My view
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Table of contents
community zone
Panorama
4 Events 6 News 7 People 7 Fellows opinion 8 Tribute to Martin Allgöwer Report
expert zone
Case study
A case of a symphysis fracture with bilateral condyles: the debate
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James F Kellam Editor-in-Chief james.kellam@aofoundation.org
Clinical topic
Extending the indications of intramedullary nailing
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11 The wisdom of the desert
Proximal humeral fractures
14 Positioned for the future: AONA reorganizes its CME
Trochanteric femoral fractures
From the regions
16 AO Asia Pacific Internet
19 The AO Surgery Reference’s executive editors Inside AO
21 The Specialty Academic Council General Trauma
Clinical experience with the expert tibial nail
30 32
Focal point
Musculoskeletal surgeons 35 should care about osteoporosis AO Vet news
Plate/rod constructs for 36 semi-rigid stabilization in the dog and cat The next 50 years
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8 11 36
The AO spirit There is one aspect of AO that contributes to its longstanding success which is hardly ever mentioned and that is the “AO spirit”. This very special spirit stems from the origination of the first AO group, which was founded on the basis of a fraternity of likeminded individuals—friends and colleagues— working toward a specific goal: better patient care. One has to know that within the Swiss tradition, the concept of a fraternity or confederation is nothing new, as are the values of liberty, equality, and loyalty to serve a common purpose. This means that AO’s founding group’s relationships were strongly influenced by these and other values—trust and credibility being possibly the most important for a professional network of surgeons. That the AO spirit is based not on vague assumptions, but on very specific values has permeated the whole organization and is now one of the cornerstones on which the AO Foundation has been built. But the AO spirit itself is not made of stone: It changes continually und is trongly affected by the fact that AO is a socalled “face-to-face” community where members know each other personally: individuals talk to individuals, their opinions filter through and shape the AO spirit as much as it shapes them. It’s called “dialogue”, I think.
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Panorama
AONA Muskuloskeletal Faculty gathers for forum The AO North America Musculoskeletal Faculty held their 3rd Development Forum under the chairmanship of Steve Schelkun, Jorge Alonso, Mike Baugaertner, and Jack Wilber. Faculty participants represented a cross section of faculty experience and interests. The first day dealt with a review of AO Specialty Courses in hand and foot, the AO alumni and membership, research opportunities, faculty issues and AO career pathways. The second day included a brief introduction to the musculoskeletal faculty training program with sessions on lecturing, moderation, table instruction, small group discussion, and electronic support for education. The forum showed that AO North America Musculoskeletal Faculty continue to improve themselves and participate collaboratively worldwide and regionally.
A message
community zone
from Chris van der Werken President AO Foundation
Dear friends The year 2008 is a special one for we will then commemorate the first 50 years of the AO. I wonder if any of the 13 founding members had any inkling of the effect their group would have— on their own lives, on accepted theories of fracture care, and most especially, on the lives of countless patients. We owe it to them and to others who followed to celebrate their achievements in a fitting manner. We are planning many exciting activities through the year and all over the globe. The opening ceremony will be performed at the AO Davos Courses in December 2007 when the special jubilee logo will be unveiled. A series of symposia will be put on at congresses and AO-organized alumni events and regional courses throughout the whole of 2008. The 2008 Trustees Meeting will be held in Davos and promises to be a big party for past and present Trustees as well as AO employees and many other guests—approximately 850 people!
Nonoperative course in Ghana Organized by Paul Demmer, Chairman of the AO Socio Economic Committee and W Addo of St Joseph’s Hospital, Koforidua, a nonoperative course was held in Ghana from July 4 to July 6. The course was well attended with lectures starting daily at 8:30 am lasting to midday. After lunch the course continued with practical exercises until the evening. Comments T Chagwiza: “The nonoperative course video made by AO in conjunction with the University of Pretoria was a great teaching help and we referred to it quite often.” Then, every morning one of the participating doctors gave a report of what he/she had learnt the previous day. There were some suggestions that a longer course would be preferable and that some topics deserve more focus, but overall the course was received with great enthusiasm.
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The anniversary website can be accessed through the main AO Foundation website: www.aofoundation.org. Here you will find lots of information throughout 2008. You can also send us your anecdotes and pictures from AO-related events for a special ‘memories’ section. While we will of course be reflecting on the first 50 years throughout the anniversary year, I can assure you that the AO as a whole is firmly focused on the goal of how we can continue to improve patient care. Just as it was 50 years ago.
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News
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Successful AO at the German Congress for Orthpedic and Trauma Surgery, Berlin
Its scientific symposia and an improved lounge helped the AO Foundation to put its best foot forward at the German Congress for Orthopedic and Trauma Surgery, held in October at the International Congress Center in Berlin, Germany. The theme of the congress was aptly named “Looking forward— standing still is going backward” (Blick nach vorn - Stillstand ist Rückschritt), thus reflecting future developments. Around 7,000 people attended and approximately 250 meetings, workshops, and symposiums were held. The AO Foundation once again concentrated on nurturing and expanding its network with the AO Lounge the focal point for many surgeons. Also AO Foundation CEO Georg Strasser found it “an oasis of calm during the congress” concluding that “this year the AO was very successfully represented.”
New
AO
Surgery
Reference
module:
Surgeon General’s award won by AO website When the 2007 “International Health & Medical Media Awards” were given out this year, the online-tool AO Surgery Reference was decorated with the prestigious “Surgeon General’s award”, which goes to the best medium for healthcare professionals. Nominated by the US President, the Surgeon General is the head of the American public health service. Representing the more than 60 international authors who worked on AO Surgery Reference, Peter Trafton received the awards in Philadelphia on November 2. More than 12,000 surgeons viewed the website of AO Surgery Reference alone in the month of October with its userbase further expanding.
proximal
forearm
The AO Surgery Reference is a webtool that allows surgeons to access surgical knowledge for reference purposes during their clinical work. Due to the vast body of information it is being developed stepby-step and now the forarm fractures are “online” as well (according to the Müller AO Classification). The authors, Kodi Kojima (Brazil) and Steve Velkes (Israel), under the executive editorship of Peter Trafton (USA) have put together all the material describing the whole of the surgical management of forarm fractures in a clearly structured and easy to follow format (www. aosurgery.org)
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Cooperation with Siemens Medical Solutions announced On August 29, 2007, the AO Foundation and Siemens Medical Solutions signed an agreement to make digital imaging techniques a standard part of global AO training programs for surgeons. A rapid transfer of progress in digital imaging technologies to clinical practice enables improved surgical procedures.
22.11.2007 9:42:36 Uhr
Geoff Richards is the Program Leader of bioperformance of materials and devices at the AO Research Institute in Davos, Switzerland. Cardiff University in Wales, the United Kingdom, has appointed him Honorary visiting Professor in the Cardiff School of Biosciences. This position is to take effect from September 1, 2007, until August 31, 2012.
Thomas Rüedi honored At the opening ceremony of the International Surgical Week of the ISS/SIC on August 25 in Montreal, Canada, Thomas P Rüedi, Switzerland, Yoshiki Hiki, Japan, and Donald D Trunkey, USA, received Honorary Memberships of the International Society of Surgery in recognition of their distinguished services rendered. Thomas Rüedi served the ISS for seven years (from 1993 to 1999) as Secretary General and in this position he organized four World Congresses/ International Surgical Weeks.
Joshua C Patt
Completed fellowships in musculoskeletal oncology and spine surgery at University of Washington, Seattle, WA
While each of us leaves residency with knowledge of how to do certain operations, what we all take away and have forever are the personal relationships with our mentors. These are the teachers who help us understand not just how, but when and why, we do what we do. Finding an engaging mentor provides a young surgeon with the opportunity for personal and professional enrichment and an understanding of what it takes to become a leader in our profession. involvement with AOSpine “Finding mentors on the My began with a fellowship and has road less traveled.” given me access to a group of established leaders in my chosen field. As a young surgeon it is easy to feel isolated, but through the AO FounJoshua C Patt
MD, MPH Carolinas Medical Center, Charlotte, NC joshua.patt@ carolinashealthcare.org
dation and AOSpine‘s educational opportunities, I have been able to cultivate personal relationships with the pioneers and current leaders in both orthopedics and neurosurgery. My involvement in AOSpine has allowed me to establish these friendships and mentorships at the nascence of my career.
Fellows opinion
Geoff Richards awarded Professorship
7
Panorama
People
community zone
AOSpine Fellows Forum in Banff, Alberta, 2007. From left to right Jens Chapman, Troy Caron, Joshua Patt, and Carlo Bellabarba.
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well-documented evidence, supported by research results as well as teaching the operative techniques, enabled worldwide acceptance of the AO principles and today operative stabilization has become the standard treatment of fractures.
tin Allgöwer also introduced innovative surgical techniques in visceral surgery. At the same time he kept evaluating the outcome. He had the strength to admit unfavorable results and to change the techniques and guidelines for treatment accordingly.
In 1967, Martin Allgöwer was appointed director of the Surgical Department at the University of Basel. He realized the need for specialization in surgery and established a department including all different surgical specialties collaborating to make the idea a success. The polytraumatized patient for example, was managed from the moment of admission to the hospital by a team of different competent specialists with the most experienced surgeon as the team leader. Mar-
Martin Allgöwer was a great teacher and frequently assisted his collaborators in operations. He was always ready to scrub in and to help to overcome complications. He was a respected personality and mentor for many generations of surgeons; his influence is visible worldwide. He received multiple honorary doctor titles from universities and honorary memberships in many societies. We all realize that with his death we have lost an outstanding pioneer who helped so many surgeons in planning their careers. A very special era has come to an end; however, Martin Allgöwer will continue to influence our daily activities. We are most grateful to have had the chance to know him as a friend, as a colleague, and as a surgeon and a teacher for the benefit of our patients. Many wonderful memories will keep him alive.
“His legacy of work will live on in the AO Principles he helped to establish and popularize. “ —Chris van der Werken Vintage Allgöwer: Martin celebrating his 90th birthday at a dinnerparty in Zürich
Martin Allgöwer was ambtious—not only as a surgeon but in other endeavers as well. In winter and while in Chur, Switzerland, he often went skiing with his whole team while joking that he wouldn’t take it lightly if one of his younger assistants would overtake him on the slope. Still, some dared anyway and afterwards there was always some friendly verbal fighting about the true reasons for his coming in second. Illustration: Haab/AO Vet
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21.11.2007 9:07:24 Uhr
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Report
The wisdom of the desert Australian AO ORP faculty member Nicola Kildea recounts her teaching experience in Saudi Arabia
Nicola Kildea Registered Nurse Adelaide, Australia nkildea@yahoo.com
Preparations for my 2005 ORP experience in Riyadh included a three-month visa application process and preparation of my presentations for the course. I asked Susanne Bäuerle, AO Foundation‘s Director ORP/Nurse Education and myself, “Do I prepare the same type of presentation as I would for Australian participants?” The answer was, “Yes.” Since I would be teaching in a new environment, I also tried to learn as much as I could about the culture of Saudi Arabia. First impressions
My first impression of Saudi Arabia was of a hot, dry desert. The inhabitants dressed in black or white; most heads, and some faces, were covered. Initially, this seemed very strange because multicolored style and dress are common in Australia, but I came to appreciate the individual style and
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character of Saudi Arabian attire, including the abaya: the traditional black overgarment worn by most Saudi women. I was very fortunate, upon my arrival, to be given an abaya which I enjoyed wearing. It was extremely cool and comfortable and I did not have to think about what to wear each morning. This liberating experience gave me more time to think about other things. My first outing was to the desert, where we had an exhilarating all-terrain vehicle (ATVs) ride through the rolling sand hills with some of Europe’s most talented orthopedic surgeons. This culminated in a desert picnic at two large tents, one of which had desert air-conditioning. In the other tent we were served lamb roasted over hot coals and a pot of simmering rice: an amazingly delicious and unique experience. Among
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Report
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1 Author and faculty member Nicola Kildea introducing a participant to the practical exercise. 2 All the Jeddah course 2007 participants. 3 Jeddah 2007: participants with faculty. Isabel Van Rie (2nd from left), Nicola Kildea (3rd from left), and Eija Vasama (5th from left). 4 The Rhiyadh 2005 facult (from left to right): Guido Wahler, Karl Rabitsch, Mamoun Kremli, Theddy Slongo, and Nicola Kildea.
Great moment in history
This course began with a preparatory meeting conducted by Piet de Boer, Director of AO Education, who led discussion of course-related issues and gave insightful educational tips. The courses began with a combined session of surgeons and ORP, this time with no partition between men and women. It was also during the Jeddah courses that the AO Alumni chapter of the Kingdom of Saudi Arabia began; I felt privileged to be part of a great moment in history. The AO family has expanded again, this time to the benefit of patients in Saudi Arabia.
Other highlights of the Jeddah event were a tour of the old part of the city, an overview of its history, and a faculty dinner in a restaurant on the beach. My experiences as international AO ORP faculty member have expanded my understanding of other cultures and made me a better, more focused AO educator, dedicated to the course participants. I know this will benefit our patients.
Historical tour
The three-day ORP basic principles course included great discussions, a positive learning atmosphere and excellent presentations during the practical session. The presentation and discussion room was small, creating an intimate environment in which participants felt comfortable asking questions.
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community zone
Report
ence over CME staff that have faculty- and content-related responsibilities. In Phase I of AIM, implemented in July 2007, AONA assumed direct employment of 13 CMED staff members who previously had been employed by Synthes. Phase II, to be completed in December, will relocate AONA staff from Synthes offices to a nearby independent office facility and provides for establishment of dedicated CME telephone and computer
“AONA has one of the finest CME organizations in the world, offering 60 high-quality, live, hands-on activities taught by hundreds of faculty experts in our four specialties for over 4,400 surgeons and operating personnel every year.”
Jack Wilber President AO North America Cleveland, OH, USA j_wilber@adelphia.net
systems and related infrastructure. The newly reorganized AONA CMED staff is now headed by Andrea McClimon, Director, AONA CMED. Andrea reports directly to Jack Wilber, MD, President, AONA. With 11 years of service to AONA and Synthes, Andrea‘s experience includes serving as Faculty Relations Manager, supporting the four surgeon-led AONA Education Committees, directing CME administration and compliance and managing other key AONA activities. Reporting to her will be the five managers of AONA CME Course Development, Course Registration, and Faculty Relations Coordinator. Also reporting to Andrea McClimon is Jane Mihelic, who assumed the role of Director of CME last June. With 25 years of CME experience, Jane
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is a member of the Alliance for CME, the Global Alliance for CME and is a recent ACME Fellowship Award recipient. She comes to AONA from the FCG Institute, where she served as executive director. Jane will be working closely with the CMEAB to assure compliance and excellence in AONA CME activities. All of these measures reflect an appropriate response by AONA to a changing regulatory environment in North America. The reorganization has not affected our CME content; and our primary commercial partner, Synthes, has always respected the integrity of CME and has supported us in establishing a new and logical organization for our CME activities. In addition to promoting independence of AONA and satisfying ACCME and other regulatory guidelines, the restructuring now under way sets the stage for AONA to strategically position itself for increased CME leadership as regulatory standards continue to evolve. Future steps would include establishing processes for measuring the success of AONA‘s CME activities, ensuring that CME participants continue to gain knowledge and transfer that knowledge to their practices, and measuring how the organization‘s CME activities are affecting patient care. AONA has one of the finest CME organizations in the world, offering 60 high-quality, live, hands-on activities taught by hundreds of faculty experts in our four specialties for over 4,400 surgeons and operating personnel every year. The changes we have implemented in order to comply with regulatory authorities and gain ACCME reaccreditation should be invisible to the course participants. Essentially, what these changes mean is that the outstanding CME that AONA and its commercial partners have supported for so many years is now being supported by a structure that addresses the challenges of a new compliance environment while also assuring the integrity of the educational process.
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AO Asia Pacific
regionalization is alive AO Asia Pacific is a new organization which was born under the regionalization concept.
All three specialties (orthopedic trauma, spine, and craniomaxillofacial) have their own governing bodies. We do not have a chairman for AO Asia Pacific, but a coordination board resolves issues that are considered relevant for all three of the specialties. Coordination board chairmen representing the three specialties are: Tadashi Tanaka (Japan) for AO Trauma Asia Pacific; Thiam Chye Lim (Singapore) for AO Craniomaxillofacial Asia Pacific; and KV Menon (India) for AOSpine Asia Pacific. Short formation process
Urs Mattes AO Regional Manager AO Asia Pacific Hong Kong urs.mattes@aofoundation.org
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Within a few months, AO Trauma Asia Pacific was formed by China, India, Australia, and New Zealand agreeing to join the former AO East Asia. G On Tong, the chairman of AO East Asia, was the driving force to bring those four new countries into the former AO East Asia and rename it AO Trauma Asia Pacific. Currently, 13 countries are represented on the regional trauma board, which consists of an executive committee and 13 national delegates. In addition to Tadashi Tanaka as chairman, Bingfang Zeng as vice chairman, and G On Tong as past chairman, there are four functional committees: Education under Suthorn Bavonratanavech (Thailand), Fellowship headed by Onkar Nagi (India), Clinical Research
22.11.2007 10:15:52 Uhr
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From the regions
Int. Trauma Board
Cou Co Cou ountr nttrries ie ie Cou C Co o ntr ntries ie es es
Cou Co Cou untr ntries ie Cou Co C ountr o nt ies ie ess
Cou C un ntr nt t ies es es Cou Cou Co ountr un ntr trie tr ie ies ess
Cou C Co Countr ou oun nttr ntr tries iess
Cou C Countr ountr ntr t ies tries es es
Co Co Cou ou un ntr trriies ie e
Cou Co ountr trrie iies es es
C ntr Cou triie ies es e
Co Cou C ou o untr nt ies e
Cou o ntr ntries trrie iies e
Cou ou ountr untries nttr ntr n tries ess
Cou o ntr ou tries ies ess e
Asia Pacific Trauma Board
Int. Spine Board
Asia Pacific Spine Board
AO Asia Pacific Coordination Board
Int. CMF Board
Asia Pacific CMF Board
(3 Specialty, Delegates & Urs Mattes)
AO Asia Pacific Limited Urs Mattes & Employees AO Asia Pacific Legal Entity
Administrative Board GS. MP. UM
HK delegates AOVA
(3 for signature by two)
Organizational chart of AO Asia Pacific.
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led by Frankie Leung (Hong Kong), and Communication and Publicity under Miles DeLa Rosa (Philippines). What about craniomaxillofacial? Similar to orthopaedic trauma, the first steps were those of integration. Australia and New Zealand joined AO Craniomaxillofacial under Chairman Thiam Chye Lim in August 2007 at the AO CranioMaxillofacial faculty retreat in Kota Kinabalu. This group consists of 12 countries and we will certainly see further expansion in the future.
between the countries. Thus, we can learn and prosper from one another‘s experience and expertise.
AOSpine
Teaching
AOSpine has a different setup in Asia Pacific, presenting a nice model for bringing responsibilities directly down to the countries and using regional bodies as a force to determine the framework. In AOSpine the countries decide what happens in terms of education, fellowship and and other issues deemed important at the country level. AO Asia Pacific consists of a heterogeneous group of countries. In order to ensure amiable relationships between and within the governing bodies, it is important that each country be treated equally. This has led us to the concept of: One country/territory, one vote! Size must not be dominant. Our spirit is to have equal exchanges
The fast-growing number of AO teaching activities requires regional support. On March 20, 2007, AO Asia Pacific obtained the Certificate of Incorporation from the Hong Kong authorities. Why Hong Kong? There is no doubt that in many ways Hong Kong is the center of Asia and almost every destination within Asia can be reached by plane in less than 5 hours. Hong Kong offers an efficient and transparent legal system originating from its British heritage. Hong Kong also is the gateway to mainland China and many Hong Kong citizens are fluent in Mandarin which is used on the mainland. On July 23, 2007, after obtaining a Hong Kong employment permit,
There are still some burning issues from the past which must be solved within the next few years. No doubt, the AO group in Asia Pacific will master the future well. Regionalization not only alludes to the governance of the three boards but also adds support to our numerous auxillary activities.
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From the regions
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AO Trauma Asia Pacific
AOSpine Asia Pacific
AO CMF Asia Pacific
Au A Aus u s tra us t alia li
Chi C Ch h na na
Au Aus u s ttra us trr lillia iaa
Ch Chi C hii na h na
I nd ia In Ind ia
C hi na Chi na
Hon H on ng Kong ng ng
Jap ap p an an
Ho Hon H on o gK Kong o ngg ong
IInd n iaa nd
Sou u th t h Kor Kor eaa Ko
Ind nd d one ne e sia sia si ia
I one In Ind nesia ne s sia
Au Aus us tra u rraalia & New Ne Ne ew Ze Z ala aall nd n
Jap p aan n
Jap Japan ap p an
S outh Sou tth h Eas Eaa t A sia i
M ays Ma Mal aysia ay ia
Malays Ma Mal a ysia ays ia
New Ze Zeala a nd al ala d
Ph lip Phi p pin pines i ess
Ph lip Phi i pin pines i es
N ew Ze New e ala aland n nd
Singap Sin gapore gap oe ore
Sin nggap p ore e
Sou outh th Kor Ko ea
South Korea ea
T wan Ta Tai
Taiwan Tai wan/Ch /Ch h ine inese se Tai T pei p
T iland Tha d
Thailand d Organization of AO Specialties in AO Asia Pacific.
I assumed my position at the new AO Asia Pacific office in Hong Kong, and I am privileged to work for such a prestigious organization.
goal is to be prepared as a CME accreditation provider in Asia Pacific when the guidelines become a part of our world.
Decision making
Fellowships
A key factor of regionalization is that the region and countries decide what best meets their local educational needs according to their developmental status (ie, equipment, supplies, type of work, etc). It does make no sense to teach hightech applications of internal fixation if the equipment necessary to perform a fixation is not widely available in a country. AO teaching must be adapted to the needs of the local surgeons. Only if we teach the right applications and procedures can the patient benefit. Further, AO teaching must occur within the principles and framework of the AO Foundation. In many countries, the number of course applicants exceeds the number of seats available. Thus, AO Asia Pacific has no choice but to define course entry criteria, particularly for specialty courses (eg, pelvic, hand, minimal invasive, foot and ankle).
Besides courses, seminars and symposia, fellowships play a key role. Fellowships offer a great opportunity to learn from experienced surgeons almost any place in the world. In cooperation with AO Education, AO Asia Pacific has introduced a new type of fellowship, called a “Starter Fellowship�, in which surgeons from developing countries are trained in neighboring countries in AO principles. Those surgeons will create a core group in developing countries and will be responsible for AO education back in their countries. AO Asia Pacific and the AOAP website have further information on those fellowships.
At the moment, most AO activities in Asia Pacific are devoted to organization and education. Although CME (Continuous Medical Education) accreditation guidelines are available only in a few in Asia Pacific countries (for example, Australia, New Zealand, and Japan), AO Asia Pacific strives to have a high standard in education matching that of courses in the western world where CME accreditation is a serious issue. Our
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Clinical studies
Fracture is a rare disease. For this reason, Asia will become a key contributor to clinical studies within the clinical priority projects of the AO Foundation. The clinical priority projects in orthopedic trauma are large bone defects and osteoporosis. Undoubtedly, the large populations, particularly of India and China, will offer opportunities to perform clinical studies in this part of the world and to apply the same high standards of clinical studies as in Europe and North America. AOCID is similarly interested in clinical studies in Asia Pacific.
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continued from page 19
into a working website. As collating all this information is very difficult, being involved in the earlier steps is invaluable.” CC : “We scrutinize the test website to check that the information is accurate and the illustrations clearly demonstrate the fracture at hand. The text must also be appropriate for non-native English speakers and agree with published work on the matter. A final element is to check that all the links work. This can be quite time-consuming and tedious (eg, the distal humeral module took about 60 hours of intensive executive editing) but is also very necessary.”
Tobias Hüttl AO Foundation General Manager Academic Council Business Manager AO CMF Davos, Switzerland tobias.huettl@aofoundation.org
Review CC : “The module is then submitted to the AO
Specialty Academic Council (SAcC) for ratification. Nikolaus Renner, the chairman, and the SAcC perform an important quality assurance step, having at an earlier stage ensured that the module is consistent with AO philosophy. Members of the SAcC can then review the test website and make comments and recommendations if need be. Once these have been acted upon, the module is ready to be published.” PT: “The SAcC also help us focus on new areas of knowledge and identify areas where further research is required.” ER : “It is important that we remain neutral with regard to the implants that we recommend as the website is for everyone, not just those connected to the AO Foundation.” The future of the AO Surgery Reference ER: “This is unique: a website where everyone
in the world with an internet connection can find their way through a maze of fracture treatments.” PT: “We need to identify who these users are and to learn what their expectations and needs are.” CC: “The AO Surgery Reference has been a runaway success. In its short existence, it has scooped eight internet awards, testimony to the skill of the entire team behind it. There are several new modules already in progress.”
The recently established SAcC General Trauma took up its work in 2006. The group consists of active clinicians with outstanding reputations, representing the AO regions. Under the leadership of its Chairman, Nikolaus Renner, SAcC General Trauma is responsible for the identification and prioritization of clinical problems in the field of General Trauma. The identified clinical priorities are included in the direction-setting process for AO activities such as research, development, and education, and help to focus AO resources to constantly improve patient care.
In 2007, major steps were accomplished in defining a concept of how to facilitate the identification of clinical problems. A workflow was designed to ensure input by surgeons within the worldwide AO network and invite their valuable expertise and ideas for potential focus fields. In addition, a roadmapping process was established. Roadmapping is a widely used technique for supporting strategy development, idea generation, and priority setting. The roadmapping process to be used by the SAcC General Trauma was developed by the Centre for Technol-
Want to address a potential clinical problem?
Go to www.aosurgery.org to visit the AO Surgery Reference.
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Inside AO
The Specialty Academic Council General Trauma:
focus on constantly improving patient care Guided by its new Specialty Academic Council (SAcC), General Trauma continually seeks to identify clinical problems and to promote innovative concepts for improved fracture treatment.
ogy Management, from the Department of Engineering, University of Cambridge, which has an international reputation and proven track record for developing technology roadmaps across a range of wide range of disciplines. Focusing on idea generation and prioritization, roadmapping uses a graphical approach to visualize an entire strategy on one sheet of paper. The visual format cuts through complexity to highlight linkages, gaps, opportunities and potential problems, providing a framework to answer the questions: Where are we now? Where do we want to go? How can we get there? Other significant fea-
tures of roadmapping are its breadth and versatility: roadmaps can encompass a very broad scope of issues and long time frames while also focusing down on critical details. The SAcC roadmapping procedure includes interdisciplinary workshops with surgeons, researchers, and other relevant participants. Core to this process is to have guided constructive discussions with relevant parties using a logical sequence of layers developed together with the surgeons. The roadmap becomes an effective way of capturing the results of these discussions and identifying well-defined clinical priorities.
2007 Members of the SAcC General Trauma Chairperson: Nikolaus Renner, Switzerland (Chairperson) Members: Piet de Boer, Switzerland David Helfet, USA Tobias HĂźttl, Switzerland Frankie Leung, China Peter Messmer, Switzerland Chris Moran, UK Antonio Pace, Italy David Stephen, USA Rodrigo Pesantez, Colombia Mark Vrahas, USA
Here‘s how to approach the Specialty Academic Council (SAcC) General Trauma. You are a clinician in the field of general trauma and: 1. You have encountered a significant clinical problem in your daily practice, which is of high relevance and has not been studied or solved until today, and/or 2. You have an idea for how to study or solve a clinical problem
Please, feel free to approach the Specialty Academic Council General Trauma or one of its members. Your input will be reviewed and you will receive a notification and feedback. If your input is considered highly relevant, it will be included in a SAcC interdisciplinary workshop to which you will be invited. Inputs and proposals can be submitted to: sacc.trauma@aofoundation.org The feedback of an extensive network will provide valuable expertise for the direction-setting process and help to focus on relevant clinical problems to constantly improve patient care.
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Case study
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Fig 1–3 Preoeprative panoramic x-ray and CT views. Fig 4
Panoramic view 24 hours after surgery.
Fig 5
Panoramic view 5 days after surgery.
Fig 6
Displaced left condyle 2 weeks postoperatively.
Fig 7
Fixation of left joint, posteroperative view.
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and visible deformity in the preauricular region. In addition, the loss of condylar articulation with the fossa leads to the well-known shortening of the posterior vertical height with the resultant premature posterior occlusion and anterior open bite [3, 4]. Also reported, but less often referred to is the increased risk for long-term joint pain associated with the closed treatment of these displaced fractures [5]. This patient’s grouping of fractures, a symphysis fracture and bilateral subcondylar fracture, is a pattern with high risk of resulting in anterior open bite, posterior crossbite, and widened mandibular angles. The difficulty of treating this fracture pattern with closed treatment is a clear indication for operative therapy of the symphysis fracture. With endoscopic assistance, the risk of complications from the surgical approach to the condyle is believed to be decreased [6], and because the patient was already receiving surgical intervention, the decision to treat the displaced condyle surgically is fairly straightforward, assuming the patient is well informed and in agreement. The more difficult decision is whether to open a subcondylar fracture that appears to be nondisplaced or minimally displaced. In this situation, there may be little or no loss of posterior height or occlusal change. If the status of this fracture could be clearly determined to be nondisplaced, all the risks of surgery to that area could be avoided. Obviously, this can rarely be determined with certainty. The method used in this situation to gain information regarding the function of the left subcondyle fracture was to manipulate the patient’s mandible throughout the full range of mandibular motion to detect crepitus or obvious displacement of that fracture; a positive finding would be an indication to open the fracture. If, during the mandibular manipulations, the surgeon does not detect mobility or crepitus from the fracture segment, then there is support for treating that fracture closed. In this instance, the segment may have only a greenstick fracture or may have early callus formation. In either case, 1–2 weeks of a soft mechanical diet are all that is needed for stable healing in an otherwise healthy patient; this modification of diet is usually self-imposed until pain and swelling from the other surgical sites have improved. The reason for late displacement of the left condylar segment in this case probably cannot be determined with certainty. One possibility is that the fractured segment was interlocked well enough after repair of the other fractures to provide smooth mandibular movements at the end of surgery, but that later resorption of the fractured segments during healing created a mobile segment that became displaced by muscular forces.
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Another possibility is that the operating surgeon did not detect a crepitus that should have indicated the need to open the fracture. In either case, the patient received the standard for closed treatment of a subcondylar fracture; namely, elastic therapy to maintain appropriate occlusion during fracture healing. Whether due to muscle splinting, patient compliance, or inadequate follow-up, it is clear that the elastic therapy was inadequate to overcome muscle pull, and the patient ultimately returned to the operating room for open treatment of the left subcondylar fracture.
Bibliography 1. Villarreal PM, Monje F, Junquera LM, et al (2004) Mandibular condyle fractures: determinants of treatment and outcome. J Oral Maxillofac Surg; 62:155. 2. Ellis E, III, McFadden D, Simon P, et al (2000) Surgical complications with open treatment of mandibular condylar process fractures. J Oral Maxillofac Surg; 58:950. 3. Ellis E, III, Simon P, Throckmorton GS (2000) Occlusal results after open or closed treatment of fractures of the mandibular condylar process. J Oral Maxillofac Surg; 58:260. 4. Ellis E, III, Throckmorton G (2000) Facial symmetry after closed and open treatment of fractures of the mandibular condylar process. J Oral Maxillofac Surg; 58:719. 5. Haug RH, Assael LA (2001) Outcomes of open versus closed treatment of mandibular subcondylar fractures. J Oral Maxillofac Surg; 59:370. 6. Miloro M (2003) Endoscopic-assisted repair of subcondylar fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod; 96:387.
Commentary 2 James Q Swift, DDS
This case is one of the most challenging situations in the treatment of maxillofacial trauma: bilateral condyle fractures of the mandible with a corresponding symphysis fracture. Compared to unilateral or bilateral mandibular condyle fractures only, the addition of the symphysis fracture increases the difficulty of treatment and alters surgical decision-making. If this patient had sustained the exact same fractures of the condyles only (without the symphysis fracture) and was treated with open reduction and internal fixation of the right condyle fracture and closed reduction or treatment of the left condyle fracture with occlusal guidance with arch bars and elastic intermaxillary fixation, the opportunity for a more favorable outcome would have been dramatically increased. The transverse flaring at the inferior borders of the mandible increases the loss of vertical height or dimension of the mandibular ramus. It is also difficult to reposition the condylar segments to the premorbid condition in the glenoid fossa with the flaring
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Fig 3a
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Three part fracture of the proximal humerus with metaphyseal comminution.
A prospective standardized international multicenter study of the PHN was performed to answer the following basic questions: • Is intramedullary nailing with a new angle stable titanium nail a safe procedure in the treatment of proximal humeral fractures • Does it provide a good outcome (Constant-Morley and DASH)?
Fig 3b
Stabilization with PHN and spiral blade.
Analyzing the complications, perforation of the articular surface by screw or spiral blade and pain due to the implant or impingement at the nail base are clearly related with a suboptimal surgical technique. The nail has not been properly introduced or the length for the spiral blade was not exactly determined and its correct position was not controlled intraoperatively (Fig 4). The development of nonunion (2/108) shows a ratio equal to or even better than what is reported in conservative treatment or plate osteosynthesis. Dislocation of fragments shows the limit of this procedure. In multifragmentary fracture types, one spiral blade will not be able to fix all fragments. Using additional hardware is possible, but might reduce the effect of an initially low invasive approach.
In 11 hospitals, 151 fractures had been treated, of which 72 were extraarticular unifocal A type (2 part), 67 extraarticular bifocal B type (3 part) and 12 intraarticular C type (4 part, valgus impacted) (AO-classification) (Fig 3a–c). There were 37 male and 114 female patients, median age 66 years, ranging from 16–97 years. In total, 108 patients could be followed up for one year. The important complications noted were perforation of the articular surface by screw or spiral blade (n=8), pain due to the implant (n=10), displacement of fragments (n=2), nonunion (n=2), humeral head necrosis (n=3) and wound infection (n=1).
The study data as well as personal experience with the PHN since 2002 lead to the conclusion that proximal humeral nailing seems to be beneficial in A-type metaphyseal fractures, if not treated conservatively. Even in many B-type fractures it is still a good alternative with a more limited incision in comparison to plate osteosynthesis. In C-type fractures, nailing is not advisable as a standard routine.
The Constant-Morley score shows mean values of 75.3 on the injured side at one year postoperatively and 89.9 on the noninjured side. The mean DASH score was pre-operatively 5.9 and 9.3 at one year postoperatively. These results are similar to those with plate osteosynthesis. C-type fractures clearly have the worst prognosis.
Retrospectively, the initial idea of finding a nail solution for almost all fracture types in the proximal humerus is not realistic. Nevertheless, the PHN has a clear role in the repertoire of reliable implants for proximal humerus fracture fixation when minimal invasive approaches are desired and an anglestable plate is not necessary.
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Clinical topic
Fig 3c
Fracture healing after 4 month. Correct placement of spiral blade and end cap.
Fig 4
Suboptimal surgical technique. Perforation of the spiral blade and loosening of the proximal interlocking screw (left). Protrusion of the nail base with end cap and of the spiral blade (right).
The spiral blade cannot be considered as the one and only angle-stable fixation mode proximally. Further development should focus on the integration of additional hardware at the nail’s base in order to offer a wider variety of fixation possibilities for more complex fracture types.
Data of the AO-multicenter-study on the proximal humeral nail (PHN) presented at the Orthopaedic Trauma Association OTA Annual Meeting in Boston (USA) October 2007 and German Congress of Orthopaedics and Trauma Surgery Berlin (Germany) October 2007. Jochen Blum
Director Clinic for Orthopaedic Trauma and Hand Surgery Academic Teaching Hospital of the Johannes Gutenberg University Mainz, Worms, Germany jochen.blum@klinikum-worms.de
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Unstable intertrochanteric fractures: lessons learned from a clinical study of the trochanteric femoral nail.
Michael J Gardner and Dean G Lorich
Trochanteric femoral nail Introduction Unstable intertrochanteric hip fractures can be difficult surgical challenges. Screw and side plate devices reliably stabilize stable fracture patterns [1,2], but unstable fractures require a mechanically optimized device and better implant purchase in the femoral head. These fractures have been more prone to implant failure with standard devices [3, 4]. The trochanteric femoral nail (TFN) is a helical blade device which has fins that compact the cancellous bone as it is inserted into bone and may provide improved fracture stabilization characteristics [5, 6]. A retrospective study of 273 patients with intertrochanteric hip fractures who were treated with a TFN was conducted at two institutions between 2001 and 2005. Patients underwent closed fracture reduction using traction and manipulation techniques. When the reduction was unacceptable as determined by the surgeon, adjunctive percutaneous reduction techniques were utilized. Implants were placed percutaneously, and compression of the fracture was performed in the majority of fractures. Precise measurement of movement of the blade within the femoral head and the nail was performed on all radiographs according to a previously described technique (Fig 1) [6]. The amount of telescoping was then measured as the lateral prominence of the blade lateral to the edge of the nail. X-ray measurements were made immediately postoperatively, at six weeks postoperatively, and at subsequent follow-up.
• The length of the nail was also not related to blade tip migration. • Increased telescoping in unstable fractures was controlled and limited, maintaining abductor tendon length, but did not predict subsequent cut out or additional blade migration in the femoral head. Less telescoping also occurred with a greater initial lateral blade prominence (as a result of initial fracture impaction). • After the six-week follow-up, minimal additional blade migration and telescoping occurred, indicating these movements resulted in fracture settling in a stable position. • Blade penetration through the subchondral bone occurred in some unstable fracture patterns and could be attributed to technical error, including varus neck-shaft angle, superior blade placement in the femoral head, or distraction at the fracture site.
Notable findings
• The average blade tip migration was 2 mm. In a multivariate regression, fracture stability, calcar reduction achieved, age, and gender showed no correlation to blade migration. This implies that the strong purchase of the blade in the cancellous bone of the femoral head may be able to overcome imperfect reductions of the posteromedial cortex and provides adequate stability in elderly patients.
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Fig 1 A coordinate system, based on the center of the femoral head, was used to calculate the change in position of the implant over time. Measurements were corrected for rotation and magnification.
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AO Vet news
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A noncompliant owner/animal will markedly increase the incidence of implant-related complications. Catastrophic or fatigue plate failure are examples of implant failure associated with overuse prior to adequate bone healing (Fig 1). Rapid callus formation Strategies to reduce the incidence of implant failure include methods to accelerate callus formation and/or methods to reduce implant stress. Methods to hasten callus formation include preservation of the surrounding soft tissue envelop during surgery and insertion of graft material to enhance osteogenesis and osteoinduction. Allogeneic and autogeneic cancellous bone grafts are frequently used in Veterinary surgery to stimulate osteogenesis and/or osteoinduction. Preserving the soft tissue envelope, ie, atraumatic surgery, has always been advocated as a principle vital to the AO technique. Atraumatic technique is fundamental when managing comminuted fractures using indirect reduction tech-
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Bone plate failure following stabilization of a comminuted tibial fracture in a dog. Surgical view showing location of portals for minimally invasive plate osteosynthesis. Postoperative view showing position of bridging plate and intramedullary pin for application of plate/rod construct.
Fig 4
Image showing good weight bearing 24 hours postoperatively after MIPO with a stable plate/rod construct.
Fig 5
Bone union 9 weeks postoperatively.
niques. Veterinary surgeons have long adopted the principle of OBDNT. This acronym (Open But Do Not Touch) signifies an open exposure without manipulation of fragments within the zone of bony comminution. Doing so helps preserve the biologic potential of the fracture milieu and maintains an environment of low interfragmentary strain. Both factors are conducive to rapid callus formation and early bone union. Minimally invasive plate osteosynthesis
Within the last decade, the concept in minimally invasive plate osteosynthesis (MIPO) was introduced and is becoming the standard method by which human and veterinary surgeons may achieve maximal preservation of soft tissues adjacent to the fracture site. Using minimally invasive technique, soft tissue portals are made at strategic locations to facilitate bone plate and screw insertion. Spatial alignment of the fracture is achieved with the aid of intraoperative imaging; alternatively, the surgeon
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