The magazine for the AO community
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A ne new w m ile e stt on o e in i o ort rtt ho hope pe e di d c su u rg rger err y
Biomedical research in schools | Old-timer rally from Beijing to Paris AO Latin America operations | Prehospital care of equine fracture patients
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30.4.2008
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From the AO Institutes
AO Dialogue 2008 Editor-in-Chief: James F Kellam Managing Editor: Elena Grimaud Ineichen Contributors: Diarmuid De Faoite Editorial Advisory Board: Jorge E Alonso James Hunter Frankie Leung Rodrigo Pesantez Pol M Rommens Publisher: AO Foundation Production: AO Publishing 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 © 2008 AO Foundation, Switzerland
All rights reserved. Any reproduction, 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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AO Research Institute (ARI)
AO Development (ADI)
AO Education (AOE)
The surface of any implant influences the body’s response to it. In vivo tests show that polishing titanium cortical screws reduces removal torque. Other tests regarding bony in-growth onto intramedullary (IM) nails showed that polishing significantly reduced the extraction force required for titanium alloy (TAN) IM nail removal. As TAN is preferred over stainless steel for IM nailing, due to its better biocompatibility and mechanical properties, these results can be used to recommend changes to current surface characteristics of IM nails. This should reduce complications seen with nail removal, especially with rapidly growing bone in pediatrics.
Due to AOVA’s decision of December 2007, an R&D Competence Center will be created by combining the existing AO Research Institute (ARI) and AO Development Institute (ADI).
A record number of 17 courses were successfully completed in Davos in 2007. Course evaluations showed a small but significant improvement in the quality of education, as assessed by course participants.
The first steps to establish the AO R&D Competence Center will be taken through workshops and task forces. Participants drawn from all levels of the ARI and ADI hierarchy will be invited to take part. Current and future project work will be analyzed and developed during the design process throughout 2008. The complete changeover is planned for 2009.
Education plans for 2008 show an increase in course days of 16%, with the largest increase in education occurring in Asia-Pacific. Much of this is due to the growing number of specialty courses, reflecting the needs of course participants on a worldwide basis. Achieving our education goals within necessary budgetary constraints will be the challenge for 2008.
AO Clinical Investigation & Documentation (AOCID)
The annual audit by SQS went very well, with no complaints recorded; as a result, renewal of the ISO9001:2000 has been granted. The contract with FIDIA, an Italian biotechnology company, for the conduct of a Phase II trial has been signed, with the trial set to start in June 2008. The product under investigation is an antiscar-forming device used during spinal surgery.
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My view
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Table of contents
community zone
Panorama
4–7 News & Events 8–9 People Report
10 Taking biomedical research to schools 12 Old-timer rally from Beijing to Paris
expert zone
Clinical topic
Minimally invasive osteosynthesis MIPO of the humeral shaft
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Percutaneous fixation of pelvic and acetabular fractures 30 MIPO in the lower extremity: a Latin American perspective 34 AO Vet news
Inside AO
18 The AO’s 50th anniversary celebration
Prehospital care of equine fracture patients 36
From the regions
22 AO Latin America Internet
25 AO Portal redesign
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6 18
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22 26
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James F Kellam Editor-in-Chief james.kellam@aofoundation.org
On March 28, 2008, Maurice Müller unveiled a plaque commemorating the AO’s first 50 years at the Hotel Elite in Biel, Switzerland, where the AO was founded. Maurice Müller had a vision, and together with twelve other innovative Swiss surgeons, he provided a platform to allow interested, inventive and collaborative people the opportunity to build upon his ideas. This was not limited to orthopedics and fracture surgery, but to all aspects of life. This issue of AO Dialogue shows how the AO and those involved with the Foundation continue to promote the founders’ concepts. Markus Rauh, chairman of the AO Board of Directors, was instrumental in the reenactment of the 1907 Peking-to-Paris car rally last year, showing how one individual with an idea can bring people together to accomplish a goal. AO Research Fund prize winner Karen Burg has a mission to open the imaginations of young people to scientific method. She discusses taking science and its attendant excitement to the classrooms of elementary and high school students. In the Expert Zone, Rodrigo Pesantez has put together several articles by innovators in the newer techniques of minimally invasive fracture surgery, who discuss its use with humeral shaft fractures, and look at different options around the pelvis, acetabulum, and the lower extremity. These diverse articles show how our founders created an organization that provides a platform for individuals to be creative, innovative, and most significant, to add something important to others’ lives.
30.4.2008 7:57:05 Uhr
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News & Events
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World Forum for Spine Research
AO Italy courses held in Davos The Congress Center in Davos in February 2008 welcomed Italian surgeons taking part in three courses organized by AO Italy, including the AO Principles Course (Base) and the AO Advances Course (Avanzato), each of which attracted 72 participants and a handful of invited observers. Forty participants attended an additional course, AO Comprehensive sul ginocchio—a comprehensive course focusing on the knee. Innovations this year included a joint session for all three courses to help foster communication between the groups, an imaging workshop featuring state-of-the-art technology, and follow-up discussions, all of which were wellappreciated. “The courses offered are based upon the needs of Italian surgeons and there is certainly great demand for AO courses in Italy,” says AO Italy Education Board Faculty Member Nicola Annicchiarico.
The World Forum for Spine Research, held at end-January 2008 in Kyoto, Japan, was a great success and a fitting start to the AO Foundation’s 50th anniversary celebrations. The AO Foundation and AOSpine were two of the major sponsors of this high-caliber meeting of clinicians, biologists, engineers and scientists, which received excellent reviews, not only from participants, but also from faculty members. It consisted of lectures by faculty, invited talks, short poster talks, and general poster presentations. The young age of many of the participants was noticeable and may have contributed to the high levels of enthusiasm and motivation that were much in evidence. With just over 200 scientific participants from 32 countries, this was a truly international gathering of experts, and clearly demonstrated the value of such meetings.
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Two-day celebrations in Kobe, Japan to commemorate the 20th anniversary of AO courses in Japan, the 10th anniversary of the AOAA Japan Chapter, and the AO’s 50th anniversary, began with a memorial party on Saturday, February 23, 2008, and closed with a memorial lecture the following morning. The first AO course in Japan was held in 1987 and for the next ten years courses were conducted mainly by foreign faculty and professors with Japanese universities. With the formal inauguration of the AOAA Japan chapter in October 1998, this changed and today, the chapter’s 240 members are involved in AO courses, seminars, translation of AO books, clinical research, and web page updates. Reflecting on AO Japan’s 20-yearhistory, as well as the next 50 years, celebrants appreciated the important role the AO Foundation has played and will continue to play in terms of improved trauma care, daily clinical practice, and research and development in Japan.
30.4.2008 7:57:24 Uhr
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Panorama
AO SEC trauma symposium in Nepal
The Orthopedic & Trauma Foundation, Nepal, hosted a two-day trauma symposium on nonoperative fracture treatment from January 11 to 12, 2008, at Janakpurdham. This program was sponsored by the Socio Economic Committee (SEC) of the AO Foundation and for the second time took place in Nepal. Forty-six participants and four faculty members took part. The main objective was to make young trauma surgeons and general medical doctors in Nepal aware of the “Principles and Practice of Nonoperative Fracture Management” through presentations, demonstrations, discussions, and hands-on workshops. Local problems were discussed at length with an emphasis on local adaptations, and a special session on close management of common fractures with plaster and traction application was held. Problem-based learning and evidence-based teaching are the two prongs of this educational program specially designed for underfinanced and developing countries.
CMF symposium celebrations in Utah
On the occasion of the annual advanced craniomaxillofacial symposium at Snowbird, Utah, from February 22 to 24, 2008, AO CMF NA (North America) and AO CMF LAT (Latin America) joined together to celebrate the AO’s 50th anniversary. The theme of the advanced symposium was CMF surgery in the age extremes (pediatrics and geriatrics). Up for discussion were a number of topics dealing with the intricate nature of operating on these two age populations. The keynote lecture was delivered by Joseph Gruss, pioneer in the treatment of craniomaxillofacial fractures and congenital deformities in children and long time AO CMF faculty member. The symposium’s highlight was the reception organized by AONA to celebrate the AO’s 50th anniversary. The event was attended by symposium participants as well as by a number of AONA medical education key personnel and AO CMF NA faculty members.
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30.4.2008 7:57:30 Uhr
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News & Events
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Medical students at the AO Center Two courses for medical students from five different Swiss universities took place in January 2008 at the AO Center in Davos, Switzerland. For the first time since these annual courses began more than 30 years ago, they were given in French and in German. Over 80 students from Lausanne and Geneva participated in the French-language course on January 16 and 17, 2008, while the German-language course held on January 18 and 19 welcomed 144 students. Elyazid Mouhsine, Volker Braunstein, and Christian Ryf supervised the ever-popular practical exercises in operating techniques using synthetic bone models. Students learned of new developments in the AO Foundation, in research, and about the multi-awardwinning online reference website, the AO Surgery Reference. Lectures on developments in the most common winter sports injuries over the past 30 years, and on rescue operations in the Parsenn ski region completed the course.
Geriatric Fracture Management course in Hong Kong The Hong Kong AO Alumni chapter held the first AO course in geriatric fracture management in Asia. Through the leadership of course chairman Frankie Leung, a comprehensive scientific program and practical exercises for state-of-the-art fragility fracture fixation methods were conducted during the three-day program. Distinguished faculty including Michael Blauth, Stephen Kates, Robert McCann and AOTAP old guards Suthorn Bavonratanavech and G On Tong shared their experience in fracture management of fragility fractures with the 45 course participants, who realized they share common issues and problems in effecting the ideal clinical pathway, notwithstanding the difference in geographical regions. The recently launched “hip fracture surgery clinical pathway� presented by TW Lau was commended for taking the first step of starting such a program in Hong Kong. Participants will return to their respective practices and lead their colleagues in the formulation of health policies to improve geriatric fracture care management, something which should be a co-managed program.
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30.4.2008 7:57:35 Uhr
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AOSpine’s new membership concept
Since December 9, 2007, AOSpine has operated a subscription service for members offering three packages—Basic, Classic, and Professional, each with a selection of benefits to suit different needs. In addition to their chosen benefits, members receive hard copies of AOSpine journals, eg, the new members’ magazine, “myAOSpine”. eMembers pay a reduced fee and can download these journals in electronic format only. AOSpine follows a simple, transparent system of member progression regardless of the package chosen: Bronze, Silver, Gold, and Platinum. Every position or activity within AOSpine is assigned a defined points value. You earn your points by contributing to AOSpine. Subscribing members who get involved in the AOSpine community are entitled to further privileges, rewards, and exclusive offers. To join, go to www.aospine.org and click on the link: Apply for membership. Subscriptions go directly back into benefits. As membership grows, AOSpine will be able to leverage funds into delivering increased and more varied benefits for its members.
AO North America has been granted reaccreditation for four more years until March 2012 by the Accreditation Council for Continuing Medical Education. AONA was evaluated and found in compliance with all criteria from its purpose and mission, educational planning and evaluation processes, administration, standards for commercial support, to its accreditation policies. It received exemplary compliance for consistent use of multiple sources of needs assessment data to plan continuing medical education activities. The reaccreditation reaffirms AONA’s mission to improve patient care through education and research in the principles, practice, and results of treatment. AONA has also been reviewed and approved by the American Association of Veterinary State Boards as a Registry of Approved Continuing Education provider for veterinarians through to February 2010.
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The AO Educators’ Seminar for ORP, from December 9 to 14, 2007, in Davos, provided an excellent opportunity for course participants to improve professional skills relevant to their everyday work. The seminar focused on “Teaching and Learning” and “Leading and Organization” and subjects proved “an inspiration to my work in the theatre and education,” says participant Forcina Mdala of Malawi. “I learned more about giving a lecture, leading discussion groups and running a practical exercise. My confidence is enhanced due to the knowledge and skills I acquired.” Interacting with colleagues from other countries “gave us the chance to exchange experiences about our daily professional lives…and has motivated me to reach out to ORP nurses in other hospitals,” she says. Cristina Mariscal of Spain appreciates that: “Everyone in the group wanted to help each other. I met wonderful people, faculty and participants and learned so many useful things. I will never forget this week.”
30.4.2008 7:57:40 Uhr
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A Tribute to Berton Rahn
On March 26, 2008, Berton A Rahn finally found release from a long and difficult illness. Berton studied dentistry and medicine in Zurich and Berlin. In 1968 he joined the Laboratory for Experimental Surgery in Davos, a group whose future was uncertain, as the AO Research Institute then had secure funding for only a few months. He stayed for 37 years. Berton studied oral surgery and he made important contributions to the development of craniomaxillofacial surgery as well as dental implantology. He also was interested in the microscopic anatomy (histology) of bone healing and developed polychrome sequence labeling for newly formed bone, today used worldwide in bone research. He also looked at the chemical stimulation of bone healing, which in conjunction with the treatment of bone loss (osteoporosis), is currently receiving a lot of attention. His research was characterized by its scientific creativity, and particularly by the support he offered to young researchers. Berton was also vice-director of the AO Research Institute and in his retirement served as Scientific Advisor to AO research. We have lost a quiet man of depth; we regret he could not enjoy the fruits of his labors for a longer time. His many scientific contributions to journals and books will outlast him.
AOLAT honorary memberships awarded On December 12, 2007, AOLAT paid tribute to Erich Schneider, Jesse B Jupiter, and Esther Stoop to demonstrate AOLAT’s gratitude for the outstanding contributions the three have made to the region’s development and evolution. Erich Schneider and Jesse Jupiter received from Jaime Quintero, on behalf of Carlos Sancineto and AOLAT, a diploma naming them as honorary members of AOLAT. Esther Stoop has been instrumental in developing the AO Alumni Association (AOAA) all over Latin America. Jesse Jupiter has been to almost every country south of Mexico to teach different techniques in trauma and upper extremity surgery and many Latin American surgeons have visited him at Massachusetts General Hospital in Boston as AO fellows and visiting professors. Erich Schneider has helped AOLAT take its first steps in basic research and at the last AOAA meeting in Cancún, Mexico, both he and Beate Hanson taught members how to assemble a “Road to Research Map” in basic and clinical investigation.
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Dedication to both patients and medical staff: Cathy Connolly
The Australian and international nursing communities are mourning the loss of a valued mentor, colleague and friend with the death due to cancer of Cathy Connolly, aged 42, on September 24, 2007. Cathy participated in the AO ORP basic course in Sydney, Australia, in 2000 and her enthusiasm to teach and mentor lead to her being invited to the ORP Educators’ Seminar later that year. An active faculty member, in 2002 she took part in the formation of the ORP Alumni Chapter, welcomed into the AOAA during the Davos courses that year. In 2003, Cathy was appointed the first chairperson of the executive committee of the ORP Alumni. Ever active in the Australian AO community, she was named a director for AO Oceania in 2005. In her free time, Cathy volunteered for an orthopedic outreach program providing treatment for the underprivileged. Cathy is remembered for her dedication to both patients and medical staff and for her natural skills at mentoring younger nurses, inspiring them with her passion for orthopedic trauma surgery.
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Joseph Schatzker honored AO Foundation Past-President Joseph Schatzker has received the highest distinction awarded to Canadian citizens, the Order of Canada, in recognition of his contributions to orthopedic surgery, particularly for introducing surgical procedures for the internal fixation of fractures to North American surgeons. The Right Honorable Michaëlle Jean, Governor General of Canada, announced the appointment of Professor Schatzker, of Toronto, on December 29, 2007.
TK Awards 2007
The Technical Commissions and Specialty Expert Groups (comprising the TK-System) gave their highest accolade, the TK Innovation Prize 2007, to two Japanese surgeons. Takeshi Sawaguchi was recognized for his numerous contributions to developments in the distal tibia and foot, as well as adaptations of existing implants to the Asian anatomy. Toru Sato also received the prize for his numerous contributions to developments in intramedullary nailing and adaptations of existing implants to the Asian anatomy. Peter Messmer, from Basel, Switzerland, was honored with the TK Certificate of Merit 2007, for his outstanding contributions to the development of the co-axial clamp.
Paula Sotelo
Completed a fellowship in Clinical Investigation and Documentation at AOCID, Dübendorf.
Paula Sotelo, MD Hospital del Trabajador Santiago, Chile psotelo@hts.cl
A fellowship is beyond learning techniques or aptitudes, it broadens our views, experience and world in order that we become better doctors. Being a young orthopedic surgeon involved for some years in the hand surgery field, I needed concepts on clinical investigation. The AOCID fellowship offered all that I was searching for. I learned new concepts and investigation techniques, but it was even more than that. It was tutoring by people with great experience in clinical investigation sharing their knowledge and know-how in a friendly and open manner. The friendships established, new concepts I learned, and being involved from the first day in up-todate clinical investigation techniques were more than just “learning experiences”–they were life changing.
Having these mentors-friends is the most powerful tool the AOCID fellowship gave me. Even though I am no longer their fellow, they continue to encourage, teach and help me. This has allowed me to develop a new branch in my practice, not only for myself, but to share with colleagues at my hospital and with orthopedic surgeons in Latin America. A career and life learning experience, with mentors-friends made along the way.
Fellow’s opinion
community zone
Upper row, (left to right): Andreas Fäh, Theddy Slongo, Laurent Audige, Jim Kellam, Bottom row, (left to right): Isabel Diterich, Paula Sotelo, Jannicke Juchli, and Michael Weninger.
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30.4.2008 7:57:46 Uhr
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So, what do you want to be when you grow up? An AO Research Fund Prize winner takes biomedical research to schools
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Karen Burg Department of Bioengineering Clemson University Clemson, South Carolina, US kburg@exchange.clemson.edu
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I first learned about the amazing world (no bias) of biomedical engineering when I was 17 and considering “what I wanted to be when I grew up.” The discovery was completely by happenstance: a good friend of mine relayed to me her ambition to be a designer of biomedical implants and systems—hips, hearts, and knees. What an exciting concept! Her enthusiasm for this career was contagious and I subsequently focused my
goals on obtaining engineering degrees, then working as a research fellow at a medical center, and eventually obtaining a faculty position and building a research program in engineered tissues. I feel enormously fortunate to have stumbled into this line of work, however, I also feel that students should not have to stumble into careers and should have more awareness of science, engineering, and medical careers at an earlier
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age than I did. I feel that we who are in the field of medical research should be proactive in ensuring that students have every opportunity to learn about our field. I have attempted to respond to this obligation by integrating an outreach component into my research activities. The issue is knowledge
My overarching goal is to assist in creating informed individuals with an understanding of biomedicine and the role it plays in their lives; my expectation is not to convert the world’s children to clinicians and biomedical researchers. Will I be ecstatic if our efforts convince a few kids to become bioengineers or physicians? Absolutely! However, the larger issue at stake is knowledge, access to that knowledge, and the effect on public policy. There are so many medical policies that are defined with input from the public. An uninformed public means an uninformed decisionmaking process. I believe that we want our children to become critical thinkers, able to observe, listen, synthesize, and act accordingly. Seeing and learning
1 Karen Burg receives the 2006 AO Research Fund Prize Award from Fund Chairman Adrian Sugar. 2 Karen Burg (left) and Clemson University graduate students Cheryl Gomillion and Cheryl Parzel at a workshop for teachers at the Boston Museum of Science.
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My specific outreach activities center on community engagement projects with particular focus on injecting the school system with biomedical/ bioengineering concepts and ideas. The AO Research Grant is one of several grants that have produced content that has been translated into a classroom setting. The concept is simple: I work with a team of my graduate students in distilling complicated research topics (like the development of bone graft for critical size defects) into simple, “real world” words and laboratory demonstrations that a seven-year-old or a 15-yearold or a stranger on the street could understand. We gather household items to simulate medical problems and repairs (crafting beads for bone cells, fabric for a skin graft, etc), but we also collect actual medical devices (knees, hips, bone graft, reamers, etc) from hospitals and biomedical companies so that students can see and learn about the actual device—the clinical need, the design process, the clinical process, etc—while experiencing some of the concepts by working with household items to simulate biomedical/
bioengineering concepts and ideas. This process also teaches our graduate students how to be better communicators (try explaining the bone defect repair process to a friend with a non-scientific/medical background, then try explaining it to a seven-year-old—communication is such a difficult, but crucial skill). It is our responsibility to educate others in what we do. It is, in fact, in our own best interest to do so. Additionally, it’s downright fun! Sharing biomedical knowledge
Clemson University, a public, land-grant institution with a very defined educational mission to the southeastern region of the United States, endorses “service learning,” where university courses may be specifically designed to incorporate a community engagement project. In these projects the students receive formalized opportunities to experience the connection between their own studies and the community. I have used this framework in three ways: teaching teachers, creating learning modules, and hosting on-site learning tours. Our interest is in reaching schoolchildren and so our activities are also directed towards individuals who teach these children. Accordingly, we teach a biomedical course annually at the Museum of Science in Boston and we have partnered with the Howard Hughes Medical Institute to teach introductory biomedical courses at Clemson University to science teachers. Rewards are enormous
We have recently developed a new program where graduate student researchers work with education graduate students to help produce course content that the education students can use in their student teaching. We have published biomedical modules in magazines that are specific to teachers. We also host tours and school groups biannually. I have never encountered a group of schoolchildren or schoolteachers that was not extremely enthusiastic about the topic of biomedicine. The reward is enormous and is seen in the faces of children who realize for the first time they can be problem solvers and they do have valuable opinions. I express my sincere gratitude to the AO Foundation leadership for caring about the future of biomedicine and for giving my graduate students and me the opportunity to leverage our research grant into a series of biomedical experiences for schoolchildren.
30.4.2008 7:57:56 Uhr
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Old-timer rally from Beijing to Paris An unforgettable experience
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Markus Rauh Chairman, AO Board of Directors Davos, Switzerland markus.rauh@aofoundation.org
1 AOVA Chairman Markus Rauh (left), teammate David Hove, and Rauh’s wife Brigitte celebrate the rally’s successful finish in Paris, August 2007. 2 A 40 m-high monument to Genghis Kahn outside Ulaanbaatar.
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During a break in a business meeting in March 2005, Urs Ramsauer, an old friend of mine, complained to me about the frustration of his divorce. I tried to cheer him up and encouraged him to do something ‘crazy’ to help him forget his problems. All of a sudden his eyes started to glow and he said, “I’ll drive with my old-timer Ford V8 Sahara 1947 from Peking to Paris!” Not hesitating for a second, I replied, “Urs, if that is not a joke and if you organize it, I’ll join you!” That moment was the beginning of a great adventure. Urs is an old-timer-automobile fan and I am anything but that—I didn’t even have an old-timer car and had never participated in a rally. But the idea of doing something like this fascinated me so much that even my wife Brigitte recognized there was no discouraging me from undertaking this adventure. Only days later, I found out the reason Urs had proposed the Peking to Paris route: to mark the centenary of one of the greatest adventures in
the history of automobiles—the Peking-Paris Raid, a 14,000-km drive across the Gobi Desert and Siberia. In March 1907, the French newspaper “Le Matin” published a challenge to motoring enthusiasts to race from Peking (now Beijing) to Paris, an unthinkable endeavour given the automobiles and roads of the time. All of Europe was betting on whether or not it could be done. On June 10, 1907, five teams started the race at the Doschmen Gate of the Great Wall, north of Peking (incidentally, where the “Dinner on the Great Wall” took place during the last AO Trustees meeting in June 2007). Count Scipione Borghese won the race in 60 days with his Itala, a predecessor of today’s Fiat, arriving in Paris on August 10, 1907, a full two weeks before the second place Spyker. Borghese was accompanied by a journalist who regularly
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Report
forehand, were predominantly Swiss and from totally diverse backgrounds. We had a broad variety of cars, ranging from a 1907 Spyker (identical to the runner-up in the original race) to a 1960 Willys Jeep. Among us were 46 men and 17 women, aged between 50 and 70 years. I motivated my brother-in-law, a retired teacher and a longstanding old-timer hobbyist to prepare a Ford V8 1938 convertible as our vehicle. He took care of the mechanics and I took charge of administration. Our cars were shipped in containers (almost free of charge because of the lack of cargo from Europe to China) from Basel to Tianjin. On June 10, 2007, one day after the close of the AO Trustees meeting, we began our journey at the Doschmen Gate with an impressive ceremony organized by a Chinese TV chain. In 42 stages we drove more than 14,000 kilometers through China, Mongolia, Russia, the Baltic States, Poland, Germany and finally into Paris, where we had a great welcome party at the Place Vendôme on August 10, 2007. Overcoming unexpected obstacles
We had so many adventures and enduring impressions that a full report is impossible, but I will summarize a few highlights. During our extensive preparations we were warned about the lack of a proper infrastructure to provide us with quality fuel, water, repair facilities, communications and money. The possibility of heavy rainfall (as Borghese had experienced) also concerned us. But in these respects we had no problems at all. 2
telegraphed dramatic progress reports to Italian and French newspapers so that millions of fans could feverishly follow the race. A book published afterwards featuring many race photographs became a bestseller and was translated into 21 languages. But then came the First World War and this great adventure sank into oblivion. Recreating a daring adventure
Urs and I decided to organize a commemorative rally, not a race, but a well-organized event for friends who would assist each other in overcoming the hurdles on the long journey from Peking to Paris. It would commence on the same departure date, end on the same arrival dates, and more or less follow the same route as the original rally, knowing that with today’s roads and support infrastructure we could devote almost 20 of the 62 race days to visiting places of cultural and historical interest. So far as the old-time cars were concerned, they would be at least 40 years old. Thanks to word of mouth, a group of 30 teams finally came together. The participants, who did not know each other be-
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The infrastructure was much better than expected. For example, I was able to call my wife using a normal GSM (mobile) phone every day except for five in the Gobi Desert, when I needed my Iridium phone. The phone bill, however, was more than CHF 5,000! We were very fortunate with the weather, having excellent conditions all the way to Berlin. We were also warned about the dangers of crime, but we did not experience a single negative incident, although we came to realize there was very little respect for private property—a legacy of communism. People both young and old did not hesitate to sit (without asking) on our parked cars in order to take photos and have fun. We innocently assumed that our old-timers (which had so far been used only for concours d’élégance) could withstand the challenge of the terrible roads in Mongolia and Siberia and so we did not take a repair vehicle with us. This was totally naïve as almost all the teams were plagued by severe technical problems. Minor repair jobs could be handled by car mechanics in our group or at one of the many Toyota garages along the route. The availability of spare parts, however, remained a major logistical nightmare. In the middle of Siberia, our transmission broke and could not be repaired. Thanks to personal connections we were able to find a replacement in Am-
30.4.2008 7:58:06 Uhr
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sterdam. This was the easy part—getting it to Yekaterinburg within 36 hours was the challenge, as this could only be done by couriers with Russian visas and knowledge of how to get through Russian customs (with lying, cheating and bribing). Nobody believed it could happen, but wonder of wonders, it did. Thanks to the tremendous commitment of the very qualified specialists at the Toyota garage we were able to join the group leaving Yekaterinburg.
Memories to last a lifetime
The Gobi Desert is the world’s biggest, with no roads—and no maps available to help chart our path across it. To do so you need a guide: unfortunately ours was totally drunk and lost his orientation. We drove in circles on terrible terrain. At midnight we camped where we were, completely lost in the desert. Some drivers slept in their cars, others, like us, on the sand covered with whatever we had. It was very cold at night, but thanks to the new moon we had the most wonderful experience, seeing millions of stars in the totally black sky. My
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3 Driving in the last sunbeams before a cold Gobi Desert night. 4 The author’s Ford V8 1938 being fitted with a new transmission in Yekaterinburg.
memory of that night is almost mythic and now I know why the Milky Way bears its name. Mongolia has a dramatic history. In the 13th century, Genghis Kahn ruled it, the largest empire in world history, from his capital, Karakorum. Today nothing is left of that culture, the Chinese and Russians having destroyed it. Since the breakdown of the Soviet Union, Mongolia has become independent and its populace is desper-
ate to develop a new national identity. They are basing it on Genghis Kahn, who is omnipresent and praised like a godfather. As part of an official welcome party in the capital of Ulaanbaatar, we all had to walk up a red-carpeted stairway to a gigantic statue of the historic ruler, before which we were expected to bow for at least one minute. Walking up the stairs I pleaded with myself not to do it, but standing there under the eyes of our hosts, the military commanders, I relented.
@gVhcdnVgh` @ZbZgdkd >g`jih` Cdkdh^W^gh` JaVVcWVViVg 7Z^_^c\ &%# ?jcZ 9Vidc\ H]^_^Vo]jVc\
5
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30.4.2008 7:58:12 Uhr
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5
5 Moscow’s Red Square: 9,934 km and two-thirds into the rally.
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Witnessing Siberia’s rebirth
The revival of Christianity in Siberia is an unexpected and unbelievable surprise. In every major city, magnificent churches and monasteries destroyed by the communists during the revolution are being rebuilt to look exactly as they originally did. But before beginning reconstruction, the sites have to be excavated from factories and other buildings the Soviets built to cover up the past with the intent of erasing people’s memories. The new churches hold services every day and are full–not only with elderly women, but also with many youngsters and especially, men. On weekends, Russia and the Baltic
States are full of glamorous weddings with wonderful brides and grooms and millions of rose petals. We experienced all kinds of accommodation, from tents to “jurte” camps, from old, run-down Soviet sanatoriums to all classes of hotel. The reception was mostly friendly with the exception of the luxury hotels in big Russian cities, where they ripped off their foreign guests with exorbitant prices, like beer for USD 20 and cleaning a pair of underwear for USD 10. All in all, recreating the Peking-Paris Rally was the greatest experience of my life (and Urs forgot all about his divorce)— but would I do it again? Clearly, no! The safety risks we took on the unbelievably dangerous roads in Russia were so tremendous that we have to thank God we all safely made it to the end. To repeat the experience with the same cars (with pre-Second World War safety standards) would be to gamble with our lives.
30.4.2008 7:58:17 Uhr
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Inside AO
Erich Schneider — “a caring mentor and friend” AO Research Institute director leaves to take up new challenges Tim Pohlemann Member, AO Board of Directors Homburg-Saar, Germany chtpohl@uniklinik-saarland.de
After ten years as director of the AO Research Institute (ARI), Erich Schneider left the post on January 31, 2008, to take up new challenges. Erich Schneider was born in Wettingen, canton Aargau, and studied at the renowned Swiss Federal Institute of Technology (ETH Zürich) from 1969 to 1974, then at its Institute of Electrical Equipment Design (1975–1976), before switching to the Biomechanics Laboratory under Jürg Wartenweiler and Benno Nigg (1976–1980) to complete his dissertation.
Erich Schneider (far right) with his wife, Dorothee, and members of the “AO Family”, in Venice for the 2004 AO Trustees Meeting.
Thanks to him, a huge group of young surgeons were lead through their first steps in science.
After a research fellowship at the Biomechanical Laboratory, Department of Orthopedics at the Mayo Clinic in Rochester, New York, US, under Edmund Chao (1980–1982), he was appointed research associate and vice-director of the Maurice Müller Institute for Biomechanics, University of Bern, directed by Stefan Perren from 1982 to 1988, with interim lead until 1989. During this period, several fundamental projects were accomplished, including the inauguration of a spine simulator, motion analyses after pelvic fractures, primary stability of end prosthetic components, 3-D imaging and intravital force monitoring after femoral nailing.
Elected chairman of the renowned Institute for Biomechanics at Hamburg-Harburg Technical University, Erich and his family moved to northern Germany in 1990. In 1997, the chance to once again enjoy Swiss mountain culture came when he was appointed director of the AO Research Institute in Davos. Over the past ten years the Institute went through major structural changes and widened the spectrum from biomechanics and bone pathology to a full-scale “bone-and-cell-biology research unit” focusing on the mechanisms of bone and cell
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Erich Schneider
healing, tissue engineering, imaging and translational research. In addition to his many responsibilities with the AO Foundation, Erich taught at the University of Bern and ETH Zürich and held a travelling professorship with the Rush-Presbyterian-St.Luke’s Medical Center in Chicago. He has published more than 132 original articles in wellknown journals, 80 book chapters, 400 abstracts and presentations. Erich Schneider was a caring mentor and friend to many of us and later to our residents and fellows. Thanks to him, a huge group of young surgeons were lead through their first steps in basic and applied science, and experienced the fascination of interpreting sound scientific results after proper experiment planning and execution. Erich Schneider has been honored with many renowned awards including the Walter Brendel Award in 1999, the Ferdinand Sauerbruch Award in 2002, the Osteology Travel Award in the same year, the Arthur Vick Prize in 2005, and the Dieffenbach Büste of the German Trauma Society in 2006, to mention only a few. I want to thank him for all he has given to our medical community and to the AO and wish him the very best in his future professional achievements and private endeavors.
30.4.2008 7:58:20 Uhr
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As AO President Chris van der Werken applauds (left), Maurice E Müller, an AO founding father, unveils a commemorative plaque marking the AO’s 50th Anniversary at the Hotel Elite in Biel.
Transforming Surgery—Changing Lives
The AO’s 50th anniversary celebrations Diarmuid De Faoite Editor, AO Communications & Events diarmuid.defaoite@aofoundation.org
Fifty years ago the AO was founded by a group of 13 visionary surgeons in Biel in Switzerland. These ‘founding fathers’ came together to create ideas and technology to improve patient care in the field of traumatology and diseases of the musculoskeletal system. Their success truly transformed surgery, changing lives. Today’s AO wants to pay tribute to these pioneers. Throughout 2008, the AO is celebrating
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the achievements of its founders, and those who later carried the torch, in a fitting manner with a variety of events. Exciting array of international events
To help ensure this will be a memorable year, a 50th Anniversary Steering Board began working on the celebration at the end of 2005. Many exciting activities have been planned all over the globe. Some of these are annual events, with a
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Inside AO
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Being sent as a young resident in 1985 to the Jubilee AO Davos Course by Harald Tscherne, I was deeply impressed by a perfect course organization and for me up until that point, an unseen level of didactics, presentations, and practical exercises. However, when asked to remember specific details I was mostly impressed by three circumstances: 1. Being able to get a photograph showing Maurice Müller together with me and my colleagues (see below). 2. Riding uphill together with Martin Allgöwer in the same compartment on the Parsenn ski trail. Martin wore a bobble cap and talked with us about skiing techniques. 3. Having received a Swiss watch as a present on the occasion of the Jubilee AO Davos Course, I entered the Davos swimming pool thanks to a sponsored sports ticket with about 25 fellow participants to check the water resistance of the watch in a practical experiment...the watch turned out to be completely waterproof and is still in perfect shape today! Tim Pohlemann
From right to left: Tim Pohlemann, Philipp Lobenhoffer, Norbert Südkamp and Maurice Müller, with fellow Davos course participants.
special touch of the 50th anniversary theme, and others are unique events developed just for the celebration. The opening ceremony was performed at the AO Davos Courses in December 2007, where the special jubilee logo was unveiled. A series of symposia will be staged at congresses and AO Alumni events and regional courses throughout the whole of 2008.
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On the occasion of his 90th birthday, Friday, March 28, 2008, Maurice Müller, an AO founding father, unveiled a commemorative plaque at the Hotel Elite in Biel, where the AO was founded. A meeting of the Board of Directors and Academic Council also took place there the same weekend. The Jubilee Trustees Meeting will be held in Davos in June, where a special car-free evening in the town will help cement the AO’s special relationship with the townsfolk of Davos.
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The AO Alumni Association is contributing to the celebrations by replacing their triennial event with three events to be held in Greece, Thailand, and the United Arab Emirates. Amirah Blackmore is the Anniversary Manager based in Switzerland with responsibility for coordinating the celebrations around the world. “The jubilee year will be a celebration of the past while looking forward to the future. This is reflected in the slogan to be used throughout 2008 which is: the first 50 years. This wording ensures that the AO is seen as a forward-looking organization.�
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Special website keeps members up to date
A special anniversary website has been commissioned and is the best method to keep up to date with the many events related to the celebrations. It can be viewed at www.aofoundation.org/anniversary or by following the link from the AO’s home page. Content is being added all the time as events happen so it is advisable to check back frequently over the course of the year. While the focus within the AO quite rightly is on the scientific aspects, the anniversary celebrations are a unique opportunity to highlight the role interpersonal relationships have played over the
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How to access the TK-System The AO appreciates feedback on existing instruments and implants and welcomes input to solve unmet clinical needs. New ideas are introduced to the System of Technical Commissions (TK-System), in which over 120 highly specialized surgeons from around the world work on new solutions. They form Expert Groups in the respective areas of medical specialty, which are professionally supported by teams of engineers, researchers and other specialists from the AO and its commercial partners. To initiate discussion of new ideas, we ask for a description of the clinical problem being addressed and for suggestions on how to approach it. Technical drawings and first prototypes are made according to the proposal and presented to the specialists; together with them, the proposal’s potential is evaluated and improvements and alternative approaches are discussed. past 50 years of the AO. To this end, an interactive section has been created on the website where everyone can submit their memories, anecdotes, and photographs of how the AO has touched their life. The President of the AO Foundation, Chris van der Werken has been involved in the event planning since the very beginning. He is aware of the need to strike the right balance while commemorating the AO’s proud past. “While we will of course be reflecting on the first 50 years throughout the anniversary year, I can assure you that the AO as a whole is firmly focused on the goal of how we can continue to improve patient care. Just as it was 50 years ago.”
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If the submitter’s innovation is successfully completed, they will be involved as a faculty member in AO teaching activities that ensure proper training of the new device. The overall process is described on the AO website at www.aofoundation.org (see AO indepth; Activities; AOTK; Expert Groups). Ideas may be proposed via e-mail at aotk@aofoundation.org or by approaching any member of the TK-System directly. For specialists involved in the relevant area, please look under Expert Groups (as above). If the project is not pursued we guarantee that intellectual property rights are wholly respected.
30.4.2008 7:58:29 Uhr
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AO Latin America: 1
a thriving and dynamic region Specialty collaboration features prominently in AO activities organized on this vast continent.
Luis Javier Parra
AO Latin America (AOLAT)
AOLAT Regional Director
In 1998, AO Alumni Association members in Latin America formed AOLAT, an AO region. Since its inception, AOLAT’s success and influence has grown tremendously under the leadership of its presidents, Jaime Quintero (1998–2002), Fiesky Nuñez (2003–2007), and the newly elected Carlos Sancineto (2007–2009) from Argentina.
luisjavier.parra@aofoundation.org
AOLAT is currently very active in all three specialties across 17 different Latin American countries, and over 3,000 members participated in one of 49 courses and five seminars offered in the region in 2007. Two new countries are currently being drawn into the AOLAT fold. Puerto Rico joined in 2007 and will have its first AOLAT seminar this year.
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In 2007, the first ever AO trauma seminar in Cuba was held in Havana under the direction of Fernando de la Huerta. AOLAT’s specialty collaboration
Reorganization in 2006 saw Trauma and CMF join Spine in having a regional specialty board, with each board chairperson represented on the AOLAT Executive Board. There were four Executive Board meetings in 2007, something which contributes to a more integrated region, both in terms of specialties and countries. This momentum of specialty collaboration was maintained by a multispecialty event on research and clinical investigation that took place in 2007 in Cancún, Mexico. More than 100 doctors drawn from all three specialties attended,
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From the regions
1 The Temple of Kukulkan at Chichen Itza, Mexico. 2 Passing the presidential baton: Fiesky Nu単ez welcomes Carlos Sancineto in 2007.
2
and top researchers kept the participants enthralled by their insights. Additionally, a Tips for Trainers course was held in Panama for all three specialties.
AO Latin America Executive Board
AOSpine Latin America Regional Board
AO Trauma Latin America Regional Board
AOSpine Latin America Regional Board
Visual representation of how the AOLAT region is organized.
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AO CMF Latin America Regional Board
AO Latin America Specialty & Country Support / Executive Office
AOLAT regional office support
In February 2006, Luis Javier Parra began work in the AOLAT office in Colombia. Over the past two years he has supervised many exciting changes and process implementations. The complexity of the region and the interrelationships between the various bodies is evident from the diagram at left. Parra has understood and planned the changes in structure to handle this complexity while maintaining normal operations without any disturbance. He has also maintained a close collaboration with the AOSpine regional office in Brazil.
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3 AO trauma group at an AOLAT multispecialty event, Cancún, Mexico, 2007. 4 Luis Javier Parra (left) with Carlos Sancineto at the AOLAT Jubilee Meeting in Puerto Iguazú, Argentina, 2008. 5 Participants in a multispecialty Tips for Trainers course in Panama, 2007. 6 AOSpine participants at a 2007 AOLAT multispecialty event in Cancún.
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Administration also forms a large part of the work Parra’s office carries out. New agreements with the main airlines that fly into and out of Latin America have been made. Similar agreements with major hotel chains to host board meetings and courses should also lead to further cost reductions. The regional office is not only responsible for local events and courses, but is also involved in supporting fellowships and Socio-Economic Committee activities. Communication is also an essential element. This is mainly achieved through the infoLAT newsletter, sent out three times in 2007 to all Trustees and AOLAT doctors and of which four issues are planned for 2008. The AOLAT website (www.aolat.org), which kicked-off in 2006, is to be overhauled this year. It will become the main source of timely AOLAT news and information
resulting from the close collaboration of the regional specialty boards. Clinical investigation in Latin America
AOLAT is also heavily involved in clinical research. For example, eight hospitals are taking part in an international study sponsored by AOSpine and managed by AOCID on the assessment of surgical techniques for treating cervical spondylotic myelopathy. No continent provides more sites for this worldwide prospective cohort study than Latin America. Other specialties are also identifying similar projects that take advantage of this regional feature. A bright future
AOLAT is a region that is thriving due to the AO Foundation’s regionalization policy. Given the distances, differences in living standards, and languages involved in Latin America, it is likely to remain a very dynamic region for AO activities.
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Internet
AO Portal redesign Visitors to the AO Foundation website (www.aofoundation.org) since mid-March 2008 have been greeted by a completely overhauled and streamlined website that boasts a variety of enhanced features. Diarmuid De Faoite Editor, AO Communications & Events
What the revamped AO Portal has to offer users:
diarmuid.defaoite@aofoundation.org
Greater overview A logical grouping of AO activities More modern, streamlined design
Selected statistics, March 2008:
Regions and specialties more prominently featured Expandable menus
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Background to the redesign
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The top 5 users, by country, were US, then Germany, UK, Italy, and Spain.
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Over 36,000 users visited the portal.
The average duration of a visit was, impressively, just over 10 minutes.
More than 1 million pages were viewed.
The single most frequent visitor is in Germany.
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The AO Foundation has had an Internet presence since 1994. Both technology and the AO have of course made great strides since then. In 2001 it was decided to develop the AO website into a knowledge portal. Content was continually added over the past few years, leading to a website comprised of approximately 12,000 active pages. However, adding content alone was not enough to meet the needs of users, many of whom visited the AO Portal with very specific intentions in mind. There was a growing realization within the AO Foundation’s Web Editorial Board that the needs of users had to be addressed. With so much content on offer, finding the pages of interest was becoming increasingly more problematic for users. Just under a year ago the redesign of the website began involving members of the AO’s Knowledge Services and Communications & Events teams. The main focus was on making it easier for users to navigate to the page they wanted in as few mouse clicks as possible.
The many sections of the website were identified, broken down and then rebuilt in a logical manner. Cognizance was also taken of the areas which have grown in importance over recent years to ensure that they were given appropriate prominence as part of the newly designed structure. The proposed new website configuration went through various test models on paper and feedback was sought from various departments and institutes internally until the current structure was arrived at. A team of computer specialists from the AO’s Knowledge Services team was kept very busy over the past few months migrating content from the old website to the new one. On March 13, 2008, the newly redesigned website went live and feedback received from users has been very positive. The AO Portal will continue to remain the primary source for AO information for many users the world over. See the new look website for yourself at www.aofoundation.org.
30.4.2008 7:58:40 Uhr
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This article introduces a series of contributions concerning new techniques of minimally invasive fracture surgery.
Rodrigo Pesantez
Minimally invasive osteosynthesis In an editorial in “Injury” Stephan Perren asked two questions: 1. What can we expect from minimally invasive technology? 2. Are the length and the position of the skin incisions critical? Although we still are looking for the answers, minimally invasive surgery has become part of many different surgical specialties. In fracture treatment it began with intramedullary nailing and external fixation, and has evolved to become part of the orthopedic surgeon’s armamentarium with all types of implants. Minimally invasive surgical technique avoids the additive open surgical trauma to the noninjured components of the fracture site by preserving the vascularity to the bone, periosteum, and soft-tissue structures. During the late eighties, Jeffrey Mast, Ronald Jakob, and Reinhold Ganz published “Planning and Reduction Techniques in Fracture Surgery,” which reported their techniques for indirect reduction of fractures. These methods decrease the surgical dissection at the fracture site and rely on traction across the intact soft tissues to obtain a reduction. Although compression was still widely applied for fracture stabilization, the goal of these procedures was to maintain bone perfusion so as to assure a “biological internal fixation.”
ternal fixators and LCPs. Despite these “new advances,” what must be realized is that all fracture fixations must respect the viability of the soft-tissue components in the zone of injury. To achieve this goal, new reduction clamps and instruments were developed to improve the quality of reduction and ease of percutaneous plate application. But malalignment and inadequate fracture fixation are the price we pay if care is not taken in the application of minimally invasive fracture surgery. In the last issue of AO Dialogue, there was an excellent review about intramedullary nailing and its expanded indications. In this issue, several experts in minimally invasive plate osteosynthesis will outline how to apply this technique successfully. William Belangero, Juan Concha, and Bruno Livani review the use of plates in humeral shaft fractures, Rami Mosheiff takes a look at the different options around the pelvis and acetabulum, and Edgardo Ramos, Fernando Garcia, and Gabriel Chávez discuss the lower extremity. Minimally invasive techniques for fracture treatment will continue to evolve, and probably what is today considered minimally invasive will be considered maximally invasive in a few years. So we have to keep on working to improve our current techniques for the future. Rodrigo Pesantez
Krettek et al published their results on minimally invasive plate osteosynthesis, initially using conventional plates (DCS, angle blade plates, LC-DCP, etc) and then evolved to locked in-
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Fundacion Santa Fe de Bogotà, Orthopedic Surgery, Bogotà, Colombia rpesantez@gmail.com
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clinical topic
The application of minimally invasive surgical techniques with humeral shaft fractures.
William Dias Belangero, Juan Manuel Concha and Bruno Livani
Minimally invasive plate osteosynthesis of the humeral shaft Although conservative management of humeral diaphyseal fractures has shown good results in about 90% of cases [1, 2], there are both absolute and relative indications for surgical treatment, such as polytrauma, open fractures, bilateral fractures, floating elbow, etc [3]. Minimally invasive surgical techniques in diaphyseal fractures of long bones have shown advantages over the open conventional techniques, especially when they preserve the biological media of the fracture focus allowing a better environment for consolidation with fewer complications such as infection and nonunion [3, 4]. These techniques have not been very popular in the humeral diaphysis due to its anatomical complexity and the fear of damaging vital structures. The surgical technique was described in Belangero and Livani´s publication [5]. Based on cadaveric anatomical studies and clinical experience with 43 cases, the most relevant points of the surgical technique will be presented so complications that may derive from faulty indications or inadequate technical performance are avoided. Contraindications for the application of this technique As in every biological fixation method, the objective is to achieve relative stability at the fracture site so that callus is formed. Thus patients with a compromised soft-tissue environment such as a flaccid paralysis (brachial plexus lesion, poliomyelitis, etc) or open fractures with soft-tissue loss are contraindicated for this procedure [5].
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Surgical technique for fractures of the middle third of the humerus Patient positioning
The patient is in the supine position, with the arm resting on the surgical table and the elbow flexed to approximately 70°. The forearm and the elbow are kept in this position by an assistant who applies slight traction during the whole procedure. This position facilitates access for plate introduction reducing the risk of vital structure injury. Surgical approach
An anterior approach to the surface of the humerus should be used to avoid a radial nerve lesion. Two cuts, approximately 3 cm long, are made on the anterior arm surface. The proximal access is located between the biceps brachii muscle medially, and the deltoid and the cephalic vein laterally. The distal access is located on the anterior surface of the arm and the biceps muscle is retracted medially. After the lateral cutaneous nerve of the forearm is identified, the brachii muscle is longitudinally split to expose the anterior surface of the humerus. Brachialis function is not compromised due to its double innervations. Under no circumstances should lever retractors be used for humeral exposure. Instead, Farabeuf type retractors should be applied in order to avoid radial nerve lesion from compression or stretching. Implant placement
In middle third fractures the plate should be introduced in a proximal to distal direction, sliding on the anterior surface of the humerus (Fig 1). The implant should not reach the coronoid fossa. After the plate is introduced, the first
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Fig 1
Approach and plate insertion.
Fig 2
Immediate postoperative x-rays and result 4 months postoperatively.
Fig 3
Surgical approach and plate insertion in a distal diaphyseal fracture.
screw should be placed in the distal fragment and left relatively loose to allow the final fracture reduction. The varus deformity is corrected by arm abduction at 90° and rotational deviations are avoided by aligning the bicondylar axis on an orthogonal plane to the biceps brachii tendon. After these maneuvers the second screw is placed in the proximal fragment and the distal one is tightened, securing the plate to the bone. Reduction quality is clinically and radiographically assessed before the remaining proximal and distal screws are placed (Fig 2). In good quality bone only two screws inclined and well spaced need to be inserted into each bone segment. The utilization of wide plates should be avoided, as this may increase assembly rigidity and lead to retardation of fracture healing. For the same reason, locked plates should use only two locked screws in each fragment so that the assembly does not become excessively rigid [7]. Surgical technique for distal humeral fractures Patient positioning
The same position as used for medial
third fractures. Surgical approach The proximal access is the same as previously described. For distal access, when there is not enough space for plate fixation on the anterior humeral surface, Kocher’s incision is used to expose the lateral column of the humerus. Subperiosteal dissection of the brachioradialis and extensor carpi radialis longus muscles, together with the radial nerve, exposes this surface. There is no need to identify the radial nerve, unless it becomes necessary to explore it further.
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Implant placement
In this type of fracture the plate has to be contoured internally to adapt it to the lateral column and to the anterior surface of the humerus. It is introduced in a distal to proximal direction, sliding on the lateral column and the anterior surface of the humerus, with the assistant keeping the elbow flexed and the arm under slight traction, supported by the surgical table [5]. Screw insertion is similar to the previously described technique (Fig 3). Humeral fractures associated with radial nerve lesion The systematic and careful analysis of studies published in the last forty years concerning radial nerve injury associated with a humeral shaft fracture shows an incidence of 11.8%. The average spontaneous radial nerve resolution rate is 70 to 80%. Therefore expectant management regarding the radial nerve is indicated [8–10].
The use of minimally invasive plate techniques has not been popular in humerus because of the fear of damaging the neurovascular structures that traverse the humerus. However, if employed according to these recommendations, the application of minimally-invasive technique is still possible in this situation. In the proximal third of arm the radial nerve is not tethered by the intramuscular septum so fractures occurring in this region usually cause a neuropraxia, with greater possibility of spontaneous recovery. In the distal third of the humerus the radial nerve is tethered by the intramuscular septum and in close contact with the humeral diaphysis, creating a greater chance of nerve injury by fracture site impingement thus
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clinical topic
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Fig 4
Patient with radial nerve palsy after nonsurgical treatment of a distal humeral shaft fracture.
Fig 5
The approaches used to explore the radial nerve and sliding in the plate.
Fig 6
Humeral fracture fixed by minimally invasive plate osteosynthesis.
making spontaneous recovery unpredictable [10]. When the treatment of choice for distal third humeral fractures with a radial nerve lesion is the MIPO technique, the nerve should be first explored by means of an oblique access between the brachialis and brachioradialis muscles. After its identification, the nerve should be explored past the fracture site and its entry through the lateral intermuscular septum (Figs 4–6). Following that procedure, the same technique already described for distal humeral fractures is performed [6]. Conclusion Minimally invasive osteosynthesis is a simple technique, reproducible, with few risks. The method is supported by the fact that the radial nerve crosses the anterior surface of the humerus only in its distal third. Thus, the iatrogenic lesion of this structure will only take place if the implant is not placed in the anterior surface of the diaphysis or if there is nerve contusion or compression as a result of inadequate use of retractors or levers during humeral exposure.
6. Livani B, Belangero WD, Castro de Medeiros R (2006) Fractures of the distal third of the humerus with palsy of the radial nerve: management using minimally-invasive percutaneous plate osteosynthesis. J Bone Joint Surg Br; 88(12):1625–1628. 7. Perren S, Claes L (2000) Biology and biomechanics in fracture management. Ruedi TP, Murphy WM (eds), AO Principles of Fracture Management. Stuttgart New York: Thieme Verlag, 17–19. 8. Sonnebeld GJ, Patka P, Van Mourik JC, et al (1987) Treatment of fractures of the shaft of the humerus accompanied by paralysis of the radial nerve. Injury; 18 (6):404–406. 9. Shah JJ, Bhatti NA (1983) Radial nerve paralysis associated with fractures of the humerus. A review of 62 cases. Clin Ortop Relat Res; Jan–Feb;(172):171–176. 10. Shao YC, Harwood P, Grotz MR, et al (2005) Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review. JBJS Br; (87):1647–1652.
William Dias Belangero
Hospital das Clinicas UNICAMP, Brazil belanger@sigmanet.com.br
Bibliography Juan Manuel Concha 1. Belfour GW, Marrero CE (1995) Fracture brace for the treatment of humeral shaft fractures caused by gunshot wounds. Orthop Clin North Am; 26:55–63. 2. Latta LL, Sarmiento A, Tarr RR (1980) The rationale of functional bracing of fractures. Clin Orthop; 146:28–36 3. Green A, Reid J, Du Wayne A (2005) Fractures of the humerus. OKU: Trauma 3 American Academy of Orthopaedic Surgeons; 169–178. 4. Baumgaertel F, Buhl M, Rahn BA (1998) Fracture healing in biological plate osteosynthesis. Injury ; 29 (suppl 3):C3–C6. 5. Livani B, Belangero W (2004) Bridging plate osteosynthesis of humeral shaft fractures. Injury ; 35:587–595.
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Universidad del Cauca Popayán, Colombia juan.conchasandoval@aoalumni.org
Bruno Livani
Hospital das Clinicas UNICAMP, Brazil brunolivani@hotmail.com
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The application of percutaneous fixation techniques with pelvic and acetabular fractures.
Rami Mosheiff
Percutaneous fixation of pelvic and acetabular fractures Unstable pelvic-ring injuries call for anatomical reconstruction and stable fixation to allow for early function. As the surrounding anatomical vicinity contains vital vulnerable structures, the percutaneous surgical approach becomes an attractive treatment option minimizing exposure, blood loss, risk of infection, and protecting vital structures. To safely apply percutaneous reduction and fixation techniques, a thorough understanding of the complex three-dimensional pelvic anatomy and radiology is necessary. This knowledge is more complex than that required for long bone fixation. Indications
Although percutaneous pelvic surgery is controversial [1], this approach has gained popularity due to the following:
• A pelvic-ring fracture is not an intraarticular fracture requiring a perfect reduction so a “near anatomical” reconstruction is accepted without significantly affecting the clinical outcome. • The percutaneous approach complements the more “open” traditional method by minimizing the open approach in certain areas where it can be safely implemented. The percutaneous fixation of acetabular fractures has a completely different approach. This is a weight-bearing joint so anatomical reconstruction is recommended and inaccuracy in reduction and/or fixation will result in a compromised outcome. In certain circumstances, it is acceptable to achieve secondary congruency while avoiding the use of extensile and
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unsafe exposures. Additionally, some of the screw pathways, routinely used in percutaneous pelvic surgery, can be used in acetabular fracture fixation. The learning curve achieved during pelvic surgery procedures can be utilized for more demanding acetabular surgery. Implementation
Implementation of percutaneous pelvic and acetabular fracture surgery occurs in three stages: understanding the fracture and preoperative planning; indirect reduction techniques; and percutaneous fixation. Preoperative planning Although 3-D CT has considerably improved the understanding of fracture patterns it has not yet allowed the percutaneous placement of plates or improved reduction techniques. Currently, the control of screw orientation is possible only with fluoroscopy so strict pre-operative planning is mandatory in percutaneous pelvic and acetabular surgical treatment to avoid complications. Recently, computer programs have been developed enabling the performance of virtually all steps of the real surgical procedure including determination of the safe zones for fixation, precise planning of screw dimensions, and pre-checking of the percutaneous option as an alternative to open approach (Figs 1–4) [2–3]. Reduction A precise closed reduction is a prerequisite for percutaneous pelvic fixation and even more so for acetabular fractures. As a consequence, there are three indications for percutaneous pelvic fixation: minimally displaced pelvic or acetabular fractures, displaced fractures with a feasible closed
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3 Fig 1a–b A computerized preoperative planning device (SQ Pelvis software) enables complete virtual operation on the model acquired from real patient data (CT). Using 3-D viewing tools, the virtual model of a fractured acetabulum is built. Following reduction, fixation can be undertaken. The direction and length of the screws is controlled by turning the pelvis (a) or by making the bones more transparent (b). Fig 2 Percutaneous screw insertion by means of computerized fluoroscopic navigation system enables the simultaneous use of several radiographic projections. This system has the potential to significantly reduce radiation exposure and operative time, while allowing the surgeon to achieve maximum accuracy.
4
Fig 3 Three-dimensional fluoroscopy allows the acquisition of CT-like images during surgery by taking about 100 fluoroscopic x-ray images at 1° intervals with a motorized isocentric C-arm. The navigation images consist of both CT and fluoroscopic x-ray images. The advantages being that complex fractures can be better visualized and that CT images, prior to and following reduction, can be taken. Fig 4 Immediate postoperative x-ray. Closed disruption of left side of pelvic ring with vertical displacement through left sacroiliac joint. The patient was hemodynamically unstable on arrival.
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5a Fig 5a–b
5b Preoperative x-ray (a) and CT image (b).
reduction, and complex fractures in which a combination of closed and open reduction is necessary. It is quite clear that the development of closed reduction techniques is pertinent for achieving a breakthrough in this field. Recently, innovative table–skeletal pelvic fixation frames have been devised to secure the normal side of the pelvis to the table so as to more effectively apply the reduction maneuvers to the displaced hemipelvis [4] (Figs 5–7). Intraoperative control Intraoperative rather than postoperative confirmation of the reduction and fixation can save patients and surgeons from uncertainty relating to the quality of reduction and implant position. The introduction of operative 3-D imaging (SireMobil IsoC-3-D, Siemens Medical Solutions, Erlangen, Germany), combines the capabilities of routine intraoperative fluoroscopy with resultant axial cuts, 2-D and 3-D reformations. This unique imaging modality can help the surgeon assess the acetabulum and the posterior pelvic ring anatomy intraoperatively [5–6]. The persisting disadvantage of 3-D fluoroscopes is a limited image size, however newer modifications will allow superior image quality, increased field of view, higher spatial resolution, and soft-tissue visibility as well as the elimination of the need to rotate around a fixed point (isocentricity).
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Fixation Conventional fluoroscopy is used most frequently in percutaneous pelvic fixation. However, it provides only a two-dimensional image and requires multiple images in different projections to determine the correct point of entry and trajectory of the screw resulting in prolonged exposure for the patient and surgical team screw position error and the need for a proficient and available radiology technician. The introduction of computerized navigational systems may overcome many of the previous objections to this technique [7–8]. Several studies have already demonstrated higher precision, decreased radiation exposure and lower revision rates with the use of navigation techniques for percutaneous screw fixation around the pelvis and acetabulum (Fig 1). Summary
The goals in the treatment of pelvic and acetabular fractures are achieving anatomic reduction of articular lesions (sacroiliac joint, acetabulum) followed by stable fixation. Only the experienced pelvic and acetabular surgeon has the surgical judgment and experience to decide if it is possible to achieve these goals with a percutaneous procedure. If the difficulties entailed in integrating the new technology despite its initial cumbersomeness is accomplished then the advanced preplanning capabilities, improved accuracy of implant placement, significant reduction in radiation exposure, and creation of a powerful educational and quality control tool will be available.
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7a After external fixation and arterial embolization.
Bibliography 1. Rommens PM (2007) Is there a role for percutaneous pelvic and acetabular reconstruction? Injury ; Apr;38(4):463–477. 2. Cimerman M, Kristan A (2007) Preoperative planning in pelvic and acetabular surgery: the value of advanced computerised planning modules. Injury ; 38(4):442–449. 3. Attias N, Lindsey RW, Starr AJ, et al (2005) The use of a virtual three-dimensional model to evaluate the intraosseous space available for percutaneous screw fixation of acetabular fractures. J Bone Joint Surg Br ; 87(11):1520–1523. 4. Matta JM, Yerasimides JG (2007) Table–Skeletal Fixation as an adjunct to pelvic ring reduction. J Orthop Trauma; 21(9):647–656. 5. Atesok K, Finkelstein J, Khoury A, et al (2007) The use of intraoperative three-dimensional imaging (ISO-C-3D) in fixation of intraarticular fractures. Injury ; 38(10):1163–1169. 6. Atesok K, Finkelstein J, Khoury A, et al (2008) CT (ISO-C-3D) image based computer assisted navigation in trauma surgery: A preliminary report. Injury ; 39:39–43. 7. Mosheiff R, Khoury A, Weil Y, et al (2004) First generation computerized fluoroscopic navigation in percutaneous pelvic surgery. J Orthop Trauma; 18(2):106–111. 8. Stöckle U, Schaser K, König B (2007) Image guidance in pelvic and acetabular surgery – expectations, success and limitations. Injury ; 38(4):450–462.
7b Fig 7 The Starr frame assists with closed anatomical correction of the deformity. The device is based on table–skeletal pelvic fixation: securing the normal side of the pelvis to the table and maneuvering the other hemipelvis. After reduction, percutaneous sacro-illiac fixation can easily be achieved (Courtesy of Adam J. Starr, MD).
Rami Mosheiff
Hadassah University Medical Center Jerusalem, Israel ramim@hadassah.org.il
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Examining the benefits of MIPO in the lower extremity.
Edgardo Ramos, Fernando García and Gabriel Chávez
MIPO in the lower extremity: a Latin American perspective Minimally invasive plate osteosynthesis (MIPO) has become a new milestone in the development of orthopedic surgery. A recent review of traditional versus MIPO techniques has not demonstrated many differences. So why do we use MIPO? We use it because we offer a benefit to the patient in achieving an earlier and painless rehabilitation respecting the biological fracture environment, and because it is a pleasure to perform minimally invasive surgery, the current state-of-the-art procedure. The lower extremities offer some advantages for practicing minimally invasive procedures due to bigger dimensions and better anatomical accessibility. Proximal femur
The dynamic hip screw (DHS) by itself is a biological fixation, so it is only necessary to diminish the incision to be MIPO. Key points: • Incision according to angle plate projection. • Leave the dynamic screw 2–3 mm out the cortex. • Introduce the plate inverted inside-out; turn it with a clamp (Fig 1). • Insert the plate in the dynamic screw end, elevating the distal plate end making rotational movements. • 4.5 mm screw placement through the same incision or percutaneously (Fig 2).
Key points:
• Choose the correct plate length, plate contouring and indirect reduction. • The entry path of the plate is from metaphysis to diaphysis (Fig 3) otherwise the plate can damage soft tissues. MIPO diminishes the necessity of bone grafting. Distal femur
In this segment minimally invasive procedures are useful especially if there is coexisting damage (Fig 4). They help to perform a very light, quick, and patientfriendly surgery. It may be necessary to separate the proximal end plate to engage the dynamic screw into the plate barrel if a DCS is used. We use the L-shaped tibial plate for distal femoral fractures in small patients (Fig 5). Proximal tibia
MIPO for fractures of the proximal tibia is not very common because most of them have intraarticular participation and need direct and anatomical reconstruction. Despite the use of angular stable implants sometimes it is necessary to add another plate. In Mexico we use nuts as “Schuhlis” to get angular stability (Fig 6). Distal tibia
This is a very challenging area so meticulous preoperative planning is need. Surgery has to be done following articular fracture treatment principles, with gentle handling of soft tissues and a “minimax” technique (Fig 7).
Femoral and tibial diaphysis
Indications for MIPO are polytrauma patients, hospitals without technological facilities for nailing, or local soft-tissue damage at the nail entry point.
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Ankle
Minimal ankle displacements are unacceptable and it is very difficult to perform MIPO techniques (Fig 8). A depu-
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Edgardo Ramos
Hospital de Urgencias Traumatológicas, Mexico bastian6@gmail.com
rated surgical technique and comparison with the healthy side are mandatory (Fig 9).
Fernando García
With MIPO techniques, we have possibilities to treat a broad spectrum of injuries, offering the patients quicker surgeries with fewer complications, and bloodless, painless, and shorter rehabilitation before they return to their previous activities with very good satisfaction rates.
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Hospital de Urgencias Traumatológicas, Mexico polifx@prodigy.net.mx
Gabriel Chávez
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Hospital de Urgencias Traumatológicas, Mexico gabich@prodigy.net.mx
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Considering optimal prehospital care of equine fracture patients.
Anton E Fürst and Jörg A Auer
Prehospital care of equine fracture patients The initial treatment of injuries to the equine extremity greatly affects the chances of perfect healing especially for long bone fractures [1]. Unfortunately, most fractures are exposed to substantial additional trauma during the transportation of the injured horse. Proper emergency equine transport, first aid and fracture splinting are critical to assure the best possible outcome. Rescue of severely injured horses A specially trained large animal rescue team, operating in Switzerland and Liechtenstein, specializes in the rescue of large animals involved in automobile accidents or trapped in precarious situations (Fig 1). Depending on the circumstance, it may be necessary to use a rescue net and crane or a helicopter. Rescues efforts may be conducted in the upright, lateral or dorsal recumbency positions. Rescuing horses must be well planned and calmly executed under the supervision of an experienced equine veterinary specialist (Fig 2). Up to now no complications have been encountered during these rescue efforts. Although every rescue operation must be performed promptly, time is of secondary importance to the mental well-being of the horse. As flight is a horse’s only protective response, any injury preventing this activity represents mental anguish for the animal. Thus, hastily improvised rescue procedures will be inadequate and result in additional trauma. Optimal treatment includes: initial wound management, infection prophylaxis, proper analgesia, intravenous fluid therapy, sedation and possibly anesthesia, stabilization of the fracture and careful and safe rescue with proper transportation.
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1 Fig 1 Ideal emergency vehicle: The SUV is equipped with blinking lights and all the necessary emergency equipment for rescuing horses. The trailer has an axle constructed close to the ground, which results in a ramp with a gentle slope. The roof is reinforced to allow the installation of a support harness. A winch is built into the front wall to allow a recumbent patient to be pulled into the trailer.
Transport of the injured horse in a supporting harness
A harness which supports the horse’s entire weight and does not interfere with their respiration and balance should be used (Fig 3). It allows the horse to rest its limbs during transport, reducing anxiety and pain, and improves the general attitude of the patient. It is imperative that everything is checked repeatedly throughout the transport, so that problems can be immediately identified and corrected promptly. Most horses alternately rest one limb after the other. After some time, horses with a properly splinted fractured limb will frequently bear some weight on it while being supported by a harness, thereby resting the healthy contralateral limb.
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Fig 2 A horse with an ulnar fracture is rescued with the help of a crane and lifted to the trailer, which could not drive to the injured horse because of the snow. After intravenous sedation, it took between 3 and 8 minutes to accomplish this rescue. Fig 3 A fracture patient supported by a harness is ready to be transported to a specialty clinic. A splint is applied to the limb to temporarily fix the fractured limb. Fig 4 A horse is standing in a trailer with its properly bandaged fractured limb. The left side of the trailer is filled with straw bales to build up a lateral support for the horse.
For this type of transport, a person experienced in large animal rescue operations should always be present in the trailer to provide optimal care for the patient. In extreme cases, a veterinarian may be required to travel with the horse. Experience has shown that horses transported with a harness arrive at the hospital in much better general condition than those that are not.
4
If such a rescue sling is not available, the patient should be supported on all sides so the animal’s body weight leans against the wall or bales of straw placed on one side of its body (Fig 4). One has to keep in mind that the horse can neither see the
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5 Fig 5 A recumbent patient was pulled into the trailer and rests comfortably on an air mattress. Two assistants help with anesthesia.
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6a
Fig 6 Left: A drawing of a horse suffering from a proximal radius fracture, demonstrating the muscle induced valgus deformity. Right: The limb is properly supported with layered bandage up to the elbow and an additional lateral splint to the shoulder, effectively counteracting the deforming forces.
curves ahead of it nor the red lights suddenly appearing in front of the vehicle. Transport of recumbent horses Horses that are unable to stand are transported to the clinic in lateral recumbency, and if anesthesia is used, it must be induced and maintained by a veterinarian (Fig 5). Transportation is as rapid as possible (not to exceed 90 minutes) and requires that the veterinarian travel with the horse. The transportation may even require police escort. Equipment required for this transportation includes a mechanical or electric winch, transport mat and insulated air mattress. In order to maintain control of the horse’s well-being, an indwelling intravenous catheter is placed and intravenous fluids are started. To reduce injury for the recumbent horse, leather boots are placed on the hooves, and hobbles are applied to all limbs. After the halter has been removed to prevent damage to the facial nerves, the head and eyes must be well protected with padded leather headgear.
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6b
The recumbent horse is pulled into the van using a slide mat. Recently, special air mattresses have been developed for the transport of recumbent horses and are used by the large animal rescue units in Switzerland and Liechtenstein. Before inflation the air mattress is placed between the horse and the transport mat, which are then pulled into the van. Once the horse is in the trailer the mattress is inflated with compressed air in about 2 minutes and assures a comfortable ride for the patient. Horses can be transported great distances without the risk of pressure necrosis or nerve damage. Often, the amount of drugs used to sedate the horse can be reduced. An audio-video system between the van driver and the assistants in the trailer helps to ensure the safety of the personnel accompanying the horse. For long distances, the use of a mobile anesthetic machine operated by experienced assistants may be necessary. This enables the administration of intravenous fluids and supplemental oxygen (approximately 2–12 l of oxygen per minute). Unloading the recumbent horse
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is achieved by pulling the transport mat out of the van with a winch, crane or by hand. It is important to keep track of all the types, quantities and concentrations of the medications the rescue team administered to the patient and to hand this information to the treatment team at the specialist hospital. As a rule only fracture patients with open fractures and those that cannot stand up are treated immediately by means of internal fixation. The vast majority are properly diagnosed and provided with state of the art fixation by means of a splint or fiberglass bandage. During this time the horse gets used to its “stiff” leg and learns to use it. First aid treatment
Skin wounds must be treated with care. After covering the wound with a water-soluble antibiotic ointment, the hair surrounding the wound is removed and a sterile dressing applied under the bandage. With open fractures, the bone must be cleaned and covered with a sterile dressing. Immediate administration of systemic antibiotics is indicated in horses with open fractures or large wounds. The notion that analgesics should not be administered to horses with fractures is unfounded. Systemic analgesics should be given as soon as the fracture is stabilized. Fractures are rarely associated with severe hemorrhage. However, pain and shock lead to substantial fluid loss, which should be replaced using intravenous fluid therapy.
The equine cast, also referred to as a synthetic splint, is formed from fiberglass tape impregnated with a polyurethane resin. It is very strong and cures quickly, is easy to apply and very light. When applying the cast, the horse should stand quietly to prevent the occurrence of micro-fractures and folds in the cast, which may reduce its strength and cause pressure sores.
Bibliography 1. Fürst A (2006) Emergency treatment and transportation of equine fracture patients. Auer JA, Stick JA (eds): Equine Surgery. 3 ed. St. Louis, MO: Saunders Elsevier, 972–980. 2. Fürst A, Keller R, von Salis B (2006) Entwicklung eines verbesserten Hängegeschirrs für Pferde: Das Tier - Bergungs- und Transportnetz (TBTN). Pferdeheilkunde ; 22:767–772.
In most cases, judicious use of a sedative makes the examination and emergency treatment of an acutely traumatized horse much easier, particularly in horses that are already stressed from competition or are in pain. Furthermore, horses do not tolerate external coaptation well, especially when the fixation extends above the carpus or tarsus. The use of a sedative may be necessary to induce acceptance of the external coaptation device. Pain from instability is extremely stressful for the fracture patient. Effective stabilization of the fracture substantially improves the general well-being of the animal and it is better prepared for surgery. The stabilized fractured limb allows the horse to bear some weight on it for balancing during the transport. Therefore, the horse is much quieter once stabilization has been provided. There are a variety of splints that are suitable for stabilization of equine fractures. Splints applied in two planes at right angles (90 degrees) to each other must be placed in layers to the cranial, caudal, lateral or medial aspects of the padded limb and held in place with non-elastic tape. The splint should be placed such that the contractural forces caused by the limb muscles are counteracted. From the midradius and distal tibia proximally, the splint cannot be applied high enough, so an additional lateral splint reaching to the shoulder is incorporated into the bandage to counteract the muscular forces, which tends to induce a valgus deformity at the fracture site (Fig 6).
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Anton E Fürst
Diplomate ECVS Equine Department, Vetsuisse Faculty, University of Switzerland, Zurich afuerst@vetclinics.uzh.ch
Jörg A Auer
Diplomate ACVS/ECVS Equine Department, Vetsuisse Faculty, University of Switzerland, Zurich jauer@vetclinics.uzh.ch
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