AO Foundation Annual Report 2016

ANNUAL REPORT 2016 A global network of surgeons

Our

vision is excellence in the

surgical management of trauma and disorders of the musculoskeletal system.

mission

Our is to foster and expand our network of health care professionals in education, research, development, and clinical investigation to achieve more effective patient care worldwide.

Editorial 2

Letter from the President and the CEO and Vice-Chairman of the AOFB

Executive Summary 4

AO Foundation highlights of 2016

Corporate Social Responsibility 6

Corporate Social Responsibility at the AO

Good Practice Policies 8

Code of Ethics and Transparency Policy

Innovation 10

All paths lead to innovation

AO Statistics 12

From carbon to people

AO Clinical Divisions 14 16 18 22

AOVET—advancing the practice of veterinary surgery AOCMF—excellence in facial surgery across the specialties AOSpine—increasing reputation as the leading academic community AOTrauma—sustainable leadership and growth for the largest trauma network

AO Initiatives 28 29

AONeuro—advancing the treatment of traumatic brain injury AORecon—expanding impact in joint preservation and replacement

AO Institutes 30 33 36 38

AO Research Institute (ARI) AOTK System AO Clinical Investigation and Documentation (AOCID) AO Education Institute

Governance 40 44 46 48

Finance Governance Governing bodies of the AO Foundation Addresses

Table of contents

Annual Report 2016 ┃ Editorial

Letter from the CEO and Vice-Chairman and the President Dear colleagues and friends, This has been a year of continued change and development throughout the organization and we would like to update you on some of AO’s recent accomplishments, many of which are elaborated on in this annual report.

In 2016, the AO continued to prioritize the creation of innovation instruments to open pathways to new ideas and create more intellectual property. With almost all funding committed and more than 20 approved projects well underway for the AO Strategy Fund, this year saw the establishment of two new innovation initiatives. Firstly AO Invest which is an investment fund for start-ups wholly funded by the AO. Its inaugural investment ina start-up improving surgical educational standards is closely aligned with the AO’s mission to significantly impact the advancement of patient care. And more recently, the AO Development Incubator, which supports inventors to build and execute project plans towards a proof of concept, constituted its board and its first calls for proposals will happen in March 2017. More detail about the AO’s pathways to innovation can be found on pages 10 and 11.

Transparency is critical to the AO and, in addition to establishing a Code of Ethics and Conduct that will apply to all staff and members of the AO’s network, the AO Foundation

Rolf Jeker CEO and Vice-Chairman 2

Board has decided to issue its own Transparency Policy in order to demonstrate its proactive approach in this matter. According to this policy, the AO will, once a year, publish aggregate remuneration figures for the AOFB, international boards of the clinical divisions and the AO Executive Management. These figures are published on page 43 of this annual report and a report on good practice policies appears on pages 8 and 9.

In 2015, the AO created a Corporate Social Responsibility (CSR) initiative in which the organization aims to take into account in its daily business its impact on society, the environment, and employees. This work gained pace in 2016 and many of the CSR activities that the AO is investing in have reached new levels of maturity and positive impact. For more information on what the AO achieved in CSR during 2016, please refer to pages 6 and 7.

Reducing the cost of governance was a key aspect of the Trustees Meeting Review. And in 2016 the review concluded that in order to ensure that the Trustees Meeting remains sustainable in the future, and to make the organization more agile, it proposed that the number of Trustees be reduced from 160 to 100. This will be voted on by the Assembly of Trustees in July 2017.

A final decision on the future of the AONeuro and AORecon Initiatives (see pages 28 and 29) will also be taken at the latest by mid-2017.

Finally, we would like to express our thanks to our volunteer officers and faculty for their cooperation and enormous assistance and support in all activities; our employees for their committed work; our members for their interest; and our partners for their continued dedication.

Sincerely,

Nikolaus Renner President of the AO Foundation

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Annual Report 2016 ┃ Executive Summary

AO Foundation highlights of 2016

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Annual Report 2016 ┃ Corporate Social Responsibility

Corporate Social Responsibility at the AO The AO Foundation strives to be a good global citizen. To achieve this, it has created a Corporate Social Responsibility (CSR) initiative taking into consideration its impact on society, the environment, and employees. AO surgeon faculty and board members are able to donate a percentage of their per diems in support of the AO’s CSR activities. In December, the AO launched a web page detailing the full range of CSR activities the AO is engaged in, a few of which are elaborated on below.

SOCIETY PROGRAM AO Alliance Foundation (AOAF) is where the AO makes its greatest CSR contribution investing annually in the developmental nonprofit organization dedicated to improving fracture care in low- and middle-income countries (LMICs). This year, the AOAF has focused its efforts on five LMICs: Malawi, Ethiopia, Ghana, Myanmar and Nepal. Malawi is the first beneficiary of AOAF’s country initiatives which will carry out a five-year capacity-building project aimed at strengthening fracture care and local capacity for neglected trauma patients. The AOAF is developing plans for improving fracture care education and infrastructure in Ethiopia to lighten the trauma burden of fractures. The AOAF also supports projects that AO surgeons are working on in the developing world. Alongside the country initiatives the AOAF continues to deliver Fracture Care Courses in Africa (16 countries) and Asia (9 countries).

ARGO is a foundation with commercial workshops and residential homes for adults with disabilities in Davos and one of the local charities that the AO supports. Aside from an annual contribution to a special fund for needy people within ARGO’s organization, the AO encourages employees and network members to make direct contributions and also to buy their gifts from ARGO’s online site.

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ENVIRONMENT PROGRAM Carbon compensation is the second biggest AO CSR project. Since 2013, the AO has voluntarily offset parts of its carbon footprint to make events carbon neutral. In 2016, the AO offset the Trustees Meeting and TK System meetings’ carbon emissions through the financial support of clean cooking stoves and water filters in rural Kenya. Now the AO has decided to compensate the majority of carbon emissions for all flights taken by AO surgeons and staff in the course of their work from 2017 forward. To achieve this, the AO has placed a focus on two projects in Malawi (rehabilitation of community boreholes and training local community members to maintain them, and restoring and improving existing health clinic infrastructures) that fit the AO’s vision and mission, have a social impact, and fulfill voluntary carbon market (CDM Gold Standard) requirements.

PEOPLE PROGRAM Human Resources policies reflect the AO’s commitment to providing a fair workplace for employees. These activities range from no gender bias in salaries, flexible working hours, study support, free language courses, and home office working, to insurance savings, accident insurance, sickness indemnity and pension funds and other beneficial Human Resources policies. In all of these the AO currently meets best practice requirements.

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Annual Report 2016 ┃ Good Practice Policies

Code of Ethics From a handful of visionary surgeons nearly 60 years ago, the AO has grown to become a global network of 220 employees and more than 19,000 surgeons practicing, teaching, researching, and learning worldwide with the ultimate goal of improving patient care. As part of the AO’s voluntary undertaking to attain the highest integrity and ethical standards for the organization, an Ethics and Compliance Committee (ECC) was established in January 2015. One of the key tasks for the ECC has been to elaborate a Code of Ethics and Conduct applicable to all staff and members of the AO network. The Code of Ethics will be submitted for a final vote to the Assembly of Trustees in July 2017.

The AO’s Code of Ethics outlines the policies, procedures, and standards of behavior that apply to the AO Foundation’s employees and officers (non-employees in an official role within the AO Foundation’s). These guidelines also apply to surgeons and health care providers making use of the AO brand. It defines the best standard of practice within the AO’s community, and towards AO’s partners (public authorities, hospitals, research institutes, universities, health care providers, suppliers, industry, etc).

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Transparency Policy Times are changing, especially in the health care sector and transparency has become a key focus. Not only governmental authorities, but also the industry and patient organizations, as well as the general public, demand transparency. In order to proactively address these needs the AO Foundation Board decided in 2016 to introduce a Transparency Policy for the AO Foundation. According to this Transparency Policy, the AO Foundation will, once a year, publish in an aggregate fashion (in the annual report and on its web pages) the total remunerations of the AOFB, international boards of the clinical divisions, and the AO Executive Management in addition to disclosing all scientific grants to third parties.

These figures are available in the Finance section on page 43.

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Annual Report 2016 ┃ Innovation

All paths lead to innovation AO Strategy Fund The AO Strategy Fund was created to support projects aimed at developing new services and technologies for unmet needs. After three years and three calls for applications, more than 20 approved projects across five focus areas—education; knowledge sharing; outreach and the AO brand; patient care; research—are well underway.

The AOTK System The AOTK System constantly innovates new operation techniques and technology instruments designed to solve existing clinical problems, under the medical guidance of independent surgeons, in close collaboration with industrial partners. The AOTK comprises 140 surgeons organized into specialized technical commissions, expert groups and task forces—structured around anatomy and surgical techniques—responsible for the concept development, clinical testing and device approval.

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Capitalizing on its 60-year history of innovation, the AO has in recent years launched three new initiatives to complement one of the primary innovation arms of the organization—the AOTK System. This strategy is opening up yet more pathways to compelling innovative ideas for the AO. Each innovation instrument has distinct goals and targets, and together they deliver a successful approach to innovation that will echo far into the future.

AO Invest AO Invest is a new investment fund for start-ups. This fund is wholly owned by the AO Foundation and run by a board of medical and business experts. The scope of investment is start-ups developing innovative technology that makes a significant contribution to advancing patient care in orthopedic and trauma surgery. The fund invests globally in areas such as visualization, simulation, robotics, data management, and digital health.

The AO Development Incubator The AO Development Incubator (AODI) supports inventors to secure intellectual property, build and execute project plans towards a proof of concept (PoC) and plan the PoC valorization. AODI, which launches in early 2017, will have at least one call a year for new proposals. The area of focus for the first call in March 2017 is “improvement in patient care as it applies to orthopedic trauma, spinal conditions, craniomaxillofacial surgery and veterinary surgery.�

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Annual Report 2016 ┃AO Statistics

Electricity consumption in kWh

2010 45,638 liters of oil

2010 706,866

2016 19,915

2016 533,640

Energy efficiency at the AO Center

There has been a 36% reduction in electricity consumption in the AO Center in Davos (CH) since the energy saving initiatives began in 2007.

liters of oil

Heating oil use

There has been a 47% reduction in heating oil use since the energy saving initiatives began in 2007.

Years of service

Place of work Davos 61.3% Dübendorf 25.3% USA 6.7% Colombia 1.1% Brazil 1.1% Hong Kong

86.6% 8.9% 4.6%

20 7.6% 10–20 18.5% 5–10 18.9% 3–5 15.9% 1–3 22.8% <1 16.2% >

Fellowships per clinical division

232 AOTrauma 201 AOSpine

49 AOCMF 3 AOVET 485 Total Number of paying members per Clinical Division

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9,447 AOTrauma 6,306 AOSpine

3,132 AOCMF 945 AOVET 19,860 Total

From carbon to people Trees saved

2016 4,650

People impacted

2016 1,100 Impact in Kenya of the 1,648 tons of carbon emissions offset by the AO Foundation in 2016

Talent management

Climate protection and sustainable development

The AO Trustees Meeting 2016 offset 650 tons of carbon emissions (tCO2e) and the AOTK System’s meetings in 2015 offset 998 tons tCO2e through the financial support of clean cooking stoves and water filters in rural Kenya, saving lives and forests.

Staff statistics (in %): Education PhD 17 Master’s degree 28 Bachelor’s degree 22 Further education 10 Apprenticeship 23

Gender Female 53.7 Male 46.3

Nationalities of staff in Switzerland Where they come from (in %): Austria Canada Finland France Germany Greece Ireland

0.7 1.2 0.9 0.9 16.8 0.9 0.9

Italy 4.4 The Netherlands 1.0 Spain 1.9 Switzerland 59.8 United Kingdom 4.0 United States 1.2 Others 5.0

Educational events and participants

Educational events and participants

by clinical division

by region

AOTrauma

AOSpine

407 30,129

186 9,463

Asia Pacific

274 14,721

Europe incl South Africa

118 7,133

AOCMF

161 9,738

Latin America

40 2,274

AOVET

Number of registered users per Clinical Division AOTrauma

90,101

AOSpine

32,881

AOCMF 21,428 AOVET Total

150,776

6,366

55 2,603

Operating Room Personnel Educational events 806 Participants 51,602 Total

193 14,769

79 4,439

North America

64 3,001

Middle East and Africa

35

4,934

International

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Annual Report 2016 ┃ AOVET

AOVET Course–Advances in Small Animal Fracture Management, practical exercises, Oxford (UK), October 2016

Future outlook Roll out new curricula for the Principles, Advanced, and Masters courses Roll out Category 3 courses in Asia Pacific, Europe, and Latin America with new educational sponsors Engage in the AO Foundation’s new soft-tissue initiative

AOVET—advancing the practice of veterinary surgery To become the preeminent educator for orthopedics in animals, AOVET implemented a new strategy for the delivery of its educational courses. The new, three-tier structure reflects the level of financial and logistics support provided by DePuy Synthes: Category 1 = complete; Category 2 = logistics only; Category 3 = none. For the Category 3 courses, two new educational partners have been secured for global courses in 2017 and beyond.

To facilitate this new strategy, Eberhard Denk was appointed AOVET’s new Executive Director. In addition, a Community Development department was created, and further support personnel were assigned to Education, as well as the Latin America and Asia Pacific regions.

Education In 2016, AOVET successfully delivered 40 global educational activities (22 Category 1, 6 Category 2, and 10 Category 3) and two webinars to a total of 2,274 participants, with 284 faculty members. The Education Commission enhanced the quality and content of the course curricula through the introduction of an Advanced and Master course offering. During the year, four Faculty Education Program (FEP) courses were held. This training is now required for all AOVET faculty, to ensure effective delivery of educational content.

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Michael Kowaleski presenting at an AOVET course lecture on orthopedic injuries and problems of the growing animal

AOVET Course–Advances in Small Animal Fracture Management, practical exercise group discussions, AO Davos Courses, December 2016

Research and development As the AO Foundation is committed to the pursuit of best policies and practices in the context of animal welfare as it relates to animal-based research. Accordingly the AOVET Research and Development Commission finalized all of the required documents from institutions seeking certification as a Member Organization of the Association for the Assessment and Accreditation of Laboratory Animal Care International (AAALAC) in 2016. Additionally, the commission developed a global animal welfare approval program for all institutions seeking AO Foundation funding for animal research activities.

Two 2016 AOVET Start-up Grant projects have shown good progress at the mid-term assessment: “Robotic evaluation of canine stifle joint kinematics” (Allen et al) won the 2016 Hohn Johnson Research Award from the Veterinary Orthopedic Society, while “Fetlock joint kinematics in non-fatigued and fatigued horses and the effects of protective leg wear” (Kirker-Head et al) was completed and presented at the 2016 European College of Veterinary Surgeons and the 2016 American College of Veterinary Surgeons Annual Meetings.

Community development The AOVET community continued to grow to approximately 1,000 members by the end of 2016. New initiatives, including a thorough redesign of the AOVET website, helped to reach a larger audience. Additionally, four new small animal modules in AO Surgery Reference VET were completed.

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Annual Report 2016 ┃ AOCMF

AOCMF, Challenges and Controversies in Facial Trauma, practical exercise, AO Davos Courses, December 2016

AOCMF—excellence in facial surgery across the specialties This year, AOCMF organized more events than ever before, and nearly 50 fellows learnt from surgeons at AOCMF host centers. Research activities for the investigation of antiresorptive agent-induced osteonecrosis of the jaw (ARONJ) brought attention to help change standard operating procedures. While the finalization of a new Management of Facial Trauma course set a new standard in medical education.

Education AOCMF successfully delivered 118 educational events (+11% growth vs 2015) and provided education to 7,133 participants (+39% vs 2015) in 2016. For the first time, three Master’s courses—Orthognathic Surgery, Management of Facial Trauma, and Oncology and Reconstruction—were offered at the Davos Courses. These courses attracted 98 participants and included a practical session using human anatomical specimens. The AOCMF Curriculum Development Education Taskforce finalized the new interactive Management of Facial Trauma course to replace the Principles Course. For a successful rollout, the course was piloted, and a faculty support package was created. The AOCMF International Retreat, a 2016 faculty development highlight, brought 70 key opinion leaders together to discuss AOCMF developments and to set priorities. Almost 100 AOCMF fellowship program applications were received, with numerous fellows assigned to AOCMF host clinics, which also increased in number from 22 to 26.

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Andrew Murr, Reporting back from breakout sessions, AOCMF International Retreat, Lisbon (PT), September 2016

Future outlook New AOCMF website that works on mobile devices Introduce a learning tool for surgical training on mobile phones Create the AOCMF Advanced Manual

Research and development Led by Risto Kontio, Chair of Research and Development, AOCMF continued its ARONJ Clinical Priority Program, reaching milestones such as the guide to research book, a webinar with 188 participants from 57 countries, and a conference. In addition to the ongoing ARONJ projects, five new projects commenced. With the AO Research Institute, two ARONJ projects were completed and publications are being prepared. Five new projects have been defined in the area of 3D bioprintable materials, of which two are feasibility studies. AO Clinical Investigation and Documentation (AOCID) was mandated to conduct the medication-related osteonecrosis of the jaw (MRONJ) registry, an international, multicenter, prospective registry, to collect data on the treatment and outcome of 500 MRONJ patients. AOCIDâ&#x20AC;&#x2122;s ongoing double mandible fracture study was pushed forward and a classification validation was conducted. AOCMF Research and Development also contributed to the AO Program for Education and Excellence in Research (AOPEER) project.

Community development The AOâ&#x20AC;&#x2122;s online presence reached a new level with an updated AOCMF website created in 2016. The launch of CMTR Open, an open access e-journal, attracted surgeons at the EACMFS congress. Fueled by increased activities worldwide, the AOCMF community grew to nearly 3,200 members, an almost 15% increase from 2015.

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Annual Report 2016 ┃ AOSpine

AOSpine Advanced Level Specimen Course, practical exercise, Muttenz (CH), September 2016

Future outlook Continue implementation of the guiding principle Focus on innovation in education and research Build a strong community for knowledge exchange

AOSpine—increasing reputation as the leading academic community AOSpine began implementing its guiding principle, TEAM: Transparency, Egalitarian, Accountable and Meritocratic, into all of its activities in 2016. New Terms of Reference for all boards and commission were established. The increased success of the Global Spine Journal and Global Spine Congress confirmed the community’s vast interest in knowledge exchange. The introduction of new educational concepts, such as the BioSkill Simulator Lab at the AO Davos Courses, and the globalization of research, laid the foundations for future positive impact in education and research.

Education AOSpine strengthened its status as the global leader in spine surgeon education in 2016.

Overall, nearly 190 educational events were delivered. The innovative Bioskills Lab course, with state-of-the-art simulation models, set new standards in practical learning and provided participants with an extraordinary learning experience at the Davos Courses. AOSpine continued to lead the way in online surgeon education by creating a blended learning module on Minimally Invasive Surgery for Spinal Disorders. Online pre-course activities included high-quality videos, a step-by-step guide, and moderated case discussions, to ensure that participants had comparable levels of knowledge and faculty face-to-face time.

Finally, the faculty career pathway was aligned with other clinical divisions, offering an opportunity for spine surgeons to develop as faculty members and leaders.

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AOSpine Advanced Level Specimen Course, Muttenz (CH), September 2016

Research To fulfill the AOSpine International Research Commission’s aim to become the leading knowledge creator in spine surgery, a global research strategy was developed, which integrates AOSpine’s research activities and Knowledge Forums (KFs). The strategy’s first pillar, clinical research, is driven by the pathology-specific KFs in tumor, deformity, trauma, spinal cord injury, and degenerative disease. These flagship working groups are mandated to conduct clinical research, and develop AOSpine classifications, guidelines, and outcome measures. The KFs produced over 50 peer-reviewed publications and 70 presentations in 2016. The second pillar integrates pre-clinical and clinical research to address common, unmet clinical needs involving the AO Research Institute (ARI) and the KFs. The third strategic pillar, research education, develops young surgeons as researchers, to secure future research programs.

Community development AOSpine’s 2016 community development activities focused on facilitating communication, the exchange of knowledge, and the sharing of best practices through an increased number of education, research, and network activities worldwide. Five international newsletters were published, providing up-to-date information on events, education, and research. A global social media strategy was also developed and rolled out. Further communication initiatives included the Global Spine Congress, the Global Spine Journal, and the AOSpine Membership Program.

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Annual Report 2016 â&#x201D;&#x192; AOSpine

The Global Spine Congress (GSC) and World Forum for Spine Research (WFSR), Dubai (UAE) April 2016

Breakout session, AOSpine, AO Trustees Meeting, Amsterdam (NL), July 2016

Middle East In 2016, AOSpine Middle East (AOSME), the leading spine community in the region, staged courses in new countries, and higher-level courses were offered. The Masters Level Specimen Course in Dubai adopted a new, blended learning format, giving participants access to online pre-course activities including videos, instructive book chapters, and online case discussions. The region hosted the 2016 Global Spine Congress in Dubai, where Alaa Azmi Ahmad (PS) was elected the first Member Representative.

Europe and Africa AOSpine Europe (AOSEU) conducted webinars and educational events across 21 countries for 1,600 surgeons, and 1,200 participants attended AOSpine regional symposia. Member numbers in Europe increased by 12%, and by 20% in Germany alone. In July, the new AOSEU Regional Boardâ&#x20AC;&#x2122;s term commenced. The region intensified its cooperation with other scientific societies, and the first Germany-Austria-Switzerland sub-regional event was realized. In Africa, activities were expanded into Botswana and Zambia to improve patient care.

Asia Pacific AOSpine Asia Pacific (AOSAP) delivered 52 courses to more than 2,700 participants in 2016. Membership increased by 2.8% to 2,299, and the number of Talented Asia Pacific Young Surgeon fellowships rose from 57 to 72. In 2016, 27 country research projects and one regional project were awarded for various pathologies. The Faculty Educational Program (FEP) and Chairperson Educational Program (CEP) developed 32 AOSpine experts to conduct high-quality educational courses and events.

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Michael Grevitt, keynote speaker for the 14th Annual Fellows Forum in Banff (CA), discusses the future of education in AOSpine

Asdrubal Falavigna, AOSpine Latin America Chairperson, at the regional courses, Bogota (CO)

North America Education remains a cornerstone of AOSpine North America (AOSNA) activities, with nine courses, six webinars, and an oral board review course held in 2016. Research efforts included over 40 publications and 89 abstracts in peer-reviewed publications, as well as clinical guidelines on cervical myelopathy and spinal cord injury. AOSNA hosted its third annual reception at the North American Spine Society meeting, which reinforced the camaraderie of AOSpine members worldwide. Efforts to retain fellows were enhanced by expanding engagement and networking opportunities after training.

Latin America AOSpine Latin America (AOSLA) delivered 58 educational activities, including anatomical specimen and online courses, to 3,500 participants in 2016. In November, the first set of regional courses was launched in Bogota (CO). It was attended by more than 200 surgeons, and provided an exceptional opportunity to meet and exchange ideas with colleagues from other countries. In research, AOSLA has the highest AOSpine productivity score for the second consecutive year. Elected in 2016 were Jaime Segura as Community Development Officer and Emiliano Vialle as the Spine Centers and Fellowships Officer.

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Annual Report 2016 ┃ AOTrauma

AOTrauma Masters Course–Current Concepts–Upper Extremity, Anatomical Specimen Laboratory, AO Davos Courses, December 2016

AOTrauma—sustainable leadership and growth for the largest trauma network A total of 30,129 health care professionals participated in 407 AOTrauma courses for surgeons in 2016. AOTrauma additionally hosted ten webinars and two webcasts.

AOTrauma’s membership reached more than 9,400 members in 2016. During the year, the AOTrauma International Board finalized a global strategy definition process, selecting the following five key strategic priorities for the next three years: being the knowledge leader in musculoskeletal trauma care; focusing strongly on recruiting, developing and retaining the best faculty worldwide; enhancing awareness and recognition of AOTrauma as the global leader for excellence in musculoskeletal orthopedic trauma care; and expanding and enriching the AOTrauma community of health care professionals with personal and professional development opportunities.

There were a couple of changes in AOTrauma leadership: Tobias Hüttl took over as AOTrauma’s Executive Director from Matthias Dunkel. Kodi Kojima (BR) was elected as Chair-Elect of the AOTrauma International Board.

AOTrauma’s Educational Task Forces continued to develop and update scientific content, and focus was placed on designing hospital-based activities to increase access to education.

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AOTrauma Course, Advanced Principles of Fracture Management, practical exercise, AO Davos Courses, December 2016

Future outlook Improving through a global strategic plan Continue to pursue global educational excellence Success throughout the regional network

Education AOTrauma’s Education Task Forces (ETF) continued to develop and update scientific content, and actively designed and evaluated various types of hospital-based activities to provide increased access to education for surgeons and Operating Room Personnel (ORP). Of these, a new Intramedullary (IM) Nailing Education Working Group half-day seminar for residents was piloted in hospitals in Brazil, Germany, Belgium, and Singapore. An in-hospital seminar on intraoperative imaging was held in Germany, Switzerland, and the United States. In-hospital Clinical Training Modules (CTMs) for ORP were the most extensively implemented hospital-based education initiative. A completed research study showed improvements in image quality, and related aspects of fracture fixation were displayed following the use of an educational video and poster.

Through its ETF, AOTrauma further developed its scientific content by completing two new curricula on infection and IM Nailing. Two textbooks were published: Principles of Orthopedic Infection Management, by Stephen Kates, Olivier Borens, and The Foot–Arts, Myths, and Secrets, by Stefan Rammelt, and Hans Zwipp. A new ETF on Periprosthetic Fractures commenced in cooperation with AORecon, and AOTrauma participated in the AO Foundation’s ETF on Soft-Tissue Management. A new Working Group on External Fixation launched with members Vajara Phiphobmongkol, Spence Reid, and Andrey Volna.

The year 2016 concluded with another edition of the AO Davos Courses, which brought together 282 faculty members and 918 participants from 76 countries. The flexible academic program received excellent feedback and set the bar high for the upcoming years.

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Annual Report 2016 â&#x201D;&#x192; AOTrauma

Stephen Kates launches the Program for Education and Excellence in Research (AOPEER), December 2016

Community development AOTrauma membership grew to 9,447 in 2016, a 2.3% increase from 2015. At the end of 2016, AOTrauma had more than 90,000 registered users. The newly introduced membership plus package was well accepted; around one-third of global members subscribed.

With over 12,000 Facebook likes, social media became more important for communication. There were 26 local country chapter projects supported, and collaboration with Insights Orthopedics was expanded to deliver value for members on mobile platforms.

Research In 2016, AOTrauma launched AO Education and Excellence in Research (AOPEER), a web-based platform that contains reference documents, articles, grant application templates, checklists, eLearning modules, and webinars to help surgeons conduct high-quality clinical research in their fields. With AOPEER, AO members are able to develop the skills they need and gain confidence in order to contribute to evidence-based medicine.

The platform was developed by Michael Blauth (AOTrauma), Stephen Kates (AOTrauma), Asdrubal Falavigna (AOSpine), and Risto Kontio (AOCMF).

ORP Following a successful start to hospital-based education in 2015, ORP produced two additional learning modules: Osteosynthesis with Intramedullary Nail, and Osteosynthesis with Tension Band Wire and External Fixation. In 2016, 27 in-hospital CTMs were organized for 542 participants worldwide. An ORP Faculty Training was also organized to educate participants on running a CTM.

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AOTAP Country Council Meeting, Chengdu (CI), May 2016

Faculty from the Principles of Fracture Management Seminar, Yerevan (AR), November 2016

Asia Pacific In AOTrauma Asia Pacific (AOTAP), 99 events were held in 17 countries for over 10,000 surgeons and ORP in 2016. Highlights included a second AOTAP Current Concept Course in Seoul (KR) and a third AOTrauma AP Scientific Congress in Chengdu (CN), where over 640 surgeons showcased their work, exchanged knowledge, and became involved with AOTrauma. Seminars were conducted at national conferences including AOA, COA, HKOA, POA, SOA, JSFC, and TOA. At the sixth AOTrauma Day at COA 2016, in Beijing, AOTraumaâ&#x20AC;&#x2122;s New Approaches and Innovations lectures attracted over 4,000 participants.

In 2016, faculty development remained an important pillar: coaching sessions, five FEPs, and one CTP took place. Fourteen regional faculty fellows were trained. CW Oh (KR) was elected AOTAP Regional Board Chair-Elect, and Mandeep Dhillon (IN) was elected as the next AOTAP Research Committee Chairperson. Both terms start on July 1, 2017.

Europe With 3,500 members, AOTrauma Europe (AOTEU) remained AOTraumaâ&#x20AC;&#x2122;s largest region in 2016, and held 191 educational events for surgeons and ORPs. Many events showcased new and innovative educational formats such as the Principles of Fracture Management Seminar for underserved countries using a standardized program and a fixed set of regional and local faculty running the event directly in the hospital or training center. Another innovation was the Educational Events online submission tool to collect and analyze educational needs from member countries. Faculty development remained a priority. Five national and three regional FEP events took place, as well as two faculty retreats. Thirty-eight Principles Courses were coached, and 33 coaches were trained in 2016. To strengthen the AOTEU community; 120 fellowships were granted; AOTEU research provided six mini research grants, and a grant-writing course took place in Zurich (CH). Matej Cimerman (SI) was elected Chairperson. His term will commence in July 2017.

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Annual Report 2016 ┃ AOTrauma

Narayan Ramachandran (second from left) and Rodrigo Pesantez, teaching at the AOTrauma Course– Advanced Principles of Fracture Management AOTrauma Regional Master Course–Surgical Approaches with Anatomical Specimen, Upper Limb and Lower Limb, regional course, Dubai (UAE), October 2016

Latin America AOTrauma Latin America (AOTLA) conducted 57 events for over 2,700 participants, one specimen course for 24 participants, and six webinars attracting 1,165 participants from multiple continents in 2016. AOTLA held eleven symposia at national congresses. In 2016, AOTLA significantly increased its faculty database with three FEP courses for 47 participants, and one CTP course for 16 participants. Newly trained regional faculty supported 17 courses, and faculty members attended the fourth specimen faculty course, Fin de Semana AOTrauma Lat, in Miami, USA. AOTLA granted 34 regional fellowships.

Additionally, 25 teaching videos were recorded and made accessible on the website, providing exclusive, relevant, and high-quality benefits to the 1,300 member community.

Juan Manuel Concha (CO) was elected as the new AOTLA chairperson. His term will start in July 2017.

Middle East AOTrauma Middle East (AOTME) organized 50 courses, seminars, and symposia in 2016.

This year’s educational highlights included a number of firsts. An AOTrauma course took place for the first time in the state of Palestine at the An-Najah National University.

In Nigeria, the first AOTrauma course was held in collaboration with AOAF. In Dubai, an Approaches to Extremities for Surgeons course with anatomical specimen lab workshops was held for the first time at the regional courses in Dubai, and in Sudan, the first AOTrauma Symposium took place in more than ten years, bringing together 100 participants. Increasing educational activities in the State of Palestine and Sudan led to the creation of two new country councils.

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AOTrauma/AORecon Symposiumâ&#x20AC;&#x201C;Prevention and Management of Periprosthetic Fractures, Part 2: Hip, DKOU 2016, Berlin (DE), October 2016

North America AOTrauma North America (AOTNA) in 2016 held over 25 live educational events, where over 500 faculty members trained more than 2,000 residents, fellows, and practicing surgeons. Of these, the co-managed Fragility Fractures and Orthogeriatrics course, which has been running for ten years, was expanded upon in 2016 to include the contemporary issues and challenges of multidisciplinary geriatric teams. Six hundred participants attended eleven webinars, and four FEPs were held for over 60 faculty members. AOTNA supported numerous research projects focused on clinical applications and solutions, and the Advanced Clinical Education Program provided grants and educational offerings to 27 trauma fellowship programs. AOTNA participated in the 2016 Orthopaedic Trauma Association (OTA) Annual Meeting, where Professor Stephan Perren, a former Director of the AO Research Institute and a pillar of the AO Foundation, received honorary membership.

27

Annual Report 2016 â&#x201D;&#x192; AONeuro

AONeuro Course, Neurotrauma, Murnau (DE), July 2016

Future outlook Ensure a solid basis for AONeuro and enhance the quality of education offerings Further develop Master Level offering and AONeuro faculty Strengthen neurosociety collaboration

AONeuroâ&#x20AC;&#x201D;advancing the treatment of traumatic brain injury AONeuro conducted 17 successful educational events with nearly 600 participants in 14 countries in 2016. A newly adapted dry-bone model enhanced practical sessions by enabling EVD placement, to check catheter positioning and posterior fossa compression.

Education In 2016, AONeuro brought education to areas where the rates of traumatic brain injuries (TBI) are high. A neurotrauma course was held on the African continent for the first time in Cape Town (ZA), where experts led delegates through discussions, lectures, and practical exercises. In Changsha (CN), the latest TBI insights were given to over 80 symposium participants. At the International Conference of Recent Advances in Neurotraumatology (ICRAN) in Bogota (CO), 56 participants gathered for a decompressive craniectomy symposium. AONeuro will continue to bring education to countries with the greatest unmet needs through collaboration with neurosocieties.

Curriculum development To improve patient care, a cranial access and reconstruction curriculum is being implemented, and a neurovascular curriculum is being developed.

New commission A new technical commission will focus on developing new technologies to address the global problem of neurological trauma and related pathologies.

28

Annual Report 2016┃AORecon

Knee templating exercise at the AORecon Davos Principles course

Future outlook Create innovative educational formats and content based on AO educational principles Foster global AORecon faculty and attract new generation of high potential faculty members Increase reach of courses

AORecon—strengthening impact in joint preservation and replacement AORecon, in its mission to improve patient care in arthroplasty and joint preservation, developed in 2016 as a global educational institution in the orthopedic world.

Education During the initiative’s third year, five courses on four continents were conducted. Long registration waiting lists in China, India, and Colombia showed a huge need for education in the field of hip and knee arthroplasty. In 2016, events were held for the first time in seven countries. Symposia were held at congresses and meetings including COMOC in South Africa, EFORT, DKOU, and SICOT in Europe, ELCCR and AAOT in South America, and SOA, ASIA, and COA in Asia. All activities were well received and led to requests from surgeons and societies for future events.

Curriculum development AORecon focused mainly on hip and knee topics in 2016, presenting its Principles Course as well as current concepts and controversies in the fields of joint preservation and replacement. With a dedicated session focusing on shoulder disorders at SICOT, AORecon started to address additional anatomical regions.

Increased activities evoked a need for more faculty members. With this, AORecon started developing its network of teaching experts, who were selected and confirmed by the education delegation to ensure quality and educational excellence.

29

Annual Report 2016 ┃ Institutes

The initial setup of the X-in-One

An intraoperative x-ray image enables evaluation of the achieved correction

AO Research Institute (ARI) X-in-One: Computer assistance for corrective osteotomies and more One of the crucial steps during trauma and orthopedic surgery is the precise positioning of the implant within the anatomy. This key task is still predominantly executed manually; hence, the outcome depends largely on the skill and experience of the operator. Markus Windolf, Leader of the Concept Development Focus Area within ARI, identified technical complexity and inefficacy of current surgical navigation as major barriers and reasons for the reluctance of the surgical community in the field. He came up with a simple approach using projections of holes in metal, widely present in conventional X-ray images, to deliver valuable information on the implant position. This concept, called X-in-One, has evolved from an abstract idea to an alternative to freehand positioning for a variety of surgical applications.

ARI is now striving to translate this principle into a medical device supporting the daily clinical routine. In 2016 another system module was realized in collaboration with the Joint Preservation and Osteotomy Expert Group (JPEG). Dr Steffen Schröter, BG Klinik Tübingen in Germany proposed using the X-in-One principle to control anatomical relations in the field of corrective osteotomies. Introducing an intraoperative feedback system makes sense given that the goal of the osteotomy is correction and restoration of healthy anatomical relations. The X-in-One technology consists of two metallic flags attachable to Schanz-pins and an image processing algorithm. The system appears suitable to facilitate surgery and increase precision. Feasibility of the device was proven in ex vivo experiments and bench tests. A clinical feasibility trial, regarded as first step towards clinical application, is currently running at the BG Klinik Tübingen.

30

Contact radiograph

Histological image

Future outlook Support clinical divisions with cutting edge research Develop Implant Sensors, Autogauge, and X-in-One Maintain world-class research level, and nurture innovative talent

Bisphosphonate related osteonecrosis of the jaw In the images above you see on the left a contact radiograph and on the right a histological image of a section of a tissue section of a BRONJ afflicted left mandibular tooth extraction side (PM4). There is decreased bone density (osteonecrosis and osteoclastic bone degradation), incomplete coverage of the bone surface at the tooth extraction site along with inflammation of gingiva and bone marrow, as well as bluish stained inflammatory cells and bacterial colonies in the canalis mandibularis (empyema). There is peri- and endosteal bone proliferation (open arrow head), which is more radiolucent compared to the mandibular cortex.

Nitrogen-containing bisphosphonates (BPs) are used as a treatment for osteoporosis or cancer. Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is an unexplained necrosis of the mandible, or less frequently maxilla, and is a rare side effect of sustained BP exposure. Although the frequency of BRONJ is low, the vast number of people treated with BPs has led to an increasing number of BRONJ patients.

Within the framework of the AOCMF BRONJ clinical priority program, ARI has been extensively collaborating with AOCMF surgeons under the coordination of Prof Martin Stoddart. With PD Sven Otto (Department of Oral and Maxillofacial Surgery, Ludwig-Maximilians University of Munich, DE), ARI has developed a robust BRONJ large animal model in the minipig. A yearly oncological dose of zoledronate is applied over twelve weekly infusions, followed by a tooth extraction. Using this model, potential preventative strategies were investigated as a primary step towards evidence-based clinical recommendations.

31

Annual Report 2016 â&#x201D;&#x192; Institutes

Markus Windolf speaking about the X-in-One at the DKOU 2016, Berlin (DE), October 2016

There are a number of disease pathogenesis hypotheses and a standardized, reliable model of BRONJ allows for detailed investigations into the various mechanisms. A clinically proposed preventative strategy after tooth removal is a combination of soft tissue flap and antibiotics. Within the minipig model this reduced the incidence of BRONJ from 100% to 50% and decreased severity.

The incidence of BRONJ could be further reduced if there were a pause between the last BP administration and tooth extraction. The additional application of a drug holiday reduced BRONJ incidence to ~10%. Due to the long-term binding of BPs to bone, the pause between last administration and tooth removal suggests an influence on soft tissue healing.

Further studies into the use of platelet-rich plasma did not demonstrate any additional benefits. Taken together, the data suggests that BP application potentially delays soft tissue healing after wounding, thus allowing a bacterial infection to take hold, creating an environment for BRONJ to develop.

ARI Good Laboratory Practice (GLP) Certification ARI has been awarded the official Statement of GLP Compliance from the Federal Office of Public Health of the Swiss Confederation through Swissmedic (Swiss agency for therapeutic products) together representing the Swiss GLP monitoring authorities. This is a particularly important award as ARI is one of only two academic institutes certified for GLP in Switzerland.

32

Annual Report 2016┃Institutes

Doug Campbell, Chairman of the HAEG (Hand Expert Group) presents the new instrumentation from the Variable Angle Locking Hand System at the AOTK Meet the Experts session during the Davos Courses in 2015

Future outlook Adoption of working process for third-party collaboration on off-ramp projects Provision of innovative clinical solutions with evidence-based development A focus on dynamic and SMART fracture healing

AOTK System With a continued dedication to innovation and evidence creation, the AOTK System effectively contributes to the AO Foundation’s vision for excellence in the surgical management of trauma and disorders of the musculoskeletal system. In order to protect the mission of the AO, the AOTK strives to take advantage of the contractual opportunity to work with external partners for selected concepts in 2017 to ensure more effective patient care worldwide.

AOTK Innovations magazine Following the success of the magazine’s revival in 2015 and the positive feedback received, the AOTK System delivered another insightful magazine in 2016 to celebrate the year’s innovations.

The AOTK approved Variable Angle Locking Hand System represents a complete overhaul of the LCP Compact Hand System and offers a solution for fracture fixation, arthrodesis, non-unions, and the reconstruction of small bones and small bone fragments (particularly in adults with osteopenic bone). The system contains instrumentation to aid in fracture reduction, provisional fixation, implant adaptation, and construct creation.

The TFN-ADVANCED Proximal Femoral Nailing System was launched in 2015, boasting an improved anatomical fit, reduced procedural complexity, and comprehensive surgical options. Last year witnessed the release of additional instruments, which aid specifically with fracture reduction, distraction prevention, and screw insertion.

33

Annual Report 2016 ┃Institutes

Prototype testing during an AOTK Expert Group meeting with the Lower Extremity Group (LEEG) in Solothurn (CH)

Prototype testing during an AOTK Expert Group meeting with the Reamer Irrigator Aspirator Task Force (RIATF) in Solothurn (CH)

AOSpine TK approved a variety of products in 2016 including Synfix Evolution, a new implant for stand-alone Anterior Lumbar Interbody Fusion, and the Zero-P Natural plate designed to maintain stability and support bone growth in neck spinal fusion procedures. The EXPEDIUM VERSE Pedicle Screw was released in late 2015 and combines the attributes of multiple screw types while also offering intraoperative flexibility in one versatile implant.

The AOTK approved Tibial Tuberosity Advancement (TTA) System is indicated for the treatment of Cranial Cruciate Ligament (CrCL) disease in canines. The TTA System is compatible with both Small and Mini Fragment Systems and available in left and right versions.

The screw trajectories are designed to optimize screw purchase within the tibial crest and the incorporation of locking technology proximally permits a fixed-angle device to increase construct strength.

AOTK-approved solutions The AOTK System’s Approved Solutions function was launched through an app and a website. Showcasing surgical products approved by the AOTK System, the new website is modern and intuitive. Users can access comprehensive product information including clinical cases, surgical image galleries, and descriptions of associated instruments. The app, designed for both smartphones and tablets, is freely available in app shops. These advancements further consolidate the AOTK’s branding.

34

Impressive attendance at the 11th European AOTK Experts Symposium

Participants discuss stability requirements in distal femur fractures at the 11th European AOTK Experts’ Symposium in Tübingen (DE), October 2016

Expert symposia The Asia Pacific Experts’ Symposium in Chengdu, China, took place alongside the AOTrauma Scientific Congress, presenting an opportunity for researchers, surgeons, and members of the AOTK System to share their regional expertise, insights, and surgical experiences. The event followed a comprehensive schedule of parallel lectures and presentations over one and a half days.

The 11th European AOTK Expert’s Symposium was held in Tübingen, Germany, and brought 55 surgeons from 14 countries together. In keeping with the aim of such symposia, participants were provided with an open platform to present their most challenging clinical cases in the areas of distal tibia and femur, augmentation, suprapatellar nailing, and osteosynthesis around the elbow.

AOTK patient monitoring The AOTK continues to strive for better patient care in the area of fracture monitoring.

A Basel based workshop involved discussions around concepts like the pressure measuring insole and SMART implants for internal and external fixation. The ability to monitor weight-bearing and load and assess the effects of each upon fracture healing is a primary focus for the AOTK. Development in this area will serve to both progress patient rehabilitation and push the boundaries of product innovation.

35

Annual Report 2016 ┃ Institutes

AOCID Advisory Committee Meeting, from left Martin Schuler, Frank Kandziora, Irene Eigenmann Timmings, Mona Mathieson, Andreas Platz, Suthorn Bavonratanavech, Rolf Jeker and Stephen Kates, AO Trustees Meeting, Amsterdam (NL), July 2016

AO Clinical Investigation and Documentation (AOCID) Reorganization AOCID completed its reorganization under new leadership in 2016, bringing clarity regarding responsibility and financial transparency. “Customer Days” with key clients reflected the institute’s commitment to internal service. A streamlined portfolio enabled the institute to focus on its core mission and quality. Its inspiration remains the same: evidence, not opinion.

Major achievements • Clinical Research: 79 ongoing clinical studies, 37 articles published in 2016, cumulative h-index to date: 38 • Clinical Research Education: supported the rollout of AOPEER, organized an AOCSC networking event, and held AOSpine mentoring courses in four global sites • Health Economics: completed the first phase of two clinical education studies AOPEER After AOTrauma’s initial rollout of AOPEER, AOCID has assumed responsibility for its maintenance and expansion, with support from the AO Education Institute (AOEI) and the clinical divisions. Medically guided by an international and cross-divisional task force (Stephen Kates, Michael Blauth, Asdrubal Falavigna, and Risto Kontio), AOPEER supports surgeons in their research activities with state-of-the-art education.

36

Stephen Kates, AO Program for Education and Excellence in Research, AO Davos Courses, December 2016

Good Clinical Practice (GCP) course, Davos (CH), December 2016

Future outlook Expand the AOPEER program Establish the AOCSC program as an industry standard Data mining for health economics

Regional AOCSC networking event The AO Clinical Study Center (AOCSC), which leverages the expertise of its member centers to promote efficient and quality clinical studies, held a networking event in Regensburg, Germany, in 2016. Event participants exchanged know-how and shared the strengths of their centers, paving the way for future collaboration. In 2017, AOCID as the pivot of the group, will focus on collective marketing and on increasing member involvement in clinical studies.

AOSpine mentorship research program This two-year program strengthens AO regional teams in their capability to perform clinical research. In 2016, training activities were held in Egypt (and included Nigerian participants), UK, China, and Brazil. As part of a hands-on training approach, these sites are now participating in an AOCID multicenter study.

Surgeon education AOCID embarked on a venture with AOEI to seek innovative ways to appraise surgeon education in improving patient outcomes. Currently, two studies are underway: the AO IMMPACT Study, and the Performance Improvement program study (PI Study) on intraoperative image intensification. The first phase of the AO IMMPACT Study, â&#x20AC;&#x153;Does proficiency based training have any impact on surgeon performance?â&#x20AC;? is now complete.

The Delphi panel (32 surgeons from 18 countries) met and reached consensus on the performance metrics for an intramedullary nailing procedure. The results of validating these metrics will be presented during the 2017 Davos Courses. News from the PI Study: Education interventions improved the quality of diagnostic imaging, fracture reduction, and implant positioning.

37

Annual Report 2016 ┃ Institutes

AO Foundation Board members Florian Gebhard, Neal Futran and Jean-Pierre Cabassu launch AO Interact, an AO Education Institute project supported by the AO Strategy Fund

AO Education Institute Curriculum development The AO Education Institute (AOEI) continued its collaboration with clinical division task forces, with 20 curriculum projects currently being developed and implemented. AOCMF’s “Management of Facial Trauma” course was finalized. AOSpine delivered and evaluated blended learning events on MISS and bioskills, and AOPEER launched. Several new curricula started, including periprosthetic fractures (AOTrauma and AORecon), external fixation (AOTrauma), small animal fracture management (AOVET), and neurovascular (AONeuro).

Unified programs All clinical division faculty development programs were aligned through the Faculty Education Program (FEP), and the Chairperson Program (CEP). A Leader Education Program (LEP), which is targeted at experienced faculty members and chairpersons taking on important roles, was also designed and piloted with overwhelmingly positive feedback.

Surgery Reference Sponsored by the AO Strategy Fund, the Pediatric AO Surgery Reference launched with two anatomical regions (distal humerus and distal forearm), and a section on essential concepts of pediatric fracture care. AOSpine completed its trauma modules. AO Surgery Reference was accessed through 1.7 million devices in 2016.

38

A selection of the books published and translated by the AO Education Institute in 2016

Future outlook Build soft-tissue management cross-divisional curriculum Мягкие ткани в травматологии Принципы обращения и клинические случаи

Данная книга представляет знания, применимые в повседневных клинических ситуациях, с особым вниманием к меж дисциплинарному подходу при разработке стратегии лечения и обращении с мягкими тканями. Видео высокого качества и тщательно подобранные клинические случаи иллюстрируют этот комплексный подход и сложный процесс принятия решения. Кроме того, хирурги получат возможность расширить свои знания по темам: • Оценка повреждений мягких тканей • Правильный выбор инструментов и обращение с ними • Организация работы отделения неотложной помощи • Адекватная хирургическая обработка и кондиционирование раны • Варианты закрытия и укрытия раны

Дэвид А. Волгас | Ив Хардер Дэвид А. Волгас | Ив Хардер

Перелом, прежде всего, представляет собой повреждение мягких тканей, при котором наилучший возможный результат лечения зависит от правильного и своевременного принятия решения и от оптимального обращения с мягкими тканями. Ортопедам и травматологам, которые не являются пластическими хирургами, для комплексного решения этих проблем необходим определенный уровень междисциплинарного понимания.

Мягкие ткани в травматологии

Release “Touch Surgery” interactive modules

Дэвид А. Волгас | Ив Хардер

Принципы обращения и клинические случаи

Launch Assessment and Evaluation Framework for all educational activities

Мягкие ткани в травматологии Принципы обращения и клинические случаи

Видео и анимация online

www. aotrauma.org

MediaCenter.thieme.com

plus e-content online

Disaster Limb Injuries Project The Disaster Limb Injuries Project, supported by the AO Strategy Fund, culminated in the handbook, Management of Limb Injuries during Disasters and Conflicts. It was launched at the Geneva headquarters of the International Committee of the Red Cross (ICRC). A website has also been created to contain a growing collection of AOEI resources and educational tools. The guide, developed by 30 authors from the ICRC, the World Health Organizations’s Emergency Medical Teams Initiative, and the AO, offers practical guidance to international surgical teams who are in situations that hugely differ from their daily practices.

New books The Principles of Orthopedic Infection Management book, by Stephen Kates and Olivier Borens, explores principles, treatment options, and latest information and research on postoperative infection. The Antiresorptive Drug-related Osteonecrosis of the Jaw (ARONJ)—a Guide to Research, by Kenneth E Fleisher, Risto Kontio, and Sven Otto, highlights evidence into this important topic. The Foot—Arts, Myths, and Secrets by Stefan Rammelt and Hans Zwipp explores the history of foot and ankle surgery, and the foot in art, literature, and mythology.

Translated books Translations in 2016 included the Principles of Internal Fixation of the Craniomaxillofacial Skeleton, Periprosthetic Fracture Management book, and the two-volume Fractures of the Pelvis and Acetabulm in Chinese, and the Manual of Soft-Tissue Management in Russian.

AO Education Institute Advisory Committee Committee members Michael Baumgaertner, Bob Fox, Amitai Ziv and Urs Rueetschi met for the first time in Tel Aviv (IL) in February 2016.

39

Annual Report 2016 ┃ Finance

Finance Financial Overview The financial performance continued to be strong despite the challenges posed by increased activity and complex operational demands. Despite strict cost control, the Operating Expenses are 4% above the previous year reflecting additional activities supporting new operational processes, as well as activities resulting in a 2% increase in the Operating Income. Therefore the Operating Result has deteriorated by CHF 3 million, amounting to CHF -26 million compared to 2015.

With CHF 62 million, the Financial Result is a respectable achievement and rewards a consistent and long-term investment strategy with a continued high return on investment.

Due to this performance, the Net Result reached a value of CHF 36 million, increasing the Foundation’s Equity to CHF 1,229 million by the end of 2016.

AO Financial Overview

2015

2016

Variance A16/A15

abs.

abs.

abs. %

79

80

Operating Expenses

102

106

4

4 %

Operating Result

-23

-26

-3

11 %

in million CHF

Operating Income

Financial Result Net Result Equity per 31.12.

2

2 %

-7

62

69

-996 %

-30

36

66

-219 %

1,193

1,229

36

3 %

Operating Income includes the income from the Cooperation Agreements with DePuy Synthes of CHF 67.4 million and third party income amounting to CHF 12.7 million (-9% versus previous year).

Operating Expenses, excluding “Unforeseen”, “AO Strategy Fund”, “AO Alliance” contribution and “AOIT Projects”, amounted to CHF 98 million (+2% versus previous year). 69% of the operating expenses were consumed by activities related to “Education” (CHF 41.4 million) and ‘R&D’ (CHF 26.2 million). “R&D” and “AOTK System” spending increased by 4% respectively 8% versus the previous year, further strengthening two of our core competencies. This was partly compensated by further optimization and cost reduction measures in “Community Development” (-1%) and “Global & Regional Boards” (-0%).

Operating Expenses excluding “Unforeseen”, “AO Strategy Fund”, “AO Alliance” contribution and “AOIT Projects” Growth versus 2015 Actual

Breakdown 2016 Actual

5 %

in million CHF

5 % 2 %

Education

5 %

R&D

+4 %

General & Administrative

14 % CHF 98 m

27 %

40

-7 %

Education R&D General & Administrative Community Development

+13 %

42 % Community Development

-1 %

Global & Regional Boards

-0 %

AOTK System

+8 %

AONeuro/AORecon

n/a 0

Global & Regional Boards AOTK System AONeuro / AORecon

10 2015 Actual 2016 Actual

20

30

40

Income Statement The 2016 Income Statement compared to the previous year and budget looks as follows: Income Statement 2015 Actual 2016 Actual

in million CHF

abs %

Cooperation Agreements

64.6

Variance A16/A15

abs %

82 %

67.4

abs %

84 %

2.7

4 %

3rd Party Income

13.9

18 %

12.7

16 %

-1.2

-9 %

Total Operating Income

78.5

100 %

80.0

100 %

1.5

2 %

R&D

25.1

25 %

26.2

25 %

1.1

4 %

4.3

4 %

4.6

4 %

0.3

8 %

AOTK System Community Development

5.3

5 %

5.3

5 %

0.0

-1 %

Education

44.6

44 %

41.4

39 %

-3.2

-7 %

General & Administrative

11.8

12 %

13.3

13 %

1.5

13 %

Global & Regional Boards

5.0

5 %

5.0

5 %

0.0

0 %

Others

5.8

6 %

10.2

10 %

4.4

77 %

Total Operating Expenses

101.9

100 %

106.1

100 %

4.2

4 %

Operating Results

-23.4

-26.0

-2.7

11%

-6.9

62.0

69.0

-996

-30.3

36.0

66.3

-219

Financal Results Net Result

The Cooperation Agreements were, with CHF 67.4 million, above budget (+4%) and above the previous year (+4%) due to additional contributions for AONeuro and AORecon.

Thanks to a higher Financial Result amounting to CHF 62 million, a Net Result of CHF 36 million was realized and allocated to the Foundation’s reserves. Operating Expenses at CHF 106.1 million, reflects a budget underspent by 8% but is above the previous year’s amount due to lower “R&D” expenses, and lower expenses in various operational areas.

Employees The number of permanent staff increased to 242.7 full-time equivalents (FTEs), an increase of 7.8 FTEs or 3% versus 2015.

FTE weighted permanent

2015 Actual

2016 Actual

Var.

abs.

in %

abs.

in %

abs.

206.9

88 %

210.5

87%

3.6

Asia Pacific

10.0

4 %

15.0

6 %

5.0

Latin America

10.0

4 %

9.1

4 %

-0.9

North America

8.0

3 %

8.1

3 %

0.1

234.9

100 %

242.7

100 %

7.8

Total located in Switzerland

Total worldwide

2016 FTE Overview by Area (weighted permanent)

6.2; 3 % 42.1; 17 %

Clinical Divisions Support Units Others

242.7 FTE

Institutes

80.2; 33 % 114.2; 47 %

41

Annual Report 2016 ┃ Finance

Finance Course activities by region The total number of courses increased to 806, reflecting a growth of 4% versus 2015. Overall, the number of participants decreased by 3% whereas the number of participant days slightly increased by 1%.

Region Number of Courses Number of Participants

2016 Share Vs. 2015 2016

Number of Participant Days

Share Vs. 2015

2016 Share Vs. 2015

Asia Pacific

193

24%

-3%

14,769

29%

-19%

29,381

27%

-9%

Europe (incl. South Africa)

274

34%

5%

14,721

29%

20%

32,605

30%

10%

Latin America

161

20%

12%

9,738

19%

9%

18,533

17%

7%

Middle East and Africa

64

8%

8%

3,001

6%

6%

7,319

7%

11%

North America

79

10%

7%

4,439

9%

-18%

10,669

10%

-14%

International

35

4%

-8%

4,934

10%

-14%

11,411

10%

3%

806

100%

4%

51,602

100%

-3%

109,917

100%

1%

Total

Asset Management The Financial Result of CHF 62 million reflects an actual return of 5.8% on the underlying financial assets amounting to CHF 1,210 million by the end of 2016. The main drivers of this performance were the double-digit returns on the asset classes “Shares Developed” and “Shares Emerging Markets” with a share of 34% of the total assets. The outperformance relative to the benchmark of +4.1% is mainly due to the exposure to Small & Mid Cap Equities in Switzerland. The cumulative performance of the portfolio since January 2008 amounted to 44.7% by December 31, 2016.

5%

4% 2%

in million CHF

62%

Shares Bonds Swiss Real Estate Alternative Assets Liquidity

747 322 63 52 25

Total

1,210 million CHF 27%

1,210

in million CHF

Evolution 2009 – 2016

946

982

962

981

1,048

1,142

1,223

1,193

1,229

Total shares Bonds Swiss Real Alternative Liquidity

2009

42

2010

2011

2012

2013

2014

2015

2016

Equity evolution 2009-2016 Driven by positive financial markets, the AO Foundation’s equity increased to a value of CHF 1,229 by the end of December 2016.

Transparency As outlined on page 9 of this annual report according to its new Transparency Policy, the AO Foundation will publish annually the total remunerations of the AOFB, international boards of clinical divisions and the AO Executive Management in addition to disclosing all scientific grants to third parties.

Remunerations per board The total remunerations summarized for all governance activities of the International Funding Boards were CHF 1,505,735 in 2016 which is 0.4% of the total Operating Expenses of the AO Foundation and its institutions. The table below shows the total remuneration of each individual International Board in absolute amounts and as a % of the total amount of individual Operational Expenses, as well as the absolute amount of the highest stipend within each board in 2016: AO Foundation Board Total AOFB % of total Operating Expenses AO Foundation Highest Stipend AOFB AOTrauma International Board Total AOTIB % of total Operating Expenses AOTrauma Highest Stipend AOTIB AOSpine International Board Total AOSIB % of total Operating Expenses AOSpine Highest Stipend AOSIB AOCMF International Board Total AOCMFIB % of total Operating Expenses AOCMF Highest Stipend AOCMFIB AOVET International Board Total AOVETIB % of total Operating Expenses AOVET Highest Stipend AOVETIB Grand Total

10 members 386,250 0.4% 125,000 10 members 375,000 1.4% 100,000 10 members 425,000 2% 100,000 9 members 275,000 3.8% 100,000 8 members 44,485 2.3% 30,000 1,505,735

Remuneration of the AO Executive Management The total annual compensation of eleven members of the AO Executive Management in 2016 was CHF 2,541,035 (not all of them were hired for the full year). The highest individual compensation was CHF 323,500 resulting in a 1/5.1 relative ratio between the highest and the lowest paid individual compensation (permanent employees).

Assignment of scientific and other grants to third party organizations In 2016, AO Foundation funded research projects with scientific and other grants to a total of CHF 4,339,277 in 80 third party organizations.

43

Annual Report 2016 ┃ Governance

AO governance level A clear separation between governing and executive bodies guarantees optimum organizational governance.

Decision-taking function Advisory function

Annual AO Trustees Meeting

Assembly of Trustees AO Foundation President

AO Foundation Board (AOFB) AO Foundation President

Main tasks include: approval of vision and mission; setting scientific and clinical goals; election of President, elected Trustees and AOFB; resolutions to change the Charters and Bylaws and the discharge of AOFB members

Highest supervisory and executive body whose main tasks include: strategy; fund allocation to AO units; financial and risk management; compliance and legal structure; election of chairpersons and other key positions; supervision

Institutes‘ Advisory Committees

Platforms

AO Technology AG (AOTAG) CEO and Vice-Chair AOFB Strategy and management of commercial activities, intellectual property, and financial assets of AO

Clinical Divisions‘ International Boards

Guidance of the respective Institute in their corresponding content issues

Support and advise AOFB in its governing tasks and interactions with stakeholders

Strategic and financial supervision and measuring CD outcomes

AO Research Institute Advisory Committee

Education Platform President-Elect

AOTrauma International Board

AO Clinical Investigation Advisory Committee

R & D Expert AOFB

R & D Platform

AOSpine International Board

Community Development Platform CD Expert AOFB

AOCMF International Board

AO AOClinical Education Investigation Institute Advisory Committee

AOTK System Executive Board Strategic and financial supervision and outcome measurement of AOTK

AO Development Incubator Board Approves innovative proposals to develop to proof-of-concept stage

44

Annual General Meeting AOTAG

AOVET International Board

AO executive level The executive functions of the AO Foundation are directed by the CEO and Vice-Chair of the AO Foundation Board and are divided into three layers (institutes, clinical divisions, and support units) that work closely with each other.

Governing function Executive function

AO Foundation Board (AOFB) AO Foundation President

AO Executive Management (AOEM)

Human Resources

CEO and Vice-Chair AOFB

Information Technology

AOTAG Managing Director

Institutes

Clinical Divisions

Support Units

Directors

Executive Directors

COO

AOTrauma Intl. Board

AOSpine Intl. Board

AOCMF Intl. Board

AOVET Intl. Board

AOTrauma

AOSpine

AOCMF

AOVET

ARI Advisory Committee

Finance

AO Research Institute Davos AOCID Advisory Committee AO Clinical Investigation AO Education Institute Advisory Committee

Communications & Events Matrix organization • Execution, supervision and outcome measurement of activities according to direction setting/policies by AOFB, AOEM and international boards of clinical divisions with the support of the AO Foundation • Submission of proposals for decision shaping and strategy development • Installation of transparent, compliant and efficient structure and processes and best use of synergies

Legal

Facility Management

AO Education Institute AOTK System Executive Board AOTK System

AO Development Incubator Board AO Development Incubator Program Manager

45

Annual Report 2016 ┃ Governing bodies of the AO Foundation

Governing bodies of the AO Foundation Assembly of Trustees The Assembly of Trustees is the “AO parliament,” consisting of 181 leading surgeons from around the world comprising: 68 Elected Trustees; 71 Ex-Officio Trustees*; 28 Honorary Members; 4 Founding Members; 10 Past-Presidents. The Assembly of Trustees is responsible for the approval of the scientific and clinical mission of the AO Foundation, important elections and the modification of the AO Foundation Charter and Bylaws. They transmit AO information to national institutions and other AO surgeons and bring feedback regarding the specific needs of their Region.

Since each Trustee serves for a limited number of years, constant renewal of the Board is guaranteed. * Three Ex-Officio Trustees currently hold two positions each, therefore the total number of Ex-Officio seats equals 74

46

AO Foundation Board—AOFB The AO Foundation Board is the governing body of the AO Foundation. It is responsible for its strategies, target setting and supervision of all executing bodies of the AO Foundation.

Front row: Robert McGuire (President-Elect) Rolf Jeker (CEO and Vice-Chair AOFB) Nikolaus Renner (President and Chair AOFB) Suthorn Bavonratanavech (Past President)

Back row: Luiz Vialle (spine expertise) Florian Gebhard (trauma expertise) Neal Futran (craniomaxillofacial expertise) Ulf Claesson (investment/industry expertise)

Christoph Lindenmeyer (finance expertise) Keita Ito (R&D expertise) Jean-Pierre Cabassu (veterinary expertise)

The AO Executive Management—AOEM The AO Executive Management reports directly to the AO Foundation Board. It includes the CEO and line managers responsible for operational management within their respective areas.

From left to right: R Geoff Richards (AO Research Institute) Jayr Bass (AOSpine) Erich Röthlisberger (AOCMF) Irene Eigenmann Timmings (COO and CFO) Claas Albers (AOTK System)

Eberhard Denk (AOVET) Rolf Jeker (CEO and Vice-Chair AOFB) Urs Rüetschi (AO Education Institute) Martin Schuler (AO Clinical Investigation and Documentation) Tobias Hüttl (AOTrauma)

47

Annual Report 2016â&#x201D;&#x192; Addresses

AO Clinical Divisions AOTrauma

AOCMF

Clavadelerstrasse 8

Clavadelerstrasse 8

7270 Davos

7270 Davos

Switzerland

Switzerland

Phone +41 81 414 21 11

Phone +41 81 414 25 55

Fax

Fax

+41 81 414 22 80

+41 81 414 25 80

info@aotrauma.org

info@aocmf.org

AO Head Office

www.aotrauma.org

www.aocmf.org

AO Foundation

AOSpine

AOVET

Clavadelerstrasse 8

Clavadelerstrasse 8

Clavadelerstrasse 8

7270 Davos

7270 Davos

7270 Davos

Switzerland

Switzerland

Switzerland

Phone +41 81 414 28 01

Phone +41 81 414 21 11

Phone +41 81 414 25 55

Fax

Fax

Fax

+41 81 414 22 80

+41 81 414 22 80

+41 81 414 25 80

foundation@aofoundation.org

info@aospine.org

info@aovet.org

www.aofoundation.org

www.aospine.org

www.aovet.org

*Contact information for regional offices can be found on individual clinical division websites

48

AO Institutes AO Research Institute Davos Clavadelerstrasse 8

AOTK System

7270 Davos

Clavadelerstrasse 8

Switzerland

7270 Davos

Phone +41 81 414 22 11

Switzerland

Fax

Phone +41 81 414 24 70

+41 81 414 22 88

sonia.wahl@aofoundation.org

Fax

www.aofoundation.org/ari

aotk@aofoundation.org

AO Foundation, Communications and Events, Davos, Switzerland

+41 81 414 22 90

www.aofoundation.org/tk

Photography: AO Foundation, Communications and Events, Davos, Switzerland

AO Clinical Investigation and Documentation

AO Education Institute

Stettbachstrasse 6

Clavadelerstrasse 8

8600 Dübendorf

7270 Davos

Switzerland

Switzerland

Phone +41 44 200 24 20

Phone +41 81 414 26 01

Fax

Fax

+41 44 200 24 60

Concept, editing, and layout:

+41 81 414 22 83

Manuel Kurth (pages 4-5, 6-7, 8-9, 10-11, 12-13, 48-49, 50) Print: BUDAG, Südostschweiz Presse und Print AG, Davos, Switzerland © April 2017, AO Foundation This annual report is climate neutral,

aocid@aofoundation.org

aoe@aofoundation.org

compensation through www.climatepartner.com

www.aofoundation.org/cid

www.aofoundation.org

Certificate No SC2014040102

AO Foundation Clavadelerstrasse 8 7270 Davos Switzerland Phone +41 81 414 21 11 Fax +41 81 414 22 80 foundation@aofoundation.org www.aofoundation.org