AO Dialogue 2|12The newsletter for the AO community

Impressions from AO SEC Chairman John Croser

AO SEC faculty in developing countries have often encountered the SIGN nail in use for intra-medullary fixation. At our meeting in Davos in June 2012 the AO SEC committee had discussed whether the SIGN implant should be used in courses. It was therefore opportune when Jim Kellam, Dialogue Editor-in Chief, suggested that Susanne Bauerle, AOTrauma ORP, and I should attend the 2012 annual SIGN conference. The four day course was themed “Treatment of difficult fracures” and included clinical presentations, workshops on plastic bones and a full social program. The striking

feature of the conference was the close associa-tion between the founder, Lewis (Lew) Zirkle, the SIGN administrative and production staff, and the surgeons from developing countries who are using the SIGN nail.

The clinical sessions were quite astounding in terms of the complexity of the fractures and the recorded outcomes—all highlighted by “squat and smile” photos—the unique outcome mea-sure developed by SIGN.

The package of SIGN instruments and a starter set of nails of various sizes are provided free

SIGN repor ts 1-4

My view, James Kellam 4

DKOU conference update 5

Clinical Divisions 6-9

Ber ton Rahn prize 10

AO Institutes 11-17

AO President ’s interview 18

Table of contents

[ continued on page 2 ]

Surgical Implant Generation Network (SIGN)Reports from the annual SIGN conference in Richland, Washington, US

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of charge to selected clinics and resupply of nails is dependent on the reporting of results to the central database. The pivotal feature of the SIGN system is that cross-locking can be achieved without the need for x-ray guid-ance which significantly reduces the need for expensive infrastructure. You could not help but be impressed by the results being achieved with complex fractures in developing countries many racked by war and civil strife. In these countries the fractures are often the result of gunshot wounds, shrapnel wounds or blast injuries and a significant proportion are open fractures. Many of the cases presented involved failed conservative treatment or failed previous fixation and so were at the upper end of the spectrum of difficult fractures.

I found many similarities between AO and SIGN in terms of the philosophy and ethics of the two organizations and I believe it would be to our mutual benefit to work together in developing countries.

To learn more about the work of SIGN log on to www.signfracturecare.org

AO Dialogue-SIGN Fellow Duong Bunn reports on his experiences as an ortho-pedic trauma surgeon in Phnom Penh, Cambodia.

On returning from my two-year residency at Victor Segalen Bordeaux University, France in 2000, I was appointed as Chief of Ortho-pedics at Preah Kossamak Hospital, Phnom Penh, Cambodia. My ambition was to develop my ward, my hospital and my country in this field. My first day of work set me back as I did not have a working C-arm, a traction table and useful implants. My requests for new affordable implants were denied forcing me to use local products and modify what we had. I fashioned an external fixator from a metal tube from India as well as making other necessary modi-fications to treat both acute fractures and the large numbers of malunions and non-unions seen after traditional bone setting treatment.

In January 2003, the director of HOPE hospital (an NGO hospital in Phnom Penh, Cambodia) called me to transfer his SIGN Nail set to me. This was a wonderful breakthrough as it finally gave me something to treat my patients with.

Surgical Implant Generation

All rights reserved. Any re production, whole or in part, without 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 respon-sible for errors or any consequences arising from the use of the information contained in this publication. Some of the products, names, instruments, treatments, logos, designs, etc. referred to in this publication are also protected by patents and trademarks or by other intellectual property protection laws (eg, “AO”, “TRI-ANGLE/GLOBE Logo” are registered trademarks) even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name, instrument, etc. without designation as proprietary is not to be construed as a representa-tion by the publisher that is in the public domain.

Impressum AO Dialogue 2|12Editor-in-Chief: James F Kellam Managing Editor: Olga Harrington Publisher: AO Foundation Design and typesetting: Manuel Kurth and AO Foundation, Communication & EventsPrinted by: BUDAG AG, Switzerland Editorial contact address: AO Foundation, Clavadelerstrasse 8, CH-7270 Davos Platz, Phone: +41 81 414 28 14, Fax: +41 81 414 22 97, E-mail: dialogue@aofoundation.orgCopyright © 2012, AO Foundation, Switzerland

Susanne Baeuerle and John Croser present the AO Dialogue SIGN Fellow Duong Bunn with his certificate

AO Dialogue 2|12 Page 2

Through my contact with Dr Lew Zirkle and Dr Tuan Hai (Ho Chi Minh, Vietnam) over the phone and email, I learned how to use the SIGN nail. After seeing my successful results, I com-municated my SIGN nail experience to other Cambodian surgeons culminating on Septem-ber 2, 2004, with my first regional SIGN Meet-ing with Dr Zirkle and Jeanne Dillner, CEO of SIGN. From this time, fracture patients realized that fracture care had improved in Cambodia. Now we are able to treat both acute injuries, as well as the non and malunions.

In 2007, I arranged a regional and international SIGN Meeting which was attended by many doctors from Cambodia, Laos, Papua New Guinea, and Australia with a view to start-

ing SIGN programs in their countries or taking them to developing countries. In 2008, I was elected President of the Cambodia Society of Orthopedics and Traumatology and began a program to improve Cambodian orthopedic and traumatology care. Dr Dalton Boot from World Orthopaedic Concern (UK) and Dr Tim Keenan from Orthopedic Outreach (Australia) helped to build an extension at our hospital as well sup-plying equipment and implants. In June 2012, I went with Dr Thomas Vasileff (Alaska, US) to share my experiences on SIGN nail practice at a new program he sponsored. I was chosen in 2008 for the OTA SIGN Scholarship, and in 2012 as the AO Dialogue-SIGN fellow. It is my great honor to be awarded these prizes and to be a surgeon that helps many people.

Network (SIGN)continued…

“Squat and smile”

2012 SIGN conference participants, speakers and staff gather for a group photo

AO Dialogue 2|12 Page 3

Impressions from Susanne Baeuerle, Senior ORP Manager, AOTrauma

The level of enthusiasm that the SIGN team (Lewis Zirkle, Joanne Dill-ner, the engineers and employees) showed for their common goal, sup-porting surgeons working with the SIGN nail in developing countries, was so inspiring. It was thrilling to meet surgeons that I have heard of in my work at the conference and learn about their knowledge of, or relationship with the AO Foundation.

The level of detail in the presentations at the conference gave invalu-able insights into what surgeons are doing with the SIGN nail which is extremely relevant and useful for people facing similar but differ-ent issues in the field. The AO Dialogue Fellow, Duong Bunn gave a wonderful presentation about his use of external fixation in neglected elbow luxations. Our attendance at the SIGN conference provided John Croser with a unique opportunity to present Bunn with his fellowship certificate and for me to give him what every surgeon needs, some chocolate knives from Switzerland.

Surgical Implant Generation Network…end My view

James F KellamEditor-in-Chief

james.kellam@aofoundation.org

Is it time the AO started to collaborate with SIGN?The lead article of this AO Dialogue highlights the

SIGN Annual Conference. For the past four years, AO

Dialogue has sponsored a member of the SIGN Net-

work to attend this meeting. Why has this been done?

The AO Foundation for years has tried to understand

its relationship with the developing world and fracture

care management. This involvement has ranged from

providing old implants, to a variety of education initia-

tives. Recently under the direction of Paul Demmer,

Cleber Paccola and John Croser, AO SEC which is

responsible for promoting AO in developing nations,

has emphasized education as the way forward. They

have developed programs of reverse fellowships in

Brazil, support of resident education in Africa, the

development of non-operative fracture courses, op-

erating room personnel courses and the production

of literature through the AO Education Institute and

AOTrauma. However, is this enough? SIGN (under Lew

Zirkle’s leadership) has introduced an intramedullary

nail which has become extremely popular in devel-

oping nations to provide low resource areas with an

effective treatment for femoral and tibia diaphyseal

fractures. SIGN is similar to the AO as it is based on

the four pillars of research, education, development

and documentation. The group has a large database

of cases for research, runs educational courses and

has a growing implant development program aimed

at providing techniques and implants suitable for use

in developing healthcare systems. It may now be

time for the AO Foundation to consider collaborating

with SIGN. This would allow us to build our expertise

and surgical network for the improvement of fracture

management in developing nations with the many

groups and individuals who are interested in doing

this. With our strong AO international presence, it

may also be possible for the AO Foundation to use

this strength to coordinate other organizations and

funding foundations to improve fracture care through

education and development.

Conference workshop on plastic bones using the SIGN nail

AO Dialogue 2|12 Page 4

The motto for the Deutscher Kongress für Or-thopädie und Unfallchirurgie (DKOU) held in Berlin this year in October was “Quality, ethics and efficiency”. The interactive congress fea-tured seminars and talks from various experts from throughout German-speaking Europe.

With 242 exhibitors spread across nearly 6,000 square metres, more than 8,500 registered par-ticipant surgeons and scientists, 42 seminars, symposiums and workshops, the DKOU is the biggest congress in the world after the Annual Meeting of the American Academy of Ortho-paedic Surgeons (AAOS) and the biggest in Europe for orthopedic surgery. The main topic this year concerned sports-related injuries es-pecially in older people but other issues were addressed in several scientific lessons.

The AO Foundation had a meeting lounge where AO members or interested doctors could have relax and meet colleagues. Booths from AOTrauma and AOSpine were integrated into the lounge. The AO playground demonstrated the AO methods to several visitors and was one of the key attractions of the AO lounge.

AOTrauma organized a symposium on “How much micro movement is beneficial for fracture healing” where the Dynamic Locking Screw (DLS) technology was presented using various

DKOU—The biggest orthopedic event in Europe

examples and studies. The symposium was moderated by Norbert Haas, Nikolaus Renner and Hans-Joerg Oestern. The interest was so high that the auditorium was not big enough to contain the audience.

Afterwards the audience was invited to a reception at the AO lounge. In his address AOTrauma chairman Nikolaus Renner said that there are three main reasons for the AO presence at the congress: membership, en-couraging surgeons to become a member of a worldwide network of knowledge; Global Needs Analysis, finding out what the doctors need for their daily work; and finally showcas-ing new AO Books like the latest from Babst/Bavonratanavech/Pesantez “Minimally Inva-sive Plate Osteosynthesis” and “Principles of Internal Fixation of the Craniomaxillofacial Skeleton” from Ehrenfeld/Manson/Prein.

Alongside AOTrauma and AOSpine, the AO Research Institute Davos (ARI) was also active with workshops and presentations. ARI director Geoff Richards gave lectures about “Bone compensatory material” and “Medulla stem cells”

All in all the DKOU is one of the most important events for the AO and the visibility is crucial especially in the German language region.

Demonstrating the playground to interested surgeons at DKOU Nikolaus Renner addresses the audience after the AOTrauma symposium

AO Dialogue 2|12 Page 5

Realizing positive change

In a previous issue of AO Dialogue, AOTrauma reported on how it is consolidating activities through governance changes, and more streamlined processes. Nikolaus Renner, AOTrauma Inter-national Board Chairperson, is now 18 months into his leader-ship position. Setting goals and moving forward as an organiza-tion, has been supported by our committed and sharply focused leadership. With the assistance of dedicated board members and regional representatives, AOTrauma is realizing positive change and planning for the future.

Global Needs Analysis Survey

Engaging surgeons in an open dialogue about the development of future educational offerings is necessary for AOTrauma to con-tinue supplying the highest quality education, while remaining relevant to surgeons. AOTrauma continues to gather quantitative and qualitative data through the Global Needs Analysis, an online survey project that seeks to learn about the clinical problems members face and their learning preferences. This project will provide key information to help ensure our educational activities meet the needs of practicing surgeons worldwide.

AOTrauma Education Transformation

Started in 2012, this transformation represents both a strategic and philosophical shift in our three pillars of education: faculty development, content development, and delivery of education activities. New formats have been, or are in the process of being developed to meet diverse set needs that are beyond provided

by our traditional course format. The strategic shift in delivery also includes powerful leveraging of the latest technologies. The transformation of AOTrauma Education will result is a compre-hensive, diverse educational portfolio of educational activities and resources. It will support, at its core, the continued face-to-face interaction learning activities with the leading experts in the field.

Clinical Priority Program (CPP)—Bone infection

The current Clinical Priority Program (CPP) addresses clinical challenges related to bone infections. The five-year research program aspires to improve physician experiences and patient outcomes with targeted, state-of-the-art projects funded by an investment of CHF 2.75 million. The selected consortium will be led by Stephen Kates from University of Rochester, New York and will include other international research partners as well as AOCID and ARI internally.

AOTrauma Community

Providing valuable benefits and networking opportunities to members is an overarching aim that directs the efforts of AO-Trauma. With members distributed all over the world, one of our strengths is the truly international nature of our organization. We are excitedly exploring how to meet the evolving needs of surgeons through each stage of their career. Benefits, including access to selected OVID journals, the network directory, free e-books, AOTrauma webinars and webcasts, bring tangible value to members. Exceeding 6,300 AOTrauma members globally; the reach is there, and the means are coming together.

AOTrauma Course, Principles in Operative Fracture ManagementAOTrauma Masters Workshop, Foot and Ankle with Anatomical Specimens

From the Clinical DivisionsAOTrauma

AO Dialogue 2|12 Page 6

The journey ahead

AOSpine International Chairperson Jeff Wang reflects on his first four months ‘in office’ and talks about the journey ahead to ensure that AOSpine is recognized as the premier global academic spine society. This year, innovation, research expansion, education, and new membership offerings by way of enhanced methods of deliver-ing education at courses, symposia, and seminars; and developing new online media and collaboration platforms remain a priority.

Upcoming innovations

With improvement and progress in mind, AOSpine will intro-duce its new web and tablet based Surgery Reference to the spine community as soon as end-2013, or early-2014. Supporting the increasing demand of its members, AOSpine is in the process of transforming InSpine Magazine from a print journal to a digital product. The new digital InSpine Magazine will be launched in March 2013, and cater to mobile, plugged-in spine care profession-als. Later, the digital InSpine will include interactive content, online discussions, and links to AOSpine membership content to further enhance articles related to clinical and practice management.

Research

AOSpine’s new and ongoing research initiatives continue to gather real evidence to appropriately judge clinical interventions, and improve patient care. The Spine Research Network—AOSpine’s translational research initiative—continues to explore the mecha-nisms behind degeneration and regeneration of the intervertebral disc. The Knowledge Forums, which are clinical research working

groups in the areas of Tumor, Deformity, and Spinal Cord Injury & Trauma, will commence to analyze their first results. In addi-tion, a new Knowledge Forum on degeneration is in the process being formed.

A dynamic global community

The AOSpine community is on a global growth curve! It is busy connecting members by way of organizing educational activities at regional and national levels, and creating initiatives that encourage member involvement, continually adding value to each other, and to the community. In 2012, local and global collaborations, along with cooperative educational efforts with regional spine societies, such as: the North American Spine Society (NASS), the Chinese Orthopaedic Association (COA), and the Spine Society of Europe (EuroSpine), have greatly contributed to the mission of AOSpine to become a truly global academic community.

Setting standards

Following in the footsteps of AOSpine’s founders, Jeff Wang continues to realize the organization’s vision to be recognized as the premier global academic spine society by setting the standard for education and research. He strongly believes that the orga-nization is on its way to building the most active and respected academic society that interacts on a worldwide basis, thanks to an extraordinary, dedicated, and knowledgeable community of spine care professionals, and AOSpine’s staff worldwide.The future is exciting, and AOSpine looks forward to celebrating the 10th anniversary in 2013!

AOSpine Davos Courses 2011 participants gaining hands-on experienceAOSpine Chairperson Jeff Wang and Past Chairperson Luiz Vialle

AOSpine

AO Dialogue 2|12 Page 7

A growing community

AOCMF, a global leader in high quality post-graduate education in the craniomaxillofacial field, serves as the voice and profes-sional resource for craniomaxillofacial trauma and reconstruction. As a member, your benefits include: access to the journal of Cra-niomaxillofacial Trauma & Reconstruction, online access to eight current and archives of 23 scientific journals, access to evidence-based rankings of publications (CMFline), AOCMF teaching videos, other online resources, discount on AO publications, and global membership support, to name a few.

Technology-savvy education and publications

The online AO Surgery Reference describes the complete surgical management process from diagnosis to aftercare, and assembles relevant published AO material. The CMF section of AO Surgery Reference currently covers four anatomical areas: skull base and cranial vault, midface, dentoalveolar trauma, and mandible. There is also excellent material on congenital deformities, orthognathic, and postablative reconstruction.

AOCMF’s clinical evidence database application, the CMFline for the iPhone and Android-based mobile devices, provides bib-liographic information on therapy, prognosis and diagnosis; and enlists key study results.

The most recent CMF publication, Principles of Internal Fixation of the Craniomaxillofacial Skeleton— Trauma and Orthognathic Surgery, serves as a tribute to the individuals who have taught as AO faculty at courses and symposia over the last 50 years.

Co-authored by Joachim Prein, Michael Ehrenfeld and Paul N. Manson, it presents the collective expertise and competence of different specialties, resulting in an all-inclusive work of consid-erable scope. AOCMF offers its members a 25% discount on the original price of both print and electronic versions.

The official AOCMF membership journal of Craniomaxillofacial Trauma and Reconstruction is in its fifth year of publication. AOCMF is reorganizing its structure and doubling its scientific content.

Increased education offerings

AOCMF educational activities worldwide exceeded the 100 mark in 2012, with over 4,500 participants. The growth has mainly been seen in Asia Pacific and Latin America. North America, Europe, and the Middle East continue to remain stable.

The AOCMF Neurotrauma working group (founded in 2010 as subgroup to AOCMF Europe) is developing a new curriculum for Neurotrauma with an initial focus on the Principles Course in collaboration with AOCMF Education and AO Education.

This year’s AOCMF International Retreat was attended by 70 members and guests. The program focused on the future develop-ment of AOCMF’s educational offerings, and included informa-tion from the AO Foundation, AOCMF Education, Community Development and Research & Development, and a session on educational program development. It presented the perfect oppor-tunity for the international faculty to foster the community spirit.

CMFlineAOCMF International Retreat in Magaliesburg, South Africa, November 2012

From the Clinical DivisionsAOCMF

AO Dialogue 2|12 Page 8

First AOVET Small Animal Principles Course in South Africa, October 2012

A diverse and dynamic community

The AOVET community is committed to improving the quality of patient care through state-of-the-art education, and provides a vital link for veterinary specialists across the globe. With a growing membership community of more than 600 individuals, AOVET is the leading organization in the field of veterinary medicine. Combining presentations from leading specialists with cutting-edge surgical skills and techniques on anatomic models is a well-estab-lished and proven method, allowing veterinary surgeons to effec-tively apply theory to practice and improve treatment techniques.

Education

Besides the well-established courses, AOVET organized a successful first-time small animal principles course in Cape Town, South Africa. Recently, Latin America has been established as a region chaired by Cassio Ferrigno from the University of Sao Paulo. The first Latin American Faculty Training was held in Brazil in November 2011. In response to the high demand of the Brazilian veterinarians, AOVET organized four instead of the three planned courses in Sao Paulo: one in equine principles, two small animal principles courses, and one small animal advanced course.

Istanbul held the second international retreat this summer, fo-cusing on the future of AOVET Education. The newly established European Board was invited to this event along with the AOVET international board and management of AO Foundation.

At the Davos Courses 2012, AOVET has offered two courses: Advances in Small Animal Fracture Management, chaired by Rico

Vannini (Switzerland) and Daniel Damur (Switzerland). And, the Minimal invasive osteosynthesis, chaired by Loic Dejardin (USA) along with co-chair James Tomlinson (USA).

Inviting attendees to the Davos Courses 2012, Jörg Auer, Chair-person, AOVET International, says “It is my profound belief that you will not regret having participated in any one of these two exceptional educational offerings. Come, join us and be a part of our ‘cool-n-competitive’ AOVET group.”

New book release

What and where was AOVET founded? Who was the first President of AOVET? Who was the first American AOVET President? What did the “Waldenburg Circle” represent? Who was “Maxlie”? For all interested in the history of AOVET, a new publication—His-tory of AOVET—The First 40 Years will be released in time for the Trustee Meeting 2013 in Lima, Peru.

History of AOVET—The First 40 Years is a combined effort by Auer J.A., Schlünder M., von Salis B., Kàsa, F., Kàsa G., Olmstead M., Fackelman, G.E., Pohler O; based on the work of Martina Schlünder, an understudy of Thomas Schilch, who published the history of the AO Foundation in: A Revolution in Fracture Care, 1950-1990s. Basingstoke: Palgrave Macmillan, 2002.

AOVET looks forward to bringing you the History of AOVET—The First 40 Years in the form of a booklet with an online version, too. We will keep the AOVET community informed on further interesting developments!

First AOVET Latin American Faculty Training in Brazil, November 2011

AOVET

AO Dialogue 2|12 Page 9

2012 Berton Rahn Prize WinnerEsmaiel Jabbari

In-situ Crosslinkable Osteoinductive Poly(Lactide) Scaf-fold for Bone RegenerationEsmaiel Jabbari, University of South Carolina Chemical Engineering, Columbia, South Carolina, US

The overarching goal of this research was to develop engineered matrices to accelerate the process of bone regeneration. While the natural bone regenerative process is biologically optimal, ac-celeration of the process can reduce the recovery of patients with skeletal defects. An exciting strategy to accelerate bone formation is the use of osteoinductive factors like BMP-2 delivered in a car-rier to the regeneration site. However, high doses coupled with the diffusion of the protein away from the intended site of re-generation, and soft tissue compression reduce efficacy and cause undesired side effects such as bone overgrowth, immunological reaction, and tumorigenesis. The collagen sponge packed inside a titanium cage is the most widely used carrier for BMP-2 but the bone density and integration with the host tissue are limited by stress shielding. Bioactive calcium phosphates have also been used as a carrier for BMP-2 but fatigue fracture is a potential drawback. We hypothesized that a carrier that can withstand soft tissue compression and reduce the diffusion of the protein away of the regeneration site will significantly improve BMP-2 efficacy and reduce the side effects of the protein. In an effort to reduce BMP-2 loss by soft tissue compression, we developed a mechanically robust degradable scaffold with well-defined pore geometry. In that regard, a novel poly(lactide fumarate) (PLAF) macromer consisting of short lactide segments functionalized with fumarate groups was synthesized in our laboratory. The salient feature of this macromer is that the short lactide segments allow the macromer to crosslink into a mechanically stable scaffold

while imparting long-term degradability to the scaffold. A rapid prototyping technology was used to produce PLAF scaffolds with well-defined pore geometry. The PLAF scaffolds demonstrated short-term stability against soft tissue compression and long-term degradability. In an effort to reduce BMP-2 loss by diffusion and bone overgrowth, we utilized nanotechnology, specifically the lower mobility of nanoparticles (NPs) than biomolecules, to in-crease the residence time of the protein in the regeneration site. In that regard, novel degradable poly(lactide-ethylene oxide fu-marate) (PLEOF) macromers were synthesized that self-assembled spontaneously in aqueous environment to form NPs with 5-150 nm in size. Next, BMP-2 is chemically attached or grafted to the NPs surface to immobilize the protein on the NPs. The grafting process significantly reduces the diffusion of the protein, thus reducing bone overgrowth outside the regeneration site. Then, the BMP-2 grafted NPs are loaded in porous PLAF scaffold to produce a degradable mechanically stable carrier for BMP-2 de-livery with long residence time and extended release of BMP-2 in the intended site of regeneration. The NPs not only immobilize BMP-2 in the regeneration site but they also present a multivalent form of the protein to cell surface receptors, leading to a stron-ger activation of osteogenic signaling pathways. Bone marrow derived mesenchymal stem cells (MSCs) cultured in osteogenic medium supplemented with BMP-2 grafted NPs expressed sig-nificantly higher levels of osteogenic and vasculogenic markers and produced higher extent of mineralization than the medium supplemented with the free ungrafted protein. The findings of this research demonstrate that nanotechnology has the potential to greatly improve efficacy and reduce the harmful side effects associated with the delivery of osteoinductive factors in the in-tended site of regeneration in orthopedic surgery.

Esmaiel Jabbari presenting his findings at the Trustees Meeting 2012 in Davos Mark Markel awarding the Berton Rahn Prize

AO Dialogue 2|12 Page 10

TK Innovations magazine

Demonstrating detailed descriptions of the latest approved techniques, a new issue of the TK Innovations magazine will be published at the time of the AO Foundation Courses in Davos in December 2012.

The latest edition examines 22 new implants and instruments for use in trauma, spine, CMF, and veterinary surgery, with the lead article providing an interesting overview on the Dynamic Locking Screw, developed to address delayed bone healing in distal tibia and femur fractures.

Other implants and instruments examined include the LCP Elbow Plating system and the LCP Ulna Osteotomy system, the Proximal Femoral Nail Antirotation (PFNA) Asia, and a wide range of new screws, plates, and power tools for Trauma specialists.

For CMF surgeons, the Strut Plate is the newest design for fractures of the condylar process, and for Vets, the new Mini Tibia Leveling Os-teotomy Jig helps greatly in orthopedic procedures for small animals.

Numerous new Spine instruments are also discussed, including items for degenerative disc disease, implants that protect sensitive vessels during spine surgery, as well as vertebral body replace-ment devices. Additionally, there is a feature article celebrating 10 years of AOSpine.

As always, please contact the publication’s editors for comments and feedback at aotk@aofoundation.org.

In 2012 the TK System has increased its efforts to strengthen the aspect of evidence based development in its activities. As an in-terface between AO surgeons, engineers, scientists and industrial partners in the management of surgical innovations, development and approval of products and techniques for the treatment of injuries, deformities and diseases of the musculoskeletal system, the AOTKs and their Expert Groups have initiated a new program named “mini registries” to measure the added value of a new technology for patient, surgeons and/or healthcare environments in its workflows.

Meet the Experts at the Davos Courses 2012

After the highly successful introduction of the “TK Innovations: Meet the Experts” at the Davos Courses in 2011, this year’s course participants can visit first hand presentations and hands-on demonstration of surgical techniques based on projects which have recently achieved AOTK approval. These daily lunchtime sessions are hosted by members of the Expert Groups and surgeons with direct involvement in the development processes.

Again the three areas of trauma, spine and CMF surgery are covered by dedicated sessions, furthermore special focus areas such as Computer-Assisted surgery and Biomaterials are part of the program as well.

Participation is free for all and 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.

From the AO InstitutesAO Technical Commission (AOTK)

Cumhur Onur and Robert McGuire present at a Meet the Experts session during the 2011 Davos CoursesCumhur Onur and Robert McGuire present at a Meet the Experts session during the 2011 Davos Courses TK System Innovations magazine coverTK System Innovations magazine cover

AO Dialogue 2|12 Page 11

AO Outcome Center–a powerful new assessment tool in development

AO Clinical Investigation and Documentation

(AOCID) uses outcomes measures as an integral

part of the many clinical studies it conducts in

over 300 clinics worldwide. Since the ultimate

aim of these studies is improved patient out-

comes, it is important to measure the effect of

treatment on patients.

Traditionally, clinicians have evaluated outcomes

using clinical parameters such as range of motion

and strength. In recent years, outcome evalua-

tions based on patient self-report (Patient-Report-

ed Outcomes or PROs) have gained in popularity.

However, collecting PROs is not easy for many

reasons. It involves using questionnaires which

From the AO InstitutesAO Clinical Investigation and

Documentation (AOCID)

may be lengthy and unwieldy in a real-life clini-

cal setting. Automated scoring and reporting is

needed in order to utilize the PRO in clinical care.

Recent developments in the science of clinical

evaluation have made it possible to create com-

puter-adaptive tests (CATs). By harnessing the

processing power of computers and applying Item

Response Theory (IRT), it is possible to greatly

reduce the patient question burden while achiev-

ing similar measurement precision.

How does CAT work? The test “adapts” to the

individual based on the answer to the previous

items. The set of asked items differs from person

to person, depending on the answers to the pre-

vious questions. Unlike static questionnaires to

measure patient outcomes, there is no one unique

test. A complex computer algorithm creates the

subject-specifi c test by drawing appropriate items

from a large item bank (a collection of items).

Mark Vrahas, MD, Chairman of the AOCID Com-

mittee (pictured on the next page), is the Principal

Clinical Investigator behind the AO Foundation’s

CAT project. The main objective is to create a web-

based software application, the Outcome Center,

which will enable a clinician to administer CATs

to patients. Instruments appropriate for trauma

surgery patients will be included, with a particu-

lar focus on upper and lower extremity function.

Signifi cant work on this project with multiple

funding sources has already been performed.

AOCID worked hand in hand with Dr Mark

Vrahas and his team from Massachusetts Gen-

eral Hospital, the Assessment Center-Team

from Northwestern University, led by Nan

Rothrock, PhD, and several other trauma

AO Dialogue 2|12 Page 12

surgeons. Patient–Reported Outcomes Measure-

ment Information System (PROMIS®) instru-

ments including CATs are a central feature of

the AO Outcome Center instrument library. The

default AO outcomes measure assessment battery

will include Mobility, Upper Extremity, and Pain

Interference CATs. The AO Outcome Center is in

development and is currently undergoing quality

assurance testing. In the meantime, the working

group is adding AO fracture classifi cation con-

tent to the module and fi nalizing the instrument

library content.

The pilot phase of AO Outcome Center is

slated to begin in early 2013. In this phase

the CATs will be tested with patients and the

usability of the application for both patients and

clinicians will be assessed by members of the AO

Outcome Center team.

Sometime in the near future in North America,

AO surgeons and their patients will be able to

take advantage of advances in patient-reported

outcome measurement in clinical care with less

cumbersome assessment that retains measure-

ment precision.

The AO Clinical Study Center program now has its

own dedicated website.

Visit www.aocsc.org to find out more about

this concept to standardize the conduct of clini-

cal research!

Use your Smartphone to scan this code and visit the AOCSC website directly.

AO Dialogue 2|12 Page 13

Traditional paper-based outcome measurement instruments

Mark Vrahas, MD, Chairman of the AOCID Committee

Musculoskeletal Regeneration Program

This program aims to provide innovative

tissue engineering and regenerative medicine

solutions for the short and long term. The

four focus areas of bone regeneration, disc

regeneration, stem cells, and polymers and

surfaces interact to develop novel combi-

nations of scaffolds, cells and stimuli for

the repair of bone, cartilage and interver-

tebral disc (IVD). Translational and regula-

tory aspects are always considered when develop-

ing therapies to ensure the potential for clinical

applicability.

Bone Regeneration Focus Area

Due to diverse pathological processes such as

trauma, tumor, inflammation and infection, criti-

cal sized bone defects (CSD) do not heal sponta-

neously if left untreated. This constitutes a major

challenge for trauma surgeons. This focus area

aims to develop biological substitutes, capable

of mimicking the natural bone environment,

and to improve the functional state of damaged

tissue. Therefore, tissue engineering approaches

are used to create pre-cellularized and pre-vas-

cularized constructs based on the association of

artifi cial scaffolds (polyurethane) with autologous

biological components (cells, growth factors). In

parallel, the effect of post-operative mechanical

stimulation of such constructs in an orthotopic

model on the speed and quality of bone healing

are investigated.

Disc Regeneration Focus Area

This focus area investigates methods by which

MSCs can gain access to IVDs. Two main ap-

proaches are under investigation: direct injection

From the AO InstitutesAO Research Institute (ARI)

At the AO Research Institute Davos (ARI) our mission is excellence in research and concept development within trauma and disorders of the musculoskeletal system and

translation of this knowledge to achieve more effective patient care worldwide.

and homing to a damaged disc by way of soluble

signals. Investigations have shown that mesen-

chymal stem cells can differentiate towards the

disc cell phenotype when suspended in thermo-

reversible hyaluronan hydrogel and injected into

an IVD ex vivo. Alternatively, recruitment (hom-

ing) of mesenchymal stem cells into induced

degenerative discs in a whole organ culture sys-

tem has also been demonstrated. This approach

is of particular interest as it does not introduce

any new damage to the annulus fi brosus. Work

is now underway to identify the signals involved

to eventually optimize the endogenous homing

repair response.

Stem Cells Focus Area

The main goal of this focus area is developing in-

traoperative solutions for the repair of cartilage and

bone. This has involved investigating the potential

of mechanical stimulation alone to control stem

cell fate decisions. Using a multiaxial load bioreac-

tor it has been shown that human MSCs can be

directed towards a chondrogenic phenotype when

the correct mechanical stimulation is applied. This

opens the possibility for rehabilitation protocols

being used to direct and enhance the natural heal-

ing response or improve outcomes of cell based

therapies. Cell therapies can also be improved

by the use of gene therapy. Although viral vec-

tors have safety considerations, these are being

overcome, with the European Medicines Agency

recently recommending a viral gene therapy for

clinical use. This focus area has developed a 3D

method that results in protein expression levels

which are clinically relevant, can be performed

intraoperatively and requires twenty fold less vi-

rus than standard protocols, further increasing its

safety profi le.

Using a three-dimensional statistical computer model of the sacrum (in yellow) its anatomical

variation is analyzed and compared with the mean shape

(in grey)

AO Dialogue 2|12 Page 14

Polymers and Surfaces Focus Area

Creating innovative bio-functional hyaluronan

hydrogels to biomimetically recreate the multiple

signals that occur during the normal bone healing

process is the purpose of this focus area. It must

be capable of inducing rapid vascularization while

presenting osteogenic properties. A combination

of 1) hyaluronan molecules of different molecu-

lar weight and biological activity, with or without

functionalization and 2) self-assembling peptides

(e.g. RADA-16i) and fi brinogen are prepared. The

hypothesis is that the composition of the hydrogel

prepared will provide a 3D instructive matrix for

encapsulated cells and that the degradation prod-

ucts (hyaluronan and fi brinogen fragments) of

the biomaterial can provide biological signals im-

proving angiogenesis and bone healing. The po-

tential of a regenerative approach to CSD healing

based on the combination of selected biomate-

rial with human autologous bone marrow derived

MSCs will be evaluated.

Human Morphology Services (HMS)

This is a computer laboratory for advanced medi-

cal image processing and analysis with a focus

on maintaining a database of CT scans and con-

verting them to 3D statistical bone models. With-

in this scope, HMS members perform research

and development projects, and educate medical

research fellows. Collaboration between HMS

and surgeons of the TK System has been estab-

lished to assess the anatomical variability of the

sacrum in order to help improving fracture fi xa-

tion in this complex shaped bone. Internal fi xa-

tion using trans-sacral implants has been advo-

cated for earlier mobilization and pain relief of

sacral insuffi ciency fractures. Surgical treatment

includes positioning of implants through trans-

sacral corridors mainly at the level of the fi rst sacral

vertebra. More than 150 pelvic Computer Tomo-

graphy (CT) scans are currently being processed

to generate a 3D statistical model of the sacrum,

which will improve understanding of the sacral

anatomy, leading to safer implant positioning.

Musculoskeletal Infection Group

This group performs research that covers the in

vitro investigation of bacterial virulence, the deve-

lopment of antimicrobial delivery vehicles and the

development of improved preclinical models of

infection. In collaboration with the Polymers and

Surfaces focus area, a novel hydrogel designed to

deliver antimicrobial agents directly to the surgi-

cal or wound site is being developed. Thermo-

responsive hydrogels prepared from hyaluronic

acid are prepared using a “click chemistry” reaction

and these injectable biodegradable materials have

been shown to kill even early bacterial biofi lms. This

technology has great potential in the prevention of

infection of open traumatic wounds in particular,

which suffer from particularly high infection rates.

The fl exibility of the hydrogel platform will allow

for incorporation of numerous antimicrobials and

allow different application mechanisms, including

direct application by a spraying mechanism.

AO Dialogue 2|12 Page 15

Medical education experts agree that in order to enhance the quality and impact of programs, educational offerings should be based on needs. This new way of thinking moves beyond

the traditional measures of participation and satisfaction, to additionally consider clinical performance and patient care. The AO Education Institiute (AOEI) is also committed to conducting educational research and developing new tools in the fi eld of performance

improvement (PI).

Improving outcomes through performance

Imaging educational research

AOEI is working to design and develop targeted

imaging educational interventions and to mea-

sure their impact on key performance and patient

care issues.

Funded through an educational grant from

Siemens. These projects involve support from

colleagues in AO Clinical Investigation and Docu-

mentation (AOCID).

In 2012, two PI projects started. Daniel Rikli,

Michael Blauth, and Samir Mehta with AOTrauma

lead a program on intraoperative imaging and Flo-

rian Gebhard, Michael Kraus, Bastian Scheiderer,

and Bettina Ammann at Ulm University lead a

program on the use of MRI in orthopedic trauma.

improvement (PI).

AO skills lab

A training ground for orthopedic and trauma surgeons

From the AO InstitutesAO Education Institute

Performance Improvement (PI) program 3 key steps:

1. Participants assess current practice using selected measures

2. They undertake an educational intervention related to practice issues

3. Participants reassess their practice using the same measures

A hands-on, multi-station work-shop offers an

innovative way for surgeons to enhance knowl-

edge of underlying principles and skills of fracture

management. Used to gather experimental data

for a study on the effect that sharp or blunt instru-

ments have on the performance of experienced

and inexperienced surgeons. Results were pub-

lished in the Journal of Orthopedic Trauma. See

list of publications for further information.

Addresses four principles of four major orthopedic

trauma topics: bone healing, fracture reduction,

fracture fixation, and surgical skills. Exercises

allow surgeons to get a feeling for a specifi c tech-

nique and improve their skills.

AO Dialogue 2|12 Page 16

Participants: surgeons (36)

Surgical techniques, timing, weight bearing, etc. 12

Comanaged care (or some part of teamwork, communication, etc) 10

Osteoporosis, metabolic bone, Vitamin D 9

Misc medical/medication issues 8

Develop/QA GF center/program 7

Pre/postoperative prep & orders 4

Delirium 3

4

3-month follow-up

(self-report data) n=12 participants, 14 practice changes

3

7

Fully im plemented

Partially implemented

Not implemented

75 patients

115 patients

Estimated no. of patients who have benefi ted

In 2010 and 2011, CTC was implemented in more

than 20 face-to-face educational courses delivered

to 600 practicing trauma and spine surgeons.

Analysis of barriers to implementing change also

provides information to inform ongoing curricu-

lum development.

Example data

Topics where change of practice intended

AO Education Institute essentials

Targeting the highest level

AOTrauma: Global Needs Analysis

Throughout 2012, AOEI and AOTrauma are

gathering detailed information on the individual

needs of every surgeon, in every region and coun-

try where AOTrauma education is offered.

In collaboration with the existing network and

local organizations, data will be analyzed and

used to plan more relevant and responsive educa-

tional activities, better meeting the needs of prac-

ticing surgeons.

The extensive, quantitative online survey is a

major project building on past research in lifelong

learning.

Commitment to change

A tool for assessing the impact of education on clinical practice

The commitment to change (CTC) practice survey

is now integrated in the AO‘s Learning Assess-

ment Toolkit.

AO Education Institute essentials

Targeting the highest level

AO Dialogue 2|12 Page 17

Jaime Quintero, AO Dialogue is published every year to coincide with the AO Foundation Davos Courses, what is the history behind these courses?

The Davos courses have always been innovative. Back in 1960’s when they were established, the courses were innovative because they introduced the concept of workshops, simulat-ing a surgical procedure, and in addition, the AO founding father Maurice E Mueller was a young guy teaching more senior surgeons (this was unheard of at the time). Thanks to the reputation for excellence we have at the AO we have access to the best sur-geon faculty and we ensure that they are trained to the highest standards. The fact that our surgeon faculty is comprised of volunteers is unparalleled in the field; these teachers are not AO employees, but rather surgeons imbued with the AO spirit.

In the last two decades, once the Davos courses were well-established, the second phase of our education strategy came into play whereby our organization committed to constantly improving the quality, performance and skill of our teachers. This is achieved through educator’s workshops, tips for trainers and faculty education programs.

Now we are in the third phase using e-learning and blended learning. We are commit-ted to developing educational offerings that are accessible via mobile devices and online portals. Content can be easily updated ensuring that learners have access to the most current data quickly and easily. Learners are best served when oral, visual and written media are brought together to emphasize key learning points and we want to enhance the learning experience through assimilating video into our educational programs. We are introducing new evaluation methodologies and techniques to get feedback on the quality of our education which we call assessment of educational outcomes and measurement of the transfer to surgical practice.

What are the unique benefits for surgeons from around the world of attending the AO Foundation Courses in Davos?At the 2012 Davos Courses the AO has expanded its education initiative with a new focus on offering more of the relevant education workshops and seminars that meet the specific needs of the surgeons during the 12:00-16:00 afternoon sessions. This new initiative is called: Education Activities for Individual Continuing Professional Development (CPD). Our CPD program is in direct response to feedback we have received from our surgeon network and designed to maximise a surgeon’s time in Davos.

The opportunity the AO Davos Courses provide for networking with fellow surgeons and surgeon faculty is second to none. There are membership programs and the chance to meet members of a clinical division. Workshops allow direct interaction with teachers and fellow participants from around the globe. This is the first step in building a network, becoming part of the fraternity. The next step is becoming a member of the relevant clinical division; this is a formal network/fraternity which is an essential part of being a surgeon in these fields.

From the PresidentJaime Quintero talks to AO Dialogue

AO Dialogue 2|12 Page 18