AO Dialogue 2|08 by AO Foundation

The magazine for the AO community 2 | 08

The 2008 Trustees Meeting and the AO’s 50th anniversary celebrations

Surgical missions to Gaza | AONA Faculty Educator Course Arthroscopic ankle arthrodesis | Why are horses high-performance athletes?

Contents

2 Impressum AO Dialogue 2 | 08 Editor-in-Chief: James F Kellam Managing Editor: Elena Ineichen-Grimaud Contributors: Juergen Staiger Editorial Advisory Board: Jorge E Alonso James Hunter Frankie Leung Rodrigo Pesantez Pol M Rommens Publisher: AO Foundation Design and typesetting: nougat.ch Printed by: Bruhin Druck AG, Switzerland Editorial contact address: AO Foundation Clavadelerstrasse 8 CH-7270 Davos Platz Phone: +41(0)44 200 24 80 Fax: +41(0)44 200 24 21 E-mail: dialogue@aofoundation.org Copyright © 2008 AO Foundation, Switzerland

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Cover story

4 | N ews & Events eople 8 | P

10 | T he 2008 Trustees Meeting and the AO’s 50th anniversary celebrations

In Discussion 16 | C hris van der Werken and Paul Manson talk about how the AO has changed their lives All rights reserved. Any rep roduction, whole or in part, without the publisher’s written consent is prohibited. Great care has been taken to maintain the accuracy of the information contained in this publication. However, the publisher, and/or the distributor and/or the editors, and/ or the authors cannot be held responsible for errors or any consequences arising from the use of the information contained in this publication. Some of the products, names, instruments, treatments, logos, designs, etc. referred to in this publication are also protected by patents and trademarks or by other intellectual property protection laws (eg, “AO”, “TRIANGLE/ GLOBE Logo” are registered trademarks) even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name, instrument, etc. without designation as proprietary is not to be construed as a representation by the publisher that is in the public domain.

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Report 18 | S urgical missions to Gaza

From the regions 22 | AONA Faculty Educator Course: a critical resource

Inside AO 24 | T he AO Research Fund celebrates 25 years of funding throughout the world

Internet 26 | A O Traumaline–Connecting surgeons with the latest, best evidence-based medicine

Editorial

3 My view

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

expert zone Case study 28 | A rthroscopic ankle arthrodesis: where does the technique fit in?

Clinical topic 32 | E xternal fixators: principles of application, design and assembly

Research 44 | The AO Research Fund 2008 Prize Award winner

AO Vet 47 | W hy are horses high-performance athletes? Reflections on exercise physiology and sports medicine

Anniversaries—and especially important ones such as a 50th anniversary—tend to evoke mixed feelings as to how one should celebrate them. The AO Foundation has now passed the half-way mark of its 50th anniversary celebrations. As editor, I look back upon these past eight months and am impressed that the Foundation has been able through its celebrations to emphasize its traditions and its friendships while at the same time looking to the future and building on these strengths. The 50th anniversary Trustees Meeting was the ultimate example of what the AO Foundation is and will be. The meeting was innovative in its design, interesting in its presentation, and impressive in its events. However, the most important aspect of the meeting was the renewal of the Foundation’s values—its collegial friendships based upon a common goal. This occurred through the meeting of AO trustees both past and present. Former trustees renewed old acquaintances and interacted with current trustees. For the latter, it was an opportunity to meet the giants of the past and to discuss with them what the Foundation meant and where it should be going. As I participated in the meeting, it was obvious there was a new level of commitment, enthusiasm and dedication to what the AO will be based upon in the next 50 years. On another note, I would like to welcome Elena Ineichen as our new managing editor. Elena joined us in March 2008 and has been instrumental in providing the new look to AO Dialogue. I look forward to collaborating with Elena to provide you, the reader, with an informative and stimulating look at the AO world. 2 | 08

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Panorama News, Events, People

AO Latin America Jubilee Symposium AO Latin America held its Jubilee Symposium in Puerto Iguazú (10–12 April), celebrating not only the AO’s first 50 years, but also the region’s first ten. The Latin American “AO family”—137 in total, with surgeons, spouses and guests—gathered at Puerto Iguazú, where Argentina, Brazil, and Paraguay meet. AO Foundation President Chris van der Werken joined the first Scientific General Session via video conference and officially opened the Symposium. He pointed out the importance of the regional concept and the region’s service function for the AO Specialties. AOLAT President Carlos Sancineto reminisced about the beginnings of the region ten years ago. David Grainger, of the Biotechnology Advisory Board gave a scientific lecture on biotechnology. AOLAT’s “family spirit” was evident during a visit to nearby Iguazú Falls and during the festive Jubilee Gala Dinner.

3rd General Meeting of AO CPP FFOB The third general meeting of the AO Clinical Priority Program, “Fracture Fixation in Osteoporotic Bone”, was held in Zurich (28–29 March) to discuss goals reached over the previous year and to set objectives for the next. The CPP FFOB Program consists of twelve projects with a comprehensive overview of treating geriatric fractures. Fifty-five participants were given updates by project groups showing how far the program has advanced— some projects have already reached the clinical investigation stage or have led to follow-up projects being defined. Davis Marsh lectured on co-managing the clinical process between surgeons, anesthetists, and geriatricians in treating elderly patients with osteoporotic fractures.

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5 From the AO Institutes AO Development (ADI)

Now that DensiProbe™ Hip—the diagnostic instrument for intraoperative measurement of bone strength—has proven successful in a two-center clinical case study that started at the end of 2007, the evaluation of this oneof-a-kind method will be broadened to include a multi-center study with five European clinics. All participating clinics qualified to take part based on their specialization in osteoporosis treatment. AO Education (AOE) The Trustees Meeting enabled AO Education to share with Trustees the results of the assessment tool kit that has been developed over the last two years. These results showed how the tool kit can be used to make education more effective and gave all the Trustees an insight into the complexity of ensuring that education results in improved patient care. At the same meeting, AOE also presented an outline proposal—AO Life Long Learning—which will enable the AO Foundation to interact with its members throughout the entire length of their professional careers.

Nonoperative trauma/ORP courses

Lusaka hosted a nonoperative trauma course (13–15 March) organized by James Munthali of the University Teaching Hospital (UTH) in Lusaka, Zambia, and the AO Foundation’s Socio Economic Committee. Taking part were three international faculty members, seven local faculty members, and two senior registrars in orthopedics who train at UTH. Twenty doctors who treat orthopedic patients throughout the country, plaster technicians, and a few ORP nurses participated. Lectures emphasizing nonoperative techniques were followed by practical exercises focusing on plaster techniques and the reduction of common fractures such as distal radial fractures in adults and Salter-Harris fractures in children. Running simultaneously, an AO course for ORP on “Principles in Operative Management of Fractures” was also hosted by the UTH. Twenty-six nurses from six of Zambia’s nine provinces attended, as well as a team of international and local faculty members.

AO Research Institute (ARI) In a stable internal fixation system (ie, locked), where there is minimal damage to the periosteal vasculature, polishing of titanium and titanium alloy (TAN) does not have a large influence on the infection rate. Therefore, polishing that has previously been shown in ARI both to ease implant removal, by prevention of bony integration, and to prevent gliding tissue damage, could be clinically implemented with plates and screws, since we now show that it does not reduce infection resistance. AO Clinical Investigation & Documentation (AOCID)

With the successful integration of changes required by Schatzalp 1, AOCID is now ready to assume its role as the competence center for clinical investigation. • AOCID is ready to start patient recruitment for the ASLS study after only four months’ of preparation, demonstrating the entire team’s efficiency. • Intensive discussions between Synthes and AOCID will result in several new studies being performed in collaboration with Synthes’s clinical department.

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Panorama News, Events, People

AOAA celebrates AO’s 50th anniversary in Greece This year the AO Alumni Association (AOAA) is

hosting three events, and Thessaloniki in Greece hosted the first (15–17 April), right after regional courses. Events for the CMF specialty, Trauma, and ORP ran concurrently. AO Foundation President Chris van der Werken opened the event and AOAA President Antonio Pace (Trauma), Joachim Prein (CMF), and Nicola Kildea (ORP) introduced the following days’ agendas. The trauma course focused on intraarticular fractures of the upper extremity, management of the geriatric fracture patient, and featured a short lecture followed by hands-on workshops. CMF members heard lectures on CMF treatment and programs, before participating in a BrainLAB hands-on planning and virtual surgery workshop. ORP course participants received the latest news from the regions, and the newly formed Education Steering Group presented their strategy findings. Regional strategy, mentorship, team building, and educational support rounded off the course.

AO tri-country meeting in Dresden Some 153 participants from

Switzerland, Austria, Germany, and a few from Eastern Europe, travelled to Dresden at end-May for a top-class scientific and social program. Otto Wieland received an honorary membership for establishing the AO Principles in the former East Germany and the AO Germany scientific prize went to Jan Korner. AO Foundation President Chris van der Werken and AOVA Chairman Markus Rauh spoke about the AO’s current status around the world, with a special look at Europe and Germany. Top class reports from research institute leaders were given and world-renowned experts from Germany, Switzerland and Austria reported on current developments and results in trauma surgery and orthopedics.

The AO at Eurotrauma 2008 The European Society for Trauma

and Emergency Surgery (ESTES) held its first congress, Eurotrauma 2008, in Budapest, Hungary (24–27 May), hosting 1,500 participants from four continents. An AO jubilee symposium, “Controversies in Intramedullary Nailing”, attracted 160 participants. Jenó Manninger, Max Landolt, Thomas Rüedi, and Michael Nerlich received honorary awards for assisting the AO in Hungary. Over 500 participants visited the AO Foundation’s booth to view the AO Surgery Reference. At the closing gala dinner in Budapest’s History Museum, Vilmos Vècsei led a spontaneous toast to the AO’s first 50 years.

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EFORT Congress in Nice The annual Congress

ECM IX Musculoskeletal Trauma: 50 Years of AO Research The 9th European Cells and Materials

conference was held in the Congress Center in Davos, Switzerland (June 15–18). The scientific program was put together by Geoff Richards and Mauro Alini of the AO Research Institute, and by Charlie Archer from Cardiff University in Wales. The conference was structured to highlight 50 years of AO research. AO collaborators both past and present showcased the achievements of AO research during their time there and also what they have done since leaving. The wide scope of AO Research within the field of trauma was highlighted. Separate sessions were organized for each of the main research fields of the AO Research Institute: Bone, Cartilage, Spine, and Infection. Tribute was paid to Iolo ap Gwynn from the University of Wales in Aberystwyth who has worked in biological electron microscopy for over 40 years. ECM X Stem Cells for Musculoskeletal Regeneration: From Basic Biology to Clinical Issues is scheduled for June 29 to July 2, 2009, in Davos.

took place in Nice, France, (May 29–June 1) and many of the 2,500 participants explored topics in addition to traumatology. The scientific program was put together by AOVA member Pierre Hoffmeyer of Geneva. The AO hosted a very attractive booth whose theme was the AO’s 50th anniversary, and associated problems of fracture fixation in osteoporotic bone—one of the AO Foundation’s Clinical Priority Programs. Participants learned about the AO Portal, in particular the AO Surgery Reference. The AO Jubilee Symposium, introduced by Joachim Prein, Vice-Director of AO Education, described the AO, its history and structure with particular focus on educational activities globally. An outdoor jubilee reception immediately after the symposium celebrated the AO’s first 50 years.

BritSpine and SpineWeek AOSpine attended the fifth annual BritSpine congress in Belfast (April 30–May 2), which combined keynote lectures with interactive debates and free paper sessions. Over 300 participants presented research papers on a wide spectrum of spinal conditions. AOSpine provided the Audience Response System used to evaluate presentations and AOSpine’s Alex Vaccaro and Kenneth Cheung delivered keynote lectures. AOSpine also took part in the second SpineWeek meeting held in Geneva (26–31 May) where over 2,000 participants presented research papers and discussed cases. AOSpine members John Webb, Mike Janssen, Alexander Vaccaro, Jeffrey Wang, J-M Vital, and Bernard Jeanneret participated as faculty. The first combined AOSpine and EANS seminar took place on May 27, 2008, on “Imaging and Navigation in Spine Surgery”. Forty participants enjoyed some very active discussions and debates.

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Panorama News, Events, People

Dr Phillip G Spiegel Dr Phillip G Spiegel, born on July 6, 1936, in Chicago, Illinois, sadly

passed away on June 26, 2008. He was a real pioneer of AO techniques in North America, serving as the Chairman of several early AO courses in the Region. He became Professor and Chairman of the Department of Orthopedics at the University of South Florida in Tampa in the early 1980s, and built up that unit into one of the premier orthopedic trauma education centers in the world, a reputation it still enjoys today. Dr Spiegel was also the founding editor of the Journal of Orthopaedic Trauma. He was a mentor to many AO surgeons, and he was famous at AO courses for his “How not to do AO” presentation, which was quite humorous and ended each course on a lighthearted note. He was also one of the original AO Trustees when the Foundation was formed in 1984.

Professor Philippe Vichard Professor Philippe Vichard, born on March 26, 1931, in Laxou, France, passed away on July 12, 2008. He was an AO pioneer in France and a great supporter of the AO’s mission. Over the years Professor Vichard was regularly invited to participate actively as a faculty member. He was instrumental in setting up the French Chapter of the AO Alumni Association in 1989 and was elected as a Trustee of the AO Foundation in 1991 and went on to become a Senior Trustee. An enthusiastic and wise teacher, he took an active part in the courses held in France. AO members from the French-speaking part of Switzerland held him in high regard, knowing that they could count on him to further the AO philosophy. This great teacher and master in his field will be missed by very many.

Naeder Helmy

Naeder Helmy, MD Uniklinik Balgrist, Zurich,Switzerland nader.helmy@gmail.com

After training with Otmar Trentz and Christian Gerber in orthopedic surgery, I was looking outside of Switzerland to broaden my knowledge in the subspecialty of orthopedic trauma. My academic career also needed a ‘blast’ so I applied for a fellowship position in Vancouver. The Vancouver General Hospital is a level 1 trauma centre and the tertiary referral centre of the Province of British Columbia, which covers a land mass three times that of Germany! Coming from a very small country I was over-

Fellow’s opinion

Completed a fellowship in orthopedic trauma at the Vancouver General Hospital, University of British Columbia, Vancouver, Canada

whelmed by the size of the hospital, the catchment area, the number of complex articular injuries, and the amount of acetabular and pelvic ring injuries treated there. As a trauma fellow I worked very closely with all the staff surgeons, enhancing the learning experience, as I was exposed to different treatment modalities and surgical techniques. The fellowship program is designed as an excellent hands-on experience and provides a fruitful teaching environment. My year in Vancouver was clinically and

also academically, a full success. Working closely with the Department of Orthopedic Research, I successfully completed several papers. I also had the opportunity to complete clinical studies with the Department of Orthopedic Trauma and with the Department of Anesthesiology. The AO gave my wife, three children and me the opportunity to live a fantastic year in Vancouver! This unique experience has had a great impact on my daily life and made it possible to meet great teachers and make friends all over the world.

Trauma fellows at Vancouver General Hospital (l to r): Ralph Schoniger, Switzerland, Paul Fearon, Great Britain, and Naeder Helmy, Switzerland.

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August Guggenbühl (l) greets Maurice E Müller (r) as AO President Chris van der Werken (c) looks on, at the unveiling of an AO commemorative plaque in Biel, Switzerland, March, 2008. Walter Stähli sent his congratulations on the occasion.

50 years of the AO Let’s imagine the early days when 13 pioneers set out to create something special. Besides the main push given the AO by its five leaders, eight surgeons from Swiss hospitals formed a study group to test the newly created instruments Maurice E Müller and Robert Mathys created in 1958. Each of these placed his work under the level of scientific scrutiny necessary to convince their “enemies” of its merit. Imagine their enthusiasm as they witnessed a revolution in fracture care condensed in a systematic fashion to instrumentation withstanding scientific testing that could be taught through courses and hands-on exercises. The AO was a growing continuum of efforts, successes, and ups and downs that gained momentum and became something absolutely unique, enduring until today. It is medicine universally applicable, a philosophy uniting us the world over, based upon achieving something together, as a group. The 13 founding fathers were good friends. Today, three original members remain to inspire us—Walter Stähli, 97, still full of the pioneer spirit, August Guggenbühl, 90 this November—both send their best regards to the AO community; and of course, Maurice E Müller, 90, the master and the “maker”, to whom we owe the most! AO Switzerland President Roland Jakob

Gregor Strasser: a singular dedication to the AO’s goals, principles and programs In 2000, as President-Elect of the AO Foundation,

I had the opportunity to interview candidates for the new Chief Executive Officer position of the AO Foundation. I vividly remember Gregor Strasser arriving for his interview and proceeding to pull from his briefcase a binder that was about 6 inches thick and placing it on the table. I asked Gregor what was in the binder. He turned to me and said, “AO.” It became obvious during the interview that Gregor Strasser was extremely well prepared. He knew more about the Foundation, its products, its goals, it objectives, and its surgeons than most of the Foundation’s surgeons did. Over the next six years, this dedication to the AO and its goals, principles and programs was the mark of Gregor’s leadership as CEO. He was instrumental in establishing a professional business administration in the Foundation and was supportive of its membership initiatives and regionalization program. Gregor also understood the needs of the volunteer surgeons and worked hard to assure that every surgeon, scientist and ORP who participated in the Foundation’s activities was treated with respect and friendship. As Gregor leaves the Foundation, we are saddened, but we also wish him the best in his career. It has been an excellent six years. AO Past-President Jim Kellam

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Cover story

Celebrating the past, looking to the future The 2008 Trustees Meeting and the AO’s 50th anniversary celebrations in Davos, Switzerland Diarmuid De Faoite Editor, AO Communications & Events Dübendorf, Switzerland diarmuid.defaoite@aofoundation.org

The Congress Center in Davos, Switzerland, was the main venue for the AO Foundation’s Board of Trustees Meeting from June 11 to June 14, 2008. As part of the AO’s 50th anniversary celebrations, in addition to currently serving Trustees, all Senior Trustees, Founding and Honorary Members, and AO Alumni Chapter Chairpersons were invited to participate in this very special event. Wednesday, June 11: setting the tone The traditional welcome cocktail and evening dinner took place at the Hotel Belvédère and set

the tone of collegiality that was to permeate over the next few days. While the Trustees Meeting is always an opportunity for old friends to meet up, the presence of so many AO members from down through the decades lent the occasion an extra degree of piquancy. Thursday, June 12: electing new Trustees The morning began with the annual new Trustees breakfast and the following were elected to join the fold next year: Haluk Agus, Felix Bonnaire, Friedrich Hahn, Dominik Heim, Bernhard Jean-

“We’re meeting people from all over the world; I just attended a talk on surgery in earthquake regions.” Herbert Resch, Germany “The program is very good and the organization very well done—the Swiss way!” Jacinto Monteiro, Portugal 2 | 08

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1 AO Trustees, June 2008. 2 AO CMF Specialty Board. 3 Trustees’ partners learning to “fix the fracture”. 4 The Gala Dinner’s elegant setting.

neret, Randall Matthew Chesnut, Robert Morton Kellman, Timothy G Weber, Marcelo Gruenberg, Bartolome Marré, and Yuan-Kun Tu. In his formal welcome, Chris van der Werken, outgoing President of the AO Foundation, outlined the organization’s commitment to Davos and the history of the AO, which binds the two irrevocably. A living legend was present in the audience in the form of August Guggenbühl, one of the AO’s 13 founders, who took part in the entire Trustees Meeting. When asked if he ever imagined the AO would spread around the globe when he sat down to form the organization with the twelve other founders in 1958, August Guggenbühl replied, “I still can’t believe it. Everywhere you go in the world, even to the smallest hospital, they know the AO.” Hansjörg Wyss paid tribute to Martin Allgöwer, another of the AO’s founding fathers, who sadly passed away since last year’s Trustees Meeting in China. The driving force behind the creation of the AO Foundation in 1984 was Martin Allgöwer, said Wyss, who then led all present in a minute’s silence for the man missed by so many. Charting the organization’s development In a session entitled “From a local idea to global recognition,” various speakers outlined how the AO has developed from a small working group of mostly Swiss surgeons to one of the world’s

largest and most important networks of medical professionals. After a short coffee break, it was time for the parallel sessions, which repeated over the three days of the scientific program to afford everyone the opportunity to attend each lecture, which covered the topics of imaging, endoscopic surgery, infection, medico-legal aspects of AO practice, and special trauma surgery. The afternoon’s session changed the focus of the meeting so far by looking ahead to the next five years, more particularly to the challenges and developments faced by the AO Specialties and Institutes. The evening dinner was held on Schatzalp mountain, requiring the Trustees to board a funicular cable car to dine high above the city of Davos. The view was breathtaking and the restaurant a wonderful location for the Trustees to discuss the points raised during the day’s meeting. Friday, June 13: appointing a new President At various hotels around Davos, one-hour-long early-morning sessions were held, allowing the Trustees to select from among a wide range of topics. At nine o’clock sharp, the Trustees’ General Assembly began. The Trustees act as the AO’s parliament and play a critical role in deciding the direction the organization will take. Several reports on the current status of the AO were presented, and elections were held.

“It’s the only opportunity to be all together, as normally we are all separated due to our different specialties.” Dante Marchesi, Switzerland “For those of us from the Middle East we can discuss the future of the region, which is important to us.” Masoud Norouzi, Iran 2 | 08

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Cover story

Paul Manson was elected President of the AO Foundation and assumed the office from Chris van der Werken. Manson is Professor and Chief of Plastic Surgery at Johns Hopkins School of Medicine in Baltimore, US, and is a member of the AO Board of Directors (AOVA). He has already served as the president of the major surgical societies for maxillofacial and plastic surgeons in the United States. Chosen as President-Elect was Norbert Haas, currently the President of the TK-System and a Member of the Academic Council. Recognizing outstanding achievement Two more parallel sessions took up the bulk of the day until it was time to bestow awards upon two worthy recipients. The AO Research Fund Prize Award went to Wolfgang Köstler for the project “Clinical applicability of computer-assisted arthroplasty using bio-engineered autografts.” Jörg Auer received the AO Recognition Prize, the highest award the AO can bestow upon one of its members, for his outstanding contributions to and longstanding leadership in the Veterinary TK-System and AO Vet Specialty.

roads was blocked off from traffic and refreshment stands replaced parked cars for the night. The importance of the AO to the local community was noted by one resident who commented that: “The AO has helped make Davos famous all around the world. It is great that the party is open to everyone, it really gives you a new perspective on the AO.” Saturday, June 14: continuing a tradition of openness Once again, the day began with very informative early morning breakfast sessions, including two parallel sessions in the Congress Center. A special treat was guest lecturer Stephan Perren’s very engaging talk on his flight around the world to stimulate awareness and support for research on the scientific and clinical aspects of osteoporosis.

With AO business set aside for another day, Davos Mayor Hans Peter Michel held an evening reception in the magnificent surroundings of the Town Hall’s wood-paneled council chamber to celebrate the symbiotic relationship the AO and Davos have enjoyed for decades.

There was more levity in the afternoon session as the topic “Did the AO improve patient care?” was tackled. Contributors from CMF, Veterinary, Spine, and Trauma analyzed the results of decades of engagement by the AO in these areas. The overall summation was largely positive, with speakers not afraid to share what went less well in a spirit of openness they inherited from the founders of the AO who always emphasized detailing both good and bad experiences.

A brass band parade from the Town Hall began the evening’s outdoor festivities, drawing in the populace of Davos. One of the alpine resort’s main

The final summation officially drew the scientific proceedings to a close and recognized some of those who have contributed so much to the AO.

“I’m getting to know so many famous people within the AO and I’ve had a chance to speak with them—it’s great!” Martin Richardson, Australia “…a fascinating meeting where we had abundant fellowship, understanding, and also the latest trends in trauma management.” Shantharam Shetty, India 2 | 08

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8 5 Paul Manson and his wife Kathryn. 6 Members of the AOLAT “family” enjoy a festive gala evening. 7 Jürg Auer (c) receives the AO Recognition Prize from Chris van der Werken (l) and Norbert Haas (r). 8 Participants in the new Trustees Breakfast. 9 Paul Manson (l) and August Guggenbühl (r) with Davos Mayor Hans Peter Michel (c) at Davos Town Hall. 10 Working group discussing the AOE PreopPlanner software.

There is a maximum limit of five years for someone to serve as a Trustee. This ensures a constant flow of new blood and ideas into the AO Foundation. Chris van der Werken thanked the following for all they had achieved and for their service over the past few years: Ernesto Bersusky, Joseph Borelli, Yu-Ray Chen, Sergio Fernandez, Dante Marchesi, Michael Stürmer, Clifford Turen, Mark Vrahas, Klaus Wenda, and Rico Vannini.

of him in his new role, he addressed the Trustees saying, “I rely on you…and because of your excellence I don’t think I can fail.”

Three Trustees were awarded honorary membership of the AO Foundation. Thomas Rüedi, a founding member of the AO Foundation in 1984 and a pupil of Martin Allgöwer was the first to be recognized. Hansjörg Wyss, who has had an AO connection since 1975, was the second recipient of this award. Jim Kellam, Past-President of the AO Foundation and editor-in-chief of AO Dialogue magazine was similarly honored.

The ice hockey stadium in Davos, the only venue in town large enough to accommodate so many people, was transformed into a lavish dining hall. Huge black drapes, a multimedia show, and topnotch entertainment meant that the scoreboard hanging down from the roof was the only reminder of the venue’s true purpose.Everyone present took home a commemorative, specially commissioned book entitled “Transforming Surgery—Changing Lives”, a mixture of facts and anecdotes that really brings the AO’s history to life.

Welcoming the new AO President Chris van der Werken, in his last official act as President of the AO Foundation, outlined the role the president plays and sketched some of the highlights from his two-year term. He delivered a humorous presentation to prepare the new President of the AO Foundation, Paul Manson, for the challenges he will face. Paul Manson responded with a similarly tongue-in-cheek presentation in which he thanked Chris van der Werken for all he had done as President. Manson drew attention to the fact that as a craniomaxillofacial surgeon he is the first ‘minority’ president. While aware of the challenges ahead

The scientific and administrative part of the meeting over, it was time for what was probably the social highlight of the AO’s jubilee year—the gala dinner for Trustees, Senior Trustees, AO employees, and invited guests: in all, some 750 people.

For one night only, almost every member of the AO Family was gathered in one place. Everywhere you looked you could see people who have given so much to the AO and who have gained so much from it, too. Despite the cold weather in Davos, the warmth the AO Family generated that night was more than sufficient to fill the cavernous venue. It was an evening the likes of which we will never see again and a fitting peak of the AO’s 50th anniversary year celebrations. The next Trustees Meeting will be held in Chicago, US, in 2009.

“…it’s like a family reunion. The Senior Trustees can see what the next generation has done and that the future is very promising. We are unique. We are one. And thanks to the AO Spirit, we will continue.” Suthorn Bavonratanavech,Thailand 2 | 08

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Cover story

“One revolution per day” An exceptional artwork honors the AO and the innovative work of Robert Mathys Senior.

To mark the AO’s 50th anniversary, Esther and Robert Mathys Junior commissioned a sculpture by Dublin-based American artist Paul Gregg for the AO Center in Davos. The piece, entitled “One revolution per day”, had its unveiling in June in the presence of Mr and Mrs Mathys, Paul Gregg, AO President Chris van der Werken, AO Founding Member August Guggenbühl, AO representatives and honorary guests. The steel and birch sculpture encompasses two connecting and harmonious parts, both referencing the international scope of the AO. On one side a large pendulum swings across a polar-view map of the world in synchronicity with a slowly-revolving, 18-inch crystal globe on the other side. The town of Davos marks the reference point on the sphere, upon which visiting scientists can chart the time in their homelands in relation to the AO’s home.

1 Chris van der Werken, Esther and Robert Mathys Jr, and Paul Gregg.

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Stainless steel fastenings on the sculpture are clearly evident and call to mind AO faculty’s dexterity with instrumentation, while the inscription “life is movement” attests to the fact that “movement is a healthy part of the world and also of joints. It ties in with the AO philosophy that external fixation

promotes quick recovery and early movement,” says artist Paul Gregg. “Great care was taken to ensure the sculpture reflects the meticulous craftsmanship and precise engineering that appeals to me as an artist, and is vitally important to the AO in the advancement of orthopedic surgery,” he adds. The artist’s sculptures for the Royal Victoria Hospital in Belfast, Ireland, of bombed-out buildings repaired using external fixators as architectural scaffolding brought him to the attention of AO Past President Peter Matter, who later recommended Gregg’s work to Robert Mathys Junior. Mathys had confidence in Gregg’s vision of an extraordinary artwork to honor the AO’s first halfcentury; it’s noteworthy that the material used nods to the exceptional craftsmanship and skill with stainless steel shown by his father, the late Robert Mathys Senior, pioneering designer of AO instruments and implants. “I deliberately worked with stainless steel to reference orthopedic fixation,” Gregg explains. “I included wood as this has a fibrous make-up similar to bone. It also offers “warmth” to the overall piece so as to balance the “clinical” reference stainless steel brings. By fixing these materials together with clearly visible bolts my fabrication displays the kinship of techniques between an orthopedic surgeon and a carpenter.” The theme of kinship also resonates with Robert Mathys Jr, who at the sculpture’s unveiling said the artwork’s two main components: “are locked to each other so that one part can not work without the other part. For me it is a symbol of partnership and steady development and of an idea spread across the globe. I am very proud to still be a member of this great AO Family.” eig (www.paulgreggstudio.com)

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Documenting a milestone in AO history The AO publishes a commemorative book on its first half-century.

A thoroughly engaging and informative book specially commissioned to celebrate the AO’s 50th anniversary, entitled “Transforming Surgery, Changing Lives: The First 50 Years of the AO”, has proved very popular since its launch at the Anniversary Gala Party in Davos in June.

1 August Guggenbühl with his copy of the AO anniversary book. 2 Richard Bird, Amirah Blackmore and Sandro Isler.

This hundred-page, hardcover book provides a comprehensive introduction to all aspects of the AO, from its earliest days and the unique contributions of the 13 founding fathers, through its development from a Swiss to a global organization, to its current structure, activities and objectives, together with pertinent discussions on its future. The AO’s ubiquitous sense of family and fellowship, its unique spirit, and the abiding principles and values put in place by its founders resonate on its pages.

The result of 16 months of creative effort, the book is a valuable reference and memorable keepsake, appropriate for AO ‘old-timers’ and newcomers alike—and for an external audience, a first-time insight into a groundbreaking organization whose excellent work and dedication benefit patients the “One highlight was interviewing the legworld over. endary Maurice E Müller, who recently celebrated his 90th birthday, at his home in Bern. His daughter, Janine Aebi-Müller, rem ind ed him that it was important to drink enough liquids and asked if he would like some tea. ‘No,’ he replied in Swiss German, ‘I would prefer Campari.’ So, we all proposed a toast and I clinked glasses with the man who started it all....”

Richard Bird

Crafting a book with such broad appeal proved a challenging but ultimately successful task for a devoted and enthusiastic team of collaborators, including the book’s writer, Richard Bird.

“As I began this project, I was struck by how few people outside specialized surgical fields knew the compelling story of the AO. At the same time, the concept called for subject matter for AO insiders as part of the 50th anniversary celebration. It was a tough balancing act. “I was fortunate to have the guidance and support of an excellent project manager and editorial team led by Jim Kellam, as well as graphic artists who immediately grasped the layout concept and infused it with their creative talent,” Bird says. Graphic designer Sandro Isler came up with a dynamic design that marries text, original interviews, and humorous anecdotes with photographs both old and new, whimsical sketches, and colorful illustrations so that the result is authoritative yet warm and welcoming. It’s a book that rewards each reader in a uniquely personal way. For AO Foundation Anniversary Manager Amirah Blackmore that meant learning what the AO spirit means to surgeons around the world. “As long as the friendship and sharing prevail, the AO’s future will be assured and thereby benefit us all,” she says. The book was distributed to Trustees during the Trustees Meeting in June, and will be given to AO employees, faculty active around the world in 2008, AO Alumni members at regional courses in Dubai, UAE, and Chiang Mai, Thailand, to the AO’s industrial partners, and on special request from health authorities. A book teaser will appear on the AO website at www.aofoundation.org in September, where the book will be available to order at a cost of CHF 50.– plus packaging and postage. eig

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In Discussion

“The AO has not only changed my life, but enriched it.” Chris van der Werken’s term as President of the AO Foundation has ended and Paul Manson’s has just begun. In its jubilee year, the AO is reflecting upon its past while gearing up for the future. AO Foundation Editor Diarmuid De Faoite speaks to the two AO Presidents who straddle the divide between the AO’s first, and next, 50 years.

Chris van der Werken (CvW), what did your role as AOF President entail these last two years? CvW: I was preoccupied with the main roles each AO Foundation President has to play. These include chairing the Academic Council to set the AO’s scientific direction, acting 2 | 08

as the Foundation’s ambassador at various events as well as specifically representing the AO’s medical community to various audiences, and organizing the yearly Trustees Meeting. The two Trustees Meetings in Beijing in 2007 and the jubilee meeting in Davos in June 2008 were

the highlights of my presidency. The 50th anniversary of the AO naturally dominated my workload. Planning for this anniversary year began in September 2005 so it has been a huge part of my life these past few years, culminating with celebratory events all over the world in 2008.

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17 Paul Manson (PM), what are your plans for the next two years? PM: My principal focus is education. I would like to see the AO Foundation enlarge its offerings and provide broader reach across the globe. Additionally, I am a proponent of regionalization and the AO Membership concept. I would like to maximize the potential for regional governance, while helping the central activities of the Foundation better communicate with the Regions. Helping the various AO Regions adapt to a new structure is a big challenge. I would also like to help AO Vet establish its own independent governance as well as to assist other groups, like AO Hand, in the further development of their specialties. I will also have a role to play in helping to get the AO Trauma Specialty and the AO Europe Region up and running.

Chris van der Werken

Regionalization was also a watchword during your term of office, wasn’t it, Chris? CvW: There were a couple of regionalization highlights during my presidency. Of course I cannot take credit for all of these as many of them have their roots in projects begun in the recent past. The creation of the AO Asia Pacific Region is a notable achievement—3.4 billion people live

in this catchment area! Similarly, the AO has made strides in the Middle East with the creation of Trauma and Craniomaxillofacial groupings there. Will we see increased attention to CMF during your presidency, Paul? PM: While I do have a CMF background, and am the first non-Canadian North American President, I also have a global perspective across all Regions and Specialties. You can expect me to focus on the big issues, such as how we spend our money. With the economy today, you can expect to see increased attention to resource allocation across the entire AO. For example, the recent rises in fuel prices increase travel costs—all of which affects the AO’s operating costs for courses. Transforming Surgery—Changing Lives is the slogan during the AO’s anniversary year. Is it an apt expression? CvW: Most certainly! The 13 surgeons who founded the AO in 1958 revolutionized fracture care. While such a fundamental revolution in orthopedics is perhaps not imaginable today, through the 500-plus AO courses worldwide this year, our extremely well-visited Internet portal, and also through projects like the four Clinical Priority Programs, the AO is continuing to make incremental strides in the improvement of patient care. PM: The AO has certainly transformed CMF surgery. AO teaching methods have spread CMF techniques throughout the world in a way that was not previously possible or likely. Prior to the AO, education in CMF was channeled through three distinct CMF Specialties (Oral and Maxillofacial Surgery, Plastic Surgery, and Otolaryngology). The AO did something uniquely different by making CMF education an interspecialty exercise.

How has the AO changed your life? CvW: On a personal level, the AO has not only changed my life, but enriched it through the people I’ve met from different cultures as a result of the AO’s huge international network. In addition to gaining an awareness of the large variations in medical care in the world, I’ve also made friends across all the AO Regions and Specialties. This is equally true for my wife Martina, who has also benefited from my being part of the AO Family. PM: The AO has exposed me to a wide variety of surgeons from every continent in the world, giving me insight into how different medical and surgical practices are around the world. The AO has allowed me to participate in a worldwide, first rate educational program, and I have

Paul Manson

had some uniquely rewarding personal experiences with other CMF practitioners.

Thanks to you both for giving your time for this interview and for all you’ve done for the AO Foundation. Wishing you both continued success. 2 | 08

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Report

Surgical missions to Gaza AO Alumni Member Sylvain Terver shares his experiences of orthopedic care in hospitals of the Gaza Strip.

Palestine

Tel Aviv

Jerusalem Gaza City

Hebron

Gaza Strip Rafah El Arish

Khan Younis

I s r a e l

E g y p t

Sylvain Terver

Surgical needs in trouble zones are often difficult to evaluate as current events often push daily realities from the spotlight to concentrate on complex political data, particularly in the Middle East. The situation on the Gaza Strip is back in the headlines since Hamasâ&#x20AC;&#x2122;s win in the January 2006 parliamenAl-'Aqabah tary elections and the end of the ensuing HamasFatah unity government [with Hamas taking full Saudi Arabia control of the Strip in June 2007]. Nevertheless, the daily reality for inhabitants of this little piece of land is poorly illuminated by media coverage.

AO Alumni Association Member Clermond-Ferrand, France 0

sylvain.terver@aoalumni.org

Elat

Red Sea 0

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Keep in mind that on a territory 40 km long and at most 10 km wide live almost 1.5 million people, or about 4,000 per sq km! I twice had an opportunity to visit, the first time in March 2007 under the unity government and the second in September 2007 under Hamas. The first visit was to evaluate orthopedic needs: conducted on behalf of MĂŠdecins du Monde, we were permitted to visit the Al-Shifa Hospital in Gaza City (population 400,000) in northern Gaza and

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1 1 A market scene in Khan Younis. 2 Performing the first intramedullary locked nailing of the femur in Gaza; head surgeon Nabil Shawa (2nd from left) with the author (left) assisting, Al-Shifa Hospital, Gaza City.

the European Hospital in Khan Younis (population 200,000) in south-central Gaza, but we were unable to visit the Nasser Hospital, also in Khan Younis.

Hospital operations are totally dedicated to the possibility of major emergencies.

Consultations are anarchic Al-Shifa Hospital dates from the 1970s, and operating conditions are maintained as much as is possible under a blockade. [Israel gained control of the Gaza Strip during the 1967 Arab-Israeli war, pulled its troops out in 2005, but today still exercises control over most of Gaza’s land borders, territorial waters and airspace.]

nization appears to be in place: patient dossiers are reduced to the admission sheet and operating room results, and x-rays are returned to patients.

Orthopedics consists of the following: • Two departments with rooms of two-to-eight beds each: one for men, with 28 beds, and one for women and children, with 20 beds. • Two operating rooms (“cold” and emergency). • Four teams of surgeons, each using the operating room once per week. • Sufficiently numerous support personnel. The layout consists of eight rooms in a line with a room running peripherally—there is no air conditioning whatsoever. The instrumentation is outdated and increasingly difficult to maintain. Consultations are totally anarchic and dominated by emergencies with, at times, influxes of 50-to100 casualties resulting from Israeli interventions or from inter-familial conflicts. Hospital operations are totally dedicated to the possibility of major emergencies and no real orga-

We can find a sheet of paper with the patient’s temperature and a few remarks noted. No mail or secretarial function exists. Hospital stays are generally very brief and patients with open fractures of the lower extremities caused by ballistic damage usually don’t stay more than 48 hours, just enough time to place an external fixator and bandage. On one hand, one must admire the team’s remarkable, instantaneous efficiency. On the other, there is no cooperation between operating teams, no dossiers discussed or filed, no patient follow-up or after-care, and no relationship with the town. Operating technique is that which is acquired by team heads from their study of a few, recent materials allowed through the blockade. Patients chafe at hospital regulations The European Hospital, constructed in the 198090s with European funds, is comparatively more modern and corresponds positively to those in France in its operating rooms with air flow; rooms for two-to-four patients; and its modern equipment (arthroscopy, knee prostheses, microsurgery with 2 | 08

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Report

Gaza Strip colleagues hope to be reintroduced to modern orthopedics.

a microscope, etc). But this hospital, run along European lines, is poorly accepted by the population who are irritated by its few existing regulations.

Aside of emergencies and their follow-up, orthopedic surgery is dominated by infantile orthopedics (60% under the age of 15!!) and some tumors. But injuries associated with the conflict largely dictate services and include ballistic fractures of the knee (a favorite zone for all soldiers—it doesn’t kill but handicaps for life!), infected pseudo-arthritis more or less open, at very least severe stiffness, shortenings and mal-unions, etc.

3 The author near a water purification system for a hand-washing trough, Al-Shifa Hospital, Gaza City. 4 Patient with an elbow LCP implant, Al-Shifa Hospital. 5 The author (center left) with medical colleagues at the home of Nabil Shawa (center right), Gaza Strip, March 2007. 6 The author (left) with Nabil Shawa, acting head of Al-Shifa Hospital. 7 Al-Shifa Hospital surgical bloc staff members.

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Our first conclusions were: • An evident need of organization, first with the maintenance of dossiers (a secretariat, posthospitalization follow-up, discussion of dossiers, etc). • Post-emergency follow-up care including: inhome care, physical therapy, a reeducation center, organization of consultations, etc. • For surgeons (too long isolated), a return to a higher level of expertise principally in infantile surgery, arthroscopy, and post-traumatic care of bone infections. • Surgical formation for flaps. Additionally, a renewal of reference materials, instruments and osteosynthesis materials is required. The problem lies as much with what the Israeli police will let through as with what suppliers can sell.

Sanctions make life difficult In reality the problem is that the Gaza Strip is a vast prison enclosed by walls and surveyed by observation towers, balloons with cameras, and drones. It is not possible to leave by land, air, or sea. The Israeli government has perfectly judged what is necessary to let in so the population does not die of hunger and limits it strictly to that. By personal experience we can say that official statements stating that humanitarian efforts are aided are false. For surgeons, the principal difficulty is imprisonment—at least that was the case in March 2007. During our second trip in September, made possible with AO help, we returned with two surgeons who had been allowed to leave for a course in Dubai. The situation had changed a lot: security was much greater and it was now possible to move about on the streets, which was not the case in March. This was possible because Hamas had collected the majority of arms circulating in the city and had put a ‘city police’ in place, regulating the traffic of people and exercising a permanent watch. On the other hand, the weight of Islam felt stronger as did, to a greater extent, the duality of power. Thus the Ministry of Health, which pays all persons involved in healthcare, is found in the Fatah-governed West Bank. The message relayed by professional unions is that all persons working in the Gaza Strip should be considered Hamas supporters and as a consequence are subject to salary sanctions. Authorized working hours are limited to between 8 am and 11 am, with all activity out-

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The Internet frees colleagues from intellectual and professional isolation.

side those hours penalized. It is difficult to know to which extent these sanctions exist in reality and to which extent they exist due to misinformation. The fact is that hospital staff only work during these hours, except for surgeons “of character”, of which we encountered a few examples.

Operating sessions are very restrained due to limited working hours, but we participated in a few, including the following: • The first locking compression plate (LCP) implants in Gaza (the material was purchased on an NGO budget without expatriate control and at the suggestion of Gaza surgeons who did not know what it was!). • The first cases of intramedullary locked nailing of the femur. • The first examples of knee ligamentoplasty (anterior cruciate ligament) without screws, because they didn’t have any—they didn’t know it can be done without them! • Infantile surgery.

Internet alleviates professional isolation Our thoughts during this second visit focused largely on the “imprisonment” of these colleagues who very much hope to be reintroduced into the great current of modern orthopedics. We must reflect on what is indispensible to our practice, what is useful, and what only contributes to an improvement of the surgeon’s comfort level. The only medical representatives these surgeons can meet are courageous representatives who go to present their products, as they are instructed to do. This contributes to the absurdity of purchasing a LCP on NGO credit even though they don’t have any C2 and C3 plates or dynamic hip screws!! Internet access in Gaza is indisputably regulated by Israel with unforeseeable interruptions and without a doubt, automatic surveillance of certain key words. Nevertheless the Internet offers an irreplaceable chance to free these colleagues from isolation both intellectual and professional. Our stay in this country permitted us to make solid friendships and to better understand the sentiments of Gaza Palestinians regarding the Israeli government and army. We also came to understand to what extent a small gesture like going for a visit means to them and how it helps them continue to believe in their profession in circumstances, the difficulty of which escapes us. (Ed. Note: On Tuesday, June 17, 2008, Israel and Hamas agreed to a six-month truce in and around the Gaza Strip.) 2 | 08

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From the regions

AONA Faculty Educator Course: a critical resource The FEC maintains the existing teaching skills of current members and exposes new faculty to effective teaching strategies. Michael Baumgaertner AO North America Musculoskeletal Trauma Education Committee, New Haven, Connecticut, US michael.baumgaertner@yale.edu

Responding to a request from North American faculty, and borrowing proven techniques from AO Educationâ&#x20AC;&#x2122;s Tips for Trainers (T4T) course, the North American Musculoskeletal Trauma Education Committee (NAMTEC) has developed the Faculty Educator Course (FEC) and to date, nearly 100 AO North America (AONA) faculty members have participated in some or all of the course modules. FEC ranked most important The impetus to create the program occurred at the 2005 AONA Faculty Forum in Scottsdale, Arizona, US, where an ad-hoc committee to explore future educational offerings presented several new courses and a specific program to improve the teaching skills of AONA faculty. The Faculty Educator Course (FEC) was ranked most important of all the course offerings, and AONA President Jack Wilber charged NAMTEC to create

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the program. NAMTEC then invited five members of the original ad-hoc committee (Steve Schelken, Larry Bone, James Stannard, Roger Wilber and Michael Baumgaertner) to develop the course. A needs assessment questionnaire was sent to a sampling of AONA members that included (and stratified) new, established, and senior faculty. Two committee members attended an AO Educationâ&#x20AC;&#x2122;s T4T course to see first-hand the techniques employed in this well-received course led by Lisa Hadfield-Law. AO publications on teaching and learning were used as source materials, and a professional communicator (Patricia Scott) offered insight and experience in adult medical education. Multiple conference calls and a weekend organizational meeting led to the first FEC being offered the day before the AONA Basic Principles course in Burlington, Massachusetts, US, in May 2007.

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23 The FEC has three primary objectives: Firstly, to focus the participants on how the different faculty roles (lecturer/moderator/small group facilitator/ lab table instructor) are each critical to effectively teach the course content; secondly, to review the key principles of adult learning to identify successful learning strategies; and lastly, to improve AONA faculty skill sets through interactive and small group formats.

3 1 Participant Dave Karges at a FEC in Houston, Texas. 2 Malcolm Smith (right) in a FEC table instructor session. 3 Roger Wilber introducing a FEC session in Houston.

Focus on the learner The current course is formatted for one day, to precede an AONA Principles Course. After introductions, Pat Scott offers a keynote presentation on effective communication. To prepare and deliver a presentation, she emphasizes that “It’s not about you: It’s about them!” in order to relax the speaker, but more importantly to frame the lesson in a context that is meaningful and memorable to the learner. To organize the subject to fit within the time allotted and to deliver it effectively calls for verbal, and also visual and vocal tools. Participants then break into smaller, interactive groups to specifically address each of the critical teaching roles asked of AONA faculty: lecturing, table instruction, small group facilitation, and moderating. The “mini-lecture” module allows faculty to present a brief talk, and then selfcritique it, followed by observations from the group. The format is borrowed directly from the T4T course, including the strong emphasis on the frequently overlooked strengths of each presenter. Organization and visual and vocal aspects of the presentation are all open to analysis. Each speaker gets a DVD recording of their own presentation for self-assessment. Highlighting good technique The module on facilitating small group discussion attempts to improve on what is generally reported by Principles Course participants as their most effective learning experience. The interactive format employs situational video clips from recent courses to initiate discussion and highlight good technique for common situations such as emphasizing the learning point, controlling the dominating participant, refocusing a wandering discussion, etc. Lab table instruction, as well as lab moderating, is also addressed as a small group module, usually around a table with instruments and implants, just as would occur at a course.

This module emphasizes pre-lab preparation, and uses video clips, “huddling”, and impromptu role playing and critique to improve hands-on guidance skills. Effective strategies for moderators Nowhere in the AO world does the lecture session moderator have more responsibility for the success of the course than in AONA courses. Generally reserved for experienced, proven faculty, it falls to this person not only to stay on time and allow for feedback, but to correct inconsistencies, clarify important concepts, and finally, to ensure that the lecture session’s learning objectives have been met. The module on moderating offers strategies and practice for this critical role, one that requires an equal amount of pre-course communication and coordination as it does podium policing and “on-the-fly” impromptu session modification to optimize the participant experience. The course concludes with a lecture on giving and receiving feedback—a duty most faculty members feel somewhat ill at ease performing (based on the needs assessment questionnaire responses). With 500 active faculty members in AONA, the FEC provides a critical resource to maintain the teaching skills of our current members and offers new members concentrated exposure to known, effective teaching strategies. There is no doubt the need for this resource will continue, but the format and venues may change. Currently, there are plans for an AONA annual meeting: a perfect place to offer a stand-alone FEC as well as “refresher” modules, not only for trauma faculty, but also craniomaxillofacial and veterinary educators as well. Clarity of purpose NAMTEC is exploring the option of packaging much of the course into “e-learning” modules, which could be completed on-line at the learner’s convenience. The FEC offers tools to ensure that regardless of the range of treatment preferences among the AONA faculty, the course participant learns and comes to believe in the AO principles that bind and unite the faculty. It is often this clarity of purpose that distinguishes the AONA course from other educational offerings, allowing the participant “to see the forest through the trees.” 2 | 08

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Inside AO

The AO Research Fund celebrates 25 years of funding throughout the world Anita Anthon AO Research Fund Commission Manager Dübendorf, Switzerland anita.anthon@aofoundation.org

Encouraging research excellence As a research-based organization, the AO Foundation has been encouraging excellence in research by funding scientific projects for the past 25 years. From the very beginning—with the first AO Research Fund (AORF) meeting in 1983 chaired by Martin Allgöwer—until the present, the research community has highly valued the unique opportunity to submit novel and innovative projects as encouraged by the AORF research guidelines. Improving patients’ quality of life A strong and highly productive reviewing structure has ensured a professional selection process,

resulting in almost 900 funded research projects during the last 25 years. Many scientific careers have been initiated and supported by the AO Research Fund, thus strengthening the AO’s international network. Worldwide, numerous patients have benefited from optimized techniques and processes, therefore maintaining and/or improving their quality of life. A desire to recognize the brilliant research work achieved by funded investigators led to the AO Research Fund inaugurating a yearly Prize Award in 2006. In this special 25th anniversary year, Fund Chairman Adrian Sugar and the AO Re-

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1 2008 Research Fund Prize Award winner Wolfgang Köstler with Fund Chairman Adrian Sugar, Davos, Switzerland, June 2008.

2 AO Research Fund Commission members discussing grant applications.

search Fund commission members were proud to announce the third prize winner so far, Wolfgang Köstler. A description of his award-winning project can be found in the Expert Zone on page 44. How to apply for an AO Research Grant Individual researchers and research groups are invited to apply for either a start-up grant or a focus grant. Start-up grants are designed to encourage researchers to develop unconventional, novel and innovative projects, and to expand on a wide range of research fields within the AO Foundation’s general areas of interest. Experienced and proven researchers in all the specialty groups (general trauma, orthopedics, spine, craniomaxillofacial and veterinary surgery) are eligible to apply for a focus grant, as are related basic scientists. Focus grant projects are designed to add to our knowledge of key research areas as determined by the AO Academic Council. For the 2008/2009 calls, the clinical focus/priority areas are as follows: • Fracture fixation in osteoporotic bone • Large bone defect healing

• Imaging and planning of surgery • Degeneration and regeneration of the intervertebral disc Application deadline and review process Deadlines for grant applications are February 15 and August 15 each year. The application forms and guidelines can be downloaded from the AO website at www.aofoundation.org/aorf Each application will be reviewed by at least two independent experts. The reviewers follow a structured questionnaire that guarantees every aspect of the application is thoroughly elaborated on. Based on the individual reviews, AO Research Fund Commission members then discuss the applications and select those projects worthy of funding. Once a study is accepted, the research will be supervised by a monitor who is usually a member of the Commission. Contact information Further information can be obtained by contacting the AO Research Fund Office at the direct telephone number: +41 44 200 24 10, or at email: anita.anthon@aofoundation.org

“A few years ago, we received a research proposal from an applicant in the developing world. It was handwritten and had few details about the project—certainly not up to our usual standards. But there was something about it that was both serious and sincere. The applicant asked for a modest amount of support, so we decided to fund it. Not only was the research project finished on time, but it achieved very interesting scientific results. Sometimes you have to trust your instincts and give people a Adrian Sugar chance; the results can be astonishing.”

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Internet

AO Traumaline–Connecting surgeons with the latest, best evidence-based medicine Michael Redies Head of AO Knowledge Services Davos, Switzerland michael.redies@aofoundation.org

From the very beginning, the AO’s founding fathers recognized the value of documenting patient case records as a basis for learning and for proving the legitimacy of AO methods. In the last few decades, however, a shift has taken place from relying on “eminence-based” medicine—citing the practices and opinions of respected, senior surgeons, to evidence-based medicine—citing hard scientific data. An initiative to answer the growing needs of surgeons for the latest, most reliable evidence-based medicine based upon clinical trials of the highest accepted standard resulted in the birth of AO Traumaline™ in 2006. The brainchild of AOCID Director Beate Hanson and Educational Products Head Urs Rüetschi, Traumaline was brought into practical existence by AO Knowledge Services with design and development assistance, and using input from AO surgeons.

That Traumaline can be regarded as a major success is evidenced by the close to 15,000 “requests” it receives from AO and external surgeons every month with a steady trend toward increasing usage. “With Traumaline I get fast, focused, and the latest results, which is important for doctors who are very busy and don’t want to lose too much time,” says Jorge Rubio-Avila, an AOCID Fellow in Dübendorf. He conducted research work on the topics of total knee replacement, and quality of life with nails and plates in tibial fractures, and found Traumaline a very valuable information resource. AO Traumaline: a one-of-its-kind innovation The internet-based search engine locates orthopedic and trauma studies published since 2000 in leading medical and scientific journals. At

1 3 A computer in Beijing, China, most often paid a call, conducting 310 searches during 20 visits.

Traumaline

In May 2008, 14,500 visitors searched Traumaline. 14,500 visitors

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The keywords “ankle fractures” (66 searches), followed by “proximal femoral nail” (53 searches), and then “clavicle” (51 searches) appeared most frequently.

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1 AOCID Fellow Jorge Rubio-Avila finds Traumaline “fast and focused.”

present there are some 3,500 studies available on Traumaline that have been sourced from MEDLINE, the US National Library of Medicine’s premier bibliographic database, as well as eleven authoritative trauma journals.

Studies are added on a monthly basis and are all man- rather than machine-selected because: “It’s too difficult for a machine to recognize studies we want (clinical research of therapy, prognosis or diagnosis) and to exclude those we don’t want,” explains Michael Redies, head of the award-winning AO Knowledge Services team that manages and updates the search engine. What distinguishes Traumaline from other similar services, he adds, is that “it includes only trauma studies; it’s a research database; and many study parameters are listed that are not available [elsewhere]. These include the study type, design and purpose; and the PICO (patients, intervention, control, outcome) or PPO (patients, prognostic factors, outcome) parameters.”

A unique feature and major advantage of the service is that all entries are rated according to four classes of evidence, with those offering the highest level of evidence, Class I, listed first and those offering less scientifically rigorous results listed in descending order. Service destined to improve The benefits offered by Traumaline to its core audience—trauma professionals who undertake academic work, give lectures and presentations or teach—are certain to grow, and user feedback is invited to help improve the service and make it more user-friendly. Michael Redies would like to offer personalized summaries and free “subscriptions” (the service itself is already free-of-charge for all) that would provide users with notification of new studies in their chosen fields. While pleased with Traumaline’s success, he admits the service is not too well known yet and could certainly draw even more users—something that with time this latest in a long line of groundbreaking AO innovations is sure to do. eig To visit Traumaline, please go to: www.aofoundation.org and “Web Services”. 2 | 08

expert zone

Case study

28 This article considers where arthroscopic techniques fit into the surgical armamentarium, what their limits are, and what tricks and pitfalls are associated with them.

Ian G Winson (UK) and Les Grujic (AUS), members of the AO Foundation’s Foot and Ankle Expert Group (FAEG) together with Andrew Sands (US), Per-Henrik Agren (Sweden), Michael Castro (US), and Juan Gerstner Garces (Colombia).

Arthroscopic ankle arthrodesis: where does this technique fit in? 3 debate over the role of arthroscopic techniques in arthrodThe esis of the ankle remains an active one. Recent publications, including one from a member of FAEG, the largest series published to date, have established this technique as safe and reliable. But where does it fit into our surgical armamentarium, what are its limits, and what are the tricks and pitfalls of this surgical technique? This article is a discussion between Les Grujic (LG), a member of FAEG, who has large experience with open arthrodesis, and Ian Winson (IW), president of the European Foot and Ankle Society and a member of FAEG, who has large experience of arthroscopic ankle arthrodesis.

Early publications of arthroscopic arthrodesis described various features of the technique and yet showed a contrast in information about success rates and benefits. Assumptions seem to be that the fusion rates were lower or at best equal to other techniques and yet it was also suggested that fusion occurred more rapidly. In spite of no scientific data, presumptive limitations were placed on the achievable degree of angular correction. Though it remains obligatory to study the technique scientifically, some further guidance can be obtained from the literature to date. Question 1 Many techniques for ankle arthrodesis exist with variable fusion rates. Is the fusion rate lower with arthroscopic ankle arthrodesis as adequate exposure and preparation of the joint surface appears difficult? The fusion rate for arthroscopic arthrodesis reported in the published literature equals the highest fusion rates for open

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arthrodesis. In the series I (IW) have published in the JBJS, there were 9 nonunions in 118 cases. There is a learning curve, as the nonunion rate in the first 16 cases was 5 cases as compared to 4 cases in the last 102 cases. This is in keeping with more recent, large series of arthroscopic arthrodesis reporting non-union rates between 3 and 4%. It appears to be an effective and reproducible technique in terms of union rates in different practitioner’s hands. Access to the ankle for an arthroscopic arthrodesis can be difficult for someone not undertaking ankle arthroscopy on a regular basis. With arthrodesis being essentially a destructive procedure unlike conventional arthroscopy, access to the joint can be “forceful”! It should be remembered that in most forms of arthritis the joint space is not narrowed, but due to loss of the articular cartilage there is a relative increase in the joint space. With the use of an ankle distracter the joint space in many cases can be relatively wide. The exception to this is where there are genuine soft-tissue contractures as evident after very extensive trauma where genuine arthrofibrosis has occurred or in psoriatic arthritis. It always remains good advice to start with the simpler cases and as experience is gained advance to more difficult cases. Once access to the joint is achieved, conventional power instrumentation can be used to prepare the joint surface to bleeding cancellous bone. Fixation with percutaneous screws under image intensifier control is relatively straightforward.

expert zone

Fig 1 Standard correction of a valgus deformity.

Question 2 Is arthroscopic ankle arthrodesis an in situ arthrodesis?

Posterior translation has been advocated by many authors to improve gait. Is an adequate posterior translation possible using arthroscopy? Early reports of arthroscopic ankle arthrodesis advocated the use of cross screws, one through the fibula and one put in medially. This distribution of screws has been abandoned by most people regularly undertaking this procedure. One of the major reasons for this is the need to address the positional issues dictated by ideal biomechanical considerations. The first part of translating the talus into the ideal position mechanically is to produce a degree of external rotation; this can be achieved by clearing the osteophytes laterally and if necessary, anteriorly. Similarly, translation posteriorly can be achieved by careful resection down the medial side and posteriorly. In particular, the posterior part of the tibia can be resected from the front. Two screws placed from the medial side of the tibia and sloping from posterior medially to anterior laterally and approximately parallel, pull the talus posteriorly against the medial malleolus. If there is a need to maintain external rotation, placing the most lateral screw first will promote this. Question 3 Various approaches are available for open arthrodesis,

dependant on deformity, previous incisions, and implants. This versatility allows you to address both valgus and varus deformity. How does arthroscopic arthrodesis cope with these problems? Of course the critical issue with any ankle arthrodesis is the position in which the foot ends up. Angular deformity at the level of the ankle is one thing, but the position of the rest of the foot has to be correct. The ideal position for the foot is plantigrade

with 5–10 degrees of external rotation and with the forefoot balanced on the floor in weight bearing. Assuming that the only deformity not allowing this position is in the ankle, then arthroscopically this is dealt with in exactly the same way as it would be in an open case. It is notable that in the majority of cases the loss of bone that creates the deformity is on the tibia and as such, removing sufficient bone from the appropriate side, either medial for valgus or lateral for varus, will reduce the angular deformity. Two other issues, the rotational alignment and osteophytes blocking reduction, must be recognized. There is almost invariably an element of equinus and internal rotation of the talus in varus and these have to be corrected, but the same applies to open fusion. In our series it was relatively easy to correct deformity of 25 degrees. A recent publication looked at the correction of 30 degrees-plus and found no difference in the pain and functional scores in this group compared with a group starting with neutral alignment. Question 4 In your experience, what are the advantages of arthroscop-

ic ankle arthrodesis? What about surgical time, time to fusion, degree of swelling, postoperative pain, and degree of surgical difficulty? The best cases for this technique are those with poor skin or extensive scarring. This technique lowers the risk of postoperative soft-tissue complications as you use only four small stab incisions and avoid major scarred areas. Surgical times vary depending on the complexity of the deformity. I (IW) also think that as you become more experienced you get quicker. An average time would be about an hour, you can rarely force it under 45 minutes, and occasionally it would take two hours, but that 2 | 08

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Case study

Fig 2 Preparation of the joint surface.

would be exceptional. This consistency of union rates across large series with low nonunion rates speaks for itself. Some authors think that union can be faster with arthroscopic arthrodesis. I have adopted a cautious approach. I would rarely take them out of a removable cast prior to twelve weeks. But my standard post-operative regime would be two weeks nonweight bearing, 6 weeks partial and one month fully-weight bearing; there is some evidence that you can start weight bearing from the start. One of the features of arthroscopic arthrodesis is the low incidence of postoperative pain; it is not unusual for patients to comment that they have had no postoperative pain at any stage.

Question 5 Do you get good apposition of bony surfaces or is a hole

created? The answer to this is probably yes and yes. Effectively, you always take off a little more centrally than you do at the edges of both tibia and talus. This produces a central contained defect of cancellous bone that should be healthy and bleeding. This appearance can easily be seen at the time of surgery as you are examining the surface with a 2.5 X microscope. The construct is held rigidly in compression with well-placed screws and any relative defect fills in. By producing a relatively uneven surface in good apposition you increase the surface area. Initial x-rays often show a decreased bone density (never a true gap) and serial films show this simply fills in. Question 6 Do you ever use bone graft?

Swelling is difficult to judge as it is dependant on so many factors; again the general impression is for it to be less compared with other hind-foot fusions, but there is no scientific basis to this observation.

No. There are circumstances where there is massive bone loss and as a consequence some form of structural graft is necessary: these are cases where even conventional open arthrodesis may need considerable modification.

Surgical difficulty is relative, and if you are used to doing arthroscopic procedures the technique is relatively straightforward. Most surgical trainees are ready to undertake one on their own after seeing about 3–4, but I think the full learning curve is 15–20. It is important to undertake some training with someone who is experienced in the technique, as many of the tricks, and what to be avoided, can be demonstrated quite quickly.

Question 7 How do you deal with a revision?

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Obviously this is essentially a primary technique. But for a straightforward fibrous non-union you can remove the metal work and break the fibrous tissue down. I have now revised halfa-dozen cases this way with only one persistent nonunion.

expert zone

Fig 3 Early postoperative gap with in-filling at 12 weeks.

Question 8 Are there any complications specific to arthroscopic arthrodesis? Not really. Theoretically, ankle arthroscopy does have an incidence of cutaneous nerve damage not really seen in other types of arthroscopy due to the well-documented variations in anatomy, but this is also the case with open arthrodesis. The incidence of some form of persistent nerve problem is under 1%. Question 9 What do you consider to be the disadvantages of arthroscopic arthrodesis? Few! The main problem is the lack of surgical experience with arthroscopic surgery. If you have passable arthroscopic skills and spend a bit of time with someone who knows what they are doing, this is a technique most people can learn to do and the advantages of soft-tissue handling with all arthroscopic techniques are obvious. Ian G Winson

Southmead Hospital Bristol, UK ianwinson@doctors.org.uk

Les Grujic

Sydney Orthopedic Research Institute Chatswood, NSW, Australia talus@optushome.com.au

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Clinical topic

32 External fixation is one of the mainstays of surgical fracture management. This type of osteosynthesis allows for “local” and “general” damage-control procedures. It also permits correction of deformities, bone lengthening and segmental bone transport, arthrodesis, as well as joint contractions and bone infection treatment. The following articles give an overview on the various applications of external fixation. They have been assembled and edited by the members of the ExFix working group (EFWG) of the AOTK and other recognized experts. Dankward Höntzsch and Suthorn Bavonratanavech

Principles of the application, design, and assembly of external fixators 3 external fixation? Why

Biomechanical principles of assembly

External fixation is recommended when the local or general condition of the patient is compromised or when logistic circumstances make external fixation the obvious choice.

The external fixator must guarantee adequate stability to maintain reduction under different loading conditions. As a rule, at least two pins or tensioned wires are inserted into each fragment or segment. Placement of the pins and/or wires must take into account the injury pattern of the bone and, above all, of the soft tissues. The pins should be placed in the anatomically safe zones. Proper assembly also makes adequate provision for secondary internal osteosynthesis later.

External fixation: • Is a minimally invasive, versatile method for any type of fracture. • Has a short application time. • Is applicable in open and closed fractures of any configuration. • Allows for bridging of periarticular fractures. • Allows for secondary corrections and lengthening. • Can be used both as a temporary or definitive treatment. • Can be exchanged for internal fixation. • Has an easy-removal technique. External fixation components

The components of external fixators consist of screws, pins, or wires (into the bone); tubes or rings; and, clamps (connection of pins to tubes or rings) (Fig 1a-c.)

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Principles of assembly

There is a basic differentiation between unilateral and bilateral frame assemblies and ring fixators. Hybrid and ring fixators are multiplanar constructions. External fixators can be constructed in a static or dynamic mode. Observations have shown that additional dynamization elements within the fixator are not necessary with weight bearing.

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Fig 1a Schanz screws with standard trochanter or self-drilling tips. Fig 1b Stainless steel tubes and carbon fiber rods for the large system. Fig 1c Sample of clamps for different usages. There are 3 sizes (small: 4 mm, medium: 8 mm, large: 11 mm) with the same design and function and compatible to each other.

Temporary or definitive treatment method?

There are basically three treatment concepts: 1. A definitive treatment with the external fixator until bone consolidation is completed 2. An early change of management to internal fixation 3. Conversion to a nonsurgical treatment, eg, plaster cast, brace, etc. The concept of damage-control orthopedics (DCO), relative to limb surgery in patients with severe multiple injuries, is an attempt to minimize the “second hit” of an emergency procedure of pelvic and long bone stabilization that is performed rapidly and atraumatically, mostly using methods of unilateral external fracture fixation, and releasing of compartment syndromes. Vital for achieving this goal are minimizing the duration of initial surgery, avoiding additional blood loss, and performing only life- and limb-saving procedures.

Dankward Höntzsch

Suthorn Bavonratanavech

BG Unfallklinik Tübingen Tübingen, Germany hoentzsch@t-online.de

Bumrungrad Hospital Bangkok, Thailand suthorn@bumrungrad.com

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Clinical topic

34 The modular frame technique (small, medium and large) can be employed for the fixation of diaphyseal bone and joint (nonbridging and bridging) fractures with soft-tissue injury (closed or open).

Dankward Höntzsch and Alberto Fernandez

Modular frame technique

3 Modular frame technique The modularity of the external fix-

Advantages The advantage of modular external fixation is that

ator makes it versatile and allows it to be used both as an indirect reduction tool and fixation device.

all long bones, areas adjacent to joints, and the joints themselves (joint-bridging) can be reduced, bridged, and stabilized.

The principle Schanz screws are inserted into each main frag-

The Schanz screws can be positioned freely, which allows the most favorable anatomical insertion site for the Schanz screws and the most favorable zone for the fracture pattern or softtissue injury. Manipulation of the main fragments is facilitated by leverage and indirect reduction techniques, which preserves bone and soft-tissue vascularity. Primary and secondary adjustments to the reduction can be performed at any time with this technique.

ment or, in the case of joint-bridging configurations, into each of the two bones supporting the bridge (in some cases possibly more than two) (Fig 1a-c). If single-pin clamps are used, there is the great advantage that the position and orientation of the Schanz screws are unrestricted. The Schanz screws within one fragment are then firmly connected to a tube or rod. This produces a partial frame for each main fragment/affected bone. The two partial frames are then connected by means of tube-to-tube clamps. As long as the tubeto-tube connections are open, reduction can be performed in all planes. The desired reduction, once achieved, can be checked clinically and/or radiologically, the tube-to-tube clamps can be tightened and the system is stable (Fig 2). Modifications The two Schanz screws in any one main fragment can be held in place by double pin or multipin clamps. These double or multipin clamps can be applied on one side or on both sides of the fracture. The partial frame can also be formed by a ring or a partial ring system (hybrid fixator).

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Dankward Höntzsch

BG Unfallklinik Tübingen Tübingen, Germany hoentzsch@t-online.de

Alberto Fernandez

British Hospital Montevideo, Uruguay aafernan@netgate.com.uy

expert zone

Fig 1 The modular reduction technique: a Type B diaphyseal tibial fracture. Two pins are inserted in each main fragment outside the zone of injury. b Fixed to a bar by universal clamps, two handles are produced for indirect reduction. c After reduction, the two bars are united by a third tube and two tube-to-tube clamps. Fig 2 Modular fixation of a tibial fracture. Fig 3 Case example: Fractures of the pelvic ring, proximal femur, and proximal tibia. All fixed with temporary external fixators, bridging the knee and ankle joints.

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Clinical topic

36 Hybrid fixation is appropriate for fixation of complex proximal and distal tibial fractures, particularly those involving the joint, when soft-tissue injuries preclude open reduction and internal fixation, or the fracture pattern does not allow placement of Schanz screws for construction of a standard external fixator frame. Dankward Höntzsch and Alexander Lerner

Hybrid technique Hybrid fixation technique The hybrid external fixator is used in fractures close to a joint. It is called “hybrid” because it combines fine-wire fixation and an external half ring at the joint with pin fixation in the diaphysis (Fig 1). It requires tensioned 3 K-wires for the ring and conventional Schanz screws for the shaft. Generally, 3/4 circumference rings are used. K-wires with an olive allow fragment reduction and some compression.

to insert a hybrid fixator correctly in an articular fracture, nor is it a quick procedure. In polytrauma or complex articular fractures, it is recommended that hybrid fixation is planned as a delayed procedure after initial joint-bridging external fixation. It is important to know the anatomy of the joint capsule, as intraarticular placement of the wires should be avoided in order to reduce the risk of joint infection.

Indications Hybrid ring fixators have mainly been used in type

A and B fractures of the proximal and distal tibia, either alone or to protect an internal fixation with lag screws. It is not easy

Technique With the open, 3/4 rings, tensioning of the second

and/or third wire may produce a partial reduction and some compression. For this reason, sequential tensioning of the first wire (wire 1-2-1) or simultaneous tensioning with two tensioning devices is recommended. This will provide a uniform, well-balanced level of tension in all wires. An additional Schanz screw can be inserted to secure the ring if increased stability is required. However, two or three crossed wires under tension are often sufficient. It is usually better to use a V- or A-shaped frame as this increases stability and avoids the cantilever effect that can be seen if a simple unilateral frame is applied to a ring.

Dankward Höntzsch

BG Unfallklinik Tübingen Tübingen, Germany hoentzsch@t-online.de

Fig 1 Hybrid fixator used on a tibial plateau fracture. It is also useful for distal tibial periarticular fractures. The V-frame provides good stability.

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Alexander Lerner

Rambam Medical Center, Technion, Israel Institute of Technology, Haifa, Israel alex_lerner@yahoo.com a_lerner@rambam.health.gov.il

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37 Case study: Hybrid fixation

Case contibutor: Dankward Höntzsch

Fig 1 Proximal tibial fracture, initially treated with the less invasive stabilization system (LISS). Fig 2 Removal of the LISS after infection and application of a hybrid external fixator. Fig 3 Duration of treatment: 20 weeks. a A pplication of frame. b F lexion of knee joint: 0-0-100 degrees and full weight bearing after 6 weeks. c Showering and bathing possible and recommended throughout treatment. Fig 4 Removal of external fixator 20 weeks after consolidation of fracture. Full weight bearing and good function.

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Clinical topic

38 Distraction osteogenesis is a well-established method in the treatment of bone defects or limb shortening.

Carlos Satizabal and Dalia Sepúlveda Part 1 Wade R Smith, Theddy Slongo and Federico Santolini Part 2

Distraction osteogenesis

3 1: Unilateral distraction Part The use of unilateral external fixation devices for bone lengthening, bone transportation, angular deformities correction, and even arthrodiatasis is simple, allowing the patient to easily understand the instructions for handling.

The unilateral external device has some advantages over circular external devices. It allows surgical debridement, has less compromise to the soft tissues, and is better tolerated by the patient. Indications Based on a short learning curve, the use of external fixation has gained ground in handling a variety of diseases, making this technique virtually limitless. The main applications are: • Bone lengthening (unifocal or bifocal osteotomies) • Segment transport • Deformity correction

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Relative contraindications for distraction osteogenesis There are some cases where the use of external devices has its limits, mainly because of a lack of good consolidation, such as with the following: • Patients with severe osteoporosis • Patients with vascular lesions • Malnutrition and vegetarian eating habits • Smoking Complications Because of the monoplanar application of the pins, skin problems as well as pin track infection is more frequent. Loss of alignment may occur in cases of long lengthening (eg, femur). In cases of early removal of the external fixator, to prevent callus deformity or fracture afterwards, the use of an intramedullary nail or plate or brace is indicated.

Carlos Satizabal

Dalia Sepúlveda

Hospital Militar Central Bogotà, Colombia satizabalcarlos@cable.net.co

Universidad de Chile Santiago, Chile dsa@vtr.net

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39 Case study 1: Osteogenesis distraction unilaterally

Case contibutor: Dankward Höntzsch

Fig 1 Revision osteosynthesis with bone grafting after failed fixation (plate breakage) of open femoral fracture. Fig 2 Bone necrosis without infect leads to removal of implant and a segment resection (7 cm). Fig 3 Preoperative planning and application of the distractor. Fig 4 Finished distraction after 14 weeks (100 days). Fig 5 Additional stabilization with plates after 20 weeks. Fig 6 5½ years follow-up after the trauma: removal of condylar plate. Good function and full weight bearing.

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Clinical topic

40 Part 2: Ring distraction Advantages of ring external fixation in the three-dimensional management of traumatic and post-traumatic conditions include the ability to advance to full weight bearing within weeks, thus helping the patient functionally and psychologically; to treat infections with minimal implanted metal; and to correct deformity and bone loss in a gradual, tissue-sensitive manner. The disadvantages include: • Transfixation of soft tissue including muscles and tendons • Difficult approach to soft tissue in cases of reconstructive surgery • Problematic application with proximal femur and humerus • Discomfort • Time consuming and technically demanding application Instrumentation Given the wide array of minimally invasive implants currently available, the ring fixator is primarily recommended for cases of bone transport due to bone loss in open fractures or resection for oseomyelitis, and angular deformity corrections and

selected periarticular fractures with very small segments. In these cases a ring fixator for a tibial plateau or pilon fracture can change the patient’s condition from wheelchair to weight bearing in a walker. A minimally invasive, highly modular fixation to correct severe musculoskeletal problems was the goal of the AOTK Ex-Fix working group during the design and testing period. The new design is based on the original concepts with the integration of newer materials providing for a stronger, lighter and more user-friendly frame. The AO ring fixator has been effectively used throughout the world in the past year for fractures, infections, bone transports, lengthening, angular corrections and pediatric cases (Fig 1). The development of ring fixation into the AO surgeon’s armamentarium makes sense because the principle of biologic fixation is shared by the AO and Ilizarov. The AOTK now seeks to apply its educational principles and methods to the teaching of ring external fixation. In the end, that our patients benefit is what truly matters. Any technique that can help in this task is worth learning.

Fig 1 In this case, a circular frame is used to transport the tibia into 6 cm distal bone defect.

Federico Santolini Theddy Slongo Wade R Smith

Denver Health Medical Center Denver, Colorado, USA wade.smith@dhha.org

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Paediatric Trauma and Orthopaedics University Children’s Hospital Bern, Switzerland theddy.slongo@insel.ch

Clinica Ortopedica e Traumatologica San Martino Genoa, Italy federico.santolini@ hsanmartino.liguria.it

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41 Case study 2: Distraction osteogenesis with ring fixator

Case contributor: Wade R Smith

Fig 1 55-year-old male with infected nonunion of the proximal tibia. Hardware removal after secondary surgery with autograft and BMP treatment. Fig 2 Application of ring distractor after corticotomy and bone resection in the length of 5 cm. Fig 3 Result 6 weeks postoperatively. Fig 4 31 weeks after operation and before frame removal. Fig 5 No pain and no evidence of infection 38 weeks postoperatively. Patient is back to work as a salesman.

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Clinical topic

42 Tips and tricks for the postoperative management of external fixation.

JC Goslings, Federico Santolini and Vajara Phiphobmongkol

Postoperative care

3 and swelling managementâ&#x20AC;&#x192; In the early postoperative pePain

riod, elevation and standard postoperative pain control is applied. Generally, oral pain medication suffices for later stages. If the pain remains inappropriately, careful evaluation of the limb should be immediately performed to rule out any limbthreatening condition. Pin careâ&#x20AC;&#x192; Dry gauze dressings are wrapped around each fixator

pin (below the bars) to reduce swelling and to absorb blood or wound secretion. Once the stab incisions are dry, pin sites are best left open. There is very little evidence as to what the best method is to clean pin sites and most methods are based on doctor or nurse preference rather than research. There is no reason to prohibit showering and the use of tap water (Fig 1). Motion exercisesâ&#x20AC;&#x192; Early active and passive range of motion

exercise of the adjacent joints can prevent contractures and reduce disuse atrophy. With adequate pain control this can be done early after the operation. These exercises can reduce the risk of deep vein thromboses from immobilization.

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Fig 1

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43 Tips and tricks from the Expert Group Damage control

Soft-tissue care

Covering the pins

In the damage-control setting: build the simplest frame (ie, one unilateral layer of rods); time is the important factor, not maximum stability.

Prevention of pin-track complications: use irrigation during drilling and sharp drills (both to prevent bone necrosis), and avoid tension of the skin around the pins.

You can cover the sharp ends of pins by moving up the clamps, putting on rubber from a drain, or a small LEGO® part.

Alignment Aligning the bone: pinning or tension wiring of the most proximal and distal pins or wires parallel to the adjacent joint will be a good reference and can easily be used to correct valgus or varus angulation of that tibia after the frame is completely constructed.

Ring fixators—wire tension

Blisters

Pin insertion

Dealing with or prevention of blisters around the ankle: add an extra L-shaped rod construction to the frame in order to lift the foot from the ground beneath.

After perforating the far cortex with the wire, reduce the drill speed or advance the wire by slowly hammering it in. To prevent slipping from the curved side of the bone, start drilling backwards to make a small hole and then progress with forward drilling.

Ring fixators: wire tension should be adequate to maintain the stability of the wire to bone and the wire to soft tissue. This will minimize the motion between wire and soft tissue and reduce wire site complications.

Weight bearing Weight bearing may be allowed as early as the first postoperative day or delayed until consolidation of the fracture gap is observed. This depends on many factors, such as the fracture gap size, the stability of the bone-external fixator construct, the presence of delayed- or non-union, and whether a bone transportation or limb lengthening procedure is planned. Complications and problems for external fixation in general

Many complications and problems have been described from the use of external fixation. They include pin tract infections, pin loosening or breakage, iatrogenic soft tissue lesions, con-

Limited resources With limited resources, ie, without a rod-to-rod clamp, simple pin-rod clamps are useful to connect one rod with another rod.

Radiation To avoid radiation of the surgeon’s hands, use temporary handles made from fixator bars.

tractures, stiffness, and obstruction of wound access by the frame. Mechanical complications can be caused by misuse of components or inadequate frame construction relative to the clinical and biomechanical needs. Careful operative technique can prevent some of the complications and problems. Safe zones for pin placement should always be used. Pin tract infections are recognized by pain, swelling, and discharge of exudate or pus. Initial management consists of rest, elevation, increased pin care, and antibiotics. Coating of pins with antibiotics, silver, or hydroxyapatite might reduce the incidence of pin-tract infections.

JC Goslings

Federico Santolini

Vajara Phiphobmongkol

Academisch Medisch Centrum Amsterdam, The Netherlands j.c.goslings@amc.uva.nl

Clinica Ortopedica e Traumatologica San Martino Genoa, Italy federico.santolini@ hsanmartino.liguria.it

Bhumibol Adulyadej Hospital Royal Thai Air Force Bangkok, Thailand deeknee@yahoo.com

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Research

44 Computer assisted ankle joint arthroplasty using bio-engineered autografts.

Winners: Wolfgang Köstler, Norbert P Südkamp, Rudolf Sidler and Lutz-Peter Nolte

The AO Research Fund 2008 Prize Award winner 3 Introduction Tissue-engineered articular cartilage has been a subject of research for a number of years [1]. Although difficulties with cartilage structure and integration still persist, techniques based on combined grafts using cancellous bone and autologous cartilage are approaching clinical application [2]. Common to all therapies with in vitro engineered autografts is the need for optimal fit of the implant, which is imperative for press-fit implantation and successful integration. Computer Assisted Surgery (CAS) techniques have the potential both to ensure the required accuracy and simplify the therapy.

A pilot study was conducted aimed at assembling a set of methods to realize and prove the feasibility of computer-assisted ankle joint arthroplasty using bioengineered autografts. The computer-assisted procedure, first presented at CAOS 2005, consists of planning based on CT imaging, harvesting mesenchymal stem cells by needle biopsy, constructing the autograft according to the planning and conducting one single intervention for the arthrotomy and construct implantation. Using bovine cancellous bone grafts, this new approach was tested in cadaveric operations with promising results.

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Methods A new software was developed to perform the interactive planning of ankle joint arthroplasty. Based on the hinge-like articulation, a simple model of the ankle joint was used, defining both Talus and Tibia grafts as objects with a rotational symmetric joint surface. The arthroplasty planning is done in four steps: 1. Interactively determine the joint axis. 2. Interactively determine the lateral graft profile. 3. Interactively determine the frontal graft profile. 4. Visualize the resulting construct shape. Shape and position of the implant are completely defined by the planning process. It can be directly used to program a CAM device to manufacture the implant and to conduct the navigated surgical intervention. We designed and produced angled navigable chisels for the cadaveric operations. The implants were custom milled according to this plan in bovine cancellous bone “Tutobone” from Tutogen Inc., Neunkirchen, Germany. An optical navigation system for orthopaedic surgery was used to perform the arthroplasty according to plan.

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Tibia

Talus

The outcome was analyzed based on post-operative CT images. Four criteria were defined: 1. Does the implant fit properly into the defect made? acceptable = yes 2. Quality of surface in direction of joint function acceptable = no edge > 1mm, no gap >2mm 3. Quality of surface across the joint acceptable = no edge > 2mm, no gap > 3mm 4. Quality of non-surface faces of the implant acceptable = no gap more than 4mm

A total of eight implant sites were treated with a full cycle from surgical planning to navigated intervention. Results It was possible to achieve acceptability in all four criteria, although not to meet all criteria for all implantation sites. As an example, Figure 1 shows a postoperative frontal CT image of one of the operated feet.

2c Fig 1

Postoperative CT, Frontal view

Fig 2a Preop Talus region of interest in 3D. Fig 2b A 3D view of the characteristic contours. Fig 2c An error signal obtained for one characteristic contour.

In this case, the Talus graft could be positioned very well, with excellent surface fit both in the frontal and lateral views. Due to difficulties with chiseling of the rear face, inacceptable gaps resulted at the bottom and at the rear of the graft.

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Research

46 The postoperative CT Scans were analyzed by two surgeons not involved in the procedures. To improve the manual measurements we tried to develop an automatic, objective quality measurement of the joint surface. We have therefore developed software to extract the characteristic contours of a joint in a region of interest which can interactively be defined on a 3D surface model. We have further designed a one–dimensional digital filter to extract the curvature given by the joint anatomy, leaving an error signal reflecting the unwanted edges along the characteristic contours. The final algorithm combines the error signals of n=10 characteristic contours in the selected region of interest and yields a single surface quality measure. The outcome score is mapped to a value of zero to 100 to make it comparable with classical outcome scores. We have successfully applied this method to pre- and post-operative surface models of a cadaveric human talus bone. As this approach is not restricted to ankle joint arthroplasty, optimization of evaluation problems in a variety of applications may benefit from the use of digital filters for surface quality assessment. The correlation and combination with clinical scores may lead to more objective measurements for the results after intraarticular surgery.

Discussion Following a new computer-assisted approach to the treatment of post-traumatic ankle joint arthroplasty using bio-engineered autografts, a complete cycle of treatment was successfully conducted on cadaveric human feet. General feasibility and potential of the method could be shown and valuable experience for clinical application could be obtained. Apart from a navigated chisel, an additional milling device is required to ensure a planar rear face of the defect. For the tibia graft, drilled corners will help to cope with the hard cortical bone and improve the accuracy of defect debridement. Intraoperative verification of the defect before insertion of the graft would help reduce the risk of malpositioning or damaging of the graft. Using a novel approach, the use of digital filters could help to establish an objective surface quality measure. Unlike other methods it takes into account the direction of joint function. Finally, the more objective outcome analysis would allow the evaluation of a series of trials, to develop a limit for clinical acceptability and to prove the feasibility of the therapy in clinical practice.

Bibliography

1. Caplan, A, et al (1997) Principles of cartilage repair and regeneration. Clinical Orthopaedics and Related Research; 342:254–269. 2. Landis, W, et al (2005) The potential of tissue engineering in orthopedics. Orthopedic Clinics of North America; 36:97–104.

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Wolfgang Köstler

Rudolf Sidler

Department of Orthopedics and Trauma Surgery, University Clinic, Freiburg, Germany wolfgang.koestler@uniklinik-freiburg.de

ME Müller Research Centre, Institute for Surgical Technology and Biomechanics, University of Bern, Switzerland rudolf.sidler@ypsomed.com

Norbert P Südkamp

Lutz-Peter Nolte

Department of Orthopedics and Trauma Surgery, University Clinic, Freiburg, Germany norbert.südkamp@uniklinik-freiburg.de

ME Müller Research Centre, Institute for Surgical Technology and Biomechanics, University of Bern, Switzerland Lutz.nolte@MEMcenter.unibe.ch

AO Vet

expert zone

47 Reflections pertaining to exercise physiology and sports medicine.

Michael A Weishaupt and Jörg A Auer

Why are horses high-performance athletes? It is pure fascination to watch the field of steaming Thoroughbreds thundering in full racing speed past the tightly packed stands of spectators in the marvelous mountain arena on the snow-covered lake of St. Moritz! A horse is able to accelerate from 0 to 60 km/h in only a few seconds, the heart rate speeding up to 200 bpm. Per minute, over 300 liters of blood are pumped through the body and about 2000 liters of air are pulled into the lungs. The horse does not need any EPOdoping or high-altitude training to increase its haematocrit (Hct, or the packed cell volume (PCV)), which is the decisive factor defining oxygen transport capacity: The PCV may easily be double depending upon the intensity of work. Everything in a horse is geared towards speed and endurance—starting shortly after its birth. Speed and endurance at birth Through century-long breeding selection the horse developed from a herd- and flight animal into a highly specialized high performance athlete, equipped with an extraordinary athletic capacity. Speed, strength, endurance and high-precision locomotor skills are well developed at birth. Furthermore, it is astonishing to note that these athletic abilities developed differently in the various breeds. The locomotor muscles best reflect the breed-specific differentiation of the athletic abilities: There are some breeds, such as Thoroughbreds, with a high percentage of anaerobic and aerobic fast-twitch fibers, which are especially used for high-speed racing competitions, whereas Arabian horses are equipped with a high percentage

of aerobic slow-twitch fibers and therefore are predestined for endurance races. Accordingly, horses are able to perform at exceptionally high levels in racing and jumping: Over sprint distances of up to 400 meters, American Quarter Horses reach speeds of up to 1200 m/min (72 km/h). In flat races (1000-1400 m), Thoroughbreds run at speeds of 1100 m/min (65 km/h), and over the classic distances (up to 4000 m), barely under 1000 m/min (57 km/h). The mile record for Standardbreds (trotters or pacers) lies at 1’42”, which results in a mean speed of about 950 m/min. The best endurance horses nowadays finish a 100-mile race cross country in less than 8 hours with an average speed of 22 km/h. The high jump record (Puissance) is 2.47 m. In phase D, the cross-country phase of a 4-star 3-Day Eventing, horses jump over 45 obstacles of up to 1.20 m in height and 3.00 m in width, spaced out over a course distance of 6 to 7.5 km. It is interesting to notice that contrary to human athletic disciplines, new records are rarely broken in equestrian sports. The fastest time for the world-famous 1.25-mile Kentucky Derby was set in 1973 by the legendary Secretariat. All the acquired knowledge from the last 20 years on how to raise, feed, train and keep sound an equine athlete seems not to have resulted in faster-running or higher-jumping horses. For this reason there is good evidence that all the body systems contributing to performance capacity are highly tuned to an “end-stage” of differentiation.

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AO Vet

1 Fig 1 White Turf International Horse Racing on snow at St. Moritz, Switzerland 3

Enormous aerobic capacity The above-mentioned impressive athletic accomplishments result in mechanic and metabolic peak loads on the entire body. The bones, joints, ligaments and tendons, especially of the lower limbs, are exposed to extremely high external peak loads. Already at a trot, a 500 kg horse loads each limb with more than its body weight. The loads encountered on the forelimbs during landing after jumping over an obstacle of 1.3 m in height amounts to nearly one ton. During a racing gallop, the forelimbs are loaded with 2.5 times the body weight at each step! In addition, the flexor tendons and the suspensory ligament are exposed to extreme tensional forces. The very strong suspensory apparatus, positioned palmarly/plantarly to the cannon bone (McIII/MtIII) prevents over-extension of the meatcarpo-/ metatasophalangeal joint during loading, exhibits shock-absorbing characteristics, and may store and return mechanical energy. A healthy tendon has a unique tensional resistance: The superficial digital flexor tendon with a cross sectional area of 1.5 cm 2 withstands tensional loads of up to 1.5 tons before rupturing. The fact that during training or a race a tendon may fully or partially rupture allows an estimation of the dimension of the tensional forces these structures are exposed to during the stance phase. Another outstanding quality of the equine athlete is its enormous aerobic capacity, the basis for all equestrian disciplines. The 2 | 08

oxidative metabolism, meaning the transport and consumption of oxygen for energy production, is the key to endurance competence. Along the oxygen chain from the lungs to the skeletal muscles, every organ or organ-system involved is structurally and functionally optimized and exceptionally well developed. The lung of a horse contains an enormous surface (equivalent to the surface of 7 tennis fields), which guarantees the high diffusion capacity for respiration gases; the heart impresses through its size and pumping capacity; and erythrocytes can be ejected from the spleen into the circulation in no time, to significantly increase oxygen transport capacity (Tab 1). Finally the skeletal musculature contains exceptional biochemical tools to transDuring rest

under maximal work load

24–32

220–240

310

PCV [%]

32–46

60–65

Respiration rate [1/min]

12–16

120–135

Minute ventilation [l/min]

80–95

1600–1900

4–6

85–100

Heart rate [1/min] Cardiac output [l/min]

Peak flow [l/s]

Tab 1

Functional plasticity of key parameters determining

aerobic capacity.

expert zone

Fig 2 Three-Day Eventing, the summit of equestrian sports disciplines. (photo courtesy B. Mühlebach)

Fig 3 Exercise spirometry used to quantify upper airway resistance.

form nutrients into ATP. The resulting VO2max, the maximal oxygen uptake capacity, in horses reaches 180–200 mlO2/kg/ min compared to its endurance-trained human counterpart, which reaches 105 mlO2/kg/min; untrained persons attain just 30–45 mlO2/kg/min.

An open cooperation between horse owner, rider, trainer and the clinician is essential. This accounts not only for problemsolving strategies, but also for an optimal fine-tuning of the various prerequisites for a successful athletic career. Only fit and mentally well-balanced horses with a superb health status can reach their full athletic potential.

Internal and external factors determine potential The athletic potential depends upon different internal and external factors. Internal factors are inherited physical and mental capacities. The most important external factors include training, nutrition, boarding facilities, recovery time and most importantly the horse’s physical and mental health. From the sports medicine point of view, the health status of and ability to train the athlete are the most important key factors to manage. It is therefore a central aspect in the philosophy of equine sports medicine to get to know in detail the physical and mental strengths and weaknesses of an equine athlete in order to be able to address minor health problems at an early stage and to implement individual training in a careful and efficient manner. Stagnant improvements in training and declining competition results in any athlete have to be taken seriously, even if there are no apparent symptoms or disease to explain it. In most cases poor performance is an unspecific manifestation of simultaneously apparent, complex interrelated problems, which should neither be approached emotionally nor purely scientifically.

For detection of subclinical diseases, it is imperative that the affected horses be assessed at work in order to test the function of the body systems involved in exertion. Ideally, this is done on a high-speed treadmill with the horse hooked up to various modern diagnostic tools. Poor performance evaluation normally focuses on the locomotor, respiratory and cardiovascular system first. Routine tests include the following: exercise testing, exercise ECG and post-exercise echocardiography for evaluation of cardiac function; exercise endoscopy and spirometry for evaluation of the upper respiratory tract (Fig 3); and evaluation on the treadmill of the patient’s gait at different gaits up to racing speeds. More than half of racehorses experience lameness Musculoskeletal injuries are the main reason for wastage in the horse industry worldwide. Epidemiologic studies revealed that more than 50% of racehorses experienced some period of lameness in their sporting career and in 20% of those cases the lameness is sufficient to prevent the individuals from racing after the injury. Furthermore, it is estimated that three-quarters of 2 | 08

expert zone

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4 Fig 4â&#x20AC;&#x192; â&#x20AC;&#x153;TiFâ&#x20AC;?, a treadmill-integrated force measuring system able to record the vertical ground reaction forces of all four limbs simultaneously, here at the walk.

poorly performing horses suffer from subclinical disorders of the locomotor system. The expenses ensuing from veterinary treatment and the costs of all lameness-related loss-of-use are estimated to exceed USD 1 billion per year in the US alone.

load situation in another limb [2-3]. The gait analysis with the treadmill integrated force measuring system is especially useful in combination with diagnostic nerve blocks to assess instantaneously and reliably changes in weight bearing (Fig 5).

Conformation, management factors such as training methods, level of schooling and performance, time intervals between starts, type of ground surface in training and competition, and quality of horseshoeing and saddle fitting can all contribute to injury that may affect the ability to compete successfully. Therefore, prevention and early identification of locomotor deficiencies have a high priority in equine sports medicine and animal welfare. Visual assessment of gait abnormalities and lameness is based on subjective assessments and therefore relies strongly on the expertise of the orthopedic clinician. The measurement of ground reaction forces proved to be a very reliable technique for detecting subclinical lameness. The development of an instrumented treadmill at the Equine Performance Centre of the Equine Department at the University of Zurich was an important step forward to assess lameness objectively in a clinical setup [1]. The force measuring system is able to record the vertical ground reaction forces of all four limbs simultaneously over multiple strides and to provide the clinician with the results of weight-bearing instantaneously (Fig 4).

Fitness tests help prevent over-training The athletic potential is a combination of different parameters, which can be roughly divided into endurance, speed, strength, agility, and coordination. These parameters are adjusted through training for each equestrian discipline specifically. It is obvious that some of these abilities, such as strength or coordination are difficult to assess and quantify in the horse. However, the assessment of aerobic capacity is relatively easy to perform with the help of an exercise test. A fitness test, which is preferably conducted on a treadmill under standardized conditions, involves working the horse during intervals of 90 seconds at progressively higher intensities. The heart rate is determined continually and during each work level a blood sample is taken for the determination of the blood lactate concentration: The lower the heart rate and the lower the lactate concentration for a defined workload, the fitter the horse. The results of a fitness test should never be interpreted on their own, separated from competitive results or the impressions of the trainer. With repetitive fitness tests during a training period, the effect of the training can be objectified and the training stimuli can be fine tuned, over-training can be prevented and health issues recognized at an early stage.

Studies on load redistribution in lame horses revealed that horses apply strategies that do not necessarily induce an over2 | 08

expert zone

Fig 5a–c Graphical presentation of the asymmetry index of peak vertical force (ASI Fz peak) in a horse with proximal suspensory desmitis. The triangle represents the ASI Fz peak of the forelimbs, and the square the ASI Fz peak of the hindlimbs.

a initial lameness clinically scored as grade 2/5 weight-bearing left forelimb (FL) lameness and grade 2/5 weight-bearing left hindlimb (HL) lameness. b lameness after a low palmar nerve block on the FL; lameness score grade 2/5 FL and grade 1-2/5 HL. c lameness after perineural analgesia of the palmar metacarpal nerves on the FL; lameness score grade 1/5 right forelimb and grade 1-2/5 HL.

The application of knowledge pertaining to sports medicine does not aim to increase the speed of the horse or allow it to jump higher, but to keep the athlete sound, prepare it optimally for a specific event, and to recognize detrimental influences early in order to avoid an untimely end to an athletic career.

Bibliography 1. Weishaupt MA, Hogg HP, Wiestner T, et al (2002) Instrumented treadmill for measuring vertical ground reaction forces in horses. Am J Vet Res; 63: 520-527. 2. Weishaupt MA, Wiestner T, Hogg HP, et al (2004) Compensatory load redistribution of horses with induced weight-bearing hindlimb lameness trotting on a treadmill. Equine Vet J; 36: 727-733. 3. Weishaupt MA, Wiestner T, Hogg HP, et al (2006) Compensatory load redistribution of horses with induced weight-bearing forelimb lameness trotting on a treadmill. Equine Vet J; 171: 135-146.

Michael A Weishaupt, Dr.med.vet., PhD

Jörg A Auer, Diplomate ACVS/ECVS

Equine Department, Vetsuisse Faculty, University of Switzerland, Zurich mweishaupt@vetclinics.uzh.ch

Equine Department, Vetsuisse Faculty, University of Switzerland, Zurich jauer@vetclinics.uzh.ch

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