Foreword
M.E. Müller

The AO documentation was established at the beginning of 1959, only 3 months after the founding of the AO. We used from the very beginning our X-ray cards and code sheets. Progress was rapid. Toward the end of 1959, we had already over 1000 X-ray cards with miniaturized X-rays representing the initial X-ray, the one after s u rg e r y, and the one at the 4-month follow-up. From the very beginning, the documentation was one of our main pillars and provided us with mainfold services. The documentation helped us in teaching the use of our instruments and implants, made it possible for us to establish a quality control system, helped us establish the indications for treatment, made it possible for us to plan graphically the operative procedures, and was of enormous help for us when we were developing our operative techniques. As an added bonus, the documentation provided us also with many slides of X-rays of the cases which we had documented. These we used in our lectures on the AO method.

The X-ray cards of the documentation became also the basis for the AO technical comission in its evaluation of the instruments. Furthermore, the chief of each participating clinic received duplicates of all miniaturized X-rays which the documentation received from his institution. This helped him to see immediately what his co-workers were able to achieve and whether his co-workers had grasped the essence of the AO metod and its applications .

The X-ray cards became also very important for us in our teaching and as illustrations for our publications. Thus we used them as illustrations for our first publication "The technique of internal fixation of fractures" which appeared in 1963 and for the publication of the 3 editions of the A O Manual, which appeared in 1969, 1979 and 1991.

In 1997, at the University Hospital of Bern, we tested for the first time the methodology of organizing fractures of bone segments into triads, which became subsequently the basis of the Müller comprehensive fracture classification. Between the the years 1979 and 1987, the AO documented about 60,000 fractures. 52,280 X-ray cards were of sufficient good quality to allow for subsequent classification of the fractures. The fractures of long bones were divided into those of the 4 long bones, which yielded 13 Segments, 39 Types, 117 Groups, and 351 Subgroups. We used most of these X-ray cards as reference material when we wrote the two books about our fracture classification, "The AO Classification of Fractures" by Müller, Nazarian and Koch, which appeared in 1987, and "The Comprehensive Classification of Fractures" by Müller, Narzarian, Koch and Schatzker, which appered in 1990.

A very talented Spanish group working in Barcelona under the leadership of Rafael Orozco studied the 54,280 fractures which the AO documented between the years 1980 and 1988. This task took them 5 years. The y found 99% of the 351 Subgroups. Less than 0.5% of the fractures could not be classified with our alphanumeric coding system.

Their work resulted in the documentation of our databank which was compiled using to the same criteria, the same methodology, the same nomenclature and the same hierarchical principles of organization. The fractures were ordered in an ascending order of severity which corresponded to their morphologic complexity, the difficulties of treatment, and their prognosis.

This databank is probably unique not only in Traumatology and Surgery, but probably also in all of Medicine. All termiology is careflly defined in the "glossary". This has made it possible to compare data. The statisical evaluation of the databank of the 54,280 fractures by Orozco and his co-workers has given us very important statistical information on the incidence of the different fractures.

The first 1500 copies of the first Spanish edition of the "Atlas" sold out in 3 months. The second and slightly improved edition of 5000 copies went quickly to press. The English edition will open for the English-speaking world the treasures of the contribution of our Spanish colleagues.

In 1994, we concluded that the method which we had recommended in our first publications for classifying a fracture which consisted of comparing an X-ray to the three schematic drawings which represented the Types , Groups, and Subgroups of a particular segment, resulted in too many intra- and interpersonal errors. This motivted us to design a new method which consists of a binary system of questions which are used in the classification of the triads of Types, and Groups. Thus, with a set of 2-4 specific questions which one must always be able to answer with either a "yes" or "no" we can always arrive at a very accurate classification. If a clear answer to one of the questions is not possible, it means that the necessary information is not available from the X-rays and that further imaging is necessary either in the form of further plain X-rays or CT scans.

If we consider the great and rapid technological progress of today, and the steadily rising life expectancy, as well as the rising cost of health care delivery, and the greater and greater expectations of our patients, we come to understand and appreciate the great need for quality assurance. Quality assurance and documentation are inseparably linked. The cost of healthcare, patient satisfaction, the motivation of one's assistants, and the demands of the competition authorities are all issues which are very closely intertwined and issues which must be built into every documentation. The demands today are for data which can be subjected to analysis and comparison, for full transparency of organization of our institutions, and for an easily and universally accepted and used documentation methodology. Subjective residual disability, disability payments, and the length of recovery are essential issues to be dealt with.

The databank of Orozco has made it possible to demonstrate the many of the newer and much more expensive implants are not all necessary. In this way, the Classification can be used to provide support for the new current philosphy which mantains that we should concentrate all our efforts in providing for the needs of the patients .

In conclusion, in the name of the whole orthopaedic community I would like to thank the Barcelona team, Rafael Orozco, J. Miquel Sales, and Miquel Videla for their Atlas, an immense and invaluable contribution to the orthopaedic literature.

To Learn, and then understand, one must Teach . To Learn and Teach, it is necessary without exeption to Evaluate the choices, the concepts and the results.