Where Science meets Clinics 1-3
My view, James Kellam 3
AO President’s interview 4
AO Dialogue–SIGN fellow 5-7
Berton Rahn Prize Winner 8
From the AO Clinical Divisions 9-13
From the AO Institutes 14-20
AO Dialogue 2|13The newsletter for the AO community
The annual “Where Science meets Clinics”
symposium provides an open platform to
foster exchange and networking between
research, clinics and the healthcare indus-
try to stimulate successful clinical trans-
lation of innovative science. This second
edition of the symposium held in Sep-
tember 2013 at the Davos Congress Cen-
ter 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 rep-
resentatives 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 com-
menced with a brief introduction to the
AO Foundation, provided by AO Founda-
tion President, Professor Jaime Quintero
(CO). After three full days of presentations
and extended panel and podium discus-
sions, 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.
[ continued on page 2 ]
The whys and wherefores of advanced orthopedic tissue engineering
were explored at this annual symposium
Where Science meets Clinics 2013
Table of contents
bThe 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
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 bioma-
terials for tissue regeneration and stem cell
bioengineering’ by Ali Khademhosseini (US);
‘Molecular strategies for adaptive materials’ by
Philip Messersmith (US); and on ‘How mecha-
nobiology 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
Where Science meets Clinics 2013
AO Dialogue 2|13 2
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 Buch-
binder (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 im-
plantation 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 Nor-
bert 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.
My view
James F KellamEditor-in-Chief
The “Gemeinschaft”
We all know that Arbeitsgemenischaft für Osteosyn-thesefragen 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 individu-als 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 clini-cal “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 rep-resentative 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.
continued…
AO Dialogue 2|13 3
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 clini-
cal 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 fellow-
ships. 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 Euro-
pean 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 as-
sociation 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.
An interview with AO President Jaime Quintero
AO Dialogue 2|13 4
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 Min-
nesota. 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.
SIGN (Surgical Implant Generation Network)
AO Dialogue 2|13 5
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, Wash-
ington (US) from September 11-14, 2013.
Methods and Patients
This was a retrospective study which was conducted at Bugando Medical Cen-
tre 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 super-
ficial 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
SIGN (Surgical Implant Generation Network)
AO Dialogue 2|13 6
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 fixa-
tion 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.
continued…
AO Dialogue 2|13 7
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 chal-
lenge with an increasing global aging popula-
tion. 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 in-
jury. 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 frac-
ture healing by 38% in normal bones in many
clinical trials but its effects on osteoporotic frac-
ture had not been addressed. The hypothesis
of this study was that LIPUS could accelerate
osteoporotic fracture healing and up-regulate
the expression in osteogenesis-, remodeling-
and 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 heal-
ing was assessed by gene expression (real-time
PCR), radiographic callus width/area, microCT
and histomorphometry at 2, 4, 8 weeks post-
fracture, where Col1 (type 1 collagen), bone
morphogenetic protein-2 (BMP-2) [osteogene-
sis-related]; RANKL (NF-kappaB ligand), OPG
(osteoprotegerin) [remodeling-related]; and
VEGF (vascular endothelial growth factor) [an-
giogenesis-related] were target genes. Results
indicated that the LIPUS group showed ear-
lier callus bridging at 5-6 weeks post-fracture,
Wing-Hoi Cheung
2013 Berton Rahn Prize Winner
while the Control group occurred at 7-8 weeks
instead, with significantly higher callus width/
area than the Control at all time points. Mi-
croCT 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 in-
creased by LIPUS during the reparative phase.
Therefore, we conclude that LIPUS can acceler-
ate osteoporotic fracture healing by enhancing
callus formation, bone remodeling and angio-
genesis. With the support of another AO start-
up 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 osteo-
porotic 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 8
Transformation
2013 was a milestone year for AOTrauma,
embarking on a historic journey to trans-
form its education strategy as well as its
portfolio of activities and resources. The
positive outcomes of this significant initia-
tive 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 tech-
niques 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 con-
cepts in a hands-on environment. Each
station is moderated by AOTrauma faculty.
Participants have the opportunity to inter-
act 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 Prin-
ciples 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 impor-
tant 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—Educa-
tion, Research and Community Develop-
ment—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 com-
plete his second term. Further details will
be available in 2014.
AOTrauma takes this opportunity to thank
Nikolaus Renner for his extraordinary com-
mitment to AOTrauma over the last three
years. He has led the organization in suc-
cessfully improving patient care and ex-
panding 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 togeth-
er distinguished regional and international
speakers to share their expertise and expe-
rience, and host interactive sessions which
will foster valuable discussions. Visit www.
aotrauma.org for details and registration.
From the Clinical Divisions
AOTrauma
AO Dialogue 2|13 9
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, col-
laboration 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
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.”
From the Clinical Divisions
AOSpine
Xi’an China; home to the Army of Terracotta Soldiers and
hosts of the WFSR 2014
AO Dialogue 2|13 10
A new concept spells success For the past few years, AOCMF in North America has been successfully incor-
porating 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 par-
ticipants stated that this was the most interesting course they had ever attended.
The course faculty noted high levels of participant engagement. It was the con-
sensus 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 (Malay-
sia), 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. Profes-
sional 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; defor-
mities, 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.
From the Clinical Divisions
AOCMF
AO Dialogue 2|13 11
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 educa-
tion. 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. AO-
Neuro is committed to communicating the latest educational advances, informa-
tion 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 com-
bining 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 man-
agement, 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 Bei-
jing. The goal of the courses was to teach the principles of cranial trauma and to
acquaint the practitioners with guidelines for management and for decompres-
sive 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 Sci-
ence 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.
From the Clinical Divisions
AONeuro Initiative
AO Dialogue 2|13 12
Improving patient care through high quality education AOVET’s member community continues to grow. Today, over 650 members sup-
port 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 op-
tions, 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 prac-
titioners 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 vet-
erinary 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 self-
assessment 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 em-
phasis 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 cov-
ered. The group was unequivocal in the feeling that they are more capable and
confident faculty as a result of the program.
From the Clinical Divisions
AOVET
AO Dialogue 2|13 13
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 recog-
nition 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 Road-
map to Research course (an introduction to
EBM) has been given on four different con-
tinents 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
AO Documentation began operations in 1959
and around 1,000 cases were recorded dur-
ing the first year alone. It was this docu-
mentation of fracture cases that created the
necessary scientific evidence to prove the
value of internal fracture fixation to an ini-
tially skeptical public. AO Documentation’s
unique repository of collected cases provid-
ed 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.
However, by the 1990s it was realized that
the concept of documentation no longer met
contemporary standards and that a reorgani-
zation of AO clinical study activities was nec-
essary to include prospective trials in order to
proactively answer clinical questions.
AO Clinical Investigation and Documenta-
tion (AOCID) was officially founded in 1998
to conduct clinical studies. Ruedi Moser was
the first director and so began the move
from documentation center to clinical in-
vestigation 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.
The AOCID mission is to provide evidence-
based 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.
From just a handful of clinical trials in the
early years, AOCID is currently involved
in approximately 50 multicenter inter-
national studies of every type of study
design. In addition to this, around 20
Focused Registry projects are either run-
ning or in development. The internation-
alization of AOCID is also evident. Over
330 different clinics scattered around the
globe have participated in clinical investi-
gations. Over the past 15 years, well over
Historical documentation cards from the AOCID archive
From the AO Institutes
AOCID
AO Dialogue 2|13 14
AOCID
THE FIRST 15 YEARS
conduct of studies. More courses are in the
pipeline to suit the growing needs of health-
care professionals.
As a result of AOCID’s experience, the
“AO Clinical Study Center” (AOCSC)
global qualification program was devel-
oped. Among the advantages to becom-
ing an AOCSC clinic are increased ef-
ficiency in clinical studies and ensured
ethical and regulatory compliance (ICH-
GCP / 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 coordina-
tors, patients, AOCID advisors and employees
who have all played their part in our success. Screenshot of a classification software developed for AOCMF
47
93 94 105132
179201
261276
288302 310
333 333
010
020
030
040
0N
umbe
r of c
linic
s
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
Source: AOCID CTM Database (as per 25 sep 2013)
Regional Expansion: Number of clinics since 2000
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
The AOCSC qualified clinic in Regensburg, Germany
AO Dialogue 2|13 15
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 dif-
ficult to handle, which disqualifies it for the
majority of routine interventions. A novel
concept is proposed for simplified implant
positioning utilizing conventional radio-
graphic 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 vari-
ous applications within trauma and ortho-
pedics, in particular nailing, plating, ana-
tomical 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 place-
ment at the hip, dynamic hip screw place-
ment, general anatomical plating, distal nail
interlocking and adjustment of femoral ante-
version. The system reveals strong potential
in terms of improving surgical precision, di-
minishing 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 Pro-
gram (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 com-
prehensive program, updating participants
on the most recent progress within CPP.
In the past year, the CPP has commenced
activities on a global bone infection reg-
istry, with a significant contribution from
previous ARI research fellow Mario Mor-
genstern (Germany), and the AOCID.
Within the CPP, there have been new de-
velopments in laboratory-based diagnostic
assays. The huge potential offered by the
continuously growing bank of clinical sam-
ples, including microbiological cultures and
serum samples, has already shown first re-
sults. Other projects on the theme of Bone
Infection are also emerging with new re-
sults, 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.
Members of ARI and AOTrauma CPP Bone Infection at the recent annual meeting
From the AO Institutes
ARI
AO Dialogue 2|13 16
Collaborative Research Program “Annulus Fibrosus Rupture Repair”
Disc herniation is the pathological condi-
tion 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 situa-
tions, the outcome is often not satisfying
and the economic burden is enormous. A bi-
ological 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 en-
able 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 addi-
tion of molecular signals that enable new
matrix synthesis to occur at the defect site,
while the biomaterials provide immediate
closure of the defect and maintain the me-
chanical properties of the disc.
Progress of individual partners has led
to definition of the mechanical require-
ments, the identification of the cellular
phenotype, cell surface markers and pro-
genitor cells of the functional AF, the de-
velopment of a delivery system for cells
and therapeutics using nanospheres and
microgels, and the optimization of scaf-
Dynamic histomorphometry surrounding a screw in an uninfected (L) and infected (R)
rat femur. Images taken in live animal using high resolution viva CT
Bacterial microcolony adjacent to medullary adipocytes in an infected rabbit tibia
Members of the Collaborative Research Programs consortia
Damaged disc histology
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 adhe-
sion 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
AO Dialogue 2|13 17
AOSpine and AOVET publications launched in 2013
The AOSpine book Minimally Invasive Spine
Surgery—Techniques, Evidence, and Contro-
versies, which details the history, peer-
reviewed evidence, and modern surgical
techniques in minimally invasive surgery
of the spine, was released with immediate
success, becoming the number one online
seller of AO’s partner publisher, Thieme
Publishing. Measurements in Spine Care and
SMART Approach to Spine Clinical Research, the
final two books in a four-book series from
AOSpine that examines clinical manage-
ment, outcome assessment, and research in
spine surgery, were also published in 2013.
During the AO Trustees Meeting 2013 the
publication AOVET—The First 40 Years was
launched. Written and edited by AO veteri-
nary professionals and founding members,
it traces the milestones, history, and key
individuals responsible for the formation
of AOVET.
AOTrauma publications to be laun-ched at the Davos Courses 2013
Casts, Splints, and Support Bandages—Non-
operative Treatment and Perioperative Pro-
tection, is a comprehensive guide to the
treatment of fractures and ligaments using
nonoperative casting techniques. It explains
the principles and techniques of casting and
includes 55 videos showing how to prepare
and apply splints and casts to all parts of
the body.
Periprosthetic Fracture Management, brings to-
gether the latest knowledge on periprosthet-
ic fractures, including a full review of the
anatomical regions typically affected, plus
recommended techniques, surgical pitfalls,
and a wide selection of complex cases and
illustrations. Most significantly the publica-
tion introduces a new “Unified Classifica-
tion System” specifically on periprosthetic
fractures. It is hoped this new classifica-
tion system will become as recognized as
the AO/OTA Fracture and Dislocation
Michael Schütz | Carsten Perka
Periprosthetic Fracture Management
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.
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.
Carefully selected case studies illustrate and describe individual solutions for often problematic fracture situations, providing comprehensive information from experts globally.
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
Michael Schütz | C
arsten Perka
Periprosthetic Fracture Managem
ent
www.aotrauma.org
Periprosthetic Fracture Management
Michael Schütz | Carsten Perka
9 7 8 3 1 3 1 7 1 5 1 1 1
ISBN: 978-3-13-171511-1
From the AO Institutes
AO Education Institute
AO Dialogue 2|13 18
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 offer-
ings of certifying bodies and teaching
hospitals
Web-based resource for residents
Residents have unique learning needs. As
distance learning techniques evolve, self-
directed learning becomes increasingly im-
portant. Three features, detailed in the box
below, address distinct learning strategies.
Interactive e-learning activities
Interactive case discussions promote
learning based on common patient
problems. Quizzes enable focused
learning through immediate feed-
back. Tips and tricks and direct links
to further learning materials help
residents to deepen their knowledge
of the topic.
Self-assessment questions
To help identify their knowledge
gaps, learners can test themselves
with multiple-choice questions (basic,
intermediate, or complex level ques-
tions), and receive feedback on their
answers. References and further read-
ing help to close the identified knowl-
edge gaps.
Overview of AO resources for residents
Structured access to existing learning
material allows residents to quickly
identify available AO resources. All
learning material is labeled accord-
ing to complexity and includes videos,
webinars, recorded lectures, e-learning
modules, readings, mobile Apps, and
access to AO Surgery Reference.
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 pro-
gram 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.
STaRT will be launched in April 2014 with
offerings in six anatomical regions: tibial
shaft, femoral neck and trochanter, malle-
oli, distal radius, and proximal humerus.
Classification and it has been specifically
developed to help trauma surgeons recog-
nize and treat prosthetic related fractures.
AO Dialogue 2|13 19
AOTK System
Innovations 1|2013
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 pre-
sentations 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 spontane-
ous 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 sup-
porting 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.
From the AO Institutes
AO Technical Commission (AOTK)
AO Dialogue 2|13 20
All rights reserved. Any re production, whole or in part, with-out the publisher’s writ ten 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 publica-tion. 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 intellec-tual property protection laws (eg, “AO”, “TRIANGLE/GLOBE Logo” are registered trademarks) even though specific refer-ence 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.
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 14Fax: +41 81 414 22 97 E-mail: [email protected] © 2013, AO Foundation, Switzerland