto, 9 September 1983. 44. Sozialismus 1968, p. 78. 45. Letter from M. Madl to H. Willenegger, 14 September 1972. 46. Rohland and Spaar 1973, p. 155; Pritzel 1977; pp. 82–7; Mecklinger 1994, p. 64; Spaar 1994a; Müller 1997, pp. 258–60. 47. Letters from H. Willenegger to M. Allgöwer, M.E. Müller, R. Schneider, P. von Rechenberg, 24 August 1976; H. Willenegger to A.K. Schmauss, 17 April 1976; Rohland and Spaar 1973, p. 168. 48. Sander, 1974; note by H. Willenegger on his conversation with A.K. Schmauss, 4 and 5 June 1976. 49. Hildebrandt 1987, p. 4. 50. Sander 1990; Sander 1999, p. 8. 51. Brückner 1969, p. 60; Uebermuth 1975, pp. 206–7. 52. Mörl 1968, pp. 155, 161. 53. Sander 1999, p. 8. 54. Sander 1974; Willenegger and Schneider 1987. 55. Hildebrandt 1987, p. 4. 56. TK 24 November 1972, p. 14. 57. AO 6 April 1974, admin. session, annex 1: Annual Report 1972/73, p. 8. 58. Letter from H. Willenegger to E. Sander, 1 July 1975. 59. Letters from U. Heim to E. Sander, 3 October 1990, H. Willenegger to E. Sander, 10 April 1990.

Notes

295

Chapter 9 1. Irvin Leinbach was from St Petersburg, Florida. See Schneider 1969, pp. 8, 52; Schneider 1983, p. 141. 2. List of participants; also interview with Howard Rosen, Davos, 16 December 1997. 3. Schneider 1969, pp. 9–10. 4. Harvey 1984. 5. Crenshaw 1963, pp. 34–5 (but the AO is not mentioned, nor is the AO technique mentioned in the relevant passages: see ibid., pp. 376–80). See also Müller et al. 1963b, p. 16. For the Memphis animal experiments see Boyd and Anderson 1961. For clinical experience see Anderson 1965, p. 192. 6. Starr 1982, pp. 337–51, 374–8. 7. Gaston 1975; see also Trunkey 1983; Shires 1989. 8. Hampton and Fitts 1959, p. vi; retrospectively, Allgöwer 1978, p. 1071. 9. Venable and Stuck 1947, p. 77; Robinson 1978, p. 362. 10. Interviews with James Hughes, Davos, 15 December 1998, Joseph Schatzker, 16 December 1998. 11. Venable and Stuck 1947, pp. 84–96, 159; Aufranc et al. 1964; Sakellarides et al. 1964 (with numerous references to earlier similar studies); Brashear 1965. 12. Bagby had invented a compression plate in 1956 and used it in only 100 cases in his more than 20 years of practice because he could not justify the risks involved in opening up the fracture site: see Bagby 1977, p. 630. 13. Moore 1960, quotations from pp. 872 and 874. 14. Crenshaw 1963, p. 374 (quotation) and p. 48. 15. Retrospectively, Cast Banishment? The AO Method of Internal Fixation, in Lynn Magazine, Winter–Spring 1982, pp. 1–3 (USA 2); letter from B. Friedrich, Bremen, to H. Willenegger, 6 April 1982 (USA 2); interview with Marvin Tile, 16 December 1998. 16. Eaton 1965, p. 1293; similarly Charnley’s review (Charnley 1966, p. 200). 17. Stewart et al. 1966, pp. 799–800; Neer et al. 1967, pp. 600–12. 18. Wickstrom et al. 1967, and minutes of the subsequent discussion. 19. Wade 1970, pp. 513–15. As will be explained in more detail later, the abbreviation ASIF for ‘Association for the Study of Internal Fixation’ was used by the AO in the US. 20. Dodge and Cady 1972, p. 1172. 21. B.R. Cahill and R.E. Palmer, Dark Side of Davos, typescript, October 1976 (USA 1); see also letter from James E. Gerry to M. Allgöwer, 13 October 1976 (USA 1). 22. Interview with Howard Rosen, 16 December 1997. 23. Rosen became corresponding AO member in 1967 (AO 17–18 November 1967). He was a very enthusiastic teacher of the AO technique and never missed a single Davos course (interview with Howard Rosen, Davos, 16 December 1997; Rosen 1979; Fragments 7, 4 (1987), pp. 1–2. 24. Jeffrey Malka, for example, spent two years in Geneva in the early 1960s. See also letter from J. Malka to H. Willenegger, 20 December 1977 (USA 1). 25. AO 6 April 1974, admin. session, Annual Report 1972/73, p. 8. 26. H. Willenegger, report on a conversation with Dr Lawson, 14 October 1983 (USA 2). 27. Interview with Marvin Tile, Davos, 16 December 1998. 28. TK 24 April and 8 May 1970, pp. 21–3.

296


29. TK 14 November 1970, p. 8; TK 23 April 1971, p. 6; TK 28 April 1972, p. 10; TK 5 May 1973, p. 5. Also, handwritten project outline, Davos 1977 (no date) (anonymous) (USA 1). 30. Interview with Joseph Schatzker, Zürich, 16 December 1998. 31. Interview with Howard Rosen, Davos, 16 December 1997. 32. TK 16 September 1977, p. 2; AO 25–26 April 1980, Annual Report 1979/80, p. 3. 33. TK 15 July 1964, pp. 3–4. 34. TK 27 January 1968, p. 14; AO 9–10 May 1969, Annual Report 1968, p. 6. 35. TK 22 November 1968, supplement 1. See also Wade 1970, p. 513; personal communication, James E. Gerry, 12 February 2001. 36. AO 19–20 November 1982, p. 7; von Rechenberg 1983, p. 269; Fragments 7, 2 (July 1986), p. 1; Fragments 7, 5 (May 1987), p. 1. Also, interview with M. JaquesBaumann, Zürich, 13 July 1999. Synthes began selling AO products in January 1975 (personal communication, James E. Gerry, 12 February 2001). 37. This was at least Allgöwer’s assessment (TK 16 September 1977, p. 2). 38. TK 15 July 1964, p. 8; TK 10 December 1966, p. 11. 39. TK 28 April 1972, pp. 14–15. 40. Interview with Joseph Schatzker, Davos, 16 December 1998. 41. Fragments 7, 5 (August 1987), p. 2. Also, interview with M. Jaques-Baumann, Zürich, 13 July 1999. 42. Letter from J.G. Stein, Florida, to H. Willenegger, 24 October 1975, box: contact travel Prof. Willenegger 1976 (AOI). 43. Letter from H. Willenegger to M. Jaques-Baumann, 23 July 1975 (USA 1). 44. TK 16 Sept. 1977, p. 2; letter from H. Wyss to H. Willenegger, 6 September 1984 (USA 3). 45. AO 25–26 April 1980, Annual Report 1979/80, p. 3; von Rechenberg 1983, p. 269. Also, interview with M. Jaques-Baumann, Zürich, 13 July 99. 46. Handwritten notes by H. Willenegger, box: H. Willenegger contact journeys 1976; M. Allgöwer in AO 6 April 1973, admin. session, p. 8. Also, interview with Joseph Schatzker, Davos, 16 December 1998. 47. See the files on Willenegger’s contact journeys in the US: H. Willenegger, memorandum on his experience in the US, 12 July 1976 (USA 1); H. Willenegger, some remarks on the visit of Prof. A. Sarmiento, Los Angeles, 12 October 1979 (USA 1); Laros and Spiegel 1979, p. 2. Also, interview with James Hughes, Davos, 15 December 1998. 48. Letter from H. Willenegger to M. Jaques-Baumann, 23 July 1975 (USA 1). 49. Letter from H. Willenegger to Prof. J.P. Harvey, Los Angeles, 30 March 1976, box Prof. Willenegger contact journeys 1976 (AOI); H. Willenegger, report on the visit of the Yale University Medical School in New Haven, 25 July 1980 (USA 1). 50. Letter from H. Willenegger to Robert A. Winquist, Seattle, 17 July 1978 (USA 1). 51. Letter from H. Willenegger to M. Jaques-Baumann, 23 July 1975 (USA 1). Similarly, H. Willenegger, report on his visit to the Sarmiento clinic, 16–18 July 1980 (USA 1) and his report on the visit of the Yale University Medical School in New Haven, 25 July 1980 (USA 1). Interview with James Hughes, Davos, 15 December 1998. 52. Letter from W-W. Rittmann to H. Willenegger, 24 May 1983 (USA 2); letter from H. Willenegger to W-W. Rittmann, 1 June 1983 (USA 2). Harvey (1984, p. 13) spoke of the ‘ASIF company’.

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53. H. Willenegger, report on visit to the Sarmiento clinic, 16–18 July 1980 (USA 1); letter from B. Friedrich, Bremen, to H. Willenegger, 6 April 1982 (USA 2). 54. W. Bandi, report on the clinic in Jackson, MS, 18 November 1980 (USA 1). Also, interview with Marvin Tile, Davos, 16 December 1998. 55. H. Willenegger, visit to the Sarmiento clinic, 16–18 July 1980 (USA 1). Sarmiento was famous for his invention of a new type of plaster cast treatment. The AO first made contact with this American pioneer of conservative fracture care in the mid-1970s. Sarmiento was first reluctant and later very impressed by the AO’s systematic approach after he had visited its institutions in Switzerland. On his treatment method see Sarmiento and Latta 1981. 56. Interview with Joseph Schatzker, Davos, 16 December 1998. 57. Starr 1982, pp. 379–93 (quotation, p. 390). 58. Robinson 1978, p. 358. 59. W. Bandi, report on visit to the clinic in Jackson, MS, 18 November 1980 (USA 1); H. Willenegger, report on visit to the University of Connecticut and the Hartford Hospital, 23–24 July 1980 (USA 1); H. Willenegger, notes on conversation with C. Gerber at the AOI office, 15 August 1984 (USA 3). Also, interview with Howard Rosen, Davos, 16 December 1997. On the considerable divergence of the American and the Swiss situation with regard to malpractice see Stürner 1984. 60. Interviews with Marvin Tile, Davos, 16 December 1998, Joseph Schatzker, Davos, 16 December 1998. 61. Interviews with Howard Rosen, Davos, 16 December 1997, Joseph Schatzker, Davos, 16 December 1998. 62. Wickstrom et al. 1967 and minutes of the subsequent discussion. See also Naiman et al. 1970; Crawford 1976. 63. TK 14 August 1965, p. 2. 64. Ibid. 65. Wickstrom et al. 1967, p. 215. 66. TK 15 July 1964, pp. 5, 8; Crawford 1976; Rosen 1979, p. 154; Giles et al. 1982, p. 865. 67. Interview with James Hughes, Davos, 15 December 1998. 68. Crenshaw 1971, pp. 45, 477, 522. 69. Interview with M.E. Müller, Bern, 23 March 1999. 70. Rahn et al. 1971. 71. Olerud 1972; Olerud and Karlström 1972b; Dodge and Cady 1972. 72. H. Willenegger, memorandum on his experience in the US, 12 July 1976, (USA 1); H. Willenegger, some remarks on the visit of Prof. A. Sarmiento, Los Angeles, 12 October 1979 (USA 1); Allgöwer 1979, pp. 1090–91; H. Willenegger, conversation with C. Gerber, 15 August 1984 (USA 3). 73. Crenshaw 1971, p. 477; Olerud and Karlström 1972b; Olerud 1972; Dodge and Cady 1972; Schatzker et al. 1974; Anderson et al. 1975. 74. Schneider 1983, p. 262. 75. TK 20 October 1973, p. 3a; letter from Bruce Hohn to P.R. Lipscomb, 19 April 1976, box: Prof. Willenegger contact travels 1976 (AOI); Fragments 7, 4 (1987), pp. 1–2. 76. Letter from Bruce Hohn to P.R. Lipscomb, 19 April 1976, box: Prof. Willenegger contact travels 1976 (AOI); Programme of the Seventh Annual Course, Internal Fixation of Fractures and Non-Union, 3–6 March 1978 in Columbus, OH (USA 1); also Schneider 1983, p. 260; interview with Howard Rosen, Davos, 16 December 1997.

298


77. TK 24 March and 8 May 1970, p. 22; AO 8–9 May 1970, p. 32; course programme 5–7 March 1970 (MEM); Schneider 1983, p. 260; interview with Joseph Schatzker, Davos, 16 December 1998. 78. AO 11–12 November 1983, pp. 12–15. 79. Interview with James Hughes, Davos, 15 December 1998. 80. Laros and Spiegel 1979, pp. 2–3; Allgöwer and Spiegel 1979, p. 28. Schatzker and Lambert 1979; see also Schatzker et al. 1974. Schatzker’s line of argument was obviously convincing: see Mize et al. 1982, p. 877; Burri et al. 1979. 81. Edmonson and Crenshaw 1980, pp. 508–71. 82. Grace and Eversmann 1980; Rand et al. 1981; Mize et al. 1982; Stern et al. 1984. 83. Grace and Eversmann 1980, p. 434. 84. H. Willenegger, notes on a conversation with H. Tscherne, 18 December 1980, (USA 1). 85. Cast Banishment? The AO Method of Internal Fixation, in Lynn Magazine, Winter–Spring 1982, pp. 1–3 (USA 2). 86. Letter from B. Friedrich, Bremen, to H. Willenegger, 6 April 1982 (USA 2). 87. AO 11–12 November 1983, p. 12. 88. Interview with James Hughes, Davos, 15 December 1998. 89. AO 25–26 April 1980, Annual Report 1979/80, p. 3; letter from H. Wyss to H. Willenegger, 6 September 1984 (USA 3). For Allgöwer’s praise see Fragments 7, 7 (July 1986), p. 1. 90. Interview with M. Jaques-Baumann, Zürich 13 July 99. 91. Interview with Marvin Tile, Davos, 16 December 1998. 92. Interview with M. Jaques-Baumann, Zürich 13 July 1999. 93. Dialogue 6, 1 (June 1993), pp. 10, 16; Dialogue 10, 2 (December 1997), pp. 16–17. 94. For the following conclusion, see also Schlich 2002, pp. 119–21.

Chapter 10 1. Perren 1999, p. S-B4. 2. Chapman and Madison 1988, vol. 1, p. xxi; Chapman and Madison 1993, vol. 1; pp. 229–30; Browner et al. 1998, vol. 1, p. xiv; Latta et al. 1998 (the last two papers explicitly name the AO as the main cause of the predominance of operative treatment). 3. Schatzker and Tile 1987, preface (no page given). 4. Müller et al. 1969, pp. 32, 38–9; see also for example Perren and Rahn 1978, pp. 137–8; Chapman and Madison 1988, vol. 1, pp. 135–40. 5. Zorn et al. (1969, pp. 267–8), for instance, used the phenomenon in their argumentation against the AO technique. See also Willenegger et al. 1971, pp. 248–51; Schneider 1971, p. 93; Dodge and Cady 1972, p. 1174; Rhinelander 1974, p. 77; Allgöwer 1978, p. 1090. 6. Annual Report of the AO Laboratory 1968/69, p. 5; Perren et al. 1969b, p. 7; AO 8–9 May 1970, p. 20; AO 7–8 May 1971, scientific session, pp. 9–11; Allgöwer 1978, p. 1074; Perren and Rahn 1978, p. 132. 7. AO 3–4 May 1968, Annual Report 1967, pp. 1–2. 8. See for example Sargent and Teipner 1965, pp. 1484–5; Anderson et al. 1975, p. 295; Rockwood and Green 1975, p. 58; Woo et al. 1976 (with a survey and numerous references); also Rand et al. 1981, p. 439. 9. Perren and Rahn 1978, p. 124. 10. Woo et al. 1976; Moyen et al. 1978 (with a wealth of references to other works on the subject); Allgöwer 1978, p. 1074; Allgöwer and Spiegel 1979, p. 27.

Notes

299

11. Perren et al. 1969a, pp. 19, 25–7; Cochran 1969; Coletti 1969; Matter et al. 1975, p. 42; Mathews and Cooper 1976; Perren and Rahn 1978, pp. 108–13, 132. 12. AO 17 November 1973, scientific session, pp. 5–6; Perren and Rahn 1978, pp. 132–3. 13. Annual Report of the AO Laboratory 1968/69, p. 7; AO 23 November 1974, scientific session, pp. 4–5; Perren 1979, p. 191. However, stress protection remained a plausible explanation for many surgeons, and even in the 1980s there was no general consensus about the cause of the phenomenon of bone resorption beneath plates that was still regarded as a side effect of rigidity (Edmonson and Crenshaw 1980, p. 527; Rand et al. 1981, p. 439; Chapman and Madison 1988, vol. 1, pp. 119, 136). 14. Perren and Buchanan (1991, p. 1) mention seven phases, one of which was characterised by the aim of achieving rigid fixation and absolute stability. Also Schatzker 1995, pp. S-B51, S-B53; interview with Siegfried Weller, Davos, 16 December 1997. 15. Charnley 1957, p. vii; Badger 1959a, p. 123; Moore 1960, p. 870; Buff 1971, p. 1194; see also Chapters 5 and 6. 16. Burwell and Charnley 1964, p. 423; Sargent and Teipner 1965; Anderson 1965, pp. 206–7. 17. Willenegger et al. 1971, pp. 248–9. 18. Allgöwer 1971, p. 1128, 1134–5. 19. See for example Olerud and Karlström 1972a, p. 16, 24; Edmonson and Crenshaw 1980, pp. 508–13; Mize et al. 1982, p. 877. 20. Rockwood and Green 1975, p. 75. 21. Neff, contribution to the discussion, printed in Langebecks Archiv für Chirurgie 308 (1964), p. 460. 22. Willenegger et al. 1971, pp. 248–9. 23. 17 November 1973, scientific session, p. 6; Perren 1979, pp. 181–93. 24. Schatzker and Tile 1987, p. 6; Schatzker and Tile 1996, p. 12. 25. Schatzker 1995, p. S-B54; see also Schenk (1998, p. 65) who notes, however, that fracture necrosis does not exist. 26. Latta et al. 1998, p. 239. 27. Schneider 1969, p. 15. 28. One example is the introduction of systematic prebending of the plates, see Bagby and Janes 1958, p. 761; Schneider 1983, p. 54; Wittner and Holz 2000, p. 180. 29. Allgöwer 1964, p. 432; see also Murray et al. 1964 (with numerous references to literature on double plating); also Sargent and Teipner 1965; Charnley 1968, p. 23. 30. As surveys, see Schneider 1969, pp. 25–6; Müller 1983b, pp. 256–9 with a list of newly introduced instruments and implants up to 1983. 31. For the origin of these structures see Chapter 3. For instances of its workings see AO 9–10 May 1969, Annual Report 1968, p. 2; AO 21–22 November 1969, pp. 6–7; 8–9 May 1970, p. 37; AO 26–27 November 1971, admin. session, p. 8; AO 22 November 1974, admin. session, pp. 3–4 (with a presentation of numerous innovations by Müller and Mathys); Müller 1983b, pp. 257–8, see also minutes of the TK meetings. 32. TK 23 January 1965, p. 6; TK 18 September 1965, pp. 6–8; Müller 1983b, p. 258; Pannike 1972; TK 24 November 1972, p. 7; Heim and Pfeiffer 1972; Heim and Pfeiffer 1982.

300


33. Allgöwer 1978, p. 1076. 34. Allgöwer et al. 1973, pp. 12–19; Perren and Rahn 1978, p. 138; Perren 1979, p. 183; Fragments 6, 1 (March 1985), p. 5. On the history of self-compressing plates see Bagby 1957; Bagby 1958; Perren et al. 1969c, p. 33; Allgöwer et al. 1973, pp. 3–4; Bagby 1977, pp. 627–30; Allgöwer et al. 1978, pp. 1080–1; Perren and Buchanan 1991, pp. 5–8. 35. Perren et al. 1969c, p. 39; Allgöwer et al. 1969, p. 47–9; Allgöwer et al. 1970, p. 41; Allgöwer et al. 1973, p. 6. 36. Galeazzi 1972; Allgöwer 1978, p. 1080. This made the DCP the only reliable plate for research in the relationship between pressure and stress protection: see for example Matter et al. 1975, p. 5; Perren 1979, p. 190. 37. Allgöwer et al. 1969, pp. 49–53; Allgöwer et al. 1970, p. 41; Bagby 1977, p. 629. 38. TK 13 July 1966, p. 16; TK 10 December 1966, p. 9; TK 24 February 1969, p. 4; TK 4 July 1969, p. 16; TK 25 October 1969, p. 4; Perren et al. 1969c, pp. 32–3; Allgöwer et al. 1970, pp. 40, 45–6; Willenegger et al. 1971, p. 248; AO 7 May 1971, Annual Report 1970, p. 2. On the use of titanium in surgery see Venable and Stuck 1947, p. 73; Leventhal 1951; Hicks 1959, p. 212; Williams 1973, p. 19. 39. TK 10 December 1966, p. 12; Annual Report of the AO Laboratory 1966/67, p. 6; TK 3 May 1968, pp. 1–5 and appendix; TK 1 June 1968, p. 6; Perren et al. 1969c, pp. 37–41; Allgöwer et al. 1969, pp. 51–61; TK 14 November 1970, p. 13; AO 27–28 November 1970, scientific session, pp. 14, 17–19; Allgöwer et al. 1970, pp. 42, 45; Rüedi et al. 1975, p. 252; Rüedi and Lüscher 1979; Müller 1983b, p. 258. 40. Allgöwer et al. 1970, p. 42; Matter et al. 1975, p. 5; Perren and Rahn 1978, p. 119; Perren 1979, p. 190. 41. For sales see TK 20 February 1976, p. 4; for the textbook see for example Edmonson and Crenshaw 1980, p. 518. 42. See for example Rockwood and Green 1975, pp. 55–7; Perren and Buchanan 1991, p. 7. In the early 1980s the DCP was supplemented and partially replaced by the Dynamic Compression Unit (DCU) which offered more versatility in its combination with various types of screws (Schneider 1983, p. 94; Perren and Buchanan 1991, pp. 8–10). 43. TK 22 September 1978, p. 10; AO 25–26 April 1980, Annual Report 1979/80, pp. 3–4; AO 25 May 1984, admin. session, p. 4; company brochures by Osteo, Richards, Zimmer (no date given – late 1970s, early 1980s) (AOD); Regazzoni et al. 1985; AO 3 May 1986, scientific session, pp. 12–26; AO Foundation Annual Report 1986/87, p. 13; Mazzocca et al. 1998, pp. 319–21. 44. Allgöwer 1961, p. 222; Schneider 1961; Müller 1961, p. 210; TK 24 May 1962; AO 29–30 April, Annual Report 1965, p. 1; Schneider 1983, pp. 28, 38; Müller 1983b, p. 257. 45. TK 23 March 1963; TK 20 August 1963; Müller et al. 1963b, pp. 57–8; Müller et al. 1969, pp. 14, 82–3; Allgöwer 1978, p. 1079. 46. Müller et al. 1963b, pp. 10, 57–66; KTK 12 November 1976, p. 5; Weller 1996, p. 10. 47. Chapman and Madison 1988, vol. 1, p. 119; Perren and Buchanan 1991, p. 1; Krettek 2000, p. 195. 48. Schatzker and Tile 1987, p. 10; Perren and Claes 2000, p. 12; Krettek 2000, p. 195. 49. Schatzker and Tile 1996, p. 23. For the development of second-generation locked nails, see ibid., p. 16; Mazzocca et al. 1998, pp. 328–9. 50. Martin Allgöwer: Message of the President, Dialogue 5, 2 (December 1992), p. 4.

Notes

301

51. TK 27 May 1977, p. 8. 52. KTK 14 April 1978, pp. 3–4; KTK 10 April 1981, pp. 7–8. 53. J. Pinsent: Reflections on a Life in the Orthopaedic Industry, Dialogue 10, 11 (December) 1997, p. 1. 54. KTK 2 March 1984, p. 9; AO 25 May 1984, admin. session, p. 4. 55. KTK 5 January 1984, p. 4. 56. KTK 13. September 1983, pp. 8–9; KTK 11 November 1983, p. 7; KTK 22 May 1984, pp. 14–16; KTK 23 November 1984, pp. 8–9; AO Foundation Annual Report 1986/87, p. 3; Weller 1996, p. 11. In a further attempt at reducing trauma, techniques of intramedullary nailing without prior reaming of the intramedullary canal were introduced for certain indications (Perren and Buchanan 1991, p. 1; Schatzker 1995, p. S-B54; Schatzker and Tile 1996, p. 17). 57. Hierholzer et al. 1985, pp. 1–3; Weber and Magerl 1985, pp. 4–6. 58. KTK 1 April 1976, pp. 8, 211; Spiessl 1976, p. v; Schneider 1983, p. 63; Spiessl 1998, p. vii; personal communication Stephan Perren, 7 December 2001; ZM online, p. 2, (8 December 2001). 59. TK 4 April 1975, p. 1; KTK 14 May 1976, p . 3 (decision to include maxillofacial instruments in the Synthes catalogue); Spiessl 1976, p. v; Müller 1983b, p. 259; Spiessl 1998, p. vii. 60. Fragments 7, 3 (1986), pp. 3–4. 61. Spiessl 1998, p. viii. 62. Schneider 1983, p. 85. 63. Schneider 1983, pp. 94, 186. 64. KTK 9 July 1982, p. 3. 65. AO 23–24 November 1984, scientific session, pp. 14–51; Weber and Magerl 1985, p. 6. 66. Fragments 13, 1 (1994), pp. 3–4. 67. Hey-Groves 1914, p. 435. On early reports of osteosynthesis in veterinary surgery see Prieur 1985, pp. 161–9. 68. Küntscher 1940c; Prieur 1985, pp. 169–78. 69. Fragments 6, 2 (July 1985), p. 2; Müller et al. 1982, pp. vii–ix. 70. AO 9–10 May 1969, pp. 8, 13, appendices 8 and 10. 71. AO 21–22 November 1969, p. 2; AO 8–9 May 1970, pp. 63–5; ibid., Annual Report 1969, p. 6; Schneider 1983, pp. 56–7; AO 28–30 April 1972, Annual Report 1971/72, p. 1; AO 16 November 1973, admin. session, p. 8. 72. TK 24 January 1969, p. 14; TK 24 March and 8 May 1970, p. 61; Müller 1983b, p. 258. 73. AOI Delegates’ Assembly, 10 December 1977, pp. 3–4; Stamm 1985, p. 26. 74. Rosen 1984, p. vii; Fragments 6, 2 (July 1985), p. 2; interview with Howard Rosen, Davos, 16 December 1997. 75. TK 2 April 1976, p. 2. 76. AOI Delegates’ Assembly, 10 December 1977, pp. 3–4; Willenegger and Bandi 1983, p. 274. 77. See minutes of the AO meetings from 1974 onwards. 78. Chapman and Madison 1993, vol. 1, p. 230; similarly Latta et al. 1998, p. 237. 79. Latta et al. 1998, p. 239. 80. Weber and Magerl 1985, Preface by Weber, p. vii. 81. Latta et al. 1998, pp. 237, 238.

302


82. AO 4 May 1974, scientific session, pp. 29–30; AO 23 November 1974, scientific session, p. 11; Rhinelander 1974, p. 77; Perren and Rahn 1978, p. 123; Edmonson and Crenshaw 1980, p. 509; Giles et al. 1982, p. 864. 83. Perren 1999, p. S-B2. Besides Perren’s scientific initiative, the clinical attempts at biological osteosynthesis by Reinhold Ganz were important for changing the outlook within the AO (personal communication, Stephan Perren, 7 December 2001). 84. Chapman and Madison 1993, vol. 1, p. 227. Perren (1999, p. S-B2) spoke of the ‘watchmaker’ phase of fracture care. 85. Perren and Buchanan 1991, p. 4. 86. Perren and Claes 2000, p. 17. 87. Baumgaertel 2000, p. 221. 88. Perren 1999, pp. S-B2–3. 89. Latta et al. 1998, p. 239. 90. Perren and Claes 2000, p. 23. 91. Schatzker 1995, p. S-B51; Perren 1999, p. S-B3; Perren and Claes 2000, p. 23. 92. Perren and Buchanan 1991, p. 3; Chapman and Madison 1993, vol. 1, p. 326; Perren and Buchanan 1995, p. S-B3; Schatzker 1995, p. S-B54; Schatzker and Tile 1996, pp. 18–19. 93. Perren and Buchanan 1991, pp. 4–5; Perren and Buchanan 1995, p. S-B3; Schatzker and Tile 1996, p. 22; Schenk 1998, p. 68; Schatzker 2000, p. 3. 94. Perren and Claes 2000, p. 16. 95. Schatzker 1995, p. S-B54. 96. Perren and Buchanan 1991, p. 4; Chapman and Madison 1993, vol. 1, p. 326; Schatzker 1995, p. S-B55; Schatzker and Tile 1996, p. 17. As a survey on bridge plating see Baumgaertel 2000. 97. Perren and Buchanan 1991, pp. 14–16. As early as 1959 a plate had been designed for the tibia that had ‘the equivalent of “built-in-washers”, making the main shank stand clear of the surface of the bone by a fraction of an inch’, so as not ‘to squash’ the periosteum ‘as occurs when an ordinary plate is screwed down tightly’ (Hicks 1959, p. 200). 98. Perren and Buchanan 1995, pp. S-B3, S-B7; Perren and Claes 2000, pp. 24–7; Fernandez Dell’Oca and Regazzoni 2000, pp. 249–53. 99. See Krettek and Buchanan 1997; Baumgaertel 2000, p. 227 (quote). 100. See for example TK 22 November 1974, p. 7; KTK 12 December 1975, p. 2. 101. ‘Das Bessere ist der Feind des Guten ... Es wurde am Allerheiligsten gerüttelt’ (AO 7–8 May 1971, Annual Report 1979, p. 2). On the modification see also TK 23 April 1971, p. 12; Müller 1983b, p. 258. 102. Perren 1992a, p. 4. 103. Ibid., p. 5. 104. KTK 20 October 1973, p. 2. 105. TK 23 January 1965, pp. 14–6. 106. See above and TK 1 June 1968, p. 8. 107. TK 23 January 1965, p. 17; TK 10 December 1966, p. 6; TK 21 June 1967, p. 4; TK 28 April 1972, p. 2; TK 24 November 1972, p. 2; TK 22 September 1978, p. 5; 108. TK 27 September 1967, pp. 9–10. 109. Dialogue 6, 1 (June 1993), p. 3. 110. AO 29 April 1989, scientific session, p. 10. 111. Krettek and Buchanan 1997, p. S-A1. 112. Blume 1992, p. 68.

Notes

113. 114. 115. 116. 117. 118. 119. 120. 121. 122. 123.

124. 125. 126. 127.

128. 129.

130.

131. 132.

133. 134.

135. 136. 137. 138. 139. 140.

303

Latta et al. (the second author is Augusto Sarmiento) 1998, p. 237. Allgöwer: Message of the President, Dialogue 5, 2 (December 1992), p. 4. Perren and Buchanan 1991, p. 8. Schatzker and Tile 1996, p. 21. Schatzker 2000 (quotations at pp. 1–3). Helfet 2000, p. ix. C.C. Colton (1780–1832), in The Lacon. I thank Urs Heim for the idea to include this quotation. TK 27 January 1968, p. 7; see also AO 25–26 April 1980, Annual Report 1979/80, p. 3. KTK 16 November 1973, pp. 2–3; KTK 8 December 1973, p. 2. TK 24 March and 8 May 1979, p. 31. All these cases were discussed in the TK: TK 14 November 1970, p. 3; TK 14 June 1974, p. 9; TK 4 April 1974, p. 7; KTK 24 October 1975, p. 1; TK 19 June 1976, p. 13; TK 14 April 1978, p. 2. TK 24 March and 8 May 1979, p. 31. TK 20 August 1963, p. 9; TK 21 November 1963, p. 5; TK 22 May 1965, pp. 13, 16; KTK 12 November 1976, p. 2. Blume 1992, p. 65; see also ibid., pp. 44, 62, 253. AO 3 May 1974, Annual Report 1973/74, p. 1; AO 13–14 November 1981, admin. session, appendix 3, p. 3. However, as the AO soon noticed in its encounters with state-run health care systems, this rule was only valid as long as the doctors decided on the purchase of the material (AO 3 May 1974, Annual Report 1973/74, p. 1; see also Chapter 8 on the GDR). KTK 1978, p. 3; interview with Suthorn Bavonratanavech, Davos, 16 December 1998. TK 27 January 1968, p. 6; TK 1 June 1968, p. 10; TK 8 December 1973, p. 8; TK 22 November 1974, p. 8; TK 8 October 1976, p. 7; Hans Willenegger: Notes on my experience in the US, 12 July 1976 (USA 1). So the TK was regularly informed about products of other firms, their quality, and their prices. See for example TK 27 January 1968, p. 6; TK 21 June 1975, p. 2; KTK 22 April 1977, p. 3; see also minutes of the KTK 1973–77. KTK 15 July 1977 (Mathys); KTK 7 July 1978, p. 5 (Müller). TK 14 November 1975, p. 3; TK 2 April 1976, p. 12; KTK 7 July 1978, p. 5. One lawsuit against the US company Zimmer in France, which the AO won in the end, took eleven years: see KTK 22 May 1984, p. 7; Fragments 6, 1 (March 1985), p. 5. TK 24 March and 8 May 1970, p. 31. AO 25–26 April 1980, Annual Report 1979/80, p. 3. One DCP copy looked exactly like its original model but did not have the same compressing effect (personal communication, Stephan Perren, 7 December 2001). KTK 16 November 1979, p. 4. See for example Müller et al. 1969, p. 14. Heim 2001, pp. 109–10; personal communication, Urs Heim, 20 November 2001; see also Maurice E. Müller’s patent of 1 September 1959 on the implant (MEM). For example TK 27 September 1967, p. 16; TK 1 June 1968, p. 6; TK 25 October 1969, p. 4; TK 24 March and 8 May 1979, p. 35; TK 24 November 1972, p. 17. Cambrosio and Keating (1995, pp. 167–207) have shown that this is true for the medical instruments industry in general. AO 21–22 November 1969, p. 5.

304


141. 142. 143. 144. 145. 146. 147. 148.

TK 14 November 1970, p. 14. TK 5 May 1973, p. 6 (Perren). TK 29 August 1975, p. 1 (von Rechenberg); KTK 4 April 1975, p. 4. KTK 12 November 1976, p. 2. Schneider 1983, p. 91. TK 25 October 1969, pp. 10–11. See for example Allgöwer 1978, p. 1981. See for example TK 25 October 1969, pp. 10–11; AO 21–22 November 1969, p. 6; AO 8–9 May 1970, Annual Report 1969, p. 3; AO 7 May 1971, Annual Report 1970/71, pp. 2–3. AO 8–9 May 1970, pp. 2–3. KTK 7 July 1978, p. 7. Blume 1992, p. 65; see also ibid., pp. 44, 62, 253. TK 24 January 1969, p. 13. J. Pinsent: Reflections on a Life in the Orthopaedic Industry, Dialogue 10, 11 (December 1997), p. 2.

149. 150. 151. 152. 153.

Chapter 11 1. AO 29–30 April 1966, Annual Report 1965, p. 1. 2. Schneider 1969, p. 16; AO 8–9 May 1979, Annual Report 1969, p. 1; AO 7 May 1971, admin. session, Annual Report 1970, p. 2. 3. H. Willenegger: activity report 1977, p. 4 (AOI, Davos). 4. Report H. Willenegger on his stay in Los Angeles, 15–19 July 1980 (USA 1). 5. AO 28–30 April 1972, admin. session, Annual Report 1971/72, p. 2. 6. AO 26–27 November 1971, admin. session, p. 10. 7. TK 13 July 1966, p. 13. 8. An advertisement in the American journal Hospital News showed a number of screws and plates on the background of a map of Europe and a large-letter title saying: ‘Richards Osteo Systems – A Swiss Made Improvement of the A.O. System’ (Hospital News, May 1982 (no page given) (AOD)). 9. Hans Willenegger, notes on my experience in the US, 12 July 1976 (USA 1); TK 19 June 1976, p. 12; TK 8 October 1976, p. 7. The issue remained on the agenda even in the 1980s, when Synthes USA provided its representatives with an example letter to surgeons explaining in detail why the mixing of different systems was not advisable (Synthes Eagle, V, 4 (11 April 1985), p. 5 and appendix). 10. TK 4 May 1979, p. 5. 11. TK 10 December 1967, p. 2. 12. Letter from Prof. Dr B. Friedrich to H. Willenegger, 6 April 1982 (USA 2). 13. AO 21–22 November 1960, pp. 13–14; AO 4 May 1974, scientific session, pp. 12–29. 14. Tscherne 1971, p. 1137. 15. Müller 1971, p. 1144. 16. TK 10 December 1966, p. 13. 17. TK 25 October 1969, p. 10. 18. Ibid. 19. TK 27 January 1968, p. 14. 20. TK 4 December 1971, p. 15; TK 24 November 1972, p. 6; TK 5 May 1973, p. 9; AO 3 May 1974, Annual Report 1973/74, pp. 1–2. 21. TK 24 March and 8 May 1970, p. 19; TK 28 April 1972, p. 11. 22. TK 13 July 1966, p. 12; TK 21 June 1967, p. 12.

Notes

305

23. TK 14 November 1970, pp. 9–10; TK 23 April 1971, p. 8; AO 28–30 April, Annual Report 1971/72, p. 2. 24. AO 28–30 April 1972, admin. session, Annual Report 1971/72, p. 2. 25. AO 26–27 November 1971, preparatory session, p. 1. 26. AO 8–9 May 1970, Annual Report 1969, p. 6. During the preparatory discussion for founding a German AO in 1970 this was exactly one of the points at issue, since some of the German surgeons wanted to be independent of the Swiss concerning the development of instruments and rejected a draft contract that subjected them to the Swiss AO’s control. As a result the foundation of the German subsidiary was postponed (TK 24 March and 8 May 1970, pp. 19–20). 27. TK 28 April 1972, p. 11. 28. AO 8–9 May 1970, Annual Report 1969, p. 6. As early as 1966 the question of accepting members of foreign AO groups into the Swiss AO and the TK was discussed (TK 13 July 1966, p. 12). 29. TK 24 March and 8 May 1970, pp. 20–3. 30. Ibid., pp. 19–23; TK 14 November 1970, p. 10; TK 23 April 1971, p. 7. 31. TK 14 November 1970, p. 9. 32. AO 28–30 April 1972, admin. session, p. 9. 33. TK 14 November 1970, p. 10. 34. Ibid. 35. AO 26–27 November 1971, preparatory session, p. 3. 36. AO 7 May 1971, admin. session, p. 5; AO 26–27 November 1971, First Assembly of the AO International. 37. AO 28–30 April 1972, Annual Report 1971/72, p. 4; TK 28 April 1972, p. 11. 38. Minutes of the founding assembly of the International Working Group for the Study of Osteosynthesis (Internationale Arbeitsgemeinschaft für Osteosynthesefragen), 25 November 1972; Willenegger and Bandi 1983, p. 273. 39. AOI Statutes, 1972, 1975; see also minutes of the Delegates’ Assemblies and H. Willenegger, report ‘What is AO?’, 3 February 1976, folder Prof. Willenegger Kontaktreisen (AOI, Davos). 40. Minutes of the founding assembly of the International Working Group for the Study of Osteosynthesis, 25 November 1972. 41. TK 14 November 1970, p. 10, at the AOI Delegates’ Assembly in 1975 the statutes were even changed to include the recommendation that each national section was to provide the president alternately. 42. The Italian ‘Club’ had more than 200 members (AOI Delegates’ Assembly 1975, pp. 3–4); see also AO 3 May 1974, admin. session, p. 11; Willenegger and Bandi 1983, pp. 273–4. 43. Minutes of the AOI Delegates’ Assemblies of 1975, 1976 and 1977; Willenegger and Bandi 1983, p. 274. On individual memberships see TK 23 April 1971, p. 7. 44. Letter from H. Willenegger to U. Heusser, 6 September 1990 (AOI, Davos). It took until 1982 for the Norwegian and Mexican sections to be officially dissolved. See also letter from H. Willenegger to Siegfried Weller, 25 September 1982 (AOI, Davos). 45. AO 25–26 April 1980, admin. session, pp. 10–11; AO 11–12 November 1983, admin. session, p. 10. 46. TK 20 February 1976, p. 7. 47. Quotation from TK 8 February 1974, p. 9 (emphasis in the original). For the TK’s assignment of the courses to the AOI see TK 8 December 1973, p. 3. 48. Willenegger 1989, p. 203.

306


49. Quotation from TK 4 April 1975, p. 6. See also TK 14 April 1978, p. 3; H. Willenegger: Notes on a conversation with Prof. Ganz, 1 November 1982 (USA 2). 50. KTK 9 December 1978, p. 2. 51. AO 3 May 1974, Annual Report 1973/74, p. 8; H. Willenegger: Speech at the AO Spring Meeting in Thusis, 4–5 May 1990, manuscript, p. 4. As mentioned in Chapter 4, coordination was also necessary because for many years there was only one set of practice equipment for all the courses. 52. AO 23–24 April 1982, admin. session, p. 15; H. Willenegger: Speech at the AO Spring Meeting in Thusis, 4–5 May 1990, manuscript, p. 4. 53. Willenegger and Bandi 1983, pp. 274–6; Allgöwer described the AOI as an organisation in charge of coordinating postgraduate teaching on an international level (Allgöwer 1978, p. 1082). 54. H. Willenegger: Speech at the AO Spring Meeting in Thusis, 4–5 May 1990, manuscript, p. 5. 55. See Willenegger’s numerous reports in the AOI files. See also minutes of the delegates assemblies; TK 8 February 1974; AO 3 May 1974, admin. session, p. 11; H. Willenegger: Speech at the AO Spring Meeting in Thusis, 4–5 May 1990, manuscript, p. 2; H. Willenegger: Message from Founder Members, brochure, AO and ASIF Foundation 2000, p. 8. 56. See for example H. Willenegger, activity report 1977 (AOI, Davos). 57. Willenegger 1989, p. 203. After retiring in 1978, Walter Bandi joined Willenegger in working for the AOI (AO 21–2 November 1980, admin. session, p. 10). In 1983 Willenegger retired as AOI president, Allgöwer took over office and was followed by Urs Heim in 1988 and Peter Matter in 1993, who was AOI president until 2000, when Thomas Rüedi succeeded him in office (AO 11–12 November 1983, admin. session, pp. 8–9; AO 29 April 1988, admin. session, p. 7; Dialogue 13, 1 (June 2000), p. 4). In March 1985 the AOI started its own journal, the AO and ASIF Dialogue, published once a year, and from 1989 twice yearly, as a means of communication with the surgical community. On Walter Bandi see Notes from the Editor, Dialogue 1, 1 (March 1985), p. 1; on T. Rüedi see Note from the Editor, Dialogue 2, 2 (December 1989), p. 1. 58. Agreement of the shareholders of Synthes AG Chur concerning themselves and their legal successors, 27 January 1968. 59. H. Willenegger, activity report 1977, p. 4 (AOI, Davos); TK 3 February 1977, p. 2. 60. See for example AO 8–9 May 1970, p. 9; AO 28–30 April 1972, admin. session, pp. 6–8. 61. AO 25–26 April 1980, p. 4; AO 23–24 April 1982, p. 4; Schneider 1983, p. 111. 62. Von Rechenberg 1983, p. 270. 63. Committee session of the AOI, 6 January 1975 (AOI, Davos); letters from S. Weller to H. Willenegger 23 August 1982 (AOI, Davos), 15 November 1982; H. Willenegger to S. Weller, 25 September 1982 (AOI, Davos); H. Willenegger: Thoughts on the future design of the AOI, memorandum of November 1982 (AOI, Davos). 64. Committee session of the AOI, 6 January 1975 (AOI, Davos). 65. Allgöwer 1978, p. 1082; minutes of the planning session, 5 May 1979; letter from P. von Rechenberg to the members of the commission, 26 June 1979 (AOI, Davos); notes on a meeting of H. Willenegger and H.J. Wyss, 11 June 1981 (AOI, Davos). 66. Letters from S. Weller to H. Willenegger, 23 August 1982, 15 November 1982 (AOI, Davos); H. Willenegger to S. Weller, 25 September 1982 (AOI, Davos); H.

Notes

67.

68.

69. 70.

71.

72. 73. 74. 75.

76. 77. 78. 79.

80.

81. 82.

83.

307

Willenegger: Thoughts on the future design of the AOI, memorandum of November 1982; M. Allgöwer: Notes on a conversation with German traumatologists, 19 December 1983 (AOI, Davos). This had the effect that Maurice Müller no longer held his 28 per cent of shares that had been the economic basis of his paramount influence (AO 19–20 November 1982, admin. session, p. 6; AO 29–30 April, admin. session, p. 10; interview with M.E. Müller, Bern, 23 March 1999). Foundation Charter, 8 December 1984, brochure AO Stiftung/ASIF Foundation 1984; Allgöwer and Jann 1988, pp. 6–7; Foundation Charter 17 June 1999. The shares were transferred at their nominal value of SFr1000 per share, while, according to M.E. Müller, their real value by that time amounted to some SFr50 million (interview with M.E. Müller, Bern, 23 March 1999). Organisation of the AO, memorandum, 2 March 1984; Session of the Business Council, 8 March 1985; AO 19–20 April 1985, admin. session, p. 2. The Swiss AO itself became a regional AO subsidiary (AO 2–3 May 1986, admin. session, pp. 2–5). See also the Statutes of the Switzerland Section of the AOI, 29 April 1988. AO 23–24 November 1984, admin. session, pp. 9–10; Foundation Charter, 8 December 1984; brochure AO Stiftung/ASIF Foundation 1984. In 1990 the size of the Board of Trustees was increased from 80 to 90, a Senior Membership for Members of the Board of Trustees was introduced, and a Nominating Committee for new Trustees was established (Dialogue 3, 1 (June 1990), p. 8). Foundation Charter, 8 December 1984; brochure AO Stiftung/ASIF Foundation 1984; Allgöwer and Jann 1988, pp. 6–9. Ibid.; Dialogue 8, 2 (December 1995), p. 5; brochure AO Stiftung/ASIF Foundation 1995, p. 5. AO 2–3 May 1986, admin. session, p. 1. On the Business Council see for example AO 23–24 November 1984, admin. session, pp. 9–10; Foundation Charter, 8 December 1984; Allgöwer and Jann 1988, pp. 6–9. Until 1992 the Council’s chairman was Peter von Rechenberg, who was succeeded by the Zürich lawyer Jean-Claude Wenger, and then from 1995 by Wolfram Einars. See also Dialogue 5, 1 (June 1992), p. 8; Dialogue 8, 2 (December 1995), p. 4. Brochure AO/ASIF Foundation, pp. 10–11. Martin Allgöwer: Introduction by the President, Dialogue 1, 4 (March 1988), p. 5. M. Allgöwer: Die AO-Stiftung/ASIF Foundation, report, Chur, 24 June 1985. Letters from M.E. Müller to P. von Rechenberg, 5 December 1984 and 11 January 1989 (MEM); interview with Maurice E. Müller, Bern, 23 March 1999; report by M.E. Müller, 23 March 1999. Dialogue 5, 2 (December 1992), p. 14. The subsequent presidents were Siegfried Weller, Germany (1994–96), Christopher Colton, UK (1996–98), Joseph Schatzker, Canada (1998–2000) and Peter Matter, Switzerland (2000–02). AO 1 May 1987, admin. session, p. 1. Dialogue 6, 1 (June 1993), pp. 10, 16; Dialogue 7, 1 (June 1994), pp. 10–11; Suthorn Bavonratanavech, History of AO East Asian (1 August 2001); brochure AOLAT, 2001; Dialogue 1, 2 (December 2000), p. 5. AO 1 May 1987, admin. session, p. 6; AO 29 April 1988, admin. session, p. 7; Dialogue 2, 2 (December 1989), p. 4; Dialogue 3, 1 (June 1990), p. 5; Dialogue 9, 2 (December 1996), pp. 10–11; By-Laws of the AO Alumni Association,

308

84. 85.

86. 87.


(27 August 2001); (25 September 2001). The legislative body of the AOAA is the General Assembly, which meets every three years. One of the Assembly’s tasks is the election of a committee of up to five members which meets more often in order to perform everyday management. Financial resources consist of the one-year membership fees and voluntary contributions and donations. Dialogue 1, 4 (March 1988), pp. 1–2; Perren, AO Research 1990, pp. 6–7. AO 29 April 1989, scientific session, p. 6; M. Allgöwer: Message of the President, Dialogue 5, 2 (December 1992), p. 4; report by M.E. Müller, 23 March 1999; interview with Berton Rahn, Davos, 6 July 1999. Dialogue 5, 2 (December 1992), pp. 1–4; Dialogue 6, 1 (June 1993), p. 10; brochure AO – 40 Years of Service to Patients; brochure AO/ASIF Foundation, pp. 14–15. AO 29 April 1989, scientific session, pp. 6–7; Perren, AO Research 1990, pp. 6–7; Dialogue 5, 2 (December 1992), pp. 1–4.

Conclusion 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30.

Pinch and Bijker 1987, pp. 22–4. Stanton 1999, p. 169. See Hirschauer 1991. Bijker et al. 1987b, p. 4; Howell 1995, p. 8. Howell 1995, pp. 11, 227; Pickstone 1992, p. 1. Pickstone 1992, pp. 1, 9; Löwy 1992, pp. 1–4. Cf. Liebenau 1983; Marks 1993; Stanton 1999. Lachmund 1997, p. 194; Latour 1987, p. 107. For Latour critical of the term ‘diffusion’ see ibid., pp. 141–4. Law 1987, p. 112. Cf. Berg 1997, p. 166; Lachmund 1997, pp. 14–22. Called ‘social worlds’ in symbolic interactionist sociology of science. Cf. Clarke and Fujimura 1992, p. 5; Star 1995, pp. 1–35. Law 1987, p. 114. Star and Griesemer 1989, p. 404. Löwy 1996, p. 248. Löwy 1996, pp. 59, 161–2. Blume 1992, p. 62; see also ibid., pp. 234–5. Cf. Löwy (1996, p. 162) on cooperation between medicine, science and industry. For this perspective, see Star and Griesemer 1989, pp. 387–92; Fujimura 1992, pp. 168–9; Epstein 1996, p. 18; Lachmund 1997, pp. 14–22. Löwy 1996, p. 161. Cf. Fujimura (1992, p. 180) on the oncogene theory of cancer. Star and Griesemer 1989, pp. 393, 412; see also Fujimura 1992 and Star 1995. Shapin 1992, p. 356; Star and Griesemer 1989, p. 392. Berg 1997, pp. 113, 166–7. Berg 1997, p. 97. Cf. Shapin 1994, pp. 414–15. Cunningham and Williams 1992; Pickstone 1993, pp. 449–52; Warner 1995; Löwy 1996, pp. 15–18. Cf. for example Rosenberg 1988, p. 568. Cf. Sturdy and Cooter 1998, p. 449; Blume 1992, p. 17; Howell 1995, p. 2. Berg 1997, p. 177. This is the title of Porter 1995.

Notes

309

31. Tröhler 1991, p. 90; Howell 1995, p. 66; Tröhler 2000. 32. Berg 1995, p. 449; Berg 1997, p. 22; Marks 1997, p. 2. 33. Of course, the AO’s participation in inducing the success of their technique does not diminish the fact that the technique did work in clinical reality. 34. Cf. Löwy 1996, p. 279; Berg 1997, p. 164. 35. Berg 1997, pp. 173–4. 36. Beck 1986, p. 260. 37. Douglas and Wildavsky 1982; Beck 1986, pp. 62, 76–7, 95, 289, 292; Girgerenzer et al. 1989, p. 266. 38. On statistical techniques as a social technology for creating trust see Porter 1995, pp. 208–9; Epstein 1996, p. 33; Jones 2000, pp. 507, 527. 39. Wynne 1995, p. 377; Porter 1995, p. 214; Jones 2000, p. 536. 40. Pickstone 1992, p. 1. 41. Howell 1995, p. 11. 42. Jones 2000, p. 523. 43. Beck 1986, p. 79. 44. Gigerenzer et al. 1989, p. 261; Howell 1995, p. 131; Löwy 1996, pp. 48–54. 45. Marks 1993, p. 159; Howell 1995, p. 245; Berg 1995, p. 442. 46. Gordon 1988, pp. 259–60; Girgerenzer et al. 1989, pp. 236, 265; Porter 1995, p. 204; Marks 1997, p. 3; Sturdy and Cooter 1998, pp. 446–7. 47. See Lawrence 1985; Gordon 1988, pp. 257–9; Cooter 1993b, pp. 245–7; Lawrence 1998; Sturdy and Cooter 1998, pp. 435–9. 48. Cf. Gordon 1988, p. 283. 49. Latta et al. 1998, p. 237; interviews with Hans-Ulrich Buff, Zürich, 31 March 1999, Augusto Sarmiento, Zürich, 15 February 2001. 50. Cf. Casper and Clarke 1998, pp. 258–63. 51. Pinch and Bijker (1987, p. 44) draw the analogy to the constructivist view of the production of scientific facts. 52. Epstein 1996, p. 37. 53. On such an approach see Caspar and Clarke 1998, p. 257. 54. On the irreversibility of many technological choices in medicine see Löwy 1996, p. 280. 55. Cf. Knorr-Cetina 1999. 56. Löwy 1996, p. 280. 57. Howell 1995, p. 229.

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Index

Aachen, 89 absorption of bone ends see pressure necrosis academic surgery see university surgery accident insurance, 12–16, 111, 125, 148, 156, 158, 160, 250, 261–2 accidents, 9–15, 26, 170, 181, 189, 193, 239, 249 domestic, 11–12 industrial, 12–14, 158, 170 prevention of , 10–13, 249 sports, 12, 170 traffic, 9–12, 170 Aesculap, company, 175, 219 Aetna Life Insurance Company, 25 Africa, 58, 166 AIDS, 128, 132 Allgöwer, Martin, xi, 32–42, 44, 53–4, 56–7, 60, 62–3, 66, 69, 72, 76, 78, 82, 88, 94–5, 122, 131, 135, 142, 144, 148–9, 154, 170, 185, 187, 192, 198–200, 204–5, 208, 213, 216, 220, 224–5, 227–9, 231–2, 265, 285, 306 allocation of health care resources, 169, 172–3, 178–9 of AO equipment, 172–9 see also availability of AO material America see USA American College of Veterinary Surgeons, 191 American Optical, 186 American Orthopaedic Association, 181 Anderson, Julie, xi animal experiments, 42, 87, 89, 91–3, 96–109, 201, 207, 279 anti-scientific tendencies in fracture treatment, 87 antisepsis, 19, 20 AO advanced courses, 69–70, 224, 232 Centre, 130, 213, 234–6 classification, 116–19

AO continued compression plate, 50, 51, 52, 91–3, 100–4, 143, 180, 197–9, 200–5 courses, xi, 43, 56, 271, 65–6, 68–75, 81–5, 124, 134–5, 146, 156, 158, 160–1, 163–4, 166–7, 170–1, 173, 178, 180, 184–5, 187, 191, 213, 220, 223–5, 242, 244–7, 253, 295 critics, 40, 53–5, 65–6, 70–2, 82, 87, 90–91, 93, 97–9, 101, 104, 108, 113, 114,120–1, 132–9, 141–5, 152–4, 181–4, 199, 213, 232, 252–4, 257–8, 269, 286, 297 Development Institute, 235 documentation cards, 126, 127 documentation centre, 35, 42–3, 57, 62, 73, 77, 93–4, 110, 116, 124–32, 148, 222–3, 228, 235, 242, 274 Documentation Commission, 129 equipment, 45, 46–52, 55, 59–64 executive committee, 36 fellowships, xi, 65, 79–81, 85, 163–4, 167, 178, 191–3, 225, 247 founding, 28, 32, 34–6, 49 laboratory, 35, 41–2, 56, 57, 68, 93–5, 106, 222–3, 229, 234–6 Manual, 50, 77–9, 83–4, 102–3, 107, 129, 132, 134, 197, 213, 225, 247 manufacturers see producers meetings, 36–8, 40, 42–3, 48, 50, 57, 61, 76–8, 155, 157, 160, 213 naming, 32 Operating Room Personnel Courses, xi, 75–6, 274, 291–2 ‘philosophy’, 34–5, 45, 86, 192, 196–217, 220, 232 president (Obmann), 36 Principles of Fracture Care, 213 producers, 34, 35, 45, 55–64, 68–73, 95, 132, 146, 149–50, 154, 164–5, 186–8, 214–17, 222, 228–32, 242–5, 252, 255 regional associations, 193, 232, 234 research institute see AO laboratory seminars, 225

337

338


ski racing competitions, 38 ‘spirit’, 39, 234, 243, 257 statutes, 35–6, 40 symposia, 71, 167, 171 textbooks, 43, 46, 51, 55, 60, 65–6, 68, 73, 75, 76–9, 85, 91, 131, 146, 162,174, 205, 209, 213–14, 220, 242, 245–7 veterinary courses, 70, 191, 207 workshops, 71, 175, 191, 225 AO Alumni Association (AOAA), xi, 232, 234, 308 AO Dialogue, 234 AO East Asia (AOEA) AO Foundation, x–xi, 129, 228–33, 235 Academic Council, 230 Board of Directors, 231–2 Board of Trustees, 229–31, 235 Business Council, 229–32 Executive Committee, 229–32 AO-International (AOI), x, 73, 81, 174–8, 185–6, 208, 222–228, 230, 232, 235 founding, 155, 222–4 individual members, 224 AO Latin America (AOLAT), 232 AO North America (AONA), 193, 232 AO United Kingdom (AOUK), 232 AO Vet, 207–8, 224 apprenticeship and surgery, 67–8, 79, 136 Arabian countries, 163 Argentina, 164–5, 292 Army, Swiss, 30 art, medicine and surgery as, 40, 66, 87, 112, 134–7, 248, 252–4, 286 social dimension of surgery as, 135–7, 253–4 arthrodesis, 89, 108 artificial bones, 70, 74–5, 82, 247, 274–5 asepsis, 19, 20, 25–6, 66, 82, 122–3, 142, 166 Asia, 58 ASIF, acronym, 186 aspirin, 107 Associación Español para el estudio de la Osteosíntesis, 163 Australia, 60, 163–5, 291

Austria, 14–18, 24, 39, 45, 58, 68, 70, 72, 111, 146, 154–5, 158–9, 160–5, 223, 229, 232, 255–6, 264, 291 Austrian AO, 159, 161–2, 221 Austrian section of the AOI, 223 Austrian Surgical Society, 161 authoritarian style of leadership, 39–40, 43 AUVA, Austrian Accident Insurance Company, 125, 158, 160–1 availability of AO material, 51, 58, 66, 84, 141, 172–9, 187–8, 193–5, 256 Bad Gleichenberg, 161 Badrutt, Isabella, xi Bagby, George W., 23, 99, 181, 295 Bahrain, 164, 292 Balgrist, orthopaedic hospital, 28–30, 32, 44, 68, 156 Bandi, Walter, 31, 34, 37, 53, 82, 149, 165, 168, 306 Bardenheuer, Bernhard, 96–7 Basel, 29, 31–3, 41, 44, 49, 56, 94, 95, 99, 100, 149, 204, 206 basic science see laboratory science Basset, Andrew, 278 Batten, Richard Lindsay, 78, 162–3 Baumann, Ernst, 33 Bauer, K.H., 286 Baur, Dr, SUVA representative, 148 Bavonratanavech, Suthorn, xi, 166 Beck, Ulrich, 62, 124, 133, 251, 253, 290 Belgian section of the AOI, 162, 224 Belgium, 19–20, 23–4, 29, 151, 162, 164–5 Bellanger, Silke, xi Bérenger-Féraud, L.J.B., 19 Berg, Marc, 43–4, 77, 246, 249 Bergmannsheil, accident hospital, 54–5, 156, 158, 160 Berlin, 169, 173 Bern, x, 29, 30–1, 33, 44–5, 49, 53, 94, 95, 98, 126–7, 129–30, 148–9, 151, 187, 223, 228, 242 Bernard, Claude, 106, 112, 281 Berufsgenossenschaft, insurance company, 156, 158–9, 160 Bettlach, 49, 58, 164, 172 Bianchi-Maiocchi, A., 223 Bienne, 28, 30, 37, 48–9, 56, 219

Index

biocompatibility, 94 see also metals, used for implants biological approach to osteosynthesis, 115, 198–9, 205, 208, 209–11, 214, 281, 302 biological basis of AO technique, 86–109, 196–9, 209–11 see also fracture healing biological plating, 209–11 biologisation see biological approach to osteosynthesis biomechanics, 84–5, 88–93, 94, 276 Bircher, H., 153 Birmingham, 162–3, 287 Bitterfeld, 173 blood supply, importance for fracture healing, 198–9, 209–11, 213 Blume, Stuart, 61, 86, 213–14, 217 Bochum, 54, 131, 156, 158 Böhler, Jörg, 160–1 Böhler, Lorenz, 14–19, 21–2, 24, 25, 26–7, 29, 32, 34, 42, 45, 47, 54, 68, 71, 73, 77–8, 87, 90, 111, 119, 124–5, 143–4, 158, 160–2, 165, 266, 269, 286 Bolivia, 164–5, 291 bone healing see fracture healing bone infection, 19–20, 24, 26, 83, 122–3, 142, 181, 210 bone remodelling see fracture healing bone setters, 166, 256 Bosnia, 164 Boston, 21, 180 boundary object, 90, 97, 102, 104, 245, 249, 267 Bozen, 18 brand name, AO as, 254–5 Brazil, 163, 165, 291 breakage of plates, 283–4 bridging fixation, 205, 210, 302 British Medical Association, 115, 119 Bristol, 20 Brücke, Hans, 223 Brunner, C.F., 78, 123 Brussels, 23, 29, 187 Brussatis, Fritz, 156, 265, 290 Budapest, 96, 226 Buff, Hans-Ulrich, xi, 40, 53, 87, 93, 133–7, 144, 152, 154 Buffalo, New York, 124 Bulgaria, 58, 164

339

Bürkle de la Camp, Heinrich, 54–5, 70–1, 131, 142–3, 156 business and medical ethics, 61–4, 72–3, 188, 204, 214–17, 231–2, 244, 246, 257 methods in medicine, 284 buttressing, effect of plate, 197 cadaver bones, 67–8, 74 California, 128 callus, 24, 29, 33, 89, 92, 96–104, 199, 208–11, 265 Cambrosio, Alberto, xi Campbell, Willis, 133 Campbell Clinic, Memphis, Tennessee, 277 Campbell’s Operative Orthopaedics, 93, 180, 182, 190, 192 Canada, 70, 163, 185, 292, 232, 308 career chances of AO surgeons, 63, 149, 244 careers of AO surgeons, 94, 148–9 Carnegie Steel Company, 20 causal attribution of outcome, 119, 121, 123, 283 see also evaluation of treatment methods cerclage, 19, 55, 98 Charnley, John, 55, 70, 71, 86, 89–90, 98–9, 104, 108, 115, 123, 135–6, 144, 152, 215, 266, 287, 289 Chile, 163, 165, 291 China, 79, 164, 292 choice of treatment see indication Christinat, Werner, 175 Chur, 32–4, 41, 94, 154, 170 Ciba, Company, 33 classification in clinical research, 110, 250 of fractures, 18, 114–19, 121, 133 clinical experience, 89, 93, 104, 133–7 see also rationality, clinical Clinical Orthopaedics and Related Research, journal, 192 clinical perspective, 110–14, 133–7, 252–4 clinical research, 42–3, 87, 110–37, 222, 250–2, 287 see also AO documentation, documentation, statistics

340


clinical studies, see also clinical research, documentation prospective, 128–30 randomised, 129, 132, 133, 285 retrospective, 127–9 Club Italiano degli Amici dell’AO, 162, 220, 306 coapteur, 23, 29, 32, 90 collaboration between medicine, science and industry see symbiosis of surgery, science and industry Collins, Harry, 67, 81 Colombia, 164–5, 292 Colton, Christopher, 308 Columbia University, 278 commercialism, reproach of, 72, 187–8 see also business and medical ethics comparability of fractures, 105, 114–19, 133 competence of surgeon see skills of surgeon competitors, 60–4, 70, 72, 82, 150, 175, 204–5, 211, 214–17, 219, 221 complications of osteosynthesis, 105, 121–4, 127, 132, 173, 179, 182–4, 189, 194, 208, 218, 253 attribution of blame to the individual surgeon, 122–4, 191, 283–4 compression osteosynthesis, 21, 23–4, 34, 55, 86–93, 96, 98, 100–4, 122–3, 170, 175, 180, 182–3, 197–205, 209, 211, 213, 245, 249, 278, 295, 304 computer see data processing system confederation (Bund), 36, 243 see also fraternity Connecticut, 190 conservative fracture care, 16–19, 26–7, 34, 82, 84, 120, 137, 143–6, 152–3, 160, 163, 165, 181, 189, 208, 247, 254–7, 290, 297 contact healing, 100–5 control and expansion of AO, 168, 169–79, 193–5, 220–2, 242, 247, 249, 255–7 Cooter, Roger, 11, 12, 13, 15, 17, 18, 25, 87, 108, 111, 137, 262 copies of AO instruments and implants, 63–4, 174–5, 214–16, 304 relative character of, 215–16

copyright on AO material , 57 infringement, 64, 214–16 Cordey, Jacques, 210 coronary artery bypass, 286 corrosion see metals used for implants cortex screw, 49–50 cortical bone and fracture healing, 99–104 Costa Rica, 164 costs of treatment, 15, 148, 172, 174, 257 craftsmanship and surgery, 67, 88 credibility, 60–4, 71, 81–5, 130–2, 144–8, 150, 154, 188, 213, 215–17, 225–6, 246–8, 251–2, 354–5, 286 cycle of, 63 Croatia, 164, 292 Cuba, 164, 292 cultural factors and AO expansion, 165–8, 185–6, 193–5, 255–7 culture and technology, 242–4, 255–7 Curaçao, 164 Cyprus, 164, 292 Czechoslovakia, 58 Czech Republic, 164–5, 292 Danis, Robert, 23–4, 26, 29, 32, 34–5, 43, 54–5, 76, 86, 88, 90, 96, 98, 113, 162, 215, 240, 278 Danz, Richard, xi data processing system, 116, 124–7, 129 Davos, x, 1, 3, 35, 41–2, 56, 68–70, 72, 75, 79, 84, 93–6, 104, 106, 130, 143, 154, 158, 160–1, 164, 166, 170, 172, 178, 180, 182, 184, 191, 207, 222–3, 228, 231, 234–6, 295 symbolic value for AO, 94, 235–6 DCP (Dynamic Compression Plate), 104, 187, 200–4, 211–12, 214–16 DCU (Dynamic Compression Unit), 300 Delhi, 164, 166 Denmark, 164–5, 292 DHS (Dynamic Hip Screw), 204, 211 deterministic approach to medicine, 112–13, 250, 252 dietetics, 121 direct ossification, term, 97 see also primary bone healing

Index

disability, 14–15, 34, 119–21, 148, 181, 183, 293 distribution of AO instruments see availability of AO material documentation, 32, 33, 42–3, 78, 110–12, 124–32, 144, 146–7, 171–2, 221–3, 232, 235, 250–2, 293 and credibility, 130–2, 252 code sheets, 126–7, 130 cost, 127, 129 decentralised, 130 of outcome 16–17, 111–25, 172, 190, 250–2 double plating, 200 Douglas, Mary, 121 drug therapy, 84–5, 121, 287 Dynamic Compression Plate see DCP dynamic fixation, 23, 90, 200–1 economy, arguments from, 14–15, 148, 170, 293 of science, 63 Ecuador, 163, 165, 291 education see instruction egalitarianism, 39–40, 43, 158, 253, 266 Eggers, George W.N., 23, 87, 89, 90, 105, 109 Egle, Rainer, xi Egypt, 163, 292 Einars, Wolfram, 397 England see Great Britain enculturation of users, 85 engineering, 48, 88, 136, 248 Epstein, Steven, 128, 132 ethics, 61–4, 72–3, 110, 121, 130, 134–7, 177, 253–4, 258, 285 Ethiopia, 28 European Association for Experimental Surgery, 94 evaluation of treatment methods, 114–21, 128, 130, 133, 183, 283 anatomical versus functional outcome, 120–1, 189 standards of, 119–21, 282 see also documentation of outcome expansion of AO, 81, 83–5, 90, 141–95, 218–34, 255–7 experimental medicine, 112–13, 281 experimental science see laboratory science

341

expertise, different models of, 135–7, 253–4 external fixation, 17, 206, 211, 256 face-to-face interaction in science and medicine, 37–41, 44, 222, 243, 248, 256–7, 266 training of surgeons, 65–6, 83–4 feedback between research and business, 95, 147, 244 between users and makers of instruments, 61, 244 see also symbiosis of surgery, science and industry Felmy, Allison, x femoral neck fractures, 17, 19, 21, 22, 24, 47, 54, 89, 119, 170, 240 Filisur, 273 films for instruction, 73–4 financial profit from osteosynthesis, 145 Finland, 163, 165, 291 fixateur externe see external fixation Fleisch, Herbert, 94–5 Florida, 180, 295 follow-up, 112, 120, 127, 184 see also documentation Ford, Henry, 20, 137 fracture disease, 34 fracture healing, 26, 265, 86–109, 181, 196–9, 209–11, 248–50, 280 France, 19, 58, 68, 79, 150, 162, 164–5, 205, 291, 303 Francillon, Max René, 29 Frankfurt on Main, 157 Frankfurt on the Oder, 175 fraternity, 35–41, 43, 62–4, 82, 155, 158, 162, 186, 194, 243, 255, 265 see also student fraternities Freiburg, Germany, x, 55, 70–2, 76, 148, 155–9, 160–1, 167, 206, 219 Freidson, Eliot, 151 French, George, 89 Fribourg, 29, 76 Friedenberg, Zachary B., 89 friendship among surgeons, 37–41, 81, 243 function of injured limb, 120–1, 152

342


functional exercise, 16–17, 21, 24, 29, 32–5, 86, 143–4, 183, 211, 245 Galveston, Texas, 33, 89 Ganz, Reinhold, 302 gap healing, 100–5 gauge plate see pressure measuring device GDR see Germany, East GDR section of AOI, 177, 193 GDR Surgeons’ Association, 171, 177, 223 Geiser, Max, 53, 98–9, 104, 120, 133–5, 141, 144, 279 general surgery, 148–9 and fractures, 30, 158, 161–2, 199 and AO, 31, 166 Geneva, 53, 296 German AO, 157–9, 221, 224, 305 German Orthopaedic Society, 54, 269 German Research Council (DFG), x German section of the AOI, 223 German Surgical Society, 54, 70, 144, 159 Germany, 10–11, 14, 21, 23, 25, 26, 39, 45, 54–5, 68, 70–1, 89, 141–4, 150, 161–2, 164–7, 169, 192, 216, 219, 223, 228, 232, 264, 286, 290, 291, 291, 308 East, 58, 70, 83, 155, 163, 166, 168, 169–79, 193–5, 223, 256 West, 58, 84, 154, 155–9, 160, 163, 168, 169, 174–5, 177, 221, 228, 229, 255 Gerry, Jim, xi Ghana, 164 Girdlestone, Gathorne Robert, 209 Gissane, William, 287 Gorbachev, Mikhail, 167 Gordon, Deborah, 135–7 Göttingen, 156 Graz, 160–2, 206 Great Britain, 10, 11, 17–21, 24, 25, 55, 58, 70, 111, 115, 134, 151, 152, 162–3, 165, 168, 225, 229, 232, 255, 272, 282, 287, 291, 308 Greece, 164–5, 292 Grenchen, 49 Griesemer, James, 43, 245 Grisons, Canton of, 32, 42, 95

Grosshöchstetten, 30 Gubser, Claudio, xi Guggenbühl, August, 49 Halle, 170–2, 178 Hannover, 159 Haversian canals, 100–3, 199 Heede, Alexis, x Heidelberg, 286 Heim, Urs, x–xi, 44–5, 78, 116, 147, 178, 306 Helfet, David, 214 Herzog, Kurt, 26 Hey-Groves, Ernest, 15, 20, 67, 106, 207 Hip Documentation Centre, 129–30 hip nailing see femoral neck fractures hip prostheses, 70, 129–30, 270, 289 histological examination, 89, 96–104 Hofer, Georg, xi Hoffmann-La Roche, 100 Hohn, Bruce, 191, 207–8 Hollerith, Hermann, 124–5, 284 Hong Kong, 164, 232, 292 Howell, Joel D., 44, 53, 134, 252 Howmedica, 272 Hübner, Arthur, 134 Hughes, James, xi, 190, 192 Hungary, 58, 163, 165, 291 IDES, International Documentation and Evaluation System, 130 Ilizarov, Gavriil A., 165, 256 implants see surgical equipment indications for osteosynthesis, 21, 26, 108, 114, 141–4, 154, 157,171 individualising approach to medicine, 113, 132–7, 252–4, 258 India, 164, 166, 292 Indonesia, 163, 232, 292 infection see bone infection innovation, definition, 241 as network building, 241–2 Innsbruck, 162 instruction, 32, 43, 64, 68–71, 108, 134–6, 146, 157, 171, 183–8, 196, 210–14, 220, 222–7, 235, 246–8, 253–4, 256 instruction courses, 32, 52 see also AO courses

Index

instruction sheets, 43, 76 7 instruments see surgical equipment instruments box system, 51–2 insulin, 62 interfragmentary pressure see compression osteosynthesis and fracture healing Interlaken, 31, 155, 158 intramedullary nailing, 17, 21–3, 24, 26, 35, 45, 48, 53–5, 119, 131, 153, 199, 204–7, 210–11, 240, 272, 301 Ionesco, Eugène, 45 Iran, 164, 292 Iraq, 164 Ireland, 164–5, 292 Iselin, Marc, 68 Israel, 70, 163, 292 Italian section of AOI, 224 Italy, 69, 70, 79, 120, 162–5, 220–1, 223, 291 Ivory Coast, 164 Jann, Urs, xi, 230 Japan, 79, 164, 166–7, 292 Jaques-Baumann, Margrit, xi Jenny, Jacques, 191, 207 Jones, David, 286 Jordan, 164, 292 Jost, Giovannina, xi Journal of Bone and Joint Surgery (JBJS), 87, 180, 190 Journal of Trauma, 182 Karpf, 60, 63 Katzer, Tobias, xi Kempff and Grosse, instruments providers, 205 Kenya, 164, 292 Kiel, 272 Kirschner, Martin, 10 König, Fritz, 25 Koslowski, Leo, 155–8 Krauss, Hermann, 55, 71, 76, 148, 155, 157–9, 290 Krompecher, Stefan, 96, 99, 107, 278 Kümmerle, Fritz, 156 Kuner, Eugen, xi, 159 Küntscher, Gerhard, 21, 23, 48, 97, 105, 119, 204–5, 207, 215, 279 Küntscher nail, 21, 23, 26, 90, 170, 205 Kuwait, 164, 292

343

laboratory models, 88, 91, 104–6, 279 laboratory revolution in medicine, 87, 248 laboratory science, 32, 33, 66, 67, 86–109, 110, 112–14, 121, 133–5, 146, 190, 204, 207, 222–3, 242, 248–50, 274, 279, 280, 281 relationship to clinic, 88, 104–9 Lambotte, Albin, 20, 24, 25, 43, 48, 67, 88, 96, 119, 151, 162 Landolt, Max, xi Lane, William Arbuthnot, 19–20, 24, 25, 4, 119, 151 Lane plate, 19–20, 55 Lange, Max 48, 54, 120 Latin America, 163, 165 Latour, Bruno, 63 Latvia, 164 Lausanne, 29 Law, John, 241–2 Lawrence, Christopher, 113 LC-DCP, 120 Lebanon, 164 Leinbach, Irvin, 180, 290, 295 Leipzig, 170 Lenggenhager, Karl, 53 Lengwiler, Martin, xi Liestal, 29, 32, 126, 225 Linné, Carl von, 116 Linz, 160 LISS, 210 Lister, Joseph, 19 Liverpool, 21 Libya, 164 local knowledge see tacit knowledge local practices, 43–5, 185, 246 see also standardisation local surgical cultures see local practices locked intramedullary nail, 205–6, 211 Loeliger, Ursula, x long-term documentation see follow-up long-term function, 34, 120, 146, 250, 254 Los Angeles, 180, 189 Lösch, Andreas, xi Löwy, Ilana, 62, 107, 243 Luckin, Bill, 11, 12, 13 Maatz, Richard, 48 Madrid, 221

344


Magerl, Fritz, 206 Mainz, 149, 156–7 Mainz Traumatological Symposia, 156 Malans, 274 Malaysia, 164–5, 232, 292 Malka, Jeffrey, 296 Mann, Thomas, 3, 41 manufacture of surgical devices see surgical equipment Marcel Benoist Prize, 149 marketing, 46, 49, 58, 60–4,187–8, 196, 242, 246 Marks, Harry, 62, 111–12, 128 Massachusetts, 180 Mathys, company, 172, 174–6, 230 Mathys, Robert, xi, 48–52, 55–64, 69, 72, 88, 150, 156, 164–5, 166–7, 215–17, 221, 229, 231, 271, 289 Mathys subsidiaries, 164 Matter, Peter, x–xi, 129, 153–4, 227, 229, 306, 308 Matthisson, Regula, xi Matti, Hermann, 151 Matzen, Peter F., 170 Maurice E. Müller Centre, 130 Maurice E. Müller Foundation, 289 Mayo Clinic, 23 maxillo-facial surgery, 204, 206, 217 medical technology and historiography, 240–1 medullary nailing see intramedullary nailing Memphis, Tennessee, 180 metallurgy, 47–8, 56, 270 metals, used for implants, 20, 46–8, 56 Mexican section of the AOI, 163, 223–4, 306 Mexico, 70, 163, 165, 223, 292 microscopic examination see histological examination mistakes, surgical, 66, 123–4 mobilisation see functional exercises modern society, 37, 44, 239–59, 266 Monument, Colorado, 188 Moore, John R., 181 moral integrity of surgeons, 83, 136–7, 247 Moraz-Müller, Violette, 49, 60, 270 Mörl, Franz, 170, 174, 178 Morocco, 164

Moscow, 166–7 Müller, Maurice E., xi, 28–45, 48–60, 63, 66, 68, 69, 76, 79, 81, 83, 88–91, 93, 94, 97, 116, 122, 125, 126–7, 129–31, 142, 148–9, 154, 155, 156, 160–3, 166, 176, 180, 183–5, 187, 190, 212, 215, 219–20, 223–5, 228–9, 231–2, 235, 264, 289, 307 Müller plate see AO compression plate Müller’s tension device see AO compression plate multiple trauma see polytrauma Munich, 48, 54 Namibia, 292 Nanterre, 68 National Institutes of Health (USA), 95 necrosis of fracture ends see pressure necrosis Netherland Antilles, 292 Netherlands, 150, 164, 292 neutralisation, effect of plate, 197 New Jersey, 190 New York, 154, 180, 184, 190–1 New Zealand, 164, 164, 292 Nicoll, Ernst Alexander, 134–5, 286 Nigeria, 164 Nikolow, Sybilla, xi non-operative treatment see conservative fracture care non-profit character of AO, 57, 62–4, 72, 146, 166, 188, 223, 226–7, 244, 255 non-unions, 19, 83, 109, 120, 122, 142–3, 190 North Korea, 292 Norway, 163, 165, 292 Norwegian section of AOI, 163, 223–4, 306 Notz steel company, 48 nurses, 75–6 nurses course see AO Operating Room Personnel Course Oberli, Klaus, 147 Obrecht, Sibylle, xi occupational accidents see accident in industry Ohio State University, 191, 207 Olten, 58 Oman, 164, 292

Index

open fractures, 19 orthopaedic surgery, 130, 148–9, 181, 293 and fractures, 30, 158 and the AO, 32, 166, 255 Osteo, company, 63, 204, 214–16, 219, 222, 304 Oswestry, 70 outcome studies see documentation of outcome Pakistan, 164, 292 Panama, 164 Paraguay, 164–5, 292 Paris, 68, 71 patents, 57, 63–4, 215–16 paternalistic attitude of surgeons, 152–3 patient–doctor relationship, 152–4, 189, 248 patients, 150–4, 189, 242, 245, 247–8 and documentation, 127–8 compliance, 151–4, 189, 248, 290 consent, 152–3 individualising view on, 132–7, 286 making statements about outcome, 119–20 popularity of osteosynthesis with, 63, 136–7, 151–2, 244 role in the rise of the AO, 150–4, 247–8 Patry, René, 265 Pauwels, Friedrich, 89, 96, 99, 167, 197 PC-Fix, 210 penicillin, 62, 268 Pernyész, Sándor, 106 Perren, Stephan, xi, 91–5, 107–8, 196–9, 200, 205, 209–13, 216, 229, 235, 302 personal authority, 39, 145–7 personal knowledge, 78, 81 see also tacit knowledge personal relationships between surgeons, 31, 37–41, 44, 81–3, 225, 247, 256–7 personal skill, 40, 134–7 see also tacit knowledge Peru, 164–5, 292 pharmaceutical industry, 62, 95, 186 Pfeiffer, K.M., 78 Philadelphia, 89, 186

345

Philippines, 164 Pickstone, John, xi Pinsent, J., 272 Pittsburgh, 13, 20 plaster cast, 16, 20–1, 24, 123, 143, 150, 153, 183, 220, 297 plastic surgery, 33 plate osteosynthesis, 19–21, 23–4, 26, 45, 54–5, 90, 199 Platt, Harry, 17, 112 Plowden, William, 11 Pohl, Ernst, 48, 204 Poland, 58, 79, 164–5, 292 Polanyi, Michael, 67 political restrictions for the AO, 166–7, 176–9 polytrauma, 143 Porter, Theodore, 111, 132 Portugal, 164–5, 292 Postel, Michel, 71 post-operative treatment, 35, 123, 143–4, 150, 161–2, 183, 190, 220, 265 see also functional exercise pressure measuring device, 89, 91–3, 201 pressure necrosis, 89–93, 98–9, 101, 199 see also compression osteosynthesis pressure on fracture line see compression osteosynthesis primary bone healing, 24, 29, 34–5, 86–8, 96–104, 107, 191, 199, 204, 209, 245, 249, 278 terminology, 97 probabilistic approach to medicine, 112–13, 250, 252 producers see AO producers professionalisation, 135–7, 151, 253–4 of traumatology, 158–9, 161–2, 255 promotion of AO equipment, 61, 71–3, 244 Protek AG, 289 psychology, 111 punch-cards, 124–7, 131 quality control of equipment, 48–52, 59–60, 64, 146, 150, 215–17, 240, 246, 254 quantification, 111–13, 119, 124–5, 132, 250–3 see also statistics

346


radiographs see X-ray diagnostics Rahn, Berton, xi, 104, 108, 198 rationality, clinical, 108, 113–14, 133–9, 252–4 different views on, 110–14, 132–9, 252–4 statistical, 133, 287, 252 Rechenberg, Peter von, 56–7, 60, 64, 216, 221–2, 227, 229, 307 record-keeping see documentation refracture, 122, 154, 200 regionalisation see AO regional associations rehabilitation, 14–15, 34–5, 119–21, 127, 151, 250, 254 Rehn, Jörg, xi, 131, 143, 156–7, 160 replication of results, 66, 76–7, 84, 101, 104, 106–7, 113, 116, 133–5, 182, 240, 281 representation, and photography, 114 in instruction, 74, 274 in laboratory science, 99, 104–6, 249, 274 reproducibility of outcome see replication of results Richards, company, 204 Richards, Evelleen, 132 rigid fixation see stability of fixation risk associated with osteosynthesis, 19, 24–7, 54–5, 66, 83–5, 120–4, 142, 146–7, 182–4, 254 financial of manufacturers, 60–2, 244 of litigation, 189 perception and assessment, 121–4, 132–3, 251–3, 283, 286, 289 therapeutic, 110–11, 283 Romania, 58, 164 Rosen, Howard, xi, 163, 180, 184, 190–1, 207, 295 Rosenberg, Charles, 108 Roux, Wilhelm, 89 royalties, 57, 60, 166, 222, 228, 230, 249, 252 Rüedi, Thomas, 229, 306 Russenberger, Max, 91 Russe, Otto, 160 Russel and Taylor, instruments providers, 205

Russia, 79, 164–5, 166–7, 256, 292 Saarbrücken, 144 sales areas of AO producers, 58 Salis, Björn von, 207 Salzburg, 164 Sander, Eberhard, xi, 170–3, 176–8 Sandick, Herbert, 180, 184 Sarmiento, Augusto, xi, 82, 120, 189, 208, 297 Sarmiento brace, 208 Saudi Arabia, 164, 292, Sauerbruch, Ferdinand, 158 Sauerteig, Lutz, xi Scandinavia, 58, 163 scarcity of AO material see availability of AO material Schatzker, Joseph, xi, 79, 187, 190, 199, 213, 308 Schenk, Robert, xi, 41, 91, 93, 100–2, 105, 280 Schmid, Peter, xi Schneider, Robert, 30–4, 36–8, 53, 56–7, 60, 69, 70–2, 77, 83, 84, 86, 94, 123, 126, 131, 143–4, 146, 149, 154, 157, 178, 185, 200, 211, 216, 218–19, 221–2, 224, 227, 229, 232 Schürch, Otto, 32–3 Schweikert, Carl-Heinz, 156–7 science, cultural power of, 108, 249 medicine and surgery as, 40, 66, 77–8, 86–8, 106–9, 110–14, 133–7, 286, 287, 248–54 social dimension of surgery as, 135–7, 253–4 scientific management in medicine, 111 scientific medicine, values associated with, 39, 43, 66, 77–8, 86–8, 106–9, 110–14, 133–7, 248–54, 287 screws, self-tapping, 20, 49 Seattle, 204 SED, East German Party, 169, 173, 178 Segmüller, Gottfried, 78 Senn, N., 106 Shapin, Steven, 37, 248 Sherman, William O’Neill, 13, 20, 47, 268 SICOT, 130, 154, 180, 184

Index

Singapore, 164–5, 232, 292 skiing fractures, 12, 32, 150, 152, 189, 247, 281 skills of surgeon, 24–7, 38, 46, 65–7, 70–4, 77, 79–85, 122–4, 133–7, 142, 161, 174, 182–6, 190–4, 202, 204, 225, 227, 240–2, 246–7, 252–4 slides, 73, 82, 224, 247, 273 Slovenia, 164, 292 small fragment instruments an implants, 200–1 Smith, Kline & French (SKF), 79, 185–7, 190 Smith-Petersen, Marius Nygaard, 21, 23 socialist health care system, 169–79, 193 societies, registered, 35–6, 40–2 soft tissue damage, 114, 115, 123, 143, 199, 213 Solothurn, 53 soudure autogène see primary bone healing South Africa, 163–4, 291–2 South Korea, 164, 232, 292 Soviet Union, 164–7, 256 Spain, 70, 79, 120, 163, 165, 221, 223, 291 Spanish section of the AOI, 163, 223 Spath, Franz, 160 Spicher, Elisabeth, xi, 273 spine, surgery of, 70, 206–7, 217 spreading of AO see expansion of AO Springer, publisher, 79 stability of fixation, 24, 29, 35, 54–5, 91, 98–9, 104–5, 119, 123, 143, 183, 205, 209–10, 279 standardisation, 17–18, 105, 110–13, 124–5, 133–7, 219–24, 240, 248–9, 272 limits of, 44–5, 65, 246 of documentation, 114–19, 124–5, 128, 133, 222 of instruction, 52, 66, 68, 71, 73–5, 76–8, 85, 222, 224–5, 247 of instruments and implants, 20, 34, 48–52, 59–60, 124, 150, 212, 219–22, 242, 245, 268 of language, 114 of procedures, 18, 21, 26–7, 34, 42–5, 51–2, 65–6, 71, 73–5, 104–6, 111,

347

113, 116, 119, 121, 133–4, 185, 220–1, 246, 253, 282 standards of correct treatment, 119–21, 123 Star, Susan Leigh, 43, 245 Starr, Paul, 189 statistics, 13–15, 42–3, 110–14, 123–5, 130, 132, 148, 250–4, 262, 267, 280, 286, 287 as social technology, 132 Steinmann, Fritz, 25, 151 sterile operating rooms see asepsis St Gallen, 33, 44–5, 74, 78, 148, 154, 160–1, 163, 184, 206, 208 Stoop, Esther, xi strain gauge see pressure measuring device Strasbourg, 272 Stratec, company, 165 strain theory, 210 Straumann, Fritz, 56–64, 69, 72, 91,156–7, 164, 187, 204, 207, 214, 219, 221, 229, 231 Straumann Institute, 56–64, 150, 165, 207, 230 Straumann, Reinhard, 56 Straumann subsidiaries, 165 streptomycin, 293 stress protection, 197–9, 201, 299, 300 Stuck, Walter Goodloe, 23, 25 student fraternities, 31, 37, 264 Sturdy, Steve, 108, 111, 137 Stuttgart, 56, 219 styles, different of AO technique, 44–5, 220, 274 Sulzer, company, 289 surgical equipment, design, 20, 46–52, 59–62, 88, 271, 200–7, 209–17, 221, 241, 245–6 development see design manufacture, 20, 46–8, 55–64, 210–11, 216, 241–2 modification, 200–7, 209–17, 245–6 need of high-quality, 20, 24–7, 46–8, 66, 120, 142, 146, 215, 254 surgical instruments see surgical equipment SUVA (accident insurance company), 34, 148 see also accident insurance

348


Sweden, 114, 163, 165, 214, 291 Swiss fraternity culture see fraternity Swiss National Foundation, 95, 222 Swiss section of the AOI, 223 Swiss Surgical Society, 53, 131 Switzerland, 12, 28–45, 58, 68, 71, 72, 75, 79, 82–3, 142–4, 148–50, 154–64, 166–8, 172 , 176, 178, 183–90, 192, 194, 223, 228–9, 232, 242–3, 246–7, 255, 264, 286, 291, 297, 308 symbiosis of surgery, science and industry, 45, 46–64, 71–3, 83, 95, 146–7, 157, 166, 177, 188, 217, 221–2, 236, 243–6, 252, 254–6, 269 symbolic interactionist sociology, 244–5, 308 Synbone, 74, 273–4 Synthes AG Chur, 56–64, 65, 71, 72, 74, 76, 83, 95, 157, 166, 175–6, 193, 204, 212, 214, 216, 219, 221–2, 227–9, 231, 245, 270, 273–4 Synthes España, 163, 221 Synthes USA, 72, 150, 165, 186–8, 191–3, 206, 230–1, 304 Syria, 164 system trust, 37, 44 Szyszkowitz, Rudolf, vi, 146 tacit knowledge, 65, 67–8, 71, 78–9, 83–5, 134–7, 220, 247, 253, 287 see also personal skill Taiwan, 232, 292 Tanzania, 292 teaching see instruction Technical Commission see TK technical innovation, 200–17 AO surgeons’ resistance to, 212–17 Technique of Internal Fixation of Fractures, 76–7, 182 see also AO textbooks technology, sociological definition, 240–1 tension band principle, 197 tension device see AO compression plate testing of instruments and implants see quality control tetracycline as marker substance, 102 Thailand, 164, 166–8, 232, 256, 292 Thai Orthopaedic Association, 168 Thuringia, 175

tibia fractures, 33, 53, 77–8, 114, 131, 153, 183, 286 Tile, Marvin, xi, 185, 213, 232 titanium as implant material, 201, 212 TK, 59–64, 83, 95, 156, 185, 190, 205, 211–12, 214–15, 219, 221–4, 230, 242 Toronto, 190, 232 traction, skeletal, 16–17, 18, 21, 35, 143, 152 training, 65–85 lack of, 24–26, 65–6 systematic, 16–18, 134, 142, 159 see also skills of surgeon translation of textbooks, 79 trauma surgery, 10–16, 26, 110, 156, 158–9, 160–2, 169–70, 178, 181–2, 206, 239–40, 291 as technical solution, 239–40, 249 traumatology see trauma surgery triangulation in science, 99 Tröhler, Ulrich, x–xi, 111 Trojan, Emanuel, xi, 161 trust, in instrument suppliers, 47–8 of AO in other surgeons, 82–3, 227 of patients in surgeons, 137, 154, 247–8 of surgeons in AO, 37–41, 44, 64, 81–5, 93, 131–2, 144–8, 188, 225–7, 266, 247, 251, 254–5, 275 of surgeons in patients, 153–4, 247–8 Tscherne, Harald, 146, 159, 160–1 tuberculosis institutions, re-dedication of, 41, 266 Tübingen, 156–7, 159 Tunisia, 164 Turkey, 164 Uganda, 164 university surgery, 31, 39, 148–9, 157–9, 161–2, 243 Uppsala, 163 Uruguay, 164, 292 USA, 13, 15, 19, 20, 23, 25, 26, 33, 41, 44–5, 58, 62, 68, 70, 72, 74, 75, 79, 82–4, 93, 111, 124, 132, 134, 137, 151, 153, 154, 155, 162, 163, 165, 168, 180–95, 196, 204–7, 219–21, 229, 232, 235, 256, 268, 269, 280, 282, 286, 290, 291

Index

US Army, 192 US Bureau of Standards, 47 US Steel Corporation, 13 user education see instruction USSR see Soviet Union Van der Elst, E., 162 Venable, Charles Scott, 23, 25, 47 Venezuela, 164–5, 292 veterinary surgery, 191, 201, 207–8, 224 videos for instruction, 72–3, 75, 85, 247 Vienna, 14–15, 18, 32, 68, 119, 124–5, 160–2, visualisation and surgery, 73–4, 114–15 in science, 99 Vogt, 60, 63 Voka, 63–4, 214 Waldenburg, 56, 58, 207, 270 War, 16, 18, 23 Warner, John Harley, 87 Watson-Jones, Reginald, 21, 24, 87, 90, 165, 181 Wayne, Pennsylvania, 186 Weber, Bernhard G., xi, 44–5, 74, 78, 116, 123, 153, 208 Weller, Siegfried, xi, 155–9, 223, 308

349

Wenger, Jean-Claude, 307 Wildavsky, Aaron, 121 Willenegger, Hans, 32–4, 37, 41, 43, 44, 53, 56–7, 66, 69, 73, 78, 81–2, 84, 91, 93, 99–102, 105, 131, 148–9, 155, 160, 165–8, 172, 175–8, 185, 187–9, 198, 216, 219, 223–5, 226, 227, 229, 306 Winterthur, 32–3 wire suture, 19, 55 Wolff, Julius, 88–9 Wolff’s law, 88–9, 197–8 Woolgar, Steve, 63 work accidents see accidents, industrial Wrightington, 70, 266 Wyss, Hansjörg, 72, 187–8, 192–3, 205, 229, 232 X-ray diagnostics, 19, 99, 101–2, 114–15, 119–20, 123–31, 144, 152, 156, 184, 281, 282 tomography, 115 Yugoslavia, 70, 73–4, 163, 221, 292 Zimmer, company, 204, 215, 303 Zürich, 28, 31, 32, 36, 40, 53, 87, 137, 152, 154, 264

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