AO Dialogue 2|10 The newsletter for the AO community
AO Education enters a new era
New initiatives fulfill AO’s mission as an innovator of high-quality educational activities and resources
Education is more than just a course
For nearly half of a century, surgeons and ORP have looked to AO as the leading provider of medical education, and to its traditional courses as the best way to avail of it. However, faced with fast-paced medical developments and mounting practice-based demands, there is a growing awareness at AO that offering courses is not enough. Urs Rüetschi, Director of AO Education (AOE), puts it best: “The needs in the healthcare environment are changing, with different pressures and a constant stream of new technologies and techniques adults seem to learn differently
than in the past and their educational needs patterns have changed.” If a surgeon has a problem today they may look for the solution in a book, on a website, or talk to colleagues. If they decide to attend a course, they would probably opt to prepare with eLearning or Internet-based resources, DVDs, or videos. To answer these demands AOE is adopting a “blended learning” approach —d ifferent learning methods assembled in a way that addresses the learner’s needs. [ continued on page 2 ]
Table of contents Education 1 SIGN 4 AOSEC 6 TK System Focus 8 AO Research Fund 12 Regional Highlights 18 Norbert Haas 24
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Program development–a new approach
Having taken these findings onboard, AOE realized that an entirely new approach to postgraduate training was needed. “We now take a comprehensive view, focusing on developing educational programs, not only individual courses,” Doris Straub Piccirillo, Program Developer in AOE, explains. “This also includes providing all the learning activities or products that can be linked to or embedded in an entire program of study.”
Patient Health Status Clinical Performance Competencies Learning Outcome
Educational Activities
Competencies Learning Outcome Clinical Performance Patient Outcomes
Fig 1
To develop comprehensive programs that offer educational experiences designed to meet practice-based demands is neither quick nor easy. It takes a systematic, ongoing, and interactive approach involving a process that Mike Cunningham and Ursula Brack, newly appointed Program Developers, call “backwards planning”—identifying the health problem and then working ‘backwards’ to devise a solution (Fig 1). Backwards planning is a six-step process
they will then be prepared for worldwide application. AOSpine—with support from AOE Program Development—has started to create a curriculum concept that will lead to a new generation of learning activities and resources. Connecting the Specialties for exchange of best practice
A huge advantage afforded by AOE’s position as in-house service provider is that it operates as an active interface between the four AO Specialties, thus enabling and facilitating the sharing of best practice in program development. An excellent example is the blended approach in the Faculty development program that AOE recently established for AOSpine. While it was AOSpine’s initiative, AO Education used their expertise to build a new series of eLearning modules for Faculty training. AOE then presented the concept to the other Specialties and as a result the team is now building a similar Faculty development program for AOTrauma, adjusted to their particular needs.
which unfolds as follows:
“Program development is a surgeon-driven approach,” states Urs Rüetschi, head of AO Education.
• Identify the problems (clinical issues) or practice gaps • A ssess the targeted learners and the learning environment • Define goals and specific, measurable learning objectives • Develop and assign educational strategies (content & methods) • I mplement the process, which includes securing the support of relevant players (regional education committees, Faculty, internal departments, etc), developing resources, addressing barriers, introducing and administering the program • Evaluate the program and obtain feedback from learners to constantly optimize the program AOE takes a “surgeon-driven approach”— surgeon-led task forces, chosen by the AO Specialties’ education commissions, work together with AOE team members to design, develop, and coordinate each step. This strategy has already been translated into action: initiatives developed in the planning of Principles-level and ortho-geriatrics education will be piloted at the Davos Courses 2010. Following evaluation and adjustments,
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“We constantly synergize between the AO Specialties, who can then benefit from AOE’s accumulated knowledge and expertise. Were they to rely on external consultants, they would have to start from scratch,” Urs Rüetschi points out. The head of AOTrauma’s Education Department, Clint Miner, concurs with this assessment. “The AOTrauma Faculty development project is a good example of the benefits of using a shared service provider,” he says. “We could build upon the experience of another AO Specialty, which definitely made it easier for us.” Blended learning equals more effective
prepared for live events and can instead focus on personal, interactive elements, like sharing feedback and participating in small group discussions.” (Fig 2). Four new eLearning modules for AOTrauma are now in production, involving the newly formed eServices team under the leadership of Michael Redies. “We are using different methodologies, ranging from classical web based trainings to a highly motivational “serious game approach”,” says Pascal Schmidt head of eLearning. A “serious game” uses the principles of game playing for achieving real learning objectives. A prototype of this method, the Müller AO Classification of Fractures, will be launched at the Davos Courses in December 2010 (Fig 3). Also in the works is an “interactive video” on radiation hazards that invites viewers to identify and thereby avoid future errors in the use of C-arm technology during surgery. A large number of lectures videotaped during last year’s Davos Courses can be accessed online by AOTrauma members for self-directed learning or as a source for Faculty when creating their own lectures (Fig 4).
Course Postcourse eLearning
Precourse eLearning
Fig 2
Add to this the upcoming release of eBooks (as part of clinical collections) and the launch of the AO’s first two iPhone applications, and it becomes clear that AOE harnesses the best of modern media to offer surgeons and ORP a wide range of educational tools and techniques. The development of these resources is possible because of a wide range of skill sets in the teams of Kathrin Lüssi (Publications and Faculty Support Media) and Thomas Lopatka (Video Production).
Fig 3
learning
“Faculty development across the AO Specialties certainly benefits from the crossfertilization of ideas and expertise afforded by AO Education’s coordinating role,” says Miriam Uhlmann, Program Developer for Faculty Development. However she believes that where AOE makes the biggest contribution to Faculty development is in providing the latest techniques and tools and combining distance learning with live events. “Now that the theoretical elements of a course are featured online beforehand, Faculty are well
AOE is delivering all this without neglecting its traditional, valued role of supporting course development and delivery of Faculty support media, publishing books and journals, producing DVDs and videos, as well as advancing the ever-popular Surgery Reference and AO Traumaline. “Our strategic goal,” concludes Urs Rüetschi “is to enable the AO Specialties and the AO Foundation to remain world-class educators within their areas of expertise.”
Fig 4 C-arm and radiation
Clickable C-arm and radiation
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Surgical Implant Generation Network (SIGN)
Ponseti Method of serial casting monitored by Pirani’s Clubfoot Score
AO Dialogue-SIGN fellow Bhaskar Raj Pant reports from the 2010 SIGN Conference
Report by AO Dialogue-SIGN fellow Bhaskar Raj Pant and co-researchers at the Philippines Medical Center
“A well conducted orthopedic treatment, based on a sound tion of locally available aquarium pumps, foam and food wraps help to produce good results. Thanks to a SIGN initiative 52 participants attended the Soft Tissue Flap Course organized by the Institute for Global Orthopaedics & Traumatology and University of California, San Francisco prior to the conference. There they learnt different methods of early soft tissue coverage to minimize infections, hospital stays and financial burden to their patients.
Bottom: AO Dialogue-SIGN fellow Bhaskar Raj Pant
Bhaskar Raj Pant, Southern Philippines Medical Center, Davao, Philippines; bhpant@gmail.com
Creating equality of fracture care is the raison d’etre of the annual Surgical Implant Generation Network (SIGN) meeting. The community comprises surgeons from around the world who share a passion to improve the lives of their patients. The 9th Annual SIGN Conference took place in Richland, Washington from Sept 15–18, 2010. The meeting kicked off with a talk on the use of SIGN Nails for antegrade versus retrograde IM Nailing of femoral fractures. This was followed by nearly 60 presentations and workshops over the next three days.
The use of IM Nails versus external fixation, with emphasis on the timely use of antibiotics and role of good debridement, was addressed. The existing classification for open fractures was discussed and a new “AO Open Fractures Classification” was introduced by James Kellam. The keynote address by President of the Orthopedic Trauma Association (OTA) Tim Bray, dealt with issues in the management of hip fractures. Wound Care and Soft Tissue Coverage
The role of negative pressure wound therapy on different extremity wounds secondary to trauma, in combination with dermatotraction, was well explained with case results from Thailand and Philippines. The innovative modifica-
in direction of mechanical stimuli, can gradually reduce or almost eliminate deformities in most clubfeet.” (Ponseti 1996)
Pant Bhaskar, bhpant@gmail.com Reyes Esperidion, info@orthodavao.com
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Department of Orthopedics, Southern Philippines Medical Center,
The classification of pelvic fractures anatomy was explained by OTA Past President David Templeman, and the role of “Sheet Binder” in emergency management was emphasized. The different management of pelvic ring injuries both with and without C-arm was analyzed.
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Davao, Philippines.
Spine
An update on the developments in spine trauma was presented by Jens Chapman while surgeons from the Philippines presented on cervical facet dislocation and spine trauma care in developing countries with the help of Orthopedics Link.
The aim in management of pediatric femur fractures is to restore length, alignment and rotation by preventing osteonecrosis and physeal injury. The different techniques of management in developing countries were discussed with the experience of Ender nailing from the Philippines. Lou Zirkle demonstrated the uses of the new paediatric nail (designed by and exclusive to SIGN) which comprises a combination of the SIGN-Fin nail and a flexible nail. A number of presentations focused on the functional anatomy of club foot, Pirani Scoring, Ponseti manipulation with serial casting, tenotomy, bracing and treatment of relapse. All the participants shared their experiences during the workshop on Ponseti manipulation and casting and common errors were discussed.
Pre-Casting Two week old baby with bilateral clubfoot
KK: Clubfoot Scores with Ponseti Treatment
Valera Carlito Jr, info@orthodavao.com
Pelvis
Paediatric Open Fractures
biological response of young connective tissue and bone to changes
Clubfoot is easily corrected when the functional anatomy of the foot is well understood. The completely supinated foot is abducted under the talus which is secured against rotation by the ankle mortise. With the application of counter pressure by the thumb against the lateral aspect of the head of the talus, the varus, inversion, and adduction of the hindfoot are corrected simultaneously. This is because the tarsal joints are in strict mechanical interdependence and cannot be corrected sequentially. Most clubfeet correct with about five cast applications. The first cast corrects the cavus. Subsequent casts correct the adduction and varus by progressively abducting the foot. The last cast, in combination with tenotomy, corrects the equinus. There are three phases to applying each cast: manipulation, applying padding and plaster, and moulding after the cast is applied. Different hand positions are required for each phase. Reliable valid measurements are key to science. The Pirani Clubfoot Score is a simple scoring system which measures the amount of clubfoot deformity. The six clinical signs seen in all clubfeet, that change in severity as the foot deformity changes, are each scored 0 (normal), 0.5 (mildly abnormal) or 1 (severely abnormal). Scoring the foot at every visit helps indicate to the treating practitioner if deformity is correcting satisfactorily and
4 Score
Top: SIGN conference organizers and attendees
understanding of the functional anatomy of the foot, and on the
CHS CMS CTS
3 2 1 0
1
2
3
4
5 - tal 5 + tal
Weeks of Treatment Fig 1 CHS – Clinical Hindfoot Score; CMS – Clinical Midfoot Score; CTS – Clinical Total Score
Casting 1st casting, April 2, 2008
when achilles tenotomy is indicated. Scores and graphs are part of the patient’s notes allowing the clinicians and parents to monitor the progress of treatment. All serial Ponseti castings from the Davao Clubfoot Club at the Philippines Medical Center, where the research was undertaken, were analysed as per Pirani’s Score (Fig 1). Among 57 patients enrolled, 54 feet were corrected. Only three clubfeet required surgical correction. There were six relapses, the cause being lack of compliance with the foot abduction brace regimen. Based on this level of initial success, we believe that surgical release is no longer necessary for the majority of cases of congenital clubfeet. Ponseti Serial Corrective Casting when monitored with Pirani’s Score allows adequate monitoring, meaningful comparison of results, to know when tenotomy is indicated and to reassure parents regarding progress.
Post-Tenotomy 2nd casting , June 2, 2008
Brace Application of typical cast brace July 1, 2008
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AO Trustees made generous donations to the Malawi fund during the June 2010 Trustees Meeting
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Techniques and Principles for the Operating Room by Matthew Porteous and Susanne Bäuerle
Jim Harrison, reports on how these funds are being put to use The Techniques and Principles for the Operating Room book was conceived as a guide for operating room personnel (ORP). However residents embarking on an orthopedic career will also find it an excellent introduction to trauma surgery.
Jim Harrison, third from left, with members of the AOSEC Africa Steering Committee
New Tanzanian fellow, Deo Masatu
Jim Harrison, AOSEC Africa representative
In July 2010 I had the privilege of being invited by, the then, AO President Paul Manson to speak at the AO Trustees Meeting in Lisbon on the topic of “What should the AO reasonably do for the developing world?” As a result of living and working for a decade in Malawi, I know the answer to this question is not an easy one. Paul Demmer, recently retired Chair of the AO Socio Economic Committee (AOSEC), and I have spent hours discussing this issue. Most aid to Africa fails to make an impact or indeed makes things worse. It fosters helplessness, or worse corruption. In AOSEC we have sought to make partnerships to help Africa to help itself—a slow and steady approach. On presenting such a challenge to the Trustees, and with immediate affirmation from AO Foundation founding member Thomas Ruedi and Paul Manson, the Trustees responded with a free-will donation, amounting to CHF23,873, from their own pockets. So how will we use the money? To help Africans to help themselves, naturally! So far I have hosted a meeting of the newly formed AOSEC Africa Steering Committee—a group of three doctors and one nurse leading various aspects of the development work. This gives us
a structure within which to grow our effectiveness and have an impact across the continent. A Zimbabwean nurse, Cebelihle Ndlovu, has been sponsored to participate in our first regional nurse fellowship hosted at Beit Cure International hospital, Blantyre Malawi. The fellowship culminated in Cebelihle taking part as junior faculty in our local ORP course. Our hope is that she and her colleagues from Bulawayo will host the first ever ORP course in Zimbabwe next year. We are discovering that teaching is essential but only contributes to an on-going transformation when balanced with continuing supportive friendships. Regional doctor fellowships, hosted in Pretoria, South Africa, have been established for some years now. Such has been the impact of these fellowships, that all our AOSEC Africa Steering Team are actually former fellows. We have now been able to start a fellowship programme in Blantyre, and last week we welcomed Deo Masatu from Tanzania to start a six month fellowship here. The donation from the Trustees has spurred a gentle acceleration in the process of Africans teaching and encouraging fellow Africans in the face of the huge challenge of caring for our trauma patients. Thank you!
The book is divided into three sections. Section one covers the management of a trauma operating room. It contains units on conduct, organization and the use, storage and sterilization of equipment. Section two outlines the basic principles of trauma care; written by experienced trauma surgeons it explains the rationale behind various treatment options in a way that assumes little prior knowledge of the subject. Section three is a guide to common trauma operations. A special feature of this section is the full-color illustrations of all instruments and implants for 38 trauma operations. Each operation is outlined in an identical format covering: indications for surgery, patient and x-ray positioning, anesthesia, disinfecting and draping, OR set-up, as well as a structured step-by-step guide to the procedure itself. Of special interest are the “key points” to surgeons and ORP in every chapter. It is lavishly illustrated not only with line drawings, for each step of the procedure, but also with photographs of each piece of equipment used.
“I consult this book to answer questions or to complete information that I need to apply in my job. It is very useful for the preparation of ORP training programs. The basic concepts are clearly explained and it gives good direction on how to standardize patient care and safety in the operating room,” according to Myriam Sanchez, ORP, Chile.
“It works like a bridge between students, who are making a decision about what kind of specialty they should choose; residents who are making their first steps in trauma and orthopedic surgery; ORP who are trying to achieve the best result in surgery and some experienced surgeons, who need a quick refresher on specific knowledge in special fields,” says Andrey Volna, surgeon, Russia.
For more information and to order, please visit www.aopublishing.com
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AOFoundation TK System Focus An overview of the most important areas of CAS technology development Assisted Surgery Expert Group (CSEG). Since its first meeting in February 2001 this group has been an integral part of the AO TK System. The other specialties addressed this area by appointing their own dedicated groups on CAS development: The Computer Assisted Surgery Working Group (CAWG), chaired by Alexander Schramm represents craniomaxillofacial interests. For spine surgery projects the Access & Navigation Expert Group (ANEG) was active from 2005-2009. Although the group has now been dissolved, their CAS projects were assigned to the remaining expert groups and its chairman Frank Kandziora represents this field of activity with his membership on the AOSpine TK.
Co-author Hüfner with CSEG chairman Krettek and member Gebhard at a CSEG meeting
Tobias Hüfner, Unfallchirurgische Klinik Medizinische Hochschule Hannover
software and the surgeon in the operating theater, thus enhancing the surgery quality.
Amir Matityahu, Director of Education, San Francisco General Hospital, Department of Orthopedic Surgery
History
Claas Albers, Director TK System, AO Foundation
In recognition of the growing significance of CAS technology to its members, the AO Foundation set the scene to develop projects in this area more than a decade ago. The Academic Council initiated a steering committee lead by Christian Krettek (Director of the Department of Trauma and Orthopedic surgery, Medizinische Hochschule Hannover, Germany), and established a collaboration with the Maurice Mueller Research Center University Berne, Switzerland. These initiatives and the strategic paper “Technology Integration” coauthored by Tim Pohlemann, today’s TK Executive Board Chairman, together with Lutz Nolte and Markus Hehli lead to the founding of the Navigation and Robotic Expert Group (NREG.) which soon became the Computer
When discussing computer assisted surgery (CAS), most people immediately think of navigation—used as a nice tool for inserting cannulated screws, yet complicated and not particularly useful. However, CAS has far more to offer. It is a developing field that integrates fluoroscopy, CAT scan (CT) and computers, with remote sending to assist the surgeon in the pre-operative digital surgical planning, the intra-operative navigation of reduction, alignment of long bone fractures, minimally invasive hardware insertion, and intra-operative post-fixation three dimensional (3-D) control. Current systems are more seamless and easier to use than earlier set-ups with an enhanced technological interface between the
As with all activities within the TK System, the AO Foundation’s main industrial partner Synthes Global is represented in these groups. Since 2004 the main projects are also developed with BrainLAB AG (Feldkirchen, Germany). All projects in these groups are managed according to the established TK Milestone Concept, allowing the medical members the major decisions making power within the development process (project authorization, design freeze, TK approval) thereby ensuring products are developed according to clinical needs rather than market requirements. Activities
Computers provide various options to make surgical procedures more effective, covering all aspects of surgery from planning to postoperative control. The following sub-sections provide an overview of the most important areas of CAS technology development. Surgical Planning
Modern surgical planning tools use digital x-rays and CTs in conjunction with implant databases to plan the fracture reduction and ideal implant selection (Fig 1). The pre-opera-
Fig 1
tive images are imported into a computer program that gives the surgeon the opportunity to mark the fracture lines and virtually reduce the fragments. The orthopedic surgeon then performs a virtual osteosynthesis planning the reduction maneuvers and choosing the correct implant. Anatomical CT based datasets of numerous specimens serve as 3D templates for contouring implants. The surgeon can then share the surgical plan with other surgeons and operating room staff. This saves valuable time, increases surgeon and hospital efficiency, and decreases intra-operative er-
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Fig 3
rors. Only last year iPlan 3.0, a comprehensive tool for pre-operative planning became the first TK approved CAS tool for craniomaxillofacial procedures. Intraoperative Navigation
Navigation is an intraoperative creator of a virtual 3-D space that provides the surgeon with a reduced radiation visualization and manipulation tool. The surgeon works in the virtual space and can reduce fracture fragments, accurately reconstruct rotation, length, and alignment, and then use navigatable tools to insert implants without the need to continually use x-rays (Fig 2–6). The preoperative surgical plan and imaging can be combined to achieve exceptionally accurate placement of implants with visualization of surgically relevant information. Specific fractures that can routinely be treated with computer assisted navigation are sacral/pelvic (Fig 2), acetabular (Fig 3), hip, and long bone fractures (Fig 4, 6). Moreover, the total leg axis in high tibial osteotomies (Fig 5) and long bone fractures (Fig 6) can be accurately planned preoperatively and assessed intraoperatively to within 1–3°. In all cases of computer assisted navigation osteosynthesis, an important step is the registration process that fuses the patient data (ie, pelvis, spine, long bone) with the images. Commonly, trauma surgery imaging is via intraoperative fluoroscopy. Two dimensional navigation systems import images in
Fig 4
multiple planes and display them to the surgeon on one screen. The operation can then be performed without additional images. This has the potential of reducing intraoperative radiation and increasing efficiency. CT imaging from intraoperative melding of multiple fluoroscopic views (3-D imaging) can also be imported into the navigation systems. In patients with pelvis and acetabular fractures, this can be an invaluable tool. For instance, when inserting iliosacral screws (SI) into a dysmorphic sacrum, the corridor for screw insertion after reduction may be very narrow and in an unusual trajectory. In order to avoid neurological injury to the L5 or S1 nerve roots, intraoperative CT scans can be performed, imported into the navigation system software, and the iliosacral screws placed into this corridor accurately (Fig 7). Moreover, when fluoroscopic imaging of the sacrum is obscured by bowl gas, intraoperative CT reconstruction with navigation can allow the surgeon to safely place SI screws.
in an intuitive, easy to use, and reliable application. The interface provides only relevant information needed by the surgeon to perform the operation with a simple, intuitive, stepwise progression during the surgery (Fig 5). Moreover, the workflow can be individualized to suit each surgeon and operation or can by used as a generic tool. Well known Synthes instruments have been modified to allow a smooth interface with the navigation system (Fig 6). Therefore, the virtual visualization of almost every percutaneously jig driven implant is supported by this module. Intraoperative 3D Imaging For Articular Reduction
Articular fracture reduction can be difficult to assess during an operation. For instance, in
Fig 5
a complex tibial plateau fracture, intraoperative visualization may be limited and fluroscopic images may not reflect the 3-D problem in an adequate fashion. Some studies report 20-30% intraoperative revision rate due to malreduction or implant malplacement. The introduction of 3-D C-arms has enhanced the quality of articular facture visualization (Fig 7). Although long term studies describing the outcomes after intraoperative CT scanning are lacking, this may translate to a significant improvement for the patient and help to reduce long term costs. The future implementation of computer assisted navigation of orthopedic trauma surgery lies not only in long bone reduction, alignment, length, and insertion of implants but also in articular reduction.
Interfaces
Navigation is meant to provide more information in an intuitive way that may not be provided by fluoroscopic imaging alone. Recently, through a collaboration between the CSEG, BrainLAB, and Synthes, the new Trauma 3.0 module was developed to enhance the interface between the surgeon and the navigation software. The experience and competence of the surgeons and the producers has resulted Fig 6
Fig 7
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The AO Research Fund (AORF)
New central peer review process for the AO Foundation
A history from 1983–2010
The newly formed AO Research Review Commission (AORRC) launches its operations on January 1, 2011
Adrian Sugar, AORF Commission Chairman
At the end of 2010, The AO Research Fund (AORF) will cease to exist as a legal and eponymous entity. However, with some changes in personnel, it will continue its work as the AO Research Review Commission (AORRC). The AORF Commission was established in Bern on January 22, 1983 as the Forschungskommission der AO Stiftung (FORK). Its first chairman was Martin Allgöwer and its ten other members were Walter Bandi, Robert Mathys, Peter Matter, Maurice Müller, Stephan Perren, Peter von Rechenberg, Robert Schneider, Fritz Straumann, Hans Willenegger, and Hansjörg Wyss. Allgöwer handed over the chairmanship to Reinhold Ganz in 1985 and Ganz remained chairman for following twelve years, succeeded by Otmar Trentz from 1997 to 2000.
Top: Handover on November 5th with Adrian Sugar and Mark Markel Bottom: Attendees of the last AORF meeting in November 2010
My first contact with AORF/FORK was as a successful applicant for a research grant which I received from, the then Commission Manager, Margrit Jaques. In 2001, I was nominated and then elected to the Commission, succeeding Joachim Prein. Initially the CMF and Spine groups were not represented on FORK and Professor Prein was the sole CMF commission member prior to me. I attended my first meeting during Otmar Trentz’ tenure and discovered a chairman with the utmost integrity, commission members with a broad range of surgical disciplines and pure scientists who constantly challenged our assumptions. I made the mistake, as did many other new members, of not realising how high a standard of reviewing was expected of me—nor how
vigorously I would have to defend my opinions. During a typical four to five hour meeting we discussed 40 to 50 grant applications and needed to make clear decisions. It always amused me when we were accused of favoring friends. Some of those accusers were the first to complain when their own applications or those of their friends were rejected. Chris van der Werken took over the reins for a short while in 2004, during which time a successor to Prof Trentz was elected. I took over the chairmanship in 2005 and was immediately involved in a major reorganization at the instigation of the AO Board of Directors and the Academic Council. AORF boosted its Speciality representation and became more professional. We introduced larger Focus grants for experienced researchers in the clinical priority fields of the Specialties. I acknowledge the excellent collaboration that I had with Anita Anthon in bringing this new professionalism into play. Our budget was never enough—it never could be. Yet in the past 28 years we have provided CHF 51.116 million of funds to 976 applicants. There has been a real camaraderie among Commission members. Every member is a working member with specific reviewing and decision making responsibilities. Consequently members conclude the meetings with the sense that they have really achieved something. The majority of members are from the Specialties and they always feel very close to their interests. I am sure that with their scientist colleagues, under the leadership of Mark Markel and with the support of Anita Anthon, this spirit of collaboration will continue into the AORRC era.
Wouter Dhert
Torsten Reichert
Stephen Ferguson
James Stannard
Steve Krikler
Henk Jan Ten Duis
The AO Research Review Commission (AORRC) was created to implement a new centralized review process for all research supported by the AO Foundation. The AOVA elected Mark Markel as Chairman of the AORRC effective January 1, 2011. Organizational and administrative support will be provided by Commission Manager, Anita Anthon.
Mark Markel
Ivan Martin
Ingo Marzi
Christof Mueller
In addition to the AORRC members seen here, newly elected members David Grainger, Manabu Ito and Emre Rifat Acaroglu will start their term in January 2011.
The AORRC is an independent group of worldclass scientists, researchers and clinicians and is currently co-chaired by Adrian Sugar and Mark Markel. The AORRC will issue calls for the AO startup grants on the same basis that it did for the AORF. All research grant applications will be discussed by the AORRC resulting in recommendations to the relevant funding body or AO Foundation research units. The funding body decides on funding based on the recommendation provided by the AORRC. The AORRC has recruited over 400 external reviewers to date to ensure that all AO research projects are assessed and evaluated by experienced reviewers who are experts in their chosen field. The AORRC anticipates at least two review processes in 2011 with deadlines of February 15, 2011 and July 15, 2011. The review process takes approximately four months to complete. The AORRC looks forward to working with clinicians and scientists from around the world in order to support the most innovative and clinically relevant projects possible for the AO and its mission.
The goals of the AORRC: • To ensure the highest possible quality of research supported by the AO Foundation • To implement an independent peer review process that meets international standards of impartiality and expertise
When asked about the AORRC’s mission, Mark Markel declared that, “I’m excited about the future of research at the AO Foundation and • To separate grant reviewing the role that the AORRC will serve in the new from funding decisions central peer review process. I’m particularly • To establish a central register pleased to continue the long history of the AO of all research projects within Research Fund (AORF) and its role in the peer the AO Foundation review process. I would like to acknowledge Adrian Sugar’s vision, both during his tenure as Chair of the AORF and in his role assisting in the creation of the AORRC. The new central peer review process would not have been possible without the joint efforts of the AO Specialties and other vested partners in AO who helped create this vision. I would also like to thank the AOVA The peer review process will be initiated by the AO Specialties, the AO Exploratory and other leaders in Research Board and other funding bodies of the AO Foundation who will issue the AO Foundation individual calls for proposals as appropriate to their body. Proposals will be for their support of independently reviewed by at least two external experts and will be consolidated by a this new centralized peer review process.” composite reviewer who will be a member of the AORRC.
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Berton Rahn Research Prize: award winner summary
Teppo Jarvinen, Department Orthopedics, Tampere University Hospital, Tampere, Finland; teppo.jarvinen@uta.fi
Estrogen, locomotion and their interaction are true bones of contention. Wolff’s Law of “form follows function”, the operating principle of the loading-driven feedback system responsible for the mechanical integrity of the bones, was introduced over a century ago and has since become an axiom in skeletal biology. Estrogen, the primary female sex hormone, has been suggested to exert its influence on skeletal homeostasis by increasing the sensitivity of this mechanical control system. Subsequently, one of the leading pathomechanistic proposals for postmenopausal osteoporosis has been that the withdrawal of estrogen at menopause desensitizes bones to loading-induced stimuli [1]. However, we have previously shown that estrogen per se has little, if any, primary effect on the mechanoresponsiveness of bones [2]. In fact, using a novel approach of assessing bone strength relative to the locomotive loading to which they are subjected, we discovered that estrogen simply deposits an extra stock of bone in the female skeleton around puberty and then maintains this mineral until menopause—an apparent safety deposit for the purpose of reproduction. This bone stock is then shed at menopause, when it becomes redundant from the reproductive perspective, marking the beginning of postmenopausal osteoporosis [3].
Teppo Jarvinen receiving the Berton Rahn research prize award from Adrian Sugar
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The objective of the present series of experiments was to either prove or disprove our hypothesis on the skeletal effects of estrogen, and accordingly, on the pathogenesis of postmenopausal osteoporosis. We hypothesized that if estrogen and loading were indeed coupled in the regulation of bone mass/strength, then their respective inhibitory/stimulatory effects should become distinct after their separate or combined removal. Before we could proceed with these experiments, we had to justify our unconventional approach of evaluating bones as locomotive structures, rather than focusing on charac-
Skeletal effects of estrogen
terization of various complex microstructural features of bones—an approach that seemed to be the trend in skeletal biology at the time (and still is). As a prologue to our actual experiments on the skeletal effects of estrogen, we published an editorial entitled “Revival of Bone Strength: the Bottom Line” [4], summarizing our approach to evaluating bones. Our pursuit of more appropriate research methodology also led to the development and validation of a novel biomechanical testing protocol of rat femoral midshaft: Instead of the conventional testing in anteroposterior (AP) axis, we showed that rat femurs should be tested in mediolateral plane [5]. We also devised a tool for all researchers working with the biomechanics of bones to calculate the minimum sample size (study power) needed to detect a treatment effect in biomechanical traits with statistical significance [6]. After all this work validating our research setup, we were able to prove our main hypothesis on the skeletal effects of estrogen, ie, that the loading-induced effects on bones were virtually identical in both the estrogen-replete and estrogen-deplete animals [7]. Our data challenges the alleged modulatory effect of estrogen on skeletal mechanosensitivity. Contrary to the prevailing view [8], estrogen was not shown to have an independent effect on the
cross-sectional geometry of bones. Instead, according to its primary reproductive function, the skeletal effects of estrogen were shown to be restricted to accrual of bone mass only (reb productive skeletal hormone) [3,7], and mostly at the biomechanically less relevant endosteal bone surface [9]. During the AO funding period, we addressed ab couple of myths about osteoporosis:
Bone qualit y was a widely embraced concept in 2005 as it was said to of fer a solution to the classic paradox of osteoporosis: While low bone densit y (BMD) values are associated with increased relative risk of fracture at the population level, the predictive value of BMD in an individual patient remains quite marginal. We argued that the entire concept is an “empt y term”—similar to the Emperor’s new clothes in the Hans Christian Andersen children’s fair y tale [10,11]. Our proposal for the pathogenesis of postmenopausal osteoporosis was claimed to be flawed based on apparent paradox: Why do women sustain more fractures (have more fragile bones) than men, if we claim that they have stronger bones due to estrogen (at least relative to the locomotive-loading to which they are subjected)? Our response [12,13] highlighted that falling, not osteoporosis, is the most important risk factor for elderly fractures.
References: 1. Lee K, Jessop H, Suswillo R et al (2003) Endocrinology: bone adaptation requires oestrogen receptor-alpha. Nature; 424(6947):389. 2. Järvinen TL, Kannus P, Pajamäki I et al (2003) Estrogen deposits extra mineral into bones of female rats in puberty, but simultaneously seems to suppress the responsiveness of female skeleton to mechanical loading. Bone; 32(6):642–651. 3. Järvinen TL, Kannus P, Sievänen H (2003) Estrogen and bone—a reproductive and locomotive perspective. J Bone Miner Res; 18(11):1921–1931. 4. Järvinen TL, Sievänen H, Jokihaara J et al (2005) Revival of bone strength: the bottom line. J Bone Miner Res; 20(5):717–720. 5. Leppänen O, Sievänen H, Jokihaara J et al (2006) Three-point bending of rat femur in the mediolateral direction: introduction and validation of a novel biomechanical testing protocol. J Bone Miner Res; 21(8):1231–1237 6. Leppänen OV, Sievänen H, Järvinen TL et al (2008) Biomechanical testing in experimental bone interventions—May the power be with you. J Biomech; 41(8):1623–1631. Epub 2008 May 5. 7. Pajamäki I, Sievänen H, Kannus P et al (2008) Skeletal effects of estrogen and mechanical loading are structurally distinct. Bone; 43(4):748–757. Epub Jun 20. 8. Seeman E (2003) Periosteal bone formation—a neglected determinant of bone strength. N Engl J Med; 349(4):320–323. 9. Leppänen OV, Sievänen H, Jokihaara J et al (2010) The effects of loading and estrogen on rat bone growth. J Appl Physiol; In Press. 10. Sievänen H, Kannus P, Järvinen TL (2007) Bone quality: an empty term. PLoS Med; 4(3):e27. 11. Järvinen TLN, Kannus P, Sievänen H (2008) Bone quality: Emperor’s new clothes. J Musculoskelet Neuronal Interact; 8(1):2–9. 12. Kannus P, Sievänen H, Palvanen M et al (2005) Prevention of falls and consequent injuries in elderly people. Lancet; 366(9500):1885–1893. 13. Järvinen TL, Sievänen H, Khan KM et al (2008) Shifting the focus in fracture prevention from osteoporosis to falls. BMJ; 336(7636):124–126.
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From the AO Service Units AO Education
(AOE)
New AO “apps” for trauma surgeons
AO Education and AOTrauma have launched an iPhone application (“app”) offering trauma surgeons on-the-go access to the Müller AO Classification of Fractures–Long Bones. “The app reflects the high-quality standard of our medical illustrations and also displays good-quality x-rays,” say the two project managers Kathrin Lüssi and Rudolf Elmer of AO Education. Version 1.0, in English, of this app is available exclusively through the Apple iTunes App Store (an iTunes account is required). It is compatible with the iPhone, iPod Touch and can be used on the iPad as well. Each main fracture is presented with a text description, a line diagram, and in most cases an x-ray and/or CT scan. In addition, users will find detailed text-only information on fracture subgroups. At the same time the first release of the “AO Surgery Reference” app will also be available from December 2010, providing access to core Surgery Reference content a surgeon’s fingertips.
AO Surgery Reference: building on synergies
AO Education’s award-winning AO Surgery Reference has just launched its latest module, on the Foot. Under the executive editorship of Joseph Schatzker, authors Richard Buckley and Andrew Sands have covered the surgical management process for fractures of the talus, calcaneus, and midfoot. Modules on the pelvic ring and the skull base are under preparation. This rigorous approach explains why AO Surgery Reference remains a favorite resource for trauma and CMF surgeons: more than 1, 500 users visit every day, calling up more than 15,000 pages, and most return on a regular basis. These numbers bode well for the reception the forthcoming AOVET modules will receive when they are added in the months and years ahead. The relationship between the Surgery Reference team and the AO Specialties is “highly synergistic”, says Tobias Hövekamp, Team Leader AO Surgery Reference. “We can hugely profit from what we did for AOCMF and AOTrauma—building on the strengths and avoiding the shortcomings—when we build modules for AOVET, and, hopefully, eventually for AOSpine.”
AO Technical Commission
AO Clinical Investigation and Documentation (AOCID)
(AOTK)
5th European Experts´ Symposium
The Fifth European Experts’ Symposium took place in Mainz, Germany, on October 1–2, 2010. Chaired by Tim Pohlemann, Dankward Höntzsch, and Pol Rommens, 58 surgeons from 19 countries exchanged their clinical experiences in locked plating and intramedullary nailing. Clinical issues, problem fractures, complications and limitations of the existing techniques were discussed by case presentations. The screening of clinical problems at an early stage triggers further developments. As part of the success control of the TK System this was the second of three symposia worldwide with identical programs. The results will be compared to analyze regional differences.
Studies
The final report of the sacroiliac screw study has been completed. This randomized multicenter trial evaluated the precision of sacroiliac screw placement using computer-assisted navigation compared to the conventional technique. Two new studies have begun recruitment. Midfoot Fusion Bolt (MFB) is a randomized controlled multicenter study to assess the effectiveness of surgical treatment with MFB in the early stage of diabeticneuropathic Charcot feet. Orbita3 is a prospective multicenter study to compare the accuracy of orbital reconstruction after fractures of the medial orbital wall and/or the orbital floor with preoperatively preformed versus non-preformed orbital plates. Study Center Certification Project
In proximal humerus, additional lateral tension bending/use of sutures provides better results. The amount of screws in the plate head was discussed controversially and aside from the number, the geometric configuration and directions seems to have a major influence on secondary joint penetration. In proximal femur the surgeon should always use the longest suitable implant (regardless of plate or nail) and locking screws far away from the fracture zone will lower the risk of implant breakage. ASLS may be beneficial in reducing pain due to fracture movement and might have a beneficial influence in prevention of nonunions. In tibia plateau fractures a detailed analyses of fracture type and injury mechanisms is still important as also angular stable implants have to be placed in biomechanically optimal positions to avoid secondary displacement (‘posterio-medial buttress’). In nailing of the proximal tibia, what is the best approach is still under discussion. Poller screws might help to improve indirect reduction and avoid malalignment by nail insertion. If anatomically pre-shaped plates do not fit well, eg, small stature patients, malreduction may result when the plate shaft is brought down to the bone. Therefore anatomical variations have to be considered even when using ‘anatomically shaped’ plates. In the distal tibia, plating has become more successful with MIO technique. The low bend distal tibia plate showed promising results. Gap free reduction is still recommended. In simple fractures types, bridging plates seemed not to be sufficient for adequate healing reactions. If intramedullary nailing is used as a treatment in this anatomical region, ASLS is very promising but, nevertheless, the correct nail position remains essential (deep enough and centralcentral). Additional fibular plating remains controversial.
Over time, AOCID has been able to collect a substantial amount of study-related data concerning the quality of performance and cooperation of >200 participating study centers. Using the existing “Reference Clinics Database” and based upon input from AO Specialties and the Regions, a decision was made to introduce a system for clinics as well as personnel directly involved in clinical studies to be certified by AOCID. Work on the concept is at an advanced stage. Presentations to the relevant internal AO bodies are ongoing and very positive feedback from sites and surgeons has been received. The first pilot certifying visits have already been made to sites in Switzerland and Singapore and a full launch is planned for 2011. Awards
Sabine Goldhahn, AOCID’s Senior Research Scientist and Japan specialist recently collected the Best Poster Prize at the Conference of the International Society for Fracture Repair (ISFR) in London. Cross-cultural adaptation and validation of two knee function scores for Japanese-speaking patients sprang from research conducted by Dr Goldhahn, R Takeuchi, N Nakamura, H Ishikawa, and T Sawaguchi. Gerhard Konrad won the best presentation award at the annual congress of the German Society for Shoulder and Elbow Surgery. He presented the results of an AOCID multicenter study on functional results and complications in the use of Locking Proximal Humerus Plate (LPHP) on behalf of his co-authors P Hepp, C Voigt, N Südkamp et al.
AO Research Institute Davos
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(ARI)
Extramural Funding
ARI has received two major European funding grants from the European Commission (FP7) to fund the program area of Biomimetic gels and polymers for tissue repair. Project 1—Gene Activated Matrices for Bone and Cartilage Regeneration in Arthritis with EUR 493,000 granted over three years. Project 2—Biomimetic nano-fiberbased nucleus pulposus regeneration for the treatment of degenerative disc disease with EUR 532,000 granted over three years. TK Innovation Prize 2010 awarded for the “Playground”
Playground / OSkill is a technical training ground for trauma surgeons with a focus on manual surgical skills to enhance principles knowledge through practical hands-on exercises. This innovative mode of surgeon education has been running for several years and can be seen in action at many of the courses in Davos in 2010. It won the prestigious award TK Innovation Prize 2010, awarded during the 2010 Trustees Meeting in Lisbon, Portugal. eCM Impact Factor
eCM, published by ARI, is a True Open Access electronic journal with zero submission, publishing or accessing fees. Due to its rigorous, detailed and rapid review process eCM has seen its impact factor to 5.378, making it number one in Trauma research. eCM XI and EORS2010 Conferences
eCM XI was held in Davos from June 28 to June 30, 2010. Around 150 participants, including biologists, clinicians, engineers, and material scientists attended the meeting, encouraging multidisciplinary discussion and networking. The single sessions promoted exchange of expert knowledge in basic, translational, and clinical research in the field of traumatic and degenerative disc and cartilage diseases. Specific topics included the development, maintenance and degeneration of cartilage and disc, as well as scaffolds, mechano-regulation, clinical problems, and repair. The conference ended with sessions on clinical aspects and future repair approaches. eCMXI was followed by EORS2010, the 18th conference of the European Orthopaedic Research Society (EORS), organized by ARI, it was attended by more than 300 researchers and clinicians. EORS2010 had 100 oral and 140 poster presentations, in addition to the 17 invited keynotes lectures.
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Regional highlights AO North America (AONA)
AO Dialogue 2|10
and structured approach for AONA faculty to advance within the organization; collaboration with the AOF while respecting compliance requirements; allowing and enhancing cross specialty cooperation in North America.
The Power of Synergy—Working Together for a Stronger Tomorrow was the theme of the AONA sponsored scientific meeting
Co-Management of the Geriatric Fracture Patient course report
organized by AONA in Phoenix, Arizona on November 11–14, 2010. This is the first time AONA has designed a meeting to bring s urgeons in orthopedic trauma, craniomaxillofacial and veterinary surgery together to discuss challenges in musculoskeletal fracture management in an open, peer-reviewed, cross-specialty, scientific meeting. Over 200 participants attended this first successful meeting, showing the synergy that exists between the different specialties in the realm of basic science. It also demonstrated the similarities in practice and in particular the complications that surgeons face across disciplines. Interactive discussions amongst the specialties lead to new ideas for each group. As well as the scientific content, plenary lectures by AO Foundation Past President Paul Manson, Director of AO Trauma Education Steve Schelkun and President of AONA Jack Wilber, showed the AO spirit and the need to continue to strive to ensure that AO can deliver on its mission to improve patient care for those injured or crippled by musculoskeletal disease and injury.
is Professor of Orthopaedic Surgery and Rehabilitation at Yale School of Medicine in New Haven, Conneticut and is the current Chair of the North American Musculoskeletal Trauma Education Committee. He will succeed Jack Wilber at the 2011 Trustees Meeting in Berlin.
by orthopedic surgeon Joshua Patt. For the past 16 months I have been part of a team working towards the development of a geriatric fracture service at my hospital. Working with a multidisciplinary team proved challenging as each team member was outwardly enthusiastic about the project but maintained a self-protectionist stance with regard to his or her subspecialty. As I struggled to keep moving the project forward I found that the biggest obstacle to progress was rooted in the classic hospital turf wars. To move forward we needed to shift the paradigm and remove the pre-existing stigmas of my job and your job, as well as the risk aversion and self-protectionist strategies we have been historically taught to employ. Having recently returned from the comanagement of the geriatric fracture patient course in Arizona in September, I have realized that I went about this process in the wrong order. The course co-directors Stephen Kates and Daniel Mendelson have put together an interactive meeting that teaches the participants how this process can only happen with open communication and partnership between specialties. The curriculum, with its combined expertise of surgeons, medical doctors and even an anesthesiologist, allow recognition of the challenges that all parties face to provide efficient surgical care. The concept of co-management allows for a more systematic, protocol driven care that has been proven to improve patient outcomes and more importantly patient satisfaction. My only regret is that I was unable to convince any of the internists from my institution to join me at the course.
A new governance structure for AONA presented by AONA Presi-
Profile of a giant in the world of AONA
dent Jack Wilber. Introduced at the AO North American Trustee
“Who’ll be the next Ted Hansen?” At the end of 2010, the AONA “Father of Traumatology,” Sigvard “Ted” Hansen, retires from full-time practice. His innovations of aggressive and expeditious orthopedic care of polytrauma patients revolutionized the field. Up to his retirement Ted has served as Professor and Director at the eponymous Sigvard T Han-
Michael R Baumgaertner is now President-Elect of AONA. Baumgaertner
Council meeting in Lisbon in July 2010, all specialties had reviewed and tentatively accepted the structure pending final approval by the AONA Trustee Council. The new structure has significant benefits for the specialties including allowing for adaptability to unique situations; offering a transparent
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sen, Jr. Foot and Ankle Institute, University of Washington Medical School and he is listed in The Best Doctors in America publication. He performs specialized proc edures including foot and ankle reconstruction, total ankle arthroplasty for ankle arthritis and treatment of rheumatoid feet and neuromuscular deformity. Ted Hansen received his medical degree and residency training at the University of Washington, Seattle and his career honors include the 1994 endowment of the Sig T Hansen Endowed Chair for Traumatology Research at UW; an honorary doctor of science degree from Whitman in 1997; and the 2000 dedication of Harborview’s Sigvard T Hansen Jr. Foot and Ankle Institute. However, he considers his top career honor to be the AO Foundation’s lifetime achievement award, the “Award for Innovation” which he received in 2006. Through the AO Foundation he has “met… fantastic people and been invited to teach and operate all over the world.” Hansen is a true orthopedic pioneer who has revolutionized trauma care in the United States. Through these vast improvements in treatment, through his warmly personal and honest relationships with patients, and through remarkably innovative, skilled, and fearless surgeries, he has improved the quality of lives for countless patients for forty years and counting. (Material from the Department of Orthopaedics& Sports Medicine e-NEWS was used in the writing of this article.)
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AOTrauma Latin America (AOLAT)
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AO Asia Pacific (AOAP)
First research workshop for AOLAT
AO Biomaterials
First AOTrauma Asia Pacific Clinical Research Forum
Held in Panama on May 1, 2010, this initiative brought together 10 participants, representing different Latin America countries and universities, as well as representatives from the AOTrauma Research Commission and AO Clinical Investigation and Documentation. After one day of discussions, it was possible to identify regional weaknesses and strengths while defining a list of action points to be accomplished in future months. A first result is a proposal for a multicentric clinical prospective trial on trochanteric fractures evaluating predicting factors for mortality in Latin America population. This study, proposed by Prof William Belangero, will generate data for the first AOLAT regional publication as a team and enhance the culture of clinical investigation in AOLAT, while promoting quality in medical assistance.
Symposium
This event took place in Kowloon Shangri-La Hotel, Hong Kong on September 16 and 17, 2010. The aim of this Forum was to bring together research expertise in the region in order to demonstrate and showcase their research work and achievements within the Asia Pacific region. A total of 19 participants from eleven countries attended. Given the success of this event, the AOTAP Research Committee is planning to hold similar events in the future.
As a national initiative undertaken by the Colombian AOTrauma, AOSpine and AOCMF chapters, the first AO Biomaterials Symposium for Latin America took place in Bogotá on September 11, 2010. Over 120 participants from the different specialty groups across the country gathered together to discuss general concepts and new trends in the clinical applications of biomaterials, bone substitutes and tissue engineering. Prof Mauro Alini Head of Musculoskeletal Regeneration Program, from the AO Research Institute in Davos (a worldwide authority in research of biotechnology, tissue engineering) introduced the participants, through eight separate talks, to basic concepts, current development and future trends of biotechnology, with emphasis in the concepts and treatment of critical sized bone defects (CSD). The knee under a single approach
The knee is a joint normally evaluated under different perspectives, depending on the specialist who manages its injuries. On July 1-3 2010, the Orthopedic Trauma Group of Ribeirao Preto Medical School, Sao Paulo University promoted a course for knee and trauma surgeons aimed at presenting current evidence on bone, cartilage and ligament injuries of the knee. A number of international guests supported this course: Joseph Schatzker, Christian Krettek, James Stannard, Alex Staubli, Phillip Lobenhofer, James Cook and Juan Concha. 533 physicians from 14 different countries attended the course which has also generated content for online education and a book supported by the Brazilian Orthopedic Trauma Society. This successful experience will be repeated on July 5–7, 2012.
Open platform for Asia Pacific researchers
AOSpine Research Commission member, Richard Williams is driving the AOSAP Research Committee into an open platform for Asia Pacific researchers, with the creation of an online Research Knowledge Forum and a new task force. The task force consists of current council members as well as prominent researchers from different countries within the region. The Research Knowledge Forum was established to support the collaboration of ideas and to foster discussions. The research committee met in Osaka in the middle of June 2010 to discuss the research protocol on the main pilot study: A Comparison of Surgical Outcome for Lumbar Degenerative Spondylolisthesis with Neurog enic Claudication amongst countries of the Asia-Pacific Region. Phase I of this project is underway and the Patient recruitment Phase of this pilot study will take place from March 2011 to March 2012. The next AOSAP Research Taskforce meeting is scheduled for June 2011.
L4 degenerative spondylolisthesis
Joseph Schatzker and Christian Krettek had huge audiences attending their presentations.
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The AO Veterinary Advisory Committee established at the request of the AO Research and Development Committee
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AOVAC members in photo from left to right: W McIlwaith, A Goodship, J Auer, L Bouré (missing from the photo: T Schaer)
My view James F Kellam Editor-in-Chief james.kellam@aofoundation.org
Positioning
The AO Veterinary Advisory Committee (AOVAC) was set up, at the request of the AO Research and Development Committee (AO R+D Committee), to evaluate and advise on: • L ive animal models applied at the AO Research Institute (ARI) in Davos • Expand this evaluation to all AO funded projects using live animals
The members have to fulfill the following duties: • To take all efforts to fulfill the tasks and responsibilities set out above • To actively support ARI within both the AO Foundation and external world • To advance the interests of AO in Research and Development
AOVAC is an interdisciplinary group of veterinarians with expertise relevant to the use of live experimental animals in the area of research of the locomotor (or musculoskeletal) system. It acts as a sounding board for the usage of animal models at ARI and more widely for AO funded experimental studies. It has no budget to fund its own projects.
The AOVAC meets once a year at the ARI headquarters Davos. The first meeting took place on February 12, 2010, where the AOVAC members toured the ARI facility and met with collaborators for discussions on specific projects. During the tour the AOVAC members met with members of the Muscloskeletal Research program, the Implant Bioperformance program, the Biomedical Services program, the Innovations group and the PreClinical Testing program.
Tasks and responsibilities
An in-depth look at the ARI animal experimentation project
AOVAC’s tasks and responsibilities are to: • To review and approve Standard Operative Protocols (SOPs) for preclinical models used at the ARI and for AO funded studies • To act as an Institutional Animal Care and Use Committee (IACUC): – Temporarily until the ARI has its own IACUC – For any AO funded study performed at a site that has no IACUC • To serve as a consulting/advisory committee for the Director of preclinical surgery at the ARI and any researcher receiving AO funds
flow addressed:
Definition
Members
Members will be on the committee for three years. Joerg Auer acts as provisional chair of the committee for the first year. Initially it was proposed that after the first year the chair would be passed to another AOVAC member. After having established the AOVET R&D Commission, the Specialty Board AOVET decided that the Chair of the R&D Commission, Carl Kirker-Head should lead the AOVAC. This will consolidate the research activities with those of ARI and the live animal research of the AO Foundation. The chair of the committee will automatically become a member of the AO R+D committee. The four other AOVAC members are Wayne McIlwraith, Allen Goodship, Thomas Schaer, Ludovic Bouré.
• A nimal studies at ARI • A nimal utilization authorization for animal studies conducted at ARI • A nimal utilization monitoring • A nimal rights in Switzerland • I nstitutional Animal Care and Use Committee • Performance of animal surgery at the ARI • External, AO funded, animal experiments (not performed at ARI) Standard Operative procedures:
Eight standard operative procedures (SOP’s) for animal experimentation were reviewed by the AOVAC members approved. These SOP’s may be used in any AO Foundation funded projects. Anyone interested should get in contact with the Director of Preclinical Studies at the ARI, Ludovic Boré. Up to now no projects turned in by the AO Foundation Specialties to the Research review Committee, which is chaired by another veterinarian, Mark Markel, has been forwarded to the AOVAC for review of the animal use protocol. This will change in the near future. The next AOVAC meeting is scheduled for Spring, 2011 in Davos.
What is the best way for a surgeon to have a meaningful and ethical relationship with an orthopedic implant producer? From the outset the AO has attempted to address this issue. When Maurice Müller first began to develop AO implants, he realized the need for skilled manufacturing and production facilities and support. With Robert Mathys and then Fritz Straumann, he built a very strong industrial partnership under the control of AO surgeons. In order to strengthen this, the AO Technical Commission was created, consisting of surgeons meeting with engineers and producers to discuss and approve implants. Members received no money and no patents from either manufacturers or the AO and developers and inventors received minimal if any compensation. Developed to maximize the quality of the implant, its use and its technique, all for the betterment of patient care, today it has expanded into the AO Technical System (TK System). There are many different expert surgeon groups who develop implants and techniques to be approved by Technical Commissions. This system allows surgeons to be involved in implant development at the same time as maintaining a healthy relationship with manufacturers and avoiding the types of conflicts that have recently arisen.
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 2|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
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New AO Foundation President, Norbert Haas identifies his strategic priorities to guide the development of the AO Foundation (AOF) during his term in office Strengthen AO Foundation as a single entity
To foster the continuous growth of its activities, the AOF decided to decentralize responsibilities. This is an ongoing process in which the first experiences within the AO Specialties and AO Regions need to be carefully evaluated and corrective action taken as required. Certain interfaces need to be more clearly defined, ie, between the Regions, Specialties and the core AO Service Units. Furthermore, the need for a closer integration of the AO Regional Offices into the core processes has been identified. The first step to enable good governance was to adapt the AO Bylaws and Specialty Charters to clearly define the roles and responsibilities within our network. The changes also mandated the Presidential Team to hold the Foundation and its entities together. Improved efficiency in resource allocation
The recently established mid-term plan process will continue to be enhanced, focusing on common target setting through a bottomup approach and more intensive collaboration to make optimal use of resources. The grouping together of research activities into exploratory research with focus fields and collaborative research programs, and start-up grants with the respective delegation of decision-making to the appropriate funding bodies, should improve selection of relevant projects. This will have an impact on daily clinical practice. To maintain AO´s high quality standards, a common peer review standard and process becomes mandatory from January 1, 2011.
balance between specialization and a comprehensive approach. I want to see an increased focus on innovation overall. This implies improvement of patient care through new methods and concepts but also implementation of state-of-the-art technologies in all relevant areas of AO activities. eLearning, curriculum building, new course formats
We have to be aware that there’s strong competition out there in the marketplace. The AOF has been unique in its educational offering for decades now, but we cannot ignore the fact that young surgeons find alternative offers from a variety of organizations these days. In order to remain at the cutting-edge of education we must provide up-to-date services, especially in eLearning. Face-to-face courses remain an important part of what we do but we need to look at our course formats and the different types of practical exercises. Global perspectives—new partnerships
The world is facing a global trauma epidemic, especially in developing countries and it is our objective to make a difference according to our mission. However, the AOF will not be able to achieve this alone. Therefore, the AOF has initiated a cooperation with the WHO’s Global Forum for Trauma Care. This is only a first step and we have to open ourselves to partners who were considered to be competitors until now eg, EFORT and other academic and scientific societies and institutions, and universities.
Interdisciplinary approach in research & innovation
Stabilization & Evolution
Today’s challenges in research cannot be isolated within Specialties since many are related to biology. The human body doesn’t care about our organizational structure. Bone defects and appropriate substitutes are just one example of cross-specialty issues, infection is another, the use of wires and cables in trauma, spine, CMF and veterinary surgery another. Therefore it makes perfect sense to perform research across institutional boundaries. So, as in industry, where innovation groups are composed of experts from different disciplines, the AOF needs to find a
Independent from all changes, we carefully need to maintain the great, worldwide network, and safeguard AO’s good reputation. It will be decisive for the success of all these issues to encourage a culture of honest discussion and controversy with constructive solutions within our global network of colleagues and friends. I am looking forward to this fruitful exchange with the AO family respecting the successful history and tradition of the AOF and I encourage everybody to participate actively in the development of the AOF´s future.