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Presentation This book was born out of gratitude to Professor Maurice E. Müller, and to honour him on his first 80th anniversary. Much to my surprise, I will be turning 60 very soon. Maurice has been not only my Master but also a second father to me. That is the reason why I beleive that the best birthday present that I can offer him is a survey of the surgical practice, which, faithfully followed his teachings, during the 30 years of his fatherhood. Not only am I pleased to publish this testimony of admiration and loyalty but I am also especially eager to show him, in the same book, many cases successfully operated on by my own pupils following his techniques. Therefore my pupils are part of the third generation of “fans” which is also teaching younger surgeons, the fourth generation of surgeons, some of whom have con-tributed to this book with some cases. One of the latest articles written by a recently deceased Professor of history of medicine states that the oscillating rhythm of modern medicine would make any surgical technique obsolete in less than 30 years. This does not seem to be the case with the techniques proposed by Maurice; after the extensive review of cases for this book, I have been able to verify that many of his initial techniques are still up-to-date and will presumably be difficult to excel in years to come. The book shows a mixture of cases performed during three decades but their chronology will not be apparent to the reader since the surgical criteria have been maintained unaltered. To aid cronological orientation we point out that the first cases are those with unnecessary screws (excessive) since only the experience enabled us to learn how many screws are strictly necessary. When Maurice Müller was invested as Doctor Honoris Causa of our “Universidad Autónoma de Barcelona”, his speech leitmotif was: “Learn, Teach, Evaluate”. Many years ago, in the inscription he wrote to me on the first page of one of his books, he encouraged me to document every case, not only with the written medical records but also with the X-rays which, in our specialty, prove almost everything and compromise the surgeon with his surgical technique. In his inscription, he also stated that only the continued evaluation of my own cases would allow me to persist with the technique. Having verified my commitments to such undertaking, he gave me a Log Etronics device which, at the time, was the most up-to-date apparatus for making slides from X-ray film. Some years later, he entrusted me with his Foundation in Spain, its main objective being documentation. The follow-up of the surgical cases done by me and my co-workers has allowed us a continuous autoevaluation that has given, very satisfactory results and, at the same time, it has helped us to learn from our mistakes. On the other hand, the recollected material has encouraged us to teach and propagate, while checking the indications and the surgical fracture treatment techniques. |
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Documentation Our counsel to the next generation of surgeons of the school is to persist in documentation for their own continuous autoevaluation. I know their answer: difficulties encountered because of the patient overload as well as the need to spend many hours in direct patient clinicalcare in order to survive economically, in the setting of a progressively socialized and not well remunerated profession create great difficulties. I can cite for them more additinal obstacles to prospective documentation. Theeme rgency rooms’ overload demands quick radiology, without a quality control, that too many times result in images so bad that they do not allow even an accurate diagnosis. Furthermore, conventional bone radiology does not appear to be attractive to radiologists, who usually delegate it to less qualified co-workers. So it is difficult to obtain good quality imagery, constant beam-film distances or accurate projections. To further complicate the problem, artefacts are created by the splints used by the emergency sevices, which either show up as a metallic structure or, in the case of air-splints, blurring of the film. The timeing of follow-ups is also not easy. Some patients feel cured and do not return for follow-up. Others are diverted to other doctors or hospitals, move to another address or are simply lost. Some elderly people with a hip fracture languish without follow-up in nursing-homes or at home because of transportation problems. Finally, the economic difficulties - making slides is expensive: it requires equipment, photographic material, developing, files, etc. In summary, time and money. All of this is true, but just as in social life no situation seems to have occurred unless it is shown on T V, in our case without graphic records, there cannot be evaluation, statistical studies, or a right to persist with a specific technique. We the surgeons, probably as the result of an unconcious autodefense mechanism, tend to forget our bad results and magnify our good statistics. Only formal documentation will allow strict scientific opinion. I am sure that most of our readers will agree that the formula is personal sacrifice. If one wants to get a good emergency X-ray film, one must show-up in the radiology department, supervise and help in the patients’ transfer to the table, remove the metallic splints while immobilizing the fracture with one’s own hands, many times with the risk of irradiaton, and also control the result and have the courage to cordially ask for a repetition or a new projection. For routine follow-ups it will be necessary to advise the patient, remind her/him either by phone or mail, and again be physically present if necessary. A fracture is of interest as a clinical case only if its process of healing, callus formation and functional recovery can be followed. If it has been treated by internal fixation, many years of follow-up will be of interest. This task, up to this point in time, has required vocation, or at least enthusiasm, and persistence. Nevertheless, it seems that Insurance Companies will soon require computerized documentation with imagery demonstrating healing before paying for the damages; this situation will lead to a remodelling of the system to the benefit of the patient and of the scientific work that should be the patient care. On the other hand, younger surgeons should learn that doing surgery well or very well “only” benefits the patient and the hospital. If they do not document their cases with intention to study and publish them, the cases will be cast into oblivion after a few months and with that the possibility of their utilization for the legitimate professional promotion of the surgeon. Some hospitals believe their archive is a jewel. It is true but, from the scientific standpoint, thousands of dust-covered medical records are useless if they cannot be used for clinical research and teaching. |
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Fracture Classification This Atlas is the result of the continued effort of many and also that of our own inadequacies. Many good cases colud not be published because of radiographic deficiencies, loss or damage of one of the images or lack of followu-up. Other cases are wasted because of medical records retrieval difficulties , mainly because their diagnostic classification was erroneous, obsolete or not clearly defined. The new generation should not have this problem: the new General Fracture Classification proposed by Maurice E. Müller9 is alpha-numeric and computerizable and allows a single language based on a clear-cut glossary. No classification is perfect but the sequential logic used by Müller is extraordinary, specially for types and groups. It is somewhat more complex for some subgroups. That is the reason why I asked him to reflect in the Foreword on the intelectual process he followed, the historical evolution of his ideas up to the definition of the four points that grant originality to the Classification. The origins of the Classification are the documentation cards which Müller created in 1958 which we updated and computerized in 1995. Its practical usefulness is demonstrated in this Atlas, where the reader will be able to easily find any kind of fracture by simply skimming through its pages.
The Classification allowed four of our Residents, experts in the use of the classification, (Norberto, Sales, Videla and Vilamajó) to review under the supervision of Peter Koch over 54.280 fractures at the Berne Foundation Documentation Centre. This extensive work which took several months to complete has yielded the percentages of the different fracture types, groups and subgroups, as well as the selection of one radiographic image for every subgroup, which is shown in the Atlas next to the corresponding well-known drawings of the classification from the book by Müller, Nazarian, Koch, Schazcker10. In some cases the radiographic image is not identical to the drawing but there is correspondence between the image shown and the definition of the fracture in the text and, altogether it demonstrates that the Classification proposed by Müller matches with the pathoanatomic reality. This is the first publication in which the drawings are shown next to their corresponding X-ray photograph. Not every image is of perfect quality but, as stated above, too many times the X-rays taken at the emergency services are of a poor or very poor quality. From the computer standpoint, every image of the Atlas has been digitalized and processed with the Photo-Shop program. All fractures have been turned to the right side for didactic purposes. Some of the fracture lines have been enhanced for a better viewing. Grey contrast filtering and focusing of the images has been done as well as the necessary size adjusting for editing composition. Digital technology allows to take good images, store them without using physical space and preserve them indefinitely. Some of the images shown are from the Barcelona Foundation files since they are of a better radiographic quality or more demostrative but they are not included in the statistical study as clinical cases.
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Internal Fixation Techniques The second reason for the making of this Atlas is to show surgical cases operated on following the Müller techniques, especially those exposed in the second edition of the AO Manual, for which Müller makes himself responsible. We endorse his didactic teaching with clinical examples. We have also included examples of techniques proposed in the third edition, such as the interlocking nailing or the biological internal fixation, indications that we consider still as experimental. Thus, our indications for their use are very limited. With the greatest respect for all of those who follow these techniques, we our continue to beleive in anatomic reduction and interfragmentary compression so that the bone shares the stability of the internal fixation, neutralizing the loads with a protection plate. The use of an intramedullary device which separates the fragments as it penetrates through them and ends up suspending the main fragments between two or three screws; this seems to us a less “delicate” yet not less aggressive s u rgical procedure. A hypertrophic callus formation is efficacious but as is a direct intercortical callus protected by a plate as it forms in absolute stability, seeking a perfect anatomic reconstruction. Throughout the Atlas as a whole, one or several of the techniques used by us for the treatment of each group of fractures can be observed along with a short discussion about the clinical case and a reference to the page where the corresponding drawing is shown in the third edition of the AO Manual. T h e order of presentation is usually established by the order of our preferences in technique. Some obsolete techniques, such as the humeralization of complex proximal femoral fractures are shown because of their historical interest and also to prevent them from falling into oblivion since they can be very useful as salvage procedures. It has not been possible to show one example of every subgroup, as was our endeavour, either because we did not have at our disposal such a case, or because the radiographic quality of the image was not publishable, or because the treatment was too similar to the remainder of the group or because the treatment was unsatisfactory technically. We have almost completely attained our objective for the lower extremity, the most common surgical indication. Not so for the upper extremity, where we have found difficulties in completing the subgroups. This is the reason why we sought Dr. Diego Fernández and Urs Heim’s contribution since they have each published recently one excellent book about distal forearm fractures and pilon fractures. Another aspect that we would like to emphasize is the difficulty to find “perfectly treated” fractures among our files. Besides the indications, which many could argue, every case has some defect in surgical technique or some aspect that could have been improved, including those which appeared brilliant at first sight. We have concluded that the perfect case does not exist and we want to give written evidence of this point as a warning to those readers that may try to reproduce our images in their surgical procedures. T h e published cases do prove that it is possible to obtain anatomic reductions that, after being compressed by whatever static or dynamic internal fixation procedure, either with bone sharing of stability or with graft substitution of bone stock loss, always achieved the healing of the fracture through direct or indirect callus formation. On the other hand, it is also apparently true that, in multifragmentary femoral diaphyseal fractures, the non-anatomic reductions (understanding as such the non-perfect fracture fragment adaptation in order to preserve the blood supply) also lead to healing with exhuberant callus when the internal fixation is stable enough. Other cases demonstrate how perfect reductions of small fragments, inevitably devascularized, have also healed either by primary bone healing or by creeping substitution, although sometimes the X-rays do not show it. The Atlas demonstrates the sequential process of callus formation, especially in the diaphyseal fractures, with the dates being shown with every image. Only the experience and good criteria of the surgeon will allow him to choose the better option among those available depending on his own capabilities and on the hospital possibilities. A general discussion to decide whether a nail is better than a plate seems of no use to us. What we do firmly believe is that the ideal situation would be to obtain healing with perfect reductions that restore the bone to its previous anatomic structure and, of course, its function.
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