Preface to the Spanish Edition
A. Navarro

The “Atlas of Internal Fixation. Fractures of Long Bones”, written by Rafael Orozco, J. Miguel Sales and Miguel Videla is the result of a minute in depth analysis of the said fractures at the Centre for Documentation of the M.E. Müller Foundation in Bern and Barcelona. It encompasses 273 operations, the majority performed by the first author, and it includes contributions from the members belonging to his School and the AO group who were invited to participate in the Atlas that was a tribute to M.E. Müller. We would like to highlight two completely different aspects of the book: the Classification of Fractures and their treatment as advocated by the Swiss School at the end of the 1950s and the beginning of the 1960s.

In biology, classification (taxonomy) is the most frecuently used tool in approaching the essence of truth; it is only when we create groups and subgroups that we are able to set up measurable and reproducible relationships that will allow us to employ the statistical method in the processing of facts. We should not forget , likewise, that statistical methods are only applicable at the level of validation that will allow for the establishment of significant correlations, that is to say probabilities, a causal relationship. In the field of biology, on occasions, we cannot resort to the method of measuring, that is to say physical or mathematical quantification, so we proceed on the basis of statistics. To this end, classifications are necessary. When we use this methodology we attempt as much as possible to "mathematize" experience. We try to translate the biologically concrete, the form as posed by Aristotles into platonic abstraction, but this transformation, at least in biology, is only partial.

The Global Classification by Müller does not designate, it is not pure drawing or schemata but entails a meaning of a prognostic and therapeutical nature. It is a synthetic classification, as Nazarian points out. It reports the severerity of the fracture and the appropriate treatment. In this classification we find letters, numbers, drawings and explanatory text. They are different forms of language or vehicles of thought. In general, language, though we may have formalised it from a schematic and syntactic standpoint, is not able to produce an adequate fit between the content of the concept and how it is signified. Language can be broken down into three aspects: the sign, the symbol and the signification. The sign is the support of the signifying value of language to the extent that it relates the object, the fact and its expression. It would seem clear that the sign -as a meeting point for the sensitive and the intelligible- controles perceptual activity, which, in turn, appears as the natural source of language. The symbol has always been part of the graphic expression -be it figurative or numerical- of science. If the meaning of words and the sign that denominates coincide, then the symbol is equally the sign.This scientific language is understood by all the people of this earth, and it does not pose the barriers of spoken or written language. It is what makes it of universal nature. That is why scientific ideas are spread so rapidly.

The Classification of Fractures by M.E. Müller and collaborators based on signs and symbols has in it the traits of scientific realism and phylosophical idealism. It is based on an idea but then uses objects to evaluate this way of thinking and draws conclusions that may change the order and bestow upon its reliability. Orozco et al. demonstrate that, upon the basis of radiographs for all the subgroups, the Classification of Fractures is reliable. In order to validate a classification one needs a great deal of data. And equally important is easy acces to the said data. I am conviced that the Classification would not have been possible without the Centre of Documentation that the AO founded in 1959. The processing of data and X-ray images have not only facilitated the creation of types, groups and subgroups, but have become the very basis for self evaluation, without which what we teach lacks direction. It is through analysis our daily work that we can be sure that we convey in our teachings is real. This is the metaphysical aspect of the technique of ostheosynthesis. It is not my intention to dwell upon the importance of documentation, its ability of being processed electronically with easy access to the processed data as a way of study pertaining to our daily practice. However, given the great interest nowadays in clinical auditing, we beleive in the urgency to establish health care centres which would be able to forecast the needs in technical infrastructure and human resources. Without these evaluation of medical practice and teaching and quality-cost ratio would not be possible.

The second and completely separated aspect of one book is the methods of internal fixation which follow the dictum of Müller et al. as set out in the book “Tecknik der operativen Fracturenbehandlung”; norms that were identical in the Handbooks of 1963 and 1977 and have not changed since then: Our clinical experiences repeatedly emphasize the significance of the stability and blood suply of the fractures we operated on. When these two objectives were attained, firm and rapid union of the fractures resulted in all cases. The quantity of metal used does not appear to be of primary significance. The healing of the bone, however, represents only part of the problem. The practice of emphasizing the bone lesion to the exclusion of the soft tissue damage should be firmly abandoned. Modern fracture treatment has as its goal the restoration of full function to the injured extremity. In our view, internal fixation can be only satisfactory when the fracture is mechanically neutralized, so that the patient can actively and without pain move muscles and joints of the broken extremity at the earliest possible moment after surgery. Open treatment of fractures is a valuable but difficult method which involves much resposability. We cannot advise too strongly against internal fixation if it is carried out by an inadequtely 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 skeptics or outright opponents.⁵

For Orozco et al. hese principles have remained unaltered. How is it that the method underwent such a loss of prestige to the point that experts of great talent now mention biological ostesynthesis in opposition to mechanically stable osteosynthesis? Let us not forget that all the ideas in the method could not be more biological from the very beginning! Let us try to understand what may have happened. The practical instruction that all surgeons were given was progressively more relaxed and the method was performed by surgeons with a lower level of training, skill and knowledge. They did not respect the rules mentioned above and only sought a good radiological image. The logical consequence was a higher rate of complications: wound dehiscencies, skin necrosis, infection, bone necrosis, pseudoarthrosis, implant brekage, etc. In spite of the instructions they had been given some surgeons were not skillfull enough to perform this demanding surgical technique. Nowadays, we know that not all surgeons can perform highly skillfull techniques; for example, approximately 30% of surgeons are not able to perform arthroscopies. Should we become able to verbalise kinesthesia, that is to say to put into symbols manual skills, a new philosophical era would be born. In agreement with Haldane, we beleive that a fairy larg e part of our frustrations stem from the existing gap between muscular ability and symbolic expression. The A O , in the context of their manual training courses for the acquirement of greater skill was a pioneer in this sense. But evidently, the courses did not suffice. However, the aforementioned does not justify the new wave of biological ostheosynthesis. The latter, in my opinion, does not entail the advantages of thorough stabilization of fractures for prevention of muscular and bone atrophy, joint stiffness, in other words fracture disease, with early mobilization.

Rafael Orozco et al. offer us a whiff of fresh air and put us at great ease. They present a well done job entailing good results. The issue still is: Is it a method easy and reliable enough to become generalized? Possibly not. But that should not discourage us. We should be ever careful in the training of this technique, offering more courses of a theoretical and practical in nature and keeping on trying to find a better way of conveying the necessary skills that will lead to excellence in this technique.

I would like to congratulate the authors of this master work on the treatment of fractures as well as congratulating them for their loyalty to Maurice Müller and his teachings. This Atlas is the best gift that a disciple could offer his m a e s t ro on his 80th anniversary. It is an honor to participate in this celebration by writing this foreword for a book dedicated to a man who no doubt will become a landmark in traumatology, and whom we proposed as Doctor Honoris Causa of the Autonomous University of Barcelona in 1985. After our proposal another ten universities awarded him this same title of Doctor Honoris Causa.