Surgeon of the Century: RIP

Maurice Edmond Müller's imagination and invisible hand guides every orthopedic surgeon performing surgery today.

His work described below may have made him the most influential surgeon of the 20th century.

“Surgeon of the Century”

Maurice Müller, M.D.The international organization of orthopedic surgeons (SICOT) recognized Dr. MÏ‹ller’s unique talents and contributions to science by naming him “The Orthopedic Surgeon of the Century” a few years ago.

This "Surgeon of the Century's" spirit passed on May 10, 2009. He died peacefully and in the presence of his family at his hometown of Bern, Switzerland, in his 92nd year. He departed to join his wife Marti who had recently passed away.

Dr. Müller's influence on orthopedics cannot be overstated. Writing this piece was an exercise in humility as we began to understand the breadth and depth of this surgeon/scientist’s contributions to patients and colleagues.

We reached out to orthopedic leaders and asked them to describe Dr. Müller's impact on orthopedics and why he was worthy of the SICOT title. They kindly agreed to share their thoughts with our readers.

AO Founder

Bruce D. Browner, M.D., FACS, called him the architect of modern fracture surgery as he presented Dr. Müller for an Honorary Fellowship in the American College of Surgeons (ACS) a few years ago.

Browner told the ACS that prior to Müller's revolutionary efforts, fractures had been treated for decades with plaster and traction.

Laboratory for Experimental Surgery
at the "Obere Strasse" in Davos

An excessive emphasis on rest, thought necessary for boney union, led to frequent joint stiffness and muscle atrophy. In 1950 Dr. Müller visited Robert Danis in Brussels, Belgium. Danis had achieved stable osteosynthesis through plates with compression devices. His methods allowed the patient immediate mobilization of the injured extremities and prevented the stiffness and disability, which were seen with traditional methods. These concepts formed the basis of the system of fracture treatment that Maurice Müller subsequently developed, ” said Browner.

Added Browner, “In 1958, the dream of organizing an Association of Internal Fixation was realized, with the formation of the Die Arbeitgemeinschaft für Osteosynthesefragen or AO, which is roughly translated into the Association for the Study of Internal Fixation (ASIF).”  

Maurice E. Müller pictured on his 90th birthday
at the plaque unveiling in Biel to honor the AO Founders

Jesse Jupiter, M.D., Chair of AAOS' International Committee and Chief of the Hand and Upper Extremity Service in the Department of Orthopaedic Surgery at Massachusetts General Hospital, wrote us:

While a world-class hip surgeon, [Dr. Müller's] real impact on patients around the world was his evolution, with several other Swiss surgeons, to develop the AO which revolutionized not only the treatment of fractures but also traumatic injuries as a whole.

He was instrumental in developing surgical education with hands-on training, decades in advance of others, and clinical and basic research into traumatic injuries to the musculoskeletal system which has culminated in a world renown[ed] research center.

Last but not least, in the era of evidence-based medicine, [Dr. MÏ‹ller] was really among the first to establish documentation as the foundation of understanding the outcomes of the efforts of his colleagues in the AO.

I really believe that his impact worldwide far eclipses Charnley or just about any other orthopaedic surgeon in the 20th century regarding the improvement in the treatment of musculoskeletal injuries and reconstruction to become the standard of care for most countries in the world.

Dr. h.c. mult. Hansjörg Wyss, Executive Chairman of Synthes, wrote for our readers this about Dr. Müller:

Maurice Müller was a personal friend of mine and a great spiritual and entrepreneurial mind.

Those who knew Maurice and were awed by his brilliance and amazing contributions will certainly miss him, but they will know that his legacy lives on in the millions of patients who have been treated according to the AO principals he was central in creating.

He was one of the true icons of modern orthopedics, having made a profound and lasting impact on fracture treatment, total joint replacement, and corrective and reconstructive surgery.

He was a teacher and mentor to countless orthopedists all over the world. Without him the AO would not have achieved what it did.

Biomet Founder Dane Miller, Ph.D., wants our readers to know:

Prof. Maurice Müller was a true pioneer in total joint replacement and trauma. His scientific approach to clinical and data collection set a standard never before achieved by a clinician. He will be sadly missed in the field of orthopedics.

Müller’s Epiphany

Maurice Edmond Müller was born in the last year of the Great War, 1918, in a village that sat on the border of the German and French speaking Swiss areas. He received his medical degree in 1946 and described his moment of epiphany in an undated interview with Maitrise Orthopedique.

From the age of eight, my only ambition was to become a surgeon. I should mention that my father had been a surgeon in the States, but had to give up his career to live in Switzerland, because his wife did not want to move to the USA.

At the age of 20, after some psychometric tests, my choice of profession was approved by the experts. They told me that their tests had identified a three-dimensional gift, which could be used to advantage in orthopaedic surgery. After my state medical examinations in 1944 I worked as a locum GP for three weeks.

Two patients made a particular impression on me. The gait of the first was normal. He told me he had fractured his femur during the war between Finland and Russia in 1940 and that a German military surgeon named Küntscher had operated on him at the front and inserted a long nail. Less than two weeks later he was walking comfortably with just one stick. At that time, this was amazing. He had only come in to find out where he should go to have his nail removed.

The other patient was having trouble walking with a stick. When I suggested that he must be in great pain he replied: “No, I am extremely well. Two years ago I had a Leveuf hip arthroplasty. Before that I had been in excruciating pain both day and night; my hip had seized in a very poor position. It’s true that my hip is now unstable and I can’t walk without a stick, but at least I can move it and it doesn’t hurt. This operation has changed my life.”

Two weeks later I had decided to devote my surgical career firstly to fracture fixation and secondly to hip surgery. I was convinced that one of these fields would eventually revolutionize orthopaedic surgery. During the next 15 years, they became the most important aspects of orthopaedics, and my workload increased accordingly.

Collaboration With Industry

Sir John Charnley, M.D.

Dr. Müller built on the pioneering work of Sir John Charnley of Manchester, England, and began to develop implants for prosthetic replacement of arthritic hip joints. Based on his earlier work with AO/ASIF, he believed that a close collaboration between surgeons, scientists and industrialists was indispensable for successful development of surgical devices and implants. His work with Robert Mathys and the Sulzer organizations in the early 1960s resulted in the first manufactured stainless steel and later chrome-cobalt prosthetic hip implants.

This embrace of collaboration between industry and surgeons was noted in the Maitrise Orthopedique interview:

I noticed in 1951 that Van Nes and Danis were using a number of instruments which they had developed themselves. So, in 1951 I arranged for a number of technicians and small manufacturers to make some spike retractors, a set of chisels and elevators, Schanz screws, twin external fixators, etc.

Eventually, a stainless steel importer recommended a very capable technician who had never made surgical instruments before, but who would certainly be able to understand my ideas. This was Mr. Mathys, who agreed not to sell my instruments until they had been evaluated for 4 years. I immediately decided to work exclusively with him. This was in April ‘58 and in November of the same year, when the instrumentation had been completed, we founded AO/ASIF, which was to subject the devices to systematic testing for more than 3 years.

When the Maitrise Orthopedique interviewer asked about how he managed the financial aspects of the sale of his instruments, he replied:

In 1958 we decided not to market the equipment. It was sold only from 1963 onwards, that is, after the publication of our first book on fracture fixation according to AO/ASIF principles. Like the founder members of AO/ASIF, all those who wanted to become members of our association had to sign the charter, which required them to keep records of all patients undergoing surgery, and at the same time to waive any remuneration for the current and future equipment.

All receipts from the sale of instruments went from the outset into the public company Synthes, which operated as a charity without remuneration of any kind. No dividend was paid and all the money received was to be used in research and education.

Synthes was created before anyone had had the opportunity to buy these tools and implants. We initially allowed the hardware to be sold only to those who had attended a theoretical and practical AO/ASIF course. The first of these training events was held in December 1960. At that time there was, throughout the world, a wide variety of instruments; and in particular so many different screws that it was necessary to have an incredible range of screwdrivers to hand when an implant was being removed. Our plan was to produce a range of hardware with a basic screw and a basic screwdriver. The rest you know. Our hexagonal socket-head screw was to be used all over the world.

(To read the entire transcript of this remarkable interview, please click here.)

Eventually, Dr. Müller and his associates founded Protek AG, a company dedicated to the sale of prostheses and instruments manufactured by Sulzer and Mathys. The royalties and profits of Protek were given for research, education and documentation through a foundation called the Protek Foundation.

Enduring Foundations

In 1974, the Protek Foundation was renamed the Maurice E. Müller Foundation for Continuing Education, Research and Documentation in Orthopaedic Surgery.

In 1983 the M. E. Müller Foundation of North America (MEMF NA) was established to foster postgraduate education, research and documentation among American and Canadian orthopedic surgery graduates. The foundation has funded advanced postgraduate education of qualified candidates through fellowships at approved centers in Europe and North America.

The Foundation has collaborated with the American Hip Society, the American Academy of Orthopaedic Surgeons and the SICOT Commission on Documentation and Evaluation in reaching a consensus on terminology and clinical and radiological evaluation.

Teacher

Daniel Berry, M.D., was a fellow with Dr. Müller for six months in 1990. Berry is also AAOS’ Second Vice-President and the Department Chair of Orthopedic Surgery at the Mayo Clinic. Dr. Berry wrote us:

"He was a man with a remarkable combination of gifts: he was a gifted and artistic surgeon and he also had tremendous intellectual capability.

He was excited about and understood ideas extremely quickly and was always thinking about how new information could be used to move orthopedics forward.

Dr. Müller (left) pictured at the first AO Davos course in 1960

He was a great educator and understood that rigorous education in surgical principles could lead to better results with new technology. An example is the success of the educational courses built around the principles and devices for internal fixation he helped develop with the AO. He was a charismatic man, and understood that it was important to engage surgeons and interest them in an idea to successfully disseminate information. 

He also understood the importance of documentation of results and evaluation of results to move orthopedics forward. He spent a lot of his career carefully documenting and evaluating the results of new technologies in which he was interested.

He was a phenomenally hard worker, and constantly had his mind engaged in the questions which interested him. He demanded rigor in all that he did, both from himself and those around him.  An example was the detailed preoperative plan he made for every case he performed.

Finally, he was a remarkable philanthropist. He established a number of important foundations which have contributed greatly to the profession of orthopedics and to the arts.

Other Highlights

Here are some other highlights of Dr. Müller’s accomplishments:

Original M.E. Müller Straight Stem
Photo courtesy of Zimmer

• Invented the "Straight Stem" hip and instrumentation in 1977 that is still sold by Zimmer today and is inside over 1 million patients
• Performed over 20, 000 surgeries (4, 000 hip replacements)
• Founding Father of AO with four fellow Swiss surgeons
• Wrote 250 scientific papers
• Received 14 honorary degrees from universities around the world
• Developed the most comprehensive system of classification (The Müller AO Classification of Fractures in Long Bones) in 1990 for fractures and orthopedic surgery outcomes, which became the "universal language for orthopedic surgeons."
• Lead author of the 409-page "Manuel der Osteosynthese: AO-Technik" published in 1977

A Noble Life

As AO leaders informed their friends of Dr. MÏ‹ller's death, they wrote:

A life full of achievements

Biel is not only the birthplace of the AO, but is also where Maurice saw the first light of day in 1918. By 1944 he had graduated from medical school in Lausanne and a combination of restlessness and adventure saw him volunteer for medical service in Ethiopia [where he married Marti] which helped to round his medical education.

In May 1950 he made the pilgrimage to see Robert Danis in Belgium. The techniques he witnessed there formed the basis of the future AO technologies Maurice would help to systemize. Word of his astounding technique in the operating room led a group of friends to coalesce around Maurice, men who would go on to form the AO. Maurice was well known for his love of magic and would often entertain using sleight of hand. However, probably his greatest trick was when he conjured up, with the help of the late instrument maker Robert Mathys, a full range of AO implants within two short years.

Possibly no one else embraced the AO philosophy of allowing others to learn from your knowledge more than Maurice did. To ensure a continuous flow of money for AO activities, he donated all of his intellectual property rights for the good of the AO. He showed his heart for others again in 1967 when he founded the M E Müller Foundation and also endowed chairs of orthopedic surgery in several countries. The museum in Bern dedicated to the famous Swiss born painter, the Paul Klee Zentrum, was only made possible thanks to the generosity of Maurice and his late wife Marti.

His name will live on in the Müller AO Classification of Fractures in Long Bones, which was released in 1990 and has become a worldwide standard.

They conclude:

"What a noble life he lived."

Dr. Müller’s funeral took place in the Berner Münster (Cathedral of Bern) on Monday, May 18, 2009.

Those who would like to express their condolences please send them marked “Maurice E. Müller condolences” to: AO Foundation, Clavadelerstrasse 8, 7270 Davos, Switzerland, or by email to condolences@aofoundation.org. AO will collect all of your tributes together and forward them to his family in the name of the AO Family.

Godspeed Dr. Müller

As a publication, we have the privilege of a front-row seat to the remarkable work done by orthopedic surgeons, nurses, surgical teams, engineers, scientists, and industry pioneers every day. On occasion we get to catch a star and pay honor to a Founding Father of modern orthopedics.

A noble life indeed. Godspeed, Dr. Müller. If someone “up there” needs surgery, we’ll know who will be holding the scalpel and reporting the results.