AO Dialogue 1|10

AO Dialogue 1|10 The newsletter for the AO community

Interview with Paul Manson A look back at his tenure as AO President

Olga Harrington, AO Dialogue

What was the highlight of your Presidency?

The highlight for any President is getting to know other physicians, employees and ­educators in the organization that you other­ wise wouldn’t—what an amazing group of people. Also the fact that a CMF person, mem­ ber of a relatively small Specialty, got to be the ­P resident is special.

office. It is difficult to influence the destina­ tion of the Foundation, the managers drive the business of the Foundation. However, I don’t think the term is too short, as there must be turnover. The complexity of medical life means that you can’t know a lot outside your own Specialty; the success of the AO confirms the need for differentiation.

Did the role live up to your expectations?

Have there been any major disappointments for you during your tenure?

The AO President is largely a figurehead and you can’t achieve a lot with a finite term of

I wish I had been able to do more; it is hard for one individual to overcome the inertia of a large organization. Things happened that had their own consequences, [ continued on page 2 ]

Table of contents Paul Manson 1 Socio Economic Committee 3 AOVET 5 Legal aspects of AO Education 6 Research Focus 10 From the AO Service Units 14 Regional highlights 16

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which caused me to modify my plans as I learnt more about the organization, in particular, the details I might utilize to accomplish what I wanted to achieve.

What have you learnt personally from this

Did the AO change a lot during your presidency?

We moved very fast and we changed a lot. It is too early to say whether we’re going to be better off or not; it will be the job of the next President to assess the outcome of the changes and decide how we should modify any of that.

experience as President?

I’ve learnt some things about running a large entity; I’m a physician not a business person so I’ve learnt how to get along in a volunteer organization.

Do you think changing the bylaws will strengthen the role of Presidents?

No, the veto power is after-the-fact, so can’t be effective. If we want to change the role of the President we would have to change the structure of the organization: I for one feel that should happen. The Specialties believe they should control their own destiny, view the Foundation as a bank and want to be able to do whatever they choose with their fund­ ing. The recent AOVA structural change— with Specialties included—creates a chal­ lenging situation for the Board members. I strongly believe that the Board of Directors should be independent, and members should work for the good of the AO, even if they are Specialty representatives. The AOVA ought not to contain people who have a desire to be President and are thus unlikely to take an unpopular stand.

What challenges does Norbert Haas face as he assumes this role?

Convincing the Specialties of the value of cen­ tral Foundation functions is perhaps the biggest priority, followed by realigning our educational strategy with e-learning advances. We have to explore what will work and what will not and decide how to spend our money. How much of the old style courses should we be doing and how much learning should we be offering people, when and where they want. The place of research within the Foundation is another key focus. Some Specialties want to go to any University they choose but that would mean that our research institute, ARI, would lose its central function and our staff would leave.

What will the legacy of your presidency be?

I leave this Foundation in a better position ­­with our producer partner. We’ve gone through some tough times but one of the relationships I’ve always appreciated within the AO Foun­ dation, is the one I have with Synthes officers and employees—we’ve mended bridges and it’s heading in a good direction.

A profile of new AOFoundation President, Norbert Haas

Norbert Haas takes over from Paul Manson as the 11th President of the AO Foundation on July 12th 2010.

With connections to the organization stretching back to the 1970’s, Norbert served as chairman of the AO Technical Commission for ten years prior to assuming the role of President-Elect in 2008.

As a native of Ludwigsburg, Germany, Norbert Haas studied medicine at the universities of Tübingen and Kiel, obtaining his medical degree in1974. During his studies in Tübingen, he met his wife Judith, a Professor­of Neurology with whom he has two daughters—Anna, currently completing an MBA in Zurich and Elisabeth, studying medicine in Salzburg.

In 1983, Haas became Professor of Trauma and Recon­ structive Surgery at the Medizinische Hochschule Hannover and in 1992, was appointed director of the Clinic for Trauma and Reconstructive surgery at the Virchow Clinic, Free University Berlin. Over time, his area of responsibility grew to include the Clinic for Trauma Surgery at the Charité, Humboldt University and the Clinic for Orthopedic Surgery—thus forming the first Centre for Musculoskeletal Surgery in

­ ermany. This merger mirrors Norbert’s commitment G to both close cooperation between orthopedics and trauma as well as the “common trunk” for consultant training in Germany which he fought for during his presidencies of the German Trauma Society (DGU) in 2000, the Berlin-Brandenburg Surgical Society in 2001/2 and the German Surgical Society (DGCh) in 2002/3. Under his leadership, a research lab was founded in Berlin in 1997 which evolved into the Julius Wolff Institute currently employing 90 staff.

Norbert Haas is a member of the Scientific Advisory Board of the German National Medical Association and Senator of the German Research Foundation (DFG) and since 2007, he is also the Chairman of the Centre for Sports Science and Sports Medicine at the Humboldt University and Charité, Berlin.

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AOSEC leadership change Insights into Paul Demmer as he hands over to John Croser Married with a son and daughter, Paul was born in Germany, graduated as a Fellow of the Royal College of Surgeons in Scotland and worked in Austria before moving to South ­A frica. Joining AOSEC in 2001 as Africa­ ­Representative and Chairman, Paul is a true AO missionary and ambassador in third world countries. His main educational focus has been on non-operative fracture treatment, tailored to local needs and limited resources. He is the godfather of the South African AO community, traveling to many Sub Saharan African coun­ tries to provide AO teaching to doctors, nurses and orthopedic clinical officers. Paul particu­ larly endeavoured to identify local surgeons to train so that they could deliver self-supporting and locally-run projects and courses. He also provided funding­ for the East Central and Southern African ­Orthopaedic Association so they could directly administer education and training in their countries. Another of Paul’s priorities was to educate room personal— knowing that without their support and understanding ­fracture surgery was an even more dangerous undertak­ ing. Paul’s ­ability to forge personal ­relationships with key doctors and governmental author­ities gave him access where others failed.

As testament to the high regard in which Paul Demmer is held by the AO Foundation network he has been awarded the “Hardy Weber Prize” in 2010 for his outstanding contribution in the field of education.

On the one hand Paul Demmer repeatedly gave his unbiased, realistic and sometimes painful opinion on AO´s responsibilities in the developing world, while on the other he was extremely critical when looking back on the practical outcomes of all his efforts. The people who work with him respect him for his honesty, integrity and ability to focus on a problem and deliver its solution. Paul’s legacy is to have produced a network of surgeons trained to deliver training and to have established a template for delivering aid and education at a level which is relevant to the individual needs of communities.

New AOSEC Chairman, John Croser, outlines his plans As incoming chairman my aim is to continue the work that Paul Demmer started, and to preserve the principles we have established.

The concept of providing education appropriate to local needs has stood the test of time. The continued enthusiasm for AO teaching in developing countries is testimony to the recipe being correct. Where other aid agencies spend millions and have little in the way of tangible results to show for their investment, we have given local practitioners the tools they need to develop their own programs—AOSEC has managed to maintain a high interest at minimum cost. I intend to utilize the local ­k nowledge and expertise of the AOSEC members to ensure that we continue to get maximum value for our AO ­d ollar. Paul will, hopefully, continue to be ­a ctive in AO affairs for years to come and his expertise and ­e xperience in Africa and the contacts he has made worldwide will be an ­invaluable ­r esource. We have watched the AO evolve over the years and AOSEC must adapt to accommodate changing situations both within the Foundation and the regions we serve. I am sure I will find this a challenge and only hope that I can emulate my predecessor.

Thanks to Chris van der Werken and John Croser for their insights.

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Interview with AO ORP International Faculty member Eija Vasama Tell us a little bit about your nursing background

Can you see a real difference in the way the

I was born in a small village in Finland, got my Nursing Diploma in 1982 and my Special­ ized Anaesthesia and Perioperative Nursing Diploma in 1991. During this time I worked in Kanta-Häme Central Hospital in Hämeen­ linna. I left home to work in Saudi Arabia in 2001 and spent more than seven years at King Abdulaziz Medical City, Riyadh.

AO ORP operates in the Middle East, Western

Why did you decide to get involved with the AO Foundation?

“Through my work with the AO ORP, I have learnt about life and people in different places. I have made friends—good friends— all over the world.”

I attended an AO ORP course in Finland 1998, but it was only in Saudi Arabia, that I really got involved with AO Education at the suggestion of Dr. Wa’el Taha at King Abdulaziz Medical­ City, Riyadh. My first experience was as a Table Instructor on an AO ORP course in Jeddah­ in 2007. A special highlight was to be invited to an ORP faculty training seminar in Davos, where I was introduced to the international network. I have subsequently worked with a Spanish OR Nurse, Elena Miguel to help local Croatian ORP faculty to organize their own AO ORP course.

and Eastern Europe?

During AO ORP courses you find the same enthusiastic and eager-to-learn participants everywhere you go, although the ways of ­i nteracting and the willingness to discuss ­d iffers from culture to culture. It is important that AO ORP faculty is available to deal with participants’ individual questions and con­ cerns both during and after courses. In other countries, like in the Middle East, they are lots of foreign ORP working in the country and it is very difficult to gain continuity within the AOTrauma ORP faculty, as people come and go regularly. Where hospitals can’t afford to provide the modern AO fracture management systems in their ORs, it is important for faculty members to enlighten the orthopedic surgeons and ORP that no matter what system they can afford to use, they can still apply AO techniques when treating fractures.

Do you think it is important that people have experience beyond their own country when they work with the AO?

I don’t think it’s necessary for all AO faculty members to have experience outside their own country—but it is a bonus and advantage. It helps them see that the problems are the same everywhere—and that solutions can be found together, helping each other. I hope that AOT ORP continues to communicate so actively with its ORP members. This support is vital for us to be able to stay motivated, focused and informed so we can deliver and spread the same AO message, with the same AO passion.

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New opportunities for AOVET members Launch of membership initiative

July 2010 sees the worldwide launch of the new AOVET membership initiative to expand its network and provide colleagues across the globe with clear value and improved benefits, while still maintaining a strong community spirit.

The AOVET Specialty Board has redefined the existing AOVET membership scheme to appeal to both existing and new members, thus al­ lowing the specialty to expand its ­position as a global community of veterinary orthopedic specialists, focused on surgeon education. This comes about due to the emphasis placed by the AO Foundation on clinical divisions since 2009 and the consequent strengthening of the role of AOVET (as the fourth AO Specialty).

The new AOVET membership structure is made up of four award levels (Affiliate, Active,­ ­A mbassador, and Acknowledged), each of which has different prerequisites and benefits attached to it. Existing members are valued contributors to the community and are thus invited to join the new AOVET membership at the level of an AOVET Ambassador. A brief outline of the new structure, highlighting what the status means to new and existing members is available on www.aovet.org.

Details of the AOVET membership program is being made available during the 19th Annual Scientific Meeting of the European College of Veterinary Surgeons (ECVS) in Helsinki, ­Finland July 1 to 4. Further information drives are scheduled for educational events in São Paolo, Brazil in July and La Jolla, California, USA in September, offering direct access to Latin American and North American partici­ pants attending AOVET courses.

Benefit offerings

Affiliate

Active

Ambassador

Acknowledged

Access to AOVET news via website

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Online access to VCOT

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Online access to OrthoVetSuperSite

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10% discount on all AO publications

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Access to AOVET member directory names and clinic associations

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Ability to submit and participate in online case discussionsº

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Sampling of educational materials

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Access to the AOVET lounge at society events

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Full access to AOVET member directory detailsº Online access to additional scientific journal optionsº

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Ability to submit/participate in online discussions º

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Permanent access to educational materials related to AOVET courses attended by memberº

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Eligible to peer review cases & moderate online discussionsº

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Eligible to vote

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Access to all Faculty resources

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Eligible to become involved in AOVET Boards & Task Forces

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Eligible to be an Ambassador of the AOVET community

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100 CHF

100 CHF*

º benefit under development

75 CHF

100 CHF

*No fee for retired individuals

Prerequisites Affiliate Active Ambassador

Open to anyone with interest in orthopedic veterinary science

Acknowledged

Member of International Specialty Board

Participation in at least one AOVET certified educational event within the previous 6 years AOVET Active member for a minimum of 3 years

The emphasis of the new membership program is on delivering high value to new and existing members while maintaining the character of the network.

The goal is to ensure global reach and embrace the sub-specialties of small and large animal surgery while continuing to deliver the highest quality education.

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Legal aspects of being involved with AO Education Michael Ehrenfeld, Urs Weber-Stecher, Oliver Staffelbach

Surgeons who present scientific lectures at courses, congresses and symposia must con­ tend with the fact that their material can be downloaded, copied, and altered without their authorization. Is this an unavoidable byprod­ uct of new technology or do legal means exist to protect intellectual work? Many countries have strong patient privacy protection rights.

These must be respected by physicians who have an obligation to ensure that patient images and data are not distributed in an uncontrolled way. There is growing demand for educational courses involving live surgery, which necessi­ tates malpractice insurance and health insur­ ance for the surgeons involved. Insurance of AO Fellows, is a legal issue which needs to be addressed.

Taking into account these important AO related issues this article focuses on: • Protection of intellectual property (IP) • Patient protection rights • I nsurance for live surgery performed during educational events • Insurance aspects for Fellows

Protection of intellectual property Legal basis for protecting lecture material

Intellectual property laws guarantee protection of non-tangible values. Sources of intellectual property law include copyright, trademark, de­ sign and patent law. For the protection of sci­ entific lectures, copyright law—which protects literary, dramatic, musical and artistic works— this is the relevant legal basis.

In an international context, it is important to note that each country has its own copy­ right law. Therefore, the location of an alleged copyright infringement is relevant when de­ termining the applicable copyright law. The fundamental principle of territoriality allows authors to claim their rights in the countries where the infringement occurred. So if, for example, the copyright to a scientific lecture written by a German surgeon is infringed upon in China, Chinese copyright law applies.

Moreover, their rights can be claimed either in China, ie, at the place of the infringement, or at the domicile of the infringer, but most likely not in German courts (except if the

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infringer is also domiciled in Germany). This makes prosecution rather complex.

To a certain extent, copyright law is harmo­ nized through international treaties between most industrialized countries in the world.

One of the most important is the 1886 Berne Convention for the Protection of Literary and Artistic Works, revised in Paris in 1971. The 163 signatories constitute the Berne Union, which covers almost the entire world. How­ ever, because international treaties such as the Berne Convention and the WTO’s Agreement on Trade-Related Aspects of Intellectual Prop­ erty Rights (TRIPS) are not directly applicable and only guarantee international minimum standards of authorial protection, it is impor­ tant to examine the applicable national laws of participating countries, as they may provide for better protection.

What kind of “work” qualifies for legal protection?

The answer to this question can only be found in applicable national laws, not in international treaties. Lectures given by surgeons are pro­ tected by the copyright laws of most developed countries. How broad is that protection? Un­ fortunately, not very. As a rule, only a specific form or way of communicating the scientific content is protected by copyright laws, not the content itself. This is because scientific works (if unprotected by a specific design or patent right) should be available to interested scientific circles in order to foster scientific progress.

The arrangement, choice, classification and tri­ age of the content as well as the structure of a lecture often belong neither to the form nor to the content. However, if the structure of the content of a lecture is not predetermined by the content itself, it may be possible that such structure is protected. But again, how much a

The authors

Michael Ehrenfeld, Chairman and Professor Department for Oral and Maxillofacial Surgery Ludwig-Maximilians-University München, Germany michael.ehrenfeld@med.uni-muenchen.de

Urs Weber-Stecher Wenger & Vieli AG, Zurich, Switzerland u.weber@wengervieli.ch

Oliver Staffelbach Wenger & Vieli AG, Zurich, Switzerland o.staffelbach@wengervieli.ch Urs Weber-Stecher and Oliver Staffelbach are legal advisors to the AO Foundation.

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lecture is protected is defined by national laws and may vary from country to country.

In most developed countries, citations of sci­ entific works are legally permitted subject to certain conditions. In Switzerland, for example, published works of third persons may be quot­ ed if the quotation serves as an explanation, a reference or illustration, and the extent of the quotation permitted results from its purpose.

Moreover, the quotation must be designated as such and the source indicated.

In many developed countries it is irrelevant whether a work is—or is not—fixed in a mate­ rial form in order for it to merit legal protection, ie, a work does not have to be written down or recorded to be protected by copyright law. In countries such as the UK and the US, however, copyright protection of a work requires fixation in a specific form, eg, in a manuscript.

Conclusion on the protection of (IP)

In most countries a scientific lecture is protected without respecting specific formalities except in the USA and the UK, where works must exist in a specific form. The best legal protec­ tion available is still rather weak. If surgeons wish to protect their intellectual property legally we recommend producing the presentation in material form, eg, a manuscript or a specifically labelled powerpoint presentation, and explicitly informing the audience that the lecture is pro­ tected by copyright law (eg, by writing it down on the first or last page of the presentation).

As it is virtually impossible to enforce and conduct legal actions in cases of intellectual property right violations the following prac­ tical ­suggestions will help avoid uncontrolled copying and distribution of lectures: • Store the presentation on the lecturer’s pri­ vate laptop and use this laptop exclusively for presentation.

• Use a password protected memory stick that can only be opened by the lecturer.

• A lecture should not be handed over to any­ one else (including the congress organizer) in order to protect the lecture from being downloaded, copied, or duplicated.

• Lectures should only be copied onto a central server in an environment which guarantees, in a written and individually signed state­ ment, that the lectures are deleted according to the wish of the lecturer at the end of an educational event.

Watermarking or labelling of slides can make uncontrolled use and distribution less likely, but does not prevent uncontrolled copying in a reli­ able way and it does not guarantee protection of patients rights. It should also be noted that data transfer from private laptops via memory stick to central laptops has led to virus acquisition and considerable damage to soft- and hardware of AO faculty. This can easily be avoided if a presenter exclusively uses their own laptop for presentation.

AO Dialogue 1|10

Patient protection rights

Many countries have strong privacy protection laws preventing patient identification in pictures or x-rays used for presentation. These privacy protection laws may vary from country to coun­ try and every surgeon needs to be familiar with the legal situation in their ­country. In most countries it is necessary to have a written signed patient consent before patient specific material can be used for presentation or publication. This may be done on a broad and unlimited basis, allowing the physicians to use patient material in an unrestricted way, or on a limited basis, for allowing a physician to use the material only for student education and scientific presentations including scientific prints. It is much more likely that a patient will agree to the latter.

Aside from protection of IP, ­patient protection laws underline the need for a presenter to take actions to make uncontrolled use and distribu­ tion of patient material impossible.

Insurance aspects for fellows

Before starting their fellowship, AO Fellows receive a written notice in their confirmation letter from the AO Foundation informing them that they need health insurance coverage for the duration of their fellowship. To ensure the Fellow has taken notice of this information, they must send the signed final confirmation to the respective AO Foundation unit. Cur­ rently there is no additional mechanism within AO to prove that every Fellow is appropriately insured, which is a potential conflict should a Fellow become seriously ill during a fellowship.

In departments where Fellows are involved with patient care activities, it is highly recom­ mended that the host department ensure that the Fellow is properly credentialed by the hos­ pital, regional and national medical licensing bodies. It is also highly recommended in the confirmation letter that a Fellow should have malpractice insurance coverage, either as an individual or institutionally.

Live surgery during educational events events

With the improvement in telecommunications and more emphasis on interactive courses, AO faculty are called upon more often to perform live surgery. There is a risk that a surgeon be charged with malpractice should something ­adverse occur during such an educational event.

In addition a surgeon may acquire a transmit­ table disease during surgery. At this time the AO Foundation does not provide malpractice or health insurance for faculty nor does it get involved with local accreditation procedures.

The following suggestions will help minimize a surgeons’ risk should they perform live sur­ gery: • Ensure the local host obtains the necessary accreditation to allow surgeons to practice surgery in the involved locale.

• A surgeon should contact their own mal­ practice insurance carrier to see if they cover occasional itinerant volunteer work eg, in Germany this is the case.

• If coverage is not available request the host to obtain temporary malpractice insurance in the country and for the time of the course.

• In addition a surgeon should contact their health and disability insurance in advance to find out if the risks associated with education related live operations are covered.

Summary

In a number of scenarios surgeons involved with AO Education may encounter potential legal challenges and conflicts, such as protec­ tion of intellectual property, patient protection­ rights, insurance issues—especially if in­ volved with live surgery during educational events—and insurance aspects for fellows. It is of critical importance to create awareness and to offer solutions and ideas for areas with potential conflicts.

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AO Foundation Research Focus Insight into research and development activities at ARI and Exploratory Research Geoff Richards, Director, ARI

The aim of the research team within the AO Foundation is to contribute high quality basic and translational research and development (both innovative and service oriented) in trau­ ma and disorders of the musculoskeletal system in close cooperation with the AO Specialties (AOTrauma, AOSpine, AOCMF, AOVET) and AO Exploratory Research.

As a core function within the AO Foundation, research has recently undergone significant change which culminated in the integration of the AO Development Institute (ADI) into the AO Research Institute Davos (ARI) and the appointment of Geoff Richard’s as its director in 2009. Strengthening collaborations with the AO surgeon network, international universities and AO Foundation’s industrial partners while driving AO Research Fellowships for surgeons

(mainly funded by the AO Exploratory Board) and maintaining the high level of publications in peer reviewed journals are the key strategic goals of this restructured group.

To ensure the efficient deployment of the AO Foundation infrastructure, the AO R&D Com­ mittee was established in 2009 to advise and guide ARI. The committee is composed of four research persons nominated by the Specialties, one nominated person from the AO Explor­ atory Board, one industrial partner member, one member at large, an external research busi­ ness person and an AOVA appointed chairman along with the AO R&D Director as an ex of­ ficio (non voting) member. At the request of the AO R&D Committee, the AO Veterinary Advisory Committee (AOVAC) was created to review animal models used in all AO Founda­ tion funded projects.

ARI workstream organigram

ARI Director

Financial Controlling Quality Management Central Functions GCTM AG

Preclinical Innovations Group

Musculoskeletal Infection Group

Research Implant Technology • Skill Training Technology

•­ Infection Models • Infection Diagnosis

Preclinical Testing Program

Biomedical Services Program

Musculoskeletal Regeneration Program

• Experimental Surgery • Tissue Morphology • Imaging • Human Morphology Services

• Biomechanical R&D • Prototype Workshop • Concept Development

• • • •

Bone Regeneration Disc Regeneration Stem Cells Polymers / Surfaces

AO Dialogue 1|10

PreClinical Testing Program

Experimental surgery planning and develop­ ment in addition to running of preclinical test­ ing studies in the musculoskeletal area, are the focus of this team. Experienced personnel are involved in study plan development; anesthe­ sia; surgical procedures; postoperative care; in vivo analysis (radiography, ultrasonography and computed tomography); tissue collection; data collection and report writing.

Tissue Morphology and Imaging

Collaborative and research services are the focus fields within this team. This includes uti­ lizing techniques in routine histology such as paraffin and cryosectioning, and also in nonroutine undecalcified hard tissue histology, with or without implants. Standard protocols are developed using different methods of la­ beling and detection for immunocyto- and immunohistochemistry. Microscopic inves­ tigations, including image analysis, can be performed using conventional transmitted and several reflected light methods including fluorescence and confocal microscopy. Surface characterisation techniques include white light profilometry. Scanning Electron Microscopy (SEM) is available for use in material morpho­ logical analysis as well as routine elemental determination using Energy Dispersive X-Ray Microanalysis (EDX). SEM techniques have been developed internally for biomaterial, cell, tissue and bacterial interface studies.

Human Morphology Services

Advanced medical imaging and analysis tech­ niques are applied for different procedures such as the build up of three-dimensional statistical bone models.

Fig 1

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Biomedical Services Program

Biomechanical R&D, prototype workshop and concept development fall within the remit of this program. Both a unique biomechanical test setup, standardized for different anatom­ ical regions, and finite element studies are used to improve fracture fixation with spe­ cial emphasis on osteoporotic bone conditions. In concept development, techniques for simplified intraoperative nav­ igation are currently being evaluated. Cement augmen­ tation and the assessment of bone strength in the osteo­ porotic bone are also being Fig 2 assessed.

Musculoskeletal Regeneration Program b Polymers Thermoreversible hyaluronan hy­

drogels have been successfully tailored by ‘click chemistry’ and RAFT polymerization for cell and drug therapy. In vitro evaluation has demonstrated high potential to be used asb cytocompatible injectable cell carriers for intervertebral disc regeneration, with possi­ bilities in substance delivery such as growth factors or antibiotics.

Stem Cells The loading protocol (amplitude and frequency) applied to human bone mar­ row derived stem cells, plays a major role in determining whether the cells will eventually become cartilage or bone, which can be used to determine optimal rehabilitation protocols for cell based therapies.

Intervertebral Disc Research projects have iden­ tified potential markers to distinguish human intervertebral disc from cartilage cells, and have also revealed molecules that may indi­ cate ‘juvenile’ or ‘degenerative’ aging discs.

Furthermore growth factor mediated differ­ entiation of human mesenchymal stem cells towards an intervertebral disc-like phenotype has been evidenced.

Bone defect Platelet Released Growth Factor has been shown to have a positive effect on En­ dothelial Progenitor Cells growth while main­ taining differentiation capacity. On Bone Mar­ row Mesenchymal Stem Cells, it stimulates the bone morphogenetic protein-2 (BMP2) trans­

Fig 1 Tissue morphology—calcium phosphate resorption Fig 2 Augemented blade in osteoporotic foam model

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duction pathway, leading to matrix mineraliza­ tion. In vivo implantation of this combi­nation in a sheep 3cm defect demonstrated that the newly formed bone reached ~70% of stiffness compared to the contra-lateral control bone, while histological observations showed the presence of blood vessel-like structures and the initiation of bone remodeling.

Implant Surfaces Smoothening of metal sur­ faces has been shown to ease removal and reduce operation time and screw stripping, which is in part controlled on a cellular level through changes in osteoblast gene regulation and cell shape. Direct surface modification of Polyether ether ketone (PEEK) to improve cell and tissue­integration has been found in vitro to increase mineralization and phenotypic primary human osteoblast gene expression (indicating that this modification is likely to improve bony integration).

standard microrough or polished. There was also no difference in susceptibility to infection between standard and polished titanium alloy intramedullary nails.

Innovations Group Research Implant Technology The RISystem

implant kits provide standardized and repro­ ducible biomechanics to study bone reactions.

The locking RabbitNail and the metaphyseal MouseFix are now in development.

Skill Training Technology To support the contin­ uous education of a surgeon, the student level will be mainly addressed with an autodidactic tool kit to under­ stand and train the biomechanics of fixations. For the resident level a face-to-face ap­ proach will be sup­ ported by problem related teaching modules (Play­ Ground for Ortho­ Fig 5 pedic Surgeons).

GCTM AG PreClinical Fig 3a

Fig 3b

Musculoskeletal Infection Group Infection Models and Diagnosis In vitro and in

vivo models are being developed to understand bacterial behavior with the aim of influenc­ ing infection risk by implant design changes.

Preclinical evaluation showed no significant difference in susceptibility to infection be­ tween titanium and steel locked plates, be they

Fig 3 a Cell isolation C ell isolation

b Resorbable Polymers for Osteosynthesis & Tissue Engineering

Fig 4 Locking compression plates used for in vivo infection studies Fig 5 Playground for Surgeons

Fig 4

Global Clinical Trials Management AG, Pre­ Clinical Division offers the full range of ARI services to commercial sponsors. Recent stud­ ies conducted include: long and short term tissue reactions to bone filling materials in cancellous bone and iliac wing defect models; ISO10993-6 studies to test soft tissue reactions to novel implant materials; cartilage regenera­ tion studies in goats; histological analysis of dental implants; tissue engineering solutions for the treatment of long bone defects; GLPlike studies to test osteointegration of novel implant materials; ex vivo analysis of novel augmentation techniques and testing of new orthopedic devices.

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This program is aimed at­ ­developing solutions for large bone defect healing in adverse environments, a problem faced by many orthopedic trauma surgeons. The CRP entered a new funding round in January 2010, based on the con­ sortium funding strategy. The 5th Annual General Meeting of CRP LBDH will be held September 23–24, 2010 in Boston, USA.

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The AO Exploratory Research (AOER) has a unique funding strategy—instead of funding stand-alone projects by individual research teams, the AO Exploratory Research Board (AOERB) funds research consortia which work collaboratively, on a peer-to-peer basis, towards solving a clinical problem. Consortium funds are distributed to research partners based on their project contributions and all project applications are peer-reviewed by external reviewers.

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Large Bone Defect Healing

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• Bone repair and regeneration mechanisms; bone induction and repair; bone substitute; implant design • Cartilage-disc repair and regeneration mechanisms; inflammation; replace­ ment; implant design

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Focus Fields

responsible for the ­scientific coordination. As the AO Foundation’s research institute, ARI takes the role of “primus inter pares” with an ARI research expert being assigned to each pro­ ject and ARI is also a mandatory partner in each AOERB funded consortium.

ar

Sandra Steiner, Manager, Exploratory Research

The mission of AO Exploratory Research (AOER) is to foster and expand a network of scientific professionals that focus on true novel approaches and theories in two focus fields of musculoskeletal science, and to translate emerging knowledge and expertise to the benefit of the AO Mission.

Consortium funding strategy process

Annulus Fibrosus Rupture

This program is aimed at developing solutions for treatment of annulus fibrosus rupture.

Acute Cartilage Injury

Collaborative Research Programs

Within each of the two focus fields, proposed by the AOERB and approved by the Aca­ demic Council in 2009, there are one or two collaborative research programs (CRP). Each CRP is composed of an international, inter­ disciplinary network of research teams which work on collaborative projects towards the consortium goal. To ensure proper function­ ing of the ­network a “primus inter pares” is

This program is aimed at assessing problems of acute cartilage injury and at developing solutions for treatment.

At the end of 2009, the AOERB initiated these two new CRPs. An external advisor was ­assigned to each program committee, which is responsible for setting up its corresponding research consortia. The plan is to have three CRPs operative by January 2011.

In situ Approaches

Autologous Grafts

Autologous Blood derived Precursor Cells

Gene-achived autologous Muscle / Fat Grafts GENEDEF

RP Large Bone Defect— C Research Network

In vitro Approaches

Genetic Manipulation

Delivery Vehicle

Progenitor Cells

Non-viral Gene Delivery

Thermo-sensitive Hydrogel

Biomembrane Formation BIOMEMBRANE

Mesenchymal Stem cells Endo thelial Progenitor cells

EPCGRAFT

Vascularization

In vivo Vascularization Analysis SCAF ANALYSIS

Scaffolds

Bioactive Factor Delivery

LBD Scaffold Platform WFB LBD-SP

Bone Sialoprotein BSP BONE

Growthsfactorreleasing Carriers GFBONE LBD-CT

Page 14

AO Dialogue 1|10

From the AO Service Units AO Education

(AOE)

AO Technical Commission

(AOTK)

AO Dialogue Editor-in-Chief, James F Kellam, reviews a newly

AO Asia Pacific Experts’ Symposium

released handbook from AOTrauma

The 4th AO Experts’ Symposium in the AO Asia Pacific Region took place in Shanghai on May 22–23, 2010. The symposium, jointly or­ ganized by the TK System and AOTrauma Asia Pacific, was chaired by local chairman, Bingfang Zeng and AO Asia Pacific President, Tadashi Tanaka. Surgeons exchanged their clinical experiences in Locking Compression Plate (LCP) systems and Expert Intramedul­ lary Nail Family. Keys to success mentioned in most discussions were good reduction and keeping the reduction by proper fixation, preservation or even reconstruction of the blood supply/vascular­ ity in all structural bone fragments, and good management of soft tissue damages and/or infections. The Asian experts pointed out that certain fracture patterns eg, split lateral wall in interochanteric fractures, are more common in Asian patients and that this has to be considered in future implant developments.

“Osteotomies for Post Traumatic Deformities” by Rene K Marti and Ronald J van Heerwaarden This handbook is a very accessible presentation of a complicated subject matter—deformity and malunion surgery—which is not well covered in standard orthopedic textbooks. The editors have used expert surgeons from the AO network to provide clinical examples and illuminate the decision making process.

The book is divided into two sections. The first covers the prin­ ciples of dealing with deformities, different types of osteotomies, indication for these osteotomies, methods of fixation, as well as an excellent chapter on diagnostics and planning of deformity correction. In the second section, the material is presented in a revolutionary fashion as if the reader were at a master class seminar or a group case discussion with an expert. The type of deformity is introduced, a case described, the diagnosis reviewed, the correction planned and finally images demonstrating how this should be executed, are presented. Finally postoperative docu­ mentation of long term results showing function, complete the case presentation. A summary outlining the pitfalls in each of these problems concludes the section. It is not advisable to treat this as a classic textbook but rather take a patient problem, refer to the index to find a case that best represents it, and then read the appropriate clinical example.

The handbook is aimed at surgeons who are interested in post traumatic deformity, in addition to other deformities, in which a biological nonarthroplasty solution through corrections of the bone is required. This book leans heavily towards open osteotomy and internal fixation techniques rather than external fixation and other methods of deformity correction. The authors are to be congratulated on presenting very complex material in a easily digestible manner.

For more information and to order, please visit www.aopublishing.com

Chairmanship AOSpine TK

Paul Pavlov handed over the chairmanship of the AOSpine TK to Robert McGuire during a meet­ ing in Amsterdam on May 21, 2010—see photo on the right. Paul joined the Spine Expert Group in 1998, be­ coming its chairman three years later. Under his leadership the Spine Technical Commission was established as the first Specialty pillar of the TK System with four dedicated Expert Groups. In this function the AOSpine TK also became the first commission of AOSpine International, of which Paul was a founding member.

Paul saw through many innovative changes such as the integration of neurosurgeons, their techniques and priorities and a dedicated platform for MISS—a process for the assessment of new tech­ niques based on sound clinical experience. The AOTK wishes to thank Paul Pavlov for his great commitment over these years.

TK News 2010

This first combined issue of TK News in years, and the largest in its history, features newly approved products from all Special­ ties, a lead article on the new Angular Stable Locking System for Intramedullary Nails by Dankward Höntzsch and another on bridge plating by Emanuel Gautier.

Changes in the TK Office

Claas Albers is the new Head of TK Office while Karsten Schwieger joined as Expert Group manager with additional responsibilities for project screening and innovation mining.

AO Dialogue 1|10

Page 15

AO Clinical Investigation and Documentation (AOCID)

AO Research Institute Davos

Recent AOCID Highlights

The ARI Medical Research Fellowship program—funded by the AO Exploratory Research Board—is attracting resident and senior surgeons from around the world.

The Trauma Expectation Factor/Trauma Outcomes Measure (TEFTOM) study, investigating patient and surgeon expectations, ran in the USA, Canada, and Brazil from 2006 to 2009. From the first analysis of the TEFTOM results important cultural differences among the respondents were revealed. AOTrauma has mandated AOCID to replicate the study in Europe and Asia.

A total of 14 studies are currently in the planning phase. Among the multicenter studies beginning enrolment in the latter half of 2010 are: VAL CP DR (prospective case-series of patients treated with the Variable Angle LCP Two-Column Volar Distal Radius Plate to evaluate the risk of postoperative loss of reduction); ­Orbita3 (prospective study to compare the accuracy of posttrau­ matic orbital reconstruction of the medial orbital wall and/or the orbital floor with preoperatively preformed versus non-preformed orbital plates); and MFB (randomized controlled study to assess the effectiveness of surgical treatment with Midfoot Fusion Bolt in early stages of diabetic-neuropathic Charcot feet).

AOCID underwent internal restructuring at the start of 2010 in order to better meet its customers’ needs—AO Specialties and external clients now have dedicated contact people for clinical research. The first AOCID customers’ day in April lead to many new ideas and suggestions which will be elaborated on during a June strategy retreat and, due to its success, this event is now set to take place annually. The new role of Business Developer has been created within the AOCID team, underscoring the unit’s commitment to its internal and external customers.

AOCID hosted its 9th research fellow from January to March 2010. Pratik Desai, a 3rd year orthopedic surgery resident from Shands Hospital at the University of Florida, became the first surgeon from the USA to complete an AOCID Clini­ cal Research Fellowship— seen here with AOCID Director, Beate Han­ son. During his stay he developed a solid grounding in clini­ cal methodology and study design.

Finally, Riitta Schmid, who has been responsible for literature services and x-rays at the AO Centre, Davos, is retiring after 16 years working for AOCID. She will be sorely missed by her col­ leagues and many friends at the AO.

(ARI)

ARI Medical Research Fellowships

Some of the many benefits of an ARI Fellowship to a surgeon are: • Creating tangible research results • Possibility of co-authoring publications in medical journals • Learning how to approach future research challenges • Being a member of a multidisciplinary R&D team • Enlarging personal networks for future R&D activities • Having access to research colleagues and mentors Applications from surgeons with independent funding from hospitals, foundations or government grants is encouraged by ARI. More information on the application procedure available at www.aofoundation.org/ari/fellowships AO Veterinary Advisory Committee (AOVAC)

AOVAC evaluates live animal models in AO funded projects. The Committe’s responsibilities include: reviewing and approving Standard Operative Protocols for animal models used, acting as an Institutional Animal Care and Use Committee (IACUC) for AO funded study performed at a site with no IACUC, and serving as an advisory committee for researchers receiving AO funds.

ARI Project Highlight

Thermoresponsive poly(N-isopropylacrylamide) graft hyaluronan ­hydrogel compositions have been developed at ARI—featuring high water content, tissue-like elasticity, tunable diffusion characteristics, favorable tolerance by the body. The biode­ gradable polymeric architecture has been precisely tailored to perform multi-functionalization of the hyaluronan backbone.

The hydrogels can potentially be injected and manipulated at room temperature (liquid state) before solidifying in situ in the body (around 30ºC) without the need of a curing instru­ ment. They could be easily applied at the implantation site of an ­orthopedic device and are promising solutions for cell and drug therapies, tissue engineering grafts as well as local delivery of antibiotics to damaged tissue as a device or coating.

Page 16

AO Dialogue 1|10

Regional highlights My view James F Kellam Editor-in-Chief james.kellam@aofoundation.org

The AO Foundation is once again going through the process of leadership change and being a leader in the AO is a monumental task. Our organization is made up of many leaders worldwide who manage our Specialties and core activities. From this group, leaders are chosen to run each of the various Specialties and Foundation functions and out of this pool of dynamic individuals, one person is elected President.

The President must provide the direction to allow colleagues to contribute to making something extraordinary happen which positively influences the AO and its mission. The President needs to balance the desires and demands of the Specialties with the needs and requirements of the Service and Support Units within the Foundation, while granting them all the appropriate level of independence to be innovative and productive. In addition, our President must also tend to our important relationships with Synthes or other producer/partners. Paul Manson has taken a difficult circumstance, with the recent emergence of the Specialties, and has endeavoured to provide a platform for these groups to work together and with the AO Foundation. We warmly welcome Norbert Haas, our next President, and wish him all the best as he enlists the support of others to make something extraordinary happen within the AO.

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

Impressum AO Dialogue 1|10 Editor-in-Chief: James F Kellam Managing Editor: Olga Harrington Publisher: AO Foundation Design and typesetting: nougat.ch Printed by: Buchdruckerei Davos AG, Switzerland Editorial contact address: AO Foundation, Clavadelerstrasse 8, CH-7270 Davos Platz, Phone: +41(0)81 414 28 14, Fax: +41(0)81 414 22 97, E-mail: dialogue@aofoundation.org Copyright © 2010, AO Foundation, Switzerland

AO Asia Pacific (AOAP) The AOTrauma Asia Pacific (AOTAP) held a remarkable retreat in Kuala Lumpur March 5-7, 2010.

This retreat was a follow up to the AOTAP Extraordinary Board Meeting in September 2009 and the success of this event marked the true transformation of the AOTAP regional board and national country council structure, which was fully aligned with the AOTrauma Transition Board (AOTTB).

The AOTAP regional board and 13 AOTAP country council officers (including chairperson, education officers and community officers) were well accepted as the official regional and national body for the coming two years (transition term).

With this new structure achieved, the AOTAP board and national councils will truly be working as a team in the drive for excellence at AOAP. AO Latin America (AOLAT) In 2010, AOLAT started conducting virtual Board Meetings using state-of-the-art videoconferencing technology, allowing them to advance important issues in various areas at a low cost to the organization.

In keeping with the AOLAT policy to incentivize research, the Region has been offering virtual courses. This provides faculties from Trauma, CMF and Spine access to distance learning courses including Research Methodology and Internet bibliographic database searches at the Virtual Campus of the Hospital Italiano in Buenos Aires. Recent administrative restructuring of the Bogotá office (including new Specialty and Regional Directors, education officers, administrative and accounting assistants), has been undertaken to improve daily operations management and performance for AOLAT. AO North America (AONA) On January 12, 2010, Haiti experienced a magnitude 7.0 earthquake leaving many Haitians dead, homeless or seriously injured. Several groups of AO faculty from New York, Colorado and the University of Maryland’s R Adams Cowley Shock Trauma travelled to Haiti to offer assistance. The New York team, led by David Helfet and Dean Lorich, arrived within two days of the disaster. The Colorado team, led by Richard Meinig, arrived January 25 and the R Adams Cowley Shock Trauma team, led by Andrew Pollak, arrived March 27. The trauma was overwhelming and the surgeons and their team members worked tirelessly. Ex-fix and plate fixations were used to heal fractures when amputation could be avoided. AO North America applauds all of the teams who helped and continue to help the Haitian nation recover from this tragedy.