AO Dialogue 2 | 2013

Where Science meets Clinics 1-3

My view, James Kellam 3

AO President’s interview 4

AO Dialogue–SIGN fellow 5-7

Berton Rahn Prize Winner 8

From the AO Clinical Divisions 9-13

From the AO Institutes 14-20

AO Dialogue 2|13The newsletter for the AO community

The annual “Where Science meets Clinics”

symposium provides an open platform to

foster exchange and networking between

research, clinics and the healthcare indus-

try to stimulate successful clinical trans-

lation of innovative science. This second

edition of the symposium held in Sep-

tember 2013 at the Davos Congress Cen-

ter was jointly hosted by AO Exploratory

Research (AOER) and the AOTK System.

Michael Schütz (AU) and Sandra Steiner

(CH) welcomed over 100 participants

comprising scientists, clinicians, and rep-

resentatives from the healthcare industry

and regulatory agencies involved in the

clinical translation of bone, interverte-

bral disc and articular cartilage repair and

regeneration strategies. The event com-

menced with a brief introduction to the

AO Foundation, provided by AO Founda-

tion President, Professor Jaime Quintero

(CO). After three full days of presentations

and extended panel and podium discus-

sions, the participant feedback ranked the

symposium extremely highly, sending out

a clear message that the AO must continue

hosting this symposium regularly. This

notion is fully supported by the AOTK

System—a first-time official partner of

the symposium.

[ continued on page 2 ]

The whys and wherefores of advanced orthopedic tissue engineering

were explored at this annual symposium

Where Science meets Clinics 2013

Table of contents

bThe symposium 2013 at a glance

Global experts shared this platform to talk

about the current procedures, achievements,

and challenges regarding the latest strategies

on the symposium’s core topics:

• Cell Therapy and Responsive Materials

in Bone, Intervertebral Disc and

Articular Cartilage Repair

• Barriers and Strategies for Translation

of New Tissue-Engineered Materials to

the Clinic

This year, the unique symposium format had

plenary and parallel breakout discussion groups

to encourage participants to actively contribute.

Presentations

In the Cell Therapy session keynote lectures were

delivered on ‘Cell therapy in intervertebral disc

degeneration’ by Gunnar Anderson (US); on

‘Technovolution of cartilage repair’ by Daniel

Saris (NL); and on ‘Cell therapy for bone repair

and regenerations’ by Hamish Simpson (UK).

These keynote lectures were followed by several

oral presentations from a diverse group of in-

vestigators. The session was chaired by Brigitte

Vollmar and Tim Pohlemann (both from DE). The

level of involvement and interaction was reflected

in the many questions fielded by these experts.

The Responsive Materials session, chaired by

David Eglin (CH) and Robert McGuire (US),

featured keynote lectures on ‘Merging micro/

nanoscale technologies and advanced bioma-

terials for tissue regeneration and stem cell

bioengineering’ by Ali Khademhosseini (US);

‘Molecular strategies for adaptive materials’ by

Philip Messersmith (US); and on ‘How mecha-

nobiology inspires new approaches on the path

from basic sciences to the clinics’ by Viola Vogel

(CH). These lectures, too, were followed by oral

presentations. Emphasis Poster Presentations

on cell therapy and responsive materials in

bone, cartilage and disc repair marked the end

of the second day.

Parallel Breakout Panels

On both days, the presentations were followed

by three parallel breakout discussion sessions.

Each panel included a keynote speaker, AOER

and AOTK members, Clinical Research Program

partners and an expert advisor. The breakout

Where Science meets Clinics 2013

AO Dialogue 2|13 2

sessions stimulated all participants to contribute actively and led to further

questions and potential solutions so as to enhance clinical translation. The

panel discussions will be summarized in a series of papers to be published

in the eCM Journal (published by the AO Research Institute Davos).

The final day of the symposium featured an interactive session on Barriers

and Strategies for Translation chaired by Michael Schütz and Daniel Buch-

binder (US). Chris Evans (US) presented an interesting view on ‘An academic

biologist’s perspective on research translation’. Mats Brittberg (SE) spoke

on ‘Cartilage repair; barriers and strategies for translation’s highlighting

that the new cell regulations are a big roadblock today. Anthony Ratcliffe

(US) spoke on ‘Translating concept to product for articular cartilage repair:

barriers and strategies’, mentioning that articular cartilage repair remains

a major clinical opportunity requiring a comprehensive and coordinated

approach. ‘Regulatory perspectives on the translation of chondrocyte im-

plantation products’ was Lennart Akerblom’s (SE) topic. Interesting and

interactive podium discussions took place among the participants, keynote

speakers, and the podium members: Jörg Goldhahn (CH), Henning Madry

(DE) and Christian Matula (AT). The discussions were moderated by Nor-

bert Suedkamp (DE). The main message supported by all was the need to

create synergetic environments between clinicians, scientists, industry and

regulatory experts.

Michael Schütz and Sandra Steiner closed the symposium expressing their

gratitude to the participants and the organizing team—and received an

overwhelming positive acclaim on the success of Where Science meets

Clinics 2013.

My view

James F KellamEditor-in-Chief

[email protected]

The “Gemeinschaft”

We all know that Arbeitsgemenischaft für Osteosyn-thesefragen is the original german name of the AO Foundation but what does this word (Gemeinschaft) have to do with the work (Arbeit) of fracture fixation (Osteosynthesefragen). In 1912, a social scientist defined the word Gemeinschaft as a community based on values and beliefs. This community is built upon a division of labor among people with strong personal relationships within families and having relatively simple social institutions. The individu-als within this community have a direct sense of loyalty to the Gemeinschaft and hence no rules or appointed leaders are necessary. This described the original community of AO surgeons—each member had a defined work responsibility and all worked toward improving patient outcomes from fracture care.

Looking at the AO now, one can see that it is similar albeit much larger. It consists of numerous strong people and relationships, its Trustees and Officers, dedicated to an organization which they believe can achieve more than any single individual, in improved patient care. This organization currently comprises four families (AOTrauma, AOSpine, AOCMF and AOVET) each strong in their own right but they understand that cooperation and responsibility to the organization is more important than their clini-cal “families”. Finally, the organization is supported by an infrastructure of research, documentation, technical development, and a worldwide regional and central administration.

The AO’s leadership is evolving into that of a Gemeinschaft as the AO leaders speak for their representative bodies, which allow for consensus decision-making in the form of platforms and rep-resentative boards. Thus the power of the AO is not in fixing fractures but in its community of surgeons who put the vision and mission of the AO above their personal and nationalistic concerns.

continued…

AO Dialogue 2|13 3

Many leading AO surgeons have completed an AO fellowship, what about the next generation?

Doing a fellowship in a renowned clinic or university hospital has been the

gateway to the AO for many of us. The Davos Courses participants will discover

the different AO fellowship programs ranging from clinical fellowships with one

of our clinical divisions (AOTrauma, AOSpine, AOCMF and AOVET), to clini-

cal research or pre-clinical and translational research fellowships at one of our

institutes (AO Clinical Investigation and Documentation and the AO Research

Institute Davos respectively). As a clinical fellow, which I was, you get exposure

to a surgeon’s day-to-day working life in a hospital, and you get an AO mentor

(as do fellows in our institutes). Many leading AO surgeons did AO fellowships

and stayed in touch with their mentor, which has had a very positive impact on

their career. I did a fellowship in Augsburg, Germany, in the early eighties and

it created a connection to the AO which has evolved and grown throughout my

career culminating in this presidency.

It is very important to the AO that we build close relationships with the young

surgeons and scientists who are the future of this organization through fellow-

ships. An AO fellowship offers both an excellent education opportunity and

participation in a community of dedicated and talented surgeons and scientists.

Relationships and possible alliances with scientific associations are important to the AO, what has been achieved to date?

In the last years AOSpine has had great success in building alliances in particular

with the SRS (Scoliosis Research Society) and AO Foundation has pursued a

mutual alliance with the AAOS (American Academy of Orthopaedic Surgeons).

AOTrauma has continued to develop ongoing relationships with leading Euro-

pean orthopedic associations—EFORT, ESTES and DGOU and in 2013 formed

an alliance with the Spanish orthopedic association, SECOT. Reputation and

the recognition of academic values of the AO are important elements in these

relationships

One of our most significant developments this year was in Beijing with the

Chinese Orthopaedic Association (COA), which is the culmination of an as-

sociation that has been growing over the past three years. Building on the

success of the clinical division’s (AOTrauma and AOSpine) days at the annual

COA congress, this year the AO Foundation also delivered an educational

event instructing surgeons on basic principles of hip and knee arthroplasty

surgery (AORECON Day at COA). All three of these events were attended by

more than 1,000 delegates.

An interview with AO President Jaime Quintero

AO Dialogue 2|13 4

Impressions from the SIGN conference SIGN Fracture Care International was started in 1999 with the mission to create

equality of fracture care throughout the world. More than 5,000 SIGN surgeons

have played a role in furthering the innovations and treatment of the poor.

The Eleventh Annual SIGN International Conference was held in Richland,

Washington (US) from September 11-14, 2013 with keynote speaker Dr Andrew

Schmidt President of the Orthopaedic Trauma Association (OTA) who discussed

treatment of fractures of the proximal femur and infected fractures. A selection

of the many highlights is detailed below.

Long bone fractures

Comparisons of treatment of long bone fractures using SIGN nails and hollow

nails were discussed. A ten year case series of humerus, femur and tibia fracture

treatment was presented by Hilario Diaz from Southern Philippines Medical

Center, various patterns of fractures of long bones from Regional hospitals in

Nigeria as well as comparative studies of SIGN solid versus hollow nails were

shown. Kristopher Tolosa discussed a comparison of the squat and smile picture

compared with X-rays in evaluating bone healing. Lew Zirkle led a workshop

discussing the SIGN technique with new modifications.

Pelvic and hip

Technical tips and tricks for avoiding malreduction on proximal femur fractures

were demonstrated by Professor Andrew Schmidt from the University of Min-

nesota. Intertrochanteric and neck femur fractures using Sign Hip Construct

demonstrated excellent stabilization without using C-arm. “The pelvis is a place

to work not to play” was the conclusion of a pelvic fracture symposium discussing

pre-operative planning, approaches and fixation of complex pelvic fractures led

by Professor Kyle Dickson, Pierre Guy and Duane Anderson.

Pediatric fractures

The newly launched SIGN pediatric fin nail, which is flexible with a distal fin,

has a healing rate with minimal complications. Raymond Liu described the

treatment of acute physical injuries in the lower limb. New SIGN implants were

later exhibited in the SIGN workshop where all participants had access to a

variety of practical exercises.

Infections

Andrew Schmidt talked about the challenges of infected fractures with hardware,

treatment of infected diaphyseal fractures using antibiotic cemented nails, and

bone transport with SIGN nail which was shown to be successful. There was no

difference in infection rate between infected and uninfected HIV AIDS patients.

SIGN (Surgical Implant Generation Network)

AO Dialogue 2|13 5

AO Dialogue-SIGN Fellow Presentation

Outcome of SIGN fin nails surgeries in the treatment of long bone fractures Growing indications for the use of SIGN nails and the fact that longer and larger

SIGN fin nails will be produced has stimulated a number of case series recording

the results of using these nails. AO Dialogue-SIGN Fellow, Dr Isidor Ngayomela

presented a case series from Bugando medical Center, Mwanza, Tanzania at the

Eleventh Annual SIGN International Conference was held in Richland, Wash-

ington (US) from September 11-14, 2013.

Methods and Patients

This was a retrospective study which was conducted at Bugando Medical Cen-

tre in Northwestern Tanzania over a period of five years from July 2008-June,

2013. Data was derived from the SIGN database at Bugando Medical Centre and

analyzed using SPSS version 17.0.

Results

A total of 70 patients were studied aged from 15-78 years with a median age of

39.5 years. The ratio of males to females was 3 to 1. Ten percent (seven cases)

presented with open fractures (3 Gustillo I and 4 Gustillo II) and all except one

of these presented within 48 hours of the injury. Two of them presented with

infected wounds after nail insertion, one had deep infection and the other super-

ficial infection, and all had a repeat surgical debridement with antibiotic cover

and responded well. One patient had a previous implant which was exchanged

for a SIGN fin nail.

The majority of fractures (68.6%) were on the right side and the femur was the

most frequent bone affected (70% of cases), no SIGN fin nail was inserted in

tibia fractures.

There were 75.7%(53 cases) distal fractures with 240mm and 280mm nails being

commonly used, retrograde femur was the most common surgical approach

performed in 63.38% (45 cases) of fractures.

The time taken from injury to definitive surgery ranged from one day to 54

weeks with a median duration of 2.23 weeks. Post-operative reduction and nail

SIGN (Surgical Implant Generation Network)

AO Dialogue 2|13 6

position was excellent in all cases. The infection rate was 2.82% (two cases) and other

complications were minimal and acceptable. Fracture healing by X-ray was reported in

92.96% of cases and the median time for radiological healing as defined by X-rays was

5.2 months (range 3-12), five cases did not show radiological and clinical signs of healing

even after their follow up beyond five months. The majority of knees and elbows had at

least 90 degree of flexion in 97.8% of cases. Only ten (14.29%), six (8.6%) and sixteen

(22.9%) patients returned for follow up at six weeks, three months and later, respectively.

There were six patients who had more than one long bone fracture.

Conclusion

Surgical Implant Generation Network (SIGN) nailing promotes predictable fracture healing

with low infection rate, minimal postoperative complications, and early mobilization of

the patient. The SIGN fin nail, like the standard SIGN IM nail, provides adequate fixa-

tion of long bones. In the developing world the SIGN fin nail can be desirable in fixation

of multiple fractures in a moderately dynamic stable patient and it takes shorter time of

surgery. A poor follow up is still a challenge to our hospital; this may mean that patients

are cured and do not feel like returning for their follow ups or simply that follow ups

are inadequately attended. This short case series study has encouraged us to develop a

comparative study between SIGN fin nails and SIGN IM nails in the couple of years to

discover their differences and similarities in fracture management.

continued…

AO Dialogue 2|13 7

Can Low Intensity Pulsed Ultrasound Accelerate Osteoporotic Fracture Healing?

Wing-Hoi Cheung, Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong (HK)

Osteoporotic fracture is a critical medical chal-

lenge with an increasing global aging popula-

tion. In the US, there are more than 1.5 million

fragility fracture cases each year. Mortality is

also high within the first four years after in-

jury. Many studies confirm that osteoporosis

impairs fracture healing at different stages.

The contributing factors include decrease in

mesenchymal stem cells (MSCs) and reduced

mitogenic potential, impaired angiogenesis and

reduced osteoinductivity of demineralized bone

matrix. A general belief proven by some in vitro

studies also suggests the reduced responsiveness

of osteoporotic bones to mechanical signals. In

the meantime, low intensity pulsed ultrasound

(LIPUS) was widely reported to accelerate frac-

ture healing by 38% in normal bones in many

clinical trials but its effects on osteoporotic frac-

ture had not been addressed. The hypothesis

of this study was that LIPUS could accelerate

osteoporotic fracture healing and up-regulate

the expression in osteogenesis-, remodeling-

and angiogenesis-related genes.

An osteoporotic fracture rat model was used

in this study. Rats were randomly assigned to

either LIPUS or Control group and the heal-

ing was assessed by gene expression (real-time

PCR), radiographic callus width/area, microCT

and histomorphometry at 2, 4, 8 weeks post-

fracture, where Col1 (type 1 collagen), bone

morphogenetic protein-2 (BMP-2) [osteogene-

sis-related]; RANKL (NF-kappaB ligand), OPG

(osteoprotegerin) [remodeling-related]; and

VEGF (vascular endothelial growth factor) [an-

giogenesis-related] were target genes. Results

indicated that the LIPUS group showed ear-

lier callus bridging at 5-6 weeks post-fracture,

Wing-Hoi Cheung

2013 Berton Rahn Prize Winner

while the Control group occurred at 7-8 weeks

instead, with significantly higher callus width/

area than the Control at all time points. Mi-

croCT demonstrated a higher increase of BV/TV

from week 2 to 4 in LIPUS group (+26.1%) than

the Control (+16.3%), although the differences

were not significant. For gene expression, Col1

was significantly up-regulated in LIPUS group

at week 2 and 4 (3.11X and 1.96X); BMP-2 was

significantly up-regulated in LIPUS group at

week 2 (7.81X) but lowered at week 8; OPG was

up-regulated at week 2, followed by the surge

of RANKL expression, despite no significant

difference; VEGF was also up-regulated at week

4 and 8 (3.3X and 1.55X). Histologically, the

LIPUS group showed more cartilage at week 2,

more active endochondral ossification at week

4 and lesser cartilage content at week 8, which

was supported by significantly higher cartilage

area in the LIPUS group at week 2 and 4, as

assessed by quantitative histomorphometry.

In this study, osteoporotic bones were shown

to be responsive to mechanical signals while

leading to an accelerated healing process. The

gene expression data, supplemented by other

traditional assessments, confirmed that callus

formation was increased by LIPUS during the

inflammatory phase; the remodeling phase

was occurred sooner; and angiogenesis was in-

creased by LIPUS during the reparative phase.

Therefore, we conclude that LIPUS can acceler-

ate osteoporotic fracture healing by enhancing

callus formation, bone remodeling and angio-

genesis. With the support of another AO start-

up grant (Ref: S-11-10C), we further elaborated

on this study and the most updated results of

the on-going study demonstrate that one of

the mechanisms of LIPUS accelerating osteo-

porotic fracture healing is through enhanced

recruitment of MSCs. All these findings help

us understand the mechanism of osteoporotic

fracture healing and provide useful pre-clinical

data for applying LIPUS on fragility fractures

clinically.

AO Dialogue 2|13 8

Transformation

2013 was a milestone year for AOTrauma,

embarking on a historic journey to trans-

form its education strategy as well as its

portfolio of activities and resources. The

positive outcomes of this significant initia-

tive are now dramatically reshaping how

AOTrauma improves patient care.

AOTrauma Skills Lab Industrialization

It is a challenge to learn and train certain

skills and concepts during live surgeries.

These include basic principles and tech-

niques eg, proper tightening of screws and

feeling the difference when drilling with

sharp or blunt drill bits. The AO Skills Lab

comprises ten stations which give surgeons

an opportunity to train these clinical motor

skills and experience biomechanical con-

cepts in a hands-on environment. Each

station is moderated by AOTrauma faculty.

Participants have the opportunity to inter-

act with and receive immediate feedback

from trauma surgeons.

In October 2012, the AOTrauma Education

Commission decided to make the AO Skills

Lab a core part of the AOTrauma Basic Prin-

ciples Courses—of which there are over 100

offered worldwide annually. To address this

need Skills Lab is being updated and will be

introduced into Basic Principles Courses in

2014. By 2015, all courses will be delivered

with the new AO Skills Lab.

AOTrauma International Board changes

During the Trustees Meeting 2014 in June

in Budapest (HU) there will be an impor-

tant governance change in the AOTrauma

International Board. Jack Wilber will take

over Nikolaus Renner’s lead as the Chair,

AOTrauma International Board. The three

Chairs of the global commissions—Educa-

tion, Research and Community Develop-

ment—will successfully end their tenure.

Elections will take place in early 2014 for the

three global commission Chair positions.

Two of the Chairs, Kodi Kojima (Education)

and Frankie Leung (Research) are eligible

for re-election. Klaus Dresing (Community

Development) is not eligible, as he will com-

plete his second term. Further details will

be available in 2014.

AOTrauma takes this opportunity to thank

Nikolaus Renner for his extraordinary com-

mitment to AOTrauma over the last three

years. He has led the organization in suc-

cessfully improving patient care and ex-

panding the network.

Upcoming scientific congress and symposium

Following the success of the first congress

in Hong Kong in 2012, the forthcoming 2nd

AOTrauma Asia Pacific Scientific Congress

& TK Experts’ Symposium will be held in

Seoul, Korea at the COEX Exhibition and

Convention Center on May 16-17, 2014. The

two-day program will cover the scientific and

technical aspects of orthopedic traumatology

in various topics. This event will bring togeth-

er distinguished regional and international

speakers to share their expertise and expe-

rience, and host interactive sessions which

will foster valuable discussions. Visit www.

aotrauma.org for details and registration.

From the Clinical Divisions

AOTrauma

AO Dialogue 2|13 9

World Forum for Spine Research

From May 15–17, 2014, in Xi’an, China, the World Forum for Spine Research

(WFSR) will gather renowned clinicians and established researchers in the fields

of disc biology and biomedical engineering from around the world in a unique,

stimulating, and focused environment. The WFSR has established itself at the

forefront of international spine care research through its commitment towards

supporting researchers in developing and promoting scientific innovation, col-

laboration and contribution in the field of intervertebral disc degeneration.

Xi’an is home to the Army of Terracotta Soldiers, ranked as a UNESCO World

Heritage Site and considered to be the Eighth Wonder of the World. Please visit

the WFSR website at www.spineresearchforum.org to view the latest program

and list of confirmed faculty. You can also register for the event on this site; early

bird registration fees are available until March 3, 2014.

Beyond the spine: Xi’an 2014

Over 30 of the world’s experts on the intervertebral disc will be speaking at

this event, in a series of keynote addresses, plenary lectures, poster viewings

and interactive discussion sessions, which will shed new light on the care and

management of this unique tissue. In addition to the world’s top researchers and

clinicians, key representatives from industry will also contribute their findings

on advances in technology.

Why focus on the intervertebral disc?

According to Chairperson Keita Ito, the topic was chosen following an AOSpine

member poll. “We have decided to focus on the intervertebral disc because our

members felt this to be an area of high priority and interest.” In addition there

will be a special focus on degeneration to therapeutic motion preservation.

A unique concept

The WFSR is based upon the concept of a multidisciplinary meeting with a clear

focus on one key topic. Chairperson Kenneth Cheung says: “We choose to hold

all talks in one hall, and organize only one running session so we could ensure

that clinicians, scientists, engineers, and anyone else in the field would have

plenty of opportunities to meet and discuss with their peers.”

The mission

The goal of the WFSR is to bring all those working in a specific field under one

roof, to foster discussion and knowledge exchange. “In doing so, we hope to

encourage new friendships and collaboration amongst world experts in this

area,” says Keita Ito. “This complies with the mission of AOSpine: to act as a

catalyst for enriching knowledge, and ultimately help the patients who suffer

from intervertebral disc disorders.”


AOSpine

Xi’an China; home to the Army of Terracotta Soldiers and

hosts of the WFSR 2014

AO Dialogue 2|13 10

A new concept spells success For the past few years, AOCMF in North America has been successfully incor-

porating small group discussions (SGD) into their course programs at all levels.

This new format, which was inspired by a similar approach used in AOSpine,

offers an alternative to the traditional approach of large group lectures and

participant feedback has been very favorable.

More recently, in August 2013, the AONA CMF held a course in Minneapolis

(US) where for the first time the traditional group lecture was almost entirely

replaced by a two-day series of SGD. The program for this new course included

only two brief lectures at the beginning of each day. The lectures were based

on fundamental topics like bone biology and internal fixation mechanics. With

these basic concepts and some new vocabulary, participants rotated through a

series of small group discussions using cases that illustrated the principles of

CMF musculoskeletal repair. Each case focused on concepts that were previously

taught using group lecture format.

The evaluations for this new course format were extremely positive. Many par-

ticipants stated that this was the most interesting course they had ever attended.

The course faculty noted high levels of participant engagement. It was the con-

sensus of the faculty that this new format was very successful in delivering high

quality education with the promise of high information retention.

Asia Pacific moves towards sound expansion

AOCMF Asia Pacific held its first Regional Scientific Forum in Penang (Malay-

sia), in September 2013. A packed and intense one-and-a-half days’ program

focused on the area of orbit and midface, which often presents unique challenges

in reconstruction following trauma and oncologic resection. Chaired by Dr Lay

Hooi Lim, prominent experts from the US, Europe and Asia Pacific were invited

as speakers. Discussions during the forum were vibrant and demonstrated the

value of cross-fertilization of ideas at a multi-specialty meeting. This was much

valued by the 67 participants from seven different countries in the region. The

Regional Scientific Forum was followed by a Faculty Education Program. Profes-

sional educators trained 60 of the 130 currently approved AOCMF Asia Pacific

faculty members.

New research priority area

The March call on ‘TM joint, subcondylar and adjacent bone and cartilage; defor-

mities, defects, injuries and disorders’ received 35 proposals from 22 countries.

The Research & Development Commission now invites the AOCMF community

to submit proposals in the research field of ‘Anti-osteoclastic drugs and their

impact on maxillofacial and orthopedic bone biology, disease, diagnosis, surgery,

and treatment modalities (ARONJ)’ by January 13, 2014.


AOCMF

AO Dialogue 2|13 11

The background to AONeuro

AONeuro is an initiative, kicked off to learn more about the needs and educational

structure required by cranial neurological to improve patient care. Together with

AOSpine and AOCMF, AONeuro aims to provide multidisciplinary course educa-

tion. It seeks to add a cranial dimension to the existing AO Education portfolio.

Today, AONeuro has a global multispecialty community that includes cranial

neurosurgeons, neurologists, neurointensivists, neuro anesthesiologists, and

neuro traumatologists. The members also include other neurological professionals

involved in cranial neurological trauma, cranial oncologic and cerebrovascular

surgery, cranial reconstruction and cranial congenital anomalies surgery. AO-

Neuro is committed to communicating the latest educational advances, informa-

tion on treatment, protocol, equipment and new developments.

Although over the last few years, neurosurgery courses have been conducted by

AOCMF, in November 2013 that the first North American Neuro course com-

bining Cranial Traumatic Brain Injury and Spinal Cord Injury was conducted

in Toronto (CA) jointly by AONeuro and AOSpine. Michael Fehlings and Geoff

Manley were the course chairs. The course was attended by 50 individuals,

mostly residents. The course included updates on the neurological aspects of

injury and recovery, imaging, and decompressive craniectomy.

AONeuro Courses 2013–China

With the publication of the China Guidelines for Traumatic Brain Injury man-

agement, it seemed appropriate to host AONeuro educational courses in China

this year. Hence, in August 2013, two AONeurotrauma Principles Courses were

held in China. 51 participants attended the course in Shanghai, and 60 in Bei-

jing. The goal of the courses was to teach the principles of cranial trauma and to

acquaint the practitioners with guidelines for management and for decompres-

sive craniectomy, including techniques for proper performance. The courses

taught by an international faculty were held in Mandarin and English with

simultaneous translations. The course in Shanghai was held at Huashan Hospital,

Shanghai. Dr Liang-Fu Zhou, Shanghai (China) was the Local Chairperson, and

Prof Geoffrey Manley, California (USA) stepped in as the International Chair.

The course in Beijing was held at the Johnson & Johnson Medical China Sci-

ence Center and chaired by Prof Geoffrey Manley, California (US); participant

feedback was excellent.

Coming up

AONeuro plans to organize a total of 28 courses globally in 2013/14. Webinars

on cranial reconstruction are planned. A webinar on decompressive craniotomy

techniques is being developed by the TK System. Continued resident education

courses have been proposed for AO North America, and an Advanced Course

has been planned for 2014-2015 as well.


AONeuro Initiative

AO Dialogue 2|13 12

Improving patient care through high quality education AOVET’s member community continues to grow. Today, over 650 members sup-

port AOVET in its mission to improve patient care across species by providing

high quality education that meets their needs. To maintain its leading position,

AOVET’s community development division is exploring the evolving needs of

surgeons across the globe in the different stages of their career. In response to

the community’s growing demands, AOVET has enhanced its membership op-

tions, offering a three-year membership program with exclusive benefits such as:

access to selected journals, the veterinary section of the AO Surgery Reference,

educational material and videos, webinars and webcasts, and more.

Introduction of AOVET to South Korea An introductory AOVET seminar was held on August 25, in Seoul, South Korea.

AO Foundation’s honorary Trustee, Prof Key-Yong Kim, welcomed a group of 55

veterinarians that included faculty from four veterinary colleges, private prac-

titioners and some of the recent graduates. He introduced the AO Foundation

and its activities. Dr Young-Soo Byun, a Senior Trustee of the AO Foundation

presented the Principles of Human Fracture Management at the seminar. Joerg

Auer, Chair AOVET International spoke about the challenges large animal vet-

erinary surgeons face when dealing with fracture management in horses and

cattle. He then introduced AOVET International, explaining the benefits of being

a member of the AOVET community. The seminar included three laboratory

exercises conducted by Prof Key-Yong Kim and Dr Byun in the area of internal

fixation. Dr Jae-Suk Chang, a newly-elected AO Foundation Trustee assisted

the laboratory exercises. Prof Woo-Shin Cho joined the group, uniting all the

former and present South Korean Trustees at the inaugural function of the new

AOVET South Korea. The first AOVET Course—Principles in Small Animal

Fracture Management has now been planned for end of 2014.

Faculty Development

AOVET and AOCMF organized a Faculty Education Program (FEP). It consisted

of five weeks of structured online preparations, followed by a two-day event in

Zurich (CH) on October 19–20. The program concluded with post-course self-

assessment and online reflection. Thirteen participants represented ten countries

from the European region. The core subjects of the program included: lecture

presentation, leading a discussion group, and teaching practical skills. The em-

phasis was on result-oriented teaching and effective feedback. Less tangible, but

equally important elements of teaching and learning; such as how to motivate

learners and encourage interaction among course participants were also cov-

ered. The group was unequivocal in the feeling that they are more capable and

confident faculty as a result of the program.


AOVET

AO Dialogue 2|13 13

9,000 patients have been recruited to an

AOCID study.

Careful planning and processes are key to

success in clinical trials. AOCID is ISO 9001

certified and an increasing amount of outside

vendors have audited and appointed AOCID

a “Preferred Third Party Provider” in recog-

nition of the expertize housed within.

While AOCID carries out the functions of

a typical Contract Research Organization

(CRO), one element which sets AOCID

apart from industry is the focus on spreading

knowledge about evidence-based medicine

(EBM). For example, Beate Hanson’s Road-

map to Research course (an introduction to

EBM) has been given on four different con-

tinents and in 2013 celebrates a decade as a

permanent fixture at the AO Davos Courses.

Around 20 young surgeons have availed of

the unique clinical research fellowship to

spend three months at a time in the AOCID

offices to learn about the planning and

AO Documentation began operations in 1959

and around 1,000 cases were recorded dur-

ing the first year alone. It was this docu-

mentation of fracture cases that created the

necessary scientific evidence to prove the

value of internal fracture fixation to an ini-

tially skeptical public. AO Documentation’s

unique repository of collected cases provid-

ed the basis in the 1980s for the Müller AO

Classification–Long Bone Fractures, a system

known and used as standard by surgeons

around the world.

However, by the 1990s it was realized that

the concept of documentation no longer met

contemporary standards and that a reorgani-

zation of AO clinical study activities was nec-

essary to include prospective trials in order to

proactively answer clinical questions.

AO Clinical Investigation and Documenta-

tion (AOCID) was officially founded in 1998

to conduct clinical studies. Ruedi Moser was

the first director and so began the move

from documentation center to clinical in-

vestigation center. Beate Hanson accepted an

offer in 2002 from the then AOCID Chairman

David Helfet and became AOCID director, a

position she still holds today.

The AOCID mission is to provide evidence-

based knowledge through independently

conducted clinical studies, education and

methodological services. In the past 15 years,

AOCID has grown beyond all expectations

in terms of both size and capabilities.

From just a handful of clinical trials in the

early years, AOCID is currently involved

in approximately 50 multicenter inter-

national studies of every type of study

design. In addition to this, around 20

Focused Registry projects are either run-

ning or in development. The internation-

alization of AOCID is also evident. Over

330 different clinics scattered around the

globe have participated in clinical investi-

gations. Over the past 15 years, well over

Historical documentation cards from the AOCID archive

From the AO Institutes

AOCID

AO Dialogue 2|13 14

AOCID

THE FIRST 15 YEARS

conduct of studies. More courses are in the

pipeline to suit the growing needs of health-

care professionals.

As a result of AOCID’s experience, the

“AO Clinical Study Center” (AOCSC)

global qualification program was devel-

oped. Among the advantages to becom-

ing an AOCSC clinic are increased ef-

ficiency in clinical studies and ensured

ethical and regulatory compliance (ICH-

GCP / ISO 14155). Over 30 centers from

Aarau to Woolloongabba are part of the

AOCSC program. The dedicated website:

www.aocsc.org has all the information.

The first 15 years at AOCID were exciting

ones as capabilities and networks were built

up, the promise of the next 15 years and

beyond for AOCID seems great.

Our thanks to the surgeons, study coordina-

tors, patients, AOCID advisors and employees

who have all played their part in our success. Screenshot of a classification software developed for AOCMF

47

93 94 105132

179201

261276

288302 310

333 333

010

020

030

040

0N

umbe

r of c

linic

s

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Source: AOCID CTM Database (as per 25 sep 2013)

Regional Expansion: Number of clinics since 2000

The worldwide growth of AOCID as measured by participating clinics

AOCID employees discussing a clinical study with surgeons AOCID Study Coordinator Course held in Boston in 2013

The AOCSC qualified clinic in Regensburg, Germany

AO Dialogue 2|13 15

AO Implant Positioning Assistance

The task of placing implants plays a key role

in trauma and orthopedics, determining the

surgical outcome. Current computer-aided

surgery is costly, highly specialized and dif-

ficult to handle, which disqualifies it for the

majority of routine interventions. A novel

concept is proposed for simplified implant

positioning utilizing conventional radio-

graphic images. The method is based on the

extraction of characteristic features from

cylindrical hole projections within X-ray

images for determining spatial alignment of

objects and anatomy to guide the implant.

The concept carries potential for use in vari-

ous applications within trauma and ortho-

pedics, in particular nailing, plating, ana-

tomical fracture reduction and prosthetics.

A functioning prototype was experimentally

tested on several applications in the field of

fracture care. These include plating of the

proximal humerus, cephalic implant place-

ment at the hip, dynamic hip screw place-

ment, general anatomical plating, distal nail

interlocking and adjustment of femoral ante-

version. The system reveals strong potential

in terms of improving surgical precision, di-

minishing radiation exposure and reducing

operational time.

Musculoskeletal Infection Group

The Musculoskeletal Infection group in

ARI has had a busy 2013, culminating in

the 2nd AOTrauma Clinical Priority Pro-

gram (CPP) Bone Infection meeting in

Venice, Italy organized by the AOTrauma

Research Commission. The CPP Bone

Infection has entered the second year of

activity and ARI director Geoff Richards

and the musculoskeletal Infection group,

headed by Fintan Moriarty presented

their findings in Venice. The principal

investigator of the CPP Bone Infection,

Steven Kates (USA) and his co-Principal

Investigators Volker Alt (Germany) and

Edward Schwarz (USA) assembled a com-

prehensive program, updating participants

on the most recent progress within CPP.

In the past year, the CPP has commenced

activities on a global bone infection reg-

istry, with a significant contribution from

previous ARI research fellow Mario Mor-

genstern (Germany), and the AOCID.

Within the CPP, there have been new de-

velopments in laboratory-based diagnostic

assays. The huge potential offered by the

continuously growing bank of clinical sam-

ples, including microbiological cultures and

serum samples, has already shown first re-

sults. Other projects on the theme of Bone

Infection are also emerging with new re-

sults, including a better understanding of

the role of implant stability on infection,

as well as large animal models of two-stage

revision of infected intramedullary nail,

which is expected to set a standard within

the field.

Members of ARI and AOTrauma CPP Bone Infection at the recent annual meeting


ARI

AO Dialogue 2|13 16

Collaborative Research Program “Annulus Fibrosus Rupture Repair”

Disc herniation is the pathological condi-

tion for which spinal surgery is most often

performed. While the discectomy approach

provides favorable results in the majority of

the cases, there are conditions where unmet

needs exist in terms of treatment, such as

large disc protrusions with only minimal

disc degeneration. In these clinical situa-

tions, the outcome is often not satisfying

and the economic burden is enormous. A bi-

ological annulus fibrosus (AF) repair would

significantly improve the surgical outcome

in patients with contained disc herniations

but otherwise minor degenerative changes.

The aim of this consortium is to develop

tissue-engineered biomaterials that will en-

able and stimulate the repair of the ruptured

AF. The consortium’s general approach is

to generate 3D scaffolds and activate them

either by seeding with cells or by the addi-

tion of molecular signals that enable new

matrix synthesis to occur at the defect site,

while the biomaterials provide immediate

closure of the defect and maintain the me-

chanical properties of the disc.

Progress of individual partners has led

to definition of the mechanical require-

ments, the identification of the cellular

phenotype, cell surface markers and pro-

genitor cells of the functional AF, the de-

velopment of a delivery system for cells

and therapeutics using nanospheres and

microgels, and the optimization of scaf-

Dynamic histomorphometry surrounding a screw in an uninfected (L) and infected (R)

rat femur. Images taken in live animal using high resolution viva CT

Bacterial microcolony adjacent to medullary adipocytes in an infected rabbit tibia

Members of the Collaborative Research Programs consortia

Damaged disc histology

folds, membranes and glues to be used

for AF rupture treatment. These elements

are combined to provide biological solutions

in a modular system that can be adapted

depending on the surgeon’s needs. Delivery,

fixation techniques and methods for adhe-

sion prevention are addressed while moving

closer towards pre-clinical application. As

this program develops, efforts will be made

toward single-stage intra-operative tissue

engineering approaches.

Partners of the AFR Program:

Daisuke Sakai, Tokai University School of

Medicine, Kanagawa, JAP

Abhay Pandit, National University of

Ireland, Galway, IRL

Stephen Ferguson, Lorin Benneker, ETH

Zürich / University of Bern, CH

James Iatridis, Mount Sinai Medical

Center, New York, USA

Dirk Grijpma, University of Twente,

Enschede, NL

David Eglin, Sibylle Grad, Mauro Alini,

AO Research Institute Davos, CH

AO Dialogue 2|13 17

AOSpine and AOVET publications launched in 2013

The AOSpine book Minimally Invasive Spine

Surgery—Techniques, Evidence, and Contro-

versies, which details the history, peer-

reviewed evidence, and modern surgical

techniques in minimally invasive surgery

of the spine, was released with immediate

success, becoming the number one online

seller of AO’s partner publisher, Thieme

Publishing. Measurements in Spine Care and

SMART Approach to Spine Clinical Research, the

final two books in a four-book series from

AOSpine that examines clinical manage-

ment, outcome assessment, and research in

spine surgery, were also published in 2013.

During the AO Trustees Meeting 2013 the

publication AOVET—The First 40 Years was

launched. Written and edited by AO veteri-

nary professionals and founding members,

it traces the milestones, history, and key

individuals responsible for the formation

of AOVET.

AOTrauma publications to be laun-ched at the Davos Courses 2013

Casts, Splints, and Support Bandages—Non-

operative Treatment and Perioperative Pro-

tection, is a comprehensive guide to the

treatment of fractures and ligaments using

nonoperative casting techniques. It explains

the principles and techniques of casting and

includes 55 videos showing how to prepare

and apply splints and casts to all parts of

the body.

Periprosthetic Fracture Management, brings to-

gether the latest knowledge on periprosthet-

ic fractures, including a full review of the

anatomical regions typically affected, plus

recommended techniques, surgical pitfalls,

and a wide selection of complex cases and

illustrations. Most significantly the publica-

tion introduces a new “Unified Classifica-

tion System” specifically on periprosthetic

fractures. It is hoped this new classifica-

tion system will become as recognized as

the AO/OTA Fracture and Dislocation

Michael Schütz | Carsten Perka

Periprosthetic Fracture Management

The incidence of periprosthetic fractures is continuously rising. Their treatment and outcome largely depends on a correct assessment, diagnosis and choice of procedure—revision surgery or internal fixation. This requires interdisciplinary knowledge and considerable experience from the orthopedic and trauma surgeons as well.

This textbook—the first of its kind—accumulates the latest global knowledge on periprosthetic fractures, including all relevant anatomical regions, surgical pitfalls, complex cases, and a brand new comprehensive “Unified Classification System, (UCS)” on periprosthetic fractures, combining the original Vancouver Classification with the AO/OTA Fracture and Dislocation Classification.

Carefully selected case studies illustrate and describe individual solutions for often problematic fracture situations, providing comprehensive information from experts globally.

Orthopedic and trauma surgeons will be able to expand their knowledge regarding:• Risk factors and assessment of periprosthetic fractures and the patient• A new “Unified Classification System (UCS)”• Options and choices of fracture fixations techniques as well as more

complex revisions or reconstructive procedures• More than 350 pages containing superb illustrations and images

“This book on periprosthetic fractures is unique, as it represents a true collaboration between the world of joint arthroplasty and the world of Orthopedic trauma.” David L Helfet, MD

Michael Schütz | C

arsten Perka

Periprosthetic Fracture Managem

ent

www.aotrauma.org

Periprosthetic Fracture Management

Michael Schütz | Carsten Perka

9 7 8 3 1 3 1 7 1 5 1 1 1

ISBN: 978-3-13-171511-1


AO Education Institute

AO Dialogue 2|13 18

STaRT–a new tool for orthopedic trauma residents

AOTrauma’s new online learning resource,

STaRT (Surgical Training for Residents)

applies the best educational strategies for

residents to benefit from the wealth of

knowledge available within the AO. The

educational tool provides easy access to

tailored information that:

• Supports self-directed learning

• Enhances effectiveness of adopting

basic principles in clinical decision

making

• Complements formal educational offer-

ings of certifying bodies and teaching

hospitals

Web-based resource for residents

Residents have unique learning needs. As

distance learning techniques evolve, self-

directed learning becomes increasingly im-

portant. Three features, detailed in the box

below, address distinct learning strategies.

Interactive e-learning activities

Interactive case discussions promote

learning based on common patient

problems. Quizzes enable focused

learning through immediate feed-

back. Tips and tricks and direct links

to further learning materials help

residents to deepen their knowledge

of the topic.

Self-assessment questions

To help identify their knowledge

gaps, learners can test themselves

with multiple-choice questions (basic,

intermediate, or complex level ques-

tions), and receive feedback on their

answers. References and further read-

ing help to close the identified knowl-

edge gaps.

Overview of AO resources for residents

Structured access to existing learning

material allows residents to quickly

identify available AO resources. All

learning material is labeled accord-

ing to complexity and includes videos,

webinars, recorded lectures, e-learning

modules, readings, mobile Apps, and

access to AO Surgery Reference.

Collaborative content creation

STaRT content is developed by international

teams of experienced surgeons involved in

resident training. Learning outcomes for

every module are defined based on our

overall learning objectives for AOTrauma

resident education. Evaluation of the pro-

gram and its content will be an ongoing

process to keep it up-to-date and applicable

to the learners needs.

A sneak peek at the STaRT booth

The first offerings of STaRT (tibial shaft,

femoral neck, trochanteric, and malleolar

fractures) will be showcased at the AO

Education Institute booth.

STaRT will be launched in April 2014 with

offerings in six anatomical regions: tibial

shaft, femoral neck and trochanter, malle-

oli, distal radius, and proximal humerus.

Classification and it has been specifically

developed to help trauma surgeons recog-

nize and treat prosthetic related fractures.

AO Dialogue 2|13 19

AOTK System

Innovations 1|2013

Meet the Experts at the Davos Courses 2013

After the highly successful “AOTK Innovations: Meet the Experts” at the Davos

Courses in 2012, the course participants will again be able to visit first hand pre-

sentations and hands-on demonstration of surgical techniques based on solutions

which have recently achieved AOTK approval. These daily lunchtime sessions

are hosted by members of the AOTK System’s Expert Groups and surgeons with

direct involvement in the development processes.

The three fields of trauma, spine and craniomaxillofacial surgery will be covered

by dedicated sessions and special focus areas, such as neurosurgery and thoracic

surgery, will also be part of the program as well. Admission is free and spontane-

ous participation is welcome. Attendees will not only get firsthand information

about the new technology and the clinical basis and application, they will also

have the opportunity to discuss with the presenting expert surgeons on site.

AOTK Innovations magazine

During the Davos Courses 2013, AOTK will once again showcase the results

of its strong relationship with its Expert Groups, industrial partner, internal

partners, and clinical divisions and staff, with the release of the 2013 AOTK

Innovations magazine.

The 2013 edition details information on 15 new implants and instruments for

use in trauma, spine, CMF, and veterinary surgery, and includes a range of sup-

porting articles on the history of Neurosurgery in the AOTK system, a welcome

to the new AOTK CMF Chair, and an interesting portrait on AO Faculty member

and Professor of Sports Medicine, Yi Lu.

New trauma implants and instruments include the Radial Head Prosthesis system,

the LCP Ankle Trauma 2.7/3.5 system, and new Expert Nailing instrumentation,

plus there are details about the expanded Matrix Rib Fixation system, and new

Facial Shape chin and malar implants within CMF.

For neuro, new items include the MatrixNeuro Rigid Mesh and Bender and the

MatrixNeuro Ultra Low Profile plates and screws.

The spine section provides details on the Synflate Vertebral Balloon system and

the Zero-P ChronOS, and in VET, the Locking Reconstruction Plate and Mini

Pate article comes with detailed descriptions and interesting case studies. Please

enjoy AOTK Innovations 2013.


AO Technical Commission (AOTK)

AO Dialogue 2|13 20

All rights reserved. Any re production, whole or in part, with-out the publisher’s writ ten consent is prohibited. Great care has been taken to maintain the accuracy of the information contained in this publication. However, the publisher, and/or the distributor and/or the editors, and/or the authors cannot be held responsible for errors or any consequences arising from the use of the information contained in this publica-tion. Some of the products, names, instruments, treatments, logos, designs, etc. referred to in this publication are also protected by patents and trademarks or by other intellec-tual property protection laws (eg, “AO”, “TRIANGLE/GLOBE Logo” are registered trademarks) even though specific refer-ence to this fact is not always made in the text. Therefore, the appearance of a name, instrument, etc. without designation as proprietary is not to be construed as a representation by the publisher that is in the public domain.

Impressum AO Dialogue 2|13

Editor-in-Chief:James F Kellam Managing Editor: Olga Harrington Publisher: AO Foundation Design and typesetting: Manuel Kurth Editorial contact address: AO Foundation, Clavadelerstrasse 8, CH-7270 Davos Platz, Phone: +41 81 414 28 14Fax: +41 81 414 22 97 E-mail: [email protected] © 2013, AO Foundation, Switzerland

AO Dialogue 2 | 2013

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