AO Foundation Annual Report 2009 by AO Foundation

Annual Report 2009 Transforming Surgeryâ&#x2C6;&#x2019;Changing Lives

Table of contents Our vision is excellence in the surgical management of trauma and disorders of the musculoskeletal system. Our mission is to foster and expand our network of healthcare professionals in education, research, development, and clinical investigation to achieve more effective patient care worldwide.

Feature stories—Specialties and Service Units join forces Making a real difference: ARI supports AOTrauma’s focus on treatment of fragility fractures On the move for AOSpine: how an ex-AOCID fellow became an AO representative in India Collaboration fosters innovation: TK System is a vital link between CMF surgeons and industry The making of an AOVET video: patients benefit from AO expertise

2 6 10 14

Strategy Interview with the President and the Chairman Specialties and Service Units take center stage in 2009

18 22

AO Specialties AOTrauma: empowering the next generation AOSEC—making the AO network better aware of our work AOSpine—becoming a leading global academic community AOCMF—further evolution of a successful global community AOVET—40th anniversary of the youngest Specialty

24 30 32 36 38

AO Service Units Research and Development—improving clinical practices Exploratory Research—team up for impact Clinical Investigation—a leader in evidence-based clinical trials TK System—a year of evolution Education—building the structure to respond to AO Specialties’ needs

47 50 51 52 53

Governance Approved bylaws deliver increase in organization transparency Finance—a continuation of the consolidation phase Governing bodies of tbe AO Foundation Addresses

54 56 58 60

Annual Report 2009

AOTrauma

Making a real difference

ARI supports AOTrauma fragility fracture treatment At the AO Research Institute (ARI) in Davos, Switzerland, a young scientist specializing in biomechanics clicked at a computer keyboard, searching the ARI database not for a perfect section of cadaver bone, but for one with a bone mineral density low enough to simulate osteoporosis. About 130 kilometers away, the Director of the Department of Trauma Surgery at the Medical University Innsbruck, Austria, Prof Michael Blauth MD, put the finishing touches on preparations for the Annual General Meeting of the AO Clinical Priority Program Fracture Fixation in Osteoporotic Bone (CPP FFOB).

research is among the many activities which puts the AO Foundation on the forefront of osteoporotic fracture patient treatment. AOTrauma has gained worldwide recognition and is visible in numerous collaborations with industrial, institutional and scientific partners. Blauth offered as an example a challenge that AOTrauma research is successfully addressing: loss of reduction when a rigid implant cuts into soft osteoporotic bone, leading to mechanical failure and often unleashing a cascade of related health problems for the patient.

“AOTrauma research within the CPP FFOB translates directly into improved patient care. This was a prerequisite to get the program started.” Prof Michael Blauth Most people will never see the faces behind the work being done by AOTrauma’s global network of clinicians and researchers, but for the more than 9 million people who sustain osteoporotic fractures each year worldwide, their efforts mean improved fracture treatment, fewer revisional surgeries and better quality of life. The paramount and increasing significance of fragility fractures was the main reason for AOTrauma to focus research and teaching in its first Clinical Priority Program. Blauth, Program Director since the CPP FFOB’s 2005 inception, said that ARI’s

Preoperative planning in the ARI facilities in Davos

One solution investigated by ARI, is a bone augmentation technique using surgical cement to improve the load transfer from osteoporotic bone to the rigid implant. “There are many people and details behind significant improvements in patient care: investigating bone quality and ways of measuring it preoperatively, reducing the chance of lung embolisms by washing out the fat around a fracture, and preserving cartilage nutrition by avoiding the injection of cement too close to the articular surface,” he explained. > page 4

ARI researchers and Innsbruck surgeons meet in Basel

Annual Report 2009

AOTrauma

Making a real difference ARI supports mission of AO Trauma “AOTrauma is contributing to better fixation and overall treatment of fragility fracture patients.” Prof Michael Blauth “Scientific inquiry can take a long time, but it’s very exciting to be part of a process that will benefit patients,” he added. In the near future, based on ambitious and cutting edge finite element models generated in the ETH Zürich, it will be also possible to invent and test totally new fixation that matches much better with reduced bone quality, first in the computer, then after welldirected prototyping, in cadaveric bones and finally in patients. Fragility fracture patients often have other health challenges associated with advanced age; heart and lung problems, diabetes, dementia, anticoagulation, to name a few, need immediate “single shot surgery” with the least possible amount of revisions. “And they need more than just fracture repair,” Blauth said. “They need a comprehensive approach with ortho-geriatric co-management to improve the quality of life after an osteoporotic fracture. Our studies will con-

tribute directly to these ambitious goals and also have a socio economic dimension.” “Not only has our research contributed to real strides in improving patient care, but our efforts have heightened awareness of osteoporosis,” he added. “Osteoporosis is treated in fewer than 10 percent of patients, but we know from our research that after the first fracture, future fractures can be reduced by 50 percent with good treatment. Nutrition is another example: 90 percent of osteoporotic fracture patients we see are malnourished. So, in addition to research, education of orthopedic and trauma surgeons and geriatricians is essential.” Ladina Fliri, Biomechanical Research Project Leader at ARI, shares Blauth’s boundless enthusiasm for the CPP FFOB and the research supporting it. One of more than 70 ARI researchers, she cannot imagine a more stimulating challenge than being part of research that leads to improved patient care.

by Melody M Corrieri

“It’s research that makes a real difference.” Ladina Fliri, Biomechanical Research Project Leader, ARI

Augmented blade in an osteoporotic foam model

Image of a femoral head with augmented blade fixation

Prof Blauth using a bone model to explain surgery outcomes to a patient

Annual Report 2009

AOSpine

On the move for AOSpine

How an ex-AO Fellow became an AO representative Dr Vikas Kulshrestha is a classified specialist in orthopedics at the Air Force Command Hospital in Bangalore, India. In 2008, he spent three months in Switzerland on the AO Clinical Investigation and Documentation (AOCID) research fellowship program. “My stay at AOCID was a wonderful learning experience during which I analyzed results of my studies, submitted two articles for publication in an international journal, and designed a new study proposal for my hospital in India,” he enthuses. “My time at AOCID has been of immense benefit to me in my clinical research work. In short, I learnt every necessary step from the initial idea to planning, implementation, conduct, monitoring, evaluation and publication of a trial,” said Vikas, as he is widely known. Dr Peter Langer, AOSpine Research Manager, got to know Vikas during his stay in Switzerland and realized his research capabilities. “We were looking for a reliable study monitor for a hospital in India. It is very important

to have qualified local people on-site. They are best positioned to deal with the various language and cultural issues which may arise. It is also critical that these local monitors can be relied upon to stay in close contact with the study coordinators.” The solution was obvious. Negotiations were quickly concluded and Vikas found himself tasked with monitoring a New Delhi hospital which is participating in the AOSpine CSM-International (Cervical Spondylotic Myelopathy) trial. Prof Michael Fehlings, Toronto, the study’s Principal Investigator, explains, “The AOSpine CSM-International study is the largest multicenter study which has ever been conducted to assess the outcomes of treatment of CSM (the commonest cause of spinal cord impairment worldwide). This study is running on four continents which is unprecedented. This places a great level of importance on the need for close monitoring of the sites to ensure a high degree of data integrity.” > page 8

“As a trauma surgeon, being associated with the AO has been a wonderful experience.” Dr Vikas Kulshrestha

Annual Report 2009

AOSpine

On the move for AOSpine Site monitoring is good clinical practice “The CSM-I study is an exciting project and to be able to contribute to it is extremely satisfying.” Dr Vikas Kulshrestha The CSM-I study is currently running in 12 countries at 16 sites in nine local languages. Multicenter studies guarantee the generalizability of the results. By the end of 2009, more than 300 (out of a target of 500) patients world-wide had been recruited. Vikas works in Bangalore and travels to New Delhi on monitoring visits three or four times a year—a roundtrip of over 2,000 miles. While at the All India Institute of Medical Sciences (AIIMS) he meets with Prof Shashank Sharad Kale, the Primary Investigator, his co-workers and research assistants. Prof Kale notes, “On the one hand it is exciting to be part of something unprecedented— a study as big as the CSM-I. On the other hand it underlines the value of good data collection and reporting which are vital responsibilities in such major projects. In this regard Vikas Kulshrestha plays a key role at all levels as site monitor. His inputs are pivotal to this institute’s successful participation in the trial.”

checks the data entry into a Web-based case report form system, and images are transmitted to AOCID’s image handling section in Switzerland. Vikas monitors the conduct of the study and ensures continued enrolment and follow-up. He is in close contact with research at the institute to initiate and maintain infrastructure needed to conduct the study. Peter Langer is responsible for the worldwide coordination and therefore is reliant upon local know-how. “The CSM-I study is a really challenging project for myself—more so for our investigators at the clinics. Although the study involves a huge amount of additional work for the spine surgeons and their teams, I am really impressed by their dedication and commitment to this unique research project in particular and to AOSpine in general.” The last word belongs to Vikas. “I am proud to be associated with the AO Foundation. My AOCID Fellowship and current work with AOSpine gave me the opportunity to become an integral part of the AO community.”

Vikas verifies all the patient documentation and interacts closely with the AIIMS. He

Vikas pictured with the staff of AIIMS in New Delhi

Vikas pictured during his AOCID Fellowship in Switzerland

by Diarmuid DeFaoite

Vikas and Prof Kale meeting some non-study patients at AIIMS

Prof Kale and Vikas checking that all CSM-I documentation is present and correct

Annual Report 2009

AOCMF

Collaboration fosters innovation

TK System—a vital link between CMF surgeons and industry At the AO Research Institute (ARI) in Davos, Germany’s majestic Black Forest is renowned for its scenery—sweeping highland views, woods dense with fir and pine trees, and postcard-perfect villages—inviting thousands of people each year to explore its wonders from an adventurer’s vantage point. Against this picturesque backdrop lies a story of innovation in patient care that could only arise within the framework of the AO Foundation’s global network of expert craniomaxillofacial (CMF) surgeons and the TK System that supports the AO’s specialties. “Our hospital is in Freiburg, at the western edge of the Black Forest, so we deal with a lot of orbital trauma resulting from bicycling and mountain biking accidents. We were not happy with the work we could do only with bone graft because the results often did not resemble the normal anatomy of the orbit,” said Prof Rainer Schmelzeisen, MD, DDS, an AO member since 1986 and Medical Director, Department of Oral and Maxillofacial Surgery, University Hospital Freiburg. What Schmelzeisen conceived was a preformed orbital plate eliminating the need to cut and bend plates in the operating room and providing for a true-to-original reconstruction. The direct patient benefits are obvious.

With fluoroscopy and 3D imaging—technological advances championed by AO’s Prof Nils-Claudius Gellrich, MD, DMD, Chairman of the Department of Oral and Craniomaxillofacial Surgery at the Medical School of Hannover, and Prof Alexander Schramm, MD, DDS, Chairman of the Oral and Maxillofacial Surgery at the Military Hospital Ulm— surgeons can see in advance exactly how the preformed implant will fit and the patient leaves the operating room more quickly, knowing that the reconstruction is perfect. “Thanks to my colleague Marc Metzger’s idea of producing preformed orbital plates in average sizes, patients get a perfect fit, and 3D imaging means we don’t have to wait two days to get a CT scan and then perhaps have to do surgical revision. Less time on the operating table means a shorter anesthesia time, plus there is reduced swelling . These are huge patient benefits,” he said. Helping to enable such impressive patient benefits is the AO’s TK System, responsible for the development and testing of new techniques, implants and instruments. More than 140 AO surgeons comprise the Specialty Technical Commissions and Expert Groups; they collaborate with the AO Foundation’s industrial partners to solve clinical problems. > page 12

“Patients are at the heart of everything we do, whether it’s a teaching activity or an innovation in our techniques and tools.” Prof Rainer Schmelzeisen

Annual Report 2009

AOCMF

Collaboration fosters innovation Improving CMF patient care “AO’s TK System is unique because it is a direct link between our non-profit organization and industry. Dedicated surgeons bring in ideas, filter them through the TK System, think in the Expert Groups about the pros and cons, and then can more easily assure that a product will be appropriate for a patient,” said Gellrich, who uses the Matrix preformed orbital plate in concert with fluoroscopy and 3D navigation in his medical and teaching activities. The data collection for the Matrix preformed orbital plate is another example of the TK System’s rigorous demands. In developing this implant, more than 3,000 CT scans were reviewed to determine the anatomical averages of the orbital floor. “Taking an idea through our TK System is an intense process, and not every idea makes it, but for the very valuable ideas that do make it, there is superior quality assurance,” said Gellrich, principal clinical investigator for a 150-patient study to measure the accuracy of

the true-to-original reconstruction of the medial orbital wall and/or orbital floor. A partnership between AO CMF and AO Clinical Investigation and Documentation, the study is being conducted over the next one to two years at 12 research centers around the world. It is part of the large scale clinical priority program “Imaging and Planning of Surgery (IPS)”, driven and supervised by a dedicated program committee under the aegis of AOCMF’s International Specialty Board’s Research and Development Commission. For Schmelzeisen, medical godfather of the Matrix Preformed Orbital Plate, all of those activities benefit one key stakeholder: the patient. “Patients are at the heart of everything we do, whether it’s a teaching activity or an innovation in our techniques and tools. I am grateful to be part of such a strong network of people working together to improve the care we give our patients,” he said.

by Melody M Corrieri

“Taking an idea through our TK System is an intense process, and not every idea makes it.” Prof Nils-Claudius Gellrich

Prof Michael Ehrenfeld teaching with a video

Prof Gellrich teaches during Davos Courses

A Matrix preformed orbital plate

Annual Report 2009

AOVET

The making of an AOVET video Patients benefit from AO expertise On a chilly, gray morning in winter, the threat of snow hung in the air, but in a small conference room at the AO Foundation’s offices, two veterinarian surgeons and a four-man video production team were oblivious to the world outside as they worked together, intent on flawlessly executing their roles in the production of four AOVET educational videos.

Over a two-day period they demonstrated for the cameras the use of locking compression plates (LCP) for fixation of fractures caused by arthritic conditions of the joints, to restore comfort and function in cases of complex fracture of the middle phalanx of the equine forelimb, and for osteosynthesis of complicated lower jaw fractures.

“Our videos and practical exercises offer one very important advantage: Prof Joerg Auer it doesn’t hurt the patient if a mistake is made.” The surgeons, Prof Joerg A Auer DVM from the University of Zurich’s Equine Department, and Prof Christoph Lischer DVM, Acting Director of the Free University of Berlin’s Equine, General Surgery and Radiology Clinic, would be the first to explain that though surgeons and AO Education’s Video Production team play important supporting roles in the making of an AOVET video, the stars are the equine patients that will benefit from the visual depiction of improved techniques and tools.

Video preproduction planning

Behind the cameras were AO Education Video Production Director/Senior Editor, Mike Laws and Junior Editor, Serguei Nikokochev with additional support from Computer Graphics Artist, Olivier Jallard and Production Coordinator, Eric Lorup. > page 16

Discussing implementation of 3D visualizations

Mike Laws editing video takes

Annual Report 2009

AOVET

The making of an AOVET video “Our hands-on approach to teaching, supported by activities developed by AO Education, is really special.” Prof Joerg Auer The videos resulting from their collaboration are part of the AO’s commitment to lifelong learning of medical professionals and among the many ways the AOVET is supported by a wide range of AO Educational activities, from videos and online reference and learning materials to medical illustrations, journals and books. Like all Specialties, AOVET sets its own strategies and goals, and AO Education supports the realization of the Specialty’s vision. As AO’s smallest Specialty, AOVET benefits from the service unit’s cost-sharing approach.

AO Foundation and Specialty websites and, in some cases, podcast. In 2009, AO videos were accessed more than 500,000 times.

Behind the making of an AOVET teaching video are a host of resources: the surgeons who comprise the specialty’s expert groups, surgical consultants who write each video script, a production coordinator who develops a storyboard with guidance from those consultants, videographers who record the production, editors who pare hours of video footage down to the essentials, and surgeons who review the edited footage—often over three or four iterations. Last year, 11 AOVET Small Animal and five Equine teaching videos were released to the AO Foundation server, joining nearly 400 educational videos now available for public viewing. All AO videos are available in English and many are available in as many as eight languages. Distribution is by DVD, the

“A lot of work goes into the development and production of our teaching videos, including long days requiring intense concentration to properly demonstrate the techniques and tools. Our patients, whether they are large or small animals, are the focus and teaching ways of providing better patient care is our priority,” Auer explained. “Our videos and practical exercises offer one very important advantage: surgeons and operating room personnel can apply techniques and tools in an environment where it doesn’t hurt the patient if a mistake is made. Our hands-on approach to teaching, supported by activities developed by AO Education, is really special.” by Melody M Corrieri

Educating veterinary surgeons all over the world

Videos produced by AO Education are the backbone of practical exercises conducted at AO Courses. Course participants watch a video and then—with assistance from table instructors—perform the practical exercises. The beauty of educational videos is that they are a direct link to improved patient care, AO veterinarians say.

Practicing surgical techniques in Hong Kong

Annual Report 2009

Strategy

“Reorganization gives the Regions a new home in the Specialty” A talk with Paul Manson, President of the AO Foundation, and Markus Rauh, Chairman of the AO Board of Directors (AOVA) and CEO Do we see a completely new AO Foundation after the establishment of AOTrauma? The AO Foundation has been around for 52 years so it has an enormous history, its processes are constantly evolving and AOTrauma is an evolution that will allow it to develop and better relate to the local communities. Rauh There have been changes coming from the outside world and our organization has grown tremendously over the last six years. The founders have more or less disappeared so the AO Foundation is going to be less of a founder-driven organization and more of a professionally-governed organization. Manson

What are the benefits to surgeons and patients after the reorganization of the AO Foundation with its clinical divisions? Manson Due to the increasing complexity of our disciplines we found it necessary to have Specialty organization with regional branches. We organized all the groups in the Foundation in a way that allowed them to be cooperative and to minimize duplication, so that we could provide them with resources that they wouldn’t be able to enjoy individually. Surgeons benefit from these centralized resources which we could never provide on that scale in each local environment. Rauh Reorganization gives the Regions a new home in the Specialty on the one side and in the regional organization on the other side.

What progress has been made with membership in AOCMF and AOTrauma? The idea behind the membership project is to define the way in which an AO member can join an international organization with distinct benefits, for which we charge a small fee. The benefits they receive, gaining access to journals, are individually far more expensive than the membership fee. Manson

Markus Rauh, Chairman of the AO Board of Directors

Rauh There are questions to be addressed ; we

need an IT system that supports this membership concept and we have made many mistakes in setting up this project. We have a new membership and course management project in the pipeline, which I hope will serve the membership structure by the end of next year.

There are fears that the Specialties could break away from the AO Foundation? Initially Specialties wanted as much independence as possible. With maturity they are discovering the benefits of what the Foundation can provide—camaraderie and association with other Specialties. The Foundation could simply be a bank where the Specialties go to withdraw their resources but we have much more faith that the Foundation will remain a guiding force for them. Rauh Specialties want independence, which is natural, it’s like puberty, when they grow up and see that they can’t finance everything they want to do and that there’s duplication and overlap, they will come back to the Foundation family and going forward we’ll have greater harmonization and more commonality. Manson

What has changed with regard to the competitive position of ARI and AOCID? Research and Development has, for many years, been an independent entity. We felt strongly that there was a need to relate the research we do to the clinical priorities of doctors, no matter what their Specialty. So the new ARI (AO Research Institute Davos) structure allows Specialties to express their priorities to the research unit so that we can do research that is clinically relevant. Most of the research we do is tied to clinical needs, however some of it is exploratory and for that there is a certain amount of input that the research persons themselves are able to determine. Manson

Annual Report 2009

Strategy

“Our principal business is education” In this healthcare economy one has to demonstrate that treatments are effective and economically justified and AOCID (AO Clinical Investigation and Documentation) is uniquely qualified to provide this information. The fact that a project is possible doesn’t mean that it should be pursued but it has to be judged against project methods and within the regional economy taking into account what the health care provider is willing to underwrite.

Do our Service Units answer their customers’ needs? Rauh One of the key Foundation services is the

TK System (AO Technical Commission). It is a very important pillar of our activities, involving about 130 highly specialized members of

expert groups who make sure that products which are released to the market are safe, cost-effective and free from potential litigation issues.

The AO Regions are becoming integrated into the Specialties’ matrix structure. How likely is this integration with the AO Sections in Europe? Manson Integration of the AO Sections in Eu-

rope into a European governance structure is happening and it will reach the stage where it is a workable participatory group that functions successfully together and I hope they will be happy to be part of that structure. Rauh In the countries where we have Sections, we also have Alumni, and in some countries there are good connections between the two,

in others this is not the case. The Alumni have been fully integrated into the membership scheme in AOTrauma and I think we have to respect that the Sections have a long standing history, with their own values and their own successes. Alongside that, they have to become part of the regional organization Europe that belongs to AOTrauma.

Which key challenges will you hand over to your successor Norbert Haas in Lisbon?

Manson The President is a medical doctor and

this is a huge organization with enormous needs that can only be met by someone with considerable business knowledge. Rauh Formerly there was a clear distance between the Board of Directors (AOVA) and executive management. It is one of my objectives to bring executive management closer to the Board so that there is a common way of thinking, a common culture and also a sharing of common priorities.

Manson If our principal business is education,

our principal challenge will be to keep up with all the advances in online education, providing it in ways and to groups who have not used e-learning up until now. The Internet is a very powerful tool for communicating with surgeons.

Which measures are we taking to manage our exposure to strategic risks? Manson We have reduced our executive man-

agement numbers and changed the way our investments are structured in order to create diversification and protect ourselves from isolated economic events. In all areas we have tried to be more economical and to educate our faculty that they should observe prudent economic policies. Rauh Like any professional organization we have gone through an elaborate process to define and rank our risks and the board has approved these risks.

Dr Rauh, you will act as Chairman and CEO until summer 2011. In business this double function is criticized due to issues with separation of powers. Rauh Up until now we have had three heavy-

weights at the top level of the organization, CEO, Chairman and President and this led to over-managing. The President has clearly defined responsibilities and the other roles are more operational.

How did the restructuring of the AO Foundation affect the workforce? Our workforce has been pretty stable over the last few years, we are now running at 230 full time staff and the only place where we made some change in skill profile was in Research and Development. It was never our intention to save costs by reducing numbers. The big cultural change that we’ve initiated is that everyone in this organization is now customer oriented. We know that the clinicians are our customers and we need to satisfy their needs. Rauh

Prof Manson, what do you think the organization will look like when you hand over to your successor, Norbert Haas? Manson One of my personal concerns is Foundation leadership. I believe this can only be developed by longitudinally relating to an organization with the proper role models to facilitate an appreciation for the culture and knowing the intricacies of our educational process. I initiated an inquiry into what young surgeons wanted from us so we can provide them with things they need and couldn’t ordinarily afford themselves (access to journals, wide ranging Internet opportunities for education, networking) in order to link them to the Foundation in a way that becomes the first step toward finding our future leaders.

Paul Manson, President of the AO Foundation

Annual Report 2009

Strategy

Specialties and Service Units take center stage in 2009 Course and membership management, education, and research—strategic priorities in 2009 for the AO Foundation

In 2009, the AO Foundation consolidated key strategic initiatives embarked upon in 2008, namely the establishment of AOTrauma and the restructuring of its three commission groups, Community Development, Education, and Research, the realization of course and membership management, and the integration of Education and Knowledge Services.

1 Markus Rauh thanks Marcel Dissel for his contribution as CEO of the AO Foundation 2 New AOTrauma website (www.aotrauma.org)

Course and Membership Management After careful analysis and a risk assessment, the AOSpine system was trialed by all AO Specialties for the purpose of course management during the 2009 AO Davos Courses. The 2010 membership management rollout across the Specialties will see the system implemented by AOCMF, AOTrauma and AOVET. Other milestones recorded were the launches of the dedicated AOTrauma and AOCMF websites. A future system providing business processes and applications in

the areas of membership, education and research—the fundamental principle being to connect AO people and knowledge across the entire Foundation—is being researched and analysed with a view to rolling out phase one of the new platform mid-2011. Education and Knowledge Services The task force established to integrate the nonoperational activities of Education and Knowledge Services delivered a final integration structure mid-year to ensure high quality educational and knowledge management activities on Fondation level. Subsequent to this, AO Education made plans with the Specialties to develop the AO Education Platform in conjunction with AO President-Elect Norbert Haas. Research and Development Evaluation and alignment of the project port-

folio with the specific requirements of the Specialties were delivered during the year. This was also supported by new Exploratory Research roles and responsibilities. The AO Research Fund, now transformed into the AO Review Commission, was acknowledged for its success, expertise and experience. The role of the new Review Commission is to manage and handle the process of peerreview for the decision-making bodies. External reviewers will review the projects and the peer-review body ranks the proposa ls based on the results of these reviews and compiles an evaluation report for the decision-making body. Personnel news A new human resources (HR) policy was implemented in June 2009 to harmonize policies across the Foundation and bring Specialties and Service Units into alignment. Alain Baumann and Geoff Richards joined the AO Executive Management (AOEM) as the new Directors of AOSpine and ARI

respectively in September 2009, at the same time that Michael Piccirillo assumed the role of AOTrauma Director and Urs Rüetschi was appointed Head of Education. Subsequent to this appointment, the AOEM agreed to include the Head of Education in the AOEM. The roles of Exploratory Research Manager, Head of Communications and Head of HR now report directly to the Chief Operating Officer (COO). A new Code of Behavior, which marks the new leadership structure, was adopted by the AOEM and implemented as Markus Rauh took over the chair of the AOEM from Marcel Dissel in December 2009—at the same time as Lukas Kreienbühl assumed the role of COO. Branding strategy Communications and Specialties worked together on a branding strategy that better fits the strategic direction of the AO. A suite of branding tools was launched in the final quarter of 2009 to align all of the Specialties and Service Units including visual identity marks for each of the Specialties.

1 New AOCMF website (www.aocmf.org) 2 New Specialty brand identities—logos and visual marks

Annual Report 2009

AOTrauma

AOTrauma—empowering the next

generation of surgeons

Reinforcing the AO as the true thought leader, innovator, and driver in the world of trauma

AOTTB Goals — D rive academic excellence and community spirit — B ring ownership of the organization back to trauma surgeons — D evelop coherent and aligned projects and activities — M ake the organization leaner, faster, and more efficient — W ork closely with AO Service Units and other AO Specialties — S trong and clean cooperation with Synthes — E mpowered Regions within the new specialty structure

Creating value for AOTrauma and the AO Foundation The year 2009 saw the realization of the Foundation’s vision to create AOTrauma, the clinical division representing the specific interests of trauma and orthopedic surgeons and operating room personnel (ORP) globally. The new AOTrauma is a decentralized organization where key operational decisions and budgets are held by regional and national bodies. The AOVA authorized the establishment of an AOTrauma Transition Board (AOTTB) comprising the International Board (five regional representatives from Asia Pacific, Europe, Latin America, Middle East, North America) and Global Commissions Board (three commission heads from Research, Education, Community Development). The AOTTB members solely are charged with guidance, as well as leveraging and focusing resources, and have a two-year mandate to create a fully functioning Specialty.

Each international body is made up of the defined and elected representatives who are there to represent their Region’s interests. These new structures will ensure there is a clear and transparent point of contact at a national, regional, and global level to capture, share, and implement ideas in a timely and cost-effective manner. AOTrauma membership ready to go For the first time in the 50 years history of trauma within the AO, a single, universal membership program has been devised to drive the new Specialty to unprecendented levels of engagement with its surgeons and ORP communities. This program, to be launched in 2010, is set to change the face of AOTrauma by making engagement and progression in the organization open, transparent, and based on merit. The concept behind the program is revolutionary, open to all healthcare professionals and researchers interested in orthopedic trauma care, and encouraging progression by providing multiple levels of interaction and a variety of member packages with different benefits.

The newly formed AOTrauma Community Development Commission (AOTCDC) is driven by the regional representatives to leverage resources, ideas, and expertise across the regions.

3 4

During the 2009 Davos Courses, AOTrauma took the opportunity to test its membership 1

concept with participants and faculty. One of the critical problems discovered by the Davos Focus Groups sessions was lack of communication from governing bodies to members. Many respondents confirmed a keen interest in having more timely information and a pipeline of knowledge-based benefits throughout their career. What particularly appealed to potential members about the proposal is that it revolves around a knowledge sharing community and provides members with the opportunity to freely progress through the four levels of membership based on their contributions. Building blocks for AOTrauma Education AOTrauma Education Commission (AOTEC) was established with the strategic goals of combining the right knowledge and surgical skills to empower the orthopedic trauma surgeons and ORP, putting theory into practice, and the guiding principle of improving fracture management for the benefit of the patient. With that principle, the commission set about the task of building on the existing quality education programs and establishing AOT education priorities. It defined the two fundamental elements of quality education as effective program development and quality faculty. A program was defined as a comprehensive education program of related courses, online modules, publications, videos, fellowships, and current research that focuses on the needs of a specific target audience such as residents or foot and ankle specialists. 3

The AOTrauma approach to developing quality education is to create program task forces that include lead clinicians, representatives from each region, an education expert, and researchers in the appropriate content area. AOT has continued to expand its important relationship with the Foundation’s partner Siemens. Imaging technology was integrated into nearly 50 courses and new online imaging modules were developed. An important feat was the alignment of the AO Technical Commission (AOTK) and AOT Education processes to ensure that the work of the TK Expert Groups is incorporated into AOT’s education activities. AOTrauma Research focus on CPPs As with all commissions, AOTrauma Research Commission (AOTRC) was established in 2009, to define strategic research direction, establish priorities, and allocate resources to all research activities of the worldwide trauma and orthopedic community according to the strategy of the AOTTB. AOTRC is focused on clinically relevant research topics (case reports, clinical studies, patient outcome measurements) and applied research. AOTrauma has inherited diverse research projects initiated by the AO Research Institute Davos (ARI). During 2009 AOTRC 4

AOTCDC Key Priorities — C reate a single value-oriented global membership program — G enerate and launch a pipeline of valued benefits — D evelop the AOTrauma website and provide valued services — B uild up and enforce the AOTrauma corporate identity — C reate and implement community magazines — Integrate marketing activities into the AOTrauma strategic plan — W ork with AOSpine and AOCMF Marketing Commissions — E stablish community programs in developing countries — E stablish alliances with academic societies and agencies

Annual Report 2009

AOTrauma

Empowering the next generation AOTEC Priority Projects — A doption of a well proven education development process with surgeons at the center — A review of the content and focus of the Principles and Advances Programs including assessing the flow between the principles and advances courses — D evelop a complete Geriatrics Program to meet the needs of surgeons treating patients with osteoporosis — D evelop an e-learning strategy designed to provide the AOT community access to a wide range of educational resources at their time of need — C reate a course Chair Education Program (CEP) to provide course chairpersons with the tools they need to supervise quality education courses — C reate a meaningful, comprehensive portfolio of fellowship programs — D evelop and register pool of a world-class faculty

1 Adrian Sugar congratulates the AO Research Fund project winners 2 T he Epoca Glenoid Components enable reconstruction

identified all ongoing research activities and restructured the AO’s research expenditures accordingly. A viable peer-review process has been defined to deliver a clear and transparent approval process.

through quantification of the interplay between bone cells and their environment,” and Dr James Iatridis for his project “Effects of cyclic compression on intervertebral disc cell metabolism.”

A research focus within a Clinical Priority Program “Fracture Fixation in Osteoporotic Bone” (CPP FFOB) has been identified for the Specialty. Within that program, 28 peerreviewed papers (impact factors 42.3) have been published to date. Furthermore a guideline on preoperative preparation of geriatric patients for fragility fracture surgery has been defined within AOTrauma Asia Pacific and is soon to be published. A second CPP focusing on bone infection is soon to be initiated. AOTrauma implemented regional structures which deliver integrated clinical researchers within the Regions.

New TK products on the increase The AOTK (Trauma) approved 33 new products, nine of which were complete sets, a higher number compared to prior years. The Epoca Glenoid Components enable reconstruction of the glenoid by an anatomically shaped implant. Indications range from primary osteoarthrosis, posttraumatic arthrosis, and posttraumatic avascular necrosis to failed hemi- and total-arthroplasty. The Revision Instrument Set removes all Epoca implants and supports re-implantation of a long or extralong stem. The Asian Femoral Nail based on CT scans matches Asian anatomy but may also fit small stature patients. 3.5mm and 4.5mm Curved Femoral Plates broad and narrow fit the femoral bow (ante-curvation) of pediatric, young adolescent and small stature patients.

The AO Research Fund project winners The demand for research money remained unchanged. A total of 113 grant applications requesting over 15 million CHF were received. Applications were rigorously vetted by an appointed pool of experts. Ultimately, 24 new projects were approved in 2008. Four are focus grants in the areas of “Imaging and planning of surgery”, “Large bone defects” and “Degeneration/regeneration of the intervetrabal disc.” The AO Research Fund currently supports 44 projects to the value of 2.3 million CHF. The best research project is awarded the Berton Rahn Prize Award (formerly AO Research Fund Prize Award). The 2009 evaluation resulted in two prize winners: Prof Melissa Knothe Tate for the project “Unravelling endogenous mechanisms of bone regeneration

ORP integration into AOTrauma ORP integration into AOTrauma The year 2009 saw the integration of Operating Room Personnel (ORP) into the new clinical division and its membership program. During the first quarter of the year the focus was on setting up the AOTrauma ORP Transition Committee—with representation by all five Regions. The AOT ORP Transition Committee first came together mid-year in Zürich, Switzerland to discuss the future of AOT ORP within the new structure of AOTrauma—aiming for full integration of the ORP community in the national, regional, and global activities of AOTrauma. In addition, a development plan for the ORP community which goes beyond just education was also debated. After this first meeting the chairperson of the AOT ORP Transition Committee was invited to become a member of the AOTEC. This representation ensures ORP’s involvement in the commission’s decision making processes.

The ongoing activities of AOT ORP ORP educational activities went ahead as planned, alongside the structural changes, to satisfy high course demand worldwide. In 2009 AOT ORP ran 96 courses in 40 different countries training more than 6,100 participants. Courses were held for the first time in Croatia, Kenya and the United Arab Emirates. With the help of international faculty and the motivation and devotion of local faculty, well structured and successful courses adapted to the needs of the participants, were offered in each of these new learning venues.

Due to the increased number of courses offered in 2009, AOT ORP also focused on teaching local faculty members. In countries such as India, Indonesia, Iran, and Malawi, a one-day teaching event, preceding the AOT ORP course, allowed faculty to immediately put theory into practice. Faculty mentoring during course delivery resulted in real-time improvements in teaching skills.

The Trauma Recon System is a battery driven power tool system with high power but low weight for trauma and orthopedic indications. Norian Drillable is a synthetic ceramic bone void filler with improved toughness to allow drilling, tapping, and screw placement at any time after implantation. Existing sets have been enhanced as the Elastic Stable Intramedullary Nail with small size end caps, 2.4 mm VA-LCP Two-Column Volar Distal Radius Narrow for small stature and Asian anatomy as well as 6-hole length, and 1.5 mm Headless Compression Screw extrasmall for toes and fingers.

1 Kenya delegates engaged in Dispofix practical 2 Indonesian ORP in discussion 3 AOT ORP Transition Committee in Zürich

Annual Report 2009

AOTrauma

Regional activities

1 AONA members enjoying the events in Las Vegas 2 Team exercise at the Singapore retreat 3 AOLAT Tips for Trainers course

AOT Regions push the education agenda As regional courses continue to be a mainstay of education, the Regions are in the process of creating their own AOT Regional Education Committees and National Education Officers with responsibility for several important regional education initiatives. AOTrauma Europe continues to build quality faculty and co-opt new countries into the AOT education family. AOTrauma Asia Pacific is also focusing on faculty development. The region is meeting the challenge of a growing demand by increasing its course offerings and providing education tailored to the specific clinical needs of national level AOT communities. AOTrauma Latin America is at the forefront of innovations in with e-learning activities, competency assessments, and new course formats. AOT Middle East hosted the largest AO education event outside of Davos with a multi-course event in Cairo, Egypt. This event also featured a new faculty pre-course model which contributed significantly to the quality of the education. AOTrauma North America showcased its multi-specialty course and continued to emphasize fellowship opportunities. This Region is also taking the lead in developing a new geriatrics course focused on total patient care. A breakthrough year for Asia Pacific The Singapore retreat and the extraordinary board meeting in Hong Kong in 2009 marked a new milestone for the region; and at that point, the regional board structure was fully aligned with the AOTTB. With a lean, fast and efficient structure, the board successfully

outlined the 2010 key strategies and defined the related action plans for governance issues, education and research activities, and community development and fellowship planning. AOTAP ran more than 90 courses and symposiums in 2009, training over 6,000 trauma surgeons and 1,000 ORP. A consistent and coherent education guideline and course funding structure were launched. In addition to organizing the regional Tips for Trainers Program (T4T), the need to identify the local trainers and educators was also addressed. AOTAP also moved beyond faculty and courses with its first clinical research workshop in September. This workshop aimed to identify committed young surgeons and researchers to work on clinical research work and create a pan Asia Pacific project with an intention to complete the protocol in 2011. Education dominates activities in North America In response to numerous requests by participants, a Principles Course Companion book was developed and introduced this year. It was so enthusiastically received that an Advances Course Companion book is to be published in 2010. In an attempt to improve educational efficiency and decrease course attrition, a three day Basic Principles Course was successfully trialed. An online evaluation process for all courses was introduced, permitting participants to download lecture material and claim Continuing Medical Education (CME) credits while also improving the evaluation process.

The CME department also conducted an Educational Strategic Review which resulted in the formation of a task force mandated to develop online educational opportunities. Two very successful AONA Alumni events were held in conjunction with the American Academy of Orthopedic Surgeons in Las Vegas and the Orthopedic Trauma Association in San Diego. Tremendous progress has been made towards the first multi-specialty meeting -“Challenges in Fracture Care Across Disciplines” to be held in Phoenix, Arizona, USA in November 2010. Latin America is busy with education Hosting 52 Trauma Principles, Advances and Specialty courses while participating in 15 Latin American Congresses kept AOLAT busy in 2009. A key, ongoing strategic goal of AOLAT is welcoming a new generation of doctors. Active participation by new, younger members will help the association grow stronger. It was with that objective in mind that many training activities involving future course directors were developed during the year. By the end of 2009 all course directors for the 2010 courses had already taken the T4T in preparation for next year’s educational activities. Work completed in 2009 was essential to the construc-

tion of solid foundations that will develop and strengthen the research and education activitites of current and future faculty members. Transition Board mandate extended in Europe There have been a great many stand-out events in Europe during the course of 2009. AO surgeons from around Europe gathered in northern Greece, for the Sixth AO Middle Europe (AO MID) Regional Courses. In addition to the coursework, some changes were made to the regional board. Rami Mosheiff handed over the presidency of the AOTrauma MID Transition Board to Endre Varga, who will serve a two-year term, while Jarek Budnicki from Poland was elected vice-president. The mandate of AO MID Educational Committee was extended for a further two transitional years and the committee includes one representative from each AO MID country. In Athens, Greece a successful two-day T4T event took place offering faculty practical advice on how to improve their skills in lecture presentation, group discussion work, and teaching practicals—a valuable tool in increasing the pool of qualified faculty members available to the AO throughout the region. In Germany, the annual Alumni meeting took place in March in Wartburg, while two months later, in May, the annual Section meeting happened in Aalen.

1 E xtraordinary board meeting in Hong Kong 2 Team building exercises during T4T course 3 Faculty gathering in the Dominican Republic

Annual Report 2009

AOSEC

AOSEC—making the AO network better aware of our work Interview with the AO Socio Economic Committee (AOSEC) Chairperson and Africa Representative Paul J Demmer What have been some of the AOSEC highlights in 2009?

Paul J Demmer

1 Zambia ORP delegates in practical exercises 2 M alaysia ORP delegates practice nonoperative skills 3 Z ambia ORP delegates reviewing an x-ray

In Africa, AOSEC is active in ten countries and well established in six countries. Of course there are far too many achievements to list in detail here, but within this group Malawi is a real success story. It is a model of the AOSEC goal to improve care of the injured in developing countries through education courses and training. Similar activities are happening all over the Regions, but Malawi is unique in exemplifying the full spectrum of what AOSEC wants to achieve in terms of self sufficiency and long term sustainability. The team of four operating room personnel (ORP) developed in the CURE International Hospital, is now organizing its own courses and its members are exporting their knowledge to neighboring countries. AOSEC has also helped to train over 80 practicing Orthopedic Clinical Officers (OCOs) who are the backbone of initial fracture care in Malawi. Training the first female orthopedic surgeon in the CURE Hospital was possible with AOSEC support and a second resident is well on his way to qualifying. The Trauma Fellowship, hosted in Malawi, has helped AOSEC gain a foothold in the Ortho Teaching Unit in Addis Ababa, Ethiopia, where the qualified Fellow is now organizing nonoperative courses. Lastly, an AOSEC sponsored prospective randomized research project on open reduction internal fixation (ORIF) in HIV+ patients, with a 97% follow-up over five years, is nearing completion.

Taking just one highlight from another region, Latin America, and the fellowship program in Brazil: To date 148 fellows have been hosted in Ribeirao Preto and 90 fellows in Sao Paolo and the program is to be extended in 2010.

What can be done better in the future? In order to do our job well we need to make the AO network better aware of our work: We need to help AO surgeons from all AO Specialties to understand who they should approach when they have an idea or query. We must also find ways to better advertise the nonoperative AOSEC courses in developing countries. And finally we have to find a way to get implants into hospitals where surgeons have the skills and training to fix fractures operatively—through attending courses and fellowships—but don’t have the money to buy the basic sets.

No doubt there have been some disappointments along the way? Despite all the achievements there are of course ongoing issues that AOSEC has been dealing with throughout the regions. In Oceania, the unstable political situation in countries we have focused on—Papua New Guinea, Fiji, Solomon Islands and East Timor—largely prevents our teaching activities. Back in Africa, four one-year trauma fellowships given annually to applicants from Africa are supervised by the East-CentralSouthern African Orthopaedic Association (ECSAOA). The selection, registration, and

duration of the fellowships have, over the past two years, become administratively complex and are at present under review. Furthermore, the licentiate program in Zambia, to which AOSEC has allocated money, has not got off the ground. The aim of this program is to train non-doctors to deal with trauma injuries in district hospitals outside main cities where surgeons are unavailable. Furthermore the worldwide emphasis on addressing malaria, tuberculosis and HIV overshadows the trauma pandemic crippling developing countries.

What is the nature of the challenges AOSEC faces going forward? One of AOSEC’s primary concerns is funding: The 2010 budget has been fully allocated and there is no money to help people finance new training courses or take advantage of opportunities to extend existing ones. Although there are many demands on our time we must attempt to gain a foothold in African francophone countries next year and work towards cooperation with our commercial partner to deliver complete hardware sets for training purposes.

How does the work of the AOSEC differ around the world? Differences in healthcare systems mean different surgeon and ORP requirements and challenges associated with ensuring the appropriate training in different Regions, teaching medical staff to work safely in their specific environment. To choose just two

examples: Brazil has areas with very high concentrations of surgeons and others with none, while in India there are high concentrations of surgeons, often working privately, around large cities and a complete lack of surgeons in the poorer states in the north east.

How important is your involvement in the developing world? In these areas the AOSEC is the visible arm of the AO Foundation. In developing countries, 70-80% of trauma patients are treated by licentiates, OCOs and nurses, rather than doctors. Our primary fracture management training is critical to this working well for patients. Surgeons who have studied in developed countries will not treat patients nonoperatively because they have not been trained to do so. However if there are no implants available in their hospital for them to treat operatively then the patient suffers and this is where our nonoperative courses have a huge impact.

What difference can individuals in the AO network make to AOSEC work? We want to ensure that AO surgeons are aware of where the gaps are so they can see where they might be able to help themselves or recommend an appropriately skilled surgeon. Ideally AOSEC would like to build reverse fellowships where people with very specific skills come and spend time teaching local staff to implement rather than doing the work for them over a short intense period.

Projects Africa Cameroon Ethiopia Ghana Kenya Malawi Mozambique Rwanda Tanzania Uganda Zambia Projects AO Latin America Brazil Mexico Projects AO Asia Pacific East Timor Fiji Papa New Guinea Solomon Islands Projects Indian and Asian Subcontinent Bangladesh India Nepal Pakistan

1 Ghana AOSEC course delegates 2 Malawi ORP delegates during practical exercises

Annual Report 2009

AOSpine

AOSpine—becoming a leading global academic community AOSpine is composed of surgeons, researchers, ORP, and healthcare professionals from all continents providing educational, research, consulting, and networking opportunities A year of leadership changes Mid-year 2009, both the new Chairman of the AOSpine International Board (AOSIB) and the Executive Director of AOSpine came on board. As a result of an open election, Luiz Vialle was elected to succeed Michael Janssen to the position of AOSIB Chairperson and Alain Baumann was hired to follow Michael Piccirillo as the new Executive Director of AOSpine. Building on the success of his predecessors, Luiz Vialle is committed to guiding AOSpine to become the leading global academic community for spine surgery. Meeting aggressive Community Development goals The AOSpine’s Scientific Marketing Commission, now renamed the AOSpine Community Development Commission (AOSCDC), met its commitment to deliver a total of 4,000 members in 2009, looking toward even more accelerated membership growth in 2010.

1 Practical demonstrations during a course in Cairo 2 Global Spine Congress 2009 in San Francisco

The last annual survey results (November 2009) showed that 88% of AOSpine’s members are satisfied with their membership; of which 43% were very satisfied. The vast majority of respondents also confirmed that they would renew their membership when it expires (90%); and 77% said that they were very likely to recommend AOSpine membership to a colleague. This is extremely good news for a young and dynamic community which is gearing up to play an increasingly leading academic role in the spine world.

In 2009, the AOSpine’s Community Development team was a major contributor to the AO’s largest business process integration projects in recent years—bringing increased interactivity and networking opportunities to members and the latest communication and collaboration tools to AOSpine’s website. 2010 will represent an important transition year: consolidating AOSpine’s offering and processes, in an effort to get ready for integration and the next phase of growth. Major new developments in Research Cervical Spondylotic Myelopathy—International Study (CSM-I) AOSpine International’s most ambitious clinical project, CSM-I, entered its second year of recruitment. The study is running in four regions, twelve countries and 16 sites, is dealing with nine local languages, and is aiming to include 500 patients in total. By the end of 2009, more than 300 patients worldwide were recruited. Due to the great commitment of the principal investigators Michael Fehlings and Branko Kopjar, as well as special grants from Synthes Singapore and Asia Pacific, one site in Singapore and three sites in Japan have also joined the study in 2009. Hansjörg Wyss Research Award (HJWRA) As a result of the generous donation from the Hansjörg Wyss Foundation, AOSpine was able to fund six research projects. Following a rigorous peer review process, all three clinical

and two laboratory studies, as well as one project containing both approaches, were selected. Their research focuses are broad and cover the fields of scoliosis, spinal tumor, degenerative disc disease, and osteoporosis. AOSpine Research Network (AOSRN) All seven projects of the AOSpine Research Network (AOSRN), focusing on the intervertebral disc, made significant progress in 2009. Four projects will end in 2010 and a new strategy for future collaboration of the AOSRN will be considered. AOSpine Classification Group (AOSCG) The AOSCG held a very animated session during the AO Davos Courses in December 2009, presenting their suggestion for a modified classification system followed by case presentation involving participant feedback. Clinical Priority Program Fracture Fixation in Osteoporotic Bone (CPP FFOB) The CPP FFOB, an AOTrauma project, offered AOSpine the opportunity to join their program with selected studies in the field of spine research. In 2009, the support of one study concerning the treatment of osteoporotic vertebral compression fractures was continued and a peer review of two further projects was initiated. TK System provides technical expertise Minimally Invasive Spine Surgery (MISS) Two Expert Group members initiated a book on these demanding and often controversial techniques in 2009, with the goal of defining state-of-the-art standard methods for this area in which techniques are often

wrongly applied. It is based, wherever possible, on AOSpine Principles and clinical evidence. Authorship will be balanced between neurological and orthopedic surgeons, members and non-members of the Spine AO Technical Commission, AOTK (Spine). Outlook 2010 AOTK (Spine) is constantly seeking opportunities to better interact with and provide their technical expertise to the rest of the global AOSpine community. A Spine Technical Symposium lead by AOTK (Spine) and Expert Group members will be held during a livetissue course in Brazil in 2010. The focus will be on nonfusion technologies, offering an interactive format where faculty members talk about new developments and participants are encouraged to discuss problems with current techniques. Two working groups are envisioned for 2010: the MISS Working Group, dedicated to minimally invasive techniques and the Asian Working Group which has been established in order to give this region more weight in product development. An outstanding year for international education events AOSpine’s inaugural Global Spine Congress, which took place mid-year in San Francisco, USA, was designed to meet the specific needs and interests of spine specialists from around the world. The success of the event further established AOSpine’s reputation for academic excellence. The congress was supported by world renowned international faculty and a broad range of industry sponsors.

1 Paul Manson, Bartolomé Marré and Jeffrey Wang 2 Global Spine Congress 2009 in San Francisco

Annual Report 2009

AOSpine

Leading the way The Global Interactive Courses, held in Kuala Lumpur, Malaysia, were another first for AOSpine education. AOSpine held a “Davosstyle” event in one of the Regions, attracting more than 300 surgeons, predominantly from Asia. The traditional lecture format was complemented by a broad choice of cadaver labs, live surgery sessions, live-tissue workshops, professional development sessions, and a unique plenary day. At the December courses in Davos, Spine Masters met during the four symposia offered to participants. Key educational projects in 2009 New faculty processes bring AOSpine education a few steps closer to its shared objective of academic excellence. In an effort to streamline faculty selection and make it fairer and more transparent, new faculty follow predefined steps, including: online application, selection according to defined criteria, online training modules, face-to-face training, and feedback. The new role of Educational Director is the final piece in the portfolio of faculty roles— these committed individuals will be of great value to continued success as a credible academic organization, responsible for the key areas of peer evaluation of faculty. 1

1 AOSpine booth during the Davos Courses 2009 2 Discussion during an AOSpine course in Davos 3 AOSpine Davos Courses 2009

The AOSpine Principles, based on the AO Trauma principles, were launched in 2009— six elementary building blocks on which to develop course curricula and syllabi in a modular fashion. The next step is to develop the official AOSpine Curriculum for Lifelong Learning to cover the needs of spine surgeons from the start of their specialization right up to retirement age.

Regional activities Regional activities Asia Pacific: new management In the year 2009, the AOSpine Asia Pacific (AOSAP) management team was established, with a regional director and a project manager for regional support and development. In addition, two local administrators for China and India respectively were brought onboard to support various education events and activities. By year end, regional membership exceeded 1,000 members and AOSAP became the second largest regional community. Twentysix courses and seminars were conducted, with 1,864 participating surgeons. All of the Asia Pacific councils defined timelines and roadmaps for reaching full election of their respective council formations. This included steps to establish delegate groups among all members from the Region to create an open and sustainable leadership platform for the future of the AOSAP surgeon community. Latin America: increase in participation The year 2009 proved very productive for Latin America in the field of education. One-day seminars and the use of technological tools allowing remote participation have proven to be the best solution to delivering cost-effective, high-quality education to a greater number of individuals and an important resource for training and identifying new faculty. A notable increase in participant numbers at official educational events run by AOSpine was achieved in 2009. This was only possible due to the commitment of country councils

and the interaction between board, staff, and councils who teamed up to put together programs, faculty selection, promotion, branding, and logistics. Between 2008 and 2009 there was a 100% increase in the number of events and 70% increase in the number of participants. North America: involving fellows To celebrate the accomplishments of fellows and Program Directors, AOSpine North America (AOSNA) hosted its Seventh Annual AOSNA Banff Fellowship Forum at the beginning of April in Banff Springs, Alberta, Canada, chaired by Michael Fehlings, with keynote speakers Luiz Vialle and Michael Bliss. AOSNA welcomed their new fellows for the academic year of 2009/2010 with the first Annual Fellowship Induction Program—held in conjunction with the AOSNA Advanced Concepts in the Management of Spinal Disorders course in Miami, Florida, USA in August—with the aim of involving fellows in AOSpine from the outset. The Toronto Western Hospital Foundation awarded the Upper Canada Medal to AOSNA in recognition of their generosity in contributing to excellence in healthcare and medical research as well as their commitment to advancing patient care. Europe and Africa: membership surge The membership base for AOSpine Europe and Africa grew even larger in 2009, reaching over 1,300 members.

Over 30 educational events were held throughout Europe during 2009 and representatives from the AOSpine Europe team were present at nine congresses across the Region including EuroSpine in Poland in October. At this successful event,congress participants were offered a lively symposium and access to a members’ lounge. A live tissue training event was hosted for the second year running in Strasbourg, France, with faculty showing the complications associated with spine surgery, while a master level symposium was held in Reykjavik, Iceland, to discuss lower back pain. The democratic election of the delegates and new chapter councils that took place in the various countries across both regions increased AOSpine’s drive to create an impartial organization. Middle East: newest chapter AOSpine’s newest chapter was launched in 2009 with a new chairperson, Zayed Al Zayed, at its helm. Over 250 new members were signed up either online or by AOSpine staff at various educational events within the Region. The existing country chapters within the Middle East region were joined by Pakistan and Jordan in 2009, bringing the total number of country councils to six. A Principles course took place in Beirut, Lebanon, an Advances cadaveric course was held in Ryadh, Saudia Arabia, and the regional Advances course was hosted in Cairo, Egypt, late in the year.

1 Cadaver lab at the first ever Global Interactive Course 2 Taking a coffee break during the course 3 C adaver lab discussion group in Kuala Lumpur

Annual Report 2009

AOCMF

AOCMF—further evolution of a successful global community AOCMF uses modern techniques to achieve successful patient rehabilitation. In 2009, education came under the spotlight and membership grew to unprecedented levels Positioning AOCMF globally AO Craniomaxillofacial (AOCMF) is now fully aligned with the AO Foundation’s strategic emphasis on clinical divisions, while ensuring the new structure addresses regional and functional needs. AOCMF continues to position itself as a successful global community rigorously inclusive of all specialists involved in craniomaxillofacial surgery. In-depth analysis of educational output In addition to its regular worldwide educational activities (66 courses worldwide, 24 fellowships) in 2009, concerted efforts have been made to solicit feedback from CMF clinicians to better analyze the attractiveness and relevance of AOCMF educational formats. To this end, a faculty survey was sent to 422 faculty members worldwide and a satisfying 46% showed high levels of interest.

2 Faculty and participants in Ho Chi Minh City (HCMC) 1 Faculty Development and Strategic Meeting in HCMC 3 Workshop during course in Ho Chi Minh City

In early August the 2009 AOCMF International Retreat took place over two days in San Francisco, USA. Sixty-eight participants from 20 countries discussed the AOCMF education strategy in great depth. The following month AOCMF Asia Pacific successfully conducted a faculty development meeting in Ho Chi Minh City, Vietnam. This meeting aimed to identify teaching strategies for AO courses and develop the community of AOCMF faculty in the region. Fifty-three participants from 13 countries benefited from intensive lectures, group discussions and workshops conducted

by prominent faculty, while the Asia Pacific Education Committee worked to establish regional faculty selection criteria and the faculty pool for each country. Multiple international and regional retreats in 2009 allowed AOCMF to analyze educational output, challenges, and opportunities. In 2010 there will be a strong focus on the formulation of an education strategy, based on the outcomes of this analysis, as the Specialty grows its position as the world’s leading CMF education provider with a complete educational profile. Membership growing rapidly In 2009, the AOCMF membership community success story continued, entering a new phase in its development with the introduction of two paid subscription packages. In the second half of the year, 660 individual clinicians registered for the new offering, far exceeding the expectations of the membership commission. As a new benefit, the AOCMF scientific journal, Craniomaxillofacial Trauma & Reconstruction has been made available, free of charge, to all registered members, offering access to four issues in 2009. A further specific offering to members, undertaken during the AOCMF Principles course in Davos, consisted of two live webcasts, where participants posed questions via an online chat room and moderation was provided by onsite faculty.

A further key focus of the AOCMF International Retreat was the launch of membership for North American colleagues. AOCMF International provided a booth where faculty could learn more about AOCMF membership Strong response to research activities The AOCMF Clinical Priority Program, “Imaging and Planning in Surgery” was successfully launched in 2009. A guide to this research focus program was established and a first call for grant applications was issued. Seven applications, requesting a total of 1.8 million CHF, were received. These applications were subject to a thorough peer review which resulted in five projects being approved with a total funding of almost 500,000 CHF. A second call in the same field of expertise was launched, this time requesting pre-proposals. Thirty-three proposals were duly scored and ranked, and the 13 successful applicants were invited to submit a full application. In addition, a call for proposals was issued in the area of “Large bone defects/Critical size defects” as it pertains to CMF. Researchers were invited to submit full proposals. The call resulted in a high number of applications requesting a total of 7 million CHF. The applications were subject to a rigorous vetting procedure by an appointed pool of experts. In addition, AOCID (Clinical Investigation and Documentation) and the AO Research Institute (ARI) continued their CMF-supported studies. A study on orbital fractures has been approved and will start in 2010 as an international multicenter study.

Significant output from TK In 2009 the AOTK (CMF) approved a number of additions to the Matrix Mandible System, in particular the preformed reconstruction plate. Following on from the successful preformed orbital plate, this implant delivers a three dimensional shape approximated to statistical mandibular anatomy along with a section of increased strength in the body and angle regions. Reducing the need to bend a straight plate will help to decrease operating times significantly and avoid plate failure caused by fatigue fractures. The newest addition to the Matrix platform for internal fixation of the craniomaxillofacial skeleton is the Matrix Orthognathic System. It offers one standard screw diameter for all orthognathic indications in the midface and mandible and consequently only one screwdriver blade is needed for all screws. Furthermore, some of the plates are reversible and can be used on both the right and left sides allowing for a significant reduction of the implant inventory. Addressing the growing importance of image-guided and computer-assisted surgery for CMF, the planning tool iPlan 3.0 was approved as the first AO software product for craniomaxillofacial surgery. Developed in collaboration with BrainLAB (Germany), it allows for objective preoperative planning procedures, including custom orientation, automatic multimodality image fusion of pre- and postoperative data and automatic atlas-based segmentation of cranial bone segments.

1 Matrix Orthognatic System Plate selection 2 AOCMF International Retreat in San Francisco 3 AOCMF World Café during the San Francisco retreat

Annual Report 2009

AOVET

AOVET—40th anniversary of the youngest AOVET’s mission is to advance the practice of veterinary surgery to improve patient outcomes by promoting experimental and clinical research, education, and development AOVET structural journey complete AO Veterinary’s journey to become the fourth AO Foundation Specialty was officially completed late in 2009, when AOVET International Specialty Chairman Jean-Pierre Cabassu was elected as a member to the AO Board of Directors (AOVA), and Executive Director Tobias Hüttl was assigned. AOVET has worked tirelessly to position itself as the leading community in veterinary orthopedics with global reach, high quality education, and a focus on the generation of member value.

1 AOVET Specialty Board meeting delegates 2 Alessandro Piras instructs AOVET course participants 3 Tobias Hüttl in discussion during the Board meeting

To achieve this, AOVET has started to align itself with the AO Foundation Specialty strategy and to implement the branding guidelines. Furthermore it will establish a Research and Development Commission and expand into the Regions, with AOVET Europe and AOVET North America being the first to launch in 2010. Further strategic decisions were taken at an AOVET strategy retreat in Boston, USA, in March 2010. Restructuring initiative—full steam ahead The AOVET organization is a matrix structure, consisting of a central body, AOVET International Board (AOVIB), responsible for governance and strategic initiatives, and regional bodies: AOVET Europe (AOVEU) and AOVET North America (AOVNA), responsible for operational activities within their Regions.

The matrix structure recognizes the need for global initiatives directed by commissions to share expertise and leverage resources between the Regions in order to provide the organization with the drive to meet the challenges of the highly dynamic veterinary community. This restructuring activity ensures that AOVET focuses on transparency and rejuvenation of the network, enabling regional expansion and synergies with other AO Foundation Specialties. It is key that the AOVET network of surgeons is accessible to all members and that the accountability of the different boards and bodies is guaranteed. To facilitate the transition from the current to the new AOVET governance structure, a transition organization has been established with a two year timeline and temporary appointments. The transition chairs of the various entities represented are mandated to develop the necessary job descriptions and charters while establishing transparent election processes for the entities. Community development program gets underway AOVET initiated a Community Development program in 2009 with the goal of attracting 2,000 paying members within the first three years. In order to reach this goal there must be tangible member benefits which the Specialty

Specialty Board deliberated on at several international meetings throughout the year. Among the member benefits discussed were: free access to key veterinary and human journals; an in-house journal for our members; case discussions as well as providing free access to teaching videos and lectures. The participants of an AOVET International Retreat taking place in early 2010 elected a chairperson to the Community Development board and decided upon the offering. The new AOVET portal was launched in January 2010 while the membership scheme will be officially launched later in the year.

created for LCP exercises in collaboration with Sawbone were judged effective according to faculty and participant course feedback. The Laboratory Manual will be replaced by a newer version in line with the new videos and released within the first three months of 2010.

Educational output continues to grow A total of 24 courses were organized worldwide in 2009. New events included a one-day lecture seminar in Taiwan and two parallel courses in Mexico City. There, in addition to, the annual small animal course, the first equine course in Latin America was also offered to veterinary surgeons. Both courses were fully subscribed and well received by participants.

AOVET 40 th anniversary celebrations At the beginning of the 2009 AO Davos Courses, AOVET organized a special two-day program to celebrate its 40th anniversary. The purpose of this event was to gather AOVET members, young and old, together with AOVET Davos courses faculty in one room to gain real insight into the history and future of the Specialty. The 43 delegates enjoyed the interesting and entertaining program put together by dedicated AOVET members Rico Vannini, Daniel Damur, and Jörg Auer. The highlight of the overall event was the traditional Annual Fondue Party to which course participants and guests from the AO Foundation (including the President) were also invited. This year will see the publishing of the AOVET 40-year history commemorative booklet. The booklet, loosely based on material written by a medical researcher in 2007, has been extensively reworked and added to by many of the founders and staunch supporters of AOVET and is greatly anticipated.

The new videos developed in 2009 for the small animal Principles Course were officially approved and used in several AOVET courses: Columbus, USA; Kobe, Japan; and San Diego, USA. These videos were also translated into German, French, and Spanish by the end of the year. The small animal group developed four new videos to add to its broad offering of AOVET multimedia teaching and learning materials available online to the members, with three focused on LCP and one on the proper use of the TPLO plate. New bone models

The equine group received permission to develop a surgical reference module in 2010. This pilot project will then be evaluated by a larger group with the intention of developing additional modules for equine and small animals. This content will be a member benefit available through the new AOVET website.

1 AOVET Annual Fondue Party in Davos 2 Mexico city AOVET course faculty

What is the AO Center‘s contribution to the global surgeons‘ network ?

Let‘s have a look!

AO Center, Davos, Switzerland

Annual Report 2009

Foundation

Behind the scenes at the AO Center

A day in the life of Davos staff

Communications and Events, Roman Kellenberger While he is currently completing graphic design work on the event brochure, flyers, invitation cards, and bags for the upcoming Trustees Meeting, Roman usually works on providing each of the Specialties with course programs, exhibition panels and banners for use at international and regional events worldwide.

Clinical Investigation and Documentation, Anja Tobien As one of two picture processing assistants in Davos, Anja prepares x-rays and CT and MRI scans for use in clinical studies conducted by her AOCID colleagues based at the AO office in Dübendorf. The ISO certified department is working on multiple concurrent studies for AOTrauma, AOSpine and AOCMF.

Human Resources, Birte Dobat Guaranteeing that each of the Service and Support Units is staffed by highly qualified and motivated professionals to support the surgeons’ clinical network is Birte’s mission. Full-service recruitment packages, target setting, and professional development programs are some of the tools she uses to deliver this.

Education, Priska Inauen Illustrating the proximal humerus for the trauma module of the AO Surgery Reference, Priska is contributing to a body of work that surgeons use as an online guide to fracture repair. This resource has received numerous international health and medical awards in recognition of its benefit to the surgical community.

Research—Muscoskeletal Regeneration, David Eglin Purifying materials for use in regenerative therapy is a small element of the process David is working on as Principal Investigator. His findings are used in multiple collaborative research programs (CRPs) for bone and cartilage-disc repair undertaken with researchers and surgeons around the world to the ultimate benefit of the patient.

Technical Commission, Nia Jenkins Organizing meetings around the globe for members of the TK System Expert and Working Groups across all four Specialties, taking minutes, and subsequently ensuring all technical information exchanged during these meetings is made available to group members is key to the work that TK Office assistants offer their Specialty partners.

IT Service Desk, Romeo Accola As part of a team of four, Romeo and his colleagues provide daily computer infrastructure support to all AO employees in Foundation offices from Dübendorf to Hong Kong while offering their expert support to faculty and surgeons working on courses, in expert groups and at events from Asia to South America.

Research—Preclinical Testing, Jennifer Lansdowne, Ludovic Bouré, Stephanie Nees These veterinarian surgeons, operating on a critical sized bone defect, play a key part in the research cycle whereby human problems are transferred into rigorous animal models to arrive at solutions for use in human surgery, supporting the work of both AO surgeons and commercial partners.

Finance and Administration, Nina Jacobs Working on the annual financial report and monthly and mid-term planning are some of the many ways that the financial controllers assist Service and Support Units and Specialty management in delivering the best value to their internal and external partners in terms of the ratio of resources to output and services provided.

Research—Biomedical Services, Dirk Wähnert Working as a scientific assistant, Research Fellow Dirk is engaged here in mechanical testing of wires as a potential aid to surgeon for fragment stabilization in fracture repair. The research fellowship program provides motivated surgeons with on-site research training in R&D projects focused on relevant clinical problems.

Annual Report 2009

Service Units

Strategically aligned value chain Service Units pursue excellence in patient care The end of 2009 saw the completion of the AO Foundation’s two-year restructuring plan. In particular, the successful reorganization of the AO Service Units—research and development, clinical investigation and documentation, education and knowledge services and the TK system—proves the AO Foundation’s commitment to delivering value-added products and services to its clinical divisions, surgical network and partners through a strategicallyaligned value chain. The key focus of AO Service Unit activities continues to be on producing new concepts for improved fracture care, delivering evidence-based decision making, guaranteeing rigorous concept and product approval as well as timely and comprehensive dissemination of knowledge and expertise.

The following eight pages offer insights into the core processes and activities undertaken by the AO Service Units in 2009. Joint projects between AO Service Units and clinical divisions, with a unique Specialty focus, are reported on in the dedicated Specialty sections from pages 18–39. An overview of Foundation-wide strategic initiatives implemented in 2009, can be found on pages 22 and 23.

AO value chain

Exploratory research Clinical work

Education

Approval

Research and Development ARI integration achieved Completion of the integration of AO Development Institute (ADI) into the AO Research Institute Davos (ARI) was achieved with Geoff Richards’ appointment as the new Director of the Service Unit in 2009. He assumed this role with the strategic goals of: strengthening collaborations with the AO surgeon network, international universities and AO Foundation’s industrial partners; restarting AO Research Fellowships for surgeons; maintaining the high level of publications in peer reviewed journals. In 2009 ARI published its highest number of peer reviewed manuscripts to date, 74 with an average impact factor of 2.46 and accumulated over 2.5 million extramural funds. ARI’s eCM journal received a 2009 impact factor of 4.289. eCM has worldwide, true open access—no submission, publication or reading charges of any kind—and passed 10,000 registered readers world wide. In addition the successful eCM X: Stem Cells for Musculoskeletal Regeneration congress was opened by 2007 Nobel Prize for Medicine winner, Sir Martin Evans. Geoff Richards, as president of the Swiss Society for Biomaterials (SSB), hosted the 22nd European Conference on Biomaterials (ESB2009), in September 2009 in Lausanne: 1044 abstracts were submitted for

Improving clinical practices presentation (previous record 750 abstracts); 250 oral presentations were made in addition to more than 750 posters and 1,200 attendees. The event also featured a scientific session dedicated to the memory of Berton Rahn, formerly of ARI. AO Research and Development Committee The AO R&D Committee was established in 2009. It gives advice and guidance to ARI and assures the efficient deployment of the AO Foundation infrastructure. The AO Veterinary Advisory Committee (AOVAC) was created at the request of the AO R&D Committee and its role will be to review animal models used in all AO Foundation funded projects. Musculoskeletal Regeneration Program Polymers. Thermoreversible hyaluronan hydrogels were successfully tailored by “click chemistry” and RAFT polymerization for cell and drug therapy. In vitro evaluation has demonstrated high potential to be used as cytocompatible injectable cell carriers for intervertebral disc regeneration, with possibilities in substance delivery such as growth factors or antibiotics. Stem Cells. The loading protocol (amplitude and frequency) applied to human bone marrow derived stem cells plays a major role in

Applied/translational research

Clinical investigation

1 Sir Martin Evans reviews ARI projects with Geoff Richards 2 eCM online journal (www.ecmjournal.org)

Annual Report 2009

Service Units

Improving clinical practices determining whether the cells will eventually become cartilage or bone, which can be used to determine optimal rehabilitation protocols for cell based therapies. Intervertebral Disc. Research projects identified potential markers to distinguish human intervertebral disc from cartilage cells and also revealed molecules that may indicate “juvenile” or “degenerative” aging discs. Furthermore, ARI showed growth factor mediated differentiation of human mesenchymal stem cells towards an intervertebral disc-like phenotype. Bone Defect. Platelet released growth factor has been shown to have a positive effect on endothelial progenitor cells growth while maintaining differentiation capacity. On bone marrow mesenchymal stem cells, it stimulates the bone morphogenetic protein-2 (BMP2) transduction pathway, leading to matrix mineralization. In vivo implantation of this combination in a sheep 3 cm defect demonstrated that the newly formed bone reached ~70% of stiffness compared to the contra-lateral control bone, while histological observations showed the presence of blood vessel-like structures and the initiation of bone remodeling. 1

1 ESB2009 conference organizers

Implant Bioperformance Implant Surfaces. Smoothening of metal surfaces was shown to ease removal and reduce operation time and screw stripping,

which is in part controlled on a cellular level through changes in osteoblast gene regulation and cell shape. Direct surface modification of polyether ether ketone (PEEK) to improve cell and tissue integration has been found in vitro to increase mineralization and phenotypic primary human osteoblast gene expression (indicating that this modification is likely to improve bony integration). Musculoskeletal Infection. In vitro and in vivo models are being developed to understand bacterial behavior with the aim of influencing infection risk by implant design changes. Preclinical evaluation showed no significant difference in susceptibility to infection between titanium and steel locked plates, be they standard microrough or polished. There was also no difference in susceptibility to infection between standard and polished titanium alloy intramedullary nails. Innovations 2009 The RISystem implant kits provide standardized and reproducible biomechanics to study bone reactions. The locking RabbitNail and the metaphyseal MouseFix are now in development. To support the continuous education of a surgeon, the student level will be mainly addressed with an autodidactic tool kit to understand and train the biomechanics of fixations. For the resident level a face-to-face approach will be supported by problem related teaching modules (PlayGround for Orthopedic Surgeons).

Biomedical Services Program Biomechanical R&D, Human Morphology Services and Concept Development are researched within this program. Both a unique biomechanical test setup, standardized for different anatomical regions, and finite element studies are used to improve fracture fixation with special emphasis on osteoporotic bone conditions. Advanced medical imaging and analysis techniques are applied for different procedures such as bone mineral density measurement or the build up of threedimensional statistical bone models. In concept development, techniques for simplified intraoperative navigation are currently being evaluated. Cement augmentation and the assessment of bone strength in the osteoporotic bone are also being evaluated.

routine undecalcified hard tissue histology, with or without implants. Standard protocols are developed using different methods of labeling and detection for immunocyto- and immunohistochemistry. Microscopic investigations, including image analysis, can be performed using conventional transmitted and several reflected light methods including fluorescence and confocal microscopy. Surface characterisation techniques include white light profilometry. Scanning Electron Microscopy (SEM) is available for use in material morphological analysis as well as routine elemental determination using Energy Dispersive X-Ray Microanalysis (EDX). SEM techniques have been developed internally for biomaterial, cell, tissue, and bacterial interface studies.

Preclinical Testing The Experimental Surgery focus field specializes in the planning, development and running of preclinical testing studies in the musculoskeletal area. It has experienced personnel for: study plan development; anesthesia; surgical procedures; postoperative care; in vivo analysis (radiography, ultrasonography and computed tomography); tissue collection; data collection; report writing and publications.

GCTM preclinical activity In 2009, Global Clinical Trials Management AG (GCTM), PreClinical Division offered the full range of ARI services to commercial sponsors. Studies conducted included: long and short term tissue reactions to bone filling materials in cancellous bone and iliac wing defect models; ISO10993-6 studies to test soft tissue reactions to novel implant materials; cartilage regeneration studies in goats; histological analysis of dental implants; tissue engineering solutions for the treatment of long bone defects; GLP-like studies to test osteointegration of novel implant materials; ex vivo analysis of novel augmentation techniques and testing of new orthopedic devices.

The Tissue Morphology focus field provides collaborative and research services. These include techniques in routine histology such as paraffin and cryosectioning, and also in non-

1 The metaphyseal MouseFix 2 Computing the spatial position of the orbital rim

Annual Report 2009

Service Units

Exploratory Research Team up for impact Consortium funding strategy In order to deliver on the credo that it is necessary to “team up for impact” in research, AO Exploratory Research (AOER) adopted a funding strategy in 2009 which is novel to the AO Foundation. Instead of funding stand-alone projects from individual research teams, the AO Exploratory Research Board (AOERB) is funding research consortia which work collaboratively, on a peer-to-peer basis, towards solving a clinical problem. Consortium funds are distributed to research partners based on their project contributions. All projects applications are peer-reviewed by external reviewers.

A leader in evidence-based clinical trials

Reorganization AO Clinical Investigation and Documentation (AOCID) adapted its structure to take account of the focus on AO Specialties and to streamline its operations, leading to the closure of the US office in Princeton. All studies in this Region are continuing, with monitoring services outsourced where necessary and expert support provided by AOCID in Switzerland. Studies The year ended with 32 major ongoing studies at various levels of completion. Among projects concluded in 2009 was a pre-study investigating the handling and possible complications of the Angular Stable Locking System (ASLS) for intramedullary nails. Recruitment ended in December for a study examining the accuracy of navigation in the placement of sacroiliac screws. Nine clinics recruited 124 patients with 205 screws on schedule. Primary results will be available in mid-2010. The recruitment end phase of patients for two studies which form part of the AO’s Clinical Priority Program “Fracture Fixation in Osteoporotic Bone”, was reached in 2009. AOCID also proved its competitiveness in the commercial marketplace by submitting the earliest and winning bid for the Cervical Spondylotic Myelopathy (CSM) Project study beginning in 2010.

Fellowship Dr Joost van Middendorp from The Netherlands became the eighth AOCID fellow. He worked on methodological issues in spinal trauma research and attended the AO Davos Courses. Publications and presentations AOCID released a record number of 59 publications, presentations and posters and work conducted and published by AOCID in recent years was cited over 170 times in peerreviewed publications in 2009. A highlight was the positive reaction to the AO Symposium entitled “Evidence—Motor or Brakes” at the DKOU Congress in Berlin demonstrating the topicality of evidencebased medicine. The AOTrauma Statistics and Data Management Handbook: A Practical Guide for Orthopedic Surgeons by AOCID Director Beate Hanson, Dirk Stengel and Mohit Bhandari was published. AO Davos Courses Results from the AOCID survey “We care for our surgeons” conducted during the 2008 AO Davos Courses were released in 2009. Analysis revealed that although the 519 surgeons who responded feel themselves to be in good health, they are aware that their job places a strain on them both physically and mentally.

C o nsor tiu m P r im

us inter Pares A RI

arc

Par t

r ne

R ese arch

tn er h Par

rch

R ese a

2 Consortium funding strategy process

ner

1 L arge Bone Defect Healing annual meeting attendees

Outlook By the end of 2009 the AOERB initiated two new CRPs. One of them addresses the clinical problem of “Annulus Fibrosus Rupture” and the other, “Acute Cartilage Injury”. A program committee, including an external advisor, was assigned to each new CRP, with responsibility for establishing the corresponding research consortia. The plan is to have three CRPs by January 2011.

rt Pa

Large Bone Defect Healing The CRP “Large Bone Defect Healing”, is aimed at finding solutions for healing large bone defects, a problem faced by many orthopedic trauma surgeons. This CRP entered a new funding round in January 2010 based on the consortium funding strategy. The fourth annual meeting was hosted in the Foundation’s headquarters in Davos. The meeting included a guided visit to the ARI facilities followed by summaries of the scientific progress achieved in the last twelve months. It concluded with presentations and discussions of the collaborative projects of the new funding round. Participants of the meeting included several AOERB members responsible for monitoring and guidance of the CRPs. At the end of the meeting it was decided that future annual meetings will be held at different research partner sites on a rotating basis. The 2010 annual meeting will be held at the Harvard Medical School in Boston, USA.

Collaborative Research Programs Bone repair/regeneration and cartilagedisc repair/regeneration were proposed by the AOERB and approved by the Academic Council in 2009 as the two AOER focus fields. Within each focus field there are one or two collaborative research programs (CRPs). Each CRP is composed of an international, interdisciplinary network of research teams which work on collaborative projects towards the consortium goal. To ensure proper function of the network, a “primus inter pares”—technically equal, but looked upon as an authority of special importance by their peers—is responsible for the scientific coordination. As the AO has its own research institute, the AO Research Institute Davos (ARI), the role of “primus inter pares” is assigned to an ARI research expert and thus ARI is a mandatory partner in each AOERB funded consortium.

Clinical Investigation

1 Testing grip strength at AOCID booth in Davos 2 Davos course participants try the pinch test

Annual Report 2009

Service Units

TK System

Education

A year of evolution Change supported by new initiatives Transition was the order of the day with a newly-composed TK Executive Board and Tim Pohlemann’s chairmanship. Processes for developing new devices are well established but were realigned to an evidence-based approach, required due to regulatory changes and to maintain the AO’s high clinical standards. The TK System enhanced its efforts to design innovative studies and clinical evaluations to obtain highly ranked publications in partnership with ARI and AOCID. New initiatives focused on idea generation by tackling extremely well-defined clinical problems according to priorities set by the medical members. Composition of the project groups responsible for delivery became more flexible thus enabling cross fertilization. Through enhanced cooperation with the Specialties, the know-how generated is consistently incorporated into education and the Milestone Concept was adapted to suit these initiatives. A number of management changes were im-plemented, including Claas Albers assuming the role of Head of TK Office. CMF TK System Five years after its inauguration, the AOTK (CMF) has adapted to changing needs. The new structure consists of two main Expert Groups (EG) addressing all aspects of craniomaxillofacial surgery. The Facial Trauma & Reconstruction EG focuses on metallic fixation for trauma and reconstructive surgery, including orthognathic and orbital surgery. The Craniofacial EG develops techniques for

Building the structure to respond to AO Specialties’ needs congenital defects with focus on distraction osteogenesis and resorbable implants. In addition to existing Working Groups (WG) for adjacent Specialties (Neuro, Thoracic), two technique-oriented WGs, for computer-assisted surgery and biomaterials, were appointed. Spine TK System In AOSpine, many of first generation EG memberships came to an end in 2009 and a more disease-based structure was implemented to align with other AOSpine commissions and product development departments of AO’s commercial partner. These new groups are: Cervical Spine EG chaired by Maarten Spruit, Lumbar Degenerative EG chaired by Roger Hartl, Deformity EG chaired by Jean A Ouellet, and Fracture and Tumor EG chaired by Paul Heini. The AOTK chairmanship change from Paul Pavlov to Robert McGuire will take place in 2010. VET TK System The Veterinary EG reacted to increased specialization and founded a Small and a Large Animal WG. Once a year, these two groups will meet, forming the Veterinary EG. Trauma TK System In AOTrauma, an in-depth evaluation and a strategic retreat took place during 2009. Based on the continuous evolution of the system, additional adaptations to changing clinical needs and environments were required. The new focus is on further sub-specialization and ad-hoc task forces to react more flexibly to potential new development areas.

Turning educational activities into programs In 2009, the former AOE was turned into a Service Unit to quickly respond to the needs of all four Specialties. While responsibility for course logistics and Fellowships and Faculty Training events maintenance was transferred to the Specialties, the teams that create publications, digital media, videos, and online content such as the Surgery Reference became the core service group of the newly positioned AO Education. As an interface to the Specialties, a group of so-called Program Developers was installed. These educational specialists will develop educational programs on behalf of the Specialties, partnering with their Commissions and expert surgeons. The Program Developers will also coordinate the creation of educational activities and material with the production teams of AOE. As a first step, joint programming activities were established with AOTrauma on the principles and advances level, as well as for the geriatric fracture care program. At the Foundation level a new group called AO Education Platform was established. This group, led by AO President-Elect Norbert Haas, unites all Chairpersons of the Specialties’ Education Commissions with the goal of aligning strategies, making use of shared resources and knowledge and envisioning the future of education in AO.

AO Surgery Reference The world’s largest and most important trauma reference service, AO Surgery Reference, continued to grow in 2009. The CMF section has seen the addition of “Midface” and “Dentoalveolar Trauma” modules and is now almost complete. In the general trauma section, the introduction of procedures aimed especially at surgeons practicing in emerging countries, has been a particular success. A large part of the population in the emerging world is now wealthy enough to afford operative fracture care, but the operating circumstances and indeed the types of injury are often quite different from the first world. An ongoing pilot project in tibial fractures has focused on adequate treatment procedures and the special injury types such as delayed presentation, infection, and significant soft-tissue compromise, including compartment syndrome. The success of this venture has already been documented by the strength of demand from such countries as India, Brazil, Mexico, and China, which are now among the most prolific users of AO Surgery Reference. 1

With a surge in usage—a 68% increase in visits from September 2008 to 2009—AOE introduced redesigns both in the general presentation and in the structure of the AO Surgery Reference to make the service easier to use with a high end user interface.

1 AO Surgery Reference (www.aosurgery.org) 2 AO Education Platform process chart

Inspire, exchange, and strategically align

AO Education Platform 1 TK and EG chairmen at the EG Chairmen Meeting

AOTrauma Education Comimission

2 T im Pohlemann presenting at the meeting in Davos

AOSpine Education Comimission

AO Education

AOCMF Education

AOVET Education

Annual Report 2009

Governance

Approved bylaws deliver increase in organizational transparency Newly approved bylaws govern the AO Foundation’s structure and processes while defining collaboration between surgeons and the organization’s employees

In line with the implementation of the strategic initiatives to reshape the institutes into Service Units and AO Specialties into clinical divisions—while reflecting the continuous growth of the organization, and the stronger role of the President and the Board of Directors (AOVA)—the AO Foundation’s Board of Trustees approved a revised version of the bylaws in June 2009. As a result, major changes were implemented in the Foundation’s key bodies—the Board of Trustees, the AOVA and the Academic Council—in keeping with the Specialties’ new structures. Other important outcomes from the revised bylaws deal with the steps that must be taken to ensure the continued success of the AO Foundation.

While the bylaws govern the minutae of the AO Foundation’s wide-ranging change management process—structures, processes, and collaboration rules—the AOVA agreed on a set of “Shared Values” to serve as guiding principles in issues of culture and stakeholder focus. Pending approval by the Board of Trustees during its 2010 meeting, the Shared Values will establish behavioral guidelines for all AO employees and officers. In essence, the bylaws and the Shared Values increase the transparency and cohesion of the AO Foundation. The following pages give an overview of the AO governing bodies and the AO Foundation’s financial development.

Board of Trustees

Academic Council (AcC)

Board of Directors (AOVA) Executive Management (AOEM)

AOTrauma International Board

AOTrauma

AOSpine International Board

AOSpine

AO CMF International Board

AOCMF

AO VET International Board

AOVET

AO Exploratory Research Board AO R&D Committee

ARI

AOCID Committee

AOCID

TK Executive Board

TK Office

AO Education Platform

AO Education Support Units

Annual Report 2009

Governance

Finance A continuation of the consolidation phase During 2009 the organizational responsibilities were aligned stepwise with the newly defined AO Specialty structure. However, it was decided to amend the existing financial reporting according to the new structure only from January 1, 2010, to ensure a consistent financial reporting throughout 2009.

Operating expenses decreased by 10% versus the previous year to 88 million CHF. Like for like, the decline was 7% (excluding the expenses of the 50th anniversary in 2008). Main cost categories were personnel expenses (32%), expenses non-employees (20%), scientific and regional expenses (15% and 8%).

Due to the set-up of the new governance structure and leadership changes in several operational key functions, the review process of the current activities by the respective decision bodies led to an extension of the consolidation phase, which started in 2008.

Except for “other third-party income” (14 million CHF), the financing of the organization’s operating activities is provided through the AO Foundation fund allocation.

Financial overview Overall, operating expenses were reduced by 10%, leading to a negative operating result of 22 million CHF compared to 33 million CHF in the previous year. With a financial result of 58 million CHF, the financial losses incurred in 2008 could partially be compensated, and a positive net result of 36 million CHF was achieved. Consequently, the Foundation’s equity increased to 982 million CHF by the end of 2009. Operating income increased by 3% versus 2008. It includes the income from the Cooperation Agreement with Synthes of 52 million CHF (+3% versus previous year) and other third-party income amounting to 14 million CHF (+2% versus previous year).

AO Foundation fund allocation Total fund allocation by the AO Foundation amounted to 74.2 million CHF reflecting a decrease of 12% versus 2008 (like for like = -9%). 22% were allocated to AOSpine, followed by R&D (19%) and Regional Foundation Activities (14%). In 2008, AO Management and Trustees Activities included 2.5 million CHF for the funding of the 50th anniversary event.

performed significantly below the benchmark after a similar outperformance in 2008. Secondly, due to the cautious build up of the portfolio, the funds held in liquidity were at a much higher level at the beginning of the year versus the foreseen strategic asset allocation.

However, this position was reduced from 21% to 8% during 2009, in alignment with the market improvement. Looking at the Foundation’s portfolio performance over the last two years, the actual return of -4.1% outperformed the benchmark of -14.6% by 10.5%-points.

Number of employees (based in Switzerland)

Employees by institute/Specialty 2009 (full-time equivalents based in Switzerland)

230

245

239

232

2006

2007

2008

2009

200

2005

Positive financial result The positive financial result reflects the improved market environment in 2009. Overall, the return on the Foundation’s financial assets amounted to 7.7%, leading to an asset value of 876 million CHF by end of 2009.

AO Research AO Education and Publishing AO Central Infrastructure AO Management and Trustees Clinical Research AOSpine AOTrauma Technical Commission AOCMF Regions AOVET

The underperformance versus the benchmark was driven by two factors. Firstly, the Synthes stake, with a 37% share in the portfolio,

29% 16% 14% 12% 10% 10% 7% 2% 1% 1% 0%

Royalties

Cooperation Agreement

2007 Other 3rd-party income

2008 Financial result

2009

AOTrauma

Unforseen

2006

AOVET

2005

AOCMF

–100

in million CHF

Technical Commission

–50

AO Education & Publishing

AO Central Infrastructure

AOSpine

100

AO Management & Trustees Activities

in million CHF

Regional Foundation Activities

AO Foundation fund allocation 2009 Income structure

AO R&D

5 0

Total income

Annual Report 2009

Governance

Governing bodies of the AO Foundation

Board of Trustees The Board of Trustees is the “AO parliament”, consisting of 165 leading surgeons from around the world, including ex-officio Trustees. The Trustees approve amendments to the charter and elect the members of the Academic Council (AcC). They function as ambassadors for AO in their country or region and communicate the AO philosophy. They transmit AO information to national institutions and other AO surgeons and bring feedback regarding special needs into AO. Since each Trustee serves for a limited number of years, constant rejuvenation of the Board is guaranteed.

Board of Directors—AOVA The Board of Directors is responsible for the business conduct of the AO Foundation, ensuring implementation of the goals and proposals of the Academic Council. Its members include a majority of surgeons and nonvoting representatives of the AO’s industrial partners.

Academic Council—AcC The Academic Council (AcC) is responsible for the AO Foundation’s medical and scientific goals. Elected by the Board of Trustees, it is supported by four Specialty Academic Councils (SAcCs), specialized steering boards, and other ex-officio members.

Third row, from left to right: —Jean-Pierre Cabassu —Marcel Dissel (CEO until December 2009) —Suthorn Bavonratanavech —Lukas Kreienbühl (COO) —Urs Weber-Stecher (Minutes) —Luiz Vialle

Fourth row, from left to right: —David W Grainger —James F Kellam — Hansjörg Wyss (Founding Member) —Norbert Südkamp —R Geoff Richards —Ian A Harris —Marcel Dissel —Tobias Hüttl

Third row, from left to right: —David L Helfet — Markus Rauh (Permanent Guest) —Jörg Auer —Thiam Chye Lim —Jeffrey Wang —Keita Ito —Paul Pavlov

Second row, from left to right: — Michel Orsinger (Permanent Guest) — Stephan Perren (Founding Member) —Adrian Sugar —Gregorio Sanchez —Steven Schelkun —Christian van der Werken

First row, from left to right: —Norbert Haas —Tim Pohlemann —Paul Manson —Beate Hanson — Peter Matter (Founding Member) — Thomas Rüedi (Founding Member) —Nikolaus Renner

Second row, from left to right: —Michael Wagner —Eric Johnson —Norbert Haas (President-Elect) —Ciro Römer (Synthes Inc.) —Michael Ehrenfeld —Christian van der Werken (Past-President) —Michel Orsinger (Synthes Inc.) First row, from left to right: —Jaime Quintero —Paul Manson (President) —Markus Rauh (Chairman AOVA and CEO) —Roland Brönnimann (Synthes Inc.) —Michael Janssen

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

From left to right: —Urs Rüetschi, AO Education — Beate Hanson, AO Clinical Investigation and Documentation —Alain Baumann, AOSpine —Markus Rauh, CEO and Chairman AOVA —Lukas Kreienbühl, COO —Tobias Hüttl, AOCMF and AOVET —Michael Piccirillo, AOTrauma (until March 2010) —R Geoff Richards, AO Research and Development

Not in the picture: — Robert Frigg (Permanent Guest) —Helton Defino

Annual Report 2009

Addresses

AO Head Office AO Foundation Clavadelerstrasse 8 7270 Davos Switzerland Phone +41 81 414 28 01 Fax +41 81 414 22 80 foundation@aofoundation.org www.aofoundation.org

AO Specialties, International Headquarters*

AO Service Units

AOTrauma

AO Research Institute Davos (ARI)

Stettbachstrasse 6

Clavadelerstrasse 8

8600 Dübendorf

7270 Davos

Switzerland

Phone +41 44 200 24 20

Phone +41 81 414 22 11

Fax +41 44 200 24 21

Fax +41 81 414 22 88

info@aotrauma.org

nadine.abegglen@aofoundation.org

www.aotrauma.org

www.aofoundation.org/ari

AOSpine

AO Clinical Investigation and Documentation (AOCID)

Stettbachstrasse 6

8600 Dübendorf

8600 Duebendorf

Switzerland

Phone +41 44 200 24 25

Phone +41 44 200 24 20

Fax ++41 44 200 24 12

Fax +41 44 200 24 60

info@aospine.org

aocid@aofoundation.org

www.aospine.org

www.aofoundation.org/cid

AOCMF

TK System

Clavadelerstrasse 8

7270 Davos

Switzerland

Phone +41 81 414 25 55

Phone +41 81 414 24 70

Fax +41 81 414 25 80

Fax +41 81 414 22 90

info@aocmf.org

aotk@aofoundation.org

www.aocmf.org

www.aofoundation.org/wps/portal/aotk

Concept, editing, and layout: AO Foundation, Communications and Events, Davos, Switzerland

AOVET

AO Education

Clavadelerstrasse 8

7270 Davos

AO Foundation, Communications and Events, Davos, Switzerland

Switzerland

Medizinische Universität Innsbruck (p 5)

Phone +41 81 414 25 55

Phone +41 81 414 26 01

Keystone (p 6–9, except 8 center, 16–17)

Fax +41 81 414 25 80

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Medizinische Hochschule Hannover (p 12–13, except 12 left and center)

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