Injury, 8,243-249 Printed in Great Britain 243

Accident surgery as an intellectual discipline* - -

Professor h/l. Allgijwer Kantonsspital, Bade

IN DEALING with this subject one immediately stumbles over the dilemma of whether first to consider the basic derangements of homoeostasis in the injured patient or whether first to talk about those pioneers who worked on the treat- ment of the most obvious consequence of trauma -the fractures. As injuries to the locomotor system take first place when talking of accidents, it might be justified first to mention a few relevant names in the d,evelopment of modern fracture treatment. Accident surgery-‘traumatology’- has many fathers indeed!

It is not surprising that the tremendous development in surgery at the end of the last and the beginning of this century initiated a series of endeavours by general surgeons to overcome the handicaps of conservative fracture treatment by a more aggressive surgical approach to the injured tissues, mainly the bone, by means of internal fixation and primary repair of adjacent soft tissues.

I will try to do justice to both schools of thought, but you will forgive me if I first start with those surgeons who were impressed by the considerable morbidity and disability caused by an unstable and unreduced fracture and who were anxious to apply general surgical principles in restoring normal anatomy by means of open reduction and internal fixation.

Hey Groves is certainly one of the remarkable pioneers who anticipated many of our modern means of internal fixation. He did not have the technology of our age at his disposal. It remained for the brothers Lambotte, especially Alain,

* Lecture delivered at the Birmingham Medical School under the auspices of the Institute of Accident Surgery.

to establish the basic principles of internal fixation, understanding that anatomical reduc- tion and interfragmentary fixation could be very successful means of restoring normal function to an injured limb. He was a gifted mechanic, and not only’on bone; even today there are about 40 master violins built by Lambotte to testify to his unparalleled craftsmanship. This was the fertile ground on which Danis could build. If Lambotte was an instinctive biomechanic, Danis was one just as good, but, in addition, he had a sufficiently analytical mind to formulate two basic principles which were sound physically and correct biologically, thus becoming probably the first and most outstanding pioneer of the new field of ‘bio-mechanics’.

He recognized first that any stable fixation depends on compression forces, and he under- stood secondly that bone tolerates compression to a high degree and takes advantage of the stability provided by the compression to unite. The practical corollary was to introduce inter- fragmentary compression by lag screw fixation on the one hand and axial compression along the axis of the bone on the other as the prerequisites of a biomechanically sound internal fixation. He was gratified to observe that bone manifests a specific healing property when rigidly stabilized -the primary bone union called ‘soudure autogkne’ by Danis. He was also aware that bone healing was not the main issue in fracture treat- ment. He clearly pointed out that internal fixa- tion was only worth its price in risk and effort when it can overcome the main disadvantage of conservative fracture treatment : long-lasting immobility on the one hand and loss of physio- logical stress working on the bone and muscle tissue on the other. In his careful personal

244 Injury : the British Journal of Accident Surgery Vol. ~/NO. 4

documentation he was able to prove these points very clearly, and his lag screws as well as his compression plate gained some popularity but not widespread acceptance. Mainly so because he was considered an isolated artist whose results could hardly be matched by anyone else.

Sir Arbuthnot Lane was similarly convinced of the possible advantages of stabilizing bone fragments by open reduction and plate fixation but he certainly did not take advantage of interfragmentary compression to increase stability. Although his system was successful in many cases, others failed to heal. Nowadays we know that these delays in healing were due to distraction, the plate holding the fragment apart.

Quite to the contrary, Eggers wanted the ‘tension-band muscles’ and weight bearing to help in the stabilization of broken bones. He introduced the slotted plate which, by functional compression, was intended to give stability and bone healing. If his system failed in some instances it was mainly owing to insufficient stability because his plate in combination with muscle traction was not able to overcome all variations of torsional, shearing and bending forces during weight bearing. Whereas internal fixation in the treatment of fractures of the long bones was and still is debatable, there was the fracture of the femoral neck which when treated conservatively not only resulted very often in delayed healing or pseudarthroses, but in fact very often heralded death on account of the long bed rest which can be fatal. Internal fixation of the fracture of the femoral neck introduced by Smith-Petersen was therefore welcomed almost immediately by both schools. This fact is very important in the history of internal fixation. It has been one of the most important demonstra- tions that internal fixation should not be looked upon as being the solution to a local bone prob- lem but rather a means of preventing the local and general consequences of the injury by restor- ing normal function as quickly and as completely as possible.

In Germany, Fritz Koenig was instrumental in introducing internal fixation, but the real break- through of internal fixation in combination with early function and partial or total weight bearing was brought about by Kiintscher in 1942 with his medullary nail. At the beginning his method demanded the selection of a nail that would fit the bone cavity, but later on he discovered that reaming the medullary canal would extend the usefulness of medullary nailing beyond the middle third of the long bones. By adapting the bone to

the nail he was able to increase the area of tight contact between bone and nail, thus greatly increasing stability.

With Kiintscher, who died some 3 years ago, we are in the immediate past and, indeed, the present, and here I would like to pay tribute to the contributions of Mr Hicks, who so clearly demonstrated the importance of intrafragmentary stability and bone vascularity for rapid healing and optimal antibacterial defence. Dead bone acts like a foreign body and is extremely prone to infection. Time and again, Hicks has proved that operative stabilization and removal of dead bone is the successful answer to bone sepsis.

So far we have been discussing pioneer work primarily directed at the solution of challenging biomechanical problems. While most of the pioneers mentioned certainly did not overlook the social implications of fractures, it remained for Lorenz BShler to approach fracture treatment from a completely different angle. His monu- mental work in accident surgery was mainly motivated by the socioeconomic aspects of the ever-increasing epidemic of trauma, striking people at their most productive age. He became extremely frustrated to see how little importance the university centres attributed to the treatment of trauma, and of fractures in particular, usually leaving these cases to the youngest men in charge. But BGhler with his aggressive and creative mind was not admitted to the inner sanctum of uni- versity surgery. He succeeded, however, in convincing the national insurance company of his country that the high invalidity rate resulting from fractures could be considerably reduced. Once allowed to concentrate the accident patients in special hospitals or hospital units, it did not take long to prove his point. Permanent damage due to classic fractures of long bones decreased considerably. Bohler led conservative fracture treatment from masterly neglect to careful reduction and early motor rehabilitation, thus reducing morbidity and invalidity consider- ably. He also introduced a hitherto unknown comprehensive system to learn by following up his patients. This allowed him to document his very didactic textbooks which were soon to become world-famous.

In the face of an increasing tendency of other surgeons to use operative means of reduction and stabilization of fractures, he pointed out what catastrophes could result from open treat- ment, which in his time-contrary to the teaching of Danis-very often consisted in combining the disadvantages of both methods-transforming the closed into an open fracture and immobilizing

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it immediately after operation by plaster fixation. Of the operative methods, only Kiintscher’s medullary nailing and Smith-Petersen’s nail fixation of the femoral neck caught Bohler’s fancy. In view of certain failures-mainly infections-he lost a great deal of his enthusiasm for medullary nailing.

One must admit that BGhler was not entirely negative with regard to open reduction and internal fixation. In his long professional life he had to his credit some 20 000 internal fixa- tions, which are to be weighed against several hundred thousand conservative treatments in the hospitals under his supervision. Bohler had as his ‘Anglo-Saxca’ counterparts, Sir Reginald Watson-Jones in Britain and in the USA, Cave of Boston.

In Switzerland, the neighbouring country of Austria, the impact of Bohler’s ideas was felt very clearly but probably not followed carefully enough. In any event, up to 1950 we had a rather unsatisfactory mixture of conservative and operative treatment, with the conservative treatment prevailing-traction for 3-4 weeks with 3 kg for the tibia.1 fracture followed by a long leg plaster and late weight bearing. In the operative approach of most fractures cerclage wiring was used predominantly. A survey by the Swiss national insurance company in the mid 1950s revealed that one-third of all tibia1 fractures ended with some permanent damage. In femoral fractures and forearm fractures the percentage was even higher. Many of the permanent dis- abilities resulted from severe fracture disease- often called Sudeck’s atrophy.

In 1958 a group of general and orthopaedic surgeons met to discuss what could be the reason for the rather poor results of fracture treatment in our country. This group, to which I had the privilege to belong, later on developed into the so called A0 Association for the study, not promotion, of internal fixation. The starting point was the clear recognition that there was a problem and that it might be solved by a careful group effort. We were fortunate to be able to build on the shoulders of two giants whose efforts in fracture treatment had not been combined before.

On the one hand we were aware and impressed by Bohler’s success in designing systems of fracture treatment and his careful follow-up. On the other hand we were aware of the pioneer work of the brothers Lambotte and of Danis. Danis, who was considered a rather isolated pioneer and bone magician who could do things other people could not repeat, was visited by a

man with a well-prepared mind to whom he could demonstrate his long series of successfully treated difficult fractures in forearms and tibias; this prepared mind was Maurice Mtiller’s and he brought us the message. He was able to demonstrate in practice that the internal fixation which deserves this name could be effected in such a way that no external fixation was required, thus allowing-immediate postoperative mobiliza- tion and the partial application of physiological stress to the bone-a most important element in avoiding fracture disease. We were able to reproduce to our full satisfaction the observation of Danis that the absence of instability in a fractured bone reveals a hitherto unknown healing capacity: the primary bone healing by Haversian remodelling, which Danis empirically and only on radiological grounds called ‘soudure autogene’. A double or rather a triple challenge soon became clear to our minds: first, basic research seemed necessary to understand better the reaction of bone to static and dynamic forces; secondly, it seemed worthwhile to use modern technology in improving the implants and instruments developed by Danis; thirdly, a careful follow-up organization to document the clinical group effort was indispensable.

I must resist the temptation to give you a long narration of how during the last 20 years this group has kept together in a rather surprising way, how around 1000 different devices have been designed and how a certain commercial profit made it possible to reinvest in research and teaching.

To be quite frank, we did not anticipate that our instruments could create more than a modest profit which would enable us to keep a small research unit in Davos and a small docu- mentation centre at Berne. After some very tough years, draining quite a lot out of our pockets, the easy years arrived and allowed us to equip rather generously those centres in Davos and Berne and provided some additional research money for other scientific institutions. Competi- tion has since risen considerably and I am afraid that the golden age is over because by now internal fixation is ‘in’ and therefore it is com- mercially rewarding to produce instruments and implants for this method-probably too much so!

Instead of a broad narration I would mention just four arbitrarily selected points which may illustrate how things develop. First, I would like to mention the multiply injured patient. In such cases early internal fixation very often constitutes the only means of making the patient amenable to optimal general and respiratory care. Such a

246 Injury : the British Journal of Accident Surgery Vol. ~/NO. 4

patient may illustrate all the methods worked out for stable internal fixation, screw fixation, plating and medullary nailing, and points to the necessity to give a multiply injured victim immediate total care. Coordination of local stabilization of long bones with general care is extremely vital in these cases. Here lies one of the main problems in deciding who should handle the patient with multiple injuries and by what means. We shall come back to this later on.

Another interesting story concerns the develop- ment of the compression plate. Danis had first devised a compressor device welded to the implant itself. Mtiller then developed the remov- able compressor and this seemed a very elegant solution with none of the metallurgical drawbacks of combined implants. However, using round- hole plates with a very precise geometry created new problems. Even a slight eccentricity of screws placed after the initial compression procedure will abolish all compression or even create distraction, as shown by a group of A0 surgeons who were asked to insert compression plates on an experimental bone according to their usual way of doing this. Another drawback was the rather large exposure required for appli- cation of the compressor. The development of the dynamic compression plate (DCP) was the response to this problem, but it required about 6 years for its experimental and clinical testing because even a group of friends and critical intellectuals hates to change a winning horse in spite of the fact that the other one may look better! The increased versatility and the avoid- ance of distracting forces have since paved the way for the DCP.

One gratifying spin-off of the spherical gliding principle underlying the dynamic compression plate was the creation of specific plates for maxillofacial surgery. There we are faced with the problem of having to fix the bone not on its tension side but on its bending side. This is a most unfavourable complex of factors and is avoided in long bones at all costs. The maxillo- facial surgeons of Professor Spiessl’s group had the good idea of changing the geometry of the screw hole in such a way that the inner hole would be used for axial compression and the end hole, placed at right angles, would serve to create a rotatory force closing the fracture gap on the opposite cortex. This then, in maxillo- facial surgery, allows the same result as in the long bones-immediate function after precise restoration of anatomy.

Another chapter in this history concerns the skeleton of the hand. There is probably no other

part of the body more susceptible to fracture disease than the hand if it remains painful and immobilized. Thanks to the miniaturization of the implants, these fractures have become amen- able to the same principles of care--early stabili- zation and immediate postoperative mobilization. In fact, the number of cases of so-called Sudeck’s atrophy of the hand has greatly diminished.

One very valuable reaction to the ‘aggressive Swiss internal fixation gospel’ has been the intro- duction by the conservative school of early weight bearing and some function, thus avoiding one important cause of fracture disease-lack of physiological stress to the bone. Colonel Dehney as well as Sarmiento have introduced early weight bearing in long-leg and even in lower-leg casts. General experience would tend to show that this is actually very beneficial in more or less stable fractures, but is quite questionable in unstable ones. In actual fact I think that both schools will have to learn from each other, especially with regard to tibia1 fractures, so that the patient may get the best of each in every particular case.

Not everything in accident surgery is fractures or injuries to the locomotor system. The injury to the body as a whole and the consecutive homoeostatic disorders are just as much as or probably more of a challenge than the fractures. As one practical example I would like briefly to mention the spectacular progress made in the prophylaxis and treatment of the acute post- traumatic respiratory failure. We now know that the beginning of such a failure is very insidious and cannot be detected clinically but only by careful measurement of the arterial (and venous) blood gases. It has become obvious that the increased tendency of the platelets to agglutin- ation and the ever-present tendency of the lungs’ alveoli to atelectasis can be the starting point of a vicious circle between hypoxia and disorder of the coagulation system. When manifest, it is very difficult to treat. With aggressive respiratory support of the recently injured it is largely preventable. Since we consider every multiply injured patient to be in respiratory failure until proved otherwise and treat him aggressively with prophylactic positive end expiratory pressure (PEEP) along with aggressive volume substi- tution, pulmonary insufficiency and fat em- bolism have now become extreme rarities. This progress was drought about by people interested not in chronic pulmonary insufficiency but in the acute pulmonary distress-mostly anaesthetists. They had to see the problem, understand it and- together with responsible surgeons-trust their

Allgawer : Accidenlt Surgery 247

own results before inflicting on such patients the additional trauma of prolonged intubation. As so often, only interdisciplinary contact made this progress possible.

Another interesting aspect is intravenous hyperalimentation, which has become so import- ant in certain severely injured patients. Since the famous Dr Gamble of Boston found out that glucose in excess of 100 g/day would not diminish the nitrogen loss, administration of larger quantities of glucose was said to make no sense. The official dogma was that parenteral nutrition using primarily the easily available carbohydrates was impossible. Jonathan Rhoads, without any very good reasons, simply refused to believe this dogma and, at his instigation, his collaborator Dudrick took up the problem in the dog labora- tory. In an unparalleled devotional effort, Dudrick was able to demonstrate that puppies from the same litter could be divided in two groups, one raised normally the other exclusively by the intraveenous route using glucose as practically the only calorie source. Both groups of puppies developed normally. Thus Dudrick was able to prove that apart from essential aminoacids, fatty acids and vitamins, glucose could serve as the unique calorie source, and in fact this discovery soon found a broad clinical field of beneficial application.

PROGRESS AND SPECIALIZATION In all the progress mentioned up to now, be it in fracture treatment, in respiratory physiology or hyperalimentation, people without narrow specialization hLave been extremely instrumental. The one prerequisite for producing progress and understanding where progress lies is a prepared and open mind. Very often the narrow specialist is inclined to be extremely critical of new ideas and probably rightly so, because these need to be screened by other people!

If we come to the conclusion that specialization is no prerequisite for progress, we must admit that it is indispensable for service to the com- munity in everyday surgery. However, in this more pragmati’c aspect of specialization there is a certain ambiguity of which we should not lose sight. Certainly nobody disputes the necessity of specialization in surgery because there is no man able to encompass the breathtaking progress in the various surgical fields of this century. I would like to submit, however, that there are some specialties which develop quite naturally and others which are probably problematical. ‘Natural’ specialties have evolved from anatomi- cal and functional bases-for example, urological

surgery, neurosurgery and orthopaedic surgery- or on general technical principles such as those of plastic surgery.

More of a problem are the specialties which somehow reintroduce the ‘surgical omnispecia- list’, when, for example, dealing with all systems in a patient of a given age, be it paediatrics or geriatrics. By the same token, specialization based on some kind of disease, such as oncology, is also doubtful. This now also holds true for a specialization with trauma as the common denominator.

But before going on to trauma in greater depth, another aspect of the specialty question should be mentioned briefly. It is related to what could be called ‘limits of growth’ in medi- cine. Recent years have seen the health costs increase more rapidly than the growth of the gross national product. In many developed countries it has gone from 5-g per cent of this product. This does not as yet seem out of pro- portion, considering the importance of health care, but it does understandably increase the concern of a variety of social systems. Here we are faced with true limits of growth, making it necessary to establish priorities in ‘allocating available means. The perspectives shown to us by the famous Club of Rome, concerning the rapidly growing world population and the consequent decrease in natural resources, cannot be neglected. We may all get a smaller share of the riches of this world and poorer service in many respects. The revelation that we cannot afford everything which is theoretically possible has already affected our hospital development. It will put an end to what in its extreme could be called ‘specialization neurosis’ on the part of the public and ‘specialization snobbery’ on the part of the medical profession.

There are in fact two main motives for speciali- zation. One is very positive and relates to interest in and devotion to a special problem. As an example, I would like to mention the surgeon who is fascinated by the problems of central dislocation of the hip and wants to find means to re-establish normal anatomy in this difficult joint fracture. He will elaborate a grading of such a fracture, he will be more successful in treating it and may accumulate a patient popula- tion which reflects his interests. Such an indi- vidual specialization based on enthusiasm is quite in order. It does not of necessity exclude a broader clinical activity.

The more frequent motivation of specialization may look like modesty but very often it is quite simply based on laziness. It is the restriction of a

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surgeon’s activity to a field which can be handled more or less easily with no undue interference with one’s personal extra-professional life. We are concerned to learn that there are many com- munity surgeons in the USA whose surgical work consists of three HEs per week, HE standing for ‘Hernia equivalent’.

We must keep in mind that superspecialization is one of the main reasons for the increase of hospital staff. This is all the more important as salaries constitute about 75 per cent of any hospital budget. All these facts tend to show that specialization in surgery should be limited to anatomical and physiological entities with the probable exception of paediatric surgery, which, however, should mostly consist of general surgery in children and remain in close contact with the organ specialists wherever the classic specialties are concerned.

Does trauma justify or necessitate the creation of a surgical specialty in itself? Basically we have four ways of solving the problem:

1. General surgery to be responsible for trauma in view of the fact that quite an important aspect of trauma concerns visceral surgery and the intensive care service.

2. Combined responsibility of general and orthopaedic surgery. Multiple injury and visceral trauma are the responsibility of the general surgeon, whereas the locomotor system is treated by the orthopaedic surgeon-a solution which is commonly accepted in Anglo-Saxon countries and to a certain degree also in South America.

3. ‘Fractures as of common interest’ to general and orthopaedic surgeons with no exceptions. This has been my experience for the last 20 years and I am deeply convinced of its usefulness but I will have to come back to it in a moment.

4. Traumatology as a specialty separate from general and orthopaedic surgery-a solution applying in Austria and partially also in Germany. (A concept which, I believe, has also been instrumental in introducing the Birmingham Accident Hospital with all its great pioneer merits.)

Seen from the angle of the patient load one is indeed tempted to feel that traumatology is justified as an entity. In Switzerland over 5 years we had 800 000 significant accidents to treat per million workers. That meant that 1250 hospital beds were required per million workers.

One must also admit that modern surgery in its larger sense has not as yet lived up to the challenge of trauma. Dr Fitts in his Scudder oration in 1970 rightly pointed out that in the

treatment of accidental injury the gap between what can be done and what is being done is wider than for any other disease.

Why then do I feel that accident surgery should not be an independent specialty but should be under the leadership of general surgery and in close contact with orthopaedic surgery? To point out the obvious, accident surgery is concerned with trauma to all organ systems of all ages. To put it bluntly, it treats the skin and its whole contents. By this very fact it cuts across our neatly conceived system of specialization based on anatomical areas. As Sir Frank Holdsworth put it in 1969, ‘to train a specialist in the treatment of trauma, is to train him as a specialist of all specialties’.

Furthermore, it has to be stressed that trauma is not confined to diagnosis and surgical repair but has tremendous ramifications in the field of pathophysiology, such as resuscitation, circu- latory failure, sepsis, damage to all possible organs and last, but not least, disturbance of the locomotor system and the vascular tree. The bulk of the practical work, however, con- cerns the abdomen and thorax, the locomotor system and intensive care.

It is true that trauma is a great concern to modern society and as a social problem consti- tutes a special entity. For optimal trauma care people with a very broad background and able to act as interdisciplinary team leaders are required. Thus I would go as far as to say that accident surgery is certainly an intellectual discipline but by its very interdisciplinary nature should never be an isolated specialty. In Germany and Austria there is a certain tendency to reinte- grate traumatology into general surgery because otherwise accident surgeons may find themselves in the unhappy position of mini orthopaedic surgeons. On the other hand it is not possible- as was attempted in Germany-to exclude orthopaedic surgeons from handling acute trauma to the locomotor system. Therefore, intellectually, a liberal solution which considers fractures a common interest between general and orthopaedic surgery would be the most logical and topical. But could it work in practice?

In Switzerland we are extremely parochial in our political organization and parallel with that we have many different solutions in the medical field. We have one university centre specializing in traumatology, apart from orthopaedic surgery, we have one centre with a surgical department with orthopaedic surgery integrated into it and being responsible for the fractures, we have one university organized in a departmental way,

Allgawer : Accident Surgery

where general surgery and orthopaedic surgery take turns in fracture treatment and where the multiply injured patient comes under the general surgeons. How does this work out, seen from close by ?

Our hospital system outside the university is also as parochial as our political system, involv- ing a large number of smaller hospitals, which in part is inevitable because of the isolated position of certain mountain valleys. These smaller regional hospitals cannot afford more than two full-time surgeons and they should be able to take turns for any kind of emergency surgery, which is essentially equally distributed between visceral surgery a.nd trauma. It is most important to know that once they are trained accordingly, surgeons are ver:y able to cope with most emer- gency situations. They have to know their limits and collaborate with the larger centres.

It would seem to me that every country must solve the problem of dealing with trauma accord- ing to two premises: one is to apply the best possible care to -the greatest possible number of patients and the other follows the fact that we cannot change hospital systems easily and so have to provide the existing hospitals with the surgeons they need. Owing to our parochial organization, we in Switzerland need very broadly trained general surgeons., and it is our practical experi- ence that within the relatively limited catalogue of diseases to treat, they do very well.

How does this influence the structure of the large training centre? I think in a very positive way, because nobody who does not have a permanent position is allowed to become a superspecialist to the exclusion of any other activity. This is fairly simple to achieve by keep- ing everybody-up to the registrar level-re- sponsible for all emergencies. High specialization

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at the registrar level is both unnecessary and dangerous because it may set the stage for a life of frustration if no specific appointment follows.

If we do not envisage traumatology as a specialty in itself this does not imply that large centres should refrain from having trauma units. These units, however, should be fully integrated into the surgical department and included in the programme of surgeons in training. A short period in such a unit will never be adequate for the acquisition of proficiency in the field of trauma. Such expertise needs constant exposure to the various emergency situations and therefore the general surgeon should be constantly involved in the emergency service throughout his training, thus becoming able to assume increasing re- sponsibility and finally being able to take on the responsibility of a regional hospital together with one or two more colleagues, if opportunities or intellectual inclinations do not suggest or allow a career in a large training centre.

In conclusion, I really feel that we need both: a strong healthy general surgery and a strong healthy orthopaedic surgery. Let us have a general surgery with responsibility in visceral surgery, trauma and intensive care and a strong orthopaedic surgery with its many assignments on the locomotor system in disease and trauma and let us consider fractures a common interest of both great specialties. If there is merit in what the A0 has been doing, it is the fact that whatever progress has been made was based on a close collaboration between open minds in general surgery and in orthopaedic surgery. To repeat my deep conviction once more: accident surgery is certainly an intellectual discipline and a worthwhile challenge with many facets, but by its very interdisciplinary nature should never be an isolated specialty.

Requestsfor reprints should be addressed to: Professor M. AllgGwer, MD, Kantonsspital, 4004 Bask, Switzerhd.