AO Dialogue 3|08

The magazine for the AO community 3 | 08

P ov Pr o id d in i g cu cust stom omiz izat atio at ion io n an a d suppor orr t fo f o r alll memberss

AO Assessment Tool Kit | AO Middle Europe Locking X-plates in foot and ankle surgery | Femoral fractures in young dogs

Contents

2 Impressum AO Dialogue 3 | 08 Editor-in-Chief: James F Kellam Managing Editor: Elena Ineichen-Grimaud Photo Editor: Jürgen Staiger Contributors: Alexandra Lepionka Martin Ineichen 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

All rights reserved. Any re production, 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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Community zone Panorama

Report

4 | News & Events 8 | People

10 | Susanne Bäuerle: “I’m learning it’s all about patience”

Inside AO 12 | AO Membership initiative—providing customization and support for all members 14 | AO Membership—putting the virtual AO World at your fingertips

In Discussion 16 | AO Assessment Tool Kit—promoting global excellence in the training of trauma and orthopedic surgeons

From the Regions 22 | AO Middle Europe: building the new harmony

AO and its partners 24 | Synbone—celebrating 20 years of partnership with the AO Foundation

Books 25 | New releases in 2008

Cover photo: A live-surgery practical during the AOSpine and EANS Live Tissue Training: Spine Access Surgery course, Strasbourg, France, September 2008.

Editorial

3 My view

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

Expert zone Case study 26 | Locking X-plates in foot and ankle surgery

Clinical topic 29 | Proximal tibial fractures: indications for the use of locking plates

Focal point 34 | Roadmapping: facilitating collaborative research for Clinical Priority Programs

AO Vet 39 | Femoral fractures in young dogs

Communication is such an integral part of our everyday lives that at times we forget how important it really is. This issue of Dialogue addresses different yet related areas in communication.

The membership initiative described in this issue is not an attempt to promote membership or create complexity within the AO Foundation, rather it is the Foundation’s attempt to improve communication with its members and other interested parties. The Foundation is spread around the world and with its numerous courses and fellowship programs there are a tremendous number of people who wish to communicate with it and with each other, and who are important to the Foundation’s ongoing survival. The membership initiative is the Foundation’s communication vehicle with all of them.

Another viewpoint on communication is explored in an interview with Susanne Bäuerle, who is recovering from a devastating car accident. Susanne very concisely points out the gap that exists between what we, the healthcare worker and in particular, the physician, communicate to our patient and what they understand.

It is imperative—as it is within the AO Foundation—that our communication be as precise, in-depth and also as personal as possible so that we are better able to achieve our goals and our understanding of each other.

As the 50th anniversary of the AO Foundation draws to a close, I would like to thank all its employees who worked so hard to make this year such a tremendous success.

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community zone

Panorama News, Events, People

4 AOAA Jubilee Symposium in Thailand

In conjunction with the AO’s 50th anniversary celebrations, an Asia Pacific AOAA Jubilee Symposium took place September 27–28 in Chiang Mai, Thailand following the AO Regional Courses. The 72 AO Alumni and non-member participants travelled from sixteen countries to take part in the symposium, whose theme was osteoporosis.

Three different sessions looked first at the dimensions of the problem, then at a co-managed approach to it, and finally at new developments from the TK system. Organizing committee members Suthorn Bavonratanavech, Michael Blauth, and the AO Alumni Association in Davos, Switzerland, welcomed international chairman Chris van der Werken and international faculty Piet de Boer, Michael Ehrenfeld, Frankie Leung, Takeshi Sawaguchi, Michael Schütz, and Andrew Vincent. A much enjoyed farewell Jubilee dinner on the final evening featured a spectacular Thai dancing program.

AOAA Jubilee Symposium in Dubai

From October 12–16, Dubai hosted the AO Regional Courses, an AOAA Jubilee Symposium, and the opening of the first AO Fellowship Center for the Middle East and North Africa. Some 200 participants attended the four courses—AO Principles and AO Advances in Operative Fracture Management, the AO CMF Advances Course and the AOSpine Course. A “Mini AO World” introducing the AO Surgery Reference, AO Publishing, and CMF membership highlighted the spectrum of AO offerings. AOSpine also had its own booth. On October 15, AO Foundation Past-President Chris van der Werken welcomed guests to a special Jubilee Dinner, and the following morning the AO Fellowship Center in Rashid Hospital officially opened its doors, with an AO founding father, August Guggenbühl, as special guest of honor. A half-day “High-Tech Symposium”, in which state-of-the-art operation planning, imaging and computer assisted surgery was introduced and tested by participants, completed the day’s activities.

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community zone

5 From the AO Institutes AO Research & Development (AO R&D)

22nd European Conference on Biomaterials—ESB 2009

The 22nd European Conference on Biomaterials, the annual conference of the European Society for Biomaterials, will take place from September 7–11, 2009, in Lausanne, Switzerland. The deadline for abstracts for consideration for oral presentation is January 26, 2009 and the deadline for abstracts for consideration for poster presentations is March 16, 2009. ESB 2009 intends to strengthen the scientific basis of ESB core topics while increasing interaction with both the clinical and industrial side of biomaterials; to draw on the extensive MedTech industry within Switzerland and Europe to bring closer working relationships with industry; and to try a new idea at ESB, with themes of the day (for one of the four parallel sessions): Industrial /Technological, Vascular Intervention, Spine & Infection. It will feature plenary and keynote lectures from clinicians and researchers and several educational, plus higher-level workshops. Conference organizers Geoff Richards of the AO R&D Center in Davos, Marc Bohner of the Dr Robert Mathys Foundation in Bettlach, and Christine Wandrey of EPFL Lausanne, look forward to welcoming you to ESB 2009. For info, please visit: www.esb2009.org.

Development: Together with CMF surgeons we investigate individualized, anatomy-based surgical concepts for decompression surgery in Computerized medical image analysis techniques patients with Graves’ Ophthalmopathy. This surare used to evaluate patients gical procedure is performed in order to reduce suffering from Graves’ globe protrusion and optic neuropathy. Based Ophthalmopathy. on clinical findings and post-processed CT data analysis, potential morphological orbital parameters relevant for the choice of technique in decompression surgery are currently being evaluated. This scientific investigation will provide the theoretical background for a prospective clinical multicenter study.

Research: A major problem in bone repair, especially in large segmental defects, is the lack of blood supply. Our approach to solve the problem of inadequate vascularization leading to bone healing failure is to develop bioengineered implants stimulating both neoosteogenesis and neovascularization. Our in vitro studies Immunofluorescence using an antibody showed a positive effect of endothelial and bone marrow stromal specific to CD31: after 35 cell co-culture within a platelet-rich plasma gel on both osteogenic days in a 3-dimensional coculture with BMSC and differentiation and neovessel formation. Those promising in vitro in the presence of PRP, results are currently verified in vivo, where two pilot sheep received endothelial cells formed tubular structures. such bioengineered implants in a 3 cm bone defect.

AO Education (AOE)

Things continue to be exciting in AOE: our primary efforts have been on aligning the core educational processes with the central role of the specialties. Under the project leadership of the Software Engineering department, we have made great strides in the development of the course management and faculty support functions of the AO Virtual Office. We are testing the system during the Davos Courses 2008, with the release scheduled for mid-2009.

Lastly, AOE, in collaboration with expert surgeons, is completing the development of new educational modules. One is devoted to fracture management of patients with osteo porosis and the other to imaging technology.

AO Clinical Investigation & Documentation (AOCID)

Study nurses from Germany, Switzerland and Austria gathered in Davos (25–26 September) to look at Good Clinical Practice, Biostatistics for Beginners, and other study-related issues.

The title “study nurse” has now been replaced with the official designation “Study Coordinator”. • During his stay as AOCID Fellow in Dübendorf (September to December 2008), Vikas Kulshestra will analyze his study data on “plating of displaced clavicle fractures” and prepare a protocol for a new study on “multimodal pain control after fracture fixation” to be performed at the Air Force Hospital, in Bangalore, India, where he is resident. • “ME”, a study on complications arising from the removal of metal (angular stable) plates, has been initiated with AO Austria as sponsor.

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community zone

Panorama News, Events, People

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SICOT/SIROT Congress in Hong Kong The SICOT/SIROT Triennial World Congress in Hong Kong (August 24–28) gathered 1,850 participants from every continent. A highlight was the AO Jubilee Symposium, organized by Hong Kong-based AO Trustee Frankie Leung, spotlighting “New concepts in the management of osteoporotic fractures”. AO Past-Presidents James Kellam and Chris van der Werken were invited plenary speakers along with Norbert Haas, Piet de Boer, and Norbert Suhm. The four-hour program looked at various aspects of osteoporosis, including the biomechanics of osteoporotic bone, osteoporosis drugs, and new AOTK implants for osteoporotic fracture fixation. Many of the more than 100 participants were introduced to new AO concepts for osteoporotic fractures.

Information stands gave participants an insight into the AO’s many areas of activity, a highlight being the launch of the AO Surgery Reference’s first module in Chinese.

Romania hosts AO Principles course An “AO Prin-

ciples in Operative Fracture Management” course (August 6–9) brought international and local faculty together with 58 young surgeons from the country’s most important hospitals at the Poiana Brasov mountain resort in Romania. International chairman Endre Varga and local chairman Dan Barbu led a successful course with a positive learning environment. The high proficiency level of the participants, whose average age was 32, impressed everyone. The course featured five case discussion groups where opinions freely flowed, as well as contests and debates. The surgeons now better understand the AO Principles and philosophy, a support for their entire careers.

Next on the agenda is founding an AO Alumni Association in Romania, which will be celebrated with a seminar early in 2009.

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AOSpine & EANS Live Tissue Training The second combined AOSpine and EANS event, “AOSpine & EANS Live Tissue Training: Spine Access Surgery—Management and Avoidance of Complications”, took place (September 11–13) in Strasbourg, France. This intensive course included live surgery practicals on anaesthetized pigs, and for the first time at an AOSpine event, microsurgery practicals. These practicals were supplemented by lectures on the management and avoidance of complications and by small-group case discussions. Bernard Jeanneret and Guy Matgé chaired the event for AOSpine and EANS, respectively and Mike Grevitt served as educational director. Sixty surgeons from Latin America, Europe, the Middle East and Asia Pacific participated and were joined by nine European ORP.

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7 CPP–Large Bone Defect Healing Researchers from Europe and North America gathered in Lausanne, Switzerland, on October 2 for the latest news on this Clinical Priority Program. In addition to Program-funded researchers, invited guests from the Canadian Arthritis Network, and AO Research Fund grant winners contributed their expertise. Program Director James Kellam welcomed 30 participants to “Project Updates for the Program Community”, featuring reports from Mauro Alini, Grit Kasper, Michael Laschke, Chris Evans and Karen Burg. Guests from various external institutes were Jeff Dixon, Caroline Hoemann, William Murphy and Melissa Knothe Tate, who elaborated on projects of interest to CPP members. Bringing the various groups together lead to a flowering of ideas for further research, and recognition of an overlap in research interests that led members of different institutes to commit to work together in future.

AOTK symposium in South Africa

On September 5 in Cape Town, South Africa, AOTK (Trauma) organized a Jubilee Symposium as part of the AO Foundation’s 50th anniversary. This AO event formed part of the program of the 54th Congress of the South African Orthopedic Association (SAOA). Thanks to local AO Trustee, John Campbell, the AO Jubilee Symposium was an integral part of the SAOA’s scientific program.

AOTK members Norbert Haas, David Helfet, Jesse Jupiter, Dankward Höntzsch, Cléber Paccola and AO Past-President Chris van der Werken together made over 30 presentations. Over 200 participants attended the symposium and animated debates showed the AO Principles are well known in South Africa and other African countries. As part of the AOTK’s guest appearance, a joint excursion was made with South African AO Alumni to the vineyards of Cape Town and the AOTK team enjoyed an excursion to Sabi Sabi big game park near Kruger National Park.

AO Jubilee Symposium for CMF surgeons in Italy The XIX Congress of the European Association for Cranio-Maxillo-Facial Surgery took place in Bologna, Italy, from September 9–13. As part of the AO’s 50th anniversary a Jubilee Symposium gathered guest speakers Edward Ellis, Maurice Mommaerts, Gerson Mast, Alberto Bozzetti, Christian Lindquist, Adrian Sugar and Lim K Cheung to speak on orthognathic surgery to some 400 participants. AO CMF also sponsored a booth dedicated to AO CMF Membership and many surgeons took the opportunity to find out about the benefits of the program and signed up on the spot.

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community zone

Panorama News, Events, People

8

Language that unifies

Wade Brinker: AO Vet’s founding father and its second president

Wade Oberlin Brinker, DVM, born on October 11, 1912, in Fulton, Ohio, passed away on August 7, 2008 at the age of 95. Wade graduated from Kansas State University, and received his Doctorate in 1939. After serving in World War II he joined the Michigan State University (MSU) Veterinary Medicine Department where he pioneered new techniques in the field of small animal orthopedic surgery. He was a founding father of AO Vet and its second president. He founded the Veterinary Orthopedic Society, was a former president of the International Veterinary Orthopedic Society, and co-founded the American College of Veterinary Surgery. Dr Brinker was a longtime member of the Michigan Veterinary Association and the American Veterinary Association. Wade Brinker will be remembered as someone soft-spoken and kind with a great sense of humor who selected his words precisely—a true gentleman.

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The treatment of knee injuries interests at least two groups of specialists: knee surgeons, who usually focus on chondral, ligamental and meniscus injuries, and trauma surgeons, who concentrate on bone injuries and those of the soft-tissue envelope. This difference in focus contributes to a lack of consensual guidelines for decision making in knee trauma cases. A “Course on Fractures around the Knee” in Ribeirão Preto, Brazil (July 11–12) brought together the Brazilian Society of Orthopedic Trauma and the Brazilian Knee Surgery Society to unify the approach to traumatic knee injuries.

The Ribeirão Preto Medical School of São Paulo University— whose hospital is a Latin American AO Reference Center— supported the event, which gathered 350 specialists from 16 different Brazilian states and also US, Canada, Colombia, Peru and Venezuela. International faculty Joseph Schatzker, James Stannard and Rodrigo Pesantez joined 15 Brazilian faculty, among them Cléber Paccola and José Hungria Neto.

A system of approach was adopted for osteoporotic bone fractures, fractures in children, and which considers the importance of the soft tissue envelope and preoperative planning.

Current medical evidence for treating fractures of the tibial plateau, distal femur, and patella was discussed. A module for knee dislocations was designed with an emphasis on the different possible combinations of ligamental injuries and their respective treatment algorithms. Another module with a detailed discussion on complications focused on corrective intraarticular osteotomies and guidelines for approaching articular rigidity.

A “total immersion” approach, with participants and faculty eating and interacting together, favored a pleasant atmosphere. The language between knee and trauma specialty societies was unified and a closer relationship was developed so that in future, a common consensus for the diagnosis and treatment of knee injuries can be sought. The next course in this format is already set for July 1–3, 2010 in Ribeirão Preto.

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Chairperson of AOTK (Trauma) and TKEB elected

On January 1, 2009, Tim Pohlemann will become Chairman of both the AOTK (Trauma) and the TK Executive Boards, taking over from Norbert Haas.

Tim Pohlemann possesses vast experience gained over 16 years in the TK-System, including eight years as Chairman of the Pelvic Expert Group. He was also a member of the AO Board of Directors for five years. He is director of the highly regarded trauma and orthopedic clinic in Homburg/Saar, and is president-elect of the German Trauma Society.

Norbert Haas was Chairman of the Long Bone EG for seven years before he took over the AOTK on January 1, 1998, from Stephan Perren. During his eleven years at the helm, the size of the TK-System tripled. He implemented substantial reforms, for example, the formation of independent specialty pillars for Trauma, Spine and CMF in 2005. This new organization called for the establishment of an overall steering board, the TK Executive Board, which he also chaired. Norbert Haas resigns from his positions in the TK-System due to his new role as the AO’s President-Elect.

The AO thanks Norbert Haas for the outstanding performance of the TK-System under his leadership. His successor, Tim Pohlemann, is optimally qualified to safeguard the high TK standards that have been set over the past decades.

Philip Schreiterer, Project Manager, Trauma, TK Office

Jorge Rubio-Avila

Fellow’s opinion

Completed a 3-month fellowship in Clinical Investigation and Documentation at AOCID, Dübendorf

Jorge Rubio-Avila, MD Unidad Medica de Alta Especialidad, Centro Medico Nacional de Occidente Guadalajara, Jalisco, Mexico jrubio_avila@hotmail.com

In my work as an orthopedic trauma surgeon for a university hospital in Guadalajara, which has a population of five million people, I am responsible for teaching 40 residents, with at least ten more arriving every year.

Throughout the day and during surgery they are always asking me clinical questions, and so to be better able to answer them and to improve my knowledge of methodology and statistics, I decided to pursue a fellowship in the best possible place to obtain such knowledge, at AOCID based in Dübendorf and Davos.

The most important thing I learned while there is to focus on the patient

and the importance of clinical data and how to use available technology, such as AO Traumaline, to retrieve it.

During my stay, I realized that in Switzerland nature is very important. It has a transformative effect on people, who find peace in their surroundings– it had the same effect on me! It promotes a feeling of calm and inspires you to come up with new ideas.

When I return to Mexico, I will be able to answer the questions I’ve been asked and to work in collaboration with my residents and colleagues at AOCID Switzerland, with a view to publishing papers on various topics of investigation.

Jorge Rubio-Avila and Jan Ljungqvist in Davos.

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community zone

Report

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Susanne Bäuerle: “I’m learning it’s all about patience.”

In January 2008 a head-on collision left Susanne Bäuerle, an ORP traumatology nurse for 21 years and the AO’s Director of ORP/nurse education for the past six, with life-threatening injuries. With the support of AO surgeons, therapists, and a little help from “GMEROF”, Susanne is rebuilding her life with the same dynamism and determination for which she is admired throughout the AO community. Here, she shares with AO Foundation Editor Elena Ineichen some impressions of her experience so far.

Susanne, how did the accident occur?

It was noon on a bright day. An oncoming driver had an epileptic incident and hit me head-on. The driver behind couldn’t stop so I was badly squeezed in my own car. It took 45 minutes to cut the roof and door off and get me out. I woke up 24 hours later thinking I was at an AO course somewhere in the world.

1, 2 Susanne Bäuerle with physiotherapist Frank Janowski

A nd An And ndy dyy M Met eett tle tler tl l eerr

3 Susanne cycling in Davos, November 2008.

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What was the extent of your injuries?

I had an orbital fracture, contusions to the thorax and spleen, a tibial head fracture of the left knee, and open talus, patella and tibial plateau fractures of the right knee, as well as finger fractures. Within two weeks I had full movement in my left leg, so I thought, My right leg is a little more severely injured, it will take a little longer. I compared the two legs. What an error.

What has the treatment of your right leg consisted of?

I’ve had three surgeries. First they did emergency treatment using an external fixator and repaired the talus and patella. A week later they removed the exterior fixator and put in a plate using MIPO techniques. Last September, after they removed the tension band wiring from the patella and did an arthrolysis, I became convinced that my right leg would become good again. Before that, I really wondered, Can I ever walk again, do sports; how will I be able to handle this situation? That surgery was ideal timing—I gained 30–40° (from 90°) of movement in two hours!

Did your experience as an ORP help your recovery?

It was my daily business for years and we worked hard to put everything together for the patient, but when they left the OR, for us, the story stopped.

But actually, the story only starts there. We have these AO slogans, “life is movement and movement is life”, and one of the Principles is that the patient can go back to normal, walk and move his joints, but the part about recovery was really far away from my knowledge. Ten months after my accident I’m still working very hard to get that normal lifestyle back again.

Did you receive good advice from your surgeons and colleagues?

Older doctors comforted me, saying, “It was such a severe injury, it takes time.” That was very helpful and I built on that advice. With the young doctors, I was put under pressure: I wasn’t fast enough, I should be further ahead. This was really the problem I must say. For instance, after 12 weeks, when I could bear some weight on the right leg, my surgeon said, “Throw away your crutches and walk.” As a patient, you take this very seriously and you think he really means that you can walk, but this doesn’t work. It takes months to be able to walk without the sticks—they were my security.

Surgeons have the focus that surgery is the most important thing, but they don’t see as clearly as physiotherapists, who see us every day, that this healing process and regaining normal movement just takes time. It takes time.

community zone

11 What about psychological support? Did the doctors address your mental recovery?

The interest from the AO has touched me. It was impressive how many people from around the world told one another, sent emails, letters and flowers. I think that’s the nicest gift you can give to a person when you express first, I’m so sorry that this happened to you. But the mental aspect, I’m too down to earth. I know all the pressure and time limitations that everyone faces. Surgeons won’t have time to take care of your psychological needs.

So who helped you with that?

I talked my worries over with my physiotherapist and ergotherapist. You build up relationships with them, share your ups and downs, and they encourage you. I’ve learned to really treasure and appreciate my physiotherapist: you are consistently together and it’s the person who really goes on the journey with you. And friends were very important.

pists for innovative ideas to make the exercises interesting and fun. And a therapist in Slovenia reminded me of the importance of “boring exercises.” So I started a diary and every day I make time for: “G” (for Gleichgewicht, balance exercises); “M” (for massage the scars with cream); “E” (for Eis (ice), because the knee is hot and swollen); “O” (for outdoor exercises); “R” (for Rad (bicycle), so I cycle every day) and “F” (for exercising my fingers). GMEROF…it gives me satisfaction when I’ve done it.

Looking back, would you do anything differently?

I don’t think so. Sometimes I feel I should do even more, but my therapist says, “You can’t do more.”

My whole attitude to life is I don’t want to spend too much time on how it could have been. I face today.

How has your therapy progressed?

Initially, at the Akutspital in Chur, hydrotherapy was a highlight for me because I could stand upright and put weight on both legs. After three weeks I transferred to the Zürcher Höhenklinik in Davos. I was an in-patient there for two months, with two sessions of water therapy a day, and then five days a week as an out-patient. Now it’s three times a week for individual therapy, muscle- and balance building and cardio exercises.

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Andy Mettler

Is it hard to stay motivated?

You need somebody who pushes you. I don’t feel weak when I admit I need help to really keep it up and not to give up. So I asked my physiothera-

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community zone

Inside AO

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AO Membership initiative— providing customization and support for all members Jim Kellam AO Foundation Past-President Charlotte, North Carolina, US james.kellam@ aofoundation.org

In recent years, the AO network has experienced substantial growth, spanning six continents and linking nearly 6,000 individuals. Such widespread developments, while certainly impressive, provide a significant challenge to the organization’s capacity to maintain its legacy of effective relationship building and knowledge sharing across borders.

Furthermore, with the evolution of new communications and learning tools, the possibilities for expansion are multiplying all the time.

Consequently, the AO network is becoming increasingly diverse and its members’ needs more varied based on their Specialties, geographic affili-

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ations, career statuses, and personal interests. The requirements of a young resident are very different from those of an established senior surgeon, and the varying health care systems, practices, and socioeconomic environments around the world play an important role in determining what is considered relevant from an individual surgeon’s point of view.

That being said, the strength of the AO lies in the breadth of its network. While it is important to focus on the individual needs of our surgeons, we must also strive to maintain a common identity that members can be proud to affiliate themselves

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Today, the AO offers a great variety of benefits to its surgeons, including: • Personal contact and exchange in a global network • Meetings, workshops, member events, etc.

• Case discussions • Association with the AO image of quality • AO Courses/AO Faculty • Online Resources: eg, the Surgery Reference • AO Books/Journals/Videos • Research Projects/Grants • Participation on Boards

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We must strive to maintain a common identity that members can be proud to affiliate themselves with.

1 August Guggenbühl (l), an AO founding father, and Jim Kellam (r) AO Foundation Past-President.

with. To this end, a group of senior AO surgeons, with the support of the AO leadership, conceived the AO Membership initiative in order to create a common roof, providing customization and support for all members.

The underlying goal of this initiative is to uphold the AO’s leading position as the most attractive community in the field of trauma and musculoskeletal surgery by maintaining and strengthening the AO community spirit in a growing global network. As a first step in achieving this goal, we must focus on creating value for our members and on improving member information services.

Under current circumstances, however, it is mostly left up to the individual to determine how to realize these opportunities. Without better guidance, it is often unclear to surgeons how they can access their benefits and increase their involvement within the AO. To address this situation, the AO has dedicated considerable resources to the development of a new, personalized online user tool, which will substantially improve the information flow between the AO community and its individual members.

This tool, known as the Member Dashboard, will not only provide more efficient communication paths between members, but will also facilitate decentralized updates (concerning courses, events, benefits, etc), ensuring that members are always able to rely on relevant and up-to-date information that pertains specifically to their regional and Specialty affiliations.

In essence, with this sophisticated new tool, the AO Membership initiative intends to demonstrate the AO’s dedication to its members by addressing the needs of the different communities, shaping and developing the AO network, and providing more relevance and convenience for the individual surgeon. al

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Inside AO

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My Profile Specifically personalized based on your profile. You decide what your colleagues can discover about you.

AO Events View upcoming courses and events. Find out how to register for and manage your AO commitments.

My AO Contacts View and manage your personal network of AO contacts.

My AO Services Easy access to high quality academic resources. Take advantage of AO member-specific opportunities.

My Member Search Connect to your colleagues through the AO’s exclusive network facility.

My AO History Follow your activities within the AO community.

Monthly Member Feedback Question Simplified feedback channel. Guaranteed effort to continually improve member benefits and opportunities.

AO Membership: putting the virtual AO World at your fingertips Clint Miner Head of International Course Management, Dübendorf, Switzerland clinton.miner@ aofoundation.org

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As mentioned in the previous introduction to the AO Dashboard, the AO community has grown substantially over the past few years. To meet the needs of our community, educational activities have continued to increase, with more fellowships being offered and several years of 15% growth in the number of AO courses held worldwide.

Our international network of surgeons and ORPs has been transformed into an interactive, knowledge-building community that continues the same vision of the AO’s first 50 years—improving patient care. The AO community creates, shares, and practices evidenced-based principles and methods that improve trauma treatment outcomes.

community zone

15 The AO virtual meeting place will facilitate global interaction and answer educational needs.

Our community knows neither borders nor boundaries, however, the interaction of shared ideas is often restricted to the physical confines of meeting and course rooms.

The growth of the AO community, the increased need for a wider range of education and research services, and an emphasis on building shared knowledge has resulted in a new AO initiative to create a virtual, web-based membership and education meeting place.

This initiative will bear fruit in 2009 when the AO will roll out a comprehensive virtual education site that is designed to facilitate the interaction of our worldwide community and to answer each person’s educational needs as part of their life-long learning pursuits as medical practitioners.

So what is offered at this new site? The opportunity to meet with any member of the AO World community; with experts to help resolve a difficult case; with colleagues as you look at different treatment options; or with discussion groups to look at emerging technologies such as imaging. With only an Internet connection, surgeons and ORPs can at any time access a library of cases, presentations, videos, articles, and other materials, as well as assessment tools and a whole array of E-learning modules on a wide range of topics.

The AO virtual education meeting place will allow you to apply for fellowships or register for courses online, print your course/CME certificates, manage your life-long learning goals, and many other related functions. Specific tailored services will also be available to course chairpersons and faculty to support their success in providing world-class educational experiences to course participants.

The functions above are just an introduction to what will be available to you when the system is fully up-and-running. It will be a virtual AO community meeting place that supports the AO’s global reach and network as it begins its next fifty years of improving patient care through research and education. The extensive range of online activities and services can be a bit daunting for those of my generation who fondly remember 8-track tapes and faithfully hold on to their vinyl LP records.

However, I encourage you to jump in when the AO opens the doors to this dynamic site in 2009. We promise you all the support you may need.

This initiative brings the AO World to you, wherever you are and whenever you need it, with only a click on the AO Dashboard. I look forward to seeing you in our AO virtual meeting place.

With only an Internet connection members will access a wide range of materials and services.

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community zone

In Discussion

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AO Assessment Tool Kit— Promoting global excellence in the training of trauma and orthopedic surgeons The Assessment Tool Kit (ATK)—an AO Education innovation—will be available in mid-2009 to assess the success of Principles and Advances Courses.

Here, education experts, course chairmen and faculty look at how it will optimize learning for generations of surgeons to come.

In 2005 members of the AO Education Board under the chairmanship of Jesse Jupiter participated in a retreat at the Triennial AOAA Symposium in Sardinia, where they were asked the following question: What should AO Foundation be doing in the next five years to ensure it remains number one in education around the world?

“The surgeons/educators wanted to know about the people who come on courses, how effective their teaching is, and they wanted tools developed to answer those questions. So the number one priority was to develop an assessment tool to use in all our educational events,” recalls AO Education Director, Piet de Boer.

Pre-course assessment tool The instrument that became the first tool in the ATK–the pre-course assessment survey–already existed as an online needs assessment survey developed for the American College of Cardiology by Robert Fox, AO Education’s Director of Research and Development.

Piet de Boer AO Education Director Dübendorf, Switzerland piet.deboer@ aofoundation.org

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This survey, which has been adapted to suit orthopedic surgeons, “allows you to say to a course participant: these are the things we’re going to teach you on a course, how important are they to you and how much do you think you already know?” de Boer explains. In other words, it provides a subjective evaluation of how skilled the surgeon thinks he is and how skilled he thinks he wants to be.

“The difference between the two, the “gap score”, is a very sensitive measure of motivation, which is the most important thing to know about a student before you start deciding how to teach him, because if someone is not motivated to learn, no matter what you do, you will not succeed,” he elaborates.

To complement this subjective analysis, a working group of senior clinicians and trainees developed multiple-choice questions for each of 14 competencies. These questions have withstood rigorous pilot testing and lend themselves to sensitive computer analysis that in turn provides a highly accurate, objective assessment of the participants’ actual skills level.

The information culled from these subjective and objective assessments, completed by participants online and anonymously in the weeks before a course, allows faculty to make changes to the content and presentation of teaching material so as to optimally tailor it to students’ specific needs. And because the latter can confidentially retrieve their performance scores in advance, if need be they can brush-up on course material beforehand using Elearning modules, the AO Surgery Reference, and suggested reading materials.

Post-course assessment tool The next step in the ATK process takes place two weeks after the course is completed and assesses how much participants actually learned from it. As with the pre-course assessment, evidence shows that with the online post-course assessment survey—identical to the first but for a new set of multiple-choice questions—self-perception does not always match with reality.

“Participants say: ‘Tremendous lecture; I now know all about this (competence),’ but the objective testing says they don’t,” Piet de Boer says.

Unfortunately, the resulting misplaced confidence

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17

“No learning without teaching, no learning and teaching without evaluation.“ Maurice E Müller

can lower motivation to continue learning about a valuable— and sometimes still largely unknown—area of competence.

Course evaluation tool Low motivation can also influence the results of the course evaluation tool, conducted during the course, with which participants rate a presentation’s effectiveness and relevance.

Piet de Boer provides this example: “A Principles course lecture was the lowest-rated lecture of the entire Davos program, but the same lecture given to a different group (in the Roadmap to Research program) was rated one of the best ever. The determining facture? The second group had signed up specifically for this lecture so they were motivated to learn. What is significant,” he points out, “is if somebody says: ‘This was actually terribly important to me, but I hated it.’ ” In this case, the problem lies elsewhere and to help identify where, two faculty assessors also evaluate the presentation using ten criteria from AO Education’s book on teaching and learning. Solutions may include changing formats from a lecture to a hands-on practical or adding an interactive case discussion. “You must tailor-make the solution to fit the problem,” de Boer states.

The barriers survey For all the best intentions, lessons learned in the classroom are only truly successful if they can be implemented in real-life situations, for as de Boer puts it: “The intention to change is not the same as the ability to change.”

The barriers survey, completed six weeks after course completion, identifies the daily challenges

— Don’t mind the gap: high motivation — will help you succeed.

participants faced putting into practice what they learned on the course and how they may have overcome them. Their testimony is fed back into future course material so that if, for example, a lack of cutting edge equipment is the barrier, faculty will cover low- as well as high-tech methods in upcoming courses.

Supporting life-long learning To date, the ATK has been pilot-tested on 16 Principles courses in the Asia Pacific, Europe, North and Latin America Regions: great progress has been made in its development, feedback is very positive and support enthusiastic.

Other than having to redefine the pre- and postassessment survey questions and core competencies to reflect the different Specialties and regional/ local learning needs, the system is fully applicable to Advances and Masters as well as Principles courses, and all at a negligible cost to course organizers.

The ATK is part of an interconnected, forwardthinking strategy, de Boer says: “The AO wants to develop a relationship with its learners that will last them their entire lives: initially we’re looking at our courses, but in time we’ll build up teaching and directed-learning opportunities based on a surgeon’s individual needs and interests so that throughout his entire practicing career we are there to support him.”

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community zone

In Discussion

18

“

— Focusing teaching on individual needs. —

“

Robert Fox • Professor Emeritus of Adult Education, University of Oklahoma, US • AO Education’s Director of Educational Research and Development robert.fox@aofoundation.org

This is the kind of challenge that AO Education needs to meet to move into the next era.

We need to help surgeons to see themselves accurately, to be able to build courses around surgical needs, and to be able to correct ourselves according to what has succeeded and failed.

With the pre-assessment, the course director and faculty understand where a learner is not motivated because he already knows the answer—or he doesn’t know it, which is a terrible situation. In surgical education, we give unmotivated learners the opportunity to see they are not okay as part of the learning experience, whereas if they’re already motivated, we go straight into giving them the knowledge and skills they need.

The post-assessment outcome is critical. You can tell how successful you have been and what has to be followed up on. The chairs can make a change to the way the course is taught, the materials presented, or how much emphasis is put on a subject. We need to constantly provide that kind of feedback.

We are giving learners a voice. The ATK gives them a way to communicate with faculty and course chairs exactly what their needs are, what their motivation is, and how well they have done taking part in the course. It adds a new dimension to AO Education—faculty and course chairs who know about their learners and learners who know about themselves.

Robert Fox co-developed the pre- and postcourse assessment surveys and the barriers survey

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In the objective testing section of the preand post-course assessment surveys, we use four different multiple-choice questions per competence to test each participant’s actual knowledge and skills level before and after the course. The goal is to determine if after the course participants score higher on key aspects of the various competencies, eg, whether they can clearly differentiate the function of a compression plate versus that of a neutralization plate (see Fig 1).

The task force that developed the questions used research-based rules of test question writing. The questions were pilot-tested to check their validity and the resulting statistical scores showed if a test question was too easy, of medium difficulty, or too hard. Fine tuning achieved the right difficulty level for each question.

Test results help course chairmen and faculty to compare how much participants know before the course and after it. From this they can adapt their course to the learners’ actual knowledge level, emphasizing issues where needed.

Pascal Schmidt • Head of E-learning Dübendorf, Switzerland pascal.schmidt@aofoundation.org

“The ATK was an innovative method for testing our knowledge previous to the course and to assure knowledge retention after the course.“ Gustavo Gil, participant, AO Principles course, Sao Paulo, Brazil

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19 What is the function of the illustrated plate? a) Compression plate b) Neutralization plate c) Buttress plate d) Bridge plate

Response options

Pre-Test # persons

Post-Test %

# persons

%

a) Compression plate

38

45%

36

45%!

b) Neutralization plate

33

39%

42

53%

c) Buttress plate

8

10%

2

3%

d) Bridge plate

5

6%

0

0%

Rationale

A neutralization plate is applied across a fracture after it has been compressed

with a lag screw. The screw provides interfragmentary compression for absolute stability.

The plate adds strength to the construct, to resist repetitive axial and torsional forces.

Fig 1 This example shows that after the course 45% of respondents still selected the wrong answer (option a). As a result, the course would be reviewed to assess whether the concept of neutralization and compression plates was clearly explained. Test results could be emphasized in future courses to highlight potential lack of understanding of this competence.

“

We’ve made a major effort to focus on developing questions that really match with the competencies and in a way that works for course attendees from around the world. I think the questions are of very high quality (but) those that aren’t will be revised or dropped—it’s a continuous improvement process.

The questions have the potential to shape course content to emphasize poorly understood competencies but there has to be a very good way of making sure that a significant number of students take the questionnaire and that the results are provided to the faculty early enough so they can make adjustments in the course material.

I think the ATK is at the cutting edge of CME assessment. We’ve defined core competencies, defined what and how we’re trying to teach. I think this is the only way we’re going to be able to develop courses that clearly focus on communicating the essence of currently perceived fracture care to our students.

Because the AO is ahead of the rest of the world in actually using this process and because we have a body of knowledge, willing students, and faculty who are committed to helping students learn, it establishes that we’re set up for taking this important next step in the process of lifelong education and surgery.

Peter Trafton edited the pre- and post-course assessment multiple-choice questions

Peter Trafton

Roland Jakob • President of AO Switzerland • Instructor, AO Principles course for first-year residents, Bangkok, Thailand, August 2008 jakobr@h-fr.ch

“

When I saw the pre-assessment survey, I said, ‘hey, that’s interesting, good question, good discussions.’ If speakers have that information a month before, it would give us a chance to balance the academic level of teaching to the knowledge of participants. It would be easier, so you don’t talk over their heads.

When talks are given it would be rewarding to immediately go back and discuss the specific preassessment questions relating to certain fields of application and say, ‘thirty per cent of you got this wrong. Why? Who wants to discuss that?’ That would be very meaningful. I thought the assessment tool was very good.

Roland Jakob observed the pre-course

• Professor of Orthopedic Surgery, Brown University, Providence, Rhode Island, US • AO Faculty for Principles, Advances and Masters courses Peter_Trafton@brown.edu

“The ATK is good for self-evaluation and as a guideline for study.“ Jirayus Paripo, participant, AO Principles course, Bangkok, Thailand

assessment survey process and results

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community zone

In Discussion

20

en artme p m Co drom Syn

t

e ative per Prre-- op a niing an plan pl

P staelvis bil iza tio n R teceduc hn tion iqu es — Aiming for mastery of surgical competencies. —

“

The pre-assessment tool is necessary, first because it stimulates interest among participants and faculty before the course. Second, because it lets faculty know the basic knowledge level of the participants so they can focus on what is necessary, prepare changes to the lecture, and focus on points that were missing. Even if it’s taking 30 seconds more or adding one or two more slides, it can improve the quality of the course.

Third, participants will know where their knowledge level is, what they have to do to prepare for the course, and what they have to concentrate on during the course.

Participants should receive the survey four to five weeks before the course and have about two weeks to answer the questions. It’s also helpful that in future the online software will allow them to do the survey in parts rather than in only one sitting.

Faculty should have at least one-to-two weeks to prepare the course based on the survey results.

The pre-and post-course surveys should be compulsory in order to get the certificate. I think the package is already good, and the material should be updated once a year to avoid repetition.

Vajara Phiphobmongkol pilot-tested the pre- and post-course assessment surveys

Kodi Kojima • Chairman of Principles and Advances courses 2006–2007, Sao Paulo and Rio de Janeiro, Brazil kodikojima@uol.com.br

“

The questions have improved a lot: initially, some of the questions were specifically for European countries, so what we tried to do is make general questions to use everywhere, and then specific questions for one area, say Asia Pacific or Latin America.

It’s hard to know how to apply what we learn from the surveys to improve the course. The pre- and post-assessments are more useful for making new formats for future courses than for improving existing ones.

We have to find a friendly and easier way to present the pre- and post-assessment results so that faculty can take the information from them and find them easy to understand.

The pre- and post-course surveys are important and we have to find ways to encourage participants to use them, (especially) the postcourse assessment, because participants have already done the course.

Kodi Kojima co-developed questions for the pre- and post-assessment surveys

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Vajara Phiphobmongkol • Course chairman and organizer, AO Principles course, Bangkok, Thailand, August 2008 deeknee@yahoo.com

“Through the pre- and post-course assessments I realized how much the course improved my knowledge of the AO Principles of Fracture Management.“ Nemi Sabeh Jr, participant, AO Principles course, Sao Paulo, Brazil.

community zone

21

“

— Equipping surgeons with all the right tools to succeed. —

Rick Buckley • Head of Orthopedic Trauma, University of Calgary, Canada • Chairman of the Davos Advances courses 2004 to 2007 • Co-chairman of the 2008 Davos Masters course buckclin@ucalgary.ca

“

We’re on the cutting edge in determining how to make an educational offering better, so that it will change your life, your practice—that’s what we’re really focusing on.

Early demonstrations of the ATK have shown that qualitatively participants are happy, but also quantitatively their knowledge is better: they’ve had a real jump in their ability to both understand the concepts and to be excited about them.

As a course instructor, if you study your students beforehand you find out what they’re about, and whatever you then provide is much better: you can tailor the course, spend more time, have a few more questions and discussion groups, and promote their questions to make sure you listen to what their needs are.

The ATK development isn’t Davos-centric, it’s a global effort. By getting input from many different people for the development of questions and competencies, it touches many different cultures, educational needs and languages. It’s also being tested globally to make it applicable to all the places that the AO touches.

Participants need to understand that the ATK is for their betterment and that what we’re doing is taking education to the next level. We’re in this together: the best education is something where we can prove that we do what we hope to do, which is to teach them more efficiently.

Rick Buckley co-developed the questions

I think the ATK is absolutely necessary and I’m very impressed with this strategy because it’s a way to evaluate and engage participants before the course and it helps to organize the structure of each specific course.

We should encourage participants to know that the course lasts three months, (starting) one month before the actual start date with the online precourse evaluation, then 100% participation in all the activities, and ending one month after the course with the post-course evaluation, and that it’s an obligation, not an option, in order to get the certificate of participation. Brazilian surgeons will accept this if it is established as a rule (beforehand).

The ATK has to be tailored to the specific needs of the Regions in order to know the level of interest, the expectations and knowledge of participants.

You then have to cross this information with the profile of participants because you may get a completely different interpretation. If you get a low level of interest and you discover that 100% of these people constitute a group of tenured or sponsored surgeons then you understand why they are less motivated. It’s dangerous to evaluate only the interest of the participants without considering the participants’ profiles.

AO Education is looking to improve the quality of our course, to enhance delivering information that is not only for participants’ knowledge, but also their use during the practical activities of their daily lives—this is important.

Mauricio Kfuri pilot-tested the pre-course assessment survey

Mauricio Kfuri • Assistant Professor of Orthopedics, Sao Paulo University • Course chairman, AO Principles course, Sao Paulo, Brazil, October 2007 kfuri@fmrp.usp.br

“I think AO fosters teachers who are in it for the right reasons.“ Rick Buckley

and competencies upon which participants are assessed

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community zone

From the Regions

22

AO Middle Europe: building the new harmony This burgeoning region reflects European culture and civilization as well as its geographic location.

1

Jarek Brudnicki Orthopedics and Trauma Clinic, Rydygier Hospital, Academy of Physical Education Cracow, Poland jarek.brudnicki@aoalumni.org jarbru@mp.pl

Everyone knows that proverbs, which are present in every culture, often contain a profound wisdom.

A Polish proverb says: “Harmony builds, discord ruins.” Our history confirms this truth.

AO Middle Europe: an open group of nations In 2005, at the first regional course in Portoroz, Slovenia, representatives of that country together with those from Israel, Turkey, Hungary, and Poland signed a letter of intent proposing the creation of a new AO region. We wanted to create a union of countries with similar economies, clinical experience, and political conditions to facilitate scientific exchanges, make access to the AO’s philosophy and courses easier, and to share our experience. We wanted to affirm our potential to be recognized as equal and rightful members of the AO family.

The idea of creating a new region met with great enthusiasm from other European countries and from representatives of AO Education and the AO as a whole. Soon other countries interested in the idea of regional cooperation joined the core group of signatories.

We knew we had a lot of work to do. European countries are more diverse than those in Latin or North America in that we have different cultures, languages (even alphabets) and religions,

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and sometimes a cruel and painful history behind us. We spent many hours in discussion, organized and held many meetings, and sent many letters to set up the rules of cooperation. We decided to call ourselves the AOMID region. Firstly, for Middle Europe, but also to reference the Mediterranean Sea–the cradle of European culture and civilization. We are an open group and we do not want to be recognized only as a union of countries from Middle Europe.

From the moment the idea for an AOMID region was born, we received strong support from the AO in organizing regional courses and other events.

We were also lucky in that we had great leaders: Andrej Ales from Slovenia and Rami Mosheiff from Israel. We constantly improved our courses, corrected mistakes, and worked to create a spirit of cooperation and to bring about as many benefits as possible. Our efforts were well appreciated and now, after our last meeting in Thessaloniki, Greece, in April 2008, there are 15 countries either united in AOMID or applying for membership.

AOMID faculty dominate regional courses After three years we can say that in a sense we are already successful. During the third regional course, in Antalya, Turkey, in 2007, the faculty

community zone

23

2

3

1 AOMID members enjoy a mountainbiking tour in Slovenia, September 2008.

2 (l to r) Jarek Brudnicki, Matej Cimerman, Rami Mosheiff, and Steven Velkes at the Davos courses banquet in December 2006.

3 AOMID general assembly in Porto Karras, Greece, April 2008.

was made up of lecturers and instructors from AOMID countries. We had guest lecturers, of course, but the core faculty was from the region.

The course was highly rated by participants.

In between the second regional course, also held in Antalya, in 2006, and the last regional course, in Thessaloniki, in 2008, we also organized three Tips for Trainers courses, in Budapest, Istanbul and Cracow. Thanks to the regional course in Thessaloniki, which was very highly rated, more than 80% of faculty was well trained in teaching techniques.

The high caliber of the regional courses and the great needs of countries united in AOMID led to a proposal that we organize a regional course twice a year; we accepted with great satisfaction.

During the meeting in Thessaloniki we took additional steps to improve our mutual cooperation and to be officially recognized as an AO region.

We drafted and accepted bylaws, regulating the relationships between members of AOMID and establishing the rules of cooperation. This extensive document covers most if not all of the possible issues and problems we may face in our future.

We also established structures that will make our mutual cooperation more effective and orderly.

Finally, we established a board of directors and committees for science and education.

A focus on exchanges and scientific activity AOMID countries not only focused on organizing courses and the structure of our union, we also increased our scientific activity and exchanges. For example, the software for preoperative planning in pelvic surgery created in Ljubljana, Slovenia, is accessible to everyone, and facilitates decisionmaking in most difficult cases. The discussion of difficult cases via the Internet has become a kind of tradition for us.

Why do we already consider ourselves successful? Though we are not yet recognized as an official AO region, we have proven that cooperation among different countries is possible and leads to excellent results. We have proven that AOMID members constitute a valuable faculty for many AO events, and we have created a positive, effective movement whose contributions and benefits are already apparent.

Building together in harmony From the moment we sent the letter of intent we had a strong feeling we were participating in something exceptional and worthy. We built our cooperation on personal relationships, mutual respect and friendship. It’s a great experience to observe a serious scientific event like the AO regional course where the atmosphere feels like a family meeting.

Another reason for our success is the exceptional enthusiasm of the people engaged in our regional activity. The third reason is the great, reliable work of so many people in AOMID. There are many plans for the months and years ahead. Beyond organizing courses, we will set up our Web site to facilitate communication between AOMID members; we are planning an exchange of resident surgeons within the region; we are going to lead multi-center clinical trials; and we need to create an archive of course presentations and publications written by AOMID members.

The region will also coordinate and support any scientific events organized by the AO in AOMID countries.

Three years ago we started to build in harmony and we will do our best to maintain it because it is the only way for the future. We believe that our recognition as an official AO region is only a matter of time.

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community zone

AO and its partners

24

Synbone—celebrating 20 years of partnership with the AO Foundation Domenic Scharplatz former Surgical Department Head, Regional Hospital Thusis, Switzerland dscharplatz@bluewin.ch

A little more than twenty years ago, on January 15, 1988, Synbone was founded to create artificial bones and anatomic models for teaching trauma and orthopedic surgery, enabling the AO Foundation to offer courses of the highest standard.

Filisur, Switzerland, took over production and developed several new bone models, simulated cortical bone and spongiosa, and created several fracture types.

The task of fracturing the models in a standardized way was delegated to the private institution ARGO in Davos and its capable team of handicapped employees, one of whom, Alberto Castella, is today a recognized fracture specialist.

The number of courses has dramatically increased since the first one took place at the AO Research Institute in Davos in 1960: in 1975, 30 courses were offered worldwide, and in 1997, 120 courses. By 2007, almost 273,000 surgeons in 124 countries, and some 130,000 operating room personnel in 69 countries had been trained in the AO techniques.

Keeping pace with educational needs Initially, training was done on human cadaveric bones, then on sheep bones as they were easier to obtain, but as demand increased issues of safety, hygiene, preservation, transportation and aesthetics needed to be addressed and it became obvious that another material was needed.

In 1973–74 the first tibia models were developed in a laboratory using plaster and liquid plastic, and in 1975 the Zurich-based company Contraves created artificial bones from polyurethane. This material offered a variety of shapes and different stiffness, hardness and density as required by the method being learned, be it with screws, nails or plates. In 1983 Johann Steiner in 3 | 08

From sheep bones to Syn-bones From Steiner’s business Synbone came to life in 1988 and nine years later the company moved to a larger, modern location in Malans, some 50 km from Davos.

The following year, Synbone-manufactured bones became commercially available. Over the years Synbone has developed models for virtual reality training, leading to new techniques for navigation around the hip and pelvis. Innovations include “Synman” for Advanced Trauma Life Support training; a model for exercises in laparoscopy; and “Synpelvis”, which simulates pelvic fracture bleeding.

As AO education has become more sophisticated, so have the models it requires: today, minimally invasive osteosynthesis and computer assisted surgery models with soft tissue have become standard.

With ever-increasing demands on development, production and sales support, the Synbone team has grown from its initial ten to 26 employees, and as a result, this year the company is enlarging its facilities.

Synbone’s CEO Thomas Parkel and his team can look back on its first twenty years with pride for its many accomplishments while looking forward to its next twenty with anticipation for the many new developments it will achieve together with its partners, most prominent among them, the AO Foundation. www.synbone.ch h

Books

community zone

25 Osteotomies for Posttraumatic Deformities René K Marti Ronald J van Heerwaarden

An international group of renowned surgeons present an outstanding hands-on approach to performing correction osteotomies in posttraumatic deformities from the clavicle to the foot.

Most of the content is based on case presentation and each case provides a step-by-step description of the case history, planning, surgical approach, Osteotomies for osteotomy, fixation, rehabilitaPosttraumatic Deformities René K Marti Ronald J van Heerwaarden

9/15/08 10:46:32 AM

Editors Philipp Lobenhoffer Ronald J van Heerwaarden Alex E Staubli Roland P Jakob

New books in 2008 Osteotomies around the Knee Indication—Planning—Surgical Technique using Plate Fixators

Co-editors Mellany Galla Jens D Agneskirchner

Osteotomies around the Knee Indication—Planning—Surgical Techniques using Plate Fixators

Editors: Philipp Lobenhoffer, Ronald J van Heerwaarden, Alex E Staubli, Roland P Jakob Co-editors: Mellany Galla, Jens D Agneskirchner

This book offers a comprehensive overview of the present knowledge on indications and techniques for osteotomies around the knee, including recent experimental and clinical results and new developments in surgical techniques and implants.

9/15/08 10:42:33 AM

tion, and finally the pitfalls and pearls. Hundreds 1 of full-color photographs, precise illustrations, and x-rays demonstrate the significant steps achieved in deformity correction. Long-term follow-ups demonstrate the efficacy of osteotomies in the treatment of malunions.

In the principles section preceding the case presentations relevant theoretical information on posttraumatic deformities and osteotomies, operative techniques, and fixation methods, as well as the formation of a surgical plan is provided.

This book should convince surgeons to use osteotomies in the treatment of posttraumatic deformities and to consider joint-preserving techniques in the treatment of posttraumatic osteoarthritis.

The reader will gain insight into: • The basis of clinical and radiological deformity analysis.

• The principles and details of preoperative planning, including frontal and sagittal corrections.

• The surgical techniques for osteotomies of the distal femur and the proximal tibia, including frontal and sagittal plane corrections, and rotational corrections.

• The use of specifically designed plate fixators for osteotomy fixation (TomoFix plates).

• The handling of perioperative and postoperative complications.

• Appropriate techniques for revision after osteotomy around the knee.

For more information and to order please visit our website: www.aopublishing.com.

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expert zone

Case study

26 This article considers how the new locking X-plates answer requirements presented by complex cases in foot and ankle surgery.

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

in foot and ankle surgery 3 When looking for a solution to a complex case in foot and ankle surgery, one should consider an implant whose characteristics match the needs of the preoperative plan. The implant may be required to provide stability in all planes including rotation, to enhance fixation in osteoporotic bone, to allow early weight bearing and to be friendly to the soft tissue.

The implant should have adequate contour to adapt itself to the shape of the bone but be as thin as possible to avoid prominences that preclude the use of normal shoe wear while being adaptable to many locations around the foot. Finally the surgeon’s learning curve should be simple and quick.

1

The new locking X-plate fits all these requirements. It is indicated for calcaneal and distal tibial osteotomies, for acute and revision surgery of fractures around the mid- and forefoot, for correction of primary and revision hallux valgus deformities, diabetic reconstructions, bridging defects of bone, and primary and secondary fusions for arthritic joint disease throughout the foot.

The plate comes in four different sizes, according to the anatomical region and size of the foot: mini, small, medium, and large. The plate has four locking holes that accommodate 2.7 mm locking or cortical screws, and can be directed using the bending threaded pins so the screws cannot collide. The area around the screw holes is thicker than the actual body of the plate to allow bending without compromising the threads of the holes, and to provide the best stability for biomechanical demands 3 | 08

Fig 1 The X-plate is available in four different sizes to be used in different anatomical regions in foot and ankle surgery.

(Fig 1). The two dorsal holes are more angulated and enable the surgeon to cross the osteotomy site when fixing proximal metatarsal osteotomies, providing the highest stability. Interfragmentary compression can be achieved through a separate interfragmentary screw.

Plates can be bent with pliers to get the anatomical shape of the bone, although they are available prebent according to the shape of a CT database of the foot. The arch design corresponds to the oldest architectural principles to get an ideal stress distribution with the least amount of material and so produce minimal effect on the bone periostium.

expert zone

27

2

3

4a

Fig 2

Preoperative x-ray showing instability of the first metatarsal-cuneiform joint.

Fig 3

Intraoperative placement of the x-plate under spinal anesthesia.

Fig 4a–b

4b

Postoperative AP and lateral views.

Case study 1 A 62-year-old female had minimally invasive hallux valgus correction surgery and in the subsequent 11 months felt progressive pain over the second and third metatarsal, and the initial deformity recurred.

During a physical exam, normal neurovascular status and no pain over the previous scars were noted. Mild hallux valgus deformity was present and instability of the first metatarsalcuneiform joint was the main problem that led to the transfer lesions of the second and third metatarsal heads (Fig 2).

On x-rays an intermetatarsal angle of 17 degrees was measured and normal distal articular metatarsal angle was noted. A decision to perform a first metatarsal-cuneiform arthrodesis was chosen to address both the correction of the intermetatarsal angle and to relieve the transfer to the lateral metatarsal heads.

Modified Weil osteotomies of the second and third metatarsal heads were planned as well as to obtain a plantigrade forefoot.

Under spinal anesthesia a dorsal incision accessed the first metatarsal-cuneiform joint. Cartilage excision and subchondral bone bleeding was obtained using sharp chisels. Bone graft from the iliac crest was placed and correction of the intermetatarsal angle was obtained using a large clamp and a Kirschner wire through the joint. A small locking x-plate was contoured to purchase both sides of the fusion bones, using four 2.7 mm locking screws, and an extra cortical 2.7 mm screw directed from proximal to distal for maximum stability (Fig 3). Modified Weil osteotomies were performed in the second and third metatarsal heads and fixed with 2.0 mm cortical screws. Wounds were closed in layers, an anesthetic ankle block was performed, and ice compression was applied to reduce early swelling (Fig 4).

Immediate weight bearing was allowed on a wooden-soled shoe and early resolution of the patient’s symptoms was noted at four weeks following surgery. Complete fusion was noted by the seventh week.

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expert zone

Case study

28

5a 3 5a–b Fig

5b Postooperative AP and lateral x-ray showing result of fusion.

Case study 2 A 62-year-old woman complained of progressive pain on her left midfoot that was aggravated by standing or walking short distances. On clinical examination, no gross deformity was seen.

Neurovascular status was normal and pain appeared when trying to abduct or adduct the midfoot. On x-rays and a CT scan, mild arthritic changes were seen at the level of medial and intermediate cuneiforms and in the navicular-medial cuneiform as well. Injection of steroids and orthotics to support the arch were prescribed but the pain continued to bother her and as a consequence, three months later she underwent surgery.

A midfoot fusion was undertaken including harvesting bone graft from her left iliac crest and using a large locking x-plate for definitive fixation (Fig 5a–b).

The advantages of using locking X-plates in foot and ankle surgery include more stable fixation of the osteotomy and fusion site, closer bone contact, shorter bone healing time and thus early weight bearing, avoiding transfer lesions due to minimal shortening, less dorsal malunion or nonunion, and less elevation of the MTP1-head.

Following the principles of locking X-plates, neutralization plates, and interfragmentary compression, locking X-plates are easy to adapt to almost every indication noted above. With some clinical experience a surgeon can expand the applications for this plate.

Partial weight bearing of 20 kg on crutches was begun immediately and analgesic protocol was followed as well. Radiological fusion was obtained nine weeks after surgery.

Juan Bernardo Gerstner Garcés

Centro Medico Imbanacco Cali, Colombia jbgerstner@imbanaco.com.co

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Clinical topic

expert zone

29 This article looks at the most important factors in treating tibial plateau fractures and indications for the use of locking plates.

Fabio Castelli

Proximal tibial fractures: indications for the use of locking plates Fractures of the tibial plateau are caused by a combination of axial loading and bending forces resulting in several fracture patterns, the most common being either a multifragmentary wedge fracture or articular surface depression. The result is a decrease in the joint surface area available for weight bearing and axial malalignment.

Angular-stable fixation

Understanding the injury by a careful assessment of the patient, the limb and the radiographic examinations (plain x-rays: AP, lateral, and oblique, as well as the CT scan and its reformations) is mandatory so that an acceptable treatment plan may be developed. The most important factors in the treatment of tibial plateau fractures are:

• • • • •

• • • • • •

Joint dislocation or subluxation Articular surface fragmentation and depression Meniscal lesions Ligament lesions with consequent joint instability Malalignment Soft-tissue conditions

These factors are probably cumulative in negatively influencing the prognosis and resulting in arthritis and instability. The treatment goal is to obtain joint congruity, axial alignment, and sufficient stability to allow for early functional rehabilitation.

The new locking plates allow angular stability and improved purchase in osteoporotic bone. Depending on the plate type they may be used in either the locking mode (LISS and LCP) or as a standard plate (LCP). This provides the opportunity to use these new implants in different plate functions of fixation: Neutralization plate (LCP) Locking compression plate (LCP) Internal fixator or “locked splinting” (LISS, LCP) “Antiglide” or buttress—(usually LCP, but LISS will work) Bridging plate (LCP, LISS)

As well, the locking plates may be applied so as to avoid compression of the periosteal vessels and hence limit the disruption to the blood supply to the cortex.

Therefore in the preoperative tactic, it is necessary to plan: • • • •

The approach The steps and the instruments for reduction The method of osteosynthesis The choice of implants based on the function necessary to stabilize the different fracture pathoanatomies

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Clinical topic

30

1a Fig 1a-h

1b

1c

1d

Case example 1.

3 Pathoanatomy of the fracture and locked plate indications

Split fractures (Schatzker Type I, M端ller AO/OTA 41-B1)

Joint depression fracture (Schatzker Type III, M端ller AO/OTA 41-B2)

This is a simple joint fracture with the potential for meniscal entrapment at the fracture site. Reduction may be performed in a direct open or arthroscopic manner. Fracture fixation requires independent lag screw compression beneath the joint surface and either a fracture apex screw with washer or a buttress plate.

Locking plate use for this pattern is uncommon except with osteoporotic bone.

Fractures with pure depression are rare. Normally the joint is elevated through a cortical window in the metaphysis and the reduction controlled arthroscopically or with image intensification. The window is packed with a bone void filler and buttressed with a nonlocking mode plate. Independent rafter screws are placed next to the reduced joint surface to help support the reduction. In young people lag screws are sufficient.

Split depression (Schatzker Type II, M端ller AO/OTA 41-B3)

Medial plateau fracture (Schatzker Type IV, M端ller AO/OTA 41-B1.2, B2.3, B3.2)

This fracture pattern requires an open direct reduction to assure that the depressed joint surface is reduced and stabilized with some form of bone void filler (cancellous bone or bone graft substitute). Fracture stability is achieved by lag screw compression across the split fracture line with the screws placed close to the reduced joint surface to act as support. The axial forces are buttressed with a plate. As there is no angular instability, no locking is necessary unless the bone is osteoporotic, and usually a LCP 3.5 is used or uncommonly a LISS plate.

Fractures of the medial tibial plateau are generally considered occult knee joint dislocations or subluxations as the femur displaces medially and posterior with progressive internal rotation.

An injury to the popliteal artery may be present and arteriography or another form of arterial imaging should be considered.

Through a direct reduction technique using a posteromedial approach, the joint is reduced and stabilized with lag screws.

Joint depression when encountered is reduced and stabilized as with the lateral plateau fractures. A buttress plate is mandatory to neutralize the medial axial forces or else secondary displacement will occur. Usually a locking plate function is not necessary except with osteoporotic bone.

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31

1e

1f

1g

1h

a–b

Multifragmentary tibial plateau fracture leading to vertical instability.

c–e

Treatment by direct articular reduction using 5.0 mm compression screws and application of a bridging LISS-plate. The whole procedure was performed using the less invasive technique.

Postoperative result: Fast callus formation and return to full function after 4 months.

f–h

Complete proximal intra-articular tibial fractures (Schatzker Type V, Müller AO/OTA 41-C1) These are simple fractures of both tibial plateaus with simple extension to the metaphyseal region. As a consequence, reduction can be achieved easily with axial traction. Through a posteromedial approach, the medial plateau is reduced and stabilized first as it provides the guide to the right length of the limb and allows the various stresses necessary for the reconstruction of the lateral tibial plateau. Fracture stability is achieved by lag screws between the two plateaus and buttress plates on both sides. Generally it is not necessary to use angular stable fixation as the reduction is anatomical and stable, and also, the dual plating will prevent collapse. In selected cases, if the medial plateau is undisplaced it’s possible to fix the medial plateau to the lateral plateau with lag screws and buttress the lateral plateau with a locking plate using locking screws to prevent the potential secondary varus collapse of the medial plateau through angular stable fixation.

Multifragmentary complete intraarticular proximal tibial fractures (Schatzker Type VI, Müller AO/OTA 41-C2-C3) These are multifragmented articular fractures of both plateaus with extension to the metaphysis and diaphysis. These fractures will require a direct reduction of the joint surfaces and support by a bone void filler. After reducing the fracture through a mini-arthrotomy (TARPO approach), the medial fracture is fixed and then the lateral plateau built back to the medial side transforming itself from an intra-articular to extra-articular fracture. The metaphyseal component and diaphyseal extension are reduced by distraction and stabilized with locking type plates. The surgeon must determine in the preoperative tactic the function of each screw inserted–whether locked or not. In these fractures it is common to use locked screws as position screws so as to help support the joint reduction. As locked screws they will provide more stability than the nonlocking position screws as they are angular stable.

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2a 3

Fig 2

2b Case example 2.

Conclusion

After an atraumatic anatomical reduction including elevation of the impacted articular surface with bone defect filling, stable fixation of the construct may require the use of angular stable fixation. This will be determined by the fracture pattern, the need to enhance the stability of the reduction, the need for articular surface support and the quality of the bone. The more fragmented the extraarticular fracture component and joint surface is, the greater the need for locking plates, as well as with those patients with poor bone quality.

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expert zone

33 Recommended reading Buchko GM, Johnson DH (1996) Arthroscopy assisted operative management of tibial plateau fractures. Clin Orthop Relat Res; (332):29–36.

Chan PS, Klimkiewicz JJ, Luchetti WT, et al (1997) Impact of CT scan on treatment plan and fracture classification of tibial plateau fractures. J Orthop Trauma; 11 (7):484–489.

Court-Brown CM, McBirnie J (1995) The epidemiology of tibial fractures. J Bone Joint Surg Br; 77(3):417–42.

Duwelius PJ, Rangitsch MR, Colville MR, et al (1997) Treatment of tibial fractures by limited internal fixation. Clin Orthop Relat Res; (339):47–57.

Gosling T, Schandelmaier P, Müller M, et al (2005) Single lateral locked screw plating of bicondylar tibial plateau fractures. Clin Orthop Relat Res; 439:207–214.

Honkonen SE (1995) Degenerative arthritis after tibial plateau fractures. J Orthop Trauma; 9(4):273–277.

Messmer P, Regazzoni P, Gross T (2003) [New stabilization techniques for fixation of proximal tibial fractures (LISS/LCP)]. Ther Umsch; 60(12):762–767. [German] Schatzker J (1974) Compression in the surgical treatment of fractures of the tibia. Clin Orthop Relat Res; Nov-Dec;(105):220–239.

2c a

Spiral fracture of the tibial metaphysis.

b

Treatment by using two compression screws in the tibial plateau and a LISS bridging plate in a neutralization function.

c

Healing process postoperatively.

Schatzker J, McBroom R, Bruce D (1979) The tibial plateau fracture.

The Toronto experience 1968-1975. Clin Orthop Relat Res; Jan-Feb; (138):94–104.

Schutz M, Kaab MJ, Haas N (2003) Stabilization of proximal tibial fractures with the LIS-System: early clinical experience in Berlin. Injury; 34 Suppl 1:A30–35.

Stevens DG, Beharry R, McKee MD, et al (2001) The long-term functional outcome of operatively treated tibial plateau fractures.

J Orthop Trauma; 15(5):312–320.

Tscherne H, Lobenhoffer P (1993) Tibial plateau fractures.

Management and expected results. Clin Orthop Relat Res; (292):87–100.

Wagner M (2003) General principles for the clinical use of the LCP. Injury; 34 Suppl 2:31–42.

Fabio Castelli

Orthopedics and Traumatology, DEA, Ospedale Niguarda Ca’ Granda, Milan, Italy md.castelli@fastwebnet.it

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Focal point

34 This innovative new approach supports AO research networks to build the consensus on clinical priorities, technologies and other research priorities that is required to further improve the surgical management of trauma and disorders of the musculoskeletal system.

Marcel Dissel, Nikolaus L Renner and Tobias Hüttl

Roadmapping: facilitating collaborative research strategy for Clinical Priority Programs 3

The task of the Specialty Academic Council (SAcC) General Trauma is to identify and define clinical problems within the Specialty and set priorities concerning them for integration into the direction-setting process of the Academic Council. These SAcC activities began three years ago, after it was deemed necessary to have so-called Clinical Priority Programs (CPP) in order to focus AO research activities.

The aims of a CPP are to: • Focus AO research activities.

• Work on problems of outstanding clinical relevance.

• Follow realistic and achievable goals (3–5 years).

• Include and foster the research network of surgeons and scientists.

• Include close collaboration with industrial partners to ensure technology transfer and implementation.

which has an international reputation and proven track record for developing technology roadmaps across a wide range of disciplines.

Roadmapping approaches are now widely used at company, sector and national levels to align research investments and other actions with goals and policy. This article provides an overview of the technique, focusing on how it can support research networks to build the consensus on clinical priorities, technologies and other research priorities that is required to move forward within the AO Foundation.

In order to identify clinical priorities, the SAcC embarked on creating a work flow and put a notification in AO Dialogue magazine for those with a clinical problem of high priority to come forward. Unfortunately the response rate was very low, resulting in the SAcC having to find other ways of identifying clinical priorities.

In 2007, the SAcC adopted an innovative new roadmapping approach with support from the Centre for Technology Management at the Institute for Manufacturing, Cambridge University, 3 | 08

Fig 1

The SAcC roadmapping workshop in Davos, December 2007.

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35 Roadmap architecture

Timeline

2007

Short term “investment”

2012

Medium term “strategy”

2017

Long term “vision”

ntt en nme onm on iro vir nvir n Env rs on a vers ve rive ds & dri ends TTrren ree: care e t ca patititien f r pa v l fo leve ro le cro maacr m ciaall ci Social • So g onnaall reegi call///re ica g apphhiica mogr mo Demo • De t l eennta nmen ronm iro viro E vi • En al ical ic mical onom onom on Econ • Ec iccaal Polil ttiica Po • Poli Funnddinng • Fu

What are the key trends and drivers in patient care with respect to infections?

Cli lini lini nica n ca cal al is issu ssu su ues es and nd nee eeds ds Cllinnic ical al nnee eeds ee d aare ds reas re ass: • Di Diag aggnoosi siss • Th T er erap a ie ap iess • Pr Prev even ev entitition en on

What are the clinical issues and needs that follow from the trends and drivers in the area of infections?

Cluster and Prioritize.

Sol olut utio utio ions ns Solu So lutition ioonns: s: • Produc odducts uc tss uc • Te Techni Tech chni ch n qu q es es • Co Conc ncep eptss ep

What could be solutions that address the clinical issues and needs for infection for trauma and orthopedic surgery?

l rs lers able nab ena AO en D: &D: RR& caal - cliiniical ree -c • Preal cal nicca • Clil ni ion ucattio Edduc Educ k r ork or w tw e Ne N y t allititi Q al Qu

What could the AO contribute to finding solutions for the identified clinical needs and solutions?

Sci cien enttifi tiifi f c ch c al a le alle leng eng nges gess • Bi Biom o eeccha cha hani nica ni nica c l • BBiiot otec echn ec chn hnol olog ol o y • Ph P ar arma ma/c ma /che /c h mi he mist stry st ry • Na Nano noote tech chnooloogy ch chno g • Bi B ol olog log o y • Ma Mateeriial Mate al sci c en ence cees • Innfo form rm mat atio ioon teechhno nolo logy lo gy • Ot O he h rs rs........

What are the scientific challenges to achieve the solutions?

Fig 2 Customized roadmap architecture for the SAcC.

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36

Fig 3

Impressions of the SAcC roadmapping workshop in Davos.

A flexible, adaptable approach Roadmapping was originally developed by Motorola in the 1970s to support improved alignment between technology and product development. Since then the approach has been widely adopted by many organizations in different sectors around the world, at company, sector, and national levels. The underlying concept is very flexible and roadmapping methods have been adapted to suit many different goals, supporting innovation, research, strategy and policy development, and deployment.

3

Many different approaches to roadmapping have been developed and roadmaps can take many forms, but generally the focus is a graphical representation that provides a high-strategic view of the topic of interest. A holistic roadmap framework links directly to fundamental questions that apply in any strategic context: 1. Where do we want to go? Where are we now?

How can we get there?

2. Why do we need to act? What should we do?

How should we do it? By when?

In essence, roadmaps are simple, adaptable “strategic lenses” through which the evolution of complex systems can be viewed, supporting dialogue and communication.

The most frequently cited benefit of the approach is communication . The process of roadmap development brings together the various key people and perspectives, building consensus.

Once a roadmap has been developed it can be more widely disseminated, acting as a reference point for ongoing dialogue and action.

A “roadmap” is an extended look at the future of a chosen field of inquiry derived from the collective knowledge and imagination of the brightest drivers of change in that field. This definition emphasizes the importance that knowledge and expertise play

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in the process, the forward-looking nature of the approach, and its flexibility.

Roadmapping at the AO In 2007 the SAcC embarked on an experiment to test the usability of the roadmapping approach for clinical priorities. As a test field, the topic of implant associated infection was selected as a major issue for trauma clinicians.

It is often claimed that the process of developing roadmaps is as important as the roadmaps themselves, due to the associated communication and network-building benefits. The process needs to be customized to suit the context, along with the structure and format of the roadmap. Consideration should be given as to how the first roadmap is developed and also as to how the roadmap can be maintained, to provide an ongoing reference point for communities of interest. Typically, for substantial research roadmaps, it might take several months or more for a first good-quality roadmap to be developed that is suitable for publication.

With this in mind a first workshop was integrated into the SAcC meeting in New York in September 2007 in order to customize the approach to suit the needs of the AO. During this workshop the structure of the roadmap was developed and consisted of five distinct layers (Fig 2). The meeting in New York formed the basis of the first full roadmapping workshop held on December 7, 2007, in Davos (Fig 1, 3).

In the Davos workshop, a large roadmap chart (Fig 4) was used to share perspectives across the full scope of the topic of infection, and to create a “strategic landscape”. This landscape provides the context within which specific opportunities or issues of concern can be identified (“landmarks”). For this occasion the SAcC invited several researchers and representatives of industrial partners to support the process.

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37

Fig 4

A roadmap wall chart used to share different perspectives on a topic.

The first cut of the roadmap delivered numerous insights into the topic of implant associated infection. Under the header of the first layer “Environment: trends and drivers” it quickly became apparent that infection is a key issue not only from a surgeon’s or patient’s perspective, as it was noted, for example, that with infected hip fractures, operative costs doubled, investigation costs tripled, and the bed day costs in hospital quadrupled.

The most input was generated in the second layer “Clinical issues and needs”, since the majority of the members of the group were active surgeons. In a second step this input, brought up on dozens of Post-it notes, was grouped and revealed three different main areas as vital: • AO guidelines for prevention, diagnosis and treatment of infections (eg, an AO risk matrix for infection) • New approaches to prevent, diagnose and treat infections • Debridement (eg, how to differentiate living from dead bone) The third layer consists of brainstorming ideas regarding possible “Solutions”. These solutions were arranged on a time line (short term, medium term, long term) according to the time assumed to be required to reach any proposed solution. To give an idea of some topics discussed, for example, minimally invasive surgery (MIS) was considered as a short term solution. MIS potentially could reduce infection rates. Although this needs to be proven first, it would then mean making these expert techniques safely applicable for the entire community of orthopedic trauma surgeons. This requires—besides the development of new instruments—to teach more MIS courses and to improve the teaching facilities for these techniques .

Another example discussed was debridement, which emerged as a specific topic in the prevention and treatment of infections (cf. second layer). As a medium term solution surgery would be

much easier and success much more predictable if the surgeon had some diagnostic tools at hand to determine the amount of infection of tissues and to quantify the perfusion of bone. As a long-term solution one would even envision smart instruments for debridement that stop in vital bone or tissue.

Communication and network-building promoted Although the roadmapping approach is quickly delivering on the promise of identifying clinical needs in the field of infection, the initial aim was in fact to test the approach. All members were actively involved during brainstorming, which was generally seen as a good experience! As some of the content was based on assumptions it was soon clear that many Post-its would need further validation—an iterative process.

Based on the initial positive experience, the SAcC has decided to validate the results and to define small groups to explore the specific topics in more detail. They will do so together with the AO’s relevant bodies such as the TK Expert Groups, R&D, CID, Education, the AO Network, as well as Synthes and other industrial partners. The goal is to use a common template, to develop “first-cut” roadmaps for review and discussion, to agree to priorities, to a way forward and to actions. Further work is typically required before, between and after workshops to collect data, analyze results, and to develop roadmap representations and associated reports.

Guidelines for good practice In 2003 the Dutch Ministry of Economic Affairs sponsored a study of the effectiveness of “supra-company” (network level) roadmapping initiatives around the world, with the aim of assessing how roadmapping can support national (Dutch) innovation policy and systems. The study reviewed a total of 78 roadmapping initiatives, mainly in Europe, US, Canada and Japan, from which the following good practices and lessons were identified:

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expert zone

Focal point

38 Planning: • The roadmapping initiative should be clearly linked to broader strategy initiatives (eg, national innovation priorities).

• It is much easier to launch a roadmapping activity within an existing “social infrastructure ” (eg, an industry association).

• In order to mobilize participants there must be a sense of “urgency”.

• Creating high-level commitment from the start is critical, involving decision makers within companies (and government) throughout the process.

• Visioning and goal setting is important, as a focus for developing consensus within the community.

• Industry-oriented roadmapping activities should be owned by industry from the outset to encourage take-up.

• A clear link to decision makers is important if roadmapping is to have impact.

Implementation: • No single format is suitable for all situations—the approach generally has to be customized.

• It is important that momentum is sustained, to keep participants interested and involved.

• Roadmapping is inherently exploratory in nature, and so 3 the plan should be flexible to accommodate learning as the process advances.

• A spirit of openness is important, to encourage new participants and thinking throughout the process.

• The financial aspects need to be clear—generally the costs of such initiatives are shared between the administrating and participating organizations.

Follow-up: • Roadmapping is typically an iterative process , benefiting from review after the first roadmap is produced.

• Outcomes should be monitored , including uptake and impact.

Marcel Dissel

Interim CEO, AO Foundation Davos, Switzerland marcel.dissel@aofoundation.org

Nikolaus L Renner

Chairman, SAcC General Trauma Aarau, Switzerland nikolaus.renner@ksa.ch

Tobias Hüttl

Business Director AO CMF General Manager Academic Council Davos, Switzerland tobias.huettl@aofoundation.org

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AO Vet

expert zone

39 The treatment of femoral shaft fractures in children was reviewed in AO Dialogue (Volume 18, Issue II, October 2005). As a comparison, the present article briefly describes current trends in the treatment of similar fractures in immature dogs.

Loïc M Déjardin and Jean Pierre Cabassu

Femoral fractures in young dogs femoral shaft fractures is the treatment of choice regardless of the animal’s age.

Although the femur of immature dogs and children present numerous anatomical similarities, the orientation of the hind/ lower limb as well as the distribution of the thigh musculature are quite different between the two species, which in turn dictates and limits treatment options. Specifically, the medial aspect of the canine hind limb is, to a certain extent, attached to the abdominal wall and often rapidly tapers down from the hip to the knee. Because of these anatomical traits the use of external coaptation, such as casts or splints is ineffective and contra-indicated for the treatment of diaphyseal fractures, particularly in young, rapidly growing dogs. Conversely, because of its high success rate, surgical reduction and stabilization of

Depending on the breed, dogs reach skeletal maturity between 5 months (toy breeds) and 18 months (giant breeds) through a very rapid, biphasic growth rate (Fig 1b). During the initial growth phase, both structural and material properties of immature bone are considerably different from those of adult bone and are characterized by lower strength, and stiffness, as well as lower yield stress and elastic modulus [1–2]. In addition, the diaphyseal cortices are considerably thinner in young dogs compared to adults (Fig 1a-c). As a result, immature canine bone is

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Fig 1 Diagram illustrating the difference in growth rates between dog breeds of various sizes (b). Skeletal maturity is reached between 5 and 18 months depending on the breed.

X-rays of a comminuted diaphyseal femoral fracture in a 4-month-old puppy (a) and in an adult dog (c), illustrating the dramatic variation in cortical thickness with age (arrows).

The lower biomechanical properties of immature canine bones, including strength and modulus, jeopardize the integrity of the bone/screw interface.

(BW: body weight).

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AO Vet

40

2a

2b

highly susceptible to implant failure via screw pullout. In addition, due to the rapid initial growth phase and the natural knee 3 flexion angle (~140°), the immobilization of the knee in young dogs will ineluctably result in stiffening of the joint secondary to adhesion formation and quadriceps contracture [3]. Importantly, this so called â&#x20AC;&#x153;fracture diseaseâ&#x20AC;? leads to irreversible loss of limb function even after short-term (a few days) immobilization.

To prevent this debilitating complication, early post-operative mobilization is therefore essential, which in itself represents a real challenge in hyperactive, non-leash-trained puppies.

Surgical options Classic intramedullary nailing Regardless of the osteosynthesis technique chosen, the capital, trochanteric and condylar physes must be preserved at all cost. This absolute requirement renders the use of normograde intramedullary devices such as pins or interlocking nails ill advised. Indeed, classic intramedullary nailing via the inter-trochanteric fossa has been associated with dramatic alterations of the femoral head and neck anatomy including coxa valga, hyper anteversion, small malformed femoral head, short thin femoral neck and coxofemoral subluxation [4].

Elastic stable intramedullary nailing (ESIN) While ESIN has been highly successful in children, this technique is not currently available in veterinary orthopedics. The adaptation of this technique in quadrupeds, along with the development of a large series of appropriately sized implants, may prove challenging in dogs due to the great variability of patient size and body weight.

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2c

External fixation The use of external fixation is poorly suited for the treatment of femoral shaft fractures in young dogs for several mechanical and biological reasons. The remote position of the external fixator frame away from the neutral axis of the femur accentuates the bending stresses at the pin/bone interface, which becomes an even greater stress riser. This poor biomechanical configuration promotes early failure via implant pullout even with use of positive cancellous profile trans-osseous pins. From a biological standpoint, the transfixation of the biceps femoris and vastus lateralis generates post-operative pain, precludes free range of motion at the knee, and routinely results in fracture disease (quadriceps contracture).

Plate osteosynthesis Due to the shortcomings of intramedullary nailing and external fixation techniques, plate osteosynthesis remains the treatment of choice for femoral diaphyseal fractures in juvenile dogs. However, strict adherence to the classic AO principles of anatomical reduction and rigid internal fixation during the early growth phase routinely results in catastrophic implant failure via screw pullout. The critical evaluation of these failures has led to the development of a new biological, elastic plate osteosynthesis technique (EPO) better suited to the treatment of femoral diaphyseal fractures in puppies [5]. The technique relies on the increased overall compliance of the femur/plate construct to reduce the risk of focal failure of the screw/bone interface. We have been using EPO in conjunction with minimally invasive surgical strategies (MIS) such as restoration of alignment rather than anatomical reconstruction and percutaneous sliding plate techniques to further decrease post-operative morbidity and optimize functional recovery.

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41

Fig 2 X-rays of a long oblique, mid-diaphyseal femoral fracture in a 12 kg, 12-week-old, female mixed breed dog prior to (a) and after (b) elastic ďŹ xation using an 11-hole VCP 2.0 secured with four 2.0 mm screws. Postoperative x-rays showing clinical union at 14 days (c). Implant removal at 21 days shows advanced callus remodeling as well as restoration of alignment (d).

2d

Elastic plate osteosynthesis Fractures are repaired with Veterinary Cuttable Plates (VCP) applied via a lateral approach to the femoral shaft. The approach can be extended by partial (caudolateral) elevation of the proximal insertion of the vastus lateralis. The fracture hematoma is not removed because of its favorable effects on healing. The plate is applied according to the principles of bridge plating (use of a longer plate and fewer screws) [6]. Indirect fracture reduction is accomplished by traction on the distal fragment with small fragment forceps and/or by means of the plate. Sometimes the tip of a small fragment forcep is used to realign a large fragment or an oblique fracture, but without attempting a precise reduction.

(VCP) allows controlled motion at the fracture site, which in turn promotes rapid bone healing via callus formation [7]. The flexural deformation of the femur/plate construct is achieved, in part, by controlling the working length of the implant (ie, the central section of the plate devoid of bone screws). From experience, the central plate span without screws should be as long as possible and include no less than 3 consecutive empty screw holes. This screw distribution decreases the stress riser effect of a single empty screw hole, thus reducing the risk of implant fatigue failure. Similarly, it increases the overall compliance of the repaired bone/plate construct and therefore reduces bone/screw interface stresses, which limits the risk of implant failure via screw pullout.

Since anatomical reduction is not attempted, restoration of the femoral length is achieved by determining the appropriate plate length from cranio-caudal radiographic views of the contralateral intact femur. The plate is cut to the desired length according to the anticipated position of the screws in relation to the growth plates. The screws are placed in the two most proximal and the two most distal holes of the plates. The two proximal screws are inserted near the origin of the vastus lateralis muscle, their direction being influenced by the configuration of the fracture. The two distal screws are inserted proximally to the distal growth plate. Cortical 2.0 mm or 2.7 mm screws are inserted without tapping. Two adjacent screws should always be oriented in diverging planes in order to increase resistance to pullout. Closure is routine.

The outcome of elastic fixation using VCPs 2.0 and 2.7 has been evaluated in a series of 24 consecutive juvenile femoral fractures [5]. The working length of the plates encompassed from 7 to 20 adjacent empty holes. All plates were secured via two proximal and 2 distal cortical screws inserted without tapping. Clinical union occurred as early as two weeks and was achieved in all cases by four weeks post-operatively. Implant failure, whether from screw loosening or plate plastic deformation or fracture, was not found. In most cases, callus remodeling could be observed after two months and bony union was achieved by four months. Diaphyseal growth was undisturbed and consistently occurred without loss of alignment or anatomical deformation of either epiphyses (Fig 2).

With this technique, the preservation of the strong periosteal sleeve, in conjunction with the use of an undersized implant

Minimally invasive techniques Minimally invasive [percutaneous] plate osteosynthesis (MI[P] PO) was recently combined with elastic fixation in an effort to 3 | 08

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AO Vet

42 Fig 3 X-rays of a transverse, mid-diaphyseal femoral fracture in an 18 kg, 12-weekold, female German shorthair pointer (a). Intraoperative view illustrating fracture reduction and stabilization using MIPPO techniques (b). Alignment is maintained via two small Bishop bone reduction forceps placed in the subtrochanteric (top) and distal metaphyseal areas (bottom) through limited skin incisions and fascial dissection. A 16-hole VCP 2.7 is then percutaneously slid under the vastus lateralis from a proximal to distal direction (b) to achieve elastic fixation.

Post-operative x-ray showing restoration of alignment (c).

4 3a

3b

3c Fig 4 X-rays of a long oblique, mid-diaphyseal femoral fracture with a Salter I fracture of the capital physis in a 15 kg, 8-weekold, male Terrier (a). Intraoperative fluoroscopy (b) is used to verify alignment and proper implant position (inserts). This approach was combined with MIPPO and MIS techniques to effectively treat the diaphyseal and Salter fractures respectively. While anatomical reduction is not a primary focus when using MIPPO techniques, one must strive to restore limb alignment (c).

3

4a

4c

4b

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expert zone

43 further reduce post-operative morbidity [8]. Here, cutaneous and fascial incisions are limited to the subtrochanteric and para-patellar regions on the lateral aspect of the femur (Fig 3).

As with traditional “open but do not touch” approaches, restoration of alignment is achieved via small bone forceps. Using the cranio-caudal radiograph of the contra-lateral femur, the VCP is cut to length, bent proximally to follow the subtrochanteric flare and twisted distally along the lateral surface of the distal metaphysis. The contoured plate is then slid underneath the vastus lateralis from either direction and secured to the proximal and distal metaphyses (Fig 3). Since the fracture site is not exposed, it is beneficial to verify proper alignment via intra-operative fluoroscopy (Fig 4). By virtually eliminating exposure of the fracture site, this approach helps preserve the fracture hematoma, a critical step in enhancing bone healing [9]. In addition, it minimizes damage to the soft tissues (muscles, fascia and periarticular retinaculum) thus reducing scar tissue formation and promoting early use of the fractured limb. Both factors have been shown to be greatly beneficial in children and are likely to show similar advantages in young dogs.

Bibliography: 1. Torzilli PA, Takebe K, Burstein AH, et al (1981) Structural properties of immature canine bone. J Biomech Eng; 103:232–238.

2. Torzilli PA, Takebe K, Burstein AH, et al (1982) The material properties of immature bone. J Biomech Eng; 104:12–20.

3. Bardet JF, Hohn RB (1983) Quadriceps contracture in dogs.

J Am Vet Med Assoc; 183:680–685.

4. Black A, Withrow S (1979) Changes in the proximal femur and coxofemoral joint following intramedullary pinning of diaphyseal fractures in young dogs. Vet Surg; 8:19–24.

5. Cabassu J (2001) Elastic plate osteosynthesis of femoral shaft fractures in young dogs. Veterinary and Comparative Orthopaedics and Traumatology; 14:40–45.

6. Schatzker J (1995) Changes in the AO/ASIF principles and method.

Injury; 26:51–55.

7. Grundnes O, Reikeras O (1993) Effects of instability on bone healing.

Femoral osteotomies studied in rats. Acta Orthop Scand; 64:55–58.

8. Cabassu JP, Dejardin LM (2005) Minimally Invasive Plating.

American College of Veterinary Surgeons 15th Annual Symposium; CD ROM Proceedings.

9. Grundnes O, Reikeras O (1993) The importance of the hematoma for fracture healing in rats. Acta Orthop Scand; 64:340–342.

Postoperative care Although weight bearing and range of motion are recommended immediately after surgery, high impact activities (jumping, rough play), while difficult to control, should be avoided. In contrast, physical activities such as leash walking, trotting, and swimming or wading are beneficial. Professional physical rehabilitation using an underwater treadmill is rarely needed in puppies that are naturally active.

One must keep in mind that the single most important factor contributing to the success of this new surgical approach (EPO) to femoral fractures in immature dogs is the higher construct compliance, which reduces the risk of screw pullout. Second, by promoting rapid bone healing and by minimizing iatrogenic soft tissue injuries, the use of minimally invasive techniques (MIPPO) optimizes early functional recovery.

Loïc M. Déjardin, DVM, MS, Diplomate ACVS, ECVS

Jean Pierre Cabassu, DVM, Diplomate ECVS

Orthopedic Surgery College of Veterinary Medicine Michigan State University, Michigan, US Dejardin@cvm.msu.edu

Marseille, France jpcabassu@numericable.fr

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