AO Dialogue 2 | 2013

AO Dialogue 2|13 The newsletter for the AO community

Where Science meets Clinics 2013 The whys and wherefores of advanced orthopedic tissue engineering were explored at this annual symposium

The annual “Where Science meets Clinics” symposium provides an open platform to foster exchange and networking between research, clinics and the healthcare industry to stimulate successful clinical translation of innovative science. This second edition of the symposium held in September 2013 at the Davos Congress Center was jointly hosted by AO Exploratory Research (AOER) and the AOTK System.

Michael Schütz (AU) and Sandra Steiner (CH) welcomed over 100 participants comprising scientists, clinicians, and representatives from the healthcare industry and regulatory agencies involved in the clinical translation of bone, interverte-

bral disc and articular cartilage repair and regeneration strategies. The event commenced with a brief introduction to the AO Foundation, provided by AO Foundation President, Professor Jaime Quintero (CO). After three full days of presentations and extended panel and podium discussions, the participant feedback ranked the symposium extremely highly, sending out a clear message that the AO must continue hosting this symposium regularly. This notion is fully supported by the AOTK System—a first-time official partner of the symposium.

Table of contents Where Science meets Clinics My view, James Kellam

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AO President’s interview

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AO Dialogue–SIGN fellow

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Berton Rahn Prize Winner

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From the AO Clinical Divisions 9-13 From the AO Institutes

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Where Science meets Clinics 2013

The symposium 2013 at a glance Global experts shared this platform to talk about the current procedures, achievements, and challenges regarding the latest strategies on the symposium’s core topics: • Cell Therapy and Responsive Materials

in Bone, Intervertebral Disc and

Articular Cartilage Repair • Barriers and Strategies for Translation

of New Tissue-Engineered Materials to

the Clinic This year, the unique symposium format had plenary and parallel breakout discussion groups to encourage participants to actively contribute.

Presentations In the Cell Therapy session keynote lectures were delivered on ‘Cell therapy in intervertebral disc degeneration’ by Gunnar Anderson (US); on ‘Technovolution of cartilage repair’ by Daniel Saris (NL); and on ‘Cell therapy for bone repair and regenerations’ by Hamish Simpson (UK).

These keynote lectures were followed by several oral presentations from a diverse group of in-

vestigators. The session was chaired by Brigitte b Vollmar and Tim Pohlemann (both from DE). The level of involvement and interaction was reflected in the many questions fielded by these experts.

The Responsive Materials session, chaired by David Eglin (CH) and Robert McGuire (US), featured keynote lectures on ‘Merging micro/ nanoscale technologies and advanced biomaterials for tissue regeneration and stem cell bioengineering’ by Ali Khademhosseini (US); ‘Molecular strategies for adaptive materials’ by Philip Messersmith (US); and on ‘How mechanobiology inspires new approaches on the path from basic sciences to the clinics’ by Viola Vogel (CH). These lectures, too, were followed by oral presentations. Emphasis Poster Presentations on cell therapy and responsive materials in bone, cartilage and disc repair marked the end of the second day.

Parallel Breakout Panels On both days, the presentations were followed by three parallel breakout discussion sessions.

Each panel included a keynote speaker, AOER and AOTK members, Clinical Research Program partners and an expert advisor. The breakout

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

The “Gemeinschaft”

sessions stimulated all participants to contribute actively and led to further questions and potential solutions so as to enhance clinical translation. The panel discussions will be summarized in a series of papers to be published in the eCM Journal (published by the AO Research Institute Davos).

The final day of the symposium featured an interactive session on Barriers and Strategies for Translation chaired by Michael Schütz and Daniel Buchbinder (US). Chris Evans (US) presented an interesting view on ‘An academic biologist’s perspective on research translation’. Mats Brittberg (SE) spoke on ‘Cartilage repair; barriers and strategies for translation’s highlighting that the new cell regulations are a big roadblock today. Anthony Ratcliffe (US) spoke on ‘Translating concept to product for articular cartilage repair: barriers and strategies’, mentioning that articular cartilage repair remains a major clinical opportunity requiring a comprehensive and coordinated approach. ‘Regulatory perspectives on the translation of chondrocyte implantation products’ was Lennart Akerblom’s (SE) topic. Interesting and interactive podium discussions took place among the participants, keynote speakers, and the podium members: Jörg Goldhahn (CH), Henning Madry (DE) and Christian Matula (AT). The discussions were moderated by Norbert Suedkamp (DE). The main message supported by all was the need to create synergetic environments between clinicians, scientists, industry and regulatory experts.

Michael Schütz and Sandra Steiner closed the symposium expressing their gratitude to the participants and the organizing team—and received an overwhelming positive acclaim on the success of Where Science meets Clinics 2013.

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

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

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

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An interview with AO President Jaime Quintero Many leading AO surgeons have completed an AO fellowship, what about the next generation?

Doing a fellowship in a renowned clinic or university hospital has been the gateway to the AO for many of us. The Davos Courses participants will discover the different AO fellowship programs ranging from clinical fellowships with one of our clinical divisions (AOTrauma, AOSpine, AOCMF and AOVET), to clinical research or pre-clinical and translational research fellowships at one of our institutes (AO Clinical Investigation and Documentation and the AO Research Institute Davos respectively). As a clinical fellow, which I was, you get exposure to a surgeon’s day-to-day working life in a hospital, and you get an AO mentor (as do fellows in our institutes). Many leading AO surgeons did AO fellowships and stayed in touch with their mentor, which has had a very positive impact on their career. I did a fellowship in Augsburg, Germany, in the early eighties and it created a connection to the AO which has evolved and grown throughout my career culminating in this presidency.

It is very important to the AO that we build close relationships with the young surgeons and scientists who are the future of this organization through fellowships. An AO fellowship offers both an excellent education opportunity and participation in a community of dedicated and talented surgeons and scientists.

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

In the last years AOSpine has had great success in building alliances in particular with the SRS (Scoliosis Research Society) and AO Foundation has pursued a mutual alliance with the AAOS (American Academy of Orthopaedic Surgeons).

AOTrauma has continued to develop ongoing relationships with leading European orthopedic associations—EFORT, ESTES and DGOU and in 2013 formed an alliance with the Spanish orthopedic association, SECOT. Reputation and the recognition of academic values of the AO are important elements in these relationships One of our most significant developments this year was in Beijing with the Chinese Orthopaedic Association (COA), which is the culmination of an association that has been growing over the past three years. Building on the success of the clinical division’s (AOTrauma and AOSpine) days at the annual COA congress, this year the AO Foundation also delivered an educational event instructing surgeons on basic principles of hip and knee arthroplasty surgery (AORECON Day at COA). All three of these events were attended by more than 1,000 delegates.

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SIGN (Surgical Implant Generation Network) Impressions from the SIGN conference SIGN Fracture Care International was started in 1999 with the mission to create equality of fracture care throughout the world. More than 5,000 SIGN surgeons have played a role in furthering the innovations and treatment of the poor.

The Eleventh Annual SIGN International Conference was held in Richland, Washington (US) from September 11-14, 2013 with keynote speaker Dr Andrew Schmidt President of the Orthopaedic Trauma Association (OTA) who discussed treatment of fractures of the proximal femur and infected fractures. A selection of the many highlights is detailed below.

Long bone fractures Comparisons of treatment of long bone fractures using SIGN nails and hollow nails were discussed. A ten year case series of humerus, femur and tibia fracture treatment was presented by Hilario Diaz from Southern Philippines Medical Center, various patterns of fractures of long bones from Regional hospitals in Nigeria as well as comparative studies of SIGN solid versus hollow nails were shown. Kristopher Tolosa discussed a comparison of the squat and smile picture compared with X-rays in evaluating bone healing. Lew Zirkle led a workshop discussing the SIGN technique with new modifications.

Pelvic and hip Technical tips and tricks for avoiding malreduction on proximal femur fractures were demonstrated by Professor Andrew Schmidt from the University of Minnesota. Intertrochanteric and neck femur fractures using Sign Hip Construct demonstrated excellent stabilization without using C-arm. “The pelvis is a place to work not to play” was the conclusion of a pelvic fracture symposium discussing pre-operative planning, approaches and fixation of complex pelvic fractures led

by Professor Kyle Dickson, Pierre Guy and Duane Anderson.

Pediatric fractures The newly launched SIGN pediatric fin nail, which is flexible with a distal fin, has a healing rate with minimal complications. Raymond Liu described the treatment of acute physical injuries in the lower limb. New SIGN implants were later exhibited in the SIGN workshop where all participants had access to a variety of practical exercises.

Infections Andrew Schmidt talked about the challenges of infected fractures with hardware, treatment of infected diaphyseal fractures using antibiotic cemented nails, and bone transport with SIGN nail which was shown to be successful. There was no difference in infection rate between infected and uninfected HIV AIDS patients.

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SIGN (Surgical Implant Generation Network) AO Dialogue-SIGN Fellow Presentation Outcome of SIGN fin nails surgeries in the treatment of long bone fractures Growing indications for the use of SIGN nails and the fact that longer and larger SIGN fin nails will be produced has stimulated a number of case series recording the results of using these nails. AO Dialogue-SIGN Fellow, Dr Isidor Ngayomela presented a case series from Bugando medical Center, Mwanza, Tanzania at the Eleventh Annual SIGN International Conference was held in Richland, Washington (US) from September 11-14, 2013.

Methods and Patients This was a retrospective study which was conducted at Bugando Medical Centre in Northwestern Tanzania over a period of five years from July 2008-June, 2013. Data was derived from the SIGN database at Bugando Medical Centre and analyzed using SPSS version 17.0.

Results A total of 70 patients were studied aged from 15-78 years with a median age of 39.5 years. The ratio of males to females was 3 to 1. Ten percent (seven cases) presented with open fractures (3 Gustillo I and 4 Gustillo II) and all except one of these presented within 48 hours of the injury. Two of them presented with infected wounds after nail insertion, one had deep infection and the other superficial infection, and all had a repeat surgical debridement with antibiotic cover and responded well. One patient had a previous implant which was exchanged for a SIGN fin nail.

The majority of fractures (68.6%) were on the right side and the femur was the most frequent bone affected (70% of cases), no SIGN fin nail was inserted in tibia fractures.

There were 75.7%(53 cases) distal fractures with 240mm and 280mm nails being commonly used, retrograde femur was the most common surgical approach performed in 63.38% (45 cases) of fractures.

The time taken from injury to definitive surgery ranged from one day to 54 weeks with a median duration of 2.23 weeks. Post-operative reduction and nail

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position was excellent in all cases. The infection rate was 2.82% (two cases) and other complications were minimal and acceptable. Fracture healing by X-ray was reported in 92.96% of cases and the median time for radiological healing as defined by X-rays was 5.2 months (range 3-12), five cases did not show radiological and clinical signs of healing even after their follow up beyond five months. The majority of knees and elbows had at least 90 degree of flexion in 97.8% of cases. Only ten (14.29%), six (8.6%) and sixteen (22.9%) patients returned for follow up at six weeks, three months and later, respectively.

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

Conclusion Surgical Implant Generation Network (SIGN) nailing promotes predictable fracture healing with low infection rate, minimal postoperative complications, and early mobilization of the patient. The SIGN fin nail, like the standard SIGN IM nail, provides adequate fixation of long bones. In the developing world the SIGN fin nail can be desirable in fixation of multiple fractures in a moderately dynamic stable patient and it takes shorter time of surgery. A poor follow up is still a challenge to our hospital; this may mean that patients are cured and do not feel like returning for their follow ups or simply that follow ups are inadequately attended. This short case series study has encouraged us to develop a comparative study between SIGN fin nails and SIGN IM nails in the couple of years to discover their differences and similarities in fracture management.

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Wing-Hoi Cheung

2013 Berton Rahn Prize Winner Can Low Intensity Pulsed Ultrasound Accelerate Osteoporotic Fracture Healing?

Wing-Hoi Cheung, Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong (HK) Osteoporotic fracture is a critical medical challenge with an increasing global aging population. In the US, there are more than 1.5 million fragility fracture cases each year. Mortality is also high within the first four years after injury. Many studies confirm that osteoporosis impairs fracture healing at different stages.

The contributing factors include decrease in mesenchymal stem cells (MSCs) and reduced mitogenic potential, impaired angiogenesis and reduced osteoinductivity of demineralized bone matrix. A general belief proven by some in vitro studies also suggests the reduced responsiveness of osteoporotic bones to mechanical signals. In the meantime, low intensity pulsed ultrasound (LIPUS) was widely reported to accelerate fracture healing by 38% in normal bones in many clinical trials but its effects on osteoporotic fracture had not been addressed. The hypothesis of this study was that LIPUS could accelerate osteoporotic fracture healing and up-regulate the expression in osteogenesis-, remodelingand angiogenesis-related genes.

An osteoporotic fracture rat model was used in this study. Rats were randomly assigned to either LIPUS or Control group and the healing was assessed by gene expression (real-time PCR), radiographic callus width/area, microCT and histomorphometry at 2, 4, 8 weeks postfracture, where Col1 (type 1 collagen), bone morphogenetic protein-2 (BMP-2) [osteogenesis-related]; RANKL (NF-kappaB ligand), OPG (osteoprotegerin) [remodeling-related]; and VEGF (vascular endothelial growth factor) [angiogenesis-related] were target genes. Results indicated that the LIPUS group showed earlier callus bridging at 5-6 weeks post-fracture,

while the Control group occurred at 7-8 weeks instead, with significantly higher callus width/ area than the Control at all time points. MicroCT demonstrated a higher increase of BV/TV from week 2 to 4 in LIPUS group (+26.1%) than the Control (+16.3%), although the differences were not significant. For gene expression, Col1 was significantly up-regulated in LIPUS group at week 2 and 4 (3.11X and 1.96X); BMP-2 was significantly up-regulated in LIPUS group at week 2 (7.81X) but lowered at week 8; OPG was up-regulated at week 2, followed by the surge of RANKL expression, despite no significant difference; VEGF was also up-regulated at week 4 and 8 (3.3X and 1.55X). Histologically, the LIPUS group showed more cartilage at week 2, more active endochondral ossification at week 4 and lesser cartilage content at week 8, which was supported by significantly higher cartilage area in the LIPUS group at week 2 and 4, as assessed by quantitative histomorphometry.

In this study, osteoporotic bones were shown to be responsive to mechanical signals while leading to an accelerated healing process. The gene expression data, supplemented by other traditional assessments, confirmed that callus formation was increased by LIPUS during the inflammatory phase; the remodeling phase was occurred sooner; and angiogenesis was increased by LIPUS during the reparative phase.

Therefore, we conclude that LIPUS can accelerate osteoporotic fracture healing by enhancing callus formation, bone remodeling and angiogenesis. With the support of another AO startup grant (Ref: S-11-10C), we further elaborated on this study and the most updated results of the on-going study demonstrate that one of the mechanisms of LIPUS accelerating osteoporotic fracture healing is through enhanced recruitment of MSCs. All these findings help us understand the mechanism of osteoporotic fracture healing and provide useful pre-clinical data for applying LIPUS on fragility fractures clinically.

AO Dialogue 2|13

From the Clinical Divisions

AOTrauma Transformation 2013 was a milestone year for AOTrauma, embarking on a historic journey to transform its education strategy as well as its portfolio of activities and resources. The positive outcomes of this significant initiative are now dramatically reshaping how AOTrauma improves patient care.

AOTrauma Skills Lab Industrialization It is a challenge to learn and train certain skills and concepts during live surgeries.

These include basic principles and techniques eg, proper tightening of screws and feeling the difference when drilling with sharp or blunt drill bits. The AO Skills Lab comprises ten stations which give surgeons an opportunity to train these clinical motor skills and experience biomechanical concepts in a hands-on environment. Each station is moderated by AOTrauma faculty.

Participants have the opportunity to interact with and receive immediate feedback from trauma surgeons.

In October 2012, the AOTrauma Education Commission decided to make the AO Skills Lab a core part of the AOTrauma Basic Principles Courses—of which there are over 100 offered worldwide annually. To address this need Skills Lab is being updated and will be introduced into Basic Principles Courses in 2014. By 2015, all courses will be delivered with the new AO Skills Lab.

AOTrauma International Board changes During the Trustees Meeting 2014 in June in Budapest (HU) there will be an important governance change in the AOTrauma International Board. Jack Wilber will take over Nikolaus Renner’s lead as the Chair, AOTrauma International Board. The three Chairs of the global commissions—Education, Research and Community Development—will successfully end their tenure.

Elections will take place in early 2014 for the three global commission Chair positions.

Two of the Chairs, Kodi Kojima (Education) and Frankie Leung (Research) are eligible for re-election. Klaus Dresing (Community Development) is not eligible, as he will complete his second term. Further details will be available in 2014.

AOTrauma takes this opportunity to thank Nikolaus Renner for his extraordinary commitment to AOTrauma over the last three years. He has led the organization in successfully improving patient care and expanding the network.

Upcoming scientific congress and symposium Following the success of the first congress in Hong Kong in 2012, the forthcoming 2nd AOTrauma Asia Pacific Scientific Congress & TK Experts’ Symposium will be held in Seoul, Korea at the COEX Exhibition and Convention Center on May 16-17, 2014. The two-day program will cover the scientific and technical aspects of orthopedic traumatology in various topics. This event will bring together distinguished regional and international speakers to share their expertise and experience, and host interactive sessions which will foster valuable discussions. Visit www. aotrauma.org for details and registration.

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From the Clinical Divisions

AOSpine World Forum for Spine Research From May 15–17, 2014, in Xi’an, China, the World Forum for Spine Research (WFSR) will gather renowned clinicians and established researchers in the fields of disc biology and biomedical engineering from around the world in a unique, stimulating, and focused environment. The WFSR has established itself at the forefront of international spine care research through its commitment towards supporting researchers in developing and promoting scientific innovation, collaboration and contribution in the field of intervertebral disc degeneration.

Xi’an is home to the Army of Terracotta Soldiers, ranked as a UNESCO World Heritage Site and considered to be the Eighth Wonder of the World. Please visit the WFSR website at www.spineresearchforum.org to view the latest program and list of confirmed faculty. You can also register for the event on this site; early bird registration fees are available until March 3, 2014.

Beyond the spine: Xi’an 2014 Over 30 of the world’s experts on the intervertebral disc will be speaking at this event, in a series of keynote addresses, plenary lectures, poster viewings and interactive discussion sessions, which will shed new light on the care and management of this unique tissue. In addition to the world’s top researchers and clinicians, key representatives from industry will also contribute their findings on advances in technology.

Why focus on the intervertebral disc?

According to Chairperson Keita Ito, the topic was chosen following an AOSpine member poll. “We have decided to focus on the intervertebral disc because our members felt this to be an area of high priority and interest.” In addition there will be a special focus on degeneration to therapeutic motion preservation.

A unique concept The WFSR is based upon the concept of a multidisciplinary meeting with a clear focus on one key topic. Chairperson Kenneth Cheung says: “We choose to hold all talks in one hall, and organize only one running session so we could ensure that clinicians, scientists, engineers, and anyone else in the field would have plenty of opportunities to meet and discuss with their peers.”

The mission

Xi’an China; home to the Army of Terracotta Soldiers and hosts of the WFSR 2014

The goal of the WFSR is to bring all those working in a specific field under one roof, to foster discussion and knowledge exchange. “In doing so, we hope to encourage new friendships and collaboration amongst world experts in this area,” says Keita Ito. “This complies with the mission of AOSpine: to act as a catalyst for enriching knowledge, and ultimately help the patients who suffer from intervertebral disc disorders.”

AO Dialogue 2|13

From the Clinical Divisions

AOCMF A new concept spells success For the past few years, AOCMF in North America has been successfully incorporating small group discussions (SGD) into their course programs at all levels.

This new format, which was inspired by a similar approach used in AOSpine, offers an alternative to the traditional approach of large group lectures and participant feedback has been very favorable.

More recently, in August 2013, the AONA CMF held a course in Minneapolis (US) where for the first time the traditional group lecture was almost entirely replaced by a two-day series of SGD. The program for this new course included only two brief lectures at the beginning of each day. The lectures were based on fundamental topics like bone biology and internal fixation mechanics. With these basic concepts and some new vocabulary, participants rotated through a series of small group discussions using cases that illustrated the principles of CMF musculoskeletal repair. Each case focused on concepts that were previously taught using group lecture format.

The evaluations for this new course format were extremely positive. Many participants stated that this was the most interesting course they had ever attended.

The course faculty noted high levels of participant engagement. It was the consensus of the faculty that this new format was very successful in delivering high quality education with the promise of high information retention.

Asia Pacific moves towards sound expansion AOCMF Asia Pacific held its first Regional Scientific Forum in Penang (Malaysia), in September 2013. A packed and intense one-and-a-half days’ program focused on the area of orbit and midface, which often presents unique challenges in reconstruction following trauma and oncologic resection. Chaired by Dr Lay Hooi Lim, prominent experts from the US, Europe and Asia Pacific were invited as speakers. Discussions during the forum were vibrant and demonstrated the value of cross-fertilization of ideas at a multi-specialty meeting. This was much valued by the 67 participants from seven different countries in the region. The Regional Scientific Forum was followed by a Faculty Education Program. Professional educators trained 60 of the 130 currently approved AOCMF Asia Pacific faculty members.

New research priority area The March call on ‘TM joint, subcondylar and adjacent bone and cartilage; deformities, defects, injuries and disorders’ received 35 proposals from 22 countries.

The Research & Development Commission now invites the AOCMF community to submit proposals in the research field of ‘Anti-osteoclastic drugs and their impact on maxillofacial and orthopedic bone biology, disease, diagnosis, surgery, and treatment modalities (ARONJ)’ by January 13, 2014.

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From the Clinical Divisions

AONeuro Initiative The background to AONeuro AONeuro is an initiative, kicked off to learn more about the needs and educational structure required by cranial neurological to improve patient care. Together with AOSpine and AOCMF, AONeuro aims to provide multidisciplinary course education. It seeks to add a cranial dimension to the existing AO Education portfolio.

Today, AONeuro has a global multispecialty community that includes cranial neurosurgeons, neurologists, neurointensivists, neuro anesthesiologists, and neuro traumatologists. The members also include other neurological professionals involved in cranial neurological trauma, cranial oncologic and cerebrovascular surgery, cranial reconstruction and cranial congenital anomalies surgery. AONeuro is committed to communicating the latest educational advances, information on treatment, protocol, equipment and new developments.

Although over the last few years, neurosurgery courses have been conducted by AOCMF, in November 2013 that the first North American Neuro course combining Cranial Traumatic Brain Injury and Spinal Cord Injury was conducted in Toronto (CA) jointly by AONeuro and AOSpine. Michael Fehlings and Geoff Manley were the course chairs. The course was attended by 50 individuals, mostly residents. The course included updates on the neurological aspects of injury and recovery, imaging, and decompressive craniectomy.

AONeuro Courses 2013–China With the publication of the China Guidelines for Traumatic Brain Injury management, it seemed appropriate to host AONeuro educational courses in China this year. Hence, in August 2013, two AONeurotrauma Principles Courses were held in China. 51 participants attended the course in Shanghai, and 60 in Beijing. The goal of the courses was to teach the principles of cranial trauma and to acquaint the practitioners with guidelines for management and for decompressive craniectomy, including techniques for proper performance. The courses taught by an international faculty were held in Mandarin and English with simultaneous translations. The course in Shanghai was held at Huashan Hospital, Shanghai. Dr Liang-Fu Zhou, Shanghai (China) was the Local Chairperson, and Prof Geoffrey Manley, California (USA) stepped in as the International Chair.

The course in Beijing was held at the Johnson & Johnson Medical China Science Center and chaired by Prof Geoffrey Manley, California (US); participant feedback was excellent.

Coming up AONeuro plans to organize a total of 28 courses globally in 2013/14. Webinars on cranial reconstruction are planned. A webinar on decompressive craniotomy techniques is being developed by the TK System. Continued resident education courses have been proposed for AO North America, and an Advanced Course has been planned for 2014-2015 as well.

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From the Clinical Divisions

AOVET Improving patient care through high quality education AOVET’s member community continues to grow. Today, over 650 members support AOVET in its mission to improve patient care across species by providing high quality education that meets their needs. To maintain its leading position, AOVET’s community development division is exploring the evolving needs of surgeons across the globe in the different stages of their career. In response to the community’s growing demands, AOVET has enhanced its membership options, offering a three-year membership program with exclusive benefits such as: access to selected journals, the veterinary section of the AO Surgery Reference, educational material and videos, webinars and webcasts, and more.

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

AO Foundation’s honorary Trustee, Prof Key-Yong Kim, welcomed a group of 55 veterinarians that included faculty from four veterinary colleges, private practitioners and some of the recent graduates. He introduced the AO Foundation and its activities. Dr Young-Soo Byun, a Senior Trustee of the AO Foundation presented the Principles of Human Fracture Management at the seminar. Joerg Auer, Chair AOVET International spoke about the challenges large animal veterinary surgeons face when dealing with fracture management in horses and cattle. He then introduced AOVET International, explaining the benefits of being a member of the AOVET community. The seminar included three laboratory exercises conducted by Prof Key-Yong Kim and Dr Byun in the area of internal fixation. Dr Jae-Suk Chang, a newly-elected AO Foundation Trustee assisted the laboratory exercises. Prof Woo-Shin Cho joined the group, uniting all the former and present South Korean Trustees at the inaugural function of the new AOVET South Korea. The first AOVET Course—Principles in Small Animal Fracture Management has now been planned for end of 2014.

Faculty Development AOVET and AOCMF organized a Faculty Education Program (FEP). It consisted of five weeks of structured online preparations, followed by a two-day event in Zurich (CH) on October 19–20. The program concluded with post-course selfassessment and online reflection. Thirteen participants represented ten countries from the European region. The core subjects of the program included: lecture presentation, leading a discussion group, and teaching practical skills. The emphasis was on result-oriented teaching and effective feedback. Less tangible, but equally important elements of teaching and learning; such as how to motivate learners and encourage interaction among course participants were also covered. The group was unequivocal in the feeling that they are more capable and confident faculty as a result of the program.

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From the AO Institutes

AOCID

Historical documentation cards from the AOCID archive

AO Documentation began operations in 1959 and around 1,000 cases were recorded during the first year alone. It was this documentation of fracture cases that created the necessary scientific evidence to prove the value of internal fracture fixation to an initially skeptical public. AO Documentation’s unique repository of collected cases provided the basis in the 1980s for the Müller AO Classification–Long Bone Fractures, a system known and used as standard by surgeons around the world.

from documentation center to clinical investigation center. Beate Hanson accepted an offer in 2002 from the then AOCID Chairman David Helfet and became AOCID director, a position she still holds today.

However, by the 1990s it was realized that the concept of documentation no longer met contemporary standards and that a reorganization of AO clinical study activities was necessary to include prospective trials in order to proactively answer clinical questions.

From just a handful of clinical trials in the early years, AOCID is currently involved in approximately 50 multicenter international studies of every type of study design. In addition to this, around 20 Focused Registry projects are either running or in development. The internationalization of AOCID is also evident. Over 330 different clinics scattered around the globe have participated in clinical investigations. Over the past 15 years, well over

AO Clinical Investigation and Documentation (AOCID) was officially founded in 1998 to conduct clinical studies. Ruedi Moser was the first director and so began the move

The AOCID mission is to provide evidencebased knowledge through independently conducted clinical studies, education and methodological services. In the past 15 years, AOCID has grown beyond all expectations in terms of both size and capabilities.

9,000 patients have been recruited to an AOCID study.

Careful planning and processes are key to success in clinical trials. AOCID is ISO 9001 certified and an increasing amount of outside vendors have audited and appointed AOCID a “Preferred Third Party Provider” in recognition of the expertize housed within.

While AOCID carries out the functions of a typical Contract Research Organization (CRO), one element which sets AOCID apart from industry is the focus on spreading knowledge about evidence-based medicine (EBM). For example, Beate Hanson’s Roadmap to Research course (an introduction to EBM) has been given on four different continents and in 2013 celebrates a decade as a permanent fixture at the AO Davos Courses.

Around 20 young surgeons have availed of the unique clinical research fellowship to spend three months at a time in the AOCID offices to learn about the planning and

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The AOCSC qualified clinic in Regensburg, Germany

400

Regional Expansion: Number of clinics since 2000

Number of clinics 200 300

333

261

179

276

288

302

333

310

201

132

100

93

94

105

47

20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 13

0

THE FIRST 15 YEARS

AOCID

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

The worldwide growth of AOCID as measured by participating clinics

AOCID employees discussing a clinical study with surgeons

AOCID Study Coordinator Course held in Boston in 2013

conduct of studies. More courses are in the pipeline to suit the growing needs of healthcare professionals.

As a result of AOCID’s experience, the “AO Clinical Study Center” (AOCSC) global qualification program was developed. Among the advantages to becoming an AOCSC clinic are increased efficiency in clinical studies and ensured ethical and regulatory compliance (ICHGCP / ISO 14155). Over 30 centers from Aarau to Woolloongabba are part of the AOCSC program. The dedicated website: www.aocsc.org has all the information.

The first 15 years at AOCID were exciting ones as capabilities and networks were built up, the promise of the next 15 years and beyond for AOCID seems great.

Our thanks to the surgeons, study coordinators, patients, AOCID advisors and employees who have all played their part in our success.

Screenshot of a classification software developed for AOCMF

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From the AO Institutes

ARI

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

AO Implant Positioning Assistance The task of placing implants plays a key role in trauma and orthopedics, determining the surgical outcome. Current computer-aided surgery is costly, highly specialized and difficult to handle, which disqualifies it for the majority of routine interventions. A novel concept is proposed for simplified implant positioning utilizing conventional radiographic images. The method is based on the extraction of characteristic features from cylindrical hole projections within X-ray images for determining spatial alignment of objects and anatomy to guide the implant.

The concept carries potential for use in various applications within trauma and orthopedics, in particular nailing, plating, anatomical fracture reduction and prosthetics.

A functioning prototype was experimentally tested on several applications in the field of fracture care. These include plating of the proximal humerus, cephalic implant placement at the hip, dynamic hip screw placement, general anatomical plating, distal nail interlocking and adjustment of femoral anteversion. The system reveals strong potential

in terms of improving surgical precision, diminishing radiation exposure and reducing operational time.

Musculoskeletal Infection Group The Musculoskeletal Infection group in ARI has had a busy 2013, culminating in the 2nd AOTrauma Clinical Priority Program (CPP) Bone Infection meeting in Venice, Italy organized by the AOTrauma Research Commission. The CPP Bone Infection has entered the second year of activity and ARI director Geoff Richards and the musculoskeletal Infection group, headed by Fintan Moriarty presented their findings in Venice. The principal investigator of the CPP Bone Infection, Steven Kates (USA) and his co-Principal Investigators Volker Alt (Germany) and Edward Schwarz (USA) assembled a comprehensive program, updating participants on the most recent progress within CPP. In the past year, the CPP has commenced activities on a global bone infection registry, with a significant contribution from previous ARI research fellow Mario Morgenstern (Germany), and the AOCID.

Within the CPP, there have been new developments in laboratory-based diagnostic assays. The huge potential offered by the continuously growing bank of clinical samples, including microbiological cultures and serum samples, has already shown first results. Other projects on the theme of Bone Infection are also emerging with new results, including a better understanding of the role of implant stability on infection, as well as large animal models of two-stage revision of infected intramedullary nail, which is expected to set a standard within the field.

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

Bacterial microcolony adjacent to medullary adipocytes in an infected rabbit tibia

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

Collaborative Research Program “Annulus Fibrosus Rupture Repair” Disc herniation is the pathological condition for which spinal surgery is most often performed. While the discectomy approach provides favorable results in the majority of the cases, there are conditions where unmet needs exist in terms of treatment, such as large disc protrusions with only minimal disc degeneration. In these clinical situations, the outcome is often not satisfying and the economic burden is enormous. A biological annulus fibrosus (AF) repair would significantly improve the surgical outcome in patients with contained disc herniations but otherwise minor degenerative changes.

The aim of this consortium is to develop tissue-engineered biomaterials that will enable and stimulate the repair of the ruptured AF. The consortium’s general approach is to generate 3D scaffolds and activate them either by seeding with cells or by the addition of molecular signals that enable new

Members of the Collaborative Research Programs consortia

matrix synthesis to occur at the defect site, while the biomaterials provide immediate closure of the defect and maintain the mechanical properties of the disc.

Damaged disc histology

Progress of individual partners has led to definition of the mechanical requirements, the identification of the cellular phenotype, cell surface markers and progenitor cells of the functional AF, the development of a delivery system for cells and therapeutics using nanospheres and microgels, and the optimization of scaf-

folds, membranes and glues to be used for AF rupture treatment. These elements are combined to provide biological solutions in a modular system that can be adapted depending on the surgeon’s needs. Delivery, fixation techniques and methods for adhesion prevention are addressed while moving closer towards pre-clinical application. As this program develops, efforts will be made toward single-stage intra-operative tissue engineering approaches.

Partners of the AFR Program: Daisuke Sakai, Tokai University School of Medicine, Kanagawa, JAP Abhay Pandit, National University of Ireland, Galway, IRL Stephen Ferguson, Lorin Benneker, ETH Zürich / University of Bern, CH James Iatridis, Mount Sinai Medical Center, New York, USA Dirk Grijpma, University of Twente, Enschede, NL David Eglin, Sibylle Grad, Mauro Alini, AO Research Institute Davos, CH

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From the AO Institutes

AO Education Institute

AOSpine and AOVET publications launched in 2013

individuals responsible for the formation of AOVET.

The AOSpine book Minimally Invasive Spine AOTrauma publications to be launSurgery—Techniques, Evidence, and Contro- ched at the Davos Courses 2013 versies, which details the history, peerFracture Management Casts, Splints, and Support Bandages—Nonreviewed evidence, and modern surgical Periprosthetic techniques in minimally invasive surgery operative Treatment and Perioperative Proof the spine, was released with immediate tection, is a comprehensive guide to the success, becoming the number one online treatment of fractures and ligaments using seller of AO’s partner publisher, Thieme nonoperative casting techniques. It explains Publishing. Measurements in Spine Care and the principles and techniques of casting and SMART Approach to Spine Clinical Research, the includes 55 videos showing how to prepare final two books in a four-book series from and apply splints and casts to all parts of AOSpine that examines clinical manage- the body. ment, outcome assessment, and research in spine surgery, were also published in 2013. Periprosthetic Fracture Management, brings together the latest knowledge on periprosthetDuring the AO Trustees Meeting 2013 the ic fractures, including a full review of the publication AOVET—The First 40 Years was anatomical regions typically affected, plus launched. Written and edited by AO veteri- recommended techniques, surgical pitfalls, nary professionals and founding members, and a wide selection of complex cases and it traces the milestones, history, and key illustrations. Most significantly the publica-

tion introduces a new “Unified Classification System” specifically on periprosthetic fractures. It is hoped this new classification system will become as recognized as the AO/OTA Fracture and Dislocation

Michael Schütz | Carsten Perka

The incidence of periprosthetic fractures is continuously rising. Their treatment and outcome largely depends on a correct assessment, diagnosis and choice of procedure—revision surgery or internal fixation.

This requires interdisciplinary knowledge and considerable experience from the orthopedic and trauma surgeons as well.

Orthopedic and trauma surgeons will be able to expand their knowledge regarding: • Risk factors and assessment of periprosthetic fractures and the patient • A new “Unified Classification System (UCS)” • Options and choices of fracture fixations techniques as well as more complex revisions or reconstructive procedures • More than 350 pages containing superb illustrations and images

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

ISBN: 978-3-13-171511-1

www.aotrauma.org

9 783131 715111

Michael Schütz | Carsten Perka

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

Periprosthetic Fracture Management

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

Michael Schütz | Carsten Perka

Periprosthetic Fracture Management

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Classification and it has been specifically developed to help trauma surgeons recognize and treat prosthetic related fractures.

STaRT–a new tool for orthopedic trauma residents AOTrauma’s new online learning resource, STaRT (Surgical Training for Residents) applies the best educational strategies for residents to benefit from the wealth of knowledge available within the AO. The educational tool provides easy access to tailored information that: • Supports self-directed learning • Enhances effectiveness of adopting basic principles in clinical decision making • Complements formal educational offerings of certifying bodies and teaching hospitals

Collaborative content creation STaRT content is developed by international teams of experienced surgeons involved in resident training. Learning outcomes for every module are defined based on our overall learning objectives for AOTrauma resident education. Evaluation of the program and its content will be an ongoing process to keep it up-to-date and applicable to the learners needs.

A sneak peek at the STaRT booth The first offerings of STaRT (tibial shaft, femoral neck, trochanteric, and malleolar fractures) will be showcased at the AO Education Institute booth.

Web-based resource for residents Residents have unique learning needs. As distance learning techniques evolve, selfdirected learning becomes increasingly important. Three features, detailed in the box below, address distinct learning strategies.

STaRT will be launched in April 2014 with offerings in six anatomical regions: tibial shaft, femoral neck and trochanter, malleoli, distal radius, and proximal humerus.

Interactive e-learning activities

Self-assessment questions

Overview of AO resources for residents

Interactive case discussions promote learning based on common patient problems. Quizzes enable focused learning through immediate feedback. Tips and tricks and direct links to further learning materials help residents to deepen their knowledge of the topic.

To help identify their knowledge gaps, learners can test themselves with multiple-choice questions (basic, intermediate, or complex level questions), and receive feedback on their answers. References and further reading help to close the identified knowledge gaps.

Structured access to existing learning material allows residents to quickly identify available AO resources. All learning material is labeled according to complexity and includes videos, webinars, recorded lectures, e-learning modules, readings, mobile Apps, and access to AO Surgery Reference.

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AO Dialogue 2|13

From the AO Institutes

AO Technical Commission (AOTK) Meet the Experts at the Davos Courses 2013 After the highly successful “AOTK Innovations: Meet the Experts” at the Davos Courses in 2012, the course participants will again be able to visit first hand presentations and hands-on demonstration of surgical techniques based on solutions which have recently achieved AOTK approval. These daily lunchtime sessions are hosted by members of the AOTK System’s Expert Groups and surgeons with direct involvement in the development processes.

The three fields of trauma, spine and craniomaxillofacial surgery will be covered by dedicated sessions and special focus areas, such as neurosurgery and thoracic surgery, will also be part of the program as well. Admission is free and spontaneous participation is welcome. Attendees will not only get firsthand information about the new technology and the clinical basis and application, they will also have the opportunity to discuss with the presenting expert surgeons on site.

AOTK Innovations magazine During the Davos Courses 2013, AOTK will once again showcase the results of its strong relationship with its Expert Groups, industrial partner, internal partners, and clinical divisions and staff, with the release of the 2013 AOTK Innovations magazine.

The 2013 edition details information on 15 new implants and instruments for use in trauma, spine, CMF, and veterinary surgery, and includes a range of supporting articles on the history of Neurosurgery in the AOTK system, a welcome to the new AOTK CMF Chair, and an interesting portrait on AO Faculty member and Professor of Sports Medicine, Yi Lu. New trauma implants and instruments include the Radial Head Prosthesis system, the LCP Ankle Trauma 2.7/3.5 system, and new Expert Nailing instrumentation, plus there are details about the expanded Matrix Rib Fixation system, and new Facial Shape chin and malar implants within CMF. For neuro, new items include the MatrixNeuro Rigid Mesh and Bender and the MatrixNeuro Ultra Low Profile plates and screws.

The spine section provides details on the Synflate Vertebral Balloon system and the Zero-P ChronOS, and in VET, the Locking Reconstruction Plate and Mini Pate article comes with detailed descriptions and interesting case studies. Please enjoy AOTK Innovations 2013.

AOTK System

Innovations

1 | 2013

Impressum AO Dialogue 2|13 Editor-in-Chief: James F Kellam Managing Editor: Olga Harrington Publisher: AO Foundation Design and typesetting: Manuel Kurth Editorial contact address: AO Foundation, Clavadelerstrasse 8, CH-7270 Davos Platz, Phone: +41 81 414 28 14 Fax: +41 81 414 22 97 E-mail: dialogue@aofoundation.org www.aofoundation.org Copyright © 2013, AO Foundation, Switzerland

All rights reserved. Any re­p roduction, 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.