AO Foundation Annual Report 2012

A global network of surgeons Annual Report 2012

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 health care professionals in education, research, development, and clinical investigation to achieve more effective patient care worldwide.

Table of contents Editorial Letter from the President and the CEO and Vice-Chairman

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Feature stories Continuing Professional Development—Individual Education Activities add value to Davos Courses experience 4 The AO Surgery Reference—first-in-class guide for surgeons worldwide continues to grow 8 Clinical Priority Program on Bone Infection—consortium tackles highly relevant clinical problem 12 AO Clinical Divisions AOTrauma—driving excellence in trauma care AOSpine—delivering best-in-class spine education AOCMF—achieving its goals and staying ahead AOVET—continuing on its path to success

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AO Institutes Exploratory Research—a stake in next-generation knowledge and therapies Research and Development—consolidating an international reputation for excellence Research Review—the independent peer review process Clinical Investigation—setting standards for clinical research TK System—ready for the future of medical technique development Education—driving transformation of the way the AO educates

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AO SEC—activities in Asia, Africa, Latin America

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Governance Finance—continuing growth in core competences Governing bodies of the AO Foundation Addresses

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Annual Report 2012 ┃ Editorial

Letter from the President and the CEO and Vice-Chairman Dear colleagues and friends, The year 2012 was full of challenges but all in all it was a year of positive development and success— characterized by exceptional activities throughout the organization.

In April the European Commission approved Johnson & Johnson’s (J&J) purchase of our industrial partner Synthes, Inc., and we continued our internal discussions on how to prepare the AO for possible upcoming changes. It was clear that the approach under J&J would differ with regard to finances and compliance requirements but there would also be new opportunities opening up.

At the 2012 Trustees Meeting in Davos the General Assembly elected a new President for the next two years.

Prof Jaime Quintero, a Colombian citizen, orthopedic trauma surgeon and long-standing AO officer, took over the presidency from Prof Norbert Haas. The General Assembly also mandated a change in governance to eliminate potential conflicts of interest by more clearly separating supervisory and executive functions within the AO. It was decided to create an independent AO Foundation Board (AOFB) to replace the present Board of Directors (AOVA). The new AOFB, the highest executive body of the foundation and responsible for its management, will consist of no more than eleven members. Alongside the President, President-Elect, Immediate Past President and Vice-Chairperson of the AO Foundation, four of the new members will bring to the table the experience and competencies of the respective clinical divisions while the three other open positions are reserved for candidates with research, industry and finance expertise respectively. The industrial partners and chairs of clinical divisions are no longer members of the Board. The CEO and AOVA Vice-Chairman, as the delegate of the AO Executive Management (AOEM), remains a member but without voting rights. The Partnership Coordination Board and the Presidential Team will be abolished. The Board of Trustees is called the Assembly of Trustees and retains the same rights and obligations as before. The significant changes that have been made at the top governance level of the organization will help reduce complexity and costs, increase transparency and better prepare the AO for the future.

Another very important issue of the past year was the AO’s Research and Development (R&D) Review. In 2012 PricewaterhouseCoopers (PWC) was mandated to develop a first report. The aim of the review was to address the findings of the PWC report which highlighted the complexity and the large numbers of funding bodies, distributing the annual AO R&D budget of CHF 25 million across a large number of projects with significant administrative costs. The objective of the review was to establish to what extent and in what areas the AO should conduct future research activities and how the AO can improve its effectiveness and efficiency in research activities. Based on these findings the AO acknowledged the need for action. Final decisions are expected to be made in the first half of 2013.

In order to address the communication needs of a global organization the AO Connect project was launched two years ago. This ambitious IT project aims to help the AO meet the challenges of the increasing complexity of its operations as well as improve the interaction between surgeons, faculty and specialty members. Phase I went live in May 2012. The project is extremely complex and requires our fullest attention and effort to overcome the numerous challenges.

In the Human Resources area we implemented a 360-degree feedback system at the AOEM level allowing each individual to understand how his or her effectiveness as a manager, coworker and employee is viewed

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Jaime Quintero and Rolf Jeker

by others. The feedback underlines each individual’s strengths and weaknesses, and contributes insights into aspects of his or her work needing professional development. The goal of introducing this performance management measure was to positively influence the management culture of the AO Foundation.

The AO Center’s 20th anniversary celebrations in Davos in June 2012 coincided with the Trustees Meeting, creating a unique opportunity to create a more direct link between Trustees and AO employees. The associated ceremony took an in-depth look into the past 20 years of the AO Center.

The AO is moving towards leaner structures and more effective decision making. This trend will continue into 2013. Moreover, the AO is inclined to open new opportunities to our surgeon community to improve patient care. To this end a new initiative has been proposed for the AO to become more active in developing countries.

Finally, we would like to express our thanks to our volunteer officers and faculty for their cooperation and enormous assistance and support in all activities, our employees for their committed work, our members for their interest and our partners for their continued dedication. A special thanks also goes to our colleagues in the AOVA; the new situation has required additional efforts and leadership to guide the AO into the future.

Sincerely,

Jaime Quintero President of the AO Foundation

Rolf Jeker CEO and Vice-Chairman of the Board of Directors (AOVA)

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Annual Report 2012 ┃ Continuing Professional Development

Continuing Professional Development Individual Education Activities add value to Davos Courses experience

What traditionally had been a four-hour interval between the core morning session and evening educational events at the AO’s annual Davos Courses became an afternoon full of new learning opportunities in 2012, with the formal addition of a Continuing Professional Development (CPD) component. Participants and organizers say the inclusion of more than 50 free Individual Education Activities for CPD brought added value to the 2012 Davos experience.

The AO began adding short, information-packed educational activities to the Davos Courses in 2010, according to Dr Claude Martin, Executive Director of AOTrauma.

He said the expanded CPD offering in 2012 was a direct response to clinicians’ requests for educational activities to complement the Davos Courses.

“The idea was to offer the 1,500 participants in the Davos Courses free, educational events delivering high-quality faculty and content with a focus on topics that met gaps in their practices and enhanced their development as faculty members, presenters, surgeons and individuals,” Martin said. “Ultimately, such professional development translates into better patient care.”

The CPD activities ranged from the TK System’s Meet the Experts (MTE) sessions, practical exercises, hands-on learning about 3D imaging and AO Skills Lab, to special topics such as leadership, influence, patient safety, quality in patient care, and research.

The MTE sessions were an example of how CPD provides fi rst-look insights and hands-on exploration of new, highend technologies, with modules purposely aligned to the same clinical situations as the courses. Prof Theddy Slongo, an AO Faculty member for more than two decades, was one of the experts delivering MTE content.

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Michael Mayer and Robert McGuire delivering an MTE session as part of the CPD program

Annual Report 2012 ┃ Continuing Professional Development

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“The MTE sessions are a very good educational tool not only for the participants but also for us experts.”

Prof Theddy Slongo

“All participants were there by choice for a personal, up-close learning experience,” Slongo explained. “The MTE sessions are a very good educational tool not only for the participants but also for us experts. I always thank the participants for giving me an opportunity to become a better presenter.”

Hands-on learning activities with AO industrial partner Siemens illustrated the role technology plays in improving patient care. Dr Alex Grafenberg, Siemens Clinical Educations Manager for Mobile C-Arms, conducted sessions on 3D imaging.

“We hid a synthetic bone and some magnetic letters spelling out the name of the machine inside of a box.

Participants made a normal X-ray of the box, just as they would in surgery, from the top and the side,” he said.

“Then, without moving the C-arm, we did 3D imaging of the box, and asked participants to compare the two images. On the normal X-ray, they could not read the words spelled out by the magnetic letters, but the word was quite clear in the 3D image. The sound of awe—the ‘wow’ of that moment—was incredible.”

The CPD activities were delivered using different learning methodologies: lectures, symposia, workshops and webcasts. To make that happen, the AO Video and Visual Media team developed a studio with high-defi nition cameras that could be easily be moved between activity venues while ensuring flexible, secure, and stable capture and delivery of content.

“In terms of the combination of video media, surgeons and educationalists, we are close to number one [in the field of CPD] when you look at the quality of our content and its delivery,” said Robin Greene, Manager Video and Visual Media.

The impressive array of 2012 CPD activities meant that many participants had to carefully choose between activities, Martin said.

“In 2013, we will look at adding value for the participants without overwhelming them with choices,” he said. “The key is having a balance between the right offerings and an efficient schedule that meets the needs of the participants.”

The Biomaterials and PFNA Augmentation Symposium during the Davos Courses 2012

Annual Report 2012 ┃ Surgery Reference

The AO Surgery Reference First-in-class guide for surgeons worldwide continues to grow

Launched online in 2005 and cascaded as a mobile application beginning in 2010, the AO Surgery Reference remains the gold standard surgical reference worldwide, with more than 121,000 iPhone, iPad and Android downloads since its launch and nearly 54,000 downloads in 2012 alone. The AO Surgery Reference is poised to become even more valuable with the addition of the fi rst AOSpine modules by the end of 2013.

With the addition of the spine module on deformity by the end of this year, all four of our clinical divisions— AOTrauma, AOCMF, AOSpine and AOVET—will be represented in the reference. Prof Chris Colton, one of three executive editors who guide content development for AOTrauma, said the reference continues to evolve with surgeons’ needs.

“When it fi rst came online, nothing like the AO Surgery Reference had ever been done before. Now, eight years later, virtually the whole skeleton is covered and we are making continuous improvements to the way we develop, author, add and review the content,” Colton explained. “Access to the AO Surgery Reference is essential for surgeons, students and educators, and that’s why the mobile charge was launched.”

Since 2010, the AO Surgery Reference has grown from 8,000 pages to 9,000 pages outlining hundreds of surgical procedures across 30 anatomical regions. The number of expert medical illustrations in the reference has increased to 18,000 over the past three years.

Colton said every addition is driven by clinicians’ recommendations, guided by the editorial college of the relevant AO clinical division, and reviewed every three years to ensure that every module contains the most highly accurate, clinically relevant, evidence-based information.

“From selection of content to actually going live, there is meticulous attention to detail throughout the content development process which can take as long as two years,” he said.

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Chris Colton speaking during an AO Surgery Reference editorial meeting

Annual Report 2012 ┃ Surgery Reference

“From selection of content to actually going live, there is meticulous attention to detail throughout the content development process. ” Prof Chris Colton

“The result of this painstaking approach is much better content with information relating specifically to the fracture being addressed and a greater number of minds focused on refi nement of the content.”

That scrupulous process has led to the addition of highly relevant new content, such as the complication segments.

“As we review and revise content segments, we build in content specific to the complications of each anatomical region,” Colton said. “For example, compartment syndrome in the forearm has different anatomical indications than in the tibia. The introduction of region-specific information about the complications and their treatments adds tremendous value to the AO Surgery Reference.

Easily accessible information about complications like nonunion and delayed presentation is extremely relevant for treating patients who don’t have easy access to medical facilities because delayed management presents additional treatment challenges.”

What does the future hold for the AO Surgery Reference?

AOSpine Education Chairman Germán Ochoa sees the reference continuing as a high-value platform for cascading AO educational content to those closest to the patients: surgeons.

“I see the AO Surgery Reference as a tool for approaching not only the current generation of surgeons but future generations who are comfortable with new technologies and educational platforms,” he said. “We are impacting not only surgeons’ daily practices, but health care systems around the world by providing the most up-to-date information, staying current with technology, and making the AO Surgery Reference easily and quickly accessible.”

Colton concurs.

“I can say with certainty that the AO Surgery Reference will become even more comprehensive. There is a world of directions it can go in to improve patient care,” he said.

“Fracture treatment itself will evolve and the AO Surgery Reference will evolve along with it in order to better serve surgeons and improve patient care.”

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AO illustrators Michele Haller and Priska Inauen studying bone models

Annual Report 2012 ┃ Clinical Priority Program

Clinical Priority Program on Bone Infection Consortium tackles highly relevant clinical problem

Launched in July 2011, AOTrauma’s new, five-year Clinical Priority Program (CPP) on Bone Infection—a highly relevant clinical problem—is already showing its potential to be a game changer in terms of prevention, diagnosis, therapy, research, and education.

Funded by AOTrauma Research, the CPP on Bone Infection is led by Prof Stephen Kates, University of Rochester (US), who explained that the project tackles multidrugresistant Staphylococcus aureus (MRSA), an organism now endemic in many hospitals, long-term care facilities and communities.

The problem with MRSA and other multidrug-resistant organisms (MDROs) is that we are running out of drugs.

The organisms are smart and have the ability to change over time and resist antibiotics,” Kates said. “We believe that 30 to 40 percent of bone infections in the US and 20 to 30 percent of bone infections in Europe are caused

by MRSA.” “The costs of MRSAs are enormous, ranging from loss of life or limb to infected heart valves, pacemakers, defibrillators and orthopedic implants, and the potential for spreading to animals and infecting the food supply,” he said.

“For these reasons, MRSA is a highly relevant clinical problem, and AOTrauma’s CPP on Bone Infection has the potential to change the way clinicians think about bone infection,” Kates explained. “The CPP is already discovering that MRSA is not a random event: It appears that some patients are susceptible and some are not. This CPP is ambitious, but I am confident that we can make a real difference in patient care.”

The various projects (there were eight at the outset which has now increased to ten and this number may grow further over the course of the CPP’s lifetime) that make up the CPP take on Bone Infection from a variety of directions.

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Stephen Kates demonstrates a point to his CPP consortium partners during a project meeting

Annual Report 2012 ┃ Clinical Priority Program

“This CPP is ambitious, but I am confident that we can make a real difference in patient care.”

Prof Stephen Kates

Three of these projects focus on anti-autolysin (anti-ALT) monoclonal antibodies as passive immunization against Staphylococcal infections and the development of rat, rabbit and sheep models at laboratories in Rochester (US), Giessen (DE), and the AO Research Institute (ARI) in Davos (CH). A fourth project is the development of the world’s fi rst bone infection registry in conjunction with AO Clinical Investigation and Documentation, with 20 AO clinics around the world collecting data on a variety of samples of patients’ blood serum and cells and characteristics. A fi fth project that the AO is involved in, addresses bone infection education, including a comprehensive literature review, courses across various platforms, and a treatment monograph.

Dr Fintan Moriarty, ARI Musculoskeletal Infection Group Leader, said the fact that the CPP on Bone Infection was up and running so quickly—and generating results—is due to the complementary expertise brought to bear by the AO’s vast collaborative network of engineers, industrial partners, research scientists and orthopedic and veterinary surgeons.

“There are only one or two places in the world that could attempt the project dedicated to translation sciences using a sheep model, and we in ARI are the only ones doing it.

We want to provide a better understanding of who gets bone infections and why; this will lead to better treatment and improved patient care,” Moriarty said. “This CPP will provide an extremely clinically relevant model that replicates the most challenging cases of bone infection and is just not available right now. This will make it possible for us to test a powerful new therapeutic in this model in the later phases of the CPP and provide a very exciting, robust proof of our concept.”

Dr Mario Morgenstern, a fi fth-year trauma surgery resident at the Trauma Center Murnau (DE), successfully advocated for his hospital to become involved in the CPP’s Bone Infection registry.

“I was a medical fellow in ARI’s Musculoskeletal Infection Group for eight months in 2012, so I know the value of ARI and the whole AO network,” he said. “This project gives us a chance to be at the forefront of a revolution in solving a very relevant clinical problem.”

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Members of the ARI Musculosketal Infection Group in surgery at the ARI facilities in Davos

Annual Report 2012 ┃ AOTrauma

AOTrauma—driving excellence in trauma care AOTrauma is the largest global community of trauma and orthopedic surgeons

AOTrauma maintains its position as the largest global community of trauma and orthopedic surgeons

This world-leading community is guided by its three value statements: driving excellence in trauma care, empowering the next generation of trauma surgeons, and earning trust through transparency and mutual respect.

In February 2009, the surgeon leadership of AOTrauma realized that attracting the next generation of trauma surgeons was vitally important, and that 50 years of tradition were part of its heritage. On September 1, 2010, the global AOTrauma membership— designed to provide trauma surgeons, orthopedic surgeons and ORP with a structured and beneficial membership program—was launched, integrating all parties globally and creating a cohesive structure for AOTrauma worldwide. Governance changes in 2012 delivered stability and significant developments: notable investments in education, community development and research. By the end of 2012, AOTrauma membership had grown to over 6,700 members—a 28% increase from 2011.

1 1 Rami Mosheiff (IL) gives a lecture on the benefits of AOTrauma membership

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AOTrauma held 315 educational events in 2012 in the five regions. Although faceto-face education remains at the core of AOTrauma educational strategy, online interactions (webinars and webcasts) and e-learning modules continue to be developed and the video library of surgical approaches and techniques updated. In 2012, responding to its members’ changing needs and recognizing the importance of knowledge transfer in advancing better patient care, AOTrauma initiated an education transformation. This will continue through 2013 and 2014.

Collaboration with like-minded organizations in providing world-class faculty to deliver evidence-based courses, symposia and seminars globally continues to be a priority.

Transforming continuing medical education

AOTrauma Education has been anchored in well-accepted face-to-face courses incorporating lectures, small group discussions, and hands-on exercises. These courses have offered effective education experiences that have shaped surgeon and Operating Room Personnel (ORP) practice for over 50 years.

However, the AOTrauma community has grown in terms of numbers and complexity, and has become more varied in its learning needs. AOTrauma faces the challenge of providing education experiences that range from addressing the clinical problems faced by a community surgeon to those faced by a Level 1 trauma surgeon specializing in treating complex fractures. This spectrum represents an extremely complicated and diverse set of learning needs that evolve and change over time. Hence, the need for this education transformation, directed by the AOTrauma Education Commission. The transformation is essentially a strategic and philosophical shift in the three pillars of education: faculty development, content development, and delivery of education activities.

Ten regional Faculty Education Programs (FEPs) were organized in 2012. FEPs are designed to develop new faculty into skilled teachers and mentors. The purpose of the Chair Education Program (CEP) is to prepare those selected to chair AOTrauma courses to manage the scientific content and instructional design, and to provide the best

education experience to their course participants. Regional Education Teams (RET) are regionally selected teams of surgeons and educationalists centrally trained to be experts in faculty development and quality assurance. Two such teams (ten teams in total) per region were trained by 2012.

AOTrauma has implemented a systematic process to develop effective educational material and content based on sound modern education concepts. It shifts the teaching focus to the competencies that surgeons need to hone. In 2012, a team of senior surgeon thought leaders and educationalists established Education Task Forces focusing on five areas of trauma education.

This strategic shift expands the AOTrauma Education offering, incorporating a comprehensive portfolio of activities and resources that meet surgeons’ needs, to be delivered by way of both traditional face-to-face interactions and new formats that leverage the latest technologies.

Focused research for maximum efďŹ ciency

AOTrauma recognized the clinical problem of infection as one of the most serious and

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1 Practical exercises during an AOTrauma course 2 Chris Morrey (AU) teaching at a course in the OR

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Annual Report 2012 ┃ AOTrauma

AOTrauma—driving excellence in trauma care continued … distressing complications of orthopedic procedures. Following an external peerreview process and carefully conducted discussions, a research consortium led by Stephen Kates, University of Rochester (US), in conjunction with multiple international clinicians and research partners began its activities in June 2012. This consortium currently consists of ten projects.

In October 2012, some 35 clinicians and researchers from around the world met to discuss the progress and upcoming developments of the research activities.

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1 Past and present AOTrauma leaders at ESTES in Basel 2 Demonstrating the benefits of AOTrauma membership at EFORT

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Osteoporosis and related fragility fractures remain the second research priority.

AOTrauma explored the option of studying fracture healing and functional recovery in geriatric fracture patients. Unique results may be expected, as this is the fi rst time that the pre-fracture functional status is documented with a study in the field. This investigation is being performed as an ancillary study of the DO-HEALTH trial.

DO-HEALTH is Europe’s largest healthy aging population study, a randomized double blind placebo-controlled multicenter trial to study 2,000 healthy-at-start community dwelling seniors aged 70 and older. The study will test the efficacy and

safety of three interventions that are meant to improve functional mobility and reduce falls and fractures in seniors: vitamin D, omega-3 fatty acids and a simple home exercise program. The European Commission, within the European 7th Framework Program for Research and Technological Development, funds the DO-HEALTH main trial.

AOTrauma offered several one-year, standalone funding grants of up to CHF 8,000 per research grant to allow clinicians to develop innovative projects dealing with trauma, surgery of the musculoskeletal system, and related translational and clinical research.

Providing valuable benefits to members

With members distributed globally, one of the strengths of AOTrauma is its truly international reach. Hence, the community development arm of the organization continues to explore how to meet the evolving needs of surgeons from different countries and cultures, and in different stages of their careers. Exclusive benefits, like access to select journals, the global network directory, free e-books and AOTrauma webinars and webcasts, bring tangible value to the

members. The launch of the exclusive ebook program for its members was well received in 2012.

Creating awareness of AOTrauma’s educational services and assets among young surgeons is imperative. Community development endeavors have promoted AOTrauma at all major trauma events worldwide, including: ESTES in Basel, EFORT Congress in Berlin, AOTrauma Day at the Chinese Orthopedic Association Congress Beijing, APOA Annual Meeting New Delhi, and OTA Annual Meeting in Phoenix.

Under AOTrauma Community Development’s Fellowship initiative, eleven AOTrauma fellows were selected by the regions to attend the AO Davos Courses 2012.

AOTrauma Community Development continues to fi nancially support activities at a country level, aiming to develop a strong and dynamic community that makes a positive change through learning, teaching and sharing clinical experiences to improve patient care.

ORP curriculum continued its development

Slightly fewer AOTrauma ORP courses

were organized in 2012 due to economic pressures, particularly in Europe. A debut AOTrauma ORP course organized in Lebanon was attended by 60 ORP. Host hospitals in Germany, Switzerland and the United Kingdom continued to offer the AOTrauma ORP Fellowship program. Several fellows expressed how valuable these weeks abroad were for their professional development, and reported on what they could transfer to their home hospitals. Some continued their involvement with AOTrauma as faculty.

The AOTrauma ORP curriculum developed steadily with a focus on production of educational material for the AOTrauma Principles in Operative Fracture Management Course. For this, international faculty involvement (both surgeons and ORP) was requested, and 23 ORP from 22 countries participated in the international mentoring training program in Davos in December 2012. These ORP mentors are engaged in faculty team building in their countries. The training combined the FEP and the implementation/trial of the new material for the AOTrauma Principles in Operative Fracture Management Course.

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1 Nikolaus Renner (CH) at the AO Davos Courses 2012 opening ceremony 2 AOTrauma Fellows at the Davos Courses 2012

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Annual Report 2012 ┃ AOTrauma

Regional activities North America

The AOTrauma Principles and Advances Courses in Operative Fracture Management in Marco Island, Florida had a high turnout, with 200 residents and fellows in attendance. A number of special programs took place, including: AOTrauma CEP, pre-post course knowledge questionnaires, Pre-Operative Planning Awards, and the award-winning AO Skills Lab. AOTrauma North America (AOTNA) exhibited at the 28th Annual Orthopaedic Trauma Association meeting in October in Minneapolis, Minnesota. In October, AOTNA hosted its fi rst annual fellows reception followed by the AOTNA annual reception. Here, the AOTNA video, featuring interviews from AOTNA faculty expressing the benefits of AOTNA involvement, made its debut. AOTNA hosted over 300 members and faculty for an evening of networking in the AO spirit of fellowship and camaraderie.

Asia Pacific 1

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1 Mamoun Kremli (SA) at an AOTrauma Middle East Regional Board meeting 2 Pierre Guy (CA) teaching a course delivered by AONA

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In 2012, Regional Board Chair Tadashi Tanaka (JP) stepped down and Chris Morrey (AU) became the AOTrauma Asia Pacific (AOTAP) Chairperson.

The region hosted 84 courses in 16 countries in 2012. AOTAP participated in a number of national conferences including: AOTrauma

Day at the Chinese Orthopaedic Association Congress Beijing, which registered over 2,000 participants. Thirty-one surgeons attended two FEPs. The Regional Young Faculty Fellow Program continued with eleven faculty fellows. The highlight of the year was the fi rst AOTAP Scientific Congress and TK Experts’ Symposium held in May 2012 in Hong Kong.

Chaired by Frankie Leung, the event was a tremendous success. Themed “Trauma Management—the Global Perspectives,” the two-day program provided an opportunity for academic exchange and experience sharing; 555 orthopedic surgeons and researchers from 35 countries worldwide participated.

Middle East

The most important event for AOTrauma Middle East (AOTME) was the completion of the governance change for the Regional Board. Since its creation, Mamoun Kremli has been at the helm of the AOTME leadership. Much has been accomplished through his wisdom, guidance, and diplomatic flair in sometimes-turbulent times. Twenty courses were conducted in the region in 2012, educating over 1,000 surgeons. The flagship Dubai Regional Courses attracted 170 participants. Towards the end of the year, as part of its partnership with the PanArab Orthopaedic Association, the

third AOTrauma symposium was held in Dubai. This has become an annual event that AOTME members look forward to.

A successful peer-reviewed Davos Faculty Retreat held in December 2012 brought in over 60 faculty members from Europe.

Education, research and community development commissions elected new chairpersons: Mahmoud Odat, Sohail Bajammal and Wajid Muhammad, respectively.

Latin America

Europe

AOTrauma Europe (AOTEU) continues to hold the largest number of annual courses of all the regions: 123 courses were delivered across Europe, Israel and South Africa in 2012, eleven flagship events and the AOTrauma European Masters Workshops and Seminars were held for senior surgeons.

AOTrauma had an important presence at three major European congresses: Deutscher Kongress für Orthopädie und Umfallchirurgie (DGU), European Society for Trauma and Emergency Surgery (ESTES) and European Federation of National Associations of Orthopaedics and Traumatology (EFORT).

Peter Brink (NL) took over the reins of the AOTrauma Europe Education Committee in 2012. The board continued its efforts to unite Europe under the leadership of Rami Mosheiff (IL) and Paul Szypryt (UK). With activities in over 40 countries, this remains a challenging task, but fi nding shared commonalities remains a strong driving force.

AOTrauma Latin America (AOTLA) hosted more than 70 courses, seminars and symposia offering educational opportunities to almost 4,000 participants. Highlights included the Advances Course in Brazil, a comprehensive course attended by almost 200 orthopedic surgeons. This has been used as a pilot for implementing the newest course template. In parallel, a professional studio has been set up to record over 80 conferences in either Spanish or Portuguese to build a video library available free of charge to AOTrauma members.

The Colombian National Congress, Peruvian National Congress and the International Symposium on Knee Trauma-Brazil, brought together almost 700 orthopedic surgeons from 14 different countries. For the fi rst time, a one-hour 3D video session was offered at an AO-supported event.

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AOTLA offered 50 Latin American AOTrauma surgeons the AOCID Roadmap to Research course. The region began collecting its fi rst data on hip fracture mortality and morbidity to support the fi rst prospective regional multicenter clinical study.

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1 First AOTrauma Asia Pacific Scientific Congress and TK Experts’ Symposium 2 Kodi Kojima (BR) teaches at an Advances course in Brazil

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Annual Report 2012 ┃ AOSpine

AOSpine—delivering best-in-class AOSpine is the leading worldwide academic community for innovative education and research in spine care, inspiring lifelong learning and improving patients’ lives A transitional year for AOSpine

On August 1, 2012, AOSpine welcomed Jeff Wang as its new AOSpine International Board Chairperson; Daniel Riew as AOSpine Research Commission Chairperson and Carlos Tucci as AOSpine Community Development Commission Chairperson. During this transitional year, AOSpine continued to invest in targeted spine research (via Knowledge Forums, the Spinal Research Network, and the World Forum for Spine Research); offer state-of-the-art education courses, including successful regional courses in Kuala Lumpur (MY) and Buenos Aires (AR) and hold community programs to augment surgeons’ knowledge of spine principles and techniques. Many of these would not have been possible without the dedication of AOSpine’s past Chairperson, Luiz Vialle; along with past Chairpersons Karsten Wiechert (Community Development) and Keita Ito (Research).

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1 AOSpine International Board meets in Helsinki, Finland for the official handover 2 Welcome to the world of AOSpine

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Education—focusing on excellence

AOSpine delivered more than 150 educational events in 2012, providing up-todate education of the highest standard to more than 7,000 participants worldwide.

Focused working groups were created to develop solutions for the most significant issues in delivering best-in-class continuing

medical education. This included the full implementation of the AOSpine Curriculum; refi nement of the evaluation of courses and assessment of faculty and participants; evaluation of videos for practical workshops; and innovation in the delivery of education.

Following its successful launch in 2011, the AOSpine Curriculum was implemented fully in more than 50 educational activities worldwide in 2012. In order to be recognized as curriculum-aligned, these activities met a strict set of criteria, with educational content structured around a framework of defi ned competencies and key learning outcomes across several spine pathologies.

A working group identified the key evaluation and assessment requirements of faculty, course participants, AOSpine staff, continuing education approval bodies, and other stakeholders. In conjunction with the AO Foundation’s education platform, the group recommended evaluative tools and trialed several of these at the Davos Courses in 2012.

Working groups approved several new videos produced in a fresh, distinct style to support practical workshops. They examined options for innovative teaching

spine education tools, such as smartphones, tablet apps, and virtual reality learning games. Work commenced in late 2012 on the AO Surgery Reference for the spine, a major project which will provide a comprehensive teaching and clinical resource to aid treatment of spinal disorders.

Research—producing results and creating value

AOSpine Research (AOSRC) is currently managing and sponsoring 14 translational and 17 clinical research studies across the world. More than ten peer-reviewed manuscripts and 58 presentations were published in 2012. The research outputs from 2007 to 2011 are now demonstrating their value.

Their average normalized citation impact (1.41) is greater than the world average (1.00), implying that these outputs are focused, more likely to be cited than other papers, and are published in highly ranked journals within their fields.

The Spine Research Network (SRN) is AOSpine’s platform for intervertebral disc research (IVD). Now represented by Keita Ito, the SRN is composed of 26 AOSpine investigators worldwide. SRN members and collaborators recently published in Nature Communications. Their research shows that

a decrease in a specific subset of cells within the IVD is linked to its aging and degeneration. Identifying the profile and mechanisms of these cells will help in the development of therapeutic strategies against IVD degeneration in the future.

Knowledge Forums (KFs) are working groups focused on five spine pathologies: tumor, deformity, spinal cord injury, trauma, and degenerative disease (DD). In 2012, the KF Biologics was initiated, focusing on the application of biologics in the treatment of DD. The KF Tumor developed a novel evidence-based medicine model for primary spinal column tumors (PST). The model implements an international multicenter approach, whereby clinical data is collected and linked to PST molecular profiles. They have attained the largest international collection to date (13 spine centers, 1,496 PSTs, 18 PST subtypes).

At the World Forum for Spine Research in Helsinki in June 2012, renowned clinicians and established researchers in the fields of disc biology and biomedical engineering had the opportunity to share their knowledge on basic, translational, and clinical research in the field of intervertebral disc and back/neck pain.

1

2

1 Keita Ito (front left) hands over the research commission chairmanship to Dan Riew (front right) 2 Massimo Balsano (IT) teaching during the Advanced AOSpine course in Davos 2012

23

Annual Report 2012 ┃ AOSpine

Community Development Community Development—advancing spine care with collaboration

1

2

1 AOSpine Principles Specimen Course, AMTS Lucerne (CH) 2 A successful specimen lab in Saudi Arabia

24

AOSpine Community Development continued to provide channels for members to share their fi ndings, and facilitate knowledge exchange and collaboration. Critical to this endeavor are the AOSpine publications. Highlights include: the PubMed indexing of the Evidence-Based Spine-Care Journal (EBSJ), the fi rst full year of the Global Spine Journal, and the promotion of two new AOSpine Books: • Minimally Invasive Spine Surgery—Techniques, Evidence, and Controversies: a comprehensive book including more than 500 pages of surgical techniques, illustrations, case images, and research (Developed by the AOSpine TK expert group).

• Measurements in Spine Care: a publication that explicitly outlines the measurement of the spine from a clinical, laboratory, and radiographic approach.

Asia Pacific—reaching new heights

Delivering quality education was of paramount importance in AOSpine Asia Pacific (AOSAP), with over 3,000 participants attending almost 50 events. A highlight of

the year was the regional course in Kuala Lumpur (MY): a range of events at all levels, including a cadaver lab, attracted more than 230 participants from over 30 countries. Other highlights included: fi rst-time events in Myanmar and Bangladesh; the AOSpine seminar at the Chinese Orthopaedic Association that was attended by 1,500 participants; 52 new fellows in the region; and the regional degenerative spondylolisthesis research project that saw 34 clinics recruit 448 patients.

Europe—excelling in education

AOSpine Europe (AOSEU) continued to build on its unique strengths and excel as the primary provider of lifelong education for spine surgeons in the region. AOSEU successfully delivered curriculum-based knowledge to more than 1,600 spine professionals at around 40 educational events. Close to 400 AOSpine members accessed AOSEU’s groundbreaking series of live webinars with leading faculty. The year 2012 also saw the first ever event in Rwanda, which will be followed by a course in Uganda in 2013. In research, 17 leading European clinics were selected for the AOSEU-sponsored multicenter study.

Regional activities The Young Researcher Award attracted a record number of quality applications.

Middle East and North Africa—continuous and unprecedented growth

AOSpine Middle East (AOSME) experienced yet another year of unprecedented growth in awareness, activities, and membership numbers, reinforcing its position as the region’s leading spine community.

In 2012, nine educational events with close to 500 participants took place, and the region’s eighth council was founded in Iraq. AOSME organized successful symposia at two international congresses in the region, attracting over 100 spine experts at both events. Involvement of six surgeons from the Middle East in the Deformity Knowledge Forum has brought prestige to the region, as has the expansion of the AOSpine Center network.

Latin America—shaping the future of spine education

AOSpine Latin America (AOSLA) hosted 40 education events with 2,966 participants, successfully implementing the AOSpine Curriculum. AOSLA also delivered three faculty training programs with

the main objectives of strengthening and improving faculty teaching skills; and further enhancing the quality of our educational activities. Additional highlights include the implementation of the new fellowship process, and the launch of the Continuing Education Program.

North America—channeling the core strength of members

The AOSpine North America (AOSNA) Education Committee hosted eleven successful events in 2012, including the Maintenance of Certification sessions, as well as many hands-on labs using human anatomic specimens. AOSNA brought together top experts to tackle the subject of “Adjacent Segment Pathology,” leading to a focus issue in The Spine Journal devoted to symptomatic or imaging-based findings that occur at a segment adjacent to a previously operated spinal motion segment.

Other major AOSNA highlights in 2012 included: the tenth anniversary for the AOSNA Fellowship Forum, participation in a multispecialty meeting on fracture care, and partnering with various American societies: AANS, CNS, NASS, and CSRS.

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1 John France at the AOSNA Fellows Forum in Banff (CA) 2 AOSpine Interactive Courses, Buenos Aires (AR)

25

Annual Report 2012 ┃ AOCMF

AOCMF—achieving its goals and staying ahead Providing the best in education and research to the AOCMF community continues to be a priority in 2012 Change at the top

For the seventh consecutive year, AOCMF has expanded its educational activities globally, and the worldwide membership network has grown to over 1,700 members.

After six years of leadership, Prof Michael Ehrenfeld (DE) stepped down in July 2012 as International Chairperson and Prof Warren Schubert (US) was elected to the position.

Growth in educational activities

In 2012, AOCMF organized more than 100 educational activities for surgeons and twelve for ORP—a 24% increase from 2011, and a 50% growth over 2010. Of these, Asia Pacific recorded a 42% increase.

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1 Paul Manson (US) speaking at the AOCMF International Retreat in Magaliesburg, Gauteng (ZA), November 2012 2 Practicals during AOCMF Course—Principles in Craniomaxillofacial Fracture Management, Oberdorf, (CH) June 2012

26

China commemorated the tenth anniversary of AOCMF courses in Nanjing while Latin America showed an upward growth trend, and celebrated the 20th anniversary of AOCMF courses in Mexico City. AO North America and Europe activities remained constant at 2011 levels. Europe’s second AOCMF Advanced European Forum held in June, in Madrid (ES) provided updates on the craniomaxillofacial post-traumatic sequels, and a platform to discuss specific subtopics. Despite the political situation in the Middle East, AOCMF hosted several

very successful educational activities, including a debut AOCMF Symposium on Reconstruction in Tunisia.

The AOCMF International Retreat 2012 near Johannesburg (ZA) was attended by over 80 faculty members and guests with specific expertise, who formed workgroups to discuss challenges, potential improvements, and opportunities for new educational programs in the future as well defining the overall direction of AOCMF Education. Each group’s conclusions were shared with all the participants and the AOCMF International Board will follow up on the defined initiatives.

The AOCMF Neuro Core Group, founded in 2011, developed neurotrauma competencies and related content modules, and at the Davos Courses 2012, successfully based the AOCMF Neurotrauma Course on this new framework.

Fellowships remain a strategic focus; increased demand, with 41 fellowships in 2012 compared to 39 in 2011, indicates the popularity and importance of these fellowships in attracting young clinicians.

New AOCMF Fellowship Centers, such as Shanghai, China were approved in 2012.

The global network

With over 1,700 members worldwide, AOCMF has launched the affi liate category (with limited access to member benefits) open to all healthcare professionals and students interested in craniomaxillofacial surgery. The AOCMF team has been supporting AOCMF events and promoting membership at global courses and congresses.

Among its expanded membership benefits, AOCMF offers its members a 25% discount on the original price of both print and electronic versions of Principles of Internal Fixation of the Craniomaxillofacial Skeleton—Trauma and Orthognathic Surgery published in August 2012. Co-authored by AOCMF champions Michael Ehrenfeld, Paul Manson, and Joachim Prein, this manual encompasses the collective expertise and competence of different specialties, resulting in an allinclusive work of considerable scope.

Surgery Reference content expanded

Daniel Buchbinder and his team of editors and authors have made important additions to the comprehensive trauma content in the CMF section of the AO Surgery Reference. Members can access the AO Surgery Reference covering four anatomical areas: skull base and cranial vault, midface, den-

toalveolar trauma, and mandible. There is also content on congenital deformities, orthognathic, and post-ablative reconstruction. Additional material on posttraumatic deformities will be launched soon. AOCMF’s clinical evidence database application, CMFline (for iPhones and Android-based mobile devices) provides members with bibliographic information on therapy, prognosis and diagnosis, and enlists key study results with evidence-based scale rating.

Research and Development

The call for the Clinical Priority Program (CPP) “Imaging and planning in surgery” in 2012 received 29 pre-proposals. Following AO Foundation’s review process, the AOCMF Research and Development (R&D) Commission funded three of these proposals. This AOCMF CPP is scheduled to end in 2014.

At a strategy retreat, the AOCMF R&D Commission, together with the AOCMF International Board and 70 participants, discussed the topics proposed by the AOCMF community for the next CPP. “TM Joint, subcondylar and adjacent bone and cartilage; deformities, defects, injuries and disorders” ranked highest in the field of interest. The R&D Commission is planning further steps to establish this new AOCMF CPP.

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1 CPD workshop with Daniel Buchbinder (US) on CMF 3D Computer assisted planning for orthognathic surgery 2 Warren Schubert (US) speaking at the 2012 Trustees Meeting

27

Annual Report 2012 ┃ AOVET

AOVET—continuing on its path to success Organizational transparency, increased member involvement, enhanced courses, and regional expansion delivered in 2012.

Governance changes

Education initiatives redefined

Prof Jörg Auer (CH) took over as AOVET International Chairperson from Jean Pierre Cabassu (FR) in July 2012. Other newly-elected AO officers include: Rico Vannini as AOVET Education Commission Chair; Alessandro Piras, reelected in December 2012 as AOVET Community Development Chair, and Bruno Peirone as elected chair of the restructured AOVET EU Board.

Education strategy initiatives—the Global Initiative to assess the specific needs of AOVET course participants; the Communication Initiative to better disseminate information about education activities; the Curriculum Development Initiative for educational offerings; the Global Course Evaluation Initiative to establish pre- and post-course evaluations of participants; and the Faculty Development Program focusing on faculty education and support material—were redefi ned at the International Strategy Retreat while it was decided that fellowships shall remain a priority.

AOVET held its International Strategy Retreat in Istanbul (TR) in September 2012, where the new AOVET European Board also held its inaugural meeting. During this strategically important event, the AOVET leadership reiterated its focus on: • Providing additional and new course offerings, fi nding new educational formats, and expanding into emerging countries • Establishing and implementing reporting systems and transparent faculty selection processes • Ensuring organizational transparency by creating clear communications processes and identifying career pathways • Providing possibilities for AOVET members to get involved in the fields of education and research and delivering career advancement opportunities for young AOVET members showing high potential.

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1 Joerg Auer (CH) delivers a presentation during the Davos Course 2 Practical exercise during AOVET Course—Advanced Techniques in Equine Fracture Management

28

Regional activities expanded

In Europe, the Davos Courses 2012 successfully featured the fi rst Masters course on cadaveric specimens. Latin America offered successful Small Animal Courses and an Equine Course again. AOVET was represented at the National Veterinary Congress in Brazil by equine and small animal AOVET surgeons. The current goal is to expand into other Latin American countries and fi nd new fi nancial support for educational events. South Africa’s Small Animal Course was a success and this course will continue to be offered regularly.

Asia Pacific held successful courses in India, Japan, China, and Taiwan in 2012 and will continue to offer these courses in 2013.

India will, once again, be considered for an educational event in 2014 focusing on small animals and ruminants. Last year’s decentralization of Asia Pacific and Latin America is an ongoing task.

Research and development update

Under the direction of Prof Carl KirkerHead (Chairman of the AOVET Research and Development Commission) two research grants were allocated, after the first call in 2011. A second call for R&D pre-proposals was made in summer 2012.

The topics remained unchanged and 24 pre-proposals in the fields of biomechanics of the spine, joint biomechanics, and implant design biomechanics were submitted.

Eleven (of the twelve invited) submitted full proposals. Based on this year’s evaluation, another call may be made with new focus topics in 2014.

A dynamic community

Since the launch of the membership program in June 2010, AOVET has grown from 164 members to over 600. Among its member benefits, AOVET provides the CaseBase, where members can post

specific cases and receive feedback from surgeons worldwide.

The equine section of AO Surgery Reference was launched in early 2012. The available content covers parts of the phalanges and will be enhanced by a new module as well as major additions to the existing content in 2013. All modules contain material relating to diagnosis, indications, preparation, approaches, treatment and aftercare. All the procedures are richly illustrated with drawings, photos and x-rays, and some are accompanied by an online video. The small animal section of AO Surgery Reference is in its early planning stages. In the future, most of the AOVET Surgery Reference will be restricted to members only, and will enhance the membership benefits offering.

Looking to the future

In 2013, AOVET will expand into the Middle East with its first one-day seminar at the AO Regional courses. Going forward, AOVET will be more involved in all faculty trainings organized by AO Education.

AOVET will also evaluate the needs and possibilities of courses in eastern Europe, and look for cooperation with other organizations and companies to support educational events.

1

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1 Lih-Seng (Jason) Yeh with participants during the practical exercises at the AOVET Course - Advanced techniques in small animal fracture management, in Taipei (TW), November 2012 2 Group Picture of first AOVET Course - Principles in small animal fracture management in Cape Town (ZA), September 2012

29

Annual Report 2012 ┃ Institutes

Exploratory Research A stake in next-generation knowledge and therapies

1

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1 Annual CRP Meetings 2012 in the lecture hall 2 Annual CRP Meetings 2012 AFR breakout session

30

From concept to impact

CRP Meetings 2012 and more

In 2012 the AO Exploratory Research (AOER) Collaborative Research Program (CRP) concept was fully implemented with the three CRPs: Large Bone Defect Healing (LBDH), Annulus Fibrosus Rupture (AFR) and Acute Cartilage Injury (ACI) being on solid footing. The years from AOER inception in 2009 to full program implementations in 2012 reflect the time necessary to: define clinically relevant programs, set up program steering committees with renowned clinical and scientific experts and establish a consortium of international, interdisciplinary top-tier scientists who work collaboratively with the AO Research Institute Davos (ARI) towards clinical solutions.

In November 2012, CRP partners, committees and AOER board met at the Institute for Clinical Experimental Surgery in Homburg/Saar (DE) for the Annual CRP Meetings hosted by CRP partners Matthias Laschke and Prof Michael Menger. The three-day event included partner presentations, breakout sessions with partners and their respective committees and was complemented by host laboratory tours and presentations.

A first output of the AFR and ACI consortia are two jointly-prepared review articles; these set the stage for their respective collaborative research to take off and expand from. CRPs are expected to deliver proof-ofconcept of novel treatment strategies within six years and their output will sustain the AO value chain with novel approaches, applicable for translation by AO clinical divisions. The expanded and intensive interactions of ARI and CRP partners has already resulted in several successful joint grant applications which contributed to increasing ARI third party income.

The AFR team continued its meeting the next day at the AO Center in Davos with a joint workshop at ARI hosted by Sibylle Grad and D. Sakai; this provided consortium partners with an optimized protocol for pure annulus fibrosus cell isolation.

Outlook

From September 3–7, 2013 AOER is hosting in Davos the Annual CRP Meetings followed by the second Where Science meets Clinics symposium. The symposium includes a session on “barriers and strategies for translation to the clinic” as well as parallel breakout sessions, providing participants with ample opportunities to actively contribute to in-depth discussions. CRP partners, advisors, AOERB and the TK System will be actively involved with several members engaged in discussion panels or as speakers.

Research and Development Consolidating an international reputation for excellence Mesenchymal stem cell homing for intervertebral disc repair

The AO Research Institute (ARI) has demonstrated that human bone marrow derived stem cells have an increased ability to migrate/”home” into simulated degenerative discs compared to healthy physiologically cultured discs. Assessment of the proteins secreted from the disc showed the presence of two chemoattractants, CXCL6 (GCP-2) and CCL5 (RANTES). ARI now aims to incorporate these chemoattractants into a thermoreversible hydrogel system that may be injected into degenerative discs within an operating theater, thus enabling the “homing” of stem cells into the disc to aid tissue regeneration. This offers a unique therapy for different stages of degeneration and may be a technique that could be utilized for various tissues.

A combination of gene therapy and biomechanics for the repair of intra-articular fractures

ARI has been investigating the combinatorial effect of adenoviral BMP-2 gene therapy and mechanical stimulation in a multiaxial load bioreactor on the fate of human bone marrow derived stem cells. A combination of the two stimuli led to an increase in chondrogenic gene expression in the ab-

sence of exogenous chondrogenic growth factors. As this study utilizes unstimulated mesenchymal stem cells, and combines each component in a single procedure, it can be performed within the operating theater.

This offers potentially new rehabilitation protocols using intraoperative gene therapy for the repair of intra-articular fractures.

Efficient, scale-up ready, single-step synthesis of stimuli-responsive hyaluronan hydrogels

Stimuli responsive matrices based on hyaluronan are the archetype of “smart” biomaterials, and recently, have been investigated for drug delivery systems and scaffolds in tissue engineering. However, none of the reported fabrication techniques developed so far can easily be scaled up from the laboratory to production. Thus, ARI has established an efficient and scale-up ready single step synthesis of stimuli-responsive hyaluronan hydrogels that offers flexibility and potential for their translation into an applicable industrial process.

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1 2012 ARI fellows examining an x-ray at the AO Center

Cement augmentation methods for improved fracture fixation in osteoporotic bone

It is aimed at supporting the development process of new fi xation devices and

2 Thermoresponsive hydrogel for the delivery of cells or small molecules such as antibiotics or growth factors

Thermoresponsive Hyaluronan Hydrogel (HA-PNIPAM gel) Solution

< 32°C

Gel

> 32°C physically entrapped ciprofloxacin covalently bound ciprofloxacin

31

Annual Report 2012 â&#x201D;&#x192; Institutes

Research and Development continuedâ&#x20AC;Ś surgical cement injection procedures related to augmentation to establish the concept in clinics. A clear biomechanical potential of augmentation procedures could be demonstrated in various anatomical regions, namely at the hip, at the foot, at the proximal humerus and at the knee. Besides biomechanical aspects, adverse side effects of implant augmentation such as thermal necrosis or the generation of supraphysiological pressures are critically investigated.

Additional steps will be undertaken to further improve the safety of the procedure.

For example, a study investigating the effect of subchondral cement augmentation on the adjacent articular cartilage is ongoing.

AO implant positioning assistance

The task of placing implants plays a key role in trauma and orthopedics determining the surgical outcome. A novel concept is proposed for simplified implant positioning utilizing conventional radiographic devices as imaging and tracking means.

Existing clinical workflows are supported; no complex navigation equipment is required. The method is based on extraction of characteristic features from cylindrical hole projections within conventional Xrays for determining spatial alignment of objects and anatomy to guide the implant into place. The concept carries strong potential for use in various applications within trauma and orthopedics, in particular

nailing, plating, general screw insertions, anatomical fracture reduction and prosthetics. Pilot applications include placement of a proximal humerus plate and controlling an intramedullary hip nail insertion in terms of center-center positioning of the blade, adjusting femoral anteversion and performing distal interlocking.

Bio-feedback technology for investigating fracture healing

Flexible internal fi xation aims to improve induction of callus by imposing confi ned, reversible displacement at the fracture site.

Optimizing mechano-biology is particularly important under difficult biological conditions such as infection, atrophic delayed/ non-unions or osteoporosis. Creating defi ned mechanical conditions at the fracture site while allowing continuous data collection shall provide valuable information to optimize implant designs. A research implant system with a novel biofeedback concept has been developed and is currently under evaluation in an in-vivo experiment.

While installing specific deformations of repair tissue, the system allows continuously acquiring relevant data during natural locomotion. Based on the same principle, a second device attachable to an external fi xator for monitoring of fracture healing under clinical conditions was developed.

First clinical handling trials are in preparation and will be conducted soon.

Implant positionig assistance 1

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1 Multiple infrared dots allowing for the monitoring of sample motion in three dimensional space during mechanical testing 2 Aiming device allowing for accurate placement of locking screws in multiple implants, taking only one planning image and one control image

32

Nailing/cephalic implants Plating

Screw insertions

Anatomical reduction

Orthopedics

Research Review The independent peer review process The AO Research Review Commission was mandated by the AO Foundation’s Board of Directors to act as an independent review board for all research projects supported by the AO. Each of the 261 submitted grant proposals were independently reviewed by at least two external experts, the result of which was consolidated by a composite reviewer. The available pool of over 450 experts functions as independent external reviewers ensures that all AO research projects are assessed and evaluated by experienced expert reviewers. In addition, the AO Veterinary Advisory Committee supports the review process with its expertise in animal models. In this way, the AO Foundation can continue to develop and support the most innovative and clinically relevant projects.

The submitting funding bodies, the clinical divisions and the AO Exploratory Research Board (AOERB), were provided with the recommendations and a detailed review report for each project.

The fi nal decisions are taken by the respective funding bodies. The applied review process meets international standards of impartiality and expertise. In order to make the process transparent to a wider public, a video (which can be viewed on the AO Foundation website) was produced

explaining who evaluates the projects.

AO Start-Up Grants

Two years ago the Academic Council Grant Committee was established as the funding body for AO Start-Up Grants in which all clinical divisions and the AOERB are represented. In 2012, 143 grant applications were made, and a total of 25 Approved projects in 2012: projects were approved for funding. All appliNUMBER Amount SUBJECT cants received a deOF PROJECTS in CHF 1000 tailed summary of the Biomaterials/ 4 470 Metallurgy reviewers’ comments.

Berton Rahn Research Fund Prize Award

Each year the best AO Start-Up Grant project is awarded the annual Berton Rahn Research Fund Prize Award.

After a rigorous evaluation, Dr Esmaiel Jabbari (US) was awarded the 2012 prize for his project “In-situ crosslinkable osteoinductive poly(lactide) scaffold for bone regeneration” (Project S-05-95J).

% 17.5

Biomechanical general Bone healing Clinical Maxillofacial Spine Tissue reaction Transplantation

3

350

13.0

6 5 1 2 3 1

628 474 54 240 347 120

23.4 17.7 2.0 8.9 12.9 4.5 100

Total

25

2,683

COUNTRY United States Germany Switzerland The Netherlands Canada United Kingdom China France New Zealand Spain Australia

5 3 4 2 5 1 1 1 1 1 1

600 330 416 130 529 107 120 107 120 110 114

Total

25

2,683

1

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1 Esmaiel Jabbari (CO) delivers a presentation at the 2012 Trustees Meeting 2 Mark Markel (US) presents the Berton Rahn Research Prize to Esmaiel Jabbari

33

Annual Report 2012 ┃ Institutes

Clinical Investigation Setting standards for clinical research Ten-year anniversary

AO Clinical Investigation and Documentation (AOCID) in 2012 celebrated a decade of publishing the results of clinical studies.

AOCID offers professional clinical research services in 34 countries and over 8,000 patients have been recruited on AOCID-conducted clinical studies during this time. AOCID Director Beate Hanson also celebrated a decade at the helm of this dynamic research provider.

program to serve the needs of study coordinators which premiered in Zurich (CH) in the fall and will be repeated in Boston (US) in 2013.

AOCID’s independently accredited Good Clinical Practice course was delivered five times during 2012, including at its now traditional place during the AO Davos Courses, where Roadmap to Research courses were also given for the ninth year in a row.

Clinical studies

AOCID managed over 45 different studies in 2012. The Fracture Fixation in Osteoporotic Bone (Humerus and Radius) studies which form part of the AO Clinical Priority Program were completed along with other studies.

There was widespread interest among AO clinical divisions and the AOTK in AOCIDdeveloped Focus Registries designed to answer specific clinical questions. During 2012, AOCID worked on 13 Focus Registries.

New horizons with industrial partners

In addition to a new service retainer with AOCID’s main industrial partner, successful audits by Eli Lilly and the Swiss Quality Management System attest to the highly professional processes by which AOCID is run.

Education

AOCID developed a new three-day training

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1 Beate Hanson at the Crash Scene Investigation— CSI: Davos 2 Getting to grips with an exercise on the three-day Study Coordinators’ Course

34

Biyu Rui from China (tibial plateau fractures), Cumhur Kilincer from Turkey (lumbar degenerative disorders), Alexander Joeris from Germany (AO Pediatric Comprehensive Classification of Long-Bone Fractures) and Leonardo Righesso from Brazil (AOCMF) were the 2012 AOCID Clinical Research Fellows. With AOCID expert help, they worked on their projects and took in-house classes on clinical research.

Publications

AOCID published more than 20 manuscripts in 19 different peer-reviewed journals reflecting the research breadth and international reach of the clinical studies conducted. Independent statistics showed that AOCID research was cited over 450 times in peer-reviewed journals in 2012. A record number of 63 different presentations of AOCID studies and work were given at scientific conferences around the world.

AO Clinical Study Center program AO Clinical Study Center (AOCSC) program

The AOCSC program enables clinics to meet defi ned standards for clinical research and to receive an AO qualification valid for three years. The program arose from the clear need to have well-organized and collaborative sites involved in AO clinical investigations.

AOCID developed the concept and the nine standard operating procedures (SOPs) which candidate clinics have to adopt. These are easy to implement and improve the internal organization of clinical research operations. An initial site visit ensures that all local personnel are trained, and that the stringent requirements are met before a qualification can be awarded.

In addition to being better organized and having improved clinical research abilities, other advantages accrue to qualified sites. The SOPs act as a useful checklist, especially for the preparation of visits and audits. Qualification often acts as a spur to improve processes in other areas of the hospital. There is also the prestige of being part of an AO international network and being known to the AO (and further afield) as a capable center for conducting clinical studies. University connected centers can also make a good case for extra funding due to quality improvement.

By the end of 2012, there were 27 fully qualified clinics from around the world. In addition, 34 centers were at different stages

of interaction with the AOCSC team, ranging from initial contact to being very close to qualification.

The internal processes which guide the AOCSC program have now been ISO certified, further testimony to the program’s strength. In addition, a select number of regional representatives have been trained to qualify centers to extend the program’s reach and to reduce travel costs.

For more information, a dedicated website is available at www.aocsc.org.

Feedback

Research conducted among qualified clinics has shown a high level of positive feedback. In particular, the centers highlight: improved research processes, better team organization, clearer defi nitions of responsibilities, and usefulness for all study team members.

Next steps

The AOCSC project is now entering a critical phase. The fi rst requalifications will take place in 2013. The AOCSC concept has the potential to physically embed the AO Foundation’s clinical research know-how in a very practical way in clinics around the world. With the expansion of the program planned for 2013, and crucially with the support of the wider AO Community, it is hoped that this vision can soon be realized.

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1 The team at Regensburg University Medical Center (DE) displaying their AOCSC qualification 2 The worldwide spread of the AOCSC concept in December 2012

AO Clinical Study Center Program Status December 2012

Qualified Candidate clinic

35

Annual Report 2012 ┃ Institutes

TK System Ready for the future of medical technique development The TK System continued its technical innovation quality management for the AO Foundation and its industrial partners. As the healthcare environment becomes more complex, today’s medical device development must incorporate a growing number of requirements. Consequently in 2012 many of the TK’s internal activities were aimed at preparing for the challenges and opportunities this will present.

A thorough TK review

1

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1 AOTK Meet the Experts during AO Davos Courses 2 Pietro Regazzoni (C) receives the AO Recognition Award from Tim Pohlemann (L) and Norbert Haas

36

In response to future changes in the relationship with the industrial partner, the TK System conducted a complete review of its strategies, organization and processes in order to ensure that it remains at the cutting edge of innovative medical device development. A thorough assessment involving key people from the industrial partner established the industry’s needs and expectations of our surgical driven development process. This evaluation was followed by a survey of medical and non-medical members of the TK System and key opinion leaders from within the AO (such as the members of the clinical divisions’ international boards) to gain further insights. The review results were analyzed by Expert Group (EG) chairmen, and the TK Executive Board subsequently decided upon the appropriate actions and activities.

A unique value proposition for the AO Foundation

The review findings clearly demonstrated a common understanding of the added value provided by the TK System to the AO Foundation and its industrial partner. The TK System offers the industry an extra quality control process that is complementary (if not superior to) regulatory control, without delaying internal product development processes. It also helps to provide insights into the clinical needs of emerging markets. For the AO Foundation, education cannot be separated from the TK System. By safeguarding the AO course standard of teaching only techniques which have been developed with, and approved by, our TK System network of surgeons, the TK System actively contributes to the academic credibility of the organization, which remains a critical success factor.

Paving the way towards evidence-based development

The review also validated the steps already taken by the TK System towards implementing new requirements and which address the changing environment of the healthcare world. In practice this means that any new project in the EGs needs to validate the following key questions: • What is the benefit to the patient?

• What is the benefit to the surgeon?

• What is the value to the healthcare system?

A key element of the TK Systemâ&#x20AC;&#x2122;s strategy is obtaining evidence for the improvement of medical innovations and procedures. Leveraging its longstanding cooperation with AO Clinical Investigation and Documentation, the TK System currently runs 13 clinical studies, with more in the planning phase.

In addition, small Focus Registries are now used on a regular basis by the various EGs to evaluate clinical experience. This is much needed in determining the benefits of a new technique in its early phase. This strategy demonstrates how the AO approach to rigorously assessing new technology in the operating room has been further refi ned to deliver the added value that the TK System provides over standard industrial development processes.

A priority has also been placed on the standardization of biomechanical testing of implants in collaboration with the AO Research Institute Davos in order to better compare the obtained data.

New developments in 2012

A number of new products received TK approval: The new Dynamic Locking Screw was developed to address the problem of delayed bone healing mainly seen in distal tibia and distal femur fractures. The basic principle of this technique is indirect reduction and bridging the fracture zone, with

the benefit of keeping the surrounding soft tissue unaffected. This relative stability leads to indirect bone healing, with callus formation to bridge the unstable area.

Small bend

Responding to the specifics of proximal ulna fractures, the Variable Angle LCP Elbow of pre-contoured plates with a lower profi le was developed. The system recognizes the particular biomechanical requirements of each fracture type, offering specific implants with optimized shapes and screw configurations. Also, the new LCP Ulna Osteotomy System addresses the ulna impaction syndrome as it allows accurate oblique or transverse osteotomy cuts and restoration of bone alignment.

The VA-Locking Proximal Tibial Plate 3.5 covers various indications with one (small fragment) implant, which had previously been restricted to different plate types, ie, fractures of the tibial plateau and buttressing of split-type fractures. In addition, the overall plate stability allows for the treatment of complex metaphyseal, bicondylar and (associated) shaft fractures with small fragment screws. Furthermore instruments for the Tibia Nail System were created to insert the nail with the leg in extension through the suprapatellar pouch, while protecting cartilage and soft tissues.

Large bend

1

2

3

4

1 Small and large bend versions of the VA-LCP Proximal Tibia Plate 3.5 2 VA-LCP Elbow Plating System 3 The new Strut Plate 4 Dynamic Locking Screw (DLS)

37

Annual Report 2012 ┃ Institutes

TK System continued …

For craniomaxillofacial surgeons, the Strut Plate was the third and newest design for the subcondylar plate family, for fractures of the condylar process. It presents an alternative to double plating, with improved strength and stability to the fracture reduction.

The new USS Fracture MIS allows a minimally invasive surgical technique for fracture management in the spine, and encompasses Schanz screws and clamps for routine clinical conditions of the posterior thoracolumbar spine. The Prodisc-C Vivo is the next evolution of the cervical total disc replacement, and maintains the biomechanical and radiographic features of its predecessor while offering a two-step surgical technique of trial placement and insertion.

1

2

3

1 USS Fracture MIS 2 TK Innovation Prize Award, Davos Courses, 2012 3 Meet the Experts, Davos Courses, 2012

38

The approach of generating an interdisciplinary innovation transfer was continued with an increased idea exchange between the various EGs through combined meetings and labs in addition to standardized channels such as the EG chairmen meeting project fair. As part of supporting the work of existing groups with complementary flexible and efficient task forces, a dedicated patella group developed a surgical technique to address fractures of the patella.

This was as identified as one of the few areas for which a standardized treatment method for fractures does not yet exist.

In 2012 the TK System again organized Experts Symposia in Europe, Asia and, for the fi rst time, also in Latin America. The purpose of these meetings is to gather a large group of Experts and “heavy users” of specific techniques and technology to share their thoughts and feedback in order to establish if all the requirements of the original concept have been met.

Meet the Experts sessions in Davos

Following its successful launch in 2011 a full suite of Meet the Experts sessions was organized during the AO Davos Courses 2012, complementing the main course activities. These sessions gave course participants a fi rst impression of newly developed techniques presented by members of the TK System who had been actively involved in the development. Video clips of these events will be available in 2013 from the TK System section of the AO Foundation web portal. Furthermore a new issue of the popular “TK Innovations” brochure was published in December containing detailed information on the latest AO-approved technology and clinical activities in the TK System.

The TK system is committed to delivering the highest possible standards for its oneof-a-kind, evidence-based development now and in years to come. It is ready and well-prepared for the future.

AO Education Institute Driving transformation of the way the AO educates Understanding the lifelong learning pathway

Concluding a two-year research project based on in-depth interviews with 147 surgeons throughout the world, the AO Education Institute (AOEI) released a 122page research report in December 2012. The aim of the study was to fi nd out whether distinct career pathways could be identified for orthopedic surgeons and if the educational needs and preferences of the surgeons changed according to the stage of their career. It is the largest study of its kind to date.

The book, which includes the fi ndings of the study “Changing patterns in lifelong learning—a study in surgeon education,” shows that career pathways can be described but have changed over time and vary from country to country. Learning needs and preferences often relate to a surgeon’s career stage with the result that educational offerings targeted at the wrong audience are likely to fail. The book also illustrates that learning modalities have changed but the desire of doctors to learn from experience gained in treating patients has not. The Internet has revolutionized information gathering but is not as popular with surgeons as might be expected. Moreover, the book, written by Profs Robert D Fox and Piet de Boer, experts in medical education and

Trauma surgeons life long learning path

orthopedics, gives insights into the future of successful medical education.

Educational research: building evidence

The AOEI was invited to present its concepts and research at almost all leading peer-reviewed conferences in the field of medical education: • Alliance for Continuing Education in the Health Professions Annual Conference in Orlando (US), January 2012: Implementation of a competency-based global faculty education program. Presenters: Miriam Uhlmann, Clinton Miner.

• Alliance for Continuing Education in the Health Professions Annual Conference in Orlando (US), January 2012: Lifelong Learning in Surgeons: Do surgeons have defi nable stages in their careers and how do their learning needs and preferences change during these stages? Presenters: Piet de Boer, Bob Fox. • CME Congress in Toronto (CA), June 2012: Global implementation of a competency-based curriculum for spine surgeons. Presenters: Jane Thorley Wiedler, Mike Cunningham, Laurence Rhines, Carlo Bellabarba.

• Association for Medical Education in Europe (AMEE) Conference in Lyon (FR) August 2012: Using backward planning to create competencies for

1

2

1 Result of a two-year qualitative research project: a global view on career patterns and educational needs.

2 A clear focus of the AO Education Institute research projects: measuring the outcomes of education using the Moore levels of outcome system.

AO Education Essentials Targeting the highest level Community health Patient health Performance Competence Learning Satisfaction Participation

Are they able to do it?

Can they show how how?

Does the health status of patients improve due to changes in practice behavior?

Does the health status of a community of patients change due to changes in practice behavior?

Do they know, know and know how how?

Are they happy happy?

Do they show up up?

Measurement

Measurement

Measurements

Measurements

Measurements

Measurements

Measurements

• Attendance records

• Evaluation questionnaires

• Pre- and posttests • Self-reports • Focus groups

• Observation in educational setting • Self-report of competence

• Observation in patient-care setting • Patient charts & administrative databases review • Self-report of performance

• Health status measures recorded in charts or databases • Patient self-report of health status (eg, QoL reports)

• Epidemiological data and reports (eg, length of stay) • Community self-report

Level I

Level II

Level III

Level IV

Level V

Level VI

Level VII

39

Annual Report 2012 ┃ Institutes

AO Education Institute continued …

1

2

1 Collecting data to generate a comprehensive report: AOTrauma conducted 4,316 in depth-online interviews with surgeons 2 Course chair education: a fully blended educational activity

curriculum development in pediatric orthopedic trauma. Presenters: Jane Thorley Wiedler, Urs Rüetschi, Clinton Miner, Mike Cunningham.

• Association for Medical Education in Europe (AMEE) Conference in Lyon, France, August 2012: Commitment to change: lessons learned in applying this tool in the education of orthopedic trauma and spine surgeons worldwide.

Presenters: Mike Cunningham, Pascal Schmidt, Urs Rüetschi.

• Swiss eLearning Conference, 3rd Specialists‘ convention for eLearning, knowledge management and employee development in Zurich (CH), April 2012: Learning and reference mobile apps will overtake traditional PC-based tools. Presenter: Pascal Schmidt.

followed up by post-event assessment and other online activities.

Developing world-class faculty

In 2012 almost all AO clinical divisions released new publications, available in print format or as digitally delivered ebooks. In their basic research series AOSpine published Measurements in Spine Care (Chapman, Lee, Hermsmeyer, Dettori, Norvell) as the third volume looking at the underlaying concepts when doing clinical research.

AOTrauma updated and expanded their classic textbook Minimally Invasive Plate Osteosynthesis (Bapst, Bavonratanavech, Pesantez) while AOCMF released the newest version of their basic principles book Principles of Fixation of the Craniomaxillofacial Skeleton-Trauma and Orthogantic Surgery (Ehrenfeld, Manson, Prein).

In 2012 all clinical divisions focused on developing their faculty. In close collaboration with the different education commissions, AOEI has developed a comprehensive faculty development program comprising educational activities targeted at different stages in a faculty members’ career. There is a selection of educational offerings available for use built on competency-based curricula for different faculty roles. For the fi rst time the AO has introduced blended-learning into the Chair Education Program (CEP).

Participants engage in a four-week online activity with learning modules and online discussion before a face-to-face event,

Looking at the needs globally

Throughout 2012, AOEI and AOTrauma gathered detailed information on the individual needs of surgeons, in all countries where AOTrauma education is offered. In collaboration with the AO surgeon network and local organizations, this data is being analyzed and used to plan more relevant and responsive educational activities, thus better meeting the needs of practicing surgeons. This extensive, quantitative online survey is another major project building on past research in the field of lifelong learning.

Expanding the analog and digital bookshelf

Course chair Education Global Needs Analysis in Orthopedic Trauma for Practicing Surgeons

Online precourse activities/assessment

Live activity

Online postcourse activities/assessment

Repor t for Unite d K ingdom and Ireland A pr il 2013

4 weeks Confidential information. © Copyright of AOTrauma, 2013.

40

1–2 days

3 weeks

AO SEC—activities in Asia, Africa, Latin America Looking toward the future with strategy and collaborations Where AO SEC is in Africa

Progress in Asia and Latin America

In English speaking Africa AO SEC continues to support fellowships in South Africa, Ethiopia, Kenya and Malawi, a residency program in Kenya for doctors, and a nurse fellowship in Malawi. In December 2012 there was an Africa vision day with 20 attendees at which AO SEC member, Sylvain Terver represented French-speaking Africa (FSA).

The year 2012 has seen an expansion of AO SEC activities in Asia into Cambodia in addition to the existing courses delivered in Pakistan, Sri Lanka, Myanmar and Nepal while Principles courses were conducted in India for ORP. In total there were nine courses and six fellowships in the region.

Throughout the year non-operative courses were conducted in Ifakara (TZ), Limbe (CM), Mekele (ET), Koforidua (GA), Kisumu and Mombasa (KE) in addition to an Operating Room Personnel (ORP) course in Eldoret (KE). There were also non-operative courses offered in Mangochi (MW) along with a course for Orthopedic Clinical Officers (OCO). An ORP course was conducted in Bulawayo (ZW) in April and, like all other courses, the faculty and participants came from a variety of African countries.

For the first time operative courses for doctors and ORP were conducted in Addis Ababa, Ethiopia in November and the national and regional chairpersons were all from Africa; the fact that most faculty were regional rather than national is a good indicator of how well the AO SEC’s Africa programs have evolved.

In FSA, courses were conducted in Gabon, Democratic Republic of Congo, Burkina Faso and Senegal and a steering committee meeting in Libreville (GA) developed ongoing programs for 2013–2015.

In Latin America the successful fellowship program initiated by Prof Cleber Paccolo continues and a total of 308 regional surgeons have benefited from this program ever since.

What the future holds

At the Annual AO SEC Meeting in Davos in December 2012 committee members identified countries in Africa with significant populations where AO SEC currently has no presence. The aim of this strategic exercise was to formulate a five- and ten-year course development plan, subject to fi nancing. To support this desired expansion AO SEC is exploring affi liations with other aid organizations and charities who might enhance the education work of the group without compromising its identity.

AO SEC is continuing to explore a collaboration with the Surgical Implant Generation Network (SIGN), a humanitarian organization dedicated to creating equality of fracture care throughout the world, which the socio-economic committee members believes will be mutually beneficial.

1

2

1 Discussion prior to hands-on practical at ORP course in Kenya 2 Ram Khah Shah teaching surgeons in Myanmar

41

Annual Report 2012 ┃ Governance

Finance Continuing growth in core competences Financial Overview 2012 was a very positive year from a financial perspective. Overall, operating income grew by 4% versus 2011 where operating expenses decreased by 1%. The financing of the strategically important area of education continued to grow by 3%, after a 14% increase in 2011, while expenses for non-core activities were reduced.

Overall, the Operating Result amounted to CHF -25 million in 2012 compared to CHF -30 million in the previous year. Thanks to the very positive development of the financial markets in 2012, a strong Financial Result of CHF 92 million was achieved, leading to a Net Result of CHF 67 million. Consequently, the Foundation’s Equity increased 7% to CHF 1’048 million by the end of 2012.

AO Financial Overview

2011

2012

abs.

abs.

abs.

%

75

78

3

4%

Operating Expenses

105

103

-2

-1 %

Operating Result

-30

-25

5

-15 %

in million CHF

Operating Income

Variance 12/11

Financial Result

50

92

42

85 %

Net Result

20

67

47

231 %

981

1,048

67

7%

Equity per 31.12.* * 2011 restated due to change in accounting standard from Swiss Code of Obligations to Swiss GAAP FER

Operating income includes the income from the Collaboration & Support Agreement with DePuy Synthes of CHF 64 million (+7% versus previous year) and third party income amounting to CHF 14 million (-7% versus previous year).

Operating expenses decreased from CHF 105 million in 2011 to CHF 103 million in 2012. Hence, the compounded annual growth rate from 2007 to 2012 is 2%. Looking at the operating expenses excluding “AO Connect project” and “Unforeseen”, 41% of the total amount of CHF 99 million was allocated to education activities, followed by research and development with 30%.

Breakdown 2012

Growth versus 2011 4%

6%

in million CHF

6%

13 % 99 million CHF

41 %

30 % Education R&D General & Administrative

42

Education

+3 %

R&D

+7 %

General & Administrative

+0 %

Global & Regional Boards

-5 %

Community Development

-11 %

TK System

-1 % 0

Global & Regional Boards Community Development TK System

10 2012 2011

20

30

40

Income Statement The 2012 Income Statement looks as follows in comparison to the previous year: Income Statement in million CHF

AO Foundation Contribution

2011

2012

Variance 12/11

abs

%

abs

%

abs

%

89.6

86 %

89.2

87 %

-0.3

0%

Collaboration & Support Agreement

60.0

57 %

64.0

62 %

4.0

7%

Financial Result

49.8

48 %

92.0

89 %

42.3

85 %

Change in Reserves

-20.2

-19 %

-66.8

-65 %

-46.6

231 %

15.0

14 %

13.9

13 %

-1.1

-7 %

104.5

100 %

103.1

100 %

-1.4

-1 %

28.0

27 %

30.0

29 %

2.0

7%

TK System

3.6

3%

3.5

3%

-0.0

-1 %

Community Development

6.8

7%

6.0

6%

-0.8

-11 %

Education 1)

39.4

37 %

40.5

39 %

1.1

3%

General & Administrative

13.3

13 %

13.2

13 %

-0.1

0%

Global & Regional Boards

6.4

6%

6.1

6%

-0.3

-5 %

Others

7.0

7%

3.7

4%

-3.4

-48 %

AO Connect

6.6

6%

3.6

3%

-3.0

-46 %

Unforeseen

0.4

1%

0.1

0%

-0.4

-86 %

104.5

100 %

103.1

100 %

-1.4

-1 %

3rd Party Income Total Income R&D

Total Expenses 1)

incl. Reference Centers & Fellowships, 2011 restated accordingly

The AO Foundation contribution remained at CHF 89.2 million slightly below previous year driven by the lower expenses. CHF 66.8 million was allocated to the Foundation’s reserves, mainly thanks to the financial result amounting to CHF 92 million.

Operating expenses amounted to CHF 103.1 million and remained CHF 1.4 million below 2011 due to lower expenses for “AO Connect project” and “Unforeseen” and lower expenses in various operational areas to compensate the growth in R&D and Education.

A comment on the accounting standard: According to the new Swiss accounting standard regulations, not-for-profit organizations the size of the AO are required to apply the Swiss GAAP FER accounting standard by 2015 at the latest. Since the new standard increases comparability with similar organizations as well as transparency, the new accounting standard has been applied as of 2012 including a corresponding restatement of the 2011 figures.

43

Annual Report 2012 ┃ Governance

Finance Continuing growth in core competences Course-related expenses In 2012, course-related expenses increased for another year, amounting to CHF 26 million (+10% versus 2011). With 49% AOTrauma had the biggest share, followed by AOSpine with 25% and AOCMF with 12% respectively.

Breakdown 2012 4%

2% 2%

6% AOTrauma AOSpine AOCMF AO Foundation AOVET OR Personnel Socio Economic Committee

12% 24 26 million million CHF CHF 49%

25%

Evolution 2009 – 2012 +20%*

+10%*

+10%*

18

21

24

26

2009

2010

2011

in million CHF

+6%*

2012 * growth

vs. previous year

Course activities The total number of courses increased to 711, reflecting a growth of 2% versus 2011. Overall, the number of participants increased by 8% whereas the number of participant days slightly decreased by 3%.

Region

Number of Participants

Number of Participant Days

2012

Share

Vs. 2011

2012

Share

Vs. 2011

2012

Share

Vs. 2011

Asia Pacific

198

28%

+8%

14,118

28%

+29%

28,322

27%

+21%

Europe (incl. South Africa)

249

35%

-3%

12,126

34%

-8%

32,102

31%

-19%

Latin America

119

17%

+3%

7,471

16%

+21%

16,762

16%

+6%

Middle East and Africa

63

9%

+29%

2,861

6%

+20%

7,909

8%

+18%

North America

59

8%

-5%

3,898

11%

-6%

12,746

12%

-4%

International

23

3%

-12%

1,503

5%

-26%

7,005

7%

-24%

711

100%

+2%

41,977

100%

+8%

104,846

100%

-3%

Total

44

Number of Courses

Employees The number of permanent staff increased to 246.6 full-time equivalents (FTEs), an increase of 2.4 FTEs or 1% versus 2011.

Employee Structure by Region FTE weighted permanent

2011

2012

Variance 12/11

abs.

in %

abs.

in %

International

209.6

86 %

212.3

86 %

2.7

Middle East

1.5

0%

1.4

1%

-0.1

Europe

4.8

2%

5.8

2%

1.0 3.6

Total located in Switzerland

abs.

215.9

88 %

219.5

89 %

Asia Pacific

8.2

3%

10.0

4%

1.8

Latin America

9.0

4%

9.0

4%

0.0

North America

11.1

5%

8.1

3%

-3.0

244.2

100 %

246.6

100 %

2.4

Total worldwide

FTE Overview by Area 2012 3% 17 %

246.6 FTE

51 %

AO Institutes AO Clinical Divisions AO Support Units Others Total

29 %

126.5 72.4 40.3 7.4 246.6

International Asia Europe

Asset Management The Financial Result of CHF 92 million reflects an actual return of 9.7% on the underlying financial assets. The total asset value amounted to CHF 1,033 million by the end of 2012. The strong performance was driven by the very positive return on the asset class “Shares” with a double-digit return. The cumulative performance of the portfolio since January 2008 amounted to 11.9% by December 31, 2012.

Latin

Portfolio Structure 9% 11%

62%

1,033 million CHF 18%

in million CHF Shares Bonds Liquidity Alternative Assets Total

639 187 109 97 1,033

45

Annual Report 2012 ┃ Governing Bodies

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 the AO in their countries or regions and communicate the AO philosophy. They transmit AO information to national institutions and other AO surgeons and bring feedback regarding special needs into the AO. Since each Trustee serves for a limited number of years, constant rejuvenation of the Board is guaranteed.

Front row, left to right: — Thomas Rüedi (founding member) —Suthorn Bavonratanavech — Stephan Perren — Jaime Quintero — Tim Pohlemann —Merng Koon Wong — Frankie Leung

Third row, left to right: —Jeffrey Wang —Loïc Déjardin —Carl Kirker-Head —Warren Schubert — Kodi Kojima —Urs Rüetschi —Risto Kontio

Second row, left to right: — Germán Ochoa — Peter Matter —Norbert Haas —Rolf Jeker —Beate Hanson —Luiz Vialle

Top row, left to right: —Rico Vannini —Michael Schütz —Mark Markel —R Geoff Richards —Tobias Hüttl —Anders Westermark

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.

46

From left to right: —Urs Rüetschi (AO Education Institute) — Beate Hanson (AO Clinical Investigation and Documentation) —Alain Baumann (AOSpine) —Rolf Jeker (CEO and Vice Chairperson AOVA) —Claas Albers (AOTK) —Lukas Kreienbühl (COO) —Tobias Hüttl (AOCMF and AOVET) —Claude Martin (AOTrauma) —R Geoff Richards (AO Research and Development)

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.

Front row, left to right: —Suthorn Bavonratanavech (President-Elect) —Jaime Quintero (President and Chairperson AOVA) —Nikolaus Renner —Norbert Haas (Past-President) —Luiz Vialle —Rolf Jeker (CEO and Vice Chairperson AOVA) Middle row, left to right: —Warren Schubert —Florian Gebhard —Jack Wilber —Jörg Auer —Jeffrey Wang —Michel Orsinger (DePuy Synthes) Back row, left to right: —Pierrre Hoffmeyer —Ciro Römer (DePuy Synthes) —Lukas Kreienbühl (COO) —Roland Brönniman (DePuy Synthes) —Urs Weber-Stecher (Minutes)

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 non-voting representatives of the AO’s industrial partners.

47

Annual Report 2012 ┃ 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 Clinical Divisions

AO Institutes

AOTrauma

AO Research Institute Davos

Clavadelerstrasse 8

Stettbachstrasse 6

Clavadelerstrasse 8

7270 Davos

8600 Dübendorf

7270 Davos

Switzerland

Switzerland

Switzerland

Phone +41 81 414 21 11

Phone +41 44 200 24 20

Phone +41 81 414 22 11

Fax

Fax

Fax

+41 81 414 22 80

+41 44 200 24 21

+41 81 414 22 88

info@aotrauma.org

info@aotrauma.org

sonia.wahl@aofoundation.org

www.aotrauma.org

www.aotrauma.org

www.aofoundation.org/ari

AOSpine

AO Clinical Investigation and Documentation

Clavadelerstrasse 8

Stettbachstrasse 6

Stettbachstrasse 6

7270 Davos

8600 Dübendorf

8600 Dübendorf

Switzerland

Switzerland

Switzerland

Phone +41 81 414 21 11

Phone +41 44 200 24 25

Phone +41 44 200 24 20

Fax

Fax

Fax

+41 81 414 22 80

+41 44 200 24 12

+41 44 200 24 60

info@aospine.org

info@aospine.org

aocid@aofoundation.org

www.aospine.org

www.aospine.org

www.aofoundation.org/cid

AOCMF

TK System

Clavadelerstrasse 8

Clavadelerstrasse 8

7270 Davos

7270 Davos

Switzerland

Switzerland

Phone +41 81 414 25 55

Phone +41 81 414 24 70

Fax

Fax

+41 81 414 25 80

+41 81 414 22 90

info@aocmf.org

aotk@aofoundation.org

www.aocmf.org

www.aofoundation.org/tk

AOVET

AO Education Institute

Clavadelerstrasse 8

Clavadelerstrasse 8

7270 Davos

7270 Davos

Switzerland

Switzerland

Phone +41 81 414 25 55

Phone +41 81 414 26 01

Fax

Fax

+41 81 414 25 80

+41 81 414 22 83

info@aovet.org

aoe@aofoundation.org

www.aovet.org

www.aofoundation.org

*Contact information for Regional Offices can be found on individual clinical division websites

48

Concept, editing, and layout: AO Foundation, Communications and Events, Davos, Switzerland Manuel Kurth, Graphic Design and Photography

Photography: AO Foundation, Communications and Events, Davos, Switzerland Manuel Kurth, Graphic Design and Photography (pages 1, 6, 14, 50) Foto-net, Alexandra Wey (page 8)

Print: BUDAG, Sßdostschweiz Presse und Print AG, Davos, Switzerland Š May 2013, AO Foundation This annual report is climate neutral, compensation through www.climatepartner.com Certificate No SC2012040402

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