CMF Matrix

Literature Review

MatrixRIB. Stable fixation ofnormal and osteoporotic ribs.

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Image courtesy of Mario G. Gasparri, MDat Medical College of Wisconsin, USA

MatrixRIB. Stable fixation of normal and osteoporotic ribs.

IndicationsThe Synthes MatrixRIB Fixation System is indicated for the fixation and stabiliza-tion of rib fractures, fusions and osteotomies of normal and osteoporotic bone.

IntroductionThe Synthes MatrixRIB Fixation System consists of precontoured locking plates,locking screws, and intramedullary splints for the fixation and stabilization of ribs.

Although some rib fractures are treated with pain management and bracing, aswell as endotracheal intubation and mechanical ventilation if necessary, somepatients could benefit from surgical stabilization (osteosynthesis).

There are several potential benefits of surgical stabilization of rib fractures. Theseinclude reduced mortality and increased cost effectiveness due to a reduced du-ration of mechanical ventilation support, shortened ICU stays, and less compli-cations. Patients could also benefit from preserved pulmonary function, im-proved pain control, better clearance of secretions through efficient cough,minimized chest wall deformities resulting from trauma and shorter back towork time.1,2,3,4

1 Ahmed Z, Mohyuddin Z, 1995, 1676-802 Engel C, et al., 2005, 181-63 Lardinois D, et al., 2001, 496-5014 Tanaka H, et al., 2002, 727-32

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Right plates

Longitudinaltwist

Locking holes In-plane radius

R3

R4-5

R6-7

R8-9

Locking plates– Plates are precontoured to fit an average rib shape, which minimizes

intraoperative bending5

– Locking plate construct provides stable fixation

MatrixRIB. Stable fixation of normal and osteoporotic ribs.

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5 Mohr M, et al., 2007, 1310-7

Features– Designed to be used without removing periosteum, to maximize blood

supply to the bone– All implants are manufactured from titanium alloy* for flexibility and

strength

Locking screws– Screws work with self-retaining screwdriver blades

to reduce cam-out– Locking design for stable construct– One screw diameter for use with all plates and

splints

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s Left plates

Tubularradius

Out ofplane radius

Etching

L3

L4-5

L6-7

L8-9

– Low-profile 1.5 mm thick plates– Plates are color-coded to distinguish left and right designs– Plates are etched on medial end to indicate the corresponding rib– A universal plate with 8 holes is available

Intramedullary splints– Intramedullary splints allow

minimally invasive procedures– Three widths available

(3 mm, 4 mm, 5 mm)– Only one screw needed to secure

splint

– Drill bit with stop to prevent over-drilling– Self-retaining screwdriver blades

* Ti-6Al-7Nb

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Fatality risk and the presence of rib fractures

BackgroundThis study assesses the effect of concomitant rib injuries on fatality risk followinga car crash, and compares the effect as a function of patient age.

MethodThe National Trauma Databank was sampled to identify 181,331 adults thatwere in motor vehicle crashes and had complete data available. Characteristicsamong several populations were compared, including the association betweenrib fractures and fatality risk in two age groups (18 to 45 years old and over 64 years old). Descriptive statistics were compiled to contrast the injury patternsand outcomes. Propensity scores were then generated using logistic regression,where the “treatment group” was those patients with rib fractures of at least anabbreviated injury scale (AIS) 3. Covariates for generating the propensity scoreincluded gender and the presence or absence of AIS 3, 4 or greater injuries tothe head, abdomen or pelvis. Matching was performed using calipers on thepropensity scores for all patients within the two age groups. Odds ratios for theoutcome death were calculated for the matched datasets and compared between the two age groups

ResultsThe probability that an adult with automotive blunt trauma had a rib injury asthe maximum AIS (MAIS) increased significantly (p<0.001) with age. Further-more, the probability of the patient having an MAIS defined by rib fractures in-creased significantly with age for adults who died with a thoracic MAIS: from30.4% at age 21 to 51.3% at age 65. Rib fractures defined the MAIS for 55.9%of all patients over age 60 who died with a thoracic MAIS. In other words, over55% of patients over 60 who died of a chest injury had no injury worse than ribinjuries. The odds ratio for death for younger patients (aged 18–45) was 1.4(95% CI 1.3–1.6) if rib fractures of at least AIS 3 or greater were present. Forolder patients (over 64 years) the odds ratio was 2.5 (95% CI 2.3–2.8).

ConclusionsIn other words, regardless of the presence or absence of concomitant trauma,crash-injured patients with rib fractures of at least AIS 3 have a significantly in-creased risk of in-hospital mortality, and of two patients having similar non-ribtrauma, one with AIS 3+ rib fractures has a substantially higher expected risk ofdeath than one without. This effect is more dramatic for older patients.

Key points:– Rib fractures defined the MAIS for 55.9% of all patients over

age 60 who died with a thoracic MAIS– Odds ratio for Death due to Rib fractures: 1.4 (18-45yr) & 2.5 (>45yr)

Kent R, et alAssociation for the Advancement of Automotive Medicine 2008;52():73–82

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Morbidity from Rib Fractures Increases after Age 45

BackgroundRecent studies have demonstrated increased morbidity in elderly patients withrib fractures after blunt trauma. As a first step in creating a multidisciplinary ribfracture clinical pathway, we sought to determine the relationship between in-creasing age, number of rib fractures, and adverse outcomes in blunt chesttrauma patients, without major abdominal or brain injury.

Method We performed a retrospective cohort study involving all blunt patients greaterthan 15 years old with rib fractures, excluding those with Abbreviated InjuryScores (AIS) greater than 2 for abdomen and head, admitted to an urban LevelI trauma center during 20 months. Outcomes parameters included the numberof rib fractures, Injury Severity Score (ISS), intrathoracic injuries, pulmonary com-plications, number of ventilator days, length of stay in the intensive care unit(ICU), hospital stay, and type of analgesia.

ResultsOf the 6,096 patients admitted, 171 (2.8%) met the inclusion criteria. Based onan analysis of increasing age, number of rib fractures, and adverse outcomesvariables, patients were separated into four groups: group 1, 15 to 44 years oldwith 1 to 4 rib fractures; group 2, 15 to 44 years old with more than 4 rib frac-tures; group 3, 45 years or older with 1 to 4 rib fractures; and group 4, 45 yearsor more with more than 4 rib fractures. The four groups had similar numbers ofpulmonary contusions (30%) and incidence of hemopneumothorax (51%). Ven-tilator days (5.8 ± 1.8), ICU days (7.5 ± 1.8), and total hospital stay (14.0 ± 2.2)were increased in group 4 patients compared with the other groups (p < 0.05).Epidural analgesia did not affect outcomes. Overall mortality was 2.9% and wasnot different between groups.

ConclusionsPatients over the age of 45 with more than four rib fractures are more severelyinjured and at increased risk of adverse outcomes. Efforts to decrease rib fracturemorbidity should focus not only on elderly patients but those as young as 45years. Based on these data we have initiated a multidisciplinary clinical pathwayfocusing on patients 45 years and older who have more than four rib fractures.

Key points:– Patients over the age of 45 with more than four rib fractures

have an increased risk of adverse outcomes (prolonged mechanicalventilator dependent days, ICU stay and overall hospital stay)

Holcomb J, et alJ Am Coll Surg 2003;196:549–55

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A multidisciplinary clinical pathway decreasesrib fracture – associated infectious morbidityand mortality in high-risk trauma patients

BackgroundWe initiated a multidisciplinary clinical pathway targeting patients greater than45 years of age with more than 4 rib fractures. The purpose of the current studywas to evaluate the effect of this pathway on infectious morbidity and mortality.

MethodThis was a prospective cohort study. Data evaluated included patient demo-graphics, injury characteristics, pain management details, lengths of stay, mor-bidity, and mortality. Univariate and multivariate analyses were performed usinga significance level of P < .05.

ResultsWhen adjusting for age, injury severity score, and number of rib fractures, theclinical pathway was associated with decreased intensive care unit length of stayby 2.4 days (95% confidence interval [CI] −4.3, −0.52 days, P = .01) hospitallength of stay by 3.7 days (95% CI −7.1, −0.42 days, P = .02), pneumonias (oddsratio [OR] 0.12, 95% CI 0.04 to 0.34, P < .001), and mortality (OR 0.37, 95% CI0.13 to 1.03, P = .06).

ConclusionsImplementation of a rib fracture multidisciplinary clinical pathway decreased mechanical ventilator-dependent days, lengths of stay, infectious morbidity, andmortality.

Key points:– 25% trauma deaths due to thoracic trauma– In 2/3 of trauma patients rib fractures are present– Introduction of multi-disciplinary pathway reduced ICU stay,

overall hospital stay, morbidity and mortality.

Todd R, et alThe American Journal of Surgery 192 (2006) 806–811

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Management of Flail Chest Injury: InternalFixation versus Endotracheal Intubation andVentilation

A total of 427 patients with major chest trauma were treated in two major hos-pitals in Abu Dhabi, United Arab Emirates, during a 10-year period. In 64 of 426patients, flail chest injury was the dominant factor among other injuries thatwere insignificant. Among 64 cases of flail chest injury, 26 were managed by internal fixation of ribs, whereas the remaining 38 were managed by endotra-cheal intubation and intermittent positive-pressure ventilation alone. Of the patients treated by internal fixation 80% (21/26) were weaned from the venti-lator within an average of 1.3 days, whereas the remaining 20% (5/26) contin-ued to need assisted ventilation for a longer duration; the total average durationof assisted ventilation for the whole group was 3.9 days. In comparison, among38 patients with flail chest injury treated by endotracheal intubation and venti-lation alone, the average duration of assisted ventilation was 15 days. In thegroup treated by internal fixation 11% (3/26) of the patients ultimately requireda tracheostomy, whereas in the patients treated by intubation and ventilationalone tracheostomy was required in 37% (14/38) of the cases. In the grouptreated by internal fixation, chest infection was documented in 15% (4/26), sep-ticaemia in 4% (1/26), and barotrauma in 0%; in the other group these compli-cations occurred in 50% (19/38), 24% (9/38), and 8% (3/38) of the cases, respectively. The mortality rate was 8% (2/26) in the surgically treated patients,whereas it was 29% (11/38) in the other group. All the deaths in both groupswere ascribed to adult respiratory distress syndrome. Average stay in the inten-sive care unit was 9 days for the patients treated by internal fixation, whereas itwas 21 days in the group treated by intubation and ventilation alone. The treatment of flail chest injury in our series by internal fixation resulted in speedyrecovery, decreased complications, and better ultimate cosmetic and functionalresults and proved to be cost effective.

Key points:– Surgical stabilization of Flail Chest patients leads to

– Reduced mortality rate– Less chest wall infections– Shorter ventilation time and ICU stay

– Better functional and cosmetic results were achieved withsurgical stabilization

– Proven to be cost effective

Ahmed Z, et alJ THORAC CARDIOVASC SURG 1995;110:1676–80

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Surgical Stabilization of Internal PneumaticStabilization? A Prospective Randomized Studyof Management of Severe Flail Chest Patients

BackgroundWe compared the clinical efficacy of surgical stabilization and internal pneu-matic stabilization in severe flail chest patients who required prolonged ventila-tory support.

MethodThirty-seven consecutive severe flail chest patients who required mechanicalventilation were enrolled in this study. All the patients received identical respira-tory management, including end-tracheal intubation, mechanical ventilation,continuous epidural anesthesia, analgesia, bronchoscopic aspiration, posturaldrainage, and pulmonary hygiene. At 5 days after injury, surgical stabilizationwith Judet struts (S group, n =18) or internal pneumatic stabilization (I group,n=19) was randomly assigned. Most respiratory management was identical between the two groups except the surgical procedure. Statistical analysis usingtwo way analysis of variance and Tukey’s test was used to compare the groups.

ResultsAge, sex, Injury Severity Score, chest Abbreviated Injury Score, number of ribfractures, severity of lung contusion, and PaO2/FIO2 ratio at admission were allequivalent in the two groups. The S group showed a shorter ventilatory period(10.8 + 3.4 days) than the I group (18.3 + 7.4 days) (p < 0.05), shorter intensivecare unit stay (S group, 16.5 + 7.4 days; I group, 26.8 +13.2 days; p < 0.05), andlower incidence of pneumonia (S group, 24%; I group, 77%; p < 0.05). Percentforced vital capacity was higher in the S group at 1 month and thereafter (p < 0.05). The percentage of patients who had returned to full-time employ-ment at 6 months was significantly higher in the S group (11 of 18) than in theI group (1 of 19).

Tanaka H, et alJ Trauma. 2002;52:727–732

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ConclusionsThis study proved that in severe flail chest patients, surgical stabilization usingJudet struts has beneficial effects with respect to less ventilatory support, lowerincidence of pneumonia, shorter trauma intensive care unit stay, and reducedmedical cost than internal fixation. Moreover, surgical stabilization with Judetstruts improved percent forced vital capacity from the early phase after surgicalfixation. Also, patients with surgical stabilization could return to their previousemployment quicker than those with internal pneumatic stabilization, even inthose with the same severity of flail chest. We therefore concluded that surgicalstabilization with Judet struts may be preferably applied to patients with severeflail chest who need ventilator support.

Key points:– Surgical stabilization of Flail Chest patients with struts leads to

– Shorter ventilation time– Shorter ICU stay– Lower incidence of Pneumonia

– Number of patient returned back to full-time work within 6 monthswas significantly higher in patients with surgical approach

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Treatment of Chest Wall Implosion InjuriesWithout Thoracotomy: Technique andClinical Outcomes

BackgroundChest wall implosion injuries secondary to side impact are unusual but devastat-ing injuries. The purpose of this series is to describe the clinical entity, present asurgical technique to reduce and repair the thoracic cage deformity without thoracotomy, and report outcomes in nine patients.

MethodTwenty-two patients were admitted during 7 year period with thoracic cage implosion injuries and multiple segmental rib fractures from a side impact mechanism. All patients’ required mechanical ventilation and had an implosiondeformity along the posterolateral thoracic cage, pulmonary contusion, andclavicular fractures. Nine patients underwent repair of rib fractures through aparamidline posterior approach without thoracotomy using standard 2.4 mm titanium plates. Seven patients with similar fracture pattern treated nonopera-tively were used as a historical control. Total intubation time, intensive care unit(ICU) length of stay (LOS), and final shoulder function using the Constant Murleyscoring system were compared between the two groups.

ResultsAverage age, male to female ratio, and injury severe score were comparable forboth cohorts (p > 0.6). Average follow-up was 16 months versus 12 months forthe operative and nonoperative groups, respectively, (p = 0.11). In the operativegroup, 8 of 9 (89%) patients were extubated within 24 hours of surgery; 3 of 9(33%) were extubated in the operating room. In the operative group, seven patients underwent internal fixation of the clavicle and progressed to union witha mean Constant score of 93. Nine patients had nonoperative treatment of theclavicle with a mean Constant score of 75 (p = 0.04). Total intubation time (1.9 days) was significantly shorter in the operative group than the nonoperativecontrols at 13.3 days (p < 0.01) and length of ICU stay was also shortened at 5.7 (4–8) days versus 16.7 (10–26) days, respectively, (p < 0.01).

Solberg B, et alThe Journal of TRAUMA® Injury, Infection, and Critical Care, Volume 67,Number 1, July 2009

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ConclusionsChest wall implosion injuries with fixed deformities of the thoracic cage, multiplesegmental rib fractures, and clavicular injury are a distinct clinical entity, whichcan be effectively managed with a posterior paramidline approach without thoracotomy. Reduction of the deformity and repair of the rib fractures led to adramatic reduction in time to extubation, ICU LOS, and in-hospital complicationsincluding pneumonia and sepsis. Repair of the clavicular fracture appeared to bebeneficial.

Key points:– Effective management of implosion injuries with fixed deformities

of the thoracic cage, multiple segmental rib fractures with aposterior paramidline approach

– Dramatic reduction in time to extubation, ICU length of stay, and in-hospital complications including pneumonia and sepsis

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Evaluation of intramedullary rib splints forless-invasive stabilisation of rib fractures

BackgroundIntramedullary fixation of rib fractures with generic Kirschner wires has beenpracticed for over 50 years. However, this technique has not been advanced toaddress reported complications of wire migration and cut-out. This biomechan-ical study evaluated a novel rib splint designed to replicate the less-invasive fixa-tion approach of Kirschner wires while mitigating their associated complications.

MethodThe durability, strength, and failure mode of rib fracture fixation with in-tramedullary rib splints were evaluated in 27 cadaveric ribs. First, intact ribs wereloaded to failure to determine their strength and to induce realistic rib fractures.Subsequently, fractures were stabilised with a novel rib splint made of titaniumalloy with a rectangular cross-section that was secured with a locking screw. Allfixation constructs were dynamically loaded to 360,000 cycles at five times therespiratory load magnitude to determine their durability. Finally, constructs wereloaded to failure to determine their residual strength and failure modes.

ResultsNative ribs had a strength of 9.7±5.0Nm, with a range of 3.5–19.6Nm. Fracturefixation with rib splints was uneventful. All 27 splint constructs sustained dynamic loading without fixation failure, implant migration or implant cut-out.Dynamic loading caused no significant decrease in construct stiffness (p=0.85)and construct subsidence remained on average below 0.5mm. The residualstrength of splint constructs after dynamic loading was 1.1±0.24Nm. Constructsfailed by splint bending in 44% of specimens and by developing fracture linesalong the superior and inferior cortices in 56% of specimens. Regardless of thefailure mode, all rib splint constructs recoiled elastically after failure and retainedfunctional reduction and fixation. No construct exhibited implant cut-out or migration through the lateral cortex.

Helzel I, et alInjury, Volume 40, Issue 10, Pages 1104–1110

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ConclusionsRib splints can provide sufficient stability to support respiratory loading through-out the healing phase, but they cannot restore the full strength of native ribs.Most importantly, rib splints mitigated the complications reported for rib fracturefixation with generic Kirschner wires, namely implant cut-out and migrationthrough the lateral cortex. Therefore, rib splints may provide an advanced alter-native to the original Kirschner wire technique for less-invasive fixation of ribfractures.

Key points:– Rib splints may provide an advanced alternative to the original

Kirschner wire technique– Rib splints can provide sufficient stability to support respiratory

loading throughout the healing phase – Rib splints mitigated the complications reported for rib fracture

fixation with generic Kirschner wires, namely implant cut-out andmigration through the lateral cortex

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Anatomically Contoured Plates forFixation of Rib Fractures

BackgroundIntraoperative contouring of long bridging plates for stabilization of flail chestinjuries is difficult and time consuming. This study implemented for the first timebiometric parameters to derive anatomically contoured rib plates. These plateswere tested on a range of cadaveric ribs to quantify plate fit and to extract abest-fit plating configuration.

MethodThree left and three right rib plates were designed, which accounted foranatomic parameters required when conforming a plate to the rib surface. Thelength lP over which each plate could trace the rib surface was evaluated on 109cadaveric ribs. For each rib level 3–9, the plate design with the highest lP valuewas extracted to determine a best-fit plating configuration. Furthermore, thecharacteristic twist of rib surfaces was measured on 49 ribs to determine the sur-face congruency of anatomic plates with a constant twist.

ResultsThe tracing length lP of the best-fit plating configuration ranged from 12.5 cmto 14.7 cm for ribs 3–9. The corresponding range for standard plates was 7.1–13.7 cm. The average twist of ribs over 8 cm, 12 cm, and 16 cm segmentswas 8.3 degrees, 20.6 degrees, and 32.7 degrees, respectively. The constanttwist of anatomic rib plates was not significantly different from the average ribtwist.

ConclusionsA small set of anatomic rib plates can minimize the need for intraoperative platecontouring for fixation of ribs 3–9. Anatomic rib plates can therefore reduce thetime and complexity of flail chest stabilization and facilitate spanning of flail segments with long plates

Key points:– A small set of anatomic rib plates can minimize the need for

intra-operative plate contouring and can therefore reduce the timeand complexity of rib fracture fixation.

– A close fit between the anatomic plate and the rib surface mayfurthermore contribute to construct strength and enables low-profile fixation to minimize implant-induced discomfort

Bottlang M, et alJ Trauma 2010

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References

Kent R, et al; Fatality risk and the presence ofrib fractures; Association for the Advancement ofAutomotive Medicine 2008;52():73-82.

Holcomb J, et al; Morbidity from Rib FracturesIncreases after Age 45; J Am Coll Surg2003;196:549 –55.

Todd R, et al; A multidisciplinary clinicalpathway decreases rib fracture – associatedinfectious morbidity and mortality in high-risktrauma patients; The American Journal ofSurgery 192 (2006) 806–811

Tanaka Z, et al; Surgical Stabilization of InternalPneumatic Stabilization? A ProspectiveRandomized Study of Management of SevereFlail Chest Patients; J Trauma. 2002;52:727–732.

Ahmed H, et al; Management of Flail ChestInjury: Internal Fixation versus EndotrachealIntubation and Ventilation; J THORACCARDIOVASC SURG 1995;110:1676-80)

Solberg B, et al; Treatment of Chest WallImplosion Injuries Without Thoracotomy:Technique and Clinical Outcomes; The Journal ofTRAUMA® Injury, Infection, and Critical Care0– Volume 67, Number 1, July 2009

Helzel I, et al; Evaluation of intramedullary ribsplints for less-invasive stabilisation of ribfractures; Injury, Volume 40, Issue 10, Pages1104-1110

Bottlang M, et al; Anatomically ContouredPlates for Fixation of Rib Fractures; J Trauma.2010.

Further reading

Nirula R, et al; Rib Fracture Repair: Indications,Technical Issues, and Future Directions; World J Surg (2009) 33:14–22

Lardinois D, et al; Pulmonary function testingafter operative stabilization of the chest wall forflail chest; European Journal of Cardio-thoracicSurgery 20(2001) 496-501

Bulger E, et al; Rib Fractures in the Elderly; TheJournal of TRAUMA® Injury, Infection, andCritical Care – Volume 48,, Number 6, July 2000

Bibliography

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Synthes – In the service of health

1 AO stands for “Arbeitsgemeinschaft für Osteosynthesefragen” [Association for the Study ofOsteosynthesis]. The AO Foundation and “AO philosophy” are viewed as the professional standard fortrauma surgery worldwide. The initials “AO” have become a household name among an internationalnetwork of surgeons.

Synthes is an internationally leading company in medical technologyOver 10,000 employees worldwide are involved in serving the needs of surgeons,surgical support staff and patients. Synthes – a company specializing in the fieldof osteosynthesis – develops, produces and markets surgical instruments, im-plants, and biomaterials for the surgical treatment of bone fractures and recon-structions of the human skeleton and its associated soft tissue.

The main goal of Synthes is to provide safe and highly advanced implants, sur-gical instruments and technologies that enable reliable operations, fast healingand a complaint-free life after surgery. We gua rantee high quality, continuousinnovation and a focused customer orientation.

AO1 – A medically oriented non-profit organization in the service of surgeons and patientsSynthes works closely with the AO Foundation. AO stands for “Arbeitsgemein-schaft für Osteosynthese” [Association for the Study of Osteosynthesis]. Thefoundation boasts more than 5,000 surgeons who participate in AO activitiesthroughout the world – one of the largest networks in the field of medicine. Inthe professional world, this surgeon-led, scientific non-profit organization focused on treating bone fractures and diseases of the musculoskeletal systemis a pioneer in research, documentation and development. Yet even the best implants and instruments are useless if they are not used properly. AO Interna-tional, the arm of the foundation responsible for training, annually organizesmore than 160 AO courses throughout the world that offer practical exercisesand discussions. Since the beginnings of the AO, experienced AO physicianshave provided theoretical and practical training for more than 500,000 surgeonsand more than 150,000 surgical support staff members.

Synthes products area familiar sight innearly every operationroom in the world

AO Foundation, Davos, SwitzerlandThe AO Foundationoffers numerous trainingcourses worldwide

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