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  • Surgery and Industry: A Revolution in Fracture Care, 1950s–1990s
  • Marc A. Asher
Thomas Schlick. Surgery and Industry: A Revolution in Fracture Care, 1950s–1990s. New York, Palgrave Macmillan, 2002. 349 pp., illus. $65.

This is an authorized history of the development of a system of a therapeutic fracture methodology. Begun in 1958 by a group of five Swiss surgeons (Martin Allgower, Walter Bandi, Maurice Muller, Robert Schneider, and Hans Willenegger) and their colleagues, their organization named AO/ASIF (Arbeitsgemeinschaft für Osteosynthesefragen [Association for the Study of Osteosynthesis]/Association for the Study of Internal Fixation of Fractures) is a case study of medical-industrial interaction.

The problem that attracted these surgeons' attention was the increasing incidence of lower and upper limb/extremity fractures, the result of traffic, industry, and sports accidents. The accepted nonoperative care of the day resulted in long periods of treatment with traction, casting, or both and was often an enormous burden to the injured, his or her family, and society. In addition the results were often poor with lack of bone healing and healing in poor position.

Beginning in the first years of the twentieth century, many serious attempts had been made to develop surgical treatment by open manual reapproximation/reduction and fixation with metal implants. However, up to 1958, only those procedures for fractures of the hip (Marius Smith [End Page 493] Peterson, United States, 1925) and femoral shaft (Gerhard Kuntscher, Germany, 1940s) had been widely accepted into practice. Otherwise, surgical treatment of fractures had generally resulted in too many complications, including infection, failure to heal, and loss of position.

The Swiss group theorized that these problems could be solved by open anatomical reduction and compression fixation with greatly improved bone plates and screws. The resulting rigid internal fixation would then result in improved bone and soft tissue healing and earlier return to function. The solution was based on the concept of primary (end-to-end) bone healing, rather than on healing by callus. The theory had been proposed, studied, and applied in a limited manner by several earlier surgeons, most notably Robert Danis (Denmark, 1949), but had never been accepted by most students of fracture healing.

The Swiss group set out to improve operative fracture care systematically. For several reasons theirs is a notable example of the development and application of medical technology driven by surgeons. First, they shared a personal knowledge and trust of one another. Second, they proceeded with a high level of personal altruism and took early safeguards to prevent financial conflict of interest. This was done by providing a mechanism for proceeds from royalties and licenses to be entirely reinvested in research, development, and education. Third, they maintained control of the bone plate and screw technology they developed. Fourth, they developed and taught standardized surgical techniques that included management of complications. Fifth, they instituted documentation procedures for surveillance of their practices, which allowed early identification of both technique and technology problems. Sixth, they pursued both laboratory and clinical studies to refine and, when necessary, redefine the scientific basis of their solution. Seventh, they were able to evolve structurally while maintaining these basic principles, as their effort became an international success story extending its scope of activity to include bone surgery of all types in both human and veterinary practice.

The author, who is qualified in both medicine and history, captures all of this and more as he explains how sensitive to cultural context their process of research and development was. The Swiss health-care system, and that of neighboring Germany and Austria, had already evolved regional organization in trauma care that lent itself to a systematic approach to the introduction of new technology. The benefits of such control are best illustrated by contrasting implementation of their techniques and technology in East Germany, where a high level of success was achieved early; and with the United States, where traditions of individualism and resistance to standardization and surveillance are cited as reasons for delay in successful application and ultimate acceptance. [End Page 494]

Even though this is an authorized history of an almost entirely positive medical/industrial interaction, the author has provided insight into some of the tensions that...

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