AO Dialogue 2 | 2011

AO Dialogue 2|11
The newsletter for the AO community

AO Foundation continues
the mobile march
AO Education adds to its mobile portfolio on
behalf of the AO Specialties
Olga Harrington, AO Dialogue uptake by both new and existing users more
mobile resources (AO Traumaline, EBSS.live
With constantly improving wireless tech- and CMFline) are being launched at the AO Table of contents
nologies and the growing impact and con- Foundation Davos Courses 2011. These apps-
AO Education 1
venience of virtual and mobile technologies, give surgeons easy access to an even greater
AO Specialties (AOTrauma and AOCMF) took range of AO learning and reference material. ESTES 3
the bold step of launching mobile versions of
SIGN report 4
the hugely successful resources AO Surgery For those unfamiliar with AO Education’s
Reference and Müller AO Classification of online and mobile learning resources, AO ARI Focus 6
Fractures at the end of 2010. The response to Surgery Reference is a resource for the man-
Service Units 10
both has been phenomenal, with more than agement of fractures, based on current clinical
47,000 downloads for the AO Surgery Refer- principles, practices and available evidence. Specialties 12
ence app and in excess of 25,000 downloads While AO Surgery Reference is primarily di-
Norbert Haas 16
of the Müller AO Classification of Fractures rected at surgeons in learning situations, it
app in their first year. Encouraged by the rapid [ continued on page 2 ]

AO Dialogue 2|11 AO Dialogue 2|11 Page 3

AO Foundation continues 13th European Congress for Trauma
the mobile march and Emergency Surgery in Basel
continued… Just another congress?
also offers valuable content for experienced most cases good-quality, enlargeable x-rays
surgeons. AO Surgery Reference presents rel- and some CT scans are also included. Frac-
evant advances in fracture fixation and estab- ture subgroups are described in detail for most
lished techniques of proven value in order to bone segments.
offer a range of fracture solutions to the widest
possible surgical community. The guide is ex- Confident of the usability, accuracy and
tensively illustrated with over 20,000 illustra- success of its recent launches, AOTrauma,
tions on the website and hundreds of clinical AOSpine and AOCMF are now launching
photographs and x-rays. While describing the three clinical evidence database applications
complete surgical management process from for iPhone and Android, namely Traumaline
diagnosis to aftercare for fractures in a given (trauma content), EBSS.live (spine content),
anatomical region (in the fields of orthopaedic and CMFline (CMF content). Unlike Trauma-
and craniomaxillofacial trauma), AO Surgery line, which is freely available, EBSS.live and
Reference also assembles relevant published CMFline will initially be free to use and at a
AO material. The iPhone app was launched later stage, be offered as a membership benefit
in November 2010 while the Android version to Specialty members only. These three data-
followed in August 2011. bases of clinical evidence contain summarized
b
information on relevant specialty literature.
Dominik Heim, Frutigen, and Reto Babst, Lucerne , Switzerland There are several congress sessions organized
A second key resource, the Müller AO Classi- They provide not only access to bibliographic
The annual Congress of the European Society in association with the AO, in particular one
fication of Fractures is the standard classifica- information on articles of therapy, progno-
for Trauma and Emergency Surgery (ESTES) addressing the past, present and future of the
tion used by trauma surgeons and physicians sis, and diagnosis but also list key study re-
will take place in Basel from 12-15 May 2012. Foundation. Other sessions will highlight current
dealing with skeletal trauma worldwide. This sults. Individual studies are graded according
b Switzerland has been chosen as the location research, documentation and quality care, and
‘app’ is a reference tool that assists beginners to Class of Evidence allowing users to find
for the congress next year as part of the one the most up-to-date techniques in trauma care.
as well as experts in classifying any fracture relevant clinical evidence. Regular updates
hundredth anniversary celebrations of one of
of the long bones. Fractures are presented will ensure that the database is always up to
the two organizing Swiss societies, the Swiss The main congress topics are: minimally in-
with an enlargeable line drawing, the spe- date, making them a premier tool for clini-
Society of Traumatology and Insurance Medi- vasive versus conventional surgery; unnec-
cific classification code, and clinical infor- cal research and practice. Stay tuned for the
cine, SGTV. essary surgery; vascular injuries; sport inju-
mation including AO reference material. In launches.
ries, implant removal and mountain rescue.
All rights reserved. Any re production, whole or in part, without
the publisher’s written consent is prohibited. Great care has been ESTES is a product of the merger of the Eu- Special sessions will be dedicated to the Red
taken to maintain the accuracy of the information contained in
this publication. However, the publisher, and/or the distributor
ropean Trauma Society (ETS) and the Euro- Cross, trauma in Asia (with the participation
and/or the editors, and/or the authors cannot be held respon- pean Association for Trauma and Emergency of members of AOTrauma Asia Pacific) and the
sible for errors or any consequences arising from the use of the
information contained in this publication. Some of the products, Surgery (EATES) in 2007. It is the home of 26 latest research findings from the University
names, instruments, treatments, logos, designs, etc. referred to
in this publication are also protected by patents and trademarks national trauma and emergency societies in of Basel. In the “12 to 12” sessions (just be-
or by other intellectual property protection laws (eg, “AO”, “TRI-
ANGLE/GLOBE Logo” are registered trademarks) even though Europe with more than 10,000 institutional fore lunchtime) some prominent speakers will
specific reference to this fact is not always made in the text.
Therefore, the appearance of a name, instrument, etc. without
members. Its first joint congress was held in present short statements on the state-of-the-art
designation as proprietary is not to be construed as a representa- Graz in May 2007 and since then its annual in trauma and emergency situations. “How I
tion by the publisher that is in the public domain.
congresses have been held in Budapest, Brus- do it sessions” in the early morning offer the
sels and Milan. The broad scientific approach chance to learn more about personal attitudes
Impressum AO Dialogue 2|11 taken by the ESTES congress—ranging from and convictions regarding specific problems
Editor-in-Chief: James F Kellam
Managing Editor: Olga Harrington trauma sessions about proximal humerus frac- while lunchtime symposia offer opportunities
Publisher: AO Foundation
tures to keynote lectures on cholecystectomy to experience the diverse product ranges from
Design and typesetting: nougat.ch and
AO Foundation, Communication and Events in acute cholecystitis—makes it a good reflec- different implant manufacturers.
Printed by: BUDAG AG, Switzerland
Editorial contact address: AO Foundation,
tion of current discussions about acute care
Clavadelerstrasse 8, surgeons in a world where each specialty has a All this will be embedded in a rich, cultural
CH-7270 Davos Platz, Phone: +41(0)81 414 28 14,
Fax: +41(0)81 414 22 97,
role to play in the management of the complex program in the town of Basel. For more infor-
E-mail: dialogue@aofoundation.org trauma and emergency patient. mation see www.estesonline.org
Copyright © 2011, AO Foundation, Switzerland


Surgical Implant Generation Network AO Dialogue-SIGN fellow Biruk
Lambisso Wamisho reports from the
2011 SIGN Conference
Biruk Lambisso Wamisho, Addis Ababa University, Black Lion Hospi- union is essential. Technical improvements for for finding references on the Internet. Poster and presentations to the benefit of the entire
tal, Ethiopia; lbiruklw@yahoo.com; http://birukorthopaed.com/ locking without C-arm were reported from the sessions were times for ideas exchange between orthopedic community. The value of follow up
The Surgical Implant Generation Network Philippines and Kenya, giving more meaning surgeons and engineers. was emphasized as the basis for fracture treat-
(SIGN) international orthopedic conference to the C-arm for SIGN surgeons. The fin nail ment studies.
is beyond a simple scientific conference, it is a is designed so that using locking screws is not Soft tissue coverage
family of partners networking with common necessary. A series of fractures of the femur from To provide SIGN surgeons with soft tissue cov- Research Presentation by AO Dialogue-SIGN
fracture-treating goals. The purpose of SIGN is Uganda and humerus from Bangladesh showed erage expertise, SIGN, in collaboration with fellow
to continue to understand fracture treatment good stability with the fin nail demonstrating IGOT and UCSF Orthopedic Trauma Institute, Scarcity of orthopedic research output from a develop-
and treat more patients with different types of that perhaps distal screw interlocking is not organized a two day flap course. Different flap ing nation (Ethiopia).
fractures. 165 surgeons from 30 countries came required techniques and indications were explored by There were a total of 4,687 biomedical research
together at the 10th Annual SIGN Conference participants through cadaver, hands-on and articles published in Ethiopia between 1980 and
in September 2011 to: Hip fractures video demonstrations by renowned plastic sur- 2010 (this was reviewed using PubMed). Even
• Provide a venue for surgeons in developing The SHC (Sign Hip Construct) continues to grow geons at the institute. Negative pressure wound though the impact Factor is low, the Ethiopian
countries to discuss fracture care, in a in popularity. An Ethiopian study compared therapy, using a low cost, locally-made machine Medical Journal is a leading publisher of sci-
scientific manner different implants for pertrochnateric fractures, was described by Dr Jinco from the Philippines. entific articles from Ethiopia with 839 publica-
• Promote the dissemination of knowledge demonstrating that the SHC allowed surgery Dr Faruque from Dhaka presented 12 grades tions during the 30 year period under review.
between North American and overseas with fewer complications in patients with medi- IIIb tibia fractures where gastroc flap over SIGN HIV/AIDS and tuberculosis related health issues
surgeons cal co-morbidity. Dr Shah from Pakistan fol- nails done within 72 hours with nine having were the most frequently published research.
• Receive reports from surgeons in SIGN lowed 29 of 46 hip patients and concluded that excellent outcomes! The total number of articles published yearly
centers of excellence on new SIGN products in resource-limited centers, SHC done without showed steady growth from 49 in 1980 to 367 in
• Facilitate relationships between surgeons C-arm gives stable fixation and good early re- Research 2010. The increase in the number of published
from different parts of the world sults. Among the 211 SIGN surgeries reported A one day Research Symposium was given articles matched the growth of the National Do-
by Dr Mukherjee from India, nine were hip prior to the flap course. Dr Bhandari and his mestic Product, per capita. In conclusion, the
The keynote speaker at the three day event fractures with SHC showing good results. colleagues equipped attendees with a sound number of published works from Ethiopia over
held in Richland, Washington was Andrew N knowledge on basic surgical research. The goal the last three decades is one of the lowest in
Pollak, Orthopedic Trauma Association (OTA) Pediatric fractures of the symposium was to instruct SIGN surgeons the world. Ethiopian first authorship emerged
President who spoke on the development of an The new SIGN semi rigid pediatric nail is being on how to better document research results in 15 years ago. This trend of knowledge transfer
Orthopedic Trauma Education Program for de- evaluated in a sheep study in Ethiopia to assess a statistical manner and improve publications through collaborative research must continue.
veloping world surgeons. damage to the distal femoral epiphysis. This nail
is inserted retrograde fashion so this will be an
Long bone fractures important proof-of-concept study to evaluate Biruk Lambisso Wamisho giving his presentation 2011 SIGN conference organizers and attendees
Daniel Laverly’s cost effectiveness study from using pediatric nail in a retrograde approach.
Sierra Leone confirmed that IM nail treatment
of fractures decreases hospital costs and disabil- Workshops
ity. The SIGN nail used in infected nonunions The workshop topics ranged from Afghan Exfix
combined with bone transport was presented by (AEF), rods for forearm fractures, distal humer-
Tobias Otieno from Kenya showing success in us plating osteotomy to treat hip deformity, to
10 patients. The smaller but stronger SIGN nail Ottawa sterile drill system and the Portland
allows for better transport of the bone. Fletcher design and new designs for negative pressure
Beniyasi from Malawi showed that the infec- wound therapy all of which provoked robust
tion rates of both open and closed femur and disussions. Breakout sessions studying the
tibial fractures treated with the SIGN nail was Ponseti method, pelvic fracture and sawbones
0.8% and 1.3% respectively. Studies from Haiti, workshop provided plenty of opportunity for
Nigeria, India, Myanmar, and Kenya were pre- knowledge exchange. The IT workshops and
sented showing that follow-up until fracture resource materials on CD were very valuable


AO Research Institute Davos in Focus
Osteoporotic fracture treatment: a systematic approach to a growing problem
Decision making –> Implant positioning –> Fracture stabilization –> Reinforcement

Nailing/Cephalic implants Plating

Orthopedics

Screw insertions Anatomical fracture reduction

X-in- ne Implant Positioning Assistance
Fig 1 Markus Windolf, Ladina Fliri, Matthias Forte, Lukas Kamer, An ing them, carries future potential to prevent to turn the blade about its axis and to break site to avoid complications since internal body Fig 3
Proximal Femoral Nail Sermon, R Geoff Richards, ARI, Switerland devastating and non-devastating complications the local trabecular structure, is recorded. The forces are high and bone stock is limited. Not Implant positioning
Antirotation augmented with assistance for various
Approximately 75 million people in Europe, in fracture care of the elderly. measured value correlates with the local bone only for the inexperienced surgeon, orienta-
bone cement applications in trauma
Japan and the US suffer from osteoporosis re- strength and suggests eg, the use of a specific tion in anatomical terrain remains difficult and orthopedics
sulting in over 5.5 million fractures every year. Intraoperative decision making: Assessment implant or the application of bone cement for and is all too often associated with considerable
With an ageing population, the medical and of local bone quality (Fig 2) additional reinforcement. exposure to radiation.
socioeconomic effect of osteoporosis, particu- Bone quality is known as important indicator
larly postmenopausal osteoporosis, will further determining the biomechanical stability fol- The concept was proven by several in vitro A novel concept for assisting implant place-
increase. AO Trauma has, therefore, nominated lowing fracture fixation. Intraoperative mea- studies correlating the DensiProbe measurement is introduced to improve surgical rou-
osteoporotic fracture care as a research focus. surement of the bone quality carries potential ment with mechanical fatigue tests and image tine interventions worldwide. Opposed to
The AO Research Institute Davos (ARI) has put to markedly support the decision making pro- based parameters (CT). Prototypes were de- current navigation solutions, the concept
this mandate into practice by systematically cess regarding choice of fixation hardware or veloped for several anatomical key regions, utilizes a conventional C-arm as imaging
Fig 2 improving the various steps of fragility frac- operational technique in order to optimize the namely hip, spine, proximal humerus and and navigation means extracting hidden in-
Denisprobe™ for application ture treatment. These involve intraoperative fracture fixation. hind-foot. A clinical multicenter study is cur- formation from 2-dimensional radiographic
In Spine decision making by assessment of local bone rently ongoing to obtain threshold values for projections. The new method is exemplified
quality, enhancing accuracy of implant posi- The concept of a handheld mechanical mea- clinical decision making, preparing the ground on intramedullary nailing using a cephalic
tioning, improving facture fixation in reduced surement probe was recently introduced for successful translation into clinical practice. hip implant. Application covers center-center
bone mass by computer methods for systematic (DensiProbe™) consisting of a specifically de- positioning of the blade in the femoral head,
refinement of implant designs, and reinforc- signed blade and an attached measuring unit. Implant positioning (Fig 3) adjusting anatomical leg rotation and distal
ing implant purchase by cement augmentation The device is manually inserted into the can- Particularly in reduced bone mass accurate interlocking with minimal requirements for
techniques. Strengthening the different aspects cellous bone prior to osteosythesis to the aimed placement of implants is of utmost importance. radiation. Further applications are in the
of fragility fracture treatment and interlink- location of the implant. The torque, necessary Adequate implant positioning is a prerequi- planning stage.


AO Research Institute Davos in Focus
continued…
tent is not homogenous (uniform) inside a bone of augmentation procedures could be demon-
clini
and between individuals, it appears essential to strated in various applications, namely at the arch c al
l rese pra
c ti
target specific bone regions with an implant. hip (Dynamic Hip Screw, Proximal Femoral nta ce
r i me
FE-models allow testing implants in different Nail Antirotation), at the foot (Expert Hindfoot pe
ex
bone qualities and individual distributions of Arthrodesis Nail) and at the proximal humer-
bone mineral as derived from CT data. us. Further applications will follow.

Very little is known about statistical distribu- Aside from biomechanical aspects, it is aimed
tion of bone density in the human skeleton. to continuously improve and optimize aug-
Therefore a goal is to analyse the local bone mentation techniques in terms of safety and
stock and its variations at osteoporosis relevant efficacy. ARI targets diminishing associated
sites under consideration of bone surface shape risks by reducing the required amount of ce-
and size, influenced by body height, gender, ment and optimizing the cement properties
ethnicity or age. PQCT based three-dimen- and localizations. New cement formulations
sional statistical modelling is performed on with biodegradable or non-degradable charac-
the basis of advanced computerized image teristics are coming into focus. Adverse side ef-
processing in order to improve the predictive fects of implant augmentation such as thermal
value of computational implant evaluation. necrosis are critically investigated. Studies re-
Furthermore, the fracture pattern is known vealed, for example, negligible heat generation
to be an important indicator determining the for augmentation of hip implants if properly Fig 6 Interlinking research and clinics
Fig 4 Finite elements representation of
a proximal humerus repair construct outcome of an osteosynthesis. Clinically real- applied—important base line knowledge for
istic fracture patterns will be included in the the clinical application. Additional steps will be From experimental research to clinics (Fig 6)
Fracture stabilization: Implant design optimi- FE representations. undertaken to further improve the safety of the ARI offers multiple medical fellowships annu-
zation (Fig 4) procedure. For example, a study investigating ally to create a link between applied research
Sound fracture fixation in reduced bone stock Last but not least, implant performance should the effect of subchondral cement augmentation and clinical practice. This practice has enabled
requires implant designs optimized to the ana- be evaluated under realistic physical loading. on the adjacent articular cartilage is planned. An Sermon, a Belgian trauma surgeon under-
tomical environment, under consideration of Recent mathematical concepts allow accurate The long term goal of ARI is to provide detailed taking a fellowship at ARI, to strengthen her
biomechanical and morphological parameters. estimation of internal body loads at patient scientific evidence on cement augmentation clinical work on osteoporotic fractures through
We hypothesize that particularly in porotic bone routine activities providing an important tool techniques allowing confident use on the pa- experimental research. Both accumulated evi-
recent implant generations do not fully exploit for systematic implant evaluation. tient for significantly reduced fixation failures dence from literature and personal experience
the existing potential for fracture fixation. in porotic bone. as a trauma surgeon dealing with an exponen-
Reinforcement: Cement augmentation tech- tially growing number of geriatric hip fractures,
Computational simulation is a powerful tool niques (Fig 1) stimulated Sermon to actively approach two of
to predict the performance of new implant In osteoporotic patients the trabecular bone the most important gaps in current knowledge,
designs and to assist in the development pro- is strongly reduced in its quality and quantity namely implant design and fixation methods
cess prior to clinical evaluation. Finite element which makes it difficult to anchor implants. In for preventing fixation failure in porotic bone.
(FE) models allow rapid and systematic pre- extreme cases, where metallic implants reach Within the Biomedical Services Program, Ser-
evaluation of several test parameters (eg, screw their limits, the concept of additional implant mon performed several biomechanical studies
design, implant arrangement and geometry). augmentation aims at improving the implant on the influence of cement augmentation upon
Computer simulations and physical experi- purchase by increasing the area of anchorage. implant purchase in the osteoporotic femoral
mental models can be cross-validated and can A small amount of bone cement around the head. As a surgeon, Sermon participated in the
work hand-in-hand as reliable performance implant fills the intertrabecular space allow- first clinical trials on this novel technique. In
indicators. Such a model is currently created ing a smooth load transition between implant the course of her PhD thesis, further clinical
and refined in the ARI comprising several key- and bone. work is planned for implementing a referral
features. pathway for hip-fracture patients, improving
Up to now, several investigations were per- patient outcome and potentially reducing the
One of the most important parameters in os- formed to draw an overall picture of the con- fracture recurrence risk. Experimental and
teoporotic fracture treatment is the bone (min- cept and to objectively assess its strengths and clinical approaches become force multipliers
eral) density. As the distribution of bone con- weaknesses. A clear biomechanical potential Fig 5 Statistical bone model of the distal tibia to improve geriatric patient care.


From the AO Service Units
AO Education (AOE) AO Technical Commission (AOTK)
AO Clinical Investigation and AO Research Institute Davos (ARI)
Documentation (AOCID) Rapid bandwidth growth, development of new social media
channels and the evolution of mobile delivery has meant that
The TK System
The TK System—an interface between AO surgeons, engineers,
Clinical Research Fellowships Basic Scientific Highlights: Musculoskeletal Regeneration educational video and audio-visual content is now undergoing scientists and industrial partners—manages the development and
Two new fellows began their clinical research training at AOCID in A combination of shear and dynamic compression leads to mechanically a revival in public and professional spheres. In 2011, AO Educa- approval of products and techniques aimed at improving the
the Fall. Kerstin Schneider (Bürgerspital Solothurn, Switzerland) induced chondrogenesis of human mesenchymal stem cells was published tion put considerable resources behind meeting the fast-growing treatment of injuries, deformities and diseases of the musculo-
will conduct research on minimally invasive surgery for hip frac- in the eCM Journal (Impact Factor 9.65). The study demonstrated demand for this type of content from surgeons throughout the skeletal system. This work is conducted in accordance with the
tures. Christian Hainz’s fellowship is a product of the deepening that mechanically induced chondrogenesis of human bone marrow AO Specialties. AO Education's video team grew in response to philosophy of the AO Foundation and to the benefit of patients.
cooperation between the AO and Audi. The primary objective of derived stem cells requires a shear component. This could play a this and was assigned more responsibility in the delivery of new The development process takes place through the TK System's
this Bavarian surgeon’s fellowship is to review and analyze data major role in rehabilitation protocols after intra-articular trauma. formats and educational methods. Expert Groups, where surgeons worldwide contribute their clini-
collected by the Audi Accident Research Unit (AARU) and a larger The data obtained will also be able to improve the outcome of stem cal experience in the relevant field.
German database across certain medical parameters to see if pre- cell based repair for articular damage. Interactive Webcasts and Webinars
dictive factors regarding injury severity etc. can be established. The changing technology landscape enables new interactive TK Innovations: Meet the Experts
In collaboration with the National University of Ireland, Galway, distance learning on a large global scale. Hundreds of surgeons The AO Foundation Davos Courses 2011, with its large number
Study coordinator training in Switzerland an injectable hydrogel, acting as a reservoir for cell delivery and participated in four live webcasts (moderated live surgery on of participants, presents the TK System an ideal opportunity to
The fourth AOCID study coordinators’ meeting took place in Oc- mimicking the native environment, was developed for interver- anatomical specimen) and five webinars (interactive online lec- introduce the newly-devised "TK Innovations: Meet the Experts"
tober with 15 international participants learning clinical research tebral disc repair and regeneration. Culture in the injectable gel tures) run by AOTrauma in 2011. This new format allows direct workshops. These sessions offer live demonstrations of current
principles and documentation. Feedback was extremely positive. did not influence the disc cell phenotype. The optimally stabilised interaction with presenters while creating valuable content for clinical needs that have been translated into tangible solutions.
and functionalised type II collagen/HA hydrogel system developed AO's fast growing video repository. Daily lunchtime sessions are hosted over the two weeks of the
AO Certified Study Center (AOCSC) program in this study shows promise as an injectable reservoir system courses by expert surgeons directly involved in product develop-
This demanding program completes its successful pilot phase at the for intervertebral disc regeneration. This study was published in Go beyond practical exercise videos ment. These workshops feature the latest TK-approved technology
end of 2011. There are 21 recognized candidate clinics, two-thirds of Biomaterials (Impact Factor 7.88). See Fig 1 below. In 2011 the existing AO online video library drew an average in the fields of trauma, CMF and spine. Some workshops showcase
which have been visited and evaluated. Seven clinics have already of 40,000 viewer requests per month. This significant growth a cross-specialty approach: the piezoelectric used in craniofacial
implemented the necessary processes and are AOCSC certified. Good news in interest from surgeon members prompted the AO Education osteotomies could also be used in spine, plastic, hand or foot sur-
Prof Geoff Richards, (ARI Director) co-organized with Ted Miclau Video and Visual Media Department, in conjunction with the AO gery; the sternal closure system is also relevant to cardiothoracic,
Webinar (San Francisco, USA) a Basic Science Focus Forum at this year’s Specialties' Commissions, in education and community develop- trauma or plastic surgeons.
AOCID Director Beate Hanson was invited by AOTrauma to put Orthopaedic Trauma Association (OTA) conference at which he ment to think about a range of new formats. This involves moving
together an entertaining Webinar on an aspect of clinical research. and Dr Fintan Moriarty (ARI) presented on implant surfaces and beyond the traditional filming of techniques for the support of Free participation for all Davos Course delegates means that
The Clinical Research Casino—Statistical Concepts used in Gam- anti-infective surfaces respectively. In the Orthopaedic Research hands-on simulations at face-to-face courses. workshop attendees gain firsthand information from the experts
bling and Clinical Research was held in September 2011. Over Society (ORS, American), Prof Richards will chair a workshop at about new technology, products and, most importantly, their
100 international participants joined in. A recording will be made ORS 2012 entitled Bone Infection: An unresolved problem and With the support of AO Education's video team, AOSpine has clinical basis and applications. The experts in turn gain prelimi-
available online in due course. Prof Mauro Alini will give a keynote talk on Injectable Hydrogels explored ways to expand the "traditional" practical exercise nary surgeon feedback from international surgeons to take into
TK system

AO Davos Courses 2011
for the Application of Cell-Based degenerative Approaches in
Intervertebral Disc Degeneration.
video. Using the same basic material (showing the procedure
on an artificial Synbone model) the videos were expanded and
Innovations
consideration in future development.
2 2011
|
AOCID continues its series of fun studies at the AO Davos Courses enriched with both extra clinical footage and an expert surgeon
with a mechanized test set-up for course participants’ coordination providing his personal "pitfalls and pearls" experience. This new
using an automobile simulator. The Roadmap of Research breakfast format functions as both a stand-alone learning experience and
course is offered on 6/7 December and again on 13/14 December to a teaching tool to be used in education in hospitals or other self-
whet surgeons’ appetites for clinical research. AOCID has developed directed training.
a Good Clinical Practice (GCP) course to meet the needs of site
investigators and this 8-hour training will be held on 9 December AOCMF and AOVET started to use short video clips featuring re-
2011 in Davos. This accredited course counts for 6 CME credits. search results and evidence in a new time-saving way. Short video
clips were produced to make the AO Playground skills-simulation
Statistics: parcours a self-explanatory educational tool. Specialties put more
AOCID has 38 running studies. So far in 2011, AOCID released 18 emphasis on the use of video in their overall communication: an-
peer-reviewed publications and was cited 300+ times by research- nouncing educational activities, reporting from events and congress-
ers around the world. es, promoting membership and expanding educational offerings.
Fig 1 Cell-seeded scaffolds after 1, 7, & 14 days of culture. Hydrogels The TK System Innovations magazine features all new products
with different molar ratios of type II collagen:hyaluronan shown. developed through the TK System


From the Specialties

AOTrauma AOSpine
The world of AOTrauma techniques and best practices at the Masters’ level including new AOSpine is pleased to report significant progress with the AOSpine The Curriculum is delivered using a combination of face-to-face
2011 was a year of consolidation; evolution, not revolution. A new surgical approaches, current treatment methods, and the manage- Curriculum and the AOSpine Knowledge Forums. educational events, distance learning, and self-directed resources,
AOTrauma International Chairperson, Nikolaus Renner, took over ment of complications. The daily modules are dynamic, fast-paced, supported by many educational tools that enable measurement
the reins from Michael Wagner. Two of the Global Commissions with heavy interaction focusing on real cases and encouraging open The AOSpine Curriculum of knowledge and skills and the implementation of learning into
(Education and Research) also underwent changes in their leader- debate of difficult clinical problems and interventions. With the recent completion of ten AOSpine Curriculum pilot practice.
ship. The five regions (Asia Pacific, Europe, Latin America, Middle courses, the information gathered has been analyzed by the Cur-
East and North America) continued with focused activities meeting AOTrauma Education, Research and Community Development: riculum advisory group under the leadership of Germán Ochoa AOSpine Knowledge Forums
the needs of their regions. 2012 will see exciting educational activi- vibrantly active (AOSpine Education Commission Chairperson) and Bryan Ash- AOSpine Knowledge Forums are working groups led by 5-10
ties for AOTrauma for example the scientific meeting “Challenges Much effort has been focused this year on program development man (AOSpine Asia Pacific Chairperson). This information now worldwide key opinion leaders in a specific spine pathology. Their
in Fracture Care Across Disciplines” on February 23-25, 2012 in and faculty development in education in order to continue to meet guides the broader implementation of the AOSpine Curriculum aim is to generate knowledge by performing clinical studies and
Florida, US. The meeting theme, “The Magic of Synergy—Work- the ever-changing needs of the surgical community. The lifelong worldwide. publishing evidence based recommendations as well as to inte-
ing Together For A Stronger Tomorrow,” is uniquely designed to learning path for Continuing Professional Development (CPD) is grate their latest advances and outcomes into AOSpine’s education
bring together and share the knowledge of orthopedic trauma, an example of the commitment the AOTrauma Education Com- The Davos Courses 2011 sees the first large-scale implementation program to assist surgeons in clinical decision-making.
craniomaxillofacial, veterinary and spine surgeons addressing the mission makes to this significant task. of the new AOSpine Curriculum at an international educational
challenges of musculoskeletal fracture management. event, with all activities—the Advanced Courses and the Masters At this time the Knowledge Forum Tumor is performing two
AOTrauma Research will see its second clinical priority program Symposium and Knowledge Forum—structured around the Cur- clinical studies:
An AOTrauma Scientific Congress will be held in Hong Kong on (CPP) commence in 2012. Clinical problems plagued by infec- riculum. The Curriculum provides a framework of competencies • Predictors of Mortality and Morbidity in the Surgical
May 11-12, 2012. This will be the first AOTrauma scientific congress tions, acute and chronic, will be tackled as new developments and and key learning outcomes for several spinal pathologies. These Management of Primary Tumors of the Spine: A multi-
in Asia Pacific, combining both scientific and technical aspects of research contribute to improving care of patients. guide the delivery of education that meets the needs of spine center Retrospective Cohort Study with a Cross-Sectional
orthopaedic traumatology. Clinicians will have the opportunity care professionals at different levels of their career (Principles, Survival Check.
to share knowledge and ideas with their peers. Community development now has a simplified and transparent Advanced, and Masters). • Interdisciplinary validity and reliability of the Spinal In-
membership program with clear entry criteria and a single price stability Neoplasia Score (SINS) in radiologists and oncologists.
New concepts at the AO Foundation Courses Davos 2011 for becoming a member. AOTrauma shapes all its activities around Our educational content is also based on the AOSpine Principles
An exciting new educational format—AOTrauma Masters Course- three core value statements: excellence in trauma care, empowering of stability, biology, alignment, and function. Spine surgeons The first project of the Knowledge Forum Deformity is a collabo-
Current Concepts—makes its debut at the Davos Courses this year. the next generation, and transparency and mutual trust within who participate in our educational learning activities will be ration with the Scoliosis Research Society (SRS) joining forces
Participants build their own course program by selecting four one- our network. Involving senior trauma surgeons from the network better able to: to conduct a multi-center study to evaluate risks and complica-
day modules from a schedule of eight different topics. Two of these through leadership positions, while nurturing new interests and • Perform effectively across the various areas of pathology tions associated with Adult Spinal Deformity surgery. AOSpine’s
four modules can include anatomical specimen dissections. This opportunities for younger future leaders is an important building in their practice setting Knowledge Forum Spinal Cord Injury & Trauma is currently
new course format addresses the latest state-of-the-art clinical block for community development. • Meet the overall standards of the profession. evaluating several opportunities for its first research initiative.

Nikolaus Renner during the DKOU congress in Berlin 2011 Anatomical specimen dissections are included in 4 of the 8 modules AOSpine Curriculum planning meeting SRS and AOSpine kick-off Scoli-RISK-1 Study


From the Specialties Berton Rahn Research Prize:
continued… award winner summary
Interleukin-12 local delivery for infection prevention after a traumatic open fracture

AOCMF AOVET Li Bingyun, Assistant Professor, Department of Orthopedics, School of Medicine, West Virginia icking the “golden hour” of trauma patients, and then fixed with
University, US a K-wire [7]. This model was used to examine the stability of
At this year’s AO Foundation Davos Courses 2011 an AOCMF The AOVET community welcomes more than 50 veterinarians
IL-12 nanocoatings and the effect of IL-12 nanocoatings on pre-
Neurocourse is on offer for the second year running to neurosur- to the AO Foundation Davos Courses 2011 with two high-quality
Two major issues related to open fractures have driven us to venting infection. We found that the IL-12 nanocoatings on K-
geons who manage neurotrauma and reconstruction. The course educational events. The AOVET Equine Advanced Fracture Man-
conduct this project. (i) Large number of bone fractures and high wires were stable and could withstand the implantation process
goal is to teach the theoretical basis and practical principles of agement Course offers an introduction to the field of advanced
infection rates. Millions of patients are hospitalized annually for in our rat model. IL-12 nanocoatings substantially decreased S.
neurotrauma management and complications, and considerations equine fracture treatment delivered by a team of international
bone fractures, and such injuries are increasingly common be- aureus-induced infection: infection rates decreased from 100%
for state-of-the-art reconstructive surgery. Covering the strategies experts. In addition to the core course topics, delegates also learn
cause of increased survivability of high energy trauma in civilian (control) to 50% (IL-12 treated) at post-operative day 6 and from
and considerations in managing neurotrauma patients, the course the application of locking head plates to different fractures, prac-
settings as well as continuing military conflicts. It is well docu- 90% to 20% at day 21 [7]. Moreover, the effect of IL-12 on infec-
has been developed for neurological surgeons who have a strong tice arthroscopic control of fracture reduction, participate in the
mented that patients with traumatic open fractures have a high tion prevention was found to be dose dependent [7,8]. Our data
interest in trauma and is taught by an international faculty and ‘Playground’ (experiencing how basic fracture treatment principles
risk of infection: the incidence of infection in Gustilo grade III also showed that local IL-12 treatment improved fracture healing
guest lecturers focusing on their areas of expertise. work) and discuss their cases with experts. Two lectures from the
open fractures may exceed 30% [1], and 2-15% of the extremity (data not published) and better callus formation and bone quality
equine event will be streamed live over the internet during the
injuries inflicted in war developed osteomyelitis or infection [2]. were observed.
The main topics dealt with over the 2-day course range from: neu- Davos Courses.
(ii) Ongoing and widespread emergence of virulent and multi-
rotrauma and interdisciplinary management of the neurotrauma
drug resistant bacterial strains. Strains of Staphylococcus aureus Therefore, we proved our hypothesis that IL-12 nanocoating could
patient to special topics such as reconstruction and dural repair. A The AOVET Principles of Small Animal Fracture Management
(S. aureus) that resist or have reduced susceptibility to methicil- reduce open fracture-associated infection [7-9]. Our study has laid
variety of pedagogical approaches are used in the course delivery— Course brings together recognized leaders in small animal or-
lin, vancomycin, and other antibiotics emerged decades ago, and the conceptual foundation for the development of IL-12 thera-
comprehensive lectures concentrate on the understanding of core thopedics from Europe and North America. Through pre-course
“Superbugs” like methicillin-resistant S. aureus (MRSA) now peutic approaches that may decrease the use of antibiotics and
material; practical sessions teach the application of AO principles eLearning, seminars and hands-on laboratory sessions, course
kill more Americans than AIDS [3]. The causes of multi-drug thus to a reduced emergence of antibiotic resistant “superbugs.”
to the management of common injuries and case-based discus- participants are presented with the most up-to-date information
resistance are mainly attributed to overuse of antibiotics and
sions link the lecture material and practical skills taught with the in the art and science of fracture repair in veterinary surgery. Par- References:
bacterial mutation. In time, without the development of new
problems encountered by the course participants in real practice. ticipant interaction with faculty is an important part of this course.
and effective antibacterial treatments, it is possible that multi- 1. Zalavras CG, Patzakis MJ. Open fractures: evaluation and management. J Amer Acad
drug resistant pathogens will be untreatable with conventional Orthop Surg. 11(3);212-9, 2003.
AOCMF webcasts build on success of previous two years As usual all AOVET course participants will have an opportunity 2. Murray CK, Hsu JR, Solomkin JS, et al. Prevention and management of infections
antibiotic therapies. associated with combat-related extremity injuries. J Trauma. 64(3 Suppl); S239-51,
This year’s Craniomaxillofacial Fracture Management course fea- to get to know AOVET faculty, the researchers at the AO Research
2008.
tures two 2-hour webcasts. Both sessions are made up of a number Institute Davos and the members of the AO Foundation at the 3. Klevens RM, Morrison MA, Nadle J, et al. Invasive methicillin-resistant Staphylococcus
Interleukin-12p70 (commonly designated IL-12) is a natural cy-
of different keynote lectures each lasting 30 minutes including annual AOVET Fondue Party. In addition the AOVET member- aureus infections in the United States. JAMA. 298;1763-71, 2007.
tokine that plays a central role in cell-mediated immune response 4. Trinchieri G. Interleukin-12: a proinflammatory cytokine with immunoregulatory
5-10 minutes where webcast participants post questions online ship booth is open daily to all participants at the AO World in the
and bridges innate and adaptive immunities [4,5]. Our objec- functions that bridge innate resistance and antigen-specific adaptive immunity.
to the keynote speakers. Congress Center. Annu Rev Immunol. 13;251-76, 1995.
tive was to explore local delivery of IL-12 at the implant/tissue 5. Hamza T, Barnett JB, Li B. Interleukin 12 a key immunoregulatory cytokine in
interface for infection prevention in rats following traumatic, infection applications. Int J Mol Sci 11;789-806, 2010.
open femur fracture and internal fixation. We hypothesized that 6. O’Sullivan ST, Lederer JA, Horgan AF, et al. Major injury leads to predominance of
the T helper-2 lymphocyte phenotype and diminished interleukin-12 production
IL-12 embedded as multilayer nanocoatings at the implant/tissue associated with decreased resistance to infection. Ann Surg. 222(4);482-90, 1995.
Practical demonstrations during the AOCMF Neurotrauma Course 2010 Practical exercises at an Equine Advanced Fracture Management course
interface will restore resistance, decreased due to trauma [6], to 7. Li B, Jiang B, Boyce B, et al. Multilayer polypeptide nanoscale coatings incorporating
IL-12 for the prevention of biomedical device-associated infections. Biomaterials
pathogenic infection and reduce the severity of infection after a
30;2552-8, 2009.
traumatic open fracture. 8. Li B, Jiang B, Dietz MJ, et al. Evaluation of local MCP-1 and IL-12 nanocoatings for
infection prevention in open fractures. J Orthop Res 28;48-54, 2010.
9. Li B, McKeague AL. IL-12 nanocoatings and microcapsules prevent open fracture
To prove our hypothesis, we first developed polypeptide multilayer infections. Clin Orthop Relat Res DOI: 10.1007/s11999-010-1690-0, 2011.
nanocoatings on an implant model (i.e. Kirschner-wire or K-wire)
using layer-by-layer (LBL) nano-assembly and we incorporated
drugs like IL-12 into the nanocoatings [7,8]. We were able to
finely tune the incorporated amount (0-50 ng/cm2) and the re-
lease duration (0-9 days) of IL-12 by controlling the LBL process.

Next, we created an open femur fracture infection model using
Sprague-Dawley rats. The rats’ femurs were fractured, infected
with a clinical isolate of S. aureus, left open for one hour, mim-

AO Dialogue 2|11

My view

From the President
James F Kellam
Editor-in-Chief
james.kellam@aofoundation.org

Norbert Haas talks Research: Where we are today?
The question of whether the AO Foundation should

to AO Dialogue be doing research has been asked for years. The
answers have been many, and have driven multiple
reorganizations in the philosophy, methods and types
This past year has been an exciting one for the AO Foundation, especially in the of research. Research is important because it is the
area of education where we are at the forefront of almost revolutionary changes. premise of the founders that understanding what hap-
The progress is so rapid that I strongly recommend you visit the AO Foundation pens further improves how one delivers clinical care.
and AO Specialty websites as often as you can in order to keep up-to-date with all When the founders began their goal was to understand
the newly available tools for further education and faculty support. how bone healed and responded to internal fixation.
However, in the past 50 years, bone research has
This years’ AO Foundation Courses in Davos delivers new several education initia- evolved. This has required the Foundation to respond
tives such as the “Current Concepts Course” in which participants can select four or be left behind. This response has been the reorga-
from eight available modules, and the “Technological Innovation Programs” which nization of AO Research to provide clinical direction
is a series of daily events on new treatment options in CMF, spine, and trauma into what research is performed thus returning to the
surgery. Three AOSpine Knowledge Forums on “Spinal Cord Injury & Trauma”, AO roots but becoming far more diverse in projects.
“Tumor”, and “Deformities”, and the AOCID eLearning module on Clinical Research The AO Specialties are responsible for the clinical
are also being launched during the courses. priority programs which address their primary clinical
problems and are translational in nature, hoping for an
In research, AOTrauma has run an open call for proposals for the “Clinical Priority answer in three to five years. The Exploratory Research
Program on Bone Infection”, while AOCMF has open calls for “Bisphosphonate- Board and the Exploratory Research Programs provide
related Osteonecrosis of the Jaws” and “Imaging & Planning”. AOCID’s research the Foundation with the ability to do basic innovative
was recognized by a record number of citations. It has also started to build up a research in the focus fields of bone healing and carti-
network of “AO Certified Study Centers” to improve and standardize the quality lage regeneration. The early success of this concept
of clinical research, and to foster an exchange between these centers. was demonstrated in September when the Exploratory
Research Board brought together its exploratory pro-
The AO Trustees’ meeting has supported the social bonding of our ambassadors grams along with a symposium on the focused fields
and fostered the unity of the AO Foundation. The return of focus to central core of bone healing and cartilage regeneration. These
institutes for basic and clinical research, as well as education was important in meetings demonstrated that the basic innovational
order to balance our organizational evolution in respect to the clinical specialties research for the future is on solid footing. The inter-
and regionalization. This also ensures that Davos remains the focal point of the action between the basic science and translational
“AO Spirit”. aspects are now connected and focused through the
Foundation. This new integration will definitely place
I would like to thank our volunteer surgeons and AO employees for all their hard the AO Foundation back in a leadership position and
work. I am very positive that the AO Foundation can face its upcoming challenges provide a platform for discussion of issues relating
in these interesting times. to research and clinical outcomes.

AO Dialogue 2 | 2011

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