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The magazine for the AO community

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A st stro ro o ng g and d c ol ollectivve vo vo ice

The AO COIAC classification system | The AOTK System The hindfoot arthrodesis nail | Fracture repair at the racetrack


Contents

2 Impressum AO Dialogue 1 | 09 Editor-in-Chief: James F Kellam Managing Editor: Elena Ineichen-Grimaud Photo Editor: Jürgen Staiger Editorial Advisory Board: Jorge E Alonso James Hunter Frankie Leung Rodrigo Pesantez Pol M Rommens Publisher: AO Foundation Design and typesetting: nougat.ch Printed by: Bruhin Druck AG, Switzerland Editorial contact address: AO Foundation Clavadelerstrasse 8 CH-7270 Davos Platz Phone: +41(0)44 200 24 80 Fax: +41(0)44 200 24 21 E-mail: dialogue@aofoundation.org Copyright © 2009 AO Foundation, Switzerland

Community zone Panorama

Report

4 | News & Events 8 | People

10 | From obesity to fitness and philanthropy 11 | The Hank Hanff Fellowship—benefitting many future careers

In discussion All rights reserved. Any re production, whole or in part, without the publisher’s written 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 publication. 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 intellectual property protection laws (eg, “AO”, “TRIANGLE/ GLOBE Logo” are registered trademarks) even though specific reference 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.

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12 | “A unique opportunity to express our gratitude”

From the regions 14 | AO Trauma Middle East: a strong and collective voice

Internet 18 | AO COIAC: an indispensible tool 19 | AO Surgery Reference: an ever-expanding repertoire


Editorial

3 My view

James F Kellam Editor-in-Chief james.kellam@aofoundation.org

Expert zone Case study 20 | Advancing technology: the hindfoot arthrodesis nail

Clinical topic 24 | Ventral plating of the humerus using MIPO techniques

AO VET 28 | Fracture repair at the racetrack

Focal point 31 | The AO Technical Commission (AOTK) System

We have over time become deeply aware of our relationship as surgeons with the pharmaceutical and medical device industries, leading many to suggest that it is impractical. But the contribution made by industry to medical progress in patient care is imperative and cannot be done without clinical relevance and hence the intimate involvement of physicians and surgeons. The big question is how this can occur without conflicts of interest and inappropriate influence on education and research and still produce the best patient care. The AO Technical Commission (AOTK), highlighted in this issue, is the AO Foundation’s answer to that question. The AOTK was established to allow for the research and development of pharmaceutical and medical devices that solve a clinical need identified by a surgeon—the best system possible. The AOTK Expert Groups consist of clinicians who with researchers, scientists, and engineers seek solutions to clinical problems. Solutions are then developed in collaboration with a medical device company and when proven sound in clinical trials, the resulting implant and technique are approved by surgeons. Any payment is directed to an arms-length holding company without influence on the Foundation’s educational or scientific offerings. Today the AO Foundation is supported by an endowment, and a relationship with industry that maintains its independence and avoids conflict of interests; the AOTK is a viable method to maintain a medical association’s proper relationship with industry.

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community zone

Panorama News, Events, People

4 SEC in the spotlight In an article entitled “Don’t Give a Fish: Building Orthopedic

Infrastructure”, posted February 10, 2009 on the online trade publication “Orthopedics This Week” (www.ryortho.com), author Elizabeth Hofheinz looks at the efforts of medical organizations, including the AO Socio Economic Committee, to build up an orthopedic infrastructure in nations of the developing world. In the article, AO SEC Chairman Paul Demmer discusses the SEC’s efforts to match medical instruction with local needs and abilities, its long-term residency programs in Zambia, Kenya and Malawi, the SEC Reverse Fellowship Program, where local medical staff drive training projects, and its focus on medical independence and sustainability in developing nations.

AO Dialogue readers have their say In a reader-

ship survey conducted last year, almost 1,000 respondents comprised primarily of AO Alumni, Faculty, and course participants, the majority residing in Europe, shared their opinions on various aspects of AO Dialogue magazine. They selected the Expert Zone (clinical topics) section as the most relevant in the magazine and most respondents also said that the section should be detachable so that it can be filed separately for reference. They found the Community Zone’s “Inside the AO”, followed by “Report”, as the second and third most pertinent sections. “The AO teaches principles and methods for better patient care” is the concept most strongly communicated by the magazine according to the poll. A resounding majority, more than 85%, said they were very satisfied/satisfied with the magazine. The AO Dialogue editorial team thanks all those readers who generously gave their time to participate in the survey.

Welcome to the

Prof. Chris van der Past President AOF Werken

first AO Trauma NOW

where we intend to keep you informed about how the new AO Trauma specialty is developi ng.

The AO Foundation (AOF) has just completed its 50 years’ celebration s, where we honored (a) the endeavors of our founding fathers; that band of 13 focused and dedicated surgeons who truly revolutionized the field trauma surgery and (b) the expansion and developme pment nt of the AO into the w world’s premier general trauma and ortho orthopedic community, which is now recognized recogniz as the gold standard in Trauma care. Therefore, what better time than during the highlight of the 50th anniversary year ye in Davos, June 2008, for the Board of Directors Directo of the AO Foundation (AOVA) to confirm the final, f but crucial piece in the jigsaw for the fut future of a modern AOF… … the creation c reaa t ioon ooff the AO Trauma specialty. For 40 of its 50 years, it can be correctly corre argued that Trauma and the AO were synonymou synonym s—AO was Trauma and Trauma was AO. The sp spirit of AO was in Trauma, the philosophy of AO was in Trauma, and the pride of AO was in Trauma. Over time, AO has evolved Trau from a community of generalists into one of specialists. specialis This emerging community of specialists has ha continued to share AO’s vision of improving patient care, but each group has also developed develope their

own unique interests and different needs. The specialist groups were no longer served by an AO organization with one common approach for all. AO clearly needed to differentiate between the specialties and provide AO O C MF structures and finances

Newsletter,

We have demonstrat ed that as Trauma we are open to others; and as a Trauma surgeon within AO I say with pride that this new AO,

AO Foundation

AOSpine AO e AO Trauma AO O V ETT to meet their unique needs while maintaining the spirit of its first 50 years. Hence the this expanded AO family natural emergence of is still united in its the specialties. The first sole purpose to improve group to identify themselves patient care. For me was our Vet colleagues, personally, AO will always be Trauma, then came Spine, and it is later the CMF surgeons. what I know; it is my heritage, and it is in As these “specialty” my groups developed, soul. However, the AO and Trauma continued new generations of Trauma as they had done for surgeons already see the last 50 years seema new AO Foundation , ingly as one; after all a multi-speci alty foundation we had our traditions, , where the name we had our ways—we had AO is shared and strengthene our club. d. As our family gets bigger and matures, Nobody, however, predicted those groups that the new we have nurtured also specialties’ success to growing and want a say in the family affairs. It makes total attracting surgeons to the AO community sense, therefore, that . Trauma now also creates Clearly, by focusing exclusively on the a new structure and needs of the specialty, an own identity within by opening the this new modern AO doors to new persons Foundation . with new ideas and new ways, the three I can therefore say young specialty groups with pride that the birth have demonstrated of AO Trauma was in dynamic growth, great fact a major highlight of resourcefulness, and the anniversary year fostered a new spirit. and one of the greatest moments of my two-year presidency.

AO F Foundation

from streng th to streng

th

The founders created the AO Foundation Foundatio (AOF) consisting orthopedic and fracture of like-minded surgeons from around at the table to assure Prof. James Kellam a the world. For the past 50 years, the AOF has Chairperson AO grown and evolved, that it is well heard evolve and over time R&D in of Veterinary, Crainiomax the specialties illofacial, and Spine a cooperative, collegial Sp surgeons have “specialties ” within created the AOF. fashion. AO Trauma is The specialties have grown to a size that now fully franchised th they are now recognized entities within the AOF into with their own gov this process. Although governance over their and scientific areas academic of interest. Recognizin being the original founder the need for worldwide developme nt, the Foundation Recognizing of the Foundation , AO Trauma is now the newest of the specialties. itself has evolved ev from a strictly SwissGerman group to a As this specialty develops worldwide organizatio as well as personal many uncertaintie s n to promulgate the and regional issues This regionalizat regionaliza tion AO vision. will need to be addressed. ion has been extremely process should not important because This be considered as an provided a common it has attempt to infrastructu re within divest any region or eeach of the regions section of their independen centralize power or AO Foundation to support and the the specialties. IIn the ce. It is important that 50th anniversary year, the AO Foundation all involved in this process found it suitable to work together in the spirit of the founders fina finally complete the with the creation of to define AO Trauma’s specializatio n AO Trauma, a specialty own personality as consensus builder and involving those people a interested in musculoske collegial partner in the AOF. letal trauma and disease, The cooperative interaction d subsequen t complicatio fractures, and its between AO Trauma ns and problems. This and and its the regions Foundation Th will has now completed continue to assure that specialization of the the Foundation. AO remains the world what it does best—educa leader in What is now important tion and research. I believe that the next for the Foundation years will see tremendou 5, 10, 20 is the fact that each specialty can govern s growth as each of its science, its academics, the specialties controls own academic and academic and will their scientific destiny in now have a voice cooperation with each with the support of other and the Foundation and its regional infrastructu res.

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Issue1 2009

A pair of publishing firsts The first issue of the AO CMF Specialty’s official

membership journal “Craniomaxillofacial Trauma & Reconstruction”, Volume 1 Number 1, appeared in December 2008. AO Foundation President Paul Manson is supported in the role of editor-in-chief by an editorial board of international AO CMF experts. The journal appears four times a year, in March, June, September, and December, and is available free of charge for CMF members. For information, visit www.thieme.com/ cmtr. Another publication, AOTrauma now!, Issue 1/2009, arrived on AO Foundation computer desktops in February. The newsletter, which intends to keep AOF members informed of how the new AO Trauma Specialty is developing, included messages from AOF President Paul Manson, AOF Past-President Chris van der Werken, AO R&D Chairperson Jim Kellam, and AO Trauma Chairperson Michael Wagner. The newsletter discussed the benefits of the dedicated Trauma Specialty for the AOF’s 5,000-strong network of trauma surgeons.


community zone

5 From the AO Institutes AO Research and Development (AO R&D)

Based on ideas and clinical input from our partners Thomas Mendel and Florian Radetzki of the Pelvic Project Group of the Orthopedic & Trauma Department, Martin Luther University (MLU) Halle-Wittenberg, Germany, and in cooperation with Corridors for accurate transversal the Department of Radiology of MLU (Karsten Stock), methods SI screw location into the were developed for computing transversal iliosacral screw 3-D first, second, and third sacral corridors in CT-data of the pelvis. Iliosacral screws are used to body of a pelvis. stabilize sacroiliac joint dislocations and sacral fractures. The implementation of these 3-D-visualized safe sacroiliac corridors could prospectively enhance the performance of computer-assisted navigation systems. Also, the results of an animal study showed the potential of a new surgical technique aimed at increasing the safety of vertebroplasty. Intravertebral fat removal by means of pulsed irrigation combined with an applied vacuum prior to bone cement injection reduced pulmonary fat embolism and concurrent cardiopulmonary reactions. Furthermore, irrigation improved cement filling of the vertebrae. The new technique might be of use in patients with impaired CT evaluation and reconstruction of a sheep cardiopulmonary function. spine after augmentation with PMMA (blue).

AO Education (AOE)

North American Spine Society The NASS 23rd Annual Meeting took place at the Metro Convention Center in Toronto, Canada, in October 2008. Global spine experts discussed the latest scientific developments and best practices in spine care. The symposia covered many topics, including an “Update on Biologics and Basic Research for Spinal Disorders”, and “Lessons Learned from Disc Arthroplasty”. These discussions, together with over 100 podium presentations and 189 EPosters provided the latest information on spine care. AOSpine sponsored a booth supported by the AOSpine North America Team. AOSpine received a lot of interest from both existing members and non-members in their educational programs, courses, Global Spine Congress, and fellowships. Nineteen members signed up, 13 of whom were new to AOSpine. This year’s NASS meeting also formed part of the AO’s 50th anniversary celebrations.

AO Education and AO Knowledge Services will in the future combine to form a new department designed to support educational activities throughout the AO Foundation. The integration of the skills and experience, especially of those members connected with the AO Surgery Reference, will give the AO Foundation a much broader base to interact with our learners and in particular will give it the ability to interact with more senior surgeons in practice.

AO Clinical Investigation & Documentation (AOCID)

A prospective multicenter case series has been conducted in collaboration with Dankward Höntzsch (BG Unfallklinik Tübingen) and Synthes GmbH to assess the performance of the angular stable locking system (ASLS) in patients with proximal and distal tibial, femoral and humeral fractures treated with intramedullary nails. ASLS offers angular stable locking for intramedullary nails.

Angular Stable Locking System (ASLS) consisting of a locking screw and resorbable The interim analysis of the first 23 patients showed promising results: sleeve providing angular In 65% of cases the surgeon has been extremely satisfied with the stability.

achieved fracture stability; handling has been considered simple and very satisfactory and no complications related to ASLS have been reported. The average time to full weight bearing has been 9.4 weeks, compared to 12 weeks in patients with conventional locking, according to literature. These results support the hypothesis that patients treated with ASLS bear full weight earlier compared to patients with conventional locking. Further investigation using a randomized controlled study will be undertaken to further prove the advantages of ASLS regarding fracture healing and weight bearing compared to conventional locking.

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community zone

Panorama News, Events, People

6 AO symposium in Prague To mark the AO’s 50th anniversary, in late Sep-

tember 2008, AO Alumni Czech Republic and local Synthes representatives held a symposium on injuries of the pelvis and acetabulum, gathering over 130 participants. The keynote lecture, highlighting the major contributions of AO founding father Maurice E Müller, was given by Oldrˇ ich Cˇech, who brought the AO Principles to the Czech Republic, and who celebrated his 80th birthday during the symposium. The scientific presentations were divided into three blocks. The first covered the historical development, diagnostics, classification, and primary care of pelvic injuries. The second looked at current concepts in treating pelvic injuries, treatment of spino-pelvic injuries, the use of navigation in pelvic trauma, and complications. The third dealt with the diagnostics, classification, treatment, and complications of acetabular injuries. Marvin Tile presented three lectures on his career experience treating acetabular and pelvic injuries. All lectures are available at: http://medical-cisp.lf3.cuni.cz/ (“Symposium“, login: guest, password: cispcz).

AO European Faculty Seminar This “invitation only” two-day event gathered

AO Faculty from 22 European countries in Davos last December for interactive peer discussions on complex cases of the upper limb. Under the leadership of Michael Wagner, two programs ran in parallel, one each for German- and English-speaking participants. Chairmen for the former were Hans-Jörg Oestern and Klaus Dresing, and for the latter, Chris Oliver and Jan van Mourik. In the English-language program, mini lectures focused on AO in 2008, in the past and in the future (Jim Kellam); AO Implant surface developments (Geoff Richards); safer operative surgery (John O’Dowd); and LCPs in forearm shaft fractures (Michael Wagner). Lisa Hadfield-Law ran a session on “Educational aspects of AO courses”, focusing on how to teach the LCP. Chris Oliver and Jan Van Mourik explained to participants how surgery closely resembles cooking— to some amusement.

CPP member wins URIST Award Christopher Evans, PhD, the Maurice Müller Professor of Orthopedic Surgery at Harvard Medical School and a member of the CPP “Large Bone Defect Healing”, has received the Marshall R. Urist Award for 2009 from the US Orthopedic Research Society (ORS). This prestigious award honors an investigator who has established him/ herself as a cutting-edge researcher in tissue regeneration with an ongoing body of work of sustained excellence. The award, which carries a prize of USD 5000.–, was presented to Professor Evans by Lori Setton, chair of the ORS’ Special Projects Committee, at the ORS meeting in Las Vegas on February 23, 2009 in recognition of his “outstanding achievements over the years in the areas of bone and mineral metabolism and growth factors.”

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community zone

7

AOAA Germany annual meeting In early March, the AO Alumni Association Germany Chapter held its

annual meeting in the Wappensaal (coat of arms room) of historic Wartburg Castle. Michael Erler organized the event and Tim Pohlemann opened the proceedings with a state-of-the-art lecture on injuries to the pelvis and related concepts of care. Theddy Slongo looked at injuries to children and teenagers and discussed conservative and operative treatment options. The meeting provided the perfect environment for alumni members to openly exchange ideas and case examples. Participants enjoyed an evening celebration to mark the AO Alumni Association’s 20th anniversary this year. They also admired an exhibition entitled “Bewegung” (movement), sponsored by AOAA Germany, featuring 57 quilts that will be sold to raise funds for health projects in Malawi.

AOLAT Honorary Memberships In Davos in December, AO Latin

America President Carlos Sancineto paid tribute to AOLAT’s newly elected honorary members, James Kellam and Chris van der Werken, both AO Foundation Past-Presidents. The annual memberships demonstrate AOLAT’s gratitude for outstanding contributions by individuals to the Region’s development and evolution. Previous AOLAT Honorary Members Thomas Rüedi, Jesse Jupiter, and Urs Jann attended the celebration. Chris van der Werken first visited Latin America in 1996 as an invited guest of an AO Alumni Association (AOAA) meeting in Cartagena, Colombia. He has returned to the Region several times since then. Jim Kellam’s most important trip to the Region was to Puna Cana in the Dominican Republic. A hurricane delayed the third AOAA meeting by a month, but nevertheless he lent his support to the rescheduled event, one of the most successful meetings in the Region.

TK Innovation Prize 2008 The Technical Commissions and Specialty Expert Groups (TK-

System) have given their highest accolade, the TK Innovation Prize 2008 to Alberto Fernandez Dell’Oca from Montevideo, Uruguay, for his numerous contributions to the improvement of patient care. Norbert Haas and Pietro Regazzoni hosted the awards ceremony held in Davos on the occasion of a dinner for the chairmen of the TK Specialty Expert Groups. Alberto Fernandez was praised as a “lateral thinker”, a person who always questions established assertions and is unafraid to wander off the beaten track. He not only generates new ideas, it was said, but also possesses the assertiveness to convince others and to realize these new concepts. A brilliant surgeon-engineer, Dr Dell’Oca has over the years developed an incredible number of ingenious tools to faciliate surgical procedures.

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community zone

Panorama News, Events, People

8

Annual visit of Swiss students Some 70 French- and 130 German-speaking Swiss medical students took part in the annual “AO Courses for Medical Students—Treatment of Fractures” at the AO Center in Davos (21–24 January). Elyazid Mouhsine and Michael Wettstein ran the French-language course with Pierre Hoffmeyer participating, and Ali Djahangiri, Attila Güleryüz, and Eva Drescher assisting as lecturers and table instructors. Karl Stoffel and Christian Ryf ran the German-language course with support from local surgeons. Practical exercises on operating techniques using synthetic bone models proved the most popular for many students, who also learned of new developments in AO research and about the AO Surgery Reference. Clinical questions were discussed and professional and social friendships made during breaks and evening meals.

Vikas Kulshrestha Completed a 3-month fellowship in Clinical Investigation and Documentation at AOCID, Dübendorf

Vikas Kulshrestha, MS (Orth) Classified Specialist, Orthopedics Department of Surgery Command Hospital Air Force, Bangalore, India vikaskulshrestha71@gmail.com

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A major part of my work involves treating skeletal trauma in large hospitals. In my practice, clinical work, teaching and research go hand in hand as I routinely train residents, interns, nurses and paramedics. I also conduct medical research, which involves setting up high-quality clinical trials based on a sound knowledge of research methodology. AOCID in Dübendorf/Davos is unique in providing research training focused on trauma. I had the opportunity to work with world class epidemiologists, statisticians and other experts in this field. My stay at AOCID was a wonderful learning experience during which I analyzed results of my studies, submitted two articles for publication in an international journal, and designed a new

study proposal for my hospital in India. What I learned at AOCID will immensely benefi t my clinical research work. This fellowship also gave me an opportunity to connect with the AO community and this association will continue. I already was an AO Alumni member but this experience has further strengthened my bonds with AO, which I strongly feel a part of. Having watched Bollywood movies, we Indians know that Switzerland is a beautiful country, but what was extremely heartening to discover was its beautiful people, who are so friendly and helpful. Travelling around this extremely scenic country was an unbelievable experience. I am sure I will visit Switzerland again and next time I will not miss the Davos Courses.

Fellow’s opinion


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The AO says farewell to founding father Walter Stähli A key player in assessing the quality of AO instruments and implants, he was known for his quiet manner and wonderful sense of humor. Walter Stähli, one of 13 pioneering surgeons who started the AO in Biel, Switzerland, in 1958, passed away in his birthplace of Saint-Imier, canton Bern, on February 10, 2009, aged 97.

such as AO implants and instruments. When it came to testing them, he said that: “The quality of both the instruments and implants was very good. The village locksmith only had to be called in once” in order to remove an intramedullary nail.

Only a few months earlier, on November 6, 2008, Dr Stähli joined fellow AO Founding Members Maurice E Müller and August Guggenbühl for a special AO jubilee celebration at the Hotel Elite in Biel, where the AO was founded exactly 50 years before.

1 August Guggenbühl (left) and Walter Stähli (right) at the Hotel Elite in Biel, November 2008. 2 Walter Stähli in conversation with Alexander Boitzy, November 2008.

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Dr Stähli was born on October 20, 1911, in SaintImier. He studied medicine in Bern and Lausanne and obtained his Doctorate in Bern in 1940. He was assistant surgeon at the District Hospital in Biel and the Cantonal Women’s Clinic in Bern, as well as assistant medical director at the Solothurn District Hospital. From 1945 to 1981 he was chief surgeon at the Saint-Imier District Hospital in the Bernese Jura valley. From 1964 to 1982, Dr Stähli was a member of the hospital and home commission of canton Bern.

In an interview with AO World News late last year, Dr Stähli described his role in the AO’s early days. “Along with Dr (Walter) Schär, (a fellow AO founding father and close friend), I was an internist. We wanted people to use the items developed by the AO in their clinical practice. Our task was to check if the instruments were being developed properly and also used properly.”

Dr Stähli is survived by his wife, Annemarie, his son, Jean-Jacques, and numerous grandchildren and great-grandchildren. eig/ddf

Walter Stähli was known for his great sense of humor, even regarding a technical subject

2

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community zone

Report

10

From obesity to fitness and philanthropy AO Faculty member Chris Oliver made a drastic decision that changed his life and enabled him to help others in ways he never imagined. Chris Oliver AO co-Chairman European Faculty Seminar, Davos 2008 cwoliver@btopenworld.com

In February 2007 I was almost 168 kg and was morbidly obese; my body mass index was 53! I was really struggling at work, was desperate to lose weight, and had tried every diet. I could barely climb a flight of stairs and had severe metabolic syndrome. I decided to have an adjustable laparoscopic gastric band (lap band) placed around my stomach, which creates an upper pouch. As the name suggests, the band can be adjusted in follow-up, outpatient procedures to ensure the pouch is the right size to control weight loss, and it allows for full reversal, if needed. With this procedure, weight loss progresses steadily over a two-to-three year period and then stabilizes. The final result is usually a loss of between 50 and 60% of the excess weight. I wrote my living will and then “went for it”. The lap band has radically changed my life. Now, just over two years later, I have lost over 55 kg and am back to a reasonable weight and physical activity. The stomach pouch is about the size of a banana. If I eat too much I will be sick: I do not eat bread and rice, and my diet has changed to a fish- more than a meat-type one. My waist has decreased from 56 to 40 inches (142 to 102 cm) and I have progressed through a dynasty of trousers. I was fortunate to have had no postoperative complications. After surgery I had three weeks at home to recover. I had a deep reflective period and decided how I was going to live my life. I set myself a number of targets. One was to exercise as I had as a medical student. I have now returned to whitewater kayaking, cycling, and running. I have completed three triathlons and have learned how to

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scuba dive. In 2010 I am booked to go white-water kayaking in the Grand Canyon in Arizona. In 2008 my life as an AO Faculty member was much easier and I had much more energy. I taught on the AO Advances Course in Dubai, was a coauthor of the AO Surgery Reference module on the Distal Femur and Patella, and was co-Chairman of the European Faculty Seminar during the AO Davos Courses. As a very public figure, coping with the lap band has been very interesting. My patients no longer recognize me! I decided from the outset that I would tell everyone about my experience. I wrote a blog (www.christopheroliver.blogspot.com), which has become a tool for self-reflection and education. I get many visits from lap band patients all over the world. The British media has written a number of articles about me, which has spurred me on even further. I am one of the trauma surgeons who treated Edinburgh resident Olivia Giles, who lost both her hands and feet due to meningitis. In 2009 I’m going to cycle almost 1000 miles (1600 km) across the United Kingdom from Lands Ends, England, to John O’Groats, Scotland, to raise money for Olivia’s charity, 500 Miles FlySpec. It’s a service that takes free orthopedic, plastic, and reconstructive surgery, principally by air, to amputees and disabled persons in rural communities in Zambia. I could never have contemplated doing this before. To support me on the 500 Miles Fly Spec cycle, please go to: http://www.justgiving.com/chrisoliver500


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The Hank Hanff Fellowship— benefitting many future careers Diarmuid De Faoite Editor, AO Communications and Events Dübendorf, Switzerland diarmuid.defaoite@ aofoundation.org

Since the AO Fellowship program began in 1971, a total of about 5,000 Fellows have been sponsored through a variety of programs (see box). The AO Foundation is now one Fellowship richer thanks to the generosity of one of its long-serving faculty members. Hank Hanff, an American orthopedist with a practice in New Port Richey, Florida, has donated a large endowment to the AO to enable surgeons from North America, Ireland, Switzerland or Great Britain to apply for an AO Fellowship in one of these four places. These are the locations in which he has been most active in his faculty role.

Hank has attended more than 100 AO Courses in his career, serving as a faculty member on most of them. He calculates that in total he has spent a year of his life on AO courses. This makes his gesture all the more magnanimous. Paul Manson, President of the AO Foundation, gratefully accepted Hank’s check as part of the opening ceremony of the AO Davos Courses in December 2008. Hank’s passion and commitment to the AO was explicitly mentioned at the ceremony and is well known to all those who have ever met this genial Floridian. Addressing the audience in Davos, Hank explained the reason for his generosity, saying, “I was always too busy to put my ideas into practice—this is my way of giving something back. I am honored.” Piet de Boer, Director of AO Education, adds: “Hank has the AO running through his veins. His enthusiasm and commitment have been an example to us all. His hospitality has also been legendary.” The AO Foundation thanks you, Hank, for sponsoring this Fellowship: your gift will resonate in the careers of many AO surgeons to come.

Three distinct AO Fellowship programs are offered: AO Fellowship

AOCID Fellowship

AOSpine Fellowships

• AO Education offers 220 Fellowships (Trauma, CMF,

• AOCID’s Fellowship allows young motivated surgeons

• The purpose of AOSpine Fellowships is to provide

Vet, and CAS) for surgeons and ten Fellowships for

to get trained and gain experience in clinical research.

additional experience in AO techniques for fully trained

ORP every year.

The three main aspects are study planning, study

orthopedic and neurosurgeons.

• These Fellowships provide additional experience in AO techniques and philosophy for fully trained orthopedic or general surgeons and ORP with an interest in trauma.

monitoring, and finally, data analysis, reports and publication. • The Fellowship program is currently completely full, but motivated surgeons are welcome to submit their

• Fellowships are available for four to eight weeks in designated hospitals all over the world.

application before December 1, 2009 for an AOCID Fellowship in 2010.

• AOSpine offers five different types of Fellowships: observerships (one day-to-two weeks), short-term (one-to-three months), and long-term (nine-to-twelve months), along with self-funded and joint society Fellowships. • For further information, please go to www.aospine.org/fellowships.aspx.

You can find comprehensive Fellowship information as well as application forms on the AO website (www.aofoundation.org) in the ‘Web Services’ section under the heading ‘Funding’.

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community zone

In discussion

12

“A unique opportunity to express our gratitude to the AO network” In this interview, AO Foundation Past-President Chris van der Werken shares with AO Communications and Events Editor Diarmuid de Faoite his impressions of the AO’s 50th anniversary celebrations in 2008.

Chris van der Werken, why was it important to celebrate 50 years of the AO? Because it was a unique opportunity to express our gratitude to the network that made it so successful! It was also a chance to give something back to the people, the silent workers who do the work—researchers, doctors, etc. We’re talking about thousands and thousands of people all over the world. When did the event planning get underway? We began planning in September 2005. It was a good decision to start so early, as we needed that time. The goals were to have an unforgettable party and to give the whole network an opportunity to celebrate. What were your highpoints of the anniversary year? It started in March 2008 with the commemorative plaque unveiling in the Hotel Elite in Biel, which was particularly special since AO founding fathers Maurice E Müller and August Guggenbühl could be there.

Another highlight was the Trustees Meeting in Davos in the summer. It was rewarding for so many, especially since the Senior Trustees were also invited. It proved to be a major plus to have them there because the different generations got to mingle and the older members had the chance to meet one another again. It fitted with the anniversary year concept. A sizable chunk of the anniversary budget was spent on this but remember, without these senior surgeons there would have been no AO history. The traffic-free promenade, when the main street in Davos was blocked off and populated with stands and bands, was an excellent chance to interact 1 | 09


community zone

13 with local people from the town. Another notable event held during the Trustees Meeting was the unveiling of the sculpture commissioned by Robert Mathys Junior and his wife, Esther, which is on view in the lobby of the AO Center. The meeting was crowned by the gala dinner party. On one night we were able to give so many people from around the world a sense of the jubilee year. The gala dinner was the event! Every anniversary event had a social and a scientific element—why is that? One reason is that many of these events were organized together with, or on the occasion of, other existing events or congresses that take place annually. Since most people would be there anyway it was a low cost way to reach out to them: “business as usual”. It made sense from a logistics/ operational point of view—in this way we could cut travel costs, etc. The network also ‘bought in’ to this way of celebrating because we are a serious scientific organization. Was there media reaction to the celebrations? Not too much, it was quite low profile because the AO is an organization for surgeons. The AO is not too interesting for the wider public. People who live in Davos are obviously keener to learn about these doctors who come from all over the world to their town. That’s why it was a good decision to focus on the network and to host the Jubilee Trustees Meeting in Davos. A lot of your presidency was taken up with the anniversary year: did it ever get to be too much for you? No, I enjoyed it very much. If an enterprise is successful then you are in a winning mood. The Trustees Meeting week in Davos, with so many people, was a once-in-a-lifetime experience. People still say to me that “it was a wonderful party”. We selected the company to put on the show at the gala dinner in the ice stadium in Davos and they proved to be winners! They really did a fantastic job. So it’s not just the story of our success, it’s the success of everyone involved in putting on the celebrations.

that carries out Trojan work to make sure everything runs smoothly. How important is it to document the AO’s history, and is that even possible anymore given the organization’s size? I prefer to be future-orientated, but you have to reflect on history and prepare for the future. If you don’t learn from the past you will make the same mistakes in the future. Focusing on history also allows you to pay tribute to the people who made it possible.

Amirah Blackmore, as part of her work as the AO Anniversary Manager, began collecting photographs, documents, etc. These will be used to complete the AO archive and to make a start for the next 50 years. This is something positive, especially since in 50 years the AO will be 100 years old and living testimonies on the early years will be impossible to collect. It is proper and right to take the opportunity to collect things now, even if you can’t see the immediate benefit of doing so. The surgeons who did the pioneer work in the early days really had to fight to establish the AO Principles. We have all benefitted from their revolutionary work; it should be remembered and commemorated. What did the celebrations contribute to the AO? Overall, I have the feeling that the anniversary was good for the AO. It added to the wider AO family’s sense of belonging. My instinct is that people are proud to be a part of this network. The celebrations all went well and we did not make any grave mistakes, like forgetting to include certain people, sections, or regions. Last, but not least, we also managed to keep within our budget. Thank you very much for sharing your thoughts with us, Professor van der Werken.

Amirah Blackmore and Annina Schneider deserve special mention for their great organizational abilities. Amirah was responsible for the great program of events throughout the jubilee year and Annina is the main coordinator of the annual Trustees Meeting. Of course, there is an AO Events Team 1 | 09


community zone

From the regions

14

AO Trauma Middle East: a strong and collective voice

1

Mamoun Kremli AOTME Chairman Riyadh, Saudi Arabia mamoun.kremli@aoalumni.org

2

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community zone

15 Moving with the AO times Over the years, as the AO Foundation grew, numerous AO Education (AOE) activities were taking place in several countries of the Middle East. These events were coordinated by AOE together with individuals in each country and were neither consistent nor regular. Meanwhile, with the gradual development and expansion of AO activities in several regions around the world, came the AO Foundation’s idea of forming and strengthening distinct AO Regions.

4 A high-tech symposium during the fifth AO Regional Courses in Dubai.

The proposal to form a defined AO Middle East Region initially arose at a meeting of regional faculty members during the AO Regional Courses in Dubai in September 2005. During the following year’s Courses in October, the idea was further explored together with AOE Vice-Director Joachim Prein and participants from several Middle Eastern countries. The decision was made to begin working to have the Middle East established as an official AO Region, and Mamoun Kremli from Saudi Arabia assumed the task of preparing the bylaws, agenda, and material for the next meeting. On December 11, 2006, the AO Middle East (AOME) Board was established in Davos, where its first official meeting took place with Professor Prein in attendance.

5 AO Founding Member August Guggenbühl takes part in an AO Advances Course in Dubai, October 2008.

Surmounting challenges The road to incorporation presented several challenges. First of all, the newly established AOME Board needed clear bylaws that would solicit agree-

1

A focused participant in the AO Advances Course in Dubai, October 2008

2

The rapidly changing skyline of Dubai.

3 AO members enjoy dinner under the glowing lights of Dubai harbor.

4

ment and action. The Board Chairman needed to be elected from among members from different countries who had little knowledge of each other. In spite of this, the first meeting was a great success: the proposed bylaws were approved and the Chairman was unanimously elected thanks to the goodwill, enthusiasm and spirit of the Board Members. Further challenges included ensuring that all issues related to the AO would be discussed by the Board, and that all communication and implementation of decisions should pass through the Board Chairman. Again thanks to overwhelming cooperation among the Board Members, these challenges were smoothly accomplished within the first year. Meetings were regularly held and discussions were open and aimed at achieving a common goal—improving the quality of services provided to patients in the region by upgrading the level of surgical care. In no time, the members became one family with strong ties and a shared objective, all working for a common goal. All possible queries, cautions and reservations that usually accompany establishing a new Board completely disappeared. Full speed ahead Since December 2006, the AOME Board has held seven meetings. Ten countries have now joined and all have AO Alumni Association (AOAA) Chapters. Going east to west, these countries are Pakistan, Iran, the United Arab Emirates, Oman, Bahrain, Saudi Arabia, Jordan, Lebanon, Egypt,

5

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community zone

From the regions

16

6 AOTME trustees Hazem Abdul Azim, Kamel Afifi, and Mamoun Kremli, in Davos, December 2008. 7

AO Principles Course international faculty, in Dubai, October 2008.

8

Avidly applying new skills during an AO Principles Course.

and Libya. Several other countries are expected to join once their AOAA Chapters are established.

activities in the region are openly discussed in regular Board meetings.

All the countries represented on the AOME Board have equal voting power. Five of the member countries are now represented on the AO Board of Trustees. In addition, an AOME Board Secretary has been appointed and an annual administrative budget approved by the AO Foundation. This burgeoning Region has enjoyed continuous support from the AO Foundation, the AO administration, and particularly AO Education.

The AOME Region has proved the fastest growing in the AO’s history. The number of AO courses has steadily increased from nine in 2005 to 17 in 2006, 27 in 2007, and 28 in 2008. In 2009, 31 AO Courses are planned, some of which will be offered in countries that do not yet have members on the AOME Board in order to help them collect enough AO Alumni Members to start AOAA Chapters and thus become official members.

Multifaceted achievements Achievements on many tracks are being accomplished. The AOME Board has become the body through which countries in the region communicate with the AO, and all issues relating to AO

The annual AO Regional Courses in the Middle East have earned a very good reputation and have become the avenue for many surgeons from Africa, Asia and Europe to participate. Cooperation between AOME and AO Trauma Asia Pacific (AOTAP) has led to faculty interchange between the two Regions. Global faculty participation The number and quality of regional AO Faculty has progressively grown and improved. More than sixty AO Faculty Members from the region have attended an AO Tips for Trainers Course—some also teach the course, and several have become wellknown participants in AO Courses worldwide. AO Middle East has established a faculty development program at the local and regional course level where regional faculty have the chance to meet, interact with, and learn from renowned and experienced international AO Faculty members. For example, at the fifth AO Regional Courses in Dubai last October, international AO Faculty

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7

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community zone

17

8

member Mathew Porteous participated as a fulltime faculty mentor/facilitator, benefitting participants and thus improving the quality of local and regional faculty. Strong faculty support packages have been developed and are used across the Region to ensure high-quality local and regional courses, and well-tailored modules have been developed for AOME Principles and Advances Courses. An AO Fellowship Center was officially opened in Dubai as part of the AOAA Jubilee Symposium activities in October, which will surely provide excellent training facilities for all interested surgeons. In order to more accurately represent new developments within the AO, at a Board meeting in February 2009 the name AOME was changed to AO Trauma Middle East (AOTME) to represent the AO Trauma Specialty, and to differentiate it from AOSpine ME and AO CMF Middle East and North Africa. Although member countries come from a geographic area larger than the Middle

East, it was decided to keep that designation for simplicity’s sake. Exciting plans for the future AOTME will continue to develop and grow, and more countries are expected to join. To encourage this, several AO Courses are planned for nonmember countries to help improve their national medical services and stimulate their desire to become members. Without a doubt, local and regional courses will flourish in number and quality. The faculty development program will continue, enhancing the quality and quantity of regional faculty, and inciting new members to participate as faculty. An AOTME website and newsletter are expected to be launched in 2009, and it is anticipated that more AO Fellowship Centers will be recognized in the region. AOTME will become more integrated into the global AO family as well as being represented on various AO bodies and in AO activities.

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community zone

Internet

18

AO COIAC software: an indispensible tool The latest version, 3.0, was downloaded 1,500 times in its first four months.

Laurent Audigé Manager Methodology, AOCID Dübendorf, Switzerland aocoiac@aofoundation.org

As a result of longstanding collaboration between the AO Classification Supervisory Committee, AO Classification Groups, and the Orthopedic Trauma Association (OTA), in December 2008, AO Clinical Investigation and Documentation (AOCID) released the new, updated, version 3.0 of the AO Comprehensive Injury Automatic Classifier (AO COIAC), which is available to trauma surgeons worldwide as a free download. Software overview AO COIAC is a PC-based software with a flexible, open-source database system (MySQL). The updated, version 3.0 includes the adult AO/ OTA long bone and the pediatric long bone fracture classification systems, as well as a newly developed craniomaxillofacial system for injury location. A skeleton interface provides access to one of several area-specific classification modules. Clicking with the mouse on standard bone drawings provides the user with successive drop-down menus and classification options, making for a quick and easy-to-use classification process. In addition, clinical notes and diagnostic images can be saved in a specific history tab. Some of the major new features in version 3.0 include: • • • • • •

Server-client installation for multiple users Password-controlled access to the database Registration of clinical studies Improved searching tool Data export for exchange between databases Text-delimited data export for statistical analyses

Success around the world In just the first three months following AO COIAC version 3.0’s release, the 1,000th download barrier was broken and today surgeons all around the 1 | 09

world are benefiting from the software. The largest proportion of users is located in Europe, followed by Latin America, Asia Pacific, the Middle East, North America, and finally, Africa. Clinical implantation AO COIAC can be installed in a server-client setting that allows for multiple users to access patient and injury data from anywhere in the clinic network, for example, from the radiology department, surgeon’s office, and meeting rooms. A full pediatric documentation database including treatment, complications, and outcomes is currently being used in a pilot phase by members of the Pediatric Classification Group (PACG) in five clinics in Europe and the US. Tailoring AO COIAC to surgeons’ needs A free copy of AO COIAC and a detailed user’s manual can be downloaded from the AOCID page of the AO Foundation’s web portal using the following URL address: www.aofoundation.org/aocoiac AO COIAC has the capacity to be further developed as a standardized classification and documentation tool, all the while meeting your needs. Regular software updates will be made available. To help us tailor the development process to suit end-users’ requirements, a web-based survey was implemented within the AO surgeon community. Half-way through the survey, close to 80% of respondents rated AO COIAC as very/tremendously useful, and a similar proportion reported that the software should be further developed. As reported by 84%, a full version allowing complete case documentation would be extremely valuable for the AO Foundation. Feel free to contact us with your comments or questions at: aocoiac@aofoundation.org.


community zone

19

AO Surgery Reference: an ever-expanding repertoire tively, of the Distal Femur and Patella modules, and the text was composed by another group of international experts, Florian Gebhard (Germany), Phil Kregor (USA), and Chris Oliver (UK).

Just as the AO Surgery Reference was picking up its 11th award (the HIRC “WWW Health Award” for Best Health Website for a Professional Audience) in late December 2008, it crowned that event with yet another achievement, the release of three new modules, on the Hand, the Distal Femur and Patella, and the Mandible. Hand: 100 surgical procedures The Hand module is the largest and most elaborate to date with almost 100 surgical procedures. Under the executive editorship of Chris Colton (UK), and general editor Piet de Boer, authors Fiesky Nuñez (Venezuela), Renato Fricker (Switzerland), and Matej Kastelec (Slovenia) assembled material describing the whole of the surgical management process for most of the common fractures of the phalanges, metacarpals, carpus, and thumb. All the procedures are richly illustrated with drawings, clinical photographs and x-rays, and many are accompanied by an online video. “The Hand Module is an excellent teaching instrument,” says module co-author Fiesky Nuñez. “During my travels to meetings and courses, I frequently hear comments from fellow surgeons that the module ‘is an excellent publication,’ ‘it’s of great practical use,’ and ‘the structure is very easy to handle,’ and they are recommending it to their residents for treating patients.” Distal Femur and Patella: all-inclusive Chris Colton and Piet de Boer once again assumed the roles of executive and general editor, respec-

The authors, who were originally invited to create only the distal femoral module, volunteered to assemble the second module, on the patella, resulting in a consistent and comprehensive approach to the area. The entire surgical management process for all distal femoral and patellar fractures of the Müller AO classification system has been covered. As with the Hand module, drawings, photos and x-rays, as well as many online videos, supplement the procedures. Mandible: a CMF first In response to requests from the CMF community, the Surgery Reference has also released the first module for that Specialty, on the Mandible. Marcelo Figari (Argentina) and Gregorio SánchezAniceto (Spain) served as executive editors, and Daniel Buchbiner (US) acted as general editor. CMF surgeons Ricardo Cienfuegos (Mexico), CarlPeter Cornelius (Germany), Edward Ellis III and George Kushner (US) collaborated as authors. The navigation process for the Mandible module was specially adapted to better suit the decisionmaking process and terminology used in the treatment of mandibular fractures, says Tobias Hövekamp, project manager in AO Knowledge Services. “Most significant is that on the ‘Decision’ page (which replaces the ‘Indication’ page of the General Trauma section) all treatment options for a specific fracture location and morphology are listed on one screen, and along with each treatment option the respective indications are stated,” he explains. The release of the CMF midface module is scheduled for summer 2009, and the remaining anaeig tomical sections, in 2010 and 2011. To use the AO Surgery Reference, please go to: www.aosurgery.org

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expert zone Case study

20 This article considers how the hindfoot arthrodesis nail (HAN) answers requirements presented by complex cases in foot and ankle surgery.

Michael Castro (US), a member of the AO Foundation’s Foot and Ankle Expert Group (FAEG) together with Ian G Winson (UK), Les Grujic (AUS), Andrew Sands (US), Per-Henrik Agren (Sweden), and Juan Bernardo Gerstner Garcés (Colombia).

Advancing technology: the hindfoot arthrodesis nail The indications for tibiotalocalcaneal or tibiocalcaneal arthrodesis include pantalar arthritis, neuropathic fracture, osseous necrosis of the talus, failed total ankle arthroplasty, and symptomatic traumatic arthrosis involving the ankle and subtalar joints. Arthrodesis of these joints can be accomplished in several ways. Using large lag screws and plate fixation or a combination of these techniques has resulted in satisfactory outcomes, however, until consolidation is sufficient, weight bearing must be restricted to avoid hardware failure and mal- or nonunion. Intramedullary fixation has provided a means by which fusion can be achieved while allowing protected weight bearing 4-to-6 weeks after surgery. Implants designed for use in the distal femur were initially used for this purpose. Soon, many manufacturers produced intramedullary nails specific to the hindfoot and ankle. Almost without exception these devices are straight and are stabilized with locking screws both proximally and distally. The straight nail design has several inherent pitfalls. If the nail is inserted in alignment with the medullary canal of the tibia, the entry is through the sustentaculum tali, and the 1 | 09

neurovascular bundle and flexor hallucis longus tendon are at risk. If one places the nail in the medial/lateral center of the calcaneus, the nail must be angled medially to come to rest in the medullary canal of the tibia in order to avoid a varus position of the hindfoot. Angling of the nail results in a bending stress being applied to the device with weight bearing prior to consolidation. In addition, cantilever stress applied to the calcaneus causes problems with loosening or failure of the distal locking screws, osteolysis around the nail itself or failure of the nail. The hindfoot arthrodesis nail (HAN) differs from implants currently available on three main points. The first unique point is a 12° valgus bend at the level of the tibial plafond (Fig 1). This design allows the nail to be inserted in the medial/lateral center of the calcaneus and advanced through the talus or graft and into the medullary canal of the tibia. This feature allows for anatomical alignment (valgus) of the hindfoot while allowing axial loading of the implant. The distal locking options represent another feature unique to the HAN. In addition to distal locking with one or two 6.0 mm screws paralleling the long axis of the calcaneus, a twisted blade can be inserted and locked, creating a fixed, angled device. The blade’s geometry and broad surface equates with


expert zone

21

Fig 2 Fig 1

Fig 3

increased stability, which is paramount to the consolidation of the subtalar joint. A third unique feature is an oblique screw-hole at the level of the talus providing several options. When aligned with the longitudinal axis, a locking screw can be placed through the body, neck, and head of the talus. A lag screw can be used to achieve compression of graft material and a viable talar head in the case of osseous necrosis of the body of the talus. Another available option is the use of a screw of sufficient length to be advanced through the talus, navicular, medial cuneiform, and across the tarsometatarsal joint as adjunct stabilization of the medial column. The specific technique can be performed with the patient in prone, supine or lateral position. The tibiotalar and subtalar joints are exposed through a transfibular approach and prepared for arthrodesis. The plantar aspect of the calcaneus is exposed through a longitudinal plantar incision taking care to avoid injury to the plantar nerves. Reaming the calcaneus, talus, and tibia for nail placement is a two-step process. With the subtalar joint maintained in a weight-bearing position, a guide-wire is advanced with fluoroscopic assistance. The guide-wire is inserted in the medial/

lateral center of the calcaneus and advanced to the center of the dome of the talus, aligned with the center of the medullary canal of the tibia from a lateral projection (Fig 2). The guide-wire is over-reamed and removed. The ankle and subtalar joints are then inverted and a defect created in the center of the plafond. A ball-tipped guide-wire is advanced into the medullary canal and the tibia over-reamed to a diameter 1-to-2 mm greater then the diameter of the nail to be implanted. The nail is then inserted and locked, first distally, then proximally. The distal fibula is fixed to the tibia, talus, and calcaneus after removal of the medial cortex and subchondral bone. The fibula acts as a “living plate� and contributes to the fusion mass (Fig 3). The postoperative protocol is individualized. Generally, patients are non-weight-bearing for the first two weeks and then flatfoot-to-balance in a CAM walker for an additional three-to-four weeks. Weight bearing is increased slowly over the next fourto-six weeks based on x-ray and clinical examination. Once the patient is no longer restricted and wearing regular footgear, he/she is encouraged to have several pairs of shoes modified with a stiff rocker sole. This will help alleviate stresses to the midfoot and tibia. The HFN is available in three diameters (10, 12, and 13 mm) and three lengths (150, 180, and 240 mm). 1 | 09


expert zone Case study

22

4a

4b

4c

4d

Case study 1

5a

5b Case study 2

Case study 1

Case study 2

A 72-year-old male with a neuropathic fracture/dislocation involving the talus and subtalar joint (Fig 4a–b). The patient had become wheelchair bound due to his pain. His swelling precluded the use of off-the-shelf shoes. His treating physician, who referred him for a second opinion, had recommended an amputation. Arthrodesis of the ankle and subtalar joints was proposed. The patient was informed of the risks and benefits as well as the possibility of below knee amputation in the future. Following surgery, the patient began partial weight bearing at six weeks. At 12 weeks the CAM walker boot was discontinued and he was fitted with a UCBL shoe insert. At his 18-month follow up (Fig 4c–d) he was able to walk with a cane and the UCBL insert. His swelling had resolved sufficiently to wear regular footgear.

A 57-year-old diabetic male sustained a neuropathic fracture dislocation of the right ankle. He had been casted for eight weeks without first reducing the ankle. He was unable to bear weight and could not return to work as a chef. He was treated surgically with the HAN. As illustrated in the lateral x-ray, the anterior plafond had to be removed in order to realign the ankle joint. At his eight-week postoperative visit the patient was instructed to progress his weight bearing as tolerated using the CAM walker. At four months (x-rays) he was released to return to work. At six months his swelling had resolved by 50% (Fig 5a–b).

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expert zone

23

6a

6b

6c

6d

Case study 3

Case study 3 A 60-year-old male had been involved in a motor vehicle accident three years prior. He had sustained an open, trimalleolar ankle fracture with a comminuted fracture of the left talar body and a closed right trimalleolar ankle fracture. He had undergone open treatment of both injuries. Approximately one year after his accident he developed increasing pain and swelling. X-rays demonstrated collapse of the body of the talus and malunion of the medial malleolar osteotomy (Fig 6a-b). A plan was made to remove the necrotic, infected talar body. The head was maintained. A cement, antibiotic spacer was placed and the patient was immobilized with an external fixator while undergoing IV antibiotic therapy. Six weeks later the frame was removed. The antibiotic, cement spacer was removed in favor of a contoured femoral head allograft. The HAN was inserted

and a lag screw used to compress the talar head-graft interface (Fig 6c–d). Weight bearing was begun at three months. The patient walks with a cane and is to be suppressed with long-term oral antibiotic therapy.

Michael Castro

The CORE Institute–Paradise Valley Phoenix, Arizona, United States michael.castro@mac.com

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expert zone Clinical topic

24 Considering the advantages of percutaneous plating of the humerus combined with MIPO techniques.

Nikolaus Schwarz

Ventral plating of the humerus using minimally invasive plate osteosynthesis (MIPO) techniques

Rationale Conventional open plate osteosynthesis of the hu-

merus risks damage to the radial nerve; nailing may cause problems with the shoulder joint or the elbow; and there are fractures that are too complex to be fixed by intramedullary (IM) nailing. The ventral aspect of the humerus offers an approach that does not interfere with nerves or major blood vessels. Percutaneous plating is therefore feasible, and MIPO allows bridging of complex fractures. So far, three authors have reported on ventral humeral plating with a total of 19 patients [1–3].

Fracture reduction has been carried out with the plate in situ, eventually even after provisory fixation of the plate to one or both main fragments. The use of an arm-positioning instrument eases fracture reduction, but an external frame may be advantageous. Plate fixation itself follows the rules of MIPO. A locking compression plate (LCP) is the standard fixation device for shaft fractures. Long PHILOS plates are used in fractures that extend proximally into the humeral head. Results The age of the patients in a first series of 28 patients

Technique Two skin incisions are necessary: the proximal one is

a deltopectoral approach, or part of one, and the distal incision is done about 3 cm long over the biceps tendon. The sensory branch of the musculocutaneous nerve has to be preserved in the distal wound. Once the bone is prepared in both incisions, tunnelling of the ventral side of the humeral shaft with close contact to the bone is cautiously carried out. This is a smooth and easy manoeuvre, the deltoid insertion being the only structure giving some resistance. 1 | 09

varied between 38 and 84 years. So far, 17 patients have been followed for at least 6 months. Ten long PHILOS plates; four LCPs 4.5, three LCPs 3.5, and one tibial metaphyseal plate were used. Two out of 17 fractures have not healed: one pseudarthrosis is still stable with an intact plate and does not need further treatment; in the other patient a pseudarthrosis needed reoperation. One patient was lost during follow-up. There were no nerve injuries and no infections or other complications intraor postoperatively.


expert zone

25

1a

1c

1b

1d

Fig 1a–d An 82-year–old patient with a closed acute fracture, Müller AO Classification 12-A1, and no nerve injury (a). One small incision is placed over the deltopectoral groove, a second one over the distal biceps tendon (b). The LCP is introduced in a caudad direction (c). Healed fracture after 4 months (d).

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expert zone Clinical topic

26

2a

2b

2d

2c

Fig 2a–f

2e

2f

A 39-year-old patient with a closed acute fracture, Müller AO Classification 12-B1, and no nerve injury (a,b). Conservative treatment failed (c,d). Healed fracture after 11 months (e,f).

Conclusions MIPO of even complex humeral shaft fractures

Bibliography:

without exposure of the radial nerve can be done safely if the plate is placed anteriorly. Twisted plates would facilitate placement and reduction. More experience, especially regarding reduction technique, is still needed.

1. Apivatthakakul T, Arpornchayanon O, Bavornratanavech S (2005) Minimally invasive plate osteosynthesis (MIPO) of the humeral shaft fracture. Injury; 36:530–538. 2. Livani B, Dias Belangero W (2004) Bridging plate osteosynthesis of humeral shaft fractures. Injury; 35:587–595. 3. Suckel A (2007) [Minimal-invasive winkelstabile Plattenosteosynthese bei komplexer Humerusfraktur.] Unfallchirurg ; 110(8):707–710.


expert zone

27

3a

3b

3c

Fig 3a窶電 Same patient as in Fig 2. Range of motion 11 months after injury.

4b

4a Fig 4a窶田

A 39-year-old patient with a closed acute 12-C1 fracture, and no nerve injury (a). MIPO with PHILOS and follow-up after 14 weeks (b,c).

Nikolaus Schwarz

Trauma Hospital (Unfallkrankenhaus) Klagenfurt, Austria Nikolaus.Schwarz@auva.at

4c

3d


expert zone AO VET

28 Racetrack practice has become a very specialized field in equine veterinary medicine. This type of practice encompasses many aspects of sports medicine, not only that of the musculoskeletal system, but also of the respiratory and cardiovascular systems.

Patricia M Hogan

Fracture repair at the racetrack

As discussed in previous AO VET articles in AO Dialogue magazine, the issues relating to the poor performance of the equine athlete have many faces. Because there is often a significant financial investment involved with these horses, racetrack veterinarians are frequently presented with very difficult scenarios as to the care and treatment of their patients. Often the owner/ trainer desire a swift solution to a problem in order to participate in an important race, but they may not have the knowledge base or the presence of mind to take into account that the consequences of the swift solution may in fact be detrimental in the long run for the patient. Fortunately, the positive aspects of the economic factor allow for an eye on the future when dealing with an injury in a valuable racehorse. In these cases, the owner, trainer, and veterinarian can work together to devise a reasonable plan of action that may involve surgery and/or rest and will allow for a return to athletic activity at the horse’s previous level of racing. The important point is that the advances made in equine surgery have allowed for the luxury of having options, and have provided today’s racetrack veterinarian with multiple choices that may encourage an investment by the owner in a course of action that ultimately benefits the patient.

Orthopedic cases dominate racetrack practice Typically, orthopedic cases dominate in a racetrack referral surgical practice. This will include arthroscopic surgery for chip fracture removal, and tendon and ligament surgeries. In the author’s experience, condylar fractures comprise the overwhelming majority of the cases referred for internal fixation (2008:63) in a racetrack practice. This is followed by slab fractures of the carpus (2008:25), and sagittal fractures of the first phalanx (2008:15). In most of these cases, some form of an athletic career is desired and this is the impetus for repair. In the author’s practice, Thoroughbred and Standardbred racehorses predominate. This is somewhat unusual, as most surgeons working in the racetrack referral setting deal primarily with only one of these breeds, or with racing Quarter Horses. Specializing in both of the racing breeds allows for the opportunity to repair a larger number of the specific fractures listed previously compared to most other equine surgical practices. The observations noted here are based upon personal experience and are a reflection of the specific caseload seen in this author’s practice.


expert zone

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Fig 1a–b Preoperative digital x-rays (DP view at left, oblique view

Fig 2a–b

at right) of the right hind fetlock of a three-year-old Thoroughbred

as in Fig 1. The fracture healed with excellent anatomic alignment.

Digital x-rays of the right hind fetlock of the same horse

gelding (castrated stallion). This horse had sustained an unusual

After a rehabilitation period of eight months the horse successfully

displaced fracture of the distal axial portion of the lateral sesamoid

returned to racing.

bone (arrows). The fracture was successfully repaired with two cortex screws in lag fashion using arthroscopic technique to supervise anatomic reduction.

Evolving objectives in fracture repair Few advances in equine veterinary medicine have made as much of a clinical impact in recent years as those achieved in fracture repair. Surgical repair of fractures in horses has evolved over the past 30 years from one with purely a “salvage” objective to that of a “return to athletic performance,” and now in many cases, a “return to previous athletic form.” Combined with improvements in both general anesthesia and anesthetic recovery methods, the world of equine fracture repair has enjoyed remarkable growth and success in a relatively brief period of time. The overwhelming majority of fractures that occur in the Thoroughbred or Standardbred racehorse involve an articulation (Fig 1a–b). Since the introduction of arthroscopic surgery in the early 1970s, arthroscopic technique has become the standard of care for joint surgery in the horse. This in turn has led to the development of arthroscopically-assisted fracture repair techniques, which has contributed greatly to the increased success in returning horses to an athletic career following injury.

Continued advances in imaging technology have also provided tremendous advantages in the form of computed tomography and digital radiography, and direct digital radiography, thereby reducing operative time and surgical error. Fractures that were once considered too delicate to be repaired adequately using conventional open techniques can now be repaired using arthroscopically-assisted, minimally-invasive techniques that not only preserve joint function but also ensure a perfect articular reduction (Fig 2a–b). From euthanasia to a return to racing form The most common fractures seen in the racehorse involve the bones of the fore fetlock joint. Condylar fractures, involving the distal end of the cannon bone, are relatively frequent. These fractures occur in various forms and with differing degrees of severity. As recently as 15 years ago, a spiraling condylar fracture that extended the length of the cannon bone was considered a certain candidate for euthanasia, as repair and recovery was considered to be too risky. With the advent of better implants, such as the locking compression plate (LCP), improved anesthetic recovery methods, and refined surgical techniques,


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Fig 3a–b Pre- and postoperative xero x-rays of the right hind fetlock and cannon bone of a two-year-old Thoroughbred racehorse. There is a medial condylar fracture that propagated proximally the entire length of the third metatarsal bone (MtIII). This fracture was repaired successfully and the horse returned to its previous level of performance, until incurring an almost identical spiral condylar fracture in the left fore fetlock one year later. That fracture was then repaired using the same technique and the horse again returned to racing and remained competitive for 4 more years.

horses with these fractures now carry a very acceptable degree of risk for repair with the assumption that a return to racing is an attainable goal (Fig 3).

osteosynthesis will likely provide adjunctive measures in the form of gene therapy and mesenchymal stem cells that will continue to expand our horizons and abilities to accelerate and strengthen bone healing.

Even the most severe of orthopedic injuries in the racehorse have benefited from just the advances achieved in implant development alone. The increased strength and stability provided by the advent of the 5.5 mm cortical screw has been a major contributor to the improvement in success rates noted in equine fracture repair. And more recently, the introduction of the LCP has already made a positive impact on the surgical treatment of breakdown injuries, providing a stronger construct for arthrodesis techniques. A promising future It is very exciting to consider what the future may hold for equine fracture repair. The emphasis will certainly be on the continued development of stronger, more effective implants and on the expansion of minimally-invasive fixation techniques. Additionally, it appears that progressive research in the field of

Patricia M Hogan, DVM, Diplomate ACVS

Hogan Equine at Fair Winds Farm Cream Ridge, New Jersey, US www.HoganEquine.com info@hoganequine.com


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31 The AO Foundation develops new surgical techniques, techniques implants, implants and instruments under the medical guidance of independent surgeons. Responsible for the development and clinical testing of these devices as well as their educational concepts is an organization of medical-technical committees—the TK System. The interaction between industrial and medical experts cooperating according to AO Principles makes the TK System a unique institution for continuous innovation. Tim Pohlemann and Philip Schreiterer

The AO Technical Commission (AOTK) System

History and evolution At the AO’s very first meeting in March 1958, after testing the available osteosynthesis equipment on cadavers, it was decided to develop an AO standardized, comprehensive set of instruments and implants. Control over testing and power of decision making over the introduction of these new AO instruments and implants was given to the Technical Commission (AOTK), established in November 1961. The potential for innovation and specialization grew along with the increasing size of the AO community. Over the years, the AOTK founded subgroups, today called Expert Groups, for the different anatomical areas/clinical problems. The participation of more and more surgeons from all around the world provided the TK System with a comprehensive and diverse “voice of the practicing surgeon”, which influenced or even changed several points of view in the AO. The highest principles The TK System is an open forum for ideas concerning relevant clinical problems and possible solutions. Its different committees consist of surgeons (regular members and invited guests) who are the leading specialists in the relevant field. Under their clinical guidance, highly qualified engineers develop new devices. AO Research and Development (AO R&D) provides its expertise

by answering research-related questions or by informing about the latest findings. To ensure decision making according to clinical necessities, only medical members have voting rights and the chairman of each group is always a surgeon. Other than a per diem and reimbursement for travel expenses, participating surgeons receive no compensation. They are motivated by professional recognition, the chance to form friendships with respected colleagues, and the opportunity to see their ideas for improving patient care transformed into reality. Cooperation with industry Interaction with industrial partners is a key element of the TK System. The medical members seldom have a finished solution to a clinical problem right from the start, but rely on engineers and other specialists for design feedback, prototyping, testing, and framing the discussion in terms of manufacturing specifications. After identifying medical needs and defining critical characteristics, the engineers work on technical solutions and present them to the surgeons. These devices are discussed, adapted, and


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Fig 1

One of the first AO tool kits.

Fig 2

Norbert Haas teaching at the AO Combined Courses in Chiang Mai, Thailand, in 2006.

Fig 3

Carlos Ries Centeno of the Craniomaxillofacial Expert Group (CMFEG).

Fig 4

Tim Pohlemann instructs course participants in the use of the Pelvic Emergency Clamp.

tested (material, mechanical, biomechanical, and/or cadaver) until a final prototype is felt to be adequate. With this design the industrial partner then obtains regulatory approvals. After FDA-approval and CE-Marking have been received, clinical evaluation starts until the device is proven to be of “AO Standard”. Only then does the responsible Expert Group propose the device to the AOTK for a final quality assurance check. Only the AOTK has the authority to release a new device, which may then be brought onto the market by Synthes. The length of time needed for developing and testing a new product depends on the degree of innovation: line extensions may take less than six months, whereas major innovations may take as long as three to four years. It is worth repeating that only medical members have voting rights, and that all legal obligations relating to the CE mark or FDA approval have been obtained long before the AOTK decision about market release, implying that AO quality standards are higher than any existing legal requirements worldwide. This is the heart of what makes the TK system unique. Synthes deserves

high credit for complying with the TK process, delegating the power to an independent body of clinicians to make decisions on the market introduction of any new product. Interface to education Depending on the complexity of the new device, teaching concepts and materials (videos, publications, course contents, etc) are defined and their production controlled by the Expert Group that was responsible during the development process. The medical content of all publications produced by the AO about these products is supervised by the Expert Group. In many courses, the TK System provides the initial faculty, since they are the only ones possessing clinical experience with the new devices at that point of time. The TK System today One of the most significant changes in recent years was the “Three Pillars” reform of 2005, which created an overall steering board, the TK Executive Board (TKEB), and three separate pillars for Trauma, Spine, and CMF. Each pillar has its own


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Fig 5

The Spine Non-Fusion Expert Group (NFEG) in the lab.

Fig 6

The Trauma Foot and Ankle Expert Group (FAEG) testing the hindfoot arthrodesis nail (HAN).

Fig 7

A new navigation device gets the AO Foundation stamp of approval.

Fig 8

CS Expert Group member Florian Gebhard teaching computer-assisted surgery.

Specialty AOTK with the power to approve new devices and Specialty Expert Groups. The greater autonomy of the Specialty pillars has encouraged more involvement from surgeons who are not AO members, and facilitated interaction with highly specialized experts in research and engineering. Another recent focus was regionalization. Overall membership of the TK System increased to 134 surgeons worldwide, welcoming the first three members from the Middle East in 2008. A regional group was founded in Asia Pacific to adapt existing devices to the specific anatomical needs of patients in that region. Regional events such as the Experts’ Symposia, which foster open clinical exchange, were held in Europe, Asia, US, and, for the first time, Africa. Since 2008, the TK System has assumed responsibility for clinical studies of new devices. With the support of AO Clinical Investigation and Documentation (AOCID), studies are planned by the Expert Group that developed the new device, and are approved by the AOTK.

Involvement from idea to education Any surgeon can address his approach for solving a clinical problem to the TK System. After a first assessment, mainly concerning novelty, contact will be established with other innovative AO surgeons in the relevant Expert Group. In collaboration with them, the potential for the technique, possible improvements, and alternative approaches will be evaluated. If a project is started, the surgeon who proposed the idea will be involved in all further activities, such as:

• Development and non-clinical testing until final prototype • Clinical testing in selected reference clinics • Publication of test results/clinical evaluation • Production of teaching concepts and materials in collaboration with AO Education • Teaching at AO Courses • Exchange meetings with the main clinical users, which provide clinical feedback for further improvements of the device or its handling


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9 Fig 9

10 Different generations of the AOTK together in Davos, December 2008.

Fig 10 Fernandez Dell’Oca, TK Innovation Prize 2008 winner, feeling the pinch from TK Executive Board Member Pietro Regazzoni.

A recent change in leadership In January 2009, Tim Pohlemann took over the chairmanship of the TK System. In the 48 years since the inauguration of the AOTK, he is only the fourth chairman, succeeding Maurice Müller (1961–82), Stephan Perren (1982–97), and Norbert Haas (1998–2008). Tim Pohlemann is Director of the Department of Trauma, Hand and Reconstructive Surgery of the Saarland University Hospital, Homburg/Saar, Germany. He possesses vast experience gained over 16 years in the TK System, including eight years as chairman of the Pelvic Expert Group. Challenges to the TK System Challenges facing the TK System include increasingly restrictive regulations at hospitals, the chronic shortage of surgeons’ time, complex requirements for project coordination and information exchange, and the increasing number and variety of new products. An increased level of evidence is required to maintain the AO’s high clinical standard, but also due to regulatory and economic changes. Together with AOCID, the TK System needs to design innovative studies and enhance clinical evaluation in order to secure highly ranked publications.

A main focus will be the identification of potential new areas. As new, even more complex technologies evolve, such as biotechnology or nanotechnology, the TK System needs to attract specialists without AO affiliation. Experience has shown that the integration of these new technologies into musculoskeletal surgery should be guided by surgeons according to clinical needs. Summary and outlook The TK System offers any surgeon an opportunity to realize his ideas. Innovative surgeons are provided with optimal technical support and introduced to an international network of surgeons dedicated to research, development, clinical testing, and teaching. As part of this clinical think tank he/she can provide the surgical community with continuously improved treatment options. To learn more, please visit www.aofoundation.org/ (AO in-depth; Activities; AOTK)

Tim Pohlemann

Philip Schreiterer

Chairman, TK Executive Board (TKEB) Homburg/Saar, Germany Tim.Pohlemann@uniklinikum-saarland.de

Project Manager, Trauma, TK Office Davos, Switzerland philip.schreiterer@aofoundation.org


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35 A visual representation of how the TK Executive Board is organized.

TK Executive Board

AOTK (Trauma)

AOSpine TK

AOTK (CMF)

Lower Extremity EG

Fusion EG

Craniomaxillofacial EG

Veterinary EG

Deformity EG

Mandible EG

Foot & Ankle EG

Non-Fusion EG

Comprehensive EG

Hand EG

Access & Navigation EG

Knee EG Paediatric EG Pelvic EG Upper Extremity EG Min. invasive Osteosynthesis EG Computer Assisted Surgery EG Computer Assisted d Surgery WG for North America External Fixation WG Intramedullary Nailing WG Asian Pacific (Trauma) WG

Neuro WG Sternum WG


1 | 09

Upcoming Events

Moscow, Russian Federation

Teheran, Iran

— Principles of Operative Fracture Management

— CMF Advanced Seminar

June 1–5, 2009

June 18–19, 2009

Siófok, Hungary

Wildbad Kreuth, Germany

— Advances in Operative Fracture Management

— Süddeutsches AO Seminar für Aerzte

June 3– 6, 2009

June 18–19, 2009

Lusaka, Zambia

El Mechtel Tunis, Tunisia

— AO/SEC Principles of Operative Fracture Management–ORP

— Advances in Operative Fracture Management

June 4– 6, 2009

June 18–21, 2009

Tomar, Portugal

Madrid, Spain

— Principles of Operative Fracture Management–ORP

— Small Animal Principles Course

June 4– 6, 2009

June 18–21, 2009

Kobe, Japan

Tripoli, Libyan Arab Jamahiriya

— Vet Small Animal Principles Course

— Principles in Operative Fracture Management — Advances in Operative Fracture Management

June 5–7, 2009

June 21–24, 2009 Baguio City, Philippines

— CMF Advances Course June 6–7, 2009

Sydney, Australia

— Craniomaxillofacial Course for ORP June 22–23, 2009

Dhaka, Bangladesh

— AO/SEC Nonoperative Fracture Treatment June 6–8, 2009 Copenhagen, Denmark

— 3rd Nordic Craniomaxillofacial Principles Course

Sinaia, Romania

— Principles in Operative Fracture Management — Advances in Operative Fracture Management — Geriatric Fractures Course June 22–25, 2009

June 8–10, 2009 Leeds, United Kingdom Surabaya, Indonesia

— CMF Principles Course June 12–14, 2009

— Principles in Operative Fracture Management June 22–25, 2009

— Advances in Operative Fracture Management June 23–26, 2009

Linko, Taiwan, R.O.C.

— CMF Advances Course—resorbable and distraction June 13–14, 2009

— Advances in Operative Fracture Management-ORP June 24–26, 2009

– Principles in Operative Fracture Management-ORP June 30–July 2, 2009

Salzburg, Austria

— Bone Management in Neurotrauma June 15–16, 2009

For more news and events, visit

www.aofoundation.org


AO Dialogue 1|09